wx P51im I893 PHILADELPHIA DISPENSARY FOR SKIN DISEASES REPORT tt o A«v»an ivnoiivn jnoiqjw jo auvbbii ivnoiivn jnoiqjw jo uvmn ivnoiivn inisi IBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIC o ABvaan ivnoiivn jnoiosw jo uvim ivnoiivn jnisiqjw jo xivisii ivnoiivn jnidi IBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIO I BR ARY OF ME Dl CI NE N A T I O N A L 11 B R A R Y O F M E D I C I N E N A T I O N A L L I B R A R Y O F M E D I C I N E NATIO JO AaVOail IVNOIIVN 3NI3IOJW JO Am » AaViail IVNOIIVN 1NI3I03W JO AaVaBIl IVNOIIVN 1NI3I0JW JO AaVaBIl IVNOIIVN 3NI3I Medical Report OP THE PHILADELPHIA Dispensary for Skin Diseases COVERING A PERIOD OF TEN YEARS AND NINE MONTHS (February, 1880, to November, i8go) BY THE ATTENDING PHYSICIAN HENRY W. STELWAGON, M. D. ISJB c.t NATIONAL LIBRARY OF MEDICINE BETHESOA 14, MD. /r////- 7t'i> ■7-/^L, REPORT OF Ten Years' Service AT THE Philadelphia Dispensary for Skin Diseases, BY Henry W. Stelwagon, M. D. This report covers my ten years service as physician-in-charge of the Philadelphia Dispensary for Skin Diseases. During this period about 4200 cases applied for treatment. Of these about 60 or 70 cases have been omitted in this review, for the reason that they were seen during my absence or the absence of the regular assistants by gentlemen temporarily in charge who either did not make sufficiently full notes or who did not care to assume the respon- sibility of making a positive diagnosis, this being deferred till a future visit; when such patients neglected to return the record remained, necessarily, incomplete. All varieties of diseased conditions were represented. The rather large proportion of molluscum contagiosum, a comparatively rare affection, is explained in the summary of the cases of that disease. Among others of the rarer diseases recorded may be mentioned morphoea, dermatitis herpetiformis, dermatitis papillaris capillitii, dermatitis exfoliativa, and pityriasis rosea. Of later years psoriasis has seemed less common than formerly; this is doubtless merely relative and owing to the increase in such diseases as scabies, pediculosis, etc. Indeed the character of recent immigration has materially changed the aspect of dispensary practice. Scabies is almost an every day affair now, whereas some years ago an observation of 10 to 15 cases yearly was considered large. Favus was formerly almost a curiosity, but the ingress of Russians, Poles, Huns, and the like, are furnishing sufficient cases at the present time for all clinical purposes. Regarding the therapeutic experience of this Institution during this period of ten years, it is to be understood that all remedies whose claims were strongly advanced were given a more or less extended trial; man}- of these failed to substantiate such claims sufficiently to warrant their continued use and others failed to show superiority over the more common and less expensive remedies. This negative experience, for obvious reasons, will rarely be specifically mentioned in the following pages, reference being more especially made to those remedies or methods of treatment which, taking the service as a *J 'aits of this report were variously published in the "Therapeutic Gazette," for April; "University Magazine," "North Carolina Medical Journal," " Annals of Gynecology and Pediatry," for May ; "International Magazine," "Virginia Medical Monthly,'' "Journal of Cutaneous and Genito-Urinary Diseases." for June; and' "Medical News," April 22, 1893. The cuts published in several of these Journals are here reproduced. 2 whole, were found to give the best results. TheJbllowing list gives, in alphabetical order, the diseases and the number 01 cases of each observed : Acne........................ Acne rosacea.................. Adenitis................. Alopecia..................... Alopecia areata .............. Angioma .................... Anidrosis ................. Atrophia unguis......•....... Bromidrosis.................. Callositas.................. Canities . .................. Carbuuculus................ Carcinoma ................ Chloasma ................... Cicatrix.................... Clavus ................. .... Comedo .................... Dermatitis .................. Dermatitis exfoliativa......... Dermatitis factitia .......... Dermatitis herpetiformis....... Dermatitis papillaris capillitii.. Dy sidrosis.................... Ecthyma..................... Eczema ....................1 Epithelioma.................. Erysipelas........... ....... Erythema multiforme.......... Erythema simplex ........... Furuncnlus .................. Herpes simplex .... .......... Herpes zoster. ............... Hyperidrosis ................. Hypertrichosis................ Ichthyosis .'.................. Impetigo contagiosa ...... 270 86 3 10 16 1 6 1 2 3 14 2 4 10 56 1 2 6 3 3 23 594 27 14 43 14 34 25 10 I 13 138 Keloid....................... * Keratosis pilaris.............. y Lentigo...................... A Lichen planus............... ** Lupus erythematosus.......... ly Lupus vulgaris................ 1" Miliaria...................... 2^ Milium...................... ^ Molluscum contagiosum........ 30 Morphoea............... •* Naevus pigmentosus .......... 6 Onychauxis.................. :' Paronychia................... ? Pediculosis................. 185 Pityriasis rosea............... 5 Pruritus .................... 136 Psoriasis..................... 155 Purpura..................... 16 Rubeola....... .............. 4 Sarcoma..................... 1 Scabies ....................372 Scarlatina.................... 2 Seborrhcea .................. 125 Steatoma................... 6 Sycosis....................... 47 Syphiloderma................ 280 Telangiectasis................ 1 Tinea favosa................. 20 Tinea trichophytina........... 199 Tinea versicolor............... 44 Urticaria..................... 70 Varicella..................... 20 Variola....................... 2 Verruca...................... 28 Vitiligo...................... 11 Xanthoma................... 1 Acne.—This disease was represented by 270 cases, or a proportion of 6.5 per cent.; of these, 123 were males and 147 females. The ten years between the ages of puberty and maturity —between the ages of fifteen and twenty-five—furnished 199 of the cases. The youngest patient was aged thirteen and the oldest aged fifty-three. The relationship of age to the disease is shown in the following : Years. Cases. Under 15 ...................... 18 Between 15 and 20 ............. 108 Between 20 and 25.............. 91 Between 25 and 30.............. 28 Years. Cases. Between 30 and 35.............. 12 Between 35 and 40............. 8 Between 40 and 45 ............. 3 Over 45........................ 2 In 237 cases the eruption was essentially confined to the face ; in a proportion of these several or more scattered lesions showing themselves from time to time upon the neck and shoulders. In 26 cases the eruption was equally well developed upon face and back, and in 7 cases it was limited to the back, in some of these latter no lesions, in others not more than two or three, appear- ing upon the face. In the cases involving the back, either alone or 3 conjointly with the face, the eruption was quite abundant, and commonly extended down as far as the sacral region. The type of the eruption in 8 cases was minutely papular, more of the nature of comedo ; in 38, almost purely pustular, the preceding papular stage being scarcely noticeable ; and in 105 cases it was papular or papulo-pustular, the pustular element being comparatively slight. In 9 cases the variety known as acne indurata was represented, and in 7 cases the type designated atrophic, in which the lesions, usually sluggish-papular and small, leave behind pit-like scars The remaining cases were of mixed type. The most common etiological factor in acne, next to adoles- cence, was some disturbance of the gastro-intestinal tract. Func- tional and organic disease of the reproductive organs in females was not infrequently the active predisposing influence. Another etiological element in many of these cases was the fact that the work in which the patients were engaged was of a dusty or dirty character, or done in that kind of an atmosphere. Constitutional treatment was entirely dependent upon the active etiological factor or factors; experiments with specific remedies were not fruitful of good results. The external treatment consisted first in keeping the skin clean and the ducts free by means of soap-and water-washings, hot-water sponging or steam- ing, and by pressing out the blackheads with a suitable instru- ment. Among the most valuable lotions were the following : One containing from 20 to 100 grains each of zinc sulphate and potassium sulphuret to 4 ounces of water ; a lotion (Kummerfeld's) containing 2 drachms each of sulphur, mucilage of tragacanth, and spirits of camphor, with enough lime-water to make the 4 ounces ; one containing 2 drachms of sulphur, Yz ounce of ether, and $Y ounces of alcohol; Vleminckx's solution, with 6 to 10 parts of water up to the pure solution ; a saturated alcoholic solution of boric acid ; an aqueous solution of boric acid, with 5 to 20 grains of zinc sulphate to the ounce ; and one containing 5 to 40 grains of resorcin to the ounce. The most valuable ointments were : One of sulphur, 30 to 120 grains to the ounce ; the same ointment made more stimulating by the addition of j4 to 2 drachms of sapo viridis ; 2 drachms of sulphur and 1 drachm of ichthyol to the ounce ; one of ichthyol, 20 to 50 per cent, strength ; and one of white precipitate, 20 to a 100 grains to the ounce. The mercurials were seldom employed, as the sulphur preparations were by far the more valuable. In addition to the white precipitate ointment mentioned, one of oleate of mercury, 5 to 20 per cent, strength, and a lotion of corrosive sublimate, ^ to 2 grains to the ounce, were sometimes prescribed. In many cases the deep-seated lesions were punctured, the contents pressed out, and the interior then touched with carbolic acid, applied by means of a pointed stick. AexE Rosacea.—Of this disease 86 cases were met with— 39 males and 47 females. In 42 cases the disease presented itself as a simple hyperaemic condition or a stasis, with or without one or several acne lesions ; the seat of this type was the nose, or the nose and the closely-adjacent skin. In other cases—40—there was more or less hypersemia, with dilated capillaries, and acne lesions of a markedly inflammatory character ; the nose, surrounding 4 parts, and, in a number, the cheeks, forehead, and chin also were the seat of the disease. In two instances there was a diffused hypersemia, with hypertrophy of the vessels and all the cutaneous tissues. Seventy-six cases were seen between the ages of twenty and sixty ; 4 under the age of twenty, and these usually repre- senting a cold hypersemia of the nose, associated with an oily seborrhoea. The most common causes seemed to be digestive irregularities, uterine disturbances, and debility ; in a proportion, which was not large, drink was an important factor. Systemic treatment had for its aim a correction or removal of the predisposing causes, salines, antacids, bitter tonics, and digestives playing an important role; ergot, more especially in women and in those cases in which some uterine disturbance was the apparent factor, was sometimes of value. The main treatment was external. In those cases of sensitive skin in which the hyperaemic element and inflammatory condition were marked features, the early treatment consisted of mild astringent applica- tions, such as calamine lotions and ointments, tannin lotions and ointments, and boric-acid washes with one or more grains of zinc sulphate to the ounce; later, in these cases, and at once in those of a more sluggish or colder type, stimulating applications were made. The most important of these were such as are used in the treatment of ordinary acne. Particular mention should be made of Vleminckx's solution, a compound lotion of zinc sulphate and potassium sulphuret, and ichthyol ointments. Simple multiple punctures, or these combined with electrolysis, were employed in persistent cases, and especially in those in which there was distinct capillary hypertrophy. For destroying the enlarged vessels, electrolysis or the bistoury was resorted to ; to accomplish this frequent repetitions were necessary. Alopecia. Areata.