COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00034770 ■Si' 1 l THE Trustees of the Fiske Fund, at the annual meeting of the Rhode Island Medical Society, held at Providence, May 31, 1917, announced that they had awarded a premium of two hundred dollars to an essay on "The Role of the Teeth and Tonsils in the Causation of Arthritis," bearing the motto: "Dum spiro, spero; cum Notis variorum." The author was found to be Dr. Joseph F. Hawkins, of Providence, R.I. DR. EDMUND D. CHESEBRO, Providence, R. I., DR. JOHN CHAMPLIN, Westerly, R. I., DR. GARDNER T. SWARTS, Providence, R. I., Trustees. HALSEY DeWOLF, M. D., Secretary of the Trustees, 305 Brook Street, Providence, R. I. The Role of the Teeth and Tonsils in the Causation of Arthritis. That the absorption of chemical toxins from micro-organisms can and does produce serious pathological lesions in the organs, glands and joints of the body is an established and accepted fact by the medical man who is abreast of the latest research in experimental medicine. To have an acute tonsillitis the initial event of an acute rheumatic attack is so common that it is now generally accepted as a clinical fact, and, upon minute history taking, one will find it in the majority of cases. As far back as 1798 Eyerlen 1 noted that not only in primary attacks of rheu- matic fever, but in subsequent attacks, there was a history of tonsillitis preceding. Other observers have noted this fact and recorded their opinions: 3 that they found sore throats as a precedent in from 1.5% to 80% of the cases. It is evident to every clinical observer that, many times, a con- stant forerunner of almost any systemic disturb- ance is of so slight importance that it may be over- looked or not mentioned by the patient unless brought out by the questioning of the physician; while, on the other hand, there might be quite serious disease in or about the teeth and tonsils, with little or no local manifestation. Tonsils are 6 THE ROLE OF THE TEETH AND TONSILS removed in children usually on account of their size. They are obstructive mechanically. In adults the tonsils may be small, even to being com- pletely submerged out of the line of vision of the observer, yet be an infected, toxin-producing, chronic poisoning source of various vague pains, and would never be removed for the same reason as in childhood, but when removed, have proved to have been the grave menace just mentioned. Recent writers, employing better methods of ex- amining the teeth and tonsils, are finding many more cases of arthritis when these organs are diseased than formerly. Goadby, 4 and others, re- port cases of polyarthritis originating in pus pockets about the teeth, and all are apparently agreed, at this time, that the most frequent port of entry is there or through the tonsils. As far back as 1904 Gurich, 5 who, by the way, believed that joint symptoms, endocarditis, pericarditis, pneumonia, myocarditis, pleurisy, and all the other complications of an acute rheumatic fever, were all the result of metastases from a primary focus elsewhere in the body, was the first to at- tempt systemic treatment of acute rheumatic fever through the tonsils. He reports 12 cases of ton- sillitis and four of peritonsillar abscess preceding the appearance of the acute arthritis, and 14 cases where plugs were seen in the crypts. A year later he reported 6 140 cases of acute and chronic arthritis treated by tonsillar therapy, with 98 cures and 23 cases unaffected by the treatment, which consisted IN THE CAUSATION OF ARTHRITIS. 7 of making parallel incisions through the tonsils and curetting the tonsillar tissue. Enucleation was not done at that time. Four years later Rosenheim 7 reported 10 cases of acute articular rheumatism treated by tonsillectomy and he was probably the first to enucleate the tonsils in acute rheumatic fever. One year later Hess 8 stated he thought acute follicular, phlegmonous, catarrhal tonsillitis or quinsy ushered in attacks of arthritis, and emphasized the importance of the tonsils in the etiology of the disease, but did not resort to sur- gical treatment of the tonsils. One year later still, 1910, Schichold 9 reported 70 cases, and called at- tention to other sources than the tonsil, and par- ticularly mentioned the sinuses and the teeth. Among the latest organisms to be studied in re- lation to arthritis is a small gram negative diplo- coccus, first observed by Connellan in 1914, while examining extracted teeth for Hasbrouck and Palmer, and now known as the Connellan-King diplococcus. He was searching for Endamoeba buccalis, and on examining abscesses situated upon the roots of many of the teeth found the Strep- tococcus viridans, and Streptococcus