problems of dental disease and of oral sepsis, another body is no less steadily engaged in promoting sepsis of the worst character and degree by ignoring the fundamental truths connected with the anatomy, physiology, and pathology of the tissues with which they deal. To gold-cap a healthy or a diseased tooth in order to beautify or "preserve" (!) it is the negation of every one of these truths a veritable apotheosis of septic surgery, and of surgical and medical malpractice.

The medical ill effects of this septic surgery are to be seen every day in those who are the victims of this gilded dentistry-in their dirty-gray, sallow, pale, waxlike complexions, and in the chronic dyspepsias, intestinal disorders, ill health, anemias, and nervous ("neurotic") complaints from which they suffer. In no class of patients and in no country are these, in my observation, more common than among Americans and in America, the original home of this class of work.

CLINICAL EFFECTS OF SEPSIS.

The chief feature of this particular oral sepsis is that the whole of it is swallowed or absorbed into the lymphatics and blood. Unlike the sepsis of open wounds on the outside of the body, none of it is got rid of by free discharge on the surface. The effects of it, therefore, fall in the first place upon the whole of the alimentary tract from the tonsils downward. These effects include every degree and variety of tonsillitis and pharyngitis, of gastric trouble from functional dyspepsia up to gastritis and gastric ulcer, and every degree and variety of enteritis and colitis, and troubles in adjacent partse.g. appendicitis. The effects fall in the second place upon the glands (adenitis), on the blood (septic anemia, purpura, fever, septicemia), on the joints (arthritis), on the kidneys (nephritis), and on the nervous system.

I cannot within the time at my disposal bring before you all the facts relating to medical sepsis or to its greatest cause oral sepsis on which these

conclusions as to their importance are based. This I have done in the series of papers already referred to. I propose rather to deal with you as you dealt with your assumed inquirer in the matter of antiseptic surgery, namely, enunciate briefly certain definite principles that may appeal to you, and illustrate these by a few recent cases selected at random.

The first of these principles is that the sepsis here had in view is all swallowed or absorbed, and that infection with staphylococcal and streptococcal organisms carries with it certain definite and deleterious effects wherever it is

found. These effects vary, naturally,

with the site of the infection and the degree of resistance offered by the tissues which are the seat of the invasion.

In the case of the mouth the mere presence of staphylococci and streptococci on the surface of the mucosa, or on the tongue, or in the mouth secretions, or in the saprophytic flora which abounds in the mouth, does not of itself cause disease, any more than their presence on the uninjured skin. But the matter is totally different when they become seated in open wounds in the edges of the gums adjacent to carious teeth; or extend from this, their first site, downward along the periosteum (periodontal membrane) of the tooth socket. The infection is then no longer a superficial one, it is in connection with the soft tissues, periosteum, and bone. The resistance of these tissues, especially the gums, is fortunately very great, hence a degree of infection which anywhere else in the body would certainly draw attention to itself by its redness, swelling, heat, and pain, may indeed cause redness and swelling, but does not necessarily cause any pain. This is the more to be regretted in that a feature of septic infection in the gums, the teeth, or the sockets of the teeth, is that it is infection in contact with diseased bone, and its virulence is intensely aggravated by this fact. For no septic infection is more intensely virulent than that connected with diseased bone. I speak from personal experience on this point. The

only two occasions in which I ran a very close risk-in one instance of my life, in the other of a limb or my lifewere two in which in my postmortem work I contracted a blood poisoning from pus arising in connection with diseased bone. One of these was of a case of "septic anemia," in which I pricked. my finger while handling the tongue from a mouth full of oral sepsis. The symptoms showed themselves in twelve hours, and were ushered in by faintness and rigors, fever of 103° to 104°, and cellulitis of the whole arm before any local disturbance had shown itself.

Such untoward effects in the case of infection of the gums or jaws are very rare, although I have seen complete gangrenous necrosis of the whole of the alveolus and the bone of the hard palate, pyemia, and death to result from this infection. But although such fulminating effects are exceptional, septic effects of various kinds and degrees are invariably present. These effects are not proportionate to the mere amount of the existing sepsis, but depend on its virulence. The most intense anemia, blood poisoning, hectic fever, and even ulcerative endocarditis may in my experience be produced by one septic amalgam filling, or by a small deep-seated alveolar abscess, or an unrecognized suppuration of the antrum or nasal sinuses. On the other hand, a man may have the foulest sepsis for years without apparently any ill effect. But he need not vaunt himself unduly upon this comparative immunity; sooner or later his sepsis will find him out (see case 10). For even if it does not itself produce definite disease of its own, it will certainly complicate any independent disease from which he may afterward suffer, and its effects, although unrecognized, may really constitute some of the most prominent features of his disease (cases 7, 8, 9, and 10).

