ms en/j /de fsSa/do't. 
Till PATHOLOGY Ml TREATMENT OF HE 
Address delivered, by invitation, befoi'e the Wisconsin 
Dental Society during its Annual Session in 
Milwaukee, 1880, and published 
request of the Society. 
BY 
IT. SEW1T, M.D., 
Of Milwaukee. 
Reprint from DENTAL COSMOS, October, 1880. 
PHILADELPHIA: 
PRINTED BY J. B. LIPPINCOTT & CO. 
1880. THE 
Pathology and Treatment of Epulis. 
It gives me great pleasure to meet with you on this your tenth 
anniversary as a society, and I take advantage of the opportunity to 
congratulate you upon the success attained by this organization, as 
well as the high rank your profession occupies in the esteem of the 
people here and abroad. You may well be proud of the reputation 
and distinction achieved by your profession. The fame of American 
dentistry is world-wide. American dentists are sought and patron- 
ized everywhere. Your profession furnishes a fertile field for the 
exercise of ingenuity and the application of mechanical skill, which 
constitute such a prominent and characteristic feature of our people. 
When, a few weeks ago, I was honored by an invitation to appear 
before you this evening, I fully realized the responsibility I was as- 
suming in accepting it. It is no easy task for an outsider, although 
belonging to a kindred profession, to come before such an intelligent 
audience and offer something that shall be of sufficient value and 
interest to merit its attention. After mature reflection, I have con- 
cluded to call your attention to a disease which occupies the boundary- 
line between the dentist and surgeon,—an affection which, for its 
successful management, requires the services of both. I allude to 
Epulis. 
The term epulis is derived from two Greek words, signifying 
“ upon the gums.” The ancients applied this word to designate a 
variety of tumors found in and underneath the gums. The designa- 
tion originated at an early period in the history of medicine, when 
the locality and external appearances of a disease received more at- 
tention than its pathology. Like many other vague and indefinite 
terms, it has been handed down to us from the distant past through 
the current of medical literature, and at the present time occupies 
still a position, although in a modified form, in most of our text-books. 
In speaking of malignant diseases of the bones, Billroth says,* 
* General Surgical Pathology and Therapeutics, p. 602, New York, 1872, 2 
THE PATHOLOGY AND TREATMENT OF EPULIS. 
“ Some also call epithelial cancer epulis; it is well either not to use 
such terms, or to restrict them by certain adjectives, as sarcomatous, 
fibrous, carcinomatous epulis, etc.” 
This affection is no longer considered a primary disease of the 
gums; it includes no longer the variety of inflammatory, hypertrophic 
and malignant processes which originate in the gums or the neigh- 
boring tissues. The term epulis is still giving rise to considerable 
confusion, as authors continue to apply it to different pathological 
conditions. As used in the present sense, we understand by it a 
fibro-plastic tumor, which originates in the endosteum or periosteum 
of the alveolar process; which manifests a strong disposition to return 
if not thoroughly removed; which never heals spontaneously, and 
but seldom invades the system by general infection. Epuloid growths 
may therefore be appropriately classified under the head of semi- 
malignant,—a class of tumors prone to local but not to general 
infection. 
Clinical History.—The clinical history of all epuloid growths de- 
monstrates the fact that they have a certain relation to the teeth, in 
the proximity of which they always take their origin. These tumors 
never occur in jaws which have no teeth, nor in parts of jaws where 
the teeth have long been removed. 
Mr. Salter gives a case which at first sight seemed an exception to 
this rule: “ One of the most severe examples of this malady which I 
have seen consisted of a bilobate mass, the size of a walnut, extending 
on the right side of the lower jaw, from the dens sapientias to the 
canine teeth, the four intermediate teeth having been removed. Its 
removal on this occasion disclosed the remains of one fang of the first 
molar tooth in its very axis. This was extracted, and the disease 
did not again make its appearance.”* 
Infants and the aged, with edentulous and atrophied jaws, are 
exempt. The 37oungest patient that has come under my observation 
was eighteen, and the oldest fifty-five years of age. The disease is 
most frequently met with in persons from twenty to fifty years of age. 
