Document 151OzQzwZpBgjreyN4J6KDN0q

PLAINTIFF'S EXHIBIT CHR-MI i i Second Revised Edition FRANK A. PATTY, Editor VOLUME I GENERAL PRINCIPLES Authors C. D. Clayton 1. R. Cox. J. L. F. Cpwim S. K. Gvtb 1. Hartmann T. F. Hatch C. IV. Jo.vts E. A. Ljnsdav C. P. McCord R. A. McFarland F. A. Pattt R. B. Pattt K- E. Rom.vaon O. A. Sanma L. Schaaartt M. A. Shariro H. SricBT IV. X, WlTHCRIDOt 19 5 8 INTERSCIENCE PUBLISHERS, INC., NET YORK INTERSCIENCE PUBLISHERS LTD., LONDON SCF-ALLF-01910 i of high concentration* of o tuberculosis. While this io the application of all o healthful workini eondiol methods. Actually there aioum duet, there mey be symptoms io a very am*]) lome group* ie more favor- the general application of partially controlled clinical ing silicosis in man. In the .t have been found effective ' ost authorities it* this ` ically controlled studies 5 statement in any way. been increasing interest j j ponse and in the use of 1 n the lungs. Cortisone, ' to have an inhibitoryas'desoxycorticosterono ' ation of fibrous'tissue. ! hat produces' silicosis, " ' ud their effect on the " stresses tend to deplete fibrosis. He lisle tuber* ronment, and inhalation rdes that it is necessary velop increased fibrotic such persons might be he dusty type of work, ier way can be retarded insulin with the ACTH. tobin, which affects experipereons having silicosis and of silicotic nodules, Bril. J. V9. and Occupational Med,, rn.MONA.RY DUST DISEASES 39? tuberculosis by Raulc and Cnalcr." should be given, m my opinion, only to person* with active tuberculosis. It should not be given in eases of purely silicotic reactions because of the dtuger of enhancing the silicotic process. Important is the prevention of inflammation, both the inflammation of bronchitis in the spring and autumn and that of tuberculous origin. I suggest the prophylactic administration of salicylate* in spring and autumn, as these deprea* the inflam matory reaction, and, as is the case with fibrous rheumatic nodules, may also beneficially affect the silicotic nodules. Undoubtedly, we shall see much research in this direction in the next few years, which may lead to satisfactory drug prophylaxis and therapy of silicosis. The evidence today, however, is not sufficiently conclusive to warrant applying any of these methods clinically. Until more specific therapy is available, treatment of disabling silicosis will continue to be symptomatic. It is principally directed at the associated emphysema to improve drainage of retained bronchial secretions. Bronchodilator drugs, such as Neo-Svnephrine (1.5 cc. of 0.5 per cent) or Isuprel (6 to 8 drops of 1:200 solution), when placed in a nebulizer with 100 per cent oxygen and inhaled with the intermittent positive-pressure technique proposed by Motley, have given very effective results. The resulting improved ventilation, although temporary, has caused such a frank improvement in the morale and feeling of well-being of many coal miners that this form of therapy is recommended for disabling silicosis and emphysema from any cause. Courses of treatments may have to be repeated at rather frequent intervals, depending on the severity of the case. ' Other measures that must be a part of the therapy regimen are prevention and active treatment of-colds and. other respiratory infections,, the maximum possible prevention of contacts.with active Cases of tuberculosis, and discourage ment of smoking to reduce bronchial irritation and secretion to a minimum. Any measures that will prevent bronchial obstruction are indicated. The cough reflex, therefore, should not be subdued and codeine should be withheld unless the cough is severe. Maintenance of the general nutrition of the patient also must be part of the treatment program. Continuing graded exercise is especially necessary to prevent further atelectatic areas of the lungs from developing. Support of the lower Bbdomen with its resulting support of the diaphragm will improve ventila tion in many cases with advanced nonobstructive emphysema, but is contraindi cated where there is considerable bronchial obstruction. B. ASBESTOSIS Asbestos is a hydrated magnesium silicate. More than 90 per cent of the raw mineral used in this country* and Great Britian is produced in the Canadian chrysotile mines. Asbestos is used in two general types of manufacturing processes. It may be used either by itself or mixed with other insulating materials, such as diatomaceous earth, for fireproofing, packing, or insulating; or it may be com " A. Raule and R. Grisler, Primi risultati clinic! ottenuti nelia silieo-luberculosi, Med. lavoro, 45, 4 (1652). I 398 0. A. SAWDER bined with cotton and woven at a textile for fireproof and heat-resistant clothing and other substances. Lanza" estimates that there are about 10,000 persons ex posed to asbestos in the United States. Most observers fed that the incidence of asbestosis in American asbestos workers is quite low. Asbestosis has, however, been reported more frequently in England and Canada. 2^ Lanza, McConnell, and Fehnc!" concluded from their study of asbestosis that prolonged exposure to asbestos dust causes pulmonary fibrosis different from that produced in silicosis and demonstrable by roentgenogram. Clinically it re sembles silicosis in that it is not disabling in the early stages, but it may be markedly disabling when advanced, and frequently leads to death by right heart failure. Although tuberculosis has been shown to be no more prevalent in persons with asbestosis than in the general population, lung cancer is under suspicion as occurring more frequently with asbestosis, especially in England. Symptoms. The onset of symptoms of asbestosis, as of silicosis, is slow although symptoms in advanced cases are apt to be somewhat more marked than in silicosis. As in silicosis, dyspnea is the cardinal symptom. Anorexia occurs frequently in advanced stages, and cyanosis and clubbing of the fingers are apt to: appear with greater constancy in asbestosis. . Pathology The fibrosis in asbestosis is diffuse and tends to predominate in the basal portions of the lungs in contrast to the generalized nodular fibrosis of silicosis with a predominance in the upper portions of the lung. Bronchiectasis and bronchiolectasis are frequent* especially in the more fibrous portions. Whereas the proliferation of fibrous tissue is caused by chemical action in.silica exposure, it is induced by mechanical action in asbestos exposures. Gardner? found that the fibrosis-producing character of asbestos could be almost eliminated by grinding the fibers so that no particles more than 20 p in length were present. As previously mentioned, asbestos is classified among the inert dusts. Vorwald, Durkan and Pratt" report that the typical bronchioiar fibrosis is best produced by fibers ranging from 20 to 50 p in length but not by fibers shorter than 20 The signifi cance of this finding on prevention of the disease will be discussed below. Microscopic anatomy. Johnstone*' described the microscopic appearance of the lungs somewhat as follows: In the early phases of the disease there is thicken ing of the alveolar septa which results from fibroblastic proliferation. The alveolar spaces contain numerous phagocytes. With progression of the disease fibrosis be comes more marked; the alveolar structure gradually disappears, and in its place there is now dense fibrous tissue. The few alveoli that remain in the area of fibrosis are lined with low cuboidal epithelium giving them an almost glandular appear ance. A. J. Lints. J. Am. Mtd. Assoc., 106. 368 (1936). A. J. Lints, W.J. McConnell, and 3. W. Pehnel, U. S. Pub. Health Rrp/*.,SD, ) (1936). "L. U. Gardner. Ind. Mtd.. 9. <5 (1940). A. J. Vorwald, Experimental studies of asbestosis. Atch. Ind. Hyg. end Ornjpolionni Mtd.. y ) (1951). " R. T. Johnstone, Occupational Dittoes. Ssunders. Philadelphia. 1942. )d heat-resistant clothing about 10,000 persons exi*eel that the incidence of Asbestosis has, however, their study of asbestosis ry fibrosis different from nogram. Clinically it re y stages, but it may be s to death by right heart tore prevalent in persons cer is under suspicion as ngland. . as of silicosis, is slow swhat more marked than nptom. Anorexia occurs ig of the fingers are apt tends to predominate in liied nodular fibrosis of lung. Bronchiectasis and . us portions. Whereas the a in silicA exposure, it is r<fnerM found that the eliminated by grinding e present. As previously Vorwald, Durkan and >est produced by fibers ' r than 20 p. The significussed below, roscopic appearance of disease there is thickenliberation. The alveolar the disease fibrosis beppears. and in its place in in the area of fibrosis nost glandular appear- leaUh Hrpu.. SO. 1 <1935). d. Hug. and Ocrupolionni hi*. 1M2. Scattered throughout the lung in both the diseased and healthy parts arc spindle-shaped structures described first by McDonald.*' These bodies are 20 to 100 ft in length and are bulbous on one or both ends so that they appear club- or dumbbell-shaped. They are brownish in color, do not stain, and give a Prussianblue reaction for iron. Simson** has produced these bodies in guinea pigs by ex perimental exposure to atmosphere containing asbestos. Lynch** concludes that these "curious bodies" signify exposure to asbestos dust but do not necessarily indicate.asbestosis. In other words, they are more properly referred to as "asbestos bodies" and not "asbestosis bodies." A*-i;oy examination. For an excellent review of roentgenographic findings in both silicosis and asbestosis the reader might well refer to Pendergrass.*0 Char acteristic differences in the roentgenographic findings in silicosis and asbestosis are tabulated below: Asbestosis Fibrosis diffuse (film mnv have ground glass appearance from pleural isvolvemeDt). Findings may be either bilateral or uni lateral. Lesions largely in the lower one halt or (wo thirds of the lung fields. Emphysema in upper portion of lung fields.. Borderline degree difficult to recognise. Silicosis Fibrosis nodular. Finding* characteristically bilateral. Lcsiona predominantly in the upper twothirds of the lung fields. Emphysema in lower portion of lung fields. Borderline degree more easily recognised. Control. Prevention of asbestosis depends largely on preventing exposure to sufficiently high concent rat ipns of long fibers to produce the characteristic reac tion. Also, if only long fibers cause the diseasc.'fine dust respirators are not neces sary. The more comfortable gaute respirators appear to be perfectly adequate filters for the long fibers. Up to this time, however, they have not been approved by the United States Bureau of Mines for this purpose. y Allowable concentrations. Dreessen. DallaValle, Edwards, Miller, and Sayers01 have found evidence to indicate that 5 million particles per cubic foot of air is a satisfactory figure for the maximum permissible atmospheric concentra tion of asbestos to which workers may be exposed. However, in setting up this figure, only fibers less than 10 in length were counted and the longer ones were disregarded. It now appears that the shorter fibers may have to be disregarded 8nd permissible concentrations of long fibers established, which has not been done. The prognosis with early to moderately advanced asbestosis is good, pro vided the inhalation of asbestos fibers is materially decreased. Unlike silicosis, - " S. McDonald. Brit. Med. ),, 2, 1025 (1027). F. W. Simson. Brit. Med. J., 1,885 (1028). *K. M. Lynch, J. Am. Med. Amoc., 109, 1M7 (1036). " E. P. Pendergrass, "Roentgen-Ray Diagnosis in Silicosis and Asbestosis.*' in A. J. Lanas, ed., Silieotu and Aibeifoau. Oxford Univ. Press. New York. 1038. " W. C. Dreessen, J. M. DallaValle, T. I. Edwards, J. W. Miller, and R. R. Sayers. V. S. Pub. Health Bull. So. 241, 1038. 