hemolyticus; also a gram negative diplococcus which he had never seen before, nor could he find anything in the literature calling attention to this organism. King made cultures from other parts of the mouth and throat, and the new organism was found in the crypts of the tonsils and around the teeth. It is a typical bean-shaped, gram negative diplococcus, 8 THE ROLE OF THE TEETH AND TONSILS slightly smaller than the gonococcus when it has attained its maximum growth on its best growing medium, which has been found to be human blood agar with a little veal serum added. It has a char- acteristic appearance on the medium, the colony- being a light dull yellowish brown with a rounded contour, about the size of staphylococcus albus, growing best at a temperature of 39°-40° C. Dunham, Van Lingelshein, Elser and others have reported several gram negative organisms found in the mouth and in other parts of the body, but this organism does not compare with them and has never been found outside the mouth and throat, after over three years' searching investigation. It is necessary, in preparing the medium, to use the titration method, and the acidity must be 0.2% or less. With the Hiss sugar serums no reaction oc- curred except coagulation of albumen, showing it is not a gas producer, and thus accounting for the absence of pain in the teeth, where it was found in the apical abscesses. Cultures have been made from the ear, nose and accessory sinuses, but all have been negative for this organism. When found it has been in a ton- sillar crypt, or some sinus in the tonsillar fossae after the tonsils have been removed, or around the roots of teeth; partially anaerobic chambers. It is not pyogenic, but is a powerful toxin producer; causes local infection, and is non-infectious for the general blood stream. IN THE CAUSATION OF ARTHRITIS. 9 Many arthritic or so-called rheumatic joints in which this organism was suspected to be the cause, were aspirated: blood cultures have been made from patients in whom it was found and all have been negative for the organism. A similar condi- tion is met with in the Tetanus and Klebs-Loeffler bacilli. It grows best in the presence of moisture. Clinically, the throats in which it is found are also moist and have other characteristic appearances. The mucosa is darker than normal, of a purplish, unhealthy hue, and the tonsils are usually rather small and submerged, with a brownish yellow serum exuding from their crypts. While the sub- ject of the treatment is not under consideration here, if we are to prove our case and make good the claim that arthritis is produced, in many in- stances at least, by a focal infection from the teeth and tonsils and would be and are relieved or cured by the elimination of that focal infection, it must be shown that cases of arthritis are relieved or cured by the removal of infected tonsils and teeth. This has been done by many accurate observers. These have been freely quoted throughout this es- say and the author will personally reminisce upon one. Dozens could have been quoted as easily. Not from psychic females open to suggestion and relieved by the same, but by strong men and in- nocent children who knew not the meaning of the word psychology. They have received no sugges- tion. They have received relief. It has happened that the removal of infected ton- sils and teeth has been followed also by very seri- 10 THE ROLE OF THE TEETH AND TONSILS ous complications due to the absorption of chem- ical toxins, but the contention that this diplococ- cus was responsible in these cases is strengthened by the immediate improvement of the patient upon receiving an autogenous vaccine of the organism. In 1916, in this country, Morris 10 reported 12 cases with very complete history records showing the condition before, during and after the opera- tion. In the tonsillar cases the association of pyorrhoea is noticeable. The twelfth case was not operated upon, probably not because the tonsils were small, but because the history relates ten at- tacks of gonorrhoea. He is a strong believer in the teeth and tonsils as factors in causing arthritis, and has operated upon many cases during the at- tack. He says that while no general conclusions may be drawn from so few cases, it is encouraging to note that the fever subsided promptly after the operation in so many of the cases. In Case 2 streptococcus viridans was isolated from the blood on two different occasions, and within three days after tonsillectomy the patient's temperature be- came normal and remained so. He thinks in this case the portal of entry was through the tonsils, and concludes as follows: "In conclusion, it seems to the writer advisable, in patients suffering with acute rheumatic fever, in whom evidence of tonsil- lar infection, acute or chronic, can be obtained, to remove the tonsils as soon as the joint pains can be controlled, provided the main conditions, as out- lined in the body of the paper, can be fulfilled. IN THE CAUSATION OF ARTHRITIS. 