« AnteriorContinuar »
pyrexia, and was followed some days afterwards by inflammation of the throat and pharynx. The matter appeared to be of little importance at first, but a sudden severe pain in one of her ears, together with the continuance of the pyrexia, caused her medical advisers to suspect suppuration of the middle ear. These conditions remained without change for some days until the symptoms of mastoid suppuration appeared. She was operated on at once, but a general infection caused by streptococci followed the operation, and as soon as this diagnosis was established Marmorek's serum was used, but produced no effect, and patient died in a week, during which her temperature was always about 105° F.
In the second case:
The patient was a man, 48 years of age, who had been in good health until the age of 40 years, when he began to suffer from chronic inflammation of the gums and the maxillary alveoli, accompanied by the formation of pus. He consulted many specialists, but no one was able to effect a cure. When he reached the age of 45 years I was obliged to remove his right testicle, because it was found to be affected by tuberculosis. He made a good recovery after the operation, and apart from his dental trouble his health was otherwise satisfactory. One day in November last year he had a severe sore-throat, which he did not treat in any way, but went to his business as usual. In the evening he had a violent fit of shivering followed by high temperature, and it was obvious that this sore-throat and pyrexia were caused by a phlegmon of the pharynx. In the course of the next few days an abscess formed in the right tonsil. This abscess was opened four days after the beginning of the inflammation of the pharynx; a moderate quantity of pus escaped, and this on cultivation showed the presence of a very small streptococcus and of a saccharomyces of which I will speak subsequently. After the operation the patient felt very much better, the pain in his throat subsided so that he became able to swallow, and his temperature, which had hitherto been about 100° F., fell to 98°. But about 7 a.m. next day he was suddenly seized with a shivering fit, followed by a rise of temperature to 104°. The suspicion of a general infection produced by one of the micro-organisms that I had found in the pus of the abscess entered my mind at once, and with a view of confirming the diagnosis some blood was taken from a vein of his left arm. In order not to lose time, and thinking that the infection was due most probably to the streptococcus, I begun to use Marmorek's serum. In the first twenty-four hours 50 cubic centimetres were injected, but the patient's condition grew worse, and his temperature remained permanently high, being always about 104°. The use of Marmorek's serum was continued during the next two days, but in spite of it the patient died from failure of the heart unaccompanied by any localised lesion.
The micro-organism isolated from the blood was a streptococcus which had the same microscopical character as had that found in the abscess.
In the two cases the stages of the illness are interesting. first we have (a) a history of suppurative periodontitis, and gingivitis followed by (b) a catarrh of the larynx and pharynx which subsequently assumed a suppurative type, probably by direct infection from the mouth, (c) general infection from the suppuration in the middle
In the second case the sequence was as follows: (a) suppurative periodontitis and gingivitis, (b) septic tonsillitis, (c) general infection.
In commenting on the second case Dr. Bellei throws out the suggestion that the saccharomyces may have influenced the migration of the streptoccocus into the blood, the phagocytes becoming inefficient on account of the streptococcus and saccharomyces acting together, while they might have been efficient if the streptococcus had acted alone.
It may be argued that so many cases of suppurative periodontitis are seen in which general symptoms do not appear, that we need not view with much apprehension pus in the mouth. In answer to those holding such views it must be urged (1) that the part played by suppurative conditions in the mouth in the production of general affections has yet to be determined; (2) that suppurative inflammations in other parts of the body are always liable to act as foci of general infection, and there is no reason why the same should not be the case with the mouth; (3) that although under ordinary conditions pyogenic organisms are met with in the mouth, and are apparently non-pathogenic, there is no reason why, with an alteration in their environment which occurs in certain inflammations, they should not acquire a certain virulence.
In conclusion, I must render you an apology for the somewhat rambling character of my paper. The subject, although one of great importance to us all, is as yet quite in its infancy. There are but few really well recorded cases, and very much more work, clinical, chemical, bacteriological, must be done before we are able to arrive at a correct idea of the relationship which does exist between oral sepsis and general disease. We should, I think, endeavour to approach the subject with unbiassed minds, and not too hurriedly assume that a septic mouth is the direct cause of some remote affection merely because the remote affection disappears on removal of the sepsis.
