all sizes and lengths ; usually it will be found that
it is best to use a combination of strips and
cylinders, filling the greater part of the cavity with
the former, and finishing with the latter. A certain
amount of condensation has, of course, been going
on all the time. The corners have been secured,
and the edges have been packed, but when we have
packed in as many pieces as there seems room for,
we go over the whole surface again, beginning in
the middle of the filling with a small truncated
cone-shaped instrument, and, wherever we find a
soft place, we try, by pressing the gold laterally, to
force the plugger down to the floor of the cavity,
and thus make space for more ropes, or cylinders.
Thus forcing the plugger into every soft spot, we
gradually condense the mass, until the plugger will
make no more impression upon it ; but even now
the gold should everywhere stand higher than the
walls of the cavity. The burnisher may now be
used over the whole surface with plenty of muscular
power, and the surface filed down with a thin
dividing file (an file is not too thin in the case
of front teeth). Then the burnisher must be used



TREATMENT OP ADULT TEETH. 129

again, alternately with the file, until the surface is
smooth and shaped as we wish it to be, when the
polishing tape will complete the work. Very excel-
lent fillings are made in this way, and I quite
believe that in many cases it is the most trust-
worthy method ; but we must not be confined to
one method. In general practice, one will, I think,
find that lining the cavity with soft gold, packing it
well against the lateral walls and floor of the cavity,
filling the cavity half full, in fact, and then finish-
ing with cohesive gold, will give better results, with
less time in the manipulation, especially in front
teeth which are badly decayed and have thin
delicate walls. A loose twist of No. 6 foil is first
packed against the cervical wall of the cavity and
part of the labial wall, then, before it is wholly
condensed, another piece is packed into the narrow
part of the cavity towards the cutting edge, securing
these two points so that there is no rocking of any
portion of the gold. Another piece may then be
added at the cervical and lingual corner, and
secured there. Then, if the gold is sufiiciently
clean and dry, that is, if it has not been fingered
with moist hands, the whole may be packed down
together, — the loose thin ends of the twists being in
this way interlaced. Only fine serrated points are
to be used for a filling of this kind, and the surface
is never to be smooth until the last piece of gold
has been added. A small piece of cohesive gold
may be added now and then, while the soft portion
of the filling is being packed down and thoroughly

I



130 DENTAL PEACTICE.

condensed. The cohesive pieces serve to unite the
loose folds of soft gold, and, being packed into the
corners, are useful for anchorage to the bulk of the
cohesive portion of the filling ; but if sufficient care
has been taken to keep the work and the material
quite dry, there will be no difficulty about the parts
adhering, and the filling can be built up from the
soft gold foundation, so as to make it a perfectly
cohesive mass. The best soft gold can always be
made sufficiently cohesive by passing it through the
flame of a spirit lamp, thus thoroughly drying away
the moisture it has absorbed from the atmosphere, and
burning any greasy deposits it may have received in
the process of manufacture, or from subsequent
handling. A filliug may be built up to any desired
contour, if only the ultimate form of the filling is
kept constantly in mind ; and those parts which are
most difficult to reach with the instruments are
built up first, and so on, finishing with the most
accessible parts. Great care must be taken to
finish the gold down flush with the surface of the
tooth, particularly at the cervical edge, where any
projection of the gold, or overlapping, will quickly
destroy the work by causing renewed decay.

Some practitioners use gold in the cohesive
form from the beginning of the filling. A few
retaining points are made with a drill, and then are
packed with cohesive gold, which is added to, little
by little, until the starting points are all connected,
and then the work may proceed with a little more
rapidity. Screws are sometimes used instead of



TREATMENT OF ADULT TEETH. 131

retaining points made with a drill simply, but as a
drill must be used to make the screw-hole, and as
one piece of gold can be united to another in a tube
so as to sustain a weight almost equal to what
would be sustained by the same quality of gold
melted and drawn into wire, it is difficult to see
what advantage is derived from the screw. It may
save a little time now and then in very accessible
places, but, as a rule, the difficulty of securing the
screws only complicates the work without any real
advantage. Indeed, to any one who has dry hands so
as to be able to make up the twists, or folds of soft
foil, without making the gold greasy, there can be
no possible advantage in making the whole filling of
cohesive gold.

