Three Cases of Dermatitis ITerpetiformis Due to Pregnancy {Herpes Gestationisf BY GEORGE T. ELLIOT, M.D., OF NEW YoTk T'lTY. FROM THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, July, 1895. Extracted from The American Journal of the Medical Sciences, July, 1895. THREE CASES OF DERMATITIS HERPETIFORMIS DUE TO PREGNANCY (HERPES GESTATIONIS). By George T. Elliot, M.D., OF NEW YORK CITY. The number of cases of the herpes gestationis of Milton and Bulk- ley recorded in literature is not so great that the report of further ones need be useless. Up to 1888, Brocq1 was only able to collect some twenty-two, and since then I have not been able to find more than ten additional examples of the process. Among these latter is one which was reported by me in 1892, in connection with some other cases of dermatitis herpetiformis of uterine origin,2 and I classed it with that disease instead of regarding it as an instance of a separate and distinc- tive process. Duhring had previously claimed that herpes gestationis was only a phase of the dermatitis herpetiformis first described and dif- ferentiated by himself, and Brocq had ably supported that position in his resume of the entire subject, so that I was thus in entire agreement with them. The case I referred to furnished, moreover, so strong a proof of the position taken that Brocq, in reviewing it in 1893,3 stated " it seems difficult now still to make two entirely different diseases of der- matitis herpetiformis and of herpes gestationis." This case was char- acterized by being the first one which, possessing all the requisites for the diagnosis of herpes gestationis, yet persisted, contrary to the course of all others recorded, continuously for several years from its primary inception, and in the entire absence of any new pregnancies and during its existence, presented, moreover, none but those symptoms belong- ing in a greater or less degree to every case of dermatitis herpetiformis, of whatever origin or from whatever cause. The following examples of the process are reported as " dermatitis herpetiformis," and not as " herpes gestationis," in view of the opinion expressed ; and one of them shows, although in a much less degree, much the same tendency to per- sistency for a long period of time after termination of the first pregnancy, as did the case reported by me in 1892. Case I.-Mrs. , aged twenty-eight years, was seen by me March 9, 1894, in consultation with Dr. Blundell, of Paterson, N. J. The 1 Brocq: De la Dermatite herpetiforme de Duhring. Paris, 1888. 2 Elliot: American Journal of the Medical Sciences, 1892. 3 Annales de Dermatologie et de Syph., January, 1893. 2 ELLIOT: HERPES GESTATIONIS. patient had always enjoyed good health, and her position in life enabled her to live in ease and comfort, without worries, anxieties, or other mental or moral shocks. Her first pregnancy occurred in 1888 and ran a natural course. The labor was normal and uncomplicated, but three days after the birth of the child an eruption appeared on the hands and feet. It was accompanied by intense burning and itching, and con- sisted of bullse, some as large as a pigeon's egg. Extension took place rapidly and similar lesions appeared over the extremities, but on the body only erythematous blotches were noticed. This eruption gradually subsided, but was followed by others cropping out at variable intervals, made up of vesicles, small bullse, and erythematous patches, accom- panied by intense burning and itching. At the end of a year the cutaneous disturbances gradually declined and disappeared. In 1891, she again became pregnant and the same phenomena devel- oped, but much earlier-in the sixth month of pregnancy. The process began on the same regions as before, and its morbid manifestations were entirely similar to those seen in the primary outbreak. Great soreness, itching, and burning accompanied the eruption, and insomnia, nervous irritability, etc., were the consequences. During the remainder of her pregnancy the process appeared in successive crops, and after confine- ment it became exceedingly aggravated. Severe outbreaks continued for four months and then a gradual cessation occurred, though even up to the present pregnancy there would be from time to time slight erup- tions of itchy and burning " spots," which would last a few days and then disappear. The patient's third pregnancy began in 1893, and when I saw her she was in the sixth month. She stated to me that the eruption had become manifested even before she knew that she was pregnant. The lesions had been preceded by intense burning and itch- ing, and they had first appeared on the abdomen, and next on the feet and legs. A little later, they had cropped out on the hands and on the arms, but none had developed on the face. The abdomen had been severely affected, but the back had been almost entirely free. The sub- jective symptoms had been intense from the first, and owing to their being worse at night insomnia, nervous irritability, and general debility had ensued. The itching and burning were, however, not very severe when the patient remained quiet, but the slightest excitement increased her suffering very greatly. When I saw the case the woman was ap- parently in a good condition of health, though a little anaemic. She was well nourished, her functions were natural, the pregnancy produced no gastric