THE MEDICAL NEWS.A WEEKLY JOURNAL OF MEDICAL SCIENCE.

No. 16.Vol. XLVII. Saturday, October 17, 1885.

ORIGINAL ARTICLES.

RELATION OF HERPES GESTATIONIS ANDCERTAIN OTHER FORMS OF DISEASE

TO DERMATITIS HERPETIFORMIS. 1

By LOUIS A. DU PIRING, M.D.,PROFESSOR OF SKIN DISEASES IN THE UNIVERSITY OF PENNSYLVANIA.

In my original communication on Dermatitis Her-petiformis, read before the American Medical Asso-ciation, 2 that disease was described, and its symp-toms and several varieties given. It was there statedthat the pustular variety is the same manifestation asthe affection described by Hebra as “ impetigo her-petiformis.” This latter subject has more recentlybeen elaborated by me in a paper read before thisAssociation 3 at its last meeting.

On the same occasion I presented a “ PreliminaryNote on the Relation of Dermatitis Herpetiformis toHerpes Gestationis and Other Similar Forms of Dis-ease,” 1 which communication embodied the resultsof considerable research into literature bearing uponthe subject. It was there stated, as had been inti-mated in my previous articles, that so-called herpesgestationis, as well as certain other similar formsof eruption, reported with various titles, are all in-stances ot one process, namely, dermatitis herpeti-formis, as I had defined this disease.

The remarks about to be made must be regardedas supplementary to the preliminary note referred to,since presenting which I have been able to investi-gate further and collate the notes of some of thesecases, which I desire now to bring forward in sub-stantiation of my statement. It will be observedthat the clinical features of the cases bear a strongresemblance to one another. It will not be neces-sary, however, for my purpose to quote all the casesin extenso.

The object of this communication will be to show:1. The identity of so-called herpes gestationis with

the vesicular variety of dermatitisherpetiformis.2. That certain other forms of so-called herpes re-

ported with various titles are likewise manifestationsof the same variety of this disease.

3. That certain cases reported as “ peculiar formsof pemphigus ’ ’ must also be viewed as examples ofthe vesicular or bullous varieties of this disease.

4. That instances of dermatitis herpetiformis arealso to be found in literature under the title “hydroa”and under divers other captions.

In view of the fact that the general features of der-matitis herpetiformis have been so fully described byme, and, moreover, that numerous examples of the

1 Read before the American Dermatological Association at theNinth Annual Meeting, \ugust 27, 1885.

2 Journal of the American Medical Association, Aug. 30, 1884.3 American Journal of the Medical Sciences, Oct. 1884.i Published in The Medical News, Nov. 22, 1884.

disease portraying the more important varieties of theprocess have been reported during the past year, 1 itwill not be necessary to reconsider the disease on thepresent occasion beyond pointing out the principalfeatures of the two varieties which concern thispaper,namely, the vesicular and bullous. The followingis an abstract of the original description of the ves-icular variety.

It is characterized by variously sized, varying from apin-head to a pea, flat or raised, irregularly shaped orstellate, glistening, pale-yellowish or pearly, usually firmor tensely distended vesicles, as a rule, unaccompaniedby areolae. In their early stages they can be seen onlywith difficulty, and are liable to be overlooked in theexamination. Sometimes they can only be detected orseen to advantage in an oblique light In size they varyextremely, large and small being formed side by side,and in this respect they differ from the vesicles of ec-zema. Here and there papules, papulo-vesicles, vesico-pustules, and small blebs will sometimes be encountered.The eruption as a whole is disseminate, the lesions ex-isting scattered more or less profusely over a givenregion, as, for example, the neck or the back, but theyare for the most part aggregated in the form of smallclusters or groups of two, three or more; or there maybe patches here and there as large as a silver dollar,upon which a number will be seated. When in closeproximity they incline to coalesce, as in herpes zoster,forming multilocular vesicles or small blebs. Wherethis occurs they are generally slightly raised and aresurrounded with a pale or reddish areola, which showsforth the irregular, angular or stellate outline of thelesion. At this stage, moreover, the little cluster willgenerally present a “puckered” or “drawn up” ap-pearance, indicative of its herpetic nature. The erup-tion is usually profuse, sometimes to the extent of theupper extremities, trunk and thighs being well covered.It may attack any region, but the neck, chest, back,abdomen, upper extremities and thighs are especiallyliable to invasion.

