Postgrad Med J: first published as 10.1136/pgmj.27.306.177 on 1 April 1951. Downloaded from

April - 95 LLOYD: Syphilis of the Oral Cavity 177 GILBERT', N. C., DEY, F. L., and RALL, J. E. (1946), J.A.M.., POLLEY, H. F. (194I), J.A.M.A., Ix6, 82t. 133, I132. RADLOFF, F. F., and KING, R. L. (1947), Gastroenterology, 9, GOLDNER, M. G., and LEVY, J. H. (1947), Gastroenterology, 8, 249. 788. RAU, L. (1949), Proc. Roy. Soc. Med., 42, 864. GROSS, R. E. (1946), Am. J. Dis. Child., 71, 579. RENNIE, J. B., LAND, F. T., and SCOTT PARK, S. D. (I949), HARRINGTON, S. W. (1943), Am. J. Roentgenol., 49, I85. Brit. Med. J., 2, 1443. HARRINGTON, S. W. (1945), Ann. Surg., 122, 546. RITCHEY, J. 0., and WINSAUER, H. J. (1947), Am. J. Med. Sc., JANKELSON, I. R., and MOREIN, S. (1940), Rev. Gastroenterol., 214, 476. 7, 134. RITVO, M. (1930), J.A.M.A., 94, I5. KIRKLIN, B. R., and HODGSON, J. R. (1947), Am.J. Roentgenol., SAHLER, O. D., and HAMPTOM, A. 0. (1943), Am. J. Roent- 58, 77. genol., 49, 433. MENDELSON, E. A. (1946), Radiology, 46, 502. SCHWARTZ, S. 0., and BLUMENTHAL. S. A. (1949), Am. J. Med., 7, 501. MORRISON, L. G. (1925), J.A.M.A., 84, i6i. SMITHERS, W. D. (1945), Brit. J. Radiol., I8, 199. MURPHY, W. P., and HAY, W. E. (I943), Arch. Int. Med., 72, 58. TRUEMAN, K. R. (1947), Canad. Med. Ass. J., 56, 149. NAZUM, F. R. (i947), Am. Heart J., 33, 724. 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 affected advice is sought. S. pallida can be found, by dark with syphilis in any of the various stages of that ground microscopy, in the exudate from the lesion disca3e. No decade of life is immune, from in- as readily as from a genital chancre, but when the fancy to senility. A study of the characters of the lesion has been present for four or five weeks and various lesions and of thtir course provides an is regressing the number of spirochaetes present is epitome of the habitual behaviour of this ex- small and their recognition not easy. For some chronic infection. From various observa- when the number of is quisitely weeks, spirochaetes large,by copyright. tions upon the lesions of the , and the lesions are highly infectious. Schamberg re- we can learn much of the natural history ports a veritable epidemic of chancre of the of the disease. resulting from a party given for adolescents at which the main recreations were kissing games; Primary Infection in the Oral Cavity unfortunately a youth was present who had a Chancre of the Lip chancre of the lip, and of the 12 maidens who It is by no means rare for infection with syphilis attended the party seven subsequently developed to occur in the lip, a chancre in this situation being a chancre of the lip. the most of all Without treatment a chancre of the frequent the primary lesions which appropriate http://pmj.bmj.com/ occur in extra-genital locations. It may be seen lip may persist for many weeks but, eventually, it in the adult or in the child, and upon the upper or will heal and absorb leaving only a minute scar. lower lip. The chancre is usually an isolated ulcer, the glandular swelling, however, regresses much situated on the free edge of the lip, presenting the more slowly and may be palpable many weeks familiar features of a genital chancre, such as after the chancre has vanished. indolence, painlessness and slow growth with in- creasing induration. Because of exposure to the Chancre of the Tongue air, the formation of a firm dry crust is more fre- A chancre elsewhere in the oral cavity is much on September 23, 2021 by guest. Protected quently seen than in a genital chancre. Adenitis of less frequent than one on the lip. They are oc- the regional lymphatic glands-sub-mental or sub- casionally seen on the tongue or the tonsil, and maxillary-is well marked. Occasionally the rarely on the gum or in the . In former glandular swelling is especially large, densely times when syphilis was more prevalent and when hard and fixed; simulation of an epithelioma of catheterization of the Eustachian tube with un- the lip may then be very close, but the age of the clean instruments was frequently performed, a patient, the lack of pain and the absence of a chancre of the orifice of the Eustachian tube was a pearly, rolled edge to the ulcer are helpful dis- not uncommon event. tinguishing features. A chancre of the tongue is more frequent in A secondary syphilitic rash is often present in men than in women, and in middle-aged or elderly these cases because the lesion has usually been re- men gives rise to a suspicion of a malignant garded as trivial for some weeks before medical growth, especially when the sub-maxillary lym- phatic glands are enlarged and hard, as they often are. The * Based on a lecture delivered at the Royal College chancre is usually single and situated on of Surgeons, under the auspices of the Institute of the anterior half of the dorsum of the tongue. It Urology, February I950. may occur as a smooth circular erosion if seen at Postgrad Med J: first published as 10.1136/pgmj.27.306.177 on 1 April 1951. Downloaded from

