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A Cilliated Protozoan. Recently observed. Showing its extreme motility, which is probably 100 times that of the endameba. Intervals between views, one-twentieth of a second. Total time crossing this field, twelve twentieths of a second. It is usually larger than a leucocyte.
under uniform conditions. We have also had the presidents of the various state societies select for us a half a dozen of the dental pathologists of their state to co-operate with us in making observations. Correspondence with these two groups of men and the study of their slides indicate that, in the type of cases that have been selected by them for the smears, the presence of the endameba is almost universal at the time of and the conditions under which the observations were made. There are, apparently, few exceptions, which will be taken up later under the evidence against the endamebic etiology of pyorrhea.
Among this number I have absolutely cured five cases. The balance are still under treatment." (b) "I have been using the emetine since September last and would say that with one exception I have had the best results. I have used it by the stomach, subcutaneously, and by flooding the pockets, and have had gratifying results in all but one case, but in many of them I have had to be very persistent when, no doubt, others would have given up hope, etc." (c) "In regard to the results of the emetine treatment would say that with but one exception I have had very gratifying outcomes. Some cases, of course, yielded more than
others and some are, apparently, entirely well. The case that refused to yield was one on which I have also used autogenous vaccine with negative results." Several of the other correspondents state that the emetine treatment is frequently, or generally, successful in improving, either in part or very materially, the condition, tho very few refer to them as being cured.
5. The authors of this report have found an endameba on the apex of a root that had been extracted where the pyorrhea pockets of the mouth did not show endameba, and while it is possible that the sterilization about the teeth was not perfect enough to prevent the contamination of the root end at the time of its withdrawal thru the tissue, the fact that sterilization was used and that the root apex was very conical and that the the smear was taken from very tip, strongly suggests that the organism was an inhabitant of the tissue about the apex.
6. The authors have also found three very motile endamebae of the Kartulisi variety in the blood of an extirpated pulp, which operation was done under novocain. The pulp was exposed mechanically, accidentally, after the removal of a poorly fitting gold crown. The exposure was covered with calxine cement for one week. We believe there was no possibility of the organism entooth thru the tering the artificial opening made into the pulp chamber uncement. This less it past thru the patient is suffering from an obscure irritation of an old heart lesion. This is a very significant finding and, so far as we know, the first time an endameba has been found in the tissues of the mouth, and suggests pathogenic nature of the Kartulisi variety.
7. It is possible that there is some metabolic that is produced by the endameba, which exerts an enzymic action.
Evidences against the endamebic etiology of pyorrhea and the treatment of the disease with emetine.
1. The statements of skilled bacteriologists, mostly specializing in dental pathology are that, while they find the endameba present, they do not consider it an important causative factor. (15).
2. The correspondence (16) with selected observers from different parts of the country shows the majority of them to be very conservative and reluctant to claim much benefit from the emetine treatment and some are strongly negative. I quote the following: (a) "My clinical experiments show that the treatment by emetine is not what it is 'cracked up' to be. I have tried it in every way possible in all kinds of cases and my experience is the same as in autogenous vaccination, that is that it does no good unless thoro instrumentation has first been accomplished and then it is not necessary. Proper surgical work is what does the work and is a great deal better than the emetine treatment, etc." (b) "You ask for general observations as to the endameba. I will say that in the mouths I have found them I do not find them after I have carried out my thoro pyorrhea and prophylactic work, and this without the use of any drugs, whatever. I have used the emetine religiously and have found no results from its use in addition to results I obtained without it." We would also refer you to another paper published in this department of the Journal, which directly discusses this question. In the correspondence received 11% have been positively against the use of emetine, 47% conservative and noncommittal, in other words still earnestly studying its effects, and 42% are favorable to its use, generally in conjunction with thoro instrumentation.
3. A few observers, including ourselves, have not found the ameba present in certain cases before treatment with emetine and have found it in those
same cases shortly after treatment. This we will discuss later.