—This affection was met with in 16 instances, or a proportion of about 0.4 per cent. As to sex, 10 were males and 6 females. The disease was seen at all ages : 3 cases under the age of ten; 4 between ten and twenty ; 3 between twenty and thirty ; 5 between thirty and fortv, and but one above this age; the youngest was aged eight, and the oldest sixty. The disease was seated upon the scalp alone in 10 cases ; upon the scalp and face (bearded portion, or eyebrows, or eye- lashes) in 3 cases ; bearded part alone in 1 case, and in 2 cases the hair loss was essentially universal. In the scalp cases, usually two or more half-dollar to dollar-sized patches were present." In almost all the cases, the loss of hair was rapid—that is taking place in the course of one or two weeks. The duration of the disease, when the patients came under observation, varied from two weeks to four years. Of the two cases of universal alopecia, both subjects were males—one a painter, aged thirty-two, and the other a moulder aged sixty. In the former, the hair had begun to come out two and a half months previously, and within two weeks there was none remaining on any part of the body, except one to two hundred scattered, isolated hairs upon the scalp ; in the second case it w^ complete, except a few scattered hairs upon the bearded part and had begun to fall out two years before, following an acute illne« and within ten days thereafter the patient was hairless 5 A history of recurrences was not uncommon. The most striking in this respect was the case of a woman, aged thirty-two, who for three years had been devoid of hair on the scalp, and for a year and a half, eyebrows and eyelashes had also been absent; she first had the disease as several patches upon the scalp, when seven years old, from which recovery was made ; when fifteen years old, the disease returned, two patches presenting, which soon disappeared ; she was free from the disease till the present onset, four years ago ; her general health has been good, and there was no apparent explanation for the attacks. This lack of con- stitutional cause or explanation for the affection was the rule, although in several instances there was increased perturbation of a naturally nervous temperament. In no instance was a history of contagion given. Treatment was, in every case, both by constitutional and local medication ; the former in the line of improving the nerve tone, with such remedies as arsenic, strychnia, phosphorus, quinia and iron ; and the latter having in view the production of a mild, persistent irritation, with such applications as sulphur ointment, oleate of mercury ointment, 5 to 20 per cent strength; beta-naphthol ointment, )4 to 2 drachms to the ounce ; tarry oils and salves ; weak chrysarobin ointments, 10 to 40 grains to the ounce ; tincture of cantharides, and the like. The two universal cases failed to respond even temporarily. Dermatitis.—Of the 53 cases scheduled under this head, 32 belonged to the class known as '' rhus " or " ivy '' poisoning. In this class all degrees of cutaneous disturbance, from the mild transitory erythematous irritation to an inflammation of the most violent and painful character, were observed. All ages too seemed equally susceptible. The most successful plans of treatment were found to be those that kept in view three properties—protective, astringent, and in antipruritic. Carbolized boric acic lotions, lotio nigra, weak lotions of the fluid extract of grindelia robusta, solution of acetate of lead, and of the sulphate of zinc, were the liquid applications, most commonly prescribed. As a rule, how- ever, better results were obtainable by supplementing the lotion with mild and astringent ointment, such as the oxide-of-zinc oint- ment, cold cream, calamine ointment, and Goulard's cerate. If a wash was used alone the parts were kept constantly wet with it by means of linen cloths. In the mildest type a dusting powder of boric acid, zinc oxide and talc was often all that was needed. Of the other cases of dermatitis, six were of medicinal origin, three of traumatic, one due to the wearing of new red flannel, two to heat or cold, and one to contact with petroleum products ; and in nine the cause was not recorded. Dermatitis Herpetiformis.—Of this disease only 6 cases came under observation, representing, with one exception, almost exclusively the vesicular type. The recorded notes of these several cases may be here given : Case 1.—Man, aged 32, a ship's carpenter, of English birth, first applied to the Dispensary in December, 1881. At that time there were patches of vesico- papules and vesicles scattered over trunk, buttocks, and slightly on the face. 6 Previous duration had been six months. The lesions were for the m«»t part grouped in clusters of three and four, here and there two or three vesicles run ning together and forming irregular small-sized blebs. The itch g was intense, and beginning pigmentation of the scratched parts was "('tlt^blf This case was under observation seven or eight years the skm being rareiy,ii ever, entirely free. The disease had, however, periods of activity and quies- cence. The herpetic character of the eruption was quite a conspicuous feature, but the lesions were mostly small pin-head to pea-sized, a few only at times showing pustular tendency. There was, in fact, never much variation in the type. The general health was good, and there was no apparent cause tor tne ^ctse 2.—A woman aged 29, a housewife, of Irish birth, was first seen in October, 1884. The eruption, of a markedly itchy character, consisted ol discrete and grouped vesicles, chiefly small to large pin-head in size, scatterert over trunk, and limbs, especially about the joints ; there were also several groups upon the face. The disease had already lasted seven years, but was variable in its intensity. The lesions appeared in outbreaks at intervals, between which, however, the skin was never entirely free. This case was seen but once. ' Case 3.—A woman aged 54, a domestic, of American birth, sought advice in July, 1886. The eruption consisted of vesico-papules and vesicles, discrete and in groups of several or more, scattered over trunk and limbs. Previous duration had been eleven years. The eruption was variable, and there were short periods of quiescence. The subjective symptoms of itching and burning were present to a troublesome degree. The case remained under observation but one month ; in this time new lesions continued to appear, and the disease failed to show any improvement. Case 4.—A man aged 43, a millwright, came under notice in June, 1889, with an eruption of papules, vesico-papules and vesicles, grouped and discrete, covering trunk, neck and extremities. Previous duration, thirteen years, with remissions. Four years previously the entire surface was covered with vesico- papules, vesicles and bullae. This patient remained under the care of the Dispensary one month, in which time no change for the better was noted, new lesions making their appearance from time to time. As no memorandum of general condition was made, it was presumably good. Case 5.—A man, (age not recorded) tailor by occupation, of Russian birth, applied for treatment in October, 1889. The eruption was general, consisting of discrete and grouped vesico-papules, vesicles and vesico-pustules. irregularly scattered over face, trunk and limbs. The groups consisted of several small lesions, some tending to become pustular. On palms also were some vesicles, somewhat deep-seated, discrete and in bunches. The eruption was abundant upon the face and scalp ; on the former looking not unlike vesicular eczema. Disease dated back two years, when he had an attack in which the brunt of the eruption was upon the hands and feet, on the latter consisting of large pus- containing blebs. Present attack was of four weeks' duration. Itching and burning were prominent symptoms. Under treatment theie was temporarily marked improvement, but at the end of several weeks a strong tendency to recurrence displayed itself, and the patient disappeared from observation. The general health was noted to have been good. Case 6.—A woman, aged 60, of German birth, a housewife, applied to the Dispensary in August, 1890. In this case the eruption covered the left thigh. left arm and the chest, and consisted of irregular circinate aud gyrate papules and pale macules, presenting the erythematous and the erythemato-papular types, roughly simulating erythema multiforme. The previous duration had been one year. Itching was intense. Several of these cases were under notice such a short time that it would be difficult to state positively the value of treatment, as a whole, or the value of individual applications. The constitu- tional treatment consisted of tonics, more especially arsenic, nux vomica and quinia. As in almost all inflammatory diseases of the *For a full report of this case see " Journal of Cutaneous and Genito-Urinarv Diseases " for February, 1890. * ' 7 skin, saline laxatives given to free purgation brought about temporary amelioration. The most comforting external applica- tions were—liquor carbonis detergens, with several or more parts of water up to the pure solution ; liquor picis alkalinus, i to 4 drachms to the pint of water ; thymol lotions, 1 to 3 grains to the ounce; boric acid solution, with one of the above mentioned remedies as the active ingredient; and resorcin lotions, 1 to 5 per cent, strength. Carbolic acid washes were also beneficial, but not so much so as in eczematous inflammations. The effect of the lotion used was heightened by a supplementary application of a dusting powder. Where an eczematous condition was brought about by the patient's scratching, and where large areas of closely aggregated or confluent vesicles presented, ointments of a mild character were grateful. Dermatitis Papillaris Capillitii. Dermatitis Papillaris Capillitii.