THE DENTAL REGISTER.
Vol. XLVI.]	AUGUST, 1892.	[No. 8.
Communications.
Syphilitic Disease of the Tongue.
BY C. H. DARLING, M.D.
The lesions in syphilis, which may appear upon the tongue,
are quite distinct and confined to no period of the disease. It is
rarely the seat of the primary lesion, because the accidental
transmission of virus to this locality rarely happens. When
found upon the tongue, it is near the tip. It is hard, circum-
scribed, and quite prominent, varying in size from a small pea to
a large bean. The base is sloping and rounded, while the lym-
phatic glands beneath the jaw are hard and enlarged. The sore
is quite superficial and free from pain ; it differs little in color
from the surrounding tissue, and has a slight watery discharge.
The primary lesion pursues much the same course here that it
does in other localities, unless it is irritated, then it becomes
inflamed, the discharge increases, and its course is prolonged
beyond the usual period.
The lesions of the secondary stage are far more common, and
are of two kinds. Those which are formed by injury or breaking
down of mucous patches, the others formed by breaking down of
muscular and connective tissues, or by irritation by diseased
teeth.
Tubercule of mucous membrane may be sometimes taken for
syphilis, but may be recognized by the portions of tuberculous
tissues remaining behind, not fully destroyed by ulceration.
Ulceration of the tongue will be limited in its course accord-
ing to the constitutional condition of the patient, or the amount
of irritation present. The ulcers not only increase in area but
become deeper. The deeper an ulcer becomes, the more clean
cut will be the edges, and more unhealthy its appearance. The
surrounding tissues may be thickened and no healthy granula-
tions appear until treatment has been carried on for some time.
Whatever may be the cause of these ulcers they show little
tendency to inflammation. The inflammation is slight, indeed,
when compared with ulcerative conditions in other than syphilitic
persons. The second variety appears as small excoriations on
the upper portion of the tongue, at the tip or edges. They will
present no sign at first that they belong more to syphilis than to
other constitutional diseases; there will be no inflammation, only
one or two slight cracks or fissures. In all of these lesions syphilis
may be looked upon as the predisposing cause, while irritation by
the teeth is the exciting cause.
Ulcers of the secondary stage may remain a long time sta-
tionary as regards their growth, or they may slowly increase in
size; they may remain for months the same, being neither better
nor worse. Though not painful, they may be extremely sensitive ,*
this together with the slight tendency toward recovery may
cause the patient much uneasiness, and are constant reminders
to the possessor that he has syphilis.
How can one determine that the ulcers on the tongue are
due to syphilis? Sometimes this will be easy, at other times
quite difficult. When the ulcer is formed by breaking down of
tubercule, a portion of it remaining behind, the diagnosis is easy.
In syphilis the skin lesions or enlarged, lymphatic glands may
be present, at the same time, frequently there are lesions in other
parts of the mouth; then there is the characteristic absence of
pain and inflammation so common to syphilis. It must not be
forgotten that disease of the teeth may cause similar lesions or
may be an active cause in producing syphilitic lesions. Some-
times the diagnosis may be made rather by the absence of other
diseases than by the presence of syphilis, no other disease pre-
sents such a variety of symptoms or is so obstinate and unyield-
ing in its course. Healing of the ulcers of the secondary stage
leaves scars on the tongue, not deep or extensive, but plainly
visible; they are bright outlines which preserve with marked
distinctness, the shape of the ulcer as it previously existed; a
written record of past syphilis to aid us in diagnosis.
As ulcers of the tertiary period of syphilis begin in gummata,
it may be well to describe them as they form in the tongue.
When first formed and unbroken gummata may be superficial or
deep, appearing at any time in the third stage, but usually four
or five years after the primary lesion. Superficial gummata are
found on the dorsum, borders and tip of the tongue. They
form hard points or nodes of various sizes from a pin point to a
small bean, and may be felt as hard bodies beneath the mucous
membrane. They are not always well defined, but fade away
into the surrounding tissue. They are indolent at first, causing
no pain. When first noticed they are slightly elevated above the
mucous membrane. Soon this point becomes slightly reddened
and the membranes get smoother than that surrounding the
point , of disease. They are nearly always multiple, and a large
number of them may be found on the dorsum of the tongue at
one time. Soon they may become redder, softer, and in the
course of time they may break down, but in some cases they
may remain unchanged for months according to the condition
and habits of life of the patient. The deeper gummata remain
unchanged longer than the superficial.
