>J^ ^^A / THE ^ O LIBRARIES ^ HEALTH Digitized by tine Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/industrialmediciOOmock INDUSTRIAL MEDICINE AND SURGERY> BY HARRY E. MOCK, B.S., M.D., F.A.C.S. Assistant Professor qi'Ihdustrial Medicine and Surgery at Rush Medical College; Attending Surgeon, St. Luke's Hospital; Visiting Surgeon to Washington Boulevard Hospital; Chief Surgeon to Sears, Roebuck & Company; Fellow Institute of Medicine, Chicago; Lieutenant-Colonel, Medical Corps, U. S. A. WITH 210 ILLUSTRATIONS PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1919 m9 Copyright, iqiq, by W. B. Saunders Company . PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA To MARY MINERVA JACKSON MOCK and GOLDA TAYLOR MOCK MY MOTHER and MY WIFE This book is affectionately dedicated. PREFACE In presenting this book to the medical profession, and to those laymen interested in the subject, I am quite conscious of the fact that it is a deviation from the usual character of a text-book on medicine or surgery. Instead of dealing with the pathology, diagnosis and treatment of specific diseases or the individualistic practice of medicine, I have endeavored to sat forth the reasons for, and the methods of a form of group medicine which has stood the test of years, and proven its practicability in many of the large industries of the country. The conservation of the lives and limbs of the working people and the reclamation of those disabled in the daily strife have become a definite program in the industrial world. The humanizing influence of this work has caused many an employer to consider other means of contributing to the health, comfort and contentment of his working force. Wherever these principles have been adopted, the industry has been rewarded by greater efficiency among its employees, with a corresponding increase in production. With the growth of this form of medicine the field has extended into the living and home conditions of the working forces, gradually resulting in closer co-operation with the public health authorities. In fact, it has become a vital factor in public health. To-day the achievements of industrial medicine and surgery are one of the strongest arguments in favor of a national health program. It is less than ten years since the majority of leaders in our pro- fession could see naught but a questionable future, a sort of lowering of the prescribed standards, for those physicians who entered the field of the company doctor. To the pioneers in this new specialty, however, it seemed that these industries offered a veritable human laboratory where the constant supervision of the health of thousands of employees would enable the development of a real system of pre- ventive medicine and preventive surgery. It was their first glimpse of group medicine, a form of practice radically different from that taught in the medical colleges and learned during the one or two years of hospital interneship following graduation. The comprehensive systems of industrial medicine and surgery established in many industries to-day were the result of a gradual devel- opment. The glimpse grew into a vision — the vision broadened with each subsequent year. No one man nor no one establishment can 7 8 PREFACE claim the honor of creating this work, for a number of concerns throughout the country engaged competent physicians and surgeons who simultaneously developed these new principles in medicine. The community of purpose drew together these physicians. By frequent consultations, exchange of ideas and experiences, and by the comparison of results, the vision of each individual broadened and the scope of the work expanded. It would be extremely remiss on my part to refrain from acknowledging with sincere gratitude the great assistance which I have received from many of the leaders, both medical and lay, in this work. Because of our close association, I am especially indebted to Drs. Otto Geier, C. W. Schereschewsky, Francis Patterson, W. Irving Clark, C. W. Farnum, Wilbur Post, Thomas Crowder, C. D. Selby, A. M. Harvey, and James Britton. During a period of nine years as chief surgeon of one of the largest industries of Chicago, I kept careful notes of the development of this form of medical practice as well as complete records of the results obtained. For the last two years of that period I taught this new specialty to the students at Rush Medical College, where a night clinic on Industrial Medicine and Surgery was established. This afforded an excellent opportunity to study conditions in other indus- tries lacking adequate health services. I am greatly indebted to my associates in this college work and especially to Dr. John Ellis, Dr. John Dodson, Dean of Push Medical College, and Mr. John E. Ransom, Superintendent of the Central Free Dispensary. This book endeavors to present these various experiences. It is based upon the practical application of every principle herein de- tailed not only in this one industry but in many of the other large concerns of the country. With the growth of this work of human maintenance in industry, it is becoming more and more apparent that our medical schools must correlate these broad social and eco- nomic principles with their teaching of medicine. Therefore, while it will be of value to those physicians engaged in industrial practice, it is felt that such a book will be especially valuable to the coming genera- tion of medical students. As far as possible highly technical language has been avoided in order to extend its usefulness to the layman — to those employers, industrial engineers, social workers, and labor leaders who are honestly striving to improve the condition of those who must produce and provide. To those pioneer industries having the foresight to establish and stimulate the growth of a genuine health service among their employees, the world is everlastingly indebted. Physicians working in this field could have made little progress without the moral and financial back- ing of these employers. No one realizes this better than the author. PREFACE 9 The opportunity of publicly acknowledging this fact cannot be re- sisted. For all that has been accomplished in their medical depart- ment, the greatest credit must be given to the present management of Sears, Roebuck & Company. To the ten doctors and twelve nurses on their medical staff, I wish to express my deepest gratitude for their loyalty and co-opera- tion during these years of serving together. I am especially grateful to Dr. Edward A. Oliver, my associate for seven years, and to Miss May Middleton, the Superintendent of nurses, both of whom have rendered invaluable assistance. A number of my colleagues in other industries have been unusually generous in furnishing data and other material and every effort has been made to properly accredit these and all other references. To the publishers and those others who have so willingly co-operated in the preparation of this book, I will always be exceedingly grateful. Harry E. Mock. 122 S. Michigan Ave., Chicago, III., August, 1919. CONTENTS PART I INDUSTRIAL HEALTH SERVICE CHAPTER I Page Health Supervision 1' CHAPTER II The Plant Hospital or Doctor's Office 33 CHAPTER III The Medical Staff 43 CHAPTER IV The Nurse in Industry •• 51 CHAPTER V Employees Dental Service 60 CHAPTER VI A Practical System OF Industrial Medicine AND Surgery . 67 CHAPTER VII Benefits and Profits of the Medical Department . 79 CHAPTER VIII Cost of the Medical Department • 90 CHAPTER IX Supervision of the Health of the Managerial Staff 98 CHAPTER X Recreation and Exercise as Related to Supervision of Health of Em- ployees CHAPTER XI 102 Food 10^ 11 12 CONTENTS CHAPTER XII Page Records . 116 CHAPTER XIII Industrial HiJalth Service 125 PART II PREVENTION CHAPTER XIV Preventive Medicine and Preventive Surgery in Industries 133 CHAPTER XV Industrial Hygiene: A General Outline of the Problems 141 CHAPTER XVI Industrial Hygiene: Specific Problems 151 CHAPTER XVII Industrial Hygiene and Production 167 CHAPTER XVIII Epidemiology in Industry 178 CHAPTER XIX Health Hazards in Occupations 201 CHAPTER XX The National Safety Council . . . . 310 CHAPTER XXI Accident Prevention 318 CHAPTER XXII The Spirit of Prevention 335 CHAPTER XXIII The Influence of New Employees and "Speeding-up" on Accident Rate 351 CONTENTS 13 PART III INDUSTRIAL MEDICINE CHAPTER XXIV Page Medical, Examination of Employees 355 CHAPTER XXV Medical Examination of Applicants for Work 370 CHAPTER XXVI Examination and Correction of Eye Conditions 386 CHAPTER XXVII Medical Treatment of Employees 391 CHAPTER XXVIII Women in Industry 405 CHAPTER XXIX The Tuberculous Employee 429 CHAPTER XXX Reclaiming the Tuberculous Soldiers from the Military and Industrial Armies 461 PART IV INDUSTRIAL SURGERY CHAPTER XXXI The Surgical Dispensary, Staff and Equipment; Preventive Surgery 475 CHAPTER XXXII First Aid 492 CHAPTER XXXin Emergency Surgery ..... 511 CHAPTER XXXIV The Subsequent or Permanent Treatment of Certain Injuries. . . . 542 14 CONTENTS CHAPTER XXXV Page X-RAY IN Industrial Surgery 568 CHAPTER XXXVI Hand Infections 574 CHAPTER XXXVII Fractures ..... 598 CHAPTER XXXVIII Open Treatment of Fractures 629 CHAPTER XXXIX Amputations 639 CHAPTER XL The Employees Foot 657 PART V COMPENSATION. INSURANCE. MEDICOLEGAL PHASES CHAPTER XLI Employees' Compensation from the Medical Viewpoint ....... 667 CHAPTER XLII Compensable Hernia 690 CHAPTER XLIII The Coincidence of Accidents with Disease ............ 707 CHAPTER XLIV Other Traumatisms with Medicolegal Aspects ... i ...... . 719 CHAPTER XLV Health Insurance .,..,... 740 CHAPTER XLVI Employees' Mutual Benefit Associations. ............. 760 CONTENTS 15 PART VI RECONSTRUCTION CHAPTER XLVII Page AiMBRICANIZATION OF THE FOREIGN EMPLOYEE 769 CHAPTER XLVIII Human Conservation and Reclamation of the Disabled. ...... 776 Bibliography 801 Index ............................... 825 INDUSTRIAL MEDICINE AND SURGERY Part I INDUSTRIAL HEALTH SERVICE CHAPTER I HEALTH SUPERVISION EMPLOYEES' SERVICE DEPARTMENTS Industrial medicine and surgery, the new specialty, deals with the human maintenance problem in mdustry. Our modern mdustrial concerns have regularly employed experts to study their expensive, comphcated machines in order to preserve their mechanism and obtain their maximum efficiency. The human machine alone has been neglected. It is true that company surgeons have existed for many years but rarely did the scope of their work extend beyond the repair of injuries. This new specialty in medicine not only furnishes adequate medical and surgical care when necessary, but includes all measures bearing upon the health, welfare and working ability of employees. Supervision of Health of Employees has become an essential part of the organization of many large mdustries. The past decade has witnessed the birth, in this country, of this one of the most im- portant of human conservation movements, and the last four years have seen it expand into a great, five issue with far-reaching influence. Since its birth, many other issues offering service to the great mass of wage-earners have been created. Chief among these are the Mutual Benefit Associations, the Safety Movement, and Employees' Compensa- tion Acts. The latter still is an ugly child in many respects, but gives promise of a great future. Its brothers, Employees' Health Insurance, Old Age Insurance and Insurance against Non-employment have not as yet been born, but this new specialty is rapidly demonstrating their need. 2 17 18 INDUSTRIAL MEDICINE AND SURGERY A comprehensive system of the supervision of the health of em- ployees must include every branch of preventive medicine and surgery and of remedial medicine and surgery, as well as industrial hygiene and sanitation. These are primarily medical functions and must be ad- ministered by the medical department of an industry. Many other activities have been developed in our best organized industries, however, which have a direct bearing on the comfort, convenience, and state of mind of the employees, and therefore have the closest relationship to health supervision. Recognition of this fact has caused the creation of Employees' Service Departments in several concerns. or HEALTH or EMPLOYES OP MAINTENANCE DEPART. SUPO HUMAN CEIiTRAL MAffAGSR EneiNEER CMPLOrfS yismm NURSe3 Fig. 1. — A successful plan of organization in one industry. Usually a broad-visioned business man, or occasionally a trained sociologist, has been placed at the head of such a department. It is his duty to co-ordinate all these activities so that the greatest service will be given to the employees. The actual work of the medical department is under the doctor, the safety work is under the safety engineer, the employment manager attends to employment. In other words, the functions of these various services are decentralized as to activities but are centralized under one head as to policy, adminis- tration, etc. (Fig. 1). In at least three large concerns all these functions have been placed directly under the supervision of the chief of the medical staff. The argument in favor of this is that the broadly trained physician, with a proper economic and social sense, because of his close relation- ship to the employees, is the best manager for such a department. HEALTH SUPERVISION 19 Time alone will prove which is the best plan. The tendency to give more and more power to the medical director is growing, and certainly demonstrates that all things which increase the health of employees must increase dividends to the employer. It also demon- strates that the vision of the physician in industry must constantly expand, and he must become fully cognizant of those activities which can well be called the adjuncts to health supervision. This fact is positive, namely, all activities which deal directly with the health and safety of the employees should be placed under the medical director, and those functions which look to the comfort and welfare of the employees, although administered by various lay managers, must be closely co-ordinated with, and often supervised by the health department. In fact, everything about the industry which in any way touches the health problem should be subject to the ap- proval or criticism of the medical staff if the greatest benefits from such a system are to be obtained. What are the activities of an Employees' Service Department? From a medical standpoint they can be divided into those services which deal directly with health supervision, and those which are adjuncts to health supervision, as follows: 1. Health Supervision of Employees : (a) Medical Service. (6) Surgical Service. (c) Dental Service. (d) Nursing Service. (e) Safety Service. (/) Sanitation Service. 2. Adjuncts to Health Supervision: (a) Employment Service. (6) Restaurant Service. (c) Recreation Service. (d) Welfare Service. (e) Insurance Service. (/) Banking and Loan Service. (g) Housing and Community Service. To the internist, surgeon, or the regular family physician, it is quite evident that this new type of physician, working in industry, is confronted with many problems which have not been included in the usual medical curriculum. Let me assure you, however, that all these services in the working homes of your patients have a decided bearing on their health. Recognition of the relationship between conditions in industry and the health of the people will become more and more essential in the teaching of medicine in the future. 20 INDUSTRIAL MEDICINE AND SURGERY Details of this work — the general principles, the purposes and the results of all the functions of industrial medicine and surgery, will be given in subsequent chapters. This discussion will be limited to outhning the scope of health supervision. I want to emphasize that the plan of supervision which I am about to offer is the ideal for which all company surgeons should strive — an ideal to which no industrial concern as yet has fully attained. The prevention of sickness, accidents and inefficiency among employees is the purpose of all forms of health supervision. A general survey of the component parts is the first step in prevention, be it prevention of fires, accidents, burglaries, war, flood, or what not. Thus, the first step should be a general survey of the working place; the mechanical appliances therein; the employees, individually and in a group; and even the employers and their attitude and state of mind toward supervision of health. The physician entering an industry where this work has not been in vogue will usually have to develop this proper mental attitude on the part of both the employer and the employed. MEDICAL SERVICE The medical service in a properly conducted health supervision plan, includes those activities dealing directly with the equation of health in the employees and the treatment of their diseased conditions. One of the first requirements in the general survey of this field is the complete physical examination of every employee, and, when practicable, a periodical re-examination of these employees, approx- imately every six months. I qualify the re-examinations, because, whereas in a plant employing only a few hundred people this can be done with a very small medical staff, in one employing ten or fifteen thousand people it would take a staff of four doctors doing nothing else to re-examine the force every six months. Such a plan would interfere with the work of the employees to the extent that few man- agements would consent to this unusual precaution. The medical examination should be complete in every case, both male and female. The history in each case can be obtained by a trained nurse, who can also take the temperature, pulse, height and weight of the employee before he is sent in to the doctor. The phys- ical examination can be made while a qualified laboratory assistant is analyzing the urine, the specimen being obtained just before the em- ployee is sent to the examining room. Next, the dentist and the nose-thro at-and-eye specialist examine the individual in turn. Provided plenty of office space is available and sufficient and efficient assistance is given, this examination can be completed in 25 HEALTH SUPERVISION 21 minutes. This includes the time necessary for disrobing and dressing again, and the short wait for his turn. Unless some condition is found which requires careful study, this examination need not take over ten minutes of any of the doctors' or nurses' time before whom the employee appears for each step in his examination. Many times a day individual cases will present themselves which require considerably more of the doctor's time; for instance, certain diseased conditions must be carefully explained; advice appli- cable to each case must be given; the doctor must ascertain if the proper hne of treatment is being followed in a certain case, and, if not, must arrange for it; questions must be taken up with the employees' manager pertaining to change of work, etc.; matters of personal hygiene must be discussed; and numerous other factors deaUng with the per- sonal equation between the doctor and the employee must be met and carefully considered. In no instance should this medical super- vision attain such a high plane of efficiency, as regards speed and the number of employees examined per day, as to lose sight of this personal element — the benefit of the personal contact of the employees with the doctor. Many company physicians may object to such a thorough physical examination of employees as is here outlined, but, remember, this plan is based upon the assumption that the industry wants the same efficiency in its human maintenance department which it demands in all other departments, and efficiency means thoroughness. The inspection of employees and choosing only those for physical examina- tion who seem below par is better than no medical supervision; the physical examinations usually made on girls, namely, the head, neck and chest, have given wonderful results in supervising the health of these female employees, but to obtain the maximum of results a complete survey of the entire body of each individual is necessary in order not to overlook anything which might be detrimental to health. The pxirpose of a complete physical survey must not be to ehminate the unfit from the working force, but must be done absolutely from the standpoint of supervising the health of the entire group. Thus, it is essential to ascertain the condition of health of each individual to discover diseases in the earliest stages, while still curable ; to find any- one suffering from a communicable contagious disease, and to seek out the employee chronically diseased yet still able to work and re- commend for him a position where he can be efficient without hastening the course of his disease. Until such time as the State takes up its burden, employers should make adequate provision to render proper medical care and sufficient financial aid to him who is forced to stop work because of this system 22 INDUSTRIAL MEDICINE AND SURGERY of supervision; otherwise, the very purpose of such a system will be defeated, namely, the restoration to health in the shortest time possible. Lack of money and the worry over debts are great drawbacks to the regaining of health. Of equal importance with the medical examination and re-examina- tion of the old working force is the thorough examination of every applicant for work; in fact, this is just as essential as keeping the work- ing place sanitary when once you have removed all unsanitary con- ditions. The examinations of applicants, however, should not be made for the purpose of choosing only the strongest, healthiest workers, but to protect the old working force from any applicant who might have some contagious disease. An excellent means is also given for supervision of the health of these prospective employees by preventing those with serious diseased conditions from going to work, for their own protection; and by choosing the proper type of work for those with chronic diseases which do not totally unfit them for employment. I have talked with two national labor officials, and they assure me that, if all industries would approach this procedure from as humane a standpoint, as above outhned, they would thoroughly endorse the plan. Medical treatment of diseased employees is still a mooted question. The treatment of conditions directly the result of occupations, for which the employer is considered responsible, is almost universally recognized as a logical part of the work of the company surgeon ; but the care of the workman injured outside the plant, or whose sickness has no connection with his work rightfully belongs in the opinion of many to the family physician. To give the best results to both em- ployees and employer, complete remedial measures must go hand in hand with the work of investigation and supervision. This medical and surgical treatment has already been instituted in a few industries, and the results are proving its worth. Most medical staffs furnish complete surgical care to those injured while at work and the more rapid recoveries, fewer permanent disabilities, and lower death rate furnish the strongest arguments in favor of such a plan. Every company surgeon has seen the most deplorable surgical treat- ment given to workmen injured while at home. Many of these home accident cases are neglected by the employee himself until some severe infection or other complication finally forces him to consult his family doctor. Even then, many family doctors, untrained in emergency surgery, will give inadequate treatment, for example, making a small incision in an infected area when a wide-open incision is indicated. As a result, the disability of the outside accident case is often pro- longed and frequently a permanent deformity occurs which could HEALTH SUPERVISION 23 have been prevented by the prompt, early treatment of the accident by the surgical mechanism of the industry. Many surgeons are daily interfering in the care of some home accident case in order to prevent these dire results. Almost the same situation exists in the medical cases. When a diseased condition is found, the employee is advised as to the best line of treatment and then is referred to his family physician. Often he receives the very best of care from the latter, again only mediocre care, and occasionally he neglects to follow the advice to consult his doctor, waiting until the condition becomes so serious that he is forced to do so. In many instances the case is treated without any effort at a diagnosis being made. Time and again a blood examination or a stomach analysis would show the true state of affairs and would indicate the proper line of treatment, whereas the employee is taking pills from a "bhnd doctor," or is receiving electrical treatment from a quack. Daily the medical staffs of industries are interfering in the treat- ment of sick employees. They are operating more and more on employees who have some surgical condition, when careful inquiry shows that they cannot afford to obtain proper surgical and hospital care, or when it is apparent that the condition is being neglected by the family physician. A few industries have assumed the care of all cases of tuberculosis found among their workmen. Most of these are sent to sanatoria. Some refuse this care and choose home treatment under the family physician. A comparison of the results between this home treatment and sanatorium treatment proves that these concerns have saved Hves by taking complete charge of the tuberculous employees. Some industrial medical staffs are now treating all syphilitic and gonorrheal cases, with the result that scientific care is curing the early cases, and, best of ?il, society is protected. The old plan of firing the venereals and leaving many of them to the mercy of the quack is no longer practiced. Those with defective vision are now being cared for by competent ophthalmologists, instead of allowing the employee to go to the corner optician for their glasses. In 1915 the writer found 799 cases of defect- ive vision, and cared for 179 of these, the remainder going without care or to whomsoever they saw fit. In 1916 he found 1014 cases of defective vision and corrected 930. Supervision of these shows that they have remained corrected, and the increased efficiency resulting therefrom has far more than paid for the cost of this service. These examples therefore prove that, hand in hand with the super- vision of the health of employees, there must be proper medical and surgical treatment rendered — the two are almost inseparable. I 24 INDUSTRIAL MEDICINE AND SURGERY do not mean to insinuate that the medical men of an industry are better physicians than the average family physician, but I do know- that systematic care by a unit of medical men, each trained especially in some particular line, will give the surest, quickest and best results. NURSING SERVICE One of the chief aids in the supervision of the health of employ- ees is a well-trained staff of industrial nurses. Special training is necessary before any nurse can learn all the ramifications of the work of an industrial nurse. Through her the employers can show their friendly interest in the force. The small merchant, with five or six employees, can personally visit and offer aid to one of his men when the latter is sick or in trouble; but the large employer, with several thousand workmen, must depend upon some other agency in order to show his friendly interest in their welfare. Thus, every industry should have a sufficient number of these nurses to visit each sick employee; to render nursing aid when necessary; to report on his condition and whether or not he is receiving proper medical care. She also diplomatically ascertains whether or not financial aid is needed; if the sick one is worrying over accumu- lating debts; if the home environments and housing conditions are such as to interfere in his rapid recovery; in fact, she is able to supervise the health of the employee, to a certain extent, while at home. SURGICAL SERVICE The Surgical Service is one of the most vital branches of the med- ical department. The company surgeon, working in the front Line trench of industry, is in the strategic position to develop the most comprehensive system of preventive surgery. His first duty is to study and enforce every possible form of accident prevention. In the minor accidents, such as pin-pricks, bruises, and the like, which are almost unavoidable, he must devise means of preventing comphca- tions such as infections. When an accident occurs he must be close at hand to render the earliest possible treatment, and must continue to treat the case from the standpoint of preventing undue loss of time from work, preventing permanent disability, and, above all, to prevent the death of the patient. The restoring of the most perfect function in an injured member must be his aim. Such a surgeon is constantly striving for the best economic-end result, as well as for a medical-end result. Every industry should have on its medical staff a surgeon com- petent to handle every type of surgical condition. Even where a HEALTH SUPERVISION 25 specialist is required for certain operations this company surgeon should continue to supervise the treatment. Employees sent to a hospital for surgical care usually receive more prompt attention and more careful after-treatment from the surgeon who is directly responsible to the management of an industry. Many an employee has been referred to one of the large hospitals in a city for operation when his occupation was not responsible for the condition. Often three or four days elapse before the hospital surgeon finds time to operate, except, of course, in very acute conditions. After the operation the treatment is left largely to the interne. Unfortunately, many internes have not yet developed the proper social sense, or do not consider the great economic loss due to keeping the patient in the hospital longer than is necessary. These employees leave the hospital dissatisfied with the treatment which they have received. Their statements are often exaggerated, but nevertheless it is apparent to the management that the cases cared for by the company surgeon are expedited, while too often those referred to the general staff of a hospital sustain an un- necessary loss of time. This condition is resulting in the company surgeon being requested by the management to operate more and more often on workmen with conditions other than injuries, especially when the early return of a man to his work is vital to the production of the plant. In many industries the workmen are so scattered that it is often im- possible for the surgeon to render prompt treatment when an accident occurs. In this case he must arrange for proper first-aid treatment by some competent fellow-employee. First-aid stations in some plants have been established at regular intervals throughout the buildings with trained laymen in charge to render first-aid to every injured employee. In others three or four intelligent employees are chosen in each department and are carefully drilled in every form of first-aid treatment by the company surgeon. When an accident occurs in that department these men take charge of the case and render the early treatment indicated. This first-aid work, however, should never re- place the doctor. Practically every injury, no matter how slight, should be sent or taken to the central office at once where a competent surgeon can take charge. In many places this first-aid service has been developed to such a high degree that it is one of the most impor- tant features in their plans for health supervision. SAFETY SERVICE No system of supervision of health of employees is complete imless suitable provision is made for the prevention of accidents. Therefore, a safety engineer is essential in making the general survey of mechan- 26 INDUSTRIAL MEDICINE AND SURGERY ical conditions of the working place and in adding every appliance known for protection. After this is done he must make daily inspec- tions of the plant to see that these safeguards against accidents are used by the employees. He must also investigate every accident in order to devise some means to prevent its recurrence. There must be the closest co-operation between the safety engi- neer and the company surgeon; in fact, he should be directly con- nected with the medical department. The surgeon must report every accident promptly with all data pertaining to its cause which he obtains from the injured employee. By talking freely with an in- jured man during the period of caring for him the doctor can learn many apparently insignificant facts, even from the most ignorant employee, which are invaluable in this work of prevention. Like- wise, the company surgeon is the safety engineer as regards the human mechanism. By thoroughly examining the injured man he often finds some physical or mental defect as the cause for the accident. SANITATION SERVICE Sanitary conditions of the plant have a very definite bearing on the comfort and health of the employees. Industrial engineers are con- stantly pointing to the relationship between industrial sanitation and maximum production. There is no doubt but what unsanitary condi- tions about a plant cause more sickness, more discontent among the employees, greater labor turn-over, and a very definite slowing up of production. From a medical standpoint the sanitary inspec- tions are almost of equal importance as the inspections of the force by physical examinations. The medical staff should see that every unsanitary condition is removed and the plant is made as healthful and comfortable as possible. To accomplish this the clean- liness of the building, the ventilation, the lighting, the temperature and humidity, the disinfection of toilets and cuspidors, the installa- tion of proper washing and bathing facilities, the removal of dangerous gases and dusts and the fumigation of departments or rooms where contagious cases have developed must be made perfect and kept so by frequent inspections. EMPLOYMENT SERVICE The question may well be asked by those unfamiliar with this work, why the employment service should be included as an adjunct to health supervision. The very fact that some employment managers in certain industries are endeavoring to have the medical departments placed under them demonstrates that there must be a very definite HEALTH SUPERVISION 27 connection between health and employment. But the employment problem is only a small portion of the health program in any industry, and it is bound to curtail the work of the medical department if it is made subordinate to the employment department. As a means of health supervision it would be more logical to place employment under the medical director. The majority of concerns, however, con- sider it best to have the closest co-operation between these two depart- ments, but to have them operate under separate heads. Every applicant for work should be thoroughly examined by the medical staff in order to prevent the introduction of contagious diseases into, the plant and to provide for the proper selection of work for every man according to his physical and mental qualifications. The employment department should see that the recommendation of the doctor as to the type of work a man is qualified for is carefully followed. In many concerns the employees are no longer subject to the whims of the foreman. The studies in labor turn-over have revealed the fact that the employing and training of a man to the point where he is efficient is too expensive a proposition to warrant his careless dis- charge unless there is a very good reason. In most of these concerns no employee is discharged without the approval of the employment manager. The latter ascertains why the man has not made good on his job, and sees if there is any other position in the plant in which he could make good. The medical department has become one of the most important allies in these efforts to conserve man-power. Fre- quently some incompatibility between the occupation and the physical condition of the employee is responsible for his failure to succeed in a given position. The earliest impressions the new employee receives concerning his future working home are received in the employment and the medical departments. Both should endeavor to at once familiarize the new man with every branch of the employees' service department. These first impressions go a long way toward engendering in the novice the proper mental attitude toward his future work and his employer. RESTAURANT SERVICE Many industries provide proper restaurant service for their working force, or at least a proper place in which to eat their lunches. No group can be kept at the highest point of efficiency if allowed to remain in the department during the noon hour. The change from the working place to a suitable eating place, with the short walk in the open air which this should involve, is one of the best efficiency measures which any concern can adopt (Fig. 2). 28 INDUSTRIAL MEDICINE AND SURGERY The providing of the proper food for employees, the supervision of the sanitary conditions of the restaurant and the physical examination of the help preparing or serving this food is a logical part of the health supervision program. Fig. 2. — Employees Dining Room. (Courtesy Cincinnati Milling Machine Co.) RECREATIONAL SERVICE Athletics has become almost as popular among industrial employees as among college students. Almost every small concern, as well as the large ones, has its baseball team, its tennis team, and even its golf team. Competitive games between different working forces are quite frequent. Some of the largest industries have their athletic directors and employ coaches similar to the athletic departments of universities. Teams are developed in the different departments and competition is very keen. The annual field meet of one of the large industries of Chicago now attracts almost as large a crowd as the Conference Meet at the University (Fig. 3). These athletic contests are not hmited to the male employees, but the girls have their teams and tournaments likewise. No better means of improving the physical condition of employees and of supervising their health can be established than this form of recreation. The doctor should take a very active part in all such organizations and should constantly stimulate the employees to HEALTH SUPERVISION 29 join some one of the athletic teams, or to join the gymnastic classes. In this industry, above referred to, no person can become a member of one of these teams or take part in any form of physical recreation connected with the plant without first being thoroughly examined by one of the doctors and pronounced physically fit to compete. This affords another channel for health supervision. 30 INDUSTRIAL MEDICINE AND SURGERY WELFARE SERVICE The term "welfare " is disliked by many employees. It smacks too much of charity. Nevertheless, it is one of the most important branches of the employees service department. It has been variously termed in th6 different industries as The Industrial Relations Service, The Employees Advisors, The Sociological Service, etc. No matter by what term you call it, the work of such a division has a logical place in industry, and it must have the closest connection with the medical department. Many times little controversies will occur between a boss and a worker, or little injustices will be done an employee and will so prey on his mind that he first becomes mentally then physically unfit. All Ibaaf the lUbfit THE 1 VICIOUS cih;l£ Censure f r )m BOBS IiOirarM Health CcmditlW ■"* Worry ^— -^ and nervousness psar otf 103 to^ job Fig. 4. — All things tending to lower the health of an employee lower his efficiency. Result — The Vicious Circle. The preventive is a properly organized Human Main- tenance Department. Again, misfits between the job and the man, misfits in temperament between the boss and an employee, and many other allied conditions, often lead to the development of a vicious circle. A misfit means inefficiency, inefficiency causes censure and fear of losing his job, this fear causes worry, then nervousness, then lowered health conditions, and this last physical state makes him a greater misfit (Fig. 4). Fears of all kinds; discontent; lack of living wage; worry over sick- ness or trouble at home; worry over debts; over a love affair; over a crime committed; bad habits, especially intemperance; bad home environments; insufficient food; unsanitary housing conditions; and innumerable other stimuli for mental and physical depression, are daily arising to undermine the health of employees. It is just as es- sential to remove these conditions as it is to make the plant sanitary. HEALTH SUPERVISION 31 The ability to meet these problems and to help the medical de- partment to solve them is the duty of the so-called welfare department. Let the employees know that their confidential friends are located in this department — a sympathetic man for men, and a woman for women — where they can take every problem of the above nature and receive help. In a large industry these advisors furnish an excellent means of personal contact between the employer and employee — a personal contact which is essential to the comfort and well-being of every worker. This department is responsible, to a large extent, in educating the force to co-operate in all plans for accident prevention and health supervision. INSURANCE SERVICE The need of some form of health insurance for sick employees is clearly demonstrated by the fact that most large industries have pro- vided mutual benefit associations to which the employer in most cases contributes a certain amount as well as the employee. The insurance thus received in case of sickness enables the workman to secure proper medical care. In most concerns membership in these benefit associations is entirely voluntary. The medical staff, which is in the best position to realize the value of this form of insurance, should never miss the opportunity of urging the employees to join such associations. As a rule these organizations are a great stimulus to health supervision. Employees contributing to a benefit association are easily impressed with the saving which results from keeping the sick rate down to a minimum by proper preventive measures. BANKING AND LOAN SERVICE While the banking department of an industry, which provides for savings at a good rate of interest, may not have a very close connection to the problems of health supervision, yet the loan de- partment of this banking service has one of the closest connections. Time and again the visiting nurses will report that an employee who is at home sick needs special nursing service, or that the home conditions are responsible for the ill-health, or that an operation requiring the expenditure of a considerable surd is necessary, and that funds to meet the situation are lacking. After a careful investigation the medical director can recommend to the banking department that a loan of money be granted such an employee. As a rule these loans are repaid in very small amounts from the weekly wage after he is able to return to work. In one industry advantage has been taken of this loan privilege to urge employees to have much needed dental work done. This 32 INDUSTRIAL MEDICINE AND SURGERY same concern has arranged for all old employees, and all applicants for work who are accepted, who are in need of glasses to correct defective vision to buy the same, the money being provided by a loan. - — . HOUSING AND COMMUNITY SERVICE No system of health supervision in the plant is complete that does not consider the home conditions of its employees. The best means of securing reports on these home conditions is through the visiting nurses. Close co-operation with the Municipal Public Health Service will enable the medical director to secure the necessary correction of unsanitary conditions in the community. If the head of a concern, or a man very close to him, will take charge of this service and will take an active interest in improving the housing conditions for the entu'e community as well as for his em- ployees, the greatest benefits will result. From this short resume of the functions of the various services represented in a complete Employees' Service Department, it is quite evident that the supervision of the health of the employees forms the very foundation of all this work. Before such a comprehensive system of supervision of the working place, the mechanical appliances therein, and of the employees, can be instituted the employers must be educated to the value of such a procedure. Some employers, with a vision and a social sense, will see the humane side, while others, of a more calculating disposition, will look for the dollar-and-cent value before installing this system. In those industries where pioneer work in Industrial Medicine and Surgery has been done, the results should satisfy either of the above types of employers that such supervision pays dividends and makes a happier, more contented working force. It must be the duty, there- fore, of every company surgeon, of every safety engineer, and of every so-called welfare worker, to show that the benefits to the employer are in direct ratio to the thoroughness and completeness of the plan which he adopts for the Supervision of the Health of his Employees. Very few employers, even in industries where various plans of health supervision have been inaugurated, realize the reasons therefor and the full significance of this work. If they would awake to a real comprehension of the value of this form of supervision, a social evolu- tion would occur which would react to the great welfare of both the employer and employee and would solve more labor disputes in a minute than the old system could evolve in a year. This is not Socialism — so-called — but it is the broadest socializing influence, the most forward step for preparedness, and the greatest conservation movement our country has ever witnessed. CHAPTER II THE PLANT HOSPITAL OR DOCTOR'S OFFICE The term "Doctor's OflEice" is usually applied to the medical de- partment of an industry. In many places it has the functions, tem- porarily, of a hospital, but because a special license is required to operate a hospital and because patients are seldom kept at the plant over night, the term "hospital" is rarely used. In some concerns it is called the "Plant Dispensary," in others, "The Medical Depart- ment," and in one industry the sign "Employees' Doctor" marks the location of this department. Every industry with a few hundred employees, as well as those employing thousands, will find it greatly to their advantage to have a Fig. 5. — Industrial Dispensary at Primero, Colo. {Courtesy Colorado Fuel & Iron Co.) medical department located somewhere about the plant. The smaller industries will not require a doctor all day, but there should be a doc- tor's oflfice and a physician in attendance for a few hours every day. For industries of a thousand employees or more it is very im- perative that there should be a plant dispensary and constant medical attendance. The duties of the physician will be taken up in the next chapter. The location of the medical departments in those industries which have installed them varies considerably. Some have built very hand- 3 33 34 INDUSTRIAL MEDICINE AND SURGERY S^. X] fl ^ 1 RF = ^ C = c 3 C 3 = j c = ^ 1 f 1 ■= = = — - . :^ " H r ^ p: ±J S u®o J. :2) si ^3 0© K~ FiG. 6. — Medical Department and service room plan. Cincinnati Milling Machine Co. (From "Employees Service News.") Foreword. — The two floor plans of the Employees' Service Department of the Cincinnati Milling Machine Company include some 23,000 sq. ft. of floor space, which is given over to the Medical, Dental and Employment Departments, the comforts and convenience of the locker room, the Commissary and the Cafeteria. While the growth of this Department has been gradual, the whole layout is distinc- tive in that all of the facilities mentioned above have been brought together and cen- tralized for the purpose of supervision and convenience and efficiency of operation. Considerable study is evidenced in its compact arrangement, providing everything that the human engineer would first think of, except, perhaps, recreational facilities. Looking first at the office end of the Employees' Service Department one notes that the Employment Department and the Medical Department are side by side. THE PLANT HOSPITAL OR DOCTOR' S OFFICE 35 some buildings in close proximity to the plant (Fig. 5). Others have; set aside spacious, well lighted rooms directly in the plant and equipped them as the most ideal doctor's offices, surpassing in many respects the private offices of any physician in the country. Many of these would delight the heart of the most fastidious physician. Too often, however, the company physician has been unable to demonstrate the value of efficient medical service to his employers and as a result they have furnished him very poor quarters in which to work. Or the management may feel that the medical department is an unprofitable, expensive necessity and therefore crowd it into some place where it will not take up space capable of productivity. The best argument against this attitude is that some of the largest, most successful concerns have assigned the best location in their plants to their medical departments. Some time ago a successful business man visited one of the pro- gressive industries and made a careful inspection of their doctor's office. When he had finished he said : "This is all very fine but how can you afford to give over such a large amount of valuable space to your Medical Department?" The official of the concern who was present said: "Why, man, this department pays the biggest dividends of any of our departments and therefore it deserves all the space it needs." The selection of the proper location for the doctor's office or plant dispensary must depend upon many local factors, but a few general rules can be laid down which should be of great assistance to the company surgeon. 1. Choose a central location in the plant where the doctor's office will be the most available to the greatest number of employees. 2. If one portion of the plant is engaged in work where accidents are more liable to occur, the office should be located in that vicinity. 3. Whenever possible the employment department should be in close proximity so as to facilitate the examination of applicants for work (Fig. 6). separated only by the employees' entrance, whose doors are locked at the start- ing hour. Thereafter all late comers must pass through the Employment Office, where the clerk makes record as to his cause of lateness. Similarly, all men leaving the shop at irregular periods can only pass out through the Employment Department and by the same clerk, who makes record of his exit. All successful applicants for jobs readily pass into the Medical Department for a physical examination. After starting hours the doors leading from the locker room to the plant are locked. The floor arrangement shown indicates how accessible the Medical, Dental, Employ- ment and Paymaster's Offices are to all the men of the shop. Complete privacy is assured any employee who wishes to discuss his personal affairs with the Employment Manager, the Assistant Superintendent, or the Medical Chief, who happens also to be the Director of the Employees' Service Department. It is here also that office rooin is provided for the group of men who manage the Health and Insurance Association of the plant. The floor plan is practically self-descriptive ' and needs no further elaboration. 36 INDUSTRIAL MEDICINE AND SURGERY 4. It should not be placed in a noisy portion of the plant where the rumble of machinery, or of heavy trucks, etc., will interfere with the efficient use of the stethoscope in examinations. 5. The rooms should be spacious, well ventilated and well lighted and of sufficient number that the work can be done with more or less privacy. 6. The doctor's office should at all times be a model of cleanliness. 7. Whenever the size of the industry warrants it the office should be located upon the grounds or in the building. 8. Keep the medical work centralized in one office as far as pos- sible, but if the plant is scattered, it may be necessary to have sub- stations. 