DURATION. TRIVATE. PUBLIC. TOTAL

mo. to 3 mos. . .

IG

1 yr. . . .

yr. lo 2 yrs . . .

Total .

Ti

It is seen here that a large number of cases, over one half, were seen for comparatively short periods of time, less than six months, and in looking.at the notes of these cases we fmd that quite a proportion of them yielded to treatment and were apparently cured, while of course a large number were lost sight of before any conclusions could be drawn as to the ultimate results of treatment; the remaining half of the cases were seen for varying periods of time, more commoniy, however, not in consecutive months or years, but often after a lapse of a greater or less length of time. In studying the records of these cases we ünd that as we advance in the length of time during which the patients had previously had the disease, and also in that during which they were under treatment, we discover a smaller proportion of them receiving permanent benefit, until, in many cases which hâve been for some years under observation and treatment the question of therapeutics has narrowed itself down to removing récurrent éruptions or preventing tbeir appearance on

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exposed régions. In sonie instances, however, careful and continuons treatment has held the éruption almost entirely in abeyance, even for a great number of years, as in the following case :

This case, which has been for the longest period of ail the cases under observation and treatment, is that of a clergyman now 50 years of âge, who was flrst seen about twenty years ago. The éruption had begun about eight years. previous to his flrst visit, when he was 22 years of âge, it appearing flrst in the scalp. The disease progressed very slowly and did not become very general until four years later. He has spent much time at different minerai springs with varying results, at times the éruption improves greatly but always relapsed into a worse condition. He was also under various medical treatment until the time of his flrst visit in 1869. He then had a very general, psoriasis, and on account of this and a throat difficulty he was unable to pursue his calling as a clergyman for some years.

He was put upon Fowler’s solution with the occasional use of other remédies, the local treatment consisting mainly of tarry applications, with the effect of keeping him practically free from his éruption which, however, would return with any great neglect of treatment. He has taken as high as almost eight ounces of pure Fowler’s solution in the course of a single year, and, as he calculated it several years ago, he had taken over half a gallon of pure Fowler’s solution in the course of fourteen years.

The case next longest under observation is that of a gentleman also now 50 years old, who was flrst seen in 1869, twenty years ago, and at intervals up to the présent time; the éruption flrst appeared on him also at about twenty years of âge, ten years before his flrst visit. During this interval of thirty years he has been at 'times under the care of many physicians in this country and abroad, and has tried many minerai springs, but when last seen, quite recently, he returned for treatment in about the worst condition that he had ever been. The disease then covered large areas, forming great patches many inches in diameter, resembling the surface of pityriasis rubra, and at times causing him great suffering. He is*a very gouty subject.

Another case which has been under observation and treatment off and on seventeen years is that of a gentleman who, curiously enough, is now also just fifty years of âge, in whom the éruption flrst showed itself when he was twenty-flve years old, eight years before his flrst visit. During this period the éruption has varied greatly in intensity, at times disappearing almost entirely when he relaxes from work, especially during the summer vacations. Of late years the disease has become quiescent, giving but little annoyance but still lingering in certain localities, as the scalp, and increasing when he is taxed with overwork. Numbers of cases could be cited where the disease had been watched and treated with varying success during periods of from ten to fifteen years, with the history that with each neglect of treatment a récurrence or an increase of the disease has more or less quickly followed.

In very many instances it appears to be quite clear that the obstinacy of the disease dépends Jargely upon the irregular and imperfect manner in which the patient has carried out the treatment, and upon an interruption of the same just when it promised success ; for with an éruption of this nature which gives comparatively little personal discomfort, especially when it has been lai’gely removed, it is exceedingly difflcult to secure a faithful and persistent

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carrying out of the remédiai measures suggested. So many patients fondly suppose that when the éruption is improving the gain will be continuons and constant, that they to a greater or less degree relax their efforts, and become more or less careless in their treatment, until,[finally, a fresh crop of éruption warns them of the necessity of resuming the active fight.

There can be no greater error than this on the part of the physician or patient, for the natural history of the disease shows conclusively that it has almost no tendency to a self limitation; but, having once begun the disease exceedingly likely to continue during ali of the patient’s life, unless checked by medical means or by other influences relating to diet, hygiene or climate, of which we know but little.

Although it has just been remarked that in a considérable share of cases the rebelliousness of psoriasis is largely chargeable to the patient’s carelessness and want of persistency in treatment, it is doubtless true that in a certain proportion of instances, which I believe to be relatively small, the disease really seems to be incurable, however faithfully and intelligently the treatment may hâve been prescribed or carried out.

