AN ANALYSIS 
OF 
FIVE THOUSAND CASES OF SKIN DISEASE, 
* 
WITH REMARKS UPON SOME OF THE PRINCIPAL 
GROUPS AND CASES. 
By JAMES C. WHITE, M. D., 
PROFESSOR OF DERMATOLOGY IN HARVARD UNIVERSITY. 
[Reprinted from The Boston Medical and Surgical Journal.] 
CAMBRIDGE: 
®rintc& at tljc 
1876. AN ANALYSIS 
OF 
FIVE THOUSAND CASES OF SKIN DISEASE, 
WITH REMARKS UPON SOME OF THE PRINCIPAL GROUPS AND CASES. 
BY JAMES C. WHITE, M. D., 
Professor of Dermatology in Harvard University. 
These cases are taken from the records of the out-patient department 
for skin diseases of the Massachusetts General Hospital, and they in- 
clude, in consecutive order, all the cases which have been treated there 
during the past six years. The value of such analyses, incomplete as 
they necessarily are in many respects, is still great, as they yield valuable 
information concerning the mtiological relations of many cutaneous dis- 
eases, and furnish the data for comparing the prevalence of these affec- 
tions in various countries. The publication of similar reports, even when 
consisting of mere lists, in the'principal cities of the Old World and our 
own by competent dermatologists, has established the fact of remarkable 
variation in the occurrence of certain affections, for which as yet no sat- 
isfactory explanation has been discovered. Other cutaneous diseases 
seem to be under the action of a law which works alike among all classes 
and nations ; while on the other hand local influences of climate and 
customs are found to be productive of distinct types of affections of the 
skin. These questions of geographical " and race influence should form 
one of the most important subjects of discussion at the dermatological 
section of the coming centennial international medical congress at Phil- 
adelphia. 
The establishment of special departments for skin diseases in connec- 
tion with the dispensaries of the large hospitals of our great cities dur- 
ing the past few years has made the collection of such data possible, but 
has done very little besides this for the advance of the study of derma- 
tology. We still lack the opportunities of hospital accommodation for 
this class of patients, which is so essential for the complete study and 
treatment of these affections. The dermatologist in charge sees, and 
can show for a moment to the student, great numbers of cases, it may 
be, in a year, but the faculty of a snap diagnosis thus taught and ac- 2 
Analysis of Cases of Skin Disease. 
quired is but a small part of the subject. A knowledge of the natural 
progress of disease and of the modifications effected in it by treatment 
can be acquired only by daily observation of individual cases under the 
complete control of the teacher. This is the knowledge which makes 
the understanding and successful treatment of skin diseases possible, 
and it can be acquired only by the establishment of wards for their ex- 
clusive care. Without them the dermatologist of America is deprived 
of advantages for self-improvement and instructing which his foreign 
brethren have long been provided with; our students must seek abroad 
the means of perfecting themselves which are denied them at home ; 
and the pitiable subjects of these distressing affections must suffer from 
such unequal distribution of hospital charity. 
The class of cases presenting themselves for treatment at the skin 
department of the Massachusetts General Hospital, represented below, is 
different in some respects from that found in some other dispensaries, as it 
is drawn from a wider district, patients coming to it from a large portion 
of New England. The relative preponderance of foreigners over natives 
is thereby considerably reduced, and the proportion of serious over trivial 
affections correspondingly increased, as the number of the latter seek- 
ing relief from a distance is naturally small. The nature of the cases, 
however, is as diverse as is usually presented in such lists, representing, 
as they do, such various relations of life ; for it is by no means the poor 
alone who avail themselves of the gratuitous advice of the department. 
Most notable differences, however, will be discovered in the' character 
of the diseases by comparing the list below with those drawn from the 
private case-book of the dermatologist; the extremes being, on the one 
hand, the representatives of poverty and filth, on the other of luxury 
and the refinement of bodily care. But no one without the experience 
derived from the study of both classes can form an intelligent opinion 
of the nature of the cutaneous diseases of any community. 
There is a most necessary preliminary question to be settled in the 
preparation of an analysis of this sort, that, namely, of nomenclature 
and classification. Such a necessity is the great misfortune of dermatol- 
ogy, for until it has a fixed language of terms which can be universally 
understood and used, there can be no greater chance of establishing it 
upon a stable and working basis than there was of erecting the structure 
of Babel. Nearly every dermatologist feels at liberty to invent new 
and change old names, and some are not satisfied long even with those 
of their own creation. Titles, to be understood, should be written not 
only with the author’s initial after them, as those in zoology and botany, 
but with the date of issue as well. A large part of a lecture to students 
on any of the common affections of the skin must be wasted in attempting 
to explain and reconcile such differences of nomenclature as occur even 
in their common text-books on the subject. It is hard to say whose is Analysis of Cases of Skill Disease. 
3 
the whole fault of such confusion; it certainly is not inherent in der- 
matology itself. One reason for it, no doubt, is the constant attempt of 
individual authors to correct it by substituting a system of their own in- 
vention as a panacea. Such efforts are worse than useless, for they only 
add a new element of discord for future elimination. There is but one 
way, as it seems to me, out of the maze ; that is, the establishment of 
an international committee on the subject, to be appointed by a congress 
of dermatologists from all parts of Europe and America, who by mut- 
ual concessions shall agree upon a system of nomenclature and classifi- 
cation, which shall be adopted and left inviolate by individual writers, 
and altered only at future sessions of the congress, to which all proposed 
changes and additions shall be referred. Such a plan should not be im- 
practicable, at least so far as concerns nomenclature, and in view of the 
universal dissatisfaction with the present state of affairs, would, I be- 
lieve, be eagerly entertained. This question, too, certainly should re- 
ceive the earnest consideration of the committee having in charge the 
organization of the'-section of dermatology of the centennial congress. 
In want of such a key at present, however, what plan shall be fol- 
lowed in the registration of the cases to be published below, that the 
names employed may convey to readers everywhere the exact nature of 
the cases ? Evidently one which is already clearly understood and most 
widely distributed. In selecting, therefore, as best adapted for such pur- 
pose, the system of Professor Hebra, I shall succeed in informing every 
dermatologist who may chance to see them of the character of the affec- 
tions contained in the following lists, even if I do not wholly agree with 
that distinguished teacher as to the proper position and name of some 
of them. Such exceptions will, however, be more appropriately con- 
sidered in subsequent papers upon some of the principal groups and re- 
markable cases tabulated below. It will be understood, therefore, that 
the diseases arranged alphabetically, for convenience’ sake, in Table I. 
are mainly those described by Hebra under the titles there used; and 
that in Table 11. they are grouped in accordance with his system of 
classification. 
That the sum of these diseases therein enumerated will be found 
somewhat larger than the number of patients given, is explained by the 
fact that some of them were affected by two or more of the diseases at 
one time. 
The sex and nationality of the patients were as follows : Men, 1414 ; 
women, 1678; children under fourteen years, 1908 ; of native stock, 
1885 ; of foreign stock, 3115. 4 
Analysis of Oases of Skin Disease. 
TABLE I. DISEASES ARRANGED ALPHABETICALLY. 
Abscess .... 6 
Acne .... 348 
Alopecia .... 13 
Alopecia areata . . 17 
Ambustio .... 7 
Bromidrosis ... 1 
Chloasma .... 16 
Comedo . . 3 
Condyloma ... 2 
Cornu cutaneum . . 1 
Dermatitis .... 34 
Ecthyma ... 55 
Eczema .... 2242 
Elephantiasis Arabum . 5 
Epithelioma ... 25 
Erysipelas . ... 62 
Erythema exudativum multi- 
forme . . . .73 
Erythema nodosum . 8 
Folliculitis (heat) . . 12 
Furunculosis ... 65 
Herpes .... 28 
Herpes zoster . . 73 
Hirsuties . . . . 1 
Hyperaesthesia . . 2 
Hyperidrosis ... 5 
Hypertrophied scars . 3 
Ichthyosis .... 5 
Impetigo . . . 19 
Keloid .... 11 
Lentigo ... 1 
Leprosy 1 
Leucoderma ... 1 
Lupus . . . .11 
Lupus erythematosus . 6 
Maculae atrophicae . . 1 
Melasma ... 1 
Milium .... 3 
Molluscum contagiosum . 9 
Molluscum fibrosum . . 2 
Morbilli . » . . . 1 
Musquito poisoning . . 53 
Nails, disease of 5 
Naevus vascularis . . 18 
Pemphigus ... 15 
Pernio .... 7 
Phtheiriasis capitis . 216 
Phtheiriasis corporis . . 48 
Phtheiriasis pubis . . 7 
Pruritus . . . .50 
Psoriasis . . . 162 
Purpura . . . .19 
Rhus poisoning . , 20 
Scabies .... 139 
Scarlatina ... 1 
Scleroderma ... 4 
Scrofuloderma . . 27 
Sebaceous cyst ... 2 
Seborrhoea . . 55 
Syphiloderma . . . 327 
Tinea favosa ... 17 
Tinea tonsurans . . .180 
Tinea versicolor . . 81 
Tyloma .... 2 
Ulcer .... 309 
Urticaria .... 132 
Varicella ... 22 
Varix .... 2 
Verruca ... 14 
Xeroderma . . .13 
Xanthoma ... 2 
Imperfect diagnosis . . 108 Analysis of Cases of Skin Disease. 
TABLE 11. DISEASES ARRANGED UNDER HEBRA’s CLASSES. 
Class I. Hyperaemise. 
Class 11. Anaemiae. 
Class 111. Disorders of the glands, 91. 
Sebaceous Glands : Seborrhoea, 65 ; xeroderma, 18 ; mollnscum 
contagiosum, 9 ; milium, 3 ; comedo, 8 ; sebaceous cyst, 2. 
Sweat Grlands : Hyperidrosis, 5 ; bromidrosis, 1. 
Class IV. Exudative diseases, 3561. 