9. Whenever practicable a separate building in close proximity to the plant should be used. This affords better light and ventilation and quieter examining and rest rooms. Sick and injured employees are also exposed to less unpleasant publicity. The minimum requirements for the doctor's office in an industrial concern, suitable for conducting the medical examination of employees, can best be shown by quoting from the report of the "Committee on Factories," made to the Chicago Tuberculosis Institute in 1913. This committee consisted of : Dr. Harry E. Mock, Sears, Roebuck and Company, chairman. Dr. A. M. Harvey, Crane Company. Dr. James A. Britton, International Harvester Company. Dr. W. H. Lipman, Swift and Company. Dr. L. Z. Little, Western Electric Company. " 'Provision for the Medical Office and Equipment in an Industrial Concern' was the subject of the committee's report. "That it marked an epoch-making advance in the promulgation of the systematic supervision of the health of employees, was pointed out in the words of the chairman of the Factory Committee, Dr. Theodore Sachs: 'The most significant point in connection with this report is that in a comparatively short period of three years or so, the medical departments in the industrial concerns became an important integral part of the concern and this report certainly presents a good basis for all others, who are contemplating the installation of a health depart- ment, to follow.' " The committee report follows: "In the judgment of your committee, the subject matter proposed for their consideration was entirely too broad : ''First. — Because a great many industries already have a medical department in connection with their plants. "Second. — Because an industry planning to take up this medical work should first choose a competent physician to take charge, and THE PLANT HOSPITAL OR DOCTOR'S OFFICE 37 the arrangement, equipment, size and location of the doctor's office should be left to his judgment and discretion in practically every case. '^ Third. — Because most industries contemplating the installation of a doctor's office must of necessity have in mind the care of injured employees as one of the chief duties of the medical department. "Therefore, we have dealt with this subject from one aspect only, namely: 'What should be the minimum requirements for the doctor's office and equipment, in an industrial concern, suitable for conducting the medical examination of employees.' "The ideal arrangement would be a group of offices, well-lighted, well-aired, removed from all noises, and housed in a building prefer- ably detached from the plant, but conveniently accessible to a majority of the employees. "There are now a few such ideal doctors' offices in connection with certain industries here in Chicago, but it must be remembered that it has taken years to accomplish this. "It can hardly be expected that a medical department will be in- stalled on such a grand scale before its value has been absolutely proven to an industrial concern. "As stated before, most large industries already have a medical department in connection with their plant for the care of accident cases. These offices can be used at certain times of the day for the examina- tion of the employees. As the value of this procedure, in the increased efficiency of the working force, is demonstrated, larger and better equipped offices will undoubtedly be estabhshed. "For small concerns desiring to adopt a system of medical examina- tion of employees, but where the installation of a doctor's office is not practical and space is not available, this can usually be accom- plished by sending the employees to a doctor's office in the neighbor- hood ; or a group of small industries can unite and employ a doctor who will visit them in succession. Every concern, no matter how small could give a small office to the doctor for an hour a day where he could conduct the examinations. The specimens for the laboratory work could even be carried back to this doctor's own office for analysis. "For a concern contemplating the installation of an office for the purpose of examination of employees the following should be the minimum requirements: "Location. — This may be directly in connection with the plant, but an effort should be made to choose as quiet a location as possible. Thus, noisy machinery overhead or in the adjoining room may detract to a certain extent from the value of the examination. "Offices. — The size and number of these must depend upon the number of employees to be examined daily. For this reason, the 38 INDUSTRIAL MEDICINE AND SURGERY physician in charge should be chosen first and consulted freely as to his needs. The following rooms are necessary, however : "A waiting room equipped with chairs or suitable benches for seating. A separate waiting room for men and women is a more ideal arrangement, but not at all necessary (Fig. 7). "A general office: where a stenographer can work and where files can be kept. It is very essential that the most careful record be kept on each case examined (Fig. 8). "An Examining Room. — This should be made as quiet as possible, should be well-lighted, even if artificial light is necessary to accomplish Fig. 7. — Waiting Room. this, and should be completely closed off from the rest of the rooms. It should contain a chair for the doctor, a stool (a revolving piano stool is ideal) for the employee, and a simple, padded examining table, for frequently it is desired to examine the employee in a recumbent posi- tion; also a small stand for writing or on which to lay the stethoscope, the blood pressure outfit or other instruments. Two hooks placed in the wall can be used as clothes hangers. "If a number of employees are to be examined each day, two or more such rooms should be thus equipped. An ideal arrangement is to have a dressing room in connection with a small examining room. Two or more men can then remove their clothing in the dressing room and come into the examining room prepared for the examination. Thus, the doctor can remain continually in this room, examining the employees as they are brought to him. "For examination of the female help, the separate dressing room and examining room is very essential. The girl employee should remove her waist and underclothing over her chest in the dressing room, and the nurse should then cover her chest and shoulders with a sheet or an THE PLANT HOSPITAL OR DOCTOR' S OFFICE 39 examination cape. The girl is then taken before the doctor to be examined. In all cases the nurse should be present when a girl is examined. "A History Room. — This is not essential, as the history of each case may be taken in the examining room ; but it saves a great deal of the physician's time if a separate history room is provided. Here, the temperature, pulse, height, and weight of the employee can be taken, and the few points desired in regard to his age, nationality, and past history obtained. This can be done by a nurse, or, if the nurse's time is occupied elsewhere, by a well-trained attendant. Clerical and Filing Room in Doctor's Office. "A Laboratory. — This is absolutely essential, for no examination is complete without certain laboratory tests are made. It should be equipped, therefore, for careful urinalysis with a microscope, blood counting, and blood pressure apparatus (Figs. 9 and 10). '' A private office for the physician in charge is desirable, where con- fidential conversations with the various employees may be conducted. In the absence of such an office, one of the examining rooms can be used for this purpose. " As the medical examination of employees is such a broad subject and as there are so many problems to be considered, we would recom- mend that this organization appoint a permanent committee to meet with and co-operate with other committees, such as the Industrial Hygiene Committee of the Ilhnois Manufacturers Association, the Health Committee of the National Safety Council and the Health Committees of the various labor organizations who are also considering this subject of the medical examination of employees." The above report covers only the essentials for a doctor's office, equipped for the medical examinations. In addition this office must have : 40 INDUSTRIAL MEDICINE AND SURGERY A surgical room, where the accident cases can receive immediate attention and where the subsequent dressings can be done. If the industry employs a large proportion of women, there should be two of Fig. 9. — Laboratory in hospital of Colorado Fuel and Iron Co. .^^^ } "^ Fig. 10. — Laboratory in Medical Department. {Ford Co.) these rooms. Good light and ventilation are very essential. They should be closed off from the rest of the office as the sight of wounds being dressed will tend to prevent employees from coming to the office. THE PLANT HOSPITAL OR DOCTOR S OFFICE 41 Here above all places cleanliness must be the rule. The room should be white and furnished in white enamel (Fig. 11). Instruments, as far as possible, should be kept out of sight. The furniture should consist of: (a) White enamel table where the patient can lie down if neces- sary. (6) White enamel dressing table. (c) White enamel stand for instrument sterilizer. (d) Glass jars for the dressings. (e) Instrument cabinet. (/) The few necessary drugs. (g) White enamel chairs or stools. Fig. 11. — Surgical dressing room in Medical Department. (Courtesy Ford Co.) (/),) White enamel stands suitable for resting of leg or arm for dressing wounds of these extremities. (i) Hot and cold running water (foot control). (j) As an adjunct to this equipment there should be space, or pref- erably a separate room, for hydrotherapy and baking apparatus. A sterilizing room, where all dressings used on the wounds can be thoroughly sterilized. An X-ray Laboratory. — This is very essential in connection with every doctor's office where accidents of a severer nature are liable to occur. 42 INDUSTRIAL MEDICINE AND SURGERY Rest Rooms. — One for the women employees and one for the men should be provided in every industry and should be in connection with the doctor's office. Sudden acute illness among the employees will often necessitate their lying down until a cab or ambulance can be called to take them home or to the outside hospital. Likewise, a suit- able rest room will enable employees to overcome some temporary condition and return to work after an hour or two. The value of these rest rooms will be touched on in subsequent chapters. Proper toilet facilities must be provided in the doctor's ofl&ce. Bath tubs in connection with these will frequently be of advantage. Cases of heat exhaustion have undoubtedly been saved by the imme- diate use of a tub of cold water. Again the nurses by keen diplomacy have persuaded employees, unused to a bath more often than twice a year, to enter these tubs and learn the joys of a good bath. A dental office and rooms for eye, ear, nose and throat work are most valuable additions to this office and are necessary when a concern is sufficiently farsighted to see the great economic value of an efficient, comprehensive system of Industrial Medicine and Surgery. When a small number of persons are employed it is unprofitable to have a medical department connected with the plant. In this case arrangements should be made with a nearby physician to render immediate care to their injured and to use his office for the purpose of making the medical examinations. This physician should visit the plant once or twice a week to make sanitary inspections and in other ways supervise the health of these employees. In some cities several small employers have combined and selected a physician with a central emergency office convenient to all their plants to carry on this medical and surgical work for them. The point is that every employer should voluntarily assume this protection for his employees or the states should pass legislation making such a pro- cedure compulsory. CHAPTER III THE MEDICAL STAFF SIZE, DUTIES, AND ADJUNCTS The character of the work, the number of employees, and the size of the industry must determine the number of doctors, the location of the plant dispensary, and the amount of service necessary to conduct a comprehensive system of health supervision. These are details which" each company surgeon must meet, and which will certainly be subjected to changes with the growth of his work. For instance, one industry, a pioneer in this type of medical and surgical work, has gradually expanded its space, equipment and medical staff from a small four room office with one doctor and two nurses in 1909, to a large eighteen room office with ten doctors, twelve nurses, and two dentists in 1916. These doctors spend d}-2 hours per day at this work, so rotating that there is always one or more in attendance at the company office. While many expert company surgeons devote all of their time to the industries employing them, yet as a rule better-trained and more able physicians can be secured, if employers require them to give only a part of their time to this work. This perhaps would not be true if they would pay a salary commensurate to the services rendered by the up-to-date company surgeon. Industry should require the very best talent in the medical profession, but such men can make a much greater income in private practice. Undoubtedly the time is rapidly approach- ing when large salaries wiU be paid in order to engage the best medical and surgical talent in the country for this type of work. However, an industry can employ two physicians of this caliber for part time service, and their combined salaries will be much less than if one of them gave his full time to the work. An additional incentive to a good internist or surgeon entering upon such an arrange- ment is the great amount of clinical material placed at his disposal. These medical departments of industries afford the greatest human laboratories for study ever offered to a physician. The situation is quite analogous to that found in our leading medical schools. The heads of departments and those associated with them give a portion of each day to teaching and clinical work — the rest of their time is given to private practice, study and investiga- tion. Because of their clinical experience, plus the broadening in- 43 44 INDUSTRIAL MEDICINE AND SURGERY fluence of their private and public work, these men become the leaders and scholars in our profession, and their influence in the community at large is much greater than if they devoted their entire time, on an inadequate salary, to teaching in a medical school. The tendency for medical teachers to give full time to this work is due to the willingness of a few Universities to pay an adequate income. But the best full time teachers are those who have had the experience and broadening influence of actually practising medicine previous to limiting their work to teaching. (Certain laboratory men and specialists are exceptions, of course.) So with a company surgeon — the greater name and prestige he can build for himself in his community, the greater his value to the industry with which he is connected, and the better his influence over the employees and their confidence in him. As stated before, the composition of the medical staff will vary according to the number of employees and the size of the industry. The sex of the employees also plays a part in this decision. The first requisite is a well-trained medical man in charge of the work, known as the Medical Director or Chief Surgeon. He should always be a man, if the working force is entirely male or composed of both male and female help. In those concerns employing chiefly women a properly qualified woman physician will undoubtedly be of the greatest service. Where the amount of work demands it, one or more medical assistants must be employed. A nurse, preferably female, is the most valuable aid to the medical staff. Her duties are outlined in a subsequent chapter. If the size of the plant warrants it, an oculist and dentist should be employed. At least arrangements should be made with some able ocuHst and good dentist to take care of this branch of the medical work at their private offices. The medical man entering this field must be a very broadly trained physician. Some of the largest industries can afford to have several doctors on their staff and thus can divide the work into its various specialties; but even here the chief of staff must be trained thoroughly in all the branches of this work. In the smaller corporations, however, the company surgeon must be a surgeon, an internist, a diagnostician, a sanitation expert, and an all-around medical utility man. The duties and size of the staff can best be illustrated by outHn- ing specific examples in several typical industries. I. A stove factory employing approximately 800 men. This factory has a one room doctor's office, well hghted, and equipped with sufficient surgical appliances and dressings to do all types of emergency surgery, as well as routine ambulatory dressings; a chair and table suitable for making medical examinations; a small but THE MEDICAL STAFF 45 practical and adequate laboratory. A physician, whose office is two miles away, is employed on a monthly salary by this concern. He is a general practitioner — a good internist and a good surgeon, and a man who keeps abreast of new developments in medical science. He visits the plant for two hours every morning. His duties there consist of, dressing all minor accident cases; examining any new employees hired within the last 24 hours (he calls early in the morning and the concern tries to have all applicants for work examined before employing them) ; examining all employees who have been absent on account of sickness; examining a certain number of the old working force, so that those needing it will have their peri- odical physical examinations; and making the necessary sanitary inspections to properly supervise the health of all the employees. One employee in this concern has been carefully trained in first aid work. All workers sustaining injuries, no matter how slight, are made to report to the doctor's office at once. Here, during the physician's absence, this first aid man applies iodine and a simple ster- ile dressing to only the very minor accidents and allows them to wait until the next morning before seeing the doctor. To the other cases he applies iodine and a sterile dressing and sends them at once to this physician's private office. Or, if the case is serious, the doctor is immediately called to the plant. He has two associates who are on call for these cases providing he is away from the office. This physician has a similar arrangement with two smaller indus- tries but calls only twice a week at their plants. Their accident cases are sent to his office for dressings, but all medical examinations are made on his calls at these plants. His income is greatly enhanced by this work, and at the same time he is rendering a valuable service to over two thousand employees in his city. And for a nominal cost these employers are increasing the efficiency of their working force to a greater extent than they realize. II. A large department store employing about 4000 people. This store has a woman physician who spends her mornings at their doctor's office. In the afternoon she does a similar work in a second but smaller store. She dresses the few accident cases which arise and spends the remainder of the time in rendering medical care to the girls who become sick while at work, in medical examinations of all applicants for work and similar examinations among the old employees, and in general health supervision. Besides store sanitation this involves a close study of working conditions, home conditions, habits, and environ- ments of the girls, and all matters which would tend to undermine their health. She has a wonderful personality which enables her to gain the girls' confidence. Three trained nurses assist in this work. One is at the doctor's 46 INDUSTRIAL MEDICINE AND SURGERY office at all times to render first aid in her absence, in the case of either accident or sickness. The other two visit the sick employees in their homes and render any aid they can to these — showing the friendly interest of the concern in their welfare. The information gathered by the nurses , gives the doctor her insight into the home environ- ments and habits of the girls. This woman besides being a physician to the individual case, pre- scribing a pill here and bandaging a cut finger there, is also the medical advisor and confidential friend to 7000 girls, and has become an effi- ciency expert to her employers. A job certainly big enough for any individual! Large rooms for recreation have been set aside for these employees. Adjoining them are dining rooms where food, prepared by the direction of the doctor, is served at a rate below that of outside restau- rants. The lunch hour has been extended from 3^^ hour to % hour, and this allows the girls to dance and play games during the noon period, thus returning to their work refreshed and energetic. Evening entertainments have been provided which are much more beneficial to the girls from both a moral and health standpoint than the average festivities of the city. Many and varied talks to the employees, in groups and individually, have corrected conditions in their diets, modes of dressing, improper sleeping rooms, loss of sleep, and unsani- tary home surroundings. These, combined with corrective measures in the individual from a medical and surgical standpoint, have increased the efficiency of the forces in these stores and decreased time- loss on account of sickness almost fifty percent. It is no wonder that the proprietors have installed ventilating systems, inverted lighting systems, and many other costly yet helpful health measures, on the recommendations of this physician. III. An electrical concern with 5000 employees. Here we have the example of the chief surgeon as a full-time man, with a full-time assistant. This concern has a well-equipped, four-room doctor's office and an additional staff of four nurses. The work was primarily surgical, but gradually this has extended until the assistant's time is devoted altogether to the medical examination of employees. Applicants for work are not examined until they have been employed for at least three months. This plan is adopted as it obviates the examining of many applicants who only remain a week or a month on the job. Naturally the two chief purposes of a medical examination of applicants are lost by such a procedure ; namely, the protection of the old force from contagion, and the proper selection of a job for the partially handicapped. One nurse is constantly in attendance at the doctor's office as an assistant to the physicians. The other three nurses spend their time THE MEDICAL STAFF 47 iu visiting all absent employees. These visits are fifty percent helpful to the working force and fifty percent for the purpose of spying on the employees to ascertain why they are away from work. While the latter work may be necessary, yet it cannot be connected with the former and give the desired results from a medical standpoint. Visit- ing nurses' work among employees, to be beneficial and to have the co-operation of the entire force, must be based on altruistic, humani- tarian grounds only — friendly interest, health supervision, and a desire to help whenever and wherever possible. IV. A large automobile concern employing some 30,000 men and women. The system herein outlined is similar in many respects to that in vogue in several of our large industrial establishments. Here we have the example of the large, full-time medical staff, which is very efficient, and is represented by some of the best medical and surgical talent of the country, because this concern, and many like it, are willing to pay for the best, especially for the chief of staff. The central doctor's office consists of twelve rooms, large, airy, well lighted, with tile floors, white walls, and furnished in white enamel fixtures. It has a large waiting room, two private consultation rooms, two surgical dressing rooms, a room for eye, ear, nose and throat work, examining rooms, a;-ray laboratory, and a general laboratory. In addition to this central office there are six medical sub-offices, or first aid stations. These are in charge of well-trained, first aid laymen whose duties are to render immediate care to any injured employee, and, except in case of very slight injury, to see that the patient goes at once to the central office for care by the physician in charge. The reduction in infections and other complications more than pays for the extra expense of maintaining these first aid stations. Be- sides this first aid work, these men have been trained as experts in accident prevention. Whenever an accident occurs they investigate the cause and report the same in great detail with recommendations for its correction. The duties of the medical staff are as follows : 1. To render proper and immediate surgical care to the injured coming directly to the office or sent there from the first aid stations. The major injuries requiring outside hospital care are sent there in an ambulance, and the surgeon on the staff goes to the hospital and does whatever operative work is indicated. Neither this surgeon nor any of the others on the staff are permitted to have private cases. Their time is given entirely to this concern. 2. To examine all applicants for work and to so co-operate with the employment department that all new employees are placed at work for which they are physically fit. 3. To examine and re-examine any employee whenever some 48 INDUSTRIAL MEDICINE AND SURGERY condition in the man himself, in his work, or in his environment indi- cates the necessity. 4. To periodically examine those with handicapped conditions who were allowed to go to work, or who have been discovered subsequent to employment and to place them at suitable occupations. 5. To supervise the medical or surgical treatment which the sick employees receive in their homes from their family physicians. When mal-treatment indicates the need, the medical staff of this industry does not hesitate to take charge of the case. 6. Special medical care is given to tuberculous employees in a sanatorium owned bj'' the concern. 7. To co-operate with the welfare or sociological department on all matters pertaining to the health of the employees either in their working place or in their homes. The medical staff necessary to carry on this work consists of seven doctors, four nurses and twelve lay assistants. Much of the visiting work done by nurses in other establishments is left to the visitors of the sociological department in this plant. V. The Industrial Medical Office Serving Several Industries.^ — Several cities have examples of this system, but Doctors Selby, Heath and Heim of Toledo, Ohio, have developed it to the greatest extent. It consists of establishing a well-equipped doctor's office in the vicinity of several industries. These concerns can thus secure excel- lent medical and surgical services for their employees at a much less cost than if they created a separate system. Three such offices are maintained in different sections of the city by these physicians. In the mornings they spend their time at these offices and in the afternoon at the hospital, caring for the more serious cases it has been necessary to refer there. During their absence from these offices as- sistants are constantly in attendance to render emergency treatment and to call one of the doctors in the more serious cases. Nurses are employed to assist the doctors in their surgical dress- ings and to do visiting nurses' work for those concerns employing this branch of the service. The doctors have influenced the different plants to install safety engineers and are constantly co-operating with these to prevent accidents. Likewise, sanitary inspections of the plants are made by these physicians. Since one of them is a member of the City Board of Health, unsanitary conditions in the community surrounding the plants are carefully investigated and corrected. Recently they have extended their health supervision to include physical examinations of employees. As their work grows it will become necessary to double and triple their staffs. THE MEDICAL STAFF 49 Such an arrangement as this is ideal in many respects. Every industry in a city should co-operate to secure some such central plan which includes every branch of preventive medicine when they cannot develop their own medical department. By insisting upon the physical examination of every applicant for work and by periodical medical examinations of their old forces, a card index of the physical condition of every employee would soon be filed in the central office. Vaccinations, typhoid inoculations and other preventive measures could be included in the work. Then by following up every case of sickness by a large, competent staff of visiting nurses communicable disease could soon be controlled. Doctors employed for the sole purpose of visiting sick employees, without interfering with the treatment except where definitely indi- cated, but to ascertain that medical attention has been sought and is being given, would reduce the length of sickness and therefore time- loss to a marked degree. Such a system would have wonderful influence over the public health of the community, would raise the standards of medical and surgical practices in the city, and by having a central office would ob- viate much duplication of work. Who should be more interested in the health of the community than the industries employing the people of that community? There- fore such a co-operative plan is logical and results in benefits to both the employer and employee. VI. Complete Medical and Surgical Care for the Employees and Their Families. — For many years large mines in the West, and a few railroads, have had arrangements with their medical staffs whereby for a stipulated sum, usually one dollar per month, the employee and his family can receive free medical and surgical treatment at any time. Some of these have developed large hospitals and render excellent medical care to their sick. Practically all these systems employ entirely too small a staff of physicians. The doctors are busy day and night caring for the sick and injured and can give very little time to devel'oping preventive medicine and health supervision. In recent years, however, some of these concerns have turned their atten- tion to this more humane work. Nowhere could a more ideal system of industrial medicine and surgery be evolved than in these mining communities and railroad systems with their extensive hospital arrangements. One large street railway corporation has extended its health and safety work to include free medical and surgical care for its employees and their families. There is no cost whatever to the workman for this service. They have figures showing that the reduction in time 4 50 INDUSTRIAL MEDICINE AND SURGERY lost due to immediate and competent medical care more than offsets the expense of this work. A great many concerns employing from 1000 to 10,000 people have established in their plants well-equipped doctor's offices. They have retained their old company surgeon whose sole idea of the work is the dressing of injured cases, or they have put an untrained man in charge on an inadequate salary. Such concerns wonder why their medical departments are so expensive and why they do not obtain the results so glowingly spoken of by other establishments. One of these industries, a most progressive automobile factory, built a beautiful medical dispensary. They retained their old company surgeon just to do their surgical work and sought a younger man to take charge of the medical work and supervision of the health of their employees. I was asked to recommend a suitably trained physician and sent in names of four men trained in the Industrial Medical Clinic of Rush Medical College. These men all refused the job because the concern asked them to give their full time to the work for one hundred and fifty dollars per month. They finally secured the services of a man for such a salary. In six months they let him go. Another man was employed for a similar salary. His requests for assistants and nurses were not granted for reasons quite obvious considering the initial pay for the chief of staff. This concern is not at all enthusiastic over the results of industrial medicine and surgery. No individual proprietor, president of a corporation, board of directors, or anyone else in authority should contemplate introducing a comprehensive system of medical and surgical work among their employees without being willing to stand an initial outlay of money far in excess of what can actually be shown in dollars and cents as a monetary gain to them for such work. They must first see the vision of what lies within their power to do for human conservation. They must first be imbued with a great desire to see the working home of their people a healthful, sanitary place, with protection of every kind for both life and limb. Then the happier, contented working force, the healthier, more efficient employees, the reduction in "time-loss" from sickness and accidents, the decrease in "hiring and firing," the ever increasing loyalty and experience of old hands, these and many other by-products from such a system will be theirs to place in the credit column. "But how much money can we credit to these?" Who knows! Many a good man has tried to estimate the value of this work in dol- lars and cents but has always failed. Rest assured, Mr. Employer, that the increased productivity will pay far in excess of outlay for such protection. CHAPTER IV THE NURSE IN INDUSTRY Industrial nursing, like industrial medicine, has developed into a new specialty in the medical field. These nurses are absolutely- essential in any comprehensive plan for the supervision of the health of employees. The successful industrial nurse must have a strong and likable personality, a well-developed social sense, leavened with much common sense, and a creative instinct which will enable her to devise new meth- ods of increasing the scope of her work. It is impossible to outline the exact duties which the nurse in industry must perform for new duties and new methods of approaching them are constantly arising. No nurse's training school can fit a nurse for this special work but she must learn it by actual experience in the field. At present it is planned to start an industrial course in Chicago which will enable these girls to obtain an interneship, as it were, in some of the large industrial dis- pensaries. Such a plan would greatly increase the effectiveness of the work of the human maintenance departments in industry. Miss Mae Middleton, one of the most prominent industrial nurses in this country, has written the following article for this book. Her experience, extending over a period of several years, enables her to speak authoritatively on this subject. "Although Industrial Nursing, as we know it, is a comparatively new branch of Public Health work, it is at least twenty years since industries began to realize the necessity of having medical and nursing service, especially where a large number of people was employed and where the work was hazardous. "At first this work was confined to emergencies only and was en- trusted to the care of a man who had received some instruction in First Aid, or to the so-called nurse, who frequently had little or no training; the graduate nurse was seldom employed. 'The benefits to be derived from well organized medical and nurs- ing service, conducted by professional workers, had not yet been rec- ognized or demonstrated in the business world, although it had been thought out and applied in relation to the community by many earnest civic students and workers. Facts revealed by comparatively recent and intensive studies in social and economic conditions, as well as the obligations imposed by employers' liability laws, have led employers 51 52 INDUSTRIAL MEDICINE AND SURGERY to recognize it as a very important asset in the prevention of disease and accident, and in the preservation of the health and efficiency of the employee ; it is also of great value in creating a spirit of loyalty and contentment among the employees, where, for various reasons, it was often sadly lacking or non-existent — so that now the employers seek, for the management of their medical departments, the expert physician or surgeon and the graduate nurse with special social service training. ''The medical and nursing service of a large plant is responsible for maintaining the health of the employees to the highest point of efficiency possible, in order that the firm may receive for the. services of this department adequate compensatory returns in the form of less time lost, fewer accidents, and better sanitary conditions — with the result that there is a better quality of work done by the employees, and an increased output. "The hospital department, with its staff, in addition to the healing of disease and alleviation of pain, is ever on the look-out for sources, causes, and conditions from which they may arise, and must engage in study and effort, in co-operation with other departments and or- ganizations for their cure and removal, as, for instance, in the case of Mr. S. '*Mr. S., employed as porter, was usually a very industrious and good employee, but, owing to the frequent illness of his children, he became absent-minded, worried and very much run-down. The first call by the nurse was made at his home July 28, 1917. The nurse found five children, ages eleven, eight, five, and two years, and a baby four months old. All the children appeared undernourished. The family lived in a four room basement flat, poorly ventilated but fairly clean. The mother seemed to have no conception as to the proper food for the children, the two-year-old eating as many as 10 bananas in one day. Little Joe, the four-months baby, was very ill, and though the ther- mometer registered nearly 90 degrees, the poor little fellow was tightly bound up in a feather pillow. There were no screens on the windows, and the place was just swarming with flies. The baby was given a cool bath immediately (he had a temperature of 103) and made comfortable. "On July 30th the nurse called again and brought the baby in to one of the house physicians, who makes a specialty of infant feeding. The doctor examined the baby thoroughly and said that, although the baby was very ill, he would pull through with proper care. The mother and baby were sent home in a cab, owing to the extreme heat, and the nurse followed soon after, with nursing bottles, nipples, a small kettle, and everything needed for preparing infants' food. She taught the mother every detail in regard to the sterilization of bottles, THE NURSE IN INDUSTRY 53 the care of milk, etc., but they had no ice. This great need was ex- plained to the welfare department, and the nurse was given a check to purchase an ice-box. In less than one hour the ice-box was in- stalled. The mother was also taught the proper method of bathing the baby, and the two-year-old child was put on a diet. "On her next call, August 1st, the nurse found the baby much im- proved; the mother carrying out instructions to the letter. The landlord had put screens in the windows, and there were no flies this day. Also, the department manager reported that Mr. S. was doing much better, taking more interest in his work, and looking better. "When again examined by the doctor, August 6th, the baby was found to have gained ^ pound, and its diet was increased. "By this time all the children seemed better. The nurse called every other day for a while, and the baby continued to improve. Later, owing to the busy season, the nurse was unable to call so often, but she left word with the family to report any change. Then some neighbor suggested that they give the baby tea, and he became very ill. The nurse again called every day and gave the baby care, but he did not improve and later died. "However, the work was well worth while, for the change in the rest of the family was wonderful. In place of coffee and buns every morning and noon, they now have cereals, vegetables, etc., and in consequence Mr. S., as well as the children, is better nourished and happier. "The daily routine of the nurses department involves: "Assisting the doctors in the examination of employees return- ing to work after absence on account of illness. "Assisting in the dressings of surgical cases. "Administering to the employees sent to the rest rooms. "Calling of all employees who, at the doctors' request, have been scheduled for re-examination. "Assisting in the examination of new employees and those desiring to join the benefit association. "Assisting in the examination of those sent from their depart- ments for examination because of frequent absence or inability to keep up with their work. "Assisting in the care of relatives of employees, who, on account ■ of financial conditions, are unable to obtain medical or hospital care. "Visiting sick employees in their homes. "The nurses answer calls made by the departments on all emergency and accident cases which are of such serious nature that they are un- able to come to the doctor's office alone and must be brought by means 54 INDUSTRIAL MEDICINE AND SURGERY of wheel chairs or stretchers. Many of these cases are temporary conditions, such as dysmenorrhea, faints, headaches, etc., and after rest and care are frequently able to return to their work. "The routine examinations, however, often disclose cases of acute infection, such as typhoid, pneumonia, or those requiring surgical care. Provision is made for the care of these employees in hospitals, sanatoria, homes or other institutions, through co-operation with the welfare department, the family, and the family physician. In urgent cases, requiring immediate hospital care, the family and their physician (if they have one) are reached by telephone. This is followed by a call from the nurse, in order to assure the patient, who is usually concerned about conditions at home, and to allay the fears of relatives, as in the case of Mr R., who was sent to the doctor's office because he com- plained of pain in the right arm. He was examined and sent to the hospital with a diagnosis of cellulitis. "The nurse called at his home, to tell his wife, and found he had two children, one 23=^^ years and one nine months old. The oldest child had a temperature of 103.4, axillary, and was in a comatose condition; the other child had a temperature of 102.6, a sore throat and rash. The mother herself had a temperature of 99.8 and was tired out, as she had had no sleep for three nights. The nurse immediately gave both children sponge baths, to reduce their temperatures, prepared milk for them and instructed the mother how to give them the neces- sary care. She then returned to the plant and reported the case to one of the company physicians, who was also an infant welfare special- ist, and he went with her to the home to see the children. After prescribing treatment, he advised putting on a special nurse for one week. Through co-operation with the welfare department this was done, the firm paying for the nurse. At the end of the week both children were so much improved that the nurse left. However, a week later the older child became very ill again with a discharging ear and an enlarged cervical gland, so the nurse brought him in to the doctor's office^ where the gland was opened. As this required subse- quent dressings, the nurse called daily, making 25 calls in all on the child, besides frequent visits to the hospital to let the child's father know of his condition. "The man is now back at work, his wife and children are in good health and all are very grateful to the firm for the interest shown and aid given. "The following illustrates the daily routine of the nurses at the plant and in the homes. "Usually morning duty is in the hospital. Possibly the first patient complains of headache. The temperature is taken and found normal, as is also the pulse; nothing abnormal about the throat. The patient THE NURSE IN INDUSTRY 55 is taken to the doctor who prescribes aspirin or Seidhtz powder, and is then allowed to go to the rest rooms and lie down until better and feeUng able to return to his department. "Perhaps the next patient coming in complains of stomach trouble, wishes to see the doctor and to have a thorough examination. He is very fearful of an ulcer of the stomach. He was not able to retain any of his dinner the night before; had just a 'common dinner,' consisting of pork, cabbage, potatoes, jelly cake and tea. This patient is referred at once to the doctor. "Last, but not least, comes a new employee, who must have height, weight, pulse, temperature, eye-test, personal and family history taken. He is asked to please take off his wraps and hang them on the back of the chair. From the effort he makes to find a chair in the next room, ignoring the one pointed out to him, and from his answer, 'Leedle bidt, missus — -not so much/ to the very common question, 'Do you speak English, mister?,' the nurse is prepared for almost any sort of answers to her questions. " 'When were you vaccinated?' " 'Vacci-? Vacci-? Me no understand, missus.' " 'When did the doctor scratch your arm and put medicine in it?' The part of the arm is indicated. " 'No, sir. Me no got scratched.' " 'How many years have you been in America, Mister?' " 'Four years — maybe five, all right.' " 'When you came over on the boat, didn't the doctor on the boat scratch your arm and put medicine in it?' "A look of understanding dawns. He smiles and says, "Yes, sir. Me got it.' "Then, 'Do you read English, mister?' " 'Leedle bidt, all right.' " 'See that card hanging out there, with the letters on it?' " 'Yes, sir.' " 'See the red Hne?' " 'Yes, sir.' " 'Will you please read the letters on it?' "This is done, and, to be sure the letters have not been memorized while he has been awaiting his turn, the nurse says, ' All right. Now read them backward, with your left eye.' -She places a shield over the right eye and wonders why the man gets up and slowly turns around, putting his knee on the chair and craning his neck over his shoulder ; then it dawns upon her that he is really trying his best to read them 'backward.' "So it goes through the morning — with variations. 56 INDUSTRIAL MEDICINE AND SURGERY "In the afternoon the nurse takes a list of the absent employees in her district and tries to visit as many as she can. "Call No. 1. — Possibly this takes her to a neighborhood with which she is not familiar. She asks a youngster, 'Is this N. Place?' and receives the following answer: 'Naw, this ain't it. This is N. Avenue. Go down this way and jerk over, and that's it.' "She finds the street and number and learns that her patient lives on the third floor. When she inquires for her, she is told, ' No, she isn't in just now. She hasn't been feeling well, but is better to-day, so went for a walk.' The nurse is very glad to know that the patient is feeling better and 'Will she please report at the Doctor's Office in the morning?' " Call No. 2. — On this call she finds her patient quite ill with a cold and sore throat. He is subject to two or three similar attacks during a winter. The tongue is badly coated; tonsils are very much enlarged, with very small, white patches. She inquires if the patient is under the care of a doctor. 'No. He has been taking hot drinks and used a gargle prescribed for the last attack, but hasn't any more left.' The patient is advised to take a cathartic, preferably castor oil; to gargle the throat with a hot solution of baking soda every two or three hours — a teaspoonful to a glass of water; to drink as much water as possible; to get plenty of fresh air; to keep his dishes separate from those used by the other members of the family; and to be very careful of excretion from the throat and nose. If not better by noon, he is told to call his family doctor, and last, but not least, to see his own doctor or the doctor at the plant as to advice about tonsillectomy. In two days the employee reports, wishing to return to work, and is referred to the doctor. " Call No. 3. — This patient is found to be very ill. He has had a stroke of paralysis, involving the entire right side, several days ago. He is in a semicomatose condition, and has just been made comfortable by a practical nurse, who is a relative. Evidently there is nothing that can be done for the patient at this time. The nurse tells the wife that if there is anything she can do, she will be very glad to do it. The wife replies, 'No, there isn't anything to-day.' " ' Very well, I'll call again tomorrow.' " On revisit, the following day, the patient's condition is apparently the same. The pulse seems of a fairly good quality, slightly irregular; respirations seem to be Cheyne-Stokes type. The patient has been lying on a davenport, and his wife is very anxious to have him moved to the bed, but the nurse (at the home) is not feeling well and, ' Will you please help?' The wife is asked if she has the doctor's permission to move the patient and she says, ' Yes, he thought it a very good idea.' The nurse suggests the placing of the bed, so the best light and venti- THE NURSE IN INDUSTRY 57 lation are obtained. The bed is made up with an oilcloth protector and draw sheet, and instructions are given as to how to remove the sheet with least discomfort to the patient. Blankets are placed in readiness to place the patient between for a bath. Fellow employees soon come to help move the patient to the bed. His condition does not seem any worse because of having been moved, and he is allowed to rest for a short time before given the bath. A sponge bath and alcohol rub are given, and the patient is made as comfortable as possible. The bedding is adjusted so that the weight will not he too much on the extremities, and the wife is told that if help is needed again, the nurse will be very glad to come. " In the meantime, some observing forelady at the plant has noticed the condition of the head of one of her employees and has sent her to the hospital. The girl's head is inspected by one of the nurses and found to be in need of treatment at once. It is necessary to cut some of the hair and apply ointment to the scalp where the skin has been scratched, and the first of a series of treatments is given. The girl is sent home and told to leave her head just as it is; that a nurse will call in the morning to give another treatment. " In the morning the nurse, armed with gown, gloves, tooth picks and ointment, makes the promised call. She finds that there is no kerosene in the house and has to wait until someone goes out to buy some. There is quite an improvement in the condition of the head. After all her articles are laid in readiness, the nurse proceeds to relieve the head of as much vermin as she can, then applies more ointment to abrased area, saturates the hair with equal parts of olive oil and kero- sene, and ties up the head, with instructions to leave it that way for four or five hours, then to fine comb the hair and wash with warm water and soap, and, when nearly dry, to apply hot vinegar and use the fine comb again. This treatment is to be continued for two more days; then the girl is to report at the hospital. Before leaving the home, the nurse makes sure that the rest of the family is going to be taken care of in the same way, if necessary. " In all of the examinations made at the hospital, the nurse can be of great assistance to the company physician by conserving his time and preventing duplication of work. As it is impossible for the physi- cian to see all cases coming to the doctor's office, it is the duty of the nurse to select only such cases as it is absolutely necessary for him to see. The nurse should make sure: "First. — That the physician has all the data concerning patient's home, financial and working conditions. " Second. — That he has a complete record of all previous medical, surgical or dental examinations; also any family medical history that might aid him in making his diagnosis and in recommending such 58 INDUSTRIAL MEDICINE AND SURGERY disposition of the case as would be to best advantage of both the employee and his employers. "In well-organized medical departments of large concerns, one nurse is usually assigned to follow up tuberculous cases only. It is not just the case of the tuberculous employee; the whole family must be ex- amined for possible infected contacts; home conditions must be looked into and changed, if necessary, and the family instructed as to home and personal hygiene. The home of Mr. 0. is a case in point. "Mr. 0., who had been placed in a sanatorium, wrote as follows: ' I desire to inform you that on Tuesday, September 25th, I left the F. A. Hospital and came home, after spending 15 months in the institution. For the past three months I have been confined to bed because of high fever, so I decided that as my progress was none, it was as advantageous to come home as remain in the institution, since there, I must confess, improvement is rather slight. 