[Reprinted from The Tri-State Medical Journal, St. Louis, December, 1896.] 
SYPHILITIC PERFORATIONS OF THE BONES, 
By A. H. Ohmann-DumeSnil, 
Professor of Dermatology and Syphilology in the Marion-Sims College of Medicine, 
St. Louis. 
SYPHILIS in its protean manifestations shows changes of the most varied 
character and pathological changes of the greatest dissimilarity. Like 
leprosy and tuberculosis it may attack any and all the tissues of the 
organism, sparing none, and often proving most destructive in its character. 
Whilst there is no donbt that syphilis is a proliferative disease, consisting of 
ronnd-cell proliferation at its inception and, later on, of connective tissue 
hyperplasia of a fibrous character, it is equally indisputable that there are 
other changes which may be observed at times. Processes which are very 
destructive will manifest themselves more as a consequence of the disease, 
perhaps, than as a condition inherent to it. In other words, the destruction 
is rather an indirect than a direct one, yet is possessed of sufficient charac- 
teristics to justify its being called specific in form and character. In the so- 
called tertiary or post-syphilitic stages of the disease we meet with more or 
less marked involvements of the deeper tissues. These are rather prone to 
suffer and undergo a certain amount of destruction on account of a loss of 
resisting power as well as of reparative tendency. This element of de- 
structiveness may be of a varying degree of severity, the quantity being 
dependent upon the locality attacked and the general state of the subject and 
of his tissues. In some cases the loss of substance and encroachments made 
upon vital organs may become so extensive as to endanger life even. Not 
infrequently permanent deformities of a very annoying character and per- 
manent in their duration are the result of apparently trivial lesions which 
were neglected at their inception. 
To even attempt a description of the various syphilitic perforations of 
bones and their varieties would involve the writing of a volume. On this 
account but two of the more frequently seen forms will be sketched in the 
present article. They are interesting to a high degree, more especially on 
account of the deformities caused and the inconveniences incident to them. 
Perforation of the nasal bone and of the hard palate are the two post-syph- 
ilitic lesions which attract so much attention and for which help is fre- 
quently sought, the subjects being anxious to obtain relief and being ambulant 
are very apt to have attention directed to their trouble and thus lead to em- 
barrassing explanations or have the mortification of being continually 
stared at and otherwise annoyed. 
It is quite a well-known fact that the nose is one of the organs which is 
prone to be affected by syphilis, more especially in those cases in which 
treatment has been neglected. Perhaps the most common example of the 
affection of the nasal bones which is met with is that peculiar condition known 
as ' 'saddle-back" nose. It is not only seen in cases of acquired lues, but is one 
of the most typical of the signs of prenatal, or, as it is better known, hereditary 
syphilis. Another condition which is observed in acquired syphilis and 
which, while not visible, is distressing is one limited to the interior of the 
nasal cavities-perforation of the septum. The form of nasal trouble 
which will engage our attention is entirely different from those mentioned. 
It is a result of acquired syphilis and, so far as I have been able to determine 
in the cases I have had an opportunity to observe, it is dependent for its 2 
cause upon an inadequate treatment or a neglect of the therapeutic measures 
and rules of conduct which should be most imperatively carried out. As a 
matter of fact, there is no excuse nowadays for the formation of perforation of 
the nose due to syphilis. The merest tyro who has even but a superficial 
knowledge of syphilology is capable of treating a patient sufficiently well to 
prevent such an untoward accident; but there is one condition against which 
even the most learned is impotent-the neglect of the patient. This is a 
condition around which no safeguard exists and against which the physician 
has no adequate protection. 
In syphilitic perforation of the nose we have a manifestation which is 
either of late secondary origin or, most frequently, of that period which is a 
sequence of the secondary process and bordering on or inclusive of the so- 
called tertiary stage of the disease. The perforation is an indication of an 
involvement of the deeper tissues and is a direct consequence of a destructive 
inflammatory process of the nasal mucous membrane, which has culminated 
in ulcerative lesions. These destructive lesions may begin high up or 
lower down, being usually caused by some form of irritation, chiefly of a 
mechanical nature, such as scratching the nares with the finger-nail. The 
destructive lesion, beginning comparatively low down in the nasal fossa, 
gradually extends upwards by continuity of tissue until the upper portion of 
the anterior nasal fossa is attacked. As the process extends, healing and 
cicatrization takes place, but, when it is limited at the upper portion by the 
anatomical peculiarities existing there, destruction takes place in another 
manner. The process begins to extend through the mucous membrane and 
into the submucous structures. There seems to be but little pain connected 
with the ulceration and the patient is under the impression that he is suffer- 
ing from an aggravated case of catarrh. A sanguino-purulent secretion 
accumulates and it possesses a very fetid odor which later on becomes un- 
endurable to others and a source of considerable annoyance to the patient. 