Varicella, 22 ; measles, 1 ; scarlatina, 1 ; erythema exudativum 
multiforme, 73 ; erythema nodosum, 8 ; urticaria, 132 ; dermati- 
tis calorica, 26; dermatitis traumatica, 2 ; dermatitis venenata, 
73; dermatitis erythematosa, 86; dermatitis phlegmonosa, 71; 
herpes, 101; pemphigus, 15 ; psoriasis, 152 ; eczema, 2242 ; sca- 
bies 139 ; acne, 348 ; impetigo, 19 ; ecthyma, 55. 
Class V. Haemorrhages, 19. 
Purpura, 19. 
Class VI. Hypertrophies, 40. 
Pigment: Lentigo, 1 ; chloasma, 16; melasma, 1. 
Keratoses : Tyloma, 2 ; ichthyosis, 5 ; verruca, 14 ; cornu, 1 ; con- 
dyloma, 2 ; hirsuties, L| Scleroderma, 4 ; elephantiasis Arabum, 5. 
Class VII. Atrophies, 37. 
Leucoderma, 1 ; maculae atrophicae, 1; alopecia, 30 ; atrophy of 
nails, 5. 
Class VIII. Benign new growths, 448.. if«?, 
Keloid, 11 ; hypertrophied scars, 3 ; molluscum fibrosum, 2 ; xan- 
thoma, 2 ; naevus vascularis, 18 ; varix, 2j P”* 
Class IX. Malignant new growths, -96. 
CLupus erythematosus, 6 ; lupus vulgaris, 11 ; scrofuloderma, 27 ; 
leprosy, 1; epithelioma, 25. 
Class X. Ulcerations, 309. 
Ulcers (non-syphilitic), 309. 
Class XI. Neuroses, 52. 
Pruritus, 50 ; hyperaesthesia, 2. 
Class XII. Parasitic, 549, 
Vegetable: Tinea tonsurans, 180 ; tinea versicolor, 81; tinea fa- 
vosa, 17. 
Animal: Phtheiriasis capitis, 216 ; phtheiriasis corporis, 48; 
phtheiriasis pubis, 7. 
Cutaneous syphilides: acquired, 264 ; congenital, 63. 
Uncertain diagnosis, 108. 6 
Analysis of Cases of Skin Disease. 
As already stated the affections enumerated in the tables may be 
more particularly considered to best advantage by the groups or classes 
into which they naturally fall by mutual relationship. Just what is the 
most natural or practical system of dividing or arranging skin diseases 
it is not the purpose of this paper to discuss. I have adopted that of 
Professor Hebra (Table II.), not that I think it perfect, for it might 
be made simpler by reducing the number of its classes, but because I 
think it is on the whole by far the best, and the best known. 
Class 1., Hyperoemias, and Class 11., Ancemias, for instance, might 
seem to be useless in a system of classification, because of five thousand 
consecutive cases of disease not one is referred to them, while hyper- 
semia is one of the most constant and important phenomena of a large 
proportion of them. It is, however, because it is a symptom merely, 
and one in a chain of tissue-changes, that its occurrence in them does 
not suffice to characterize and enroll them in the class of which it is the 
sole and essential type. The hyperaemic affections belonging properly 
to Class I. are mainly the fugitive congestions of the skin, like the ery- 
themas and roseolas accompanying the exanthemata, and following con- 
tact with the milder irritants (rubefacients), which are so trivial and 
fleeting in their course that they do not present themselves at dispensa- 
ries for treatment. The anaemias of the skin (Class II.) are almost 
wholly symptomatic of general conditions of disease, and can scarcely 
be considered as independent cutaneous affections. 
Class 111. Affections of the Cutaneous Glands (91 cases). It is largely 
in connection with the diseases placed in this group that the remark 
made in the beginning concerning the differences in character of the 
affections occurring in private and in dispensary practice holds true, 
especially if we were to consider with them those which might be held 
to be merely their advanced stages The cause of such difference is of 
* £5 * # 
easy explanation. The disorders of the glands, both functional and 
structural, seldom give rise to subjective symptoms of a distressing char- 
acter, or in any way affect the general condition or life of the patient, 
although they are most frequent sources of disfigurement. They are, 
therefore, largely neglected by those classes of society which care little 
for troubles which do not interfere with their grosser ideas of comfort, 
while on the other hand they are so annoying to those who prize beauty 
and cleanliness as essentials of living, that they are often considered as of 
more importance than other really serious derangements of the system. 
Affecting apparently all classes alike, the number of patients seeking 
relief from them among the refined and wealthy is therefore vastly in 
excess of the proportion they bear in these tables, which mainly repre- 
sent the other class. We see, for instance, that seborrhoea occurs but 
fifty-five times, and forms only about one per cent, of all cases, whereas 
in two thousand consecutive cases tabulated from my private record- Analysis of Cases of Shin Disease. 
7 
books it occurs more than two hundred times, or ten per cent, of all 
cases. 
Of the affections of the sebaceous glands, the most common, as will 
be seen, are those embraced under this term seborrhoea, which accord- 
ing to Hebra’s definition, too abundant flow of sebum, includes a great 
variety of forms, according to seat and changes in the character of the 
secretion. A few of the cases were of the oleosa type and of the face, 
affecting the nose and forehead, giving to these parts the greasy look, and 
accompanied in a small proportion by the reddened and congested con- 
dition of the cutaneous tissues, called seborrhoea congestiva. The larger 
part of them, however, in the proportion of three to one, were seated 
upon the scalp, and were either of the dry (sicca) type, characterized 
by white branny scales, or of the moist (oleosa) kind, marked by col- 
lections of greasy matter. This affection, commonly called dandruff or 
pityriasis, and often regarded as a disease of the epidermis, is really but 
a modified secretion of sebum, the cells of the glands failing to undergo 
their normal fatty degeneration and conversion into fluid oil within the 
glands, and escaping either in the form of dry and silvery, or greasy 
and adherent epithelial cells upon the general surface of the scalp. In 
addition to the discomfort and disfigurement it causes, it is of great im- 
portance in its relations to alopecia and eczema of the scalp. Of the 
former, the alopecia furfuracea of Hebra and Kohn,1 it is the earliest 
stage, the change in the formation of the epithelial cells of the gland ex- 
tending gradually to the corresponding cells of the annexed hair follicle, 
and thus preventing the development of healthy and long-lived hairs. 
It is by far the most frequent cause of early baldness, and rarely comes 
under treatment until its real importance is impressed upon the patient 
by the loss of hair. Its great frequency may be estimated by the large 
percentage it forms of the cases in private practice above given, for 
although a small proportion of the two hundred there enumerated were 
undoubtedly seborrhoea of the face alone, yet if to these had been added 
the very numerous cases recorded simply as alopecia, but which are 
really the later stages of this affection, it would show a still higher pre- 
ponderance. 
Of eczema, too, seborrhoea of the scalp is a very frequent cause, both 
in adult life and in childhood. The constant attempts of the patient to 
remove the offensive collections by such rough means as fine-toothed 
combs, stiff brushes, irritating hair-washes, and the like, together with 
the heat, itching, and scratching provoked by the presence of the 
scales, lead sooner or later to congestion of the skin, and in turn to 
chronic infiltrated eczema, or moist and acute eczematous inflammation, 
not only of the scalp but of the neighboring parts also. The very com- 
1 See the Journal of June 8, 1871, for an excellent description of this affection by 
Kohn. 8 
Analysis of Cases, of Skin Disease. 
mon form of infantile eczema caused by the collection of the sebum 
upon the scalp can hardly be referred to this class, for in the majority of 
cases there is no seborrhoea present, and the formations are merely accu- 
mulations of normal sebum and dirt, in consequence of ignorance on the 
part of the mothers and nurses as to the importance and proper means 
of its removal. 
That but three cases of so common an occurrence as comedones are 
recorded in this class is explained by the statement that only those were 
recorded as such in which they formed the sole affection of the seba- 
ceous glands, and which were so abundant as of themselves to lead the 
patient to seek relief. Associated with acne, however, they occurred in 
a large majority of cases, and as an important factor in the aetiology of 
that disease. The same may be said of milium, so far as the individ- 
uality of the cases mentioned is concerned, but it was not infrequently 
seen in connection with, although forming no part of, other cutaneous 
diseases. 
Molluscum contagiosum was observed nine times. The position of 
this mysterious affection in this class may, in the light of recent inves- 
tigations into its anatomy, be looked upon doubtfully. Reference to the 
last semi-annual report on dermatology in the Journal1 will show that 
good grounds exist for the opinion that the peculiar cells which form the 
structure of these tumors are modifications and growths of the rete mu- 
cosum, and not of the sebaceous glands.2 This change of seat, however, 
even if accepted as a fact, would throw no additional light into the ob- 
scurity surrounding the nature of the disease. The cases yielded no 
positive evidence of its contagious character, as in every instance the 
patient wras the only member of the family affected. One case was that 
of a nursing mother with a numerous crop upon the left breast. Five 
of the patients were young children, and four of this number were only 
two years old. In five of them the growths were limited to the face, 
and were almost wholly seated about the eyelids. 
Xeroderma, too, of which thirteen cases were observed, is placed in 
this group with some hesitation. The term is used here to mean simply 
dry skin, the integument over parts of the body, or over the whole of it, 
being from birth harsh, dry, and at times scaly and cracked, as if there 
were a diminution in the normal secretion of both sebaceous and sweat 
glands. The peculiarities, however, are quite as marked in the palms, 
where none of the former exist, as elsewhere. This same condition of 
the skin is also a prominent symptom in ichthyosis, and is no doubt some- 
times mistaken for that affection, even when occurring independently. 
The cases recorded here, however, were accompanied by no hypertrophy 
1 December 2,1875. 
2 See paper by Dr. Casar Boeck, Yierteljahresschrift fur Dermatologic und Syphilis, ii. 
Jahrgang, i. Heft. Analysis of Cases of Skin Disease. 
9 
of the papillge, which is the characteristic and essential lesion of ichthy- 
osis, and the scaly condition of parts of the skin was due to accumulation 
of epidermal cells upon the surface, not to their excessive formation. 
The few cases of affections of the sweat glands were of little interest. 
