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 Implants in the
esthetic zone
A step-by-step treatment
strategy
www.telegram.me/dentistrybooks

QUINTESSENCE PUBLISHING

Berlin, Chicago, Tokyo, Barcelona, Istanbul, London, Milan, Moscow,

New Delhi, Paris, Prague, Sao Paulo, Seoul, Singapore, Warsaw

A CIP record for this book is available from the British Library.
ISBN: 978-1 ·85097·283 9

®.. QUINTESSENCE PUBLISHING

Quintessence Publishing Co. Ltd,

Grafton Road, New Malden, Surrey KT3 3AB,
United Kingdom
www.quintpub:co.~
Copyright rf 2016 )
Quintessen~blishing Co. Ltd

All rights reserved. This book or any part thereof may not be reprodu-
ced, stored 1n a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, or otherwise. without pri-
or written permission of the publisher.
Translation: Rosana Jelaska
Editing: Quintessence Publishing Co. Ltd, London, UK
Layout and Production: Quintessenz Verlags-GmbH, Berlin, Germany

ISBN: 978-1 85097-283 9

Printed in Germany
 TABLE OF CONTENTS

1 Introduction 1 4.7 Summary 62

1 .1 Why this book? 2 References 62
1.2 Citing of references 3
1.3 Instruments used 4 5 Treatment planning principles 63
1.4 Materials used 5 5.1 General 64
References 6 5.2 Dental history 64
5.3 Clinical examination 65
2 Esthetics 7 5.4 Radiographic examination 65

I 2.1
2.2
2.3
General
Long-term results
Summary
8
12
12
5.5

5.6
Special aspects of clinical and
radiographic evaluation
Summary
68
70

I 3
References

Possible failures
12

15 6
References

Prosthetic planning/
70

3.1 Excessively long clinical crown 16 alternatives to dental implants 71

3.2 Scarring 16 6.1 General 72
3.3 Absence of papillae 18 6.2 Replacing a single missing tooth 73
3.4 Buccal tissue volume deficiency 20 6.3 Replacing two missing teeth 77
3.5 Restorative materials that cause soft 6.4 Restoring a large edentulous space 78
tissue discoloration 20 6.5 Summary 81
3.6 Summary 22 References 81
References 22
7 Prosthetic options to compensate
4 Biological principles 25 for tissue deficits 83
4.1 Introduction 26 7.1 General 84
4.2 Papilla between an implant and 7.2 Compensating for vertical defects 84
a natural tooth 28 7.3 Compensating for lack of papillae 87
4.3 Papilla between two adjacent 7.4 Compensating for horizontal defects 92

,
implants 38 7.5 Compensating for lack of lip support 94
4.4 Buccal area 42 7.6 Summary 96
4.5 Effect of the implant-abutment References lj 97
interface 56
4.6 Limits of planning 61
Table of contents Table of contents

8 Initial analysis 99 10 Implant position 187 13 Two-stage implant procedures 491 17 Temporary restoration 657
8.1 General 100 10.1 General 188 13.1 Ridge augmentation before implant 17.1 Requirements 658
8.2 Lip line 102 10.2 Bucco-oral positioning 189 placement - General 492 17.2 The ideal temporary restoration 660
8.3 Shape of the jaw 106 10.3 Axial inclination 196 13.2 Augmentation with membrane 17.3 Summary 664
8.4 Tooth shape 108 10.4 Mesiodistal positioning 200 and xenograft 492
8.5 Tooth position 111 10.5 Apicocoronal depth 206 13.3 Augmentation with an autogenous 18 Prosthetics 665
8.6 Adjacent teeth 11 5 10.6 Ideal implant positioning 212 bone block 498 18.1 General 666
8.7 Soft tissue 118 10.7 Influence of implant position on 13.4 Augmentation with an autogenous 18.2 Cemented versus screw-retained 668
8.8 Available bone 132 prosthetic options 214 bone block and membrane 500 18.3 Soft tissue management with the
8.9 Width of the edentulous space 146 10.8 Number of implants 217 13.5 Augmentation with autogenous bone implant suprastructure 674
8.10 Function 150 10.9 Application example 223 cone, xenograft, and membrane 502 18.4 Final impression of the two-part
8.11 Occlusion 150 10.10 Consequences of implant 13.6 Summary 525 suprastructure 732
8.12 Treatment planning based on malpositioning 225 References 525 18.5 Two-piece crown 740
the pretreatment evaluation 153 10.11 Surgical template 227 18.6 One-piece crown 769
8.13 Application example 154 10.12 Summary 231 14 Soft tissue grafting 527 18.7 One-piece bridge 772
8.14 Summary 158 References 231 14.1 General 528 18.8 Retainer for natural teeth 776
References 158 14.2 Surgical procedure 542 18.9 Summary 778
11 Immediate implants 233 14.3 Limits of possibility 584 References 778
9 Extraction 159 11 .1 Initial mistakes 234 14.4 Typical errors 588
9.1 General 160 11.2 Learning effects 242 14.5 Inlay graft technique 590 19 Summary:
9.2 Papilla collapse at the adjacent 11.3 Procedures to compensate for 14.6 Summary 592 Six case examples step by step 779
tooth after extraction 163 tissue loss 262 References 592 19.1 Immediate implant placement 780
9.3 Papilla preservation atthe 11.4 Temporization 290 19.2 Single-tooth implant with GBR 790
adjacenttooth 165 11.5 Summary 297 15 Stage-two implant surgery 593 19.3 Two implants with GBR 800
9.4 Buccal soft tissue support 170 References 298 15.1 With papilla-sparing incision 594 19.4 Two-stage implant procedure
9.5 Preservation of papilla between 15.2 With flap reflection 596 for single tooth replacement 808
two teeth to be extracted 170 12 Implant placement with 15.3 With scalloped incision 598 19.5 Two implants, two-stage procedure 816
9.6 Ridge preservation procedures 173 simultaneous guided bone 15.4 Limited punch technique 600 19.6 Complex case 826
9.7 No ridge preservation measures regeneration (GBR) 299 15.5 Summary 616
before implant placement 184 12.1 Biological rationale 300 References 616
9.8 Summary 186 12.2 Esthetic rationale 302
References 186 12.3 Long-term results 311 16 Stage-two surgery with
12.4 Surgical procedure 315 simultaneous soft tissue grafting 617
12.5 Failure 462 16.1 With a horizontal incision 618
12.6 Summary 470 16.2 With flap mobilization 620
References 488 16.3 Roll flap technique 622
16.4 Envelope technique (tunnel technique) 626
16.5 Inlay graft 628
16.6 Summary 656
References 656
1 INTRODUCTION
1 Introduction
--
1.1 WHY THIS BOOK?

While it has long been known that dental implants have offered dentistry wonderful treatment op-
tions, 1 and although both scientific evidence and clinical experience show that very high success rates
can be achieved with dental implants, it is not a simple undertaking to achieve optimal esthetic out-
comes when placing dental implants, even today. If the success or failure of implant therapy is consid-
ered from a purely functional point of view, then success is defined in terms of implant survival. Ac-
cording to this definition, it is relatively irrelevant whether there are one to two millimeters more or
less of bone around the implant; however, if the goal is to achieve optimal esthetics, a one-millimeter
loss of soft tissue may mean an esthetic compromise. Likewise, the local biological conditions may
prove to be a limiting factor that makes it impossible to achieve optimal esthetic results. Therefore,
ensuring good esthetics is still one of the greatest challenges in dental implant therapy.
Teeth have a very specific function in the context of the alveolar ridge and the surrounding soft tis-
sue. At sites where no teeth develop, the alveolar ridge and periodontal soft tissue will not develop to
normal dimensions. The teeth are thus the actual lead structures for hard and soft tissue develop-
ment, and the presence of teeth is a condition necessary for a harmonious appearance and esthetic
result. Loss of teeth results in a loss of the necessary structure to maintain the surrounding bone and
soft tissue, and this inevitably leads to changes in the tissue, with corresponding changes in esthetics.
For this reason, it is necessary to either prevent tissue loss or to perform tissue augmentation proced-
ures to compensate for tissue loss when implants are used to treat tooth loss in the esthetic zone. The
fact that the process of tooth extraction itself leads to tissue loss is aggravated by the reality that tooth
extraction is most commonly performed due to infection, a pathology associated with additional tissue
loss.
Dental implant surgery is a special challenge because both oral surgery and prosthodontic expertise
are needed to achieve the desired goals of treatment. Moreover, each stage of treatment has impacts
upon the subsequent stages. Such a complex, multistage treatment process can only be successful if
possibilities and limitations are identified and incorporated into the treatment plan at each stage of
treatment.
In implant therapy concepts, which were developed with the goal of achieving optimal esthetic re-
sults, undisputed factors that must be considered in every case have been identified over the course
of time. However, there are various treatment approaches that lead to the same goal. The author does
not claim that the approaches described in this book are the only ones possible. However, most of
them have proven to be effective over many years of clinical experience. For each procedure de-
scribed, details to consider when using other treatment modalities are also mentioned. In the following
chapters, the goal is not only to provide general guidelines but also to discuss numerous details. This
step-by-step approach is reflected in the subtitle of the book. In order to achieve truly optimal results
and avoid unpleasant surprises, it is crucial to follow a good general strategy, while taking countless
small details into account.
I hope this book will be a useful resource that helps to avoid failures and achieve successes that de-
light not only the patient but also the dentist.
 1.2 Citing of references

