THE MEDICAL NEWS. 
A WEEKLY JOURNAL OF MEDICAL SCIENCE. 
Vol. XLVII. 
Saturday, October 17, 1885. 
No. 16. 
ORIGINAL ARTICLES. 
disease portraying the more important varieties of the 
process have been reported during the past year,1 it 
will not be necessary to reconsider the disease on the 
present occasion beyond pointing out the principal 
features of the two varieties which concern this paper, 
namely, the vesicular and bullous. The following 
is an abstract of the original description of the ves- 
icular variety. 
RELATION OF HERPES GESTATIONIS AND 
CERTAIN OTHER FORMS OF DISEASE 
TO DERMATITIS HERPETIFORMIS.1 
PROFESSOR OF SKIN DISEASES IN THE UNIVERSITY OF PENNSYLVANIA. 
By LOUIS A. DU PI RING, M.D., 
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 stated 
that the pustular variety is the same manifestation as 
the affection described by Hebra as “ impetigo her- 
petiformis.” This latter subject has more recently 
been elaborated by me in a paper read before this 
Association3 at its last meeting. 
On the same occasion I presented a “ Preliminary 
Note on the Relation of Dermatitis Herpetiformis to 
Herpes Gestationis and Other Similar Forms of Dis- 
ease,”1 which communication embodied the results 
of considerable research into literature bearing upon 
the subject. It was there stated, as had been inti- 
mated in my previous articles, that so-called herpes 
gestationis, as well as certain other similar forms 
of eruption, reported with various titles, are all in- 
stances ot one process, namely, dermatitis herpeti- 
formis, as I had defined this disease. 
It is characterized by variously sized, varying from a 
pin-head to a pea, flat or raised, irregularly shaped or 
stellate, glistening, pale-yellowish or pearly, usually firm 
or tensely distended vesicles, as a rule, unaccompanied 
by areolae. In their early stages they can be seen only 
with difficulty, and are liable to be overlooked in the 
examination. Sometimes they can only be detected or 
seen to advantage in an oblique light In size they vary 
extremely, 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 given 
region, as, for example, the neck or the back, but they 
are for the most part aggregated in the form of small 
clusters or groups of two, three or more; or there may 
be patches here and there as large as a silver dollar, 
upon which a number will be seated. When in close 
proximity they incline to coalesce, as in herpes zoster, 
forming multilocular vesicles or small blebs. Where 
this occurs they are generally slightly raised and are 
surrounded with a pale or reddish areola, which shows 
forth the irregular, angular or stellate outline of the 
lesion. At this stage, moreover, the little cluster will 
generally present a “puckered” or “drawn up” ap- 
pearance, indicative of its herpetic nature. The erup- 
tion is usually profuse, sometimes to the extent of the 
upper extremities, trunk and thighs being well covered. 
It may attack any region, but the neck, chest, back, 
abdomen, upper extremities and thighs are especially 
liable to invasion. 
The remarks about to be made must be regarded 
as 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 these 
cases, which I desire now to bring forward in sub- 
stantiation of my statement. It will be observed 
that the clinical features of the cases bear a strong 
resemblance to one another. It will not be neces- 
sary, however, for my purpose to quote all the cases 
in extenso. 
The most striking symptom is the itching. Not in- 
frequently burning is also complained of. Itching, 
however, predominates, and is violent or intense. It is 
altogether disproportionately in excess of the amount 
of 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 lesions 
have been ruptured. From my observation I should 
say that it is usually more severe and more lasting than 
The object of this communication will be to show: 
1. The identity of so-called herpes gestationis with 
the vesicular variety of dermatitis herpetiformis. 
2. That certain other forms of so-called herpes re- 
ported with various titles are likewise manifestations 
of the same variety of this disease. 
3. That certain cases reported as “ peculiar forms 
of pemphigus ’ ’ must also be viewed as examples of 
the vesicular or bullous varieties of this disease. 
1 Notes of a Case of Dermatitis Herpetiformis Extending over 
Eleven Years, Illustrating the Several Varieties of the Disease. 
Philadelphia Medical Times, July 12, 1884. 
Case of Dermatitis Herpetiformis (Multiformis) Aggravated by 
Pregnancy and Irregular Menstruation. THE MEDICAL NEWS, 
July 19, 1884. 
A Case of Dermatitis Herpetiformis (Bullosa). The New York 
Medical Journal, July 19, 1884. 
