ORAL SURGERY. 
G. L. Parmele, M.D., D.M.D. [From the Proceedings Conn. Medical Society, 1883.] 
SOME POINTS IN ORAL SURGERY 
OF INTEREST TO THE GENERAL PRACTITIONER. 
By George L. Pahmele, M.D., D.M.D. 
[Presented to the Ninety-Second Annual Meeting of the Connecticut 
Medical Society, May 23, 1883.] 
I should much rather at this time be a silent listener to words 
of wisdom and instruction from those older in membership in this 
Society and profession than myself, and consequently better quali- 
fied to be one of your essayists at this our ninety-second annual 
convention; but as you have seen fit to detail me for this task I 
will not shirk it, as I should be pleased to do, but endeavor to pre- 
sent for your consideration a few ideas concerning the specialty I 
have adopted, which I hope may not be without interest to you. 
Contrary to the prevailing idea, dentistry is not of recent origin. 
The Egyptians had specialists in every department, and it is 
claimed that artificial dentures of wood, ivory, and gold have been 
found in the jaws of mummies. It has also been asserted that 
fillings of gold have been found in their teeth; but recent investiga- 
tions by several English dentists of high repute tend to throw 
discredit on this statement, and they incline to the belief that the 
teeth were only gilded, as oftentimes were their faces, as a means 
of decoration. On the other hand, there is the authority of Sir 
Gardiner W ilkinson, who states that he has seen teeth filled with 
gold in the mouth of a mummy at Thebes, and the fact that 
Herodotus mentions the existence of both oculists and dentists as 
specialists among the ancient Egyptians, makes the statement 
appear probable. 
Hippocrates, 500 B.C., and Aristotle, 350 B. C., wrote largely 
on the teeth. 2 
ORAL SURGERY. 
Celsus, 100 B. C., recomended the use of the file for removing 
the sharp edges of carious teeth. 
Galen, A. D. 100, treated the subject more extensively than any 
ancient author. 
iEtius, an Arabian, A. D. 300, discovered the apical foramen 
through which the nerves and vessels enter the dental pulp. 
From this time until the latter part of the middle ages, the 
practice of this specialty, like that of surgery, fell into the hands of 
mechanics. But about the time of the revival of surgery some 
advantages toward modern dentistry were made. Among the 
writers of this period were such men as Fallopius, Fustachius, and 
Pare. Later came John Hunter, and others of his day. Dentistry 
in those days consisted mainly in the construction of artificial 
dentures, and was practiced as an art, by jewelers—as a century or 
two before rude surgery was performed by barbers. 
During the eighteenth century the practice of this art began in 
America, but it was soon discovered that for the intelligent and 
successful treatment of the teeth some anatomical knowledge of 
these organs and the surrounding tissues was necessary, and the 
better class of those engaged in this calling began the study of 
their anatomy, physiology, pathology, etc., and some medical men 
began to engage in the practice. 
Societies were organized, journals and text-books published, and 
about 1839 the first dental college was established. American 
dentists soon became acknowledged of superior skill the world 
over. At this time the almost universal remedy for nearly all 
diseased conditions of the teeth, except simple caries, was the 
forceps and the substitution of artificial teeth. Now, exposed and 
inflamed pulps are saved alive; abscessed teeth, atrophied sockets 
and necrossed jaws, are successfully treated and saved; extraction, 
pxcept in extreme cases, is considered malpractice. 
Dental deformities are corrected; fractures of the maxillae, 
diseased antra, and all abnormal conditions of the mouth, are 
considered as coming within the province of a thoroughly educated 
dental and oral surgeon. Not only this, but by proper prophy- 
lactic measures in the young, impairment of these organs is, to a 
great extent, arrested. 
But while scientific dentistry has rapidly advanced, empiricism 
has not been idle, and it would be impossible to estimate the ORAL SURGERY. 
3 
amount of injury inflicted by the quacks with which the country 
abounds. 
The Society for the Prevention of Cruelty to Animals protests 
strongly against vivisections for original investigations; would it 
not be better employed in waging war against the wholesale 
extraction and mutilation of the valuable organs under considera- 
tion? 
The importance of good teeth to mankind is greater than is 
appreciated by many. Like the eye, ear, tongue, and other special 
organs, they are designed for a life service, and their preservation 
contributes valuable service to the human economy, while their 
premature loss is of serious damage to the whole body. 