It is a very characteristic smell such as is always found in connection with 
the bone caries of syphilitics. To resume, however, the unchecked continu- 
ation of the ulceration next attacks the periosteum of the nasal bone, giving 
rise to a constant, dull pain. This proceeds until caries of the bone takes 
place. This caries is limited in extent but not in depth, for the final re- 
sult is that the skin ulcerates and the perforation is established. A good 
example of a typical case is shown in Figure 1. The process apparently 
stops when the perforation is established; but, it also remains stationary 
and there seems to be no tendency to spontaneous recovery. The edges of 
the opening become rounded off and even calloused. They will remain in 
this state unless ulceration is caused by either trauma or some other active 
cause. The perforation may remain stationary for years unless means be 
adopted to relieve the condition. One curious fact in connection with 
syphilitic perforation of the nose is that it is unilateral and, in all the cases 
I have had occasion to observe, it was located on the left side. 
The treatment of the condition just described is one which is, of neces- 
sity, both medicinal and operative. Both are really indispensable in order 
to obtain a good result. The former, however, is of the highest importance, 
not only in the way of a preparatory method, but as a means to render the 
latter of permanent benefit, and here it is that it is employed to follow the 
surgical procedure. To place the patient in the best possible condition for 
an operation, both internal and local measures should be pursued. To begin 3 
with, iodide of potassium should be administered in half-drachm or drachm 
doses, in milk, after each meal for some two weeks. This should be fol- 
lowed by some mercurial for an equal length of time. A good preparation 
to give is the biniodide of mercury pill after each meal, the ordinary dose 
Fig. i. Syphilitic Perforation of the Nose. 
being a quarter of a grain. Such a course of medication will place the tis- 
sues in a good condition and, in addition, will greatly aid in a rapid healing 
of the wound made by the operation. So far as local preliminary treatment 
is concerned, some few details must be attended to in order to obtain a good 
operative field. Of course cleanliness is indispensable, but the beneficent 4 
effects of local mercurial treatment will make themselves very apparent 
when proper and judicious use is made of it. For the purpose of cleansing 
the nasal cavity the following mixture may be sprayed twice or three times 
daily: 
$ Ol. eucalyptigtt xx 
Benzoinol 
M. 
The spraying should be thorough, and after each spray the nares well 
blown. Following this cleansing spray the following should be employed 
and permitted to remain on the tissues: 
Hydrarg. oleat 5% 3ss 
Ol. amygdal. dulc „ 3j 
M. 
But little of this need be sprayed each time. 
One important part of the local treatment, which is of no mean import- 
ance, is the removal of all small pieces of necrosed bone which may lie in 
the upper and middle portions of the nasal cavity. The local treatment 
which has just been mentioned, in conjunction with the general measures 
given, will hasten a reparative process, and the removal of necrosed or 
carious bone will do away with a possible source of local irritation so detri- 
mental to the success of all surgical operations. It may be necessary in 
some cases to curette carious bone, and this had better be done before the 
external opening is closed. The general and local measures which are 
proper having been carried out, the operation proper may then be performed. 
This is a plastic in which the borders of the opening are freshened and two 
flaps, one on either side, cut and their free borders approximated by means 
of the procedure known as "sliding." This should be performed in a very 
thorough manner and care taken that there be as little strain upon the tis- 
sues as is compatible with good coaptation of the edges. This will greatly 
aid in securing a good result. An important point to secure a good result 
is to enjoin absolute rest of the parts operated upon, as well as complete 
protection from all irritating influences, mechanical and otherwise. Many 
an operation of this sort has been completely spoiled by neglect of these 
precepts and subsequent attempts at repair rendered more difficult. Of 
course, the strict avoidance of alcoholics is absolutely necessary, and this 
can be inaugurated during the preliminary treatment. It will be found that 
medicinal treatment during the course of the healing is of the greatest ad- 
vantage, and the use of arsenauro in 10- to 15-drop doses in water, after 
meals, will fill all necessary requirements. A strict observance of these 
recommendations will bring about most favorable results and will lead to a 
recovery which can be made permanent by continuing appropriate consti- 
tutional treatment. 
