epithelial cells and in places the basement membrane is destroyed. We probably have here the picture of the beginning cancer, but at a stage in which, if the local lesion is completely excised a permanent cure should always be accomplished.

Fig's. 8 and 9 (colored) illustrate a patch of leucoplacia on a tongue the seat of diffuse tobacco glossitis. This nodule was excised. The condition of the tongue entirely disappeared after the patient ceased smoking, and it is now almost three years since the operation.

Fig. 10 shows a diffuse leucoplakia of the tongue, this patient smoked and played a cornet, and the Wassermann

Giant Cell Tumor, Microscopically.

they should know the best advice to give their patients. They must be especially careful about these lesions when they are situated on the gum, because here dental treatment would be irritating, and if carcinoma had already developed, dangerous. In cases of this kind there should be consultation with a surgical colleague. If a piece is to be taken out for diagnosis, it should be done with the electric cautery, or, if the knife is employed, the wound should be cauterized, best, with the electric or Paquelin cautery.

LESIONS OF THE ALVEOLAR

BORDER OF THE JAWS. Bleeding, anemic or diffusely swollen gums are often signs of some general disease-hæmophilia, scurvy, purpura, anemia, or leukæmia.

Fig. 12 is a sketch of the diffusely swollen gums of a boy aged seventeen. The swollen gums have been present

Fig. 17.

associated with infected teeth there is a growth of new bone from the alveolar border. Clinically and from the X-ray one might be suspicious of a periosteal ossifying sarcoma, but the latter always involves the body of the jaw, and I have never observed it on the upper jaw, while ossifying periostitis is confined chiefly to the alveolar border and has been observed on the upper as well as on the lower jaw. Microscopically, it

Epulis Tumor from False Teeth.

two and one-half months. The teeth were loose. As he was having trouble from a wisdom tooth, a dentist extracted it; but there was not much hemorrhage. Later, when the boy's general condition began to suffer, the dentist and physician became suspicious that the teeth were not the cause of the local condition. A piece was excised for diagnosis (Fig. 13). Then the patient came under my observation, and a blood-count showed a leukocytosis of 39,000, small lymphocytes 71%. The boy died a few months later of leukæmia.

Ossifying Periostitis. In some cases

Jaw. Fibroma of the Gum.

can be distinguished from sarcoma by the character of the connective tissue between the bone lamellæ (Fig. 14). In many of these cases there is a positive Wassermann reaction. Proper care of the teeth and specific treatment in the syphilitic cases is followed by the disappearance of the new growth of bone. I am confident that the X-ray will be a great help in recognizing these cases.

Epulis. The epulis is a very common gum tumor. The growth is chiefly on the outer side of the teeth (Fig. 15). They are often mistaken for gum boils and incised. Microscopically they are either fibromas, fibroangiomas, or a giantcell tumor. (Fig. 16.) When removed with the knife they often recur unless one

sure of false teeth. Fig. 17 illustrates such a growth on the upper jaw near the position of the wisdom tooth. Microscopically (Fig. 18) it was a cellular fibroma, and there has been no recurrence seven years since its removal.

Adamantine Epithelioma of the Gum. This is the least common form of epulis. As a rule the mucous membrane is more apt to be intact, the tumor is firmer, and does not bleed as the other forms of epulides just discust. Fig. 19 illustrates such a tumor, and Fig. 20, its

Jaw.

Adamantine Epithelioma.

epithelioma. In one case the X-ray of the teeth showed a cavity about the root of the cuspid. In this case there had been a persisting sinus about the tooth for three years. I extracted the three teeth and burned the cavity with the cautery. A piece of the connective-tissue wall of this cavity shows adamantine epithelioma. There has been no recur

rence.

In the beginning of my paper I called attention to the danger of persistent sinuses in the region of the teeth as an etiological factor in cancer. In this case the epithelial growth is of a benign, or rather, less malignant character. This observation also shows the value of the

X-ray in diagnosis. Here the dentist had attempted to heal the sinus and to save the tooth for a period of three years without taking an X-ray.

I have illustrated some of the simpler lesions. Those interested in the subject I would refer to my chapter on Diseases of the Jaws in Bryant and Buck's Surgery, vol. vi., p. 813. There I have described and illustrated the more malignant sarcomas and carcinomas of, and in the region of, the upper and lower jaw, and also the tumors originating from the dental embryonic residuesthe dentigerous cysts and the solid and cystic adamantine epithelioma.

Discussions.

Dr. Truman W. Brophy, Chicago, Ill. Mr. President, Dr. Bloodgood, Ladies and Gentlemen:

During the address of the evening my thoughts went back to the time when the great dental educational struggle was on, and if it were possible for that celebrated professor, Dr. Chapin A. Harris, who founded the first dental college in the world, the Baltimore College of Dental Surgery, to come here to-night, he would feel that his early work had not been in vain. When the predecessors of the distinguished surgeon who has addrest you this evening did not feel that dentistry, with all it represented, was entitled to a place in the medical institutes, Dr. Harris began his work in his own way, and he accomplished much. In striking contrast with those early days, one of the most celebrated surgeons of the City of Baltimore comes to us to present the results of modern investigations so that we may benefit thereby. (Applause.)