400 0. A. SANDED asbestosis does not tend to progress after exposure is stopped or markedly reduced. Advanced asbestosis usually is associated with considerable emphysema and commonly leads to right heart strain and failure. C. BAUXITE PNEUMOCONIOSIS (SHAVER'S DISEASE) A new occupational fibrosis of the lungs was recognised for the first time in 1942 by Dr. Cecil G. Shaver,M Niagara Peninsula Sanatorium, St. Catherines, Ontario. It is essentially a diffuse interstitial fibrosis and marked associated emphysema, with a complete absence of any nodular fibrosis. It has been found only in workers exposed to the fumes resulting from the fusion of bauxite in the manufacture of artificial aluminum abrasives. Bauxite is a natural hydrated aluminum oxide (Al-Oj) containing small amounts of silica and iron. When it is fused by heating at a high temperature in open electric furnaces, a crystalline artificial corundum results. This process gives off dense white fumes containing from 40 to 60 per cent aluminum and 30 to 45 per cent amorphous silica. Particle size ranges of the fume are remarkably small-- from 0.5 y down to .02 y--and scan be visualized only with the electron micro scope. Workers with the heaviest exposures have been the overhead crane oper ators and those who shovel the mix into the furnaces. . In the early stages there are no symptoms or clinical signs.-The early x-ray pattern "is characterised by indefinite granular or lacelike shadows, particularly in the upper lobes, resembling early tuberculous infiltration. Ae the pathological changes progress, involvement Of the lower lobes occurs. The'shadows may remain granular or may assume an irregular nodular pattern. The root shadows usually are enlarged and increased in density. Emphysema usually is present and may be extreme, with large emphysematous blebs. Spontaneous pneumothorax has occurred in numerous cases and resulted in the death of several of these workers. The main symptom of those with advanced disease is shortness of breath. This may be sudden and extreme at the time the pneumothorax occurs. Most cases have developed in a rather short period of exposure: from two to five years. Approximately 50 cases had been discovered in the Niagara Palls area up to about five years ago. No tuberculosis was found in any of them. Since better fume control measures have been instituted, no new cases have come to light. It is of interest that no cases of the disease were recognised until 1942, even though the fusion process had been used since 1914. The only explanation for this is the tremendous increase in production of the artificial abrasives during the war years. The precise causative factor in the fume has not been positively identified. Heretofore, aluminum and amorphous silica had been thought to be innocuous. Also, extremely fine particles of any dust, less than 0.5 y in sire, had been thought to have no significance in the development of lung fibrosis. It wbs believed that "C. G. Shaver and A. R. Riddell. Lung rhange* associated with the manufacture of alumina abrasives, J. Ind. Hyg. Toxicol, 29, 1(5 (IM7). CHAPTER XV The Visible Marks of Occupation and Occupational Diseases ' CAREY P. McCORD, M.D. _ I. Introduction Some, but not all, trades lead to external markings or signs on workers that may serve to identify either the trade or the diseases associated with the trade. In times past the term "stigmata" has been widely applied to these marks, but this term is at times inappropriate and confusing. In medicine, "stigma" or "stigmata" has been chiefly limited to the skin, and often possesses religious connotation. In general, the term denotes disgrace or inferiority. This is far removed from the purposes of a manifest of the signs of various trades imprinted v upon the worker, many of which constitute honorable badges of long years of service. For this reason the designation "stigmata" is carefully avoided in relation to occupation. As here presented, the markings of trades and trade diseases are limited to those evidences that may be seen by the layman as he may observe attired human beings at the factory entryway or on a bus or train, or as he passes along the aisle of a work department. The term "layman" in this instance merely indicates that the observer is not a physician, a nurse, or a dentist; he might well be highly skilled as an engineer, a chemist, or lawyer. Frequently the signs that may be observed are not single but occur in groups to which the term "syndrome" is well applied. Thus, given a known exposure to manganese, anyone presenting an expressionless, masklike face, who is unable to purse the lips as in whistling, whose gait is apparently not quite controlled, and who indulges in fits of un provoked laughter or crying, should be suspected of having manganese poisoning. These signs constitute the syndrome of that disease. While some definite medical ends may be served by a knowledge of occupa tional signs in their hundreds of variations, greater interest may reside in in tellectual curiosity about the tell-tale indications of different trades or different trade diseases as branded onto the bodies of those who ply them. On the street, or anywhere else, there might be observed a man who reveals a circular hole about the size of a dime in the midline of his teeth as they rest in apposition. Further, it might be noted that this individual is having some difficulty with his breathing, the inhalations being feeble and short while the exhalations are prolonged and 479 480 CAREY P. MC CORD possibly labored. The astute observer at once will realize that he is in the presence of an old-time glass blower with emphysema--the characteristic occupational disease of that trade. The unfavorable critic may urge that such is not the case, that the observed individual is merely an aged pipe smoker with asthma. But there is a difference. The pipe smoker's dental hole is smaller, more likely to be oval and, moreover, to be right or left of the midline. Other signs may reveal not especially the trade, but a specific occupational affection. Let it be assumed that a stranger unexpectedly enters a workroom, whereupon the workers therein immediately appear to be frozen in whatever position exists at the moment. An entire group of workers on such an occasion may resemble a grotesque lot of statues--utterly embarrassed, incapable of motion, little capable of speech. To the knowing one, these signs at once should suggest the erethismus of mercury poisoning. One of the classical stories about mercurial erethismus centers about a group of hat makers with nondisabling mercury poisoning who were gathered together after work in a saloon for drinking purposes when a stranger entered. During the entire time the unfamiliar person remained, not one of these hat makers was able to lift a glass to his lips or to make other movements--because of pathologic shyness and timidity. There is no intention here to suggest that all occupational diseases present obvious outward evidences of their existence so that he who runs through a factory may make precise diagnoses. More often than not, when a disease state has reached the poipt of gross, external characteristics, the time has long passed at which the condition should have been recognized. It is equally obvious that many visible marks are related to nonoccupational diseases and injuries. It is nonetheless true for nonmedical workers in industry, and significantly for the industrial hygienist, the safety engineer, the chemist, the foreman, and the super intendent, that a wide acquaintance with unusual markings on the body or in the actions of workers may serve an end helpful to all. Such workers should know that many drugs taken internally may lead to peculiar markings on the skin; thus, some laxatives containing phenolphthalein may, even when taken by the manu facturer's directions, produce pigmented skin blotches as large as those of the leopard. They should know that some diseases and some work materials may identify themselves in the breath of the person involved, even though this does not constitute a visible sign. They should know that some tradesmen may suggest their jobs through bodily markings or actions, for example, the dirt farmer by his bronzed, warty skin, the train dispatcher by his proneness to cock his right ear toward you because of partial deafness in the left. They should know that the evidences of some acute diseases may be found in the altered color of the skin, as the cherry red skin of the victim of carbon monoxide. They should know that from the gait of some workers some diseases may be spotted with precision, as in the case of some syphilitics who go about their duties with high, slapping steps like a prancing horse. The unfavorable critic; with some justification, may claim that a mere VISIBLE MARKS OF OCCUPATIONAL DISEASES 481 familiarity with a large number of heterogeneous signs provides insufficient information for any practical application--rthat engineers, hygienists, chemists, and others may not be transformed into other than pseudo-physicians by the acquisition of miscellaneous lore about the external characteristics of diseases. Conceding part of the point, there still remain opportunities for the simple application of facts gained, as in the following instance. Expansion in a small plant led to the employment of a number of young women for the first time and under somewhat unfavorable work conditions. Soon thereafter, more than half of the women developed what was for them an alarming livid eruption over their shins, roughly resembling a bluish-red Scotch plaid. No male worker, although in the same department, was afflicted. Sheer panic was in the , making, claims and acrimony. Then came the safety engineer, not a physician, but experienced in the markings of some diseases. He simply pointed out that in that expanding department it has been necessary to introduce several coal stoves^ and that the girls, being more thinly clad than the men, had stood or sat for long periods close to these hot stoves, with the resulting patchy lattice work corre sponding to the,distribution of the superficial blood vessels in these girl's lower legs. This common condition is known to the dermatologist as "erythema ab igne" --"skin redness from fire." This condition is familiar to every country boy and girl who goes barefoot late in the fall or early in the spring and hovers close by the open fireplace or stove. It is information of this character that provides everexpanding opportunities for nonmedical personnel in industry. Widely, characters in fact and fiction have become famous through infinite capacity to observe and interpret apparently trivial external markings on the human body. In no small part, the fame of Osier, America's greatest contribution to medicine, rests upon this ability, while in fiction Sherlock Holmes, as created by another physician, gained part of his immortality through this same quality of genius. However, there is nothing so sacred in the domain of medicine as to bar nonmedical personnel in industry from observing physical peculiarities of workers, and setting in motion appropriate steps that may lead to helpful interpretation. II. Stigmata of Degeneration In an earlier period, and chiefly among criminologists, a vogue long existed centering about numerous anatomic or physiologic deviations from the usual in relation to criminals, perverts, the insane, the epileptic, the feeble-minded, and the degenerate. These deviations were termed "stigmata of degeneration," and this term designedly indicated inferiority or disgrace. It was thought that the unfortunate possessors of such abnormalities as supernumerary fingers, webbed toes, pointed ears, or microcephalic (small) heads might in the over-all picture be more frequently encountered in the undesirable citizenry than elsewhere. While in feeble-minded, insane, or penal institutions there may be found a greater number of divers stigmata of degeneration, it does not follow in every instance that 482 CAREY P. MC CORD these markings are significant. In a court trial, some stigmata of degeneration might as often be found on the prosecuting attorney, the judge, the doctor in the witness chair, as on the prisoner at the bar. Inevitably, many of these stigmata of degeneration will be exhibited by industrial workers and be wholly unrelated to occupational signs. Since so many unhappy interpretations of these congenital or hereditary markings are made, it may be desirable, even on a negative basis or basis of sympathetic understanding, that some of these so-called degenerative signs here be included. The most obvious stigmata of degeneration are anatomic. On a lbwer level of