Case of Dermatitis Herpetiformis, Illustrating in Particular the 
Pustular Variety (Impetigo Herpetiformis of Hebra). Journal of 
Cutaneous and Venereal Diseases, Aug. 1884. 
Notes of a Case of Dermatitis Herpetiformis During Thirteen 
Years. The N. Y. Med. Jour., Nov. 15, 1884. 
Case of Dermatitis Herpetiformis, with Peculiar Gelatinous 
Lesions. The Medical News, March 7, 1885. 
Case of Dermatitis 11 <?rp e t Nervous Shock, 
Amer. Jour Med. Sci., Jan, iBBJf. T J.~ " '— 
4. That instances of dermatitis herpetiformis are 
also 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 by 
me, and, moreover, that numerous examples of the 
1 Read before the American Dermatological Association at the 
Ninth 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. HERPES GESTATIONIS AND DERMATITIS HERPETIFORMIS. [Medical News 
422 
in vesicular eczema. The vesicles generally make their 
appearance slowly, so that several days or a week may 
be required for their complete development. Notwith- 
standing the fact that scratching is indulged in in the 
early stages of the disease, excoriations are not promi- 
nent, owing to the fact that the lesions do not readily 
rupture, and, also, that they incline to refill immediately 
on being evacuated. 
ally in groups of two to four. They were mostly 
prominent and pointed in shape, but some were ob- 
long with the ends apparently communicating. The 
disease developed rapidly, so that in a few days the 
greater part of the body was involved. There was 
constitutional disturbance, and the local irritation 
was most distressing. Two weeks after delivery she 
was on the road to recovery. She had had similar 
attacks twice previously, with her first and fifth preg- 
nancies. 
If we look into the subject of herpes gestationis, 
it will be found that the term was introduced by 
Milton in 1872. Previous to this date, in 1867, 
Erasmus Wilson1 gave brief notes of two examples 
of a disease which he designated * ‘ herpes circinatus 
bullosus,” considering them in a chapter devoted to 
the “chronic forms of herpes.” In both cases the 
disease was associated with pregnancy, beginning 
with conception and ending with the completion of 
parturition. Mr. Wilson describes them as follows : 
“ Both cases were remarkable for perpetual irritation 
and intense pruritic suffering. The bullae were of 
the flat and foliaceous kind, some filled with limpid 
serum and others with a mucopurulent fluid, and were 
associated with moist excoriations, thin crusts, papulae, 
and pruritus. In one patient the cutaneous disease 
was the first intimation of pregnancy; the disease 
continued during the whole period, accompanied four 
or five pregnancies in succession, and completely ex- 
hausted her strength and health. In other respects, 
and in the intervals of being pregnant, she was a 
strong and healthy woman. The other patient was 
a woman aged thirty-six, the mother of nine chil- 
dren. The eruption made its appearance with the 
fourth pregnancy, and has accompanied every preg- 
nancy since. When parturition was over the erup- 
tion ceased; but on the last occasion, nine months 
ago, it remained, and has now assumed a permanent 
character. In both cases the eruption was accom- 
panied with sympathetic gastric disturbance and with 
a duskiness and cachexia of the skin.” 
We next meet with Bulkley’s case,’ which he, like- 
wise, designated “herpes gestationis,” adopting the 
name proposed by Milton. The case was that of a 
married woman, thirty-two years of age, who was 
confined 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. It 
began in the form of papules, which rapidly passed 
into vesicles, and later blebs developed. The vesi- 
cles, which were generally in groups, varied in size 
from very minute elevations to large blebs. After 
they had ruptured a brownish stain remained There 
was at no time any resemblance to vesicular eczema, 
nor did the lesions pass into pustules. The eruption 
was attended with intense itching, and later with 
much prostration and considerable fever. 
The disease disappeared after delivery, but recurred 
with her second pregnancy. 
