I do not hesitate, however, in destroying a pulp to-day so much as I did some years ago, when we were taught to believe that the devitalizing of an exposed pulp was almost a certain forerunner to the total destruction of the tooth. There has been a radical change in that theory, Dr. Atkinson, of New York, has written a paper in which he speaks of the amputation of a pulp. If I remember rightly, he claims that you may amputate a pulp up to the bifurcation of the roots, that it is good surgery and it will live. I do not agree with him; and yet when I have been trying to destroy pulps up in the canals, I have sometimes thought they would live, no matter what you did to them. I do not hesitate to destroy pulps to-day, because we have such an excellent knowledge of the structure of the tooth, and we now know that simply because the pulp is lost we must not suppose the tooth to be entirely dead, but there is still life from the membranes of the root. So I am now inclined to cap only those pulps which present the best conditions for capping. If a pulp presents any symptoms of congestion or inflammation, I believe you had better dispatch it at once, in order to give the best results to the patient, but I am not a believer in the wholesale destroying of pulps. I believe, gentlemen, in conservative treatment.
Dr. Eddy:—Mr. President and Gentlemen: I am a firm believer in treating exposed pulps, with arsenious acid. I have tried almost everything else during the last fifteen years and have found nothing that will especially preserve the life of a pulp. I have had cases apparently benefited by some kinds of treatment; but I think it has been due fully as much to the temperament of the patient and general condition of health. I believe that oxyphosphate will destroy a pulp just as surely as arsenic, only not as soon. I believe this because I used it nearly eight years, and have seen some of the results. I have also had cases where I have used oxyphosphate of zinc underneath amalgam fillings, as a cement, a non-conductor, but not in direct contact with the pulp, and the pulps have died, and I laid it to the oxyphosphate of zinc. Of course, I have had my experience with fresh exposure, which I suppose was due to my being a graduate, and in those cases I think I have had good results by doing nothing more than touching the exposed pulp with carbolic acid and packing gold directly over that, and it seemed to work very well. I have tried almost everything that has come before us; and in those cases of exposure resulting from decay, or even in cases where there is no exposure, but a zone of softened tissue remains, which is liable to break down, I think it will give the patient the most satisfaction to devitalize the pulp. It may be a little more painful at first, but it is better than having the neuralgia every now and then for from one to five years and then destroy the pulp.
Another thing, Mr. President, when a pulp is destroyed by an oxyphosphate filling it makes one of the dirtiest heaps of debris that I have met. It goes all to pieces and makes a very bad mess. I have used oxychloride for capping and had better results than with the oxyphosphate.
Dr. Blaisdell:—I would like to ask if Dr. Eddy has ever used oxysulphate?
Dr. Eddy:—I have not.
Dr. Gillett:—I would like to hear more about this idea of oxyphosphate destroying the pulp. As I understand the gentleman, he makes the statement that he has ascribed the death of certain pulps to oxyphosphate used either as a lining, or as a filling in cases where there has been no exposure. Am I right?
Dr. Eddy:—Yes, sir. I had one to-day, Mr. President, that I can attribute to nothing but oxyphosphate. There was no exposure.
Dr. Niles:—Mr. President, I used to cap pulps, but I seldom perform that operation now. When I do, I feel that death will occur sooner or later. I never cap with oxyphosphate unless I wish death to take place. It has been said by one of the speakers to-night that the nerve has no means of absorbing dead matter, as the pulp has no absorbents. Even if it had, I should not want it to come in contact with the oxyphosphate. Phosphoric acid is an escharotic, and I don't know why a creamy mixture of it and the oxide should be flown over an exposed pulp, unless to destroy it. If a pulp stands this treatment and lives, it is tough. An acid that will etch glass, or dissolve silver, will destroy soft tissue. It seems to me out of reason to use such things on exposed pulps. Phosphates or chlorides mixed to the consistency of cream make an unstable, strongly acid compound, that when hard very soon dissolves in water, or to a large extent will become deteriorated in water or moisture. In my opinion, the best treatment to save a pulp, provided the patient is strong and robust enough to help out any treatment, is to relieve it from all irritation, disinfect it, and let nature take care of it. Any non-irritating mechanical means you can use to that end will be more beneficial than stimulating, bleeding, etc. I would not use strong carbolic acid or creosote to disinfect an exposed pulp, for they also destroy its surface, and the dead matter remaining decomposes and irritates the adjoining tissue. Sooner or later that pulp dies. The most of the patients who come to us with exposed pulps have a debilitated state of the system. It is not the best vitalized class of people, but those who are sickly and delicate, and who have not much reserve force for the body, to say nothing about the teeth. The question of conservative treatment, in a large majority of cases, with the hope of any lasting results, I shrink from. If I can painlessly treat my patient and take him past the trouble by destroying the pulp and filling the cavity and canal, I feel that I have done the best that can be done for him.
Dr. Taft:—In my own practice I think I have been reasonably fortunate in saving what exposed pulps I have had to deal with. I suppose I have my proportionate share of them, and my practice has been almost invariably to cap them. I think I am safe in saying that I have not used arsenious acid half a dozen times for the purpose of destroying pulps in the four years that I have been out of the school—I do not think I have used it four times. In those cases where I have used it, the pulps have come to me in a highly inflamed condition, have been aching a long time, and trying to save them by capping has seemed at once to be out of the question, and in those cases—and in those cases only—have I devitalized them at once. I do not believe in flowing oxyphosphate directly over the pulp; neither do I believe it a good plan to put carbolic acid over it. My method is either to mix oxide of zinc with oil of cloves and apply it carefully, or to apply the oil of cloves directly to the exposed portion, then dust the oxide of zinc on that; afterwards flowing oxyphosphate in a creamy condition, and waiting until it hardened, then fill the rest of the cavity with oxyphosphate or amalgam.
I keep a record of all the pulps that come to me exposed, or that I expose myself, and some I treat differently from others, but the majority of them, when seen subsequently, are alive. Occasionally I find one that comes back after a time, showing signs that the tooth is dead, and of course the tooth is then opened and treated; but the proportion of them is so very small that I believe in a conservative treatment of them, and think the first thing to be done is to get rid of whatever congestion there may be, if any, and I do not see why a pulp should not then live as well under a careful and skillful capping as it should against the hard, bony wall of the pulp cavity. I have had such good success in the treatment of them that I do not believe in destroying them at once.