GLYCOSURIA AS AN ADDITIONAL SYMPTOM INDICATING THE NEUROTIC ORIGIN OF DER- MATITIS HERPETIFORMIS (DUHRING). BY JAMES McF. WINFIELD, M.D., Attending Dermatologist* to the Kings County Hospital, the Long Island Hospital, O. D. P., Assistant to the Chair of Skin Disease at the Long Island College, etc., etc. REPRINTED FROM THE JOURNAL OF CUTANEOUS AND GENITO-URINARY DISEASES FOR NOVEMBER, 1883. GLYCOSURIA AS AN ADDITIONAL SYMPTOM INDICATING THE NEUROTIC ORIGIN OF DERMATITIS HERPETIFORMIS (DUHRING).1 BY JAMES McF. WINFIELD, M. D., Attending Dermatologist to the Kings County Hospital, the Long Island Hospital, 0. D. P., Assistant to the Chair of Skin Disease at the Long Island College, etc., etc. MANY cases of dermatitis herpetiformis have been re- ported by Elliot, Brocq and others, pointing to some severe nervous shock as the essential etiological factor in the production of this interesting cutaneous disease. But in the writings of each no mention is made of any change in the urinary secretions. In the following cases glycosuria was pres- ent to a greater or less extent, and in all of the cases person- ally observed, irrespective of those herein reported, the original and recurrent attacks followed some unusual mental exertion or severe nervous shock, showing an intimate relationship be- tween the advent of the eruption and the reception of the shock. Case I.-Mr. S., age 29 years; strong and well-developed man ; no history of any specific taint ; habits temperate ; skin dark but perfectly healthy as to texture, etc. During a severe and prolonged mental strain (endeavoring to abort a strike at a foundry in which he was a foreman), he noticed a few painful itchy vesicles over the neck and right ear. These rapidly mul- tiplied until the shoulders, arms, chest walls, buttocks and thighs were invaded. At the time of consultation the following was observed: the parts enumerated were covered with a pro- fuse eruption of a multiform character, chronic, sub-acute and acute. There were papules, vesicles and pustules scattered throughout the entire portion affected. Frequently the three would be closely grouped together in a circumscribed patch. In parts the arrangement and distribution closely resembled zos- 1 Read by title at the Pan-American Medical Congress, September 5, 6, 7 and 8, 1893. 2 Original Communication. ter. The vesicles were of various sizes, many of them being minutely small, while others were as large as pemphigoid bullae. The pustules dried into dark brown scabs. At first the patient complained of severe burning in the diseased skin, but after the eruption had existed for two days this was accompanied with itching, which grew more intense as the process continued. The treatment was wholly palliative: bromide and chloral to quiet the nervous irritation and to produce sleep, external lotions and ointments containing anti-pruritics to allay the itching. All through the illness there had been polyuria. On account of this symptom and at the suggestion of Dr. Sherwell1 who had seen the case in consultation, the urine was examined with the following results-color light, specific gravity 1030, nothing special by microscope test for albumen negative. On testing for sugar it was found at all times, in varying quantities from a trace to as high as five per cent. With this clue, the treat- ment was directed to the relief of the diabetic condition. Diet was regulated, mental worry removed, and the administration of codia and bromide, and lastly tonics containing arsenic. The external treatment was soothing ; the patient rapidly improved and was dismissed cured in about one month from the advent of the disease. Fourteen months after he again presented himself with the same cutaneous manifestations in a less degree, which had again followed mental worry. The urine being examined was found to contain about one per cent, of sugar. Beneficial results were obtained by about the same line of treatment as in the preceding attack. Since then the patient has avoided mental shock and worry and there has been no recurrence of the cu- taneous disease, now nearly six years. Case II.-Boy, age 13. After a severe fright voided large quantities of urine, which were found to contain traces of sugar. A short time after the reception of the nervous shock erythe- matous patches appeared on the neck, buttocks, and inner side of the arms and thighs. The patches became thickly studded with papules which rapidly developed into vesicles and pustules which finally dried into dark brown scabs. The treatment was to quiet the disturbed nerves, soothing applications to the skin lesions, to subdue the intense itching, which was the most an- noying symptom, antipyretics for the fever, and finally tonics. After two or three relapses the patient became fully convales- cent. 1 Dr. Sherwell referred to this case at the twelfth annual meeting of the American Dermatological Association, 1888. Glycosuria in Dermatitis Herpetiformis, etc. 3 Case III.-Mrs. M. A slight, but well-built woman, mother of three children, temperament nervous and hysterical, general health always good. Before the cutaneous process began she had been subjected to excessive mental anxiety and shock, superinduced by the illness and death of her youngest child. The eruption was principally over the neck, chest and thighs, presenting the typical picture of dermatitis herpetiformis, as described by Dr. Duhring. There was no polyuria except just after the death of her child, which was probably wholly hyster- ical. However, the urine was found to contain sugar in small quantities. The treatment was quite similar to that of the first case, but in spite of physical improvement the mental state re- mained bad. The cutaneous condition would improve for a few days, followed by a relapse, successive crops of papules and vesicles appearing at short intervals. The patient was advised to seek change of scene and climate, when slow but permanent convalescence was established. Case IV.-Mr. S., age 40 years. Of a highly nervous and excitable temperament; worries about the slightest things. Had been given to excesses in early life. The eruption, which had existed for over a year, consisted of vesicles and papules on the neck and shoulders. There was also a papulo-vesicular erythematous plaque over right buttock and thigh. Fre- quently during the course of the disease the small vesicles would coalesce and large bullae would be the result. There was itching at all times, being more intense during the acme of the eruption than in the beginning or the ending of the out- break. The initial attack followed anxiety over business diffi- culties. The urinary secretion was greatly increased in both the first and subsequent attacks; tests for sugar always re- vealed it in varying amounts. When the mental disquiet sub- sided the urine became normal and the eruption grew less, fresh exacerbations following the slightest anxiety or worry. The patient being easily discouraged and not receiving rapid results from treatment became dissatisfied and consulted an- other physician, with what results is unknown. These cases are interesting inasmuch as they all present a symptom (glycosuria) which has not been referred to in any ar- ticle on this much-discussed disease. It is not the object of this paper to consider in extenso the other clinical facts, but it is proper to refer briefly to the bear- ing of this symptom on the theory of the disease. Since the time of Claude Bernard the existence of a sugar center in the 4 Original Communication. oblongata lias been generally recognized. It is further known that not only after direct puncture of this center, but also in some cases of general brain shock and in even more localized sudden lesions in distant parts of the brain, sugar in the urine has been observed. Beyond the cases of direct injury to the oblongata there is so little uniformity in the other cases of cere- bral injury that it is impossible to draw any inferences from them bearing more closely on the disease under discussion, although the presumption is admissible that in all of them there is indication of the sugar center. Whether this repre- sents a distinct mechanical irritation, as by pressure, or whether it be produced indirectly by influences from the higher centers radiated to the oblongata, is more properly a neurolog- ical point. It is sufficient that the facts are established and that they offer a reasonable explanation of the glycosuria fol- lowing nervous shock in the four cases reported. The occur- rence of sugar in the urine coupled with the neurotic symptoms described by other observers, corroborates the view that the cu- taneous manifestations of dermatitis herpetiformis are of nerv- ous origin. 1255 Pacific Street, Brooklyn.