ANALYSIS OF SIX HUNDRED AND SEVENTEEN CASES OF SKIN-DISEASE, I ■ WITH CASES AND REMARKS ON TREATMENT. BEING A STUDY ON THE CASES OF DISEASE OF THE SKIN TREATED AT DEMILT DISPENSARY DURING THE YEAR 1875. By L. DUNCAN BULKLEY, A. M., M. D., Physician to the Skin Department, Demilt Dispensary, New York; Fellow of the New York Academy of Medicine ; Member of the New York County Medical and Dermatological Societies, etc. Reprinted from the American Practitioner for April and May, 1876. NEW YORK: G. P. Putnam's Sons, 308 Fourth Avenue. 1876. ANALYSIS OF SIX HUNDRED AND SEVENTEEN CASES OF SKIN-DISEASE, WITH CASES AND REMARKS ON TREATMENT. BEING A STUDY ON THE CASES OF DISEASE OF THE SKIN TREATED AT DEMILT DISPENSARY DURING THE YEAR 1875. By L. DUNCAN TJULKLEY, A. M.. M. D., Physician to the Skin Department, Demilt Dispensary, New York; Fellow of the New York Academy of Medicine; Member of the New York County Medical and Dermatological Societies, etc. Reprinted from the American Practitioner for April and May, 1876. G. P. Putnam's Sons, 308 Fourth Avenue. NEW YORK: 1876. A STUDY ON THE CASES OF DISEASE OF THE SKIN TREATED AT DEMILT DISPENSARY DURING THE YEAR 1875 * The number of cases of diseases of the skin which have come under my care in the Demilt Dispensary during the past year, and which I propose to analyze in the present paper, is six hundred and seventeen; besides which fifteen other patients, with miscellaneous affections, were wrongly entered and subsequently referred to proper departments. I am stimulated to thus study disease, as we actually observe it, by the very favorable reception accorded to the "Analysis of One Thousand Cases of Skin Disease," which I had the honor to present to this society one year ago,f and also by the belief that those occupying public positions owe to the profession the record, at least, of the experience gained in them; and finally because, while rare diseases and new thera- peutic measures are often made the subject of study and report, the more homely details of every-day conflict with diseases of the skin are seldom offered to the medical public. As in my "Analysis" of last year, I shall first invite atten- tion to a short statistical inquiry as to the relative frequency *Read before the New York Medical Journal Association, January 21, 1876. t American Practitioner, May, 1875. 4 A Study of Diseases of the Skin. of the different forms of cutaneous affections, and afterward speak more in detail of the different diseases and their treat- ment, introducing such cases as may seem appropriate and as time and space will permit, touching also, as far as possi- ble, upon the influence of age, sex, occupation, etc., in their production. I will here express my hearty thanks to my clinical assistant, Dr. Robert Campbell, for his most faithful attendance at the Dispensary, and for the very great assist- ance he has rendered me in recording and analyzing the cases, and also for the many clinical histories he has written out. The cases of diseases of the skin are presented in two tables:-the first, for easy reference, giving an alphabetical list of the diseases and the number of instances of each, together with the sex of the patients; and the second, ar- ranged in the order of frequency, showing also the varieties of each disease and with a column of percentage, in order that these statistics may be readily compared with others. I have adopted and endeavored to follow what I conceive to be the simplest as well as the most correct principle of nomenclature, namely, adhering as far as possible to the Greek names of diseases for the primary term, while second- ary terms and expletives are given in Latin. In these tables I have endeavored, as much as possible, to simplify the study by accepting the more commonly em- ployed terms, and excluding any of doubtful meaning, as sycosis, ecthyma, etc.; and, indeed, during the past year, in entering the cases, it has been my aim, by accuracy of diag- nosis and uniformity of nomenclature, to render the subject clear and simple, both for those who have followed me in the practice of the Dispensary, and for those who shall learn of it by means of this report. Moreover, many of the diseases which are usually accorded separate names, will here be found grouped together as varieties of other affections; thus acne will be found to include seborrhcea, comedones, and the rosa- ceous acne, now isolated from this class by some writers, as will be explained later; eczema embraces as varieties the A Study of Diseases of the Skin. 5 pustular and papular forms, which by others might be distin- guished as impetigo and lichen; dermatitis represents inflam- mation of the skin from heat, cold, mechanical irritants and poisons, which lesions might, perhaps, be classified as com- bustio, pernio, excoriations, etc.; while all the vegetable para- sitic diseases are grouped together with the generic term tinea. TABLE I. Disease. Males. Females. Total. Disease. Males. Females. Total. Abscessus I 1 Paronychia 1 1 Acne 16 27 43 Pemphigus 1 1 Anthrax i 1 Phthiriasis 21 36 57 Bromidrosis i 1 Pityriasis 1 1 Chloasma 3 3 Pruritus 7 4 11 Clavus 2 2 4 Psoriasis 5 15 20 Dermatitis 15 8 23 Purpura 2 2 Eczema no 108 218 Roseola 1 1 Elephantiasis Graecorum I 1 Rubeola I 1 Epithelioma I 1 Scabies 15 II 26 Eruptio e potass, iodid... I I Scrofuloderma 4 4 8 Erysipelas IO 9 19 Syphiloderma 22 17 39 Erythema 6 8 14 Tinea 8 13 21 Folliculitis capitis 1 I Ulcus 1 4 5 Furunculus 6 11 17 Ulcus erodens 2 4 6 Herpes 12 5 17 Urticaria 7 IO 17 Hyperidrosis pedum 1 1 Varicella 1 1 2 Keloid e cicatrice 1 1 Verruca 9 1 IO Lichen 6 11 17 Xeroderma 1 1 Naevus Onychia 2 2 Total 295 322 617 6 A Study of Diseases of the Skin. TABLE II. Disease. Number. Per Cent. f Impetiginodes [ Papulatum Intertrigo ... 63' Eczema .. 16 .. I 218 35-1 I ( Capitis ... 1 Corooris .. ..138 J Phthiriasis - 45 ... 12 57 9.2 ' Sebacea .. 2 Punctata ... 4 Acne Molluscum Simplex 43 6.9. Indurata •• 4 Rosacea •• 7. Syphiloderma 39 6.3 Scabies 26 4.2 ' Calorica .. 81 Dermatitis Venenata .... Traumatica.. •• 4 •• 3 23 3-7 .. 8 J Tinea - Tricophytina Versicolor Circinata .... Tonsurans . ..121 .. 2 I •• 5 J 21 3-4 Favosa .. 2 J Psoriasis .. 20 3-2 Erysipelas { Faciei 19 3-i Furunculus 17 2.7 Zoster .. Labialis •• 3 Herpes Praeputialis 17 2-7 Nasalis Lichen a- 1 f AcutUS ... Simplex < r [Chronicus Pilaris .. 14 .. I .. I >7 2-7 Urticaria Planus .. I 17 2.7 Faciei - 3 Erythema Papulatum.... Multiforme ... - 14 2-3 Pruritus ... 8 11 1.8 Verruca IO 1.6 Scrofuloderma 8 1.3 Ulcus erodens 6 •97 Ulcus.... 5 .8 Clavus .. 4 .6 Chloasma... 3 .5 Onychia. 2 .3 Purpura { demorrhagica .. <heumatica _ ::: 1} 2 •3 A Study of Diseases of the Skin. 7 TABLE II.-Continued. Disease. Number. Per Cent. Varicella 2 I I I I I I I I I I I I I I I I 617 •3 .16 .16 . 16 .16 .16 .16 .16 .16 .16 .16 .16 .16 .16 .16 .16 .16 Abscessus Anthrax Bromidrosis Elephantiasis Graecorum Epithelioma Eruptio e potass, iodid Eolliculitis capitis Hyperidrosis pedum Keloid e cicatrice Nsevus Paronychia Pemphigus Pityriasis Roseola Rubeola Xeroderma Total These six hundred and seventeen cases, then, will be found arranged under forty-one principal heads, many of them em- bracing several divisions, while sixteen represent but single examples of the diseases recorded; in some instances the same patient was treated for two distinct diseases, and these are entered under their proper heads. The ratio of males to females was much closer than in the analysis of last year; of these, two hundred and ninety-five were males to three hun- dred and twenty-two females, or a trifle over four and a half per cent, in favor of the females, the proportion in the one thousand cases of last year giving the females the prepon- derance by fifteen per cent. The difference may, in part, be explained by the fact that the patients at Demilt being, as a rule, of a rather better class, mechanics and small store- keepers-the men have more time and inclination to attend to personal comfort than the poorer laboring classes com- posing the attendance at Bellevue. In Balmanno Squire's statistics from five thousand consecutive cases entered at the 8 A Study of Diseases of the Skin. British Hospital for Diseases of the Skin, the males were in excess by nearly seven and a half per cent. About one-third of the entire number of cases-one hun- dred and ninety-one-occurred in children of ten years and under; one hundred and nine of these being five years or less of age. The larger proportion of children, as compared with the analysis of last year, is due to the more careful sepa- ration of patients and their allotment to the proper classes; although very many cases of cutaneous disease in children still find their way into the department of diseases of children, thus lessening the proportion with me. The ages belonging to the different diseases will be spoken of when considering the individual maladies. No general deductions can be made as to the influence of the seasons in the production of cu- taneous disease from the cases here analyzed, other than to state that the largest number of patients were entered on the book, including those on the alternate days by my colleague, Dr. Donor, during the month of September, the smallest number in January, which gave but two-thirds the number recorded during the former month. The season of the ap- pearance of individual diseases will be mentioned, as far as possible, in the proper place. A smaller proportion of lesions due to syphilis were re- corded than last year, namely, but thirty-nine in the six hun- dred and seventeen, or 6.33 per cent, of the whole, against ninety-eight per thousand, or 9.8 per cent, in the former analysis, the difference being due to the class of patients. The percentage of animal and vegetable parasitic