[Reprinted frotn The &ews*» March 7, 1885.] CASE OF DERMATITIS HERPETIFORMIS, WITH PECULIAR GELATINOUS LESIONS. PROFESSOR OF SKIN DISEASES IN THE UNIVERSITY OF PENNSYLVANIA. LOUIS A. BURRING, M.D., John S., set. 64, a native of Wilmington, Dela- ware, and a peddler by occupation. Fie has always enjoyed good general health; weight, 175 pounds. No family history. The present skin disease is of five years’ duration, but he has had the same only in winter. It has been in the habit of coming on with cold weather and disappearing about the middle of May, and it has pursued this course every year. He never had any skin disease or illness of any kind be- fore seven years ago, when an “eczema” of the right leg appeared, which has been cured repeatedly by ointments, but has relapsed. He is of the opinion that the disease of the general surface which he now has is the same disease that he has had for the last five years; but that it is worse this winter than ever be- fore When it first came out (in October, 1874) he was in his usual good health . It manifested itself by 2 intense itching on the back, localized chiefly about the lumbar region, which asserted itself in paroxysms, lasting from a half-hour to two hours. They were invariably relieved in the course of ten or twenty minutes by scratching. Unless scratched or rubbed, itching would persist for hours. The itching was unaccompanied by redness. The scratching did not injure the skin, notwithstanding that he was in the habit of employing harsh measures for relief. This pruritus continued all winter, confined to the back, and at no time was accompanied by any eruption. With May it disappeared quite abruptly, as soon, he states, as he began sweating in the course of his pedestrianism. He was entirely well all summer, until October, when the disease again began as in the previous year with intense itching without eruption, and confined to the back, occupying, however, more surface than before. It continued all that winter, as during the previous season, and again disappeared in May. The following October it reappeared, and now for the first time in the form of small, pinhead-sized, elevated, inflammatory, acne-like, very itchy pustules, which, after having been emptied, disappeared. They were scattered over the back, and were not grouped. They came at irregular intervals, and not in crops. They were present throughout the autufnn and winter in varying numbers, and entirely left him in May. The itching was quite as intense as during the two previous years. He states that after these lesions were opened and scratched, decided relief was experienced. In October (third year), itching upon the back again manifested itself, which gradu- 3 ally increased in severity, and continued all winter. The small inflammatory, acne-like, pustular lesions which were present during the second winter did not reappear; but toward the middle of April, what he describes as small, “ blind-boil-like ’ ’ lesions appeared on the back. They neither discharged nor crusted. Two or three came at a time and were very itchy at first, but in the course of two or three days became sore. In the course of the following month there occurred some twenty of these lesions, when, toward the middle of May, they entirely disappeared. He remained well through the summer, as usual, until October, when the itching confined to the back began as before, unaccompanied by eruption, but a week later the itching began to subside, and now a new kind of lesion appeared, which he describes as follows: When first noticed, two were present over the right scapular region. They were the size of a large thumb-nail, distinctly raised, but flat, with little or no inflammatory areola, of a golden-yellow color, and contained a thick, consistent, orange or deep golden yellow-colored mass. These lesions were in many ways peculiar. They came suddenly, often in the course of ten or fifteen minutes. His attention would be directed to the affected part by a sharp sen- sation, “like the sting of a bee;” examining the skin he would find one or more lesions present, and, as a rule, already fully formed. They were neither pre- ceded by, nor accompanied with, itching: the sen- sation was that of a sting. They were superficially seated, appearing to have their seat just beneath the epidermis. They would continue “to sting ” until opened with a knife or needle, a knife being the in- 4 strument usually selected for the purpose. (He was at this period an inmate of the Wilmington Alms- house Hospital, and was under the care of Dr. Thomas Ogle.) The lesions were too tough to permit of being rup- tured with the finger-nail. He describes them as being circumscribed, firm but not hard, “puffed-up,” raised but flat on their summits, and movable under the skin. Some were raised as much as a quarter of an inch or more; others less. As soon as he became aware of their existence, by the stinging sensation, they were opened ; the sting was sharp and persistent until they were evacuated. All of these lesions were much alike as to size, shape, color, and other general characters. When opened with a knife, the mass or contents referred to would come out, or “pop out” entire, without any pressure being exerted, and in the form of the pulp and of the consistence of an ox-heart cherry; the mass was, however, flattened rather than round. These curious pulpy, gelatinous masses, he states, could be picked up between the fingers, handled, and, if squeezed, would disintegrate. No blood accom- panied