The destruction of the bony, cartilaginous, and epidermic portions of the septum produces a characteristic deformity of the profile, consisting in a depression of the nose, which; deprived of its posterior support, becomes a mere mass of flesh overhanging the nasal cavity, and, in obedience to the laws of gravity, approaches the upper lip. Various other deformities may be seen as the result of destruction of other parts of the bony or cartilaginous framework of the external nose, among which we may mention one that is particularly common in the hereditary forms of syphilis, and in which, in addition to the saddle-shape, there is a complete flattening of the nose by destruction of the alæ and cartilages of the lateral walls, so that in profile the nose is not raised above the level of the face, and in the front view presents the appearance of two irregular, distorted openings, corresponding to the anterior nares, covered by a perforated plate of tissue. 1 The pharynx is a favorite seat of syphilis in all its forms. The primary chancre is found on the palatal tonsils, which are much swollen, dark blue in color, and frequently the seat of superficial ulceration, while the submaxillary and submental glands are at the same time greatly enlarged. Infection may take place in a variety of ways-by direct inoculation during improper practices, by eating with infected forks or spoons, and sometimes even by surgical instruments. It is important to mention that a chancre on the tonsil may be mistaken for diphtheric tonsillitis, tonsillary abscess, carcinoma or sarcoma of the tonsils, or for a gumma. The erythematous and papular eruptions which occur on the faucial pillars, on the tonsils, and on the soft palate are so well known that their description may here be omitted. They are never observed on the posterior laryngeal wall, but are occasionally seen in the postrhinoscopic image on the posterior surface of the uvula. Condylomata resembling papillomata are sometimes seen on the hard and soft palate, on the pillars of the fauces, and on the tonsils, in the form of pale gray nodular excres cences. The tertiary forms of acquired syphilis and the various hereditary types produce marked alterations in the pharynx. 1 1 Some instructive illustrations are found in Rang, loc. cit., Figs. 62-68. To begin with the tonsillar space, we may mention the gumma infiltrations, tumors, and ulcerations that are usually found associated with diseases in the nose and in the oral pharynx. The diagnosis in such cases presents no difficulties. It is more difficult when the nasopharynx alone is diseased. The symptoms complained of by the patient are very vague: headache, depression, lassitude, loss of appetite, and occasionally earache-nothing that might point to an exact diagnosis; and the diseased focus may remain undiscovered until for some reason a postrhinoscopic examination is made. We then find ulcerations in the roof of the pharynx, in the neighborhood of the choanæ, and sometimes on the lateral pharyngeal wall, which are readily recognized as syphilitic ulcers by their irregular outline, sharp edges, and excavated floors covered with yellowish secretions. The disease may invade the periosteum and the bone, or there may be from the beginning a syphilitic osteitis, ending in necrosis and extensive destruction of the surrounding bony walls. If the disease is situated in the roof of the pharynx, part of the sphenoid bone, if on the posterior wall, parts of the cervical vertebræ, especially the atlas and axis, may give way and cause large openings into the vertebral canal, or ulceration and severe hemorrhage from the vertebral artery may occur. A gumma on the posterior surface of the soft palate generally results in perforation of that structure, usually just below its attachment to the palatal bone, and leads to various deformities, according to the size of the perforation. If the tissue destruction is great, the soft palate is loosened from its attachment and drops down, so that if the perforation is situated in the middle line above the uvula, the latter may come in contact with the base of the tongue. In extensive ulcerations the entire uvula and large portions of the soft palate and faucial pillars may be destroyed; and as the disease is not limited to the soft parts, the palatal bone itself is often perforated, so that it is possible to obtain a view of the nose from below. The syphilitic alterations in the posterior and lateral walls of the pharynx deserve special attention, as they may be mistaken for follicular catarrh or for a chronic hypertrophic catarrh of the plica salpingopharyngea (Neumann), if they appear in the nodular form or in the form of diffuse infiltrations. The true nature of the disease is easily recognized by its tendency to cause rapid destruction of tissue. Krecke1 once saw two hard, spherical granulation tumors, the size of a pigeon's egg, on the posterior wall of the pharynx, which showed no tendency to break down, and disappeared on the administration of potassium iodid. They probably belonged to the same category as the granulation tumors described by Kuhn-Manasse. As has been stated, the tissue destructions that occur in the course of tertiary or hereditary syphilis are of the greatest importance, and their practical significance is accentuated by the subsequent cicatricial contractions and adhesions, which may lead to marked functional disturbances. While, on the one hand, destruction of the hard and soft palates produces changes in the voice and difficulty in swallowing by making it impossible to effect a closure of the posterior nares, the cicatricial contractions, on the other hand, frequently lead to stenoses in the nasal pharynx, which embarrass nasal respiration, and rarely to a stenosis in the deeper portions of the pharynx, which interferes with the ingestion of food. The scar that follows