PSORIASIS AND SYPHILIS.1 By J. Abbott Cantrell, M. D., ADJUNCT PROFESSOR OF DISEASES OF THE SKIN IN THE PHILADELPHIA POLYCLINIC, • DERMATOLOGIST TO THE PHILADELPHIA HOSPITAL. After having witnessed many mistakes in the diagnosis of the two affections, psoriasis and syphilis, I have decided to make the differential diagnosis of these affections, as we see them manifested upon the skin, the subject of my remaiks this evening. I have here cases of each, giving you visual examples of the affections, as well as the ease with which you may distinguish one from the other after studying several features which are prominent in each. It is, of course, well understood to-day that syphilis is caused by a specific virus, the entrance of that virus into the system occurring only after certain conditions are fulfilled, viz.: that of coming into contact with one who has previously met and contracted the poison, so that the virus enters and passes through the system, occasioning such symptoms as should be constantly in the mind of the practitioner of medicine. I refer to the initial lesion, or the chancre, the infiltration and enlargement of the glands, and the sub- sequent manifestation of its presence by the roseola (which does not concern us this evening) and the appearance of papules, covered or not with a desquamating epithelium. As to the appearance of one of these affections upon the skin, I show you a man 24 years of age, who first noticed this rash upon his body, arms and legs about three days ago, he being frightened is what brings him before us, as other than the appearance upon the skin, he knows nothing of it, as there is no itching and no pain. The lesions are symmetrical, discrete and well defined, there being no coalescence of them, and consequently no patches; the lesions are all covered with a dark desquamating epithelium. When a man presents himself before you with a rash of this kind you necessarily think of both psoriasis and syphilis; and while at times they may both have the same appearance upon the skin, there are other symptoms with which a diagnosis may be made. In the case before us, the lesions are symmetrical, they are general, discrete, and being all of one stage of develop- 1 A Clinical Lecture. PSORIASIS AND SYPHILIS. 15 ment, they are the size of a half pea. In a psoriasis the lesions may be found in different stages of development, showing an old and large lesion here, and a new and small one there. The spots are covered with a darkish llattened scale and this on being removed shows a dark brownish color of the skin. In a psoriasis the scales are imbricated and mother-of-pearl or silvery-white in color, and upon removal show a lightish red color of the skin and some spots of exuding blood. The lesions in both diseases are sharply defined—and often times as in this case, you must go further than the appearance of the skin, examin- ing for the initial lesion. I find here a suspicious scar, which is evidently a healed initial lesion, as no other disease, unless a traumatic disturbance, leaves a scar here. I suppose you notice that I myself looked for a sore, not having asked for it, simply because the answer to that ques- tion may be misleading and may prejudice one in favor of one disease or the other. Often the lesion may have been a herpes as well as the chancre, and may have been diagnosed incorrectly even by a good practitioner. Examining further into this case we find a chain of enlarged glands in either inguinal region, also in the cervical region and in the epitrochlear space. These enlargements are not found in a psoriasis; consequently without reference to any more symptoms in this case we can safely conclude that we have a syphiloderm. In case number two, a man 40 years of age complains of an eruption on the head alone, in the hairy scalp, these spots he says have existed for about four months; he has had previous attacks, over the body, but never before in this region. These spots you notice are covered with a crust, dark in color, which has continued forming and is now somewhat raised above the surface, and as these conditions are often witnessed in both of the affections to which I referred, we must necessarily study this carefully before coming to a positive diagnosis. Syphilis affecting this region and having the char- acters seen here, shows you that the lesions are the later ones; the crusts are conoidal, the point being at the top and widening out toward the base, which here is distinctly broad. On removing this crust, it is found to be well made and 10 CANTRELL, holds together, and the parts underneath are shown to be a cavity filled with pus, the edges somewhat undermined. While in psoriasis, the color of the pyramid would be lightish or gray, it would be seen as if one scale was put upon the other, in fact imbricated, not being conoidal, being somewhat flattened upon the summit; this scale upon re- moval would be found somewhat brittle, and the surface underneath would be reddish, with minute drops of blood, but no cavity, the skin being on a level with the surrounded unaffected skin. And in additon, we would likely find lesions scattered here and there on the body, not scars, of previously existing lesions as in this case. The lesions of psoriasis when upon the scalp generally affect the region along the edges of the hair as well as the parts beneath it; and here they are generally of a violent red and covered with its peculiar scale. The general health of the patient may suffer no inconven- ience in psoriasis, while in a syphilis, without treatment, the man would certainly sink under its influence; the hair would generally fall out, as in the case before us, while in a psoriasis, the hair may only slightly show this influence. In this case I doubted whether we would find any enlarge- ments of the glands; and as I thought, there are not any ; these are seldom found in the later syphiloderms. In the two remaining cases, which I purposely show you together, we find that the outbreak in both is general; in this man, the disease has existed previously, having gotten well under my care some four years ago, and now he returns with the disease, if I remember correctly, worse than before. He is 22 years of age, the eruption having existed at this attack about six months, his being out in the country and not able to attend to himself has allowed the disease to reach the proportion seen ; we have lesions here the size of a pea, and some larger ones, and here and there some that have coalesced; the whole of the diseased portion is covered with silvery-white imbricated scales, resembling the shingles of a roof. We notice that the lesions are at differ- ent stages of development; here we see a lesion size of a pin head, which was noticed yesterday, while over here we see a collection of lesions forming a patch ; he complains of severe itching; the lesions all have a distinctly marked border, in 17 PSORIASIS AND SYPHILIS. fact somewhat raised. Examining as in the previous case, wo find a coalescence of the lesions, a fact not noticed in the previous case: we find no glandular enlargement, the man being in good health, weighing about 15 lbs. more than when attacked. I think all can see, without further question- ing, that we have here a psoriasis. This man, 22 years of age, has had the disease since 12 years of age, has never been entirely free from it. He is in good health otherwise. I distinctly remember when I first saw him, when 16 years of age, he had a slight outbreak, for which the usual remedies were ordered, and from time to time during the past six years, he has appeared at the clinic. Each time I found that the disease was worse, and when he appeared before me this evening, I found that the body had very few healthy portions, the eruption is nearly universal. Stripping him of his clothing, we find over the chest and back, large lesions, which cover these regions in their entirety. We see others on the legs and thighs, also these large lesions on the scalp and around the border of the hair, all covered with the peculiar silvery-white scale. We notice that the lesions are well defined, somewhat raised and abrupt, there is considerable itching which often totally unfits him for work. No one would say that this case was syphilitic, because we have lesions large in size, showing that a number of smaller ones have coalesced to form them, it has the silvery-white imbricated scale, he has never been free from it since first seen, there is no glandular infiltration; while in a syphilitic the lesions would have been of one size, the scale would be a flattened one, dark in color, no itching or if present only slight, there would be glandular swellings, and if a syphilitic and lasting as long as this disease has existed, we could find scars of previous lesions as well, or certainly great destruction of tissue, if not life. Referring to a cause for psoriasis, I find myself entirely at a loss to ascribe one, and why the disease should attack one in good health as frequently as it does one in bad health, I also cannot understand. But whether from a known cause or not, the disease is perfectly harmless and causes no disturbance, except the disfigurement of the skin, and the consequent itching. Reprinted from The Philadelphia Polyclinic, January 15, 181)5.