ANSWEES QUESTIONS PKESCEIBED BY DENTAL STATE BOARDS. BY EOBERT B. LUDY, M. D., LATE ACTING-ASSISTANT SURGEON, U. S. A., LECTURER ON PRACTICE OF MEDICINL IN TEMPLE COLLEGE OF PHILADELPHIA, AUTHOR OF "ANSWERS TO QUESTIONS PRESCRIBED BY MEDICAL STATE BOARDS," ETC. SECOND EDITION, REWRITTEN AND ENLARGED. PHILADELPHIA : JOHN JOS. McVEY. 1905. LIBRARY of CONGRESS Two Copies deceived JAN 4 1905 Cowngnt tntry JW< t 3,/9o 6' 0USS (X XXc, Noj / 4 5~7 7/ COPY B. Entered according to Act of Congress, in the year 1905, By JOHN JOS. McVEY, In the Office of the Librarian at Washington, D. C. PREFACE, The indorsement of the first edition of this book by teachers and students, as shown by numerous expressions of approval, as well as by its rapid sale, is extremely gratifying to the author and seems to warrant its continuance. In the present edition the entire text has been completely re- written and thoroughly revised, and all new State Board Ques- tions which appeared since the publication of the first edition have been added. It is hoped that the careful revision to which the work has been subjected has eliminated the errors which appeared in the first edition. Many persons having an adequate knowledge of the subject in which they are tested, fail, because of their inability to inter- pret properly the intents and purposes of the questions to be answered by them. To aid in this, as well as to afford a con- venient manual for the general preparation of Dental Students in their work, is the sole object of this book. Having collected a large number of questions from different States, it was found that duplications occurred ranging from 30% to 80%, varying according to the several subjects. Thus a comprehensive knowledge of these questions and answers will serve excellently in the preparation for future examinations before such Boards. In order to secure a critical interpretation of the questions, and concise, } r et complete, answers to the same, the author has been favored by the assistance of well-known specialists in their several lines, whose competence and experience give to the work a range and value impossible of attainment in the product of a single author. It has been deemed advisable to unite all questions from the cm) iv PREFACE. different States under their respective headings, so that undue repetitions of similar questions might be avoided. Although standard literature has necessarily been consulted, yet, in a work of this character, references would only prove cumbersome ; hence they have been generally omitted. To Drs. Boom, Buckley, Good, Northrop, Rice, Salvas and Thomas, the author makes grateful acknowledgment. The high value of their carefully prepared answers is fully appre- ciated by him, and will be, he is assured, by those into whose hands the work is committed. ROBERT B. LUDY. SPECIAL AUTHOES. Henry H. Boom, 31. JD. Professor of Chemistry, Physics and Metallurgy in the Philadelphia Dental College. Albert C. Buckley, A. M., M. D. Associate Professor of Histology in the Medico-Chirurgical College of Philadelphia. Wm. Harmar Good, A. B., M. D. Demonstrator in Physiology at the Medico-Chirurgical College of Philadelphia. Herbert L. Northrop, 31. D. Professor of Anatomy and Associate Professor of Surgery in Hahne- mann Medical College of Philadelphia. Earl C. Bice, J). Z>. S. Professor of Dental Pathology and Therapeutics in the Medico- Chiurgical College of Philadelphia. J. Clarence Salvas, 1), D. S. Philadelphia. W. Herscy Thomas, 31. D. Lecturer on Surgery, Medico-Chirurgical College ; Assistant Surgeon, Medico-Chirurgical Hospital. (v) CONTENTS. PAGE I. OPERATIVE DENTISTRY 1 By J. Clarence Salvas, D. D. S. H. PROSTHETIC DENTISTRY 41 By J. Clarence Salvas, D. D. S. IIL ORAL SURGERY 95 By W. Hersey Thomas, M. D. IV. PATHOLOGY 171 By W. Hersey Thomas, M. D. V. PATHOLOGY AND THERAPEUTICS 193 By Earl C. Rice, D. D. S. VI. THERAPEUTICS AND MATERIA MEDICA 207 By Earl C. Rice, D. D. S. 1 VII. PHYSICS, CHEMISTRY AND METALLURGY {. 249 By Henry H. Boom, M. D. VIII. HISTOLOGY 317 By Albert C. Buckley, A. M. , M. D. IX. PHYSIOLOGY 353 By William Harmar Good, A. B., M. D. X. HYGIENE 389 By Robert B. Ludy, M. D. XI. ANATOMY 413 By Herbert L. Northrop, M. D. (vii) OPERATIVE DENTISTRY. What is dental caries? Dental caries is the disintegration of tooth tissue. Give the etiology and the general preventive treatment of dental caries. Lactic fermentation. Thorough cleansing of the teeth by means of tooth-brushes, powder, dental floss and antiseptic Avashes. How is dental caries classified? It is classified as follows: Superficial, deep-seated, simple and complicated. What is superficial dental caries? Give treatment. It is that stage of the disease in which the caries has not penetrated the enamel. The treatment consists in its removal with disks and fine stones. What is deep=seated dental caries? Give treatment. It is that stage of the disease which involves the zone of dentin in close proximity to the pulp-chamber. Removal of all decay, sterilization, coating the cavity with a cavity-lining and filling. Give the etiology, prognosis and treatment of inflamma- tion of the membranes of the mouth preparatory to oper- ations on the teeth? The local causes of inflammatory conditions o( the mem- branes of the mouth are due to the presence oi' salivary cal- culus, to carious, loose, dead or diseased tooth or roots. The prognosis is favorable. The treatment consists in the 2 OPERATIVE DENTISTRY. mechanical removal of the deposits on the surfaces of the teeth, and in the extraction of incurably-diseased teeth. The gums should be massaged at each sitting and the parts sprayed several times a day with the following well diluted antiseptic solution : Euformol 5 j Glycothymoline § iv Acidi curb gttxxx Where the inflammatory condition is the expression of constitutional disorder, derangement of the alimentary func- tions or catarrhal affection, general treatment is indicated. Give a genera! rule for the preparation and formation of cavities. Name the points that require special care in excavating. All frail overhanging walls should be removed, the cavity thoroughly excavated, sterilized, and made retentive in form. The margins should be smoothed. Care must be taken, while excavating, not to expose the pulp. Give the recognized stages in the preparation of a cavity for filling. The recognized stages are : Opening the cavity, removing the decay, shaping the cavity. Give the general principles governing (a) the prepara= tion of cavities for gold fillings, (b) the insertion of gold fillings. (a) Opening the cavity; removal of the decay; shaping the cavity to receive and retain the filling and the prepara- tion of the margins. (b) Accurate adaptation to the cavity walls; solidity and proper contour. How should the preparation of a cavity for a gold filling differ from the preparation of a cavity for an amalgam filling? A cavity for gold requires direct access; the walls should OPERATIVE DENTISTRY. 3 be strong, and the margins smooth and beveled. Retention should be secured by well-defined pits or grooves drilled in the dentin. A cavity for amalgam should be more or less ball-shaped; the cavity should be enlarged from within, the enamel-walls parallel, the angles removed and straight sides made concave. What form of burs is preferable for removing deep= seated decay? Give reason for using this form and state method of use. The round or oval form of burs. They are preferable be- cause their form is similar to that of the natural outline of the cavity and, when properly used, they are not so apt to injure the subjacent dentin. They are manipulated by means of the handpiece of the engine and should revolve rapidly. The instrument should be lifted at short intervals and allowed to run free, to avoid heat from friction, and consequent pain. What instruments should be used to smooth or finish cavity margins? Chisels, broad-faced excavators, approximal trimmers, and file-cut enamel finishing-burs, Arkansas stones, etc. What form of bur should be used (a) for opening and following the course of sulci; (b) for forming the floor of a cavity for a gold filling? (a) The fissure-bur; (b) the inverted cone. Mention the form and advantage of excavator points for removing deep=seated decay in teeth. Spoon-shaped or round-bladed. Their cutting edge being oval or circular in form, the layers of decayed tissue can be removed without injuring the subjacent tissue. Describe the method of excavating a cavity extending to the pulp, giving the form of excavator and the manner of use. The orifice of the cavity is enlarged and. with a round- bladed excavator, the decay is removed just below the enamel 4 OPERATIVE DENTISTRY. line. The remaining portion of the carious dentin is re- moved by placing the blade of the excavator near the base of the cavity and with draw-cuts towards the orifice each layer of decay is removed. Round-bladed excavators of various shapes, according to the position of the cavity, are used. Give the general treatment and care of teeth in case of white decay. The carious matter should be carefully removed and the cavity sterilized, after which it should be filled with perma- nent gutta-percha or some other plastic. Teeth prone to this kind of decay should be subjected to frequent examination. Describe your method of preparing and filling approxi= mal cavities in bicuspids and molars. Access to the cavity is secured by separating the teeth. If the occlusal surface is weak, it should be removed, thus converting the cavity into a compound cavity. All decal- cified tooth structure is removed. Frail walls should be trimmed away and the cervical aspect of the cavity extended so as to secure a solid base. The floor of the cavity is made flat, avoiding sharp angles. The occlusal portion of the cavity should have a V shape, and the margins should be beveled and smoothed. A retaining groove or pit should be placed at the cervical termination of the cavity and slight under- cuts made in the approximo-occlusal walls. The rubber dam and the matrix adjusted, a mat of crystal or fiber gold is introduced and with a foot-shaped plugger malleted to place, care being taken to carry the gold over the cervical wall. By this method the upper third of the cavity is filled. Cohesive gold is then added and used to complete the remainder of the filling, which should be contoured the natural shape of the tooth. The gold should be well burnished and polished with strips and sandpaper disks. In simple approximal cavities the cavity should be ex- tended buccally, so that it can be approached from the buc- cal aspect. The decay and the margins should be treated as OPERATIVE DENTISTRY. 5 before described. With an inverted cone-drill the cavity can be made retentive in form and crystal or fiber gold inserted. How would you prepare and fill an approximal cavity with frail walls extending to the cutting edge of an incisor? The cavity should be thoroughly excavated and all frail margins of enamel should be removed. The labial margin of the cavity is brought to the cutting edge in a direct line, the cervical aspect of the cavity shaped as a flat ledge, the base at right angles with the axis of the tooth. The lingual margin should correspond to that of the labial to within a few lines of the cutting edge, where it should turn at right angles and extend across the tooth at the cutting edge to a point a little beyond the depth of the cavity. Anchorage is obtained by cutting a groove in the cervical ledge and by making an undercut in the dentin near the incisal border. The margins should be bevelled and smoothed. Cohesive gold in the form of ropes or cylinders is used. The cervical groove is filled first and the gold built down towards the incisal edge, where it is securely anchored. The mass should be kept on a line with the labial and palatal Avails. The gold should be carried well over the margins and thoroughly condensed with a broad-faced plugger, using sufficient to permit of proper shaping and finishing. How should cervical cavities be prepared with reference to the gum margin? The margin should be extended well rootwards in order to include any defect in the enamel bordering it. The walls should be made smooth and free from angles. By what means can cavities be protected from moisture without recourse to the rubber dam? By the use of cottonoid or small linen napkins in conjunc- tion with the saliva-ejector. What is hypersensitive dentin? Give treatment. It is an irritated state of the tubular contents of the den- 6 OPERATIVE DENTISTRY. tin and prevails principally near the junction of the dentin with the enamel. The cavity should be thoroughly dried by the use of abso- lute alcohol, followed by blasts of warm air ; this may be fol- lowed by Robinson's remedy, caustic potassa and carbolic acid, equal parts. How should a cavity be treated and filled when the dentin is highly inflamed?' 1 ' Oil of cloves should be sealed into the cavity for a few days, the decay then removed, using sharp instruments, and the cavity lined with "cavitine, " after which it may be filled with cement. State the most efficient and satisfactory treatment of teeth that have become sensitive with a tendency to decay under plate clasps. The affected parts should be treated with a 25 per cent, solution of nitrate of silver. Describe the treatment of anterior teeth that are sensi= tive at the gingival border. An ant-acid mouth-wash should be prescribed and a solu- tion of glycerin and tannic acid applied to the sensitive part. Why does the contact of fillings of different metals re= suit in shock to the teeth? Because of a galvanic action taking place when the two metals are brought in contact. Why are teeth recently filled more liable to shock from thermal changes than other teeth? Give preventive treatment. It is because of the immediate contact of a filling, espec- ially a metallic filling, with the tubular structure of the * This question is answered presuming that its author used the expression "highly inflamed dentin" as synonymous with hypersensitive dentin. In- flammation of the dentin, if there is such a pathological condition, has no bearing whatever on cavity preparation. OPERATIVE DENTISTRY. 7 dentin. It may be prevented by interposing a layer of non- conductive material. Describe the treatment of a tooth that is extremely sen= sitive to thermal changes after filling. A gutta-percha cap placed over the affected tooth and allowed to remain until the pulp recovers from the hyper- emia. "When the severity and continuance of the pain is such as would give rise to inflammation, the filling should be removed and the cavity treated, after which it should be lined with a cavity-lining and a soft filling inserted. Give the cause and treatment of pits on the labial sur- face of teeth near the incisaS edge. They are caused by imperfect development of the enamel. If the pits are shallow, they may be obliterated by grinding the surface with a corundum wheel, converting the surface at this point into a distinct concavity. When the pits are deeper, they are enlarged and filled. What is erosion? Give its cause and treatment. It is a chemical disintegration of tooth tissue, occurring principally upon the labial surfaces of the teeth. It is caused by the action of an acid secretion, the motion of the lips assisting in the disintegrative process. The treatment consists in prescribing an ant-acid mouth- wash. When the disintegration involves the dentin to any extent, the cavity is prepared and filled. Define abrasion. State causes and give method of restoration. Abrasion is a mechanical wearing of the crowns of the teeth. It is caused by defective occlusion and excessive wear. Restoration is effected by the adjustment of crowns or porcelain tips, etc. Is the deposit of secondary dentin physiologic or patho- logic? It is physiologic. 8 OPERATIVE DEXTISTBY. What is meant by the term " eburnation?" The process by which the dentinal tubuli become obliter- ated by calcific deposits. How should teeth be separated for the purpose of in= serting a filling? By means of pellets of cotton, linen tape, strips of caout- chouc or by the mechanical separator. What pathologic condition may result from wedging teeth? Disorganization and consequent death of the pulp. Why are the risks especially great in rapid wedging of the superior central incisors? Because there may occur a separation of the superior maxilla and the possibility of the incisors not returning to their normal position. How should teeth that have been wedged be guarded to prevent injury during the process of filling? They should be held firmly in place by means of orange wood, gutta-percha or phosphate of zinc. What is the best treatment to render a cavity aseptic? The removal of decay and the application of carbolic acid. Name the different materials used in filling teeth. Oxysulphate of zinc, oxychloride of zinc, oxyphosphate of zinc, oxyphosphate of copper, gutta-percha, amalgam, tin. gold and porcelain. What advantages has gutta=percha as a filling material? It is non-conductive, non-irritating, insoluble, and easily manipulated. In what class of cavities should gutta=percha rather than metallic fillings be used? In deep cavities upon the buccal surfaces of molars ex- tending beneath the sum and not involving the masticating OPERATIVE DENTISTRY. 9 surface ; in approximal cavities of the anterior teeth extend- ing beneath the gum, in labial cavities, especially in teeth which are loose. Describe the insertion and finishing of a gutta=percha filling. The gutta-percha should be softened by warming it over a suitable device, after which it is introduced piece by piece, using broad-faced instruments, care being taken to adapt the gutta-percha to the margins of the cavity. The finishing consists in trimming the portions overlying the margins with a warm instrument. The instrument should be directed towards the margin and not from it. For what class of teeth and for what operations is phos- phate of zinc valuable? For children's teeth and as a temporary filling in per- manent teeth ; in frail teeth with extensive cavities or as a lining to be covered with a metallic filling; as a retaining medium in crowns, bridge-work and porcelain inlays. In what class of cavities is cement unsafe? In cervical cavities. In what class of operations is the oxychloride of zinc indicated? In filling root-canals, capping pulps and lining cavities. State the advantages of amalgam over the other plastic fillings. Give reasons. It is more durable and possesses a wider range of appli- cation, which is due to its insolubility and its property of withstanding the stress of mastication. State the conditions under which amalgam should be used for fillings. Give reasons. Wherever it is not exposed to view or where gold is contra-indicated. Its unsatisfactory color excludes it as a filling for the anterior teeth. 10 OPERATIVE DENTISTRY. Describe the method of preparing and inserting an amal= gam filling. The alloy and the mercury in proper proportions are placed in a mortar and with a pestle the mass is mixed. When amalgamation is completed, it is transferred to the palm of the hand and kneaded with the fingers, after which the sur- plus mercury is squeezed out. It is introduced into the cav- ity in small pieces and pressed against the walls by tapping or burnishing. "When the cavity is filled, the edges are neatly trimmed with pieces of punk. The filling should be polished at a subsequent sitting. How should the margins of a cavity wall be prepared for an amalgam filling? The margin should be so prepared that the amalgam in its adaptation is not worked to a feather edge. What are the physical changes in an amalgam filling after it is placed in a tooth? Crystallization, contraction and expansion. How should an amalgam filling in a compound cavity, involving the approximal and masticating surfaces of a molar, be inserted? A matrix should be adjusted and the amalgam introduced from the masticating surface, care being taken to have it well burnished against the matrix and the margins of the cavity. What advantage has amalgam over gold for filling teeth? The plastic nature of the amalgam renders its introduc- tion simpler and quicker. In cavities difficult of access it can be better adapted to the margins. Under what conditions are the plastic fillings preferable to gold? When the dentin is in a hypersensitive condition; when the cavity encroaches upon the pulp-chamber; in frail teeth and in deciduous teeth. OPERATIVE DENTISTRY. 11 In what class of cavities is tin preferable for filling? In temporary teeth. Describe method of inserting a filling of tin. The tooth should be isolated with the rubber dam, the tin introduced in strips or rolls, using shallow but well- defined serrated points. The tin is carried to the floor and walls of the cavity, and by the wedging process it is thor- oughly adapted. As the filling approaches the marginal sur- face, broader points and condensers are employed. The surface should be well burnished and the filling finished by means of fine stones and disks. State why tin fillings arrest decay in teeth when gold fillings fail? Because the tin possesses antiseptic properties and, owing to its softness, is better adapted to the Avails of the cavity. What are the characteristics that render gold such a desirable filling material. Pliabilty, softness, tenacity and agreeableness of color. What advantages has gold over the other materials used for fillings? It possesses better edge strength, it is not affected by the oral fluids, and it retains its form when properly inserted. How should a cavity be prepared for a gold filling? Frail walls should be removed, the cavity thoroughly ex- cavated, and the margins carefully bevelled and smoothed. Anchorage is obtained by deepening the cavity at its cervical termination and by making a shallow groove in the denim near the incisal or occlusal border. What special precautions should be observed in insert- ing gold fillings in approximal cavities? . They should conform to the natural shape of the tooth and should be as inconspicuous as possible. 12 OPERATIVE DENTISTRY. What is the difference between cohesive and non= cohesive gold? State the working method of each. Cohesive gold is a preparation of gold which possesses the property of cohesion. It is worked on the welding principle. Non-cohesive gold does not possess the property of cohesion. It is worked on the wedging principle. In what respect is non=cohesive gold preferable to cohesive gold for filling teeth? It is more readily adapted to the walls of the cavity. State the advantages of cohesive gold? Give reasons. Owing to its cohesive property the pieces may be welded one to another, thus a filling of any size or shape can be made with it. Give the technic of preparing and filling with cohesive gold an approximal cavity. The teeth are separated until sufficient space is secured, the rubber dam adjusted and the frail walls on the approx- imal surface broken away with a small chisel, care being taken to preserve as much of the labial wall as possible. After the decay has been removed, using burs or excavators, the margins should be beveled and smoothed by means of plug-finishing burs. Anchorage is obtained by grooving the dentin at the cervical termination, using small, inverted cone- burs, and by making a shallow undercut in the dentin near the incisal border. The gold is introduced in small pieces, packed into the groove at the cervical border, using shallow, serrated plugger-points. When firmly anchored, the gold is built along the floor and the palatal wall to the incisal groove. The construction of the filling along the palatal wall should precede that of the labial aspect of the cavity, thus facili- tating contouring. When the filling approaches the labial margins of the cavity, a shallow, serrated foot-plugger should be used for the remainder of the operation. The pellets of gold should be laid in regular order and carried well over the margin of the cavity, care being taken not to allow the plugger to come in contact with the enamel. OPERATIVE DENTISTRY. 13 Where would you use non=cohesive gold? In occlusal, buccal, lingual, labial and simple approximal cavities; also as a lining in cavities with frail walls in com- bination with cohesive gold. It is especially serviceable in minute cavities and in those difficult of access. Give the technic of preparing and filling an approximal cavity with non=cohesive gold. Access to the cavity is secured by separating the teeth. The cavity is excavated by means of rose-head burs and spoon-shaped excavators. It should be made oval or circular in form, the margins bevelled and smoothed, and the floor of the cavity made flat and larger than the orifice, employ- ing for this purpose the inverted cone-shaped bur. The gold is introduced in strips or rolls, using broad, well- serrated pluggers and by means of hand-pressure. Consid- erable and well directed force is essential. Describe a method of securely anchoring a gold filling in a distal cavity with frail palatal walls in a vital superior cuspid. Anchorage is secured by cutting grooves in the dentin at the cervical border and by cutting an extension-arm in the palatal surface near the incisal edge. Describe a method of filling an occlusal cavity in a molar with shallow sulci radiating from a deep central cavity. Describe the form and condition of gold used in the operation. The central portion of the cavity should be filled with semi-cohesive foil and the radiating sulci with cohesive foil, care being taken to have the filling well anchored at the ex- tremities of the fissures. State the best method of applying gold to the walls of cavities in poorly calcified teeth. Cavities in teeth of this character should be lined with oxyphosphate. While the cement is still soft, pieces of plas- U OPERATIVE DEXTISTFY. tic gold are pressed into it, and the surplus cement carefully removed. When the cement has become hard, the pieces of plastic gold are thoroughly condensed and the filling com- pleted with cohesive foil. Give method of treating and filling a very sensitive su= perficial cavity with gold. The sensitiveness is relieved by the use of carbolic acid and blasts of warm air, after which the cavity is prepared aid coated with a solution of Canada balsam and chloro- form. It should then be filled with either non-cohesive or with plastic gold. Mention the class of cavities in which a combination of non=cohesive and cohesive gold should be used. Give reason for their use. A combination of non-cohesive and cohesive gold is indi- cated in approximal cavities with frail walls, in meso- occlusal and disto-occlusal. in occluso-buccal and occluso- lingual cavities. The advantage of employing non-cohesive and cohesive gold in combination is. that the non-cohesive can be easier and better adapted to the floor and margins of the cavity, while with the cohesive gold for finishing the filling, contour and greater density is obtained. Give the technic of filling a cavity with a combination of cohesive and non=cohesive gold. Where a matrix is indicated, this device is adjusted, the tooth having been previously isolated with the rubber dam. The cavity prepared, a roll or mat of non-cohesive gold is placed in the cavity, extending some distance beyond the cervical border. This is followed by one or more rolls, which should be malleted to place, using a foot-shaped plugger. This is continued till a third of the cavity is filled, when very cohesive gold is introduced and the filling com- pleted, using slightly serrated plugger-points. The gold should be carried well bevond the beveled margin on the OPERATIVE DENTISTRY. 15 occlusal surface and thoroughly condensed with a small, finely-serrated foot-plugger. What causes the surface of gold fillings to blacken in some mouths? The action of sulphites, either taken with the food or produced chemically in the mouth; the incorporation of for- eign substances with the gold during its insertion; imper- fectly prepared cavities, where the gold next to the floor and walls of the cavity, if poorly condensed, will absorb more or less of the carious products. The contamination of the gold with mercury, owing to the use of an amalgam- burnisher, is also a potent factor in causing discoloration of gold fillings. When the walls of a cavity have softened beneath an approximal gold filling extending beneath the gums, how should the cavity be treated and filled? The softened tissue is thoroughly removed, extending the cavity well rootward, space having been previously secured and the gums forced away. The repair can then be made either with permanent gutta-percha or with plastic gold. Mention the various combination fillings and state the advantage of their use. Gutta-percha and cement, amalgam and cement, gold and cement, gold and amalgam, gold and tin, and the different forms of gold in combination. The advantage of combining filling materials consists in the elimination of the disadvan- tages of each when used separately, and in the utilizing the advantages of each when in combination. Designate a class of cavities in frail teeth when a com- bination filling of gutta=percha and zinc phosphate is in= dicated and give technic of operation. In those cavities that extend beneath the gum. The rub- ber dam and matrix is adjusted, the latter to prevent the gutta-percha from being forced out into the soft tissue. The cavity is excavated, sterilized and coated with Canada 16 OPERATIVE DENTISTRY. balsam dissolved in chloroform. The cervical margin is then filled with gutta-percha and the remainder of the cav- ity with cement. When sufficiently hard, it is polished and coated with melted paraffin. Give the technic of filling with gold and tin. The tin is introduced into the cavity in strips or rolls and with a short foot-plugger it is condensed against the floor and lower walls, carrying it over the cervical wall. Non- cohesive gold is then inserted in the same manner until two- thirds of the cavity is filled. The remainder of the cavity is filled with cohesive gold, which is contoured the natural shape of the tooth. Or a sheet of tin foil may be placed be- tween two sheets of gold and the whole folded and used as would be gold or tin alone. Describe a method of restoring with a combination of gold and cement badly=decayed, frail crowns of teeth. The rubber dam adjusted and the cavity margins bevelled, the lower third of the cavity and the walls are lined with a quick-setting cement. When the cement is hard, retaining- grooves are made and the gold introduced, and the filling finished in the usual manner. Mention the class of operations in which a combina= tion of gold and amalgam is preferable to either material used separately. Give reason. In cavities involving the disto-occlusal surface of bicus- pids and the meso-occlusal surface of molars. Amalgam alone is objectionable owing to its color. It is, however, valuable in filling the cervical borders of cavities difficult of access. Because of its plastic nature, adaptation to the mar- gins is better and more easily secured than with gold alone. Give technic for inserting a combination filling of gold and amalgam. The matrix and rubber dam are adjusted and the cavity sterilized and dried. A quick-setting amalgam is introduced OPERATIVE DENTISTRY. 17 and burnished well against the floor and lower walls, filling in this way a third of the cavity. A rope of non-cohesive gold is then inserted, holding it in place with one hand, while with the other it is packed on the amalgam and against the Avails, using an oval-shaped foot-plugger. Several layers of this gold are used ; the filling is finished with cohesive gold. Describe in detail the method of restoring with a com- bination of amalgam and cement frail, broken crowns. The edges of the cavity should be carefully trimmed and the rubber dam adjusted. Amalgam sufficient to fill one- third of the cavity is prepared. Before inserting it, two-thirds of the cavity are filled with soft cement, into Avhich the amal- gam is placed, forcing the cement into every portion of the cavity. That which oozes out is carefully removed from the margins and the filling finished with amalgam. State in what class of cavities and under what condi- tions a matrix is essential. In distal compound cavities of bicuspids and molars. It is especially essential when plastics are employed. State the advantage and disadvantage of a matrix. It converts compound cavities into simple cavities and facilitates contouring. When employed in mesial cavities, it obstructs the light and makes it difficult to adapt the gold to the cavity margins. What are the camparative merits of hand and mallet pressure? Hand pressure permits of greater distribution of force, Avhich is essential in the condensation of the non-cohesive and the plastic golds. It produces less shock to the tooth and is less liable to injure the walls of the cavity AA'hen brought in contact with them. Mallet pressure permits of Avorking with greater rapidity It possesses marked penetrative force and gives greater den- sity to filling. 18 OPERATIVE DENTISTRY. Give technic of the operation of restoring teeth by the use of porcelain inlays. The cavity should be prepared so as to be free from under- cuts, the edges should be smooth and square. Where high- fusing porcelain is to be employed, the matrix must be made of rolled platinum one one-thousandth of an inch in thick- ness. It should be well annealed and placed over the cavity into which it is forced with a ball-burnisher or with a pellet of wet cotton, care being taken to have the margins smooth and sharply defined. The matrix is then removed and heated to redness in order to destroy all organic matter. The body should be thoroughly mixed with distilled water, dried with blotting-paper and placed in the matrix with a fine-pointed spatula. Tapping the pliers which hold the platinum, will settle the body to the bottom. It is then dried by holding it a few seconds at the opening of the muffle, into which it is gradually introduced and baked until a gloss appears. When cool, it is placed in the cavity. The edges are now re- burnished and sufficient body is added to fill the matrix com- pletely and to give the desired shape to the filling. It is dried and baked as before. The platinum should now be stripped off and the under surface grooved with fine disks. The cavity should be thoroughly dried and undercuts made, after which it is partially filled with cement and the inlay pressed home. How may excessive contraction be avoided in making large contour porcelain fillings? By imbedding one or two small chips of a porcelain tooth in the body mixed for the first baking. What class of cavities and what condition of the teeth are most favorable for the insertion of porcelain inlays? Labial, buccal and simple approximal cavities. Frail and sensitive teeth. What are the advantages of the porcelain inlay as a filling material? It resists the action of the oral fluids, is non-conductive OPERATIVE DENTISTRY. 19 and possesses harmony of color and strength to withstand mastication. Describe a method of making gold inlays. An impression of the cavity should be taken in modeling compound and run in oxyphosphate of zinc. From this is made a matrix of No. 36-gauge pure gold, which is also burnished to fit the cavity in the tooth. It is then removed (the under surface should be coated with whiting to prevent, the solder from flowing over the edge) and 22-carat solder flowed into the matrix, using enough to fill it partially. The contour or cusp, as the case may be, is obtained by placing in the matrix mats of crystal gold, and filling the interstices with 22-carat solder. The filling is then inserted in the same manner as a porcelain inlay. In what class of cavities and in what condition of teeth is the gold inlay indicated? In frail teeth and in compound approximal cavities of bi- cuspids and molars. When are artificial crowns and bridges indicated and when not? A crown is indicated when filling materials fail to prop- erly restore a tooth to usefulness. It is counter-indicated when the root is diseased. When one or more teeth are to be inserted and proper anchorage can be secured, a bridge is indicated. AYhen there are no desirable abutments and when gum tissue is to be restored, a bridge is counter-indicated. (a) What is thermal test? (b) how is it conducted, (c) for what purposes is it useful? (a) Thermal test is the application of water to the teeth 20 to 60 degrees F. below the blood-heat, and 20 to e used. Pink rubber is employed in the anterior part of the mouth, because it approximates the color of the gums. What is weighted rubber, and where is its use indicated? Rubber in which tin filings are incorporated. It is em- ployed in lower dentures, to be used in mouths where there is little or no ridge and where weight is essential to the re- tention of the plate. At what degree of heat and how long should a rubber denture be vulcanized in order that the best results may be obtained? It should be vulcanized for fifty-five minutes at a temper- ature of 320 degrees F. PROSTHETIC DENTISTRY. 51 What part of an upper denture has the greatest in= fluence on the expression of the face? The anterior part. What are plumpers? where placed? state their use. Plumpers are rolls of vulcanite placed on the labial and buccal rim of the denture. They serve to restore the features of the face. What is the guide for the amount of rubber to be used in packing a case? The wax from the model plate is placed in Starr's meas- uring-glass which is half filled with water, noting the height to which the water rises. The wax is then removed and sufficient rubber is put into the glass to raise the water to the same level or a little higher. Describe the method of constructing an artificial den= ture on a vulcanite base. An impression of the mouth is taken in plaster-of-Paris, from which is secured a plaster model. If an air-chamber is required, it is cut from sheet tin and secured in position on the model. A base plate of modeling compound is made to conform to the model. To this is attached the wax guide or rim, which is trimmed to the desired width, fulness and contour. This is placed in the mouth and the bite secured, after which it is returned to the model and, with the antagonizing model, is placed in the articulator. The teeth are arranged and waxed on this temporary plate, which is carved and trimmed just as the finished plate is desired to be. The model, with the plate, is removed from the articulator, the plaster trimmed, moistened and invested in the lower half of the flask, the plaster extending to the external rim of the wax. The plaster is then smoothed and varnishe ' and the upper section of the flask placed in position an filled with plaster. When the plaster is hard, the flask is heated sufficiently to soften the wax. and the parts are separ- ated. The wax is then carefully and completely removed 52 PROSTHETIC DENTISTRY. by pouring a stream of boiling water into the flask and over the teeth. After the flask has dried for a few minutes, the vents are cut and the two halves of the flask placed on the stove and heated to about the boiling-point, of water. The case is now ready for packing. The rubber is cut in strips and thor- oughly warmed: small pieces of the pink, packed between the teeth and strips, wide enough to extend from above the pins to the edge of the plate, are placed in position. The pins are completely covered with the red rubber, which is also placed over the palatal portion. No. 3 tin-foil is burn- ished to the model and coated with a solution of soap, which facilitates the removal of the foil from the vulcanite. The flask is closed and heated sufficiently to soften the rubber; the parts are then screwed together. The case is vulcanized, and when thoroughly cool, the plate is removed, filed, scraped, sandpapered and polished. With a protruding lower jaw, how far toward the tongue may the lower teeth be placed? What relation must they bear to the alveolar ridge? The lower teeth should not be placed towards the tongue farther than the centre of the edentulous ridge. They should be arranged as close to the centre of the alveolar ridge as possible. When would you arrange the teeth of an upper plate to occlude directly on the cutting edges of the lower teeth? In a case of a person of advanced age. where the lower teeth are so abraded that the masticating surfaces are per- fectly flat. The cusps of the upper artificial teeth should be ground off and the surfaces roughened. When a vulcanite upper plate cracks, why does the crack usually occur near the median line? It is due to the improper arrangement of the molars, in consequence of which the strain of mastication is thrown on the outside instead of on the top of the ridge. Imperfect PROSTHETIC DENTISTRY. 53 vulcanization, also insufficient rubber behind the incisor teeth, are factors in the cause of plates cracking at or near the median line. It may be due to resorption of the ridge sub- jecting the plate to undue strain. How should faulty articulation of artificial teeth be corrected? When the articulation is slightly faulty the interfering points can be detected by placing a strip of carbon paper in the mouth and instructing the patient to bite; the points thus marked should be removed with a corundum-stone. If the articulation is seriously faulty, the denture should be remade. State how the setting of plaster may be hastened? By the addition of a few grains of common salt to the mixture. Mention some of the causes of failure of artificial den- tures. Imperfect impression or cast, inaccurate articulation and warping of the plate. Give a method of correcting a warped vulcanite rubber plate. A cast of the mouth is secured and thoroughly dried. The portion of the plate that needs correcting is heated over a spirit-lamp sufficient to render the vulcanite flexible. It is then placed on the model, held firm, and with a heavy burn- ishing instrument the plate is adapted to the cast. State the effect of a hard center and a soft ridge on the fit of an upper denture. Unless the hard centre is properly relieved, the plate will rock. A common result of wearing lower plates that accurately fit a model, is a tendency of the plates to bury their buccal 54 PROSTHETIC DENTISTRY. edges in the soft tissues; state how this tendency may be overcome. By cutting away the buccal edge until the plate, when in the mouth, will not bear on the soft tissues. Mention some of the various methods of retaining arti= ficial dentures. Atmospheric pressure and clasps and springs. Give the normal occlusion of the teeth. All of the superior teeth overlap the lower; the six supe- rior anterior teeth extend over and cover part of the labial surface of the six inferior teeth. In the buccal region the buccal cusps of the superior bicuspids and molars cover the buccal cusps of the inferior bicuspids and molars. Each tooth, except the inferior central incisors and the last supe- rior molar strikes against two opposing teeth. What is your method of repairing a rubber plate frac= tured through the center? The two parts of the plate are adjusted together and held by means of hard wax dropped on the lingual surface. The palatal portion is then oiled and filled with plaster. "When the plaster has hardened, the plate is removed from the model and the line of fracture enlarged with a file. With a jewel- er's saw, dovetails are cut opposite each other, after which the parts are placed on the model and the prepared spaces filled with wax. The case is invested in the usual way, packed and vulcanized. Give the method of polishing a vulcanite plate on the palatal surface. Little or no polishing should be done to the palatal sur- face of a plate. A smooth, bright surface can be obtained by burnishing No. 3 tin-foil to the model and coating this with a solution of soap, just before the flask is closed prior to vulcanizing. PROSTHETIC DENTISTRY. 55 How may a gold clasp be attached to a rubber plate? By soldering a perforated gold tongue to the clasp in such a way that it will be well embedded in the rubber when the plate is finished. What would result if an upper denture extended too far posteriorly and touched the soft palate? The muscles of the soft palate would displace the plate during the act of swallowing. It is also apt to cause retching. Describe a method of producing a very thin and rough vulcanite plate, both surfaces of which will be nearly finished when removed from the flask. The case is prepared for flasking in the usual manner; it should be smooth and as thin as the finished plate is intended to be. No. 60 tin-foil is burnished to the wax ; it should be ap- plied in two pieces, one for the lingual surface and one for the buccal and labial surface. The edges of the tin-foil are bent out sufficiently to escape the investment in the lower section of the flask and, at the same time, so as to be grasped by the plaster when the upper section of the flask is poured. The case is then flasked. When the plaster is hard, the flask is placed in warm water to soften the wax; it is opened, the wax removed and boiling water poured into the flask and over the pins. No. 3 tin-foil is burnished to the cast and soaped. The waste-gates are cut and the flask dried, heated, packed and vulcanized in the usual manner. Can rubber be vulcanized in direct contact with silver? Give explanation. Rubber cannot be vulcanized in direct contact with silver owing to the affinity of the sulphur in the rubber for the silver. State a method of treating silver so that rubber can be vukarized in contact with it. The silver may be gilded or coated with tin. 56 PROSTHETIC DENTISTRY. Describe the method of using " Victoria " or other metal to strengthen or reinforce vulcanite partial dentures. When ''Victoria" metal is used, it is cut to the desired size and made to conform to the shape of the mould, placing it so that the roughened surface will be embedded in the rubber, which is packed directly over the metal. When a bar is used, it is embedded in the rubber during the process of packing, so as not to show in the finished plate. What will be the effect on a rubber plate if it is vul= canized for twenty=four hours at 320 degrees F.? The rubber will become dark and very brittle. Describe the process of constructing an artificial den= ture on a celluloid base. The plaster impression secured, a metal cast is obtained by running the impression in block tin. If a vacuum- chamber is required, it should be cut in the impression be- fore the model is poured. Taking the bite, articulating the case and arranging the teeth is the same as for rubber work. The base-plate is made of paraffin and wax compound. With a curved knife-blade the wax on the lingual surface and on the labial and buccal surfaces is carved so as to reproduce the natural characteristics of the gums. The wax is made smooth by passing it over the flame of a small burner. No. 60 tin-foil is then burnished over the surface of the wax. The case is ready for flasking; it is invested in the shallow half of the flask designed for this work. The plaster must extend just to the borders of the plate. When hard, it is trimmed and coated with liquid soap. The deep por- tion of the flask is adjusted and filled. When the plaster is hard and after sufficient heat has been applied to soften the wax, the two sections of the flask are separated. The wax is thoroughly removed by pouring a stream of hot water over the mould. A groove to permit of the escape of surplus material is cut in the plaster encircling the matrix, but not connected with the mould. A celluloid blank of the desired size is selected and made to conform to the shape of the PROSTHETIC DENTISTRY. 57 mould by heating it in boiling water and pressing it with the fingers into the section containing the teeth. The flask is then closed and placed in water so as to saturate the plaster. The case is ready for moulding, using the hot, moist-air machine. The flask is placed in the clamp and the top screwed down until it presses the flask, after which it is put in the tank and the heat applied. When the temperature raises to 225 degrees F., slight pressure should be applied, and as the heat increases and the celluloid becomes more plastic the pressure is increased. This is continued until the flask is completely closed. The heat is then turned off and the piece allowed to cool gradually. When perfectly cold, the sections of the flask are separated and the plaster and tin-foil removed from the case, which is now trimmed and polished, employing the same instruments as used in rubber work. Give the composition of Celluloid. Pyroxylin, camphor, oxid of zinc and vermilion. Describe the method of constructing a lower artificial denture made by the cheoplastic process. From a plaster impression a cast of equal parts plaster and marble dust is secured. The steps concerned in this method are the same as for rubber work up to the flashing. In a flask designed for this work the case is invested, using equal parts of plaster and marble dust as investment mate- rial. After the investment is hard, the sections of the flask are separated and grooves cut from the posterior margin of the mould to the openings of the flask. All traces of wax are removed by boiling water. The mould is then thoroughly dried by placing the two halves of the flask over a low heat for an hour or more, after which the parts of the flask are placed together and clamped tight. The fusible alloy is then melted and poured into the mould through one of the open- ings of the flask. When cold, the case is removed, smoothed with files and sandpaper, and polished with pumice-stone. \S 58 PROSTHETIC DENTISTRY. Give the essential properties of metals used for dies. Hardness, low fusibility, a minimum of contractility, and ability to withstand the force used in swaging. Define die, counter=die. Mention the best metals for each. A die is a metal duplicate of a model. A counter-die is a cast, the counterpart of a die. Zinc and Babitt metal are used for dies; lead for coun- ter-dies. Of what is Babitt metal composed? Of copper one part, antimony two parts, tin eight parts. Give the fusing=points of tin, zinc, and lead. Tin about 460° F., lead about 617° P., zinc about 773° P. Describe a Hawes rnolding=fiask and state why it is used. It is composed of two sections or rings. The lower con- sists of three movable pieces with extensions projecting to- wards the centre, and which are held together when in use by means of pins passing through openings in the joints. The upper section is a plain ring which fits on the lower. It is used for securing moulds or casts with deep undercuts. Describe the method for making and using cores to ob= tain accurate moulds from models with deep undercuts. The surface of the undercut on the cast is oiled. A mix- ture of marble dust and plaster is run into the undercut and the wall of the model is extended so as to slant to the base of the cast, When this is hard it is detached from the model and thoroughly dried over a stove, after which it is placed in position on the model and the mould made, the outlines of the core being plainly marked. The core is then removed from the model and placed in its position in the mould and the metal poured. Describe a method of obtaining a correct die from a lower mode! thit has several anterior teeth standing, the PROSTHETIC DENTISTRY. 59 jaw very much undercut lingually below the neck of the teeth. The undercut on the model is overcome by means of two cores joining at the median line. A mould is then made, the cores are removed from the model and placed in position in the mould, which should be thoroughly dried and the metal poured. State the uses of aluminum in dentistry. Describe the method of annealing. Aluminum is used as a base for artificial dentures and for shell crowns. It is annealed by coating the metal with oil and holding it over a Bunsen burner until the oil is burned off, leaving a white surface. State two methods of using aluminum in the construc= tion of artificial dentures. The method of swaging and of casting. Describe the method of making an upper denture on swaged aluminum, the teeth to be attached with rubber. The die and counter-die secured, aluminum plate of twenty guage is annealed and swaged the same as gold. The sur- face to which the rubber is to be attached is roughened and perforated. The bite and articulation secured, the teeth are arranged in the usual manner. The case is invested in the lower section of the flask, the plaster extending to the wax rim and imbedding the exposed metal surface (the palatal portion of the plate) . When the upper section of the flask is run and the plaster is hard, the flask is placed in warm water to soften the wax. It is opened, the wax removed, and boiling water poured over the teeth and over the plate. The roughened surface of the plate should be washed with absolute alcohol to remove all traces of the wax. The case is packed and vulcanized in the usual way. The rubber attachment is finished as usual: the metal is polished with fine pumice and rouge. 60 PROSTHETIC DENTISTRY. What is the fusing=point of aluminum? 1160° F. Give a formula of aluminum solder suitable for dental purposes. Tin 55 parts. Zinc 23 " Silver 5 " Aluminum 2 " Give two methods of swaging a metal plate. A plate cut to the proper size is annealed and placed on the die; with a horn mallet the posterior part of the plate is driven into position; by this means the central part of the plate is brought in contact with the die at its deepest portion. The plate is cleansed, re-annealed and placed on the die; with a partial counter-die the palatal portion of the plate is now swaged, using a heavy swaging-hammer. The plate is again annealed, placed on the die and swaged with a counter-die extending over the alveolar ridge. The third swaging is done with a counter-die that extends beyond the plate line. Any wrinkles which have formed are removed by means of the horn mallet. The Parker 's swaging device : The plate is first roughly swaged by means of a die and counter-die and adjusted to the plaster model. In this position it is placed in a cast- iron cylinder and covered with fine bird-shot; this should nearly fill the cylinder. Over this is placed the plunger, and with a few blows from a heavy hammer the plate is brought into accurate apposition with the plaster model. What gauge of gold plate is used for an upper denture? what for a lower? State carat. 26 gauge for an upper denture and two thicknesses of 30 gauge each for a lower. 18 or 20-carat. What is the result of over=annealing of gold or silver plate? The surface of the metal fuses, thus destroying its texture and rendering it more or less brittle. PROSTHETIC DENTISTRY. 61 What causes gold and silver plates to warp while sold- ering? How can it be prevented? The warping is due to the contraction of the solder and the want of support when heated, or from excess of invest- ing material. It can be prevented by having the plate well imbedded in the investment, avoiding the use of more mate- rial than is needed to make a wall a half-inch thick around the teeth. What method should be used to correct a slightly warped plate with teeth in order to fit a plaster model? The plaster model should be dried so as to make it per- fectly hard. The plate is placed upon the model and the defective portion carefully noted. With a few carefully- directed blows from the bench-hammer the plate can be brought in contact with the cast. Describe the method of forming a rim of a full upper gold plate. A plaster impression of the gum surfaces of the teeth and the exposed border of the plate is taken in two sections, each extending from the median line to the heel. From this are secured models. Dies and counter-dies are obtained, and strips of plate of sufficient width are swaged, fitted to the plate and trimmed, after which the rims are held together with small clamps and soldered. State the precaution that should be taken to prevent gold plate from cracking during swaging. Frequent annealing. Describe the method of constructing an artificial den- ture on a gold base using single gum teeth. The plaster cast is scraped along the posterior margin of the plate line so as to increase the bearing of the plate at this point. The die and counter-dies are secured, the plate is well annealed and swaged. The vacuum-chamber is cut out and one, swaged up separately, is soldered in. The bite and articulation are secured and the models adjusted in the 62 PROSTHETIC DENTISTRY. articulator. The teeth are ground to fit the plate accurately, allowing a minute space between the blocks for expansion. The plate with the teeth waxed in place is invested in an investment of* plaster and sand, equal parts. When the plaster is hard, the wax is removed and the backings are adjusted to the teeth, eare being taken to have them in direct contact with the plate. The platinum pins are split and spread apart to hold the backings securely in place. The case is then boraxed and heated preparatory to solder- ing. W Tien it is heated to redness, it is removed, placed on a soldering-block and soldered. When eool. the plaster is removed and the plate placed in a bath of sulphuric acid, after which it is smoothed and polished. How is gold solder confined to the desired surface? The parts to be kept free from solder are coated with a paste of whiting. Why is flux used? To free the surface of oxides. What is the proper method of directing the flow of the solder? The application of borax and the management of the blow- pipe. Describe the construction of a gold plate with rubber attachment. The plate is made and the teeth arranged precisely as they would be for a denture where the teeth are backed and soldered, except that teeth suitable for vulcanite work are selected. Either before the teeth are arranged, or after they have been waxed to the plate and adjusted in the mouth, a triangular gold wire about Xo. 18 gauge is soldered around the alveolar border of the plate to a little beyond the last molar of each side, where it should cross the ridge and be extended along the inner or lingual line or border of the rubber attachment. The object of this wire is to strengthen the plate, and also to hold secure the edges of the attachment PROSTHETIC DENTISTRY. 63 and prevent them curling up, as otherwise they are apt to do after the denture has been worn for some time. To secure the rubber attachment to the plate, gold or platinum pins or wire loops are soldered on the ridge, inside the line of triangular wire; they should be so arranged as not to in- terfere with the teeth nor to show through the rubber after the denture is finished. If this is done after the teeth have been arranged, plaster guides should be made before the position of the teeth has been disturbed, so that they can be accurately returned to place after these additions to the plate have been made. The plate is now smoothed, the teeth arranged, and wax built out and contoured precisely as the rubber attachment is desired to be. The case is flasked so that the gold plate will be in the bottom portion of the flask and the teeth in the upper. It is now packed, vul- canized, and finished as would be a vulcanite denture. Is a gold lining in a vulcanite plate beneficial? Explain. It is, in so far as the gold prevents any irritation of the tissues from the rubber. How may an old plate be lined with gold? The surface of the plate to be covered with the gold is thoroughly cleansed with soap and water, after which the entire surface is roughened with a sharp-pointed instrument. A solution of rubber and naphtha is painted over the rough- ened surface and allowed to dry to the point of stickiness. Strips of No. 60 gold foil, one side of which have been roughened by the electro-deposition of gold, are cut of suffi- cient size to form the rim. Where there are depression*, the lining should be pressed with a suitably-shaped piece of rubber eraser to the lowest point in the plate. Each strip should slightly overlap the other, care being taken to avoid wrinkling. The plate is then flasked in the usual way and vulcanized for twenty-five minutes at from 320° to 330° P. It will require no finishing except where the edges of the lining overlap. 64 PROSTHETIC DENTISTRY. What are English tube teeth? Describe a method of attaching them to a gold plate. They are a class of plain teeth made with a platinum tube baked in the porcelain, extending through the centre of the tooth and corresponding to its long axis. The English tube teeth are attached to a gold plate by first grinding them to fit the position they are desired to occupy. They are held in place by means of hard wax. A marking-wire, tipped with vermilion paint, is passed down each tooth till it touches the plate. This marks the place at which the holes are to be drilled to receive the pins. The teeth are removed and the holes drilled. Gold pin-wire of the desired length is cut and the end to be inserted into the drilled hole is tapered so as to fit tight and project through on the palatal surface. The tapered end of the pin and the pin-hole are then boraxed and the pin soldered to the plate. The teeth are then placed on their respective pins and the final adjustment made. Previous to attaching the teeth to the pins, shallow grooves are made in the latter with a fine file. The teeth are thoroughly cleansed, dried and re- placed on the pins. In a small porcelain receptacle sulphur is melted, and with a wire spatula the sulphur is conveyed to the plate, which is kept heated by holding it with the pliers over a burner. The sulphur runs under the teeth and along the pins. When cool, it sets hard and the teeth are immovable. (American Textbook of Prosthetic Dentistry.) Describe a method of constructing a partial lower den= ture of gold, the teeth of which are soldered to the plate, the six anterior natural teeth being in the mouth. The die and counter-die are made, and a pattern of the desired plate is obtained in tin-foil. From this is cut two plates of gold, 18-carat fine and 30 gauge in thickness. The plates are annealed and swaged separately, the under plate being a little larger than the upper and both extending one- half on the lingual surface of the anterior teeth. The plates are trimmed, re-annealed and swaged together. After boil- PROSTHETIC DENTISTRY. 65 ing in the acid solution, the surfaces to be soldered are pol- ished and boraxed. They are then placed in apposition, heated to redness, after which they are placed between the die and counter-die and with a few blows from the swaging- mallet are brought in absolute contact. The plates are then soldered with 18-carat solder. The plate is now polished, placed in the mouth, the bite taken, and with the antagon- izing model mounted in the articulator. The teeth are ground to fit the plate accurately and the backings adjusted to each. With hard wax the teeth are now attached to the plate and the case invested in a mixture of plaster and asbestos fiber. When thoroughly dried, it is heated to redness and soldered. The case is allowed to cool gradually until perfectly cold, when it is removed from the investment, boiled in the acid solution and finished with files and fine stones, using pumice and rouge for polishing. Give method of strengthening an upper or lower gold plate behind the anterior teeth. A duplicate plate, extending from the position of the bicuspid of one side to the bicuspid of the other is swaged and soldered to the plate proper. The re-inforcement for the lower plate should be the same width as the plate ; for an upper plate it should extend an eighth of an inch from the festooned margins to a point within the same distance of the edge of the vacuum-chamber. What is the method of repairing a cracked plate of gold? The parts to be soldered are cleansed. The crack in the palatal surface of the plate is covered with a layer of gold- foil and the case invested. A piece of plate is then placed over the crack and made to conform to the shape of the portion of the plate to be repaired. The investment is then dried and the case heated and boraxed, after which solder is flowed between the two plates. 5 66 PROSTHETIC DENTISTRY. Can you solder i8=carat plate with i8=carat solder? Explain. Yes. The alloy of the solder being a low-fusing metal, the solder fuses at a lower temperature, although the plate and solder are of the same fineness. Describe the process of sweating together two pieces of gold plate of the same degree of fineness. The pieces are placed in apposition and, by careful manip- ulation of a broad, full flame of the blowpipe, the plates are united by partial fusing of the surfaces in contact. Give the fusing=point of gold, silver, copper. Gold, 2016° F.; silver, 1873° F. ; copper, 2000° F. Give the formula for 20=carat gold plate. Pure gold, 20 dwts. ; copper, 2 dwts. ; silver, 2 dwts. Which is finer, 20=carat plate or 20=carat solder? Which fuses at the lower degree of heat? Why? They are of the same fineness. The solder being alloyed with a low-fusing metal, fuses at a lower temperature than the plate, although they are of the same fineness. (Dr. ¥m. H. Trueman.) Give a formula for a 22=carat solder. Gold ■ 22 parts. Copper 1 part. Silver f of 1 part. Zinc I of 1 part. What is the difference between platinous gold and platinized gold? Platinous gold is the alloy of gold and platinum. Platin- ized gold is gold covered with platinum. What would be the effect of placing a piece of lead on a gold plate during the process of annealing? It would impair the ductility of the gold or destroy the plate at the spot where the lead fuses on the gold. PROSTHETIC DENTISTRY. G7 What effect has zinc on gold solder? It makes it flow easy. Impure, or commercial zinc also makes solder brittle. If the zinc is chemically pure it does not have this effect. Express in carats the fineness of American gold coin. 21.6 carat. Give formula for clasp gold. Pure gold 20 dwts. Fine copper 2 " Fine silver 1 dvvt. Platinum 1 " Give a method of making a gold clasp. State thickness of the metal used. From an accurate model of the tooth a pattern is made of heavy pattern-tin. This is reproduced in clasp-metal, 24 gauge. The edges are filed to conform with those of the pattern, and the metal, well annealed, is shaped with round- nose pliers. Give method of attaching a clasp to a gold plate. The clasp is adjusted to the tooth in the mouth. The plate is placed in its position, and with a plaster impression the plate and clasp are removed. The model is obtained and the clasp attached to the plate with hard wax. They are then removed from the model and embedded in a mixture of plaster and sand. The case is then dried and soldered. Should a gold clasp be used about a tooth containing a large amalgam filling? There are objections. In some mouths the contact of the two metals may cause more or less galvanic action; this is. however, usually but temporary. What kind of a denture should be constructed in the case of a patient whose superior canines and second molars are in position? A horse-shoe plate of gold or vulcanite ret ai nod in posi- tion by clasping the second molars. 68 PBOSTHETIC DENTISTRY. How are porcelain teeth attached to a metallic base? By means of vulcanite or by backing the teeth and solder- ing them to the metallic base. Why is platinum used for pins in teeth? Because it expands less under heat than any other metal and possesses the property of fusing at a high temperature. What is the fusing=point of platinum? 3500 - F. How would you solder platinum? By means of pure gold or an alloy of gold and platinum. What are the advantages of continuous gum? Cleanliness, natural appearance, durability. It is non- irritating and easy of repair. Describe the method of constructing a continuous gum denture. A platinum plate, 29 gauge for the upper or 26 for the lower denture, is swaged the same as in gold work. The outer edge is re-inforced with No. 19 gauge, half-round plat- inum wire, bent to fit the plate along the alveolar edge to about an eighth of an inch from the posterior edge of the plate ; this is soldered with pure gold. To the posterior edge of the plate a strip of platinum one-eighth of an inch wide is swaged and soldered, turning up the inner edge before soldering. The bite is taken in the usual way. The teeth (continuous gum teeth) are arranged and secured with hard wax. The}^ are then coated with an alcoholic solution of shellac and the case is embedded in an investment of plaster and asbestos. When the investment is sufficiently hard, the wax is removed and the plate and the pins are thoroughly cleansed for soldering. Strips of plat- inum of the same gauge as the plate are then fitted to the palatal surface of the teeth, extending from the pins to the plate. The pins are then bent down over the strip, holding it firmly in place. PROSTHETIC DENTISTRY. 69 The case is now boraxed, slowly heated, and when brought to a red heat it is removed and soldered with pure gold. When cool, the plate is taken out of the investment, cleansed and adjusted to the mouth. If satisfactory, the body is then applied. The body is mixed with a solution of gum-arabic and water, and with a small spatula it is packed around the necks of the teeth and spread over the surface of the plate. The gum is stippled to give a natural appearance. The moisture is absorbed with a linen cloth, and with a fine blade clean cuts are made between the teeth extending through the body and over the surface of the plate, in order to prevent distortion of the plate by the shrinkage of the body. The plate is now placed upon the investment material and thoroughly dried, after which it is conveyed to the mouth of the heated muffle, into which it is gradually introduced. The muffle is brought up to a white heat, and when the body preserts shiny crystals the heat is turned off and the case allowed to cool gradually. When thoroughly cold, it is placed on the die and the incisions and cracks in the body packed solid with new body. The gum enamel is then ap- plied. Tapping the plate gently will bring the moisture to the surface, which can be absorbed with a napkin. The case is dried and baked, using a higher temperature than for the first baking. The case is cooled as before and the metallic surface polished. What is meant by " stippling?" Dotting the tin-foil which is burnished over the wax gum with a dull-pointed instrument. By this means a more nat- ural appearance is produced on the gums of the finished denture. State the method of replacing a tooth broken from a denture of continuous gum. The remains of the broken tooth and the contiguous por- celain are ground away and a new tooth fitted in place. New body is then packed around the tooth, the case dried and 70 PROSTHETIC DENTISTRY. biscuited. When sufficiently cool, the gum enamel is applied and the case baked until it becomes smooth and glossy. About what degree of heat is required to fuse porce= lain in continuous gum work? About 2200° F. In continuous gum or other work in which porcelain is used what is the cause of the porosity sometimes found on breaking the piece? Insufficient baking, or over-heating. Describe the construction of an upper denture of porce= lain. Two casts are taken from a plaster impression of the mouth and a thin lead plate is burnished to one of the casts. Soft- ened beeswax is then placed on the ridge and the articula- tion obtained in the usual way. The cast and the articu- lating model must then be enlarged to allow for the con- traction of the porcelain in burning. To accomplish this, the cast and articulation are divided into four sections with a thin saw. The first division is made at the centre, along the mesial line, to the back of the cast; the second division back of where the cuspid teeth are located. Before cutting the cast, the bottom should be made smooth and level. After the case has been divided, the sections are placed together, leaving a space of a quarter of an inch between each. This is filled with freshly-mixed plaster, the sections being held in position by wax. When the plaster is hard, a new lead plate is cut and burnished to the cast. The sections of the wax articulating model are placed on the enlarged cast and the interspaces filled with melted wax; thus the model con- forms to the size of the enlarged cast. An outside wall is now made for moulding the body. This is done by bending a piece of tin around the front and sides of the cast (with the wax articulating model on it) to get the correct, curve. The tin is then removed one-fourth of an inch from the cast in front and at the sides, and is sus- PROSTHETIC DENTISTRY. 