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Diseases of the Skin Due to Foods
DISEASES OF THE SKIN DUE TO FOODS LEONARD F. WEBER, M.D.* FOOD, clothing and shelter are the three necessities of life. Of these, food is the only one that is unconditionally essential. Animals and primitive men have successfully dispensed with clothing and shelter but never with food. In one way or another man is busy most of the day filling his stomach. To grow, handle and prepare foods to overcome man's hunger requires many workers. Some of these workers will have the ordinary diseases of life, the same diseases which trouble all of us. In addition, there will be another group with occupational dermatoses, that is, diseases of the skin due to their work. These are not new diseases of the skin, they are only better known today because many states have passed laws entitling workers to medical care if their diseases are due to their occupations. This is the reason that the Food Section of the National Safety Council has been interested in calling attention to diseases of the skin due to foods. It is to be expected that some workers will attribute all of their diseases to their occupation. When such complaints arise the employer must engage a physician with experience in occupational diseases. The physician, after a careful examination of the patient, must then decide if a given disease arises out of the patient's employment. The examination of patients handling food is a daily routine with the present writer. Foods which, through direct contact or otherwise, cause diseases of the skin of workers engaged in the food industry include fruits, vegetables, meats, fish, milk, pastries and candies. The inexperienced physician is not impressed with this list of foods as a cause of occupational dermatoses, but a few years' experience with patients handling the same irritants who have similar ailments will convince him of its importance, as in my own case. CONTACT DERMATITIS DUE TO FOODS
There seems to be no limit to the foods which, it is alleged, can cause contact dermatitis. They range from artificial manures essential to the growing of foods to the arsenic irritation in grape pickers. This type of From the Department of Dermatology, University of Illinois College of Medicine, Chicago. * Clinical Professor of Dermatology, University of Illinois College of Medicine; Dermatologist to St. Anthony's, St. Joseph's and the University Hospitals, Chicago. ~39
240
LEONAHD F. WJimER
exogenous dermatitis is known as occupational or industrial dermatitis, a generic term applied to any inflammation of the skin caused by exposure of the skin to injurious substances during the course of the patient's employment. History and Examination.-A careful history is of first importance in the finding of contact dermatitis. I attempt to obtain information on the following points when examining industrial patients: l. Name and address of the employer. 2. Name of the employee, his address, occupation, age and sex. S. Name of the insurance carrier and the person who sent the patient for examination; in other words, who is to be responsible for the patient's medical expense. 4. The patient's complaint in his own words. Most of the patients have a definite opinion that coming in contact with something in their work has caused their trouble. 5. Previous diseases of the skin. Often one finds that the dermatosis was present before the patient was employed by the present employer. 6. Present disease of the skin and the date of its onset. One should always be concerned about the incubation period of the disease. 7. The sites affected in order. It is to be expected that contact dermatitis will appear first on the areas of maximum exposure to a cutaneous irritant. Usually this means the hands and forearms. 8. The progress of the disease. Has it been slow or rapid? 9. Has the eruption changed in character? Here one should not rely too much on the patient's observation of his disease. 10. After this preliminary questioning I make it a routine to examine the patient's skin carefully, after asking him to remove his clothes. The character of the eruption should be carefully noted. Is it uniform or multiform? What is the arrangement of the eruption? Its color, shape and size? 1 keep for my records all evidence of scars and stains on or in the skin, which may be significant if the patient takes his case to the Industrial Commission. 11. Inquiry is made of treatments provided for the patient in the past. Many patients can give r~liable information on this point. Some have definite convinctions that their eruption is worse because of previous treatments. 12. The laboratory findings are of importance and careful records should be kept. 13. The next part of the history concerns the work of the employee. What has been his previous job or jobs? How long has he been with the present employer and what was the exact date he began to work? 14. What substances are handled in his daily work?
