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YORRHEA alveolaris begins in the gum margins. The writer of this article voiced this thought in a paper read before the Northeastern Dental Association in 1911.* Perhaps no more conclusive argument can be adduced on this point than the fact that every dentist has noticed that the removal of infected teeth results ninety-nine times out of a hundred in cessation of all inflammatory symptoms. The second corroborative fact is that removal of the infected porous root surface usually checks all types of interstitial gingivitis quickly if the work be accurately done, but if the tooth's surface be neglected and dirty, gingivitis recurs.

In the observation of more than two thousand cases, the author has found no exception to this general rule, except in cases of acute diffused nephritis, diabetes-mellitus, and certain types of drug poisoning. The above observation was published in the Canadian Dental Journal, June 5, 1912.

That gingival inflammation is the originating point from which pyorrhoeal inflammations continue has been observed by many writers. A close study of the

*Published in the Dental Cosmos, 1911.

pictures of transverse section of both human and animal jaws by Talbot, (*1) and human jaws by Hopewell Smith (*2) and Znamensky (*3) of the University of Moscow, all show the deepest inflammation in the gingivae and the masses of leucocytes progressively less as we recede from the gingival margin. This point seems to have been given little weight by Talbot and Smith in their efforts to determine the point of origin, they, becoming deeply interested in the changes going on in the deeper structures of the advanced case, while on the contrary, Znamensky emphasizes his belief that the gingival margin is the point of origin. (See lantern slides of Talbot (Fig. 1), Smith, (Fig. 2), and Znamensky (Fig. 3). Perhaps the most notable article in which a rather comprehensive series of observations has been accumulated is that of Doctor Arthur Black which was published in the Dental Cosmos, page 1219, year 1913. These observations were accumulated by a group of men who worked in conjunction with him and confirmed the view already stat

1-Talbot--Interstitial Gingivitis.

#2 -Smith-Dental Cosmos, 1911. *3-Znamensky- British Dental Journal, 1908.

Fig. 3. d. dentine of the tooth; p, tartar; f, papillary layer of gum; z, epithelial covering; i, infiltration of the gum with white blood corpuscles; c, healthy part of the gum; y, healthy bone. Magnified 80 times.-Znamensky.

Fig. 3 A-Shows the same parts at a further extension of the disease. The peeling off of the epithelial covering can be seen (h); a wounded surface is being formed (y). Magnified 80 times. -Znamensky.

tention first to a study of a series of stained tooth surfaces in mouths in which no especial care had been taken of the tooth surfaces in the gingival neighborhood, but in which the teeth to the casual observer seemed to be clean.

You will notice from the illustration that the necks of all these teeth and approximal surfaces are black. This black color is due to the application of a solution of iodine and iodides, first suggested to us by Doctor Talbot for treatment of inflamed and irritated tissues and later modified by Doctor Skin

ner for the purpose of revealing to the eye of the observer the bacterial masses upon tooth surfaces.

The question is, what is this material which stands out in such bold relief when treated with disclosing stain? Is it simply muco-plaque material, or is it living bacteria, or both? If it is largely bacterial, what are the most constant forms found on tooth surfaces? The study of hundreds of smears taken from this locality on the tooth surfaces discloses the fact that we have universally present on the tooth surfaces and at the gingival margin, several types of bacteria, and these types do not stain equally well with the same stain. The absolutely universal type which stains best by the Gram method is the streptococcus viridans or the streptococcus salivarus, by others called the streptococcus mites. This organism is absolutely universal and the writer believes it an impossibility to find a human mouth that will not produce this organism. If the Giemse method for staining bacterial smears be followed, one is equally certain to find the presence of fusiform bacillus and spirochaete. The author believes that this member of the streptococcus viridans family just mentioned and the fusiform bacillus and its accompanying* spirochaete are universally present in all pyorrhea pockets and tooth surfaces. The fact that some observers report one thing and some another does not alter the fact that these bacteria are present. It is merely an evidence of the fact that the individual has not followed proper methods for staining to make their presence evident. If he is dependent on one type of stain, it may be that that particular stain was not suited to bring out the character of growth there present. For instance, the Gram method for staining does not show clearly spirochaete and fusiform bacilli, while the Giemse method for staining will show fusiform

*T. J. Oleary in Dental Cosmos 1910, Vol. 52, page 52.