11 Further experience alone can determine whether the so-called complications and recurrences can be prevented in this manner." It is but a short time ago when almost every ailment of the human body that could possibly be ascribed to an infective origin, was attributed to disease of the teeth or tonsils. This theory, like all other new proposals or discoveries in medicine, or, for that matter, in any field of endeavor and human activity, was obliged to pass through the usual stages of reaction characterized by incre- dulity, popularity, acceptance and abuse, and hold its place for a while, only to find the pendulum swing to the other extreme. This latter has hap- pened, and we are now fortunately traveling the middle road, acknowledging many cases of arthri- tis to be due to focal infection through the teeth and tonsils, and also assenting that many are of unknown origin. One must also agree with Irons, 11 that alveolar abscess and arthritis may be coincidental, or that there may be other sources of infection than the teeth in the case of arthritis, if we are only able to find them. From an exam- ination of an unselected group of 329 patients in Cook County hospitals, who were studied and the incidence of all discoverable infectious processes determined and tabulated, it was found that 76% of the arthritic group had alveolar abscesses. Other diseases, including pneumonias, respiratory, gastro-intestinal, only 23%, or less than one third of the percentage in the arthritic group. Abnor- 12 THE ROLE OF THE TEETH AND TONSILS malities in the tonsils were present in 45% of the arthritic group, but only 24% in the cardio-vascular group, and in 19% of the remainder. Irons says: "All arthritis or other metastatic and systemic disease is not due to alveolar abscess or to tonsillar infection, of course, but the preponderance of such lesions in this group suggests that these infections may play an important part in the production of chronic arthritis and similar ailments. ... In the Arthritic group therapeutic measures directed to the removal of infectious processes have been followed by gratifying results, even in rather un- favorable material. Our readmissions for recur- rences of arthritis — which in former years were frequent, some patients returning as many as four times in a season — have been relatively fewer, and usually of patients who for some reason or other could not be submitted to proper surgical atten- tion." King 12 reports among his tentative conclusions drawn from 100 cases: "Every case of septic arthritis, commonly called rheumatism, is caused by a focus of infection somewhere in the body. It may be found in the tonsils ... or in and around the the teeth. . . . The most frequent focus is found in the mouth, and tonsils, on account of their crypts, harbor the focus more frequently than any other gland or organ. . . . The in- fection may become latent and produce serious trouble weeks or months later, at a point far re- moved from its original site." IN THE CAUSATION OF ARTHRITIS. 13 White and Wright, 13 reporting 56 cases of varied infections met with while working upon a treat- ment for Pyorrhea Alveolaris, say: "The high percentage of arthritis cases in this series is due to the fact that these men first reported for treat- ment of so-called rheumatism, and the pyorrhea was detected when search was being made for a local focus of infection." Murray, 14 reporting on a study of 848 cases of tonsillectomies, says he has constantly observed that where a tonsil is a focal infection and has been removed, the patient's power of resistance im- proves, and often remote affections like arthritis will disappear. While Rosenow, Klotz, Poynton, Payne and many others have worked with the Streptococcus in its invasion of tissues and organs and have demonstrated through animal experimentation that they can produce the same organism in the same anatomical position in the animal as in the human from whom it came, they have worked without particular reference to the dental avenues of infec- tion, and it was not until the work of Goadby 10 that particular reference to the tooth avenue of infection received systematic or detailed study in the English language. From 1910 to 1912 through a series of studies he was able to produce experimentally arthritis in rabbits. Then, by the elimination of the primary foci and the use of vac- cines to supplement the elimination, to