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15. What cleaning process is employed after he finishes his day's work at the plant? Are the same cleaning processes used at home? Have there been any changes in the substances handled in his work or any changes in the cleaning process? How many workers doing the same work are affected? Does the employee do work outside of the plant? Does the patient have any hobbies? What are the irritants handled in his home? By such questioning the examining physician obtains some knowledge of the irritants handled by the patient and learns whether these irritants are handled in his work or elsewhere. A preliminary history of this sort is of value in making a choice of substances used in patch tests. In my history I always list my reasons for or against making patch tests. 16. Finally, two questions are asked which have been of considerable importance to me in dealing with occupational patients: First, did the patient's eruption improve after quitting 'of work and how long did it require before the eruption improved? Second, did the eruption recur on re-exposure to previous occupational irritants? Foods Which May Act as Cutaneous Irritants.-The following cutaneous irritants, given in alphabetical order, have been mentioned in the literature: Angelica causes an extensive dermatitis if the green plant is cut. Artichokes in canneries where it is peeled, cut and dried cause dermatitis, particularly if its juices remain in contact with the skin. Dermatitis due to cleaning and selling of artichokes has been reported. The lesions were mainly on the hands and back of the neck. About 20 per cent of the women workers were affected and the eruption disappeared upon avoiding artichokes. Asparagus. The juice has caused a contact dermatitis in canning plant workers and cooks in hotels. Even the eating of asparagus has been known to cause an eruption on the mucosa of the gums. Beef fat. A worker in a packing house had a dyshidrotic eruption on the hands apparently caused by contact sensitivity to beef fat. Carrots. The juice causes irritation in occupational workers. Occasionally circumoral dermatitis is traced to the eating of carrots. Celery. The washing of celery hearts is a fairly common cause of dermatitis. The causative agent is the limonine in the celery oil, which is liberated during the washing process. Dermatitis of this origin has also been reported as occurring in the Orient. Ch.icken blood. Only one report mentions this as a cause of contact dermatitis. A worker employed in killing and cleaning chickens developed a hypersensitivity to chicken blood: Cinnamon as a cause of contact dermatitis often escapes suspicion. I have had two patients with a severe dermatitis of the hands due to con-
242
LEONARD F. WEBER
tact with cinnamon; both of them were compelled to change their occupation and after this change was made their hands remained well. Corn. Cornstarch causes urticaria through direct contact. Eggs. I mention raw eggs at this time not as a cause of contact dermatitis but of urticaria. Several years ago a number of women became sensitized to raw eggs after an average incubation period of ten to fqurteen days. In their work they ware required to remove the shell from the egg and separate the white from the yolk. One patient after this experience was unable to eat foods containing a minimum amount of eggs. Figs frequently cause an occupational dermatitis. The juice of the raw figs coming in direct contact with the hands causes a bullous eruption. The milky sap of the fig can cause a photosensitization dermatitis. Garlic. Field workers developed a dermatitis the day following work pulling up garlic. The hands, forearms, legs and face became erythematous and vesicular. Grapes. Dermatitis caused by washing grapes has been reported. Patch tests with the inside of the grape skin were positive only after the patient ate grapes. There have been reports of arsenic poisoning in grape pickers. Grapefruit causes a contact dermatitis. Irish potatoes have been reported as a cause of contact dermatitis. Lemons and oranges are at times cutaneous irritants. The causal factor is the volatile oil contained in the outer layers of the peel. The orange skin has been reported to produce a contact dermatitis of the eyelids in housewives and others. Recently, a private patient of mine had a contact dermatitis of the upper eyelids due to oranges. Another patient who had been sorting and selling oranges had a contact dermatitis of the hands. He changed his work for a while to the selling of groceries, during which time the condition cleared. Two months later upon his return to the selling of oranges this exposure provoked another attack involving his hands. Mango dermatitis is produced by direct contact with the peel or stem of the fruit or with the sap of the tree. Dermatitis of the face and cheilitis have occurred twenty-four hours after eating mangoes. Meat. One case of dermatitis of the hands due to contact with meat which had been processed with 1 per cent sodium sulfite has been reported. Mint has been reported as a cause of contact dermatitis. Mushrooms not only cause dermatitis but also a conjunctivitis. Black mustard. The crushing of seeds liberates the volatile oil from the glycoside and this serves as a cutan_eous irritant. Parsnip. The juice of the foliage of wild parsnip caused dermatitis in field workers. Dermatitis of the forearms and legs has been observed in
