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Citation of Original:

Miller, WD. The Human Mouth as a Focus of Infection. Dental Cosmos 33(9) Sep. 1891:689-706.

ORIGINAL COMMUNICATIONS: The Human Mouth as a Focus of Infection

By W.D. Miller, M.D., D.D.S, Berlin.

During the last few years the conviction has grown continually stronger, among physicians as well as dentists, that the human mouth, as a gathering-place and incubator of diverse pathogenic germs, performs a significant role in the production of varied disorders of the body, and that if many diseases whose origin is enveloped in mystery could be traced to their source, they would be found to have originated in the oral cavity.

It shall be my endeavor in the following pages (I) to call attention to the various diseases, both local and general, which have been found to result from the action of micro-organisms which have collected in the mouth, and to the various channels through which these micro-organisms or their waste products may obtain entrance to parts of the body adjacent to or remote from the mouth. The secondary nervous affections due to diseased teeth will not receive consideration; (2) to present in very brief form the present condition of our knowledge of the pathogenic bacteria met with in the mouth and the means at our command for combating them. I shall refer only cursorily to those topics which are of minor importance, or which have already become familiar to the profession through the periodicals, text-books, etc., giving more attention to those which are still subjects of study. I hope finally to be able to add some results of original investigations in this field, which may help to establish the great importance of a thorough understanding on the part of the physician, no less than of the dentist, of mouth-germs as a factor in the production of disease. The subject will be presented under the three following heads:


I. Disturbances of the Human Body which have been traced to the Action of Germs growing in the Mouth.
II. The Pathogenic Mouth-Bacteria.
III. Prophylactic Measures*


1. Decay of the Teeth.

In conformity with the nearly unanimous verdict of all recent investigations, decay of the teeth must be set down as the most widespread of all parasitic diseases to which the human body is subject; and although, as far as the life of the patient is concerned, the prognosis is exceedingly good and decay of the teeth may be pronounced one of the most trivial disturbances in the human economy, yet, if we take into consideration the results which follow a case of general decay, particularly in the mouth of young or weak persons, it often becomes a disease of very grave nature.

I venture to say that most practitioners of dentistry will agree with me that the havoc wrought by dental caries in the mouths of vast numbers of children, or even adults, among the lower classes is a much more serious thing than an attack of chicken-pox, rubeola, or even measles.

2-4. Pulpitis, Gangrene of the Pulp, Pericementitis

Inflammation of the dental pulp, with the exception of the comparatively few cases where the result of trauma or of calcareous formations in the pulp-chamber, erosion, abrasion, etc., is due directly or indirectly to parasitic influences, while gangrene of the pulp can never have any other origin under any circumstances.

Pericementitis apicalis, the form of pericementitis which is most severe and gives rise to the most serious consequences, is likewise of parasitic origin, being produced by germs of their products, or by both together passing from the root-canal through the apical foramen.

That the pain attending a severe case of pulpitis or pericementitis is usually of so intense a character as to make it a very serious matter to the person who has to bear it, is too well known to need any comment. That the sufferer usually receives so little sympathy is to be accounted for by the fact that the direct mortality is almost zero, while the eventual loss of the tooth is often short-sightedly regarded as a matter of little consequence, in consideration of the fact that it is only one of a large number, and may eventually be replaced by a better one of porcelain, which cannot ache.

*Sections II and III of this series will appear in the October and November issues of the Dental Cosmos respectively. -Editor Dental Cosmos.

5. Alveolar Abscess.

Alveolar abscess is an infectious disease, primarily of a local character, but frequently, or usually, accompanied by general symptoms of varying intensity, and sometimes attended by complications of a most serious nature. Severe cases of alveolar abscess, particularly in weak persons, not unfrequently present symptoms of an alarming nature. The extensive oedema, general debility, fever, chills, forcibly suggest the thought of a general infection, which, it must be admitted, is always possible where large masses of pus accumulate about the point of the root. Leaving out of account for the present the more common complications of alveolar abscess, I wish to call particular attention to the many cases in which it has terminated fatally through the supervention of septicaemia or pyaemia.

It must be constantly borne in mind that wherever micro-organisms are accumulated in large masses in any part of the body, the possibility of their being carried to other parts through the blood or lymph-channels, and of their producing, accordingly, metastatic abscesses wherever a point of diminished resistance exists, can never with certainty be excluded. It has been repeatedly observed that most stubborn cases of chronic pyaemia, which have baffled all attempts of physicians either to cure them or to determine their cause, have disappeared on the removal or proper treatment of a diseased tooth. In like manner, general blood-poisoning (septicaemia), with speedily fatal termination, has been seen to result from accumulations of infectious material about the roots of a tooth.