One of the cases of hyperidrosis was unilateral and partial. The cases 
of folliculitis, placed in the next class, were mostly inflammations of 
the tissues surrounding the glands, induced by excessive action of the 
sudoriparous glands (sudamina). They are not, however, primarily 
affections of the glands. 
Class IV. Exudations (3661 cases). The great class of exuda- 
tive diseases comprises, as will be seen, more than two thirds of the 
whole number of cases upon the list, and is divided by Professor Hebra 
into the acute and chronic, the dividing line being at pemphigus (Table 
II.). This division seems arbitrary, because some of the diseases in the 
first group are chronic in course at times, —some of the forms of urticaria 
and erythema, for instance, while of the latter some may be acute both 
in type and in duration ; but on the whole, it is well founded. The 
first group is again divided into the contagious (the exanthemata), and 
the non-contagious. 
The number of cases of exanthematous disease which find their way 
to the hospital is surprisingly small, but twenty-four cases in all having 
presented themselves at the skin department. That so large a propor- 
tion of these, twenty-two, were varicella seems stranger still, but can 
be explained, perhaps, by the facts that chicken-pox is not a “ rash,” 
that it is more variable and protracted in its period of efflorescence than 
the other exanthems, and that the eruption is more like that of some 
of the commoner skin diseases, and lasts longer than that of the others. 
In the erythematous group there were seventy-three cases of ery- 
thema exudativum multiforme, eight of erythema nodosum, and one 
hundred and thirty-two of urticaria. The cases of the first named were 
distributed about equally among men, women, and children, and 
amongst all ages. They were most various in kind and degree. The 
causes were mostly obscure, but in three of them copaiba gave rise to 
a general outbreak. In one of the latter the body was universally cov- 
ered at first with a fine scarlet papular rash, with brilliant congestion of 
the mucous membrane within the mouth, so as to suggest an attack of 
scarlet fever until it was discovered that the patient was taking the drug. 
Erythema papulatum was observed in twelve of the cases, confined 
mostly to the hands, and in nearly all of them the disease had shown a 
marked tendency to recur at intervals of a year or more, and to a 
chronic course. Erythema nodosum occurred but eight times, and was 
confined mostly to the lower legs of young girls and children. The 
arms were affected as well as the legs, in throe of the cases. In many 
instances erythema was intimately associated with urticaria. Analysis of Cases of Shin Disease. 
Urticaria occurred twice as often with women as with men, and a 
large third of the cases were chronic. Only in a very few instances in 
either class was it possible to discover the cause of the disease, either in 
the action of specific excitants affecting directly the skin or organs of 
digestion, or in any special faults of the general economy. In a few it 
was secondary to other skin affections of an itching character, in which 
the patience of the cutaneous nerves had been long abused by scratching, 
and in others it was similarly induced by the harassing action of animal 
parasites upon the skin. Many of the patients were troubled by chronic 
disorders of various functions and organs, and many were anaemic 
and debilitated, but such troubles were not more noticeable in these 
patients than in those affected by other cutaneous diseases of equal 
frequency. Neither did the results of treatment throw much light 
upon the aetiology of the disease in its relations to internal disorders. 
In some cases, however, it seemed to have more than a chance connec- 
tion with chronic disturbances of digestion. In a very large proportion 
of them the health was, with the exception of the urticaria, faultless in 
every way. 
The relations of urticaria to the nervous system have, like those of 
most skin diseases, lately been much discussed. The grounds and 
methods of such agitation in general will be briefly and more appropri- 
ately considered when we come to the class Neuroses. Dr. Bulkley, of 
New York, has recently called attention to the connection of chronic 
urticaria with exophthalmic goitre as additional evidence of such rela- 
tionship, as this rare affection, otherwise called Graves’ or Basedow’s 
disease, is supposed to be due to some disturbance of the sympathetic 
system. He published two cases of this sort in The Chicago Journal 
of Nervous and Mental Disease, October, 1875. To these may be 
added a similar case from the list of patients with urticaria. 
■ i Chronic Urticaria with Exophthalmic Gioitre.—The patient was an 
Irish girl twenty-six years old. She had always been well and strong 
until 1871, when she took a severe cold, which was followed by a very 
hard cough and repeated haemoptysis of three months’ duration. She 
then gave up work and remained in bed, after which the haemorrhages 
ceased and the cough gradually disappeared. During this time her 
lungs were examined, but no positive signs of disease of their tissues 
were • discovered. With the cessation of the pulmonary symptoms, 
there came on incessant nausea and violent vomiting whenever any- 
thing was eaten or drunk; this lasted five months. At the same time 
she began to have severe palpitation, paroxysmal in character, and ag- 
gravated by emotions. She then noticed for the first time that her eyes 
were more prominent than usual, and thinks that they were forced out 
by straining in vomiting. Her neck also became larger than before. 
During this time she was seen by several physicians, but they failed to Analysis of Cases of Skin Disease. 
11 
find any structural disease of the heart. The obstinacy of the vomit- 
ing led to the examination of the urine, and it was found to contain 
“ albumen and casts,” so that the symptoms were referred to disease of 
the kidneys. She went into the country and slowly recovered from 
the vomiting and partially regained her strength. During the last three 
years there has been little change in her condition, the most prominent 
symptom having been nearly constant palpitation, stimulated by emo- 
tional causes at times to the sensation of impending death. The condi- 
tion of the eyes and neck has not changed in the same period. In 
April last, ulceration of the skin of the right lower leg took place, for 
which, and for her general state, she sought relief at the hospital. She 
was examined by Drs. Hayden and Knight, and mitral regurgitation 
and enlargement of the heart were recognized. The urine was ex- 
amined and found normal. 
In August, urticaria for the first time manifested itself as a general 
outbreak, for which she was referred to the skin department. The 
patient presented a startled, anxious look, and was pale. Her eyes 
were very prominent, and had a staring expression. Pear-shaped, flat- 
tened protuberances were seen on either side of the front neck, dimin- 
ishing in size as they extended from the junctures of the clavicles and 
sternum upward and backward nearly to the angles of the jaws. They 
were soft to the touch, and when squeezed gave the patient the feeling 
that the “ eyes were coming, out of her head.” The neck measured 
thirteen inches in its largest circumference. The urticaria exhibited 
itself in the form of medium-sized wheals, with occasional erythematous 
patches. It affected all parts of the surface, including the head. It 
came at all times, most frequently mornings and evenings, and appar- 
ently quite independently of diet or other appreciable agents. The 
attacks lasted, too, for quite variable periods, and were sometimes absent 
several days. The general condition of the patient was pretty good 
for one with so serious an organic disease of the heart. Her digestion 
was correct and the menstrual function regular. She was very easily 
startled, and the palpitation and tumultuous action of the heart then 
became distressing, but ordinarily, and when quiet at home, she was 
very comfortable. A tonic and an antipruritic wash were prescribed. 
Since her first visit, her condition has remained without material 
change. She thinks that the severity of the attacks of urticaria are 
o 
controlled to some extent by the use of the wash, and that the intervals 
between them are somewhat longer, sometimes extending to two or 
three weeks. 
The dermatitides form a separate group of the acute exudative dis- 
eases in Hebra’s scheme, and are subdivided by him into the idiopathic 
and symptomatic. The first comprises the varieties traumatica, vene- 
nata, and calorica ; the latter, erythematosa and phlegmonosa. Under 
the head of dermatitis venenata, I have placed those inflammatory 12 
Analysis of Cases of Skin Disease. 
affections of the skin which are produced by the action of certain veg- 
etable and animal poisons when brought into more or less intimate con- 
tact with it. They include fifty-three cases of mosquito poisoning and 
twenty of rhus poisoning. They will be spoken of here that there may 
be no deviation from the plan of arrangement according to Hebra pro- 
posed in the beginning, even if, as in this case, the affections are regarded 
by the writer as misplaced. Dermatitis is a very general term, and 
might, with the latitude of signification here given it by Hebra, be as 
appropriately applied to many of the diseases of this class, to herpes or 
acute eczema, for instance, to the latter of which the changes in the tis- 
sues of the skin produced by contact with rhus properly belong. 
The cases of mosquito poisoning, so called, cannot be so closely de- 
fined as to admit of a narrow classification upon the basis of pathological 
anatomy, for they vary greatly in their cutaneous manifestations. They 
represent the effects of the insertion of a peculiar poison into the skin 
of persons previously unused to it. In volume Ixxxv., No. 19, of the 
Journal, there was published by the writer a paper on The Protection 
acquired by the Human Skin and other Tissues against the Action of cer- 
tain Animal Poisons after Repeated Inoculation ; in that paper the ap- 
pearances caused by mosquito poison were described in an account of a 
series of cases observed at that time. As those cases formed a part of 
the fifty-three above mentioned, and are strongly typical, I cannot do 
better than repeat here the description of them there given. 
On the 28th of August, 1871, a family consisting of parents and four 
children, the latter between six and eighteen years of age, came to the 
skin-department for advice. The father and mother presented upon 
their faces, necks, forearms, and hands a very abundant outbreak of 
large and small papules, more or less prominent and mostly excoriated, 
among which were a few wheals and large vesicles. In the children, in 
addition to these forms of efflorescence, the whole skin of these parts 
was in an erythematous condition, and in the older two there were nu- 
merous pustular and furuncular, almost ecthymatous lesions. It was in 
the youngest two children, however, that the climax of the disturbance 
was developed ; for upon them the process of free exudation was car- 
ried to its extreme limit in the form of very large bullae, which were so 
generally distributed upon the regions above named as to give a predom- 
inant character to the whole efflorescence, and constitute an apparent 
pemphigus of extreme grade. Some of these blebs upon the arm of the 
boy were more than three inches long, and contained more than half an 
ounce of fluid. No better illustrations of the progressive passage of one 
form of well-defined efflorescence into another, from erythematous spot, 
through papule, vesicle, pustule, to furuncle, or from wheal to bleb, and 
of the insufficient basis their halting stages alone afford for the estab- 
lishment of distinct titles in nosology, could be desired. Yet this great 
diversity of appearances, embracing nearly every form of acute cutane- Analysis of Cases of Skin Disease. 