1.2 CITING OF REFERENCES

A list of references is usually provided at the end of a textbook or scientific article. The literature listed
in the reference section serves to give readers the opportunity to deepen their knowledge of the sub-
ject matter of the article or book by reading the scientific literature. Literature references are also an
important way to give credit to the experts who first described something or made an important scien-
tific contribution. However, literature references are rarely selected in an objective manner. In addition
to citing important research results, the articles cited in the literature list are very often mainly those
that provide scientific evidence in support of the concepts the author is putting forward. As you would
expect, supporting evidence for any concept you can imagine can be found in the literature. This high-
ly subjective method of literature selection may suggest to the reader that the text published by an
author is not the author's own personal opinion but a consensus that has been arrived at with other
authors/colleagues who have drawn similar conclusions. When citing the literature, authors often de-
liberately fail to mention articles with contradictory results or conclusions, even if such articles are of a
high scientific standard or describe valid evidence.
Different types of studies are assigned different levels when it comes to the value of the scientific
evidence presented. A case report, for example, is assigned a much lower level than a randomized
double-blind study. However, those in clinical practice may not quite agree. Case studies, which de-
scribe nothing more than the clinical experience of the author - who is usually a skilled clinician - are
often extremely valuable. 2 Conversely, many articles that are assigned high levels in terms of their evi-
dence are indeed subject to criticism. Double-blind studies, for example, are designed to eliminate
selection bias (case selection), yet double-blinding can be quite problematic once one starts perform-
ing studies in patients. For the experienced clinician, case selection is probably the most important
factor when deciding which method is appropriate or inappropriate for successful treatment. If case
selection is not carried out - in spite of the fact that the experienced clinician usually already knows
that a certain method will most likely yield better results in a specific case, or that a certain method
would be more beneficial in another case - it can only be regarded as ethically questionable when
studies that deliberately eliminate patient selection are still performed. A lack of experience is no ex-
cuse when it comes to the selection of the best method for the individual patient case.
On a deeper reading of the dental literature, it is amazing to discover how many scientific papers that
supposedly have a high level of scientific evidence have been accepted by an ethics committee. Per-
forming such randomized double-blind studies on patients is only justifiable when comparing two
methods or materials in cases where even the experienced clinician must admit that both have the
same odds of success in all patients (independent of patient selection), and that the study is only in-
tended to identify any potential differences between the two.
Literature reviews (systematic reviews) have been published in steadily increasing numbers in recent
years. This is a method offiltering the literature on a particular topic using inclusion and exclusion criteria
so that in the end only a few appropriate articles remain. In theory, it makes sense that only high-quality
scientific work is included in the study. In practice, however, it is possible to greatly influence the outcome
through the use of inclusion and exclusion criteria. The initial mass of available studies is further reduced

3
 -
1 Introduction

based on the contents of the summary (abstract) alone and, in the end, only a few studies remai n in the
final selection of articles that are actually read and discussed in detail. Finally, systematic reviews are of-
ten written by less experienced dentists (for continuing education and training purposes). 3.4
Besides the issues related to the definition of inclusion and exclusion criteria and the resulting influ-
ence on the results, another point of criticism is that a study can rarely be fully appreciated based on
the abstract. As there are hardly any studies that are not funded by the industry, particularly in implan-
tology,5,6 the results often have to be published in ways that reflect the interests of the industry. Con-
sequently, one will often not find any really interesting or relevant results in the abstracts. Instead, they
often contain conclusions that prove to be questionable on closer scrutiny and when one performs an
in-depth analysis of the text, results, and numbers. Anothe r facto r to consider is that associates in clin-
ical practice rarely read systematic reviews in detail. These articles often serve to help find appropriate
secondary literature when writing articles.
Meta-analyses are somewhat more useful. Although the inclusion and exclusion criteria have a deci-
sive potential for bias, meta-analyses attempt to aggregate and scientifically analyze very large volumes
of data from various studies. Unfortunately, meta-analyses on the really interesting research problems
are rarely available because high-quality studies on such topics are lacking.
Due to these very critical but probably rea listic reflections regarding the issues relating to the selec-
tion of references cited in the literature (including lectures, articles, or textbooks), this book wi ll d is-
pense with citing countless literature references. Instead, only a small list of relevant scientific literature
is provided at the end of each chapter. The references are, of cou rse, selected according to the au-
thor's subjective opinion. In many cases, the aim of inclusion was to give credit to authors who first
published very interesting work, or to those who succeeded in publishing very useful summaries for
their colleagues in clinical practice. The author recognizes this selection bias and makes no cla im to
objectivity. The number of authors per article has steadily increased in the dental literature in recent
years.7 Against this rather unscientific trend, in this book, if there are more than five authors of a given
article, only the name of the first author plus "et al" is included in the citation. The rationale behind this
is that, unfortunately, most of the countless additional authors often have nothing to do with the actu-
al research. Many researchers mention colleagues as coauthors in order for those colleagues to obtain
as many published articles on their resumes as possible.

1.3 INSTRUMENTS USED

The author deliberately avoids giving a detailed description of the instruments used in the procedures
described in this book. In the cases presented here, surgery was usually performed using convention-
al instruments. Microsurgical instruments were rarely used because, in the author's opinion, they have
no visible benefits. Although we dentists tend to have preferences for certain instruments and often
talk about them, it makes little sense to give general advice on instrument selection. In clinical practice,
dentists must find out for themselves which scalpel or needle holder works best for them. However,
the goal is always the same: To select an instrument that allows for fast yet very precise work. It is not
necessarily a good idea to use extremely fine instruments that slow down the workflow if one can
 1.4 Materials used

achieve exactly the same precision with conventional instruments. Furthermore, experience has shown
that it is usually not advantageous to perform the surgical procedures described here under a micro-
scope in clinical practice because the field of view of a microscope is too small for these applications.
The use of a loupe (4X to 6X magnification) has proven to be an ideal solution. Due to the fact that the
dentist can observe the patient's movements while wearing the loupe, unnecessary workfiow interrup-
tions that increase the working time are avoided.

1.4 MATERIALS USED

The proprietary names of the materials used are not mentioned throughout the book. Especially in the
case of dental implants, there is a wide range of products that produce optimal results.
In the early years, the choice of implant had historical significance, but nowadays, implant selection
is driven primarily by the available suprastructure options. Therefore, the implant system should be
selected primarily by the prosthodontic dentist and not the surgeon. Today, the biggest differences
between the various implant systems relate to the connection between the implant and the supra-
structure, and to the available materials and parts for the implant-abutment connection. Titanium
implants from the following manufacturers were used in the cases presented in this book: Biomet 3i,
Nobel Biocare, and Thommen Medical.
The non-resorbable membrane most commonly used for ridge augmentation procedures was the
Gore-Tex expanded polytetrafluoroethylene (ePTFE) membrane, which is no longer available on the
market. In more recent cases, Cytoplast (Osteogenics), a dense polytetrafluoroethylene (PTFE) mem-
brane, was used as an alternative, following exactly the same principle as for the ePTFE membrane.
OsseoGuard (Biomet 3i) is the cross-linked collagen membrane used today. Bio-Gide (Geistlich Phar-
ma) was the most commonly used pure collagen membrane. Bio-Oss (Geistlich Pharma) was often
used as the bone filler material for alveolar ridge augmentation; this bovine xenograft material was
generally employed as a ready-to-use mixture in combination with Bio-Oss Collagen (Geistlich Phar-
ma), a porcine collagen product. Various other collagen membranes and bovine xenograft products
were occasionally used.
Regarding suture materials, Gore-Tex 50, 60, and 70 monofilament sutures manufactured from PTFE
were most commonly used. In addition, Seralene 7-0 (American Dental System) monofilament polyvi-
nylidene fluoride sutures were used for the adaptation of wound edges. As regards postoperative
medications, our patients were given mefenamic acid * 1 (Ponstan, Pfizer) for pain, and chlorhexidine
rinse (Plak-Out, KerrHawe) to control postoperative inflammation. All ridge augmentation patients re-
ceived antibiotic prophylaxis with Clamoxyl (GlaxoSmithKline) or, in more recent cases, other amoxicil-
lin products.
Regarding innovations, the same rule applies to materials as to surgical techniques, which is that it
only makes sense to switch to new products (which are constantly being introduced onto the market)

*1 Drug approved in many countries around the world, but not in Germany.

c:;
1 Introduction

if they rea lly make it possible to accomplish something that was not possible with the products used
so far. Bearing this in mind, most new products are of no consequence because they usually only offer
that which is already on the market in another form, and their so-called advant ages over existing prod-
ucts, according to the claims of the manufacturers, do not pan out in cl inical practice.

REFERENCES
1. Branemark Pl, et al. Intra osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969;3:81-100.
2. Fitzpatrick B. Evidence-based dentistry - it subdivided: accepted truths, once divided, may lack va lidity. Int J Prosthodont 2008;21:
358 363.
3. Creugers NH, Kreulen CM. Systematic review of 10 years of systematic reviews in prosthodontics. Int J Prosthodont 2003;16:123-127.
4. Lang LA, Teich ST. A critical appraisal of the systematic review process: systematic reviews of zirconia single crowns. J Prosthet Dent
2014;111 :476- 484.
5. Koka S. Conflict of interest: the Achilles heel of evidence-based dentistry. lntJ Prosthodont 2008;21 364 368.
6. Barao VA. et al. Trends in funding, internationalization, and types of study for original articles published 1n five implant-related Journals
between 2005 and 2006. Int J Oral Maxillofac Implants 2012;27:69 76.
7. Yuan JC. Lee DJ, Knoernschild KL, Campbell SD. Sukotjo C. Authorship characteristics in prosthodontic literature: proliferation and inter-
nationalization. A review and analysis following a 10-year observation. J Prosthet Dent 2010;104·158-164.
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 Introduction

if they really make it possible to accomplish something that was not possible with the products used
so far. Bearing this in mind, most new products are of no consequence because they usually only offer
that which is already on the market in another form, and their so-called advantages over existing prod- 2 ESTHETICS
ucts, according to the claims of the manufacturers, do not pan out in clinical practice.