The cases 1-70 of the table, pages 706-709, which I am convinced are but a small proportion of those which have actually occurred, may serve to illustrate this category of infections through alveolar abscess.

6 and 7. Ostitis, Osteomyelitis.

Ostitis and osteomyelitis belong to more common complications of decay of the teeth. Every severe inflammation of the pericementum is naturally accompanied by more or less inflammation of the bone marrow, or of the bone (osteitis), or of both together (osteomyelitis). Severe cases of osteomyelitis, fortunately of comparatively rare occurrence, are of exceedingly doubtful prognosis. Schede (table, 7-14) reports nine cases, of which all but one ended fatally, death resulting from acute or chronic sepsis, or from a spreading of the infection through the floor of the mouth and retrotonsillar tissue into the mediastinum, producing pleuritis, pericarditis, etc., with purulent exudations. In the table many cases of osteomyelitis resulting from diseased


conditions of the teeth or from operations upon them will be found. I refer in particular to No. 1-16, also 71, 76, and 77. It is worthy of remark that these cases occurred, almost without exception, in the lower jaw.

8 and 9. Periostitis and Necrosis.

A slight inflammation of the periosteum of the alveolar process and a slight necrosis of the bone necessarily accompany all abscesses in which the pus makes its way to the surface of the bone; ordinarily, however, the symptoms are of minor importance, and disappear as soon as the pus has discharged through the gums.

Not unfrequently, however, periosteal inflammations resulting from caries are of an exceedingly violent character; intense, continuous pain, often lasting for days, enormous swelling, devility, fever, chills, sometimes terminating fatally, as many cases in dental and medical literature show, through pyaemia or septicaemia, after in intervening stage of phlegmon.

Kohler* observed in two years forty-four cases of periostitis, which in some had led to extensive necrotic destruction. The periostitis proceeded often from diseased roots and quite as often from extractions, which seldom lead to a kind of gangrene of the mouth (gangraena acutissima), and occasionally to general sepsis. "Consequently this little operation must in the future be carried out more in accordance with the fundamental principles of antisepsis than has been the case in the past."

Necrosis is but a more advanced stage of osteomyelitis and periostitis. The bond, deprived of all sources of nutrition, dies (becomes necrotic), and is afterward thrown off by the surrounding tissue in the for of a so-called suquestrum.

Whether the periostitis and necrosis result from a diseased condition of the teeth or of the gums (stomacaca, noma), or accompany certain general diseases (syphilis, scrofula, the exanthemata), or follow upon the incorporation of certain mineral positions (mercury, phosphorus, lead, arsenic), or finally, result from traumatic injuries or impeded eruption of the wisdom-teeth, in many cases the sole agent, and in all an important one in bringing about the disturbance is to be found in the bacteria of the human mouth.

Undoubtedly nearly all the cases given in the table were more or less complicated by periostitis, it being often lost sight of on account of other more serious symptoms. I call attention to Nos. 16-27, 77, 78, and 80-90, from which it will be seen again that the lower jaw is the usual seat of the trouble.

*2Charite Annalen. Jahrg. XIV and XV, 1888-89.

10. Dental Fistulae.

In this connection I refer in particular to those fistulae of dental origin which open on the neck, shoulder, arm, or breast, thus giving rise to so-called "running sores," which of course defy all treatment until the true source is discovered.

Nicolai (table, 56) relates a case where the connection of a chronic fistula on the breast just above the nipple was discovered by the discharge, on the day following a visit to the dentist, smelling like the medicament used by the dentist in treating a badly diseased root. A solution of cochineal injected into the root also made its appearance at the opening of the fistula a few hours later.

11. Septicaemia.

Many cases may be found in medical and dental literature in which a general infection of the blood causing the death of the patient in a few hours has resulted from the accumulation of pus about a diseased tooth or from operations in the mouth. Cases 28-31 and 91, 92 are of this nature. Fracture of the mandibula not unfrequently leads to a general septic infection. Malgaigne saw death result from fracture four times in seventeen cases, Richet twice in ten. Unfortunately, we know absolutely nothing about the specific bacteria present in these different cases, and as far as I know no attempt has ever been made to cultivate them or even to examine the blood and various organs microscopically in any case of septicaemia of dental origin.

