With the Compliments of the Author. 
SOME ADDITIONAL 
Clinical Notes on 
Psoriasis: 
F. B. GREENOUGH, M.I). 
BY 
READ AT THE MEETING OF THE AMERICAN DERMATOLOGICAL 
ASSOCIATION, AUGUST 26, 1886. 
[Reprintedfrom the Boston Medical and Surgical Journal 
of October 7, 7886.] 
BOSTON : 
CUPPLES, UPHAM & 00., 
©Hi (Corner Book .Store. 
1886. A FEW ADDITIONAL NOTES ON PSORIASIS. 
BY F. B. GREENOUGH, M.D., OF BOSTON. 
The few notes that I have made on the cases of 
psoriasis that have come under my observation during 
the past dermatological year, hardly merit the title of 
a communication to the Association. I had hoped that 
some paper on this subject would be read, which would 
permit me to say the few words I wish to during its 
discussion. As, however, none such has been presented, 
I am forced to give you the results of my year’s in- 
vestigation on this subject, brief as they are, which 
briefness may perhaps be their greatest merit. My 
notes are supplementary to the paper I read last year,1 
containing the statistics as to sex, age of patients 
when seen, and, as far as seemingly reliable testimony 
could be obtained, the age when the disease manifested 
itself for the first time; also the evidence, either af- 
firmative or negative, of an hereditary tendency. 
In addition to these points, there is one in which I 
have been especially interested, which I referred to in- 
cidentally last year, but which was much more elabo- 
rately treated of by Dr. Sherwell in a later communi- 
cation ; namely, the fact that patients subject to psori- 
asis, as a rule, are remarkably healthy and strong. 
This, during the discussion, was doubted, and I 
thought I would test the matter as far as the number 
of cases that I should see would allow me to do. 
I find on my case-books for the year from July 1, 
1885, to June 30, 1886, twenty-five cases in dispensary 
practice, and seven in my private work. Of this 
number, that is, thirty-two, I have statistics of twenty- 
1 See Vol. CXIII, p. 24. 2 
nine, the other three being cases that were seen when 
I was absent, and the records on these points were not 
noted by my colleagues. With the object of trying 
to reduce to figures the condition of patients with 
psoriasis, as far as general health goes, I started to 
mark each case on a scale of five, that is to say, I as- 
sumed that five represented a patient in perfect health, 
and marked each of the twenty-nine cases on that scale. 
This is, of course, rough work, as I have not subjected 
the patients to a thorough examination, but when they 
seemed in blooming health, and reported themselves 
as being perfectly well, I have marked them five, and 
when they seemed below par, have marked them on 
that scale to the best of my ability. I must say, how- 
ever, that I have been so anxious not to force the 
point that I hoped and expected to prove, that I really 
think I have been inclined rather to under, than over- 
mark. The points that my statistics showed last year 
which seemed to me most interesting and important 
were not noticed in the discussion, namely, the fact that 
while out of the whole number of cases seen, that is, 
three hundred and ninety-four, twenty-one were under 
ten years old, there were five cases who insisted that 
they were first affected by the disease after the age of 
fifty, and that in ninety-seven cases where the patients 
felt able to testify as to the fact of a hereditary ten- 
dency or not, thirty-one gave an affirmative answer. 
A table of the twenty-nine cases observed is given 
on the next page. It appears that sixteen of the pa- 
tients were of the male sex, and thirteen female. That 
the youngest case seen was nine years old. That in 
nineteen cases, what appeared to he reliable infor- 
mation as to the age at which the disease first mani- 
fested itself was obtained, according to which it was 
under ten in nine cases, the earliest definitely reported 
being at three years of age, and four being stated as 3 
having first shown symptoms of psoriasis during early 
childhood. That one case seen at the age of fifty- 
seven insisted that she never had had any simi- 
lar trouble before. That these twenty-nine cases 
showed a percentage of psoriasis to total number of 
cases of skin diseases seen, that is, twelve hundred and 
twenty, of a little over two and one-third per cent. 
Twelve cases gave decided evidence as to the existence 
or not of psoriasis in their parents or other members 
of their family. Of these, four were affirmative and 
eight negative. 
Cases of Psoriasis seen from July 1, 1885, to June 30, 1886. 
No. of 
Case. 
Health 
on a 
Sex. 
Age. 
Heredi- 
tary in- 
Age at the 
Arst mani- 
Remarks. 
Scale of 5. 
fluence. 
festations. 
1 
5 
Female. 
50 
2 
4 
Male. 
42 
3 
4 
Female. 
50 
4 
4 
Male. 
25 
5 
3 
“ 
12 
6 
5 
Female. 
36 
7 
4 
Male. 
34 
8 
4 
Female. 
23 
No. 
7 
9 
5 
Male. 
30 
25 
10 
4 
40 
15 
11 
4 
Female. 
49 
42 
12 
5 
“ 
12 
14 
13 
2 
26 
14 
Phthisis. 
14 
5 
10 
7 
15 
5 
“ 
15 
16 
4 
“ 
21 
3 
17 
5 
Male. 
31 
No. 
21 
18 
5 
“ 
22 
21 
19 
5 
a 
9 
No. 
9 
20 
21 
22 
4 
5 
5 
Female. 
Male. 
25 
57 
24 
No. 
No. 
Childhood. 
57 
(Is sure this is 
(Arst attack. 
23 
4 
Female. 
45 
Yes. 
35 
Father has it. 
24 
4 
Male. 
13 
No. 