A patient's illness is not necessarily made up of the effects of his chief disease. The degree of ill health or of the gastric, intestinal, febrile, anemic, and nervous disturbances from which he suffers are by no means necessarily con

nected with, and due to, his chief disease. The chief interest of clinical as distinguished from systemic medicine, lies in the recognition of this great fact-in, so great fact-in, so to speak, dissecting out all the causal factors operating in any individual case, and in removing so far as possible every adventitious factor, even if the chief one, e.g. permanent organic disease, is beyond control.

CASES.

CASE 1. Septic gastritis. A patient, a man, age thirty-two, was admitted suffering from chronic indigestion and gastric trouble. His habits had been regular, his bodily physique was good. There was no apparent reason why he of all men should be subject to gastric trouble. On examination I found he had a tooth-plate in his upper jaw which he had not removed for two and a half years (having been told not to do so), and which, even now, he could only remove with difficulty and after persuasion. On its removal there was found the most intense septic inflammation and ulceration of the gums around a number of necrosed roots underneath the plate. This was immediately dressed by me. After careful antiseptic dressing for several days to get rid of some of the septic infection, with immediate and obvious benefit to the patient, he ultimately consented to have the roots removed, and the patient left the hospital in a week or two entirely free from all gastric trouble. The condition was septic gastritis produced by an intense oral sepsis, due to the insensate action of a dentist in supplying and fixing a plate to be worn over necrosed roots.

Nine-tenths of the cases of dysepsia and gastric trouble which I see are caused or complicated by similar oral sepsis, and respond at once to removal of this sepsis. Nevertheless the sepsis is overlooked because not looked for.

CASE 2. Septic gastritis. I was shown recently a very severe and obscure case of gastritis in a woman of thirty-three. She presented a dirty gray complexion and a broken-down appearance. The fullest report of her case was read to me, including the results of a chemical and microscopical examination of her stomach contents and of her feces. On examination she presented the most intense oral sepsis, ulceration of

the gums, with large deposits of tartar covering the ulcers and extending up to, and inclosing, the teeth, many of these being quite loose in their sockets. She had swallowed this infection for years, and it had caused not only "septic" gastritis, but also septic colitis, for, as was duly noted, pus was present in the feces.

Everything in connection with the case had been duly observed and recorded, including the presence of pus in the feces. But the condition of the mouth, although noted to be bad, had not been dealt with.

CASE 3. "Septic colitis." A patient was admitted suffering from chronic colitis of many years' standing; he had been an inpatient of other hospitals for the same complaint. He passed large masses of mucus with each motion. The case was so-called "mucous colitis," a title which seems to mean something definite, but merely means that he has some kind of colitis, and that he is passing mucus. On examination I found he had some twenty rotten roots in his mouth, all of them necrosed down to the level of the gum. The infection had all been swallowed for many years. I termed the condition septic colitis. The teeth were carefully dressed for several days and then extracted. Three or four days later the patient ceased to pass any more clumps of mucus in his stools, the bowels became regular, and in two or three weeks' time he went out free from all intestinal trouble. The condition was one of septic colitis caused by oral sepsis.

Even if the colitis had been originally due to some other cause-e.g. dysentery, typhoid-it would have been intensely aggravated and complicated by this additional septic infection. I have seen many similar cases, and the connection between oral sepsis and colitis is by no means sufficiently recognized.

CASE 4. Septic anemia. A patient had suffered from anemia for six or seven years. Five or six years ago the anemia was SO marked that she was warned by a distinguished surgeon who saw her that it might become "pernicious." When seen by me (1907) she was leading an invalid's life, suffering from chronic anemia, weakness, giddiness, and palpitation, going about from place to place in search of health. Her history was the following: For the last twelve years she had had pains, very acute, of a

neuralgic character over the right frontal region, and this was followed by a discharge of pus from the nose, followed by a similar attack the following winter. From time to time there was tenderness over the right frontal region with increase of discharge. She was sent to me by a well-known nose specialist with the following note: "She has a chronic, foul empyema of the right frontal sinus, and there is muco-pus in the corresponding antrum. Whether these conditions cause the anemia I do not know; they do not help its getting better. My suggestion is that she should let you relieve her anemia as far as possible, and when she is well enough she might have the sinus dealt with." My own opinion was quite definite. The whole history and the degree of the blood changeviz, 50 per cent. of hemoglobin-satisfied me that the anemia was "septic anemia," and that it owed its origin to the suppuration of the frontal sinus. I therefore recommended that this latter should be dealt with at once. This was done, and the patient left the home in a few weeks' time entirely cured of her ill health and anemia, from which she had suffered for six or seven years.

