PSORIASIS

Synonyms.—Lepra and Lepra alphos (of old authors); Fr., Psoriasis; Ger., Psori­
asis; Schuppenflechte.

Definition.—Psoriasis is a chronic inflammatory disease, charac­
terized by more or less numerous dry, reddish, variously sized, rounded
and sharply defined, more or less thickened patches, covered with white,
grayish-white, or mother-of-pearl-colored imbricated scales, usually
abundant in quantity.

Symptoms.—Psoriasis is always a dry scaly-papular eruption—
oozing or liquid exudation never occurs, and such other lesions as vesicles,
pustules, etc., are never observed.² It usually begins slowly by the
appearance of a variable number, few or many, of scattered pin­point
or pin-head-sized, slightly elevated maculopapules or papules, covered
with whitish or grayish-white scales, at first thin and epidermic. These
lesions increase slowly and, as a rule, very gradually in size, and, as

¹ Graham Little (Discussion, Brit. Jour. Derm., 1911, p. 182) cleared up the
eruption in a case with an ointment consisting of 1 ounce of salicylic acid and 3 drams
of oil of cade, after many other applications had failed.

² Some of the more recent literature upon clinical phases:
Analytic and clinical:

Greenough, Boston Med. and Surg. Jour., Sept. 10, 1885; Bulkley, Maryland Med.
Jour., Sept. 26 and Oct. 4, 1891; Pye-Smith, Guy's Hospital Reports, 1880-81, vol. xxv,
p. 233, and 1889, vol. xlvi, p. 419; Nielsen (with full consideration of etiology and
pathogeny, and rare atypical clinical types, with numerous literature references),
Monatshefte, 1892, vol. xv, pp. 317 and 365; also in New Sydenham Society's Selected
Monographs on Dermatology, 1893, p. 571;Rille (in children, with complete bibliog­
raphy), Wien. med. Wochenschr., 1895, p. 2098; P. S. Abraham, Brit. Med. Jour.,
April 14, 1906.

Atypical cases:

Rosenthal, Archiv, Ergänzungsheft, 1893, i, p. 79; Waelsch, Prager med. Wochen-
schr., 1898, p. 73; Deutsch. Wien. klin. Wochenschr., 1898, p. 130; Beyer, Wien. klin.
Wochenschr., 1901, p. 824 (with full review of the subject).

Horny formations, with epitheliomatous development: White (J. C), Amer. Jour.
Med. Sci., Jan., 1885; Hebra, Jr., Monatshefte, 1887, vol. vi, p. 1; Hartzell (bibliog­
raphy to date, and especially bearing upon arsenic as the causative factor), Amer.
Jour. Med. Sci., Sept., 1899; Schamberg, Jour. Cutan. Dis., 1907, p. 26.

Leukodermic areas: Hallopeau et Gasne, Bull, de Soc. framaise, July, 1898; Rille,
Dermatolog. Zeitschrift, Nov., 1898.

Kleoidal formation: Purdon, Jour. Cutan. Dis., 1883, p. 203; Anderson, quoted by
Crocker, Diseases of Skin, third, ed., p. 363.

PSORIASIS

237

they grow peripherally, the scale accumulation becomes more marked
and imbricated. During this time new spots are usually appearing.
The earliest lesions growing larger, often at different rates of rapidity,
together with the appearance of the new scaly papules, soon result in a
characteristic clinical picture:

Twenty to a hundred or more patches, varying in size from a pin-
head to a silver dollar, are usually present; they are sharply defined
against the sound skin, are slightly elevated and thickened or infiltrated,
and, if undisturbed, are more or less abundantly covered with whitish,

Fig. 46.—Psoriasis in a lad aged twelve, of a year‘s duration, showing small (guttate)
lesions and larger plaques on arms; distribution general.

silvery, grayish, or mother-of-pearl-colored scales; at the extreme per­
iphery the red edge of the underlying skin beneath the scales can be
seen; from a few or many of the patches the scales have probably been
rubbed off by the clothing or intentionally removed, and the bases are
then seen to be bright or dark red in color, disclosing the inflammatory
nature of the disease. Gently scraping the uncovered surface of a
patch, which seems to be coated over with a thin whitish or reddish-
white pellicle (Bulkley), with the finger-nail will result in minute abra­
sions of the vascular papillary layer of the corium, and the appearance

238

INFLAMMATIONS

of one or several minute drops of blood. The patches are usually scat­
tered irregularly over the general surface, but are commonly more
numerous on the extensor surfaces of the arms and legs, especially
about the knees and elbows. Several lesions which may have been
close together will often have coalesced and a large irregularly shaped
patch be formed—always, however, with the edges sharply defined against
the sound skin; movement of joints affected may give rise to fissuring.
It is possible, too, that in a few patches the central portion may have
begun to undergo retrogressive change, and, sunken down, become less
scaly or entirely disappear; such patches are then circinate or ring-
like.

Such a clinical picture is the one usually seen after the disease has
lasted several months or longer. It will be observed that the history
of the appearance and growth of one lesion is essentially the history of
all. The larger patches cannot arise as such, but are the result of per­
ipheral growth from a beginning small lesion; and as the growth of the
lesions may stop at any time and remain stationary for a shorter or
longer period, or almost indefinitely, it can readily be understood how
the so-called clinical varieties of the disease are produced. For in
some instances the lesions, or the most of them, progress no further
than pin-head in size, and then remain stationary, constituting pso­
riasis punctata; in other cases they may stop short after having reached
the size of drops—psoriasis guttata; in others, as in the descriptive pic­
ture above given, the patches develop to the size of coins—psoriasis
nummularis, psoriasis discoidea—and remain stationary. In other
cases, having attained a certain but variable size, more usually small or
large coin size, involution changes set in, and the central part of many, or
the majority or even more, begins to disappear, and there result a number
of patches with clear centers and a surrounding inflammatory scaly band
—psoriasis circinata, psoriasis annulata. If it happens that several of
the ring-shaped patches are close together and begin to extend again
peripherally, at the same time undergoing involution at the inner part of
the ring, coalescence takes place, and the coalescing portions disappear,
and there is left an eruption of serpentine inflammatory scaly bands-
psoriasis gyrata.¹ Or if several or more closely situated solid scaly
plaques continue to increase in size, they coalesce and form large areas
of varying dimensions, sometimes sufficiently large to cover a part or an
entire region—psoriasis diffusa; when about joints, the mobility of the
part is often painful, and fissures, somewhat deep, are often noted. These
diffused areas are usually markedly infiltrated and of a somewhat in­
veterate character, and hence the term sometimes applied—psoriasis
inveterata. Should, by gradual increase of old patches and the appear­
ance of new lesions in the interspaces, almost the entire surface be one

¹ Very rarely is observed a type which might be termed psoriasis gyrata in minia­
ture, which Jadassohn and Gassman have described as small circinate psoriasis (kein-
zirzinäre psoriasis), and later by Hoffman as psoriasis microgyrata. The gyrate bands
are narrow, scarcely elevated, but slightly (hardly noticeably) inflammatory, and the
gyrations are usually small—the whole having some resemblance to a profuse pityriasis
rosea in its stage of beginning disappearance. It may be persistent or run a com­
paratively rapid course, with the usual tendency to recurrences.

PSORIASIS

239

sheet of eruption, the name psoriasis universalis is applicable. For­
tunately, such extensive covering of the surface is rarely observed.

In extremely exceptional instances (McCall Anderson, Waelsch,
Deutsch) there is displayed on some patches a tendency to central
heaping of the scales, which may also be quite hard, almost horny—
hence the term psoriasis rupioides, psoriasis ostreacea ;¹ in some of these
cases, however, there is an admixture of fluid (gummy or oily) exudation,
indicating an eczematous or at least a seborrheic complication (psoriatic
eczema, seborrheic psoriasis); sometimes also with associated symptoms
of arthritis (arthropathia psoriatica) and cachexia. When on the
scalp, this heaped-up scale accumulation may be quite adherent and

Fig. 47.—Psoriasis in a male adult of several years’ duration. Shows a not unusual
development on the elbows in slight cases. In this instance the scalp was also in­
volved, but other parts were almost wholly free.

almost horny (Gassman). Rarely a tendency in one or several areas to
papillary hypertrophy is noted, giving rise to the term psoriasis verru--
cosa; such has been observed on the legs (Kaposi), on the extremities
(Waelsch), and on the palmar and dorsal aspects of the hands (Besnier).
While the involution begins frequently at the central part of the
patch, and in a very perceptible manner, yet this is by no means always
so, for in many cases there is a gradual disappearance, more or less

¹ Under the name “Parakeratosis Ostreacea (Scutularis),” Weiss, Jour. Amer.
Med. Assoc, Aug. 3, 1912, p. 343 (case and histologic illustration), records a case
having many of the features of this type; moisture and oozing were noted underneath
the lesions, and thorn-like projections present on the under side of the crusts extended
into the follicular openings.

