CASES OF

ARSENICAL DERMATITIS.

BT

JAMES C. WHITE, M. D.,PROFESSOR OF DEEMATOLOGY IN*HARVAXID UNIVERSITY.

[Reprinted from the Boston Medical and SurgicalJournal of November 6, 1884.]

CAMBRIDGE:Printeb at tlje Himsibe puss.

1884.

CASES OF

ARSENICAL DERMATITIS.

BY

JAMES C. WHITE, M. D.,PROFESSOR OF DERMATOLOGY IN HARVARD UNIVERSITY,

[Reprinted from the Boston Medical and SurgicalJournal of November 6, 1884.]

CAMBRIDGE:|Jrinteir at tt)e Himrsibc |Jtess.

1884.

CASES OF ARSENICAL DERMATITIS. 1

BY JAMES C. WHITE, M. D.,

Professor ofDermatology in Harvard University.

Concerning the possible effects of arsenic upon theskin we have a great number of recorded observations,from which it appears that nearly every form of erup-tion which it is capable of exhibiting in its most variedforms of disease has occurred after the administrationof arsenic, and has been attributed to it: macular anderythematous efflorescences, papules, vesicles, and pus-tules, wheals, furuncles, and ulcers, scales, petechias,and pigment deposits. These have presented them-selves as local manifestations of cutaneous disturbance,or universally distributed, or have simulated in theirarrangement and course distinct forms of dermatoses,as the exanthemata, erythema, erysipelas, herpes, zos-ter, eczema, pityriasis, psoriasis, etc. Such are thephenomena which, it is claimed, have followed theinternal administration of arsenic. Its action upon thecutaneous tissues may, however, be regarded as possiblyalways a purely local one, inasmuch as it is excretedin part by the glandular structures of the integument.

As to the effects produced by it when brought incontact with the skin in any form from without wehave less positive information. Applied purposely asa caustic we know that it causes, in combination withother substances, a rapid destruction of the cutaneoustissues, or that, on the other hand, its action by dilu-tion may be limited to that of a simple depilatory. As

1 Read at the meeting of the American Dermatological Associa-tion, August 27, 1884.

4 Cases of Arsenical Dermatitis.

employed by workmen in the numerous arts in whichit is used, its effects upon the skin are of all degrees ofintensity from a fugitive erythema to deep-seated gan-grene, and varying in extent of distribution from thelimited ulceration about the nails of the taxidermist towidespread forms of dermatitis of all grades. It is mypurpose in this paper to present brief notes of threecases of dermatitis, the first two of which were un-doubtedly the result of direct contact with greeijarsenical paper, while in the third case the mtiology isso much a matter of doubt that it furnishes the reasonfor offering this communication to your criticism.

Cash I. A few years ago a medical student con-sulted me about his hands. The palmar surfaces wereuniversally occupied by vesicles buried deeply beneaththe thick horny layer, as closely approximated as pos-sible without becoming confluent, and varying in sizefrom a large pin’s head to a medium-sized pea. Theypresented with their semi-translucent coverings thatpeculiar boiled-sago-like appearance considered to becharacteristic of the so-called dysidrosis, of whichpseudo-dermatosis it might have been taken as a goodexample. The pressure of the imprisoned fluid pro-duced but a slight bulging of the cuticle overlying theindividual efflorescences, but towards the lateral sur-faces of the fingers the lesions became more prominent,and in the more yielding epidermis between them well-developed, elevated vesicles. There was considerablegeneral thickening of the integument with much burn-ing and itching. All these manifestations of an acutedermatitis reached their height of development in threeor four days, and subsided in the course of the follow-ing week, leaving a somewhat prolonged desquamationof the palms, corresponding to the depressed roofs ofthe vesicles in their stage of involution, none of whichwere able to discharge their fluid contents. An inves-tigation of the possible exciting causes of the troubleshowed that the patient had been using, a few even-ings before the onset of the inflammation, a pack of

Cases of Arsenical Dermatitis. 5playing cards, the backs of which were covered with alarge amount of arsenical green, and I had no doubtthat the dermatitis was the result of such contact.

Case 11. On the 19th of March, this year, myopinion was asked with regard to a patient applyingfor admission to the Massachusetts General Hospital,from which he had been discharged “ well ” twelvedays previously, after five weeks’ residence on accountof “anaemia and general debility.” He had been atwork for a week, but for two days his mouth had feltsore, and he had noticed red spots upon his hands andfore-arms. When I saw him these parts were swollen,and presented numerous erythematous patches, whichin some parts had already passed into papular formsof inflammation. His face was very red and greatlyswollen, so that his eyes were nearly closed. Theears were of nearly double their natural thickness, andwere discharging serum. The oedema and redness ex-tended downwards upon the neck as far as it wasexposed to view only. There was also serous oozingand crust formation upon the chin.