cure the joint conditions. Hartzell, in a paper upon the 14 THE ROLE OF THE TEETH AND TONSILS dental path of infection says, "If there be anything of marked value in this paper which may be of future use, it will be in the fact that it offers definite and positive proof that the so-called dental path of infection, hitherto little appreciated, is shown to be important, and that organisms taken from the dental path have produced in animals almost all of the same forms of lesions hitherto described." That either the teeth or the tonsils, or both, may be the source of infection in arthritis is well shown in a case operated upon over a year ago by the writer. The patient was a practicing physician, aged 48, who had been suffering from vague pains in various parts of his body for many months. Pains in the back of his neck he attributed to cur- rents of air from the top of his auto windshield; pain in the back of his legs and under the knees to an old phlebitis (that had not bothered him for years) following typhoid fever; pains in his arms and shoulders to golf, and so ad infinitum, until one day it was brought home to him in some man- ner, it matters not how, that an existing pyorrhea alveolaris might be the source of his trouble. A dentist was forthwith consulted and the tartar scraped from off the roots of his teeth; the pockets injected with emetin and alcresta tablets ingested almost ad lib. and the teeth scrubbed with a solu- tion of ipecac. There was some slight improve- ment noted, but not enough to satisfy him, and he then bethought him of his tonsils, and having set his mind upon them, nothing would satisfy him IN THE CAUSATION OF ARTHRITIS. 15 until they were removed, and as he had employed me many times to enucleate tonsils from the throats of his patients and liked the style of work, would have no one else remove his own. As he was a bleeder, of a family of bleeders, it occurred to me to suggest he take his tonsils somewhere else. He persistently refused to do this, and when he was unsuccessful in his pleadings, he solicited and secured the aid of his wife, and I succumbed to the combined battery. Let us pass over the operation. I am always glad to do so. It nearly turned me prematurely gray. The interest in this essay lies in the result. Sufficient time has now elapsed to judge the result. He considers himself a normal, healthy man. Pains have gone and he cannot even produce them now as formerly, that is, by crossing one leg over the other and resting one knee on the other he would at once produce a pain in the hip of the uppermost leg. In fact, to get the leg upon the other knee he was usually obliged to assist with the opposite hand. He now crosses his knees and lets them stay so indefinitely. No cultures were made from the tonsils (the haemorrhage took all bacteriology from our minds), but they were odorous, with a thick, cheesy like excretion oozing from every crypt as the snare compressed the tissue. This same condition has many times been noted by the writer when enucleating tonsils for the relief of chorea, 100% of which enuclea- tions have been successful up to date, by the 16 THE ROLE OF THE TEETH AND TONSILS way, in stopping the choreic movements. Some cases will not be benefited in the least, without a doubt; but they have not appeared yet. One would be brave indeed to state that every case of chorea was or could be cured by tonsillectomy. No such claim is being made here. What is claimed is this: The cases of chorea operated upon by the writer were referred to him by men who believed, in that special case, an infection through a tonsil to be the cause of the chorea. Or they were cases found by me in my work and believed, as did the other men, to be cases that would be benefited, as far as their chorea was concerned, or at least their general health would be improved, by removal of the tonsils as the most likely causative factor. The results stated above have confirmed this opin- ion most convincingly. All cases of chorea are not of focal infective origin in all probability. The claim that they are, is not made. The claim is made, and proven, to the writer's satisfaction, that the cases that appear to come from tonsil infec- tions, are diagnosed as such, and are operated upon for relief from that condition, have given results that would satisfy the most exacting. The association between chorea and the great rheumatic group need not be gone into here, as it would be quite outside the title of the essay. Suf- ficient it is to draw attention to the fact and to the strong statement of Billings, 17 who makes no modi- fication, even, when he says, "Rheumatic fever and endocarditis are unquestionably the result of focal IN THE CAUSATION OF ARTHRITIS. 