and lastly as a mere irregularity of pigment distribution, the so-called "marmoraceous" form, in which the coloring-matter of the skin seems to have been swept away from certain small, well-defined areas, only to be heaped up in excess over those immediately adjacent. Gradually, and very slowly as a rule, the pigment is diminished in the centre of each deposit, and there is formed a whitish central punctum from which the pigment is at last wholly removed. These colorations occur as uniform ill-defined shadings, as pea- to coin-sized spots, or as a reticular arrangement, one form often slowly passing into another as the pigment atrophy and hypertrophy progress side by side. The eruption is seen rather more often in women, and in them chiefly on the neck and shoulders, but it occurs also in men, and over the face, neck, and forearms.

This condition is decidedly more often seen in brunettes than in blondes, in this particular sharing the lot of most of the achromias of the skin. It especially affects in both sexes the Chinese, Indians, and negroes who have contracted the disease. It was once supposed to be rare, but without question is more common than was believed.

The eruption, if such it may be called, develops at any time after general syphilis is declared, but it is much more common in the earlier months of the malady. It is exceedingly indolent, persisting for months, and even in exceptional cases for years, being in but a slight degree amenable to specific treatment. Though thus persisting, the complete involution. of the affection occurs without ulterior changes in the skin, which, as a result, does not become the seat of infiltration, of degeneration, nor of scaling. Indeed, it is probably more an indirect than a direct result of infection, and is peculiar in that it is decidedly more common not merely in those predisposed by individual. characteristics to pigment anomalies, but also in the uncleanly and the neglected. Anatomically, it is found

that a chronic endothelial inflammation of the smaller cutaneous capillaries occurs, under the influence of which the red corpuscles gradually lose their coloring matters, while eventually an obliterating endarteritis chokes the vascular channels. In the portions where the pigment has apparently been removed the normal quantity of coloring matter has at times been recognized; in other cases a true vitiliginous atrophy of the pigment has followed. It is highly probable that all these changes are under the immediate influence of the trophic nerves.

The pigmentary syphilide should not be confounded with tinea versicolor, which develops often on the neck and the breast, for in the disease last named not only is a fungus visible under the microscope, but the fawncolored patches are usually the seat of a fine furfuraceous desquamation, readily recognized when the fingernail is employed as a curette over the surface. The several chloasmata of other sources are, however, to be differentiated with care. Many of them appear on the face, and not elsewhere (the reverse of what is usual in the pigmentary syphiloderm). Vitiligo or leucoderma occurs often on the scalp as well as over the body and the face. Its disks are far more extensive than those of the syphiloderm, being often palm-sized and larger, and when occurring upon the scalp the hairs which spring from the achromatous patch are commonly white. any doubtful case the symptoms of syphilis, usually declared by other signs in the event of a syphiloderm, should decide the diagnosis.

In

Circumscribed pigmentations of the skin in syphilis, and even of syphilitic lesions themselves, differ in a marked degree from the pigmentary syphiloderm, since all the former are, without exception, sequences of some other disturbance (relics of a papular or tubercular syphiloderm, ulceration and cicatrization of gummata, especially in the lower extremities, etc.).

The Erythematous Syphiloderm ("Syphilitic roseola," "Syphilitic erythema"). It has already been

shown that there are grounds for believing that syphilis in an ideal case, occurring in a strong and healthy young subject, well managed throughout the entire career of the disease, would probably have but one cutaneous expression. That expression would be the erythematous syphiloderm. If syphilis be in type a disease of but a single efflorescence, the eruption here designated represents that exanthem. It is the most common, the most frequent, the most benign, the earliest, and the most classical of the skin-symptoms of the disease, to be expected in the great majority of all patients, and rarely failing to appear when awaited and searched for by the eye of the trained physician. It is also in syphilis the exanthem most often overlooked, as it may be limited to regions covered by the clothing, and is for the most part unaccompanied by any subjective sensation such as itching. Women, especially those who are fleshy, when viewing its blush often suppose themselves to have been simply "overheated," and men, especially those inured to work in heavy flannels, look upon its lesions with no anxiety. It it often first demonstrated by the physician engaged in examining a patient for the detection of the character of a chancre.

The exanthem usually first appears between the sixth and the seventh week after the appearance of the chancre, and with exceedingly insidious onset, so that on the very first inspection only a few delicatelytinted spots occur on the surface of the belly; and in some cases, especially after indulging in a Turkish bath, a dance, or a generous dinner with wine, its lesions may be evolved with surprising rapidity.

The faintest expression of this syphiloderm can scarcely be described. It resembles to a degree the delicate marbling produced when the skin of a healthy person is exposed to cool air after immersion in a hot bath. When well defined, the spots appear as multiple, oval-shaped or rounded, irregularly-defined macules, neither elevated above nor depressed below the general level of the integu