The student should first learn to do these things
well, and then to do them quickly. The amount of
time spent in many operdltions on the teeth, and
the appliances which become necessary, because of
the time, render these operations far more formid-
ble to the patient, and fatiguing to the operator,
than is necessary or profitable. And here let us
consider who is benefited by the greater part of the
modern appliances used in operations on the teeth.
Admitting that a man must be paid for his work,
and for the time he has spent in learning to do it,
the chief object in the practice of dentistry is, or
should be, the good of the patient. The ideal
physician is not one who makes it the chief object
of his life to put money in his purse ; and even
looking at it from the purely selfish point of view.



132 DENTAL PRACTICE.

lie would not find it for his interest to have his
patients consider this to be the ruling motive of his
practice. Nor would any one be willing to admit
that, in our own speciality, the chief end of dental
practice is the glory or profit of the dentist. What,
then, is the object of the greatly increased amount
of labour and time bestowed upon these operations
now, compared to those of thirty years ago ? The
best operators of those days saved the teeth, and
made them useful. Many of their fillings are to be
found in the teeth of middle-aged men and women
now, yet I doubt if many of them spent four or six
hours over any one fiUing. Someone will say that
they condemned many teeth which are now saved.
It may be so, but the teeth that they considered
hopeless, can be saved, and made comfortable with-
out spending so many hours over them, as I will
show later on. But do we now, by spending so
much more time and labour, save the majority of
the teeth we fill any longer than they did by their
much less pretentious method of practice ? A case
came under my observation a short time ago which
will illustrate my meaning. A young man, who
had been under my own and my brother's care
almost from childhood, was staying in New York
for a time, and while he was there an upper molar,
in which my brother had been trying to save the
pulp, began to give the usual indications that the
pulp was in a putrescent state. The patient was
well informed as to what might occur, and at once
sought advice, and obtained relief by the usual



TEEATMENT OP ADULT TEETH. 133

treatment. When the periostitis was supposed to
be cured, the tooth was filled. But it had been pre-
viously filled in several places, and it was thought
expedient to remove all these fillings, and make one
grand gold filling of about two-thirds the crown of
the tooth. After all preparations were made, four
hours were spent in packing the gold, by the
malleting process, and two hours in finishing the
work. This proved to be too much for the poor
dead tooth, and alveolar abscess of the most obsti-
nate and persistent character was the result. Four
months later he came back io England, and at
once came to my brother for advice. Pus was
oozing from around all the roots, and the probe
indicated great loss of bone, which indeed was quite
perceptible to the touch of the fingers. The tooth
was loose and sore. Except about the neck, it
was quite evident that the alveolus was entirely
destroyed. Treatment was hopeless, and as the
patient thought he had borne with it long enough,
the tooth was extracted. I have no doubt that if
this tooth had been filled with amalgam, it would
have been a comfortable, useful tooth for years ;
only, it is possible, somebody might have made the
patient believe he was being poisoned. But it was a
favourable opportunity to show the dentist who
had looked after this mouth, what beautiful work
could be done with gold, and the patient was
undoubtedly pleased with the idea of having such a
piece of work in his mouth. It was indeed a
beautiful filling, but it was time aud expense



134 DENTAL PRACTICE.

wasted, for it was an utter failure. Certainly this
was not an instance where modern practice was an
improvement on that of thirty years ago.