'in conclusion, I will say that I am very grateful to S., R. and Co. for the effort put forth in bringing about my recovery, also I am highly pleased with the medical department for the kindness shown on all occasions.' "A few days after his return home, the company physician and nurse were called and found the patient had developed a discharging right pyothorax, necessitating his return to bed. The nurse made daily calls to dress the wound and give bedside care. "The efforts of the nurse to instruct Mrs. O. will best illustrate the difficulties encountered in attempting this hygienic education. "Mrs. 0. seemed to think that the care given by the nurse was suffi- cient, and it seemed almost impossible to make her realize that Mr. 0. should be bathed frequently, and that the bed should be kept neat and clean. After explaining in detail just what to do, to make Mr. 0. comfortable, the nurse would be answeted in the following manner : " 'Sure, whin he do be in good hilth, he always washed his face and hands ivery mornin' before goin' to woork. He always looked so nice the neighbors often wundered how he could git out of this dirty hole lookin' so foine. Nurse, I don't think it would be nicessary to wash him ivery day now. He never shwits. Sure, he could wear a pair of socks for a long toime and they do be niver shtiff with the dirt.' "As it seemed impossible to persuade Mrs. 0. to give the patient proper care, he was induced to return to the sanatorium, where he now is. "Qualifications of the Industrial Nurse.^ — The nurse intending to take up industrial work should have as her foundation training in a good general hospital, and, in addition to this, some experience in other forms of public health nursing, as this is almost as essential. She should be in good physical condition; have patience, tact and sympathy, acting as the employer's representative, both at the plant and in the home, in bringing aid and comfort to his injured or sick THE NURSE IN INDUSTRY 59 employee; she must have insight and wisdom, in order to interpret correctly the employer to the employee, and vice versa. "In the last five or six years much has been done in the field of in- dustrial nursing, and many nurses have taken up this work. About 13^^ years ago the Chicago Industrial Nurses Club was organized, and it now has an enrolled membership of between 65 and 70 nurses, all of whom are employed in industries in Chicago. While this shows clearly the possibilities of the future development of this branch of public health work, as yet it has simply cleared the way to larger horizons, and it is to the industrial nurse of to-day that we must look to create the standard for industrial nursing. To her is given the opportunity to make the work so valuable, not only to the employee, but to the employer, that she will be considered an integral part of any plans made by him for the health and welfare of his employees.'* CHAPTER V EMPLOYEES DENTAL SERVICE The medical and surgical dispensary in industry is not considered complete unless it provides some form of dental service for the em- ployees. For several years a number of our best industrial clinics have included dentists on their staffs. In this respect they have taken a more advanced scientific position than the majority of our medica' dispensaries connected with medical colleges. During the last ten years Billings, Rosenow, Davis, Dick and many other investigators have absolutely proven that foci of infection hid- den in different parts of the body are the actual cause of many on- stitutional diseases. The commonest sites for hidden infection are about the teeth. As a result, the medical profession now includes a careful examination of the teeth as a definite part of the systematic physical examination of the patient. Closer co-operation with the dentist has been established and just as the internist refers his gall-bladder and diseased appendix cases to the surgeon for operation, so he refers his patients with infected mouths to the dentist for treat- ment. The x-ray has become the most valued ally of both the doc- tor and the dentist in discovering these foci of infection about the teeth. Physicians and surgeons connected with industries were among the first to recognize the great economic value of properly supervis- ing and caring for the employee's teeth. These men who had advanced industrial sanitation to such an extent now realized that the same laws of sanitation must be applied to the individuals. The work of the dentist in industry is quite analogous to that of the sanitary in- spector. His inspections, however, are limited to the employees' mouths and his corrective measures are directed to cleaning up the dirty teeth. No medical school of to-day which prides itself upon its efforts to teach preventive medicine can longer afford to neglect the establishment of a dental department in its dispensary. During the year prior to the establishment of a dental clinic in the concern with which the author was connected, 1100 employees re- ported to the doctor's oflice on account of toothache, abscessed teeth, or some other condition traceable directly to the teeth. It was necessary to send many of these employees to an outside dentist for emergency treatment. Because of the lack of adequate supervision of 60 EMPLOYEES DENTAL SERVICE 61 these cases, many of them were satisfied with the immediate reHef and failed to continue the treatment until permanent relief was obtained. Naturally recurrences were common and such employees lost considerable time from work. Even if no actual time away from the plant was lost, yet a workman with a toothache has a very questionable efficiency. It was impossible to obtain actual figures as to the financial loss this concern was sustaining due to diseased teeth among the workers, but sufficient data were collected to convince the management that a dental clinic would be a great economy. The prevalence of unclean mouths among the employees due to decayed teeth, pyorrhea, hidden abscesses and other like conditions is shown by the reports of the examinations of applicants for work by different surgeons. Dr. Irving Clark found that 92 per cent, of all applicants showed some diseased condition and this high disability rate was due chiefly to faulty mouth conditions. The reports from my clinic showed that approximately 90 per cent, of the applicants had some dental defects. The Life Extension Institute reports 98 per cent, of the people examined by their doctors showed physical defects and practically all of these were due to diseased conditions of the mouth alone or combined with other conditions. I recently had the opportunity of examining 16,000 draftees who were placed in "limited service class" because of some physical dis- ability and were ordered to report to Syracuse Recruit Camp. Over 4000 of these young men had been placed in limited service because of diseased teeth or because of an insufficient number of teeth. Approxi- mately 500 of them had plates and over 200 had lost all of their upper and lower teeth. Approximately 70 per cent, of the contingent sent from the New 'England States had fine physiques, and their only dsfects were due to the teeth, many of these having lost all of their upper or lower teeth or both. Such figures clearly prove that as a nation we are neglecting the care of the children's teeth and when they reach the age to voluntarily seek dental care, it is too late and the dentist is forced to his last resort, namely, extraction. The above figures conclusively demonstrate the prevalence of diseased teeth. The spirit of prevention should certainly force every physician in industry to attack this problem with renewed energy and his greatest ally should be a qualified dentist working with him in the plant. In 1914 I found approximately 20 industrial concerns were giving some form of dental service to their employees. Dr. Lee K. Frankel, in 1916, sent a questionnaire to several industries for the purpose of ascertaining the number giving dental service to employees and the kind of treatment given. He received replies from 27 establishments all of whom either employed dentists or had some arrangement with 62 INDUSTRIAL MEDICINE AND SURGERY outside dentists. Dr. Selby in his recent investigations, conducted by personal visits to a great number of industries, found that quite a number were paying considerable attention to the care of the employees' teeth. The various systems in vogue in different industries can be classi- fied as follows: 1, Dentists employed on part or full time; a fully equipped dental office in connection with the plant; dental service given to the em- ployees at the company's expense and on the company's time. The dental service given consists of: (a) Examination, cleaning, filling, bridge, crown and plate work and extraction; (6) examination Fig. 12. — Tooth-brush drill conducted by the company nurse. {Colorado Fuel & Iron Co.) and cleaning only, with the necessary dental work performed by out- side dentists under supervision of the plant dentist; (c) examination only, with supervision of the necessary dental work performed by the outside dentist. 2. Dentists employed by industries; a fully equipped dental ofiice in connection with the plant; dental service given at employee's expense but on the company's time. Frankel found at least six concerns operating under this system. The dental service given extends all the way from examination with complete dental operations to examinations and cleaning only. The service and the material used, such as gold and porcelain crowns, material for filling, etc., are furnished at cost. 3. Arrangements made with outside dentists, or dental dispensaries, to furnish dental service at a reduced rate to the employees. Practically all of the concerns using this system have their own EMPLOYEES DENTAL SERVICE 63 medical staffs. The doctors examine the teeth at the time of physical examination of employees and refer those needing dental service to the outside dentist or the dispensary. 4. At least three industries furnish free dental service to the children of employees. The visiting nurses of these concerns have been thoroughly trained in examining the teeth of the children and are in- structed to refer all needing dental care to the dental clinic at the plant. These nurses likewise give lectures to the mothers and children on dental hygiene and instruct them concerning the proper use of the toothbrush (Fig. 12). Practically all of the industries operating under the above systems give lectures and individual instruction to the employees concerning dental hygiene. Some of them furnish toothbrushes and mouth washes at cost to their people. The equipment of the dental offices in most places is very complete. A few concerns have even installed x-ray machines for radiographic examinations. Those giving complete dental service must naturally have more chairs and more elaborate equipment than those simply making examinations, and then supervising the treatment given by outside dentists. Dr. Frankel's description of the dental clinic at the home office of the Metropolitan Life Insurance Company, gives an excellent illus- tration of this form of employee's service. " The clinic was opened July 1, 1915. The equipment was the best obtainable. It included: ''Four S. S. White Evans-Forsythe Dental Units, which consists of chair, bracket, engine, cuspidor, and compressed air attachment. "Four S. S White Lyons operating stools. "Four electric spray heaters. ''One Hitter Columbia dental chair. *'One Ritter dental engine. ''One electro-dental switchboard. "One Waugh radiographic machine and lead screen. "Two sterilizing outfits. "Four small cabinets. ''One large dental cabinet. "One metal and glass linen cabinet. "Complete set of instruments, towels, bibs, etc. "It was planned that the work should be limited to a careful exami- nation and cleansing of the employees' teeth each six months. The results of the examination are charted and copies of the charts are given to the employees, indicating what subsequent treatment will be nec- essary by their own dentists. "A follow-up system was inaugurated to ascertain whether the neces- 64 INDUSTRIAL MEDICINE AND SURGERY sary attention is given. No attempt was made to require or compel employees to come to the clinic. From time to time addresses were delivered by the dentists in charge to the employees, indicating the value of proper care of the teeth. "There are, approximately 5000 employees in the company's service at the home office; 2870 treatments were given to 2707 patients in the first six months, July 1, 1915, to Dec. 20, 1915. In the second six months 3383 treatments were given to 2843 patients. In the first six months the average time required for examination and cleansing was approximately sixty-six minutes. With the experience gained by the dentists in charge this was reduced so that in the second six months the average time was forty-nine minutes. The average time required is constantly decreasing. Viewed month by month this is shown very clearly. In January, 1916, the average time was sixty- three minutes, in February fifty-four minutes, in March fifty-three minutes, in April forty-eight minutes, in May forty-seven minutes, and in June thirty-five minutes. "The clinic is in charge of Dr. Thaddeus P. Hyatt, who has under him four assistants and a radiographer. Seven women are employed in the dental clinic as assistants to the dentists, as telephone operator, in the sterilizing room, etc. All the dentists are full-time employees with the exception of Dr. Hyatt. The service given to the employees is free and on the company's time. "I am giving you, herewith, the statistics for the second six months, namely: Jan 1, 1916, to June 30, 1916, as these are probably more indicative than would be those in the first six months of the service. In this time prophylactic treatment was given to 2315 patients and emergency care to 528 additional patients, making a total of 2843 patients cared for in the period. The average time for emergency cases twenty-one and one-half minutes. Under this term is included : treatment for abscess, pyorrhea, exposed pulp, gingivitis, pulpitis, pericementitis, infected tooth socket, toothache, and extractions and consultations. "The cost of the entire service was S7229, or an average of S3.00 per hour, and an average per patient of S2.33. Subdividing the pro- phylactic work from the emergency work the cost per patient for the former is $2.46 and for the emergency work the cost per patient was $1 .06. Assuming that employees accept service of this kind each six months, the cost per treatment per patient per annum would, of course, be dou- ble the figure given per employee treated. "The results even thus far obtained are of considerable interest: Of the clerks who appeared in the first six months, 1637 who showed cavi- ties on the first examination reappeared during the second six months. These clerks on the original examination had 7753 cavities or an aver- EMPLOYEES DENTAL SERVICE 65 age of 4.6 cavities per person. During the interval between the first and second examination 916 clerks (56 per cent.) out of the 1637 who had cavities had 2936 fillings made, or an average of 3.2 fillings per clerk. "There are other evidences of improvement although they are not of such importance. At the time of the first examination 3.9 per cent, of the clerks did not use a toothbrush. At the second examination it was found that this had been reduced to 2.9 per cent. At the time of the first examination 32.9 per cent, of the clerks did not show clean mouths. At the second examination only 22.5 per cent, showed such condition." In June, 1914 a dental department for employees was established in connection with the doctor's office in a concern employing at that Fig. 13.^ — The Dental Office, an essential adjunct to the Industrial Dispensary. {Courtesy Sears, Roebuck & Co.) time approximately 12,000 people. The full-time service of a dentist was secured at first but this was later changed to the part-time service plan — one dentist spending four hours in the morning at the plant and another dentist four hours in the afternoon. Each dentist was paid a salary of $150 a month for this part-time service. The mistake which many concerns have made is in endeavoring to secure cheap dental service for their employees. A reaUy good dentist cannot afford to give all of his time to an industry for less than $300 a month. The work of the dentists consisted in examining the teeth of all appli- cants for work referred to them by the doctors, whose duty it was to thoroughly exaniine the mouth, and to examine the teeth of all old employees, department after department, as rapidly as possible. Em- ployees needing dental care were furnished with a card showing the dental work needed and were referred to their family dentist or to a dentist in the neighborhood in which they resided. The plant dentist s 66 INDUSTRIAL MEDICINE AND SURGERY would then supervise this dental work and by every possible means short of compulsion would persuade the employees to continue treatment until permanent relief was afforded. Most of this dental work was per- formed at night but when it was necessary for the employee to report to his dentist in the daytime, this was done on the company's time. Those stating that they could not afford to pay for proper dental care were given a loan of money by the company, said loan being repaid at the rate of 25^ to 50«f a week. This dental service has become very popular with the employees and the results obtained, especially the decreased loss of time from work due to diseased teeth, has more than paid for the cost of the dental department. In the six months of 1914, 391 employees were cared for by the dental department; in 1915, 6081 employees; and in 1916, 8502 em- ployees received this service. These figures clearly demonstrate the need for a dental department; that such service is looked upon with increasing favor by the working force is evident. This is only another method whereby the employer can express a friendly interest in his employees. The returns from such service are shown by decreased time loss from work, a more efficient working force, and better health and generally increased morale on the part of the employees. CHAPTER VI A PRACTICAL SYSTEM OF INDUSTRIAL MEDICINE AND SURGERY A DETAILED OUTLINE OF THIS WORK IN ONE LARGE INDUSTRY In the metropolis of the middle west industrial medicine and sur- gery, as it is known in its broadest aspects, has become a recognized specialty. Here, in Chicago, at least forty of the larger concerns have developed some system of this work far superior to the old-time plan of a company surgeon simply to bandage the injured. Co-operation between the employers, employees and the various medical staffs has resulted in the rapid growth of this new specialty, and to-day the doctrine of human conservation is fairly established in this city. The practical application of this doctrine is yet far from completion. Here you see the Manufacturers Association holding joint meet- ings with the Industrial Surgeons Association, the Labor Organi- zations doing likewise, and all of these being represented on the Committee on Factories of the Chicago Tuberculosis Institute, the purpose of which is to extend this work into all industries. Six of the largest concerns have built shacks at Naperville for the free care of their tuberculous employees. Thirty-eight concerns have jointly bought a thousand acres of land in New Mexico and established the Valmora Sanatorium for the care of their more advanced tuberculous employees. But other cities and states are rapidly overtaking Chicago in this great work. Pennsylvania Ohio, Massachusetts, Wisconsin, Cali- fornia, and a few other states, through their departments of Labor and Industry, have given a wonderful impetus to this work, and no longer can any one locality claim to be a leader without having the point well and vigorously disputed. One of these industries in Chicago, employing over 15,000 men and women, has developed a system of industrial medicine and sur- gery which embodies most of the good points of the various plans. Therefore a rather detailed outline of the medical work in this indus- try is herewith submitted. The doctor's office has nineteen rooms finished in the most up-to- date manner, and located on the top floor of the main building away from all noise and dirt. Every ,room, except three, has outside win- dow light. These rooms are for the following purposes: one large 67 68 INDUSTRIAL MEDICINE AND SURGERY general waiting room; one large office and record room; one private office for the chief of staff; one private office for the super ntendent of nurses two history rooms; four examination rooms (one equipped for nose and throat examinations) ; a laboratory; a drug room; two well equipped surgical dressing rooms; a sterilizing room; two rest rooms; and two toilet and bath rooms. The medical staff consists of nine physicians, two dentists, and twelve nurses during the busy seasons, and drops down to seven doc- FiG. 14. — A view from the Doctor's Office. (Sears, Roebuck & Co.) tors during the summer. An oculist is on the staff but does not spend any time at the plant. Each doctor spends three and one-half hours at the plant, so rotating that during the busy morning hours there are at least four physicians in attendance, the remainder filling in the rest of the day. Recently a full-time woman physician has been added to the staff. Her work among the girl employees has more than demonstrated the great advantage of having a diplomatic, well-balanced woman physi- cian to handle many of the problems presented by the girls. A PRACTICAL SYSTEM OF INDUSTRIAL MEDICINE AND SURGERY 69 Practically every one of these doctors is a specialist in some line of medicine or surgery, and his work at the plant is largely along this special line. Thus two good surgeons are represented; an orthopedic specialist is of the greatest value in many of these cases; a specialist on skin and venereal diseases is in constant demand for diagnosis, es- pecially in differentiating between certain skin lesions and the actue contagious eruptions; a specialist on nervous and mental d'seases, who is also a good diagnostician, conducts many of the examinations of applicants for work. Such a specialist is of the greatest value in fitting handicapped individuals to the proper job. A tuberculosis expert, an internist and a gynecologist are also included on the staff. These men are well-trained, broad-gauged industrial physicians during their three and one-half hours at the plant, capable of doing any work that usually falls to the plant physician. The remainder of the day they have free to themselves to develop their special line of work, and incidentally they are becoming more valuable to the concern because of this development. The salaries paid these men are good, but the concern could not employ them for full time without an outlay that would make it pro- hibitive. But two good men, experts in their line of work and of con- siderable reputation in their community, can be employed for part time and their combined salaries do not exceed what the concern would pay for one mediocre physician giving his full time to the work. The chief surgeon of this industry likewise devotes three and a half hours of his time at the plant. In the afternoon he operates on the major cases sent to the hospital and visits all such cases already in the hospital. When necessary he visits the employees in their homes. The administration of this work takes most of his time while at the plant. None of the medical staff is allowed to accept as private patients any of the employees of this concern. This is necessary to remove the idea of any selfish motive on the part of the doctor when he strongly urges them to undergo some remedial work. An exception to this rule is when some one of the managerial force desires such service from one of the staff during the period he is away from the plant. The duties of this medical staff can be outlined as follows : 1. Emergency treatment for all injured employees. 2. Subsequent daily dressings of injured. 3. The care of major surgical cases in the outside hospital. 4. Free surgical care for those who cannot afford to pay for proper care, or for minor conditions which would be neglected if the employee was referred to his family physician. 5. Free surgical care for all cases where the responsibility for their cause is doubtful. 70 INDUSTRIAL MEDICINE AND SURGERY 6. Free surgical care for members of the employee' family where the nurse's report, or findings of the welfare department, show a dire need for aid. 7. The medical examination of every applicant for work and co- operation with the employment department to place the handicapped in suitable occupations. 8. The examination of old employees: (a) Those returning to work after an absence on account of illness. (b) Those seeking a pass home on account of illness. (c) Those slated for re-examinations because of some pre-exist- ing condition. (d) Those seeking medical advice because they have learned to use the doctor's office, or on the suggestion of their floor manager (usually because they "look bad," are "slowing-up" in their work, poor attendance, etc.). (e) Those referred from the surgical department for examinations. (/) Those examined for membership in the benefit association. (g) Those working in hazardous occupations. Monthly re- examinations are made of all exposed to occupational diseases. 9. Supervision of those needing medical treatment until they are placed under the care of the family physician or in outside hospitals. 10. Medical treatment where investigation shows they are not receiving proper care. 11. Medical treatment furnished free for all tuberculous employees, syphilitic and gonorrheal cases, and for those needing expensive, special medical care but who cannot afford to pay for it. 12. Emergency medical care for the acutely sick or for those with some temporary condition which medical treatment will relieve at once and allow them to return to work. Every case must be handled as an individual and no hard and fast rules can be laid down which will cover every condition arising during the day's work. 13. Periodical sanitary inspections of the plant. 14. Supervision of the ventilation, lighting, control of dust, care of cuspidors and toilets, and all other conditions tending to promote health. 15. Co-operation with the safety engineer in the prevention of accidents. 16. Health and accident prevention talks and letters. 17. Fumigation of departments where contagious cases have devel- oped, and constant watchfulness for new contagious cases. 18. Co-operation with the visiting nurses to relieve conditions found in the homes. 19. Co-operation with the city health authorities, the Tuberculosis A PRACTICAL SYSTEM OF INDUSTRIAL MEDICINE AND SURGERY 71 Institute, and with all family physicians for the protection of the patient and the community. 20. Co-operation with the welfare department to see that condi- tions revealed by the medical work are corrected in each individual case, as, faulty home conditions, lack of proper food and clothing, insufficient wage, lack of recreation, misfits in jobs, trouble between a boss and an employee, and numerous other conditions tending to undermine the health of the workers. The two dentists each spend four hours at the plant. Their duties are: 1. The examination of all applicants found with bad teeth and referred to them by the medical staff. 2. The examination of the teeth of all old employees. 3. Recommending necessary work to be done, and charting this on a card which the employee is told to take to his family dentist. 4. Co-operation with the family dentist to see that work is com- pleted and reasonable charge for the same is made and paid for. 5. Co-operation with the welfare department to arrange loans when necessary so that the family dentist can be properly paid at once. The employee repays the firm in weekly installments of fifty cents each. 6. Periodical re-examinations to see that work recommended for teeth has been done or is in progress, as well as to see that all pro- phylactic care is being carried out as directed. 7. Consultation work with the medical staff in running down hidden foci of in ections. The oculist on the staff receives cases sent to him from the plant. The ordinary Snellen test is made at the plant dispensary and those falling below a certain standard are referred to the oculist. The latter examines these cases and corrects all with faulty vision. A loan arrangement is made with the employee whereby he can pay the oculist a reasonable charge and then repay the firm as described under dental cases. The details of this work are described in Chapter XXV. The nurses devote all their time to the work. Their duties are indicated in the following outline: 1. AU twelve nurses spend their mornings at the plant. In the afternoon eight of them visit sick employees residing in their prescribed districts. 2. Two assist the surgeons in the surgical dressings. They also prepare and sterilize all dressings. 3. Four are engaged in history taking and the eye tests. This is done on every case before being referred to the doctors. 4. Two are present in the girls' examining rooms at all times. 72 INDUSTRIAL MEDICINE AND SURGERY 5. One nurse is in charge of the drug room, issuing medicine only on the order of the doctors. 6. One is in charge of the rest rooms. It is her duty to see that every employee going to the rest rooms receives every attention pos- sible, does not take advantage of this as a means of loafing, and that any case needing medical care is brought to the attention of the doctor. 7. The superintendent of nurses and her assistant are busy in the administration of this machinery. It is their duty to see that every employee is waited on immediately without undue loss of time from his work. The visiting nurses' work in the afternoon: 1. It is the duty of each nurse to visit as many of the sick em- ployees in her distr ct as possible during the afternoon. In order to do this all calls are restricted to those employees who have been absent at least three days, and only periodical calls are made on those absent with long illnesses. 2. The nurse ascertains the condition of the patient, the nature of illness, if adequate medical or surgical care is being given, the name of the family physician, the home conditions, and if any special care is needed to insure the patient's recovery. Whenever necessary the nurse renders nursing care, such as a sponge bath, changing of the bed, instructing the mother or wife in food preparation, etc. 3. The nurse reports on these facts at once by telephone if urgent or the next morning on her return to the plant. 4. By co-operation with the welfare department special nursing care is given to a sick employee when these reports show the need. Or, based on the findings of the nurse, the patient may be removed to a hospital and further treatment rendered by the medical staff of the plant. Food, ice, bed-clothing, and many other necessities of the sick-room are supplied when ready money for these is lacking. 5. Reports on faulty housing conditions are investigated, and by diplomacy, education, and the judicious use of money, often in the form of increased wages, the family is moved into healthier, more sanitary surroundings. An expert laboratory girl is in charge of a well-equipped labora- tory (Fig. 15). Her duties can thus be classified: 1. Urinalyses.^ — ^Every applicant for work and every old employee given a thorough medical examination likewise has a specimen of urine examined. Re-examinations, two or more times, of the urine are made whenever a pathological condition is found in order to be positive of that condition before a report of the same is made to the employee. Five years ago the specimen from one of the managers was ex- amined and found to contain sugar in large quantity. He was told A PRACTICAL SYSTEM OF INDUSTRIAL MEDICINE AND SURGERY 73 that he had diabetes. The next day he went to his family physician who failed to find anything wrong. After seeing three good inter- nists, all of whom reported the urine negative, he presented himself before the chief surgeon. The examination at this time was also nega- tive. This man's indignation over the scare and expense he had been subjected to was a source of great embarrassment to the doctor's office. It takes months to live down one little mistake like this, which all doctors know is liable to occur, and therefore every precau- tion is taken to avoid them. Fig. 15. — ^Laboratory in connection with Doctor's OflBce. Specimens of urine for examination are secured from the men directly in the examining rooms where special arrangements have been made for this purpose. The women's specimens are obtained in the toilet room before going to the examining rooms. A boy and a girl respectively carry these specimens, properly marked, in a covered wire compartment basket to the laboratory. 2. Blood Analyses. — Every employee examined whose condition indicates the need of it is given a thorough blood examination in the laboratory on the order of the doctor. This includes red and white count, hemoglobin, differential count, and very frequently a "Wasser- mann test. 3. Sputum Examination.^ — ^The sputum of suspected tuberculous employees is submitted to repeated examinations. Frequently in cases, clinically tuberculous, as many as ten to twenty sputum ex- aminations are made before the bacilli are found. It is only by using the laboratory to its uttermost in this way that its full value is obtained. 4. Bacteriological Examinations. — Frequent use of the laboratory for ascertaining the nature of infections in the surgical cases is resorted 74 INDUSTEIAL MEDICINE AND SURGERY to. But the greatest service has been rendered in the early differential diagnosis between severe tonsillitis and diphtheria. Every case with the least suspicious sore throat is subjected to a bacteriological exami- nation. Smears are examined at once and cultures prepared and incubated both at the plant and at the city health department. An average of one out of twenty of these cultures is positive for diphtheria but in its discovery the fellow employees are protected from this contagion. Many of these cases of diphtheria are very mild for the individual but could be the source of a very severe epidemic among the others. 5. Stomach Analyses and fecal examinations are occasionally made but usually the employees are referred to an outside laboratory for this work. In every instance the family physician is given a copy of the labora- tory findings in order to aid him in diagnosing and treating the case. The average family physician has not the facilities for making these laboratory tests early in the course of the disease, and they are there- fore not usually made until the case becomes serious or evidence of a spread of contagion indicates their need. We are positive therefore that this laboratory has been the means of saving life many times. It is impossible to estimate the amount of lost time from work which it has saved. Example.^ — ^Lulu M., an employee of this concern, became sick one night at home. The third day of her illness the nurse called. She found Lulu suffering from stomach trouble or ptomain poisoning, "the result of eating fish." The family doctor had been in to see her every day. The nurse reported that Lulu seemed very sick and her pain was all localized in her right side. She was sent back the next day and found Lulu's temperature much higher, the pain more severe and the abdomen distended. The family doctor was called but again stated that it was ptomain poisoning and that she would be all right in a few days. The chief surgeon of the plant was informed and he ordered the laboratory attendant to call and make a blood-count. This count showed 26,000 leukocytes. Consultation with the family physician was immediately demanded, and as a result he was convinced of the diagnosis of appendicitis with general peritonitis developing. The girl was referred to another surgeon and operated at once. The abdomen was filled with pus. The appendix was never found. Ex- tensive drainage saved her life, but five months elapsed before she was able to return to work. Her position was one in which an experienced girl meant everything to the work. Example. — Nellie 0., another employee, took sick while at work. She was sent to the doctor's office but wanted to go right home as she was positive her abdominal cramps were due either to her approaching A PRACTICAL SYSTEM OF INDUSTRIAL MEDICINE AND SURGERY 75 period or to fish she had eaten at lunch. The nurse, however, per- suaded her to be examined. The doctor found tenderness and rigidity- over the appendix region. A blood-count was made and showed 18,000 leukocytes. The young lady's family physician was called and acquainted with the facts. As Nellie had been told of the diagnosis and the importance of receiving immediate attention, her doctor suggested that she be sent to the hospital where he was accustomed to work. This was done (a taxicab being used for the purpose), and a nurse went to the girl's home and notified her mother. Four hours later Nellie was operated and a gangrenous appendix removed. She was back at work in three weeks. Nellie's home conditions were known, and the careless attitude of her family toward disease, and there is no question but what weeks of illness, if not her life, were saved by this prompt action. During 1916 there were 200 cases of appendicitis diagnosed in this way. Some of these, who had no family physician, or were boarding in the city, or for other reasons could not receive proper attention at home, were operated at once by the chief surgeon. The others were referred to their family physicians but were so closely followed up by the medical staff that proper surgical care was soon given in every case. None of these died. During this same period two deaths from appendicitis occurred among employees who had become sick while at home and therefore did not have the advantages of this scientific, diagnostic attention. Example. — In one department tonsillitis became quite prevalent. The first four cases, however, developed the disease at home. The fifth came to the doctor's office. Smears were taken from the throat but showed nothing suspicious. However, cultures were made. The next morning a diagnosis was made of diphtheria. The family physician was notified and he gave antitoxin treatment at once. A nurse immediately called on the other girls and made smears and cultures. Three of these had diphtheria. The department was fumigated and every throat examined bacteriologically. Only one other case of diphtheria developed, although the people in that depart- ment were watched very closely. It is easily conceived that this prompt action aborted a more than incipient epidemic. An industrial medical and surgical service such as described needs a considerable clerical force to carry on this work. In addition to the medical and nursing staff this office employs one office manager, a private secretary to the chief of staff, four record clerks for the med- ical cases, one record clerk for the surgical cases, a girl who stamps the coming and going of each patient with a time clock (this is neces- sary where 500 and more employees visit the doctor's office during the day, to prevent undue loss of time from a patient being overlooked), 76 INDUSTRIAL MEDICINE AND SURGERY and a girl in charge of telephones. Two colored matrons are in con- stant attendance to keep the offices clean. "While this chapter is dealing with the specific medical and surgical work of an industrial plant, yet it is impossible to draw a line between this work and that of the so-called welfare department in many in- stances. The two must work in the closest co-operation. For that matter the profession is recognizing more and more the indispensable aid which social workers and all social movements are giving to medical treatment. Medicine, the exalted, has descended to a human plane, and in the industrial world and in many other places we are witnessing a marriage between medicine and sociology. In this concern the welfare department (which by the way is not known by that terminology) co-ordinates the work between the safety engineer and the medical staff, and authorizes the changes in plant sanitation recommended by the medical staff. All suggestions along the lines of industrial hygiene and individual hygiene are put into opera- tion or assisted by this department. It provides restaurant service for the employees and supervises the food preparation. It provides recreation rooms for the girls and various kinds of entertainments. For the men athletic fields, tennis courts, ball diamonds, and all types of healthful recreation are under this department's supervision. Investigations of housing conditions and co-operation with the city authorities and with other industries for the correction of faulty con- ditions come within the scope of this department and here it has a very definite connection with the medical and surgical work. Transportation problems, overcrowded street cars, ill-ventilated and cold cars; collection of garbage, cleaning of streets and alleys, sewage conditions, and all public health problems must be entered into by the welfare department, assisted by the medical staff, as a means of maintaining the health standards fixed by this industry. No system of industrial medicine can be perfected that does not take cognizance of the conditions in the community from whence its employees come. To the uninitiated, or to the average employer thinking only of production, the large, expensive medical and welfare departments herein outlined seem a rather extravagant, non-producing piece of machinery. No effort will be made to refute this impression, leaving that argument for a subsequent chapter. This establishment has endeavored to build up a comprehensive system for conserving its human machinery. Even the size of its staff is not sufficient to do all that should be done. For instance, much better results would be obtained if competent medical and surgical care were furnished at a reasonable price to every employee. The nursing A PRACTICAL SYSTEM OF INDUSTRIAL MEDICINE AND SURGERY 77 staff should be enlarged so that a visit could be made on every employee the first day of his illness and as often thereafter as was indicated. A nearby hospital for the immediate care of serious cases would be much better than transporting them two or three miles to a general hospital. Many other improvements will suggest themselves to the industrial surgeon. The following table from the hospital report of this concern dem- onstrates the need of the present size of its medical staff : Table 1 SUMMARY REPORT OF WORK OF MEDICAL STAFF Years 1914 1915 1916 1917 Total number examinations 12,380 23,771 28,167 391 5,470 16,535 28,009 25,944 6,081 4,702 24,826 37,906 35,216 8,502 6,374 30,100 37,900 33,481 3,746 6,561 Total — Medical cases Total — Surgical cases Total — Dental cases Total — Nurses visits ' Grand total 70,179 81,271 112,824 111,7881 1 Decrease in amount of work due to reduced staff because of war service. 78 INDUSTRIAL MEDICINE AND SUEGERY .«->*' ; ^vx\^\\\\vv<==4K\\\s==^=i v\'^^ S T/^ooa >iava i^'K^VV\\V\V\V\ VV\^^\VV^\H^^l\\\\^l==l^^ \-^^-'] [,\\\\\V\\V\\\'t^ CHAPTER VII BENEFITS AND PROFITS OF THE MEDICAL DEPARTMENT The ramifications and influences of a genuine human maintenance department in any industry are so intricate and subtle that it is im- possible to estimate in dollars and cents the tangible returns from such a system. The salaries of the doctors and nurses, the rental of the office space, the supplies used, the equipment, the outside hospital bills, and all other expenditures can be ascertained to an exactness and represent the cost to the employer of such a department. But when the employer endeavors to definitely determine or approxi- mately estimate the actual monetary returns from this investment he is soon hopelessly confused. How can he estimate the financial returns due to the increased efficiency of an employee who for years has been below par because of some chronic ailment which was discovered and removed by the med- ical department, thereby restoring this man to full producing capacity? During each succeeding year the number of these restored individuals throughout the working force is increased making his problem even harder. How can he estimate the returns from the cure of hundreds of employees suffering from imaginary diseases? These men and women imagining that they have heart disease, kidney trouble, "displaced" vertebrae, lung trouble, "ulcers," and numerous other conditions, ease-up on their work to protect their health. They move slowly, appear distraught, and worry incessantly over their condition. Some take time from work to go from doctor to doctor, while others shun a physician dreading to have their fears confirmed. These neuras- thenics make up a large proportion of the medical work of an industrial dispensary. Their efficiency is greatly reduced but to what extent it is impossible to say. The industrial surgeon examines and re- examines them, gains their confidence, and finally convinces them that no organic disease is present. This may be accompHshed at once or it may take weeks of patient psychotherapy. But the buoyant spirits which replace the depression, the added "pep," the increased efficiency resulting, bring great returns to the employer — returns of which he is seldom aware, and cannot compute. When a foreman is the victim of this neurasthenic condition he 79 80 INDUSTRIAL MEDICINE AND SURGERY can become a source of great loss to the employer. His worries and depression react on the men and women under him. It is a contagious condition. Many of his employees will develop imaginary ailments. Or the worried foreman grows irritable and is unjust; thus, the labor turn-over in that department increases and the productivity decreases. The foreman is censured by the management and this adds to his nerv- ous condition. An alert industrial surgeon soon learns to recognize such a situation and becomes the efficiency expert who remedies the trouble. But who can estimate the dollar and cent value of such work? What sum will the employer place in his debit column to represent the increased productivity resulting from the happier, more contented, healthier working force, the direct result of a human maintenance department such as has been described in the preceding chapters? When a concern adopts such a system it is usually due to an awakened conscience, a desire to improve the welfare of its employees. There- fore, many other betterment movements are installed besides the health department. Thus it is often impossible to separate the returns from the medical work from those of other types of welfare work. In a majority of industries, however, the medical department lias been the forerunner and incentive for this additional work. Since our employer is unable to demonstrate actual financial gains from his medical department, it behooves industrial surgeons to show in some concrete form what benefits he may expect from such a system. Since these benefits must react to the good of both the employee and employer before either can receive full compensation, we must show them in terms of both. Table 2 endeavors to do this. Whenever an elaborate medical system is installed, both the em- ployer and the doctor expect to see, after a year or two, a reduction in the number of cases needing treatment. Both will be disappointed providing the medical department is successful and gains the full con- fidence of the employees. A medical service which can show such a reduction is failing in its purposes. It takes at least a year, and usually five years, before the company doctors gain the confidence of the working force. As this confidence increases the number of cases coming to the office for advice or treat- ment will increase. This is desirable for the greater number of em- ployees visiting the doctor's office affords a correspondingly greater supervision over their health. After a few years these employees develop the habit of coming to the doctor's office for threatened ail- ments instead of awaiting the full development of some diseased con- dition. This affords the opportunity of treating sickness in its earliest stage and aborting more serious trouble. The few minutes necessary to visit the doctor's office for this purpose is a great saving of time when BENEFITS AND PROFITS OF THE MEDICAL DEPARTMENT 81 T3 a ^ W w rt <1 IS M I— I '^ 9 -^ .2 § 1 J 9^ '3 o3 W 1=1 b\2 03 O 01 5 2 Sea CO oj r- (i; O a; g OJ o :3l 11 o3 cc 5R bC 5^ S « ^ T3 -d ^ -J Ph OJ Ph o3 I— I «« e3 . £ «^ " -^ O S S g g ■« 03 O 03 CU 0)00 l-H ^ HH C/2 o o X o g o !^ .S2 CO CO O tJ •^ -f^S t+-4 a o3 03 O OJ >J ^ a • S ° w Tl, bC bJO M S^ S^ 03 -S "" -S 'O t^ C tH -rt -e S ^ •?H C . o3 •73 03 £^ ^ O) O) Ol a> 03 « ^ ^ -C a; 03 C ^ tH CO 2? o P^ 32 t3 Ph 01 ^ 5 .^ a '^ 03 3 "tJ 4^ T3 -73 vh O) 03 OJ rj £ CQ PQ rt i t^ 00 Oi tH a O O 03 03 T-I cJ t>s (d 03 O 03 2 .a bJO J 03 03 Sx -►^ 03 t-i 03 .3 >l 8 O •S .2 ■2 S _r3 03 CD r! -« bio "2 rl ^ f3 o3 ° fe^ d 03 03 ~oSS-5a3-^^<^<^<3^ JWH-i 03 .T3 c 03 .a e J fl 3 o -^ o S o . -ff ^ - •.e .2 -^s bc g 03 ^ e -g 03 c 03 > .3 •g +i -^ -tj a, ^ ^ § 'S 1=3 'S, S K 03 03' "g e T-l (N CO ■<** "3 CO '82 INDUSTRIAL MEDICINE AND SURGERY r2 ^ ^1 o c- 0) •in c3 a 03 p— m o3 H^ fi .-S 'o a& M IB o o m m w ^ IB O nd tS o CD ;h •li L^ fL, P^ Pm T-H im' CO o >> 73 t3 .2 XD "^H CD O 73 :3 p: •n o CD OJ fl ^ _o o '•+3 o3 ti O >. c3 a o t4_4 o C o _aj o 73 o '3 l •73 c3 > ^ o o ^ bC 3 a 73 «4-l CO 73 73 S 01 o o D< 1— H 03 'T3 73 & ^ V 9. ^ ^ ^. -S -3 _. q o o o3 a bD i s ^ > oj (B fl a> PQ M Q '^ Q;9^'T-!'