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pericementum and alveolar processes to a very great extent, the

condition is amendable to intelligent treatment and cure. In answer

to the assertion that "Reflected nerve influences manifest themselves

much oftener since dentistry has come more extensively into practice

during the present generation," I would say, that with equal propriety

it might be said that reflected nerve influences manifest themselves

more frequently since gyn?cology has come more extensively into

practice. To attribute the obvious increase of nervous diseases during

the present generation to diseases of the teeth is a statement not

only "sweeping," but "overdrawn." _Much harm_ is no doubt done by some

of the modern appliances "for retention in the mouth of substitutes

for absent teeth," and the unhealthy state of the gums and contiguous

parts, established and maintained by the presence of these substitutes,

unquestionably give rise in many cases to reflected pain.

When Dr. Sexton attempts to establish a _law_ governing the management

of diseased teeth, it must be based on more substantial grounds

than those which he presents. The case related of his patient, the

"medical man, who practices dentistry," and who was convinced that

an inflammation of one of his ears began from the time the upper

second molar of that side was treated for a diseased pulp, is simply

an assumption, on the part of the patient, that the ear trouble had

its origin from the diseased tooth, and the patient's diagnosis of

his own case seems to have been accepted by Dr. S. as conclusive. The

ear disease in this case may have emanated from the diseased tooth,

but no evidence is produced to that effect. In regard to the query as

to "whether it is safe practice to retain dead teeth in the jaws," I

would say that thousands of people in our own country have had pulpless

(not dead) teeth in their jaws many years, which are exempt from

pericemental disease, and which serve all the purposes for which teeth

were provided. To ask whether it is safe practice to retain these,

so-called, dead teeth in the jaws when they have been comfortable and

useful from ten to forty years and promise to remain so through life,

seems like a proposition too injudicious to need comment. While the

death of the pulp results in "cutting off the source of nutrition from

the dentine," it does not follow "that in a large number of instances

irritation can not be easily controlled."

Neither does the tooth become a foreign substance. The dentine and the

enamel are, of course, no longer nourished after the death of the pulp,

but their resisting structure renders them capable of maintaining their

integrity many years after the pulp has been removed; and pericementum

will nourish the cementum and thereby retain the tooth in its alveolus

in a comfortable condition. In order, however, to thus retain the

tooth and prevent inflammation from supervening, the devitalized pulp

must be removed, the pulp canals thoroughly disinfected and filled

with a plastic material which hardens when in position. Dr. S. most

clearly exhibits his imperfect knowledge of the dental operations in

vogue when he says: "Inflammation of exposed dentine cannot surely

be entirely arrested in any case by filling the pulp cavity with any

known extraneous material, and especially is handicraft wanting to

even imperfectly protect the minute and often tortuous canals leading

down to the apical foramina of the majority of the teeth." To arrest

"inflammation of exposed dentine by filling the pulp cavity," in the

opinion of Dr. S. would seem to be most desirable. How a tissue without

nourishment and consequently without vitality can take or maintain

inflammation is beyond comprehension. The impervious filling which

I have mentioned will close the apical foramina, together with the

canal, which "in the majority of cases" _is not_ tortuous to a degree

of rendering the perfect filling of the root difficult or uncertain,

and the assertion that the dental surgeon "is able only to offer a

hopeful but uncertain prognosis in these cases" is contrary to well

established fact. There are no diseases to which mankind is heir more

scientifically and effectually cured than the diseases of the teeth in

question.

Again: "The dead tissues of the dentine will sooner or later, most

likely, be transmitted through the tissues of the cementum to the

periosteum." Communication between the lacun? canaliculi of the

cementum with the tubuli of the dentine is not free; indeed, it seldom

exists, hence it cannot be "that through the periosteum alone the

dentine may long derive some nourishment."