The rubber dam is very useful sometimes ; but,
in a large proportion of the cases one has to treat, it
is unnecessary, except for the convenience of the
dentist, because it enables him to leave the patient,
without danger to his work, and go to his lunch, or
to see another case for a moment. This is a mani-
fest injustice to the patient, who is fairly entitled to
be considered, and whose time may be as valuable
as our own. There are few cavities where more
than fifteen, twenty, or thirty minutes will be
required for packing the gold, and there are not
many mouths where a napkin, properly arranged,
will not preserve absolute dryness for that length of
time. If the gum has been wounded, a twist of
cotton pressed up between the gum and the neck of
the tooth, or a little elastic band, cut from a piece
one-eighth inch French elastic tubing, slipped over
two teeth, or the cotton twist and the elastic band
in conjunction, will be enough to stop any exuda-
tion of blood or lymph, and certainly these are not
so formidable as the way patients are often gagged
with the rubber dam. But this is not enough for
some operators. The "saliva ejector" is fixed to
the mouth — a sort of hydraulic pump— to take away
the saliva as fast as it is secreted. A "tongue
depressor" prevents any movement of that organ.
And with all these fixtures in the mouth a man may
go on operating for hours, if he likes, or, as a



TREATMENT OF ADULT TEETH. 135

patient told me a few days ago of an occurrence
that happened to himself, he was left with these
fixtm-es in his mouth, and a filling half completed,
for the ''consultation hour," at the expiration of
which the dentist came back refreshed, and resumed
his work. It cannot be said that this is done for
the good of the patient.

Again, there is the mallet, which is, without
doubt, a useful instrument sometimes ; but it does
not follow, because a little of it is good, that a great
deal must be better. It is an instrument to be used
with caution, because it causes absolute torture in
some cases, and it cracks the enamel of many a
delicate tooth ; yet it is used persistently and con-
stantly even in small fillings of the size of a pin's
head, because it saves the strength of the dentist.
This is a reason good enough in itself if it is frankly
admitted, but do not let it be urged that it is
entirely for the patient's benefit. No doubt it
makes a harder filling than is ordinarily made by
hand-pressure, but in approximal cavities it is not
the hardness of the filling which saves the tooth.*

' The late Dr. Marshall Webb, who was regarded as one of the chief
Bupportera of the theory that teeth which can be filled at all should be filled
with gold, and that wedging and malleting are essential processes in the
perfecting of gold fillings, wrote as follows in a letter published in the
Dental Cosmos of January, 1883 ; a letter which was evidently intended to
correct an extreme interpretation of his teachings and practice in the use of
the mallet, and which is emphatic enough in condemnation of its indis-
criminate employment : — " I cannot understand why men whose judgment
seems to be so sound on everything else, should in the use of the mallet
display such ignorance. They say you can pack more gold into a given
cavity by the use of the electric mallet than by any other process. Just as
thongh it was our aim to give our patients the value of their money in gold



136 DENTAL PEACTICE.

I am certain that the vitaHty of many a delicate
incisor has been destroyed by the " tap tap " of the
mallet. Every stroke is a shock, and, an assistant
being required to use it, the strength of the stroke
is not always under the control of the operator's
will. Last, but not least, the use of the wedge is,
as I have already shown, an abomination, which
intensifies the torture of the poor patient from all
the other appliances, and is itself the least excus-
able; for the only object that can be claimed for it is,
that it may enable the operator to restore a condi-
tion of things which led to caries, when the tooth
was sound, and is to prevent it in the restored state,
because the gold will not decay. No ; but the gold
filling never was made that was so perfect as the
natural covering of the approximal surface of a
tooth. If there are defects and fissures found by
the microscope in the enamel of a tooth, are they
not also to be found, by the same means, around
the edges of the most perfectly made filling ? I
contend that a contour filling is liable to fail,



foil, regardless of the ever-existing conditions debarring us from such a
course, and leading one to suppose that the greatest good to ourselves, and
to those for whom we operate, depends upon the greatest power we can
bring to bear in crowding and cramming the precious metal into the cavity.
I believe rather that our ultimate success lies in the reverse of this, — that
is to crowd as little as possible, bringing very little if any pressure upon the
walls of the cavity, — and in order to do this to use that form of gold which
requires the least force to consolidate. I think that successes are ten
to one in favour of this kind of gold, manipulated by hand-pressure instead
of by the mallet, no matter how light the blows may be. The mallet is a
good thing in its place, but it is, in the majority of cases, out of its place in
the insertion of gold fillings where cohesive gold is used in the form which
I have referred to." The reference is to small loosely rolled gold cylinders.



