768 CHRONIC INFECTIOUS DISEASES. 



which proceeds from ossification of the periosteum, there is another, 

 dependent upon inflammation and proliferation of the bone itself 

 Tophi and exostoses by pressure upon neighboring nerves may cause 

 neuralgia, anaesthesia, or palsy, and when situated upon the inner sur- 

 face of the skull may occasion serious disorder of the brain. 



Syphilitic caries and necrosis are sometimes the consequence of 

 purulent periostitis, where the pus effused between the bone and peri- 

 osteum has cut off the portion of bone affected from its nutrient blood- 

 vessels. At other times it proceeds from an ulceration, originating in 

 the soft parts, and which has destroyed the periosteum, and laid bare 

 the bone ; while, in still another series of instances, the periosteum, at 

 first, is healthy, and the caries and necrosis are the result of a simple 

 or gummy syphilitic inflammation. The question why the denuding 

 of the bone of its periosteum and the ostitis sometimes cause an ul- 

 ceration of the bone, or caries, while, at others, it induces the death 

 and separation of large pieces of bone, or necrosis, we shall leave un- 

 discussed, as being a question belonging to general surgery. When 

 bone exfoliates from syphilitic necrosis, the loss of substance is seldom 

 filled up by new bone. A depressed spot almost always remains, or, 

 if the bone has been perforated, there will always be a hole in it with 

 smooth edges. Syphilitic caries and necrosis occur more frequently 

 upon the bones of the face and skull than upon those of the trunk 

 and extremities, although the latter, especially the sternum, tibiae, and 

 clavicles, do not always escape. The most dreadful devastation occurs 

 in the bones of the nose and hard palate. The vomer and the vertical 

 plate of the ethmoid usually go first, so that the two nostrils commu- 

 nicate by an orifice of variable size. Afterward the entire bony sep 

 turn perishes, and the turbinated bones, the walls of the ethmoid cells 

 and frontal sinus, the nasal and lachrymal bones, are also destroyed. 

 The nose thus loses its support, and sinks in behind its apex, which 

 then points upward. If the disease attack the floor of the nostrils, 

 after perforation of the hard palate, a communication is established be- 

 tween the cavities of the mouth and nose ; so that food and drink can 

 enter the latter. More rarely, destruction of the hard palate com- 

 mences in the mouth, although I have seen a piece of bone as large as 

 a florin exfoliate from the lower surface of the hard palate, without 

 any syphilitic ozaena. When caries and necrosis of the nasal bones 

 arise from ulceration of the mucous membrane which has penetrated 

 and destroyed the periosteum, the patients suffer long from an ill-smell- 

 ing ichorous and often bloody discharge from the nose, which, at a later 

 period, also contains bits of blackened bone. The septum of the nose is 

 often perforated in such cases without its external covering exhibiting 

 any particular change ; but, if the destruction of the nasal bones be 



