[Extracted irum Tut: Mi-mru. Nkws, July 19, 1884.] CASE OF DERMATITIS HERPETIFORMIS (MULTIFORMIS), AGGRAVATED BY PREGNANCY AND IRREGULAR MENSTRUATION. PROFESSOR OF SKIN DISEASES IN THE UNIVERSITY OF PENNSYLVANIA. LOUIS A. DUHRING, M.D., Mrs. M., aged twenty-eight, a resident of St. Paul, Minn., consulted me February 3, 1883, for a chronic inflammatory disease of the skin, involving the entire surface. She was of spare fraffie, with brown hair, and of a nervous temperament. She gave the following clear and interesting history of her case : Her ill-health began three and a half years ago, up to which date she had been in good general health; had menstruated regularly and normally, and had weighed one hundred and thirty-five pounds. She had borne a healthy child three years before, without difficulty. The first manifestations were upon the tongue and in the throat, in the form of whitish spots, similar to so-called “canker-sores,” which continued for six months, desquamating from time to time, the mouth being so sore and sensitive as to render eating painful. She was in the third month of her second pregnancy when the first sign of cutaneous disease appeared on the flexor surfaces of 2 the right arm and thigh, and on the abdomen, in the form of small, annular clusters of vesicles, occupying the space of a five-cent silver piece. The lesions were itchy from the beginning. They spread slowly, new “ little water-blisters” coming out from day to day. This process progressed for six weeks, when the body was well covered with eruption, and she was compelled to remain in bed. Three weeks after the attack began blebs appeared, accompanied by com- paratively slight itching. They ruptured easily and left excoriated surfaces. As gestation proceeded, the disease became steadily worse, being at its height during the fourth and fifth months, at which date vesicles and blebs of all sizes were very numerous, and the itching intense, accompanied by extensive ex- coriations and scratch-marks, with more or less oozing and crusting. No treatment used seemed to have any effect in relieving the symptoms. At this date very curious lesions were noticed on the wrists and on the palms and soles. They were elongate (about an inch in length), rounded (about an eighth of an inch in thickness), firm, whitish, striated elevations, situated transversely on the wrists, the same condition existing on the palms and soles. When opened a non-offensive, cheesy mass “popped out,” to use the words of the patient. The contents were not expressed, but were forced out naturally. The lesions were opened every day for several weeks, when they ceased appearing. At the sixth month of pregnancy the skin cleared off, the lesions disappearing, except a large bedsore, which did not heal until a month after delivery. The skin remained comparatively clear about one week, when small pin-head-sized vesicles, soon followed by- large, hazelnut-sized blebs, again appeared. This crop also manifested itself on the legs and feet, re- 3 gions hitherto exempt. The blebs were all large, very abundant, crowded one another, and were very itchy. Some of the lesions became pustular. Three or four weeks before delivery the whole integument became cedematous, swelled, or “puffed up,” as she expressed it. This condition gradually subsided a week or ten days after the birth of the child, which was born healthy at full term, but lived only four days. After delivery, and for three weeks following, the vesicles and blebs became fewer, the skin becoming again entirely clear of eruption, and she regarded herself as cured. She remained free, however, only a few days, when small pustules, pin-point in size, appeared in abundance ; these disappeared, and were followed by a crop of mixed lesions—of pustules and blebs. This condition continued, better and worse, during the winter, the disease towards summer locat- ing itself chiefly about the axillae and groins, charac- terized now by an offensive, excoriated, at times weeping, crusted surface, with itching. Through the summer the skin of the palms and soles thickened, beneath which pus formed, undermining it. This continued for three or four months. In August, 1881, she indulged in a bath, just be- fore the menstrual epoch, after which the face became blotchy, bluish, and swollen, giving her “a dissipated look.” Vapor baths taken repeatedly for one month completely exhausted her. September ist the menses failed to appear, and October ist there was a slight discharge, at which date she again broke out with variously sized vesicles and blebs, the latter, for the most part, as large as a hazelnut, many of them having puriform contents. There was now much excoria- tion and crusting, the bed-linen everywhere adhering to the raw skin. Numerous small, pin-point-sized 4 vesicles, closely crowding one another, again came out over the whole surface. They were so abundant that a pin-point could scarcely be put down between them. She was “literally covered with them,” and this condition, in the form of crops, lasted all winter. The skin disease later again changed its character, large blebs and pustules appearing, especially upon the face, which was much swollen. The menstrual flow remained absent five months (from October, 1881, to February, 1882). Arsenic in large doses, and later electricity, were used, and it was thought that she was benefited by the latter. Improvement continued slowly but steadily up to July, 1882, when suddenly, and without apparent cause, violent inflammation of the hands and feet, with large pustules on the palms and soles and on the face, manifested itself. These continued to appear and to disappear, in crops, through the summer and autumn, up to the present date, the lesions being, as a rule, shot-sized, whitish