If we look into the four cases just quoted, it will 
be seen that they resemble one another closely in 
their clinical features, and that the cause (pregnancy) 
in all was the same, from which fact both Milton and 
Bulkley concluded that the term herpes gestationis 
was expressive and appropriate. This name, as is 
well 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 also 
encountered in men,—an observation which my ar- 
ticles and several of my published cases show; also 
that it may occur associated with other primary le- 
sions than vesicles, thus rendering the name herpes 
inappropriate and misleading. The name proposed 
by Mr. Wilson is even more descriptive than herpes 
gestationis, and has the advantage of being non- 
committal as to the etiology of the process. But the 
term is not sufficiently comprehensive to include other 
known manifestations of the same extensive patho- 
logical process which cannot be regarded either as 
varieties of herpes (as this term is understood by der- 
matologists) nor as having either circinate charac- 
teristics or blebs. Thus, we note that while the 
titles proposed by these observers answered the pur- 
pose provisionally, recent studies have demonstrated 
that 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 Milton and Bulkley, 
which must be looked upon as the mildest expression 
of the disease. The patient was a woman, aged 
It is evident that the cases illustrate the “herpes 
gestationis” of certain more recent writers, and, as 
I have stated elsewhere, that the disease is the same 
as described later by Hebra under the titles “herpes 
impetiginiformis ” and “impetigo herpetiformis.” 
It must be remarked, however, that Wilson gives no 
special account of the lesions, nor of the peculiarities 
of the disease, and it is doubtless for this reason that 
the attention of dermatologists was not fairly directed 
to the subject until Milton’s report of a case in the 
Journal of Cutaneous Medicine, Vol. i., No. 3, the 
paper being designated “ on certain unusual forms of 
vesicular eruption,” and the disease classed as an ex- 
ample of the “ herpes circinatus bullosus” of Wilson. 
In Milton’s work on the “ pathology and treatment 
of skin diseases, ”2 published a few years later, this 
case is again brought forward, on this occasion with 
the 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 of 
the skin of the arms and forearms, upon which parts 
a 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* 
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, which 
were confined to the fingers, toes, backs of hand and 
wrists, feet and ankles. The attack was an acute one, 
recovery taking place after delivery, which occurred 
three weeks after the beginning of the cutaneous 
manifestations. 
itching, and burning. She remained perfectly free 
from any cutaneous disease until three months preg- 
nant with the seventh child, the eruption appearing 
around the umbilicus in exactly the same way as in 
the first attack, namely, as a cluster of papules or 
vesicles. Within the first week after parturition the 
eruption underwent a great aggravation. “Large 
vesicles and blebs formed, and when punctured clear 
fluid spurted out with force.” When the child was 
three 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 the 
arms ; clusters of pimples on the thighs and knees, 
disseminate lesions down the legs, and blebs on the 
soles of the feet. Later, there were still to be found 
a few papules and imperfect vesicles, which looked 
and felt like the first stage of a variolous eruption.” 
.... After each delivery that was preceded by the 
eruption the nails fell off the hands and feet. At 
present 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 of Skin Diseases. Hebra regarded 
this case as illustrating his “ impetigo herpetiformis,” 
an observation to which I have elsewhere directed 
attention. 
With the title “clinical remarks on a case of 
herpes gestationis,” Liveing1 reports a case that had 
been under his observation in Middlesex Hospital 
occuring in a woman thirty-seven years of age. The 
principal features may be briefly cited. The third 
day after delivery “a copious eruption of scattered 
solid papules and discrete vesicles appeared ; the 
latter quickly developed into blebs of various sizes. 
. . . . The bullae had a tendency to form groups, 
but were all discrete, the skin in the neighborhood 
being more or less covered with scattered solid 
papules as large as good-sized shot. The itching 
was intense.” Here there was present a marked 
papular element, the disease being characterized by 
papules, vesicles, and blebs, and the use of the term 
herpes, it must be noted, is altogether inappropriate 
and fails to convey an idea of the clinical picture. 
Cottle2 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 years 
of age, the cutaneous manifestation in the first attack, 
in the first pregnancy, being urticarial in form—in 
“bumps,” to quote the author. In the second 
attack it was of the same character, but in the third 
it occurred in the form of relapsing blebs and vesi- 
cles. In the same paper mention is made of another 
similar case, where the lesions were hard papules 
which later developed into small blisters. 
Gale’s3 two cases (“herpes gestationis”) may also 
be 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 is 
stated that the disease began like “erythema pap- 
ulosum,” later blebs appearing, and that there was 
no pigmentation or grouping of the lesions. The 
second case occurred in a woman thirty-four years 
of age, the disease having appeared no less than 
eight times in a period of eleven years, accompanying 
her pregnancies. 