or other disturbances. The renal conditions were likewise unaffected. In fact, the eruption and its entailed discomforts were all she complained of. The lesions consisted of bullae of all sizes, from a pin-head to a nut; tense, prominent, and filled with clear serum. There were also more or less large groups of vesicles and papulo-vesicles, but no pustules. Here and there were patches of large size, composed of a slightly depressed, pale centre, bounded by an elevated, gyrate, red, urticarial-looking border about a quarter of an inch broad. There were others which were solid, elevated, sharply defined, of a bright-red color, and varying in size from a silver dollar to two or more inches in di- ameter. Scratch-marks, crusts, and fading blotches were also abun- dantly distributed between the new and fresh lesions. Dr. Blundell has kindly informed me that the eruption continued during the remainder of the pregnancy, uninfluenced by any treatment. ELLIOT: HERPES GESTATIONIS. 3 After confinement, it became greatly aggravated and then gradually subsided, ceasing at the end of about four months. The last report re- ceived states that the patient is again pregnant, but no mention is made in regard to the reappearance of the skin affection. Case II.-Mrs. -, aged thirty-one years, came under my care March, 1894. She had been married in 1882, and her first child had been born one year later. Between this child and her second one, born in 1889, she had had six miscarriages, but she would not state whether they had occurred spontaneously or had been induced. She was con- fined of her second child in April, 1889, and the cutaneous process had first appeared in the sixth month of this pregnancy. Synchronously with its inception she had had watery vaginal discharges at short in- tervals, and these continued up to the time of her confinement. The cutaneous symptoms in this attack consisted primarily of intense pru- ritus and burning of the palms and soles, followed by the formation of bullse on the hands and feet, and later on the abdomen around the um- bilicus. On these surfaces the eruption remained localized during the remainder of the pregnancy, but after delivery a more or less general eruption of bullae, preceded by intense burning and itching, appeared over the body. For four to five weeks afterward these lesions arose in successive crops, and then the process gradually subsided, the patient being at the end of three months entirely free from the cutaneous dis- turbance. Between the pregnancy of 1889 and her present one the woman has had two miscarriages-one at five and the other at three months. Dur- ing these pregnancies no skin-symptoms developed. After her last mis- carriage she had had severe flooding every two to three weeks up to Octo- ber 1, 1893, when she says there was only a show. She thought she had felt life in January, 1894. About February 1st the first manifestations of the cutaneous process were noticed in the form of intense itching and of small " blisters" on the palms and the fingers and on the soles, while bullae appeared around the umbilicus. Their outbreak occurred in successive crops with great rapidity, and she entered Bellevue Hospital in Dr. Brannan's service on February 6th. The eruption became, however, steadily severer in degree and extent, and when I saw her about ten days later in consultation with him the entire cutaneous surface was affected and covered with erythematous patches, groups of vesicles and papulo- vesicles, bullae, and crusts, while the woman complained of the most intense itching and burning. After leaving the hospital she came to my clinic at Demilt Dispensary about March 1st. On examination she gave me the details of her prior history as I have already enumerated them, stating in addition, however, that previous to her marriage she had been in good health, and that subsequent to it she had felt well and had been able to work, notwithstanding her many miscarriages. She was judged to be pregnant about six months. She was very ansemic and weak and in a very depressed somatic condition. Constipation was marked, a move- ment of the bowels not having occurred in eight days; the tongue was badly coated, the breath very foul, and complete anorexia existed. The eruption was found to be more or less generalized over the entire body, following, however, no particular rule in its localization. Its primary out- break had been preceded by an intense burning and itching on the sur- faces upon which the lesions originally developed, and this feature was a constant one, occurring prior to every outcropping which subsequently 4 ELLIOT : HERPES GESTATIONIS. took place. The backs of the hands were occupied by erythematous, irregularly shaped patches, upon which were groups of small crusts, and by papules, single and grouped. Purplish stains were also present as residua of older lesions. The palms were not affected. The arms, over both their flexor and extensor surfaces, were covered to the shoul- ders with erythematous patches, papules, vesicles, and bullse, distributed without order or arrangement. The papules, papulo-vesicles, and vesi- cles were a pin-head to a small pea in size and were arranged in groups. The bullse were as large as a buckshot to a penny, tense and resistant, with clear, turbid, or purulent contents. Crusts were also abundant, and the arms were in