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Malpractice is the failure to use due care, average skill, and precaution. Personal injury cases (torts) make up 80% of Superior Court dockets. Professional liability cases against physicians comprise a very small proportion of these. Compare, for example, the effect of 70 million automobiles colliding with each other with the alleged negligent acts of only 280,000 physicians. However, in addition to the size of possible judgments ($100,000 is no longer uncommon), the physician may go through three or four years of soul-searching anguish as a malpractice defendant. Insurance comes high. For a California dermatologist, $500 to $700 per year is not unusual, depending on how provident he is or how insecure he feels. About half of this amount goes for radiation coverage. In actual fact, suits against the dermatologist for presumably careless use of radiation are rare, and judgments have not been astronomic. Despite hydrogen bombs, with subsequent worry

Antifolics are rational for psoriasis. Normal renal clearance is of vital importance; this may be true of normal liver functions as well. No fatal or near fatal reactions occurred in our series. We have reviewed two deaths following aminopterin (Aminopterin Sodium) therapy, apparently from inadequate renal clearance, one severe reaction for the same reason, and one death apparently due to inadequacy of bone marrow function. One death after parenteral methotrexate was from sepsis following leukopenia. Fatal reactions may occur after leukopenia develops; it is therefore vital to select patients carefully and to make certain that there are no contraindications at the onset. Antifolics should not be used when there is any possibility of pregnancy, because of possible fetal malformation. However, normal full-term pregnancies have occurred following administration of these compounds to either the father or the mother before the pregnancy started. Most dermatologic teaching services in this country use antifolics for severe psoriasis and would support a petition to the Food and Drug Administration to include listing of severe psoriasis as an indication for these drugs. Most services also would support the continued manufacture of aminopterin. There are many variables to account for relative unpredictability of toxic and beneficial effects, such as instability of the compounds, presence or absence of relative folic acid deficiency in the patient, variable absorption and excretion, and all the other variables which affect the action of any drug. Elderly patients, possibly due to occult decline in renal and liver function, are poor candidates for antifolic therapy. Rare hypersensitivity reactions may occur. Only about 10% of our original group of patients still take antifolics for psoriasis. Reasons for discontinuation of the drugs include lasting remission in about 10%, response to other treatment in some instances, advanced age, unwillingness to undergo necessary safeguards in some, and unknown reasons in others. Two patients have developed leukemia, one of an aleukemic nonclassified variety, and the other an acute leukemia. Neither case of leukemia occurred in close relationship to antifolic therapy. Some of the reactions encountered in the past apparently may now be explained on the basis of impaired renal clearance. Liver function tests (serum glutamic pyruvic transaminase and cephalin flocculation) performed on 31 patients receiving over 100 tablets of aminopterin or in those who have had reactions in the past have showed normal readings for the most part. Three patients showed abnormality in 48-hour cephalin flocculation test reading. Methotrexate for psoriasis needs further investigation, both for oral and parenteral use, because this compound might possibly be safer and more effective than aminopterin if adequate and safe dosage schedules can be found. For summary of standard approach, see Table.

• Although there were relatively few dermatologists in the United States in the years 1870 to 1920, San Francisco was well represented by the nine dermatologists who were active in the city during that time. These included George J. Bucknall, Alfred E. Regensburger, Douglass W. Montgomery, Howard Morrow, Harry E. Alderson, George D. Culver, Ernest D. Chipman, Hiram E. Miller, and Lawrence R. Taussig. Seven were members of the American Dermatological Association, all but one were active academically, and several rose to great heights in their profession, community, and nation. (Arch Dermatol111:1377-1381, 1975)

Outstanding advances relating to dermatology for the period 1968 to mid-1969 include discovery of an enzyme-lack for removing ultraviolet damage in xeroderma pigmentosum, the promise of viral control by enzyme inducers and new drugs, finding smudged and shattered chromosomes in untreated psoriasis, radiologic cure of Hodgkin's disease, synonymy of the virus implicated in infectious mononucleosis with that recovered from Burkitt's lymphoma, similarity of Langerhan's cell and that found in histiocytosis-X, deep corneal dystrophy in X-linked ichthyosis, widespread application of immunofluorescent techniques in investigation of pemphigus, pemphigoid, lupus erythematosus, and vasculitis, qualitative defect of leukocytes in granulomatous disease of childhood, real effectiveness of paraaminobenzoic acid (PABA) and its salts in ethyl alcohol for light-sensitivity disorders, a simple and useful culture medium responding with color change when griseofulvin-treatable organisms are present, and many others.

