Tho American Journal of the Medical Science* for June, 1890. 
Ex trad ed fro 
CASE OF TYPICAL DERMATITIS HERPETIFORMIS. 
Louis A. Duhrino, M.D., 
fßoncaeoH or «kin kinkahkk in thi i-niv tmurr or i-BNNi>rivANiA 
During the past month it typical example of thin affection has been 
under almost daily observation, and the symptoms have been so pro- 
nounced and so characteristic of the usual form of the disease that I 
desire to add the ettse to the list of those already published. I describe 
the case, moreover, because there seemed to Ik- some doubt as to the 
diagnosis in the minds of the several well-known practitioners who had 
charge of the gentleman before he dime under my observation. 
Mr. S., of Cincinnati, consulted me about the middle of January of 
the present year, with a letter describing his previous condition and 
treatment from Dr. RansohofT, under whose cart* he had been for some 
time. The doctor’s letter states that the patient (a man about fifty years 
of age and of dark complexion), who had before always enjoyed good 
health, manifested “ squamous eczema ” of both hands about a year ago. 
Four months later the present illness began with the development of 
blisters of the size of a pea or bean on the hands, wrists, feet, and ankles. 
In duly last, a fully developed “ pemphigus simplex ” existed, the blebs 
being as large as a silver dollar, tense, and containing at clear fluid. 
These appeared in successive crops all over the body. During the four 
months of the acute attack hardly a square inch of the surface was left 
uninvaded. When the blebs disappeared excoriations of similar dimen- 
sions remained, but which were soon covered again with epidermis. 
Loss in weight, most distressing itching (“pemphigus pruriginosus”), 
and from time to time septic manifestations; low, muttering delirium, 
slight elevation of temperature, rapid and irregular heart action, heavily 
coated, dry tongue, diarrhoea, and profuse night-sweats, were all present. 
Under sustaining treatment and local remedies, such as the continuous 
bath for two weeks, swathing in oil,oxide of zinc and bismuth bandages, 
the patient finally began to improve, and was able to leave borne for a 
change of climate. When hist seen the itching still persisted, and the 
skin, especially of the extremities, presented a livid hue and was sodden. 
It, moreover, was elevated in the form of large, indurated papules where 
formerly vesicles (which did not rupture) had existed. Dr. RansohofT 
concludes his letter by stating that at first the diagnosis of dermatitis 
herpetiformis was made, but that later, when at its height, the disease 
seemed to possess the features of |»emphigus pruriginosus; while still 
later, us improvement set in, it again approached dermatitis herpetiformis. 
When I first saw tin* case the skin was much inflamed, excessively 
pigmented, of a dirty-looking, mottled, yellowish, brownish color, thick- 
ened. and the seat of an extensive eruption, consisting of gmnU and larger- 2 
DUHRING, DERMATITIS HERPETIFORMIS. 
more or less confluent, inflammatory patches, together with distinct indi- 
vidual lesions, occupying almost the entire general surface. The trunk 
and the upper and lower extremities were completely covered with a 
multiform eruption of a mixed chronic, subacute, and acute character, 
arising from a chronically inflamed, infiltrated, and toughened skin. 
The greatest possible variety of inflammation existed in the form of a 
continuous mass or sheet of eruption, there being no healthy skin on the 
affected regions. 
The lesions were macules, maculo-papules, papules, irregularly shaped 
and defined, flat or spread out (as in erythema multifbrme), and of vari- 
able dimensions; vesico-papules and vesicles varying in size from si 
small pinhead to a j>ea, some being flat, glistening, and blister-like, 
others raised and surrounded with a somewhat drawn-together or puck- 
ered, highly inflamed base, as in herpes zoster. Many of the vesicles 
were minute and scarcely visible, except in oblique light. Here and 
there blebs existed, some small, others large; also small pustules, which 
evidently had begun as pustules, some of them being flat and punctate, 
pinhead ami millet-seed sized. 
On the shoulders and upper part of the back the existence of small, 
mostly miliary lesions (papules, papulo-vesicles, vesicles, and pustules), 
commingled and in all stages of evolution, and grouped into patches, 
some of them marginate, together with the marked pigmentation, sug- 
gested a likeness to a subacute, copious, miliary, herpet iform syphiloderm. 
