Radical Treatment of Local Foci of Infection or Toxic Absorption
When discussing the etiology of gout we emphasised the probability of the intrusion of an infective element in its genesis. We commented, too, on the extreme frequency with which local infective foci are encountered in gouty subjects and the imperative necessity of their early recognition and radical treatment. In doing so, we but conform to what should be regarded as the salient canon in the treatment of any form of arthritis, viz., a diligent search for a focus of infection. A monarticular arthritis, such as gout in its initial outbreaks almost invariably is, calls for the same painstaking investigation as a polyarticular, for one never knows when the former may merge into the latter. Nor, if we find one focus, should we rest content, assuming that this is the only one of significance. For in many instances there are probably several foci. Thus, how frequently are septic teeth conjoined with tonsillar and aural troubles, and, as modern investigation shows, these, again, may be associated with remote foci in gall bladder, appendix, etc.
To begin with, a thorough examination of the mouth and nasopharynx is essential. During the inspection any artificial dentures must be removed, lest we overlook concealed and septic stumps. “Bridges,” again, are a notable source of sepsis. The roots upon which they are fixed or the related gums may be infected. Phlebitis, as we know, is a common associate of gout, and C. A. Clark, emphasising the septic potentialities of bridges, cites an obstinate case of phlebitis which only cleared up after removal of a filthy device of this nature.
Again, devitalised teeth that have been “crowned” should always be suspect. Infection at the root is common, with abscess formation. Such are not necessarily painful, and may give no indication of their presence until they find an exit of discharge, maybe by a gumboil or viâ the antrum, etc. These abscesses around the apices of non-vital teeth are difficult of diagnosis in their early stages. Even the X-rays may fail to detect them when minute, this owing to the small amount of pus, or because abstraction of the lime salts from the bone has not proceeded to an extent that may be appreciable by skiagraphy. The first indication of their presence is a small area of rarefaction in the bone around the apex of the root.
It is important to recognise that teeth that appear sound upon external examination are not necessarily so. In short, ordinary clinical examination may be quite inadequate. Not only must the condition of the “crowns” of the teeth, but that of their roots also, be ascertained. For when we reflect that, in addition to abscesses, cysts, buried roots, inflamed and impacted molars may be present, we see, if we are to achieve a full and accurate diagnosis, radiographs of the jaws are essential. A single-plate negative is practically of no value. A series of films taken all round the mouth is the only satisfactory procedure. Such give finer detail, and show up the interstices of the teeth—the sites of predilection for periodontal disease or pyorrhœa alveolaris.
Passing to pyorrhœa alveolaris, which has been defined as the twentieth century scourge, it cannot be denied that if all the evils attributed thereto are to be nipped in the bud, then X-ray examination of the teeth must be resorted to at a much earlier stage than it commonly is. Clean as well as unclean mouths fall a prey thereto, and, as a rule, investigation of the teeth is an after-thought, this particularly in the subjects of gouty arthritis. Usually the gout has been in full swing for years. The patient’s dyspeptic symptoms have been dismissed as “gouty,” and “alkaline stomachics,” etc., have been his lot, though his teeth may be in a foul condition—one which would not have been tolerated probably in any form of arthritis other than “gouty.”
But if to diagnose pyorrhœa alveolaris in its early stages we must needs invoke radiography, on the other hand we should be careful not to overlook its presence when advanced. The gums may be pale and shrunken, at other times red and swollen and very prone to bleed. When pockets form round the teeth, pus and blood may be expressed. Probing may not reveal their true depth, whereas X-rays do.
Sometimes only one or two teeth are affected, at other times many, and these not necessarily adjacent to each other. Thus it happens that the disease is more advanced at one part of the mouth than at another. Exacerbations frequently occur—a blessing in disguise. The affected teeth become tender to bite on and loose in their sockets, but often pain lessens, and the tooth again tightens up, and the all-necessary visit to the dentist is again and again postponed. Sometimes abscesses form, which discharge into the peridental pockets. Eventually the teeth may drop out almost painlessly. Herein resides the danger of the condition, its relative painlessness. Hence the ease with which secondary infections may ensue, e.g., in the tonsils, the gastrointestinal tract, etc., while the original source may be altogether overlooked.
The subjects of gout are often middle-aged or old. We should recollect then that chronic periodontitis may in their instance ensue in sequence to senile atrophy of the alveolus. Recently in a patient of mine nearly eighty, a sufferer from gout and sciatica, a persistent pyrexia, of apparently cryptic origin, forthwith ceased after extraction of his teeth. He lived some considerable time afterwards, but I often regret that his septic teeth had not been drawn long before.
