288

PROGNOSIS IN CHRONIC DISEASE.

PROGNOSIS IN CHRONIC DISEASE.

IT IS a curious fact in practical medicine that thedoctor is valued by the laity as much for his powerof prophecy as for his skill in healing. A sick manwants to be well, but he wants as much or more toknow whether he is going to get well or not. In acute

illness the doctor’s great function is to assume theresponsibility, in normal circumstances belonging tothe patient, for deciding the course of life, and thenurse’s part is to take responsibility for ordering itsminute details, while the patient’s share is to yieldall his will to these guardians and be "a goodpatient." In chronic sickness the patient asks for

assurance about what is to come almost as much asfor immediate relief ; here in particular he needssomeone else to take the burden of his future. Withthe progress of hygiene and good living the proportionof creaking doors in the population has much increased ;instead of dying by the means which are

" natural "

when his tissues begin to decay, modern man is

disappointed if he cannot live twice as long as hisprimeval ancestors. Add to this the rise in thedemanded standard of " feeling well," which has

naturally followed the general increase in healthiness,and it is easy to understand why the patient is so

anxious to know whether he will get well, and if not whenmay he expect to die; and if the answer is that he

may anticipate a partial restoration to health, howwell he may expect to be and when.As Dr. M. 0. RAVEN points out on another page, in

acute and subacute diseases, where the whole historyis easily grasped in one view, prognosis is relativelysimple and has reached a standard which is for themoment not unsatisfactory; and whether the outlookis good or bad its comparative certainty alleviatesmuch human misery. The certainty of death in

inoperable cancer is in its way as helpful a piece ofknowledge as the certainty of recovery in chicken-pox,and the wretchedness of a migraine or an acute

lumbago would certainly not be taken in the light-hearted way in which they are commonly received,were the sufferers not fully assured from their own ortheir friends’ experience that a few hours or dayswould see an end of their pain and he succeeded bya period of almost certain immunity from anotherattack. But in a great number of disease processes,often very ill-defined in their early stages, prognosisremains more dubious and speculative than it

should be. As consequential events become morewidely separated in time, so it becomes more and

more difficult for the human mind to apprehend thatthere is a connexion between them. Man has long sincepassed the stage when he discovered that the sowingof a seed was causally related to the springing of aplant, but there are still considerable difficulties in

viewing the facts of 20 or 30 years of slight andslowly progressing ill-health as a whole ; the past isdim and not very clearly remembered, the best ofnotes cannot be complete, and a host of similar

processes have intervened and obscured the view.Patients move about and change their doctors, and

our centres of medical researcsh have the most

inadequate methods for finding out what ultimatelyhappens to the patients who pass through the wards ;and here it may be interjected the follow-up systemsof some American hospitals deserve study, for it is

surely possible to reach, for other diseases, some ofthe success which has accompanied the organisedattention paid to tuberculosis. Administrative

exigencies seem to have wiped out the high hopeswhich were entertained of the knowledge whichwould come from the history of war pensioners. Atthe moment everyone will be thinking of the shiningexample set by JAMES MACKENZIE ; that there is a

fruitful road which can be travelled he showed

plainly enough, but there is no doubt that it is a, roughpath and requires grit and genius, if it is to be

pursued to any definite end.If, then, there are singularly few facts on which the

prognosis of chronic disease can be based, are thereany general principles which may he helpful tillmore definite data are available ’? Dr. RAVENindicates one which seems to rest on a good basis.Disease is a process, not a state, and it must thereforeprogress in one direction or another. The natural

history of the acute infections diseases is so wellknown that, in defiance of Mr. YULE, a typicalcourse for the rise, fastigium and decline of each ofthem is defined in the text-books ; something ishappening all the time. Of thoroughly chronicdiseases we can think of two kinds, one in whichdegenerative processes begin slowly and more or lesssteadily progress till the economy can no longercompensate for its defects, the other in which with arelatively sudden onset a substantial degree of illnessis reached which proceeds slowly and gradually tocomplete or partial cure. The rules which summarisethe history of these cases are no doubt discoverable;and are possibly as precise as those which enable

