## SYPHILIS TERTIARIA

### Syphilis ulcerosa nasi.

Syphilitic ulceration of the nose is a not uncommon late tertiary manifestation. It is the sequel of either diffuse or circumscribed gummatous infiltration, though the latter, that is the distinct gummatous tumor, is much more rare than the former. It is unusual to see either lesion before ulceration has occurred, probably because being painless and starting frequently on the inner wall of the nasal cavity the process does not attract attention until ulceration supervenes. Gummata of the external nose exhibit predilection for the alae and septum. Beginning in the submucous or subcutaneous tissue they spread and involve cartilage and bone, and unless promptly and energetically treated cause marked permanent deformity. The destruction produced by a circumscribed node is much less than that incident to the breaking down of a diffuse infiltration. The latter extends rapidly and after causing perichondritis and periostitis interferes with the circulation to such an extent that necrosis ensues comparatively early. The slough often appears to extend wide of the original infiltration. When the ulceration is deep and the bone has become involved the nasal discharge is frequently extremely offensive. Non-specific inflammation and ulceration often accompany the sequestration and may obliterate the characteristics of the typical syphilitic

ulcer. **DIAGNOSIS:** The history or presence of other specific lesions or scars sometimes aids in the diagnosis. When there is perforation of the septum the disease is almost certainly syphilis, although very exceptionally tuberculosis may produce the same result. *Lupous ulcers* begin at an earlier age, progress very much more slowly and never attack the bone. The syphilitic ulcer is most frequently confused with *epithelioma*, although as a rule the distinction is not difficult. The cancerous ulcer starts from a pimple, wart, mole or scurfy patch and develops slowly at first. It has an uneven floor and a firm, everted, waxy, telangiectatic border. The very rare cases in which the margin of the syphilitic ulcer counterfeits the rolled edge of the epithelioma can be differentiated by microscopic examination, serodiagnostic reaction or therapeutic test. **TREATMENT:** When there is marked secondary infection mercury and potassium iodid may not alone suffice to arrest the ulceration, but operative procedures, removal of sequestra, curetting, etc., should always be postponed until the specific remedies have had time to exert their maximum effect. Cleansing with peroxide of hydrogen or other mild antiseptic lotion, and dusting with calomel are local measures that should be employed from the start.

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## SYPHILIS TERTIARIA

**Syphilis ulcero-serpiginosa.**

The ulcerative tendency of a tubercular syphilid may exist from the earliest appearance of the lesion or show itself only after a group or patch of tubercles has formed and lasted for some time. The ulceration may be deep or shallow and may attack all or only a few of the tubercular lesions, so that in some patches both tubercles, ulcers and crusts are present. There is the same disposition for seg-mental grouping and circinate contour that the tubercles themselves display. The ulcers travel slowly over the skin by healing and scarring at one margin and advancing at the other. The advancing edge is usually elevated and convex. The spreading ulcer may form a large arc of a circle, seldom does it form a complete ring. More often the pattern is composed of several discrete punched-out ulcers occupying the periphery of a cicatricial area. The scars are soft and at first brownish red, later white, except upon the legs, where the pigmentation may be permanent. The only subjective symptom is oc-casional slight tenderness.

DIAGNOSIS: A circumscribed, soft, irregular, pale scar, with here and there the small round depressions left by individual tubercles is almost pathognomonic of syphilis. In the active syphilid the serpiginous formation, method of spread and the color, together with the history and sometimes the scars of earlier lesions, usually suffice for a positive diagnosis. *Lupous ulcers* usually start earlier in life, are superficial and incomparably slower in development, the edges are brighter red, softer and often undermined, and applejelly nodules are frequently to be found; the scars are more diffuse, tough and deforming. An *epitheliomatous ulcer* begins as a pimple, wart or keratotic patch, is usually a single lesion on the face, and its sharp border is almost invariably in some part typically hard, everted and waxy-looking, with dilated capillaries crossing it. **TREATMENT:** It is unusual for any except the early and superficial ulcers to heal spontaneously, although almost invariably they all respond rapidly to specific constitutional treatment with mercury and potassium iodid.

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