[New York Medical Journal, June 22, 1918. (Scientific Proceedings of the American Medical Association.)]

Retention Cysts of the Mucosa of the Lip. BY R. L. SUTTON AND F. SIMPSON.

He

Sutton had several cases of these retention cysts on the lower lip. They were about one-fourth to one-half inch in circumference, covered with normal mucous membrane, and contained mucous secretion and cells. had treated them by evacuation, cauterizing the base with some chemical agent. W. A. Pusey had had considerable success in treating these cysts by the cautery.

The Lipoids in Tumors of the Dental System. BY K. W. Dewey.

The chief lipoid in tumors about the mouth, as in other parts of the body, was cholesterol, occurring as the stable ester compound and much more frequently in more or less loose combinations with fatty acids and other lipoids. Such crystals were mostly doubly refractive. Mixtures of cholesterol with glycerin esters or neutral fat had no such properties. In the tumors studied cholesterol in these various forms was found to occur much more in the connective tissue stroma, in endothelial and other connective tissue cells than in the tumor cells themselves. A noteworthy observation was that frequently leucocytes were completely filled with these lipoids. A finding which is almost without notice in the literature was the presence of fatty acids and soaps in the zone of squamous epithelial cells of papillomata and other pathological conditions of the mucosa. A condition resembling cornification of the epidermis, characterized by the occurrence of fatty acids, was not so rarely found. The lipoid substances associated with degenerative processes found in tumors of the dental system were possibly particularly suitable for investigation of the important question as to what substances were involved in the process of calcification.

A soldering iron and a water-cooled retractor were the most satisfactory means of cauterization. This was followed by radium treatment. The immediate results of this treatment in this group of cases are very encouraging. Twelve of the twenty patients on whom this report is based had no recurrence locally or in the cervical lymph nodes for from six to eighteen months.

[Journal of the National Dental Association, July 1918.]

Progress of the Year in the Investigation of Mottled Enamel, with Special Reference to Its Association with Artesian Water. BY FREDERICK S. MCKAY.

The present report is primarily a survey of the geographical distribution of this peculiar lesion, with special emphasis on the artesian basin of South Dakota. The evidence presented by the examinations of this district make it plain that there is a relation most definite and conclusive existing between the use of water drawn from these artesian wells during the period of enamel growth and the existence of the enamel lesion.

Another endemic region is found in the Bahama Islands. In this locality it appears that if the water be the cause of the lesion it is because of something it takes from the soil, since water which does not come into contact with the soil (rain-water gathered in tanks) is unassociated with mottled enamel. It is difficult to understand what relation can exist between water obtained from the shallow wells in these limestone coral islands, in the ocean, and that flowing from the Rocky Mountain range, hundreds of miles underground, to supply deep artesian wells far in the interior of the country (South Dakota region). Undoubtedly it strengthens McKay's attitude in directing the study of this problem, that the only way a solution can be reached is by a most careful comparative chemical analysis of the waters.

The rest of the report is occupied by a consideration of two theories which have been advanced to explain the etiology of mottled enamel.

Grevers of Utrecht, Holland, is decidedly of the opinion that thyroid disturbance, or at least underlying constitutional factors, will be found to contain the solution of the difficulty. The one circumstance connected with

glandular dystrophy (goiter and cretinism) that exists in common with mottled enamel is its sharply defined geographical localization. But against the correctness of this analogy is the fact that the individuals with mottled enamel fail in any particular degree to present unmistakable evidence in other parts of the body of malfunctioning of the endocrine organs.

Grever's conclusion is that mottled enamel is simply immature or not fully calcified enamel, and not a manifestation of an inherent lack of the cementing substance. Whether or not this view be eventually corroborated, to McKay the real problem remains unchanged, viz, to locate the influence which either prevents the maturing of the outer layers of the enamel or else partially destroys this layer after it has once been fully formed.

The second theory to be discussed by McKay is that of Gasparini and Piergili (see DENTAL COSMOS, July 1918, p. 631). In harmony with the views of these men, in the American endemic districts the waters have been lacking in "mineral salts in general, and in calcium salts in particular." But the conditions in the Bahama Islands' endemic region invalidate the significance ascribed to the calcium content of the potable waters. These islands are coral reefs, solid, calcareous material. What shall we say of rain-water with reference to its lime content after running over and through such a soil?