178 POSTGRADUATE MEDICAL JOURNAL April 1951 by copyright. (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 of ment with potassium iodide, and two weeks later some size. Pain is of slight degree or absent. was excised, the incision healing rapidly. Sections Occasionally the chancre develops as an indurated were reported as being suggestive of a degenerating mass within the substance of the tongue, with but fibrosarcoma. The man disappeared for nearly slight projection and superficial ulceration. The three months and at the end of that period was http://pmj.bmj.com/ mobility of the tongue may then be impaired and found to have well-marked extensive secondary simulation of a carcinoma is particularly close. syphilis and thoroughly positive serological tests. The achievement of the correct diagnosis is Almost certainly this lingual ulcer was a chancre; rarely a simple matter unless the rash of secondary there was no sign of a chancre elsewhere. The syphilis is present. One of my recent cases man has been under observation for seven years illustrates very well some of the difficulties in after antisyphilitc treatment and his tongue has diagnosis and management which may be en- remained normal. countered. on September 23, 2021 by guest. Protected A man, aged 48, complained of a sore on Chancre of the Tonsil the dorsum of the tongue which had increased in A chancre of the tonsil is always unilateral and size and had become hard and slightly painful causes considerable swelling of the tonsil, which over a period of two weeks. His tongue presented becomes dusky red in colour and of a firm con- an oval ulcer near the lateral border about an inch sistency. There may be superficial ulceration with from the tip. It was about the size of a sixpenny few symptoms, or a deep ulcer causing pain and piece, with a raised rounded margin and contained dysphagia. A malignant growth or Vincent's a central grey slough. There was an underlying angina may be simulated. S. pallida can be found hard lump in the tongue about the size of a on dark-ground microscopy of the tonsillar ex- marble. One enlarged gland, hard and discrete udate, but there may be some confusion owing to but not tender, was found in the superior cervical the presence of S. dentium which is so similar in group. appearance. As with most chancres; the Wasser- The Wassermann reaction and the Kahn test mann reaction does not become positive until were negative. Two attempts to find S. pallida by several weeks have elapsed. dark-ground microscopy were made, but without The true cause of the tonsillar swelling is often success. The ulcer made no response to treat- unsuspected for a considerable period. In one of Postgrad Med J: first published as 10.1136/pgmj.27.306.177 on 1 April 1951. Downloaded from

April 1951 LLOYD: Syphilis of the Oral Cavity I79 by copyright.

