TROPHIC LESIONS OF THE JAWS IN TABES 
DORSALIS. 
BY 
LEO NEWMARK, M.D., 
OF SAN FRANCISCO, CAL. J 
PHYSICIAN TO THE SAN FRANCISCO POLYCLINIC. 
FROM 
THE MEDICAL NEWS, 
January 26, 1895. [Reprinted from The MEDICAL News, January 26, 1895.] 
TROPHIC LESIONS OF THE JAWS IN TABES 
DORSALIS. 
By LEO NEWMARK, M.D., 
OF SAN FRANCISCO, CAL. ; 
PHYSICIAN TO THE SAN FRANCISCO POLYCLINIC. 
Trophic changes in the jaws have been much less 
frequently observed in tabes dorsalis than the disturb- 
ances in the nutrition of the joints and the bones of 
the extremities which so interestingly vary the course 
of that most common disease of the spinal marrow. 
Although the first observations of a tabetic maxillary 
affection were published as long ago as 1868, a Ger- 
man author1 in 1891 was not able to collect more than 
1 Rosin : Deutsche Zeitschrift fur Nervenheilkunde, 1891, Bd. 
i, P- S32' This writer collated the cases reported up to that date 
and appended a bibliography to his article ; but his list is not 
quite complete. Since then Hudelo has recorded a case in 
Annales de Dermatologie et de Syphiligraphie, May, 1893, and 
Wickham has republished this case and added another in the 
same journal for January, 1894. A review of several French 
cases, most of which are referred to by Rosin, will be found in a 
paper entitled " Les Alterations Dentaires au Cours du Tab^s," 
by Lemarie and Albert Bernard in L'Odontologie, February, 
1894; a translation of this paper is contained in the Pacific Coast 
Dentist for May, 1894. In his contribution to the jubilee-volume 
of the University of Halle (" Ueber traumatische Tabes," etc., 
1894; page 27 of the reprint), Hitzig gives a brief account of a 
tabetic patient observed in 1870 who had been affected in 1863 
with the jaw-disease now under consideration. A case is men- 
tioned by Gowers in his Manual of Diseases of the Nervous 
System, second American edition, vol. i, p. 411. 2 
twenty-two cases. All of these were gathered from 
the French and German literature. Brief mention 
of the loss of teeth may occasionally be met in some 
English or American work, but no description of 
the typical tabetic disease of the jaw is presented. 
It is therefore hoped that the following account of 
a case which was observed at the San Francisco 
Polyclinic will not be deemed superfluous. 
The patient, a man forty-three years of age, came 
under observation February 6, 1894, complaining 
of shooting pains in the lower extremities. Twenty 
years ago he had three or four soft venereal sores 
followed by suppurating buboes. No syphilitic 
symptoms supervened. During eighteen years of 
married life his wife had been well and had borne 
him three children, two of whom still live and are 
healthy, while the other died at fourteen years of 
some acute disease. About eight or nine years ago 
there were two miscarriages. 
The patient was in good health until about seven 
years ago, when he was seized with his present dis- 
ease-rather acutely, according to his account. 
While lifting a heavy piece of lumber he felt some- 
thing give way in his back, and was unable to stand 
upright for several days thereafter. Then he stag- 
gered in walking, his legs yielded, and his thighs 
felt numb. A week after the injury there was com- 
plete retention of urine, and the catheter had to 
be passed during five or six weeks. The bladder 
gradually recovered to a great extent, but some 
weakness of the urinary current has persisted. For 
several years past he has experienced no normal 
desire to micturate, and passes his water at regular 
intervals, not in response to any stimulus, but as a 
matter of habit and prudence. When worried he 
is compelled to have recourse to the catheter. The 
bowels gave no cause for complaint. 3 
For over two years after the time from which he 
dates his disease he had pain in the small of the back, 
and needed the support of a cane in walking. 
When the pain ceased and his gait improved the 
lightning-pains began in the legs and in the sides 
of the trunk, sometimes darting up into the left 
arm-pit, and they have continued to torment him 
frequently. There is no girdle-sensation. Sexual 
power is abolished. There have been neither laryn- 
geal nor gastric crises. Vision is not disturbed. 