—Three cases of this rare disease were met with, two of which were negroes. The disease in all covered about the same extent of the lower occipital and upper neck region. The notes of the white case are here given : A man, aged 39, a ship's carpenter, of American birth, came under treat- ment in November, 1880. The seat of the disease was the extreme lower part of the hairy scalp posteriorly, verging on to the neck. It consisted of discrete and grouped papules, papnlo-tubercles and tuberculo-pustnles,crowded together,with here and there small interstices of healthy skin. The groups were made up'of closely crowded lesions heaped up against each other so as to form large pea to 8 cherry-sized irregular elevations, through which here and there projected single straight or twisted hairs or tufts of hair ; in one or two such tuits the nairs pointed in diverse directions, as if each hair was repellent of the others, home of the larger tubercles and several of the above described groups contained m their depths a small quantity of pus. There were also single lesions wmcn were distinctly sycosiform. The disease had, moreover, especially in some parts, a keloidal aspect. Previous duration had been three years. The subjective symptoms were slight or entirely absent. The other two cases, as remarked, were negroes; the disease in one being quite extensive, going well up the occipital region. In these two cases the resemblance to keloidal growths was strik- ing, but deep seated pus formation was also present. In one the disease had lasted three years, and in the other one year. These two cases remained under treatment such a short time as to prevent any estimate of the remedies employed. The first case, however, was under observation six months, and improved considerably under depilation and the constant application of an ointment con- taining sulphur. Eczema.—The cases of this disease numbered 1394, or a proportion of 30 per cent. Of these 772 were males and 622 were females. Season had apparently the influence usually accredited to it; thus, in the half years between January and July, in which the weather is usually the coldest, the most windy and changeable, 836 cases were met with, against 558 in the seasons between July and January. The frequency, as related to age, corroborated what is well known, the disease being common in infancy and early childhood, becoming less so until the age of active working life is reached, when it again shows a marked increase. This is shown in the following table. Between 30 and 40 years.....230 cases. 40 " 50 " .....204 •' " 50 " 60 " .....172 " Over 60 " .....108 " Age not recorded............ 31 " In many patients the eruption was of a mixed character, showing an intermingling of several varieties of the primary and secondary lesions ; in most cases, however, the disease was either characterized by a uniformity or by a marked predominance of one kind of lesion. These latter cases were therefore classed in the record according to the prevailing type of lesion, with the following results : E. erythematosum...........228 cases. E. vesiculosum..........127 cases. " fissum................... 40 " " vesico-papulosum......127 " ' papillosum..............171 " " verrucosum........... 3 " " pustulosum ..............116 " "of mixed type .......106 " " rubrum ................ 185 " Type not recorded (but " squamosum ..............170 " presumably mixed) ...121 " The face was the common site for the erythematous type the hands for the fissured form, the legs for eczema rubrum, the neigh- borhood of the ankles for the verrucous, and the scalp or parts of the head for the pustular ; in the other types there was decidedly less predilection shown, or not sufficiently so to deserve particular remark. The part of the body most frequently the site of the Under 5 years . .. 203 cases. Between 5 and 10 " ..74 " " 10 " 15 " .. ..55 " 15 " 20 " .. ..82 " " 20 " 30 " . ..235 " 9 disease, without regard to type, was the face, the legs coming next in order of frequency,' and the hands following, as here shown : ="ace........................195 cases. Face and hands.......... 21 cases. Legs.......................1!)4 " Ears..................... 20 " Hands (palms alone, 16)......189 " Neck..................... 18 "' ScaJP...................... 97 " Hands and feet............' 10 " Scalp and face............... 62 " Lips.................. 9 " Genitalia...................61 " Anus"..'.'.'.'.'.'.'.'.'.'.'.'.'...... 6 " Arrms...................... 4:; « Nares.................... 4 « Hands and forearms......... 39 <; Buttocks.................. 4 " irunk..................... 36 Several or more regions.... 222 " Arms and legs ............. 32 •' Site not recorded..........105 " I'eet .......................27 " In many of the hand cases occupation was a potent factor ; in others it was difficult to point to any external agency as a possible exciting cause. The most common predisposing causes, which, indeed, in some cases seemed to be the active exciting factor or factors, lay in the digestive tract, consisting-of errors of digestion or assimilation, or both. A family history of gout or rheumatism was often obtainable. In many cases, too, it was clearly evident that the causative element was a temporary or permanent nervous or physical breakdown. That in a proportion of the cases the disease was due, in part, at least, to reflex influence, as, for instance, in the teething in infants, etc., was scarcely to be doubted. In the treatment of the disease several factors had to be con- sidered, such as the circumstances of the patient, the location of the disease, the ability to carry out certain lines of medication, and occupation. Expensive methods, it need scarcely be said, were impracticable. It may be remarked here that in no single instance was the palliation or cure of the disease followed by any other re- sult than that of great relief; this would ordinarily not have been worth stating, but recently there has been a tendency in certain quarters to ascribe dire results, in some instances, to the cure of the skin ailment. In the treatment various new therapeutic agents were tried from time to time, but very few proved worthy of a permanent place. Resorcin, ichthyol, thymol, beta-naphthol, aristol, and some of the manufactured plasters and lanolin, may be mentioned as among the more recent drugs or preparations as being of proved value. The character of the external treatment was based, irrespec- tive of the duration of the disease, upon the degree of inflamma- tory action. In those cases in which the disease was acute, or of an acute type, boric acid lotion, with a supplementary mild ointment, played an important part; the same may be said, less emphatically, however, of lotio nigra, and the supplementary use of an ointment; of a calamine and oxide of zinc lotion ; of a weak thymol lotion, J4 to i grain to the ounce; of resorcin lotion, j4 to 5 grains to the ounce ; of a compound ointment of calamine— calamine i drachm, salicylic acid io grains, starch i drachm, with equal parts of zinc ointment and vaselin to make up the ounce. Lassar's salicylic acid paste was also frequently used with benefit. In some long-continued cases of a mildly acute type, and in those of a subacute type, stronger lotions of resorcin; of thymol ; liquor carbonis detergens, with several or more parts water ; white precipitate ointment, 5 to 30 grains to the ounce ; calomel oint- ment, 5 to 30 grains to the ounce ; an ointment of tar and zinc—a IO drachm of tar ointment, or a half to one drachm of oil of cade to the ounce of zinc ointment; salol ointment, 5 to 20 grains to the ounce ; ichthyol washes and ointments, 2 to 10 per cent, strength ; were variously used. In chronic, sluggish cases pure tar ointment; beta-naphthol ointment, 20 to 60 grains to the ounce ; calomel or white precipitate ointments, 40 to 100 grains to the ounce ; pyro- gallic acid ointment, 5 to 60 grains to the ounce ; chrysarobin oint- ment or plaster, 1 to 6 per cent, strength ;— were among the most valuable remedies. In stubborn, thickened patches, and in cases of eczema rubrum of the leg, in which there was marked infiltration, Hebra's method of shampooing with sapo viridis, supplemented immediately with a mild ointment applied as a plaster, should not be forgotten. Some of the manufactured plasters of tar, salicylic acid and other stimulating drugs were found useful in a limited number of cases of chronic thickened scaly or verrucous patches. The constitutional treatment prescribed rested entirely upon a study of the predisposing conditions and of the individual patient's needs. The experience of this Dispensary, like that of others, has failed to find any constitutional remedy having a specific value. Arsenic, when prescribed, was usually given in small doses, and for its tonic and alterative effect, and not with the belief that it had in itself, except in rare cases, any specific influence over the disease. There were especially two lines of constitutional treatment which were most frequently prescribed and to which recovery could often be clearly traced : one consisting of salines, mild laxatives, mild alkalies, such as sodium bicarbonate and sodium salicylate, salol, the vegetable bitters and digestives ; the other of small tonic alterative doses of arsenic, strychnia, quinia, iron and the nutritive tonics. Of the nutritive tonics cod-liver oil is deserv- ing of special mention. Epithelioma.—In all, 27 cases came under treatment—10 males and 17 females. Excepting one case, all were of the super- ficial type. Of these patients, only 7 were under the age of fifty ; between fifty and sixty there were 7 cases, and over sixty there were 13 cases. The youngest patient was aged thirty-five, and presented a small lesion of six months duration over the left eye- lid. The duration was noted in only 11 cases, and in these it varied from six months to ten years. As to the site of the disease, in 12 cases it was the nose, either upon theala, side or bridge ; in 4' under the right eyelid ; in 1, under the left evelid ; in 3, on the cheek ; in 2, close to the ear ; in 1, on the ear; in 2, on the fore- head ; in 1, on the left side of the vulva ; and in one, on the back of the hand. The treatment selected depended upon the size and location of the lesion, and to some extent upon the patient's inclinations. It consisted in the use of a plaster of resorcin or pyrogallic acid, two drachms to the ounce, applied continuously for from one to several weeks ; in the use of an arsenical paste made up of one part of arsemous acid to two or more parts of acacia, and sufficient water • in excision ; in curetting, followed by cauterization with caustic potash, or a few days' use of the pyrogallic acid plaster The surest results as regards permanence may, upon the whole be said to have followed the methods of treatment by excision' and bv arsenical paste. y II Erythema Multiforme.