Columbia Hnibergitp in tte Citp of i^eio gorfe B>d}ml of Cental anb C^ral ^urgcrp H^eference Eiftrarp Jp: 4tUJu V. ^MjctL CHANCRE OF LI P (Take t! from SaunJfrs' Hand Atlas) SYPHILIS IN DENTISTRY BY L. BLAKE BALDWIN, M. D. CHICAGO, ILL. Professor of Dermntologv and Venereal Diseases, Post-OraduaU Medical School; Professor Clinical Dermatology, Medical Department, University of Illinois {College of P. and S.) ; Attendiiig Dermatologist to Cook County Hospital and the Provident Hospital; Presi- dent of the Samaritan Hospital; Fel- low Chicago Academy of Medi- cine; Etc., Etc., Etc., Etc. EZRA READ EARNED, M. D. CHICAGO, ILL. American Association for the Advancement of Science; Chicago Academy of Science; American Medical Associa- tion; Illinois State Medical Society; Chicago Medical Society, Etc. CHICAGO H. COLEGROVE 1903 Copyrighted BY L. BLAKE BALDWIN 1903 "To our brothers in arms;', the memhers of the dental profession, this book is respectfully dedicated, witli the earnest hope that it may help in the recognition and alleviation of one of the gravest diseases of mankind. Digitized by tine Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/syphilisindentisOObald CONTENTS. Part I. Part II. Part III. Part IV. Part V. Part VI. Part VII. Part VIII. Part IX. Part X. Part XI. Part XII. Part XIII. PAGE Introduction - - - - 7 Historical - - - - 15 Nomenclature - - - 21 Bacteriology - - - 27 Infection - - - - 35 The Initial Lesion and Pathology 49 Secondary Manifestations - 63 Mucous Patches - - - 75 Tertiary Syphilis - - 85 Interstitial Gingivitis - - 95 Differenial Diagnosis - - 101 Illustrative Cases - - - 107 Medico-Legal Aspects - - 117 SYPHILIS IN DENTISTRY. PART 1. INTRODUCTION. In many brancliesi of medical science, progress and advancement have been great — the achievementsi in the depart- ments of surgery and bacteriology have out-rivaled the dreams of the enthusiast of a few years ago, but very much remains to be done. Every progressive man should take a part in unraveling the many mys- teries in medicine and its allied sciences. The modern dentist, as well as the physi- cian, must be "up-to-date," if it is his ambi- tion to remain in the front rank of his pro- fession. The authors believe that dentists have nearly as much to do with the recognition and prevention of syphilis as have physi- cians and surgeons, and propose that this work shall call the attention of those prac- 7 8 SYPHILIS IN DENTISTRY. ticing dental surgery to their opportun- ities and responsibilities. "The deaths, sufferings and expense due to syphilis are incomprehensible and appalling, and the rotting poison is still working ruin in every city, village and hospital in the land, creating the inevit- able impotence, paralysis and death which so surely follow in its train." "Ignorance of the law does not excuse." How culpable, then, is he who shall even unwittingly infect an innocent human be- ing with this dreadful disease, and how derelict in his duty is he who shall fail in detecting the disease in others who may come to him for advice and assistance. Dentists, as a class, give very little con- sideration to this very important subject, but they should give it the most careful study, as we shall endeavor to point out. They should recognize the mouth le- sions of syjihilis, so that they can guard against infecting themselves, and so that they may not infect others, by instruments used in a syphilitic mouth. If they do not recognize syphilis in a patient's mouth, how many people may INTRODUCTION. 9 they expose before some one else diagnoses the condition for tbem, and calls a halt in the deadly work? To briefly point out the prevalence of syphilis in the mouth, etc., let us call yoTir attention to the following facts: — Fournier collected 1,124 cases of extra- genital chancre, of which 847 cases were in the region of the head, most of them located about the lips. Bulkley gives a total of 9,058 extra- genital infections, and the site of the tonsil is sixth in frequeiDGif. The tonsils and throat together are given as the site of 571 cases, which place the throat as fourth in frequeneif, being exceeded only by the lips, breast and nipples. Kyle says that next to the genitalia, the tonsil and pharynx are the most frequent sites for the primary lesion. Many cases of chancre of the tonsil are overlooked, for they have little resem- blance to cancers which occur on the genitals. The source of syphilis in the mouth is varied: kissing, infected utensils, the pipe or cigar, and dental instruments, convey the infection. 10 SYPHILIS IN DENTISTEY. The diagnosis of secondary and tertiary syphilis of the throat is easy, but that of primary involvement is difficult. Many case histories illustrative of these facts could be presented here, but experi- ence has shown that the syphilitics coming under the dentist's care are not those .suffering from extra-genital ,chancre, but those presenting mucous patches, com- monly known as smokers' patches, which resemble, in some cases, ulcerative stom- atitis. In these patches lie the danger to the dentist and his patients. (1) They are as infectious as the initial lesion. (2) They occur in ninety cases out of a hun- dred during the first year of the disease. (3) Very few dentists are able to recog- nize the condition. (4) If patients are asked if they have syphilis, they will deny it; some because they do not know it; others, because they wish to conceal the fact. El R. OarDenter, in the "Dental Review," says: "The undeniable fact that there exists such a gross ignorance on this sub- ject among our profession is undoubtedly due to the lack of professional informa- INTEODUCTION. 11 tion in regard to it. While it should be considered as thoughtfully and compre- hensively as other diseases of far less prevalence, it is not intelligently recog- nized in the curriculum of any dental col- lege in this country. That this fact is true is as indisputable as its existence is repre- hensible." If this little book stimulates its readers to a closer study of this terrible disease, whose only visible expression may be entirely in the mouth, and serves to awaken a clearer perception of the great responsibilities of the dental profession in the care of public health, and thereby con- tributes to the more thoughtful study, and, mayhap, a little tO' the control of syphilis, it will have gratified the hopes and ambi- tions of the authors. For hearty encouragement and valu- able assistance, the authors gratefully acknowledge their indebtedness to A. E. Baldwin, M. D., D. D. S.; E. S. Talbot, M. D., D. D. S.; J. N. Grouse, D. D. S.; G. W. Cook, D. D. S.; James G. Kiernan, M. D., and to Dr. A. H. Ohmann-Dumesnil, for his kind permission to use his researches 13 SYPHILIS IK DENTISTRY. in the subject of Interstitial Gingivitis, in Part X., asi well as toi other writers on similar or allied subjects, whose works have been levied upon in the preparation of this book. PART II. , = HISTORICAL. "Nihil sub sole novum"— Eccles., I, 10. While a dissertation upon the antiquity of syphilis is not properly a part of a work of this character, still, in view of the fact that the age and source of syphilis have lately been made the subject of much vehe- ment argument pro and con, we desire to register our belief in the great antiquity of this disease, and to call attention to a few facts in support of our contention. In the Mus^e d'Histoire Naturelle and the Mus^e d'Anthropologie, in Paris, France, are skeletons of the pre-historic man of Europe, whose bones bear the un- deniable traces of syphilitic alterations, some of which are perfectly typical. In ani interesting article, published by J. Parrott, in the "Revue Scientifique," in 1882, entitled "Une Maladie Prehistor- ique/' the author produces some incontro- 15 16 SYPHILIS IN DENTISTRY. yertible facts in support of the antiquity of syphilis. We quote: "Upon the teeth the imprints of hereditary syphilis are tenacious and characteristic. "They often preserve their original appearance, not only during the life of the individual, but after death." No other disease, says Parrott, can pro- duce them, so that their existence justifies us in affirming that the subject affected with such remains was a syphilitic. He there speaks of the lower jaw of a young Frank of the Merovingian epoch, found in a sepulchre at Brenej (Aisne). The teeth in this jaw clearly show lesions, such as are produced by hereditary syph- ilis, and hence this disease existed in France certainly before the seventh cen- tury. In the celebrated medical treatise, Nuei- King, compiled by the Chinese Emperor, Hoang-ty, at a time which corresponds to 2637 B. C, there are descriptions of a disease which exactly corresponds tO' what we know as syphilis, and this treatise speaks of it as a "very ancient disease." Ancient, 4540 years ago! HISTOEICAL. 17 The ancient books of India (the Bible of India), the Yedas, is a collection of writings, religious, literary and scientific, the latter part being called Ayurreda. The beginning of the period of which the Ayurveda treats is lost in the immensity of time, but is believed to end about the year 1000 B. C, or 2900 years ago. It has many passages which treat of cer- tain diseases, whose identity with modern syphilis it were folly to deny. The works of Hippocrates, T^Titten either by himself or his iDupils, were com- posed about the middle of the fifth cen- tury B. C, for the ''Father of Medicine" practiced at Cos in the year 460 B. C. In Hippocrates' works there cannot be found any exact description of syphilis, in the strict acceptance of the term, but there are hosts of allusions which cannot refer to anything else, as many writers admit. Galen, the Greek physician, who was born at Pergamos, A. D. 131, refers many times to lesions which cannot but spell syphilis, and especially does he speak of peculiar pains of the periosteum, which were so deep and constant that the patient 18 SYPHILIS IN DENTISTEY. believed the bones themselvesi were the seat of the pains, which were undoubtedly syphilitic. Pliny, the celebrated Ronian, wrote upon diseases of the Eomans, which must be diagnosed as tertiary lesions of syphilis. The Bible is full of fairly accurate de- scriptions of syphilis. But enough; to those whose inclinations are to pursue this subject more fully, we heartily recom- mend a perusal of the interesting work of Dr. Buret ("Syphilis in Ancient and Modern Times"), to which we are indebted for liberal quotations. PART III, NOMENCLATURE. The word sypliilis is now almost univer- sally employed to designate a definite disease which may be recognized by cer- tain more or less constant signs and symptoms. It was first used in a celebrated poem by Jerome Frascator, written about the year 1521, and entitled "Syphilis Sive Morbus Gallicus." In this poem it is sup- posed that a shepherd named Syphilus has offended, and is punished by Apollo, who sent him a disease of the genitals, and which the inhabitants of the country called "the disease of Syphilus." Before this, the most common name was Morbus Gallicus, or disease of the Gauls, meaning disease of the French. Later on, as points of resemblance between the pus- tules of syphilis and variola were noted, the Morbus Gallicus was called the "gTo^se 21 23 SYPHILIS IN DENTISTRY. verole" (big pox), and to avoid confusion, variola was called "petite verole" (small pox), by wbicb nam© it is now universally known. Another nam© also in quite common use, Lues Venerea, was first proposed in 1527 by JacqueSi de Bethencourt. There have been many names applied to certain con- ditions which were undoubtedly of a syph- ilitic character, and this very multiplicity of names has confused investigators into the history of the disease. Some of these names ar© yet used occa- sionally, although practically superseded by the more common terms, syphilis and lues. In his study, "Der Ursprung der Syph- ilis," Dr. Bloch has collected the various names given to syphilis, and has classified them, as follows: 34 names according to the supposed country of origin. 46 names referring to the physical symptomsi. 18 names combining the two foregoing. 