prognosis of acute conditions to be as good as it is.And it seems more or less obvious that the wholeduration of the processes must be proportional to therates at which they are proceeding at any time.What the proportion is we do not know, for we do notknow the rules which these rates of change follow.The progressive destruction of the liver in cirrhosis

may likely be expressed graphically by a straightline with some deviation due to compensatory over-growth ; the healing of a periostitis more probablyfollows a logarithmic curve, rapid at first andbecoming slower and slower as the restoration tonormal is approached. But it seems evident thatfor a first trial a measurement of the time in which a

just perceptible change takes place gives some sortof gauge of the time which will be occupied by thewhole. In any case the establishment of the fact ofchange indicates active advance or retreat, as waselegantly illustrated by DREYER when he pointedout that variations from day to day in the agglutinintitre of the blood would distinguish a genuine case ofenteric infection from some similar pyrexia in a manwho, in consequence of antityphoid inoculation, gavea positive Widal test but without any material changesin titre over a week or more. Similarly, the absenceof perceptible change over a period of months or yearsmust signify that for practical purposes the advanceor retrogression of the process has gone as far as itmeans to. It seems as if it is along some such lines asthese that data could be obtained from which themathematicians might ultimately tell us how chronicdisease goes along. But it is no simple matter.

289THE TREATMENT OF PULPLESS TEETH.

THE TREATMENT OF PULPLESS TEETH.TECHNIQUE in treating pulpless teeth, though

primarily the concern of the dental profession, is also ofinterest to the medical practitioner, who may bewitness of the infection supervening on dental treat-ment. The broader aspect of pulpless teeth and theirpossible relation to systemic infection was touched onincidentally only in the interesting paper read by Mr.L. E. CLAREMONT before the Odontological Sectionof the Royal Society of Medicine on Jan. 26th.Both Mr. CLAREMONT and those who joined in thediscussion took up the attitude that while the treat-ment of pulpless teeth is not always satisfactory, yetthere is no valid reason for refusing to treat suchteeth under suitable conditions and within definitelimitations. The fact that focal infection has assumedso important a place in modern medicine has placed aheavy responsibility on the dentist, but it has notlaid an embargo on his treatment of pulpless teeth tothe extent of making it a pathological offence toconserve teeth which have no longer a vital pulp.Even taking at its highest value all that has been saidin condemnation of dental infection, it is legitimateand, indeed, desirable that the dentist should saverather than extract teeth. But conservation must beattempted after careful consideration of many factors,and should imply a standard of technique which isoften lacking at present.

The pulpless tooth may be considered from twopoints of view. There is the tooth in which theprogress of caries has led to an exposure of the pulp.Here treatment involves the extirpation of the pulpand filling the root canal. Secondly, there is thetooth in which the pulp has died as a result of inflam-mation, and an infected and septic condition of thepulp-root canals has been established, often extendingbeyond the apex of the tooth into the peri-apicaltissue. With regard to the first class, the fact thatthe pulp is still vital does not of necessity imply thatit is free from bacterial contamination, for, as Mr. J. G.TURNER in this country, and HENRICI and HARTZELLin America, have shown, even the pulps of teeth freefrom caries may contain bacteria. Yet there is everyreason to think that any infection is only superficialand has not penetrated into the dentine lining theroot canal or beyond the apex. Provided that anadequate technique is employed there is every reasonto believe that the pulp can be removed and the canalfilled in a way to render it free from infection andreasonably immune to subsequent bacterial invasion.Unfortunately, clinical experience shows that in acertain number of cases infection follows, and mayresult either in an acute abscess or more commonly in achronic infection leading to a painless apical rarefac-tion which may only be discovered if the teeth areradiographed. There are no statistics to show howoften this occurs ; all that can be said is that it isnot uncommon. Although infection via the blood-stream is a possibility, it is much more likely that it isintroduced by the operator in the process of extir-pating the pulp and filling the root. A knowledge ofwhat may be regarded as the average root canaltechnique bears out this hypothesis. Indeed, it is nottoo much to say that it is surprising that infection doesnot occur more frequently. This sounds like a severeindictment of dental technique, but it does not over-state the case. Aseptic dentistry is an impossibilityfor many reasons, but a greater degree of antisepticdentistry is undoubtedly possible. Mr. CLAREMONToutlined a careful method of treating devitalisedteeth which though not absolutely proof againstfailure, would certainly make it much less common.There is no doubt, however, that the standard of rootcanal treatment has progressively improved duringthe last decade, and that an increasing number ofdentists are adopting methods which are deliberatelyplanned so as to exclude infection during the stagesof root canal treatment. In this matter dentistry ismuch indebted to Mr. J. B. PARFITT, who has elabo-rated a method which is logical and thorough, and