—Forty-three cases of this disease, or a proportion of about i per cent., were observed—22 males and 21 females. Of the types of the eruption met with, 15 cases exhibited the papular, 13 the multiform, 2 the annular, 1 the con- figurate, 4 the herpetic and bullous, and one the nodose ; in 7 cases it was not noted. As regards the site of the eruption, in 8 cases it was upon the back of the hands and forearms; in 6 on the forearms, hands and face; in 3 on the forearms, hands and neck ; in 2 on the forearms, hands and trunk ; in 7 on the arms and legs, more especially the lower portions; in 2 on the trunk ; in 1 on the face and limbs ; in 1 on the face ; in 10 it was more or less general; and in 3 it was not recorded. The eruption occurring upon the backs of the hands and forearms was almost invariably papular or papulo-tubercular, and this was even so in generalized cases when the eruption elsewhere was multiform. In two of the bullous cases the eruption was wide-spread, but that upon the trunk was erythematous and multiform, while that upon the hands and forearms, and to a less degree that upon the face, developed rapidly into bullae ; in the third and fourth bullous cases, the eruption in the former was limited to the backs of the hands and forearms, and in the latter mainly to the trunk and upper arms, and was made up of patches of one or several concentric erythe- mato-vesicular, vesicular and vesiculo-bullous rings—so-called herpes iris. In the nodose case—erythema nodosum—the patient was a boy of thirteen, and the eruption, consisting of a number of typical erythematous erysipelas-like nodes and swellings, and a few papules and rings, was seated upon the forearms and tibial sur- faces. In a number of cases there were no subjective symptoms, but this cannot be said of all; itching, it is true, was never an urgent symptom, but in some cases, especially in the beginning disease, it was sufficiently annoying to be the subject of complaint. In but few instances was there any constitutional disturbance, and this consisted of a light febrile action preceding or accompanying the early part of the attack, gastric uneasiness, and in one or two instances a slight tendency to rheumatic pain and swelling of one or several of the larger joints ; the systemic symptoms were most marked in the case of nodose erythema. The duration of the disease in the cases here tabulated, varied from a week or so to one or two months, the longer duration being due more to fresh outbreaks than to persistence of the original efflorescences. The average duration was probably about two to three weeks. A study of the cases sheds but little light upon etiology. Sex was not a factor ; and although 19 of the cases were seen in the spring, season did not have the predisposing influence usually credited to it, as in the winter months 9 cases were met with, in the summer 12 cases, and in the autumn but 2 cases. Age had apparently some influence inasmuch as 35 of the cases occurred in patients under the age of thirty, as will be seen by the following : Under 5 vears ............... s cases. Between 30 and 40 years ... 3 cases. Between 5 and 10 years...... 1 " " 40 " 50 ' --- 3 " " 10 '' 15 " .......10 '• " 50 "60 •' ---0 " " If, -'20 " ......5 " Over 60 years ............. 1 " " 20 " 30 " .......12 '• 12 The youngest patient was aged fifteen months, and exhibited the multiform type upon face, trunk and limbs ; the oldest was sixty-five, and presented the papular variety upon the backs of the hands and wrists. It is questionable whether treatment had any influence what- ever ; so far as could be judged saline aperients, antacids, and quinia had in some instances a good effect. External treatment, except in the bullous cases in which mild protective applications were made, was seldom called for. Furunculus.—Under this head were recorded 34 cases, 22 males and 12 females. There were 13 patients in whom the lesions, singly or in numbers, continued to appear from time to time for several weeks or months—furunculosis. The remaining 21 cases were examples of an individual lesion or group of lesions running an average course and disappearing. In the cases here tabulated the disease was by far most frequent in infancy and early childhood, in such patients being commonly associated with or following along with miliaria ; the conditions which cause this latter undoubtedly favoring furuncular infection. There were 13 patients under five years, 8 between five and ten, and but five above thirty years. As to treatment the most successful seemed to be the follow- ing : In ordinary cases where the lesion was single, the dressing consisted of a 15 to 20 per cent, ichthyol ointment continuously applied ; to a group of lesions the same treatment was used, or the parts were soaked with a saturated solution of boric acid and before it dried on, freely sprinkled with a boric acid powder, and then covered with clean linen or a bandage, the dressing being repeated once or twice in the twenty-four hours ; in some cases instead of a boric acid wash, a lotion of resorcin 5 to 30 grains to the ounce was advised. In those cases in which suppuration was well advanced and pointing had taken place, the lesion was first incised and then treated as above detailed. In furunculosis, in addition to these external applications, constitutional treatment was prescribed ; and it was the line of treatment—always of a tonic nature—rather than any special remedy which brought recovery. Herpes Zoster.—This disease was observed in 28 instances a proportion of a little less than 0.7 per cent. There was a large preponderance of males, 21 being of this sex, while but 7 were females As judged by these cases, season had apparently but little influence. All ages were noted ; although it was most com- mon during the age of active adult life, five of the cases occurred in those under ten years of age, and five in those over sixty Out of 23 cases, in which it was recorded, the disease was upon the left side in 13 instances, and on the right in 10. As to particular region affected, there were : p dr Z facialis . . ........... 4 cases. Z. dorso-abdominalis..... •> caSes occipdo-collans ..... 3 " " lumbo-inguinalis . " £ CafkeS cervico-subc aviculans..... 2 • •' lumbo-femoralis. . ' "1 <■ cervico-brachiahs........ 1 •• Site not recorded . . ......1 « dorso-pectoralis.......... 13 '• ....... *3 While precursory neuralgic pain was a common symptom, it was by no means noted in all; in most cases the pain was con- comitant with the eruption, and it was more of the nature of a soreness than of a neuralgic character. The course of the disease, in all these cases, was favorable, recovery taking place in ten days to several weeks. In most of the instances, the disease was attri- buted to exposure to cold or wet. In one instance, the outbreak occurred while the patient was taking moderately large doses of arsenic for another disease. The object of all local treatment was the protection of the affected region, and consisted variously of the free use of a dusting powder, over which was placed a layer of cotton ; of salicylated oxide-of-zinc ointment applied constantly as a plaster ; and in those instances in which the disease was of an abortive type, the lesions scarcely reaching active vesiculation, a simple covering of cotton or patent lint was advised. In sore or neuralgic cases, an ointment containing small quantities of opium and cocaine was spread over the parts. In a few abortive cases, the protection was afforded by coatings of flexible collodion. Constitutional treatment, outside of special indications, con- sisted in the administration of phosphide of zinc and quinia, and, when needed, narcotics. Ichthyosis.—But 13 cases of this affection—about 0.3 per cent.—came under observation ; 6 males and 7 females. Of the 13 four were of foreign birth. In 3 cases the mild form of the Ichthyosis. disease was presented, in 5 cases the moderately well-developed, and in 5 the well-marked type. In all it had dated since infancy or early childhood ; the oldest patient coming under notice was aged sixty-eight. In one instance a brother of the patient had the same disease. The treatment which gave the greatest alleviation con- 14 sisted of daily or tri weekly plain warm or alkaline baths accord- ing to the severity of the case, with the supplemental use of a salicylated ointment, 2 to 5 per cent, strength. In two or three of the more severe cases a small quantity of precipitated sulphur, 10 to 30 grains to the ounce, was added to the ointment. The most satisfactory ointment base was that made up of equal parts of lanolin, vaselin, and lard. Impetigo Contagiosa.—This disease was seen in the pro- portion of 3.3 per cent. —138 cases. Of these 87 were males, and Impetigo Contagiosa. It occurred more frequently during the warm months t was, as is well known, essentially a disease of 51 females. of the year. early childhood, as the following shows : Under > years ...............84 cases Between 5-10 years ..........29 " " 10-15 " ........... 9 " Between 20-30 years....... 5 cases 30-40 " ........ 5 « Age not noted.............. 6 " • In ? few cases- more especially when the eruption was exten- sive and widely distributed, slight malaise and transitorv febrile action were reported as having ushered in the outbreak. In manv instances the disease ran through the children of a family one after another; while m other families several would be attacked simultaneously. The site of the which it was noted was as follows Face........................49 cases. Face and hands.............12 " Face and limbs ........ .....6 " Face and scalp .............. 5 ■ <■ Face, scalp and hands.......5 '• Face, hands and other parts .. 4 " Face and trunk.............. 3 " Face and buttock ............ 3 ■• Face and feet .............. 1 << Legs ....................... 3 « eruption in the 103 cases Trunk and legs............. 2 in Trunk and limbs Hands and neck. . %. Hands and buttocks Scalp ........... Buttock........... Limbs ........... Distribution more or less general ................ 4 15 In two cases, in addition to the eruption on the skin, one or several lesions were to be seen upon the conjunctiva ; these disap- peared, however, without trace. In several infants, and in one or two older children, the eruption was distinctly pemphigoid. In a few cases also some lesions, especially upon the legs, assumed an ecthymatous character, the eruption elsewhere being of the ordi- nary type. Subjective symptoms beyond a slight soreness were in many cases absent; in the majority, however, itching, variable as to degree, was noted. Although the disease usually ran an acute course of one or two weeks, disappearing spontaneously, making it difficult to measure the effect of medication, yet it may be stated that treat- ment had a positive influence. That which gave satisfactory results was either an ointment of white precipitate, 10 to 20 grains to the ounce, or a similar ointment containing 5 to 10 grains each of the white and the red precipitate to the ounce ; it was well rubbed into the lesions, the crusts, if possible, having been first removed with washings of warm water and soap. In cases markedly itchy, and in which, therefore, excoriations were pro- duced and the disease kept up by auto-inoculation, in addition to the above application to the lesions themselves, a lotion of boric acid, with } •_> to 1Y2 drachms of carbolic acid to the pint, was applied to the parts generally. Lichen Planus.—Fourteen casses of lichen planus were recorded, 10 males and 4 females. The youngest patient was aged twenty-two, presenting the eruption on the flexor sides of the forearms ; and the oldest was aged seventy-two, showing the eruption upon the hands and forearms, mainly on the dorsal aspect. All ages between these extremes were about equally rep- resented. The disease was of the ordinary type; in a few instances the papules were hypertrophic. The eruption was, with the exception of one or two cases, limited in extent; seated upon the upper extremities, especially the forearms, in 4 cases ; upon the lower extremities, more particularly the region of the ankles, in 4 cases ; the trunk in 2 ; arms and legs in 1 ; trunk and fore- arms in 1 ; and in 2 it was not noted. The previous duration varied from several months to a year or longer : in 2 cases there was a history of recurrences. It may be said that constitutional treatment, consisting of arsenic, quinia, strychnia and other tonics, had a positive influence. The external treatment was chiefly by resorcin lotions or ointments, 2 to 10 per cent, strength ; tarry lotions, especially the liquor carbonis detergens ; thymol lotions, and tarry ointments. Lupus Erythematosus.