diseases, however, is greater, being about seventeen per hundred, against fourteen in the former report; the discrepancy again being due to the class of patients, because in the better ranks these affections are more noticed and abhorred, whereas among the lower walks they are looked upon as a necessary part of their poverty. The order of frequency of various affections of the skin differs considerably from that afforded by the former analysis of one thousand cases, showing that positive deductions as A Study of Diseases of the Skin. 9 to the relative preponderance of this or that disease can not be drawn conclusively, except from an average of very many such studies. Eczema still stands first in the list, as it ever will, in regard to frequency, and forms a trifle over thirty-five per cent, of all the cases, the percentage of last year being but 30.2; while acne, which before came second with a per- centage of 11.1, gave here but 6.98 per cent.; psoriasis also appeared much less frequently, yielding but 3-24 per cent, in place of the five per cent, of last year. On comparing the lists, it will be further found that fifteen names of diseases appear on that of last year which are not found on this, and twelve names occur in the present one which are absent from the former. Ecthyma, excoriations, and sycosis, are excluded from the present list by being en- tered in their proper places as phases or varieties of other diseases, while not a single case of the following, not very uncommon, diseases was recorded, namely, alopecia, ichthy- osis, lupus, prurigo, and scleroderma. There were, however, several cases which casual observation might call lupus, but which close study discovered to be epithelioma or rodent ulcer, or else due to syphilis. The term prurigo I restrict wholly to the eruption which Hebra has described under that name, whose definition is accepted by most dermatologists; and I call those cases pruritus where itching exists as the only symptom, excepting, of course, any which are more properly classed under eczema, phthiriasis, etc.; and although I doubt not but that the term prurigo would have been applied by some to certain of the cases here analyzed, no single case of the true disease was observed. The twelve diseases appear- ing here and not in the former analysis, will be spoken of in due order. As far as I know but two patients died within the year, both infants-one, twenty months old, with purpura hemorrhagia; the other, four months old, with syphilitic pemphigus. In both of these patients the disease was far advanced when they were brought to the Dispensary, they being almost in extremis. We will now proceed to consider some of the points in the 10 A Study of Diseases of the Skin. separate diseases which have come under observation, and will speak of them in the order of their frequency of occur- rence. I. Eczema.-Of the two hundred and eighteen cases of eczema, one hundred and eleven were in male and one hun- dred and seven in female subjects, giving a preponderance of four males; whereas in my former analysis the females were in excess by twenty-seven in three hundred and two, or about nine per cent.; other statistics agree in making the disease more common in males than in females. Quite a large pro- portion of the eczema cases were in children, seventy-one being five years old or under; of these seven were four and a half months or younger, fourteen from that to twelve months, and a total of thirty-nine from two years downward. Calling those cases of four years of age or under, infantile ec- zema, there were sixty-nine of this variety, or u.2 per cent, of the whole. This presents a striking contrast to the statis- tics published by Mr. Wilson,* who formulates his deductions by saying that the percentage of eczema infantile to eczema of the rest of life, is as one to sixteen; whereas here the pro- portion is nearly double that. He also asserts that the dis- ease is more common in the male child; whereas among these children there were eleven males to ten females of a year old and under; up to three years of age, they stood twenty-six males to twenty-eight females; and at four years or under, the period which I have assigned as infantile eczema, there were thirty-five females to thirty-four males. Without wishing to depreciate Mr. Wilson's work in this field of sta- tistical investigation, I would, by these figures, show the need of great care in formulating any rules or laws in regard to disease, for I can not suppose that these great differences are entirely due either to the country or to the class of patients. It is, perhaps, interesting to note that of the two hundred and eighteen cases of eczema, seventy-one, or almost one- third, occurred during the first five years of life, and one hun- dred and two, or nearly one-half, within the first decade; of * Lectures on Eczema. London, 1870: pp. 265 and 275. A Study of Diseases of the Skin. 11 these one hundred and two cases, fifty-two were in boys and fifty in girls. These figures exhibit quite a contrast to those given last year, where the percentage of cases of five years and under was only 5.6 of the entire number of cases of eczema against almost thirty-three per cent, this year; and the average of those ten years and less was but 7.6 per cent, to over forty-seven per cent, in the present study. They contrast also yet more strongly with Wilson's statistics from middle and high life in England, where an average of two thousand gave but four per cent, for the first decade against our forty-seven per cent, for the same time of life. It is also seen that the decade from twenty to thirty pre- sents the next greatest number of cases of eczema. Bal- manno Squire* has shown this period, between twenty and thirty, to exhibit proportionately more cases of cutaneous disease in general than any other in life, basing his calcula- tions on a careful study of the census of London, in which those living at each period of five years are compared with the number of cases of general skin disease at the same ages, among five thousand skin cases at the British Hospital for Diseases of the Skin. Wilson's statistics further show ecze- ma to be more common during this period than during the first decade, though with him that between thirty and sixty years yields a still larger proportion of cases, showing, as I remarked in my former analysis, that among the higher classes the elements of ill-health, due to over-indulgence and gouty disease, far exceed those existing among the poor with us; that is, while eczema, like all disease, must be looked upon as a lowering of vitality, in the higher classes of society this is due to over-indulgence and too little bodily exercise, together with the depressing influence of mental care; and that in this class of society these agents are far more produc- tive of eczema than are the supposed elements of lowered vitality in the poor, under-nutrition and overwork. From these conclusions important therapeutic considerations are drawn, namely, eczema among the better classes yields better *On the Influence of Age in the Causation of Skin Diseases. London, 1873. 12 A Study of Diseases of the Skin. to deobstruent remedies, as alkalies, purgatives, etc., together with nerve tonics; whereas among the poor direct nutritive elements are more often called for-cod liver oil, iron and tonics, directed to improve the state of the general system. The following table gives the ages of the patients with eczema at the time of applying for relief: TABLE III. Age of Patient. Males. Females. Total. 6 months and under 2 6 months to I year of age O 8 6 14 I year to 2 years of age IO 8 18 2 years to 3 years of age 5 IO IS 3 years to 4 years of age 8 7 IS 4 years to 5 years of age 1 1 2 5 years to 10 years of age 17 14 31 10 years to 20 years of age 9 14 23 20 years to 30 years of age 16 14 30 30 years to 40 years of age 11 IO 21 40 years to 50 years of age 5 14 19 50 years to 60 years of age 7 4 11 60 years to 70 years of age 8 2 IO Over 70 years of age 2 Total I IO 218 The youngest patient with eczema presented for treatment, was aged six weeks; the oldest, seventy-six years. In regard to the location of the disease, in seventy-one cases where this was noted it occurred in the following order: Head, eighteen; hands, thirteen; legs, thirteen ; ears, eight; beard, four; face, four; palms, three; arms, two; handsand arms, two; scrotum, two ; lip, one; eyelid, one. Of eleven cases in which the side of the body was recorded, the disease affected the left side in eight, and the right in three. In the treatment of eczema I have, of course, followed, to a greater or less degree, the accepted and well known methods as indicated in the text-books; but in the two hundred and eighteen cases, probably at least fifty modes of treatment A Study of Diseases of the Skin. 13 have been required; for no disease of the skin exemplifies more than eczema the error of a routine habit of prescribing, and none exhibits more clearly the necessity of studying the case, and not simply ordering this or that accepted remedy irrespective of the particular requirements of the patient, or, as I have elsewhere stated, eczema requires management quite as much as treatment. The treatment of eczema in children, of which we have seen that there were one hundred and two cases of ten years or less of age, offers a field of great interest for the study of the therapeutics of the disease. Every phase of it is here seen-acute, sub-acute and chronic, moist, pustular, squamous and papular; and the measures applicable to one form do positive harm in another. While, therefore, I can not discuss in full the treatment, I will mention a few of the more salient features of the disease as they have presented themselves in this clinic during the past year. I will