April - 95 LLOYD: Syphilis of the Oral Cavity 177

GILBERT', N. C., DEY, F. L., and RALL, J. E. (1946), J.A.M..,133, I132.

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GROSS, R. E. (1946), Am. J. Dis. Child., 71, 579.HARRINGTON, S. W. (1943), Am. J. Roentgenol., 49, I85.HARRINGTON, S. W. (1945), Ann. Surg., 122, 546.JANKELSON, I. R., and MOREIN, S. (1940), Rev. Gastroenterol.,

7, 134.KIRKLIN, B. R., and HODGSON, J. R. (1947), Am.J. Roentgenol.,

58, 77.MENDELSON, E. A. (1946), Radiology, 46, 502.MORRISON, L. G. (1925), J.A.M.A., 84, i6i.MURPHY, W. P., and HAY, W. E. (I943), Arch. Int. Med., 72, 58.NAZUM, F. R. (i947), Am. Heart J., 33, 724.

POLLEY, H. F. (194I), J.A.M.A., Ix6, 82t.RADLOFF, F. F., and KING, R. L. (1947), Gastroenterology, 9,

249.RAU, L. (1949), Proc. Roy. Soc. Med., 42, 864.RENNIE, J. B., LAND, F. T., and SCOTT PARK, S. D. (I949),

Brit. Med. J., 2, 1443.RITCHEY, J. 0., and WINSAUER, H. J. (1947), Am. J. Med. Sc.,

214, 476.RITVO, M. (1930), J.A.M.A., 94, I5.SAHLER, O. D., and HAMPTOM, A. 0. (1943), Am. J. Roent-

genol., 49, 433.SCHWARTZ, S. 0., and BLUMENTHAL. S. A. (1949), Am. J.

Med., 7, 501.SMITHERS, W. D. (1945), Brit. J. Radiol., I8, 199.TRUEMAN, K. R. (1947), Canad. Med. Ass. J., 56, 149.WEINTRAUB, S., and TRUGGLE, A. (1941), Radiology, 36, 297.

SYPHILIS OF THE ORAL CAVITY*By V. E. LLOYD, M.B., B.S.

Direc;or of Department for Ven?real Diseases, Guy's Hospital, London

The structures of the oral cavity may be affectedwith syphilis in any of the various stages of thatdisca3e. No decade of life is immune, from in-fancy to senility. A study of the characters of thevarious lesions and of thtir course provides anepitome of the habitual behaviour of this ex-quisitely chronic infection. From various observa-tions upon the lesions of the mouth, tongue andthroat we can learn much of the natural historyof the disease.

Primary Infection in the Oral CavityChancre of the Lip

It is by no means rare for infection with syphilisto occur in the lip, a chancre in this situation beingthe most frequent of all the primary lesions whichoccur in extra-genital locations. It may be seenin the adult or in the child, and upon the upper orlower lip. The chancre is usually an isolated ulcer,situated on the free edge of the lip, presenting thefamiliar features of a genital chancre, such asindolence, painlessness and slow growth with in-creasing induration. Because of exposure to theair, the formation of a firm dry crust is more fre-quently seen than in a genital chancre. Adenitis ofthe regional lymphatic glands-sub-mental or sub-maxillary-is well marked. Occasionally theglandular swelling is especially large, denselyhard and fixed; simulation of an epithelioma ofthe lip may then be very close, but the age of thepatient, the lack of pain and the absence of apearly, rolled edge to the ulcer are helpful dis-tinguishing features.A secondary syphilitic rash is often present in

these cases because the lesion has usually been re-garded as trivial for some weeks before medical

* Based on a lecture delivered at the Royal Collegeof Surgeons, under the auspices of the Institute ofUrology, February I950.

advice is sought. S. pallida can be found, by darkground microscopy, in the exudate from the lesionas readily as from a genital chancre, but when thelesion has been present for four or five weeks andis regressing the number of spirochaetes present issmall and their recognition not easy. For someweeks, when the number of spirochaetes is large,the lesions are highly infectious. Schamberg re-ports a veritable epidemic of chancre of the lipresulting from a party given for adolescents atwhich the main recreations were kissing games;unfortunately a youth was present who had achancre of the lip, and of the 12 maidens whoattended the party seven subsequently developeda chancre of the lip.Without appropriate treatment a chancre of the

lip may persist for many weeks but, eventually, itwill heal and absorb leaving only a minute scar.the glandular swelling, however, regresses muchmore slowly and may be palpable many weeksafter the chancre has vanished.