13 
ous lesion recognized, was produced by one and the same exciting cause 
in all the cases, namely, the bites of mosquitoes. The differences pre- 
sented by the various individuals of the family were such as are con- 
sistent with the well-known greater tendency to exudation in inflamma- 
tory processes of the skin in childhood than in the same affections in 
adult life. The subjective symptoms in all were only slight itching, and 
the soreness necessarily consequent upon the gravity of the lesions. 
There was no constitutional disturbance. 
How, now, shall we explain the serious and unusual effects of so sim- 
ple and common a disturbing cause as mosquito bites in this instance ? 
Similar manifestations, and of as varied a type, although of much milder 
degree, I have often seen in individual cases before ; but the fact of six 
persons of one family simultaneously exhibiting such extraordinary re- 
sults shows the existence of some unusual element in the case. That 
element I believe to have been a want of protection against the poison 
of these insects through prior inoculation. The family, leaving their 
home in England, had arrived in Boston well and clean two weeks pre- 
vious to my seeing them, and had spent that interval in lodgings in a 
street at the North End, where there were many mosquitoes, insects 
they had never seen before. Although the appearances were confined 
to parts exposed to their bites, they were quite unsuspicious of the cause 
of trouble. 
Since the occurrence of the above, I have seen every summer and 
autumn many cases almost identical with them in character, although 
none more severe, so that I am confirmed in the correctness of the con- 
clusions then offered. Even in the 'winter, in a single instance, I vent- 
ured to say, on seeing a patient for the first time, “ Were the season sum- 
mer, I should say that this was a case of mosquito poisoning in a freshly- 
arrived immigrant.” On inquiry it was ascertained that the patient had 
but just landed, and had found shelter in a hot, underground dwelling, 
where mosquitoes were actually passing the winter in great quantities 
and undiminished activity. So characteristic are the appearances of 
these cases in spite of the great diversity of their cutaneous lesions. It 
is this diversity, however, which warrants the use of the general title 
dermatitis for them. 
In rims poisoning, on the contrary, we have neither diversity of efflo- 
rescence nor severity of inflammation enough to warrant the application 
of this name to the appearances of the skin. They are those simply of 
ordinary acute eczema, with just enough individuality in the majority of 
cases to suggest to the educated eye their peculiar and artificial nature. 
That the inflammation of the skin provoked by this poison may in rare 
instances exceed in depth and intensity that ■which belongs to eczema in 
its whole possible range Ido not deny, but I have never seen such. An 
account of the nature of the poison, and a description of the cutaneous 
manifestations produced by it, may be found in the New York Medical 14 
Analysis of Cases of Skin Disease. 
Journal, March, 1873.1 In that article reference was made to tire prep- 
aration of the celebrated Japanese varnish, which is made from a closely 
allied species of rims, and to its effects upon workmen while using it. I 
have just received, through the kindness of Dr. Hodges, of this city, 
the following additional and interesting information concerning the ef- 
fects of this varnish upon persons in China, which was communicated to 
him by Dr. A. P. Chamberlain. This gentleman spent two years in 
that country, and left it partly on account of the frequency and severity 
with which he was poisoned there. The juice of the tree is obtained by 
tapping, and the boys who collect it are said to die sometimes from its 
effects. The first time Dr. Chamberlain ever saw the varnish applied 
was on a rainy day, and remarking on the oddity of painting a porch of a 
house in such weather, he was told by the Chinese workmen that the var- 
nish dried better in the dark and wet, and that this was one of its several 
“ devilish ” characteristics. It is only in its fresh state, Dr. Chamber- 
lain says, that the lacquer poisons ; when once dried it is inactive. He 
was poisoned once by unlocking a door, where an old keyhole had been 
stopped by putty mixed with the lacquer ; once by opening a freshly- 
painted window for a lady ; once by walking up the Hong Kong Club 
stairs on some pieces of board laid down temporarily on the freshly- 
painted stairs ; once, as he believes, by passing two freshly-painted cof- 
fins in the street. At one time, while he was there, a ship, which had 
come down the river with some of the paint on board, took fire at the 
wharf. To save her cargo, it was hastily tumbled out, and one of the jars 
got broken. Its emanations so poisoned some of the sailors that they 
had to be taken to the hospital. In one of his attacks Dr. Chamberlain 
employed a Chinese physician. His treatment was a “ whitewash ” 
made of extract of garlic and plaster of Paris. It had no special efficacy. 
The cases which occurred at the hospital were mostly among work- 
ingmen who had handled the vines of rhus toxicodendron while work- 
ing in gardens and about stone walls, and among children after occasional 
visits to the country and woods. They were mostly of mild type, and 
would more properly have been placed with other cases of artificial ec- 
zema.2 Several cases of other affections of the skin, eczema, acne, etc., 
it may be mentioned in this connection, have also been observed at the 
hospital, in which poisoning by ivy was referred to by the patients as 
the cause and starting-point of the later affection; a belief, as stated in 
the article referred to, of quite common prevalence in all classes of so- 
ciety, and well founded only so far as consistent with the possibility that 
such secondary affections may be indirectly due to the morbid impression 
left upon the cutaneous tissues by the severity of the original process. 
1 On the Action of Rhus Toxicodendron and Rhus Venenata upon the Human Skin. 
2 During the past winter cases of rhus poisoning have been of frequent occurrence in this 
vicinity, as many as ten or twelve within the writer’s knowledge. They were nearly all 
caused by cutting sticks from rhus venenata while on skating parties. Analysis of Cases of Skin Disease. 
15 
Dermatitis calorica includes seven cases of burns, seven of chilblains, 
and twelve of folliculitis (so called). The first two, caused by extremes 
of temperature, presented nothing of interest; about the last a word of 
explanation is due. As above stated, the term, as here used, means in- 
flammation of the skin surrounding the sweat glands, as the result of 
their over-activity (hyperidrosis) in hot weather. Beginning as simple 
hyperseraia or congestion of the capillary plexus which envelops the 
glands, the process advances under prolonged stimulation, assisted no 
doubt by the itching it excites, to well-marked inflammation of the cu- 
taneous tissues immediately surrounding the glands. The surface of 
the skin presents at first the appearance of fine red dots, which rapidly 
become well-developed papules. In other words, we have established 
u prickly heat,” or the sudamina of Hebra, which may go on under further 
provocation to eczema of any grade, or develop into the more advanced 
form of dermatitis phlegmonosa or furuncular inflammation. Many of 
the cases of eczema and of furunculosis of infants and workingmen, 
occurring especially in hot weather, were of this origin. 
Dermatitis erythematosa. —Of the eighty-six cases in this group, 
fifty-two were ordinary erysipelas, and thirty-four true inflammation of 
the dermal tissues, not distinctly erysipelatous, and produced by a great 
variety of causes. In many of them the eventual nature of the process 
was not definitely ascertained, as they were not sufficiently long under 
observation. The cases of erysipelas were mostly of a mild, self-limited 
type, and their traumatic origin was generally made out. 
Dermatitis phlegmonosa. This group of the more deeply-seated 
and destructive inflammations of the skin was represented by six cases of 
cutaneous abscess and sixty-five of furunculosis. The tetiological rela- 
tions of the latter were very diverse. 
There were one hundred and one cases of herpes, including twenty- 
two of herpes labialis, three of herpes prseputialis, and seventy-six of 
herpes zoster. Many of the cases of labialis were relapsing in charac- 
ter, and their reflex origin could be directly traced to irritation about 
the anus or vagina. An analysis of the cases of zoster is presented in 
the following table, the anatomical divisions being those given in Pro- 
fessor Hebra’s work. 
Men. 
Women. 
Children. 
Total. 
llight. 
Left. 
Zoster capillitii 
3 
1 
4 
3 
1 
Zoster faciei 
- 
3 
3 
2 
1 
Zoster nuchaa 
3 
1 
3 
7 
5 
2 
Zoster brachialis 
2 
1 
6 
9 
5 
4 
Zoster pectoralis 
12 
10 
16 
38 
17 
21 
Zoster abdominalis 
2 
2 
5 
9 
2 
7 
Zoster femoralis 
3 
3 
6 
3 
3 
25 
15 
36 
76 
37 
39 16 
Analysis of Cases of Skin Disease. 
In only twenty of the cases was neuralgic pain a prominent symptom 
at any stage. It was most marked and persistent in old people, and oc- 
curred most frequently in the thoracic and abdominal forms. In none 
of the frontal cases was the eye seriously affected. Nothing was learned 
by special inquiry in any case that threw light upon the aetiology of 
the affection. 
The cases of pemphigus, fifteen in number, exhibited nothing of espe- 
cial interest. A large proportion of them were in infants. 
Psoriasis occurred one hundred and fifty-two times. The cases were 
in no way remarkable. In a great majority of them the patients were 
perfectly healthy in every other way, so far as could be ascertained, 
and in only a small percentage of them was any hereditary tendency to 
be traced. 
Eczema formed nearly one half of the whole number of cases upon 
the list, two thousand two hundred and forty-two, and if to these were 
added the cases of rhus poisoning and a part of those of impetigo and 
ecthyma, as might appropriately be done, this proportion would be still 
greater. This percentage is extraordinary, even when considered in 
view of the widely open definition given to the term by the writer, in- 
cluding as it does several of the forms of lichen, strophulus, pityriasis, 
and impetigo of some dermatologists, especially those of the English 
school, as mere stages or varieties in form of one general inflammatory 
process of the skin, which cannot consistently be separated. But in the 
statistics drawn from similar sources by Dr. Anderson, of Glasgow, who 
alone among English writers on dermatology adopts this same broad def- 
inition of the German school, eczema occurred only two thousand five hun- 
dred and twenty- seven times in ten thousand consecutive cases. Certainly 
in private practice it does not approach this frequency of occurrence. 