In a table of 28 cases observed in the London hospitals, the youngest 
patient was a boy of nine, whilst the oldest wTas a woman of seventy- 
three. Five were under the age of twenty, eight between the ages 
of twenty and thirty, seven between thirty and forty, three between 
forty and fifty, two between fifty and sixty, and three above sixty. 
The average age of the whole number was thirty-three.'f 
Females suffer more frequently from this disease than males, the 
relative number among my cases being in the ratio of 3 to 1. This 
* Holmes’s System of Surgery, vol. iv. p. 340. New York, 1875. 
f Heath, Injuries and Diseases of the Jaws, p. 204. London, 1872, THE PATHOLOGY AND TREATMENT OF EPULIS. 
3 
disproportion is explained by the well-known fact that females suffer 
more frequently from diseased teeth than males. 
A discrepancy of opinion prevails in regard to the relative fre- 
quency with which the lower and upper jaws are affected. Erichsen 
has met with it more frequently in the lower jaw, while Pollock’s 
experience has been the reverse, having had twice as many cases 
where the upper jaw was the seat of disease as where the lower was 
affected. I have seen it more frequently in the lower than in the 
upper jaw. 
Inasmuch as the anatomical structures surrounding the roots of 
the teeth are the same in both jaws, we can safely assume that were 
all the cases tabulated, there would be no great disproportion in re- 
gard to the frequency with which these bones are affected. The dif- 
ference in the statistics of individuals must be considered as acci- 
dental. The disease affects more frequently the sockets of the molars 
than the incisors and canines, and is attached more frequently to the 
outer than the inner alveolar process. 
The starting-point of an epulis is usually in one of the alveolar 
cavities; as a rule only one tumor exists. As the neoplastic forma- 
tion increases in size, its pressure soon produces displacement of its 
surrounding structures. One of the first results of this pressure is a 
loosening of the teeth around which the growth develops itself, and 
a dilatation of the alveolar spaces. The tumor projects in the direc- 
tion which offers the least amount of resistance, which is usually 
between a tootb and the outer alveolus, or between two adjacent 
teeth. 
The progress of the disease is slow and painless. Probably the first 
thing the patient will notice will be a preternatural prominence of 
one or more teeth, which eventually become loose; and this fact in- 
duces the patient to consult a dentist for the purpose of having them 
extracted. At this stage, besides the loosening of the teeth, a firm 
fibrous growth is found around the base of the tooth first affected, 
and usually more prominent between, and to the outer side of, the 
teeth. The mucous membrane covering the tumor presents a natu- 
ral appearance, and rarely is the seat of ulceration, unless the tumor 
has acquired a large size, or its surface has been subjected to mechani- 
cal injury. If the base of the tumor remains circumscribed, the dis- 
ease manifesting no tendency to invade the adjacent alveoli, then the 
growth projects into the cavity of the mouth and assumes a pedun- 
culated or polypoid shape. The shape of the tumor is determined, 
to a certain degree, by the extent of its base, and the pressure to 
which it has been exposed on part of the surfaces with which it comes 
in contact. The consistence of the tumor is variable, and depends 
upon the abundance or paucity of its fibroid elements. The rapidity 4 
THE PATHOLOGY 4ND TREATMENT OF EPULIS. 
of its growth depends, in part, upon the character of the cells which 
constitute its principal bulk. The more closely the tumor resembles 
a purely fibroid structure the firmer its consistence and the slower 
its growth ; if, on the other hand, the myeloid cells preponderate, 
then it is very vascular, soft, grows rapidly, and is more prone to 
ulcerative destruction. 
