ids, and gummata in the tertiary stage. The cases recorded in the literature are comparatively few, and confirm what we learn from statistical sources of the infrequency of these complications. The course of the papular form in the external meatus is remarkable; it was first carefully described by Stöhr1. The wall of the meatus at first shows a muddy, bluish-red discoloration; this is followed by swelling and diffuse redness embracing the tympanic membrane, in which Stöhr also observed similar muddy, bluishred patches. A few authors (Kretschmann, Lang) observed papules on the tympanic membrane, described by Lang as pale, glistening patches, the size of a millet seed, over the processus brevis. In the auditory meatus the papules lead to excoriations; the walls become very much swollen, and there is a copious flow of bloody, purulent fluid. Later, these excoriated patches become the seat of excrescences which eventually lead to the formation of condylomata presenting themselves as villi or polypoid structures with small bases, either within the external meatus or protruding from the canal. According to Christinneck, there is a tendency to the formation of circular ulcers at the entrance of the external auditory meatus. The diagnosis of these affections is based on the presence of constitutional syphilis, as they are very easily confounded with otitis externa eczematosa or with granulations due to some other cause. 6 Gummata have been described on the external ear (Hessler 2), on the bony wall of the external auditory meatus (Brieger, 3 Habermann 4); on the tympanic membrane (Baratoux 5); in the mastoid process, both central (Schede, Haug 7) and in the periosteum (Pollak,8 Brieger 3); they present no special characteristics. These affections all yield to antisyphilitic treatment, but they leave scars which may produce marked stenosis of the external auditory meatus, or periosteal deposits and exostoses on the bony portions of the external meatus and on the mastoid process. The pharyngeal orifices of the Eustachian tubes may 1❝ Arch. f. Ohr.," v, p. 130. 3 Beitr. z. Ohrenheilk.," p 161. 5 Rev. mens. de lar.," 1885, No. 7. 2" Arch. f. Ohr.," XX, p. 242. 6 Quoted from Kloos, "Schwartze's Handb.," I, p. 486, 29, No. 14. 7 Arch. f. Ohr.," XXXVI, pp. 201, 202. 8 See "Arch. f. Ohr.," XVIII, p. 204. share in the syphilitic process in a variety of ways; they may be the seat of primary syphilis in consequence of infection by a polluted catheter, or they may be attacked during the secondary and tertiary stages in connection with the postnasal space and become involved in the resulting cicatricial contractions and adhesions. The seat and the nature of the disease are easily demonstrated by a rhinoscopic examination after symptoms in the middle ear, retraction, opacities, difficult hearing, and tinnitus aurium have aroused the suspicion of tubular occlusion. Suppuration from the middle ear is common in syphilitic subjects. So far, our clinical and anatomic observations do not justify us in regarding it as a specific suppuration, since it has not been possible to demonstrate the occurrence of irritative syphilitic processes in the middle ear, although theoretically the existence of syphilitic disease of the middle ear seems plausible. "Authorities in the main agree that in acute and subacute simple, as well as in acute and chronic purulent, affections of the middle ear occurring in the course of syphilis, the nasal and pharyngeal disease plays an important rôle" (Bezold 1). The same etiology may be assumed for suppuration from the middle ear in hereditary syphilis. Fournier,2 it is true, says that these suppurations may constitute the primary manifestations of hereditary syphilis, and mentions the absence of pain as a characteristic symptom in such cases, but his observations are not satisfactory from an otologic standpoint, and do not carry much weight. Exudative inflammation of the middle ear is mentioned by Schwartze 3; and Kirchner 4 subsequently observed such a case, which was, however, complicated by the existence of ulcers in the nasopharynx. At the autopsy Kirchner found in the middle ear, besides a serosanguineous exudate, round-celled infiltrations, split-pea-shaped neoplasms in the bone, and a constriction of the bloodvessels, which he interpreted as a syphilitic endarteritis. Kirchner's case is, however, not very convincing, and it seems remarkable that in his microscopic investigations he did not take any account of the fact that the cadaver had 1" Arch. f. Ohr.," xxI, p. 260. 2 Lectures on Late Hereditary Syphilis, translated by Körbl and Zeissel, 1894, p. 150. 3 Arch. f. Ohr," vi, 267. 4"Arch. f. Ohr.," XXVIII, p. 172. been in water several days, and that he found no postmortem changes. Finally, a form of sclerotic middle-ear catarrh has been described as a consequence of syphilis. Gradinego 1 and Chambellan assume a sclerosis of the middle ear, which the former explains as a parasyphilitic affection in hereditary lues. 1 2 There is a form of syphilis affecting the nervous apparatus of the organ of hearing the existence of which is based solely on clinical observation. During the tertiary, and even more frequently during the secondary, stage, a few weeks after the appearance of the skin eruption, the patient suddenly complains of severe headache and loss of hearing, which may go on to complete deafness within a few days; the condition is always accompanied by tinnitus aurium or other subjective noises or harmonic tones, sometimes with vertigo and vomiting, and Schwartze 3 adds to these symptoms a reeling gait in the dark. The disease is usually unilateral, occasionally bilateral. Otoscopic examination reveals no alterations, but the functional test shows that the lesion is in the nervous path: Rinne's test is positive, and when the tuning-fork is placed on the head the tone may suddenly change to the healthy side; frequently there is inability to hear high-pitched notes. 