DERMATITIS MULTIFORMIS GESTATIONIS. BY CHARLES W. ALLEN, M. D., SURGEON TO CHARITY HOSPITAL, ETC. REPRINTED FROM THE JOURNAL OF CUTANEOUS AND GENITO-URINARY DISEASES FOR AUGUST, 1839. DERMATITIS MULTIFORMIS GESTATIONIS BY CHARLES W. ALLEN, M. D., SURGEON TO CHARITY HOSPITAL, ETC. REPRINTED FROM " THE JOURNAL OF CUTANEOUS AND GEN1T0-URINARY DISEASES" FOR AUGUST, 1889 NEW YORK D. APPLETON AND COMPANY 1, 3, and 5 BOND STREET 1889 DERMATITIS MULTIFORMIS GESTATIONIS. By CHARLES W. ALLEN, M. D., Surgeon to Charity Hospital, etc. ON April 18, 1889, I was asked by Dr. S. Barnett, of this city, to see with him a patient in childbed who had some severe skin affec- tion. Mrs. Mary N., native of England, twenty-six years of age, had been deliv- ered, at term, one week before of a healthy-looking child. The history given was that her first pregnancy had resulted in the birth of a living healthy child five years ago, which had subsequently died of diphtheria, and that in the interval she had aborted six times without known cause, usually in the third or fourth month. She had never known of a syphilitic taint, had never had any eruption of any kind upon the skin, and, indeed, no evidences of syphilis were to be found upon the body or in her history, or in that of her husband, so far as obtainable. One month before the date of her present confinement the " waters broke," and so much fluid was discharged that she thought she was again to have a miscarriage. This fact gave the patient great worriment and concern, for she was most anxious to bear a living child. One week before delivery and two weeks before I first saw her there had appeared a good-sized bulla just over the umbilicus, and in a half-circle above and to one side of this a num- 292 Original Communications. her of small vesicles. This eruption had been preceded by several days at least of itching confined to this portion of the abdomen. Almost at the same time vesicles were noticed between the fingers, upon the toes, backs of the feet, and inner surface of the thighs. These lesions were not at all troublesome, did not give rise to subjective symptoms, excepting a slight itching, and, as they showed little tendency to rupture, did not receive much attention. As soon as the child was born, however, the eruption became greatly aggravated. Erythematous patches, which were extremely itchy and had a disagreeable feeling, which patient says was neither a burning nor a pain, but was " nasty," appeared upon the anterior surfaces of the thighs, and within a few days became covered with small vesicles and moderately large bullae, while the whole of the right arm from the shoulder to the wrist presented the appearance of a typical pemphi- gus vulgaris, the bullae, without noticeable surrounding areola, arising from apparently healthy skin, not the seat of previous erythema. When I first saw the lady the right arm was found thickly studded with tense round and oval bullae from the size of a pea to that of a small hen's egg. For the most parts the walls of the bleb were tense and the contents a citron-yellow fluid of slightly alkaline reaction. A few of the lesions which had first appeared had become confluent, ruptured, and the walls were either entirely gone or were lying upon the denuded areas in folds and shreds of whitened epithe- lium. The arm was very painful, and where the epidermis had been rubbed oft* was suggestive of a burn. Groups of vesicles from the size of a pin's head to that of a pea were scat- tered over the thighs, especially upon the reddened patches already men- tioned, which in places appeared as though made up of minute vesicles which had dried up, become red and flattened, and shining on their summits. Sin- gle frank vesicles and groups of two or three were also seen to arise from skin in every way normal in appearance. In the region of the ankles there were a number of round tense bullae which had become pustular, and upon the chin there was a group of lentil-sized pustules (they had begun as vesi- cles) seated on an inflamed base. Upon the sole of the right foot was a clus- ter of deep-seated vesicles which had appeared on the preceding day. The back was entirely free from any signs of eruption, and remained so through- out. The mucous membranes were also exempt. The patient's general condition was one of marked depression, despond- ency, and suffering. The tongue was flabby and thickly coated with a white fur. Diarrhoea and headache were present, the arm was very painful, and the temperature, which had been elevated since the onset, was now 102° in the axilla. The lochia had been very scanty. Treatment consisted in the application of the following paste so as to thickly cover all affected regions: I> Pulv. zinci oxidi, Bismuth i subnit aa 3 iij; Amyli § ijss.; Tinct. benzoini co 3 ss.; Acidi carbolici 3 ss.; Petrolati q. s. ad § iv. M. Ft. pastam. Dermatitis Multiformis Gestationis. 