On the Relatioii of Impetigo Herpetiformis 
(11ebra and Kaposi) to Dermatitis 
Herpetiformis (Duhring). 
BY 
LOUIS A. DUHRING, M. D., 
l'r»/tttor a/ Skin Ditrturt in fit Univtrtitf a/ Ptnntylvanin 
mow 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
March, iSyo. Extruded from 
The American Journal of the Medical Science* for March, 1890. 
ON THE RELATION OF IMPETIGO HERPETIFORMIS (HEBRA 
AND KAPOSI; TO DERMATITIS HERPETIFORMIS 
(DUHRINO). 
Louis A. Duhrino, M.D., 
morcMioß or akin Pimuiir* in the vni veeaitt or Pennsylvania* 
Ah there have been considerable discussion and some diversity of opin- 
ion as to the propriety of grouping impetigo herjKJtiformis under derma- 
titis herpetiformis, I desire briefly to present my reasons for having 
originally adopted this view. It may be well to premise my remarks 
with the statement that heretofore, in my several communications on 
this disease, I have confined rny observations largely, if not exclu- 
sively, to the cutaneous manifestation—to the skin disease proper— 
with the idea mainly of calling attention to the multiform phases of 
the disease. The symptoms alone, it may be said, have up to the present 
time received attention; the equally, if not more, important subjects 
of etiology and pathology being for the time intentionally slighted. 
In all rare or obscure affections the eruption itself, including its 
history, symptoms, evolution and involution, is first to be considered. 
After these points have been determined upon, as far as the material 
at hand will permit of, the questions of the cause and nature of the 
disease naturally follow for investigation and discussion. In addition 
to the clinical memoranda and observations presented from time to 
time, I have sought to bring together into one group such previously 
reported cases, scattered throughout literature, and certain other allied 
forms of disease, as seemed to me might pro|»erly be included under one 
head. Circumstances have, for sometime past, prevented me from con- 
tinuing my study on the subject, which will account for what may seem 
indifference or neglect of the question. 
It in now over five years since I first called attention to a disease of 
the skin, which, up to that time, hud not received special notice. A 
number of cases of a peculiar cutaneous disease had, from time to time, 
previously come under my observation, possessing ccjlntij sinking'' 2 
DUHRING, IMPETIGO HERPETIFORMIS, 
features in common when viewed in their totality—that is, throughout 
their complete history, including relapses. There existed manifestly 
several quite different varieties of the affection, as shown by the presence 
in some instances of a decided predominance of certain lesions, while in 
other cases different forms even prevailed. Hut beneath this cloak of 
multiformity, and notwithstanding the occurrence of diverse lesions 
simultaneously or of those which made their appearance from time to 
time as the affection ran its course, certain striking pathognomonic 
symptoms could not fail to impress themselves upon the observer, 
showing the existence of a peculiar and undescribed disease. Had a 
few cases only been encountered at long intervals, these features might 
not have been recognized so readily. 
As the disease represented by these examples was practically un- 
known and had no place in literature, it seemed necessary to bestow 
upon it a title. The relatively large number of cases that I had 
encountered seemed to warrant such recognition. By reason of the 
uncertain and variable character of the eruption, of its conspicuously 
diverse primary lesions and their distribution and arrangement, occur- 
ring in the several forms or varieties in which it usually appeared, and, 
moreover, because of its distinctly herpetiform feature, the name 
dermatitis herj>etiformis was selected. The term dermatitis, owing to 
the idea of widespread or general and varied inflammation thereby 
conveyed or implied, and because of its being non-committal as to 
etiology and pathology, appeared to meet the requirements better than 
any other that suggested itself; while one of the most distinctive char- 
acteristics was made plain by the word herpetiform. To this hitter 
point I wish to direct special attention, and I would here say that the 
herpetiform element has been present in all of the cases (now, perhaps, 
twenty in number) that I have seen, in some instances marked, in others 
existing to a moderate or only a slight extent. 
As the matter stands to-day, the disease is sufficiently well defined to 
l>e readily recognizable by all observers, where typical cases are con- 
cerned. I cannot well see how pronounced forms, especially if held 
under observation long enough to note the ever-changing lesions and 
the varied aspect of the eruption, can be confounded with other better 
known affections. In ill-defined, atypical forms it is, of course, liable to 
be mistaken for certain other diseases to which it may bear more or less 
resemblance, more especially erythema multiforme, herpes iris, pem- 
phigus, and eczema, according to the views held by the observer, pre- 
cisely as in other doubtful forms of skin disease. Thus, for example, 
as is well known, discrepancy in diagnosis is not infrequently encountered 
in eruptions characterized by the formation of blebs, one observer 
regarding all such manifestations as varieties of “ pemphigus,” another DI'HIUNG, IMPETIGO HERPETIFORMIS. 