discemibility are physiologic and physical signs. On an anatomic basis, almost any organ, system, or portion of the body may be involved, or even the body as a whole. Thus, there may be decidedly large, small, elongated, or asymmetric heads. Common are deformities of the palate, best observed as "harelip." Quite apart from dental anomalies associated with work causes, there may arise con genital dental defects. Tongues may be excessively large, small, or bound down. In the eyes at birth there may exist cataracts; the two eyes may be of wholly different color; the eyes may be crossed (strabismus). Occasionally, eyes may be pathologically small. Unusual closeness of the eyes one to another is sometimes regarded as a sign of degeneration. A number of stigmata are associated with the ears, and perhaps without great significance, such as: the implantation of ears at different levels, excessive length of ears, the absence of one or both ears, very small ears, the binding down of the lobule to the neck, the congenitally thickened or knobbed ear, which is in distinction to the "cauliflower ear" of the boxer, ears that are implanted too far forward or too far rearward, the ear without external auditory canal, etc. In the realm of stigmata of limbs, there may be mentioned: excessive num bers of fingers or toes, varying degrees of webbing of fingers or toes, the absence of one or more fingers or toes, improper location of fingers or toes, excessive length or shortness of entire limbs or portion of limbs, such as in achondroplasia (one form of dwarfism). In addition, many stigmata are seen in such instances as the clubfoot, entire absence of certain muscles or muscle groups, or the absence of certain joints. A wide variety of congenital peculiarities of the skin may be classed in the category of degeneration. A few of these are the absence or scantiness of hair, the occurrence of hair in unusual places, unusual colors of the skin, albinism, absence of nails, ichthyosis (fish scale skin), congenital tumors, and so on. Some deviations from the normal affect the body as a whole, such as: dwarfism, gigantism, infantilism, femininism, masculinism, certain types of obesity, progeria (childhood characterized by premature senility), mongolism (one form of physical and mental defection characterized by physical resemblance to Mongol races), and so forth. In like manner, anatomic stigmata of degeneration by the hundreds have been associated with every other portion of the body, including the lips, nose, neck, VISIBLE MARKS OF OCCUPATIONAL DISEASES 483 chest, spinal column, and glands. In order that these anatomic defects may not appear too far afield from the practical, let it be pointed out that with few ex ceptions all inguinal hernias represent congenital defects, constituting in the majority of instances failure of complete anatomic structure in the inguinal area. Further, lest there be prideful feeling of freedom from the stigma of defects, let it be pointed out that every woman or man whose beauty or handsomeness partly depends upon winsome or seductive dimples is merely presenting minor anatomic defects. All persons possess some anatomic defects, and only when the number is large or the condition profound should much significance be attached to them as evincing degeneration. It is not remarkable that the mythologies of primitive people should center about some of the severer malformations of bodies. Thus, Janus undoubtedly had his counterpart in some actual human born with two faces. Medusa probably is to be associated with some woman afflicted with numerous horny growths of the scalp. The legendary mermaid finds basis in those rare cases of sympus or sirenomelus, a gross malformation in which the two lower extremities are fused. In more modem times and reminiscent of the side show, gross stigmata of degeneration are exhibited as the "turtle boy," the "dog faced woman," the "bearded lady," and so forth. The stigmata of degeneration on a physiologic basis are not so numerous, or at least not so obvious, though many compel attention. Likewise, physiologic deficiencies on a hereditary or congenital basis are not so readily "separated as the anatomic ones from those caused during postnatal life. Again it may be pointed out that physiologic stigmata of degeneration may involve any portion of the body. Representative examples are: color blindness, some deafness, mutism, stuttering, blindness, constricted visual field, migraine, anesthesia, hyperesthesia, astigmatism, epilepsy, endocrine dysfunction (abnormal function), colored sweat, hyperodorous sweat, vicarious menstruation, dysfunction of appetite, and delayed puberty. Many instances of such conditions as deafness and blindness in no sense represent stigmata of degeneration. . In the psychic province there are unfortunately almost unlimited evidences of degeneration. These embrace some, but not all, feeble-mindedness, idiocy, imbecility, insanity, precocity, eccentricities, sexual perversions, and so on. Even genius itself, when warped, may be a sign more of degeneration than of exceptional brilliance. The practical man at this point may be disposed to disavow any connection between the foregoing and the day-by-day world of medicine and industrial hygiene. This attitude is unwarranted. Many hundreds of thousands of workers go about their tasks with continuous mental, if not physical, discomfiture as a consequence of the departure from the usual found in their bodies, their physio logic functions, or their minds. They are in need of human understanding, of medical guidance. After all, industrial medicine is not limited to lead poisoning, silicosis, and broken bones. 484 CAREY P. MC CORD III. Marks from Work and Work Diseases Manifestly,, occupational markings on the body are not the stigmata of degeneration in the above sense. Almost equally manifest is the fact that work signs are directly acquired and are not congenital; yet this statement is not pre cisely true, since some occupational affections of one or both parents may adversely influence the offspring. Hence, some children may present stigmata of degeneration when one or the other of the parents has suffered from such afflictions as lead, radium, or phosphorus poisoning. These and other materials constitute race poison ing and may, in fact, contribute to the degeneration of offspring. As under foregoing circumstances, work marks, as observed in those portions of the body of an attired person that may be seen with the eye, may involve any external portion of the body, such as the skin and its appendages, the eyes, ears, nose, teeth, lips, limbs, and bones. Other signs may derive from posture, gait, mannerisms, or facial expressions. A number of more common ones such as should challenge the attention of nonmedical persons are listed on pages 486-610. For the purpose of differentiation between occupational and nonoccupational afflic tions, some nonoccupational affection signs are included. E. M. I. represents "Recommended Medical Investigation." IV. Summary In cursory fashion, numerous signs of disease and near-disease states directly or indirectly related to work are presented in terms designed for nonmedical personnel.1 Never. will any listing of occupational and disease stigmata be complete. New items continually are appearing. By iteration it is observed that the objective here is to take notice of physical peculiarities that readily attract the curiosity of the layman and at times provoke apprehension lest there exist some state of communicability. Conversely, the point of view is not that of the physician making more nearly exact observations, interpretation, and ultimate diagnoses^ Most occupational dermatoses and callosities are far from characteristic of any one or few trades and thus are not revealing. However, a callosity (for example) that characteristically appears on just one or two fingers would possess identifying values and thereby justify inclusion here. Always the emphasis is on the striking as observable through the eyes of the layman. The purpose has been twofold: (1) the hope of piquing the interest of nonmedical personnel in medical matters, and (8) the hope of bringing to the attention of physicians larger numbers of persons at workplaces genuinely in need of medical care. In a measure all of this material fits into the precepts of the remarkable 1 For more extensive and technical medical data, reference is made to: W. E. and H. F. Robertson, Diagnostic Signs, Reflexes and Syndromes. 2nd rev. ed., Davis, Philadelphia, 1942. W. M. Barton and W. M. Yater, Symptom Diagnosis. 4th ed., Appleton-Century, New York, 1942. F. Ronchese, Occupational Marks and Other Physical Signs, Grune and Stratton, New York, 1948. VISIBLE MARKS OF OCCUPATIONAL DISEASES 485 Dr. Joseph Bell who wrote: "Nearly every handicraft writes its sign-manual on the hands. The scars of the miner differ from those of the quarryman. The carpenter's callosities are not those of the mason. . . . The soldier and sailor differ in gait. Accent helps you to district and, to an educated ear, almost to county. . . ; With a woman, especially, the observant doctor can often tell what part of her body she is going to talk about." X 486 CAREY P. MC CORD V. Common External Marks of Occupation or Occupational Diseases or Other Diseases Mark or sign Probable cause Significance Comment Skin Pallor--transient (white skin). Pallor--persistent (white skin). Pallor--localized (white skin). Abnormal color (cherry red skin). Abnormal color (slatish purpie skin). Temporary blanching from fainting, fear, pain, nausea, loss of blood, shock. Anemia from any of many causes. Hysteria, freezing, pressure, local ized poisoning such as from in sect stings. Carbon monoxide, Silver, Dependent on cause, R. M. I. R. M. I. May be absent in carbon mon oxide poisoning. More likely to involve ears, cheeks, lips, fin gertips; instead of cherry red, carbon monoxide color may be yellowish red, greenish red, bluish red. R. M. I. Condition of argyria; may be uni form, may be patchy. Color not always same in different cases. Not necessarily occupational. Many specific types of anemia re lated to work, such as "baker's anemia." More common among women. Patient usually prostrate. Not always occupational; must have been exposed to silver; essentially incurable; not dis abling. Abnormal color (slatish vio- Phenolphthalein. let, red splotches on skin). Skin damage from laxatives containing phenolphthalein: splotches usually on arms ana chest: may be one or a score; variable sizes; persistent; no superficial skin rash. Sometimes leads to compensation claims. Unwarranted except in phenolphthalein workers. Abnormal color (bluish pur- Methemoglobinemia, pie skin). Distribution may be limited to ears, lips, fingertips, or pos sibly generalized. R. M. I. May be associated with other forms of abnormal hemoglobin, such as sulfhemoglobin. Abnormal color (bluish pur- Heart disease, pie). Cyanosis. Resembles preceding item as to color, but not cause; common manifestation of cardiovascular disease. R. M. I. Ordinarily not occupational. Abnormal color (yellow jaun dice icterus). Bile in skin; many.causes of jaun dice, including occupational causes, catarrh, cancer. Abnormal color (bronze). Abnormal color (coffee color). Many causes, such as suprarenal disease, arsenic, pellagra. Endocarditis. Abnormal color (yellow). Carotinoid. Abnormal color (yellow). Picric acid. From, the eating of excessive quantities of carrots, squash, oranges. Picric acid and picrates. Abnormal color (orange). Tetryl. Munition materials. Abnormal color (green).' Abnormal color (bluish-green streak or blotches). Abnormal color (hectic flushed cheeks). Either from sweat from copper content, or external contact with fine copper. Powder burns or ground-in coal dust; usually limited to miners, and chiefly coal miners. Heart disease or tuberculosis. Abnormal color (red skin). Abnormal color (leucoderma). - Impending sunstroke, high blood pressure; may be natural for some types or races. May be caused by external con tact with certain rubber anti oxidants. Monobenzyl ether of hydroquinone. Abnormal color (absence of normal skin sheen in Ne gro). May be caused by any organic disease. Depends upon exact