293 Internally, Fowler's solution of arsenic was given three times daily, begin, ning with six minims, gradually decreasing a drop at each dose till a two- minim dose was reached, and then increasing in the same way up to eight minims. April 19. New bullae have appeared upon the inner aspects of the thighs, preceded by erythema and great itching. Bullae the size of English walnuts have formed upon the posterior aspect of the right arm, and there is now a denuded patch as large as the palm. (The first crops were all upon the ante- rior surface.) The left arm, which was yesterday entirely free from eruption, now shows its first crop of bean-sized, clear, round, tense bullae. The flexor surface of this arm about the elbow and the regions above and below it are occupied by an extensive cicatrix, the result of a burn received in childhood. No lesions have as yet formed upon this cicatricial tissue. A single large bulla is located upon the upper lip. Those upon the chin are drying up and the erythema has disappeared. There are still diarrhoea, headache, pain, prostration, and the same fever as yesterday. April 20. A narrow red band of erythema has made its appearance around one side of the abdomen, and extending from the median line in front to the axillary line is a single chain of oblong vesicles, whose long diameters corre- spond with the circumference of the body and suggest by their distribution a zoster, although groups of vesicles are absent. In one place several of these vesicles have coalesced, producing a single long and narrow bulla. There are a few new bullae about the ankles. The lesions upon the backs of the feet have dried into crusts. The erythematous element has almost disap- peared from the thighs. The arms are both erythematous and itchy, and upon the anterior surface of the right wrist are two large wheals. The red patches which have appeared since yesterday upon the arms have that same peculiarity noted as existing upon the thighs-i. e., that they seemed to be formed by an aggregation of minute vesicles whose fluid contents have in some way disappeared, leaving the summit of each minute lesion flat and shiny, resembling the condition seen in lichen tropicus of children. These patches are very itchy when they first appear, and the pruritus usually pre- cedes the outbreak, as it also does each crop of bullae. The paste employed has a very soothing effect on these patches. Upon the areola of the left breast is an oblong bulla, whose contents have already become purulent, and upon the apex of the right nipple are two sago- pearl-like vesicles which make the nipple quite painful to the touch. A number of flat papules are seen upon the thighs to-day for the first time. The child is not put to the breast, but receives the milk after it has been ar- tificially withdrawn. April 21. Whole right side of face and a portion of the neck are of a bright scarlet color and have an infiltrated appearance. (Although it was anticipated that bullae would be produced upon these patches, such was not the case, and the redness disappeared within a few days.) About twenty large-sized bullae were carefully pricked and the contents allowed to escape, while the bleb wall was preserved to cover the surface beneath. The fluid 294 Original Communications. was of all colors, ranging from a clear, watery liquid to white, yellow, pink, and purplish (hemorrhagic). The temperature to-day reaches 101° in the axilla. Ten grains of calomel were given to relieve the bowels. April 23. Patient sitting up. Feels quite well. Only a few new bulla? about the wrists, and the older lesions are healing. Temperature, 98|°. May 1. Patient has continued taking Fowler's solution in eight-minim doses. Now has nausea, vomiting, abdominal pain, and the tongue has again become coated with thick, white fur. Arsenic was now stopped and a tonic mixture containing strychnine substituted. May 3. There are some new vesicles on the arms and the skin is very itchy; also a few papulo-pustules and furuncular lesions upon the upper portion of the arms and in the axillae. A number of bullae have arisen upon the scar tissue of the arm mentioned under note of April 20. May 7. Feels well again. Abdominal symptoms have disappeared. Sev- eral bullae have formed on the arms and a group of small vesicles in the cen- ter of the right palm. Began Fowler's solution again in five-drop doses. May 11. Few frank vesicles continue to appear upon the arms and backs of the hands. Boil-like lesions are still present in the axillae and upon the chest. They are inflammatory, tender to the touch, and contain pus. May 21. Patient has continued taking Fowler's solution for past two weeks, the dose being increased to eight drops three times daily. A few bullae con- tinue to crop out, but they are now flattened, do not become filled with fluid or get tense, and the diameter does not exceed that of a three- or flve-cent silver piece. The secretion from these lesions quickly dries into yellow fri- able crusts like those seen in impetigo. The sites of previous lesions which have healed are now desquamating, as are also the palms. Vesicles in round- ed groups are still present upon the soles, sides of feet, and insteps. June 1. No new lesions have appeared since last note. Patient considers