DISEASES OF SKIN DUE TO FOODS
243
workers weeding parsnips. By rubbing the parsnip on the healthy skin the lesions could be reproduced. Peaches. Here is one for Ripley's "Believe it or not". The fuzz of the peach acts as a mechanical irritant and later true sensitization of the skin may appear. Radish has been reported as a cause of contact dermatitis. Spinach has been known to cause a circumoral dermatitis. Dermatitis of the hands in a vegetable dealer was caused by spinach. Tomato. The wet vine of the tomato irritates the hands and the forearms. Even the peeling of tomatoes may cause a dermatitis of the hands. Turnip greens have been mentioned as a cause of contact dermatitis. Vanilla. The sorters, pickers and cleaners of the pods suffer from a severe dermatitis at times. My past experience with patients sensitized to vanilla verifies this statement. Apparently, it is a fairly common sensitizer. Watercress has been mentioned as a cause of contact dermatitis. Finding the cause of contact dermatitis in food handlers is often difficult because many are women with the added exposure of the irritants in their homes. The examiner, if he is to be successful, must be familiar with all known cutaneous irritants. In the listed group of irritants I have found ittle help from patch tests. DISEASES OF THE SKIN DUE TO THE HANDLING OR EATING OF MEAT
Anthrax is an acute infection, sometimes a fatal disease, which is less frequent than years ago. It begins with the lesion resembling a carbuncle and suppurative adenitis developing metastatic abscesses and constitutional symptoms which are often grave. Human infection generally comes from the handling of hides or animal products from stock which has died of splenic fever. Butchers, cattlemen, woolsorters and tanners are liable to infection. Brucella dermatitis is most frequent in veterinarians who acquire the disease from contact with the vaginal tract of cows and pigs infected with Brucella abortus. The disease consists of two types: (1) the more common allergic type which is limited to those parts in contact with the infected secretions and which may consist of a transient pruritic erythema or a papulovesicular eruption, and (2) the rarer generalized allergic type which may be papular, papulovesicular, erythema multiforme-like or bullous hemorrhagic. Butcher's pemphigus is a rare disease which occurs chiefly among butchers and other persons who handle dead animals. A septic wound of the hand is followed by bullae which arise from the clear skin twentyfour to forty-eight hours later.
244
LEONARD F. WEBER
Foot and mouth disease is transmitted from domestic animals to man. Of the domestic animals cattle are most susceptible, hogs, sheep and goats being less affected. The disease is an acute febrile one in which vesicles occur on the mucous membranes of the cheeks and the skin of the digits. The disease has occurred following the eating of butter. Foot and mouth disease in domestic animals is prevalent in Mexico and is appearing in our country. Erysipeloid is an infection caused by Erysipelothrix rhusiopathiae. The organism occurs in fish, poultry and shellfish. The infection usually follows a puncture of the human skin by bone, scales or shells. The cut of a knife used for cutting meat may cause the disease. The disease has a higher incidence during summer and autumn. Erysipeloid is characterized by an erythematous bluish, marginated swelling on the hands. The disease may occur on other parts and if it does the diagnosis is more difficult because erysipeloid has not been considered. Hog itch is an inflammation of the skin among abattoir workers who sort the intestines of hogs which are infected with Strongyloides lumbricoides. The hands and arms come in contact with roundworms and their ova accounts for the localization. Sweetbreads or the pancreas causes an erosion of the fingernails when it is removed out of the carcass. Actinomycosis is an infective granuloma characterized by the formation of nodules which ulcerate and discharge the typical pus. The disease may follow an infection from external sources as animals, cereal and hay. Tularemia is an infectious disease caused by Bacterium tularense and characterized by constitutional symptoms which mayor may not be associated with cutaneous manifestations. The role of the wild rabbit as a causative factor in the disease has been so emphasized that contacts with pheasants and squirrels are often overlooked. Verruca necrogenica or anatomic warts are due to inoculation of the skin with the tubercle bacillus. The lesions usually arise at the site of an abrasion on the back of the knuckle. They are more frequently seen in butchers, slaughter house workers and the handlers of cattle. Sheep "tick", the cause of kad itch, crawls in the wool of the sheep. Woolsorters and sheep herders"are attacked causing hemorrhagic papules nearly always with a central puncta. The favorite sites are on the abdomen and hips. Occasionally sheep grazing on small lots near cities have sheep tick and persons in this vicinity have been sufferers of this annoying itch. The fowl mite (Dermanyssis avium) is a red parasite which lives on poultry and birds. Those who handle poultry are especially liable to the disease called gamasoidosi8. The bite of this mite on man produces in-