17 infection of the mouth and throat." And again, "Probably the frequent relation of pyorrhoea to rheumatic fever . . . has not been given the etiological importance it deserves." Many au- thorities do not agree to this theory, but they are greatly outnumbered when one compares them with the array quoted by Billings, 57 in number, in the bibliography at the end of the volume, or by Dillingham, ls with 41 references at the end of his article. It is indeed strange that these same au- thorities are, almost to a man, the very ones who accept, recognize and acknowledge gonorrheal arthritis to be of urethral gonorrheal origin. Among these dissenters may be mentioned Roily, 19 who found blood sterile in a large number of cases, even when taken at the height of the febrile stage. He does not claim all others are wrong in their contention for bacterial infection in acute rheu- matic cases previously reported, but questions if mixed infections might not be responsible for the positive findings. He examined the blood rather than the contents of the tonsils, because he claims the presence of bacteria on the tonsils, and not in the interior of the body, is no evidence that these bacteria are responsible for the articular rheuma- tism. Yet from his own figures, if we take the cases of tonsillitis, sore throat, pain in the throat, suppurating tonsils, tonsils found red and en- larged, or both, tonsils with plugs visible, and his so-called coated tonsils, and add them all together we get an even 500 cases in his 1450 patients ex- 18 THE ROLE OF THE TEETH AND TONSILS amined. Add to the 238 where he says other parts of the throat were red and swollen, or both, and it leaves such a large percentage of actual throat cases, even if he insists throat cases are not neces- sarily tonsil cases, that one hesitates to take his objections seriously. And Rolly's argument that he did not find the organisms in the blood in his cases does not hold, because it has been acknow- ledged by observers before and stated by Billings, that "doubt of etiologic relation to acute rheuma- tism also arose from the fact that it was not usually found by cultured methods in the joint exudate and circulating blood of patients." Dick 20 reports two cases of arthritis due to a Friedlander Bacillus (Bacillus Mucosus). Re- peated cultures from the throats of which (yield- ing colonies of the bacillus isolated in pure culture) produced arthritis experimentally in all three rab- bits which were inoculated intravenously. Crowe et al. 21 reports on a series of 1000 cases of tonsillectomies, wherein a histologic examination of the tonsils and adenoids removed at operation was made in every case. Ten per cent of these cases had an infective type of arthritis. In the first 31 cases, where the author was able to follow up the cases, 24 had normal joints. Four are classified as improved, because the patients are now able to walk without pain, two are not improved, and one is worse. All classes improved, except the old chronic ankylosed cases, which he classes as Rheu- matoid Arthritis, and in which he found only two IN THE CAUSATION OF ARTHRITIS. 19 benefited and five are much worse. He says re- moval of the tonsils and adenoids in cases of rheu- matic fever eliminates one of the portals of infec- tion. He says he believes this removal is not a very satisfactory therapeutic or prophylactic meas- ure in chorea, and appears to base it upon the fact that of 23 cases of Sydenham's chorea, there was a recurrence of the disease in eight cases after the operation. One feels like asking, what about the success in the majority of the cases? Fifteen is nearly twice eight. He advises against the re- moval of the tonsils in the acute stages of chorea. The writer desires to differ strenuously with this opinion, and has had in his own practice within the last year over a dozen cases that positively refute the statement that there is grave danger. Quite to the contrary, he has had to date universal suc- cess in such cases. Writing editorially upon this article the Journal of the American Medical Association says, "Despite the many uncertainties and unsolved problems which still exist, however, Crowe and his collabor- ators state that their records tend to support the evidence of Billings and others in regard to the importance of focal infections in many of the gen- eral disorders seen by the internist, the pediatri- cian, and the general surgeon." Notwithstanding the statement of Billings given above, Rosenow 22 has studied the bacteria obtained from joint exu- date and rheumatic nodes in acute rheumatism, and found organisms corresponding closely to the 20 THE ROLE OF THE TEETH AND TONSILS