This latter difference is, in some measure at least, due to the absence in 
great degree among the better classes of certain extraneous exciting 
causes of the disease, such as the presence of pediculi, improper care of 
the skin, contact with irritating matters in daily occupation, etc., but it 
is impossible to explain this great disparity between the figures of the 
Glasgow statistics and our own, which include the same classes of so- 
ciety. I shall not attempt to divide the cases according to the well 
recognized and defined varieties founded on surface appearances, such 
as eczema papulosum, vesiculosum, pustulosum, squamosum, and the 
like, nor into acute and chronic forms, partly because a large proportion 
of them presented several of the former varieties or stages at the same 
time upon different parts of the body, or at successive periods, and were 
equally mixed in course ; and also because the cases were not as a whole 
sufficiently under control or long enough under observation to make 
such an analysis reliable, even if it were practicable. With regard to 
the aetiology of the affection, an analysis of the cases may, perhaps, Analysis of Cases of Shin Disease. 
afford more valuable information. The following table will show, for 
example, the comparative prevalence of the disease in the two sexes 
at various periods of life : 
Ages. 
Males. 
Females. 
Total. 
Under 1 
year. 
157 
112 
269 
Between 
1 and 
5 
236 
261 
497 
\c 
5 “ 
10 
74 
125 
199 
“ 
10 “ 
15 
39 
75 
114 
“ 
15 “ 
20 
42 
52 
94 
“ 
20 “ 
30 
134 
129 
263 
“ 
30 “ 
40 
139 
110 
249 
“ 
40 “ 
50 
122 
129 
251 
“ 
50 “ 
60 
91 
83 
174 
tc 
60 “ 
70 
55 
55 
110 
“ 
70 “ 
80 
14 
8 
22 
1103 
1139 
2242 
It will be seen that eczema occurs oftener in the first than in any sub- 
sequent year of life, and that starting with seven hundred and sixty-six 
cases in the first five years, its frequency diminishes in the subsequent 
periods of equal length up to the twentieth year, when it begins to in- 
crease. The same result is more strongly developed if its comparative 
prevalence is expressed by decades ; thus in the first decade the table 
presents nine hundred and sixty-five cases, in the second two hundred 
and eight, in the third two hundred and sixty-three, and so on. This 
excessive prevalence of the disease in earliest childhood, and especially 
in the first year of life, must be owing, in some measure, to the very 
tender condition of the cutaneous tissues at this period and to the im- 
proper care it receives among the classes here represented, although this 
will account but for the smaller proportion of the cases, I think. It 
would be, perhaps, impossible to make a comparative estimate of the 
occurrence of infantile eczema of this class and that of other classes of 
society, because the latter is seldom seen by the specialist, but is treated 
by the family physician. 
In a great majority of cases the cause of the disease could not be dis- 
covered. Some of the patients were poorly fed, weak, and anaemic, or 
sick in other ways, but such were the exception, and certainly three 
fourths of them were well nourished and in good condition in every way 
otherwise, except for the effects upon the health due to the eczema it- 
self. Like all other infants, those with eczema were “ teething.” The 
disease, and this may be said of adults as well, was not found to be 
prominently associated with, far less dependent upon, any special disor- 
der of digestion, errors of diet, rheumatic diathesis, blood change, per- 
verted innervation, hereditary influences, or others of the many recently 
assumed causes of its production. As he recently stated in the Jouk- 18 
Analysis of Oases of Skin Disease. 
nal,1 the writer would not deny that there are often in patients with 
eczema faults of the general economy, or disorders of special organs 
and functions, but that they are generally or necessarily present, or that 
when present they can be demonstrated in most cases to be the cause of 
the disease, cannot be accepted except upon some show of legitimate 
evidence. His observations of these cases, as well as of those in pri- 
vate practice, confirm him in the conclusions there expressed, that the 
causes of eczema are almost wholly unknown, not yet within the range 
of demonstrative reasoning, in which respect it is like most diseases of 
the skin, like most diseases in general. 
As exceptions to this confession of ignorance are to be regarded the 
cases of artificial or extraneous origin, of which, as will be seen, not a 
few were observed. The action of irritants in exciting eczema has been 
alluded to above in connection with some of the cases of dermatitis ca- 
lorica and venenata. Of the influence of heat in this direction there 
were fifty examples, which occurred during periods of excessive solar 
heat, and mainly in young infants and laboring men. Beginning, many 
of them, as the folliculitis there described, the inflammation extended 
to the surrounding cutaneous tissues in the form of acute eczema, and 
was often accompanied by painful furunculosis. The direct application 
to the skin of the following substances gave rise to acute eczema; ar- 
nica,2 one case ; sulphur in lard, two ; blister, one ; cantharides wash, 
one ; mustard bath, one ; tincture of balm of Gilead buds, one ; salt pork 
slices, two; cyanide of potassium, one ; alkalies, two ; mercurial oint- 
ment, two; croton-oil, one ; poultices, four ; liniments (nature unknown), 
twelve. In certain occupations the hands were affected from contact with 
similar substances, as follows: currier, one case ; washerwomen, two ; bar- 
tender, one ; sugar workers, two ; soap maker, one; bakers, seven ; print- 
ers, two ; burnishers, three ; polishers, two ; dye-house man, one. The 
most frequent cause of artificial eczema, however, was the irritating pres- 
ence of lice. Of such cases there were two hundred and seventeen re- 
corded, but there were doubtless others. They were mostly eczema of 
the scalp and adjoining parts. A few of them were caused by clothes 
lice. In not a few instances the local origin of the eczema, although 
not of an extraneous nature, could be made out. Upon the lower legs 
it could be referred, in many cases, to disturbance in the circulation 
produced by varicose veins. Here it was mostly of a chronic type. 
It followed vaccination, beginning about the seat of inoculation in eight 
instances, and was the result, not of any impurity of virus or direct 
transference from another person, but of the disturbance of the whole 
cutaneous tissues in a patient disposed to the disease. The same effect 
is often produced by measles and other exanthemata, a more or less gen- 
1 December 2, 1875. 
2 See Journal, January 21, 1875. Analysis of Cases of Skin Disease. 
19 
eral eczema immediately following their disappearance in consequence 
of the excitement of the skin they give rise to. Several instances of 
this kind were observed. In a few cases eczema was dii’ectly caused by 
the irritating character of discharges from the ears and nostrils in affec- 
tions of these passages, and in a few others, in which the skin surround- 
ing the mouth and nostrils was affected, it was sympathetic with irrita- 
tion about the genital or anal regions. In a great many cases the dis- 
ease was of secondary origin, and was scratched into existence in the 
course of other affections of which pruritus was a marked symptom. 
The sexes were about equally represented in the table, and were quite 
uniformly so at all ages, excepting the period from five to fifteen years, 
in which the number of girls affected was twice that of the boys. It is 
possible that this apparent inequality may be explained by the fact that 
boys of this age are far less tractable than girls, and therefore are not 
so easily induced to come to the hospital for treatment. 
It would not be worth while to attempt to subdivide the cases into as 
many varieties, according to regional distribution, as are given in many 
works, because any single limited district is so seldom alone affected, ex- 
cept in the cases of local origin as above given. In specifying the dis- 
tribution of the disease, therefore, I shall refer only to the general di- 
visions of the body, and it will be understood that only portions of these 
were in the great majority of cases implicated In any individual case. 
Eczema affected the head, including the neck, in one thousand one 
hundred and sixty-seven cases; the tfunk in two hundred and twenty; 
the arms in one hundred and seventy-five ; the hands in two hundred 
and eighty-five ; the legs in four hundred and sixty-three ; the feet in 
forty ; the genital and anal regions in ninety-three ; and the whole body 
in seventy-three cases. The head and neck are here considered one re- 
gion because eczema of the latter is generally associated with that of the 
face and scalp. The hands, as will be seen, suffered much more fre- 
quently than the arms, partly, no doubt, on account of their greater ex- 
posure to fluctuations of temperature and moisture, to contact with irritat- 
ing substances, and to the pressure, friction, and strains to which they 
are so generally liable. So, too, eczema of the genital and anal regions 
is combined, because the former is so frequently the starting point of 
the latter. The cases of general or universal eczema were mostly in- 
fantile. 
Scabies occurred only one hundred and thirty-nine times. The fluct- 
uations in the prevalence of this disease during the past twenty years 
have been remarkable. In the early part of this century, if report be 
true, it was quite a common affection in many parts of New England, 
and was one of the evils to be especially guarded against at public 
schools, as lice are now. Later, it died out so largely that physicians 
were generally unacquainted with its appearances, and often failed to 20 
Analysis of Oases of Skin Disease. 
recognize it, tire disease appearing only at intervals in any community, 
and being kept up apparently through fresh importation by immigrants. 
During the war of the rebellion, however, it found the most favorable 
conditions for development in the camp life of our soldiery, and soon 
became a universal and serious endemic in the armies. But so little 
familiar were our military surgeons with scabies that it was regarded as 
some peculiar form of the disease, and was called army itch. It was 
not confined to the camps, however, but was carried to their homes all 
over the land by returning soldiers of all ranks, and imparted to the 
household. In this way all classes of society became affected, and the 
disease once more became familiar to physicians. After the war ended 
it very slowly subsided, until in the past few years it has again become, 
in New England at least,’ as rare an affection as it was twentv years ago. 
This, is strikingly shown by a comparison of its yearly occurrence since 
the skin-department was opened. In 1869, its first year, there were 
eighteen cases among the one hundred and nine patients ; in 1875 but 
eight cases were observed in one thousand and seventy-three patients, 
and among the two thousand and twenty-seven patients of the last two 
years it occurred but twenty-five times. It is becoming, in fact, a dif- 
ficult matter to properly illustrate the disease to classes, and were it not 
for its occasional importation through foreign immigration, it might be- 
come obsolete here. If we compare now the prevalence of the disease 
amongst us and in European countries we shall find a most marked dif- 
ference. In the Vienna skin clinic six hundred and seventy cases were 
treated in 1871, and of Dr. Anderson’s ten thousand consecutive cases 
of skin disease in the Glasgow hospital, two thousand five hundred and 
twenty-seven were scabies ; whereas among more than ten thousand 
similar cases in our two Boston hospitals, it occurred only two hundred 
and fifty-three times. Such difference can be accounted for only by the 
more cleanly manners of all our classes. With such abundant foreign 
sources of supply to colonize from, sarcoptes hominis will scarcely be- 
come extinct in our day. , 
Acne. —As above stated, it is mostly in connection with the affections 
of the sebaceous glands that the most notable difference between private 
and dispensary practice is observed. Regarding acne as one of their 
advanced stages, a comparison of its occurrence in the two classes of 
patients confirms the data there given. In the five thousand hospital 
cases it was observed three hundred and forty-eight times, whereas 
among the two thousand tabulated from my private case-book it occurs 
three hundred and sixty times. The cases comprise acne disseminata, 
acne rosacea, and non-parasitic sycosis, and present little of special in- 
terest. The accompanying table shows the distribution of the cases of 
simple acne according to sex and age. Analysis of Cases of Skin Disease. 
