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mouths. We cannot confirm Bass and Johns in their statement that the parasites are always most numerous in the deep parts of the pockets, for we have repeatedly found them in considerable numbers in soft deposits on the teeth well above the gingival margin.
We have repeatedly cut sections of the gums from cases of pyorrhea where amœbæ were present in the pus, and searched carefully for ambæ in the tissues. In no instance have they been found, and we must conclude that they do not invade the tissues, but remain in the superficial pus.
We have pointed out as most significant the character of the food material ingested by the amœbæ. This consists altogether of bacteria and pus cells. The bacteria which are ingested are almost all cocci. Occasional cells are found containing fusiform bacilli. Apparently only dead or degenerating leucocytes are ingested, for we have never found a well preserved pus cell in the amœbæ. This parasite is therefore found constantly in pyorrhea pus because here it obtains its favorite food. We have attempted to cultivate the ambæ on a great variety of media,-white of egg, blood serum, saliva, and pus, in all combinations, together with the usual bacteriological media, but have never obtained a growth. ARTHUR T. HENRICI.
perintendent, and Miss L. M. Powell, superintendent of the school for nurses of the University of Minnesota, for their co-operation in the work of this department.
The work at the University Hospital this year has been a continuation of the study and treatment of oral sepsis in patients suffering from rheumatism, gastric ulcer, kidney disease, heart disease and such other diseases as do not arise from some other recognized cause.
A large number of these cases of oral infection have been tested for the predominating micro-organism, and for several, vaccines have been prepared from the cultures taken from the oral lesion and have been administered.
The number of cases which have been treated during the year approximates 150. Most of these were referred for dental treatment because of suspected connection between the oral conditions and the systemic condition.
The diseases which have been most thoroly studied from the standpoint of their relation to oral infection have been arthritis, acute and chronic, stomach ulcer, heart lesions, pernicious anemia, nephritis and nervous diseases of the neuralgic type. The following are among the most characteristic arthritic
Case 5641, Miss A. F.-Irish-American, age 31, a nurse; family history and previous illnesses, negative; has always been a healthy, vigorous women. Her present illness started in February 1913 with a series of boils on her body. In July, 1914, a soft corn on her toe became infected and swelled her whole foot before it was checked. Both of these were staphylococcus infections. On October 6, 1914, she came down with back ache and head ache, which increased for several days. Presently her feet and joints became swelled; muscles in the back became lame; the hips, knees, ankles and feet became involved; the feet were cyanosed and moist and the
heart became slightly involved. A blood count at this time showed 70 per cent hemoglobin and a leucocyte count of 14,500. Her mouth and tonsils were apparently in good condition, but the tonsils were removed on December 9, as a possible focus. Her condition improved thereafter, but chronic soreness of the joints and acute attacks of arthritis continued to show, according to Dr. Ulrich, the physician in charge, absorp. tion from some local focus. Thoro examination of the mouth revealed very slight gingivitis on the lingual aspect of the upper posterior teeth. This was treated and a vaccine made from a culture obtained from the gum pocket. February 10, at the time of her discharge, before administration of the vaccine was begun, the attacks of arthritis had ceased and the soreness was nearly gone from her feet. This was attributed by those in charge to the effects of the dental work. Vaccine injections were given from February 10 to March 7, every seven days, as an added measure of treatment. Each administration was followed by slight lameness thruout the affected joints. From then on she made a perfect recovery and since March 1, has been doing her work with no further symptoms. The hemoglobin, which, on December 22, was 63, had risen on January 30 to 72, and has been rising since. Urine analysis at no time showed abnormal elements.
Case 3937, Mr. J. W. S.-This case was one which was reported last year. There was no family history; a German workman of 39 years; previous illnesses negative. He had been a healthy man up to three years ago when his right knee beinflammation painful. The increased; the knee swelled, and a milky fluid was aspirated. A few weeks later the left knee became involved; then the right ankle and right hip. He has never At had any throat trouble or tonsilitis. the time of entrance to the hospital, December 1, 1913, both knees were greatly
swelled and painful, the right elbow was partially ankylosed; he was weak and reduced in weight, with occasional night sweats. Physical examination showed a slight cyanosis of the lips and fingernails, skin soft and a good tone, pyorrhea, coated tongue, palpable glands, peridental abscesses, poly-arthritis with effusion in both knee joints. An examination of the mouth showed a bad gingival pyorrhea and abscesses in three teeth. Between this time and March 12, his mouth was apparently made clean by dental treatment, and vaccines were started on March 14. On April 9 patient came down with smallpox and was sent to the quarantine hospital. When he returned he was much improved, altho the knees were still very much swelled and stiff. Administration of the vaccine was kept up all thru the summer, each time followed by a slight reaction at the hips and knees, causing lameness and general malaise. The last injection was given on September 16. For some time his condition has been stationary, the knees being swelled and somewhat stiff, altho he was doing light work. On January 9, 1915, he reappeared in the hospital with an acute exacerbation, both knees were enlarged, with grating upon motion, grating in the elbow joints upon motion, embarrassment of motion in both hips, and the ankles were thickened, with some limitation of motion. Tonsillectomy was advised but refused by the patient, and he was discharged before much improvement was noted. A few weeks afterward, however, he was seen on the street and reported that he was entirely well.