-^ CD bC . I 1-^ §D-^ "^ S-l^^: ^^ -l-Sig-g 03 O ac bCg bJOMfl^ bJ3bX)0^ ^.S 03 k -^ -S ^ • 3 > II J g^ > I g ^ • 3 g g "^s. i-I im' CO ■*' id .2 rH (N CO s r-I (m' co' -*' id OQ 1^ feq BENEFITS AND PROFITS OF THE MEDICAL DEPARTMENT 83 compared with the few days or weeks which may result from neglect- ing minor symptoms. These same employees would not seek the counsel of their family physician, because of the expense, for these apparently trivial matters, whereas they will come to the doctor's office providing this confidence is established. With each succeeding year, therefore, the number of medical cases increases. The doctor soon learns to eliminate those who are taking advantage of the system. The medical cases not only increase but apparently the surgical cases likewise and this in spite of the fact that accident prevention methods are always installed wherever a human maintenance depart- ment is in existence. The safety first measures reduce the number of serious accidents, but the minor and so-called trivial injuries are almost impossible to prevent. But we can prevent infections and other serious complications from developing in these minor accidents. Experience has taught us that the greatest safety first measure for these minor injuries is the immediate reporting to the surgeon for proper treat- ment. In a concern, therefore, where the medical department is efficient each year will show an increase in the number of employees reporting for immediate care of all injuries no matter how trivial. In which case, each year will show a corresponding decrease in the number of infections resulting from injuries. In an industry employing an average of 12,000 men and women, which adopted an efficient medical and surgical system nine years ago, the following table illustrates the increased confidence of the employees, the better medical supervision, and the greater surgical preventive measures which developed with each succeeding year: Table 3 Year Number of medical and surgical visits to doctor's office 1909 14,643 1910 17,889 1911 22,400 1912 48,000 1913 56,720 1914 70,179 1915 81,271 1916 112,824 The question naturally arises, did not this great increase in the number of patients using the doctor's office make the cost of such a system prohibitive ? The best reply to this question is to submit the following comparative report of the cost of medical and surgical work for two years in this same concern: 84 INDUSTRIAL MEDICINE AND SURGERY Table 4 COST OF MEDICAL AND SURGICAL SUPERVISION OF EMPLOYEES 1915 1916 Increase, per cent. 11,068 6 1 12 32,800 15,447 4,137 52,384 4,702 174 2,666 16,535 $38,239.59 $3.46 81,271 13,324 1 7 1 12 43,766 22,486 6,870 73,122 6,374 262 3,341 24,826 $49,075.99 $3.68 112,824 20.4 Plivc!if>ifin<5 pmnlnvpd full time 16.7 Physicians engaged for call service Surgical and medical cases treated 33.4 45.6 66.1 Total medical and surgical visits to 39.6 35.6 50.6 25.3 Physical examinations made 50.1 Total medical and surgical cost 28.3 Average cost per employee 6.4 Total nAjmber of patients visiting doctor's office 38.8 You will note that the per cent, of increase in the medical staff is below the per cent, of increase in the number of employees. The average amount of increase in the medical and surgical work is 43.2 per cent., while the increase in the total cost is 28.3 per cent. But the actual cost per employee for the year 1916 was only twenty-two cents more than for 1915. A cost of only $3.68 per employee per year for such an extensive amount of work is certainly not prohibitive. However, it is impossible to show in dollars and cents what the income amounted to from this work. We can only prophesy and estimate what the loss in time and loss in compensation might have been without it. Some of the sources of profit to this concern from their human maintenance department, however, can be classified as follows : 1. An average of 500 applicants for work per year or 3.4 per cent, who had diseased conditions unfitting them for employment have been weeded out, thus reducing labor turn-over. 2. One hundred and sixty-three cases of active tuberculosis were prevented from being employed during a period of three years, thus protecting the old employees, preventing loss of time due to the spread of the disease, reducing labor turn-over, and eliminating inefficient employees — a group who would have had a gradual, imperceptible slowing-up in their work. 3. Discovering 263 cases of tuberculosis among the old employees BENEFITS AND PROFITS OF THE MEDICAL DEPARTMENT 85 during the same period, the majority of whom were found in the in- cipient stage, thus accomplishing the same results set forth in 2. 4. During the so-called "grip" epidemic of the winter of 1915 and 1916 the medical work in this concern held the number of absentees down to 9 per cent, of the total working force during a period of four months. Whereas, several concerns had an absentee rate from 25 to 33)-^ per cent, of their total number of employees during that epidemic. 5. Labor turn-over has been reduced to a considerable extent in this industry, but as many other factors enter into this the medical work can only be given credit for a part of this reduction. 6. The number of infections following injuries has been reduced from 28.6 per cent, in 1912 to 7.57 per cent, in 1916. The time lost from infections in 1912 amounted to 1987 days, or an average of 2^^ days per case, while time loss from this cause in 1916 amounted to 816 days, or an average of Ij-'g days. This was accomplished in spite of the fact that the working force had increased approximately one- fourth during the same period. This represents a saving of some $3000 in wages and approximately $5000 in hospital bills, compensa- tion, etc. 7. Because of this health supervision and preventive surgery a few deaths are prevented every year. On an average of twice every year the medical supervision has prevented this concern from being blamed with a death for which they were in nowise responsible, thus saving either compensation for loss of life or long and expensive litigation. Example. — The visiting nurse reported that an ex-employee was in a hospital dying. His doctor had diagnosed lead poisoning and blamed his work in the printing department for the condition. Ref- erence to his records showed that he had been examined in the doctor's office several times. A lowgrade nephritis had been diagnosed. There was also a history of syphilis The man quit his job, and the company surgeon had lost track of his case for several months. Consultation with the attending physician was sought and granted. The examination of the patient at this time showed a saddle anesthesia, a three plus Wassermann reaction in the spinal fluid, and other symp- toms justifying a definite diagnosis of cerebrospinal syphilis. Lead poisoning was ruled out to the satisfaction of his family physician. The man died a few days later. His wife secured a lawyer, but the case was so thoroughly worked up that it was dropped, no effort being made to collect an unjust claim. Similar cases are very common in the experience of every surgeon in industry, and it is impossible to estimate the savings to their con- cerns by avoiding compensation and litigation due to these unjust death claims. 86 INDUSTRIAL MEDICINE AND SURGERY One of the greatest spurces of saving to the employer is the physical selection of employees for work. This is done by the physical examina- tion of all applicants for work before employment. The value to the employer depends upon the thoroughness of these examinations and the amount of co-operation between the employment department, the medical department and the foreman. The old system in vogue before medical examinations of employees was introduced into industry, and which is still in vogue in so many places, resulted in the following wasteful methods: 1. A man appUed to the employment department or to the foreman for a job. He had had words with his foreman in another industry and quit. (This was the result of less and less work due to a physical handicap of which he was not aware.) Experience made him valu- able for certain types of work. He was employed and thrown into the human machinery of that industry without any investigation as to his physical fitness. His work was on a machine and was very heavy. He exerted himself to make good and at first succeeded, but gradually the production of his machine fell behind and after two months the foreman was forced to let this man go. For two months an expensive machine had failed to produce sufficiently to pay for its maintenance; a definite loss for the employer. And why? Be- cause this man who was employed blindly had a beginning locomotor ataxia and was physically unable to make good. An examination when he applied would have prevented his employment, saved the loss from inefficient operation of the machine, and the cost of hiring and firing a man. 2. A man was employed as a laborer by an electrical concern. This concern had a medical staff but did not include medical examination of applicants as a part of their work. Therefore, this laborer, without knowing his fitness, was assigned to help repair boilers. After two weeks of work this man suddenly dropped dead. At the time of death he was drawing an electric light attached to a wooden handle into the boiler and in falling this light was broken and a fuse burned out. At autopsy it was found that this man had an old chronic heart lesion and death was due to acute dilatation of the heart. There was no sign of an electrical burn. But the coincidence of the light break- ing and the fuse burning out was seized upon by his relatives and a shyster lawyer and made the basis of a claim before the Employees .Compensation Board. Thirty-five hundred dollars was allowed by this Board. The concern carried the case to court and after a long fight and by employing expert witnesses they were absolved of all responsibility for the man's death. BENEFITS AND PROFITS OF THE MEDICAL DEPARTMENT 87 This blindly hiring of a defective human machine cost this concern over $5000 for two weeks of service. The placing of all comers on jobs without any effort at a physical selection for their work is responsible for a great financial waste which cannot be shown in dollars and cents but which nevertheless is very evident. This waste is due to the following : 1. The employment of the physically unfit who later must be discharged because of inability to do tHe work. 2. The employment of the physically unfit who continue to work for a few months or a year with a gradual decrease in their efficiency due to the advancing disease until finally they are forced to quit work. They have been a source of loss to the concern from the time of their employment. 3. The employment of the physically unfit who because of their condition are subject to frequent accidents. Every accident is a loss to the concern. 4. The employment of the physically unfit who suffer accidents which ordinarily would not be serious but because of the coincidental, unknown physical condition are fatal, or, at least, cause prolonged disability. The loss to concerns from this source is far heavier than any employer is aware of. 5. The employment of the person with some contagious disease who communicates it to others in the working force. The acute contagious diseases are more common, but tuberculosis and syphilis also cause a great loss. 6. The employment of the mentally deficient who never can be fitted to a job and who form a certain percentage of floating labor on account of this fact. An observant industrial physician will pick out this type during the course of his examination. Those concerns which have an efficient medical system always in- clude the examination of applicants as a definite part of the work. These examinations are not made for the purpose of selecting only the physically fit and refusing employment to all others, but are made for the following purposes: (a) To prevent those with diseased conditions, making work of any kind dangerous to them, from going to work; (6) to select proper jobs for those with certain defects where they can still be efficient and yet the work will not be hazardous to them; (c) to prevent those with contagious diseases from mingling with the old working force. The author has collected statistics from ten large industries, having very excellent medical staffs, which examine all applicants for work. Their rejections are based, for the most part, on the above standards. The following table shows the results of these examinations : 88 INDUSTRIAL MEDICINE AND SURGERY Table 5 1. Total number of applicants examined in one year. . . 118,900 2. Total number employed having disabilities that did not interfere with selected work 41,158 or 34.7 per cent. 3. Total number rejected for work because of disabilities 11,433 or 9.7 per cent. 4. Total number having no disabilities of any moment. 66,309 or 55.6 per cent. 5. Total number of regular employees in these ten industries 102,400 It is fair to assume that these 11,433 apphcants who were rejected for work would have soon lost their positions because of inefficiency, or would have quit because of sickness. Certainly by the end of a year practically all of these would have been eliminated from the work- ing force. It is impossible to accurately estimate what the loss to these concerns would have been during that year from having these men and women in their employ. It would have been considerable, how- ever, from decreasing efficiency due to the disease, from an increased accident rate, from loss of time due to sickness and the resulting sick benefits in many cases. Several estimates have been made of the cost of labor turn-over. These are based on the cost of employing people, teaching them the job, and the time elapsing before they become efficient or productive. These estimates vary from $10.00 to $200.00. One authority, after a careful study of this problem in many industries, gives as a low average the amount of $35.00 as representing the cost of hiring and training an individual.^ Therefore, these 11,433 rejected cases can be estimated as saving these concerns $400,155 in labor turn-over. Magnus Alexander in a comprehensive study of the cost of health supervision in ninety-nine different industries found that the average cost per employee for all medical work was $2.50. Using this figure as a fair average, and taking the regular number of employees as 102,400, we can estimate the cost of the entire medical work in these ten industries at $256,000. Thus the examination of applicants alone undoubtedly saved these concerns over $140,000 during the course of one year. Table 6 1. Saving to ten concerns from rejection of physically unfit $400,155 2. Cost of entire medical work in these concerns 256,000 3. Profit to the concerns from this one branch of medical work alone. . . $144,155 It is fair and conservative to estimate that at least 10 per cent, of those applicants with physical disabilities, who were employed, 1 A more recent estimate places this at $45.00. BENEFITS AND PROFITS OF THE MEDICAL DEPARTMENT 89 would have quit very shortly if physical selection of the proper job had not been used, thus adding to their efficiency, contentment and health protection. This adds another $144,000 to the profit of the em- ployers from this system. While the above figures can only be estimated, yet the most skep- tical must surely agree that the examination of applicants for work, and the rejection of the physically unfit, even when based on the most humane standards for rejection, certainly pays any concern adopting this method. And the saving to that concern from his procedure alone will more than pay the costs of the most efficient Human Main- tenance Department they can establish. 1 CHAPTER VIII COST OF THE MEDICAL DEPARTMENT In the preceding chapter an endeavor was made to show the profit which a concern derives from its human maintenance department and to point out the difficulty of obtaining actual figures on, this subject. The cost of maintaining such a department is of equal interest. In fact, it is very essential for an industrial surgeon to have a clear con- ception of costs in making recommendations to an employer con- templating extending the medical and surgical work in his plant. Naturally the cost of such a service depends upon many factors. Chief among these are : 1. The caliber of the physicians employed. 2. The number of physicians on the staff. 3. The number of hours the physicians are engaged. 4. The use of outside medical and surgical service. 5. The number of industrial nurses. 6. The number of clerks, stenographers and other lay assistants. 7. The number of employees in the concern. 8. The comprehensiveness and thoroughness of the medical and surgical work. 9. The amount of medical and surgical supplies used. 10. The extent to which laboratory and rc-ray methods are em- ployed. It is quite evident that in estimating the cost of this health service each of the above factors must be considered in connection with each individual concern. However, certain facts and figures can be given which will be of assistance in estimating cost. The Caliber of the Physicians Employed.— This is one of the most important considerations for the success of the work and the effi- ciency with which it is done. All industries will find it more effective and much more economical in the long run to employ the best medical and surgical talent which they can secure. By this I do not mean highly specialized physicians to represent each particular specialty of medicine in their plant hospitals, but broad-minded, well -trained, all- around physicians. In addition these doctors should have a highly developed sociological sense and should be filled with enthusiasm for the service which they can render to their fellowmen. The oppor- tunity for service is offered to a greater extent in industrial practice 90 COST OF THE MEDICAL DEPARTMENT 91 than in any other line of medicine. It is true that the cost of em- ploying this type of physician is considerably more than to employ a mediocre doctor, but the efficient service, the vision to develop a truly human maintenance system, and the saving in life and limb will more than compensate for this initial expense, A number of large industries have chief surgeons of this caliber. Some of these men devote their entire time to the work while others give only a part of their time. The salaries paid these full-time men vary from $4000 to $15,000 annually. The part-time men draw annual salaries from $2000 to $10,000 depending largely upon the amount of time devoted to the work. Industrial concerns cannot expect to secure well-trained physi- cians at a lower salary. In fact, as our better surgeons take up this work employers are found to be paying greater salaries. "While the opportunity for service is abundant in industries, yet human nature is such that the majority desire to be paid for this service. Men who have devoted eight and ten years preparing for their life work at a very great cost naturally will seek that line of work most remunerative. Too many industries, in the past and even at the present time, are employing company surgeons who have failed to make a success of the practice of medicine or who do not desire to put forth the strenuous effort necessary to make a success. They are paying these men $150 to $250 a month for their full time but frequently fail to get value received. Not all the poorly paid industrial surgeons belong in this class, for many a well-trained young man takes up this work on a small salary simply as a means of accumulating a little capital which will enable him to enter private practice or some one of the specialties. He renders good service but as soon as financially able he relinquishes the industrial practice. This is a source of great loss to those concerns pursuing such a shortsighted course. The old time company surgeon who accepted a small fee for emer- gency work or took a contract, at a low figure, to do only the surgical work for an industry, as a rule rendered very inefficient service to the employees. His standing in the profession was of a very low average and the character of his work was of a low standard. He was a com- pany surgeon in word and deed and too often was only on the side of the employer as represented by the insurance company. The stand- ards of industrial medical and surgical practices as represented by these men reached a very low plane. Fortunately a few large concerns and some of the insurance com- panies awakened to the importance of efficient medical care for em- ployees and began to pay for better trained physicians. These men had a vision of the great opportunities for preventive medicine and pre- 92 INDUSTRIAL MEDICINE AND SURGERY ventive surgery offered by industrial medicine, and during the last decade have developed this line of practice into one of the greatest specialties of our profession. And with the industries of the nation devoting more and more attention to the conserving of our man power this specialty will develop far beyond our present dreams. The best medical talent of the country will be brought into this line of work. Their sole effort will be devoted to the welfare of the employee, but it will be retroactive to the welfare of the employer. The old type employer's physician is passing and the new era of the employee's physician is here. The Number of Physicians on the Staff and the Number of Hours Spent on the Job. — Among the leading surgeons in industry opinion is divided as to the number of hours the company physician should spend on the job. Some advocate the full-time doctor while others favor the part-time plan. Unfortunately in' the past too many of the full-time physicians have been underpaid, have been held too closely to the plant, pre- venting their scientific development, and have settled into a "rut." Such a policy has deterred the best trained men from taking a full-time position. A few industries, willing to pay for the best of service, have been able to secure and hold men of the highest professional standing who give their entire time to this work. The strongest argu- ment for such a plan is the doctor's undivided attention devoted to the employees. Very few industries are willing to pay a salary commensurate to what a well-trained, scientific physician can earn in private practice. They can secure, however, the services of such a man for part time, leaving him free to develop his special practice on the outside. Thus doctors who have been thoroughly trained in every branch of medicine and surgery, but who are developing a specialty, will accept a part-time position. In this way a group of specialists can be gathered together in the plant hospital, who make a diagnostic and treatment group far superior to the majority of full-time staffs. If they are paid sufficiently well for this part-time work, most of these men will remain with the concerns for years^ — each succeeding year becoming more and more valuable to them as a specialist. The full-time staff will find it necessary to consult outside special- ists more frequently than a part-time staff composed of men thoroughly qualified to represent some special line of practice. For example, one large industry employs ten physicians including the chief surgeon, all of whom spend three and one-half hours at the plant. During this time they work at a pace it would be impossible to continue for the entire day. Among these doctors are represented the following special- ties : surgery, orthopedics, gynecology, internal medicine, tuberculosis, COST OF THE MEDICAL DEPARTMENT 93 psychiatry, dermatology, and an expert laboratory man. They are not so highly specialized, however, that they are not efficient as examiners and general emergency men. All of them, from the very nature of the work, are highly specialized in preventive medicine and preventive surgery which after ail is the very backbone of indus- trial medicine and surgery. It would be financially prohibitive for this industry to employ half of this staff for full-time work, whereas, by the part-time system they are able to avail themselves of the best type of special service whenever needed. These nine assistants receive an average of $150 per month for the three and one-half hours work per day at the plant. They are free to care for any member of the family of an employee but are pro- hibited from accepting as a private pay patient any one of the employees. This is very essential as it removes the danger of a physician soliciting patients from among those whom he must advise to seek certain medical or surgical remedial measures. It adds to the weight of the physician's advice when no ulterior motive can be connected with it. Number of Physicians Needed. — For a comprehensive system of industrial medicine and surgery at least one full-time or two part-time physicians for a thousand employees is necessary. Three full-time or five part-time physicians or eight part-time physicians are needed for a working force of 8000 to 12,000. If applicants are not examined for work or if re-examinations are not made frequently, or if other phases of a comprehensive sys- tem are not incorporated in the work, the number of physicians can be reduced. The Number of Industrial Nurses Employed. — These nurses are the most valuable assistants to the doctors and are necessary to carry on any efficient system of industrial medicine. The above estimate of doctors needed depends upon the employment of these nurses. Besides assisting the medical staff they must act as visiting nurses to the sick and injured employees. They are the best means of constantly keeping in touch with the absent employees. Two nurses for 1000 employees are essential. Three to four nurses are needed up to 5000 employees. Five to eight nurses for 5000 to 10,000, and as many as twelve nurses for at least 15,000 employees will be necessary. If all sick employees are to be visited, however, the above number of nurses should be doubled. The number of lay assistants will depend upon the complete- ness of the records and files. Money expended for keeping up-to-date records on all patients visiting the doctor's office is money well spent by the concern. These records furnish valuable comparative data from year to year and will enable the discovery of many conditions 94 INDUSTRIAL MEDICINE AND SURGERY effecting the health of employees which can be corrected. One stenographer and one filing clerk are necessary for each 2000 employees. In one industry where from 600 to 800 workers per day visited the doctor's office during the busy months it was found to be most eco- nomical to employ a girl time keeper in the waiting room. It was her duty to stamp on the hospital pass, with a time clock, the hour of admission to the office of every employee and the hour of leaving. In this way the employees were seen in turn and none were allowed to waste an undue amount of time waiting for the attention of the doctor. On the busiest day of last year with an average of four doctors and eight nurses on the job all the time one employee passed through the office every half minute. Every one of these were seen by either a doctor or nurse, and notation of what was done placed upon the employee's record. This office employs eleven lay assistants, girls, thus making pos- sible a system which can efficiently handle such a large number of cases. The average salary paid these girls is $15 a week. The total cost increases with the number of employees but as a rule the average cost of this work per person decreases with every thousand employees. This is shown very well in the accompanying table. Also, the outlay increases with the hazardousness of the occupa- tions. Thus, the cost of such a system is greater in a manufacturing plant than in a mercantile concern. The increased amount of surgical supplies alone is responsible for a greater expense. The comprehensiveness and thoroughness of the work depends largely upon the caliber of the medical men employed. Good scien- tific physicians will demand and use a laboratory and the x-ray more than in a plant where slip-shod methods are tolerated. All of this will increase the immediate costs but the results obtained will far more than compensate a concern for the additional expense. Cost of Health Supervision in Industry. — The Conference Board of Physicians in Industrial Practice, composed of industrial surgeons representing many of the largest industries of the eastern states, has contributed much valuable material to Industrial Medicine and Sur- gery. Magnus W. Alexander, Secretary of this Board, is responsible for the compilation of the attached table showing the cost of health supervision in industries. The author is indebted to Mr. Alexander for the privilege of reprinting this material. "The accompanying table presents data for the year 1916 as re- ported by ninety-nine industrial plants located in fifteen states. The total average number of employees represented was 495,544; the average number per plant was 5005, the maximum 37,107, the minimum 141. COST OF THE MEDICAL DEPARTMENT 95 "While the average cost per person as indicated in the summary, is $2.50, it is not representative, as the total cost on which the average is based includes that of four plants (71, 85, 95 and 96) which render unusual service, giving both medical and surgical attention to their employees at the plant and in their homes as well, besides assuming the medical care of employees' families. Omitting these four plants from consideration, the average cost for the 479,634 employees in the other 95 plants was $2.21. "A total of 3,165,114 cases was reported, an average of more than six cases per person employed, at an average cost of thirty-nine cents per case. The number of cases reported, however, does not include all of the service rendered. In many plants, no record is kept of slight injuries, of injuries redressed, of medical cases treated, of home visits made, or of physical examinations. In others, even the most trivial cases are counted. Furthermore, as 'cases' are so varied in gravity and in the time required for treatment, any comparisons of costs per case are not of much value. "The 'Total Medical and Surgical Cost' includes salaries of physi- cians and nurses, cost of outside medical and surgical service and cost of medical and surgical supplies, whether or not paid for by insurance companies as a part of the insurance contract; it excludes all compensa- tion for injuries, all overhead expenses and any wages paid to em- ployees while off duty to have their injuries treated. The chief significance of this data, from a general viewpoint, is that it is possible to give such a large amount of medical and surgical service at a cost which averages only $2.21 per employee per year. Convincing proof of the economic value of health supervision in industry is afforded by the fact that, when collecting the data con- tained in this report, it was found that no employer had abandoned the health supervision activities established in his plant. On the con- trary, the prevailing tendency has been to invest even more money in extending the service." 96 INDUSTRIAL MEDICINE AND SURGERY Table 7. — Cost of Health Supebvision. QCU] 1.244 1,561 1,730 1,92S 2,000 2,200 2,400 2,565 2.G00 5 f< 1 hJ S s 1 M., 1 F. Yes 1 F, 2M.,1F. 7,922 8,000 10,000 11,000 1,321 2,653 2,700 4,,500 -3,050 4,782 4,850 1.000 1.060 1,908 6,603 1.200 1.500 2.500 3.000 6,450 1 3 hrs, djily 1 1 hr. daily 1.294 7.200 6.657 . 1.623 4,596 ( 6.522 2.360 1.10!) (I 3.968 16,992 . 14,394 10.680 , 6.194 15.659 S.IM 8.122 1.327 23.112 17,516 . 11,177 9,600 32,160 (' 53,006 29,626 . 12,200 55,728 (' 1 2 hrs. 1 4 hrs. 3 3 hrs. t 3 hrs. daily 4,944 4,843 18,M4 30,500 9,360 3.826 4,872 6,416 7,254 2,745 42,972 39,931 . 24,502 32.000 36.676 62,891 ( 71,914 . 32,3M 6.538 37,746 8,092 37,492 40,642 40,602 60,000 2,800 1,500 11,697 15.413 5,934 10.835 3.303 8,207 5,200 6,225 7,147 1,278 ' 5,666 4,992 6,274 2.006 3,341 2,679 10.624 12,960 10.458 10.332 4,080 1.294 11.400 17,820 4,600 28,208 7,6SS 7,000 23,136 1,970 6,388 15,665 25,458 16,000 5,749 15,648 21,800 21,362 ^ 5,780 14,244 39,044 41,586 24,580 21,087 95,110 11,915 102,616 57,447 56,242 186,170 107,289 62,064 1,754 4,746 11,314 11,072 1,307 1,709 885 7,140 2,651 3,112 6,744 1.038 3.160 5,878 4,040 1,332 3,485 4,939 2.330 7,517 3,550 8,820 10,980 11.376 15.494 5.157 6.728 8,272 l.."00 10.369 6.200 1,020 1.250 7,810 9,400 13,253 48.752 12.336 53.987 53.492 86,551 90,200 2,832 617 7,865 5,721 6.257 18.910 8.564 1,112 4.050 7,253 27,497 33.327 0,461 1,132 ■15,118 7,017 17,813 8,401 29,173 22.40) 5,940 41,169 22,010 7.074 7,713 9.616 19.897 9,002 14.997 18,897 17,680 17,267 13,641 30,200 32,961 28,749 34,409 22,650 21,6 87,717 4,130 9,113 5,606 16,081 11,010 36,104 65,000 6,932 2,020 8,200 10,700 5,959 28,923 12,919 23,880 3.105 5,155 19,212 29,507 12,654 14,182 5,100 2,835 9,018 10,072 12,550 2.41 S5.00 1.38 3.es 4.09 ~ 7.40 1.43 2.10 t.U4 2.87 1.S8 1.17 3.17 1.4S 2.31 1.01 1.77 1.67 1.07 2.08 2.09 1.71 2.04 1.30 S.13 3.43 2.ns 3,S7 4.S0 1.89 3.61 3.3« 2 30 1.49 3.91 1.09 1.000 1.350 2.000 4,589 ■ 3,217 2.45! 2cri .Ideam t'n'dtlsK 1 first aider 1,443 7,430 2,184 . 1,032 8,000 288 5,800 3,600 1,528 27,673 1,512 2,842 62,128 131,898 1,720 4,173 4,826 1,563 6,2,50 5,361 12.000 56 3,417 4,637 35,590 130,000 1.89 ('•) 14.24 ('•) 11.82 1.47 2.S9 2.»0 COST OF THE MEDICAL DEPARTMENT 97 SUMMARY INDUSTRY Nombor ot llcprcscntcU Averngc Number o( Employcca Supervised o(°iii kSS Total Mediol aod Surgical Cost AveraB* Annual and Suriiical Supervision per Employee 47 7 1 7 5 6 5 5 4 2 1 1 1 3 99 291,646 49,317 1,270 24,921 33,795 10,572 13,050 27,402 8,939 4,023 3,026 3,358 2,454 2,500 11,000 2,611 495,644 1,988,991 358,574 2,832 49,046 81,591 78,744 09,565 234,069 67,380 10,255 9,440 0,742 2,842 02,126 131,898 11,019 3,16S,1U 8541,771 137,047 , 6,932 92,001 09,033 34,797 39,875 76,089 24,177 29,035 0,102 3,473 4,637 35,590 130,000 6,126 $1,238,486 $1.84 2.78 5.46 3.72 1.96 3.29 2.92 2.77 2.70 7.37 2.02 1.03 1.89 ('•) 14.24 (")n.82 ■ 2.35 •$2J0 Smelting and Rc6ning ChemicaU Coal and Iron Mining *Thc average annual cost per employee, excluding Plants Nos. 71, 85, 95, and 96, for which the cost includes sickness CHAPTER IX SUPERVISION OF THE HEALTH OF THE MANAGERIAL STAFF The human maintenance department should not be operated only for the employees; the managerial staff of the concern should likewise be included in its scope. The supervision of the health of the president, the vice-president, the general manager, and of all the department managers is of equal or greater economic importance to the industry. Every industrial surgeon agrees that the success of his work de- pends upon interesting the head of the concern and securing his co- operation. Many surgeons insist upon reporting direct to the chief executive, or his highest representative, depending upon this as the best means of securing the indorsement and assistance of the managers. Too often the physician fails to take advantage of this opportunity by neglecting to offer this medical supervision to the managerial force. On the other hand, the attitude of these managers is often incon- sistent. They will lend every assistance toward extending the work to the employees but refuse to apply it to themselves. Some executives and managers have adopted the principle that all work and no play does not pay dividends and for these the supervi- sion is not so essential. But the majority of busy business men are over-burdened with work, are irregular in their habits, eating at all hours, sleeping too little, and failing to take sufficient exercise. They work at high tension and develop a high tension machine. They depend upon their few weeks' vacation once a year in which to recu- perate their wasting energies. None of these practical business men would think of working an expensive, high powered machine day in and day out without peri- odically inspecting it and repairing damaged parts before the machine was ruined. They should give the same attention to the human mechanism. Many of these men develop circulatory conditions or damaged nervous systems which totally unfit them for further service, often prematurely. In this way the concern suffers the loss of a valuable executive — & loss which the industrial surgeon might prevent. Therefore, the medical staff should extend its work to include everybody from the president of the concern down to the lowest em- 98 SUPERVISION OF HEALTH OF MANAGERIAL STAFF 99 ployee. In a few places this is done with the result that the manage- rial staff sets the example for the rank and file of the employees. When it is necessary for the entire force to be vaccinated the president and general manager are the first to submit to the operation. When the president and the managers undergo a periodical medical examina- tion and talk about it freely it is an easy matter to win over the rest of the force to such a procedure and to gain their confidence. But aside from the example it is of the greatest value to these executives to develop habits of prevention. They owe it to themselves,* to their families and to the business which they represent. The periodical medical examination and the resulting health super- vision should be applied to the executives and all the department managers of every industry. At least twice a year these officials should be thoroughly examined; this should include urinalysis and blood-pressure tests. If the examination reveals the need of a more thorough study, the same should be made at once. It is necessary to maintain a tickler system on these officials, calling them to the office for examination when their turn arrives. This should not be left to their memory. Great care and diplomacy must be exercised in telling these men of any little condition which is found and which needs some correct- ive treatment. These officials very frequently become panicky over some minor condition, developing a real neurasthenia because of the suggestion contained in some warning which the doctor gives. This is often truer of managers than of the employees in the ranks. It may be due to the high tension at which they live and work, or to the responsibilities which rest upon them, or more probably to the fact that they can afford to go from doctor to doctor, trying to find one who will confirm their worst fears. The case of Manager P. illustrates this point very forcibly. On the managers' tickler system it was Mr. P.'s day to be examined. He was called to the office and the physical examination made which showed Mr. P. perfectly normal physically. However, he was tired and nervous and complained of stomach trouble. In a manner he censured the doctor for not discovering the condition. Undiplomatically the company physician said, "Well, you had better go and have a stomach analysis made." Instead of following up the case and reassuring this tired manager the doctor let him depart unsatisfied. Mr. P. went to his family physician who did not make a stomach analysis but who agreed with his patient's diagnosis of stomach trouble. Mr. P. was not satisfied, however, because he was still thinking of that "stomach analysis" suggested by the company doctor. He finally went to a specialist who for $25 made the analysis and 100 INDUSTRIAL MEDICINE AND SURGERY e while it failed to show anything definite yet the specialist suggested further study to rule out the possibility of cancer. Poor Mr. P. became panicky and started to jump from doctor to doctor most of whom reassured him and laughed at his fears. He was unconsciously looking for the doctor who would agree with his own diagnosis of his case. After three months the general superintendent of this concern called up the company surgeon and asked what was the matter with manager P. who was falling down in his work and whose department was going to pieces. ° The doctor had not seen Mr. P. for three months but he would do so at once. Mr. P. was called to the office. After two weeks of careful study, and patiently demonstrating to the man that he did not have a cancer, the doctor was able to enter into the status of the case at the point where he should have started three months previously at the first examination. Mr. P.'s first symptoms were tiredness, nervousness and a "funny, sick feeling" in the stomach. The doctor after gaining his confidence, found that the production in his department had fallen off, that the general superintendent had had Mr. P. "on the carpet" a number of times, causing fear of losing his job. This fear was the etiologic factor and beginning of his entire trouble. The general superintendent when informed of the condition re- moved the fear, a short vacation was prescribed which was spent at hard work on a farm, and Mr. P. returned a month later a well man and with no thought ever given to whether he had a stomach or not. Not only the managers but all the employees learn to lean upon the medical staff for advice and guidance concerning their health. Many foolish fears and symptoms are brought to the attention of these doc- tors. Every case must be considered carefully and seriously treated, no matter how trivial it may seem to the doctor. Only in this way can you avoid the panic which overcame Mr. P. and the resulting economic loss to his industry. Besides examining and advising these managers on health mat- ters the medical staff should take an interest in seeing that healthful recreation and exercise is provided for them as well as for the em- ployees. Some concerns insist on their managers taking one afternoon a week to play golf. Others provide tennis courts about the plant grounds for the use of the managers. These arrangements are of great aid in the months when least needed. In the winter months the lack of healthful exercise is most apparent. Steps should be taken by every concern to meet this condition. One industry has provided a gymnasium for its executive and managerial staff. This gym contains the usual apparatus for exercise, a SUPERVISION OF HEALTH OF MANAGERIAL STAFF 101 shower bath, needle bath, electric cabinet and table for a thorough rub down. A physical director is in attendance at all times. The managers have their regular period each day for reporting here for a short work out. The president and vice-president of this concern are the most faithful followers of this plan and use their influence to see that every manager takes advantage of the gymnasium. Supervision of the health of the managerial staff should be a very definite part of the work of the industrial physician and surgeon in every concern. It will do more than anything else to prevent the frequent and unnecessary nervous breakdowns which are entirely too prevalent among the busy business men of to-day. CHAPTER X RECREATION AND EXERCISE AS RELATED TO SUPERVISION OF HEALTH OF EMPLOYEES In many up-to-date industries much attention is devoted to proper recreation and physical exercise for the employees. This is true in industries where medical departments have never been installed. In others with excellent medical staffs this health adjunct is neglected; or, if it exists, it is not considered in any way related to the medical service. Too often the provisions for recreation and playgrounds are left to the welfare department or to employees' committees, and the plant physicians take no interest in the work. No better health movement can be inaugurated by any concern for its employees than by providing proper facilities for recreation and exercise in close proximity to the working place. Besides proving of healthful benefit such an interest displayed by the employers tends to create a loyalty and good fellowship among the employees themselves. In all industries the medical departments should take a very active part in the formation and maintenance of all movements for the rec- reation and physical exercise of employees. These recreational movements have taken many and varied forms. In some cases they are not only for the benefit of the employees but for their families likewise. Their purposes are diversional, educational, healthful and to develop loyalty toward the industry. They are carried on in connection with the plant itself, in the grounds about the plant, in halls provided for the purpose, in Y. M. C. A.'s, or gymnasiums built near the plant, and may be extended to the schools and churches of the community where the industfy is the means of stimulating them. The following examples of recreation for the employees are more purely diversional and educational and therefore are not so closely related to the medical department. Activity in them by the doctors and nurses, however, increases the influence and standing of the medical staff with both the employees and employers. Motion picture shows. Picnics for the employees. Boat and train excursions. Lectures and concerts. Dances and parties. 102 RECREATION AND EXERCISE OF EMPLOYEES 103 :'y(?4 A 104 INDUSTRIAL MEDICINE AND SURGERY RECREATION AND EXERCISE OF EMPLOYEES 105 Sewing and cooking classes. Libraries and plant journal. Advantage can be taken of the motion picture shows, the lectures and the plant journal as a means of injecting snappy health talks or demonstration of disease and accident prevention methods into the minds of the employees. These are very effective measures especially when introduced as a part of a purely recreational program. The recreations tending to improve the health of the employees are the ones in which the medical staff should take the greatest interest. These are: 1. Physical Drills or Exercise Conducted During Working Hours. — Much benefit is gained for employees and their working capacity is increased especially where their work is sedentary, if ten minutes every two hours are devoted to physical exercise. The windows should be thrown wide open and the employees put through a drill or calisthenic movements. Deep breathing exercises should always be included. Every department manager should be given instructions in proper exercises by a well trained physical director so he or she can conduct these recreational periods. There is nothing which tends to overcome the loss of efficiency from fatigue as much as this. The employees should be urged to go through similar setting up exercises on arising in the morning. 2. The Recreation Room. — Many industries have built in connec- tion with their plants large club rooms — one for women and one for men. Here reading and writing rooms are provided, gymnasiums with all kinds of appliances are furnished and the rooms may be used as meeting halls for shows, lectures, dances, etc. The doctor should stimulate the physical exercise features of these recreational rooms. He should also see that they are light, airy and clean at all times (Fig. 18). Often a prescription providing for certain hours spent in the gym wiU do far more toward overcoming some threatened disease or break- down in an employee than a prescription for iron, quinine and strych- nia. In fact the more of these healthful adjuncts the physician can add to his armamentarium the less drugs will he dispense. 3. The Playgrounds and Athletic Fields. — Om- colleges were the first to recognize an athletic field as a definite and essential part of the educational plant. To-day many industries have adopted the idea and have provided ball grounds, tennis courts, cinder tracks, and all the appliances that make up a regular athletic field (Fig. 19).^ Teams are organized in various departments and compete with one another. Much friendly rivalry is developed. The silver cups won by department teams in tennis, the baseball pennants won, and ^ Figs. 17 to 19 by courtesy of Sears, Roebuck & Co. 106 INDUSTRIAL MEDICINE AND SURGERY RECREATION AND EXERCISE OF EMPLOYEES 107 the individual medals and prizes stimulate these athletic contests and make them very popular with the employees. These provisions for outdoor athletics are of great aid to the med- ical department. Many a hollow chested, shallow breathing, stoop shouldered employee who is frequently absent on account of minor ailments can be broadened out into a well man by persuading him to use the athletic field. Many of these boys began work very young and never had the advantages of athletic training at school or college. They enter into the sport with all the enthusiasm of a freshman. Besides invigorated bodies, their minds are benefited. For the first time the spirit of perseverance and conquest is instilled into them. The joy of winning on the athletic field is an incentive to strive to win in life's competition. These athletic contests should receive the most enthusiastic backing from the medical department of the industry. The doctor's responsibility for the men entering these strenuous exercises should always be kept in the foreground. No man should be allowed to enter a contest on the athletic field without undergoing a thorough physical examination. One large industry, with which the writer was connected; has as complete an athletic field as any university in the land. This consists of a quarter mile cinder track, baseball diamonds, fourteen, tennis courts, and all the paraphernaHa for a complete field day, as hurdles, jumping and pole vaulting standards, etc. Every year a field day meet is held with at least 300 entries. The preliminaries may be held the week preceding the meet. The attendance at these meets is from 12,000 to 15,000 people. Besides the track teams, this concern has twelve regular ball teams, and innumerable pick up teams for ball games at the noon hour or in the evening. Hundreds of employees take advantage of the tennis courts. All of these athletes are thoroughly examined hj the medical staff before being allowed to participate in the training for these contests or to join a team. Many a man with an unknow^n heart lesion, a beginning lung condition, a hernia, or some other early defect is discovered in this way. For these the strenuous athletic sports would have been detrimental and in many cases absolutely dangerous. Therefore, while physical exercise may be a great boon to the employees and may be a favorite prescription for the doctor to give, yet it should never be prescribed without previously examining your patient and selecting the proper type of exercise and the amount of the dose. These examinations are thorough from head to foot and always include a urinalysis and other laboratory tests when needed. College athletes are supposed to be examined before entering into similar 108 INDUSTRIAL MEDICINE AND SURGERY contests, but with only four or five exceptions no college or university submits their athletes to an examination that is worthy of the name. On £,ccount of this, great damage is done to the physical make-up of many of our college youths. A wonderful .opportunity is given to the industrial physician to introduce healthful exercise and athletic contests among millions of boys and girls and men and women throughout our country. But in doing this they should impress upon the people the importance of examining the machine before undertaking the strenuous work. Universal military training would be a mighty boon to the health of our young manhood because it would be accompanied with medical examinations and the type and amount of drill would be on a select- ive physical basis. The stimulating of athletics among employees, if based on a similar plan of physical selection, would be equally beneficial. A comprehensive human maintenance department therefore must include in the scope of its work these recreational provisions. CHAPTER XI FOOD Food is one of the most significant factors in the maintenance of health. The medical department of an industry that pays no atten- tion to the food of the employees is neglecting an important duty. The inalienable right to eat whatever one wants cannot be tam- pered with by any employer. Even the company physician cannot prescribe the proper diet for employees and force them to follow it. But in many subtle ways the physician can influence the diet of a large group of people just as he does for an individual patient. The responsibility does not cease with the suggestion of proper food to eat but deals more with correlated subjects. Therefore, the physician responsible for the health of hundreds of employees must be on the alert to discover group defects in nourishment and quick to find the cause and remedy for the same. In dealing with the individual employee he can inquire into the question of diet and suggest corrective changes when needed. He can ascertain whether or not the wages paid are inadequate to properly nourish the employee and those dependent upon him. Often the dependents are so numerous that this becomes a real cause for under- nourishment and resulting sickness. He will discover certain con- ditions which are the result of improper food, improper eating places, irregular meals, hasty consumption, insufficient teeth for proper mastication, peculiarities of diet detrimental to the individual and many other conditions where the food and eating habits have a direct bearing on the physical condition. These faults are best corrected by frequently repeated advice to the individual. He can even take up the question of low wage with the management, when he feels that this is the cause, and usually have it corrected. Even a wrong diet at home for the employee and his family can be corrected by proper advise from the physician assisted by the subtle, diplomatic suggestions of the visiting nurse who drops in for a friendly call on the wife. But in dealing with the entire group of employees the industrial physician can do many things, with and ^\ithout the assistance of the employer, to influence the health of the people under him as related to food and food conditions. 