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atrophic, form of rhinitis were common affections amongthe citizens of ancient Greece and Rome. Finally, as theterm ozaena, especially when used in the sense of a stenchfrom the nostrils, serves to express a number of differentpathological states, and in the light of our present knowl-edge concerning atrophic rhinitis, it is illogical to main-tain that the ancients were acquainted with the nasalform of syphilis because of the frequent allusion to ozaenain their medical writings.

The foul mouth, hoarse voice, and snoring respirationof the cunnilingus, fellator and irrumator 8 have beenthought to indicate syphilitic affections of the throat, but,as I have suggested elsewhere, they were doubtless thesymptoms of a catarrhal process acquired in the dischargeof their filthy occupations.

Reiskes thus describes the cimedus or sodomite : “ Inkiaribus et in palato vitium, a qua clare non potuerinteloqui, sed, stertere et rhoncissare debuerint.” 9

ITlie value of this passage iu evidence, it seems to me, turnsupon the rendering of the word vitium (and not, as Ro-senbaum 10 and others maintain, upon the verb peyxeiv )>which may mean anything from a simple inflammatorycondition todestruction by ulceration ; and it may be withequal justice contended that the affection described byReiskes may be referred to the advanced forms of hypertrophic naso-pliaryngeal catarrh. At all events, there isno possible reason why we should lay the affection ofthe sodomite at the doors of syphilis.

Equally uncertain is the evidence adduced by the samewriter 11 from the disease of the armpits among the Les-bians, which destroyed their noses and voices, and wassupposed by Dio Crysostom, who drew attention to it, tohave been the angry visitation of the goddess Aphrodite.

If now we turn to the passages which have been takenfrom the satirical writers of antiquity, the same uncer-tainty is found. The following are the only ones, itseems to me, worthy of the slightest consideration. Thefirst is taken from Martial ; a certain Festus, after liefouud that a dire disease had invaded his fauces, andcrept into his countenance, committed suicide.

“ Indignas premeret cum tabida faucesInquo ipsos vultus saperet atra lues.” 12

The second is also from Martial, and refers to the de-bauchee and sodomite :

“ Qui recitat lana fauces et colla revinctusHie se posse loqui, posse tacere negat.” 13

Now, it is perfectly obvious that the disease from whichFestus was supposed to suffer may have been a cancerousor other malignant affection ; and in the case of the de-bauchee it is manifestly absurd to infer the existence ofsyphilis from what was most probably a simple sorethroat.

In the fifteenth century there lived an obscure poet, byname Pacificus Maximus, who, in spite of his apparentlydissolute tendencies, as reflected in a volume of wantonpoems published by him in 1489, managed to eke outa lascivious existence of exactly one hundred years.*Among his poems is the following invocation of Priapus,which"possesses a certain historical value :

“ Tuque meum si non properas sanare Priapum,Decidet heu ! non hoc nobile robur erit.Ante meis oculis orbatus priver, et anteAbscissas foedo nasus ab ore cadat!

» Non me respiciet, nec me vollet ullapuella,In me etiam mittet tristia spata puer,Lsetior heu ! toto me non erat alter In orbe !

Si cadet hie, non me tristior alter erit.Me miserum ! Sordes quas marcidus oreremittet!Ulcera quae foedo marcidus ore gerit!Aspioe me miserum, precor, O ! per poma, per hortos,Per caput hoc sacrum, per rigidamque trabem,Hinc ego commendo tota tibi menta, Priape,Fac valeat, sic sit sanus ut ante fuit.” +

In connection with the early origin of the venerealcomplaint I wmuld like to call attention to the follow-ing passages, which I discovered accidentally while en-gaged in an historical research foreign to the subject now

f LARYNX, TRACHEA, AND BRONCHI, SYPHILISOF THE. Historical Sketch.—It is not the purpose othe present article to discuss the antiquity of the venereacomplaint, but simply to briefly review the evidence oits ancient origin as far as it relates to affections of tinnose and throat. As some of the weightiest argument!in favor of the remote existence of syphilis rest upon thensupposed early recognition of specific disease of the up-\per respiratory apparatus, it may be interesting to ex-amine the reasons alleged for this assumption, which hasbeen defended with so much talent and erudition.

It has been maintained by some that certain passagesin the ancient records of Chinese and Hindu medicinerender it probable that syphilitic affections of the noseand throat have been recognized from the earliest times. 1

The evidence deducible from the researches of Dabryis, however, as Verneuil 2 has pointed out, inconclusivein view of their many chronological inaccuracies, whilethere is no sufficient reason for the belief that the diseasedescribed in the Ayur Veda is the affection which wenow recognize as syphilis.

Both Hippocrates 3 and Galen 4 allude to falling in anddepression of the nose from recession of the palate bones,and they and their followers refer to destructive ulcera-tion of the larynx, trachea, and nose. Aretseus, 6 in hisfamous and much-discussed description of the diseasecalled uva, asserts that the palate bone is sometimes laidbare, and that the ulcerative process spreads over to thefauces and even the epiglottis ; but these isolated obser-vations furnish obviously slender data upon which tobase the antiquity of the venereal complaint.

The attention paid to, and the frequency with whichthe disease called by the Greeks ozama, is encountered inthe writings of the ancients, are at first sight naturallysuggestive of their acquaintance with syphilitic affectionsof the nasal passages; but, if we reflect upon the sensein which this term was employed by the large majorityof physicians and grammarians of those times, we shallbe obliged to confess that it forms an uncertain elementin the chain of evidence which links the nasal syphilis ofto-day with the ozsena of the Greek physicians.

By many of the ancient medical waiters ozama andpolypus are used as convertible terms, and the cure ofthe two affections is considered under the same head.

In this sense, too (i.e., as synonymous with polypus),the term is used by Pliny; and even among the laterLatin grammarians the appellation ozeenosus was appliedto those who suffered from nasal polypi. It is exceed-ingly probable, then, that the term ozaena did not carrywith it the same significance which attaches to its use atthe present day. The ancients have left but scanty rec-ord of the measures they adopted in cleansing the nasalpassages, and indeed, if we consider their notions con-cerning the pathology of nasal discharges, it would notbe surprising if they neglected that important processaltogether. A form of instrument, the rhinencliytes, forinjecting the nasal cavities, is mentioned by Aurelian 6and Scribonius Largus, 1 but it is highly probable thatthe important hygienic measure of systematic cleansingand disinfection was neglected, and that the secretionwas allowed to accumulate and decompose within thenostrils—a condition which we know favors the de-velopment of a peculiar odor even in simple catarrhalinflammation of these cavities. It is, moreover, veryprobable that the hypertrophic, and consequently the

* Born 1400, died 1500.tAttention was first cailed to this poem by Sanchez, in the Journal de

Vandermonde forOctober, 1759, tom. ix.

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under review. The sonnet is one by Sulpicius Luper-cus Servastus, Junior,* and runs as follows :

“ Atqni sunt, quod propter honestum rumpere foedus,Audeat inlicite pallida avaritia.Romani sermonis egens, ridendaque verbaFrangit ad horrifleos tarbida lingua sonos.Sed tamen exvultu adpetitur spes grata nepotum.Saltern istud nostri forsan honoris habent.Ambusti torris species, exesaque secloAbduntur priscis corpora de tumulisPerplexi crines, frons improba, tempora pressa,Extantes mala deficiente genreSimatque jacentpando sinuamine nares.Territat os nudum, cresaque labra treinent.Defossum in ventrem propulso pondere tergumFrangitur, et vacuo crure tument genua.Discolor in manibus species, ac turpius illud,Quod cutis obscure pallet in invidiam.” 14

Leaving now the question of the ancient recognitionof the throat and nasal lesions of syphilis, and comingdown to the close of the fifteenth century, when the af-fection is generally supposed to have been discovered, wefind that the earlier writers on the lues venerea lookedupon “softening” of the uvula, ulceration of the pha-rynx, tonsils, and fauces, perforation of the palate, catar-rhal and destructive disease of the nasal passages, and ahoarse and raucous character of the voice as diagnosticsigns of the disease. 15 Among them Frascatorius, 16 inhis celebrated poem on syphilis, speaks of affections ofthe voice and obstruction in the pharynx, and AlexanderTrajanus Petronius 11 (1566) refers to liquids taken bythe mouth returning thereby, and to chronic hoarseness

Cvox rauca perseverans) as symptoms of syphilitic infec-tion. Both Maynardi 18 and Fallopius mention diffi-cult breathing from disease of the larynx and trachea,and tinnitus and other symptoms referable to disease ofthe ear were observed, among others, by Botallus, Tomi-tanus, and Petronius.

While these writers were doubtless thoroughly conver-sant with the ravages produced by syphilis in the noseand pharynx, and with affections of the voice and respi-ration, nothing definite was known concerning the patho-logical changes in the larynx until about the middle ofthe seventeenth century, when Marcus Aurelius Severi-nus 19 found in the body of a girl, dead of syphilis, theepiglottis completely destroyed by ulceration. Thiswriter 20 seems also to have been familiar with ulcerationof the trachea, bronchi, and oesophagus.! In 1678 Gun-ther Christopher Sclielhammer 21 adverted to dryness ofthe larynx from ulceration of the uvula, and in the earlypart of the following century Yercollonius 22 gave asystematic account of syphilitic affections of the tonsils,pharynx, larynx, trachea, and oesophagus. Later on thesubject of throat syphilis, from a clinical standpoint, wastreated of in detail by Boerhaave, 23 Astruc, 24 Plenck, 25Benjamin Bell, 26 John Hunter, 21 and Swediaur, 28 whileMorgagni 29 directed attention to the anatomical appear-ances of the affection. Among the writers of the eigh-teenth century Raulin 30 seems to have been acquaintedwith syphilitic ulceration as it affects the larynx, trachea,and oesophagus.!

At the beginning of the present century Thomann 31drew attention to syphilis of the windpipe, and Alten-

hofer 32 announced, in a very valuable paper based onextensive experience, that tracheal phthisis is often theresult of malignant or neglected syphilitic throat ulcera-tion.

The impulse given to the pursuit of pathological anat-omy by the colossal labors of Morgagni led, among otherthings, to the study of ulceration of the upper air-pas-sages and to the publication of a number of special trea-tises on the subject, 33 which culminated in the classicalm6moire of Trousseau and Belloc. 34 These observers, aswell as those who preceded them, included syphilis, tu-berculosis, and other chronic laryngeal affections underthe generic term “phthisis laryngea,” and this confusionpractically reigned until the introduction of the laryngo-scope, and the pathway to differential diagnosis wasopened by the laryngoscopic studies of Tuerek. 35

Syphilis of the Larynx.—Statistics differ widely asto the frequency with which syphilis attacks the larynx.While the elementary character of the present work pre-cludes a critical examination of the sources of error dis-coverable in the antagonistic reports of different observ-ers, it may be said, in general, that reconciliation ofdiverging opinions upon this subject can only be accom-plished by taking the life-histories of the cases uponwhich the statistical evidence is based. Were this methoduniversally adopted,we believe that few syphilitics wouldbe found who had not, at some period or other of the dis-ease, suffered from some form of laryngeal affection.

