sometimes mixed with small portions of bone. An ordinary syphilitic ostitis, or periostitis, affects the ossa nasi, by which they are frequently thickened to a considerable extent. I have seen one or two cases of this character. The secondary syphilitic diseases which affect the nose are, however, most frequent in its interior, and affect the lateral or central cartilages, the spongy bones, or the membrane covering these parts.

These diseases of the nassal fossæ very commonly occur as isolated symptoms of secondary syphilis, and under such circumstances, without a correct history of the case, their nature might be mistaken; they are sometimes the only remnants of a syphilitic taint, the health being otherwise good. I have known one or two cases where persons in such states have married, and had healthy children. These diseases are sometimes congenital and hereditary. I saw a young lady, aged 16, who had had an affection of the nose of this nature since she was three weeks old. It commenced with that snuffling so characteristic of infantile syphilis, and which I believe to be due to syphilitic inflammation of the mucous membrane of the turbinated bones: if not cured, this ends in exfoliation of these bones, and probable sinking of the ossa nasi. This happened in the case just alluded to. The father had been diseased in this case, the mother never.

The treatment is constitutional and local. The former is that of secondary syphilis generally. The local treatment consists of the vapour of the iodide or bisulphuret of mercury, or calomel, directed by a very simple process into the nassal fossa, for a few minutes daily; injections of calomel and lime-water, or solutions of kreasote, the nitrate of silver, or the chloride of zinc.

The naso-lacrymal canal is frequently obliterated by secondary syphilitic diseases of the nasal fossæ.

CHAPTER XXV.

ON SYPHILITIC DISEASES OF THE LACRYMAL PASSAGES.

SYPHILITIC diseases of the lacrymal passages are commonly associated with or produced by affections of a similar character, existing in the interior of the nose. I have in several cases scattered through this work alluded to such diseases, but here I wish to speak of them more specifically.

When, during the presence of a syphilitic taint in the system, the lacrymal passages become obstructed, and the tears run over the face, there is reason to suppose that such obstruction is due to syphilis, and that it is produced by one of two causes : 1. Syphilitic inflammation of some part of the mucous membrane of the lacrymal passages, or nasal duct. Nothing can be more likely, where the mucous membrane of the nose is affected, than that the disease should extend through the nasal duct, and terminate in its obstruction, the formation of an abscess, and subsequently a lacrymal fistula. Or, 2. Disease may be produced by affection of the bones entering into the composition of the nasal duct, such as the os unguis, the nasal process of the superior maxillary bone, or even the internal angular process of the frontal. A true venereal ostitis may exist in these bones, by which they are swollen and enlarged, and the lacrymal or nasal passages consequently obstructed, or even obliterated. I have elsewhere spoken of syphilitic ostitis or periostitis of the nasal bones. Should these diseases coexist with a well-marked syphilitic taint, and succeed to or be complicated with syphilitic disease of the nostrils or nasal fossæ, there can be little doubt of their nature: they may occur, however, as isolated symptoms of syphilis after all others have for some time disappeared, and, like syphilitic sarcocele and many other diseases which are clearly due to syphilis, may cause a doubt as to their nature, especially where the patient denies all syphilitic antecedent.1

1 See an excellent paper by Lagnean fils, Archives Générales de Médecine,' March, 1857: it contains ten original and selected cases.

R

CASE XXXIV.

Obliteration of the nasal duct by syphilitic periostitis of the nasal process of the superior maxillary bone.

A. B., a girl æt. 22, was admitted into the Queen's Hospital under my care in July, 1857, with a lichenoid eruption, ulcers on the labia, and a sore throat. The tears from the left eye flowed over the cheek. On examination, the left nasal duct was found completely obstructed. A large, distinct nodular swelling, tender to the touch, was situated in the course of the duct, extending half-way down the nose, closely resembling a node, of the nature of which it doubtless partook, being due to syphilitic ostitis of bones entering into the compositiou of the nasal duct. The disease, in this instance, was chiefly seated in the nasal process of the superior maxillary bone.

Some curious cases bearing upon this subject have been collected by Yvaren, p. 234—“ Fistula lacrymalis a lue venerea.”