The most striking symptom is the itching. Not in-frequently burning is also complained of. Itching,however, predominates, and is violent or intense. It isaltogether disproportionately in excess of the amountof eruption. It is, moreover, a persistent itching, caus-ing the sufferer to scratch constantly. It generally pre-cedes the outbreak, and does not abate until the lesionshave been ruptured. From my observation I shouldsay that it is usually more severe and more lasting than

1 Notes of a Case of Dermatitis Herpetiformis Extending overEleven Years, Illustrating the Several Varieties of the Disease.Philadelphia Medical Times, July 12, 1884.

Case of Dermatitis Herpetiformis (Multiformis) Aggravated byPregnancy and Irregular Menstruation. THE MEDICAL NEWS,July 19, 1884.

A Case ofDermatitis Herpetiformis (Bullosa). The New YorkMedical Journal, July 19, 1884.

Case of Dermatitis Herpetiformis, Illustrating in Particular thePustular Variety (Impetigo Herpetiformis of Hebra). Journal ofCutaneous and Venereal Diseases, Aug. 1884.

Notes of a Case of Dermatitis Herpetiformis During ThirteenYears. The N. Y. Med. Jour., Nov. 15, 1884.

Case of Dermatitis Herpetiformis, with Peculiar GelatinousLesions. The MedicalNews, March 7, 1885.

Case of Dermatitis 11<?rp e t Nervous Shock,Amer. Jour Med. Sci., Jan, iBBJf. T J.

~ "

'—

HERPES GESTATIONIS AND DERMATITIS HERPETIFORMIS. [Medical News422

in vesicular eczema. The vesicles generally make theirappearance slowly, so that several days or a week maybe required for their complete development. Notwith-standing the fact that scratching is indulged in in theearly stages of the disease, excoriations are not promi-nent, owing to the fact that the lesions do not readilyrupture, and, also, that they incline to refill immediatelyon being evacuated.

If we look into the subject of herpes gestationis,it will be found that the term was introduced byMilton in 1872. Previous to this date, in 1867,Erasmus Wilson 1 gave brief notes of two examplesof a disease which he designated * ‘ herpes circinatusbullosus,” considering them in a chapter devoted tothe “chronic forms of herpes.” In both cases thedisease was associated with pregnancy, beginningwith conception and ending with the completion ofparturition. Mr. Wilson describes them as follows :

“Both cases were remarkable for perpetual irritationand intense pruritic suffering. The bullae were ofthe flat and foliaceous kind, some filled with limpidserum and others with a mucopurulent fluid, and wereassociated with moistexcoriations, thin crusts, papulae,and pruritus. In one patient the cutaneous diseasewas the first intimation of pregnancy; the diseasecontinued during the wholeperiod, accompanied fouror five pregnancies in succession, and completely ex-hausted her strength and health. In other respects,and in the intervals of being pregnant, she was astrong and healthy woman. The other patient wasa woman aged thirty-six, the mother of nine chil-dren. The eruption made its appearance with thefourth pregnancy, and has accompanied every preg-nancy since. When parturition was over the erup-tion ceased; but on the last occasion, nine monthsago, it remained, and has now assumed a permanentcharacter. In both cases the eruption was accom-panied with sympathetic gastric disturbance and witha duskiness and cachexia of the skin.”

It is evident that the cases illustrate the “herpesgestationis” of certain more recent writers, and, asI have stated elsewhere, that the disease is the sameas described later by Hebra under the titles “herpesimpetiginiformis ” and “impetigo herpetiformis.”It must be remarked, however, that Wilson gives nospecial account of the lesions, nor of the peculiaritiesof the disease, and it is doubtless for this reason thatthe attention ofdermatologists was not fairly directedto the subject until Milton’s report ofa case in theJournal of Cutaneous Medicine, Vol. i., No. 3, thepaper being designated “on certain unusual forms ofvesicular eruption,” and the disease classed as an ex-ample of the “ herpes circinatus bullosus” ofWilson.In Milton’s work on the “pathology and treatmentof skin diseases, ” 2 published a few years later, thiscase is again brought forward, on this occasion withthe name “ herpes gestationis.”

