JAFFREY: DERMATITIS VENENATA
13. MCNALLY, W. D., J. Am. M. Ass., 1917, lxix, 1586.
14. SUNDELL, C. E., Lancet, 1926, 1, 957.
15. RUTHERFORD, W. J., Lancet, 1920, 1, 184.
16. ARMSTRONG, H. E., Brit. M. J., 1922, 1, 992.
17. JONES, G. W., YANT, W. P., AND BERGER, L. B.,
U.S. Bur. Mines, 1923, Serial 2539.
18. MCGURN, W. J., Interstate Med. J., 1917, xxiv, 479.
19. MOGURN, W. J., Boston M. _S S. J., 1917, Clxxvi, 231.
20. EGDAHL, A., J. Am. M. Ass., 1923, lxxi, 282.
21. HENDERSON, Y., HAGGARD, H. W., TEAGUE, M. C.,
PRINCE, A. L., AND WUNDERLICH, R. M., J. Indus.
flyg., 1921, iii, 79 and 137.
22. LUDEN, G., Modern Med., 1921, vol. iii.
23. MAYER, M. R., Am. J. Pub. Health, 1927, xvii, 108.
24. HAYHURST, E. R., Ibid., 1926, xvi, 218.
25. BATTLEY, J. C. S., Ibid., 1927, xvii, 1024.
26. MCCOMBS, R. S., Am. J. M. Sc., 1912, cxliv, 577.
27. KARASEE, M., Trans. Chicago Path. Soc., 1901-1912,
viii, 173.
2S. NASAM ITH, G., AND GRAHAIM, D. A. L., J. Physiol.,
1906-190`7, xxv, 32.
29. RICHARDSON, W., Boston M. 45 S. J., 1927, cxcvii, 57.
30. PHILLIPS, P., Brit. M. J., 1924, i, 14.
31. FORBES, H. S., COBB, S., AND FREMONT-SMITH, F.,
Arch. Neurol. J. Psychiat., 1924, xi, 264.
32. Any, I. A., AND WITT, D. B., Med. Clin. N. A., 1922,
V, 1645.
33. ALPERS, B. J., Am. J. M. Sc., 1925, Clxx, 390.
34. BECK. H. Y., AND FORT, W., Ann. Clin. Med., 1924,
iii, 437.
DERMATITIS VENENATA*
WX. R. JAFFREY, M.B.
Hamilton
D ERMATITIS venenata is a very large gienic and prophylactic aspect of the case should
subject. Newer work on the problem is
clearing up the field, and the purpose of this
paper is to offer and discuss a few examples of
the dermatoses caused by external irritants.
Emphasis will be placed on those coming under
the classification of occupational or industrial,
as these are the most important, economically,
to the worker; and unless they are studied care-
fully, we cannot expect to get proper recognition
from the employer or the compensation board.
In England these cases are carefully investigated
by the compensation authorities. Some states
in the American Union do this also, while others
depend on insurance companies, but in Ontario
there is no adequate clause covering these cases,
unless a definite injury precedes the attack,
and then it is classed as an injury. Therefore,
a very careful history must be taken of the
patient's past, as well as present, envircnment.
that the case may be properly presented if
necessity arises. Although the treatment of
the patient seems most important, yet the hy-
* Read at the meeting of the Ontario Medical Asso-
ciation, Kingston, May 31, 1928.
163
35. WOLFF, H. G., J. Neur. Psychopath., 1927, vii, 213.
36, XMILMER, W. H., Am. J. Ophth., 1921, ivy 73.
37. KURLANDER, J. J., J. A1n. M. Ass., 1924, lxxxiii, 271.
38. HAZLETON, E. B., Brit. M. J., 1923, ii, 763.
39. STEVENS, A. M., J. Am. M. Ass., 1926, lxxxvi, 1201.
40. MULLER, F., Minch. med. Wohwschr., 1925, lxxii,
1337.
41. GURICH, Muinch. med. Wchnischr., 1925, lxxii, 2194.
42. DourIs, R., Bull. Acad. de Med., Paris, 1927, xcvii,
317.
43. BOURQUIGNON, G., AND DESOILLE, H., Rev. Neurol.,
1927, i, 360.
44. RAILLIET, G., Nourisson, 1922, x, 191.
45. STEWART, R. M., J. Neutrol, 45 Psychopath., 1920-21,
1, 105.
46. HILL, E., AND SEMARAK, C. B., J. Am. M. Ass., 1916,
lxxi, 644.
47. HALDANE, J., J. Physiol., 1895, xviii, 430.
48. SAYERS, R. R., MERIWETHER, F. V., AND YANT, W.
P., U.S. Pub. Health Rpts., 1922, xxxvii, 1127.
49. HALDANE, J. S., J. Physiol., 1895, xviii, 201.
50. HALDANE, J. B. S., Biochem. J., 1927, xxi, 1068.
51. HAGGARD, H. W., Am. J. Physiol., 1922, Lx, 244.
52. O 'BRIEN, H. R., AND PAR1KER, W. L., J. Biol. Chem.,
1922, 1, 289.