micrococcus Rheumaticus in seven out of eight cases. He claims certain strains of bacteria as- sume different cultural and morphological charac- teristics under certain conditions and environment. He classifies the streptococci as follows, their vio- lence increasing in the order named: Hemolytic Streptococcus, Streptococcus Rheumaticus, Strep- tococcus Viridans, Pneumococcus, and the Step- tococcus Mucosus. The hemolytic variety has an affinity for joint structures, while the viridans has an affinity for heart valves. No other reason seems as plausible for the prevalence of rheumatic fever in children as the local infection in the throat, mouth and nose. A short time ago a patient who had had repeated attacks of arthritis some years ago, but who had been free from an attack for a long time, suffered with a tonsillitis" that ended in peritonsillar abscess requiring operation for evacuation of the pus. Re- lief to the throat was immediate upon release of the pus, but the system had taken part in the pyae- mia evidently, for he had an attack of arthritis be- fore his convalescence from the quinsy. The writer believes he would have been spared this last attack, both of tonsillitis and rheumatism, if he had had his tonsils removed when advised to do so, some time ago. The writer is a firm believer that neuralgias, neuritis and most myalgias are all members of the rheumatic family. And with that as a basis for his reasoning, has repeatedly advised tonsillec- IN THE CAUSATION OF ARTHRITIS. 21 tomy when no other source of infection could be ascertained. And the tonsil may look innocent enough. A tonsil may contain foci which are caus- ing the most serious systemic infection, where a careful examination may fail to discover anything which would throw suspicion upon these struc- tures, and where the infection in the tonsil can be disclosed only after the tonsils are removed. The absence of an acute attack of sore throat at the time when systemic disease developed in no way excludes the tonsils as the possible focus for the trouble. The history of attacks of tonsillitis in previous years should always throw suspicion on the tonsils as the possible seat of chronic latent foci, and when the systemic condition is serious enough to justify the procedure, the faucial tonsils should be enucleated unless foci of infection can be detected elsewhere. In searching for the cause of an obscure systemic disease, and everything done to eliminate the source, one may be misled by the statement of the patient that they have never had tonsillitis or a sore throat. And yet an examina- tion of the tonsils will disclose the presence of pus that can be expressed quite easily. The tonsil may or may not be enlarged. When it is distinctly enlarged the evidence of chronic infection is, per- haps, more readily recognized than when the ton- sil is shrunken. Dillingham, quoted above, says: "In a case suffering from a chronic systemic infec- tion, the faucial tonsil should always be under sus- picion as the most frequent source of the trouble, 22 THE ROLE OF THE TEETH AND TONSILS and in cases where no other foci can be detected, one should not hesitate to consider the removal of the tonsil, provided the systemic infection is severe enough to warrant the operation, even in the case where the history of the patient and the examina- tion of the tonsil discloses no positive evidence of the tonsillar origin of the trouble." The writer wishes to heartily endorse these sentiments. As shown by the case of the physician and many others, especially the type mentioned when the claim was made that neuralgia was of the rheu- matic family. Cases have been operated upon by me after internists have eliminated all other pos- sible causes for the systemic disturbance; and while the tonsils in some cases have not been inflamed (some never having had an attack of tonsilitis), and in some cases were not even able to be seen between the pillars, even with counter pressure externally on the neck, were found, when removed, to have been foul-smelling beds of pus of a cheesy consistency; and, best of all, their removal has given relief and cure to the various pains through- out the system. If one is uncertain, it is no crime to remove the tonsils as one more possible source of infection removed. Another reason is, because with properly carried out technique there is less danger and inconvenience to the patient than accompanies almost any other procedure (surely less for the great gain that may be accomplished), and without losing or interfering with some func- tioning structure. The tonsils are only one of the IN THE CAUSATION OF ARTHRITIS. 