NOTES ON DERMATITIS VENENATA

BY

JAMES C. WHITE, M.D.BOSTON

Professor Of Dermatology in Harvard University

Reprintedfrom the Boston Medical and Surgical Journalof January 28, iBgj

BOSTONDAMRELL & UPHAM, PUBLISHERS

283 Washington Street1897

NOTES ON DERMATITIS VENENATA. 1

BY JAMES 0. WHITE, M.D., BOSTON,Professor of Dermatology in Harvard University.

I desire to present to the Association some briefnotes on the occurrence of forms of dermatitisvenenata produced by certain substances which werenot included in my work on this subject published in1887, because not previously met with by me. Someof these instances have been already published, 2 andwill only be referred to by title; the others are newto my own experience, and of them I find no referencein medical literature.

Inflammation of the skin induced by external agen-cies is of frequent occurrence, as illustrated by thefollowing figures taken from the reports of my clinicat the Massachusetts General Hospital during the lastseven years. In this period 20,000 new patients af-fected with skin diseases have presented themselves,among which were 360 cases of undoubted dermatitisvenenata. Of those occurring within the past twoyears the exciting causes were recorded as follows:rhus, 30; iodoform, 5 ; articles of clothing, 5 ; washesof unknown nature, 7 ; mosquito poison, 5; kerosene,4; furniture polish, 3 ; tincture of iodine, 3 ; chromicacid, 2; caustic potash, 2; carbolic acid, 2; causticlime, vapor of acid, balm of Gilead, mustard water,pyoctannin, croton oil, tincture of arnica, arsenic, tinc-ture of guiacum with vinegar, of each one. In 35 theparticular cause was not ascertained.

1 Read at Meeting of American Dermatological Association, Sep-tember8, 1896.

2 On Primula obconica, Garden and Forest, February 29,1889 ; Bos-ton Medical and Surgical Journal, May 1, 1890. On Poisoning by“Violet Water,”Boston Medical and Surgical Journal,December 12,1889.

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An analysis of the etiology of the cases extendingover the seven years would have without doubt addedmany other irritating agents to this list, but this willsuffice to illustrate the great diversity of their nature.The large proportion of unascertained causes recordedis interesting, and may ha explained in various ways:

(1) The lack of observation in patients. You allknow how well-nigh impossible it is to get from agreat majority of persons of all classes satisfactory in-formation as to the minutias of their doings of a fewdays back only. When, therefore, in your investiga-tion of the cause in a case of dermatitis venenata itbecomes important to learn just where the patient hasbeen, what he has done, and with what substances hehas come in contact during the week preceding thebeginning of the attack, one gets little assistance ordi-narily from his replies. It is so customary for thepatient to positively deny having been in this or thatsuspected situation, warranted by the appearances ofthe case, and later to return and say, “ Oh, I forgotthat I had done so and so,” that I ana accustomed toinform my class that, as a rule, they need not expectto learn the nature of the exciting agency in any caseuntil the second visit. When it comes to being con-scious of and later to remembering the chance break-ing of a twig by the roadside, the sitting for a momenton a stone wall, perhaps, and the hundred habitualincidents of daily life, any one of which may possiblybe connected with such dangers, it is not strange thatthe data for a satisfactory diagnosis are not generallysupplied by the patient.

(2) Then we must consider how great is the numberof substances ordinarily employed in the arts, with theirritating properties of which the workman is whollyunacquainted, so that he is not at all upon his guardagainst them. Managers do not always, I regret tosay, instruct their employees as to the necessary pre-cautions in such cases. Nor does the physician makehimself sufficiently acquainted with the processes andmaterials employed in the arts and trades, to recognize

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the nature of many such cases which come to him for re-lief, and to warn the patient against renewed dangers,

(3) Nor must we forget the constant discovery ofnew chemical compounds and their introduction intomanufactures of many kinds, substances of which wedo not even know the name, far less their compositionor properties. For such novel causes of dermatitisvenenata we must always maintain an expectant atti-tude. And new physical forces are beingemployed in the daily work of life, with the possibledangerous effects upon those engaged in the manipula-tion of which we should make ourselves familiar. Asan instance, we have all, no doubt, seen a considerablevariety of cutaneous changes exhibited by those whoare engaged in the various applications of electricityin the useful arts, not only the result of the agenciesemployed in its generation, but of the direct action ofthe mysterious power itself.8

It is not suprisiug, therefore, that we so often failto discover the immediate causes of artificial dermatitis.

Moreover, in considering the question of this or thatplant or other substance as the exciting cause of anevidently artificial dermatitis, with which the patienthas been in contact, we must always bear in mind theidiosyncratic vagaries of the human skin. Just as theindividual stomach will not tolerate articles of foodwhich are eaten with impunity by all mankind, sothere are individual integuments which are throwninto local excitement by contact with substances whichare handled by all other persons without harm. Evenplants which “ poison ” the great majority of personswho touch them, like the venomous species of rhus,fail to produce the slightest irritation upon thoroughapplication to the skin of a favored few. It is impos-sible to explain such individual susceptibility and ex-emption. We have to be satisfied with a word—•idiosyncrasy. But we must always be prepared torecognize the woi'king of such a law, and be Justified' 3 See Journalof December 3, 1896, for an account of severe derma-titis produced by exposure to Kontgen rays.

