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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 cases.
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 it. self. 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 that there 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 many 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. Be side 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 cases.
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 Illustration 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 medicament or its effect on bacterial growth. An additional danger seems to have arisen by the causing of a more or less serious paralysis. We have just been informed of a case, where emetine was injected into the shoulder with the result of producing a partial paralysis of the arm lasting two days. We have not as yet received the full particulars. The authors have also seen a case of local necrosis of the alveolus from the injection of a few minims of a 12 of a 1% emetin hydrochlorid solution in the gums around a pyorrhea pocket.
CONCLUSIONS. Owing to the fact that the evidence is largely circumstantial, which has indicated that endamebae are the chief causative factor in pyorrhea alveolaris, based, in a great part, on the known bad reputation of its cousin's species, the endameba histolytica of amebic dysentery, and since the evidence against this conclusion is in great part incomplete, we strongly urge the withholding of judg. ment until further researches shall have established sufficient of the following data.
1. The successful production of the lesions of pyorrhea alveolaris by inoculation with endameba, according to Koch's law, namely, (a) an organism, if it causes the disease, must be present in all cases, (b) the organism shall be isolated in pure culture, (c) a pure culture, if inoculated into a susceptible animal, must produce the disease, (d) the chemical products must produce the same alterations.
2. Or, the successful production of the lesions by inoculation with some other organism, or organisms, or by some other means.
3. Or, the demonstration that the endamebae of the mouth are non-pathogenic and are incidental or helpful inhabitants of the oral cavity as scavengers; not only harmless of themselves, but not producing either toxins or harmful enzymes.
4. If the endameba buccalis is the chief causative factor in pyorrhea alveolaris why is the endameba Kartulisi found alone is so many of the typical cases?
5. The establishment of the role of emetine, including a close differentiation between its amebicidal and its bactericidal actions.
6. A determination as to whether the beneficial action of emetine is that of an amboceptor, acting upon the bacteria or protozoa with their protein and toxin contents (the toxiphor group) thru the agency of the complement, and also whether the action of emetine is that of a complement as in the case of lecithin with snake venomen. (22).
7. A determination as to what is involved in so-called bacteremia, which is clinically so common as a result of instrumentation and of certain medications and is this action bacteremic, septicemic or toxemic.
8. The establishment of the precise local tissue changes involved in the development of the lesion of pyorrhea alveolaris and of the successive processes constituting its repair.
9. The establishment of the precise role served by instrumentation in the process of repair of pyorrhetic lesions and the significance in this process of the removal of foreign material, bacterial plaques and degenerating tissue, also of polished surfaces, local stimulation of circulation by frequent massage, etc.
10. The development of a means for the reattachment of vital tissue to dead and denuded cemental surfaces of roots.
11. The establishment of the role of pyorrhea alveolaris pockets as culturing places for pathogenic organisms, those of the streptococcus-pneumococcus group, which from this lesion as a primary focus, affect other organs and tissues of the body, and the establishment of the symbiotic effects of the organisms on each other.
12. Granting that the endameba is the causative factor of pyorrhea alveolaris and that emetine hydrochlorid is a specific for it, why has no pyorrhea pocket, of the many cases treated by the authors, been more greatly modified in the way of repair than the more or less marked improvement of the following factors: the quantity of pus flowing; the relative quantity of micro-organisms growing in the pockets and the general tonicity of the surrounding connective tissues, with practically no considerable change within several months of the bone lesion itself surrounding the tooth.
13. And chiefly, by the establishment of a mass of circumstantial evidence, bearing on the above and related problems, which shall be so carefully interpreted and tabulated that it will indicate the probable answers to most all of the above questions, before they can be clinically and technically established. This will best be done by as large a number of skilled observers as possible, including those skillfully treating pyorrhea alveolaris, either as a local lesion, as a systemic lesion, or as both; those treating other diseases primarily but al. so observing, competently, the effects on local mouth lesion and those studying by intensive methods in pathological and bacteriological laboratories, etc., etc., sending reliable statements of their observations and findings to some central committee or organization, such as the Research Commission of the National Dental Association, for classification and publication, a considerable quantity of which has already been received.
We would suggest the following simple technic fo those who are not familiar with detailed procedure. Take suitable half round instrument like a scaler, or a smooth tapered toothpick, preferably the hardwood Japanese pointed toothpick, and with it remove some of the contents from the suspected pyorrhea pocket, being careful not to produce a hemorrhage of the gingival tissue, for
the blood cells will greatly interfere with the observations of the endameba and other organisms. Place a small drop of warm normal salt solution on a warm slide, and without allowing the temperature to change, carefully dissolve the material carried on the instrument or toothpick in the normal salt solution, being careful not to grind up the organisms unduly. We do not advise the use of the so-called hanging drop slides but prefer a plain 3x1 inch slide and a square thin cover siip, 34 inch. Lay the cover slip on the drop of water, after the solid matter has been pushed to one side, leaving mostly stained liquid. After placing the cover slip in position make slight pressure to reduce the layer of fluid to an even strata. Dry off around the cover slip and while keeping the slide warm, quickly heat the end of a piece of sticky wax, such as S. S. White's Orange Sticky Wax, and run a thin layer of the hot wax along each of the four sides of the cover slip. This prevents currents in the fluid from air drafts, also the changes due to surface tension of the fluid, as well as the evaporation, and if the microscope is kept in a warm place the endameba and mouth organisms will usually stay alive for hours, not infrequently for half a day, if the warm stage is used on the microscope, and for an hour or two without the warm stage if the microscope is in a warm place. It is desirable to have the warm stage temperature slightly higher than body heat. By referring to the illustrations of the various forms taken of the endameba previously presented in this article, you will readily recognize these organisms by the fact that they are usually larger than the erythrocytes or the leukocytes and have peculiarly refractile areas or pseudopods resembling seg. ments of disks of paraffine or wax, when in the motile stages and characteristic granular centers in the resting or spore stages. The endameba buccalis is much less motile than the endameba Kartulisi, the former throwing out lobose pseudo