REF ERENCES
1. Branemark Pl, et al. Intra-osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969;3:81-100.
2. Fitzpatrick B. Evidence-based dentistry - it subdivided: accepted truths, once divided, may lack validity. Int J Prosthodont 2008;21:
358-363.
3. Creugers NH, Kreulen CM. Systematic review of 10 years of systematic reviews in prosthodontics. Int J Prosthodont 2003;16:123-127.
4. Lang LA, Teich ST. A critical appraisal of the systematic review process: systematic reviews of zirconia single crowns. J Prosthet Dent
2014;111 :476-484.
S. Koka S. Conflict of interest: the Achilles heel of evidence-based dentistry. Int J Prosthodont 2008;21 :364-368.
6. Sarao VA, et al. Trends in funding, internationalization, and types of study for original articles published in five implant-related journals
between 2005 and 2006. lntJ Oral Maxillofac Implants 2012;27:69-76.
7. Yuan JC, Lee DJ, Knoernschild KL, Campbell SD, Sukotjo C. Authorship characteristics in prosthodontic literature: proliferation and inter-
nationalization. A review and analysis following a 10-year observation. J Prosthet Dent 2010;104:158-164.

;'
2 Esthetics 2.1 General

2.1 GENERAL ~
2.1
The term "esthetic" is often overused. In dentistry, countless books and numerous guidelines have
been published on this top ic.
In the context of implant therapy, it soon becomes clear that the key to optimal esthetics is a harmo-
nious soft tissue profile (assuming an otherwise healthy clinical situation). Harmony is that which is
..
beautiful and esthetically pleasing to the eye of the beholder. It is not possible to achieve the absolute-
ly essential harmony in tooth shape without a harmonious soft tissue profile. Tissue quality and clinical •
•
crown quality are also critical factors because they are ultimately visible. Therefore, the main focus of 2.1a Irregular glngiva margin before extraction of tooth 21 . 2.1 b Good fi nal result thanks to gingival co rrection.
the dentist's work is to establish soft tissue harmony. If this condition is not met, it will be impossible
for the dental technician to fabricate a crown that fits in harmoniously with the surrounding gums and Fig
teeth. A tissue deficit can be very difficult or impossible to correct after the completion of treatment, 2.2
especially in the case of implant therapy. If certain treatment procedures are not performed in a mean-
ingful sequence, it is difficult to achieve the desired result predictably or with high probability.
As described in the introduction section, the tissue deficits encountered in dental implantology gen-
erally occur as a result of tooth loss. Therefore, the restoration of bone and soft tissue volume is a key
element of dental implant therapy (Fig 2.1).

2.2.1 What does "esthetic" mean? 2.2a Missing teeth in the maxillary right quadrant of a heavy 2.2b Nature-inspired implant-supported bridge.
smoker.
The term "esthetic," as used in dentistry, means nothing more than "inspired by nature," provided that
nature has created something that suits the person in question. Only that which suits the patient and Fig
his or her individual appearance and character is esthetic and harmonious. By this definition, a tooth 2.3
replacement for a patient who smokes 80 cigarettes a day must be designed differently from one for a
patient with beautiful white teeth without any caries. A dental prosthesis that reflects the character and
habits of an older smoker can by all means be viewed as an optimal esthetic result (Fig 2.2).
When inserted, the tooth replacement should fit in harmoniously with the natural teeth of the re-
maining dentition . It is usually harder to achieve this goal when replacing a single tooth than multiple
teeth because of the direct comparison with the immediately adjacent natural teeth (Fig 2.3).
If there is a large edentulous space, a harmonious result can still be achieved, for example, if exten- 2.3a Tooth 21 has to be extracted. 2.3b Implant-supported crown 21 matches natural crown 11.

sive papillae loss is present but is symmetrically distributed on both sides (Fig 2.4).

Fig
2.4

2.4a Large edentulous space after ridge augmentation and place 2.4b Harmonious final result although papillae are hardly present.
ment of two mp/ants.
2 Esthetics 2.1 General

It becomes clear relatively quickly that dental treatments have their limits, especially from the esthet- Fig
ic perspective. Tissue around natural teeth that is lost, for example, due to attachment loss (which of- 2.5
ten occurs as a complication of inflammatory periodontal disease) cannot be regenerated in most
cases. In some cases, this may be accepted as an ind ividual characteristic of the patient. On the other
hand, many patients with long teeth and missing papi llae, which appear as "black triangles," do not find
this attractive. However (as was already mentioned above but is often forgotten in clinical practice), not
all problems can be treated, and not all patient wishes fulfilled or, if they can, then only by means that
might not meet the patient's a priori approval.
Periodontal attachment loss is a classic example, where the loss of attachment results in the appear- 2.Sa and b Status after per odontal therapy.

ance of long clinical crowns and, in some cases, the missing papillae. A removable gingival mask can
satisfy the desire of some patients for optimal esthetics in these cases. However, the patient must be
willing to accept the disadvantage that the restoration will have a removable part (Fig 2.5).
Although the esthetic appearance of a restoration is not judged by objective criteria alone because
patient preferences and perceptions of esthetics vary, there are certain esthetic guidelines that have
to be followed that imitate that which nature produces when it creates a harmonious dental appear-
ance. Scharer et al 1 published anesthetic checklist for fixed prostheses in 1980. Although the origina l
version has frequently been copied and modified since then, it is still valid today (Fig 2.6). These esthet-
ic guidelines for restorative dentistry provide rules for ensuring that the soft tissue and clinical crowns
are in harmony with the restoration. Without going into detail, it is sufficient to say that these criteria 2.Sc Flexible, removable gingival mask.

are well known. Even in patients with unsightly presenting conditions, a very harmonious final result
can be achieved by following these guidelines. With this approach, it quickly becomes evident that cre-
ating a harmonious soft tissue profile ("pink esthetics") is the primary key to success, followed by the
restoration with harmonious tooth shape.

2.Sd and e Good esthetic result with the gingival epithesis in place.

__L_ Midline (axis of symmetry) - Tooth shape Fig

2.6
- Tooth axis - lncisal edge

- Gingival margin - lnterincisal angle

-+- Gingival zenith - Furrows and grooves

- Trigone - Smile line (lrer lip line)

- lnterproximal contact point lnc,sal edges

2.6 Modified esthet1c scheme of Scharer et al.

2 Esthetics References

2.2 LONG-TERM RESULTS Fig

2.7
The true success or failure of a treatment can only be determined after several years. From the pa -
tient's perspective, the long-term results are just as important as the immediate results achieved at the
end of active treatment. An optima l esthetic outcome should remain intact for many years .
In the early years of implant therapy, knowledge about the requirements needed for primary success
was lacking. A lot about the rate of osseointegration of dental implants was already known in the
1980s. Information on long-term survival rates and risk factors for implant failure was available. In con-
trast, no real data on the esthetic aspects of implant dentistry was available until the late 1980s to 2.7a and b Implant-supported restoration of the maxillary central Inc sors completed in 1987.
early 1990s. There was a lot of luck involved in many cases that are classified as a success after more
than 25 years of follow-up (Fig 2.7). Much of the knowledge and experience that we have today was
lacking during the period of active treatment back then.
As always in life, learning from failure is the fastest way to learn, assuming that a critical analysis of
the results takes place. Over time, it became clear that non-gentle tooth extraction could result in soft
tissue loss. Experience showed which types of incisions should not be used, what consequences im-
proper implant placement could have, and which tissue augmentation technique did not produce the
desired results. With time, it also became evident which materials failed to achieve the desired results,
and what could go wrong when designing and manufacturing the suprastructure, in terms of tech-
nique as well as choice of materials. 2.7c and d 10-year result.

It is also important to remember that changes occur in the patient's mouth over the course of time
that are not necessarily pathological in nature. Two examples are the change in tooth color, and the
natural soft tissue recession that occurs even around healthy teeth (Fig 2.8). Nowadays, these predict-
able changes can be taken into account to a certain degree.

2.3 SUMMARY
If the dentist pursues the goal of creating dental restorations inspired by nature, then a pleasing es-
thetic outcome will usually be achieved. Ultimately, the widely published guidelines for optimal dental
esthetics are merely the result of careful smile analysis using images of healthy natural teeth that we 2.7e and f 20-year result.

subjectively like or consider to be attractive. However, conditions vary from one individual to another.
Therefore, these idealized notions must be adapted to the individual situation so as to produce an
image that suits the patient - in other words, an optimal esthetic result.

REFERENCES
1. Scharer P, Rinn LA, Kopp FR. Asthetische Richtlinien fur die rekonstruktive Zahnheilkunde. Berlin: Quintessenz, 1980.

2.7g and h Good long-term result after 25 years.

 2 Esthetics

Fig
2.8
3 POSSIBLE FAILURES

2.8a and b Implant supported restorat on of the maxil ary central incisors completed in 1995.

2.8c and d Tissue loss around the mplants and natural teeth after 5 years.

2.Se and f 10-year result.

2.8g and h 15-year result.

 2 Esthetics

Fig
2.8
3 POSSIBLE FAILURES

2.8a and b Implant-supported restoration of the maxillary central incisors completed in 1995.

2.8c and d Tissue loss around the implants and natural teeth after 5 years.

2.Se and f 10-year result.

3 Possible failures 3.2 Scarring

Fuhrhauser et al 1 were the first to publish a scoring system for "pink esthetics." If the presenting clinic- Fig
al conditions are extremely adverse, failure can be unavoidable in some cases. When replacing teeth 3.1
with implant-supported reconstructions, an important goal is to achieve a harmonious soft tissue pro-
file with beautiful pink esthetics.