Chancre of the TongueA chancre elsewhere in the oral cavity is much

less frequent than one on the lip. They are oc-casionally seen on the tongue or the tonsil, andrarely on the gum or in the pharynx. In formertimes when syphilis was more prevalent and whencatheterization of the Eustachian tube with un-clean instruments was frequently performed, achancre of the orifice of the Eustachian tube was anot uncommon event.A chancre of the tongue is more frequent in

men than in women, and in middle-aged or elderlymen gives rise to a suspicion of a malignantgrowth, especially when the sub-maxillary lym-phatic glands are enlarged and hard, as they oftenare. The chancre is usually single and situated onthe anterior half of the dorsum of the tongue. Itmay occur as a smooth circular erosion if seen at

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(a) (b)FIG. I.-9390. Male aged 44. Gummatous ulcer of lateral border of tongue. Noted by patient only 14

days before photography. No history of syphilis. WR+ + Photographic Department, Guy's Hospital

an early stage or, later, as an indurated ulcer ofsome size. Pain is of slight degree or absent.Occasionally the chancre develops as an induratedmass within the substance of the tongue, with butslight projection and superficial ulceration. Themobility of the tongue may then be impaired andsimulation of a carcinoma is particularly close.The achievement of the correct diagnosis is

rarely a simple matter unless the rash of secondarysyphilis is present. One of my recent casesillustrates very well some of the difficulties indiagnosis and management which may be en-countered.A man, aged 48, complained of a sore on

the dorsum of the tongue which had increased insize and had become hard and slightly painfulover a period of two weeks. His tongue presentedan oval ulcer near the lateral border about an inchfrom the tip. It was about the size of a sixpennypiece, with a raised rounded margin and containeda central grey slough. There was an underlyinghard lump in the tongue about the size of amarble. One enlarged gland, hard and discretebut not tender, was found in the superior cervicalgroup.The Wassermann reaction and the Kahn test

were negative. Two attempts to find S. pallida bydark-ground microscopy were made, but withoutsuccess. The ulcer made no response to treat-

ment with potassium iodide, and two weeks laterwas excised, the incision healing rapidly. Sectionswere reported as being suggestive of a degeneratingfibrosarcoma. The man disappeared for nearlythree months and at the end of that period wasfound to have well-marked extensive secondarysyphilis and thoroughly positive serological tests.Almost certainly this lingual ulcer was a chancre;

there was no sign of a chancre elsewhere. Theman has been under observation for seven yearsafter antisyphilitc treatment and his tongue hasremained normal.

Chancre of the TonsilA chancre of the tonsil is always unilateral and

causes considerable swelling of the tonsil, whichbecomes dusky red in colour and of a firm con-sistency. There may be superficial ulceration withfew symptoms, or a deep ulcer causing pain anddysphagia. A malignant growth or Vincent'sangina may be simulated. S. pallida can be foundon dark-ground microscopy of the tonsillar ex-udate, but there may be some confusion owing tothe presence of S. dentium which is so similar inappearance. As with most chancres; the Wasser-mann reaction does not become positive untilseveral weeks have elapsed.The true cause of the tonsillar swelling is often

unsuspected for a considerable period. In one of

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FIG. 2.-Gummatous ulcer of tongue in congenital syphilis, with amputation of the tip of the tongue. (a)Extensive superficial ulceration of the tip of the tongue of an I x-year-old girl ,The ulcer was not tenderand tongue movements were free. History of soreness of the tongue for a few weeks only. WR+ +.(b) The tongue ten weeks later after treatment with potassium iodide and weekly N.A.B. injections.

(Reproduced by permission of the Hon. Editow of 'The British Journal of VenerealDiseases,' and of the publishers, Messrs. Butterworth & Co. (Publishers) Ltd.)

my four cases the tonsil and surrounding swellinghad been incised, as a quinsy, on two separateoccasions before the onset of secondary syphiliticmanifestations betrayed the true nature of thedisease. I have seen a considerable number ofpatients with secondary syphilis in whom no genitalchancre could be found, but by whom a history ofa recent prolonged and troublesome tonsillitis wasgiven. A chancre of the tonsil is rarely diagnosed,but I suspect that it is much more common than isgenerally believed. In one of the cases ofsecondary syphilis referred to, a dusky-red swollentonsil was still present and the glands below theangle of the jaw on the same side were much en-larged but not tender. I had little doubt that thetonsillar swelling was due to a recently healedchancre.