Ages. 
Males. 
Females. 
Total. 
Between 
10 
and 
15 
_ 
10 
10 
“ 
15 
iC 
20 
32 
94 
126 
(( 
20 
“ 
25 
30 
59 
89 
“ 
25 
“ 
30 
11 
14 
25 
e< 
30 
“ 
35 
10 
13 
23 
u 
35 
“ 
40 
3 
8 
11 
u 
40 
(C 
45 
4 
12 
16 
“ 
45 
“ 
so! 
3 
8 
‘ 11 
“ 
50 
“ 
60 
7 
2 
9 
“ 
60 
“ 
70 
i 
1 
2 
101 
221 
322 
It will be seen that by far the larger part of the patients were be- 
tween the ages of fifteen and twenty-five, and this proportion would be 
much larger if all the cases which began during this period were added 
to it, the ages given being those at which the patients presented them- 
selves for treatment. In many it had already existed for years. The 
youngest of them was thirteen years old. The apparent difference in 
frequency of occurrence between the sexes must not be regarded as an 
actual representation in this respect, because girls care so much more for 
their “complexion,” and seek medical relief accordingly. Nothing was 
learned by inquiry or observation in the whole series of cases which 
would satisfactorily explain the occurrence of acne. It was associated 
with disturbances of the digestive and sexual systems in a small pro- 
portion of cases, but just these disturbances are among the most com- 
mon ills of the period of life in which acne most frequently occurs, and 
yet are only exceptionally accompanied by the latter. That the cuta- 
neous affection is often aggravated by such internal disorders is, without 
doubt, true. 
The few cases of impetigo (nineteen) and ecthyma (fifty-five) here 
recorded need but a word of explanation. The names do not necessa- 
rily signify distinct individuality of the affections included under them, 
but certain conditions of the skin due to a variety of causes,- and closely 
allied to, or merely advanced stages of, eczematous inflammation. The 
distinction between them is largely one of degree ; impetigo meaning 
the occurrence of small, discrete pustules without other accompanying 
forms of efflorescence, and not in the course of other cutaneous diseases, 
and ecthyma comprising the larger and deeper seated forms of efflo- 
rescence, such as occur in connection with, or as sequelae of several affec- 
tions of the skin accompanied by irritation, and in persons whose gen- 
eral condition is below the healthy standard. Groups of cases presented 
themselves in several instances which might, perhaps, be called impet- 
igo contagiosa, if we were prepared to admit the existence of such an 
independent affection. They were remarkable, however, chiefly for oc- 22 
Analysis of Cases of Skin Disease. 
earring simultaneously in members of one family or of contiguous house- 
holds, but individually were not strikingly peculiar. Similar cases at 
least, if occurring singly, would not attract especial attention. No 
element or certainty of contagion was discovered in connection with 
them. 
Class Y. Haemorrhages (19 cases). The affections comprised under 
this class were cases of simple purpura. They were of a mild type, 
affected mostly the legs, and were rarely associated with apparent dis- 
turbance of the general economy; indeed, the presence of the attack 
was in several instances discovered only by accident. A feeling of slight 
weakness in the legs was the most prominent accompanying symptom. 
Several of the cases were chronic in course, outbreaks of the haemor- 
rhagic spots following each other either continuously or interruptedly for 
weeks and months. Unfortunately, they yielded no insight into the 
causes of this mysterious disease. 
Class VI. Hypertrophies (40 cases). The hypertrophies of the 
cutaneous tissues are divided by Hebra into three groups, characterized 
as follows : Ist, increase of pigment; 2d, thickening of the epidermal or 
horny layer with or without accompanying changes in the papillae, called 
keratoses; and 3d, hypertrophies of the connective tissue. In Table 
11. the separation of the last two is not properly indicated, scleroderma, 
and elephantiasis arabuni belonging to the third group. The cases of 
pigment change included in the list, eighteen in number, were trivial in 
character, and consisted of an abnormal increase in amount of the col- 
ored cells of the rete distributed either in the form of small spots, len- 
tigines; larger patches upon the face, chloasma (moth) ; or more ex- 
tensive and more generally distributed stains upon the skin, melasma or 
nigrities. 
Among the keratoses, or affections of the epidermal structures of the 
integument and its appendages, the most interesting cases were five of 
ichthyosis and one of cornu cutaneum. Of the former, four were girls 
between the ages of four and nineteen ; the other was a man, aged 
7 O 
twenty-six. All had had the affection from earliest childhood. It was of 
a mild type, ichthyosis simplex, and of general distribution. In one of 
the cases only was there an approach to the form called ichthyosis 
hystrix, and in this only of partial distribution. All but one were in 
good general health. 
o o 
Cornu cutaneum penis. The case of cornu was a remarkable one, 
and deserves especial mention. The subject was a gentleman thirty-six 
years old, who at the age of twenty-two was circumcised for congenital 
phymosis. The surface of the glans and sulcus coronalis remained 
ever afterwards very sensitive, and there was an undue amount of 
seborrhoeal secretion from the parts. In 1870 this secretion became 
still more excessive, and the parts gradually assumed the condition he Analysis of Cases of Skin Disease. 
23 
presented at his first visit, in October, 1874. At that time the remnant 
of the foreskin, about a quarter of an inch in length, was converted into 
a thickened collar standing up perpendicularly to the body of the penis, 
and having a horny, cartilaginous feel. The exterior cuticular portion 
was red and scaly; its inner surface, the deep cavity of the sulcus, and 
the posterior half of the glans around their whole circumference, were 
uniformly covered with a thick, white, pasty coating. This material 
was soft in some parts like putty, in others, where exposed to the air, as 
hard as spermaceti, and could be dug out with a knife by the patient from 
behind the glans to a considerable depth without sensation. The only 
thing complained of by him was the inconvenience and annoyance of 
the affection. When pressed upon, “it hurt,” he said, “just as any 
other foreign substance would in such a sensitive location.” The for- 
mation of the material was stated to be quite rapid, “ at the rate of 
one-hundredth of an inch in thickness per diem.” From the parts ex- 
posed it sometimes cracked off when dry, but the material was every- 
where kept down by the patient by frequent scraping with a knife. This 
was the only treatment the disease had received. Some of the sub- 
stance was examined by the microscope, and found to be composed of 
epithelial and sebaceous cells. Of the condition of the skin beneath the 
coating nothing could be learned, as it was completely concealed by it. 
The patient was directed to envelop the parts in a thick layer of diach- 
ylon ointment spread upon cloth by night, to apply sweet oil freely in 
the morning, then to wash them with soft soap, and to keep them cov- 
ered by day with a cloth thickly spread with glycerin-plasma. A strong 
solution of tannin in glycerin was also to be painted on daily after the 
removal of the coating. . . . After a fortnight’s treatment the patient 
wrote: “ The results are very satisfactory so far. The ointment softens 
the layer, and the oil and soap aid the process so that after their use I 
can remove with my knife thin layers from the surface of the secretion 
by simple scraping, without cutting and without injury to the part, and 
I have thus removed more than nine tenths of it. On the removal of 
this dense, gristly mass the foreskin, which you saw curled up, and 
which could not be straightened, has now resumed its original form, flat- 
tening out into its natural shape. The whole layer is now so thin that it 
is no longer white, but flesh-color, from the color of the subjacent skin. 
The tannic acid now penetrates and causes in some places a certain 
amount of redness and congestion underneath. lam confident that the 
daily amount of secretion is much less.” 
I heard nothing further from the case for seven months, when the 
patient wrote that he had used the treatment four months and then had 
left it off to see what had been accomplished. The result, as he stated, 
was that in a month the parts were again covered as thickly as befofe, 
and that they had also become quite sensitive and at times painful. The 24 
Analysis of Cases of Skin Disease. 
matter had collected to one fourth of an inch in thickness in some parts, 
and when removed was found to grow from closely-matted, fringe-like 
projections rising from tire surface of the skin. In other parts the base 
was described as resembling a seed-wart. Where the disease bordered 
•upon the true skin at the edge of the prepuce the growth was said to be 
as “ hard as horn.” 
Six months afterwards, when he came for further advice, a great 
change was found to have taken place in the affection ; from its ’seat, as 
above described, had grown up a remarkable horn. Its base occupied 
the inner surface of the remnant of the foreskin, the sulcus coronalis, 
and the adjacent half of the glans, narrowing in width gradually on the 
under side of the organ, and failing to meet and complete the ring only 
by the breadth of the frsenum, which remained unaffected. In its widest 
portion for two thirds of its circumference the base measured three 
fourths of an inch. It had a uniform height of about half an inch, 
but in its central portion, corresponding to the median line of the 
dorsum penis, the growth presented a marked prominence or peak 
more than three fourths of an inch in height. Its greatest diam- 
eter .laterally was an inch and a half, while from the dorsum to the 
frsenum it measured an inch and an eighth. Viewed from above it 
resembled the vertebral axis in shape more than any other familiar 
object of comparison, the central opening occupied by the free surface 
of the glans corresponding to the cavity for the spinal cord. Its per- 
pendicular surface was marked by parallel upright striae and ridges, 
resembling coarse nail-tissue, while its broad, plane tip offered a trans- 
verse section view of its lamellar or fibrous structure. Its color was 
yellowish-white. The exterior surface was very firm and horn-like, but 
the central portions were comparatively soft and waxy in consistence. 