them, nor did the cavity which remained after the exit of the mass contain any blood, but it subse- quently oozed a few drops of a yellowish fluid, of a creamy consistence. A cavity, of course, remained after the exit of these bodies, into which the tip of the index finger could be inserted; but, under a stimulating lotion of iodide of potassium, this healed over, with slight scaling, in a few days, no stain re- maining. Sometimes these cavities would refill, and often with surprising rapidity, in less than ten minutes 5 with a material similar to the first product, hut not so yellow, and invariably thinner—more of the consist- ence of thick cream—which could be squeezed out by pressure with the blade of a knife. But not all of the lesions would refill; some would refill as often as three times, and this in from one to twelve hours. He continued to have these very singular lesions throughout the autumn and winter, one, two, three, or more making their appearance, on the average, every day. They did not come in crops, but at irregular intervals, and, as stated, seldom oftener than at the rate of one or two daily. They were at first confined to the back, but subsequently attacked all portions of the surface except the face and scalp They disappeared gradually in the following April, and he was free from these and all other lesions throughout the summer. Present condition, January 13, 1879: The patient was admitted to the Ward for Skin Diseases of the Philadelphia Hospital on November 1, 1878, but did not come under my observation until some weeks later. When admitted, he presented a slight vesi- cular and papulu-vesicular eruption, in patches and much scratched, occupying the back, abdomen, and extremities. It appeared to be trivial eczema, al- though he complained greatly of the itching, de- claring that it was intolerable. The case, as stated, was regarded as one of eczema, and was placed upon the usual treatment for this disease. The disease disappeared, in a great measure, in the course of a fortnight, but soon recurred, exhibiting the same characters as before. 6 December i$.—An outbreak of vesicular eruption has recently appeared, showing the lesions in a more positive form. They are vesicles, varying in size from a small pin-head to a pea, and possess irregular, angular, jagged borders, such as are encountered in herpes zoster. Although manifestly inflammatory, they are unaccompanied by marked signs of inflam- mation, being for the most part altogether without areolae, though the skin between (hem is somewhat reddened and considerably excoriated from scratch- ing. They are, as a rule, quite flat, but some are raised, looking as though they might develop into blebs. Their contents are either clear and watery or pale yellowish. Those which are flat, and contain a clear fluid, are inconspicuous, and even in some places difficult to detect, and resemble sudamina. The lesions show a distinct disposition to form patches, and, moreover, to cluster, and here and there even to run together; but the grouping is not pronounced, and might readily be overlooked by a casual observer. The back of the neck, shoulders, back, arms, and thighs are the regions especially in- volved, though other parts are also invaded, but with disseminated, abortive, papulo-vesicular, more or less excoriated lesions. Antipruritic lotions have been freely used, but with indifferent results, an alkaline tarry preparation affording the most relief. The itching has been in- tense, preventing sleep and causing the patient to scratch incessantly day and night. The vesicular lesions above described gradually subsided in the course of two weeks, leaving the skin quite free of lesions, except a general dirty- yellowish pigmentation, the result of scratching. The patient remained well, except that he was still much annoyed with general itching for a week, when the present lesions, pustular in character, began to appear. They have been very gradually increasing in size, and multiplying from day to day, until the existing condition has been reached. The lesions are distinctly pustular, varying in size from a pin-head to a finger-nail. They are of a yellowish-white color; tensely distended in their early stage ; flat; surrounded with marked areolae; and of irregular, more or less rounded or angular outline, and have a contracted or puckered appear- ance. The older ones are crusted with a yellowish, slightly greenish, flat, uneven, honeycomb crust. The recent small crusts, in many instances, show a decided umbilicated or cupped formation, reminding one of tinea favosa. The lesions are numerous, and exist upon the scalp, neck, shoulders, arms, forearms, sacral region, buttocks, thighs, popliteal spaces, legs, breast, and abdomen. The hands and feet and genitals are almost free. Viewing the eruption as a whole, the lesions may be said to be disseminated, though they are more abundant in some localities than others, and in some places—as on the buttocks—even incline to cluster. The clusters or groups are made up of two, three, or four lesions, of different sizes, situated closely together, in some instances so closely as to run together. Two decided clusters, of half-dozen lesions each, occupy either buttock, the lesions being small and large, inflammatory, more or less crusted, 8 and evidently increasing in size, accompanied with severe itching. 27th.