yet not so exacting as to place it without the scope ofthe usual conditions under which dentistry is per-formed. In spite of a certain number of failures, manyof which could undoubtedly be prevented by a morescientific technique, there seems no reason to adopt thepessimistic attitude of some who argue that it isunwise to retain in the mouth any tooth which has nota living pulp. A dentist who is aware of the potentialdangers of an infected tooth and shapes his treatmentaccordingly so as to exclude avoidable infection.during the process of treatment, is justified in treatingand saving teeth with exposed pulps. It wouldbe a wise precaution, however, to have the teethradiographed periodically to provide against thecontingency of apical infection later, for a pulp-less tooth is undoubtedly less resistant than a vitaltooth.The problem of the tooth already pulpless and with

infected canals is much more difficult, and there ismore to be said for the attitude of those who are soimpressed by the difficulties of sterilising the peri-apical tissues that they do not consider it justifiable tosubject their patients to the risk of leaving infectionbehind, the more especially as it is usually painlessand may, therefore, give no local signs of its presence.Mr. CLAREMONT took up a guarded attitude on thissubject. Provided that certain essential conditionswere fulfilled, he thought that it was legitimate toundertake the treatment of such teeth, and that it wasoften possible to do so with success. Treatment ismost likely to be successful on the anterior teethwith single roots. It should only be attempted onteeth which have healthy periodontal membranesand do not show any signs of marked apical infection.A radiograph should precede treatment, and the teethwhen filled should be regarded as being on probationand examined at intervals, and, if possible, radio-graphed. The ideal treatment should logicallyinclude cultures from the root canal to ascertairwhen thev were free from infection. Mr. E. C.SPRAWSON, in the discussion which followed, statedthat this step is being introduced at the LondonHospital Dental School as a routine procedure.This is an admirable innovation, the educationalvalue of which to the student should be considerable.As a practical addition to private practice it isscarcely feasible, for it would add so much to the costand length of treatment as to make it prohibitiveexcept to a favoured few. It was noteworthy thatthough the discussion revealed a wide variety ofmethods of attempting disinfection of septic rootcanals, there was a very general endorsement ofMr. Ci.AREMONT’s moderate attitude, that though thetreatment of infected teeth presents great difficultiesand places a great responsibility on the dentist whoundertakes it, yet there are cases in which treatmentis fully justified and is often completely successful asjudged by both clinical and radiographic tests.Indeed, even the presence of apical rarefaction maynot be a barrier to successful treatment, for boneregeneration is possible, as was shown by someexcellent radiographs exhibited by Mr. CLAREMONT.To put it shortly: the forceps is not the only

way of treating dental sepsis. In many cases

extraction is the only possible remedy, but in others itis possible to remove the infection and still leave to thepatient the use of his teeth. The amount of attentionwhich is being paid to this aspect of dental surgeryleads us to hope that the conservative treatment ofdental infection will become increasingly successful.

INDEX TO "THE LANCET," VoL. II., 1924.

THE Index and Title-page to Vol. II., 1924, whichwas completed with the issue of Dec. 27th, willshortly be published. A copy will be sent gratisto subscribers on receipt of a post-card addressedto the Manager of THE LANCET, 1, Bedford-street,Strand, W.C. 2.