In a late report of the Odontological Society, of Great Britain, 
Edward Canton, F. R. S., gives a large number of cases of habit- 
ual constipation, with enormous accumulations of faeces in the 
descending colon and distressing symptoms of all kinds, which 
were distinctly traceable to absence of, or a diseased condition of 
the teeth, to such an extent that mastication was not properly 
performed, and where treatment was without avail, until the mas- 
ticatory apparatus was put in proper condition, when the constipa- 
tion was cured. He says: “It is well known that imperfect 
mastication of food is a common cause of diarrhea, but few 
medical practitioners appear to be aware that habitual constipation 
is not unfrequently due to this cause.” 
“It is, in fact, scarcely possible to exaggerate the importance of 
proper mastication of the food. It should be reduced by the 
teeth to a complete pulp, and unless so reduced the digestion is 
sure to be deranged and general lowering of health will follow. The 
imperfectly digested mass, which passes through the pylorus, does 
not take up a proper amount of bile, nature’s purgative, and the 
consequences which I have just been describing follow as a matter 
of course. I have said that imperfect mastication always causes 
more or less general impairment of nutrition; this is sometimes 
very marked; the patient continues for some time thin and weak, 
and at last falls an easy victim to any illness by which he may be 
attacked. In women this general low state of nutrition greatly 
predisposes to barrenness. A young lady was brought to me by 
her husband; she had been married for some time, but had no 
family. She was thin, “ nervous, ” had no appetite, suffered from 
indigestion when she did eat, was restless at night, and had bad 4 
ORAL SURGERY. 
dreams. I asked her if she masticated her food properly, and she 
answered, “Oh yes;” but, on looking into her mouth. I found that 
her teeth were very badly decayed. I recommended the supply of 
molar teeth; they were adopted, the lady got stout and strong, 
soon became pregnant, and eventually had several children. So 
marked was the improvement in her health, and so evident the 
connection between this and the subsequent pregnancies, that when 
the husband paid me an occasional visit, and I asked after his 
wife, he used to answer, “Oh, she is quite well, thank you, Mr. 
Canton, she does not want any more teeth ! ” 
Dr. Oliver Wendell Holmes, in a commencement address 
delivered before the students of the Dental Department of Har- 
vard University, after speaking in his happy strain of the value 
of the teeth in relation to the beauty of the human countenance, 
says: “ But we must add to this the consideration, that speech is 
so largely dependent on the perfection of the teeth, that language, 
we might say, loses a little with every tooth that falls. What can 
be more painful to witness than the efforts of a hapless friend to 
bite his consonants out of the alphabet when he is reduced to the 
condition of the infant, whose boneless gums are unfit for any 
task but the caressing pressure of the maternal mouthful! ” “ And 
then the humbler, but still necessary function of mastication, how 
much depends upon the ease and perfection with which this is 
performed! You can tell the state of a village by going to the 
mill. If it has enough to grind, and grinds it well and cheaply, 
you will find good farms and well fed people; so if you see a good 
square jaw, filled with good sound teeth, and moved by a set of 
muscles that mean business, and do it, you will find in all proba- 
bility, that they nourish a sound frame in man or woman.” The 
teeth and their surrounding tissues, connected as they are through 
the fifth pair of nerves with the centers of inervation and the 
vasomoter system, do undoubtedly, when in an abnormal condition, 
exert through the ramifications of these nerves a baneful influence 
through the body. I am continually impressed with the ignorance 
of the public in regard to this matter of so much value to their 
general health, that if they could only be made to understand 
more fully about it, I think they would be saved a great amount of 
suffering, to say nothing of saving them from bad dental practice, 
which instead of encouraging the preservation of these useful 
organs, hasten their destruction and loss. Even physicians are ORAL SURGERY. 