Excision of the horn was advised, and the operation was performed 
by Prof. H. J. Bigelow. The growth was dissected away entire with 
the scalpel and scissors, and the mucous membranes of the foreskin and 
glans were brought together by sutures, as in the operation for phymosis. 
Some little haemorrhage followed, and the wound healed well. Exam- 
ined by the microscope after removal, the outer surface was seen to be 
composed of epithelial cells compressed into compact fibrillse or longitu- 
dinal bundles, which on cross section appeared to be arranged somewhat 
concentrically. The cells which made up the inner portion were far 
less compactly or systematically arranged, and numerous small, empty 
interspaces were visible between them. At the junction of its pe- 
riphery with the skin, the epithelial cells of the horn were seen to be 
continuous with those of the mucous layer of the epidermis, and the 
papillae were found to be greatly elongated and running up into the 
growth. No examination of the dermal tissues underlying the central 
portions, the sulcus, was made, so that the relations of the growth to the Analysis of Cases of Skin Disease. 
25 
sebaceous glands of the part were undetermined. There would seem 
to be little doubt, however, as to the mode of development in this case. 
In consequence of the congenital phyrnosis the glands of the head of 
the penis had been stimulated into overactivity, and the retention of 
this secretion beneath the prepuce had caused an inflammatory action of 
its inner surface and of the opposing glans. After circumcision the 
parts remained still very sensitive and the secretion excessive. It is 
very probable that even then there may have been some papillomatous 
growth from the sulcus, as is so frequently the case after balanopos- 
thitis from any cause, but at the time of his first visit nothing could be 
learned as to the condition of the tissues below the thick epidermal coat- 
ing. At least after the subsequent removal of the latter by the means 
suggested at that time a closely-matted, fringe-like outgrowth was seen 
by the patient, which was undoubtedly hypertrophied papillae. The 
rapid course from this period and the horny transformation of the cell- 
growth have been sufficiently explained above. We have here, then, all 
the elements essential to the formation of horns in accordance with the 
theory of their development either from disorders of the sebaceous 
glands or from hypertrophied papillae, the cells of the rete, of which 
they are composed, being deflected downwards to line the former or 
upwards to cover the latter. In the last semi-annual report on derma- 
tology 1 will be found an account of a case very closely resembling this, 
by Professor Pick, of Prag, who gives two colored plates of the growth, 
which would serve equally well for ours, had the latter been allowed to 
grow a little longer. The history of the two horns, moreover, was very 
similar. Both affected individuals were below middle life, both had 
undergone circumcision for phyrnosis, and in both the growth was of 
very rapid formation. Dr. Pick in his article refers to ten other cases of 
horns upon the glans and foreskin. This one will make the twelfth, 
therefore, of this rare affection. 
Under hypertrophy of the connective tissue there are placed four 
cases of scleroderma and five of elephantiasis arabum, diseases closely 
allied in their anatomical structures, but little similar in their getiological 
relations. Of the former, three of the cases have already been reported 
at length ;2 the other may be briefly described here. The patient was 
an Irishman, fifty-one years old. In August, 1874, he was under treat- 
ment at the skin department for chronic papular eczema of the limbs, 
the legs being the parts principally affected, which disappeared in a few 
weeks. In October, 1875, he came again, stating that his hands had 
been getting hard for a year. The integument of the whole hands 
was found to be very firm, and the fingers were of a stony hardness, 
semiflexed, and immovable in their farther joints. The hands looked 
1 The Journal, December 9, 1875, from Yierteljahresschrift fur Dermatologic und Syph- 
ilis, 1875, page 315. 
- Archives.of Dermatology, New York, July, 1875. 26 
Analysis of Cases of Skin Disease. 
dried up and horn-like. The pigment and glandular structures were 
apparently unaffected. Elsewhere upon the body the integument was 
then in a normal condition, and the general health was unaffected. The 
local sclerosis was probably in no way connected with the more general 
eczema which preceded it. 
Three of the cases of elephantiasis arabum, or pachydermia, deserve 
some notice. The first is especially interesting as an illustration of that 
variety which is associated with and apparently caused directly by peri- 
odical attacks of erysipelatous inflammation of the cutaneous tissues 
and the ensuing oedema. The patient was a girl, aged twenty-three, 
who for nine years had had recurrent erysipelatous inflammation of the 
right hand and fore-arm at irregular intervals of few or many months. 
The acute stage was generally of short duration and accompanied by 
nausea, headache, and fever. Desquamation followed, and the parts 
were left swollen for a considerable time, the duration of the oedema 
increasing with each such successive attack. When seen, the integ- 
ument of the right hand and lower fore-arm was moderately thickened 
and firm, but presented.no unusual surface-changes. No cause for the 
frequent attacks of dermatitis could be discovered. The second case 
was an Irishwoman fifty-six years old. For six years her right leg 
had been gradually enlarging from the knee downwards, without ap- 
parent cause or any positive symptoms, local or general. For a year 
before her visit the skin of the part had become eczematous, chiefly 
through scratching, and it was this symptom which brought her to the 
hospital for relief. The skin of the lower two thirds of the leg was 
greatly thickened, so that the part was about one half as large again as 
the corresponding portion of the other. Just above the ankle there was 
quite a deep sulcus. The eczematous condition, which so often accom- 
panies the affection, was in the rubrum stage, and was secondary to the 
deeper tissue changes. The case deserves notice principally for the 
entire absence of previous inflammatory processes within or beneath the 
integument, or other of the usual exciting causes of the affection. The 
third case to be mentioned was an erect and stoutly-built American 
woman, five feet eleven inches in height. She was born in Vermont, 
and is forty-eight years old. In early life she had some “ humor,” and 
afterwards “ salt rheum ” until puberty, at the age of sixteen, when it 
disappeared. Twenty-five years ago, when twenty-three years old, 
she sprained her left ankle, and dates her trouble back to that event. 
The part never became quite strong again, and some months afterwards 
it began to be red and swollen, and itched greatly. It was much 
scratched, but there was no breaking of the skin or ulceration, although 
the veins became varicose from the knee downwards. From this period 
the leg constantly increased in size, although very gradually, the sur- 
face-changes in the skin never wholly disappearing. Analysis of Cases of Skin Disease. 
27 
At twenty-six she was married, and has given birth to three healthy 
children. She never had milk-leg or other puerperal process. Nine- 
teen years ago she could wear, by stretching, an ordinary stocking, but 
four years afterwards she was obliged to have a special last made for her 
foot. Its greatest increase in size, fully one half, has been gained during 
the past ten years. Sixteen years ago she for the first time had a chill, 
followed by feverish reaction, but without any especial local symptoms. 
Since then these attacks have been numerous, several each year, accom- 
panied or preceded by pain extending from the sole of the affected ex- 
tremity to the hip. Red streaks are seen running up the leg, but there 
is no pain produced by deep pressure or impeded motion in the limb at 
such times. Nausea has been a constant accompaniment of the attacks, 
which last about forty-eight hours. There have been three so-called 
abscesses in different parts of the leg below the knee, discharging, when 
opened, one half a cup of clear, colorless, thin fluid, and continuing to 
run for some time afterwards (lymphorrhoea). At other times a similar 
fluid has oozed from the deep fissures in parts of the skin. She never 
feels so well generally when the parts are leaking in this way. Seven 
years ago a chronic ulcerative process of the skin began on the right 
wrist and left elbow, which lasted many months, and left scrofulous-look- 
ing scars and some still prominent and red tubercles there. 
When first seen, four years ago, her condition was recorded as fol- 
lows : Patient manages this enormous limb with comparative ease and 
little suffering. She is able to walk quite long distances, and does her 
general housework with little fatigue. The catamenia have not yet 
ceased, and her general health is good enough. 
The left thigh just above the knee-joint is somewhat fuller than the 
corresponding portion of the right, but the patella is easily felt. Below 
the knee the limb bulges abruptly to an immense mass, and continues of 
about the same size nearly down to the ankle. The foot is also much 
enlarged, and the skin covering the dorsal surface of the toes is very 
thick. Half-way down the calf the mass is divided by a very deep sulcus. 
To the feel it is brawny and resisting, not pitting easily on pressure. The 
surface of the skin covering the upper portion of the leg is coarse in 
texture, the hair follicles being widely separated, and largely occupied 
by eczematous fissures. Over the lower third and upon the dorsum of 
the foot the skin is largely covered by thick collections of discolored 
epidermal scales, separated in parts by deep fissures or sulci. In a few 
places the elongated papillae, capped by brown epidermal tips, stand out 
individually or in slender groups, forming a sort of shag. All parts of 
the leg are at times affected by eczema, and itch extremely. 28 
Analysis of Gases of Skin Disease. 
The dimensions of the two legs are 
Left. 
Right. 
Three inches above patella 
22 inches. 
Around patella 
19 “ 
Middle of calf 
17 “ 
Below sulcus 
28* “ 
Just above ankle 
20* “ 
12 “ 
Between folds at ankle 
16* “ 
Over dorsum of foot 
14 “ 
9 “ 
The patient weighs two hundred and twenty-five pounds. 
Since 1872 there has been but little change in her condition. The 
leg certainly lias not gained in size, and the eczema has been kept under 
by the applications used. There have been no fresh attacks of inflamma- 
tion of the lymphatics or discharge of lymph from the part. The patient 
weighs at the present time two hundred and fifty pounds. 