109 110 INDUSTRIAL MEDICINE AND SURGERY Talks to employees individually and in groups concerning food hygiene will bear certain fruit. Written pamphlets handed out from the office or distributed to the employees through the pay envelope will give further results and are of greater value because they usually are read by the wife or mother at home. After inquiring into the food eaten by thousands of employees, one is convinced that bread, meat and potatoes are used to excess, and that milk, green vegetables and nourishing soups are neglected by the majority of housewives who are responsible for maintaining the man power of the industries of the country. A campaign of education directed along these lines by the medical staff will result in great benefit to the health of the working force. Too long has the doctor neglected this power at home which could be directed into useful co- operative channels. Where employees carry their lunches to work two problems present themselves for the attention of the doctor. First, a study of the food will show that the average lunch is far deficient in calories. The writer has investigated hundreds of such lunches and the average contains a cold bread and meat sandwich (the bread is often a cold biscuit), a piece of pie and a banana. This would do occasionally but the same thing day in and day out is not a sufficient lunch for a hard working man. His fuel box is not replenished at the noon hour and his efficiency in the afternoon is bound to suffer. This is not so true in smaller towns where the dinner pail is still in use. But in our cities the dinner pail is out of fashion and the small paper sack which can be stuck in the pocket has replaced it. The second problem is, Where are these lunches eaten? The majority of girls carrying their hmches will eat them at their desks and then will spend the remainder of the noon hour sewing or reading. Or, they will congregate in some dark corner where the lunches are consumed, sitting there and talking for the rest of the hour. The men will find some secluded spot, eat their lunch, and then curl up for a nap or will sit inside and smoke. The incentive to get out of the building at the noon hour and exercise in the fresh air by walking somewhere for their lunch is removed when it is carried to work and kept in the desk or locker. To correct these two conditions every industry will find it worth while to provide lunches and proper eating places for their employees. The plant restaurant is a fixture in many concerns. The food should be excellently prepared and sold so reasonably that it would be chosen in preference to neighboring restaurants or even to carrying the lunch. The majority of concerns do not give sufficient attention to the quality and preparation of the food in their restaurants. FOOD 111 The profit from such a restaurant should not be made from the sale of food but from the more efficient, happy, well nourished working force. The restaurant should be located outside the plant, forcing all employees to go out at the noon hour. A place should be provided in it for those employees to eat who carry their lunches. Some concerns serve milk and coffee to these in order to get them to the restaurant. A proper eating place should always be provided and then a rule made and enforced by the management that no employee could remain inside at the noon hour. During this period the department should be aired out thoroughly. In addition to this rule the medical staff should constantly urge the employees to get out of the plant at the noon hour and secure some healthful, invigorating exercise. If a restaurant is maintained at the plant, it is the duty of the medical staff to keep a close supervision over it. The following measures should be adopted in this respect: 1. Periodical medical examination of all employees in the restau- rant. Every employee handling or preparing the food or working in the kitchens should be thoroughly examined every three months to ascertain if any diseased condition exists that could contaminate the food being served to the employees. No one should be allowed to go to work in the restaurant without first being examined. In one industry, during one year, where this plan was followed, two cases of tuberculosis, two of active syphilis, one of diphtheria and one gonorrheal case were prevented from being employed in the restaurant. In addition a young girl, a foreigner, who was to be employed as a dishwasher was found to be bodily filthy. She had not bathed for seven months according to her own statement. No, she was not rejected, but rather was given a bath by the nurse and was then employed with the understanding that she could hold her job by bathing twice a week. She reported once a week to the nurse who ascertained if she was living up to the contract. The contract, by the way, was made between the doctor, the nurse and the girl and no one else knew of the condition. This girl is now one of the best waitresses. The ruling out of these diseased conditions undoubtedly prevented the spread of disease among many employees. Such a system should become universal and should be carried on by every city health de- partment in the land as regards the public eating places. A business man, whom I told of this condition, immediatelj^ had his four servants at home examined by his family physician, and one or them, the cook, was discovered to have an active tuberculosis. 2. A sanitary inspection of the kitchen and dining rooms, the store rooms, pantries, and refrigerators should be made frequently by 112 INDUSTRIAL MEDICINE AND SURGERY the medical staff. These inspections if backed up vigorously by the management will do more than anything else to provide clean, sanitary conditions in the restaurant. They are essentially a part of the health supervision of the employees. The following outline suggests the things which should be inspected. SANITARY INSPECTION OF A RESTAURANT I. General Survey : (a) Is it clean? (b) Is it well ventilated? (c) Is it well lighted and frequently aired out? (d) Is it smelly? (e) Is it located near unsanitary surroundings? II. The Kitchen : (a) Is it clean? (b) Is it screened? (c) Are flies present. (d) Is the food left unduly exposed? (e) Are the tables greasy or covered with remnants of food? (/) Are the cracks in tables clean? (g) Is the stove clean? (h) Are the ovens clean? (i) Are cobwebs present? (j) Is the plumbing in good condition and drain pipes free? (fc) Is garbage left about and exposed? (l) Is the refrigerator clean, free of spoiled food, sweet smelling, and are the corners free of grease and food particles? Is good drainage from ice-box provided? (m) Are the store rooms clean; the shelves well arranged; and no spoiled food about? III. The Dining Room : (a) Is it clean? (5) Is it screened? (c) Are flies present? (d) Are the tables clean and free of particles of food? (e) Are the dishes clean? (/) Are cracks in tables free from food particles? IV. Any Other Unsanitary Conditions Present? 3. The food should be frequently inspected. The milk and ice cream should be bacteriologically examined. Every effort should be made to see that nourishing, well prepared food is served. FOOD 113 In a cafeteria conducted by an industry the lunches ordered were carefully studied. This revealed that among the girls and younger employees especially, the average lunch consisted of ice cream, a dill pickle, a piece of cake and some candy; or some other equally un- balanced diet. The management was prevailed upon to serve only nourishing food. Suggested menus were displayed and every effort made to influence the employees to buy proper food. Some went to outside cafes where the pastries and pickles were served but the majority fell into line. Fig. 20. — A model cafeteria for employees. Where restaurants in the neighborhood of the plant are patronized the plant physician can take it upon himself to make an unofficial inspection of these places. If unsanitary conditions are found or questionable food is being served, he can report the place to the municipal health authorities. Close co-operation should be developed between the medical de- partment and the city health department as frequently you are forced to appeal to them on many accounts. The Cincinnati MilHng Machine Company under the direction of Dr. Otto Geier has recently developed a most efficient system for feeding their employees. Through the courtesy of Dr. Geier I am permitted to publish pictures of this restaurant and of the floor plan- 114 INDUSTRIAL MEDICINE AND SURGERY FOOD 115 No national health program will ever be complete that does not include careful supervision of foodstuffs, the places where they are prepared and served, the people handling them, combined with an educational campaign as to the proper foods which should be eaten. The physician in industry has it within his power to initiate this fea- ture of a health program for a limited number of people at least. Fig. 21. — Dining room, floor plan, showing Cafeteria and its relation to commissary •and locker room. (Cincinnati Milling Machine Co., Cincinnati, Ohio.) {From "Employees Service News.") Tlie dining room has a seating capacity of six hundred. The flow of the employees through the locker room into the dining room at the noon hour is indicated by the arrows. The three self service counters with cashiers at the cash registers, with their corresponding checkers, permit of a very rapid movement into the dining hall. But ten minutes is consumed in passing six hundred into the dining room. The convenient position of the kitchen reduces labor cost. The shop band plays in the dining room during the lunch period. The space under the band stand provides a place for the re- frigerating machinery which is connected up with the refrigerators in the kitchen and within the self service counters space. The self service plan makes it possible for the employees to have their choice of two or three kinds of meats, as many vegetables, salads and pastries as will suit both their appetites and their purses. It affords hot, well cooked, clean foods at a minimum cost, and thus should add much to the physical well-being of the shop force. The average check, in spite of the high cost of food, is twenty cents. CHAPTER XII RECORDS In any industry sufficiently modern to recognize the value of a medical service, practical, business-like methods prevail — the same must be applied to the medical department. It has been pointed out in previous chapters that the frequent, periodical medical examinatiork of each employee would be more ideal, but such a plan is not feasible. More practical methods of meeting the situation had to be formed. Again it might be more efficacious if the doctor spent more time in the routine medical examination of applicants but such would interfere with the real business of the industry, which after all is not the running of a young hospital. Rapid, efficient methods are demanded in all departments and the successful industrial surgeon has met these demands. At the same time the high standards of professional work have been maintained. Records setting forth the history of the patient, the diagnosis, the character of the treatment given and other necessary data are now recognized as indispensable to the really scientific physician. The history sheets and records usually employed, however, are entirely too voluminous for industrial practices. Therefore the records of the various medical departments in industries have been boiled down until we now have several very efficient systems of record keeping. Practically all such records show only positive statements or findings. Thus if the history is negative the space for history is left blank. If venereal diseases are denied nothing is mentioned about them. On the other hand it is much wiser to record either positive or negative findings wherever the question of compensation may be involved. For example an applicant is found to have no hernia at his examination for employment. The record should show ''no hernia. " In the following pages I have presented examples of record cards used in my industrial clinic wliich have been adopted after several years of experience. While this may not represent the best system yet it shows the number of different records it is necessary to keep and the manner of combining them into one record. FILING Formerly separate cards were kept for medical, surgical, social and dental cases. Now all of these are combined in one record called Doctor's Office Record. This record is kept in a folder and filed ac- cording to the cross-index system (according to name and number). 116 RECORDS 117 In order to quickly discern the medical, surgical or dental record on a case, the surgical record and all pertaining to it, namely, nurse's calls, laboratory or rc-ray reports are typed in red; the medical record in black and the dental in purple. INFORMATION RECORD Name- Hosp. No.. Serial No.. Married I Single i nil S Dale Address Dept. Telephone Occupation Date Emp. or Rein. * Dale Resigned Caase Physical Examination (History of Diseases, Acddents or Operations.) Family Exam, for Emp. Temp. Pulse Height Weight Eye Test Urinalysis: Albumin Sugar Micro. R Result of Exam. L Both Doctor's Recommendations He.examinations Fig. 22. — Information record for applicants for work. This is made out in dupli- cate by the employment department and is sent with the applicant when he comes to the doctor's office for physical examination. The nurse takes the medical personal history of applicant, also temperature, pulse, weight, height, eye test and urinalysis. The applicant is then sent in to the doctor, who examines him. If physical defects are found which might interfere with his work at present, applicant is asked to report for re-examination. After being examined, he takes both original and duplicate to employment department. If he is employed, the employment department notes the department to which he is assigned, also serial number and returns original copj^ with this information to doctor's office. In case of handicapped persons who are employed their job is selected after a conference between the employment manager and the doctor. 118 INDUSTRIAL MEDICINE AND SURGERY DOCTOR'S OFHCE PASS M 18351 Date. Name Oept. Serial Address Number O.K.. I Duplicate and Send Both Copies to Doctor'* Office. Fig. 23. — Doctor's office pass. This pass is issued in duplicate to the employee who wishes to go or is called to report at the doctor's office. He gives it to the record clerk at the door, she numbers and stamps time in on it, then gives the original to the file clerk to look up employee's record. When employee is ready to leave the depart- ment, the doctor or nurse who last cared for him, returns pass and he again presents it to the record clerk at the door. She looks up duplicate, stamps both with time out and gives duplicate to the employee to give to his manager and retains the original at this office. RECORDS 119 n^tlrmpfeyrf 10/16/191 6. DOCXOH'3 OFPICR BBCOBD 6. M. B. A. '■ Name Casey, John. Dept 187 Hosp. No. XXXX. DATE 'Tl.f Pnji ,.,. REMARKS AND SICNATUIIE OF PHYSICIAN OR NURSE "!.t,v' umiin. V^'r 1/3/1 it n 131 IndlKesUfn. SeldllU. Daot. C.M.E 1/18/ .0 Abraded left thumb on broken china. Piece of chlnet removed. D.D. To report In A.M. DR . VA RMRTiRR • i/ia/ A p,p. niof-h- i^/ 20/16: 00 66 Headache. Aches all over. Influenza. 10. 3C DR. ELLIS. 12 '22/lC &9. 6 Reporting. In no condition to return to work. ■ Horn*, again. DR. ELLIS 12 27/16 Nurse's call A.V.C. Absent since 12/20/16. .- . Reported 12/22/16, but Was given pass home aRain. Has grippe. Has had no doctor, but la using home remedies. Is up and ground, but very weak and rundown. Temp. 96.2 Return indefln Ito. 1 12/17 n* 12/ Influenza. Examination neRatlva. 22/ H^ 2 f,i faA.I [17 da tlnnt. 1-^0- 17 All t.BBth pyorrhelc. Referrad to family D.D.S advleing cleanln£ and 1 filling. Beoall ?-!>fi^^7 . 5r., mobtgoheby. Dmry* . !>-?R- 17 Raportlnj. i'roper prophylaxla adminlsterad ty family D.D.S. Euaceptiblllty to focal infect- ion nflglegitle. DR. MOHTGOMiRY. 3 22/17 Resigned. 2 '10/ie Reinstated. 1 4 '29/18 6.30 A.M. Tlhlle at work on 4/27/ifl panhlne hardware, pat lent punctured right index finger to It and did not us© iodine. Mo witness. Reported, here 4/29/18 8.30 A.M. Finger swollen 1. ana painrui. Temp. 100.4. Sean by Dr. Pox and Advised because of lyBphangltls.At 1 P.M. tampni.atnT>n JOO.fi. <»Ant f,n WflphlnfT^^n Plvd HOBl for continuous hot dressings. . /3/18 Reporting. Left hospital this A.M. /6/18 Returned to work. OB.POX'. Fig. 24. — Doctor's ofl&ce record. This is made out either the first time the em- ployee comes to the doctor's office for examination or treatment or when a nurse's call is made at an employee's home. All subsequent information and treatment of whatever nature is kept on this record. The medical record is written in black; the accident record in red and the dental record in purple thus facilitating the reading of the record. 120 INDUSTRIAL MEDICINE AND SURGERY EMPLOYE'S GENERAL PASS This pass to be o&ed £oix^ ironk one department to another* one building to anotherp or Trhen leaving plant for any purpose whatsoever. To Usher: Ffom Dppt fn Reason . .. _. .... On the above Udcs dcelenate the department and bulldlnff to which tbo employe is sent If the cmploro is Jcavlnu tbe prcrolfles, stale If for oerbonal reason or on house business. TUIb paes win serre as an ItlentiflcaUon card and when going out of or into dlfTerent buUdlngB must be showti tZw premises not to return for the day, in which caee it will be taken the i)erBon O. K." except where em{>loyo loaves Fig. 25. — Employee's pass home. This is issued by the doctor's office when an employee is sent home on account of illness. EMPLOYES' RETURN TO WORK PASS Date employed. _Date Member nf S. M. B. A._ Name_ Dept. Returned to work today. Absent- account of : _days on Should report to Doctor's office- Signed- Fig. 26. — Return to work pass. This is issued by the doctor's office when employee is able to return to work after absence on account of illness. RECORDS 121 REPORT OF ACCIDENT No.- INSTRUCTIONS:— Accidents, However Slight, Must Be Reported In Full Date 191- ALL OF THESE 16 QUESTIONS WILL BE FILLED OUT IN THE DOCTOR'S OFFICE 1. Name ^ 2. Address 3. Department 4 Age Years Mos. 5. Occupation- 6. Nature and Extent of Injury 7- Description of Accident by Injured Person (Give full details). 8. Statement of Witness or Other Person Familiar with Accident- 9. Name and Location of Machine, Appliance or Thing Causing Accident- 10. Wtere Taken After Accident? 11. Name of Attending Physician 12. Probable Length of Disability 13. Date of Accident Hour 14. Date Reported to Doctor's OfEc 15. Remarks 16. If sent outside of Doctor's Office for treatment, state where sent, why, and when sent (date and hour) In case of operation or treatment of any kind, outside of Doctor's Office, full details must be given in space pro» vided on Final Accident Report. Signed- FiG. 27. — Report of accident. This record is made out in quadruplicate on all accident cases where time is lost. One copy is retained in employee's record, one is sent to the safety engineer, one is sent to the manager and the other is sent to the payroll department. 122 INDUSTRIAL MEDICINE AND SURGERY QUESTIONS 17 TO 32 TO BE FILLED OUT IN THE DEPARTMENT 17. Length of Service of the Employe. 18. Has He a Wife or Children? 19. How Long Engaged on This Work? 20. Was Injured Person Familiar or Not With the Work Engaged in, or With the Machinery Operated at the Time of the Accident?- 21. Instructed as to Its Hazards? 22. Has He Done Similar Work Prior to This Employment? 23. Was Accident Due to Want of Care on the Part of Injured Person?- 24. Was Accident Due to Negligence on the Part of Any Person? 25. If So, How? 26. Who Was in Charge of the Work Where Accident Occurred?- 27. Give Names and Addresses of Witnesses 28. Is Injured Person a Mer^ber of the S "M B. A. ? 29. Should S.. R & Co Pay Salary Durmg Disability' 30. Serial No 32. Remarks 31. Time Card No.. Signed- Date- Manager Dcpt.. A. E. & C. CHECKS ISSUft) FOR TIME LOST Chech Isftued For Week Ending Days Paid For Amonnt Check Issued For Week Ending DayaPaM For AmoDDt Check Issued For Week EadlDp DaysPatd For Amount Fig. 28. — Back of accident report to be filled out in the department. RECORDS 123 FINAL ACCIDENT REPORT. SUPPLEMENTARY TO ORIGINAL REPORT. 3. Department- . Emp. No 5. Nature of Injury . 4. Occupatio 6. Dateof Accidenl- 7. Date of Returning to Work — 8. Partial or Complete Recovery - 9. Amount ol DisabiLty (time). Fr< 10. Name of Attending Physician 11. Remarks 12. If taken to an outside hospital, fill out the following; Name of Hospital Date Nature of Treatment or Operation Attending Physician or Surgeon- Length of Time in Hospital 13. If given treatment outside of Doctor's Office or outside hospital, fill out the following: ■Where Treated . Nature of Treatment- Name of Physi Signed- FiG. 29. — Final accident report. This report is made out in quadruplicate on all accident cases where time is lost, when an employee returns to work. One copy is retained in employee's record, one sent to the safety engineer, one sent to the manager and the other is sent to the payroll department. 124 INDUSTRIAL MEDICINE AND SURGERY Date RLPORT OF NUR5L'5 CALL „ . , Kequesfed by_ Name Dept. _5. M. B. A._ Length of Service 1st Day Absent. Dr Address_ Instructive . .Nursing Remarks . F«9L9 To be made out in TRIPLICATL. Fig. 30. — Request for nurse's call. This is made out in triplicate by departments and sent to the doctor's office when requesting a nurse's call. One copy is retained in the doctor's office, one is sent to the department and the third is sent to the welfare department. The one retained by the doctor's office is filed according to date and kept for one month or until the monthly report is made out. If the doctors or nurses wish call or revisit made on an employee, they also fill out one of these blanks, dating it for the day they wish call to be made. It is then put in file for that day and is auto- matically handled at that time. CHAPTER XIII INDUSTRIAL HEALTH SERVICE A RESUME OF ITS GROWTH Hygiene, which is the science of health preservation, and deals with all the laws of sanitation, has developed a specific significance when applied to Industry. It includes plant sanitation, prevention of occupational diseases and most of the measures adopted for the super- vision of the health of employees. From the employer's standpoint industrial hy giene is now lecognized as the cornerstone of maximum production. From the standpoint of the medical man it is the cornerstone of preventive medicine. Industrial Hygiene, however, does not include the entire field of Industrial Medicine and Surgery — a mistake which apparently has been made by some workers in this field. The all-round Industrial Surgeon must have a clear understanding of these laws of industrial sanitation but he must also be a competent diagnostician and capable of treating disease and injuries. This form of public health service was rarely mentioned prior to fifteen years ago, but to-day it is receiving the attention of engineers, physicians and employers in general. Medical schools and engineering schools are teaching their students various phases of Industrial Hygi- ene. State Legislatures are enacting new laws to better the sanitary conditions of workmen. In fact, few subjects have received such widespread attention or have reacted for greater good to the nation in so short a time. In 1911 the author published the following statements in a booklet on Medical Work and Sanitation in Industry: "Industrial sanitation is practically a new subject. While it is years behind other forms of sanitation, such as the work of our municipal and state boards of health, the improvement of conditions in state prisons and asylums, and the United States Government meth- ods for the preservation of health among our soldiers and sailors, yet, in this country, during the last decade, some notable advances have been made tending to vastly improve the conditionsof the working men and women. Chief among these has been the creation of departments of Industry and Labor in many states of the Union. Through the work of these departments child labor has diminished, shorter hours (especially for women and children) have been obtained, women are 125 126 INDUSTRIAL MEDICINE AND SURGERY allowed to sit while at work and are surrounded by healthier and less demoralizing conditions, overcrowding of workshops has been greatly reduced, and employees are more and more protected from dangerous machinery and injurious gases and dusts. But, the advancement thus far along these lines is only a very small beginning, and a careful study of our various state labor laws reveals the fact that until these are made more stringent, very little can be accomplished for the bet- terment of health in our industries. "The report of the Department of Commerce and Labor for 1909 and the various state labor laws show that only twenty-one states have a section bearing directly upon the subject of factory and workshop sanitation. Alabama, Illinois, Massachusetts, Minnesota, Ohio, Ore- gon, Tennessee and West Virginia state that all workshops must have 'proper ventilation and proper sanitary conditions,' but none of these makes specific recommendations as to what constitutes 'proper.' The standard for these conditions is evidently left to the judgment of the State Factory Inspector — which is not always a good plan. The laws of Indiana, Maryland, New Jersey, New York, Pennsylvania and Wis- consin are somewhat better, because these states require that every employee within an enclosure must have a certain amount of air space, varying from 250 to 400 cubic feet per person. These states are also slightly more specific in their requirements for proper sanitary conditions. Illinois and New York have stronger laws than the few other states that mention it, dealing with the restriction of the sale of articles manufactured by diseased employees or made in unhealthy surroundings. Practically all of these states require that fans, blowers and suction pipes shall be installed in workshops where injurious gases or dust exist, to facilitate the removal of the same. Missouri and New Jersey require the painting or whitewashing of the interior of all workshops at least once a year. Missouri has a law against overcrowding of factories, which can be enforced if a certificate is obtained from any reputable physician that said factory is crowded to the extent that it is unhealthful. "Massachusetts alone requires the placing of cuspidors in all buildings where people are employed. But neither Massachusetts nor any other state legally stipulates how these cuspidors shall be cleaned or handled. It is, indeed, paradoxical that we have laws prohibiting spitting anywhere but in cuspidors, and yet there are no laws designat- ing how the contents of the same shall be disposed of. In most cases disposal is left to the whims of the porter in charge. The fact that the death rate from consumption is higher among porters than among any other class of workers points to the highly infectious nature of the contents of these cuspidors. Not alone the porters, but the whole community is exposed by the careless handling of these germ incu- INDUSTRIAL HEALTH SERVICE 127 bators where the flies dehght to feed. There is no state law in the country prohibiting consumptives from working in intimate contact with other employees, and only a few states specify that consumptives shall not be employed in bakeries or other places where food products are prepared. Even these do not provide for regular inspection of such employees by a physician in order to rule out the tuberculous. "This short resume of the various state labor laws in their relation to sanitation will certainly impress the layman, who is especially in- terested, as well as any medical man, with their great lack of preventive legislation, which, if enacted and enforced, would greatly reduce the death rate among the wage earners, and at the same time improve the hygienic and economic conditions of every community." Since the above was published almost every state in the Union has enacted laws seeking to improve the working conditions of employees. Thirty-seven of our states now have laws on Employees Compensa- tion. Recently some of these states have included occupational dis- eases under the causes for compensation. To-day at least four of the states are considering laws for sickness insurance for workmen. All of these laws, enacted for the benefit of employees, have improved industrial health conditions to a great extent. Yet, we can repeat our statement made in 1911, that a resume of the laws must impress one with the lack of preventive legislation, which if enacted and enforced, would greatly reduce the death rate among wage earners. If the legislative advancement along these lines has been rather slow, the voluntary advancement of industrial hygiene by many of our large concerns, by national organizations and by a few state departments of Industry and Labor has been very rapid. Prior to 1909 a few state factory inspectors and a few other indi- viduals had called the nation's attention to the wastage of human Ufe by some of the more flagrant unsanitary conditions in industry. About this date there seemed to be a great incentive given to the subject by the writings of a number of physicians connected with industrial concerns. The studies of Dr. Thomas Crowder on ventilation, of Dr. Alice Hamilton on lead poisoning, of Dr. J. W. Schereschewsky, and of Dr. George Price on health conditions among garment workers, and of men like Dr. E. R. Hayhurst and Dr. Francis Patterson working in connec- tion with the departments of Industry and Labor of the states of Ohio and Pennsylvania respectively, stand out as milestones in the advance- ment of Industrial Health in this country. Extending inspection to the employees themselves, by physical examinations, as well as the inspections of their working places, was one of the greatest advances ever made in health supervision in this country. In 1906 Dr. Frank Fulton, in Providence, R. I., examined a number of 128 INDUSTRIAL MEDICINE AND SURGERY employees free of charge for the purpose of discovering tuberculous workers. This is one of the first examples recorded of a careful effort at supervision of the health of workmen. In 1909 Mock started the examination of employees in the concern of Sears, Roebuck & Company, of Chicago, for the purpose of discovering the tuberculous. It soon became evident that such a procedure revealed many other diseases, which, taken in their incipiency, could be checked. This fact, because of its economic basis, became one of the strongest arguments in favor of the physical examination of employees. Similar reports setting forth the benefits of this practice were made during the next few years by Dr. Irving Clark of the Norton Grinding Company, Worcester, Massachusetts, by Dr. Otto Geier of the Cincinnati Milling Machine Company, by Dr. Wilbur Post, of the Peoples Gas Co., Chicago, by Dr. C. G. Farnum of the Avery Company, Peoria, Ill- inois, by Dr. S. M. McCurdy, of the Youngstown Sheet and Tube Company, by W.G. Hudson, of the Du Pont Company, and other work- ers in this field. By 1914 physical examinations of employees was a fixture in many industries. The Committee on Factories of the Chicago Tuberculosis Institute, composed of Drs. James Britton, Theodore Sachs and Henry Faville, was instrumental in extending this system to a number of the other industries of Chicago. Their report on this work, presented before the National Tuberculosis Association in 1914, gave a marked impetus to this branch of Industrial Hygiene throughout the country. Since then the National Tuberculosis Association has been a stanch advocate of this form of medical work. With the formation of the National Safety Council such physicians as Geier, Patterson, A. M. Harvey, Farnum, Irving Clark, Mock, McCurdy, C. A. Lauffer, L. A. Shoudy and others, pointed out the need of improving the hygienic conditions of the workmen as a definite part of any accident prevention program. As a result, this great organiza- tion formed its Health Service Section in 1914, which has been instru- mental in improving sanitation in so many of our large industrial concerns. In the American Public Health Association Drs. W. A. Evans, E. T. Fisk, Alice Hamilton and others were among the first to recognize the influence of this form of public health work, and with some 50 other physicians formed the Section of Industrial Hygiene in that organization during the fall of 1914. For years the American Medical Association had frowned on the contract practices and other types of work of the company surgeon. The standard of this work in many instances had been far below par. But public recognition of this new specialty of industrial medicine was given in 1915 by this association. In the annual meeting of that year INDUSTRIAL HEALTH SERVICE 129 the Preventive Medical Section of the American Medical Association, Dr. Otto Geier, Chairman, had a symposium on industrial Hygiene. Since then industrial medicine and surgery has had a place on every annual program of that section. In addition, this year the Orthopedic section of the American Medical Association had a symposium on industrial surgery. The recognition of this work by the leading mem- bers of our profession testifies to the higher professional standard which it has attained. In the East, a number of physicians in 1914 formed the Conference Board of Industrial Physicians, under the secretaryship of Magnus Alexander. Many of the leaders in industrial medicine and surgery are numbered among its members. Some of the greatest contributions to industrial hygiene have been made by this group. In the West, such men as Dr. R. W. Corwin, of Colorado, Drs. Tucker, Philip King Brown and Robert T. Legge, of California, Dr. J. R. Yocom, of Washington, and others, have been responsible for improving condi- tions in the mining and lumbering industries. Recognizing that the public health of the nation was being influ- enced to a very marked degree by these various efforts of local and national organizations, the U. S. Public Health Service formed its divi- sion of industrial sanitation. With such men as Schereschewsky, C. F. Rucker, B. S. Warren and A. J. Lanza in the Public Health Service, and such consultants as David Edsall, Price, Oilman Thompson, A. S. Stengel, C. D. Selby, and others, great progress has been made during the last five years in improving health conditions among employees engaged in certain industrial lines where the health hazards have been excessive. Likewise, the U. S. Department of Labor has rendered most valuable servicetothecountiy through the work of Drs. Alice Hamilton, Royal Meeker, L. P. Cheney, and others. These workers and their assistants have made exhaustive studies along various lines of industrial sanita- tion. Their work on occupational diseases, accident hazards, fatigue, ventilation, lighting and numerous other subjects, has formed a basis for correcting faulty conditions in many kinds of industry. The Bureau of Mines has been engaged in a similar service in the mining industries of the country. These efforts of the National Gov- ernment to improve the hygienic conditions of the employees of the nation's industries are most praiseworthy. They mark the beginning of what must finally come to pass — a centralized supervision of health conditions throughout the country, not only among industrial employees but in all walks of life. It is to be deplored that several Federal departments are engaged in this work, as at present. The desire to justify appropriations, to secure credit for doing a piece of work, and certain interdepartmental 130 INDUSTRIAL MEDICINE AND SURGERY jealousies which prevent proper co-operation between departments, all tend to duplication of effort and retardation of results. There is no doubt that certain angles of this work has to do directly with the question of labor. But the chief problems of indus- trial hygiene are primarily health problems and should be centralized under that federal agency which is responsible for the public health of the nation. In 1916, recognizing the great need of uniting to secure the greatest advancement in these health problems in industry, the physicians and surgeons of the country, engaged in industrial medicine and sur- gery, organized the American Association of Industrial Physicians and Surgeons. The men, who during the preceding eight or ten years, had been striving alone or in subsections of other organizations, now met for the first time as a united group with a common purpose. The combined efforts of this association has undoubtedly done more to raise the standards of the physician engaged in industrial practice, and to increase the benefits from this work to both employees and employers, than any other one agency which has entered this field. During the last five years medical schools have recognized the great opportunity for service offered to physicians in the field of in- dustrial medicine and surgery. Doctor Legge, at the University of California, started a course on Industrial Hygiene which has become very popular with all the students. Hayhurst instituted a similar course in the University of Ohio. Stengel at the University of Pennsylva- nia, and Thompson at Cornell, introduced the subject of occupational diseases in the curriculum of those schools. Harvard, co-operating with the Massachusetts General Hospital, has held clinics on occupa- tional diseases for several years. Mock at Rush Medical College, some three years ago, started a night clinic on industrial medicine and surgery. It has had the strong support of such men as Billings, Herrick, Dodson, Ellis and others, and is now recognized as one of the great sociologic movements of Chicago. This course affords the stu- dents a very broad training in every phase of work encountered by the physician in industrial practice. No one effort put forth by medical schools will yield so great a return in benefits to the nation's health as these courses on industrial medicine. A great many other men, both physicians and laymen, have had an important part in developing this great public health movement. Through their efforts industrial medicine and hygiene have become most potent factors in the Industrial life of our nation. Never again will we return to those dark ages when the human machine was driven to the limit without lubrication or repair and simply "scrapped" when disease, often the direct result of the occupation, robbed it of further usefulness. INDUSTRIAL HEALTH SERVICE 131 The physicians and other workers in industrial hygiene cannot cla-im all the credit for the developments that have taken place in this field. Some of our large corporations, without the help or advice of medical men, have voluntarily started improvements in the working conditions of their employees. The work of the National Cash Regis- ter Company, at Dayton, Ohio, will always stand out in the industrial history of our country as one of the pioneer efforts to improve condi- tions for the comfort and welfare of the employees. There may be many criticisms of the system adopted by that concern, but neverthe- less its example and influence was a great stimulus to other em- ployers to take a more humane attitude toward their people. In more recent years the Ford Motor Company has adopted a broad economic and sociologic policy toward their employees which has for its very foundation most of the principles of industrial hygiene. They have found it necessary to form the closest co-operation between their sociologic department and their medical department. In fact, in very few concerns is the medico-sociologic aspects of this work in industry more clearly demonstrated. The housing experiments of the United States Steel Corporation are well known, and mark a decided advance in industrial hygiene. Many other concerns in this country have recognized the relation- ship between improved home conditions, better health and increased production. As a result of these combined efforts of individuals, organizations, and certain employers on the one hand, and of the various state and federal agencies on the other, we are able to point to approximately 8,000,000 of the workers of the nation who are receiving the benefits of this enlightened era in industry to a more or less degree. There still remain about 30,000,000 of our people who are responsible for pro- duction of some type in this country who are not receiving any kind of health supervision. Many of these are working under intolerable conditions. The amount of child labor still in use is unbelievable. The lack of protection against the commonest forms of occupational diseases is appalling. Even in many of those concerns where maximum production is so essential at this time for the winning of the War we find inadequate housing conditions, unsanitary factory conditions, prevalence of occu- pational diseases, and a high accident rate due to speeding up and "green hands." The labor turn-over in some of these concerns is over 500 per cent. To counteract this labor turn-over higher and still higher wages are being paid^ — often defeating their purpose by increas- ing turn-over. Even patriotism cannot overcome the bad influence on the working man of such intolerable conditions. The adoption of the sane principles of industrial hygiene by these 132 INDUSTRIAL MEDICINE AND SURGERY concerns is already taking place. The shipbuilding yards, under the direction of Major Philip Doane, M. C. U. S. A. and later under the direction of the U. S. Public Health Service, are completing a com- prehensive system in every yard. The housing bureau is beginning to improve the living conditions of these men. The United States Public Health Service, the National Research Bureau and the Commit- tee on Hazardous Occupations of the Department of Labor are all working to improve the protection afforded to munition workers, and others in war industries, against occupational diseases. Thus, under the stimulus of war, industrial medicine is making its greatest advances. Decreased sickness, decreased accident rate, de- creased labor turn-over have already resulted in increased production. Production everywhere is the most vital need of the day. On it depends the victory or defeat of our armies. Those concerns which continue to waste their man power with a resulting diminution of output should be Commandeered. Conservation of man power with maximum production is the battle cry of the country. The adoption of Industrial Health Services by every industry is the answer. Part II PREVENTION CHAPTER XIV PREVENTIVE MEDICINE AND PREVENTIVE SURGERY IN INDUSTRIES Industrial medicine and surgery consists of applying the general principles of medicine and surgery to a large group of people as a unit. While individuals receive special medical or surgical care when- eVer needed, yet it is apparent in every chapter of this book that prevention is the keynote of all this work; -prevention of diseases or accidents among the entire group of employees; prevention of undue loss of time when injury or disease assails an employee; prevention of deformities and permanent disabilities, the result of diseases or acci- dents; prevention of inefficiency on the job when traceable to some physical condition; in fact, the prevention of everything which would tend to undermine the physical or mental welfare of the individual or of the entire group of employees. In order to accomplish this many of our largest industries have developed large staffs of capable physicians and surgeons who spend half or all of their time at the plant. Here by being on the job — in the front line trench of industry — they are not only in the strategic position to study and apply every phase of prevention, but also to practise the best form of prevention, namely, immediate and proper medical and surgical care for every sick or injured employee. It is quite evident therefore that industrial medicine and surgery must include many activities aside from the specific treatment of disease. As the various chapters deal with some phase of prevention we will endeavor here to give only an outline of the preventive work with which the industrial surgeon must familiarize himself in order to become proficient. Thinking of the work therefore in terms of prevention we must consider first, the employees; second, the physical conditions of the plant; third, the activities of the concern. 133 134 INDUSTRIAL MEDICINE AND SURGERY I. PREVENTION AMONG THE EMPLOYEES A. The applicants for work: 1. Complete physical examination of: (a) To protect the old force from men capable of spreading disease among them. (6) To prevent the diseased applicants from going to work when work of any kind would be injurious to them, (c) To prevent applicants with physical handicaps from being placed at hazardous work for them, or at jobs where they could not be efficient. 2. Acquainting the applicants with all forms of disease and accident prevention measures in operation in the plant immediately upon employment. (a) This prevents disaster because of ignorance. (6) They at once become co-operative units with the existing system. B. The old employees: 1. Complete physical examination of, either periodically or whenever some condition arises showing the need of a general survey. (a) To discover threatened disease early, while still prevent- able or curable. (6) To discover any existing condition that makes the em- ployee prone to accident or to cause accident to others. It is just as important to survey the human machine to prevent accidents as it is to survey the mechanical appli- ances of the plant. (c) To rule out those with contagious conditions to prevent spread of disease. {d) To discover those with handicapped conditions, either physical or mental, and to place them at types of work which will not be hazardous for them and where they can still be efficient in spite of the handicap. (e) Examination should precede the treatment of any con- dition, no matter how minor, thus preventing the admin- istering of the wrong type of treatment through lack of knowledge of the true condition or coincident disorders. 2. Secure the co-operation and interest of employees in your efforts for prevention of disease and accidents by : (a) Explaining the reasons for any action taken, to each individual. (6) Secure team work by employees' committees on "accident prevention," "disease prevention," "sanitation move- PREVENTIVE MEDICINE AND SURGERY IN INDUSTRIES 135 the committees fre- often. Make them merits." Add new members to quently and meet with them working committees, (c) Spread prevention propaganda on every phase of the subject throughout the working force by personal con- ferences with individuals, by lectures and motion picture shows, by use of bulletin boards, by terse facts printed on backs of pay envelopes, by circulars inserted in pay envelopes, by a plant paper or bulletin issued weekly. (d) Get the officials of the concern interested and use their influence to put across the ideas. Fig. 31. — This toilet caused 17 cases of typhoid, two of them fatal. Loss in wages and care of the 17 men amounted to $3000.00. (Typhoid Bulletin, issued by Industrial Surgeons' Association of Washington.) (e) Assist the diseased employees at all times in securing the best forms of treatment, thus demonstrating your friendly interest in them. These become "medical missionaries" throughout the working force. 3. Study the relationship between employee and his work: (a) Study this relationsip in every case coming before you to ascertain if "a round peg is fitted in a round hole, " or if the work is incompatible to the employee's mental or physical well-being. This will not only prevent a phys- ical or nervous breakdown often but will prevent in- efficiency in production — an inefficiency preventable by transferring the man to work for which he is better qualified. 136 INDUSTRIAL MEDICINE AND SURGERY (h) Fatigue poisoning from overwork, from monotony of the same and rapidly repeated motions and other causes, will be discovered and can be prevented. Occupational diseases, and latent possibilities for such diseases in occupations heretofore unsuspected, will thus be found, and steps taken to prevent them. Suggestions for the prevention of accidents will follow, a study of this relationship of man to his work. 4. Study the relationship between employee and fellow employees: (a) Incompatibility between an employee and his foreman or some fellow employee may be the cause of a nervous or physical breakdown. The doctor, if he secures the con- (0 id) Fig. 32. — "Same toilet as in Figure 31 rendered safe and fly-proof at cost of less than $5.00 — after the epidemic. Why not before?" The Industrial Surgeons' As- sociation of Washington has carried on an unceasing warfare against typhoid fever among the lumbermen of the Northwest. fiderices of all employees, may be the first to discover such a condition and by reporting it to the proper authorities can prevent both inefficiency and the threatened break- down. (6) Among girl employees one given to infrequent bathing with resulting bad odors may be the cause of nervousness and unrest among the other employees — a condition which the doctor is often called upon to correct and which demands diplomacy in handling. (c) A close study of this relationship is necessary to prevent many diseases, many accidents, and much inefficiency. 5. Specific preventive measures rendered employees: (a) Search for focal infections and removal of same — special- ists such as dentists, nose and throat men will be needed on the staff for this work. PREVENTIVE MEDICINE AND SURGERY IN INDUSTRIES 137 (&) Recommending vacations, change of work, special treat- ment and other specific measures to prevent more serious conditions from developing. (c) Vaccination and specific inoculations against disease, as antityphoid prevention. (d) Fumigation of working rooms after an employee is found with some contagious disease. (e) Recommending proper and immediate treatment for all conditions found and supervising the employee to see that same is carried out. I. Employees' home conditions: (a) Unsanitary home conditions, home worries, sickness in the family, and many other conditions may be the cause of an employee's physical or mental breakdown. The doctor musb subtly study these conditions and suggest needed remedies as a part of his prevention program. Assistance must often be obtained from the employer to correct many of them. (6) The employees must be taughb to report contagious dis- eases in their family in order that the doctor can safe- guard the fellow employees. (c) Friendly interest in and constructive help to the members of an employee's family always react favorably on the health and productivity of an employee, and therefore is a definite part of the prevention program. n. PREVENTION AS RELATED TO THE PHYSICAL CONDITIONS OF THE PLANT Industrial Hygiene: 1. This deals with the hygienic and sanitary conditions of the working place. These must be brought to the highest stand- ards in order to prevent disease among the employees as a result of working conditions. This involves a study of the sanitary arrangements of the following and correction when necessary : (a) The construction of the building. (h) Arrangements for Ughting and ventilation. (c) Cleaning of the interior of the buildings. (d) Washing and toilet facilities, (e) Removal of fumes and dust. (f) Removal of refuse that would tend to breed flies, mos- quitoes, and other disease agencies. 138 INDUSTRIAL MEDICINE AND SURGERY (g) Drainage, and sewage disposal. (h) Proper protection of employees from fumes, or direct contact with material that is detrimental to health, and all other forms of protection from occupational diseases. B. Accident Prevention: 1. Changes in construction of building so that dangerous stair- ways, unprotected elevator shafts or light shafts, unprotected platforms or other elevations, narrow halls, sharp corners, doors opening the wrong way, or similar conditions, will not tend to cause accidents. Fig. 33. — Shell filling factory in England. Cleanliness, good ventilation, proper lighting, concrete floors, and respirators aid in production by preventing disease. 