CASE OF DERMATITIS HERPETIFORMIS 
CAUSED BY NERVOUS SHOCK. 
LOUIS A. DUHRING, M. D., 
rttOFKSKOR OP SKIN DINSAMKM IN TUK UMVKUMTV OP PRNNNVI.VANIA. 
rsuM 
THE AMERICAN JOURNAL OF TUK MEDICAL SCIENCES, 
January, IRHS Extracted from the 
American Journal of the .Medical Sciences for January, 188 R. 
CASE OF DERMATITIS HERPETIFORMIS CAUSED 
BY NERVOUS BHOGK, 
Hy LOUIS A. DUHRING, M.D., 
Professor of Skin Diseases In the University of Pennsylvania. 
In November, IK7H, I was asked by my friend, the* late Dr. F. F. 
Maury, to see a “curious case of bullous skin disease’* under his care. 
It proved to be a market! example of what I have described as dermatitis 
herpetiformis.1 The following notes, which I think worthy of record, 
were made at the time. The disease was then fully expressed, and showed 
the lesions not only in abundance but in all stages of development. 
The patient (Capt. K—) is a man thirty-four years of age, of large 
frame, stout and strong, and in the enjoyment of good general health, lie 
never experienced any disease of the skin until six weeks ago, when the 
present eruption made its appearance. There is no family history worthy 
of record. 
While gunning in the meadows, he unexjiectedly found himself in a 
bog of soil, blackish, strong-smelling earth, into which he sank deeper 
with every step, lie at once recognized the nature of the spot and the 
danger, and endeavored to extricate himself, but this proved no easy 
matter, for with every step he sank deeper into the mire, until in a short 
time he was buried up to his armpits. He realized his extreme danger, 
and looked forward to a speedy and miserable death. After struggling 
for a full half hour in the above predicament he succeeded in seizing a 
tuft of grass just within reach. Hy gradually working himself loose and 
pulling on the grass he finally, in an exhausted state, managed to reach 
firm ground. lit; was carried home in a weak condition, bathed and 
cared for. Three days after this adventure, which had greatly shocked 
his whole system, the eruption appeared in the form of small, variously 
shaped, round, oval and angular vesicles, or small “ blisters containing 
clear fluid.*' 
They came out in number, and were scattered over the flexor surfaces 
of arms and forearms. When first noticed they were pin-head in size, 
and were not accompanied hy areolae, but seemed to rise directly from 
the sound skin ; two days later, however, inflammation surrounded their 
bases. At first they were free of itching, but towards the fourth or fifth 
day, by which time they had slowly grown to the size of peas, this symp- 
1 Communication read before the Section on Medicine of the American Medical 
Association, May 0, 1884. Journal of the Am. Mod. Assoc., Aug. 30, 1881. Sec, also, 
Auku. Jcjl un. ok Med. Soi., Oct. 1881. 2 
tom set in violently. On the second day of the attack scattered lesions 
of the same character appeared here and there over the trunk, legs, and 
thighs, and were especially numerous on the posterior surfaces of the 
thighs, over the shins, and about the ankles, and were quite symmetrically 
distributed. On the trunk they were on the back, chiefly between the 
scapulae, and on the abdomen about the umbilicus and pubes. On the chest 
they were few in number and disseminated. 
By the fifth or six day they had attained the size of largo peas—in 
short became blebs: were tensely distended with clear, serous contents; 
showed no disposition to rupture; and were accompanied with slight 
areolae. The itching now became annoying and was constant, the desire 
to scratch being uncontrollable. The general health remained good ; no 
chilliness or fever. About this date he was rubbed with olive oil, which 
aggravated his condition, the skin by the next day becoming hot and 
more irritable. New lesions continued to appear, especially on the back, 
and the older ones increased in size without showing any sign of rupturing, 
and where two or more were in close proximity they often coalesced. 
