NOTES OF A CASE OF DERMATITIS HERPETIFORMIS, 
EXTENDING OVER ELEVEN YEARS, 
ILLUSTRATING THE SEVERAL VARIETIES OF THE DISEASE. 
BY LOUIS A. DUHRING, M.DJ, 
Professor of Skin Diseases in the University of Pennsylvania. 
[•REPRINTED FROM THE PHILADELPHIA MEDICAL TIMES FOR JULY 12, 1884.] 
IN the following case the pustular, vesic- 
ular, bullous, and papular manifesta- 
tions of the disease* were all developed 
on one or on several occasions during the 
long period the patient was under my ob- 
servation. The characteristic features of 
the affection are clearly defined in the 
history, the notes of which, it may be re- 
marked, were recorded at the time of each 
examination. 
while better, and even nearly well, at times, 
it had never entirely left him ; it was the 
source of great annoyance to him, itched 
considerably, manifested itself in different 
forms from time to time, and was apt to ap- 
pear in distinct crops from week to week or 
month to month. He was not aware that he 
had ever contracted syphilis, but several 
physicians had assured him that the pres- 
ent eruption was a manifestation of this 
malady. 
James W., set. 38, a native of Philadel- 
phia, and a wood-carver by occupation, 
was admitted to the Philadelphia Dispen- 
sary for Skin Diseases, January 16, 1873. 
According to the notes in the record-book, 
he was suffering from an imperfectly de- 
fined inflammatory, multiform eruption, 
composed of erythematous spots and 
patches which had evidently been the seat 
of previous disease, papulo-vesicles, pus- 
tules, and excoriations. It occupied the 
general surface, with preference for the 
arms and forearms, sacral region, buttocks, 
and thighs. The lesions were not very nu- 
merous, and were disseminated, except over 
the sacral region, where a dozen or more 
formed a conspicuous patch. The disease 
appeared to be fading away, and, inasmuch 
as the patient gave a history of having re- 
cently had quite active treatment, internal 
as well as external, and that he had been 
treated for supposed “ secondary syphilis,” 
the diagnosis was for the time being with- 
held. According to a note, the eruption 
resembled that resulting from the internal 
use of the iodide or the bromide of potas- 
sium. 
He was placed upon a simple tonic treat- 
ment until the diagnosis might be more 
definitely ascertained. 
January 25.—New pustular lesions have 
appeared on the buttocks and on the thighs. 
These are highly inflammatory, flat, and 
incline to crust in the centre and to 
spread on the circumference. Alkaline 
lotions and baths were ordered; also a 
saline aperient. 
February 8. Considerable improve- 
ment, the disease being in about the same 
state as when the patient first came under 
observation. 
February 12.—New lesions are appear- 
ing. 
February 19.—The disease has been man- 
ifesting itself chiefly on the arms and on 
the buttocks, new pustules making their 
appearance from day to day. 
February 24.—No new lesions; con- 
dition decidedly better. 
March 19.—There has been steady im- 
provement since last note. The remedies 
used during the past two months have been 
syrup of the iodide of iron; bitartrate of 
potassium from time to. time; and a car- 
bolic acid lotion. 
May 12.—The disease continued im- 
proving during the last two months until 
within the present week, when a crop of nev 
pustular lesions began to appear, scattered 
He stated that he had been suffering 
from the disease for five years, and that 
* For an account of Dermatitis Herpetiformis the reader is 
referred to my paper read before the American Medical As- 
sociation, May 6, 1884, abstracts of which may be found in 
Hem York Medical journal, p. 562, May 17, 1884, and in 
Philadelphia Medical Times, p. 603, May 17, 1884. 2 
NOTES OF A CASE OF DERMATITIS HERPETIFORMIS, 
here and there over the general surface, 
especially upon the arms, buttocks, and 
thighs. The patient enjoys average gen- 
eral health, notwithstanding the eruption, 
which now is abundant, and is unusually 
active. 
formed papules and papulo-vesicles, which 
closely resembled eczema. He was again 
placed upon a preparation of iron, and a 
saline aperient, the bowels being habitu- 
ally constipated. 
November 18.—The eruption has en- 
tirely disappeared, leaving the skin pig- 
mented in dirty-yellowish, brownish spots 
and patches, and in some places deprived 
of the normal pigment, dirty-whitish 
patches existing. 
It may be described in its present state 
as a pustular form of disease, the lesions 
beginning as pin-head and split-pea sized, 
flat pustules with extensive, bright-red are- 
olae. They increase rather slowly in size, 
and soon begin to crust over with a yellow- 
ish-brown crust, after which they continue 
to increase in size by new, small, flat, pin- 
head sized pustules forming on the per- 
iphery. This process goes on until the 
lesions assume the size of a dime or quar- 
ter dollar, when it ceases and a crust cov- 
ering the whole remains. The crust is ad- 
herent from the beginning; if detached, it 
shows a circumscribed, superficially exco- 
riated surface, covered with a puriform 
fluid. Later, at the end of two or three 
weeks, the crust drops off, leaving a dark- 
red, infiltrated spot, but no scar. These 
inflammatory infiltrations are slow to disap- 
pear, weeks being necessary for the larger 
ones to become effaced. 