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 tender and 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 Venereal Diseases,' and of the publishers, Messrs. Butterworth & Co. (Publishers) Ltd.) my four cases the tonsil and surrounding swelling clearly the fundamental characters of the lesions of had been incised, as a quinsy, on two separate the secondary stage of the disease. These dis- http://pmj.bmj.com/ occasions before the onset of secondary syphilitic tinctive qualities are their richness in spirochaetes, manifestations betrayed the true nature of the their multiplicity and symmetry, their transient disease. I have seen a considerable number of duration, their lack of destructive tendency and patients with secondary syphilis in whom no genital their capacity for healing without scar formation. chancre could be found, but by whom a history of These oral lesions may appear before, during or a recent prolonged and troublesome tonsillitis was after the cutaneous lesions of the secondary stage. A chancre of the tonsil is Therefore be seen in the absence of the

given. rarely diagnosed, they may on September 23, 2021 by guest. Protected but I suspect that it is much more common than is syphilitic eruption, a fact which adds to the generally believed. In one of the cases of difficulty of diagnosis. However, signs of an secondary syphilis referred to, a dusky-red swollen active or recently-healed genital or extra-genital tonsil was still present and the glands below the chancre may still be present and a careful search angle of the jaw on the same side were much en- for such a lesion should always be made. larged but not tender. I had little doubt that the The lesions of the mucosa in the secondary stage tonsillar swelling was due to a recently healed are of several varieties. Among the earliest is a chancre. small red papule to be seen on the soft surrounded by an area of bright erythema. More Lesions in the Oral Cavity in the Secondary frequent, in fact very common, are the irregular Stage superficial erosions on the , , Lesions of the mucosa of the oral cavity in the and sides or tip of the tongue. These are usually florid secondary stage of syphilis are very fre- multiple and symmetrical and, at first, present a quent, and no doubt most doctors are familiar pearly-grey centre of macerating epithelium, at with their appearance. Similar lesions are seen which stage they are termed 'mucous patches.' in young infants suffering from congenital syphilis. Later, when the macerated epithelium has been The syphilides in this situation exhibit very worn away a superficial erosion is exposed which is Postgrad Med J: first published as 10.1136/pgmj.27.306.177 on 1 April 1951. Downloaded from i8o POSTGRADUATE MEDICAL JOURNAI, April I 951

FIG. 3.-5063 F. Girl aged I5. WR+ +. Indefinite history of soreness of tongue and inability to eat solids for some years. Crooked linear fissure in centre of dorsum of tongue. Some lobulation at by copyright. sides of fissure. Slight leucoplakic changes of the lobules. Could eat well eight days after injection of 0.3 ??. N.A.B. FIG. 4.-6927 F. Aged 48. Parenchymatous glossitis. Photographic Department, Guy's Hospital Central fissure with adjacent lobulation. Slight leucoplakic changes of surface lobules. History of soft to the touch and is painless. The patient is soreness of tongue for i6 months. often unaware of the presence of such lesions. Photographic Department, (ruy'sxospital These syphilides are usually of brief duration and blowers were almost certainly due to a workman heal without scar formation. lesions of this type. having http://pmj.bmj.com/ Not infrequently, especially on the fauces or The oral cavity may be unaffected by syphilis palate, they increase in area (but not in depth) and during the secondary stage and yet suffer later, coalesce to form extensive, serpiginous areas which particularly between the second and fifth year of have received the very apt name of ' snail track the infection. These delayed lesions exhibit some ulcers.' On the fauces or tonsil they may develop of the characters of the tertiary stage, such as occasionally into ulcers of considerable depth, to greater depth of ulceration, chronicity and slower which secondary bacterial infection is soon added. response to treatment. Such lesions are known as Sloughs are formed and separate slowly, so that ' precocious tertiaries ' because they anticipate the on September 23, 2021 by guest. Protected healing is delayed. In some areas, for example on later tertiary period by many years. These lesions the dorsum of the tongue or at the angle of the sometimes show a considerable resistance to treat- mouth, the lesions may become hypertrophic and ment or recur soon after an initial response to form elevated papules known as condylomata; treatment. they are similar in character to anal condylomata. A good example of this type of refractory ulcera- Similar lesions are seen on the mucosa of the tion occurred in a man aged 32 years, whom I oral cavity in the congenital syphilitic infant. first saw in I939 a few months after irregular They occur at or about the same time as the well- treatment for a chancre had been given elsewhere known snuffles and eczema oris syphiliticum. over a period of four years. He presented an ex- Curiously enough, the adult with secondary tensive gummatous infiltration with some scattered syphilis rarely has lesions in the nasal cavity, ulcers of the posterior wall of the pharynx ex- although this region is by no means immune in tending from its upper limit to the level of the the tertiary stage of the disease. cricoid. After eight injections of neoarsphenamine All these lesions of the secondary stage are rich and of a bismuth compound, together with in spirochaetes and are highly infectious. The potassium iodide, the ulceration was almost healed well-known epidemics of syphilis among glass but there was still some infiltration of the naso- Postgrad Med J: first published as 10.1136/pgmj.27.306.177 on 1 April 1951. Downloaded from