As the tumor increases in size it becomes more or less lobulated, 
the number and shape of the lobes depending upon the resistance 
with which it meets and the arrangement of the fibrous stroma in its 
interior. As long as its investing membrane remains intact there is 
no tenderness, and the surface does not bleed on being touched ; when 
ulceration takes place the abraded surface often becomes tender, and 
the source of frequent debilitating hemorrhages. The chief inconve- 
nience arises from its presence when its size is sufficient to interfere 
with the functions of the mouth, speech, mastication, and deglutition. 
If the tumor is permitted to grow to a large size it will produce ex- 
ternal deformity of the face. 
Mr. Liston removed an enormous tumor of this kind from the upper 
jaw of Mary Griffiths, in October, 1836.* The disease had existed 
for eight years. An operation was performed when the tumor was 
of small size, but the disease returned, owing to an imperfect removal 
of the morbid product. The tumor belonged to the fibroid variety. 
The growth primarily took its origin from the sockets of the in- 
cisor and canine teeth of the left side of the upper jaw. It early pro- 
truded from the mouth, pushing the lips and cheek before it. It 
filled the cavity of the mouth anteriorly, and formed a large tumor in 
front of the face, and was the cause of great inconvenience and suf- 
fering. Ulcerations had taken place over some parts of the surface, 
but its other qualities indicated a benign nature. An operation per- 
formed for its removal restored the symmetry of the face, and was 
followed by complete and permanent recovery. 
Dr. Kinloch, of Charleston, S. C., performed a similar operation in 
1869. The patient was a negress, aged twenty-five, who suffered 
from a tumor originating from the same locality, and having attained 
about the same dimensions. It had originated in the alveolus, but 
had involved a considerable portion of the superior maxillary bone. 
The mass, after removal, weighed nearly two pounds, and the patient 
made a good recovery. 
It is difficult to estimato the natural duration of this disease, as the 
patients suffering from it readily submit to an operation before it 
endangers life by interfering wTith essential functions. In the table 
of 28 cases previously quoted, the longest period mentioned was 
* Heath, op. cit, THE PATHOLOGY AND TREATMENT OF EPULIS. 
5 
twenty years, in a patient of sixty, and the shortest three months, 
in a patient of fifty. 
The disease remains local, and destroys life only if it is permitted 
to attain sufficient size to interfere mechanically with alimentation 
or respiration. 
Causes.—Our knowledge concerning the essential cause of epulis 
is absolutely nil. The disease .does not appear to be hereditary. We 
are ignorant regarding any special general condition favorable to its 
development. There is no evidence of the disease being the result, 
or a manifestation of, a general condition or dyscrasia. 
Prof. Rust believed that these growths, in some instances, are caused 
by a general dyscrasia, and in support of this assertion he relates 
a very singular case that came under his observation.* A woman 
suffered from a sarcomatous epulis during her pregnancy. The tumor 
was attached to the alveolar processes of the upper jaw; it presented 
a reddish-blue appearance, and at times gave rise to copious hemor- 
rhage. Repeated fruitless attempts were made to destroy it by 
means of the ligature and caustics. Soon after delivery it disap- 
peared spontaneously. It reappeared regularly during four succes- 
sive pregnancies and disappeared promptly after each delivery, with- 
out treatment, so that the woman began to look upon its appearance 
as the most reliable indication of her condition. 
The immediate or exciting cause is in many instances referable 
directly to a local irritant, as a diseased tooth. When the jaw is 
devoid of teeth at the site of disease it may be safely assumed that 
a root or a loose spicula of bone is buried somewhere in the interior of 
the mass. Incrustation of tartar around the base of the teeth has 
undoubtedly in some instances acted as a cause, and it is only rea- 
sonable to presume that the prolonged irritation incidental to the 
second dentition and the appearance of the last molars has been in- 
strumental in originating the morbid process. It is a well-known 
fact in pathology that any long-continued irritation may so alter the 
nutrition of normal structures and benign growths as to impart to 
them a semi-malignant or malignant type. 
