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its symptoms. The underlying cause that stirs this pathway to activity may sometimes be inflammatory processes near the nasal ganglion, or more frequently it is an hereditary something affecting the cortex of the brain, merely travelling down by means of that ganglion as its pathway; and that most cases of migraine could be no more cured by treating a normal ganglion in a normal nose than could a war between nations, caused by economic rivalry, be stopped by enforced disarmament in one particular means of warfare.

Even within the confines of neurology itself, there are very definite borderlands. The writer was much impressed with this when a patient was referred to him suffering from some seizures, not very clear-cut as to their nature. On carefully studying the situation he pronounced the condition epilepsy. Since this diagnosis involved considerable responsibility as to prolonged treatment, etc., he said he would be glad to have his opinion confirmed by any other capable neurologist. The patient's family being willing to do so, consulted a man very able in that specialty: That they might have his unbiased opinion, it was asked that they say nothing of having had other advice. This man, after a careful examination, pronounced the condition as being one of migraine. Of course, it was then necessary to find out which of us was right, and another man, equally competent, was consulted under the same circumstances; be brought much order out of the discord by giving an unhesitating opinion that the patient was suffering from hysteria.

all is found in the methods that every doctor who is successful employs in his personal contact with this patients; the means that he uses to impress them inspire their confidence and help them by means of his personality. This is really, unconscious though it may be, a form of applied psychology. We are all neurologists or psychologists to that extent and the difference between an individual learned in medicine and one successful in his practice of that art, depends more upon the use of these means than on anything else. This statement applies with special emphasis to those in whom what might be called "The anxiety neurosis" exists. In such patients anxiety is the main thing of which it is important that they be cured, not the things that they are anxious about. To express it forcefully but not grammatically, I have often told such patients that I do not want to cure them of what they think they have, I want to thinking they have it. Such are the patients that are shining marks for the various quacks and charlatans. Such also are the patients who having cried wolf too often, no one believes them when the real wolf appears. It is in these patients in particular that the establishing of confidence, interesting them in matters outside of themselves, establishing a good physical regime, can accomplish much.

cure them of

We all have our methods of exerting psychotherapy. One method I have found quite useful is to administer a certain medicine which I am sure will produce some definite and desired effect; to predict this effect beforehand in as much detail as possible and

Probably the greatest borderland of tell the patient that the appearance of

this effect indicates that the medicine is working as it should, and that his case is amenable to that treatment. The patient finding that these effects occur will have his confidence in the doctor established, and will feel that the doctor understands his case, and this confidence once established, it will largely be a case of the doctor curing the patient rather than any of his medicine. Such a patient will follow the doctor's advice almost religiously, and if the doctor is level-headed and. outlines a proper regime; proper selfcontrol, proper arrangement of life conditions and the proper viewpoint, very much can often be attained.

In summary, then it may be said that the neurologist considers a tissue which coördinates and harmonizes all

the other tissues and activities of the body. In certain cases, the faulty adjustments are primarily due to this controlling mechanism, the nervous system-such cases might be said to legitimately belong in his domain. In many other cases, the fault is primarily with the body tissues and the nerves are only secondarily involved-these cases can not be said to always belong to him. It is this adjustment between the two that constitutes the borderland.

This borderland is the more involved as we learn more of the intimate relations between the endocrine glands, the emotions, the sympathetic and parasympathetic nervous system and its varying balance, and the effects of hormones, resulting from the interaction of these conditions.

I

The Relation of Dental Infection

to Systemic Disease'

BY RALPH PEMBERTON, Philadelphia, Pennsylvania

AM very glad to have the oppor

tunity of taking part in a meeting which inaugurates closer coöperation between the medical profession and the important field of dentistry which is in reality a subdivision of medicine at large. In speaking to you upon the relation of dental infection to systemic disease there will be, in the few moments at my disposal, opportunity to consider only a small portion of this large field. It will be my purpose therefore to touch upon some of the important principles involved and especially upon one or two not widely recognized. Furthermore, I take it that there is small advantage in reiterating facts which are pretty generally accepted; and that attempts to indicate the direction in which experiment and progressive thought are leading us will be apropos. Some of you may not know that focal infections are among the oldest pathologic disturbances of which there is any record; necrosis and caries occurring, for example, in the cretaceous period long before the advent of man. Notwithstanding this and the fact that medical literature contains isolated instances of recognition of the relation between infectious

1 Read by invitation before the Philadelphia County Medical Society, December

10, 1924.

foci and disease, within the past ten or fifteen years only has the matter received the recognition it deserves. Innumerable clinical observations and much precise laboratory study have indicated that focal infections haboring microorganisms, chiefly streptococci, may be productive of pathological distrubances in almost any of the tissues of the body. The clinical manifestations which arise, however, are varied; so much so indeed, as often to mask the exact relationship.

A review of the pathological conditions known to stand in relationship to focal infection reveals that one of the most common is heart disease, in the form of endocarditis, myocarditis, or pericarditis. Of equal frequency or even greater, according to some authorities, is the arthritic syndrome which includes arthritis, myositis or muscular rheumatism, neuritis and chorea. Another outstanding result of focal infection is nephritis, not only in the acute form secondary to scarlet fever, but in the more chronic forms associated often with widespread vascular disease. It is probable indeed, that arteriosclerosis per se, may be a secondary result. Pancreatitis, gastric ulcer, diseases of the thyroid, various skin conditions including herpes are recognized consequences and there should also be mentioned the

important and obscure field of func- showed foci in the tonsils; 33.5 per tional nervous disturbances.

