to designate an initial lesion so situated. No such lesion, however, the result of infection from coitus, occurs further back in the canal than the posterior margin of the fossa navicularis. If a chancre in this position be associated with marked induration, the calibre of the urethra may become so constricted that actual retention results.

The corona of the glans penis is a fairly frequent site, and so, also, is the cutaneous sheath of the organ. Less frequent positions are other portions of the glans, at the meatus, in the fossa navicularis, on the hairy abdominal surface about the root of the penis, and on the anterior portion of the scrotum.

As from the foregoing description it is seen that the majority of chancres occur in connection with the foreskin, the prophylactic value of circumcision is evident. In connection with the female genitals, chancre, if the subject be unaccustomed to coitus, is most frequent in the region of the hymen, and at the fourchette. In these, however, as well as in other subjects of a similar sex, both labia, the space between them, the vestibule, the meatus and the region of the clitoris are also frequent sites. Chancre on the mons veneris, and on the cutaneous surface, just beyond the labia majora, is rare. So, also, is chancre on the walls of the vagina, owing to the firm character of the epithelium covering that part, and also to the lubricated state of its surface. Chancre on the os uteri is very rare, and it might be said to be confined to those in whom that part has been lacerated and secondarily eroded as the result of childbirth, abortion or instrumentation.

Extra-genital chancres may be subdivided into two classes, those resulting from irregularities in connection with the sexual act, and those which bear no relation to that act. Practically all chancres at, about, and just within the rectum, result from inoculations which have occurred when that orifice has been made to play the part of the vagina. Such lesions are seen most frequently in the cases of boys and young adult males. Their occurrence in women is not, however, especially unusual. Although a surgeon might easily go a lifetime without encountering chancre in connection with

the rectum, it is not difficult to find examples of such lesions, if one will only investigate, in countries where sodomy is common, or where males, usually of the lower strata, are for long periods crowded rather indiscriminately together.

Chancre connected with the fauces, tonsils, tongue, palate, the mucous surfaces of the cheeks, and the lips, can also result from irregularities in the sexual act. There is this important distinction, however, between chancres in these latter positions and those about the rectum, and that is that a large percentage of the former, and especially of such as are situated on the lips, bear no relation to any antecedent irregularity in the sexual act itself, but are directly due to kissing between the sexes, amorousness causing the act to be prolonged and violent.

Extra-genital chancres which bear no relation to an antecedent sexual act may occur on any portion of the body. The female nipple is not an unusual place, a syphilitic baby infecting its wet nurse; vice versa, a syphilitic wet nurse may infect the nursing baby on its lips, tongue or gums. The hands of surgeons, as the result of digital examinations in gynecological practice not infrequently become inoculated, provided they are exposed when the seat of abrasions, chaps, hangnails, etc. If a person with a chapped lip drinks out of a vessel without cleaning it immediately after one whose mouth is contaminated chancre may result. Dentists who do not clean their instruments after using may cause infection. A considerable number of such cases have been reported. Surgeons who are similarly careless may and do spread infection. The popular practice of sucking fresh wounds to supposedly avoid subsequent inflammation may affect a like result. A case recently came to my notice where a chancre on the bridge of the nose was the direct result of an attempt to suck away some granules of powder which had become lodged under the skin in that part. Abrasions received while in the hands of the barber may become infected.

Not long since, a gentleman reported with a chancre on the cheek, the sore being grafted on a little mole, the top of which had been removed by the razor.

The various sources of infection in connection with extra-genital chancre, and the positions assumed by the lesions, are varied in the extreme. The detailed recital of such histories generally appeals to the popular fancy. Syphilis in the innocent is a somewhat sensational manner of alluding to the disease in this class of subjects. It seems unnecessary, however, in this connection to treat the subject in a special detail. Extra-genital chancres, especially when those on the lips and mouth, the result of kissing, are excluded, represent a very small proportion of the entire number of infections. It is true, however, that a considerable number of the cases of syphilis which have been acquired without arousing the suspicions of the afflicted belong to that category.