—This disease was not common, although more so than lupus vulgaris. Nineteen cases, or a pro- portion of less than 0.5 per cent., were observed ; females largely predominated, this sex being represented by 15 cases. Eight of the 19 cases were of foreign birth, 5 of Irish, 2 of Scotch, and 1 of German. With the exception of a few cases, which presented a diseased area covering the nose and extending partly over the cheeks, the eruption was slight in extent and of a mild superficial type, consisting of two or three dime to quarter-dollar-sized patches. i6 The previous duration varied from a few months to four years. The youngest patient was a woman aged twenty-one, and from this age up to thirty the largest number, 9 cases, were met with : the oldest patient was aged sixty-six. The nose was the site of the disease in 5 cases ; the cheek in 5 cases ; the nose and cheeks in 3 cases ; in the remaining cases there were two or more small scattered patches over different parts of face. The eruption was not seen outside of the face limit, except in one case, which, in addition to a patch upon the chin, presented a patch upon the scalp also. Nothing was learned as to etiology. The main treatment was external, although in a few cases advantage seemed derived from the administration of cod-liver oil, and from phosphorus. The most valuable external applications were : A lotion of a drachm each of zinc sulphate potassium sul- phide to four ounces of water ; sulphur ointments ; tarry ointments and oils; salicylic acid ointments ; ichthyol ointments and lotions, of ■ from 5 to 50 per cent, strength ; resorcin lotions, of from five to sixty grains to the ounce ; pure carbolic acid ; and painting with a col- lodion solution of pyrogallic acid, of from ten to sixty grains to the ounce ; and finally, in suitable cases, linear scarification, and the curette. Lupus Vulgaris.—Tuberculous infection of the integument was seen in 16 instances, in 6 males and 10 females. Of these Lupus Case. cases 11 represented the clinical type usually designated 1,,™ 3 cases the clinical type commonl/known as scrZodermaP"he i7 disease having had its beginning in a breaking down of one or several of the lymphatic glands ; and in 2 cases the so-called small papulo-pustular scrofuloderm described by Duhring some years ago was presented. Three of the patients were of foreign birth. In 6 of the lupus cases the disease had appeared before the tenth year, and in 1 as early as the second year of life ; in only 3 instances did the disease appear after the age of twenty-five. The previous duration varied in the 16 cases, from six months (scrofu- loderma) to ten or more years. The disease was, as a rule, slight in extent, and in all instances, except 4, limited to the face or con- tiguous part; even in the two cases of superficial scrofulous ulcera- tion beginning in the cervical glands, the disease had encroached slightly on to the face. One case especially deserving of note here involved the tip, right ala, and side of the nose, appearing as a mush-room-like ulceration. * The most extensive case was in a boy of fifteen, the disease of years' duration, presenting several large areas on the face, leg, and arm, spreading peripherally like a syphilide. The treatment consisted variously of the continuous applica- tion of pyrogallic acid plaster, of from 20 to 25 per cent, strength ; arsenical paste ; curetting, supplemented either with a momentary cauterization with caustic potash, or several days' use of pyrogal- lic acid plaster; and excision. In these cases, as in all lupus cases, the disease exhibited a strong disposition to recurrence. The constitutional treatment was based on indications; in many cases it was not prescribed at all, while in a number cod-liver oil was advised, with, in a few instances, decided benefit. Molluscum Contagiosum.—The record of the Dispensary shows a total of 30 cases ; 25 of these were really seen at one of Molluscum Contagiosum. * This case is reported in full in the Journal of Cutaneous and GenitO' Urinary Diseases for November, 1H>2. i8 the "Homes for Children," but belonging to the dispensary class they were recorded in connection with this service. Of the thirty cases, 20 were females. Those visited at the "home," varied in ages from three and a half to eight years, and were seen on two different occasions, 13 at one time, and 12 some mouths or a year later, occurring as two separate and distinct sets of cases, and in a manner to strongly support the belief in the contagiousness of the disease.* The other cases may be here referred to briefly. In one instance a girl of twelve years exhibited several lesions upon the hip, thigh and back, and later upon the face; at the same time, according to the patient's statement, her sister had a single lesion on the thigh, and her father one upon the neck ; several months afterward her mother appeared at the Dispensary with a character- istic lesion upon the eyelid. The youngest patient was a child of one and a half years, with two large and four small lesions in the fold of the neck ; a brother, the mother stated, had four or five similar lesions several months previously. In the remaining cases, one a boy of six years, there were about thirty lesions scattered over the face, of one to two months' duration ; and the other, a boy of the same age, there were eight or nine lesions upon the chin, of five weeks' duration; in neither of these cases was there a history of contagion. Experimental efforts at inoculation, beyond the production of small inflammatory papules, in no way significant, were unsuccessful. Many of the cases, in fact almost all, tended after a time to spontaneous recovery. In many a mild mercurial ointment, white precipitate ointment usually, vigorously rubbed in, was used ; lesions in which there was a tendency to pedunculation were either snipped off or a ligature thrown around them ; and in a few obstinate and large-sized lesions a puncture, followed by a light cauterization with the stick of silver nitrate, or with carbolic acid applied by means of a pointed stick, was made. Morphcea.—This rare disease was seen in 3 cases, the brief notes of all of which are here appended : Case 1.—A woman aged 39, housewife, of American birth, came under observation in June, 1880. On the right side of the breast, on the mammary gland, midway between the nipple and axillary line, was a patch of skin, brownish yellow in color, smooth, somewhat raised ; glistening and waxy in appearance, hard and leathery. It was irregularly oval in shape, two and a half inches in its long, and one inch in its transverse diameter. It looked not unlike an inlaid piece of ivory or bacon. At the right border there was a small, tongue-like elongation, extending toward the axilla, and presenting the same characters as the body of the patch. The border of the patch was somewhat pinkish. Sensibility was about normal. It had been coming for about a year, beginning as a small, red spot. Considerable burning and pricking, and at times "burns like fire." Recently she had noticed that the skin of the arm of that side was painful at times, but there was nothing to be seen • but on the forearm, on the extensor surface, there was a dime-sized, red, uneven spot at points slightly hard, presenting, according to the patient's statement the same appearance as had been original ly presented by the patch on the breast Family history cancerous, but otherwise good. General health was good 'Fowler's solution was prescribed in two to three minim doses three times daily The *See paper by the writer in the " Journal of Cutaneous and Genitn-TTrinarv Diseases," for February, 1889. Benito-Urinary 19 patient was not seen till some months later, when she returned to say that she had taken the' solution for two months continuously, during which time the disease had begun to disappear, and at the end of three months no trace was left. It will be noted that during the third month no medicine was taken. '.. Case 2.— Woman aged :«, millhand, of American birth, applied for treat- ment in September, 1hn:>. On the left side of the face toward the nose, was a quarter-dollar sized, whitish and hard, ivory-like patch, surrounded with an erythematous halo. It had begun to make its appearance twelve months Morphoea. previously, its progress being steady but slow ; during the past few months, however, it had been apparently stationary. There was no special change in sensibility. General health was good. The case was under observation and treatment one month, treatment consisting of the administration of arsenic. At the end of this time there had been no change in the appearance of the patch (Vr.s( 3,—A woman, aged 40, housewife, of Irish birth, came under notice in February, 1887. An examination disclosed a hard, whitish, waxy, inlaid- looking patch on the front part of the leg; oval in outline, long diameter up and down of six to seven inches, and transverse diameter of two inches. It was somewhat hard and inelastic to the touch. Another patch much smaller in size, but of the same general characters, was on the outside of the same leg. There 20 was no marked change in the sensibility of the affected areas. It had been of about two years duration. The subjective symptoms had been nil. In several parts of the larger patch there was a decided tendency, here and there, o destructive changes. The disease was sharply defined against the healthy skin by a narrow band of pinkish coloration or hyperemia. Ihe case was under observation about one month, the treatment being arsenical. In tins time m was thought a slight change for the better had taken place. Pediculosis.—This condition was represented by 185 cases, a proportion of 4.5 per cent. Of these there were 83 cases of pediculosis capitis, 97 of pediculosis corporis, and five of the pubic variety. As to sex,-"in the aggregate they were about evenly divided, but there was great diversity in this respect in the several varieties of the disease ; thus, in the head variety there were 15 males and 68 females ; in pediculosis corporis, 69 males and 28 females ; and of the five cases of the pubic variety, all were males. A study of age, as related to variety, disclosed the following : Head. Body. Pubes. Under 5 years, 13 cases. Between 5 and 10 '" 32 '" 2 cases. " 10 and 15 " 28 " 1 " " 15 and 20 " 5 " 3 " " 20 and 30 " 2 " 26 " 3 cases. 30 and 40 " 2 " 17 " 2 " 40 and 50 " 1 " 17 " " 50 and 60 '" 15 " Over 60 " 16 " Another fact of interest disclosed was that a large proportion —68 cases—were of foreign birth, many of recent immigration. Season evidently had an influence, for whereas during the cold months between October and April, when huddling together and infrequent washing prevail, 111 of the cases were recorded, while in the other months, when crowding is apt to be avoided and ablu- tions of greater frequency, but 74 cases came under notice. Treatment of head-lousiness was usually with applications of either strong carbolic acid lotions, white precipitate ointments, oleate of mercury ointments, beta-naphthol ointments, or crude petroleum ; subsequently or concurrently, frequent washings with alkaline lotions or vinegar or dilute acetic acid, with or without a minute quantity of corrosive sublimate. In body-lousiness, bak- ing or boiling the apparel was directed, and carbolic acid washes prescribed ; in those cases in which proper attention to the cloth- ing was improbable, strong carbolic acid washes, ointments of sulphur, or sulphur and beta-naphthol, or an ointment of stavesacre were advised. In pediculosis pubis, oleate of mercury ointments' beta-naphthol ointments, weak washes of corrosive sublimate and water or dilute acetic acid, were variously advised. Pruritus.