71 tained in this position until freshly-mixed plaster is poured into the space between the cast and tin. This wall is then trimmed; after the removal of the wax the wall should be lined with tin-foil. The parts are then thoroughly cleansed for moulding. The lead plate and inside of the wall should be oiled and a piece of body laid on the lead plate before the wall is put in place. This is worked over the edge of the gum to the limit of the plate line. The wall is then put in place and the body packed up against it. The rest of the body is pressed down against the surface of the lead plate, extending back as far as the plate is to be carried. The body is then dried sufficiently to be carved into shape. This is clone roughly on the cast, and when reduced to the proper thickness it is dried and biscuit-baked When the case is cool, the enamel is applied and the final carving and gumming completed. It is then dried, placed in the muffle and burned until fully glazed. When cool, it is ground to fit the original cast, which was left unenlarged. ("American System of Den- tistry.") What combination of metals makes a good clasp for a continuous gum partial case? Platinum and iridium. Give the formula of platinum solder. Gold 95 parts. Platinum , 5 " Mention the carat and gauge of plate most desirable for crowns. 22-carat and 30-gauge. What effect on the shade of teeth has (a) platinum, (b) gold backing? (a) Platinum gives a bluish, (b) gold a yellowish tint. State the precautions that should be taken in backing a porcelain facing to prevent checking during soldering. The pins should not bo bent close to the tooth. 72 PROSTHETIC DENTISTRY. The pin-holes in the backing should be so placed that the metal can be adjusted without using force. The backing should be in perfect contact with the por- celain so as to protect it from borax. Upon what conditions does successful soldering depend? Upon the cleanliness and the contact of the two surfaces to be united; upon a good solder, and sufficient and proper distribution of heat. What causes porcelain facings to check and crack in soldering? Borax on the porcelain and the too suddeu heating and cooling of the case. State the cause of pits in soldering. The use of too little borax or borax contaminated with sand or grit, or keeping the solder too long under insufficient heat, causing it to oxidize. (Dr. Win. H. Trueman.) In soldering a small piece of gold to a larger piece, on which should the solder be placed? Why? The solder should be placed on the larger piece, the larger being harder to heat, the flow of the solder is easier directed towards the smaller piece. State which, in your opinion, is the best artificial crown for any of the six upper anterior teeth. Give reasons. Where the bite is close, a banded or partially banded crown, such as the Richmond, Litch or banded Logan crown, is most serviceable. Crowns of this style are best adapted to the root, possess greater strength and protect the root from fracture. Describe the method of constructing a banded Logan cuspid crown. A cap is made and adjusted to the root; it is then per- forated to permit the dowel of the crown to pass into the root. The crown is ground to fit the labial portion of the cap, while the lingual portion may extend one-sixteenth of PROSTHETIC DENTISTRY. 73 an inch from the cap to permit of the solder. The crown is then removed and a piece of pure gold or platinum, 33 gauge, burnished to the base of the crown. It is then placed in position on the root and the tooth and cap united with hard wax, after which it is removed, invested and soldered. Give method of preparing a root for a Richmond crown. The root is trimmed to within a sixteenth of an inch of the gum line, except the labial portion which is cut slightly below the gum margin. The ridge of enamel remaining upon the root is thoroughly removed by means of cleavers, and with a fine disk the sides of the root are made smooth and parallel. [With a root reamer or fissure drill the canal is enlarged for the reception of the dowel. Describe a Richmond crown. The Richmond crown consists of a gold ferrule with a soldered base, through the center of which a pin is attached by means of solder. To the cap thus made, a facing backed with gold or platinum is soldered. The palatal surface of the crown corresponds in shape to that of the natural crown. In soldering a Richmond crown, how may the solder be drawn to the front so that a perfect joint between the porcelain and the gold may be obtained? Liqiid borax is run over the labial joint and covered with a layer of melted wax. After the case is invested and the wax removed, the joint from the inside is boraxed. In soldering, the heat should be applied from the undersurface of the in- vestment and when sufficiently hot, the solder is applied and made to flow through to the labial edge. Give a method of removing a Richmond crown in order to repair tl\e broken porcelain. If the crown is set with gutta-percha, it can be removed by applying heat to the palatal surface. If set with cement, the band on the posterior surface is cut and forced away from the root. AVith a rose head bur the cement between the cap and the root is remWed. A strong instrument with the point 74 PROSTHETIC DENTISTRY. bent at right angles is inserted and the crown forced ont. It is sometimes necessary to cut the pin. How would you repair a Richmond crown with a broken facing? The remains of the porcelain are removed, also the backing. A facing is prepared, backed and adjusted with hard wax, after which it is invested and soldered. Describe the BonwiJl crown and the method of its attachment to the root. It is an all-porcelain crown with an opening through the center for the passage of the supporting post. The base is concave and the upper portion of the opening is shaped to form a dovetail, which, when the crown is fixed upon its post, prevents its displacement. The edges of the porcelain are designed to rest uniformly upon the outer edge of the pre- pared root-surface. The method of its attachment consists in trimming the ioot face as for the reception of any post crown. By means of a corundum stone the crown is accurately adapted to the edges of the root and made to occlude properly Avith the antagon- izing teeth. The root canal is reamed so as to receive a large- sized pin and with a small wheel bur it is grooved similar to a screw thread. With a corundum wheel the porcelain on the base of the crown, except the edges that have been adapted to the root, is removed sufficient to admit of a thicker layer of amalgam than when the crown is in close contact with the root. Zinc phosphate is then mixed and carried to the md of the root-canal and the post pressed into it. The crown is now placed over the pin and into its proper position ; ic is allowed to remain until the cement is hard, when it is removed and amalgam packed into the canal and about the pin. The con- cavity in the base of the crown is also packed with amalgam and the crown firmly pressed into position \j means of a crown-driver, devised for that purpose. A fresh mix of amalgam is packed about the pin in the cavity on the occlusal surface, which when hard, is dressed and polished. PROSTHETIC DENTISTRY. 75 Describe the method of constructing a porcelain=faced bicuspid crown. A shell crown is made and fitted to the root. The buccal portion is cut out, leaving the band intact at the gum margin to the depth of a sixteenth of an inch. A cross-pin facing is ground to fit the opening, backed with 33-gauge pure gold, and readjusted to the crown. The crown and facing are held together with binding wire wrapped directly over the facing, which should be protected from discoloration with asbestos fibre. Flux is added and the crown soldered by holding it over the flame of a Bunsen burner. Describe a method of constructing a bicuspid jacket crown with a porcelain facing fused to it. A ferrule is made of platinum plate of 30 gauge. This is fitted to the tooth. It is then trimmed to be even with the tooth crown. A piece of iridio-platinum plate is soldered to the band, allowing the buccal half to be free. Pure gold should be used for solder. The face of the cap is then cut out; the portion of the top plate which is free, is shaped to form a cusp. A facing of the proper shade and size is ground to fit the opening. The porcelain is now mixed and packed into the spaces and against the metal to which the facing is to be fused. The facing is then pressed into place, the case care- fully dried and the porcelain fused. If more body is re- quired, it can be added and the case re-fused. State the method of adding a low=fusing porcelain face to a gold shell crown. A seamless crown is made and fitted to the root. The por- tion of the surface of the crown to which the porcelain is to b* added, is crushed in with a few taps from the bench ham- mer; it should be sufficient to admit of a thick body of porce- lain. The surface is then roughened or perforated. The oody is mixed, packed on to the gold, dried and baked. This is repeated until the desired shape and size is obtained, when the crown may be polished. 76 PROSTHETIC DENTISTRY. Describe a Mason detachable porcelain=faced crown. State the advantage of its use and where applicable. It consists of a drop-forged backing of heavy gold plate which has a triangular slot throughout its length, and a porce- lain facing with a triangular bar baked in the longitudinal axis of its lingual surface ; this is constructed so as to slip into the slot of the backing. The advantage of this crown is, that in case of fracture a new facing can be adjusted without necessitating the removal of the collar and post. It is applicable on all post and collar crowns or as dummies in anterior bridges. What advantage, if any, have Richmond crowns over others? They protect the root from fracture and decay and are stronger where an unusual stress has to be borne by the root. Describe fully the method of preparing a molar tooth for a gold crown. With carborundum stones and disks, the sides of the na- tural crown and neck of the tooth are made parallel, or the circumference of the crown less than that of the root. Describe fully a method of constructing a gold cap or shell crown for a molar tooth, the cusps of which occlude accurately with the antagonizing teeth. The tooth properly prepared, a measurement is taken at the neck of the tooth by means of the dentimeter and annealed brass wire No. 33 gauge. The wire is cut, straightened, laid on the gold and a band cut of corresponding length and wide enough to extend from below the gum margin to within a sixteenth of an inch of the opposing tooth. The band is now annealed, the ends are beveled and united with 20-carat solder. The cylinder is trimmed and fitted to the tooth, the joint placed so as to come on the palatal aspect. It is re- moved, contoured and re-adjusted; a small roll of softened beeswax is placed in the mouth and the bite taken including two or three of the adjoining teeth. This is removed and a PROSTHETIC DENTISTRY. 11 plaster impression taken, in which the barrel is embedded. A model and an articulating model are made and mounted upon a crown articulator. The occluding teeth are then varnished, the barrel filled with soft plaster and the occlusion made. AVhen the plaster is set, it is trimmed sufficient to expose the gold rim. Cusps and sulci are then carved in such a manner as to occlude properly with the antagonizing teeth. The collar and the plaster cusps are then pressed into moldine, re- moved, and Mellotte 's metal poured into the mold. Annealed 22-carat plate 30 gauge is placed on a pine block and with the die the cusps are swaged. It is now trimmed, and ad- justed to the cylinder. Both sections are pickled, the parts brought together and held in apposition with binding wire; flux is added and the parts united with 20-carat solder by holding them over the Bunsen flame. The crown is then trimmed and polished. How would you repair a gold cap with a hole in it? The crown is boiled in acid, after which the hole is filled with a large pellet of soft gold and solder flowed over. How would you remove a gold crown from a diseased molar tooth? The palatal surface of the crown is slit with either a chisel or cutter devised for that purpose, and the laps of gold pulled away from the tooth. A sharp-pointed instrument is then worked between it and the crown surface of the tooth, and with slight pressure the crown can be forced away from the tooth. Give details of constructing a gold cap for a cuspid. The measurement of the root to be crowned is taken with an annealed copper strip which is placed around the root and grasped firmly with pliers. The strip is removed, the surplus ends trimmed and the band cut through the center. The re- spective halves are bent over the lingual and labial forms of a Holingsworth mould-plate. When the proper form is selected, it is placed on the moulding plate with a rubber ring 78 PROSTHETIC DENTISTRY. around it; into this is poured Mellotte's metal and a die of the two surfaces secured. Annealed 22-carat, 30-gauge gold is }> laced over the die and the sections swaged separately. They are now boiled in acid, the edge smoothed and trimmed, the parts brought together and held with binding wire. Flux is applied and the halves united with 20-carat solder. Describe the method of constructing a bicuspid crown with a porcelain front for a tooth having a vital pulp. The tooth is trimmed for the reception of the collar. Suffi- cient of the buccal surface of the tooth is removed to accommo- date the porcelain, care being taken not to injure the pulp. A seamless gold crown is then made and fitted on the tooth; the buccal surface is cut out, leaving intact a sixteenth of an inch, the portion extending above the gum line. No. 60 gold foil is burnished on the tooth and, while in place, the crown is adjusted; through the opening cut for the facing a small nodule of soft beeswax is forced. The crown with the wax and gold foil is removed and invested in a mixture of silex and plaster. The case is then dried, the wax thoroughly re- moved and low-fusing body packed into the space occupied by the wax and over the face of the crown. This is baked, after which sufficient porcelain is added to give the desired shape and size. It is again baked and the crown polished. What style of a crown would you use to restore abraded front teeth? A barrel crown of either gold or platinum with a veneer soldered or fused to it. Describe the Davis crown, State how you would adjust it to the root. The Davis crown consists of two parts : The pin, which is separate from the crown, and the crown itself. The crown is all-porcelain with an opening extending well into the body for the reception of the pin. In adjusting it, the edges of the crown are ground to fit the face of the root accurately. The root canal is reamed to receive the pin, which is cemented into PROSTHETIC DENTISTRY. 79 the canal. The cavity in the crown is then filled with ce- ment and the crown placed over the pin, is forced into position. What is the advantage of the Davis crown? In case of fracture a new crown can be adjusted without removing the dowel. Describe the process of making a molar crown with a gold band and a saddle=back or plain rubber tooth. A ferrule is made as for an all-gold crown. A bite and im- pression are taken and the models mounted upon a crown arti- culator. A wire measurement is then taken of the circum- ference of the upper portion of the ferrule. A tooth is selected, the circumference of which is the same as that of the ferrule. The buccal face of the ferrule is cut out, except the slight rim of gold extending beneath the gum. By means of corundum wheels the edges of the porcelain are made to fit the edges of the gold at the cervical and approximal borders, care being taken to have the articulation perfect. Pure gold No. 35 gauge is burnished to the under-surface of the porce- lain ; it is now adjusted to the barrel, invested and soldered. Describe a method of making and attaching a swaged shell corner for a central incisor, the cavity of which in= volves both labial and lingual wall and the masticating surface. The tooth is thoroughly excavated; the enamel edges beveled and smoothed. A small piece of softened modeling compound is pressed into the cavity and allowed to harden, when it is removed and with a sharp-bladed instrument trimmed and carved to correspond to the desired shape of the corner. It is then pressed into " moldine " and a die of Mellotte's metal made. Annealed 24-carat gold 30 gauge is swaged; the edges are trimmed and made to slightly overlap the cavity margins. The shell is re-inforced with 20-carat solder, to which two pins, made to extend well into the cavity, are soldered. The corner is now polished and adjusted by first filling the cavity, then the shell with cement; it is now 80 PROSTHETIC DENTISTRY. placed in position and held until the cement is hard. That which oozes out is removed and the margins coated with varnish. Describe the method of preparing a root for the recep= tion of a Buttner crown. A special set of instruments is required for this process : drill, root-facer and trephine. The root-facer, guided by a central pin, cuts the face of the root level. The drill is used to open and enlarge the canal, and by means of the trephine the neck of the root is made cylindrical. Describe the method of preparing and attaching a por= celain tip (lower third) to a central incisor with a vital pulp. The surface of the tooth is made smooth and square. To this is burnished a piece of platinum plate No. 35. With, the plate in position on the tooth, three holes are drilled as deep as may be done without injuring the pulp ; in each of the openings a post is placed and adhesive wax flowed over the projecting ends, attaching them to the plate. The plate is then carefully removed, invested, and the pins united to the plate with pure gold. The piece is placed on the root, the pins trimmed to within a thirty-second of an inch of the plate, care being taken to have the plate well burnished. A plaster impression is taken and removed with the small plate embedded in it, A model is made with sand and plaster, which when hard, is carefully removed from the impression. A cross pin tooth of the desired shape and size and with the pins close to the cutting edge is selected. The facing is then cut down to about the desired length and the final fitting to the tooth made with a fine grit stone. It is then backed with platinum No. 28, attached to the plate with sticky wax and invested in sand and plaster. When dried, the case is soldered with 22-carat solder. In setting it, the rubber dam is adjusted to the tooth, the holes in the tooth are filled Avith soft cement and the tip is placed in position; it should be held firm until the cement is hard. IkOSTHETIC DENTISTRY. 81 What are the requisites of a crown? It must protect the root from decay and should restore the appearance and the function of the natural tooth. In bridge=work should the teeth fit the gum perfectly or should a space be left between the gum and the bridge? Explain. A space should be left between the gum and the teeth in order to facilitate cleansing. Describe the construction of a bridge to replace the inferior central incisors, the remaining teeth being sound and in place. With disks and corundum wheels the lateral incisors are prepared for the reception of open-face crowns which are made of 22-carat gold, 29 guage. The crowns are adjusted to the teeth, and a wax bite and a plaster impression are taken with the crowns in place ; when the impression is removed, the crowns, if not imbedded in the plaster, should be placed in their respective position in the impression. The model is run with plaster and marble dust and with the articulating model it is mounted on the crown articulator. Facings of the de- sired shape and size are selected, backed and adjusted to the cast with hard wax. The case is now invested, dried and heated, the borax applied and the case soldered. Describe a method of constructing a gold bridge to re- place lost teeth between the cuspid and second molar, both named teeth being in place and sound. The cuspid tooth is devitalized, the pulp extirpated and the natural crown cut off. The root is then prepared for the re- ception of a collar crown which is made and adjusted. The molar tooth is prepared and a shell crown made of 22-carat gold, 29 gauge. This is placed in position and a wax bite taken of the entire side. An impression of the antagonizing teeth is taken in wax and the model poured. A plaster im- pression is now taken with the crowns in position which should be imbedded in the plaster when the impression is re- 6 l^ 82 PROSTHETIC DENTISTRY. moved. A model is then run and with the articulating model it is mounted on the articulator. The bicuspids and the molar facings are selected and ground to fit the model, the upper edge extending to within a few lines of the gum. The occluding edge of the facing — ground to within a six- teenth of an inch of contact with the opposing teeth — is be- veled toward the outer edge. Backings are fitted to the facings, extending from the cutting edge to near the gum line. Cusps for the respective teeth are then swaged on a die plate and fitted to the facings. They are united with hard wax, invested and soldered separ- ately with 20-carat solder, using sufficient to give the proper shape. When cool, they are boiled in acid and mounted on the cast, to which they are attached with hard wax. The bridge is now carefully removed from the articulator and em- bedded in an investment of plaster and asbestos fibre; it is dried, heated in the furnace, boraxed and soldered. When cold, it is removed from the investment, boiled in the acid, trimmed and polished. State the method of making the grinding surface of a bridge with one continuous piece of gold. The abutment crowns in place, a bite and plaster impression are taken and the models mounted on the articulator. Suit- able facings are selected, and fitted to the cast. The cutting edges are shortened sufficient to permit of a protecting cover- ing of gold. The backings are adapted, the facings invested and solder flowed over the backings, having the pins well covered with the solder. They are now trimmed, adjusted to the cast and a roll of softened bees-wax is placed be- tween the abutments and extended over the cutting edge of the facings. The cusps of the antagonizing teeth are oiled as is also the surface of the wax which is again warmed and the jaws of the articulator brought together. When separ- ated, the cusps and sulci are carved to occlude accurately with the antagonizing teeth. The wax cusps are then removed from the model and embedded in a mixture of plaster. A rim PROSTHETIC DENTISTRY. 83 of thin copper about an inch in width is placed around the wax and in the soft plaster. When the plaster is hard, it is placed over a burner and gradually heated until the wax is soft enough to be removed. When the mould is thoroughly dried, it is run with Mellotte's metal. On the die thus se- cured a strip of annealed gold 22-carat 30 gauge is swaged. This is boiled in acid, the edges trimmed and the cusps re- inforced with 20-carat solder. It is then placed on the model and the facings adjusted to their proper position. The case is now invested and soldered in the usual way. Give a method of making and attaching a removable bridge. The abutments are properly prepared and collars with flat tops are made and cemented in place. Telescoping caps are then constructed and fitted over the barrel-covered abutments. A bit and an impression are taken, the caps being embedded in the impression. Models are made and mounted on the arti- culator. The dummies are made and soldered to the caps. The bridge is then trimmed and polished. The caps are warmed, lined with a film of gutta-percha, placed in posi- tion over the barrel-covered abutments and the bridge forced into place. If a bridge, extending from the canine to the third molar, breaks in the middle, what is the method of repairing it? The bridge is removed, boiled in acid and re-adjusted in the mouth. By means of a plaster matrix it is removed, in- vested and soldered. How should the loss of a superior lateral incisor be supplied? An impression, including the adjoining teeth, is taken and a die made. Gold plate, 22-carat, 29 gauge is swaged to the palatal surface of the cuspid and central incisor. Holes are drilled in the palatal surface of each tooth extending into the dentin, care being taken not to encroach upon the pulp; the openings should be well undercut and large enough to ae- 84 PROSTHETIC DENTISTRY. commodate a flat-headed platinum pin. The plates are then placed in position, a hole corresponding to the one in the tooth is drilled and the pin inserted and united to the plate with sticky wax. The plates are removed, invested and sol- dered with 22-carat solder. They are then adjusted to the teeth and held with a little soft gutta-percha. A plaster im- pression is taken with the plates in position; Avhen removed, the plates' are placed in position in the impression and the model run in plaster and marble dust. A facing is selected, backed and fitted to the model, it is attached to the backings with hard wax. The case is then invested and soldered. Describe a method of constructing a bridge extending from a lower first bicuspid to a third molar, both teeth inclining towards each other. Abutment caps are constructed with square tubes soldered to the distal surface of the bicuspid and mesial surface of the molar. A bar, extending across the space, is bent so that the ends will slip into the tubes. The abutments are placed on the teeth and a bite and plaster impression taken. The crowns are then placed in their position in the impression and the models made and mounted. The bar is now adjusted to its place and plain rubber teeth waxed to the bar. The teeth and bar are removed from the cast, the case is flasked, packed and vulcanized. The crowns are cemented in place and the bar with the teeth vulcanized to it, is slipped into position. What is the object of an investment? The protection of the porcelain from the flame, to afford at- tachment, and to support in proper position the parts to be soldered. What is the best investment for crown and bridge work? A combination of fibre asbestos and plaster of Paris. Why is silver not used in crown and bridge work? Because it is soon corroded by the oral secretion. PROSTHETIC DENTISTRY. 85 How may a badly decayed root be re=inforced or strengthened sufficiently to carry a dowel or pin crown? The decay should be removed and the tooth thoroughly sterilized with nitrate of silver. Small grooves are cut with a wheel bur in the root canal, which has been well reamed. The canal is then packed with amalgam and while soft, a steel pin is forced well up in the centre. More amalgam is added and banked up around the pin. The amalgam is then held firmly with the fingers of one hand, while the pin is carefully removed with the other. Give method of taking an impression of a root for a gold crown. An annealed copper band is shaped and placed on the root ; while in position, an impression is taken with plaster in a small tray. State the difference in degrees between the boiling=point of water and the fusing=point of gold. About 1804 degrees. Describe Brown's porcelain bridge, stating advantages and disadvantages. It consists of a rigid supporting and anchoring bar to which are adjusted porcelain teeth, atta'ched to the bar by means of porcelain fused about the parts. The advantages claimed for it are: that it is less liable to fracture than facings employed in the regular bridge; its na- tural appearances and cleanliness. Its disadvantage is, that in many cases its application necessitates the mutilation of sound teeth. How would you secure an anchoring bar to a vital tooth? By means of a filling of cohesive gold, which should be inserted with the electric mallet. In the posterior teeth amalgam can be used for the same purpose. State the method of preparing and filling a cavity in a porcelain tooth. The cavity is prepared by means of a diamond-pointed drill. 86 PROSTHETIC DENTISTRY. The tooth is placed in plaster to facilitate holding it during the process of filling, which is done in the usual way. At what age is the regulating of the teeth permissible? At about the ninth year, or as soon as appliances can be used to advantage. State the principle of Farrar's system of regulating. The moving of teeth should be by force that is positive in character. Describe Dr. Farrar's appliance for moving roots for= ward. "The base of support is a transpalatal screw-jack, an- chored by two clamp bands that embrace the side teeth ; from this jack to the posterior sides of the necks of the incisors are two other screw-jacks to press against these front teeth. To hold these jacks upon them, a broad band with a U-shaped lug soldered on the lingual side is cemented to each incisor in which a bar connecting the anterior ends of the jack rests. To hold firmly the end of the crown of each incisor, and to prevent them from moving forward when the jacks are set at work against the necks of the teeth, the ends are tied to the transpalatal jack by two wire cords connected with a cross bar lodged in other U-shaped lugs soldered to the labial side of the bands." (The American Text Book of Operative Dentistry.) Describe Dr. Farrar's appliance for moving roots back. "The crowns are stayed by an inside rectangular frame resting in U-shaped lugs at the ends of the crowns and braced against nuts soldered to two anchor clamp bands on the side teeth. The roots are drawn back by a labial bow, attached to the clamp bands by screws." Describe the Jackson crib and base wire. It consists of a base wire. No. 13 or 14 B. & S. gauge, con- necting cribs placed on the two opposite molars or bicuspids, and bent in a bow corresponding to the lingual surfaces of PBOSTHETIC DENTISTBY. 87 the teeth. To this base wire are soldered springs for moving teeth in different directions according to the requirements of the case. State a method of rotating a lateral incisor. It can be rotated by means of piano wire soldered to a band which is cemented to the lateral incisor, the free end of the wire held by a lug on the second bicuspid band. Describe the Angle method of retracting a protruding lower jaw. A large traction screw is attached to clamp bands which encircle the first lower molars. The ends of the bar are hooked into small staples soldered to the distal angles of bands upon the canines; while a piece of gold wire attached by solder, connects these bands and passes in front of the in- cisors. This appliance is used in conjunction with a metal cup swaged to fit the chin and connected by rubber bands with a cap on the back of the head. Describe a method of bringing into proper position a right upper cuspid that bites inside the circle of the lower teeth. A jack-screw extending from the palatal surface of the first bicuspid to the palatal surface of the cuspid is adjusted. By turning the screw a little each day the cuspid will be forced into position. Describe Angle's appliance for retracting a cuspid. Angle's drag-screw consists of a stiff wire, screw-cut at one end and bent into a hook at the other. Anchorage is secured by soldering a tube to a molar and a bicuspid band. The screw- cut end is passed through the tube and the nut placed in position. The end with the hook is slipped into a tube soldered to a band which is cemented on the cuspid. Give a method of elongating bicuspids when they fail to occlude properly. Bands to which hooks are soldered are cemented to the up- 88 PROSTHETIC DENTISTRY. per and lower bicuspid teeth. A rubber band is stretched from the hooks on the upper bicuspids to the corresponding ones on the lower bands. Describe Dr. Case's appliance for raising the occlusion of the lower bicuspids. On each bicuspid is cemented a band with a buccal hook pointing downward. On the band for the molars is sol- dered a hollow tube. On the incisors are cemented bands with hooks turned upward. A labial bow of piano wire with the ends inserted in the tubes on the molars bands, the front resting above the hooks on the incisors and the sides pressed under the hooks on the bicuspids. Describe Case's retainer for the anterior teeth. It consists of a series of bands soldered together at their point of contact with an excess of solder in front. The labial surface of all but the end bands are cut away, so as to leave only a small portion between the teeth; these are filed so as to resemble gold fillings. The appliance is stiffened by sol- dering a piece of swaged plate to the lingual surface. Describe a simple retainer for a single tooth that has been rotated. A wire is soldered to the labial surface of a band which is cemented to the tooth. The wire should project so as to rest on the labial surface of the adjoining teeth. Describe an appliance for expanding or enlarging the arch. AYide bands are made for the first bicuspid and first molar of each side. The bands on each side are joined by a bar soldered to the lingual surface. This bar is made of clasp gold of Xo. 22 gauge and should be about one-eighth of an inch wide ; in this holes are punched at short intervals. Angle's jack-crew is then adjusted, placing the pointed end of the tube in a hole in the bar on one side, and one prong of the forked end in a hole in the opposite bar. The force is applied by turning the nut. PROSTHETIC DENTISTRY. 89 Give the method of obtaining an impression of a per= forated hard palate. With quick-setting plaster the cavity above the roof of the mouth is filled even with the border of the fissure, and while soft, the palatal impression is taken and retained in position until the plaster is hard. The palatal surface of the plaster above the roof of the mouth should be coated with a solution of soap to prevent the two masses from adhering when brought in contact. The impression of the palate is removed in the usual way and with a pair of pliers the mass from the nasal portion is carried backward and withdrawn from the mouth. The two portions are then placed together and waxed. Give the method of taking an impression of a cleft palate. An impression tray of the proper size is selected; it should extend slightly beyond the posterior borders of the hard palate. It is sometimes necessary to lengthen the tray by means of a flap of base plate gutta-percha, which may be carried back as far as the uvula. Plaster of Paris mixed in the usual way is placed in the tray, care being taken not to use too much. The tray is introduced into the mouth and pressed up quickly and firmly, holding it in place until the plaster will break with a clear fracture, when it is removed. What is an obturator? It is an appliance employed to close an opening in the hard or soft palate. Define an artificial velum. It is an appliance made to supply the loss of the posterior' soft palate. Describe the method of constructing an obturator. A model having been obtained, the fissure in the hard palate is filled with wax. Dies are made and a gold plate swaged to fit the re-constructed model. The plate is provided with an extension at the posterior extremity which is to sup- port the obturator and is attached to the teeth by clasping the 90 PROSTHETIC DENTISTBY. six-year molars. The plate is then fitted to the mouth and a loop of copper wire soldered (with soft solder) to the upper side of the plate and extended backward about two-thirds of the length of the fissure. A mass of softened beeswax is wrapped about the wire loop and shaped to correspond to the fissure. It is then slightly softened in warm water and placed in the mouth ; the patient is directed to swallow several times ; by this means the softened mass is moulded to the re- quired shape. When removed from the mouth, the palatal surface is trimmed into a continuous flat surface; the upper surface is treated similarly. In the region of the uvula the sides must be trimmed away so that they may close under the obturator. Plaster is then mixed and a little placed upon the upper side of the plate, extending from the wax bulb for- ward to reach the end of the fissure when placed in the mouth. The plate with plaster upon it, is then introduced in the mouth and carried into place. By this means an im- pression of the forward part of the cleft is obtained. Plaster moulds are now made and the case flasked. Before packing, patterns of the upper and under surfaces of the bulb are cut from No. 60 tin foil, and a single pattern to extent around the sides and end. These are reproduced from sheet rubber and are united to form the bulb by placing the edges tight together. Before finally closing, water should be introduced, filling the bulb about half full, care being taken that the edges of the rubber do not become wet. The flask is closed and the case vulcanized. The bulb is then fitted to the plate. A hole is drilled through the bulb and plate, through which an iridio- platinum bar is passed and soldered to the plate, the opposite end being screAv-cut and supplied with a nut. The surface of the plate, on which the bulb is to lie, is smeared with gutta- percha, the bulb slipped over the bar, and the nut screwed down until it impinges. The plate is then warmed over a burner, the gutta-percha softened and the nut screwed tight. The plate and bulb are trimmed and polished. Describe the method and material vou would use to se= PROSTHETIC DENTISTRY. 91 cure a perfect impression of the inferior maxilla when fractured. Plaster of Paris is prepared and placed upon the oiled sur- face of a large impression tray. The fragments of the jaw should be held in position by an assistant and the tray intro- duced and carefully pressed into place. When the plaster is hardened, the tray is detached and by means of a sharp instru- ment the impression is cut and removed in sections. The pieces are replaced on the tray and held together with wax. Describe the method of constructing an interdental splint. The model of both jaws being obtained, they are carefully articulated by cutting with a small saw the lower cast at the point of fracture. The sections are re-arranged so as to bring the teeth of the two models into proper articulation. They are then secured with plaster and the two models mounted on the articulator. The interdental dovetail spaces are filled with soft plaster. The bite is opened about half an inch by means of the set- screw in the articulator. The teeth and a portion of the gums of both casts are covered with No. 60 tin foil. A layer of rubber is then cut so as to completely cover the foil, one for the upper and one for the lower cast. The rubber is warmed and with a hot instrument it is adapted and fastened to the cast. The articulator with the casts is then brought into proper position and united with rubber posts placed in the position of the cuspids and molars. With a hot spatula the surface of the rubber is made smooth and the edges fastened to the plaster. The case is now ready for flasking. Soft plaster is run into the interior of the moulds which are then embedded in a large flask containing soft plaster. The case is vulcanized and finished in the usual manner. State the relative merits of gutta=percha and cement as a retentive medium for crowns and bridges. The adhesive properties, as well as the hardness of oxy- 92 PEOSTHETIC DENTISTRY. phosphate render it valuable in such cases as require rigidity and support. Gutta-percha is valuable in cases where removal may be desirable and where the retentive medium is exposed to the fluids of the mouth. Describe the Bonwill articulator. It is composed of brass wire and tubing, and consists of a base and a pair of bows. The upper bow is narrower than the lower bow; they are detachable by loosening the set- screws. At either extremity of the cross-bar is an eyelet, through which the "condyle" of the articulator works. Back of the condyle are two spiral springs which represent the muscles. This construction permits the side motions of the lower jaAv to be fairly well imitated. State the method of facing a black rubber plate with pink rubber by vulcanizing once. The preparatory steps for flashing and packing are the same as for the ordinary case. Strips of pink rubber are placed between the teeth, and extending from above the pins to the top of the rim. A layer of pink rubber, the exact size and shape of the palatal portion of the plate, is cut and placed in position, care being taken to have no spaces or crevices. A sheet of- black rubber is stretched to one-half its regular thickness. It is cut to the desired shape and size and placed in position over the pink; the edges should be neatly packed about the pins. A piece of holland is placed over the rubber, the flask closed, heated, and the bolts tight- ened. The flask is then opened, the cloth removed, and a narrow rim or roll of black rubber, extending from heel to heel of the plate, is placed at the junction of the black and pink rubber. The flask is closed and the case vulcanized. Describe the method of reproducing the rugae in a vul= canite plate. State the advantage. Heavy tin-foil is swaged or burnished upon the palatal portion of a model having well-defined rugae. The tin-foil PROSTHETIC DENTISTRY. 93 is carefully removed and the lines of the rugae neatly filled with yellow beeswax. The tin-foil is then fitted to the pala- tal portion of the denture while it is in the lower section of the flask and before the upper section has been filled with plaster. The beeswax in the lines of the rugae prevent their being crushed while the tin-foil is being made to conform to the palatal surface of the denture. When this has been adjusted, the flasking is completed and the case finished. The tin-foil imparts to the vulcanite a polished surface, and no smoothing is needed on this portion of the plate. The advantages of the rugae on the vulcanite plate are : the tendency to lisp is greatly lessened, it has a more natural fe°ling to the tongue, and pronunciation is assisted. How may the extreme limit of the posterior border of an upper plate be determined? By the degree of sensitiveness of the tissues to the plate. The posterior border should not encroach upon the soft pal- ate nor should it cause discomfort to the patient. How would you repair a broken clasp on a rubber plate? A new clasp should be made and attached to the plate by vulcanizing. What are the uses of silex in dentistry? To prevent the adhesion of plaster to, and to produce a smooth surface on vulcanite. It is used also to unite por- tions of a broken plaster model. Describe the blowpipe invented by Dr. J. Rollo Knapp and state some of its uses. It consists of blowpipe attachments connected with a nitrous oxide gas cylinder, the cylinder being set upright and attached to an iron base, at the other end of which is a movable table upon which to rest the work. The blowpipe proper is a continuation of the outlet tube of the gas cylin- der. A lever- valve regulates the supply of nitrous oxide. Beyond this valve is the mixing chamber, to which illumin- 94 PROSTHETIC DENTISTRY. ating gas is conducted from the gas-pipe through a rubber tubing entering the bottom of the chamber. The mixing chamber is provided with a gauze screen to prevent the flame from being drawn into the tubes. Beyond the mixing chamber a pipe is branched so as to afford two flames of different sizes. It is practically an oxy-hydrogen blowpipe. It may be used to melt small quantities of platinum, but it is especially useful in crown and bridge-work manipulations, where an extremely high temperature is required to fuse metals so quickly that the heat will not extend beyond where it is required. ORAL SURGERY What conditions are necessary to obtain bony consoli= dation after fracture? Accurate apposition of the fractured surfaces without the interposition of pieces of muscle, connective tissue or an ex- cessive amount of blood-clot, immobilization for a sufficient length of time, sufficient blood supply to both fragments, sufficient innervation, absence of surface inflammation and constitutional causes of non-union. Asepsis is greatly to be desired, but bony union can occur in suppurating wounds by a process analogous to the healing of wounds by second intention. In what stage of inflammation is cold a valuable remedial agent? Give reasons. Cold is a valuable remedial agent in the beginning of in- flammation since it causes a contraction of the blood-vessels and therefore lessens the amount of blood in the part. When permanently employed it dilates the vessels by paralysis of the muscular coat and the increased amount of blood brings to the part an increased quantity of leucocytes and protect- ive proteids. If applied for too long a time, it lowers the vitality of the tissues, promotes stasis, and interferes with the ameboid action of the leucocytes. At what age are the best results obtained from opera= tions for cleft palate? Give reasons. The best results are obtained by operating between the second and third years. It is not advisable to operate upon infants since they stand hemorrhage poorly, suck the stitches and disturb them with the tongue, and because the tissues are (95) 96 ORAL SURGERY. delicate and friable. It should not be deferred later than the period indicated, as bad habits of articulation will be con- tracted and subsequent success, as gauged by the quality of the speech, is much less likely to follow. Differentiate lacerated and contused wounds. A lacerated wound is a wound produced by a tearing of the tissues. j*. contused wound is a wound produced by a bruising of the tissues. In practice the distinction is not well drawn, since the edges of most lacerated wounds are also more or less contused. State the predisposing causes of lingual carcinoma. Age of the patient (past 40) ; any irritation, such as a sharp tooth, the stem of a pipe, or a badly fitting plate; psoriasis and scars produced by syphilis or injury; smoking. What are wounds and how are they classified? A wound is a solution of continuity of an external or internal surface of tiie body. Wounds are classified as follows : Incised, lacerated, con- tused, punctured, poisoned and gunshot. Give varieties of fracture of the inferior maxilla. Through the body of the bone in the neighborhood of the mental foramen, at the angle or within the vertical ramus, through the neck of the condyle, and at the base of the coronoid process. Describe the operation for ligating the facial artery. After all aseptic precautions have been carried out, a horizontal incision, one inch in length, is made directly over the vessel as it crosses the lower border of the jaw immediately in front of the masseter. The incision divides the integument, the fascia, and the platysma myoides. In making the in- cision, the skin should be drawn upward over the bone, so that when the skin retracts, the scar will not be visible upon the face. The A'essel is ligated just as it emerges from the. ORAL SURGERY. 97 substance of the submaxillary gland. The aneurism needle is passed from behind forward. What is anesthesia? Anesthesia is a condition of total or partial insensibility, particularly to touch. Define synovitis. Give symptoms and treatment. By synovitis is meant the inflammation of a synovial membrane. Symptoms. — The joint becomes the seat of lancinating pain and is filled with fluid. If the articulation is superficial, the overlying skin may be hot and hyperemic. There is a spasm of the surrounding .muscles, causing the joint to be held in that position which affords the greatest ease to the patient. In some cases, the muscles controlling the joint un- dergo a rapid atrophy. If suppuration occurs, the overly- ing integument becomes dusky red and edematous. The pain becomes throbbing in character, and the individual is fre- quently awakened at night by starting pains in the ex- tremity. The temperature is high and there is emaciation. Treatment. — Immobilization. In the early stages and in young people, cold is of value (evaporating lotions, ice bag, Leiter's tubes). Later on, warm fomentations may be used or a few leeches applied. If painful distention is present, some of the fluid may be aspirated under strict aseptic pre- cautions. Should suppuration occur, the joint must be opened, irrigated, and a rubber drainage tube introduced into the most dependent portion. Any underlying diathesis should receive appropriate con- stitutional treatment. Describe the operation for ligating the temporal artery. Make a vertical incision one inch in length, a half inch in front of the tragus, and just above the zygomatic arch. Divide skin, superficial fascia and deep fascia, and then feel for the pulsation of the vessel. The aneurism needle 7 98 ORAL SURGERY. is to be passed from behind forward so as to avoid the temporal vein and the auriculotemporal nerve. Give the varieties of gangrene. 1. Symptomatic gangrene: embolic, senile, diabetic, Ray- naud's disease, ergotic. 2. Traumatic gangrene : direct and indirect. 3. Infective gangrene : acute rapidly spreading gangrene, hospital gangrene, necrosis of bone, noma or cancrum oris, carbuncle and boil. 4. Thermal gangrene: frost-bite, burns, and scalds. Name the different methods for arresting arterial hemor= rhage. Direct pressure, acupressure, forcipressure, torsion, cau- terization, and ligation. Is necrosis found more frequently in the inferior or in the superior maxilla? Why? Necrosis is found rather more frequently in the inferior maxilla because its blood supply is not so abundant. Differentiate a syphilitic ulcer of the tongue from a traumatic ulcer of the tongue. Syphilitic ulcer. — There is a superficial crack or fissure upon the side or tip of the tongue. Such fissures may be multiple, chronic, or relapsing. It is common in the second- ary period of the disease, and is often accompanied by mucous patches, by similar ulcers upon the cheeks, or by papular eruptions upon the skin. It improves under specific treatment. Traumatic ulcer. — The ulcer is usually situated upon the side of the tongue, is ragged or irregular in outline, and is usually opposite a collection of tartar, an angle of a tooth, or the edge of a plate. The glands are not enlarged. Recovery follows the removal of the local irritant. Define orthodontia. By orthodontia is meant the correction of irregularities of the teeth. ORAL SURGERY. 99 State the best method of sterilizing instruments. The best method of sterilizing instruments is to boil them for ten minutes in a 1% solution of sodium carbonate. What are the causes of secondary hemorrhage? Chief cause, — septic arteritis. Contributory causes : 1. Early absorption of ligature. 2. Faulty application of ligature. 3. Ligature too near a collateral branch. 4. A diseased condition of the arterial wall. 5. A state of blood unfavorable to repair of any wound (albuminuria or diabetes). 6. Increased blood pressure (plethora, Bright 's disease, fever, injudicious excitement, or unwise administration of stimulants). Define staphylorrhaphy. State the most favorable age for the operation. By staphylorrhaphy is meant the plastic operation for closing a cleft in the soft palate. The most favorable age for the performance of the oper- ation is between the second and third year. It is very im- portant that staphylorraphy should be performed before the child commences to talk. Mention two methods of preserving the aseptic char= acter of a wound. The aseptic method and the antiseptic method. Give etiology and treatment of syncope. Syncope is due to anemia of the brain produced by sudden failure of the heart's action. Lay patient flat on his back with the head low. Make friction over the precordial region or apply galvanism. Apply smelling salts to nostrils and give a little brandy as soon as the patient can swallow. Give the clinical appearance and treatment of osteoma of the inferior maxilla. Osteoma of the inferior maxilla may consist either of a general thickening or enlargement of the entire bone or of a L.ofC. 100 ORAL SURGERY. local outgrowth. The tumor is extremely hard, grows slowly, and causes no pain unless it presses upon important sensory nerves. The neighboring lymphatic glands are not enlarged. Treatment. — These tumors are best left alone unless the deformity is great or the movements of the mandible are in- terfered with. They may be partially excised, the offending portions being chiselled, drilled, or ground away, or they may be wholly removed by excising a portion of the mandible. Describe suppurative cellulitis. The affected part is hot, tender, and infiltrated; if super- ficial, it looks red and angry and is brawny to the touch. Fever is usually present and, in severe cases, one or more rigors may occur. If the part is not incised, the process rapidly spreads throughout the entire extremity or region; the toxic fever rapidly exhausts the patient's strength and the entire subcutaneous and intermuscular areolar tissue of the part is destroyed. Define surgical shock. Give the treatment. Surgical shock is the immediate constitutional effect of an injury. Treatment. — When slight, rest in the recumbent posture and the use of some aromatic stimulant (ammonia). If severe, recumbent position with the head low; surround the patient with hot bottles (well protected) and blankets to maintain and bring up body-temperature. If conscious and able to swallow, give a little warm tea or stimulant; if unconscious, a small hot coffee or brandy enema, or a hypo- dermatic injection of ether or strychnine. Care should be taken not to waste vital power by over-stimulation which will result in excessive reaction. The intravenous injec- tion of normal saline solution frequently gives excellent results. If the shock is maintained by the presence of a mangled limb, it may be well to perform an amputation. What diseases of the tongue may be mistaken for carcinoma? Primary, secondary, or tertiary syphilis, leukoplakia, ORAL SURGERY. 101 chronic glossitis, traumatic ulcers, tubercular ulcers, sarcoma, and actinomycosis. Mention two varieties of cysts of the tongue. Give the treatment of one variety. Dermoid cyst. — Retention cyst, due to the occlusion of the duct of a small mucous gland. The retention cyst is best treated by excision. Mention the materials employed for sutures, and de- scribe the twisted or hare=lip suture. Silk, silkworm-gut, catgut, kangaroo tendon, silver wire, and horse-hair. The hair-lip or twisted suture consists of metallic pins or needles thrust through both lips of the wound, the edges of which are kept in contact over the pins by figure-eight turns of silk. Give the etiology, clinical appearance, and the treatment of acute ranula. Acute ranula is an accumulation of saliva (from obstruc- tion and rupture of Wharton's duct) in a serous sac known as Fleischmann 's bursa (Tillaux). Duplay considers the acute ranula to consist of a dilatation of the duct itself. The cystic tumor is situated in the floor of the mouth to one side of the median line. It is globular, semi-transparent, and may attain the size of a bantam's egg, pushing the tongue upwards and backwards and interfering with degluti- tion and speech. It contains a glairy mucous fluid. Treatment. Excision of a portion of the anterior wall of the cyst and swabbing out the cavity with pure carbolic acid. The cavity is then packed with iodoform gauze and made to heal by granulation. If the condition recurs, the entire growth is to be excised. Mention the varieties of displacement in fracture of the inferior maxilla. Give the symptoms and treatment of one variety. Tn fractures through the angle, or lower part of the 102 ORAL SURGERY. ramus, there is usually little displacement, as the masseter on the outer side and the internal pterygoid on the inner side, maintain the fragments in apposition. When the fracture passes through the neck of the condyle, that process is drawn forward and inward by the external pterygoid, whilst the body of the bone is freely movable antero-posteriorly, and is displaced toward the sound side. "When the coronoid process is detached, it is drawn up- wards by the temporal tendon, but no great displacement can occur, owing to the extensive attachment of the tendinous fibres. In the most common fracture, through the body of the bone near the mental foramen, the large anterior fragment is displaced downwards by the muscles passing from the hyoid bone to the jaw. The smaller fragment is drawn up- wards by the muscles of mastication and is displaced out- wards, so that it overlaps the anterior fragment. In a fracture through the body of the jaw there will usually be hemorrhage from the mouth, irregularity of the denture, crepitus, and a displacement as described above. The treat- ment consists of the reduction of the displacement, the appli- cation of a Barton bandage and the maintenance of an aseptic condition of the oral cavity. If necessary, Hammond's splint may be applied. Define neurasthenia and give its symptoms and treat= ment. A condition of lack of power of the nerve-centres, not de- pendent upon the existence of organic disease in any portion of the body. Symptoms. — Loss of weight and slight anemia, excessive irritability of the heart, spots of local tenderness over the spine, weariness upon exertion, weakness of memory, dis- turbance of sleep, flushes of heat, profuse sweating, and occa- sionally disturbances of sensation. Treatment. — Rest, with change of scene and diet; massage, out of door life, avoidance of excitement, strychnine in full doses, and, best of all, the " rest cure " as prescribed by Dr. S. Weir Mitchell. ORAL SURGERY. 103 Define odontoma. Give the classification, clinical ap- pearance, and the treatment of odontoma. An odontoma is a tumor originating from some abnormal condition of the teeth or teeth germs. 1. Epithelial odontoma. Originates from enamel organs, usually affects lower jaw, forms tumor of great size, and as a rule runs a perfectly benign course. The only treat- ment consists in complete removal of the affected portion of the jaw. 2. Follicular odontoma (dentigerous cysts). More common in lower jaw, tumor, at first, hard and solid, but subse- quently gives egg-shell crackling and even fluctuation. A permanent tooth will be found missing, and there is no history of its having been extracted. The treatment consists in excising a portion of the wall of the cyst from the mouth and extracting the misplaced tooth. The interior of the cyst is then to be thoroughly scraped, flushed with an anti- septic solution and packed with gauze. 3. Fibrous odontoma. Occurs rarely in rickety children; there is thickening and condensation of the connective tissues around a tooth-sac. Treatment, thorough removal. 4. Radicular odontoma. A tumor composed of cement de- veloping at the root of a tooth. It causes severe pain and may result in septic inflammation of the surrounding bone. Treatment, thorough removal. 5. Composite odontoma. — These may be very large and resemble osteomata of the antrum. Treatment, thorough removal if causing trouble. Give the etiology, clinical division, pathologic classi= fication, and the treatment of tumors. Etiology. — Injury or irritation, infection, heredity, fetal residues. Clinical Division. Benign and Malignant, Pathologic Classification. I. Mesoblastic or Connective Tissue Tumors. A. Those conforming to the types of fully formed con- nective tissues : 104 ORAL SURGERY. 1. Fibroma. 2. Lipoma. 3. Chondroma. 4. Osteoma. 5. Myxoma. B. Those conforming to the types of the higher connective tissues : 1. Myoma. 2. Angioma. 3. Lymphangioma. 4. Neuroma. C. Those conforming to the types of embryonic connective tissue : Sarcoma. II. Epiblastic and hypoblastic tumors, i. e., those conform- ing to the type of Epithelial Tissues : 1. Papilloma. 2. Adenoma. 3. Carcinoma. III. Tumors composed of Epiblastic, Hypoblastic and Mesoblastic Elements: Teratoma. Treatment. In Benign Tumors, removal if annoying or if they show a tendency to become malignant . In Malignant Tumors, secondary deposits should be re- moved with the primary growths. If complete removal is im- possible they had best be left alone. Give the causes and treatment of spasmodic respiratory failure. Laryngitis, laryngismus stridulus, tetanus, and hydrophobia. Treatment. In tetanus and hydrophobia treatment is practically useless. It consists of the administration of chloral between, and of chloroform during the attacks. In laryngitis and laryngismus stridulus, place child in hot bath. Give syrup of ipecac to produce vomiting and place hot compresses about the throat. If child cannot swal- low, tickle throat with finger to produce emesis. Describe the operation of extracting molar teeth. Men- ORAL SURGERY. 105 tion accidents that may occur in the extraction of these teeth. First and second upper molars. The operator stands at right of patient, passing the left arm around the head, and holding the lip out of place with the fingers of the left hand. In using the cow-horn forceps, take care to thrust the points of the horn directly into the interspace and then carry the flat, blade along the palatine fang as high as possible. A few rocks of the tooth inward and outward combined with direct force in the line of its long axis will cause it to give way. First and second lower molars. Position of operator as before. Use the cow-horn forceps for lower molars, and so apply them that the closure of the handle forces the points into the interspace where they will meet. If closing the handle does not loosen the tooth, gently rock the forceps in- ward and outward until the tooth is felt to yield, when it is at once to be lifted from its socket. In extracting the third molar, an appropriate forceps must be selected and the traction made in the axis of the single curved root, usually backwards and upwards or downwards, as the case may be. The accidents of extraction are : Laceration of gum, frac- ture of alveolar process, paralysis, excessive hemorrhage, loosening or breaking of other teeth, and luxation of the in- ferior maxilla. Define replantation of teeth, transplantation of teeth, and implantation of teeth. By replantation is meant the return of a tooth to its na- tural socket after extraction. By transplantation is meant the transference of a tooth from its original socket to one existing in another jaw. By implantation is meant making a socket in a jaw where none exists and inserting a tooth into it. Give a differential diagnosis of traumatic ulcer of the tongue and epithelioma of the tongue. The traumatic ulcer is usually situated upon the side of 106 ORAL SURGERY. the tongue opposite a mass of tartar, an angle of a tooth, or the edge of a plate. The ulcer is ragged, irregular, without induration (unless very chronic,) and the lymphatic glands beneath the lower jaw are not enlarged. Epithelioma occurs in middle-aged or elderly individuals. The ulcer has a widely indurated base, thick everted edge, an irregular warty surface, a watery discharge, and there is an enlargement of one or more of the submental glands. Give a differential diagnosis of suppuration of the maxil- lary sinus and tumor of the maxillary sinus. Suppuration. History of preceding alveolar ab- scess or rhinitis. Tumor. No such history. Causes same deformity, but to a less degree. Exophthalmos, encroachment upon nasal fossae, a flattening of roof of mouth, and a projection of the cheek below the malar bone. Intermittent discharge of pus from Xo suppuration, nostril of affected side. Fever. Xo fever If acute, the cheek is red, hot, and swollen, and the part is painful. May be painful or painless. Exploratory puncture reveals pus. Exploratory puncture does not re- veal pus. It may reveal blood (sarcoma), or exploratory punc- ture may be impossible (oste- oma). Give the etiology, diagnosis, and treatment of cystic dilatation of Steno's duct or of Wharton's duct. Etiology. — A salivary calculus may be formed within Steno's duct and completely occlude its lumen. Diagnosis : Painful swelling in region of parotid gland, pain increased by the ingestion of food. The calculus may ORAL SURGERY. 107 be readily detected by probing the duct, or it may be felt through the tissues of the cheek. Treatment. — Remove the calculus by an incision into the overlying buccal mucous membrane. State how syncope spontaneously arrests hemorrhage. By reducing the force of the blood current and thus per- mitting coagulation to occur within the wounded vessel. Describe the Hammond wire splint and state in what class of fractures it can be successfully employed. It consists of a firm wire collar or framework which en- circles the whole series of teeth in the lower jaw. It is ac- curately fitted to the jaw and fixed by several short wires passing from the lingual to the buccal wire between the teeth. It can be successfully employed in a fractured mandible where there is much displacement. Define fracture. Give the local and the constitutional causes of non=union of fractures. A fracture is a sudden solution of continuity in a bone, usually due to excessive violence. The local causes of non- union are : 1. Faulty apposition. 2. The interposition of fluid, muscular or aponeurotic tissue, or pieces of bone between the ends of the fragments. 3. Want of rest. 4. Defective blood supply. 5. Defective innervation. 6. Inflammation on the surface of the limb. 7. Faulty treatment, and, 8. Local affections of bone (malignant tumors, destruction of the periosteum by inflammation). The constitutional causes are : 1. General constitutional weakness. 2. Osteomalacia. 3. Scurvy. 4. Syphilis. 108 ORAL SURGERY. 5. Senility (probably). 6. Pregnancy, and 7. The cancerous cachexia. Differentiate sapremia, septicemia and pyemia. Sapremia (septic intoxication) is a wound fever due to the absorption of the products of putrefaction into the system. It is a toxemia or condition due to chemical poisoning, and the blood is not infective. Septicemia (septic infection) is a wound fever due to the introduction into the blood and tissues of bacteria which rapidly multiply. The blood is infective, since it contains not only the toxins but also the organisms which produce them. Pyemia is a wound fever developed during the process of suppuration and is due to the absorption of pyogenic organ- isms into the circulation. Clinically, pyemia is septicemia plus metastatic abscesses. State precautions that should be taken when operating on syphilitic patients. Any cracks or abrasions upon the hands of the operator should be protected by a collodion dressing and the hands should be encased in a pair of sterile rubber gloves. At various intervals during the operation, the hands should be immersed in an antiseptic solution and then rinsed in sterile water. At the conclusion of the operation the hands should be well scrubbed, soaked for several minutes in a bichloride of mercury solution (1-1000), and then washed in sterile water. In trifacial neuralgia caused by infection, malaria, or grip, what division of the nerve is usually involved? The first or ophthalmic division. What produces mechanical asphyxia during ether or chloroform anesthesia? Mechanical asphyxia is produced by the tongue falling backward over the glottis. ORAL SURGERY. 109 Give the differential diagnosis of fracture and dislocation. Fracture. Dislocation. Preternatural mobility. Immobility. Crepitus. No crepitus. The deformity usually returns im- The deformity does not usually re- mediately after it has been cor- cur after it has been corrected, rected. Give the anatomic and the clinical varieties of hemor- rhage. The anatomic varieties of hemorrhage are the arterial, the venous, and the capillary. The clinical varieties of hemorrhage are primary hemor- rhage, intermediate or reactionary hemorrhage, and second- ary hemorrhage. State why an alveolar abscess may cause suppurative inflammation of the maxillary sinus. Because the suppuration is in the floor of the sinus and may point towards its cavity or cause a suppurative inflamma- tion by contiguity of structure. Mention the predisposing and the exciting causes, to- gether with the local and the constitutional symptoms of inflammation. The predisposing causes include everything which lowers the general resistance of the body; such as Bright 's disease, diabetes, anemia, tuberculosis, and chronic alcoholism. The exciting causes are traumatism, heat, cold, chemical agents, and bacteria. The local symptoms are redness, heat, pain, swelling, and modified function. The constitutional symptom is fever. Give the pathology, symptoms and treatment of in- flammation. Pathology. — There are three sets of changes: 1. Changes in the blood vessels and in the circulation. The blood vessels dilate. The current is at first more rapid 110 ORAL SURGERY. but soon becomes slower, so that an axial stream (red blood corpuscles) and a periaxial stream (white blood corpuscles and blood placques) may be differentiated. In addition to dilating, the vessels become elongated and tortuous. The current finally becomes so sluggish that it moves onward with each systole and backward with each diastole (oscillation). This is followed by stasis. 2. Exudation of serum and transmigration of the leucocytes. 3. Changes in the tissues themselves. These consist of a multiplication of the fixed and wandering connective tissue cells. Symptoms. — The local symptoms are redness, heat, pain, swelling, and modified function. The constitutional symp- tom is fever. Treatment. — The local treatment includes rest, elevation, the use of heat or cold, local blood-letting, astringents, anti- septics, counter-irritation, compression, and massage. The constitutional treatment comprises good hygiene, a light nutritious diet, purgatives, venesection, antipyretics, hypnotics, analgesics, stimulants, and tonics. Give the cause and treatment of noisy movements of the temporo=maxilIary articulation. Cause. — Laxity of ligaments and weakness of surrounding muscles. In some cases it is due to a displacement of the inter-articular cartilage. Treatment. — Tonics, electricity. The wearing of an occi- pito-mental sling. If the inter-articular cartilage is displaced an incision may be made into the joint and the cartilage sutured in its normal position. Define septic intoxication. Give treatment. Septic intoxication is a form of poisoning resulting from the absorption of the products of putrefaction. The local treatment consists of the thorough removal of the source of infection and of the antiseptic treatment of the wound. The constitutional treatment must be of a supporting char- ORAL SURGERY. Ill acter. Alcohol and hypodermatic injections of strychnine are to be recommended. Enteroclysis or hypodermoclysis. Define stomatitis. Mention the varieties of stomatitis and give treatment of one variety. By stomatitis is meant an inflammation of the oral mucous membrane. The varieties are catarrhal, aphthous, ulcerative, para- sitic, gangrenous, mercurial, syphilitic, and scorbutic. Treatment of ulcerative stomatitis : Correct the hygiene. Tonic doses of quinine. Touch ulcers with nitrate of silver. Use as a mouth wash a solution of potassium chlorate or hydrogen peroxide. Differentiate acquired cleft palate and congenital cleft palate. Congenital cleft palate exists at birth and is due to want of union of the two palatal segments of the maxillary processes. Acquired cleft palate is produced at some period of extra- uterine life by losses of substance resulting from injury or syphilis. How would you treat persistent bleeding after lancing the gums of a child? By pressure with compresses soaked in peroxide of hydro- gen; by packing the incision with a pledget of cotton satur- ated with phenate of soda or a solution of tannic acid. In some cases the lips of the wound may be temporarily ap- proximated by a suture. Monsel's salts and solutions are only to be used in extreme cases, since they impair the vitality of the tissues and increase the danger of secondary hemor- rhage. In addition to the local treatment, one of the follow- ing hemostatics may be administered : Tr. ergot (gtt. V, repeated in one or two hours'). Tr. erigeron canadensis (gtt. 1, in water every minute until bleeding ceases, or until twenty doses have been taken), gallic acid (gr. 1, every two hours'). 