The delicate structure of the larynx, the irritation towhich it is exposed in the natural discharge of function,or in the unnatural exercise of the same from disease ofadjacent and communicating organs, as the nose andpharynx, the common invasion of its structures in otherforms of acute and chronic blood-poisoning, and its fre-quent exposure to a host of other unfavorable influencesfrom direct or reflected irritation, furnish, & priori,grounds for regarding this organ as a frequent seat ofthe manifestations of constitutional and hereditary syph-ilis. The impairment of nutrition induced in its struct-ures by the circulation within their substance of a viti-ated fluid, and the consequent vulnerability of its mucousmembrane to the causes that determine catarrhal condi-tions, predispose, among other things, to the phases ofso-called secondary inflammation, while its wealth infibrous tissue and fibro-cartilage doubtless invites inva-sion by the tertiary processes of the disease.

While it is therefore probably true that the majorityof cases of constitutional or hereditary syphilis, if un-treated or neglected, will sooner or later develop somephase of laryngeal disorder, it is equally certain that theeruption of the disease in the larynx can be preventedor modified by early therapeutic interference. As thevirulence of syphilitic lesions in general is modified bythe employment of the more advanced and rationalmethods for its cure, so the destructive affections of thelarynx are less frequently met with now than in thetime when the therapeutics of the disease were less per-fectly understood, and when the exhibition of mercury tosalivation was the catliolicon of the profession.

Certain it is, that the proportion of the more destruc-tive forms of laryngeal syphilis is small, compared withtheir constancy and the terrible ravages to which theygave rise, as described by the writers of the fifteenth andsixteenth centuries. While, therefore, it is safe to affirmthat the proportion of cases of laryngeal disease in syph-ilis has been notably diminished by the rational use ofmercury, and especially by the tonic treatment of the dis-ease, as formulated by Iveyes, 36 the injudicious use ofthat drug, on the other hand, may be looked upon ashaving, contributed in the past in no small degree to thedetermination of the disease to the throat. For when werecall the extensive ulceration of the pharynx and larynxsometimes produced by mercurials, and the free way inwhich the latter were often administered, 31 it is easy toconceive of the disastrous influence of their incautiousadministration upon structures peculiarly obnoxious tothe ulcerative forms of syphilis.

The time elapsing between inoculation and invasion ofthe larynx varies greatly. Lewin, 3B who has given this

* Nothing is known concerning the age at which this member of theSulpicii lived, the only trace of his literaryexistence being preserved inthe above.t Severinus’s observations were made in the post-mortem room of alarge hospital for venereal complaints, and must be regarded as the firstpathological researches in the direction of syphilitic affections of thelarynx.t In the sixteenth century Schenck, of Grafenberg (Observat. mediciede capite humano ; hoc est exempla capitis morborum, etc., obs. cccxlix.

P; 397, Basilias, 1584) spoke of the “gula ex ulcere Gallico exesa pro-cidens devorata,” and also of perforation and loss of the palate (ob.cccxlvii., from Par6). In 1778 Andrew Duncan (Medical Cases, etc.,p. 1 et seq., Edinburgh, 1778) called attention to dysphagia resultingfromincreased sensibility of the pharynx from pre-existing syphiliticsore throat; and Zeviani (quoted byVoigtel, Handbuch d. path. Anat.,Bd. ii., Halle, 1804) placed on record a case in which a syphiliticulcer ofthe windpipe communicated with the oesophagus. I would also call at-tention to the fact that Dolasus (Encyclopedia chirurgica rationalis,etc., ii., cap. v., p. 276, Francofurt. ad Mcenum, 1703), in his chapter onstrictures of the oesophagus, observes, “aliquando angustia haec fierisolet a caruncula gulss ex ulcere venereo aborta.” These cases of oesopha-geal syphilis may be added to those collected from the older literature ofthe subject byAstruc, Van Swieten, and Lieutaud.

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particular attention, asserts that the minimum period isfrom two and a half to three months, while in the well-known case of Turck, the laryngeal affection developedthirty years after infection. 39

The rarity of primary inoculation of the pharynx andtonsils precludes the framing of any definite conclusionsconcerning the rapidity of subsequent laryngeal invasion,nor has any relationship been established between the se-verity of the respiratory lesions and the size of the pri-mary sore. Reasoning by analogy, however, it might besaid that an early invasion of the larynx may be lookedfor in primary disease of the tonsils, and that the de-structive tendency may vary with the character of theinitial lesion.

The laryngeal lesions of syphilis are superficial anddeep. Superficial changes usually appear early duringthe secondary stage of the disease, while the deeper, de-structive lesions occur later, in the period of tertiary phe-nomena. The laryngeal inflammation is therefore, as arule, associated with the corresponding external phenom-ena of these periods.* This relationship between thelaryngeal and cutaneous lesions is, however, by no meansinvariable, especially as regards the superficial lesions,and even deep ulceration may be met with at an earlyperiod of the disease.

It sometimes happens that laryngeal inflammation andulceration appear many years after the constitutionalmalady has run its course, and lesions of the pliaryngo-laryngeal tract are occasionally encountered without an-tecedent cutaneous or visceral changes. In several casesseen by me, it was from the appearance of ulceration inthe larynx that the patients and their attendant first be-came aware of the previous existence of the initial lesion.This remarkable tendency of syphilitic lesions to maketheir appearance in some portion of the upper respira-tory tract long after the affection has apparently run itscourse, or without antecedent cutaneous and visceralphenomena, is especially worthy of note, and also thefact of their isolation, under these circumstances, in thenose, pharynx, larynx, or trachea, without disease of adja-cent or communicating organs. Syphilis of the larynxis generally consecutive to inflammatory changes in thepharynx or nasal passages, but occasionally occurs as anindependent affection. In rare instances it is the resultof extension from the trachea. The age at which thedisease appears will depend, of course, upon the time ofinfection, and, as men are more exposed to the excitingcauses of inflammatory affections of the larynx, it ismore frequently met with in the male sex.

The experience of the writer as regards the relativefrequency of secondary and tertiary lesions is in favor ofthe more common occurrence of the former, if the sim-ple catarrhal affections of that period be included underthe head of true syphilitic phenomena.

Varieties.—The lesions of laryngeal syphilis are patho-logically separable into two main groups, correspondingto the secondary and tertiary periods of the constitutionalaffection. In addition to these, there is a class of casewhich cannot be assigned to either extreme, and whichbelong to what Whistler 40 has aptly termed the “inter-mediate ” period.

I. Lesions of the Secondary Period.—In this stage themucous membrane and submucous tissues are the struct-ures involved, and the appearances consist either in tran-sient or permanent liyperaemia, or in well-defined ca-tarrhal inflammation. The former presents nothingcharacteristic, the latter is differentiated from simple in-flammation by the less pronouncedcharacter of the hyper-aemia, and by the tendency to multiple superficial ulcera-tion. There is, however, nothing absolutely characteristicin the anatomical appearances of this form of syphilis.The mucous membrane is, as a rule, paler than normal,sometimes even almost white, and the presence of minuteulcers, especially in number, and associated with similar

appearances in the pharynx, is of value in the anatomicaldiagnosis of syphilis.

In the laryngoscopic image the existence of a brownish-red, mottled appearance of the vocal cords, especially ifthe condition be symmetrical, togetherwith erosions orsuperficial ulceration of the edges of the vocal cords, onthe free border and posterior surface of the epiglottis orventricular bands, should lead to a suspicion of the spe-cific nature of the inflammation.

While these appearances are strong presumptive evi-dence in favor of the existence of syphilis, it were moreprudent to look for other phenomena and historical databefore giving a decided opinion. The ulcers of this pe-riod are either follicular in origin or result from thebreaking down of the more superficial portions of themucous membrane. These minute losses of substanceoften coalesce to form a large ulcer with well-defined,elevated walls, and grayish-mottled base, which, in heal-ing, leaves a small, somewhat depressed cicatrix. Thislatter from a clinical standpoint offers weighty evidencein favor of syphilis.

Whether ulceration of the laryngeal mucous membraneever results from inoculation by the pharyngeal secre-tion cannot be affirmed with any degree of positiveness.

Mucous patches and condylomata. The utmost con-fusion prevails concerning the occurrence and frequencyof mucous patches in the larynx. While their exist-ence in this organ is strenuously denied by some whohave specially investigated the subject, the very oppositeopinion is entertained by equally competent observers.In a large number of patients with laryngeal syphilisthat have come under the observation of the writer, herecalls but one case concerning the nature of which therecould be little doubt.* The failure to detect the presenceof mucous patches in the larynx may be due, as MorellMackenzie 41 observes, to their fleeting character ; while,on the other hand, it is highly probable that many of theso-called mucous patches described by writers are inreality nothing more than papillomatous excrescences orsmall ulcerating gummata.

The laryngeal mucous patch, so-called, appears in themirror as a grayish-red or whitish-yellow elevation,rounded or oval in contour, and surrounded by an in-flammatory areola. ' This may disappear completely ordisintegration and ulceration may ensue. Small papil-lary hyperplasia} not infrequently occur in the neighbor-hood of existing ulcerations or on the confines of an oldcicatrix, which should, however, not be confounded, ashas been done, with the true condylomata.

II. Lesions of the Intermediate Period. —These havebeen well described by Whistler. The anatomical pecu-liarity of this stage resides in a chronic diffuse laryngitis,characterized by its constant tendency to relapse, and bythe existence of ragged ulceration of the vocal cords.These ulcers, in fact, represent, so to speak, a transitionstage from the superficial destruction of the secondary tothe deeper and more malignant ulceration of the tertiaryperiod.

The ulceration of both the secondary and intermediateperiods occasionally extends to the fibro-cartilaginousstructures, but the latter complication is much more fre-quently due to ulceration of tertiary development.

III. Lesions of the Tertiary Period. —In this stage allthe structures of the larynx may be involved, singly or incombination. The proclivity of syphilis to attack thosecartilages only that are invested with perichondrium ap-plies with especial force to the cartilaginous structuresof this organ. The characteristic lesions of this periodare gummata, deep ulceration, and fibroid degeneration.

1. Gummata appear as solitary or multiple tumors ofvarying size and shape, and of smooth, regular contour,which may proceed from any of the laryngeal structures,

* The subjectwas a womansuffering from secondary syphilis. On theleft vocal cord, about its centre, was a small, oval, yellowish-white patch,smooth in contour, and slightly elevated above the surface of the cord.Its long diameterwas parallel with the free border of the cord, and itsbase surrounded by a scarlet inflammatory areola. The laryngeal mem-brane was slightly erythematous. Three days afterward both patch andareola had disappeared.

* M. Dance has attempted to show that roseola, and even the tubercu-lar and papular syphilide occur in the larynx simultaneously with theireruption upon the external surface (Eruptions du larynx survenantesdans la periode secondaire de la syphilis, Paris, 1864). These observa-tions have never been confirmed.