I

CASE 5. Septic anemia. A patient, age sixty-four, sent to me on September 8th for severe anemia, from which he had suffered since February. Red corpuscles 41 per cent., hemoglobin 40 per cent., leucocytes 5000. No history of loss of blood. I suspected septic anemia and looked for possible causes. found he had only five teeth markedly septic (oral sepsis 3°), with two small necrosed roots buried in the gum of the right upper alveolus, the gum margin and alveolus being what swollen and puffy, with some pain in much thickened. The right cheek was some

the left side and tenderness of the last molar. On inquiry I learnt that at the beginning of the illness he had an aching tooth, and went to a dentist who supplied him with a set of plates ill-fitting and uncomfortable, which had to be rejected; then supplied another set which also had to be rejected. (The dentist, it will be seen, failed to recognize the actual septic trouble presented by the remaining teeth.) The patient was placed in a home on September 14th. On transillumination no antrum disease was discovered. I had the five teeth extracted with difficulty, owing to chronic osteitis. On September 20th the corpuscles and hemoglobin had risen to 49 and 58 per cent. respectively, and the patient left the home on September 25th looking well, with 75 per cent. of corpuscles and 75 per cent. of hemoglobin. By October 18th he had 84 per cent. of hemo

globin, and on November 17th he had 91 per cent. of corpuscles and 94 per cent. of hemoglobin, and was looking in good health.

CASE 6. Septic anemia. A man was admitted into a surgical ward on account of gastric symptoms with some hematemesis, suggestive of cancer. On examination nothing surgical was found justifying operation, but his anemia was most profound, and he was transferred to my medical ward. On examination I considered the degree of anemia to be too great to be accounted for by any loss of blood there had been, and there was marked fever. I therefore examined him for other causes. The gums were very pale and clean, and the teeth good with the exception of one upper bicuspid. Even on inspection I drew the attention of my class to its importance as a possible seat of hidden sepsis. On examining it a teaspoonful of pus burst from it. On further examination by transillumination the antrum above showed a deep shadow. The necrosed root was extracted and the antrum opened up and found full of the most offensively smelling pus. Between the time when he was first examined by me and the operation the pus discharged from the socket of the necrosed tooth was about two or three teaspoonfuls daily. He had swallowed and absorbed this daily-probably for many months, possibly years with resulting gastritis and anemia, and he was transferred from the surgical to the medical ward because his condition was essentially a medical one, not a surgical one (!). The condition was one of oral medical sepsis, unlooked for, unrecognized, due to the sepsis produced by one septic root, which had probably "never given him any trouble."

CASE 7. Septic anemia as a complication of phthisis. A man suffering from advanced phthisis looked so exceptionally, pale and anemic that had he had no phthisical signs in the lung he might well have been considered a case of anemia. His pallor and anemia, however, were not connected with his phthisis, but with the extremest degree of oral sepsis which he also presented. His health greatly improved when the condition had been dealt with. His anemia was largely the anemia which I have termed septic anemia.

CASE 8. Septic anemia as a complication of chronic nephritis. A patient suffering from chronic nephritis may, and often does, present an extremely anemic appearance, and in many cases a very severe degree of anemia may be present in the blood. But that also

is not necessarily a result of his nephritis, but may be, and often is, due to co-existing oral sepsis, sometimes of an extreme degree. So far from his anemia being the result of his nephritis, the nephritis may be, and, in my experience and judgment often is, largely a concurrent effect of the sepsis causing his anemia.

CASE 9. Septic anemia complicating gastric ulcer and chlorosis. A girl is admitted suffering from the symptoms of gastric ulcer, and she may, and often does, present an extremely anemic appearance. In her case the anemia is promptly designated chlorosis, but it is not necessarily wholly of that character. For she may, and frequently does, present an extreme degree of oral sepsis. This sepsis is, in my observation, largely the cause not only of her anemia but also of the gastric ulcer. Her trouble is by no means only gastric ulcer; both the gastric ulceration and her anemia have originally been caused by the overlooked sepsis of her mouth. They are really septic in their nature, and if the temperature of cases of gastric ulcer be watched it will be found that a certain amount of fever is very often present. And a still more interesting practical result may be noted-viz, that on removal of the oral sepsis the three conditions of gastric trouble. anemia, and fever clear up together.

