REPRINTED FROM 
CIk Boston &?ctiical anti Surgical journal 
MARCH 28. 1889. 
DERMATITIS GESTATIONIS 
The History of a Recurrent 
Dermatosis 
BY 
JAMES C. WHITE, M.D. 
Professor of Dermatology in Harvard University 
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Boston. DERMATITIS GESTATIONIS; 
THE HISTORY OF A RECURRENT DERMATOSIS.1 
JAMES C. WHITE, M.D., 
I purpose to give a brief account of the changes 
which have taken place in the skin of a young 
married woman during the past two years. I first 
saw her in November, 1886. She was then twenty- 
two years old. Her general health, and the condi- 
tion of her skin, had been perfectly normal until 
after the birth of her first child in July of that 
year. Three weeks after that event, from which 
she made a good recovery, there appeared upon her 
front chest a “fine rash/'* which her attending phy- 
sician called an eczema. Three days after its out- 
break she visited the seashore and ate some clams, 
and on the following day her whole skin became 
intensely red, and a few wheals made their appear- 
ance, accompanied by great itching. The affection 
was supposed by the family to be nettle-rash, but 
as it persisted Dr. Whittier was called, who has 
kindly given me the following account of her con- 
dition at that time: — 
“ I first noticed across the upper portion of the 
chest in front, and not dependent upon any disturb- 
ance in the breasts, a pronounced erythema, with 
papular elevations and wheals, varying in outline 
Professor of Dermatology in Harvard University. 
1 Read by invitation before the Obstetrical Society of Boston, 
January 12,1889. and in length from a few lines to nearly an inch. 
The entire surface conditions were associated with 
slight constitutional disturbance (fever, etc.), but 
with a degree of heat and irritation very difficult 
to allay or control. My period of observation of 
Mrs. X. covered about six weeks. During this time, 
beginning on the chest, and quite rapidly at the; 
outset, and more slowly as the extremities became 
involved, the eruption invaded the whole surface of 
the body, but did not involve to any particular ex- 
tent the face or scalp. About the waist and genitals, 
on the inside of the thighs and forearms, thfe red- 
ness was extreme, and papules and vesicles abounded 
with exudation and desquamation, and most intol- 
erable burning, itching, and painful sensations. I 
concluded that the disease in its entire stages was 
an intense urticaria, dependent upon parturition 
and some error in ingesta or digestion, and that 
later on, and because of the intense local irritation, 
much aggravated by a lack of power of control on 
the part of the patient (it was impossible to keep 
her from scratching), a true eczema was set up. 
The treatment was local and constitutional, and a 
wash of zinc oxide with lime water was most satis- 
factory, while iron, quinine, and strychnia in the 
earlier stages gave place to Fowler’s solution later 
on.” 
I first saw Mrs. X. as an out-patient at the skin 
department of the Massachusetts General Hospital 
nine weeks after her confinement, whither she had 
been referred to me by Dr. Whittier. Her face 
then presented appearances which would have been 
regarded as those of an ordinary eczema of subacute 
type, viz., papules, excoriations, and scales, with 
diffused redness and considerable cell infiltration. 
The general surface elsewhere, however, exhibited 
nifestations of chronic urticaria, areas of fugi- 
ma 3 
tive erythema, and sparse wheals. The skin in all 
parts returned to a normal condition in two or three 
weeks under a soothing local treatment. 
Second Attack. — Six months after her recovery, 
during which time the patient remained in good 
health in all respects, I was called to see her. I 
found her in bed, with a skin of an intense redness 
everywhere. Upon the limbs were a few wheals. 
There was a sensation of great heat and itching 
over the whole surface. 'he complained of slight 
nausea, headache, and frequent chills. The tongue 
was somewhat coated, and the pulse a little acceler- 
ated. Thirty-six hours previously she had eaten 
roast pork, and twenty-four hours afterwards the 
cutaneous symptoms had begun to manifest them- 
selves, without marked signs of intestinal disturb- 
ance, and rapidly developed to the condition present 
at my visit. The indications at that time were 
those of a universal urticaria rubra. The skin was 
everywhere thrown up into firm, white, and promi- 
nent ridges on scratching it (dermographismus). 
