Supporting my contentions by the means most familiar to me, that of clinical observation, which I have shown to be in accord with the most recent work on pathological anatomy, I have sought to establish the relations of these diverse

elements, and to present to you finally what I believe to be the logical and true evolution of the disease.

I consider that an exact conception of the development of pyorrhea is intimately associated with its prophylaxis. That is why I should be very happy if this communication should be a useful contribution to the study of this disease and to the battle against an affection which is the despair of the patient.

Conclusions.

(1) The term pyorrhea alveolaris is applied to a disease characterized, in its advanced period, by the presence of a more or less deep gingival pocket at the neck of the tooth, with corresponding denudation of the root over all that portion which comes into relation with the pocket.

(2) Pericemental abscesses upon vital teeth are not due to gouty tophus; these are pyorrhetic abscesses, formed in a serpiginous pocket, whose opening at the neck is unrecognized by virtue of its location, being situated at a point apart from the gingival abscess.

(3) The initial lesions of pyorrhea alveolaris can be determined only by the

study of the disease at its initial period, i.e. at a time when they are not masked by other associated affections.

(4) Precocious senile alveolar resorption of the alveolus is the initial lesion of pyorrhea. It is constant, and precedes all others.

(5) This resorption is of an absolutely general origin, since it can occur independently of any local cause.

(6) All local causes, invoked as the cause of pyorrhea alveolaris, are only adjuvant causes, since they can exist without pyorrhea, and since this diseasenotably at its initial period-can exist in their absence. This would be inadmordial causes. missible if they played the rôle of pri

(7) In the absence of any local adjuvant cause, pyorrhea slowly progresses as long as the general causes exist which provoke precocious senile alveolar resorption.

(8) Pyorrhea is established by its primary lesion, precocious alveolar resorption; but it would not reach its advanced state, that which marks the serious period of the disease, if none of the local adjuvant causes intervened to complete the primary lesion.

(9) The prophylactic treatment of pyorrhea, leaving out of consideration any general treatment, will emphasize a disregard of all adjuvant causes (disturbance of articular equilibrium, infection, gingivitis, etc.).

(10) The normal functioning of the teeth affected with pyorrhea is an element favorable to their organic resistance. It should always be re-established, if it has been destroyed.

(11) The hygiene of pyorrhetics should always be inspired by this essential principle; that the pyorrhetic pockets are formed around a tooth only when any point of the gingival neck of this tooth cannot be kept in a satisfactory state of cleanliness.

(12) The dentist should, therefore, undertake the education of his patients, whose co-operation is indispensable in the prophylaxis of pyorrhea; and, by a regular surveillance, he should treat the slightest complications of the disease.

YONSERVATION of time and money is the watchword in every department in these stirring war times. How to obtain the most out of the least expenditure of time and money is the crying need in every walk of life.

The art of ship-building, the manufacture of munitions of war, the production of food products for feeding the armies and the peoples of the world, have all been placed upon a scientific basis. The fully developed and equipped soldier ready for active service, which has required three or more years to produce in European countries, is now prepared in America in one year or less by intensive training. A prominent colonel in the United States army told me that one American soldier was as good in fighting qualities as five German soldiers.

At the present time the medical teachers throughout the country are engaged in formulating plans whereby the medical student and the trained nurse may be properly equipped to enter active service in the shortest possible time. The report of the Council on Medical Education, under "Continuous Sessions in Medical Schools," is as follows:

**

At the conference held in February, the chairman of the Council, who is a member of the Surgeon-general's staff at Washington, presented a scheme for a continuous session in medical schools. The scheme outlined suggested that, for the duration of the war, each year be divided into three periods of four months each, these sessions beginning in October, February, and July of each year. It was shown that the student could enter on the study of medicine at the beginning of any one of these periods, and continue for eight successive periods of four months each,

at which time he would graduate and enter upon an intern service of one calendar year. This would require just four calendar years, when he would be ready for active service with the army. It was argued that by the adoption of this or some similar scheme the summer periods heretofore looked on as a vacation time would be utilized; the extensive teaching plants would be kept in continuous operation, and students would be graduated from nine to twelve months earlier than under the methods heretofore prevailing. Under this scheme the present junior class would be graduated four months earlier; the

present sophomore class would be graduated

eight months earlier, and the present freshman class would be graduated a year earlier, than under the former method. It was argued also that since there would be no vacations for the boys in the trenches, or for the medical officers in the service, there appeared to be no reason why those remaining at home in the enlisted reserve corps or on the teaching staffs should not utilize the summer months to good advantage. The Council, however, is not unanimously in favor of the continuous session, since one member believes that the speed of production gained would not compensate for the loss of the thoroughness in teaching and the drain on the students" health. It is stated that at McGill and Toronto universities in Canada the system has been abandoned excepting for the last year students.