4 Gradenigo describes three different varieties, according to the course of the inflammation: a slowly progressing, a rapidly progressing, and one with apoplectiform onset. Fournier very correctly points out a similarity between the latter form and the loss of hearing in tabes, without, however, recognizing an etiologic connection for all cases. In the hereditary form there is a disease of the inner ear analogous to that which occurs in tertiary syphilis. It occurs principally between the ages of ten and twenty (six to eighteen), and is frequently associated with interstitial keratitis and Hutchinson's teeth, although it is much rarer than the ocular disease; Fournier met with it in only 40 out of 212 cases. Gradenigo says that the power of hearing often varies from one day to the next, but except for this, and the fact that the disease is always painless and bilateral, it does not differ from the form seen in acquired 1" Arch. f. Ohr.," XXXVIII, p. 310. 2 Ann. des mal. de l'oreille," 1895, p. 267. syphilis. There is, however, a marked difference in the matter of prognosis; for, whereas secondary and tertiary nervous diseases of the ear may be favorably influenced or even cured by antisyphilitic treatment if they are taken in hand early, the prognosis in the hereditary form is unfavorable. The term "nervous disease of the ear in syphilis " has been used designedly, as the seat of the lesion is unknown. The value of the investigations in regard to histologic changes in the labyrinths of syphilitic subjects is impaired by the fact that the etiology in these cases of alleged hereditary syphilis is doubtful (see Gradenigo 1); and, in the second place, the changes found in secondary and tertiary syphilis described as round-celled infiltration, calcifications, and hyperemia are so general that nothing is gained for the pathology by the recording of such doubtful cases, which can only by much ingenuity be brought into harmony with the classic description of syphilis. There is a general tendency to ascribe syphilitic deafness to disease of the vestibule and of the first turn of the cochlea, but there is nothing to justify such an assumption, and the seat of the disease might just as well be placed in the nerve-endings or in the nerve-trunk itself. In an interesting variety of cases the loss of hearing is due to direct lesion of the auditory nerve or of its centers by a gumma in the brain, or gummatous basal meningitis, or cerebrospinal meningitis; for the auditory nerve may be implicated in this disease as well as any of the other cranial nerves. Such a case is described by Oppenheim, 2 who in another place (p. 16) remarks that "it may eventually be possible to demonstrate the same symptoms in the auditory nerve-which, up to the present time, has been rather neglected (treated like a stepchild)—that have been accurately observed in the ocular, motor, and facial nerves." Schwartze3 mentions a case of intracranial syphilitic paralysis of the left auditory nerve, associated with paresis of the left arm and paralysis of the tongue, but without facial paralysis; Gradenigo quotes a case from Helmet of suddenly developing deafness in a young syphilitic woman, in which, at the autopsy, scattered foci of encephalitis were found, one of them at the exit of the auditory nerve-trunk. 1 "Schwartze's Handb.," II, p. 431. 2 46 Syphil. Erkrank. des centr. Nervensystems," 1890, p. 30. 3“ Arch. f. Ohr.,” Iv, p. 267 (1869). “Schwartze's Handb.,” II, p. 529. X. DISEASES OF THE EYE. 1. RELATIONS BETWEEN THE EYE AND THE NOSE. DURING the past few years particular attention has been directed to the relations existing between the eye and the nose, and it is being recognized more and more that pathologic conditions of the nose play an important part in the genesis of ocular diseases. Although the cases that tend to throw light on this etiologic connection are not numerous, they are all the more convincing. Seifert,1 in a series of investigations in v. Michel's eye clinic, found nasal disease in all but 2 among 38 cases of dacryocystoblennorrhea. In another series of 48 cases the nose was regularly involved. 2 Winckler, among all the children which he examined in the course of three years in the Children's Hospital at Bremen, found the nose diseased in 50% of those suffering with scrofulous eye disease, and Ziem3 gives it as his belief that two-thirds of all cases of ocular disease are due to disease of the nose. It is often difficult to determine after a single examination whether or not there is any connection between the nose and the eye, as the conditions in the nose are much influenced by the presence of swelling, and the amount of mucus is variable, especially in scrofulous patients, who furnish the bulk of the material. Hence, the question whether or not the nose is diseased depends more or less on the judgment of the examiner and on his standard of regularity in structure and degree of moisture for the normal nose. Ziem appears to have the highest standard in this respect, and this may explain his large percentage of nasal disease accompanying disease of the eye, and, as will |