Aminopterin (4-a m i n o-pteroylglutamic acid) is a potentially dangerous drug. It can favorably affect the lesions of psoriasis regularly, but the range between beneficial and toxic doses is narrow. The possibility of irreversible bone marrow aplasia is of chief concern in toxicity. Gubner 1 has shown, however, that administration of the drug in conservative doses to nonleukemic individuals does not provoke such a disastrous complication. He has made the following observations: significant changes in psoriatic lesions were observed regularly in all patients (a total of 13, of whom 7 had associated arthritis) who were given Aminopterin. The dosage was 1.5 to 2.0 mg. daily, the total dose varying in individual cases from 14 to 140 mg. in from 10 days to nine months. Scaling stopped between the 5th and 10th days. Several patients had hemorrhagic crusting in the lesions at the time of improve

Acrokeratosis Verruciformis (Hopf). Presented by Major James Drake, M.C., U. S. A. Captain W., a 43-year-old white nurse-anesthetist, first noted the present eruption on her hands and feet at the age of 23. However, she recalls that as a 6-year-old child she was taken to a physician because of excessive peeling of the feet unaccompanied by any inflammatory phenomena. Since the onset at 23 there has been no remission. During the period from 1938 to 1940, the patient received an estimated total of about 1,500 r. to the hands and feet with no benefit. She believes that her father has this same condition on the hands, and, on close questioning, it is probable that his eruption is of this general nature rather than eczematous. Her general health has been good, with the exception of a three-year period when she was a Japanese prisoner-of-war during World War II. At that

Methotrexate is used for psoriasis by the majority of teaching services of dermatology in the United States. Three modes of administration were compared: small daily doses by mouth in interrupted schedules, single large weekly oral doses, and parenteral doses. All methods were effective and had toxicity, but the parenteral route showed the greatest toxicity. The drug is contraindicated in pregnancy, hematological disorders, peptic ulceration, and liver disease. Chromosomal breaks have been reported with greater frequency than normal. Renal clearance is vital. The drug should be considered only for very severe forms of psoriasis.

The prudent physician needs professional liability insurance to indemnify him against judgments, the cost of defense, and false or unfounded claims and suits. A physician is not a warrantor of cures, yet the public (who make up juries) expects near infallibility from physicians. 1 Malpractice is the failure of a physician to use average skill, due care, and precaution in rendering his professional services to a patient. 2 The concept of medical malpractice has been altered by the courts and by articles written by legal scholars in recent years to compare the physician's care of a patient in the light of what may be looked on as the very best care in a community. 3 The care rendered by a board-certified dermatologist will generally be compared with the practice by other specialists in the same field, since specialists probably will be called to testify concerning the prevailing standard of care rendered in that community.

The value of antimetabolites for psoriasis was first observed by Gubner. 1 He pointed out that the suppressive effects of aminopterin were much greater on epithelium than on blood-forming organs. Aminopterin (4-aminopteroylglutamic acid) is a metabolically useless analogue of folic acid. Folic acid is necessary for normal cell reproduction because it is converted in the body to folinic acid (citrovorum factor) which participates in several essential biochemical reactions. Aminopterin competes with folic acid to prevent its conversion to folinic acid and also competes with folinic acid in its biochemical reactions. 2 Methotrexate (4-amino-N10-methylpteroylglutamic acid) is another folic acid antagonist related to aminopterin in structure. Methotrexate tablets contain 5 times the concentration of drug as aminopterin tablets, but produce fewer toxic reactions. The pathologic state of the epidermis in psoriasis is one of excessive mitotic activity and incomplete cellular maturation. The benefit of both topically and systemically used therapeutic agents can

To the Editor.— I wish to point out a source of error in the cooperative study titled "Psoriasis-Liver-Methotrexate Interactions" appearing in theArchives(108:36, 1973). I have been puzzled for some time now by the statement of the International Cooperative Committee on this subject to the effect that the daily oral dosage schedule of methotrexate was found to be significantly associated with the presence of liver damage, with the implication that the weekly schedule and the Weinstein schedule were less offensive. This has not been the experience that a group at the University of California at San Francisco has recently shown in an article submitted to theArchivesfor publication. Some clarification of the problem is made in a separate article by one of the leaders of the aforementioned cooperative study. The statement is made in the article by Weinstein ( Dermatol Digest 12:49, 1973) that the daily oral schedule referred

Recent demonstrations of chloroquine retinopathy suggest the need for re-evaluation of the drug's therapeutic efficacies as compared with toxicity. This review attempts to summarize the portion of the massive chloroquine literature most pertinent to dermamatology. Mode of Action The mode of action of chloroquine remains poorly understood. Granuloma pouches produced by air and croton oil in guinea pig skin treated by chloroquine demonstrate an anti-inflammatory mechanism different than that of corticotropin, cortisone, or the salicylates. 1 In addition, therapeutic action is not related to adrenal cortical function. 2,3 Chloroquine does not act as a sun-filtering agent systemically, but may suppress a specific photoallergic response. 4 The claim that chloroquine's structure resembles riboflavin and apresoline has led to an intriguing hypothesis 5 ; such speculation has not been useful. There are many theories as to mechanism of action, but none is proved. 6,7 Distribution and Excretion Urinary excretion of chloroquine is slow