April I 951 LLOYD: Syphilis of the Oral Cavity8 i8i by copyright.

FIG. 5.-Tertiary ulcer of palate. Photographed immediately after removal of the slough. Perforation into nasal Woman No of infection.

cavity. aged 40. history syphilitic Photographic Department, Guy's Hospital http://pmj.bmj.com/ pharyngeal mucosa. The posterior pillars of the ally healed firmly but with extensive and de- fauces were adherent to the pharyngeal wall. The forming cicatriclal tissue in the pharynx and naso- airway through the nasopharynx was much re- pharynx. By that time I had treated him with a stricted. A second course of neoarsphenamine and few lapses for nearly three years. bismuth was given but a week after reaching a Resistant lesions, although rare, are well known. total of 5.8 gm. of neoarsphenamine and of ii They appear to be less common in the mucous injections of a bismuth preparation, the symptoms membranes than in the skin and in most of the on September 23, 2021 by guest. Protected returned and the pharynx showed thickened in- reported cases of resistant lesions in the oral cavity flamed areas with overlying grey membrane. In they have been situated in the pharynx. spite of continuing the injections an ulcer, i in. in diameter, formed in the posterior pharyngeal The Tongue in the Tertiary Stage of S3philis wall. This ulcer eventually healed with a con- Leucoplakia of the tongue is frequently seen in tinuation of the treatment, but within three weeks the tertiary stage, chiefly in men; it is much less of ceasing treatment it recurred. The patient then common in women and is quite a rarity in children disappeared for a period of eight months, at the with congenital syphilis. Various factors play a end of which he had a large ulcer of the pharynx part in the production of leucoplakia, e.g. tobacco, extending forward to involve the postelior pillars alcohol, spices, dental sepsis and syphilis. The of the fauces. condition, however, is not essentially syphilitic in At this stage, although the Wassermann re- origin. action was repeatedly positive, a tuberculous The true syphilitic affections of the tongue in origin of the ulceration was considered, but ap- the tertiary stage are described as being of two propriate clinical and X-ray examinations showed main varieties-superficial sclerosing glossitis and no supporting evidence. The ulceration eventu- deep parenchymatous glossitis. These divisions E Postgrad Med J: first published as 10.1136/pgmj.27.306.177 on 1 April 1951. Downloaded from

