OTHER TREATMENT NECESSARY.

While I am strongly advocating an absolutely vegetarian diet in psoriasis, therefore, I wish emphatically to declare that this is only one element in the treatment of the disease — although perhaps the most important one. In order to obtain the best results there is constant need of careful medical supervision in order to secure the proper working of the economy in all directions, and internal and external medication are called for as necessity arises. I know that with all that has been said in regard to the absolute avoidance of meat, many are ready to reply that some years ago exactly the opposite plan of treatment was advocated, namely, an exclusive or almost exclusive meat diet in psoriasis; this fact has been so frequently alluded to in text-books and current literature that it is necessary to devote a few words to it.

EXCLUSIVE MEAT DIET IN PSORIASIS.

In 1867 Gustav Passavant of Frankfort, Germany, in an open letter to Prof. F. V. Hebra , 7 reported his own case of psoriasis of twenty-five years standing. After trying for many years all known external and internal treatment, with but temporary benefit, he states that he was soon free of psoriasis and from an accompanying catarrh, after entering on an almost absolute meat diet, including soups, pork, fats, cod liver oil, milk, and bacon, and practically no vegetables or bread. He advised against any amount of vegetables, wine, beer, coffee and tea or spices. He cites one case of squamous eczema also relieved by this treatment.

There are a number of points in connection with this brief report which quite invalidate any importance which might be attached to it. First, Dr. Passavant does not mention if possibly he used any treatment, external or internal, in connection with the diet; then he does not state if the improvement in his condition lasted any length of time, or if he had any return to the eruption, either under the diet or without it. He refers also to only one other case, and that of eczema, which was benefited by this plan of treatment. Finally, Hebra . 8 to whom Dr. Passavant addressed his open letter, ridiculed the claim made, some years after its publication, and, as far as I can find, there has been no subsequent corroboration in literature of the correctness of the claims of Passavant that psoriasis can be cured by a meat diet. Surely if there were any truth in it some proof would be forthcoming in the forty years which have elapsed since its publication. On the other hand, there are abundant, though brief, allusions in literature in regard to the injurious effect of excessive meat-eating in psoriasis. More attention has been given to this matter than is perhaps warranted, but as the statement of Passavant is so often called up whenever the subject of diet in psoriasis is referred to, it is thought worthwhile to analyze the subject and refute the error, once for all. My personal experience in regard to the effect of diet on psoriasis extends over more than twenty years, as has been already stated.

EXPERIENCE WITH VEGETARIAN TREATMENT. 

