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same cases shortly after treatment. This we will discuss later.
4. Many obser rs, 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. In 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 ere examined ring 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 sig. nificant 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,
Curres 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. 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 nappened to see, etc.” It was known to the writer what this observer had not ivund tutu du pituului in the mid-wwwter months as in the Fall. We will be very glad to know the experience OL other observers who have been looking for the endameba during the Fall, winter and Spring and, if possible, to have the accompanying data on 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 incerims 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
in which the general symptoms responded 10 treatment of pyorrhea, but in which cases no endamebae were found before anu during the period of treatment, while the patient was suffering Systematically, ana yet arter a tuor treatment and arter subsiuence or Спе symptoms, que encameoa appeared witaout any return of the symptoms. These were chieny non-suppurative cases or pyorrhea and in all probability would have been overlooked by all except very observing dental pathologists. The mouth lesions were relatively very insignificant.
6. The effect of emetine other micro-organisms. Emetine Hydrochlorid bas a proiound action on other microorganisms, including the various varieties found in the mouth, which effect is almost as striking in many instances as its action on the endamebae, and granting, as there is abundance of evidence, that, in many cases, the emetine has positive beneficial effects, both on the local and the systemic conditions, whether injected intravenously, subcutaneously, or in the pyorrhea pockets, it is not established that its beneficial effects are, in a part or whole, not due to its action on these other organisms rather than the endameba. It is particularly to be regretted that this point has been almost entirely overlooked in the writing of the literature that has been published relative to the endamebic infections. There are exceptions, however, namely the discussion of Curet of New Orleans, (17) in which he says "that 1-10 per cent solution of emetine hinders perceptibly, in thirty minutes, the growth of a 24 hour culture of diphtheria and streptococcus mucosus. In one hour's time it lessens considerably the growth of streptococcus pyogenes, and in 12 hour's time that of staphylococcus citreus. It kills B. diphtheriae and streptococcus mucous in one hour and staphylococcus citreus in 12 hours' time." Wherry, (18) of Cincinnati Hospital, who has found that emetine
one to 50 thousand killed ameba and one to 100 thousand paramaecium and balanudium. Leemetmized Ipecac failed to Kill one too uusand. veuer, who founu wuen two per ceuu uuiu extract 01 тресас was
wamu agai, iu exerceu marneu inaipitive and germiciual acuou Uu D. Ly puuduw, D. paralypuosus, b. Uys enteriae and stappylococcus pyogenes aureus. inis 18 important when оде consiutis me like role played by symbiotic bacteria in amepic lesions. Tue researches of the authors on this point lo determine toe germicidal and inbibilive acuou Of Ipecac anu ils pivuucls, emetine and cephaline, have demonstrated that the organisms taken from pyorrhea pockets are very directly infiuenced by these drugs, particularly the emetine. Ipecac, from wca muese two alkaloids have been extracted, has very little, if any, germicidal action. Emetine in solutions up to one to 10 thousand inhibits the growth of these organisms, besides having marked germicidal action upon them. Cephaline has also marked germicidal and amebicidal properties, but not to the extent that emetine has. An interesting experiment that any one can make very easily is to expose various culture media to the air contamination. So small an amount of emetine as a loop full to 5 C. C. of media will have the effect of preventing the growth of these organisms for 24 hours, at which time the controls will have a profuse growth.
There is much clinical evidence to indicate that the beneficial influence of emetine is due to its effect on other micro-organisms that the endameba. We sight one of several cases in detail. A man of good habits and good history, about forty years of age, had suffered for months with recurring extreme headaches lasting from two to three days and so severe as to put him to bed. His vision was disturbed with what he called liver spots. These attacks recurred at varying intervals at from two to three
weeks and were getting slowly, but progressively, worse. All conceivable meaus had been resorted to in good medical practise, witavui inore wan lenipoialy relief. Accompanying these attacks there was considerable distress in the liver and a digestive disturbance. Frequent examinations of his mouth during November, Deceinber, January and February for endameba were negative, aliho a great many siides were made. Careful examination of the gingival tissues showed a couple of small pyorrhea pockets and the lingual root of the upper ligat first molar was aimost eureny denuded of its attachment. We could not, at that time, get the slightest showing of pus.
The cultures from the pockets showed a prolific growth of an organism which, for the present we will call X. Since the attachment of the other two roots of this tooth were excelient, the lingual root was amputated ciose to the crown, but before doing so animals were inoculated with tue cultures aspirated from this pocket. We were able to recover the organism in question daily for several days from the blood of the tail of a rat inoculated. Within a monta the rat
died with multiple miliary abscesses of the liver, both macroscopic and microscopic. These abscesses produced a pure culture of the organism, which only lived 24 hours in artificial media. This organism would not grow at any time in artificial media. Other animals inoculated with the same culture, directly from this rat, died with similar lesions. Immediately following the amputation of this root the patient had an attack of his recurrent headache and digestive disturbance, which, however, was slightly different from former attacks, particularly in the rapidity and extent of his recovery. A thoro instrumentation was done on all his teeth. About three weeks later, January 8th, after he had had a recurring attack of his original disturbing symptoms, we started the emetine treatment, which
consisted of injecting a small quantity of emetine into the pockets and luto the tissue surrounding the socket wuero we had amputated the root. On January 1310 we maue the following Tecuiu in
our notes. "Since last appeaiduce (January 8) patient has nad recurrents of old symptoms without liver spous in eyes. Extreme pain like neuralgia starteu in the lempie and extended succesbaveny
Suppneu wy triracial until it involved all its branches. The pain was so severe that a physiciau was called and gave him sedatives. The attack started mildly on Friday evening, the day of our injection with emetine, and became gradually worse, reaching the climax on Monday morning, Jailuary 11th. His recovery. was very rapid, so much so as to greatıy in press Ilus and when seen on this Wednesday, the 13th, he is feeling unusually well.” This clinical picture and reaction was re peated with diminishing intensity after each treatment, with emetine, whether by flushing the pockets or by subcutaneous injection into the arm, and with such regularity that the patient dreaded the treatments because of their after effect 3. On February 9th the treatment was nade into the pockets with flavored normal salt solution, unknown to the patient, and he waited in dread for the oncoming reaction, which, he cheerfully reported by phone the following morning, had not materialized. The bacterial growth in the pockets was greatly modified by emetine treatments. Suddenly the patient ceased to have any reaction after the emetine injections, since which time he has been receiving one injection each week or two. Since the emetine ceased to cause reaction, he has not had a single recurrence of his digestive or neuralgia and headache troubles. He washes the pockets daily with a syringe, using 1-10 per cent. solution of emetine. He has gained in weight and is feeling better than any time for a year.