182 POSTGRADUATE MEDICAL JOURNAL April 1951 are convenient for the purpose of classification, but may expand slowly for weeks or months. But, there is no sharp dividing line between them and, eventually, the gumma softens and perforates on in fact, they may be found together. the dorsal or lateral aspect of the tongue and then rapidly forms a sloughing ulcer of considerable Superficial Sclerosing Glossitis depth. Until the gumma commences to perforate In this variety there is a widespread gummatous there may be no pain or tenderness. In contrast infiltration of the sub-epithelial tissues of the to a carcinomatous ulcer the movements of the tongue which gradually involutes and contracts. tongue are unimpaired and unless the gummatous In appearance the dorsum and sides of the tongue ulcer becomes heavily infected with pyogenic show dark-red areas which are smooth and shiny organisms the cervical glands do not enlarge. from atrophy of the papillae. Later, as the con- In cases of chronic ulcer of the tongue, even dition progresses, the mucosa becomes wiinkled when the infection of syphilis is recognized from and divided into numerous plaques or lobules. blood tests or the presence ofsyphilitic lesions else- When widely affected the tongue has been termed where in the patient, there may still be much the ' cobblestone tongue,' a name which fits the doubt as to the nature of the ulcer. It has been picture remarkably well. The surface of the customary for many years to use the rapid healing plaques may show leucoplakic changes and action of the iodides or of neoarsphenamine as a fissures may appear in between. The patient therapeutic test. Penicillin will doubtless be used rarely complains of any pain until fissures are in a similar manner, and a recent experience in present. Most of the affected with this this respect is not without interest. variety of glossitis show leucoplakic changes. A This was in the case of a man aged 52 years long experience of attempts to improve this con- who had two lingual ulcers of about six weeks' dition has confirmed the general opinion that duration. One of the ulcers was small and super- leucoplakia itself is relatively unresponsive to anti- ficial and was situated on the tip of the tongue. syphilitic treatment although fissures and ulcers The other was a large deep ulcer, tender and in-by copyright. may respond favourably. durated, situated on the left lateral border of the There is one important aspect of the results of tongue. No enlarged lymphatic glands could be anti-syphilitic treatment for this condition which detected. The mobility of the tongue was ex- I have not seen mentioned, and that is its effect cellent. The Wassermann test was strongly upon the ultimate development of carcinoma of the positive. tongue. I have yet to see the subsequent develop- The diagnosis was in doubt because the re- ment of carcinoma in any of my cases of syphilitic mainder of the tongue showed no leucoplakia or glossitis when thorough anti-syphilitic treatment signs of syphilitic glossitis, and the ulcers con- has been given for that condition. Treatment for tained no wash-leather slough. Whilst the patient http://pmj.bmj.com/ any dental sepsis was also given at the same time was awaiting admission to hospital for a biopsy I and no doubt this may have had an important treated him with 3 m.u. penicillin in eight days. effect. By the eighth day the ulcers were smaller, cleaner and less painful. Nevertheless biopsy revealed Deep Parenchjmatous glossitis carcinomatous changes in both ulcers. As a result Another well known but rare variety of late of this experience I feel that penicillin should not of the is that of be used in a differential test for syphilis tongue parenchymatous therapeutic on September 23, 2021 by guest. Protected glossitis, in which the gummatous infiltiations may syphilis in lingual ulcers of uncertain origin. be widespread throughout the tongue. I have Gummatous ulceration in the floor of the mouth records of I8 cases. In contrast to leucoplakia or on the under surface of the tongue appears to the two sexes appear to be affected with equal be rare; I have not seen an example of this frequency-seven men, nine women and two nature. Gummatous infiltration commencing in children, both girls. In the early stage the tongue the mucosa of the is rare, although an ex- is enlarged, bright red and tender, but later, with tension into the cheek from a tertiary cutaneous ensuing fibrosis, it pales and shrinks. The con- syphilide is not uncommon. I can recollect seeing traction is iiregular and the tongue may be dis- only one example in this location, in which a torted by large film nodules, reminiscent of those localized gummatous swelling of characteristic seen in a syphilitic liver. Sometimes the nodules type, and of about the diameter of a penny, was are situated deep in the substance of the tongue situated in the mucosa of the cheek in apposition and unite to form a firm, smooth, painless tumour with the right upper molar teeth of an elderly man. which. in time, projects on the surface of the The swelling ulcerated in a few weeks and, after tongue usually on the dorsum near the mid-line the separation of a deep slough, healed promptly (five in lateral border in my I8 cases). These deep after treatment with iodides and neoarsphenamine. gummas are slow to break down and the lump Subsequent scarring and deformity was very slight. Postgrad Med J: first published as 10.1136/pgmj.27.306.177 on 1 April 1951. Downloaded from