not, however, reiterate points made in my analysis of the preceding year, and would refer those interested in the subject to that, as expressive of much that would be said at the present time did space permit. I have ordered poultices to the heads of infants with eczema very seldom (I believe but twice) at the Dispensary during the year, and then only a single application of the same, and that after the eruption had been left alone for a while, with only the repeated application of an ointment. The object of the poultice is to remove an incrustation; and after a single application over night, the head is to be washed in borax and lukewarm water, two drachms to a pint, no soap; and the appropriate ointment is to be reapplied as often as necessary in order to keep the parts thoroughly protected. I therefore order no more poultices nor washings, unless absolutely required; for, as a rule, the crusts which form afterwards will separate in a few days under the continued soaking with a soft ointment or cod liver or almond oil. Last year I mentioned the use of tannin in ointment, one drachm to the ounce, as having given me good results; this year habit, perhaps, and the desire to test the value of differ- 14 A Study of Diseases of the Skin. ent remedies, has led me to employ largely the bismuth sub- nitrate in ointment, half a drachm or one drachm to an ounce; and with many skins it acts very much better than the zinc ointment. I have also returned, in a measure, to the em- ployment of the old unguentum picis or tar ointment of the pharmacopoeia, diluted two, three or even more times, either with simple or rose ointment, or in combination with oxide of zinc ointment, and I find that it does not merit the neglect into which it appears to have fallen. I have no new experi- ence to add in regard to the tannin ointment before recom- mended; when used it has proved serviceable. I have employed baths more than formerly in the treat- ment of eczema, both in children and adults, among the poor, and they have at times rendered great service. As is well known, the application of simple water to eczematous skin does harm, and is to be avoided as far as possible; but the same does not hold true in regard to water medicated so as to offer a soothing element, by means of the carbonates of potash and soda, borax, acetate of potash, etc., combined with starch. In a case of eczema of the scrotum in a boy, which I have reported elsewhere,* vqry great relief was obtained by soak- ing in a warm bath every night in an ordinary wash-tub half full, with something over an ounce of carbonate of potash and about half an ounce of carbonate of soda, with four table- spoonfuls of dry starch boiled, and the subsequent application of the tar ointment diluted with twice as much simple oint- ment, cured the case, which had been most distressing and troublesome. The boy took, at the same time, a little arsenic in rhubarb and soda mixture; but the relief afforded by the local treatment was so immediate and certain that no doubt could be entertained of its very great value. Acute and exuding eczemas do not as a rule do well in baths, at least in my hands; but many children with sub- acute and chronic forms of the disease, more or less general, were treated with baths similar in the main to the above with * Archives of Dermatology, January, 1876, p. 155. A Study of Diseases of the Skin. 15 advantage. It must be remembered that after coming from a bath all the diseased parts must be dried with the least pos- sible friction, which is best attained by throwing a warmed linen sheet around the body and drying by pressing this on the surface; and also equally important that diseased surfaces must always be covered immediately with some protective dressing, otherwise the effect of the bath may be irritating, having dried the skin more than can be remedied by the natural oiliness of the surface. In private practice, after a bath, the glycerate of starch or vaseline-the perfumed or "pomade vaseline" is most agreeable-may be applied to the entire surface if there is any tendency to general roughness or scaling, and furnishes a most elegant means of rendering the integument soft and supple. In regard to the internal treatment of eczema, I find no reason to alter the opinions expressed last year as to the internal origin of a large share of cases, and of the conse- quent necessity of properly selected internal medication and dietary regulation. I confess that I have been a little surprised, however, at the effects which I have obtained from arsenic in many cases. For the purpose of clinical study, I have given a large num- ber of children no other treatment but arsenic, except occa- sionally a little zinc ointment as a placebo. I have given it to infants as well as older persons, administering it in increas- ing doses till some of the physiological effects were observed, though this limit was not always sought, and I have seen both impetiginous and dry eczemas disappear in a very short time. I regret that I can not, at the present time, give definite results from my experience, for I am not yet able to determine exactly in what cases this method will do good, and when it will be inert or harmful. I believe, however, that the effect of arsenic is much more marked in the eruptions of children than in adults, my previous experience in the latter having forced me to report much less favorably than has been done by certain dermatologists, notably of the English and French schools; but of its very great efficacy in certain cases of 16 A Study of Diseases of the Skin. eczema in children, there can be no doubt. I will mention in brief a striking case which has attended very regularly at Demilt during the past year. Thomas Hayes, five years of age, was first presented at myelinic May n, 1875, with the following history: When four months old an eruption, answering to the description of impetiginous eczema, developed upon the cheeks and head, and from that time he has never been free from the disease. It has gotten somewhat better at times under certain treat- ments but has never left him, nor at any time has he been so as not to be much distressed with it. It has occupied in turn much of the body, affecting at times the popliteal spaces and other parts. When first seen, his whole face, eyes, head and neck, were covered with a moist papular eczema, bearing evidences of great itching; and his father testified that he tore the parts constantly, his sleep at night being almost en- tirely prevented. The arms were likewise the seat of a dry papular eczema, considerably scratched, which had persisted since twelve months of age. The little patient wore the troubled, exhausted look common to such sufferers, and the father appeared almost equally distressed because of the ap- parent hopelessness of the case. He was immediately given cod liver oil in increasing doses and the oxide of zinc ointment, with directions not to wash the parts but to keep them con- stantly coated with the ointment, and to remove the woolen tippet which he had worn and which was irritating the in- flamed head, neck and ears. There was but slight improve- ment from this; but in view of the very chronic character of the case, and because the child seemed to be one who re- quired the oil, this treatment was continued unaltered till July 10th, a period of two months, when he was given a mix- ture containing three minims of Fowler's solution and two grains of ammonio-citrate of iron with bark tincture, three times a day, and the tar ointment was added to the zinc to assist in allaying the itching, the oil being continued. This treatment was followed faithfully for six weeks, till August 31st, with really no gain, when, in view of the great A Study of Diseases of the Skin. 17 amount of itching, I resolved to give arsenic and push it till good or bad results were obtained. Accordingly, the other treatment being suspended, equal parts of Fowler's solution and cinnamon water were prescribed; and four drops of this were ordered three times a day, the dose to be increased by two drops every other day until twenty drops three times a day were reached-the same local treatment being used, the ointment to be washed off with a solution of two teaspoon- fuls of baking soda in a teacup of water, once daily. At this time the eruption was about in the state described as existing at the first visit, three and a half months previously, his gen- eral condition having improved but very slightly also under the oil and tonic. In twelve days it was recorded that there was great im- provement, and four days later (Sept. 16) still more relief; he was then taking twenty drops of the mixture, or ten drops of Fowler, three times a day; a large portion of the eruption had become papular, there were almost no excoriations; the child slept well and looked fifty per cent, better. The dose was then increased to thirty drops after meals, augmenting in the same manner two drops every other day. This dose being soon reached, it was continued at thirty drops, or fifteen of Fowler's solution of arsenic, three times daily, until Decem- ber 4, three weeks longer, when it was noted that the erup- tion had nearly disappeared, the father stating that the child had never before been so free from the eruption since its inception. December 30, he still continues well. The father testifies that whenever the arsenic is omitted, even for a day or two, the itching returns. The dose of the mixture was then ordered to be increased to forty drops (twenty of Fow- ler) three times a day, the dose of thirty drops not having caused any inconvenience. On January 15, 1876, it was recorded that the forty drops had disagreed with the stomach and caused vomiting; in order, therefore, not to withdraw the remedy entirely, the dose