REVIEW OF CURRENT DENTAL LITERATURE 3. [Bulletin de l'Académie de Médicine, An Alleged Dental Stigma of Congenital 4. [Bull. et Mém. de la Soc. Méd. des Hôpitaux, Paris.] The Fifth Cusp and Congenital Syphilis. BY C. MANTOUX. 5. [Bull. et Mém, de la Soc. Méd. des Hôpitaux, Paris.] The Mammillary Eminence of Sabouraud: Its Clinical Significance. BY G. RAILLIET. 6. [Journal of the American Medical Association, February 9, 1918.] Syphilitic Joint Lesions Simulating Tuberculosis. BY PERCY W. ROBERTS. 7. [Presse Médicale, Paris, March 4, 1918.] The Significance of the Tubercle of Carabelli. By E. JEANSELME. The above titles represent the major part of a discussion which has grown around a statement of Sabouraud (see DENTAL COSMOS, July 1917, p. 759; Oct. 1917, p. 1043) that an accessory cusp on the lingual surface of the maxillary first molars is in the highest degree pathognomic of congenital syphilis. In article 1 there were examined 60 children, who were known to be afflicted with congenital syphilis, and 1400 patients, rhachitic or tubercular, children or adults. The histories of these cases were unusually complete. The work was thoroughly done, with radiographic and serologic control. The results are: (1) Among the congenital syphilitics Hutchinson's teeth were found 4 times: the authors observed but once the maxillary molars carrying on the anterior part of their lingual face the fifth cusp; the Wassermann in this case was strongly positive. (2) Among the other patients, in whom it was impossible to discover any recognized syphilitic taint, this fifth cusp was found clearly and unmistakably 19 times. These clinical data, verified by the laboratory, show that this new "sign" of congenital syphilis does not in reality possess any such value. This fifth cusp does not appear to have, from the point of view of syphilis, the interest attributed to it by Sabouraud. Article 2 describes in detail a case which to the authors confirms the hypothesis of Sabouraud. It is a case of unmistakable congenital syphilis, and the dentition of the patient presents this fifth cusp. This is merely an example of coincidence, and is without value in proving the validity of Sabouraud's "sign." Article 3 is the most extensive of the ones collected. and at the same time pre-eminently sane and judicial. It has been admirably summed up in the Journal of the American Medical Society as follows: Galippe devotes 41 pages to demonstrate that physicians have paid too little heed to the work of dentists, and hence when they find peculiar dental malformations in their syphilitic patients they ascribe them to syphilis. If they had wider experience with teeth they would find that to date there is no dental anomaly of shape, size, site, or structure which belongs exclusively to congenital syphilis and cannot be found with other congenital taints. Article 4 gives the following argument: Seven tuberculous patients were found who presented clearly the fifth cusp. None of these presented in their personal or hereditary antecedents anything which could be suggestive of congenital syphilis. The most careful examination of each of them failed to reveal a single acknowledged stigma. Five of the seven gave negative Wassermanns, while the other two gave positive. Both of these were affected with acquired syphilis. Mantoux is convinced that the fifth cusp is not a sign of congenital syphilis. Article 5 consists of two brief notes. The first one likewise essentially appeared in Paris Médical, November 24, 1917. It is a consideration of the coincidences of the fifth cusp with various other oral anomalies. Railliet finds a to him impressive coincidence between the frequency of the fifth cusp and leucoplakia (out of 100 patients with the fifth cusp, 35 showed leucoplakia). The author decides that without further examination (and he is cognizant of the work of Mozer and Chanet, Mantoux, and Galippe), one cannot contradict the correctness of Sabouraud's assertion. In this he appears to forget that the novelty of the assertion places the burden of proof upon its advocates. The second note was upon a study whose material was furnished by 65 children, between three and eighteen years-18 of the 65 showing the fifth cusp. Of these 9 were without permanent teeth, and showed the fifth cusp on the maxillary second premolars. In those cases where Railliet was able to see the environment, and particularly the brothers and sisters of the little patients, it was rare that their fifth cusp did not find its justification in the family pathology. He believes that the fifth cusp represents a dystrophy, oftentimes sequent to a syphilitic ancestry. Article 6 represents an American echo of this controversy. In a former paper (DENTAL COSMOS, Oct. 1917, p. 1037) Roberts inculpated widely-spaced incisors as a frequent anomaly most suggestive of congenital syphilis. He has become aware of Sabouraud's views, and apparently agrees with them perfectly. To the molar with the fifth cusp he assigns the very awkward and decidedly non-descriptive term "humpy molar." This is present in a large percentage of subjects with proved congenital