12 names after the part of the body afflicted. NOMENCLATUEE. 23 34 names according to cause and extent. 12 names in general. 14 names after saints. 24 names used especially in Spain. 26 names used especially in Italy. 110 names used especially in France. 46 names used especially in Germany. IT names used especially in England. 9 names used especially in Holland. 7 names used especially in Denmark. 4 names used especially in Sweden. 12 names used especially in Portugal. 11 names used especially in Eussia. 37 names used especially in Poland. The havoc which the disease wrought among the morally and physically defect- ive people of Europe struck their imagina- tion powerfully, and the following are a few of the names which they gave to what we know as syphilis : Malum francicum. Malum francigenarum. Malum francorum. Malum Castellanum. Malum Indicum. Malum pustularum. Malum St. Menti. 24 SYPHILIS IN DENTISTRY. Malum franciae. Malum francosiae. Malum Americanum. Mai de St. Main. Mai de simiente. Mai dei Naples. Mai Celtico. Mai St. Gillain. Mai de lai Isla Espanola. Mai de los. Castillanos. Mai gallico. Lo male de lo Brosule. Das Venerisclie Uebel. Malefrancum. Malum Neapolitanum. Malum aphrodisiacum. Mai Sr. Kemi. Mai Serpentino. II Male venereo'. Grosse Verole (big pox). Syphilis is now generally regarded as the most acceptable term, and is almost universally used in scientific works. PART IV. BACTERIOLOGY. Syphilis is a chronic infectious disease, produced by a specific organism not yet definitely isolated, and exhibiting char- acteristic early local and late constitu- tional manifestations. Lustgarten demonstrated in syphilitic tissues, and in secretions from syphilitic ulcers a bacillus, somewhat resembling the tubercle bacillus, but differing from it in being more frequently curved, and in hav- ing clubbed ends, as well as its behavior when treated with stains and acids. After staining by the Ziehl-Neelsen method, the tubercle and lepra bacilli are not decolor- ized by nitric and hydrochloric acids, unless subjected to their action for a long time, while the Lustgarten bacillus readily yields its stain when subjected to these reagents. Since Lustgarten's announcement, iu 2.7 28 SYPHILIS IN DENTISTEY. 1884, of the cliseovery of a "bacillus of sypiiiiis," scientific men have been at work almost constantly upon the question of the microorganism of syphilis. The results until last year have been entirely negative. Lustgarten's work was never completed to anyone's satisfaction, and it has never been proved that Lustgarten's bacillus is not identical with the bacillus smegmatis. Eve and Lingard, in 1886; Disse and Taguchi, in the same year, and Golasz, in 1894, have all failed to establish their claims, or gain any serious recognition. In July, 1901, however, an announce- ment of unusual significance and promise was made before the Paris Academy of Medicine, by Justin de Lisle and Louis Jullien (Bulletin de I'Academie de Medi- cine de Paris, July 2, 1901). De Lisle and Jullien chose as the starting point of their investigation the classic experiment of Pellizari, in 1868. By Pellizari, it will be recalled, three 3^oung men were success- ively inoculated from a woman "in full flower," with the secondary accidents of untreated syphilis. The first took syphilis; the second and third did not. No explana- BACTEEIOLOGY. 39 tion of this fact was apparent till the recent discoyery of the bactericidal alexin liberated from the leucocytes in clotted blood, which, as appeared to the writers jnst mentioned, might haye killed the syphilitic germ in the interyal elapsing between the first and second inoculations. Proceeding on this assumption, de Lisle and Jullien deyised a method of growing the suspected organism in blood depriyed of its leucocytes, and hence of its alexin^ immediately after drawing. An exact method of procedure was at first diflftcult, but the writers finally succeeded in iso- lating a bacillus, which grows on numer- ous media, stains well with gentian yiolet and carbol-fuchsin, poorly with methylene blue, and not at all by the Gram method. The germ grows remarkably on amniotic fluid. The bacillus is described as being essen- tially polymorphous, its aspect yarying from that of a short bacillus, measuring five to eight microns in length and 15-100 to 3-10 microns in thickness, to that of a very long filament. Its extremities are vaguely rounded, but not club-shaped. 30 SYPHILIS IN DENTISTEY. Under the microscope, the bacillus is seen to be very lively and performs evolutions. It is easily colored by the ordinary staining materials, but care must be taken not to dry it in the flame or at a higher tempera- ture than 60° C. (140° F.). Alcoholic ether, or a solution of osmic acid, may be employed mth advantage. Sown or culti- vated in bouillon, the latter becomes tur- bid within twenty-four hours. After four or five days a thin veil is perceptible, but neither spreads nor thickens. Gelatin is slowly liquefied by it. If the gelatin be scratched and the bacillus deposited, nei- ther the conical nor funnel-shaped forms are determined. The liquid in the tube be- comes turbid and flaky, with a gTeenish tint; the gelatin is not colored, and the surface remains even. Upon layers of soft gelatin, rounded, grayish, irregular bor- dered colonies of microbes appear within four or five days, and in from twenty to thirty days the whole gelatin is liquefied. Upon ordinary gelose and glycerinated gelose, as also peptonized gelose, a creamy coating is formed, always moist and of a faint greenish hue. BACTERIOLOGY. 31 Cultures injected into laboratory ani- mals caused rapid death, but, as might have been expected, post-mortem libera- tion of alexins killed the germs and the ca- davei^ were found always sterile. Most interesting and important fact of all, the blood of cases of secondary syph- ilis, untreated with mercury, made a per- fect agglutination of the cultures, while no other blood was ever found to do so. Inoculation of the germ into syphilitic sub- jects gave no result. We understand that Dr. de Lisle has of late greatly improved his method of isolating the bacillus from the blood, and that he expects shortly to make another and convincing communication on the subject. Following upon this paper, and appar- ently relating to the independent discovery of the same germ, is the paper of Dr. Max Joseph and Dr. Piarkowsky, in the Ber- liner Klinische Wochenschrift for March 24 and 31, 1902. The starting point of Dr. Joseph's work was the fact that the sperm of a man in- fected with secondary syphilis retains its capacity to transmit syphilis to the off- 32 SYPHILIS IN DENTISTEY. spring even after the patient has been ap- parently long cured. Sterile sperm was inoculated upon sterile bits of fresh placenta. On the first day small "dew-drop" colonies could with difficulty be made out. These subsequently turned gray and became confluent. Some of the colonies contained staphylo- cocci only; some, however, contained a ba- cillus corresponding in many ways with the bacillus of de Lisle. There is no mention of the results of the Gram stain. Inocula- tions from the placenta colonies on the agar-slant, on urine-agar, and on blood serum, grew, though the sperm itself upon these media remained sterile. Experiments were made upon twenty-two patients — cases of from ten months to three and a half years' standing. The germ was found in all in whose spermatic fluid sper- matozoa could be demonstrated. Aggluti- nation was also observed with the bacillus, and inoculation was made into swine with positive result. The authors make no ex- travagant claims, but express the hope that the field thus opened may be exploited in other parts of the world by other observers. BACTERIOLOGY. 33 Meanwhile, we await the final outcome with more than usual interest. The Justus test for syphilis, first de- scribed by Dr. Jacob Justus, an assistant in Schwimmer's clinic at Buda Pest, was based upon the fact that mercury given either by subcutaneous or intravenous injec- tion, or by inunction, will cause a diminu- tion of the hemoglobin of the blood. Nature was said to rapidly replace this loss in healthy subjects, but not in syphi- litics. Great claims were made for this test as an aid to the diagnosis of syphilis, but from many researches since made it seems to be of no diagnostic value. (Phil. Med. Journal, May 10, 1902.) Note. — In the authors' experience, mer- cury administered to a syphilitic subject in- creases hemoglobin.) PART V. INFECTION. The infection is always conveyed from one person to another either by direct con- tact or through the medium of some instru- ment, utensil or other article upon which the virus has recently been deposited; but even when the virus finds lodgment upon healthy integument or mucous membrane, infection does not always occur. It is nec- essary for the virus to enter the circulation through some spot where the skin or mu- cous membrane had been abraded. The so- lution of continuity may be so slight as to be unnoticed; for example, a tiny scratch or the loss of the most superficial layer of epithelium, but when the virus is implanted upon an abraded surface, syphilis will un- doubtedly result. The infectious material may be derived from the secretion of a primary lesion or chancre, from mucous patches, from the se- 35 36 SYPHILIS IN DENTISTEY. cretions of Becondary lesions, and from syphilitic blood during the secondary stage of the disease. The secretions from non-sj^hilitic lesions are not infectious^ — that is, they do not con- vey syphilis, unless they contain blood ; for example, the acne of vaccinia, chancroid ul- cers, etc. The physiological secretions of the body, such as sweat, urine and milk, are non-contagious, as are also the blood and secretions of lesions during the tertiary pe- riod. Certain cases have been reported which are exceptions to the last rule. By far the most frequent mode of infec- tion is sexual intercourse, but extra-genital chancres are very common. Munchheimer states that the average is from six to seven per cent of all cases. Women are more fre- quently the victims of extra-genital syphilis than men. Jullien is authority for the state- ments that extra-genital syphilis occurs in men in five to six per cent of all cases, and in women from twenty-five to twenty-six per cent. Kreftig finds a larger average. Site. — It is with extra-genital chancres only that we have to deal in this present work, and they form a considerable propor- INFECTION. 