112 ORAL SURGERY. What treatment would you pursue in excessive hemor- rhage after tooth extraction? Remove all clots and pieces of root, plug the tooth-socket with a strip of gauze saturated with peroxide of hydrogen, and reinforce the plug by means of a supporting pad. Should this fail, a plug may be made of gauze, the meshes of which contain tannic acid or alum. The advantage of the clot formed by tannin is that it is insoluble in the blood. Per- chlorid of iron and Monsel's solution should not be employed on account of their injurious effects upon the tissues and the danger of secondary hemorrhage. In obstinate cases, the hemorrhage may always be controlled by packing the tooth- socket with a strip of gauze, in the meshes of which rapidly setting plaster-of-Paris has been incorporated. A pledget of cotton saturated with adrecalin chloride (1-1000) may also be used. Give one of the causes of antral disease, its diagnosis, and treatment. An alveolo-dental abscess discharging into the antrum. The diagnosis will be made by the presence of the follow- ing signs and symptoms : Pain over the affected region and the discovery of the offending tooth or root. Tenderness upon percussion of the antrum. The escape of pus through the nostril of the affected side. If the antrum contains a con- siderable quantity of pus, it will be opaque to transmitted light, as compared with the opposite side. The examination is made by taking the patient into a dark room and introducing a small incandescent lamp into the mouth, which is then closed. If the pus can find no outlet, the floor of the orbit will be pushed up, causing exophthalmos, the nasal fossae will be encroached upon, and there will be edema of the cheek. The treatment consists in the establishment of efficient drainage and the thorough irrigation of the cavity of the antrum. This may be accomplished by extracting the offend- ing tooth or root and enlarging the opening into the antrum. The antrum may also be entered above the root of the second ORAL SURGERY. 113 bicuspid tooth, about one inch above the border of the gum. The opening into the antrum must be kept open by a gauze or tubular drain until the discharge entirely ceases. During this time the cavity of the antrum may be irrigated, — at first daily, and subsequently at longer intervals. How would you treat a case of external fistula with ad- hesion from an alveolar abscess? The entire fistulous tract must be dissected out and all cicatricial tissue removed. The necrotic bone must be burred away until healthy bone is reached. After the hemorrhage has been arrested the adjacent skin is to be loosened up and a flap slid over the site of the bone lesion, so that the cutaneous wound shall not directly overlie the wound in the bone. How would you diagnose and treat hypertrophy of the gums, and in what class of persons, as to age and mentality, does it occur? Diagnosis. — Diffuse, spongy, bleeding overgrowth of gums. Teeth show that they have been greatly neglected and are covered with accumulated deposits. The affection occurs after second dentition, usually between the ages of 18 and 25, in those who are ignorant and careless in their personal hygiene. Treatment. — Remove all deposits. Clean teeth. Give antiseptic mouth washes. Instruct in care of mouth, and, if necessary, leech, incise, or excise redundant tissue, or galvano- cautery may be used. How wouEd you treat luxation of the inferior maxilla? Describe the lesion and treatment anatomically. The mechanism is as follows : When the mouth is opened the condyle slides forward upon the eminentia articularis and only a slight traumatism is necessary to displace it still further forward into the zygomatic fossa. The inter-articular cartilage may or may not follow the condyle. The luxation may be unilateral or bilateral, more frequently the latter. The mouth cannot be closed and the lower jaw projects anteriorly beyond its normal position. A hollow 8 1 14 ORAL SURGERY. may be felt just in front of the tragus, in the position nor- mally occupied by the condyle. The condyle may be felt in front of this hollow. If the finger is inserted into the mouth, the coronoid process may be felt in an abnormal posi- tion beneath the zygoma. If the dislocation is unilateral, the symptoms are less marked, the jaw is more mobile, and the chin is displaced towards the sound side. Treatment. — All that is needed is to depress the condyle "below the level of the eminentia articularis, when the mas- seter, temporal and internal pterygoid muscles readily draw it back into the glenoid cavity. The patient is to be seated in a chair; the surgeon stands in front of the patient and presses downward upon the molar teeth with his thumbs, which are guarded with a towel. This pressure is continued in a downward and backward direction until the condyle clears the eminentia articularis, when the chin is raised by the fingers. The jaw is then to be kept at rest for four or five days by a Barton bandage. Give briefly your method of procedure in the treatment of a compound fracture of the inferior maxilla. The mouth, or the external wound, is to be kept as aseptic as possible. In ordinary cases, an external moulded splint may be applied to the chin, and the lower jaw held against the upper one by means of a Barton or a four-tailed bandage. The fragments may be held in place by a wire collar en- circling all of the teeth of the lower jaw. This collar is to be accurately fitted, first to a cast of the jaw and then to the jaw itself, and fixed by several wires passing from one-half to the other, between the teeth. If the teeth are defective, Kingley's splint may be employed. This consists of a vulcanite splint fitted over the alveolar pro- cess. Curved metal bars are attached to the front of the splint and extend backward over the cheeks from the angles of the mouth. The splint is kept in position by a bandage passing over the bars and under the chin. This splint will immobilize the fragments, even when the mouth is opened. In obstinate cases the fragments may be wired. ORAL SURGERY. 115 Give the diagnosis and treatment of a dentigerous cyst. Diagnosis : These cysts are usually encountered in young individuals, but may occur in later life. They are far more common in the lower than in the upper jaw. At first the tumor is hard and solid, but as the bone expands it becomes thinned, and palpation reveals egg-shell crackling or even fluctuation. Upon examination of the denture, one of the teeth will be missing and there will be no history of its extraction. Treatment, — Excise a portion of the wall of the cyst (through the mouth) and extract the misplaced tooth. The interior of the cyst should then be scraped, irrigated, and packed with iodoform gauze. How would you diagnose and treat epulic tumors? Diagnosis. — Benign or fibrous epulis appears as a red, fleshy mass, smooth or lobulated, elastic to the touch and probably showing some superficial ulceration. It is a pain- less tumor of slow growth. Malignant or myeloid epulis forms a soft, rapidly grow- ing, painful tumor, dusky red in color, and soon ulcerating. Treatment. — The best treatment for fibrous epulis is to re- move the growth, together with that portion of the alveolus from which it takes its origin. If necessary, a tooth on either side of the tumor must be extracted, each socket cut through vertically with a saw, and the incisions united be- low with a chisel. In this manner, a quadrangular piece of the alveolus is removed without interfering with the con- tinuity of the jaw. In malignant epulis, it is necessary to operate as early as possible and to carry the bone incisions quite wide of the margin of the tumor. If the tumor is large, it may be neces- sary to remove the entire thickness of the lower, or the palatal segment of the upper jaw, as the case may be. What is a ranula? A ranula is a retention cyst, due to the obstruction and dilatation of one of the ducts of the sublingual or submaxil- lary gland. 116 ORAL SURGERY. What do you know about aphthae and their treatment? The term "aphthae" is an old one and includes aphthous stomatitis, ulcerative stomatitis, thrush, and cancrum oris. Aphthous stomatitis. — Seen in nursing children. Inspec- tion reveals numerous small round vesicles on the cheek, lips, and tongue; the vesicles soon break, leaving shallow ulcers with a red areola. Treatment. — Sterilize the milk. Correct any gastric dis- turbance. Use a mouth wash of boric acid. Ulcerative stomatitis. — Attacks children and adults when in poor health or subjected to bad hygienic surroundings. Inspection reveals linear ulcers with gray sloughing bases. The sub-maxillary glands are swollen. In severe cases, loos- ening of teeth and necrosis of bone may follow. Treatment. — Correct hygiene. Tonic doses of quinine. Touch ulcers with nitrate of silver. Use as a mouth wash a solution of potassium chlorate or hydrogen peroxide. Parasitic stomatitis (Thrush). Inspection reveals numer- ous white elevations, which on removal leave a raw surface. Microscopic examination reveals the saccharomyces albicans. Treatment. — Correct the hygiene. Treat any gastric dis- turbance. Tonics. Some antiseptic mouth-wash, such as so- lutions of borax, boric acid, or hydrogen peroxide. Gangrenous stomatitis (Cancrum oris). — Usually seen in debilitated children and after one of the specific fevers, par- ticularly measles and whooping cough. The cheek is the part affected. Externally, it is swollen, hard, red, and glazed; internally, an irregular sloughing ulcer is noted. Treatment, — Good hygiene and stimulants. Chloroform the child and excise the gangrenous area, cutting widely into healthy tissue. The edges of the wound are then cauterized with fuming nitric acid, bromine, or the actual cautery. The resulting deformity must be treated later by a plastic operation. Describe trismus and how it differs from tetanus. Trismus simply means a spasmodic locking of the jaws. It ORAL SURGERY. 117 may have its cause in associated dental lesions, causing irri- tation of the nerves of the part ; it is also a symptom of tetanus. Tetanus is an acute infectious disease, due to the bacillus of tetanus and characterized by tonic spasms with clonic exacerbations. The spasms also affect the muscles of the trunk. What is a traumatic lesion? A traumatic lesion is a solution of continuity due to injury. By what surgical operation would you abort an im= pending alveolar abscess? Make a slight cut with a sharp scalpel through the soft parts at the apex of the affected tooth. Pierce the outer plate of bone with a spear-pointed drill, thus entering the region in which the suppuration is impending. This wound should be kept patulous for several days. What are the indications for the use of the lance in de= ciduous dentition? The lance should never be used until the appearance of the white line, which is due to the pressure exerted by the erupt- ing tooth. Lancing should never be performed unless re- flex disturbances are produced. What anatomical irregularity of the inferior third molar tooth frequently presents itself in extraction? Anticipat- ing this condition, how would you extract it? The roots of the inferior third molar are almost always fused and curve backward. This throws the tooth against the second molar. Always endeavor to determine the course of the root, and then make traction in a corresponding direc- tion, usually upwards and backwards. Name some of the forms of sutures employed in the closing of surgical wounds, and what substances are used? The interrupted, the continuous, the mattress, the quilled, and the shotted suture. The materials employed are silk, silkworm-gut, cat-gut, kangaroo tendon, and silver wire. 118 ORAL SURGERY. What is torsion, and when is it preferable to other means in arresting arterial hemorrhage? By torsion is meant the twisting of an artery until its middle and internal coats are lacerated. It is preferable to other means in plastic operations, where it is not considered desirable to leave too many ligatures be- hind. It is also preferable where aseptic ligatures cannot be obtained. When it is surgically necessary to make an incision through a muscle and a choice exists for carrying the in= cision parallel or transverse to the fibres of the muscle, which way would you adopt, and why? Make the incision in the direction of the fibres. The reason for this is that fewer fibres will be severed and the function of the muscle will be practically unimpaired. What is a sequestrum? A sequestrum is a piece of dead bone resulting from necrosis. At what point is the trunk of the facial nerve most liable to injury? If severed, what change occurs? At its exit from the stylo-mastoid foramen. If severed, a paralysis of the muscles of expression of the affected side is produced. The folds and wrinkles are obliterated upon the paralyzed side. The eyelid cannot be completely closed. On attempting to laugh or show the teeth, the muscles of the non- paralyzed side alone are contracted, and marked asymmetry results from the drawing over of the opposite side. The lips cannot be closed firmly, and whistling is impossible. Food collects between the cheek and the teeth, owing to the paralysis of the buccinator muscle. What is hare=lip? Describe a remedial operation and give the best age for its performance. A hare-lip is a congenital fissure of the upper lip, which may extend for a variable distance through the tissues. Rose's Operation. The incision extends from the apex of the cleft, or from within the nostril, in a concentric manner ORAL SURGERY. 119 so that a slight angular projection is formed to constitute a prolabium. This is done on each side and, where the nose is much flattened, more tissue is removed from the outer than from the inner side, so that when the parts are sutured to- gether, the nostrils become as nearly symmetrical as possible. By this means, the depth of the lip is increased to allow of subsequent contraction ; the vermilion borders must be accu- rately approximated. Two deep silkworm-gut sutures should be introduced, one just above the red margin and one close to the nose. Cat-gut sutures are used to bring the margins of the wound together accurately. The dressing consists of gauze and collodion. The gauze is cut in the shape of a paddle, the broad ends being fastened to the cheek. This should be so applied as to prevent tension upon the wound. The silkworm-gut sutures are removed upon the fourth day. The best age for the performance of the operation is from 6 weeks to 3 months. Define ankylosis. Give an example. Ankylosis is a condition of partial or complete immobility of a joint, resulting from some preceding inflammation of the articular structures. As an example might be given that form which is seen in the elbow joint after fractures into the articulation, and the subsequent period of enforced rest. How are fractures classified? Simple. — Not communicating with the external air. Compound. — Communicating with the external air. Comminuted. — A number of small fractures. Complicated. — Associated with a dislocation or with a lacer- ation of the main arterial or nervous trunk. Fractures are also divided into complete and incomplete. According to the line of fracture, they are called longitu- dinal, transverse, oblique, stellate, etc. Describe several methods for arresting hemorrhage in general. Ligation. — Make an incision at a slight angle to the line of the artery. Expose the sheath. Make as small an opening 120 ORAL SURGERY. in the sheath as possible and pass a ligature about the vessel by means of an aneurysm needle. Tie the ligature tight enough to lacerate the inner and middle coats. Torsion. — Dissect the end of the artery free from the sheath for half an inch. Seize- it transversely with a hemostatic forceps, and then twist the free end of the artery by means of a second hemostatic forceps until the internal and middle coats are lacerated. Arrest capillary hemorrhage by filling the wound with hot water (125° P.)-. Give the etiology, clinical appearance, and the treat= ment of spongy gums. Etiology. — Stomatitis, systemic derangements of any kind, from mild fevers to acute diseases, uncleanliness, calcareous deposits around the necks of teeth. Clinical appearance. — The gums appear swollen and flabby around the necks of the teeth. They have a peculiar spongy appearance and their margins are dotted and streaked with bright red spots and lines. They bleed upon the slightest provocation. Treatment. — Removal of exciting cause, cleanliness, local blood-letting, the use of antiseptic mouth-washes, and sys- temic treatment according to condition of general health. Give the etiology, pathology and treatment of perice= mental abscesses. Etiology. — Infection from the root or from a pocket of pus (as in pyorrhea alveolaris) . A deposit of uric acid upon the root may irritate the surrounding tissues and lessen resist- ance to infection. Pathology. — The same as that of any other abscess. Treatment. — Secure free drainage for pus, render the ab- scess cavity as aseptic as possible, and prescribe an antiseptic mouth wash. Give the etiology, clinical appearance, and treatment of arsenic necrosis of the alveolar process. Etiology. — The arsenic usually gains access to the alveolus from an application made to the pulp. ORAL SURGERY. 121 Clinical appearance. — A red tumefied area in the centre of which a slough is located. The process generally extends down into the alveolus and affects the septa between the teeth. Treatment. — Removal of necrotic tissue. The local ap- plication of sesqui-oxide of iron has-been highly recommended. Repeated syringings and antiseptic mouth washes. Give the method of removing a broken bur or nerve broach from a pulp canal. Drill around the bur with a fine fissure drill ; iodine may be applied and the part rusted out; sulphuric acid may be used to remove some of the tooth structure, or an attempt may be made to draw out the bur with a barbed Donaldson broach. Give the causes, pathologic conditions, and the symp= toms of traumatic dislocation. Causes. — The application of external violence and muscular force, acting alone or in combination. Pathologic conditions. — The ligaments are partially or completely torn. In closely fitting joints (particularly hinge- joints), the bony surfaces are frequently fractured. The cartilages may be bruised or partially detached and the neigh- boring muscles and tendons lacerated or displaced. Sur- rounding vessels and nerves are frequently injured and the area involved is always infiltrated by a considerable effusion of blood. Symptoms. — Pain, bruising, and swelling of the soft tissues. Deformity, since the articular end of the bone is displaced into a new position where it may often be felt and sometimes seen. Restricted mobility of the affected joint. True crepitus is not present unless a fracture co-exists. Give the diagnosis, prognosis, and treatment of moist gangrene of the pulp. Diagnosis. — If there is an outlet for the escape of the gases of decomposition, pain is not necessarily experienced. Or- dinarily, however, the condition causes more or less intense 122 ORAL SURGERY. pain, which is usually of a throbbing and heavy character. If inflammation has spread to the surrounding tissues, the ap- plication of heat may cause an increased amount of pain. A foul-smelling odor is constantly present. Prognosis. — Not necessarily bad. The tooth may be saved in a majority of cases. Treatment, — Removal of all decomposed parts and pro- ducts, disinfection of pulp canal, hermetical sealing of apex of the tooth, and filling of the pulp canal. Give the etiology, diagnosis, and treatment of acute nonpurulent marginal gingivitis. Etiology. — Mechanical or thermal irritants (such as rough edges of an overhanging filling) , rough treatment in excavat- ing or filling a cavity, overheating while drying a cavity, fric- tion while excavating with bur, or cutting down of fillings with sand-paper discs, careless use of ligatures (particularly when they are left upon the tooth for some time), the use of some strong caustics, or other drugs. Diagnosis. — ^Severe pain, usually of a throbbing character and other local signs of inflammation. The tooth is slightly loose, and protrudes somewhat from its socket. Treatment, — Removal of cause, local blood-letting, paint parts affected with iodine. Give the clinical appearance and the treatment of syph= ilitic interstitial gingivitis. Inflammation, attended with superficial ulceration of mucous membrane and general oozing of a grayish- white color. Treatment. — Iodides internally. Antiseptic mouth-washes locally. Describe the " direct method " of producing artificial respiration. In the direct method, the air is warmed and pumped into the lungs. The apparatus required is a pair of bellows, a face mask, and intubation tubes (in case the mask does not suffice). There should be a metal tube, with an opening ORAL SURGERY. 123 in it, set in the rubber tubing, so that the operator can allow the escape of any excess of air blown by the bellows. If the mask is used a ligature should be passed through the tongue so that it may be readily held forward. If the air cannot enter the lung, intubation is to be performed, and there will be no difficulty. A respiratory rate of 16 to 20 a minute should be maintained. If there is no apparatus for warming the air, the temperature of the room must be raised to at least 85° F. Give the etiology, pathology, symptoms, and treatment of hyperemia of the pulp. Etiology. — Irritation of bacteria, lactic acid, traumatism, exposure, denudation of root, and irritation from a filling. Pathology. — Practically that of a beginning inflammation. When cut into, it bleeds, rather freely. Symptoms. — Pain, increased by percussion, or by the appli-. cation of either hot or cold substances. Treatment. — Local and general sedatives. Counter-irrita- tion. If pulp does not respond, local blood letting. As a last resort the pulp may be destroyed. What precautionary measures should be observed in the ligation of arteries? Asepsis, avoid wounding important surrounding structures, make as small an opening as possible in the sheath, never tie near a collateral branch (or if forced to do so, tie branch also), and be sure that the ligature damages the inner and middle coats sufficiently to insure the obliteration of the vessel at that point. Give the treatment of septic wounds. Cleanse the wound as thoroughly as possible, syringe with hydrogen peroxide, and irrigate with bichloride (1-1000). If the septic condition of the wound is marked, solutions of chloride of zinc should be applied to all of its recesses. If the wound is large and irregular, rubber drainage tubes should be introduced into the most dependent positions. If 124 ORAL SURGERY. the wound is small, gauze drainage may suffice. The best dressing is one of wet bichloride gauze. The constitutional treatment should be of a supporting character. Give the etiology, symptoms, and treatment of acute periostitis of the inferior maxilla. Etiology. — Traumatism, extension from a contiguous in- flammation (such as an alveolar abscess), the exanthemata (particularly measles and scarlet fever). It may also be caused by general conditions, such as rheumatism, gout, or pyemia. Symptoms. — The ordinary phenomena of acute inflamma- tion. The pain is of an intense aching character, worse at night, and increased by pressure. If the outer surface is involved, and the process go on to suppuration, a brawny swelling develops which softens in the center, the overlying skin becoming reddened and edematous. "When the abscess is opened, bare bone is felt, and the greater portion of the de- nuded structure dies. Treatment. — Eest, leeches, and fomentations locally, if seen early. A good purge should be given, and any underlying diathesis treated. If suppuration is threatened, a free in- cision should be made down to the bone. If necrosis has occurred, the parts must be dressed antiseptically, until the sequestrum is detached. If the sinus opens internally, anti- septic mouth-washes. Give the etiology and treatment of epistaxis. Etiology. — Traumatism, ulcers or tumors of the nasal sep- tum, rupture of varicose veins in mucous membrane of sep- tum, cerebral congestion, hemophilia, purpura, scurvy. Treatment. — In the majority of cases there is a local cause. If the bleeding point is detected, it should be touched with a pointed gal vano- cautery or with a swab saturated with a so- lution of chromic acid. Cold may be applied to the root of the nose and to the nape of the neck. If the bleeding point cannot be located, the anterior nares should be packed with strips of aseptic gauze saturated with hydrogen peroxide. If ORAL SURGERY. 125 the hemorrhage still continues and the blood drips into the nasopharynx, the posterior nares must be plugged with the aid of Bellocq's sound or a rubber catheter. Describe the necessary preparation of patients for gen- eral anesthesia by ether or chloroform. State what re=» medies and instruments should be at hand. The patient should be examined as carefully as though he were an applicant for life insurance, and all organic diseases should be excluded. This includes physical examination of the lungs, heart, abdomen, etc, and chemical and microscopical examination of the urine. The night before the anesthesia, the patient should receive a half ounce of Epsom salts, and on the morning of the operation, the lower bowel should be emptied by enema. Just before the anesthesia, all loose bodies, false teeth, etc., should be removed from the mouth. No food should be taken for at least six hours before the anesthesia. Instruments and remedies. — Sterile hypodermatic syringe and sterile solutions of atropine sulphate, strychnine sulphate, nitro-glycerine. Brandy, ammonia, tongue forceps, and mouth gag. Tracheotomy instruments, a battery, and an ap- paratus for forced artificial respiration should always be within reach in a hospital. Give the treatment of wounds of the tongue. Arrest hemorrhage by exposure to the air, ice, hot water or ligation. If wound is small, sutures are not required. If large, deep-seated sutures should be introduced and the ends tied with more than ordinary care, since the motions of the tongue are apt to loosen the suture. An antiseptic mouth- wash should be prescribed. Define scarification. Give the method of this operation and state the results obtained, mention the necessary pre- cautions to be observed in scarification. By scarification is meant the operation of making numerous small superficial incisions. The incisions should be parallel, arranged in the form of a lozenge, and extend almost through the skin. 126 ORAL SURGERY. The results obtained are bleeding and the relief of tension. The necessary precautions to be observed are the details of rigid asepsis. Mention three tumors of antrum. Give treatment. Osteoma, sarcoma, and carcinoma. Treatment. — The osteoma requires no treatment unless it presses upon important structures, or causes great deformity, when the offending portions of the tumor may be removed. Before such a partial operation is done, however, malignancy must be absolutely excluded. If a sarcoma or carcinoma can be thoroughly removed by an excision of the superior max- illa, this operation is indicated. If the malignant growth can not be thoroughly removed, the toxins of erysipelas may be injected. Give the local treatment of hemorrhage. Exposure to air, cold, hot water, position (usually eleva- tion) , direct pressure, styptics, cauterization, acupressure, forcipressure, torsion, arid ligation. Give treatment of injuries of the mouth caused by car= bolic acid. Apply alcohol as quickly as possible to dissolve excess of carbolic acid. An antiseptic mouth-wash should then be used. Give the diagnosis and treatment of papillomata of the gums. Diagnosis. — It is an innocent epithelial tumor consisting of a fibrous stroma which contains blood-vessels, lymphatics, and an epithelial covering peculiar to the part from which it springs. The tumors are generally multiple, wart-like growths, usually soft and seen upon the mucous membrane. They do not, as a rule, give pain, and are either smooth, rounded or of cauliflower shape. They are generally very vascular and bleed quite freely. Treatment. — Immediate and thorough removal since they show a most pronounced tend- ency to become malignant. ORAL SURGERY. 127 Describe the technic of ligation of arteries. Thoroughly asepticize the part. Make an incision over the line of the artery. It is best to make this incision at an angle of five degrees to the line of the vessel. Divide the structures layer by layer, avoiding important vessels and nerves. After dividing skin, superficial and deep fascia, the pulsations of the vessel should be sought for. When the sheath of the vessel is reached, it should be opened as far away from the vein as possible (example, open carotid sheath upon inner side). This opening in sheath should be just large enough to allow room for the aneurism needle. In passing the aneurism needle always go from the most difficult to the least difficult side, and never lift the artery up from its bed to a greater extent than is absolutely essential. Before tying the ligature, be sure that it controls the circulation. In tying the ligature exert an equal amount of force upon both ends. After the vessel is ligated, the cutaneous wound is sutured and an aseptic dressing is applied. Give the differential diagnosis of ozaena and empyema of the antrum. In ozaena, the offensive discharge proceeds from both nostrils, and the nasal mucous membrane is atrophic. The maxillary sinuses transmit light when the patient is in a dark room with an incandescent lamp in the mouth. There is an absence of any inflammatory symptoms in the tissues over- lying the antrum. In empyema of the antrum, the discharge proceeds from the nostrils of the affected side ; the nasal mucous membrane upon the opposite side may be normal ; and the diseased maxil- lary sinus is more opaque to transmitted light than is the nor- mal antrum. There are inflammatory symptoms in the tissues overlying the antrum. The cause of the empyema (such as an alveolar abscess) may be found. Give the diagnosis and clinical appearance of myeloid sarcoma. Mveloid sarcoma alwavs grows from bone. It affects the 128 ORAL SURGERY. long bones (particularly the upper end of humerus and tibia, lower end of femur). It most commonly affects individuals between 10 and 40 years of age. but it may occur in old age. The tumor is one of rather slow growth ; it may pulsate, fluc- tuate in certain portions of its extent, or give rise to egg- shell crackling. Give treatment of fracture of superior maxilla. State the complications that may arise. Correct any displacement; as a rule, all the treatment re- quired is to keep the patient quiet and apply cooling lotions to the part. The patient should be fed through a tube if the palatal process is involved. A dental plate should be applied to a broken alveolus. The complications that may arise are severe hemorrhage, suppuration (empyema of antrum), and necrosis. Give the clinical appearance, the symptoms and treat- ment of necrosis caused by an impacted wisdom tooth. The gums are usually discolored, slight bleeding is common, pus exudes from numerous openings over affected area. Pain may or may not be present. If the condition is allowed to per- sist the general health is impaired. Treatment. — Remove cause by extracting the malplaced tooth: antiseptic mouth- washes should be freely employed. The necrosed portions of the alveolus should be freely removed. Give the diagnosis and treatment of fracture of the in- ferior maxilla. Crepitus may be obtained. The condyle is usually drawn forwards and inwards by the external pterygoid, while the body of the bone is freely movable antero-posteriorly, and is displaced toward the fractured side. Treatment, — Barton's bandage. Intermaxillary splints are deservedly unpopular. The most perfect results are un- doubtedly obtained by wiring. Differentiate neuritis and neuralgia. Bv neuritis is meant the inflammation of a nerve. ORAL SURGERY. 129 By neuralgia is meant severe paroxysmal pain along the course of a nerve, and not associated with demonstrable structural changes in the nerve. The pain of neuritis is increased by pressure; the pain of neuralgia is frequently relieved by pressure. A differential diagnosis is sometimes impossible. Give the etiology and clinical features of epithelioma of the lip. Etiology. — It is commonly stated that this tumor is due to the irritation produced by smoking a short clay pipe, which is allowed to rest on one or the other side of the lip near the angle. It may also originate opposite a projecting rough or carious tooth. Pathology. — The affection may be a typical malignant ulcer, a wart-like growth subsequently becoming fungus and ul- cerated, or a chronic infiltration leading to an irregular, nodu- lar thickening. Sections of the growth show an abundance of 1 ' epithelial pearls. ' ' Clinical features. — Almost always affect lower lip. Karely met with in women (1 in 20). Occurs past middle life. Sub- mental and sub-maxillary glands not implicated for three or four months. Sore develops slowly. Sharp burning or lan- cinating pains. Odor often extremely offensive. Why should the hands be disinfected before a surgical operation. Describe the method used. Because the epidermis always contains pathogenic bacteria. Furbinger's method. — Hands and forearms are scrubbed continuously for five minutes with soap and aseptic nail-brush. The nails should be thoroughly cleaned and trimmed short. The hands are then plunged into absolute alcohol for at least one minute, and then are plunged while wet into a hot sub- limate solution (1-1000) and thoroughly scrubbed with a nail-brush for at least one minute, particular attention being directed to the nails. A better method is that of Kelly : — The hands and forearms are cleansed as before with soap and water and the nails 9 130 ORAL SURGERY. cleaned and pared. The hands and forearms are then im- mersed in a saturated solution of potassium permanganate un- til they are stained a deep mahogany red, or almost black. They are then immersed in a saturated solution of oxalic acid until they are completely decolorized. The oxalic acid is then washed off in sterile water. Describe the methods used in plastic surgery. Displacement. — Stretching or sliding of tissues. 1. Simple approximation after freshening the edges. 2. Sliding into position after transferring tension to adjoining localities. Interpolation — Borrowing material from adjacent regions, from a limb or from another person. 1. Transferring a flap with a pedicle. 2. Transplanting without a pedicle. Retrenchment. — Removing redundant material and causing cicatricial contraction. Describe local anesthesia. State the precaution neces= sary in producing it. Local anesthesia is best effected by the use of cocaine, and may be employed with safety when the cocaine can be con- fined to a limited area. The part, say a finger, is asepticized and a stout ligature or fillet placed about its base. The cocaine is then injected between the layers of the skin and also in the vicinity of the digital nerves. The entire finger will be anesthetized within three or five minutes. Precautions. — Asepsis — Never risk the absorption of an amount of cocaine which exceeds the normal dose. At the conclusion of the operation, loosen the ligature and then tighten it again after five or ten seconds. Repeat at intervals so that the cocaine in the tissues will not all be absorbed at one time. Give the clinical appearance of squamous lesions of syphilis in the mouth. The epithelium is whitish and opaline resembling a surface that has been touched by nitrate of silver. If eroded, the surface is red and smooth after the superficial epithelium has ORAL SURGE RY. 131 desquamated. The patch is always circular or regularly oval aud the derma is thickened upon its surface. Give a differential diagnosis of an abscess, a cyst and a fatty tumor. An abscess is characterized by redness, heat, pain, swelling, fever, fluctuation, pointing, and the hypodermatic needle re- veals pus. A cyst is characterized by an absence of inflammatory symp- toms, unless it is inflamed. Fluctuation is present and the hypodermatic needle reveals a non-purulent fluid. A super- ficial cyst can be better outlined than is the case with an abscess. A fatty tumor is inelastic and doughy to the touch. It is adherent to the skin and, when it is moved, causes a dimpling of the overlying integument. There is an absence of in- flammatory symptoms. State a method of sterilizing sponges. The sponges should be placed in a muslin bag and well pounded to remove all particles of sand and other foreign materials. They are then rinsed out in water several times. A very good way is to place them in a basin, or pail, and al- low T the water to run in upon them from a tap for several hours. They are next soaked in a saturated solution of per- manganate of potassium, are afterwards decolorized in a so- lution of oxalic or of sulphuric acid, and are then left for twenty-four hours in an aqueous solution of hydrochloric acid, made strong enough to taste slightly sour. After this, they are again soaked in water until the washings are clear. They are next placed in a bichloride solution (1-500) for twelve hours, and finally are rinsed in warm water and preserved in covered glass jars containing a three percent, aqueous so- lution of carbolic acid, the solution being changed every week. What class of patients should not be anesthetized by (a) nitrous oxide, (b) chloroform, (c) ether? (a) Those with diseased blood vessels. Those in whom com- plete muscular relaxation is desired. 132 ORAL SURGERY. .(b) Those with myocardial disease, (c) Those with bronchitis or Bright 's disease. Give reason for removing a blood clot from the surface of a wound. The chief reason for removing a clot is that it is capable of forming a most excellent culture medium for the growth of bacteria. Its presence consequently favors the development of sepsis. If the clot is not removed by the surgeon, it will be removed by nature, since it is nothing more nor less than a foreign body. Give the etiology and treatment of erosion. Etiology. — Acids attacking the necks of the teeth. The acid may proceed from the buccal glands or be regurgitated from the stomach. Treatment. — Applications of milk of magnesia, chalk, or some such alkaline substance. Correct any digestive defect and destroy the glands by the cautery, if they can be definitely located. The eroded places should be filled. Give the method of operation for exposing the inferior dental nerve. Incision, two inches in length, along the lower border of the jaw, beginning slightly behind the angle and well under the border. The upper edge of the wound is displaced up- ward over the ramus, the Masseter muscle is separated from the bone with a periosteal elevator, and a %-inch trephine applied one inch and a quarter above the angle. This ex- poses the nerve at its entrance into the inferior dental fora- men. The nerve may' be brought to the surface by a small hook or, the incision may be prolonged above and parallel to the edge of the jaw and the canal for the nerve laid open all the way to the mental foramen. What dangers may result from punctured wounds? Give treatment. The greatest danger is sepsis. Another is tetanus. A lesser danger is injury of deep structures. ORAL SURGERY. 133 Treatment. — Secure efficient drainage and pack the wound so as to make it heal up from the bottom. Infection with tetanus should be guarded against by opening up all parts of the wound so that the oxygen of the air may gain free access. Describe Barton's bandage. The roller should be two inches in width and six yards in length. The initial extremity of the roller is placed on the head just behind the mastoid process. The bandage is then carried under the occipital protuberance, obliquely upward, under and in front of the parietal eminence, across the vertex of the skull, then downward over the zygomatic arch, under the chin, thence upward over the opposite zygomatic arch and over the top of the head, crossing the first turn as nearly as possible in the median line, and thence carrying the turns of the roller under the parietal eminence to the point of com- mencement. The bandage is then passed obliquely around under the occipital protuberance and forward under the ear to the front of the chin, thence back to the point from which the roller started. These figure-eight turns over the head and the circular turns from the occiput to the chin should be repeated, each turn exactly overlapping the pre- ceding one until the bandage is exhausted. Differentiate an ulcer and a fistula. An ulcer is a solution of continuity of the skin or mucous membrane due to molecular death of the part. A fistula is a suppurating tract connecting a cutaneous or mucous surface with a normal cavity of the body, or connect- ing two normal cavities. Strictly speaking a fistula always has two openings. Give the diagnosis of ulcerating gumma of the oral cavity. Preceding history of syphilitic infection and the presence of an inflammatory swelling, the surface of which is ulcer- ated. The ulcer is deeply excavated, the edge is undermined, the surrounding tissues are hyperemic, and there is a tough 134 ORAL SURGERY. or soft tenacious slough adherent to its base. There is no glandular involvement, as a rule; the sore will heal under specific treatment and leave a depressed scar or a perforation. Give the differential diagnosis between malignant and non=ma!ignant tumors of the upper jaw. Malignant tumors grow rapidly, give metastasis, are pain- ful, recur after removal, may ulcerate, and finally cause death. Non-malignant tumors grow slowly, do not give metastasis, are not painful (except by pressure), do not recur after re- moval, rarely ulcerate, and do not cause death (except me- chanically) . The malignant tumors of the upper jaw are of more frequent occurrence than are the benign. Give the direction for diagnosis of mercurial stomatitis. The diagnosis is made by observing the following points: The individual may work in mercury or have been taking the drug internally. There will be tenderness of the gums, mani- fested by bringing the teeth forcibly together, redness of the gums near the insertion of the teeth, a metallic taste, profuse salivation, fetor of breath, the tongue may be reddened, swollen, and ulcerated, and protrude from the mouth. In severe cases, ulceration of the mucous membrane, loss of teeth, and necrosis of the jaw may result. Describe a four=tai!ed bandage. This bandage is prepared by taking a portion of a roller bandage, three inches wide and one yard in length, and split- ting each extremity up to within two inches of the centre. The undivided portion of the bandage is placed upon the point of the chin. The two lower tails are then drawn up and tied over the vertex while the two upper tails are secured behind the occiput and then, to prevent slipping, these ends are knotted to the ends of the former. What precaution should be taken in extracting molars and bicuspids of the inferior maxilla? The usual antiseptic precautions, such as sterilization of instruments, and cleansing of parts by germicidal solutions. ORAL SURGERY. 135 The selection of a proper forceps, the history as to previous ex- traction, whether difficult or a tendency to hemophilia, and above all, keep in mind the fact that fracture may occur either in the body or in the alveolar process if violence is used. The jaw may also be dislocated. The proper motion for loosening root attachments should be applied and some guard placed over the upper teeth to prevent breaking them. Be prepared to treat shock and hemorrhage. Give the pathology and treatment of epithelioma. Patholog t y. — Squamous epitheliomata are nodular or wart- like elevations of the skin or mucous membranes tending to superficial ulceration. The microscope reveals branching columns of epithelial cells extending from the papillae of the skin into the deeper structures. "Cell-nests" are frequent. Involvement of the lymphatic glands is less marked than in the remaining forms of carcinoma. Cylindric epithelioma. — Found in gastro-intestinal tract and in uterus. They are composed of acinus-like tubular structures, frequently composed of a number of layers of epi- thelium, the outer layer often being distinctly columnar. Later on, the acini become filled with epithelial cells of vari- ous shapes and the cylindric character is lost. They more nearly resemble the glandular cancers in their general char- acteristics than does the squamous variety. Treatment. — Thorough excision of the involved tissue wher- ever found. If a squamous epithelioma is local beyond doubt, and there be no lymphatic involvement (as in rodent ulcer), the growth may be destroyed by Michel's or Bougard's paste. Describe palliative treatment of malignant tumors of the mouth. The palliative treatment of malignant tumors of the mouth consists in keeping the buccal cavity as aseptic as possible by means of antiseptic mouth-washes. Local anesthetics (cocaine, menthol) are employed. Morphine is administered and, in some cases, it has been advised to divide the lingual nerve. If the case is one of sarcoma, Coley's fluid may be tried. The X-ray is a recent addition. 136 ORAL SURGERY. Give the treatment of a case of non=union in fracture of the inferior maxilla. Make incision along lower border of the body of the jaw, expose fragments, remove any intervening tissue, freshen edges, and wire together. In some cases it may suffice to rub the ends of the fragments together and then apply a Ham- mond splint. Give treatment of a lacerated wound. If the wound can be thoroughly cleansed and the edges have not been markedly contused, such a wound should be sutured and a wet bichloride dressing applied. If the wound cannot be thoroughly cleansed or if the edges are contused, clean the wound as thoroughly as possible, irrigate with a bichloride solution (1-2000), and apply warm antiseptic fo- mentations until all sloughs have separated. The wound should then be treated like any granulating surface. What is arthritis? Give treatment. By arthritis is meant an inflammation of a joint which in- volves all the structures of which it is composed. Treatment of Acute Arthritis.^In early stage, elevate the limb, immobilize absolutely, and put in such position that, if ankylosis occurs, the part will be of some use to the patient. Fomentations or an ice-bag may also be applied. As soon as symptoms of approaching suppuration appear, open joint freely in one (or better two) places, and wash out with some sterile or antiseptic solution (normal saline solution or sublimate 1-8000). Maintain fixation, continue irrigation until all symptoms of inflammation have disappeared, and look after the general health. If ankylosis occurs in a faulty position, resection of the joint may be required. How would you arrest hemorrhage from the tongue? Hemorrhage from the tongue may be arrested by exposure to the air, by ice, hot water, ligation, suture, and the cautery. Give etiology and treatment of false ankylosis. Etiology. — Inflammation outside of the joint, disuse. DEAL SURGERY. 137 Treatment. — Where inflammation has been cured, massage and passive motion, the alternate hot and cold douche, and graduated exercise. If due to disuse, exercise, massage and galvanism. Define neuritis. Give cause and treatment. By neuritis is meant the inflammation of a nerve. Causes. — Inflammation, exposure to cold, some abnormal condition of the blood induced by rheumatism, chronic al- cholism, diabetes, etc. Treatment. — Keep part at rest. Apply blisters along the course of the nerve. The administration of small doeses of bichloride of mercury is sometimes of benefit, Treat any local cause or constitutional dyscrasia. It may be necessary to control pain by hypodermatic injections of morphine. When should a sequestrum be removed? A sequestrum should be removed as soon as it has se- parated. If the sequestrum is central (as in inferior maxilla), it should be left until the involucrum becomes sufficiently strong, the case meanwhile receiving appropriate antiseptic treatment. In such an instance, etc., the sequestrum acts as a splint. Define asphyxia. Give treatment. Asphyxia is suffocation. The suspension of vital pheno- mena which results when the lungs are deprived of oxygen. Treatment. — Remove any local cause. If impossible to re- move cause (in the larnyx for example), quickly perform tracheotomy below obstruction. After obstruction is removed or circumvented, artificial respiration is always indicated. If no local obstruction, artificial respiration from beginning; strychnine, atropine or probably cocaine should be given by an assistant while the operator is performing artificial re- spiration. How should chloroform be administered? Ether? What accidents may occur? Give treatment. Chloroform should be administered in free admixture with air (chloroform vapor 5%, air 95%). 138 ORAL SURGERY. Ether should also be administered by the open method (ether vapor 95%, air 5%). Accidents. — Death from cardiac or respiratory paralysis, mechanical asphyxia, congestion of brain, or by the entrance of vomited material into the larnyx. Treatment. — Failure of respiration is treated by with- drawal of anesthetic, clearing out throat and pulling forward of tongue, the performance of artificial respiration, the ex- hibition of pungent aroma tics (ammonia), the hypodermatic injection of strychnine, atropine, or cocaine, the alternate douche of hot and cold water, and the use of the ''electric brush. ' ' Failure of circulation. — Withdraw the anesthetic, invert the patient, give hypodermatic injections of whiskey and strychnine, and perform artificial respiration, clearing out the mouth and holding the tongue forward. Describe the operation for removing calculi from the salivary duct. The calculus is located by means of a probe and the pal- pating finger: the duct is incised and the calculus removed. If the calculus is situated in the substance of the submaxil- lary gland, total removal of the gland may be necessary. In some cases the calculus may be seen projecting from the main duct of a gland, in which case it may be removed without incision. How are the wounds of arteries classified? Incised, lacerated, contused, punctured, poisoned, and gun-shot. They are sometimes divided into those in which the artery is completely divided and into those in which the artery is only partially divided. What is the difference between a traumatic and a con= genital dislocation? A traumatic dislocation is one produced by the application of external violence and muscular force, acting alone or in combination. ORAL SURGERY. 139 A congenital dislocation is a malformation of a joint which exists at birth. Describe Gibson's bandage, The roller should be two inches in width and six yards in length. The initial extremity of the roller should be placed upon the vertex of the skull in a line with the anterior por- tion of the ear; the bandage is then carried downward in front of the ear to the chin, passed under the chin, and carried upward on the same line until it reaches the point of starting. The same turns are repeated until three com- plete turns have been made. The bandage is then continued until it reaches a point just above the ear, where it is re- versed, carried backward around the occiput, and continued around the head and forehead until it reaches its point of origin; these circular turns are continued until three turns have been made. "When the bandage reaches the occiput, hav- ing completed the third turn, it is allowed to drop down to the base of the skull, and it is then carried forward below the ear and across the chin, being brought back upon the opposite side of the head and neck to the point of origin; these turns are repeated until three complete turns have been made, and upon the completion of the third turn, the band- age is reversed and carried forward over the occiput and vertex to the forehead, and its extremity is here secured with a pin. Pins should also be applied at the points where the turns of the bandage cross each other. Give the etiology, diagnosis, and treatment of tetanus. Etiology. — The infection of a wound with the bacillus tetani. It is more common in hot climates, in dark-skinned races, and in those who are employed about stables. Hygienic errors favor development, particularly the overcrowding of sick and wounded in a limited space. Diagnosis. — Trismus, opisthotonos, emprosthotonos, or pleurosthotonos. The spasms are tonic in character with clonic exacerbations. Constipation and retention of urine are present. The mind is clear, there is a hypersecretion of 140 ORAL SURGERY. sweat, and little or no fever. It may be possible to discover the source of infection. Treatment. — Preventive treatment consists of applying the principles of antisepsis to every wound encountered. Local treatment. — Antiseptic treatment of wound. Symptomatic treatment. — Chloroform during the exacer- bations of the spasm and chloral between the exacerbations. The introduction of food into the stomach by stomach tube, and the evacuation of the rectum and bladder at regular in- tervals. Calabar bean has been highly recommended. Specific treatment. — The administration of the anti-toxin, which is best done by trephining and introducing it beneath the dura mater. The results obtained in man are anything but promising. What is pyorrhea alveolaris? Give the etiology and treatment. Pyorrhea alveolaris is an inflammatory condition of the margins of the gums, accompanied by a muco-purulent dis- charge, which arises from pockets or pouches extending for a greater or less distance along the roots of the teeth. Etiology. — Gout, uric acid, diabetes, certain conditions of diet, and irregularities of the teeth might be mentioned as pre- disposing factors. It is always preceded by an excessive de- posit of tartar, beneath which bacterial infection occurs. Treatment. — Removal of tartar and application of astrin- gents and antiseptics, preferably peroxide of hydrogen. These applications must be made to all parts of the pouches or pockets. Sulphuric acid has been recently recommended. The treatment is prolonged and tedious. In many cases the teeth have been sacrificed. Define a cyst. Mention three divisons of cysts and give the etiology and treatment of one division. By a cyst is meant a more or less rounded cavity with a dis- tinct lining membrane, distended with some fluid or semi- solid material. 1. Cysts formed by the distension of pre-existing spaces. ORAL SURGERY. 141 2. Cysts of embryonic origin. 3. Cysts of new formation. Etiology. — Dermoids may be due to the persistence of epithelial cells, in the deeper tissues, in situations where fleshy segments coalesce during fetal life. They may also be due to the persistence of certain tubular canals (thyro- glossal duct, post-anal gut). Cysts of embryonic origin (dermoids) are to be removed by careful dissection. What are aseptic wounds? Describe an aseptic wound. Aseptic wounds include all which are preserved from con- tamination by poisonous bacterial products, whether such poison come in contact with the wound directly or be gener- ated in it by the action of germs that gain access to it. In an aseptic wound the process of healing is undisturbed, union occurs by first intention, there is no suppuration and no visible sign of inflammation. How should a penetrating wound of the temporo=maxil= lary articulation be treated? If the wound is small and there is reason to believe that it was made by an aseptic instrument, the skin should be thoroughly cleansed and an antiseptic dressing applied. A careful watch is then kept upon the condition of the joint and the temperature of the patient; as soon as signs of acute arthritis manifest themselves, free incisions are to be made into the joint, so as to relieve tension and allow of irrigation. If the wound was inflicted by a dirty instrument, the wound should be enlarged, if necessary, so that its depths may be carefully examined and thoroughly cleansed. The cavity should be irrigated and drainage inserted. If acute arthritis supervenes, it must be treated in the usual way. Where are salivary calculi most frequently found? Give treatment. Salivary calculi are most frequently found upon the necks of the teeth opposite to the salivary ducts and in the duct of Wharton. 142 ORAL SURGERY. Treatment. — Removal and the regular use of Philipp 's milk of magnesia. If protruding from orifice of the duct, they may simply be extracted. If within the duct, they should be cut down upon and removed. How should a salivary fistula be treated? This affection practically always occurs in relation to Sten- son 's duct. If the buccal portion is involved, the duct may be slit up from within the mouth. If the masseteric portion is wounded, a fine probe should be passed into the duct (from the mouth) as far as the fistulous opening, and then brought out at this orifice. A double thread of silk is now tied to the end of the probe and drawn through the thickness of the cheek, along the buccal portion of the duct, and out of the external wound. A fine drainage tube is then carried along the same tract, and left to project both externally and in- ternally. A silk thread is attached to each end of the tube and knotted around the angle of the mouth. In this manner a passage is re-established into the mouth, and as soon as it becomes easier for the saliva to travel along this than through the external wound, the fistula will close. The outer half of the tube may be removed in a few days, and only a thread allowed to remain in the external wound, which gradu- ally contracts so that more and more of the saliva, finds its way to the mouth. The silk thread and tube are finally removed, and, if the canal remains patent, the external wound soon heals. If the buccal portion of duct is obliterated so that the probe cannot be introduced, the thread and tube may be passed through all of the tissues of the cheek by means of a trocar and canula. The subsequent steps are similar to those of the previous method. How should hemorrhage from the gums be treated? By means of hot water, cold, compression, peroxide of hydro- gen, styptics, suprarenal extract, or the actual cautery. If due to scurvy, appropriate antiscorbutic treatment ; if due to hemophilia, calcium chloride gr. xxx t, i. d. and apply fibrin ferment, suprarenal extract, or cocaine, locally. ORAL SURGERY. 143 Define necrosis. Give its diagnosis and treatment. By necrosis is meant the death of bone en masse. The diagnosis is made by the presence of a sinus, the history of a preceding inflammation, and the results obtained by prob- ing. Dead bone feels rough and hard ; the probing is not painful nor is it followed by bleeding. Treatment. — Early in necrosis, endeavor to moderate in- flammation upon which the affection depends and open any abscesses that may form. During the time occupied by the loosening of the dead bone, no operative treatment should be instituted, as a rule, but attention should be given to the general health. As soon as the necrosed portion has become detached, it should be removed. What is a dislocation? Name the varieties, and give the causes. A dislocation is a displacement of one or more bones of a joint from its natural position. It is also the displacement of any organ from its natural position. Traumatic. — Due to violence or muscular action. Pathologic. — Due to disease. Congenital. — Due to an error of development as a result of which a normal location of the bony constituents has never been present. (The term congenital "dislocation" is really a misnomer — it is a congenital malformation.) What is an incised wound? Give the prognosis and treatment. An incised wound is one made by any sharp cutting instru- ment. Prognosis. — Nearly always favorable, but depends upon the region involved and asepsis of the wound. Treatment. — Arrest hemorrhage. Render the wound as aseptic as possible. Unite the edges of the wound by means of sutures and apply a septic dressing. Give diagnosis and treatment of caries. The symptoms of caries are those of osteitis complicated by 144 ORAL SURGERY. an abscess leading to the softened bone. When caries is prim- ary, it particularly involves the cancellous tissue (ends of long bones, flat bones). The pus from carious bone contains an excess of phosphate of lime. Treatment. — If syphilitic, give potassium iodide; if tuber- cular, cod-liver oil with iodide of iron. Secure best hygienic surroundings. In early stages while the disease is advancing, keep the parts clean and free from irritation. When acute symptoms have subsided, an attempt may be made to remove the diseased bone by applications of iodine or of the mineral acids. If the carious bone can be reached from the surface, it may be removed with a gouge or with a burr-head drill. If the disease is extensive, excision may be required. In some cases amputation is necessary to prevent fatal exhaustion. How may general infection be caused by oral operations? The wound in the buccal cavity may become infected by any of the micro-organisms found within the mouth. From this local source, the bacteria, their products, or both, may pass into the general circulation. Give the symptoms and treatment of acute suppurative periostitis. If the bone is superficial, there will be all of the symptoms and signs of inflammation. If the bone is deep, redness, swelling, and heat may not be observed over the inflamed area, on account of the density of the periosteum. The pain is of a most intense, aching character, worse at night, and greatly increased by pressure or by a dependent position of the part. If swelling is present, it is brawny in character and subse- quently becomes red, edematous and softened in the centre. If the abscess has opened spontaneously or has been incised, bare bone is exposed, the greater portion of which usually dies. This dead bone is either absorbed (if very small in amount) or cast off as a sequestrum. Treatment. — A free aseptic incision down to the bone at the earliest possible moment, Antiseptic dressing. If necrosis ORAL SURGERY. 145 has occurred, it must receive appropriate treatment. Sup- porting or antidiabetic treatment constitutionally. Give the differential diagnosis between syphilitic and aphthous ulceration. Syphilitic ulcers occur in the shape of cracks or fissures upon the sides or tip of the tongue, or upon the cheeks and lips. They are common in the secondary period of the disease. Papular eruptions of the skin and mucous patches may also be observed. These ulcers respond to anti-syphilitic treatment. Aphthae commence as small blisters, which run a rapid course and are accompanied by slight salivation. The ulcers are superficial, sharply outlined, multiple, and are situated not only upon the tongue, but particularly upon the cheeks and lips. Give the etiology and symptoms of the congenital mal = formation known as cleft palate. Etiology. — Failure of the palatal processes to unite. Symptoms. — Inspection reveals a cleft in the' median line. If the palatal process of one side has united with the ethmo- vomerine septum, a cleft slightly to one side (usually to the left) of the median line is observed. Since the union of the palatal processes takes place from before backward, it is rare to have a cleft of the anterior portion of the palate without the posterior portion being also involved. As a rule, there is considerable impairment of nutrition, from interference with deglutition. The exposure of the nasal mucous mem- brane leads to the formation of scabs which undergo putrefac- tive changes, producing a condition somewhat resembling ozaena. When the child learns to talk, articulation is fre- quently so indistinct that it is difficult to understand, and the voice has a peculiar and characteristic intonation. The so-called explosives (whether dentals, labials, or gutturals) which require a certain amount of air-pressure within the mouth for their proper pronunciation, are difficult to pro- duce. This is particularly to be observed in the letters b, d, p, t, g and f. 10 146 ORAL SURGERY. Give the diagnosis and treatment of trismus caused by impacted third molar. Diagnosis. — There is a partial or complete inability to open the jaws. Inspection reveals the impaction of the third molar. Necrosis may be present. Treatment. — Relief of the impaction, either by extraction of the offending tooth or of the second molar. If necrosis is present, it must be treated upon general principles. Mention the most reliable agent for the destruction of microorganisms. How should it be used? Heat. — It may be used in the form of dry heat or moist heat (steam, under pressure if necessary, hot water). It should penetrate to the centre of the material to be sterilized. What diseases of the tongue may be caused by diseased teeth? Traumatic ulceration, glossitis, abscess, and epithelioma. Describe the preparation of the oral cavity for an aseptic operation. Asepsis, as applied to the oral cavity, is but a relative term. All cavities in the teeth should be cleansed, disinfected and filled. The interstices between the teeth must be carefully cleansed and the mouth repeatedly washed out by a boric acid solution as hot as can be borne. The nasal cavity should also be rendered as aseptic as possible, and the patient should gargle repeatedly with hot boric acid solutions. Define a multilocular cyst. A multilocular cyst is one which is composed of a number of loculi or chambers. Describe treatment and appliance for acquired cleft palate. Acquired perforations of the palate are usually due to syphilis, but lupus and traumatism are also occasional causes. Treatment should first be directed to the underlying cause. When inflammatory symptoms have subsided and nature has ORAL SURGERY. 147 done all she can to repair the defect, the local treatment is in- dicated. If the perforation is small, an attempt may be made to close it by freshening the edges of the perforation, dissect- ing np muco-periosteal flaps and suturing them together. This will rarely be practicable, however, and in the great ma- jority of cases an obturator or an artificial velum must be introduced. An obturator is a plate which is so adjusted as to close the perforation. It should never be made in the form of a plug, since the opening may be enlarged by the constant pressure and irritation. It is made of thin vulcanite or gold, and is fixed to the teeth and held in position by suction. Intra- nasal projection will sometimes improve the quality of the articulation by diminishing the size of the nasal cavity. An artificial velum is a plate obturator, to the posterior portion of which a hinged segment is attached, to take the place of the normal velum. This hinged segment may rest upon the nasal side of the soft palate. A thin rubber bag, filled with air and sewn to the posterior portion of the obturator, is sometimes used in place of the hinged segment. Artificial vela are by no means so satisfactory, as a rule, as are the plate obturators. Define odontalgia. Give the etiology and treatment of odontalgia. Toothache. It may be caused by many different pathologic conditions of the tooth or surrounding tissues, such as congestion of the pulp, exostosis of the roots, pulp nodules, mechanical or chemical irritation, reflected pains from irritation of areas supplied by other branches of the fifth nerve (impacted body in external auditory meatus, etc.), infection, mal-occlusion, exposure of dentine and denudation of roots. Treatment. — Removal of the cause. In the majority of cases the pulp of the tooth must be removed. Tincture of iodine to the gums and chloroform or oil of cloves to cavities in teeth, might be mentioned as temporary measures. 148 ORAL SURGERY. Describe (a) Sylvester's method of producing artificial respiration; (b) Laborde's method of producing artificial respiration. (a) Sylvester's method. — The patient is placed upon his back with a folded coat or a pillow beneath the interscapular region, the throat is cleared of mucus, the tongue held well for- ward, and all constricting clothing removed from throat and abdomen. The operator kneels or stands behind the patient. The forearms are grasped near the fully flexed elbows and the lower portion of the thorax is compressed for a few seconds by forcing the patient's elbows against the thoracic wall. The arms are then moved outwards and upwards until the hands cross over the head. This secures elevation of the costal walls and simulates inspiration. The arms are kept in this position for a few seconds and then brought down- ward to the first position, pressure being made upon the costal walls with the elbows of the patient. This simulates expiration. These movements are to be repeated from twelve to fifteen times a minute. (t) Laborde's method. — After clearing the throat of mucus, rhythmic traction is made upon the tongue. Describe the effect of arsenic upon the pulp of a tooth. The pulp becomes devitalized and there is an absence of the previously existing sensibility, as may be demonstrated by the use of any exploring instrument. State the pathologic changes in chronic inflammation. Dilatation of blood vessels, slowing of current, exudation of fluid, transmigration of leucocytes and multiplication of the pre-existing connective tissue cells of the part. The only dif- ference between acute and chronic inflammation is one of degree. In chronic inflammation the productive changes are much more marked than the exudative or the degenera- tive ones. Describe the healing of wounds, irrespective of the ana= tomic structure of the tissue involved. The healing of an aseptic wound will be described. There ORAL SURGERY. 149 is a certain amount of exudation, resulting in the formation of fibrin, which temporarily binds the lips of the wound to- gether. This network of fibrin serves as a framework for the leucocytes and multiplied connective tissue cells. The exu- date becomes vascularized and is then known as granulation tissue. The leucocytes have nothing to do with the building up of tissue. They destroy the fibrin network and then either return to the circulation or are fed upon by the connective tissue cells or fibroblasts. The fibroblasts soon become spindle- shaped, and their ends become split up into primitive fibrillar This conversion of the round fibroblasts into the connective tissue fibre results in the contraction of the cicatrix, which binds the lips of the wound tightly together. Define contusion, luxation and fracture. A contusion is a subcutaneous laceration of the tissues. A luxation is a displacement, as regards their relative posi- tion, of the bones which enter into the formation of a joint. A fracture is a solution of continuity of bone, produced by violence. Name two forms of tumors which may involve the tissues of the face or jaws. State whether benign or maHgnant and briefly outline surgical treatment. Epithelioma, sarcoma. Both of these tumors are malignant. The treatment consists of the thorough removal of all of the affected tissues. If a complete operation cannot be performed, the treatment is simply palliative. Name three congenital deformities of the oral tissues which affect the speech. Briefly outline the surgical treatment of each. Microglossia, hare-lip, and cleft palate. Microglossia is best treated by removing a V-shaped piece of the tongue, with the apex directed backward, and uniting the resulting wound by sutures. Hare-lip is treated by paring the edges of the cleft and 150 ORAL SURGERY. bringing them together by sutures. The depth of the lip should be increased to allow for subsequent contraction. Cleft palate is treated by paring the margins of the cleft, together with its anterior angle, elevating the two lateral flaps of mucoperiosteum and uniting them in the median line by sutures. Lateral incisions are made if it is necessary to re- lieve tension. Give the causes of antral empyema. The extension of inflammation from carious teeth, direct violence applied over the cavity, an injury to the alveolar pro- cess which opens the antrum, and the extension of a suppura- tive process from the nasal cavity. Differentiate between fracture and dislocation of the mandibular condyle. Tn fracture of the neck of the condyle, the condyloid frag- ment is drawn forward and inward by the external pterygoid muscle and the body of the bone is displaced toward the oppo- site side, somewhat simulating a dislocation. The mouth is closed, however, and any attempt to open it produces pain and generally crepitus. The deformity recurs almost immediately after reduction unless the fragments are held in apposition. Tn dislocation of the mandibular condyle (unilateral dis- location of the jaw) the mouth is open and cannot be closed. The chin is directed toward the sound side. Upon external palpation the condyle can be felt in front of its normal posi- tion which is the site of a vacuity; upon internal palpation the coronoid process may be felt in an advanced position. Crepitus is absent and the deformity does not recur after reduction as long as the mouth is kept closed. a. Describe tic doloreux. b, Why is it of special inter- est to the dentist? c. What surgical operations are prac- ticed for its relief? Tic doloreux or trifacial neuralgia is characterized by severe paroxysmal pain in the region supplied by one or more of the divisions of the trifacial nerve and is not associated with structural changes in the nerve. ORAL SURGERY. 