Benjamin Bell, in a remarkable passage, speaks also of another mode in which the flow of the tears through the natural course may be interupted from causes of a syphilitic nature.1

1 "In some cases the venereal virus fixes upon the eyelids, and chiefly upon their cartilaginous borders. This sometimes happens by itself, but for the most part it is connected with syphilitic eruptions in other parts of the body. The parts become red and somewhat tender, and an effusion takes place among the eyelashes, either in the form of a dry scurf, or of a gummy, viscid matter. In this last case the effusion proves always extremely troublesome, particularly after sleep, as it glues the eyelids so firmly together as to render it difficult, and even painful, to open them. In this affection of the eyelids, I have in different instances observed a symptom which has not, so far as I know, been taken notice of by authors. The tears at first fall in drops near the internal angle of the eye, and this terminates in a constant trickling over the cheeks. Those who are not accustomed to examine the eyes in this state are apt to consider this flow of tears as the commencement of fistula lachrymalis, whereas it proceeds from a cause which tends effectually to prevent the formation of this disease. On minute inspection, it appears evidently to arise from the puncta lachrymalia being obstructed by the viscid matter forming upon the cartilages of the eyelids, by which the tears which should pass by these openings into the lachrymal sac, and from thence into the nose, are necessarily forced over the cheeks. In some cases this weeping state of the eyes proves to be temporary, and disappears with the cause by which it was produced; but in others it continues permanent, owing, I suppose, to the puncta being obliterated by the long continuance of the disease."-B. Bell on Lues Venerea, vol. ii., p. 142.

CHAPTER XXVI.

ON SYPHILITIC DISEASES OF THE EAR.

ALTHOUGH Syphilis doubtless plays an important part in the etiology of deafness, many modern writers on "Diseases of the Ear" are comparatively silent on the subject. Mr Wilde, however, remarks that "Syphilis has played a more extensive part in the production of deafness than the Profession is aware of." Nothing is definitely known of the effects of syphilis in the middle ear, although it is not improbable that some of the changes observed in the diseases of this part may be due to syphilis. Syphilitic diseases of the external and internal ear are, however, not uncommon, and can be definitely traced and diagnosed. The most evident cause of syphilitic disease of the ear would appear to be ulceration of the throat and fauces. I have given numerous cases, in the course of this work, of destruction of the whole of the soft palate and faucial mucous membrane by syphilitic ulceration; and in these ravages it is utterly impossible that the faucial extremity of the Eustachian tube could escape being implicated in the mischief: yet I do not recollect ever having seen a case where the hearing was totally destroyed from such a cause; although I have seen it more or less impaired. In these cases the faucial orifices of the tubes may be more or less occluded by pus, mucus, sloughs, or the cicatrices of ulcers.

M. Vidal says that he has seen the meatus auditorius filled with mucous tubercles, producing a profuse otorrhoea. Mr Wilde (Aural Surgery,' p. 261) describes an inflammation of a specific character (syphilitic) as occurring in the membrane of the tympanum. He says, "The disease appeared suddenly as an eruption was fading off, and was accompanied by loss of hair generally speaking, eruptions, copper-coloured blotches, fissures and ulcers of the tongue, and slight nocturnal pains,

preceded the aural affection. The symptoms consisted in a sensation of fulness in the head, and often vertigo in stooping or rising up suddenly; the patients have usually a feeling of fulness in the ear, but in no instance accompanied by acute pain in this consists one of the chief characteristics of the disease, that whilst it is unaccompanied by local pain, as in ordinary sub-acute inflammation, the membrana tympani will be found to present a degree of redness equal to, and sometimes exceeding, that seen in acute myringitis. The redness has generally a brownish hue in the syphilitic form; there is not at first much loss of polish, but in a short time the membrane assumes a fuzzy appearance: both ears are usually affected at the same time. The amount of deafness is always very great, and is the symptom that first attracts the patient's attention, and it seldom varies. Tinnitus is not usually present; but in two cases the deafness was ushered in by a very loud noise, which passed away in a few days. The inflammation does not end in muco-purulent discharge from the tympanum, the surface of the membrana tympani, or the sides of the auditory canal. Nor is lymph effused in the membrane; but from its brownish-red colour in the very early stage, from a yellowish speckled opacity which is generally observable in it in the subsidence of the redness, and from the intense degree of thickening and dulness present in some cases, evidently the result of syphilitic disease, it was evident that lymph was largely effused between the lamina, or on the inner surface of the membrana tympani." (P. 262). Mr Wilde states that two of the worst cases of non-congenital deafness he ever saw were the result of syphilitic inflammation; and in both there was great thickening, opacity, and insensibility of the membrane.

The treatment of these cases consists in the application of leeches behind the ear, and the administration of calomel, blue pill, and opium, and afterwards of the iodide of potassium.