Excoriations and abrasions, due to scratching, blood-crusts, and slight 
yellowish and brownish crusts about the summits of vesicles and pustules, 
together with torn adherent epidermis, were also present, the whole pic- 
ture being one of great multiformity, such as is noted in no other disease. 
As is well known, marked multiformity is often observed in scabies of 
several months’ duration, but the affection here was even more polymor- 
phous than occurs in that disease. 
The lesions were aggregated, grouped, and disseminated, but the erup- 
tion as a whole was herpetiforra, the distribution, general arrangement 
of the individual lesions and of the patches, the progress and the manner 
of extension, all suggesting certain symptoms common to either erythema 
multiforme, herpes iris, or herpes simplex. Here and there the close 
grouping or bunching of three or four usually minute or small vesicles 
or vesico-pustules upon an inflamed base resembled an abortive patch of 
herpes zoster. The disease, however, bore more likeness to erythema 
multiforme of an advanced stage and of a severe type than to any other 
affection. Furthermore, itching and burning were present to an exces- 
sive degree, tormenting him by day and by night, lie was, moreover, 
nervous, irritable, and anxious. 
I will now enumerate the local remedies that were employed, and 
comment briefly on their action, which, it may be here remarked, was 
far from satisfactory. 
The patient stated that a number of remedies bad been previously 
used without affording much relief, among t hem the various soothing 
and more stimulating washes and ointments useful iu eczema. Those 
prescribed by me consisted of sulphur in the form of ointment, both weak 
and strong, and also in the form of a dusting powder, “ liquor carbon is 
detergens, ichthyol, as a wash and as an ointment, weak and strong; DUH RING, DERMATITIS HERPETIFORMIS. 
3 
mild salicylic acid ointment, fluid extract of grindelia robustaas a lotion, 
weak and strong, and carbolic acid as a lotion, all having been made 
use of from time to time. The most useful were sulphur ointment, two 
to three drachms to the ounce, and “ liquor carbon is detergcns,” from 
one-half to two drachms to the ounce. These remedies, as well as others, 
were employed on various parts of the body, and with each experiment 
it was the rule to make the application of one remedy to one lateral half 
and another to the other half of the body with the view of determining 
the relative merits of each. The fluid extract of grindelia robusta on 
several occasions was found to Ik* of some value, but the sulphur oint- 
ment was the most useful. This was used with considerable friction in 
order to break down the vesicles, us in the cast* of scabies, and on several 
occasions improved the skin and relieved the itching. Internally, anti- 
pyrin, antifenrin, phcnacetin, chloral, and belladonna were all prescribed 
to meet symptoms, but with only moderate success. 
During the four or five weeks which followed, the disease on two occa- 
sions improved considerably, but again became worse, the process mani- 
festing itself in the form of exacerbations, each lasting about a week. 
Now and then large blebs formed here and there, especially on the 
thighs. On the trunk the lesions were at one time more erythematous, 
at another time more vesicular. The herpetiform element, more or less 
well-defined, remained constant, and constituted a feature of the disease. 
In conclusion, the case may be summed up as showing the disease in 
its typical form, characterized by a multiform eruption of slightly raised, 
erythematous, herpetic patches, more or less confluent, together with 
papulo-vesicles ami vesicles and hlel>s of variable size, shape, and outline, 
likewise as a rule heretic. The thickening of the integument and the 
marked pigmentation from (he oft-repeated attacks of eruption and 
scratching, and the itching and burning were also conspicuous symptoms. 
The general health was at turn's considerably disturbed, as shown by the 
nervous, anxious, irritable state, the h»ss of ap)>etite and of sleep, and the 
excessive sweating and great thirst. The urine was cloudy and dark, 
and variable in quantity, as is the case in other forms of general nerve 
depression. 
In the matter of diagnosis, the disease, during the period it was 
under my observation, could hardly 1h? mistaken for any other affection, 
surely not (H'mphigus, because blebs were the exception ; nor would 
eczema suggest itself, because of the prevailing herpetiform characters of 
the individual lesions and of the patches. Everywhere and on all occa- 
sions the eruption showed itself to be under the control of the peripheral 
nerves, jis in the other more marked and better known forms of herpetic 
diseases.