37 tion of all primary sores which, are seen, even in venereal clinics, to which the vic- tims turn for relic f from tlie secondary man- ifestations of the disease. In the venereal clinics of Paris, it is found that over five per cent of all chancres were extra-genital, and of the extra-genital chancres over sixty-three per cent were oral, including lips, throat, tongue and buccal cavity. The sites of extra-genital chancres in the order of frequency are the lips, anus, fingers, e^-e, tongue, breast, abdomen, leg and palate. It has been stated that syphilis runs a more severe course w^hen the chancre is extra- genital, but this is probably due to the fact that the lesions are uot recognized until late in their course. The failure to make a diagnosis is likewise responsible for the ''epidemics" which not infrequently attack entire families, and even communi- ties. The chancres of the mouth are by far the most important, from a dentist's point of view. Under the heading are included those of the lips, tongue, tonsils, pillars, uvula, gums and the buccal cavity. A chancre of the mouth does not differ in any respect 38 SYPHILIS IN DENTISTEY. from a chancre found on other mucous membranes, and persists from one to five weeks. Chancres of the mouth are acquired in a variety of ways, but two conditions are necessarily present. An abrasion of the mucous membrane of an uninfected in- dividual, to which the virus of syphilis is applied, either directly or through the me- dium of some article on which the virus ha>s been deposited, or fluid in which the virus is in suspension. Perhaps the most fre- quent mode of transmission is through the act of kissing, but besides this mode of in- fection a syphilitic is a constant menace to the health of the family, and to those with whom he has to deal in the daily rou- tine of his life, no matter how careful he may be. If, instead of constant watchful- ness and care, he is ignorant of his disease, or careless of the danger of infecting others, the conditions are ripe for a rapid and far- reaching spread of the malady. In his own home he uses the eating and drinking uten- sils, the same knives, forks, spoons, in com- mon ^dth the other members of the family, and upon them are lodged through the sa- INFECTIOK 39 liva the virus of an orl^l chancre, or much more frequently the secretion of a "mucous patch." There is no thought of sterili- zation, and the utensils, not being surgi- cally clean, the virus is not dislodged, and finds its way to the abraded mucous mem- brane of the lips or mouth of the unin- fected persons who use them. The pipe habit is another source of infec- tion, for many men have a habit of passing around their pipes for every one to have a smoke from them. Cigars and cigarettes are passed from mouth to mouth "for a light,'' and the slight amount of saliva ad- hering is as baneful as though there were large quantities of it. The cigars made in sweat shops are likewise a source of dan- ger, as it is the custom of many cigarmakers to wet the wrapper with saliva in order to make it adhere more closely. Tooth brushes, in some families, are re- garded as common property (a most filthy habit), and occasionally a servant tempora- rily appropriates one of these useful articles in the absence of the employer, to the eter- nal regret of one or the other. Handkerchiefs are more frequently ex- 40 SYPHILIS IN DENTISTEY. changed or loaned, and tlie innocent-looking pin can create much havoc. Those persons whose occupation compels them to use in common with others any im- plement whatsoever are in more or less dan- ger, but where this common work necessi- tates the use of the mouth, the danger is magnified a hundredfold. Among those whose daily occupation thus exposes them to syphilitic contagion are glass-blowers, who find it impractical to use individual pipes ; assayers, who are accustomed to use the blow-pipe in common; conductors' whistles, weavers' sprinklers, and the mouthpieces of wind instruments are in- cluded in the list, while the public tele- phone and speaking-tube in business houses are a menace to the entire population. There is scarcely a vocation which does not have its attendant possibilities for dan- ger, when there are associated together many people, for the habit of putting things into the mouth temporarily is so widespread and deep-rooted that it is next to impossible to break it. The upholsterers' tacks, the shoemakers' pegs, the seamstresses' pins and needles, the pens and pencils of the INTECTION. 41 clerk or scribe, the labels of druggists, the money of everybody, find their way into un- suspecting mouths. Infants are frequently infected in the mouth by nursing a syphilitic wet-nurse, and by unclean nursing bottles. They, in their turn, may become syphilitic and spread contagion. As has been mentioned, the danger of promiscuous kissing is great, and syphilis of the mouth may be acquired as easily by kissing an unresponsive infant as by kissing an older person. In addition to this danger there is added the accidental infection that would result from the sput- tering of an infant in the face of its attend- ant. In previous times there prevailed customs which were at once dangerous and offensive, but which have happily fallen into disuse. As the result of these antiquated customs, much infection was spread. Among these customs may be mentioned breast-drawing and wound-sucking. Even to this day it is not uncommon in the rural and frontier districts, where some one is the victim of the bite of a rabid dog, for a friend to at- tempt to draw the poison from the wound 43 SYPHILIS IF DENTISTRY. by means of suction. Until the advent of tlie tracheal catheter, mouth to mouth insuf- flation of the asphyxiated neAV-born infant was one of the most frequent modes of re- suscitation. Under the heading; of chancres of the mouth, too much stress cannot be laid upon the possibility of dentists and physicians infecting their patients from tongue depres- sors, mouth gags, scalpels, tonsillotomes, and the various dental instruments, where there is not absolutely perfect asepsis. InfecUom Through Fingers and Hands. — Infection through the fingers is by far the most frequent mode of inoculation among physicians and dentists. If cuts, abrasions and hang-nails exist, a nidus is present for the reception of the virus, but if no such solution of continuity exists^ the poison may be carried to the hands, face, lips, or any other portion of the body, and may be de- posited on an abraded spot, or, as is not in- frequently the case, the virus may be trans- planted on a third and healthy person and take effect. Presuming that some of the syphilitic vi- rus be lodged beneath the nails, the slight IJiTFECTIO^. 43 irritation caused by scratching or pinching is enough to give an entrance to the infec- tious material. Laundresses handling soiled clothing are in constant danger, for the underclothing, containing the dried discharges of secreting primary, or, more frequently, secondary, eruptions, are teeming with danger and in- fection. In the same manner, and for the same reason, old clothes dealers and rag pickers are frequently infected through their hands. It is not known how long the virus of syphilis may retain its potency, but it is possible for the infectious material to find lodgment upon unbroken skin, and there re- main some days before some accidental abrasion produces the necessary opening, through which the long latent poison finds its way into the system, and the result is the same as though the infection had been di- rect. In the same way it is impossible to state, though some experiments have been made in this direction, just how long the virus may live when deposited on instru- ments or other inanimate articles, but that it lives several days is certain, and that it M SYPHILIS IN DENTISTRY. withstands some antiseptic treatment is equally certain. Nurses and maids attendant upon syph- ilitic infants are constantly exposed through handling the nursing bottles, bath- ing and dressing the babe, caring for the mother during and after labor, and through the use of the many articles necessary for the care of the infant and invalid. Then, again, babies have a habit of clutching at everytliing within reach, and their nails not infrequently produce slight wounds. But to the dentist the imminent danger lies in every-day performance of his professional duties. In the dissection of a green cadaver, an accidental wound may be inflicted, or an unnoticed abrasion may exist. In operating upon a patient where syphilis is unsus- pected, an instrument may slip, and a slight cut or scratch be produced, and the mis- chief is done. Or the saliva, infected from mucous patches, may lodge in some unno- ticed scratch, or, the patient coughing, the saliva may fly in the face or even the eye of the operator. If a dentist should be so unfortunate as to become infected through the fingers, then INFECTION. 45 every patient who comes to him is in immi- nent danger of infection. Breast infection does noi. concern us in this treatise, and may be dismissed with mention that it is usually wet-nurses who receive a chancre on the nipple, but it must be borne in mind that it may be the result of an examination by the soiled or infected fingers of a physician. Infection on the other regions of the body are accidental, and are produced in a variety of ways, usu- ally being carried there by soiled fingers or flying saliva. Syphilis is transferred either by mediate or direct contact ; there probably is no such thing as aerial transmission of the virus of syphilis. Chancres of the lips may be the result of direct contact, but chancres of the throat are always due to the virus be- ing brought by a carrier, either the finger or instruments, or tbe germ is held in sus- pension in the saliva and carried backward. "Syphilis d'embl^e" is the direct entrance of the syphilitic virus into the circulation of a healthy person without the production of primary chancres. The possibility of such a condition of affairs has been affirmed 46 SYPHILIS IN DENTISTRY. and disputed with great vehemence. While such cases are certainly rare, it is quite pos- sible for them to exist, and may explain in- stances in which no trace of chancre could be found. The British Medical Journal re- ports two cases, which are undoubtedly cases in point. Dr. A. was operating upon an emergency case for an abscess. The pa- tient had secondary syphilis. The needle was refractory, and, slipping, punctured a blood vessel in Dr. A.'s hand. His assist- ant. Dr. B., took up the suturing, when the needle again slipped and punctured a blood vessel in the hand of Dr. B., in almost iden- tically the same way as with Dr. A. No chancre was produced in either case, but in twenty-eight days both physicians broke out with a characteristic secondary roseola, and both cases ran an otherwise typical course. There is no class of persons who are so constantly exposed to the danger of syphi- litic infection, or who, through carelessness, have the possibility of exposing others, as the dentists. The syphilitic consults the physician for a sore throat, an ulcer or neuralgic pain, INFECTION. 47 perhaps. In the course of the examination many symptoms are brought out, and the tell-tale marks — rash, eruption or ulcers — are discovered, and the diagnosis easily made; but when he consults the dentist there is little likelihood that any portion of the patient's anatomy, other than the mouth and face, can be scrutinized by him. If a suggestive question is asked, the pa- tient is apt to give misleading answers or deliberately falsify. There is an old say- ing that "All syphilitics are liars," and no one who has had experience in venereal dis- ease doubts the truth of the adage. So the necessity for knowledge by the dentist of the appearance of skin and mucous lesions in all stages is apparent and imperative, and when thoroughly familiar with all the varied manifestations of luetic disease, it is equally important that the dentist know how to protect himself and others, and more important that he put that knowledge into execution. PART VI. THE INITIAL LESIONS. The chancre, or initial lesion, usually ap- pears about three weeks after inoculation. The site is the point where there existed a solution of continuity of the epidermis at the time of the absorption of the virus. It is usually single, but is occasionally double and even multiple. The Hunterian chancre is the typical ini- tial lesion of syphilis found in the male. In the female the typical form is much less common. According to Reed, the course of the chancre in women is irregular and the diagnosis difficult, sometimes being pro- nounced and typical, at others being small and ephemeral. This author, agreeing with many others, divides chancres clinically into six classes: (a) Superficial or chancrous erosion. (b) Scaling papule. 49 50 SYPHILIS IN DENTISTEY. (c) Elevated papule or ulcus elevation. (d) Incrusted chancre. (e) Indurated nodules. (f) Diffuse exulcerated chancre. (a) Chancrousi erosion is a non-suppu- rating superficial loss of epithelium. It is found more frequently in women than in men. It is always found on a mucous- mem- brane and is often very difficult of diagnosis because of its insignificant appearance. It begins as a deep red spot, and losing its epithelium appears asi a simple erosion. It is smooth, round or oval, and secretes a thin serous fluid. Pus only forms when the erosion becomes the seat of secondary pyo- genic infection. This is the form of chan- cre most frequently found in the vagina and also in the mouth. The induration is very superficial, called by Fournier chancre parchemine. The diagnosis may be difficult or impossible for a few days, until the adenitis in the neighboring lymphatic glands occurs. The duration of this chancre is very brief, and the physician may never be consulted, and the patient think nothing of it. When it occurs in the mouth, it is easily THE INITIAL LESIONS. 