151 b. Tic doloreux is of special interest to the dentist because it may simulate affections of the teeth, of the alveolar pro- cess, or of the maxillary antrum. c. The surgical operations practised for its relief are neurec- tomy of the affected branch of the fifth nerve, excision of the nerve and plugging the particular canal, removal of Meckel 's ganglion, and removal of the Gasserian ganglion. Give the diagnosis of ranula. A ranula is a cystic swelling in the floor of the mouth gener- ally to one side of the median line. It is translucent and bluish in appearance and is covered with thin healthy mucous membrane. The fluctuating mass may push up the anterior portion of the tongue and interfere with deglutition and arti- culation. Inflammatory symptoms are absent. Puncture re- veals a glairy viscid fluid somewhat resembling saliva. A dermoid cyst in this region usually involves the tongue to a greater or less degree, is more deeply placed than a ranula, and is more apt to project and give fluctuation in the submaxil- lary region. Differentiate between dislocation and double fracture of the lower jaw. In bilateral dislocation, the mouth is wide open and cannot be closed. Upon both sides, there is a vacuity in front of the tragus and the condyle may be palpated in an advanced posi- tion ; palpation from within the mouth reveals an anterior dis- placement of the coronoid processes. The chin is carried for- ward and downward so that face seems to be elongated. Double fracture is characterized by loosening and irregular- ity of the teeth, preternatural mobility, crepitus, and drib- bling of bloody saliva. The central fragment is displaced downwards by the suprahyoid muscles. Name and describe the surgical operation for cleft palate. The operation proposed by Brophy of Chicago promises to revolutionize the treatment of cleft palate. lie perfers operating at the third month. Observing all 152 ORAL SURGERY. antiseptic detail, the mucous membrane at the margin of the cleft is divided and all of the soft tissues are elevated from the hard palate, including the periosteum. The edges of the cleft are then pared throughout the entire length of the soft palate and the membranes at the distal surface of the hori- zontal plates of the palate bones are divided. This allows the soft parts to fall together and obviates the necessity of mak- ing lateral incisions into or through the palate. Four tension sutures of silver wire No. 22 are now introduced and their extremities are passed through lead plates. These lead plates (No. 22 American gauge), are perforated with holes, corres- ponding to the number of sutures, and extend from the an- terior margin of the fissure to the distal border of the soft palate and are moulded to conform to its shape. Before the lead plates are fixed in place, coaptation sutures of silk are introduced into the margins of the cleft but are not tied until the edges of the cleft have been approximated by the tension sutures and lead plates. Immediate union should be secured. If the patient is older and the bones have commenced to harden, Brophy thoroughly removes the edges of the fissure and trims the opposing edges of the bones. The cheek is then raised and a strong special needle threaded with a large braided silk ligature, is passed through the substance of the bone to the central fissure. The needle is introduced just back of the malar process and high enough to insure its passage above the palate bone. An opposite needle now carries a corresponding suture through the opposite side, one loop is threaded into the other, and one loop may thus be carried through both maxillary bones. Silver wire No. 20 is now threaded into the loop of silk and drawn through both bones. In a similar manner a second wire suture is passed nearer the anterior portion of the maxilla above the palatal plate. Two lead plates (No. 17 American gauge) are now made to fit the buccal convexity of the bone and are perforated for the re- ception of the silver sutures. Upon each side the posterior suture is twisted with the anterior suture until the bones are approximated. If the bones do not come together a hori- ORAL SURGERY. 153 zontal section of the malar process is made upon each side when the bone can be readily moved toward the median line. Any irregularities of the cleft may be closed by a few coapta- tion sutures of silk, but this is not usually necessary. a. How is a simple cyst in soft tissues differentiated from other tumors? b. What surgical measures are necessary to prevent its recurrence? c. Are cystic growths classi= tied as benign or malignant? a. A cyst is characterized by an absence of inflammatory symptoms, unless it is inflamed. Fluctuation is present and the hypodermatic needle reveals a non-purulent fluid. A superficial cyst can be better outlined than is the case with an abscess. b. The complete removal of the cyst wall. c. Cystic growths are classified as benign. a. Give diagnosis of necrotic alveolar process, b. What important condition of the diseased bone should be deter= mined before operating? c. Outline the operation. a. There will usually be one or more sinuses which lead down to sequestra. Necrosed bone can be readily recognized by the hard and rough sensation communicated by the probe. b. No operation should be performed until the sequestrum has become detached. c. Make an incision down to the bone in the line of the prin- cipal cloacae. Two or more of these are united by sawing through the invaginating bony tissue with a Hey's or Gigli saw and the sequestrum is freely exposed. The sequestrum may now be withdrawn entire, or, if necessary, sawn in two and each half extracted separately. The cavity should be thoroughly irrigated and packed with antiseptic gauze. a. In a case of accidental obstruction of the glottis with strangulation and death impending, what should be done to save the life of the patient? b. Give details of procedure. a. Tracheotomy. b. The patient is placed in the dorsal position with the 154 ORAL SURGERY. head extended and held in such a position that the median line of the face will correspond to the median line of the neck. An incision, about two inches in length is made in the median line, from below upward, and terminating at the thy- roid cartilage. This incision divides the skin and superficial fascia. The anterior jugular veins, lying to either side of the median line, should be avoided by cutting between them and drawing them aside. The deep cervical fascia is next divided, the interval between the pretracheal muscles re- cognized, and the wound deepened by blunt dissection. The pretracheal fascia is now divided and the isthmus of the thyroid gland drawn downward. After hemorrhage has been checked and the tracheal rings exposed, the trachea is steadied (by a tenaculum if possible) and two or three rings are divided from below upward. The edges of the tracheal wound are then held apart. The wound and surrounding area should now be rendered as aseptic as possible, a suitable tracheotomy tube procured and inserted, and an antiseptic dressing applied. What facial and ora! tissues are usually attacked by epithelioma? The lip and the tongue are the parts most commonly af- fected but any portion of the epithelial surface (such as the gums or the buccal parieties) may be attacked. How may a foreign body be removed from the posterior nasal passages when lodged beyond the reach of tweezers or forceps? Example — a grain of corn, bead, or button. The foreign body can generally be pushed down into the pharynx by a probe introduced into the anterior nares. Care should be taken that it is not inhaled into the larynx or trachea or swallowed. In some cases it may be possible to dislodge it by the use of the Politzer bag or by syringing. Sajou's method may be tried, — it consists of drawing a cotton or wool tampon through the nasal passage from behind. It may be necessary to first break up the foreign body by drilling. ORAL SURGERY. 155 What is the treatment for the relief of empyema of the antrum when the teeth are sound and in place? The establishment of efficient drainage and thorough irri- gation of the cavity of the antrum. A sufficiently large open- ing should be made in the anterior wall of the antrum in the region of the canine fossa. The cause of the disease should also receive appropriate treatment. Give the etiology and characteristics of suppurative in= flarnmation. From a clinical standpoint all suppurative inflammations are due to the presence of pyogenic bacteria which may gain access to the affected part, through a wound or through the circulation. When an inflammation terminates in suppuration, the pain is at first dull and aching, and then assumes a throbbing character. The hard and brawny swelling becomes soft and fluctuating in the center and the overlying skin is edematous. The swelling also becomes more localized than in simple in- flammation and the redness assumes a dusky hue. The con- stitutional symptoms of impending suppuration are the oc- currence of a rigor or merely a sensation of chilliness, sweat- ing, and a sharp rise of temperature. Describe the intermittent pu!se, the thready pulse, and the hard pulse. An intermittent pulse is one in which a beat is occassionally missing while the pulse, in the intervals, is perfectly regular. The thready pulse is one of low tension and the artery can be palpated only during the beat. The hard pulse is one of high tension and the artery is full between the beats and can be rolled beneath the finger. Mention the disinfecting lotions used for surgical ir= rigations. Solution of bichloride of mercury (1-4000) and of car- bolic acid (1-100) are the ones usually employed. Mention might be made of lysol, creolin, salicylic acid, boric acid, hy- 156 ORAL SURGERY. drogen peroxide, potassium permanganate, oxalic acid, and chlorin water. State what the elevation of the body temperature dur= ing the treatment of fractures of the maxillae indicates. Give treatment. If the rise of temperature is not marked it is simply a con- comitant of the healing process and requires no special treat- ment. If the fracture is compound the most rigid asepsis possible should be observed. A considerable rise of temperature accompanied by a rigor or a chilly sensation and throbbing pain indicates the forma- tion of pus. The treatment would naturally consist in the evacuation of the pus, free drainage and the maintenance of the parts in as aseptic a condition as possible. Give the etiology, pathology, and treatment of chronic alveolar abscess. Practically all cases of alveolar abscess are due to carious teeth. The pathology is that of any chronic abscess in bone. First we have an osteitis and the inflammatory exudate, instead of becoming vascularized and converted into new tissue, breaks down ; its cells perish from malnutrition, degeneration occurs, and suppuration is the result. While the abscess may be reached through the alveolus, the best method is to extract the tooth, thus removing the original cause and securing drainage. In obstinate cases the abscess cavity should be curetted and packed with iodoform gauze. If a fragment of necrosed bone is present it must be removed to secure closure of the sinus. State the method of arresting hemorrhage from the in- ferior dental canal. By plugging the bleeding point with Halsted's "gut wool/' or with Horsley's antiseptic wax (beeswax seven parts, al- mond oil one part, and salicylic acid one part) . ORAL SURGERY. 157 Give the etiology, diagnosis, and prognosis of carcinoma of the mucous membrane of the buccal cavity. The etiology of carcinoma of the buccal mucous membrane is as obscure as is that of carcinoma in general. A predis- posing cause may be furnished by continual irritation such as the edge of a carious tooth or the taking of hot foods or undiluted spirits. The affection may commence as an ulcer or fissure, as a papilloma, or as a nodule, but in nearly all cases it is char- acterized by the early occurrence of ulceration and the ulcer- ated surface is surrounded by an indurated everted margin. Pain is not present early in the disease but may prove a valu- able factor in the diagnosis. The neighboring lymphatic glands may be involved. The age of the patient will usually furnish an additional aid. The prognosis is guardedly favorable if the growth can be entirely removed. If a complete operation is impossible the prognosis is absolutely unfavorable. Mention the rules necessary for surgical cleanliness. The entire field of operation, and the hands of the oper- ator should be rendered as aseptic as possible. The instruments, sponges, sutures, ligatures and everything coming in contact with the wound should be sterile. Free drainage should be provided if much exudation is ex- pected in the wound. After the operation the wound should be kept as aseptic as possible either by sterile occlusive dressings or by irrigation with antiseptic solutions according to the exigencies of the case. Describe (a) a quick pulse; (b) a feeble pulse; (c) an irregular pulse. State what each indicates. (a) The term "quick pulse' 1 is ambiguous. According to Broadbent, the word quick is capable of two applications in this connection since it may apply either to the rate at which the beats follow each other or to the character of the in- dividual beats. A "quick pulse" may consequently mean 158 ORAL SURGERY. either a frequent pulse or one in which the individual pulsa- tions are of short duration. A frequent pulse may be due to septic infection. A pulse in which the individual beats are of short duration is due to diminished intravascular tension. (6) A feeble pulse is one that is weaker than normal and usually indicates cardiac insufficiency. (c) An irregular pulse is one in which the beats follow each other at irregular intervals and are unequal in force. If of occasional occurrence it indicates reflex disturbance of the cardiac rhythm, gastric derangement with or without flatu- lence, or other functional affections. If permanent in char- acter it may indicate cardiac disease, affections of the re- spiratory organs, or the abuse of tobacco, tea, &c. Describe the operation of removing a benign tumor. A lipoma of the back will be selected as an example. After all aseptic precautions have been observed, an incision is made over the tumor extending down to its capsule. The fatty tumor and its capsule are then enucleated, usually by blunt dissection, all hemorrhage checked, the edges of the wound are united by sutures, and an aseptic dressing is applied. Describe the operation of removing a malignant tumor. We operate just as in the case of the benign growth but the incisions must be carried wide of the tumor and well into the surrounding healthy tissue. If neighboring lymphatic glands are involved they must be removed in continuity with the growth and no incision is to be made across the interven- ing lymphatic channels. The primary object is the complete removal of the tumor and the closure of the wound is of secondary importance. If a great deal of skin must be sacri- ficed the wound may be closed by sliding one or more flaps over it or by skin grafting. A rigid aseptic technique should be observed. dive the etiology, clinical appearance, and treatment of smoker's patch of the tongue. Smoker's patch is the stage of chronic superficial glossitis which is known as leukoplakia. It is due to an inflammation ORAL SURGERY. 159 of the mucous membrane causing an overgrowth of epithelium, which becomes heaped up into rough, dry, horny patches. The inflammation may be caused by excessive smoking, the drinking of undiluted spirits, the ingestion of highly seasoned foods, syphilis, or a combination of several of these causes. The treatment is unsatisfactory as far as cure is concerned. The exciting factor should be removed and the patch carefully watched for signs of commencing malignancy. The diet should be bland, sterile, and unirritating, and, after each meal, the teeth should be brushed and the mouth rinsed out with some mild antiseptic solution. No local applications should be made. Appropriate constitutional treatment should be instituted in syphilitic cases. Differentiate shock and syncope. Shock may be denned as the immediate constitutional ef- fect of an injury. "It is that state of general depression of the vital activity which occurs after severe injuries, especially where there has been violent stimulation of the peripheral nerves and nerve-endings, but may be induced also by some powerful impression applied to nerve centres" (Pick). Syncope is a state of suspended animation, due to sudden failure of the heart's action, producing anemia of the brain. It may occur without injury and be produced by the emotions, intrinsic cardiac conditions, depression of the heart from hunger or exhaustion, or by a sudden loss of blood. Differentiate carcinoma of the tongue and gummatous ulcer of the tongue. Carcinoma. Gummatous ulcer. Always single. May be multiple. Usually in the anterior half and Chiefly far back on the dorsum, at the side of the tongue. Other syphilitic lesions may be present in the mouth. Lymphatic glands usually involved. Lymphatic glands rarely involved. Painful. Painless. 160 ORAL SURGERY. Induration follows ulceration. Induration precedes ulceration. Everted ragged edges. Sharp-cut edges. There may be a history of preced- History of preceding syphilis, ing chronic superficial glossitis. Patient usually past 40. May be younger. Does not improve on potassium Improves rapidly on potassium iodide. iodide. The microscope may determine the diagnosis in doubtful cases. Both carcinoma and gumma are much more frequent in males than females (5 to 1). Describe the symptoms of syncope that may occur during the administration of chloroform. Give treatment. Sudden cessation of the pulse, sudden dilation of the pupil, blanching of the face, and secondary failure of respiration. Treatment. Stop the anesthetic. Invert the patient. An assistant should administer a hypodermatic injection of ether followed by one of strychnine and the operator should com- mence artificial respiration as soon as possible, care being taken that the tongue is held well forward to allow the air to enter the lungs. Give the etiology, diagnosis, and treatment of ulcer. The causes of ulceration are either constitutional or local. The constitutional causes all act by producing an impair- ment of vitality. These causes are senility, deficient innerva- tion, and diseases which induce malnutrition such as scurvy, diabetes, tuberculosis, and syphilis. The local causes are either interference with the circula- tion of a part or some irritation applied to a part. Diagnosis. An ulcer is a solution of continuity of the skin or mucous membrane due to molecular or particulate death of the part. Treatment. The constitutional treatment is that of the underlying disease or condition of malnutrition. It may be ORAL SURGERY. 161 said in general that the local treatment consists of the re- moval of the cause and the maintenance of the ulcer in as aseptic a condition as possible; it will naturally vary with the particular variety of ulcer. Describe (a) a frequent pulse; (b) a soft puSse. State what each indicates. (a) A frequent pulse is one which beats more rapidly than that of the average healthy individual. It may be due to idiosyncrasy, the action of drugs, or almost any departure from a normal state of health. (&) A soft pulse is one in which there is no increase of the intravascular tension. It may be felt in health. Give the etiology and treatment of acute infectious osteomyelitis of the inferior maxilla. Acute infectious osteomyelitis of the inferior maxilla may result from infection from without (as in a compound frac- ture) or from infection from within (hematogenous infec- tion). Various micro-organisms may be responsible, such as staphylococci, streptococci, typhoid bacilli, and the bacillus coli communis. The treatment should be early and energetic. It consists of making a large opening in the mandible and scraping out all of the diseased marrow. The medullary cavity should then be irrigated by strong solutions of bichloride of mercury (1-1000) and packed with iodoform gauze. State the complication that may arise from a compound fracture of the inferior maxilla. Give treatment. Acute infectious osteomyelitis. See answer to preceding question. Give the etiology, the pathologic anatomy, the constitu- tional symptoms, and the treatment of necrosis of the maxilla. Necrosis is practically always due to arrested circulation in the bone. This may result from injury, as when the 11 162 ORAL SURGERY. periosteum is torn away in a compound fracture. In ostitis the vessels may be compressed by the exudate in the Haversian canals and in acute periostitis and osteomyelitis the nutritive supply may be entirely destroyed and extensive necrosis re- sult. Necrosis of the jaw may also occur from exposure to the fumes of phosphorus or as the result of mercury when given to excess. Pathologic Anatomy. Where the necrosis is due to injury and only the outer laminae perish we speak of peripheral ne- crosis. If there is a limited inflammation of the cancellous tissue, usually tubercular, which leads to the death of a por- tion of the bone, as in chronic abscess, we speak of central necrosis. If the entire thickness of the bone is destroyed, as in cases of panosteitis, the term total necrosis is applied. The portion of dead bone is called a sequestrum. The peri- osteum surrounding a sequestrum deposits new bone and so forms an involucrum or invaginating sheath about the dead tissue. In this involucrum are a number of openings or cloacae which allow the pus to escape externally through sinuses in the soft parts. Where the periosteum has been torn away, re- sulting in peripheral necrosis, an invaginating sheath is not formed but the sequestrum is cast off by exfoliation. The constitutional symptoms vary according to the amount of tissue involved and the nature of the infection. If the ne- crosis is peripheral the only constitutional symptom may be a slight rise of temperature; but if it be total, as in cases of acute osteomyelitis, the patient is violently ill, and chills, hyperpyrexia, and profuse sweating are observed. The treatment consists of the removal of the sequestrum as soon as it has become loosened, the disinfection of the remain- ing cavity, and tamponade with iodoform gauze maintaining the parts in as aseptic a condition as possible and supporting the general health by appropriate measures. In cases of acute osteomyelitis, we do not wait for the sequestrum to form but clean out the medullary cavity at once as previously de- scribed. ■ i ORAL SURGERY. 163 Give the etiology, the pathologic anatomy, and the microscopic appearance of acute local periostitis. Acute local periostitis is usually the result of injury but may also be due to extension of an inflammation from the surrounding parts (example periostitis of the jaw from alveo- lar abscess). It may also result from constitutional diseases such as tuberculosis or syphilis and may follow acute rheu- matism, typhoid fever, scarlet fever, or measles. Pathologic Anatomy. The periosteum is swollen and red; its deeper layers in particular are infiltrated by inflammatory exudate which accumulate between the periosteum and the bone. The swelling produced in this manner is known as a periosteal node. The microscopic appearance is that of any acute inflam- mation. The vessels are distended and tortuous and the tissues are infiltrated with small round cells. If the disease has lasted some time areas of necrosis may be observed. Give the etioSogy and pathologic anatomy of caries of the maxillae. Caries is usually a tubercular affection but may be due to other conditions. It may occur upon the surface of a bone beneath a superiosteal gumma. It may also be the result of a non-tubercular rarefying ostitis where the entire bony struc- ture is absorbed and converted into granulation tissue. Pathologic Anatomy. As a result of hyperemia and the outpouring of an inflammatory exudate, the Haversian canals and trabecular spaces become crowded with granulation tissue which may show the characteristic structure of tuberculous disease. Some of these cells destroy the walls of the Haver- sian canals, forming the so-called Howship's lacunae. The cells situated within these lacunae are known as osteoclasts. The remainder of the granulation tissue undergoes caseation and this form of caries is called caries suppurativa. When the granulation tissue destroys the bone and then becomes absorbed, instead of undergoing caseation, we speak of caries sicca. If the granulation tissue is excessive and the destruc- 164 ORAL SURGERY. tion of bone is rapid so that it fungates into a joint or be- neath the skin, the name of caries fungosa. is applied. In some instances the granulation tissue dies before it absorbs and replaces the bone. In such a case, a mass of bone may be cut off from its nutritive vessels and die en masse when we speak of caries necrotica. Describe the character of the pain in trifacial neuralgia. State the location of pain when each of the three divisions is affected. The pain of trifacial neuralgia is paroxysmal and may be burning, darting, or lancinating in character. The skin may be exquisitely tender, particularly at certain points along the course of the nerve, the so-called tender points. The pain may sometimes be preceded by a tingling sensation and is usually limited to a certain group of nerves upon one side of the face. It may sometimes be relieved by pressure. . "When the ophthalmic division is affected the pain is located in the forehead, orbit, and nose. W 7 hen the superior maxillary division is affected the pain is located in the lower lid, in the side of the nose, in the lip, in the upper jaw, in the roof of the mouth, and in the upper teeth. WQien the inferior maxillary division is affected the pain is located in the ear, in the temporal region, in the lower jaw, and in the lower teeth. Give the symptoms and treatment of syphilitic perio- stitis. State the pathologic changes that may occur in syphilitic periostitis. In the early stages of secondary syphilis there may be ach- ing pains in the superficial bones and their surfaces may ex- hibit swellings which are very tender to the touch. The tem- perature of the patient is slightly increased. This form of periostitis soon disappears under the administration of mer- cury to which it is well to add some iodide of potassium which generally relieves the pain immediately. In the later stages of secondary syphilis a single periosteal ORAL SURGERY. 165 node may appear upon one of the superficial bones. It is ac- companied by aching pain which is always worse when the patient is warm in bed. The treatment consists of the ad- ministration of iodide of potassium. The pathologic changes that may occur in syphilitic peri- ostitis are caries, necrosis, the formation of gummata, and the formation of new bone. Give the etiology and symptoms of salivary calculus. Mixed saliva contains a certain percentage of calcium salts which are held in solution by carbon dioxid. Lactic acid fer- mentation is so common in the human mouth as to be almost a characteristic. This lactic acid coagulates the mucin; the calcium salts are precipitated by the escape of their solvent, carbon dioxide, and become entangled in the mucin coagulum. It is stated that coagulation of the mucin is not necessary to bring about this condition of affairs but that it's inspissation is alone sufficient. Symptom. The calculi are found upon the surfaces of the teeth, particularly opposite the mouths of salivary glands; beneath the margins of the gums, and in the ducts of the muciparous salivary glands (sublingual and submaxillary). The symptoms in general are those of a persistent foreign body in contact with a vital tissue. Give the etiology, pathology and treatment of acute alveolar abscess. Acute alveolar abscess is practically always the result of decayed teeth. The most superficial variety is known as ' ' gum-boil. ' ' The deeper varieties commence at the apex of a decayed fang. The pus may perforate the alveolar wall (or pass over its edge) and form a localized collection beneath the periosteum which may ultimately lead to necrosis of the jaw. In the upper jaw, the affection may cause empyema of the maxillary sinus or burrow along the hard palate; in the lower jaw, it may point on the cheek or at the lower margin of the bone. 166 ORAL SURGERY. The treatment consists of removing the offending tooth and establishing free drainage. In some cases drainage may be secured by drilling through the alveolar process but it is not a satisfactory method in general, owing to the difficulty of locating the particular fang involved. In the very super- ficial forms of acute alveolar abscess the tooth may be saved. Give the etiology of acute arthritis. Acute arthritis may begin in the synovial membrane as a rheumatic synovitis, as a septic synovitis (from the intro- duction of septic material from without through a wound), or as an infective synovitis (from the introduction of organ- isms from within through the blood) . It may also result from disease of the contiguous soft parts (as in suppurative bursitis, phlegmonous erysipelas) or from disease of the neighboring bones (as in the acute arthritis of infants). Give the treatment of aseptic wounds. Rest and the maintenance of asepsis by a sterile occlusive dressing. State the causes of irregularities of the teeth. Early extraction of deciduous teeth, delayed loss of de- ciduous teeth, early extraction of permanent first molar, and cleft palate. Give the etiology and clinical appearance of salivary fistula. Salivary fistula may be due to a wound of the cheek divid- ing Stenson's duct; the saliva escapes through the opening and prevents closure of the external wound. It may also result from an abscess of the duct caused by an impacted salivary calculus. Clinical Appearance. There is a fistulous opening in the cheek which is generally surrounded by a number of small granulations. Saliva flows through the fistula as soon as the patient commences to eat and produces excoriation of the surrounding skin. ORAL SURGERY. 167 Give the etiology, diagnosis, prognosis, and treatment of chronic traumatic ulcers of the tongue. Chronic traumatic ulcers of the tongue are due to irrita- tion from a jagged tooth, a mass of tartar, or the edge of a plate. The diagnosis is made by the discovery of the exciting cause and the exclusion of the other varieties of ulceration. These ulcers are usually situated at the side of the tongue opposite the offending tooth ; they are ragged and irregular. If the ulcer has been present for a long time, slight indura- tion may be observed. The glands are not enlarged. The diagnosis is confirmed by the healing of the ulcer after the re- moval of the local irritation. The prognosis is favorable. The treatment consists of the removal of the cause and the maintenance of the oral cavity in as aseptic a condition as possible. State how the different forms of heat may be applied in the treatment of inflammation. How does heat affect the white blood corpuscles? Dry heat may be applied by an india-rubber bag containing hot water ; by a rubber tube or a Leiter 's tube through which flows a stream of hot water ; or by the application of a flannel bag containing hot salt. Moist heat is applied by poultices or fomentations. The ameboid movements of the white blood corpuscles of mammalian blood are increased by a temperature of 38 de- grees C. (100.4 deg. F.). Considerable elevations of tem- perature destroy the white blood corpuscles. Give the etiology and treatment of cellulitis. Cellulitis may be due to infection with the streptococcus pyogenes, the bites of snakes, dissecting wounds, and to some animal poisons (as those of fetid urine extravasated into the tissues in cases of ruptured urethra.) The treatment consists of early and free incisions to afford a. ready exit for the effused products of inflammation. 168 ORAL SURGERY. Warmth and moisture should be applied in the shape of anti- septic fomentations and the part should be kept at rest. Tho constitutional treatment should be supporting in character. The diet should be liquid and nourishing. Give the etiology and treatment of primary swelling in inflammation. The swelling in inflammation is due to the engorgement of the blood vessels, to the exudation of the watery elements of the blood, and to the transmigration of leucocytes. In the so-called third stage of inflammation, this swelling is in- creased by the multiplication of the pre-existing connective tissut cells of the part. The treatment consists of rest, position the application of heat or cold, local depletion and the other measures previ- ously mentioned under the treatment of inflammation in general. State the effect of local bleeding upon inflamed tissues. Local bleeding depletes the inflammatory area and conse- quently diminishes the amount of exudate by decreasing the intravascular tension. When does secondary hemorrhage occur? Give the treatment of secondary hemorrhage. At a later period than twenty-four hours after the accident or operation. Preventive Treatment. Thorough asepsis, the proper ap- plication of ligatures to all bleeding points, and the avoidance of the injudicious use of stimulants. Curative Treatment. This will depend upon whether the hemorrhage comes from the end of a divided artery (as in a stump) or whether it comes from an artery that has been ligated in its continuity. Much might be written under this head from a surgical standpoint; but as far as dentistry is concerned it suffices to say, in a general way, that the treat- ment consists in securing the blood vessels by one or more ligatures. In mild cases of secondary hemorrhage from the ORAL SURGERY. 169 end of a divided artery, elevation, exposure to air, irrigation with hot sterile saline solution, and firm bandaging may be sufficient. If ligatures can not be employed on account of the septic condition of the tissues, the actual cautery will be of service. All septic sloughs should be curetted away, and the wound swabbed out with carbolic solution (1-20) or with a solution of chloride of zinc (1-12). The wound should then be dusted with iodoform crystals, firmly packed with iodo- form gauze, and a firm bandage applied. State the causes of arrest of development of the maxil= lary bones. Early extraction of deciduous teeth, early extraction of the permanent first molar, ankylosis of the temporo-maxillary articulation. Describe Angle's method of treating a fractured maxilla or mandible. Angle 's method of treating a fractured maxilla or mandible consists of holding the jaws in fixed contact by means of wire ligatures wrapped in the form of the figure 8 around buttons attached to bands encircling suitable opposite or nearly oppo- site teeth. This method is not based upon sound principles. A better result can always be obtained by wiring. Describe the treatment of a single fracture of an eden=» tulous jaw when the patient has an artificial upper and lower denture. The upper and lower dentures are to be united (by solder- ing or vulcanization as the case may be) and used as an inter- maxillary splint. The upper and lower central incisors are removed to facilitate the feeding of the patient and external support is furnished by a Barton bandage. If the patient is a fit subject for anesthesia such a fracture would be better treated by wiring the fragments together. PATHOLOGY. What are spores? How may nutrient media be freed from spores at a temperature below ioo degrees C? Spores are reproductive bodies of lower vegetable organ- isms (of bacteria, for example). Nutrient media may be freed from spores at a temperature below 100° C. by the process of fractional sterilization. The nutrient media are exposed to a temperature of 80° C. for 15 minutes. This destroys the bacteria, and the media are then kept at the room temperature for 24 hours so that the spores may develop into bacteria. These bacteria are de- stroyed by an exposure to 80° C. for 15 minutes upon the second day. This process is repeated the third and some- times the fourth day, at which time the media will be free from spores. Define Pathology. Pathology is that branch of medical science which treats of modifications of function and changes in structure caused by disease. Define leukomains. State where they are found. By leukomains are meant any of the nitrogenous bases or alkaloids normally developed by the metabolic activity of living organisms, as distinguished from the alkaloid a] sub- stances developed in dead bodies and called ptomains. They have been found in almost all of the tissues of the body. Mention the different kinds of tumors of the gums. Simple epulis (fibroma), malignant epulis (myeloid sar- (171) 172 PATHOLOGY. coma), round-celled sarcoma, spindle-celled sarcoma, and epithelioma. State the difference between parasites and saprophytes. A parasite is an animal or vegetable organism living upon or within another living organism. A saprophyte is a vegetable organism living upon dead organic matter. How may inflammation terminate? Inflammation may terminate by resolution, retrogression (the formation of cicatricial tissue), suppuration, ulceration, or gangrene. Name the various tumors of the tongue. Papilloma, fibroma, lipoma, myxoma, angioma, lymphan- gioma, and epithelioma. Lymphadenoma and lymphosar- coma may occur at the root of the tongue. Chondroma has also been found in the submucous tissue of the tongue. What is the most common syphilitic lesion upon the tongue? Mucous patch. What is inflammation? Inflammation is the succession of changes which occur in a living tissue when it is injured, providing the injury is not of such a degree as to at once destroy its structure and vitality (Burdon Sanderson). It is "the response of living tissue to injury." Define sepsis, asepsis. Sepsis is a condition of poisoning produced by the ab- sorption of putrefactive substances. Asepsis is the absence of pathogenic micro-organisms. Give the differential diagnosis between sarcoma and carcinoma. A sarcoma arises from connective tissue, may occur at any age, may be encapsulated, gives metastasis through the blood- PATHOLOGY. 173 vessels, and the overlying integument frequently contains dilated veins. A carcinoma arises from epithelial tissue, usually occurs after middle life, is never encapsulated, and gives metas- tasis through the lymphatic vessels. What is the difference between a ptomain and a toxin? A ptomain is a basic compound resembling the alkaloids, formed during the decomposition of animal or vegetable tissues. A toxin is any poisonous substance, either albuminous or basic, produced by the action of bacteria upon organic matter. A toxin is a poisonous ptomain. Give the pathology of sarcoma of the superior maxilla. Sarcoma originates from the anterior wall or from the cavity of the antrum or from the sphenomaxillary fossa be- hind the bone. The maxilla may be secondarily involved by sarcomatous naso-pharyngeal polypi which extend from the nose. These growths frequently contain considerable ossific deposits, and this is occasionally so extensive that the antral cavity is obliterated and the bone converted into a solid mass. Name tumors of the buccal parietes. Papilloma, naevus, cavernous angioma, and epithelioma. Mention four forms of abscesses. Acute or hot, chronic or cold, residual, and metastatic. What is an embolus? An embolus is a particle of fibrin or other material which is swept into the blood current and which is capable of forming an obstruction at its place of lodgment. What is an aneurism? Mention three varieties. An aneurism may be denned as a sac containing blood and communicating with the interior of an artery. Fusiform, saccular, and dissecting. 171 PATHOLOGY. fl Mention five forms of inflammation. Fibrinous, diphtheritic, suppurative, hemorrhagic, and gan- grenous. What are the active agents in decomposition? The active agents in decomposition are the saprophytic bacteria. Define pasteurization. How does pasteurization differ from disinfection and sterilization? Pasteurization is a process of checking fermentation in organic fluids by heating them to 60° or 70° C. It differs from disinfection, since in disinfection, the bac- teria are destroyed by the use of chemical agents. It differs from sterilization, since in sterilization, the tem- perature is carried higher and the bacteria are destroyed, whereas in pasteurization the temperature is simply raised to a point where few fungi can flourish. Give the lesions in syphilitic affections of the buccal mucous membrane. The initial lesion (chancre) may rarely occur in this situa- tion. In secondary syphilis there is often a chronic inflam- mation of the buccal mucous membrane and mucous patches (mucous tubercles, condylomata) are not infrequently present. State what micro=organisms produce pus. Staphylococcus pyogenes aureus, staphylococcus pyogenes albus (staphylococcus epidermidis albus), staphylococcus pyo- genes citreus, streptococcus, bacillus coli communis, bacillus typhosus, pneumococcus, and gonococcus. Describe the structure of a bacterial cell. The cell is principally composed of an albuminous sub- stance known as mycoprotein. There is a large nucleus situated in the centre of the cell constituting its great bulk. This is surrounded by a very delicate cell-wall. In some bacteria, cilia or flagella may be observed extending away from the cell-wall. In other bacteria, the cell-wall seems to PATHOLOGY. lib undergo a gelatinous transformation so that the bacteria seem to be surrounded by a halo or capsule (pneumococcus). State the difference between benign and malignant tumors. Benign tumors are usually encapsulated, do not give metas- tasis, do not recur upon removal, produce no cachexia, grow slowly, do not infiltrate, are not painful (except by pres- sure), and do not cause death (except by location). Malignant tumors are never effectively encapsulated, give metastasis, recur upon removal, produce cachexia, usually grow rapidly, infiltrate, are painful, and cause death. What is the usual source from which pathogenic bac= teria are derived? State the conditions under which micro=organisms get into the air. Pathogenic bacteria are practically always derived in- directly from the bodies of diseased human beings or lower animals. They may be inhaled with the air (tuberculosis), ingested with the liquids or food (cholera and typhoid), or gain access through wounds. The micro-organisms get into the air from the soil. The excreta of diseased individuals becomes dried, ground up into dust, and these dust particles loaded with bacteria are dis- seminated by the winds. Micro-organisms rarely pass from fluids into the air. Describe a method of making gelatine plates. Three tubes of sterile gelatine are to be liquefied by heat. Tube No. 1 is inoculated with the infectious material by means of a platinum wire. Tube No. 2 is now inoculated from tube No. 1, and tube No. 3 is inoculated from tube No. 2. The contents of these tubes are now poured into three previously sterilized Petri dishes. In all of these manipulations, precautions must be taken to avoid accidental contamination of the culture medium. Differentiate thrombosis and embolism. By thrombosis is meant a clotting of the blood within the 176 PATHOLOGY. heart or blood-vessels. It is due to a slowing of the current, or to an altered condition of the blood or blood-vessel walls. By embolism is meant the obstruction of a blood-vessel (particularly an artery) by a fragment of matter brought from another point. This fragment of matter or embolus may be a detached piece of a thrombus. How does suppuration spread? Suppuration spreads by the peptonization of the inflam- matory exudate by the pyogenic cocci. It spreads in the direction of least resistance. State the usual method of cultivating bacteria. The usual method of cultivating bacteria is to inoculate any of the ordinary culture media with the bacteria in ques- tion, and then to keep the media under conditions favorable for the growth of the micro-organisms. Bouillon, agar agar, potato, etc., may be kept in the brood-oven; gelatine is kept at room-temperature. Define oral pathology. Oral pathology is the study of the modifications of func- tion and changes in structure as they occur in the mouth and adjacent parts. Mention the principal diseases of the maxillary bones. Osteo-myelitis and its sequelae, alveolar abscesses, peri- ostitis, tuberculosis, syphilis (gummata), osteoma, chon- droma, fibroma, myxoma, carcinoma, sarcoma, and empyema (upper jaw). Describe the histologic structure of carcinoma. The structure will vary according to the region involved. The tumor is made up of epithelial cells and a stroma of connective tissue. In epithelioma of the skin, the cells are of a squamous type ; in carcinoma of mucous membranes, they are cylindrical and there is a tendency to the formation of cuboidal epithelium. The cells show secondary changes (dropsical infiltration, mucoid degeneration, fatty degenera- PATHOLOGY. Ill tion, etc.). Karyokinetic figures may be abundant and are frequently atypical. The epithelial cells are usually grouped into acini or into alveoli containing several layers of epithelial cells. At the periphery of the acini, the cells may break through the base- ment membrane. The connective tissue stroma is of varying density, but is always of a fibrous character. It is arranged so as to form hollow spaces which contain the epithelial cells. What are the active causes of carcinoma of the buccal cavity? Any irritation, such as smoking, a sharp tooth, the stem of a pipe, or a badly-fitting plate. Leukoplakia, chronic glossitis, and probably caustics. What is the cause of pain in inflammation? The pain in inflammation is caused by the exudate stretch- ing and pressing upon the filaments of the sensory nerves. Another factor in the production of inflammatory pain is the chemical irritation of the sensory filaments by the toxins produced by the bacteria. What is the difference between catarrhal and suppura- tive inflammation? In catarrhal inflammation there is usually considerable liquid exudation, retention cysts may form in the mucous glands, and even localized erosions may appear. There is a hypersecretion of mucus and a desquamation of epithelium. In suppurative inflammation, the exudate contains a large amount of leukocytes, which are killed and transformed into pus cells. What is periostitis? Periostitis is an inflammation of the periosteum. What is provisional callus, and where is it found? Provisional callus is the temporary splinting material which nature throws out about the ends of fractured bones. 12 178 PATHOLOGY. It is found outside of the ends of the fragments (ring callus) and within the medullary cavities of the fragments (pin callus). Give some of the pathologic and anatomic character istics of a benign tumor. Benign tumors usually resemble the tissue from which they grow, tend to unlimited growth, are encapsulated, do not adhere to surrounding structures, do not infiltrate, do not give rise to metastasis, do not recur when thoroughly re- moved, have a nutrition which is independent of the general nutrition of the body, and do not cause death (except mechan- ically) . What is meant by intermediate or definitive callus? Where is it found? Definitive callus is the callus which ultimately unites the fragments of fractured bone. It is the metamorphosis of this tissue that results in bony union. It is found between the ends of fractured bones. What effect has increased nutrition on tissues? It may result in fatty infiltration, in more rapid growth, or in hypertrophy. What effect has imperfect nutrition on tissues? It causes them to degenerate and atrophy. Differentiate between syphilitic and congenital cleft palate. Syphilitic perforation is practically always due to a broken- down gumma. There will be a history of preceding syphilis and concomitant lesions in some portion of the body. The perforation will have been accompanied by marked inflam- matory symptoms, well remembered by the individual. Congenital cleft palate is present at birth and is due to a failure of union of the two palatal processes. PATHOLOGY. 179 Differentiate fibrous from sarcomatous epulis. Fibrous epulis grows slowly, is hard, painless, pale-red, and rarely attains a larger size than that of a walnut. Sarcomatous epulis grows rapidly, is softer, painful, livid in color, ulcerates sooner, and may attain the size of an apple- Mention the tumors of the buccal cavity. Fibroma, lipoma, myxoma, chondroma, osteoma, lympha- denoma, lymphosarcoma, spindle-celled sarcoma, myeloid sar- coma, papilloma, and carcinoma. Define abscess. State of what the walls of an abscess consist and describe its growth. An abscess is a circumscribed collection of pus in a cavity of abnormal formation. The walls consist of granulation tissue. The vessels of the affected area become dilated and the various elements of the blood pass through the walls. As the pyogenic organisms develop, retardation and stasis followed by thrombosis occur successively, whilst the exudation of cells becomes so great that the original tissue of the part disap- pears, after passing through a stage of coagulation necrosis. This removal of the infiltrated tissues is largely caused by their liquefaction, owing to the peptonizing power of the bacteria. State how a dead pulp may cause empyema of the maxillary sinus. The dead pulp may become infected and give rise to an alveolo-dental abscess, which ruptures into the maxillary sinus or causes a purulent inflammation of its lining by contiguity of structure. Define atrophy. Give the pathologic anatomy of atrophy. Atrophy is a reduction in bulk of one or more of the component parts of an organ, and the functional activity is reduced. The organ is reduced in size; its consistency may be in- creased; the outline of the organ may become irregular, and 180 PATHOLOGY. there is an increase of pigment. The microscope shows a re- duction in the size of the individual cells. Give an effective method of sterilizing hypodermic syringes. The modern hypodermic syringe consists entirely of metal, and can be effectively sterilized by boiling it for five minutes in a 1% solution of sodium carbonate. If boiling water is drawn up into the old glass and metal syringe and then ejected, and this is repeated six or eight times, the syringe will be practically sterile. This method is more reliable than solutions of carbolic acid or bichloride (Eiselsberg). State in what manner micro=organisms enter the body. Through the respiratory tract, through the gastro-intestinal tract, through solutions of continuity of the skin and mucous membranes, and through the placenta, State the difference between asepsis and antisepsis. In asepsis, an effort is made to prevent the entrance of germs into a wound. The greatest reliance is placed upon mechanical purification and upon sterilization by heat. In antisepsis, an effort is made to destroy the germs in a wound as well as to prevent the entrance of more bacteria. The greatest reliance is placed upon chemical agents. How and under what conditions do bacteria multiply? Bacteria multiply by fission (direct division), and by sporulation (development of spores). The following conditions are requisite for the multiplica- tion of bacteria : 1. Presence of oxygen (aerobic bacteria). Absence of oxygen (anaerobic). 2. A certain amount of organic matter. 3. A certain amount of moisture. 4. A neutral or feebly alkaline reaction, for the majority of bacteria. PATHOLOG/. 181 5. A temperature above 16° C. and below 40° C. 6. The majority of bacteria multiply most rapidly when the medium in which they grow is at rest. Define antitoxin, virulent germ, non=viru!ent germ. An antitoxin is a counter poison elaborated by the body to counteract the toxins of bacteria. A virulent germ is one having marked pathogenetic prop- erties. A non-virulent germ is one, the pathogenetic properties of which are not marked. Differentiate hypertrophy and tumor. Hypertrophy is an increase in bulk of a tissue or organ occurring independently of the general growth of the body. In a true hypertrophy the function is increased. A tumor is an atypical new formation tending to unlim- ited growth, having no function, differing from the tissue in which it is found in gross and minute structure, the nutri- tion of which is independent of the nutrition of the body in general, and which is not dependent upon or coincident with inflammation. What are pathogenic bacteria? State how pathogenic bacteria incite disease processes. Pathogenic bacteria are those which produce disease. After gaining an entrance to the tissues, they may incite disease processes in one of the following ways: They may grow so rapidly that they completely block up the blood and lymphatic channels. They may cause a local inflammation, due partly to the presence of the foreign organisms and partly to their toxic metabolic products. More often, however, they produce powerful metabolic poisons, which destroy the tissues immediately acted upon, or circulate through the organisms and overthrow the normal physiologic equilibrium. 182 PATHOLOGY. Define carcinoma. Give with reference to carcinoma (a) congenita! theory, (b) traumatic theory, (c) clinical appearance. A carcinoma is a malignant epithelial tumor, composed of a connective tissue stroma, surrounding groups or nests of epithelial cells. (a) Congenital theory. — The carcinoma is supposed to grow from embryonal rests or "resting spores." (b) Traumatic theory. — The carcinoma develops as the result of a single traumatism or of repeated irritations. (c) Clinical appearance. — The tumor occurs in an indi- vidual past middle life, is fixed to the surrounding tissues, and may be ulcerated. The neighboring lymphatic glands are enlarged, the tumor is the seat of lancinating pain, and cachexia is present. Distinguish between pathologic regeneration and physi= ologic regeneration. Physiologic regeneration is that which occurs in the nor- mal life of the organism, and by which the cellular wear and tear is counterbalanced. The tissue destroyed is replaced by similar tissues. Pathologic regeneration is the more massive and open atypical reconstruction that follows disease or injuries. The tissue destroyed is almost always replaced by connective tissue. What is disinfection? How may the strength of a dis= infectant be determined? Disinfection is the destruction of micro-organisms, partic- ularly by the action of chemicals. The strength of a disinfectant may be determined by bringing definite quantities of the infected material in con- tact with definite quantities of a series of solutions of graded strengths, and subsequently making cultures from the in- fected material, which has been thus exposed, to determine whether the organisms have been completely destroyed. PATHOLOGY. 183 How do wounds heal? Wounds heal: 1. By immediate union. 2. By first intention. 3. By organization of a blood clot. 4. Under a scab. 5. By second intention (granulation). 6. By third intention (adhesion of granulating surfaces). By the first four methods the wound heals without the for- mation of pus ; in the last two methods suppuration is present. Mention the different varieties of tumors of the supe= rior maxilla. Myxoma, fibroma, chondroma, osteoma, odontoma, sarcoma, and carcinoma. Define pus. Give the specific gravity and varieties of pus. Pus is a thick, opaque, creamy fluid; it is smooth and slightly glutinous to the touch, has a faint odor and a slightly sweetish taste. It is neutral or feebly alkaline in reaction. The specific gravity of pus varies between 1021 and 1042. The varieties of pus are : The so-called healthy pus, ichorous pus, sanious pus, fetid pus, curdy pus, muco-pus, and sero-pus. Define suppuration. By suppuration is meant the formation of pus. Define diathesis. A state or condition of the body whereby it is especially liable to certain diseases. It may be acquired or hereditary. Define cachexia. A depraved condition of general nutrition due to some serious disease, such as syphilis, tuberculosis, carcinoma. Into what classes are bacteria divided? According to their morphology, bacteria are divided into: (1) Cocci, (2) Bacilli, (3) Spirilla. These are relatively 184 PATHOLOGY. monomorphous. Three other varieties might be mentioned: (4) Spirulina, (5) Leptothrix, (6) Cladothrix. These are relatively pleomorphous. Define plethora, anemia, hyperemia. By plethora is meant an increase of the total amount of the blood in the body. By anemia is meant a deficiency of the blood as a whole, a deficiency of the red corpuscles, or of the hemoglobin. By hyperemia is meant an increased amount of blood in the more or less dilated vessels of a part. Describe (a) local hyperemia; (b) passive hyperemia. All hyperemias are local. By hyperemia is meant an in- creased amount of blood in the more or less dilated vessels of a part. By passive hyperemia is meant an increased amount of blood in the more or less dilated veins and capillaries of a part with diminished velocity of the blood stream. The part is bluish and swollen. Nutrition, function, and temperature are all decreased. Define hemorrhage. By hemorrhage is meant the escape of the several con- stituents of the blood from the blood-vessels. What is meant by chromogenic and pyogenic bacteria? Chromogenic bacteria are those which produce colored colonies or impart color to the medium in which they grow. Pyogenic bacteria are those capable of producing pus. What is a culture medium? What is a pure culture? A culture medium is a mixture in which it is possible to cultivate bacteria. A pure culture is a culture of a single species of bacteria. What are toxalbumins? Toxalbumins are toxic substances produced by either ani- mal or vegetable cells. They are albuminous in character, giving the ordinary reactions for albumin. PATHOLOGY. 185 Distinguish between cocci, bacilli, and spirilla. Cocci are bacteria having a spherical shape. Bacilli are elongated or rod-shaped bacteria. Spirilla are bacteria having a spiral shape and bear some resemblance to a cork-screw. State why the mouth is a favorable place for the development of bacteria. Because heat, moisture, oxygen, and decomposing organic matter are constantly present. Name the classification of cocci from the number and order of arrangement of the cells. Diplococei, tetragenococci, merismopedia, sarcina, strep- tococci, streptodiplococci, and staphylococci. Differentiate between aerobic, anaerobic, and faculta= tive bacteria. Aerobic bacteria are those which grow in the presence of oxygen. Anaerobic bacteria are those which do not grow in the presence of oxygen. Facultative bacteria are those which grow either with or without oxygen. Define general pathology; special pathology. General pathology is the study of morbid processes in gen- eral without reference to the individual organs. Special pathology is the study of morbid processes in the individual organs. State what is meant by (a) the predisposing cause of disease; (b) the exciting cause of disease. A predisposing cause of disease is one which places the individual in a condition favoring the action of the exciting cause ; it prepares the system or part by rendering it weaker and less resistant. The exciting cause of disease is the immediate or specific cause of the disease. 186 PATHOLOGY. Classify the diseases due to bacteria. The following is the classification of McFarland: A. The Phlogistic Diseases. 1. The Acute Inflammatory Diseases, suppuration. 2. The Chronic Inflammatory Diseases, (a) Tuberculosis; (b) Leprosy; (c) Glanders; (d) Syphilis; (e) Actinomy- cosis; (/) Mycetoma or Madura-foot; (g) Farcin du Boeuf ; (h) Rhinoscleroma. B. The Toxic Diseases. (a) Diphtheria; (&) Tetanus; (c) Hydrophobia or rabies; (d) Symptomatic anthrax; (e) Typhoid fever; (/) Cholera; (g) Pneumonia. C. The Septic Diseases, (a) Relapsing fever; (&) Influ- enza; (c) Malignant Edema; (d) Measles; (e) Bubonic Plague; (/) Tetragenus; (g) Chicken Cholera; (h) Mouse Septicemia; (i) Anthrax; (j) Typhus Murium. Mention the pathologic changes in gangrenous stom= atitis. The pathologic changes are those of a rapid necrosis of all the tissues; the micro-organisms of suppuration and putre- faction are present. Putrefactive changes are always in evi- dence ; intense septic infection and intoxication are almost always observed. From what do cysts of the alveolar process arise? Dental cysts are inflammatory in their origin and are formed in connection with the fang of a tooth. Dentigerous cysts arise from imperfectly developed teeth which have been retained in the jaw. Multilocular cysts may be either fibrocystic tumors or cysts developed in adenomatous or sarcomatous tissues. Describe the process of repair of fractures. In a simple fracture the ends of a broken bone and the contiguous lacerated tissues are immediately surrounded by a clot of blood. As a result of simple traumatic inflamma- tion, exudation occurs and the clot is invaded by leucocytes, PATHOLOGY. 187 which absorb it and the damaged tissues. There now occurs an infiltration of large plasma cells derived from a multipli- cation of the pre-existing connective tissue cells of the part. Vessels grow into this tissue from the surrounding parts so that it becomes organized and converted into granulation tissue, which is known as callus. The plasma cells destroy the emigrated leucocytes and are converted into fibrous tissue, which contracts and obliterates the vessel. This scar tissue now undergoes calcification and ossification. The intercel- lular substance increases in quantity, the cells become an- gular, resembling osteoblasts, lime salts are deposited around them, and true bone is formed in the same manner as in the usual process of ossification. Mention and explain the causes of inflammation. The predisposing causes of inflammation are those which depress the vital powers and render the individual more susceptible to the action of the exciting causes. The pre- disposing causes of inflammation are hereditary tendencies, bad habits, faulty hygiene, and dietetic errors, diminished innervation, organic visceral disease, and certain states of the blood (such as anemia). The exciting causes of inflammation are the immediate or specific causes of the inflammation. These are: (1) Direct injury (mechanical, chemical, physical) ; (2) the chemical products of putrefaction; (3) infective micro-organisms. What is meant by regeneration of tissue and how is it brought about? By regeneration is meant the formation of new cells or tissues to take the place of those destroyed. Physiologic regeneration is brought about by a process of gradual cell-multiplication without marked changes of any sort. Pathologic regeneration is brought about by the process of inflammation. 188 PATHOLOGY. Define (a) etiology, (b) morbid anatomy, (c) diagnosis, (d) prognosis. Etiology is that branch of pathology which treats of the causation of disease. Morbid anatomy is that branch of pathology which treats of the changes of structure and form that take place in diseased conditions. Diagnosis is the determination of the nature of a disease by a study of its symptoms. Prognosis is a judgment in advance concerning the dura- tion, course, and termination of a disease. What pathologic conditions may be caused by an im= pacted third molar? Hypertrophy of the pericementum, pressure-resorption of adjacent roots, the formation of a capsule of new bone about the impacted tooth, infringement of the root-apex upon the inferior dental vessels and nerve, and necrosis of the bone. What is fermentation? What causes it? Fermentation is the decomposition of complex molecules under the influence of ferments. Fermentation is caused by enzymes, yeasts, and bacteria. What precautions should be taken to prevent septic infection? The wound or operative area should be made as sterile as possible and no septic substance should be allowed to come in contact with it subsequently. Asepsis is secured by mechanical purification, sterilization by heat, chemical dis- infection, or by some combination of the three methods. What is the cause of an apical alveolar abscess? De- scribe the process of its formation. The infection of the pericementum by pyogenic organisms. The purulent apical pericementitis is almost always pre- ceded by death and putrefaction of the pulp, but consider- PATHOLOGY. 189 able purulent destruction of the pericementum may occur near the apex of the tooth and the pulp of the tooth remain alive for a short time. In the latter case the path of in- fection is unknown, but the pyogenic organisms may be carried here by the blood from a distant focus of suppuration. An abundant exudate is poured out into the interstices of the pericementum, the leucocytes die and form pus cells, the exudate is peptonized, and we have all the phenomena of abscess formation in other situations. What are salivary calculi? What conditions are pro= duced by them? Salivary calculi are hard concretions composed of the cal- cium salts of the saliva which have been precipitated and combined with organic substances (usually mucin). When situated in the salivary ducts, calculi may cause retention of saliva with inflammatory phenomena tending to abscess and subsequent salivary fistula. When situated upon the teeth, they may cause gingivitis, absorption of the gum, destruction of the alveolus, or an ulcer of the tongue. What is the difference between a tumor and an in- flammatory swelling? The reader is referred to the definitions of tumor and in- flammation given in answer to some of the preceding ques- tions. To differentiate these conditions further, it might be said that tumors are almost always unaccompanied by fever, unless there is some intercurrent infection, and that the tumor is not characterized by a local increase of temperature unless it is of very rapid growth. The benign tumors do not give rise to pain (unless by pressure), and the pain of a malig- nant tumor differs in character from that of inflammation. The swelling is usually more acute in the inflammation than in the tumor. Redness may be entirely absent in the neo- plasm. 190 PATHOLOGY. Mention the varieties of pathogenic bacteria found in the air. The particular variety depends entirely upon the sur- roundings. The air of stables is apt to contain tetanus bacilli and possibly the bacillus of malignant edema. The air of a room in which a tubercular patient is kept may contain the tubercle bacillus, particularly if the sputum dries and is ground up and disseminated by the dust. The air of hospital wards may contain any of the bacteria producing infectious diseases or suppuration. Describe the characteristics of carcinomatous ulcer. Give the cause of putrefaction of carcinomatous ulcer. Epitheliomatous ulcers occur in individuals at or past middle life. They commence as a wart or fissure and stead- ily progress. The base of the ulcer bleeds easily; it is in- durated, uneven, and covered with firm, pink granulations containing small, yellow specks. The edges are indurated and everted. The neighboring lymphatic glands enlarge after a time and become adherent to each other and to the overlying skin. Early in the disease the secretion is scanty and viscid and pain may be entirely absent. If the epithelioma is deep-seated, it commences as a red- dish tubercle, which breaks down into an irregular ulcer with a foul, bleeding, indurated base. Pain is often severe, and lymphatic involvement occurs earlier than in the more super- ficial variety first described, but is not so precocious as in the other forms of carcinoma. Carcinomatous ulcers also result from the breaking down of deep-seated carcinomata. They vary with the structure of the tumor and may be fungating or excavated. They are always attended by pain, involvement of the neighboring lymphatic glands, foul discharge, and cachexia. Putrefaction in a carcinomatous ulcer is due to the same causes as putrefaction elsewhere, i. e., the presence of saprophytes and dead organic matter. The malignant neo- plasm outgrows its circulation, a portion necessarily dies, and PATHOLOGY. 191 this dead organic matter is attacked by the saprophytes. The heat, oxygen, and moisture which are always present, aid in the process. Name two culture media. Gelatin and agar-agar. What is a sanguinary or serumal calculus? A sanguinary or serumal calculus is a hard dark calculus which may be deposited anywhere between the neck of the tooth and the apex of the root. As indicated by the name, it is derived from the blood instead of from the saliva. What are phleboliths? Literally, "vein-stones." The term is applied to concre- tions formed in the veins. They usually consist of dense, fibrous bodies, the result of calcification following a venous thrombus. What is exostosis? It is a circumscribed overgrowth of the cementum, ex- tending beyond the line of the fang of the tooth and giving an irregular outline to its external surface. PATHOLOGY AND THERAPEUTICS. What changes occur in inflammation? Primarily. — A marked increase in the velocity of the blood-current and a dilatation of the vessels (arteries and capillaries), caused by a stimulation of the vaso-dilator, or a paralysis of the vaso-constrictor, nerves, followed by a de- crease in the velocity of the blood and increased pressure with heightened temperature and redness. Leucocytes collect along the walls of the vessels and migrate through them by a process called diapedesis. Exudates pour into the intercellu- lar spaces and the part becomes swollen, causing pain by pressure upon the nerve filaments. If resolution occurs, the inflammatory effusions will be taken up by the lymphatics and the part restored to health. If, on the other hand, sup- puration occurs, death of the part, or necrosis, may follow. What is septicemia and what causes it? It is a condition in which septic matter gains access to the circulating fluids of the body, caused by the absorption of the toxins produced by bacteria. How do you treat putrescent pulps? The contents of the pulp cavity and canals should be steri- lized with a ten per cent, solution of formalin, after which the pulp should be removed with sterilized broaches, great care being exercised not to force any of the canal contents into the apical space. Canals should then be thoroughly cleansed with sodium dioxide, followed by an application of dilute sulphuric acid. Neutralize the acid with a bicarbon- ate of soda solution, dry with absolute alcohol and fill canals with antiseptics on cotton, or fill permanently as indicated. 13 (193) 194 PATHOLOGY AND THERAPEUTICS. What symptoms indicate diseases of the dental pulp? Paroxysms of pain upon application of thermal test, in- creased pain upon assuming a recumbent position, neuralgic pain along the course of the fifth nerve. Why is a pulp capped? When? How? To preserve its vitality. In young patients when the pulp has been exposed by accident in excavating. Make a concave disc of gold, platinum, tin or copper, large enough to completely cover the exposure; fill the disc with a paste made from zinc oxide and one of the essential oils, place this over the exposure and seal over with zinc oxysulphate. Cover the whole with a temporary filling. If pulp continues vital and normal for three or six months, it is reasonably safe to insert a permanent filling. Which tissue of the tooth dies with the pulp, and which remains alive? The dentine dies with the pulp, and the cementum re- mains alive. What are parasitic bacteria, and how do they cause disease? Parasitic bacteria are those forms which subsist upon liv- ing animal tissue, producing toxins, which, when taken into the circulation, cause disease. How does mercuric chloride act as an antiseptic? Mercuric chloride acts as an antiseptic by destroying bacteria. The mercury in the compound when brought into contact with albuminous substances, combines with the al- bumin, thereby destroying its identity, as well as its vitality. What are some of the manifestations of pathological dentition? In deciduous pathological dentition, we may have gastro- intestinal disturbances, marked stomatitis and, in severe cases, convulsions may occur. In permanent dentition, some of the pathological conditions most frequently met with are PATHOLOGY AND THERAPEUTICS. 