LOCATION

General .

Head . . .

Body .

Upper extremities . .

Lower extremities .

Genitals .

Palms and soles . .

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Thus, it was found to be diffused in ail parts of the body irr 213 instances ; tbe head was affected in 157, the body in 139, the upper extremities in 184, etc. Psoriasis very rarely affects the palms and soles, but 13 instances having been noted among the cases here analyzed.

The complications of psoriasis are often very inleresting and at times very important; appearing as itdoesat ail âges, and often lasting during many years, it naturally often co-exists with many other affections and conditions of the body As is well known, during certain general or exhaustive diseases psoriasis will often disappear spontaneously and rapidly, especially during pneumonia, only to reappear with renewed activity when the acute disease has passed off. The éruption is not at ail infrequently seen to co-exist with other éruptions upon the same patient, the one more or less masking and complicating the other; thus, among the piâvate cases psoriasis was recorded to hâve co-existed in different individuals with no less than eighteen other well recognized skin affections : in many other instances such co-existence may hâve happened without particular note having been made of the matter. First among these stands eczema, which was noted in 20 individuals with psoriasis ; acné also existed in about the same number, in a degree to call for record and treatment ; syphilis occurred in 12 psoriatic patients, while the rest of the skin affections were exhibited in one or more patients with psoriasis. Syphilis stands first perhaps in importance in this connection, and will often so complicate and mask psoriasis that it is exceedingly difficuit to détermine, with certainty, exactly the share which the two diseases bear in the éruption présent. When syphilitic infection takes place in psoriatic patients, the earliest lésions will often be found to more or less represent the disease under considération ; indeed, the spots of psoriasis will thus undergo a modification and will so resemble the new syphilitic papules scattered among them, that they are Lardly distinguishable one from the other ; the lésions of psoriasis will become more succulent, more raised, of darker red, and covered with more adhèrent, Armer, thicker, more yellow and less shiny scales. As the syphilitic poison yields to vigorous treatment, the psoriasis again résumés its more indolent, character, the lésions become paler and flatter, the scales more transparent and shiny; occasionally it will be seen that the psoriasis will yield in a remarkable manner, and largely disappear, under the effect of an active treatment given for the syphilis. But this gain is not permanent, and the psoriasis, if not properly treated, relapses speedily.

The most interesting complications or relations of psoriasis are those with rheumatism, goût, and the so-called scrofulous habit. The true causative relations between these blood conditions and psoriasis, hâve not been as yet determined, and it is very difficuit te establish them with any degree of certainty ; but clinical expérience certainly shows them to co-exist with the disease, and the symptoms of the one to vary with the symptoms of the other, to such a degree and in such a manner that there can be little doubt but that some causal relation exists between them. This is a subject which has been already considerably dwelt upon by many writers, and the French school especially hâve long recognized the arthritic relations of psoriasis. Bourdillon (1) has recently elaborated the subject very fully in regard to joint

(1) Bourdillon. Psoriasis et Arthropathies, Paris, 1888.

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changes winch take place in connection with aggravated cases of the disease, and has collected a considérable number of illustrative cases : that there is any question that these psoriatic and arthritic symptoms dépend upon the same systemic change or poison, there can be little doubt by one who has at ail carefully studied the subject and followed such cases elinically for any period of time.

While it is difficult to détermine and démon strate any accurate relation between the strumous State and psoriasis, elinically it is very easy to distinguish cases which may be placed under the scrofulous type of the disease from those which belong to the gouty class. While the éruption in this latter condition is characterized by a considérable amount of congestion of surface, frequently by much irritation of the skin, either with pain or itching, and the abundant production of thin white scales, easily shed and frequently renewed, the strumous form of psoriasis is characterized by its more indolent nature, a duller red of the patches, a greater accumulation of more yellow, thicker, and more adhèrent scales, and the total absence of any irritation on the skin. The treatment of the two classes of éruption is also quite different, and the internai remedies of value in the strumous variety prove préjudiciai to the éruption in arthritic patients. No statistics hâve ' been prepared to exhibit these features, but, from a rough estimate, I should judge that fiilly one half of the patients with psoriasis exhibited to a greater or less degree the arthritic éléments calling for treatment,- while in about one half of the remainder the strumous nature of the disease should be recognized; in the other quarter an accurate détermination with regard to these features could hardly be made.