In

The primary occurrence of chancroid extra-genitally is rare, and when it does exist it is usually at or about the rectum, the direct result of infection in connection with an irregular practice of the sexual act. Chancroid, the result of auto-inoculation or reinfection, is of comparatively common extra-genital Occurrence. women it shows a marked tendency to extend from the genitals back about the rectum or onto the buttocks, while in both sexes the inner surfaces of the thighs, the inguinal region and the hypogastrium are frequently so invaded. With the male extension from the penis on to the scrotum is not unusual, while in exceptional cases a still further dissemination of the disease from the scrotum on to or about the rectum is observed.

Although the lesions on the genitals which bear no relation whatsoever to a preceding contamination from sexual intercourse are numerous, still certain of them occur with a fair degree of frequency, and can be classed under two headings, first those having no relation to a preceding sexual act, and, second, those directly so dependent. Under the first heading can be grouped herpes progenitalis, balanitis, inflammation of sebaceous follicles and cysts, eczemas, and other general cutaneous eruptions, warts and vegetations, cutaneous thickenings in connection with the glans, stings of parasites and insects, scabies, suppuration in connection with the glands of Littre, trau

matisms variously caused, and malignancy.

Under the second heading are placed traumatisms caused by coitus itself, namely, tears, abrasions, sub-cutaneous hemorrhage, and serous extravasations. Secondary and late syphilis of the genitals belong to another group, these lesions bearing an indirect relation in most instances to some preceding sexual act. To this group might perhaps be added the interesting lesion peculiar to women which older writers have spoken of as lupus of the vulva, and which others more recently have called chronic chancroid, both of which diagnoses I am inclined to doubt. The last two divisions can not be spoken of as groups, since they each consist of one definite lesion, namely, chancre and chancroid.

Herpes progenitalis is a lesion exactly analogous to herpes labialis, and is dependent for its being on a localized neurosis or neuritis. It first manifests itself as several, generally about half a dozen or so, little punctate red blotches, closely clustered over an area about the size of a split pea. If the lesion, as is usually the case, develops still further, a vesicle forms over each punctate red spot. If these vesicles are not disturbed, they either shortly disappear from a reabsorption of their contents, or a change taking place therein, they are transformed into pustules. In most instances, however, the thin epithelial covering to those fluid collections ruptures, leaving an abraded area over which a crust tends to form. Very frequently the epithelium between such areas desquamates, the result being a confluent ulcerated surface. These lesions are usually situated on the mucous cutaneous surface of the foreskin. Less frequently on the penile sheath, and rather rarely on the glans. Certain individuals are peculiarly prone to recurring outbursts of herpes. Where the lesion exists in its natural state, the characteristics just described are usually sufficiently marked to enable an examiner to make a correct diagnosis. Where, however, a confluent ulcer has resulted, it may be impossible, from a single observation to exIclude a venereal lesion.

Not infrequently an inexperienced examiner mistaking herpes for chancroid, or

possibly for chancre, applies a caustic, the result being a destruction of all herpetic evidences, together with the formation of a somewhat deep ulcer, the edges of which are so infiltrated and inflamed, that it may be, and often is, impossible for any one subsequently examining the case not only to tell what the original trouble was, but also to exclude chancre or chancroid without keeping the case under observation for a period.

If such be done it will be seen that the lesion tends to heal promptly and naturally, without leaving any undue induration at its base. If a person subject to herpes indulges himself somewhat indiscriminately sexually, he runs an extra risk of becoming infected, since the braded surface accompanying the lesion renders the conditions governing inoculation most favorable.

Accordingly, if a patient presents himself with a lesion distinctly herpetic, and with the story also that he has recently indulged in suspicious coitus, it is always well before dismissing him with the assurance that everything is all right, to keep him sufficiently long under observation to make it certain that a venereal sore does not appear at the site of the original lesion.

Herpes, if non-irritated, causes so little pain or discomfort, that it is apt to be disregarded by the patient, provided no antecedent suspicious intercourse has occurred, and there is consequently no fear aroused that the appearance presented ushers in the beginning of resulting trouble. Curiously enough, herpes frequently occur in those subject to it after a suspicious coitus. I have in mind the case of a gentleman usually quiet and domestic, who is never so affected except after such times. It is probable that overindulgence, associated with alcoholic stimulation are factors which favor the development of the lesion, and so account for its frequent appearance after a sexual debauch. Unless herpes has become secondarily inflamed to a marked degree, it is associated with no lymphatic involvement or induration of the surrounding tissues.