I have purposely quoted this report in full for future reference.

Prof. Arthur Dean Bevan, president of the American Medical Association, in his address,* says, in regard to the training of nurses:

One of the serious problems now confronting us is the securing of the necessary number of women nurses for our army and navy hospitals. We shall need from 25,000 to 40,000 women nurses. These cannot be secured from

*Ibid., p. 1808.

the trained and registered nurses of the country and leave a sufficient number of nurses to care for our civilian population. It requires three years of training in times of peace to educate a nurse. But we must remember that in peace times it requires a four years' training at West Point and Annapolis to make an officer of the army or navy. In the emergency of this war we are developing splendid officers from well-educated, capable men taken from civil life, by intensive short three months' courses in our officers' training camps. The same plan should be adopted in securing the necessary

nurses.

There are thousands of well-educated, capable young women in this country who are not only willing but anxious to offer their services to the country. Nurses' training camps and training schools can be developed in our army and navy cantonments, where, with an intensive three months' training, these young Women can be developed into most useful war nurses, and meet the needs of the Government. The Surgeon-general of the army has already taken steps to encourage these nurses' training schools.

The report of the Council on Medical Education, because of the adverse opinion of one member, did not affect the views of Surgeon-general Gorgas. It will be observed on page 1950,* under the heading "Memorandum for the Surgeon-general of the United States Army," that he called a meeting of the Advisory Committee on Medical Schools on June 11th, and devised a plan by which the best medical schools in the country could carry out the views suggested in the report of the Council on Medical Education. It will be seen, therefore, that the most difficult situations may be overcome when there is a disposition to correct faulty methods or to improve old methods. of teaching.

In the evolution of dental training for our students from a two-year course to a three- and then to a four-year course, I have from time to time advocated the utilization of the summer months to reduce the length of time for study and graduation. In these strenuous times I am again offering suggestions whereby the student may attain all that is re

Ibid., June 22, 1918.

quired of him and at the same time curtail the length of the curriculum.

The teaching of dentistry proper has no analogue in any other department of science. In all other departments of science taught in schools and colleges, the mental capacity of the student is frequently strained before the end of the term, and brain-fag is likely to occur when pushed to the utmost, as noticed in the report of the Council on Medical Education.

The dental curriculum in our colleges is divided into two distinct departments. It is composed of part mental and part physical training. The principal part of the student's course which qualifies him for graduation is made up of mechanics, where brain strenuousity is not required. He naturally exerts the greater part of his energies in this direction at the expense of the mental and theoretical. The question naturally asked is, Why should not dental schools follow the medical, by adopting a three- or perhaps a two-term yearly course, thereby curtailing the time of the dental students? Surely this can be accomplished to the advantage of both the students and the colleges without detriment to either. The winter course could be utilized for the mental and theoretical, and the summer for the mechanical and practical work. By this method, a year and perhaps more time could be saved.

In other walks of life, such as bookkeeping, typewriting, proofreading, money-counting in the treasury department of the Government, in machine shops, in foundries, in boiler shops, in jewelry manufactories and shops, in sweatshops, and in fact in almost all of the avocations of life, men and women beyond the middle age of life toil from fifty to fifty-two weeks throughout the year, confined in the same close room all day and almost all the time in the same position, usually with artificial lights. Those who do obtain a vacation are satisfied, as a rule, with two weeks. Surely two or three weeks' vacation is all that a young man or woman requires each year while studying for the dental degree.

Brain-fag from overwork due to constant use of one set of brain-cells is overcome by professional men by substituting light fiction reading. By this substitution literary men and scientists may and do live many years without feeling fatigued in the least. The dental student, therefore, has the advantage over all other students in that he can substitute for his winter course of mental training a summer course of mechanics. A student entering college is always

desirous of finishing his studies as soon as possible, so that he may enter his profession and become independent of his family. By the present methods of college teaching he is losing a year's time in the four-year course. This, with the cost of tuition and the expense of office equipment, is quite a drain upon any young man entering upon a professional

career.

31 N. STATE ST.

T

HE dentist has a great responsibility concerning cancer of the oral cavity,

for he of all others is most likely to see the beginnings of the disease. Every malignant lesion has its origin in an often insignificant focus, and if properly treated at a very early stage the prospects of a cure are immeasurably greater, or rather, the prospects of an unfavorable result are materially lessened; for the end results of cancer of the oral cavity are thus far very discouraging, except in regard to cancer of the lip when taken very early.