3.1 EXCESSIVELY LONG CLINICAL CROWN

The first possible complication that comes to mind is excessive clinical crown length. Crown length is
defined as the distance from the incisal edge (smile line) to the most concave part of the gingival mar- 3.1a and b An irregular gingival margin resulted in excessively long clinical crown length of tooth 21.

gin, which defines the apical end of the clinical crown. If a certain amount of soft tissue deficit is present
in the apicocoronal direction, the clinical crown will appear too long, if the position of the incisal edge Fig
is correct. The fact that this does not necessarily cause excessive disharmony in every case is demon- 3.2
strated by the case of a patient who needed to have a natural tooth crowned (Fig 3.1 ). As can be seen
in the photographs, although the entire maxillary anterior segment was not ideal, the overall appear-
ance of the anterior teeth is not inharmonious.
Excessively long clinical crown length is a common failure of dental implant therapy. In most cases,
the surgical error leading to this compromise can be readily identified: improper implant positioning or
inadequate treatment planning with or without sufficient soft tissue augmentation (Fig 3.2).
3.2a and b Failure occu rred due to a vertical soft tissue deficit around the implant crown.

3.2 SCARRING
Fig
If scarring suddenly appears after treatment in an area where there was no scar tissue before treat- 3.3
ment, then it can be assumed that a surgical error was made. Certain surgical techniques can leave
scars in visible places - not in every case, but often (Fig 3.3). Needless to say, these surgical procedures
must be modified accordingly when used in the esthetic zone. Conversely, visible scars are sometimes
already present before surgery. Appropriate measures to eliminate these scars (if possible) should be
incorporated into the treatment plan for such patients.

3.3a The gingival margin was relatively harmonious before the 3.3b Unfavorable incision placement when inserting the implant.
extraction of tooth 11 .
3 Possible failures 3.3 Absence of papillae

3.3 ABSENCE OF PAPILLAE Fig

3.4
The loss of attachment between two natural teeth (which usually occurs due to inflammation) results
in the loss of soft t issue support and of perfect papillae esthetics. As the predictable regeneration of
the papil la between two adjacent teeth is hardly possible by therapeutic means, prosthetic correction
is just about the only option. This is done by reshaping the two adjacent teeth so as to move the con-
tact point between them to a more apical position and thus close the open embrasure or "black trian-
gle." The result, however, is an altered tooth shape that no longer fits in harmoniously with its sur-
roundings. The practice of changing a triangular tooth shape into a square tooth shape to compensate 3.4a Missing papilla between the central and latera l incisor. 3.4b Partial interdental space cl osure achieved at the expense of
ideal crown shape (tooth 12).
for the absence of a papilla is a classic example. The square tooth shape is the trade-off for the de-
creased size of the black triangle (Fig 3.4). Fig
Similar rules apply to implants. In some cases, soft tissue loss in the interproximal region may make 3.5
it impossible to restore the papillae at the implant site. In other cases, interproximal soft tissue is pres-
ent initially but destroyed in the course of surgery, resulting in an iatrogenic compromise (Fig 3.5). The
data is clear regarding the factors that must be considered in dental implant surgery to preserve exist-
ing papillae or restore missing papillae to some degree. A papilla missing from an otherwise harmoni-
ous soft tissue profile in which all other papillae are present can have a very disruptive effect. There-
fore, this is an important factor that must be given due consideration.
Experience has shown that, from a biological perspective, a papilla between an implant and an adja- 3.Sa and b Treatment failure due to soft tissue deficiencies, especially in the papillary region.

cent tooth must be treated differently from a papilla between two adjacent implants. Preservation or
reconstruction of the papilla between two adjacent implants is possible but extremely difficult, and a Fig
poor surgical technique will result in immediate failure (Fig 3.6). 3.6

3.6a Preoperative view of a site with three missing teeth. 3.6b Three implants placed very cl ose together.
3 Possible failures 3.5 Restorative materials that cau se soft t issue discoloration

3.4 BUCCAL TISSUE VOLUME DEFICIENCY Fig

3.7
A tissue vo lume deficiency on the buccal side results in the development of a concavity relative to the
adjacent tissue levels. The presence of such a concavity always means one thing: shadowing! Shadow-
ing results in dark discoloration and, in many cases, esthetic compromise. This is already known from
traditiona l crown and bridge work: If, at the pantie site, there is adequate tissue in the vertical dimen-
sion but not on the buccal side, the deficiency cannot be corrected by prosthetic means, and the dark
discoloration and shadowing described above occur (Fig 3.7).
Obviously, the same phenomenon must be taken into account in implant therapy. Again, the pres- 3.7a and b Shadowing on this bridge restoration in the left maxilla due to a buccal concavity of the alveolar ridge.
ence of adequate tissue in the vertical dimension alone will not suffice to prevent shadowing. Sufficient
tissue must also be present on the buccal side, and the tissue volume must harmonize with that of the Fig
adjacent teeth. Otherwise, the result may look great from the intraoral frontal view, but from the extra- 3.8
oral smile view, a patient with a high smile line exposes the volume deficit and reveals the esthetic
compromise (Fig 3.8). The implications for practice are that measures must be undertaken to prevent
buccal tissue resorption, or an appropriate surgical tissue augmentation procedure must be per-
formed.

3.5 RESTORATIVE MATERIALS THAT CAUSE SOFT TISSUE

3.8a and b Failure due to shadowing resulting from a buccal soft tissue deficit around implant crown 22.
DISCOLORATION

In traditional crown and bridge work, it is a well-known fact that dark tooth roots and metal frameworks Fig
supporting crowns can cause soft tissue discoloration. These mostly dark areas have a very negative 3.9

esthetic effect. In conventional prosthodontics we have learnt that the effects of discolored roots,
which are intensified by the crown, can be significantly reduced simply by replacing the restoration with
a metal-free reconstruction (Fig 3.9).
The same applies in implant therapy. In patients with certa in soft tissue types, the insertion of gray
metallic structures in the submucosa can result in unsightly discoloration (Fig 3.10). Again, there are
ways and means available to replace these metal structures with all-ceramic restorations in order to
minimize the problem. 3.9a The effects of soft tissue discoloration are amplified by the 3.9b The appearance improves after switching to an all -ceramic
meta l parts of the crown. crown.

Fig
3.1
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3 Possible failures References

3.6 SUMMARY Fig

3.1
When replacing teeth with implant-supported restorations, it is important to use a surgical procedure
that will not destroy the available soft tissue. Failure analysis of one's own cases is a quick way to learn
which guidel ines must be followed in order to prevent such failures in the future. Many key points that
help to prevent tissue destruction from occurring as a consequence of implant therapy are discussed
in the following chapters. Conversely, the limits of modern dental implantology are also discussed.
It does not necessarily take an accident or pathological event to produce tissue conditions that do
not meet the standards for esthetic success. Sometimes, the available tissue provided by nature simply 3.11 a Preoperative view of site with multiple congenitally missing 3.11 b to d Final result with quantitative and qualitative improve-
teeth, some with bone deficiencies and thin soft tissue. ment of tissue conditions.
does not permit an optimal solution. In these cases, as always, the goal of treatment is to make a pos-
itive change in the tissues affected. Congenitally missing teeth, for example, are often associated with
the presence of bone deficiencies and thin soft tissue. Therefore, sufficient bone and soft tissue vol-
ume have to be created. In other words, we have to change the bone and tissue conditions determined
by nature in order to be able to achieve an optimal result. Furthermore, our therapeutic efforts are
only a success if the optimal esthetics achieved by implant therapy can be maintained over the long
term (Fig 3.11). Studies on the long-term stability of esthetic outcomes are scarce, 2•3 but there is an
abundance of clinical experience, albeit not positive in every case.
The choice of treatment procedures is a decisive factor that determines whether the goal of achiev-
ing a harmonious esthetic outcome can also be maintained over the long term. 3.11c 3.11 d

REFERENCES
1. Furhauser R, et al. Evaluation of soft tissue around single-tooth implant crowns: the pink esthetic score. Clin Oral Implants Res
2005;16:639- 644.
2. Buser D, et al. Long-term stability of contour augmentation with early implant placement fol lowing single tooth extraction in the esthetic
zone: a prospective, cross -sectional study in 41 patients with a 5- to 9 year fol low up. J Periodontal 2013;84:1517- 1527.
3. Chen ST, Buser D. Esthetic outcomes following immediate and early implant placement in the anterior maxilla a systematic review. Int
J Oral Maxillofac Implants 2014;29:186- 215.

3.11 e and f 10-year result.

S=1ldlJNlc1d lVJl:)07018 17
 1 Biological principles

4.1 INTRODUCTION

4.1.1 General
The dental restorative possibilities and procedures for both natural teeth and dental implants ar-e
largely determined by biological principles. When restoring natural teeth, the main structures o• Tter
est are the teeth themselves, the periodontium between them, the bone, and the soft tissue. r 1rr
plants, only the periodontium is absent, so the structures to consider are the implant, the bone and
the soft tissue.
In final, result-driven dental implant planning, the goal is to establish and maintain an optima sc rt
tissue position over the long term. However, the thickness of this soft tissue cannot be augmer ted
arbitrarily. A substantial increase in soft tissue thickness can be achieved by surgical means, t ut rre
augmented tissue is resorbed relatively quickly and returns to a more or less naturally predeterm ned
level. The amount of available bone is an important indicator of the level at which the soft t '=> :: .JP w I,
become established. This bone level along a natural tooth corresponds to the height of bory cit�cldl
ment (attachment level).