Mr. Stanley,f in speaking of malignant disease of the periosteum, 
says, “ The grounds upon which I have considered this to be a dis- 
ease of the periosteum are, that in some instances the fungous excres- 
cence appeared to have arisen directly from the periosteum, altered 
in structure by inflammation, that is, thickened and softened, and 
but loosely adherent to the bone; further, that these alterations in 
* Aufsaetze, u. Abhandlungen aus dem Gebiete der Medizin, Chirurgie, etc. 
Berlin, 1834. Band i. p. 263. 
f A Treatise on Diseases of the Bones, p. 281. Philadelphia, 1849. 6 
THE PATHOLOGY AND TREATMENT OF EPULIS. 
the periosteum have been observed to extend beyond the limits of 
the fungus, and indeed far beyond the existence of any change in 
the skin indicating unsoundness of the subjacent parts. Thus, in one 
case where the fungus was confined to the lower third of the front 
of the leg, the periosteum was found preternaturally vascular, thick, 
soft, and pulpy over the whole of the tibia and upon the fibula also. 
It seemed, therefore, from these observations, that a diseased state of 
the periosteum had preceded the growth of the fungous excrescence 
on it.” 
Traumatic injury of the teeth or alveolar processes, the excessive 
use of phosphorus and mercury, deserve to be enumerated as pos- 
sible causes; in fact, I believe that any cause or causes which produce 
a prolonged and continuous congestion of such vascular membranes 
as the endosteum and periosteum of the alveolar plates may event- 
ually engender this disease. 
Pathology.—Epuloid tumors, as described above, belong to a class 
of tumors which have been described under different names as fibro- 
plastic by Lebert, sarcoma by Virchow, and myeloid by Paget.* 
The term fibro-plastic defines their structure and clinical behavior 
better than any other which has been proposed, and should be retained 
until a more accurate knowledge of their essential nature warrants 
us in adopting something better. On section, the tumor appears 
smooth, and presents usually spots of discoloration varying from a 
bright pink to a dark brown. This mingling of colors is one of its 
characteristic properties. In structure it is composed of spindle- 
shaped fibro-cells, and larger polynucleated and nucleolated cells. 
(Riesenzellen.) The spindle-shaped or caudate cells contain single 
nuclei and nucleoli; the large cells are irregular, round, oval, or 
flask-shaped, measuring from -g-i- to T(jVu- of an inch in diameter, and 
contain from two to ten distinct nuclei with nucleoli. The fibro-cells 
consist of an abnormal increase of the fibrous elements of tbe organs 
from which the tumor made its starting-point; while the larger or 
myeloid cells, lodged in varying proportions in its meshes, comprise 
one of its products, and impart to it its semi-malignant properties. 
When a tumor is largely composed of these giant-cells it grows 
rapidly, is soft and vascular, and very prone to infiltrate and infect 
the tissues around it. The neoplastic deposit penetrates the bones 
by dilating the Haversian canals and following the fibrous tissue 
lining these channels. 
Mr. Paget says of these tumors, “ In all these characters of con- 
nection the fibrous tumors on the exterior of the jaws and about 
other bones resemble outgrowths; they are as if some limited por- 
* Paget’s Surgical Pathology, p. 544. Philadelphia, 1870. THE PATHOLOGY AND TREATMENT OP EPULIS. 
7 
tion of the periosteum had grown into a tumor overlying or sur- 
rounding the bone. The character of outgrowth is indeed generally 
recognized in the epulis, or tumor of the gums and alveoli, but I 
believe Mr. Hawkins is quite right in the view which he has ex- 
pressed that the fibrous epulis should be regarded as a tumor growing 
like most of the fibrous tumors from the bone and periosteum, and 
continuous with them. That it is prominent and lobed is because it 
grows into the open cavity of the mouth, and it resembles gum only 
because it carries with it and involves the natural substance of the 
gum.”* 
The mucous membrane covering the tumor is intimately connected 
with its substance, presenting no distinct boundary-line. The tumor 
is connected primarily with the endosteum or periosteum of the 
alveolar processes, and Otto Weberf has traced its origin to the pulp 
of a tooth. The bone to which the tumor is attached becomes very 
vascular and osteo-porotic, portions of its substance being absorbed, 
and the space appropriated by the neoplasm. Deposits of bone are 
frequently found in the interior of these tumors. It has been a 
question among pathologists to determine whether the bone thus 
found is derived from the alveolar processes, or whether it originates 
de novo,—a product of the tissues. 