April 1951 LLOYD: Syphilis of the Oral Cavity I83 Gummatous Inflammation of the Palate, periostitis.and bony necrosis with perforation is Fauces and Pharynx not uncommon. Sometimes the destruction is so On the recrudescence of syphilis, after the widespread that the greater part of the hard and interval of the torpid latent stage in both acquired soft palate is destroyed leaving a wide cleft through and congenital syphilis, the mucosa of the palate, which the turbinate bones can easily be seen. The fauces, tonsil and pharynx is frequently affected by patient's voice is grossly altered in tone when a gummatous infiltration. In'these regions we see large perforation is present. the destructive tendency of gummatous inflam- Gummatous infiltration may also affect the mation at its worst. Examples of gross ulceration tonsils and pillars of the fauces in a similar manner, are by no means rare, even at the present day. but less frequently than in the palate. The same This gummatous infiltration may appear in either tendency to gross destruction of tissue with sex and at almost any age. In my series of ioo subsequent deformity on healing is seen in these cases the ages ranged from four to 70. structures. The uvula often disappears com- Tertiary syphilis or late congenital syphilis in pletely. A perforation in the upper part of the these regions may appear as a diffuse indolent in- anterior pillar of the fauces is sometimes seen; it filtration of the mucosa or as a flattened tumour of is usually unilateral, slit-like in appearance and slow growth. The former-gummatous infiltra- set in the long axis of the anterior pillar. An tion-presents as a thickened congested area of isolated gumma of the tonsil, in the absence of the mucosa, dull red in colour, relatively painless involvement of the palate or pharynx, appears to and firm to the touch. In some patients there is be rare (there were four examples in my series of slight local discomfort which may have been ioo cases) and gives rise to considerable difficulty present for weeks or months. Eventually ulcera- in diagnosis. In contradistinction to an ulcerated tion takes place and may spread widely creating an malignant growth there is less pain and less ten- indolent ulcer, in outline, which dency to bleed in a syphilitic ulcer; and involve-

serpiginous may by copyright. heal in one area whilst advancing in another. The ment of the cervical glands is not common. But condition, even then, may exist without prominent in these cases as in many others when there is any symptoms. doubt about the nature of the ulcer on clinical Less often tertiary syphilis presents as a small grounds it is wise to perform a biopsy and to avoid localized tumour-the gumma-which forms a being too impiessed by a positive Wassermann smooth rounded mass of a dull red colour. Local test. pain may be absent and tenderness may be only of I have learnt by bitter experience to regard slight degree. The small tumour, which at first these late gummatous affections of the palate and is firm. softens from central necrosis and fauces as therapeutic urgencies. Perforation or ex-

slowly http://pmj.bmj.com/ on the surface a small necrotic area appears which tensive sloughing of the soft palate, uvula and rapidly develops into a deep, punched-out ulcer fauces may take place very rapidly. Treatment, at with a central adherent slough of the appearance of the very least with potassium iodide, should be wet wash-leather. The amount of tissue destruc- commenced as soon as a syphilitic origin of the tion is invariably greater than at first is apparent ulceration is suspected. In the past I have greatly and cannot be fully appreciated until the slough regretted delaying treatment until the report of a has and been removed. Wassermann test has arrived, for in the few days' separated interval that I have known ulceration to elapsed on September 23, 2021 by guest. Protected Palate and Fauces progress rapidly and to cause destruction of tissues Gummatous infiltration of the palate usually that might have been avoided byprompt treatment. occurs in the mid-line of the hard or soft palate and is particularly prone to rapid and deep TABLE I ulceration. In many cases this leads to a small perforation of the palate conmmunicating with the DISTRIBUTION OF GUMMATOUS ULCERS IN I00 CASES OF nasal cavity or to even more extensive destruction SYPHILIS OF THE ORAL CAVITY (EXCLUDING TONGUE) of the palate or fauces. Among 8I of my cases of Palate Tonsil ulceration of the palate in the late stage of syphilis Pharynx there were one or more perforations into the nasal Acquired: cavity in 28. In some instances the perforation was Men 45 I I a tiny slit or a small round hole which gave rise to Women 19 4 9 little disability. But in others the opening was Congenital: large enough to permit constant regurgitation of Male 7 o I fluids into the nose on . When ulcera- Female 10 I4 . tion appears in the mucosa attached to the there is almost always some local underlying Total number of lesions 81 16 29 Postgrad Med J: first published as 10.1136/pgmj.27.306.177 on 1 April 1951. Downloaded from