It seems to McKay that the conception of Gasparini and Piergili of this lesion and its production is faulty in its first fundamental, and it cannot be understood how they failed to notice that teeth which have mottled enamel erupt with the enamel in this condition, which means that this is brought about during the developmental period, and before the enamel could possibly have come into contact with any water which passed through the mouth during the act of drinking.

In conclusion, McKay states his belief that the damage is wrought by some influence which acts either in an inhibitory or in a destructive way upon the enamel during or immediately after the building period (which of these two hypotheses, if either, will finally be found to be correct, it is impossible at present to say), and reiterates that the con

dition is established prior to eruption (contra Piergili).

[Laryngoscope, St. Louis, December 1917.] Salivary Calculus. BY W. W. CARTER. [Revue Médicale de la Suisse Romande, November and December 1916, per Laryngoscope, St. Louis, March 1918.] Acute Suppurative Whartonitis.

The latter of the two above articles is a brief case history. It concerns a woman, age forty-eight years, complaining of severe pain and swelling in the right submaxillary region, difficulty in opening the mouth, salivation, and immobility of the tongue. Examination revealed a calculus in Wharton's duct, which when extracted was found to be 1.5 cm. long and 2 mm. thick. It had a slight longitudinal groove so that the duct had not been completely occluded. Removal of the calculus was followed by escape of thick pus.

The subject of Carter's report was an adult male, who experienced a sudden, stinging pain on the right side of the tongue. The right side of the floor of the mouth became swollen. increasing rapidly on taking food, and subsiding a short time after a meal. A small calculus, about the size of a mustard seed, could be seen obstructing the mouth of Wharton's duct. Upon removal, symptoms disappeared.

was

A little less than two years later there a reappearance of similar symptoms. The X-ray showed a large, pear-shaped calculus and two smaller calculi. On removal the largest was about the size of a cherry pit; the small ones about the size of mustard seeds.

After apparently almost immediate recovery from the operation, there occurred an unexpected complication, which Carter has not found mentioned in the literature. On the third day after operation the opposite submaxillary and both sublinguals became sympathetically involved, and for four or five days the patient was completely incapacitated. The parotids did not participate.

Sixty per cent. of salivary calculi are said to be found in the submaxillary glands, twenty per cent. in the sublinguals, and twenty per cent. in the parotids. The stones are usually found in Wharton's duct, where they are generally round or cylindrical. When found

in the gland they are usually larger, irreg ular, and multiple.

Carter is inclined to look upon salivary calculi as the result of a local inflammatory process-a clump of bacteria serving as a nidus around which is deposited the salts of the saliva. The prompt removal of calculi, especially if they are located in the gland, should be urged, not only on account of the pain but because of the likelihood of abscess formation, which may result in cellulitis, a condition always to be dreaded in this locality.

[Medical Clinics of North America (Phila

delphia number), September 1917.] Ulcerative Endocarditis, Secondary to Dental Sepsis, Treated by Autogenous Vaccine. BY JUDSON DALAND.

The three cases which furnish the text of this clinic are those referred to by Daland in the DENTAL COSMOS, 1917, p. 1101.

Case 1 was a man of forty-three, complaining of weakness, mental depression, fear of crowds, tremor, irritability, epigastric distress with distention, attacks of fever at intervals of from ten to fourteen days, loss in weight of thirty pounds. These symptoms began six months ago. Family and personal history were unimportant. The maxillary left premolar and first molar and right molar were crowned. Absence of teeth on the right side prevented good mastication. By exclusion of other possibilities resort was had to radiographing the teeth.

This showed peri

apical abscesses at the roots of the left mandibular premolar and first molar, and left maxillary second premolar. Exploration showed that the left maxillary second premolar contained cotton, offensive in odor. The root-canal was enlarged, and cultures taken, yielding a non-hemolytic streptococcus of low virulence. From this a vaccine was made. The infected teeth were extracted and the sockets curetted. The equivalent of 500,000,000 organisms was injected at intervals of five days, later increased to 750,000,000, and toward the end gradually decreased to 150,000,000. The leucocytes were increased 1000 after the first injection; the larger doses caused depression. Vaccine treatment was continued for two months and was of no benefit. Death ensued. In Daland's opinion the beginning of this fatal illness was due to

septic ulcerative endocarditis involving the previously diseased mitral valves, secondary to streptococcus infection from tonsils or roots of teeth, or both. The large doses of vaccine did harm by causing increased weakness.