LueckeJ believes in the osteo-genetic functions of the neoplasm, 
when he says that the main feature of a periosteal sarcoma does not 
consist in this or that form of cells, but that it depends upon its 
proneness to produce bone or a substance resembling bone. Mr. 
Tomes,§ on the other hand, takes it for granted that the bones found 
in these tumors are detached pieces from the jaw, and during their 
growth are imbedded in their substance. He thinks that its micro- 
scopic character “ fully justified the assumption that it had at one 
time formed a portion of the subjacent alveolus, and that its detach- 
ment had been effected by absorption; and further, that when so de- 
tached it had formed a source of irritation, and thus led to the devel- 
opment of the epulis.” 
Stanley, Jonathan Hutchinson, Heath, Hawkins, and De Morgan 
have each removed epuloid growths of large size, with bony deposits 
at a distance from their point of drigin, so that there can be no fur- 
ther doubt that ossification had taken place in the tumor itself. These 
tumors possess a great amount of vitality and power of resistance. 
They are seldom (especially the fibroid variety) the seat of ulcera- 
* Opus cit., p. 488. 
f Yerletz. u. Chir. Krankh. des Gesichts. Pitha und Billroth Chirurg., p. 270. 
J Die Lehre von den Geschwuelsten, p. 179, Pitha und Billroth. 
\ Dental Surgery, p. 521. 8 
THE PATHOLOGY AND TREATMENT OF EPULIS. 
tion, and when this occurrence takes place it does so only when the 
tumor has attained a large size, or as the result of extraneous causes. 
Enlargement of the lymphatic glands does not belong to the clini- 
cal history of epulis. In the few cases where it was alleged that the 
disease became general, the secondary deposits were found, not in the 
lymphatics, but along the course of the blood-vessels. 
Diagnosis.—The clinical history and the physical appearances of 
the tumor furnish the most important facts in arriving at a correct 
diagnosis. Should any doubt remain, it may be effectually dispelled 
by a microscopical examination of small particles taken from the 
interior of the tumor. The absence of pain or tenderness, the slow 
growth, the firmness of the tumor and its attachment within or in 
the immediate vicinity of an alveolus, are conditions which belong 
to the history of every case of epulis. Hypertrophy of the gum is 
an exceedingly rare affection, and the morbid process never extends 
beyond the tissues primarily involved. Granulations or polypoid 
growths from the cavity of a tooth or an alveolus are soft, bleed easily 
on being touched, and are therefore not liable to be mistaken for an 
epulis. 
Parulis, or abscess of the gum, is an acute affection, and always 
terminates in suppuration. In scorbutus we have an inflammation 
of the gums and the alveolar contents, which, if limited, might resem- 
ble the disease under consideration; but the disease is usually dis- 
tributed over a larger surface, and the history of the case furnishes 
evidence of the presence of causes which have given rise to a general 
dyscrasia. Cartilaginous and osseous tumors of the alveolar pro- 
cesses present such characteristic features as to offer no difficulties 
in view of a differential diagnosis. Epithelial cancer is not a pri- 
mary affection of an alveolus, but affects this locality by extension, 
usually from the lips. This affection attacks persons only advanced 
in years. It does not give rise to a tumor, properly speaking, but 
falls an early prey to destructive ulceration. Lymphatic infection 
is a constant occurrence in cancer, but is seldom or never present in 
uncomplicated cases of epulis. 
