unless their diagnostic suggestion be corroborated by a bacteriological finding. The day has arrived-in fact, it never should have been otherwise when the dentist or stomatologist should interpret his own radiograph, and perhaps in a large percentage of instances this is done, the radioscope now having become an important adjunct in our modern office equipment.

This possibility of systemic disease arising from tooth and mouth infection has had to a certain extent the effect of letting down the bars between medicine and dentistry, and will no doubt eventually result in transforming dental practice into stomatology.

While this is all well and good, we are at the same time compelled to take exception to the too frequent action of the physician-that, viz, of advising the extraction of teeth without dental consultation. Stomatology, or dentistry, whichever you may choose to call it, can no longer continue to be party to the wholesale removal of teeth simply because the physician advises their extraction. There is but one remedy for this unfortunate situation; it simply means the expression by the physician of a more substantial confidence in the dentist, and the nearer we approach the field of stomatology the greater this confidence. will become.

DENTAL EDUCATION TENDING TOWARD

STOMATOLOGY.

It is an undisputed fact that the past few years has shown a remarkable tendency for dentistry to broaden into stomatology, and much of the credit for this is due to the constantly increasing curriculum adopted by the dental colleges. Included in this are many subjects formerly thought to be of value to the medical students only, but now are recognized as an essential part of the dental course. By this means the average dental practitioner of today has fortified himself with sufficient medical knowledge to enable him to intelligently take part in the discussion of many general medical subjects, and more especially those which belong or are closely allied to dentistry. It is with much regret that

the same remarks cannot be applied to the general medical practitioner.

The failure of medical schools of the present day to instruct students even in the elementary principles of a branch of the healing art which the fathers of medicine did not disdain to teach, has long been regarded by dentists as a defect in the medical curriculum which should be overcome. While there can be no doubt as to the good results which might be expected to follow the adoption of the recommendation of the National Dental Association some years ago suggesting the inauguration of a course in oral hygiene in the medical curriculum, against such action will be urged the fact that the curriculum is already overcrowded and that the number of theoretical studies the student is required to pursue with more or less thoroughness, and the mass of technical detail in laboratory and clinical work which he is called upon to master, already tax to the utmost his mental and physical resources.

Great as is this obstacle to the inauguration in medical schools of a course in oral hygiene, prophylaxis, and fundamental dental pathology, room could doubtless be made for it, if it were deemed of sufficient importance, or were there any general demand for it on the part of the medical profession and the undergraduate body.

As a matter of fact, however, the interest manifested by medical students in dental pathology and associated subjects when taught in medical schools has never been of a very active or encouraging character. A few years ago an annual course of lectures covering that field, delivered in a prominent medical school by one of the most eminent dental teachers in the profession, was ultimately abandoned by him, chiefly because of lack of interest on the part of the students of the institution; and the course has never been resumed.

The fact that unhygienic conditions in the oral cavity are a prolific cause of grave systemic disorders can no longer be questioned, for it is manifest that the constant ingestion of septic organisms must in time overcome the resisting power inherent in healthy tissue and lead

to pathological changes more or less grave in character. These facts being now fully known to all well-informed physicians, it may be confidently hoped that even if overcrowded, room may soon be found in the curriculum of medical schools for at least the subjects of oral hygiene and prophylaxis. This being done, practitioners of medicine will be enabled to co-operate intelligently with those of the dental profession in their effort to arrest dental deterioration, and will be inspired to use all the weight of their potent influence with the community in support of measures looking to that end.

LINE OF DEMARCATION BETWEEN MEDICINE AND DENTISTRY.

The foregoing remarks are purely the oretical and problematic, therefore let us in conclusion consider the general subject from a practical point of view; and, first, as to the dividing line between medical and dental practice. If we continue to speak of a dental practice, then the line is clearly drawn. No physician would attempt to transgress upon the field rightfully belonging to the dentist. That is, he would refrain from filling, treating, or extracting diseased teeth. But suppose these diseased teeth are known to be the cause of some more serious condition in the mouth, and remote from them into whose hands should such a case fall? Say, for example, through the persistent irritation of the tongue from contact with the jagged edges of a necrosed tooth, an epithelioma is developed. In such a case the dentist extracts the tooth, and the physician or surgeon operates upon the tongue. Or suppose the case to be the too frequent one of an external buccal sinus, originating, as these sinuses do in a vast majority of instances, from a pulpless tooth. In this case the dentist extracts the tooth, and if the sinus does not heal the patient is usually referred to the physician for further treatment.

Many cases of acute and semi-acute inflammation of the hard and soft palate, tonsils, and fauces have their origin in defective teeth, yet how often is a dentist called upon even to assist in arriv

ing at a satisfactory diagnosis? Necrotic conditions of the maxillæ are perhaps in a majority of instances of dental origin, yet these cases are usually treated on the "fifty-fifty" plan, i.e. the dentist getting fifty cents and the surgeon fifty dollars.