cause, such as carbon tetrachloride. R. M. I. May be universal, diffused, or localized. R. M. I. May resemble Addison's disease or nicotinic acid deficiency ex cept for distribution of latter. R. M. I. Harmless; rapidly disappears on correcting diet; resembles jaun dice. Usually limited to point of con tact. Discolored area limited to contact points; may be associated with dermatitis. Clinically not important; at times may be washed away. Not ordinarily disabling, al though previous injury may have been disabling. Represents localized capillary dilatation. R. M. I. Frequently from nonoccupational causes; vitiligo; may be related to avitaminoses. In reflected light, normal skin sheen almost invariably present in absence of organic disease. In the young, commonly ca tarrhal; in the middle aged, usu ally gall bladder disease; in the old, usually cancer. Important if extensive and per sistent. Unrelated to work as cause. Most often found on palms and soles and around nose; unlike jaundice, does not involve eyes. May be associated with dermati tis;. some picrates used in the treatment of bums may both discolor skin and induce derma titis. Sometimes removed by washing. Hair may turn either green or blue; disturbing to workers, particularly women. May resemble chlorosis in ap pearance. In tuberculosis occurs only in far advanced state. More discern ible in men. May indicate fever; may be localized as on head, cheeks, or hands. More prominent in Negroes and other dark races; loss of pig ment fairly readily spontane ously replaced in some condi tions. A possible test for malingering in the Negro. (continued) VISIBLE MABKS OF OCCUPATIONAL DISEASES -3 Common External Marks of Occupation or Occupational Diseases or Other Diseases (continued) Mark or sign Probable cause Significance Comment Skin, continued Abnormal color (excess pig mentation). Abnormal color (any color-- industrial tattooing). Abnormal color (any. color). Abnormal color (chocolate pigmentation with hyper keratosis). Abnormal color (bronze de posits). Abnormal color (blue nevi). Abnormal color (Berlocque pigmentation). Abnormal color (orange, through brown to blue- black). 4 Rashes (misc.). Dermatitis. May -be due solely to sunburn; some industrial causes, includ ing superficial infection; nico tinic acid deficiency. Mechanical imbedding of fine materials; any color. Scores of chemicals directly color the skin, such as silver nitrate. Possibly hydrocarbon oils, greases, or tars. May follow use of iron compounds in treatment of dermatitis such as that from poison ivy. Unknown. Sunlight exposure after some co lognes, perfumes, or lotions. Benzanthrone. Almost unlimited industrial causes; bacterial and fungal in factions; drugs used for thera peutic -purposes; mechanical and physical factors involving any portion of the body. May be localized, spotty, or gen eralized; growing pigmented moles dangerous. R. M. I. Usually limited to small areas. Equivalent of tattooing; not disabling. External contact with many types of Work. Materials discolor skin with or without producing dermatitis, such as materials of photographers. May involve forehead, sides of face, backs of hands, extensor surfaces of forearm, axillary folds. Deposits sometimes disappear after long periods. No more prone to become malig nant than other nevi. Chiefly in summer in connection with bathing or sun bathing. Common site face, neck, upper part of chest, sometimes hands and. forearms. Types, sites, severity, diagnostic features too numerous to re ceive mention. Significance de pends on exact cause and sever ity. R. M. I. All marked hyperpigmentation without obvious cause should be investigated; characteristic of many trades, such as sailors. Bismuth, mercury, and arsenic used for therapy may induce excess pigmentation; also some cologne waters. Frequently associated with some scarring. Such skin coloration frequently only identifies the trade, but may be associated with derma titis. Pruritus common. May repre sent Riehl's occupational mela nosis. Ultraviolet application sometimes causes disappearance as does cantharides blister. When any nevus changes in character, such as size or color. R. M. I. Involvement only of exposed part. Acute dermatitis some times present. Related to oil of bergamot. May result from specific fiver damage. Apart from mild acne, mild seb orrhea, mild erythema, mild sunburn, all skin rashes should be investigated. See subsequent references to distribution pat terns of dermatoses. CAREY P. MC CORD oo 00 Scars. Obviously many; mechanical, chemical, infection. Often serves as proof of previous disease states, such as chicken pox, smallpox, syphilis, "com memorative scars," i.e., small pox vaccination; or identifies trades such as moulders from multiple burn scars on lower legs. Scars suggest, when on thumb, shoemakers and skivers; on tongue, epileptics; when jagged on nose and face, windshield accidents; when short and straight above collar-bone, tuberculosis; when long and curved across neck, thyroid operation; long, linear scars, knife wounds; when jagged and furrowed, from gun snot acci dent; behind ears, mastoid dis ease; irregular, oblique on neck, scrofula; star-shaped at base of neck, previous tracheotomy; multiple bum scars on forearm, welders; pitted scare on back, shoulders and face, healed acne: pitted scars on forehead and face, chicken pox or smallpox. V IS IB LE MARKS OP OCCUPATIONAL DISEASES Skin parasitism (scabies, pedic Animal parasites. ulosis). May be chiefly indicated by scratch marks. Lice or nits may be seen on hair. R. M. I. Readily eliminated from intelli gent persons; recurrences prob able in unintelligent, unhygi enic persons. . Skin atrophy. May indicate normal senility or may constitute portion of dam age from dermatoses; from many industrial causes. Typical example--long standing . Some atrophy irreparable; fur x-ray dermatitis. ther exposure elimination al ways desirable. Capillary dilatations (chronic). Many causes both industrial and nonindustrial, such as alcohol ism and x-ray exposures. Minor condition of obscure cause and significance; cosmetically unattractive. If limited, sometimes may be re moved by electrolysis. Keloids. Peculiar skin hypertrophy follow ing superficial injury. More common among Negroes; usually follows mechanical in jury, such as incised wound; characterized by overgrowth of scar tissue at site of previous injury; tumorlike; multiple or single. Occasional troublesome sequela of industrial injury. . (continued) Common External Marks of Occupation or Occupational Diseases or Other Diseases (continued) Mark or sign Probable cause Significance Comment Skin, continued Itching (pruritus). Erysipeloid lesions. Swimmer's itch. Creeping eruption. Thresher's itch, Grain itch, Bunkhouse itch. Rat mite dermatitis. Anesthesia, hyperesthesia, paresthesia. Numerous; both industrial and nonindustrial. Bacterial origin--staphylococci, streptocci. Caused by snail parasite Schis tosoma cercariae. Animal parasite, larva migrans. Animal parasite pediculoides ventricosus. Liponyssus bacoti. Usually neuroses and unassoci ated with work; also chemi cals, such as formaldehyde, phenol. Obviously not a visible mark. Scratch lines constitute the mark. May be associated with neurosis, dermatitis, parasit ism, diabetes, leukemias. R. M.I. Chiefly on hand and forearm. Highly common among fish handlers, particularly fish butchers. Commonest occupa tional disease on ocean liners. As an occupational disease arises among fishermen, clam diggers, and other workers in outside waters. Burrowing parasite moves 1 to 2 cm. per day. Intense itching. Several parasites may be creat ing burrows at the same time. Not always occupational. Chiefly limited to the threshing season. Acute dermatitis with pruritus. Common form of acute dermatitis with intense itching, urticaria. Commonly appears in areas under belts, girdles, bras, or socks. Not visible markings; encoun tered from complaints of in creased localized skin sensitiv ity; numbness, burning, prick ing; may be symptom m some occupational disease, such as arsenic poisoning. R. M. I. Undue scratching of head Bugpests seborrhea or lice: scratch ing on back of shoulders, usu ally acne; scratching of feet, frequently fungal dermatitis; scratching in older persons, fre quent in diabetics; scratching of anal region, parasites, fungal dermatitis, or neurosis. May arise among butchers other than of fish. Often called "salt water sores." Mechani cal injury from fish scales and bones may be a factor. The parasite lives in both fresh ana salt water although exact form may be different. Common occupational disease in Florida among construction workers. Chiefly acquired from cat and dog feces. Condition known as Brazilian Hookworm. Several other parasites pro duce similar creeping erup tions. May arise in manufacturing plants using straw for packing. Many other mites may produce human dermatitis. More common among pharma ceutical workers, lepers, pneu matic tool operators. CAREY P. MCCORD o Hair abnormalities (patchy baldness--alopecia areata). Hair abnormalities (alopecia totalis). Hair abnormalities (blue or violet colored hair). Hair abnormalities (localized canities). Hair abnormalities (excess hairiness on faces of women). Loss of nails. Watchmaker's nail. Beau's lines (transverse color ation of nails, brown or black). Discoloration of nails. Nail inflammation (and tis sues immediately around nails). Common causes--syphilis, arse nic, fungal infections; thallium, barium sulfides; synthetic rub ber intemediates. Baldness in industry; may be caused by x-ray, industrial or medical. . Suspect improper or excessive hair dyeing; sometimes deliber ate. Chiefly hereditary. Hormonal dysfunction. Both industrial and nonindustrial causes, such as arsenic, fungal infection, alkalies. Characteristic _ occupational stigma involving hypertrophy of left thumbnail. Occur among mercury workers. Many industrial chemicals. Large number of industrial and nonindustrial chemicals; also nonindustrial infection. Industrially more important than widespread loss of hair because of possible industrial causation R. M. I. Extensive baldness commonly unrelated to work causes, and perhaps more related to testicu lar function, heredity. ' Usually unrelated to work, but various work materials settling on hair or scalp may impart divers colors. A fair number of persons present localized greying in midst of normally colored hair. In women cosmetic unsightliness from hair often associated with multiple indications of mascu linity. _ Depends upon specific cause. R. M. I. Due to continual opening of watches. Arise in many forms of debilitat ing disease. Many different colors produced, such as purple from acetanilid, brown from chromates, yellow from TNT, yellow from nitric acid, black from mercury, brown from photographers* chemicals, light yellow from picric acid, Drown from hair dyes; many others. Among many others, it occurs among confectionery workers, arsenic workers, bakers, brick layers, chemists, dye workers; seek out particular exposure. Some forms of patchy baldness may involve eyebrows, beard, eyelashes, and the cause may be unknown. . Any sudden extensive baldness or any baldness occurring in groups of workers quickly should be investigated. Not disabling and usually tem porary. Ordinarily harmless condition existing from early life. Rarely associated with scalp, skin tumors. May appear first at puberty or only in later life. . Frequently nails are slowly sepa rated from bed among dish washers, bottle washers, laun dry workers, etc. . Occurrence of condition on wane. R. M. I. Apart from contact, some nail discoloration may be produced as part of general involvement as m argyna. Nails themselves little subject to inflammation. See Chapter XIV. (continued) V IS IB LE M ASKS OF OCCUPATIONAL DISEASES co Common External Marks of Occupation or Occupational Diseases or Other Diseases (continued) 492 Mark or sign Probable cause Significance Comment Skin, continued CAREY P. M C CORD Nail dissolution. Nail deformities (thickening, curvature, pitting, linear markings, spotting). Vagabond's skin. Morphea. Ichthyosis (fish skin). Milker's nodules. Barber's dermatitis (not Barber's Itch). Hives ("Bold Hives" Urti caria). Prickly Heat (Miliaria). Many industrial keratin solvents; notably alkalies. Large numbers of industrial con tact chemicals. Unknown but usually congenital. A virus disease (false cowpox). (Always associated with milk ing or udder cleaning.) Incu bative period 5 to 7 days. Mechanical punctures from cus tomers' hair. Usually allergic causes. Many occupational excitants. Some forms related to photosensi tivity. Related to profuse sweating. Common summer dermatitis. May occur in winter among cooks, bakers, bathhouse at tendants, furnace workers, etc. Complete destruction of nails rare; typical examples of causes --formalin, cement. Common among furriers, dyers, lace makers, packers, cordage makers, thallium workers, auto washers, engravers, etchers, glass makers, miners, sulfide workers, x-ray technicians, string instrument players, tan ners, many others. Deep, patchy bronzing of skin from irritation of lice bite and possibly lice excreta. Diffused white spots, usually over torso and upper extremities representing a patchy sclero derma. Entire skin rough, scaly, thick ened. Usually permanent. Usually involves exposed parts, chiefly fingers, hands, forearms. The reddish or reddish-blue nodules may be as large as 2 cm. in diameter. Sometimes as manv as 40 present at one time. Mild systemic disease with lymphangitis, lymphadenitis may appear. Chiefly limited-to webs of fingers, or at least to fingers: Layman's "Bold Hives" means "giant urticaria." Gross le sions may appear in a few min utes usually accompanied by itching. Commonly not an occupational disease but may be. Outstanding feature inflamma tion of tissues adjacent to nails. Apart from infection, condition rarely disabling. White spots and transverse markings may indicate antecedent disease. Usually associated with low order of personal hygiene. Startling when present on Ne groes or other dark races. Grossly troublesome to owner. Harmless to fellow-workmen. Self-limiting disease. Requires no treatment, but complica tions such as secondary mfection may require treatment. Burrowing sinuses made trouble some by secondary infection. Urticaria may involve such tis sues as around larynx and pharynx. Extreme edema may lead to prompt fatality. Common sites chest, back, axil* lary folds. Fungicide Furunculosis, Chloracne. Pathological sweating. Brick red (warm weather). Plum colored (cold weather). Paroxysmal face and head flushing. Lymphangitis. Keratoses (farmer's warts). Asbestos warts. Tumors (on skin). While causes are multiple, such as "oil furunculosis," a specific type is caused by pentacnlorophenol, an insecticide and fun gicide causing gross furuncules and other skm eruptions. Exposure to certain chlorinated compounds, chiefly waxes. Many nonindustrial causes, but sometimes seen in lead poison ing. Polycythemia(pathologic increase in numbers of red blood cells). Chiefly associated with the meno pause, this type chiefly limited to women 40 to 50. Infection. Excessive sunlight, ultraviolet light .etc. Mechanical penetration by asbes tos fibers; possibly chemical action akin to production of silicotic nodules. Several types, both benign and malignant. Commonest vari ety, epithelioma. New furuncules and acne may arise months after elimination of exposure. Characterized by extraordinary numbers of comedones, some times wdth typical acne pus tules. Unusual sweating may be local ized, odoriferous, colored, ex cessive. Sometimes found in heart disease, rickets, syphilis, palsy, tuberculosis, goiter, etc. May be a manifestation of re peated exposure to carbon mon oxide in relatively low concen trations. R. M. I. . May be associated with mental depression, excessive perspira tion, weakness, insomnia, emo tional instability. . .. Red streak up arm or.leg. Alarm ing indication of extension of localized .. pyogenic infection. R. M. I. Represent warty, flat, or horny, fieraistent overgrowth of outer ayers of skin. Characteristic of past middle age life; usually limited to exposed parts of skin; characteristic of many trades including farmers, sailors, fish ermen, gardeners, trappers. Condition usually limited to fin gers and hands. Apart from nongrowing warts and obvious abscesses of skin, any enlarging mass on or in skin should be investigated. R.M.I. Lesions not limited to exposed areas. Secondary infection may be prominent. Systemic involvement may be associated. In arsenic or lead poisoning, ab normal sweating usually local to parts involved in neuritis. Engorgement and congestion of superficial blood vessels. Most prominent on face. May in volve conjunctivae. Not occupational. Frequently associated with "ker nels" such as in axilla or groin. Rarely become cancerous; readily removed by electrocauteriza tion, by x-ray and by electric needle; less well by keratin solvents. Quite common both in and out of industry. Similar condition with glass fiber workers, but in that case al ways mechanical. Pigmented moles are prone to become malignant. (continued) VISIBLE M ABKS OF OCCUPATIONAL DISEASES cS 494 Common External Marks of Occupation or Occupational Diseases or Other Diseases (continued) Mark or sign Probable cause Significance Comment Skin, continued CAREY P. M C COED Tumors (beneath skin). Subcutaneous lymph nodes (enlarged). Skin cysts. Work callosities. Skin corrugation (rugosity). Skin hemorrhage (purpura). Frequently harmless, fatty tu mors (lipomas). Attain to large Bize. Lymph nodes of neck, axilla, groin, etc., may become en larged ana observable; many causes, but chiefly infection. "Kernels." Plugged-up oil glands. Pressure and friction. Several nonindustrial causes; out standing cause in industry, tan nins; less definitely alkalies. Many nonindustrial causes in cluding infection, tuberculosis, cachexia, endocarditis. In in dustry suspect benzol. Because of uncertainty, every mass beneath the skin should be investigated by a physician. Depends upon precise cause of gland enlargement. R. M. I. Large or small sacs in skin with fluid or pasty content; few or numerous cysts may appear al most anywhere on skin surface, particularly about head; on scalp called "wens"; rela tively harmless; disfiguring. Characteristic of many trades, the exact location usually iden tifying the trade or profession, e.g.', fingertips in harp players, base of little finger m bundle tiers, hod carriers on shoulders, sailors bn abdomen, hand type setters on fingertips, violinists on left jaw, basket makers on outer edge of palm, engravers on little finger, wood cutters on face, porters on palms and shoulders. . In tan yards, some workers' skin of hands' literally, may be tanned, grossly rugose and brown discolored. From" alka lies, hypertrophy with Assuring is common; somewhat dissimi lar to rugosity; many other examples. Always significant. R. M. I. Skin over lipomas, if squeezed, becomes dimpled, "orange peel" sign. See next item. Lice in head hair frequently is cause of enlarged lymph glands on sides of neck. Milium "white heads" ordinarily represent multiple minute cysts. Callosities are often more reveal ing of a trade than important as disease state. Merely skin hypertrophy of fingers, hands, feet, or other local portions of body. Tendency to recover on elimina tion of exposure; some per manent damage. In benzol poisoning may be asso ciated with bleeding from gums, nose, genitalia. "Birthmarks.' Hypodermic skin markings. Pattern contact dermatitis. Lesion distribution. Lesion distribution. Lesion distribution. Lesion distribution. Never industrial, and not prop erly "birthmarks." Improper or extensive use of hypodermic needle. Area of birthmarks sometimes more susceptible to action of industrial irritants, pressure, etc.; may become cancerous. Marks the hypodermic introduc tion of drugs, such as morphine or insulin. Skin Patterns Variety of chemicals. Contact dermatitis. Psoriasis. Cutaneous syphilis. Erythema multiforme (papular erythema). Distribution and shape of lesions commonly reveal the cause. Almost unlimited varieties such as peculiar distribution of lesions from handling bowling balls, hairpins, combs, wrist- watch bands, shoelaces, door knobs, steering wheels, brief case handles, cigarette light ers, hat bands, spectacles, etc. Common distribution--back of hands and fingers, wrists, fore arms (any surface), elbow folds, upper arms, neck and face, but not scalp; waistline, thighs, lower legs, with no or little in volvement of chest or back, knees or feet. R. M. I. Elbow points, knee caps, palms, back of head, shins, abdominal - wall. R. M. I. Characteristic distribution -- palms, cheeks, forehead, chest, abdomen, genitalia, anal re gion, soles of feet. R. M. I. . Characteristic distribution--back and front of hands but not fingers; front of wrists, around elbows, around mouth, fore head, rarely on torso, rarely on thighs, front of knees, front of feet. R. M. I. To eliminate disfigurement, many so-called "birthmarks" may be removed by electric needle, x-ray. Usually important to rule on the desirability of work applicants --drug addicts, diabetics. On side of chest, may be associated with collapsed lung in tubercu losis. Extensive information chiefly de veloped by Waldbott in his Contact Dermatitis. . Apart from traumatic injury, palms'are seldom primarily in volved'in industrial dermatitis. This distribution almost rules out all industrial dermatitis. Almost opposite that of indus trial dermatitis. This distribution varies greatly. {continued) V IS IB LE MABKS OP OCCUPATIONAL DISEASES 496 CAREY P. MC CORD Common External Marks of Occupation or Occupational Diseases or Other Diseases (continued) Mark or sign Probable cause Significance Comment Skin Patterns, continued Lesion distribution. Lesion distribution. Lesion distribution. 'Lesion distribution. Lesion distribution. Acne. Shingles (herpes zoster). Seborrhea (on oily skin). Scabies (itch). Mycotic dermatitis (ringworm). Shoulders, chest, neck, face but not scalp, back. Characteristic distribution fol lows nerve courses; front of arms, forehead and upper face, obliquely on chest and abdo men, outer surface of thighs, rarely around shoulders, rarely below knees. R. M. I. Scalp, forehead, sternal region, armpits, midway between shoulders, genital region; prac tically never on back or ab domen. Webbing between fingers, palms of hands, armpits, breasts in women, around and on geni talia, between buttocks. R. M. I. Palmar surfaces of fingers and hands including webbing of fmgers, but seldom backs . of fingers and hands, forearm, scalp, bearded region, midsec tion of chest (certain varieties), around genitalia, anal region, between toes, soles of feet, around ankles. R. M. I. Lesions and distribution quite dissimilar to industrial derma titis. Associated with much more pain than many forms of dermatitis. Seborrhea on dry skin may have different distribution and chiefly involves extremities. Less frequent in lower extremities. Fungal lesions as seen in industry seldom are characterized by the circular involvement witn clearing center. Eyes Blindness (in industry usually partial). Arsenic, benzol, carbon monoxide, hydrocyanic acid, hydrogen sulfide, lead, methanol, nitroglycerin, tobacco, trauma; many nonindustrial causes. The pathology of industrial blind- ness as occupational diseases varies highly; e.g., from methanol, optic neuritis; from benzol, intraocular hemorrhage. R. M. I. Many other substances than those listed may impair vision. Cataracts. Conjunctiva (yellow - brown pigmentation of conjunc tiva and cornea). Conjunctivitis. Conjunctival xerosis (dry eye). Exophthalmos (protruding eyes). Xanthelasma (buttery eye lids). Abnormal pupil size. Strabismus (cross eyes). Discoloration of eyes (blue sclera). Discoloration of eyes (yellow sclera). Usually not an occupational dis ease, but traditionally associ- - ated with glass making, fur nace work, and other incan descent operations. Common from penetrating foreign bodies around lens. Frequently con genital, and frequent among diabetics. Many chemical causes, chiefly aniline and its derivatives, par ticularly hydroquinone. Almost unlimited; nonindustrial and industrial agents, such as vapors, acids, dust, ultraviolet rays (Klieg eye). Vitamin A deficiency. Usually bilateral from hyperthy roidism; monolateral from brain or eye tumors. Caused by fatty