addition mottled with dark-red and purplish blotches, evidences of former lesions. The face was entirely free, except for one bulla on the chin ; but over the thorax there were numerous groups of papules and vesicles and dis- crete bullse. A curious phenomenon was noted around each nipple, it being encircled at a distance of about half an inch from the areola by a narrow, slightly elevated, scalloped erythematous band, which formed an irregular ring. The back was thickly covered with groups of vesicles and papules, with bullse, crusts, and stains. On the abdomen the pap- ular and vesicular groups predominated, but in the groins there were only large bullse. The legs and feet presented the same appearances as were noted on the arms. The mucous membranes were entirely free from the eruption. The patient remained under observation for a month. During that time it was noted that crop after crop of vesicles, papules, and bullse appeared, subsided, and were replaced by new outbreaks. The pruritus and burn- ing were intense and not ameliorated by any treatment. The patient was lost sight of, and the further course and termination of the preg- nancy and the cutaneous process are not known. Case III.-Female, Russian, aged thirty years, entered the Skin and Cancer Hospital (Dr. Bulkley's service) February 21, 1894. She had always been strong and well; gave no history of syphilis or of any cu- taneous disease different or similar to the one she was then suffering from. Her first pregnancy terminated on January 10, 1894, when she had given birth to a full-term, but dead, child. Her pregnancy had been normal, and she was unable to give any traumatic or other cause for the death of the child in utero. She stated that three days before her confinement a number of intensely pruritic papules and erythema- tous patches had appeared over the abdomen. Vesicles developed a day or two after delivery and enlarged rapidly to the size of a buckshot, and even larger. Rupture then took place and the exposed raw, moist surface became crusted over. Rapid extension of the eruption ensued and lesions developed in quick succession over the extremities, the trunk, and the scalp. Similar lesions, always accompanied by intense burning and itching, kept cropping out steadily up to the date of her admission to the hospital, and her general condition deteriorated greatly. What had been the course of the puerperium, whether she had any chills, temperature, localized peritonitis, or other morbid symptoms, could not be ascertained from the patient. The woman was found on examination to be poorly nourished. The bowels were costive and she could not retain any solid food in the stomach. The tongue was thickly furred. There were no remains of lochia or of offensive discharges from the genitals, no tenderness or sen- ELLIOT: HERPES GESTATIONIS. 5 sitiveness of the uterus or pelvic organs. No renal disturbances. Hem- orrhoids and a slight prolapse of the rectum were alone noted. The patient was restless and anxious, mentally excited, and somewhat hys- terical. Her temperature was 1001° ; pulse 110. The eruption occupied more or less of the entire body. The chest and abdomen were covered with crusts. The major part of the back was raw and denuded of epidermis, but here and there were a few bullse, about as large as a nut, filled with clear serum. Over the arms, legs, feet, and hands there were a large number of bullae of all sizes: some recent and tense, others older and flaccid, others already having formed crusts. On the lower half of the legs these lesions had become confluent and their rupture left a raw-looking surface, which quickly became crusted over. There were, in addition to the bullse and crusts, erythematous patches and a few papular and vesicular aggregations. Many stains and scratch-marks were also present. The burning and itching caused great suffering and were bitterly complained of. While in the hospital the course of the eruption consisted in a suc- cession of outbreaks of bullous lesions, preceded and accompanied by intense itching. Her general systemic condition deteriorated steadily ; her temperature varied between 99J° and 100°, evening rise and morn- ing fall; she grew weaker and weaker, the stomach refused to retain any nourishment, tympanites developed, and the patient died March 27th. No autopsy could be obtained. Notwithstanding the differences in degree, mode of inception, and duration of these cases, yet they all show distinctly those clinical ob- jective and subjective symptoms and course characterizing dermatitis herpetiformis in general. Arising in connection with pregnancy in- cludes them in that phase of the disease called herpes gestationis, but in the multiformity of their lesions, the constant relapses and succession of outbreaks, accompanied by intense burning and itching, we find the cardinal symptoms of Duhring's disease, and Case I. appears to me to emphasize this view much in the same manner as did the case reported by me in 1892. It is true that it began only three days after delivery, but that does not exclude it from the category of those cases arising from pregnancy, as similar instances have already been recorded. Be- sides, the eruption developed earlier in each successive conception, as has been repeatedly observed by others, and in its whole behavior, ex- cept its long continuance after