12. Pyaemia.

Cases of pyaemia resulting from diseased conditions of the mouth and teeth are of more frequent occurrence than those of septicaemia, and in some respects of greater interest, particularly to the practitioner of medicine.

Chronic pyaemia presents itself in form of abscesses of varying intensity occurring in different parts of the body, healing spontaneously at one point, only to break out again at some other more or less remote. An abscess at the point of the finger or on the toe may originate in a diseased tooth as well as an abscess at the point of the root. The focus of infection maintained by the diseased tooth constantly gives up its virus to the blood or lymph by which it circulates through the system, and, under favorable conditions, establishes itself at any point where, at the time, there may be a diminished vitality, or in other words, a locus minoris resistentiae. In all cases of chronic pyaemia a thorough inspection of the oral cavity should be made by a dentist or a physician whose education in regard to oral pathology has not been so entirely neglected as heretofore has usually been the case.


A number of cases of pyaemia of dental origin will be found in the table, Nos. 32-47,75, 90, 93, etc.

13. Meningitis, Encephalitis, Abscess of the Brain, etc.

It may at first thought not appear quite clear how an inflammation of the brain or its membranes, abscess of the brain, etc., may be brought about by carious teeth. A superficial examination of the relations of the teeth to the cavity of the skull will, however, show us that an inflammatory process incited by the teeth of the upper jaw may reach the brain cavity either through the maxillary sinus, nasal cavity, and cribriform plate of ethmoid bone (or directly through the nasal cavity and ethmoid), or through the pterygoid fossa and foramina at the base of the skull, or by way of the spheno-maxillary fossa, inferior sphenoidal fissure, orbit, etc. Inflammatory processes in the lower jaw ascending the ramus usually obtain entrance to the skull cavity by way of the orbit, less frequently, it seems, through the pterygoid fossa. Septic meningitis may be produced by germs obtaining entrance to the blood through wounds or abscesses and lodging at some weak point on the brain, while the possibility has been suggested that the micrococcus of sputum septicaemia may enter the blood through the lungs without the intermediary stage of pneumonia. Finally, inasmuch as croupous pneumonia is caused by a mouth-germ, so must the metastatic meningitis of pneumonia be looked upon as the work of a mouth-germ. Cases will be found in the table, Nos. 47-49, 54, 55, 64, 96-101, 117, 119, etc.

14. Impeded Eruption of Wisdom-Teeth.

The chronic state of irritation upon the gums and periosteum resulting from impacted wisdom-teeth, and the consequent state of diminished resistance, make it possible for micro-organisms; which obtain entrance between the crown of the tooth and the overlapping gums (assisted as they so frequently are by the irritating action of small particles of food undergoing fermentation), to multiply in large numbers and, penetrating along the curse of the distal root into the depths of the jaw, to bring about the series of disturbances, ostitis, osteomyelitis, periostitis, phlegmon, trismus, and in some cases necrosis or even septicaemia. It is one of the many cases where bacteria which may be present in the mouth without leading to any disastrous results as long as the soft tissues are in perfectly healthy condition, never allow any opportunity presented by the diminished resistance of the tissue to escape their notice. (See table, 117-120.)

15. Pyorrhea Alveolaris.

There are many reasons for believing that pyorrhea alveolaris has


an origin similar to that of the suppurative processes associated with the impeded eruption of the lower wisdom-teeth. A predisposing cause which may be in part general and in part local sufficiently impairs the resistance to allow the pyogenic bacteria of the mouth to fain a footing. This view, which I have maintained for years, was supported by Galippe in a paper read before the dental section of the International Medical Congress, 1890. He found chiefly streptococci in all cases of pyorrhea alveolaris recently examined.

The evil results of allowing this disease to gain the upper hand manifest themselves not only in the impairing or complete loss of the efficiency of the teeth as organs of mastication, but also, as has been expressed by Galippe, when a secretion of matter in the mouth becomes general patients may suffer from fever, loss of appetite, stiffness, severe disturbances of the alimentary canal, insomnia, subictoritic discoloration of the skin, etc.