195 impaction or eruption in malposition of third molars, im- paction of lateral incisors, supernumerary teeth, fusion, irre- gularities as to the number of cusps, odontoceles and dentiger- ous cysts. What are the principles of treatment in dental caries? The employment of an alkaline solution to neutralize acids present, removal of carious tissue, the destruction of micro- organisms by the use of germicides, and the hermetical seal- ing of the cavity by means of filling materials. What is the danger of chronic septic pericementitis, and what is the treatment? The danger is the opening of the pus cavity upon the face, or the infiltration of pus into the tissues surrounding the tooth, causing necrosis of the pericemental membrane and loss of tooth. The treatment consists of the mechanical removal by warm water of pus masses and the antiseptic treatment of the affected part, after which mild stimulation should be em- ployed to hasten formation of granulation tissue. Name four agents used in acute diseases of the pulp and give the physiological action of each. Tr. Aconite administered in one drop doses reduces the force of the circulation and acts as a sedative to the nervous system. Carbolic acid, being antiseptic and sedative in its action, may be used in cases of hyperaemia of the pulp. A saturated solution of menthol in chloroform, if placed in a cavity of a tooth exhibiting symptoms of pulpitis (acute), has an anesthe- tic and antiseptic effect. A paste of cocaine and glycerine may also be used in cases of pulpitis, which acts as an analgesic. What causes an alveolar abscess? Access of septic matter to the apical space, or direct bacterial invasion of that area during an attack of apical pericementitis. 196 PATHOLOGY AND THERAPEUTICS. What is phagedenic pericementitis? A disease of the pericemental membrane producing necrosis of that organ. In this particular condition, calcareous de- posits may be present, and gingivitis may not be marked. How do you diagnose exostosis? Exostosis is accompanied by the presence of vaguely re- flected pains, it being usually impossible to locate the seat of the trouble; the X-ray, however, demonstrates the condi- tion very efficiently. What causes induce periodontitis? Traumatism and septic infection. What dangers are to be apprehended from abscess upon the temporary teeth? Pus gaining access to the follicle of the permanent successor, interfering with its development. Non-resorption of the de- ciduous root causing mal-eruption of permanent tooth. Possible necessity for premature extraction of the tempor- ary tooth, resulting in impaction or mal-eruption of per- manent tooth. What results are likely to follow abrasion of the teeth? Heightened sensitivity of the dentine, and deposits of secondary dentine in the pulp cavity. What causes superinduce the devitalization of non= carious teeth? Traumatism, causing severe hyperemia and death of the pulp by strangulation. This includes too rapid wedging, as well as too rapid movement in regulating cases. How would you conduct a thermal test to locate an in- flamed pulp? By isolating each tooth with rubber dam and projecting against it, alternately, jets of cold and hot water, until the offending member has been located by an exaggerated re- sponse to the test. PATHOLOGY AND THERAPEUTICS. 197 Give some causes of necrosis. Thrombus in a terminal artery; or, ligation of a vessel cutting off the supply of nutrition to the part. Which of the permanent teeth are most liable to patho= logical eruption, and why? The upper and lower third molars. The former frequently erupt with their occlusal faces directed toward the cheek ow- ing to an insufficient space between the second molars and the pterygoid processes for their accommodation normally within the arch. The lower third molars are more frequently retarded in their eruption, also due to lack of space. Describe epulis within tooth cavity. Describe fungoid pulp. Epulis within a tooth cavity is a pedunculated fibrous growth gaining access to the cavity usually through an open- ing at the bifurcation of the roots of molar teeth. This opening is caused by caries. The condition resembles very closely fungoid pulp, a hypertrophic condition of the pulp which is fibrous in character and highly vascular. In what abnormal condition will resorption of the tem= porary teeth cease? In temporary teeth containing putrescent pulps, or a peri- cemental membrane in a suppurating condition, resorption may not occur. Describe and give the supposed cause for Hutchinson's teeth. Hutchinson's teeth present a notched appearance upon the cutting edges, the longitudinal axis of these edges being shortened. The supposed cause is congenital syphilis. How is pulp irritation from loss of tooth substance dis= tinguished from sensitive dentine? If exaggerated pain is experienced from contact with in- struments upon the abraded surface, the condition is that of hypersensitive dentine. If this contact causes but a mild 198 PATHOLOGY AND THERAPEUTICS. response and the thermal test produces marked paroxysms of pain, the condition may be diagnosed as irritation of the pulp. What results may follow the premature extraction of the temporary molars? The first permanent molar may tip forward and occupy the space which the second bicuspid should take upon erup- tion, thereby causing either mal-eruption or impaction of the bicuspid tooth. How would you differentiate between pericementitis and alveolar abscess? In pericementitis, the pericemental membrane becomes thickened, the tooth elongated and extremely sensitive to per- cussion. A reddening of the gum tissue is noted over the affected tooth. In alveolar abscess we have an exaggerated likeness to these symptoms together with swelling over the affected tooth, intense pain with a subsequent discharge of pus. Name some of the pathological conditions of the dental pulp. Passive and active hyperaemia, pulpitis, pulp nodules, dry and moist gangrene, and pulp hypertrophy. Give the cause of dental exostosis and describe the symptoms. The cause of dental exostosis may be extraction of the occluding tooth, the pericementum not being met by the ac- customed resistance, proliferates cementum upon the apex of the root. Or, traumatic injury, causing continued mild irritation of the pericementum, may give rise to a like condi- tion. The symptoms are vague pains about the affected tooth, sometimes assuming a reflected neuralgic type. How would you diagnose and locate an inflamed pulp where no cavity exists? Bv the thermal test. PATHOLOGY AND THERAPEUTICS. 199 What are bacteria? Bacteria are minute organisms representing the lowest or- der of plant life. Give the symptoms of septicemia. The general symptoms of septicemia are fever and chills, diarrhoea, rapid and weak pulse and clammy condition of the skin. If the infection has been from a wound, the discharge coming from it will be putrid. What conditions are necessary for the growth and de= velopment of bacteria? Proper food supply, removal of waste products, moisture, sufficient temperature and the presence of free oxygen. This last-named condition, however, is not necessary for the exist- ence of the anaerobic bacteria. Give Miller's theory of dental caries. The presence of sugar in the mouth causes fermentation and the production of lactic acid which dissolves out the lime con- stituents of the teeth. Micro-organisms gain access to the dentinal tubuli and proliferate; they follow in the wake of the decalcifying process and subsist upon the organic tooth substance, producing acids. By what and under what conditions is pus produced? Pus is produced by the invasion of the staphylococcus pyogenes aureus, citreus or albus, or by streptococcus pyo- genes, the gonococcus, the bacillus pneumonae or other pyo- genic organisms into an area susceptible to inflammatory changes, or already inflamed. The white blood corpuscles to- gether with other wandering cells of the body, are devital- ized by the bacteria and become pus corpuscles. What are leucocytes and what are their functions? Leucocytes are the white blood corpuscles. They exercise phagocytic activity, devouring and carrying away invading bacteria and other irritating organic substances which gain access to the tissues. 200 PATHOLOGY AND THERAPEUTICS. Name some of the pathogenic fungi found in the mouth. Micrococcus of sputum septicemia. Bacillus salivarius septicus. Micrococcus gingivae pyogenes. Saccharomyces albicans. Pneumo-bacillus. What is meant by lactic fermentation and why is it of extreme interest to dentists? Lactic fermentation is that process or change which occurs in solutions of the fermentable carbohydrates, producing lactic acid. This product is of interest to dentists, as it is the prime factor in the production of dental caries. What effects may be produced in the mouth from the administration of large doses of calomel? Describe the condition. Large doses of calomel produce a condition known as mer- curial stomatitis. The gums around the necks of the teeth become inflamed and swollen, ulceration of the mucous mem- brane occurs, the teeth become loosened, and there is a marked increase in the flow of saliva. The breath is fetid, and there is an unpleasant metallic taste in the mouth. The severity of these, symptoms depends upon the susceptibility of the patient, as, in some cases, loss of the teeth occurs, and even necrosis of the maxillary bones. Differentiate between hyperaemia, inflammation and suppuration. Llyperaemia is an excess of blood in a part. Inflammation is the succession of changes (hyperaemia being one of these changes) which occur in a tissue during its effort to rid itself of an irritant, provided the irritant is not of sufficient strength to cause immediate death of the part. If, in the last stages of inflammation, resolution does not occur, and pyogenic or- ganisms invade the inflamed area, suppuration, or the forma- tion of pus, will occur. PATHOLOGY AND THERAPEUTICS. 201 What is the source of nourishment of bacteria? How do they obtain oxygen. Bacteria contain no chlorophyl, and, therefore, have not the power to decompose water and carbon dioxide to effect the synthesis of starch. Hence, they are compelled to derive their nourishment from organic compounds. According to their method of obtaining oxygen, bacteria are divided into three classes: aerobic, those depending upon the presence of free oxygen; anaerobic, those not requiring free oxygen, as they possess the pow r er to appropriate the oxygen from unstable organic compounds; and facultative, or those which flourish in either condition. What is salivary calculus, where is it found, and what effect has it? Salivary calculus is a deposition of the salts of lime (car- bonate and phosphate), held in solution in the saliva, upon the surfaces of the teeth, usually near the gum margin, in proxi- mal spaces and deep sulci. Carbon dioxide plays an active part in the precipitation of the calculus. Large deposits are frequently found near Steno's duct, the opening of the parotid gland, and on the lingual and labial surfaces of the lower anterior teeth. Deposits of tartar have the effect of producing recession of the gum, causing sufficient irritation at times to produce inflammation and even suppuration. If allowed to continue, the deposits may be responsible for affec- tions of the pericemental membrane and alveolar process, and also tooth loss. What is the difference between an antiseptic and a germicide, and give examples? Antiseptics prevent the action of pathogenic organisms and their products on the living body, but do not necessarily kill the micro-organisms. Germicides destroy the vitality of the germs of disease. Germicides are antiseptics, though anti- septics are not necessarily germicides. Iodoform is an anti- septic: mercuric chloride is a germicide. 202 PATHOLOGY AND THERAPEUTICS. What is pyrozone? How does it act, and for what is it used? Pyrozone is a solution of hydrogen dioxide in water or ether. A 3% aqueous solution acts as an antiseptic and dis- infectant; these properties are due to the setting free of oxygen when the solution is brought in contact with organic matter. In this strength, it is valuable in cases of ulcerative stomatitis, and also in softening deposits of calculus. For cleansing pus pockets, it is an effective agent. A 25% ethereal solution is used as a bleaching agent, caustic and styptic. How are the diseases of the pericementum diagnosed from those of the pulp? Diseases of the pericementum respond freely in paroxysms of pain to any pressure brought to bear upon the tooth, while the pulp disorders are demonstrated by the thermal test. Pericemental disorders can always be located by the patient. Pains from pulp affections are more often reflected. When one is complicated by the presence of the other both symp- toms may be in evidence. At what age is the first permanent tooth erupted, and which tooth is it? The first permanent tooth is erupted at about the sixth year ; it is called the first molar, or sixth year molar. How do you treat hypersensitive dentine? In the treatment of hypersensitive dentine the rubber dam should be applied if possible and absolute dryness secured. This, in itself, ofttimes produces sufficient anaesthesia to per- mit instrumentation. In obstinate cases, however, it may be necessary to employ other therapeutic measures. If the cavity be not deep, a solution of caustic soda (ten grains to the ounce of water) is sometimes effective. A paste of cocaine muriate and glycerine, sealed in the cavity for 24 hours, may be used with good results. Cocaine may also be employed by cataphoresis. Carbolic acid, chloroform, ethyl or methyl PATHOLOGY AND THERAPEUTICS. 203 chloride (in spray) are also indicated. In cases of hyper- sensitivity of abraded teeth (where no cavity exists), the tooth or teeth should be isolated by the rubber dam and strong mineral acids, such as nitric, sulphuric and hydrochloric applied. These agents coagulate the contents of the tubules. The surfaces, treated in this manner, should always be ex- cavated and filled. What dangers must be guarded against in the use of arsenic for devitalizing the pulp of a tooth? Arsenic, for the purpose of devitalizing the pulp, should be employed with great care. If possible the tooth should be isolated with rubber dam. If carelessly applied, a minute portion of arsenic may come in contact with the gum tissue or be insinuated in the gingival space, producing sloughing of the peridental membrane and gum tissue, or necrosis of the process, or both. Great care should be exercised in seal- ing arsenic in a cavity to prepare the margins of the cavity in such a way as to permit hermetical sealing. Pastes of arsenic should be applied without an excess of fluid, as there is danger of oozing about the margins during the process of sealing. This drug should never be used for the devitaliza- tion of pulps in deciduous teeth. Give the differential diagnosis between hyperaemia, in= flammation and suppuration of the pulp. In hyperaemia the pulp responds to the application of heat or cold in a somewhat exaggerated degree, owing to the dilatation of the vessels. Cases of hyperaemia usually give a history of mild attacks of odontalgia, transient in character. In inflammation of the pulp the response to cold is somewhat diminished ; the application of heat produces pain of a severe type. Odontalgia becomes constant, throbbing in character, increasing when the patient assumes a recumbent position. Neuralgic pains may be felt along the course of the fifth nerve. Suppuration begins in the late stage of inflammation, and is indicated by a cessation of response to cold applications. Heat produces agonizing paroxysms of pain, only alleviated by 204 PATHOLOGY AND THERAPEUTICS. the immediate application of cold. The pain now assumes a gnawing character, persistently increasing, while throbbing ceases. What are saprophytic bacteria, and how do they cause disease? Saprophytic bacteria are those forms which nourish upon dead organic substances, effecting their decomposition, and producing poisons, through the agency of which they become causes of disease. What objections are there to the premature extraction of the temporary teeth? Premature extraction of the temporary teeth is followed by insufficient space for the normal eruption of their permanent successors, resulting in malposed permanent teeth, and, not infrequently, their impaction. How do you distinguish erosion of the teeth and caries? Erosion is characterized by cupped out cavities with hard, glossy surfaces usually on the labial aspects of teeth, while caries presents a softening of the tooth structure. Caries may follow erosion. How is the destruction of tissue brought about in dental caries? The product of lactic fermentation (lactic acid) decalcifies the tooth at a vulnerable point, and the micro-organisms of the mouth attack and destroy the organic remains. What is resorption of the roots of deciduous teeth? Is it a ph3'siological or pathological condition? Resorption of the roots of deciduous teeth is a physiological process brought about by the phagocytic action of multi- nucleated cells, these cells secrete a ferment, which liquefies the roots, and in this condition they are taken up by the lym- phatics. In short it is nature's method of preparing a path for the eruption of the permanent successors. PATHOLOGY AND THERAPEUTICS. 205 Describe the pathologic changes which occur in the dental pulp starting from irritation and ending in pus formation. Pulp irritation may result from traumatism, excessive thermal stimuli, drug action, or infection. Active hyper- aemia of the pulp occurs with a marked dilatation of the arteries and arterial capillaries. If the cause of the irritation is not removed, the white blood cells in these vessels collect along the walls in* great numbers, thereby im- peding the flow of the blood stream. If dilatation occurs in the arteries near the apex of the tooth, the return flow of the blood is cut off by an impingement of the engorged arteries upon the apical veins. Diapedesis now occurs and the white blood cells, together with effusions of inflammation, are poured out into interstitial spaces. This phenomenon marks the on- set of pulpitis. If the pulp be infected by pyogenic organ- isms, the lencocytes are overpowered and die, becoming pus corpuscles. Why should deciduous teeth receive early and system- atic treatment? Deciduous teeth should receive systematic treatment, be- cause their retention in the arch until the time of eruption of their permanent successors, has much to do with the normal eruption of these latter. What effect may be produced on the dental pulp by con* tinued mild irritation? Continued mild irritation may excite the functional activity of the odontoblasts, thereby producing secondary dentine at the expense of the volume of the pulp and its chamber. Give the differential diagnosis between pulpitis and pericementitis. Pulpitis is characterized by throbbing pains of a severe type, aggravated in its early stages by contact with hot or cold substances. The pain is of a reflected type, due to the fact that the pulp has no tactile sense. But very mild response 206 PATHOLOGY AND THEBAPEUTICS. is elicited from percussion. In pericementitis, the tooth is some- what elongated by a thickening of the inflamed apical perice- mentum, and responds exquisitely upon percussion. Describe the treatment for restoring a sound, superior, central incisor tooth displaced from its socket by violence. The tooth should be placed in a solution of bichloride of mercury (1 to 1000) for some minutes, after which the pulp cavity should be cleansed and filled. Replace the tooth in bichloride solution. Now thoroughly cleanse the tooth socket with jets of warm water, removing all clot, and sterilize with stimulating antiseptics such as campho-phenique, etc. Great care must be observed to keep the mouth in an aseptic condi- tion, both during and for a considerable period after the operation. The tooth should be removed with sterile forceps from the solution, and thrust back into its socket without handling. Immobilization may be accomplished by a cap of gold securing it to its fellows, and this allowed to remain until the tooth has become thoroughly fixed. THERAPEUTICS AND MATERIA MEDICA. What is meant by idiosyncrasy? A peculiar or abnormal response to the action of a drug. For what conditions in the mouth is sulphuric acid use= ful? In what strength and in what manner may it be employed? In hypersensitive dentine, in simple cavities of decay, to open and enlarge minute root canals. In these cases it is em- ployed in 50% strength, applied with a gold probe and neu- tralized with sodium bicarbonate. In about 10% solutions, it may be employed to remove dead bone. In what manner may the teeth be best protected from the effects of acids administered internally through the mouth? Acids should be well diluted, taken through a tube, and an antacid at once used to counteract any acidity induced through their use. What is a counter=irritant? Name two used in the mouth. A counter-irritant is an agent used to excite vascularity where applied, resulting in the relief of pain and vascularity in other parts, e. g. capsicum and tincture of iodine. What is the dose of tincture of aconite root? One half to five minims. What is the local action of aconite? It acts as a powerful sedative, causing tingling and numb- (207) 208 THERAPEUTICS AND MATERIA MEDICA. ness, due to paralysis of terminal nerve filaments. Slightly irritating at first. What preparation of arsenic is most used in dentistry, and what is the local action of this preparation? Arsenic Trioxid. When brought in contact with the tooth pulp we have con- gestion, accompanied by grumbling pain which in a few hours becomes acute and throbbing. The blood vessels be- come strangulated at the apex of the root, resulting in the death of the pulp, with cessation of pain. What preparation of iron is particularly injurious to the teeth? Why is it injurious? Tincture chloride of iron. On account of the free hydro- chloric acid it contains. Name the drugs that may be combined with arsenic for devitalizing a tooth pulp, and state what purposes these drugs serve. Combined with acetate or sulphate of morphine or hydro- chlorate of cocaine, as local anodynes, with an essential oil to make a paste and facilitate the application as well as action. Name three local anesthetics used in dentistry, and state the conditions that call for their application. Cocaine hydrochlorate, carbolic acid, tincture of aconite. Cocaine hydrochlorate, for hypodermic use in extraction. Carbolic acid, where the sensibility of the gum is to be de- stroyed to permit of painless incision being made. Tincture of aconite, to allay pain by its application to the gum tissue in cases of pericementitis. What desirable qualities should a disinfectant possess for use in a pulp canal? Ability to neutralize various products resulting from putrefactive processes, and the attribute of penetrability. What conditions about the mouth call for the use of iodine, and what are its effects? In pericementitis, oedema of cheeks or lips, as an aid in THERAPEUTICS AND MATERIA MEDIC A. 209 removing green stain from the surfaces of teeth. Acts as a counter-irritant and stimulates absorption of effusions. What conditions about the mouth call for the use of carbolic acid, and what are its effects? Full strength acts as a caustic and may be used to touch ulcers. In a 1% or 2% solution, as an antiseptic mouth wash in stomatitis. How should any injurious results arising from the local action of arsenic on the gums be treated? By removing all necrotic tissue and touching with an iron preparation or tincture of iodine. Name two preparations of opium. State the dose of each. Tincture of opium or laudanum. Dose, 5 to 15 minims. Camphorated tincture of opium or paregoric. Dose, 1 to 4 fluid drachms. Of what drugs are morphine and atropine the alkaloids? Opium and belladonna respectively. Name a physiologic antidote to cocaine. Morphine, whiskey, or nitrite of amyl. For what is permanganate of potassium used in dentistry? Ulcer of the mouth with offensive breath, abscesses, diseases of the antrum, necrosis and caries of bone. What are the dental uses of the essential oils? To obtund hypersensitive dentin, to allay pain in an irri- tated pulp, to promote antisepsis in septic root canals and cavities. Describe the effect of aconite on the heart and name two other drugs which have a similar effect. Small doses decrease the force of ventricular contraction and slow the action of the heart. Large doses cause rapid weak action with tendency to stop in diastole. Veratrum viride and antimony have a similar effect. 14 210 THERAPEUTICS AND MATERIA MEDIC A. For what is amyl nitrite used, and how is it admin- istered, and what is the dose? Stimulant, particularly in cocaine poisoning. Usually ad- ministered by inhalation in three to five minim doses. What is the danger of using acids in the mouth? What precaution should be taken? They may cause decalcification of tooth structure. They should be followed by antacid mouth washes. For what is hydrogen peroxide used? To destroy pus, cleanse putrescent pulp canals, and whenever a germicide, deodorant or disinfectant is required in the mouth. Name two escharotics, and state when escharotics should be used. Silver nitrate, carbolic acid. Escharotics are employed for the removal of hypertrophied gum tissue. To obtund hyper- sensitive dentin. In the treatment of ulcerative stomatitis, and to destroy pulp filaments in roots. What precautions should be observed in the adminis= tration of the general anesthetics? Patients should not eat anything for several hours pre- vious, should have bowels thoroughly evacuated, should be placed in a horizontal position, all foreign substances re- moved from the mouth, clothing loose around the neck and chest, a third party present if the patient be a female, and the anesthetic selected with reference to any or- ganic disease of the patient. Development of dangerous symptoms should be watched for, and the anesthetic should not be given in an overdose. Resuscitating means should be at hand. Define hemostatic. Give three examples. Hemostatics are agents which stop hemorrhage by coagu- lating albumin and contracting the muscle fibres, e. g. tannic acid, tincture of iron, and adrenalin chloride. THEBAPEUTICS AND MATERIA MEDICA. 211 Mention a medicine whose local action contracts the blood vessels of a part. Adrenalin chloride. Mention a medicine whose local action dilates the blood vessels of the part. Aconite. Differentiate disinfectant from antiseptic. Give illus- trations of each. Disinfectants are agents which destroy the germs of dis- ease. Antiseptics inhibit the growth of micro-organisms and neutralize the toxins, but do not necessarily kill the germs. Permanganate of potassium (2% solution), bichloride of mercury (1-1000), peroxide of hydrogen are disinfectants. Boric acid and the essential oils in mild solution act as antiseptics. What is the objection to the use of iodoform? Men- tion three drugs that may be used in place of iodoform. Its very objectionable odor. Iodol, aristol and europhen may be used in place of iodoform. What is the advantage of the cataphoric as compared with the ordinary local application? The deeper layers of the dentin and the pulp itself may be affected, whereas the ordinary application could not be made to affect these. What two medicines are particularly useful in cata- phoric applications? Cocaine hydrochlorate to desensitize dentin and pulp, and 25% pyrozone for bleaching. Mention (a) three remedies for toothache caused by ex- posure of the pulp; (b) two remedies for pericementitis. (a) Oil of cloves, oil of cinnamon, carbolic acid, (b) Tincture of aconite and tincture of iodine. 212 THERAPEUTICS AND MATERIA MEDIC A. Mention (a) a remedy that antagonizes the constitutional action of aconite; (b) a remedy that increases the constitu- tional action of aconite. (a) Opium, (b) Veratrum viride. Mention the dose of two of the preparations of opium, and the dose of one of the alkaloids of opium. Tincture of opium, 5 to 20 minims; powdered opium, y 2 to 2 grains ; sulphate of morphine, % to % grain. Mention the dose of (a) potassium bromide, (b) chloral, (c) acetanilid. (a) Potassium bromide, 10 to 60 grains; (b) chloral hy- drate, 5 to 20 grains; (c) acetanilid, 2 to 10 grains. Mention two heart stimulants that act rapidly, and give the dose of each. Aromatic spirits of ammonia, 30 to 60 minims. Ether, 10 to 60 minims. State the action of digitalis on (a) the heart, (b) the blood vessels, (c) the kidneys. (a) Increases the force of the heart contractions; lengthens diastole, decreasing the number of beats by stimulation of the pneumogastric. (b) Raises arterial tension by stimulating vasomotor centre, by direct action on the muscular coat and by increasing the force of the heart's contraction. (c) Dilatation of the renal arteries resulting in an in- creased flow of urine, without an irritating effect on the renal epithelium. What drug is often combined with morphia when given hypodermically? Explain. Sulphate of atropine. Atropine being the physiological antagonist, it diminishes the danger of morphia poisoning. Which of the general anesthetics is most depressing to (a) the circulation, (b) the respiration? Chloroform to the circulation, and ether to the respiration. THERAPEUTICS AND MATERIA MEDICA. 213 Mention two medicines that increase blood pressure. Digitalis and strophanthus. Distinguish between a stimulant and an irritant. A stimulant produces increased functional activity. An irritant exceeds the effect of a stimulant and induces venous hyperemia, and possibly inflammation. A stimulant acting continuously may become an irritant. With what class of remedies are the coal tar products prescribed for action on the heart? With cardiac stimulants. What are the dental uses of the alkalies? Mention three alkalies. To counteract any acid condition in the mouth, as in erosion or after acid medicaments. Lime, magnesium, sodium bi- carbonate. What effect on blood pressure has (a) ether, (b) chloroform? Ether increases blood pressure. Chloroform lowers blood pressure. State the dental uses of nitrate of silver. In the form of lunar caustic it may be used to destroy ulcers in the mouth, or to destroy hypersensitiveness of the dentin; in a 5% or even 10% solution, it is employed in gangrenous stomatitis. In 50% solutions it has been re- commended in the treatment of root canals. State with reference to formaldehyde (a) its dental uses, (b) the advantages of its use, (c) the objections to its use. In mild solutions', in association with other agents, as an antiseptic mouth wash; in strong solutions, about 5 to 10% of formalin, it is used to disinfect instruments. In the treat- ment of moist gangrene of the pulp, and wherever a power- ful disinfectant is indicated without regard to its intensely irritating effect upon mucous surfaces. It is a powerful 214 THERAPEUTICS AND MATERIA MEDICA. disinfectant, and has a hardening effect upon disintegrated organic matter. It is intensely irritating to mucous surfaces. State the conditions under which it is more advantageous to give medicines hypodermically than to administer them internally. When you wish to produce an immediate effect. When the patient cannot swallow, or is in a condition where absorption from the stomach would take place slowly. Mention one drug that contracts the pupil of the eye; one drug that dilates the pupil of the eye. Eserine contracts; belladonna dilates. State the reasons for or against the use of arsenious acid to obtund sensitive dentin. It should not be used to obtund hypersensitive dentin, as it will devitalize the pulp. Of what is each of the following an alkaloid (a) strych- nine, (b) atropine, (c) morphine. State the dose of each. (a)Nux vomica, (b) belladonna, (c) opium. Strychnine, ^ to -^ g r - 5 atropine, T ^ to T ^ gr. ; morphine i to i gr. What property of tincture of iodine makes it of value in pericementitis? Its counter-irritating property, and its ability to stimulate the lymphatics to absorb inflammatory products. In what position should the patient be during the ad- ministration of chloroform? Why? In the recumbent position, to allow of the easy flow of blood to the heart; to counteract the paralyzing influences of chloroform upon the circulation. Name four properties that a dentifrice should possess. Alkaline, antiseptic, sufficiently coarse to be cleansing, and agreeable flavor. THERAPEUTICS AND MATERIA MEDICA. 215 What is an antiphlogistic? Any therapeutic means of combating the heat of inflamma- tory reactions. What is an escharotic? An agent which devitalizes the tissue upon which it acts, producing an eschar or slough. Define narcotics and sedatives and give an example of each. Narcotics are agents that stimulate and stupefy the brain, allay pain and induce sleep, as opium. Sedatives are agents that depress the nervous centres and allay their irritability or excitability, as bromide of potassium. Describe what is meant by an aqueous solution, and write a prescription, giving example. An aqueous solution is a drug held in solution with water. R . Acidi tannici gr. x Aquse f3J Sig. — Use as directed. What is arsenous acid? Give medical properties and special dental use and antidote. Trioxide of arsenic. Internally, in small doses, it acts as an alterative tonic, promoting appetite and digestion, stimulating respiration and circulation, and increasing mental faculties. In dentistry, it is employed to devitalize the pulp. The anti- dote in cases of poisoning is freshly prepared hydrated ferric oxide. Give the medical properties and dose; when indicated in dental practice, and how used; toxic effects, if any; anti» dotal treatment of each of the following: — Aconite, quinine, napthol, creasote, oil of cloves. Aconite locally paralyzes the terminal sensory filaments, causing numbness and loss of sensibility. Internally, in small doses it depresses respiration and circulation, and in large doses it paralyzes the heart's, action. In dental practice it may be used locally to stop pain from an irritated pulp, or as 216 THERAPEUTICS AND MATERIA MEDICA. a sedative applied over the gum in pericementitis. Opium, or any cardiac stimulant, together with artificial respiration, is used in cases of poisoning. The dose is 1 to 3 minims of the tincture. Quinine is a tonic, antiseptic, antipyretic and antiperiodic. It interferes with the functions of the red blood corpuscles and arrests the movements of the white. In small doses it stimulates the brain; in large doses, it produces cerebral anemia, ringing in the ears, headache, delirium and coma. The tonic dose is 2 grs., the antipyretic 5- 1 ** grs., and the anti- periodic 10-20 grs. Morphine antagonizes its cerebral action, atropine its cardiac and antipyretic effects. Its use in den- tistry is indicated when a patient gives evidence of septic fever through absorption of septic products in cases of acute septic pericementitis or alveolar abscess; in combination with acetanilid and salol, two grains of the sulphate of quinine given every two or three hours will have a controlling effect. Naphthol is a derivative of naphthalin, and has marked antiseptic properties. In dentistry it is used as hydro- naphthol, a powerful antiseptic in a 1 to 200 solution. Creasote locally acts as an anodyne. Internally in small doses, its action is similar to carbolic acid. It is eliminated by the bronchial mucous membrane, which it stimulates, pro- ducing the effects of an expectorant. It is sedative to the mucous membrane of the stomach. In dentistry, it is indi- cated wherever carbolic acid is used, although the latter is favored because it has not the intensely disagreeable odor of creasote. Dose. 1 to 3 minims in oil. Oil of cloves belongs to a group of aromatic oils that possess many properties in general. They are antiseptics, stimu- lants, and local anesthetics. Dose, 1 to 5 minims. In den- tistry, they are used generally to allay pain in an aching pulp. Name three drugs useful in the treatment of empyema of the antrum, and write a prescription containing one such drug in solution. Hydrogen dioxide, chloride of zinc, hydronaphthol. THERAPEUTICS AND MATERIA MEDIC A. 217 J*. Hydronaphthol 3 j Alcohol f £ j Sig. — Teaspoonful in a wineglass of water. Name three heart stimulants administered hypodermi- cally in the order of their rapidity of action. State dose of each. Alcohol, strychnine, digitalis. Alcohol (whiskey), 30 to 60 minims. Strychnia sulphate, ^ to ^ gr. Digitalis (tincture), 5 to 10 minims. Define styptic and irritant, and give an example of each. A styptic is an agent applied locally to check hemorrhage, like tannic acid. An irritant is an agent capable of drawing an excess of blood to the part upon which it is acting, like iodine. Name two drugs that are physiologically incompatible, and two that are chemically incompatible. Aconite and morphine; belladonna and opium, are phy- siologically incompatible. Tannic acid and iron; sulphuric acid and lime, are chemically incompatible. Give the dental uses of oil of cinnamon, silver nitrate, aconite, capsicum. Oil of cinnamon is used to allay pain in an irritated pulp, or as an antiseptic application in root canals. Silver nitrate may be used in the form of lunar caustic to touch ulcers ap- pearing in the mouth, or in full strength to obtund hyper- sensitive dentin. It has also been recommended, in 50% solution, in the treatment of pulpless canals. Tincture of aconite is used as a sedative application in pericementitis; also, to control an aching pulp, and as an ingredient of oint- ments for neuralgia. Capsicum is used as a counter-irritant in pericementitis, and as a stimulating ingredient in mouth washes. 218 THERAPEUTICS AND MATERIA MEDIC A. How is the muscular system affected in complete anes- thesia under ether and under nitrous oxide? Under ether the muscles are relaxed. Under nitrous oxide the muscles are contracted. What are the advantages and disadvantages in the use of chloroform as an anesthetic in tooth extraction? The anesthesia resulting from inhalations of chloroform is prolonged, affording free opportunity for the removal of any number of teeth. The disadvantages are decided. The up- right position is against the patient; and, furthermore, fail- ure of the heart's action is apt to result in consequence of the irritation of the pneumogastric induced through irritation of the fifth pair of nerves in the extraction. What is ethyl chloride? Describe method of producing local anesthesia by its use, and state precautions to be observed. Ethyl chloride is a volatile colorless liquid with a boiling- point of about 60° F. When a spray is directed against tissue it acts as a freezing agent by its very rapid volatilization. The tissue not to be affected should be protected against the spray. By the use of cold applications the tissue may be pre- vented from too quickly returning to a normal state, and thus lessen the incident pain which is usually felt after the use of chloride of ethyl. Give the precautions to be observed before and during the administration of nitrous oxide. The patient should be examined as to physical condition, and also as to what teeth or roots are to be extracted, so that no time is lost later. Care should be taken that sufficient nitrous oxide is at hand for the operation, and a third party should be present. The jaws should be kept separated. Dur- ing the administration, the respiration should be carefully watched. Interference with respiration is the chief source of danger. As soon as the anesthetic state ; is induced, further administration should at once cease. THERAPEUTICS AND MATERIA MEDIC A. 219 Describe fully two methods for producing local anes- thesia. Hypodermically, with a 1% or 2% solution of cocaine hydrochlorate, injecting about 20 minims of the 1% or 10 minims of the 2% solution about the alveolar tissue; or by means of a spray of ethyl chloride, protecting the tissues not to be affected. The spray is directed until the tissues whiten. It is better not to allow a too rapid return to a normal condition of the anesthetized parts. This may be produced by directing the patient to hold cold water in the mouth. Describe methods of procedure and precautions neces- sary in hypodermic injections for producing local anes- thesia. The parts to be operated upon should be treated antisepti- eally, so that no adherent septic matter is carried into the subtissues. The needle and solution should be perfectly aseptic. Care should be taken not to penetrate a blood vessel. After injection the fluid should not be allowed to escape. The proper quantity and no more should be injected. How is anesthesia modified by age, sex and tem- perament? In children we find a ready response to the inhalation of anesthetics. When ether is used, a hypersensitive mucous surface in the pharynx and larynx induces coughing; in the aged, chronic bronchial irritation is apt to produce the same result. Women are apt to give manifestations of hysterical tendencies. Sex and temperament may influence the amount necessary to induce anesthesia. The stage of excitement may be prolonged in hysterical subjects, and also in those of bilious attributes. What anesthetic do you prefer, and for what reason? For the extraction of teeth and minor operations in the mouth that require little time for their execution, nitrous oxide is the safest anesthetic we have at the present time. 220 THERAPEUTICS AND MATERIA MEDIC A. From a most extended experience during which hundreds of thousands of patients have been placed under its influence, the death rate is practically nil. Mention the differences between cocaine and eucaine. Cocaine is an alkaloid, soluble to the extent of over 30% in water, decomposes upon boiling, and frequently is fol- lowed by poisonous symptoms. Eucaine is synthetically pre- pared; is soluble to the extent of about 4% in water, does not decompose when subjected to heat, and its use is not so frequently followed by dangerous symptoms. At what period in nitrous oxide anesthesia may you have failure in circulation? After the anesthetic stage, owing to anemia of the brain. What causes the darkened appearance of the patient under nitrous oxide, and state in what manner this may be lessened? The accumulation of carbon dioxide. Giving oxygen in combination with nitrous oxide will considerably lessen the bluish appearance of the countenance. What is liquid nitrous oxide? The gas nitrous oxide liquefies when subjected to a pressure of about 700 pounds at a temperature of about 45° F. What is the appearance of the face under ether an- esthesia? Generally flushed. What appliances should be at hand and in readiness when anesthetics are used? Hypodermic syringe, with various respiratory and circula- tory stimulants. Also the facilities for performing artificial respiration. How is bromide of ethyl administered, and what is its action? The quantity to be administered is poured out upon a towel (about 2 drachms) and inhaled by the patient. Bro- THERAPEUTICS AND MATERIA MEDICA. 221 mide of ethyl resembles chloroform in its action upon the heart. It interferes with the function of the red corpuscles, and affects consciousness last; in many cases patients are conscious and yet not perceptive of any pain. The anes- thesia generally lasts about five minutes. What strength of solution of cocaine would you employ for hypodermic use, and how much of the solution would you use? Generally 1% or 2% solution is employed. 20 minims of the 1%, or about 10 minims of the 2% solution may be injected. Give the antidote of the following drugs, (a) iodine, (b) bichloride of mercury, (c) arsenic, (d) phosphorus. (a) Starch, (b) albumin, (c) hydrated ferric oxide (freshly prepared), (d) turpentine. Mention two drugs insoluble in water. Bismuth subnitrate and mercurous chloride. What alkaloids are found in opium? What is its active principle? Morphine, codeine, narcotine, thebaine. The most important active principle is morphine. What is meant by a mydriatic? Name one. A mydriatic is an agent which causes dilatation of the pupil of the eye, e. g. belladonna. What is meant by a synergist? Name the synergists of aconite. A synergist signifies an aid. Veratrum viride, tartar emetic or bromide of potassium act as synergists to aconite. What is a cathartic, and how are cathartics divided? Cathartics are agents which produce evacuation of the in- testinal tract. They may be arranged according to the severity of the effect. Laxatives are the mildest, purgatives are more severe, and drastics most severe in their action. 222 THERAPEUTICS AND MATERIA MEDIC A. Give the treatment of poisoning from cocaine. Fresh air, inhalations of nitrite of amyl or ammonia. Alcohol, (brandy or whiskey), aromatic spirits of ammonia, strychnine, digitalis and atropine, hypodermically or by the mouth. External heat. State the local action of cocaine on the blood vessels. Cocaine applied to a mucous membrane or injected under the skin causes the blood vessels of the part to contract. As the effect passes off, the reaction results in dilatation. Name three mineral acids employed in dentistry and give their properties and uses of each. Hydrochloric acid. — The strong acid is a powerful caustic and escharotic; also disinfectant and fumigant. The dilute acid is tonic, refrigerant and astringent. The strong acid is employed as a local application in gangrenous stomatitis, or cancrum oris, for arresting the ulcerative process. Combined with equal parts of glycerine it is useful in inflammation and ulceration of the oral mucous membrane; also in cases of sloughing. In aphthous ulcera- tion of the mouths of children, it is often useful. Nitric Acid. — Pure nitric acid is a powerful caustic and escharotic. The dilute acid is an antalkaline, alterative, tonic and refrigerant. The strong acid, when mixed with two parts of hydro- chloric acid, is a solvent for gold. It is employed as a caustic in cancrum oris; also for malignant ulcers of the mouth and for devitalizing pulp of teeth when nearly exposed by mechanical abrasion. Sulphuric acid. — The strong acid is a powerful escharotic, the dilute acid is refrigerant, astringent and tonic. The concentrated sulphuric acid is used as a caustic in malignant ulcers, cancrum oris and gangrene in the form of a paste, made by mixing it with powdered sulphate of zinc. It is also used to cleanse metal plates. The dilute acid or the aromatic sulphuric acid which is more agreeable, is used in pyorrhoea alveolaris, and in caries and necrosis of the maxillary bones, THERAPEUTICS AND MATERIA MEDIC A. 223 as an injection or lotion. It is also employed in cases of re- cession of the gums and absorption of the processes. It is valuable in alveolar abscesses as an injection. It is employed in stomatitis and ulcers of the mouth. Mention (a) two heart stimulants, (b) two heart seda- tives. State the dose of each. (a) Aromatic Spirits of Ammonia, 20 minims to 1 drachm. Whiskey, 2 drachms to 1 ounce. (b) Tincture of aconite, 1 to 5 minims. Tincture of veratrum viride, 3 to 30 minims. Mention three medicines used to produce emesis and state how each is administered. Sulphate of zinc, 10-30 grs. by mouth. Mustard 1 to 2 drs. by mouth. Apomorphine hydrochlorate, ^-J- gr. hypodermically. Mention three medicines used to produce diaphoresis. Pilocarpine, tartar emetic and Dover's powder. What is the local action of chloroform? Placed on the skin and allowed to evaporate it produces a sensation of cold. If the vapor be confined it causes irrita- tion with redness and even vesication accompanied by a sen- sation of heat, followed by numbness and a decreased sensa- tion of the part. Define materia medica, therapeutics. Materia medica treats of the source of drugs, their physi- cal and chemical properties and may also include their phy- siological action. Therapeutics treats of the application of remedial agents to disease. In what ways may medicines enter the system? Mouth, rectum, respiratory tract, absorbed through the skin and injected under the skin. s 224 THERAPEUTICS AND MATERIA MED1CA. Name two drugs whose poisonous action is markedly manifest in the mouth. Give the distinguishing char- acteristics of the effects of these drugs. Iodides and mercury. Iodism is manifest by swelling and redness of the gums, fauces, hard and soft palate, foulness of the tongue, fetid breath, and increase of mucus in the mouth; also headache, coryza and increased bronchial secretion. Mercury may in- crease the salivary flow to several pints per day. At first the secretion is thick but later becomes thin. Fetid breath, sore gums, may go on to ulceration of the mouth and cheeks. Low fever. Which of the vital organs fails first in collapse from (a) ether, (b) chloroform? (a) Kills by paralysis of respiratory center, (b) usually the heart, but may be respiratory center. Name two medicines that decrease blood pressure. Tartar emetic and tincture of aconite. Describe the method of administering a medicine by which its quickest action is obtained. The medicine in solution is placed in a hypodermic syringe (the syringe and solution being as near aseptic as possible). The air is expelled while the needle points upward, sterilize the skin and inject contents into the cellular tissue. Define diuretic, diaphoretic, expectorant. Diuretics are agents which increase the flow of urine. Diaphoretics increase the perspiration. Expectorants in- crease and modify the secretion of the bronchial mucous membrane. Differentiate a tonic and a stimulant. Tonics promote secretion and give tone to the system. Stimulants increase the function of the part or organ. Mention two medicines that may be used as cauteries. Nitrate of silver and carbolic acid. THERAPEUTICS AND MATERIA MEDIC A. 225 State the treatment of carbolic acid poisoning. Administer a soluble sulphate (sodium or magnesium) and follow by albumin and mucilaginous drinks. Wash out the stomach. Combat collapse by external heat and with hypo- dermic injections of strychnine and atropine. What is an emetic? Emetics are agents which excite vomiting either by local or central action. Mention two drugs that reduce fever. Acetanilid. Quinine. Describe the symptoms of cocaine poisoning. A rapid, feeble and irregular pulse, with shallow and lab- ored respiration, clammy skin, dilated pupils, delirium and hallucinations. May have clonic convulsions and increased temperature. What restoratives are most desirable in case of threat- ened collapse during the administration of (a) Nitrous Oxide, (b) Ether, (c) Chloroform. (a) Amyl nitrite, oxygen, atropine. (b) Ammonia, oxygen, strychnine, atropine and faradic current. (c) Ammonia, strychnine and digitalis. What is the antidote for opium? ]/ Potassium permanganate (chemical). Atropine (physio- logical) . What is the dose of bichloride of mercury? fa t0 tV g r - Mention two purposes for which medicines may be applied cataphorically in dentistry. Por painless tooth extraction, and to antisepticize pulp canals. 15 V 226 THERAPEUTICS AND MATERIA MEDICA. What medicines are indicated and about how long should they be applied cataphorically for the purposes mentioned in the preceding question. (a) Cocaine, (b) Silver Nitrate, 8 to 20 minutes. Mention three saline cathartics and state the dose of each. Sulphate of magnesia (Epsom salt), 1 drachm to iy 2 ounces. Tartrate of Potassium and Sodium (Rochelle salt), 1 drachm to 1 ounce. Solution of Citrate of Magnesia, 12 ounces. Mention three good counter=irritants. Cantharides, tr. of iodine, and mustard. Define chemical antidote for a poison, physiological anti= dote for a poison. By chemical antidote is meant some substance which com- bines chemically with the poison, producing an inert or in- soluble compound. By physiological antidote is meant a sub- stance which is opposed to the poison in its action on- the economy. State three properties of carbolic acid. Local anesthetic, caustic and antiseptic. Name the antacids valuable for use in the mouth. Sodium bicarbonate, lime water, chalk and charcoal. What is the chief use of capsicum in dentistry? As tincture or plaster in periodontitis. What is meant by chemical and physiological incom= patibility of medicines? Agents are said to be chemically incompatible when their mixture results in the decomposition of one or more of the ingredients. Physiological incompatibility is where one drug produces effects upon the system opposite to the action of some other drug, like aconite and opium. THERAPEUTICS AND MATERIA MEDIC A. 227 Give the physiological action of belladonna. Belladonna is an anodyne, an anti-spasmodic, a mydriatic, an irritant narcotic ; in small doses a respiratory, cardiac, and spinal stimulant; in large doses a paralyzer of the secretory and motor nerve endings, and a stimulant of the sympathetic system. It produces dryness of the mucous membranes of the nose, mouth, throat and larynx ; and at first lessens the gastric and intestinal secretions, but soon reproduces them in large quantity. The heart-rate is at first slowed, but soon becomes vigorous and rapid. Give the mouth signs of mercurial poisoning. Hyperemic mucous surface, teeth tender upon pressure and loose, increased flow of saliva, swollen tongue, and metallic taste. How should the administration of chloroform differ from that of ether? Chloroform should be administered a few drops at a time and the vapor allowed to mix freely with air, while ether is administered in larger quantities and only a small amount of air allowed to mix with the vapor. State the objection to the use of iron salts, as styptics. The clot which is formed is soluble in the fluids of the mouth, frequently resulting in secondary hemorrhage. Iron solutions used are also strongly acid. Mention, with doses, three coaNtar preparations, useful in the treatment of neuralgia. Acetanilid, 2 to 10 grs. ; phenacetin, 2 to 10 grains ; anti- pyrine, 5 to 10 grs. Differentiate poisoning by atropine and poisoning by strychnine. In atropine poisoning we have motor paralysis, delirium and death. In strychnine poisoning we have convulsive ac- tion of the muscles with consciousness. Death follows from exhaustion and asphyxia. 228 THERAPEUTICS AND MATERIA MEDIC A. Write a prescription for an antiseptic mouth wash. R. Acidi carbolici (95%) mm Aquae q. s. f | v Sig. — Use as mouth wash. What is meant by the active principles of a drug? Give an example. The extractive substance which gives the drug its medicinal properties. Quinine is an active principle of cinchona bark. Mention three alteratives. Arsenic, mercury and iodine. Give the physiological action of ergot. Externally it acts as a siight astringent on the broken skin or mucous membrane. G-astro-intestinal tract. — Disagreeable taste and may pro- duce nausea and vomiting. Circulation. — Heart-beat becomes slow and increased in force. It stimulates the vaso-motor centre and unstriped mus- cular fibres of arteries/ raising blood-pressure. Uterus. — It stimulates the contraction of the parturient uterus, increasing the force and frequency. There is a marked decrease in the blood supply of the nonparturient uterus. Nervous system. — It causes anaemia of the centres, par- ticularly in the spinal cord. Give the physiological action of digitalis. Gastro-intestinal tract. — Digitalis may cause nausea, vomit- ing and diarrhoea. Circulation. — Decreases the number of heart beats, length- ening diastole ( stimulation of inhibitory fibres of vagus) . It increases the force of the contractions (intrinsic ganglia). Arterial tension rises from increased cardiac force, excita- tion of vaso-motor centre, and direct action on the muscular coats of the arteries. By relaxation of renal arteries it increases flow of urine. Later the heart becomes weak and irregular, beating with increased frequency. Large doses decrease abnormal temperature. It may cause head- ache, vertigo or delirium. It also stimulates the uterine contractions. THERAPEUTICS AND MATERIA MEDICA. 229 i^ Give the physiological action of nux vomica. Gastro-intestinal tract. — Small doses act as a bitter tonic, increasing appetite, secretion and digestion. It increases the muscular tone of the stomach and peristalsis is also increased. Circulation. — Cardiac centre, vaso-motor centre and cardiac ganglia are stimulated, raising arterial tension, increasing the force of heart action but slowing its beat. The respiratory centre is stimulated, the pupils dilated, the contractile power of the bladder is stimulated, the reflex activity of the spinal cord is increased. It also acts as an aphrodisiac. Give the physiological action Of opium. Externally it is slightly sedative. Stomach. — It decreases sensation, secretion and peristalsis, reducing hunger and pain. Continued use deranges digestion. Intestines. — Sedative action, relieving pain, secretion de- creased and peristalsis is decreased by stimulation of the splanchnics (inhibitory nerves). Large doses may cause diarrhoea leading to paralysis of the splanchnics. Bile and pancreatic juice are decreased. Nervous System. — The convolutions of the brain are briefly excited, then depressed by direct action on nerve cells (possi- bly by causing anemia). Stage of Excitement. — Exaltation of feelings, happiness, brilliancy of imagination, increase of intellectual power and mental vigor. Imagination becomes extravagant, dreams of grotesque and impossible things. Sensory and perceptive centres become depressed, stupor and sleep. Pupils contracted. Write a complete prescription for a four ounce aqueous solution containing three drugs, (b) State the amount of each drug contained in a teaspoonful of the solution. For John Smith. R . Potassii bromidi gr. clx Chloralis gr. lxiv Tincturse digitalis m. xlviii Aquae, q. s. ad f 5 iv M. Sig. — Teaspoonful in water every hour until relieved. 10-29-' 04. OR. I>. . 230 THERAPEUTICS AND MATERIA MEDIC A. (b) Potassium bromide, 5grs. ; chloral, 2grs. ; tincture of digitalis, iy 2 minims. Under what conditions is ether contra-indicated as an anesthetic? In acute inflammatory infections of the respiratory tract, advanced arteriosclerosis, severe nephritis, especially when associated with cardiovascular lesions and anemia when the hemoglobin is less than 30%. Diabetes mellitus, especially when well established and associated with acetonuria (Stevens). Name the most common aftereffects of the administra- tion of ether. Nausea and vomiting. Name the accidents that may happen during the admin- istration of ether, and give the treatment in each case. In the early part of the administration of ether we may have failure of respiration, which is due to reflex spasm of the laryngeal muscles excited by the ether. By giving more air with the ether we can correct this trouble. Embarrassed respiration may be due to the accumulation of mucus in the upper air passages. In this condition we simply turn the head to one side. Respiratory failure may be caused by the action of the ether on the respiratory centre. In this case we withdraw the ether; push the jaw forward by pressing on its angles, draw the tongue forward by means of a tenaculum or forceps and make rhythmic traction of the tongue. Pour ether on the abdomen or chest in order to stimulate inspiration by reflex action, give strychnine and atropin hypodermically. Practice artificial respiration. When is chloroform preferred to ether as an anaesthetic? In acute inflammation of the bronchi or lungs, aneurism, atheroma and nephritis. THERAPEUTICS AND MATERIA MED1CA. 231 Give the signs of danger in chloroform anaesthesia and tell what should be done. Lividity of the face, irregular or stertorous breathing or feebleness of the pulse. Withdraw the anesthetic, lower the head, use artificial respiration and give a hypodermic in- jection of strychnine, digitalis, or ammonia. What are topical remedies? (b) Mention two classes. (c) Give two examples of each. Topical remedies are those which are applied locally. (b) Plasters and liniments. (c) Belladonna plaster and capsicum plaster — turpentine liniment and chloroform liniment. What systemic conditions contra=indicate the use of nitrous oxide gas? (b) State why? Atheromatous vessels, fatty heart and pulmonary em- physema. (Burchard.) (b) Nitrous oxide gas increases blood pressure and in atheromatous degeneration of the arteries this may result in rupture of these vessels and if in the brain, apoplexy or early death may ensue. In fatty heart the muscles are weakened, and on account of the increased resistance in the blood-vessels there may be sudden dilatation of this organ. In pulmonary emphysema the danger is in the engorgement of the blood vessels of the lungs which causes an increased resistance to the right heart, which may result in the sudden dilatation of this organ, or there may be pulmonary edema or hemorrhage. Give the indications for the use in producing sleep of (a) morphine, (b) chloral, (c) potassium bromide. (a) Morphine is used when sleeplessness is due to pain. (b) Chloral is indicated when sleeplessness is due to mental overwork and where a more powerful hypnotic than potassium bromide is required. If the heart or stomach are in bad condition it should not be given. 232 THERAPEUTICS AND MATERIA MEDICA. (c) Potassium bromide is given when insomnia is caused by cerebral excitement, nervous excitement (especially when connected with the genital function) and motor activity. Ac- cording to Wood it is contra-indicated by an excessive irri- tability of the gastro-intestinal mucous membrane and great exhaustion. What is an analgesic? Mention three. An analgesic or anodyne is an agent which relieves pain. This may be accomplished by local or central action. Opium, cocaine and chloroform are examples. Why is the use of ether as an anaesthetic contra=indi- cated in diseases of the lungs and kidneys? Because it is eliminated by the lungs and kidneys, and on account of its irritating qualities it would aggravate the diseased condition. Describe the three stages of chloroform narcosis. 1st stage. This stage is very short and the symptoms are very similar to those of alcoholic intoxication. Conscious- ness is not lost but the sensibility is generally dulled, but rarely altogether abolished. 2d stage. This is the stage of anesthesia, consciousness and sensibility are abolished, the muscles are relaxed and the patient is quiet. The pulse is generally normal in frequency, but somewhat weakened. 3d. stage. This stage is one of profound narcosis with ster- torous breathing, intense muscular relaxation, abolition of the ordinary reflexes and fall of bodily temperature. Pulse is weak and rapid. Give the contraindications to the use of anaesthetics. Organic brain disease, including tumors, atheromatous con- ditions of the blood vessels, organic affections of the heart, lungs and kidneys (Wood). Some authorities add diabetes mellitus, chronic alchoholism and enlarged tonsils. THERAPEUTICS AND MATERIA MEDICA. 233 Describe the three stages of anesthesia under ether. 1st stage. Burning in the fauces, feeling of strangulation, sense of exhilaration, lightness in the head with a buzzing or roaring in the ears. These symptoms are soon followed by a feeling that the surroundings of the patient are at a distance, which fades into semi-unconsciousness with visions and illu- sions. Patients may laugh, shout, weep, fight or pray. 2d. stage. This stage begins with a complete loss of con- sciousness. Muscular rigidity soon passes off and the patient is quiet. Respiration is slow and regular. 3d stage. Same as the third stage under chloroform narcosis. Name the ingredients of a desirable dentifrice and specify the properties that make each of these ingredients desirable. Precipitated chalk gives body, is abrasive and also antacid. Orris root gives flavor and masks the soap. Powdered soap is antiseptic a,nd removes fatty film from the teeth. Saccharine sweetens, and disguises earthy taste of chalk. Menthol is strongly antiseptic and cooling. What is meant by cataphoric application of a remedy? By cataphoric application of a remedy is meant the in- filtrating of the tissue with some drug by electrical osmosis. Differentiate a decoction, an infusion and a tincture. Decoctions are solutions of the active constituents of drugs obtained by boiling them with water. Infusions are aqueous solutions of the medicinal consti- tuents of plants, obtained by infusing the drug with hot water, the drug not being subjected to boiling. Tinctures are solutions of non-volatile substances in alcohol. Differentiate fixed oils and volatile oils and give three examples of each. Fixed or fatty oils are permanent liquids, or at certain tem- ) X 234 THERAPEUTICS AND MATERIA MEDICA. peratures solid substances, not volatilized by heat, and leave greasy stain on paper. They consist mainly of varying pro- portions of olein, palmitin, stearin. Castor, linseed and olive oils belong to this class. Volatile or essential oils, so called' because they usually rep- resent the odorous principles of plants, are entirely dissi- pated by exposure to the air or heat. They leave no stain on paper, have hot, pungent taste, but when diluted are agree- ably aromatic. They consist of two principles — a solid stearopten, and a liquid eleopten portion. They are limpid fluids at ordinary temperatures. Oils of cloves, winter green and cinnamon belong to this class. What is hydrogen dioxide? Give its formula and dental uses? Hydrogen Dioxide (U. S. P.) is a slightly acid, aqueous solution containing, when freshly prepared, about 3% by weight of the pure dioxide, corresponding to about 10% of available oxygen. Formula is H 2 2 . Its dental uses are to destroy pus and whenever a non-toxic disinfectant is indicated. What is iodoform? Give a solvent and state dental uses. Iodoform occurs as small, lemon-yellow crystals of a very persistent, disagreeable odor, made from the action of iodine on alcohol with potassium hydrate or carbonate. It is almost insoluble in water, very soluble in alcohol, ether, chloroform, fixed and volatile oils. In dentistry it is employed as a root canal dressing. What is formaldehyde? State the dental uses and the strength of solution that should be used for each purpose. Formaldehyde is a colorless irritating gas, produced by the oxidation of methyl- alcohol. It is very soluble in water and alcohol, and occurs commercially as a 40% aqueous solu- tion. It is used in dentistry in mouth washes as an antiseptic in % to 1% solution. THERAPEUTICS AND MATERIA MEDICA. 235 Write two complete prescriptions, one containing a drug in aqueous solution and the other containing a drug insoluble in water, also in solution. For Miss Jones. Be . Plumbi acetatis gr. v Aquse dist f^j M. Sig. — Use as directed. J. V. Doe. For Miss . i£ . Hydro-naphthol 3J Alcohol f 3 j M. Sig. — Teaspoonful in wineglass of water, as a wash. J. V. Doe. What are fluid extracts? They are liquid, alcoholic preparations of drugs, permanent and concentrated to such a strength that 1 c. c. represents the equivalent of one gram of the drug. What is bromide of ethyl? Bromide of ethyl is a colorless, volatile liquid with ethereal odor. Made by distilling a mixture of potassium bromide, al- cohol and sulphuric acid and purifying the distillate. Distinguish between narcotics and hypnotics. Narcotics are drugs, all more or less poisonous, which de- press the higher functions, lessen, and in large doses abolish sensibility to pain and cause sleep, which is usually followed by unpleasant symptoms. Hypnotics induce refreshing sleep with no untoward after effects. They are cerebral sedatives. Write a prescription for a wash for a purulent antrum, using no proprietary terms. B . Sodium bicarbonate gr. xxx Thymol gr. v Alcohol f o iv Glycerine f 3 i Water, q s f £ iv M. Sig. — To be used as directed. 236 THERAPEUTICS AND MATERIA MEDIC A. Mention two heart stimulants administered by inhala- tion and state under what circumstances they are par- ticularly useful. Amyl-nitrite — in chloroform anesthesia should cardiac fail- ure occur. Ammonia — in syncope from any cause. What physical states of medicine are most suitable for different methods of administration? By mouth — solution, pill, powder or capsule. By inunction — liniment, ointment or plaster. By inhalation — vapor. By rectum — solution or suppository. By hypodermic injection — always in solution. Write a prescription for an astringent mouth wash, using no proprietary terms. R . Sodium bicarbonate <■ gr. xxx Tincture of iodine ■ • • • • f 3 j Tannic acid gr. xxx Water f Jf vi Sig. — To be used as a mouth wash as directed. Mention three disinfectants suitable for use in putres- cent pulp canals. Formaldehyde. Carbolic acid. Bichloride of mercury. Mention a chemical antidote for carbolic acid. Magnesium sulphate. Define germicide, deodorant. Germicides are agents that destroy germs. Deodorants cover or destroy disagreeable odors. How do drugs produce emesis? Drugs produce emesis by acting on the stomach directly, afferent impulses stimulating the vomiting centre in the medulla, and by stimulation of the centre in the medulla itself. THEBAPEVTICS AND MATERIA MEDICA. 237 Write a complete prescription calling for three drugs which may be suitably combined. R . Acetanilid 3 j Sodium bicarbonate Caffeine aa gr. xv. M. et ft. chartae no. xii. Sig. — Take one every two hours. Define antipyretics. Mention three. Antipyretics are drugs which reduce temperature when ab- normally high by retarding oxidation, by increasing heat dis- sipation, or by acting either on the heat-producing center of the brain or on the circulation. Acetanilid. Aconite. Quinine. Mention, with the dose of each (a) saline cathartic, (b) laxative cathartic, (c) cholagogue cathartic. (a) Magnesium sulphate, dose 2 to 8 drams. (b) Cascara sagrada (fluid extract) 15 to 60 minims. (c) Calomel in large doses, 2 to 10 grs. Mention three medicines used as styptics. Alum. Tannic acid. Solution of ferric subsulphate. Mention a medicine that stimulates absorption by the lymphatics. Potassium iodide. Mention three essential oils and state their dental uses. Oil of cinnamon — antiseptic root canal dressing. Oil of cloves — to relieve toothache. Oil of wintergreen — for its agreeable taste and antiseptic qualities in dentifrices. Mention two agents used in bleaching teeth and de- scribe the method of their application. Sodium dioxide placed in moist cavity, liberates nascent oxygen, thereby bleaching the dental tissues. Twenty-five per cent, pyrozone has similar action. \ 238 THERAPEUTICS AND MATERIA MEDICA. What remedies, general or local, aside from operative procedure, are useful for the relief of toothache? (a) when the pulp is alive and not exposed? (b) when perice=- mentitis has supervened on death of the pulp. (a) Oil of cinnamon. Oil of cloves. Tincture of aconite given internally in y 2 drop doses. (b) Tincture of aconite and tincture of iodine in equal parts applied to the gum over the affected tooth. in death from ether, which of the vital organs fail first? The organs of respiration. Mention (a) a coagulating antiseptic, (b) a non=coagu= lating antiseptic. (a) Carbolic acid, (b) Oil of cinnamon. Define astringents. Mention two vegetable and two mineral astringents. Astringents are remedies which cause contraction of mus- cular tissue, coagulate albumen and lessen secretions from mucous surfaces. In weak solutions, they act as tonics; in concentrated form they act as irritants and caustics. Vegetable astringents, tannic acid, krameria. Mineral astringents, alum, iron subsulphate. Define sialagogue. Mention one. Sialagogues increase the action of the salivary glands. Pilocarpine. Mention three alteratives and state the dose of each. Mercuric bichloride, -^ to y-j- gr. Potassium iodide, 5 to 60 grs. Fluid extract of stillingia, y± to 1 fluid dram. What is meant by the physiologic action of a drug? The physiologic action of a drug is the altered action, func- tion, and behavior of the tissue and organs while under its influence. THERAPEUTICS AND MATERIA MEDIC A. 239 Arrange the following in the order of their efficiency as disinfectants; carbolic acid, bichloride of mercury, oil of cloves. Bichloride of mercury. Carbolic acid. Oil of cloves. Mention the drugs useful in the treatment of pyorrhea alveolaris and state their effects. Hydrogen peroxide attacks pus and dead tissue vigorously, destroying them by the liberation of oxygen. Hydro-naphthol is an efficient germicide for use after pus pockets have been otherwise cleansed. Aromatic sulphuric acid is useful to soften and remove cal- careous deposits, besides having marked antiseptic and stimu- lating properties. Describe the physiological action of amyl=nitrite. State the dose and the method of administering it. Amyl-nitrite stimulates the rate of heart beats, though not its force; vessels dilate, causing fall in arterial tension; the respiration is first stimulated, but later depressed; action on the nervous system — great depression of motor centres; tem- perature falls. The dose is three to five minims dropped on a napkin and administered by inhalation. What is cocaine hydrochlorate? How is it obtained? State its properties and dose. Cocaine hydrochlorate is an alkaloid obtained from the leaves of Erythroxylon Coca by removing the tannin from an aqueous infusion of the drug with lead subacetate, and the addition of sodium or potassium hydrate to alkalinity. Then it is agitated with ether and the ethereal portion evaporated. It is finally purified by repeated crystallization from alcoholic solutions after having neutralized the salt with hydrochloric acid. It occurs as colorless, transparent, odorless, neutral crystals, bitter to the taste. It is soluble in half its weight of water or alcohol, less soluble in chloroform, and almost insoluble in sulphuric ether. It acts first as a stimu- lant, but later as a narcotic and depressant. Dose "• s to 1 2 S r - 240 THERAPEUTICS AND MATERIA MEDIC A. How many grains of a drug are necessary to make one pint of a i to 2000 solution? Write a prescription for a 1 to 2000 solution of bichloride of mercury. A pint of water weighs 7291.2 grains. A 1 to 2000 solution contains 2W0 °^ a § ra ^ n i n every grain of water. Therefore, llii x 2W0 — number of grains in a pint of the solution; or 3.6456 grains. R . Bichloride of mercury gr. 3.6456 Distilled water f J xvi M. Sig.