—The course of the lesions has been care- fully noted from day to day. While the greater number of pustules appeared simultaneously during the first few days of the outbreak, new ones have not ceased coming out up to the present period. As a rule, the pustules have started as pin-head or split-pea sized lesions, and have slowly and gradu- ally increased to their determinate size, this vary- ing from a split-pea to a silver half dollar. The time occupied for the growth to the largest size named has been from two to three weeks, a remark- ably slow growth considering the character of lesions. Many of the smaller ones have assumed their deter- minate size and have begun to disappear in the course of a week or ten days. In almost all instances, the increase in size has taken place plainly in the form of a complete or broken, narrow ring of flat pustules, which has been kept up just beyond the line of the central crust; as rapidly as this would form, the ring or circle (often imperfectly developed) would appear, which in turn would become merged into the central crust. Many of the older crusts have been dropping off, leaving dark red, more or less pigmented areas of infiltrated skin. Since the attack began to subside, the itching has decreased, and he now experiences great relief and comparative ease. During the out- break, “liquor picis alkalinus,” a drachm to two or three ounces of water, has been used as a lotion to one side of the body ; while on the other half, fluid extract of grindelia robusta, one drachm to the 9 ounce of water, has been employed. The patient states that both remedies gave relief, but that he pre- fers the tarry preparation. He has also been taking a pill of one-thirtieth of a grain of arsenious acid and a saline laxative as required. February 4. —No new lesions have appeared, and the recent attack has completely subsided, the skin being in better condition than it has been for many months. Considerable pigmentation, how- ever, remains, and the dark red spots, scattered and in groups, the seat of former pustules, are likewise conspicuous. The itching has abated, though he states that he is still obliged to scratch at night. 22d.—Improvement has been slowly going on during the past fortnight, the pigmentation and staining being, however, very tardy in disappearing. The patient remarks that he fears another outbreak, for within the last four days the itching has been violent. 28th.—The itching has been steadily augmenting from day to day, although until to-day nothing ap- peared on the skin. A slight papulo-veskular erup- tion, indistinctly defined, with irregularly shaped, small, flat, pale-red disseminated, but aggregated lesions, has here and there, over the back, arms, and thighs, made its appearance. The lesions are so scratched that their features can scarcely be deter- mined ; the itching, he states, is indescribably in- tense, and out of all proportion to the amount of eruption. Strong alkaline baths have been used, but without relief. March 6.—There has been but little new erup- tion since the last note, the few lesions that have appeared being, as the others in the present attack, abortive papulo-vesicles. The itching has continued, and the patient is suffering considerably; he is in expectation of more eruption, when, in the light of former experience, he looks forward to comparative relief. 22d.—The condition has scarcely changed within the fortnight. The itching and the “pricking, pick- ing sensations,” have been intolerable, especially over the trunk, arms, and thighs. To-day new vesicular lesions, as well as papulo-vesicles, have manifested themselves about the neck and over the abdomen, back, shoulders and arms. They are numerous and scattered, or are in patches of a dozen or more. Some are raised, tensely distended, shin- ing, irregularly rounded or angular in outline, varying in size from a pinhead to a split pea; while others are flat, and often are difficult to detect. None have any areolae, but rise abruptly from the surrounding healthy skin. 27th.—The eruption, which threatened to become extensive last week, has again aborted. The lesions were, without exception, all scratched and lacerated almost as soon as they began to form. The itching still continues, but in a modified degree. The offi- cinal sulphur ointment was to-day ordered, to be well rubbed into the skin twice daily. April j.—The sulphur ointment gave decided and prompt relief, the patient stating that no remedy that he had ever before used had acted so effectu- ally upon the itching. May 1.—A few scattered papulo-vesicular and vesicular lesions, accompanied with itching, have shown themselves from time to time during the month, but there have been no signs of a serious outbreak. The patient is improving, he thinks, from week to week, and eagerly looks forward to the approaching warm weather as a source of relief. It will be remembered that every year he has recovered with summer. The internal remedies, consisting mainly of arsenic, have some time since been discon- tinued. The patient, at his own request, has been discharged from the hospital, and has not since been heard from. The notes, extending over a period of several years, have been given at length, because the case is very interesting, especially with reference to the ‘ ‘ gelatinous lesions ” described. At present I shall not dwell on this subject beyond stating that these lesions have likewise occurred in several other in- stances of dermatitis herpetiformis which have come under my notice. I believe them to be peculiar to this disease, and to constitute a hitherto undescribed form of cutaneous manifestation.