was lowered at once to ten drops three times a day, with instructions to increase slowly to thirty, a point at which 2 18 A Study of Diseases of the Skin. he had previously tolerated the arsenic perfectly. At his last visit almost every trace of eczema had disappeared; the color of his cheeks was of a natural rosy hue and the skin there smooth, the ears perfectly normal, and, but for slight papula- tion here and there, the disease could hardly be suspected. He sleepswell and eats well. March u, 1876, he remains well. To complete this history, I should state that the father is a decided asthmatic, and had eczema eighteen years ago; the mother is healthy. The child had wheezing lately, that is before commencing treatment; it has improved with the im- provement in the eruption. There was no change made in the local treatment from first to last, and during the latter part of the time this was rather neglected. I have elsewhere* written strongly against the evil of fall- ing into the "rut" of treating eczema by means of Fowler's solution and zinc ointment, and mention the fact here to warn any against believing that because I have given a single case where arsenic proved the remedy, that therefore it is valuable and to be administered in every case of eczema. Far from it; the cases, in my experience, are comparatively few where anything like this effect can be obtained. In this child I believe it was indicated by the asthma of the father and slight wheezing in the child; while the great amount of itching showed a nervous element which called for such a nerve tonic. During the past few months I have been using a prepara- tion of arsenic but little known or used in this country, but which I think bids fair to be far more useful than the well known Fowler's solution. This is the solution of the chlo- ride of arsenic, the liquor arsenici chloridi of our Dispensa- tory-the old DeValangin's solution. Its advantages are, that it is better tolerated by the stomach, and that it can be administered in large quantities; and thus far, in public and private practice, it has yielded results which I have failed to obtain from the more commonly employed forms of arsenic. * The Management of Eczema. G. P. Putnam's Sons, 1875. A Study of Diseases of the Skin. 19 The Dispensatory states that its strength is two-thirds that of Fowler's solution, but that it is to be given in the same doses. In one very old and obstinate case of eczema of the beard, in a man aged thirty, this preparation has been admin- istered in doses of forty drops three times a day with the happiest results. He has been under treatment elsewhere for several years; and although persistent epilation and local remedies have done the most toward removing the disease, he still feels that when he omits the arsenic he has more irri- tation than when under its influence. He, of course, reached these large doses slowly, beginning with five drops after meals; he gradually increased by a drop or two a day to the full doses mentioned. In pustular or impetiginous eczema, I have had very good success with the hyposulphite of soda, in large doses, thirty grains for an adult three or four times a day, largely diluted and given usually in cinnamon water, on an empty stomach. Last year I reported favorably of its employment in furun- cles. I refer now to the more superficial suppuration of eczema. I think I have not used as much cod liver oil this year as last, the class of patients not requiring it, they being in the main better fed and less depressed and exhausted. I have, however, employed more acetate of potassa; indeed, as we rise in society we find, as I have before suggested, more need of two classes of internal remedies in treating many diseases of the skin, namely, evacuants or diuretics and nerve tonics; that is, we find more the results of over and wrong indulgence among those better able to procure luxuries, for which cathartics and diuretics are demanded, and we encoun- ter also nerve exhaustion from responsibility and mental strain, which requires nerve tonics. Infantile eczema was very generally treated after Mr. Wil- son's plan, namely, a grain or two of calomel every day or two, or twice a week, according to the effect; and arsenic and iron, with a syrup internally, with generally a little compound tincture of bark to take the place of the wine. Cod liver oil was given to those of strumous habit. 20 A Study of Diseases of the Skin. 2. Phthiriasis.-Second on our list this year, in point of frequency, come the cutaneous phenomena caused by the presence of lice on the body, there being fifty-seven cases, exactly the number noted in the entire thousand of last year, when it stood fourth in order of succession. The reason, as before stated, of the apparent greater proportion in the pres- ent statistics is because these troubles are noticed more by the more cleanly classes; and rarely have I demonstrated their presence when the individual or parents have not ex- pressed regret or sorrow, and looked upon them as a shame. Females were more affected than males, thirty-six to twenty- one-the preponderance being made up by the cases of phthiriasis capitis in girls from eight to twenty years old, where untidy habits foster the lodgment and multiplication of lice in the head. The youngest patient in which this state was found in the head was four years; the oldest, a woman of forty, who, with two girls aged twenty-one and twenty- two, were the only patients with this disease over twenty years of age. Body lice were found in older persons from forty to seventy-five years of age, and seldom if ever in very young persons. The treatment employed for the head form was always that described last year, namely, soaking three times in kerosene oil within twenty-four hours; then washing thoroughly with castile soap and warm water, and applying afterwards cod liver oil, if the head be very sore, or zinc ointment, or the white precipitate diluted three times. I have used this plan in private practice, and do not find that it is objected to; whereas the thoroughness and certainty of cure of a single soaking renders it a treatment to be recommended. It kills the nits and they become detached on repeated combing, which does not happen when an agent has been used which does not penetrate them. In private practice good results are obtained, but not so quickly, by means of highly scented white precipitate or citrine ointment, diluted three times; and the nits may be separated by means of a wash of equal parts of acetic acid and cologne. A Study of Diseases of the Skin. 21 3. Acne.-This disease, which yielded 11.1 per cent, in our analysis of last year, gives now but 6.9 per cent. Of the forty-three cases treated during the past year, twenty-seven were females and sixteen males, which is almost exactly the ratio between the sexes found during the previous year. These forty-three cases presented the following varieties: acne sebacea, two; acne punctata, four; acne simplex, twen- ty-six; acne indurata, four; acne rosacea, seven. The early age at which acne is prone to affect the skin is seen from the following: TABLE IV. Age of Patient. Males. Females. ' Total. I At 14 years of age 4 3 2 3 3 1 2 3 6 4 4 2 6 3 3 6 6 9 At 15 years of age 1 At 16 years of age At 17 years of age 3 At 18 years of age At 19 years of age 2 4 3 3 At 20 years of age 20 to 30 years of age Over 30 years of age Total 16 27 43 At sixteen years of age or under there were ten cases, nine of which were females; after that period the sexes were about equally divided. The oldest patient recorded with acne sim- plex was fifty years of age, a period usually stated to be free from this form of acne. The youngest patient with the ro- saceous form was a man aged twenty-three, the oldest a man of forty; of the seven cases, five were females and two males. In regard to the causation of acne, a large share of the patients presented some of the manifestations of imperfect digestion, coated tongue, constipated bowels, flatulence or oppression after eating; although a first general question will commonly elicit the answer that these patients are perfectly 22 A Study of Diseases of the Skin. well with the exception of the eruption on the face. Most of the girls with the simplex and punctata forms worked in fac- tories, went to school, or lived out as servants; and another year's experience convinces me more firmly than ever that this disease is due to imperfect digestion, even though the results of it are not shown before they reach the urinary secretion, where, in place of the normal results of disintegra- tion, we find urates, oxalates or phosphates. The element of confinement to the house and want of fresh air seems to be wanting in those of the male sex who were affected with acne simplex and punctata; for we find among them two laborers, a farmer, butcher, driver, plumber and carpenter. But when one studies the diet commonly em- ployed, it will be found that many habitually transgress in quality and quantity; and these are the ones prone to be affected with skin diseases and acne especially. Our people need much education on the subject of hygiene and diet- topics sadly neglected in the teaching of the schools, lay and medical, and which the practitioner has mainly to study and develop for himself, and should instruct the patient in. Quite a share of the patients with the simplex and punc- tata forms of acne received acetate of potassa first, followed by tincture of the muriate of iron as soon as the new ele- ments of disease cease to form. I have also given glycerine internally, with citrate of iron and quinia dissolved in it, with good results to those with thick, doughy skins. Last year I stated that arsenic, in my experience, was of very little use in acne. I must modify this in regard to the DeValan- gin's solution already alluded to, which I have used in cer- tain cases with excellent results, which I hope to communi- cate more in full at a later day. Locally I have little new to offer at present, beyond what was reported last year, except that certain cases I have found to do well under citrine ointment, diluted three times, and well rubbed in at night. The first effect is stimulating and the face appears worse, when the treatment is to be sus- pended and returned to in a few days. A Study of Diseases of the Skin. 23 4. Syphilodermata.