Malignancy, tuberculosis, lupus, each have their distinctive history, symptoms, course, and should not be confused.

Passing on to the tertiary lesions in the nose we are brought face to face with the seeming ignorance of many medical men as to these luetic manifestations. This phase is an exceedingly important one because next to the skin no one particular organ is so liable to be the seat of the gumma as is the nose, and a gumma of the nose that has been allowed to run its course is so often followed by sequelae so destructive to our modern idea of beauty, that from this viewpoint alone it is indeed important that these unfortunate new growths be early determined and rapidly disposed of.

The diagnosis of a nasal gumma should not be a particularly difficult one. To be sure, the stage of infiltration here, as in other places, is characterized mostly by the absence of symptoms, yet symptoms quite distinctive present themselves sooner here than in any other part, save the epipharynx, for soon there is apparent a persistent increasing obstruction to respiration, accompanied by a peculiar boring pain, noticed especially at night; as the obstruction increases, so the pain increases. By the time the gumma has reached a considerable size there will be noticed oftentimes a slight external venous stasis over the part involved.

Any part of the nasal cavities may be involved in a gummatous invasion or several parts may be included in the same infiltration; however, the most frequent sites are the bony septum and the middle third of the inferior turbinate. In making the nasal examination to discover the cause of the obstruction, a distant round swelling will be noted and the discharge will be serous. This growth will be hard, will not be affected by the application of cocaine, if seen before the second stage has started the mucous membrane covering it will be but little altered in color, and will not be over-sensitive to manipulation. There is no other nasal condition that simulates this, all other growths are soft, have associated a different history and a different symptom complex. If the diagnosis is now made and treatment instituted and pushed, all the succeeding stages and sequelae can be avoided.

When the gumma begins to soften, the progress is rapid, complete ulceration soon follows and necrosis results. The pain ceases, but the low grade intra-nasal inflammatory signs increase, the discharge becomes very offensive, examination reveals dead bone, and the deformity, which will later exist, de

pends entirely upon how extensive is the necrosis and upon the energy exhibited in pushing the proper treatment.

Every case of syphilis should be studied carefully, when in doubt a Wasserman should be made, an effort should be made to find the spirochete, yet few physicians are so situated as to take advantage of these laboratory privileges and must depend entirely upon clinical data. The importance of the questions discussed in this paper, and the personal pride of the physician, should make each one feel it his duty to familiarize himself with the methods of precision to make the examinations mentioned, and to recognize the conditions stated. I have purposely avoided the ultra scientific and I trust my expressions of opinion have not seemed illogical or too unorthodox.

Syphilis of the Skin

*By ALFRED SCHALEK, M. D., Omaha.

The skin manifestations of syphilis play a very important, if not the most important role, in the symptomotology, diagnosis, prognosis and treatment of this disease.

It is a well known fact that syphilis is a constitutional disease caused by micro-organisms, which quickly flood the lymphatic and blood circulation, may infest every tissue and organ, and may even result in serious disturbances and death. As the skin is involved in every case of syphilis, and exclusively in about 90 per cent of them, it naturally results that it must be relied on mainly in its understanding and management. Only a few points shall be mentioned to show why the consideration of the skin manifestations are paramount, for the guidance of the physician. Shortly after the infection and frequently during the whole course of the disease, they are the only clinical evidence permitting a diagnosis. In this connection it might be mentioned that the Wasserman test is called for affirmation usually, only in consequence of their appearance, and cannot take their place in diagnostic importance. Experience teaches that the cases of syphilis which proceed to the late stages, threatening the most important functions, are, as a rule, such that their character was not recognized early and the lack of timely treatment gave the virus every chance of development, and deleterious action. The type and time of appearance of the specific eruption may foretell the probable

*Read before the Nebraska State Medical Association at Lincoln, May 7-9, 1912.

course of the disease and permit a provisional prognosis. Superficial and evanescent lesions, appearing infrequently during an early period point to a mild virulence, and to a speedy and complete recovery. The reaction of the syphilitic skin eruptions to specific treatment is a valuable guide to its efficiency. Their persistence and their progressive tendency for deeper structures should put the physician at once on his guard to push his drugs or use a more intense method of medication. Syphilis of the skin, including the mucous orifices, is furthermore responsible for nine-tenths of all infections, and for this reason alone requires more attention than when involving other parts of the body. An individual with a syphilitic eruption is a greater menace than one with smallpox, being by far more numérous, not enough incapacitated to seek seclusion and not as easily recognized and guarded against as the latter. By attending his daily business and social duties he may contaminate directly and indirectly any object with which he comes into contact, and scatter the infection broadcast. Here again the physician shoulders a great responsibility, if he does not perfect himself sufficiently in the knowledge of syphilis of the skin to recognize it early, so as to protect the community by proper measures. The other extreme is just as reprehensible, though more of an injury to the individual than to the public. It is the indiscriminate jumping at a diagnosis of syphilis at the very least suspicion. It should be remembered that syphilis is a great imitator of almost every pathological condition, and that at times it leads experts astray. To condemn an individual to social ostracism, possibly to break up family ties, and to subject him to mental and physical misery for years is not permissible except upon the strongest evidence. As there are usually a group of symptoms present indicating syphilis, it is a good general rule never to rely on one feature alone for a definite diagnosis. The old fashioned classification of syphilis into a primary, secondary and tertiary stage has outlived its usefulness, except possibly for convenience only. It referred to the belief that certain manifestations were appearing at certain periods of the disease. It is known now, however, that such is not the case, that early and late manifestations merge into one another, preceed and succeed each other without any regularity, and are not dependent on any special period of the disease. The same classification also inferred the idea that the tertiary lesions were only consequences of the infection, but in themselves not capable of transmitting the infection. This theory has been completely upset by the proof of the presence