Some care is required to ''regulate his walk," 
especially when descending stairs. 
Incidentally the patient remarked that, although 
he had never suffered from toothache, he had in the 
course of the last three or four months lost thirteen 
of his upper teeth. He had previously had slight 
neuralgia in the right cheek and temple. The fall- 
ing out of the teeth was quite painless and attended 
with very little or no bleeding. Thus, while eating, 
he would become aware that a tooth was loose, 
would easily extract it with his fingers, and then 
proceed with his meal, or the tooth would not even 
require "picking" (as the patient termed it), but 
fell spontaneously into his mouth. 
He furthermore related that two pieces of bone 
had recently been painlessly cast off from the left 
side of the upper jaw. 
In the course of his illness this man had taken a 
considerable quantity of drugs, among them po- 
tassium iodid, especially during the last two years, 
but he has not had stomatitis nor been salivated. 
On the 6th of February the patient was described 
as a gray-haired individual of medium height. A 
large cicatrix in the right groin was the only re- 
minder of the venereal infection. His gait was not 
conspicuously ataxic, but the usual tests disclosed a 
moderate degree of incoordination in the lower 
limbs. Romberg's symptom was quite marked. 4 
There was the Argyll-Robertson pupil, and the left 
pupil was larger than the right. The knee-jerks 
were absent, as were also the plantar reflexes. The 
cremasteric reflex was faint on either side; the 
abdominal reflex was present and brisker on the 
right than on the left side, being rather excessive 
on the former; the right abdominal reflex could be 
provoked by stroking the upper part of the anterior 
and inner surfaces of the right thigh, as in the 
manipulation employed to produce the cremasteric 
reflex. There was slight anesthesia at the outer and 
inner borders of the feet and on the outer surface of 
both thighs; the anesthesia was more marked in 
the right gluteal region. Sensation was sa'd to be 
less acute in the left half of the abdominal surface 
than the right, but this difference was purely sub- 
jective. 
There was no anesthesia or ataxia in the upper 
extremities. The triceps reflex was not obtained ; 
the periosteal reflexes of the forearm were present. 
Sensibility in the face was normal. The special 
senses were unimpaired. Thirteen teeth of the 
upper jaw were missing; only the two central in- 
cisors and the right wisdom-tooth remained. The 
lower set was complete. 
In that part of the left superior maxilla from which 
the two fragments of bone mentioned by the patient 
were eliminated the gum1 was swollen and lacerated, 
exposing the bone and secreting pus. This region, 
as well as the rest of the upper gums, was insensitive 
to pain ; prodding the mucous membrane with hot 
needles or tapping on the exposed bone produced no 
discomfort. There was much tartar on the lower 
teeth, and the gums were irritated ; the two central 
incisors were somewhat loose and tender. This was 
1 It had been subjected to dental treatment before the patient 
came to me. 5 
the first time the patient had ever experienced any- 
thing like pain in a tooth. Apart from this, there 
seemed to be some analgesia of the lower gums 
also. Sensation in the tongue and mucous mem- 
brane of the cheek was preserved, also in the nasal 
mucosa. 
On the 26th of February the patient reported that 
a few days before he had felt something loose in the 
left side of the upper jaw, and with his tongue had 
dislodged a third piece of bone, which he brought 
for inspection. The exfoliation of this sequestrum 
was perfectly painless. The sequestrum contained 
an alveolus. After this event the erosion of the 
gum promptly began to heal, and in a short time 
only a depression in the alveolar process marked the 
site of the necrosis. One of the lower incisors, 
which was loose and tender, was extracted at about 
this time by a dentist, as it projected beyond the 
line of the teeth, and was deemed superfluous. Its 
extraction was stated to have been quite painful. It 
is well to emphasize the fact that this trouble in the 
lower jaw was solely due to the accumulation of 
tartar. There has been no disturbance since. 
Until nearly the middle of May there was no 
further alteration in the patient's dental condition. 