In analyzing the notes of 565 cases of psoriasis observed in private practice I find that about one-half of the cases were seen in consultation, or for but a short period, and, of course, many others only at intervals. But of those cases which were observed long and frequently enough to understand their true condition and observe the results of treatment over a long period, I find that there were forty in whom a more or less vegetarian diet was observed, and from a dozen to twenty patients who carried it out strictly, and from whom conclusions can be drawn. The limits of this paper do not admit of the presentation of the histories of individual cases. During the earlier years the restriction was less severe and related mainly to the abstinence from beef and mutton; and even these patients noticed a marked change in the character and severity of the eruption, and often attributed a relapse to indulgence in the prohibited articles. But of late years I have made the diet much more strict, excluding entirely all animal food, even strong soups, poultry, eggs and fish ; and I have had a number of patients for years on an absolutely vegetarian diet, only allowing butter, but not milk as a beverage, and in some cases I have excluded tea and coffee. The effect of this cutting off the supply of animal nitrogenous food has been very remarkable and striking in many instances (a considerable amount of nitrogen is still supplied by certain vegetables, as the legumes and oatmeal). Patients continually notice the change in the color and character of the eruption, it paling and becoming less scaly, and even entirely disappearing in some weeks, with absolutely no local treatment. In a number of instances this diet has been given to patients who had long been under my care, even for years previously, and the patients and myself have been well able to judge of the result of this radical change in the mode of life ; and we have watched with great interest the often rapid improvement in the eruption, under precisely the same treatment as before, except that I commonly suspend local measures. This treatment has been given to patients at all periods of life, from 9 to 78 years of age, and, as has been stated, has been carried out with varying degrees of fidelity. The note has been repeatedly made that when there has been a neglect of the dietary element there has been a recurrence of the eruption, which again yielded rapidly when stringent measures were enforced. On the other hand, there have been a number of patients who have faithfully pursued this plan of treatment, in whom a long existing psoriasis has remained absent and who, having become accustomed to the diet, say that they have lost the desire for animal food and will not touch it again. This plan of treatment has been tried on some of my patients in the New York Skin and Cancer Hospital with evident benefit, but naturally it is very difficult to carry out effectively such a measure for a long time in this class of patients. In one very striking case, however, in a young woman aged 33, who had been repeatedly in the hospital with most aggravated psoriasis, of many years’ duration, the eruption, which covered, almost the entire body and assumed a general exfoliative condition, disappeared entirely under an absolutely vegetarian diet and large doses of nitric acid, with no local treatment. She remained afterward many months in the hospital free from eruption, and when she went out she was seen occasionally, still faithful to treatment and free from eruption. The oldest patient, a man 78 years of age, who had severe psoriasis all his life and had been some years under observation, showed a very remarkable improvement as soon as he was persuaded to follow this diet, some five months ago, and old thickened patches have almost disappeared. It is not always easy to convince patients of the value of this treatment, and to secure that they shall carry out an absolute vegetarian diet with perfect strictness for a sufficient length of time or permanently; and it will often require no little insistence, as well as intelligent aid on the part of the physician, in order to effect the result desired. But after an experience with it for twenty years I know that it can be effectively accomplished, at least in a certain proportion of intelligent patients in private practice, and I have a number who are really enthusiastic on the subject and have been so for many years. If from carelessness or necessary causes, as in traveling, visiting, etc., the rules of diet are transgressed and there should be some little return of the eruption, this has yielded to a very strict observance of the dietary restrictions, with other proper treatment, better than occurs with the latter alone. Little need be said in regard to the general subject of a vegetarian diet, for abundant experience has shown its value under many conditions of health and disease. The opinion is, I believe, gaining ground both among the medical profession and the laity that far too much meat is eaten by those who can get it; and in London, certainly, the practice of vegetarianism is increasing, as is evidenced by the large number of well-patronized restaurants which make this a specialty; these are also increasing in New York City. In my experience patients have felt remarkably well, when this was rightly directed and carried out, and in numerous instances I have found distinct and steady gain in weight in the spare, and loss of weight in the obese, when tested repeatedly on the same scales. Finally I wish to emphasize the fact that while an absolutely vegetarian diet is advocated in psoriasis, I believe that it has its limitations, and must be directed with care and intelligence; but that in proper cases it can control the eruption and prevent its recurrence I am confident. I wish also again to make clear that patients with this eruption at times will require in addition the most varied treatment, internal and external, in order to accomplish the quickest and best results. How internal remedies act can not yet be fully stated, but in the light of our present study they probably have their action in improving the metabolism of nitrogenous substances. 

531 Madison Avenue.

I found the cited text of Passavant to Hebra - https://archive.org/details/archivderheilku08unkngoog/page/250/mode/2up?ref=ol&view=theater 

written in German, translated to English, copied below. 

If I allow myself to address this letter to you, dear sir, it is because I wish that the treatment method against psoriasis, which I have used in a few cases with the most brilliant success, can be used on a larger scale drawn than can be done in the small number of cases of the kind accessible to me in my practice. To whom better could I turn with the request to subject this treatment method to a strict and broad-based examination than to you, to whom, like few others, a great deal of material is available, and who, as I know from oral communications and the , knows what you have published, is convinced of the inadequacy of the remedies we have used to date against psoriasis?