— Use as directed. Name three drugs useful for sterilizing instruments. Describe a method of sterilizing a mouth mirror. Formaldehyde. Carbolic acid — 5% solution. Hydrogen dioxide. Sterilize a mouth mirror by immersing it in a 10% solution of formaldehyde for at least fifteen minutes. Name three heart stimulants administered hypodermi- cally in the order of their rapidity of action and state dose of each. Strychnine sulphate, dose -^ gr. Nitroglycerine, dose t ^q gr. Alcohol, dose 30 minims. What remedies should always be at hand to meet symp- toms of danger in giving anesthetics? Aromatic spirits of ammonia. Hypodermic tablets of strychnine sulphate. Amyl-ni trite. Tincture of digitalis. Alcohol (whiskey or brandy). Nitro-glycerin. Atropine. Give maximum dose of cocaine hydrochlorate for hypo- dermic administration to an adult. One-half grain. THERAPEUTICS AND MATERIA MEDIC A, 241 Describe carbolic acid and creosote, (a) Where de- rived? (c) Their dental use. Carbolic acid occurs as clear, colorless (when fresh) inter- laced, needle-like crystals, which, after exposure to light ac- quire a pink to reddish tint. It liquifies by heat or on addi- tion of 10% of water or glycerine; has distinctive, slightly aromatic odor, and when diluted has a sweetish pungent taste. It has faint acid reaction, is soluble in alcohol, glycerine or water and coagulates albumin. Carbolic acid is obtained from coal tar by fractional distillation and subsequent purification. In full strength it is used for hypersensitive dentin, and in pulpitis as an anodyne. In carious cavities and putrescent pulp canals, it is useful as a germicide, antiseptic dressing, and as a caustic in treating ulcers. A 5% solution may be used as an antiseptic for sterilizing instruments, and in weaker solution as an antiseptic mouth wash. Creosote is an almost colorless, highly refractive oily liquid, turning red or brown on exposure to light. Its odor is pene- trating and smoky, with burning caustic taste. It is slightly soluble in water, fully so in alcohol, chloroform, ether and oils; does not coagulate albumin. It is derived from the fractional distillation of wood tar, that portion coming over between 205 and 220 degrees (Cen- tigrade) being collected as creosote. Its dental uses are very similar to those of carbolic acid, though not suitable for sterilizing instruments nor as a mouth wash, because of its insolubility in water. Write a prescription for a counter=irritant containing three drugs. B . Tincture of aconite Tincture of iodine Chloroform aa f 7, j M. Sig. — Apply as directed. How do cocaine and eucaine differ in physiological action? Eucaine has a very similar action to cocaine but does not 16 242 THERAPEUTICS AND MATERIA MEDICA. dilate the pupils nor interfere with accommodation. It does not affect the circulation nor respiration to any great ex- tent as does cocaine. Name five essential oils used in dental practice. Oil of cinnamon. Oil of cajuput. Oil of cloves. Oil of wintergreen. Oil of eucalyptus. (a) What are local anesthetics? (b) Mention three, (c) Describe the method of using them, (d) State the precautions necessary. (a) Local anesthetics are agents which produce insensibility of the part to which they are applied. (b) Cocaine hydrochlorate. Ethyl chloride. Carbolic acid. (c) Cocaine hydrochlorate is used hypodermically in 1 to 5% solution. Ethyl chloride is used as a spray. Carbolic acid is applied to the surface in solutions up to 10% for its benumbing effect which lasts several hours. (d) In the use of cocaine hydrochlorate hypodermically, have the syringe and solution perfectly aseptic, taking care not to inject an overdose. Have triturates of Y i~o grain of atropine sulphate always at hand, also morphine sulphate as antidotes. In the use of ethyl chloride care should be taken not to freeze the tissue too hard. In carbolic acid as an anesthetic, solutions stronger than 10% irritate and have caustic effects. What is trichloracetic acid? (b) What are its prop- erties and dental uses? (a) It occurs as colorless crystals, very soluble in water, obtained by the oxidation of chloral by nitric acid. THERAPEUTICS AND MATERIA MEDICA. 243 (b) It is of value in the quantitative estimation of albumin and as a caustic. Its dental uses are as an aid in removing calcic deposits, and in treatment of suppurating surfaces. Describe the properties, dental use and application of copper sulphate. Copper sulphate occurs in large blue crystals, permanent in the air, is odorless and has a bitter, metallic taste; it is soluble in about three parts of water. In strong solution it acts as a caustic and in dilute form as an astringent. In- ternally in doses of 5 to 10 grs. it is a certain and power- ful emetic. Dental use — valuable for its astringent properties. (a) From what is opium obtained? (b) Name two of its alkaloids, (c) State the adult dose of each. (a) Opium is the inspissated milky exudate obtained by the incision of the unripe capsule of Papaver Somniferum. (b) Alkaloids — morphine and codeine. (c) Dose, morphine % to ,% gr. ; codeine 14 to 2 grs. Write a prescription for the treatment of thrush, con= taining at least two drugs and a menstrum. K . Boracic acid % j Carbolic acid m v Glycerine Water aa f 3 iv Sig. — Use as a wash. How many grains of a drug are there in six fluid ounces of a 10% solution? A fluid ounce of distilled water contains 455.7 gr. Six fluid ounces therefore contain 2734.2 gr. A 10% solution must therefore contain - 2 - I rV 4 — , or 273.42 gr. What is the dose of carbolic acid for internal admin- istration? What are the chemical antidotes? Dose is % to 2 grs. Chemical antidotes — Albumin and sulphate of sodium or magnesium. 244 THERAPEUTICS AND MATERIA MEDIC A. Describe the action of a saline cathartic. Name three and give the dose of each. Saline cathartics act by generally stimulating the secre- tion of intestinal fluids. This, together with increased peris- taltic movements, results in easy evacuation. Magnesium sulphate, dose y 4 to 1% ounces. Potassium and sodium tartrate, dose 14 to 1 ounce. Sodium phosphate, dose y± to 1 ounce. Define diffusible stimulants, (b) Give three examples and mode of administering each. Diffusible stimulants are stimulants which have a prompt but transient effect. Ammonia — by inhalation. Ether — by mouth or hypodermic injection. Alcohol — by mouth or hypodermic injection. Write a prescription containing an anodyne, a styptic, and an antiseptic to be used after extensive extraction of teeth. Fob Mrs. Carpenter. R . Acidi tannici 5 ii Acidi carbolici gr. xxx Sodii hydratis gr. x v Glycerini f 3 iv Aqu se f^ iiiss M. Sig. — Use as a mouth wash. Dr. . Give a rule for determining the amount of a drug re- quired to prepare a solution of a given percentage. Multiply the amount (expressed as grains) of the finished solution by the per cent, given, and divide by one hundred. The quotient will be the quantity in grains of the drug required. In what order are the nerve centres affected in general anesthesia? Nerve centres affected in general anesthesia are the brain, sensory side of spinal cord, motor side of spinal cord and finally the nerve centres in medulla. THERAPEUTICS AND MATERIA MEDIC A. 245 What are the physiological effects of nitrous oxide gas? It is a stimulating narcotic and anesthetic. There is an increase in blood pressure, a sense of exhilara- tion, a ringing in the ears, followed by complete unconscious- ness. Anesthesia is probably due to the displacement of oxygen in the blood and to direct action of the gas on the cerebrum. Describe the preparation of nitrous oxide gas. Nitrous oxide gas is prepared by heating ammonium nitrate, the vapor of which is passed through three wash bottles con- taining, respectively pure water, solution of caustic potash, and solution of ferrous sulphate. State the dose, toxic effect, and antidote of arsenic, aeon* ite and morphia. Arsenic, dose -^ to y 1 ^ gr. Toxic effects are — faintness, nausea, epigastric tenderness, profuse diarrhoea, skin cold, pulse small and feeble. The antidote is freshly prepared ferric hydrate. Aconite (Tincture) dose is y 2 to 5 drops. (Solid extract) dose is 14 gr. Toxic effects — tingling sensation in the mouth, vomiting later, skin cold and clammy, pupils dilated, pulse small, weak and irregular, muscular weakness, death from asphyxia. Antidote — emetics, artificial respiration, keep patient warm, stimulate with brandy, ether, digitalis, atropine. Morphia, dose % to 14 gr. Toxic effects — pulse becomes slower, respiration is mark- edly reduced, reflexes become abolished, death occurs from paralysis of the respiratory centre, or carbonic acid accumu- lation in the blood. Antidotes — emetics in large doses, tannic acid as chemical antidote, strong coffee in stomach and rectum. Give the advantage and disadvantage of ether, chloro- form and nitrous oxide as general anesthetics. Ether. Advantages — administered with greater safety phatics. Having a mesodermic origin, the blood and lymph vessels first appear as "cords" of cells which later become hollow to form tubes. The innermost cells become distinctly flattened to form the endothelial lining. The first blood vessels have their beginning outside the body of the embryo, in the yolk-sac. Describe the muscular tissue. Muscular tissue is of mesodermic origin and consists prin- cipally of elongated cells (fibrous cells) which have the in- herent power of contracting. The muscle fibers contain nuclei and, sometimes, that which corresponds to a cell wall, the sarcolemma. Voluntary and cardiac muscles are striated, due to the arrangement of alternate light and dark discs. Non-striated muscle is involuntary. Microscopically, they may be differentiated as follows: HISTOLOGY. 343 Striated. Non-Striated. Cardiac. Fibers striated trans- No striations. Striated longitudinally and versely. transversely. Has sarcolemma. Hyaline sheath. No sarcolemma. Nucleus beneath sar- Nucleus in cen- Nucleus oval and in center. oolemma. ter. Fibers do not branch, Fibers short. except in the tongue. Fibers branch freely. To what class of tissues do the teeth belong? With the exception of the enamel, which is a product of epi- thelium, the teeth belong to the connective tissue group. From what is the six=year molar derived? The enamel germ of the first permanent molar appears at the extremity of the dental ridge after the manner of a temporary tooth ; it appears about a week before the budding of the germs of the temporary teeth. Give the principal tissues of the animal body. Blood and lymph, epithelium, connective, muscular and nervous. The blood and lymph are often classified with the connective tissue. State the functions of epithelium. Protective, secretory, absorptive, to permit exchange of gases, to produce motion (ciliary), for the reduction of fric- tion (endothelium) , and for the reception of nervous impulses. What are the soft fibers of Tomes? Prolongations of the odontoblasts into the dentinal tubules are known as "fibers of Tomes." State the size, shape and structure of a human red blood corpuscle. The red blood corpuscles are disc-shaped, biconcave, and are 1-3200 of an inch in diameter. They are not nucleated; and, though they probably have a delicate cell wall, none can be demonstrated. The cell contains a substance, hemoglobin, which gives the color to the cell. 344 HISTOLOGY. Describe the structure of arteries. The medium-sized arteries are composed of three coats or tunics. The tunica intima (inner), consisting of an endo- thelial lining, resting upon a sub-endothelial layer of loose connective tissue, which is separated from the middle coat by a layer of elastic tissue, lamina elastica interna. The tunica media (middle) is a muscular tunic and consists of a layer of involuntary (non-striated) muscle fibers circularly ar- ranged. The tunica adventitia (outer) consists of an ad- mixture of white fibrous and yellow elastic connective tissues. This tunic contains small vessels which nourish the artery, called vasa vasorum. To what tissue does dentine belong? To the connective tissue of the dense variety. What is bioplasm? The living substance of the cell. The term is often used synonymously with protoplasm. Mention the varieties of epithelium. Squamous, columnar, ciliated, glandular, transitional, pig- mented, and neuro-epithelium. The first three may occur in a single layer, when it is named "simple;" or, in several layers, when it is called "stratified." Describe the more minute structures which evolve the sense of taste. On the dorsum and sides of the tongue, particularly the former, are elevations of the mucous membrane in the form of papillae. A few of the papillae (8-12). situated on the posterior part of the dorsum of the tongTie. are surrounded by a fur- row, hence called the circumvallate papillae. They are ar- ranged in the form of the letter "V," the apex being directed posteriorly. These papillae usually bear secondary papillae. Embedded in the stratified squamous epithelium on the sur- face of the papillae are oval bodies composed of modified epithelial cells arranged "like the staves of a barrel." These HISTOLOGY. 345 are the taste buds which are communicant with the terminals of the gustatory nerve. The fungiform papillae, more numerous than the cir- cumvallate, receive filaments of the nerves of taste ; but there are fewer of the "special endings" than in the circumvallate. Secondary papillae do also occur on the fungiform papillae. The largest number of the papillae is of the conical or fili- form variety, consisting of a conical elevation of connective tissue covered with epithelium. They carry the terminals of the nerve fibres to the periphery. Describe the cell structure of articular cartilage. The articular surfaces are covered with hyaline cartilage, the distinguishing feature of which is the translucency of its matrix. The matrix, which presents a homogeneous appear- ance, contains many cartilage cells which occupy and com- pletely fill spaces called lacunae. Sometimes, two or more cells occur in a single lacuna. The cells are distinctly nu- cleated; the youngest are spindle-shaped and occupy a posi- tion next to the perichondrium, while the oldest cells are deeper and~are irregularly rounded, having a tendency to become angulated. How does a mucous membrane differ from a serous membrane? Mucous membranes line all cavities communicating directly or indirectly with the atmosphere. They consist of an epi- thelial covering, the variety of which varies with the loca- tion, resting upon a connective tissue base, — the tunica propria. Extensions of the epithelium into the connective tissue beneath, arranged in the form of tubes or sacs (usu- ally the latter) which secrete mucous for the purpose of moistening the surface of the membrane, form the mucous glands. Serous membranes are found lining closed sacs. They con- sist of a single layer of endothelial cells resting upon a con- nective tissue membrane. Minute openings, stomata. existing between some of the cells, communicate with lymph capillaries. 346 HISTOLOGY. The fluid found on the surface of serous membranes comes from the lymph channels. Serous sacs may be regarded as large lymph spaces. Describe the pericemental membrane. Give its origin and function. The pericemental membrane is the fibrous tissue investment which covers the root of the tooth. The fibres composing it run, for the most part, transversely. Elastic fibres are not- ably absent. It has its origin in the outer layer of the dental sac. This membrane serves to hold the tooth in the alveolus, and, to furnish the nutrition to the cementum through the blood vessels it carries. Acting as a cushion, it seems to di- minish shock during mastication. Differentiate between osteoclasts and cementoblasts. Osteoclasts are connective tissue cells found in bone-form- ing tissue. It is by their agency, the absorption of calcified matrix, that the Haversian canals and spaces are formed. Cementoblasts are also connective tissue cells, but their function is that of depositing lime salts in the matrix of the cementum. Describe the process of dental calcification. At about the end of the fourth month, the enamel of the temporary teeth is formed. From the extremity of the enamel cells, next to the papillae, develops a tuft-like pro- jection, which becomes calcified, forming an enamel prism. The process of calcification proceeds therefore from within outward. At about the same period, the deposit of dentine on the sides and apex of the dental papillae begins, and therefore proceeds from without inward. Calcification of the dentine is not complete, for the areas known as interglobular spaces are not calcified, nor are the processes of the odontoblasts, — 'the dentinal fibres. Describe the structure, blood supply and nerves of the pulp. The pulp consists of embryonic connective tissue which is HISTOLOGY. 347 composed of stellate cells arranged in a semifluid, transparent matrix. Next to the wall of the pulp canal are columnar shaped cells, the odontoblasts, processes of which enter the dentine as the dentinal fibrils. The pulp is well supplied with blood-vessels and nerves which enter at the apical foramen. After entering the pulp canal they break up to form plexuses which terminate in the layer of odontoblasts. The function of the pulp is that of furnishing nutrition to the dentine and enamel. Due to the rich nerve supply, the pulp is very sensitive. From what is the mesoblast derived? The mesoblast has its origin partly in the epiblast and partly in the hypoblast, though chiefly the latter. What two tissues are formed by the dental papilla? The dentine which is deposited at the periphery of the papilla; and the pulp, which is that portion of the papilla remaining after dentine has been formed. Describe separately the calcified products of the con- nective tissue. Bone may be considered to be of two kinds: compact, or dense, and cancellated, or spongy. Compact bone consists of a dense matrix containing lime salts, which matrix contains numerous channels for the pas- sage of nutrient vessels and fluids, also clefts or spaces, con- taining bone cells. The largest channels (1-500 inch in diameter), called "Haversian Canals," run parallel with the long axis of the bone and form anastomoses with one another. The canals are surrounded with concentric layers of osseous matrix: Haversian lamellae, between which are small spaces, the lacunae, which in recent bone contain bone cells. Radiat- ing from the Haversian canals to the lacunae, are minute channels which convey lymph. They are the canaliculi. The above named structures form what is termed an 348 HISTOLOGY. "Haversian System." Between the systems, which are circu- lar, interstitial lamellae occur, thus filling the space that otherwise would exist. Lamellae also occur concentrically with the periphery of the shaft of the bone, the circumferential lamellae, and with the medullary canal, the perimedullary lamellae. Spongy bone does not contain Haversian systems, and, therefore, no Haversian canals. There are, however, as the name implies, numerous spaces in the matrix ; they are known as "Haversian spaces." Dentine consists of a calcified matrix in which, extending through the entire thickness of the matrix, are seen the den- tinal tubules which terminate in irregular clefts at the junc- tion of the dentine with, the enamel and cementum. These clefts are known as the interglobular spaces. The part of the matrix immediately surrounding the tubules forms the dentinal sheaths. The tubules contain processes of cells at the periphery of the dentine, — the dentinal -fibres. Cementum resembles very closely the structure of bone. Near the apex of the root, where the cementum is thickest, Haversian canals may sometimes exist, though usually they are not present. What tissue is the origin of the enamel? What are ameloblasts? Enamel originates in the oral epithelium. Ameloblasts are the enamel-producing cells. They are dis- tinctly columnar in shape and occupy a position in the enamel organ nearest the dentine. Describe the development of the dental papilla? The dental papilla is of connective tissue origin. Its posi- tion is first evidenced by a proliferation and condensation of the mesodermic elements. This collection of cells soon assumes the shape of a cone, its apex pointing towards, and later invaginated by the enamel organ. The apex and sides of the conical mass become surrounded by columnar cells, — the odontoblasts, which are the producing agents of the dentine. HISTOLOGY. 349 By what cells, and under what conditions does resorp= tion occur? Cells which are endowed with the funtion of breaking down osseous tissue, namely the osteoclasts, are active in the process of resorption. Resorption takes place previous to the eruption of the permanent teeth and is stimulated by the increased blood supply and pressure of the unerupted per- manent teeth. Describe Meckel's cartilage. Meckel's cartilage is a rod of cartilage which appears in the mandibular arch and partly enters into the formation of the inferior maxilla, namely, the extremity at the symphysis and the proximal extremity, which persists with a covering of fibrous tissue to form the internal lateral ligament of the jaw. The greater part of Meckel's cartilage disappears at about the sixth month of foetal life. Name the specialized cell for each particular structure of the teeth. The specialized cell of the enamel is the ameloblast. That for the dentine is the odontoblast. For the cementum, the cementoblast. What are interglobular spaces? At the junction of the dentine with the enamel and cemen- tum are areas which are imperfectly calcified; they are some- what globular in shape, hence, called interglobular spaces. Describe the dental follicle. The dental follicle is the result of the condensation of the mesodermic cells surrounding the papilla, which later extends upward so as to surround the entire rudimentary tooth. Why should there be a difference between the struc- ture of dentine and cementum? Dentine is a product of embryonic connective tissue through the specialized cell, the odontoblast; while the cementum is produced by the connective tissue cells of the alveolar perios- 350 HISTOLOGY. teum, the cementoblasts ; therefore, the structure of the ee- mentum resembles that of bone. Describe the enamel organ and the cells that form enamel. The enamel organ has its origin in a down-growth of the oral ectodermic tissue. When fully developed it consists of a sac, the lower margin of which is indented by reason of its contact Avith the underlying papilla; structurally, it consists of three layers of cells. An upper, continuous with the super- ficial cells of the ectoderm, a middle layer of stellate cells, and an inferior layer of distinctly columnar shaped cells. The last named cells are the cells which produce enamel. The enamel cells, when active in the production of enamel, exhibit, at their lower extremity (toward the papilla), a tuft of short processes. It is along these processes that the deposit of the enamel takes place. What is the primitive dental groove? (b) What organ of the teeth is developed from it? A longitudinal furrow, seen on the surface of the ecto- dermic tissue, which marks the point of attachment of the dental ridge, lying immediately beneath, (b) The enamel organ. Describe the dental fibrillae; with what are they con- nected, and where do they terminate? The dental fibrillae occupy the dental tubules and extend throughout their length. The fibrils are protoplasmic ex- tensions of the odontoblasts terminating at the periphery of the dentine. Describe the stratum granulosum. At the periphery of the dentine, the substance is not com- pletely calcified. As a result there are small irregular clefts, the interglobular spaces. This layer of the dentine is known as the granular layer. HISTOLOGY. 351 What is Neuman's Sheath? The part of the dentinal matrix immediately surrounding the dentinal tubules constitutes the so-called dentinal sheaths, or sheaths of Neuman. What is calcification? Calcification is the process by means of which tissue may become infiltrated with lime salts. It is a product of the cellu- lar element of the tissue that is deposited in the intercullular substance of which it becomes a part. Calcification usually is effected in layers, and, in the instance of bone and oemen- tum, the well defined lamellae are formed. Mention the methods of distribution of cells in the various tissues. On surfaces, (epithelium and endothelium). Suspended in fluid, (blood and lymph). Interstitially, in a matrix (connective tissues). What is perichondrium? A fibrous investment covering cartilage. It consists of an outer fibrous, the vascular layer; an inner chondrogenetic layer, composed of spindle-shaped, cartilage-forming cells. Name the varieties of cartilage. White fibro-cartilage, yellow elastic cartilage, hyaline cartilage. Which variety of cartilage does not have a perichon= drium? White fibro-cartilage. How may all tissues be classified? According to (1) their ancestry, (2) function, (3) morpho- logical character. Explain the difference between epithelium and endo- thelium. Epithelium and endothelium occur on surfaces, but the location, the function and the arrangement varies. 352 HISTOLOGY. Ancestry Function Epithelium. Ectoderm Entoderm Mesoderm (rarely) Protective Secretory Absorptive Permit exchange of gases Motion Nervous Morphological Character Simple and Stratified Squamous Columnar and Polyhedral shaped cells Endothelium. Mesoderm Reduction of friction Always in a single layer Always squamous What is meant by the ancestry of a tissue? Its origin in the blastoderm. What is the function of connective tissue? Connective tissue enters into the formation of the structure to make a supporting framework; especially where great strength is required. Blood vessels, nerves and lymphatics are always carried in connective tissue. What is the structure of capillaries? Capillaries are the ultimate radicles of the vascular (arterial) system, and consist of a continuation of the lining of those vessels; being made of a single layer of endothelial cells, united by a small amount of intercellular cement substance. What cells form dentine? The odontoblasts. PHYSIOLOGY. Give the sources of saliva and its chemical functions and otherwise. Saliva is the secretion of the parotid, submaxillary and sublingual glands. It contains a ferment, ptyalin, which converts starch into maltose. The saliva facilitates speech by moistening the mucous membrane of the mouth; and on account of its contained mucin, facilitates deglutition by lubricating the bolus of food. By dissolving some of the solids in the food it allows them to be tasted. Where and how are the products of digestion finally incorporated into the tissues? The digested food is absorbed mainly by the villi of the small intestines. The water, soluble salts, glucose and pep- tones are passed through the columnar epithelium of the villi into the capillaries. These capillaries are radicals of the portal vein, and through this vein the products are carried to the liver. The blood of the liver passes out through the hepatic vein into the inferior vena cava and thus into the general circulation. The peptones during their passage through the columnar epithelium are converted into albumens and globulins. The digested fat passes through the columnar epithelium of the villi into the central lym- phatic vessel or lacteal. These lacteals carry the absorbed fats to the thoracic duct, which in turn empties them into the left sub-clavian vein, and thus into the general circulation. Describe the physiological process that takes place in the kidneys. The kidneys are compound tubular glands secreting urine. 23 (353) 354 PHYSIOLOGY. The tubules commence in the Malpighian corpuscles in the cortex. After leaving these the tubules become convoluted, then pass down as the loops of Henle, again become con- voluted, and finally empty into the collecting tubules. The convoluted portions are lined with rodded epithelium, and it is by these cells that the urea is picked out of the blood. All the substances found in the urine are waste products cir- culating in the blood, and these the epithelium picks out from the blood. The one exception to this is hippuric acid which is formed by the kidney cells. Describe the stomach and its secretions. The stomach is the ovoid dilatation of the gastro-intestinal tract; and is a muscular sac lined inside with mucous mem- brane, and outside with a serous membrane. The food en- ters from the oesophagus at the cardiac orifice, and passes out into the duodenum at the pyloric orifice. The stomach has two curvatures, the upper, or lesser curvature, and the lower, or greater curvature. That portion of the stomach, lying towards the spleen and forming a part of the greater cur- vature, is called the fundus. The stomach has four coats : serous, or outer; muscular, of which there are three distinct layers, circular, longitudinal and oblique; submucous; and mucous, imbedded in which we have the tubular glands that secrete the gastric juice. The gastric juice is a limpid, acid secretion, specific gravity 1005, containing salts, hydrochloric acid (.2%), and two fer- ments, pepsin and rennin. About ten pints are secreted daily. How is the skin kept moist and the cuticle pliable? The skin is kept moist by the sweat, and the cuticle pliable by the sebaceous secretion. What are the sources of heat in the body? Heat is produced in the body by katabolism, principally in the muscular and glandular tissues. PHYSIOLOGY. 355 Trace the circulation of the blood once around its course beginning at the right auricle. The blood enters the right auricle from the superior and inferior vena cavas, thence through the right aurieulo-ven- tricular or tricuspid valve into the right ventricle, past the pulmonary semilunar valve into the pulmonary artery to the capillaries of the lungs; from the lungs it is carried back through the pulmonary veins to the left auricle, past the left auriculo-ventricular or mitral valve into the left ventricle, through the aortic semilunar valve into the aorta and its branches to the capillaries of systemic circulation, and from these it is carried back to the heart by the systemic veins. What is waste, and by wljat organs is it eliminated from the system? Waste is products of metabolism of no further use to the organism. Waste is eliminated by the lungs, kidneys, skin and intestines. In what various ways is the loss by waste restored? By food, water and respiration; the blood acting as a medium of exchange. Describe the mechanical process by which the blood re- ceives oxygen. The blood receives its oxygen in the lungs where the capil- laries containing venous blood are separated from the oxygen of the air by a single layer of pavement epithelium. Three factors are concerned in the absorption of oxygen: mechani- cal law of pressure of gases, chemical affinity between hemo- globin and oxygen, and the vital activity of the epithelium of the air vessels. By what special fluid is nourishment to the tissues de- livered, and how? By the circulating blood, by osmosis through the capil- lary walls. 356 PHYSIOLOGY. Describe fully the preparation of pabulum for the blood. The starches are converted by ptyalin of saliva and amy- lopsin of pancreatic juice into maltose. Maltose and cane sugar are converted into glucose by the invertin of succus entericus. Caseinogen is converted into casein by the rennin of gastric juice, and the milk- curdling ferment of pancreatic juice. The proteids are changed into proteoses and peptones by the pepsin of gastric juice and the trypsin of pancreatic juice. Enterokinase of the succus entericus energizes the trypsin. The fats are split up into fatty acids and glycerine, saponi- fied and emulsified by the steapsin of pancreatic juice and by the bile. The digested food is then absorbed by the villi of the small intestines. The fats are carried by laoteals to the thoracic duct; and the glucose, water, soluble salts and pep- tones are carried by the portal vein to the liver, the peptones being changed into native proteids while passing through the epithelium of the villi. What is the medulla oblongata? Give a short de= scription. The medulla oblongata is that portion of the central nerv- ous system between the upper end of the spinal cord and the lower boundary of the pons varolii. It is pyramidal in shape with the base upward, and is about one inch long, three-fourths of an inch wide and half an inch thick. Anteriorly is seen the anterior median fissure, the olivary bodies, and the anterior pyramids. The posterior surface of the medulla forms part of the floor of the fourth ventricle, bounded on each side by the diverging posterior columns of white matter. Laterally we find emerg- ing the cranial nerves from the sixth to the twelfth inclusive. In structure we find that it is made up of gray and white matter. The gray matter is cut up into small masses by the motor PHYSIOLOGY. 357 and sensory decussations. These masses of gray matter form the nuclei for most of the cranial nerves. Describe the mechanism of the heart. The heart is a hollow muscular organ divided into four cavities, two on the right side and two on the left. Between the two sides there is no communication. The right side receives venous blood and forces it into the pulmonary cir- culation. The left side receives arterial blood and forces it into the general, systemic or greater circulation. The two auricles, contracting simultaneously toward the end of ventricular diastole, force the blood into the ventricles. The ventricles then contract, the auriculo-ventricular valves are closed, and the blood is forced into the arteries. The ven- tricles then relax and the blood flows in from the auricles, the auriculo-ventricular valves being open. The blood tends also to regurgitate into the ventricles from the arteries, but is prevented by the closure of the semilunar valves. The heart has been likened to a force pump, but it is also a suction pump, for during diastole, there is a negative pressure in the ventricles due to the elasticity of the muscular wall tend- ing to produce a vacuum. As to the nervous mechanism of the heart, we find in the medulla the cardio-inhibitory and the cardio-accelerating centres. The efferent nerve from the cardio-inhibitory centre to the heart is the vagus or pneumogastric ; the efferent from the cardio-accelerator centre is the accelerator branch of the sympathetic system. These nerves end in ganglionic masses in the heart. There is also an afferent nerve from the heart called the nervous depressor of Cyon and Ludwig ; when there is danger of rupture of the heart from over-pressure, it is irritated and carries an impulse to the vasomotor centre that depresses its tonus and lowers the blood pressure. Describe the pancreas, and the character and functions of its secretion. The pancreas is a tongue-shaped organ about six inches 358 PHYSIOLOGY. long, weighing about two ounces and situated back of the stomach. It is sometimes called the abdominal salivary gland. The duct enters the duodenum about an inch and a half below the pylorus. The bile duct joins with it just before it opens into the duodenum. The pancreatic juice is a transparent, viscid, alkaline fluid, specific gravity 1012. There are about eight ounces secreted daily. It contains salts, especially sodium salts and four ferments. Amylopsin converts starch into maltose. Trypsin converts proteids into peptones and even into lower bodies, leucin, tyrosin and arginin. Steapsin splits up the fats into fatty acids and glycerine. The fatty acids combine with the alkalies present to form soap and this aids the emulsification of the rest of the fat. There is also a milk-curdling ferment. The pancreas has also an internal secretion, as extirpation of the organ causes diabetes. In what way does the blood lose material? By osmosis through the capillary walls into the tissues; by excretion from the lungs, skin, kidneys and liver, and by osmosis into gastro-intestinal canal, as in the watery stool following saline cathartics. What is the cerebro=spinaI axis, and what is its function? The cerebro-spinal axis is that portion of the nervous sys- tem consisting of spinal cord, medulla, pons varolii, crura cerebri, basal ganglia, cerebrum and cerebellum. Its func- tion is to receive afferent impulses and to send out, as the result of these, efferent impulses, to keep the body in normal condition, and through the cerebrum presides over thought, volition and sensation. What is the purpose of the lymphatic system and how fulfilled? The liquid portion of the blood osmoses through the capil- lary walls into the tissue. This diluted blood plasma is called lymph. It bathes and nourishes the tissue and is PHYSIOLOGY. 359 carried by the lymphatics back to the general circulation through the thoracic duct and right lymphatic duct. They also carry absorbed material as the fat from the intestines, into the general circulation. The secretion of some of the ductless glands is emptied into the blood through its lymphatics. The cells formed in the lymph glands become leucocytes. What chemical exchange is effected in the lungs dur= ing respiration? Oxygen is absorbed by the blood. Carbon dioxide, nitro- gen, water and very small quantities of organic volatile prin- ciples are thrown off. How is the normal temperature of the human body maintained? The normal temperature of the body is maintained at about 98.4° F., by the proper balancing of heat production and heat dissipation. The production and dissipation of heat are controlled by the thermoljaxic centers of the nerv- ous system. These include the thermolytic, thermogenic and thermo-inhibitory centres. Describe the process of deglutition and name the glands where secretions are an essential aid in the process. Deglutition is the act of swallowing or passing of the food from the mouth into the stomach. There are in this act three stages, buccal, pharyngeal and oesophageal. The first is voluntary, the last two are involuntary. The bolus of food is forced by the tongue from the mouth into the pharynx. The muscular wall of which contracting from above downward forces the bolus into the oesophagus. A peristaltic wave of contraction then forces the bolus through the oesophagus into the stomach. Thus the degluti- tion of solids is a peristaltic act. But liquids are squirted through the pharynx and oesophagus with bulb syringe ef- fect by contraction of the mylo-hyoid muscle. The centre of deglutition is in the medulla. Tt receives 360 PHYSIOLOGY. afferent impulses through, the trifacial and glosso-pharyngeal nerves, and gives off efferent impulses through the inferior maxillary division of the trifacial and glosso-pharyngeal and vagus. The glands whose secretions aid deglutition are the sali- vary, especially the sub-maxillary and sublingual; also the mucous glands of the mucous membrane of the mouth, pharynx and oesophagus. Name the digestive secretions, mentioning the principal action of each upon food. Saliva, gastric juice, pancreatic juice, bile and succus en- terieus are the digestive secretions. Saliva converts starch into maltose. Gastric juice converts proteids into peptones, and case- inogen into casein. Pancreatic juice converts proteids into peptones, starch into maltose, splits up the fats into fatty acids and glycerine, and converts caseinogen into casein. Bile emulsifies fats and prevents excessive action of bacteria. Succus entericus converts maltose and cane sugar into glucose and energizes the trypsin. Give the apparent origin and general distribution of the pneumogastric nerve. Mention some of the organs whose action it influences. The superficial origin of the pneumogastric is from the groove on the lateral surface of the medulla between the olivary and restiform bodies. It is distributed to the pharynx, larynx, oesophagus, heart, lungs, stomach, and to the abdominal sympathetic system. It is the motor nerve to the pharynx; motor and sensory to the larynx; motor, sensory and respiratory to the lungs ; motor, sensory and secretory to the stomach; cardio-inhibitory to the heart, and secretory to the pancreas, motor and inhibitory to the intestines. Describe the liver, its secretion and the function thereof. The liver is the largest gland in the body, weighing about PHYSIOLOGY. 361 four pounds, and measuring transversely about twelve inches, antero-posteriorly about seven inches, and at its posterior part is about three inches thick. It is situated principally in the right hypochondriac re- gion, but extends through the epigastrium into the left hypochondriac region. It is divided by five fissures into five lobes, the largest of which is the right lobe. The most important fissure is the transverse ; for through this the blood enters the liver through the portal vein and hepatic artery, and passes out through the hepatic vein. The bile also passes out through the hepatic duct through this fissure. The secretion of the liver is bile. Bile is a reddish-yellow, or reddish-green, alkaline, viscid, bitter liquid with a specific gravity of about 1020. There are about two or two and a half pints secreted daily. It contains among other substances bilirubin, biliverdin, taurocholate and glycocholate of sodium, cholesterin, mucin and inorganic salts. The bile neutralizes the acid chyme, precipitating the pep- sin; emulsifies fats, and aids in their absorption; increases peristalsis; it is a slight antiseptic; and contains waste pro- ducts thrown off by the liver. Mention the nutritive fluids of the body. Blood, lymph and chyle. What conditions affect the body temperature? All conditions affect the body temperature that destroy the balance between heat production and heat dissipation. Among these you have muscular exercise, digestion, pro- longed exposure to extremes of temperature, shock (mental or physical), hysteria, drugs (as antipyrin, chloral hydrate and atropine), toxins of bacteria, injection of peptones and ptomaines, irritation of any one of the thermotaxic centres. Give the composition of the pancreatic secretion. According to Halliburton you have 97.6% of water: 1.8% 362 PHYSIOLOGY. of organic matter of which the most important are the fer- ments; and .6% inorganic salts, among which are sodium chloride, sodium phosphate and potassium chloride. Give the properties of pancreatic juice, and state its re= action. Where does the pancreatic juice enter the intestine. The pancreatic juice is a colorless, transparent, viscid, alka- line fluid with a specific gravity of 1012. It contains four ferments; trypsin, amylopsin, steapsin and a milk-curdling ferment. The pancreatic juice enters the intestine through an open- ing in the posterior surface of the duodenum about its middle. Give the composition of blood, and state the use of each component part. The blood is composed of sixty parts of plasma or liquor sanguinis, and forty parts of corpuscles. The plasma is the liquid portion and contains about ten per cent, of solid matter, of which four-fifths are proteids. The solid matter is made up of serum albumen, serum globulin, fibrinogen, salts, glucose, fats and extractives. There are two kinds of corpuscles, red and white. The red corpuscles are the more numerous, the propor- tion being seven hundred reds to one white. The principal substance in the red corpuscle is the hemoglobin. The white corpuscles have amoeboid movement, and have a phagocytic action. By their disintegration fibrin ferment is formed. The red corpuscles carry the oxygen to the tissues. The fibrinogen clots after leaving the vessel and thus stops bleeding. The plasma carries the absorbed food to the tissues and the waste products to the excretory organs. The blood also keeps the various parts of the body at a fixed temperature. The function of the blood plates is not known. PHYSIOLOGY. 363 State the difference between the vasoconstrictor nerves and the vaso=dilator nerves. The vasoconstrictors, when stimulated, decrease the calibre of the arterioles by causing a contraction of the muscular fibres in the middle coat of the vessels. The vaso-dilators, when stimulated, increase the calibre of the arterioles by inhibiting or decreasing the tonus of the local vaso-motor ganglia in the muscular wall. Define voluntary muscle; involuntary muscle. Give ex- ample of each. The voluntary muscles are those under the control of the will, and are transversely striated. The biceps is an ex- ample of a voluntary muscle. The involuntary muscles are those not under the control of the will, and are not transversely striated. The muscu- lar coat of the arteries is an example. State the function of the hypoglossal or sublingual nerve. It is the motor nerve of the tongue and the muscles con- nected with the hyoid bone. What special centers exist in the medulla oblongata? Deglutition, salivation, mastication, vomiting, diabetic, cardio-inhibitory, cardio-accelerator, vasomotor and re- spiratory. What is the function of the cerebrum? The cerebrum is the center of volition, sensation and ideation. What is the difference between proteid and amyloid foods? Proteids contain carbon, hydrogen, oxygen, nitrogen and sometimes phosphorus. The amyloid foods contain carbon, hydrogen and oxygen ; the last two elements in the proportion to form water ; and in the molecule, six atoms of carbon or a multiple of six. 364 PHYSIOLOGY. The body can form amyloids from proteids, but cannot form proteids from amyloids. What is meant by flexion and extension of muscle? By flexion is meant the shortening or contraction of the muscle. The relaxation or lengthening of the muscle is called extension. Give the location of the stomach. State the work ac= complished by the stomach. It is situated in the front part of the upper abdomen in the epigastric region with its pyloric end a little below and to the right of the xiphoid cartilage, and its fundus pro- jecting over into the left hypochondrium. The stomach changes the proteids into peptones, curdles milk, and liquefies fats. Describe the stomach and its movements during digestion. The stomach is an irregularly ovoid, muscular sac, lined inside with mucous membrane, and outside with serous mem- brane. It is the dilated portion of the gastro-intestinal tract between the oesophagus and small intestine. The stomach holds, when full, about three pints. It has two openings, the cardiac, through which the food enters the stomach, and the pyloric, through which the food leaves the stomach. It has two curvatures, the upper or lesser and the lower or greater. The portion of the greater curvature lying toward the spleen is called the fundus. When the food reaches the stomach the two orifices close tightly like sphincters; the muscular wall also contracts down upon the food, and by means of the three muscular layers keeps the food in constant motion. Thus it brings fresh portions constantly to the surface to be acted upon by the gastric juice. A current passes down the fundus and greater curvature to the pylorus and back along the lesser curvature. After an hour of gastric digestion, the tightly closed PHYSIOLOGY. 365 pylorus gradually relaxes, allowing some of the liquid chyme to enter the duodenum. Finally, at the end of three or four hours, even the more or less solid undigested portion is allowed to escape and enter the duodenum. Describe the alveolar process and state how it is developed. The alveolar process is made of an inner plate and an outer plate which are of compact osseous tissue. Between these plates there is a cancellous structure which is hollowed out into compartments for the different teeth. The alveolar process is of mesoblastic origin, being formed by the osteoblasts of the periosteum. As the permanent teeth form, the process is somewhat rebuilt to accommodate them. What is the epiglottis? The epiglottis is one of the single cartilages of the larynx. It is found at the base of the tongue and on the anterior edge of the upper opening of the larynx. Describe (a) the arterial system, (b) the capillary system. The arteries are tubes that carry the blood from the heart to the capillaries. The systemic arteries commence in the aorta which divides and subdivides. The cross-section of the aorta is much less than the combined cross-section of the arterioles. The arteries have three coats. The intima con- sists of a layer of endothelial cells on a basement membrane, and numerous yellow elastic fibres; the media consists prin- cipally of involuntary muscular fibres, arranged circularly, which are controlled by the local vasomotor ganglia; the ad- ventitia consists principally of areolar tissue containing some elastic fibres. The yellow elastic fibres are comparatively more abundant in the large arteries; the muscular more abundant in the arterioles. The capillaries are small tubes consisting of a single layer of lance-shaped endothelial cells. They connect the smallest 366 PHYSIOLOGY. arteries with the smallest veins. They are about one-thirtieth of an inch long, and of sufficient calibre to allow a red corpuscle to pass through. How is bone nourished? Bone is nourished by the blood through the nutrient artery circulating in the marrow and Haversian canals. It is also nourished by the periosteum. State the importance of the blood to the body. The blood carries the food and oxygen to the tissues, and carries the carbon dioxide and other waste products from the tissues to the excretory organs. It is also by the circulation of the blood that the tem- perature of the various parts of the body is equalized. State the influence of posture on the action of the heart. There is an increase of nine to sixteen pulse beats when one rises from a reclining to a standing posture; the volume and force of the pulse increases at the same time. The effect of the sitting posture is intermediate between the two. Mention three inorganic substances found in the body. State in what part of the body each is found. Hydrochloric acid in the gastric juice. Sodium chloride in blood. Calcium carbonate in bone. What is the difference in function between the right and left sides of the heart? The right side receives venous blood and forces it through the pulmonary circulation. The left side receives arterial blood and forces it through the systemic or greater circulation. Describe the physiological action of (a) saliva, (b) gas= trie juice, (c) pancreatic juice. The ptyalin of saliva converts starch into maltose. The rennin of gastric juice changes caseinogen into casein and pepsin in an acid medium converts proteids into peptones. PHYSIOLOGY. 367 As to pancreatic juice, trypsin in an alkaline solution con- verts proteids into peptones or even into lower bodies, leucin, tyrosin and arginin. It also changes some of the albuminoids into peptone-like bodies. Amylopsin converts starch into maltose. Steapsin splits up the fat into fatty acids and glycerin. The milk-curdling ferment curdles milk. State the function of each of the following muscles: (a) temporal, (b) masseter, (c) occipito=fronta!is, (d) orbicularis palpebrarum, (e) orbicularis oris. The temporal and masseter draw the lower jaw upward and are muscles of mastication. The occipito-frontaJis moves the scalp and raises the eye- brows. It is a muscle of expression. The orbicularis palpebrarum is the sphincter muscle of the eyelid ; and is also used as a muscle of expression. The orbicularis oris is the sphincter of the mouth. It is a muscle of expression ; and its contraction will carry the food backward into the oral cavity. State the normal pulse at each of the following ages: One year; ten years; fifty years. One year it is 115 to 120. Ten years it is 80 to 90. Fifty years it is 70 to 75. Why is blood light in the arteries and dark in the veins? Oxyhemoglobin found in the arteries is a lighter red than the deoxidized hemoglobin found in the veins. Is the natural condition of saliva alkaline or acid, and how is it tested? It is alkaline, and is tested with litmus or phenolphthalein. What is the normal temperature of the surface of the body? Very variable. The axillary temperature is about 98 de- grees Fahr. 368 PHYSIOLOGY. Define assimilation. Assimilation is the conversion into protoplasm of the nutri- ent material or food ingested. State the use and importance of (a) perspiration, (b) bathing. By the evaporation of perspiration the body is kept at a fixed temperature. The perspiration carries off waste pro- ducts, keeps the skin pliable, and when need exists, relieves the kidneys of work. Bathing cleanses the external surface, stimulates the func- tion of the skin, and increases the general tone of the body. State the object of respiration. By the act of respiration oxygen is taken into the blood, and carbon dioxide, small quantities of nitrogen, water and some organic volatile substances are thrown off from the body. In some animals the evaporation of water, and thus dissi- pation of heat by frequent respirations, is quite marked. Describe the movements of the heart. The two auricles contracting, force the blood through the auriculo-ventricular orifices into their corresponding ven- tricles. These in turn contracting, force the blood past the semilunar valves into the pulmonary artery and aorta. The blood is prevented from regurgitating into the auricles during systole by the closure of the auriculo-ventricular valves. The ventricles then relax to be refilled with blood from the auricles. At the same time the semilunar valves are closed by the blood attempting to regurgitate from the arteries. During ventricular systole the heart becomes shorter and more globular, the base being forced down by the recoil from the forcing of the blood into the aorta. The heart rotates a little . during systole. Give the mechanical uses of saliva. Saliva assists in deglutition, in mastication, in speaking and in taste. PHYSIOLOGY. 369 In what way does absorption of food occur? Most of the food is absorbed by the villi in the small intestines. Two factors are concerned in absorption, — osmosis and vital activity of the columnar epithelium of the villi. The soluble salts, glucose, water and peptones are carried by the capillaries through the portal vein to the liver and from here into the general circulation. The fat is carried by the lacteals to the thoracic duct, and through it into the left subclavian vein. What is the function of the liver? The liver secretes bile; it forms glycogen, urea, uric acid and conjugated sulphates. Some of the red corpuscles are formed and others destroyed in the liver. The liver also destroys some poisons in the circulating blood. What are the functions of the muscles? The muscles move the various parts of the body, and pro- duce most of the heat necessary to keep the body at the normal temperature. Give the symptoms of insufficient oxygen in the blood. Dyspnoea, cyanosis, increase of blood pressure, and finally exhaustion with decrease of blood pressure, weak, flabby pulse, irregular, shallow breathing, convulsions and death. Describe the sympathetic nervous system, and state its functions. The sympathetic nervous system consists of a double chain of ganglia extending from the base of the skull to the coccyx along the anterior surface of the vertebral column. These ganglia are connected by intervening nerves. Besides this double chain of ganglia there are three large plexuses of fibers and ganglia (cardiac, solar and hypogastric) and numer- ous smaller plexuses. Proceeding from the plexuses are numerous nonmedullated nerve fibres. The sympathetic system controls the movement of the ab- 24 t/ 370 PHYSIOLOGY. dominal viscera, and contains the vasomotor nerves and the cardio-accelerator. Describe the physiologic action of alcohol. Alcohol in small doses is a stimulant to the cerebrum, re- spiration, heart, and gastric mucous membrane. In large doses it is a depressant to cerebrum, respiration, heart, vaso- motor system and gastric mucous membrane. It interferes with nutrition and causes a fall in temperature. Mention the valves of the heart and give their location. The mitral valve is located at the left auriculo- ventricular orifice. The tricuspid valve is located at the right auriculo-ven- tricular orifice. The aortic semilunar valve is located between the left ven- tricle and aorta. The pulmonary semilunar valve is located between the right ventricle and pulmonary artery. Name five of the principal elements of the body. Carbon, hydrogen, oxygen, nitrogen and sulphur. Define function. Function is the normal activity of an organ or group of organs. State (a) the normal temperature of an adult; the nor= mal pulse of an adult. Normal temperature is 98.4 degrees Fahr. Normal male adult pulse is 72 per minute. State why blood does not coagulate within the blood vessels. The blood does not coagulate on account of its contact with the endothelium of the intima. Describe the origin and fate of the red corpuscles. In embryonic life the red corpuscles are first formed in the Islands of Pander, later by the liver and spleen. After birth PHYSIOLOGY. 371 the red corpuscles are formed in the liver and spleen and the red marrow of bones, especially of the ribs. They are probably destroyed in the liver and spleen. How does the blood coagulate? Fibrinogen, a proteid dissolved in the plasma, when acted upon by fibrin ferment in the presence of calcium salts is changed into fibrin. The clot consists of this insoluble fibrin in-the meshes of which are the corpuscles. The fibrin ferment is formed by the disintegration of the white corpuscles. Where and how is the blood changed from arterial to venous, from venous to arterial? By the process of osmosis, the oxygen passes out through the capillary walls into the tissues and carbon dioxide passes into the capillaries ; thus it is changed from arterial to venous in the capillaries of the tissues. The venous blood is forced by the right ventricle into the pulmonary capillaries where the blood is separated from the atmospheric air by only the capillary wall and the squamous epithelium of the air cells. There are three factors concerned in the exchange of the respiratory gases or changing the venous blood into arterial blood. The first is the physiological law of pressure of gases ; the second, chemical affinity between hemoglobin and oxygen ; and third, the selective vital activity of the epithelial cells of the air vesicles. State the effects of starvation on the human body. The bodily weight gradually decreases and the temperature becomes subnormal. The fats are used up first, followed finally by the proteids, especially of the muscles. The amount of urea excreted is first decreased; but as the increased oxi- dation of proteids begins, the urea is increased. Finally death ensues from exhaustion. The heart and central nervous system lose but little in weight. 372 PHYSIOLOGY. Give the physiological properties and the chemical com- position of gastric juice. Gastric juice is a limpid acid liquid with a specific gravity of about 1005. It is composed of about 99.5% water and .5% solid. The bulk of solids is made up of pepsin, rennin, and hydro- chloric acid. Of the hydrochloric acid there are about two parts to the thousand. State the effects of battery currents on the normal human nerves. The faradic current stimulates them. A nerve during the passage of a constant current through it, is said to be in a state of electrotonus. There is an in- crease of excitability at the negative pole or kathode, and decrease of excitability at the positive or anode. How is the process of nutrition carried on? The blood receives the digested and absorbed food and also the oxygen from the lungs. It carries these products to the tissues which take out what they need. The blood receives the waste and carries it to the various excretory organs. The lymphatics also carry some of the waste from the tissues and empty it into the venous blood. How does lime or other inorganic matter find its way into the blood? Lime and other inorganic matter enter the body in the food and drinking water, and being absorbed by the villi of the small intestines are carried by the portal vein to the liver and then into the general circulation. Describe the structure and give the functions of the veins. The veins have three coats : The inner, composed of a layer of endothelial cells and elastic fibers; the middle, composed principally of involuntary muscular fibers, and the outer, com- posed of areolar tissue with numerous yellow elastic fibers. Many of the veins, especially those of the extremities, con- tain valves which help the movement of the blood within them. PHYSIOLOGY. 373 The veins carry the blood from the capillaries to the heart. They all contain venous blood except the pulmonary veins which contain arterial blood. State the characteristics of the parotid and submaxillary glands. The parotid secretion is thin, watery, poor in solids (.3% to .5%) contains no mucin, and has excellent penetrating powers. The submaxillary secretion on account of containing a quantity of mucin, is ropy, contains 2% to 2.5% solids, is of a greater specific gravity, and is excellent for aiding deglutition. The mixed saliva has a specific gravity of about 1005, is alka- line, and contains especially ptyalin, potassium sulphocyanide, mucin, sodium chloride and other salts. Of what two great groups of substances is the body composed? Organic and inorganic. Mention the organs that compose the respiratory apparatus. The respiratory apparatus consists of the nose, pharynx, larynx, trachea, bronchi and air vesicles ; also of muscles mov- ing the thorax, the diaphragm, the nerves (afferent and ef- ferent) and the respiratory center in the medulla. What are the three kinds of digestion? The three kinds of digestion are that of proteids, of carbo- hydrates and of fats. What are the direct sources of the heat of the body? The most of the heat of the body is produced by katabolic changes, especially oxidation, taking place in the muscular and glandular tissues. Describe the parotid gland and give its function. Give location of the parotid gland. The parotid gland, the largest of the salivary glands, lies be- low and in front of the ear. The gland empties its secretion 374 PHYSIOLOGY. by Stenson's duct into the mouth through an opening in the mucous membrane, opposite the second upper molar tooth. It is a compound racemose gland composed of acini lined with polyhedral cells resting on a basement membrane. Un- der this is a close network of capillaries. The parotid secretes saliva. State the functions of dental pulp. The dental pulp nourishes the dentine. The odontoblasts which it contains form the dentine. The pulp contains nerves which give sensation to the tooth and thus protects it indirectly. How many pairs of cranial nerves are there? What nerves supply the teeth? There are twelve pairs of cranial nerves. The teeth are supplied by the superior and inferior maxil- lary divisions of the trifacial nerve. On what particular phenomena does the study of physio- logy depend? Physiology is the study of the phenomena of living organisms. How does alcohol affect digestion? In small doses by its irritant action on the mucous mem- brane it causes an increase in secretion of gastric juice. Large doses retard digestion, especially that of the stomach. In what organs is the blood changed? It is changed in all the organs except the heart, but es- pecially in the liver, kidneys, lungs, spleen, bone-marrow and skin. What per cent, of the weight of the body is water? State the function of water in the body, and how it is eliminated from the body. About 75% of the body weight is water. In all the fluids of the body, water acts as a general sol- vent, being necessary to secretion and the carrying of nutri- PHYSIOLOGY. 375 tion to and the waste products from the tissues. By its evaporation it dissipates large quantities of animal heat. It is eliminated from the body by the kidneys, sweat glands, lungs and in feces. What set of muscles gives the horizontal motion to the inferior maxillary? Internal and external pterygoids. Define afferent and efferent nerves. Afferent nerves carry impulses from the periphery to the central nervous system. Efferent nerves carry impulses from the central nervous system to the periphery. Name three kinds of food from which starch is derived, and give the percentage of starch in each. Potatoes 23.7%. "Wheat 70%. Rice 84.5%. What is the function of the gustatory nerve? The gustatory nerve is the nerve of taste. What is casein, and where is it found? Casein is a coagulated proteid found in curdled milk and cheese. How does the blood circulate through the heart? The blood passes from the superior and inferior vena cava into the right auricle, which contracting, forces it through the tricuspid valve into the right ventricle. The right ven- tricle then contracts and forces the blood past the pulmonary semilunar valve into the pulmonary artery. This artery carries the blood to the lungs, and from these it is carried back through the pulmonary veins into the left auricle. Then it passes through the mitral valve into the left ventricle, which, contracting, forces the blood into the aorta. What is the function of the nervous system? The function of the nervous svstem is to carry afferent im- 376 PHYSIOLOGY. pulses from the periphery and as a result of such impression to send out efferent impulses, to receive impressions, to pre- side over thought, and to control the action of the various parts of the body. How may coagulation of blood be hastened? It may be hastened by increasing the temperature, injury to the vessel walls, contact with foreign matter and oxygen, agitation and addition of calcium salts. State how many of the seventy known elements form a practical part in making up the animal tissue, and men- tion the four most important of these elements. There are sixteen to nineteen elements found in the tissues of the body. Of these the most important are carbon, oxygen, hydrogen and nitrogen. What is food? State why milk is so nearly a perfect food. Food is that which, taken into the body, nourishes the tissues or supplies heat. Milk is so nearly a perfect food because it contains all the chemical compounds necessary to life, that is, proteids, car- bohydrates, fats, salts and. water. What are proximate principles? Proximate principles are substances that enter into the composition of the body. Name three of the most important inorganic proximate principles, and state where they are found in the body. Calcium phosphate is found in bone. Sodium chloride is found in the blood. - AYater is found all through the body. Are inorganic ingredients of food necessary to sustain life? Why? They are necessary because they are indispensable constitu- ents of the structure of the body, — as calcium salts in bone; because the alkaline bases are necessary to neutralize the acids PHYSIOLOGY. 377 formed by the proteid metabolism ; because they are necess- ary for digestion and absorption, and because water is the general solvent of the body. Describe the lymphatic system and give its function. The lymphatic system consists of lymph capillaries, of nu- merous thin-walled vessels lined with endothelium, of lym- phatic glands situated on these vessels, of the thoracic duct, of the lymphatics of the intestines called lacteals, and the spleen. The thoracic duct begins in a dilated extremity called the cisterna magna about the level of the second lumbar vertebra, and runs up along . the vertebral column emptying into the left subclavian vein. It receives the lymph from the lower extremities, abdomen, left lung, left arm and left face. The lymph of the right lung, right arm and right face is emptied through a small vessel into the right subclavian vein. The lymphatic glands are found along the course of the lymphatic vessels, and are composed of lymphoid tissue in the center of which are cells rapidly undergoing karyokinesis. The lacteals are the lymphatic vessels of the intestines and carry the absorbed fats from the villi to the thoracic duct. The lymphatic system carries back into the blood circula- tion the blood plasma that has osmosed through the capillary walls into the tissues. It also forms leucocytes and carries the absorbed fat from the intestines into the general cir- culation. The secretion of some of the ductless glands passes through the lymphatics into the blood channels. Describe the circulatory apparatus. The circulatory apparatus consists of the heart, arteries, capillaries and veins. The heart is a hollow, muscular organ, lined inside with the endocardium and outside w T ith the pericardium. It is pyramidal in shape, about 5% inches long, 3y 2 inches wide and weighs about ten ounces. It is divided into four cavi- ties, two auricles and two ventricles. The ventricles are the most important cavities, the left ventricle being throe times as thick as the right, ventricle. 378 PHYSIOLOGY. The arteries are the vessels that carry the blood from the heart to the capillaries. They all contain arterial blood with the exception of the pulmonary artery. Histologically they consist of three coats. The intima or internal coat is composed of yellow elastic fibers lined internally with a layer of endothelium; the media or middle coat is made up mostly of involuntary muscular fibers running transversely to the long axis of the artery; the adventitia or external coat is composed of areolar tissue containing numerous yel- low elastic fibers. The vaso-motor nerves end in the ganglia in the muscular coat. The elastic fibers are found com- paratively more numerous in the larger arteries, and the muscular fibers in the arterioles. The capillaries are the small blood vessels connecting the smallest arteries with the smallest veins, and consist of a single layer of lance-shaped endothelial cells. The capil- laries on an average are 3^ of an inch long and 1-3000 of an inch in diameter. The veins are similar in structure to the arteries but the coats are not so thick. Some of the veins, especially those of the extremities, have valves which prevent the regurgi- tation of blood during muscular contraction. What disposition is made of gastric juice after serving its purpose in aiding digestion? The hydrochloric acid is neutralized by the alkaline bile and the pepsin is precipitated. Define endosmosis, exosmosis. Endosmosis is the passage of a liquid through a porous dia- phragm from without inward. Exosmosis is the passage of a liquid through a porous dia- phragm from within outward. Give the foramen of exit, principal branches of dis= tribution and function of the hypoglossal nerve. Anterior condyloid foramen ; branches of distribution a re : Meningeal, descendens hypoglossi, thyro-hyoid and muscular. It is the motor nerve of the tongue. PHYSIOLOGY. 