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accordingly in suspecting the commonest plant, or othersubstance, in any individual case we have to investigate.

And now let me call your attention to a brief de-scription of some cases of dermatitis venenata hithertocommonly unrecognized.

PARSNIP PASTINACA SATITA.A woman came to my office with hands and wrists

greatly swollen, and the dorsal surfaces of the formerthickly occupied by a papular-vesicular efflorescencein process of development. There was much heatand itching. Two days previously she had washedfive bushels of recently dug parsnips and wiped themwith a cloth. On the following day the inflammationbegan. The affected skin was of a peculiar luridcolor. No other explanation of the dermatitis wasapparent. As she lived at a considerable distancefrom Boston no subsequent observation of the casewas possible.

Speaking of this ease to my class, one of thestudents informed me that he had seen men and boyspresent a vesicular dermatitis of the hands and wristsafter weeding parsnips. As many as three or four ofa gang would be affected.

Very few of the umbelliferous plants contain princi-ples capable of exciting cutaneous irritation. In mybook on dermatitis venenata I mention but three:ferula gabaniflua, the source of galbanum; thapsiagarganica; and heracleum lanatum. The latter (cow-parsnip) is closely allied to edible parsnip in itsbotanical features, and its leaves when applied to theskin may produce vesication. Our garden parsnip(paslinaca) runs wild, it is well known ; and its rootis described as then degenerating in esculent proper-ties and becoming poisonous. It may be that bothfoliage and root retain under cultivation propertieswhich are irritating to some skins.

HAMAM'ELIS VIRGINIANA,

Can hamamelis produce inflammation of the skin ?

I was consulted by a man at the hospital, who had

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applied to his shoulder, on account of rheumatism, amixture of laudanum and hamamelis. The wholeupper chest, upper arm, and neck were occupied bylarge vesicles, oozing areas, and confluent papules.No other applications had been made. Of course,there is no certainty as to the composition of prepara-tions labelled hamamelis, and it is not impossible thatsome of the principles of laudanum may be irritatingto the skin of some persons, although I have neverknown it to act in this way.

Witch-hazel is used to such an enormous extent asa household external remedy that cases of cutaneousirritation should be familiar to us all, if it were possi-ble of exciting it except in the rarest instances. Onemanufactory in Boston is said to use a ton and a halfof leaves and three and a half tons of bark a year inthe preparation of the “ extract.” It must be placedin the suspected class.

OLEUM CASSLE,

I would record here an instance of inflammation ,o£the skin excited by oil of cassia, which was presentedby our associate, Dr. Greenough, at a meeting of theBoston Dermatological Club. I take the liberty ofmentioning it in his absence.

The patient was a girl engaged in dipping woodentoothpicks in oil of cassia for the purpose of givingthem an agreeable odor. A few days after enteringupon this occupation her hands began to show signsof irritation, and she was obliged to leave it after afortnight, at which time she was exhibited to thesociety by Dr. Greenough. The hands then smeltstrongly of cinnamon. Their dorsal and lateral sur-faces and the front forearms were greatly inflamed,and occupied by vesicles and oozing areas. The facewas red and blotchy, and the lower abdomen wasreported to be affected in a similar way, no doubt byprolonged contact with the hands during sleep.

Cinnamic aldehyde, the essential principle ofcassia bark and flower buds, produces no irritating

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action upon the integument, so far as I have hithertoknown. The possible presence of adulterants in sub-stances which are only rarely the cause of dermatitisshould be borne in mind as an explanation of suchaction. Petroleum compounds have been found incommercial specimens of the oil.

HOP HORNBEAM OSTRYA VIRGINICA.

I beg your attention to the following note fromCharles Sprague Sargent, Professor of Arboricultureand Director of the Arnold Arboretum, HarvardUniversity. He writes: “Do you know about thestinging properties of the hairs which grow at thebase of the fruit of the hop hornbeam ? On my handsthey cause an irritation which does not entirely dis-appear for several hours, I find no reference to thisfact in any of the books to which I have access.”

This small tree, growing in all parts of the UnitedStates, attracts notice through the resemblance of itspendulous fruit to hops, and its wood is much used onaccount of its bard quality. I was not aware of suchirritative properties, and should be pleased to hear ifmembers of this Association have knowledge of such.It may be another explanation of some of the manycases of dermatitis which we so often meet with andcannot refer to contact with any,well-known poison-ous plant, although confident that they are due tosome such cause.

ANILINE BLACK.

An account of several cases of dermatitis in mem-bers of the Boston Fire Department produced bywearing black shirts.