Lesions in the Oral Cavity in the SecondaryStageLesions of the mucosa of the oral cavity in the

florid secondary stage of syphilis are very fre-quent, and no doubt most doctors are familiarwith their appearance. Similar lesions are seenin young infants suffering from congenital syphilis.The syphilides in this situation exhibit very

clearly the fundamental characters of the lesions ofthe secondary stage of the disease. These dis-tinctive qualities are their richness in spirochaetes,their multiplicity and symmetry, their transientduration, their lack of destructive tendency andtheir capacity for healing without scar formation.These oral lesions may appear before, during orafter the cutaneous lesions of the secondary stage.Therefore they may be seen in the absence of thesyphilitic eruption, a fact which adds to thedifficulty of diagnosis. However, signs of anactive or recently-healed genital or extra-genitalchancre may still be present and a careful searchfor such a lesion should always be made.The lesions of the mucosa in the secondary stage

are of several varieties. Among the earliest is asmall red papule to be seen on the soft palatesurrounded by an area of bright erythema. Morefrequent, in fact very common, are the irregularsuperficial erosions on the soft palate, lips, faucesand sides or tip of the tongue. These are usuallymultiple and symmetrical and, at first, present apearly-grey centre of macerating epithelium, atwhich stage they are termed 'mucous patches.'Later, when the macerated epithelium has beenworn away a superficial erosion is exposed which is

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FIG. 3.-5063 F. Girl aged I5. WR+ +. Indefinitehistory of soreness of tongue and inability to eatsolids for some years. Crooked linear fissure incentre of dorsum of tongue. Some lobulation atsides of fissure. Slight leucoplakic changes of thelobules. Could eat well eight days after injectionof 0.3 ??. N.A.B.

Photographic Department, Guy's Hospital

soft to the touch and is painless. The patient isoften unaware of the presence of such lesions.These syphilides are usually of brief duration andheal without scar formation.Not infrequently, especially on the fauces or

palate, they increase in area (but not in depth) andcoalesce to form extensive, serpiginous areas whichhave received the very apt name of ' snail trackulcers.' On the fauces or tonsil they may developoccasionally into ulcers of considerable depth, towhich secondary bacterial infection is soon added.Sloughs are formed and separate slowly, so thathealing is delayed. In some areas, for example onthe dorsum of the tongue or at the angle of themouth, the lesions may become hypertrophic andform elevated papules known as condylomata;they are similar in character to anal condylomata.

Similar lesions are seen on the mucosa of theoral cavity in the congenital syphilitic infant.They occur at or about the same time as the well-known snuffles and eczema oris syphiliticum.Curiously enough, the adult with secondarysyphilis rarely has lesions in the nasal cavity,although this region is by no means immune inthe tertiary stage of the disease.

All these lesions of the secondary stage are richin spirochaetes and are highly infectious. Thewell-known epidemics of syphilis among glass

FIG. 4.-6927 F. Aged 48. Parenchymatous glossitis.Central fissure with adjacent lobulation. Slightleucoplakic changes of surface lobules. History ofsoreness of tongue for i6 months.

Photographic Department, (ruy'sxospital

blowers were almost certainly due to a workmanhaving lesions of this type.The oral cavity may be unaffected by syphilis

during the secondary stage and yet suffer later,particularly between the second and fifth year ofthe infection. These delayed lesions exhibit someof the characters of the tertiary stage, such asgreater depth of ulceration, chronicity and slowerresponse to treatment. Such lesions are known as' precocious tertiaries ' because they anticipate thelater tertiary period by many years. These lesionssometimes show a considerable resistance to treat-ment or recur soon after an initial response totreatment.A good example of this type of refractory ulcera-

tion occurred in a man aged 32 years, whom Ifirst saw in I939 a few months after irregulartreatment for a chancre had been given elsewhereover a period of four years. He presented an ex-tensive gummatous infiltration with some scatteredulcers of the posterior wall of the pharynx ex-tending from its upper limit to the level of thecricoid. After eight injections of neoarsphenamineand of a bismuth compound, together withpotassium iodide, the ulceration was almost healedbut there was still some infiltration of the naso-