The disease occurred in a woman aged forty-five,who was in the fourth month of her eighth pregnancy.It began with intense itching, smarting, and heat ofthe skin of the arms and forearms, upon which partsa vesicular and bullous eruption soon developed.The lesions were the size of a small pea, and gener-

1 Diseases of the Skin, 6th edition, p. 294. London, 1867.2 London, 1872*

ally in groups of two to four. They were mostlyprominent and pointed in shape, but some were ob-long with the ends apparently communicating. Thedisease developed rapidly, so that in a few days thegreater part of the body was involved. There wasconstitutional disturbance, and the local irritationwas most distressing. Two weeks after delivery shewas on the road to recovery. She had had similarattacks twice previously, with her first and fifth preg-nancies.

We next meet with Bulkley’s case,’ which he, like-wise, designated “herpes gestationis,” adopting thename proposed by Milton. The case was that of amarried woman, thirty-two years of age, who wasconfined with her first child. The cutaneous mani-festations appeared two months previous to her de-livery, on the hands and feet, and subsequently in-volving the greater part of the general surface. Itbegan in the form of papules, which rapidly passedinto vesicles, and later blebs developed. The vesi-cles, which were generally in groups, varied in sizefrom very minute elevations to large blebs. Afterthey had ruptured a brownish stain remained Therewas at no time any resemblance to vesicular eczema,nor did the lesions pass into pustules. The eruptionwas attended with intense itching, and later withmuch prostration and considerable fever.

The disease disappeared after delivery, but recurredwith her second pregnancy.

If we look into the four cases just quoted, it willbe seen that they resemble one another closely intheir clinical features, and that the cause (pregnancy)in all was the same, from which fact both Milton andBulkley concluded that the term herpes gestationiswas expressive and appropriate. This name, as iswell known, has since been employed by other ob-servers reporting like cases, and would not be criti-cised were it not for the fact that the affection is alsoencountered in men, —an observation which my ar-ticles and several of my published cases show; alsothat it may occur associated with other primary le-sions than vesicles, thus rendering the name herpesinappropriate and misleading. The name proposedby Mr. Wilson is even more descriptive than herpesgestationis, and has the advantage of being non-committal as to the etiology of the process. But theterm is not sufficiently comprehensive to include otherknown manifestations of the same extensive patho-logical process which cannot be regarded either asvarieties of herpes (as this term is understood by der-matologists) nor as having either circinate charac-teristics or blebs. Thus, we note that while thetitles proposed by these observers answered the pur-pose provisionally, recent studies have demonstratedthat this form of disease is but one variety of an ex-tended multiform cutaneous process.

Several other cases, some of them possessing pecu-liarities, may be cited.

Beverhout Thompson gives brief notes of a case2 of“ herpes gestationis,” following Miltonand Bulkley,which must be looked upon as the mildest expressionof the disease. The patient was a woman, aged

1 Amer. Jour, of Obstetrics, Feb. 1874.2 Archives of Dermatology, Oct. 1875.

October 17, 1885.] HERPES GESTATIONIS AND DERMATITIS HERPETIFORMIS. 423

twenty, in the eighth month of pregnancy, the erup-tion consisting of grouped vesicles and blebs, whichwere confined to the fingers, toes, backs of hand andwrists, feet and ankles. The attack was an acute one,recovery taking place after delivery, which occurredthree weeks after the beginning of the cutaneousmanifestations.

With the title “clinical remarks on a case ofherpes gestationis,” Liveing 1 reports a case that hadbeen under his observation in Middlesex Hospitaloccuring in a woman thirty-seven years ofage. Theprincipal features may be briefly cited. The thirdday after delivery “a copious eruption of scatteredsolid papules and discrete vesicles appeared ; thelatter quickly developed into blebs of various sizes.. . . . The bullae had a tendency to form groups,but were all discrete, the skin in the neighborhoodbeing more or less covered with scattered solidpapules as large as good-sized shot. The itchingwas intense.” Here there was present a markedpapular element, the disease being characterized bypapules, vesicles, and blebs, and the use of the termherpes, it must be noted, is altogether inappropriateand fails to convey an idea of the clinical picture.

Cottle 2 presents an article on “herpes gestationis,”in which a case is given, which illustrates more par-ticularly the multiform variety of dermatitis herpeti-formis. The patient was a woman, thirty-eight yearsof age, the cutaneous manifestation in the first attack,in the first pregnancy, being urticarial in form—in“bumps,” to quote the author. In the secondattack it was of the same character, but in the thirdit occurred in the form of relapsing blebs and vesi-cles. In the same paper mention is made of anothersimilar case, where the lesions were hard papuleswhich later developed into small blisters.