On the following day I found that the general 
erythematous condition had persisted, but that the 
intensity of the redness had somewhat abated. 
The skin still itched exceedingly, and wheals of 
various sizes occasionally appeared. The constitu- 
tional disturbance was less. The uniform redness 
remained three or four days, and wheals appeared 
with diminishing frequency for the same period. 
Then an abundant desquamation over the whole 
surface followed, which continued several days, 
after which the skin recovered its normal condition. 
During this attack the only tissue changes or lesions 
were the erythema, wheals, and scales. The case 
appeared to me throughout to be an exceptional 
form of urticaria. 
Third Attack.—At Easter. 1888,1 was again called 4 
to see Mrs. X. She was then two months pregnant. 
She had eaten two days previously a lobster salad, 
and in the course of the following twenty-four 
hours her skin had assumed the same condition as 
at the last attack. It was universally of an intensely 
red color, and presented numerous wheals of various 
sizes. There were also large areas of oedematous 
swelling, especially upon the legs. There was very 
little gastric disturbance, but hypercatharsis follow- 
ing the administration of some laxative before I 
saw her. She complained chiefly of itching and 
chilliness. On the fourth day a few of the wheals 
had assumed a bullous condition, so that by conflu- 
ence some of the blebs were of considerable size, 
and later were converted, by the removal of their 
coverings through contact with the clothing, or by 
decubitus, into moist, denuded areas. Excoriations 
were also developed by scratching. The general 
erythema subsided after a few days, and was suc- 
ceeded by desquamation. By the end of the second 
week all cutaneous symptoms had disappeared. 
Fourth Attack. — Mrs. X. remained well during 
her pregnancy until a week before the birth of her 
child, which took place November 8, 1888. On 
November 1st, without any known imprudence in 
diet, she had several chills accompanied by repeated 
vomiting. On the following day her skin became 
universally reddened, and presented here and there 
small water blisters, which became larger. There 
was much itching, and later slight scaling. The 
process was not seen by any physician, and the skin 
had returned to its natural condition before conflne- 
ment. November 11th, three days after delivery, 
which was normal, the secretion of milk ceased, 
and on the following day, November 12tli, a burning 
sensation was experienced in the back of the neck, 
which spread rapidly over the whole surface. The skin became at the same time intensely red every- 
where, and very irritable. There were repeated 
chills and vomiting. On the fifth day after delivery, 
November 13th, large bullse appeared upon the back, 
leaving raw, bleeding, and very painful surfaces. 
On November 15th she was seen by Dr. Tilden in 
consultation, who reported the presence of small 
vesicles upon the shoulders in addition to the in- 
tense general hyperaemia of the skin. Dr. C. M. 
Jones, the attending physician, states that at this 
time the lochial discharge was brownish, but not 
offensive. She had had after delivery a vaginal 
douche of corrosive sublimate, and later one of the 
same cornposition within the uterus. The tempera- 
ture at this period varied from 101° to 104°. 
November 16th the patient was admitted to the 
Massachusetts General Hospital under the care of 
Dr. E. N. 'Whittier, who kindly permitted me to see 
her daily. I found her on the next day in bed. The 
skin universally was of an intense redness, shining 
and tense, as if scalded. A few moderate-sized 
blebs were seen, but no small or clustered vesicles, 
nor were any well-marked wheals present. The 
upper portions of the back presented large areas 
denuded of epithelial coverings, from which serum 
and blood were oozing freely. The patient’s gen- 
eral condition was feeble; pulse 120, respiration 30, 
temperature 103°. She was enveloped in cloths 
soaked in liquid vaseline, as scalded patients are 
there treated. By my advice lard beaten up with 
rose water was substituted for this dressing, spread 
thickly upon cotton cloth, and with this was mixed 
boracic acid for application to the denuded surfaces. 