3 
merely as instances of “ bullous disease,”—a vague. non-committal 
expression, plainly indicating an unwillingness on the part of the 
observer to subscribe to the view that every bullous eruption must 
necessarily Ik* pemphigus. 
The relations of dermatitis herpetiformis to erythema multiforme, 
herpes iris, and pemphigus, are, I need not say, most interesting and 
important topics, to which I naturally have had my attention directed. 
But these subjects cannot be entered upon without a great deal of 
discussion. Here, at once, arises the matter of definition. For example, 
how shall these diseases—erythema multiforme, herj>es iris, and pemphi- 
gus—be defined? What forms of eruption shall be included and what 
excluded under these names? Shall the old, time honored, classic defi- 
nitions continue to be observed, or should new ones be framed to take in 
enlarged views concerning these processes? This «piestion cannot be 
entered into at present, nor do I wish now to speak of the relation of 
dermatitis herpetiformis to the diseases just cited, nor to any other vesic- 
ular, bullous, or pustular affections, except one, namely, tbe impetigo 
herpetiformis of Hebra. 
At this point I must be permitted to go back a few years, in order to 
make my position, views, and reasons therefor clear. As is known to 
all, Hebra described, in 1*72, a grave, pustular disease of the skin, of 
which several instances had, from time to time, been observed at the 
Vienna General Hospital. The description given was brief, and in the 
dermatological world at large the subject attracted comparatively little 
attention. Dermatologists in other parts of Europe and in this country 
seemed at a loss to identify or recognize the disease. In the United 
States it did not seem to be known. My American fellow dermatologists 
in the large cities, with whom I conversed, were not familiar with it, 
nor was I myself able to reconcile Hebra's description with any of the 
pustular affections encountered in my field of study. Nor was the 
disease recognized either in France or England. Moreover, consider- 
able confusion existed even in Vienna, competent observers there being 
by no means of the same opinion regarding the-disease and its proper 
classification. Thus, Hebra himself first looked upon it as belonging to 
the herpes group, and called it “herpes impetiginiformis,” with the idea 
that it was a form of herpes; subsequently he regarded it as an her|K*ti- 
form impetigo. Nor was the subject materially elucidated by the pub- 
lication of several of Hcbra’s original cases by Auspitz and by Gel>er, 
the first of whom looked u|>on it as herjHis, calling it “ herpes vegetans,” 
while the latter also endeavored to prove it to be herpes. Then Neu- 
mann, who was without doubt familiar with Hebra's cases, emphatically 
designated it herpes, terming it “ herpes pyjcmicus” or “ herpes puer- 
peralis.” Even at this later date, notwithstanding all that had l>een 4 
DU H KING, IMP K TIG O HERPETIFORMIS. 
written by the Viennese dermatologists, the subject was far from clear 
to the minds of foreign dermatologists. The consensus of opinion on 
the part of the Vienna observers, however, seemed to be that the 
disease was an undescribed form of herpes, us is evidenced by the names 
decided upon by the several rej)ortcrs. Nor, finally, was the matter 
made plainer by Hebra himself, who stated that the case previously 
reported by himself and Baerensprung as “herpes cireinatus” and 
figured in their atlas of skin diseases, was also an example of this same 
disease, namely, impetigo herpetiformis. It need scarcely be said now, 
in passing, that if the views (to be referred to) recently put forth by 
Kaposi be accepted, this peculiar case must be excluded from the list. 
No further examples were at this period re|)orted, and the matter for 
the time being remained quiescent. 
In the meantime, in Philadelphia, during this epoch (from 1870 to 
1880), a series of cases of an unknown, inflammatory, polymorphous 
affection of the skin had come under my observation—some in hospital, 
others in private practice. Among these was one which, when it first 
was brought to notice, apjjeared to me (and to other physicians who saw 
it) to be an example of the imjretigo herpetiformis of Hebra. It ap- 
parently represented a mild expression of that disease and showed the 
chief clinical features depicted in one of the portraits (case of 1871) in 
Hebra’s atlas. The resemblance was striking. The cutaneous mani- 
festation was altogether novel, and I was unable to classify it elsewhere. 
