restored to permanent regular rhythm although several of them have remained normal over long periods of time. However, with the exception of the 5 persons with pathologic hearts, I have seen no change in the cardiac function of any of these patients. None of the 91 has any signs of heart failure and each performs his daily duties without any cardiac embarrassment. PROGNOSTIC VALUE OF EXTRASYSTOLES so believe this should carry some weight. To me the extrasystole is no more pathologic than the occasional twitching of somatic muscles or than the spasm of the eyelid due to increased irritability of the conjunctiva. I believe it is only a symptom of increased irritability of the myocardium and there is no reason to believe that hyperirritability of any organ is pathologic. During the period of observation not one patient of the 91 who had normal hearts at the first examination has developed any cardiac pathology up to the time the tables were completed. However, for fear it might later be the cause of disease in the heart tissue, I believe it behooves us to remove any associated pathology that might be uncovered. From an intensive study of these 100 cases I cannot believe that the myocardium is impaired in any manner by the extrasystole. While some believe the auricular extrasystole is of "serious import," at present I have no reason to believe it differs prognostically from the other two types. ROLE OF CARDIOGRAPHIC INSTRUMENTS As I search each patient carefully for extrasystoles I am coming to believe more and more that this condition, if looked for diligently, can be found in the majority of people. IS THE EXTRASYSTOLE PATHOLOGIC? As I have watched these patients carefully over a period of time, I have yet to see the first one who has been embarrassed physically from extrasystoles, but many of them have been greatly worried and in grave doubt as to the outcome until the condition was carefully explained to them. I find that after they are convinced it is only a functional condition; they watch it and report on it with the same interest that I follow it. Of course this is not a large number of cases, but I feel these patients have been closely followed and carefully studied, In all cases examined I attempt to make an exact diagnosis before resorting to instruments of precision, but although I am improving, I have made so many miserable mistakes, that I feel I must depend upon cardiographic instruments for an accurate diagnosis of cardiac irregularities. While there may be a few clinicians who need not resort to them, I cannot conceive how the type, origin or differentiation of arrhythmias can be accurately and definitely diagnosed without the employment of these instruments. EXTRASYSTOLES IN INSURANCE RISKS Rulings of medical directors differ greatly concerning extrasystoles but to my knowledge there is not one insurance company that accepts as a first class risk a person with an extra systole. All seem to consider it heart disease, although none has published any statistics dealing separately with this arrhythmia. All irregularities are classed together and the basis for classification depends upon the number of irregular beats per minute. This is obviously unjust but until there is a differentiation of the cardiac irregularities no just method can be adopted. As a medical director, for the past two years I have been accepting applicants with extrasystoles, who are otherwise normal, as first class risks. CONCLUSION Extrasystoles are only symptoms of hyperirritability of the myocardium. If carefully sought for they will be revealed in a majority of persons examined. They may appear at any age. periods of time with no signs of heart failure developing. The etiology is varied but is usually extracardiac. They may arise in any part of the myocardium. They are of no prognostic value. They are a symptom and not a disease. The cardiographic instruments of precision are essential for their differentiation. While a small number of cases are here reported, they have been carefully studied and closely observed over varying periods of time and not one person who had a normal heart muscle and valves at the time of the first examination has developed any symptoms of heart failure nor has one of them shown any signs of cardiac pathology at any time during the period of observation. Certain Clinical and Pathologic Aspects of Focal Infection with Special Reference to the Teeth and Tonsils and the T Gastro-Intestinal Tract' BY GEORGE B. EUSTERMAN, Section on Medicine, Mayo Clinic, HE theory that focal infection is a cause of systemic infection and disease has, as is well known, become an established scientific fact, largely through the investigations of Billings and his coworkers, and Rosenow (29). This pioneer work has been confirmed and amplified by valuable clinical and experimental contributions from many other American and foreign sources, so that the practical importance of focal infection to general medicine in a diagnostic, prophylactic