Quinine had been given since her admission, but 
this was omitted for fear of its possibly irritant 
action upon the skin. On the 19th the general 
hypersemia had much diminished in intensity, and the denuded areas upon the back and shoulders had 
not increased in size. Fresh bullse had appeared, 
scattered over the trunk and limbs especially, but 
they were smaller than at first. Their contents 
were sero-purulent, but in one upon the ankle they 
were haemorrhagic in character. On November 21st 
the skin over the nates and lower back seemed to 
break down under the pressure of decubitus, as if 
necrosed, and was converted into a nearly uniform 
shallow ulceration, which bled freely on changing 
dressings. Small pustules began at this date to 
appear in great numbers upon the backs of the 
hands and forearms, and upon the lower legs. 
There was an improvement in the patient’s general 
condition, her strength was greater, and her appe- 
tite stronger. On November 23rd but little general 
hyperaemia was left. The denuded surfaces upon 
the shoulders were nearly healed, and the extensive 
ulcerated areas over the lower back were assuming 
a healthy appearance. New crops of small pustules 
Avere developing over the limbs, and a few deep 
furuncular processes had appeared upon the left 
breast. On the 26th the face also Avas thickly occu- 
pied by the small pustular efflorescence, and upon 
one cheek tAvo additional furuncles were present. 
The pulse, respiration, and temperature had by this 
time nearly regained their normal state. The pa- 
tient Avas removed from the bed to a couch. On 
the 28tli fresh crops of superficial pustules Avere 
appearing, chiefly upon the head and arms, A\7itli 
a feAV neAv furuncular lesions. The excoriated and 
ulcerated surfaces had nearly healed. The general 
surface of the skin, when not kept covered by the 
lard dressing, was in a state of desquamation. 
From this date no neAv changes took place in the 
condition of the skin except those of sIoav involu- 
tion, and on December 4tli she left the hospital. On December 14th the skin was still desquamating in 
a few parts, and the pruritus continued. It had 
regained its natural color. There were no new 
pustules, but the seats of the old ones were still 
marked by a deep redness. Three new large boil- 
like processes, however, had appeared upon the 
right wrist. At my last visit, on December 21st, 
the skin had returned to a normal condition. 
To this account of the cutaneous affection of 
Mrs. X. must be added that of three of the four 
nurses who were in attendance upon her in this last 
attack. Nurse one had charge of her before her 
admission to the hospital. Nurses two and three 
werq constantly employed in changing the dress- 
ings and turning her in bed. All of them had 
develop upon the backs of fingers, hands, or wrists 
from two to four firm, deep-seated, indolent, furun- 
cular abscesses during the second week of the pa- 
tient’s attack, which were very painful, and disap- 
peared slowly after poulticing and evacuation by 
incision. There was no constitutional disturbance 
in any of them. In the fourth nurse, who was also 
in constant attendance upon her in the hospital, 
and engaged in the same duties as the others, there 
were no such manifestations. It should be added 
that the three affected nurses were accustomed to 
handle all sorts of surgical dressings, and that their 
hands had never previously exhibited any such 
manifestations; also that there were no irritating- 
qualities in the dressings employed. 
How then shall we interpret this history of Mrs. 
X.’s cutaneous condition of the past two years ? We 
have a young woman, who before marriage and dur- 
ing the first pregnancy had had a perfectly healthy 
skin. Three weeks after a normal confinement an 
acute universal dermatosis developed, apparently 
an urticaria, and later a vesicular efflorescence of 8 
an eczematous type at least. When first seen by 
me the affection had lasted six weeks, and the ap- 
pearances at that time were those of a subacute 
eczema of the face and a chronic waning urticaria 
of the rest of the general surface, all of which 
rapidly disappeared under treatment. 