51 mistaken for a stomatitis. After this va- riety of chancre, constitutional symptoms are early mauifested. When the chancre disappears, there frequently remains ai per- sistent red spot which may continue for months. When this form occurs on the labia in women, an edema develops which persists for a long time after the disappear- ance of the original lesion. (b) The scaling papule is a small, dull red, slightly elevated papule, which in the course of development becomes still more elevated and of a purplish hue. The edges are distinctly circumscribed and the lesion varies in size from one-fourth to three- fourths of an inch in diameter. The papule is round or oval, hard to the touch. Through irritation and diminished nutrition the su- perficial epithelium is lost and a crust forms. This is the so-called ecthymatous chancre. (c) The elevated papule is of a deep red color, rounded or oval. It has a flat or con- cave surface with elevated margins. It se- cretes a thin serous fluid. When through lack of care, secondary infection takes place, a very obstinate edema results, so 52 SYPHILIS IN DENTISTRY. great as to frequently obscure the initial induration. This form of chancre is of much longer duration than the two preced- ing varieties, and on disappearing usually leaves a scar. Sometimes the papule becomes infected and the pus, which is of small amount, dries with the overlying debris and forms a crust instead of a scale. When the amount of pus formed is greater it does not dry, but is retained beneath the central scale, and we have a pustule or syphilitic herpes. If the secretion be watery and retained be- neath the epidermis or crust, as noticed in newly born infants suffering from heredi- tary syphilis, the result is a syphilitic pem- phigus. When the infiltration occurs in a hair fol- licle (the induration being very small is difficult of demonstration, but none the less real), infection occurs and pustule results. In the course of peripheral development of the cutaneous lesions, two or more pap- ules may coalesce, each retaining its central scale or crust, and we have a variety known as syphilitic psoriasis. (d) The incrusted chancre (a better THE INITIAL LESIONS. 53 name would be diphtheroid) is that form of initial lesion which is found on cutaneous surfaces. It may begin as an erosion or nodule, but, when the overlying epithelium has been lost, the raw surface is covered by a creamy white, grayish or greenish diph- theroid membrane. It is less common than the other forms. (e) The indurated nodule has as its usual site the junction of the skin and mu- cous membrane. It is a sharply circum- scribed plaque, tubercle or nodule, elevated, with sloping edges, and does not secrete any fluid. (f) The diffuse exulcerated chancre is found in people of the lower class whose habits and lack of personal cleanliness pro- vide the environment suited to the develop- ment and growth of all kinds of morbific germs. It begins as an erosion, increases in size, loses its epithelium and spreads over an extensive area. Its surface is deep red and uneven. Its borders are elevated and jagged, and surrounded by a densely indurated zone. It is only slightly painful. This chancre secretes a thin, watery fluid, when uncontaminated. The presence of a 54 SYPHILIS IN DENTISTRY. secondary pyogenic infection changes the secretion, giving it a purulent character. SYPHILITIC ULOEES. In the natural course of retrograde meta- morphosesi, ulceration frequently occurs. As in the papule, degeneration occurs in the center, while the peripheral infiltration continues to increase centrifugally. The edges and base of the ulcer are cov- ered with a whitish detritus resembling lard. The edges of the ulcer are firm, sharply defined, somewhat ragged and undermined. In the center is the usual crust. Fluid is secreted beneath and burrows wider and deeper. ThiSi fluid dries and forms a sec- ond crust immediately beneath the first, but of larger diameter. Again fluid is secreted raising the layers of crust above and dry- ing forms a third and still larger crust be- neath the other layers. And so the process continues, eating deeper and wider into the subjacent tissues and forming larger and yet larger layers to the central crust. When the crust is removed the typical undermined ulcer is observed. THE INITIAL LESIONS. 55 After the ulcer has reached a certain size, cicatrization occurs at one side from granu- lation from healthy tissue adjacent. The retardation of the process at one point, with the steady growth in all other directions, produces the "kidney-shaped" ulcers so characteristic of syphilis. SECRETIONS. It may be stated in a, general way that the secretion from all eroded chancres, when uncontaminated, is serous or sero- purulent. The presence of pus producing microbes as a secondary infection will give a purulent discharge; and conversely when the secretion from a chancre is purulent, it has become secondarily infected. The "hemorrhagic" chancre is occasion- ally met with, and is due to the diseased and exposed condition of the minute blood ves- sels which causes them to be easily eroded or torn. The amount of induration varies mark- edly in the different forms of chancre and in d liferent locations. It is, other things being equal, apt to be much greater on mu- cous membranes than on cutaneous sur- 56 SYPHILIS IN DENTISTRY. faces. In occasional instances the indura- tion may be so slight as to escape notice, if the examination has been hasty, or the edema is extensive or when contaminated with chancroid. The size of the chancre is likewise de- pendent upon the nature and extent of the solution of continuity at the site of the in- fection. The entire abraded surface is lil?;ely to become involved in the chancrous ulcer. Chancre of the lips, nipple and corona glandis are apt to be extensively indurated. When a chancre occurs in the throat, it is usually located on one tonsil. It is often not recognized because inflammation and hypertrophy of the tonsils are so common and because the earlier symptoms differ in no wise from those of ordinary tonsillitis. When the swelling and induration persist, and the submaxillary lymphatic glands be- come swollen, and symptoms are unaffected by the usual remedies, chancre of the tonsil should be suspected. The size and variety of the chancre will vary in this locality upon the same conditions which modify it THE INITIAL LESIONS. 57 els€wlier(i — the presence of previous inflam- matory changes and pyogenic bacteria. CICATRIX. Chancres, when small and but slightly in- durated, with free lymphatic supply, disap- pear sooner than other forms and leave "ham-colored" spots, which fade to a cop- pery hue; later they fade completely, leav- ing no trace, while stubborn, densely infil- trated, deep ulcers leave permanent and characteristic scars. In some cases scars result from the treatment of chancres. INOCULABILITY. Chancres are non-autoinoculable, and this is taken as an absolute diagnostic dif- ference between them and the ulcers of chancroid, from which it is important to differentiate them. When a chancre be- comes secondarily involved by pus cocci, it is very possible to infect the neighboring sur- face with the pyogenic organisms, but the resultant lesions are not similar to the pri- mary ulcers, and the pus from them will not produce syphilis in another individual. If the secondary infection is chancroid, there may be as many secondary chan- 58 SYPHILIS IN DENTISTEY. croidal ulcers result from autoinoculation as tliough. cliancroid existed alone. Neither are these secondary ulcers of the character of hard chancres. A case is reported, however, of autoinocu- lation with blood from the side of the initial lesion before the appearance of the ulcer. Wallace cites a case of autoinoculability, when in the eruptive stage, while Fournier states that two per cent of autoinoculations are successful. Lydston thinks that under conditions of filth, heat and moisture, a germ infection of a chancre might be pro- duced, resulting in an ulcer of a chancroid- al character. PATHOLOGY. The changes that occur in the formation of a hard chancre are inflammatory in char- acter, modified to a certain extent by the presence of the specific virus of syphilis. This virus is as yet unidentified (Vide Part IV). The same changes, under slightly dif- ferent environment, are to be found in all the secondary syphilides. When the poison of syphilis is deposited on an abrasion in otherwise healthy skin, THE INITIAL LESIONS. 59 a cycle of phenomena at once begins. The first manifestation of this cycle is the infil- tration of the tissue at the site of infection with small round cells, exactly as in any inflammation. With these small round cells are also to be seen large round or oval and polyhedral cells, filling up the interstices between the meshes of the network of blood capillaries. At first the blood vessels are not involved, but shortly by extension they are included in the inflammatory process. New connective tissue of a perishable or embryonic type is formed. This tendency to connective tissue formation is also observed in the tertiary stage in lesions of the nerv- ous system due to syphilis. The lymphatic channels are soon involved in the inflammatory process and the virus, which is either a microbe, or, as Otis sug- gests, a microbe-bearing cell, is borne along these vessels to the nearest lymphatic glands, where it is deposited, and the same process of inflammation is repeated and the glands become swollen and indurated. "First intuition virus" has traveled from the site of infection. This is the period of first incubation. 60 SYPHILIS IN DENTISTEY. MICROSOOPIOAL. A section under the microscope reveals a mass of semi-necrotic, round, multi-nuclear cells containing granules, with large poly- hedral and round cells here and there. The lumen of the blood-vessels is distinctly les- sened, and the walls thickened by the pres- ence of an inflammatory zone. There is no fluid to be found in this inflammatory zone. The thickness of the vessel walls precludes that, and accounts for the hardness of indu- ration. Around this mass of round-celled infiltration is a zone of edema, which acts as a barrier, preventing the spread of virus into the adjacent healthy tissues. A section through one of the swollen lymphatics shows a similar condition, a simple inflammation plus these, large multi- nuclear polyhedral cells. Prom the germ-laden lymphatic glands the virusi is carried by way of the larger lymphatic vessels and emptied into the re- ceptaculum chyli, thence intO' the general circulation, and the disease, which up to this time is apparently local, becomes sys- temic. THE IXITIAL LESIONS. 