Balanitis or inflammation of the mucous membranous surface of the prepuce and glans penis, when of a grade severe

enough to cause acute epithelial desquamation and surface ulceration may closely resemble a venereal sore. If a marked degree of balanitis exists in connection with a long prepuce, or with one the orifice of which is narrow and unyielding, the element of traumatism to which the inflamed part is subjected during an act of coitus, so increases the lesion that the prepuce often becomes red, edematous and inflamed to such a degree that retraction is rendered difficult or impossible, while at the same time a free purulent excretion arises from the involved mucous surface. If this condition be left for a short time uncleansed by washes and antiseptics, and still further irritated by contact with decomposed urine and sebaceous secretion, extensive ulcerations, surrounded by marked inflammatoroy infiltration result. When such a condition exists, palpation of the cutaneous surface of the prepuce with the thumb and forefinger reveals the indurated condition of the underlying mucous structures.

Although it is often, at first sight, impossible to exclude a venereal sore in the diagnostic investigation of a case of this description, still the rapid manner in which an amelioration of inflammation follows through sub-preputial douching with mild antiseptics in case there is no venereal complication, is generally sufficiently marked to be of diagnostic value. If the phimosis in such a case is not enough to prevent a retraction of the prepuce, then an exposure of the mucous surface, if no venereal infection exists, and the lesion is simple in character, is apt to show a rather general and uniform inflammatory involvement of the part. Not infrequently acute gonorrhea occurring in one with a narrow preputial orifice may excite an acute balanitis, surrounded by sufficient inflammatory infiltration to make it at first probable to the outside feel that the urethral inflammation is complicated by a venereal sore.

The cutaneous sheath of the penis, especially the under portion, together with the surface of the scrotum, contain numerous sebaceous follicles, which can be at all times readily made prominent if the parts are put somewhat on the stretch. If suppuration occurs in connection with one of these, a little deep-seated,

purulent focus with a red periphery results, which not infrequently causes an individual, especially if some time previously he has had a suspicious intercourse, to seek advice, fearing that he has become contaminated. The subcutaneous origin of a lesion of this description ought to I ́make it evident to an examiner that it is not a venereal sore, while its exact nature can be easily seen by freely incising its little indurated area, as it is held in the grasp of the thumb and forefinger, thus allowing to escape the sebaceous contents. If instead of an inflamed follicle there be an inflamed sebaceous cyst, then the same remarks as the preceding apply; only in the latter instance, the greater collection of sebaceous material ought to facilitate the making of a correct diagnosis.

Little special need be said regarding the occasional appearance of eczema, and the general cutaneous eruptions on the genitals, since there, as elsewhere, such lesions are to be diagnosed by their distinguishing characteristics. A careful inspection of the part ought to enable the examiner to distinguish the true nature of the other lesions mentioned in the first heading, and to definitely decide that they are not venereal in origin except, perhaps, in certain instances of primary malignancy. Epithelioma, commencing in the glans penis or the prepuce, may so closely resemble chancre that a true differential diagnosis can not be made without resort to a histological examination, although the fact that a suspicious lesion does not tend to rapidly resolve itself under the influence of mercury locally or systematically applied, would tend very strongly to support a diagnosis of malignancy,

The tendency shown by scabies to affect the penis, and especially the glans, not infrequently causes the person afflicted to fear venereal contagion. The resulting lesions may also be somewhat indurated if they have occasioned much scratching. The fact, however, that other portions of the body are similarly affected, that the lesions are associated with a marked itching sensation, and that those on the penis are multiple, defined, and show little tendency to ul

ill

ceration ought to determine the diagnosis.

Careful inspection would serve to distinguish a traumatism, the direct result of coitus, from a venereal sore. As, however, the occurrence of a traumatism would aid the accomplishment of infection provided the opposite party were contagious; it is always well for the surgeon on giving his opinion in a case of that nature to make it plain to the patient that such a contingency may result.