While the modern textbooks on dental pathology all include as important the subjects of stomatitis and cancrum oris, it is the exception rather than the rule that the purely dental man attempts to treat these mouth conditions.

It is quite true that in many cases of facial neuralgia the dentist is consulted, with the result that frequently the seat of the trouble proves to be a tooth lesion, but if this fails to be the case, if an examination of the teeth results in a negative finding, back goes the patient to the physician or surgeon with the possibility of a resection operation as the only means of relief.

It has perhaps never been definitely decided, legally or otherwise, just what liberties or liabilities the degree D.D.S. confers upon one possessing this title. There is an unwritten law to the effect that a man to specialize as an oral surgeon must have first of all the M.D. degree, the ideal oral surgeon possessing both degrees, the M.D. and the D.D.S. This is doubtless due to the fact that in the past the dentist appeared content to confine his operations to the teeth alone, all other operations in the mouth being referred to the general surgeon. It is believed that there is an important place for the man who specializes as an oral surgeon, and the present war has proved this beyond a question of doubt, but there is no sound reason why the D.D.S. degree should not protect its possessor sufficiently to permit him to perform any operation in or about the mouth.

The one thing most likely to handicap a man having the degree of D.D.S. is the significant word "dental," and this part of the title will disintegrate just as rapidly as we choose to have it do so, by our recognition of a new and broader field of operation-the future degree conferred to be D.S. (Doctor of Stomatol ogy) in place of D.D.S. (Doctor of Dental Surgery).

FLANDERS BLDG.

A

T a recent meeting of a state society there was shown in the progressive clinic a removable bridge, part of a system in which the burden of the entire perpendicular support of the bridge is placed upon the gum, the abutment teeth serving merely to hold the bridge in position. The system is based on the expressed belief of the clinician that Nature has not provided the human tooth with strength beyond that sufficient for its own needs, and that it is not wise or fair to place a greater burden upon it. This is taking a matter to which it has been my privilege to call attention heretofore, to the other and unwarranted extreme. It is an example added to many others of a tendency to circumscribed vision and shallow thinking which characterizes so many of our profession for that matter, I presume, all professions and it suggests to me the title of my paper, "Nature's Tolerance and Compensating Adjustments as They Relate to Oral Restoration."

A crying need of the dental profession -as, no doubt of all other professions -is for balance, perspective, the saving grace of a correct sense or estimate of relative values. We are prone to look at one thing so long and so intently that its image becomes fixed in the vision and interposes itself between our gaze and everything else to which our attention may be called. The average specialist or man with a hobby is like strychnin or atropin. He is tremendously concen

*

trated and needs an immense amount of dilution before he is fit to be taken into the system of general practice. Common sense is all too rare a quality. We hitch ourselves to a theory, and lacking the ballast of a practical rationality it develops wings and soars away with us into the ethereal blue of an impractical idealism filled with all manner of inconsistencies.

Here, for instance is a striking example of inconsistency: A tooth well imbedded in the bony structures and formed and anchored for the express purpose of performing the function of mastication is considered not to be able to bear the burden of any additional service; so, by way of sparing the tooth, the whole stress of mastication by the restoration is put upon the gum tissue, which, in the very nature of things, was not designed to bear any of it. "Circumstances alter cases," and Nature has a marvelous way of adapting herself to circumstances. If she were intolerent and insisted on the absolute normal in anything, few of us would be here to tell the tale. But she probably has no established normal from which she has not departed and will not tolerate departure in some measure. Her compensations are matters of common knowledge and observation.

The deaf, for example, frequently acquire great facility in lip reading through exceptional development of the keenness and quickness of the sense of

sight, and so are able to converse almost or quite as well as if they could hear. The blind develop a wonderful sense of touch. I have seen one totally blind tell colors with great accuracy by feeling the objects with his fingers. These are conspicuous examples, but there are many similar instances of Nature's losses or impairments and her efforts at compensation. In truth, there are few organs or tissues that she has not been able at some time or other to dispense with or bear great alteration of, perhaps both in form and function, and to compensate the possessor for his loss by increased efficiency of some other organ or tissue.

What is true of the organism in general is true of the oral cavity and its environment, in which our concern is more particularly centered. So my friend the clinician is in error. The gum, which Nature probably never intended for the purpose of supporting man-made dentures, can adapt itself to the requirements within certain limitations if circumstances necessitate it. On the other hand there is no reason why a tooth with normal and unimpaired anchorage should not be able to take up a part of the burden of its lost fellow if the additional burden be correctly adjusted and within proper limits.

The question is: How far may we expect her to go in bearing these losses or modifications and the additional burdens they entail, what compensating adjustments may we reasonably expect of her, and to what extent and by what means may we be of aid to her in her effort to repair or compensate for the deterioration wrought by time and service, the ravages of morbid processes, or the damage done by violence or accident? And let us see if there are not some lessons we may learn from Nature and her attitude toward the perversions forced upon her and the destructive effort of her transgressors and despoilers, so that when operative interference becomes necessary we may act intelligently and as far as possible in harmony with her own. plans and purposes.