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but which are usually found in the submucous tissue ofthe free border and posterior surface of the epiglottis andthe interarvtenoid space. They are occasionally metwith in the subglottic region, on the ventricular bandsand vocal cords. They vary in size from that of a mus-tard-seed to a tumor that calls for tracheotomy.

The color of the mucous membrane covering thegumma is at first intensely red, and occasionally smallvessels are developed in its vicinity. Gradually, underthe increased pressure of the submucous deposit, it be-comes pale, thin, and transparent, so that the peculiaryellow or whitish-yellow color of the gummatous infiltra-tion is distinctly visible. Necrosis of the anaemic mem-brane soon follows, and an ulcer results which rapidly

. invades the submucous tissues, forming a more or lesscrater-like excavation, not infrequently involving theperichondrium and underlying cartilage. In small gum-mata absorption of the infiltration may be secured by theexhibition of antisyphilitic remedies, even after consider-able thinning of the mucous membrane has taken place.

In histological structure the laryngeal gumma does notdiffer from similar products in other parts of the body.

An isolated case is on record where giant cells wrerefound in the gummatous infiltration of the larynx, 42 butthis is probably an exceptional and accidental occurrence.

Well-defined gummatous tumors of the larynx are com-paratively rarely met with as compared with diffusesyphilitic infiltration.

2. Fibroid Degeneration. —In the later stages of tertiarysyphilis there is in a certain proportion of cases a decidedtendency to the gradual development of fibroid tissue inthe structures of the larynx, which tends to diminish thelumen of the organ, not only by contraction of the new-formed tissue, but also by the production of large, densefibroid tumors, which are often mistaken for and de-scribed as gummy tumors, but which pathologicallyhave nothing in common with them. These fibroidutmors appear as hard, nodular masses occupying the epi-glottis, ary-epiglottic folds, and other portions of the ves-tibule and subglottic region. Sometimes the greater por-tion of the organ is converted into a dense hypertrophicmass. Acute ulceration occurs, and is fraught withgreat danger from accompanying oedema, and each suc-ceeding attack of ulceration favors a greater deposit offibrous tissue and increases proportionately the gravityof the case. In this variety of laryngeal syphilis, whichWhistler has especially insisted upon, no retrograde meta-morphosis takes place ; its processes are essentially pro-gressive, and the calibre of the larynx becomes dimin-ished sooner or later by an irregular nodular mass—halfhypertrophied tissue, half cicatricial bands—which doesnot subside under internal or local treatment, and which,if extensive, demands tracheotomy.

These fibroid tumors may be differentiated from gum-mata by their pale grayish or whitish appearance, by thesurrounding anaemia of the mucous membrane, and bythe absence of the peculiar yellowish submucous discol-oration of the latter. The hard, dense sensation com-municated to the probe contrasts, too, forcibly with thesoft elastic feel of the gummy growth.

This class of cases is only seen in hospital or dispensarypractice, and presents a long history of neglected laryn-geal trouble with gradually increasing obstruction torespiration. These tumors are more common than isgenerally supposed, and probably constitute a large pro-portion of the specimens which are labelled “ gummata ”

in anatomical museums and collections.Sections of the growths show under the microscope

thickening of the mucous membrane, a round-cell infil-tration of the submucous tissues, and abundant meshesand wavy bands of fibrous tissue, which in contractingobliterate more or less completely the vessels and glandu-lar elements of the parts. Whether this fibrous tissuestarts from the perichondrium or submucous layer, orboth, or what relation it bears to the fibroid hyperplasisewhich are found after the cicatrization of ulcers, has notas yet been made out, but it is not improbable that thishypertrophic syphilitic laryngitis may be due to the com-bined action of these different factors.

8. Tertiary Ulceration. —Ulcers of the tertiary periodresult from atrophy of the mucous membrane, throughthe pressure of the underlying infiltration and the conse-quent purulent degeneration of the latter, and in this wayexcavations are formed, of more or less circular outline,with a deep base of grayish or lardaceous appearance andwith elevated, clearly defined, and often bloodshot walls,surrounded by a scarlet zone of inflammation, and cov-ered with a foul, dirty yellowish secretion, which im-parts to the breath a peculiar and somewhat characteristicodor.

Of varying sizes, the tertiary ulcer may be multiple,and occur in any portion of the larynx and subglotticspace ; but it is generally solitary and occupies by pref-erence the lingual surface and free edge of the epiglottis.It may be said, in general, that ulceration of the upperpart of the larynx is much more common than ulcerationof the cords and subcordal region. The ulcerative pro-cess not infrequently extends along the ary-epiglottic foldto the ventricular band, or from the latter to the ven-tricles. The epiglottis may present a crenated appear-ance, like the comb of a cock, or a punched-out aspect ;or it may be depressed in various other ways. Occasion-ally it is perforated. It may be reduced to a mere rudi-ment, or finally be completely destroyed.

Syphilitic ulceration of the larynx heals by peripheralcicatrization, as has been well described by Yircliow.Around the borders of the ulcer dense, callous connec-tive tissue makes its appearance, which is characterizedby excessive peripheral growth, as in the cicatrix follow-ing a burn. The resulting scar varies in appearance, ac-cording to the size and situation of the original ulcer.On the ventricular bands and free surface of the epi-glottis, it is generally star-shaped, while in other situa-tions firm, fibrous bands are formed which connect themwith, or bind them down upon, adjacent structures.

As the ulcers heal, there spring up at the peripheryof the cicatrices small papillary or fibroid hyperplasise,and thus, later on, small areas are found decked withgrowths, which mark the site of past ulceration.

The deformities which result from the cicatrization oflarge ulcers are quite characteristic. The epiglottis maybe bound down to the base of the tongue, to the lateraland even posterior pharyngeal wall, adhesions may formbetween its free edges and the ary-epiglottic fold, be-tween the latter and the ventricular bands and pyriformsinuses, and between the free edges of the ventricularbands ; or the whole interior of the larynx may be con-verted into a contracted cicatricial channel in which alltrace of the original anatomy of the parts is lost. Occa-sionally the larynx as a whole is displaced, or individualparts are thrown into unnatural positions by the contrac-tion of the new-formed tissue. When ulceration occurs onsurfaces that are brought in contact in the natural exer-cise of function, as for example, the vocal cords, mem-branous formations composed of cicatricial tissue areoccasionally developed between the opposing ulcerativesurfaces, thus forming a web between them—a conditionwhich has been especially well described by Elsberg. 43

If cicatrization be not promoted, the ulcers rapidlydescend to the perichondrium, purulent inflammationof that structure is established and the cartilage laidbare.

Perichondritis and necrosis of the cartilages may alsodevelop as a primary affection—possibly, though rarely,as a metastatic (septic) inflammation of the fibro-carti-laginous tissue. The cartilage thus becomes surroundedby a purulent infiltration which takes place beneath andin the meshes of the perichondrium, caries occurs andthe necrotic portions are expelled as a granular detritusor as well-formed sequestra. Sometimes an entire carti-lage is expelled in the effort to expectorate. While ex-pulsion of necrotic cartilage usually takes place by themouth, it occasionally happens that the necrosed platefalls into the trachea and causes death. The entire epi-glottis has also been found in the stomach.

■ The presence of necrotic cartilage in the larynx, apartfrom other dangers to which it may give rise, aggravatesthe existing local disease, increases suppuration, and may

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even lead, if not artificially extracted, to metastatic ab-scesses in various parts of the body, to pyaemia, and death.

If perichondritis do not result fatally, recovery takesplace, at the expense of the functions of the larynx, withpermanent anchylosis, with consequent paralytic affec-tions and diminution in the calibre of the larynx, or fis-tulous tracks may be established between the cartilageand interior of the larynx, or may connect the formerwith the external surface.

A remote danger from tertiary laryngeal ulceration isdeath from haemorrhage, as in the classical case ofTiirck, 44 where the laryngeal artery was opened, and inthe one mentioned by Rokitansky,45 where sudden deathoccurred from perforation of the aorta.

In all forms of tertiary syphilis of the larynx and inthe deeper ulceration of the secondary and intermediateperiods there is a tendency to acute and chronic oedema.The former occurs suddenly, and is sometimes the imme-diate cause of death ; the latter develops slowly, and, insome instances, without danger to life, while in others itcauses progressive dyspnoea, which may terminate fatallyby sudden increase of the serous infiltration.

Symptoms and Complications. —It is manifest fromthe above that the symptoms and complications of la-ryngeal syphilis are of the most varying nature, andmay consist in very slight modification of the vocal andrespiratory functions or in their complete destruction ;and even, secondarily, abrogation of the process of degluti-tion.

Diagnosis. —The distinctive points of difference be-tween the diffuse laryngitis of the secondary period andsimple catarrhal inflammation have been already given.The older writers laid great stress upon a peculiar rau-cous character of the voice as diagnostic, and the voxrauca syphilitica was placed among the pathognomonicsymptoms of the disease. This quality of the voice is,however, met with when the vocal cords are congested,thickened, or abraded from simple inflammation, andcannot, therefore, be looked upon as characteristic ofsyphilitic laryngitis; though it may be of value in dif-ferentiating the latter from tubercular inflammation.

In the earlier laryngeal affections of tuberculosis thepronounced pallor of the mucous membrane of thepharynx, larynx, and nasal passages, the tendency toswelling and congestion of the posterior and inferior por-tions of the larynx, together with a hypenesthetic con-dition of the upper air-passages, and especially the phar-ynx, and the slow development and persistence of theulcers (generally on the vocal processes) will lead to anexamination of the lungs, where evidences of commenc-ing consolidation are generally to be found upon carefulexamination. In doubtful cases, where such evidence iswanting at the apices, the writer has repeatedly discov-ered signs of a localized bronchitis between the scapulae,and the diagnosis has been verified by the subsequentdevelopment of the case.

Tertiary syphilitic ulceration of the larynx, and thatwhich occurs in the intermediate period, may be con-founded with that of tuberculosis and carcinoma.

From tuberculosis it may be differentiated by attentionto the following points : Syphilitic ulcers are usuallysingle, develop rapidly, and are preceded or accompa-nied by localized unilateral swelling of the mucous mem-brane or by gummatous growths. Tubercular ulcers, onthe other hand, are generally multiple, are slow in devel-opment, and are preceded, as a rule, by a peculiar lustre-less, opaque thickening of the membrane (tubercular in-filtration). This may, in turn, be distinguished fromthe oedema which complicates syphilis, in that the latteris commonly unilateral, or confined to the parts princi-pally affected, is glistening, more or less translucent, anddoes not partake of the opaque, dull color of tuberculardeposit. When the latter leads to the peculiar pyriformswelling of the ary-epiglottic folds or to the turban-sliapedepiglottis (vide article on Larynx, Phthisis of) it furnishespathognomonic proof of tuberculosis. Syphiliticulcers arelarger, as a rule, than tubercular ulcers, and their favor-ite seats are the anterior surface and free edge of theepiglottis, while tubercular ulceration is most frequently

encountered in the lower and posterior portions of thelarynx and on the ventricular bands. When tuberculosisattacks the epiglottis it is generally the lower and poste-rior surface that is involved, and it may be said, in gen-eral, that the tendency of syphilitic ulceration is to de-velop from above downward, that of tuberculosis frombelow upward. Bilateral ulceration of the larynx, andespecially of opposing surfaces, other things beiug equal,is in favor of tuberculosis.