On June 22d, a fireman presented himself at myclinic with bands of dermatitis around the neck,wrists and lower nates, hips and upper thighs. Thepenis was also inflamed. The appearances were thoseof infiltrated erythema of a brilliant red color, de-cidedly elevated above the general surface, occurringeither in uniform areas of considerable extent, or in

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smaller, discrete circular patches, varying in size froma pea to a dime. The latter lesions were sharplydefined and somewhat resembled those of urticariarubra, although not fugitive. There was no sign ofvesiculation or excoriation upon the affected areas.The bands of inflammation around the neck andwrists were from two to three inches in width, andwere abruptly defined above and below. The centrallower affected region was some five or six inches inwidth, and was not so sharply outlined; The peniswas greatly swollen and reddened, and twisted uponitself. The subjective symptoms were not as intenseas might have been presupposed, a mild degree ofburning and itching only. There was no associateddisturbance of the general economy.

The peculiar distribution of the appearances sug-gested at once the artificial nature of the dermatitis,and as it was apparent that it was sharply limited toparts where the collar, cuffs and flaps of the outershirt projected beyond the lines of the undershirt,inquiry was directed to the former garment. It waslearned that some two or three weeks previously theFire Department had issued new black cotton shirtsas part of the prescribed summer uniform. Theywere worn over an undershirt, and had a rollingcollar, projecting cuffs, and were considerably longerthan the latter. It was learned also that another fire-man in the same house was similarly affected.

The symptoms had not developed for ten days orthereabouts after the shirts were first worn, and thisproved true in the other cases subsequently treated.During this earlier period the weather had been ex-ceptionally cold for the season, and it was not untilthis was followed by a period of excessive heat thatthe inflammation of the skin developed. Then it wasthat the portions of the shirt in direct contact with theparts above indicated became moistened by perspira-tion and actively irritating.

The attention of the Fire Department was called tothe case, and inquiry was instituted with regard to the

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possible existence of other instances. During the following few days three other firemen appeared at theclinic in a similar condition. The appearances werewonderfully identical in all of them ; uniform areasof perfectly smooth, elevated infiltration of varyingextent, with sharply defined abrupt borders, occupy-ing portions of the trunk, especially where the under-clothing was pressed in closest contact with theintegument. In one of the later patients the partsaffected were the same as in the first instance, but inthe others large areas upon the trunk were intenselyinflamed, and it was learned that the wearers wereprofuse sweaters and that their undershirts were satur-ated with perspiration in consequence of their ardentoccupation. In no instance did the inflammation ex-tend below the lower level of the garment on hips,buttocks and thighs. In three of the patients thepenis was affected.

Two shirts were issued to each man, and each wasworn for a week without washing. It was during thewearing of the second shirt, that is, during the intenselyhot weather of the second week, that the cases devel-oped. In a subsequent instance a shirt which hadbeen washed retained undoubtedly its irritative prop-erties. In two of the cases the affected areas onthe arms passed later, in consequence of continuedfriction and scratching, into a true eczematous condi-tion.

During the period of observation of the affectionamong the firemen an out-door laborer came to theclinic presenting similar cutaneous manifestations,which had appeared a few days after wearing a blackshirt made apparently of the same material. In thiscase, too, the dermatitis was sharply limited to the re-gions covered by the garment.

June 26th, a shirt belonging to one of the firemenmost seriously affected, one which had been worn afew days before the outbreak and which had beenthoroughly moistened by the underlying shirt, andwhich had not been washed, was sent to Prof. Wil-

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liana B. Hills of Harvard University for analysis. Hisreport follows:

Boston, July 13, 1896.Dear Doctor ; I have completed my analysis of the

black shirt which you left with me a fortnight since, andhave not been able, using about a square foot of the mate-rial, to detect any metal other than iron; antimony, arsenicand chromium are absent. The compound of iron com-monly used in the manufacture of aniline black is the chlo-ride, and this is supposed to exist in the fabric in some sortof combination with the pigment.

It would seem that the irritant action of this material isdue either to the iron compound, or, more likely, probablyto the coloring-matter itself, or to some other organicmaterial entering into the composition of the coloring mat-ter, or employed in fixing the color upon the fabric.

I suspect that some of these cases of eczema are due tothe pigments themselves; but, so far as I know, the actionof these is unknown. Ido not think their action has beenstudied experimentally. It has been customary to attri-bute the effects to arsenic, antimony, etc., especially incases in which the compounds of these metals are presentin the fabric, and to let the matter rest there. In thiscase something else is evidently the offending material.

I do not know of any facts warranting an opinion thatiron has the same irritant action that arsenic, antimonyand chromium have in the combinations used in printingand dyeing; and, it seems to me, we must look upon thepigment itself, or upon some other organic constituent ofthe fabric, as the probable cause of the trouble.

Yours truly,William B. Hills.

S. J. PARKHILL & CO., PRINTERSBOSTON