Class VII. Atrophies (87 cases). The instances of atrophy, although 
mostly of the rarer forms of cutaneous disease, were not of themselves 
remarkable. The case of leucoderma was simple and partial, the skin 
of the parts affected being unchanged, except in the loss of the pigment- 
cells. The maculm atrophicas occurred in a man to a very marked 
degree, being seated upon the thighs and hips. They were of an 
elongated, oval form mostly, and of a glistening, bluish-white color. No 
cause of their formation was apparent. Of the cases of atrophy of the 
hair, so called, eleven were due to preceding seborrhoea of the scalp, 
alopecia furfuracea, the most common form of baldness. The others, 
nineteen, were cases of alopecia areata, and are placed in this class in 
conformity with Hebra’s arrangement. It is not my intention to dis- 
cuss here the vexed question of the pathology of this affection ; but 
that it is of a mixed character, or, in other words, that there are specific 
clinical differences in the cases, and that a parasitic element may be 
observed in some and not in others, are conclusions I have drawn from 
both hospital and private practice. Several of the cases were of many 
years’ duration, and in these the scalp, eyebrows, and eyelids were 
almost wholly denuded of hair. In five instances some other member 
of the family was affected in the same way. 
Class VIII. Benign New Growths (82 cases).1 The eleven cases of 
keloid varied in extent from the single outgrowth of the size of a pea 
upon some to several elevated patches as large as the hand upon others. 
It is difficult in some cases to discriminate between true spontaneous 
keloid and the false or hypertrophied scars. In some instances I think 
there can be no doubt that unmistakable cases of the former have their 
origin in minute scar formations, perhaps the inconspicuous seats of 
former acne pustules. With one case of pronounced keloid atrophy of 
1 The number of cases included in this class is wrongly given in Table 11., the affections 
enumerated in the first line of the text under Class XI. (lupus and scrofuloderma) belong- 
ing here. , Analysis of Cases of Skin Disease. 
29 
pigment in the surrounding skin was associated, of the same form as in 
Wilson’s morphoea. Two of the most extensive cases were in negroes. 
One of the two cases of molluscum fibrosum was that described by Dr. 
Wigglesworth in the April number of the Archives of Dermatology and 
Syphilis : the other was of a trivial character. 
Lupus vulgaris occurred but eleven times. This appears to be a 
remarkably small percentage, but true lupus in my experience is a very 
rare disease in New England compared with its prevalence in Europe. 
The name as here used does not of course mean that heterogeneous 
mixture of affections which makes up the lupus of many surgical works 
and hospital reports, and which includes nearly every form of chronic 
ulcerative and crusting disease upon the face. Lupus erythematosus 
was relatively more common. The twenty-seven cases of so-called 
scrofuloderma represent a great variety of processes affecting the cuta- 
neous tissues of persons exhibiting signs of that general condition recog- 
nized as scrofulous or strumous. This group may be regarded as a con- 
venient temporary receptacle for a class of affections which cannot well 
be placed elsewhere, but which closer analysis will no doubt enable us 
to distribute more appropriately in the future. 
Class IX. Malignant New Growths (26 cases). One case of ele- 
phantiasis Graecorum, or true leprosy, was observed, and was the more 
remarkable that the patient was of native New England stock and had 
never been out of the United States, nor had there been in his family 
any record of such disease. It was of several years’ duration, and the 
cutaneous manifestations were of the tubercular type. The cases of 
epithelioma were nearly all of the superficial form, and affected the skin 
of the face, the deeper-seated forms and cases in open ulceration nat- 
urally seeking relief directly in the surgical department. The most 
noteworthy features in them were the frequency with which the seba- 
ceous glands were the starting-point of the affection, and the early age 
at which the disease manifested itself in several cases, the patients not 
being above twenty-five years old. 
Class X. Ulcerations (309 cases). Nearly all the cutaneous ulcers 
here included were seated upon the lower leg, and were of the most 
ordinary character. A large proportion of them were associated with 
eczema of the part, either primarily or secondarily, in the first instance 
provoking the inflammation in the surrounding skin by the nature of 
their discharges or of the applications made to them, or in the latter 
case being themselves the result of devitalization of the cutaneous tis- 
sues by the chronic eczematous process. 
Class XL Neuroses (52 cases). Were all the affections of the skin 
included in this class which have been claimed by the neuro-pathologist 
in recent times as belonging to it, there would be little need of other 
classes to receive them, for there is scarcely a disease among them which 30 
Analysis of Cases of Skin Disease. 
some writer lias not guessed to be caused by “ abnormal innervation,” 
“ trophic disturbance,” or other familiar verbal formulae of the sort. 
Now that its filaments have been traced through the corium up into the 
epidermal cells, the intimate connection of the whole skin with the 
nervous system has been as fully established as that of all other parts of 
the body ; but why it should be selected as the favorite field of the neuro- 
theorizers of to-day is not clear, unless it be that electro-therapeusis 
can be so directly brought to bear upon it. There is no more reason 
why affections of the skin should a priori be regarded as neuroses than 
structural diseases of the liver, or lungs, or kidneys. That disturbances 
of cutaneous sensibility are frequently associated with and caused by 
cutaneous affections, that similar disturbances of sensibility often lead 
secondarily and indirectly to structural disease of the skin, and that 
structural disease of nerves and their ganglia may directly give rise to 
certain well-marked forms of efflorescence are well-established facts, 
because they rest upon sound observation ; but beyond this most of what 
has been written upon the neuro-pathology of skin diseases is merely 
surmise and of the blindest character. Nerves go everywhere, they 
are distributed to all parts of the skin, they regulate all its functions 
and growth ; therefore, if anything about it goes wrong they are at fault, 
say the neuro-pathologists. The blood permeates all the tissues of the 
skiu, it supplies the nutrition upon which the growth and functions of 
the latter depend, itself may be laden with peccant elements, therefore, 
if the skin is diseased it is the blood, said the humoral-pathologists. Let 
us be content with the teachings of observation. That zoster might 
& o 
well be placed among the neuroses is universally acknowledged, but the 
only other affections upon the list which can claim a position in this class 
are the fifty-two of simple pruritus and the two of exalted sensitiveness 
of the skin, or hyperaesthesia. Associated with the cases of pruritus 
were many secondary changes in the skin, such as are capable of being 
excited into existence by scratching and other means resorted to for 
allaying itching. 
Class XII. Parasitic Affections (549 cases; vegetable 278, animal 
271). Tinea tonsurans was bv far the most common of the former. 
Its varieties in the one hundred and eighty cases observed were as fol- 
lows: Forty-two were seated upon the scalp, and affected children 
exclusively ; thirty-eight were of the bearded parts of the face in adult 
males, parasitic sycosis ; while the other hundred cases were ordinary 
ringworm upon various parts of the body, mostly those unprotected by 
clothing, in persons of both sexes and all ages. Most of the children 
with the disease upon the scalp had also ringworms upon other parts of 
the body, or had had them in the earlier stages of the affection. Nearly 
all the cases of parasitic sycosis, too, began as simple ringworm of the 
bearded face, which in periods ranging from three to twelve weeks Analysis of Cases of Skin Disease. 
31 
assumed the characteristic appearances of this later stage of the disease, 
and many of them exhibited recurrent outbreaks of the circinate form 
upon other parts of the body, which served as more fertile sources of 
contagion to other members of the family during the prolonged course 
of this most stubborn disorder. A large proportion of these patients 
were sure that they had taken the disease at the barber’s shop. All 
forms of the affection were shown to be easily transmitted and con- 
tracted. The clinical history and microscopic examination of these 
cases of sycosis make the existence and even the frequent occurrence of 
the parasitic form of the disease a matter far removed from question, 
and the refusal of Professor Hebra to accept the former inexplicable, 
although there can be no doubt that it is much more common here than 
in Vienna. 
Tinea versicolor comes next in order of frequency, and in this respect 
it would doubtless approach tinea tonsurans nearer, were as large a pro- 
portion of the cases which really exist treated, for whereas the latter in 
all its forms occurs generally upon the most exposed parts of the sur- 
face, tinea versicolor avoids these altogether, and may exist even for 
long periods of time without betraying itself to the bearer, so slight in 
many cases are the subjective symptoms it causes. The extent of sur- 
face affected varied from a few small circular patches in some patients 
to its almost continuous distribution over the trunk and limbs in others, 
giving a uniform dark-buff or brown color to the whole skin, excepting 
the face and hands. In many instances the disease was discovered inci- 
dentally in the examination of the chest by the physicians of the other 
departments of the hospital. In a large proportion of the cases it had 
existed several years, generally extending in summer and diminishing 
somewhat or being less apparent in winter. In four cases only out of 
the eighty-one did inquiry elicit the fact of its known transference from 
one person to another, even among married people, in cases of many 
years’ duration, nor was anything learned of the ways in which the dis- 
ease is generally contracted. 
Tinea favosa occurred only seventeen times, and even this small num- 
ber by no means represents so many individual instances or centres of 
the disease, because more than half of them were cases where two or 
three members of the same family were affected. In the others no 
known transference to other hosts had occurred. All of them had ex- 
isted for a long time, and in all but three the growth was confined to the 
scalp. In one case it not only covered the scalp, but large portions of 
the trunk and parts of the limbs. 
Tinea decalvans was represented by some of the cases placed under 
alopecia areata, but what proportion of these were parasitic cannot be 
stated for want of complete observation. 
From this very brief analysis of the vegetable parasitic affections we 32 
Analysis of Cases of Skin Disease. 
may draw the following conclusions : Tinea tonsurans in all its forms is 
of very frequent occurrence, is easily communicated, and the latter may 
sufficiently explain the former. Tinea versicolor is less common, but 
occurs oftener than is suspected, and it is communicated with very great 
difficulty. It is probable, therefore, that extraneous sources of contagion 
exist about us, the nature of which is as yet unknown. Tinea favosa is 
here very rare, and occupies with respect to contagiousness an interme- 
diate position between the above. 
Animal parasites. The number of cases of phtheiriasis capitis re- 
corded might no doubt have been greatly increased if every patient had 
been specially examined for the presence of pediculi. The number 
given includes only those cases in which the parasites were the cause 
of so rAuch eczematous inflammation of the scalp and contiguous parts 
as to lead to their discovery. 
It would have been more satisfactory if, in concluding these neces- 
sarily brief and imperfect notes upon the occurrence of skin diseases at 
the out-patient department of the hospital, the results of treatment might 
also have been presented, but, as stated in the beginning, the control of 
the physician in charge over this class of patients is so uncertain that 
anyr such conclusions must be in the main imperfect and unreliable, and 
therefore unwarranted.