CASE OF 
Dcrniaiitis Vesiculosa Nciirnirauinatia 
of Forearm. 
Read before the College of Physicians, Philadelphia, 
December 2, 1801. 
BY 
LOUIS A. DUIIRING. M.D., 
i'roftiuMir of ftkln-DiseawMi, University of Pennsylvania. 
Reprinted from the International Medical Magazine for March, 1892. CASK OF DERMATITIS VESICULOSA NEURO- 
TRAUMATICA OF FOREARM. 
A. A. is a single woman, aged twenty-nine years, of small stature, frail, and 
spare. There exists a history of varied nervous symptoms extending over the past 
three years, including frequent and protracted gagging and vomiting attacks; com- 
plete cessation of the menstrual flow two years ago, which condition still exists; 
heart palpitation; crying spells; and globus hystericus. She was burned with a 
flat-iron eighteen months ago on the flexor surface of the left forearm just above the 
wrist, the area being about the size of a silver dollar. The burn was superficial and 
only slightly blistered, and at first presented no peculiarities. It did not, however, 
heal readily or entirely, and from some unknown and internal cause began to break 
out anew, and within a month from the accident showed a superficial gangrenous 
patch, confined to the region of the burn, which remained about six weeks. The 
patch now began to bo more inflamed and painful, with at first darting then aching 
pains, which continued in about the same severity for two months. The whole fore- 
arm at the date of the gangrenous patch was reddened, swollen, and tender, and 
was accompanied with throbbing pain, which could be distinguished from the darting 
pain. 
The present form of eruption first appeared about the time the burn seemed to 
bo nearly healed, or a month or six weeks after the accident, in the form of a single 
papulo-vesicle, or a “pimple,” and this not at the site of the burn, but on the exten- 
sor surface of the forearm. In a week or two this lesion ulcerated and crusted, and 
other similar papulo-vesiclcs, vesicles and blebs appeared beside or near this one 
until the present area of disease was ultimately attained. Some healed while new 
ones formed, most of them leaving scars as they passed away. Various forms of 
local treatment were employed, none of which seemed to possess power to arrest the 
process, nor indeed to favorably influence the eruption. Arsenic was on several 
occasions prescribed, but had to bo discontinued on account of intolerance of the 
drug. Reference has been made to the swollen and painful condition of the whole 
arm at times; this has occurred frequently,—every few weeks or even oflener,—and 
is invariably aggravated by exertion or any exercise of the limb. After these attacks 
of general pain and swelling, the whole limb is sore to contact, and is painful within. 
The pain, both darting and aching, is most severe in damp or cold weather. 
When I saw the case first, in January, 1891, the lower half of the forearm was 
involved and encircled by the disease, and especially the extensor surface, the bum, 
it will bo remembered, having been seated on the flexor surface. The disease 
consisted of a small, hand-sized, irregularly-shaped, ill-defined, chronically-inflamed, 
vesicular and bullous, herpetic-looking, more or less crusted, scarred patch, with 
scars considerably beyond the inflamed skin. Apart from the old scars, it possessed 
at first sight the general appearance of an injury due rather to the local action of an 
acid or to some chemical substance than to disease from within. There was, more- 
over, some oozing and discharge from broken or ruptured vesicles, blebs, and excori- 2 
LOUIS A. DUHRING, M.D., ON 
ated surfaces. The inflammatory process of the skin was superficial, for there was 
but little thickening, and the scars were not deep. The vesicular and bullous lesions 
were irregular in outline, more or less angular; distended, but with no disposition to 
rupture; some flat, others raised, and usually were unaccompanied by areohe. They 
possessed an herpetic aspect, and from this characteristic formation were manifestly 
due to direct nerve influence. The crusts were depressed, saucer-shaped, and ad- 
herent to the skin in the centre, with everted edges. They were variegated in color, 
with bluish and blackish tints. The sears were plainly the result of the vesicular 
and bullous lesions. The patch was irritable, sore to the touch, and painful, and the 
whole extremity up to the shoulder was likewise the seat of darting nerve-pain. 
The process has continued in much the same manner up to the present date, 
although the pain in the patch and the nerve-pain in the limb are not so severe as 
last winter, nor is the inflammation of the skin so violent now as formerly. With 
the view of stimulating the nerve-trunks and fibres into healthy action, I advised 
the use of a weak galvanic current. This has been applied for a month, but no 
positive results have been obtained. Before abandoning the remedy, however, it is 
proposed not only to stimulate more freely, but also.to act upon the nerve-trunks at 
remote points above the seat of the disorder. 