It was evidently a case of severe artificial dermatitis,the exciting cause of which was not learned at thattime. The ill-defined limits of the inflammation, thewant of tenderness on pressure, and the slight constitu-tional disturbance showed that it was not erysipelas.On the following day, the 20th, the face presented amore general incrustation, and there was free oozingof serum from its surface. The eyes could be opened,partially. On the 21st the skin of the face and neckremained as before, but the backs of the hands andfore-arms were covered with serous and sero-purulentvesicles. On the 22d the face was still more crusted,and the hair was falling in great quantity from thewhole scalp. On the 23d the vesicles upon the handsand fore-arms had increased greatly in number andsize, and by confluence some groups had been con-verted into large, prominent bullte. There was someoozing from these parts, and crusts were beginning to

6 Cases of Arsenical Dermatitis.

form upon them. In the evening the patient’s condi-tion had become so much aggravated that I was sentfor. The face was so swollen that it seemed ready toburst, and, indeed, was discharging serum profuselyfrom numerous points. The eyes were entirely closed.The hands and arms were of enormous size, and werealso dripping freely. There had been a great rise inbody temperature through the day, and, as shown bythe accompanying chart, it was at my visit 102.5° F.

The pulse was 100. The patient appeared to be in avery dull mental condition, and made but little com-plaint. On the following morning, the 24th, there wasa free general sero-purulent exudation from the face,and the temperature rose again in the evening, butonly to 101° F. From this time the inflammation ofthe skin subsided slowly. On the 28th the eyes couldbe opened, and the face was nearly free from crusts.On April 7th the patient was discharged well, al-though the skin of the parts affected was still reddenedand desquamating.

Cases of Arsenical Dermatitis. 7

It was learned during his illness that be had beenengaged for three days previous to the appearance ofthe cutaneous symptoms in fastening pieces of whitewebbing into sample books, the paper linings of whichwere covered with green arsenical pigment, as deter-mined by chemical analysis. I have seen one othercase of severe dermatitis of hands and arms in a boyengaged in manufacturing elastic suspenders, but couldnot learn whether the fabric contained the poison. Inthis case, the most advanced form of cutaneous inflam-mation that I have ever seen of such artificial nature,and the only one accompanied by constitutional dis-turbance of any marked degree under my observation,there can be no doubt that the cause of the dermatitiswas the arsenical paper. That other workmen em-ployed in the same occupation were not affected in asimilar manner is in accord with the general law ofindividuality. Another exceptional feature in the casewas the stomatitis and loss of hair.

’ Case 111, In the last week of November I wascalled to see a lady on account of an affection ofthe skin which presented to her attending physiciansome unusual features. She had given birth to herfirst child seven weeks previously, and had made agood recovery. The disturbance of the skin began toappear one week after rising from her confinement,and five weeks after delivery. It had been in progress,therefore, two weeks when I was consulted. At thistime the whole trunk was thickly occupied by slightlyelevated patches of a subdued red color, varying insize from a pin’s head to a dime, circular or oval inshape, and covered with very thin, firmly adherent scales.Some of the largest and oldest patches had undergoneinvolution at their central portions and had assumedan annular form. Upon the upper arms and thighsand upon the neck there were the same appearances,but less pronounced and abundant than upon the trunk.The subjective symptoms were a slight itching or burn-ing of the skin of the parts thus affected, and there

8 Cases of Arsenical Dermatitis.was no constitutional disturbance excepting a mild chil-liness, such as accompanies many acute dermatoses ofthe general surface of similar grade. The appearancesstrongly resembled those of multiple ringworm of theskin, and at the beginning it was thought by the at-tendants that the disease might be of that nature. Itwas also not unlike the earliest manifestations of somerare forms of psoriasis of rapid onset and general dis-tribution, in which the scale formation is exceptionallyslight. Several of the patches were scraped, and theepidermal cells thus removed with difficulty were care-fully examined for the presence of fungous growth,but none was found. Acetate of potash was prescribedinternally, and a cooling wash was directed to be ap-plied to the skin.

From this time the disease extended but little moreand gradually faded out of existence. Its period ofevolution was three weeks, and of decline nearly aslong. At the end of six weeks the skin presented nosigns of the disease. The diagnosis made at the firstvisit was pityriasis maculata et circinata, and this opin-ion was adhered to during the subsequent observationof the affection; indeed the appearances and coursethroughout were typical of this uncommon dermatosis.As in other cases which have come under my notice, Iwas again impressed by the iuappropriateness of thename applied to it by the French dermatologists whofirst recognized and described its individual charac-ter, inasmuch as the scales are a very subordinate fea-ture in the appearances at any stage of the efflores-cence.