Deformity always results when any of the laryngealstructures, as, for example, the epiglottis, is perforatedfrom syphilitic ulceration, while the perforating ulcer oftuberculosis has little or no effect upon the natural shapeand position of the cartilage. The syphilitic ulcer isdeep, cleanly cut, with well-defined shelving walls ( videsupra), is surrounded by an inflammatory areola, and rap-idly invades the submucous tissues ; the tubercular ulceris surrounded by an anaemic mucous membrane, is moreshallow, presents a characteristic worm-eaten appearance,and tends to spread laterally in an irregular or serpigi-nous manner.

The secretion from tubercular ulceration is usuallyvery profuse, accumulates with great rapidity, and givesto the breath a peculiar sweetish odor that is quite char-acteristic. Microscopic examination, moreover, will gen-erally detect the presence of Koch’s bacillus, which maybe looked upon as possessing a certain crucial diagnosticvalue. In syphilis, on the other hand, the secretion isby no means as great, nor does it accumulate with therapidity observed in tuberculosis. Syphilitic ulceration,especially if the pharynx be involved, gives to the breath,moreover, a peculiar fetid odor, which may be regardedas diagnostic.

Haemorrhage from the larynx is not uncommon in tu-berculosis, and is rare in syphilis. Syphilitic ulcerationtends to heal by peripheral cicatrization ; it is doubtfulwhether extensive tubercular ulceration ever heals. Thepresence of cicatrices in the larynx isprimafacie evidenceof syphilis, and when these assume their characteristicform there can be little doubt concerning the diagnosis.

Small fibrous outgrowths in the neighborhood of ul-cers or cicatrices are additional evidence in favor ofsyphilis, while papillary hyperplasise, occurring in theinterarytenoid fold, and especially when they appear inthe early stages or precede well-marked changes in thelarynx, should awaken suspicion of tuberculosis. 46 While,moreover, small granular or papillary hyperplasias aresometimes found covering the base of tubercular ulcera-tion,* no growth ever arises from that of a syphilitic ulceror from the resulting cicatrix. Papillary hyperplasia;are not uncommon in syphilis, but generally mark theseat of past ulceration, as indicated by the presence of acicatrix or other evidence of pre-existing localized de-struction. The papillomatous excrescences of tubercu-losis tend in time to ulcerate and break down, those ofsyphilis rarely, if ever, ulcerate.

Syphilitic ulceration is, as a rule, not painful, nor is thelarynx tender to pressure, except when the deeper struct-ures are involved. Deglutition is also accomplishedwith ease, except in active ulceration of the epiglottis,when the pain is sometimes severe. In tubercular ulcer-ation, on the other hand, especially when the food comesin contact with the ulcerated surface, swallowing is in-tensely painful and sometimes impossible.

In tuberculosis the respiration is always more or lessembarrassed and the voice is enfeebled and veiled frominsufficiency of the expiratory forces, while in syphilis,unless the vocal cords be involved, the phonetic qualityof the voice is not necessarily impaired. In the differen-tial diagnosis between tuberculosis and syphilis, the so-called vox rauca may be accepted as a conclusive sign ofthe latter.

The presence of cicatrices or active ulceration in the

* The gummata of syphilis may possibly be confoundedwith tuberculartumors of the larynx, that rare formof tuberculosis first described by thewriterof this article in 1882 (N. Y. Archives of Medicine, October, 1882),and of which other cases have been since recorded bySchnitzler (WienerMed. Presse, Nos. 44 and 46, 1883), and Percy Kidd (Clin. Soc. Trans.,London, vol. xvii., p. 164, and St. Bartholomew’s Hosp. Rep., vol. xxi.).

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pharynx, on the palate, or in the nasal cavities carrieswith it weighty evidence in favor of syphilis, the condi-tion of these structures in advanced tuberculosis beingcommonly that of anaemia associated with more or lesscatarrhal disease.

By attention to the above differential points betweenthe two diseases a mistake can rarely occur. It must,however, be admitted that cases arise in which an appealto the historical narrative of the case, the physical exam-ination of the lungs and other organs, and even treatmentmay be necessary before giving a positive opinion. Itshould be remembered, too, that syphilis and tuberculosisare occasionally combined in the larynx, and that such acondition can only be recognized by the eye of a skilledobserver.

The deformities which result from tertiary syphilis maybe said to be practically characteristic ; but it is well tocall attention to the fact that certain essential fevers, e.g.,typhoid, small-pox, etc., and diphtheria, occasionally giverise to ulceration of the nasal passages, pharynx and lar-ynx, with perforation of the septum, ozoena, loss of thepalate, epiglottis, etc., which present all the gross appear-ances of syphilis, and which can only be differentiatedfrom the destruction of that disease by the history of thecase. This is especially worthy of remembrance, lest, inthe after-life of the individual, the previous existence ofsyphilis be too readily assumed from a perforation of theseptum or the loss of the uvula or palate.

Much more difficult is the differentiation of syphilis andcancerous ulceration occurring in the larynx. The chiefpoints to take into consideration here are the following :Cancer is a disease which occurs usually after the fiftiethyear of life, which develops less rapidly than syphilis,and most commonly originates fromthe space between thevocal cord and ventricular bands (except when it descendsfrom the pharynx), as a more or less clearly defined nodu-lar growth, which subsequently ulcerates and is convert-ed into a deep ulcer with bloodshot walls, whose base be-comes covered later with fungous, bleeding granulations.Associated with this, or preceding its development, areusually evidences of oesophageal obstruction, with painon swallowing, pressure, or manipulation with the bougie.

Lancinating pain in the larynx, when at rest, radiatingto the ear of the affected side is often present, althoughit cannot be considered characteristic, as it may occur inany ulcerative disease of the larynx. As the ulcerativeprocess of cancer advances, extensive haemorrhages notinfrequently take place, an uncommon occurrence evenin extensive syphilitic ulceration.

The secretion of cancer is profuse, ichorous, and differsmaterially in odor from the peculiar sickening stench ofthe discharge produced by syphilitic ulceration. Exam-ination under the microscope will occasionally determinethe nature of the case.

Cervical glandular enlargement is uncommon in laryn-geal cancer, but is not infrequently associated with ter-tiary syphilis of the larynx.

While the above may serve as reliable guides to diag-nosis, every experienced specialist can recall cases wherethe latter could only be determined by resort to the sov-ereign test of treatment. Indeed in any case in which theslightest doubt exists, it is the part of prudence in this,as in other problems of diagnosis, to give the patient thebenefit of the doubt.

Prognosis, Complications, Sequels.—The treatment ofsyphilitic affections of the larynx is generally very satis-,factory, unless the cartilages and their envelopes be at-tacked. Even then a cure may be effected, if the necroticcartilage be removed. In deep-seated destruction a curecan only be obtained with permanent injury to function.

The complications and dangers to life from tertiarysyphilis have been already alluded to in treating of thepathology of the disease. The possibility of the suddenoccurrence of oedema, even in the ulcerative laryngitis ofthe intermediate period, should never be lost sight of,and the danger of the latter increases, in every stage, asthe perichondrium is approached.

It is generally possible to produce complete cicatriza-tion of tertiary ulceration, but when the latter is exten-

sive, such an event is only accomplished with considera-ble deformity or contraction of the larynx. Ulcerationoccurring in the subglottic region and in the neighbor-hood of the crico-arytenoid joint is more dangerous tolife than when the epiglottis and ventricular bands are at-tacked. The entire epiglottis may be destroyed withoutserious impairment of the laryngeal functions and with-out impediment to deglutition.

In fibroid degeneration, when extensive hypertrophyhas taken place, no good has as yet come from constitu-tional or local treatment, and the patient drifts sooner orlater to tracheotomy. Perhaps some good could be ac-complished by the use of acids, electric cautery, andother destructive measures, with or without a preliminarytracheotomy in this apparently hopeless class of case.

If properly treated, the prognosis in simple syphiliticcatarrh, with or without ulceration, is good, and a per-manent cure can often be accomplished. In other casesrelapses of the ulcerative process occur from time totime. In both the prognosis is influenced by the previoustimely treatment of the constitutional disease. Finally,all syphilitic lesions of the larynx are rendered lessamenable to treatment by the predisposition to or coex-istence of serious organic disease, as for example, tuber-culosis.

Treatment. —The treatment of laryngeal syphilis is bothconstitutional and local. While there is, perhaps, no dis-ease of the larynx that calls for more careful local meth-ods of cure than syphilis, and in which the prognosisdepends so much upon the early laryngoscopic recogni-tion and appropriate topical treatment of its manifesta-tions, the successful accomplishment of the latter is nearlyalways assisted by and often dependent upon the exhibi-tion of constitutional remedies. Especially is this true ofthe tertiary lesions of the disease. To neglect generalantisyphilitic medication when an ulcer is approachingthe perichondrium, or when the destruction of importantparts is menaced, is, to say the least, an unsafe and in-judicious experiment.

The development and permanency of secondary laryn-geal lesions is also influenced, in a great measure, by theearly adoption of constitutional measures, for the latternot only assist in the removal of the infiltration, but, insome instances, act as a safeguard against true inflamma-tory disease.

The different methods of administration of antisyplii-litic remedies will be given in the article on Syphilis. Thewriter can recommend the tonic use of mercury, as for-mulated by Keyes, in the treatment of syphilitic affec-tions of the larynx. The most direct way of producingboth the local and general effects of the drug is by mer-curial fumigation or vapor-baths.

The local treatment of the diffuse laryngitis of second-ary syphilis does not differ materially from that of simplecatarrhal laryngitis (vide supra). Should ulceration occur,iodoform may be freely used. In the deeper form ofulceration this drug is of inestimable service, and is inthe writer’s experience superior to iodine and the nitrateof silver. Sprays of the bichloride of mercury, or thelocal application of the yellow oxide in cosmoline, vase-line, or like substance are also of considerable value.Before applying these remedies, the ulcerated surfaceshould be thoroughly cleansed by means of a detergentand disinfectant spray, for, otherwise, much of the goodeffect will be lost.

Papillomatous growths may be dissipated by the localapplication of alcohol or chromic acid, or, if extensive,may be removed at once with the forceps. Membranouswebs may be successfully divided with the galvano-cau-tery (Elsberg) or by cutting dilators, the best of which isthat devised by Whistler, to the excellent results obtain-able by which the writer of the present article can testify.

Whether any good can be accomplished by the divisionof adhesions must be determined by the peculiarities ofthe individual case. Except when function can be re-stored, or serious dyspnoea or dysphagia mitigated by theoperation, it is better, as a rule, to let them severelyalone.