Walter G. Smith4 with the heading “herpes 
(hydroa) gestationis,” gives the notes of a remark- 
able case, showing the multiform variety of dermatitis 
herpetiformis. The patient, aged thirty-five, had 
been married thirteen years, during which time she 
had 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 sought 
advice, 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, 
French writers, with some exceptions, do not seem 
to have recognized herpes gestationis. M. Barthe- 
lemy, however, in his translation of my Treatise on 
Diseases of the Skin, in a note states that “it is the 
same disease as that which Hebra calls impetigo 
herpetiformis of pregnant women.” Among the 
recent German authors, Kaposi makes no allusion 
to herpes gestationis. Behrend only incidentally 
refers to it (quoting Bulkley) in considering the eti- 
ology of pemphigus. Nor do we find more than the 
briefest reference to the subject in a recent volume 
on skin diseases by Malcolm Morris. He says “herpes 
gestationis occurs in pregnant or parturient women, 
but is rarely seen in England.” No mention what- 
ever is made of impetigo herpetiformis (Hebra). In 
this country the latest author, Robinson, makes herpes 
gestationis a variety of herpes, placing it between the 
varieties “ progenital is” and “zoster,” and stating 
that it may be regarded as belonging to the herpetic 
or pemphigus group of cutaneous diseases, and that he 
has observed two cases. A separate chapter is de- 
voted to impetigo herpetiformis (Hebra). 
Other forms of so-called herpes, such as “herpes 
pemphigoide,” “herpes vegetans,” “herpes pyse- 
micus,” and “ herpes phlyctaenodes ” may here be 
referred to. The first of these, described by Dever- 
gie, will be considered later in connection with 
pemphigoid eruptions. Herpes vegetans was em- 
ployed by Auspitz1 to designate a case subsequently 
reported and called by Hebra impetigo herpeti- 
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. 
1 Archiv flir Derm. u. Syph., 1869, p. 247. HERPES GESTATIONIS AND DERMATITIS • HERPETIFORMIS. [Medical News 
424 
for mis, the case being one of the group of Hebra’s 
cases. Neumann, in his Hand-book of Skin Diseases, 
3d edition, briefly alludes to the same disease, but 
regards the term herpes pyaemicus as more expressive 
of the condition. 
It is characterized by more or less typical blebs, tense 
or flaccid, rounded or flat, usually the former, filled with 
a clear or cloudy fluid, seated upon a non-inflammatory 
or inflamed base, varying in size from a pea to a walnut, 
and mostly irregular or angular in outline. They 
incline to group in clusters of two or three, the skin 
between them being reddish and more or less puckered. 
Sometimes in immediate proximity will exist one, two 
or three or a part of a circle of small, pin-head sized, 
flat, whitish pustules. Vesicles, small or large, flat or 
raised, are also generally found near by or disseminated 
over the affected surface. As in the other varieties of 
the disease any region may be attacked, but more 
especially the trunk, upper extremities, and thighs. 
The lesions are generally soon ruptured, crusting with 
yellowish, brownish or greenish crusts. They are 
accompanied by burning or itching, which may prove 
severe. They must be distinguished from the lesions 
of pemphigus, with which of course they may be 
readily confounded, but they are herpetic in character. 
They differ in that they incline to group, and have a 
more inflammatory, herpetic aspect, the type of which 
appearance is seen in herpes zoster. Moreover, around 
and near the bleb will usually be found vesicles and 
often pustules, the latter frequently in close proximity. 
Gibert1 describes a case representing an unusual 
form of disease under the name “ herpes phlyctae- 
-11 odes, ” as follows; The patient was a woman 
twenty-seven years of age, who was in 1814 for the 
first time attacked with a “ phlyctenoid eruption,” 
the origin of which she attributed to a severe fright, 
which she experienced on the invasion of France by 
the allied troops. Ever since, she has been subject 
to an anamolous eruption of small vesicular eleva- 
tions, appearing sometimes on the trunk, sometimes 
on the face, sometimes on the limbs, and by a bright 
redness of the skin, and intense itching and smart- 
ing. Three years later she had more frequent and 
violent returns of the cutaneous disease; the cata- 
menial periods became painful, and the discharge 
scanty. Two years afterwards she entered the hos- 
pital St. Louis. The dorsal aspect of the hands and 
forearms was red, swollen, hot, inflamed, and ex- 
tremely painful to the touch, covered with a number 
of small vesicles, most of them miliary, others the size 
of a pin’s head, others even that of a small pea. 