Six months later an apparent intense general 
urticaria rubra appeared, folloAved by universal de- 
squamation, the whole process lasting ten days. 
One year subsequently, during the second month 
of her second pregnancy, there was essentially a 
repetition of the previous attack, excepting the oc- 
currence of bullae also. 
Lastly, a universal erythematous condition, fol- 
lowed by desquamation, a week before the end of 
the same pregnancy, and a recurrence of the same 
four days after delivery, with subsequent cutaneous 
changes of much severer grade, more diversified 
type, and more serious constitutional disturbance 
than in the preceding attacks. 
Two of these, the first and last, occurred soon 
after delivery, the third took place during early 
pregnancy, whilst the second and third followed 
immediately the ingestion of articles of food which 
not infrequently produce similar gastric, constitu- 
tional, and cutaneous disturbances. Three of them 
were, therefore, connected with pregnancy. In all 
of them a universal and intense erythematous state 
of the skin was the first cutaneous manifestation, fol- 
lowed in each instance by general desquamation. In 
the first three, wheals were the subsequent most 
prominent and persistent lesion. Vesicles or bullae 
were present in all but the second attack, that, 
namely, which occurred during the quiescent state 
of the uterus. In the last the inflammation of the 
cutaneous tissues was so intense as to cause very 
extensive destruction of the vitality of the outer 9 
layers, marked by denudation and shallow ulceration 
over wide areas; and later there were developed 
successive crops of superficial pustules in great 
numbers over the head and extremities, and a few 
deeper seated furuncular processes. 
Now what do these manifestations indicate or 
suggest ? Where should we place such an affection 
in our list of skin diseases ? The first three attacks 
might be called urticaria rubra, and possibly the 
prodromal symptoms of the last might also be thus 
explained. In the third, and perhaps also in the 
first one, the vesicular or bullous efflorescences 
might be regarded, too, as indicating an urticaria 
bullosa. In the first attack the moist lesions were 
regarded as of an eczematous nature by Dr. Whit- 
tier, and when I first saw Mrs. X. the condition of 
the integument of the face seemed to warrant the 
correctness of this diagnosis. An eczema may in- 
deed follow an urticaria, induced by the pruritus 
and scratching associated with the latter. But 
urticaria is seldom accompanied by so persistent 
and general a hypersemia, or followed by such a 
universal desquamative process, as were present in 
each attack, or by such deep necrosis of the skin as 
in the last one. Neither do such successive out- 
breaks of impetiginous efflorescence ever, nor fur- 
uncular lesions ordinarily, follow true urticaria. It 
is evident that we have here some dermatosis more 
than an ordinary urticaria in the first three attacks, 
while in the last one there were no lesions typical 
of its presence. In the last attack the impetiginous 
and furuncular character of the lesions points to a 
possibly septic process, and the constitutional dis- 
turbances in its early history, the high temperature, 
rapid pulse and respiration, and chills, would seem 
to confirm such an influence. The occurrence of 
similar furuncular processes upon the hands of 10 
three of the four nurses who were in attendance 
upon the patient seems moreover to indicate its in- 
fectious nature. Indeed this latter conclusion seems 
to be inevitable. Other than these, however, there 
were no symptoms of a septic or pysemic process in 
the general condition of the patient. Such forms 
of universal scarlatiniform erythema, followed by 
desquamation, have been frequently observed in 
pyaemia, and in one instance at least associated with 
urticarial lesions. Such forms of erythema, too, 
are well known after surgical operations. The uni- 
versal cutaneous hyperaemia, and the subsequent 
purulent lesions in the patient, and the infection of 
the nurses, might then be plausibly regarded as 
positive indications of a septic or pyaemic dermato- 
sis in the former; but no such theory can possibly 
explain the identical erythematous condition and 
desquamation which have been present in all the 
attacks. 