degeneration. Occurs chiefly in elderly pa tients, women more often than men. Caused by many drugs such as pin-point pupils by morphine. Commonly congenital. May arise after one-eye blindness. Familial disease unrelated to work. Usually jaundice. Disappearing as an occupational disease. R. M. I. May be accompanied by reddish discoloration of hair and skin of hands and feet. Seek out particular cause. Fre quently associated with respira tory tract inflammation. R. M. I. Thickening of conjunctivae over eyeball; vascular injection with growth over corneal margin in severe cases. Commonly unrelated to work ex posure; causes staring expres sion. R. M. I. When prominent, gives startling appearance to eyes. Pupil size abnormalities frequent from occupational diseases, as among pharmaceutical workers handling such chemicals as atropine. May be divergent or convergent. Congenital strabismus not al ways manifest in infancy. Part of well-established syndrome of brittle bones and blue sclera. Reflects liver damage possibly from industrial causes, such as carbon tetrachloride, or instead, infection or cancer. R. M. I. Use of suitable eye protection in hot and excessively luminous industries is preventing the occurrence of cataracts. Rare condition. One of commonest manifestations of industrial irritants. One red eye more likely to be industrial than two red eyes. More general distribution than pterygium. Associated with tremors, sweats ing, flushed skin, agitation, other aspects of thyroid syn drome. Harmless except for cosmetic un sightliness. Frequently re moved surgically by those who can afford it. R. M. I. May arise as acute state after brain hemorrhage. For confirmation, observe other members of the family. Look for jaundice of skin or bile in urine. (continued) VISIBLE MAHKS OF OCCUPATIONAL DISEASES Common External Marks of Occupation or Occupational Diseases or Other Diseases (continued) Mark or sign Probable cause Significance Comment Eyes, continued CASEY P. MC CORD Discoloration of eyes (slaty grey sclera). Discoloration of eyes (purple sclera). Discoloration of eyes (mineral specking). Discoloration of eyes (misc.). Arcus senilis. Impairment of color vision (temporary--not color blindness). Restriction of color field. Diplopia (double vision). "Doll's eye.'' Impaired movement of eyes or lids. Nystagmus (fine repetitive motions of eyeballs). Deposits in or around eyelids (misc.). Part of picture of argyria. Methyl violet. Several mineral dusts. Various dyes and other industrial and therapeutic agents; lack of vitamins. Usually old age. Few drugs, such as santonin, tobacco. Chlorinated hydrocarbons; possi bly other substances. Usually nonindustrial, but may be caused by emetine and pos sibly other substances. Postdiphtheritic paralysis. Many nonindustrial causes; may be a feature of some industrial diseases as lead poisoning. Neuroses; fatigue, ear disease. Deposits of fat, pus, fibrous tissue or pigment. Produced by silver. External entry of traces of indeli ble pencil or some ball pen inks. R. M. I. Various mineral dusts, such as iron, mercury, calcium, may in duce spotty, colored deposits; color depends upon, metal. Relatively unimportant; staining of eyes from accidental or de liberate introduction of divers agents. _ White circle or arc at periphery of cornea. Temporaiy loss of color judg ment. Does not appear as a visible sign; attracts attention on complaint of worker. R. M. I. R. M. I. Dissociated movements-of head and eyes; when head is raised, the eyes are lowered, etc. Many types of paralysis. R.M.I. Fairly frequent among _ miners, train dispatchers, jewelers, draftsmen. R. M. I. May represent abscesses, cysts, or calcareous formations; many varieties. Does not always occur in argyria. Methyl violet, in addition to ab normal coloration, may induce definite irritations and rarely ulcers. Temporary. Does not always arise in presence of mineral or metal dusts; black specks also produced among workers melting sealing wax; also phenol. Usually unimportant and tempo rary except in avitaminosis. May occur in premature old age. Santonin possibly may discolor eye humors. More frequently from nonindus trial causes. Common feature of alcoholism. Sometimes associated with pro truding eyeballs. Droopy eyelids, hollow cheeks, fatigued expression, suggests myasthenia gravis. Eye motion may be lateral, verti cal, circular or combined. Certain deposits suggest diabetes or gout. V IS IB LE MASKS OF OCCUPATIONAL DISEASES Trachoma (granulated eye lids). f Pterygium. Intrascleral hemorrhage. Sty (hordeolum). Chalazion (bump in upper eyelid). Ectropion (pulling down of lower eyelid- exposing eye ball). Puffiness of eyelids. Iritis (injection of white of eye around colored portion of eye). Cloudy cornea. Pearly sclera. Photophobia (intolerance of light). A virus disease. . External chemical or mechanical repeated minor injuries. Rupture of minute blood vessel with filming of blood between scleral layers. ' Staphylococcus infection of eye glands. Mechanical stoppage of gland ducts. May follow contraction of scars, wounds, burns, or chronic con junctivitis. May be early sign of arsenic poisoning. Chiefly infection. Usually unrelated to work. Pearly white orpearly blue sclera, usually associated with anemia. Eye strain. This condition is readily com municated to others. Wedge-shaped film growing from angle of eye toward and some times covering cornea; resem bles eye condition in certain avitaminoses. R. M. I. Alarming bright red in appear ance, but usually without medi cal importance. May be related to high blood pressure. May be single or multiple. May be noninflammatory. Commoner in old workers. Frequently associated with other characteristics of eye or respira tory infection. R. M. I. Common consequence of small neglected eye injuries such as from foreign bodies. May represent beginning glau coma. R. M. I. May be associated with occupa tional anemias. Highly brilliant eyes produced by drugs, and especially in women. R. M. I. May indicate uncorrected defects in vision. R. M. I. Commonly described as a filth disease occurring and spread ing chiefly under conditions of uncleanliness. Occurs among lime burners, stonecutters, masons, sand blasters, and varnish cookers. Goes through usual stages of ecchymotic clearing, that is, purple, yellow, etc. Ordinarily unrelated to work causes. Common among dia betics. Frequently occur in crops, tend ency to recurrence. Unrelated to work except as a result of scarring from work injuries. Observe for additional swelling above eyebrows. If not infec tion, establish possibilities of arsenic exposure. Warning of beginning of serious situation. R. M. I. Usually associated with foggy vision, severe pain in eye, di lated pupil, swelling of conjunctivae and lids. Frequently suggests anemia, par ticularly when conjunctivae are pale pink. In industry may be related to ex cess light, either natural or artificial. Glare. 499 Rhinitis--"running nose.'' Infection or chemical irritation of nasal passages. Obviously one of commonest non- Rhinitis may appear on an al- occupational affections and one lergic basis from both. indus- feature of irritation from nu- trial and nonindustrial causes. merouB industrial gases, vapors, . dusts, etc. ' {continued) 5 0 0 CAREY P. MC CORD Common External Marks of Occupation or Occupational Diseases or Other Diseases (continued) Mark or sign Probable cause Significance Comment i, continued Rhinophyma (bulbous nose). "Saddle-nose." Infected nodules with severe systemic disease. Nose bleed (epistaxis). "Cauliflower" ears. Noise deafness (cocked good ear is the visible sign, or attitude may indicate deaf ness). Deafness (impaired hearing ' other than from noise). Impacted cerumen (waxplugged ears). Aural dermatitis (ear itch). Otitis media (running ears). Related to acne rosacea. Congenital syphilis. Glanders. Many nonindustrial causes. If industrial, caused by irritant gases, dusts, or mists such as chromic acid, benzol, or fluo rides. Hypertrophy of nose and nearby tissues; not associated with industry. May be due to trauma. Rare disease commonly limited to horse tenders. R. M. I. If profuse and repeated, R. M. I. Sometimes associated with alco holism; largely unproved. May occur in acquired syphilis. Nodules discharge yellow, glary pus with offensive odor. May be associated with foreign bodies in nose, deviated sep tum, many infectious diseases, such as measles, various forms of anemia, cancer, etc. Ears Trade-mark of the pugilist. Noise. Various substances, such as lead, hydrogen sulfide, carbon disul fide, are credited with capacity to produce deafness. Ear wax as such, or mixed with dusty materials. Varied; external irritants, infec tion, systemic impairment, lack of vitamins. Infection. Fibrous deposits in external ear. In the absence of protection, may arise among military tank operators. Temporary or permanent deaf Usually bilateral, even when one ness or impaired hearing to ear is protected against noise. some or many frequencies; Deafness in one ear, if occupa probably originates on a fa tional, may arise in train dis tigue basis followed by organic patchers, telephone operators, impairment. R. M. I. etc. Often difficult to differentiate be Deafness may constitute a neu tween industrial and nonindus rosis. trial deafness; normally occurs in old age. R. M. I. Common minor affliction in and Readily may be remedied by out of industry, particularly softening and washing. dusty trades; signs of hearing impairment constitute mark. R. M. I. The ears are common sites for Noise-preventing and hearing ap many forms oUdermatitis and pliances may favor aural der other dermatoses. R. M. I. matitis. Ear scratching promi nent sign. Common ear disease of all ages; A frequent source of subsequent frequent in industry, but not - deafness. often caused by it. R. M. I. Equilibration disturbances (Mnifere's disease). , Gangrene. Trophi. Increased hearing (overirrita tion by noise). Cornification of lips (thicken ing of lips). Lips (cancer, epithelioma). Lips (encrustation and ulcer ation). Cheilosis (one form of inflam mation of lips). Rhagades. Tongue (greenish-black). Swollen tongue. Tongue (scars from epileptic tongue biting). Coated tongue. Dysfunction of semicircular ca nals. Falling without obvious cause is the objective sign. In industry, frostbite. Gout. Alcohol and/or tobacco poison ing. Any defect of equilibration of grave importance in airplane operators. R. M. I. In absence of history of frostbite, suspect diabetes. R. M. I. Characterized by numerous hard, yellowish, round, pointed nod ules at ear margin. Pathologic irritation by moderate noise. Lips, Mouth, Teeth, Tongue, Neck Mechanical pressure and friction on lips. Exact cause unknown. Characteristic of many trades or professions, such as wind in strument players, glass blowers, etc. The lips are perhaps the most common site of epithelioma. R. M. I. Attributed to arc welding and presumably ultraviolet rays in absence of protection. Riboflavin deficiency. Congenital syphilis. Vanadium pentoxide dust. If industrial, suspect ingestion of corrosive poison, phenol, cresol, mineral acids, mercury, etc. Epilepsy. Constipation, gastritis,, dehydra tion, vitamin deficiency. In some welding, eyes only are protected. Undesirable. Pallor of lips with maceration of mucosa; may be one indication of vitamin lack. Fissured inflammation, or scars therefrom at angles of mouth. One item in syndrome. Among others dyspnea, emphysema, bronchitis, hypertension. Many causes unrelated to work, such as cretinism, infection, cancer, actinomycosis. R. M. I. Some epileptics will present evi dence of fresh or healed damage of the tongue from biting dur ing seizures. R. M. I. Relatively unimportant. Probably related to sea sickness, train sickness, etc. May be caused by infection. Similar nodules may appear on various portions of body, such as feet. ' Also caused by certain neuroses, quinine and salicylic acid poi soning, and migraine. Nondisabling. Rarely related to industry as the cause; said to be common in fishermen from tar on fish nets and the holding of net thread between lips. . May represent precancer lesion. Common among industrial workers; not directly related to work as a cause. Not to be confused with cheilosis from