These elevations, first noticed in the form of small 
red points, became more sensitive as they enlarged. 
At first they were colorless and transparent, after- 
wards turbid and opaque, resting on an inflamed 
base, most of them distinct, some blended and grouped 
together, discharging a considerable quantity of fluid 
on bursting. Violent itching, burning heat, and 
severe smarting accompanied the eruption, produc- 
ing restlessness, and causing intense suffering to the 
patient.” 
The case without doubt, it seems to me, was an 
example 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 Captain 
K., reported by me with the title “ A Case of Der- 
matitis Herpetiformis Caused by Nervous Shock.” 
Looking into the earlier French literature we find 
Rayer1 speaking of pemphigus “circinatus” as a 
variety of this disease; and stating, moreover, that 
he was the first to notice it. He gives a case, to 
quote his words, of “acute pemphigus, with simul- 
taneous eruption of bullae on the right forearm ; 
annular erythema; herpes phlyctsenodes.” The 
patient was an unmarried woman, twenty-three years 
of age, with regular menstruation. The disease 
began with itching and the appearance of small red 
spots which wrere succeeded by small blebs closely 
crowded together, which gradually became large and 
increased in number. Here and there they ran to- 
gether. As a rule, they were without areolae. Some 
of them were opaque. Crusts were also present. 
Annular patches of erythema were also observed. 
Another case, reported by Rayer, is that of “ chronic 
pemphigus; bullae arranged in bands; complication 
with herpes circinatus.” I shall not give the notes 
of this case because of their unusual length, but it 
may be stated that, in my opinion, the disease was 
one of dermatitis herpetiformis;—the peculiar erythe- 
matous patches, herpetic groups of vesicles,' blebs, 
the excoriations and the crusting, the itching, the 
severity of the attack, and lastly, the duration of the 
disease, all pointing to this disease rather than to 
any other affection. 
Still another case is recorded by Rayer, as one of 
“chronic pemphigus, presenting isolated bullae, and 
clusters of an eruption similar to that of herpes 
phlyctsenodes; amenorrhoea; recovery. ’ ’ The woman 
was forty-two years of age. There were constitutional 
disturbance, severe itching, and a copious diffuse 
eruption of groups of variously shaped and sized 
blebs, which appeared in successive crops. 
Chausit2 describes at length two cases, both occur- 
ring in women, with the title “pemphigus aigu pruri- 
ginosus,” which likewise are to be viewed as examples 
of dermatitis herpetiformis. One of these cases may 
I come now to the consideration of a series of cases 
which have been grouped by the reporters under the 
head of “pemphigus,” usually with various adjec- 
tival qualifications, which are clearly examples not of 
true pemphigus, but of that multiform and protean 
process under discussion. That these cases were 
not regarded as ordinary pemphigus is manifest from 
the statement of the reporters that they possessed 
peculiar characters. The titles indicate that the 
writers (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 a 
varied and uncertain nomenclature. 
I shall cite some of these cases, before doing 
which, however, a brief description of the bullous 
variety of dermatitis herpetiformis may be presented, 
the account being an abstract from my original com- 
munication. 
1 Treatise on Diseases of the Skin, English Translation, London, 
1835, p. 219, 
2 Annales des Mai. de la Peau et de Syph., Mars, 1852. 
1 A practical treatise on the special diseases of the skin. Trans- 
lation from the French, London, 1845, p. 118. 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 her 
first child six weeks before full term. At the fifth 
month of gestation itching and an eruption of numer- 
ous minute solid papules upon the body and limbs 
manifested themselves, the itching increasing in 
severity as pregnancy advanced. On the fifth day 
after delivery she experienced even greater itching 
and eneral burning, together with fever and some 
delirium. The following day the whole surface was 
covered with a confluent efflorescence of large ele- 
vated red papules, resembling in some respects those 
of erythema papulosum. The skin presented the 
same appearance for two days, and on the third there 
were noted on the arms a few disseminated trans- 
parent blebs varying in size from a haricot-bean to a 
hazel-nut. The blebs increased in number until on 
the eleventh day the whole surface, including the face, 
was invaded, the burning and itching by this date 
having ceased. The papules disappeared, new blebs, 
starting as such, coming out from day to day until 
the seventeenth day when they disappeared leaving 
brownish stains. A month after there was slight 
itching over the general surface together with a few 
groups of papules, but no more blebs formed. 