of the spirochetae in every lesion of syphilis. It is desirable to abolish these old designations entirely, and name the lesions according to the pathological changes encountered.

As already mentioned, syphilis of the skin, while closely simulating many dermatoses, always has some distinct features, which give it a character of its own. The early eruptions are more or less extensive and symmetrical, the latter few and found in limited areas only. No part of the skin is exempt but some localities are affected more frequently and by preference. The papules on the forehead, along the border of the hair, were known already to the Romans and called "corona veneris." The squamous affection of the palms and soles, the small white round spots on the neck or leucoderma, the moist papules or condylomata around the genitals and the anus are other wellknown examples. The color of the lesions become more characteristic as they grow older, or as new relapses occur, the tint changing gradually from a bright to a dark red, and even to brown, aptly compared to the color of raw ham or of copper. Frequently the early lesions have a tendency to group in circles and to form gyrate figures by coalescence. The later lesions, especially the ulcers, spread at the periphery with convex borders while healing at the center, producing circinate and serpiginous figures and assuming the shapes of horseshoes, kidney outlines, the letters S, C, etc.

The resulting scars and pigmentations retain this characteristic appearance and for a long time present to the experienced eye an incontrovertible testimony to the past infection. Compared with other inflammatory affections of the skin the syphilitic eruptions develop slowly, and in successive crops. These last appear in the original type, while the older have already undergone changes, so that another feature, that of polymorphism, is added to the picture. Macules, papules, pustules, ulcers and crusts may be seen in the same subject, an association which is rarely seen outside of syphilis. One of the most peculiar and distinctive features of syphilis of the skin, with few exceptions, is the absence of subjective symptoms, such as itching, pain, etc. A macular eruption is often overlooked entirely on this account. It is a frequent experience to see a patient almost covered with ulcerations who seems to suffer very little inconvenience.

The knowledge of pathology of syphilitic cutaneous tissue has been given a new impetus since the discovery of the spiro

chetae. These micro-organisms have been successfully demonstrated in almost all lesions. The serous secretion from an untreated chancre contains a large number of them during the first few weeks. After eight weeks they are difficult to find. They are distributed irregularly in foci, and unless these are found the search may be disappointing. The bloodvessels are early invade, peri- and endarteritis being produced. In time all the tissues in the neighborhood of the primary lesion become involved, which in itself shows the futility of an extirpation with the hope of stopping short the disease.

The constant appearance of the skin eruptions in syphilis is due to the preference of the spirochetae for certain structures, especially the epithelial cells.

The pathology of all the cutaneous lesions of syphilis is essentially the same and only differs in degree. Its main element is infiltration of round cells in the connective tissues. In the macular, the mildest and most superficial eruption, hyperaemia predominates. In the syphilitic papule, which represents the characteristic type of a specific lesion, the infiltration involves the papillary layer; if the process extends to the deeper parts of the skin, and to the subcutaneous tissues tubercles and gummata are formed. These infiltrations have no vitality and undergo degeneration. Appreciating these changes, the clinical forms are easily explained; the papule is prominent on account of the filling up of the tissues with the cellular infiltration; is shiny on account of the tensity of the epidermis; hard, due to the density of the infiltration; if the epidermis breaks on account of the stretching, scaling results; the dark redness is produced by the blood coloring matter; the gumma is produced by a globular mass of cells, increasing at the periphery and undergoing necrosis in the center.

It may be appropriate to say a few words in regard to treatment of syphilis of the skin. As a rule it needs no special attention, and will yield to the constitutional medication, except if very disfiguring or threatening important functions. Mercury and iodides are still the most valuable drugs in the treatment of syphilis, and are sufficient in all ordinary cases. Some syphilitic eruptions seem to be, however, very refractory to their action, and in such, happily, the salvarsan comes to the rescue. Mucous patches and old obstinate ulcerations, which at times resist all other treatment for months and years, often disappear rapidly after the administration of 606.