Gale’s 3 two cases (“herpes gestationis”) may alsobe referred to briefly. The first was that of a woman,aged thirty-nine, who had suffered on six occasions,usually four days previous to her confinement. It isstated that the disease began like “erythema pap-ulosum,” later blebs appearing, and that there wasno pigmentation or grouping of the lesions. Thesecond case occurred in a woman thirty-four yearsof age, the disease having appeared no less thaneight times in a period of eleven years, accompanyingher pregnancies.

Walter G. Smith 4 with the heading “herpes(hydroa) gestationis,” gives the notes of a remark-able case, showing the multiform variety of dermatitisherpetiformis. The patient, aged thirty-five, hadbeen married thirteen years, during which time shehad experienced two miscarriages and seven full-term pregnancies. Five years before while preg-nant with her third child, in about the sixth month,an eruption, similar to that for which she soughtadvice, appeared like “ringworm ” around the um-bilicus, spreading rapidly over the body and limbs.It persisted during gestation and for two months sub-sequently, and was accompanied by intense irritation,

1 Lancet, June 1, 1878, p. 783.2 St. Geo. Hospital Reports, 1879.3 Lancet, 1880. vol. 1, p. 601.4 Dublin Journ. of Med Sci., March, 1881, p. 70.

itching, and burning. She remained perfectly freefrom any cutaneous disease until three months preg-nant with the seventh child, the eruption appearingaround the umbilicus in exactly the same way as inthe first attack, namely, as a cluster of papules orvesicles. Within the first week after parturition theeruption underwent a great aggravation. “Largevesicles and blebs formed, and when punctured clearfluid spurted out with force.” When the child wasthree months old the affection had nearly disap-peared, but subsequently a relapse occurred.

The following is an abstract of Dr. Smith’s descrip-tion of the disease at the date of observation. Nu-merous irregular clusters and groups of papulo-vesi-cles, and pigmentary stains of the vesicles on thearms ; clusters of pimples on the thighs and knees,disseminate lesions down the legs, and blebs on thesoles of the feet. Later, there were still to be founda few papules and imperfect vesicles, which lookedand felt like the first stage of a variolous eruption.”.... After each delivery that was preceded by theeruption the nails fell off the hands and feet. Atpresent all the nails are marked with transverse fur-rows. The eruption came out in successive crops,and each outburst was preceded by a feeling of itch-ing and heat.

The case brings to mind that reported by Bgeren-sprung with the name “herpes circinatus,” and de-picted in his Atlas ofSkin Diseases. Hebra regardedthis case as illustrating his “ impetigo herpetiformis,”an observation to which I have elsewhere directedattention.

French writers, with some exceptions, do not seemto have recognized herpes gestationis. M. Barthe-lemy, however, in his translation of my Treatise onDiseases of the Skin, in a note states that “it is thesame disease as that which Hebra calls impetigoherpetiformis of pregnant women.” Among therecent German authors, Kaposi makes no allusionto herpes gestationis. Behrend only incidentallyrefers to it (quoting Bulkley) in considering the eti-ology of pemphigus. Nor do we find more than thebriefest reference to the subject in a recent volumeon skin diseases by Malcolm Morris. He says “herpesgestationis occurs in pregnant or parturient women,but is rarely seen in England.” No mention what-ever is made of impetigo herpetiformis (Hebra). Inthis country the latest author, Robinson, makes herpesgestationis a variety of herpes, placing it between thevarieties “progenital is” and “zoster,” and statingthat it may be regarded as belonging to the herpeticor pemphigus group of cutaneous diseases, and that hehas observed two cases. A separate chapter is de-voted to impetigo herpetiformis (Hebra).

Other forms of so-called herpes, such as “herpespemphigoide,” “herpes vegetans,” “herpes pyse-micus,” and “ herpes phlyctaenodes ” may here bereferred to. The first of these, described by Dever-gie, will be considered later in connection withpemphigoid eruptions. Herpes vegetans was em-ployed by Auspitz1 to designate a case subsequentlyreported and called by Hebra impetigo herpeti-

1 Archiv flir Derm. u. Syph., 1869, p. 247.

HERPES GESTATIONIS AND DERMATITIS • HERPETIFORMIS. [Medical News424

formis, the case being one of the group of Hebra’scases. Neumann, in his Hand-book ofSkin Diseases,3d edition, briefly alludes to the same disease, butregards the term herpes pyaemicus as more expressiveof the condition.