In the large majority of cases of psoriasis the disease maintains it proper characteristics to the end, often during a long period of years ; as it recurs after a greater or less subsidence, it may appear as a punctate, guttate, nummular, orbicular, or gyrate éruption, but it can always be recognized as psoriasis. In certain instances, however, it will more or less change its character and approach to a greater or less degree those of eczema, and ‘pityriasis rubra, occasionally being quite transformed into one or the other of these affections. As already mentioned, in no less than 20 instances among the private cases, or 6 per 100, eczema was noted as présent to a greater or less degree : I hâve always regarded any tendency in psoriasis to assume an eczematous aspect as a favorable symptom, andin proportion as this is exhibited in patients can the disease be more readily managed. Far more rarely does psoriasis develop into pityriasis rubra, but I hâve seen this to occur in two, or perhaps, three instances; in the case of a gentleman recently seen, now some 50 years of âge the disease had so extended itself during many years existence that a large share of the lower extremities, and also the trunk, had become affected with extensive, even, red, surfaces marked by superûcial lines,covering large areas and exactly resembling the tissue seen in pityriasis rubra. The heat and burning in this is sometimes intense. This patient is also a great sufferer from rheumatism. Bourdillon (1) has cited a number of cases illustrative of this.

The treatment of psoriasis is a subject upon which very much has been

(1) Bourdillon, loc. cit., pp. 8, 57, etc.

written and yet one which is by no means clearly settled ; indeed, it is one about which there is still the greatest diversity of opinion, and further, is one which, it may be said, is in a very unsatisfactory state.

To those who believe psoriasis to be incurable as a disease, and who only altempt the beneûtting or removing of the éruption présent, the task is relatively light ; for, a number of agents are known which generally succeed in effecting a great improvement, or in causing the éruption to disappear in varying lengths of time. But ail agréé that their effect is at most but local and temporary, and we find that those who argue most in favor of local treament, speak most expectantly of the probable return of the éruption, with the coming change of season. But patients with the éruption naturally seek for more than tliis, and are very properly desirous that they should be freed from the disease in such a manner that they will not be subjected to the continuai annoyance of its récurrence. In a certain small percentage of cases it is true that when once removed by local means alone the éruption sometimes remains absent, even for a period of years, but this is so much the exception that it is hardly ever counted upon or expected by localists. It has already been mentioned that in order to secure a more pei’manent removal of the éruption, treatment must include diet,hygiene, and both internai and external médication.

To one who has closely studied diseases of the skin in private practice, there can be little doubt but that diet has more or. less to do both with the production of skin diseases and their cure. In some éruptions the relations exhibited between dietary éléments and skin lésions are very striking and unmistakable ; in many others they are more obscure, while in certain instances, with our présent light, it seems very difficult to obtain much data of value with regard to the matter. In gouty and rheumatic subjects with psoriasis, the effect of a full and stimulating diet is often most markedly exhibited in the rapid increase of the éruption, in its congested and irritable character, and in the freer production of seules ; while a light and unstimulating diet without the use of stimulants will often be followed by a marked improvement in the éruption. Every thing contributing to the production of an acid state in these subjects also tends to increase the skin difficulty; and over indulgence in sweets, pastry, fermented wines, and beer will often precipitate an attaclc and will always aggravate an existing éruption.

Excessive méat eating will also increase the disease, which will frequently yield with much greater rapidity, under the same treatment as before, when the amount of méat taken is lessened, or when it is entirely eut off ; on the other hand, oils and fatty matter, if properly digested, aid in removing the disease state.

Under hygiene should be included proper attention to the clothing worn and to the mode of life, in order to avoid ail check of perspiration or the chilling of the surfaces at any time ; this latter I hâve repeatedly seen followed by the original outbreak of the disease, and also by returns of the éruption. I believe that only pure wool should beworn next to the skin by these patients, both summer and winter. A warm and equable climate undoubtedly conduces to the cure of the disease, and I hâve known patients to remain quite free from the éruption while in the tropics.

Internai médication has very considérable effect on psoriasis in a large

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share of the cases, and should never be omitted. In rheumatic and gouty subjeets a pretty free and full alkaline treatment very commonly will control tbe disease to a very great extent : acetate of potassium is about the best remedy, and may be given with a free hand, combined with nux vomica and a bitter infusion, to which colchicum may often be added with advantage. Citrate of potassium and the liquor potassæ are also often of great service, the latter being given even up to 20 to 30 drops, or more, three times a day, freely diluted. In strumous cases the most brilliant results will sometimes be otained by cod-liver oil and hypophosphites, or other suitable médication. In quite a proportion of cases the éruption will seem to be induced and largely kept up by simple debility, and a good iron tonie, with liquor potassæ and a little arsenic, will cause the great, est improvement in the éruption evenwithout any local trëatment. This is also often required in gouty and rheumatic cases after the congestive element has been removed by free alkaline remedies. Attention should always be paid to the condition of the bowels, the digestive system and urine in psoriatic cases, for if these éléments are faulty other médication is often valueless.