DISEASES OF SKIN DUE TO FOODS
245
flammatory itchy papules which are located chiefly on the hands and arms, although any site of the skin may be attacked. This disease is often confused with urticaria. DERMATITIS IN FISHERMEN AND FISH HANDLERS
Down through the ages countless fishermen have risked their lives to supply the world with food. Occupational diseases of the skin are not uncommon in the fish industry. In Chicago, however, this particular industry is mostly a consumer problem. Since my experience has been limited, I am forced to rely on the U. S. Public Health Service for valuable information. Louis Schwartz and Irving T. Tabershaw state that the frequency with which dermatitis occurs among fishermen and fish handlers makes it the chief occupational hazard of the industry. Salt used in salting fish apparently does not cause a contact dermatitis. The alkali used in washing sealed cans occasionally causes irritation of the skin. The types of cutaneous conditions occurring in the fish industry are classified as follows: , l. Abrasions, lacerations and fissures which are common throughout the industry. 2. Secondary infections due to a staphylococci and streptococci are located on the wrists and the collar line. These sites are traumatized by dirty oilskins and this is followed by infections. 3. Bites and stings from fish. Among the stinging fish are sea anemone, jellyfish, Portuguese man of war and sea nettles. 4. Redfeet dermatitis. Mackerel feed on minute crustacians, one of the most common of which is redfeet. Fish containing these spoil quickly. Redfeet plus the digestive juices from the stomach of the mackerel burns the hands, the skin of which becomes swollen and intensely red, with numerous superficial ulcerations. The pain is readily relieved by wet dressings of mild solutions. 5. Erysipeloid is a disease that resembles erysipelas but it is without fever. My earliest experience with this disease was in workers in the meat industry, that is, the large packing houses, and later in fish handlers I have already mentioned erysipeloid under the discussion of Meats. 6. Skin cancer does occur in fishermen on account of their prolonged exposure to sunlight and in some the added exposure to tar. ~. Allergy to fish oils occurs among persons handling cooked fish. MISCELLANEOUS CAUSES
In Farmers.-The skin of the farmer is liable to damage from handling lime, artificial fertilizers, insecticides, poisonous and irritating plants,
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LEONARD F. WEBER
and from fungicides, parasites and bacteria. Some of the diseases occurring in the farmer are tetanus, anthrax, glanders, foot and mouth disease, infectious abortion, paronychia, milkers' nodes, and actinomyCOSIS.
Milk.-There has been only one report of dermatitis caused by contact with milk. Milking sometimes causes callosities on the fingers and palms. Cheese at times irritates the hands if the cheese mite is present. Dried Fruits.-Dried dates, prunes, figs, apples and pears may be infested with mites which cause dermatitis. Here also it should be mentioned that onions may be infested with mites which may cause dermatitis. Nuts.-Brazilian nuts and peanut oil have been reported to cause dermatitis. There is a hazard in the handling of dried coconuts and copra while unloading them from ships if they are infested with the mites. The eruption has the localization of scabies. Bread and Cake.-There has been and is considerable controversy about the cause of dermatitis in bakers. The combination of flour, bleaches and persulfates are factors. It has been my experience that it is difficult to find the cause of dermatitis in many cases. Recently, several bakers had handled anise oil for years without having trouble. After it became their duty to measure anise oil for Christmas cookies linear redness appeared on the hands and forarms. Contact with the full strength oil caused dermatitis, but if it was diluted in the cookies they did not have irritation of the skin. One of the workers had consulted many physicians during twenty years. Knowing that anise oil is a cutaneous irritant I was fortunately able to diagnose the cause of his dermatitis. Bakers suffer from burns, pyodermas and furunculosis. Recently I have instructed all employees with pyodermas and furunculosis to quit work until they are well. I believe that this is a good rule to follow in order to avoid food poisoning. Callosities of the hands of bakers occur after working many years. Varicose veins of the legs and the associated cutaneous changes are common in bakers. I am not interested in making a point of the stasis dermatitis as a disease arising out of the work. Pickling.-Acetic acid (vinegar), strong brine, and pepper are some of the irritants used in making pickles. Recently I have had a number of workers who have had a contact dermatitis caused by brine. In some of the workers the eruption resembled an infectious eczematoid dermatitis. Much to my surprise, once the workers quit their job for two weeks the eruption disappeared. Mter they were well and returned to the job of handling brine they had a recurrence of the dermatitis.