Gibert1 describes a case representing an unusualform of disease under the name “ herpes phlyctae--11 odes, ” as follows; The patient was a womantwenty-seven years of age, who was in 1814 for thefirst time attacked with a “ phlyctenoid eruption,”the origin of which she attributed to a severe fright,which she experienced on the invasion of France bythe allied troops. Ever since, she has been subjectto an anamolous eruption of small vesicular eleva-tions, appearing sometimes on the trunk, sometimeson the face, sometimes on the limbs, and by a brightredness of the skin, and intense itching and smart-ing. Three years later she had more frequent andviolent returns of the cutaneous disease; the cata-menial periods became painful, and the dischargescanty. Two years afterwards she entered the hos-pital St. Louis. The dorsal aspect of the hands andforearms was red, swollen, hot, inflamed, and ex-tremely painful to the touch, covered with a numberof small vesicles, most of themmiliary, others the sizeof a pin’s head, others even that of a small pea.These elevations, first noticed in the form of smallred points, became more sensitive as they enlarged.At first they were colorless and transparent, after-wards turbid and opaque, resting on an inflamedbase, most of them distinct, some blended and groupedtogether, discharging a considerable quantity of fluidon bursting. Violent itching, burning heat, andsevere smarting accompanied the eruption, produc-ing restlessness, and causing intense suffering to thepatient.”

The case without doubt, it seems to me, was anexample of the vesicular and bullous varieties of der-matitis herpetiformis, and calls to mind, in its sim-ilarity as concerns the etiology, the case of CaptainK., reported by me with the title “A Case of Der-matitis Herpetiformis Caused by Nervous Shock.”

I come now to the consideration of a series of caseswhich have been grouped by the reporters under thehead of “pemphigus,” usually with various adjec-tival qualifications, which are clearly examples not oftrue pemphigus, but of that multiform and proteanprocess under discussion. That these cases werenot regarded as ordinary pemphigus is manifest fromthe statement of the reporters that they possessedpeculiar characters. The titles indicate that thewriters (for the most part well-known dermatologists)were at a loss to classify them, such names as “pem-phigus herpetiforme,” “pemphigus pruriginosus,”“pemphigus compose,” “pemphigus aigu pruri-ginosus” and “pemphigus circinatus,” showing avaried and uncertain nomenclature.

I shall cite some of these cases, before doingwhich, however, a brief description of the bullousvariety of dermatitis herpetiformis may be presented,the account being an abstract from my original com-munication.

1 A practical treatise on the special diseases of theskin. Trans-lation from the French, London, 1845, p. 118.

It is characterized by more or less typical blebs, tenseor flaccid, rounded or flat, usually the former, filled witha clear or cloudy fluid, seated upon a non-inflammatoryor inflamed base, varying in size from a pea to a walnut,and mostly irregular or angular in outline. Theyincline to group in clusters of two or three, the skinbetween them being reddish and more or less puckered.Sometimes in immediate proximity will exist one, twoor three or a part of a circle of small, pin-head sized,flat, whitish pustules. Vesicles, small or large, flat orraised, are also generally found near by or disseminatedover the affected surface. As in the other varieties ofthe disease any region may be attacked, but moreespecially the trunk, upper extremities, and thighs.The lesions are generally soon ruptured, crusting withyellowish, brownish or greenish crusts. They areaccompanied by burning or itching, which may provesevere. They must be distinguished from the lesionsof pemphigus, with which of course they may bereadily confounded, but they are herpetic in character.They differ in that they incline to group, and have amore inflammatory, herpetic aspect, the type of whichappearance is seen in herpes zoster. Moreover, aroundand near the bleb will usually be found vesicles andoften pustules, the latter frequently in close proximity.