379 Give the functions of that part of the facial nerve which is distributed to the oral cavity. Influences the sense of taste, mastication and the secretion of the submaxillary and parotid glands. What is the function of the fifth pair of nerves? The fifth nerve is the sensory nerve to the face, oral and nasal cavity, and the motor nerve to the muscles of mastication. What anatomical structures are engaged when the food passes from the mouth to the stomach? The tongue, soft palate, constrictors of the pharynx, uvula, pharynx and esophagus. What noticeable change would appear if the seventh nerve were excised? Complete loss of motion of the muscles of expression of the face. Mention the difference between parotid and sublingual saliva. The parotid saliva is thin and watery, while the sublingual is thick and viscid, as it contains much mucin. More ptyalin is found in parotid saliva than in sublingual saliva. What muscles are most active in opening the mouth? Digastric, genio-hyoid, mylo-hyoid and platysma myoides. Give in the regular order the normal average age at which the deciduous teeth are erupted. C.I 5th to 7th month L. 1 9th " 11th " 1st M 12th " 14th " Cuspids, 14th " 18th " 2nd M 18th " 25th " Name the muscles concerned in the act of deglutition. Extrinsic and intrinsic muscles of the tongue, tensor palati, azygos uvuli, palato-pharyngeus. superior constrictor of 380 PHYSIOLOGY. pharynx, middle and inferior constrictor of pharynx, also the muscular coat of the esophagus. What are the fluids of the mouth? Give their active principle and function? Saliva from the salivary glands, and mucus from the mucous glands. The active principle of saliva is ptyalin, that of mucus is mucin. The function of saliva is to soften and moisten the food and to convert starch into maltose. The function of the mucus is to keep the mucous membrane of the mouth moist. Give the period of eruption of the permanent teeth. 1st M 6th to 7th year. C. I 7th " 9th L. 1 8th " 10th 1st B. C 10th " 11th 2nd B. C 11th " 12th Cuspids 12th " 13th 2nd M 12th " 13th 3rdM 16th " 25th Describe the two systems of nerves in the human body. The sympathetic nervous system consists of a double chain of ganglia anterior to the vertebrae, several large plexuses consisting of large ganglia and numerous nerve fibers and in- numerable smaller plexuses supplying the involuntary mus- cular tissue. The nerves of the sympathetic system are non- medullated. The cerebro-spinal nerves are medullated fibers given off from the cerebro-spinal axis. They are of two kinds. The efferent, supplying principally the voluntary muscular tissue and glands and afferent or sensory, carrying impressions from the various sense organs to the central nervous system. State how the nervous system influences digestion. The nervous system influences digestion by means of the various secretory nerves and their centres; by the motor and inhibitory nerves controlling the movement of the muscular PHYSIOLOGY. 381 tissue of the gastrointestinal tract and through many af- ferent or sensory nerves starts innumerable reflexes. State the physiologic relation of the pneumogastric nerve to the stomach. The pneumogastric is the sensory, motor in great part, and secretory nerve to the stomach. It may also contain some inhibitory fibres to the muscular tissue 'of the stomach. Into what classes are proximate principles divided? Mention examples of each class. The proximate principles of the body are water, salts as sodium chloride, proteids as casein, carbohydrates as starch, and fats as olein. Describe the movements of the ribs during inhalation? During inhalation the ribs are raised anteriorly and ro- tated outward like the handle of a bucket laterally. They are fixed posteriorly to the vertebrae. Describe intestinal digestion. The partly digested acid chyme passes through the pylorus into the duodenum. The bile and pancreatic juice enter through a common duct into the duodenum. The glands of Brunner of the duodenal mucosa and the crypts of Leiber- kuhn of the intestines, empty their secretion into the lumen of the intestine. The bile neutralizes the acid chyme, pre- cipitating the pepsin, thus stopping gastric digestion. It also aids in the digestion of the fats. The pancreatic juice contains four ferments: the trypsin changes the proteids into peptones, the amylopsin changes the starch into maltose, the steapsin splits up the fats and a milk- curdling ferment changes the caseinogen into casein. The invertin of the succus entericus changes the maltose into dex- trose. The enterokinase energizes the trypsin, and erepsin breaks up the peptones into simpler bodies. We have also in the intestines microbic digestion with the formation of various gases, as hydrogen sulphide, carbon dioxide, aromatic bodies, as indol, phenol, skatol, etc. 382 PHYSIOLOGY. State the function of the facial nerve. The facial nerve is the motor nerve to the muscles of ex- pression of the face. State the function of glycogen. The glycogen is used up principally by the muscular tissue to supply heat and mechanical energy. State where the absorption of proteids takes place. The proteids are absorbed principally through the villi of the small intestines. State how the act of inspiration is accomplished. Efferent impulses from the inspiratory centre are sent out to the various muscles of inspiration. The diaphragm contracts, its central tendon is lowered and the vertical diameter of the thorax is increased. The ribs are raised and rotated out- ward laterally, thus increasing the anterior, posterior and lateral diameters of the thorax. The air then rushes through the trachea into the lungs to fill up the partial vacuum thus produced. Describe the act of mastication. r ine act of mastication consists in the breaking up of the food and mixing it with saliva. This is accomplished by the teeth, assisted by the tongue and the muscles attached to the jaws and around the mouth. There are three classes of teeth; incisors or cutters, canines or tearers, and molars or grinders. What proportion of the weight of the body is blood? State with regard to blood (a) its specific gravity; (b) its reaction; (c) on what its color depends. About one-thirteenth of the body weight is blood ; its specific gravity is about 1055; reaction alkaline. The color depends upon its contained hemoglobin. Name the successive divisions of the alimentary tract. The divisions of the alimentary tract are the mouth, PHYSIOLOGY. 383 pharynx, esophagus, stomach, small intestine (duodenum, jejunum and ileum), large intestine, (caecum, ascending, transverse and descending colon and sigmoid flexure), rectum and anus. What organs excrete waste and what does each thus remove from the system? The lungs remove the carbon dioxide, the skin removes ex- cess of water and small quantities of organic material and supplements the action of the kidneys. The kidneys remove the urea, the phosphates and sulphates from the proteid kata- bolism, water, and excess of salts ingested in the food. The intestines remove waste thrown off by the liver, refuse of digestion and may at times supplement the action of the kidneys. State approximately the amount of saliva and of gastric juice secreted during 24 hours. There is secreted daily about two pints of saliva and ten to twelve pints of gastric juice. Are the albuminous matters solid or fluid? State where albuminous matters are found in the body. Albumens are solids but in the body are in solution. They are found all over the body. Give the composition of perspiration. The perspiration contains about one per cent, of solid mat- ter, two-thirds of which is inorganic (principally sodium chloride) and one-third of organic (principally fats and fatty acid) with a little urea and epithelial debris. Describe the action of the nervous system on the sali= vary glands. There is a centre in the medulla that controls the secretion of saliva. The two efferent nerves from this centre are the auriculotemporal for the parotid and the chorda tympani for the sub-maxillary and sublingual glands. The terminals of many afferent nerves when stimulated 384 PHYSIOLOGY. will cause a reflex secretion of saliva. Among these are the trifacial terminals in the mucosa of the mouth, vagus ter- minals in gastric mucosa, gustatory terminals in the tongue, olfactory in the nose, and even the terminals in the uterine mucosa. State the effect produced by the blood while passing through the muscles. The blood while passing through the muscles becomes venous, giving up the oxygen of the oxyhemoglobin, supplies nour- ishment to the muscle, carries off waste, principally in the form of CO,. State the function of the salivary glands. The salivary glands secrete a fluid containing a principle called ptyalin which converts starch into sugar. It also aids in moistening the bolus of food, thus aiding the digestion. Describe metabolism. Metabolism is the chemical change going on in organized tissue. Describe secretions. State how the process of secre= tion is carried on. Secretions are those products of activity of the epithelium of glandular tissue that are of further use to the organism. The glands receive their nourishment from the blood. The supply of blood is under the control of the vaso-motor system. The cells under the stimulus of impulses through the secre- tory nerves, or as in the case of the pancreas, from substances circulating in the blood (secretin) pick out certain ele- ments of the blood and form new substances, which are thrown out into the lumen of ducts of the gland. In the ductless glands, these products are thrown into the blood vessels directly or indirectly, through the lymphatic system. State the character of the food absorbed by the lym= phatic circulation and its manner of reaching the blood circulation. The fats are absorbed through the villi, carried by the PHYSIOLOGY. 385 lacteals to the receptaculum chyli, thence through the thoracic duct into the left subclavian vein. Define nerves of special sense. The nerves of special sense are the nerves carrying the afferent impulses from the various peripheral sense organs to the central nervous system. Describe reflex action. Give an example of a reflex action that is automatically performed. A reflex action is an afferent impulse followed by an efferent impulse and is independent of volition. A blow on the solar plexus will cause a reflex slowing or stoppage of the heart. Describe a ganglion. A ganglion is a mass of nerve cells some distance from the central cerebro-spinal axis, and has nerve fibers entering and leaving it. Mention the organs necessary for a sensation. For a physiologic sensation there must be a peripheral sense organ, the sensory nerve or pathway from it and the cerebral center to receive the impression. State the average amount of sweat excreted in 24 hours. Is this excretion necessary to sustain life? Give reasons. The average amount of sweat per day is two pints. It is a necessary excretion, as through the sweat, most of the heat produced in the body is dissipated. Give the chemical composition of muscle. Muscle contains the proteids, myosinogen, myoalbumen and myoglobulen, small quantities of glycogen and inosite, extrac- tives as urea, creatin and creatinin, a red coloring matter, myokematin and inorganic salts, especially potassium phos- phate. It is normally alkaline, but when fatigued becomes acid, from the formation of sarcolactic acid. 25 386 PHYSIOLOGY. ■■ Describe the structure and state the functions of the skin. The skin consists of the cutis vera, formed of dense fibrous tissue, the superficial layer being raised into numerous papillae. This is the vascular layer of the skin. The end bulbs of the sensory nerves are found here also. Covering the cutis vera is the epidermis, formed of numerous layers of epithelium. There are four strata of the epithelium: — the outer, horny, or stratum corneum ; the stratum lucidum ; the stratum gran- ulosum, and the inner or stratum mucosum. The function of the skin is to protect the underlying soft parts from injury and drying, to protect the sense corpuscles, and through the sweat glands and blood vessels to dissipate heat. The hair, an appendage of the skin, protects some of the organs from cold, the brain from shock and prevents fric- tion, as in the arm pits. What causes the beat or pulsation of the heart? The rhythmic activity of the heart is due to intrinsic property of the heart muscle. According to Loeb it is controlled by 'the proper balancing of the ions of sodium, calcium and potassium. Has blood plasma an alkaline or an acid reaction? Give reasons. The blood plasma is alkaline in reaction due to the dissolved alkaline salts, especially sodium carbonate and phosphate, that it contains. Describe by diagram or otherwise a transverse section of the spinal cord. The spinal cord is a rounded mass of white matter, imbedded in which is a central mass of grey matter, arranged like the letter H. The white matter consists of nerve fibers and the grey of nerve cells. These are held together with neuroglia. ^The projections backward of grey matter are called the pos- ' terior horns. These come to the surface of the cord postero- laterally. Here the posterior roots or sensory nerves enter the cord. PHYSIOLOGY. 387 The projections forward of grey matter are called the anterior horns. Fibers starting here emerge from the antero- lateral surface of the cord. In the median line there is the anterior median fissure, projecting about one-third of the distance into the cord, and the posterior median fissure, pro- jecting about half the distance into the cord. The white mat- ter between the posterior horn and the posterior median fissure is called the posterior column and is divided into the two tracts of Goll (median) and Burdach. Between the anterior horn and the anterior median fissure is the anterior column, divided into the direct pyramidal (median) tract and the anterior ground bundle. The white matter between the two horns is called the lateral column and is divided into five tracts; the crossed pyramidal tract, triangular in shape and found close to the posterior horn, then along the periphery of the cord from behind forward we have the direct cere- bellar, anterior lateral ascending cerebellar (Grower's) and anterior lateral descending cerebellar (Lowenthal's) and deep in the lateral column is the deep lateral tract. In the grey matter there are two especially well marked columns of grey cell, one situated at the base of the posterior horn (Clark's column) the other, the intermedio-lateral column, between the two horns laterally. HYGIENE. Mention eight satisfactory disinfectants and give in- dications for their use. Formaldehyde (1 pound for every 1000 cu. ft. of space), sulphur (3 pounds for every 1000 cu. ft. of space) or bleaching powder (3 pounds for every 5000 cu. ft. of space) to fumigate a room. If sulphur or bleaching powder are used, it is necessary to steam the room before beginning to fumigate. Chloride of lime to disinfect excrementitious mat- ter from typhoid fever, cholera, dysentery, etc. Carbolic acid (5% solution) or moist heat (steam and boiling water) to disinfect clothing. Bichloride of mercury or permanganate of potassium and oxalic acid to disinfect the skin. What are the most common sources of infection in diphtheria? By direct contact with the sputum or shreds of membrane from the patient. By inhaling the air in the vicinity of the patient. By fomites, clothing, books, drinking- cups, etc. What conditions are essential to a good water supply? Purity at its source, and adequate subsequent protection from contamination. Describe the hygiene of the mouth and teeth. The teeth should be cleansed after each meal and on rising in the morning, and foreign matter between the teeth should be removed. Acidity of the saliva may be counteracted by weak alkaline mouth washes. (389) 390 HYGLEXE. What methods would you suggest for the hygienic care of the skin? Simple foods; avoiding constipation; daily exercise in the open air; plenty of sleep (at least eight hours daily) ; fre- quent warm baths and a cold sponge bath on rising each morning. Name the kinds of food and the quantity of each for the daily use of the normal man. 4.5 ounces of proteids; 3.5 ounces of fats; 14 ounces of carbohydrates; 1 ounce of salts (Moleschott) . Or 118 grains proteids ; 56 grains fats ; 500 grains carbohydrates (Voit). These quantities represent dry foods. If the diet is stated as so-called solid-food (not water-free) the above quantities must be doubled. 50 to 80 ounces of water in liquid form are also taken into the system. Describe in detail the process of disinfection by for» maldehyde (formalin). Make the room as near air-tight as possible by closing all openings and cracks before beginning the process of disinfec- tion. All mattresses, pillows, clothing, books, etc., should b© exposed as fully as possible to the action of the disinfectant. Place one pound of formalin for every 1000 cu. ft. of air space in a "Novy" generator. Start the rapid volatilizing of the formaldehyde and allow the room to remain closed for one day. What hygienic means should be employed by persons prone to " catch cold?" A cold sponge bath followed by brisk rubbing on arising in the morning; daily muscular exercise in the open air and a liberal (but not excessive) diet, largely of carbohydrates. What are the sanitary requirements of house plumbing? All pipes and connections, traps, etc., should be in view or easy of access. Each house must be directly connected by pipe with the common sewer. The pipes in the house must HYGIENE. 391 be of iron with leaded joints or screwed couplings. The drainage pipes should be laid with a gradient of at least one inch fall to every four feet of length; the main house drain must be provided with a trap after it has been carried be r yond all house connecting pipes. Pipes from water closet fixtures, bath tubs, wash basins and sinks must have traps close to each fixture. Soil pipes must extend open for at least two feet above the roof and air must be admitted to the main trap upon its house-side. Describe a simple form of ventilating the sick-room. Place a wooden strip about three inches wide and as long as the window frame under the lower sash ; through the space between the top of the lower sash and the bottom of the upper, sufficient air will enter the room without producing a draught. What precautions should be taken in school rooms to protect the sight of scholars? Pupils should not sit facing the windows (the light should come from behind or over left shoulder) ; blackboards should not have a glossy surface or be placed between windows. The walls of the room should be of a neutral tint. Text books should be printed in clear, large type. Faulty pos- ture in reading and writing should be corrected by the teacher. If toilet accessories are supplied, no child suffering from an inflammatory disease of the eyes should be per- mitted the use of the general supply. Any imperfection in virion of a pupil should be reported to the parents. What are the chief sources of contamination to drink= ing water? The emptying of sewage into the stream from which the water supply is obtained; surface water in settled districts gaining entrance to the supply; sub-soil water, after passing through a filthy soil ; draining from places of burial ; and water which has dissolved poisonous minerals. 392 HYGIENE. Describe the different methods of purifying drinking water. Sedimentation, occurring when collections of water remain at rest for a considerable time, removing, in part, at least, suspended matter. Sand nitration in which the water flows upon and through prepared beds of sand, gravel and broken stone, packed in separate layers, removes from it not only suspended matter, but also dissolved organic matters and bacteria through the action of air (oxygen) in the interstices of the filter material, and the action of saprophytic bacteria. Boiling water will free it of pathogenic bacteria and tem- porary hardness, but such water, after boiling, should be aerated to fit it for use. What do you understand by the " dry earth system " as applied to excrementitious matter? The container under the privy seat contains the dry earth, and after the use of the privy, fresh earth is always to be added to the receptacle. From time to time the contents are removed and buried or otherwise disposed of. Mention some of the results of tobacco smoking in growing school boys in respect to the circulation, air pas= sages, vision and mental application. It depresses the circulation and produces palpitation of the heart. It causes low grades of inflammatory processes in the upper air passages, catarrhal conjunctivitis, mental lethargy with inability to sustained mental application. What habits of school children tend to produce myopia? Reading of small or imperfect print; faulty positions while reading or writing in which the eyes are not far enough re- moved from the page. Reading or writing in insufficient light, or when fatigued. What should be the proper temperature for a living room in winter? 72 c F. for old or weak persons; 65° F. for the young and vigorous. HYGIENE. 393 What should be the diet of a child over two years of age? The food should consist principally of milk and bread, with rice, tapioca, some vegetables of easily digestible character and sparingly of fruit, preferably cooked; but little meat should be allowed and this preferably mutton. What is the most sanitary way of disposing of city garbage? Burn it, so that all noxious vapors are also consumed. Mention six desirable factors in the location of a resort for consumptives. Equable climate, high altitude, dry atmosphere, pure air, abundant sunshine and pine forests are climatic factors for consumptives. State the accepted belief in respect to the limitation of protection from vaccination. Five years, when revaccination should be attempted. Dur- ing a small-pox epidemic it is advisable to revaccinate all individuals who have not been vaccinated within two years. Mention some of the adulterations in preparations of ground coffee for sale in the shops. Chicory, peas, roasted cereals and legumes, date stones, acorns, sawdust, etc. What class of foods should predominate for persons over sixty years of age? Use eight-tenths the quantity of proteids that the vigor- ous adult requires; seven-tenths the quantity of carbo- hydrates ; and one and two-tenths times the quantity of fats. Which in your judgment is to be preferred in vaccin- ation, animal or humanized lymph, and why? Animal lymph, because in its preparation greater care may be taken to secure its freedom from deleterious additions. 394 HYGIENE. Name some of the nuisances dangerous to health. Gases and dust of a poisonous or irritating nature arising from many .manufacturing industries. Collection of stag- nant water, garbage and animal excreta exposed to the air; leaking drains or sewers saturating the soil, or allowing the escape of gases. Industries giving rise to great noise or vibration in thickly settled communities. What is the best means for preventing the access of sewer gas in dwellings? Place a trap or water seal between the house drain and the sewer, and provide an air inlet pipe to open into the drain pipe between this trap and the house. A ventilation pipe should extend from the house drain to a point above the roof. Name the diseases the predisposition to which is greatly increased by the use of alcohol. Diseases of the heart and vascular system, the kidneys, brain and liver and of the respiratory system, particularly pneumonia and asthma. Name four diseases that are communicable to man through cows' milk. Typhoid fever, scarlet fever, cholera and tuberculosis. To what is indigestion from excessive tea drinking attributable? State a formula for the preparation of good tea. The indigestion is caused chiefly by tannin; also by theobromin. Pour one pint of boiling water over a dram of the dried tea leaves and allow it to stand, without applying further heat, for five minutes. Mention some of the advantages of carefully prepared artificial ice as compared with natural ice. It may be made from distilled water so as to be ab- solutely pure. It may be obtained in any size or shape and its texture is more uniform. HYGIENE. 395 What precautions as to food and drink should be ob- served by those forced to work under the direct rays of the sun in summer weather? A small quantity of readily digestible food should be eaten before going to work. Liquids of a nonalcoholic charac- ter may be used liberally, provided perspiratory function is actively performed. Very cold drinks should be avoided. Meat should be largely excluded from the diet. What are the best methods of ventilating dwellings, and what sanitary principles are involved? The perflating action of wind should be utilized at least once each day for all rooms. One of the best methods em- ployed is the open fireplace, provided such fireplaces be sup- plied with properly constructed chimney exits. Instead of this plan, fresh air may be admitted through ventilators, or between the upper and lower window sashes. The object sought in these devices is to admit cold air above the heads of the occupants of the room so that the fresh air may pass through the upper portions of the room and become heated before reaching the occupants. The usual outlet for foul air is the chimney flue, but when this is not present, it may be replaced by an opening for the exit of air placed near the floor of each room. When the incoming air is not heated the outlet should be at the top of the room. During cold weather the rate or interchange of air should not be greater than sufficient to change the air of the room three times an hour. The air which enters should not have a greater velo- city than five feet per second or about 3.4 miles per hour. What hygienic precautions are necessary to insure healthy sleep? A well ventilated room, temperature about 60° F. Room and bed should be perfectly clean and the covers of the bed not too heavy. The head of the person should be slightly ele- vated. Noise and light should be excluded from sleeping apartments. 396 HYGIENE. What deleterious gases accumulate in improperly venti- lated sleeping rooms? Carbon dioxid ; carbon monoxid, if rooms be heated ; hydro- gen sulphid; ammonium sulphid, and many gases of an or- ganic ammoniacal character. Does change in climate require any change in food; if so, what? Yes. In cold climates a greater quantity of food should be consumed than in hot climates. Food that is productive of the greatest number of heat units, as fats and meats, should be partaken of in cold climates. In hot climates the diet should consist almost entirely of well-cooked vegetables and ripe fruits; with the avoidance of alcoholic beverages. What are some of the dangers of the cold bath? In those of feeble circulation and at the two extremes of life, chilling of the surface of the body leading to internal congestion that may result in acute inflammation, particu- larly of the lungs, kidneys, stomach and bowels. Shock seri- ously affecting the heart ; and the production of a persistently lowered temperature of the body. What effect has ground air and water on the health? Ground air is always impure, being contaminated with bacteria, carbonic dioxid and often with more poisonous gases. It occasions various degrees of ill-health, varying from slight general malaise to one of the acute infectious diseases or tuberculosis. Ground water from near the surface of polluted soils may be noxious. It causes dampness of the walls of houses, inviting rheumatic diseases and catarrhal inflammations. Define the word " nuisance " in a broad hygienic sense. "Something which either actually injures, or is likely to injure health, and admits of a remedy either by the individual whose act or omission causes the nuisance, or by the local authority" (Winter-Blyth). HYGIENE. 397 What injurious influences, if any, do cemeteries exert on the health of persons living in their vicinity? To most persons the mental effect is depressing. Water passing through the soil of cemeteries may contaminate the water supply of the neighborhood, with organic material and micro-organisms. The constant turning of soil of cemeteries may set free imprisoned gases from organic decomposition, and lead to contamination of the surrounding air. What gases and combination of gases are most efficient as disinfectants? Formaldehyde, sulphur dioxid, chlorin, ozone. What care should be employed in exhumations? The exhumation of those dead of contagious or infectious diseases should not be allowed. When possible, the exhum- ation should be deferred until cold weather. The presence of all persons except those absolutely needed should be for- bidden. As the workmen approach the coffin the earth should have poured upon it a strong watery solution of creolin. The coffins containing the remains should not be opened, but be placed at once in a zinc-lined box and hermetically sealed. What are the hygienic requirements and the physio- logical effects of bathing? The bath should be taken to obtain personal cleanliness, as well as for its stimulation of the peripheral circulation. Bathing should be postponed until at least two hours after a meal, and should consume only twenty minutes. Never bathe when very hungry, or when the body is overheated. Unless experience has shown that good effects accrue from a cold bath, secure a temperature of about 65 to 75 degrees Fahr. of the water. The bath should be followed by a thorough drying and brisk rubbing. Effects following a bath are removal of dirt and of dead epithelium from the person, stimulation of the functional activity of the skin; a general improvement in the circulation and increased func- tional activity of the organs of elimination. 398 HYGIENE. How much fresh air is required for normal respiration during 24 hours? 3000 cubic feet per hour, or 72,000 cubic feet of air in 24 hours. How may a privy in city or country be kept while in use from becoming a nuisance? Have the privy emptied at frequent intervals. At inter- vals of five to seven days, pour into the privy vault milk of lime (about 20 grains of lime for each gallon of sewage), or strong solution of iron sulphate ; or at frequent intervals add clean, dry earth to the privy contents, and provide a ventilat- ing pipe extending high in the air and down into the privy vault. What explanation can be furnished for the greater pre= valence of diphtheria and small=pox in cold than in warm weather? During cold weather the houses are less perfectly venti- lated than in warm weather. Rooms are frequently over- heated, less attention is paid to personal cleanliness and there are more sudden changes in temperature. Such con- ditions lower the vitality of the body and predispose to disease. What are the principal adulterations of milk? Addition of water and abstraction of cream; addition of coloring water (annatto, caramel) ; preservatives (borax and boracic acid, salicylic acid, formaldehyde, chromates) ; gela- tine as a thickening for cream. What changes in food are effected by cooking? Parasites and germs are destroyed; the food is made more tender to facilitate mastication. The tough fibrous envelope of starch cells is softened, albumen is coagulated, the food is rendered more palatable, and the action of the different digestive fluids is aided. HYGIENE. 399 State the advantage of cremation over earth burial. Complete destruction of specific disease germs. If crema- tion be well performed no obnoxious gases are given to the air, no gases of putrefaction contaminate the air, and there is no danger of contaminating the water supply through drainage from cemeteries. What are the respective merits of cotton, wool and silk when used as underwear? In a variable climate wool is preferable because from a larger amount of air enclosed in its texture it acts as a good non-conductor of heat, retaining the body heat. As wool is hygroscopic it readily absorbs moisture from which it parts slowly, so preventing surface chill of the individual by too rapid evaporation. Next in order to retain the heat of the body we rank silk and least valuable for the retention of body heat is cotton. If it be our purpose to supply a cool garment we would of course reverse this order of arrangement. What conditions of ill health make residence in high altitudes dangerous? Why? Chronic Bright 's Disease, disease of the heart, emphysema; and old age. High altitudes occasion increased respiratory effort from the rarified condition of the atmosphere, causing increased heart action, and a lessened perspiratory function. State the physical condition that makes the practice of taking hot baths inadvisable. Acute inflammatory diseases, tuberculosis, organic diseases of the heart and brain, aneurism, cancer, and all diseases in which stimulation of the circulation is to be avoided. State some of the sequelae of (a) over=strain, (b) over= exertion, (c) overstraining. (a) Parting of continuity of osseous, ligamentous, muscu- lar or bloodvessel structure leading to fractures, dislocations, rupture of muscles, hernia, rupture of heart muscles, disease of valves of heart and apoplexy. 400 HYGIENE. (b) May produce same conditions as over-strain and in addi- tion cause general muscular relaxation, dyspnea, syncope, etc. (c) Loss of appetite and of muscular power, successive crops of boils appear, individual loses mental power, as of con- centration of thought, and digestive disturbances occur. What constitutes hard water and soft water? "Hardness is the capacity a water has for decomposing soap, and depends on the amount of salts of magnesia and calcium in solution." (Harrington.) Soft water contains little or no dissolved salts and rapidly forms a lather with soap. Mention the dangers of excessive shade about dwellings. Excessive shade interferes with the free movement of air, prevents penetration of the sun's rays, promotes dampness which is given off to the air by evaporation. It exerts a depressing mental action, promotes the growth of fungi and bacteria, and prevents the aspirating action of heat from the sun upon air and moisture in the soils. What is milk sterilization? How is it performed? Destruction of micro-organisms in the milk by heat. By continuous heating of the milk, under pressure, for two hours at 248° F. What infectious diseases may be due to impure drink- ing water? Typhoid fever, malarial fevers, cholera, relapsing fever, dysentery, parasitic diseases. Describe the physiological action of alcohol. Small or therapeutic doses increase the pulse rate and the arterial pressure by directly stimulating the heart. Over- doses directly depress and paralyze the heart muscle. Large doses produce decided lowering of body temperature. It is probable that the use of alcohol diminishes the elimination of C0 2 . Alcohol causes a great lessening in the excretion of the products of tissue waste. It is probable that alcohol in HYGIENE. 401 not too large quantity is entirely destroyed in the body. In small doses alcohol acts as a cerebral stimulant, while larger doses greatly depress and abolish nervous activity, and check digestion. The habitual use of alcohol is accompanied by a disposition towards fatty degeneration, particularly of heart muscle, liver and kidneys, and an enlarged and dilated con- dition of the smaller bloodvessels and a degeneration of all nervous structures. Does alcohol possess a food action? On what do you base your answer? Yes. " In the sense that it is destroyed in the system and yields force utilized by the organism, and is, when in suffi- cient quantity, a retarder of tissue change, checking the ex- cretion of nitrogen " (H. C. Wood). "We see this in its administration in typhoid and other long continued fevers. Yet it is not a true food, since it also exerts toxic effects, which foods do not. The excavation of streets in cities is frequently fol = lowed by the outbreak of disease, such as diphtheria, typhoid fever. What is the cause? Pathogenic bacteria lie dormant in the soil of cities, and when such soil is exposed to the air, it becomes dried, and its contained bacteria taking on an active existence are liberated and carried by the air to susceptible individuals. How long does a diphtheritic patient remain infective? How may it be proved that this infective period has ceased? About three weeks after local symptoms cease. Make fre- quent cultures of material from the affected site, and when such fail to show the specific germ, the patient will no longer be a source of infection. How may milk be the means of transmitting the germs of typhoid fever? Through water containing Ebertlvs bacillus, gaining access 26 402 HYGIENE. to the milk, as through diluting the milk, washing milk receptacles in polluted water. Mention the effects of working in phosphorus, as in the manufacture of phosphorus matches. How can the dan= gers be limited or prevented? Inhaling phosphorus fumes produces a form of necrosis of the jaw, particularly in such as have imperfect teeth. To avoid its development persons of sound teeth and free from abrasion of the interior of the mouth should be employed. The work room should be large and well ventilated, with special air shaft to force the fumes away from the faces of workers ; the employes should have short working hours, and frequently use a mouth wash and gargle of lime water or carbonate of sodium. Turpentine and charcoal should be exposed in the room. What fruits are preferable in cases of habitual con= stipation? Apples, prunes, figs, grapes and melons. Describe the effect of a hot and moist climate on the human system and state the class of diseases this at= mosphere is likely to induce. In hot and moist climates the inhabitants, as a rule, are of small stature and deficient in muscular development; of languid disposition and nervous temperament. The diseases most prevalent are those affecting the liver and gastrointes- tinal tract ; also various forms of malarial disease, and yellow fever. What occupations are a menace to public health? Why? Those occupations that emit irritating, poisonous or noxi- ous fumes and gases from the vitiation of the atmosphere, as in fertilizing plants, chemical manufactories, bone-boiling establishments; also such occupations as give rise to much dust, especially if this be of sharp, hard character, as from cement making, in which the respiratory tract is subjected to irritation. , HYGIENE. 403 Mention some of the objections to storage cisterns underground. What are the objections to rain water as a drink? They often receive dust and dirt ; sewer gas may gain en- trance to the water when the "standing waste" or overflow pipe of such cistern is connected with the drain or soil pipe of a house. Storage cisterns cannot be properly ventilated, and are often difficult to clean. If the first part of the rain be collected, such water will contain dust, pollen, gases and other matters washed from the air. Give an opinion as to the sanitary effect of the different methods of heating houses. The most desirable method is by Hot Water Heating by means of a complete plant with circulation of the hot water through radiators. Next in value to hot water heating is steam heating by radiators or by indirect radiation. The use of open fireplaces in the principal rooms is of great value in securing ventilation, but yields an unequal and insufficient supply of heat. Heating a house by hot air from basement heaters is efficient and gives good results, if the air supplied to the heater for distribution is pure and the house is not too large. Name eight principal carbohydrates used as food. Starch, glucose, saccharose, lactose, dextrin, cellulose, mal- tose and dextrose. Name the class of foods which should be given to chil= dren between the first and second years of age. We should supply foods in about the proportion of 2 parts proteid, 3 parts fat, 6 parts carbohydrates, the proteid food being preferably milk. What are some of the dangers involved in the domestic use of ice? Ice may contain pathogenic bacteria, and may, when re- 404 HYGIENE. moved from a sick room transmit infectious disease to other members of the household. Define the term " quarantine," mention the principal quarantinable diseases, and give the rules for determin- ing the length of time each should be quarantined. "The adoption of restrictive measures to prevent the intro- duction of diseases from one country or locality into an- other. ' ' ( Wyman ) . Quarantinable diseases include cholera, small-pox, yellow fever, plague, scarlet fever, diphtheria, typhus fever, relaps- ing fever, cerebro-spinal meningitis, leprosy. In eruptive fevers isolation of the patient (quarantine) is continued for two weeks after the eruption has disappeared, except in the case of small-pox where quarantine lasts 30 days. The quarantine in diphtheritic cases does not cease until cultures made from the throat of the patient fail to show the bacillus of diphtheria. State the best means of disinfecting sputum. Sputum may be burned or received into vessels containing strong antiseptic solutions. What is understood by the germ theory of disease? Mention all diseases whose causes are known to be specific micro=organisms. The germ theory of disease contends that the exciting cause of each infectious or contagious disease is some specific organism, and that these diseases are communicated only by the transference to and development of the particular para- site or germ within or upon the tissues of the infected individual. Diseases due to specific micro-organisms are tuberculosis, diphtheria, cholera, typhoid fever, dysentery, pneumonia, glanders, leprosy, anthrax, erysipelas, gonorrhea, relapsing fever, malaria, plague and tetanus. Can it be proved that the diminished death rate from HYGIENE. ' 405 diphtheria so generally announced is due to the use of diphtheria antitoxin? Give reasons. Yes. By comparing the death rate in hospitals treating the same class of patients, in the same community, during the same time, the one hospital using diphtheritic antitoxin, the other depending upon other methods of combatting the disease. Where the antitoxin is used, the death rate is much lower. Give the comparative nutritive value of sterilized or unsterilized cows' milk. The nutritive value of sterilized milk is less than of milk unsterilized. What evil consequences frequently result from the ex= cessive use of tobacco? Catarrhal inflammation of pharynx, tonsils and mouth. Nervous disorders of heart as palpitation, and insomnia also result. Derangements of stomach with loss of appetite, and impairment of vision together with paralysis of optic nerve, nervous tremors, and muscular twitchings may result. Mention five preventable diseases. Tuberculosis, typhoid fever, cholera, yellow fever and malaria. What is the best sanitary plan for the disposal of sewage? Collect the sewage in large tanks and to it add lime, alum or iron sulphate. Compress the solid materials after their subsidence or precipitation and cremate them. Allow the liquid sewage to flow upon specially prepared filter beds which are subdrained, the water flowing from these sub-soil pipes may then pass into a stream without great danger of adding poisonous materia] or pathogenic bacteria. What diseases are propagated by drinking water? How can their spread be prevented? Infectious diseases, particularly cholera and typhoid fever ; 406 • HYGIENE. diseases due to gastric and intestinal irritation, as forms of dyspepsia, diarrhoea, dysentery; diseases due to animal para- sites; diseases due to metallic poisons. Prohibit the use of water containing any dissolved metal. Distil the water, or boil it for at least one half hour, thus purifying it. State the results to animal life of the combustion of fuel in a room without chimney connection or other ventilation. Carbon monoxid poisoning, suffocation due to excessive quantity of carbon dioxide and diminished amount of oxygen; a systemic poisoning due to breathing products which are the result of partial burning of excretions thrown off in exhalations. State the original source of all fresh water. The original source of fresh water is rain. State the impurities which rain water may contain. Describe the great value of rain water for domestic pur- poses and state the great objection to its general use. Rain water may contain microscopic growths, bacteria, ammonia, nitric and nitrous acid and other impurities from the collecting surface. On standing in the cistern many bacteria and other mi- croscopic growths may rapidly render it unfit for use. Rain water on account of its softness is of great value for cooking and washing purposes. The great objection to use generally is the limited and uncertain supply. In what part of an occupied room is the most impure air found? Give reasons. The lower part of an occupied room contains the most im- purities. The carbon dioxide is heavy and tends to accumu- late in the lower part of the room. The dust and other solid impurities are more abundant near the floor. HYGIENE. 407 State the composition of atmospheric air. Is the mix* ture a chemical or mechanical one? Atmospheric air is made up of 20.96% of oxygen, .04% of carbon dioxide and 79% of nitrogen and other inert gases as argon and cry p ton. The mixture is a mechanical one. State the nervous disorders most common among school children. Mention some of the causes of these disorders. Among the many nervous disorders of school children are chorea, habit spasm, refractive errors of vision, deafness from catarrhal condition of nose, degeneracy, mental dullness and later in school life, neurasthenia. Among the causes of these are overcrowding, faulty light, lack of proper ventilation, improper desks, lack of personal hygiene, heredity, cramming and lack of proper food and exercise. State the average proportion of carbon dioxide in iooo parts of atmosphere. What should be the maximum limit of carbon dioxide in school rooms? Four parts of carbon dioxide to ten thousand of air is the normal. The maximum limit of carbon dioxide in a school room should be .05%. State the hygienic precautions that should be taken to prevent the spread of typhoid germs. The drinking water should be boiled, and the milk also if it is suspected of possibly being infected. The feces and all secretions, like urine and nasal mucus should either be destroyed by fire or properly disinfected with a strong solution of bichloride of mercury, chlorinated lime, formalin or carbolic acid. The clothing of the patient and the bed linen should be placed in strong bichloride solution, or preferably boiled for a half hour. The glasses and other dishes used by the patient should be boiled. 408 HYGIENE. What instruction as to hygiene and sanitation should be given in a case of diphtheria? The case should be isolated, the house quarantined, and possibly those who have been exposed (especially children) had better be given a small dose of antidiphtheritic serum. The room should be well ventilated and as much sunshine as possible allowed to enter. The discharge from the mouth and nose should be de- stroyed by fire; the dishes should be boiled. The clothing and bed linen should be boiled or destroyed by fire. After the case has terminated the room should be thor- oughly disinfected with formalin or sulphurous acid, and the woodwork washed with 1 to 1000 bichloride of mercury solution. Name some of the impurities found in rain water that is stored in cisterns. Unicellular organisms of many kinds, decaying vegetation, nitrites, ammonia, nitric acid, and mechanical impurities. What are the general effects of breathing impure air? You get the symptoms of intoxication from the impurities of the air, such as headache, general malaise, loss of appetite, interference with mental activity, also interference with mus- cular activity, weak, low-tension pulse. State the composition of pure air; of expired air. Pure air consists of 20.9 parts of oxygen, .04 parts carbon dioxide and 79.+ nitrogen and other inert gases. Expired air consist of 15.9 parts of oxygen, 4.5 parts of carbon dioxide and 79. -f- nitrogen. If a chemical analysis of water revealed the presence of nitrites and nitrates, would this condemn it for drink= ing purposes, if so, why? Yes, particularly if nitrites be present. Organic matter, particularly sewage, is converted first into nitrites and these HYGIENE. 409 into nitrates through the action of bacteria in the soil. These salts would, therefore indicate a former pollution of the water with probably some of that polluted material still in the water. If nitrates only are present and it can be shown that the organic matter is of a vegetable origin only, the water need not be condemned. On what generally accepted theory are toxins used for the prevention and cure of disease? That their presence in the system renders the blood no longer able to support the lives of bacteria that occasion such toxins. Under what condition is tyrotoxicon found in milk, cheese and other articles? Where milk, cheese, ice cream, etc., undergo decomposition in the presence of other organic matter, as rotting wood, mould, etc. Describe the agency of the ptomaines in inducing dis- eases and the disorders produced by them. Ptomaines are alkaloidal bodies resulting from decomposi- tion of nitrogenous substances. When absorbed into the blood they may give rise to fever, headache, torpor, fetid breath. They act like chemical poisons very soon after their introduction into the system. Many of them occasion dis- tinctive trains of symptoms. Mention an infectious disease which is often caused by drinking water and show how the germs of this disease are communicated to the water. Typhoid fever is frequently caused by drinking water. The excretions of the body are thrown on the ground or into im- properly made cesspools, and then drain into the drinking wells, or the excretions are thrown into a creek or river and carried down to a city that uses this river as a supply for drinking water. 410 HYGIENE. State the number of cubic feet of oxygen absorbed in 24 hours. There are 27 cubic inches of pure oxygen absorbed in one minute or 22y 2 cubic feet daily. Mention six kinds of food from which starch is derived. Starch is derived from potatoes, corn, rice, wheat, oats and sago. What is the lowest temperature of steam heat at which pus cocci are destroyed? At 240 deg. Fahr. such organisms are killed in a few minutes, while at 212 deg. Fahr. it requires an exposure to steam of from thirty to forty minutes. What is the temperature of tepid water, of hot water, of boiling water? Tepid water 75 to 85 deg. Fahr. Hot water 100 to 110 deg. Fahr. Boiling water 212 deg. Fahr. Differentiate between endemic and epidemic diseases. An endemic disease is one constantly present in a commun- ity. An epidemic disease is one which spreads rapidly, at- tacking many people at the same time. What is meant by natural and acquired immunity from disease? Give an example of each. By natural immunity we mean "that inherited trait from immune ancestors which enables an organism to resist the attacks of bacteria and their toxic secretions." Thus, as a rule the negro race do not contract yellow fever. By ac- quired immunity we understand that through a previous at- tack of an infectious disease, or by inoculation with an at- tenuated virus of that disease, the blood of the person under- goes such changes as to present a non-fertile soil to the or- ganism to whose presence the disease is due. Example, vac- cination in preventing small-pox. HYGIENE. 411 Describe vitiation of the air from lack of ventilation. The vitiation of the air from lack of proper ventilation is caused by the using-up of the oxygen, the accumulation of carbon dioxide and other waste products thrown off by the respiratory tract and skin. What should be the lowest specific gravity of fresh milk? The lowest specific gravity of fresh milk should be 1029. In ioo parts of cow's milk, mention the per cent, of proteids, fats, sugar, salts and water. There is in cow's milk about 4% each of proteids, fats and sugar, about .7% of salts and the rest is water. State the advantages of a mixed diet. In a mixed diet one is more apt to get the right amounts of proteid, fats, carbohydrates and salts, the food is not too concentrated, nor does it contain too much waste, like cel- lulose. Proteids are absolutely necessary in the food. The vegetable foods are poor in proteid and the proteid is not as readily digested. Change of diet increases the appetite and this physical influence is the most powerful in causing a proper flow of the various digestive secretions. State a method of disinfecting a room that has been occupied by a diphtheritic patient. The bedding, unless it can be subjected to superheated steam, had better be burned. The room should be thor- oughly filled with abundance of formalin spray and kept closed for 24 hours. The room then should be thoroughly aired and exposed to the sunlight. The room should be re- papered and the woodwork and the floor washed with a 1-1000 solution of mercuric chloride. How may the germs of infectious diseases be introduced into milk? The germs of infectious diseases may be introduced into milk bv washing the milk cans with infected water, bv water- 412 HYGIENE. ing the milk with infected water, from the hands of those handling the milk, from infected cows (as tuberculosis) and by contact of infected air with the milk. State the objection to the use of wells within the city limits. The objection to these wells is, they are very likely to drain the nearby cesspools and the surface sewage, unless they are thoroughly made wells that pass through at least one layer of solid rock. Does regular physical exercise affect the condition of the mouth? If so, how? It affects the condition of the mouth by increasing the tone of the whole body, stimulating especially, the circulation and secretion. What is the best method of disinfecting instruments? The best method is moist heat. • State what hygienic measures a dentist should employ after operating at a chair. He should clean the nose, throat and mouth with an anti- septic solution; he should scrub the hands and place them in antiseptic solution for a few minutes. The instruments should be sterilized and the room aired if possible. What hygienic care should be given to an operating room? An operating room should be well ventilated without draughts, well lighted, scrupulously clean, well heated and should be rendered as nearly aseptic as possible after a septic operation. . ANATOMY. What is connective tissue? (b) Where is it found in the human body? The term connective tissue includes a number of tissues which serve the purpose of "connecting" and supporting dif- ferent tissues of the body. It is generally applied to tissue which fills in the interstices between organs, etc., and binds and supports them together. Most typically, it is found between muscles and surrounding blood-vessels. Give a general description of the nervous system. It consists of central and peripheral portions, the former made up largely of cells, and the latter of fibers. The brain and cord are contained in the cranial cavity and spinal canal. The brain, or encephalon, consists of cerebrum, cerebellum, pons and medulla; 12 pairs of nerves (cranial) pass out from these divisions through foramina in the cranial floor. The spinal cord has 31 pairs of spinal nerves attached to it. The cerebro-spinal axis is protected by 3 meninges, the dura" the arachnoid and the pia. The peripheral nervous system consists of nerves of special sense, of motion and of sensation; many of them are mixed nerves, as to function. In the cervical and lumbar regions, the spinal nerves unite to form the cervical, lumbar and sacral plexuses. The so-called sympathetic system, most intimately con- nected with the cerebro-spinal system, consists of collections of nerve cells known as ganglia, and of nerve fibers proceed- ing from these ganglia and uniting to form many plexuses, the largest of which are the three prevertebral, or the cardiac, (413) 414 ANATOMY. solar and hypogastric plexuses. From these plexuses fibers proceed to supply viscera and blood-vessels. Describe the sphenoid bone. By reason of its location at the base of the skull, it arti- culates with all of the bones of the cranium and with five of the face. It forms the greater part of the middle cerebral fossae ; it consists of a body, two greater and two lesser wings, and a pair of pterygoid processes. The body is hollow and contains the sphenoidal cells, or sinuses; between the greater and lesser wings, on each side, is the sphenoidal fissure, which transmits the ophthalmic division of the 5th cranial nerve, the 3d, 4th and 6th cranials, and ophthalmic vein. On the upper surface of the body is the sella turcica, which re- ceives the pituitary body ; on either side of the body is the groove for the cavernous sinus; in the greater wing are the foramina rotundum, ovale and spinosum, . for the maxillary division of the 5th, the mandibular division of the 5th, and the middle meningeal artery, respectively. The greater wing forms, anteriorly, part of the wall of the orbit, and externally, part of the temporal fossa; the pterygoid process helps to form the pterygoid fossa, externally, and the outer wall of the posterior naris, internally. State the location, size and structure of the cerebellum. Is located in the cerebellar fossae of the occipital bone, beneath the tentorium cerebelli; it measures four (4) inches transversely, and is about two (2) inches thick; in structure it resembles the cerebrum to the extent that it has a cortex which is made up of cells (gray matter), surrounding a white center consisting of nerve fibers, and which also con- tains a special nucleus, the corpus dentatum. The cere- bellum is connected with the mid-brain (mesencephalon) by the superior peduncles, with the pons (epencephalon) by the middle peduncles, and with the medulla (metencephalon) by the inferior peduncles. Describe the trachea and give its anatomical relations. It extends from the larynx to the bronchi, and consists of ANATOMY. 415 a series of transversely directed, incomplete rings of carti- lage united by an elastic membrane which contains involun- tary muscle-fiber posteriorly, where the cartilaginous ring is deficient; it is lined with a mucous membrane which is covered with ciliated columnar epithelial cells. The trachea rests upon the oesophagus, being flattened posteriorly; in the groove between these two structures is the recurrent laryngeal nerve, upon each side ; the common carotid artery, internal jugular vein and pneumogastric nerve are close to it at its lower portion, while the isthmus of the thyroid body crosses it upon its second and third rings, and the lobes of the same rest upon it laterally. Give the number and name the bones forming the skull. There are 22 bones in the skull : Cranium, 8 bones, viz., occipital, 2 parietal, frontal, 2 temporal, sphenoid, ethmoid. Face 14 bones, viz., 2 nasal, 2 superior maxillary, 2 lachrymal, 2 malar, 2 palate, 2 inferior turbinated, vomer, inferior maxillary. Give the origin, insertion, action and nerve supply of the gastrocnemius muscle. Arises by 2 heads from the posterior surface of the condyles of the femur and adjacent part of the shaft; inserted by tendo Achillis into os calcis ; action, to extend foot upon leg ; nerve supply, internal popliteal. What structures pass through the foramen magnum? Spinal cord, meninges, spinal accessory nerves (2), verte- bral arteries (2), anterior and posterior spinal arteries. Name and give the origin and insertion of the muscles which depress the lower jaw. Genio-hyoid, from inferior genial tubercle of mandible be- hind symphysis into body of hyoid bone; mylo-hyoid, from mylo-hyoid ridge of mandible, into body of hyoid bone; an- terior belly of digastric, origin from inner surface of mandi- ble, near symphysis, into central tendon, attached to body of hyoid bone. 416 ANATOMY. Give the blood supply of the tonsils. Ascending pharyngeal, tonsillar branch of dorsalis linguae, ascending palatine and tonsillar branches of facial, and de- scending palatine branch of internal maxillary. Mention the branches of the facial artery. Tonsillar, ascending palatine, muscular, glandular, sub- mental, inferior labial, inferior and superior coronary, lateral nasal, angular. Describe the mandible. The mandible, or inferior maxillary bone, consists of a horseshoe-shaped body which corresponds in shape with the alveolar border of the upper jaw, and extends upward and backward on either side as a ramus, which is surmounted by a coronoid process and a condyle, separated from each other by the sigmoid notch. The anterior extremity of the body projects as the mental protuberance (a characteristic of the human jaw), and the posterior end of the body, where it joins the ramus, is called the angle. Just anterior to this angle is a groove for the facial artery; the alveolar process, or border, contains sockets for the teeth, and is relatively thicker in the child's jaw, than in the adult's; behind the symphysis are the genial tubercles, while laterally from these are the depressions for the digastric muscles ■ more posteriorly still are the shallow fossae for the submaxillary glands ; upon the inner surface of the body, running downward and for- ward, is the mylo-hyoid ridge, for the mylo-hyoid muscle ; the ramus is roughened externally for the masseter, and inter- nally for the internal pterygoid muscle; upon the inner surface of the ramus is the inferior dental foramen, which leads into a canal of the same name ; to the coronoid process is attached the temporal muscle, while the condyle articu- lates with glenoid fossa of the temporal bone. Describe the hyoid bone. Is placed transversely above the thyroid cartilage, con- sisting of a centrally located body connected laterally with ANATOMY. 417 two greater wings, and supporting, at the junction of the body and greater wing, on each side, the lesser wing. The hyoid bone supports the tongue and has twenty muscles at- tached to it. Describe the ethmoid bone. The ethmoid bone is a light spongy bone consisting of a central portion and two lateral masses. The central part presents a horizontal plate, perforated for the transmission of olfactory nerve filaments, hence called cribriform. Pro- jecting upward from the anterior median portion of the horizontal plate is the crista galli, serving for the attachment of the falx cerebri. From the under surface of the cribriform plate depends the perpendicular plate, which forms part of the nasal septum. The lateral mass, on each side, consists of two curling pieces of bone, the superior and middle turbinals, attached to the ethmoidal cells, which are limited exter- nally by a smooth plate called the os planum, which assists in the formation of the inner wall of the orbit. De- scending from the lateral mass is the unciform process which articulates with the inferior turbinated bone, and assists in forming part of the inner wall of the antrum of Highmore. Give origin, insertion and action of the buccinator muscle. Origin, from the alveolar processes of the superior and inferior maxillary bones, and behind, from the pterygo- maxillary ligament. Its superior fibres blend with the fibres of the orbicularis oris in the lower lip, its inferior fibres with the fibres of the orbicularis oris muscle in the upper lip. Its action is to assist in keeping the food between the teeth in mastication; it is used in such acts as whistling and in blowing a trumpet. What nerve supplies the muscles of expression? The facial, or seventh cranial nerve. What nerve supplies the muscles of mastication? Branches of the inferior maxillary division of the fifth cranial nerve. 27 418 ANATOMY. Mention the muscles attached to the occipital bone? Twelve pairs: Occipito-frontalis, sterno-mastoid, trapezius, spienius capitis et colli, complexus, obliquus capitis superior, rectus capitis anticus major and minor, rectus capitis posticus major and minor, rectus capitis lateralis and superior con- strictor of pharynx. Give the course and relations of the external jugular vein. It begins in the lower part of the parotid gland, on a level with the angle of the mandible, and courses downward from the angle of the jaw to the middle of the clavicle; it crosses the sterno-mastoid muscle, lies beneath the platysma myoides, and terminates in the subclavian vein. Name the three classes of articulations. Synarthrosis, amphiarthrosis and diarthrosis. What nerves pass through the sphenoidal fissure? The third, fourth, ophthalmic division of the fifth, and the sixth cranial nerves. Give the origin, insertion, nerve supply, and action of the pterygoid muscles. The external pterygoid muscle arises by two heads. The upper head arises from the inferior surface of the great wing of the sphenoid below the pterygoid ridge, the lower from the outer surface of the external pterygoid plate. Its fibers pass horizontally backward and outward to be inserted into the depression in front of the neck of the condyle of the lower jaw, and into the interarticular fibro-cartilage. Internal pterygoid muscle arises from the pterygoid fossa and is inserted into the inner surface of the ramus and angle of the lower jaw. Nerve supply, mandibular division 5th cranial. Action, both external pterygoids throw lower jaw forward, while each, acting alternately, produces triturating movement; in- ternal pterygoids bring lower jaw up against upper jaw, and assist external pterygoids in carrying jaw forward. ANATOMY. 419 Mention the arteries from which the superior maxillary bone derives its blood supply. Alveolar, anterior and middle dental, branches of infra- orbital, and spheno-palatine and posterior palatine, branches of internal maxillary. Describe the salivary glands. Where do these glands empty? Parotid, submaxillary, sublingual. Parotid, largest, placed in front of ear, behind ramus of mandible; duct (Steno's) passes across masseter muscle, perforates buccinator muscle, terminates in cheek wall opposite upper middle molar. Parotid gland has facial nerve, external carotid artery, temporo-maxillary vein passing through it. Submaxillary gland is located upon inner side of body of mandible posteriorly, and is crossed by facial artery; duct (Wharton's) passes forward, terminating close to fraenum linguae. Sublingual gland, located in shallow fossa upon inner side of body of mandible, near s}^mphysis, is covered by mucous membrane of mouth; ducts (of Rivinus and Bartholin) terminate near fraenum linguae. What bones enter into the formation of the orbital cavities? Frontal, sphenoid, ethmoid (3 singles) ; lachrymal, su- perior maxillae, malar, palate (4 pairs). Describe the frontal bone and give its articulations. The vertical portion forms the forehead, is convex ex- ternally, presents two slightly raised eminences, the frontal, one to either side of the median line, while below them are the superciliary ridges, and below the latter, the supra-orbital arches, which terminate externally and internally in the ex- ternal and internal angular processes, respectively. Each supra-orbital arch presents the supra-orbital notch, or fora- men, at the junction of its inner and middle thirds. Between and below the two superciliary ridges is the glabella; the 420 ANATOMY. lateral segment of the vertical portion forms part of the tem- poral fossa, and the temporal ridge has its beginning in the external angular process, curving upward and backward. Upon the inner surface of the vertical portion are irregulari- ties corresponding to cerebral convolutions; longitudinally placed is the groove for the superior longitudinal sinus. The horizontal portion is composed of the two thin orbital plates, separated from each other by the ethmoidal notch, which is filled in by the ethmoid bone ; these plates are smooth and concave underneath, but irregularly convex above. Frontal bone articulates with both parietals, both malars, both nasals, both lachrymals, both maxillae, and with the ethmoid and sphenoid. Describe the temporal bone. Is made up of 3 divisions, squamous, mastoid and petrous. Squamous bone has vertically placed scale-like plate which forms large part of temporal fossa externally and of middle cerebral fossa internally; zygomatic process curves forward from it, while beneath is the glenoid fossa for condyle of man- dible, located just behind eminentia articularis, and in front of tympanic plate (anterior wall of tympanum and external auditory canal). Mastoid bone is placed behind, is rough and convex ex- ternally and projects downward and forward as mastoid pro- cess; beneath are digastric fossa for posterior belly of digas- tric muscle, and occipital groove for occipital artery; within substance of mastoid are mastoid cells, the largest of which is called mastoid antrum, which communicates with middle ear; upon cerebral surface of mastoid is sigmoid groove for lateral sinus. Petrous bone is pyramidal and is wedged in between squa- mous and mastoid bones; base presents oval opening, the external auditory meatus, to rough edge of which (auditory process) auricle is attached; apex, directed forward and in- ward, is notched to help form middle lacerated foramen, for entrance of internal carotid artery into cranial cavity ; cranial ANATOMY. 421 aspect of petrous bone forms ridge for attachment of dura (tentorium), a depression near apex for Gasserian ganglion, and upon posterior surface, the internal auditory meatus, for auditory and facial nerves ; petrous bone forms bony part of external auditory canal, the middle ear, and contains the osseous labyrinth; upon its under surface are to be found, near the center, the beginning of the carotid canal, behind and to the outer side of which is the jugular fossa, which, with a notch on the occipital bone, completes the jugular foramen ; the styloid process, surrounded by the vaginal pro- cess at its base, may be seen projecting downward, forward and inward; the stylo-mastoid foramen, giving entrance to the stylo-mastoid artery and exit to the facial nerve, is to be found between the styloid and mastoid processes. Temporal bone articulates with 5 bones : occipital, parietal, sphenoid, malar and mandible. Describe the ophthalmic artery. Is a branch of internal carotid, given off just after carotid has left cavernous sinus; it enters orbit by passing through the optic foramen, courses toward internal angular process where it divides into frontal and nasal. Branches are lachry- mal, ciliary, arteria centralis retinae, muscular, anterior and posterior ethmoidal, palpebral and supra-orbital. Describe the pulmonary veins. They are four in number, usually, 2 for each lung, and return arterial blood from lungs to left auricle of heart. Describe the otic ganglion. Is a small, flattened ganglion situated immediately beneath foramen ovale ; it receives motor and sensory roots from mandibular division of the 5th cranial; the small superficial petrosal nerve also enters it, furnishing branches of com- munication from the glosso-pharyngeal (sensory) and facial (motor) ; the sympathetic fibers come from the middle menin- geal plexus. Its branches of distribution are to the tensor tympani and tensor palati muscles, and to the chorda tym- pani nerve. 