A Case of Dermatitis Herpeti- 
formis (Bullosa). 
Louis a. duiieing, m. d., 
PEOPESSOK OP SKIN DISEASES IN THE UNIVEESITY OF 
PENNSYLVANIA. 
BY 
REPRINTED PROM 
Koto Yodt J&tiucal Journal 
for July 19, 188J A CASE 
OF 
DERMATITIS HERPETIFORMIS 
{BULLOSA). 
BY 
LOUIS A. DUHRING, M. D., 
PROFESSOR OF SKIN DISEASES IN THE UNIVERSITY OF PENNSYLVANIA. 
REPRINTED FROM 
THE NEW YORK MEDICAL JOURNAL 
FOR JULY 19, 1884. 
NEWYORK; 
D. APPLETON AND COMPANY, 
1, 3, and 5 BOND STREET. 
1884, A CASE OF 
DERMATITIS HERPETIFORMIS (BULLOSA). 
On February 3,1879, the patient, the notes of whose case 
are about to be given, was sent to me by Dr. H. G. M. Kol- 
lock, of Newark, Del., who in his letter stated that the dis- 
ease was regarded as pemphigus. The man had been under 
treatment for some months, during which period he had 
taken quinine, iron, and arsenic, and had used varied reme- 
dies locally, all without relief. Dr. Kollock’s letter states: 
“ He has not had a full crop of bullae for about two weeks, 
prior to which they would appear in great numbers every 
two or three days. He has never been entirely free from 
them.” 
The patient, Newton B. E. by name, was admitted to 
the University Hospital, at which date the following record was 
made: He is sixty years of age, tall and slender, somewhat 
emaciated, debilitated, and nervous; he is a native of Dela- 
ware, a shoemaker by occupation, and is married. There is no 
special family history. He never suffered any disease of the 
skin, except occasional attacks of inflammation from poison- 
ivy, until eight months ago, when the present disease appeared. 
He was at the time in average health, and could attribute the 
outbreak to no cause. It began about the ankles and feet with A CASE OF DERMATITIS HERPETIFORMIS. 
swelling, heat, and violent itching; the following day eruption 
manifested itself on the arms and around the neck, and later on 
the trunk. Several household remedies were applied, but the 
disease spread until at the end of a week he was well covered 
with a mixed eruption consisting of papules, vesicles, and blebs, 
the latter predominating, and some being as large as a walnut. 
Upon bursting or being ruptured, the walls adhered to the skin 
and formed crusts. Successive crops of blebs continued to ap- 
pear until a fortnight ago—in all, during a period of eight 
months. He has lost flesh, as much, be thinks, as fifty pounds. 
A new outbreak of eruption is now manifesting itself. 
Present Condition.—The disease of the skin is almost uni- 
versal, involving the greater part of the general surface from 
the scalp to the soles of the feet. It is made up of variously 
sized and shaped vesicles, Nebs, and pustules, in all stages of 
evolution. 
The vesicles predominate and vary in size from a pin-head 
to a pea, the majority being as large as small peas. They are 
notable for their irregularity of shape, being for the most part 
very irregular, and in many instances angular in outline. Some 
are raised to the height of a line, others are flat. They are 
distended and have a glistening, glazed look, and, as a rule, are 
not surrounded by any areola, rising abruptly from the surround- 
ing healthy skin. They are yellowish and contain serous con- 
tents, as in the case of the early stage of herpes zoster. 
The blebs, some raised, others inclining to flatten, are met 
with here and there on the neck, arras, thorax, abdomen, thighs, 
legs, feet, and hands. Some are as large as a pigeon’s egg. 
They are manifestly advanced stages of the vesicles, or at least 
often grow from these lesions. They are as a rule tensely dis- 
tended and have clear contents; some show cloudy contents and 
are flaccid. They do not rupture spontaneously. Their con- 
tents are alkaline. 
The pustules are present in like manner here and there, dis- 
tributed over the same regions. They are distinctly pustular, 
having whitish contents and more or less inflammatory areolae ; 
are small, raised, irregular in outline, though less so than in the 
case of the vesicles, and have a “ puckered ” or “drawn up” A CASE OF DERMATITIS HERPETIFORMIS. 
5 
appearance. Excoriations and blood-crusts are conspicuous, 
and are plainly the result of prolonged scratching. Yellowish, 
brownish, “ dirty-looking ” patches of pigmentation, giving the 
skin the appearance of chronic pediculosis corporis, are also 
prominent symptoms. The itching and burning are most dis- 
tressing. They interfere with sleep at night. New lesions in 
great numbers are beginning to form. Some of the earliest are 
flat papulo-vesicles. They can be felt with the linger as small 
circumscribed infiltrations even before they become visible. In 
some localities there is a marked tendency for all the lesions 
to group, two, three, or four being crowded together into a 
cluster; in other places they are disseminated. Here and there 
blebs are surrounded concentrically by a variable number of 
small, flat, whitish pustules of the size of pin-heads, making a 
striking combination. 
February 7th.—During the last three days lesions of all 
kinds have appeared, accompanied by intense itching and burn- 
ing. Some of the blebs have attained the size of walnuts. On 
the forehead an abundant crop of variously sized and shaped 
herpetic vesicles are present. 
28th.—A fortnight ago the attack was at its height, vesicles, 
blebs, and pustules, as well as intermediate forms, existing in 
profusion. Almost the whole integument was invaded, scarcely 
a square inch being exempt. The blebs frequently reached the 
size of a hen’s egg; the pustules flattened, seldom exceeding 
the size of a dime or a quarter-dollar. They spread periphe- 
rally, inclining to dry and crust in the center. The course of 
both these lesions was rapid, disappearing in four or eight days, 
followed by crusting and pigmentation. 
The general condition remained fair, there being no marked 
febrile disturbance, although the appetite was impaired, and the 
patient was weak, nervous, and much distressed in mind and 
body. With the cessation of new lesions the itching and burn- 
ing declined, but did not leave entirely. Tbe treatment con- 
sisted of a generous diet, with saline laxatives and small doses 
of arsenic and strychnia, together with anti-pruritic lotions of 
carbolic acid and tar. The man remained in the hospital several 
weeks longer, during which time he improved with remarkable 6 
A CASE OF DERMATITIS HERPETIFORMIS. 
rapidity. I can not, however, attribute the recovery altogether 
to the remedies used, knowing well as we do the singularly arbi- 
trary course the disease usually pursues. 
About three years afterward (December 20, 1882) I received 
a letter from Dr. Kollock (under whose care the patient had 
since been), stating that he had not seen the man for a year, 
but that, “ according to last accounts, he had improved markedly 
in general health as well as locally under a tonic treatment. 
The eruption has appeared at longer intervals, and is confined 
to smaller areas. He seemed to derive great relief from the 
application of a lotion containing corrosive sublimate and alco- 
hol.” Since this date I have heard nothing. 
The case represents more particularly the bullous variety 
of the disease, although its multiformity, as in almost all 
instances, was repeatedly shown. As I have so recently de- 
scribed this remarkable disease in a paper * read before the 
American Medical Association, comment here is scarcely 
necessary. It may be stated, however, that the case illus- 
trates the vesicular and bullous lesions as they usually occur 
in the course of the disease, the latter predominating. The 
resemblance to pemphigus is obvious, but I think it will be 
seen that the process is different, and that it can not be 
viewed as a variety of this disease. 
* Abstracts may be found in the “ N. Y. Med. Jour.,” May IV, 1884, 
p. 562, and in the “Phila. Med. Times,” May IV, 1884, p. 603. The lew York Medical Journal, 
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