5 
not as well informed on this subject as they might be, to advant- 
age. As medical colleges are now conducted, medical graduates 
go forth in as great ignorance of diseases of the teeth as do dental 
graduates of general disease. Lest you think me opinionated in 
my views on the subject, let me quote what I heard J. Marion 
Sims, M.D., say at a meeting of the New York Odontological 
Society. “As to the effects of diseased teeth upon the general 
health, I wish medical men generally could be better educated 
upon that point. We are all familiar with the fact that decayed 
teeth frequently cause neuralgia; and this is the extent of medical 
education on this point. They usually do not recognize the fact 
that, as a general thing, decayed teeth, teeth with inflamed alveo- 
lus, with matter exuding from around the teeth, are the means of 
producing more nervous disorders, more terrible consequences to 
the general health, than almost any other thing that can happen.” 
Some simple knowledge of this subject would 
enable the medical man to treat them more successfully than he 
does. It is a matter of regret that medical men generally have 
so little knowledge of this subject.” He related numerous cases 
to illustrate his views. 
At the same meeting Dr. Frank Hamilton expressed similar 
views. 
Samuel Sexton, M.D., Surgeon to the New York Ear Dispensary, 
in the American Journal <f Medical Science, says: “The apathy 
which has always existed on the part of the profession regarding 
this subject has left the treatment of diseases of the teeth in the 
hands of men who have occupied themselves almost exclusively 
with its mechanical department, and who, as a rule, have but little 
to do with the teeth in a medical aspect. It is greatly to be 
regretted that a field of such interest has been abandoned by the 
profession. Many affections of the teeth lead to most grave and 
intractable diseases of the regions presided over by the sympa- 
thetic system, which are often suffered to be long unattended 
before they are brought under appropriate management. Thus an 
ear, eye, or throat difficulty may become firmly seated, or a neu- 
ralgia, which renders life intolerable, established. When I look 
back at the operation for the removal of Meckel’s ganglion, which 
I twice witnessed, for the relief of facial neuralgia, it occurs to 
me that the most simple of remedies could have controlled that 
disease when it was first induced, as was probable in these instances, 6 
ORAL SURGERY. 
by a carious tooth. I think you will find Dr. Sexton’s article well 
worthy of perusal. 
I cite the following case from my own practice—a simple one— 
as showing long continued unsuccessful treatment of neuralgia of 
about five years standing, of the trifacial nerve, caused by a perio- 
dontal abscess opening into the antrum, and causing severe neu- 
ralgia, with the absence of pain in the teeth, which caused the 
trouble. 
Mrs. H., aged 50, was referred to me September, 1881, by Dr. 
C., for treatment. I found the left superior canine with its crown 
missing, and the root loose from chronic periodonitis. The bicus- 
pid and first molar were missing, and half an inch above the 
margin of the gum, at a point formerly occupied by the second 
bicuspid, a fistulous opening was discovered, which, upon probing, 
was found to lead to the antrum. Removal of the canine root 
was followed by a single discharge of pus, and a probe passed 
into its socket also entered the antrum. Surrounding each of 
these openings was carious bone, greater in amount, however, at 
the canine opening where the maxilla was dissolved, for a space 
half an inch in diameter. 
Having thorouglily removed all diseased bone with bone-cutting 
burs, in the dental engine, I then, by means of a small tube 
attached to a fountain syringe, allowed about a pint of warm salt 
water to flow into the antrum at the anterior opening, which made 
its exit at the posterior opening. 
By changing the tube to the posterior opening, I reversed the 
current, thus insuring thorough cleaning of the sinus. This was 
followed by an injection of, 
Eucalypti (Sanders’ Sons), 3 i. 
Iodoformi, gr. x. 
Aquae, 3 j. 
M. 
Then a tent of candle-wicking saturated with glycerine and euca- 
lyptus, was passed into the antrum at the anterior, and brought 
out at the posterior opening where the two ends were tied together. 
A few days later floss silk was substituted for the wicking. This 
treatment continued a week, when the tent was omitted and the 
patient being instructed, from that time, kept the parts clean her- 
self. In a month, after a few stimulating injections of ORAL SURGERY. 
7 
Zinqi Sulphatis, gr. iij. 
Plumbi Acetatis, gr. v. 
Tinctura Catechu, gtts. x. 
Aquae, 3 i. 
M, 
the parts had regained their normal condition, the neuralgia dis- 
appeared, and the openings gradually healed. The fountain syr- 
inge for thorough cleansing of the antrum I find very useful. I 
have never seen its use for this purpose mentioned, nevertheless it 
may be an old idea, though new to me. It is more easily man- 
aged, either by operator or patient, than any other form of syringe. 