DISEASES OF SKIN DUE TO FOODS
~47
Spices.--The manufacture of spices and Bavoring agents is a hazardous occupation if the workers' skin becomes sensitized. Recently an unusual cutaneous irritant in my experience was creosote bush which was being used as a substitute Bavoring agent. In the southwestern part of the United States it is a common weed similar to our poison ivy. My familiarity with cutaneous irritants quickly solve this worker's problem. Candy.-The burns caused by hot candy are common. Often irritating antiseptics are applied to the burns which cause a contact dermatitis in some workers. Keloids or hypertrophic scars are fairly common following candy burns. Chocolate causes a dermatitis. Recently I found oil of cassia a frequent cause of dermatitis in one candy plant. It caused a sensitization dermatitis in both white and Negro workers.
There seems to be no limit to the foods which, it is alleged, can cause contact dermatitis. They range from artificial manures essential to the growing of foods to the arsenic irritation in grape pickers. This type of From the Department of Dermatology, University of Illinois College of Medicine, Chicago. * Clinical Professor of Dermatology, University of Illinois College of Medicine; Dermatologist to St. Anthony's, St. Joseph's and the University Hospitals, Chicago. ~39
240
LEONAHD F. WJimER
exogenous dermatitis is known as occupational or industrial dermatitis, a generic term applied to any inflammation of the skin caused by exposure of the skin to injurious substances during the course of the patient's employment. History and Examination.-A careful history is of first importance in the finding of contact dermatitis. I attempt to obtain information on the following points when examining industrial patients: l. Name and address of the employer. 2. Name of the employee, his address, occupation, age and sex. S. Name of the insurance carrier and the person who sent the patient for examination; in other words, who is to be responsible for the patient's medical expense. 4. The patient's complaint in his own words. Most of the patients have a definite opinion that coming in contact with something in their work has caused their trouble. 5. Previous diseases of the skin. Often one finds that the dermatosis was present before the patient was employed by the present employer. 6. Present disease of the skin and the date of its onset. One should always be concerned about the incubation period of the disease. 7. The sites affected in order. It is to be expected that contact dermatitis will appear first on the areas of maximum exposure to a cutaneous irritant. Usually this means the hands and forearms. 8. The progress of the disease. Has it been slow or rapid? 9. Has the eruption changed in character? Here one should not rely too much on the patient's observation of his disease. 10. After this preliminary questioning I make it a routine to examine the patient's skin carefully, after asking him to remove his clothes. The character of the eruption should be carefully noted. Is it uniform or multiform? What is the arrangement of the eruption? Its color, shape and size? 1 keep for my records all evidence of scars and stains on or in the skin, which may be significant if the patient takes his case to the Industrial Commission. 11. Inquiry is made of treatments provided for the patient in the past. Many patients can give r~liable information on this point. Some have definite convinctions that their eruption is worse because of previous treatments. 12. The laboratory findings are of importance and careful records should be kept. 13. The next part of the history concerns the work of the employee. What has been his previous job or jobs? How long has he been with the present employer and what was the exact date he began to work? 14. What substances are handled in his daily work?