CASE 10. As a complication of nephritis. A patient suffered from chronic Bright's disease, and presented all the usual symptoms and features of that condition-urinary changes, vascular changes, eye changes, edema. headache, drowsiness, etc., including also a varying degree of fever. The temperature suddenly rose, and erysipelatous cellulitis of one side of the face appeared. The condition thus appeared clinically as one of chronic Bright's disease, complicated by erysipelas. On examination a deep ulcer with much stomatitis was found on the buccal mucous membrane of the affected cheek. The condition then appeared clinically to be kidney disease complicated by erysipelas and ulcerative stomatitis. On further examination the ulcer of the mouth was found to be directly in contact with an intensely septic molar root, and many other teeth showed marked septic gingivitis, with tartar deposit and pockets (septic periodontitis). These latter septic lesions had obviously been there for years. The ulcerative stomatitis and the erysipelas were not sequela of chronic kidney disease, but the direct manifestations of an entirely different disease-viz, septic infection which had probably existed for many

years. The irregular fever presented by the case was also septic. We had thus two intercurrent conditions-kidney disease and sepsis. The latter is euphemistically termed a "terminal" infection, meaning thereby that it has come on toward the end of the patient's chief disease. But this infection was not "terminal," was not determined by the kidney disease. It had existed for many years prior possibly to the nephritis, and the continuous excretion during these years of its toxins was quite capable of producing a chronic tubular nephritis; or, failing that, was certainly aggravating any nephritis due to other

causes,

AS A COMPLICATION OF SPECIFIC FEVERS.

The following cases show to what extent oral sepsis complicates specific fevers, such as scarlet fever, typhoid, diphtheria, and the striking benefits to be got from its removal.

In 648 cases of scarlet fever ad

mitted into the London Fever Hospital under my care in the four years 1904-07, the incidence of oral sepsis, carefully noted by myself, varied from 25 per cent. to 43 per cent. The effect of oral antisepsis the removal as far as possible, immediately on admission, of every trace of oral sepsis around the patients' teeth and gums by daily swabbings with 1:40 carbolic acid solution-throughout the earlier part of the disease was very striking. The chief complications

of the disease were reduced as follows: The incidence of secondary adenitis was reduced from 9.6 per cent. in 1904 to 3.3 per cent. in 1906, and 1.8 in 1907; of cellulitis of the neck from 5.2 per cent. in 1904 to 2.8 in 1906, and nil in 1907; of glandular suppuration from 1.7 per cent. in 1904 to 0.5 in 1906, and nil in 1907. The striking improvement was due to the increasing care taken by myself and by my residents and nurses under my instructions. In only one or two cases out of the whole series were any teeth extracted.

PRINCIPLES OF TREATMENT.

What are the general principles of the treatment applicable to medical sepsis? The first and most important is curiosity

about and careful observation of the actual character and degree of the septic foci present in the mouth (nasopharynx or elsewhere) in every case of medical disease. This cannot be made by a cursory glance into the mouth, and a general conclusion to the effect that the "teeth are fairly good," or the mouth "fairly clean," or that the mouth "requires to be seen to." If you look closely into the mouths of your patients and note what you see you will observe every degree and variety of septic gingivitis, every degree and variety of septic ulceration, every degree of tartar deposit as a great effect of this septic inflammation and ulceration, every degree of suppurative inflammation of the gums, every degree and effect of septic periosteitis and periodontitis with formation of pockets and loosening of teeth, every degree and effect of septic osteitis-e.g. rarefying osteitis, causing recession of the bone socket, or formative osteitis, causing thickening of alveolus; every degree and variety of septic caries and necrosis of the teeth; and as a result of all these conditions, singly or combined, every degree and variety of septic stomatitis. simple, ulcerative, gangrenous. You will see all this in infinitely less time than it takes to examine a specimen of the gastric contents, or of the feces, or of the urine, or of the sputum; in far less time and with far less labor than it will take you to examine the nose, or the nasopharynx, or the larynx; in far less time than it takes you to examine the heart, or the liver, or indeed, any other organ of the body. In particular cases you will observe that all these septic conditions are produced, or intensely aggravated, by tooth-plates covering necrosed roots, by amalgam and gold fillings which have become septic, by porcelain crowns with gold collars, by gold caps over diseased teeth, gold bridges and other gold fixed dentures which, however good to begin with, are never really aseptic, and are liable to become extremely septic. All these you can observe in a few minutes if you look for them-in less time, almost, than it takes to mention them.