As a member of the National Dental Association, I feel that I voice the sentiments of all when I say that we are indeed indebted to Dr. B. Holly Smith for inviting Dr. Bloodgood to come here and speak to us to-night. Personally, while it is not the first opportunity I have had

to listen to him, I feel that the exposition of the subject he has presented here has been a most valuable contribution to the literature of our profession. That is to say, it will become our literature because it will be published, and I trust that the illustrations he has given us, which so beautifully portray what he has done, may also be duplicated in our transactions.

It would be impossible for me, in the brief time I am assigned, to go into detail regarding the discourse of the evening. There are some conditions, however, that I do wish to speak of, and those are regarding the inception of cancerous lesions. Professor Bloodgood has told us that they are local, they are benign, they are innocent in their beginning, they are curable. He has demonstrated that those diseases were not infectious. While he was speaking, an incident in the life of the great Professor Nicholas Senn came to my mind. In his surgical I clinic one day, as he often did, he removed a cancer of large size. After it was removed, he said to his interne, "I will inoculate some of this tissue in we your arm, and then will demonstrate to the world that this is not infectious." The interne's face blanched with fear, and the Professor said "You hesitate to allow me to do this?" He spoke to the others and they also declined. "Then" said he, "inoculate my arm." They declined, and he inoculated his own arm. "Now," said he, "if this is an infectious disease, I will have cancer." He never had cancer, and so he demonstrated in his own case the error of the opinions that were held by many that it was an infectious disease.

Regarding the statements of Dr. Bloodgood as to the use of Röntgen rays or photographs, their value as an adjunct in making a correct diagnosis and the frequency with which these patients are often treated without diagnosis, I certainly agree with him. Νο one should undertake to treat a disease of

this character, especially where the bone is involved, without securing a good Röntgen photograph. Many Röntgen photographs, however, are not good. We know that, I have often said that one of the greatest needs of the dental student is a more thoro knowledge of pathology. I believe one of the greatest needs of the medical student is a better knowledge of the anatomy and pathology of the teeth, together with a knowledge of those diseases which have direct origin with them.

As to the origin of these growths, the speaker has pointed out sources of irritation. In my conversation with him prior to his lecture I asked him in what ratio the mouth was the center of cancerous disease. He told me that onethird of all the cancerous diseases known to mankind occur in the mouth. I believed it at least came second in the list of parts subject to cancer. He tells me it is third in order. It may not have occurred to some-I have no doubt it has occurred to him-why the mouth is so frequently the center of cancerous disease. In the development of the teeth, the dipping down of the mucosa into the sub-mucous tissue and the formation of the dental enamel organ, there are left innumerable cells of epithelium which float about in the sub-mucous tissue unused. These may lie in colonies or groups dormant until advanced life. They may, in mature life, be subject to irritation, and then develop into a cancer. I believe one of the most common causes of the existence of cancer is due to these cells lying there, subject to irritation and multiplication and growth.

I want also to call attention to the matter of mutilation. More than any other surgeon I have ever heard, Dr. Bloodgood has pointed out the undesirability of opening the tissues of the face in making operations of this character and causing mutilation. The tissues of the face must be opened sometimes, but for the ordinary growth that occurs, he

can succeed in removing it within the mouth. When extensive operations are made, and there is the loss of the mandible or a part of it, the proper course to pursue is to adjust prosthesis.

I want, in closing, to thank Dr. Bloodgood for his presence here with us this evening. (Applause.)

Dr. O. A. Strauss, Milwaukee, Wis. Mr. Chairman, Dr. Bloodgood, Ladies and Gentlemen: I want also to thank Dr. Bloodgood for the privilege of hearing his lecture this evening. It was certainly a very instructive one.

In speaking of precancerous condition we should also think of the precancerous, or rather the Cancerous Age.

Cancer of the mouth, unlike malignant lesions situated in other places, invariably has a precancerous stage. After the age of thirty-five any lesions of the mouth becomes suspicious, if it does not granulate properly within ten days it should at once receive the attention of a specialist; a specialist who is familiar with all the conditions of the mouth and teeth, as well as the general condition predisposing to cancer.

In entering the field of predisposing causes we have many. Any degenerative process progressing in the system will eventually produce cancer if the exciting cause is added.

Among these conditions predisposing to cancer are: syphilis, tuberculosis, rheumatism, auto-intoxication, and faulty metabolism, (either of a katobolic or anabolic nature.) In the one we have too low a form of nourishment, in the other we have an over-stimulating influence, and so there are many more, too numerous to mention at this time.

When a lesion becomes obstinate it requires a very careful differential diagnosis, which calls for a most thoro clinical examination. The Wasserman test should never be omitted, regardless of the patient's history. Tuberculosis