—Of this disease, 136 cases were observed, a propor- tion of 3.3 per cent.; of these, 89 were males, and 47 females. In this number were included 4 cases of so-called pruritus hiemalis In 92 patients, the itching was general ; in 11, it was limited to the legs; in 10, of whom seven were males and three females to the genitalia; in 7, to the anus ; in 4, to the scalp • in 4 to the trunk; in 5, to the arms and legs, and in 3, it was not noted. Season had apparently, on the whole, but comparatively 21 little influence ; 43 cases came under notice in the first three months of the year, 40 in the second quarter, 27 in the third, and 26 in the last three months of the year. The disease was observed, as is well known, more frequently in advanced life, as is shown in the appended table : Under 20 years.............. 4 cases. Between 40 and 50 years......20 cases. Between 20 and 30 years......20 " " 50 and 60 " ......22 " 30 and 40 ,l ......25 " Over 60 years................45 " As to etiology, in a few instances, diabetes or albuminuria was the suggestive factor ; in many, gastric and intestinal indigestion ; in some, the lithic acid diathesis ; but, in the large proportion of cases, it was difficult to find any explanation of the pruritus beyond the acceptance of some obscure functional perversion of the cutaneous nerves Constitutional treatment was varied according to indications ; in many cases, free action of the bowels, some regard to diet, and the administration of an alkali, such as the sodium or lithium salts, had a curative influence. Small doses of atropia sometimes acted quickly. Among the most valuable of external applications advised, may be mentioned—carbolic acid lotions, thymol lotions, resorcin lotions, liquid carbonis detergens diluted with several or more parts water, and alkaline lotions. In those cases of pruritus of the legs, in which the skin was harsh and dry, relief was afforded by mild salicylated ointments. In the localized forms, cocaine and menthol ointments and lotions were of value. Psoriasis.—Of this disease, 155 cases or a proportion of 3.7 per-cent. were recorded. The sexes were about evenly divided, 75 males and 80 females. Forty-three patients were of foreign birth. The earliest age at which the disease had appeared was between two and three,* and the oldest patient presenting the eruption for the first time was aged sixty. The disease was by far most commonly seen in those between the ages of twenty and forty ; only 10 patients were seen over the age of fifty, and in almost all of these the disease had long existed, or there had been previous attacks. The following table shows the ages of patients : Under 5 years. .. 4 cases. Between 35 and 40years.....18 cases. Between 5 and 10 " ... 12 " " 40 " 45 " ..... 9 " " 10 " 15 " ... 12 " " 45 "50 " ..... 7 " " 15 " 20 "... 17 " " 50 " 55 " ..... 6 " " 20 " 25 •' . 27 • " 55 " 60 " ..... 1 " 25 " 30 " .....19 " Over 60 " ..... 3 " 30 and 35 " .....20 " Season had, as is commonly known, an influence, but not so strikingly, judging from these cases, as generally assumed ; 46 patients applied in the months of January to April, 40 between April and Julv, 31 between July and October, and 38 between October and January. As to the forms of the eruption, the ordinary type, consisting of variously sized patches, chiefly dime to dollar size, was usually met with ; but in 10 cases the patches remained small, being for the most part small pea-sized—psoriasis guttata ; in five cases the patches were mostly circinate ; and in 5 the eruption was more or less diffused. •See case reported in the " Medical Times," April 23, 1881. 22 In 19 cases the scalp exhibited the disease, in nine of which the eruption was limited to this region ; in the other ten the erup- tion was upon other parts as well, either to a slight or great extent. In one case the disease was limited to the scalp, finger ends and fingernails. In 12 cases the disease was confined to the extensor surfaces of the elbows and knees ; in 25 other cases these parts shared in the general eruption, being to a greater or less extent invaded ; but in the remaining cases, by far the greater Psoriasis. number, no special predilection was shown for these regions. In 40 of the patients it was the first attack ; in the remaining number, 115, advice was sought for a recurrence, or for a long existing eruption. In one patient, a woman aged thirty-two, in whom the disease had existed off and on for some years, it always reappeared while nursing a child. In two instances, two cases in the same family were recorded ; in one a father and son, and in the other a mother and daughter. As to etiology, nothing new was learned • heredity was often a factor, and in some cases debilitating influences ; m others there appeared to be a relationship to the goutv or rheumatic diathesis. As a rule, however, the patients were seemingly in good general health. The treatment usually prescribed was both constitutional and local. For the former, the chief remedies were arsenic, liquor 23 patassae, potassium iodide, potassium acetate, tar and oil of copaiba ; and in certain cases tonics, especially cod-liver oil. The most valuable of these were arsenic and liquor potassse, the latter being particularly so in the markedly inflammatory type occurring in robust patients. Arsenic was an exceedingly useful remedy in first attacks and in patients in whom the disease had been of long duration, but who had never been systematically treated ; in recur- rences and in patients who had previously taken the drug freely it was without much, if any, value. In the external treatment, plain or alkaline baths, chrysarobin, pyrogallic acid, tar, beta-naphthol, aristol and white precipitate were variously employed. In certain cases of mild type of eruption, even though more or less extensive, a daily alkaline bath, followed by a tolerably vigorous application of a salicylated ointment (10 to 30 grains to the ounce), often sufficed to remove the disease. Chrysarobin was used either as an ointment or collodion paint, 5 to 20 per cent, strength ; pyrogallic acid, as an ointment or paint, 5 to 10 per cent, strength; tar, either as the officinal tar ointment, full strength or weakened, or as an oil, for this latter purpose using the oil of cade, either pure or with one or two parts of alcohol; beta-naphthol, as an ointment, 20 to 60 grains to the ounce ; aristol, as an ointment, 5 to 15 per cent, strength ; and white precipitate, as an ointment, 40 to 100 grains to the ounce. In the experience of this Dispensary tar was the most generally applicable and useful external remedy ; chrysarobin was valuable and often rapidly curative, but it has certain known disadvan- tages which make it an unsafe remedy for general use in this class of patients. Sifting the evidence made by the use of these various local remedies, it may be said that those giving the best results were tar, chrysarobin and white precipitate ; beta-naphthol and aristol, while useful in some cases, did not compare in value to the others named. Purpura.—Of this disease, 16 cases were seen—9 males and 7 females. In all, the disease was of the milder type, without, as a rule, any constitutional symptoms, and without, too, any adequate explanation for the outbreak. Ten of the cases came under notice during the months of April, May and June. The youngest patient was aged four months, in whom the disease.had made its appear- ance two months previously and consisted when seen of fifteen to twenty patches scattered over face, trunk and limbs ; the general condition was good. The oldest patient was a German, aged fifty- seven, in whom the disease had lasted for five weeks and presented the ordinary patches over legs and thighs. In one case, a man aged forty-four, the eruption was chiefly confined to the trunk, and the patches, which were numerous, showing, for the most part the circinate or annular form.* This circinate tendency is not, judged by the cases here tabu- lated, so uncommon as has been supposed, as in two others in whom the eruption was upon the legs and thighs, the patches on this latter region displayed this same character. The site of the eruption *Reported in the "Journal of Cutaneous and Genito-Urinary Diseases,'* October, 1887. 24 was in 8 cases upon the legs ; in 3 upon the legs and forearms , in 2 it was more or less general in its distribution ; in 1 mainly upon the trunk ; in 1 on the forearms, and in 1 was not recorded. 1 ne previous duration, as a rule, varied from several weeks to a year or more ; in one case the patches had been making their appearance, at irregular intervals, for six years. The remedies employed were chiefly ergot, the oil of erigeron Canadensis, and the tincture ot the chloride of iron. Scabies.—Of this disease, 372 cases—9 per cent.—were met with. In the first several vears covered by this report this disease was rather infrequent, but during the latter period it became one of the most common. For instance, dividing these cases into five hundreds,—in the first five hundred, 13 cases; in the second, 11 cases ; in the third, 24 cases ; in the fourth, 28 cases ; in the fifth, 78 cases ; in the sixth, 67 cases ; in the seventh, 64 cases ; in the eighth, 56 cases. This number, too, is merely representative of a much larger total, inasmuch as a single patient often represented a family of several or more persons, only such as actually presented themselves at the Dispensary being recorded. As regards nation- ality, in the first half of the cases appeared only three patients outside of American, Irish, English and German birth ; while in the second half there was a large sprinkling of Italians, Russians, Hungarians and Poles. In a number of instances the disease was contracted on shipboard ; and in many, also, its spread in a family could be distinctly traced to the return of a child or infant who had been temporarily placed in a "home " or " asylum." In fact, this latter may truly be said to be a prolific propagating centre for the disease. The disease was much more frequently met with in the cold season, this doubtless due to crowding or closer contact in beds and less frequent ablutions. The record shows that between October and April 247 cases were observed, whereas during the warm months but 127 cases came under observation. Age probably exercises but little influence, except so far as at certain ages one is more frequently exposed to contagion. Thus, between the ages of fifteen and thirty the greatest number were seen—171— although in the first fifteen years of life the number was not small, 123 cases. As to treatment, with some few exceptions, a routine plan was adopted, modified somewhat by age. Thus, in children under the age of five years, an ointment consisting of y2 drachm of sulphur, 1 drachm of balsam of Peru, to the ounce, was prescribed ; to those over this age and under fifteen, and also in adults of irritable skin, the proportion of sulphur was increased to 1 drachm or ly? drachms ; to those over the age of fifteen, an ointment con- sisting of sulphur, 2 to 3 drachms ; balsam of Peru, 1 drachm ; 15 to 30 grains of beta-naphthol. to the ounce, was directed. A pre- liminary bath of hot water and soap was ordered, and six applica- tions of the prescribed ointment, at twelve-hour intervals, made thoroughly to the entire surface below the chin line ; a half-day or a day after the last application another bath was advised and a complete change of linen. In the better class of patients this one course sufficed ; in others less careful or less thorough, one or two abbreviated repetitions, at the end of a week or ten days, were found necessary. In the less cleanly class, also, in addition to the 25 ointment, a powder of sulphur was given for sprinkling in the beds, etc. In those cases in which the eczematous irritation persisted after there was every reason to believe that the scabies itself had been cured, a lotion of a saturated solution of boric acid, with i to 3 drachms of carbolic acid to the pint, to which were added a drachm of glycerine and a half-ounce of alcohol, had a happy effect. Seborrhcea.