4. Many observers, including ourselves, have found many cases of typical so-called pyorrhea alveolaris lesions which, during the period in which the observations were made, did not, at any time, show endameba. If they were present they could not be found. In one very typical case, in a mouth where several of the teeth had been lost by this disease and where another was badly affected and loose, also to be sacrificed, exhaustive studies were made to locate at least one endameba or spore. Numerous slides were made on each of seven days during November, five days during December and four days during January, in all at least one hundred slides, both by examining directly and by staining, and in no case could the organism be found. The badly infected tooth was then extracted. Emetine treatment was used in the mouth wash during February and March and on April 1st the patient was again examined and, altho her mouth was in excellent condition, endamebae were found in the first slide and in other slides made from different parts of her mouth. Another patient was examined for endameba about the pyorrhetic teeth, some of which could be nearly removed with the fingers, several times during each November, December, January and February, and they were not found. March the organisms were found even after the several badly affected teeth had been extracted, and the mouth put in good condition. These cases are typical of a number that were examined during both the Winter and Spring months, and which did not reveal the endameba during the Winter except at certain brief periods, if at all, until the spring days. This strongly suggested the relation of temperature or water supply to the varying presence of the organism. It is significant that a large proportion of the cases of true pyorrhea alveolaris do not
have even a visible amount of pus present, which is one of the reasons that our profession has been striving, so diligently for decades, to find a name that was adaptable to the disease in its various stages and conditions. I am advised that about twenty different names have been presented as being adequate to correctly identify this lesion. It has been the experience of the authors that during the months of November, December and January, particularly the latter two, the cases showing endameba were, almost universally, those with a liberal amount of pus present, while those of February, March and April, particularly the latter periods, showed the organism in a great majority of cases, whether an abundance of pus was present or not. We have examined approximately fifteen hundred slides of our own, besides approximately one hundred and fifty furnished by the presidents of the various state societies of the Union and by dental pathologists in various cities, and have carefully tabulated the data. Unfortunately, no slides have been furnished us that were made earlier than the latter part of February, most of them during March and, consequently, they do not check against our data going back into previous months. For another reason they are not comparable, namely, that they presumedly have been almost all made from those cases of pyorrhea that had a liberal amount of pus flowing, in fact the case reports, kindly provided with the slides, stated this fact in nearly all instances. We have made into a chart form (See figure 11) some of the data revealed by this large series of records and related them to the average temperatures for January, February, March and to April 7th. The heavy, straight, horizontal base line represents zero temperature, with the dates recorded below it, and the elevation represents temperature, Fahrenheit, shown by the zigzag curve. It is exceedingly interesting to note that the points marked A, B,
Curves showing relation of varying presence of endameba to mean atmospheric temperature. (See text.)
C, D, F, and the ascending line thru J represents the increasing frequency of the endameba in pyorrhetic people, and from No. F to and thru J, where the line is marked continuously on the ascension, a large number of people who have no pyorrhetic lesions have the endameba present. In several cases children with splendid healthy mouths are showing them. The points A and B in January and C, D and F in February are particularly instructive, for at these times there was a sudden sharp increase in the presence of endamebic infections, and it will be noted that these correspond to periods immediately following, by a few days, a rise of temperature. At these periods there was a decrease in the number of spores with an increase in the number of motile endameba, suggesting a period of incubation following the rise of temperature. Circumstances prevented us from making observations at the dates corresponding to E, which is the only break in the record. It is also significant that cultures we had planted to receive and grow air ameba during the winter did not show them until the ameba line was well in ascent about the first of March, tho the condition have remained constant even as to the temperature of the inside room where the culture medias were exposed to the air. It was particularly interesting to note, in this connection, that when we wrote to one of our friends, a skilled observer of mouth conditions, requesting that he observe whether or not in his locality there was the same relation of endameba to temperature changes that he replied, "I was amused at your enquiry regarding the greater prevalence of endameba in our cases of pyorrhea since the change in weather, because of the fact that for the past three weeks practically every case of pyorrhea that we had, seems to show more or less abundance of endameba. I had not attributed it to the weather so much as I had to the fortuity of the cases which
we happened to see, etc." It was known to the writer that this observer had not found them so pieniul in the mid-w ter months as in the Fall. We will be very glad to know the experience of other observers who have been looking for the endameba during the Fall, Winter and Spring and, if possible, to have the accompanying data of the relation or these conditions to the average temperatures preceding. It is not clear what the causative factor is since the temperature of the mouth must remain about constant, irrespective of the climatic conditions, nor is it clear where the organisms are sojourning in the inLerims when they seem to be absent from these particular cases. The correspondence with the large number of observers indicates that they probably are not related to the water supply, altho at one time in January all of the cases of the authors in which they were found to be present were using water from springs outside the city. It should be stated, in this connection, that the only slides we have received from the various observers in the different parts of the country, who prepared them for us according to our directions, which did not show endameba were made in the northern part of the country the latter part of February. An important fact obtained with regard to the presence or non-presence of the entamebic infections in the cases, herewith sighted, in relation to temperature changes, namely, that there was no apparent difference in the nature or systemic effect, by any means that we could determine, when the organisms were abundantly present or were not present in the same mouth, tho the variation ranged from zero to a prolific number.
5. Another argument against the endamebic origin of this infection is the relation of systemic disturbances to the presence of the organisms. During these months we have studied cases of the most profound systemic expression, and