From the sixth to the thirteenth day he had no rest, the itching being 
of the most harassing character. About the eleventh day the lesions 
became darker, the contents showing a distinct orange-yellow color, and 
instead of being serous in character were thicker and of a “jelly-like” 
consistence, so that when the blebs opened with a knife tin* mass could be 
removed as a semi-solid gelatinous substance. On the fourteenth day the 
skin generally and the lesions assumed a dark-reddish, bluish-red color, 
while the latter contracted and in a few days became crusted and hard, 
so that with his finger he could “ knock them off,” a dark-reddish stain 
remaining. The eruption at this date was at its height. The blebs were 
very numerous, the whole surface being literally covered. The scalp, face, 
ears, penis and scrotum, and even the verge of the anus, were attacked, the 
palms and soles being tin* only regions that escaped. The mouth was like- 
wise unaffected. The lesions varied in size from a pea to a walnut, the 
average size being that of a silver dime ; the larger ones were generally 
formed by the coalition of two or more lesions. They were semi-globular 
in shape, tensely distended, and in no instance flattened or umbilicated. 
None burst spontaneously, but many were ruptured by violence ; they 
invariably burst with “ a crack” or “ explosion.” As already stated, crust- 
ing took place in the course of a few days, the crust being of a yellowish- 
brown or dark-brown color, and not bulky. After these became detached, 
he observed about tin* bases of the original lesions a few small pin-head 
sized “ whitish points” or pustules, which multiplied and grew rapidly, 
itched, and burned; were raised; ran together in many instances ; and in 
four or five days developed into large yellowish pustules, some of them 
being as large as cherries. Nearly all of these lesions, hundreds in 
number, were punctured, the walls collapsing and the contents flowing 
freely but being somewhat turbid. This outbreak constitutes what he 
terms the second attack. The lesions were as abundant as in the first 
attack, and while showing a disposition to appear on the sites of the old 
lesions yet came out also on sound skin. Poultices were applied, and 
later crusts formed as before, which in the course of a few days became 
detached, leaving dark-reddish spots and stains. 
He now rapidly recovered and remained nearly well for a week, when 
the third attack set in. This was ushered in by malaise, chills, heat, 
nervousness, and a general itching of the surface, the eruption developing 
much more rapidly than before. The lesions were for the most part 3 
distinctly pustular in character, the others being vesica-pustular, vesi- 
cular and bullous ; were flat, surrounded with inflammatory areolae, and 
itchy. They appeared only on the extremities and over the abdomen. 
They differed in their distribution from the former lesions in being 
grouped, two, three or more manifesting themselves in close proximity, 
often coalescing. 
Present Condition.—November 22, 1878. He is now suffering with 
the remains of the third attack, just described, to which within the week 
has been added a fourth outbreak. New lesions have been coming out 
from day to day. lie is confined to bed, and is suffering with a profuse 
multiform eruption occupying the greater portion of the general surface. It 
consists of vesicles, blebs, vesico-pusfu/es, and pustules of various sizes and 
shapes, and in all stages of evolution ; erythematous (light and dark red) 
patches and stains, for the most part the remains of former lesions ; exco- 
riations and scratch-marks, and crusts, though these latter lesions are by no 
means abundant. The multiformity of the lesions is striking. Vesicles, 
blobs, and pustules are in about equal proportion, and arc mi intermingled as 
to exist side by side. The vesicles and blebs may he first considered, and 
I speak of them together for it is impossible to draw a line of distinction 
between them ; the difference is merely of size. They exist in large 
numbers, in hundreds. They vary in size from a pin-head to a walnut 
and larger, the majority averaging between a split pea and a hazel-nut. 
They are semi-globular or flat in form, and are either tensely distended or 
flaccid, the former condition existing in all of the smaller lesions. They 
rise abruptly from the surrounding skin to tin* height of from one to 
several lines, have moderately thick walls, similar to the lesions of pem- 
phigus, and show no disposition to rupture spontaneously. There is no 
sign of umbilication. They are of all shapes, the majority being circular 
or ovalish ; but some are irregular in outline and show angular, 
“ puckered” borders, as is often seen in herpes zoster, in which event they 
are usually surrounded with bright-red, highly inflammatory areolae. 
Many of the vesicles and blebs ri>e up without areola*, looking like mag- 
nified sudamiim. They have a pearly or pale-yellowish color, and, as in 
the case of other similar lesions, refract light, which gives them a 
glistening appearance. The contents are for the most part clear, but 
some are cloudy and in many instances are more or less tinged with blood, 
producing a mottled or streaked bluish-red hemorrhagic look. 