confinement, it agreed with those other cases reported in literature. It is, however, in the particular of its long duration after pregnancy that the case is important. In all those pre- viously seen, with the exception of the one I recorded in 1892, the erup- tion underwent aggravation within the first few days after labor, and then disappeared rapidly in a few days or weeks, rarely lasting two to three months, and it became of a chronic type and of long duration only after repeated attacks occurring in successive pregnancies. In the present case, however, the manifestations of the process continued cropping out in a series of outbreaks for a year after the primary attack, and its ten- 6 ELLIOT: HERPES GESTATIONIS. dency to chronicity was furthermore shown, after the pregnancy in 1891, by its continued outbreaks from time to time until the conception in 1893, when it became continuous, and only ceased four months after the confinement in 1894. This sudden termination is certainly curious, but not any more susceptible of explanation, however, than its non-recur- rence in the present or last pregnancy. Notwithstanding these latter peculiarities the case in its prior course and behavior appears to me, however, to furnish an additional link connecting herpes gestationis with dermatitis herpetiformis, and to aid in establishing the fact that the former is only a phase of the latter. In Case II. we see more particularly the usual and typical course of herpes gestationis. Developing in the first pregnancy after her numerous miscarriages, it lasted till the child was born, then becoming greatly aggravated it subsided and ceased altogether at the end of about three months. After a long period of freedom the process recurred in the pregnancy in 1894. She then came under my care, and the eruption in its objective and subjective symptoms was such that were it not known that conception existed, no other diagnosis but that of dermatitis herpeti- formis would have been made. In fact, my experience in studying six per- sonal cases of herpes gestationis, and in comparing them with thirty-five examples of dermatitis herpetiformis originating from causes other than pregnancy, and which have been under my care, would lead me to state that only the knowledge that the patient was a woman with an impreg- nated uterus would enable the diagnosis herpes gestationis to be made instead of that of Duhring's disease. The former is characterized by having a definite factor-pregnancy-as its determining cause, but I have failed to see how in its course and general symptomatology it differed in any way from those cases arising under the influence of some other cause than that particular one. Case III. is of interest owing to its fatal termination. The patient's death can, however, not be ascribed to the cutaneous disease, but un- questionably to septicaemia, from which she was suffering when she entered the hospital. It was not possible to determine the starting-point of the septic process, whether from the uterus or from the skin. In whatever way it developed, however, it is probable that the condition of the skin contributed to it, as the raw state of a large portion of the sur- face, covered with decomposing secretions, crusts, and dirt, certainly favored septic absorption. That the case was one of the same nature as the other two included here seems to me unquestionable, in view of its inception during pregnancy, its aggravation after delivery, the multi- formity of its lesions, the course it ran, and the intense subjective symp- toms preceding and accompanying its outbreaks. In these cardinal features the case agreed with other examples of this phase of dermatitis herpetiformis, and I have, therefore, included it in this paper. ELLIOT: HERPES GESTATIONIS. 7 It cannot, unfortunately, be said that our knowledge has progressed in regard to the mode of origin and production of dermatitis herpeti- formis. What systemic conditions favor its development and what changes preside at its inception and outbreak are entirely unknown. We are only able to judge from clinical study and observation of its etiological moments, its course, and its response to every and any dis- turbance of the nervous system, that it is essentially a dermatoneurosis, controlled in its phases and manifestations by certain changes in the nervous system, of the nature of which, however, we have absolutely no conception, though, owing to the disease being often transitory, often cured, and not accompanied by or developing grave cerebral or other conditions, we are justified in believing that they are probably only functional and not organic. Since I expressed, in former papers, my belief in the neurotic origin and nature of the disease, all the cases coming under my observation have only strengthened that opinion, and inasmuch as the most manifold causes acting upon the nervous system in one way or another have been found sufficient to produce the same effect-dermatitis herpetiformis-there can be no reason to exclude from the same category the pregnant uterus as a determining cause of the disease, in view of the neurotic disturbances in the economy naturally incident to that condition. Why, however, the effects of these disturb- ances are expended in one woman upon the skin and in another they are not, are questions awaiting solution, and an explanation for them