little as we are satisfied to treat extensive specific sores on the skin with Zittman's decoction alone, but employ, in addition, lotions, plasters, and ointments in the most active manner, so little should we be content to await the effects of internal treatment in syphilitic laryngeal ulcers, for instance, on the vocal cords, without resorting to the use of local remedies before an irremediable loss of substance or erosion of the cartilages has taken place.

The form of local treatment necessary in any given case will depend upon special circumstances; but it will always be more advantageous to treat the affected places, if possible, by direct applications; we mean thereby that more good will be accomplished by penciling the ulcers in the larynx with a solution of nitrate of silver, iodo-glycerine, tincture of iodine, etc., than by inhalations. Of the latter, those consisting of iodide of potassium or iodide of sodium are to be preferred, while corrosive sublimate always gives rise to unpleasant secondary effects. Insufflations of finely powdered iodoform upon the ulcer have proved to be of great benefit.

In ulcers of the trachea local treatment is not only useful, but often absolutely necessary, especially in those cases in which there is a marked accumulation of mucus or crusts that adhere tenaciously.

PERICHONDRITIS.

This is one of the most frequent forms of disease in syphilis; and syphilis, again, is one of the most frequent causes of perichondritis laryngea. It occurs on all the cartilages of the larynx, and may start from the perichondrium itself as well as from ulcers of the mucous membrane that spread to the cartilage. The lesion may terminate in all those morbid alterations that follow perichondritis in general, namely, abscesses, spreading of ulcers, grave destruction of carious cartilages which have become ossified, exposure of the cartilage in a suppurating cavity, and formation of cicatrices, with consecutive disfigurement of the shape of the larynx.

CICATRICES.

Syphilis is the most frequent cause of scars in the larynx. It is evident, from what has been said upon the subject of ul

cers, that they may occur on any part of the larynx. In the slightest grades they require the closest inspection to see them; in other cases, again, they are extensive and characteristic, being met with in connection with ulcers on the hard palate, that has already been partly destroyed, on the root of the tongue, or lateral and posterior walls of the fauces.

The disfigurement of the remains of the epiglottis may be very extensive; we know, however, that deglutition even in cases of complete loss of the epiglottis may be accomplished without any difficulty. In scars of the posterior laryngeal wall and the vocal cords the glottis not infrequently is distorted. Those forms in which bridge-like bands originate on the aryepiglottic folds, and especially on the false vocal cords, are very remarkable. Further, those scars that are on a level with and below the vocal cords, and which either bring about adhesions between them or membranous contractions of the glottis, deserve special mention. These contractions generally occur at its anterior angle; sometimes, however, they line the larynx in an annular form.

There occurs very often from the contractions of the cicatricial tissue, and the constriction of the blood-vessels resulting from it, disturbances of the circulation, followed by marked bulbous and oedematous thickening of some parts; even new ulcers form again as the result of this pathological condition.

Cicatrices on the posterior laryngeal wall surrounding the crico-arytenoidal joint will render it immovable.

Scars often have a characteristic appearance. Still, a thorough examination of the clinical history of the case is indispensable, for other processes, especially eschars produced by solutions of caustic potash, may give rise to similar cicatrices.

A scar very much like that described above occurs also in the trachea. Cicatricial bands that transverse its lumen in the form of a network are of great importance, for a slight accumulation of the secretion at this point may occasion the most dangerous attacks of suffocation if some of the meshes of the network become plugged up, and thus reduce the caliber of the trachea.

Cicatricial contractions of the larynx may require various degrees of surgical interference. They may be so severe as to

call for laryngotomy. If membranes have formed between the vocal cords and adhesions between the latter, their division with the knife will accomplish excellent results. These bloody operations must be supplemented by the use of laryngeal bougies of gradually increasing thicknesses, according to Schrötter's method. If the false membranes or scars are not very thick, dilatation by means of bougies alone will in many cases answer completely.

Constrictions of the trachea are to be treated in a similar

manner.

NEW GROWTHS.

Gummata having been already described, those growths which occur singly or in groups, and resemble pointed condylomata, remain to be spoken of here. They are met with mainly on the soft palate, upon the arytenoid cartilage and epiglottic folds, not so often on the anterior surface of the posterior laryngeal wall and on the vocal cords. Sometimes they form such high cockscomb-like excrescences that the probe sinks in between them to a depth of several millimetres. Painting them with tincture of iodine will cause them quickly to disappear.

These new growths, according to published reports, have also been found in the trachea.