Looking into the earlier French literature we findRayer1 speaking of pemphigus “circinatus” as avariety of this disease; and stating, moreover, thathe was the first to notice it. He gives a case, toquote his words, of “acute pemphigus, with simul-taneous eruption of bullae on the right forearm ;

annular erythema; herpes phlyctsenodes.” Thepatient was an unmarriedwoman, twenty-three yearsof age, with regular menstruation. The diseasebegan with itching and the appearance of small redspots which wr ere succeeded by small blebs closelycrowded together, which gradually became large andincreased in number. Here and there they ran to-gether. As a rule, they were without areolae. Someof them were opaque. Crusts were also present.Annular patches of erythema were also observed.

Another case, reported by Rayer, is that of “chronicpemphigus; bullae arranged in bands; complicationwith herpes circinatus.” I shall not give the notesof this case because of their unusual length, but itmay be stated that, in my opinion, the disease wasone of dermatitis herpetiformis;—the peculiar erythe-matous patches, herpetic groups of vesicles,' blebs,the excoriations and the crusting, the itching, theseverity of the attack, and lastly, the duration of thedisease, all pointing to this disease rather than toany other affection.

Still another case is recorded by Rayer, as one of“chronic pemphigus, presenting isolated bullae, andclusters of an eruption similar to that of herpesphlyctsenodes; amenorrhoea; recovery. ’ ’ Thewomanwas forty-two years of age. There were constitutionaldisturbance, severe itching, and a copious diffuseeruption of groups of variously shaped and sizedblebs, which appeared in successive crops.

Chausit 2 describes at length two cases, both occur-ring in women, with the title “pemphigus aigu pruri-ginosus,” which likewise are to be viewed as examplesof dermatitis herpetiformis. One of these cases may

1 Treatise on Diseasesof the Skin, English Translation, London,1835, p. 219,

2 Annales des Mai. de la Peau et de Syph., Mars, 1852.

October 17, 1885.] HERPES GESTATIONIS AND DERMATITIS HERPETIFORMIS. 425

be quoted. A woman, aged 23, of robust constitu-tion and good general health, was delivered of herfirst child six weeks before full term. At the fifthmonth of gestation itching and an eruption of numer-ous minute solid papules upon the body and limbsmanifested themselves, the itching increasing inseverity as pregnancy advanced. On the fifth dayafter delivery she experienced even greater itchingand eneral burning, together with fever and somedelirium. The following day the whole surface wascovered with a confluent efflorescence of large ele-vated red papules, resembling in some respects thoseof erythema papulosum. The skin presented thesame appearance for two days, and on the third therewere noted on the arms a few disseminated trans-parent blebs varying in size from a haricot-bean to ahazel-nut. The blebs increased in number until onthe eleventh day the whole surface, including the face,was invaded, the burning and itching by this datehaving ceased. The papules disappeared, new blebs,starting as such, coming out from day to day untilthe seventeenth day when they disappeared leavingbrownish stains. A month after there was slightitching over the general surface together with a fewgroups of papules, but no more blebs formed.

The papular manifestation preceding and followingthe blebs would in itself be sufficient to differentiatethe disease from true pemphigus, the affection withwhich it might be confounded.

In considering pemphigus, .Devergie, 1 under theheading, “pemphigus compose,” gives a case withthe title, “ herpes pemphigoide, ” as follows : “Thepatient was a woman, fifty years of age, who hadceased menstruating five years before. The diseasebegan with itching, followed by an inflammatorypatch covered with large vesicles, which rapidlypassed into blebs. Soon various regions were in-vaded, until the whole surface was well covered witheruption. Large red patches, more marked on theirperiphery than at the centre, surrounded by one ortwo rings of blebs, crusting in the centre, formedfrom time to time. The itching was especiallymarked on the periphery of the patches. The pa-tient recovered.

As in Chausit’s case quoted, the multiform erythe-matous patches here were marked features in themanifestation; also the subsequent evolution of thelesions, all suggesting a peculiar process. This mightbe compared to an exaggerated erythema multi-forme, showing the several varieties of the disease,especially the bullous, rather than to pemphigus.Indeed, I may here state that dermatitis herpetiformisin some cases manifests itself with many of the clini-cal features of erythema multiforme. Its relation tothis disease is a question in my mind already ripe fordiscussion.

Devergie also alludes very briefly to “pemphigusherpetiforme,” which, he states, he has frequentlyseen invade the whole body, the patient succumbingto the disease as in other forms of pemphigus.