2. Repair of all broken boards in floor, broken window panes, loose parts in walls or ceiling, or other dangerous conditions about the building 3. Removal of loose nails, boards, broken glass, broken parts of machinery, tools and all obstacles so placed as to cause accidents. 4. Careful arrangement of stock, boxes, cases, etc., so that they will not fall and cause injury. 5. Repair of all tools, machinery, and appliances used in work so that accidents will not occur to the user of the parts or to fellow employees. 6. Safeguarding all machinery and other physical appliances PREVENTIVE MEDICINE AND SURGERY IN INDUSTRIES 139 about the plant with special safety apparatus whenever possible. 7. Protection of individuals from potential accidents when their work is hazardous by the wearing of special appliances as goggles, gloves, etc. 8. Frequent inspections of the physical conditions of plant com- bined with inspection of physical conditions of the human machines — the employees — will result in the prevention of the majority of accidents. C. Fire prevention, protection from explosions, from collapse of buildings and other disasters of like nature have never been considered a feature of medical or surgical work, but the in- dustrial surgeon, responsible for the health and safety of the employees, must likewise become an expert in the prevention of these disasters. m. PREVENTION AS RELATED TO THE ACTIVITIES OF THE INDUSTRY A. General rules of prevention as above laid down are applicable to all employees and to the physical conditions of all industries. But the industrial surgeon by a study of his special industry and the nature of the work carried on will discover many specific preventive measures which he must employ. B. The railway surgeon will meet with traffic and transportation accidents which must be prevented. The physical condition of each employee must be carefully studied to see that he is not a potential cause for accidents to others. C. The mine surgeon will need to study the hazards from gases, and other conditions pertinent to mine workers. D. Munition manufacturing has introduced the need of medical men highly trained in the prevention of certain forms of poisoning. E. The physician in charge of merchandizing concerns or of large office forces must study and prevent disease from overcrowding, from sedentary working habits, from poor ventilation. F. Thus, the industrial surgeon must at the earliest opportunity acquaint himself with the activities of the industry as a whole and of each employee in order to competently meet his specific problems in prevention. From a study of the above outline it is quite evident that prevention forms the very foundation of all industrial medical and surgical work. The industrial surgeon who neglects to approach his job from this angle is failing in his responsibilities to both the employee and employer. 140 INDUSTRIAL MEDICINE AND SURGERY The shortsighted policy of providing the cheapest kind of medical treatment to the injured or occupationally diseased employee without expending any money on the prevention of these conditions is rapidly becoming a thing of the past. The employer is realizing that cheap medical care is often the most expensive and that it is far more eco- nomical to prevent than to repair. The company surgeon of the future must be thoroughly trained in preventive medicine and preventive surgery in their broadest aspects. CHAPTER XV INDUSTRIAL HYGIENE A GENERAL OUTLINE OF THE PROBLEMS Every industry has its specific problems of industrial hygiene which the surgeon in charge must endeavor to discover, master and correct or improve wherever possible. Frequently some one of the official inspectors from the United States Public Health Service or from the Department of Labor report that the plant physician in a certain industry ''did not know there was even an opportunity for lead poisoning in the processes carried on there;" or, "he didn't know a case of phosphorus poisoning when he saw one;" or, "he resented the statement that there were dust and fume hazards. " Ignorance such as this on the part of the physician who is constantly on the job, and should therefore be the best informed in regard to local conditions, is inexcusable. It reflects upon the en- tire group of industrial physicians and surgeons. Unfortunately, the reputations of many company physicians in the past have been of the lowest standard professionally. Efforts to elevate the character and good name of this group of medical men by having their work recognized everywhere as of the highest standard are being made. Each surgeon in industry must do his part. It is the solemn duty of every plant physician therefore to so im- prove the sanitary and other health conditions in his industry to the end that : the employees will have the greatest possible protection, the employers will receive the greatest possible benefits from these im- proved conditions, and the health work in the plant will be a model to others. Such an effort on the part of every company physician would be the greatest public health movement ever inaugurated in this coun- try, and the men responsible for such a movement would take their places in the foremost ranks of our profession. It is impossible to discuss all the specific problems of Industrial Hygiene which each plant physician will encounter in his industry, but the general conditions which must be considered in every case are herewith outlined. Industrial Hygiene Problems to be considered in every concern come under one of these four groups : the nature of the industry, the physical conditions of the plant and its surroundings, the physical 141 142 INDUSTRIAL MEDICINE AND SURGERY condition of the employees, and the health conditions of the community. I. Nature of the Industry and the various Processes and Occupa- tions carried on : A. What specific health hazards are present? 1. A study of all occupations, the material handled, the processes and motions involved and every other considera- tion which could influence health is necessary, B. Hours of Work: 1. Are they excessive, acting as a detriment to health of employees? 2. Are rest periods, changes of occupations and other pro- cedures allowed so as to avoid fatigue? 3. Is the night work especially hazardous to the employees? 4. Are Sunday and holiday rests observed? 5. Are washing periods, periods for going to toilet and other needed rest periods taken on company time? 6. Are the employees content with these conditions? C. Nature of the Work: 1. Is the work of such a nature as to cause constant over- exertion? 2. Are labor saving devices utilized wherever possible? 3. Are the employees instructed in the best methods of doing the work so as to avoid hazards? 4. Are "bell-cow," "pacemakers" or driving methods used which may add to the exertion, nervous strain, or other fatigue conditions of the employees?^ Is "piece-work," as carried on, detrimental? 5. Are safety devices used? 6. Are protection methods against occupational diseases, such as respirators, dust exhausts, hoods for removal of dangerous gases and fumes and all other devices in place and used by the employees? 7. Are the hazardous processes separated from the non- hazardous so that the employees in the latter are not unduly exposed? 8. Have you made careful studies to discover other occupa- tional hazards, not usually classified in dangerous occu- pations, and reported the same? 9. Have you carefully instructed the management and em- ployees in all hazards represented by their work and the *The "bell-cow" is the fastest worker in a department pointed to as an ex- ample for the other employees. INDUSTRIAL HYGIENE 143 best means of prevention? Are new employees instructed in the same before going to work? D, Wages: 1. The right of the plant physician to be concerned in wages is often questioned by the management. However when insufficient wage is a direct or indirect cause for lowered health conditions among the employees it is the duty of the plant physician to point out these facts to the manage- ment. Such data should be carefully prepared and be irrefutable. II. Physical Conditions of the Plant and its Surroundings: A. Nature and Construction of Buildings: 1. Purpose building is used for? 2. Type of construction? (a) Is it sufficiently well built to standj the stress and strain placed upon it? 3. Are the stairways strong, sufficiently wide, adequate and protected against falls? 4. Are elevators adequate, inspected and sufficiently protected? 5. Floors: (a) Type of construction and nature of supports? (6) If wooden do they absorb dangerous material which may be given off in form of dust thus adding to hazards? (c) Are they level and well drained? (d) Are they clean? Is cleaning process done with least dust hazard? (e) Are they kept in good repair? 6. Walls and Partitions: (a) What is nature of construction? (6) Are the rooms divided by too many partitions thus making dark corners and non-ventilated areas? (c) Are the walls, partitions and ceilings clean and of proper color to be least injurious on eyes? (d) Are ceilings too low? (e) Are the rooms unnecessarily damp? 7. Fire Protection: (a) Are means of escape from buildings in case of fire adequate? (6) Is there a sprinkler system? (c) Are fire extinguishers provided and in sufficient num- bers? 8. Is the building kept in a sanitary condition? 144 INDUSTRIAL MEDICINE AND SURGERY B. Surroundings: 1. Is the building located in a sanitary place? 2. Are the grounds clean, well drained and kept free of refuse and other material detrimental to health? 3. Does proximity of other buildings interfere with ven- tilation and sanitary conditions? 4. Do dangerous fumes, dusts, etc. from nearby industries interfere with health conditions in your plant? C. Ventilation: 1. Is there overcrowding of the rooms or is air space suf- ficient? 2. If ventilation is natural is there sufficient window space, stairway space and elevator and air shafts to furnish adequate ventilation? (a) Are these spaces kept unobstructed? 3. Is there any artificial ventilation system used? (a) Are the suction fans and conducting pipes adequate? (6) Are blower systems installed over dust producing processes adequate? (c) If air is washed and used again is process satis- factory? (d) Does use of natural system with artificial interfere in latter? If so, which is best system to use? (e) Is the foul air, dust, etc. discharged so as not to re- enter open windows again? D. Humidity: 1. Any artificial means needed to keep humidity at proper ratio to temperature? 2. Are "wet-bulb" thermometer tests made frequently? E. Temperature: 1. What is nature of heating plant? 2. Is temperature kept fairly constant? 3. Is there exposure to excessive heat and cold? (a) What precautions are taken to protect employees in this case? 4. Is an expert on ventilation, temperature and humidity employed or consulted to make sure that these are ade- quate? r. Fumes and Gases: 1. If present from any of the processes are proper arrange- ments made for their removal? 2. Are the employees in other parts of the building pro- tected from these? 10 INDUSTRIAL HYGIENE 145 G. Dusts: 1. Are proper facilities employed for removal of same? 2. Are employees in dusty occupations protected by res- pirators? 3. Are frequent changes from dusty occupations permitted the employees? 4. Is dry sweeping permitted? 5. Have you made a careful study of the hazards of the specific dusts in your industry? H. Illumination: 1. Natural: (a) Is the number of windows and light shafts sufficient? (6) Are the windows kept clean? 2. Artificial: (a) Direct or indirect lighting system? (6) Are the lights properly placed and of uniform type? (c) Are the bulbs and lamps kept clean and properly shaded? (d) If spot lights are used do they interfere with adjacent employees, adding to their eye-strain? (e) Are dark areas where employees must pass through illuminated ? 3. Do employees complain of eye-strain and other effects of inadequate lighting? I. Excessive Noises : 1. Have efforts been made to reduce excessive noise? 2. Are the excessively noisy occupations separated from the other processes? 3. Have you studied the effect of these noisy occupations upon the employees engaged in the same, especially as to hearing? 4. Are the employees engaged in the sedentary work re- moved from the strain of excessive noise? J. Protection against spitting and refuse: 1. Are instructions against promiscuous spitting ample and enforced? 2. Is sufficient number of cuspidors provided? 3. Are these cleaned daily and is the cleaning thorough? (a) Are they handled by hand or are the porters protected from handling the same? (&) Is any effort toward sterilization made and is this successful? 4. Are receptacles for refuse provided and are these removed and cleansed daily? 146 INDUSTRIAL MEDICINE AND SURGERY INDUSTRIAL HYGIENE 147 5. Are provisions made for the obtaining and disposal of sanitary napkins by women employees? K. Washing Facilities: '■ 1. Is running water provided? 2. Is number of faucets sufficient for number of employees using them? 3. Are stationary bowls or troughs with continuous flow used and which is safer in your industry? 4. Are arrangements made for cleansing stationary bowls? 5. Are shower baths provided when necessary? 6. Are individual towels and soap furnished the employees or do they provide these for themselves? Has the use of roller towels been abandoned? 7. Are the wash rooms clean, light and located near the toilets and locker rooms? 8. Have the employees been instructed in the need of wash- ing before eating? L. Toilet Facihties: 1. Are sufficient number of toilets provided? 2. Are they clean, light, well ventilated and kept in good re- pair and in a sanitary condition at all times? 3. Are they inspected daily? 4. Have all modern improvements furnishing protection against disease been made? 5. If privies are used are these plentiful, clean and protected from flies? Are they sufficiently removed from working places? 6. Is sewage removal suitable and sanitary? M. Locker Facilities : 1. Are the best type of lockers furnished? 2. Is the locker room airy, light and kept clean? 3. Is the smell from sweaty and dirty clothes obnoxious? 4. Is any arrangement made for drying the clothes if soaked by rain or snow on the way to work? (This is especially helpful in the case of women employees.) 5. Are the locker rooms periodically fumigated? N. Eating Facihties: 1. Is a plant restaurant operated? 2. Is food prepared under best sanitary arrangements? 3. Are the chefs, waitresses and others handling the food periodically examined? 4. Are frequent inspections made ? 5. If no restaurant at plant then is a proper place for eating of lunches provided? 148 INDUSTRIAL MEDICINE AND SURGERY 6. Is an effort made to get employees out of working rooms at lunch hour? 0. Drinking Facilities: 1. Has the source of water supply been ascertained and in- spiected? 2. Has the water been chemically and bacteriologically ex- amined and made safe? 3. Is it protected from pollution? 4. If a storage tank is used is it kept clean? 5. Is the use of common drinking cup abandoned? 6. Are bubbling fountains used and, if so, of a type to pre- vent spread of disease? 7. Is number and location of drinking places adequate and properly distributed so that employees will be furnished all the water needed? P. Recreational Facilities: 1. Does the industry provide athletic fields, gymnasium, recreation rooms, library and other facilities for the em- ployees to secure proper and necessary recreation? 2. Do the employees take advantage of them? 3. Does the medical staff take an active interest in them? Q. Rest Rooms: 1. Are rest rooms with cots furnished for employees need- ing them because of fatigue or sickness developing while at work? (These are especially needed by women employees, but should be provided for men also.) 2. Are these placed in the most restful surroundings? 3. Is a proper person in attendance? R. Doctor's Office and First Aid Station: 1. Is the number of employees and the nature of the work sufficient to warrant a central doctor's office at the plant? 2. Are first aid stations needed in other parts of the plant? 3. If no doctor's office is needed then is a first aid station provided? 4. Is the equipment of the doctor's office and aid stations sufficient for the best work? 5. Are the first aid men carefully instructed in their duties? 6. Are they used for first aid only, or is an effort made to have them replace doctors — a cheap form of service? III. Physical Conditions of the Employees: A. Physical Examinations: 1. Are the applicants for work examined and assigned to jobs according to their physical qualifications? INDUSTRIAL HYGIENE 149 2. Are the employees examined periodically when engaged in • occupations with disease hazards? 3. Are all old employees examined at intervals? 4. Is the working force protected from the diseased fellow em- ployee when necessary? 5. Is a careful study made of the relationship between occupa- tions and the employees physical and mental make-up? B. Medical Care: 1. Is every preventive measure against both disease and injury installed and in use? 2. Is complete medical care furnished the employees and is this the best system? 3. Is proper supervision of the sick employee maintained to see that he receives the best treatment possible? • . 4. Is the medical staff competent and sufficient in number? 5. Are proper hospital facilities arranged for? 6. Are competent industrial nurses employed? C. Provisions for Contagious Cases: 1. Is there any plan in force to discover contagious diseases early? 2. Are contagious cases isolated while awaiting transportation home? 3. Is the public properly protected against these contagious cases during their transportation home? 4. Are the rooms where contagious cases develop fumigated? D. Recreation, Vacations, etc.: 1. Is proper recreation prescribed for employees to counteract fatigue and other work conditions? 2. Are vacations recommended to prevent threatened break- downs? 3. Are occupations changed on recommendation of physician to prevent breakdowns? E. Have the employees been properly instructed in all matters tending to improve health conditions? F. Are the employees vaccinated, inoculated against typhoid fever or other diseases? G. Are* efforts made to relieve the employees of worries over sickness, debt and other family conditions? H. Has every effort been made to secure proper co-operation be- tween the management, the employees and the medical staff to improve health conditions? IV. Health Conditions of the Community: A. Co-operation between municipal health department and the medical staff of the industry: 150 INDUSTRIAL MEDICINE AND SURGERY 1. Are contagious diseases properly reported? 2. Does the health department notify the plant physician of contagious diseases in the families of employees? 3. Do you co-operate with the health department to improve conditions about the plant and its surroundings? 4. Do you interest yourself in the health conditions of the community? B. Home Conditions: 1. Are efforts made to improve the housing conditions of the employees in your industry? 2. Do the nurses visit the homes of employees and endeavor to improve conditions therein? C. Community Conditions: 1. Does the management interest itself in community organiza- tions such as churches, schools, hospitals, clubs, Y. M, C. A., Y. W. C. A., amusements, etc.? 3. Are proper hospital, dental and medical facilities furnished the families of employees? 4. Are there restrictions on saloons in the neighborhood of the industry and other protective measures against the excessive use of alcohol? D. Is there co-operation between local industrial concerns to secure the best possible conditions in the community as regards the health, comfort and welfare of all wage-earners? No physician in charge of the human maintenance department of an industry has fulfilled his mission until he has carefully considered the above problems in their relation to his work and taken steps to provide for their best solution. The succeeding chapters will set forth in more or less detail some of the specific problems met with in industrial hygiene. CHAPTER XVI INDUSTRIAL HYGIENE SPECIFIC PROBLEMS For the technical discussion of many of the specific problems of industrial hygiene the reader is referred to the various works on sani- tary engineering. In fact physicians will find that sanitary engineers are of the greatest value in establishing high standards of hygiene and there should be much closer co-operation between the two professions. In the army, sanitary engineers working with the medical officers have proven invaluable in developing military sanitation. Such engineers are already a definite part of the organization of many industries. Dr. Paul Fox, who has devoted considerable time to the plant sanitation in one of the large industries of Chicago, has achieved excel- lent results by practical methods of meeting many of these problems. The author is indebted to him for most of the data concerning ventila- tion and disinfection. Fox says, "the underlying principles and the question of right and wrong in sanitation are distinctly a part of the physician's work. It is therefore imperative that he have some knowl- edge of the essentials of sanitation." Ventilation By ventilation we mean the supplying of air in sufficient quantities and of proper quality to make the room a healthful place in which to work. Perhaps no one factor reduces the efficiency of a workman so noticeably as does the lack of proper and adequate ventilation. "Bad air" causes many complaints among employees and often causes an entire department to lag behind in its production. It is therefore of great economic value to have the room so ventilated that the air will always be comfortable and invigorating, thus avoiding any mental or physical depression. In main we may say that a comfortable atmosphere is a healthful atmosphere, so that our problem, therefore, is largely one of making the room comfortable for the particular type of work which is being done. In order to have a clear understanding of what constitutes "bad air," it is necessary to have some knowledge of the normal function of air, and of the means by which these functions normally maintain body comfort. 151 152 INDUSTRIAL MEDICINE AND SURGERY It is commonly known that air has two principal functions; one, is the physical, and the other chemical. By the physical property of air we mean the absorption or regulation of the body heat, while the chemical property, is the organization or the supplying of oxygen to the blood. If the air in a room is not constantly changed it soon becomes unable to perform either of these functions. The oxygen gradually is exhausted and the air becomes of such temperature and humidity that it is impossible for it to absorb the body heat. It has been thoroughly demonstrated that the physical factor causes distress far in advance of the chemical — in other words, a fault in the tempera- ture, humidity or motion of the air will cause distressing symptoms, long before the lack of oxygen or the excess of carbon dioxid becomes apparent. Cojn plaints of "bad air" are therefore in the vast majority of causes due to the fact that the air in the room is of such quality that absorption of body heat is retarded. The former theory that "bad air" was air in which the oxygen was deficient or the carbon dioxid in excess, has long since been abandoned.^ It is true that in certain industries poisonous gases are given off which cause toxic symptoms to the employees. However, this factor, although related to ventilation, properly belongs under the heading of occupational diseases and need not be discussed in this connection. The present day conception of the principles of ventilation are clearly set forth in the following outline by Dr. Thomas R. Crowder.^ 1. All trustworthy evidence goes to show that the normal expired air contains no volatile poison and that it is not capable of harming the human organism when rebreathed under the ordinary conditions of ventilation. 2. The increase of carbon dioxid and the decrease of oxygen have nothing to do with the ventilation problem under normal conditions, or with the subjective or objective effects of close air. Carbon di- oxid is a necessary constituent of the air of the lungs; it is not to be considered as a poison or the index of a poison. Its proportion in the air of a room is a convenient and fairly accurate index of the quantita- tive air supply. 3. Air performs for the body a physical function (heat abstrac- tion) which is quite as important as its chemical function (oxygen- supplying). 1 Report of the Committee on the Ventilation of Cars. Transaction of the Section on Preventive Medicine and Public Health., Am. Med. Association, Chicago, 19^1, P- 177. Paul: Ztschr. f. Hyg., 1905, xlix, 405; Flugge: Ztschr. f. Hyg., 1905, xlix, 363. 2 Crowder: Study of Ventilation of Sleeping Cars. Archives of Internal Medicine, Jan., 1913, Vol. ii, p. 66. INDUSTRIAL HYGIENE 153 4. The ordinary defects of ventilation lie with the physical func- tion of the air and not with the chemical. 5. Temperature, humidity and air movement are the physical qualities of the air which are of importance in this relation. 6. The success of ventilation depends on whether or not these physical qualities of the air are so regulated as to maintain its physical function of heat abstraction without embarrassment to the reflex mech- anism for the regulation of the body temperature. " The good effects of efficient ventilation and outdoor air depend on the coolness, the rela- tive humidity and the motion of the air and the ceaseless variation of these qualities." It will be seen from what has been said above, that for all practical purposes in ventilation, we can entirely disregard the oxygen and carbon dioxid content, and look entirely to the physical condition of the air. There are three factors which have to do with the successful perfor- mance of the physical functions of the air — namely, temperature, humidity and air motion. These three factors are interdependent and naust all enter into any question of ventilation. Thus, when the humid- ity is low, or the air motion is great, a higher temperature is required than when with high humidity and slower motion. Temperature Temperature is by far the most important of these three factors and although intimately associated with humidity and air motion we can, for all practical purposes, say that if the temperature is properly regulated there will rarely be any complaint of poor ventilation. A stuffy room usually means a room in which the temperature is too high, thus interfering with the absorption of body heat. In rooms where the occupants are relatively inactive, the temperature should never be over 70°F. whereas if it is kept between 64° and 68°F. it wiU be of the great- est comfort. Where physical labor of moderate degree is performed a temperature of 60° will be most acceptable. Therefore the character of the work or the amount of exercise being taken by the occupants of the room, must be taken into consideration when determining the proper degree of temperature to be maintained. Humidity The relative amount of moisture in the air goes hand in hand with the temperature of the air. As nearly as can be estimated the rela- tive humidity of the air should be about 50 per cent, (this may be measured by the wet and dry bulb or Taylor Hygrodeik, or by the Sling Psychrometer). However, the exact per cent, of humidity is a much debated question, and depends directly upon the temperature of the air, and upon the air motion. At 80°F. with moderate humid- 154 INDUSTRIAL MEDICINE AND SURGERY ity'or at 70° to 73.5°F. with high humidity, practically all persons begin to show evidence of depression, headache, dizziness or a tendency to nausea. The ideal condition, therefore, would be a moderate tem- perature, not above 70°F. and a moderate humidity not above 50 per cent. The advisability of adding moisture to the air during the winter months is a much disputed question, and one which has not as yet been put upon a practicable basis as far as large institutions are concerned. From the theoretical standpoint it stands to reason, that the evaporation of water in a room during the winter months should be of great value. The cold air, as well known, has a lower point of saturation than warm air. If, therefore, we take the cold winter air into the room and heat it we cause a change which is similar in effect to a reduction in the amount of moisture.^ In this way we have an atmosphere which must be heated to an excessively high degree in order that it may be comfortable; thus producing air which is both overheated and overdry. It is claimed by many authorities that the lack of moisture in the air during the winter months is responsible for many of the cases of colds, rhinitis, sore throats, etc., which are so prevalent during these months. As a matter of fact it is the excessive heat which is used to keep the dry air comfortable which is the main factor in lowering the resistance. There is also a possible factor of too rapid absorption of moisture from the body especially the nose and throat, which may be a factor in lowering resistance. It is a well established fact that with a relatively high humidity a lower temperature will be found more comfortable. Thus it will be found that dry air heated to 72°, 74°, or even 80°F. will be less comfort- able and wOl appear more chilly than a temperature of 66° or 68°F. when there is a greater degree of moisture in the air of the room. In a room in which the air is overheated and overdry the least movement of the air gives the sensation of drafts. If the moisture is increased and the temperature lowered the air will give the impression of balmi- ness and its movements unless of considerable force, will cease to be noticed as drafts. It may be said, therefore, that evaporation of water is advisable, when it is found that the relative humidity is low (below 50°) or that it is necessary to maintain an excessively high temperature (above 70°) to keep the room comfortable. The following chart illustrates the method of determining what is at fault when there is a complaint of poor ventilation. It wUl be seen that the temperature was constantly too high (averaging over 1 Hill and Flack: Influence of Ozone in Ventilation. Journal Royal Society of Arts, London, Feb. 9, 1912, p. 344. Roseman and Amoss: Organic Matter in the Expired Air. Journal Medical Research, 1911, xxv, 35. INDUSTRIAL HYGIENE 155 72°F.). This together with a relatively high humidity made a very uncomfortable room. In this case the difficulty was entirely overcome by regulating the thermostat so that the temperature did not exceed 68°F. Date Time 9 A.M 11 A.M 11/21/16 2P.M Date 5P.M Time 9A.M 11/22/16 (Foggy day) 11 AM 2P.M 5P.M Temp. 72 73 70 73 Temp. 71 74 75 74 Humidity 58 48 388 employees in room 48 55 Humidity 62 59 48 59 416 employees in room Air Motion From what has been said above, it is evident that air motion is intimately associated with temperature and humidity. If the tem- perature and humidity are high, as in the summer months, it is abso- lutely necessary to have air motion to maintain comfort. Whereas, with low temperature and low humidity even the slightest air currents cause marked effect upon metabolism and the loss of body heat. In rooms where the temperature and humidity are high, or where the temperature is high and the humidity relatively low it will be necessary to have air motion in order to have comfort. Just what rate of motion is necessary has not been clearly worked out and no standard can be established because effect of the air motion is absolutely dependent upon the temperature and humidity of the air. Professor Hill states that in his opinion slight but constant changes in the tem- perature and motion of the air lead to constant readjustments of the heat regulating mechanism of the body, and are very important in obtaining good results. It is his opinion that the impulsion of hot air into a room is the ''most objectionable of all systems of ventila- tion, and that cold air entering in small jets, heated by direct radiation, is ideal." Adequate ventilation has been recently defined by the Health Department of New York City as follows: "(1) The temperature of rooms during periods of occupancy should register preferably from 60° to 70°F. at all times, except when the outside temperature exceeds 60°. This does not apply to rooms used for special purposes, such as industrial places where high or low temperatures are essential and un- avoidable. (2) The relative humidity in occupied rooms should not exceed 70 per cent., except when the outside (wet) bulb temperature 156 INDUSTRIAL MEDICINE AND SURGERY exceeds 59°. (3) The carbon dioxid in occupied rooms of all classes should not at any time exceed 10 parts in 10,000 volumes of air in any part of the occupied spaces of the rooms. (4) The dust particles in the air. of occupied rooms in all classes of buildings should not exceed 1,000,000 per cubic foot. (5) The bacterial content should not exceed 100 per cubic foot. (6) The air of occupied rooms should be free from objectionable odors." Disinfection Fox again says: "The industrial physician should have complete supervision over all methods of disinfection. He should be in a posi- tion to pass judgment on every process which is in use and to make tests which will prove the efficiency or the inefficiency of any given process. It is clearly evident then that we must familiarize ourselves with the accepted methods in order to avoid some of the errors which are made along this line. " Perhaps in no other branch of preventive medicine, has there been such a great fluctuation of opinion as in that of disinfection. The fact that there is such a large variety of disinfectants on the market is only evidence that we have been groping about for some powerful agent which will instantly kill pathogenic bacteria. M. J. Rosenau^ of the U. S. Hygienic Laboratories most forcibly expressed this senti- ment when he said: "The stress of modern activities demands disinfecting processes that are instantaneous in their action, all pervading in their effect, cheap, harmless and free from any unpleasant odor. Such disinfec- tants are unknown. It requires time, money, and the expenditure of well directed and intelligent energy to accomplish satisfactory disinfection. "Until recently it has been the tendency to rely too largly upon the chemical agents for the destruction of bacteria, and to ignore in a great measure the natural means we have at hand. Fresh air, sunshine, cleanliness, are by far the most important agents for destruction of bac- teria and when these agents are brought into proper use, much money will be saved which is now foolishly wasted upon chemical disinfectants. It is not meant by the foregoing statement that chemical disinfection is entirely without virtue, but that entirely too much faith has been put in it to the neglect of other more effective natural methods. Proper disinfection includes the use of sunlight, fresh air, soap and water, liquid and gaseous disinfectants and above all, it implies that these agents must be used in their proper strength and allowed to act for the proper length of time. ' Whatever the method of disinfection adopted ^ M. J. Rosenau: Disinfectants. Bulletin of Hygienic Laboratory. INDUSTRIAL HYGIENE 157 or wherever it may be done, slip-shod methods can result in nothing but failure. If disinfection is worth doing at all, it is worth doing well. Careless disinfection is worse than none at all. The fact that a place has been disinfected gives the occupant a sense of safety. If the job has been done incompletely and inefficiently, this sense of security is unfounded and is a source of added danger.'^ " From the standpoint of the industrial physician it is important to know what methods are applicable in large institutions. It is the purpose of this chapter to give as briefly as possible the most accepted methods of disinfection and fumigation, and to give references which may help the reader in a further study of this subject. " For practical purposes disinfecting agents maybe divided into two classes, physical and chemical. The physical agents are sunlight, fresh air, cleanliness, heat, boiling and steam. " Sunlight and fresh air are of great value and wherever possible a conscientious effort should be made to allow as much fresh air and sun- light into the workrooms as possible. This may be especially empha- sized in the case of toilet rooms which are too often tucked into some dark corner, where fresh air and sunlight are impossible. Cleansing with the free use of soap and water and scrub brush plays an ex- tremely important role in the disinfection in large institutions. It may be truly said that much more cleaning will be accomplished if the porters are given soap and water and a scrub brush and told to clean than when they are given a strong smelling disinfecting solution which they are lead to believe will destroy disease germs by merely mop- ping over the surface of the given article. Heat is made use of largely by burning contaminated articles. Boiling may be used for such articles as will not stand this process and cannot be destroyed. The article to be disinfected must be covered by boiling water for at least twenty minutes. Steam under pressure is a very effective disinfectant and is frequently used in the disinfection of cuspidors and like articles. "Chemical disinfectants are divided into two classes (1) gaseous, (2) liquid. Gaseous Disinfectants " Of these formal dehyd and sulphur are of the greatest value. All crevices must be tightly sealed and kept so during the time of fumigation. "In using formaldehyd, it is important that a sufficient quantity be used, that the gas be evolved rapidly, that the temperature of the air be above 60°F. if possible, and its humidity at least 60 per cent, of saturation. Unless the atmospheric conditions are naturally ^ Disinfection — published by Illinois State Board of Health. 158 INDUSTRIAL MEDICINE AND SURGERY above these limitations, the defect should be overcome as much as possible by artificial heat, by placing shallow vessels of boiling water in the room, by sprinkling formalin on the floor and using an increased amount of formaldehyd." Three methods of evolving formaldehyd gas are ordinarily available : 1. The permanganate-formalin method. 2. The formalin-lime and alum-sulphate method. 3. The spraying or sheet method. 1. Permanganate -formalin Method.— Use one pint of formalin and six and a half to eight ounces of permanganate of potash crystals for every 1000 cubic feet. Use a large galvanized 'iron or tin pail or can of at least ten quarts capacity for each pint of formalin. Place the permanganate crystals in a thin even layer over the bottom. Place the pail containing the crystals in a pan or wash tub containing water, placing one or two bricks under the pail. Put the formalin in a pail, dipper, pitcher or some other wide- mouthed vessel so that it can be poured quickly. Pour it from this over the crystals and depart. Close and seal the door of exit. This must be done quickly as the evolution of the gas is very rapid. Allow the room to remain closed for at least eight hours. If the space to be fumigated exceeds 1000 cubic feet, a separate pail should be used for each pint of formalin or one which is propor- tionately taller to prevent the mixture from sputtering over on the floor. Some slight danger from fire attends this process and it should be watched through a window during the few minutes necessary for its completion. The present high price of permanganate has caused this process to be abandoned. One of the two following methods should be used until permanganate again approaches its former price. 2. Formalin-lime and Aluminum Sulphate Method. — Dissolve four (4) ounces of aluminum sulphate in one-half pint of hot water and allow the solution to stand for a few hours. Add one pint of formalin (35 to 40 per cent.) to this solution. Take three pounds of unslaked lime and just before using break into small pieces and place in a pail as described under the perman- ganate method. The lime should be of a quality that will slake easily in cold water. Pour the formalin-aluminum sulphate mixture over the lime as described in the permanganate method. The above quantities should be used for each 1000 cubic feet of air space. The time of exposure should be eight hours. INDUSTRIAL HYGIENE 159 3. Spray or Sheet Method. — This method is efficient under favorable conditions of heat and moisture, when apphed to rooms con- taining not more than 2000 cubic feet. Use at least 48 square feet of sheet surface for each pint of formalin and use this amount for each 1000 cubic feet of air space. The ordinary sheet 81 inches side by 96 inches long has an area of 54 square feet. This is a good size to use. The sheet should first be dampened, so that the formalin will not run off when sprinkled on. However, it should not be wet. Spread each sheet over cords or lines, preferably so that they will hang at an angle of 45 degrees. Pour the formalin in an ordinary sprinkling pot and pour it on the sheet through the sprinkler. Any other spraying device may be used if more convenient. The formalin does not damage the sheets. The temperature of the room must be at least 60°r. or this method is not effective. Rooms disinfected by this method must remain closed at least eight hours. By using a number of sheets and several men to spray on the formaldehyd this method has been found very useful in fumigating departments after contagious cases have developed therein. Sulphur Dioxid. — Sulphur dioxid in the dry state has practically no disinfecting power but in the presence of moisture it is changed into sulphurous acid gas and to a slight extent into sulphuric acid. It is these acids which are really the disinfecting agents. In the presence of moisture and in sufficient concentration it is effective in destroying disease producing germs but will not destroy spores. It is highly fatal to animal life and is especially applicable for destroying rats, flies, fleas, mosquitoes, lice and other vermin which may carry disease. It is much used, therefore, for disinfecting holds of ships, stables, barns, warehouses, freight cars and structures of this character. In the presence of moisture it attacks most metals although this can be prevented by spreading vaselin over the exposed surfaces. It bleaches and injures cotton, linen and woolen fabrics, curtains, house- hold furnishings, etc. It softens paint and varnish especially if they have been applied recently. It injures soap, coffee, tea, flour, sugar, matches, rice, etc., when they are freely exposed to it. It will also discolor wall paper and bleaches all vegetable and many anilin colors. The above mentioned ill effects only occur in the presence of moisture. Moisture, while essential to its action as a disinfectant, is not necessary when it is applied for the purpose of killing rats, insects or vermin. Two methods of using sulphur dioxid are commonly used : (1) the pot method and (2) the liquid sulphur dioxid method, the latter being about ten times more expensive. Owing to the fact that sulphur dioxid is rarely used for fumigating in industrial institutions, these methods will not be given in detail. 160 INDUSTRIAL MEDICINE AND SURGERY Liquid Disinfectants There is a great variety of liquid disinfectants upon the market, some of which are useful but many of which are worthless. In the use of these chemical disinfectants there has been a great economic waste which in a large measure can be replaced by the use of soap and water. If, however, a chemical disinfectant is thought advisable only those should be used which have been thoroughly tested not only by labora- tory but also by practical methods. In 1912 Thomas B. McClintic,^ Public Health and Marine Hospital Service of the United States, conducted a very elaborate series of tests on various disinfectant solutions, and it is interesting to note that he found a large per cent, of the widely advertised disinfectants to be practically worthless. It is his conclusion that liquor cresolis compositus, U. S. P., is an excel- lent disinfectant from the standpoint of both efficiency and econ- omy. It has a phenol coefficient of 3, and can be prepared on a large scale for about 50 cents per gallon Of course, the cost varies greatly with the scale upon which it is prepared. By the barrel, linseed oil and cresol can be obtained at about 80 cents and 50 cents per gallon, respectively. The commercial potassium hydroxid can be bought for a few cents per pound, or potash lye can be used in its stead. According to the United States Pharmacopeia liquor cresolis compositus (compound solution of cresol) is prepared as follows : Grams Cresol 500 Linseed oil 350 Potassium hydroxid '. 80 Water, a sufficient quantity to make 1000 Dissolve the potassium hydroxid in 50 grams of water in a tarred dish, add the linseed oil, and mix thoroughly. Then add the cresol, and stir until a clear solution is produced; and, finally, add water sufficient to make the finished product weigh 1000 grams. For the sake of completeness a few other liquid disinfectants may be mentioned. Formalin — the 35 to 40 per cent, solution of formaldehyd gas — is a very efficient disinfectant, its great drawback being the irritation caused by the liberated gas. For this reason, it is not adapted to washing floors or walls although smaller surfaces may be satisfactorily treated with it. Formalin is not corrosive. Fabrics and other arti- cles, except leathers, furs, and skins, are not usually injured by it. It is a good deodorant and is not apt to cause accidental poisoning. Its ^Thomas B. McCIintic and John T. Anderson: 1. Methods of Standardizing Disinfectants. 2. The Determination of the Phenol Coefficient of some com- mercial disinfectants. Hygienic Laboratory Bulletin No. 82, 1912. INDUSTRIAL HYGIENE 161 action is not retarded by albuminous matter and it is well adapted to the disinfection of urine, stools, sputum and other similar discharges. It will deodorize fecal matter almost instantly. A small quantity of pure or diluted formalin poured into water closet bowls, urinals, etc. will destroy offensive odors. Carbolic Acid. — This is a useful disinfectant when used in a strength of at least 3 to 5 per cent, solution. In these strengths it is not des- tructive to fabrics, colors, metals, etc. It does not actively coagulate albumin and is therefore useful for the disinfection of bed linen, soiled clothes, stools, sputum, etc. For disinfecting sputum, stools, etc. a 5 per cent, solution is added to an equal volume of the excretion, the mass then thoroughly mixed and allowed to stand for an hour before final disposal. The Cresols. — The vast majority of the disinfectants sold to the public are mixtures of cresols (carbolic acid like substances) and soap, together with other inert tar oils, etc. Unless these disinfectants have a guaranteed phenol coefficient they should not be considered. Bichlorid of Mercury. — This is a very powerful disinfectant when applied in sufficient strength to non-metallic and non-albuminous matter. It is highly corrosive and therefore is limited in its usage. The solutions usually used are of a strength of one part in 1000, or one part in 500 of water. Lim.e. — ^Lime in certain of its forms is one of the best and cheapest of disinfectants and should be much more commonly used, especially for the disinfection of stools. It may be used either as quicklime or as freshly slaked lime in the form of whitewash or milk of lime. 1. Quicklime (calcium oxid), a very caustic substance, suitable to destroy any organic matter, is often used as a disinfectant. 2. Whitewash is simply a thin mixture of slaked lime with a little glue added to make it stick to the surface to which it is applied. Its uses are well known. 3. Milk of lime is prepared by mixing slaked lime with about four times its volume of water. Freshly slaked lime must be used and the mixture itself is of no value as a disinfectant after three or four days. It is very useful as a disinfectant for stools. 4. Chlorinated lime (hypochlorite of lime, ''chlorid of lime," " hypochlorid, " "bleaching powder"), when in a fresh condition, is a very effective disinfectant. For disinfecting stools and other organic matter, it may be used in a 5 per cent, solution or the dry powder may be added to the substance to be disinfected in an amount sufficient to make a 5 per cent, mixture. The mixture must be thorough'. A mixture of six ounces of chlorinated lime to the gallon of water is largely used for scrubbing floors and other surfaces. 11 162 INDUSTRIAL MEDICINE AND SURGERY Of recent years chlorinated lime or "hypochlorite" has been ex- tensively used for disinfecting drinking water. Proper Disinfection of Cuspidors Proper disinfection of cuspidors has been one of the hardest prob- lems with which we have had to cope. This problem is handled in a great variety of ways, from the use of the old sawdust boxes to the excellent system devised by Wm. J. Manning of the U. S. Print- ing Department. Any method of disinfection which falls short of sterilization by boiling or steam, or the complete destruction of the cuspidor by burning is merely a method of cleaning and can, therefore, be done just as thoroughly with soap and water as by the use of some high priced disinfectant solution. However, after a thor- ough cleansing it is advisable to add some liquid disinfectant such as a 5 per cent, of liquor creosote compound solution, in order that the disinfectant may act immediately and for a long time on the contami- nated substance. The ideal method described by Wm. J. Manning^ consists in having metal cuspidors which can be picked up by a special handle and conveyed by a special truck to a sterilization room. The cuspidors are emptied and washed out with hot water, and then ex- posed to a jet of steam for five to ten minutes. This method has for its great advantage the absolute sterilization of the cuspidor and the fact that it is not necessary for the porters to touch the cuspidor at any time during the cleaning process. Drinking Fountains It should be one of the duties of the industrial physician to make frequent bacteriologic examinations of the source of water supply as well as to investigate the drinking cups or drinking fountains. Of recent years we have been placing considerable faith in the safety of ordinary drinking fountains. The fact that drinking fountains may be a source of contamination was demonstrated by Pettibone, Borgorl, and Clark, 2 University of Wisconsin, who were able to definitely prove that the drinking fountains of that institution were the source of con- tamination in the spreading of a grippe epidemic. Fifty-eight per cent, of the cultures taken from their drinking fountains during the epidemic showed positive cultures. Similar work has been done by other investigators with like results. Their remedy for this source of infection was to have a drinking fountain from which the water was ejected from a pipe at an angle of 15 degrees, thus preventing lip contact as well as droplet infection. 1 William J. Manning: United States Printing Department. 