Case 2, male, age forty-one. During the past three or four years the patient had had abscesses about the apex of the right maxillary first premolar; he complained of feeling tired, aching pains in legs, nightsweats, fever, loss of weight, anorexia, increased pulse rate. Vaccine prepared from an hemolytic streptococcus isolated from the blood stream gave no observable benefit. The disease steadily progressed, culminating in death. The history, examination, and autopsy all combine to show that this was a typical case of septic ulcerative endocarditis, involving the mitral and aortic leaflets, and it is probable that these diseased valves became infected with the hemolytic streptococcus from the roots of certain teeth.

Case 3, male, age forty-six, complained of weakness, chills, fever, sweats. The family history was negative. Radiographs showed abscess on the distal root of the right maxillary second molar. This tooth was removed. Considerable pus escaped. Fever, leucocytosis, and polyarthritis disappeared, and there was general symptomatic improvement, but death took place twelve days later. The marked though temporary improvement following the extraction of the infected tooth suggests that greater benefit might have been secured if that focus had been removed earlier; on the other hand the periapical abscess may itself have been secondary, as the tooth showed no evidence of previous disease.

[American Journal of Physiology, Baltimore, March 1, 1918.]

Orokinase and Ptyalin in the Saliva of the Horse. By C. E. HAYDEN.

It has been claimed that there exists an enzyme, present in the buccal and possibly the lingual glands, that activates in ptyalinogen present in the secretion of the salivary glands of the horse. From this point of view neither saliva obtained from a parotid fistula nor a glycerin extract of the parotid gland digests starch. The same claimants assert that the mixed mouth secretions obtained from an esophageal fistula are more powerful

in their amylolytic action than those obtained from the mouth. The name orokinase is given to the activating enzyme which activates the parotid saliva, and the claim is made that the enzyme is present in the mouth secretions of both horse and man.

In Hayden's present work, parotid saliva from the horse was collected through a fistula of Stenson's duct. Mixed saliva was collected from both the mouth and an esophageal fistula. Mixed human saliva was obtained from a large number of persons. Parowax was chewed in each case to stimulate the flow. Various extracts were made with fifty per cent. glycerin in water.

The data and the inferences therefrom afforded by this study have been summarized by the author as follows:

(1) Pilocarpin hydrochlorid does not digest starch. Hypodermic tablets of both pilocarpin and arecolin contain a reducing substance in comparatively large quantities, but do not in themselves digest starch.

(2) Two drops of human saliva diluted 1:50 carry 5 cc. of a one per cent. starch solution to the erythrodextrin stage in a large number of cases. A measurable amount of sugar is produced as a result of that digestion.

(3) Human saliva in such a dilution does not activate either mixed or parotid fistula saliva from the horse.

(4) Mixed human saliva digests cooked starch much more readily than either mixed or parotid fistula saliva of the horse.

(5) Two drops of mixed mouth saliva from the horse diluted 1: 10 does not activate parotid fistula saliva from that animal. It does not show any appreciable digestive power when used alone in that dilution.

(6) The filtrate from a solution of ground corn or oats contains a reducing sugar. The quantity of sugar does not show an average increase when the grains are digested with either mixed or parotid fistula saliva from the horse. Mixed human saliva does digest them under the same conditions.

(7) Extracts from the glands and mucosa of the mouth have failed to activate parotid saliva or extracts of the salivary glands of four different horses.

(8) Corn and oats passed through an esophageal fistula show no more reducing sugar than the ground grains themselves. Mixed

saliva from the esophagus has not shown any marked potency.

(9) The glands of the mouth as well as the salivary glands produced a small amount of enzyme that will digest starch within a twenty-four-hour period.

[Pennsylvania Medical Journal, Athens, January 1918.]

Diseases of the Eye from Focal Infection. BY ADOLPH KREBS.

[American Journal of Ophthalmology, Chicago, May 1918.] Blepharospasm Secondary to Pyorrhea Alveolaris. BY H. M. THOMPSON.

Krebs presents essentially seven case histories, which in a condensed form follow:

(1) Asthenopia, a woman of forty-eight years, under observation eight years. Radiographs showed periapical abscesses on both right and left maxillary first molars. These teeth were extracted. Marked improvement took place within two months, and at the present time (two years later) she can read or sew for hours without fatigue or discomfort.