—Of this disease, 125 cases, or 3 per cent., were recorded 64 males and 61 females. The type of the disease was in 3 instances oily, in 54 dry, in 51 mixed, and in 17 it was not noted. The part affected was the scalp in 69 patients, the face in 31, the sternal or interscapular region in 4 patients, the scalp and face in 15, and the scalp and breast in 6. Falling of the hair was especially complained of in 10 cases. The ages of the patients are here shown : Under 10 years--- 24 cases. Between 40 and 50 years___ 13 cases. Between 10 and 20 " ___30 " " 50 " 60 " ___ 6 " " 20 " 30 " .... 34 " Over 60 " .... 3 " " 30 " 40 " .... 15 " It was by far most frequent—56 cases—between the ages of fifteen and thirty. In many instances the patients seemed other- wise in good health. On the other hand, in a large number the seborrhceic condition fluctuated with the patient's well-being. Resorcin lotions, alcoholic or aqueous, 10 to 25 grains to the ounce ; thymol lotion, j4 to 2 grains to the ounce ; an ointment containing 5 to 30 grains of salicylic acid and 30 to 100 grains of sulphur to the ounce ; an ointment of white precipitate, 20 to 60 grains to the ounce, with or without 10 to 20 grains of salicylic acid ; an ointment of oleate of mercury, 10 to 20 per cent. strength; and beta-naphthol ointment, 5 to 30 grains to the ounce, proved to be the most valuable applications. As to con- stitutional treatment, experience showed that it was not always necessary, and when called for its character depended upon a study of the individual patient's condition. Sycosis.—47 cases—over 1 per cent.—were treated. It was seen at all ages, but by far most commonly between twenty and forty, 32 of the cases having been met with in this period. The youngest case was eighteen, with the disease upon the chin, of a few weeks' duration ; the oldest was seventy-four, with the disease upon the chin and upper lip of four years' duration. In one instance—a patient aged thirty-two—the disease had lasted several years, entirely disappearing, however, when the man kept himself shaved, reappearing immediately as soon as the hair was allowed to grow. The site of the disease was the upper lip in 14 cases, in 6 of which it was immediately under the nose and associated with a catarrhal condition ; in 10 cases, it was confined to the bearded parts of the cheeks ; in 4 cases, to the chin and neck; in 4, to cheeks, chin, and upper lip ; in 6, to chin and cheeks ; in 4, to chin and lip ; in 2 instances to the chin alone ; and in 3 the site was not recorded. Previous duration varied from a few weeks to ten years. Treatment was almost exclusively local, although in debilitated subjects cod-liver oil was administered with benefit; calx 26 sulphurata may have been of service in a few cases. The impor- tant treatment, however, was external. In acutely inflammatory cases mild, soothing applications were made until the inflammatory condition became subacute or sluggish, and then in these, as well as in all other cases, stimulating remedies were employed. Those which proved most successful were : Ointments of sulphur, 20 to 120 grains to the ounce ; oleate of mercury ointment, 10 to 25 per cent, strength ; an ointment of ichthyol, ^ to 2 drachms to the ounce ; a lotion of resorcin, 1 to 6 per cent, strength ; lotions of corrosive sublimate, ;^pto 2 grains to the ounce ; and Vleminckx's solution, with 10 parts of water up to the pure solution. It was usually necessary to change, from one remedy to another, more especially from a wash to an ointment, etc. A compound ointment, consisting of 1 drachm of sulphur, y2 drachm of balsam of Peru, and diachylon ointment to make the ounce, and one con- taining 1 drachm each of sulphur and ichthyol to the ounce, were especially useful in a number of cases. Shaving daily or every second day was insisted upon, and was an essential part of the treatment; depilation was advised in those cases in which sup- puration was a marked feature, this procedure having a controlling influence in preventing destruction of the follicles. Syphilis.—The cases of cutaneous syphilis numbered 280, a proportion of 6.8 per cent.; of these, 129 were males and 151 females. In this number are included 15 cases of hereditary infantile syphilis. Of the 265 cases of acquired syphilis, there were 132 representing the early or secondary eruptions, and 133 representing the late or localized disease. Of the t3rpes of the early eruptions, 24 cases were macular, of which several were maculo-papular ; 95 papular, of which 12 were papulo-squamous, 11 chiefly moist-papular, 4 miliary-papular, and 4 annular (all four in negroes) ; 2 papulo-pustular ; 10 pustular, of which 1 was miliary-pustular, 2 large-flat-pustular; 2 decidedly rupial; and 1 generalized tubercular. In these early cases also are included 8 patients with chancre, in whom the eruption developed after they came under observation. Of these 8 cases of chancre, 3 were extra-genital—1 on the lip, 1 on the chin, and 1 on the cheek. The length of time between exposure and the appearance of the early cutaneous outbreaks, so far as can be approximately stated, varied from seven weeks to a year. In two or three cases the disease was of the malignant variety, and these were among the pustular cases, but in no instance was a fatal ending recorded. In the great majority of the cases the disease was mild and rapidly responsive to treatment. Although the various vaunted remedies brought out from time to time were experimentally prescribed, such trials merely resulted in emphasizing the value of mercury as the specific remedy. Along with this drug were prescribed, according to indications, small doses of opium, ferruginous tonics, cod-liver oil, and other nutritives. The mercurial commonly prescribed was the protiodide or the gray powder. Of the late syphilodermata the types were : In 54 cases tuber- cular non-ulcerating ; in 51, tubercular ulcerating ; in 8, gumma- tous ; in 1, vegetating; in 19, ulcers, having resulted probably from the tubercular or gummatous type, but whose early features 27 had been lost. The site of the eruption in these late eases were : Face, 43 cases ; legs, 30 cases ; arms, 16 cases ; hands, 9 cases ; trunk, 7 cases ; scalp, 4 cases; neck, 3 cases ; arms and legs, 2 cases ; feet, 1 case ; palms and soles, 1 case ; two or more regions, 17 cases. In most of" these cases the eruption appeared several or more years after the contraction of the disease, and, in so far as could be ascertained, were especially in those in whom early treat- ment had been neglected or had been of short duration. In a number of patients ten years had elapsed since the chancre, and in one case twenty years. In most of the cases of the tubercular type, especially the non-ulcerating, the eruption was sluggish, the disease pursuing a slow and long continued course ; in one instance the duration had been ten years. In many of the cases, too, there were no other discoverable symptoms, either in the present or im- mediate past. Excepting a few cases of the superficial tuberculo-pustular type, and commonly about the nose, the disease yielded rapidly to treatment. Locally, a weak mercury oleate ointment, or white precipitate or citrine ointment, was employed, and in obstinate and rebellious cases, a weakened mercurial plaster. The ordinary constitutional methods by potassium iodide and a mercurial, usually the biniodide or corrosive chloride in small doses, were prescribed. In some cases a combination of the iodides—ammonium, potassium and sodium—was found to be better borne and therefore more efficient. The dose of the iodide in the average case scarcely ex- ceeded ten grains three times daily, and in many cases five-grain doses were sufficient to bring about recovery. The mercurial was always prescribed, as the experience of this Dispensary has always been that the late syphilodermata so treated exhibited less tendency to recur than if" the iodide salt or salts alone had been given. In exceptional cases cod-liver oil and iron preparations were necessary adjuvants to the specific treatment. Tinea Favosa.—Twenty cases of favus were recorded, 15 males and 5 females ; the youngest patient was a girl of four- and-a-half years, presenting three small areas on the scalp of one year's duration, and the oldest was an Englishman, aged twenty- two, in whom the whole scalp was more or less invaded, and in whom the disease had existed since childhood. In fact, in three cases in the last named, in an Irish girl, aged nineteen, and a Hungarian, aged twenty, the disease had begun in early child- hood, and had therefore lasted fourteen or fifteen years. A study of the nationality is interesting, disclosing as it does but 4 patients of American birth ; of the others 5 were of German, 5 of Russian, 2 of Austrian, 1 of Hungarian, 1 of Irish, 1 of English, and 1 of Canadian birth. In two of the cases of American birth, too, the disease was not seated upon the scalp, but upon the general surface, and was of transitory character. In all except three cases the scalp was the seat of the disease. In these three, in one it consisted of a half-dollar-sized patch on the chin of a week's dura- tion ; in another a dime-sized and several close-lying pea- sized' patches over the sternum of five to ten days' duration ; and in the third a small patch upon the cheek of one week's duration. In these three cases the inflammatory element was quite marked ; they were, however, rapidly cured by the ordinary sulphur oint- 28 ment. The disease as it occurred upon the scalp was, on the contrary, exasperatingly rebellious to treatment; the most emca- Favus, showing the atrophic and scar-like changes. cious remedies were essentially those used in the treatment of ring- worm of the scalp. Tinea Trichophytina.—This disease—ringworm—was met with in 197 cases—4.8 per cent. The scalp was the seat of the disease in 120 cases, the non-hairy parts in 53 cases, and the bearded regions in 24 instances. In a number of cases there were patches both upon the scalp and non-hairy regions. There was both in the aggregate and individual varieties a marked preponder- ance of males, 143 being of this sex, while there were but 54 females. The following table shows the ages of patients : General Surface. Scalp. Bearded Region Under 5 years, 3 cases 54 cases. Between 5 and 10 " 17 ' 56 " " 10 and 15 [< 8 ' ' 6 " " 15 and 20 K 4 ' 1 " 20 and 30 U 10 ' 13 cases. 30 and 40 .. 7 ' 8 " " 40 and 50 [t 3 ' 3 " " 50 and 60 u 1 ' Age not Recorded 3 " 29 Tinea Circinata.