16. Disturbances in the Alimentary Tract.

The mouth, as has been sufficiently well established, furnishes one of the chief sources for the constant recruiting of the bacteria of the stomach and intestines. Not only this, but the constant swallowing of decomposing matter and of pus from an improperly cared for mouth may lead to the most serious disturbances, both acute and chronic. Particularly where a chemical or mechanical insufficiency of the stomach exists, the digestive process, and consequently the general health of the patient, is sure to suffer severely when the care of the mouth is neglected. We have known patients under treatment for troubles of the digestive tract to most scrupulously sterilize all articles of diet and then pass them through a mouth seldom visited by a tooth-brush, thereby incorporating with them millions of bacteria. In all troubles of the digestive tract, too much care cannot be bestowed upon the antisepsis of the mouth.

17. Diseases of the Lungs.

a. Croupous Pneumonia.
The uniform results obtained by investigators on the subject of pneumonia for the last five years leave little room for doubt that the cause of this important disease is to be sought for in a species or group of micro-organisms which are constantly present in the sputum of persons suffering from pneumonia, and very frequently even in the saliva of quite healthy people. This micro-organism, or group of micro-organisms, will be discussed at length later on. At present I wish


to emphasize only the fact that pneumonia owes its origin to a mouth bacterium.

Furthermore, there is much reason in the arguments of Meltzer,* who claims that it is impossible for micro-organisms from the air to obtain direct entrance into the alveoli of the lungs through the air passages with their numerous crooks and turns; that they first lodge in the mouth or pharynx, from which they may, by a strong inspiration, be carried with particles of mucus into the broncheoli, to be then finally driven into the alveoli through the pressure of the air in the broncheoli during the middle phase of the act of coughing. This view is supported by the fact, as shown by the investigations of Hildebrandt,** that the trachea, bronchi, etc., of healthy animals contain no living germs. Hildebrandt, moreover, came to the conclusion, after a series of very careful experiments, that by far the greater part of the bacteria of the air lodge in the mouth, nose, or throat, and that under ordinary circumstances these cavities furnish an almost perfect filter for the air. Again, it is highly improbable that the number of germs inhaled at any one time would be sufficiently great to maintain themselves in the human lungs without having undergone at least a temporary stay in the mouth, which serves as their recruiting- or breeding place.

Furthermore, the micrococcus of pneumonia not only does not proliferate at the ordinary temperature of the air, but, what is of still greater importance, soon loses its virulence when cultivated out of the body even under the most favorable conditions, which is still another potent reason for the supposition that in pneumonia the mouth and not the air is the direct source of the infection.

b.Gangrene of the Lungs.
Bonome*** examined seven cases of gangrene of the lungs, and found in all seven the pyogenic staphylococci,-Staphylococcus pyogenes aureus and albus. He concludes that the necrosis of the lung tissue is due to these micro-organisms alone, whereas the putrefactive processes are brought about by any ordinary saprophytic bacteria which may obtain entrance to the necrosed parts. The former are frequent, the latter constant inhabitants of the oral cavity, and the probablilty that the invasion takes place from the mouth is at least very great. Positive evidence in support of this supposition was furnished by

*Uber die mechanischen Verhaltnisse bei der Entstehung der Pneumonie. (Med. Monatsschr., Feb. 1889)
**Beitrage zur pathol. Anatomie u. Physiologie von Ziegler und Nauwerck. Bd.II,1888, S. 143.
***Giornale della R. Accademia di Medicina, 1886, No. 7.

Leyden and Jaffe, who found in putrid sputum micro-organisms which hitherto have never been met except in the oral cavity. The relation of mouth-germs to actinomycosis of the lungs will receive consideration later on.

18. Infiltration of the Surrounding Tissue and Chronic Swelling of the Lymphatic Glands in the Region of the Lower Jaw and Neck.

The causal relation of a diseased condition of the teeth to this affection has been clearly enough established by Odenthal*,who found glandular swellings in ninety-nine per cent of all children who suffered from badly decayed teeth, and only in forty-nine per cent of those with sound teeth. We are not so much surprised at this result, inasmuch as every practitioner must have repeatedly observed marked swelling and soreness of the glands of the neck concomitant with pericementitis of the lower bicuspids and molars.