This is exemplified in the case of a young lady who was under observation and treatment for twelve years : the éruption had begun in her twenty years before she was first seen, when she was but ten years old, and itpersisted in spite of much and varied treatment, which it is believed was faithfully carried out. A certain amount of benefit could always be obtained, but it would only be transitory; remedies would soon lose their effect and disagree with thé patient and the course of the case was often most disheartening. The face was a prominent point of attack and the éruption very often caused her much distress, both mental, and at times, physical. When lest seen recently, at about 4ô years of âge, the éruption was still présent to a very tcoublesome degree.

From the well-known rebelliousness of the disease the question is often asked whether it is really curable, or whether it must not be reckoned as an incurable affection. To this I commonly reply that the disease is indeed one of the most rebellious of ail those appearing upon the skin, but that in a certain proportion of cases it is undoubtedly curable, under proper conditions. The relative curability of psoriasis appears to dépend very largely upon several conditions, such as, the âge at which the éruption first appeared, the period in the disease at which treatment is commenced, the character of the treatment employed, and the faithfulness with which the same is persisted in.

In regard to the âge at which the éruption appears, psoriasis is certainly most easily coutrolled in children, if taken hold of vigorously and if treatment is persisted in faithfully. 1 therefore urge parents most earnestly to sacrifice every thing in the attempt to free their children from the disease in their earliest years, for, if neglected or improperly treated, psoriasis is not only far more likely to persist many years naturally, but will probably become more and more rebellious to treatment. Cases of psoriasis first developing between the âges of 20 and 25 years are apt to be exceedingly rebellious, although I hâve known such instances to be cured : those in which the éruption appears much later in life will often yield very readily, especially if they occur in gouty subjects where this element can be modified by diet or treatment.

This brings us to the second point, viz. : that the prognosis of psoriasis

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dépends considerably upon the date in the disease at which the treatment is commenced. When the éruption has existed for a long time and the psoriatic habit has become, as it were, thoroughly pronounced, it often seems exceedingly difficult to do more than to give temporary relief, very little being accomplished in the way of preventing relapses or eradicating the real disease .

The third element having to do with the prognosis of psoriasis is the character of the treatment employed. I am well aware that there are not a few who, regarding psoriasis as a local disease of the skin with no constitutional relations, will not at ail agréé with me in reference to the matters about to be stated. Time does not permit of a full discussion of this most important subject of the constitutional relations of psoriasis, and as this is a clinical paper I will only briefly state my own position and belief in the matter, as it has been developed from extended study and observation.

In my judgment it is not sufficient to regard cases of psoriasis solely from the standpoint of removing the éruption which happens to be présent at the time of consultation. I believe that more ought to be accomplished than this, and I believe also that with due diligence and proper care more can be accomplished. While we cannot at présent speak of the cure of psoriasis, that is its permanent cure, with any amount of certainty or satisfaction in individual cases, it is undoubtedly true that in a certain proportion of instances such changes in the habits and condition of patients can be affected by prolonged and skillful medical care, that the disease, or its skin manifestations, will remain absent.

While we must agréé with Robinson (1) and Jamieson (2) that « the lirst step in the diseased process is taken by the cells rete Malpighi, which lie next to the derma, and not by the papillae, and that psoriasis cannot be regarded as primarily an inflamatory disease or affection of the upper layer of the cutis, » we must still hold to the belief that psoriasis is not a local disease of the skin such as are the parasitic affections, epithelioma, vei'ruca, etc. As we believe, psoriasis in some way dépends upon an unknown constitutional condition, more or less akin to rheumatism and goût, and unless this condition is altered, the éruption will recur at different periods and with varying severity. To be successful, therefore, the treatment of psoriasis must include diet, hygiene, and proper medical measures, including both internai and external médication.

The nature and character of the measures necessary to affect this will be considered later under the head of the treatment of the disease.

The heredity of psoriasis is a subject of some little interest and one which deserves more attention than has hitherto been paid to it. The impression is very general that the disease in commonly acquired by inheritance ; indeed, this is about the only etiological element which is recognized with any certainty by most writers upon the disease. It is a little difficult to obtain reliable data in regard to this matter, and but little value can be placed upon the slatements obtained from the mass of patients commonly seen in public practice. In the more intelligent class of patients seen in office practice, however, we can

(1) Robinson. New York Medical Journal, July, 1878.

(2) Jamieson. Médico-Chirurgical Society of Edinburgh, November, 6 tb, 1878.

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generally obtain the necessary facts with a little care, and this has been doae in a large share of the cases here analyzed, in private practice, the patients being interrogated both as to the positive and négative aspects of the question, and the results obtained in the 322 cases are exhibited in table Y :