syphilis. Moreover, it is seen on the permanent second molars, and in Roberts' series it appeared on the deciduous molars. Article 7 is the most interesting of this group of papers. Jeanselme approaches the subject from the broad viewpoint of history and biology. Within this report is included an earlier one in the Bulletin de l'Académie de Médecine, Paris, 1918. The fifth cusp is clearly represented in from 17 to 20 per cent. of the population. It is represented in a less sharply defined form upon the molars of about 40 to 45 per cent. of subjects examined. It shows an hereditary tendency by apparently running in families. Among idiots, epileptics, etc., or deaf-mutes, it can be associated with other aberrations of odontogenesis, but this in Jeanselme's opinion is a pure coincidence. It was present at all times in paleolithic and neolithic man. Twenty-three men, in whom there could be found no other "sign" of congenital syphilis than this fifth cusp, well developed, gave invariably negative Wassermanns. The author refers to the work of Collin and Souffland, who in 10 abnormal children presenting this fifth cusp found only one positive Wassermann. A second series worked over by Jeanselme may be tabulated as follows: There were 59 patients in all, of whom 21 (35 per cent.) lacked the fifth cusp, 29 (50 per cent.) had fifth cusps in a rudimentary state, and 9 (15 per cent.) had a well-developed fifth cusp. In the first group there was only one positive Wassermann; in the second group there were 5 positive Wassermanns, and in the third group not a single positive Wassermann. These data do not favor the view that the fifth cusp is an infallible indicator of a syphilitic taint. The evil significance attached to the fifth cusp does not accord with either view as to the history of syphilis. It is as frequent in European dentures before the great epidemic recrudescence of this disease at the end of the fifteenth century, as it is now; and it is rare in pre-Columbian American skulls. In conclusion, syphilis is definitely removed from having any influence in the production of this cusp. It is difficult to sustain the view that this cusp is the vestige of an atavistic form. Jeanselme is inclined to accept the view that it represents the remnant of the anthropoid cingulum. From this phylogenetic interpretation may be deduced the practical conclusion that the fifth cusp, the tubercle of Carabelli, is not a sign of congenital syphilis. Considering the scanty support adduced by the adherents to Sabouraud's thesis for their views, one cannot help wondering at the attention which has been given to this subject. All that has ever been proved by the advocates of the sinister interpretation of the fifth cusp is that this and congenital syphilis may occur in the same individual. They have even been unable to show that this coincidence is of a frequency in any way peculiar. The admirable and critical work of Mozer and Chenet, Galippe, Mantoux, and Jeanselme has incisively demonstrated that there is absolutely no causal connection between the syphilitic virus and the fifth cusp. [New York Medical Journal, February 9, 1918.] Kidney Infection as a Result of Pyorrhea. BY FRANK S. CROCKETT. At weekly intervals the patient had temperature elevations reaching 104° F., preceded by chill. These would last one or two days, followed by several days' remission, with only a fraction of a degree rise in temperature. The urine was cloudy, and cloudy urine could be seen coming from the left ureter on cystoscopy. Immediately after removal of the kidney (which had 2 pelves and 2 ureters) the temperature fell to 99° F. and a fraction, fluctuating to normal. Some three weeks after this operation, soreness over the right kidney developed, and the temperature shot up to 104° F. The urine became loaded with pus. The teeth of the patient, who for a period of at least a year had been afflicted with pyorrhea alveolaris of moderate severity, were the most patent source of possible infection. They were promptly removed. There was a prompt remission of the fever and pain over the remaining kidney, and the disappearance of pus in the urine. The patient made an uneventful recovery. [British Medical Journal, London, January 19, 1918.] A Serological Investigation of Vincent's Angina. BY F. E. TAYLOR AND W. H. McKINSTRY. Several contributors, scattered through the literature, maintain that in uncomplicated cases of Vincent's angina the Wassermann reaction is often found to be positive. This opinion is quite contrary to that of the authors, which is based on several hundred cases of sore throat at the Queen Alexandra Military Hospital. According to their findings the Wassermann reaction is positive in syph ilitic affections of the pharynx, and negative in all others with the exception of the angina of scarlet fever. The authors had occasion to examine bacteriologically more than three hundred cases of fuso-spirillary infection, and about onehalf of this number were typical cases of Vincent's angina verified by bacteriological findings. From this number there were taken at random fifty-five cases for