Psoriasis occurs as the product of two distinct diseases. It is either of a specific nature, one of those numerous phenomena which constitute constitutional syphilis, or it is not of a specific nature. The former, as a rule, gives way slightly to cure methods effective against that affliction. ibr is not discussed further in the following essay. Rather, this is limited to those forms of psoriasis which occur as idiopathic in otherwise mostly healthy individuals. The picture of this disease is so well known that it needs no description. Doctors are less unanimous about the treatment of this disease than they are about the diagnosis of this disease. There is no lack of recommended remedies; but it is

has always been a bad therapeutic sign when so many different remedies are proposed for an illness. Usually it is a proof that one of the recommended means does not achieve the goal, a second, a third, etc. are tried, and that often none of them bring about the desired result. The same goes for the army of remedies recommended for psoriasis. Certain doctors believe that they can cure psoriasis, at least temporarily, and it cannot be denied that many patients, both in hospitals and in private practice, improve considerably during a course of treatment, a few even for shorter or longer periods Time to stay free from their evil. Usually, however, the healing is incomplete, or recurrences soon set in, and once the disease has existed for years and has spread as so-called psoriasis inveterata over a large part of the body or over the whole body, it usually applies to incurable and the doctor and patient are satisfied if the evil is only kept within mild limits 

But to what extent, with the usual methods of treatment, whether local or general, the improvement obtained is to be ascribed to the means employed or to the changed way of life of the patient, I hope to put this question in a clearer light by what follows. It may often happen that the doctor attributes the improvement to the remedies used, while it is to be attributed to the changed lifestyle of the patient. This is not to deny, however, that there are remedies, both local and internal, which act favorably on the course of the disease, just as there are local and ingested substances which act decidedly injurious. But I have so far looked in vain at the dermatologists of various countries for a remedy which will cure the disease safely and thoroughly. And yet there is such a remedy that seems so simple when you know it that you are surprised that it has not long since been generally known.

This remedy consists of an exclusively, or almost exclusively, animal diet. When it is used, all other means prove superfluous; without them, in most cases all other means used become ineffective, or at least only of little or temporary use.
The Banting cure for obesity, which has recently gained some popularity, differs in the consumption of wine, beer, grog, etc. recommended for the Banting cure has a detrimental effect on psoriasis. On the other hand, milk, pork, fatty meats and even stewed bacon, which are forbidden in that regimen, prove useful in psoriasis. I leave it to physiologists and chemists to investigate how far a chemical explanation of the results cited is possible; but the fact is clear to me, that the predominance of vegetable food produces and maintains psoriasis in certain constitutions, while animal food rapidly cures it. A few case histories may serve to corroborate the view here expressed, and may it be permitted to communicate to my peers the observations which I have had the opportunity of making on myself during a long series of years.

The first onset of the disease was in my 20' years, it may have been about 25 years ago. It appeared as very small, later crena-sized spots covered with white scales at the tips of both elbows. These spots were quite painless and were only discovered by accident. They have remained unchanged for years. At about my 358th year these small scaly patches gradually began to spread. Small islets, the size of a pin's head, covered with scales, arose in the vicinity, which either soon disappeared again, or at other times enlarged and merged with neighboring similar places. At the same time, small patches with white flaps appeared on both knees, which remained unchanged for a long time. The disease existed like this for years, hardly noticed because it didn't cause the slightest discomfort. But it didn't stop there. This apparently quite unimportant ailment should gradually give rise to za great complaints. Over the years the scaly rash gradually spread from the areas first affected, partly due to continuous enlargement of the areas affected with*^ scales, partly due to the confluence of newly formed areas, which initially appeared in the form of islands. In general, it was the extensor sides of the arms and legs that were affected first, and only later did the rash spread to the flexor side of the limbs. Traces of it appeared on the head, first on the forehead at the edge of the hair growth, from there it spread further down the hairy head and forehead. There were also scaly spots on the back; the rash had appeared earlier on the scrotam. By this time the disease had long since lost its indolent character, and the parts covered with scales had become sensitive. In particular, in the warmth of the bed, a tiresome jacket ice had formed, which caused scratching for the moment.

The first time the scales were removed by scratching or by a lukewarm bath, they appeared all the more violently later on.  If the scales were removed by scratching or by a lukewarm bath, the spot on which they had been sitting appeared strongly reddened, probably also somewhat raised, bleeding slightly or oozing a light serum.