Serious interference with respiration from any compli-

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cation calls for tracheotomy, and the early performanceof the latter is especially to be advised when the larynxhas undergone the fibroid degeneration described above.Systematic dilatation of the larynx, as described under theheading Larynx, Stenosis of, is sometimes of value, but,as a rule, little can be expected of this line of treatmentbeyond temporary improvement, while it is much in-ferior to the cutting operation.

Loosened necrotic plates of cartilage, in view of thedangerous complications to which they may give rise,should be removed, if practicable, by endo-laryngeal op-eration or from without, by exsection.

Syphilis of the Trachea and Bronchi. —The in-dividual portions of the respiratory apparatus possess adecidedly varying disposition to the localization of syph-ilitic lesions. When the notable frequency with whichthe nose and larynx are involved during the course ofconstitutional syphilis is contrasted with the comparativerarity of affections of the trachea and bronchi, it maybe with safety said that the lesions of syphilis are morefrequently found in the upper than in the lower segmentsof the respiratory system.

Syphilis of the trachea is of relatively rare occurrence,though not as uncommon as statistics would lead us tobelieve. Many cases of tracheal syphilis are doubtlessoverlooked, and especially is this true of those isolatedinflammatory and ulcerative conditions which are foundin the lower portion and at the bifurcation of the wind-pipe. In a large proportion of cases, the tracheal affec-tion is secondary to, and consists simply in the extensiondownward of, infiltration and ulceration of the larynx ;it occasionally involves the whole length of the trachea,and even the bronchi in its destructive action.

Much less common is the existence of syphilis of thetrachea without associated or pre-existent lesions of thelarynx and pharynx, or at least, which is not the resultof extension, but which occurs as an independent affec-tion. When the syphilitic disease is thus isolated, it isusually in the lower third of the trachea, from which itextends into the bronchi, or the latter may themselves bethe seat of isolated syphilitic lesions.

Isolated syphilis of the upper third is much less com-monly met with, and may occur alone or in combinationwith lesions of the lower trachea and bronchi. Usuallyboth bronchi are affected. When one alone is involved,it is more frequently the right. Only two cases are onrecord of isolated syphilis of the windpipe in its entirelength, 41 while the isolation of the disease in the middlethird is so rare that the possibility of its existence in thislocality has been denied. This condition has, however,been found and described by the writer 48 of this article,who, at the time of publication, could find but two simi-lar cases in literature (Charnal, 49 Beger 60), to which afourth has quite recently been added by Felix Se-mon.61

Pathological Anatomy.—The changes met with in thetrachea are identical with those found in the larynxduring the secondary and tertiary period, with certaindifferences of appearance due to peculiarity of anatomi-cal structure.

Mucous patches in the trachea are liable to be over-looked. M. Mackenzie 53 states that he has found themfive times. Seidel 54 describes as a mucous patch a pale-red excrescence, the size of a pea, which was associatedwith condylomata in other parts of the body, and whichdisappeared without local treatment. Diffuse superficialinflammation, with or without ulceration, fibroid degen-eration, gummatous growths, deep ulceration involvingthe perichondrium and cartilages, leading to peritrachealabscesses, exfoliation of necrotic tissues with subsequentfistulous communication with the exterior, membranousformations and stricture from the cicatrization of ulcersare all observed, either alone or combined in the courseof constitutional syphilis.

The ulceration generally descends from the larynxalong the inner surface of the tube, presenting a more orless irregular spiral form or peculiarly forked appear-ance. In other cases, the long diameter of the ulcer isat right angles to that of the trachea, which it surrounds

in a circular manner. Usually single, the ulcers vary insize, sometimes extending the whole length of the tube,and even to the first division of the bronchi.

The stenosis which follows the contraction of the cica-tricial tissue may affect the tube as a whole, whose lu-men it sometimes obliterates almost completely, or theobstruction may be confined to its individual segments.The most common seat of obstruction is the lower third.

The stricture which results from the cicatrization of atracheal ulcer is of two kinds—excentric and concentric.The former is produced by irregularities or deformitiesof the tube from the healingof longitudinal or imperfectlyannular ulceration, or as the result of perichondritis. Inannular or concentric stricture there is often dilatationof the trachea above and below the constriction, forming,so to speak, an hour-glass appearance. The cicatrices donot differ materially from those found in the larynx.They either present a peculiar net-like form or resemblethe scars found in the oesophagus from corrosions (For-ster). In the writer’s case the cicatrix presented a re-markable resemblance to a sheaf of wheat.

Prognosis.—The prognosis of tracheal syphilis is, otherthings being equal, much less favorable than when thedisease attacks the larynx, and it becomes graver as thebifurcation into the bronchi is approached. Extensiveulceration, especially when occurring in the lower third,or when it involves the bronchi, is generally fatal, whilein obstruction in the upper third life may be prolonged byresort to tracheotomy or to systematic dilatation. In ad-dition to the usual dangers from stenosis, perichondritis,etc., death has been known to occur from haemorrhage,due to perforation of the ulcer into the aorta55 and intothe pulmonary artery.66 In other cases the ulcer hasperforated into the mediastinum 61 and into the. oesoph-agus. 58

Symptoms.—Syphilis of the trachea may run its coursewithout the production of any symptoms during life, orit may give rise to those of the most alarming and dan-gerous forms of stenosis.

Congenital Syphilis op the Larynx, Trachea,and Bronchi.— Isolated cases of laryngeal lesions incongenital syphilis are to be found scattered here andthere through medical periodicals, but systematic writershave either entirely ignored the subject, or referred to afew recorded cases as pathological curiosities. The uni-versal sentiment of authority has, until quite recently,been decidedly adverse to the frequent dangerous im-plication of the larynx, and the changes in the voice*are referred to the intervention of fortuitous catarrh.

In the American Journal of the Medical Sciences forOctober, 1880, I called attention to the frequency withwhich the throat is involved in congenital syphilis, andgave a systematic description of the lesions found inthe pharyngo-broncliial tract and oesophagus during thecourse of that disease. 69 In opposition to the then gen-erally received doctrine, I ventured to maintain, as theresult of careful investigation of the subject, that, so farfrom being rare, as was generally supposed, laryngealaffections in congenital syphilis are among the most com-mon and characteristic of its pathological phenomena,and that the invasion of the larynx may be looked forwith the same confidence in the congenital as in the ac-

* As early as 1837, Dr. Abraham Colles, of Dublin, called attention toa hoarse cry as a symptom of congenital syphilis and referred to the factthat when the voice became hoarse, the affection of the anus might beshortly expected (Pract. Observ. on the Venereal Disease, etc., Lond.,1837, p. 269.). Rosen, a distinguished Swedish physician is cited byMahon and Lamauve (Recherch. important sur l’existence, la nature etla communication des mal. syph., etc., p. 371, Paris, 1804), as mention-ing a hoarseness occurring without manifest cause, and difficult degluti-tion as symptomatic of congenital syphilis; but on referring to the Eng-lish translation of Rosen’s work, I find that the sentence relates, not tothe inherited syphilis of the child, but to the acquired diseasein the nurse(The Dis. of Children and their Remedies, by Nicolas Rosen von Rosen-stein, trans. from the Swedish edition of 1771, by Dr. Andrew Sparr-man, p. 332, London, 1776). Long before Colles wrote, Josef JacobPlenck, in speaking of the signs of inherited syphilis, observes that notinfrequently the fauces and labial commissures become exulcerated—acondition indicated by a rough voice, nocturnal cries, sleepless nights,etc. “Non raro fauces et commissurse labiorum simul eroduntur. In-dexvox rauca, clamores nocturni, noctes insomnes. deglutitio difficilis,tabes, mors ” (Doctrina de morbisvenereis, p. 149, Vienn'as, 1779). Thiswriter also refers to ulceration of the fauces in “ latent” syphilis.

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quired form of the disease. Further experience and thestudy of cures since recorded by others have only servedto strengthen the positions taken in the paper referred to,for an elaborate discussion of which I must refer to theoriginal, from which also the following account is taken.

The laryngeal lesions of congenital syphilis are constantand characteristic and play an important role in the patho-logical evolution of the disease. Often among the firstevents of its clinical history, they may rapidly terminate indeath, or stealthily advance, inducing progressive morbidchanges, which, at first controllable and evanescent, mayultimately become inveterate. And thus the laryngeal in-flammation may outlive the series of phenomena whichmark the progress of the malady, witnessing their incep-tion, course, and disappearance, itself alone rebellious tothe approaches of the treatment by which they have beencontrolled or dissipated.

The larynx may be involved at any, but usually at anearly epoch. Laryngitis may even arise during intra-uterine life. The most common period of invasion, how-ever, is within the first six months after birth. Out of76 cases of laryngitis, 53 occurred within the first year ;and of these 43 within the first six months, 17 within thefirst month, and four within the first week of life. Age,therefore, seems to exercise a predisposing influenceupon the eruption of the disease in the larynx. This ap-plies not only to the superficial changes, but also to themore malignant forms of laryngeal destruction.

The laryngeal affection is met with more frequentlyin the female than in the male sex, in the proportionof three to two. It develops at all periods of the year,without regard to season, although it is naturally aggra-vated by those atmospheric changes that determine ca-tarrhal conditions.

Imperfect nutrition and forced neglect of hygienic lawssufficiently explain its prevalence among the children ofthe poor.

The classification of the laryngeal lesions of congenitalsyphilis into secondary and tertiary will not obtain as inthe case of acquired disease. Their pathological evolu-tion is not governed by the same laws that regulate theeruption of syphilis in the adult larynx, nor can we predi-cate, in any given case, the order in which they will ap-pear. In some, not a few, the deeper destructive formsare the first indication of laryngeal mischief.

In congenital syphilis we may distinguish two princi-pal varieties of laryngeal inflammation. In the one, thechanges are limited to the mucous membrane, and, itmaybe the submucosa ; its march is essentially slow, andthere is little tendency to invasion of the deeper struct-ures. The other is characterized by deep ulceration ofan extremely acute nature, which, especially in earlylife, rapidly involves the cartilages and their envelopes,and constitutes the most frightful form of the disease.In addition to these, there is a third form, in which agradual deposit of dense, fibrous material takes placewithin the tissues of the larynx, and leads to contractionof its lumen.

These pathological facts justify a classification basedupon the anatomical seat of inflammation. The laryngeallesions may, accordingly, be classified as superficial, deep,and interstitial.

