30 CLINICAL APPLIED ANATOMY. 



localised ulceration of the interior of the ascending aorta, or 

 cause a widespread arteriosclerosis. 



The manifestations of the tertiary stage of syphilis differ from 

 those of the secondary stage in their asymmetry. The original 

 symmetrical distrihution by the blood stream may be said to 

 have left residual proclivities or possibly infected foci, which in 

 many instances are stirred up to activity by local accidents or 

 peculiarities. 



When these local inflammations attack tubular structures 

 the results may be very serious. The posterior surface of the 

 palate may become adherent to the pharyngeal wall at the level 

 of the Eustachian tubes ; strictures of the larynx, trachea, 

 bronchi, or oesophagus may be induced ; the small intestine, 

 the ileo-caecal valve, and, more particularly, the rectum, may 

 be similarly affected. .Cerebral arteries may be occluded by a 

 like process, and strictures of the common bile duct and of 

 the nasal duct have been met with. The nasal duct, from its 

 proximity to the nasal bones, may become involved as the result 

 of disease of the latter. 



The irregular areas of caseation, so characteristic of the 

 gummatous inflammations of the tertiary stage, are the result 

 of vascular obliteration. At the periphery of a gumma, where 

 the blood supply is less interfered with, organised fibrous tissue 

 will be found. A gumma, which by situation is exposed to 

 injury or to the access of septic organisms, is liable to soften 

 and to ulcerate. Gummata in the subcutaneous tissues, in 

 the mouth and in the pharynx may be given as examples of this 

 tendency. In the deeper and more protected viscera such 

 changes are rare. Tertiary visceral syphilis is commonest in 

 the liver and the spleen. The liver suffers more frequently 

 than other organs, possibly because its greater size increases the 

 possibility of infection. It is also liable to slight injury by the 

 overlying ribs. Liver gummata tend to result in depressed 

 cicatrices, and these are often met with on the surface of the 

 organ. 



The tendency of subcutaneous gummata to ulcerate has been 