Prognosis.—The repullulating disposition of epulis constitutes its 
most formidable feature. This affection, as a rule, comes under treat- 
ment earlier than most any other variety of tumors on account of its 
location and the inconvenience it occasions. Its slow growth and its 
local nature render it a favorable object for operative procedure. 
Prof. Gross,* who believes that this disease may, under certain favor- 
able circumstances, assume the most malignant form, estimates the 
time when it will prove fatal at from one to three years. When the 
* System of Surgery, vol. ii. p. 432. THE PATHOLOGY AND TREATMENT OF EPULIS. 
9 
disease is permitted to run its natural course, it destroys life in sev- 
eral ways. The size of the tumor may interfere with mastication 
and deglutition, and the patient dies of inanition; the tumor may 
encroach upon the larynx and interfere with respiration, and death 
results from asphyxia ; the tumor may ulcerate, and repeated hemor- 
rhages may result in death from exhaustion; the ulceration may 
become extensive, the source of septic infection from the products of 
putrefaction, and life is terminated by septicaemia or pyo-septicaemia ; 
or, in exceptional cases, if the disease is not eradicated by a thorough 
removal, it may assume a malignant type and prove fatal by second- 
ary deposits in the course of the blood-vessels. 
Treatment.—The ancients understood well the recurrent nature of 
epulis, and consequently resorted to effective measures to accomplish 
its early and thorough destruction. iEtius recommended the appli- 
cation of alum, verdigris, etc., and, if these failed to produce the de- 
sired result, he advised extirpation with the knife. Haly Abbas and 
Celsus recommended excision; Albucasis directed that the tumor be 
cut out with forceps and scalpel, and then to apply styptic powders 
to the part, and, in case the tumor reappeared, to resort to the actual 
cautery; Paulus iEginatus came to the conclusion that no permanent 
cure could be effected without the employment of the ferrum can- 
dens. All recent authorities agree that a thorough removal of the 
diseased tissues affords the only security against recidivation. Mr. 
Stanley says,* “ In the treatment there is but one consideration in- 
volved,—the necessity of thoroughly removing the diseased parts 
with the tissues to which they have acquired attachment; and, of 
course, this can be done far more satisfactorily when the disease 
is of small extent, and limited to its original seat. Therefore, it is 
important that the disease be recognized before it has crept, as it is 
apt to do, irregularly and indefinitely into the surrounding tissues.” 
The object of treatment—the removal of the growth—may be 
reached in different ways: 1, by excision ; 2, caustics; 3, actual cau- 
tery. To insure success it is almost always necessary to remove that 
part of the alveolar process from which the growth springs; hence, 
excision has the first claim in selecting our method of operation. It 
may be followed with profit by the actual cautery for the double pur- 
pose of arresting hemorrhage and destroying any particles of morbid 
tissue that may have evaded the cutting instruments. Caustics are 
not sufficiently reliable to successfully cope with such an insidious 
and obstinate disease. Only a few authorities recommend their use 
in mild cases. 
Prof. Gross,f in speaking of the treatment of epulis, with special 
* Opus cit. 
f Opus cit., p. 432. 10 
the pathology and treatment of epulis. 
reference to its occurrence in the lower jaw, insists that the incision 
should extend not only through the sound tissue, but, to make sure 
of complete removal, recommends excision of the entire thickness of 
the bone: “ I am satisfied that it is worse than useless to temporize 
with such a malady. The only way is to deal it at once an effectual 
blow by sawing out a piece of the jaw embracing its entire thickness, 
and reaching some distance beyond the limits of the morbid mass. 