Chronic superficial laryngitis is the condition most fre-quently met with. It is limited to the mucous mem-brane and submucosa ; is essentially chronic ; runs adefinite course ; gives rise to well-defined changes in thelarynx, and may be divided into three stages. The first,or stage of hyperaemia, presents nothing diagnostic ; theredness is generally diffuse, but sometimes is confined tospecial areas. It is commonly associated with congestionof the trachea, coryza, and erythema of the fauces andpharynx. Gradually, however, a condition of hyper-trophy is developed in the laryngeal membrane, whichbecomes swollen, thickened, and infiltrated, constitutingthe second stage or that of infiltration and hypertrophy.If the larynx be examined now, its membrane will be seento be deeply injected, and often slightly translucent fromchronic inflammatory oedema. The epiglottis, ventricu-larbands, and arytenoids have a swollen, rounded appear-

ance, while the vocal cords are thickened and reddened,and their excursive mobility is impaired. Swelling of themucous glands sometimes occurs, but the secretion is gen-erally scanty. These changes are occasionally limited toone side of the larynx. Thus, one-half of the epiglot-tis, its corresponding ary-epiglottic fold and ventricularband may be swollen and thickened, while the oppositeside of the larynx is in a state of simple congestion. Ifthe throat be neglected, minute ulcers form by the lique-faction of the superficial portions of the mucous mem-brane, which partake at first more of the nature oferosions, but which, in long-standing cases, involve thewhole thickness of the membrane, and sometimes reachthe cartilage. Arrived at this period or stage of ulcera-tion, the affection becomes stubbornly rebellious to treat-ment. Under antisyphilitic medication the ulcers heal,it is true, and temporary relief is afforded ; but sooner orlater fresh ones appear in other parts, thickening andhypertrophy become progressive, and secondary changesmay be induced in the lungs, either by direct extensionthrough the trachea and bronchi, or as the result of adiminution in the calibre of the larynx itself. As cicatri-zation of the ulcers takes place, small papillary or poly-poid liyperplasiae arise around the edges of the cicatrix.When small, they impart (post mortem) to the finger arough granular sensation. They are more common in thechild than in the adult, and the same may be said of theulcerations which precede them.

Such is the common history of this form of laryngitis.Commencing in early childhood as an ordinary catarrh,for which it is often mistaken, it gradually, but surelyasserts its specific nature. To it is due the characteristiccry and other symptoms referable to the larynx, so com-mon in the early stages of congenital syphilis. Thechanges which have been described require time for theircompletion, months and even years elapsing before theyreach their full development.

From the fact that hoarseness and other laryngealsymptoms sometimes coexisted with mucous patches onthe palate and in the pharynx, it was assumed by Diday 60

that theywere due to the presence of similar lesions withinthe larynx, in the neighborhood of the ary-epiglottic folds.Czermak 61 and Tiirck 62 have each reported cases wherethey were seen with the laryngoscope ; and one is referredto in the Gazette des Hopitaux ,63 in which they werefound in front of the arytenoids. The patches describeilby Czermak and Tiirck are, however, evidently exam-ples of true ulceration, and the account of the laryngealappearances in the child from the Hopital Necker is toomeagre to be of any value in establishing the existence ofmucous patches in the larynx of the congenital syphilitic.

The deep, destructive, ulcerative laryngitis correspondsin physical characters pretty closely to the tertiary in-flammation of acquired syphilis. It may follow the su-perficial form, but generally occurs independently of it.It is sometimes among the first symptoms of infection,and is then most destructive.

As a rule, deep pharyngeal ulceration precedes, or co-exists with, this form of laryngitis, but deep ulcerationof the larynx occurs, too, without the slightest evidenceof pre-existing pharyngeal lesions.

Laryngeal ulceration does not commonly follow thepharyngeal destruction of so-called latent syphilis. Thepalato-pharyngeal ulceration found in tardy congenitalsyphilis, has little tendency to invade the larynx ; its fu-ture theatre of action is the naso-pharynx and nose.

The first stage of this form of laryngitis consists eitherin a deposit of gummatous material in, or a round-cell in-filtration of, the structures which subsequently becomethe seats of ulceration. The resulting ulcers have thesame appearances as those found in the tertiary period ofconstitutional syphilis, and lead to similar deformity andstenosis. They are single or multiple, symmetrical, orconfined to one side of the larynx. Tlieir most frequentseat is the epiglottis ; they are often situated in the ven-tricles ; less frequently on the upper and under surfaceof the vocal cords, ventricular bands, ary-epiglottic folds,and plica meso-arytenoidea. They are also observed inthe subglottic cavity.

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There is a remarkable tendency in the laryngeal ulcer-ation of congenital syphilis to destruction of the deepertissues—the cartilages and their envelopes—and this pre-disposition is most marked in those in whom the throatis attacked at an early stage of the disease. There seemsto be an inherent virulence in the process, which findsin the imperfectly developed laryngeal structures an ap-propriate field for the display of its destructive power.Chondritis, caries, and necrosis are found in over two-thirds of the recorded cases, at all ages. Of these, overthree-fifths occurred within the first year of life.

Chronic interstitial laryngitis is intermediate betweenthe two forms of inflammation already described, and israrer than either; but it is of considerable practical im-portance, in view of its insidious tendency to stenosis. Itconsists essentially in a gradual deposit of a fibroid ma-terial in the tissues of the larynx, which leads inevitablyto serious interference with respiration. But few casesof this condition have been recorded ; it is possible, how-ever, that it may be looked for at a period when otherinterstitial changes, notably keratitis, commonly develop.

Lesions of the Trachea and Bronchi. —The trachea isthe seat, though much less frequently, of the three formsof syphilitic inflammation described as occurring in thelarynx. Apart from superficial changes, well pronouncedtracheitis and deep ulceration are relatively rare. Thecondition most commonly found is congestion, generallystreaked or confined to certain areas, with moderate swell-ing of the mucous membrane. In two cases examinedpost mortem there were numerous small ulcers confinedto the upper third of the trachea. Small granular hyper-plasiae existed in their vicinity. Ulceration and cicatriceshave also been observed by Hiittenbrunner,64 Woron-chin, 65 and Sturges, 66 and a case of stenosis has been re-corded by Steiner. 67

Symptoms of CongenitalLaryngeal Syphilis. — Voice andCry. The cry in the infant and the voice in the olderchild exhibit all degrees of phonetic impairment, fromslight huskiness to the toneless whisper of absolute apho-nia. At first the cry has a shrill, piping tone, that hasbeen compared by West and Zeissl to the sound of achild’s toy trumpet. This sometimes degenerates into apeculiar squeak. Soon it assumes a characteristic vibra-tory twang, difficult to describe, but not unlike the vocalresonance which is heard just above the level of a pleu-ritic effusion. This is probably due to the sonorous vi-brations of the thickened mucous membrane, which, at astage when infiltration has not advanced to consolidation,is loose and admits of being thrown into exaggeratedvibration by the current of expired air. Later the voicebecomes harsh, cracked, and finally completely lost. Itis surprising, however, to what extent the larynx may beinvolved without impairment of the voice.

Cough is frequently present, and is often a very dis-tressing symptom. It is paroxysmal, suffocative, inter-mittent, raucous, and often followed by vomiting. Theimpairment of phonetic quality may be of diagnosticvalue in those cases in which corresponding changes inthe voice are absent. The paroxysms may be excited bycrying, or attempted deglutition, but are generally worseat night, leading to attacks of dyspnoea, which threatensuffocation. There is not much expectoration, except inthe deep ulcerative form, when it is very profuse andmuco-purulent, filling the larynx, and interfering withlaryngoscopic examination. The amount of secretionmay be taken as an approximate measure of the extenttowhich the destructive process has advanced.

Respiration is seriously embarrassed, the rhythm hur-ried, and often interrupted. Attacks of dyspnoea arebrought on by coughing and suckling, and are worse atnight, leading to orthopnoea, cyanosis, and convulsions.Sometimes the breathing has a bronchial sound, and isstridulous and stertorous, according to the amount ofobstruction. The respiratory distress is, as a rule, com-mensurate with the amount of laryngeal stenosis ; butsecondary changes in the trachea, bronchi, and lungsare sometimes important factors in its production. It isalso modified by the degree of nasal obstruction fromcoryza.

Deglutition is difficult, and sometimes painful and im-possible. It is caused by pharyngo-laryngeal swellingand ulceration ; but we may assume that, in some cases,it is due to lesions of the oesophagus itself. Laryngismusoccurs quite frequently, and is sometimes the immediatecause of death. In a case reported by Thomas Barlow, 68it was associated with disease of the meninges of thebrain.

In many cases no definite relationship seems to existbetween the laryngeal and cutaneous lesions of congeni-tal syphilis. It is also an interesting fact that, while theexternal lesions yield readily to antisyphilitic medica-tion, the laryngeal often have a tendency to persist. Thelarynx seems to be the last organ to surrender to thera-peutic influence. Among the secondary complications inthe lungs are congestion, atelectasis, emphysema, bron-chitis, pleurisy, and pneumonia. The latter is often theimmediate cause of death. But the condition whichcommands most serious attention is the sudden and fatallaryngeal oedema, w'hich occurs without warning, andfrom which the patient dies before assistance can be ob-tained.

Diagnosis. —The laryngeal affection in its first stagemay be mistaken for simple laryngitis, and wdien asso-ciated wdth chronic bronchial irritation or pulmonaryinflammation may be confounded with tubercular laryn-gitis. But the greatest difficulty will arise in its dis-crimination from laryngeal growths. Here, if laryngo-scopic examination be impossible, the diagnosis may beinvolved in doubt.

Rapid cicatrization of laryngeal ulceration under theiodide of potassium practically settles the question ofsyphilis ; but the diagnosis can be made, in the majorityof instances, without invoking this‘aid. When ulcerationattacks the denser structures, the action of the iodidemay be slow. Here, if nutrition be stimulated by tonictreatment, and especially by cod-liver oil, the processesof repair will be accelerated. But this obviously doesnot warrant the conclusion that the destruction is notsyphilitic. The power of cod-liver oil over the phenom-ena of congenital syphilis is the same as that wdiich it ex-ercises in other wasting diseases, an influence which isoften overlooked. The assumption, therefore, that anulcer which heals under this drug, either alone or com-bined with the iodide of potassium, is necessarily scrofu-lous, diverts the mind from a rational interpretation ofthe case.

The prognosis will be influenced greatly by the age ofthe patient; the earlier the throat is attacked, the moreserious the results. Pharyngo-laryngeal ulceration occur-ringwithin the first year is almost invariably fatal. Deepulceration of the larynx, in view of its destructive ten-dency, offers a grave prognosis at any period. The prog-nosis in chronic superficial laryngitis is more favorableas regards life, though the tendency to laryngeal oedemaand spasm should not be lost sight of. Tliis form of la-rjmgeal syphilis is exceedingly persistent and intolerantof treatment. It is often the primum vivens and the ulti-mum moriens of the disease. As Vidus Vidius said ofsyphilis, “ it makes many truces, but never peace.” Inall forms of laryngeal syphilis, death may take place fromacute oedema. The prognosis will depend, furthermore,upon the gravity of the general infection and the second-ary complications in the lungs.

Treatment. —In acute laryngeal syphilis the treatmentshould consist in mercurial inunction over the thyroidcartilage, the inhalation of calomel or iodate of zinc inthe form of vapor, and the internal administration of po-tassium iodide. The aggregate daily dose of the lattershould be large, and the drug pushedrapidly to the vergeof iodism. Should the dangerous symptoms not yieldwithin forty-eight hours, the question of tracheotomyshould be considered.

In the more chronic forms, mercury in tonic doses,combined with iodide of potassium, should be exhibited,the local treatment consisting in the use of topical appli-cations and inhalations. As a topical application to theulcers, great reliance may be placed upon iodoform, orthe vapor of the iodate of zinc may be used.