—Of the 53 cases of tinea circinata, or ringworm of the general surface, 39 were males and 14 females. The disease was most common in those between the ages of five and ten years. As a rule, rarely more than two to four patches were present, but in several instances the number was as high as twelve to fifteen. All parts of the surface were apparently vulner- able, but the most common sites, in the order named, were the face, neck, and forearms. In six of the cases—all male adults—the disease was seated on the inner surface of the thighs, verging on to the scrotum, and consisted here when seen usually of one or two ring-like patches, together with a diffused sheet of inflammatory eruption with sharply-defined outlying borders, constituting the so- called eczema marginatum, or tinea cruris ; the inflammation was, however, superficial in character. Treatment was usually with one of the following applica- Favus, showing the cup-shaped crusts and atrophic changes. tions : A carbolized boric acid lotion ; sodium hyposulphite solu- tion, a drachm to the ounce ; corrosive sublimate lotion, >2 to 3 grains to the ounce ; mild sulphur and white precipitate oint- ments. In tinea cruris, a thymol and boric acid lotion, an oint- ment of sulphur, and a paint of corrosive sublimate, made up of 2 to 4 grains of the corrosive chloride to 4 drachms each of the tinctures of benzion and myrrh, were most efficacious. ftrtiiwiiML LIBRARY OF Wui\W± —^ BETHESOA 14, MO. 3Q Tinea Tonsurans—Of the 120 cases of tinea tonsurans, or ringworm of the scalp, 80 were males and 40 females. Of this number only 7 cases occurred in those over the age of ten years ; of the seven one was aged eleven, three aged twelve, one thirteen, two fourteen, and the oldest sixteen. In this last the disease occurred as a single well-defined path on the vertex. Previous duration varied from several weeks to one or two years. All stages and varieties of the disease were seen, from that of the typical rounded beginning patch to those in which almost the entire scalp was more or less invaded; only one case of kerion came under notice. The most valuable remedies were chrysarobin, 5 to 10 per Ringworm. cent, strength, either as a paint with collodion, or preferably as an ointment; oleate of mercury ointment, 5 to 25 percent strength • strong sulphur ointment, with 1 to 3 drachms of tar oil to the ounce ; oil of cade, pure, or with an equal part of alcohol • a com- pound ointment made up of 4 drachms of sulphur ointment and 2 drachms each of citrine and tar ointments, and ^ to 2 drachms of carbolic acid. It was, on the whole, more the thoroughness and perseverance with which the treatment was carried o-it than the special remedy selected which brought about results. Th- spread of the disease seemed in many cases to be controlled by frequent 3i applications of a saturated solution of boric acid containing 5 to 15 grains of carbolic acid or resorcin to the ounce ; and also by occasional soap and hot-water washings, with, according to the condition and sensitiveness of the skin, mild soap, sapo viridis, a good sulphur soap, or a naphthol-sulphur soap ; the lather was allowed to remain on from several minutes to a half-hour. In limited cases depilation was advised, and when followed out properly it was a decided aid in the cure. In more exten- sive cases the hair of the whole scalp was kept closely cut or shaved. Tinea Sycosis.—Of the 24 cases of tinea sycosis, or ring- worm of the bearded region (barber's itch), several were of the superficial type. The chin and adjoining part of the lower cheek were most commonly the seat of the disease ; in 6 instances it was limited to a single quarter-dollar-sized patch, having in two or three patients a distinctly carbuncular aspect. The upper lip was affected in one case only, and in this instance in conjunction with the disease on the chin and adjacent parts. The disease was not seen before the age of twenty, and five-sixths of the cases were under the age of forty. The most efficient remedies were lotions of sodium hyposul- phite, a drachm or so to the ounce ; of corrosive sublimate, y2 to 3 grains to the ounce ; oleate of mercury ointment, 10 to 25 per cent, strength ; and sulphur ointments. Depilation was necessary for rapid results. Tinea Versicolor.—Of this vegetable parasitic disease 44 cases (over 1 per cent.) came under treatment. There were 27 males and 17 females. Seven cases were seen in those under the age of twenty, the youngest being a girl of eleven years, who pre- sented the disease covering the greater part of the upper trunk. Thirty-four of the cases were met with between the ages of twenty and forty, twenty-four of which were between twenty and thirty. In no case was the patient beyond fifty years. Previous duration varied from several months to over ten years. In one case, a woman aged twenty-eight, the disease covering the breast and back, had recurred every summer for three years, disappearing entirely in ^the winter. In two cases there was concurrent syphilis, but the parasitic eruption remained undisturbed and uninfluenced. In one instance the disease was seen in a negro. In one case there was a coexistent tinea cruris. In two instances the disease occurred in two members of a family ; in one, mother and daughter, and in the other, two sisters. As to extent cases varied, most cases presenting several patches or diffused areas upon the upper breast or breast and back, while in exceptional cases the whole trunk, axillae, arms and crural regions were invaded. In one extreme case the trunk, lower neck, axillae, arms, forearms, wrists, upper thighs, buttocks, and poplitea were the seat of the eruption. In three cases, all women, the eruption spread upward well on the lower part of the face. The remedies most commonly employed were sodium hypo- sulphite lotions, 10 to 20 per cent, strength ; resorcin lotion, ic to 60 grains to the ounce ; corrosive sublimate lotion % to 3 grains to the ounce ; an ointment of sulphur, and an ointment of the oleate of mercury. Conjointly with the application selected, ener- 32 getic washings with, according to circumstances, plain toilet soap, sapo viridis, sulphur soap, or a sulphur-naphthol soap were advised. An excellent and energetic medicated soap was one made up of i to 2 drachms of precipitated sulphur to the ounce of sapo viridis; this alone, in mild cases, not infrequently proved curative. Urticaria.—Seventy cases of urticaria came under observa- tion, or a proportion of 1.7 per cent. Of these there were 33 males and 37 females. The ages of patients are shown in the following : Under 10 years.... 8 cases. Between 40 and 50 years. Between 10 and 20 " ___ 12 " " 50 " 60 " . " 20 " 30 " .... 20 " Over 60 " . " 30 " 40 " . . .. 11 " In as many as 20 cases the disease was more or less chronic, having lasted from a month to several years ; this large proportion being not unusual at a special dispensary, where acute cases are not apt to go. In several cases the manifestation was of the papu- lar variety. In one chronic case in which the disease had per- sisted more or less continuously for six months, sudden and evan- escent attacks of swelling of the eyelids, lips and fingers occurred from time to time. Digestive disturbance, uterine irregularities and neurasthenic conditions seemed the most common etiological factors. Internal treatment was based upon a study of the indi- vidual case, sodium salicylate, salines, salol, belladonna or its alkaloid atropia, ergot and quinia being most frequeutly prescribed. Externally relief was often afforded by applications of cooling lotions, such as diluted vinegar, alcohol and water; carbolic acid washes, 1 to 3 drachms to the pint, to which were added 1 ounce of alcohol and a drachm or so of glycerin ; by thymol lotions, of Yz to 2 grains to the ounce, with about the same proportion of alcohol and glycerin to the pint as in the carbolic acid wash ; and in some cases by liquor carbonis detergens, with several parts of water ; and finally by resorcin lotions, 1 to 4 drachms to the pint. Dusting powders were sometimes grateful, more especially when used as a supplementary application to a wash. Vitiligo.—Eleven cases were recorded, 5 males and 6 females. All were under the age of forty ; the youngest was a lad of fifteen, who presented patches upon the face. In 4 cases, the disease, which had been of from a few months' to four years' duration, was limited to the backs of the hands and wrists. In one case—a negro, aged twenty-five—presenting, when seen, patches upon the hands and shaft of the penis, there had previously been large areas upon the face and breast, which had entirely disappeared. In all cases, the progress of the disease was slow. No new information bearing upon etiology was discoverable. In one or two cases, the disease retrogressed slightly while under observation. Treatment consisted mainly of such alteratives as strychnia, phosphorus, arsenic and iron ; pilocarpin was tried, but with no perceptible effect. . 14 cases. 2 " ! 3 " 223 S- Seventeenth Street. June. 1893. Extracts from the Twentieth and Final Annual Report of the Board of Trustees of the Philadelphia Dispensary for Skin Diseases.* With the ending of the past year, the twentieth in the exist- ence of the Dispensary, the Trustees decided it advisable to bring its work to a close. Several factors influenced this determination : Probably of greatest weight was the fact that the Institution as a pioneer had succeeded in sufficiently impressing public and medical opinion as to have led to the organization of special services for the treatment of these diseases in connection with almost all of the prominent charitable institutions of Philadelphia. One of the main objects, therefore, in establishing this special Institution had been accomplished. Another reason was that the attending physician, Dr. Stelwagon, who had served continuously as medical officer since February i, 1880, was, owing to the pres- sure of other work, about to resign. Several minor difficulties, such as the necessity of finding other rooms, and the impossibility of raising sufficient funds with which to purchase a suitable build- ing and thus ensure permanent quarters, also had their influence. ********* * # # The cases under treatment when the Dispensary was closed, November 1, 1890, were referred to the services for skin diseases of the Jefferson College Hospital, 1028 Sansom Street, and the Northern Dispensary, 608 Fairmount Avenue, over both of which Dr. Stelwagon has supervising charge. ********# * * # The following resolution, referring to the balance in the hands of the Treasurer, was passed at the meeting of the Trustees : "A committee of three, consisting of Messrs. Graham, Stelwagon (W. H.) and Davids, be appointed, with full power to act,—to defray the expenses of issuing the usual annual report and the special medical report authorized, to take all necessary legal steps for the dissolution of the corporation ; and if legally admissible, to dispose of all funds left after the final closing of the Institution,' for any purpose or object connected with the charitable treatment of diseases of the skin, in such manner or direction as the said committee may think proper." Trustees: John S. Bispham, President. James Watts Mercur. George S. Graham. William H. Stelwagon. Richard W. Davids, Secretary and Treasurer. *For the year 1890 ; published January, 1891. 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