the length of shifts and decompression periods. Such a law has been passed, however, in but one state (New York) in this country. As time goes on further legislation will no doubt be needed and this could be made much more efficient if full information in regard to all cases of compressed-air illness could be reported to the state and reviewed by some competent person or board, who should recommend the necessary changes in the laws. What is now most needed is an exhaustive study of the practical application of theories which have been well worked out. In studying the causes of compressedair illness, one should not forget that many factors play a part, and that, since the human organism is concerned, it is not a purely physical question. The results of comparatively few experiments with animals should not be looked upon as final. In the same way, the results, under certain conditions, with a comparatively few men should not be considered conclusive. While much may be done by proper regulations to diminish cases of illness and death in compressed-air work, I believe that, when pressures of two or more atmospheres are being used, it should be classed as a dangerous occupation on account of individual conditions, not now understood, which I have called the personal element.

OCCUPATIONAL SKIN DISEASES

JOHN A. FORDYCE

University and Bellevue Hospital Medical College.

With the exception of certain well-defined types, occupational dermatoses as a class have not, in this country at least, received the attention they merit. While every dermatological clinic numbers among its applicants each year many patients in whom occupation has a direct or indirect bearing on the causation of their eruption, it is difficult, owing to lack of systematic investigation, to give a definite idea as to the prevalence of skin affections in the various trades. At my own clinic at the University and Bellevue Hospital Medical College about 2 per cent of the total number of new cases for 1911 constituted occupational dermatoses. The great majority of these were of the type known as trade eczemas and, while many cases yield readily to treatment and proper preventive measures, others constitute a serious inconvenience from an economic standpoint, sometimes necessitating a complete cessation from work or a change of occupation.

Cutaneous vulnerability is more or less an individual peculiarity, for while persons are met with who are so sensitive to an irritant, physical, chemical, thermal, or actinic, that they react after a short exposure or contact by an acute dermatitis, other people remain entirely unaffected. Occasionally such individuals exhibit so high a degree of sensitiveness that, instead of acquiring an immunity, an increasing susceptibility is established. Fortunately these cases are not very common and it is more usual to see workers, though subjected to continuous injury, only after a considerable time develop lesions, either from the summation effects of the irritant or because the resistance of the skin has been gradually undermined. After such a cutaneous outbreak there is frequently a tendency to acute exacerbations at regular intervals or when the occupation is resumed. These eruptions may then persist for years.

While the skin, both anatomically and physiologically, is endowed with a relative amount of protection against the action of irri

tant substances, by reason of its exposure it is subjected to injuries of every description and these may lay the foundation for a subsequent eruption. In addition there are other contributing factors, such as a special susceptibility, a delicate skin or one presenting some congenital anomaly, as excessive dryness or ichthyosis, impaired gastro-intestinal, hepatic or renal function, a depressed state of health, neglected hygiene of the skin, or its lowered resistance due to a preexisting eruption.

We often find the same etiologic factor operative in both allied and unrelated trades, owing to similar conditions under which the work is done; for example, where men or women are exposed to excessively dry or moist heat. Such an atmosphere leads to congestion and interference with the normal activity of the skin, which is followed by various inflammatory processes and sweat eruptions like prickly heat. These affections are met with in cooks, stokers, firemen, foundry workers, etc. A warm, moist medium, such as laundresses work in, sometimes produces a cystic condition of the sweat ducts of the middle third of the face, known as hydrocystoma. Cold, by favoring the development of chilblains, causes much suffering among people who are obliged to carry on their work outdoors or in poorly heated places. In factories where drastic measures are employed for the removal of dirt or stains, cleansing agents like chlorid of lime or benzine used on the hands, by divesting the skin. of its natural secretions, supply the base for an eczema. Oil, which is used wherever machinery is installed, is the causative agent of acneiform and eczematous lesions in employees who operate or are otherwise engaged about such apparatus.

In occupations which necessitate standing, people who have a tendency to varicose veins not infrequently exhibit this condition, with a secondary eczema and ulceration. Slight traumatisms lead to erosions of the skin, which often become infected in patients who, owing to venous congestion, have slight resistance. Young women who are obliged to stand at their work sometimes develop erythema induratum or Bazin's disease, which is characterized by nodules beneath the skin that may break down and produce ulcers. Some of these forms of Bazin's disease have been proved to be tuberculous. The infection is usually of benign type and readily yields to rest in bed, improved nutrition, and a change to better hygienic surroundings.

Many occupations, without being pathological in the strict sense of the word, bring about changes in the skin which are so characteristic that Blaschko1 has given them the name of trade stigmata. These include localized thickenings of the horny layer in shoemakers, tailors, musicians, etc.; bronzing of the skin in gardeners, farmers, and other people who follow outdoor occupations; staining of the hands in dyers, chimney-sweeps, etc.; pigmentation in workers in silver from a deposit of the latter metal and in millers from iron particles, etc.

The skin responds to the most diverse irritants, on the one hand by the production of a catarrhal inflammation, and on the other by the development of different types of eruption from the action of the same agent. Of the former we have an example in the trade eczemas and of the latter in the effects of working with tar, where eczema, acne, warty and epitheliomatous lesions may exist alone or intermingled.

The commonest type of occupational disease is an eczematoid dermatitis. In a recent article Herxheimer2 enumerates seventyfour trades provocative of this form of disease. It may vary in grade and intensity from an erythematous and scaling dermatitis to a vesicular and bullous eruption. As the condition becomes chronic, infiltration of the skin takes place, with desquamation and fissuring. With the cutaneous defenses lowered, pus infection is frequently superadded.

The excessive use of soap and water, by extracting the fat and macerating the horny cells, reduces the resistance of the skin. These agents may then act as direct excitants or prepare the way for some other irritant, as washing powders, etc. Severe eczemas of the hands and forearms are seen in those whose occupations require them to have their hands continually in water, as in the case of washerwomen, housemaids, barkeepers, etc. In my clinic nearly one-third of the occupational diseases during the past year were seen in persons whose vocations necessitated the frequent employment of soap and water, and in some cases of the various cleansing alkalis.

'Blaschko, "Gewerblichen Hautkrankheiten." Handbuch der Arbeiterkrankheiten, Th. Weyl-Gustav Fischer, 1908.

'Herxheimer, "Ueber die gewerblichen Erkrankungen der Haut." Deutsch. Med. Wochenschr., 1912, Nr. 1.

OCCUPATIONAL SKIN DISEASES

1. PAPILLOMA CF PALM OF THE HAND OF AN IRON-WORKER, THREE YEARS' DURATION. LESION IS DUE TO FRICTION FROM THE TOOLS OF THE TRADE

2. COMMON TYPE OF CHRONIC ECZEMA OF HANDS AND FOREARMS FOLLOWING PROLONGED CONTACT WITH IRRITANTS. IN THIS CASE THE IRKITANT WAS WOOD-ALCOHOL USED IN THE PREPARATION CF VARNISH