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FIG. 5.-Tertiary ulcer of palate. Photographed immediately after removal of the slough. Perforation intonasal cavity. Woman aged 40. No history of syphilitic infection. Photographic Department, Guy's Hospital

pharyngeal mucosa. The posterior pillars of thefauces were adherent to the pharyngeal wall. Theairway through the nasopharynx was much re-stricted. A second course of neoarsphenamine andbismuth was given but a week after reaching atotal of 5.8 gm. of neoarsphenamine and of ii

injections of a bismuth preparation, the symptomsreturned and the pharynx showed thickened in-flamed areas with overlying grey membrane. Inspite of continuing the injections an ulcer, i in.in diameter, formed in the posterior pharyngealwall. This ulcer eventually healed with a con-tinuation of the treatment, but within three weeksof ceasing treatment it recurred. The patient thendisappeared for a period of eight months, at theend of which he had a large ulcer of the pharynxextending forward to involve the postelior pillarsof the fauces.At this stage, although the Wassermann re-

action was repeatedly positive, a tuberculousorigin of the ulceration was considered, but ap-propriate clinical and X-ray examinations showedno supporting evidence. The ulceration eventu-

ally healed firmly but with extensive and de-forming cicatriclal tissue in the pharynx and naso-pharynx. By that time I had treated him with afew lapses for nearly three years.

Resistant lesions, although rare, are well known.They appear to be less common in the mucousmembranes than in the skin and in most of thereported cases of resistant lesions in the oral cavitythey have been situated in the pharynx.The Tongue in the Tertiary Stage of S3philis

Leucoplakia of the tongue is frequently seen inthe tertiary stage, chiefly in men; it is much lesscommon in women and is quite a rarity in childrenwith congenital syphilis. Various factors play apart in the production of leucoplakia, e.g. tobacco,alcohol, spices, dental sepsis and syphilis. Thecondition, however, is not essentially syphilitic inorigin.The true syphilitic affections of the tongue in

the tertiary stage are described as being of twomain varieties-superficial sclerosing glossitis anddeep parenchymatous glossitis. These divisions

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are convenient for the purpose of classification, butthere is no sharp dividing line between them and,in fact, they may be found together.Superficial Sclerosing Glossitis

In this variety there is a widespread gummatousinfiltration of the sub-epithelial tissues of thetongue which gradually involutes and contracts.In appearance the dorsum and sides of the tongueshow dark-red areas which are smooth and shinyfrom atrophy of the papillae. Later, as the con-dition progresses, the mucosa becomes wiinkledand divided into numerous plaques or lobules.When widely affected the tongue has been termedthe ' cobblestone tongue,' a name which fits thepicture remarkably well. The surface of theplaques may show leucoplakic changes andfissures may appear in between. The patientrarely complains of any pain until fissures arepresent. Most of the tongues affected with thisvariety of glossitis show leucoplakic changes. Along experience of attempts to improve this con-dition has confirmed the general opinion thatleucoplakia itself is relatively unresponsive to anti-syphilitic treatment although fissures and ulcersmay respond favourably.There is one important aspect of the results of

anti-syphilitic treatment for this condition whichI have not seen mentioned, and that is its effectupon the ultimate development of carcinoma of thetongue. I have yet to see the subsequent develop-ment of carcinoma in any of my cases of syphiliticglossitis when thorough anti-syphilitic treatmenthas been given for that condition. Treatment forany dental sepsis was also given at the same timeand no doubt this may have had an importanteffect.

Deep Parenchjmatous glossitisAnother well known but rare variety of late

syphilis of the tongue is that of parenchymatousglossitis, in which the gummatous infiltiations maybe widespread throughout the tongue. I haverecords of I8 cases. In contrast to leucoplakiathe two sexes appear to be affected with equalfrequency-seven men, nine women and twochildren, both girls. In the early stage the tongueis enlarged, bright red and tender, but later, withensuing fibrosis, it pales and shrinks. The con-traction is iiregular and the tongue may be dis-torted by large film nodules, reminiscent of thoseseen in a syphilitic liver. Sometimes the nodulesare situated deep in the substance of the tongueand unite to form a firm, smooth, painless tumourwhich. in time, projects on the surface of thetongue usually on the dorsum near the mid-line(five in lateral border in my I8 cases). These deepgummas are slow to break down and the lump

may expand slowly for weeks or months. But,eventually, the gumma softens and perforates onthe dorsal or lateral aspect of the tongue and thenrapidly forms a sloughing ulcer of considerabledepth. Until the gumma commences to perforatethere may be no pain or tenderness. In contrastto a carcinomatous ulcer the movements of thetongue are unimpaired and unless the gummatousulcer becomes heavily infected with pyogenicorganisms the cervical glands do not enlarge.