Still further we must always remember that there are two great factors in the production of disease by germs and their products, namely, the attack on the one hand and the resistance of the tissues on the other.
The PRESIDENT considered the paper a most instructive and interesting He had had under observation many cases of the class referred to, and the subject had occupied his attention very much for the last three or four years. Cases were constantly being met with at the infirmary, and the relief of the symptoms after the mouth had been made aseptic was marvellous. The majority of the cases occurred in patients who had had septic roots covered over with artificial plates; the gum grew over them, producing a condition of things admirably adapted for the septic condition.
Mr. C. ROBBINS thought it was impossible to go into the matter too care
fully. Mr. Colyer had read an important paper which required careful digesting before its full value would be fully appreciated. He wished, however, to make one note of warning, especially with reference to pernicious anæmia. He had a case which might have terminated very unfortunately for himself and placed him in a very awkward position. Dr. Hunter was one of the greatest authorities on pernicious anæmia, and he was right in the main with reference to clearing out all diseased teeth and stumps from the mouth. A young medical man, who was just finishing his career at one of the London hospitals, came to him about his mother who was lying dangerously ill a few miles from town. She had been examined by a specialist and he had asked Mr. Robbins to visit her and take out her teeth. He went down to see the patient, and it seemed to him that death was written all over her face, and yet because she had pernicious anæmia he was asked to remove all her teeth. There were centrals and laterals in the upper, and six teeth in the lower jaw. He examined the case carefully and could only find two little roots that gave any evidence of being septic. The young doctor was there, and he told him that he could not extract the teeth although he was willing to remove the two little pieces of stumps. That was done, and a few days after the young practitioner called on him again and told him that the physician was positive that the teeth should be taken out, and that his mother could never get rid of her pernicious anæmia until they were removed. Mr. Robbins did not wish to place his knowledge against that of a physician, but he told the young practitioner that he knew his mother's mouth better than the specialist, and was certain that the rest of her teeth were in an aseptic condition. He offered to meet the physician and talk it over with him, but declined to take the teeth out. Three days afterwards he heard that the patient was dead, and he considered he was right in taking strong grounds in that particular case. Although in the main Dr. Hunter was right, there were cases where a dental opinion should be given in addition to the opinion of the physician.
Mr. W. RUSHTON thought Mr. Colyer had touched on a very important subject, and agreed with Mr. Robbins in his warning that post hoc was not always propter hoc. With regard to glossitis, he did not understand Mr. Colyer whether the glossitis was from general infection or from local irritation. Some of the worst cases of glossitis he had met with had been of purely local origin and had subsided when local irritation had been taken away, there being no septic material in the mouth-such, for instance, as long teeth standing in an isolated position. One of the worst cases of gastric ulcer he had ever come across was in a patient whose mouth was in an absolutely sound condition, and a very bad case of arthritis was in a patient whose mouth was also in a fairly healthy condition, so that it was necessary to be careful not to draw too rash a conclusion. With regard to Mr. Robbins' case, he himself was called in by a physician to a patient who had diabetes and phthisis, and noticed that death had marked the patient for his own. In spite of the entreaties of the physician he refused to operate, and.in three weeks he saw the death of the patient recorded in the paper. It was certainly necessary to use common sense in such cases. It was an acknowledged fact that those soldiers in South Africa who had had the worst time with enteric fever seemed to be those whose mouths were in a bad condition.
Mr. R. GRACEY asked whether Mr. Colyer thought in all cases where general disease was found in conjunction with a septic condition of the mouth, the dentist was justified in extracting those teeth; or whether it should not be
considered that the condition of the teeth was due to the general disease, and that when the general disease was treated the teeth would recover? Cases of periostitis in the mouth were very often due to the lowered condition of the patient, and if the condition of the patient could be made generally good his teeth might tighten up and be sound for many years afterwards.