(2) Asthenopia, man of thirty-seven, under observation four years. No correction was comfortable more than a few months at a time. An extensive periodontal abscess in the right maxilla was treated and cured. All ocular symptoms disappeared.

(3) Asthenopia with marginal blepharitis, woman of twenty-one, under observation three years; was cured within a month after extraction of two abscessed left maxillary molars.

(4) Episcleritis, woman of thirty-eight. under observation seven years. No treatment had any permanent effect until two teeth were extracted. This gave complete relief for one year; then a return of the episcleritis occurred. Removal of an infected tonsil was followed by a clearing up of the inflammation. No sign of recurrence was noted for at least two years following.

(5) Phlyctenular keratitis, girl of eleven. under constant treatment for sixteen months. Extraction of an infected right mandibular first molar resulted in the prompt disappearance of the hitherto incurable photophobia and the cessation of the phlyctenular process. There was no return for at least a year.

(6) Iridocyclitis, woman of fifty-five, under

observation three years.

During the second year of unsuccessful treatment there was extracted an infected molar bridge abutment. Progressive improvement has since taken place.

(7) Uveitis, woman of thirty, under observation seven years. The radiograph showed an impacted and infected right maxillary third molar, also a left maxillary molar with a periapical abscess extending into the antrum. These were removed, and in two weeks there was marked improvement. During the next two months she had an attack of dimness lasting ten minutes. Her left antrum was operated upon, since which time there has been no return of the attacks.

Thompson's article is a brief case history which is in line with those just recorded. The patient was a man of fifty-two, in excellent health except for "rheumatic attacks." He first noticed a conjunctival irritation. A few days later the lids closed tightly in a tonic cramp. General examination; urine and Wassermann negative. For four weeks varied remedies were tried in vain. A rather severe pyorrhea suggested the chance of focal infection. The teeth were all removed. On the next day the patient was able to open his eyes, and on the fourth day was apparently in normal condition.

Thompson interprets the long-continued cramp of the orbicularis muscle as secondary to a toxic inflammation of all the coats of the eye, due to focal infection.

[Annals of Surgery, Philadelphia, May 1918.] Loose Cartilage in the Temporo-Maxillary Joint. BY RICHARD J. BEHAN.

The patient was a female, of apparently adult estate, whose chief complaint was inability to close her mouth so that the teeth would come together. It seemed that the entire mandible was swung toward the right side, so that the line of the teeth of the lower jaw was at least one-half inch from the line of the upper teeth. The lesion had been present for eight months, having resulted from a difficult effort at mastication. At first the jaw locked, but by persistent effort she was able to release it. This happened several times, until the locking in the position above described became permanent and could not be released.

A study of the joint convinced Behan that

the locking was due to a separation of the left interarticular cartilage, with a forcing back into the temporo-maxillary articulating cavity.

No description of an operation for the correction of this deformity could be found, so the author devised a technique which is given in detail. The patient made an uneventful recovery, leaving the hospital in eight days. The teeth were in perfect alignment, mastication was normal. After a lapse of eighteen months, the left joint gave no trouble, although there was some crackling in the right joint.

[American Journal of Physiology, Baltimore, April 1, 1918.]

The Salivary Factor in Relation to Dental Caries. BY PERCY R. HOWE AND MILDRED R. KENISTON.

The authors report their work upon the relation (if any) between the salivary factor and the incidence of dental caries. The "salivary factor" is an arbitrary and empirical standard to represent the degree of the saliva's power to maintain a neutrality in the mouth.

Marshall's procedure was followed. All subjects were of about the same age, ten to fifteen years. From an abundance of clinical material it was easy to eliminate any doubtful intermediates, and to choose only the two extremes, those children showing absolute immunity to dental caries and those showing excessive decay.

From the observations made on these cases, it would appear that the saliva of persons with teeth immune to caries varies, as does also the saliva of persons with carious teeth; that saliva may neutralize substances taken into the mouth, and that the average immune mouth has the greater power of neutralization; but the ratio of resting and activated saliva in immune mouths does not vary enough from that of carious mouths to prove that this ratio is indicative of the production and maintenance of immunity to caries in any individual. The tables compiled do not show consistently that as the difference between the total neutralizing powers of the resting and activated saliva diminishes, liability to incidence of caries increases. Since the average ratio or salivary factor is below 80 in both immune and carious mouths, there