-Our fourth subject of study embraces the lesions due to syphilis, exclusive of the primary sores, of which we find thirty-nine cases, or 6.3 per cent., in place of the 9.8 per cent, of last year. In the former analysis the number of females was two and a half times that of the males, seventy to twenty-eight; in the present, the propor- tion was so far reversed as that there were twenty-two males to seventeen females. There were three cases of well-marked infantile syphilis, the youngest being a female child of six weeks, with the perfectly developed papular syphilide of in- fancy; another, four months old, with syphilitic pemphigus, which died a day or two after being seen; and another child, two and a half years old, who had first syphilitic pemphigus, and later a dactylitis of the left foot. A fourth case was re- corded of a child, a year old, whose mother had tubercular syphilis, but whose only symptoms, while under observation, were a moderate anaemia and diarrhoea. The youngest patient applying with acquired syphilis was a boy, aged seventeen, with the papular form; there were in all five of twenty or less years of age, all males. Last year I recorded as the youngest a girl of thirteen; the youngest female recorded this year was twenty-two years of age. The only patients with syphilis over fifty, were two men aged fifty-one and fifty-six respectively. Many cases have possessed great interest. One patient, a woman of thirty-six, presented the very unusual lesion of syphilitic atrophy of the interosseous muscles of the right hand. The patient was plainly syphilitic, there being many cicatrices as well as still ulcerating tubercular masses on va- rious parts of the body. The case has done fairly under treatment, mainly with the iodide of potassium, combined with applications of electricity. The hand was about useless when treatment was begun; she can now sew with a moder- ate degree of swiftness and comfort. Another female, married, aged twenty-four years, presented with constitutional syphilis a very rare lesion, namely, inflam- mation of the bursa in front of the knee-joint, of which there 24 A Study of Diseases of the Skin. are a few cases on record, and upon which subject Dr. Keyes has recently read a paper before the New York Dermatologi- cal Society.* The knee was red and hot to the feel, and pre- sented the aspect known as housemaid's knee, so that it was impossible for the patient to kneel upon it, the motions of the joint, however, being but slightly impaired. This has slowly yielded to specific treatment, principally the iodide of potassium. A male syphilitic, aged thirty-nine years, with characteris- tic specific lesions on the left palm, tongue and leg, presented the peculiar and rare disease described briefly in my last year's Analysis as chronic circumscribed inflammation of the cor- pora cavernosa. The case was almost precisely similar to the one mentioned as occurring last year, and presented an indu- rated patch, deep in, on the dorsum of the penis, which, on erection, caused deviation backward with some pain, but otherwise offered no inconvenience, and was not sensitive even to moderate pressure. It was about an inch long and half an inch wide, with clearly defined edges, it feeling rather like a plate than like a rounded mass. It is not probable that it is due to the syphilis, as the same phenomenon has been observed in cases who have never had syphilis; and moreover it developed while the patient was under anti- syphilitic treatment, and has remained in spite of the same for many months. At last note it was found to be moving backward, as in the cases described by others. In some instances the syphilis has resisted treatment in a very annoying manner. In one case, a young man, aged twenty-three years, received infection on July 4th, and came for treatment October 5, 1875, just three months afterwards. He was then covered from head to foot with a small papulo- tubercular eruption of medium size, involving the palms and soles as well; and in the latter situation the tubercles had ulcerated from pressure, so that walking was very difficult and painful. This eruption disappeared under treatment, but *For full particulars of this and another case of mine, see Dr. Keyes's arti- cle. Am. Jour. Med. Science, April, 1876. A Study of Diseases of the Skin. 25 was followed by repeated attacks of deep inflammation about the insertion of the tendo Achilles, first of one foot, then of the other, seriously impeding locomotion, and by enormous double anterior cervical adenopathy, attending a very greatly diseased tongue, which resulted in suppuration of the glands on the right side. Mercurials have seemed to depress him greatly, and have been withheld from time to time to give way to mineral acids and tonics, large doses of carbonate of iron appearing to do him more good than any other remedy. Oleate of mercury, ten per cent, with morphia, has afforded most relief, applied locally to the swollen heels and to the enlarged glands. In another case, a woman aged forty-three years, who contracted syphilis from her husband three and a half years ago, an ulcerative tubercular eruption persisted in spite of vigorous and varied treatment for many months, at least six. She had been under treatment previously, being a year in a hospital, and is covered with large and disfiguring cicatrices of former ulcerations, on the face, hands, arms, legs and body. While under treatment she had new developments of tuber- cular trouble, also mucous ulcerations of the tongue. She had likewise, during treatment, specific inflammation of cer- tain joints of each hand, also osteal pains so severe as to deprive her entirely of sleep. The ulcerations finally healed under the local application of iodoform sprinkled on, and cod- liver oil and large doses of iodide of potassium have finally caused a cessation of the development of the disease, and a very manifest change in her general appearance, which was at first distressingly anaemic and depressed. From time to time she was given mercury, but it always seemed to rather do her harm. In striking contrast to such cases many might be given where a few weeks sufficed to remove, or greatly benefit, tubercular syphilitic eruptions of various durations, the same principles of treatment being applied to both sets of cases. During the past year I have made very considerable use of the cyanide of mercury, which certain persons have extolled 26 A Study of Diseases of the Skin. as the best form in which to use the drug. I have always prescribed it combined in the same solution with iodide of potassium, and have discontinued it in one case after another, because the patients did not do so well as I am accustomed to see them do with other remedies, and because it very com- monly produced more or less stomach irritation. I gave it in one-sixteenth grain doses, and it may be that some decom- position took place giving rise to irritating properties. I can not find if those who have employed it gave it alone or with the iodide of potassium. I shall make further trial of it alone, or given at different times from the iodide, and hope to obtain better results. Last year I said that I thought that I had obtained rather better results in syphilis, from the combination of the car- bonate of ammonia with iodide of potassium, than from the iodide alone, as recommended by some English surgeons. I must now state that further experience has not confirmed this, and that I have abandoned it to return to the combina- tion with iron which I have long used. I have employed with benefit local mercurial fumigations, where the tongue and throat were the seat of syphilitic dis- ease, and have also prescribed inunctions as adjuvants to other treatment, when a rapid action was desired. 5. Scabies.-A rather larger proportion of patients with scabies, twenty-six, or 4.2 per cent., against 3.6 per cent, of last year, was caused by the recent breaking up of the nursery on Randall's Island, as quite a large share of the cases occur- red within the last few months, and either came directly from there or were the results of infection thence derived. There were but two persons with the disease over twenty years of age, and these were both married women, one of whom brought a child affected with it, whence the contagion. The youngest patient was six months of age, and. eighteen out of the twenty-six cases were under fifteen years. The sexes stood fifteen males to eleven females, about the same propor- tion as last year. In four instances two members of the same family applied for treatment; no larger number was observed A Study of Diseases of the Skin. 27 in the same family. Many of the cases were in very scrofu- lous and debilitated children, in whom the acarus caused severe pustular eruptions, which required to be treated by emollient applications before the anti-parasitic remedies could be safely employed. For this purpose, the hands especially were soaked and wrapped in cod liver oil, which is in a meas- ure inimical to the insects, as it mechanically hinders their breathing, while at the same time its soothing properties ren- der it very grateful to the inflamed skin. Pure sulphur oint- ment was rarely used, because of the delicate skins generally found in those with the disease, but generally a little sulphur was used in combination with liquid storax and carbonate of potash, in ointment. 