vitamin deficiency. Rare affection. When due to industrial material, usually accidental or suicidal. Evidence of tongue chewing does not constitute proof of epilepsy. Rarely coated tongue in colors such as black may be due to fungal infection. (continued) V IS IB LE MARKS OF OCCUPATIONAL DISEASES Oo' 502 CABBY P. MC CORD Common External Marks of Occupation or Occupational Diseases or Other Diseases (continued) Mark or sign Probable cause Significance Comment Lips, Mouth, Teeth, Tongue, Neck, continued "Beefy" tongue. Herpes (labial)--"cold sores." Occupational fungal disease around mouth. Discoloredgums. Burton line (lead line). Acute multiple dental caries. Dental erosions. "Mulberry molars." Hutchinson's teeth. Vitamin B deficiency. Action of a virUB, allergy. Condition limited to Mediter ranean countries. Involves chiefly quail force-feeders. Various metal or mineral deposits, tobacco stain, etc. Bright purple line at gum margin. Common after exposure to lead. Specific form attributed to work with citric acid, chiefly bakers and confectioners. Erosion from chemicals, such as - from acids or mechanical ero sion such as from glass blowers' pipes: numerous variations; specific variations for many trades, such as battery makers from acid, sewers from thread biting, wind instrument play ers, "tack spitters," brush makers who trim bristles by biting, pencil chewers in offices. Congenital syphilis. Congenital syphilis. One manifestation of vitamin B lack. R. M. I. Virus probably always present but only becomes active under unfavorable conditions such as infection. Organism transferred by quail pecking feeders' faces. Enlarged tongue, roughened, ru gose and red; somewhat re sembles raw beef. Not to be confused with labial chancre. Condition not known in United States. The purple gum line of lead ab sorption, the similar line from bismuth, the blue line follow ing trinitrotoluene exposure or poisoning, purple line from copper, bluish line from mer cury or zinc, purple gums from scurvy. R. M. I. Not diagnostic of lead poisoning. Well recognized in European countries. Uncommon in exag gerated form in United States. Profoundly eroded teeth of acid workers seldom decayed and are not painful. Lines or discoloration of gums are not conclusive proof of any oc cupational disease. Not readily visible as a sign of abnormality. R. M. I. All sugars as used in bakeries and confectionaries may produce some excess of dental caries. Apart from dental erosion consti tuting a Bign of occupational damage in many trades, the premature loss of teeth may possibly be related to work as a contributory cause. Dome-shaped, stunted first mo lars due to overgrowth of enamel. Notched incisors with narrow edges and peg topped. Various other dental defects sug gest congenital syphilis. - May be associated with impaired hearing and baked cornea. Discolored and mottled teeth. Speech defects (not visible de fects). Goiter (hyperthyroidism). Salivation. Mouth breathing (open mouth). Breath (garlic odor). "Phossy Jaw." Bulging of breast bone (ster num). Ganglion (ganglia). Fluorine is the cause of character istic mottling, but many metals such as copper and iron bring about diffused coloration. Highly varied causes--brain tu mors, syphilis, neuroses, fa tigue, etc. Enlarged thyroid gland. Industrial causes--mercury, po tassium chlorate, phosphorus, copper, bromides. Numerous causes unrelated to work, such as adenoids. If as sociated with dyspnea, may be caused by silicosis, which is rare. If not garlic, then possibly tel lurium, selenium, or arsenic. Apparently no great harm pro duced by many forms of teeth coloration. Stammering, slurred speech, mo notonous speech, explosive speech, aphonia, etc. R. M. I. Common as simple goiter due to iodine deficiency. Also toxic goiter from hyperthyroidism. R. M. I. Excessive formation of saliva. R. M. I. Mouth breathing may be caused by nasal obstruction. R. M. I. Persists months after termina tion of exposure. Yellow phosphorus. Deformity from necrosis of facial bones, chiefly lower maxillary. Chest If associated with pulsation, suspect aneurysm; if chickenoreast-like, suspect rickets; if series of knobs on either side at rib section, suspect rickets. Any marked external protrusion Bnould lead to medical observation. ~ Extremities Apart from Skin Cysts in the region of joint capsules and tendon Bheaths. . May occur along any tendon sheath or about many joints but more common on hands and feet; may be either indus trial or nonindustrial. Smoking, and particularly pipe smoking, may lead to black deposits on teeth. . Stammering may be related to improper management in child hood of left-handedness. More common in women. Scores of nonindustrial causes, such as Vincent's angina, mumps, cancer, syphilis, scurvy, etc. If related to recent injury to face, suspect dislocation of jaw. Disappears after increased intake of ascorbic acid. Odor will return unless use of ascorbic acid is long continued. Condition now rare. Formerly common among match makers, fireworks manufacturers, rarely fertilizer operatives. Converse picture that of de pressed sternum frequently called "cobbler's chest" asso ciated with shoemakers' trade as cause. Now rare. Frequently attributed to coarse vibration as from pneumatic tools. (continued) V IS IB LE M ASKS OF OCCUPATIONAL DISEASES Common External Marks of Occupation or Occupational Diseases or Other Diseases (continued) Mark or sign " Probable cause Significance Comment - Extremities Apart from Skin, continued Bursitis (excess fluid around joints). Clubbed fingers. Joint enlargement (arthritis). Varicose veins. Flat feet (pes plenus). Saber shins. Wrist drop (wrist weakness). Tremors. Friction, pressure, or infection. Congenital, or may be related to heart disease. ' Usually infection and gout. Hydrostatic pressure, infection among others. May be congenital; may result from weight bearing; may be related to degeneration of senil ity. Congenital syphilis. Metal poisoning, usually lead or arsenic. Alcohol. Different causes for different types. Bursae are potential spaces in connective tissue around joints that grow in response to func tional demand. R. M. 1. Various occupations lead to some bulbing of finger ends from hy pertrophy; cause of the rela tionship to silicosis and heart disease obscure. Bony enlargement. frequently called rheumatism, usually in error; ordinarily represents re action of infection or infection products. May appear anywhere, but most common in lower extremities; little related to work as a cause. A well-known common affection important to industry but little caused by it. Many varieties constitute occu pational diseases, as in "beat elbow" in miners. Many other variations in shape . of fingers. Toes may be clubbed. Some occupational diseases, such as lead poisoning, infrequently lead to bone and joint enlarge ment. Frequently associated with in dolent ulcers. May be influenced for good ot bad respectively by good or poor footwear. Forward bending and thickening of middle third of tibia. A frequent feature of lead poison ing; its counterpart is ankle drop; seen in lead poisoning when leg muscles are much used. R. M. I. Many types involving many por tions of the body from fingers to tongue. May be related to various diseases and states, including fear, goiter, ParkinBon's disease, lead poisoning, etc. R. M. I. Knobby shin bones in absence of saber deformity also suggests syphilis. Many other muscle groups simi larly may be weak in metal poisoning, and chiefly in lead poisoning. Some tremors cease on the ac complishment of an intention; thus a marked tremor may exist in reaching for a book and cease when the book is picked . up. CAREY P. M C CORD o Dead fingers (white fingers'). Writer's cramp. Stereo movements. Baseball finger. Dupuytren's contraction. Trigger finger (snap finger). Sclerodactylia (deformed, pig mented fingers). Cold associated with vibration. At times, a neurosis; at times caused by local fatigue. Habit; continuation of work movements after work. Blow by baseball on end or palmar surface of finger. Shortening of the palmar fascia. Injury to fingers in or out of in dustry. Unknown, but probably unrelated to work. This condition is akin to several others involving capillary blood supply to fingers; some condi tions unrelated to cold or vibra tion, such as Buerger's disease. R. M. I. When apart from neurotic influ ence, writer's cramp constitutes a good example of localized fa tigue; ordinarily involves those , fingers and those muscles em ployed in any particular form of writing. R. M. I. In some occupations requiring highly repetitive small motions, these motions are continued long after work hours. No disa bility) but some significance related to monotony effects, etc. Somewhat characteristic swelling and deformity, usually limited to one joint of one or more fingers. Permanent flexion of little and ring fingers (at times all fingers) with rigidity of palmar tissue. May be caused by infection, may result from oft-repeated severe pressure on palm. Said to be common among uphol sterers. Difficulty in extending fingers, but after great effort fingers fly out like jackknife blade. One, and usually more, fingers of both hands become withered, shortened, deformed, nodular, waxy-white, and at times brown or black pigmented. R. M. I. Has occurred among marble cut ters working with vibrating tools in cold weather in outside sheds; persists for months. Cramplike pains may occur. Ac tual site of damage not in fingers but in arm. Well presented years ago in fa mous comic motion picture. Common among industrial workers and fairly common basis of claims for compensa tion. Rare before middle age. Associ ated with arthritis. A corresponding condition may exist in toes. Much worse in cold weather. (continued) V IS IB LE MARKS OF OCCUPATIONAL DISEASES Cn 506 CAREY P. MC CORD Common External Marks of Occupation or Occupational Diseases or Other Diseases (continued) Mark or sign Probable cause Significance Comment Extremities Apart from Skin, continued "Red Hands.'1 Seal finger, Spekk-finger, Blubber finger. Edema. Pathologic sleepiness (somno lence). Sunstroke. Myxedema (hypothyroidism). Shaking palsy, Parkinson's disease. Barrel-shaped chest. Often purely psychogenic. At times specific chemical cause, such as oxalic acid. Infection. Patch tests usually negative. Chiefly limited to Arctic sealers. General and Miscellaneous Immediate cause--increased fluid in tissue. If organic, may be related to pituitary disease or other glan dular disorders. Commoner in obese or giant-sized persons. Sometimes appears in early pregnancy. Edema may occur in any tissue, organ, or system from ankles to eyelids. Ordinarily not a disease in itself. R. M. I. May only represent lack of proper sleep. May be associated with alconolism. May be a symptom of various occupational dis eases. R. M. I. Chiefly direct exposure to sun's Represents derangement of heat heat. Less frequently artificial regulating system of body. heat. R. M. I. Lowered functioning of thyroid More frequent among women. gland. R. M. I. Unknown. Rare before middle age. R. M. I. Common among asthmatics, fairly common among glass blowers, less frequent among musicians, i.e., singers, wind in strument players. Associated with pulmonary em physema (dilation of lung sacs). R. M. I. Barrier creams sometimes effec tive, possibly constituting only psychotherapy. May arise among seal furriers anywhere. Edema around ankles after long standing in the absence of known disease may not be im portant. Many workers, particularly on late night shifts, now indulge in drug stimulation, chiefly caffein. Many proprietary prep arations available. Caffein poisoning in industry is a ready possibility. Chief characteristics--high body temperature, hot dry skin, loud breathing, unconsciousness; in early stage eye pupils dilated, later contracted. Characterized by dull, heavy features, thickened, swollen skin, some loss of nair, sub normal temperature, sleepi ness, joint pains, constipation. Chief features--shaking of head, tremors of hand and arms, muscular rigidity, masklike facies, propulsive gait; some similarity to manganese poi soning. During asthmatic attack, there may be either skin pallor or cyanosis, anxious facies, vio