Thus, a series of 100 cases admitted consecutively to my service on the medical wards of the Presbyterian Hospital, Philadelphia, was analyzed for focal infections, by Drs. B. A. Thomas, N. P. Stauffer, J. E. Aiguier and their associates, with the following results: There was demonstrable tonsillar or sinus infection in 60 per cent, dental infection in 58 per cent and genito-urinary infection in 34 per cent. Of the cases showing dental infection pyorrhea was present in 77 per cent and infection of the apices in 46 per cent. The diseases presenting most frequently in this series of 100 cases were cardiac disease, 16 per cent; nephritis, 12 per cent; arthritis, 10 per cent. Mention of the pathological states above referred to must suffice to indicate the wide range of disturbances produced by focal infection, and I think there can be no disagree ment among us in accepting this relationship.

However, perhaps the most tangible disease for clinical study in relation to focal infection is arthritis because of the visible surface phenomena. It can be taken as largely typical of the influence of foci, provided we distinguish between such consequences as disturbance of function on the one hand, and irreparable organic disease, such as endocarditis on the other. It is therefore of interest to note the incidence during the war, of focal infection in a series of 400 cases of arthritis among soldiers, the intensive study and treatment of which I was privileged to direct. Seventy-three per cent showed demonstrable surgical foci; 52 per cent of the entire series

cent showed dental foci and 12.5 per

cent were positive for a genitourinary focus. Of the cases showing dental infection 30 per cent had abscessed teeth; the balance being made up from ulcerative gingivitis and pyorrhea. These analyses were made by Captain W. E. Mentzer, Dental Corps, U. S .A., and correspond well with the figures from civil life for 100 consecutive admissions to the medical wards above referred to. In a statistical study of over 500 cases of arthritis from the arthritic clinic and from private practice my associate Dr. E. G. Peirce has found that the figures for tonsillar and dental infections are reversed, the latter being much higher in the proportion of about 70 to 40 per cent.

It is of the highest importance, however, that we also determine the limitations of the so-called doctrine of focal infection. It is difficult for anyone trained in biology to believe that all disease is caused by this mechanism alone. There is irrefutable evidence that removal of foci does not necessarily cure the functional disturbances which they have produced and there are large gaps in our ability to prove the existence of focal infections in many diseases known to arise sometimes from this premise. Finally, dispassionate observation will convince almost anyone that the syndrome so frequently caused by focal infection can apparently not only be precipitated but also be perpetuated by factors of a totally different nature. During the intensive study and treatment of arthritis in the army, two facts of great significance stood out; (1) the immediately exciting factor in 60

per cent of 400 cases of arthritis was not a preceding disease or obvious infection but unmistakable and undoubted exposure to cold or wet or both; (2) among these 400 cases an overwhelmingly larger proportion got well, 46 per cent, in the presence of demonstrable surgical foci than recovered as the result of, or following, removal of foci of infection, 8.5 per cent.

Of much interest is a recent statistical study by Appleton2 based upon a publication of the War Department, entitled "Defects found in Drafted Men." While the methods of analysis at the camps were somewhat crude, the enormous number of subjects, over two and one-half million, gives the data value within certain limits. He concluded that chronic cephalic infection is not, in males between the ages of eighteen to thirty inclusive, the sole or chief determining factor in the contemporaneous occurrence of such conditions as gastric ulcer, appendicitis, endocarditis, arthritis, osteitis deformans, myositis and muscular rheumatism.

There are at least two ways in which focal infections can produce disease at a distant site. The obvious way, supported by much experimentation, is for the microorganisms to be carried by the blood stream and lodged in one or more organs of the body. This hardly calls for further comment and time forbids it. Another method, and one inadequately appreciated, is through their influence upon normal physiologic processes by virtue of the metabolic products elaborated in situ.

2 Jos. L. Appleton. A statistical contribution to the problem of focal infection. Dental Cosmos, July, 1924.

Much useful work has emanated from bacteriological laboratories indicating clearly the nature and degree of dissemination of bacteria. It is not necessary, however, to go to the length which some workers have done and ascribe in all cases a specific strain of organism to each organ involved or symptom resulting. Thus, in arthritis one of the most common symptoms is headache. If, however, a patient has a headache on Monday followed on Tuesday by pain in the shoulder and on Wednesday or Thursday by a return of the headache, it seems fatuous to suppose that bacteria have migrated from the brain tissue or meninges to the shoulder muscle and back again.

It is increasingly clear that the influence of focal infection is towards the dislocation of a very fundamental physiology whatever the precise mechanism may be. At the present writing, the evidence points to the circulatory system particularly the finer vessels and the capillary bed as at least part of the mechanism involved. As far as functional disturbances are concerned this mechanism is independent of, and probably more fundamental than, the influence of foci through the dissemination of bacteria by the blood stream.

Thus, it must be common knowledge to everyone present that removal of focal infection frequently results in failure and it is of much interest to note that in such failures there can not infrequently be observed in the laboratory such disturbances as a greatly lowered sugar tolerance and changes in the normal blood gas relations. A lowered sugar tolerance accompanies arthritis in about 60 per cent of all

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