I have always believed that dentistry ought never to have been 
established as a separate profession, but that any one desiring to 
practice in any department of medicine should be required to fol- 
low a regular medical education, and then to perfect himself in 
the desired specialty. 
I think that a few lectures on dental pathology, introduced into 
our medical courses, would be of great value to the general prac- 
tioner. I desire to ask the cooperation of the medical profession 
in the preservation of the temporary and deciduous teeth. You 
come more in contact with the little ones, and have better chances 
of observing their mouths, and of giving advice to their parents 
than the dentist. 
The deciduous teeth for the most part receive attention only 
when the sufferings of the child render palliative treatment neces- 
sary. Perhaps you are not fully alive to the consequences, direct 
or indirect, of the premature loss of these organs upon the future 
health and comfort of the child. 
On these teeth to a great degree depends, not only the regularity 
and usefulness of the permanent set, but the perfection of the 
whole physical organization. At no other time in life are sound, 
serviceable teeth more necessary as aids to digestion than during 
these years of growth and development. It is therefore a sad 
mistake when temporary teeth are permitted to be prematurely 
extracted. Serious may be the consequences when days and nights 
of odontalgic pain are suffered to elapse without mitigation. In 
fact the health and welfare of the individual may be seriously 
impaired by a neglect of the treatment which these teeth demand 
in the majority of cases. Parents have not been educated as to 
their value, and a great many dentists practically ignore the matter 8 
ORAL SURGERY. 
because of the difficulty and tediousness of operations on the teeth 
of young children, and because these cases do not directly pay 
pecuniarily. 
I would not have you construe what I have said concerning 
premature extraction of these teeth in meaning that they should 
never be extracted, for oftentimes the removal of some of them is 
an absolute necessity, as for example, an alveolar abscess con- 
nected with the deciduous tooth not unfrequently results in necrosis 
of the surrounding bone, involving oftentimes the loss of the 
germs of several permanent teeth. The following case illustrates 
this point: 
Johnnie F., of Irish parentage, and scrofulous diathesis, about 
five years of age, was brought to me by his mother, who desired 
the extraction of the right inferior second molar to relieve pain, 
which he referred to that tooth. Examination showed the sur- 
rounding parts congested and highly offensive, but the tooth com- 
plained of was so slightly attacked by caries as to show at a glance 
that it was not the cause of the trouble. Traction upon it how- 
ever. showed it, and a portion of the adjoining bone, quite loose 
and free from the maxilla. After making a slight incision I was 
able to gently lift out the exfoliated portion (which I pass around 
for your inspection). It will be observed that the germs of the 
permanent bicuspids are in the sequestrum, but on examina- 
tion of the boy’s mouth at the present time (it being now about 
seven years since I first saw him), shows the permanent canine 
also missing, the germ of which occupied the space where the 
most acute inflammation seems to have been. Owing to igno- 
rance of the mother the history of the case is rather meager, she 
not being aware of any trouble until a day or two before consult- 
ing me. I am inclined to think, however, that the trouble resulted 
from a blow which the boy said he received about a year before. 
The only after-treatment required was thorough cleansing with 
carbolized water—the parts healing generally. 
The whole of the time allotted to me for this essay could to 
advantage be used on this question alone, but I will tax your 
patience only long enough to again ask that you use your influ- 
ence in trying to impress upon parents the necessity of having 
these teeth carefully and frequently examined by a competent 
practitioner, for more can be done to avoid impairment of the 
teeth before the age of twelve than at any other time. ORAL SURGERY. 
9 
While speaking of children, I will simply call yonr attention 
to a deformity of the oral and nasal cavities and the adjacent 
bones, which often seriously impairs mastication and speech, and 
occasions difficulty in nasal breathing, with its attendant ills. In 
this deformity, which is produced by the habit in the infant of 
thumb-sucking,* there is a forward and upward projection of the 
superior maxilla, accom- 
panied by a fan-like 
projection of the teeth 
and upper lips. The 
bones of the floor of the 
nares are elongated, nar- 
rowing the nasal cavity, 
and generally there is a 
lateral deviation of the 
bridge and septum of 
the nose which causes stenosis, from the thickening of the tissues. 
