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in which the general symptoms responded to treatment of pyorrhea, but in which cases no endamebae were found before and during the period of treatment, while the patient was suffering systematically, anu yet arter a thoro treatment and after subsidence of the symptoms, the endameoa 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 on other micro-organisms. Emetine Hydrochlorid nas a profound 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. De-emeumized ipecac failed to
Kill one to ousand. veder, who found when two per cent of and extract of Ipecac was Miat With agai, it exerieu marked innipitive and germicidal action On D. typuosus, D. paratypшosus, D. uys enteriae and stapnylococcus pyogenes aureus. This is important when one considers thе ке гоle played by symbiotic bacteria in amepic lesions. Tue researches of the authors on this point to determine the germicidal and inhibitive action of ipecac and 165 products, emetine and cephane, nave demonstrated that the organisms taken from pyorrhea pockets are very directly innuenced by these drugs, particularly the emetine. Ipecac, from when these twe 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 means had been resorted to in good medical practise, without more tuan temporary relief. Accompanying these attacks there was considerable distress in the liver and a digestive disturbance. Frequent examinations of nis mouth during November, December, January and February for endameba were negative, alino a great many sudes were made. Careful examination of the gingival tissues showed a couple of small pyorrhea pockets and the lingual root of the upper light first molar was almost entirely 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 excellent, the lingual root was amputated close to the crown, but before doing so animals were inoculated with the 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 to the tissue surrounding the socket where we had amputated the root. On January 1st we made the following record in our notes. "Since last appearance (January 8) patient nas nad recurrents of old symptoms without liver spots in eyes. Extreme pain kе neuralgia starteu in the temple and extended succesSively tulu Lue alea Supphed by we trifacial until it involved all its brancnes. The pain was so severe that a physician 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, January 11th. His recovery was very rapid, so шасn so as to greatly impress and when seen on this Wednesday, the 13th, he is feeling unusually well." This clinical picture and reaction was repeated 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 on the following morning, had not materialized. The bacterial growth in the pockets was greatly modified by ments. Suddenly the to have any reaction tine 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. Let me
emetine treatpatient ceased after the eme
recall that during November, December, January and February, diligent search did not reveal either the endameba or spores. In four days during March, and one already in April, he has been examined for the presence of endameba and on every occasion but one both spores and actively motile endameba have been found. The organism we have referred to as X has almost disappeared from these pockets. If space permitted we would present two other case histories, which are quite as striking as the above in illustration of the fact that emetine does have an effect in certain cases and, apparently, there has not been found endameba. One of these patients is now attending business eight hours daily, and had not previously more than a couple of hours a day, if at all, for six months and tho in the prime of life was completely discouraged. It should be stated in this connection that our experience in injecting emetine subcutaneously into healthy people is that it produces no reaction except a local soreness in the doses used in the above
7. The special work of Noguchi (22) on the spirochaeta, treponema mucosum strongly suggests its relation to the pathogenic processes involved in pyorrhea alveolaris.
8. The progressive pathology of the lesion, known as pyorrhea alveolaris, as it is understood by our most competent students, is one of the strongest arguments against the proposition that the lesion has, as its chief etiological factor, an endamebic infection or that the disease can be cured by injections of emetine. It is an exceedingly significant circumstance that the dental pathologists, who have been spending decades, or the most of a lifetime, in the study of the pathology and etiology of this lesion, are practically unanimous in the belief that the disease will not be cured by the injection of any medicament, nor
do they consider the fact of stopping the flow of pus as being in any sense a cure for the disease, since many procedures have been known to be competent to accomplish that change in the expression of the disease, but always with the tendency to recurrence but never with the complete obliteration of the lesion itself. The very form of nature's method of attachment to the root wall is dependent upon a vital cementoblast with its normal vital attachment to the cementum. When these cementoblasts have lost their life the possibility of a reattachment seems to be so remote, according to many of our best authorities, as to be considered practically an impossibility. The treatment that has given most uniform good results has had, as its basis, the surgical treatment of an infected wound and the stimulation of the circulation with protection from a reinfection. One of the authors of this paper has searched diligently for 20 years to find a single instance where a definitely developed pyorrhea pocket with destruction of the alveolar wall had actually produced a reattachment to the tooth wall, and in that time has seen but one case and in that case the onset of the disease was very acute and sudden. The necrotic bone was cut with a bur from the necrotic alveolus and, as nearly as possible a surgical condition observed, with the result seems to have been a perfect reattachment and in this case it is probable that the cementoblasts had not yet died but were still vital. We have seen other cases where the alveolus had grown so tightly around the root that it seemed to be ankylosed but we could not convince ourselves it was anything more than a close adaptation of the new bone to the tooth root.