TREATMENT OF ADULT TEETH. 137

because it restores the original form of the tooth,
and that, being made after an unnatural inflamma-
tion has been set up in the socket by wedging, the
socket being at the time widened so that the
pressure comes more severely upon the end of
the root, and, therefore, upon the nerve where it
enters the apical foramen, the inflammation of the
peridental membrane is increased to a dangerous
extent ; and that the shock of the repeated strokes
of the mallet crushes the nerve, so as greatly to
endanger the vitality of the tooth.

I cannot see that any of these appliances are for
the benefit of the patient. Some of them benefit
the dentist, and are at times extremely useful to
him ; but it is an error to think that good work
cannot be done without them, and it is a greater
error to use them because it has become a sine qua
non that a man should make showy gold fillings if
he wishes to stand well with his fellow-practitioners.
Any one who doubts that these operations can
be done, and I do not hesitate to say well done,
without wedging, and the use of the rubber dam
and mallet, I would ask to look at Fig. 39, page 84,
which gives a very good idea of the extent of the
fillings in what may be described as a very wet
mouth. I made all the approximal fillings in both
sides of the incisors, canine and two bicuspids, by
the method I have described as a combination of
soft and cohesive gold. One of the laterals was so
seriously decayed that a part of the labial wall was
broken down, and the lip covering the tooth well,



138 DENTAL PRACTICE.

I restored the contour. All this was done without
using wedge, or rubber dam, or mallet.

The following extract from a letter to the late
Dr. Eobert Arthur, printed as a foot-note, on page
141 of his work on the Treatment and Prevention of
Decay of the Teeth, is a frank acknowledgment of
what must occur in the practice of every man who
persistently pursues this course of treatment, but
not many of them are ready to admit their
failures: — "I have to deplore the comparative
failure of some of the most perfect and beautiful
fillings, that cost me hours and days of patient
painstaking labour. I particularly refer to those
cases where the teeth were ivedged'^ apart, carefully
and perfectly filled, without making a file scratch
upon the proximate surfaces, and then allowed to
drop back to their natural positions. Dr. Eleazer
Parmly, of New York, paid one such of my cases
the compliment of saying it presented the most per-
fect specimens of proximate filling he had ever seen,
and yet, although the patient was an attentive and
appreciative one, who was fully instructed, and
spared no pains in the care of her teeth, decay,
after a few years, commenced around the edges of
the fillings. I had to file the spaces so that the
teeth were permanently separated, and refill all the
cavities. This is only one very marked case in
my experience. Many, very many, others have
occurred in my practice, and came under my
observation."

c ' - * The italics are his own. — ^



TREATMENT OF ADULT TEETH. 13^

I have just had my attention recalled to a case
that came into my hands two or three years ago.
A lady was suffering from alveolar abscess, caused
by a dead pulp in one of the upper central incisors,
and she told me that she has been constantly
troubled with her front teeth for several years ;
indeed, they were dreadfully painful when they were
filled, and had been more or less troublesome ever
since. She had a great deal of good work in her
mouth, and the larger part of the fihings were saving
the teeth. The two central incisors had fillings in
the mesial surfaces, and both teeth were dead, but
there was nothing in the appearance of the fillings to
justify me in removing them. So I drilled into the
pulp cavities from the lingual surfaces, found
putrescent pulps, as I expected, removed them, or
the remains of them, treated the roots with anti-
septics until they were clean and healthy, and then
filled them. She told me that the teeth had been
wedged apart when she was about thirteen years
old, and filled then with gold; that she suffered
dreadfully when it was being done, and for weeks
after ; that then there was a period of comfort with
them, and afterwards she began to have a swollen
face every time she was exposed to cold. This is a
common history, such as we have all heard over
and over again. Of course it is impossible to say
whether the vitality of these two teeth was destroyed
by wedging, or by the mere insertion of the metallic
fillings on a sensitive surface, and the consequent
frequent shocks from thermal changes. But whether



140 DENTAL PRACTICE.

it was by one or the other, or by both combined,
the mischief was certainly to be traced to the
filHngs, and as certainly it would not have occurred
if the cavities had been excavated, without wedging,
from the lingual surfaces, and filled with gutta-
percha until the patient was a few years older. I
have seen the lady again quite recently. She had
not suffered again from swollen face, but one of the
teeth had begun to decay around the edge of the
approximal filling, and I had to refill it. This
gave me an opportunity of satisfying myself about
what I had before only suspected, viz., that the
original cavity had not penetrated so deeply into
the tooth as to affect the pulp.