NOTE We believe that this man's continuation of symptoms during the summer and acute attack in January, 1915, was due to the dental abscesses which were overlooked, and which, when treated, resulted in his speedy recovery from all symptoms.
troubles. The disease most frequently complained of was rheumatism,-generally, of course, not a marked form involving bony changes. The patients had come, not for rheumatism, but for pyorrhea treatment, and the fact that there was a relation was not known to them. It is significant that out of one hundred twenty-three cases in which data was obtained, forty-four (over one-third) complained of recent or present rheumatism.
Examination of the tonsils in these cases was not undertaken, SO that the relation of the tonsils to the dental infection and rheumatism is not shown.
In the hospital, of the twenty-six cases of arthritis and acute rheumatism referred to us for dental inspection, all had dental infection while only fifteen had suspicious tonsils.
Of those with chronic arthritis, seven involved both tonsils and teeth, while seven had dental infection alone, as the discoverable local focus. We have not yet obtained records of enough cases to show the relation between pyorrhea and dental abscesses as separate etiologic factors. That there is any important distinction between the two as etiologic factors, is doubtful. The same microorganisms are obtained from both, both offer an exposed surface from which bacteria and toxins can make their way into the blood and lymph channels, and from the tables, seem to be about equally responsible for the same systemic dis
There is a relation between diseased tonsils, oral foci and arthritis which shows, especially with vaccines. In cases suffering from arthritis it is quite the rule to have the rheumatic symptoms acutely increased by tonsillectomy, pyorrhea treatment, or by administration of autogenous streptococcus vaccine. Acute tonsillitis is not uncommonly caused by an excessive pyorrhea treatment. Likewise, in a case of rheu matism in which oral foci were removed
and a vaccine made, the first injection caused an acute tonsillar inflammation in the tonsils which had, to the man's remembrance, never before been sore. In this case, of course, suspicion immediately rested upon the tonsils, so that they were removed, whereupon the man became entirely well, whereas he merely improved very much by eliminating dental foci, without being completely cured. The tonsils in this instance, which, from outward appearances, were not at all badly enlarged or inflamed, were yet the slight continuing cause of his trouble. In another case administration of vaccine for arthritis caused an acute pyorrheal inflammation in a patient where only a slight gingivitis existed before
That the tonsils are responsible for the acute rheumatism and dental infections for the chronic arthritides, has been suggested by some of our medical associates. Our experience, as shown by the tables, does not seem definitely to bear this out. Of the twelve cases of acute rheumatism, seven had tonsillar and dental infection, while five were diagnosed as having dental infection alone. This shows only a slightly greater proportion of tonsillar infections in the acute cases. In the chronic rheumatic cases, as shown above, out of fourteen, seven had both tonsillar and dental infection, while seven gave evidence of dental infection alone.
There can be no question, from the evidence, which we have at hand, that oral infection, whether in the form of apical abscesses or pyorrhea, is frequently the sole cause of arthritis and rheumatic affections of the muscles and nerves as well as joints, and seems, when present, to be always an associated cause where the rheumatism is of streptococcal origin. An arthritis once started by tonsillitis or similar large foci, can be kept going by an oral infection so slight as to be scarcely recognizable in the radiograph, and systemic diseases are continued by surprisingly
shallow gingivitis, even when the larger local foci, doubtless the originators of the trouble, are removed.
Our experience in private practice, as well as in the cases shown by the tables, has taught us that these rheumatic and arthritic conditions are markedly improved by removing the local foci. All of these cases studied in the Dental College clinic in which data was obtained as to condition subsequent to the pyorrhea treatment reported a great improvement in their general condition and rheumatic condition where it existed. It is in such cases that the dentist equipped to do adequate pyorrhea work sees the best results. The rheumatism has just suggested itself and has not yet caused the bony changes which make a return to a normal condition impossible. In the cases in whom deformity has resulted, a cure consists in stopping the progress of the disease and in relieving the inflammation. Bony changes can not be expected ever to return to normal.
