OX SOME AFFECTIONS OF THE SKIN OCCURRING IN PKEGNANT AND PUERPERAL WOMEN. By Professor Hebra.*
Everyone is acquainted with the brown spots which are met with on the face and nipples and along the linea alba of the abdomen in pregnant women, and disappear after delivery. Their names of chloasma gravidarum, uterinum, etc., which are found in the works of the oldest writers, are a proof how early they were noticed and referred to their true origin. It is true that some gynaecologists have considered the chloasma
identical with pityriasis versicolor ; but this error is too striking, and the distinction between the two affections is too easily and too generally acknowledged, to render it neecssary to dwell upon their differential symptoms. My object is to draw attention to some other affections of the general surface, which are for the mo3t part met with during the early months of pregnancy, and either disappear during the later months prior to delivery, or only terminate during the puerperal period. First among these may be mentioned inflammation of the hair-follicles and of the sebaceous glands, which are found in the form of acne (varus folliculitis) on the forehead, the nose, or the chin, sometimes corresponding to acne rosacea, and at others to acne vulgaris disseminata. I have seen women whose faces had been without a blemish, have them covered during pregnancy with comedones that later become converted into knots of acne and pustules, and which, in spite of all remedies that can be resorted to, keep recurring until after *
Wiener
Medizinische Wocheiuchrift, 1S72, Mo. 13.
delivery. In others there is a vivid and persistent redness of the nose, which becomes covered by painful pustules. Some women, also, who had hitherto enjoyed excellent health, become the subjects of eczema a few days after conception has taken place. A very intelligent woman, who had borne seven children, informed me that she had suffered from eczema of her hands in each pregnancy, and that on her third concept?,;*n she was made aware that a fertile coition had taken place b v the itching of her fingers and the production of vesicles. The itching alone, without any efflorescence, and therefore coming under the general denomination of pruritus eutaneus, is a frequent attendant on pregnancy. The wife of a colleague, vt&J has been five times pregnant, has suffered so severely from violent itching during the first five months on each occasion, that her rest at night has been disturbed, her mind kept in constant irritation, and her nutrition impaired, while her skin has presented a scratched appearance, usually only seen in those suffering from epizoa. Erythema of different forms, and urticaria, are also met with in pregnancy. The former shows itself mostly in the form of pale red spots or streaks, as in inflammation of the lymphatics, and is accompanied by severe pains in every movement. Urticaria gives rise to intense itching, restlessness, and sleeplessness, becoming at last quite u.isupportable. In some cases the affection first appears in the course of quite a normal puerperal condition, and in one woman it went on to complete pemphigus. On the second day after delivery a great number of wheals appeared along the back, exactly as in urticaria ; and while some of them disappeared, the greater portion were developed into bulla) filled with clear fluid. However, they did not last long, and dried up without any reproduction As this woman had no recurrence in a later pregnancy her case may be regarded as a doubtful example of the connexion of skin disease with this condition. The same, however, cannot be said of the following case:?Several years since a young woman come to Vienna from Russia, having suffered from pemphigus during three successive pregnancies. On the first occasion it appeared during the fifth month and disappeared after delivery, and on the second it continued a month after delivery. On the third it did not thus disappear, but passed into a state of chronic pemphigus, and this it was that brought her to Vienna. Under the use of the baths of the Voslau and other means she completely recovered. Fearing a renewal of her sufferings she remained away from home until, her husband following her, conception again ensued. Even during the first month some bulla) appeared on the lower extremities, and afterwards, as in the former pregnancies, extended to the arms. Loss of appetite and of sleep reduced her to much the same condition she was in when she first came to Vienna, and she returned home. On two subseAfter delivery she soon lost her pemphigus. quent occasions she became pregnant, the pemphigus reappearing on both, and lasting for sometime after delivery. It is of great interest to observe that the physiological changes in the uterus which accompany the condition of pregnancy give rise to similar diseased conditions of the general surface as are met with in several pathological conditions of the internal female organs. Thus, chloasma occurs in changes of texture or position of the uterus, chronic urticaria in fibroid and other growths, and acne rosacea may be consquent on uteriue leucorrhooa or excoriation and ulceration of the uterine orifice. Eczema and seborrhoea. with fall of hair of the head, are observed injthose who are chlorotic, with irregular, usually profuse, menstruation, as also in the puerperal state, or after women have ceased suckling their children, and thereforo at theend of lactation; while as long as they were nursing they enjoyed excellent health. Pruritus eutaneus is a frequent occurrence in old women who are already the subjects of uterine cancer, or in whom, at a later period, this disease appears. We see, therefore, that there are manifold processes of disease which, by their localisation in the sexual apparatus, call forth diseased conditions of the general surface which do not appear when the same processes affect other organs. It should prove an object of interest for gynaecologists to investigate the nature of this connexion between the skin and internal genital organs. In conclusion, I will describe an eruption of the general surface of which I have only met with five examples occurring in pregnant and puerperal women, and of which, as far as I know, no account has ever been published. The eruption is characterised by pustules which are filled with pus at their first appearance, and by these affecting a peculiar mode of grouping and peripheric extensiou. In almost every case they have first appeared at the inner surface of the thigh, partly in groups the size of a kreuzer, and partly as separate pustules the size of a
July 1,
MEDICAL NEWS.