10 
1 Had syphilis 10 
25 
3 
“ 
27 
No. 
Childhood. 
< yrs., symptoms 
(now present. 
26 
3 
35 
Y'es. 
12 
27 
4 
34 
Yes. 
Childhood. 
28 
5 
U 
30 
No. 
29 
5 
28 
Yes. 
Childhood. 4 
With regard to what I have been especially interested 
in during the past year, the condition of these patients 
as to general condition and health, while from my pre- 
vious observations 1 felt sure that an attempt to make 
statistics bearing on this point would show that, as a 
rule, it was decidedly above the average, I did not ex- 
pect to have my supposition confirmed as strikingly as it 
has been. I marked each case on a scale of five, and the 
average mark of the twenty-nine cases is a little over 
four and one-third ! As I have previously said, this is 
loose work, hut I have tried to be fair in my estimate, 
and have not given any case a five unless they looked 
and reported themselves as perfectly well. The care- 
ful examination of some of these cases might very pos- 
sibly show that they were not as robust and hea.ty as 
they appeared, but in thirteen of the twenty-nine cases 
I felt justified in marking them five, twelve of them 
are scored as four, three as three, and one as two. 
The latter was a phthisical subject. One of the cases 
marked three, reported having acquired syphilis ten 
years ago, and when seen, had well-marked specific cu- 
taneous manifestations, concomitant with the efflores- 
cences due to psoriasis, he himself appreciating the 
difference between the two lesions. It seems to me 
that this case where syphilis and psoriasis were seen on 
the same subject is a pretty strong proof against the 
theory of any connection between the two diseases. 
The fact, also, which I have been trying to prove, that 
the subjects of psoriasis are generally strong and 
healthy, would certainly tend to make the claim that 
psoriasis was in any way connected with a syphilitic 
taint untenable. The typical subject with psoriasis, as 
I believe, is perhaps rather too fleshy to be in perfect 
health. He is very well described by the German’s 
expression of what he considers the best physical con- 
dition, “ dick und fett.” 5 
I have not seen, and from what was said at our 
meeting last year, I have looked very carefully for it, 
any case where psoriasis showed itself on the palmar 
region. 1 do not mean that I have not seen an erup- 
tion on the palms that resembled psoriasis, because I 
have seen several, but they were all syphilitic, or, at 
least I thought so, and if I should see any such 
without symptoms of psoriasis elsewhere, I should 
much consider it ipse facto specific, and be very 
astonished if it did not yield to specific treatment. 
Since the above was written, through the kindness 
of I)r. Tilden, I have seen a case which compels me to 
modify my statement. It was one of a hoy, aged six- 
teen, strong, and with decidedly more than the average 
amount of muscular and adipose tissue, who showed 
lesions on both palms and on the upper, outside, and 
posterior aspect of the calf of one leg, a typical, almost 
circular patch of psoriasis about the size of a silver 
dollar, the vertical axis of which had been a little 
elongated. The left hand, which showed decidedly 
the most development of the disease, had been sub- 
jected to local treatment, so that beyond the fact that 
we had to do with a serpiginous-shaped efflorescence, 
covering pretty much the whole of the palm, of a non- 
ulcerative character, from which the horny layer was 
being separated, not n uch could be seen. The right 
palm, however, showed several lesions, such as 
I had never seen before, and I think that had I seen 
them, even in a case where there was no characteristic 
patch of psoriasis elsewhere, I should have hesitated 
before pronouncing them syphilitic. They were cir- 
cular, from about one-eighth to three-eighths of an 
inch in diameter, scattered over the palm in such a 
way that their coalescing would produce a serpiginous 
lesion. The largest of them showed a raised margin 
of thickened epidermis with an almost cup-shaped de- 6 
pression in the centre, as though something had been 
picked out. There was no appearance of the charac- 
teristic silvery scales, nor was there any areola of con- 
gestion. The boy had not been working at any trade 
that would by the use of tools cause any irritation of 
his palms. He reported that he had been troubled 
with these symptoms for two years, and gave a pretty 
reliable account of one of his brothers having had a 
scaly eruption on his arms. The patient’s elbows and 
knees were perfectly free from any lesions. His two 
outer lower incisors did show a faint tendency 
towards notching, but it was very slight, and other- 
wise he was a decidedly stocky, well-developed boy. 
There was one case in which the result of treatment 
was very interesting to me. it was that of a very 
stout, strong young man, that I especially noticed, 
from the fact that one of my colleagues who saw it, 
was inclined to consider it as specific. The eruption 
was of short standing, generally developed, and had 
shown no signs of improvement during four or five 
weeks’ treatment. One weeks’ use of chrysorobin 
cleared his skin up entirely, and although afterwards 
there were some fresh manifestations they were easily 
kept under control. 
I am perfectly aware of the fact that the mere sta- 
tistical tabulation of cases of skin disease may be per- 
fectly useless and uninteresting, nevertheless, from 
the observation of a large number of cases some facts 
of importance and interest may be deduced, and facts 
which cannot be got at in any other way. From the 
records which I have, of four hundred and twenty- 
three cases seen, the fact is shown that psoriasis ap- 
pears, sometimes in early childhood, and sometimes 
not until the half century is past, and that the male 
sex is slightly more subject to it than the female. 
Also, it is proved that an hereditary influence exists 7 
in a certain number of cases. From the notes re- 
corded on the twentv-nine cases seen during the past 
year it would certainly seem that the average physical 
development and general health was far above the 
average.