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exists the greatest amount of gum-tissue with the least of external contact or exercise, and about the openings of the ducts of the several salivary glands. This, it is true, gives color, more or less, to the local-cause theory. Other points of attack are such as may result from peculiarly-shaped or irregularly-placed teeth in different parts of either or both maxillae, such as molars or bicuspids that have pressed forward or been pushed backward out of position; broad, square-crowned molars and bicuspids, with very narrow necks, showing depressions, either longitudinal or transverse; lateral incisors standing in from the line of arch which the position of the cuspids would indicate; broad-cutting edges and narrow necks of the incisors; the twisting or malposition of any one or number of the teeth which would favor the existence of an area of soft tissue comparatively unexercised, either by the act of mastication, by the tongue, the muscles of contiguous parts, or efforts at cleansing. As previously stated, the progress of this disease varies according to formation of parts, habits of the patient, environment, nature of cause, and whether the latter be inherited or acquired. We have just observed how much the formation of parts affects their susceptibility to initial lesions; so, in like manner does it influence, more or less, the direction of destruction, as well as the rapidity with which it takes place. In cases where the alveolar ridge is thin from posterior to anterior surface, the progress of the disease is likely to be continuous in one direction, viz., from the point where the process is first denuded of its membrane directly toward the apex of the root. Although the attack in such cases occasionally takes place on the anterior or posterior margins of the border, it is of more frequent occurrence upon the septum between the teeth, often giving evidence of little or no breaking down of the septum, but destroying the pericementum in a straight line toward the end of the root. Should the septum also be very thin between the teeth involved, and especially if this condition be present nearly the length of the root, it would be comparatively tenacious of life and slow to give way,—this arising probably from the fact of its greater density as compared with a thicker septum, and, if the disease attacked but one side, from its close association with anastomosing nutrient currents of the adjoining tooth. Upon the other hand, should the process be heavy, square, thick, and of considerable depth, a different action may be looked for, in this, that the progress of disorganization will be slower in a direct line toward the end of the root, and much more rapid upon the entire superficial area of the intervening septum; but while the latter is succumbing to the disease, the anterior or posterior plates of the process will remain standing for a much longer period of time. The gums in such instances, especially if the patient be ordinarily cleanly about bis teeth, will, particularly in the vicinity of the molars, bicuspids, and superior incisors, drop in over the borders of the posterior and anterior alveolar plates, thus presenting a flattened or somewhat squared aspect, with open depressions between the teeth. Again, in case the alveolar ridge is of extraordinary width, and at the same time of but little depth, the destruction of bone proceeds in about the same manner as in the foregoing case; but if it proceeds from the septum, it compromises much more readily the anterior and posterior attachments of the teeth, and vice versa, if proceeding from the latter points. Instead, however, of the gum becoming depressed between the teeth', as in the foregoing instance, which similar thickness of the process would lead us to expect, it seems to fill up the space caused by disintegration of the underlying bone, and still retains about the same relative position to the necks of the teeth as in health, and yet presents a more generally inflamed appearance. You will observe, so far as the process is concerned, that in all the above cases the principal action of the disease is upon the more spongy, consequently less resisting, structure between the anterior and posterior plates of the process. When beginning on the process between the teeth, the wasting away continues in the various ways mentioned until the outer plates are reached, which latter have thus far, under the nutrient supply of tissues external and still intact, held their own, but must now, with the advance of the enemy upon the territory of their life-current, go the way of the less resistive tissue they once inclosed and were a part of.
That daily conduct or habit of the patient has much to do with influencing the progress of this disease is certainly patent to all who have any knowledge whatever of its characteristics, and although effects thus arising may be scarcely noticeable in their bearings upon the predisposition, they evidently must, according to all physiological law, prevail. The effects of habit, however, to increase or lessen the amount and impress of local irritants are readily seen. Irritants of any nature tend to increase the demolition of parts, especially those denied the protection of their natural covering. Hence scrupulous care in freeing and keeping free such parts of substances so acting will retard in a degree the destruction that would otherwise ensue. Again, if patients are accustomed to wholesome outdoor exercise, such as more frequently induces the desire for good, substantial food, consequently insuring abundant and vigorous exercise of the jaws and teeth, the disease will progress much slower than if, on the other hand, they subject themselves to close confinement indoors and live almost entirely upon soft, pultaceous diet. As an evidence that the exercise of the parts involved is an important factor in the management of the malady, witness the difference between cases where tobacco is constantly chewed and those where it is not, or the difference in the progress of the disease about the teeth in the same mouth, it always being slower on the side most in use. Possibly the narcotic properties of tobacco may to some degree lessen the intensity of the trouble, but I apprehend the differences apparent are due more to the mechanical effects in exercising and cleansing the teeth of food, rather than to any therapeutic action of the tobacco per se.