240

INFLAMMATIONS

uniformly, of the entire patch; if examined closely, however, many such
patches will show that the retrogressive change is slightly more active
centrally than peripherally; in others there is no noticeable difference.
The first evidences of involution are lessened hyperemia and lessened
scale-production.

In many cases of the disease, instead of beginning with a somewhat
scattered distribution, the eruption first appears about the extensor
surfaces of the knees and elbows, insignificant or moderately well
marked, and presenting several or more small areas. It may remain
limited to these parts for some months or longer, without any disposition
to the appearance of new patches elsewhere; it may disappear during
the summer and then reappear the next winter for a few years, before

becoming more general.
As a rule, after some
months on these regions,
lesions begin to present
on other parts, few or in
great numbers, and finally
present the picture already
described. In other cases,
relatively infrequent, the
first appearance of the
patches is on the scalp,
and the malady may last
for some months or a year
or more so limited, and
then gradually or rapidly
appear on other parts.
While exceptionally the
scalp is the sole seat of the
eruption for some time,
yet, as a rule, in such
cases, if the elbows and
knees are closely examined,
two, three, or more insig­
nificant scaly spots can
usually be found, although
they may have been so
slight as to escape the patient‘s notice; not infrequently, also, a few
small insignificant spots can be found elsewhere on the limbs and
trunk.

Instead of appearing in the chronic manner already described,—
insidiously, gradually, or with moderate rapidity,—the disease may
be acute in respect to the outbreak, and within a few weeks reach ex­
tensive development, several hundred or more variously sized patches
presenting. In such cases the inflammatory element is usually of a
more pronounced type, and, as a rule, the scaliness less marked, occa­
sionally consisting of scarcely more than one or two thin epidermic
films. The subjective symptoms of burning and itching may be present

Fig. 48.—Psoriasis, generalized, of a common
clinical type, showing the sharply defined, variously
sized, scaly patches (courtesy of Dr. W. Frick).

PSORIASIS

241

to an annoying degree. After a while these cases often lose the acute
characters, and then settle down into the ordinary clinical type. In
other instances, after reaching rapid, extensive development, involution
changes present, and the disease up to a certain degree disappears quite
rapidly; the eruption left, of slight or moderate amount, assumes the
slow characters of the common clinical cases, and persists more or less
indefinitely, with periods of remission or intermission.

It will be noted, therefore, that the disease may first appear on one or
two or several regions, and then remain so limited, but, as a rule, only
for a variable time, and then present other patches elsewhere; or that it
may be from the first more or less scattered, sometimes with a more
abundant eruption on certain regions, as about the elbows, knees, and
scalp. Occasionally most patches will be found upon the legs, on and
below the knees; over the region of the sacrum is also a favorite site,
especially for one or two
large areas. On the scalp
the disease may present
scattered patches, or here
and there confluent areas;
it is not uncommon to find
several or more just over­
stepping the hairy borders
of the forehead and mas-
toid region. There is
rarely any hair loss. The
face is not often invaded,
and, if so, usually with
small lesions and to a very
slight degree, and these
are most commonly found
just in front of the ears.
The palms and soles usu­
ally escape, except in rare
instances of more or less
extensive and generalized
cases; these parts are
never the sole seat of the
eruption. Exceptionally
the palmar lesions, when
present, are hard and papular, with but little if any scaliness (Gaucher and
Hermery). The backs of the hands often escape; not infrequently
lesions may form under and about the nails, and as a result the latter
become brittle or granular, opaque, and sometimes thickened; ex­
ceptionally one or more may be cast off, but never permanently.

Psoriasis lesions are noted to form sometimes along the line or at
the points of mechanical irritation or slight injury; they are also seen on
tattoo-marks (Heller), on and about vaccine (Walters, Rohe, Hyde,
Augagneur, Mourier, Heller, and others) and other scars (Hallopeau
and Gardner), and following the course of scratch-marks. In rare in-

16

Fig. 49.—Psoriasis in a youth of fifteen, of more
or less general distribution. Shows scalp involve­
ment, and especially pronounced in mastoid region;
few small patches on the face in front of the ear.

242

INFLAMMATIONS

stances, too, the eruption has been, at first at least, somewhat limited,
and following peripheral nerve distribution (Thibiérge, Hallopeau and
Gasne), and even unilateral, on one arm, starting from a traumatism
(Kuznitzky). Psoriasis of the tongue or other mucous membranes
really does not exist; lesions, so called, are usually those of leukoplakia
buccalis; recently, however, 2 cases in which one or two lesions extended
from the skin on to the mucous surface have been recorded (Kuznitzky,
Sack).

The eruption may be scanty, moderate in quantity, or exceedingly
abundant, and may evolve slowly or rapidly. As to the inflammatory
character, that, too, varies considerably in different cases and some­
times in different patches in the same case—from slight and insignifi­
cant to that of a marked degree. The base may, therefore, show practi­
cally no inflammatory thickening, or this may be pronounced; it may be
pale red or bright or dark red in color, and in those of dark, sluggish skin
has sometimes a purplish tinge. The characters of the scaliness in a
typical case, in which the eruption has been undisturbed, and espe­
cially in those of dry skin, are, as a rule, distinctive; the scales are white
or grayish white, imbricated, and with a mother-of-pearl luster. In
many cases, especially in the working and dispensary classes, however,
the color is apt to be a dirty gray. As to the quantity of scales, this is
usually abundant, but in some cases much more so than in others.
In those who perspire freely, or who have frequent recourse to bathing,
the scales, or the greater part, are loosened and rubbed or drop off, so
that when the patient is inspected there will present some distinctly
scaly spots, some but slightly so, and many entirely free.

In rare instances the scaliness partakes measurably of the nature
of a crust, appearing somewhat as if the collected imbricated scales
had been glued together with some moist exudation, although such
does not in reality in true and typical psoriasis ever occur. Exception­
ally, however, in such atypical cases, especially in patches about the
lower part of the legs, on removing the scales, the base is noted to be
deep or beef-red in color, and the surface presents to the touch just a
suspicion of moisture. In other cases the scaliness and other features
of the disease approach somewhat closely to those of an eczematous
eruption. Such examples have been noted by most observers, and
several have come under my own care, and indicate that midway cases,
or cases presenting some features of both diseases, are, therefore, ex­
ceptionally to be met with. Such instances, and doubtless other patchy
scaly cases of the psoriatic eruption, in which the scales are somewhat
greasy to the touch, sometimes thin and filmy, and with, in some lesions, a
slightly moist or greasy base, belong chiefly to the domain of dermatitis
seborrhoica. As already remarked, some of these might very properly
be called psoriatic eczema, and others, seborrheic psoriasis, or psoriasis of
a seborrheic type.

The course of psoriasis, as may be already inferred, is in all instances
essentially chronic, old patches persisting, or some fading away, and
new areas developing. Sometimes fluctuations as to the extent and
number of patches are noted, and occasionally the disease will partly

Plate VI.

Psoriasis of extensive development in a male adult, of years’ duration, showing the white
silvery character of the scales (courtesy of Dr. J. A. Fordyce).

PSORIASIS

243

or entirely disappear, remain in abeyance some months or a year or
more, and then actively present again. In some of the milder cases
there is a complete, and in almost all cases a partial, disappearance in
warm weather. There are some exceptions to this, and in occasional
instances the disease is worse at such season. There is never any de­
structive or atrophic action produced; to this statement, however, must
be added the exceptional cases of scarring (Crocker), of keloidal forma­
tion (McCall Anderson, Purdon), of leukodermic spots (Hallopeau,
Gasne, Rille, Caspary, Löwenheim, Unna), some of which, I believe,
however, must be looked upon with suspicion, as probably purely acci­
dental or due to treatment (Besnier). It is true, in some instances,
patches will disappear, and leave for a short time a slight pale-red color
or discoloration, which quickly fades; exceptionally below the knees more
positive staining is noted, which may continue for a variable time. In a
few recorded instances in one or two patches verrucous or papillary de­
velopment has been observed, and later epithelial degenerative changes
resulted; and exceptionally warty or horny formations have been noted,
which in a few cases assumed epitheliomatous character; but in these
instances (Pozzi, Cartaz, Hebra, White, Rosenthal, Hartzell, and others)
these conditions were doubtless due, as HartzelPs collected cases would
seem to show, to prolonged administration of arsenic, as the drug seems
capable of provoking or inaugurating such action. In occasional in­
stances of extensive and severe type the disease, after persisting for
some years, during which time it may be more or less variable, finally
develops into a temporary or permanent dermatitis exfoliativa or a
condition simulating it (Devergie, Camberini, Besnier, Crocker, Jamieson,
and others). Several such cases have come under my own observation,
and in 2 of these, as also observed by others, there was associated arthritis
deformans; rarely, too, the nails and hair fall out (Besnier). Progressive
polyarthritis (arthropathia psoriatica) has been also noted in cases in
which the skin eruption had remained of the average type and extent.¹

Subjective symptoms in psoriasis are absent in a large number of
cases. In some there is slight itchiness, in others moderate in degree;
less frequently it is intense, either at irregular times or continuously,
and constituting the most troublesome feature of the disease. In acutely
developing cases there may be a sense of soreness and tenderness. The
general health does not seem to suffer except in cases in which the itch­
ing is sufficiently intense to interfere with sleep. Digestive disturbances,
exhausting mental or physical labor, and similar factors have an aggra­
vating influence upon the eruption; on the other hand, during serious
acute systemic disorders, as febrile diseases, the eruption will materially
lessen or wholly disappear.