422 ANATOMY. Give a brief description of the facial nerve. The 7th cranial nerve, after passing through facial canal (aquaeductus Fallopii) of temporal bone, emerges at the stylo-mastoid foramen, and enters substance of parotid gland. Here it divides into 2 sets of branches, temporo-facial and cervico-facial, supplying muscles of expression. Its chorda tympani branch traverses inner surface of membrana tym- pani, after leaving main trunk in facial canal, and emerging through one end of the Glaserian fissure unites with lingual branch of 5th and accompanies it to submaxillary gland and ganglion and anterior % of mucous membrane of tongue. Describe the hypoglossal nerve. The 12th cranial nerve leaves cranial cavity by anterior condyloid foramen and descends almost vertically to a point corresponding with angle of jaw; it loops around occipital artery, then lies above hyoid bone, supplying intrinsic muscles of tougue. A communication from 1st and 2d cervical nerves after uniting with hypoglossal, leaves it to form descendens hypoglossi, branches from which are distributed to extrinsic muscles of tongue and depressors of hyoid bone. Describe the nasal bone and give its articulations. It forms "the bridge" of the nose, is oblong in shape, con- cave longitudinally, convex transversely: is grooved pos- teriorly for branch of nasal nerve ; upper margin is thick and serrated, while lower is thin, and notched ; upper margin arti- culates with frontal bone, while lower has lateral cartilage of nose attached to it. It articulates with frontal, ethmoid, maxilla and opposite nasal. Mention the muscles attached to the temporal bone. Fifteen, viz. : temporal, masseter, occipito-f rontalis, sterno- mastoid, splenius capitis, trachelo-mastoid, digastric, re- trahens aurem, stylo- pharyngeus, stylo-hyoid, stylo- glossus, levator palati, tensor tympani, tensor palati, and stapedius. ANATOMY. 423 Give origin and insertion of each of the muscles of the palpebral region. Three : orbicularis palpebrarum, corrugator supereilii and levator palpebrae. Orbicularis palpebrarum : origin, internal angular process of the frontal bone, and nasal process of the superior maxilla ; passes outward around the circumference of the orbit and is inserted, some fibres into the tarsal liga- ments, others forming a complete ellipse; the remaining fibres blend with the surrounding muscles. Corrugator supereilii : origin, from the inner extremity of the superciliary ridge, passing out to be inserted into the skin. Levator palpebrae : origin, the under surface of lesser wing of sphenoid above and in front of optic foramen. It passes outward along the roof of the orbit, becomes aponeurotic, and is inserted into the upper margin of the superior tarsal plate. Describe the superior longitudinal sinus. It extends from the crista galli of ethmoid to internal occi- pital protuberance of occipital; it increases in size as it is traced backward, draining the cortex of the cerebral hemi- spheres of venous blood. It usually becomes continuous with right lateral sinus. Describe the subclavian vein. A continuation of the axillary, it extends from outer bor- der of 1st rib to near sterno-clavicular joint, where it unites with internal jugular to form innominate vein (brachio- cephalic). It is anterior to subclavian artery, on 1st rib separated from the artery by anterior scalene muscle. Its tributaries are external and anterior jugular veins; the left, at its point of junction with the internal jugular, receives the thoracic duct. Describe the submaxillary ganglion. Small in size, is situated upon deep portion of submaxillary salivary gland; is connected with lingual (gustatory) nerve, 424 ANATOMY. and receives a branch from chorda tympani of facial; it com- municates with sympathetic plexus around facial artery. Branches of distribution are to mucous membrane of mouth and Wharton's duct. Describe the ophthalmic nerve. 1st division of 5th, is entirely sensory. It arises from Gasserian ganglion, and before passing through sphenoidal fissure into orbit, divides into 3 branches, viz., lachrymal, frontal, nasal. Lachrymal supplies lachrymal gland, conjunctiva and up- per eyelid. Frontal, largest branch, divides into supratrochlear and supra-orbital, supplying skin of upper eyelid and of fore- head, and integument and pericranium over half of head as far as occiput. Nasal branch leaves orbit by anterior ethmoidal foramen, enters nose and supplies mucous membrane of nose and integument covering ala. Name the arteries and nerves of the gums. Arteries are branches of internal maxillary, anastomosing with branches of facial artery through cheek wall. Nerves are from maxillary and mandibular divisions of 5th cranial, and branches from Meckel's ganglion. What bones encase the brain and what is their relative position? Occipital, both parietals, frontal, both temporals, sphenoid and ethmoid. Occipital is behind and below, parietals are above and at the sides, frontal is anterior, temporals are be- neath and at the sides, sphenoid and ethmoid are beneath, anteriorly. Describe the spinal column. It consists of 33 separate vertebrae, distributed as follows: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccygeal. Sacral and coccygeal coalesce early in life by ossification of inter- vertebral substances ; cervical segment possesses curve with ANATOMY. 425 convexity forward, thoracic with convexity backward, lumbar with convexity forward, sacral with convexity backward ; line of gravity passes through chords of these curves. Special, or peculiar, vertebrae are: atlas, axis, 7th cervical (vertebra prominens) ; ribs articulate with thoracic series; ilia articulate with sacrum. Spinal column contains neural canal for spinal cord. What are tendons and their function? They are rounded (cord-like) or narrow (ribbon-like) bundles of white fibrous tissue attaching muscles to bones or forming ligaments of joints, (shoulder, hip). Describe the elbow=joint and the manner of its lubri= cation. Is a ginglymus, or hinge- joint, made up of lower end of humerus and upper ends of radius and ulna : head of radius articulates with capitellum, and greater sigmoid cavity of ulna with trochlear surface of humerus. Its capsule is divided into anterior and posterior, internal and external lateral ligaments. It permits of flexion and extension. It is lubricated by synovial membrane lining its capsule. Describe the knee=joint and its manner of lubrication. Trochlear surface of condyles of femur, upper surfaces of tuberosities of tibia, and posterior surface of patella form its bony parts. These are completely surrounded by a capsule which is strengthened antero-laterally by aponeurotic inser- tions of vastus externus and internus and by fascia lata ; externally by a special band, or thickening, the external lateral ligament, and internally by the internal lateral liga- ment; posteriorly by the reflected tendon of the semimem- branosus muscle. Internal ligaments are anterior and posterior crucial, be- tween intercondyloid notch of femur and non-articular sur- face around spine of tibia; also 2 semilunar fibro-cartilages. attached to spine of tibia, while the internal is also attached to internal lateral ligament. ±26 ANATOMY. Synovial membrane is large, lines capsule and is reflected into interior of joint around crucial ligaments, its folds here containing fatty tissue ; it is extended upward beneath quad- riceps tendon. What muscles are involved in respiration? Diaphragm, external and internal oblique, transversalis and rectus, of abdominal walls, external and internal inter- costals, serratus posticus superior and inferior. Give the muscles of facial expression. Occipito-frontalis, corrugator supercilii. orbicularis palpe- brarum, levator labii superioris alaeque nasi, levator labii superioris, levator anguli oris, zygomaticus major and minor orbicularis oris, depressor anguli oris, depressor labii inferioris and platysma myoides. Describe the joint in which the mandible works and the tissues constituting the joint. Bony parts are glenoid fossa and articulating eminence of temporal bone, and condyle of mandible; ligaments form a capsule, much stronger externally and posteriorly; external lateral ligament extends between tubercle of zygoma and neck of condyle; associated ligamentous bands are spheno-mandi- bular and stylo-mandibular ; an interarticular cartilage con- tained within the joint cavity has tendon of insertion of ex- ternal pterygoid muscle attached to it. Movements per- mitted are depression and elevation of jaw around a trans- verse axis, and a sliding forward of both sides, protruding chin, or of one side at a time, producing a triturating movement. Name the bones of the head and face and give the articu- lations of the maxilla. Cranium : occipital, 2 parietal, frontal, 2 temporal, sphe- noid, ethmoid. Face: 2 Lachrymal. 2 malar, 2 nasal. 2 maxillae, 2 palate, 2 inferior turbinated, vomer, mandible. Maxilla articulates with 9 bones : Frontal, ethmoid, nasal, ANATOMY. 427 lachrymal, malar, palate, inferior turbinated, vomer and op- posite maxilla. Describe the shou!der=joint. Variety, enarthrodial' (ball-and-socket) ; bones, glenoid fossa of scapula, head of humerus ; ligament, capsular, which is intimately blended with tendons of insertion of sub- scapularis, supraspinatus, infraspinatus and teres minor muscles ; tendon of long head of biceps passes within capsule over humeral head, and is surrounded by synovial mem- brane ; movements, flexion, extension, abduction, adduction, rotation and circumduction. Describe the superior maxillary bone. Consists of body and nasal, alveolar, palatal, and malar processes. Body is irregularly cuboidal, contains cavity called maxil- lary sinus (antrum of Highmore), which is lined with mucous membrane in recent state ; its external surface pres- ents eminences corresponding to roots of teeth, also incisive fossa, near median line, and canine fossa, to outer side of canine eminence ; above canine fossa is infra-orbital foramen, the termination of infra-orbital canal which traverses orbital surface ; posterior, or zygomatic, surface is convex and forms part of zygomatic fossa ; it presents orifices of posterior dental canals, for dental vessels and nerves ; internal surface is ir- regular, contains turbinated crest for articulation of inferior turbinated bone, groove for naso-lachrymal duct and helps to form outer wall of nasal meati. Maxillary sinus (antrum of Highmore) is large, pyramidal, has thin walls, opens into middle meatus of nose by aperture which is narrowed by articulating with ethmoid above, in- ferior turbinated below and palate bone behind. Nasal process projects upward, forming lateral wall of nose, articulating with nasal, frontal and lachrymal bones; alveolar process is thick, spongy and contains alveoli (8 in number) for teeth; malar process is thick, rough and ser- rated for articulation with malar bone ; palate process is di- 428 ANATOMY. rected horizontally inward and articulates with fellow of opposite bone and with palate bone behind; its superior sur- face is smooth and slightly concave from side to side, form- ing floor of nasal chamber, and rough beneath, where it con- stitutes roof of mouth; at anterior end of it is to be found anterior palatine canal, situated in median line. Give origin, insertion, action and nerve supply of the omo=hyoid muscle. Origin from superior border of scapula and occasionally from suprascapular ligament; insertion into body of hyoid bone; beneath sterno-mastoid it develops a central tendon which is held down to 1st rib and clavicle by a process of deep cervical fascia; action, to depress hyoid bone and to support soft parts of neck during prolonged or difficult in- spiratory efforts by making tense the cervical fascia; nerve supply, cervical nerves through descendens and communi- cans hypoglossi. Give the origin, insertion, action and nerve supply of the genio=hyo=glossus muscle. Origin, superior genial tubercle of mandible ; insertion, into deep part of tongue close to median septum, or raphe, from tip to base, and into body of hyoid bone ; action, to protrude base and retract tip, and to make tongue concave trans- versely; nerve, hypoglossal. Describe the superior thyroid artery. Branch of external carotid formed just above thyroid carti- lage, curves inward and downward, giving off hyoid, mus- cular, superior laryngeal, crico-thyroid and glandular branches to interior and exterior of larynx and to thyroid gland. Describe the mylo=hyoid nerve. Is a branch of inferior dental nerve given off just as the latter is about to enter inferior dental canal ; mylo-hyoid nerve passes forward and downward in groove on inner surface of body of mandible, and supplies mylo-hyoid and anterior belly of digastric muscles. ANATOMY. 429 Describe the os planum. Is a smooth, horizontally oblong plate of bone forming outer boundary of lateral mass of ethmoid and part of inner wall of orbit; it articulates with frontal above, lachrymal anteriorly, maxilla below and with sphenoid and palate bone posteriorly. Mention the number of points of ossification of the in- ferior maxillary bone, and describe its development. Five centers of ossification. Is developed chiefly in membrane, but partly from cartilage, ossification commencing earlier than in any other bone except clavicle. Most of the bone is formed from center of ossifica- tion which appears between 5th and 6th week in membrane on outer surface of Meckel 's cartilage ; 2d center appears on in- ner surface of Meckel's cartilage and develops into inner wall of teeth sockets ; anterior extremity of Meckel 's cartilage ossifies and forms body of jaw ; separate centers appear in con- dyle, coronoid process and angle. At birth mandible con- sists of 2 halves united by a fibrous symphysis, which ossi- fies during 1st year. Give origin, insertion, action and nerve supply of di» gastric muscle. Origin, posterior belly from digastric groove on under sur- face of mastoid portion of temporal, anterior belly from inner surface of mandible near symphysis; posterior belly extends downward and forward, anterior belly extends downward and backward, both to be inserted into a central tendon which perforates tendon of insertion of stylo-hyoid and is held to hyoid bone by fibrous loop. Action, raises tongue, in deg- lutition, and when hyoid bone is fixed by its depressors the digastric will depress lower jaw. Nerve supply: anterior belly by mylo-hyoid branch of inferior dental, posterior belly by facial nerve. Mention the muscles of mastication and give their origin and insertion. Temporal: origin, from temporal fossa between temporal 430 ANATOMY. ridge above and pterygoid ridge below, and from external angular process of frontal to mastoid process of temporal, also from inner surface of temporal fascia ; into coronoid pro- cess of mandible. External pterygoid : origin, by two heads, upper from under surface of great wing of sphenoid, lower from outer surface of external pterygoid plate; insertion into neck of condyle of mandible and interarticular fibro-cartilage of temporo-man- dibular joint. Internal pterygoid : origin, from pterygoid fossa ; inser- tion into inner surface of angle and ramus of mandible as high as dental foramen. Masseter: origin, from malar process of maxilla and lower border and inner surface of zygomatic arch; insertion into external surface of ramus of mandible. Mention the muscles attached to the hyoid bone. Genio-hyo-glossus, genio-hyoid, mylo-hyoid, stylo-hyoid, aponeurosis of digastric, hyo-glossus, middle constrictor of pharynx, sterno-hyoid, thyro-hyoid, omo-hyoid. Describe the aorta. Springs from left ventricle, anteriorly, extends upward to upper border of right 2d costal cartilage, then arches backward to left and descends through thorax, resting upon vertebral bodies, passes through aortic opening in diaphragm and courses through abdominal cavity as far as body of 4th lumbar vertebra. Branches are 2 coronary from ascending portion ; innomin- ate, left common carotid and left subclavian from arch ; bron- chial, intercostal, pericardiac, esophageal and posterior medi- astinal from thoracic portion ; 2 phrenic, lumbar, sacra media (parietal branches), coeliac axis (gastric, hepatic, splenic), superior mesenteric, inferior mesenteric (single branches from front), suprarenal, renal, spermatic (or ovarian) (lateral paired branches) from abdominal portion. Describe the superior vena cava. Is formed by union of right and left innominate (jugulo- ANATOMY. 431 cephaHc) ceins, just below cartilage of 1st rib (close to right border of sternum; is nearly 3 inches long and ter- minates in right auricle; it receives vena azygos major. Describe the fissure of Rolando. It is boundary line between frontal and parietal lobes of brain, extending from point at or near great longitudinal fissure just behind midpoint between anterior and posterior poles of cerebrum, downward and forward at angle of 67° with the sagittal axis, for a distance of 3% inches. Ascend- ing frontal convolution forms its anterior wall, and ascend- ing parietal convolution its posterior wall. Describe the inferior maxillary nerve. Motor root of 5th cranial unites with 3d branch of Gasserian ganglion to pass through foramen ovale, then to divide into an anterior and a posterior trunk • anterior, smaller and mostly motor, is distributed to muscles of mastication; posterior, mostly sensory, divides into auriculotemporal, lingual and inferior dental. Mention the muscles attached to the sphenoid bone. Temporal, external pterygoid, internal pterygoid, superior constrictor, tensor palati, levator palpebrae superioris, su- perior, inferior, internal and external recti, and superior oblique. Describe the Vidian nerve. Begins in cartilage filling up middle lacerated foramen by union of large superficial petrosal (branch of facial) with large deep petrosal (from carotid plexus), passes forward through Vidian canal to enter spheno-maxillary fossa, here joining Meckel's ganglion. Mention the branches of the occipital artery. Muscular, sterno-mastoid, auricular, meningeal and arteria princeps cervicis. Describe the palato=glossus muscle. Give origin, in- sertion and nerve supply. Origin, anterior surface of soft palate close to uvula; in- 432 ANATOMY. sertion, into side and substance of tongue; action, to con- strict fauces and retract tongue; nerve supply, branch of spinal accessory. Describe the internal jugular vein. Is formed just below jugular foramen by lateral and in- ferior petrosal sinuses; courses down neck beneath anterior border of sterno-mastoid muscle in a common sheath with in- ternal carotid (above), common carotid (below), and pneu- mogastric nerve, the latter behind and between, and the artery to the inner side of the vein, which partially overlaps the artery. Behind sternal end of clavicle it unites with sub- clavian to form innominate vein. Its tributaries are facial, lingual, pharyngeal, superior and middle thyroid veins and sometimes the occipital vein. What muscles control the soft palate? Tensor palati and levator palati, azygos uvulae, palato- glossus and palato-pharyngeus. What are the terminal branches of the external carotid artery? Superficial temporal and internal maxillary. Describe the maxillary sinus (or antrum of Highmore). Is a triangular cavity contained in body of maxilla, lined with mucous membrane and communicating with middle meatus of nose through one or two small openings; apex of cavity is formed by malar process of maxilla; base is formed by outer wall of nose; in its posterior wall are posterior dental canals for posterior dental vessels and nerves to the teeth ; in floor are usually seen several elevations, correspond- ing to roots of 1st and 2d molar teeth. What forms the circle of Willis? The 2 internal carotids, 2 anterior cerebrals connected by anterior communicating, 2 posterior communicating and 2 posterior cerebrals. ANATOMY. 433 Describe the gustatory (lingual) nerve. Is a branch of posterior trunk of mandibular division of 5th cranial, lying deeply placed beneath external pterygoid muscle where it is joined by chorda tympani nerve from facial; it takes a deep course until it gets beneath mucous membrane of floor of mouth, where it is distributed to papillae and mucous membrane of anterior % of tongue. What are the articulations of the malar bone? With 4 bones : frontal, sphenoid, temporal and maxilla. Name articulations of the occipital bone. With 6 bones: two temporal, two parietal, sphenoid and atlas. Describe the inferior dental artery and name its branches. Is a branch of the 1st division of the internal maxillary artery, passing into inferior dental canal at dental foramen, accompanied by inferior dental nerve, coursing along inferior dental canal to mental foramen, opposite 1st bicuspid tooth, where it divides into an incisor and a mental branch. The former remains within the jaw to supply the anterior teeth, anastomosing at symphysis with the incisor branch of the opposite side, while the latter escapes at the mental foramen to supply chin structures. Branches are : lingual, accompanying lingual nerve to mucous membrane of floor of mouth ; mylo-hyoid, accompany- ing mylo-hyoid nerve to mylo-hyoid muscle; branches which enter pulp cavities at apices of roots; terminal branches, incisor and mental. What artery supplies the tongue with blood? Lingual. (The principal one). Name the articulations of the temporal bone. Occipital, parietal, sphenoid, malar and mandible. 28 434 ANATOMY. Name the muscles of the tongue and their attachments. Intrinsic: divisions of lingualis. Extrinsic: genio-hyo- glossus, hyo-glossus, stylo-glossus, palato-glossus. Lingualis consists of superior lingualis (longitudinal fibers), transverse lingualis, inferior lingualis and vertical lingualis. These bundles and strata of muscular fibers intersect each other, being attached to under surface of mucous membrane and to raphe. Genio-hyo-glossus, origin superior genial tubercle; inser- tion deep surface of tongue and body of hyoid bone. Hyo- glossus, origin body, greater and lesser eornua of hyoid; in- sertion side of tongue. Stylo-glossus, origin styloid process; insertion side of tongue. Palato-glossus, origin anterior sur- face of soft palate ; insertion side of tongue. Describe the lingual artery and give its branches. Is a branch of external carotid, formed near greater cornu of hyoid bone, runs in curved manner forward to beneath hyo-glossus muscle, then in tortuous course to tip of tongue under name of ranine artery. Branches are, hyoid, dorsalis linguae, sublingual, ranine. Describe the occipito=frontalis. Arises from outer % of superior curved line of occipital bone and from mastoid bone as posterior belly which blends with centrally placed aponeurosis on vertex, which is con- tinued forward into anterior belly, the latter being united to the orbicularis palpebrarum, corrugator supercilii and pyramidalis nasi. Action, to raise brows, produce transverse wrinkles of forehead and move scalp backward and forward. What muscles control the eye? Superior, inferior, internal and external recti ; superior and inferior oblique. Which artery is the longer, the external or the in- ternal carotid? Internal carotid. ANATOMY. 435 Mention the muscles of the pharynx. Superior, middle and inferior constrictors (2 each), palato- pharyngeus and stylo-pharyngeus. Describe (a) facial vein, (b) the internal maxillary vein. Facial vein begins by an anastomosis with angular vein near inner canthus, passes downward and outward diagonally across face, turns over body of mandible in front of masseter muscle and unites with branch from temporo-maxillary vein to form common facial, this, in turn, emptying into internal jugular. Internal maxillary vein accompanies artery of the same name, receiving tributaries which correspond to branches of the artery, and communicating freely with facial vein and cavernous sinus (through foramen ovale and middle lacer- ated foramen) . Internal maxillary vein then unites with tem- poral vein, forming temporo-maxillary vein. Give the branches of the external carotid artery. Ascending pharyngeal, superior thyroid, lingual, facial, posterior auricular, occipital, temporal and internal maxillary. What muscles have their origin from the styloid process? Stylo-glossus, stylo-hyoid, stylo-pharyngeus. Give the origin and insertion of the sterno=mastoid muscle. Origin, by 2 heads, one from inner third of superior border of clavicle, the other from front of manubrium sterni; in- sertion into mastoid process and outer y 2 of superior curved line of occipital bone. Describe the tensor palati. Origin from scaphoid fossa of sphenoid and margin of Eustachian tube, extends downward, has tendon which hooks round hamular process of internal pterygoid plate, then to be inserted into aponeurosis of soft palate and into hori- zontal portion of palate bone. 436 ANATOMY. What bones articulate with the vomer? Sphenoid, ethmoid, 2 palate, 2 maxillae. Describe the sphenoidal fissure. Is located between orbital and cranial cavities, a triangu- lar gap between the greater and lesser wings of sphenoid bone. Its inner end is broad and rounded, its outer, narrow and pointed; its long axis extends outward, forward and upward. It transmits the 3d, 4th, the 3 branches of the ophthalmic division of the 5th cranial nerves, and the oph- thalmic vein. Describe the glenoid fossa. Is found upon under surface of temporal bone behind arti- culating eminence and in front of tympanic plate; is crossed by Glaserian fissure; posterior part receives upper end of parotid gland and anterior part receives condyle of mandible. What nerve and artery pass through the foramen ovale of the sphenoid bone? Mandibular division of 5th cranial; small meningeal branch of internal maxillary artery. Mention the muscles attached to the inferior maxillary bone. Fif ten pairs : levator menti, depressor labii inferioris, de- pressor anguli oris, platysma myoides, buccinator, masseter, orbicularis oris, genio-hyo-glossus, genio-hyoid, mylo-hyoid, digastric, superior constrictor, temporal, internal and external pterygoids. Mention the principal veins of the head and neck. Frontal, angular, facial, internal maxillary, temporo-maxil- lary, ophthalmic ; superior longitudinal, inferior longitudinal, straight, lateral, occipital, superior and inferior petrosal, transverse, circular and cavernous sinuses; external, anterior and internal jugular and vertebral veins. K ANATOMY. 437 What muscles are attached to the basilar process of the occipital bone? Rectus capitis anticus major and minor, and superior con- strictor of pharynx. Give the boundary of the anterior triangle of the neck. Is bounded anteriorly by line extending* from chin to sternum ; behind by anterior margin of sterno-mastoid muscle ; above by lower border of body of mandible and line extended posteriorly to mastoid process. Mention the muscles attached to the outer surface of the malar bone. Levator labii superioris, zygomaticus major and minor. Describe the sigmoid notch. Situated between condyle and coronoid process of mandi- ble; transmits masseteric vessels and nerves. Mention the branches of the maxillary portion of the internal maxillary artery. Tympanic, middle meningeal, small meningeal and inferior dental. Mention the branches of the posterior auricular artery. Stylo-mastoid, auricular, mastoid. Give the branches of the internal maxillary artery. From the maxillary portion : tympanic, middle meningeal, small meningeal, inferior dental. From the pterygoid por- tion : deep temporal, buccal, pterygoid, masseteric. From the spheno-maxillary portion: alveolar, infra-orbital, de- scending palatine, vidian, ptery go-palatine, sphenopalatine. Describe the Gasserian ganglion. Is developed upon the sensory root of the 5th cranial nerve, and is located in a depression on the petrous bone near its apex, cranial surface. From its anterior margin 3 divisions, the ophthalmic, maxillary and mandibular pass through the sphenoidal fissure, the foramen rotundum and the foramen 438 ANATOMY. ovale, respectively. The motor root of this nerve rests upon the petrous bone beneath the sensory root, uniting with the mandibular division after it has passed through the fora- men ovale. Give the origin and insertion of the sternothyroid muscle. From the manubrium sterni and the cartilage of the 1st rib, into the oblique ridge of the thyroid cartilage. Describe the mylo=hyoid muscle, giving its origin and insertion. It forms, with the opposite mylo-hyoid, the floor of the mouth. Origin, is from the mylo-hyoid ridge of the mandible ; insertion, into the body of the hyoid bone, meeting its fellow in a median raphe. Nerve, mylo-hyoid, a branch of inferior dental; action, to carry tongue upward and forward. Mention the orbital branches of the ophthalmic artery. Lachrymal, muscular, anterior and posterior ethmoidal, supra-orbital, frontal and nasal. Describe the temporal fossa. Is bounded above by temporal ridge, below by pterygoid ridge on great wing of sphenoid and extends from external angular process of frontal to a point above mastoid bone. It is formed by parts of five bones : sphenoid, frontal, temporal, parietal and malar. It gives origin to the temporal muscle. Describe the great wing of the sphenoid bone. A large, strong process, extending from the side of the body of the sphenoid outward, forward, upward and back- ward, and continued behind into a sharp, pointed extremity, its spinous process, which contains the foramen spinosum, transmitting the middle meningeal artery. Its upper surface is concave for the temporal lobe of the cerebrum; its external surface forms part of temporal and of zygomatic fossae, which are separated by the pterygoid ridge. The greater wing ANATOMY. 439 presents 2 important foramina, viz., foramen ovale and fora- men rotundum; it forms the lower margin of the sphenoidal fissure and the upper boundary of the spheno-maxillary fissure. Give the course and distribution of the arteries and nerves which supply the upper alveolar arch. Arterial supply is derived from alveolar or posterior dental branch of internal maxillary, which sends branches into pos- terior dental canals to supply molar and bicuspid teeth and lining of antrum ; also from anterior dental branches of infra- orbital, which descend through anterior dental canals in wall of maxilla to be distributed to incisor and canine teeth. Nerve supply comes from posterior superior dental branches of superior maxillary division of the 5th cranial, which enter posterior dental canals, to be distributed to posterior teeth and to communicate with middle superior dental branch of superior maxillary nerve which passes down through special canal in outer wall of antrum, and with anterior superior dental nerve, another branch of superior maxillary nerve which enters a canal in anterior wall of antrum, these branches supplying the teeth in their respective regions. Describe the lesser wings of the sphenoid bone. They rise from the anterior superior surface of the sphenoidal body to which they are attached by 2 roots enclosing the optic foramen, which transmits the optic nerve and oph- thalmic artery. The superior surface is smooth and flat, broad internally and tapering to a point externally, and sup- ports part of the frontal lobe of the brain. The under sur- face forms the upper boundary of the sphenoidal fissure, and the posterior border is received by the fissure of Sylvius. Describe the palatine surface of the superior maxillary bone. Is formed by the palate process which projects horizontally inward to articulate with palate process of the opposite bone, and with palate bone posteriorly. Tts inferior surface is 440 ANATOMY. slightly concave and rough for muco-periosteal covering of roof of mouth. When both superior maxillary bones are arti- culated, a large orifice, the anterior palatine canal, is formed just behind the incisor teeth in the median line. On the un- der surface of the palate process may sometimes be seen the intermaxillary suture, extending from the anterior pala- tine foramen to between the lateral incisor and canine tooth. This indicates the line of union between the maxilla and the intermaxillary, (premaxillary, or incisive) bone. Describe the submaxillary triangle. Is bounded, above, by lower border of body of mandible and a line drawn from its angle to the mastoid process; below by the posterior belly of the digastric; in front by the median line. Its floor is formed by mylo-hyoid and hyo-glossus muscles. It contains the submaxillary gland, facial artery and vein, submental artery and mylo-hyoid artery and nerve ; more posteriorly is the external carotid artery; more deeply are the internal carotid artery, internal jugular vein and the pneumogastric nerve. Describe the middle cerebral artery. Is a branch of the internal carotid, given off at the an- terior perforated space, and courses outward, upward and backward in the fissure of Sylvius. Its branches are : Antero- lateral ganglionic, (including the lenticulo-striate) inferior external frontal, ascending frontal, ascending parietal, parieto- temporal. Mention the facial branches of the facial artery. Muscular, inferior labial, superior and inferior coronary, lateral nasal and angular. Describe the lateral sinuses. Right and left lateral sinuses commence at internal occipi- tal protuberance, right being formed by superior longitudinal sinus, left by straight sinus; are located in attached margin of tentorium and groove of occipital, of parietal, of mastoid and then of occipital bone, again leaving cranial cavity through ANATOMY. 441 jugular foramen, just outside of which they unite with inferior petrosal sinus to form internal jugular vein. Mention the muscles attached to the superior maxil- lary bone. Twelve: orbicularis palpebrarum, levator labii superioris alaeque nasi, inferior oblique, levator labii superioris, levator anguli oris, compressor naris, depressor alae nasi, dilatator naris posterior, orbicularis oris, buccinator, masseter and in- ternal pterygoid. Describe the supraorbital artery. Is a branch of ophthalmic artery, passes forward between levator palpebrae and periosteum of orbital roof to supra- orbital foramen, where it appears on external surface of frontal bone and divides into superficial and deep branches supplying integument, muscles and epicranial aponeurosis, anastomosing with temporal, frontal and opposite supra- orbital. Mention the vessels and nerves that supply the sub- maxillary gland. Facial artery, facial vein; nerves from submaxillary ganglion, which is formed by branches from chorda tympani, lingual and from sympathetic plexus around facial artery. Describe the Island of Reil. Also called central lobe, is deeply placed in Sylvian fissure, is of pyramidal shape and consists of 6 or 7 convolutions. State the formation and course of the inferior vena cava. Is formed on right side of 5th lumbar vertebra by union of the 2 common iliac veins. It rests upon bodies of lumbar vertebrae, lying to right of aorta, grooves posterior surface of liver, and passes through caval opening in diaphragm to terminate in right auricle. State the origin, exit, distribution and functions of the pneumogastric nerve. Superficial origin from side of medulla in groove between 442 ANATOMY. olivary and restiform bodies; exit through jugular foramen; distributed to posterior part of auricle and external auditory meatus, motor nerve to pharynx, sensory and motor to larynx, helps to form superficial (left nerve) and deep cardiac plexuses, furnishes pulmonary, oesophageal and gastric branches. Describe the cavernous sinus. So named from being traversed by interlacing filaments. Is placed on side of body of sphenoid bone and extends from sphenoidal fissure to apex of petrous bone. It receives opthal- mic vein anteriorly, terminates in petrosal sinuses posteriorly, and communicates with opposite cavernous sinus through cir- cular sinus. The following structures pass through it: 3d, 4th and ophthalmic division of 5th nerves, 6th nerve and in- ternal carotid artery. Describe the thyroid gland. It consists of right and left lobes connected by an isthmus across 2d, 3d and 4th tracheal rings; has a capsule and trabe- cule surrounding closed follicles, which contain colloid ma- terial. Arterial supply comes from superior and inferior thyroid arteries ; thyroid veins drain it. It is intimately at- tached to trachea and alae of thyroid cartilage, and rises and falls with larynx. Bound the occipital triangle. In front, by sterno-mastoid muscle; behind, by trapezius; below, by posterior belly of omo-hyoid ; apex of triangle is at occiput. Describe the outer surface of the occipital bone. Is convex, smooth above, rough below. Superior curved line extends transversely, with external occipital protuber- ance at center; from latter, external occipital crest passes downward to posterior margin of foramen magnum, and meets inferior curved line half way down. Antero-lateral mar- gins of foramen magnum are bounded on either side by occi- pital condyles, in front of which is anterior condyloid foramen, ANATOMY. 443 and behind which is posterior condyloid foramen. Under surface of basilar process is rough for muscles, and presents pharyngeal spine at its center. Margins are roughly serrated, jugular processes extend laterally. From how many centers of ossification is the temporal bone developed? Ten. What is an aponeurosis? It is a more or less broad, flat sheet of fibrous tissue to which muscular fibers are attached, serving as a tendon of insertion for these fibers. Describe the horizontal plate of the palate bone. Is quadrilateral and presents 2 surfaces and 4 borders. Superior surface is smooth and slightly concave from side to side, forming posterior floor of nose; inferior surface is rough, forms posterior part of roof of mouth, and at outer, posterior angle is deeply grooved to help form posterior palatine canal. Anterior border is serrated to articulate with palate process of superior maxillary bone; posterior border is smooth, concave, and gives attachment to soft palate ; in- ternal border is thick and serrated for articulation with op- posite horizontal plate; external border joins perpendicular part of palate bone. What are the bones of Bertin? The sphenoidal turbinals, 2 in number, hollow, pyramidal, attached to anterior surface of body of sphenoid, near ros- trum; they form the roof of each nasal cavity and a small part of the inner wall of the spheno-maxillary fossa. Define veins, arteries, lymphatics. Veins are tubular parts of the blood-vascular system carry- ing venous blood from all parts of the body toward the right auricle, or arterial blood from the lungs toward the left auricle; their walls are thin and their tunica intima forms reduplications, or valves, in some veins. 444 ANATOMY. Arteries are vessels carrying blood away from the heart, — arterial in all cases except in the pulmonary artery, where the blood is venous, en route to the lungs; the wall of the artery is relatively thick. Lymphatics are vessels which convey lymph from all parts of body to venous circulation at base of neck, on each side; lymphatics of mesentery are called lacteals. Describe the ophthalmic vein. There are 2 ophthalmic veins, superior and inferior. Su- perior ophthalmic vein connects angular vein at inner angle of orbit with cavernous sinus; it takes the same course as the ophthalmic artery, receiving tributaries from upper or- bital contents. The inferior ophthalmic vein drains the floor of the orbit, passing through spheno-maxillary fissure to end in pterygoid plexus of veins, or through sphenoidal fissure to terminate in cavernous sinus. Mention the branches of the inferior thyroid artery. Inferior laryngeal, tracheal, esophageal, ascending cervical, muscular. Give the articulations of the ethmoid bone. With 15 : sphenoid, 2 sphenoidal turbinated, frontal, 2 superior maxillary, 2 lachrymal, 2 nasal, 2 palate, 2 inferior turbinated, and vomer. Describe the medulla oblongata. Is a part of encephalon, continuous with spinal cord be- low and with pons above; it rests upon basilar process of occipital bone, consists of white nerve matter externally and gray matter arranged irregularly, internally, the latter ap- pearing upon the surface in floor of 4th ventricle, the lower half of which is formed by medulla; upon ventral surface is anterior median fissure, partially obliterated below by de- cussation of crossed pyramidable tracts; near anterior part of inferior surface are olivary bodies; posterior columns di- verge to form calamus scriptorius and to bound 4th ven- tricle laterally for its lower half; postero-laterally are resti- ANATOMY. 445 form bodies which can be traced upward into cerebellum, forming inferior peduncles of latter. Cranial nerves from 7th to 11th inclusive arise from side of medulla, while 12th appears upon surface in groove between olivary body and anterior pyramid. Give the articulations of the lachrymal bones. With 4 bones : frontal, ethmoid, superior maxillary and in- ferior turbinated. Mention the muscles and ligaments attached to the ramus of the jaw. Masseter, temporal, external and internal pterygoids; liga- ments are capsular (external lateral), internal lateral (spheno-mandibular), and stylo-mandibular. Mention the vessels and nerves supplying the parotid gland. Arteries are derived from external carotid; veins, tribu- taries to external jugular; lymphatics terminate in super- ficial and deep cervical nodes; nerves are derived from facial, auriculotemporal, great auricular, and sympathetic plexus on external carotid artery. Describe the 9th (glosso=pharyngeal) nerve. Arises from groove between olivary and restiform bodies, passes out of cranial cavity through jugular foramen, divides into lingual and pharyngeal branches, supplying mucous membrane of posterior part of tongue (circumvallate papillae) and mucous membrane of pharynx. A branch (Jacobson's) is distributed to tympanum. Describe briefly the 5th nerve. Superficial origin of both motor and sensory roots is from pons near anterior margin; Gasserian ganglion develops on sensory root and rests on apex of petrous bone, now forming 3 divisions, ophthalmic, maxillary and mandibular ; ophthalmic division divides into frontal, nasal and lachrymal branches, which leave cranial cavity by sphenoidal fissure; maxillary 446 ANATOMY. division leaves cranial cavity by foramen rotundum, crosses spheno-maxillary fossa, enters orbit, terminating as infra- orbital nerve ; mandibular division and motor root leave cran- ial cavity by foramen ovale, unite and then divide to supply muscles of mastication with motor influence, and anterior part of auricle, lower jaw and part of tongue with sensory influence. Give a general description of the alimentary canal, nam= ing its successive divisions. Its parts, in order, are : mouth, pharynx, esophagus, cheek walls, with buccal orifice directed transversely; con- intestine (caecum, ascending, transverse, descending and sig- moid colons, rectum, and anal canal). Mouth is composed of upper and lower jaws covered by cheek walls, with buccal orifice directed transvelsely ; con- tains tongue, at base of which are fauces with anterior and posterior pillars and tonsils. Pharynx joins esophagus at lower border of cricoid carti- lage; esophagus is 10 inches long and passes through dia- phragm to be continued into stomach. Stomach occupies epigastric and left hypochondriac re- gions and presents a cardiac and a pyloric extremity and a greater and a lesser curvature. Its wall consists of 4 coats, viz., serous, muscular, areolar and mucous. Duodenum is fixed and curved around head of pancreas; common bile and pancreatic ducts open into it; jejuno-ileum, attached to posterior abdominal wall by mesentery, extends for 20 feet, or more, to ileo-caecal junction, where it joins large intestine; vermiform appendix is attached to caecum (usually inner side), below ileo-caecal valve; ascending colon passes to liver, forms hepatic flexure; transverse colon, with great omentum attached, crosses to spleen and forms splenic flexure; descending colon reaches left iliac fossa and is con- tinued into sigmoid which curves around into pelvis, resting on sacrum; rectum curves forward and anal canal, guarded by internal (involuntary) and external (voluntary) sphinc- ters, opens downward and slightly backward. ANATOMY. 447 Give the origin, course and distribution of the great sciatic nerve. Origin from lower lumbar and upper sacral nerves (sacral plexus) ; course, through great sacro-sciatic foramen below pyriformis muscle, from beneath lower margin of gluteus maximus midway between trochanter major and tuber ischii, rests upon adductor magnus and divides about middle of thigh into internal and external popliteal nerves; it supplies semitendinosus, semimembranosus, adductor magnus and biceps. Internal popliteal is continued down leg as posterior tibial, distributed to back of leg and sole of foot; external popliteal curves around below head of fibula to front of leg, becoming anterior tibial to front of leg and dorsum of foot. Describe the anatomical position of the thoracic duct, (b) Where does it terminate? (c) What does it convey? Thoracic duct begins in receptaculum chyli on body of 2d lumbar vertebra, to right of aorta, passes through aortic opening of diaphragm into posterior mediastinum, (b) It terminates at junction of left internal jugular and left sub- clavian veins, (c) It conveys lymph and chyle. Give the origin, insertion and nerve supply of the stylo- glossus muscle. Origin, from styloid process of temporal bone; insertion into side of tongue; nerve, hypoglossal. Bound the superior carotid triangle. Behind, by sterno-mastoid ; below, by anterior belly of omo- hyoid ; above, by posterior belly of digastric. INDEX. Abrasion of the teeth, 7, 196 Abscess, 131, 173, 179 Alveolar, 28,117, 165,195, 198 Apical alveolar, 188 Blind, 28 Chronic alveolar, 156 Pericemental, 27, 120 of temporary teeth, 196 Abscessed deciduous tooth, 33 Absorption, 257 of food, 369 Accidents in extracting teeth, 31 Acids, 265 Aconite, 207, 209, 245 Acquired cleft palate, 146 Acute arthritis, 166 periostitis, 163 ranula, 101 Adhesion, 254 Adipose tissue, 323 Aerobic bacteria, 185 Afferent nerves, 375 Alcohol, 291, 370, 374, 400 Alimentary canal, 446 Alkali, 270 Alkalies in dentistry, 213 Alkaline, 251 Alkaloids, 270, 290, 292 Alloys, 298 Alteratives, 238 Aluminum, 314 in dentistry, 59 solder, 60 Alveolar abscess, 117, 156, 165, 195, 198 arch, 439 dental abscess, 28 process, 365 Cysts of, 186 Necrosis of, 153 Amalgam, 294, 300, 313 and cement filling, 17 copper, 311 fillings, 9 Amalgamation process, 307 Ameloblasts, 329, 348 Amianth, 315 Ammonia, 281 Amputation of the root, 28 Amyl nitrite, 210, 239 Amyloid foods, 363 Anaerobic bacteria, 185 Analgesic, 232 Analysis, 265, 269, 288 Analytical chemistry, 274 Anatomy, 413 morbid, 188 Anchorage for gold fillings, 13 Anemia, 184 Anesthesia, 97, 125 Anesthetics, 232 General, 210 Local, 130, 219, 242 Aneurysm, 173 Angle method, 87, 169 Anhydride, 250 Anhydrous, 250 Animal life, 273 Ankylosis, 119 False, 136 Annealing, 296 Anode, 257 Anterior cervical triangle, 437 Antidote, chemical, 226 Antimony, Test for, 302 Antiphlogistic, 215 Antipyretics, 237 Antisepsis, 180 Antiseptics, 201, 211 Antitoxin, 181 Antral disease, 112 Antrum, Empyema of, 127, 150 Antrum, Tumors of, 126 Aorta, 430 Aphthae, 116 Aphthous stomatitis, 116 Apical alveolar abscess, 188 Aponeurosis, 443 Approximal cavities, 4 Aqua regia, 284 Aqueous solutions, 215 29 (449) 450 INDEX. Arrested development of maxillae, 169 Arsenic, 23. 148, 203, 208, 245, 246, 301 necrosis, 120 Arsenious acid, 214, 215 Arterial hemorrhage, 98 Arteries, 344, 365, 378, 444 Wounds of, 138 Arthritis, 136 Acute, 166 Articular cartilage, 345 Articulation, Temporo- maxillary, 110 Artificial crowns, 19 dentine, 51 respiration, 148 direct method, 122 teeth, 44 velum, 89 Asbestos, 315 Asepsis, 172, 180 Aseptic wounds, 141, 166 Asepticism of cavities, 8 Asphyxia, 137 Mechanical, 108 Assay, 287 Assimilation, 368 Astringents, 238 Atmospheric air, 282, 407, 408 Atom, 269 Atomic weight, 269, 270 Atrophy, 179 Atropine poisoning, 227 Avogadro's law, 263 Axis cylinder, 340 process, 337 Babbitt metal, 58 Bacilli, 185 Bacteria, 176, 180, 183, 184, 185, 199, 201 Diseases due to, 186 Parasitic, 194 Pathogenic, 175, 181,190 Saprophytic, 204 Bacterial cell, 174 Bandage, Barton's, 133 Bandage, Four-tailed, 134 Bandage, Gibson's, 139 Banded Logan Crown, 72 Barton's bandage, 133 Base, Celluloid, 56 metal, 297 Base plate, 44 Vulcanite, 51 Bathing, 368, 397 Belladonna, 227 Benign tumors, 175, 178 Bertin 's bones, 443 Bicuspid crown, 75 jacket crown, 75 Bile, 361 Bioplasm, 344 Blackening of gold fillings, 15 Blastoderm, 342 Bleaching, 284 of the teeth, 26 Blind abscess, 28 Blood, 340, 362, 371 -plasma, 386 -platelets, 317 Blowpipe, Knapp, 93 Blue vitriol, 285 Body-temperature, 359, 361 Bone, 287, 335, 347, 366 Bonwill articulator, 92 crown, 74 Bony consolidation after fracture, 95 Bridges, 19 Bridge, Removable, 83 -work, 81 Bromine, 278 Brophy's operation, 151 Brown's porcelain bridge, 85 Buccal cavity, Carcinoma of, 157 Buccinator, 417 Biittner crown, 80 Bunsen burner, 253 Burs, 3 Cachexia, 183 Calcification, 351 of teeth, 340 Calculus, Salivary, 37, 138, 146, 165, 189, 201 Sanguinary, 37, 191 Serumal, 191 Callus, Definitive, 178 Intermediate, 178 Provisional, 177 Calomel, 312 Canal, Pulp, 24 Root, 24 Canaliculi, 347 Cancrum oris, 116 Candle flame, 252 Cap, Gold, 77 .-■•■< INDEX. 451 Capillaries, 352, 365, 378 Capillary attraction, 257 Capping of pulp, 22, 194 Capsicum, 217 Carat, 304 Carbolic acid, 126, 209, 241 poisoning, 225 Carbon, 279 dioxide, 280 Carcinoma, 17z, 176, 182 of buccal cavity, 157 tongue, 96, 159 Carcinomatous ulcer, 190 Care of teeth in children, 35 Caries, 143, 204 Dental, 1, 195, 199 fungosa, 164 necrotica, 164 of maxillse, 163 sicca, 163 suppurativa, 163 Cartilage, 323, 327, 351 Case's appliance, 88 retainer, 88 Casein, 375 Cast-iron, 309 Cataphoresis, 225, 233 Cataphoric applications, 211 Catarrhal inflammation, 177 Cathartics, 221 , 237 saline, 244 Cathode, 258 Causes of disease, 185 Cavernous sinus, 442 Cavities, Approximal, 4 Asepticism of, 8 Cervical, 5 Excavation of, 3 Formation of, 2 Preparation of, 2 Protectk Cavity-margins, 3 Cell, 334 Bacterial, 174 Cellulitis, 167 Suppurative, 100 Celluloid, 57 base, 56 Cement, 9 Cementoblasts, 346 Cementum, 333 Centers of ossification, 326 Cerebellum, 414 Cerebrospinal axis, 358 Cerebrum, 363 Cervical cavities, 5 Chemical affinity, 273 antidote, 226 composition of muscle, 385 compound, 271, 274 equation, 266 reaction, 266 Chemistry, 249 Cheoplastic process, 57 Chlorine, 278 Chloroform, 218, 223, 230, 232, 245, 290 Syncope under, 160 Chromogenic bacteria, 184 Chronic alveolar abscess, 156 inflammation, 148 Cilia, 318 Cinnabar, 311 Circle of Willis, 432 Circuit, 258 Circulation of the blood, 355 Circulatory apparatus, 377 Clasp gold, 67 Cleansing the teeth, 39 Cleaveland vacuum-cavity, 46 Cleft palate, 89, 111, 145, 151, 178 Acquired, 146 Operation in, 95 Cocaine, 220, 222, 239, 247 poisoning, 225 Cocci, 185 Cohesion, 253 Cohesive gold, 12 Cold bath, 396 inflammation, 95 Collapse, 225, 247 Color of teeth, 26 Columnar epithelium, 322 Columns of the spinal cord, 387 Combination fillings, 15 Combined gold fillings, 14 Combustion, 275 Compact bone, 339 Compound, 267, 272 fracture of inferior maxilla, 114, 161 molecule, 271 Conductors of electricity, 255 Congenital dislocation, 139 Congested pulp, 20 Connective tissue, 319, 321, 383, 337, 352, 413 Contamination of drinking-water, 391 452 INDEX. Continuous gum denture, 68 Contused wounds, 96 Copper, 298 amalgam, 311 sulphate, 243 Cores, 58 Corrosive sublimate, 312 Cottonoid, 5 Counter-die, 58 -irritants, 207 Countersunk-pin Teeth, 48 Cremation, 399 Creasote, 216, 241 Crib, Jackson, 86 Crooked buccal root-canals, 25 Crown, Artificial, 19 Bicuspid, 75 Bicuspid jacket, 75 Bonwill, 74 Biittner, 80 Davis, 78 Logan, 72 Mason, 76 Pin, 85 Richmond, 73 Shell, 76 Crude rubber, 49 Culture medium, 184 Cylindric epithelioma, 135 Cyon and Ludwig's nerve, 357 Cystic dilatation of Steno's duct, 106 Cysts, 131, 140 of the alveolar process, 186 Dental, 186 Dentigerous, 103, 115, 186 Multilocular, 146, 186 of the tongue, 101 Dark joints in gum teeth, 49 Davis crown, 78 Dead pulp, 24 Decay in deciduous teeth, 32 under plate clasps, 6 White, 4 Deciduous teeth, 205 Decoctions, 233 Decomposition, 174 Deep-seated dental caries, 1 Definitive callus, 178 Deglutition, 359 Deliquescence, 249 Dental calcification, 346 Dental caries, 1, 195 cysts, 186 exostosis, 198 Dental fibrillse, 350 follicle, 349 neuralgia, 20 orthopedia, 35 papilla, 348 pulp, 374 ridge, 341 shock, 6 tubuli, 331 Dentifrices, 214, 233 Dentigerous cysts. 103, 115, 186 Dentine, 292, 348 Highly inflamed, 6 Hypersensitive, 202 Secondary, 7 Dentistry, Operative, 1 Prosthetic, 41 Dentition, Pathological, 194 Deodorants, 236 Deposits on teeth, 36 Dermoid cysts, 141 Destructive distillation, 255 Devitalization of pulp, 23 of teeth, 196 Diad, 264, 272 Diagnosis, 188 Diamond, 280 Diaphoretics, 224 Diathesis, 183 Diatorii Die, 58 Diffusible stimulants, 244 Diffusion, 257 Digastric muscle, 429 Digestion, 353 Digitalis, 212, 228 Diphtheria, 401, 408 -infection, 389 Direct method of artificial respir- ation, 122 Disease, Causes of, 185 of dental pulp, 194 Diseases due to bacteria, 186 of maxillse, 176 of pericementum, 202 Disinfectants, 208, 211, 389 Disinfecting lotions, 155 Disinfection, 182, 389, 390 of hands, 129 Dislocations, 109, 138, 143 Traumatic, 121 Displacement, 130 Diuretics, 224 Double fracture of inferior max- illa, 151 Dowel, 85 INDEX. 453 Drinking - water, Contamination of, 391 Dry-earth svstem, 392 Ductility, 250 Eburnation, 8 Efferent nerves, 875 Effervescence, 250 Efflorescence, 249 Elbow-joint, 425 Elastic tissue, 338 fibrous tissue, 319 Electric current, 258 Elasticity, 250, 258 Electricity in dentistry, 39 Electrolysis, 269 Electro-magnet, 256 Electro-motive force, 258 Electroplating, 252 Element, 267, 268 Embolism, 175 Embolus, 173 Embryology, 342 Emetics, 225, 236 Empyema of the antrum, 127, 150, 216 of maxillary sinus, 179 Enamel, 292, 329, 332, 348 organ, 350 Enchondronal bone, 338 Endemic diseases, 410 Endocardium, 324 Endoneurium, 317 Endosmosis, 378 Endothelium, 352 Energy, 255 English Tube teeth, 64 Epidemic diseases, 410 Epiglottis, 365 Epineurium, 317 Epistaxis, 124 Epithelioma, 135 of the lips, 129 Epithelium, 335, 343, 344, 352 Epulic tumors, 115 Epulis, 115, 178, 197 Ergot, 228 Erosion, 132 of teeth, 7, 204, 379, 380 Eruption of Teeth, 202 Erythrocytes, 340 Escharotics, 210, 215 Essential oils, 209 Ether, 230, 233, 245 Ethmoid bone, 417 Ethyl bromide, 220, 235 chloride, 218 Ethylic alcohol, 291 Etiology, 188 Eucaine, 220 Examination of teeth, 38 Excavation of cavity, 3 Excavator points, 3 Exhumations, 397 Exosmosis, 378 Exostosis, 30, 191, 196 Dental, 198 Expansion of the upper arch, 36 Expectorants, 224 Exposed pulp, 20. 33 External fistula, 113 jugular vein, 418 of teeth, 30 of deciduous teeth, 32 of molar teeth, 104 Facial artery, Ligation of, 96 nerve, 118, 442 vein, 435 Facultative bacteria, 185 False ankylosis, 136 Farrar's System, 86 Fatty tumor, 131 Feeble pulse, 158 Fermentation, 188, 290 Lactic, 200 Fibrin, 318 Fibro-cartilage, 322 Fibrous epulis, 178 Fifth nerve, 445 Filling, Amalgam, 9 and cement, 17 Cohesive gold, 12 and non-cohe- sive gold, 14 Combination, 15 of deciduous teeth, 33 gold, 2, 11 and amalgam, 16 and cement, 16 and tin, 16 Gutta-percha, 9 and zinc phos- phate, 15 -materials, 8 Metallic. 314 Non-cohesive gold, 13 Plastic, 10 Porcelain, 18 of pulp-canals, 24 454 INDEX. Filling, Tin, 11 Fistula, 133 External, 113 Salivary, 142, 166 Fixed oils, 233 Fluid extracts, 235 Fluorine, 278 Flux, 62, 300 Food, 376, 390, 403 Force, 255 Foreign body in the nose, 154 Formaldehyde, 213, 234 -disinfection, 390 Formation of Cavities, 2 Formula, 271 Four-tailed bandage, 134 Fracture, 107, 119 of mandibular condyle, 150 of inferior maxilla, 91, 96,101,128 of superior maxilla, 128. 169 Fractures, Repair of, 186 Frequent pulse, 171 Frontal bone, 419 Function, 370 Fungi in mouth, 200 Fungoid pulp, 25, 197 Furbinger's method, 129 Galvanic cells, 251 Ganglion, 334, 385 Gangrene, 98 Gangrenous stomatitis, 116, 186 Gasserian ganglion, 437 Gastric juice, 354, 372 Gastrocnemius, 415 Gelatine plates, 175 General anesthetics, 210 pathology, 185 Genio-hyo-glossus muscle, 428 Germicides, 201 , 236 Germs, 181 Germ-theory of disease, 404 Giant cells, 326 Gibson's bandage, 139 Gingivitis, Marginal, 122 Syphilitic interstitial, 122 Glacial phosphoric acid, 288 Glenoid fossa, 436 Glossopharyngeal nerve, 445 Glottis, Obstruction of, 153 Glycogen, 382 Gold, 298 and amalgam filling, 16 bridge, 81 cap, 77 and cement filling, 16 clasps, 67 Cohesive, 12 fillings, 2, 11 Anchorage for, 13 inlays, 19 ^Ton-cohesive, 12 plate, 66 Refining of, 303 and silver plates, 60 Test for, 302 and tin filling, 16 Grain alcohol, 291 Graphite, 280 Gravitation, 254 Green stain. 33 Grenet cell, 251 Grove cell, 251 Gum-boil, 165 Gumma of mouth, 133 of tongue, 159 Gums, Hemorrhage from the, 142 Hypertrophy of, 113 Papilloma of, 126 Spongy, 120 Tumors of, 111 Gustatory nerve, 375, 433 Gutta-percha, 9 and zinc phosphate fillings, 15 Gypsum, 286 Haemo- ; see Hemo- Hammond wire splint, 107 Hands, Disinfection of, 129 Hand pressure, 17 Hard pulse, 155 water, 400 Hardening of tissues, 318 Hare-lip, 118, 149 Haversian canals, 347 system, 335 Hawes molding-flask, 58 Healing of wounds, 148, 183 Heart, 324, 366, 368 Mechanism of, 357 Valves of, 370 Heat, 146, 257 in inflammation, 167 Heating of houses, 403 Hemoglobin, 333 INDEX. 455 Hemorrhage, 109, 119, 126, 184 Arterial, 98 from the gums, 142 from inferior dental canal, 151 after lancing of gums, 111 after tooth-extrac- tion, 32, 112 Secondary, 99, 168 from tongue, 136 Hemostatics, 210 Highly inflamed dentin, 6 Highmore's antrum, 427, 432 Histology, 317, 334 House-plumbing, 390 Hutchinson's teeth, 197 Hydrate, 250 Hydrochloric acid, 222, 261 Hydrogen, 275 dioxide, 234, 277 peroxide, 210 Hydrometer, 249 Hygiene, 389 Hyoid bone, 416 Hyperemia, 184, 200, 203 of the pulp, 123 Hypersensitive dentine, 5, 202 Hypertrophy, 181 of the gums, 113 Hypnotics, 235 Hypoblast, 325 Hypoglossal nerve, 363, 378, 422 Idiosyncrasy, 207 Immunity, 410 Impacted wisdom tooth, 128 Impaction of molar, 88 Implanting, 29 Implantation of teeth, 105 Impressions, 41 Impression of cleft palate, 89 Incised wound, 143 Incisor, Approximal cavity of, 5 Incompatibility of drugs, 226 Inductive force, 258 Infectious osteomyelitis of inferior maxilla, 161 Inferior dental artery, 433 maxilla, 416, 429 Compound frac- ture of, 114,161 Fracture of, 91, 96, 101, 128 Infectious osteo- myelitis of, 161 Inferior maxilla, Luxation of, 113 Necrosis of, 161 ^Osteoma of, 99 Periostitis of ,1 24 Ununited frac- ture of, 136 maxillary nerve, 431 vena cava, 441 Inflamed periosteum, 26 Inflammation, 109, 172, 174, 193, 200, 203 Catarrhal, 177 Causes of, 187 Chronic, 148 Cold in, 95 Heat in, 167 of mouth mem- branes, 1 Pain in, 177 Suppurative, 155, 177 Swelling in, 168 Infusions, 233 Inlays, Gold, 19 Porcelain, 18 Inorganic chemistry, 274 compounds, 272 Inspiration, 382 Interglobular spaces, 348, 349 Intermediate callus. 178 Intermittent pulse, 155 Internal jugular vein, 432 maxillary vein, 435 Interpolation, 130 Intestinal digestion, 381 Intramembranous bone, 339 Investments, 84 Involuntary muscles, 363 Iodine, 208, 214, 278 ' Iodism, 224 Iodoform, 211, 234 Iridium, 301 Iron, 208 Irregular pulse, 158 Irregularity of the Teeth, 35, 166 Irritable pulp, 197 Irritants, 213, 217 Irritation of the pulp, 21 Island of Eeil, 441 Jackson crib, 86 Kelly's method, 129 Kidneys, 353 Knapp blow-pipe, 93 Knee-joint, 425 456 INDEX. Laborde's method, 148 Lacerated wounds, 96, 136 Lactic acid, 289 fermentation, 200 Lacunae, 324 Lampblack, 280 Lancing, 117 of the gums, 32 Hemorrhage after, 111 Latent heat, 257 Lateral sinuses, 440 Laughing gas, 28, 220, 231, 245, 246 Law of multiple proportions, 273 Lead, 298, 314 Leucocytes, 199. 330, 341 Leukomains, 171 Ligation of arteries, 123, 127 of facial artery, 96 of temporal artery, 97 Lingual artery, 434 carcinoma, 96 nerve. 433 Lip, Epithelioma of, 129 Liquid nitrous acid, 220 Liver, 360, 369 Local anesthesia, 130, 219 anesthetics, 208, 242 hyperemia, 184 treatment of hemorrhage, 126 Logan crown, 72 Lunar caustic, 308 Luxation of inferior maxilla, 113 Lymphatic system, 358, 377 Lymphatics,~333, 444 Macroglossia, 149 Magnets, 256 Malignant tumors. 175 Malleability, 250 Mallet pressure, 17 Mandible, 416 Marginal gingivites. 122 zone, 319 Margins, cavity. 3 Marrow, 320 Mason crown, 76 Mastication, 382 muscles of, 429 Mastoid bone, 420 Materia medica, 207, 223 Matrix, 17 Matter, 255, 268 Maxilla, fracture of, 169 Maxillae, arrested development of, 169 caries of , 163 diseases of, 176 Maxillary sinus, 427, 432 empyema of, 179 suppuration of, 106 tumor of, 106 Mechanical asphyxia, 108 Mechanism of the heart, 357 i Meckel's cartilage, 349 ! Medulla oblongata, 356, -144 Medullary substance, 340 Mercurial stomatitis, 134, 200 ! Mercuric chlorid. 194, 312 i Mercury, 310, 312 ' Mesoblast, 340, 347 Metabolism . 384 Metallic compound, 294 elements, 264, 294 Metallurgy, 249. 293 Metals, 293 Method, Angle, 87 of swaging, 59 Methylic alcohol, 291 Micro-organisms, ISO of pus, 174 Middle cerebral artery, 440 Milk, 376 adulteration, 398 sterilization, 400 Miller's theory, 199 Mixed diet. 411 Mixture, 271 Moist gangrene of the pulp, 121 Molar, impaction of, 188 teeth, extraction of, 104 Molecular weight, 266 Molecule, 269, 271 Monad, 264, 272 Morbid anatomy, 188 Morphia, 245 Mouth, gumma of, 133 membranes, inflammation of, 1 syphilis of, 130, 174 tumors of, 135 Mucous membranes, 345 tissue, 338 Multilocular cyst, 146, 186 Mummification of dental pulp, 25 Muriatic acid, 279 Muscle, chemical composition of, 385 INDEX. 457 Muscles of mastication, 429 the tongue, 434 Muscular tissue, 342 Mydriatics, 221 Myeloid sarcoma, 127 Mylohyoid muscle ,438 nerve, 428 Myocardium, 324 Myxomatous tissue, 323 Naphthol, 216 Narcotics, 215, 235 Nasal bones, 422 Nasmyth's membrane, 323 Nausea in prosthetic dentistry, 43 Necrosis, 143, 197 Arsenic, 120 of alveolar process, 153 inferior maxilla, 161 the jaw, 98 Phosphorus, 402 Negative elements, 268 metallic fillings, 314 Nerve cells, 336 Facial, 118 fibers, 324, 325, 334 Nerves of special sense, 385 Nervous system, 375, 413 Neuman's sheath, 351 Neuralgia, 128 Dental, 20 Trifacial, 108, 164 Neurasthenia, 102 Neurilemma, 340 Neuritis, 128, 137 Neuro-epithelium, 339 Neuroglia, 317 Neutral, 251 Nitric acid, 222 Nitrogen, 282, 283 Nitrous oxide gas, 218, 220, 231, 245, 246, Noble metal, 297 Non-cohesive gold, 12 -conductors of electricity, 255 -metallic elements, 264 -virulent germ, 181 Normal pulse, 367 Nose, Foreign body in, 154 Nuclear matrix, 332 Nucleus, 332 Nuisance, 396 Nutrition, 372 Nux vomica, 229 Obstruction of the glottis, 153 Obturator, 89 Occipital bone, 442 triangle, 442 Occipito-frontalis, 434 Occlusion of teeth, 54 Odontalgia, 20, 147 Odontoblasts, 331, 336 Odontoma, 103 Oil of cinnamon, 217 cloves, 216 Omohyoid muscle, 428 Operation in cleft palate, 95 Operations on syphilitics, 108 Operative dentistry, 1 Ophthalmic artery, 421 nerve, 424 vein, 444 Opium, 229 Oral mucous membrane, 320 pathology, 176 surgery, 95 Organic chemistry, 274 compounds, 272 tissue, 333 Orthodontia, 98 Orthophosphoric acid, 288 Osmose, 257 Os planum, 429 Osteoblasts, 320, 339 Osteoclasts, 339, 346 Osteoma of inferior maxilla, 99 Otic ganglion, 421 Overstrain, 399 Oxalic acid, 289 Oxidizing agent, 263 Oxygen, 276, 283 Oxygenation of the blood, 355 Ozsena, 127 Ozone, 276 Pain in inflammation, 177 Painful pulp, 21 Palate bone, 443 Palatoglossus muscle, 431 Pancreas. 357 Pancreatic juice, 361 Papillae of the tongue, 344 Papilloma of the gums, 126 Parablast, 317 Parasites, 172 Parasitic bacteria, 194 stomatitis, 116 Parotid gland, 373, 319 secretion, 373 458 INDEX. Passive hyperemia, 184 Pasteurization, 174 Patch, Smoker's, 158 Pathogenic bacteria, 175, 181, 190 fungi in mouth, 200 Pathological dentition, 194 Pathology, 171, 185 of pulp, 22 Pavement epithelium, 319 Perforated hard palate, 89 Pericardium, 324 Pericemental abscess, 27, 120 membrane, 346 Pericementitis, 27, 198 Phagedenic, 196 Septic, 195 Pericementum, Disease of, 202 Perichondrium, 351 Peridental membrane, 330, 335 Perineurium, 317 Periodontitis, 196 Periosteum, 336 Inflamed, 26 Periostitis, 177 Acute, 163 of inferior maxilla, 134 Suppurative, 144 Syphilitic, 164 Permanent magnet, 256 Perspiration, 368, 383, 385 Petrous bone, 420 Peyer's patches, 319 Phagedenic pericementitis, 196 Phagocyte, 341 Phleboliths, 191 Phosphoric acid, 261, 288 Phosphorus-necrosis, 402 Physics, 249 Physiology, 353 Pin crown, 85 Pinless teeth, 48 Pits, 7 in soldering, 72 Plaster-of-Paris, 42, 286 teeth, 43 Plastic fillings, 10 Plate clasps, Decay under, 6 Platinized gold, 66 Platinous gold, 66 Platinum, 300 in dentistry, 68 solder, 71 Plethora, 184 Plumpers, 51 Pneumogastric nerve, 360, 441 Points, Excavator, 3 Poisoning by atropine, 227 carbolic acid, 225 cocaine, 225 strychnine, 227 Porcelain dentures, 70 inlays, 18 Positive elements, 268 metallic fillings, 314 Potassium permanganate in den- tistry, 209 Potential, 251,273 Preparation of cavities, 2 mouth for artificial denture, 41 Pressure, Hand, 17 Mallet, 17 Preventive treatment of dental shock, 6 Primitive dental groove, 350 Privy, 398 Prognosis, 188 Prosthetic dentistry, 41 Protection of cavities, 5 the pulp, 21 Proteids, 363 Protoplasm, 334 Provisional callus, 177 Proximate principles, 376, 381 Pterygoid muscles, 418 Ptomaines, 173, 409 Pulp, 346 -canal, 24 Capping of, 22, 194 Congested, 20 Dead, 24 Devitalization of, 23 Disease of, 194 Exposed, 20, 33 Fungoid, 25, 197 Hyperemia of, 123 Irritable, 197 Irritation of, 21 Moist gangrene of, 121 Mummification of, 25 Painful, 21 Pathology of, 22 Protection of, 21 Putrescent, 26, 193 Removal of, 25 Stones, 22 Suppuration of, 203, 205 Pulpitis, 20, 205 Pulpless teeth, 26 Pulse, Normal, 367 INDEX. 459 Punctured wounds, 132 Purple of Cassius, 47 Pus, 174, 183, 199 Putrescent pulp, 26, 193 Pyemia, 108 Pyogenic bacteria, 184 Pyorrhea alveolaris, 37, 140, 239 Pyrozone, 202 Qualitative analysis, 274 Quantitative analysis, 274 Quarantine, 404 Quick pulse, 157 Quinine, 21'i Eain water, 406 Kanula, 101, 115, 151 Ranvier's nodes, 340 Red blood corpuscles, 340, 343, 370 marrow, 321 Reducing agent, 263 Refining of gold, 303 Reflex action, 385 Regeneration of tissues, 182, 187 Regulation of the teeth, 86 Reinsch's test, 302 Removable bridge, 83 Removal of gold crown, 77 of pulp, 25 Repair of fractures, 186 Replanting of teeth, 29, 105 Reposing the features, 45 Resorption of roots, 204 Respiration, 368 Artificial, 122 Respiratory failure, 104 organs, 373 Retainers, 88 Reticulum of lymphoid tissue, 323 Retrenchment, 130 Retzius' striae, 327 Richmond crown, 73 Root amputation, 28 -canal, 24 Roots, Resorption of, 204 Rolando's fissure, 431 Rose's operation, 118 Rubber, Solvents of, 50 Weighted, 50 Rugae in a vulcanite plate, 92 Saline cathartics, 244 Saliva, 287, 353, 380, 383 Salivary Calculus, 37, 141, 165, 189, 201 Salivary duct, Calculus in, 138 fistula, 142,166 glands, 337, 419 Salter's lines, 328 Sanguinary calculus, 37, 191 Sapremia, 108 Saprophytes, 172 Saprophytic bacteria, 204 Sarcolemma, 339 Sarcoma, 172 Myeloid, 127 of superior maxilla, 173 Sarcomatous epulis, 179 Scarification, 125 Schreger's lines, 328 Schwann's white substance, 340 Sciatic nerve, 447 Secondary dentine, 7, 329, 334 hemorrhage, 99, 168 Secretions, 384 Section-cutting, 321 Sedatives, 215 Sensible heat, 257 Sensitive heat, 7 anterior teeth, 6 teeth, Treatment of, 6 Separation of teeth, 8 Sepsis, 172 Septic infection, 188 intoxication, 110 pericementitis, 195 wounds, 123 Septicemia, 108, 193, 199 Sequestrum, 118, 137 Serous membranes, 345 Serumal calculus, 191 Sewage, 405 Sewer-gas, 394 Sharpey's perforating fibers, 325 Shell crown, 76 Shock, 159 Surgical, 100 to the teeth, 6 Shoulder-joint, 427 Sialagogues, 238 Sigmoid notch, 437 Silex in dentistry, 93 Silver, 307 nitrate, 38, 213, 308 Simple cyst, 153 molecule, 271 Skin, 386 Smoker's patch, 158 Sodium, 309 silicate, 309 460 INDEX. Soft pulse, 161 water, 400 Softening of cavity walls, 15 Solder, aluminum, 60 Soldering, 299 Solvents of rubber, 50 Spasmodic respiratory failure, 104 Special pathology, 185 Specific gravity, 249, 259 heat, 250, 257 Spectroscope, 254 Spectrum analysis, 251 Sphenoid bone, 414, 438, 439 Sphenoidal fissure, 436 Spinal column, 424 Spirilla, 185 Sponges, Sterilization of, 131 Spongioplasm, 332 Spongy bone, 322, 339 gums, 120 Spores, 171 Sputum, 404 Squamous bone, 420 Stain, Green, 33 Staphylorrhaphy, 99 Starvation, 371 Steno's duct, Cystic dilatation of, 106 Sterilization of hypodermic syr- inges, 180 instruments, 99 sponges, 131 Sternomastoid muscle, 435 Sternothyroid muscle, 438 Stimulants, 213, 224 Diffusible, 244 Stippling, 69 Stomach, 354, 364 Stomatitis, 111, 116 Gangrenous, 186 Mercurial, 134, 200 Stratified epithelium, 325 Stratum granulosum, 350 Malpighii,327 Strychnine poisoning, 227 Styloglossus muscle, 447 Styptics, 217, 237 Subclavian vein, 423 Sublingual gland, 419 nerve, 363 Submaxillary ganglion, 423 gland, 419 secretion, 373 triangle, 440 Sulphur, 285 Sulphuric acid in dentistry, 38, 207,222,261,286 Sulphurous acid, 261 Superficial dental caries, 1 Superior carotid triangle, 447 longitudinal sinus, 423 maxilla, 427, 439 Fracture of, 128 Tumors of, 134, 183 Sarcoma of, 173 thyroid artery, 428 vena cava, 430 Suppuration, 176, 183, 200 of maxillary sinus, 106 of the pulp, 203, 205 Suppurative cellulitis, 100 inflammation,155, 177 periostitis, 144 Supraorbital artery, 441 Surgical shock, 100 Surgery, Oral, 95 Sutures, 117 Suture -materials, 101 Swaging, 59 Sweating, 66 Swelling in inflammation, 168 Sylvester's method, 148 Symbols, 271 Sympathetic nervous system, 369, 380, 463 Syncope, 99, 159 Synergist, 221 Synovitis, 97 Synthesis, 265. 269 Syphilis of the mouth, 130, 174 Syphilitic interstitial gingivitis, 122 periostitis, 164 ulcers, 145 ulcer of the tongue, 98 Syphilitics, Operations on, 108 System, Farrar's, 86 Tartaric acid, 290 Teeth, Abrasion of, 7, 196 Artificial, 44 Bleaching, 26 Calcification of, 340 Cleansing of, 39 Color of, 26 Counter- sunk pin, 48 Deciduous, 205 Deposits on, 36 Ja'08 INDEX. 461 Teeth, Devitalization of, 196 Diatoric, 48 English tube, 64 Erosion of, 7, 204 Eruption of, 202, 379, 380 Examination of, 38 Extraction of, 30 Formation of, 336 Hutchinson's, 197 Implantation of, 105 Irregularity of, 35, 166 Normal occlusion of, 54 Plaster, 43 Pinless, 48 Pulpless, 26 Regulation of, 86 Replanting of, 29, 105 Sensitive, 7 Separation of, 8 Shock to the, 6 Temporary, 32 Transplantation of, 105 Unerupted, 36 Wedging of, 8 Temperament and teeth, 45 Tempering, 296 Temporal artery, Ligation of, 97 bone, 420 fossa, 438 teeth, 32 Abscess of, 196 Temporo-maxillary articulation, 110 Wound of,141 Tenacity, 251 Tendons, 425 Tensor palati, 435 Test for antimony, 302 for gold, 302 Thermal, 19, 196 Tetanus, 117, 139 Therapeutics, 207, 223 Thermal test, 19, 196 Thoracic duct, 447 Thready pulse, 155 Thrombosis, 175 Thrust, 116, 243 Thyroid gland, 442 Tic doloreux, 150 Tin, 297 " Tin cry," 306 Tin fillings, 11 Tincture of iodin, 214 Tinctures, 233 Tissue, 341 Tobacco, 405 Tomes' soft fibers, 343 Tongue, Carcinoma of, 159 Cysts of , 101 Gumma of, 159 Hemorrhage from, 136 Muscles of, 434 Papillae of, 344 Syphilitic ulcer of, 98 Traumatic ulcer of, 98, 167 Tumors of, 172 Wounds of, 125 Tonics, 224 Tonsils, 416 Toothache, 147,211,248 Tooth - extraction, Hemorrhage after, 112 Tooth-germ, 335 Topical remedies, 231 Torsion, 118 Toxalbumins, 184 Toxins, 173, 409 Trachea, 414 Transplantation of teeth, 105 Traumatic dislocation, 121, 138 ulcer of tongue, 98, 167 Traumatism, 117 Treatment of sensitive teeth, 6 Triad, 264 Trichloracetic acid, 242 Trifacial neuralgia, 108, 164 Trismus, 116, 146 Tumors, 103, 175, 181, 189 of the antrum, 126 Benign, 178 of buccal cavity, 179 parietes, 173 Epulic, 115 Fatty, 131 of the gums, 171 maxillary sinus, 106 superior maxilla, 134, 183 the tongue, 172 Typhoid fever, 407 Tyrotoxicon, 409 Ulcer, 133, 160 Carcinomatous, 190 Syphilitic, 145 of the tongue,98 of tongue, 167 Traumatic, of tongue, 98 Ulcerative stomatitis, 116 462 INDEX, Underwear, 399 Unerupted teeth, 36 Ununited fracture maxilla, 136 of inferior Vaccination, 393 Vaccuum chamber, 46 Valency, 270 Valves of the heart, 370 Vasoconstrictor nerves, 363 Vasodilator nerves, 363 Vegetable life, 273 Veins, 372, 443 Velum, Artificial, 89 Ventilation, 395 Victoria, 56 Vidian nerve, 431 Virulent germ, 181 Vitriol, Blue, 285 Volatile oils, 233 Volatility, 250 Voluntary muscles, 363 Vulcanite, 50 base, 51 Waste, 355 Water, 406 of crystallization, 249 Wedging of teeth, 8 Weighted rubber, 50 Welding, 299 Wells, 412 Wharton's duct, Cystic dilatation of, 106 White decay, 4 fibrous tissue, 338 Willis's circle, 432 Wisdom tooth, Impacted, 128 Wood alcohol, 291 Wounds, 96 of arteries, 138 Aseptic, 141, 166 Contused, 96 Healing of, 148, 183 Incised, 143 Lacerated, 96, 136 Punctured, 132 Septic, 123 of temporo-maxillary articulation, 141 of the tongue, 125 Yellow marrow, 321 Zinc, 315 oxychloride, 9 phosphate, 9 K 82 6 CONGRESS 0D0Eb0fc>fi77Q