In the course of the years improvements and aggravations occurred more often, soon the rash decreased in intensity and extension, soon it increased again.  In the course of time, parts of the body that had previously been affected by the disease became free again, while others that had previously been healthy were affected. In general, however, the disease increased in severity as well as in extension from year to year.  Particularly painful were the places where smaller or larger cracks or fissures formed.  These occurred most easily where the skin was more tense due to muscle activity, e.g. on the calves when stretching the legs, but these extremely painful, weeping and bleeding sores also formed in other areas affected by dandruff, where there was no tension in the skin, either on their own or as a result of scratching.     The legs were somewhat swollen.

80 whole scraps of skin came off, especially on the legs, golden and thaler-sized and larger upper hair pieces could be pulled off. If there was some improvement, the snaps were less cohesive, they became smaller, almost small-like or even stubby.  At a certain time after a new storm, which had spread the rash over the whole body with acute vehemence, the barrels were also affected and here later the whole epidermis of the sole detached in large thick skin shreds.  Also the nails showed some times a Betheiliguag at the lichen attack.  Similar processes may have taken place in the epidermis-cell layer forming the nail as in the closely related epidermis layer of the skin, which made the nail sensitive in the infested area and could be traced for a long time in its further growth as uneven areas lacking the usual smoothness on the nail.  Sometimes pus was formed under the nail cover or pustules appeared, especially on the legs.  Sweating was almost completely suppressed. The urine was often cloudy and a red uric acid sediment was deposited.

In the fall of 1866, the parts of the body ^ face and hands, which had previously been almost completely spared, also began to be affected by the rash. The Schnppenflechte was no longer content as before with the upper half of the forehead, but in various places of the face new islands arose, which enlarged together, beard area, ears and neck were like the rest of the body completely covered by it.  In the same way, both hands were now affected, in that the rash progressed from the arms partly continuously over the hands, but even more so in that new, at first small, gradually enlarging, scale-covered areas appeared on hands and fingers and united by enlargement.  On the volar side of the fingers, apart from the fact that the hands and fingers were swollen, the affected area had a furry feeling, especially in the fingertips. This made the use of the hands very difficult, writing became difficult, and sometimes the grasped object escaped from the sensitive fingers, which were impaired in their finer feeling. Later the whole epidermis of the hands and fingers, on the back side in smaller, on the volar side in larger scales and skin fragments detached.  However, what threatened to become particularly troublesome again at this time was the bronchitis that set in again.  This time, as before, it developed from catarrh and soon reached a tremendous severity.  The coughing fits tormented and fatigued not only during the day, but also disturbed all night rest.  The quantity of green mucus coughed up was astonishingly large.  Later, the nasal mucosa was also seized and for several weeks the site of a cold characterized by unusually abundant mucus secretion.  The cavities connected with the nose also participated in the mucus secretion.  The sensitivity of the maxillary sinus on the left side (the right one remained completely insensitive), the sensitivity of the sinus area, and finally the involvement of the eustachian trumpet on the right side indicated that these sinuses, which open into the nose, were also the seat of a strong catarrh. When blowing the nose, there was an unpleasant sounding and ringing in the right ear, and not infrequently, when blowing the nose, there was a feeling of dizziness for a few moments, which is a consequence of the pressure of the stapes on the oval window.

The use of the Knr in this period caused a rapid improvement in all the symptoms of the disease, and in a few weeks they disappeared.

During this time, the application of the Knr , which caused a rapid improvement of all pathological manifestations, and in a few weeks caused their total disappearance.  First the psoriasis of the outer skin disappeared; it became smooth; the normal sweat secretion was restored at the same time; then a repeated improvement of the bronchitis took place and finally the rhinitis, the nose and its neighboring cavities as well as the right Eustachian trumpet disappeared.  The long-desired feeling of complete health returned.