I have never known a case in which any other procedure did the 
least good. In treating epulis we should not lose sight of the fact 
that it is an affection, not so much of the gums as of the jaw-bone, 
and therefore anything short of removal of this, at the site of the 
disease, is an absurdity.” In opposition to the treatment given by 
this eminent surgeon, Mr. Heath says,* “Under no circumstances, 
except when the growth is of a malignant character, can it be 
necessary, I believe, to cut through the whole thickness of the 
lower jaw, since it has been shown repeatedly that common epulis 
never involves the base of the bone, and the contour of the face de- 
pends so much upon its preservation that it should not be interfered 
with.” 
Mr. Salter sustains the views expressed by Mr. Heath when he 
refers to this part of the treatment, as follows: f “ It will never, I 
believe, be necessary to go far below the limits of the alveolar pro- 
cess ; for it is with the alveolar bone that the disease is essentially 
connected. In the lower jaw I would urge the necessity of never 
cutting through the entire bone, as the breaking of the maxillary 
arch most seriously interferes with the position of the remaining por- 
tions of the bone, and this disturbs the normal apposition of the teeth 
in the two jaws relatively.” This advice should be heeded, and even 
if the disease be extensive, a narrow bridge of healthy bone is usually 
found at the base of the lower jaw which should be carefully pre- 
served in order to maintain the proper anatomical relation of the 
parts. As the disease almost always originates from one of the sur- 
faces of the alveolar bone, the latter must be removed with the growth 
to prevent with certainty a relapse. The neoplastic deposit is very 
apt to infiltrate the whole depth of the alveoli, hence the entire length 
of the alveolar process should be removed. In a few instances, arrest 
of further development and even complete recovery has been attrib- 
uted to the physiological atrophy of the alveolar processes following 
the extraction of teeth. 
Such a favorable termination from this measure should, however, 
not be expected or relied upon. All expectative treatment must give 
* Opus cit., p. 210. 
| Holmes’s System of Surgery, vol. iv. p. 342. THE PATHOLOGY AND TREATMENT OF EPULIS. 
11 
way to a radical operation as soon as a positive diagnosis is made. The 
tooth of the socket, from which the tumor took its origin, as well as 
the adjacent tooth on each side, must be sacrificed ; after the required 
number of teeth have been extracted, the soundness of the jaw-bone 
should be examined to determine the direction of the incision and 
the amount of bone to be removed. This examination is best made 
with a small perforator or drill, which is made to penetrate the bone 
at different points to ascertain its density; the affected portion is 
soft and porous from the neoplastic infiltration, while the healthy 
jaw-bone may be known by its ivory-like hardness. 
Having ascertained the limits of the disease, two vertical incisions 
are made on the inner and outer side of the jaw, one on each side 
of the diseased mass, and at a safe distance from its border; these 
incisions are carried from the margins of the alveolar process to its 
base, or further in case the disease has penetrated into the interior of 
the jaw. These vertical incisions, which should extend to the bone, 
are connected by a horizontal incision. The incisions in the soft 
parts mark the line of application for the bone-cutting instruments, 
and guard against laceration of the periosteum. The vertical sections 
in the bone are made with a small saw, and the horizontal or con- 
necting cut with a Hey’s saw or Liston’s cross-cutting bone-forceps. 
After the tumor has been removed, the cut surfaces of the jaw should 
be carefully examined, and any suspicious portions of bone removed 
with a gouge or bur-drill; the surface can be subsequently cauter- 
ized with one of the points of Paquelin’s thermo-cauterium. 
When the tumor involves the body of the lower jaw, and we desire 
to leave a narrow bridge of bone to preserve the maxillary arch, and 
upon the preservation of which too much stress cannot be placed, 
then the use of White’s surgical engine offers advantages which can- 
not be overestimated. Any one who has undertaken to perform this 
operation with an ordinary Hey’s saw must have been fully convinced 
of its difficulties. 