2 Pettibone, Borgorl, Clark: Journal Bact., 1916, 1, 471. INDUSTRIAL HYGIENE 163 Washing Facilities Every employer should provide adequate sanitary washing facilities for his working force. Showers and bathing facilities should be included when the work involves contact with poisonous material. The installation of stationary wash bowls with the common soap and common towel adjuncts so commonly seen in many industries has been responsible for much disease contamination. It is not at all uncommon to see an employee spit or blow his nose in one of these wash basins and then turn to the common roller towel and wipe his nose on this. Consider the ease with which disease could spread to the next employee who uses these ! Many states have legislated against the common towel but have neglected precautions with regard to the common wash basin and soap. The following quotation from the Standards of the Federal Em- ployees Compensation Commission shows what should be done in every industry concerning washing facilities and lockers: "Provision of Individual Wash Basin or Trough. — No wash basins or troughs for common use should be installed. Facilities for washing hands and face should be such that employees must necessarily wash from the flowing stream. Note. — ^The wash basin with stopper is unsanitary. This requirement is designed to prevent the transmission of disease through the common use of a washing fixture made to contain water. " Spacing of Fixtures. — Fixtures for' washing the hands and face should be spaced not less than 24 inches center to center so that a man can wash without splashing his neighbor. "Number of Faucets. — The number of faucets for washing hands and face should be not less than one to every 6 employees, based upon the maximum number employed on any one shift in the departments using the equipment. Regular showers (see Sec. 7) may be substituted in part for these faucets. " Temperature Control. — (a) Both hot and cold water feeding into a common spigot should be provided for each fixture and provision made for temperature control. ' (6) Wherever practicable, automatic thermostatic control should be installed in the main supply pipe to positively limit the maximum temperature to 125°F. "Clothes Hooks. — An adequate number of clothes hooks shall be provided. "Soap Holders. — Proper holders for soap shall be provided. Showers. — The number of showers should not be less than one to every twenty-five employees, based upon the maximum number of employed on any one shift in the departments using the equipment. 164 INDUSTRIAL MEDICINE AND SURGERY " This proportion may be varied according to the character of the work. '^Showers to be Separated. — The showers should be separated by partitions in order to encourage men to use the shower who would not otherwise do so; and to prevent the user splashing his neighbor. "Finish of Walls. — The enclosure should be finished in a light color to give a neat appearance and facilitate cleaning (see also Sec. 3). "Hot and Cold Water. — (a) Showers should have hot and cold water and be equipped with a hot and cold regulating valve. Note. — The system should be arranged to prevent scalding. This does not necessarily imply the need of a thermostatic control for each shower in a battery of showers. Where such automatic control is necessary it can ordinarily be attached to the heater. "(6) A regulating device should be so located that it can be operated without standing under the shower. "Location of Supply Pipes. — Supply pipes to showers should be placed overhead to avoid the possibility of a person coming in con- tact with the hot pipes, and to facilitate the cleaning of the shower enclosures. Lockers and Dressing Rooms. "Number. — A locker or other method for caring for change of clothing, etc., should be provided for each employee. "Clothes lockers should be located in buildings or enclosures used in conjunction with washing facilities. " Material for Lockers. — ^Lockers should be of steel and have proper ventilation. They should be at least 4 inches off the floor, to facili- tate cleaning without contaminating the locker. " Size of Lockers. — The size of the lockers should be not less than 12 inches by 15 inches floor space and of sufficient height to provide at least 5 feet clear height ; where not set in wall they shall have gabled tops to prevent accumulation of rubbish and other materials." Toilets Again quoting from the Employees Compensation Commission, we find the following recommendations: " Number of Installations of Toilets. — There should be a number of small installations rather than a few large ones. Note. — This is recommended so that available space in shops and yards may be utilized. If closets are conveniently located there will be less time lost and employees will be relieved promptly, which promotes good physical condition. "Number of Toilets.- — The number of seats should be not less than one to every 15 persons, based upon the maximum number of em- ployees in any one shift in the department using the unit. INDUSTRIAL HYGIENE 165 "Specifications for Closets.^ — (a) Closets should be of individual bowl type with individual water seal and should be made of porcelain or vitreous china, and not of enameled iron. Note. — Flush range closets are considered unsanitary and similar to an open sewer and shall not be used. Enameled iron, of which the ranges are most com- monly made soon corrodes, leaving the equipment in a deplorable condition. Flushing feces under others using the range is unsanitary, disagreeable, and objec- tionable. Individual closets made of porcelain or vitreous china overcome the objectionable features and provide a sanitary, durable, neat appearing bowl, which can be thoroughly cleaned. "(b) The seat of each water closet should be made of wood or other non-heat absorbing material, coated with varnish or other finish which will make it impervious to water. Under no circumstances should the use of seats made of enameled ironware, procelain or other similar heat absorbing materials be allowed. Note. — The use of non-heat absorbing material for seats ehminates any harmful effects which might come from men sitting on a cold surface. " (c) The size of the opening should be at least 7 inches in width and 11 inches in length. Note. — This size is recommended to insure the maintenance of a clean seat. "Specifications for Privies. — (a) The hole in the seat should be of the same size as specified in rule 52 (c). "(h) There should be a close-fitting cover for each hole. Note. — Persons using the closet should be encouraged to keep the seat covered to prevent flies and other germ carrying insects coming in contact with the feces. "Provision of Washing Faucets in Toilet Rooms. — Unless wash rooms are in close proximity to the closet, each closet room should be supplied with at least one washing faucet. Note. — The installation of a washing faucet in a closet room, not in close proximity to a wash room, is to promote personal cleanliness by encouraging men to wash after using these facilities. Number of Urinals. — An adequate number of separate urinals should be placed throughout shops and yards located conveniently to the place where men work. An adequate number shall also be installed in each toilet room. The total number should be approxi- mately 1 to every 30 employees. Note. — This will avoid loss of time required for a man to walk some distance and will tend to avoid violation of sanitary rules. At least one urinal should be installed in each toilet room to discourage the unsanitary practice of using closets as urinals. Specifications for Urinals. — (a) Troughs and basins shall not be used for urinals. The wall or vertical slab urinal with proper flushing 166 INDUSTRIAL MEDICINE AND SURGERY should be used preferably to the porcelain stall. The floor in frojit of urinal must slope toward the drain." The U. S. Department of Labor, the Committee on Labor of the Council of National Defense, and the New York, Pennsylvania, Ohio and Massachusetts Departments of Industry and Labor, as well as a few of the other states, have studied the problems of illumination, ventilation, fatigue and similar problems of industrial hygiene. The physician in industry is advised to obtain the bulletins published by these various agencies in order to gain a broad knowledge concerning these technical problems. A complete set of the bulletins prepared by the Council of National Defense can be secured by writing to the Bureau of Statistics, of the U. S. Department of Labor. Recently the United States Public Health Service has made some thorough investigations of these subjects and their literature can like- wise be obtained by writing to them. The Committee on Hazardous Occupations for Women in Industry has prepared standards of sanitation which are especially applicable to this sex. These can also be secured from the Department of Labor. It is exceedingly encouraging that the National Government is taking this great interest in industrial hygiene. Our country has lagged behind other governments in meeting these problems. Such an interest now bespeaks the approach of a real national health policy. CHAPTER XVII ^ INDUSTRIAL HYGIENE AND PRODUCTION The World War has focused attention upon Production. People who have given little thought to this problem in the past are now con- sidering their responsibility toward producing the essentials, or to- ward conserving those things produced, necessary to the winning of the war. Our allies have been solving this problem for four years and as a result have made changes in their industrial life which are revolution- ary. Our own nation, for more than a year now, has been struggling with the same problem. No country has ever before been called upon to make such gigantic efforts and no country has ever succeeded in securing greater results in so short a time. But the cost has been ter- rific both financially and from the standpoint of wasted energy, and even of human life. Our government, with the master minds in control, and the whole- hearted, determined support of its people, has accomplished in a little more than a year what seemed the impossible. No criticisms, however valid, can overshadow the glory of this accomplishment. In the state of our unpreparedness it was only to be expected that excessive outlays of money, of energy and of human life would be necessary to meet this emergency. During the short period that we have been in the war the world has seen a great army mobilized and thrown into the struggle — over a million and a half men already in Europe. It has seen a great emer- gency ship building program put into motion with an ever increasing number of ships being launched to carry this army and their needed supplies across the seas. Ordnance, munitions, quartermaster supplies, hospital supplies, locomotives, trucks, wagons, automobiles, gas offensive and gas defensive supplies, food and the other daily necessi- ties of life for both men and animals, have been produced and trans- ported in quantities heretofore unheard of. Even aeroplanes finally are being produced in great numbers. And in France the world has seen unbelievable feats of engineering performed. Great docks, for the receiving of these supplies, will remain after the war as part pay- ment of our debt to heroic France and as a monument to our efforts. Great railway systems have been built meeting the problems of war 167 168 INDUSTRIAL MEDICINE AND SURGERY transportation now, and standing as a promise of the part which we must play in the rehabihtation of that country after the war. No true American lives whose heart does not swell with pride when he contemplates the accomplishments of his country during this last year. And with true American spirit we have paid the price, and will continue to pay it without a murmur even though it is a hundred times as great. All this the world has seen. But only a few see or realize the great efforts that are simultaneously being made by our government to conserve its man power, to utilize its human energy in the most eco- nomic manner and to reduce the cost of this mammoth ilndertaking to a minimum. At the beginning of the war "business as usual" was felt to be a prime essential. It was realized that speeding-up of existing machin- ery and the creation of much new machinery would be necessary, but the economic and social existence of our country would be dis- turbed the least if this principle of "business as usual" could be maintained. Gradually these business methods of the country are being revo- lutionized. Non-essential business is being curtailed and the em- ployees are being diverted to essential production. The employers of the country are readjusting wages, and hours of labor, and are beginning to recognize that improved working conditions are necessary for maximum production. Many corrections have already been made. The labor unions are making concessions permitting of open shop methods, employment of women and arbitration policies which will do away with strikes. You can call it "business as usual" if you wish, but already we have a vision of those changes in industry which before the war were called the "dreams of idealists." Changes are likewise taking place in the government. The exist- ing governmental agencies were depended upon to do most of the war work, but to assist them numerous advisory committees were formed. That these committees, advisory in character but with no executive powers, were useful there is no gainsaying. But their greatest useful- ness was the part which they have played in the transition of our peace time government. Slowly but surely we have seen these advisory committees replaced by executive boards and in turn these boards replaced by individuals who have the power to perfect, and are held responsible, for some definite part of this great war program. Gradually the federal government has taken over more and more of the time honored rights of the states. And gradually the work of departments and bureaus has been centralized and unified. This has resulted in increased production with decreased cost chiefly by doing away with duplication of effort in the different departments. The INDUSTRIAL HYGIENE AND PRODUCTION 169 executive powers given by the Overman bill to our President have even greater functions than have as yet been revealed. The lubri- cation represented by doing away with interdepartmental jealousies, and the labor saving devices, represented by doing away with duplica- tion of effort, have already given the country a smoother running ma- chine with increased production. No thinking man of to-day will deny that these changes in our social and economic existence, and these changes in the government itself, taking place because of war conditions, are here to stay. No truer words were ever spoken than those of President Wilson when he said that this was a "War to make the world safe for Democ- racy." The victory over militarism and the autocracy of the Central Powers will not equal the victory over the tyranny and autocratic practices that have marked class distinction in all countries. In the beginning this was a war against the efforts of Germany for the accession of more territory. Then it became a war for democracy. And now it is a war for social democracy. The need of maximum production to wage this war is the weapon which is gaining this victory for a true democracy. " Our Allies found that under the old relationships existing between employer and laborer maximum production could not be maintained. Changes were necessary and changes were made. These changes represent the getting together of labor and industry and the mutual adjustment of conditions. Labor could not force its contentions on industry. Neither could industry force labor to accept its views. The government could not arbitrarily decide for one or the other. But by conferences, by sacrificing radical principles on both sides, and by concessions on the part of the governments, whereby they assumed a share of certain losses to both, the new era of true democracy has been inaugurated. In England shorter hours of labor have been established and careful studies reveal the fact that this has increased production. Wages have been increased, working conditions have been improved, protection against disease and accident hazards has been established and thousands of homes for employees have been built where better living conditions can be maintained — all of these have played a decided part in increasing production. The labor class of England has asked "If these things are essential for increasing production for war purposes, then why are they not quite as essential for increasing production in peace times?" And invariably the answer from all classes has been that these things are essential and must carry on after the war. In our own land of freedom the "exploitation of labor" has been known, even the exploitation of woman and child labor. Before the war conditions were changing but it was a very slow process. With 170 INDUSTRIAL MEDICINE AND SURGERY the war this demand for production is bound to force these changes within the year. The sacrifice of blood which we are making will bring its blessings in the forna of these by-products of war- — ^by-products which will mean a greater victory than merely overwhelming our enemy. Let us hope that if an early peace should come the country will nevertheless learn these lessons. During the decade before the war our great industries in the United States made their greatest strides in efficiency. Better relationship Fig. 35.- -Model munition factory in England. Here women of all classes, under sanitary surroundings, are helping win this war. between labor and the employer had been established. Wages and hours of work were better and more nearly uniform. The problems of labor turn-over, of hiring and firing and of unemployment had received more careful and more intelligent consideration. Better social con- ditions for the worker and his family were being recognized as an efficiency measure. The problem of the effect of alcohol on our industrial life was being met. Protection from occupational hazards and from accidents had been carefully studied and methods standard- ized. Experts in Industrial Engineering were being educated and turned out in ever increasing numbers. Above all the principles of industrial hygiene had been evolved and were already installed in many concerns. Physicians, highly trained INDUSTRIAL HYGIENE AND PRODUCTION 171 and reputable, were more and more entering the field of industrial medicine and surgery. Thus, without knowing it the nation was undergoing a state of preparedness. And during these days when maximum production is the cry of the hour the influence of all this work is being felt. The principles of industrial hygiene are now recognized as the very founda- tion of maximum production. During the first year of the war the speeding-up, the forming of new industries, and the great demand on the old, threw labor and industrial conditions into a frightful state. The housing conditions for employees in many centers were soon overtaxed and became intolerable. Beds were used day and night in three shifts. Sanitary conditions deteriorated rapidly due to the increased demands on water- supplies, sewage systems, etc. Shops were overcrowded. The food supply was inadequate and profiteering became rampant. Men from nearby towns flocked to industrial centers to work and lost time and forfeited wages because of transportation conditions. The percentage of labor turn-over increased to over 1000 per cent, in some cases. Employees, discontented with the above conditions and influenced by the promise of higher wages from other concerns, would leave their jobs without notice. Two concerns, equally neces- sary to war production, would influence employees to leave one or the other. These conditions in the industries and homes added greatly to the sick-rate. The floating labor was a means of spreading diseases. "Green hands" added to the accident rate to a very marked degree. The lack of any effort to select men for proper work according to physi- cal qualifications added to the inefficiency of the working forces. The lack of precautions against occupational disease in our munition fac- tories added to the toll of war victims. The wonder is that production attained its present proportions. But during this period many different agencies of the government were at work to correct these conditions. The National Defense Council through its sections on Labor and on Medicine early drew up standards on many important industrial hygiene methods and cir- culated these freely. As it was only an advisory body however, it could not enforce these methods. The Women's Committee of the National Defense Council, "Department of Women in Industry," the Women's Division of the Department of Labor, the Women's Division of the Ordnance Department, and the various women's divi- sions of the State Defense Councils have all contributed studies and recommendations tending to improve conditions for women in industry. All such improvements will naturally better working conditions for both men and women. The great drawback to all these committees 172 INDUSTRIAL MEDICINE AND SURGERY was that they had advisory functions only. During the last few months three important groups have been designated by the Federal government to correct these industrial conditions. Their work is bound to speed up production. All of these have a direct bearing on industrial hygiene. In fact the surgeon familiar with industrial practices is represented in each group. Without discussing the other functions of these bodies we will consider here only those functions which have a direct bearing on in- ' dustrial hygiene and its relation to production. Early in the present year the Department of Labor underwent a reorganization. It formed its bureau of War Labor Administration and took specialists from all over the country and placed them as Chiefs of Divisions. These men and women are responsible for the administration and results of their divisions. Already the labor sup- ply is being controhed and dealt out and shifted according to priority importance. Large groups of field workers have been formed to study industrial and labor conditions throughout the country. The work of other sections and committees is being co-ordinated and there is less duplication of effort. It is to be hoped that all committees working on labor problems will be forced to do so under a general plan outlined by this Labor Administration. The executive powers of this Labor Administration are sufficient to enforce correction of many of the conditions which have heretofore slowed up production. Unless this is done their scope of usefulness will not exceed that of the various advisory committees. The Women's Division of the Department of Labor has recently been placed under the direction of Miss Mary Van Kleeck. A com- mittee representing the Office of the Surgeon General of the Army, the Ordnance Department, the Navy, the United States Pubhc Health Service, the National Research Bureau, the War Industries Board, the Bureau of Standards and other divisions of the Department of Labor was formed in June (1918) to act as a steering committee for the Women's Division. . ThVough their work several investigations of specific industries where women are employed have been made and reports subniitted showing the hazards of this work and what correct- ive measures are necessary. In most places the employers have shown a very marked co-operative spirit and have taken steps to im- prove conditions on the recommendations of the committee. The real value of this committee's work and of all other such agencies will depend upon the support given to them by the govern- ment. Will the failure to meet their recommendations in a given industry, where conditions are detrimental to the health of both men and women employees, be sufficient grounds for the commandeering of that industry? If so will the government act? INDUSTRIAL HYGIENE AND PRODUCTION 173 The commandeering law states that "wherever production is ob- structed" such a step can be taken. The hygienic conditions of a plant are often such that production is obstructed, first by the undue amount of sickness resulting, and second because of the excessive labor turn-over, the result of poor working conditions. If commandeering proceedings should be adopted on these grounds it will be the first time in the history of the country that the Federal government has interfered with private corporations because of lack of protection of the health of employees. Such a precedent would have most beneficial results on the public health of the nation. The second group which is working along the lines of industrial hygiene is the Federal Housing Commission. By improving the hous- ing conditions of employees one of the most important steps for con- serving labor will have been taken. Better housing conditions means better and more sanitary living conditions, a healthier, more contented working force, less labor turn-over and greater production. An op- portunity is given to this commission to re-establish homes in our industrial centers, homes which were rapidly being displaced by tenements and other cheap forms of abode. On July 1st of this year the President issued an executive order, under the powers given him to co-ordinate the work of various depart- ments, which will have the most far reaching effects of any health measure ever enacted in this country providing those in charge of the work will see their opportunity and take full advantage of it. This order states that "all sanitary or public health activities carried on by any executive bureau, agency, or office, especially created for or concerned in the prosecution of the exisiting war, shall be exercised under the supervision and control of the Secretary of the Treasury." The only exception to this is the work of the medical departments of the Army and Navy. The order designates the U. S. Public Health Service of the Treasury Department as the agency which should carry on this work. It is recognized by the Public Health Service, and by all familiar with its activities, that the most important work it is d6ing is that of its Industrial Hygiene Section. This order therefore should enable the expansion of its Industrial Hygiene work to include every industry in the country which is concerned either directly or indirectly in the production of material necessary to the continuance of the war. When we realize that the Department of Labor has had at least two groups, with physicians employed, working in this field of industrial hygiene, and that the Bureau of Mines has had a medical department working in the same field and that at least five other medical divisions of the various departments and commissions have been working on public health matters, then we can better understand the importance of 174 INDUSTRIAL MEDICINE AND SURGERY this executive order. The duplication of function in this field of public health has been a decided factor in retarding results. It is the plan of the Surgeon General of the Public Health Service not to destroy or duplicate the good work which has been done by these various agen- cies, but to co-ordinate their work and henceforth co-operate under one general plan of procedure. Already the Public Health Service has thoroughly co-operated in the work of the Women's Division of the Department of Labor by making the field studies in Industrial Hygiene in certain chemical industries and turning the results over to this Division. Since experiences in this country and abroad have demanstrated so clearly that the principles of Industrial Hygiene, where carried out, always result in increased production, it is evident that the recom- mendations of the Public Health Service should receive respectful attention by employers at this time. If faulty conditions are left uncorrected, and as a result lowered health conditions among employ- ees slow up production, it would seem logical for the federal govern- ment to take over and operate these concerns under the most up-to- date methods. Last October a committee was formed in the Medical Section of the Council of National Defense consisting of members from the American Association of Industrial Physicians and Surgeons and from the American Railway Surgeons Association, known as the Committee on Industrial Medicine and Surgery. This committee was reorganized in March of this year to include in its membership representatives of the United States Public Health Service, the Department of Agricul- ture, the Department of the Interior, the Department of Commerce, the Department of Labor, organized industry, organized labor, or- ganized medicine, organized Industrial medicine and the Medical Department of the Army. While its functions were only advisory yet there is no question but that the studies and report of this Committee on Industrial Medicine and Surgery have been strongly instrumental in bringing about the present status of industrial hygiene in its relation to war production. Just what the relationship is between industrial hygiene and production can best be explained by quoting from the report of this committee prepared by its director. Dr. Otto Geier : "The Need of the Hour. — More production of war materials by the second line of defense. "Slowing down of industry caused^ — 1. By excessive labor turn- over. Men drifting from shop to shop, therefore untrained and with low output — more subject also to accident on successive new jobs. ''2. By physical breakdown: (a) Due to unsanitary conditions of INDUSTRIAL HYGIENE AND PRODUCTION 175 shop and homes (lack of medical supervision), (b) Due to lack of early recognition and prompt treatment of ailments loading to invalidism. "3. By absence from work: (a) Due to preventable accidents. (6) Due to failure to secure prompt and efficient surgical attention when injured. ■'4. By lack of output because of those killed or permanently dis- abled (number said to be more annually than thirty times the number of soldiers expected to be permanently disabled, and for which mil- lions have been provided in the way of reconstruction facilities). "Production can be Definitely Speeded up by Protection of the Human Machinery from Preventable and Unnecessary Wear and Tear, Disease and Injury .^ — The non-effectives in the average indus- try are known to be at least 3 per cent, or 30 in each 1000 on account of sickness (study of 750,000 workers, U.S.P.H.S.), may go as high in others as 6 per cent, of non-effectives. Add to this factor an additional per cent, for absence, falsely claimed to be due to sickness ; then add one-half of 1 per cent, for absence on account of lost time due to accidents and we have a total absence of 6 per cent, to which med- ical men can direct their efforts. "The principles of industrial medicine and surgery intelligently applied can reduce this 6 per cent, loss to 3 per cent., making a gain of 30 workers on the job in every 1000. '^Additional Saving. — A cleaner plant and healthier workmen will result in a greater output per man. "Other By-products. — Better relations between employer and em- ployee — more sympathetic, understanding — -comforts and conven- iences, cafeterias, etc., supplied; all producing a better esprit de corps resulting in less labor turn-over. "The protection of the health of the community — women and chil- dren — quite as essential as the health of the workers. Fully 30 per cent, of the effective medical and surgical capacity of the profession has been drawn into the Army. Tweiity-four per cent, of the visit- ing hospital forces has been called into the service. This indicates that the civil population does not possess adequate medical service. Under strain of war conditions, disease and injury are increased. To ipaeet the discrepancy, a method must be found by which every physician not in the Army may give his maximum result with his minimum effort, so that the community may be adequately protected against disease. ''The placing of the physician in industry accomplishes that need. By applying his preventive measures to the large industrial unit on an intensive scale, the industrial physician assists the community in 176 INDUSTRIAL MEDICINE AND SURGERY its health efforts, lessens disease, and therefore lessens the strain on the physicians in private practice. '^Our problem therefore is: 1. To meet the military need for greatly increased production. "2. To offset the drain on the man power in industry brought about by raising the military force. '3. To assure adequate medical sevrice for the civil population. "To meet the problem, the government must: 1. Provide against un- necessary human waste in industry and society during the war. '"2. Increase output by maintaining workers in good health. "3. Avoid preventable deaths and disabilities from accident and disease. "4. Restore to full producing power in the shortest possible time the sick and injured workers. "5. Provide healthful places in which to work. *'6. Provide healthful homes and communities in which to live." It is still too early to report great progress in this country in these matters of improved health conditions for working men and women. But the start which has been made augurs great things for the future. The Ship-building Board was one of the first large governmental war machines to recognize the need of introducing industrial hygiene, and its allies, prevention of accidents and adequate medical and surg- ical care, into all its yards as a means of maintaining and increasing production. The health conditions of many of the communities about these yards have been permanently improved by the drastic action of this Board. For example large areas in New Jersey have been drained and other steps taken to rid them of mosquitoes and the resulting malaria. In one town a large dump heap was so infested with rats as to be a constant menace to health. A successful rat extermi- nation campaign was carried out. These examples point out the lesson that industrial hygiene to be successful must not stop within the con- fines of the industry itself. Thus far this work has been conducted under the direction of a medical officer from the Medical Department of the Army. In all of the arsenals, ordnance depots and most of the government owned munition plants a comprehensive system of industrial medicine and surgery has been or is being installed. The division of Sanitation and Safety, an organization of the Indus- trial Service Section of the Ordnance Department has been instru- mental in improving the conditions in many of the industries engaged in the manufacture of ordnance supplies. Their work has just started and promises to yield excellent results. The United States Employees Compensation Commission has recently placed safety engineers in many government industries where INDUSTRIAL HYGIENE AND PRODUCTION 177 civilians are employed and by co-operating with the United States Public Health Service and with the Medical Department of the Army has been able to start systems of industrial hygiene in several such industries. By arrangements recently made between this commission and the Surgeon General injured civilian employees from some of these government industries have been admitted to the military hospital for the blind at Baltimore to receive the same re-educational advantages which have been prepared for the blinded soldiers. If the government will extend this opportunity for reconstruction, and re-education when necessary, to the civilian employee — the indus- trial soldier — which it is giving to the military disabled soldier, then it will be more nearly meeting its full obligation to its citizens. The Railroad Administration has its safety department and is co- operating with the medical departments of railroads to improve health conditions for railway employees. We have a few examples of an active interest on the part of state governments in industrial health conditions, but these are the first examples of an active, constructive federal program for introducing industrial hygiene into specific industries. The importance of this step, and the ever increasing results which it will have may not be fully appreciated by many. But to those surgeons in industry who have devoted many years of their lives to establishing these principles of industrial hygiene, and to their lay allies, who have so thoroughly supported and abetted their efforts, the dawn of a new day has come; never again will we return to those dark ages when the human machine was worked to the limit without supervision and then prematurely scrapped because of a breakdown, often the direct result of the occupation. By the time this book is published the contents of this chapter will be ancient history considering the rapidity with which advances are being made. However, it is history which shows the signs of the time pointing ever to one inevitable solution of these problems of Industrial Hygiene and Public Health, namely, a centralized, federal Department of Health with power to act. 12 CHAPTER XVIII EPIDEMIOLOGY IN INDUSTRY ACUTE RESPIRATORY INFECTIONS, ACUTE CONTAGIOUS DISEASES, TYPHOID FEVER, ETC. The prevention of the spread of epidemic diseases among employees is one of the most important duties of the medical staff. This function has not been sufficiently recognized in the past; or, in speaking of epidemics, we have thought only of the acute exanthemata and limited our efforts to their prevention. Wide experience in industrial practice has convinced several physi- cians that many diseases, not heretofore recognized as such, were infectious. Even those conditions, usually considered as symptoms, and which attack one for a few hours or a day and are so commonplace as not to drive the patient to a doctor, are seen by the physician in industry. Epidemics of these ordinary conditions frequently occur and cause great loss in the efficiency of the working force even though no actual loss of time from work results. The following examples wiU better illustrate these minor epidemics. Colds. — These are so ordinary that both patients and physicians have adopted an attitude of indifference and tolerance toward them; yet the damage from ''colds" to the human system and the economic loss to industry cannot be estimated. In the winter months this con- dition is so widespread that its epidemic nature might be doubted, the real cause being considered due to weather conditions and exposure to the same. However, the author has witnessed many epidemics of "colds" in the summer months. For example, in the month of July, with the most ideal working conditions, six or eight employees from the same department would report to the doctor's office with "colds." The next day fifteen or twenty other employees from this department would report with the same condition. This mild epidemic might be limited to this department but usually a great number of people from other portions of the plant would be attacked by the same condition. The signs and symptoms of these "colds" take various forms but the epidemics are usually of the same type. At one time all the employees reporting will have a profuse, thin nasal discharge, while again the coryza will be very slight and most of the cases will complain of hoarseness. Another time the "colds" will be accompanied with 178 EPIDEMIOLOGY IN INDUSTRY 179 signs of sinus infection and headaches and the majority of the cases will show this involvement. I have seen ten girl employees from the same department report during the course of a day with slight "colds" and herpes. These experiences have occurred so frequently that one cannot doubt the contagiousness of "colds." Educational campaigns among the employees are the best means of combating these epidemics. Warnings against the spread of the condition; instructions as to eating, rest, care of bowels, bathing, dress and other habits; protection of fellow employees by care in handling the handkerchief, washing of the hands, covering the mouth in sneezing, never using the common towel or cup, keeping things that might be handled by others out of the mouth, and hundreds of other like suggestions, can be made. When "colds" show signs of becoming epidemic it is much more economical to the concern to send these employees home. The active treatment of all cases of "colds" by the medical staff while they remain at work is very efficacious in controlling this condition. Separate the em- ployee as far as possible from his fellow employees. Have him report to the doctor's office three times a day and gently swab the nasal passages with 10 per cent, argyrol, spray with a weak solution of dichloramine-T or inhale the fumes from hot tincture of benzoin. These methods adopted early will abort many cases. Urotropin in five grain doses, often repeated, is of benefit. But the surest methods are isola- tion and education. A wonderful opportunity is given these physicians in industry to study this condition and evolve the best form of treatment and the best means of preventing "colds." We have neglected this disease because familiarity with it has bred contempt. Lumbago. — ^Lumbago occurs in endemic forms and frequently in such proportions as to indicate an epidemic. It is not limited to de- partments as in the case of "colds" but often during the course of a week fifty or more cases of this condition will report. I have seen ten men in the examining room at the same time all complaining of pain in the back. Men are more susceptible to this than women. Torticollis or. "stiff neck" has also appeared at the same time and in numbers suggesting a mild epidemic. One morning in early fall the author arose with a stiff neck. While at breakfast his sister, who had been with him the night before, phoned and asked what she could do for a stiff neck. At the plant that morning fourteen employees reported complaining of stiff necks, four were from the same department. At his office in the same afternoon one patient called ,on account of this condition. On the same day and for several days following lumbago was very prevalent among the employees. The real origin of these conditions is undoubtedly from some focus 180 INDUSTRIAL MEDICINE AND SURGERY of infection within the patient's own body. In the case of both stiff neck and lumbago, diseased teeth, hypertrophied tonsils, or a chronic coryza can usually be found. Nevertheless when there is a sudden flare-up of these conditions in a number of people at the same time one is forced to speculate on the possibility of a spread of the trouble from one individual to another, or on what changes in the weather or the environment cause a lowered resistance among individuals with an increased virulence in the infecting organism. These minor conditions, so long considered as a necessary annoy- ance in our everyday life, need careful study and analysis. The reduc- tion in their occurrence will be one of the greatest economies in the industrial world. TONSILLITIS— INFLUENZA— PNEUMONIA The acute respiratory infections have become more and more preva- lent during the last five years. Employees have always lost consider- able time, especially during the winter months, from these causes, but recently they have occurred in such numbers as to be classed as epi- demics. Time and again the absenteeism has reached such a high rate as to materially interfere in production and output. The efforts to prevent these epidemics have caused the physician in industry more worry than almost any other condition. These acute respiratory conditions have occurred as epidemics of tonsillitis, usually the severe form of streptococcic sore throat ; influ- enza or ''grippe;" pneumonia, especially streptococcic pneumonia, and bronchopneumonia; with their complications. Previous to 1912 the employees in the concern the author was con- nected with were not affected to any unusual degree by these diseases. But in 1912 the working force was swept with an epidemic of severe colds and tonsillitis. Again in the winter of 1913 an epidemic of tonsil- litis occurred. These cases were usually of a severe streptococcic form and accompanied by many complications. These epidemics were widespread but Chicago seemed especially affected. Capps and Miller and Preble of that city all described the condition as a hemolytic streptococcus infection. Milk was thought by them to be the agency through which it was carried. In 1914 the condition was not so serious but beginning in the early winter of 1915 and continuing until March, 1916, the entire country was included in an epidemic of so-called "grippe" which was most fre- quently complicated by pneumonia. In 1 9 1 6 this disease was prevalent but not to any such extent as the previous year. We all know the fearful toll which these acute respiratory diseases have claimed in our Army during the last year and a half. At their outset they have taken various forms. In some camps measles and EPIDEMIOLOGY IN INDUSTRY 181 mumps were the starting point of the epidemic, followed by influenza, pneumonia, pleurisy with effusion and empyema. Practically all of the reports show the hemolytic streptococcus with or without pneumo- cocci, Types I, II, III and IV, as the commonest organism in these epidemics among the soldiers. In some camps the epidemic began as influenza; in others epidemics of primary streptococcic pneumonia were reported, while in still others the epidemic was secondary to the acute exanthemata. In industry the same conditions, usually classed as influenza, have been claiming their toll from the civilian population. I am told by some physicians in industry that these epidemics do not differ to any extent from the epidemic of 1915 except empyema as a complication has been more prevalent. This hasty resume demonstrates that these acute respiratory in- fections have been gradually increasing in this country for the last six years. Each new epidemic has undoubtedly increased the viru- lence of these infecting organisms. The crowding together of thou- sands of young men in camps facilitated the spread of the disease. At the same time the speeding up of industry and the overcrowding that was necessary because of the war emergency made excellent epidemic environment. A description of the epidemic of 1915 written by the author is in the main characteristic of all these acute respiratory epidemics which undoubtedly are very closely related in both cause and effect. During December, 1915, and January and February, 1916, our country, especially the Northern States, was swept with an epidemic resembling in almost all of its aspects the pandemic disease known as influenza which swept over the entire world in 1889 and 1890. From all reports, the East — New York, New Jersey, Pennsylvania and Ohio — and the Northwestern States — especially Minnesota and North and South Dakota and extending into Canada, suffered to the greatest extent from this epidemic. Because of our medical work among the employees of certain large industries in Chicago and through the various channels of examin- ing employees for occupational diseases, we had an unusual opportu- nity of studying over 1800 cases affected by this epidemic disease. Etiology. — -Clinically, the disease corresponded in practically all of its aspects with the old epidemic of influenza so well described by Osier, Laden and Senator, and Lichtenstern, and many others follow- ing the epidemic of 1890. But from a bacteriologic standpoint, we did not find the bacillus of influenza as described by Pfeiffer in 1892. From twenty-five blood cultures and a great number of cultures made from the secretions from the nose and throat of the affected indi- vidual, grown on blood agar, the organism usually found was a 182 INDUSTRIAL MEDICINE AND SURGERY hemolytic streptococcus, often associated with the pneumococcus. Unfortunately the isolation of the various types of pneumococci were not carried out in 1915 as they are to-day. During the winter of 1912-13, especially during January and February, Chicago was swept by an epidemic of a very severe form of tonsillitis. At the same time there was an epidemic resembling very much the old so-called catarrhal fever, characterized by a severe coryza and a tendency for the infection to spread to the sinuses, espe- cially the frontal sinus and the antrum. The cases were often quite severe and the course of the disease prolonged. Bacteriologic studies of these epidemics were made by many observers, but as a rule either a hemolytic streptococcus or a diplococcus was found as the cause of the infection. Again, last winter we had an epidemic characterized by fewer cases of tonsillitis, but by more cases of the nasal infection and accompanied by pharyngitis, laryngitis, and often bronchitis. Again the streptococcus and diplococcus were found as the most fre- quent organisms in the nasal and throat secretion of these cases. As in the present epidemic, the patients were usually told that they had the "grippe," although as pointed out the influenza bacillus had not been found in any of these epidemics of the last three years. Lichtenstern, in his article in Nothnagel's Handbuch, in 1898, pointed out the relationship between the epidemic influenza to the ordinary influenza cold or catarrhal fever, which is usually present in all communities. He makes three divisions: First, the pandemic influenza, vera, caused by the Pfeiffer bacillus; second, epidemic influenza, vera, which develops for several years in succession after a pandemic and is also caused by the same bacillus; third, the endemic influenza or pseudo-influenza or catarrhal fever, commonly called the "grippe" and which is due to an unknown organism. During the period from 1912 to 1915, in the winter months, we witnessed an epidemic increasing in severity until it culminated in the disastrous epidemic of 1915-16 and resembled clinically the true influenza disease. But, instead of the influenza bacillus, the hemo- lytic streptococcus mixed with the pneumococcus has been the real cause of these epidemics. The disease was highly contagious. When a member of a family was stricken, it usually attacked the entire household. It spread throughout the schoolroom, attacking both the teachers and the pupils. The most significant feature of the contagion was the way in which it spread among the clerical forces of the department stores and among the employees of those industries which were forced to speed up, to work overtime and to take on extra employees in order to handle the Christ- mas rush of business. In one office, which is always rushed to the limit by increased Christmas business, 50 per cent, of the office EPIDEMIOLOGY IN INDUSTRY 183 force was ca.ught by this epidemic. In certain industries, or in departments which were not affected by this extra Christmas work, the disease did not spread to any extent, and frequently missed them altogether. Whenever one or two cases developed in a room containing a great many employees, it was not uncommon to see sixty or eighty cases develop in that same room, within the course of a week. In many industries, a vicious circle was easily developed. The excess of work caused a spread of the disease, and the more employees that became sick, the harder did the others have to work. Those employed in outside work suffered far less than the inside workers. The hospitals, especially such institutions as the Cook County Hospital were overcrowded with patients. As a result, the nurses and hospital help were greatly overworked. The disease spread with alarming rapidity among the nurses. One hospital had 25 per cent, of their nurses sick at one time. Due to being "too busy," a great many of the above employees, and very likely the nurses neglected their bowels — constipation resulted; many neglected to eat their regular meals or to take sufficient time to eat ; and many, due to working overtime, did not get sufficient sleep or time to recuperate from one day to the next. From a study of the above facts, it would seem that the chief pre- disposing causes to the spread of this epidemic were overwork (es- pecially inside work) , overcrowding, and the neglect of the fundamental principles of health — namely, sufficient food and rest, regular meal- times, and proper elimination. The spread of this disease from one individual to another was undoubtedly through the nasal and respiratory secretions carried by the infected dust and other material of the working room. The actual onset of the disease was usually preceded by a coryza, sneez- ing, and the ordinary symptoms of "catching cold." Undoubtedly the careless sneezing and careless flipping about of the soiled hand- kerchief of the affected individual was the commonest means of communicating the infection to his fellow workers, fellow passengers in the street car, or any others who came in close contact with him. Other sources were careless spitting, careless blowing of the nose without using a handkerchief, the common towel, which can so easily collect secretions from the nose or mouth, the common drinking cup, kissing, and the handling of articles used by the affected individual. One had only to walk through our busy shopping dis- tricts, just prior to Christmas in order to see how many of both the clerks and the customers had "colds;" to see how frequently and how carelessly handkerchiefs were jerked from pockets and shaken in the air in order to spread them out; to behold customers sneezing into their hands, then handling articles which were later bought by other 184 INDUSTRIAL MEDICINE AND SURGERY purchasers; and to note the overcrowding everywhere, especially in the ill-ventilated basement salesrooms, in order to understand how such an epidemic could spread to almost every household in the city. In fact, one marvels that anybody escaped. Symptoms.