Etiology.²—Observation and clinical analysis (Greenough, Pye-

¹ Wollenberg has recently reported (Berlin, klin. Wochenschr., Jan. 11, 1909) a case
and reviewed the subject (100 cases on record).

² The whole subject of the etiology is gone over in the exhaustive investigations
by Schamberg (Schamberg, Kolmer, Raiziss, and Ringer): “Researches in Psoriasis—
Preliminary Report,” Jour. Cutan. Dis., Oct., 1913; “Studies of Protein Metabolism
in Psoriasis,” ibid., Nov., 1913; and “Summary of Research Studies in Psoriasis,”
Jour. Amer. Med. Assoc, Aug. 29, 1914; and in condensed form, Dermatolog. Woch-
enschr., vol. lvii, 1913, and vol. lviii, 1914.

244

INFLAMMATIONS

Smith, Bulkley, Nielsen, and others) furnish data as to some of the
etiologic facts. The disease constitutes 2 to 3 per cent, of all skin
cases, varying slightly in different countries; is observed in both sexes,
although occurring somewhat more frequently in males; in all ranks of
society, and at almost any age except earliest infancy—although recently
cases have been recorded (Kaposi, Crocker, Elliot, Rille, and others) in
the first one or two years of life (the youngest case by Rille, aged six
days). I have met with an extensive case at the age of three. Its first
appearance is, however, exceptional before the age of five, somewhat rare
before the age of seven or eight, and most common between the ages
of fifteen and thirty, and again relatively infrequent after forty. The
disease is, of course, often seen after this period, but usually as a con­
tinuation or a reappearance of former outbreaks. While some ob­
servers, notably Hebra, believed that it is generally seen in those of ap­
parently good physical condition, my own experience would indicate
that it is much more common in those of poor health and enfeebled
constitution. Season has usually a very important influence, in almost
all cases the eruption improving markedly in the summer, and in many
of the lighter cases entirely disappearing, usually to reappear or get worse
on the advent of cold weather, especially toward the end of winter. The
disease is less common in countries of warm climate.¹

Inherited rheumatic and gouty tendencies are often of seeming
etiologic import (Bourdillon, Gerhardt, Bulkley, Shoemaker, Corlett,
Liveing, and others), and when pronounced, often suggest the line of
treatment likely to be most successful; in some extreme cases, more par­
ticularly those cases developing into dermatitis exfoliativa, and in those
recorded as psoriasis rupioides, arthritic symptoms, especially of the
character of arthritis deformans, have been associated. Defective
kidney elimination, in such instances and in others, is also sometimes
an element in those predisposed. Digestive and nutritive disturbances
of all kinds are certainly provocative as to recurrences and of probable
causative influence. An enfeebled state of the health is also predisposing;
in women who are subjects of this disease the eruption is usually worse or
recurs during the latter part of pregnancy and during the nursing period.
It sometimes follows a severe systemic disease. While it is true that the
attacks often occur in those of visibly robust habit, yet a careful investi­
gation will usually disclose that this is more apparent than real; in such
patients defective kidney elimination, gouty and rheumatic tendency,
digestive disturbances, and in some not infrequently excessive indulgence
in alcoholic stimulants, are factors of importance. Intemperate drink­
ing of tea and coffee and excessive use of tobacco are sometimes apparent
adjuvant factors. It has no relationship to struma or syphilis, although
either condition, by bringing on a depraved state of health, could be of
import in provoking an outbreak or recurrence in those predisposed.
Bulkley, Schamberg, and others are convinced that a high protein diet
has a distinct causative influence.

¹ Bulkley (“Notes on Certain Skin Diseases Observed in the Far East,” Jour.
Cutan. Dis., Jan., 1910) states that psoriasis seems almost unknown in the warm cli­
mates of the East.

PSORIASIS

245

That heredity is seemingly an important factor is well attested by
clinical experience (E. Wilson placed it at 30 per cent.), and is a much
stronger apparent factor than is generally believed. The fact that the
disease is often present, but to a mild degree, together with the repug­
nance felt toward publicity as to skin affections, doubtless frequently
keeps the knowledge of its existence even from other members of the
family.¹ But in the light of our present knowledge and changed views
of leprosy and tuberculosis one can reasonably ask, I believe, whether
its frequency in families is not just as much in favor of communica-
bility—a parasitic cause—as of heredity.

Pathology.—The most probable views entertained as to the nature
of the influences which start the histopathologic changes are the para­
sitic and the neuropathic There is a growing belief that the disease
is parasitic, although as yet there is no uniformity of opinion on this
point. It is true Lang believed he had found a fungus, and this, or an
apparently similar one, was found by others (Wolff, Eklund, Beissel),
but others again (Neisser, Rindfleisch, Majocchi, and others) failed
to corroborate Lang, and Ries’ exhaustive investigations show that the
alleged fungus was an artificial product consisting of eleidin. Other
findings—micrococci (Angelucci, De Matei), morococci (Unna), and
“minute circular bodies with central dark spots loosely clustered and in
dense masses” (Crocker)—are also recorded, but their significance is not
established. So far, then, it can be positively stated that no specific
organism has as yet been demonstrated. But, on the other hand, the
clinical character and behavior of the eruption, as Lang has pointed out,
are suggestive of a parasitic origin; and this view receives still further
support in those cases of apparent communication (Unna, Hammer,
Aubert, and others), and also in those in which the disease started
from vaccination (Klamann, Rohé, Piffard, Wood, Hyde, Chambard,
and others); and this seems still further strengthened by the few appar­
ently successful inoculation experiments on animals (Lassar, Tom-
masoli), and in one instance on man (Destot). The fact, too, that new
psoriasis efflorescences are apt to appear at points of abrasion is like­
wise suggestive, although this may also be used in support of the neurotic
view. Upon the whole, I believe it is in the field of pathogenic organisms
that the true exciting agent of this disease is to be found, the various
factors—age, season, gouty and rheumatic tendencies, debility, etc—
being contributory in preparing the “soil” for successful parasitic in­
vasion.

The other favorite theory of the production of psoriasis is the neuro­
pathic In its support are mentioned the following clinical observations:
Relation or association with arthritic disease; heredity; its appearance,
and sometimes starting at points of cutaneous irritation; its occurrence,
though rare, over peripheral nerve distribution, and its unilateral dis­
tribution, already referred to; its occurrence during pregnancy and

¹ Knowles, “Psoriasis Familialis,” Jour. Amer. Med. Assoc, Aug. 10, 1912, p. 415,
states that his examination of case records shows that only rarely is more than 1
case found in a family; this is contrary to what has been the general belief. I have
had under observation in the past few years, 3 cases in one family—2 sisters and 1
brother.

246                                      INFLAMMATIONS

lactation; the observation of outbreaks, in those predisposed, after emo­
tional attacks (Leloir); the association, though rare, with lessened tactile
and thermic sense (Rendu) in the patches; the observation, in some in­
stances, of associated sciatica and pricking sensations in the ends of the
fingers and toes (Hebra)—all would seem to point toward a neuropathic
origin. The suggestions that it is due to reflected irritation from the
skin to the spinal center (Kuznitzky), to purely external mechanical
causes (Köbner), that it is an infection (Bernay and Piéry) due to auto-
toxin poisoning (Tommasoli) and that there is primarily a weakened vas­
cular tone (Unna), or functionally weak nervous centers regulating the
nutrition of the skin (Weyl), also bear upon the neuropathic theory, but
have as yet but little basis of support.