61 According to Besiadecki, there is first an accumulation of lymphocytes or white blood corpuscles, at the site of inoculation. These normal cells become modified by the presence of syphilitic virus. Otis claims that there is present a very minute de- graded cell, bearing the infectious material, which acts as the carrier of contagion. These modified cells bearing the germs of infection become larger and granular and possess many nuclei. Their amoeboid move- ments are increased and their powers of proliferation multiplied. When these cells come in contact with healthy normal leucocytes, as in non-in- fected individuals, these cells have the power to produce changes in the leucocytes (proliferation) and they undergo changes in themselves (Lydston). The theory that the degraded cells may be the nuclei of disintegrated leucocytes is plausible. In their travels they meet with other leucocytes by whose phagocytic ac- tion they are absorbed. In this manner the size of the leucocytes is increased, but be- cause of the morbific action of the included germs the life of the cells is imperiled. PART VII. SECONDARY MANIFESTATIONS. Secondary mauifestations of syphilis be- gin to appear from four to eight weeks after the initial lesion. They are ushered in by slight fever, headache and malaise. The appearance of the rash is the confirmation of our diagnosis of syphilis. This period from the appearance of the chancre till the appearance of the earliest secondary or con- stitutional symptoms is called the period of second incubation. It may be stated that the causes at work in the iiroduction of the chancre prevail in the production of the secondary eruption and in the formation of the gummatous de- posits of the third stage. The exciting fac- tor is the presence of the syphilitic poison, whatever its nature, because of it there are deposited in certain places cells of the same kind as were found in the chancre, which re- semble round cells of inflammation, but 63 64 SYPHILIS IN DENTISTEY. have the giant cells with them, and do not readily lend themselves, to reparative proc- ess. SECONDARY ERUPTION. The consideration of the secondary erup- tion is of the utmost importance, not only to the patient, but to the physician and den- tist as well. In many cases the chancre has been inconspicuous, and has been entirely overlooked by the patient. It is rather a difficult matter for a man to think a trivial little sore, which is not painful and does not inconvenience him, and which to his eyes looks like a dozen other little sores he has had, is the precursor to years of af- fliction by eruption and rashes, pains and SAvellings. The appearance of the second- ary rash is the first thing that attracts the patient's attention, and for which he con- sults the physician. With the absence of a history of infec- tion, as will usually be the case, when the chancre is extra-genital, with the denial by the patient of the existence of a chancre, and the lack of a tell-tale scar to throw a ray of light on an obscure case, a diagnosis ^1 PAPULOPUSTALAR - SECONDARY ERUPTION ( Takt-n from Snundcrs Ilatid Atlas) SECONDARY MANIFESTATIONS. 65 must be made from secondarj^ eruptions aloue. When there are only the c-utaneous syphilidesi to tell the stor}', the diagnosis may be difficult, but when in addition to the skin eruptions vre find nnirous patches or plaques muqueuscs, the diagnosis is abso- lutely certain. All secondary eruptions are able to com- municate the disease to others, and the plaques muqueuses are especially prolific of danger, and it is through them, far more frequently than through the chancre, that not only venereal but extra-genital syphilis is disseminated. If syphilis were characterized by but one form of eruption it would be an easy matter to identify it, but there are many skin dis- eases, each with its own peculiar rash, and syphilis, which is an imitative disease, may counterfeit in a general way any and all of them. The necessity of recognizing syphilis in all of its forms, and of differentiating it from the many diseases w^hich it may simu- late is obvious. There are several points which all syphi- lides have in common, and which, taken to- 66 SYPHILIS IN DENTISTRY. gether, may be considered as pathognomonic of syphilis. 1. Syphilitic rashes or syphilides, are su- perficial. They are situated in the papillary layer or the corium of the skin and extend only superficially. There is no tendency, as in tertiary lesions, to extend into the deep tissues, and very little tendency to increase peripherally, though twoi or more closely situated lesions may coalesce. 2. It is only the epidermis overlying the syphilides that is destroyed, and it is re- placed by new epithelium. 3. If the lesion is not contaminated by pus cocci, there is no tendency to ulcerate. 4. The epidermis is replaced and does not leave a scar. 5. There is, however, a deposit of pig- ment where the syphilide occurred, which is of a characteristic ham or copper color. This spot may disappear very shortly, leav- ing no trace. It may appear immediately or its appearance may be delayed a few days. G. Syphilitic rashes may or may not itch. 7. They are symmetrical on both sides of tlie body. 8. The roseola disappears on pressure. SECONDAEY MANIFESTATIONS. G7 LOCATION. The rashes of syphilis have a predilection for certain portions of the body which they attack first. If there is only a slight rash it may be confined to the preferred loca- tion, but in severe forms the other portions are attacked in a definite order. The lower two-thirds of the chest is most often the seat of secondary eruptions, and following in order of frequency are: The abdomen. Front of legs and thighs. Flexor surfaces of arms and forearms. Back of neck. Scalp, beginning at forehead (corona veneris) . Posterior surface of thighs and nates. Posterior surface of legs. Back. Posterior surface of arms. Face — the face is, fortunately for the victim, least often attacked, and is free, except in very severe forms of eruptions. Syphilis may attack the palms of the 68 SYPHILIS IN DENTISTRY. hands and the soles of the feet with a dry, scaly eruption which greatly resembles psoriasis, and is called syphilitic psoriasis. But this is of later date than the general rash. TIME. After a variable period, usually from forty to forty-flve daysi subsequent to the chancre, there appears a general erythema much more profuse on the anterior aspect of the trunk and flexor surfaces of the limbs; but in severe cases may include the whole body. This is known as the syphilitic roseola or roseola syphilitica. This erythe- ma is in the form of sharply defined, dull rose or bluish red blotches, which vary in size from one-fourth tO' five-eighths of an inch in diameter. The spots do not scale, never itch, and disappear without leaving a trace, but when long continued leave be- hind a ham or copper colored pigmentation. The rash may last only a few hours, in which case it may not be observed, or it may last for two or three months. The roseola may be accompanied, but is SECONDAEY MANIFESTATIONS. 69 usually followed, by an eruption of pap- ules, which are scattered over the trunk and limbs, but are especially noticed on the forehead in the border of the hair. When thickly studded they form a peculiar band which is termed the corona veneris or venereal crown. The secondary rash is not to be con- founded with the secondary eruption, known as cutaneous syph Hides or syphilo- dermata. The two may, and frequently do, co-exist. The rash disappears on pressure; the eruptions do not. It is not to be supposed that one of these spots continues throughout the entire pe- riod of secondary eruption. The blotches as they disappear leave pigmented areas and new blotches and papules form in their stead, so that several forms of the syphilides may be found at one time, and their places be taken later by other forms of eruptions. All forms of syphilodermata, with the exception of the roseola, were originally papules or nodules, and it is only location, irritation and contamination with pyogenic infection that produces the different varie- ties given by most authorities, but some 70 SYPHILIS IN DENTISTEY. -WTitersi content themselves with dividing all syphilides into two classes: Squamous and Papular, A vast amount might be written on the subject of pathology, but a practical work, such as this is intended to be, has little need of a chapter on microscopy and pathology, though a general statement of pathological conditions is not amiss. There is a slight inflammatory condition in the deep layers of the skin-papillary layer and corium. The circulation is interfered with and the hemoglobin of the blood is broken up and its pigment deposited in the skin. Owing to the inflammation and deficient supply of nourishment, as well as the ten- sion on the overlying epidermis, it dies and is desquamated, new epidermis taking its place. Under the finger the papule feels hard, like shot under the skin, or like a "pimple." It increases in diameter, but the central portion, which is the oldest, disappears and leaves a "dent," which is covered with a scale. This scale is quite characteristic and SECONDAEY MANIFESTATIONS. 71 should be borne in mind. The outer por- tion is red and shiny from the tightly drawn skin. A rather unusual, but none the less im- portant, form of secondary eruption is knoAvn as sypMlitic lichen, and also as syphilitic acne, from its resemblance to acne, though in it the sebaceous follicles are not inflamed, and the "black heads" do not break down with pustules. It is found usually on the lower part of abdomen, and anterior surfaces of the thighs. It is much more abundant than the acne, which it counterfeits, and, like all syphilides, does not itch, and has a brown- ish discoloration. A still rarer form of secondary rash is known as the pigmentary syphilide. It is found only in women and upon the neck. It is a brownish or blackish discoloration, which causes the skin to look as if it was in need of a vigorous application of soap and water. PRODEOMES. Accompanying, or in some instances pre- ceding, the roseola, as more or less constant 72 SYPHILIS IN DENTISTEY. symptoms, are what are frequently called the syphilitic prodromata; they are auor- exia, nausea, headache, neuralgic pains, nervous irritability, general malaise, and not infrequently a rise in temperature. Syphilitic fever is extremely variable in character. There may be a constant but slight pyrexia, the temperature rising to 101 degrees, or it may assume a remittent or even an intermittent form, the tempera- ture rising as high as 104 or 105 degrees, and dropping five or six degrees. Such cases are easily confounded with malaria, and the diagnosis is only cleared by the therapeutic test. Kicord and Otis are of the opinion that the fever is not dependent upon syphilitic infection, and is merely a coincidence; but the generally accepted view is that the fever is directly caused by and dependent upon the presence of the syphilitic germs or their toxines within the system; that the minor- ity of cases in which the pyrexia is not man- ifest are explained on the grounds of idio- syncrasy, or more perfect elimination through the various channels of excretion. ) (/) u I o I- < Q. 0) D O D z PART Vlll, MUCOUS PATCHES. Uudoiibtedly the most important of all the syphilitic lesions, especially from a den- tal standpoint, are the mucons patches, or plaques muqneuses, which are observed upon the mucous membranes, quasi-mucous membranes, and moist portions of the skm, during the secondary stage of the disease. These plaques are in structure, and mode of development, very similar to the papules found on cutaneous surfaces, but conditions of heat and moisture, which are ever pres- ent, together with the irritation due to fric- tion or foreign substances, modify their ap- pearance and growth. A most important feature of the plaque muqueuse is the secretiou of a glairy fluid which is highly contagious, and which is the most usual cause of syphilitic infection If the secretion of a mucous patch be placed 75 76 SYPHILIS IN DENTISTRY. upon an abraded spot in the integument of a healthy person, a chancre will undoubt- edly result, but autoinfection from the se- cretion of a mucous patch will not produce a new chancre (although another mucous patch might result) . Mucous patches! are not painful, and when few and small give rise to no incon- venience, and are consequently often ig- nored and their dangerous character not appreciated ; in fact, in some cases they are so insignificant and harmless in appearance that a diagnosis is well nigh impossible. In the mouth the first manifestation of the secondary stage of syphilitic infection is the appearance of a general dull red erythe- ma involving the entire fauces. The ery- thema soon fades, leaving symmetrically disposed erythematousi spotsi on both sides of the palate, the walls of the pharynx, the pillars of the fauces and the sides of the tongue. These patches are sharply defined, slight- ly elevated, round or oval, and vary in size from three toi five millimeters in diameter. At first they are deep red in color, but later they become a grayish white. They secrete MUCOUS PATCHES. 