The patient was a woman. The eruption was general and extensive, 
and was exclusively pustular (with no signs of erythematous, urticarial, 
vesicular, or bullous lesions) and crusted, the pustules being whitish and 
yellowish, and of varied shapes and sizes, some being distinctly elevated 
and somewhat conical or rounded, others flat; some were miliary, others 
small, pea-sized, and some larger; all being seated on more or less in- 
flamed bases or arising from inflamed patches. The eruption, as a whole, 
was, moreover, herjHjtiforrn, showing a distribution and arrangement here 
and lh> r> similar to that seen in imperfectly developed or abortive herpes 
zoster. The lesions themselves were irregularly grouped, as is sometimes 
noted in small discrete patches of zoster. The central pustules, often aggre- 
gated in little bunches of two, three, or four, were small but of variable 
size; the older ones were more or less crusted, and were closely encircled 
in an incomplete, broken manner, with new, for the most part sparse, flat, 
minute pinhead-sized pustules. There was, moreover, marked pigmen- 
tation in patches here and there; also malaise, with a disposition to be 
cold and hot alternately, hardly amounting to a regular chill. Finally, 
there were heat and burning and some itching, but recent scratch-marks 
were not conspicuously present. In brief, the case possessed, so far as 
the skin was concerned, the chief characteristics of Hebra’s impetigo her- DUHRIKO, IMPETIGO HERPETIFORMIS. 
5 
petiformis, and this diagnosis was accordingly made. The disease per- 
sisted, the eruption repeating itself in a succession of crops with the same 
kind of lesions, and within six months disappeared, to he replaced, how- 
ever, by an altogether different dermatological picture,—one with which 
I was (piite familiar, namely, a polymorphous, mixed vesicular and 
bullous, inflammatory, herj>etiform eruption, accompanied with severe 
burning and itching, or, briefly, the typical form of dermatitis herpeti- 
formis. Subsequently, the previous impetiginous, or strictly pustular 
form, recurred, manifesting itself precisely as before; and during the 
next year the eruption again became vesicular and bullous. 
There was now, after several years of observation, but one conclusion 
to draw—namely, that these diverse cutaneous manifestations all belonged 
to one pathological state, were simply varieties, or forms, of one process. 
Other similar cases later came under notice which strengthened this 
view’, and I accordingly expressed myself that Hebra’s impetigo her- 
petiformis (as I understood that disease from Hebra’s description and 
portraits) might be regarded as a pustular manifestation of an extensive 
multiform (erythematous, vesicular, bullous, and pustular) her|>etiform 
disease of the skin. This view, moreover, seemed to l>e supported by a 
case of “ impetigo herpetiformis and pemphigus," reported by Heitzmann, 
of New York, which, while it presented the characteristic cutaneous 
features of Hebra’s disease for a period of several months, abruptly 
changed from a pustular to a bullous affection, the blebs being in all 
respects like those of |>emphigus. From this case Heitzmann drew the 
conclusion that both diseases arose from identical causes, and should be 
considered as being kindred to each other. It may be added that in 
this case the disease did not occur in connection with pregnancy, and 
that no cause could be assigned for its presence, the patient having l»een 
an apparently healthy woman, fifty-two years of age. The disease, 
nevertheless, ran a fatal course in about eight months from the begin- 
ning, oedema of the meninges setting in toward the end. There can 
scarcely be any question here concerning the diagnosis of impetigo 
herpetiformis, for Dr. Heitzmann had not only seen three of Hebra’s 
cases in Vienna, but had, moreover, painted the portraits which portray 
this disease in Hebra's atlas. 
The subject remained in stain quo until my several communications 
appeared, and, later, Kaposi’s valuable contribution on impetigo herpeti- 
formis, in 1887, in which the relations of that disease to some other affec- 
tions (including dermatitis herpetiformis) are discussed. From this latter 
article a much more satisfactory idea of this disease is obtained than 
from any previous publication. The subject is presented in a different, 
if not a new, light, and is fortified by reference to additional and more 
recent observations, and we are enabled to note what the author would 6 
DUHRINO, IMPETIGO HERPETIFORMIS. 