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parently of little or no avail, they sometimes cicatrize, as ifbymagic, on the accession of an acute disease. It is to this thatI wish to direct particular attention.

The clinical study of the cases upon the analysis ofwhich the report referred to was based disclosed certainstriking facts in connection with the influence of some ofthe ordinary infectious diseases of childhood upon theprogress of the inherited syphilitic affection. From thehistorical narrative furnished by this particular group ofcases, it would appear (1) that, while congenital syphilisaffords no absolute protection against certain -acute infectiousdiseases, its existence in the individual seems often, otherthings being equal, to mitigate their severity and exert a fa-vorable influence on their course; (2) that certain acute dis-eases, accompanied by an exanthem, favor the dissipation, atleast temporarily, of the throat and other manifestations ofthe disease ; (3) that ivhile at no period of the disease is thechild exemptfrom these affections, they are more liable to becontracted during theperiod of latency—that curious inter-val of apparent health in congenital syphilis-which Cazenavehas poetically called the sleep of the virus.

These remarks are limited to scarlet fever, measles, andchicken-pox, but they coidd doubtless be extended toembrace others of the exanthemata.

They do not apply, for obvious reasons, in the case ofexcessive virulence of the syphilitic cachexia or malig-nant epidemic influence of the intercurrent disease.

Of special interest is the effect produced by acute fe-brile disease upon the throat lesions of congenital syphi-lis. Chronic inflammatory conditions and ulceration of thelarynx, pharynx, and nasal passages, are often influencedin a remarkable manner through the presence in the individ-ual of an intercurrent febrile affection. This is, moreover,eminently true of those acute blood diseases with special ten-dency to local manifestations in the throat, such as scarletfever, measles, diphtheria, etc. According to personal ex-perience, scarlet fever and measles exert, as a rule, afavor-able influence on the course of the throat affection, their su-pervention being of itself sufficient to cause its completedisappearance. The poisons of the two diseases in their cir-culation in these regions appear to be mutually destructive,and the throat escapes by virtue of such reciprocal antago-nism.* The cure here may be permanent,

or relapses of theinflammatory or ulcerative process mayfollow the removal ofthe antagonistic influence of the intercurrent disease.

These remarks do not apply to diphtheria. When thisaffection supervenes during the existence of lesions in thethroat, the patients rapidly succumb to the disease. Theexistence of syphilis in the child apparently increases thetendency to membranous formation ; indeed, in some in-stances, apart from the presence of the diphtheritic proc-ess, there seems to be a special tendency to fibrinous for-mation in the nose and retro-nasal space.

The influence of acute disease upon the manifestationsof constitutional syphilis is a subject which has receivedsome attention at the hands of syphilographers, especiallycertain of the French school ; but very little is known asyet beyond the empirical fact that the lesions of that dis-ease, and especially the cutaneous syphilides, are oftenmodified by the introduction into the blood of the virusof an intercurrent febrile affection. This modificationmay consist either in the permanent or temporary dissi-pation of existing syphilitic lesions, or in the exaggera--tion or intensification of the morbid process. Thus, forexample, various syphilitic affections, such as skin erup-tions, exostoses, etc., have been observed to disappearduring the course of erysipelas, 11 acute rheumatism, 12cholerine, 13 variola, 14 febrile furunculosis, 15 etc. La-segue 16 has recorded a case of ulceration of the pharynxand tonsils which disappeared during an attack of ery-sipelas, while in a similar one observed by Martelliere 11

a fatal result ensued from that disease. The dissipationof syphilitic eruptions has also occurred during preg-nancy, 78 and as the result of vaccination, 19 and there is acase on record where the latter apparently exerted a cura-tive influence in caries of the pharyngeal vault. 80

The Effect of Certain Acute Morbid Processesupon the Throat Affections of Syphilis, Congeni-tal and Acquired. —In a paper read before the Ameri-can Laryngological Association in 1884,69 I contributedsome observations on the manifestations of congenitalsyphilis in the throat and their behavior under the influ-ence of certain acute diseases, from which the followingextract is taken:

In the paper on congenital throat syphilis to which ref-erence has already been made in the preceding article, 10

the following conclusions were reached in regard to deepdestructive ulceration of the oro-pharyngeal cavities :

1. That deep ulceration may invade the palate, phar-ynx, and naso-pharynx at any period of life from the firstweek up to the age of pubertj r . Thus, of thirty casesanalyzed with reference to the period of invasion, four-teen occurred within the first year, and ten within thefirst six months of life, the remainder occurring at peri-ods more or less advanced toward puberty. 2. When theeruption of inherited syphilis is apparently delayed untilthe latter period, that lesions of the palate and pharynxare found with a peculiar constancy, and often first at-tract attention to the existence of a diathesis of whichthey are the sole pathological expression. 3. That fe-males are attacked more frequently than males. Thus,out of 69 cases of pharyngeal ulceration, 41 occurred inthe former sex. 4. That ulceration may occur in anysituation ; but its most frequent seat is the palate, forwhich it exhibits the closest elective affinity. 5. That,when situated at the posterior portion of the hard palate,the tendency is to involve the soft palate and velum, andthence to invade the naso-pharynx and nose; while, situ-ated more anteriorly, it seeks a more direct pathway tothe latter, which is established by perforation of the bone.6. That the next most common seats of ulceration in or-der of frequency are the fauces, naso-pharynx, posteriorpharyngeal wall, nasal fossa and septum, tongue, andgums. 7. That ulceration, especially that of the palate,shows a disposition to centrality of position, togetherwith a special tendency to caries and necrosis of the bone,a fact probably explicable by the great vascularity of theperiosteum and medullary membrane in youth. 8. Thatthe tendency to necrosis exists at all periods of life, butespecially in early youth, when it is more destructive andless amenable to treatment. 9. That while deep pharyn-geal ulceration generally precedes or co-exists with simi-lar affections of the larynx, the latter occurs, too, withoutevidence of pre-existing pharyngeal lesions. 10. Thatsimultaneous or consecutive ulceration of the palate,pharynx, and nose seems to be characteristic of syphilis,or at least occurs more frequently in this than in anyother disease.

I bring these facts again into prominence because theydiffer from commonly accepted views, and because theypossess at least a certain value by reason of the methodby which they were obtained. 1 desire also to reiteratewhat was said in connection with the confusion of theselesions with so-called “scrofulous” ulceration. With-out entering into a discussion of the subject, suffice it tosay that there is no just ground for belief in an ulcera-tive scrofulide of the throat. It needs only the most su-perficial review of the writings of those who maintain itsseparate existence to show the utter confusion which pre-vails, as the result of erroneous views handed downamong the traditions of an obsolete pathology.

It is obviously a point of great practical importance thatthis fact should be recognized, and especially in view ofthe rapidly destructive tendency of inherited syphiliticulceration in the oro-pharyngeal cavities and larynx.

The throat ulceration of congenital syphilis not onlyexhibits a special tendency to rapid invasion of the deepertissues ; it often possesses an inherent virulence whichplaces it apparently beyond the reach of therapeutic con-trol. This is markedly true of the ulceration which oc-curs in the earlier years of life. Cases are now and thenencountered in which the ulcers stubbornly refuse to cica-trize, or do so sluggishly and imperfectly, healing at onepoint and becoming simultaneously active at others.Under such circumstances, 'when remedial measures are ap-

* It is quite possible that this may alsobe true of other mucous surfacesof the body.

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The remarkable power of erysipelas over the cutaneoussyphilides has suggested its artificial production as atherapeutic agent in these affections, 81 while their behav-ior under the operation of the vaccine virus led to thenow almost forgotten practice of Lukonski. 82 It has,finally, even been proposed by an enthusiastic pupil ofM. Hardy to inoculate the poison of small-pox in cases ofsyphilis which have resisted all other methods of treat-ment.83

It is sufficiently evident, then, that a reciprocal antago-nism exists between the poison of syphilis and that of anumber of acute diseases. Bywhat pathological law thisis brought about is, in the present state of our knowledgeof the mutual relations of disease, a matferof pure specu-lation.

This remarkable influence of the febrile state uponsyphilitic inflammation and ulceration of the nasal pas-sages and throat is also, in a measure, true of simple in-flammatory conditions of these cavities. It were foreignto the purpose of the present article to elaborate this lat-ter and cognate subject, and I shall, therefore, simplyoffer for consideration the fact that simple catarrhalinflammation of these regions occasionally disappears com-pletely, and is permanently cured during the course of anacute febrile disease. Whether this occur as a phenome-non of so-called “substitution,” or as the result of a pro-found impression made upon the nutrition of the parts byvirtue of which abnormal secretion is arrested and the in-flamed tract placed in a condition favorable to resolution,can only be determined by the accumulation of more ex-act scientific data concerning the reciprocal antagonismof pathological processes.

Without, then, attempting any special explanation orgeneralization, I present the foregoing observations frommy clinical experience as a contribution to the study ofan interesting but imperfectly understood subject.

John Noland Mackenzie.

25 Joseph Jacob Plenck : Doctrina de morbis venereis, pp. 93, 94, 97,99, 100, 143, 147, and 149-151. Vienna;, 1779. This writer seems to havebeen personally familiar with syphilitic affections of the oesophagus andcicatricial stricture of the pharynx.

26 A Treatise on Gonorrhoea Virulenta and Lues Venerea,vol. ii., pp.37 and 43. Dublin, 1793.

27 Treatise on the Ven. Dis., pt. vi., chap, ii., p. 262, et seq. (in Works,with notes by Babington, Phila., 1839). See also Babington's excellentobservations, pp. 266 to 268.

28 Complete Treatise on the Symptoms, Effects, etc., of Syphilis,Phila. ed., 1815, p. 293. Swediaur also alludes to affections of the ear(tinnitus) from compression and corrosion of the Eustachian tubes, p.294.

20 De sedibus et causis morborum, Epist. xliv., cap. xv., Bond, ed.,1769.

3° Traite de la phthisie pulmonaire, par M. Raulin, pp. 13 and 79.Paris, 1784.

31 J. N. Thomann’s Annalen der klinischen Anstalt in dem JuliusHospitale zu Wurzburg f. das Jahr 1800, p. 242, Wiirzb., 1803 ; seealso case in Hufeland’s Bibliothek der prakt. Heilkunde, Bd. ii., St. ii.,S. 143.

32 Beobachtungen iiber die Natur u. Heilung der Syphilis. RussischeSammlung f. Naturwissenschaft u. Heilknnst, I. Bd., St. ii., 2ter Ab-schnitt, S. 36. Riga u. Leipzig, 1816.