Mucous patches on the glans and preputial mucous surface, especially when inflamed by contact with decomposing urine may bear a resemblance to chancre. In this connection it should always be borne in mind that it is not infrequent for secondary evidences to manifest themselves at the site of the chancre, a partial recrudescence of the initial induration, perhaps, returning, together with the mucous patch. The history of the case, together with the co-existence of secondary evidences elsewhere, ought to enable the examiner to arrive at a correct conclusion. Gumma of the penis or vulva is especially apt to be mistaken for phagedenic chancroid, to which it bears a very close resemblance. Its chief distinguishing characteristics are that it begins insidiously, and without reference to any immediately preceding suspicious intercourse, it is accompanied by little or no pain, and by no circumscribed lymphangitis, unless the latter condition has been provoked by faulty methods of treatment. If such a lesion be mistaken for chancroid, and caustic applications prescribed, it will rapidly extend itself, and the appearance of phagedenia will become more marked.

252 Lexington Avenue.

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[Written for the MEDICAL BRIEF.] The Treatment of Eczema.

BY HARRY TYLDESLEY, M. D., Member Kentucky State Medical Society; Member of Muhlenberg County Medical Society; Assistant Surgeon Illinois Central Railroad Etc. Central City, Ky.

Eczema is a noncontagious, inflammatory disease of the skin. It is seen both as an acute and chronic affection, but most cases that are met in practice will give a history of greater or less chronicity. Jackson correctly declares that eczema is a most protean disease. This statement is based on the great variety of forms which eczema assumes. But if one will bear in mind the striking symptoms of the disease, he will have no difficulty in making a diagnosis. There are six symptoms which characterize eczema. These are: redness, itching, infiltration, tendency to moisture, crusting or scaling, and cracking of the skin. Three to five of these symptoms will be found in every case, and in most instances all of them are present. The disease has no particular season of the year as a favored time for its visitation, and all parts of the skin are invaded by it, but it more commonly selects the face, the scalp or the flexures of the joints. The sulcus behind the ear has seemed to me to be a favorite site for it in infants and children. Eczema arises from local causes, but the existence of the disease is a manifest indication of some blood dyscrasia. That this is true, we have only to call to mind any case and analyze it. A woman will say that she washed her clothes and the soap irritated her hands, and the eczema appeared. But, if her blood had been normal, she would have gone along without the eczema, as she had done before. The soap only now .had caused the irritation. In France this view has long dominated the thought of dermatologists, and in the United States we have some of the ablest clinicians who hold the same opinion. The treatment of eczema must therefore be local and constitutional. Every case must be carefully studied with the view of eliciting all the elements that require therapeutic attention. In beginning with a case of eczema it is necessary to give the patient exemption from the intense itching that is pres

ent in all cases. In fact, the average patient will not remain loyal if this distressing factor is not given a quietus. Local and constitutional treatment are to be instituted as soon as the case is taken in hand. For some time I have used ecthol in the treatment of eczema, and it has brought me a larger degree of success than I have been able to attain by any other means. Ecthol corrects more readily the dyscrasia of the blood than any other agent that can be found in eczema. I first used it in treatment of small-pox cases that I had on hand last year. It appeared to me that, as ecthol rendered small-pox mild, that it would perhaps correct the dyscrasia that was present in patients with eczema. I tried it and found it very valuable. I give ecthol in doses of a teaspoonful every three hours and continue it until the patient is well. But the internal use of ecthol in nowise completes the treatment. It must also be used locally. It has proved very valuable in quieting the itching, which is so very distressing. I have patients bathe the ecematous patches with ecthol every four or six hours, according to the severity of the itching. I instruct the patient to apply the remedy freely, soaking slowly the entire diseased surface. The ecthol exerts an antiphlogistic and antipruritic effect that is gratifying to the patient, and which expedites resolution. The treatment of the disease in this way has proven so successful that I now rely upon it, to the exclusion of all other means of treatment.

Miss W., aged eleven years, residing at Mercer's Station, Ky., was brought to me for treatment of eczema which involved her arms-the flexures of the joints. She had suffered such great distress from the itching that she had almost torn the flesh by scratching. I put her on ecthol in doses of a teaspoonful every three hours, and used it locally, according to the plan already given. I applied a bandage over the eczematous patches, a practice I invariably carry out, as it protects the diseased parts from irritation, dirt, air, etc. This patient made a rapid recovery, being well in two weeks from the time she began the treatment.

Mr. T. T., twenty-five, had eczema which involved the legs and arms and gave him