4.1.2 Soft tissue complex around natural teeth

The dentogingival complex of soft tissue surrounding teeth of the natural dentition cons Ist ., cfI 1rIP
gingival sulcus, the junctional epithelium, and the gingival connective tissue. The Junctional epi•rIP I1 ,ITI
forms the epithelial attachment of a tooth via hemidesmosomes. The periodontal fiber apparatLb L Jm
prises an alveolar region as well as a supra-alveolar region in the gingival connective tissue r r" ,E'
periodontal fibers insert into the cementum. The blood supply to the soft tissue surrounding a touth ::i
provided by periodontal, alveolar, and subperiosteal blood vessels. The supra-alveolar soft tIs c ,H Lorn
plex has a relatively constant thickness of about 3 mm in the buccal region, and a th1ckne ,s o• •. rrI rrI
in the interdcntal area.'-2
Especially in the interproximal area, the soft tissue automatically adjusts to the pat1en :.,pee ill 1 1 r
acteristic thickness. If the soft tissue in the interdental area is thinned or removed, 1t Is on y a 1-riJttrr of
time before it returns to the naturally predetermined thickness. A study by Van der Velde1 ( l82) 1

showed that following denudation of the interdental soft tissues (papillae), the typica1 averagE' IJT t ., I -
sue thickness at interproximal sites (4.5 mm) is restored within 3 years (Fig 4.1 ).
As described by Tarn ow et al4 in 1992, the logical implication of this finding is that, when tl'e cl I:;,• l"c,
from the contact point to the interproximal bone height between two neighboring teetr is rJ rr rT >r
less, a papilla is almost always present. If the distance from the contact point to the bone c..i-est 1 - l.'
, -ea
er, the odds of generating enough tissue to fill the approximal space decrease s1gn1f1caritly RoJ ccv
erage surgery can achieve therapeutic improvement of reduced attachment level at buccaI., tm At I

interproximal sites, however, the success of such procedures is still unpredictable. Thus, t e tt c1,
ment level in the interproximal region mainly determines the visible papillae height (F g L 2).

26
 41 lntroduct or

Fig
4.1

4.1 b Radiographic view of intact attachment level

4.1d Intact papillae 3 years after final restoration (new crowns).

Fig
4.2

4.2b Radiograph showing s,gnificant loss of attachment

4.2c Healllly c,nft tis5ue with massive gingival recession after 4.2d Hardly any papillae are present 3 years after final restoration
p J ir G Ir �':y (new crowns and bridges).

27
4 Biological principles

4.1.3 Soft tissue complex around implants

The peri-implant soft tissue complex also consists of a sulcus, junctional epithelium, and peri-implant
connective tissue. The junctional epithelium also forms the epithelial attachment of an implant via
hemidesmosomes.
The fiber apparatus of the peri-implant connective tissue is oriented parallel to the implant or abut
ment surface. It contains a larger proportion of collagen fibers but fewer fibroblasts than the period on
tal connective tissue.5 The blood supply to the peri-implant soft tissue is provided by alveolar and
subperiosteal blood vessels, whereas the periodontal vessels are naturally missing.5 Consequently,
peri-implant soft tissue is structurally similar to scar tissue and is supplied by fewer blood vessels than
the soft tissue around the natural teeth, so blood circulation is reduced.
The peri-implant soft tissue complex has a relatively constant thickness of about 3 mm on the buccal
aspect, comparable to that of the natural dentition, and is slightly thicker (3.5 mm) between adJacent
implants.6 The thickness of the peri-implant soft tissue also reestablishes itself at a naturally predeter
mined level. If peri-implant soft tissue is thinned or removed, it is only a matter of time before the
natural level of thickness is restored, though at the expense of some bone loss.7

4.2 PAPILLA BETWEEN AN IMPLANT AND A NATURAL TOOTH

4.2.1 General
When evaluating interproximal sites, it is important to distinguish whether the interproximal site c., r
cated between a tooth and an implant or between two implants.
Between a natural tooth and an implant (as between two adjacent teeth), the attachment level at the
natural tooth is primarily responsible for papilla support.8 The most coronal interproximal point o'"
bone-to-implant contact, on the other hand, does not play a role. The clinical implication 1s that, when
calculating the level of attachment from the natural tooth to the tip of the papilla, about 4.5 mm of soft
tissue thickness can still be expected (Fig 4.3). Positively speaking, this means that even 1f the first bom
to-implant contact is significantly more apical, a satisfactory papilla will be present as long as the .:it
tachment of the natural teeth is preserved (Fig 4.4).
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 Still, even so and when you come right down to it, was there
anything so terrible about her writing a celebrity like that and asking
for his picture, if that was all she had done. But was it? Those long-
enveloped gray letters he had found in the fireplace that morning,
after that day in which he had seen her in the car (or thought he had)
—or at least traces of them. And the queer way she had looked at
him when he brought them up in connection with that closed car in
Bergley Place. She had squinted her eyes as if to think, and had
then laughed rather shakily when he charged her with receiving
letters from Raskoffsky, and with his having come here to see her.
His finding them had been entirely by accident. He always got up
early to “start things,” for Beryl was a sleepyhead, and he would start
the fire in the grate and put on the water to boil in the kitchen. And
this morning as he was bending over the grate to push away some
scraps of burnt wood so as to start a new fire, he came across five or
six letters, or the ashes of them, all close together as though they
might have been tied with a ribbon or something. What was left of
them looked as though they had been written on heavy stationery
such as a man of means might use, the envelopes long and thick.
The top one still showed the address—“Mrs. Beryl Stoddard, Care of
——” He was bending over to see the rest when a piece of wood
toppled over and destroyed it. He rescued one little scrap, the half-
charred corner of one page, and the writing on this seemed to be like
that on Raskoffsky’s picture, or so he thought, and he read: “to see
you.” Just that and nothing more, part of a sentence that ended the
page and went to the next. And that page was gone, of course!
But it was funny wasn’t it, that at sight of them the thought of
Raskoffsky should have come to him? And that ride in the park.
Come to think of it, the man in the car had looked a little like
Raskoffsky’s picture. And for all he knew, Raskoffsky might have
then been in town—returned for this especial purpose,—and she
might have been meeting him on the sly. Of course. At the Deming.
That was it. He had never been quite able to believe her. All the
circumstances at the time pointed to something of the kind, even if
he had never been able to tie them together and make her confess
to the truth of them.
 But how he had suffered after that because of that thought! Things
had seemed to go black before him. Beryl unfaithful? Beryl running
around with a man like that, even if he was a great violinist?
Everybody knew what kind of a man he was—all those men. The
papers were always saying how crazy women were over him, and
yet that he should come all the way to C—— to make trouble
between him and Beryl! (If only he could prove that!) But why should
she, with himself and Tickles to look after, and a life of her own which
was all right—why should she be wanting to run around with a man
like that, a man who would use her for a little while and then drop
her. And when she had a home of her own? And her baby? And her
mother and sister right here in C——? And him? And working as
hard as he was and trying to make things come out right for them?
That was the worst of it. That was the misery of it. And all for a little
notice from a man who was so far above her or thought he was,
anyhow, that he couldn’t care for her or any one long. The papers
had said so at the time. But that was the whole secret. She was so
crazy about people who did anything in music or painting or anything
like that, that she couldn’t reason right about them. And she might
have done a thing like that on that account. Personally he wouldn’t
give a snap of his finger for the whole outfit. They weren’t ordinary,
decent people anyhow. But making herself as common as that! And
right here in C——, too, where they were both known. Oh, if only he
had been able to prove that! If only he had been able to at that time!
When he had recovered himself a little that morning after he had
found the traces of the letters in the ashes he had wanted to go into
the bedroom where she was still asleep and drag her out by the hair
and beat her and make her confess to these things. Yes, he had.
There had been all but murder in his heart that morning. He would
show her. She couldn’t get away with any such raw stuff as that even
if she did have her mother and sister to help her. (That sly little Alice,
always putting her sister up to something and never liking him from
the first, anyhow.) But then the thought had come to him that after all
he might be wrong. Supposing the letters weren’t from Raskoffsky?
And supposing she had told the truth when she said she hadn’t been
in the car? He had nothing to go on except what he imagined, and
up to then everything had been as wonderful as could be between
them. Still....
Then another thought had come: if the letters weren’t from
Raskoffsky who were they from? He didn’t know of anybody who
would be writing her on any such paper as that. And if not
Raskoffsky whom did she know? And why should she throw them in
the fire, choosing a time when he wasn’t about? That was strange,
especially after the automobile incident of the day before. But when
he taxed her with this the night of the Bergley Place car incident—
she had denied everything and said they were from Claire Haggerty,
an old chum who had moved to New York just about the time they
were married and who had been writing her at her mother’s because
at that time he and she didn’t have a home of their own and that was
the only address she could give. She had been meaning to destroy
them but had been putting it off. But only the night before she had
come across them in a drawer and had tossed them in the fire, and
that was all there was to that.
But was that all there was to it?
For even as he had been standing there in front of the grate
wondering what to do the thought had come to him that he was not
going about this in the right way. He had had the thought that he
should hire a detective at once and have her shadowed and then if
she were doing anything, it might be possible to find it out. That
would have been better. That was really the way. Yet instead of
doing that he had gone on quarreling with her, had burst in on her
with everything that he suspected or saw, or thought he saw, and
that it was, if anything, that had given her warning each time and had
allowed her to get the upper hand of him, if she had got the upper
hand of him. That was it. Yet he had gone on and quarreled with her
that day just the same, only, after he had thought it all over, he had
decided to consult the Sol Cohn Detective Service and have her
watched. But that very night, coming back from the night conference
with Mr. Harris Cohn, which was the only time he could get to give it,
was the night he had seen the car in Bergley Place, and Beryl near
it.
 Bergley Place was a cross street two doors from where they lived
on Winton. And just around the corner in Bergley, was an old vacant
residence with a deal of shrubbery and four overarching trees in
front, which made it very dark there at night. That night as he was
coming home from Mr. Harris Cohn’s—(he had told Beryl that he was
going to the lodge, in order to throw her off and had come home
earlier in order to see what he might see) and just as he was
stepping off the Nutley Avenue car which turned into Marko Street,
about half a block above where they lived whom should he see—
But, no, let us put it this way. Just at that moment or a moment later
as he turned toward his home an automobile that had been going the
same way he was along Winton swung into Bergley Place and threw
its exceptionally brilliant lights on a big closed automobile that was
standing in front of the old house aforementioned. There were two
vacant corner lots opposite the old house at Bergley and Winton and
hence it was that he could see what was going on. Near the rear of
the automobile, just as though she had stepped out of it and was
about to leave, stood Beryl—or, he certainly thought it was Beryl,
talking to some one in the car, just as one would before parting and
returning into the house. She had on a hooded cape exactly like the
one she wore at times though not often. She did not like hooded
capes any more. They were out of style. Just the same so sure had
he been that it was Beryl and that at last he had trapped her that he
hurried on to the house or, rather, toward the car. But just as he
neared the corner the lights of the car that had been standing there
lightless flashed on for a second—then off and then sped away. Yet
even with them on there had not been enough light to see whether it
was Beryl, or who. Or what the number on the license plate was. It
was gone and with it Beryl, presumably up the alley way and into the
back door or so he had believed. So sure was he that she had gone
that way that he himself had gone that way. Yet when he reached the
rear door following her, as he chose to do, it was locked and the
kitchen was dark. And he had to rap and pound even before she
came to let him in. And when she did there she was looking as
though she had not been out at all, undressed, ready for bed and
wanting to know why he chose to come that way! And asking him not
to make so much noise for fear of waking Tickles...!
 Think of it. Not a trace of excitement. No cape with a hood on. The
light up in the dining-room and a book on the table as though she
might have been reading—one of those novels by that fellow
Barclay. And not a sign about anywhere that she might have been
out—that was the puzzling thing. And denying that she had been out
or that she had seen any car, or anything. Now what would you
make of that!
Then it was, though, that he had burst forth in a fury of suspicion
and anger and had dealt not only with this matter of the car in
Bergley Place but the one in Briscoe Park, the letters in the ashes
and the matter of Naigly seeing her come out of the Deming, to say
nothing of her writing to Raskoffsky for his picture. For it was
Raskoffsky, of course, if it was anybody. He was as positive as to
that as any one could be. Who else could it have been? He had not
even hesitated to insist that he knew who it was—Raskoffsky, of
course—and that he had seen him and had been able to recognize
him from his pictures. Yet she had denied that vehemently—even
laughingly—or that he had seen any one, or that there had been a
car there for her. And she did show him a clipping a week later which
said that Raskoffsky was in Italy.
But if it wasn’t Raskoffsky then who was it—if it was any one. “For
goodness’ sake, Gil,” was all she would say at that or any other time,
“I haven’t been out with Raskoffsky or any one and I don’t think you
ought to come in here and act as you do. It seems to me you must
be losing your mind. I haven’t seen or heard of any old car. Do you
think I could stand here and say that I hadn’t if I had? And I don’t like
the way you have of rushing in here of late every little while and
accusing me of something that I haven’t done. What grounds have
you for thinking that I have done anything wrong anyhow? That silly
picture of Raskoffsky that Alice sent for. And that you think you saw
me in an automobile. Not another thing. If you don’t stop now and let
me alone I will leave you I tell you and that is all there is to it. I won’t
be annoyed in this way and especially when you have nothing to go
on.” It was with that type of counter-argument that she had
confronted him.
 Besides, at that time—the night that he thought he saw her in
Bergley Place—and as if to emphasize what she was saying, Tickles
in the bedroom had waked up and begun to call “Mama, Mama.” And
she had gone in to him and brought him out even as she talked. And
she had seemed very serious and defiant, then—very much more
like her natural self and like a person who had been injured and was
at bay. So he had become downright doubtful, again, and had gone
back into the dining-room. And there was the light up and the book
that she had been reading. And in the closet as he had seen when
he had hung up his own coat was her hooded cape on the nail at the
back where it always hung.
And yet how could he have been mistaken as to all of those
things? Surely there must have been something to some of them. He
could never quite feel, even now, that there hadn’t been. Yet outside
of just that brief period in which all of these things had occurred there
had never been a thing that he could put his hands on, nothing that
he could say looked even suspicious before or since. And the
detective agency had not been able to find out anything about her
either—not a thing. That had been money wasted: one hundred
dollars. Now how was that?