During my early attendance upon the case my atten-tion was called to the condition of the baby, then abouttwo months old. It had been feeding upon a wetnurse, and was plump and of healthy appearance.During the preceding week there had developed apapular eczema upon the cheeks and a slight intertrigobehind the ears and in the folds of the neck. In spiteof the treatment advised the disease increased rapidly

Cases of Arsenical Dermatitis. 9

in extent and severity, the whole face presenting with-in ten days a papular eruption of vivid redness, conflu-ent and excoriated, while a considerable portion of thescalp was affected to the same degree. Upon the neckthe opposing surfaces of the integument within thedeep folds were intensely reddened and excoriated attheir juncture at the bottom of the furrows. In thefolds of the axillae, in the groins, and in several ofthe deep folds on the inner surface of the thighs theskin presented the same intense grade of intertrigo.Upon the lower legs there was an ordinary papulareczema.

I continued to treat the child from December Ist toFebruary 6th by such methods as I am accustomed touse in similar forms of cutaneous inflammation, butwith very little apparent success. One expects in in-fantile eczema more or less frequent relapses, and pos-sibly an indefinite extension of the disease undertreatment, but relapses imply a preceding improve-ment. In this case I never seemed to have it undertemporary control even, and the iutertriginous inflam-mation, which generally is easily managed, behaved asobstinately as the more advanced grades of the pro-cess. After the first two or three weeks the child’s di-gestion became disturbed, and the stools assumed abright green color and were overfrequent. It ceasedto gain in weight also. The wet nurse was changedtwice, the second one because she had several attacksof acute indigestion, but with the third, a florid, healthywoman in all respects, no improvement in the child’scondition took place.

On February 6th the wall paper upon its room at-tracted my attention (the baby had at first beenbrought down-stairs for my inspection), and on anal-ysis it was found to be highly arsenical. It was an oldFrench paper, and the pigments were loosely laid on.The patient was removed to another room, and thenursery was repapered. An immediate change in thechild took place. The intestinal discharges became

10 Cases of Arsenical Dermatitis.less frequent, and after a few days lost their greencolor ; the intertrigo became at once less red and moist;and there was a gain in weight during the first weekof three quarters of a pound. At the end of the secondweek another pound had been gained, the diarrhoeahad wholly ceased, the intertrigo had disappeared ev-erywhere, and there was only a little dry and scalyeczema left upon the cheeks. All these rapid changesensued without any alteration in the treatment em-ployed.

On the discovery of the arsenic in large amountupon the walls of the chamber the question naturallypresented itself to me: May its presumably constantpresence in the air of the room not have been thecause of these extraordinary dermatoses both in motherand child ? What were the conditions which wouldwarrant the conclusion of so direct a connection be-tween them ?

A young lady with an especially delicate skin liesfor four weeks in a chamber the walls of which areheavily covered with an arsenical pigment loosely laidon. One week after leaving it for another apartmentthere is developed over a large cutaneous surface aninflammatory process of rare occurrence, so rare, infact, that nothing whatever is known of its mtiologicalrelations. As soon as this chamber is vacated by themother the infant, who has spent the first month of itslife in another apartment, with its wet nurse, is trans-ferred to the arsenical room as its permanent nursery,and in ten days begins to present an inflammatoryaffection of the skin, one of most common occurrenceat its age, but of an unusual type. Later it developsmarked intestinal disturbances. Both sets of symptomspersist to an extraordinary degree, in spite of repeatedchanges of treatment and nurses, until the paper is re-moved from the walls, when the skin and intestinesrapidly return to their natural condition. The first wetnurse did not sleep in the arsenical room. The secondone was in the room nearly the whole day and night,

Case of Arsenical Dermatitis. 11and had several attacks of vomiting and diarrhoea.The third wet nurse was in the house but a short timebefore the discovery of the arsenic was made. Sheremained well, as did the monthly nurse who hadcharge of the mother during her confinement and sub-sequently of the child for two months. The two latternurses were especially strong women.

These are the facts. Do they furnish evidence fora suspicion that arsenic was a factor in these manifes-tations of disease in this household, or are they expli-cable on the theory of mere coincidence ? If pityriasismaculata et circinata is a well-defined entity, what pos-sible relation can arsenic have to it as cause ? Eczemais one of the most common affections of early infancy;why look for any unusual agency in its productionhere ? Has arsenic been known to produce such ef-fects? As just stated, pityriasis maculata et circinatais a rare disease, and we have no data collected toexplain its occurrence. Ido not know that its associ-ation with arsenic in any way has been hitherto ob-served. It may be that this case furnishes a clue tothe mtiology of others which have been reported, couldthe circumstances attending them be recalled. It cer-tainly should be remembered in connection with thosewhich shall be observed hereafter. 'With regard tothe eczema in the child, it did present some very un-usual peculiarities. Intertrigo in the summer monthsis very common as the only'manifestation or in con-nection with other phases of eczema, but I have nevermet with a case in which it was so marked in everypossible locality for its existence, or so little influencedby treatment in all. This feature in the winter is stillmore exceptional. Moreover its very rapid disappear- „

ance on the removal from the arsenical chamber was amost significant sequence.