First, considering the tooth as apart from its relations. Perhaps the most commonly met with transgression of Na

ture's plan for the individual tooth is caries. It is a well-known fact that any disturbance even to the enamel is taken cognizance of by the pulp, which undertakes to protect itself by throwing out secondary dentin as a bulwark of defense against the encroachment of the enemy. Here is a very familiar example of Nature's compensating adjustment to conditions as they arise; and how successful she is in accomplishing it is attested in the experience of every practitioner who observes teeth retaining their vitality and health in many instances even though a considerable portion of their substance be destroyed by caries. Only less common are erosion and attrition, and the same tolerance and effort at adjustment to meet the altered conditions are constantly to be observed.

These processes, however, have small beginnings and are more or less gradual in the progress of their encroachment toward the pulp, and that organ, taking cognizance of their very beginnings, has opportunity in many cases to build up against the invasion, and gradually withdraw to a position of safety. The question has been raised as to the safety of the pulp in cases where the sudden removal of tissue by grinding and cutting becomes necessary in the preparation of teeth for bridge anchorages or abutments, seeing that the pulp is taken unawares and has not the same opportunity for protection.

RESISTANCE OF THE PULP TO OPERATIVE MEASURES.

In discussing the comparative danger to the pulp of the gradual process of decay and the sudden operation of tissue removal there are three things to be said relative to caries and the remedial measures for its correction. First: That penetrating the dentin far deeper than any operator goes in cavity preparation are micro-organisms which precede the actual breaking-down of tissue-at least to an observable extent. Second: That in removal of decay and cavity preparation there is also much sudden and precipitate removal of tissue just as there is in abutment preparation. Third: That this operation encroaches much

nearer to the pulp in many cases than does that for abutment preparation. If experience and observations have shown, as they have, that the pulp resists all these influences and encroachments and remains vital throughout the life of the patient, it needs only the application of common intelligence to force the conclusion that it will bear the strain of tissue removal by operative procedure. And there is ample data in the experience of every operator, who has cared to observe, to demonstrate that these conclusions are founded on facts.

There are some timorous souls among us, however, who are overburdened with a sense of responsibility for Nature's welfare, and fearful lest she be unable to protect herself. Being actuated by motives in kind with those of our generoushearted and philanthropic birth-control specialists and advocates who would stand between God and a misused world to ward off His injustice and administer these affairs according to their own superior judgment-these pseudo-Solomons, usurping Nature's prerogative of death-control, destroy unoffending pulps at will, and because they adjust the rubber dam, sterilize the sword and the dirk with which the murder is committed, pack gutta-percha to the end of the canal, and take radiographs to show the mechanical precision with which every step of the assassination is conducted, they put on the virtuous airs of benefactors and talk learnedly of technique and asepsis.

The fact that all pulps are not equal to the increased effort and some of Nature's attempts at compensation and adjustment come to grief, offers no excuse whatever for the wholesale and indiscriminate slaughter of the innocents advocated and indulged in by these wiseacres to forestall the pathological process they claim always to foresee, but which, like most of our troubles, does not occur in probably the vast majority of cases. Leaving the tooth as an individual for the moment, there is an interesting reciprocal relation of the teeth of which I desire to speak. A study of the teeth and their relations reveals the individual tooth as having a free single protruding

end of varying size and shape to meet Nature's requirements, and a single or multiple submerged end, as the case may be, imbedded and anchored in the bony structures of the jaw for retention and support, and that the free ends of the teeth in the opposing jaws bear a relation to each other which we describe as occlusion. These tooth-ends with their occlusal and anchorage relations have a direct bearing each upon the other, both as to tooth service and individual tooth welfare.

EXAGGERATED

IMPORTANCE OF OCCLUSION IN BRIDGE WORK.

The chief function of the occlusal relation is the service of mastication, which in turn is the initial stage in the process of digestion. There is no doubt that in the normal occlusal and anchorage relations as Nature has planned them is to be found the highest degree of efficiency and the greatest compatibility with individual tooth welfare. The departure from the normal in occlusal relations, however, is so prevalent and so varied, frequently so aggravated and in so many instances never corrected, that we are forced to consider Nature's behavior toward these defective relations. If perfect masticating efficiency depends upon perfect or normal occlusal relations, it must be conceded that efficiency is reduced in the measure in which we depart from these normal relations, whether the departure be due to malocclusion or loss of the occlusal surfaces through deterioration or tooth removal, until in the edentulous mouth it ceases.

That Nature does not hold all of our organs and tissues to strict accountability, but gives much latitude in compensating adjustments, is patent to every lay and professional observer. It is no uncommon thing to see those possessed of disarranged or disorganized dentures with impaired occlusion, or lacking any for that matter, retain full physical vigor and come to ripe age. So much for Nature's compensations in the case of occlusal relations and function.

When, also, we come to consider occlusal relations and individual tooth wel