The papular manifestation preceding and following 
the blebs would in itself be sufficient to differentiate 
the disease from true pemphigus, the affection with 
which it might be confounded. 
In considering pemphigus, .Devergie,1 under the 
heading, “pemphigus compose,” gives a case with 
the title, “ herpes pemphigoide, ” as follows : “The 
patient was a woman, fifty years of age, who had 
ceased menstruating five years before. The disease 
began with itching, followed by an inflammatory 
patch covered with large vesicles, which rapidly 
passed into blebs. Soon various regions were in- 
vaded, until the whole surface was well covered with 
eruption. Large red patches, more marked on their 
periphery than at the centre, surrounded by one or 
two rings of blebs, crusting in the centre, formed 
from time to time. The itching was especially 
marked on the periphery of the patches. The pa- 
tient recovered. 
under the latter he makes three varieties; first, le 
pemphigus bulleux successif; second, le pemphigus 
foliace; third, le pemphigus prurigineux. The last 
variety, which he illustrates with a case, should it 
seems to me be regarded as an example of the com- 
bined vesicular and bullous varieties of dermatitis 
herpetiformis. The patient was a woman thirty-five 
years of age, who had already had nine children, 
and was at the date of observation at the close of 
the last month of her tenth pregnancy. Since her 
second pregnancy she had suffered, coming on some 
weeks after conception, from an itching eruption, 
involving the whole general surface, characterized 
by blebs the size of a walnut. At the same time the 
skin became brown, and the seat of a viscid secretion. 
Tne symptoms were augmented up to the time of 
delivery, after which they subsided insensibly. 
Under the title of “pemphigus,” Klein1 gives the 
notes 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 be 
adopted, must be looked upon as another instance 
of the combined vesicular and bullous varieties of 
dermatitis herpetiformis. The case was that of a 
woman 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’s 
egg, with contents at first clear but later becoming 
turbid. 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,” which 
were read before the New York Dermatological 
Society, and which it seems should be regarded as 
examples of that disease. The first case was a married 
lady, 40 years of age, “ who presented a very anom- 
alous eruption, which was then composed largely of 
bullae.” Three months previously, while in Europe, 
the disease had been diagnosed eczema by several 
dermatologists, and was there treated, but with little 
success. The description given by Dr. Bulkley, 
especially as relates to the bullae; the “moist exuding 
portions of surface;” the “almost unbearable itch- 
ing;” the constitutional disturbance; the wide extent 
of the eruption; and the course of the disease, are 
peculiar and unusual. The case, I think, should 
rather be classed as an instance of dermatitis herpeti- 
formis than as one of so-called hydroa, the existence 
of which latter disease, viewed as a distinct process, 
I am not willing to admit. 
In the second case occurring in a married lady aged 
26, the first outbreak consisted of ery.hematous 
patches, which burned and smarted, and passed away 
in a few days. Six weeks later there was an attack of 
As in Chausit’s case quoted, the multiform erythe- 
matous patches here were marked features in the 
manifestation; also the subsequent evolution of the 
lesions, all suggesting a peculiar process. This might 
be 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 herpetiformis 
in some cases manifests itself with many of the clini- 
cal features of erythema multiforme. Its relation to 
this disease is a question in my mind already ripe for 
discussion. 
Devergie also alludes very briefly to “pemphigus 
herpetiforme,” which, he states, he has frequently 
seen invade the whole body, the patient succumbing 
to 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. 
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 there 
was irritation of the skin, red erythematous patches, 
and blebs, occupying both arms and forearms, left 
shoulder and back, left leg and face. In both cases 
there were marked neurotic elements. 
symptoms. Up to this time it seemed to be a simple 
eczema. About the fourth week irregularly scattered 
large blebs appeared on the buttocks and lower ex- 
tremities, with sudden loss of appetite, increased fre- 
quency of pulse, higher temperature, and other signs 
of constitutional disturbance. The patient began to 
fail rapidly, the disease now taking on the form of a 
malignant pemphigus foliaceus, and died; the whole 
disease ran a rapid course of seven weeks. The 
case presents certain cutaneous symptoms common 
to 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 upon 
disturbance of or changes in the nervous system. 