On the other hand if a case of syphilitic perforation of the nose be 
permitted to go on untreated, it may remain in statzi quo for an indefinite 
period of time. If, however, the subject of the trouble will indulge in alco- 
holics and neglect proper dietetic and hygienic rules, as too many are prone 
to do, the bone necrosis will extend. The entire upper portion of the nasal 
osseous structures will suffer and thus lead to the formation of a large, 
gaping cavity which plastic surgery even may be unable to cope with in a 
satisfactory manner on account of the mechanical difficulties presented, as 
well as the bad condition of the tissues which are available for such a pur- 
pose. It is for this reason that the individual afflicted with the slightest 
syphilitic perforation should always be made acquainted with the possible 5 
dangers incident to neglect of his condition as well as with the advantages 
which accrue from prompt surgical aid and efficient general treatment. 
It is by no means a rare case to observe mucous patches occurring upon 
and implicating the lining membrane of the buccal cavity. These patches 
are interesting as well as important for a number of reasons, but the point 
at present to attract particular attention is that they not only have a great 
tendency to spread superficially but are also prone to ulcerate and attack 
the underlying tissues. This destructive process is a comparatively rapid 
one and attended with a certain amount of pain upon mastication and deg- 
lutition. In addition, there is usually a moderate discharge of a muco- 
purulent fluid, and the whole process is accompanied by a strong fetid odor 
of a nauseating nature. In order to illustrate the rapidity of the destruc- 
tive ulceration which is occasionally observed, it may not be out of place to 
quote the following:1 J. Darier observed a young man of 22 who had a 
perforation of the velum palati. The hole was large enough to admit a 
lead pencil, had thin edges, no redness, no swelling, no induration, and no 
suppuration. The patient claimed that it had formed in three days. The 
opening enlarged. Eleven days later a second perforation had appeared 
inferior to the first and to the right. Like the other it had no inflamma- 
tory characteristics but appeared as if punched out. Eight days later, at 
the time the report of the case was made, the two openings had enlarged, 
the bridge separating the two not being wider than one and a half millime- 
tres, whereas, it had been twice as broad a week previously. Whilst this 
is a rare case it has been introduced in this place to call attention to an un- 
usual process of lightning-like rapidity which might prove very puzzling, 
especially in those cases such as the one given, in which the presence of 
syphilis was never recognized. 
To resume the subject: When mucous patches of a destructive nature 
attack the roof of the mouth they should receive prompt and immediate 
attention in order to arrest the destructive action at the earliest possible 
moment. On the other hand, in older cases, it is a gummatous infiltration 
of the mucous membrane which constitutes the starting point of the trouble. 
Like all gummatous growths it has a tendency to break down and ulcerate. 
No matter what the primary lesion of the process may be, in neglected 
cases the tissues break down, ulceration sets in and the hard palate is at- 
tacked by the destructive action which has become established. The 
osseous structure gives way in a comparatively short time, forming a small 
perforation which communicates with one or both nasal cavities and not 
infrequently involving the vomer in the process of destruction. The perfo- 
ration increases in size and may attain the size of a silver dollar, as shown 
in Figure 2. Whilst in the majority of cases there is but one perforation 
about the center of the palate it occasionally happens that several perfora- 
tions occur; but, when they do the first one is nearest to the center and the 
others occur in its vicinity. As the process proceeds the perforations in- 
crease in size and finally coalesce to form one large, irregular cavity. This 
keeps on for a certain length of time until the loss of the osseous tissue 
ceases spontaneously. The soft borders which existed during the destruc- 
tive action gradually assume a rounded and rather firm form in this manner, 
making a permanent aperture. This last gives the voice a distinctly nasal 
sound besides leading to quite an amount of physical discomfort on account 
1 Bull, de la Soc. Franc, de Dermatol, et de Syphilig., June, 1896, p. 408 et seq. 6 
of the inability to swallow liquids or food with any degree of ease or com- 
fort. In the effort to swallow a liquid there is usually a regurgitation 
which takes place through the nares and it is not rare by any means for 
solid food to make its way into the nose and thus constitute a disagree- 
able source of irritation. Altogether the condition is a very unpleasant 
Fig. 2. Syphilitic Perforation of Hard Palate. 
one which calls for active interference of some sort for its amelioration. 