Unfortunately no specific germ can as yet be saddled with the responsibility for pyorrhœa alveolaris, though some would convict the endamœba buccalis. Spirillæ and staphylococci form a large proportion of the bacterial flora met with in oral sepsis, but the results of vaccine treatment would seem to indicate that streptococci, diplococci, and staphylococci are the most frequent causes of complications. Still it must not be forgotten that the streptococcus viridans is by some held to be specially related to arthritis. Hartzell (1915) invariably found it in the teeth and peridental tissues in 220 patients suffering from arthritis. This streptococcus hæmolyticus frequently leads to secondary tonsillar sepsis, and, as previously noticed, to subsequent gall bladder infection, etc.
Passing to local treatment, if oral sepsis or pyorrhœa alveolaris exists, carious teeth when present should be extracted, or their cavities cleansed and filled. Accumulations of tartar should be removed, and unhealthy gums attended to. Thus “pockets” should be swabbed, syringed, or subjected to ionisation. Exacerbations frequently follow the extraction of teeth. Acute paroxysms of gout have followed this simple operation. In cases where the extraction of many teeth is called for, it should be preceded by as thorough a cleansing of the mouth as can be assured. It is a matter of common experience that severe exacerbations of arthritis follow neglect of this precaution, owing to the enhanced toxic absorption from the extensive raw surface.
Unquestionably, whether it be a matter of curettage, of “pockets,” alveolar abscesses, or extraction of teeth, it is wiser to proceed gradatim. Hartzell, when many septic foci exist in the gums and teeth, allows three to six days to intervene between “treatments,” this in order to gain full advantage of what may be called surgical auto-inoculation. For, as he contends, any local measures, curettage, etc., necessarily involve inoculation of the subject with a large number of organisms, thus producing an effect similar to that of an efficient vaccine, “with the added advantage that the constant supply is shut off from the focus disturbed.”
Recurring attacks of tonsillitis—well-recognised determinants of gouty outbreaks—demand thorough local treatment. If this fail, the propriety of removing the tonsils will call for consideration. But, as tonsils may be very misleading in appearance, the aid of an expert is often indispensable. Thus the worst types of tonsillar sepsis may exist in the small “buried” tonsil. In such cases the indications for enucleation are the more emphatic when we note the increasing evidence that tonsillar sepsis may be etiologically related to appendicitis or cholecystitis.
Again, as before pointed out, Wynn Wirgman noted that some cases of gout are associated with nasal disorder, and certainly in non-gouty forms of arthritis expert treatment has reacted very beneficially on the joint condition. Watson Williams has recently drawn attention to “latent sinusitis” as a cause of systemic infections. He cites two cases of chronic rheumatoid arthritis which, previously resistant to treatment, were greatly improved by operation on the sphenoidal sinuses. The washings from the sinuses were free from pus, but on culture showed growths, in the one case of streptococcus albus and in the other of streptococcus aureus and streptococcus brevis.
Needless to say, the genito-urinary tract should be carefully investigated, especially in polyarticular gout, or monarticular when located in unusual articular sites, this if only to eliminate the possibility of a latent gonococcal infection. Apart from this, we should recollect that cystitis is common in gouty subjects, and, according to older authors, might occur as a result of “metastasis,” not to mention the cases of so-called “gouty” urethritis, which, it is claimed, not uncommonly supervenes at the end of an articular attack of gout. Nor should we forget the rectum, for hæmorrhoids are not uncommon in these subjects. Years ago Garrod noted that the cessation of a habitual hæmorrhoidal discharge frequently proved the signal for an outbreak of gout. Moreover, there is increasing evidence that rectal ulcerations may be causally related to some forms of arthritis.
When all the foregoing regions have been thoroughly investigated the lower levels of the gastro-intestinal tract must be thoroughly examined by all modern methods. Diminution, absence, or excess of free HCL may call for determination, while X-ray studies may afford us an explanation of dyspeptic symptoms. Lastly, the urine and fæces may call for exhaustive investigation.
In conclusion, however, if there be any local focus of infection so situated as to admit of radical measures, these should be undertaken prior to resorting to vaccine therapy.
But, obviously for the success of vaccine therapy, it is essential that an accurate bacteriological diagnosis of the case under consideration be accomplished, which of course is comparatively easy if we are able to isolate the particular organism by direct cultural experiment. To this end cultures should be made from the roots of extracted teeth, the gums, tonsils, or nasal or other discharges. Albeit, we must never be content to select haphazard any organism that we may isolate from the patient’s mouth, nose, urine, fæces, or elsewhere. Doubtless the true clue will lie in the institution of complement fixation tests for the organisms responsible for local infections. Research to this end is now in course of progress at the Royal Mineral Water Hospital, Bath, for it is becoming increasingly clear that nothing short of “team-” work will suffice for the full elucidation of the “gouty” and the non-gouty arthritides.