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15. What cleaning process is employed after he finishes his day's work at the plant? Are the same cleaning processes used at home? Have there been any changes in the substances handled in his work or any changes in the cleaning process? How many workers doing the same work are affected? Does the employee do work outside of the plant? Does the patient have any hobbies? What are the irritants handled in his home? By such questioning the examining physician obtains some knowledge of the irritants handled by the patient and learns whether these irritants are handled in his work or elsewhere. A preliminary history of this sort is of value in making a choice of substances used in patch tests. In my history I always list my reasons for or against making patch tests. 16. Finally, two questions are asked which have been of considerable importance to me in dealing with occupational patients: First, did the patient's eruption improve after quitting 'of work and how long did it require before the eruption improved? Second, did the eruption recur on re-exposure to previous occupational irritants? Foods Which May Act as Cutaneous Irritants.-The following cutaneous irritants, given in alphabetical order, have been mentioned in the literature: Angelica causes an extensive dermatitis if the green plant is cut. Artichokes in canneries where it is peeled, cut and dried cause dermatitis, particularly if its juices remain in contact with the skin. Dermatitis due to cleaning and selling of artichokes has been reported. The lesions were mainly on the hands and back of the neck. About 20 per cent of the women workers were affected and the eruption disappeared upon avoiding artichokes. Asparagus. The juice has caused a contact dermatitis in canning plant workers and cooks in hotels. Even the eating of asparagus has been known to cause an eruption on the mucosa of the gums. Beef fat. A worker in a packing house had a dyshidrotic eruption on the hands apparently caused by contact sensitivity to beef fat. Carrots. The juice causes irritation in occupational workers. Occasionally circumoral dermatitis is traced to the eating of carrots. Celery. The washing of celery hearts is a fairly common cause of dermatitis. The causative agent is the limonine in the celery oil, which is liberated during the washing process. Dermatitis of this origin has also been reported as occurring in the Orient. Ch.icken blood. Only one report mentions this as a cause of contact dermatitis. A worker employed in killing and cleaning chickens developed a hypersensitivity to chicken blood: Cinnamon as a cause of contact dermatitis often escapes suspicion. I have had two patients with a severe dermatitis of the hands due to con-
242
LEONARD F. WEBER
tact with cinnamon; both of them were compelled to change their occupation and after this change was made their hands remained well. Corn. Cornstarch causes urticaria through direct contact. Eggs. I mention raw eggs at this time not as a cause of contact dermatitis but of urticaria. Several years ago a number of women became sensitized to raw eggs after an average incubation period of ten to fqurteen days. In their work they ware required to remove the shell from the egg and separate the white from the yolk. One patient after this experience was unable to eat foods containing a minimum amount of eggs. Figs frequently cause an occupational dermatitis. The juice of the raw figs coming in direct contact with the hands causes a bullous eruption. The milky sap of the fig can cause a photosensitization dermatitis. Garlic. Field workers developed a dermatitis the day following work pulling up garlic. The hands, forearms, legs and face became erythematous and vesicular. Grapes. Dermatitis caused by washing grapes has been reported. Patch tests with the inside of the grape skin were positive only after the patient ate grapes. There have been reports of arsenic poisoning in grape pickers. Grapefruit causes a contact dermatitis. Irish potatoes have been reported as a cause of contact dermatitis. Lemons and oranges are at times cutaneous irritants. The causal factor is the volatile oil contained in the outer layers of the peel. The orange skin has been reported to produce a contact dermatitis of the eyelids in housewives and others. Recently, a private patient of mine had a contact dermatitis of the upper eyelids due to oranges. Another patient who had been sorting and selling oranges had a contact dermatitis of the hands. He changed his work for a while to the selling of groceries, during which time the condition cleared. Two months later upon his return to the selling of oranges this exposure provoked another attack involving his hands. Mango dermatitis is produced by direct contact with the peel or stem of the fruit or with the sap of the tree. Dermatitis of the face and cheilitis have occurred twenty-four hours after eating mangoes. Meat. One case of dermatitis of the hands due to contact with meat which had been processed with 1 per cent sodium sulfite has been reported. Mint has been reported as a cause of contact dermatitis. Mushrooms not only cause dermatitis but also a conjunctivitis. Black mustard. The crushing of seeds liberates the volatile oil from the glycoside and this serves as a cutan_eous irritant. Parsnip. The juice of the foliage of wild parsnip caused dermatitis in field workers. Dermatitis of the forearms and legs has been observed in
DISEASES OF SKIN DUE TO FOODS
243
workers weeding parsnips. By rubbing the parsnip on the healthy skin the lesions could be reproduced. Peaches. Here is one for Ripley's "Believe it or not". The fuzz of the peach acts as a mechanical irritant and later true sensitization of the skin may appear. Radish has been reported as a cause of contact dermatitis. Spinach has been known to cause a circumoral dermatitis. Dermatitis of the hands in a vegetable dealer was caused by spinach. Tomato. The wet vine of the tomato irritates the hands and the forearms. Even the peeling of tomatoes may cause a dermatitis of the hands. Turnip greens have been mentioned as a cause of contact dermatitis. Vanilla. The sorters, pickers and cleaners of the pods suffer from a severe dermatitis at times. My past experience with patients sensitized to vanilla verifies this statement. Apparently, it is a fairly common sensitizer. Watercress has been mentioned as a cause of contact dermatitis. Finding the cause of contact dermatitis in food handlers is often difficult because many are women with the added exposure of the irritants in their homes. The examiner, if he is to be successful, must be familiar with all known cutaneous irritants. In the listed group of irritants I have found ittle help from patch tests. DISEASES OF THE SKIN DUE TO THE HANDLING OR EATING OF MEAT
Anthrax is an acute infection, sometimes a fatal disease, which is less frequent than years ago. It begins with the lesion resembling a carbuncle and suppurative adenitis developing metastatic abscesses and constitutional symptoms which are often grave. Human infection generally comes from the handling of hides or animal products from stock which has died of splenic fever. Butchers, cattlemen, woolsorters and tanners are liable to infection. Brucella dermatitis is most frequent in veterinarians who acquire the disease from contact with the vaginal tract of cows and pigs infected with Brucella abortus. The disease consists of two types: (1) the more common allergic type which is limited to those parts in contact with the infected secretions and which may consist of a transient pruritic erythema or a papulovesicular eruption, and (2) the rarer generalized allergic type which may be papular, papulovesicular, erythema multiforme-like or bullous hemorrhagic. Butcher's pemphigus is a rare disease which occurs chiefly among butchers and other persons who handle dead animals. A septic wound of the hand is followed by bullae which arise from the clear skin twentyfour to forty-eight hours later.