77 a viscid fluid which, as before stated, is highly contagious. Under the fingers they feel hard to the touch, the borders are elevated and the cen- tral portion depressed. When mucous patches are subject to irri- tation, they have a tendency to break down and ulcerate, especially is this true of mu- cous patches situated on the tonsils. As a result of this low type of ulceration, the glands in the neighborhood become swollen so that when plaques muqueuses are found in the mouth and throat we may expect an involvement of the occipital and sterno-mas- toid glands. Mucous patches, when situated on this moist skin, or quasi-mucous membranes, change their character somewhat, and be- come considerably hypertrophied, and have a tendency to multiply, forming fungous or warty new growths. Tbese patches, unless kept most scrupulously clean, secrete a foul smelling discharge. They are termed tuber- cles or condylomata. The mouth is especially subject to mu- cous patches, because of the constant pres- 78 SYPHILIS IN DENTISTEY. ence of irritation from decayed teeth, hot foods, alcoholic beverages, tobacco^ and pipe stems. Tobacco users are especially liable to this secondary manifestation of disease. The action of the pipe stem upon one part of the lip, long continued, as with heavy pipe- smokers;, supplies the requisite irritation, and a mucous patch appears upon the smok- er's lip. It is very slightly elevated, cov- ered with a whitish film, and is very persist- ent and annoying. Such milky patches are termed plaques opalines. However, a non- specific sore closely resembling a plaque opaline may appear on the lips of a heavy smoker who is not syphilitic. This is due simply to the irritant action of the smoke and pipe stem. It is also very stubborn to treatment, and unless the source of irrita- tion is removed will remain indefinitely, in spite of all treatment. It is not elevated and not indurated. There are similar non-specific patches to be found occasionally upon the tongue and cheeks, which are termed leukoplasia or leukoplakia. MUCOUS PATCHES. 79 SECONDAEY SYPHILIS OP THE NOSE. ^Mucous patches are sometimes found in the nares. When such is the case they are situated either at the outer angle or ante- rior mucous surface near its junction with the cuticle. They are small, round, or oval, and slightly raised — in fact, presenting no difference in appearance from plaques mu- queuses found in the mouth. They occur in point of time with other mucous patches and cutaneous syphilides. They are accom- panied by a profuse mucopurulent dis- charge which interferes with the circulation of air through the nose. Mucous patches may become secondarily infected, the same as any other lesion, by pus germs, and when so complicated ulcers will result. These have the characteristic undermined appearance of syphilitic ulcers elsewhere. They ai'e situated on a hard base and have overhanging, jagged though sharply defined edges. The secondary manifestations of syphilis upon the pharynx and tonsils begins by a dull red erythema and fading, leaves 80 SYPHILIS IN DENTISTKY. patclies scattered over tlie tonsils and walls of the pharynx. The patches are similar to mucous patches seen on the lips; they are round or oval in size, symmetrically dis- posed upon both sides, elevated and sharply defined and covered with a grayish deposit. Because of the lymphatic structure of the tonsils and their tendency to pus infections, and the ease with which foreign substances may be lodged within their crypts, we find the mucous patches in the tonsils espe- cially prone to ulceration. When ulceration does occur, it sometimes extends quite deeply into the tonsils, otherwise it is the same as the ulcerating patches in other por- tions of the mouth. OCULAR SYPHILIS. The eyes are victims of the secondary manifestations of the disease, an iritis being frequently observed, but the diagnosis be- longs to the oculist, rather than to the den- tist or general practitioner. OSSEOUS SYMPTOMS. Late in the secondary stage of syphilis there is an inflammation of the periosteum of the bones; it is exceedingly painful, es- MUCOUS PATCHES. 81 pecially at night. It is not to be confounded with nodes and gummata of tertiary syphi- lis. Occasionally we find swelling of the joints, with an accumulation of fluid, as a secondary syphilitic manifestation, but such cases are infrequent and not diagnostic. ALOPECIA. About the time of the appearance of the secondary rash and sore throat, the hair may begin to fall. As a rule there is an ab- sence of rash upon the scalp, though occa- sional papules may be found scattered over the hairy portion of the head, and the trouble usually begins as a dryness of the scalp, which may go no further, but the irri- tation may become severe and crusts may even form; this, however, is unusual. The hair becomes greatly thinned, but in some places the scalp becomes entirely bald, giving the head a peculiar appearance, joc- ularly called a "polka-dot hair cut." The trouble is caused by the disease af- fecting the roots of the hairs themselves, and when the disease is brought under con- trol, there is nothing to prevent new hair from coming; in. 83 SYPHILIS IN DENTISTRY. The beard and eye-brows are subject to the same process, and the hairs of the eye- brows are not infrequently all shed, leav- ing the victim with a peculiarly bald ap- pearance of the faee. As has been previously stated, the sec- ondary rash rarely affects the face, and does so only in severe cases. Almost the only manifestations on the face in secondary syphilis is the affection of the hairy parts — the brows and beard. ,jJi&iiiS&^ 'i., ..^ .^tiiSPd.'iiiSh TERTIARY DESTRUCTION (Taketi from Saunders Hand Atlas] PART IX. TERTIAKY SYPHILIS. There can be laid down no hard and fast rule with regard to the tertiary period of syphilis. The secondary and tertiary stages may be so merged the one into the other that lesions of the two periods may co-exist. On the other hand, the appearance of the tertiary manifestations may be delayed for years, and the patient rest secure under the delusion that he is free at last from the dreaded ravages of the disease, only to be rudely awakened to the realization that there is no security from that nemesis. Many authorities consider that tertiary symptoms, properly speaking, are not syphi- litic, in the true sense of the word, but are merely sequelae, just as nephritis and mid- dle ear disease are sequels of scarlatina, and not in any sense the disease itself. Tertiary manifestations of syphilis differ from those of the true secondary stage in 85 86 SYPHILIS IN DENTIS'TEY. being non-contagious and in their tendency to eat deeply into the tissues, as well as to extend laterally and to' ulcerate. As has been stated, previously, there is no tendency on the part of the papules of the secondary stage to ulcerate. Experiments upon tertiary lesions have proved tha.t they do not communicate syphi- lis when inoculated upon healthy individ- uals, but a fact which must be borne in mind and never lost sight of is that secondary contagious lesions may exist at the same time with non-contagious tertiary lesions and communicate the disease to others. Many syphilographers divide tertiary manifestations into two classes — early and late tertiaries. While the classification is unsatisfactory and misleading, it will be adopted in this treatise in lieu of a better one. The early tertiaries appear directly after secondary cutaneous eruptions and are themselves cutaneousi. They differ from the secondary syphilides in their tendency to ulcerate. In fact, the evolution of a rash is so gTadual as to defy the elect. The sec- ondary and a number of the tertiary cuta- neous lesions are frequently coexistent. As TEETIAEY SYPHILIS. 87 the cutaneous lesions seem to merge the one into the other, they will be considered together. It may be stated, however, that the syphilitic impetigo and ecthyma are the connecting link between secondary and ter- tiary. Syphilitic rupia are a little later and may be considered as true tertiary skin lesions. Following the cutaneous tertiaries in point of time, are the tubercular syphilides. The tuberculous syphilide is really a super- ficial gumma — found in the corium of the skin. In all respects it resembles the true gumma, which is the latest of all syphilitic manifestations. The gumma is the type of tertiary lesion, just as the mucous patch is the type of sec- ondary manifestation. However, gummata are not confined to the skin and mucous membranes, as were the earlier lesions, but may and do attack every organ in the body having a special predilection for the liver, lungs, kidneys and brain. A gumma is an accumulation of cells of a peculiar tyi^e, closely resembling the round cells of inflammation, but differing from them in having no tendency to a repar- 88 SYPHILIS IN DENTISTEY. ative process, but a great tendency toward the destruction of the surrounding tissues, breaking down into ulcers with pus forma- tion, and leaving behind unsightly scars and disfiguring bands of cicatricial tissue. The gumma proper is found in subcuta- neous tissues and deeper structures. When occurring in the Sikin the term superficial gumma or tuberculous syphilide has been applied. No organ of the body is exempt from the ravages of syphilis in its late or tertiary stage, though certain organs such as the liver, lungs, kidneys and brain are more frequently the seat of the gummata. The presence of gummata in the deep- seated organs may be recognized by signsi and symptoms, if large and multiple. On the other hand, they may be so small and inconsiderable in numbers, or so situated as to interfere not at all with the functions of the organs in which they are seated, and thus give rise to no symptoms and their presence never be suspected during life. The presence of gummata in the deeper organs does not concern us, and will not be considered in this work. TERTTAEY SYPHILIS. 89 GUMMATA OF THE SKIN. Properly speaking, gummata do not at- tack the skin, but an accumulation of gum- matous cells, when found in the skin, is termed a "superficial giimma" or "tubercu- lar syphilide." Such accumulations are small, ranging in size from a fine shot to a pea. They frequently become infected and break down into ulcers, closely resembling the infected syphilides of the secondary stage, but differing from them in that their secretions are non-contagious. They may be found during the late secondary stage along with secondary manifestations. GUMMATA OF MUCOUS MEMBRANES. Gummata ai'e frequently found on mu- cous membranes and when so situated the destructive process is rapid and the tend- ency to repair is slight. The gumma is at first small, but increases in size from that of a fine shot to a small pea and softens. Finally it becomes yel- lowish and ruptures, breaking down into an ulcer. Such ulcers may be superficial or deep. Tliey have overhanging, jagged 90 SYPHILIS IN DENTISTKY. edges, are sharply defined and secrete pus with an exceedingly offensive odor. When the pus is removed, the bottom of the ulcer is seen to be made up of fungoid growths. The tendency of such ulcers is to spread lat- erally and to eat deeply into the neighbor- ing structures, sometimes wreaking havoc as they progress. Phagedena rarely attacks primary chan- cres, or even the secondary lesions of syphi- lis, but gummata are not so exempt, but on the other hand are prone to become phage- denic. While gummata and their ulcerative proc- esses are pathologically the same wherever located, their clinical effects vary with their site. They become of special importance and interest to the dental surgeon when sit- uated in the mouth or nose. GUMMATA OP THE THROAT. When occurring in the throat, gummata are small and multiple. They are found frequently on the soft palate and the pil- lars of the fauces. In these locations they break down and form ulcers of the superfi- cial variety. They last from two to three. TERTIARY DESTRUCTION (TaA-ett from Saunders' Hand Atlas) TEETIAEY SYPHILIS. 