An important phase of pyorrhea alveolaris lesions is the systemic involvement and it is a matter of extreme importance that exhaustive researches should be made to determine whether or
not the systemic expressions, as illustrated in the case sighted above, are the direct effects of toxins produced by the organisms or the irritations of proteins of bacterial origin that have been set free either by medication of instrumentation. Also, whether the bacterial protein or toxin, if such are producing the lesions, are set free from the bacteria by the action of the endameba. In support of this latter we have the splendid work of Evans, Middleton and Smith. (19) They explain the local reaction following the emetine injection as an index of a point of saturation when, with the death of numerous endameba, the lethal point of emetine has been reached and a great amount of bacteria, and possibly amebic toxin, is liberated. Smith, Middleton and Barrett, (20) in their splendid work on amebic infections of tonsils and their systemic conditions, suggest that the bacterial phagocytic action of the ameba probably set free in the system various endotoxins depending upon the kinds of ingested bacteria. It probably is not generally known, to those of other lines of practise and study than the treatment of teeth, that many patients are so sensitive to the indirect effects of instrumentation of pyorrhetic pockets that but a few teeth can be treated at a time without profound reaction, resembling, in cases, a protein poisoning. This is illustrated by the following case. A young married woman, otherwise physically strong, suffered from extreme depression and lassitude with digestive disturbance and headache, and worthy efforts were made to relieve these with good medical procedure. The mouth showed non-suppurative, shallow pyorrhetic pockets with very slight local irritation and causing no personal discomfort. Recognizing the clinical picture, which is quite frequent, in the hands of all who are specializing in the treatment of this disease, we advised that only a small part of the instrumentation of removing the
infecting and culturing masses and irritating deposits be undertaken at the first sitting. She was advised to watch for a reaction and report the next day by phone. The next day her symptoms were so extremely aggravated that she stayed in bed, and altho the phone was but a few feet from her she undertook to reach it and carry out her instructions to report, but she fell back wearily, stating "Oh well, he knows I am sick, for he told me I would be, and what is the use of reporting." This reaction recurred after each successive instrumentation, but with diminishing severity, and with no other treatment she is relieved of all her unfavorable symptoms and is, apparently, in perfect health again. Had emetine been used, it surely would have gotten the credit but nothing was done but the removal of the irritants and the culturing deposits about the teeth. Data of treatment and history of this type of case, of which there are many, should be carefully collected since they strongly indicate a bacterial protein poisoning. Beside the usual bacterial mouth organisms, consisting largely of spirochaeta, there was found in this mouth an organism similar to that shown in figure No. 10, which, as described, is probably 100 times more motile than the endamebae, in fact it is so motile that it is difficult to keep it on the field with powers high enough to study it well. It is not an endameba but is probably a cilliated protozeat a paramaecium about the size of a leukocyte. We have only found this organism in a small per cent of the
9. Another argument against the conclusion that endamebae are the causative factor in the production of the lesions we know as pyorrhea alveolaris is found in the following:
Emetine has a well established effect on some special lesions of the body that have not been suggested as being caused by endamebic infection. The illustra
tion of this is found in the fact that quite accidently it has been discovered by two different dentists that one of the most difficult of all known diseases of the skin to cure, namely; psoriasis has been found to disappear, and the skin to return to an apparently quite normal condition as an incidental effect of the use of emetine in the treatment of pyorrhea. So far as we know, no work has been done as yet to determine whether or not patients suffering from this disease have endamebic infection of their mouths. This should be done. One of these cases is reported in detail by Wm. R. Chaplin, D. D. S., Savannah, Georgia, in the February number of the Dental Cosmos, (Volume 57, No. 2, page 289.) In his case the patient had suffered for fifteen years from psoriasis. He says, "The backs of both hands were completely covered with most repulsive looking inflamed, somewhat corrugated, scaly surfaces. This condition was also found in large patches on both arms and on some parts of the body. The disorder has been many times diagnosed psoriasis." He treated the patient with emetine hydrochlorid according to the method as advocated by the Drs. Barrett and Smith, including instrumentation. After describing the case in detail, he states, "At the present time six treatments have been given-and it now being two weeks since last treatmentevery symptom of psoriasis has entirely disappeared.
Another report of a similar case has just come to us in a letter from Dr. J. W. Smoots, President South Dakota State Dental Society, Spearfish, South Dakota, in which he gives in parts the description of an experience, he has had.
Referring to his patent, he says: "She had one finger of one hand particularly in bad shape from psoriasis, and as I had just received some P. D. & Co.'s Emetine Hydrochlorid and the physician had called me in, I advised the use of the above treatment. She has had
four treatments in the last ten days and yesterday her hands seemed to be nearly normal but could not report her case cured until she has been under observation longer."
This is of very great significance, not only because of the discovery of this new treatment for this painful and humiliating affliction, which has seemed to be practically incurable, but it suggests strongly a larger application for emetine than that of an amebicide, the inference of which can be that the beneficial effect, of emetine in the treatment of pyorrhea is due rather to its effect on other organisms than on endameba.
10. Another argument against the endamebic cause of pyorrhea is the important recent discovery that succinimid of mercury seems to have not only a specific action on the treponema pallidium, the specific organism of syphilis, but also quite as striking a curative effect on pyorrhea alveolaris as emetine. This has been discovered and emphasized by White and Wright. (20).
It has not been suggested that this drug is in any way specific for endameba and it will seem very possible that its beneficial effect on pyorrhea could be explained on the assumption that the causative factor is a spirochaeta or some other vegetative organism. This conception is further supported by the fact that Noguchi has emphasized the possibility that pyorrhea alveolaris is caused by the spirochaeta, treponema mucosum, which has already been referred to in another part of this paper. (21).
The possibility of injury to the patient from hypodermic injection. We must recognize that there is a constant danger in breaking Nature's seal of our own bodies and of causing the entrance into the body of infections. This includes not only the dangers from pathogenic bacteria but the sensitizing of the body to proteins and the distressing effects of later introductions of that same protein. whether carried in solution by the medi