Then another breach was made in his epico^ M6vtuv, 
for the two remaining upper incisors became loose, 
and he " picked " one of them himself without pain 
or bleeding, while a dentist removed the other with 
almost equal ease. Soon the same process was 
established at the site of these teeth as had pre- 
viously taken place on the left side of the upper jaw, 
and on the 7th of June a fragment of bone was 
exfoliated. After this the lesion of the gum quickly 
healed. 
On the nth of June the patient complained of 
pain on the inner side of the right cheek, opposite 
the molars. Inspection revealed the presence of an 6 
ulcer of the gum, extending forward from the last 
molar about an inch, and invading laterally the 
mucosa of the cheek, but displaying no tendency 
to spread toward the hard palate. The ulcer was 
quite pale and torpid; excepting where it en- 
croached on the cheek it was analgesic ; it exposed 
the bone, which was evidently necrotic, and secreted 
considerable pus. 
At this stage of his disease the man was shown to 
several dentists who had convened in San Francisco 
to attend the'Mid-Winter Fair Dental Congress. A 
number of the teeth which had been shed were care- 
fully examined and pronounced sound. It was 
established that their falling out was not due to peri- 
cementitis, pyorrhoea alveolaris, or any other pro- 
cess with which dentists ordinarily have to deal. 
Dr. William J. Younger, a dentist of more than 
national reputation, testified that this maxillary dis- 
ease was all but unique in his very extensive experi- 
ence. 
No palpable fragments of bone were cast off from 
this ulcer, but the alveolar process was nevertheless 
undergoing disintegration, for soon a probe entered 
the antrum through the ulcer without encounter- 
ing resistance. Many weeks elapsed before a 
tendency to heal became manifest. Finally, how- 
ever, the gums closed again over the bone, leaving 
a long delicate cicatrix over the depression in the 
alveolar process and a small opening leading into 
the antrum. 
On the 25th of June the right wisdom-tooth 
dropped out, and the denudation of the upper jaw 
was now complete. A sharp-pointed instrument 
inserted into the socket of the tooth provoked no 
pain. It was now about nine months since the 
"devastation had begun," but not yet was the 
"business of destruction done." 7 
In the beginning of July, long before the ulcera- 
tion of the gums on the right side had healed, a small 
ulcer appeared in the gum on the left side of the 
upper jaw at about the site of the last molar. This 
erosion gradually extended forward until it reached 
the locality of the left lateral incisor. It was pale, 
atonic, and analgesic. Like its companion on the 
other side of the jaw, it occupied the external half 
of the alveolar ridge, tending to invade the cheek, 
but avoiding the roof of the mouth. The bone was 
exposed, and there was a discharge of thin pus. 
No fragments of bone were eliminated, but there 
was evident osseous decay, for soon the antrum was 
opened. It was not until the middle of October 
that this ulceration had healed, leaving a still 
larger depression in the alveolar process than had 
been produced by the necrosis in February, and 
the fistula of the antrum. 
At present (in the last week in October) no de- 
structive process is visible in the jaw, but a recur- 
rence must be apprehended. 
Although not pertinent to the subject under 
immediate consideration, the patient's clinical his- 
tory may be supplemented by adverting to an 
event of the 28th of June. On the morning of that 
day, as he was about to board a street-car, his left 
leg suddenly gave way at the knee; it felt "as if 
weighted with a ton," and seemed devoid of sensi- 
bility. When seen in the afternoon, the patient's 
gait was very unsteady, and he was forced to sup- 
port himself on a cane; the ataxia was now quite 
marked, but it was much more conspicuous in the 
left leg than in the right. Tactile sensation was not 
so profoundly altered as the patient's account might 
have led one to suppose, but it was somewhat 
blunted in the left lower leg and foot as compared 
with the right; there was a distinct reduction of 8 
electro-cutaneous sensibility in the former; the 
retardation in the conduction of painful and thermic 
impressions amounted to five seconds in the left 
foot and three seconds in the right; and the mus- 
cular sense was now greatly disturbed in both lower 
limbs, but especially in the left one. There was 
also some loss of power in the left foot, but the 
muscles reacted well to the faradic current. Rom- 
berg's symptom was more marked than before. 