In conclusion, it is necessary to allude to those forms of disease which, although produced by syphilis, are not located in the larynx, and only manifest their influence upon this organ. Syphilitic diseased glands which temporarily or permanently interrupt the functions of the superior laryngeal nerve, or still more frequently the inferior laryngeal nerve, cause, by the resulting paralysis of the muscles of the larynx, not only hoarseness and aphonia, but even dangerous symptoms of suffocation. In these cases, the nature of the primary affection often remains an unsolved problem in physical diagnosis.

Syphilitic Affections of the Bronchi and Lungs.

From the character of the morbid lesions found after death, Virchow came to the conclusion that syphilitic ulceration, with consequent cicatrization and stenosis, may occur in the bronchi, as it does in the larynx and trachea. Syphilitic bron

chitis may merge into chronic pneumonia, and the latter terminate in hyperplastic induration of the pulmonary structures. This form of interstitial pneumonia of specific origin is said to occur idiopathically also, and lead to the formation of callous nodules, of strong cicatricial bands running through the pulmonary tissues, and of cicatricial retractions of the pulmonary surfaces. Gummosities in the lungs undoubtedly occur in hereditary syphilis; in the acquired form they have been frequently met with and described. Nevertheless, their presence is not easily demonstrable, either clinically or pathologically. We must be able beyond a doubt to exclude the presence of tuberculosis, and for that purpose take into consideration the site of the morbid deposits. Gummata occur all over the lungs, while tuberculosis, in the vast majority of cases, is found at the apices. Finally, the antecedents and concomitants, the course of the disease, and the effects of anti-specific treatment, are very useful data in diagnosis. On the pleura, too, syphilitic cicatrices, with prolongations extending into the pulmonary tissues, are said to occur.

[Pulmonary syphilis is properly regarded as a late manifestation of the disease. It occurs mainly in two forms, diffused and circumscribed. The diffused deposits are found along the course of bronchi and their ramifications, resulting in peribronchial infiltrations, whose retraction subsequently occludes the lumen of the bronchial tubes, producing collapse of that portion of the lung. If the infiltration extends to the surface of the lung, it will become apparent even before the pleura is removed. The circumscribed form occurs as gumma nodes, varying in size from that of a small kernel up to that of a walnut, and even larger, which are found imbedded in the pulmonary tissue. These gummata may undergo absorption, fatty degeneration, cheesy transformation, or softening and suppuration, but, in any event, callous cicatrices of dense connective tissue always remain. The diffused and circumscribed forms are pathologically alike, and differ only as regards their location.

This lesion, as already observed, presents no pathognomonic symptoms. But if dullness, on percussion, is found over a circumscribed space, and dyspnoea supervenes rapidly, in a well-developed, robust person, unattended by hectic fever,

and some of the late evidences of specific disease are present, the disease may be considered pulmonary syphilis. The treatment with the iodides, and the absence of tubercle bacilli from the sputa, will, perhaps, form the most reliable evidences of the nature of the disease.]

Affections of the Kidney, Suprarenal Capsule, and the Bladder.

In addition to other diseases of the kidney found in syphilitic patients, which, however, can in no way be distinguished from the pathological lesions found in non-specific Bright's disease, gummata and chronic interstitial, syphilitic, inflammatory circumscribed deposits have also been described by medical writers. A few instances of similar affections of the suprarenal capsule are also recorded.

In a few rare cases, syphilitic ulcerations and subsequent cicatrization occurred in the bladder, these processes being usually accompanied by similar lesions in the urethra (Proksch).

Syphilitic Affections of the Testicle and Spermatic Cord.

The term syphilitic disease of the testis (orchitis, albuginitis, or sarcocele syphilitica) is applied to an inflammatory affection starting from the albuginea of the organ. In consequence of this, the albuginea and the cellular prolongations that extend from it into the substance of the testis, dividing it into small lobes, may become markedly thickened by proliferation of the connective tissue. In addition to this, however, there are sometimes found, under the thickened envelope of the specifically diseased testicle, distinctly outlined nodules, as big as milletseeds, containing a firm, yellowish nucleus. These have been regarded by Virchow and others as gummata. Hence, a simple orchitis syphilitica and an orchitis guinmosa may be distinguished. But whether connective tissue alone has formed, or gummata have developed, can not be positively ascertained during the life of the patient.

A commencing syphilitic disease of the testicle generally runs a totally painless course, and, for that reason, hardly ever attracts the attention of the patient. In exceptional instances, it manifests itself by slight pains, which run along the spermatic cord, radiating toward the corresponding inguinal