Great emphasis should be laid on the complete extirpation of infected foci in all cases. It is not sufficient that the mouth or tonsils appear well from the outside. Α minute examination with every means available is necessary. With the aid of the X-Ray and careful exploration it is still difficult to find all foci about the teeth. Without these aids it is impossible. When a physician refers a patient suffering from rheumatism or other of the diseases liable to come from dental infection, it is impossible for the dentist to make a complete determination without the use of the XRay. It is our experience and the experience of others who use the X-Ray a good deal that the majority of dental abscesses give no clinical sign of their existence. The teeth are not sore, no swelling or palpable soft spot at the root end reveals what the radiograph shows and what the subsequent operation confirms. It is not uncommon to find ab
scesses shown in the radiographs in cases in which there are no breaks in the continuity of the pulpal wall, as under crowns, fillings or even sound teeth.
Experience with a radiograph also shows that a very large proportion of artificially filled roots subsequently become abscessed. A study made by Dr. Henry Ulrich of this city of a thousand radiographs taken at random indicated that over 70 per cent of the artificially filled roots were abscessed. We partially checked this up by looking over a hundred, in which, according to our diagnosis, over 60 per cent of such were abscessed. A consideration of the necessary means to do away with this condition is out of place in this report. The point is, that this must be taken into account in a determination of dental foci in cases suffering from systemic diseases. It has been very rare that we have extracted a tooth which showed an abscess in the radiograph and failed to get streptococci when we cultured from the root end. Our technic is such that contamination in making these cultures seems impossible.
It is amazing to find in well cared for mouths how much pyorrhea may exist without being evident except to painstaking exploration. To those familiar with the systemic results coming from pyorrhea in such large proportion of cases and even from a slight pyorrhea, the careless ignoring and overlooking of such trouble on the part of most dentists, seems nothing less than malpractice.
In all the cases which we have tested for bacteria, the streptococcus viridens has been found in pyorrhea pockets and apical abscesses. Since we have used the greatest precautions to prevent contamination from the gum margin by searing them, there would seem to be no question but that this organism is constantly present in such lesions. Whether it is the etiologic micro-organism in the oral lesion or not, it is pres
ent and there can be no doubt that it or its toxins pass thence into the circulation and cause arthritis and rheumatic conditions.
The last year's work has thrown some doubt on the advisability of the use of vaccines in all of the cases. There is no question but that brilliant results frequently follow the use of autogenous vaccines or even those prepared for similar lesions in other patients. A vaccine prepared in the case of Miss A. F., whose case is given above, was used by one of the physicians for another rheumatic case, in his opinion with very satisfactory results. The use of vaccines, however, is liable to create a confidence in them which is likely to make the dentist less careful in eliminating all local foci, and until such local foci are removed it can hardly be expected that a vaccine will give any permanent relief. In most of the cases where we were sure that all local foci were removed, the recovery was sufficiently rapid and complete to indicate that vaccine was not needed.
The heart cases studied are mostly endocarditis as evidenced by valvular disease, usually insufficiency of the mitral valve. Most of these are connected with rheumatic trouble. The cases in the dental college were not very valuable in this respect, because no attempt was made to determine by physical examination either the presence or type of trouble. In the hospital where careful examination was made, these cases were detected and progress noted.
In our table of hospital patients, thirty-five cases had a diagnosis indicating endocarditis. Of these, twenty-three had or had had rheumatism, two had tuberculosis, nine were associated with nephritis, and three with neuritis. The association of endocarditis with rheumatic conditions is well known, this table merely serves to emphasize it. Of the thirty-one cases who had or had had rheumatism, twenty-three had en
docarditis. Four cases, Mrs. L. F. 5496, Mr. J. K. 4076, Mrs. M. S. 4324, and Mr. J. B. S. 4686, had a diagnosis of myocarditis, while three, Mrs. L. F. 5496 and Mrs. E. S. 4393, and Mr. F. L. H. 5556, had a diagnosis of pericarditis. All of these were wholly rheumatic cases, not complicated by tuberculosis or syphilis.
The known and apparent relation of these heart lesions to rheumatic conditions, the fact that all have dental infections, and the fact that so large a proportion of the cases studied,- thirtyfive out of sixty-six,-have endocardial lesions, seems to us to be good clinical evidence of the relation of such lesions to local infective foci of the dental type.
The response to treatment by foci removal in these cases is slow, but in the great majority of cases is marked. These lesions are much like the bony deformities of arthritis, in that altho the disease may be cured the scars remain and a heart valve once injured by inflammation is always there after leaky and insufficient. The best that can be done is to stop the progress of the disease and allow the heart to compensate. Careful rest and slow building are necessary and quick results cannot be expected.
The cases which have yielded us the most satisfactory results during the last year have been those diagnosed as gastric ulcer, of which the following are two good examples:
Case 5356. Mr. W. C.-A laborer, thirty-one years of age, of Irish descent, weighing on the average, 160 pounds. Previous history, habits, and family history are negative. His present illness began in October, 1913, with heavy burning pains in the epigastium after eating. In November he noticed blood in the stools and occasionally vomited blood clots. He went to hospital for two weeks, where he was put on a bread and milk diet and then stayed at home for eight weeks before going back to work After four weeks the pain reappeared