pustules, and vesicles, closely crowded together over almost the entire cutaneous surface. Her general condition has been variable. On many occasions she has felt ill, weak, very nervous, depressed, with chilly or heated sensations or rigors. On one occasion the tongue swelled and became coated with a puriform exudation, with profuse salivation. Menstruation when present is usually normal. Her weight now is about ninety- five pounds, forty pounds below her former average. The appetite has always remained good. She has been under the care of a skilful specialist in skin diseases for six months, but has failed to receive any benefit. The present condition (February 3, 1883) is as follows: The whole general surface is the seat of 5 a subacute and chronic inflammatory erythematous (somewhat urticarial), papular, papulo-vesicular, vesi- cular, and pustular eruption, the lesions being very markedly multiform. They are pin-point, pin-head, and pea-sized; are thickly studded ; are firm, and have a shotty feel, as in the early stage of variola. The skin is everywhere much thickened, and is even tough and leathery, and is markedly pigmented, being of a mottled, reddish, dirty-yellowish, brownish hue. The eruption is intensely itchy. The face and scalp are least affected, but, as stated, the rest of the general surface, including the palms and soles, is well covered with primary and second- ary lesions. The patient was ordered for local use an ointment of precipitated sulphur, two drachms to the ounce, to be applied to the right half of the body; to the left half, an alcoholic solution of coal-tar, diluted one to four or eight parts of water. Internally, a mixture containing sulphate of magnesium, three ounces; bitartrate of potassium, six. drachms; pre- cipitated sulphur, one drachm; glycerine, four fluid- drachms ; peppermint water, four fluidounces. Dose, a half fluidounce with a gobletful of water before breakfast. Also, a preparation of iron, bark, and arsenic (one minim dose), to be taken thrice daily. At night a mixture of chloral and bromide of potassium. Both local remedies acted happily, and for five days no preference for one or the other was expressed by the patient. A few days later more improvement was observed upon the side where the tarry solution had been used, and this was then applied, full strength, to the whole surface. Both remedies also had immediate and positive effect in relieving the distressing itching. The skin began to improve, and the eruption to decrease within 6 several days after the treatment was instituted, and at the end of a fortnight very decided benefit was noticeable in the condition of both the general health and the skin. She was well enough a month later to return home, since which time I have heard nothing from her. The history of the case, extending over three years, shows well the protean character and the multiformity of the disease. It shows the simulta- neous occurrence at several periods in the course of the process of erythematous patches, maculo-papules, papular infiltrations, vesico-papules, vesicles, blebs and pustules. At other periods vesicles and blebs prevailed ; sometimes vesicles and pustules; and oc- casionally vesicles, blebs and pustules. The lesions were always accompanied by severe itching and more or less burning. Constitutional symptoms at times were marked, consisting of rigors, sensations of alternate heat and cold, and febrile and nervous symptoms. The latter were especially prominent. The disease of the skin was unquestionably due partly to the depraved condition of general health preceding pregnancy, but more particularly to this latter state itself. It will be remembered that the cutaneous manifestations appeared in the third month of gestation. It was without doubt subsequently kept up by the disordered condition of the menstrual func- tion and the accompanying disturbed nervous system. At present I shall not consider the disease further than to say that the case may be regarded as repre- senting the multiform variety of dermatitis herpeti- formis. Noted at one period, it would have illus- trated the vesicular or the papular variety ; at another time, the bullous variety; again, the erythematous ; while more often, however, the condition was one of 7 multiformity of lesion, including at times the abundant development of peculiar pustules. The latter phase is that which was first described by Hebra as “ impetigo herpetiformis.” The vesicular variety has figured conspicuously of late years under the head of “herpes gestationis.” In a paper recently read before the American Medical Associa- tion, I have described dermatitis herpetiformis at length, giving its characteristic features together with its more prominent varieties or phases.1 I think both the impetigo herpetiformis of Hebra, and the herpes gestationis of authors, should be placed under dermatitis herpetiformis, both being mere varieties of one pathological process. The case just considered shows the disease in a severe form, characterized by marked constitutional symptoms ; profuse eruption, multiform in character, and appearing in crops ; extensive secondary changes in the skin ; and itching and burning of the most distressing kind. The patient suffered greatly, the disease for a long period being most rebellious to treatment. Concerning the diagnosis, I may add that as the eruption was noted as one or another set of lesions was out, the disease might easily have been confounded with eczema, herpes or pemphigus; but, keeping the history in mind and observing the course of the process for some time, the individuality of the disease always asserted itself. It is a distinct and clearly defined disease, which, when once recognized, cannot be confounded with any of the well-known skin diseases.