19. The Infectious Anginae (Tonsillitis, Amygdalitis Infectiosa, etc.)

It is now commonly recognized that the tonsils may harbor various pathogenic bacteria in their lacunae without any appreciable evil consequences, until, through some cause or another, which may be of a very trivial nature, their action manifests itself either in form of a local or general infection. Particularly tonsils which are chronically inflamed, hypertrophied, are dangerous accumulators of pathogenic germs, and for this reason Bouchard** recommends their destruction by ignipuncture, while von Hoffmann*** obliterates the lacunae by tearing with a blunt hook through the bridges connecting the neighboring lobes of the tonsils. He thereby not only destroys the recesses which so often contain masses of pus, bacteria, etc., in a state of putrefacation, but also produces a marked contraction of the hypertrophied gland. This operation is recommended as a prophylactic measure of great importance against diphtheria.

A. Frankel++ gives an account of two cases of severe septic infection proceeding from the organs of the throat. In the first case the disease began with a diphtheritic affection of the tonsils, and resulted in a retropharyngeal phlegmon, pericarditis, and pleuritis. In the pericardium he found a liter of pus, in the right pleural cavity extensive purulent, and in the left, sero-fibrous exudations. Cyanosis and dyspnoea were present. Heubner and Bahrdt reported similar cases in 1884.

*Inaugural Dissertation. Bonn, 1887.
**Therapie des maladies infectieuses, p. 256.
***Theurapeutische Monatshefte, October, 1889, p. 441.
++Deutsche Med. Wochenschr., 1887, No. 15, p. 553.


In the second case before mentioned, there developed endocarditis ulcerosa, broncho-pneumonia, cloudy swelling of the kidney, infarction of the spleen. The tissues of both tonsils were infiltrated with sero-purulent matter, septic infection proceeding from the organs of the throat by means of staphylococci.

Furbringer, in the discussion on Frankel's cases, calls attention to the many cases where one is obliged to write "unknown mykosis," and records (1) a case of sepsis following upon a swelling of one of the tonsils; (2) a case of sepsis resulting from carious teeth (on the right and left side, respectively, one carious lower tooth), first giving rise to inflammation of the subgingival connective tissue, periostitis, and phlegmon; (3) a case of endocarditis ulcerosa and embolic meningitis resulting from a suppurating tonsil.

Apolant records a case of pyaemia, and Leyden a case of retropharyngeal abscess resulting from sore throat. Numerous cases have been recently reported before the Societe Medicale des Hopitaux.

Among others, MM. Fereol et Rendu* report cases of phlegmon of the cellular tissue surrounding the larynx and oesophagus, followed by respiratory and cardiac troubles. Fereol** also reports a case of amygdalitis resulting fatally in five days through the supervention of a general in five days through the supervention of a general infection. This case was characterized by a hiccough lasting through the whole sickness.

The authors just named demand that the most scrupulous attention be paid to troubles of the organs of the throat, even when they are of most trivial appearance.

Little is known as to the specific micro-organisms concerned in these cases. Bouchard++ found enormous numbers of small bacteria in a case of phlegmonous amygdalitis. Cornil|| found streptococci in a case of abscess of the tonsils.

20.Angina Ludovici

Presents itself as an inflammation of the cellular tissue beneath the lower jaw, giving rise to an exceedingly hard swelling, which may extend from the border of the lower jaw to the sternum. It may terminate fatally, either through oedema of the glottis, or, when suppuration takes place, through general sepsis. Under the name of Angina Ludovici, writes Tissier++, we understand an infectious septic process, characterized by an induration with a tendency to gangrene,

*Annales de Medicine, Mai 27, 1891
**Journal des Connaissances Medicales, 1891 +Vid. David, Les Microbes de la Bouche, p.170. || Cornil et Babes, Les Bacteries.
++ Progres medical, 1886, p. 514.

always appearing under the same symptoms, resulting from a primary lesion of the mouth, which serves as point of enterance to the germs. Sufficient evidence has been accumulated* to render it highly probable that this severe, though rare affection, is the result of the invasion of micro-organisms through slight wounds, ulcerations, or other breaks in the continuity of the mucous membrane, or by way of diseased teeth, or of the tonsils, or of the ducts of the sublingual and submaxillary glands.

21. Diseases of the Maxillary Sinus

are of such frequent occurrence that every practitioner must have seen one or more cases. It is not necessary to refer to the fact that they are in the vast majority of cases, the result of the action of mouth bacteria. Complications of these troubles which require particular mention are diseases of the nasal cavity, chronic catarrh of the frontal sinuses with constant flow of offensive mucus, spreading of the affection to the orbit and hence to the brain, resulting in abscess of the orbit, abscess of the brain, meningitis. (Cases 49,52,65,114.)

22.Pneumococcus Abscesses.