Upon the character of the histologic changes evoked investiga­
tions (Wertheim, Neumann, Hebra, Kaposi, Auspitz, Bosellini, Jamie-
son, Robinson, Thin, Crocker, Unna,
Jarisch, Herxheimer, Ries, Kopy-
towski, and others) are fairly well
agreed, although there is a difference
of opinion as to whether the proc­
ess is primarily a hyperplasia of
the rete (most strongly supported
by Jamieson, Robinson, Thin), with
induced secondary inflammatory
changes, or whether it originates as
an inflammation of the papillary
layer. At all events, among the
conditions noted are: A hyper-
plasia of the rete, except directly
over the papillae; the latter are
enlarged both laterally and up­
ward; there is a dipping-down of
the interpapillary processes, enlargement of the blood-vessels; cell ex­
travasation in the upper corium, expecially in the papillary layer and
around the hair-follicles, sweat-glands ducts, and the blood-vessels.
Serous exudation, cell exudation, and congestion, together with the
enlargement of the papillae, furnish the thickened and elevated inflamma­
tory base. The rete cells undergo rapid keratinization, giving rise to the
enormous increase of the horny layer. Recent investigations (Munro),
which, however, lack confirmation, disclose the first step in the formation
of a lesion to be a minute erosion of the epidermis, in which are noted
collections of leukocytes, producing microscopic miliary abscesses,
the subsequent changes being due to the epidermic reaction. Nar-
decchia has studied the disease in alcoholics, and has found that the usual
blood-vessel changes of the latter are made much more pronounced by
the psoriatic process.

Diagnosis.—A well-developed example of psoriasis can scarcely
be mistaken for any other eruption. The scattered, rounded, sharply
defined, variously sized, slightly elevated, scaly plaques, with special
preference for the extensor surfaces, particularly the knees and elbows,

Fig. 50.—Psoriasis, from a small le­
sion in early stage, showing considerable
hyperplasia of the rete, especially in its
interpapillary portion. Blood-vessels of
the papillæ are already more or less di­
lated (courtesy of Dr. A. R. Robinson).

PSORIASIS

247

and not infrequently the presence of patches on the scalp, particularly
just overstepping the hair-border on to the forehead and on to the
mastoid region; the usually non-involvement or only slight or moderate
involvement of the face, and absence of eruption on the palms and soles;
the invariably dry nature of the disease, its course and its history, which
often includes recurrences, together with the evolution and uniform
character of the lesions, all go to make up a picture that is diagnostic
Ill-developed, rapidly developing, and atypical cases may occasionally
give rise to difficulty, but such instances are relatively rare. The disease
is to be distinguished chiefly from the papulosquamous syphiloderm,
eczema, dermatitis seborrhoica, seborrhea, lichen planus, pityriasis
rosea, and tinea circinata.

Fig. 51.—Psoriasis—from a chronic patch—showing marked hyperplasia of the
rete extending deeply downward as interpapillary prolongations, thus giving the papillae
increased length. The secondary inflammatory changes in the corium are seen, with
enlargement of the blood-vessels (a), in the cutis proper as well as the papillae, and exten­
sive (b, b) perivascular cell-infiltration (courtesy of Dr. A. R. Robinson).

The papulosquamous syphiloderm probably bears the closest re­
semblance. The syphilitic eruption, however, shows no special prefer­
ence for the extensor surfaces; on the contrary, it is not infrequently
more marked on the flexors; patches are usually to be seen upon the
face, and frequently on the palms and soles; lesions are also frequent
about the anus and genitalia, where they often become abraded, macer­
ated, and moist; they are usually much less scaly, and instead of bright
or dark inflammatory redness, have a dull ham or coppery hue: there
is distinct infiltration; there are generally several or more characteristic
papules to be found, which exhibit no tendency to scale-production; and
not infrequently a few scattered pustules; the scales are dirty gray or

248                                      INFLAMMATIONS

brownish gray, rarely ever shining, white, and lustrous; the patches usu­
ally spring up the size they retain with but little tendency to peripheral
extension; they are very rarely larger than a dime, or at the most a silver
quarter. Moreover, the disease being a manifestation of the active or
secondary stage of syphilis, other concomitant symptoms, such as sore
throat, mucous patches, glandular enlargement, rheumatic pains, falling
out of the hair, with often the history of the initial lesion, are one, several
or all always present. It will be noted that these various features and
characters are materially different from those of psoriasis. Further,
the papulosquamous syphiloderm rarely itches, except in the negro,
while psoriasis frequently does; in short, the presence of moderate or
intense itching would bear conclusively against syphilis; its absence,
however, would have no weight, inasmuch as it is not noted in a large
proportion of psoriasis cases.

The tuberculosquamous syphilid is a late or tertiary manifesta­
tion, which may occasionally show considerable scaliness, but the dis­
ease is usually limited to one or two regions, forming one or more groups
of circinate or serpiginous configuration, and generally shows ulcerative
tendency and scarring or pigmentation and atrophy. It is rarely located
on the favorite psoriasis regions, but is frequently seen on the face.

Squamous eczema can also be confused with psoriasis, but the
former never shows such small, rounded, sharply defined patches;
but a few areas generally presenting, and these, as a rule, large; it rarely
has such scattered distribution; it favors the flexor aspects, and espe­
cially the flexures; the individual areas, even when small, usually result
from an aggregation of papules, some of which can be often seen at the
border; or it arises from a thickened erythematous patch. The history
and course of the individual areas are, therefore, different; there is usu­
ally a history or the presence of oozing in eczema, especially if the dis­
ease is at all extensive; moreover, the hands and face frequently show
the disease, regions which are only occasionally or slightly invaded in
psoriasis. Eczema is almost always intensely itchy; psoriasis rarely
so, and often free from this symptom.

Dermatitis seborrhoica (eczema seborrhoicum) may show greater
resemblance than ordinary eczema, inasmuch as it is often patchy in
character; the scales are, however, less abundant, greasy, and the base
beneath is not infrequently greasy or moist; moreover, dermatitis sebor-
rhoica frequently takes its starting-point from an ordinary seborrhea
(dandruff) of the scalp or of the eyebrows, and usually involves the upper
part of the body first; the flexures, too, often show the disease, and
seborrheic patches with prolongations into the gland-ducts can be some­
times found over the sternum and between the scapulæ; in these latter
regions, too, the disease is often primarily ring-like or segmental in
shape. The patches in dermatitis seborrhoica may arise the size they
retain; those of psoriasis always develop by peripheral extension from a
small lesion.

Psoriasis of the scalp, especially when the inflammatory action is
slight, may be confounded with seborrhea of that region, but from
the average case of the latter it is distinguished by its scattered patch-

Plate VII.

Psoriasis —unusually marked tendency to gyrate and circinate variety on trunk ; on
the extremities the ordinary scattered, rounded patches. Scales have been partly re­
moved by bathing. Duration, several years; subject, male adult aged thirty.

PSORIASIS

249

formation, its often projecting just beyond the hairy border, and by the
dry character of its scales and its inflammatory element. Seborrhea
is usually diffused over the entire scalp, with little if any tendency to
patch-formation. Moreover, in cases of psoriasis of the scalp, in many
instances small lesions are often to be found on the elbows and knees.

Lichen planus differs from psoriasis in that the papular lesions
are flattened, angular in outline, usually with central depression, and
dark red or violaceous in color. The lesions rarely increase in size,
and never materially, the scaly patches of the disease resulting from
the appearance of new lesions close to the old, finally becoming so
crowded as to form solid aggregations or patches; but round about
such patches, and usually elsewhere, the typical papule is always to
be found. The patches, too, are violaceous or purplish in color, and
show much more thickening or infiltration than observed in psoriasis.
Moreover, the flexor surfaces of the wrists and forearms and the leg
near the ankle are favorite sites, with but little if any disposition to
appear on the extensors of the knees and elbows or upon the scalp.

Pityriasis rosea is a much less inflammatory disease than psoriasis,
and the eruption comes out somewhat rapidly, reaching its full devel­
opment in the course of one to two weeks, and is chiefly limited to the
trunk and upper parts of the arms and legs. The extensor surfaces are
not especially favored, and the elbows and knees rarely show patches
unless the eruption is unusually extensive. The scalp is never involved.
Some of the patches tend to become somewhat circinate almost from
the beginning. The scaliness is relatively slight, and the eruption is of
a duller color, and frequently with a yellowish or salmon tinge. More­
over, the process is an extremely superficial one; and the malady tends
to spontaneous disappearance in the course of one to two months.

The annular patches of psoriasis due to the process of involution
resemble ringworm to some extent, but the scaliness is much greater,
the inflammatory thickening more pronounced. Moreover, such lesions
are usually numerous, and there are also found many other patches in
which the clearing of the center has not developed. In ringworm seldom
more than several patches are seen, and the border is rarely so pro­
nounced, and often is made up of contiguous papules or vesicopapules.
Moreover, the history and distribution are wholly different. In obscure
cases the microscopic examination of the scrapings could be resorted to,
but this is rarely, if ever, necessary.

Lupus erythematosus patches, if carelessly examined, may sug­
gest psoriasis, but the former is seen almost always about the face, and
seldom elsewhere, whereas psoriasis patches on the face are rare and
seen only in connection with the disease on other parts of the body.
The patches of lupus erythematosus are, moreover, entirely different
in history and character. Psoriasis can scarcely be confounded with
dermatitis exfoliativa, or pityriasis rubra pilaris, as their clinical char­
acters, history, and course are materially different.