6. Dermatitis.-Under dermatitis I include inflammations of the skin distinct from eczema, furuncles or erysipelas, which are caused generally by extraneous irritating elements, but may be of internal origin. Thus, of dermatitis calorica there were eight cases, seven being caused by heat, being burns in various degrees, and one from cold, a frost bite. Of the variety dermatitis venenata, there were four cases, three from the rhus toxicodendron, two boys of fifteen and sixteen, and a girl twenty-one years of age, and one from an irritating liniment, applied for rheumatism of the knee, by a woman fifty years old. Three cases of dermatitis were of traumatic origin; and in eight others, the cause or variety was not stated or was insignificant. The total number was twenty- three, or 3.7 per cent, of the whole. The indications of treatment vary of course with the case. For the poisoning by the rhus the black wash was employed, and carron oil later in one case. 7. Tinea.-The cases of vegetable parasitic diseases were twenty-one in number, eight males and thirteen females, and were thus divided: First, those due to the parasite tricho- phyton-(a) tinea circinata (ring-worm of the body) twelve cases, (£) tinea tonsurans (ring-worm of the head) two cases, total fourteen; second, that caused by the microsporon furfur, the tinea versicolor, five cases; third, that due to the achorion 28 A Study of Diseases of the Skin. Schonleinii-tinea favosa or favus, two cases. There was no instance recorded during the year of parasitic sycosis, nor of disease of the nail of parasitic origin. In regard to another disease, reckoned by some among the vegetable parasitic dis- eases of the skin, namely, alopecia areata, I do not believe in its parasitic origin, even if there were any cases to record, which there were not. Of the dozen cases of ring-worm of the body, eight were in females and four males, most of them being in children; in one instance, a mother and child at the same time pre- sented the disease. The two cases of tinea tonsurans were in children, a girl and boy, each six years of age, and one child with the circinate form had the disease extending from the forehead up on to the hairy scalp, where it took the form of tonsurans, with broken or nibbled hairs, a clear demonstra- tion of the identity of what was formerly supposed to be two distinct affections. The four male cases were in boys, except one patient, who was a hostler, aged twenty-four years, and presented, with his ring-worm of the face, an eczema of the thighs; and although the scales of the latter were not exam- ined microscopically, we can be pretty certain that the dis- ease here was also of parasitic origin, as we know that the eczema marginatum of the thighs and scrotum is but a form of this trichophytic disease. He probably contracted both forms from horses, as we know both these animals and dogs are liable to have the disease, and contagion has been traced from them. Tinea versicolor, the pityriasis versicolor, or chloasma of the breast, of older writers, affected five persons-three females and two males; the youngest a female of fourteen, the oldest a male thirty-one years of age. Fourteen is a very early age at which to see it. I do not remember ever having seen it earlier; nor is it often met with after fifty. This eruption is very frequently called syphilitic, and I not infrequently find patients who have been salivated for it. It is, perhaps, the most harmless of all the skin affections, purely local and removable solely by local means. A Study of Diseases of the Skin. 29 The two cases of favus, or tinea favosa, were in a woman of twenty-eight, and a boy of fourteen years of age. In the woman it had already lasted fifteen years, and several years in the boy; and will probably last many years longer in both, for they were very fitful in their attendance. I have never seen in this country the severe cases covering much of the scalp, as found in Scotland and Germany. The disease here is generally confined to a few isolated or grouped spots, as in both these cases, and gives the patient so little annoyance that they are generally careless about it. In regard to the treatment, I have generally followed that mentioned in my last year's report, avoiding still the use of bi-chloride of mercury washes often recommended, because of the danger both of absorption, and also of having such a poison around where it might be taken internally by mistake. 8. Psoriasis.-Eighth in our list stands psoriasis, which I regard, from public and private statistics, to be a far less common disease than is usually supposed. There were but twenty cases, or 3.2 per cent., against five per cent, of last year's cases. As to sex of the patients, the females were three times the number of the males, fifteen to five. In age the patients ranged from seven years to sixty, as presented in the following: TABLE V. Age of Patient. J) D "rt s Females. Total. Under in years of age 2 4 6 2 5 6 3 2 2 IO to 20 years of age I 20 to 30 years of age 30 to 40 years of age 3 1 40 to 50 years of age 1 2 Oyer years of age rpntal 5 15 20 The longest duration of the disease was fifty years, in a woman aged sixty, besides which there were cases of twen- ty-two, twenty, eleven, seven, five, and three years' duration 30 A Study of Diseases of the Skin. respectively. The most recent case was in the youngest patient, a little girl of seven years, in whom the eruption appeared four weeks previous to her first visit at the Dis- pensary. The disease began three weeks after vaccination, first around the site of the insertion of the virus, and devel- oped a typical psoriasis on the chest and back as well. The eruption yielded quite promptly to treatment, and in four weeks it was noted that it had almost entirely disappeared. Eight months from the first appearance of the psoriasis, she noticed what she thought a return of the eruption, but which proved to be a scaly eczema, affecting mainly the flexor sur- faces, and which yielded at once to treatment, so that in one week there was no trace of it, and treatment was stopped. This was in October, and the patient has not called since, nearly six months; but as the family are very intelligent and pleased with the results of treatment, we may believe that the disease has not returned. Another patient, a girl of twenty-four years, was seen four months after the first occurrence of psoriasis. The disease was yielding very rapidly to the liquor picis alkalinus inter- nally, fifteen minims largely diluted, on an empty stomach, when she ceased to attend. There were two cases of psoriasis affecting the palms of the hands, which is acceded to be a very rare disease when not accompanied with psoriasis of the rest of the body. These cases, however, presented all the features of the dis- ease in question, namely, round, scaly spots scattered over the palms, always dry, not cracked, giving none of the ap- pearances of eczema. They were certainly not due to syphi- lis, nor were they a portion of a present or past eruption of general psoriasis, but the propriety of the diagnosis was be- yond doubt. One patient, a female aged fifty, who had had the disease for twenty years, presented the unusual feature of scarring or cicatrization after the disappearance of the patches of psori- asis. As a rule, the disease leaves no traces, but in rare instances depressed cicatrices are left. Here the extensor surfaces of the fore-arms were largely covered with white A Study of Diseases of the Skin. 31 depressed scars, contrasting strongly with the brown skin of the rest of the arms. On the body the eruption left no per- manent marks after its disappearance. During the past year I have been using phosphorus in many cases of psoriasis, giving it in doses of one hundred and sixtieth to one-eightieth of a grain, in cod liver oil. Very good effects have been observed in a number of cases, a part of which must of course be attributed to the oil. Another year I hope to report the drug used by itself, which may be conveniently and safely done in the solution recommended by Dr. Ashburton Thompson. I have once observed a most severe bilious attack, with jaundice, come on during the taking of the phosphorated oil, which passed away soon on ceasing the use of the same, and the adminis- tration of a cathartic and some mineral acid. But it was a warning by which I have profited, and now I generally omit the remedy every week or so, administering acetate of po- tassa in the interval, and with excellent results. Of course the permanent effect of this treatment can not be determined until a longer period of time has elapsed. 9. Erysipelas.-But little new can be said in reference to the nineteen cases of erysipelas which came under treatment. In eleven instances the face was affected, and in eight other parts of the body. Ten of the patients were males, and nine females. The youngest patient was aged six months, and had an erysipelas migrans following vaccination; and the oldest sixty-eight, a man with facial erysipelas. 10. Furuncles.- Seventeen patients were recorded with furuncles-six males and eleven females-presenting all the shades of phlyzacious inflammation, most of them in cachec- tic and scrofulous children. Some of the cases might be called ecthyma, but I have preferred to exclude that term, with impetigo, placing the superficial impetiginous eruptions, not involving the derma and leaving no scar, among eczema impetiginodes, while the deeper inflammations resulting in confined suppuration, with or without a central core, are classed as furuncles. 