I84 POSTGRADUATE MEDICAL JOURNAL April 1951 Pharynx the pharyngeal walls are replaced by extensive ir- In the pharynx gummatous infiltration or ulcera- regular cicatricial areas or bands with pits or tion in the late stage of congenital or acquired chronic ulcers in between. The thickened and syphilis may occur in the lateral or posterior walls scarred pharyngeal tissues tend to become ad- of the nasopharynx and oropharynx, but it is less herent to the anterior aspect of the cervical frequent than similar involvement of the palate or vertebrae, which may be the seat of syphilitic fauces-29 instance in my Ioo cases of gummatous osteitis and necrosis. The mobility of the pharynx involvement of the oral cavity. In the naso- during deglutition is much impaired and this, pharynx the lesion is often invisible except to together with the accompanying narrowing and rhinoscopy, and the nasopharyngeal isthmus may rigidity of the walls of the nasopharynx, con- be llcked up by the swelling. In general, the stitutes a serious disability. There may be con- gummatous inflammation is slowly progressive stant regurgitation of fluids into the nose from and after remissions and subsequent recru- inability to close the nasophaiynx during swallow- descences over some years may involve extensive ing; further, nasal respiration may be much areas of the lateral and posterior walls of the restricted or prevented. pharynx. Gummatous infiltration of the fauces often The symptoms vary with the extent of the occurs at the same time as that in the nasopharynx. disease. When the lesion is small there may be There is a tendency for the swollen ulcerated areas slight dysphagia and excess of mucus only. In to become adherent to similar areas in the naso- more extensive infiltrations or ulceration dys- pharynx. Later, on healing, the nasopharyngeal phagia is a prominent complaint and the pain may isthmus is reduced by contraction into a small radiate to the ear. Deafness from blocking of the channel surrounded by dense scar tissue-a Eustachian tube is not uncommon and otitis may veritable stricture of the nasopharynx. There is ensue. The in be con- then much impairment of the functions of speech, difficulty swallowing may by copyright. siderable and in severe cases fluids only can be respiration and deglutition. In my series of 29 swallowed. A foul discharge may emanate from cases of severe tertiary ulceration of the pharynx the ulcers, particularly from those situated in the there are five instances of such gross deformity. nasopharynx. It is curious that among the Ioo cases of The ulcerated areas heal in time and are re- ulceration in the palate, fauces or pharynx there placed by dense scar tissue. Additional ulcers was no instance of simultaneous gummatous appear and slowly heal. Finally large sections of disease of the tongue. http://pmj.bmj.com/ on September 23, 2021 by guest. Protected H.K.LEWIS&Co.Ltd. Medical Lending Library MedicaledicalPublishersPublisher ANNUAL SUBSCRIPTION from TWENTY-FIVE SHILLINGS and Booksellers For the CONVENIENCE of POST-GRADUATE STUDENTS SHORT Catalogues on request State interests PERIOD SUBSCRIPTIONS ARE ARRANGED - for 3 or 6 months 1 36 GOWE R STREET Detailed Prospectus on application The Library Catalogue revised to December, 1949, containing LO NDON, W.C. 1 classified index of authors and subjects. Ready this month. (Adjoining University College and Hospital) To subscribers 17/6 net; To non-subscribers 35/- net. Postage I/- rfdtohn. EUSton 4282 (7 lines) Bi-Monthly List of New Books and New Editions Telegrams: Publicavit, Westcent, London sent post free on request Business hours:9 am. to 5 p.m. SaturdaystI p.m. NEW BOOKS ADDED IMMEDIATELY UPON PUBLICATION