the Wassermann. In all these cases, with but two exceptions, no fixation of complement could be observed, i.e. a negative Wassermann. The two positive cases admitted a syphilitic infection. The remaining fifty-three cases were quite negative. The positive reaction in the two cases admits of a ready explanation, and was not due to the fuso-spirillary infection of Vincent. In both cases the condition was one of Vincent's angina in a subject of latent syphilis. As a result of this investigation and a careful and critical consideration of cases recorded in the literature, the authors have come to the conclusion that the prevailing belief in the occurrence of a positive Wassermann in Vincent's angina has no foundation in fact, and that the two conditions can be differentiated with absolute certainty by the application of bacteriological and serological methods; and that when the complement-fixation test of Wassermann is positive in cases of Vincent's angina, a double infection exists, either as a coincident syphilitic and Vincent's infection or as the occurrence of Vincent's angina in the subject of latent syphilis. [American Journal of the Medical Sciences, There are two principal lines of thought along which attempts have been made to explain the etiology of this disorder (1) that it was the result of an infection or toxemia, and (2) that it was due to the destruction of some substance in the diet whose presence is necessary to prevent the development of the characteristic symptoms, i.e. absence or inaction of "vitamines," "accessory growth factors," or one of the known food constituents. The views of the present article are more closely allied to the latter concept. Gerstenberger here offers an hypothesis, and he makes it clear that he is doing nothing more. The hypothesis is divided into four parts: (1) All the symptoms of scurvy as we know them today may be explained on the common basis of a primary or secondary interference with one or more of the normal functions of calcium, alone or in conjunction with its physiological anion. This condition may be denominated "a partial defunctioning of calcium and its physiological anion.” This first part of the hypothesis. alone, is considered to be based sufficiently on experimental and clinical data to permit its exit from the domain of pure hypothesis. (2) In infantile scurvy this defunctioning is caused by a substance produced through a break in the metabolism of carbohydrates. whatever their original source may be. (3) The break in carbohydrate metabolism occurs as a result of the absence or inactivity or relative insufficiency or inadequacy of some physico-chemical substance or "vitamine" essential to the establishment and performance of normal carbohydrate metabolism. This view has already been advanced by other investigators. (4) The defunctioning substance produced as a result of the break in the metabolism of carbohydrates due to a disproportionment between the carbohydrate supply on the one hand and the "vitamine" supply on the other possibly is oxalic acid, or some other agent that has a similarly strong affinity for calcium and that after combining with calcium is soluble with similarly great difficulty. The second and third parts of the hypothesis are considered to have as a basis experimental and clinical data that are distinctly suggestive, while the fourth is still purely hypothetical, although on its assumption it is possible to explain satisfactorily some of the clinical phenomena of scurvy that hitherto have not even had a hypothetical explanation. The interference with normal calcium metabolism is indicated by the increased permeability of the vessel walls and the osseous lesions in scurvy. There is a close connection between the severity of the bloodvessel lesions on the one hand and of their proximity to the bones on the other. "This is most beautifully demonstrated by the lesions occurring in the gums only when the teeth are erupting or have erupted; in other words, at a time when the alveolar periosteum is very active, and when the gums have become firmly attached at the neck of the tooth to the tooth and to the periosteum." [Journal of Laboratory and Clinical Medicine, St. Louis, December 1917.] An Experimental Study of Root-filled Teeth: Preliminary Report. By M. B. COHEN. That root canal filling in average hands does not eradicate periapical infection is shown by the following study of six cases of polyarthritis: Sixty-two cultures were made from "locked areas" beyond the apices of eighteen teeth which had been filled from six months to twenty years previously. Growth was obtained without exception from each of the sixty-two cultures on some one of the media used. The organisms usually isolated were those found normally in the mouth. The streptococcus viridans was the predominating one; it occurred in sixty cultures. The staphylococcus family was represented in sixteen, always in association with the streptococcus, while the colon bacillus was isolated in pure culture once. One culture yielded B. acidophilus. [Medical Record, New York, January 26, 1918.] Streptococcus Oral Sepsis: ComplementFixation Test and Value of Routine Blood Examinations. BY N. B. POTTER, A. MCNEIL, AND S. BRADBURY. This study represents a much-needed step in the right direction. For a long time we have been morally certain that oral sepsis was an important factor in more general disturbances, but the careful analyses of this relationship have been all too few. The present report is not only founded upon data afforded by the most painstaking and strictest procedures of laboratory science, but alsoand this fact lends them peculiar value-controlled by long-continued clinical observation. The first part of this paper deals with the particular problem, Is it possible to demonstrate the presence of immune substances (called forth in response to the irritation of streptococci of oral foci) in the blood of persons suffering from various types of systemic disturbance which are suspected of being me tastatic from oral foci? The principle of this interrogation is quite analogous to that underlying the well-known and reliable test for syphilis. The technique used in making these tests was identical with that of the classical Wassermann test, excepting that an antigen prepared from several varieties of streptococci was used. The strains of streptococci from which the antigen was prepared were obtained from clinical cases showing widely varying conditions of streptococcic infection. Complement-fixation tests were carried out on about eighty patients, as indicated clinically. Twenty-one of these cases have been very carefully followed up for two years or more, and have largely recovered or very decidedly improved, due, the authors believe, to the elimination of a definite focus of chronic infection, usually in the teeth or tonsils. The authors are convinced of the preponderating importance in etiology and treatment of these minor streptococcic infections in many serious conditions or chronic invalidism. Even with an imperfect antigen, the results of a complement-fixation test for streptococci in the oral sepsis complicating or causing many forms of chronic invalidism support in general the clinical evidence of the etiological, prophylactic, and therapeutic importance of this organism, and emphasize the desirability of further attempts along this line to assist diagnosis. The second part of this paper reports the results of routine blood examinations in pertinent cases. Of fifty-five carefully studied cases of oral sepsis, twenty-five were selected for analysis. The others were excluded because of some important pathological condition other than oral sepsis. The only suggestive feature exhibited by a routine examination of the blood is a high normal lymphocyte percentage, which, however, is certainly no more striking than in any collections of patients who consult a physician for some minor ailment. [Journal of the American Medical Association, February 9, 1918.] Paget's Disease of the Bone. BY ROBERT АВВЕ. The author had two purposes in making this report: (1) To call attention to the admirable repair of such diseased bones when surgical operation is called for, and (2) to direct attention to its not infrequent occurrence in the jaw-bones, in order that it may not come unrecognized under the notice of dentists. The essential condition of this disease is one of very chronic osteitis, productive of spongy overgrowth, with absorption of the compact structures in the long bones, and occasional development of cysts lined with epithelium, sometimes filled by fluid or granulation tissue. In fourteen private cases four showed involvement of the jaws. In two of these, extensive surgical operation was required, and most excellent results were obtained. Two such cases are described. Case 1. Female, whose lower jaw had been treated for a cyst on several occasions for twenty-two years. A roentgenogram showed a very thick skull, typical of Paget's disease. Abbe extensively removed the outer plate, and all the cancellous and cystic structure of the forward half of one side of the lower jaw, leaving the inner compact structure. Case 2. Male, for many years a victim of an enormous and repulsive overgrowth of the alveolar roof of the mouth. Roentgenoscopy showed the large characteristic overgrowth of the calvarium. A horizontal block of bone, more than one inch thick, was removed. Both of these cases illustrate the very slow development of the disease. [British Dental Journal, December 15, 1917.] Bismuth Poisoning as Affecting the Oral Cavity. BY FRED. J. BLIGHT. A somewhat analogous case is Freilich'ssee the DENTAL Cosmos, 1917, p. 466. Bismuth paste (probably bismuth subnitrate, iodoform, and paraffin liquid) had been used in treatment of a comminuted fracture of the left forearm. Within a week the gums of the patient became painful. About three weeks later a bright blue line extending around the gingival margin of both maxillary and mandibular teeth was discovered. On examination the mouth showed a condition of ulcerative stomatitis. The teeth were slightly loose; some recession of the gums had occurred. The blue discoloration, which was found on both palatal and buccal surfaces |