ing, though possibly the right carotid might have been tied another experiment in hope of relief. But I might say here that I do not approve of operative treatment of non-surgical disorders such as hysteria.

Since I began to write this paper, I heard a physician say in one of our hospitals that to make a successful practitioner, a man did not need much knowledge of anatomy, or pathology, or even to be a good diagnostician. All he needed was to know how to manage his patients. While I was willing to admit the value of being able to manage patients, and that a large number would recover anyway as he said, I had a very different idea of success than the remark quoted would imply, and asked him what of that relatively small number who will not "get well anyway?" He said "They will die anyway." But such is not the case, for many persons live to become chronic invalids for years, who with a correct diagnosis and proper management ought to be useful men and women.

I think this is sufficient in the way of illustrations to show the kind of practice of medicine this paper is directed against, that is, a practise marked by carelessness, indifference, inefficiency and guess work. That this kind of practise is all too common, and works discredit to our profession is a matter of daily observation, as much of my work is with patients who have been ailing and doctoring for months or years, often with many physicians. This discredit to the medical profession is not the result of the occasional disastrous result to the patient, for it is proverbial that when one is dead he is soon forgotten, but it often happens that a person lives and goes round saying "I doctored six months with Dr. So and So, one of your leading physicians, and was no better but rather worse at the end of that time," or as mentioned before, "I have been from doctor to doctor for five years, and one after the other has told me to try this or that, and none of them have really helped me, and no one has ever carefully examined me. I think they did not know anything about my trouble but were just experimenting."

These are the things which breed lack of confidence on the part of the public, prevent proper medical legislation, and foster the growth of every ism and pathy, and furnish a field for the quack, and advertising charlatan who announces "consultation free and a positive diagnosis of your trouble." I hope I shall not be misunderstood as arraigning the whole profession in this regard, for that is not my intention, and I believe that no more careful and conscientious body of men exists than our profession as a whole, yet the evil mentioned is sufficiently common to make a point for my paper, and it is in the interest of that large body

of careful workers that this subject is discussed, for the general medical body suffers more or less, as does the human body, when any member suffers, or imperfectly performs its function.

402 EAST GEnesee StreeT.

An Interesting Case of Dermatitis Exfoliativa

THE

BY WILLIAM A. HOWE, M. D. Phelps, N. Y.

HE case which I am desirous of bringing to your attention today, had its inception in March, 1895. It again manifested itself in January, 1900. These two attacks were incorporated in an article which I was privileged to present to this society on October 16, 1900, and were subsequently published in the BUF FALO MEDICAL JOURNAL in February, 1901. Since January, 1900, the same patient has suffered two further attacks, one in December, 1907, and the other in July, 1908.

It is these recent relapses which have induced me to supplement my former report, and still further record my latest experience with this rare and highly interesting condition.

The symptoms from which this patient suffered differed more in degree than in character. In the first two attacks he was profoundly ill, in the third he remained in bed only a few days while in the fourth he scarcely kept the house.

Inasmuch as his local and general symptoms were so fully set forth in my former article, to which reference has been made, and since you will find the symptomatology of this disease comprehensively discussed in our more recent textbooks on dermatology. it seems rather unnecessary for me to repeat them here, thereby needlessly prolonging this report. Notwithstanding the wide range of constitutional and local symptoms, which he exhibited, the characteristic desquamation of the epidermis was in each instance much the same in its extent.

Not so, however, in the damage done to the deeper tissues. Here the more intense the dermic inflammation and the longer its duration, the more serious and lasting was the damage done to the subepidermal tissues. In spite of the fact that for thirteen years he has been a periodical sufferer from this strange malady, his skin, while rather dryer and rougher than that of the average individual, is far from the condition in which you would naturally expect to find it. Between these relapsing attacks he apparently enjoys the best of health.

One subjective symptom, not mentioned, so far as I know, in any of our textbooks, has been that of gastro-intestinal fermentation, accompanied with a great deal of flatus. While not wishing to attempt the etiological consideration of this disease, the uni

formity and persistency of this prodromic symptom, in my case, has been such that I should not be justified in omitting its mention. Fossibly it is simply coincident, and yet it may, at least be suggestive of an autointoxic condition, most potent in its bearing, to the ultimate solution of the much disputed cause of this obscure affection.

But this case has appealed to my interest, not so much on account of its subjective or general symptoms, as from the rare specimens, which have been collected throughout its course.

The specimen marked No. 1, was taken from this patient in January, 1900. It is possible that some of you may recognise it as being one of those which I exhibited in Rochester, when I first presented this case. Since then, it has been kept in an ordinary paste board box, and though more than eight years have elapsed, it is, as you will see, in a perfect if not a permanent state

of preservation. This has evidently arisen from the completely desiccated condition of the epidermis when it was exfoliated.

While you will notice that only one specimen is shown from this attack, you will further observe from the photographs marked No. 1, 1900. that both hands and both feet were equally involved.

The specimens marked No. 2, were secured on December 13, 1907. Like those of 1900, they are very complete and apparently in a lasting state of preservation. At this time, the epidermis of the right hand was turned inside out in its removal, much as you would remove a glove in the same manner.

The exhibit marked No. 3, resulted from the relapsing exfoliative dermatitis from which he suffered in July, 1908. This last recurrent exacerbation, as you will note, followed the preceding one in eight months, for which reason the desquamated epidermis was much thinner and softer than that seen in the earlier attacks.

These last specimens when given off retained for several weeks an appreciable sense of moisture, yet they have never shown any disposition to disintegration and are now in the same fixed state of preservation so characteristic of the earlier ones.

While dermatitis exfoliativa or pityriasis rubra may be comparatively frequent in the experience of the busy dermatologist, I can but believe it is extremely rare to the general practition

er. Except one acute and rapidly fatal case this has been the only instance in which it has come under my observation in over twenty years of rather extensive general practice. What has been the experience of my hearers? How many of you have seen a case like it and what was your experience with it? In searching medical literature I fail, especially in the several journals at my disposal to find recorded any cases of this strange disease, which has in its existence so many possibilities.

During my patient's last illness, he was given a newspaper clipping, with an account of a similar case in Trenton, N. J. Up