Concerning the pathology of the disease, it may be stated that I believe 
the process to lie a mild form of neuritis of a peculiar kind, having its 
origin in the burn, from which it extended, involving collateral as well as 
the nerve-trunks. It appears to l>e a local disease,—that is, to be confined 
to the limb. The hysteria must, of course, be taken into consideration. 
It is questionable, however, whether the symptoms can be construed as 
indicative of a central or reflex nature. The latter explanation has been 
suggested by Kaposi, Doutrelepont, and others for a series of similar 
though not identical cases, occurring for tin; most part in hysterical women, 
to which further reference will l)e made. The jxxssible factitious nature of 
the disease need not be entertained. The question as to the infectious 
nature of the disease may be alluded to, but there do not seem to be any 
symptoms pointing that way. The wise is a rare one, although lam aware 
that more or less similar forms of disease have been recorded. With the 
title “Traumatic Neurosal Pemphigus,” Dr. J. 11. Gallon, of England, 
has recently rej»orted a case similar to the one just considered {British 
Medical Journal, June 13, 1891). 
The patient was a well-nourished, intelligent girl, aged seventeen, who bad 
suffered from fits of an epileptic nature from childhood. In December, 1887, while 
cutting wood, she chopped off the distal phalanges of the index and ring fingers and 
cut through the middle phalanx of the middle finger. The wounds did not heal 
readily, but remained open for three months. Shortly afterwards patches of redness, 
followed by blebs, appeared on the left wrist, band, and arm. The eruption was 
peculiar from the rapid way in which it spread; sometimes in a quarter of an hour 
the whole hand and arm would he covered with largo blebs, which would hurst, and 
give out a thin, sticky, watery discharge, which on drying would leave the surface of 
the skin of a purple or bluish tint. The circulation also seemed feeble. 
In February, 1889, she had a crop of these on the left leg. Up to that time 
she was rarely without a series of blebs or threatening of them for quite twelve 
months. Various remedies, including arsenic and iron, were tried without effect. DERMATITIS VESICULOSA NKUROTRAUMATICA OF FOREARM. 
3 
At this time the puckered scars of the ring ami middle fingers were very tender, and 
the stumps were amputated. 
In March, 1889, she had a much slighter return of vesicles, and since, for the 
next two years, only occasionally a few vesicles. At one period a small fragment of 
bone worked out of the dorsal surface of the wrist. The vesicles occurred in irregu- 
lar patches upon both surfaces of the forearm in the area of the median and ulnar 
nerves. 
J)r. Gallon considers that the irritation was reflex because of the dis- 
seminated distribution of its effects and the occurrence of the disease on 
the leg of the same side, as well as its cessation after removal of a source 
of irritation upon the median nerve alone. 
Erasmus Wilson 1 refers briefly to the case of a medical man who punc- 
tual his right hand. Three or four weeks afterwards an eruption of blebs 
made its appearance on the left thigh, and was repeated from time to time 
for eighteen months. Their outbreak was preceded by feverish symptoms; 
there was a scalded sensation in the skin, and the next morning a fully- 
developed bulla would l>e discovered. 
A similar form of disease has recently been narrated by Ehrmann,* that 
of a pemphigoid eruption, having its seat upon the district of the trigem- 
inus, due to a curious tooth, which later appeared on the other side of the 
face. The eruption recurred from time to time, and remained unilateral 
until the removal of the tooth, when it manifested itself on the other side. 
Professor Kaposi,3 of Vienna, with the title “ Pemphigus Neurotioo- 
traumaticus (Hystericus),” reports the case of a female nurse, aged twenty- 
two years, who had wounded the nail-fold with a rusty nail, the wound 
having Ik*cu dressed with iodoform. In a few days blebs apj>eared on the 
dorsal surface of the middle finger, and a few days later on the dorsum of 
the hand and wrist. Four weeks after the accident, when she first came 
under observation, there existed a reddened, painful patch, about the size of 
the palm of the hand, covered with large blebs. I mined lately afterwards 
blebs began to appear in other localities, being always preceded by pain in the 
affected part, followed in two or three hours by bright redness over a variably- 
sized area, upon which urticarial lesions formed, succeeded in a few hours 
by blebs, from the size of a |>ea to an egg. With each attack the cutaneous 
involvement became more general. Kaposi regards the disease as a neuritis 
following a wound, notwithstanding that the further course of the affection 
was not on the track of the wounded nerve. From the peripheral excitation 
the process, he thinks, passed over to the central nervous system, more 
esjiecially to the vaso-motor system. 