1873.]
head. Successive crops, immediately follow, extending towards the periphery in a circular or iris form, so that, in the course of a few days a gradual invasion takes place of the thighs, abdomen, legs, arms, hands, and feet, and afterwards of the neck, of centre each and the While at face, hairy scalp. group the pustules become covered with flat dark-brown' scabs, at the circumference new ones, filled with yellow pus, are being constantlv produced In this disposition they resemble herpes iris or circinntJtus ; but, as from the very first it is a pustular disease, it must be regarded as a form of impetigo, and may, from its circular mode of grouping, be termed impetigo herpetiformis. The affection throughout its whole course is attended by In three of ?.nse fever, a dry tongue, and great prostration. these cases this reproduction of the pustules continued with more or less rapidity until the patient died; while in the other two, after several weeks' duration the pustules dried up, the thick scabs finally falling off and leaving the skin beneath Some of the pustules, instead healthy but strongly pigmented. of drying, especially at the bends of the joints, were converted into a greyish, stinking mass, which, lying on a red and moistened basis, assumed an eczematous appearance. No alterations occurred, and the discharges gradually dried into scabs, beneath
pin's
reproduced. finally survived. Each outbreak of pustules was preceded by shivering, which was followed by febrile action that lasted some days. Of the five women, three had been delivered from two to five weeks before admission, and two came in during the last month of pregnancy. which the
Only
cpedermis
one
was
out of the five cases
were the same both before and after delivery. The autopsies of the four women who died revealed no certain cause of death ; and neither the mode of life, employment, or constitution of these patients threw any light upon the origin of this affection. In none of them was there any symptom of syphilis. In the absence of all other etiological data, and seeing that these cases all occurred in pregnant women, it may be stated, in connexion with the cases already referred to in this paper, as most probable that these instances of herpetiform impetigo were dependent upon a diseased change in the genital apparatus.?Medical Times and Gazette.
The appearances of the skin
195
Everyone is acquainted with the brown spots which are met with on the face and nipples and along the linea alba of the abdomen in pregnant women, and disappear after delivery. Their names of chloasma gravidarum, uterinum, etc., which are found in the works of the oldest writers, are a proof how early they were noticed and referred to their true origin. It is true that some gynaecologists have considered the chloasma
identical with pityriasis versicolor ; but this error is too striking, and the distinction between the two affections is too easily and too generally acknowledged, to render it neecssary to dwell upon their differential symptoms. My object is to draw attention to some other affections of the general surface, which are for the mo3t part met with during the early months of pregnancy, and either disappear during the later months prior to delivery, or only terminate during the puerperal period. First among these may be mentioned inflammation of the hair-follicles and of the sebaceous glands, which are found in the form of acne (varus folliculitis) on the forehead, the nose, or the chin, sometimes corresponding to acne rosacea, and at others to acne vulgaris disseminata. I have seen women whose faces had been without a blemish, have them covered during pregnancy with comedones that later become converted into knots of acne and pustules, and which, in spite of all remedies that can be resorted to, keep recurring until after *
Wiener
Medizinische Wocheiuchrift, 1S72, Mo. 13.