March 3, 1874.—Four months have 
elapsed since the last note. The disease 
has during this period been “better and 
worse.” There have been several re- 
lapses, which have continued a fortnight 
or longer and have disappeared as before. 
The patient has taken arsenic in the form 
of liq. potass, arsenit. in from two- to four- 
minim doses, but without benefit. Of late 
he has been using strong drink in excess, 
which, he states, is pretty sure to cause an 
exacerbation of the eruption. A new crop 
of lesions is to-day making its appearance. 
The character of the disease has again 
changed, the lesions now being vesicular 
and pustular, especially the latter, similar 
to the form of eruption that existed a year 
ago. The single lesions resemble ecthyma, 
while those in groups or patches bear a 
close resemblance to pustular eczema. 
March 13.—New lesions are here and 
there manifesting themselves, the neck, 
lower portion of the back, buttocks, 
thighs, and arms being the regions chiefly 
invaded. Iron and arsenic are still being 
taken, and various antipruritic lotions and 
ointments have been employed, with, how- 
ever, but little benefit. 
About the buttocks and sacral region 
and on the thighs the lesions show a dispo- 
sition to occur in patches, and, moreover, 
to group, two or three not infrequently 
existing in such close proximity as ulti- 
mately to run together. Over the arms 
and elsewhere this tendency is not so no- 
ticeable ; nor are the lesions here so well 
defined and large as on the back and 
thighs. 
May 26.—The outbreak was at its 
height when the last note was recorded, 
since which date the eruption has been 
steadily declining. 
November 3.—The patient has absented 
himself for six months. He states that he 
continued to improve through the summer, 
and that only within the last two months 
has the disease again become annoying. 
He was almost free from eruption at one 
period during the summer. Lately the 
disease has manifested itself in another 
form, the lesions being decidedly papular 
rather than pustular, and in distribution 
more scattered than formerly, and also 
much more itchy. Upon examination, the 
eruption was seen to have changed its char- 
acter completely and to consist of dissem- 
inated, here and there distinctly grouped, 
variously sized and shaped, imperfectly 
April 3.—The pustular character of the 
eruption has ceased, and variously-sized 
herpetic vesicles and small blebs have lately 
developed. Many of them are as large as 
split peas. They appear quite suddenly 
and are very itchy. The disease has lately 
attacked the folds of the axilla and the 
pubes, which regions have become exten- 
sively crusted. 
April 24.—The surface has again cleared 
off, only a trace of the former eruption 
remaining, in the form of primary lesions, 
but scratch-marks and pigmentation are 
everywhere present, the whole integument 
having a dirty, muddy, mottled look. Has 
been taking arsenic steadily; general health 
has remained good. 
April 30, 1877.—Three years have 
elapsed since last note, and since the EXTENDING OVER ELEVEN YEARS. 
3 
patient has been seen. The disease still 
exists, with the same history as formerly, 
the lesions being variable, papules, pustules, 
and vesicles occurring from time to time. 
During the past six weeks there have been 
several slight relapses and again a change 
in the character of the lesions, indistinctly 
defined, flat, variously sized and shaped 
papules appearing together, with here and 
there ill-defined abortive pustules and pap- 
ulopustules. These lesions now exist. 
The patient considers himself, upon the 
whole, considerably improved. He has 
been taking the arsenic from time to time, 
in varying quantity, from one to five min- 
ims thrice daily. 
taining a clear fluid.” They have had a 
disposition to cluster, but there have also 
been many isolated, single lesions. They 
have been very itchy, so much so that he 
lost no time in scratching and rupturing 
them. He does not know whether they 
ever ruptured spontaneously, for he has 
invariably opened them as soon as they 
appeared. Lately all regions of the sur- 
face, except the palms and soles, have 
been attacked, the scalp even being the 
seat of numerous lesions, but preference 
is still shown for the regions before in- 
vaded. 
March 2, 1879.—During the past two 
months he has been better than usual, the 
most annoyance being due to consider- 
able eruption, vesico-pustular in character, 
about the scrotum. He has been drinking 
of late, with the hope, he states, of “bring- 
ing out the disease,” but thus far without 
success. He has been better this winter 
than during any period within the past ten 
years. He is positive that the various 
forms of treatment employed have had 
little or no influence in controlling the 
disease. He is about as free of the erup- 
tion in summer as in winter, the seasons 
exerting no special influence upon his 
condition. His general health remains 
fair, although, owing to his irregular 
mode of life, he is dyspeptic, and, as a 
rule, is constipated. 
January 15, 1879.—A year and a half 
has passed since the patient was last ex- 
amined. He states that he has but little 
change to report. He has not been free 
of the eruption, and has had two very 
severe attacks and many slight ones. The 
severer attacks have continued three or 
four weeks, while the lighter ones come 
and go from week to week. He has had 
the eruption so constantly of late that no 
particular note has been made as to the 
occurrence of distinct outbreaks. The 
lesions have been coming and going with- 
out intermission. Within the year the le- 
sions have been for the most part vesicular 
and bullous, or, as he expresses it, “ they 
have been blisters of various sizes, con-