To express to you the opinion that environment is responsible for much in connection with this condition may seem like going beyond the legitimate pale of inquiry. Nevertheless, if my observations go for anything, environment has in a degree laid the foundation for the disease in question. It has caused conditions which have in some manner led to the employment of mercury to ptyalism by thousands of our people. In the early settlement of each State, as the "star of empire westward took its way," so indeed did the blight of mercury hold its sway, and the children of these people, whose principal remedial agents for almost every hidden or serious ailment were antimony, mercury, and blood-letting, are to-day, under the absolute laws of heredity, more or less victims of parental environment. Again, it may appear strange to you that chloride of sodium, an article of seasoning, will, under certain to me unknown conditions of the system, produce similar if not identical symptoms in the oral cavity as may be found resulting from the use of mercury. You ask, What has this to do with environment? Well, go and make inquiry of the people who dwell midst the swamps and marshy lowlands of malarious districts; question and notice those who are subjects of malarial poison, and learn for yourself their extraordinary craving for salt, and then observe the results upon the oral tissues. Should you conclude that other influences, such as the presence of miasmatic germs afloat in the atmosphere, have caused the lesions you will find in many mouths, then I ask you to investigate the case of the common sailor of the high seas, whose diet consists largely of salt meats, and you may be satisfied that salt is a factor in the production of this disease. If still in doubt, extend your researches to the common Irish laborer on our public works, who has been in this country for several years, and find there the effects of a long use of briny meats. Not only does it seem to me that malarious districts are among the favorite places to note the inception of this scourge, but the very atmosphere of the surroundings is abundantly fruitful of germ-life, and the gaping wounds or lesions of any character, whether pyorrhea alveolaris or otherwise, will not be the less gaping for their influx, to say nothing of their offspring, in such a habitat as would be their lot in not a few mouths.
Generally speaking, the acquired conditions resulting either from the use of mercury or salt are slow to manifest themselves. The effects of the former may indeed quickly produce ptyalism, but the objective symptoms of the latter soon pass away, especially if the patient be of vigorous constitution, and there may be no signs characteristic of the disease for several years; but as time creeps on gradually the signs become apparent, and by the time a number of years, varying, according to unknown influences, from ten to thirty, have passed, the work of destruction has begun, and so continue, until the teeth loosen and are beyond redemption.
The majority of cases of which I now speak you will find among people who have passed the meridian of life, and on up to old age; seldom, if ever, in youth or early manhood. How often do you hear the children of these afflicted ones say, "Why, father is sixty-five years of age and hasn't a decayed tooth in his mouth," and then reflectively adding, "but his teeth are awfully loose." Indeed, the children are right; for decay seldom if ever takes place in the teeth of persons so affected, and if perchance it existed before these conditions were acquired, it seemed to have stopped right there and remained in statu quo through life. But mark you the difference. Under the laws of heredity these conditions of the parent are transmitted to the offspring, and the signs and symptoms are apparent in childhood and youth instead of old age. If, however, a child is born to these parents before the conditions are acquired, no indications of the disease will be present; but, on the other hand, and as sure as laws of heredity obtain to mark the features or the color of the eyes and hair, so certainly will the younger children get the effects in the receipt of the self-same conditions more than do the elder ones. When inherited and in the first transmission, the disease is much more difficult of control; the tissues of the parts are apparently of less integrity, melting rapidly away, and the attack is usually more precipitous, uniform, and general throughout the mouth, though the gums of young patients retain their position comparatively well about the necks of the teeth long after the cancellous bony structure of the process has wasted away. The varying progress of the manifestations arising from the two different causes I believe to be noticeable. True, however, I have not met with and studied a sufficient number of cases attributable to each cause to be quite so well founded in my belief upon this point as to admit no doubt, but such experience as I have had leads me to the conclusion that the disease growing out of a transmitted mercurial taint progresses with greater rapidity than if occurring from the use of chloride of sodium.
And now concerning the treatment. First, allow me to remind you that from time to time you have heard what some have been pleased to call my mere assertion to the effect that pyorrhea areolaris could not be cured by the removal of calcareous deposits or local treatment unaided. Indeed, you may have heard me deny the possibility of a cure when the case was well developed and typically marked as such; but before proceeding further let me say that from my stand-point there is a vast difference between typical and nontypical cases. To me a typical case is one in which mercury in some shape or chloride of sodium has been a causation of conditions which have rendered possible the local manifestations, regardless of tartar, fungus, or other external irritants,—conditions which have their place of local manifestation the same as other predispositions, and which may grow into dyscrasia and bloom out into local symptoms and signs in accordance with the character of the parts predisposed. Granting you that some of these cases in their earliest stages, before much bony tissue has been involved, and especially when the disease has been acquired, or, upon the other hand, exists in the second or third generation from its origin, can be checked or cured for a time, we will proceed with remedies.
Within the past decade dental societies have every month discussed the different wonderful specifics for "Eiggs's disease," and our dental journals have regularly fed the hungry masses with allopathic doses of each and every new one. All kinds of powerful antiseptics have been on trial; germicides, parasiticides, escharotics, caustics, etc., are still in wholesale use. These may be of service in their time and place, but after all is said and done there is but one principle upon which all local—local I say—treatment should be based, viz., that new tissue will not grow upon dead tissue. In other words, broken nutrient continuity must have protection against substances inimical to the establishment of embryonic tissue.
Of the cases coming under the care of dentists the majority have passed the primary stage, and the alveolar process has been more or less involved in the gradually advancing destruction. Under these circumstances, the first thing to be accomplished is the most thorough removal of all deposits of a foreign nature from about the necks, crowns, and roots of the teeth to the process. To do this completely and to assist in the operation which follows it often becomes necessary, in order to secure room for the entrance and exit of instruments, to incise or split the gum slightly over or in the vicinity of the parts to be operated upon. Especially is this required when the lesion exists between the teeth, and the septum is much broken down, for the chances are that the bone here will not be reproduced, and, by splitting the gum from external to internal aspect, you are