Dr. W. GUY said in medical literature it was a common occurrence on perusing an article written by a medical man to find it assumed - and he thought it was a pretty general impression amongst the medical professionthat a carious condition invariably involved a septic condition. But it was well known that was not the case. There might be a number of roots in a mouth which did not look very pretty, and a number of teeth which had been attacked by caries, and yet there might not be the slightest chance of that individual patient suffering from septicemia in connection with those particular teeth. He, therefore, thought a note of warning should be sounded, because dental surgeons were constantly asked to extract carious teeth under the impression that there was absorption of septic material from those teeth going on. It was a matter of great interest to find out how it was that for many years in a patient there might be daily ingestion of a considerable quantity of actual septic material without, so far as one could see, any absorption occurring. What occurred probably was that the septic material was digested by the stomach and no toxins were formed. Then something happened—it might be influenza -and a patient who had very little wrong with the mouth at all might develop very serious general symptoms, varying from a slight temporary febrile condition to much more serious conditions. Those were points he hoped Mr. Colyer would keep in view in the researches which he was sure Mr. Colyer would continue to carry on.
Dr. GLAISBY considered it was most important in cases of septic mouths to remove all the bad roots and teeth. Hardly a day passed at the hospital in York without seeing cases sent to him by his colleagues on the staff, patients suffering from glandular mischief and gastric ulcers, and in every case where the teeth had been removed in periods under three weeks they had gained as much as 4 lb. in weight, even though they had not a single tooth in their heads, and in not a single case afterwards was there any sign of gastric mischief. That spoke for itself as to the importance of looking to the mouth.
Mr. J. F. COLYEK, in reply, said that in looking through the Journals he had rarely found a single case where the mouth condition had been correctly reported. He was trying to impress upon his medical friends the necessity, where they suspected any oral trouble, of calling in the dental practitioner in consultation. It was a bad plan when a medical man suspected something wrong to simply send the patient on to the dentist. He thought the two should meet and consult over the case. The subject was permeating the medical profession, and he felt that patients might be sent to dental surgeons with peremptory orders to remove all the teeth. The dental surgeon should be in the position to discuss the subject with the medical man; and if he were in that position he could then discuss the case intelligently with the medical practitioner. He had not tried to make out that gastric ulcer and such things were due to oral sepsis, but had simply tried to show there was a relationship which sometimes did exist; but he did not believe it was in the relation of cause and effect. He believed if the subject were worked at both by dental surgeons and by medical men, it would be a means of adding much to our knowledge of general pathology. If once the fact were established that there
was such a thing as a relationship between septic mouths and certain diseases, there was a basis to work upon; and investigators ought to be able to find out the bacteriological condition of the mouth that produced certain diseases. If it were once discovered how the two were related, much good work would have been done. For instance, in chlorosis one septic condition, he thought, produced the disease, and it was possible there was another septic condition associated with pernicious anæmia.
Advanced and Retarded Dentition-Two Cases.
READ AT THE ANNUAL GENERAL MEETING OF THE MICROSCOPICAL SECTION, HELD
BY ARTHUR W. W. BAKER, M.D., M.CH., UNIV. DUBLIN,
UNIVERSITY EXAMINER IN DENTAL SURGERY, TRINITY COLLEGE, DUBLIN.
THE specimens of advanced dentition which I bring before the Section were given to me some years ago by my friend Dr. Kidd; they were removed by him from an infant at birth.
On looking up the literature of the subject I found, in Dr. Guildford's article in the "American System of Dentistry," that premature dentition is sufficiently uncommon as to have attracted attention in the earliest times, and had connected with it certain superstitious beliefs with regard to the future welfare of the individual thus endowed by nature. Pliny, the younger, has handed down to us several instances of premature dentition, the most conspicuous of which was that of the Roman Consul, Marcus Curius, who, on account of his having been born with a full set of teeth, was surnamed Dentatus. Zoroaster, the Persian legislator, is also said to have had a complete set of teeth at birth. Louis XIV. of France and his Secretary of State, Cardinal Mazarin, were each born with two teeth. Richard III. of England, and Mirabeau are both said to have had congenital teeth. Haller collected a list of nineteen cases of teeth at birth, and very many more have been recorded since by others. The late Sir John Tomes refers to a well authenticated case of full dentition at birth occurring in a stillborn negro child in North Carolina.
Quite a difference of opinion exists as to the character of these teeth. In a number of cases recorded the congenital teeth are described as being malformed, without roots and having only a ligamentous attachment to the gum, in consequence of which they were soon lost. In other cases record is made of the teeth being normal in character, solidly implanted and retained until supplanted by their permanent successors. The truth probably is that these premature teeth are of two kinds, the one supernumerary in character,