23 many portals through which infection may enter. But it is one of the easiest to close. So even an experimental operation may be justifiable in serious cases. I have in mind a case where, after a thorough eliminative diagnosis had been made, the patient had been referred to me to find if the tonsils were the possible source of a most persistent refractory neuritis in the shoulder and arm. No inflamma- tion of the tonsils could be made out, nor could one justly accuse those two very small, innocent-look- ing glands, that had never given their possessor even so much as a suggestion that she owned them, of being the cause of her trouble, even through the greatest stretch of the surgeon's imagination. The patient persisted that the physician had eliminated all causes but that one, and she proposed to have that one eliminated. Operation was performed. Tonsils were not larger than the end of your finger when removed, but during the removal the operat- ing room was filled with the odor one gets when the abdomen is opened upon a ruptured appendix. Two weeks from the operation there was no shoulder or arm pain, and there has been none since. Many more cases of similar character could be cited. So the writer feels he should be par- doned if he appears to take too firm a stand upon the platform that says, "The Teeth and Tonsils do play an important role in Arthritis." And, if not pardoned, is willing to take punishment for say- ing he thinks they play the leading role. A long and careful tabulation by the writer has been made 24 THE ROLE OF THE TEETH AND TONSILS of the cases treated by or through him by dental and tonsillar treatment, showing the condition of the patients, both general and local, before and after this treatment. It is lengthy, and would cover many pages with tables, the persual of which would tend to no good offices more than can be obtained through the statement of the observer as to what his findings are from the series and what conclusions he draws therefrom. Those conclu- sions are in accord with the findings of Billings, Rosenow, Vanderhoof, 24 who although only de- scribing six cases in his paper, reports on 23 in which the tonsils were examined at the laboratory post operative; with Schraeder 20 in his clear-cut, well-substantiated claim of tooth origin for many infections; with Gibbes 26 in his demonstration that the X-Ray is an aid in determining the dental path of infection; with Lesemann, 27 who says in his con- clusion, "Removing the tonsils and making vac- cines from the contained bacteria in such diseases as rheumatism, endocarditis, arthritis, some cases of neuralgia and nephritis, is a duty when other treatment fails"; with Osmond 28 and his conclu- sions following observations made upon cases diagnosed through X-Ray aid; with Gearhart, 29 Crane Reede and Barnes in their "known facts re- garding the habits of certain types of micro- organisms that give important evidence respecting their tissue affinities"; with Shuman 30 in his very practical talk to his general practitioner confreres when he requests them to be on guard to observe IN THE CAUSATION OF ARTHRITIS. 25 the focal infections through the teeth and tonsils in their systemic diseases; with Higginbotham, 31 whose vigorous, fearless article is well worth the time to read it; and with all progressive men who fear not to travel toward the light. An evidence of Higginbotham's courage may be had from the following excerpt from his article referred to above: "Tradition still controls our dealing with the acutely inflamed tonsil: we cling to ancestral cus- toms, forgetting that a surgical principle must ap- ply to all parts of the body. Can it be said that the antiquated treatment of the inflamed appendix or carbuncle is less efficient than the treatment we still give the inflamed tonsil ? If the medical treat- ment of tonsillitis is right, the surgical treatment of appendicitis is wrong: a scientific principle can- not be shifted to suit conditions. "A few decades back no one understood the com- plications of appendicitis; to-day this is common knowledge. To-day, too, the sequelae of tonsillitis are well known, but no consistent effort is made to prevent them. The conscientious abdominal sur- geon removed the appendix early in the first attack in the same way the conscientious throat surgeon will come to remove the tonsils. Waiting to operate the appendix in the interim exposes the patient to subphrenic abscess and general periton- itis; waiting to operate the tonsil in the interim ex- poses the patient to arthritis, nephritis and endo- carditis. The treatment for the appendix is the treatment for the tonsil." 