244
LEONARD F. WEBER
Foot and mouth disease is transmitted from domestic animals to man. Of the domestic animals cattle are most susceptible, hogs, sheep and goats being less affected. The disease is an acute febrile one in which vesicles occur on the mucous membranes of the cheeks and the skin of the digits. The disease has occurred following the eating of butter. Foot and mouth disease in domestic animals is prevalent in Mexico and is appearing in our country. Erysipeloid is an infection caused by Erysipelothrix rhusiopathiae. The organism occurs in fish, poultry and shellfish. The infection usually follows a puncture of the human skin by bone, scales or shells. The cut of a knife used for cutting meat may cause the disease. The disease has a higher incidence during summer and autumn. Erysipeloid is characterized by an erythematous bluish, marginated swelling on the hands. The disease may occur on other parts and if it does the diagnosis is more difficult because erysipeloid has not been considered. Hog itch is an inflammation of the skin among abattoir workers who sort the intestines of hogs which are infected with Strongyloides lumbricoides. The hands and arms come in contact with roundworms and their ova accounts for the localization. Sweetbreads or the pancreas causes an erosion of the fingernails when it is removed out of the carcass. Actinomycosis is an infective granuloma characterized by the formation of nodules which ulcerate and discharge the typical pus. The disease may follow an infection from external sources as animals, cereal and hay. Tularemia is an infectious disease caused by Bacterium tularense and characterized by constitutional symptoms which mayor may not be associated with cutaneous manifestations. The role of the wild rabbit as a causative factor in the disease has been so emphasized that contacts with pheasants and squirrels are often overlooked. Verruca necrogenica or anatomic warts are due to inoculation of the skin with the tubercle bacillus. The lesions usually arise at the site of an abrasion on the back of the knuckle. They are more frequently seen in butchers, slaughter house workers and the handlers of cattle. Sheep "tick", the cause of kad itch, crawls in the wool of the sheep. Woolsorters and sheep herders"are attacked causing hemorrhagic papules nearly always with a central puncta. The favorite sites are on the abdomen and hips. Occasionally sheep grazing on small lots near cities have sheep tick and persons in this vicinity have been sufferers of this annoying itch. The fowl mite (Dermanyssis avium) is a red parasite which lives on poultry and birds. Those who handle poultry are especially liable to the disease called gamasoidosi8. The bite of this mite on man produces in-
DISEASES OF SKIN DUE TO FOODS
245
flammatory itchy papules which are located chiefly on the hands and arms, although any site of the skin may be attacked. This disease is often confused with urticaria. DERMATITIS IN FISHERMEN AND FISH HANDLERS
Down through the ages countless fishermen have risked their lives to supply the world with food. Occupational diseases of the skin are not uncommon in the fish industry. In Chicago, however, this particular industry is mostly a consumer problem. Since my experience has been limited, I am forced to rely on the U. S. Public Health Service for valuable information. Louis Schwartz and Irving T. Tabershaw state that the frequency with which dermatitis occurs among fishermen and fish handlers makes it the chief occupational hazard of the industry. Salt used in salting fish apparently does not cause a contact dermatitis. The alkali used in washing sealed cans occasionally causes irritation of the skin. The types of cutaneous conditions occurring in the fish industry are classified as follows: , l. Abrasions, lacerations and fissures which are common throughout the industry. 2. Secondary infections due to a staphylococci and streptococci are located on the wrists and the collar line. These sites are traumatized by dirty oilskins and this is followed by infections. 3. Bites and stings from fish. Among the stinging fish are sea anemone, jellyfish, Portuguese man of war and sea nettles. 4. Redfeet dermatitis. Mackerel feed on minute crustacians, one of the most common of which is redfeet. Fish containing these spoil quickly. Redfeet plus the digestive juices from the stomach of the mackerel burns the hands, the skin of which becomes swollen and intensely red, with numerous superficial ulcerations. The pain is readily relieved by wet dressings of mild solutions. 