In cases of chronic ulcer of the tongue, evenwhen the infection of syphilis is recognized fromblood tests or the presence of syphilitic lesions else-where in the patient, there may still be muchdoubt as to the nature of the ulcer. It has beencustomary for many years to use the rapid healingaction of the iodides or of neoarsphenamine as atherapeutic test. Penicillin will doubtless be usedin a similar manner, and a recent experience inthis respect is not without interest.

This was in the case of a man aged 52 yearswho had two lingual ulcers of about six weeks'duration. One of the ulcers was small and super-ficial and was situated on the tip of the tongue.The other was a large deep ulcer, tender and in-durated, situated on the left lateral border of thetongue. No enlarged lymphatic glands could bedetected. The mobility of the tongue was ex-cellent. The Wassermann test was stronglypositive.The diagnosis was in doubt because the re-

mainder of the tongue showed no leucoplakia orsigns of syphilitic glossitis, and the ulcers con-tained no wash-leather slough. Whilst the patientwas awaiting admission to hospital for a biopsy Itreated him with 3 m.u. penicillin in eight days.By the eighth day the ulcers were smaller, cleanerand less painful. Nevertheless biopsy revealedcarcinomatous changes in both ulcers. As a resultof this experience I feel that penicillin should notbe used in a differential therapeutic test forsyphilis in lingual ulcers of uncertain origin.Gummatous ulceration in the floor of the mouth

or on the under surface of the tongue appears tobe rare; I have not seen an example of thisnature. Gummatous infiltration commencing inthe mucosa of the cheek is rare, although an ex-tension into the cheek from a tertiary cutaneoussyphilide is not uncommon. I can recollect seeingonly one example in this location, in which alocalized gummatous swelling of characteristictype, and of about the diameter of a penny, wassituated in the mucosa of the cheek in appositionwith the right upper molar teeth of an elderly man.The swelling ulcerated in a few weeks and, afterthe separation of a deep slough, healed promptlyafter treatment with iodides and neoarsphenamine.Subsequent scarring and deformity was very slight.

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Gummatous Inflammation of the Palate,Fauces and PharynxOn the recrudescence of syphilis, after the

interval of the torpid latent stage in both acquiredand congenital syphilis, the mucosa of the palate,fauces, tonsil and pharynx is frequently affected bygummatous infiltration. In'these regions we seethe destructive tendency of gummatous inflam-mation at its worst. Examples of gross ulcerationare by no means rare, even at the present day.This gummatous infiltration may appear in eithersex and at almost any age. In my series of ioocases the ages ranged from four to 70.

Tertiary syphilis or late congenital syphilis inthese regions may appear as a diffuse indolent in-filtration of the mucosa or as a flattened tumour ofslow growth. The former-gummatous infiltra-tion-presents as a thickened congested area ofthe mucosa, dull red in colour, relatively painlessand firm to the touch. In some patients there isslight local discomfort which may have beenpresent for weeks or months. Eventually ulcera-tion takes place and may spread widely creating anindolent ulcer, serpiginous in outline, which mayheal in one area whilst advancing in another. Thecondition, even then, may exist without prominentsymptoms.

Less often tertiary syphilis presents as a smalllocalized tumour-the gumma-which forms asmooth rounded mass of a dull red colour. Localpain may be absent and tenderness may be only ofslight degree. The small tumour, which at firstis firm. slowly softens from central necrosis andon the surface a small necrotic area appears whichrapidly develops into a deep, punched-out ulcerwith a central adherent slough of the appearance ofwet wash-leather. The amount of tissue destruc-tion is invariably greater than at first is apparentand cannot be fully appreciated until the sloughhas separated and been removed.

Palate and FaucesGummatous infiltration of the palate usually

occurs in the mid-line of the hard or soft palateand is particularly prone to rapid and deepulceration. In many cases this leads to a smallperforation of the palate conmmunicating with thenasal cavity or to even more extensive destructionof the palate or fauces. Among 8I of my cases ofulceration of the palate in the late stage of syphilisthere were one or more perforations into the nasalcavity in 28. In some instances the perforation wasa tiny slit or a small round hole which gave rise tolittle disability. But in others the opening waslarge enough to permit constant regurgitation offluids into the nose on swallowing. When ulcera-tion appears in the mucosa attached to the hardpalate there is almost always some local underlying

periostitis. and bony necrosis with perforation isnot uncommon. Sometimes the destruction is sowidespread that the greater part of the hard andsoft palate is destroyed leaving a wide cleft throughwhich the turbinate bones can easily be seen. Thepatient's voice is grossly altered in tone when alarge perforation is present.Gummatous infiltration may also affect the