53. STAMDE, W. C., AND MARTIN, K. A., J. ClGn. Investig.,
1925-26, ii, 77.
54. ZEIGLER, W. H., J. Lab. d CliGu. Med., 1926, xii, 109.
50. HAMILTON. A., J. Am. M. Ass., 1922, lxxviii, 627.
56. Science, 1920, li, 437.
be carefully explained to him, thus teaching him
how best to avoid future attacks. Many of
these patients have had recurrences, have been
told that it was their blood, and are hard to
persuade that blood medicine is unnecessary.
Going over my statistics roughly, I would
estimate that about 20 per cent of cases seen in
my practice are dermatitis, and fully 75 per
cent of these would come under this grouping,
either directly or indirectly; therefore an insight
into the "why" is all important. R. P. White
says, "As etiology disentangles the causal from
the casual, we realize that there are comparatively
few idiopathic or primary eczemas," and if the
name of the offending irritant cannot be given,
the terms "traumatic,', "occupational," or "pro-
fessional" should be prefixed. The all important
point to remember is that in every occupation
the worker is exposed to irritants, and every
irritant can cause a dermatitis in a susceptible
skin. This depends on the sensitivity of the
individual epidermis or tissues exposed, and
such a sensitivity can be acquired, similarly to
that of horse serum and other proteins, by con-
 164 THE CANADIAN MEDicAL ASSOCIATION JOURNAL

tinued contact with the toxin, and the breaking ing applications cleared up the " collar " dermatitis
down of the patient's tolerance to it. This was in a few days, leaving a typical lesion of neuro-
demonstrated by Low with primula toxin, where dermatitis to be treated appropriately,
awcontrol skin suddenly became sensitive after The exposed surfaces of the body are to be
many negative applications, and stayed so. It examined most carefully, and the sequence of
is a fact that once an epidermis is in a state of development of the dermatitis noted. Derma-
sensitiveness to a toxin, the tissues seem to titis of the neck and face is usually due to the
lose their resistance to other toxins to which contact of a moist skin with the hands or some
that skin has always been resistant; and may, neck wear, though the hand epidermis may not
on very slight provocation, develop a derma- show any lesion, being more resistant; we seldom
titis secondary to the one existent. One of see rhus dermatitis developing on the palms.
many illustrations of this occurrence was in a A fur dermatitis, due to dye or barbes, may not
case of primula dermatitis of the hands in a occur unless the skin gets moist, or the fur wet
woman who did washing, using a brand of soap from rain or snow; and it is our duty in these
chips whiqh she had used for years, and suddenly fur cases to explain carefully to the patient that
an acute dermatitis developed on the base of it is not the fault of the fur, but of her own
the unhealed dermatitis, which was much more skin, and that the fur need not be destroyed.
extensively distributed. A well-known specialist precipitated a lawsuit
The diagnosis of these cases depends on the against himself by naming a particular brand of
history of the patient, and the nature of his soap, and I think the safest guard against such
work and surroundings. Also, environmental an occurrence is the proper explanation to the
changes about the time of the attack, such as a patient that it is the fault of his own skin or
trip to the woods, a change of work, or a new sensitiveness, except in cases where some special
brand of some substance used in the patient's trauma is evident. The site of involvement,
daily contacts are of importance. For instance, as hands, fingers, forearms, girdle area, and feet,
the varnishing of a bathroom seat has been usually has some significance.
known to start a severe dermatitis of the but- These cases should be carefully differentiated
tocks. The changing of a brand of soap, new from seborrheeal dermatitis of either the eczema-
hair dyes, the introduction of synthetics, as tous, lichenoid, or psoriasiform type, and from
turpentine, into the painting trades, and many those diseases commonly known as erythema-
other things which we might call unusual occur- tous, papular, vesicular and pustular eczemas.
rences may have to be considered. These last should be classed with the sensitive-
All this history should be obtained from the ness group for the most part, though the irritant
patient at the time that the examination of the may be of such simple nature that the victim is
primary and secondary lesions on the skin sur- unable to avoid it, such as ordinary dust, chalk,
face is being made; at the same time a complete etc.; the epidermis for some unknown reason is
idea of their distribution and duration should easily irritated by it, probably only after primary
be obtained and an endeavour made to determine trauma, or perhaps through a loss of balance of
how the irritant got on the inflamed area. Care- the potassium and calcium salts, thus throwing
ful questioning as to previous treatment will the neurocellular mechanism out of equilibrium
often reveal the cause of a generalized dermatitis and increasing cutaneous irritability.
due to such a drug as sulphur, which may have The role of the fungi in dermatitis should not
been applied by the patient to treat a scabies, be forgotten. Osborne has told me of a case of
or something advised by a friend as a cure for persistent s:-called "squamous erythematous"
some irritant dermatitis where some soothing eczema, in which he has found a fungus in the
application might have improved it. This was foot and body lesions, and has obtained positive
demonstrated recently in a case of neuroderma- inoculation tests with all the cultures he made.
titis, localized on the back of the neck, which It should not be forgotten, however, that a
was followed by a severe band-like dermatitis. fungus may plant itself on the skin surface, and
For this a fur collar was blamed, unjustly in not become active until the skin is inflamed
this instance,' as there was a definite history of or injured. This is beautifully illustrated in
the severe outbreak following the original irri- a case of Trow's, where a fungus was demon-
tation just after the application of a paste that strated in vesiculo-bullous lesions on the hands
burned, which was used for two weeks. Sooth- of a child, but these lesions were found to be
 JAFFREY: DERMATITIS VENENATA
JAFFREY: DERMATITIS
an iodide eruption from calcidin which was being
administered.