delivery. In others there is a vivid and persistent redness of the nose, which becomes covered by painful pustules. Some women, also, who had hitherto enjoyed excellent health, become the subjects of eczema a few days after conception has taken place. A very intelligent woman, who had borne seven children, informed me that she had suffered from eczema of her hands in each pregnancy, and that on her third concept?,;*n she was made aware that a fertile coition had taken place b v the itching of her fingers and the production of vesicles. The itching alone, without any efflorescence, and therefore coming under the general denomination of pruritus eutaneus, is a frequent attendant on pregnancy. The wife of a colleague, vt&J has been five times pregnant, has suffered so severely from violent itching during the first five months on each occasion, that her rest at night has been disturbed, her mind kept in constant irritation, and her nutrition impaired, while her skin has presented a scratched appearance, usually only seen in those suffering from epizoa. Erythema of different forms, and urticaria, are also met with in pregnancy. The former shows itself mostly in the form of pale red spots or streaks, as in inflammation of the lymphatics, and is accompanied by severe pains in every movement. Urticaria gives rise to intense itching, restlessness, and sleeplessness, becoming at last quite u.isupportable. In some cases the affection first appears in the course of quite a normal puerperal condition, and in one woman it went on to complete pemphigus. On the second day after delivery a great number of wheals appeared along the back, exactly as in urticaria ; and while some of them disappeared, the greater portion were developed into bulla) filled with clear fluid. However, they did not last long, and dried up without any reproduction As this woman had no recurrence in a later pregnancy her case may be regarded as a doubtful example of the connexion of skin disease with this condition. The same, however, cannot be said of the following case:?Several years since a young woman come to Vienna from Russia, having suffered from pemphigus during three successive pregnancies. On the first occasion it appeared during the fifth month and disappeared after delivery, and on the second it continued a month after delivery. On the third it did not thus disappear, but passed into a state of chronic pemphigus, and this it was that brought her to Vienna. Under the use of the baths of the Voslau and other means she completely recovered. Fearing a renewal of her sufferings she remained away from home until, her husband following her, conception again ensued. Even during the first month some bulla) appeared on the lower extremities, and afterwards, as in the former pregnancies, extended to the arms. Loss of appetite and of sleep reduced her to much the same condition she was in when she first came to Vienna, and she returned home. On two subseAfter delivery she soon lost her pemphigus. quent occasions she became pregnant, the pemphigus reappearing on both, and lasting for sometime after delivery. It is of great interest to observe that the physiological changes in the uterus which accompany the condition of pregnancy give rise to similar diseased conditions of the general surface as are met with in several pathological conditions of the internal female organs. Thus, chloasma occurs in changes of texture or position of the uterus, chronic urticaria in fibroid and other growths, and acne rosacea may be consquent on uteriue leucorrhooa or excoriation and ulceration of the uterine orifice. Eczema and seborrhoea. with fall of hair of the head, are observed injthose who are chlorotic, with irregular, usually profuse, menstruation, as also in the puerperal state, or after women have ceased suckling their children, and thereforo at theend of lactation; while as long as they were nursing they enjoyed excellent health. Pruritus eutaneus is a frequent occurrence in old women who are already the subjects of uterine cancer, or in whom, at a later period, this disease appears. We see, therefore, that there are manifold processes of disease which, by their localisation in the sexual apparatus, call forth diseased conditions of the general surface which do not appear when the same processes affect other organs. It should prove an object of interest for gynaecologists to investigate the nature of this connexion between the skin and internal genital organs. In conclusion, I will describe an eruption of the general surface of which I have only met with five examples occurring in pregnant and puerperal women, and of which, as far as I know, no account has ever been published. The eruption is characterised by pustules which are filled with pus at their first appearance, and by these affecting a peculiar mode of grouping and peripheric extensiou. In almost every case they have first appeared at the inner surface of the thigh, partly in groups the size of a kreuzer, and partly as separate pustules the size of a
July 1,
MEDICAL NEWS.
1873.]
head. Successive crops, immediately follow, extending towards the periphery in a circular or iris form, so that, in the course of a few days a gradual invasion takes place of the thighs, abdomen, legs, arms, hands, and feet, and afterwards of the neck, of centre each and the While at face, hairy scalp. group the pustules become covered with flat dark-brown' scabs, at the circumference new ones, filled with yellow pus, are being constantlv produced In this disposition they resemble herpes iris or circinntJtus ; but, as from the very first it is a pustular disease, it must be regarded as a form of impetigo, and may, from its circular mode of grouping, be termed impetigo herpetiformis. The affection throughout its whole course is attended by In three of ?.nse fever, a dry tongue, and great prostration. these cases this reproduction of the pustules continued with more or less rapidity until the patient died; while in the other two, after several weeks' duration the pustules dried up, the thick scabs finally falling off and leaving the skin beneath Some of the pustules, instead healthy but strongly pigmented. of drying, especially at the bends of the joints, were converted into a greyish, stinking mass, which, lying on a red and moistened basis, assumed an eczematous appearance. No alterations occurred, and the discharges gradually dried into scabs, beneath
pin's
reproduced. finally survived. Each outbreak of pustules was preceded by shivering, which was followed by febrile action that lasted some days. Of the five women, three had been delivered from two to five weeks before admission, and two came in during the last month of pregnancy. which the
Only
cpedermis
one
was
out of the five cases
were the same both before and after delivery. The autopsies of the four women who died revealed no certain cause of death ; and neither the mode of life, employment, or constitution of these patients threw any light upon the origin of this affection. In none of them was there any symptom of syphilis. In the absence of all other etiological data, and seeing that these cases all occurred in pregnant women, it may be stated, in connexion with the cases already referred to in this paper, as most probable that these instances of herpetiform impetigo were dependent upon a diseased change in the genital apparatus.?Medical Times and Gazette.
The appearances of the skin
195