With this acute onset, or at least sudden increase, 
of incoordination, there came a cessation of the 
lightning-pains. The appetite, sleep, and digestion 
improved, and the patient was enabled to resume 
his work (as a distributer of quack-advertisements !). 
Unfortunately, during the cool weather prevail- 
ing in the middle of August the pains recurred with 
all their former severity. Then the disturbance in 
the leg began to abate, and examination a month 
later disclosed decided improvement in regard to 
the steadiness of the gait and some diminution of 
the other symptoms. The patient now walks with- 
out any support; but the lightning-pains continue 
to torment him. 
The subjective and objective symptoms as herein 
set forth are sufficient to establish the diagnosis of 
tabes dorsalis. 
With respect to the changes in the jaw and the 
loss of teeth, this case conforms on the whole to the 
manner in which these disturbances took place in 
the majority of cases reported in neurologic litera- 
ture. A survey of all the accessible records, how- 
ever, shows certain variations in the extent and the 
rapidity of the destructive process, as well as differ- 
ences with regard to the period of tabes in which the 
maxillary disorder may supervene. 9 
The immunity of the lower jaw in the present in- 
stance is worthy of note. In no case does the disease 
appear to have involved the lower jaw before the 
upper had been affected. Either both jaws are 
seized simultaneously, or (as in the larger propor- 
tion of cases) the upper becomes diseased first. 
Years may elapse between the onset of the trouble 
in the upper jaw and the implication of the lower. 
As has been said, the shedding of the teeth and 
the destruction of the bone progress with variable 
rapidity. A few teeth having dropped out, and a 
necrotic fragment of bone having been exfoliated, 
a pause may succeed, lasting in some instances for 
years, before more teeth and more of the substance 
of the jaw undergo the same fate; or the denuda- 
tion of the jaw may be completed in a very short 
time; thus, in one instance,1 two weeks sufficed to 
deprive the upper jaw of all its teeth ; and Gowers2 
tells of a patient who found that all his upper teeth 
fell out in the course of three days, without any pain 
or decay. 
The maxillary disease may appear at any stage 
of tabes dorsalis. In some instances over twenty 
years had elapsed since the onset of the latter; in 
others fifteen, ten, seven, and four years respec- 
tively, and one individual is related by Hoffmann 
to have lost all his upper teeth in the characteristic 
way over one year and a half prior to the first typical 
manifestations of tabes. 
The dropping out of the teeth is sometimes un- 
1 Hoffmann: Berlinerklinische Wochenschrift, 1885. 
2 Manual, I, p. 411. 10 
attended with necrosis of the jawbone. In two 
such cases the patients were affected also with the 
loss of their nails, and in another there was a per- 
forating tabetic ulcer of the foot.1 
In Wickham's paper on " Ulcerations buccales 
tabetiques " (Annales de Dermatologic et de Syphili- 
graphid} a patient is described who was afflicted 
with three perforating plantar ulcers, two on one 
foot and one on the other. This individual had 
lost in a comparatively short time, without pain, all 
his upper teeth and a number of his lower teeth, 
and the alveolar process was atrophied. There was 
on the alveolar border of the upper jaw a large, in- 
dolent ulcer apparently like those seen in my 
patient, but evincing a tendency to extend toward 
the roof of the mouth ; it was anesthetic and pene- 
trated to the bone, and Fournier, considering it to be 
of the same nature as the perforating ulcers of the 
foot, proposed to call it " mal perforant buccal." 
In another case observed by Wickham and pre- 
viously reported by Hudelo, this same maxillary 
affection was not associated with trophic lesions in 
any other part. 
As far as can be judged from the description, 
there seems to be no essential difference between 
these " ulcerations buccales tabetiques " and those 
which in my patient exposed the bone. It has 
been seen that the latter are not necessarily asso- 
ciated with the elimination of appreciable fragments 
of bone, although the bone at the base is decayed, 
1 Weizsacker observed a patient with loss of teeth, necrosis of 
the upper alveolar process, and tabetic disease of the knee-joints. 
