A Case of UNIVERSAL PSORIASIS. By A, H. Ohmann-Dumesnil, A. M„ M. D, Professor of Dermatology and Syphilis, St. Louis College of Physicians and Surgeons. Reprinted from the St. Louis Medical and Surgical Journal, October, 1884. ST. LOUIS: MEDICAL JOURNAL PUBLISHING COMPANY. 2622 Washington Avenue. 1884. A Case of Universal Psoriasis. By A. H. Ohmann-Dumesnil, A.M., M.D., Professor of Dermatology and Syphilis, St. Louis College of Physicians and Surgeons. The following case is an interesting one merely from the fact that it is typical in some respects and departs from the general rule in others. Besides this, it is of some interest to the general practitioner who has few opportunities to observe such cases, and at times is likely to commit an error by relying too implicitly upon loosely made statements or impressions which are fallaci- ous. The case about to be described is one which illustrates the disease in a thorough manner and yet hardly possesses a suffi- cient number of peculiarities to prevent one, unacquainted with its various forms, from making a too hasty diagnosis or a faulty one. The patient F. M., aged 23, of medium heightand build, called at the dispensary saying that he had a 11 breaking out" on his skin. He showed his arms and upon request stripped off all his clothing. As will be seen from figures 2 and 3 he is considerably affected. The scalp is the seat of the disease which, however, is covered by the hair. Taking a front view of him, patches are seen about the right clavicle, on the arms and forearms, the chest is well covered, whilst the abdomen has less. The legs are com- paratively clean, but a few small patches existing. The back is literally covered, as also the posterior aspect of the arms, the nates being free, whilst the legs have a larger number and larger patches. The palms have a number of patches, the size of a dime, the soles having none. The history of the case is, that he first noticed some red spots coming out on his arms and these soon covered with scales and became larger. Then other spots appeared in different parts of his body. He has had this affec- tion nine years. No one in his family ever had it; nor can any history of syphilis, either hereditary or acquired, be made out. The patches are irregular in size, shape and distribution. They are sharply defined against the normal skin which is of a medium fine texture. The epidermal scales are heaped up in masses, a quarter of an inch in thickness and of a dull grey color. They separate easily and are not accompanied by pain, the only sub- jective symptom being a slight itching. The patches are sur- 4 rounded by a bright-red ring, composed for the most part of small papules, whose brightness of color is rendered greater by con- trast with the skin and the scales. The patient has been in the hands of a large number of phy- sicians and has been treated for years without any apparent bene- fit. He also states that his trouble is spreading and new spots have been observed, which will ultimately develop into patches. He does not remember having observed any of the old lesions disappear. Symptoms.-In regard to subjective and general symptoms, very little can be elicited. He eats well, sleeps well, never notices anything out of order, except an attack of itching which does not last any length of time. He never had rheumatism, has always been healthy and is now working steadily. He is fear- ful that his face will be attacked, as the disease has progressed down his scalp and involves a part of the forehead. The objec- tive symptoms are typical in one respect, as far as size and shape are concerned. The fact, however, that the scales are not of that white, pearly lustre so commonly described might lead a tyro into error. Again it will be observed that the flexor surfaces are as much involved as the extensor, more so in the legs. Besides this, the fact that there exists a psoriasis pal maris might lead to a suspicion of syphilis, as the palms is an unusual if not rare seat for this affection, and yet in such a general involvement of the surface it is nothing but natural that they should also be attacked, although there is no probability that the face will ever become the seat of the disease. Etiology.-In regard to the cause of the disease in this case nothing can be elicited. The patient appears normal and claims always to have been so. No constitutional disturbance is obser- vable and all the functions seem to be performed in a normal manner. Although syphilis never produces this disease, it may sometimes become a factor in some respect or other. The most careful questioning has brought out no history of it in the patient or his family, and he presents no marks of ever having had a chancre and denies ever having been troubled by any venereal disease. Prognosis.-Psoriasis is essentially a chronic disease. It is very liable to recur even after an apparent recovery and this is the more probable if, as in this case, a large extent of surface has Fig. 1. Fig. 2. Front and Rear View-taken from a Photograph-of a Case of Universal Psoriasis. 6 been involved in the progress of the disease. The patient has almost given up all hope, yet there is always some left, despite the assertion of Hebra that it is incurable. The patient has been fully explained the nature of the case and told that the probability of getting entirely rid of the disease is very small and that, if it should disappear, relapses are very probable. That some improve- ment may follow a course of treatment is not beyond hope and it is with this expectation that treatment has been commenced. Treatment.-The fact that but local treatment is sanctioned by the Vienna School may, perhaps, be a reason why psoriasis has been regarded as incurable. But the fact has been observed of late years, that a great many skin diseases progress much more satis- factorily when the patients are placed under constitutional treat- ment in conjunction with local means,and for this reason a num- ber of affections hitherto deemed incurable or presenting great difficulties in treatment, have been to a great extent simplified and have yielded much better results than formerly. In this case the teaching of the French, British and American masters of the art has been followed, and the patient has been placed both under general and local remedies. For the former, arsenic in very small doses seems to have yielded the best results. Care must be taken, however, to discriminate what the proper stage is for its adminis- tration. It is only of value when given in the chronic stage,, where the lower layers of the epidermis and the cutis vera are involved in the process. To give it in acute stages of any skin disease does positive harm, and to dose patients with any der- matic affection with Fowler's solution, as is a universal custom with general practitioners, is merely a display of ignorance and incapacity. In respect to local treatment, the scales were ordered to be taken off and this was easily effected, in the present instance, by the use of a non-irritating oil. The scales separate very easily, bearing the characteristic shining pellicle with a few red points projecting: This being done, a mixture of chrysarobin (chryso- phanic acid) in tincture of benzoin was ordered to be painted upon a limited area at a time, from fear that covering all the patches might induce toxic symptoms. The tincture of benzoin has been used as a vehicle from the fact that it dries quickly,, spreads the chrysarobin evenly and does not soil the clothes, forming a sort of varnish. Elastic collodion is also a good vehicle- 7 as well as traumaticin, a mixture of rubber in chloroform. The ointment of chrysarobin is not in great vogue, as it stains the clothing and is to some extent a disagreeable application. The time has been too short since the inception of treatment to report any progress. Should progress take place or not, the results in this case will be published at some future time in this Journal, and whereas this short paper has been rather one des- criptive of the case, a future one will be more especially con- cerned with its treatment. 617 Walnut St.