have us regard as impetigo herpetiformis. If this definition, then, is to 
lie accepted, and to he restricted so «is to include only such cases as the 
author refers to, I admit that it becomes questionable whether the disease 
should l»e regarded as a variety of dermatitis herpetiformis. If the defi- 
nition is to ho rigidly confined to such cases (including their nature) 
a- Kaposi quotes, the disposition of the matter would he simple, but 
other observers of this disease (or what they assume to be the same 
affection ido not entirely agree with the Vienna dermatologist. According 
to Kaposi, the disease is invariably characterized by superficial miliary 
pustule*, which bey in as such and remain unchanged throughout their 
entire course, always arranged in group* ami clusters, new lesions 
appearing on the border of older and crusted confluent pustules, in one 
or more series, on inflamed bases, while recovery takes place in the centre; 
furthermore, the disense occurs only In pregnant or puerperal women, and 
is accompanied with chills and marked fever, and Is almost invariably 
fatal. This definition is clear and simple enough, but does it include all 
forms of the disease? Is it sufficiently comprehensive ? The question 
might pertinently be raised: Is it wise to make thedefinition so circum- 
scribed; is the disease not liable to vary from this type; does it invari- 
ably show these very precise features; are, for example, the pustules 
always miliary, and from beginning to end ; may they not vary in size, 
and, more especially, he considerably larger? Surely one portrait of this 
disease in llebra's atlas (case of IM7I, referred to before) fails to portray 
a miliary eruption; on the contrary, not only are many of the pustules 
large, but there is, moreover, considerable variation in size; nor is their 
arrangement and mode of extension or spreading apparently like that 
depicted in the other cases, namely, peripherally, as in herpes circinatus. 
I may remark further on this point that I find it difficult to reconcile 
this j)ortrait with Kaposi’s description of the eruption, and, finally, that 
it was mainly upon this illustration that 1 ventured to bjiso the opinion 
of the identity of one of my cases (that of Annie McC., Journ. of Out. 
and Ven. If is., vol. ii. No. 8) with the disease depicted. If Kaposi’s 
views be adopted, Heitzmann’s case, already referred to, cannot he 
regarded as impetigo herpetiformis, although, as previously remarked, 
from the fact that Hcitzmann had the opportunity of seeing several of 
Hebra’s original cases, it would seem that he must he entirely familiar 
with the subject. Nor can Zeisler’s case (Monatshefle fur peak. I format., 
1887, No. 21) of so-called “ impetigo herpetiformis,” which he, Dr. 
Hyde, and others believed to he an example of the llebra and Kaposi 
disease, be regarded as such. 
It may he questioned further: Does impetigo herpetiformis in all 
instances exhibit the same grave general symptoms and course, termi- 
nating in almost every case fatally? Such symptoms and termination DUHRINQ, IMPETIGO HERPETIFORMIS. 
assuredly might be anticipated if’ it were generally admitted that the 
cause was uniformly septicaemia,—that the disease was always of septi- 
ciemic origin. But may not various causes give rise to the same 
cutaneous manifestations, not only here, but elsewhere, as in the case of 
certain other affections of the skin, as. for example, eczema? There was 
a time, not long ago, when Kaposi held that the disease occurred exclu- 
sively in women, hut lately he Ims himself given the notes of a cast' 
observed in a man. From this criticism I wish merely to intimate or 
suggest that our definitions should not lx* drawn too closely. Most 
observers will agree that its our experience enlarges in dermatology we 
find in all directions the need of more breadth or latitude. Expansion 
in almost all instances, we note, comes sooner or later. 
I have thus endeavored to present a concise historical sketch of 
impetigo herpetiformis, and also, more particularly, to state* ray reasons 
for having, in my earlier papers, regarded it as one of the manifestations 
of a peculiar, polymorphous, extensive process designated dermatitis 
herpetiformis. Whether I was right or in error in advancing this view 
is a question depending largely, in my opinion, u|>on the definition that 
shall be accorded to impetigo herpetiformis; and here I may remark 
that it is far from my thoughts to undervalue the observations of the 
distinguished Vienna dermatologist, whose extended and unique experi- 
ence with impetigo herpetiformis entitles his communication to due 
consideration. My desire has been from the beginning simply to arrive 
at the true position which that disease occupies, and more especially to 
define its relationship to other allied affections. 1 may say, in passing, 
that had Kaposi’s article been published at the date of my several com- 
munications, I should probably have, in some degree, qualified the con- 
clusions concerning the identity of the affections. 
In bringing these remarks to an end. I would say that 1 have always 
held to the opinion that all discussions tending to create |>erplexity 
should be avoided. On this point I feel strongly in the present case, 
concerning the relationship of the two forms of eruption which are the 
subject of this pajx*r. The matter can only lx* settled by fully recorded 
observations at the hands of competent rejxirtors, and it is highly im- 
portant for future studies and deductions that the cases be ranged under 
such titles as will convey the clearest idea of the clinical picture. Con- 
sidering, therefore, the existing difference of views, and in order that 
no possible harrier may impede progress, it will jxirhajm lx; to the 
advancement of the subject to separate, for the present at least, the 
diseases ; and that, in the future, observations be rejxirted under one 
caption or the other, as may seem most in harmony with the clinical 
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