The diagnosis of gummata is not difficult. They may be
situated on portions of the tongue not easily irritated, and show
little tendency to break down, but when irritated ulceration
begins early. A single gumma on the border of the tongue
may be mistaken for carcinoma, but the age of the patient and
previous history may make the matter clear. The deep gummata
also vary much in size. They may be single, as large as a hazel-
nut, or there may be large gummatous masses, collections of
smaller ones. They are more formidable than the superficial
and more destructive in their tendencies. They are found in any
part of the muscular portion of the tongue, but are most com-
mon near the median line. They may lie at almost any depth,
and when lying deep are noticed only as a slight bulging of the
surface of the tongue. They can be felt as rounded tumors, dis-
tinct in outline, feeling much like a foreign body in the substance
of the tongue. They are not sensitive to touch, are very indolent,
sometimes remaining unchanged for years, though their natural
tendency, like the superficial, is to break down and become
ulcers. The mucous membrane covering them is usually smooth
and normal in appearance, unless they are beginning to ulcerate.
As the disease progresses the tumor becomes softer and ap-
proaches the surface. However, rapidly they may grow they
retain their rounded or oval form, End as they approach the
surface, fluctuation may be detected in some of the larger
tumors.
When several gummata exist at the same time the tongue
may be greatly swollen; instances are known where the tongue
could not be kept in the mouth. Deep gummata may be mis-
taken for tumor, carcinoma or abscess. Innocent tumors are
usually single; deep gummata multiple; innocent tumors are
frequently lobulated—rare condition for gummata ; or innocent
tumors are clearly defined and separated from the muscular
tissue of the tongue, while gummata are not.
Cancerous lumps are single, the result of irritation, and form
opposite a carious tooth, while gumma may have no connection
with diseased or broken teeth. Cancer comes after forty years
of age; gumma may come at any age, and is usually attended
by a history of syphilis; at least in all doubtful cases the history
of syphilis should be carefully examined.
An abscess is more clearly defined than gumma, and diagnosis
may be completed by passing an exploring needle into the tumor.
Gumma may also be mistaken for a foreign body in the tongue if
there has been a preceding history of injury. Unbroken gum-
mata tend to get well if the patient is in fairly good health and
the treatment is persistently carried out. When no treatment
is employed they tend to form ulcers which pursue a varied
course according to circumstances.
These ulcers are far more formidable than those belonging to
the secondary stage. Deep fissures and extensive cicatrices form
an enduring record of the disease, which may be read while the
patient lives. There may be one large ulcer or there may be
more, according to the number of gummata which break down.
'They may be round, oval, or form deep lines or fissures. Super-
ficial fissures may deepen and at the same time widen. They
may be so numerous that they cause great deformity of the
tongue. The ulcers may be well defined, sharp cut and perpen-
dicular, or their borders may be undermined, the full extent of
the fissure not being seen until the walls are separated. The
surrounding parts may be swollen and slightly indurated, but
free from pain. The fissures are often quite sensitive and inter-
fere with mastication. Profuse salivation is frequently pro-
duced. They may become inflamed because of irritation, the
large ones presenting quite a formidable appearance, yet they
are ever chronic and indolent. When very deep there can be no
mistake in diagnosis, a single fissure might be due to tubercule,
but the furrowed tongue of old syphilitics is seen in no other
disease.
The larger ones might be mistaken for cancerous ulcers, but
•ulcers of syphilitic origin have a great liking for the dorsum of
the tongue, and that well back. They are more common in men
than in women and may sometimes be found on the tongues of
■children who have inherited syphilis. There will be a history
accompanying the condition, but no enlargement of the lym-
phatics.
Gummatous ulcers rarely heal spontaneously but may remain
indolent for an indefinite period. They may also inflame, and
extend in various directions, eating away a large portion of the
tongue. The course they pursue will depend much on the gen-
eral conditions of the patient as well as upon surroundings.