About 22,000,000 teeth are annually extracted in the United States, and

I regret to say this enormous loss of teeth is to no small extent due

to the indifference manifested by physicians in the anatomy, physiology

and pathology of these organs. It is a fact, no one will attempt to

gainsay, that hygienic measures directed toward the preservation of the

deciduous set, if understood, are seldom recommended by the general

practitioner to the families under his charge. The premature loss of

these teeth paves the way for early lesions of the permanent set. The

pain resulting from advanced caries of the deciduous teeth, owing to

the difficulties encountered in controlling the patient, is not easily

treated; moreover, the injurious impressions thus made on the system of

the child abide through life. There is no doubt hundreds of thousands

of teeth are unnecessarily extracted each year, and then drugs are

given with a view of curing the patient of the disorders of digestion

and other abnormal conditions which follow, and which in turn arise

from imperfect mastication of food, verily for the want of teeth.

We need to know "what's the matter" in the treatment of these "nervous

diseases about the head," as in all others, and apply a remedy which

will bring the abnormal tissues back to health. Too often, indeed, has

it happened that patients, by advice of their medical attendants, have

submitted to the loss of many, and, in some instances, to all their

teeth, in the vain endeavor to be relieved from trigeminal neuralgia.

You may ask, Why this useless loss of teeth, and all the resulting

evils? Because the advice given was not wise; the etiology of the

affection was not understood.

There are certain pathological conditions of the teeth which have not

been mentioned in this discussion, and which give rise to reflected

pain of the eyes, ears, and other parts.

Among these may be mentioned exostosis of the roots of teeth and

nodules of calcific matter within the pulp canals in contact with

a living pulp. The former of these conditions has been regarded

incurable, the removal of the tooth with the united bony tumor being

indicated. In favorable cases, however, this tumor may be excised and

removed without removing the tooth. The pulp nodules of calcified

deposits within the pulp chamber may be, in a large majority of cases,

successfully removed without sacrificing the tooth.

No one approves more than I the removal of the causes of disease.

It is no more necessary to extract a tooth at the root of which an

alveolar abscess has formed than it would be to amputate a limb for

the cure of an abscess of the medullary substance of its bone. Disease

of the eye sometimes requires that it be enucleated, but the honest,

skilled ophthalmologist _would not_ remove the eye when he _knew_ he

could restore it to usefulness. The spirit of the teachings of Dr.

Sexton's articles is far from being progressive. Nor is this all; many

assertions are not based on fact, but on erroneous impressions. Our

duty to our profession and the laity is not to destroy but to save; and

while ignorance is ever working its mischief in all vocations in life,

it is not just to accept the results of such work as a basis on which

to found a law.

ARTICLE IV.

DIAGNOSIS AND TREATMENT OF DENTRITIC CYSTIC TUMORS OF THE JAWS.

BY JOHN S. SMITH, D. D. S., LANCASTER, PA.

_Diagnosis._--Cystic tumors may be confounded with other affections

which occasion swellings about the jaws, as enchrondromata, sarcomata,

and myxomata, abscesses, and the collections of fluids in the antrum.

Dental alveolar abscess may be distinguished by its acute course, and

when in a chronic, condition by the discharge of its contents through

the fistula, either upon the gum, or within the oral cavity. The tumor

formed by an abscess is never so sharply definite as is the case with

cysts; with dropsy of the antral cavity the distention of the facial

wall of the jaw is more uniform than it is with cysts.

In some cases of cystic tumors, they present so formidable an

appearance at first sight, that they may be taken for solid tumors;

especially is this so when their walls are compact and well organized,

nearly if not altogether obliterating the sense of fluctuation when

pressure is made upon them.

Cases have come under the observation of the writer where it required

the most delicate touch to detect any fluctuation when pressure was

made upon the apex of the tumor.

In some cases the diagnosis cannot be determined accurately until

after one or more teeth are removed that are involved with the tumor.