II

The trouble with Gil was that he was so very suspicious by nature
and not very clever. He was really a clerk, with a clerk’s mind and a
clerk’s point of view. He would never rise to bigger things, because
he couldn’t, and yet she could not utterly dislike him either. He was
always so very much in love with her, so generous—to her, at least—
and he did the best he could to support her and Tickles which was
something, of course. A lot of the trouble was that he was too
affectionate and too clinging. He was always hanging around
whenever he was not working. And with never a thought of going any
place without her except to his lodge or on a business errand that he
couldn’t possibly escape. And if he did go he was always in such
haste to get back! Before she had ever thought of marrying him,
when he was shipping clerk at the Tri-State and she was Mr.
Baggott’s stenographer, she had seen that he was not very
remarkable as a man. He hadn’t the air or the force of Mr. Baggott,
for whom she worked then and whose assistant Gil later became.
Indeed, Mr. Baggott had once said: “Gilbert is all right, energetic and
faithful enough, but he lacks a large grasp of things.” And yet in spite
of all that she had married him.
Why?
Well, it was hard to say. He was not bad-looking, rather
handsome, in fact, and that had meant a lot to her then. He had fine,
large black eyes and a pale forehead and pink cheeks, and such
nice clean hands. And he always dressed so well for a young man in
his position. He was so faithful and yearning, a very dog at her heels.
But she shouldn’t have married him, just the same. It was all a
mistake. He was not the man for her. She knew that now. And, really,
she had known it then, only she had not allowed her common sense
to act. She was always too sentimental then—not practical enough
as she was now. It was only after she was married and surrounded
by the various problems that marriage includes that she had begun
to wake up. But then it was too late.
Yes, she had married, and by the end of the first year and a half,
during which the original glamour had had time to subside, she had
Tickles, or Gilbert, Jr., to look after. And with him had come a new
mood such as she had never dreamed of in connection with herself.
Just as her interest in Gil had begun to wane a little her interest in
Tickles had sprung into flame. And for all of three years now it had
grown stronger rather than weaker. She fairly adored her boy and
wouldn’t think of doing anything to harm him. And yet she grew so
weary at times of the humdrum life they were compelled to live. Gil
only made forty-five dollars a week, even now. And on that they had
to clothe and feed and house the three of them. It was no easy
matter. She would rather go out and work. But it was not so easy
with a three-year-old baby. And besides Gil would never hear of such
a thing. He was just one of those young husbands who thought the
wife’s place was in the home, even when he couldn’t provide a very
good home for her to live in.
 Still, during these last few years she had had a chance to read and
think, two things which up to that time she had never seemed to
have time for. Before that it had always been beaux and other girls.
But most of the girls were married now and so there was an end to
them. But reading and thinking had gradually taken up all of her
spare time, and that had brought about such a change in her. She
really wasn’t the same girl now that Gil had married at all. She was
wiser. And she knew so much more about life now than he did. And
she thought so much more, and so differently. He was still at about
the place mentally that he had been when she married him,
interested in making a better place for himself in the Tri-State office
and in playing golf or tennis out at the country club whenever he
could afford the time to go out there. And he expected her to curry
favor with Dr. and Mrs. Realk, and Mr. and Mrs. Stofft, because they
had a car and because Mr. Stofft and Gil liked to play cards together.
But beyond that he thought of nothing, not a thing.
But during all of this time she had more and more realized that Gil
would never make anything much of himself. Alice had cautioned her
against him before ever they had married. He was not a business
man in any true sense. He couldn’t think of a single thing at which he
could make any money except in the paper business, and that
required more capital than ever he would have. Everybody else they
knew was prospering. And perhaps it was that realization that had
thrown her back upon books and pictures and that sort of thing.
People who did things in those days were so much more interesting
than people who just made money, anyhow.
Yet she would never have entered upon that dangerous affair with
Mr. Barclay if it hadn’t been for the awful mental doldrums she found
herself in about the time Tickles was two years old and Gil was so
worried as to whether he would be able to keep his place at the Tri-
State any longer. He had put all the money they had been able to
save into that building and loan scheme, and when that had failed
they were certainly up against it for a time. There was just nothing to
do with, and there was no prospect of relief. To this day she had no
clothes to speak of. And there wasn’t much promise of getting them
now. And she wasn’t getting any younger. Still, there was Tickles,
and she was brushing up on her shorthand again. If the worst came
—
But she wouldn’t have entered upon that adventure that had come
so near to ending disastrously for herself and Tickles—for certainly if
Gil had ever found out he could have taken Tickles away from her—if
it hadn’t been for that book Heyday which Mr. Barclay wrote and
which she came across just when she was feeling so out of sorts
with life and Gil and everything. That had pictured her own life so
keenly and truly; indeed, it seemed to set her own life before her just
as it was and as though some one were telling her about herself. It
was the story of a girl somewhat like herself who had dreamed her
way through a rather pinched girlhood, having to work for a living
from the age of fourteen. And then just as she was able to make her
own way had made a foolish marriage with a man of no import in any
way—a clerk, just like Gil. And he had led her through more years of
meagre living, until at last, very tired of it all, she had been about to
yield herself to another man who didn’t care very much about her but
who had money and could do the things for her that her husband
couldn’t. Then of a sudden in this story her husband chose to
disappear and leave her to make her way as best she might. The
one difference between that story and her own life was that there
was no little Tickles to look after. And Gil would never disappear, of
course. But the heroine of the story had returned to her work without
compromising herself. And in the course of time had met an architect
who had the good sense or the romance to fall in love with and
marry her. And so the story, which was so much like hers, except for
Tickles and the architect, had ended happily.
But hers—well—
But the chances she had taken at that time! The restless and yet
dreamy mood in which she had been and moved and which
eventually had prompted her to write Mr. Barclay, feeling very
doubtful as to whether he would be interested in her and yet drawn
to him because of the life he had pictured. Her thought had been that
if he could take enough interest in a girl like the one in the book to
describe her so truly he might be a little interested in her real life.
Only her thought at first had been not to entice him; she had not
believed that she could. Rather, it was more the feeling that if he
would he might be of some help to her, since he had written so
sympathetically of Lila, the heroine. She was faced by the problem of
what to do with her life, as Lila had been, but at that she hadn’t
expected him to solve it for her—merely to advise her.
But afterwards, when he had written to thank her, she feared that
she might not hear from him again and had thought of that picture of
herself, the one Dr. Realk had taken of her laughing so heartily, the
one that everybody liked so much. She had felt that that might entice
him to further correspondence with her, since his letters were so
different and interesting, and she had sent it and asked him if his
heroine looked anything like her, just as an excuse for sending it.
Then had come that kindly letter in which he had explained his point
of view and advised her, unless she were very unhappy, to do
nothing until she should be able to look after herself in the great
world. Life was an economic problem. As for himself, he was too
much the rover to be more than a passing word to any one. His work
came first. Apart from that, he said he drifted up and down the world
trying to make the best of a life that tended to bore him. However if
ever he came that way he would be glad to look her up and advise
her as best he might, but that she must not let him compromise her
in any way. It was not advisable in her very difficult position.
Even then she had not been able to give him up, so interested had
she been by all he had written. And besides, he had eventually come
to U—— only a hundred and fifty miles away, and had written from
there to know if he might come over to see her. She couldn’t do other
than invite him, although she had known at the time that it was a
dangerous thing to do. There was no solution, and it had only
caused trouble—and how much trouble! And yet in the face of her
mood then, anything had been welcome as a relief. She had been
feeling that unless something happened to break the monotony she
would do something desperate. And then something did happen. He
had come, and there was nothing but trouble, and very much trouble,
until he had gone again.
You would have thought there was some secret unseen force
attending her and Gil at that time and leading him to wherever she
was at just the time she didn’t want him to be there. Take for
example, that matter of Gil finding Mr. Barclay’s letters in the fire
after she had taken such care to throw them on the live coals behind
some burning wood. He had evidently been able to make out a part
of the address, anyhow, for he had said they were addressed to her
in care of somebody he couldn’t make out. And yet he was all wrong,
as to the writer, of course. He had the crazy notion, based on his
having found that picture of Raskoffsky inscribed to Alice, some
months before, that they must be from him, just because he thought
she had used Alice to write and ask Raskoffsky for his picture—
which she had. But that was before she had ever read any of Mr.
Barclay’s books. Yet if it hadn’t been for Gil’s crazy notion that it was
Raskoffsky she was interested in she wouldn’t have had the courage
to face it out the way she had, the danger of losing Tickles, which
had come to her the moment Gil had proved so suspicious and
watchful, frightening her so. Those three terrible days! And imagine
him finding those bits of letters in the ashes and making something
out of them! The uncanniness of it all.
And then that time he saw her speeding through the gate into
Briscoe Park. They couldn’t have been more than a second passing
