There are three characteristic manifestations of acquired syphilis as follows. The primary lesion or hard chancre is a firm, indurated ulcerated mass with only slight discharge. Chancre of the nose is exceedingly rare. In secondary syphilis there is the mucous patch, the result of mucous membrane necrosis. In tertiary syphilis the local lesion is the gumma or more commonly, the ulceration left from necrosis of the gumma. These lesions may appear from a few to many years after the initial infection, but they never follow immediately. The lesions may appear on almost any part of the intranasal structures. They resemble the lesions of atrophic rhinitis but in atrophic rhinitis there is never the extent of destruction that so frequently results from tertiary syphilis. =Treatment.=—It has been my practice to refer all suspected cases to Dr. F. J. Stewart for differential diagnosis and treatment and his method of the use of salvarsan has proven efficient. Epistaxis—Nose Bleed The causes of nose bleed may be divided into two general groups, local and constitutional. The first group consists of trauma directly to the nose either external or internal, from nasal operations and other causes. The presence of a cluster of thin-walled veins on the anterior part of the septum which readily rupture from slight cause, constitutes perhaps the most common cause of nose bleed. The ulcers of atrophic rhinitis or syphilis occasionally cause bleeding. Malignant growths of the nose may cause frequent and profuse hemorrhage. The constitutional causes of epistaxis are, the acute fevers, cardiac and arterial diseases, which cause excessive tension; and cases of altered composition of the blood such as the anemias, malaria, purpura, chlorosis, hemophilia, etc. =Diagnosis.=—Direct examination of the nose will usually reveal the cause. If there are no signs of trauma or rupture of the anterior group of vessels and the bleeding does not respond quickly to packing of the affected side, there is either a rupture of a large vessel, which requires long continued packing, or it belongs to the class of constitutional disease. If there is evidence of some necrotic disease of the nose or if there are areas of exposed bone or cartilage from careless surgery, these may usually be seen and the point of bleeding located. =Treatment.=—Cold applications, irrigation of the nares with cold normal salt solution and the application of an absorbent cotton or gauze pack is usually sufficient to stop the average case of epistaxis from any cause. The direct application of cold to the lower cervical region will cause capillary restriction.