Treatment

Psoriasis is an affection that will certainly try the patience of the sufferer and the skill of the physician, more thoroughly than any other among the commoner diseases of the skin. As Wilson truly says, it "is not a disease on which to build a medical reputation."

Before detailing the methods that I personally find it most desirable to adopt in the treatment of this disease in private practice, I shall give those which are recommended by the two most noted dermatologists of the quarter century just past - namely, Wilson, of London, and Hebra, of Vienna.*

I do this the more readily as the principles underlying the methods of these eminent men are in sharp contrast, the true method I believe lying between them. I shall commence with Wilson and slightly condense the statements made in his work (77, 310 et seq.). He makes the preliminary statement that Psoriasis may be complicated with other affections, which must bo carefully considered before deciding on the treatment. One of the most common complications is that form of mal-assimilation which gives rise to the gouty and rheumatic diathesis, and this is apt to occasion an inflamed and painful state of the eruption, and must be removed before the real treatment of Psoriasis * is begun. Not unfrequent-1y, in the presence of the gouty diathesis, the eruption is attacked with a violent erythema, and not uncommonly it throws out the ichorous exudation of eczema. He then goes on to say: "The treatment of lepra therefore presents two indications: firstly, the removal of complications, together with the regulation of the assimilative organs; secondly, the adoption of a course of specific remedies.

* At the moment of writing Hebra has been dead a few months, but his works will live for many decades.

"The complications of lepra call for the same treatment that they would receive independently of their connection with lepra," consisting mainly in the use "of gentle aperients, salines, bitters with alkalies, bitters with the mineral acids, colchicum, etc. Occasionally the effects of this treatment are very remarkable. With the improvement of the general health, the lepra is always improved and sometimes will get entirely well without specific remedies. The practitioner must not, however, in this event, rush to the conclusion that the remedies have cured the lepra, and will therefore cure it again. If he endeavor to put such an idea to the test of experiment he will inevitably fail. The lepra, in his fortunate case, had reached its turning-point; it was no longer kept up by its special cause, and was only prevented from healing spontaneously, as it not uncommonly does, by the constitutional disturbance then existing. . . .

"As a specific in lepra, there is but one reliable remedy, and that remedy is arsenic. . . . Arsenic will cure lepra with certainty, but neither arsenic nor any other known medicine will prevent it from returning again; sometimes after a thorough dispersion by arsenic, the eruption never returns, but more frequently it recurs the following or after the lapse of several years.

The pharmacopoeia is rich in arsenical preparations, but none ex-ceeds the liquor potassae arsenitis, the solution of Fowler. The dose of this preparation is five minims, to be taken with meals three times a day. I frequently combine with it five minims of antimonial wine, and ten minims of tincture of ginger, making the dose of the mixture twenty drops.....

"In very chronic cases of lepra, it may be found advantageous to combine mercury, and sometimes mercury and iodine with the arsenic. . . .

"Liquor potassae and dilute nitric acid are among the remedies for lepra. The former may be taken in doses of from one to two drachms, + two or three hours after a meal, three times a day, in any convenient vehicle, such as milk or beer, or in some medicinal infusion, and is not incompatible with the arsenical treatment. The dilute nitric acid is incompatible with the arsenical treatment, and may be adopted in those cases wherein the stomach evinces a great repugnance to arsenic. The dose is one or two drachms ++ in barley-water, sweetened with sugar, to be taken an hour before meals, twice or three times a day. I have usually combined this treatment with a Plummer's pill at bedtime......

* Called Lepra by Wilson.

+ The Liq. Potassae of the British Pharmacopoeia is weaker than that of the United States, the spec. grav. of the former being 1,058, that of the latter being 1,065. The dose should consequently be smaller.

++ This seems to be a very large dose.

"Local treatment for the cure of lepra is useless; but various indications present themselves which render local treatment for the relief of irritation of the akin advantageous and necessary. An erythematous or eczematous state of the eruption, or a cracked and fissured state of the skin, will call for the use of the oxide of zinc ointment, with spirits of wine or glycerine. Where the scales cover a large extent of the surface of the body, a tepid soap-bath or vapor-bath is indicated, and is a source of much comfort. Various remedies are found to give relief by occasion-ing exfoliation of the scales, such as a lotion of the bichloride of mercury; an ointment of carbonate of potash, of iodide of potassium, the white precipitate, the concrete naphthalin ointment (

1.i.), or tar ointment. For a dry and parched state of the eruption, the best application is a lotion of equal parts of distilled glycerine and rose-water.

For the accumulation of sordes and scales which takes place in lepra capitis, the best application is the unguentum hydrargyri ammonio-chloridi; and for the dry, horny, ragged, and loosened nails of lepra unguium, steeping them in glycerine.

But 1 must repeat, the local treatment of lepra is not to be regarded as curative, it is simply palliative; the cure must come from within, from that improved and altered state of the blood which results from the proper administration of arsenic."