In the lower jaw a reversed deformity often exists which deranges 
the proper articulation of the teeth, interfering with mastication, 
and consequently impairs digestion. The practice of lip. finger, or 
tongue-sucking may be reckoned under this head, and can cause 
considerable deformity at an age when the parts are so easily moved 
and moulded, and whenever any of these pernicious habits have 
been formed in children, no pains should be spaied to break them 
up. This habit, apparently so innocent, is often encouraged by 
those ignorant of the consequences, as the peace and quiet given 
to parents while irritable infants are so engaged is considered 
especially desirable. 
Although a habit hard to correct, even in quite young children, 
and one which waxes stronger with increased years, to break it up 
is easier than to remedy the resulting deformity. A night dress 
without sleeves, fitting tightly about the neck, inside of which the 
arms can move at will, is one good mode of treatment A very 
interesting article on this subject will be found in the Boston 
Medical and Surgical Journal, 1878, by T. H. Chandler, D.M.D. 
Physicians and dentists have long observed that during preg- 
nancy the teeth of females are particularly prone to decay. W bile 
♦Through the kindness of Norman W. Kingsley, M.D.S., D.D.S., I am allowed the 
use of this figure (from his work on “Oral Deformities”), which shows a deformity result- 
ing from thumb-sucking. o. k. p. 
G. K. P. 10 
ORAL SURGERY. 
I have never met with any theory as to the cause of such increase, 
T am inclined to the opinion that to the abnormal condition of the 
female pelvic organs, acting through the digestion, together with 
a vitiated condition of the oral fluids at this time, is due this 
result. 
The same is true, to a great extent, of females suffering from 
uterine diseases. When such a condition exists, whatever the 
causes, the treatment should be of a temporary nature, so as to 
lessen the strain on the nervous system of the patient, and because 
so-called permanent operations will, while the same predisposing 
causes exist to produce caries, be found soon to fail. Gutta percha 
or oxyphosphate of zinc fillings will be found in such cases to out- 
last any metallic stoppings. 
Having often been consulted by medical men as to the advisa- 
bility of extracting teeth from the mouths of pregnant women, a 
few words here, on this topic, may not be out of place. While 
the extraction of a tooth is an operation of common occurrence, it 
should not be considered as trifling, for it produces invariably a 
sudden nervous impression—shock. 
There is a rupture of from one to three square inches of living 
tissue, containing blood-vessels, and from one to four nerves, 
while often there is more or less extensive fracture of the bony 
processes and profuse hemorrhage; and in the case of a pregnant 
woman, all these things should be borne in mind, together with 
her previous history and condition. 
That which may be endured with impunity by the nervous 
system at one time, may at another be attended by serious injury 
and prostration. The condition of the tooth also should be taken 
into consideration, as to its amenability to temporary treatment 
for allaying pain incident to it, also to the amount of force required 
in its extraction, and the consequent shock. 
Where a choice has to be made between allowing a tooth to 
remain, involving odontalgia, severe neuralgia, antral or alveolar 
abscess (conditions compromising the general health and comfort 
of the patient), and the removal of the offender, the latter course 
I should think the proper one to follow, but this contingency can 
usually be avoided, and does not often arise. It should be a choice 
between two evils, and especial care should be used to avoid, as 
far as possible, all nervous impressions. When extraction must 
be resorted to, I should advise the use of an anaesthetic, preferably ORAL SURGERY. 
11 
nitrous oxide, there being less danger attending its administration, 
and because its effects so quickly pass away; and furthermore the 
operation had better be performed at the home of the patient, 
especially if she be in delicate health, so as to avoid the nervous 
irritability which is often awakened by seeing the paraphernalia 
of the extracting room. I should consider it reprehensible to 
extract teeth at this time to prepare the mouth for an artificial 
denture, as the operation should only be performed during preg- 
nancy as a last resort. 
As the greater danger of miscarriage exists in the earlier months 
of pregnancy, temporary treatment, if possible, should then be 
resorted to, if only for a few weeks. Still, where the tooth is not 
easily amenable to treatment, I believe that the shock from extrac- 
tion would be less likely to do harm than the exhaustion produced 
by long continued pain. 
In ending, I can truly say that 1 feel honored with mv appoint- 
ment as an essayist for this occasion, an honor which I desire to 
acknowledge.