The history of our professional progress in the
last decade shows how men, who labour for the
profession, may be misunderstood and misrepre-
sented, as in the case of Dr. Foster Flagg, who has
devoted these later years to an effort to lift our
specialty out of a narrow groove, and give its
practitioners the broader views which should dis-
tinguish professional men. To do this more
effectually, he refuses to treat those teeth which can
be saved by gold fillings, and devotes himself solely
to the saving of teeth which the gold workers would
consider hopeless from their point of view. He
uses only the plastic materials which those workers
in precious metals affect to despise, and does more
than any other man has ever done to improve the
character and preparation of these materials. He
sacrifices the credit which the profession gives to



TKEATMENT OF ADULT TEETH. 141

men who do only one kind of work well, the profit
from cases which make a great show with the
exj^enditure of mere mechanical skill, and also
valuable time in analysing, testing, and preparing
alloys and mixtures, the results of which he freely
gives to the profession. Yet a large proportion of
the members of the profession he thus tries to
advance, impute the basest motives of self-interest
to his efforts, and apply an epithet, which is a pun
upon his name, to those who try to benefit by his
teachings, without following his extreme example,
which he never suggested or expected that any one
would do. So it may be that some who read these
notes will misconstrue my meaning, and say that I
am endeavouring to create a prejudice against the
use of gold for filling teeth ; but I emphatically
deny that I have any wish or intention to say a
word against the use of gold in the abstract. I do,
however, mean to protest against what I consider
to be a growing evil in our profession, viz., the
measuring of a man's ability as a dentist by the
amount of labour he bestows upon one particular
kind of work, and the consequent tendency of the
teaching and practice of dentists to devote all their
energies to the making of gold fillings, without
sufiQcient consideration for the comfort or the time
of their patients, and without exercising a reason-
able amount of judgment as to whether the case is
a suitable one for that form of treatment : thereby
incurring risk of failure of the operation after the
endurance and the purse of the patient have been



142 DENTAL PRACTICE.

severely taxed, with the inevitable result that con-
fidence in our operations is destroyed, and our
power to do good diminished. It amounts to this,
that if a man does not treat all his cases alike,
whether it be child or youth ; a young, middle-aged,
or elderly man or woman ; whether a woman be
married or single, having a child every year or two,
or having none ; delicate, sickly and nervous, or
vigorous, healthy, and knowing nothing of nerves ;
if he thinks it best to use plastic fillings for some of
these — no matter how much he may use gold for
suitable cases — he is liable, if his work is seen by
those who claim to be the regular practitioners, to
have his practice condemned, and his claim to
position in the profession disallowed. It is, there-
fore, quite time for thinking men to assert them-
selves, and to do all that lies in their power to
assist in the dissemination of more liberal and
eclectic ideas. The doctor with one medicine for
every ill is a quack, and the dentist who has but
one idea is no better; but, naturally enough, if a
man's standing in his profession is to be judged
solely by his skill in one kind of work he will not
think of anything else ; and so long as he can per-
suade his patients to submit, he will take advantage
of every aid which inventive talent can provide, to
perfect that kind of work ; and he is unwilling to
admit that another man can get as good results by
more simple means. But, after all, it is the result
that we judge ourselves by, and if a man satisfies
hinaself, he cannot go very far wrong. -



TREATMENT OF ADULT TEETH. 143

I have written to little purpose, however, if I
have conveyed an impression that I think thorough-
ness is not essential in an operator. The aim
should be to reach perfection of work; but it does
not depend solely on ourselves, and we cannot
attain it at once in every case. We shall have
nervous and weakly children to treat, or pregnant
women, whose teeth are too sensitive to bear even a