It has been well established that the so-called pneumococcus possesses invasive properties of the highest order, so that there is hardly any part or organ of the human body which may not fall prey to its action.

Leaving out of account the croupous pneumonia and its sequels, such as pleuritis, pericarditis, oedema, emphysema, embolic meningitis, etc., we may mention here perotitis, mulitple subcutaneous abscesses,+ tonsillitis,++ otitis media, abscesses of the mastoid process,|| peritonitis and meningitis (independent of pneumonia), etc. In such cases the coccus is transported from the mouth to other parts of the body through the blood or lymphatics, or as is often the case in otitis, meningitis, etc., by a direct spreading of the affection from the mouth to the neighboring cavities. The possibility has also been suggested of the pneumococcus obtaining entrance to the blood through the lungs and giving rise to a primary peritonitis, endocarditis, meningitis, etc., without the intervening stage of pneumonia.

*Chantimesse et Vidal (v.David, Microbes de la Bouche, p. 173)
+Testi, Riforma medica, 1889, Nos. 281 and 282.
++Gabbi, Lo Sperimentale, 1889, fasc. 4.
||Zanfal, Prager Med. Wochenschr., 1889, Nos. 6, 12, 15, and 36; Netter, Compt. rend. hebd. des seances de la soc. de biol., 1889, p.305.

23. Disturbances resulting from the Absorption of Products of Putrefacation through the Mucous Membrane of the Mouth.

In persons of uncleanly habits, who neglect the care of the mouth, and especially who allow rubber plates to remain in the oral cavity for weeks together, constantly covered with a thick coating of putrefying mucus and food, loss of appetite, nausea, vomiting, and chronic indigestion may result from the prolonged action of the products of decomposition upon the mucous membrane of the mouth and pharynx.

24. Stomatitis Ulcerosa (S. Scorbutica, S. Mercurialis).

These are nothing more or less than the result of the invasion of pyogenic and saprophytic bacteria of the mouth upon a tissue which has already suffered a severe diminution in its powers of resistance through the general primary affection. There can be no doubt that the intense suppurative and putrefactive processes of ten appearing in advanced stages of these diseases are not the result of the action of the mercury or of the general condition known as scorbutus, these serving only to deprive the tissue of its normal power of resistance and so to prepare it for the invasion of the ever-present bacteria. This view, if I have not misinterpreted him, has already been expressed by Galippe. The name is to a certain extent true of stomatitis diphtheritica, which seldom attacks the normal, healthy mucous membrane of the mouth, as well as of the stomatitis syphilitica, frequently met with in old cases of latent or "cured" syphilis.

25. Actinomycosis.

This disease is of so frequent occurrence and its connection with the mouth so apparent, that it requires only to be mentioned to carry with it an argument for a more commensurate estimation of the importance of careful attention to the hygiene of the mouth. Of two hundred and three cases reported in German medical literature of the last five years, the point of entrance was found to be in the region of the mouth and throat one hundred and twenty times, not including the cases of actinomycosis of the intestines, where also the fungus most probably entered through the mouth. In nine cases the point of entrance was doubtful, and in the remaining seventy-four it was outside of the mouth. How often the infection took place directly from the air or through the food, and how often through germs which had established themselves in the mouth, cannot be determined from the reports. Actinomycosis threads and glands have by various observers been repeatedly found in the saliva as well as in carious teeth, and in the


lacunae of the tonsils. Most frequently, carious teeth are brought into causal connection with the invasion, then slight wounds on the mucous membrane, colonization of the fungus in the tonsils, etc. Imminger*, who examined over one hundred cases of actinomycosis bovis yearly, found the invasion to take place almost invariably from the tonsils.

26. Noma,

although a disease of comparatively rare occurrence,+ excites particular interest on account of the fearful ravages which it produces and the rapidity with which it advances, so that in the space of three or four days the whole cheek, nose, eyelids, mucous membrane of the jaw and soft palate may be transformed into a necrosed, putrefying mass. Whereas the majority of older writers on the subject of noma look upon this disease either as a trophoneurosis, or as a necrosis similar in its origin to the decubital ulcers of the throat, the majority of recent investigators are inclined to attribute the chief role to certain micro-organisms. Froriep++ appears to have been the first to call in the aid of a living agency in the form of appearances resembling yeast-fungi, which he found in noma. After him, Strueh|| describes what he calls noma pilz, while Ranke# found masses of bacteria, almost all cocci, and Cornil et Babes## found short chains of micrococci, either free or in soogloea.