herself well and goes about. Treatment stopped. June 20. Reddish pigmentations, which have marked the location of each lesion, are fading, and in doing so assume a brownish tinge. Patient has felt very well since. July 11. Patient examined and found entirely free from any signs of der- matitis, with no indication of any recurrence. The arms are covered with various-sized rounded, brownish pigmentations, each the site of a former bulla, and patient says they appear to be growing gradually darker. I have given to this condition the name dermatitis multiformis gesta- tionis, because I believe that at the present time it is a more appropriate designation than any hitherto suggested. Had I employed any of the existing names by which to call it, I would have chosen that ot pemphigus gestationis as the one most suggestive of its striking features. I am aware that in reading the description of the case one may say, " Oh, yes, that is an instance of my herpes gestationisand another may recognize in it his erythema gestationis, while a third may put it down as hydroa, etc. Those who agree with Duhring that this condition is properly included in the group " dermatitis herpetiformis " will still possibly not object to the Dermatitis Multiformis Gestationis. 295 name here suggested, since there is a decided feeling among dermatolo- gists that " multiformis " is a more appropriate qualification than " herpe- tiformis," because the herpetic element is often absent in Duhring's dis- ease when the case falls under observation. The objection made to this- that we have already an erythema multiforme with which it might be con- founded-is not a valid one, for the distinction between an erythema and a dermatitis is marked, and there is no more similarity between the names than there is between those of impetigo contagiosa and molluscum conta- giosum. If it should be decided that this condition, occurring in preg- nancy or just after childbirth (which is now well recognized, though called by a great diversity of names), really forms a part of Duhring's dermatitis, then the termination gestationis will show to which particular variety of his disease these cases belong. Naming the disease from the appearances presented at the time the case is observed will not answer in this polymorphous and ever-varying affection, which shows such a marked tendency to recur with successive pregnancies, but not always to present the same eruptive features. For example, how ludicrous it would appear if I should call this particular outbreak " pemphigus," and in her next pregnancy the patient should de- velop an eruption readily recognized as due to the same conditions and having many of the same features, but lacking the bullous element, and I should at that time report it as a case of " herpes gestationis, or erythema gestationis, a recurrence of pemphigus gestationis of the preceding preg- nancy ! " My friend, Dr. Brocq, of Paris, has recently advanced the com- prehensive title dermatite polymorphe prurigineuse recedivante de la grossesse, forgetting for the moment that we do not all speak French, and even those who do, could scarcely speak so much of it at once whenever they wished to refer to this peculiar condition. Concerning the nature of the affection, it appears to be of reflex nerv- ous origin, and in the case here reported there is indeed the history of a shock to the nervous system by the premature rupture of the membranes and the consequent mental distress of the patient, who feared another mis- carriage and was most desirous of bearing a living child. The analogy which exists between this dermatitis of gestation and the various herpetic affections is shown by the grouping in more or less regular circles and rounded groups, as upon the palms and foot-soles, and in the first lesions observed (a bulla at the navel surrounded in part by a chain of vesicles). A further analogy to that particular form of herpes known as zoster was to be noted in the chain of herpetic vesicles upon an erythematous base which encircled the right side of the abdomen. An analogy between this case and those of impetigo herpetiformis of Hebra will be seen in the appearance of the first eruption toward the end of pregnancy, occurring about the umbilicus at first and having a central 296 Original Communications. lesion surrounded by smaller ones in the arc of a circle; in the fact that, although no lesions were positively pustular from the first, many soon be- came so, noticeably two which became confluent upon the areola of the left breast and those about the ankles. Furthermore, there were patches made up of miliary lesions, some with turbid contents. The resemblance to the descriptions of dermatitis herpetiformis, as given by Duhring and others, will be apparent; still, it seems to me that there should be a distinction made between the chronic conditions which go by this name and these acute attacks coming on in otherwise healthy individuals and depending upon the conditions furnished by the gravid uterus or the process of childbirth. 102 East Fifty-seventh Street, New York.