bacilli very clearly while certain other types of bacteria will not stand out clearly. The tooth surface scrapings have been shown to contain almost every sort of bacteria that grows, but the pyorrhea pocket itself has thus far revealed to the author and his associate only two types of organism which seem to be absolutely constant, namely, streptococcus, viridans, and the fusiform bacillus with its accompanying spirochaete, staphylococci, pneumococci, proteus, bacillus-coli, subtilus, micrococcus-catarrhalis, and many other bacteria are occasionally found and the entamoeba is present in a certain number of these cases. The author and his associate, Doctor Henrici, have not found the entamoeba to be universally present. It is true that we have found the entamoeba in three-fourths of the cases examined, whereas we find the spirochete, the fusiform bacillus, and the streptococcus viridans absolutely universal in their presence. In fact in our search for bacteria-free root ends in living teeth, we discovered that it was necessary to actually burn with a cautery the tissues under the gingival margin if we expected to find the root ends free from bacterial growth, and until we did so begin to sterilize by actually burning the tissues beneath the gum margin, we always without exception found the tooth's root infected. Personally, the author believes it to be almost an impossibility to extract a healthy living tooth and find the root free from viridans unless the tooth has been rendered free from bacteria by rubbing the tooth with iodine and by subsequently burning the gingival field with the actual cautery. Even with the above precautions we found living teeth whose roots were infected, showing that the vessels of the peridental membrane form the path thru which root ends are most commonly infected.

The finding by culture of viridans below the level of attachment in the mem

brane also impresses us with the thought that streptococci are the principal organisms of pyorrhea and that amoeba and all other germs are con、 tributing factors only. After having worked this technic out we were able to occasionally extract living healthy teeth and find the deeper tissues sterile. Furthermore, in working along this same line, we find that when the Ionic method of sterilization has been followed out carefully in teeth that previously showed areas or rate-action by the radiograph and bacterial infections by culture, by practising this careful technic for the exclusion of possible bacteria that have gotten into pyorrhea pockets from the tooth surfaces and of mouth fluids that the abscess sack on extraction would be sterile, proving conclusively that it is possible to actually destroy bacterial growth in the tissues of the abscess sack by this electrolytic* method.

The author introduced this bit of experience here because it tends to prove the universal presence of streptococcus viridans in the tissues surrounding the teeth, and, while we all recognize the fact that we may obtain from tooth surfaces at one time or another almost every known bacterium, we certainly must concede that the bacteria which we find constantly deep in the tissues are the ones logically concerned in the inflammatory disturbances going on in these tis sues. Some of you may be surprised that the writer does not attach more importance to the presence of entamoeba in pyorrhea pockets and does attach so great importance to bacteria found in the tissues beyond the pockets. Therefore, the writer will break the thread of his discussion by introducing a series of pictures of amoeba to which he invites your attention. Before showing these pictures he desires to say that he welcomed with the greatest enthusiasm

*Rhein Paper, on page 999, Cosmos 1911.

the possibility of curing pyorrhea alveolaris by destroying amoeba by the simple method recommended by Barrett and Smith of Philadelphia, (*1), and Bass and Johns of New Orleans, (*2). While the author had occasionally noticed the fact that amoeba are present in the mouth, he had never attached any particular importance to them; in fact, he might state that amoeba have been particularly prolific in his own mouth for a long time, tho he is apparently free from pyorrhoeal inflammation, so it never occurred to him to connect the amoeba with pyorrhoeal processes in any way. Believing, however, that the work of Barrett and Smith and Bass and Johns deserved full credit, he obtained from the Parke Davis and Company one quart of one per cent emetine chloride and very promptly began its use on a series of pyorrhea cases under his care, following carefully the technic advised by Barrett and Smith in this work, which is daily dosage of one per cent solution of emetine chloride discharged deep into the pockets for a series of six days, then alternating the dose every other day until twelve or fifteen doses had been given, hoping thereby to cure these cases. The writer's experience has been that the injection of emetine chloride has not in a single instance stopt pus flow, tho amoeba have been found to be present in three-fourths of the cases.

Fearing that the emetine chloride solution might be at fault, the author's associate, Doctor Henrici, administered ten cubic centimeters of the chloride to a rabbit which promptly evidenced all the constitutional effects of emetine, subsequently dying. Failing to get satisfactory results or results tending to cure with one per cent solution injected into the pockets, we therefore, obtained fifty grains of eme

*1-Barrett and Smith, Dental Cosmos, 1914. *2-Journal American Medical Association, Feb. 13, 1915.

tine and commenced a systematic use of emetine hypodermatically, giving as a routine one-half grain per day for three days, then one-half grain every other day for two or three days more, then resting. In no single case has the writer been able to notice freedom from pus flow. One patient, a child of twelve years, who had an exaggerated case of phorrhea having lost all the teeth in the upper jaw but the right cuspid and all the teeth in the lower jaw but the second molars and bicuspids, received in all twenty injections of emetine chlor

ide into the pockets about these teeth and subsequently two and a half grains emetine chloride hypodermatically. The pus flow has not in any measure been checked as far as the author is able to judge. The gums are inflamed and at a recent public clinic at the mid-winter meeting of the Minneapolis district Dental Society, many men at this clinic were able to see pus from the gums of this patient. (Lantern slide of Figures 4 and 4 A). Lantern slides of amoeba (Figures 5 A, 5 B, 5 C, 5 D.)

In this connection, study closely the amoeba found in the following lantern slides. You will notice that the amoeba in these preparations were taken from