Schimmelbosch**, to whom I am indebted for some of the above notes, found apparently a pure culture of bacilli on the border of the sound tissue, which he succeeded in cultivating upon artificial media.

Small pieces of necrotic tissue implanted under the skin of the neck of two rabbits caused abscesses, one as large as a cherry, the other three times as large, but no necrosis developed,-a result similar to that obtained by Ranke. Inoculation of rabbits with pure cultures caused oedematous swellings on the conjunctiva, in one case deratitis, in another panophthalmitis. Mice and doves proved immune; two hens showed circumscript necrosis which healed inside of three weeks.

*Adam's Thierarztliche Wochenschr., 1888, No. 18.
+V.Bruns (Die Chirurgische Pathologie und Therapie der Kau- und Geschmacks-Organe, 1859, Bd.I)collected four hundred and thirteen cases out of the English, French, German, and Dutch literature.
++Chirugische Rupfertafeln, 1884.
||Ueber Noma und deren Pilze. Inaug. Dissert., Gottingen, 1872.
#Jahrbuch f. Kinderheilkunde, 1880.
##Lec Bacteries, second ed., p. 394.
**Deutsche Med. Wochenschr., 1889, No. 26.

Likewise, Grawitz* found bacilli in nearly pure culture. The appearance was described by Loeffler+ as similar to that seen in diphtheria of calves.

27. Pharyngomycosis (Mycosis Tonsillaris Benigna)

An infection caused by a proliferation of saprophytic bacteria in the lacunae of the tonsils.

28. Stomatomycosis,

caused by the colonization of sarcina on the mucous membrane of the cheeks, and


the well-known disease caused by the invasion of a yeast-fungus, Saccharomyces albicans. These are all troubles of undoubted parasitic nature, while as to

(30) Stomacace, (31) Aphthae, (32) Herpes Labialis, opinions are still divided.

33. Inflammation and Suppuration

of the salivary glands, in particular of the parotitis, must also be mentioned as troubles which in many cases owe their origin to mouth-bacteria which find their way through the ducts to the body of the gland.

Of diseases of a general nature with a localization in the human mouth, we notice briefly

(34) Diphtheria,

which may occur primarily in the mouth chiefly after wounds of the mucous membrane (extractions, etc.), or secondarily, the disease beginning in the throat and spreading into the mouth.

The unanimous results of nearly all investigators of the last two or three years have established the Klebs-Loeffler bacillus almost beyond all doubt as the cause, or one of the chief causes, of diphtheria. It is not at all clear, however, in just what manner the bacillus obtains a footing in the mouth or throat. Whether a chance germ from the air lodging upon the mucous membrane of the throat is sufficient to

* Ibid., 1890, No. 15.

call forth an attack of diphtheria, or whether such germ only under certain predisposing conditions is able to proliferate in sufficient numbers to excite the disease, or whether, finally, the human mouth and throat in particular may harbor the diphtheritic bacilli under normal conditions until the proper moment arises for them to assert their specific action, these are questions awaiting solution. The fact that an attack of diphtheria may be provoked by slight wounds in the mouth, or by the presence of diseased teeth, and the fact that the extirpation of the tonsils has proved to be one of the most successful prophylactic measures against diphtheria, seem to point to the conclusion that the last-mentioned condition is at all events highly probable.


Many cases are on record in which primary tuberculosis of the mouth has made its first appearance around diseased teeth or roots or teeth, or following extractions and other operations in the mouth. Whether or not the bacillus of tuberculosis can exist in the mouths of non-tubercular persons for any length of time is again uncertain. Examinations of the normal saliva have given only negative results, but too much importance should not be attached to this fact, since it is sometimes necessary to examine the saliva even of consumptives repeatedly before finding tubercle-bacilli. A case has been reported where fifty-nine examinations resulted negatively, while the sixtieth disclosed the long-sought-for bacilli. At all events, there is no danger of erring when we assert that the care of the mouth is to be considered as an important factor in the prophylaxis of tuberculosis also.

36. Syphilis.

The question of syphilitic infection through dental operations (extraction, filling), through unclean rubber-dam, instruments, drinking glasses, through kisses, transplantation of teeth, bites, etc., has been so frequently discussed in dental periodicals, and must be so familiar, that a simple statistical inquiry into the question will suffice to show the importance of exceeding great care on the part of the dentist to prevent transmitting the disease to innocent patients. A few cases are presented in the table, Nos. 121-141. Anyone desirous of accumulating more will have no difficulty in finding them. Cases in which syphilis has been communicated by tooth-wounds, bites, slight wounds with instruments wet with saliva, as well as cases where the operator has been infected by syphilitic patients, must be counted by the hundreds.