Prognosis.—Psoriasis is a disease in which an unqualified opinion
as to the future cannot be safely ventured. The prognosis is, as a rule,
favorable as to the immediate eruption, and invariably so in the earlier

250                                      INFLAMMATIONS

attacks. In fact, almost all attacks can be relieved, some more readily
than others, provided the patient persists, but this persistence is, un­
fortunately, often lacking. Freedom from recurrences, with possibly
rare exceptions, is not to be expected. The patient should be clearly
informed on this point, as timely measures, as soon as the malady again
first presents, will frequently head off an extensive outbreak. The in­
tervals may be long or short—months or several years or more. In
occasional cases, however, the attack is scarcely at end before another
appears. Subsequent attacks, especially when well advanced, are less
rapidly responsive than the first eruption. As later life is approached,
however, the disease often becomes less active, and may entirely disap­
pear. In some patients prolonged, and exceptionally more or less perma­
nent, freedom from the disease is noted. The health is rarely materially
affected by the eruption except in those instances, relatively infrequent,
in which itching is sufficiently intense to deprive the patient of restful
sleep, and thus bring about a condition of nervous and physical debility.
In exceptional instances, in severe and oft-recurrent or continuous cases,
the disease may finally develop into a true dermatitis exfoliativa, and
necessarily assume a more serious aspect.

The cooperation of the patient will often have a material influence
in rendering the disease less active and the attacks less frequent; it
is a matter of observation that whatever depresses or deranges the
equilibrium of the general health will have some weight in bringing on
an attack or making the eruption worse, and patients should, therefore,
guard against all factors which favor such tendencies. I have always
pointed out to young men with pronounced to severely marked types of
this disease, who have not yet planned their life-work, the advantages of
a permanent transfer to a warm climate.

Treatment.¹—Whatever plan, both in external and internal
treatment, is instituted, it should be continued sufficiently long to
judge of its probable effects, unless aggravation is noted to ensue. In
most cases a change from one plan to another is often necessary, espe­
cially in the more extensive and rebellious cases.

¹ Some literature concerning constitutional treatment: Greve (potassium iodid),
Tidsskrift for praktisk Median, 1881, No. 16, abstract of which is in Archiv, 1882, p.
554; Haslund (potassium iodid), ibid., 1887, pp. 677 and 708; Bramwell (thyroid),
Brit. Med. Jour., Oct. 28, 1893, P- 934, and Brit. Jour. Derm., 1894, p. 193; G. T.
Jackson (thyroid), Jour. Cutan. Dis., 1894, p. 409 (with bibliography); Thibiérge
(thyroid), Annales, 1895, p. 760; Paschkis and Grosz (iodothyrin) (with report of
cases and a critical review of the entire literature of the thyroid treatment, with full
bibliography, including also that of potassium iodid), Wien. klin. Rundschau, 1896, pp.
609, 629, 646, 664; Passavant (meat diet), Archiv für Heilkunde, 1867, p. 251; Crocker
(salicin and salicylates), Lancet, June 8, 1895, p. 193; Brault (mercurial injections),
Annales, 1895, vol. vi, p. 676; Mapother (mercurial treatment), Brit. Med. Jour., Jan.
17, 1891; Danlos (cacodylic acid), Annales, 1897, pp. 198, 559; Gijselman (sodium
cacodylate), Wien. klin. Wochenschr., 1899, p. 363; Rille (sodium cacodylate), Monats-
hefte, 1899, vol. xxviii, p. 140; Murrell (sodium caœdylate) (untoward action, letter
communication, Lancet, Dec 29, 1900; Balzer et Griffin (cacodylic acid) (a resulting
exfoliative dermatitis), Annales, 1897, p. 732; Bulkley, “Report of 140 Recent Cases of
Psoriasis in Private Practice under a Strictly Vegetarian Diet,” Jour. Amer. Med.
Assoc., Aug. 26, 1911, p. 714; Sabouraud, La Clinique, June 7, 1912, and Duc, ibid.,
July 5, 1912, had some promising effects from injection of enesol; Winfield, “Lactic
Acid and Colonic Irrigation in the Treatment of Psoriasis,” Jour. Amer. Med. Assoc,
Aug. 10, 1912, p. 416.

PSORIASIS                                            251

In the systemic treatment of psoriasis, as in almost all of the chronic
skin diseases, each individual case must receive careful study, for very
often it is noted that the patient is in need of treatment fully as much
for himself as for the eruption; all possible etiologic factors should be
kept in mind. His diet should be supervised, alcoholic stimulants
practically withheld, except in old debilitated subjects; smoking kept
within moderate limits or interdicted, and an excess of tea, coffee, and
richly seasoned food avoided. In many cases it will not be necessary
to interfere with the diet beyond limiting it to easily digested food;
in others, especially in those of a plethoric habit, meat should be cut down
or for a time prohibited—Schamberg is convinced by his research studies
that a low protein diet is of great value, a view shared by Bulkley. The
state of the nervous system should be inquired into, and all depressing
influences guarded against. In fact, the patient is to be placed in as
perfect a state of health as it is possible to attain. Open-air pleasures
and sufficient exercise, systematically taken, will, in some individuals,
have a material effect in aiding the medicinal treatment. Living as much
as possible in the sunlight is beneficial (Hyde and Montgomery)—
psoriasis is not common upon exposed parts.

In the constitutional treatment, therefore, in many instances, each
case must be handled upon its merits, and upon this basis much good
can be done, and often without resorting to the several special remedies,
which, while of service in removing the eruption, are often detrimental
to digestion. If constipation is present, it is to be corrected by suit­
able laxatives, preferably the salines, and these are especially of service
in the acute and rapidly developing disease. Indigestion is to be treated
with tonics, digestives, acids, or mild alkalies, as may seem indicated,
and the diet regulated accordingly. Winfield has, on the basis of faulty
metabolism, treated a series of cases with lactic acid internally and
colonic irrigation with promising results. Neurasthenic conditions are
to be modified or removed by the use of tonics, such as strychnin, quinin,
iron, and the sedatives, such as lupulin, asafetida, potassium bromid,
and ergot, and, if deemed necessary, by general galvanization, faradiza­
tion, and static electricity. In gouty conditions the alkalis are to be
employed, sodium salicylate, potassium bicarbonate, potassium acetate,
and liquor potassæ being those most commonly prescribed; potassium
iodid in full doses also will act well in some gouty cases. If the general
nutrition is below par,—as, for instance, in the attacks of psoriasis occur­
ring or relapsing during pregnancy and lactation,—tonics, and espe­
cially cod-liver oil and the hypophosphites, should be advised; the oil,
which is often extremely valuable, can be given in doses of a half to one or
two teaspoonfuls, either pure, in emulsion, or in capsules, the last-men­
tioned method being ordinarily the most pleasant.

In many cases of the disease, however, it will be difficult to dis­
cover any material fault in the general health, and dependence is then
to be placed on the special remedies alone. Thus there are several
drugs that experience has shown to be of special value. These are
arsenic, ordinary alkalies, sodium salicylate, salicin, potassium iodid,
thyroid, copaiba and turpentine oils, and carbolic acid. Of these,

252                                  INFLAMMATIONS

arsenic is the most valuable and the most constant in its effects. Patients
are met with, however, who are intolerant to even small doses. In
all fresh—first—outbreaks of this disease, if not of an acutely inflam­
matory character, the judicious administration of this drug will often
bring about a surprising improvement in a short time, and rapidly
cause an entire disappearance of the eruption. In old-standing cases
or in recurrent attacks in those who have had no systematic treatment
and who have probably never been regularly treated with the drug, the
same favorable effect is often noted. In acutely inflammatory cases
or attacks, especially when the disease is rapidly spreading, the drug
may do actual harm, in that the inflammatory symptoms are increased
and fresh outcroppings stimulated. In recurrent attacks in those who
have previously been subjected to arsenical treatment, the drug seems
to lack its earlier power for good, even large doses often failing to influence
the eruption favorably. It is prescribed in several forms: as Fowler's
solution, arseniate of sodium solution, arsenious acid, and sodium caco-
dylate, the first named most commonly. The dose varies in different
individuals, the beginning dose being usually 3 minims (0.2) of the
solution of potassium arsenite, or its equivalent of the other preparations,
and increasing slowly, if the disease is not being favorably influenced,
to 5 minims (0.33) three times daily. In rare instances the dose of 10
minims (0.66) and larger quantity may be safely reached and continued.
As a rule, the dose is increased until its good effect upon the eruption
is noted, and then kept at the same dosage, intermitting for a day or
two if disturbing symptoms arise, and then beginning again at a slightly
smaller dose, and increasing up to the former quantity. The drug
should be continued one or two months after the eruption has disap­
peared, but in somewhat smaller amount. If moderate doses fail to
benefit, the chances are that larger doses will prove futile also, or only
benefit the eruption temporarily and at the expense of gastric and
intestinal disturbance or nervous symptoms traceable to the treatment.
The drug, therefore, while often powerful for good if judiciously admin­
istered, may, if care is not exercised, be productive of harm. Occa­
sionally its prolonged administration in large dosage produces, in addition
to possible digestive and nervous disturbance, a more or less general
pigmentation of the skin, which, however, gradually subsides when
the drug is discontinued; palmar and plantar epidermic thickening or
callosities and wart-like horny formations may also exceptionally result,
and the latter may even undergo epithelial degeneration. Evidences of
palmar and plantar epidermic thickening from its administration, should,
therefore, be considered a signal for its withdrawal and discontinuance.
The solution of sodium arsenite is, I believe, less apt to disturb
the stomach, and seems equally efficacious, and should be prescribed
in those of weak digestion in preference to Fowler's solution. Arseni-
ous acid is a convenient form, inasmuch as it can be readily prescribed
in pills; the dose should he at the start about ¹/₄₀ to ¹/₃₀ of a grain (0.0016
to 0.0021), and increased to ¹/₂₀ (0.0032), and even, if necessary and
there are no contra­indications, up to fa grain (0.0065) or more three times
daily; this drug is also sometimes administered by hypodermic injection.