The number of remedies used against this disease over the years, some of which were used with great consistency for a long time, was very large.  None of them had a substantial and lasting success, although some locally applied remedies were of definite benefit, insofar as they caused an alleviation of the pain.  A short heart count of the most important of these remedies may follow here:  Internally iodkali, arsenic, as solutio Fowleri, repeatedly and for a long time, theer water, sulfur, slightly laxative mineral water, double carbonic soda, graphite, liver thrane, etc. etc. etc. None of these remedies was able to relieve the pain.  None of these remedies has been able to cure psoriasis; in cases where improvement, almost apparent cure, has occurred during the use of one or the other of these remedies, there is no doubt that other factors, not sufficiently appreciated in their importance, have played a role, namely a change in diet.  Mention may also be made here of some foodstuffs and beverages of whose detrimental effect on the disease I have often had the opportunity to convince myself.  These include wine, beer, all spirits, coffee, tea, strongly salted food, sauerkraut, and as it turned out, a predominantly vegetable diet.  Tobacco smoking, even snuffing, proved to have a decidedly detrimental influence, as often repeated experiments have confirmed.  This influence was soon manifested by increased redness of the affected skin areas, by increased secretion of epidermal scales, by oozing of the red skin areas after removal of the scales, and by greater sensitivity, especially stronger itching at night.

When applied externally, all the least irritating agents could not be tolerated, rubbings of theer, ol.  Rusci, ol.  Cadinum, soft soap, sulfur ointment, mercury ointment, both gray and precipitated ointments, glycerin, etc., and even simple washings with cold water were not tolerated. On the other hand, lukewarm baths proved very useful in temporarily removing at least the scales, but the itching still remained, and only too soon a new scale had spread over the body.  Only during the bath there was an unusual feeling of well-being, so the bathing time was extended to 1 to 3 hours.  Thus, the bathing resorts of Leuk in Switzerland, Schlangenbad and others have gained some reputation against this disease.  Salt baths are not tolerated at all in the erethisean form of the disease, they irritate much too much, in torpid forms they may be useful like other baths for the removal of the scales.  But of most decided , even if only temporarilyiji benefit are mild oily rubs, for example, of sweet almond oil or gold cream.  During the last years of this affliction I had adopted the habit of rubbing my whole body with sweet almond oil in the evening before going to bed.

  So I could find some necbtrnbe on the first.  Otogen the 80 ftoiserst painful fissures there is nothing better than covering with a compress immersed in water, which is covered with wax or Oattapercha paper yor the dryness and is fixed with a bandage.  Physical exercise has a not insignificant influence on psoriasis.  It is decidedly useful.  Large daily walks, barrel trips reduce the rash, while in a sedentary lifestyle the disease persists at the same level or worsens.  However, there must not be any sores that are irritated by the movement, otherwise instead of improvement, increased painfulness will occur.  Finally, emotional movements seem to have a detrimental influence on the rash.

All these influences, both favorable and unfavorable, take a back seat to the infinitely more important influence that a vegetable or animal diet exerts on the disease.  The influences described above are only effective when the diet is otherwise the same; but if in the latter there is a change to one side or the other, then these influences caused by the diet significantly outweigh all those mentioned above. Thus those favorable influences will lose their effectiveness if the food is predominantly vegetable; and on the other hand, the adverse influences will not or only slightly assert themselves if at the same time the food is predominantly taken from the animal kingdom.

A further difference in the effect of the above influences, which must certainly be considered highly, is the individually conditioned one.  If in a case, as in the one described above, tobacco, wine, etc., have proved to be decidedly disadvantageous; if repeated experiments have always yielded the same result, then the individual disposition must be decisively taken into account.  What thousands tolerate well may be detrimental to individual constitutions.  The physician has daily opportunity to observe such idiosyncrasies.  There may even be natives who can live exclusively on vegetable food for a long time without being affected by psoriasis, and without their health even being impaired by it, while others become ill under the influence of such an unmixed diet.  In the present case history, taste and inclination gave rise to a predominantly vegetarian diet, which had existed for many years, almost since childhood.  Meat and meat soups were eaten daily, but only in small quantities; the main food was bread, vegetables, pastries and fruit.  At first it took some effort to eat meat again and again instead of the usual vegetarian food, but the rapid improvement easily overcame this small inconvenience. Soon nature became accustomed to the changed diet, and what used to be enforced only with some coercion, soon happened with pleasure.