32 A Sttidy of Diseases of the Skin. The hyposulphite of soda, given internally, thirty grains three or four times daily, largely diluted and on an empty stomach, has been my main reliance in checking the new formation of boils, as mentioned in my analysis of last year. Sometimes this fails, when large and repeated doses of quinia will pretty certainly do the work. The hyposulphite has failed entirely in those pseudo furuncles accompanying psori- asis and not infrequently found in the axilla. II. Herpes.-By herpes I understand, with modern derma- tologists, an acute eruption of vesicles, which may be repro- duced in successive crops, the vesicles flattened and clustered together, the skin between being sound, and acknowledging generally a neurotic origin. I mean by this to exclude the herpes circinatus of older writers, which we now recognize as a parasitic affection, and which has already been spoken of as tinea circinata; excluding also the herpes iris, which is more properly an erythema, in which the congestion goes on to effusion and consequent vesiculation; likewise excluding all old terms, as herpes esthiomenos or lupus, etc. The forms of herpes met with during the past year embrace most of the varieties recognized, and the number of cases was as follows: Herpes zoster, zona or shingles, ten cases; herpes labialis, three cases; herpes praeputialis, two cases; herpes nasalis, one; anomalous, one; total, seventeen. The disease is rather one of early life, as is seen by reference to TABLE VI. Age of Patient. Males. Females. Total. Under io years of age 2 5 2 2 2 1 4 7 3 1 2 io to 20 years of age 20 to 30 years of age 30 to 40 years of age Over 50 years of a(re Total 12 5 17 A Study of Diseases of the Skin. 33 Of the ten cases of herpes zoster, six were in males and four in females; six affected the left side and three the right, one not stated. The youngest patient with shingles was a girl of three years, the oldest a man of seventy-three; there were also a boy of four and a girl of four and a half years with the disease. Last year I reported the youngest patient to be two and a half years. It has been known in children from ten to fourteen months old (Neumann). The case of herpes mentioned as anomalous, was in a young man, twenty-nine years of age, who, within a year, has had three attacks of a vesicular eruption, occupying the buttocks and backs of the thighs, with no eczematous ten- dency. In the second attack, which I saw at the commence- ment, there were erythematous circles with vesicles devel- oped upon them, very distinct on the parts mentioned, some of them being almost bullae. The two attacks came on soon after discontinuing treatment at my direction. The deep itching and burning were at times excessive. The disease yielded each time quite soon to arsenic, strychnia and iron, internally, though new crops of vesicles formed for a while. I have employed phosphide of zinc in herpes zoster with success in relieving the pain, and in one instance aborting the development of the vesicles. It was given with extract of nux vomica, one-third of a grain of each five or six times a day. 12. Lichen.-Some writers consider the papular eruption, familiarly known as lichen, as only a form of eczema, and recognize but two forms of lichen-the lichen scrofulosorum and lichen ruber. This, as stated last year, I can not agree to, and the cases here recorded as lichen presented the papu- lar appearance described by that name in older works. There were seventeen cases thus entered-six males and eleven females-of which thirteen were of the acute form, one chronic or agrius, one lichen pilaris, and one of the rather rare affection lichen planus. The youngest patient was aged two and a half years, male; the oldest sixty-nine years of age. The internal treatment employed was fre- 3 A Study of Diseases of the Skin. 34 quently the acid magnesia and sulphate of iron mixture, known as Startin's, with cooling lotions, as the diluted liquor picis alkalinus with oxide of zinc, in the acute cases. Where the eruption persists, local stimulants are required. 13. Urticaria.-Of this peculiar disease there were recorded seventeen cases, seven males and ten females, whose ages are recorded in TABLE VII. Age of Patient. Males. Females. Total. 2 years of age and under 3 1 1 1 3 2 2 4 1 3 4 3 2 io to 20 years of age 20 to 30 years of age 2 1 1 30 to 40 years of age 40 to 50 years of age 50 to 60 years of age Total 7 10 17 One case was observed which was remarkable from its occurring in a patient with marked exophthalmic goitre, and from the neurotic nature of the latter affection and the many- well recognized neurotic elements of the eruption, I was led to infer some relation between the two, and to regard the connection as a link in the chain of evidence, pointing to the origin of urticaria in a disease, functional or other, of the sympathetic system, as I have elsewhere pointed out.* No new therapeutical measures were adopted in this erup- tion, except the administering of tincture of belladonna to the last mentioned patient, in frequent and increasing doses, with the effect of benefiting the Graves' disease and removing the urticaria, a plan of treatment which it may be well to em- ploy in obstinate cases of the latter, though unaccompanied by the former neurosis. 14. Erythema.-Of the fourteen cases of erythema-six males and eight females-six affected the face, three the * Chicago Journal of Mental and Nervous Diseases, October, 1875. A Study of Diseases of the Skin. 35 hands, one the left leg, and in four the location is not stated. Most of them were very transient eruptions, due to digestive disturbances, and yielding quickly to proper remedies. The total number, fourteen, gives about the same percent- age as that noted last year (2.5), and stands in striking con- trast to McCall Anderson's statistics, where erythema makes five per cent, of the whole number of dispensary cases, and ten per cent, in private practice; or the disease is twice as frequent in Scotland as here, among the poorer classes, and four times as frequent in those higher in society. 15. Pruritus.-Four of the eleven cases of pruritus were recorded as pruritus senilis, in persons of sixty years or over, where, with cleanly habits, there was the intolerable itching attending the senile changes in the skin, which Neumann has described. This state, of course, can be only palliated, but fortunately often that is all that is required, for, although the changes remain or go on, the itching varies with other causes. A lotion of carbolic acid and caustic potash in water-car- bolic acid two drachms, caustic potash one drachm, distilled water eight ounces - has generally afforded relief. These cases are also benefited by cathartics and alkaline diuretics, as the urinary secretion is often scanty in these patients. A man aged thirty-three, with distressing pruritus ani, with no visible lesions, obtained very much benefit from the internal use of nitric acid, with a diluted white precipitate ointment used locally, after other measures had failed. 16. Verruca.-Ten patients with warts applied for relief, nine males and one female. One patient had a single wart on the ear, which was removed by ligature, another had one on the forehead, and the rest affected the hands. One servant girl, of seventeen years, with about twenty warts, attended very faithfully and obtained a perfect cure, by the application of nitric acid at the dispensary and acetic acid at home; and after the excrescences were removed, the thickenings at the old locations were rubbed with a strong caustic potash solu- tion, one drachm to the ounce, and diachylon ointment, ap- plied till the skin was smooth and natural. 36 A Study of Diseases of the Skin. 17. Scrofuloderma.-Under this head were classed cutane- ous abscesses and inflamed superficial glands in strumous persons, of which there were eight cases, equally divided between males and females. 18. Rodent Ulcer and Epithelioma.-Without attempting to establish here the essential differences between these two morbid processes, or even to assert that they are entirely distinct, I will merely mention the clinical phenomena which have characterized the cases which have come under obser- vation at Demilt Dispensary during the past year. There have been six cases, which I regard as rodent ulcer, affecting two males, aged respectively fifty-one and seventy- two, and four females, of fifty-three, fifty-three, sixty and eighty years of age respectively; and one case of epithelioma. First of the case of epithelioma: the man, forty-one years old, a liquor dealer, had a typical epithelial ulceration of the lower lip, which was referred to the surgical department for excision. The appearances were those familiar to all, and need not detain us here. I may remark that these cases are usually sent at once to the surgeons, and so are seldom en- tered in my book. In regard to the six cases of rodent ulcer, the two women, fifty-three years of age-both married, one a widow-had the disease for many years, one on the forehead, the other on the left temple. The ulceration had never been extensive, and when first seen each presented only a dry, hard, slightly scabbed patch, with edges a little elevated and the surface slightly moist when the crust was removed. In one patient the disease had traveled quite a distance, leaving behind it a depressed pale cicatrix. The one on the temple was success- fully destroyed by Marsden's arsenical mucilage, used as described in my report of last year; the same was applied to that on the forehead of the other woman, but was tampered with and no results were obtained. The female aged sixty had a patch about the size of a small penny in the center of the forehead, which had existed many years, increasing very slowly from a small wart-like A Study of Diseases of the Skin. 37 