tonsils and pillars of the fauces in a similar manner,but less frequently than in the palate. The sametendency to gross destruction of tissue withsubsequent deformity on healing is seen in thesestructures. The uvula often disappears com-pletely. A perforation in the upper part of theanterior pillar of the fauces is sometimes seen; itis usually unilateral, slit-like in appearance andset in the long axis of the anterior pillar. Anisolated gumma of the tonsil, in the absence ofinvolvement of the palate or pharynx, appears tobe rare (there were four examples in my series ofioo cases) and gives rise to considerable difficultyin diagnosis. In contradistinction to an ulceratedmalignant growth there is less pain and less ten-dency to bleed in a syphilitic ulcer; and involve-ment of the cervical glands is not common. Butin these cases as in many others when there is anydoubt about the nature of the ulcer on clinicalgrounds it is wise to perform a biopsy and to avoidbeing too impiessed by a positive Wassermanntest.

I have learnt by bitter experience to regardthese late gummatous affections of the palate andfauces as therapeutic urgencies. Perforation or ex-tensive sloughing of the soft palate, uvula andfauces may take place very rapidly. Treatment, atthe very least with potassium iodide, should becommenced as soon as a syphilitic origin of theulceration is suspected. In the past I have greatlyregretted delaying treatment until the report of aWassermann test has arrived, for in the few days'interval that elapsed I have known ulceration toprogress rapidly and to cause destruction of tissuesthat might have been avoided by prompt treatment.

TABLE I

DISTRIBUTION OF GUMMATOUS ULCERS IN I00 CASES OFSYPHILIS OF THE ORAL CAVITY (EXCLUDING TONGUE)

Palate Tonsil PharynxAcquired:Men 45 I IWomen 19 4 9

Congenital:Male 7 o IFemale 10 I4 .

Total number of lesions 81 16 29

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I84 POSTGRADUATE MEDICAL JOURNAL April 1951

PharynxIn the pharynx gummatous infiltration or ulcera-

tion in the late stage of congenital or acquiredsyphilis may occur in the lateral or posterior wallsof the nasopharynx and oropharynx, but it is lessfrequent than similar involvement of the palate orfauces-29 instance in my Ioo cases of gummatousinvolvement of the oral cavity. In the naso-pharynx the lesion is often invisible except torhinoscopy, and the nasopharyngeal isthmus maybe llcked up by the swelling. In general, thegummatous inflammation is slowly progressiveand after remissions and subsequent recru-descences over some years may involve extensiveareas of the lateral and posterior walls of thepharynx.The symptoms vary with the extent of the

disease. When the lesion is small there may beslight dysphagia and excess of mucus only. Inmore extensive infiltrations or ulceration dys-phagia is a prominent complaint and the pain mayradiate to the ear. Deafness from blocking of theEustachian tube is not uncommon and otitis mayensue. The difficulty in swallowing may be con-siderable and in severe cases fluids only can beswallowed. A foul discharge may emanate fromthe ulcers, particularly from those situated in thenasopharynx.The ulcerated areas heal in time and are re-

placed by dense scar tissue. Additional ulcersappear and slowly heal. Finally large sections of

the pharyngeal walls are replaced by extensive ir-regular cicatricial areas or bands with pits orchronic ulcers in between. The thickened andscarred pharyngeal tissues tend to become ad-herent to the anterior aspect of the cervicalvertebrae, which may be the seat of syphiliticosteitis and necrosis. The mobility of the pharynxduring deglutition is much impaired and this,together with the accompanying narrowing andrigidity of the walls of the nasopharynx, con-stitutes a serious disability. There may be con-stant regurgitation of fluids into the nose frominability to close the nasophaiynx during swallow-ing; further, nasal respiration may be muchrestricted or prevented.Gummatous infiltration of the fauces often

occurs at the same time as that in the nasopharynx.There is a tendency for the swollen ulcerated areasto become adherent to similar areas in the naso-pharynx. Later, on healing, the nasopharyngealisthmus is reduced by contraction into a smallchannel surrounded by dense scar tissue-averitable stricture of the nasopharynx. There isthen much impairment of the functions of speech,respiration and deglutition. In my series of 29cases of severe tertiary ulceration of the pharynxthere are five instances of such gross deformity.

It is curious that among the Ioo cases ofulceration in the palate, fauces or pharynx therewas no instance of simultaneous gummatousdisease of the tongue.

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