91 weeks and constitute one of the causes of syphilitic sore throat. GUMMATA OF THE HAED PALATE. Owing to the predilection of the disease for cartilage and bone, the hard palate is frequently attacked. A gumma forms on the roof of the mouth in front of the soft palate, and this breaks down into a deep ulcer. The periosteum of the palate bones becomes involved beneath the ulcer and a perforation results. According to Ingals, this can occur in ten to fifteen days. The ulcer in time heals, but a round hole is left connecting the oral cavity with the nasal cavity. This round perforation is ab- solutely diagnostic of tertiary syphilis. It frequently calls for a surgical interference. Occasionally perforation results from the destructive process of an ulcer which was not preceded by a gumma. TEETIARY SYPHILIS OF THE NOSE. While syphilis may attack the nose in the primary and secondary stages, these are rather unusual occurrences, but in the ter- tiary stage the nasal mucous membranes 92 SYPHILIS IN DENTISTEY. are frequently attacked. The severity of the attack varies greatly. In some eases there is a slight obstruction of the nasal passages due to the thickened mucous mem- brane, in others there may be present con- dylomata, and in exaggerated cases there may be gummata which ulcerate, involving mucous membrane, cartilage and bone in their destructive processes. Necrosis of the bone and cartilage is due to periostitis and perichondritis — an exten- sion of the inflammation from the ulcer to the periosteum and perichondrium. The destruction of the nasal bones is a late tertiary manifestation, usually occur- ring several years subsequent to the pri- mary chancre, but in occasional malignant cases it may occur within a year. Accompanying the necrosis there is ob- served a mucopurulent rhinitis. The dis- charge has a peculiar stench, which is not entirely removed even by the most rigid antiseptic and thorough and frequent ablu- tions. The destruction of the nasal bones with the consequent flattening of the bridge of TEETIAEY SYPHILIS. 93 the nose when not due to fracture is due to syphilis. No other disease so completely de- stroys the bones of the nose and leaves its name so indelibly written on the features of its victims. PART X. INTERSTITIAL GINGIVITIS. Interstitial gingivitis or pyorrhea alveo- laris, variously known as Riggs' disease, Fauchard's disease, and by some other names, remains to this day a bete noire to dentists. Tliis is mainly due to the fact that they cannot cure it and the best meth- ods at their command to-day lie in pros- thetic dentistry. Without desiring to pose as carping critics, the method is bad and is surely a petitio in forma jmuperis to him wiio is able to observe and reason. In this trouble, as well as in others, it is necessary to determine the cause and then properly treat it or eliminate it, and it is to this very question of cause that the pres- ent is written. He who has had opportunity to observe a number of cases, of syphilis has not failed to observe that a peculiar mani- festation shows itself at first in connection with the lower canine teeth. This will then 95 96 SYPHILIS m DENTISTRY. spread to the incisors and at times to the first bicuspids. If the examination be pushed a little farther the gum covering the tooth root will be found to be reddened and angry looking, and if it be pressed some pain is elicited and pus is found to exude apparently from the alveolar process. This it is which has led dentists to regard it as a purulent destruction of the alveolus, be- cause drawing the tooth did not reveal any marked alteration of the bone during the earlier period of the disease, but rather a marked collection of pus in the alveolar cav- ity. As a natural consequence it was found much easier to clean out the offending teeth, and patients were advised to have all the affected teeth drawn and replaced by a bridge, which is certainly more profitable to the dentist, while more inconvenient to the patient. As an example of prosthetic den- tistry, it is certainly a success, but as a means of cure it is anything but such. Care- fully examining every case of syphilis com- ing under observation and noting the facil- ity with which pus could be made to exude from the alveoli by simple j^ressure on the INTEESTITIAL GINGIVITIS. 97 gums led to a further search, which led to the discovery of the same coudition in indi- viduals who were suffering from gout and other so-called dyscrasise. The inevitable conclusion would be that these general con- ditions were the cause of the local symp- toms observed. In other words, the trouble of the alveolar process was nothing but a local indication of some general condition which existed and which should be cor- rected in addition to the elimination of the local trouble which manifested itself. It was then that a more careful examina- tion of the teeth of syphilitics was entered into and the result was the finding of a com- paratively large number of cases of pyor- rhea alveolaris. Upon request a number of dentists submitted cases to me. These were very carefully questioned, and about two- thirds gave a history of syphilis. A suffl- cient number existed to classify them as cases of syphilis ignoree, or as old cases of tertiai'}' sj'ljhilis in which this was the only bone symptom to be observed. However, this may be, the subsequent treatment showed that the etiology had been correctly 98 SYPHILIS IN DENTISTEY. established and, as a natural consequence, the treatment was successful. In view of the fact that the few observa- tions made have shown a greater or less in- terdependence between syphilis and pyor- rhea alveolaris, would it not be a useful matter for every one to pay more attention to the dental trouble? To say the least, is it not a curious coincidence that Riggs' disease should be observed in so many cases of secondary syphilis as well as the late form of this period? It must also be remarked that pyorrhea alveolaris occurs as a parasyphilitic phenomenon. When we take into consideration that the teeth are observed to be all sound before syphilitic infection, and that after the disease has manifested itself it shows its presence ; and, further, when systemic as well as local treatment directed to the syphilis causes both to disappear we are certainly justified in concluding that lues is a factor in the production of Eiggs' disease. We are un- fortunately prevented from making experi- mental inoculations, or the matter could be definitely settled by inoculating the pus of the pyorrhea in a subject who had never INTERSTITIAL GINGIVITIS. 99 contracted syphilis. Of course, there would remain the possibility of producing nothing but a purulent infection and not a chancre. The object of this chapter has been to call the attention of syphilologists and dentists to the point announced in the title, and observation will, beyond all doubt, lead to a number of valuable ideas and the elabora- tion of methods, not only for the treatment, but for the prevention as well, of this most distressing disease of the teeth. It is for conservatism that we are ever striving, not for radical destruction, and there is no doubt whatever that a little care and study will enable us to save many valuable teeth which are being daily sacrificed on account of a confessed inability to successfully treat the condition known as pyorrhea alveolaris. PART XI. DIFFERENTIAL DIAGNOSIS. In the diagnosis of syphilis, the forego- ing features are of the greatest value col- lectively. In every case the whole situation must be reviewed and determined by care- ful questioning and observation. Learn, also, the general conditions of the suspect and whether the other tissues have been affected. It is unnecessary to enter minutely into the details of the differential diagnosis be- tween syphilis and the more frequent con- ditions which may be met with and mis- taken for this gTave disease. If attention be paid to the prominent features as described, especially when assisted by a knowledge of the history of the ease and a careful search for co-existing symptoms or signs of syphilis or traces of their previous existence, the dentist will not often be left in doubt. lOI 102 SYPHILIS m DENTISTRY. If any uncertainty exist, it is far better for all concerned if the patient have the benefit of a trial of specific remedies before resorting to operative procedures. The cardinal signs and symptoms are arranged in parallel columns for easy com- parison : — SECONDARY SYPHIL- ITIC RHINITIS. Sudden onset. Course long and obsti- nate. Coincident condylomata and mucous patches. Syphilitic history. CHRONIC RHINITIS. Onset more gradual. More amenable to treat- ment. No condylomata or mu- cous patches. No syphilitic history. TERTIARY SYPHILITIC RHINITIS. Later in life. No rice bodies. Predilection for bone equal to that for carti- lage. LUPUS. Earlier age (except her- editary syphilis). Peculiar reddish papules and rice line bodies. Predilection for cartilage and not bone. TERTIARY SYPHILITIC RHINITIS. Odor characteristic. Necrosis of bone and car- tilage. Classic symptoms of early syphilis, scars, etc. History. ATROPHIC RHINITIS. Not so offensive. No necrosed bone and cartilage. No such history or signs of syphilis, scars, etc. DIFFERENTIAL DIAGNOSIS. 103 SYPHILITIC SORE THROAT. History of infection. Inflammation slight. Little swelling. Slight rise in tempera- ture. Little pain. No difficulty in swallow- ing and opening mouth. Symmetrically disposed. ACUTE TONSILITIS. No specific history. Inflammation much greater. Much swelling. Temperature high. Pain very severe. Difllculty in opening mouth and swallowing. Usually unilateral. SYPHILITIC SORE THROAT. Syphilitic history. May be in children, if so hereditary. No emaciation. Little fever and pain. Hoarseness, no dysphagia or aphonia. Ulcer sharply defined with edges. Undermined. Situated on a thickened base with surrounding area of redness. Duration brief. TUBERCULAR SORE THROAT. Tubercular hist. sj''philitic history. Usually adults. No Rapid emaciation. High fever, much pain. Aphonia, dysphagia, dys- pnea. Ulcer superficial, indefi- nite edges, not under- mined. Grayish perforated ap- pearance. Progresses rapidly. Anaemic mucous mem- brane. SYPHILITIC ULCER OF TONSIL. Swelling and induration slight. Usually bilateral. Syphilitic history. Ulcer has indurated base. CANCER OF TONSIL. Much swelling and indu- ration. Usually unilateral. No history of syphilis. No indurated base. 104 SYPHILIS IN DENTISTRY. Edges sharply defined, undermined. May be superficial or deep. Little or no pain. No cachexia. Discharge not so offen- sive. Edges not undermined, grayish. Profuse granulations. Pain very severe before and after ulceration. Cachexia marked. Fetid discharge. MUCOUS PATCHES. Duration short. Round or oval, smaller. Seldom on cheek. Often on tip, margin and under surface of tongue. Patches thinner. Glands involved. No carcinomatous ten- dency. Patches grayish or red. XEUCOPLASIA BUCCA- LIS. May last for years. Form irregular, may grow quite large. Frequently on cheek. Never found in these lo- cations. Patches thickened. If involved, only later. Tendency to develop into carcinoma. Patches very white. PART XI ILLUSTRATIVE CASES. Illustrations of any kind often serve to impress clearly and permanently upon the mind, facts which might othei'wise be not thoroughly appreciated, and consequently easily forgotten. We, therefore, have deemed it advisable to conclude our remarks upon syphilis and its varied manifestations as pertaining or relating to the dental profession, by a series of cases taken from our own experi- ence, and from the practices of other physi- cians, which will fully demonstrate many of the points we have endeavored tO' point out in the foregoing pages. CASE 1. Dentist, American, aged thirty-two, jflrst noticed a small ulceration on the lower lip which rapidly enlarged. He applied dusting powders and ointments, which seemed to have little effect; finally the condition became so annoying that he 107 108 SYPHILIS IK DENTISTEY. consulted a, physician, who referred him to the authors for diagnosis. He absolutely denied having kissed anyone except his wife, but on questioning him, found he was in the habit of holding one instrument in his mouth while working with another. Acting upon suggestion, he produced a list of the patientsi he had treated during the previous six weeks. On going over them>, he remembered one woman who had white patches on her tongue. Upon reexamining her mouth he found several large ulcera- tions on her tongue, and both tonsils were involved. She also had enlarged cervical glands and beginning syphilitic alopecia. The woman in this case, as in many others, did not know she had syphilis. Four weeks later the secondary eruption appeared on the dentists body, and treatment was begun. CASE 2. On October 8th, 1896, there appeared in the office a young man 26 years of age, who came for consultation in regard to a peculiar eruption which had caused him much annoyance, not because of any irritation at the site of the lesions, but rather because of consequent disfiguration. ILLUSTEATIVE CASES. 