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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

eases.

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. A 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 neces. sary 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

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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 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

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 ne. phritis, 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 deformi. ties 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 nec. essary 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

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with the same symptoms. He was admitted to the University Hospital on September 15, 1914. At this time the pain was absent, but an area of tenderness was noted over the stomach. He was thin, weak, unable to work, was constipated, with blood occasionally in the stools and blood clots occasionally in the vomitus. A physical examination showed him to be well built, fairly well nourished, with marked anemia, palpable cervical glands, submerged tonsils, bad pyorrhea and many old roots. The case was diagnosed as that of gastric ulcer, marked secondary anemia, mitral insufficiency, pyorrhea and apical abscesses.

A blood count taken at this time showed the hemoglobin 35%, red blood cells 3,500,000 and leucocytes 8,000.

Between September 15 and October 1, dental infection was eradicated by extracting all the remaining upper teeth and lower molars and treating the remaining lower teeth for pyorrhea.

On November 2, the following note was made by Dr. Richards, the physician in charge: “Patient's condition has remarkably improved. His weight has increased 23 pounds. There is no abdominal pain.”

He was discharged on November 11, 1914, greatly improved, with no other treatment than a bread and milk diet and the elimination of dental foci.

He again presented for examination in March, 1915. He had been working and living as a lumberman, eating full mixed diet and doing the heaviest kind of work. There has been an occasional mild constipation, but otherwise he has been perfectly well since leaving the hospital. He states that for one and a half years before admission here he had been troubled almost continuously with stomach symptoms and has never had so long a period of freedom as this before.

A blood count taken at this time show. ed the hemoglobin to be 77%.

Case 5629, Mr. E. R.--A Finish laborer of twenty-six, weighing at present 138 pounds, of good build and nourishment. Previous history, habits and family history are negative, except that two sisters have a similar stomach complaint.

His present illness began when he was twelve years of age. He lifted a heavy block while working and immediately noticed a dull, burning pain in his abdomen. He was in bed two weeks with this pain, which kept on for two months after he got up. It then ceased, to return again in a few months. This has kept up ever since, the periods of pain occurring especially in the fall and winter with periods between of freedom from pain. Occasionally he has been nauseated and vomited, the vomitus being black in color. In the five weeks before entering the hospital he lost about ten pounds.

The physical examination at the time of entry, November 4, 1914, showed hypertrophied glands, marked pyorrhea, thickening of arteries, a tender area in the median line between the umbilicus and the ensiform cartilage, tenderness over McBurney's point, and tenderness thruout the abdomen on deep palpation.

A diagnosis of gastric ulcer, cardiac hypertrophy, mitral insufficiency, chronic tonsillitis, pyorrhea, and a pical abscesses was made. He was immediately put on a bread and milk diet and in six days showed some little improvement. From December 15 to January 15, his dental infection was cured by removing three abscessed teeth and treating those remaining for pyorrhea. From January 1 to the time of his discharge on February 11, he had no more abdominal pain or tenderness, and he gained considerably in weight. On January 23, his tonsils were removed as a probable focus. At the time of his discharge the following note was made by Dr. Richards:

“For the past month or more the patient has been free from ulcer symptoms. The foci are removed and the

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patient can be regarded as clinically cured." Note that the ulcer symptoms were gone before the tonsillectomy.

These two cases illustrate some of the difficulties in obtaining data from this type of case. The symptoms of stomach ulcer, when untreated, usually recur pe. riodically, so that unless the case is subsequently observed over a long period there cannot be said to be a permanent

Furthermore, rest and a bread and milk diet, together with antacids, will often entirely relieve these patients at least for the time being. It is only a large number of cases extending over a considerable time that will give any clinical proof that gastric or peptic ulcer is due to local infective foci as rheumatism is. The data at hand seem quite conclusive for the cases we have. Removal of all local foci has given them relief ever since, already a very much longer period than the interim between any previous attacks. The remarkable subsidence of symptoms and increase in strength, weight, and blood hemoglobin, starting with the removal of the dental infection gave these cases a dramatic interest, which does not usu. ally accompany the rheumatic and heart cases.

Whether the ulcers are due to the irri. tation of constantly swallowing infected matter, or to hematogenous infection, we are not able to determine, since all had plenty of infection by both routes. This also will require a large number of cases in order to get adequate data. It is a problem which can probably be better determined from pathological work than by clinical observation.

The cases of nephritis cannot be said to have yielded any definite data. Many cases are diagnosed as nephritis on temporary albuminaria. The cases of chronic parenchymatous nephritis giving symptoms of advanced disease, almost without exception did not respond to removal of dental infection. The cases of temporary albuminuria accom

panying rheumatism and heart conditions in practically all cases responded to treatment which benefited the other conditions. In all cases of nephritis, however, referred to our service there was considerable dental infection, and we feel sure from studying the cases that further data will show that dental infection is responsible for the conditions which lead to many cases of advanced nephritis. This subject has not been given the same consideration during the last two years as has been given to rheumatism, but during the next year greater emphasis will be placed upon it.

We have had six cases of pernicious anemia, all of whom had dental infection. The extirpation of dental foci in these cases absolutely failed to make any no. ticeable difference with the subsequent periodic rise and fall in the blood count. The presence or removal of dental infection so far has made no apparent difference whatsoever in these cases. А case reported last year showing a rather remarkable improvement coincident with dental infection treatment subsequently proved to be of this type.

NOTE--This is in marked contrast to the results gained in secondary, which have been consistently benefited by our treatment.-T. B. H.

The neuritis cases arc, as usual, spectacular and interesting. The cure of cases of tri-facial neuralgia by the removal of dental fcci is so familiar tɔ the dental profession as to need no further data. Cases of sciatica and neuri. tis in more remote parts as connected with dental infection, are not so well known. The chain of symptoms of the rheumatic type and those of the neuritic type, altho sequelar of similar dental infections, are seldom found in the same patient.

In our experience the two seldom go hand in hand. Patients of nervous temperament seem much more liable to ne i. ritis and neuralgia from pyorrhea dental abscesses than they are to rheu. matism. One frequent form of this neu

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