37.Infections following Operations in the Mouth.

In recent years the demand for the adoption by dental surgeons of the same antiseptic measures observed by the general surgeon has constantly become more and more imperative. Attention has been repeatedly called to the fact that bloody operations in the mouth, such as tooth-extractions, performed, as too many of them are, without the slightest regard to the principle of asepsis, often lead to infections of serious nature, which might have been easily avoided; not only that, but carelessness in regard to cleansing the instruments after every operation frequently results in the communication of disease from one individual to another. The following table (No. 71 et seq.) speaks for itself. It is only necessary to remark that the cases here cited form but a small proportion of those which have occurred, as every practitioner under whose hands such an infection results will naturally take all possible measures to prevent its becoming public.

38. Infections resulting from Wounds with Dental Instruments.

Numerous cases have recently been brought to light in which slight wounds upon the hand inflicted by instruments used in operations upon the teeth, also scratches of the fingers on sharp roots, have resulted in infections of a most serious nature.

To the same category belong infections received through kisses, blows upon the teeth, bites, etc., of which a few only are given below. (Table, Nos. 143-148.)

Stomatitis Epidemica.
Foot and Mouth Disease in Man.

Cases have been reported from time to time in the medical journals, in which foot and mouth disease has been communicated to man from domestic animals, particularly by contact with cows, through milk, butter, etc.

These cases are of a mild nature, exhibiting themselves chiefly in the form of vesicles on the mucous membrane of the mouth, more or less swelling of the gums, etc., but seldom manifesting severe general symptoms.

Under the above title, however, I wish to refer to an affection of a more serious nature, which, as will be shown, in all probability has the same origin as the foot and mouth disease in cattle, but which, being communicated directly from man to man, becomes more virulent than when communicated from cow to man, the relation presumably being the same as that between variola and varioloid.


The epidemic referred to occurred in one of the suburbs of Berlin, a district having a population of nine thousand persons, of which over six thousand have suffered from the disease in the last eighteen months. Through the kindness of Dr. Siegel, I have been able to make a few observations on the disease, which he himself will soon describe in full in the Deutsche Med. Wochenschrift.

The disease first presents itself in the form of dizziness, faintness, and not unfrequently repeated swoons. The face of the patient presents a serio-comic expression, similar to the risus sardonicus of tetanus; skin pale, eyes watering, neck stiff, partial trismus, partial paralysis of the tongue, the patients whom I saw being unable to protrude the tip of the tongue more than one-fourth to one-half inch beyond the teeth. One, two, or three days later vesicles appear on the lips, tongue, and in the nostrils; these break open, giving rise to ulcerating surfaces; their contents are serous or often bloody. The gums swell, and in neglected cases putrefacation sets in, the teeth become loose and fall out, the fetor of the breath is intense. In severe cases bleeding from the mouth, stomach, intestines, bloody faeces, bloody urine, albuminuria, intense swelling of the liver, clouding of the lens, and blindness are frequent accompaniments or results of the disease. In some thirty cases the disease ended fatally, and in many more it assumed a chronic form, nearly or completely incapacitating the patients for all kinds of labor.

Dr. Siegel has found in the organs (liver, kidneys, spleen, etc) of all cases (eight in number) where he made the autopsy a micro-organism which he has succeeded in cultivating, and which, injected subcutaneously, causes in goats, calves, and pigs the symptoms characteristic of foot and mouth disease; sections showing again the same mirco-organism as found in the tissues of the human subject.

The disease is supposed to have spread chiefly through the beer saloons, where little attention is paid to cleansing the glasses between drinks. Bad hygenic conditions in most of the houses also favor the spreading of the epidemic.

As clearly indicated, the following table by no means presents a complete list of the cases which have been reported. Only within the last few days a number of new cases have come to my notice. There are many deficiencies in the table which might in part have been eliminated if I could have found the necessary time. The majority of them, however, are due to the meagerness of many of the reports in regard to details in the occupation, previous condition of the patient, the course of the disease, treatment, etc.

Article continues with Tables.
Data Entry: EMM.

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Date last edited: May 12, 1999.