5. Erysipeloid is a disease that resembles erysipelas but it is without fever. My earliest experience with this disease was in workers in the meat industry, that is, the large packing houses, and later in fish handlers I have already mentioned erysipeloid under the discussion of Meats. 6. Skin cancer does occur in fishermen on account of their prolonged exposure to sunlight and in some the added exposure to tar. ~. Allergy to fish oils occurs among persons handling cooked fish. MISCELLANEOUS CAUSES
In Farmers.-The skin of the farmer is liable to damage from handling lime, artificial fertilizers, insecticides, poisonous and irritating plants,
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and from fungicides, parasites and bacteria. Some of the diseases occurring in the farmer are tetanus, anthrax, glanders, foot and mouth disease, infectious abortion, paronychia, milkers' nodes, and actinomyCOSIS.
Milk.-There has been only one report of dermatitis caused by contact with milk. Milking sometimes causes callosities on the fingers and palms. Cheese at times irritates the hands if the cheese mite is present. Dried Fruits.-Dried dates, prunes, figs, apples and pears may be infested with mites which cause dermatitis. Here also it should be mentioned that onions may be infested with mites which may cause dermatitis. Nuts.-Brazilian nuts and peanut oil have been reported to cause dermatitis. There is a hazard in the handling of dried coconuts and copra while unloading them from ships if they are infested with the mites. The eruption has the localization of scabies. Bread and Cake.-There has been and is considerable controversy about the cause of dermatitis in bakers. The combination of flour, bleaches and persulfates are factors. It has been my experience that it is difficult to find the cause of dermatitis in many cases. Recently, several bakers had handled anise oil for years without having trouble. After it became their duty to measure anise oil for Christmas cookies linear redness appeared on the hands and forarms. Contact with the full strength oil caused dermatitis, but if it was diluted in the cookies they did not have irritation of the skin. One of the workers had consulted many physicians during twenty years. Knowing that anise oil is a cutaneous irritant I was fortunately able to diagnose the cause of his dermatitis. Bakers suffer from burns, pyodermas and furunculosis. Recently I have instructed all employees with pyodermas and furunculosis to quit work until they are well. I believe that this is a good rule to follow in order to avoid food poisoning. Callosities of the hands of bakers occur after working many years. Varicose veins of the legs and the associated cutaneous changes are common in bakers. I am not interested in making a point of the stasis dermatitis as a disease arising out of the work. Pickling.-Acetic acid (vinegar), strong brine, and pepper are some of the irritants used in making pickles. Recently I have had a number of workers who have had a contact dermatitis caused by brine. In some of the workers the eruption resembled an infectious eczematoid dermatitis. Much to my surprise, once the workers quit their job for two weeks the eruption disappeared. Mter they were well and returned to the job of handling brine they had a recurrence of the dermatitis.
DISEASES OF SKIN DUE TO FOODS
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Spices.--The manufacture of spices and Bavoring agents is a hazardous occupation if the workers' skin becomes sensitized. Recently an unusual cutaneous irritant in my experience was creosote bush which was being used as a substitute Bavoring agent. In the southwestern part of the United States it is a common weed similar to our poison ivy. My familiarity with cutaneous irritants quickly solve this worker's problem. Candy.-The burns caused by hot candy are common. Often irritating antiseptics are applied to the burns which cause a contact dermatitis in some workers. Keloids or hypertrophic scars are fairly common following candy burns. Chocolate causes a dermatitis. Recently I found oil of cassia a frequent cause of dermatitis in one candy plant. It caused a sensitization dermatitis in both white and Negro workers.