During one of his recent clinics, Prof. J. E. Garretson* called the 
attention of the class in forcible language to the superiority of the 
surgical engine over all other instruments in operations involving the 
maxillary bones, and illustrated his remarks by removing a large 
sarcoma from the lower jaw, which extended from the lateral incisor 
to the ramus. After exposing the tumor by an incision through the 
center of the lower lip and along the lower margin of the jaw to its 
angle, and arresting the hemorrhage, he made a series of punctures 
with a spear-drill along the track of the proposed cut and completed 
the section with a small revolving saw, making a rapid and clear 
* Dental Cosmos, July, 1880. 12 
THE PATHOLOGY AND TREATMENT OP EPULIS. 
section of the bone. This instrument is one of the most useful and 
practical innovations in surgery, and will soon become as indispen- 
sable to the surgeon as it now is to the dentist. 
Most of these epuloid tumors can be removed through the mouth 
without incising the face; but when they have attained a large size, 
and this step becomes inevitable, then the suggestion and practice of 
Sir William Fergusson* cannot be too closely imitated, viz., to restrict 
the incision to the middle lip, which will ordinarily suffice, or, if not, 
in case the upper jaw is operated upon, to extend it into the nostril 
of the affected side; by using retractors sufficient room will bo gained 
to render any incision at the angle of the mouth superfluous. By 
adopting this or similar methods, unnecessary and unseemly scars are 
prevented. 
Should the location of the tumor require a still more extensive 
incision for its removal, then a semilunar incision is made through 
the face with the concavity downwards, as practiced by Yon Lang- 
enbeck; it is carried from the ala of the nose to the orifice of the 
ductus Stenonianus, and from here upwards and outwards towards 
the malar bone. Through this incision any part of the alveolar pro- 
cesses can be reached, while at the same time the cicatrix following 
the operation does not disfigure the face to the extent it would have 
done had the incision been carried from the angle of the mouth. 
If the disease has penetrated through the alveoli into the antrum, 
it will become necessary to resect the greater part or the whole of the 
superior maxillary bone. To expose the lower jaw, the incision is 
made through the center of the lower lip, and along the lower margin 
of the bone to its angle. 
By a very simple procedure Garretson secures the location of the 
cicatrix below the jaw so as to hide it from view. He marks the 
line of incision with a pencil, below the jaw, on the side of the neck ; 
then, by flexing the head towards that side, brings the line over the 
jaw, when the incision is made down to the bone, which affords pro- 
tection to the deeply located important organs of the neck. 
All important vessels are ligated as soon as divided. The wound 
should be united with carbolized silk sutures, embracing the whole 
thickness of the lips and cheek, and tightened after all hemorrhage 
has ceased. Wounds of the face unite in a very short time, and it 
is important to remove the sutures as soon as union has taken place, 
which often is complete on the third day. To prevent separation of 
the recently united tissues, it is advisable to support the external parts 
with strips of adhesive plaster, smoothly and well applied. The action 
of adhesive plaster is enhanced by applying collodium along its edges. 
* Lectures on Progress of Surgery, p. 239. THE PATHOLOGY AND TREATMENT OF EPULIS. 
13 
After all operations within the cavity of the mouth it is important 
to prevent fcetor and to guard against septicaemia from decomposed 
products of the wound, by the frequent use of antiseptic gargles, of 
which a solution of boracic acid and biborate of soda is one of the 
most pleasant and efficient. After the parts have wTell healed, the 
requisite number of teeth are inserted on a plate carefully made to 
fill the gap, and thus restore the symmetry of the mouth and the 
functions of mastication and speech. 
From this imperfect sketch it will be seen that, for the purpose of 
recognition and successful management of this affection, the dentist 
and surgeon must go hand in hand. In the majority of cases the den- 
tist is first consulted, and he should therefore possess the requisite 
amount of diagnostic knowledge to apprehend its nature, and then 
undertake or recommend the necessary operative treatment. 
After the removal of the tumor the services of the dentist are again 
required with a view to efface the mutilation inflicted by the surgeon 
in his attempt to eradicate a disease which slowly but surely destroys 
the life of the patient, unless stayed by the intervention of the art 
of surgery.