cannot be at present even surmised. The treatment of this cutaneous disease does not promise brilliant results nor afford great satisfaction. When it has been possible to dis- cover and reach its basic determining cause entire relief and even a cure have been sometimes obtained by me ; but when the medication was purely a symptomatic one I have not seen any beneficial effects derived beyond a certain amount of relief from the subjective discomforts of the patient. Internally, some cases have been benefited by arsenic, others by atropia, or pilocarpine, or nux vomica in large doses, or by alkaline treatment; but I have never seen any two react in the same manner toward any one drug or combination of drugs. Externally, I have obtained more benefit from ichthyol than any other application, it not being surpassed even by the tars. Sulphur, resorcin, salicylic acid, menthol, ergot, etc., have all failed in my hands, and the most reliable has been the ichthyol. Of course, in dermatitis herpetiformis resulting from pregnancy there are no measures indicated except palliative appli- cations, which may relieve the burning and itching. The large majority of the cases ceasing after delivery of the child, matters should be allowed to take their usual course, though instances may arise in which the in- duction of abortion may be necessary. Such a course would, however, have to depend more upon the complications of the pregnancy and the 8 ELLIOT: HERPES GESTATIONIS. condition of the woman than upon the discomfort, suffering, etc., pro- duced by the process on the skin. In a case seen by me in consultation some time ago, such a procedure was judged absolutely necessary, in view of the albuminuria from which the woman suffered. The cutaneous dis- ease had been severe from the beginning of the pregnancy, and had caused intense suffering, insomnia, and nervous disturbance, etc. The pruritus subsided in a couple of days after the evacuation of the four months' pregnant uterus, and the lesions disappeared rapidly, the skin being entirely clear in about ten days. Only in an extreme case, how- ever, would such measures be indicated, and these, fortuaately, are not of every-day occurrence. 14 West Thirty-third Street. Yfye Johrpal OF the MEDICAL SCIENCES. MONTHLY, $4.00 PER ANNUM. WITH 1895 The American Journal oe the Medical Sciences enters upon its seventy- sixth year, still the leader of American medical magazines. In its long career it has developed to perfection the features of usefulness in its department of literature, and presents them in unrivalled attractiveness. It is the medium chosen by the leading minds of the profession on both sides of the Atlantic for the presentation of elaborate Original Articles; its Reviews are noted for discernment and absolute candor, and its Classified Summaries of Progress each month present an epitome of medical advances gleaned by specialists in the various departments. According to unquestionable authority, " It contains many original papers of the highest value; nearly all the real criticisms and reviews which we possess, and such carefully prepared summaries of the progress of medical science and notices of foreign works that from this file alone, were all other publications of the press for the last fifty years destroyed, it would be possible to reproduce the great majority of the real contributions of the world to medical science during that period." Medical NeWs. WEEKLY, $4.00 PER ANNUM. BY KEEPING closely in touch with the needs of the active practitioner, The News has achieved a reputation for utility so extensive as to rendei' practicable its reduction in price from five to Four Dollars per annum. It is now by Jar the cheapest as well as the best large weekly medical journal published in America. Employing all the recognized resources of modern journalism, such as the cable, telegraph, resident correspondents, special reporters, etc., The News furnishes in the 28 quarto pages of each issue the latest and best infor- mation on subjects of importance and value to practitioners in all branches' of medicine. Its numerous departments are designed to subdivide and present its material in the most attractive and convenient manner. In a word The Medical News is a crisp, fresh, weekly newspaper, and as such occupies a well-marked sphere of usefulness, distinct and complementary to the ideal monthly magazine, The American Journal of the Medical -Sciences. The Year-Book of Treatment for 1895 Gives a classified summary and review of the real advances in treatment made during 1894 in all. departments of the science of medicine. Price, $1.50; or in combination with either or both the above journals, 75 cents. Ready early in 1895. The Medical News Visiting List for 1895 Published in four styles : Weekly, dated, for 30 patients; Monthly, undated, for 120 patients per month; Perpetual, undated, for 30 patients weekly per year; Perpetual, for 60 patients weekly per year. The first three styles contain 32 pages of important data and 160 pages of assorted blanks; the 60-patient perpetual consists of 256 pages of blanks. Price, each, $1.25. In com- bination with either or both above periodicals, 75 cents. Or, Journal, News, Visiting List and Year-Book, $8.50. Thumb-letter index for Visiting List, 25 cents extra. LEA BROTHERS & CO., PUBLISHERS, PHILADELPHIA, 706, 708 & 710 SANSOM STREET.