This gentleman had gonorrhoea thirty-five years back, but no other symptoms of syphilis. One of his brothers had erythema palmare.

CASE 47.-A gentleman, between 50 and 60, has a tumor of this kind excavated at its base by a deep ulceration, the latter being covered with a slough. He has suffered from the disease sixteen years; and although existing for so long a time, the ulcer now is scarcely larger than a shilling. It is of the horse-shoe form, and has burrowed into the base of the hypertrophied skin constituting the tumor. The ulcer is situated immediately in front of the tragus. The skin of the temple in front of the ulcer, and, indeed, as far as the angle of the eye, presents the appearance of a cicatrix, and along its border is an impetiginous eruption, which has crept over, and is the cause of the cicatrized skin. In this portion of the skin, and particularly in the neighborhood of the ulcer, are a number of those enlarged venules spoken of in case 23.

This gentleman had gonorrhoea many years ago, but remembers no other symptom of syphilis.

CHAPTER V.

LOCAL ACTIONS OF SYPHILIS.

Local actions in the Skin.

BESIDES the more general effects of the syphilitic poison on the skin, there are others which are local or partial; such actions being either present as symptoms among the general phenomena, or having an independent existence.

SYPHILITIC AFFECTIONS OF THE HAIR. ALOPECIA.

The fall of the hair, alopecia, sometimes follows the syphilitic fever, in the same manner as it is met with as a sequela of measles, scarlet fever, or fevers of any other type. Under the influence of the constitutional actions present in these fevers, the formation of the epiderma and hair is temporarily suspended, the epiderma as a consequence exfoliates, and the hair falls. Where the fall of the hair is a chronic action, it probably depends upon insufficient nutrition of the skin; a condition especially characteristic of the syphilitic cachexia.

In a disease so important and serious as constitutional syphilis, the fall of the hair, even as a symptom, is not calculated to excite more than a passing notice. If it be sought for, it will be found very frequently but occasionally it is brought under our attention by the immediate inconvenience to which it gives rise. Case 18

:

is an example of that circumstance, and I was therefore induced to make a note of its presence; but my silence upon this point in the narration of other cases is not to be taken as a proof of its absence in them.

In several instances, I have been consulted for alopecia, and have been led, in consequence, to examine my patient carefully, for the detection of any other symptom which might indicate its dependence on the syphilitic poison. Sometimes I have succeeded in discovering such a symptom, however obscure, and then the treatment applicable to constitutional syphilis has been remarkably successful. In one case, the concurrent symptom was a tendency to neuralgia; in another, a muddy skin, with occasional sore-throat; and in a third, a milky spot or a fissure on the tongue.

The following is an example of alopecia, depending on syphilis:

CASE 48. A gentleman contracted a venereal sore, the nature of which was doubted at the time by his medical attendant, and a week was allowed to transpire before he commenced taking mercury. He then took blue-pill until his mouth was affected; the sore healed in three weeks. Three months after the sore, his hair began to fall off in considerable patches; and a month later, he had sore-throat. On the occasion of his visit to me, the hair was falling abundantly; it was parched and shrunken, as if dead; and the scalp was dry and scurfy. Upon examination, I found the stain of a syphilitic tubercle on the nape of his neck.

SYPHILITIC AFFECTIONS OF THE NAILS.

The NAILS, like the hair, are apt to suffer from the arrested nutrition, caused by constitutional syphilis. I

have seen several instances, in which they have exhibited a tendency to peel off; or were altered in structure, being discolored or brittle; thinner or thicker than natural; or apparently fibrous in texture. Sometimes these changes are accompanied by an erythematous inflammation of the matrices of the nails or of the fingers themselves.

The matrices of the nails possess no immunity from eruptions developed on other parts of the skin. I have mentioned a case (27), in which a tubercle was developed under the thumb-nail; and ulcerations occurring under and around the nails (syphilitic onychia) are by no means uncommon. They are also very painful, and are apt to throw out an inflamed and irritable fungous growth. A case of this kind I have now under treatment, and the patient is fast getting well under the general remedies applicable to constitutional syphilis.

SYPHILITIC AFFECTIONS OF THE HANDS AND FEET.

Syphiloderma erythematosum Palmare et Plantare.

The HANDS and the FEET suffer from another peculiar affection, which may be termed ERYTHEMA PALMARE ET PLANTARE. It is an affection far from uncommon, and generally goes by a name to which it is by no means entitled, namely, psoriasis. There is a psoriasis palmaris, which belongs to the group of squamous diseases, but that to which I am now referring, although attended with desquamation, or rather exfoliation of the cuticle, is not a squamous disease.

Erythema palmare (Plate 3, C) commences usually in the middle of the palm of the hand, in one of the grooves of flexion as a reddish spot, over which the cuticle becomes hard and yellow, from destruction of its