Erythema multiforme, psoriasis, pitriasis rosea,
and the primary rash of syphilis might confuse,
but a proper history and careful examination of
the patient,-and this does not mean examination
of the lesions only, but of the whole skin surface,
-will usually put us right.
Practically all flowers, plants, and trees con-
tain active irritants to which someone is suscep-
tible, and skin tests are of particular value in
disclosing some of these offenders. An artefact
should be suspected if our history and examin-
ation do not agree, and the lesion has no definite
characteristics, and the neurological aspect of
the case should be looked into; thereby some
employer may be saved needless expense when a
patient has injured his skin with chemicals,
burns, etc., for purposes best known to himself.
Factories demand that a worker doing certain
grinding operations shall wear protective glasses,
and, to offset irritation of the skin of workmen
in certain industries, the first requisite is to keep
dusts, oils, and fumes from his skin; for if he is
a good workman, he will perspire, and the
moisture aids the irritant, either by softening
the epidermis or acting as a solvent for the
irritant. Stopping the irritant at its source
would seem to be the most logical method of
attack on the problem. Protective overalls,
body washing, and change of clothes before
leaving work, to rid the skin of any toxic sub-
stances, or in some trades, a bland ointment,
might be used to keep off the toxin. Neutral-
izing agents in the bath, using the same principle
as administration of Epsom salts in lead workers,
is sometimes practical. Tomato peelers' derma-
titis, probably due to an acid, is prevented by
dipping the hands occasionally in a 1 per cent
solution of sodium hydroxide, and then rinsing
in water. All these preventive measures must
be worked out for the specific irritant and
industry concerned. In new industries the in-
cidence is always higher than after protective
measures have been adopted through necessity
and tolerance has been developed by the workers.
Stokes' table of the objective signs of dermatitis
are well exemplified in these cases, and they ma..
pass through the whole scale of erythema, cedema,
Italy, and later, Spaiin and Germaniy, came under an
Imperial Deciee of 1224, according to -which candidates
for the profession of medicine were compelled to pass
a public examiniation in Hippocrates, Galen, anid Avi-
VENENATA 165
165
vesiculation, oozing, crusting, scaling, lichenifica
tion, fissuring, and hyperpigmentation.
The pathology is that of inflammation in its
various stages and the path of entry of the toxin
is either the follicles or through slight traumatisms.
The treatment of this class of dermatitis is
that indicated for pruritus, exudation, and
secondary infection, and these depend one upon
the other. Pruritus invites scratching, scratching
causes laceration and oozing; exudation on a
warm skin is an ideal medium for the growth of
skin cocci-so goes on a vicious circle and event-
ually a case of so-called eczema develops. It
may well be imagined that a simple impetigo
may simulate a dermatitis venenata at the
start, and a dermatitis venenata may simuilate
an impetigo at a later stage.
The methods indicated are: to remove the
cause if possible; then to soothe the pruritus, check
the exudate, and endeavour to reduce the infec-
tive element, without injuring Nature's healing
efforts. In the active exudative and irritant stage
moist dressings of astringents, such as 5 per cent
aluminum acetate are very helpful, or a painting
with a one in ten dilution in water of ten per
cent resorcin in alcohol. Building up the
patient's resistance, and looking after any other
body ailments is also indicated. There is no
strict set of rules for any case, but the use of
irritants, physical and chemical, is always con-
traindicated. Excessive sugar ingestion should
be prohibited, as some of these cases have
seborrhoeal tendencies, and recent work has
shown that increased sugar in the perspiration
is conducive to bacterial and fungus growth.
As has been stated, nearly everything with
which we come in contact may irritate a sensitive
or susceptible skin, and scarlatiniform or mor-
billiform eruptions, mesh-like erythemas, ery-
sipelatoid erythemas and purpuric lesions may
arise, but I will not undertake to go into the
specific types of reactions seen, and the many
common irritants in this short paper. How-
ever, I trust this brief discussion on der-
matitis venenata will impress you with the
importance of the subject, that you may be ever
on the lookout for these cases, for the sake of
the profession and the welfare and protection of
our patients.
ceinna.Tlhey must have studied logic for tlhree year.s
( our Arts course), medicine an-d surgery for five,
and must lhave practiced under an exper.t for onie
yeai.