case of bone swelling without suppuration the localization is of sonic importance. In general the cranial bones are more prone to syph ilis than to tuberculosis, and especially the frontal and parietal bones, particularly their eminences. Only the temporal and molar bones are more frequently the seat of tuberculosis than of syphilis. Affections of the occipital bone again are as a rule syphilitic in children.
The skin lesions of late hereditary syphilis differ in no way from the tertiary skin lesions of acquired syphilis. According to my experience there are two main forms of true skin lesions: the small nodules, and the large nodular late syphilides. In the former they are circumscribed in filtrations of the skin that feel hard at first and vary in size from a split pea to a lentil. The skin over these nodules becomes brownish in color and either desquamates or becomes covered with a crust. These nodules. are usually grouped together closely, very much as in lupus vulgaris. Below the crusts the granulation tissue disintegrates, while the crust itself grows larger and assumes the shape of a cup, or of an oyster shell. Some nodules may undergo resorption. In general these late small nodular syphilides show a serpiginous arrangement.
This serpiginous syphilide of childhood belongs to the most intract able manifestations of syphilis, from a therapeutic standpoint.
The large nodular syphilide occurs in the form of large skin gum inata, and gummatous ulcers, though not a frequent lesion. The point of origin is usually the subcutaneous tissue.
The mucous membranes also, especially those of the respiratory tract become invaded in a specific manner in late hereditary syphilis.. It is not always possible to determine whether the gummatous process, in this case, starts in the mucous membrane itself or in the deeper lying tissues. This is especially true of the lesions of the nasal and pharyn geal mucous membranes. In older children the differential diagnosis between ulcers of the skin and mucous membranes due to tuberculous lupus on the one hand and those due to syphilis on the other hand, arc to be considered. Rapidly progressive ulceration with absence of nodular infiltration always speaks for syphilis. Pharyngeal and laryn geal ulcers due to hereditary syphilis are characterized by sharply defined borders and by thick walls.
As far as the nose is concerned, a diffuse osseous and periosteal affection of the whole nasal skeleton, or the formation of gummata within the cartilaginous or bony nasal septum or at the base of the nasal cavity, may represent the primary pathological process; breaking down of the affected tissues may be followed by ulceration of the mucous mem brane. And yet circumscribed nodules may form on the mucous mem
brane of the cartilaginous and soft portions of the nose and these may lead to ulcer formation. Probably the most frequent lesion is a, gumma tous ostitis of the bony portion of the septum, the first symptom of which is an obstinate nasal obstruction. The gummatous ulceration is always. accompanied by much pus and crust formation. If proper therapeutic measures are not instituted at the right time, deep ulceration will take place with perforation of the septum, or the floor of the nose, with necrosis of the affected portions of the ethmoid and the superior maxilla. The final outcome of such nasal disturbances will be dis cussed in connection with the discussion of the stigmata of hereditary syphilis.
Atrophic rhinopharyngitis, or ozaunt, is a frequent syphilitic deuteropathy in children between six and fifteen years of age. The smooth atrophy of the base of the tongue (Levin, Heller) characterized, by smoothness and thinness of the mucous membrane and by absence of glands, likewise occurs as a luetic deuteropathy in children of the above-mentioned age with hereditary syphilis.
The palate and pharynx become invaded very frequently and in a very characteristic manner in late hereditary syphilis. I would men tion first the syphilitic tophus of the hard palate, usually projecting from the raphe. a lesion which contrasts strongly with the purely mucous membrane affections of hereditary syphilis on account of its painful character, and which represents a stage preceding ulcerative palate per foration. Furthermore, gummata occur on the velum palati and within the palatine arches, and may lead to deep ulceration and perforation. The favorite location is the point of insertion of the uvula and the middle portion of the anterior palatine arch, where at first painless swellings arise. These reveal their presence only by a slight peculiarity in the voice sounds such as exists with a tonsillar abscess, hut they do not materially interfere with swallowing. Not until ulceration or perforation has taken place do we notice the well-known functional disturbance of speech and swallowing.