During the year 1914 there were in the registration area of the United States 2270 deaths from cancer of the oral cavity, or 4.3 per cent. of the 52,420 deaths from cancer in general, or 3.4 persons per 100,000 living. Of these, 376 were from cancer of the lip, 614 of the tongue, 230 recorded as of the mouth, 851 of the jaw, and 199 others of this class. Of these 2270 cases of cancer of the oral cavity 1878 were in males and 392 in females, 82.75 and 17.25 per cent. respectively, the males being sufferers almost five times more frequently than the females.

Malignant disease is very rare in this locality before the age of twenty-five, there being only 40 deaths reported; sarcoma is the form most frequently found in the young. After the age of twentyfive the number of deaths rises steadily, reaching a maximum of 307 between sixty-five and sixty-nine years of age, and 299 from seventy to seventy-four years.

It may be interesting to note that in the United States registration area deaths from cancer of the oral cavity have increased more than those from the disease in any other locality. Thus in 1900 the deaths were 1.6 per 100,000 population, and in 1914 they were 3.4, more than double, whereas the general increase of cancer mortality during this period was from 63 to 79.4 per 100,000, or 26.6 per cent.

In regard to the early recognition of cancer in many localities it is difficult to speak certainly and concisely, but in cancer of the oral cavity there is less reasonable excuse, and the dentist will often be the first medical man who can give the warning. And this warning should be positive and clear, for even the life of the patient may be dependent upon it.

A lesion which may seem trifling at first may be the beginning of a most serious trouble, quite uncontrollable in later stages. When in doubt as to the nature of the local lesion skilled counsel should be sought.

This is all the more important when it is remembered that it is universally acknowledged that about 90 per cent. of all those once affected with cancer in general, in all localities combined, ultimately die of the disease. Also that from 1910 to 1916 the general death-rate from cancer has risen from 63 to 81.8 per 100,000 of the population, or 29.84 per cent., in spite of intelligent and active. surgical treatment.

IMPORTANCE OF ACCURATE DIFFEREN

TIAL DIAGNOSIS BETWEEN CANCER AND
OTHER DISEASES OF THE ORAL CAVITY.

One can readily see, therefore, the great importance of an early and accurate differential diagnosis between cancer and the various disease conditions which may appear in the oral cavity; some of these we will mention briefly, as time would not allow any attempt to detail fully the diagnostic features, which are well given in the textbooks.

(1) Syphilis. Next to simple aphthous sores, syphilis is probably the most frequent and important cause of oral lesions to be differentiated from cancer. These are sometimes difficult of absolute diagnosis, though the Wassermann test may often be of great help. Syphilis appears in the mouth as the primary lesion or chancre, mucous patches, and late, gummy lesions. The primary lesion of syphilis or chancre occurs in the mouth often enough to make it an object of interest in this connection, and should never be forgotten. In a study of extragenital chancre* I was able to collect from literature accounts of 9058 cases, of which 1504 were within the oral cavity and 1810 on the lips, making a total of 3314 chancres in this region, or 36.6 per cent. of all cases. Of the oral cases

there were 734 recorded as in the buccal cavity, 157 on the tongue, 307 on the tonsils, 264 in the throat, and 42 on the gums, a considerable number of which were attributed to infection through dental work or instruments.

Mucous patches are often with difficulty distinguished from aphthous stomatitis or canker sores, but should never be confounded with cancer, although the latter may occasionally develop on them.

The late gummy lesions of syphilis, especially on the tongue, often resemble cancer very closely, and indeed may be the starting-point of true cancer.

(2) Aphthous stomatitis or canker sores are generally easily recognized, but if one or more of them should persist it is always well to consider the possibility of its being the beginning of a true

cancer.

(3) Leucoplakia, generally caused by tobacco, is often spoken of as a precursor of cancer, but among scores or hundreds of instances of leucoplakia seen I do not recall a single instance in which cancer developed. It is quite possible, however, by bad treatment, as by "touching it up" with nitrate of silver, to goad this and other previously innocent lesions to take on malignant action, and I have seen cancer which had developed on leucoplakia before coming under my observation. Any ulcerative changes on a leucoplakia should always be regarded seriously, as possibly an early cancerous development.

(4) Simple ulceration of the tongue or buccal cavity should always receive careful attention, and if persistent should be regarded with suspicion as a probable. antecedent of cancer. Broken, rough, or decayed teeth are the chief source of these ulcerations, and tobacco often plays a very important part, as may be judged by the fact that cancerous lesions in the mouth are almost five times as frequent in the male as in the female. On the other hand, where the practice of chewing a mass composed of betel leaves, tobacco, and lime is common, as in the East, these malignant lesions are very common in the mouth of both sexes.

(5) Tubercular lesions, or lupus, oc