26 THE ROLE OF THE TEETH AND TONSILS And the following which is too good to quote. Complete enjoyment can be had only by getting it direct as published in the Journal of the American Medical Association for March 24, 191 7. "Current Reviews Regarding the Tonsils and Their Surgical Removal. "To the Editor: Your editorial on this subject (the Journal, March 17, 1917, page 851) is at least amusing, if not scientific. Experience is of more value than theory; therefore, if you wish to discuss a subject scientifically, you should place yourself in a position to see clinical results. Consequently come to western Kansas where 'inflamed tonsils' are removed daily for the cure of arthritis, ne- phritis, endocarditis and the prevention and cure of otitis media and its complications, as well as the 'tonsillitis.' Come out where we treat 'diphtheritic tonsillitis' by removing the foci of infection without administering 'antitoxins.' "Thomas Higginbotham, M. D., "Hutchinson, Kansas." There seems to be a preponderance of evidence on the side of those who claim the teeth and ton- sils play an important role in the production of Arthritis. IN THE CAUSATION OF ARTHRITIS. 27 The most ardent advocates do not claim all cases of rheumatism have their origin through these ports of entry, but claim to have shown a great number of them do come from that source. The writer is of that goodly company and so leaves his case before you. Bibliography i. Journal of A. M. A., Vol. LX. Vetlesen — Abstract. 2. Journal of A. M. A., Vol. LXVIII, No. i. 3. (a) Pribram citing Hess — in Medical Klinik, 1909. (b) Dieulafoy, G. Eng. Transl., 191 1. 4. Goadby, K. Practitioner, London, 1912, LXXXVIII, 107. 5. Giirich. "Uber die Beziehungen zwishen Mandelerkrankungen und die akuten Gelenkrheumatismus." Munchen Med. Wochenschr., 1904, LI. 6. Giirich. "Der Gelenkrheumatismus, sein tonsillar Ursprung und seine tonsillare Heilung." Max Woywood, Breslau, 1905. 7. Rosenhein, S. Bulletin Johns Hopkins Hospital, 1908, XIX. 8. Hess, K. Med. Klinik, 1909, V. 9. Munchen Med. Wochenschr., 1910, LVII. 10. Morris, Roger S. "Tonsillectomy during the Course of Acute Rheumatic Fever." Journal of Laboratory and Clinical Medicine, December, 1916. n. Irons, E. E. "Dental Infections and Systemic Disease." Journal of A. M. A., LXVII, 851. 12. King, J. J. "Connellan-King Diplococcus Infection of the Tonsil. Its relation to Arthritis." N. Y. Medical Journal, July 15, 1916. 13. Wright- White. Dental Cosmos, July, 191 5. 14. Murray, Gilbert D. Penn. Medical Journal, August, 1915. 15. Goadby. London Practitioner, Rheumatism Number, 1912. 16. Hartzell, T. B. Surgery Gynecology and Obstetrics, January, 1916. 17. Billings, Frank. "Focal Infection," Lane Medical Lectures, D. Appleton, 1916. Page 14. 18. Dillingham, W. R. "Chronic Infection of the Tonsils. Its Relation to Systemic Disease." Journal of Kansas Medical Society, February, 1916. 19. Roily, F. "Zur Aetiologie der akuten Gelenkrheumatismus." Medizinische Klinik, Berlin, November 5, 1916. Page 1167. BIBLIOGRAPHY 29 20. Dick, George F. "Chronic Multiple Arthritis due to Baccillus Mucosus." Journal of the A. M. A., February 24, 1917. 21. Crowe, S. J., Watkins, S. S., Rothbolz, A. S. "Relation of Tonsillar and Nasopharyngeal Infections to General Sys- temic Disorders." Bulletin of Johns Hopkins Hospital, January, 1917. 22. Rosenow, E. C. "Mouth Infections as a Source of Systemic Disease." Journal A. M. A., December 5, 1914. "The Etiology of Articular and Mascular Rheumatism." Jour- nal A. M. A., April 19, 1913. 23. "Current Views regarding the Tonsils and their Surgical Re- moval." Editorial, Journal A. M. A., March 17, 1917. 24. Vanderhoof, D. A. "The Tonsils and their Relation to Sys- temic Infections." Colorado Medicine, August, 1916. 25. Schrader, E. A. "Dental Foci of Infection, their Cause and Prevention." Journal of the Iowa State Medical Society, December, 1916. 26. Gibbes, R. W. "The X-Ray in the Diagnosis of Focal Infec- tion." Journal of the South Carolina Medical Association, July, 1916. 27. Lesemann, Frederick J. "Indications for the Removal of Ton- sils." Illinois Medical Journal, May, 1916. 28. Osmond, John D. "The Relation between Systemic Disease and a Focus of Infection in the Upper Air Passages." Cleveland Medical Journal, September, 1916. 29. Gearhart, Clyde M. "What Constitutes a Dental Diagnosis?" Washington Medical Annals, July, 1916. 30. Shuman, John W. "Focal Infection." The Journal of Lab- oratory and Clinical Medicine, August, 1916. 31. Higginbotham, T. L. "Tonsillectomy in Acute Tonsillitis." Journal of the Kansas Medical Society, February, 1916. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below or at the expiration of a definite period after the date of borrowing as provided by the library rules or by special arrangement with the Librarian in charge.