PSORIASIS

253

It, as the other arsenical preparations, can be given along with strychnin,
quinin, and iron, if indicated. A favorite method of prescribing arsenious
acid is as the so-called Asiatic pill, made up of ¹/₂₀ to ¹/₁₂ grain (0.0032-
0.0065) arsenious acid and ½ grain (0.033) black pepper, with acacia or
licorice root as the excipient.

The arsenical preparations are usually adminstered by the mouth,
and this is the most convenient method, but its administration by sub­
cutaneous injection is usually more rapid in its results, but it is a some­
what painful method, and requires great care to avoid abscess formation.
The solutions of sodium arsenite, potassium arsenite, and sodium caco-
dylate are employed. I have occasionally used this method with ad­
vantage in obstinate cases, employing Fowler‘s solution, sterilized, and
with ¹/₈ grain (0.008) carbolic acid to each dose of 5 minims (0.33), begin­
ning at first with 3 minims (0.2), with 4 or 5 parts water, and increasing
gradually, giving a daily injection. Sodium cacodylate, administered by
hypodermic injection, in doses of ½ to 3 grains (0.03-0.2), at intervals of
one to three days is occasionally valuable. Salvarsan has also been
tried, but has only exceptionally shown special value.¹ Sabouraud and
Duc (loc. cit.) have had some promising results from enesol. In occa­
sional instances, as the result of arsenical treatment, pigmentation is
noted on the sites of the plaques after their disappearance.

The alkalis are usually most promising in cases in which there
is an apparent gouty or rheumatic predisposition; but, irrespective of
these conditions, in patients of plethoric habit and of apparent robust
health, and especially in the markedly inflammatory types and those
of acute and rapid development of the disease, the administration of
these remedies, especially liquor potassæ (Thomson, Bell, Duhring),
will frequently have a marked influence toward promoting the disap­
pearance of the eruption; it is not appropriate for those of anemic tend­
ency or condition, nor for those of enfeebled health. The dose of liquor
potassæ should be, at first, 10 minims (0.65) three times daily, rapidly in­
creasing to 20 or even 30 minims (1.33 to 2.), always being taken largely
diluted. In established cases in such patients, even when the eruption
is of a decidedly inflammatory aspect, a prescription, such as the follow­
ing, containing both the potassium arsenite solution and liquor potassæ,
can often be used with advantage, and can also be prescribed cautiously
in cases in which the development is still active:

R. Liq. potass, arsenit.,                                          f3ij-iij (8.-12.);

Liq. potassæ,                                                      f3iv-f3j (16.-32.);

Aquæ menth. pip.,                                q. s. ad f 3iij (96.).

SIG—A teaspoonful in at least a half tumblerful of water after each meal.

Potassium acetate is another alkali, as well as a diuretic, that has gained
some reputation, in doses from of 10 to 30 grains (0.65 to 2.) three times
daily. Sodium salicylate and salicin (Crocker) are occasionally of de­
cided benefit, and not necessarily limited to those of arthritic tendencies
nor to any special class of cases, although more valuable in the arthritic,
the former doubtless by its alkaline character. Sodium salicylate is

¹ Schwabe, München. med. Wochenschr., 1910, lvii, No. 36 (results disappointing).

254

INFLAMMATIONS

given in dosage from 5 to 20 grains (0.33 to 1.33), and salicin, from 10 to
30 grains (0.65 to 2.), three times daily, beginning with the smaller dose,
and, if well borne, increasing. Salicin is less apt to disturb digestion
than the sodium salicylate. In place of the latter, ammonium salicylate
can be given. Almost all these alkaline remedies are diuretic, and this
probably also measurably aids in their favorable action.

Potassium iodid, in doses of from 10 to 120 grains (0.65 to 8.) or more
three times a day, has in recent years been extolled (Greve, Boeck, Has-
lund, Hillebrand) as having a specific effect, which is probably partly,
although not wholly, due to its alkaline character. While, in my ex­
perience, its favorable action is far from being so constant as claimed
for it, it is occasionally of distinct service. The larger doses are, however,
usually required, and, of course, while taking such, the patient needs
careful supervision.

Oil of turpentine (Crocker), oil of copaiba (Hardy, Simms, McCall
Anderson), and similar remedies have likewise acted well in some cases,
given in doses of from 10 to 30 minims (0.65 to 2.). They are best given
in emulsion, largely diluted, and during their use frequent potations
of barley-water or other diluent should be taken to prevent any irri­
tating action upon the kidneys. In several extensive cases under my
care the oil of copaiba proved effective in reducing the extent of the
disease, but it often fails absolutely. The wine of antimony has also been
commended (Malcolm Morris) in cases of an acute type in the dose of
from 5 to 10 minims (0.33 to 0.65) three times daily; it should not be
given in those cases in which there is general systemic depression, and its
administration should always be carefully watched.

Thyroid feeding several years back was strongly supported (Bram-
well) by the report of several brilliant cures, but the experience of
others (Thibiérge, Zarubin, Jarisch, Jackson, and others) subsequently
has been, upon the whole, unfavorable, and the remedy is now rarely
used for this disease. My own observations are in accord with its nega­
tive action in most cases, but it has been of service in a few instances
in which other plans had failed, so I believe it is entitled to be considered
as a reserve remedy for trial in rebellious cases. The dose should be small
at first—½ to 1 grain (0.033 to 0.065) of the desiccated gland, and, if
necessary and well borne, increasing to 5 grains (o.33) or more three
times daily. Its use, however, requires caution, and the remedy should
be watched and discontinued if untoward symptoms arise. Iodothyrin,
an equivalent preparation, has also been commended (Paschkis and
Grosz). I have occasionally seen benefit from Donovan's solution. The
subcutaneous injection of mercury has been commended by Brault and
Besnier.

Carbolic acid, which had the sanction of Kaposi, has served me in
some cases, but it must be administered in full dosage. It is best ad­
ministered in solution in glycerin and water (1 to 3), each dram (4.)
containing 2 grains (o.13) of chemically pure carbolic acid; beginning
with a teaspoonful (given diluted in a third to a half tumblerful of
water or more) three times daily, and after a few days, the same dose four
times daily, and so gradually up to six times daily; and then, if no im-

PSORIASIS

255

provemen ; more slowly, adding to each dose till 20 to 30 grains (1.25-2)
are given daily. Signs of toxic action should be watched for, but if the
drug is pure it is unusual to see any such action. It is contra-indicated
in those with kidney disease. Tar is another remedy that at one time
had some support, and it probably owes its alleged favorable action to its
derivative, carbolic acid. Pilocarpin is also of a value in some cases.

The various alkaline and sulphur springs, especially the former, are
also of service, partly by the fact that change to other scenery, climate,
etc, is often of benefit to the patient‘s general health, but also by the
free drinking of the waters and the frequent baths indulged in.