Have we, then, any well-recognized disease of the 
skin characterized by erythematous, urticarial, vesi- 
cular or bullous, impetiginous, furuncular, and des- 
quamative lesions, and accompanied by pruritus, 
chills, and occasionally by rapid pulse, respiration, 
and high temperature ? We may certainly call the 
case a multiform dermatitis, but is it an example of 
that very versatile affection, not yet sharply enough 
defined, by Duhring called dermatitis herpetiformis, 
more correctly in my opinion dermatitis multifor- 
mis, and more particularly that form entitled by 
Brocq dermatite polymorphe prurigineuse recedi- 
vante de la grossesse, the herpes gestationis of others? 
It is in this latter group, I believe, we must place 
it. The case is a striking illustration of the poly- 
morphism of the cutaneous lesions of the disease. 
It demonstrates, too, the narrowness and inaccuracy 
of the title herpes gestationis, inasmuch as it never 11 
exhibited, under my observation, the small grouped 
vesicles which are typical of herpes, and occurred 
once independently of pregnancy or its sequelae. 
It shows, moreover, how we have in the latter 
condition a pronounced impetiginous dermatosis 
without a feature suggestive of Hebra’s impetigo 
herpetiformis. 
The following analysis of some of the points in 
the twenty-two cases collected by Dr. Brocq may 
be of special interest to members of this society. 
These cases received various titles by the observers 
under whose care they occurred, such as herpes 
gestationis, pemphigus, pemphigus pruriginosus, 
herpes circinatus bullosus, acute pemphigus, pem- 
phigus hystericus, dermatitis herpetiformis, hydroa 
gestationis, peculiar eruption during pregnancy, and 
erythema gestationis. 
The occurrence of the disease during pregnancy 
took place in the first month once, in the third 
month five times, in the fourth month three times, 
in the fifth month five times, in the sixth month 
once, in the seventh month three times, and in the 
eighth month once. After delivery the eruption 
appeared on the second day in one case, on the 
third day in three cases, on the fourth day in one 
case, and on the fifth day in one case. The period 
of development varied greatly in successive attacks 
in the same individual. The disease occurred in 
two pregnancies in five individuals, in three preg- 
nancies in four individuals, in four pregnancies in 
one individual, in six pregnancies in two individ- 
uals, and in eight pregnancies in one individual. 
The tendency to an increasing intensity in the 
severity and duration of the dermatitis in successive 
attacks was observed. The cutaneous manifesta- 
tions occurring after delivery were generally graver 
than those noticed during pregnancy. 
It has not been my purpose before this society 12 
to consider the much discussed questions of the 
pathology and etiology of this interesting group of 
affections, but to confine myself to a brief record of 
the case. Mrs. X. has shown that she has a skin 
which, under the impression of irritating ingesta, 
and the conditions of pregnancy and childbirth, 
apparently normal in themselves, may be thrown 
into a state of universal dermatitis multiformis. 
The rare features of the case are the necrosis of 
the cutaneous tissues over large areas through the 
intensity of the inflammatory process, and the 
demonstration of its infectious character in one of 
the attacks by the simultaneous development of 
purulent lesions upon the hands of the attendants. 
Post scriptum. — January 7th Mrs. X. called upon 
me and exhibited an extensive urticaria of ordinary 
type, that is, well marked wheals of various shape 
and size, or white elevations surrounded by a red 
halo. There were no other cutaneous phenomena, 
nor was there any constitutional disturbance. She 
stated that since my last visit the skin had remained 
in a healthy condition until the previous evening, 
when the above manifestations presented them- 
selves. Her diet for the preceding forty-eight 
hours had been of the simplest nature. 
On inquiry she stated that the first attempt at 
sexual intercourse since confinement, a few days 
previously, had been very painful and was imme- 
diately followed by severe uterine colic, which was 
only relieved after a duration of twelve hours by 
an injection of morphia. The catamenia appeared 
for the first time since delivery on the following 
day. 
This attack of urticaria lasted but twenty-four 
hours. Its source may well be referred to the 
revival of uterine agitation. THE BOSTON 
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