33 The principal of these are the following: Before the era of patho-logical anatomy, Richard Morton, Phthisiologia, seu exercitationes dePhthisi, Londini, 1689; after the time of Morgagni, Petit (M. A.), Diss.de Phthisi Laryngea, Monspelii, 1790, October 25th (copies of boththese rare tracts may be found in the library of the Surgeon-General’sOffice); Sauvee, Recherches sur la phthisie laryngee, Paris, 1802 ;

Schiinbach, De phthisi laryngea, Wilmse, '1808 ; Jos. Sigaud, Recher-ches sur la phthisie laryngee, Strasburg, 1819 ; Wm. Sachse, Beitrage zurgenaueren Kenntniss u. Unterscheidung der Kehlkopfs- u. Luftrohren-Schwindsucht, Hannover, 1821 ; Barth, Mem. sur les ulcerations desvoies adriennes, Arch. gen. de Med., 1839, p. 137, et folg.

34 A Practical Treatise on Laryngeal Phthisis, Chronic Laryngitis, andDiseases of the Voice, trans. fr. the French. Philadelphia, 1839.

35 Allg. Wiener med. Zeitung, No. 48, 1861 ; No. 43, 1866 ; also Klinikder Krankheiten des Kehlkopfes, etc. Wien, 1866.

36 American Jour, of Med. Sc., January, 1876, also Tonic Treatment ofSyphilis, New York, >876.

37 See Colson, Journal Hebdom., 1831, p. 36; also Crampton (Trans.Dublin Coll, of Phys., vol. iv., p. 91), where two grains of calomel causedulceration of the throat and death, and Devergio (Archives gen de rrnkl.,tom. ix., p. 468), gangrene of the throat and death; alsoa case (Broad-bent, Mem. of Lond. Med. Soc., vol. v., p. 112) where globules of mer-cury were found upon the laryngeal cartilages after death.

38 Die Behandlung der Syphilis mit Sublimat-Injectionen,Berlin, 1869 ;Ziemssen’s Encyclop., Am. ed., vol. vii., p. 862, New York, 1876.

30 Op. cit., p. 377.40 Lectures on Syphilis of the Larynx. London, 1879.41 Diseases of Throat and Nose, vol. i., p. 356. London, 1880.42 Browicz: Centralblattf. dieMed. Wissensehaft, 1877, s. 346.43 Syphilitic Membranoid Occlusion of the Rima Glottidis, New York,

1874. 44 Klinik der Krankheiten des Kehlkopfes, 1866, S. 413.45 Path. Anat., Bd. iii., p. 22.40 Stoerck: Klinik der Krankheiten des Kehlkopfes, etc., Stuttgart,

1880, s. 282. Major; Trans. Am. Laryng. Assoc., 1883, p. 163.47 Zurhelle : Berliner klin. Woch., 1872, No. 35. Wilks: Guy’s Hosp.Rep., ix., 1863. 48 Wiener med. Jahrbiicher, 1881, I. Heft, p. 75, et seq.

49 L’Union Medicale, 1859, No. 21.60 Deutsch. Arch. f. klin. Med., 1879, S. 608.61 LondonLancet, vol. i., pp. 905-906, 1882.62 Reference omitted after electrotype plate had been made.—Editor.83 Diseases of the Throat and Nose, vol. i., p. 531. London, 1880.64 Seidel: Jenaer Zeitschr. f. Med., 1866, S. 489. Canstatt, 1866, S. 497.66 Rokitansky; Patholog. Anatomie, Bd. iii., p. 22. Wilks: Trans.

Path. Soc., vol. xvi., p. 52.56 Gerhardt: Arch. f. klin. Med., vol. ii., p. 541. Kelly: Trans. Path.

Soc., vol. xxiii., p. 45.57 Wallmann: Virchow's Archiv, Bd. xiv., p. 201.58 Beger, loc. cit., and Axel Key and Oscar Sandhal, cit. in Schmidt’s

Jahrbuch., 1870, 147, p. 48.89 Congenital Syphilis of the Throat; based on the Study of One Hun-

dred and Fifty Cases.60 Syphilis des Nouveaux-nes. New Syd. Trans., p. 64-65.61 Der Kehlkopfspiegel. New Syd. Trans., 1861, p. 53.62 Klinik, etc., Wien, 1867, 161 Fall, and Atlas, xxii., 4.83 Gaz. des Hop., 1860, No. 51, p. 202.84 Jahrbuch fur Kinderheilkunde, Bd. v., 1872, p. 338.68 Ibid., Bd. viii., 1875, p. 108.66 Vide Lond. Lancet, April 10, 1880, p. 566.87 Jahrb. f. Kinderheilkunde, Bd. vii., 1865, ii., § 64.68 Trans. Path. Soc., London, vol. xxviii., 1876-1877, p. 287.69 A Contribution to the Study of Congenital Syphilis, Trans. Am.

Laryng. Assoc., 1884, and N. Y. Medical Journal,May 31, 1884.70 See articleon Congenital Syphilis of the Larynx.71 Vide Cazenave and Schedel, Practical Synopsis of Cutan. Dis., etc.,

p. 353, Phila., 1829; Rayer, Traite des mal. de la peau, Paris, 1835 ; La-marche, De 1’drysipMe salutaire, These de Paris, 1856, and the excellentarticles of Mauriac, clinique sur l’influence d’erysipelas dans lasyphilis, Paris, 1873 ; published also in the Gaz. des Ilopitaux. Nouv.ser., 1873, pp. 305, 321, 346, 385, 410, 443, 466, 506, 546, 569, 594, 601.See also Bidenkap’s case (cited by Baumler, von Ziemssen’s Cyclopaedia,Am. ed., vol. iii., p. 98, 1875).

72 Rayer, op. cit., p. 546 (Mauriac); see also Jourjon, Infl. des mal.aiguSs sur quelques manifestations cutan. de la syph., Thdse de Paris,1870. 73 Cazenave : Traite des syphilides, p. 593 (Mauriac).

74 Gore : Lancet, September 2, 1858.75 Diday (quoted by Mauriac, 1. c.).78 Traite des angines, pp. 110-112.77 Sur l’angine syphilitique (cited by Mauriac).78 Gilbert: Bull, de l’acad. de mod., 1851, tom. xvii., p. 156.

1 For a full statement of this argument, see Lancereaux’s'treatise onSyphilis. New Syd. Soc. Trans., 1868, vol. i., pp. 8 to 10. Quotationstaken from Captain Dabry’s book, La Medecine chez les Chinois, Paris,1863, and from Hessler’s translation of the Ayur Veda.2 See Lancereaux. 3 Epid. 6, sec. 1. 4 Isag., cap. 20.

8 De causis acut. morborum, lib. i., cap. viii.8 De Chron. Morb., lib. ii., cap. 4 ; lib. iii., cap. 2.7 De Compositionibus Medicamentorum, comp. vii.8 See especially Martial, I., 66, 79 ; VI., 41 ; IV., 41 ; XI., 30 ; VI., 55 ;

XI.. 92, 61 ; VII., 33, etc. 9 Observ. Miscellan., Leid., 1745. def. p. 28.10 Die Geschichte der Lustseuche im Alterthume, Halle, 1845.11 Orationes ex recensione. Lipsiae, 1784, vol. ii., orat. 33. See also

Rosenbaum, op. cit., p. 158. 12 Lib. I., 78. 13 Lib. IV., 41.14 Sulpicius Lupercus Servastus, Junior, in Authologia veterum latin-

orum Epigrammatorum et poetarum, Lib. I., p. 515, et seq., Ed. Bur-mann, Amstelodami, 1759.

18 See Nic. Leonicini, De Epidemia, etc., in Aphrodisiac, sive de luevenerea, ab Aloysio Luisino, Lugd. Bat., 1728; Nic. Massa, De morbogallico, cap. vii., et quarti tract., cap. iv. (Aphr., pp. 46 and 96-07) ; Jacob. Cataneus, De morb. gall., cap. iv. (Aphr., p. 148); Pet.Maynardi, De morb. gall, tract., i., c. 4, Fernelius, De lue venerea caput(Aphr., pp. 613-614) ; Victorius, de morb. gall., liber, cap. iii., alludesto flattening of nose and caries of nasal bones, ozcena, polypus (hyper-trophic catarrh), etc. ; Marchelli, De morb. gall, tract. (Aphr., p. 732) ;Fallopius, De morb. gall, tract., cap. xxiii. (Aphr., p. 781), and cap. xciii.(p. 824); Botallus, Luis venerea:curandse ratio, cap. iv.; Tomitanus (B.),De morb. gall., lib. i„ cap. xxviii. (p. 1047), also lib. ii., cap. i. (p, 1053);Sylvius, De morb. gall, tract, (p. 1109) ; Paschal, De morb. gall, tract,(p. 1113) ; Borgarutius, De morb. gall, methodus. cap. vii. p. 1129),et at. See also Benevenius (Antonius), De morb. gall, tractatus, inhis work De abditis nonnullis ac mirandis morborum et sanationumcausis, Florent., 1507 ; this work is the first essay on pathological anat-omy (Library Surgeon-General’s Office, Washington).

18 Hieronymi Frascatorii, Veronensis, Syphilis, sive Morbi gallici, lib.111., lib. i. (Aphr., p. 187), B. and lib. ii. (Aphr., pp. 191-192), C. (a.d.1555); see also Frascator, De Syphilide, seu Morb. gall, lucubratio, cap.i. (Aphr., p. 199).

17 De morbo gallico, lib. ii., cap. xxii. (Aph., pp. 1222 and 1223), andlib. vii., cap. viii. and cap. xix. 18 Loc. cit.

19 This case is recorded in the Collegium Anatomicum of Severinus,from which it is taken by Bonetus (Sepulchrctum, Ludg., 1700, tom.1., p. 766).

20 See Astruc., De lue venerea, tom. ii., p. 921 ; Van Swieten, Comm,in Aphor.; Boerhaave, § 1445; and Lieutaud, Hist. Med., tom. ii., lib.iv., obs. 105, Parisiis, 1777 ; also Lieutaud, Synopsis of Pract. of Med.,ed. Atlee, Phila., 1816, p. 97.

21 Diss. inaug. devoce, ejusque afEectibus, cap. ii., p. 52, Jen®, 1678.22 De pudendorum morbis. sec. 2, 12, p. 182; 9, 10, 13, p. 183, and

14, p. 184, Lugd. Bat., 1722.23 Aphorism, de cognos., et. curand. morbis., § 1445, Lugd. Bat., 1728;also Tract, de lue venerea, Lugd. Bat., 1751.

24 De morb. ven. libri sex, etc., II., cap. ii., cap. vii., IV., cap. iv. andcap. viii. and xi., § xii. Parisiis, 1736, 1738, and 1755. See also Lond.ed. of 1754, pp. 124 to 159 of Bk, ii., and pp. 9-14, 15, 89-90 of Bk. iv.

Vol. IV. —39

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79 Vide Revue med., 1861, tom. i., p. 167, Jeltzinzld.90 Jeltzinzki, 1. c. : Sur lacure radicale de la syphilis par la vaccination.81 Sabatier: Propositions sur Fdrysipele considdre principalement

comme moyen curatif dansles mal. cutanees, etc., Th6se de Paris, 1831.82 Jeltzinzki, 1. c.83 Garrigue : De l’influence des mal. aig. sur les diatheses, Th6se deParis, 1870.