Hardy2 divides pemphigus into acute and chronic ;

1 Mai. de la Peau, Paris, 1857, p. 309.2 Lemons sur les Mai. de la Peau, 2d part, p. 136, 2d ed., Paris,

1863.

under the latter he makes three varieties; first, lepemphigus bulleux successif; second, le pemphigusfoliace; third, le pemphigus prurigineux. The lastvariety, which he illustrates with a case, should itseems to me be regarded as an example of the com-bined vesicular and bullous varieties of dermatitisherpetiformis. The patient was a woman thirty-fiveyears of age, who had already had nine children,and was at the date of observation at the close ofthe last month of her tenth pregnancy. Since hersecond pregnancy she had suffered, coming on someweeks after conception, from an itching eruption,involving the whole general surface, characterizedby blebs the size of a walnut. At the same time theskin became brown, and the seat of a viscid secretion.Tne symptoms were augmented up to the time ofdelivery, after which they subsided insensibly.

Under the title of “pemphigus,” Klein 1 gives thenotes of a case which some writers (Milton and Bulk-ley) on herpes gestationis have regarded as an ex-ample of that disease, but which, if my views beadopted, must be looked upon as another instanceof the combined vesicular and bullous varieties ofdermatitis herpetiformis. The case was that of awoman thirty-two years of age, the disease begin-ning in the seventh month of pregnancy, character-ized at first by millet-seed sized vesicles, which sub-sequently developed into blebs as large as a hen’segg, with contents at first clear but later becomingturbid. At the same time severe pains were present,ana the strength of the patient declined. The dis-ease disappeared shortly after delivery.

I have next to observe that, under that vague term“hydroa” some cases are found in literature which,I think, might more properly be regarded as ex-amples of dermatitis herpetiformis. Thus, Bulkley2

gives the notes of “two cases of hydroa,” whichwere read before the New York DermatologicalSociety, and which it seems should be regarded asexamples of that disease. The first case was a marriedlady, 40 years of age, “ who presented a very anom-alous eruption, which was then composed largely ofbullae.” Three months previously, while in Europe,the disease had been diagnosed eczema by severaldermatologists, and was there treated, but with littlesuccess. The description given by Dr. Bulkley,especially as relates to the bullae; the “moist exudingportions of surface;” the “almost unbearable itch-ing;” the constitutional disturbance; the wide extentof the eruption; and the course of the disease, arepeculiar and unusual. The case, I think, shouldrather be classed as an instance of dermatitis herpeti-formis than as one of so-called hydroa, the existenceof which latter disease, viewed as a distinct process,I am not willing to admit.

In the second case occurring in a married lady aged26, the first outbreak consisted of ery.hematouspatches, whichburned and smarted, and passed awayin a few days. Six weeks later there was an attack of

1 Allg Med. Zeitung, Vienna, August 6, 1867; quoted in Jour.Cutan. Med., 1868,p. 203.2 Archives of Dermatology, April, 1877.

426 PERFORATION OF THE MASTOID CELLS. [Medical News

blebs, preceded by considerable itching ; later therewas irritation of the skin, red erythematous patches,and blebs, occupying both arms and forearms, leftshoulder and back, left leg and face. In both casesthere were marked neurotic elements.

I shall only allude to two other cases. In anarticle bearing the title “Über die coincidenz vonErkrankungen der Haut und der grauen Achse desRiickenmarkes,” Jarisch1 gives the particulars of anunusual case, upon which his observations on thespinal cord were based, with the diagnosis “herpesiris,” to which I must refer. The patient was amarried woman sixty-one years of age. In 1874she is said to have had disseminated blebs uponher face and on the arms, which disappeared spon-taneously. In 1879 s^ie was admitted to the ViennaGeneral Hospital with an abundant, symmetricallydisposed, vesicular, bullous and pustular eruptionconfined almost exclusively to the upper half of thebody, including the upper extremities and head. Theface and scalp were much swollen, reddened, andcovered with crusts or with isolated and grouped blebsseated on a dark bluish-red base. Both arms andforearms showed a large number, for the most partgrouped, of pin-head sized papules and vesicles, withhazel-nut sized blebs or epidermis elevations the sizeof a dollar seated upon inflamed skin. Upon bothsurfaces of the thorax the epidermis in patches thesize of a hand was loose or detached. In addition,over the whole diseased surface, superficial, crowded,millet-seed sized pustules with bright-red areolce ex-isted. Upon the abdomen, dark bluish-red, slightlyscaly papules occurred in groups. The epidermis ofboth soles of the feet was raised in the form of a hem-orrhagic bleb. The mucous membrane of the tonguewas dried, the rest of the mouth swollen, reddened,and in places excoriated. There was considerablefever, and the patient was very weak and debilitated.Some days later the eruption disappeared in greatpart, and was followed by scaling, crusting andbrownish pigmentation. In the course of thenext month the patient suffered new eruptions ofvesicles, bedsores, abscess, and died ; the autopsydisclosed Bright’s disease of the kidney in the thirdstage and lobular pneumonia, with changes in thespinal cord extending from the third cervical to theeighth dorsal vertebra. The disease of the skin, itwill be remembered, extended from the vertex to theregion of the navel. In the report nothing is saidof the subjective symptoms. I have referred to thecase because it has sufficient points in common withdermatitis herpetiformis to warrant its being classedhere rather than eLewhere.

