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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. 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 ab
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 a 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 showed 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 apical 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
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 periodically, so that unless the case is subsequently observed over a long period there cannot be said to be a permanent cure. 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 usually accompany the rheumatic and heart
Whether the ulcers are due to the irritation 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 a 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 noticeable 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. A 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 are, as usual, spectacular and interesting. The cure of cases of tri-facial neuralgia by the removal of dental foci is so familiar tɔ the dental profession as to need no further data. Cases of sciatica and neuritis 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 ritis and neuralgia from pyorrhea or dental abscesses than they are to rheumatism. One frequent form of this neu
ritis is sciatica. One case of sciatica had a large number of abscessed teeth which were extracted at once under ether. The patient had the sciatica for two weeks steadily, but after the extraction there was an immediate cessation of the neuralgia. This case, however, had some slight arthritis accompanying the neuritis which, of course, was slower to respond to the treatment. A case of tri-facial neuralgia is worth recording. Mr. A. B. A., 6498, entered July 19, 1915, a man of 60 years, an American minister, whose family history, habits and past history are negative, had for three months had a true tri-facial neuralgia. The pain came on at intervals of a few minutes as a sharp spasm in the left forehead and side of the face. A physical examination revealed many teeth worn down almost to the gums, a post nasal discharge, and a tender area corresponding to the region in which the spasms occurred. Examination of the blood and urine and a Wasserman test gave negative findings. He was admitted to the hospital on July 19, and no improvement was noted by rest, diet and cathartics until on August 6, his teeth were all extracted. In twenty-four hours the spasms of pain had entirely ceased. In two weeks all pain had gone from the affected area, altho a little tender
ness remained. In this case the mental ability has been considerably impaired by the stress of the pain, and it is probable that he will not entirely recover this at his age, but the neuralgia is entirely cured.
The remarkable feature of these cases is the immediacy of the results. The effects of the neuralgia may take some little time for recovery, but removal of the irritant seems to give immediate relief. Whether these cases are due to absorption of the septic material as are the rheumatic cases, is not clear to us.
A consideration of the data obtained from the work of the last two years at the hospital gives the following conclu
Dental infection, even if slight, is responsible for a very large proportion of chronic arthritis and acute rheumatism; endocarditis is another symptom of the same streptococcal infection and is also very frequently caused by dental infection; myocarditis and pericarditis, when not caused by tuberculosis or syphilis, may also be symptoms of the same disease; nephritis, when slight as evidenced by albuminaria alone, may be a symptom; nephritis in its more advanced stages, altho it may have been originally caused by diseases connected with dental infection, is not amenable to treatment by the removal of dental foci alone; pernicious anemia seems to have little or no connection with dental infection; neuritis seems to be associated more closely with irritants than with dental infection, but a larger number of neuralgias are attributable to dental diseases.
We wish to make acknowledgment here to Dr. S. Marx White, for suggestions and help gained from his paper and tables on this subject.
Our tables cover the work to August 1st, 1915. The first table is of the hospital cases. The sign * means present. Where two signs exist, as or, the upper one regards the presence of the disease; the lower, the presence or absence of treatment.