After such operation, a probe carried through the alveolus will

usually reveal the true condition of the lesion. One or more dead

teeth are found involved--one, however, being the rule in most cases

which have come to the notice of the writer, while two, and sometimes

three, are implicated with the tumor. The dead tooth may be easily

distinguished from the living ones by its opaque appearance. Such tooth

may be carious, and it may not.

Primarily the dentritic cyst originates from what pathologists

call a "cold abscess," that is, an abscess which has never opened;

subsequently, having developed into a tumor. The interior of the cyst

has a fibrous lining, and being compact in structure, is the seat of

an inflammatory process. The cyst contains a pyriform fluid; it may

attain such magnitude as to invest several teeth and extend beyond the

alveolar process. The tumor is usually oval in shape, with its apex

on a line with the diseased tooth directly involved. The size of the

tumor may be as large as a hulled walnut or as small as hazel-nut;

crepitates under pressure, and feels like parchment. In cases of long

standing, considerable resorption of the alveolar process takes place,

and the teeth immediately connected will be loose; especially will this

be the case if the alveolar borders are broken; these teeth should be

removed. These tumors are found painless, as a rule. I have met with

cases, however, where an acute inflammatory condition was present, with

all the symptoms of acute periodontitis manifested. So that it could

have been readily mistaken for the pointing of an alveolar abscess.

_Pathology._--Cysts of the jaw may be either simple or compound;

whether they be cysts of retention, exudation cysts, or extravasation

cysts belonging to the jaws, is a matter not as yet fully established.

The exudation cyst is a secretory cyst; in a generic relation, however,

it is just the opposite of the retention cyst. Serous sacs form the

foundations of the exudation cysts. "The mode of development of cysts

of the jaws," says Wedl, "has not yet been determined; it therefore

becomes necessary, in order to throw more light on the subject, to

pursue further anatomical investigations in that direction."

Rindfleisch says: "The accumulation of the fluid is not produced

by the continuance of the normal secretion, but by an exudation

surpassing the normal measure of the serum of the blood with salts,

albumen, fibrinogenous substance, and extractives, in the most varying

proportions. The exudation cysts have little to do with pathological

new formation. Of extravasation cysts," he says, "a parenchymatous

bleeding can very well be the point of departure for the formation of

a cyst. The hemorrhagic depot can present itself primarily as a cyst,

namely, when the blood is poured out between two surfaces in themselves

smooth; for example, bone and periosteum, cartilage and perichondrium,

and thereafter remains fluid. As a cyst may also be formed when upon

the one hand the limitary parenchyma furnishes a connective tissue

membrane, upon the other hand, the blood itself is resorbed through a

series of metamorphoses up to a small remainder, and is replaced by a

clear fluid."

The above-mentioned condition is liable to manifest itself within the

body of the jaw, the bone and periosteum, after severe mechanical

injuries to the bone, and the rupture of blood-vessels within the

parenchyma. There can be little doubt that many of the so-called

dentritic cysts of the jaws have their origin primarily from causes

brought about by falls, strokes and mechanical violence, causing

rupture of blood-vessels. It is quite true, history of cases fully

confirms such facts.

Clinical observations leads us to believe, however, that only in cases

where the abscess does not open, we find the pathological new formation

taking place within the jaws. Pulpitis, and as has been observed,

followed by pericementitis and periodontitis, is a prolific cause of

the development of the dentritic cystic tumor.

_Treatment._--The removal of all dead teeth involved. Other teeth

whose pulps are living may be loose, and to a casual observer appear

to be complicated, but a careful examination will reveal the fact

that they should not be disturbed but retained in their places; only

one tooth may be the offender, being a dead one which has caused the

trouble. After the removal of the cause, let it be either one or more

dead teeth or fangs of teeth, cyst walls may be punctured with a sharp

instrument, and the contents of the sac released, this being done

by carrying the instrument through the alveoli, and not through the

bony parietes of the jaw. After the contents of the sac is let out,