Another peculiar case worthy of record here is thatreported by Dr. P. Meyer, 2 ofSlrassburg, with the title“a fatal pemphigus-like dermatitis with changes in thenervous system,” occurring in a previously healthyand well-nourished man sixty-five years of age. Thedisease began as a diffuse “eczema,” showing thevarieties “papulosum,” “vesiculosum,” and “rub-rum,” unaccompanied, fit first, by constitutional

1 Viertelj. fiir Derm. u. Syph., 2 u. 3 Hefte, 1880, p. 195.2 Archiv fiir path. Anat. u. Phys., Nov. 1883, p. 185.

symptoms. Up to this time it seemed to be a simpleeczema. About the fourth week irregularly scatteredlarge blebs appeared on the buttocks and lower ex-tremities, with sudden loss of appetite, increased fre-quency of pulse, higher temperature, and other signsof constitutional disturbance. The patient began tofail rapidly, the disease now taking on the form of amalignant pemphigus foliaceus, and died; the wholedisease ran a rapid course of seven weeks. Thecase presents certain cutaneous symptoms commonto dermatitis herpetiformis, and is entitled to men-tion in this connection because of the great multi-formity of the lesions that may occur with skin dis-eases of this nature, that is, those depending upondisturbance of or changes in the nervous system.

REPORT OF TWO CASES OFPERFORATION OF THE MASTOID CELLS FOR

SUPPURATION OF THE MIDDLE EAR.By J. D. STRAWBRIDGE, M.D.,

OF DANVILLE, PA.

In December last, while visiting with Dr. GeorgeStrawbridge, the Philadelphia Dispensary for Diseasesof the Eye and Ear, at the corner of Thirteenth andChestnut Streets, a child was presented with a largeabscess of the mastoid. The abscess was opened,and in the conversation which followed, I was askedby Dr. Strawbridge, “How do you open the mastoidcells?” I answered, “I have done it with a gimletThe expression of incredulity which passed over thecountenances of several gentlemen present, is ther.iativti 7 and must be my excuse, for reporting the fol-lowing cases, the first almost entirely from memory.The facts are as indelibly fixed in my mind as ifit had occurred but yesterday. The date has beenfixed from the recollection of several persons thenresidents in the vicinity, who saw the patient duringhis illness, and knew of the operation.

Case I.—G. R., Englishman, puddler, while atwork in a rolling mill, was taken with pain in hisright ear. Was attended by an irregular practitionerfor over six weeks. While visiting in an adjoininghouse, I was called in haste to see this man, who wasthought to be dying. I found him propped up inbed, in a stupor, with low muttering delirium fromwhich he could not be roused, the whole left side ofhishead was one enormous abscess, the scalp was raisedup from more than half the cranium, the swellingextended nearly across the forehead, around andbeneath the eye, closing it. Over nearly the wholeside of the face, and down the neck, both in frontand behind the sterno-mastoid muscle, the auriclewas doubled up, nearly covered by the swelling,and the meatus could not be seen. In fact, looking-on the distorted mass from that side alone, it couldscarcely be recognized as a human head. Withoutthe least expectation of saving life, I determined toevacuate the abscess and await results. I made afree incision behind the ear down to the bone, asecond over the anterior inferior angle of the parietalbone, and a third in the face in front of the ear :

from these three openihgs more than half a pint ofhorribly offensive pus discharged during my presence.