thereafter. With the choice of these three evils, it is not difficult to decide which one he would choose for himself; then why not make the same selection for his patients?

INFECTION.

A volume might be written upon the subject of infection, and the writer is assured in advance of severe criticism of his ideas of oral infection, but it will be noted that these criticisms only come from those who cling to practices of the past, who have not tried his methods, and therefore are in no way capable of judging of his results. Facts, like mules, are stubborn things, and the patients themselves are incontrovertible evidences of the soundness of his methods.

While some of the leading oral surgeons and clinicians of the day curet and pack the socket after removal of the impacted tooth, what have they to show for it? Only suffering and discomfort, inconvenience and expense!

MODERN SURGICAL PRACTICE.

It is an assured fact that the better class of general surgeons are getting farther and farther away from drains and packings. Twenty-five years ago, Twenty-five years ago, ninety-five per cent. of clean abdominal operations were drained. Today, unless there is considerable oozing or strong suspicion of active infection, no drains. are used. Whenever a drainage-tube is used, the natural exudate is constantly interfered with by the irritating action of the tube, and therefore the period of healing is prolonged.

Of late years the general surgeon, that is, the more observing general surgeon, has come to realize that the less he does after the operation to interfere with the natural processes of repair, the better it is for the patient.

When the writer discontinued the packing of sockets, many years ago, he still considered it necessary to wash out the wound from day to day with an antiseptic solution, and devised an apparatus for doing this, but for several years past this also has been absolutely discon

tinued, upon the principle that the less we do for that socket after a nice clean surgical operation has been performed, the better it is for the patient, and the results obtained prove the theory to be

correct.

CHARACTER OF CLIENTÈLE AS A POSSIBLE FACTOR.

Possibly the character of the practice. bears some relation to the possibility of infection. It must be admitted that all of the writer's experience has been with the better class of patients, and thus he deals practically only with rather clean mouths, pretty well taken care of.

Possibly patients in a charity clinic might not make such a favorable showing, and in that case he can conceive that even with his operation the daily flushing of the socket with warm saline solution might be advantageous for a week or so, though he doubts it. But as for packing, Never!

NATURE'S METHOD OF CARING FOR WOUNDS CAUSED BY EXTRACTION.

Let us now consider what occurs after the extraction of a tooth when nature is given a chance. First, hemorrhage occurs and then the socket is immediately flooded with saliva-saliva possibly carrying some pathogenic organisms.

A blood-clot is formed in the socket and some active ferment is at once formed in the tissues practically in contact with the blood-clot, and this successfully combats the organisms carried in the saliva. An exudate is thrown out, and under these circumstances healing takes place rapidly.

SURGICAL INTERFERENCE.

On the other hand, a tooth is removed, whereupon blood flows and the socket is again flooded with saliva. But not contented with nature's way, the socket is curetted and packed with gauze. Or, possibly, it is just packed with gauze without being curetted.

Under these adverse conditions, does

nature just "throw up the sponge" and quit, and leave it all to the surgeon? Not at all; she still does the best she can to overcome his errors, and starts the ferment, the exudate, and the process of healing. Next day comes the operator, who removes the packing, which process simply tears to pieces the work of healing which nature has been doing during the previous twenty-four hours. Then he repacks the wound, only to repeat the destructive process next day.

USE OF IODIN IN THE SOCKET CONTRAINDICATED.

Possibly the socket is swabbed with iodin. Now, what does that mean? One of two things: (1) If the socket has not been effectively dried (which usually is impossible) and iodin is applied to the wet surface, it is absolutely ineffective just so much time and iodin wasted; and (2) If it were possible to thoroughly dry this surface and apply the tincture of iodin to it, then iodin, being destructive to such a new growth as is found in a healing socket, does it more harm than good, and consequently, better results, and quicker healing would be expected without its use.

However, as a matter of fact, it being practically impossible to dry these surfaces, the iodin does not do very much harm after all. And so this continues for days and weeks! A large portion of what nature accomplishes during twentyfour or forty-eight hours is quickly destroyed by the removal of the dressings. And what have the dressings accomplished? Merely a prolongation of the period of healing.