Dr. 1). W. Montgomery,4 of San Francisco, relates the history of a medi- 
cal student, of a neurotic temperament, who received a blow on the index 
1 Di*ca.He.H of the Skin, p. 807, London, 1867. 
JArchiv fur Derm. u. Syph., 1890, p. 964. 
* Wiener Klin. Wochenschr., No. 22, 1890. • 
* Occidental Medical Times, October, 1891. 4 
I/OUIB A. DUIIRINO, M.D., ON 
finger of the left hand, causing n wound which was slow to heal, almost 
necessitating amputation. Three years afterwards, and during the following 
three years, a pemphigoid eruption invaded the skin and mucous membranes 
of different regions, which l>oth Dr. Montgomery and Dr. Regensburger, 
who also had the patient under observation, regarded as due to the previous 
traumatism, notwithstanding the long period elapsing between the wound 
and the cutaneous manifestation. 
Similar to this is the case narrated by Kopp,1 of Munich, in which, five 
years before the cutaneous manifestation, the patient was burned on the 
left hand. The wound inclined to ulcerate, but finally healed with keloidal 
scars. 
Rentier,* of Paris, gives the history of a young girl who was affected 
by panaritium, which was followed by numerous gangrenous patches on the 
skin of the same hand and forearm, which subsequently spread over the 
upper portion of the thorax. This observer is inclined to regard the dis- 
ease as due to a general neurosis. ' 
Professor Doutrelepont,8 of Bonn, under the title “ Acute Multiple 
Gangrene,” reports the case of a female nurse, twenty-one years of age, who 
stuck herself with a needle under the left thumb-nail. The disease at first 
was confines! to the left upper extremity, but it soon became bilateral, and 
during the succeeding five years, until the date of her death, every region 
of the skin, and also the mucous membrane of the upper air-passages, the 
conjunctiva;, and the vagina, l»ecame invaded. Bronchitis, catarrhal pneu- 
monia, and tuberculosis, with a fatal issue, followed. In the beginning all 
the lesions were gangrenous, but subsequently vesicles and blebs occurred 
on the gangrenous patches. Doutrelepont4 (after an interval of four years) 
has recently given the sequel of this case, and, in the light of Kaposi’s 
series of cases (to be referred to presently), is inclined to look upon it as 
a universal her(>es zoster gangramosus. Kopp now also takes the same 
view of his case, to which I have briefly referred. 
As allusl to this group of cases, I may refer to those examples of so-called 
gangrenous herpes zoster reported by Kaposi to which allusion has been 
made, and also to those cases designated by authors as “ spontaneous gan- 
grene” and “ hysterical spontaneous gangrene.” Kaposi 8 has recently reported 
four of these peculiar cases, to which he gave the name “ zoster gangrsenosus 
recidivus atypicus hystericus.” These titles sufficiently designate the charac- 
teristics of the eruption, but the manner in which they are produced, whether 
reflexly from the brain or through the vaso-motor system, is not clear. 
Kaposi is of the opinion that they arise from an hysterical basis and are 
vaso-motor or tropho-neurotic, and may be explained by the irritation going 
1 Miinchener Med. Wochenschr., 1886, No. 88. 
* La Semaine M6dicale, 1888, pp. 416 ami 428. 
* Archiv fiir Derm, und Syph., 1886, p. 171); and ibid., 1890, p. 885. 
4 Archiv fUr Derm, und Syph., 1890, p. 885. 
6 Archiv fiir Derm, und Syph., 1889, p. 661. DERMATITIS VESICULOSA NEUROTRAUMATICA OF FOREARM. 
5 
from the peripheral nerves directly through the cutaneous vaso-motor 
centres, or reflexly, meeting in the cord or brain, and calling forth the 
symptoms. 
I have thus brought forward a case which at first seemed obscure in its 
nature and difficult to classify. Upon looking into the subject we find, 
however, that more or less similar cases are on record, reported by several 
well-known observers. Notwithstanding the presence of hysteria, an ex- 
planation of the symptoms—nervous and cutaneous—may be found, I 
believe, by regarding the process as a traumatic ascending multiple neuritis. 
In all the cases to which reference has been made, there exists a positive 
neurotic pathology, which, however, differs somewhat in certain particulars. 
The most interesting point is whether they are reflex in their nature. This 
view, as we have seen, is held by several distinguished observers, and the 
explanation touches upon an almost untrodden, but important, field in cu- 
taneous pathology. In the case which I have described, however, there 
does not seem to l>e sufficient ground for regarding the affection as reflex, 
the symptoms being explicable by local pathology, but I can well under- 
stand this to be the proj»er explanation for some of the other cases to which 
•attention has been directed.