and therapeutic sense is generally conceded. As a result we now realize that certain disorders and diseases which a decade or two ago were obscure in origin, intractable to treatment, or perhaps incurable, are due wholly or in part to chronic foci, and that such diseases can often be cured or ameliorated by the proper removal of such foci. Systematic search for all possible foci of infection has revealed, in no uncertain manner, the large percentage of sick persons harboring chronic septic 1 Read before the Section on Stomatology at the Seventy-fifth Annual Session of the American Medical Association, Chicago, Ill., June 9 to 13, 1924. foci, besides the important fact that persons of mature age are hardly ever free from them. It is true that such search is often prosecuted with more diligence than discrimination, and that patients often lose teeth and other more or less useful structures without benefit, to the discredit of a fundamentally sound, but misunderstood principle. Knowledge concerning the organs in which primary foci are usually found, in order of frequency and importance, concerning the prevailing strains of bacteria, the type and stages of disease in which cure or relief seems most probable, and the indications for or against the removal of such foci under varying circumstances, is becoming gradually crystallized. The influence of chronic infection on the body metabolism, on non-related associated infections, and on glands of internal secretion, and the factors underlying anaphylactic phenomena are now more clearly understood, but statistical evidence bearing on thoroughly studied and well controlled material, preferably from the larger universities and municipal hospitals and clinics, must be collected and digested before the Patients with acute articular rheumatism, subacute or chronic infectious endocarditis, chronic myocarditis, chronic infectious arthritis, appendicitis, gastric or duodenal ulcer, chronic cholecystitis, iritis, glomerulonephritis, pyelonephritis, neuritis, neuralgia, herpes zoster, myositis, erythema nodosum, symptomatic purpura, vague aches and pains in the muscles and joints, certain types of headache, anaphylactic phenomena of a cutaneous and visceral nature, and disturbance in function of organs supplied by the autonomic nervous system are quite generally suspected of harboring foci of infection. As a rule, there are no characteristic symptoms, or signs, or laboratory aids to diagnosis. It has been said that the criteria of systemic disease are relatively crude, and the physical signs relatively gross. The value attributed to an examination of the blood, the differential leukocyte count, and so forth, by certain writers is denied by others. With the exception of the mildly acute and the anemic types, blood counts, as a rule, are of limited value in the majority of the cases. Mindful of the possible sequence of cause and effect, careful anamnesis may elicit the fact that the complaint occurred usually a few weeks to a month after an acute infection, like tonsillitis, sinusitis, or an ulcerated or "treated" tooth. Systemic or local exacerbations, or local symptoms in the foci themselves may occur during periods of lowered resistance, such as during convalescence from a long illness or operation. The fact is generally recognized that lesions more or less enclosed, such as peri apical infections or small submerged tonsils, which drain only into the circulation, are probably the most dangerous. Such foci in themselves, or in connection with predisposing factors, may sooner or later break down resistance and result in disease. Relative to the high incidence of infectious foci in persons of mature age, it is highly probable that such foci are important factors in the degenerative diseases of later life. We are periodically reminded that, since 1870, the average length of life has been increased by fifteen years. Death now commonly occurs in the early fifties instead of the late thirties. This increased expectation of life has been made possible largely by the reduction of the diseases of infancy and early youth, and the lowered mortality in cases of tuberculosis, typhoid, diphtheria, smallpox and other infectious or communicable disdiseases. Unfortunately, statisticians now tell us that this increase in the average duration of life has for a considerable period remained stationary, and that as a result of an increased number of persons reaching more mature age, the percentage of deaths resulting from degenerative cardiorenal-vascular lesions has greatly increased. Besides cancer, one of the most outstanding problems today is the control of the increasing incidence of these degenerative diseases. It seems reasonable to assume that the prevention and eradication of foci of infection is at least a partial solution of this problem. The principle of elective localization of bacteria, a modern conception of the mechanism of metastatic infection, was conceived and demonstrated |