A truthful verdict upon the procedure would probably read, "The socket gets well in spite of the operator, instead of on account of him."

CHARACTER OF THE BONY STRUCTURES.

If a section be made through the bony socket of the impacted molar, it will be observed that the portion of the bone covered by the periosteum is very dense and very smooth, while all the bony

structure within and protected by this external smooth plate is not only porous, but exceedingly so.

Under the writer's operation, very little of this dense external plate is interfered with, and consequently the bone itself is left in the very best condition for prompt healing. Under the malletand-chisel operation a large block of this external oblique line is cut away and a large surface of the porous bone is left exposed, and, from its very nature, possibly invites infection and its consequent train of troubles.

CLIMATIC EFFECTS.

The writer spends a good part of his annual vacations in visiting hospitals, clinics, and his professional friends in their own offices, all in eastern and western cities. Long ago he concluded from what was seen upon these visits as compared with what he saw in his own office, that oral infections, even after ordinary extractions, were much more common in

northern latitudes than in the south. The more he traveled and the more he practiced in his home city, the more he was convinced of this fact, but now he has changed his mind upon this point completely!

Is it a coincidence that all of this infection which follows tooth extraction which he has seen in the northern cities occurred in cases which were treated and

packed? Or was the infection due to the packing and treatment?

One of the reasons the general surgeon-the progressive one to whom reference has already been made has given up packings, is because he found that he occasionally reinfected his sterile wound by his packings.

THE TIME FACTOR.

It is admitted that the writer's operation, as practiced, is a somewhat lengthy one, but it is claimed that it is humane.

THE HUMAN FACTOR.

Simply because the method of removing such a molar by the mallet and chisel

is quick and comparatively easy, should such a method necessarily be employed? Again, simply because the writer's method is not quick and easy, but requires much more time and is much more difficult for the operator, should it be condemned? Should not the welfare of the patient be the paramount issue?

THE PRECEDENT OF GENERAL PRACTICE.

Just because a method is "general practice" does not necessarily make it correct practice. Some man of note "starts something"; it looks good and is apparently successful, and thus soon becomes general practice. After a while, possibly someone else, equally as prominent, brings out a much better method, and the most progressive men adopt it, and so what was general practice once upon a time is now only practiced by a few.

Under this rule, general surgery has undergone radical changes within the past few years, and it has been shown that some of these changes in general surgery were worked out independently by the writer in his operation for the removal of impacted third molars. Of late, a number of operators have adopted this operation, and undoubtedly, in the not distant future, all who have the best interests of their patients at heart will be compelled to give up the mallet and chisel, and also either adopt this method or devise one equally good-perhaps better-and get in line with modern surgical practice, discard the gauze packings, discontinue the disturbance of the socket, and give up using iodin where it is entirely ineffective.

1237 MAISON BLANCHE.

Notwithstanding the previous record, no curetting, packing, or washing of the socket followed, healing progressed rapidly, and the patient is not only still very much alive-two years later-but as fine a specimen of womanhood as one ever would want to see.

It would probably be difficult to find a better case than this one to illustrate the value of no after-treatment in these cases. An impression was taken before the extraction of the tooth, and after the model was poured the extracted tooth was set in the model in the position it held in the jaw.

T

HE subject about which I shall speak tonight has so long impressed me as being one of very large proportions that I am unwilling to concede that any other phase of dentistry exceeds it in importance.

I have the honor this evening to address the Pennsylvania Association of Dental Surgeons, yet I am constrained to believe that most of you are in general practice, and that many of you are at least occasionally required to perform a service in prosthesis. To be interested in but a portion of a subject is not to be interested at all, but to be interested in any subject in its entirety is to love it and find an interest in all its details.

I am bringing to you tonight, as a result of my own interest, an enthusiasm with which I hope to infect every man present; and to that end I have assembled certain facts, and evolved methods pertinent to them, to which I shall direct your attention.

It is a well-known fact that in prehistoric man, and through all subsequent periods of which we have any knowledge, there have existed at least three fundamental basal types of tooth form to which all others may be related and classified. The dentist, however, has made little use of these facts other than to accept them with reservation, and has continued to take what he could find in the way of artificial substitutes without availing himself of the practical helpfulness of a knowledge of these basal considerations now easily within his reach.