there, anyhow, and yet he had been able to pick her out! Worse, Mr.
Barclay hadn’t even intended coming back that way; they had just
made the mistake of turning down Ridgely instead of Warren. Yet, of
course, Gil had to be there, of all places, when as a rule he was
never out of the office at any time. Fortunately for her she was on
her way home, so there was no chance of his getting there ahead of
her as, plainly, he planned afterwards. Still, if it hadn’t been for her
mother whom everybody believed, and who actually believed that
she and Alice had been to the concert, she would never have had
the courage to face him. She hadn’t expected him home in the first
place, but when he did come and she realized that unless she faced
him out then and there in front of her mother who believed in her,
that she as well as he would know, there was but one thing to do—
brave it. Fortunately her mother hadn’t seen her in that coat and hat
which Gil insisted that she had on. For before going she and Alice
had taken Tickles over to her mother’s and then she had returned
and changed her dress. And before Gil had arrived Alice had gone
on home and told her mother to bring over the baby, which was the
thing that had so confused Gil really. For he didn’t know about the
change and neither did her mother. And her mother did not believe
that there had been any, which made her think that Gil was a little
crazy, talking that way. And her mother didn’t know to this day—she
was so unsuspecting.
And then that terrible night on which he thought he had seen her in
Bergley Place and came in to catch her. Would she ever forget that?
Or that evening, two days before, when he had come home and said
that Naigly had seen her coming out of the Deming. She could tell by
his manner that time that he thought nothing of that then—he was so
used to her going downtown in the daytime anyhow. But that Naigly
should have seen her just then when of all times she would rather he
would not have!
To be sure it had been a risky thing—going there to meet Mr.
Barclay in that way, only from another point of view it had not
seemed so. Every one went through the Deming Arcade for one
reason or another and that made any one’s being seen there rather
meaningless. And in the great crowd that was always there it was
the commonest thing for any one to meet any one else and stop and
talk for a moment anyhow. That was all she was there for that day—
to see Mr. Barclay on his arrival and make an appointment for the
next day. She had done it because she knew she couldn’t stay long
and she knew Gil wouldn’t be out at that time and that if any one else
saw her she could say that it was almost any one they knew casually
between them. Gil was like that, rather easy at times. But to think
that Naigly should have been passing the Deming just as she was
coming out—alone, fortunately—and should have run and told Gil.
That was like him. It was pure malice. He had never liked her since
she had turned him down for Gil. And he would like to make trouble
for her if he could, that was all. That was the way people did who
were disappointed in love.
But the worst and the most curious thing of all was that last
evening in Bergley Place, the last time she ever saw Mr. Barclay
anywhere. That was odd. She had known by then, of course, that Gil
was suspicious and might be watching her and she hadn’t intended
to give him any further excuse for complaint. But that was his lodge
night and he had never missed a meeting since they had been
married—not one. Besides she had only intended to stay out about
an hour and always within range of the house so that if Gil got off the
car or any one else came she would know of it. She had not even
turned out the light in the dining-room, intending to say if Gil came
back unexpectedly or any one else called, that she had just run
around the corner in the next block to see Mrs. Stofft. And in order
that that statement might not be questioned, she had gone over
there for just a little while before Mr. Barclay was due to arrive with
his car. She had even asked Mr. Barclay to wait in the shadow of the
old Dalrymple house in Bergley Place, under the trees, in order that
the car might not be seen. So few people went up that street,
anyhow. And it was always so dark in there. Besides it was near to
raining which made it seem safer still. And yet he had seen her. And
just as she was about to leave. And when she had concluded that
everything had turned out so well.
But how could she have foreseen that a big car with such powerful
lights as that would have turned in there just then. Or that Gil would
step off the car and look up that way? Or that he would be coming
home an hour earlier when he never did—not from lodge meeting.
And besides she hadn’t intended to go out that evening at all until
Mr. Barclay called up and said he must leave the next day, for a few
days anyhow, and wanted to see her before he went. She had
thought that if they stayed somewhere in the neighborhood in a
closed car, as he suggested, it would be all right. But, no. That big
car had to turn in there just when it did, and Gil had to be getting off
the car and looking up Bergley Place just when it did, and she had to
be standing there saying good-bye, just as the lights flashed on that
spot. Some people might be lucky, but certainly she was not one of
them. The only thing that had saved her was the fact that she had
been able to get in the house ahead of Gil, hang up her cape and go
in to her room and undress and see if Tickles was still asleep. And
yet when he did burst in she had felt that she could not face him—he
was so desperate and angry. And yet, good luck, it had ended in his
doubting whether he had really seen her or not, though even to this
day he would never admit that he doubted.
 But the real reason why she hadn’t seen Mr. Barclay since (and
that in the face of the fact that he had been here in the city once
since, and that, as he wrote, he had taken such a fancy to her and
wanted to see her and help her in any way she chose), was not that
she was afraid of Gil or that she liked him more than she did Mr.
Barclay (they were too different in all their thoughts and ways for
that) or that she would have to give up her life here and do
something else, if Gil really should have found out (she wouldn’t
have minded that at all)—but because only the day before Mr.
Barclay’s last letter she had found out that under the law Gil would
have the power to take Tickles away from her and not let her see him
any more if he caught her in any wrongdoing. That was the thing that
had frightened her more than anything else could have and had
decided her, then and there, that whatever it was she was thinking
she might want to do, it could never repay her for the pain and agony
that the loss of Tickles would bring her. She had not really stopped to
think of that before. Besides on the night of that quarrel with Gil, that
night he thought he saw her in Bergley Place and he had sworn that
if ever he could prove anything he would take Tickles away from her,
or, that he would kill her and Tickles and himself and Raskoffsky
(Raskoffsky!), it was then really that she had realized that she
couldn’t do without Tickles—no, not for a time even. Her dream of a
happier life would be nothing without him—she knew that. And so it
was that she had fought there as she had to make Gil believe he
was mistaken, even in the face of the fact that he actually knew he
had seen her. It was the danger of the loss of Tickles that had given
her the courage and humor and calmness, the thought of what the
loss of him would mean, the feeling that life would be colorless and
blank unless she could take him with her wherever she went,
whenever that might be, if ever it was.
And so when Gil had burst in as he did she had taken up Tickles
and faced him, after Gil’s loud talk had waked him. And Tickles had
put his arms about her neck and called “Mama! Mama!” even while
she was wondering how she was ever to get out of that scrape. And
then because he had fallen asleep again, lying close to her neck,
even while Gil was quarreling, she had told herself then that if she
came through that quarrel safely she would never do anything more
to jeopardize her claim to Tickles, come what might. And with that
resolution she had been able to talk to Gil so convincingly and
defiantly that he had finally begun to doubt his own senses, as she
could see. And so it was that she had managed to face him out and
to win completely.
And then the very next day she had called up Mr. Barclay and told
him that she couldn’t go on with that affair, and why—that Tickles
meant too much to her, that she would have to wait and see how her
life would work out. And he had been so nice about it then and had
sympathized with her and had told her that, all things considered, he
believed she was acting wisely and for her own happiness. And so
she had been. Only since he had written her and she had had to say
no to him again. And now he had gone for good. And she admired
him so much. And she had never heard from him since, for she had
asked him not to write to her unless she first wrote to him.
But with how much regret she had done that! And how
commonplace and humdrum this world looked at times now, even
with the possession of Tickles. Those few wonderful days.... And that
dream that had mounted so high. Yet she had Tickles. And in the
novel the husband had gone away and the architect had appeared.
 XIV
THE “MERCY” OF GOD
“Once, one of his disciples, walking with him in the garden, said:
‘Master, how may I know the Infinite, the Good, and attain to union
with it, as thou hast?’ And he replied: ‘By desiring it utterly, with all thy
heart and with all thy mind.’ And the disciple replied: ‘But that I do.’
‘Nay, not utterly,’ replied the Master, ‘or thou wouldst not now ask how
thou mayst attain to union with it. But come with me,’ he added, ‘and I
will show thee.’ And he led the way to a stream, and into the water,
and there, by reason of his greater strength, he seized upon his
disciple and immersed him completely, so that presently he could not
breathe but must have suffocated and drowned had it not been his
plan to bring him forth whole. Only when, by reason of this, the
strength of the disciple began to wane and he would have drowned,
the Master drew him forth and stretched him upon the bank and
restored him. And when he was sufficiently restored and seeing that
he was not dead but whole, he exclaimed: ‘But, Master, why didst thou
submerge me in the stream and hold me there until I was like to die?’
And the Master replied: ‘Didst thou not say that above all things thou
desirest union with the Infinite?’ ‘Yea, true; but in life, not death.’ ‘That
I know,’ answered the Master. ‘But now tell me: When thou wast thus
held in the water what was it that thou didst most desire?’ ‘To be
restored to breath, to life.’ ‘And how much didst thou desire it?’ ‘As
thou sawest—with all my strength and with all my mind.’ ‘Verily. Then
when in life thou desirest union with the All-Good, the Infinite, as
passionately as thou didst life in the water, it will come. Thou wilt know
it then, and not before.’”
Keshub Chunder Sen.