In all such cases it will be found that destructive lesions are also pres- 
ent. Among the more common ones are ulcers of the legs and upon the 
trunk. Their size and depth seems to be proportionate to that of the per- 
foration of the hard palate. The soft palate will not infrequently be found 
to present perforations or ragged, deep ulcers which are rapidly destructive 7 
and have a tendency to extend downward and destroy the uvula. The 
pharnyx is another part which will present one or more ulcers which ex- 
hibit a tendency to become large and deep. The pillars of the fauces also 
present ulcerative manifestations with marked destruction of tissue. On 
the other hand cases present themselves in which a single perforation of 
the hard palate is alone manifest in and about the upper respiratory and 
buccal tract. Bone lesions in other parts as well as gummata are not rare 
accompaniments, however. In any case the local lesions, wherever they 
may be situated, constitute a good index of the condition at large and fully 
demonstrate the want of tone and lack of resistance in the tissues of the or- 
ganism of the affected individual. 
So far as treatment is concerned it is by no means as easy a matter as 
in the case of perforation of the nasal bones. The general management 
and constitutional treatment need not be dwelt upon, as it has already been 
outlined in the case of syphilitic nasal perforation. Yet, more care must be 
taken in regard to diet, in so far as the forms of food given are concerned, on 
account of the mechanical disadvantages offered by the preparation itself. 
Instructions should be given with care as to the proper methods of degluti- 
tion, and no food requiring much mastication is to be recommended. The 
proper method of drinking so as to avoid regurgitation should be taught 
the patient and he will derive a certain degree of comfort from a strict 
observance of proper directions. 
Locally, treatment is quite difficult in some cases. All irritating food 
and liquids are to be avoided and perfect cleanliness should be observed. 
The floor of the nares should be kept scrupulously clean and all spiculae and 
small particles of bone removed. The same local detergent and 
medicinal means are applicable here as have been recommended for 
perforation of the nose. The closure of the perforation in the 
palate is, of course, of prime importance if it can be accomplished. 
In the smaller perforations a staphylorraphy is indicated and will succeed 
if the preliminary course of treatment is thorough and the paring of the 
edge of the perforation is properly done. No definite directions can be 
given or rules laid down for the surgical measures which should be adopted, 
for they must be entirely governed by the indications and necessities pre- 
sented by the case in hand. Necessarily, an operation on a syphilitic, es- 
pecially an adult, will present more difficulties than in a child or infant so 
far as closing or perforation of the palate is concerned. In the larger 
perforations more difficulties exist and but little can be advised. Surgical 
measures will be found of but little avail unless they are such as are indi- 
cated by the absolute necessities of a case. Various devices, in the way 
of an operative method, have been attempted, but they have never proven 
successful. In a large perforation too much tissue must be replaced and if 
an attempt be made to borrow it from contiguous parts a destruction of 
these latter may take place, and result, finally, in a greater destruction than 
the original lesion presented. 
One of the best methods to adopt in such a case is the use of an obtur- 
ator. It can be worn without inconvenience by the patient and will afford 
him an opportunity of eating, drinking and speaking with ease as well as 
comfort. The obturator should be attached to a dental plate and if the 
patient have any teeth missing they may be attached to the plate, and in 
that manner add to the cosmetic effects of the device. Before attempting 8 
to use such a plate with an obturator attached, two conditions are necessary: 
The mucous membrane of the mouth, especially that covering the palate, 
should be in the best possible condition to avoid the formation of any ulcera- 
tive process. Secondly, the edge of the perforation should be put in such 
a condition as not to be easily irritated. If it has not healed so as to be in 
such a condition it should be pared in such a manner as to afford an 
opportunity for cicatrization to take place in the proper manner. With 
a good edge such a lesion will permit of the use of an obturator whose 
presence will never be noticed nor its existence suspected. The plate 
should not be gold, as the use of mercurials will make it deteriorate. 
Good vulcanized rubber is the best material to employ. It is also better 
for the patient to have two obturators, as, by this means, he will always 
have a clean apparatus and thus greatly lessen the dangers of possible 
irritation which one might produce.