109 He is an American; has been practicing dentistry for four years ; he is married and the father of two children. Had never had a skin eruption before; there was no history of gonorrhea or chancre. The pres- ent eruption occurred about two weeks pre- viously in the form of small red blotches, erythematous in appearance. It was accom- panied with violent headaches and a feeling of general debility. Since then, small pap- ules appeared on the chest, back, face and extremities, and also on the scalp. There was a general indolent adenitis present. The patient could not remember any par- ticular lesion preceding these except a very stubborn sore ( small ) upon the index finger of the right hand near the matrix of the nail. This he explained by saying he had accidentally scratched himself in this place with a dental instrument while working upon the teeth of one of his patients. The epitrochlear and axillary glands upon the right side were much enlarged and some- what tender to the touch. There was no doubt this dentist had synhilis and that his infection was either from a scratch with one of his instruments previously used upon 110 SYPHILIS IN DENTISTRY. a patient with syphilis, or infection of the wound from the patient upon whose teeth he was working at the time. The latter theory he scouted, saying that she was a very estimable woman, a, social leader, and one in whom it would be almost a crime to suspect the presence of the disease. CASE 3. A man, aged 22 years, came to the clinic of the Post-Graduate School in January. 1895, with a large papular syphilide. The glands in the neck were very much enlarged and there wasi a sore on the lower lip, at the internal border of the mucous membrane at the right side. He had not been exposed to any infection that he knew of. He had been under the care of the dentist for some weeks and remem- bered sustaining a slight injury during the course of dental work. CASE 4. A man, aged 47, an express driver, in September, 1897, first noticed a small, hard lump on the edge of the upper lip, on the left side, near the margin of the mucous membrane, which became hard and wasi accompanied by considerable swell- ing. The patient remembered that a few weeks before he had been under the care ILLUSTRATIVE CASES. Ill of a dentist and while there had received an injury at this point. The glands gener- ally were enlarged, maciilo sjphila present. CASE 5. Last year a physician from one of the Western States consulted the authors in regard to complete loss of hair from the face, head, axilla, pubes, and, in fact, he was a typical case of alopecia uni- versalis; made a very careful examination of the skin, which was negative; examined the glands and found them slightly en- larged. The glands in the neck were more enlarged than in the groin. The glands in the epitrochlear region were also enlarged. The mouth and throat showed no syphilitic conditions; asked him if he had a chancre, and he denied it point blank; examined his rectum and found two small condylomata and several mucous patches. During the ex- amination he stated that he had had an in- fection on his second finger, second joint, about four months before, which he had a good deal of trouble in healing up; exam- ined the finger and found a scar about the size of a dime. He said that the condition on the fingerwas produced by opening his office door and catching it on a thumb bolt under 112 SYPHILIS IE" DENTISTEY. tlie handle of the door. He said at the time he was treating two cases of chancre of the cervix. Diagnosing the case as one of syph- ilis, and the seat of the initial lesion the second finger, he was put on syphilitic treat- ment, and before he had left the city there were several mucous patches in the nose and mouth; corresponded with him since and he reports that the alopecia has been cured, and he is recovering from the des- pondency which followed when he found he had contracted syphilis. CASE 6. An interesting case is that communicated by Dr. Baum. In August, 1897, a patient, 25 years of age, was admit- ted to Ward 18 of the Cook County Hos- pital with a sore situated upon the right hand. The examination showed a raised sore mth a markedly depressed center, situated on an indurated base, the hand somewhat swollen and edematous. The epi- trochlear and axillary glands were much enlarged and painful. The other glands were somewhat enlarged. The patient gave the following history. About six weeks be- fore his admittance to the hospital, he was in an altercation with a friend, ending in ILLUSTKATIVE CASES. 113 a fight, in course of which he struck his friend in the mouth Avith his right hand, producing an injury on the site of the pres- ent lesion. lie states that at that time his friend was suffering from a sore on the lips. Two weeks after admission the patient de- veloped the erythemato-papular macular syphilide. CASE 7. In June 1898, Mr. K., a syph- ilitic patient, brought into the authors' office the young lady to whom he was en- gaged. She had been in the care of a throat specialist two months previously for an ul- cerated condition of both tonsils. The con- dition returned, and, on examination, mucous patches were found on both tonsils, side of the mouth, uvula and tongue. On further examination found the disappearing secondary eruption, and the initial lesion, which was located in the angle of the mouth, showing more on the inner than on the outer surface. The sublingual glands on the same side were enlarged to the size of a hazel nut. The man confessed that he had not followed the authors' instructions not to kiss an^^one, but had, on the contrary, 114 SYPHILIS IN DENTISTEY. been in the liabit of kissing tliis girl, and hence had infected her. CASE 8. A baby four months old was brought to the clinic by its sister. On ex- amination of the baby, found a secondary eruption, enlarged lingual gland, and a true chancre on the left side of the lower lip; sent for mother. On examination of her, found a fast disappearing ulceration under the left nipple. The history she gave was as follows : The flow of milk was very slow and her husband had used his mouth on her breast to, as she expressed it, hurry up the milk, and the sore appeared a month afterwards. So here we have a father in- fecting a mother's breast and her breast, in turn, infecting the baby. During one of the examinations, the sister leaned over and kissed the child to quiet it; explained the danger to her of infection, but four months afterwards she presented a chancre on her upper lip. CASE 9. Miss A., perfectly healthy otherwise, was suffering from tonsilitis. She consulted a physician who advised her to have the tonsillar abscess lanced, which was done, and immediate: recovery occurred. ILLUSTRATIVE CASES. 115 Four weeks later she was again troubled with the left tonsil, the one previously affected. This time she consulted Dr. W., who found her to be suffering from chancre of the tonsil. Careful study of the case re- vealed no other source of infection than the scalpel, with which the tonsil had been lanced. Upon inquiry it was learned that the physician had last used the scalpel upon a syphilitic patient, more than a week prev- iously, and it had been sterilized (?) previous to using it upon Miss A. PART Xlll. MEDICO LEGAL ASPECTS. The medico legal aspects of this subject are as highly important as any part of it and demand the most serious consideration at the hands of the dental profession. As we have remarked earlier in the book, ig- norance of the law constitutes no bar to becoming a defendant in an action at law, and it, therefore, behooves every practicing dentist to become thoroughly familiar with this phase of the subject. Wherever the virus of syphilis is im- planted in the slightest solution of con- tinuity of epidermis of an individual who is not already syphilitic, there will be pro- duced a syphilitic sore. As the virus is so easily communicated, especially by the mucous patch, and not only directly, but by indirect means, as saliva, blood, spoons and instruments and vessels of all kinds, it is not surprising that we so "7 118 SYPHILIS IN DENTISTEY. frequently see cases where the primary chancre was obtained while in the dentist's chair. While it is indisputable that the moral responsibility of the dentist in such cases is very great, it is our opinion that the inno- cent victim has a most excellent claim at law for mulcting in very heavy damages, the dentist who infects him, no matter how innocently and unintentionally it may have been done. It, therefore, behooves us all to meet the question fairly and frankly, and, recognizing our moral and legal re- sponsibility, to take such measures that we may not at some time pose as defendants in courts of law. Every one with whom the syphilitic asso- ciates is in danger of being infected and not to SO' inform a patient suffering with syphilis is to aid in its dissemination. Do not reason and common sense dictate that it is better to confine syphilis, if possible, in the narrowest limits, even at the expense of disquietude of the patient and possible loss of the patient's patronage, than to stand idly by, when judicious explanation MEDICO LEGAL ASPECTS. 119 might place the whole matter in another light? The assumption is reasonable that if a better understanding existed as to the danger incident to syphilis, innocent per- sons would be less frequently exposed there- to in the wanton fashion now prevalent, and to which we called attention in the pre- ceding chapters. It is only just that men and women who give or propagate syphilis should be pun- ished and we feel quite certain that any court or jury in the land would impose a heavy penalty on a dentist who caused, either directly or indirectly, a patient to acquire such a horrible affliction while help- less in his care. It is the duty of every physician to pub- lish as far as it lies in his power, the knowledge that may save life. Physicians in the exercise of their pro- fession are constantly working against their best interests by teaching the preven- tion of disease. They so fulfill their mis- sion. Dentists must do the same or pay the penalty an outraged public will certainly exact. 120 SYPHILIS IN DENTISTEY. Sterilization of instruments in this day of advanced knowledge is a foregone con- clusion and that every dentist sterilizes his instruments we have not the slightest doubt, but the question arises, is ordinary sterilization sufficient for such a virulent poison? The answer is a most emphatic negative. It is customary among dentists to ster- ilize instruments with 95 per cent carbolic, neutralize the acid with alcohol, wash with water and wipe. For ordinarv cases this is sufficient, perhaps, but not for syphilis. Every practicing dentist should have an extra set of instruments for such cases. Be- fore and after using they should be boiled in water to which is added sodium bicarb. 1 dr. to a quart of water. For a purely technical consideration of the medico-legal aspects of this subject, we recommend the reader to the many excel- lent works published on Medical Juris- prudence. COLUMBIA UNIVERSITY LIBRARY 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 rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE S£P 1^' .o' ,2 1 C28(23S)M100