A FRIEND of mine, a quite celebrated neurologist, psychiatrist,

and interpreter of Freud, and myself were met one night to
discuss a very much talked-of book of his, a book of clinical studies
relative to various obsessions, perversions and inhibitions which had
afflicted various people in their day and which he, as a specialist in
these matters, had investigated and attempted to alleviate. To begin
with, I should say that he had filled many difficult and responsible
positions in hospitals, asylums, and later, as a professor of these
matters, occupied a chair in one of our principal universities. He was
kindly, thoughtful, and intensely curious as to the workings of this
formula we call life, but without lending himself to any—at least to
very few—hard and fast dogmas. More interesting still life appeared
to interest but never to discourage him. He really liked it. Pain, he
said, he accepted as an incentive, an urge to life. Strife he liked
because it hardened all to strength. And he believed in action as the
antidote to too much thought, the way out of brooding and sorrow.
Youth passes, strength passes, life forms pass; but action makes all
bearable and even enjoyable. Also he wanted more labor, not less,
more toil, more exertion, for humanity. And he insisted that through,
not round or outside, life lay the way to happiness, if there was a
way. But with action all the while. So much for his personal point of
view.
On the other hand he was always saying of me that I had a touch
of the Hindu in me, the Far East, the Brahmin. I emphasized too
much indifference to life—or, if not that, I quarreled too much with
pain, unhappiness, and did not impress strongly enough the need of
action. I was forever saying that the strain was too great, that there
had best be less of action, less of pain.... As to the need of less pain,
I agreed, but never to the need of less action; in verification of which
I pointed to my own life, the changes I had deliberately courted, the
various activities I had entered upon, the results I had sought for. He
was not to be routed from his contention entirely, nor I from mine.
Following this personal analysis we fell to discussing a third man,
whom we both admired, an eminent physiologist, then connected
with one of the great experimental laboratories of the world, who had
made many deductions and discoveries in connection with the
associative faculty of the brain and the mechanics of associative
memory. This man was a mechanist, not an evolutionist, and of the
most convinced type. To him nowhere in nature was there any
serene and directive and thoughtful conception which brought about,
and was still bringing about continually, all the marvels of structure
and form and movement that so arrest and startle our intelligence at
every turn. Nowhere any constructive or commanding force which
had thought out, for instance, and brought to pass flowers, trees,
animals, men—associative order and community life. On the
contrary, the beauty of nature as well as the order of all living, such
as it is, was an accident, and not even a necessary one, yet
unescapable, a condition or link in an accidental chain. If you would
believe him and his experiments, the greatest human beings that
ever lived and the most perfect states of society that ever were have
no more significance in nature than the most minute ephemera. The
Macedonian Alexander is as much at the mercy of fate as the lowest
infusoria. For every germ that shoots up into a tree thousands are
either killed or stunted by unfavorable conditions; and although,
beyond question, many of them—the most—bear within themselves
the same power as the successful ones to be and to do, had they the
opportunity, still they fail—a belief of my own in part, albeit a hard
doctrine.
One would have thought, as I said to Professor Z—— at this
meeting, that such a mental conviction would be dulling and
destructive to initiative and force, and I asked him why he thought it
had not operated to blunt and destroy this very great man. “For the
very reasons I am always emphasizing,” he replied. “Pain, necessity,
life stung him into action and profound thought, hence success. He is
the person he is by reason of enforced mental and physical action.”
“But,” I argued, “his philosophy makes him account it all as
worthless, or, if not that, so fleeting and unstable as to make it
scarcely worth the doing, even though he does it. As he sees it,
happiness and tribulation, glory and obscurity, are all an accident.
Science, industry, politics, like races and planets, are accidents.
Trivial conditions cause great characters and geniuses like himself to
rest or to remain inactive, and mediocre ones are occasionally
permitted to execute great deeds or frustrate them in the absence of
the chance that might have produced a master. Circumstances are
stronger than personalities, and the impotence of individuals is the
tragedy of everyday life.”
“Quite so,” agreed my friend, “and there are times when I am
inclined to agree with him, but at most times not. I used to keep
hanging in one of my offices, printed and framed, that famous
quotation from Ecclesiastes: ‘I returned, and saw under the sun that
the race is not to the swift, nor the battle to the strong, neither yet
bread to the wise, nor yet favor to men of skill; but time and chance
happeneth to them all.’ But I took it down because it was too
discouraging. And yet,” he added after a time, because we both fell
silent at this point, “although I still think it is true, as time has gone on
and I have experimented with life and with people I have come to
believe that there is something else in nature, some not as yet
understood impulse, which seeks to arrange and right and balance
things at times. I know that this sounds unduly optimistic and vainly
cheerful, especially from me, and many—you, for one, will disagree
—but I have sometimes encountered things in my work which have
caused me to feel that nature isn’t altogether hard or cruel or
careless, even though accidents appear to happen.”
“Accidents?” I said; “holocausts, you mean.” But he continued:
“Of course, I do not believe in absolute good or absolute evil,
although I do believe in relative good and relative evil. Take
tenderness and pity, in some of their results at least. Our friend Z
——, on the contrary, sees all as accident, or blind chance and
without much if any real or effective pity or amelioration, a state that I
cannot reason myself into. Quite adversely, I think there is something
that helps life along or out of its difficulties. I know that you will not
agree with me; still, I believe it, and while I do not think there is any
direct and immediate response, such as the Christian Scientists and
the New Thought devotees would have us believe, I know there is a
response at times, or at least I think there is, and I think I can prove
it. Take dreams, for instance, which, as Freud has demonstrated, are
nature’s way of permitting a man to sleep in the presence of some
mental worry that would tend to keep him awake, or if he had fallen
asleep, and stood in danger to wake him.”
I waived that as a point, but then he referred to medicine and
surgery and all the mechanical developments as well as the
ameliorative efforts of life, such as laws relating to child labor,
workingmen’s compensation and hours, compulsory safety devices
and the like, as specific proofs of a desire on the part of nature,
working through man, to make life easier for man, a wish on her part
to provide him, slowly and stumblingly, mayhap, with things helpful to
him in his condition here. Without interrupting him, I allowed him to
call to mind the Protestant Reformation, how it had ended once and
for all the iniquities of the Inquisition; the rise of Christianity, and how,
temporarily at least, it had modified if not entirely ended the
brutalities of Paganism. Anesthetics, and how they had served to
ameliorate pain. I could have pointed out that life itself was living on
life and always had been, and that as yet no substitute for the flesh
of helpless animals had been furnished man as food. (He could not
hear my thoughts.) The automobile, he went on, had already
practically eliminated the long sufferings of the horse; our anti-
slavery rebellion and humane opposition in other countries had once
and for all put an end to human slavery; also he called to mind the
growth of humane societies of one kind and another, that ministered
to many tortured animals. And humane laws were being constantly
passed and enforced to better if not entirely cure inhuman
conditions.
I confess I was interested, if not convinced. In spite of life itself
existing on life, there was too much in what he said to permit any
one to pass over it indifferently. But there came to my mind just the
same all the many instances of crass accident and brutish
mischance which are neither prevented nor cured by anything—the
thousands who are annually killed in railroad accidents and industrial
plants, despite protective mechanisms and fortifying laws compelling
their use; the thousands who die yearly from epidemics of influenza,
smallpox, yellow fever, cholera and widespread dissemination of
cancer, consumption and related ills. These I mentioned. He
admitted the force of the point but insisted that man, impelled by
nature, not only for his own immediate protection but by reason of a
sympathy aroused through pain endured by him, was moved to
kindly action. Besides if nature loved brutality and inhumanity and
suffering why should any atom of it wish to escape pain, and why in
those atoms should it generate sympathy and tears and rejoicing at
escape from suffering by man, why sorrow and horror at the
accidental or intentional infliction of disaster on man by nature or
man?