The external treatment of psoriasis is demanded in almost every
instance. The exceptions are those cases in which the inflammatory
symptoms are slight and the patches comparatively few in number, and,
for the most part, vary from the size of a pin-head to that of a pea. In
such cases a result is very often achieved by the internal treatment,
with possibly a warm plain or alkaline bath daily or three or four times
weekly. As a rule, however, in moderate and well-marked cases exter­
nal treatment is essential; and even in instances in which the constitu­
tional management of the case seems to be bringing about a favorable
result, external remedies will materially aid in shortening the course of
the disease. In fact, in those instances, fortunately not numerous, in
which constitutional medication has absolutely no influence, external
measures are the sole recourse, and the treatment of psoriasis without such
aid would be only too frequently disappointing. The primary object in
view is to rid the patches of the scaliness. In many cases in which the
scales are but slightly adherent this is accomplished by the baths to be
referred to. In the mild cases it is well to prescribe a daily ordinary bath;
if the scales remain adherent or are only partly removed, the bath may be
made alkaline by the addition of sodium carbonate, sodium biborate, or
sodium bicarbonate, from 2 to 6 ounces (64. to 192.) to the bath; a much
more efficient alkaline bath in adherent scaly cases is one made with sal
ammoniac in the same proportion. The patient remains in this from
ten to thirty minutes, and rubs himself dry with a soft towel. If the
skin is harsh and dry, or if it becomes so after several days’ use of the
alkaline baths, an ointment consisting of petrolatum or lard, or equal
parts of these, with from 10 to 20 grains (0.65 to 1.33) of salicylic acid to
the ounce (32.), is rubbed in after each bath; if the lesions are small, the
ointment is simply rubbed over the affected regions, without reference
to the individual spots, and the skin then wiped off. If some of the
lesions are large, into these the ointment, or a stronger one, with 20 to
40 grains (1.23 to 2.65) to the ounce (32.), can be rubbed. In many of
the milder cases this plan, in conjunction with proper internal treatment,
will bring about a disappearance of the eruption. In such instances if
there is any eruption upon exposed parts, this same salve can be used, or,
preferably, as usually more rapid in effect, an ointment of white precipi­
tate, from 20 to 60 grains (1.33 to 4.) to the ounce (32.); this can be
rubbed into these patches twice daily.

In the more severe and extensive cases this same plan of bath treat­
ment can be carried out, followed by the general application of the

256                                      INFLAMMATIONS

salicylated ointment if necessary, and the application of one of the
stronger remedies to be referred to, to the larger patches individually.
In fact, in all instances the baths have in view, in addition to some
possible therapeutic effect, a removal of the scales, inasmuch as smear­
ing or painting even an active remedy over the scales will have no ef­
fect upon the disease. In these more severe and more markedly scaly
cases the above baths, with frequent anointing with the salve named, or
with a bland oil, as olive or almond oil, will often suffice to remove
the scales, but it is sometimes necessary to use sapo viridis along with
the baths. Or the Turkish or home cabinet steam or hot-air bath
can be used for this purpose, these latter sometimes having a ma­
terial therapeutic influence as well. In exceptional cases linen rags
or cotton soaked in oil can be, during the interim of the baths, kept
wrapped around the worst parts and enveloped with waxed paper or
other impermeable dressing. In extreme cases of markedly adherent
scale accumulation, more especially when the bath plans cannot be
conveniently employed, rubber-cloth underwear can be worn for sev­
eral hours daily, which produces active sweat secretion and conse­
quent softening and maceration. Some skins are readily irritated by it,
however; in others of sluggish integument such treatment alone, if
persisted in, will sometimes suffice to remove the disease; there is less
chance of irritation if a thin garment is worn between the rubber and the
skin. In cases in which there are but few areas, one or several applica­
tions of a 3 to 6 per cent, alcoholic solution of salicylic acid will permit
the scales to be easily rubbed off or scraped off with a curet.

With these general preliminary remarks as to the removal of the
scales, management of the milder cases, etc., the various more active
remedies most commonly employed in the average cases met with,
and which have often rendered me more or less satisfactory service,
can be individually referred to. Aristol is a mild one, and in irritable
cases sometimes valuable, prescribed as a 5 to 10 per cent, ointment
or a 10 per cent, etheric solution; if the latter, it is painted on and coated
over with a film of collodion, and repeated when it becomes detached.
In some instances I have used on the larger patches iodin tincture full
strength or diluted with alcohol, depending upon the sensitiveness of the
skin; this is painted on as a light coating and rapidly dries; if desired, over
this can be painted a coating of collodion. While this treatment is being
carried out with these larger areas the general plan already outlined can
be continued; the painting is renewed as soon as the film or iodin coating
has come off, provided there is no irritation, in which event the repainting
is postponed. When the patches show no reaction from the iodin
painting and no improvement, two or three coats can be put on at the one
time. It sometimes acts satisfactorily.

Tar, in its various forms and varieties, has long been in use as an
external remedy in the treatment of psoriasis, and, all things consid­
ered, it is an extremely valuable one. In rare instances of extensive
application toxic symptoms from absorption have arisen, but these
subside rapidly upon withdrawal of the drug. Although I use tar
freely in the cases of psoriasis in the skin wards of the Philadelphia

PSORIASIS

257

Hospital, I have never observed such an accident. Its positive odor
makes it somewhat objectionable for every­day practice, but this does
not hold as an objection to the coal-tar preparation, and with this
latter the odor soon disappears. This preparation, too, will often agree
where, from sensitiveness of the skin or idiosyncrasy, the other tar
applications irritate. It is much less active, however, than the wood-
tars, but in mild and moderate cases it has often proved of benefit.
The proprietary preparation is known under the name of liquor car-
bonis detergens, but an equally good or superior one can be made from
the formula given under Eczema, and is the one most commonly used
by my Philadelphia colleagues and myself. It may be applied as an
ointment, 2 drams (8.) to the ounce (32.) of simple cerate, or with lanolin
and simple cerate; or it may be rubbed in as a wash, diluted with several
parts of water; the pure solution may sometimes be used without pro­
ducing irritation. Another method of employing this coal-tar solution,
which, however, makes a much stronger application, is as a mixture with
an equal quantity of Vleminckx's solution (liquor calcis sulphuratæ),
another active psoriasis remedy, diluting with from one to several parts
of water as may be required; occasionally it may be used pure. When
this, or either singly, is used as a wash, a mild ointment should be ap­
plied after each application, otherwise the skin tends to become harsh and
dry.

The other tar preparations—the vegetable, or wood, tars—may be
prescribed in various ways. The most common one is as the official
tar ointment, at first weakened with lard or petrolatum—2 parts of
tar ointment to 6 parts of the diluent, and if necessary gradually in­
creasing the proportion, sometimes finally using the pure tar ointment;
this is the most active probably, but the most offensive as to odor and
color. Another form, and that most frequently prescribed, is as the oil
of cade (oleum cadinum) or the oil of birch (oleum rusci), 1 or 2 drams
(4. to 8.) to the ounce (32.) of lard, petrolatum, or simple cerate. In
other cases the tar oil, the oil of cade, or oil of birch, weakened with 1 or
2 parts of alcohol or liquid petrolatum, may be used. The application
selected is to be thoroughly rubbed, in small quantity, into the affected
areas, the excess wiped off, and a dusting-powder applied. Another
mode of employing tar which may occasionally be used with satisfaction
is in the form of a paint, 1 dram (4.) of the oil of tar, oil of cade, or oil of
birch to the ounce (32.) of collodion. The quantity of oil contained in the
formula makes it dry with comparative slowness, but the dressing is effi­
cient in some instances, and remains adherent from one to several days.

Chrysarobin (chrysophanic acid) has an important place in the exter­
nal treatment (Squire) of this disease. The advantage of this remedy is its
rapidity of action. It is adapted to cases in which the patches are com­
paratively few and large, or to the larger patches in extensive cases. Its
disadvantages are that it stains both the garments and the skin, the former
permanently, the latter temporarily; it occasionally excites a mild or
severe dermatitis in the surrounding skin. The patient should be cau­
tioned against carrying the application to the eyes, as conjunctivitis of
varying severity may thus be provoked; it should, therefore, not be em-
17

258

INFLAMMATIONS

ployed for patches of psoriasis on the face or the scalp. If carefully used,
however, and in the paint or film forms, these untoward effects, except
staining, rarely present to an annoying degree. Accidental irritation does
not, however, necessarily mean the giving up of this plan of treatment;
as soon as it subsides it can be cautiously resumed, and if there is no
further irritation, continued.

Chrysarobin is, on the whole, the most powerful local remedy we have
in the treatment of psoriasis, and if propery used, frequently removes
the eruption. It is to be usually employed as a powdery film or as a
paint, the latter being the less active. Its efficacy is sometimes enhanced
by the addition of salicylic acid.

In its use as a powdery film (Besnier) the drug is mixed with chloro­
form, 1 to 2 drams (4. to 8.) to the ounce (32.); or it may be used as a
saturated solution, chloroform taking up about 40 grains (2.65) to the
ounce (32.). The patches, freed from scaliness, as before applications
of all remedies, are freely painted over, giving two or three coatings.
The chloroform evaporates and leaves behind a thin layer of the powder;
over this, to fix it and keep it in place, are painted a few coatings of flexible
collodion or of plain collodion, or a mixture of the two; the plain is apt to
be too hard and stiff, the flexible sometimes less adherent. Or liquor
gutta-percha (traumaticin) can be used for this purpose, as originally ad­
vised, but is not, in my judgment so satisfactory. When the films be­
come detached or considerably cracked or loosened, baths are renewed,
the films rubbed or picked off, and anew coating made. As soon as the
tendency to scaliness ceases and the skin of the patches becomes pale and
normal the application is discontinued. This is a satisfactory method for
large, stubborn patches. Staining of the surrounding skin follows, but to
a much less extent than when a chrysarobin salve is used.