I shall only allude to two other cases. In an 
article bearing the title “ Über die coincidenz von 
Erkrankungen der Haut und der grauen Achse des 
Riickenmarkes,” Jarisch1 gives the particulars of an 
unusual case, upon which his observations on the 
spinal cord were based, with the diagnosis “herpes 
iris,” to which I must refer. The patient was a 
married woman sixty-one years of age. In 1874 
she is said to have had disseminated blebs upon 
her face and on the arms, which disappeared spon- 
taneously. In 1879 s^ie was admitted to the Vienna 
General Hospital with an abundant, symmetrically 
disposed, vesicular, bullous and pustular eruption 
confined almost exclusively to the upper half of the 
body, including the upper extremities and head. The 
face and scalp were much swollen, reddened, and 
covered with crusts or with isolated and grouped blebs 
seated on a dark bluish-red base. Both arms and 
forearms showed a large number, for the most part 
grouped, of pin-head sized papules and vesicles, with 
hazel-nut sized blebs or epidermis elevations the size 
of a dollar seated upon inflamed skin. Upon both 
surfaces of the thorax the epidermis in patches the 
size 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, slightly 
scaly papules occurred in groups. The epidermis of 
both soles of the feet was raised in the form of a hem- 
orrhagic bleb. The mucous membrane of the tongue 
was dried, the rest of the mouth swollen, reddened, 
and in places excoriated. There was considerable 
fever, and the patient was very weak and debilitated. 
Some days later the eruption disappeared in great 
part, and was followed by scaling, crusting and 
brownish pigmentation. In the course of the 
next month the patient suffered new eruptions of 
vesicles, bedsores, abscess, and died ; the autopsy 
disclosed Bright’s disease of the kidney in the third 
stage and lobular pneumonia, with changes in the 
spinal cord extending from the third cervical to the 
eighth dorsal vertebra. The disease of the skin, it 
will be remembered, extended from the vertex to the 
region of the navel. In the report nothing is said 
of the subjective symptoms. I have referred to the 
case because it has sufficient points in common with 
dermatitis herpetiformis to warrant its being classed 
here rather than eLewhere. 
REPORT OF TWO CASES OF 
PERFORATION OF THE MASTOID CELLS FOR 
SUPPURATION OF THE MIDDLE EAR. 
By J. D. STRAWBRIDGE, M.D., 
In December last, while visiting with Dr. George 
Strawbridge, the Philadelphia Dispensary for Diseases 
of the Eye and Ear, at the corner of Thirteenth and 
Chestnut Streets, a child was presented with a large 
abscess of the mastoid. The abscess was opened, 
and in the conversation which followed, I was asked 
by Dr. Strawbridge, “How do you open the mastoid 
cells?” I answered, “ I have done it with a gimlet 
The expression of incredulity which passed over the 
countenances of several gentlemen present, is the 
r.iativti7 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 if 
it had occurred but yesterday. The date has been 
fixed from the recollection of several persons then 
residents in the vicinity, who saw the patient during 
his illness, and knew of the operation. 
Case I.—G. R., Englishman, puddler, while at 
work in a rolling mill, was taken with pain in his 
right ear. Was attended by an irregular practitioner 
for over six weeks. While visiting in an adjoining 
house, I was called in haste to see this man, who was 
thought to be dying. I found him propped up in 
bed, in a stupor, with low muttering delirium from 
which he could not be roused, the whole left side of his 
head was one enormous abscess, the scalp was raised 
up from more than half the cranium, the swelling 
extended nearly across the forehead, around and 
beneath the eye, closing it. Over nearly the whole 
side of the face, and down the neck, both in front 
and behind the sterno-mastoid muscle, the auricle 
was 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 could 
scarcely be recognized as a human head. Without 
the least expectation of saving life, I determined to 
evacuate the abscess and await results. I made a 
free incision behind the ear down to the bone, a 
second over the anterior inferior angle of the parietal 
bone, and a third in the face in front of the ear : 
from these three openihgs more than half a pint of 
horribly offensive pus discharged during my presence. 
OF DANVILLE, PA. 
Another peculiar case worthy of record here is that 
reported by Dr. P. Meyer,2 of Slrassburg, with the title 
“a fatal pemphigus-like dermatitis with changes in the 
nervous system,” occurring in a previously healthy 
and well-nourished man sixty-five years of age. The 
disease began as a diffuse “eczema,” showing the 
varieties “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.