lent respiratory movement, short inspiration, long, wheezy expiration. , Tics. X-ray gangrene. Phenol gangrene. Scurvy (sailors' scourge). Chiefly manifest by bruised appearance of legs, edema (chiefly of ankles) profound, weakness, loss of weight, loss of teeth, bluish, red dish, blackish spongy gums, heavily coated and brown ish tongue. Erethism (pathologic shy ness). Enlarged glands (lymphadeni tis). Hernia (inguinal). Enlarged mass in inguinal region. Hernia (umbilical). Hydrocele (water in scrotum). Spasmodic contraction of any portion of body, such as cheek, tongue, eyelid, fingers. Not directly related to industry. Improper x-ray exposure. Common among neurotics. Begins like common skin burn but advances to deep ulcera tion and sloughing. Usually involves fingers and hands. R. M. I. Extensive or prolonged contact with concentrated carbolic acid (phenol). Vitamin C deficiency. Following accidental and painless ' contact with carbolic acid, fin gers, hands or other parts be come brown, dry, shriveled, and finally black, with possible eventual spontaneous amputa tion. R. M. I. As occupational disease now rare. Term "scurvy" chiefly has dis appeared although vitamin C deficiency of nuld degree is highly common. In industry chiefly seen as mani festation of mercury poisoning. Chiefly in infections but may in dicate malignancy. Condition usually represents con genital defection. Trauma as ultimate cause rare but pos sible. Protruding mass from abdomen around navel. Relates to inflammation. Spe cific cause uncertain. In mercury poisoning many pa tients are extraordinarily hash ful, awkward, assume rigid poses. Often occurs on sides of neck, under arms, and in inguinal regions. "Scrofula," now rare, represents TB of glands, chiefly of neck. Usually unilateral. May be bi lateral. More common among women than men. May be unilateral or bilateral. Tics are frequently called "habit spasms." Common among older x-ray workers and technicians. Fre quently seen among factory workers and industrial workers as a result of poor x-ray treat ment for dermatoses. May arise apart from industry from accident or poor medica tion. Still might arise occupationally among explorers, seamen, re mote mining and lumber camps, dietary cranks, etc. Seen in other conditions unre lated to industry. . Head lice may be accompanied by enlarged glands. R. M. I. Common cause of partial or temporary disability. Rarer than inguinal hernia. May be associated with inguinal hernia. (continued) 507 V IS IB LE MARKS OF OCCUPATIONAL DISEASES Common External Marks of Occupation or Occupational Diseases or Other Diseases (continued) Mark or sign Probable cause Significance Comment General and Miscellaneous, continued Facial paralysis. Paroxysmal asthma. Effeminization of males. Nerve damage such as from toxic agents or trauma. Commonly spasmodic asthma is an allergic disease unrelated to industry. Stilbestrol and similar agents. A common variety reveals mouth drawn to one side, drooping eyelids, impaired articulation. As one manifestation of occupa tional diseases, paroxysmal asthma occasionally may arise in such conditions as trichloro ethylene poisoning, chlorine bronchitis, etc. Limited chiefly to pharmaceutical workers processing hormone like chemicals. May be char acterized by enlarged breast in males, production of feminine type of body, sexual impotency. Can arise as manifestation of oc cupational disease. R. M. I. Legally held to constitute an oc cupational disease. Manifesta tions may subside after eli mination of exposure. Mark or sign Abnormalities of gait. Characteristics The manner of walking, together with the carriage of the entire body, may afford a true insight into precise disease states, or at least may indicate abnormality to the point that a medical investigation should be carried out. It is difficult to describe in a few words the peculiarities of gait, even though on observation abnormality be quite obvious. For this reason, resort to tabular presentation is for the moment abandoned. Many peculiarities of gait call for no description since the provoking cause is at once evident. Such, for example, are the waddling gait of the woman in advanced pregnancy, the worker with an artificial leg, the victim of a stiff knee, the many types of gait abnormality following infantile paralysis, the gait oc casioned by shortening of one limb, the tottering, generally unstable gait characteristic of senility or con valescence from disease. In other states, some of which are clearly occupational, gaits, while characteris tic, may be less obvious as to cause. In any peripheral neuritis of the lower limb, e.g., from lead or arsenic, the resulting ankle drop or weakness may lead to a revealing gait. In such instances the leg is lifted high with exaggerated knee action, the foot is thrown forward, and the ground or floor is slapped at each step. The shoe is worn at the toe. Al though the condition is commonly bilateral, when unilateral an obvious variation is induced. The gait of the worker under the influence of alcohol exposes his condition. The gait is staggering, tottering, reeling. Alternately the body may be leaned forward, backward, or sideward with purposeless lurching. The drunk, apparently about to fall with each step, rarely does so. The gait in manganese poisoning is called the "rooster gait." There is propulsion with ever-increasing rapidity, until the victim may catch himself on some support; otherwise he may fall. If he starts back ward, retropulsion becomes the obvious counterpart of propulsion. CAREY P. MC CORD Ooo Abnormalities of facies. In some forms of central nervous system syphilis, the gait is ataxic. The patient walks with his eyes on the ground, and in some severe circumstances may not walk without seeing every step. Manifestly, this gait is worse at night, and some patients with this disease fall to, the ground whenever their eyes are closed. In this gait, the feet are turned out and the legs are far apart. The leg movements are excessive and the feet lifted too high. In this instance, the heels come down sharply, as may be proved by unusual wear on the heel. When one leg is paralyzed, as in hemiplegia, the afflicted leg is rigid and moves as a part of the body as a whole. The leg is thrown outward, swinging in a semicircle and with a motion toward the trunk. Thus, shoes will be worn down on the outer side. In palsy (paralysis agitans), the steps are short and shuffling, with a tendency, to walk faster and faster, as in manganese poisoning. This gait may be accompanied by a variety of tremors of hand and head, and is associated with a characteristic speech. In sciatica,the afflicted leg is kept in a position of slight bending with the heel raised and in walking, the chief pressure on that side is limited to the front part of the shoe, which part shows most wear. . Many epileptics exhibit no gait peculiarities, but some in well-established instances have a gait character ized by slouching and apparent weakness. In Huntington's chorea, a rare disease, the gait is associated with motion in all parts of the body. The arms, head, and legs move from side to side, as well as forward. There is continuous rocking and lurching with flinging motions interspersed with momentary periods in which the whole body is at a standstill. In hysteria and malingering involving the lower extremities, the assumed gait may be so bizarre as to arouse suspicion that no organic lesion exists. Variations are almost limitless. One neurotic may push an imaginary lame leg along as though on a skate- another may drag the foot with the top of the toes down ward; another may walk on the outer edge of one or both feet. Occasionally the motion made may sug gest the arc of a scythe, All of these gaits possess some feature apart from the characteristic gait of any organic lesion. In mercury poisoning there may be no involvement of a lower extremity, but on occasion may be character ized as a running gait. At least 50 other conditions unrelated to work as a cause, but occurring among workers, may be observed ranging from the ordinary limp due to corns, injury, gout, inguinal or pelvic abscess, to the complex gait of Thomsen's disease in which the legs are alternately stiff. The countenance may in itself disclose disease states, some few of which may be related to occupation. The most characteristic peculiarities of facies are related to disabling diseases, of a type not seen in workers on duty, for example, the facies of typhoid fever. Some facies that may give clue to diagnosis are now mentioned. . In the dyspneic facies, the mouth is open, the lips are dry, the nares dilate with each inhalation. The face may possess a bluish pallor, the expression is one of anxiety. This condition might be found in wellestablished silicosis, in neart disease, and in some types of asphyxiation. Manganese facies may be characterized as masklike. The skin is without wrinkles, the countenance without expression and comparatively motionless--doll's face. Other diseases of the central nervous system may give rise to masklike facies. In the presence of adenoids, and more particularly in persons younger than those in industry, the face is likely to be long and hatchetlike, the expression is dull, the nares pinched, the mouth open ana prominent, the lips dry, the eyelids droop. {continued) VISIBLE MARKS OF OCCUPATIONAL DISEASES g oH*t CAREY P. MC CORD Common External Marks of Occupation or Occupational Diseases or Other Diseases (concluded) Mark or sign Characteristics Abnormalities of facies (continued) In neurotics and hysterical persons, the facies may give a hint that such states exist. The expression is char- acterized by amiable but silly smiling on an otherwise empty face, or instead repeated but not continuous frowning may take place in the absence of any reason for such. Irregularly these faces exhibit facial tics. ' The facies of congenital syphilis are characteristic in adults. The forehead is overhanging and bumpy, the bridge of the nose is depressed (saddle nose), linear scars radiate from the angles of the mouth. Hutchin son's teeth, elsewhere described, may be present. Occasionally a patient with beginning but well-established pneumonia may be still at work. Although the characteristic facies may not have established themselves, they, if present, will show a flushed skin, the breathing may be rapid and hurried, and possibly associated with a grunt at the end of every exhalation. HerpeB may be present; the eyes glisten; the expression is that of anxiety. In some cases of hyperthyroidism, the facies continually reflect astonishment--staring facies. This is brought about by protruding eyeballs, which bare more than normal proportions of the whites of the eyes; the eyebrows may be lifted; the sfdn of the face may be flushed ana moist. In shaking palsy, the face may be so motionless as to appear neatly starched, but accompanying this there may be tremors of the entire head with eyes wide open and the eyeballs in motion. Such an expression in this disease may be accompanied by tremors of the hands or legs and a jumpy speech. ' In thyroid deficiency, the features are thick, coarse, broad. The face is moonlike, expressionless, and stolid; the outer third of the eyebrows may be missing or scanty; the skin is dry. "Pudgy" characterizes these facies. Cyanotic facies (cyanosis elsewhere mentioned) may arise from several industrial causes, as well as non industrial. In either instance, the ears, lips, cheeks will take on a bluish-purple tinge which frequently also may be observed at the finger tips. Some clearly indicative facies scarcely lend themselves to verbal presentation. Thus, the chronic alcoholic reveals his intemperance by his little-describable physiognomy; so also the facies of early tuberculous meningitis, , which is unlikely to be seen in industry. Of interest ordinarily limited to the physician are the revealing facies of complex central nervous system diseases, such as myasthenia, dyspituitarism, acromegaly, lenticular degeneration, etc. It is obvious that not in all and every case of the several states or diseases mentioned will the facies be so characteristic as here mentioned, which by design attempt to portray well-established conditions. '