The pustules are likewise in all stages of evolution both as to size and 
extent of puslulation. Some are distinct pustules no larger than pin- 
heads, flat or semi-globular in form, and circular or irregular in outline ; 
while others of the same size and larger have evidently been vesicles and 
blebs, and are passing into pustules. Still others are the size of peas and 
cherries and are distinctly pustular, like the lesions of true simple 
impetigo, and contain whitish pale-yellowish puriform contents. Some 
are in a perfect state of preservation, semi-globular or accumulate in form ; 
others are more or less collapsed. As staled, inflammatory areola* surround 
almost all of the larger pustules. 
As regards distribution, no region is free except the palms of the hands. 
It is a very general eruption, the lower extremities exhibiting the most 
lesions. The flexor surfaces are especially invaded. I'pon the thighs 
and legs there is not a square inch that is nut the scat of disease. The 
skin which is not occupied by distinct lesions is dark red and violaceous in 
color. The ankles are literally encircled with blebs and pustules, many 
of which have run together forming large, elongate, flaccid, partly bloody, 4 
dependent blebs. There is everywhere a tendency for the lesions to 
group, and while owing to their great multitude this is not striking in all 
regions, it is nevertheless very manifest in certain localities, as on the 
buttocks and thighs. The groups are for the most part small, consisting 
of from three to five lesions situated within a radius of an inch. In other 
places a dozen or more lesions occupy an area the size of the palm of the 
hand. 
A peculiarity of the lesions is their disposition to coalesce. Inclining 
to manifest themselves in ill-defined clusters of two, three or more, as 
they increase in size they run together, forming larger lesions. Around 
the immediate circumference of these lesions, whether vesicular or pustu- 
lar, smaller, flat pustules or vesicles, the size of pin-heads, an; in many 
instances present. When ruptured the lesions crust over with flat, light, 
yellowish crusts. Removing these, superficially excoriated, moist, reddish 
surfaces, having sharply defined irregular vesicular or pustular borders are 
exposed to view. Kverywhere about the older lesions there is noted a 
disposition on the part of the process to extend itself in a creeping manner 
while healing in the centre. Itching is present, and is very distressing. 
Dec. 11). A month has elapsed since the last note. During this period four 
distinct attacks or crops of eruption have manifested themselves. 'The 
lesions in the first three attacks were of the same character as those in 
the outbreak of November 22d, just described at length, namely, vesicles, 
blebs and pustules, with but little inclination to intermediate forms, while 
in the present eruption vesico-pustulet predominate. The last two attacks 
have been milder, with smaller lesions, but accompanied with more itching. 
The general course of the disease, the disposition of the lesions to (dus- 
ter, and the regions invaded, have been the same as on previous occasions. 
At present the eruption is characterized by many small, and some large, 
variously shaped, veticlet, vesiro-pustules and puatulra, occurring in patches 
or scattered over the surface, in all stages of evolution, together with 
numerous excoriations, ruptured or torn lesions, crusts and scales seated 
upon a dark-red, violaceous, mottled, pigmented skin, the remains of former 
attacks. The patient i> able to be about the house; his general health is 
good. He has used lately alkaline tarry lotions. Arsenious acid, in doses 
of one-fortieth of a grain, has also been taken for the last three weeks; 
also quinia, and a general tonic treatment. 
In December, IHH2 (four years after the last note), I received a note 
from the patient, slating “ I am still troubled with the disease,, and it has 
not failed to put in an appearance at certain periods since you saw me in 
IH7H, although tin; blisters and pustules have gradually become less, both 
in number and in si/;;. At certain times since, within the year, I was so 
free of eruption that at one time I thought surely I was rid of my pest. 
I can always tell two or three days before the eruption will appear by the 
coming on of an itching sensation. During the past six months I have 
had two attacks.” 
The history of this case, including the cause of the disease—a violent 
shock to the nervous system, is both interesting and instructive. The 
bullous variety predominated, and when I first saw him, it was highly 
developed; subsequently, however (as in almost every case that I have 
encountered), other lesions, especially pustules, manifested themselves. 
The constitutional symptoms accompanying one exacerbation were 
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