the healing of a specific ulcer on the mucous membrane has the same radiate appearance characteristically seen in the external skin after the healing of syphilitic lesions. Where there is a solid foundation, as on the posterior pharyngeal wall, the mucous membrane has a tense, glistening appearance, resembling tendon, while in the neighborhood of the isthmus the scars lead to distortions of the soft tissues. The symmetry of the posterior nares is deştroyed, the uvula is drawn to one side or rolled on itself, and the palatal ridges are distorted almost beyond recognition. Neighboring areas in the mucous membranes are frequently the seat of cicatricial adhesions, which are due to the tendency of the lesions to produce contact ulcers on opposed surfaces. Thus, we frequently see bands of adhesion uniting the posterior pharyngeal wall to the soft palate. The adhesion may be so extensive as to shut off the oral cavity completely from the postnasal space, or the adhesion may be only partial, leaving a chimney-like opening into the postnasal space, through which the secretions from the 1❝ Münch. med. Wochen.," 1894, No. 47. nose trickle down into the pharynx, as there is usually a coexistent chronic fetid rhinitis. These adhesions may be visible at the first glance on ordinary inspection, but some of them are more obscure, and require a postrhinoscopic or laryngoscopic examination for their detection. Among these we include the adhesions which are seen when the soft palate is only partly destroyed, and which take the form of a horizontal diaphragm-like membrane between the posterior surface of the soft palate, near its attachment to the palatal bone, and the posterior pharyngeal wall, or those which lead to the formation of adhesive bands in the postnasal space between the roof of the pharynx and the swollen orifices of the Eustachian tubes, or between the latter and the margins of the choanæ or the posterior pharyngeal wall. Both these forms of postsyphilitic alterations occasion great discomfort, the destructive variety interfering with nasal respiration and lending a peculiar dead quality to the voice, while the cicatricial form, by involving the tubes, leads to certain disturbances in the hearing, to be discussed later. A rare form of adhesion is one which forms between the base of the tongue and the posterior pharyngeal wall. Synechiæ between the soft palate and the posterior wall are of such frequent occurrence and give rise to such distressing symptoms that they often require operative treatment. In view of the tendency of the two divided portions of an adhesion to reunite, and thus oppose a serious obstacle to the success of the operation, it may be well to discuss briefly the conditions which explain not only the original formation of the synechia, but also its tendency to recurrence. When the soft palate performs its normal functions, and when, in obedience to the laws of gravity, it retains its perpendicular position and moves with every act of deglutition and phonation, there is small danger of the opposing surfaces becoming adherent, even when they are the seat of ulcers, as the constant movement of the soft palate would loosen any adhesive bands as fast as they formed; but when, on the contrary, the soft palate, as the result of deformity or the distortion of syphilitic scars, is brought nearer the posterior wall of the pharynx and loses its normal mobility, the conditions for the formation of an adhesion are proportionately more favorable. Neumann 1 1 "Spec. Path. u. Therap.," XXIII, p. 320. Nothnagel's " has pointed out that " adhesions are especially liable to form when the faucial pillars are totally or partially destroyed, and when, owing to an antecedent syphilitic myositis, the palatoglossus, the palatopharyngeal, and the pterygo-, mylo-, glosso-, and buccolaryngeal muscles, as well as the middle constrictor of the pharynx, fail to act." The hoarseness of syphilis, under the name of "raucego syphilitica," was formerly deemed of some importance by physicians, is still regarded among the laity as a frequent sign of an old infection. It is, therefore, surprising to learn from the statistics that syphilitic disease of the larynx is comparatively rare. Statistics based on dispensary work in diseases of the throat show a rather low percentage of laryngeal syphilis. According to Schrötter,1 8.7% among 35,826 patients; according to Rosenberg, 2 3.6% (there were 58 cases of specific laryngeal disease among 16,000 patients in B. Fränkel's polyclinic); while other authors give somewhat larger percentages, based on shorter series of cases. It might be thought that this conspicuous infrequency of the disease is due to the notorious indifference of the patients, and to the fact that many physicians do not feel called upon to devote any special attention to it, as it disappears under general antisyphilitic treatment, were it not for the fact that the investigations by syphilographers, made with a view to determining the laryngeal complications, have yielded similar results. The most reliable analysis is that made by Lewin, who, among 20,000 syphilitic subjects in his clinic, found 575 cases, or 2.9%, of laryngeal diseases, 13% of which were grave and 87% comparatively mild. Secondary syphilis appears in the larynx in the form of erythematous and papular eruptions, going on to ulceration; while the tertiary stage, which often appears as early as one year after infection (Semond 4), is represented by gummatous disease, which may manifest itself as a small nodular syphilid, as a diffuse infiltration, or as a circumscribed gumma. The symptom-complex of laryngeal syphilis further includes the ulcers due to the breakingdown of the gummatous tumors and to the perichondritis 1 See Gerber's statistics, loc. cit., p. 44. 2 Krankh. der Mundhöhle," etc., 1893; Karger, p. 306. 4 "Centralbl. f. Laryng.," X, 203. |