Arsenic long ago established its réputation and has fairly maintained it in the treatment of psoriasis, and singly and alone is perhaps the one remedy of greatest value internally in this disease. But its powers hâve been more or less overrated by many, and everyone who has had much expérience with this disease must hâve witnessed its failure many times. That in can powerfully affect the éruption and even cause its disappearance in many instances, and often effect a cure of the disease in certain cases when used freely and persistently, no one doubts. As it is a more or less safe remedy it should be given, when employed, in doses suffieient to effect the purpose desired, or until some of its physiological actions become so pronounced that the drug can no longer be borne. Individual cases vary greatly in regard to the amount of arsenic which they can stand, and in each case it must be pushed fearlessly and faithfully in the directions indicated. I do not believe there is any deleterious effect to the system from the prolonged use of the drug ; it is well to remember that it passes off rapidly with the urine, and no traces of arsenic are found in the body a short time after its use has been discontinued, even although much had been previously taken. It matters little in what form arsenic is given, as it is believed that the minerai itself is the active agent, and it seems to operate about the same in whatever combination or form it is given.

Minerai springs are often thought to be of great value in the treatment of psoriasis, but after very considérable expérience in their use and after reviewing a recorded expérience of very many patients at a great variety of minerai springs, I must confess thaï they hâve disappointed me greatly. The sulphur springs are, in the main, as is well known, those which yield the best results, but even these I hâve rarely seen to effect a permanent cure of the disease. Faithful treatment at them will very frequently be followed by the removal of the éruption présent, but it has sometimes seemed to me that the éruption bursts out again with even greater vigor subsequently on account of the treatment there taken ; so that, I cannot to-day recommend a patient with psoriasis to go to any particular minerai spring with any definite hope or expectation that great or permanent benefit will be derived therefrom.

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Tlie local treatment of psoriasis covers a large ground and has been so frequently and ably discussed that it is hardly worth while to enter upon the subject here. My expérience certainly shows that the effect of local treatment is but local and temporary, and although, when applied early and fairly it may even prevent, to a large degree, the development of the éruption, it quite frequently fails to elfect this, and only removes the éruption présent, without at ail influencing the future of the case.

Ghrysarobin undoubtedly still holds the first place as a powerful agent in removing the éruption présent, but on account of the many well-known objections to its use I employ it comparatively rarely in private practice, and then mainly in a compound with salicylic acid and collodion ; pyrogallic acid and anthrarobin are of more or less value, but second in active power to chrysarobin : I use, more than anything else, white precipitate in an ointmeht with bismuth and carbolic acid. In acutely developing psoriasis a soothing and astringent lotion of calamine, and oxide of zinc, with carbolic acid and lime water will often, when combined with proper internai treatment, check the development of the éruption very satisfactorily. Alkaline baths hâve proved to be of the greatest service in my cases of psoriasis and I make very free use of them in their treatment. Oil of cade, as is well known, is one of the most efficient remedies in the removal of the éruption of psoriasis, and I hâve found a spécial value in the combination suggested, I believe, by M. Vidal, composed of oil of cade, 50. sapo viridis 25. and glyceriti amyli 130, wrell rubbed into the surface at night and washed off in the morning.

In concluding this study of the cases of psoriasis which hâve been under my personal care I wish again to impress the view, whish expérience has developed more and more in me, that psoriasis is not a local disease of the skin but is most certainly a manifestation of some underlying constitutional condition. Of this constitutional State or condition we as yet know but little, except that there is behind it a process of sub-oxidation and acidity, often exhibiting itself in rheumatïc and gouty symptoms : that these symptoms are not marked in the larger proportion of cases does not argue against the blood state or constitutional condition underlying both. Unfortunately the microscope has not revealed to us any one essential fact in regard to the true nature or etiology of psoriasis, and although several suggestions in regard to a parasitic or microbic origin hâve been put forth, I imagine there are few, if any, who give credence to such accounts. What the future will develop, if anything, in regard to the etiology of the disease no one can predict, but it is believed that our knowledge of psoriasis will be advanced by doser cltnical observation and study of large numbers of cases, and it is in this belief that I hâve ventured to bring before you the présent analysis and study of the disease.

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