The study of the anatomy and physiology of human teeth, and the selection and adaptation of porcelain substitutes with reference to the restoration or creation of a temperamental harmony, which all true dental prosthesis embodies, is a part of our field of study as dentists that we can ill afford to neglect. To pass over this lightly is more than a neglect of duty to dentistry itself; it is to debase prosthesis by allowing that department to fall into the hands of the

mere mechanic, who is in no way equipped or competent to render anything beyond a purely mechanical service.

I do not intend to offend or to detract from the importance of the skilled mechanician, but dentistry cannot be practiced by correspondence, nor is it reasonable to expect the highest esthetic attainment in a prosthetic restoration from one who has never seen the patient. The hope of creating a demand for better things in dental prosthesis by placing the subject in a comparatively new light is uppermost in my mind.

The discussion of "type vs. temperament" has always divided the point of view of the profession to such an extent that it has impeded progress along the lines of so-called "mechanical dentistry," and furthermore, it has prevented the subject from being taught from any definitely established standpoint. Consequently, I have assumed a rôle requiring some resolution and courage on my part, in that I shall endeavor to bring all parties together on the ground that the

difference is in appearance and not in reality, a difference of nomenclature only, and that the word "temperamental" applies only to the effect obtained by the judicious selection and application of true types or their modifications. In recalling discussions upon the subject I have been convinced that the dental profession is less interested in theories along prosthetic lines than it is in facts practically systematized to their advantage and so placed before the practitioner as will enable him to make practical use of them in a systematic and rational way.

The existence of the basal types is so thoroughly an established scientific fact that argument upon that point at this date would be a waste of time. See writings of Williams and of the writer.*

The establishment of the basal types has done much to simplify matters, for as there are three prime forms as a basis for typal classification, it must also of necessity be the foundation for the temperamental theory as herein previously defined; consequently, those who once differed vehemently may now select their artificial teeth from the same assortment, and any remaining differences may be explained by the fact that the eruption and development of the teeth of the human race is from a practical viewpoint entirely arbitrary, as a result of the unrestricted interbreeding of human types, and teeth therefore become a law unto themselves. Consequently, as far as the dental profession is concerned in matters pertaining to the selection of artificial teeth, the term "temperamental" may be limited to express the result attained by the judicious arrangement and application of the basal types. Moreover, these types in nature, as progressively and automatically rearranged in the mouth of man by wear, by characteristic habitual mental traits, physical limitations, and changes due to the loss of other teeth, necessarily ex

*See, e.g., my three former articles on "Type vs. Temperament in the Selection of Teeth," DENTAL COSMOS, 1917, vol. Ix, pp. (I) 879, (II) 1110, and (III) 1218.

press characteristic temperamental harmony, or so-called temperament.

The policy which I have adopted in practice is to use as standards for the three fundamental types the strongest and most characteristic examples of each, and make suitable modifications expressive of crossings or composites to suit my purpose by changing the contour lines at certain definite points by grinding.

After carefully viewing the subject from its several angles we must eventually reach a point where we begin to discover the system or order involved in the sequence of events, which not only throws additional light on the principles underlying the question of selection, but also enables us to systematize the process and to clearly and definitely outline a policy which demonstrates its practical value, and at the same time illustrates the importance of the personal factor when methodically applied in prosthetic dentistry.

He who elects to study dentistry doubtless does so because he imagines he is by nature endowed with talents of a kind that will lead eventually to a measure of success in the practice of his chosen profession. During his collegiate preparation or the pre-graduate period an absolute failure in any one branch or department will preclude the possibility of his graduation; so also will the absence of the factor of personal fitness or adaptation to the requirements of his calling cause an absolute failure in the subsequent or post-graduate career of the student of dentistry; for one must ever be a student, and in consequence of the absence of this quality of natural or acquired fitness for the praetice, we continually meet with examples of prosthetic dentistry which shock and outrage every artistic sense, even before the observer is near enough to determine whether or not there is any technical merit in evidence in the case.

It is to this end the writer has devoted time and thought in the past with the hope that an influence for the betterment of dental prosthetics might be brought to bear upon those on whose