Referred to by Rosin, 11 
and that they ultimately heal in one part, while 
others form in other localities. We may agree with 
the statement of Wickham that the characteristics 
of these lesions are well marked ; indeed, they are 
so pronounced that Fournier was enabled in the 
second case which he encountered to diagnosticate 
tabes simply by inspection of the mouth. 
I have not been able to ascertain any instance 
in which this affection of the jaws accompanied any 
other nervous disease than tabes dorsalis.1 Nor 
does it seem to occur as an independent disorder, 
and its distinction from the effects of phosphorus, 
actinomycosis, and other agents deleterious to the 
jaws and teeth meets with no difficulty. Syphilis, 
which is credited with so preponderant an influence 
in the production of tabes, cannot be held directly 
responsible for this jaw-disease associated with 
tabes, and we have Fournier's authority for the 
statement that Hudelo's case was not syphilitic. 
Atrophy of the jawbones, especially the upper, 
and loss of teeth, may occur also in facial hemi- 
atrophy, but the course and the attending circum- 
stances are different in the two disorders. Their 
pathology, however, may be fundamentally identical, 
both being the supposed result of impaired trophic 
influence of the fifth nerve. It is interesting in this 
1 Westphal demonstrated in 1885 to the Berlin Neurological 
Society a man "who had been suffering for several years from 
severe neuralgia in the area of the right trigeminal, especially its 
maxillary branches, and now presented a peculiar disturbance in 
the nutrition of the gums and the teeth of the right upper 
and lower jaws." Archiv fur Psychiatrie, Bd. xvii. I have not 
met with any other reference to this case, explaining the nature 
of the "peculiar disturbance." 12 
connection to note the coincidence of facial hemi- 
atrophy and tabes dorsalis in a case reported by 
Jolly.1 
The fifth nerve has been found affected in its 
trunk, ganglion, roots, and nuclei in various cases 
of tabes which had presented symptoms in the area 
of its distribution during life. But the only ne- 
cropsies of cases in which the tabetic jaw-disease 
was among these symptoms are those recorded by 
Demange,2 who made an anatomic examination of 
an individual who, about the fifteenth year of his 
tabes, had lost in less than two months all the teeth 
of his upper jaw, one after the other, in the char- 
acteristic manner ; there was marked inflammation 
of the trigeminal nerves and atrophy of their bulbar 
nuclei. In another case observed by the same writer 
all the upper teeth on the left side had dropped out 
in the course of a month, while those on the right side 
were almost intact.3 The autopsy disclosed atrophy 
of both fifth nerves, that of the left greatly exceed- 
ing that of the other, and there was also complete 
atrophy of the left Gasserian ganglion. 
The anesthesia resulting from the disease of the 
nerve is by no means sufficient to account for the 
disturbance in the nutrition of the jaw; this has 
been proved by clinical observation and experimen- 
1 Berliner klinische Wochenschrift, 1891, p. 924. No mention 
is made in this case of a maxillary or dental trouble. 
2 Revue de Medecine, March, 1892. Quotedin L'Odontologie, 
February, 1894, p. 67. 
3 Charcot exhibited a tabetic woman with anesthesia of the 
left side of the face, loss of taste in the left half of the tongue, 
and falling out of teeth on the left side. Legons du Mardi, 1887 
to 1888, p. 85. 13 
tai research. We are constrained to assume an 
alteration of the trophic influence exercised by the 
nervous apparatus on the tissues. The trophic 
action of nerves has been as vehemently denied as 
it has been asserted in the discussions on the pathol- 
ogy of certain other lesions observed in the course 
of tabes j1 it is the failure to corroborate the theory 
of such action by experimental methods that has 
prevented its general acceptance as an explanation 
of occurrences like this disease of the jaw. The 
recent labors of Gaule2 have, however, shown how 
subtle are the conditions that determine the success 
or failure of experimental investigations on the 
trophic properties of the nervous system; it is to 
be hoped that the further prosecution of these re- 
searches may result in elucidating by experiment 
the effects wrought in cases like this by disease. 
1 See the debates at the Clinical Society of London, November 
and December, 1885. 
2 Berliner klinische Wochenschrift, 1893. The Medical News. 
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