The method of using chrysarobin as a paint is probably the most
common one. The drug is prescribed in collodion or in solution of
gutta-percha, 48 grains (3.2) or more to the ounce (32.) (Auspitz); the
application is rendered somewhat more active by the addition of a
proportion of salicylic acid (G. H. Fox), but with this addition it is
not, as a rule, so comfortably borne in those with delicate skin. The
compound formula with collodion is usually as follows:

R. Chrysarobini,                                                     3j (4-);

Acidi salicylici,                                                   gr. x-xx (0.65-1.33);

Ætheris,                                                           f3j (4.);

Olei ricini,                                                          mv (0.33);

Collodii,                                               q. s. ad f3j (32.).

The ether and oil are sometimes omitted, but this formula is probably
more satisfactory. I have also found it more efficient and less apt to
stain the clothing when a coating of plain or flexible unmedicated col­
lodion is painted over it.

This mixture is painted on the diseased areas with a camel's hair
brush. It quickly dries into a thin film, which adheres firmly. It usu­
ally remains somewhat longer intact than the films formed when the
method previously described is employed. The application should be
repeated every few days, or as soon as the films become detached;

PSORIASIS

259

when they begin to crack, they can, as a rule, be readily pulled off.
Underlying scales, if any, should first be removed, or as soon as the
films are partly detached the baths can be temporarily resumed, until the
patches are again free from scaliness, and then the paintings repeated.
In another method of applying chrysarobin as a paint a solution or mix­
ture is made with liquor gutta-perchæ, according to the following for­
mula:

R. Chrysarobini,                                               5j (4.);

Acidi salicylici,                                                  gr. x-xx (0.65-1.33);

Liquor gutta-perchæ,                                       f3j (32.).

This makes a thin film which is quite adherent, but does not dry quite
so rapidly as when collodion is used as the excipient, and in my experi­
ence is less satisfactory. The last two paints give rise to less staining
of the surrounding skin than does the powdery film already referred to.

Chrysarobin was originally prescribed as an ointment; this is the
most positive but the least agreeable form of application, as it dis­
colors everything with which it comes in contact. It is prescribed
ordinarily in the strength of from 40 to 60 grains (2.65 to 4.) to the
ounce (32.), of benzoated lard. A small quantity is to be rubbed in
vigorously once or twice daily, the excess being wiped off and rice-flour
or starch-flour dusted over the part. After a time the tendency to
scaliness lessens and finally ceases, the surrounding skin becomes slightly
or deeply stained of a mahogany or bronze tint, and the diseased area
or patch itself becomes pale and normal. The method of treatment
with chrysarobin ointment is called for in cases presenting obstinate and
rebellious patches, and in which the other methods of using this drug
have failed. It is also cheaper than the other plans, and for this reason
well adapted for hospital practice.

The chrysarobin treatment is to be discontinued as soon as patches
to which it has been applied become pale or distinctly whitish, as this
usually indicates a disappearance of the disease in such areas; should a
tendency to hyperemia or scale-formation present, it is to be resumed.

Pyrogallol (pyrogallic acid) is another remedy (Jarisch) of some
value, and one that has been employed for some years in the treat­
ment of the disease. It is not so rapid in its effects as chyrsarobin,
but it stains the skin less and rarely excites cutaneous inflammation unless
used in too great strength; the linen is permanently discolored. It
should not be applied to too large a surface at one time, as there is a
possibility, as demonstrated by a few recorded cases, of toxic, and even
fatal, action from absorption (Besnier, Vidal, Neisser). The drug is
commonly employed in the form of an ointment. It is prescribed with
benzoated lard or petrolatum, in the strength of from 20 to 60 grains
(1.33 to 4.) to the ounce (32.). This is well rubbed into the patches once
or twice daily, wiping off the excess and applying over the parts an in­
different dusting-powder.

B-naphthol is another valuable drug (Kaposi) in some cases, but
it takes a lower rank than any of the remedies thus far named. It is
a clean remedy, and is usually prescribed in the strength of from 20 to
60 grains (1.33 to 4.) to the ounce (32.) of ointment. Very often in

260

INFLAMMATIONS

working strength it produces considerable burning at the time of appli­
cation and for some minutes afterward. Resorcin in ointment form, 5
to 10 per cent, strength, is also serviceable in some cases. Gallaceto-
phenone is likewise employed in this disease, in the form of an ointment
in the strength of from ½ dram to 1 dram (2. to 4.) to the ounce (32.); so,
also, is anthrarobin in the same proportion. Sulphur is only occasion­
ally of service, applied as a 5 to 20 per cent, ointment. As an ointment
base for these various remedies lard, or equal parts of petrolatum and
lard, or with 10 per cent, of lanolin, can be employed. In those of sen­
sitive skin using the zinc-oxid ointment or Lassar‘s paste as the base, will
lessen the irritating effects of the various stronger drugs named.

In psoriasis of the scalp the treatment is somewhat different from that
employed when the disease is seated upon other parts. Chrysarobin and
pyrogallol are rarely used in psoriasis thus situated, and when employed,
always in the form of ointments; the pyrogallol salve is sometimes of
distinct service, but should not be used in those with blonde hair, as it
stains perceptibly. White precipitate, B-naphthol, and tar are the main­
stays in the treatment of the disease here. White precipitate in ointment,
5 to 15 per cent, strength, is the most commonly employed and is usually
efficient. Salicylic acid in the form of an ointment, from ½ to 1 dram
(2. to 4.) to the ounce (32.), is also valuable in some cases. The tarry
oils and ointments are sometimes employed, and are most serviceable
applications, especially the vegetable tars, but, owing to their odor, their
use can, as a rule, only be insisted upon if the others fail to make an
impression; the oil of cade, either pure or weakened with 1 to 3 parts of
alcohol, olive oil, or liquid petrolatum, is the most satisfactory. The
scaliness is best removed by frequent shampooing with the tincture of
sapo viridis.

Affected nails are to be treated with the free use of ointments, of the
milder and non-staining class of remedies mentioned, such as B-naphthol,
white precipitate, salicylic acid, and sulphur. Tarry ointments are of
service here, too, but are disagreeable. The parts should be enveloped
in the selected ointments as continuously as circumstances permit.
The nails should be kept trimmed, and rough or projecting parts gently
ground or scraped down with pumice, file, or knife. An occasional soak­
ing in an alkaline solution of borax or sodium bicarbonate, 1 to 5 grains
to the ounce, is often of advantage, the ointment application being re-
applied immediately afterward.

Psoriasis spots or patches on exposed parts, more particularly on
the face, are best treated with ointments of white precipitate, naphthol,
or liquor carbonis detergens, inasmuch as they are cleanly and usually
efficient.

For the rather rare acutely developing, markedly irritable cases, the
external applications must, in the beginning at least, be of the mildest
character possible. Sometimes a bran or gelatin bath, followed by plain
cold cream or petrolatum, with or without 3 or 4 grains (0.2 to 0.265)
of salicylic acid to the ounce (32.), will furnish relief and answer the de­
mands until the disease has become more sluggish. The salicylic acid
paste is one of the safest and most soothing applications. In extreme

ECZEMA

261

cases of cutaneous irritability the most comforting application is one
consisting of equal parts of lime-water and almond oil, with ½ to 5 grains
(0.035 to 0.33 of carbolic acid to the ounce (32.). The calamin-zinc-oxid
lotion or liniment is also useful in such instances.

Regarding the several new remedies or modifications of old remedies
introduced in recent years, clinical trials do not place them so high as
those already in use. Among these may be mentioned pyrogallol mon-
acetate and chrysarobin triacetate, known also respectively as eugallol
and eurobin (Kromayer, Bottstein), and oxidized pyrogallol (Unna).
These are usually prescribed in ointment form, 2 to 10 per cent, strength;
eugallol and eurobin also in chloroform or acetone, the former in 10 to
50 per cent, strength, and the latter 1 to 20 per cent.

Among the new¹ methods, I can speak favorably of the influence
of both light baths and the Röntgen rays. The most efficient light is
that of the sun, but this is rather unreliable and somewhat imprac­
ticable. Next in value, and readily obtainable, is the arc light. Baths
of light from numerous incandescent lamps are also of some value, but
not so efficient as the arc light. Repeated exposures at intervals of two
to four in five days to the Röntgen rays, at a distance of 6 to 12 inches
from the tube, have in my experience proved serviceable in removing
obstinate areas of the disease; the tube, of a vacuum equal to 1- to 2-inch
spark, should be moved from place to place—not being kept more than
three to ten minutes in one region. Occasionally, in obstinate places, the
time of exposure can be cautiously lengthened or the distance shortened.
Undue risk is not, however, justifiable in a disease of this character, so
that x-ray treatment is best reserved for large rebellious areas. Like all
remedies or methods, however, the light baths or Röntgen rays do not
ensure against relapse.

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