affair, which she would pick from time to time, when a slightly moist surface would appear and the scab soon re- form. It has never ulcerated, because she has taken care not to irritate it; and when first seen it resembled somewhat a patch of chronic eczema, but careful inspection showed a cartilaginous hardness of the base, and an unevenness of the crusted surface, which, with the history, made the diagnosis complete. She was unwilling to have any severe measures taken, and no treatment was employed, but she was coun- seled to avoid trying any remedies short of destruction. The old woman of eighty had three masses, one under the right eye, one on left cheek, and one on the forehead, which were scabbed; they had been there a number of years, and showed but little change from time to time. No treatment was adopted, because of her age and infirmity. The man fifty-one years old was a gardener, and for twelve years had had a slowly ulcerating mass at the internal angle of the right eye, involving the canthus and reaching on to the nose. It was moist and slightly ulcerating, and he had kept it covered with simple cerate for several years, it now being a little larger than a small cent, with a rather longer diameter horizontally; the margins were hard and abrupt. The case was sent to the clinic from Dr. Smith, of Jersey City, only for consultation, and excision and cauterization were advised. I have recently learned that the disease was excised, but that the patient has failed in strength since. These cases about the eye should be operated on very early; when seen it was thought that the disease had progressed internally, and rather an unfavorable prognosis was given. In the man of seventy-two, a laborer, three patches of dry, hard disease, of a character similar to that seen in the women, existed on the right and left temple, and also on the neck. None of these cases suffered any pain from the disease; there were no enlarged glands. The woman of sixty com- plained of considerable itching. I may here state that in calling these growths rodent ulcers and not epitheliomata, I have followed the distinctions of the English surgeons Bro- 38 A Study of Diseases of the Skin. die, Paget, Moore and Hutchinson; the Germans have not yet distinguished the two apart. 19. Ulcera.-In the treatment of ulcers of the leg (syphilis excluded) I have employed the recently recommended lotions of hydrate of chloral, ten grains to the ounce, with success. I direct that they shall be kept wet with it during the day, and at night order either tar and zinc ointments, equal parts, or one made of the balsam of Peru, half a drachm or one drachm to the ounce. The effect of the chloral has been plain, improvement tak- ing place and ulcers healing after its adoption, which were sta- tionary under other treatment. There were but five cases- four women and one man-recorded as ulcers, although many cases of eczema of the legs possessed this feature, and there were many other syphilitic ulcerations. 20. Clavus.- Four patients presented themselves with corns or callosities of the feet, two of which cases possess interest. One, a boy ten years old, had five upon the sole of the right foot, mostly on the ball, which gave him much pain and seriously impeded locomotion. He attended very faith- fully, and the troublesome formations disappeared under the continued application of the unguentum diachyli of the Ger- mans, covered with brown paper. A woman of forty-five years found very great relief to large callosites on the feet from wearing oiled silk, cut to fit the sole and lapping over about an inch on the side, worn night and day within the stocking. She was a washer and ironer, and the painful hard- enings were due to her occupation. 21. Chloasma.-The pigmentary disease here referred to is quite distinct from the fawn-colored eruption found upon the breast, formerly called chloasma or liver spots, but which has been already described with title tinea versicolor. This latter is due to the presence of the vegetable parasite micro- sporon furfur, whereas in the affection in question there is no parasite, but the disease is simply an abnormal collec- tion of pigment matter in the rete malpighii, which is the seat of the normal coloration in the negro, and of the physi- A Study of Diseases of the Skin. 39 ological discolorations of the areolae and elsewhere in preg- nancy. The appearances in the three cases here alluded to was that of brownish discoloration mostly of the forehead, in irregular sized and shaped patches, covering sometimes the entire surface and extending to within one-third to half an inch of the hairy scalp. They may also affect other parts of the face as well. The surface is perfectly smooth, there being no desquamation except under the action of irritants. These cases were all in females, and from its very common occurrence in this sex, and especially in those with uterine or ovarian disease, it has been designated by some chloasma uterinum; the same affection, however, is occasionally met with in men. In the remaining nineteen varieties of cutaneous disease the numbers of the cases were few, and many of the diseases unimportant. I will, therefore, briefly note only such items as may be of interest. Two cases of purpura only were entered; one of the rheu- matic variety, called by some peliosis rheiimatica, but more rightly purpura rheumatica, in a woman thirty years of age; and the other, of the hemorrhagic form, in a female child of twenty months. The latter patient was brought to the Dis- pensary in a semi-comatose condition, and lived but two days. The child had nursed nineteen months, had been prostrated by hooping cough all winter, and presented a most pitiable appearance, with otorrhoea and gangrenous ulcers of the mouth and about the ear. It had hemorrhages from the nose, and the movements from the bowels were dark as from blood. A single case of bromidrosis, and one of hyperidrosis of the feet, were prescribed for; the former received a wash of sali- cylic acid, but the result is not known; the latter, the ungu- entum diachyli of the Germans, to be worn next to the soles during the day, a treatment recommended by Hebra first, I believe, and which I have long used and found generally suc- cessful. 40 A Study of Diseases of the Skin. The patient entered as elephantiasis Grcecorum presented a most marked and striking example of this rare disease, which terminated fatally, and will be detailed in full, with another case of the same disease, on a subsequent occasion. An instance of cicatricial keloid was recorded, resulting from old syphilitic ulcerations, and presented no unusual features. There were several on the same individual. No treatment was adopted. But a single patient was seen with naevus. This was a female infant of three months, who had six bright red, vas- cular naevi; one on the back, one on the side of the trunk, one in the left groin, which was ulcerated; one on the left leg, behind, just above the ankle, and one on the forefinger of the left hand. All were on the left side of the body, and the left submaxillary gland was enlarged, suggesting some unilateral nerve disorder of central origin. No radical treat- ment was employed, and the child was seen but twice. A rather unusual form of pemphigus was observed in a school-girl, seven years old, who exhibited the remains of a bulla, about half an inch in diameter, on the inner side of the right knee almost as far back as the popliteal space; and another perfectly developed, of the same size, above and in. front of the former. This latter was intact, moderately filled with clear serum, and elevated to about one-fourth of an inch. The base was scarcely at all inflamed, nor was that of the former one, which had dried, having appeared three or four days previously. The second one was first noticed on the morning of the visit. This case corresponds to the pem- phigus solitarius of writers. In my attempt to present, as concisely as possible, a mir- ror of the practice in my department in Demilt Dispensary during the past year, it will be seen that I have studiously avoided any discussion of vexed questions, have hardly al- luded to differential diagnosis, and have not mentioned the microscopic anatomy of any of the diseases noticed. These are all important in their way; but I have desired, in the A Study of Diseases of the Skin. 41 present paper, simply to add the results of American expe- rience in the observation and treatment of diseases of the skin, and to excite, if possible, more interest in their study; for it is only with accuracy of diagnosis and well founded knowledge, based on careful clinical study, that they can be successfully managed. The material at the command of al- most every one is much larger than is used or often imagined; and I feel that I have not said one tithe of what could, with profit and pleasure, be given from the experience of this sin- gle year in one institution. I have reported many of the cases elsewhere, and have yet an abundance of notes which are highly instructive to me, and that may at some time be of service to the profession. In conclusion, let me urge the value and necessity of writ- ten records of disease as the surest basis of medical research. Were this more universally done, there would be less theoriz- ing in medicine, and practice will become a science as well as an art in proportion as it is grounded upon recorded facts. I can especially assert this in regard to diseases of the skin, whose study is fascinating and whose treatment is propor- tionately gratifying. I would again appeal for interest in the establishment of a hospital for this branch of practice, where proper treatment can be administered, and where study can be prosecuted in a manner satisfactory and profitable to the profession. 4