SYPHILIS IN THE MOUTH.
An early manifestation of the secondary stage of the disease
will be the appearance of mucous patches in the mouth. They
are rose-colored elevations rounded or oval in form, presenting a
surface which much resembles mucous membrane.
You should be familiar with these lesions above all others, for
in them lies great danger to yourselves of contracting the dis
ease. Sometimes these patches may not be elevated, but slightly
depressed. The surface may retain its epithelium, but that is
generally lost. At some period they are greyish-white, as though
penciled over with silver nitrate. This covering is not easily
removed ; it may not cover the whole surface but remains along
the border. They commonly appear at the angles of the mouth
and may begin in cracks or fissures. The inner border of the
lower lip is a favorite situation for these lesions, and there is no
part of the mucous membrane of the mouth 'where they may not
appear. When seated upon the tonsil they frequently ulcerate
because of the constant friction in swallowing. Another point
where they are frequently found is on the velum palati, the pil-
lars of the fauces, and the inner side of the cheek near the last
molar tooth. The gums are rarely affected.
These mucous patches are so large, superficial, so distinct in
outline, so free from pain and irritation, that they need hardly
be mistaken for any other disease than syphilis.
Erythema may be found in the mouth as well as upon
the skin and is usually confined to the neighborhood of the
fauces ; it may be so slight as to be mistaken for a slight cold.
There may be some swelling of the velum and uvula at times
causing it to hang far down, so that the question of removal will
be raised. This should never be done as the parts soon tend to
assume their normal condition, unless there be slight erosions
which end in ulceration.
When papular eruptions are present on the body they may
also be found in the mouth, but they are short lived, because
the mucous membrane is very thin and tends to break down.
The white patches found near the angles of the mouth are seen
most in smokers and are due to the constant accumulation of
epithelium. They may, in time, become erosions or fissures, are
persistent and obstinate, liable to recur even after the specific
virus has become extinct. Gummatous tumor of the soft palate
comes on insidiously and frequently does a large amount of
irreparable damage. The early symptoms are scarcely noticed.
The patient may, at first, think he has an ordinary cold. There
will be a slight tickling of the fauces followed by difficult deglu-
tition. When he attempts to swallow he may find that the
food regurgitates through the nostrils. Soon, and with little
warning, he may be deprived of the power of speech, the full
round voice being changed to a nasal whisper. When he
attemps to swallow the liquid portion wilFpass through the noBe.
How is gumma of this locality formed ? Between the buccal
and nasal surfaces may be found a small, slightly-thickened
growth seemingly composed of some deposit in the connective
tissue. It has the appearance of flattened tumor, at first hard
to the touch, but in time it begins to soften'and fluctuates like a
small abscess. Again, the infiltration may be diffuse, the whole
velum is tickened, the mucous membrane becomes red and the
mobility of the parts is much impaired.
The fluctuating tumor breaks or ulcerates through (it may
be on one or both walls). When only one side breaks it is
usually in the mouth, leaving a deep ulcerating cavity with
sharply cut edges. The destructive'process progresses rapidly, and
complete perforation soon follows. The whole velum may in this
way be soon destroyed, or only a limited portion be perforated.
When there is marked destruction the voice is greatly changed,
being nasal and of that pitch which the French term " duck's
voice." The slight pain present in the early stages has now dis-
appeared ; swallowing is not difficult, but the food, even some
of the solid portions, may come through the nose. Hearing may
be impaired because of swelling and inflammation about the
Eustachian tube. After a time the inflammation subsides and
the tissues gradually resume their normal condition. Some of
the tissue has been destroyed, hence a full recovery of the voice,
or the power of conveying the food along the proper channel to
the throat should.not be expected. Much improvement may be
effected by a properly constructed plate, such as you will find
fully described in works on this subject.
Is there any difficulty in determining that ulceration of the
palate belongs to syphilis? Such a result is likely to follow only
two causes, syphilis and tuberculosis ; the latter being a rarity
when compared with the first. Treatment can do much toward
limiting the destructive process of ulceration when it has once
begun, and surgery may often aid in repairing the damages.

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