— We had the unusual opportunity of seeing several hundreds of these cases of this epidemic disease at their onset, plus the questionable privilege of studying the disease as fellow sufferers. The majority of the cases reported to the doctor because of a severe cold in the head, a slight sore throat, and a general aching throughout the body, usually complaining of backache, legache, or headache, in the order named. In every case the temperature and pulse were taken at once, and, as a rule, fever was always present, varying from 100 to 103. The pulse was invariably slow in comparison to this tempera- ture, averaging from 80 to 90. Some of these complained of a severe cough, but as a rule the bronchitis symptoms developed later. In practically all cases, there was a history of prodromal symptoms, varying from one or two days to a week, such as a marked coryza or sneezing, headaches, or a general feeling of lassitude. Many complained of constipation and others of sleeplessness and loss 6f appetite. In about 5 per cent, of the cases the onset was that of a gastro- intestinal disturbance. Nausea was marked, frequently there would be severe vomiting. Occasionally diarrhea was present, but con- stipation was the rule. Frequently, severe abdominal pains were complained of, and oftenest the pain was located in the left hypo- chondriac region, near the spleen. Fever was practically always present. Because of the abdominal symptoms a blood count was usually made, but it was seldom that the leukocytes were above 14,000. In a smaller percentage of the cases, the onset was very abrupt and was marked by profound prostration. The patient would suddenly collapse while at his work. The pulse would become almost imper- ceptible and the surface of the body clammy and cold. In some of these cases, the temperature would be quite high, 103 or 104, and in two cases as high as 105^; while in others it would be subnormal. After getting the patient in bed and administering stimulants, these signs of collapse would rapidly disappear. Neither did these cases seem to run a more serious or more prolonged course than the others with the milder onset. In those with the severe onset the leukocyte count was usually 5000 to 7000. Leukopenia was very common following the illness. The symptoms most characteristic of this disease were the following: Coryza.- — This was by far the commonest symptom, beginning early in the prodromal stage, and continuing through the course of the disease, even persisting after the patient was able to resume EPIDEMIOLOGY IN INDUSTRY 185 his usual duties. The nasal secretion was very profuse and watery at first, but later tenacious in character. Sore Throat. — With only few exceptions every case had a markedly injected throat, the soft palate, pillars and pharynx usually being involved. Frequently the uvula and soft palate were dotted with vesicles — in fact this was such a common finding that it could be called characteristic of the throat condition. In those patients with hypertrophied tonsils, these were usually found infiamed. As a rule, there was a decided discrepancy between the subjective symptom and the marked inflammatory change in the throat. Myositis.- — Practically every case had a certain amount of backache and legache. In some, the aching in the muscles was acute and was the most bitterly complained of symptom. At times, this was accompanied by a sciatica or other form of neuritis. Headache. — This was usually complained of in the early course of the disease. It was commonly located in the frontal, temporal region, and caused the patient to complain of dizziness on moving. Chill. — An actual chill was uncommon, but cold extremities and chilly sensations all over the body, was the rule. Fever. — This was present in the majority of cases at the onset. It was characteristic for the temperature to be normal in the morning, but up again in the evening. In most cases the temperature would disappear after two or three days. The average temperature was 100° to 101°, but as stated before it occasionally rose very high, even to 105.5. The temperature depended a great deal upon the pa- tient's keeping quietly in bed until the symptoms disappeared. Pulse. — ^This varied between 80 and 100, but the slow pulse was the most characteristic. Bronchitis. — This was a very frequent symptom. The cough was most often paroxysmal in character, especially at first. The sputum early was thin and frothy and usually contained small, white particles. In many cases this symptom subsided without any further development; in others, the bronchitis would persist and the .sputum would become thick, yellowish, and purulent. The hemo- lytic streptococcus could usually be found in this type of sputum. As a rule, those cases ran the longest course which developed the most marked coryza and bronchitis. The examination of the lungs when bronchitis was present invariably showed fine, subcrepitant rales over the upper lobes. It was seldom that any other signs were present. Pleurisy was very uncommon. Herpes. — Herpes about the nose and on the lip were present in a few cases, but were not the rule, as pointed out in the true influenza epidemic. Delirium. — This was not noticed in any of the cases which 186 INDUSTRIAL MEDICINE AND SURGERY came under our observation. Neither were other nervous manifesta- tions noticed to any extent. The above symptoms were those which were commonly noted at the outset of this disease when the employees reported to the doctor's office. Course of the Disease. — The average length of time, in 1000 cases, for the disease to run its course was five and three-fourth days. Some recovered in twenty-four to forty-eight hours, while in others the disease persisted for three to six weeks. The course of the disease was undoubt- edly cut short by taking it in time and adopting active treatment at once. The most prolonged cases were those who persisted in working several days after the symptoms of the disease had manifested them- selves. Likewise the course was prolonged by patients getting up and about as soon as they began to feel better, instead of remaining in bed a few days after the symptoms had subsided. Relapses were very com- mon, especially among those who returned to work too soon. As a rule when a relapse did occur, the symptoms were much more severe than in the original attack. Complications. — Pneumonia was by far the most frequent com- plication of this epidemic of 1915. Most of the deaths reported were due to pneumonia. In some cities the death rate from pneumonia increased four and five times, as compared with the year previous. In Chicago the number of pneumonia deaths for the week end- ing December 11, 1915, was 77; during the week ending December 18th, the number was 108; for the week that ended Christmas Day, the number was 205, while the corresponding week a year before the pneumonia deaths totaled only 73. In talking with numerous physicians and different Board of Health officials, it was agreed by all that these increased pneumonia deaths were the terminal results of this so-called influenza epidemic. Pleurisy with, effusion and empyema were reported by many doc- tors as a cause for the long continued absence of employees from work following an attack of this infection. Various forms of neuritis, especially lumbago were common com- plications. In examining a great many of these patients after they had recovered from an attack of this disease, a number were found with rapid, irregular hearts and other signs of a distinct myocarditis. A few cases of otitis media both serous and purulent and of mastoiditis were reported. It was not uncommon to find many cases of gastro- intestinal disturbance, following an attack of this epidemic, and a few cases were seen of cholecystitis accompanied with marked jaundice. Relapses or recurring attacks of the disease were very common. The greatest number of these occurred from one to two days after the patient had recovered from his original attack and had returned to EPIDEMIOLOGY IN INDUSTRY 187 work; but a number of secondary attacks occurred as long as two and three weeks after the patient had returned to work. Many remote complications developed among the employees who had suffered from this epidemic infection, and, while the connection could not always be traced, yet we felt justified in holding this so-called influenza attack responsible. Within a period varying from two to eight weeks after their return to work, four men developed cases of acute, suppurative mastitis without any history of trauma to the gland. In two of these strepto- cocci were found and in two both streptococci and staphylococci. Hand infections following slight injuries were more prevalent in January, February, and March following this epidemic than in any other equal period of my connection with this plant. Four cases of very slight scratches developed lymphangitis followed by large axil- lary abscesses. All four of these employees had suffered a short time before from the epidemic infection. Five employees shortly after their return to work developed severe abdominal pains, rigidity and diffuse tenderness. The leu- kocyte count was below 14,000 in all of these. The cases resembled acute appendicitis. One was operated but the appendix was only slightly injected. These cases corresponded to the descriptions of abdominal complications which were prevalent during the epidemic and were described as acutely inflamed mesenteric glands. Swollen glands of the neck were seen in several cases follow- ing the attack but only two of these suppurated. One case of cellulitis of the abdominal wall and another of cellu- litis of the thigh followed slight injuries to these parts in two men who had shortly before had the ''grippe." In March, 1916, eighteen cases of tuberculosis were found among the employees. All of these had suffered during the winter from the epidemic. Twelve of these cases had been examined during the year previous to the attack and no signs of tuberculosis had then been discovered. This bears out the experience of others that these acute respiratory infections frequently tend to light up latent tuberculous areas. These remote complications demonstrate that the economic loss to industry from these increasing epidemics of streptococcic sore throat, streptococcic pneumonias, and streptococcic respiratory infections grafted on influenza or other acute infections continue for months after the acute epidemic has subsided. Treatment. — The extensiveness of these epidemics, the greatly increased death rate, and the incalculable economic loss to the com- munity and to practically all of the industrial concerns, has presented many problems, not only to the health department but to those 188 INDUSTRIAL MEDICINE AND SURGERY physicians engaged in industrial medical work. The greatest problem in the line of treatment is the prevention of the spread of such epidemics. Various health departments have done invaluable work through their newspaper campaigns of educating the public concerning the importance of isolating every case of this disease and their warnings concerning the danger of sneezing, promiscuous kissing, the use of the common towel, and all other means by which the secretion of the affected individual infect his fellows. The source of greatest menace to the public and one which is practically uncontrollable by a health department is the early case who was not sick enough to re- main at home the first two or three days of his attack, the light case who in spite of his symptoms is able to stick it out and remain at work every day, or the serious case who, as soon as he feels better mingles with the public before he ceases to be a menace as an infection carrier. More harm is done by these three classes than all the other cases put together, and in the future a great amount of education needs to be directed toward these groups. It behooves the entire medical profession to recognize the infectious nature of this disease and to use the same precautions toward it that we do toward diphtheria and scarlet fever. The medical staffs of various large industries, and there are a number of such staffs now, found a task of great magnitude on their hands in combating this epidemic of 1915. They were forced to face two problems in this work: First, to prevent the spread of the epidemic among the employees; and second, to be sufficiently conservative in their efforts as not to cripple the business, especially as there was an excessive amount of work, due to the Christmas rush. As soon as we recognized that an epidemic was among us, our medical staff took steps to subtly re-enforce the rules which are always in force concerning sickness. We notified every manager, floor manager and division head to send every employee who showed signs of "catching cold" or other signs of this disease to the doctor's office at once. Likewise, no employee was allowed to go home on account of sickness without reporting to the doctor's office first, and no employee was allowed to return to work after being home on account of sickness without first securing a permit from the doctor's office. This gave the opportunity of examining all those who were sick and of sending those who showed signs of this disease home at once, and of keeping them away from the department until they had fully recovered. A number who had apparently recovered were allowed to return to work, but as stated elsewhere, relapses were not uncommon. No opportunity was neglected to instruct the individual employee in the various means of preventing the spread of this infection. EPIDEMIOLOGY IN INDUSTRY 189 Two of our best methods of prevention were frequent airing out of the various departments and the formaldehyd fumigation of the departments overnight. The necessity of throwing open all the windows of the department for two or three hours in order to rid the room of the formaldehyd was undoubtedly one of the great benefits of the fumigation. Thus our efforts toward prevention were directed along four very definite lines : First, the ridding of the depart- ment of the affected individuals as rapidly as possible; second, educa- ting the employees concerning their individual responsibility toward preventing the spread of the infection ; third, the plentiful use of fresh air; fourth, the frequent fumigation. Active Treatment. — We early recognized that a great many of the employees did not consider the sickness sufficiently serious to consult a physician, thus often needlessly prolonging their disability. We began therefore to ascertain from each sick employee the name of his family physician and insisted upon them calling him in as soon as they reached home. In a great many cases we called the family physician and made sure that he was on the job. Many had only a light attack of the disease and did not feel sufficiently sick to call in a physician, while others did not have family physicians. To these we frequently gave a prescription for aspirin, or sodium salicylate to be taken in ten grain doses every two hours. Likewise they were given a cathartic of castor oil or magnesium sulphate at once, and a gargle of Dobell's solution, and were then sent home and told to use the medicine as directed and stay in bed for at least two days. Our visiting nurse called on as many of these as possible and made sure that they were following out these directions. In this way many of these early cases were aborted and the employees were able to return to work within two or three days. By this careful supervision and with the aid of our visiting nurses, most of our patients received active treatment for this disease from its onset. In this way many of them were saved from serious complications and the length of their disability was greatly reduced. Results. — While the death rate from pneumonia complicating the epidemic was increasing to 3 and 4 times the normal rate through- out the city, yet among the 1800 cases occurring among these employees there were only three deaths, all due to pneumonia. Three other large concerns in Chicago reported an absentee rate of from 25 per cent, to 35 per cent, of their total working force during this epidemic. In this concern 12 per cent, of the employees were involved. One physician reported 8 per cent, of the employees he was responsible for as absent on account of influenza, while a neighboring concern had 40 per cent, of their employees infected. One of the departments where the disease was very prevalent in 190 INDUSTRIAL MEDICINE AND SURGERY the author's experience had a number of employees absent for this cause during the first two weeks. We then began a thorough formal- dehyd fumigation of this department every night with the result that this infection decreased materially within the next two weeks, and after that this department had the smallest number of cases com- pared with the other departments in this concern. The fumigation method was used quite extensively after the first month of the epi- demic. Undoubtedly two sources of infection can be controlled by frequent cleaning and fumigation, namely, the material handled and the dust in the rooms. Physicians in industry are in the best position to co-operate with the public health officials in controlling these epidemics in a community. They can discover many of the cases at their onset and start early, proper treatment. They can educate the employees as to the best means of preventing the disease and its spread from one individual to another. The entire field of industrial hygiene can be utilized to combat the epidemic in both the industries and in the community. The above description of the streptococcic epidemic of 1915 and the methods employed then are applicable to the epidemics described to-day under the various titles of "Spanish influenza," influenza, epidemic of streptococcus pneumonia and empyema (Joseph Miller), epidemic streptococcal bronchopneumonia (W. G. MacCallum), hemolytic streptococcus causing severe infections (H. L. Alexander), and described by Rufus Cole under prevention of pneumonia. Most of these later epidemics have been reported from army camps where the crowding together of the soldiers has facilitated their spread. But the same epidemics are weakening our man power in industry and causing an ever increasing loss. Every year it is becoming more and more evident that the physician in industry must become an expert epidemiologist if he is to render the greatest services. While authorities differ as to the part played by the influenza bacillus in these epidemics, yet most investigators are convinced that the hemolytic streptococcus and the various types of the pneu- mococcus were the most dangerous agencies in the above described epidemic. In order to adequately meet the situation it must be determined to what extent the influenza organism lowers the patient's resistance and makes possible the invasion of these streptococcus organisms. The profession must become familiar with the exact nature of these hemolytic streptococci and pneumococci which are so prevalent in all of these epidemics. There are many unknown factors which must be cleared up before our preventive measures can be fully perfected. EPIDEMIOLOGY IN INDUSTRY 191 It is just as necessary therefore for every industrial dispensary to have a well equipped laboratory and a special laboratory worker to study this disease among the employees as it is to have a similar arrangement in the army hospitals. More attention must be paid to the scientific field of investigation of diseases among employees. The savings to industry by such efforts would pay a hundred-fold dividends. Until we know the different strains of the organisms causing these epidemics our best preventive measure, namely vaccination, cannot be perfected. Nevertheless good reports are constantly being received which point to the fact that vaccination against pneumonia will soon be perfected. Lister, in South America, has reported very decided results from vaccination against pneumonia among the natives working in the mines, among whom pneumonia has always been very fatal. The isolation of these cases in infectious hospitals, keeping them segregated from other non-infected patients, the cubicle system, and other methods of prevention after the disease is established are giving excellent results. Our greatest problem both in industry and in the army is to prevent the spread of the disease. Searching out the cases instead of waiting for them to seek the doctor, instituting early isolation and treatment, educating each individual in methods of prevention and his responsibility toward others, and re-enforcing the methods of sanitation in both the working places and the homes, are the essential elements for the control of epidemics. Searching Out the Cases. — 1. See every sick employee, take his temperature and pulse, examine his throat and in other ways ascertain if his sickness is due to this disease. 2. Instruct nurses and lay assistants among the employees (fore- men, assistant foremen and intelligent employees) to mingle with the working force and pick out anyone who shows prodromal symptoms. Send these to the doctors for examination. Early Isolation and Treatment. — 1. Immediately send every employee with fever of 99^° or with a "cold," sore throat or other prodromal symptoms home. It is better to have ten such employees away for two days each than that three of their number should develop a severe infection causing two weeks' loss of time for each. These mild cases often are the sources of infection for other employees who may lose many days from work. 2. Proper, early treatment given to those people with the prodromal symptoms will abort the more serious infections with their subsequent complications in the majority of cases. 3. Rest in bed, free catharsis, and light, nourishing food are the most essential factors in early treatment. Each case should be super- vised so that a doctor is called at the first indication. 192 INDUSTRIAL MEDICINE AND SURGERY 4. Protection of those caring for these cases by masks, gowns, rubber gloves and disinfectants is essential. Education and Individual Prevention. — 1. By individual con- ferences, talks with groups of employees, bulletin board signs, and large placards and bulletins printed in the different languages, the employees can be educated in all matters of prevention and their responsibility toward fellow employees. 2. The chief points to emphasize are: (a) Reporting to the doctor at once when prodromal symptoms are noted. (Describe these.) (6) Sources of spread of the disease, namely, by careless sneezing, coughing, blowing of the nose, breathing or talking in another's face, using common drinking cups and towels, placing things in the mouth or handling articles which others will place in their mouths, carelessly shaking the handkerchief about, promiscuous spitting and numerous other ways in which the infected employee can become a menace to others. (c) Avoiding crowded rooms, theatres, street cars, when possible, and other places where people tend to congregate. (d) Instruct in home sanitation and the means of contaminating or being contaminated by other members of the family. (e) Preach good food, plenty of fresh air, and sufficient rest at all times. (/) Avoid booze, keep bowels regular and establish other regular habits. (^f) Report every suspicious case to the doctors just as for diph- theria or small-pox. Reinforcing Sanitation Methods.^ — 1. By preventing overcrowding. 2. By adequate ventilation especially frequent airing out of the rooms. 3. By cleanliness about the plant; sweeping only at night and then wet sweeping. 4. By some adequate form of fumigation. 5. By rest periods and other means of avoiding fatigue. 6. By co-operating with the Public Health officials. This problem of the acute respiratory infections in the epidemic form has been dealt with at length because of its insidious nature, the great damage which it can do among employees, and because the methods of combating it also apply to all other types of epidemics. Diphtheria Diphtheria is another disease which requires constant alertness on the part of the physician in industry to prevent its becoming epidemic. Fortunately it can usually be diagnosed early by adequate EPIDEMIOLOGY IN INDUSTRY 193 laboratory methods. The discovery of a few cases of this disease by the plant laboratory is always one of the strongest arguments in favor of this necessary adjunct to a well equipped doctor's office. Every employee reporting with a suspicious throat or with a very marked tonsillitis should be sent to the laboratory for an immediate smear examination and culture. The latter can be sent to the City Health Department if facilities are lacking for incubation. All these suspicious cases should be sent home at once. When the smear shows diphtheria bacilli, the same should be reported to the family physician direct so that he can administer the antitoxin early. Just as soon as the report is obtained from the culture it should also be reported if positive. All of these cases must be reported to the Health Department of the community at once so that proper quarantine measures can be provided. The department where the case developed must be closely watched for any other signs of an outbreak. All employees who remain at home on account of sickness during the next ten days should be visited by the nurse and the cause of the absence ascertained. The foreman and assistant foreman should always be advised of the condition and their co-operation secured for a closer observance of the existing rules if this is possible. "Whenever a case of diphtheria develops at the plant the department should be thoroughly fumigated as soon as the employees leave at night. The watchman can throw open the windows about 4 A.M. and air out the room before the force arrives in the morning. These rules have been carefully enforced by the author for several years. Many cases of diphtheria have been found among the em- ployees but seldom has it spread from one employee to another. The nearest approach to an epidemic was when seven girls in one depart- ment developed the disease at the same time. Two of these girls who roomed together failed to report for work because they were sick. The nurse called and found that no doctor had been consulted although both girls had severe sore throats. Cultures were made by the nurse and brought to the laboratory. The next morning these were found to be positive for diphtheria. The nurse immediately called and had the girls send for their physician who took charge. The health depart- ment was also notified. That day two other girls from this same de- partment reported to the doctor's office with suspicious throats and cultures proved positive in both cases. The department was fumigated that night. Every girl who was absent during the next ten days was visited by a nurse and the three additional cases were discovered in this way. Without the help of the laboratory I am convinced that a real epidemic of diphtheria would have developed in this department where 200 girls were employed. 13 194 INDUSTRIAL MEDICINE AND SURGERY Time and again the public health department has been put in touch with these sources of contagion and has been able to stamp out a threatened epidemic in the community. The Acute Exanthemata Sporadic cases of measles, scarlet fever, mumps, chicken-pox, and other contagious diseases are more or less prevalent in all communities. These diseases appear at intervals among the employees of any large industry. Constant watchfulness is necessary to prevent their becoming epidemic among those employees who are working in close contact with one another. This watchfulness must be increased when- ever these diseases appear in epidemic proportions in the community. In order to combat these contagious diseases among employees the physician must have accurate knowledge of every sign and symptom, must be able to discover these in their earliest aspects, and must iso- late all such cases at once. Following this the constant supervision of the other employees from that department and the fumigation of the department must be carried out as described for diphtheria. The visiting nurse is the greatest ally the physician has in all of these cases. Reports from the city health departments can be obtained whenever a contagious disease is present in the homes of any of the employees, thus enabling the physician to give individual supervision to such workmen. In a large industry employing 15,000 people in Chicago, the follow- ing contagious cases were found during a period of six months. Mumps alone appeared in epidemic form and was under control after one month. Disease ' Number of cases. Mumps 22 5 cases in one department 4 cases in one department 6 cases in three departments 7 cases in seven departments Scarlet Fever 9 2 cases in one department 7 cases in seven departments Diphtheria 6 2 cases in one department 2 cases in one department 2 cases in two departments Measles 4 4 cases in four departments Erysipelas , 2 2 cases in two departments Chicken-pox 1 Total 44 EPIDEMIOLOGY IN INDUSTRY 195 The small number of these cases occurring in the same department proves the advantage of this system of supervision. Every one of these employees were potential epidemic breeders. Small-pox.^ — ^Most large industries require a certificate of vaccina- tion from every new employee. Some concerns vaccinate free of charge all applicants who fail to show a good scar or who have not been vaccinated within the last seven years. This latter plan was followed for three years in the concern with which the author was connected. It was seldom that a new employee refused to be vaccinated. Any arms that became quite sore or infected were cared for free of charge the same as an accident case, the employee receiving full wages during his absence. This took much valuable time from the other medical work and was finally abandoned. Only those cases who on examina- tion could not show a good vaccination scar were required to be vac- cinated before being employed. Twice during a period of nine years the entire working force has been vaccinated because of a case of small-pox developing in an em- ployee whUe at work. Two doctors with four nurses as assistants were able to vaccinate 3000 employees a day, thus protecting the entire force by this method within a period of five days. In both instances the president and general manager of this concern set the example by being vaccinated first. Supervision of the working force, co-operation with the city health department and vaccination are the preventive measures needed against small-pox. Typhoid Fever. — This disease has often proven very disas- trous to working forces. The chief methods of prevention consist of proper sanitation in the working force and in the community. Typhoid was very prevalent among the lumbermen of the Northwest. The industrial surgeons of Washington inaugurated an educational campaign against it which aimed at the employers and employees alike. By improving the privies and providing other means for sew- age disposal and by educating the people as to means of prevention, they were able to reduce typhoid fever to a wonderful extent. The sanitation measures necessary to prevent this disease are so well known that details are not necessary here. Every physician in in- dustry should make it his business to clean up all conditions in the plant or in the community which predispose to this disease (see Figs. 23 and 24). The experiences in the army of preventing typhoid fever by inoculation have proven how efficacious this method is. Only one death in almost 2,000,000 inoculations has been attributed to this measure. So far there has been less than 100 cases of typhoid fever in the army since this war began. Mark the con- 196 INDUSTRIAL MEDICINE AND SURGERY trast in the army during the Spanish-American War when at times 90 per cent, of the cases in the hospitals were due to this disease. Undoubtedly our civilian population will adopt this form of pre- vention as universally as they have vaccination against small-pox. The physicians in industry should provide inoculations against typhoid for all employees who voluntarily seek this form of prevention. Several things are very essential in dealing with contagious diseases among the employees. Common sense methods must be used which will yield proper protection for the entire working force and yet will not cripple or stop the production of the plant entirely. For example, when a case of scarlet fever is found in a department it would afford a greater measure of safety perhaps to at once dismiss the rest of the force and fumigate the department at once. Such a procedure would be disastrous to business and fumigation at night with the other pre- cautionary measures described have proven adequate. Every effort must also be made to avoid panics among the other employees. A cool, calm, matter of fact attitude toward the situation will allay fears among the timid ones whereas excitement, blustering or a dis- play of haste will often start a panic. I have taken smears from the throat of every employee in a department looking for diphtheria carriers without creating the least fear among them. Careful explana- tions of your reasons for doing thus and so will always result in co- operation from the working force. The doctor's office should be provided with a room where these con- tagious cases can be isolated while awaiting transportation home or to the hospital. They should never be allowed to go home on the street car or in public conveyances. The writer made arrangements with a taxicab company to take such cases home and then have the cab return for fumigation. It is our duty to make sure that all public cabs used by contagious cases are properly fumigated before accepting other passengers. Often the public health departments will furnish free transportation in an ambulance for all contagious cases. No greater opportunity for developing the most scientific epidemio- logical methods can be found than here in the practice of Industrial Medicine. All the involved economic and social problems are here combined with our medical efforts. Venereal Diseases The combating of venereal disease among employees has been woe- fully neglected by the majority of physicians in industry. This can be accounted for in two ways: (1) The indifferent attitude which EPIDEMIOLOGY IN INDUSTRY 197 the medical profession has always assumed toward the prevention of these diseases; (2) the fact that most concerns have discharged the employee who was discovered with venereal disease. The war has awakened the profession and the general public to the extensiveness and the ravages of both gonorrhea and syphilis throughout the army and the civil population. It is to be expected that a more active, nationwide fight against these conditions will be the result. The plant physicians are in the best position to take a very prominent part in such an effort. Figures obtained from many industrial physicians show that the number of venereal cases found among the employees examined varies from 2 to 10 per cent. This is exceedingly low as compared with other diseases found and as compared with the statistics given showing the great prevalence of these diseases in the army and in many of our large cities. The explanation is found in the fact that the infected employee very carefully concealed his trouble fearing the loss of his job if it became known. In 1915 I began a systematic search for these cases. The manage- ment, through their medical department, let it become known that no man would lose his job if he reported to the doctor's office when he was diseased and especially if he followed the directions given him re- garding the protection of others. As a result the number of men found with venereal diseases rapidly increased. Arrangements were made to treat all these cases at the night clinic of Industrial Medicine and Surgery at Rush Medical College. Salvarsan was administered to the syphilitic cases for the cost of the drug. In a few cases loans from the concern were made to buy this drug due to the fact that it became very expensive during the early years of the war. All employees with syphilis in its communicable stage were kept away from work until the open lesion was healed. Careful instructions were given to aU types of cases regarding the dangers of contaminating others. The acute gonorrheas were given light work always until it was safe for them to return to heavy occupations. Prevention propaganda was spread by personal talks whenever possible. I am sorry to admit that a general campaign of preven- tion against this condition, which certainly lowered the efficiency of the working force and caused much loss of time from work, was not undertaken. It is absolutely necessary for the medical staffs of industry to at once recognize that the prevention of venereal diseases is as logical a part of their work as the prevention of accidents and of other diseases. To accomplish this they should immediately adopt the following procedures : 1. Spread the propaganda concerning the prevention of venereal 198 INDUSTRIAL MEDICINE AND SURGERY diseases throughout the entire force, by posters printed in different languages and placed in every toilet; by individual talks, lectures to the men and stereopticon shows; b}'- women physicians giving lectures to the girl employees. The following bulletin taken from the State Board of Health of Michigan and adapted to industrial needs by a few changes will illustrate the type of poster to use: VENEREAL DISEASES "Gonorrhea (or clap) is a germ disease. It causes: (1) 111 health and loss of time and money to the man infected. (2) Many innocent wives to become invalids for life. (3) A large proportion of surgical operations upon women. (4) Many childless marriages. (5) Much of the blindness of children. Gonorrhea can be cured but often is not cured when the man thinks himself cured. The germs of gonorrhea often remain hidden in the body ready to cause serious trouble, even when the symptoms of disease have apparently ceased under treatment. " Syphilis (or pox) is often a germ disease. If not cured, syphilis may be transmitted to wives and children many years after infection. It may cause insanity, locomotor ataxia, or total paralysis. Syphilis can be cured, but only by long and thorough medical treatment. " Prevention. — (1) Keep away from prostitutes, both professional and non-professional. (2) Sexual intercourse is not necessary to phys- ical and mental health. (3) Antiseptic washes and other preventive measures are not always reliable. " Beware of advertising specialists, who claim to cure 'nervous debility,' and 'private diseases of men." The use of patent venereal medicines may lead to very serious consequences. Night emissions, or 'wet dreams,' if not too frequent are natural in men. They are not a sign of 'lost manhood.' Advertising specialists get large sums of money for treating 'diseases' which do not exist. " What to Do.- — (l) If you have exposed yourself, go at once to a competent physician. (2) If you contract venereal disease protect yourself and protect others — report at once to the doctor's office. The plant physician will see that you receive proper treatment. You will not lose your job and the trouble wiU be held confidential between you and the doctor. (3) Do not worry. Lead a vigorous, healthful life and forget about sex matters. (4) Be consistent and adopt the same standard of sexual conduct for yourself that you expect of women." 2. Arrange for the proper treatment of every venereal case and carefully supervise until cured. 3. Instruct each case in proper methods of protection of his fellow workmen. EPIDEMIOLOGY IN INDUSTRY 199 4. Report every case to the Department of Health and co-operate with them in tracing down the source of the infection and in freeing the community of that prostitute. 5. Subtly ascertain if the infected employee has infected other women and report these to proper authorities. 6. Work for the adoption by all state governments of the following measures suggested by the Council of National Defense, Committee for Civilian Co-operation in Combating Venereal Disease. "(a) Establishment of a Bureau or Division of Venereal Diseases of the Department of Health with an ade- quate personnel, and with provisions for free labora- tory examinations (including the "Wassermann test) and for the distribution of arsphenamine (salvarsan) under proper regulations free or at cost. "(6) Provision for the suppression of prostitution, for the examination of arrested prostitutes and for the iso- lation and treatment in public institutions of those infected. "(c) Provision for the commitment to institutions of unin- fected prostitutes for industrial training and for the commitment of all feeble-minded prostitutes to cus- todial care. "(d) Provision for the reporting of syphilis and gonococcus infection by physicians (according to regulations which protect both the patient and the public), and for the compulsory and systematic treatment of all infected persons when necessary and for the protection of the public health. "(e) Establishment of venereal disease clinics and advisory stations. "(f) Provision for the posting of venereal disease placards in men's lavatories of barber shops, Y. M. C. A.'s, hotels, railroad stations, factories, stores and similar places and for the distribution of pamphlets of information. "(g) Provisions for lectures (with or without stereopticon) and for the display of educational exhibits under the auspices of the board of health, the council of defense or other agency, before business men's organizations, employed men, women, boys, and girls, church organ- izations, women's clubs and other groups. " (i^) Provisions for the elimination of advertising specialists in men's diseases and of the sale of venereal disease nostrums." 200 INDUSTRIAL MEDICINE AND SURGERY Industrial surgeons have taken the lead in almost every branch of preventive medicine and preventive surgery. The prevention of venereal diseases alone has been neglected. Laying all other motives aside, from an economic standpoint we can no longer afford to neglect this work. CHAPTER XIX HEALTH HAZARDS IN OCCUPATIONS The physician responsible for the human maintenance in an in- dustry must become expert in the detection and prevention of every health hazard connected with the various occupations represented therein. Volumes have been written on this subject of occupational diseases. In Europe numerous laws have been enacted for the prevention of work diseases and of recent years have been vigorously enforced. In our own country the various states are beginning to awaken to their re- sponsibility toward the millions of people employed in hazardous occupations and each year sees new and better legislation on this sub- ject. Not, however, until clear and adequate laws are passed and rigidly enforced by every state and by the Federal Government wiU the prevention of these conditions be perfected. Hand in hand with the legal measures there must be a nationwide educational campaign instituted. Physicians practicing industrial medicine must know the classical occupational diseases and must be constantly on the lookout for hazards in other occupations not heretofore considered harmful to employees. These doctors must become the pioneer crusaders in this, one of the greatest health movements thus far undertaken in our country. Until within the last ten years the subject of occupational diseases has been woefuUy neglected by the majority of the medical profes- sion. As a result of the work of a few physicians in industry the sub- ject has been more and more forcibly presented with the end that at least six medical schools of the country now have courses for the stu- dents covering many of these diseases. Dr. John D. Ellis, one of the pioneer teachers in Industrial Medi- cine at Rush Medical College, University of Chicago, has written the following article on Health Hazards in Occupations for the author. This resume and the references to other authors should give the student an excellent insight into the wide range of diseases which can result from occupations and the various methods employed thus far for their prevention. For this most helpful contribution the author desires once more to express his gratitude to his co-laborer, Dr. John D. Ellis, 201 202 INDUSTRIAL MEDICINE AND SURGERY DUST AS A HEALTH HAZARD The number of men who are unfitted for work at their trades or who are incapacitated after a few years of work because of conditions resulting from working at dusty occupations far exceeds those incapa- citated by all other health hazards. Dusty trades, therefore, claim consideration of first magnitude by the industrial physician. The health hazard resulting from dusty occupations is difficult to estimate since injurious effects are not always due to dust itself, but many times to bacteria gaining entrance to the system with the dust, or to infections made possible through lowering of the general or local resistance caused by the effect of dust on the workmen. Dust, both of the invisible and visible type, is much more dense in the air in factories and workshops than in any other place in which human beings are crowded together. The coarser dusts are of course visible, but the finely pulverized particles of matter constituting in- visible dust may be far more harmful if composed of irritating me- chanical matter like silicate spicules or poisonous material such as soluble lead salts. Some of the commonest industries in which the worker inhales large amounts of dust are the textile mills, especially cotton mills, in the carding and preparing rooms and manufacturing of shoddy, in handling of rags and other waste products of such mills, manufactur- ing of clothing and furs, renovating clothing, rags and mattresses, in flour and corn mills, quarrying and grinding of stone and the manufacture of cement, the smelting, buffing and refining of metals, and in the manufacture of carborundum, graphite, carbide and lime. Rambousek ' quotes Hesse whose table of amounts of dust inhaled by men working ten hours a day in certain dusty industries is as follows : Horsehair works . 05 grams per day Saw mills 0.09 grams per day Wool mills. 0. 10 grams per day Flour mills 0. 12 grams per day Iron foundries 0. 14 grams per day Snuff-tobacco workers . 36 grams per day Cement works 1.12 grams per day 15 grams per year (300 days) 27 grams per year 30 grams per year 36 grams per year 42 grams per year 108 grams per year 336 grams per year Arens^ determinations show that in cement works while not in operation there were 130 milligrams of dust per cubic meter; while during the operation of the plant there were 244 milligrams. In a felt shoe factory in operation he estimated there were 175 milli- grams of dust per cubic meter of air; while Rogers found in skirt fac- 1 Luftnerungreinigung und Ventilation, p. 103. 2 Ibid. HEALTH HAZARDS IN OCCUPATIONS 203 tory and pearl button works 70 grams of dust per million liters of air and in a brass foundry 75.2 grams in the same volume of air. Price ^ classifies dust as follows: 1. As to source: (a) Meta . (b) Mineral. (c) Vegetable. (d) Animal. 2. As to physical qualities: (a) Size. (6) Shape. Round or sharp edges. 3. As to chemical characteristics: (a) Organic or inorganic. (6) Soluble or insoluble. Hoffman^ classifies the source of dust in forty-two dusty industries, which of course does not include entire category, into the following groups : d repair, of a total length of two feet for every five persons employed, fitted with waste pipes, and without plugs, with a sufficient supply of warm water constantly available. The lavatory shall be kept thoroughly cleansed and shall be sup- plied with a sufficient quantity of clean towels once every day. 13. Before each meal and before the end of the day's work, at least ten minutes, in addition to the regular meal times, shall be allowed for washing to each person who has been employed in the manipula- tion of dry compounds of lead or in pasting. Provided that if the lavatory accommodation specially reserved for such person exceeds that required by Regulation 12, the time allowance may be proportionately reduced, and that if there be one basin or two feet of trough for each such person this regulation shall not apply. 14. Baths. — Sufficient bath accommodation shall be provided for all persons engaged in the manipulation of dry compounds of lead or in pasting, with hot and cold water laid on, and a sufficient supply of soap and towels. This rule shall not apply if in consideration of the special cir- cumstances of any particular case, the Chief Inspector of Factories approves the use of local public baths when conveniently near, under the conditions (if any) named in such approval. 15. Cleaning. — The floors and benches of each workroom shall be thoroughly cleansed daily, at a time when no other work is being carried on in theroom. Duties of Persons Employed 16. Medical Examination.^ — All persons employed in lead processes shall present themselves at the appointed times for examination by the appointed surgeon as provided in regulation 8. No person after suspension shall work in a lead process, in any factory or workshop in which electric accumulators are manufactured, without written sanction entered in the health register by the appointed surgeon. 17. Overalls. — Every person employed in the manipulation of dry compounds of lead or in pasting shall wear the overalls provided under Regulation 9. The overalls, when not being worn, and clothing put off during working hours, shall be deposited in the places under Regulation 10. 18. Food, Etc. — No person shall introduce, keep, prepare, or 264 INDUSTRIAL MEDICINE AND SURGERY partake of any food, drink (other than any sanitary drink provided by the occupier and approved by the appointed surgeon), or tobacco in any room in which a lead process is carried on. 19. Washing. — No person employed in a lead process shall leave the premises or partake of meals without previously and carefully cleaning and washing the hands. 20. Baths. — Every person employed in the manipulation of dry compounds of lead or in pasting shall take a bath at least once a week. 21. Interference with Safety Appliances. — No person shall in any way interfere, without the concurrence of the occupier or manager, with the means and appliances provided for the removal of the dust or fumes, and for the carrying out of these regulations. The Massachusetts State Board of Health has issued the following protective measures in a publicity campaign against lead poisoning: "The poison gains entrance into the system: (1) By swallowing minute particles of lead. (2) By inhaling lead dust or fumes of lead in a molten state or the vapor of lead in a fused state. (3) By absorption from the skin in handling lead. Advice to Employees 1. General personal cleanliness is of first importance. 2. Thoroughly clean your hands before touching food or before leaving the workroom. 3. Thoroughly rinse your mouth before eating. 4. Take a substantial breakfast; an empty stomach is more sus- ceptible to the poisonous effects of lead. 5. Take good nutritious food and plenty of milk. 6. Never eat at your work. Eat your luncheon outside of the workroom away from the lead. Never smoke or use tobacco in any form while at work. 7. Avoid all excesses! Alcoholic beverages are especially injurious. 8. Wear overalls or a long coat at your work; also a cap or some head covering. Wherever practical wear gloves when lead is to be handled. 9. Persons working in white lead or other powdered compounds of lead should always wear respirators while at work. Cause as little dust as possible. 10. Consult a physician at the first sign of ill health. Advice to Employers 1. Provide washing facilities, lockers, and a place for the employees to eat luncheons away from lead. HEALTH HAZARDS IN OCCUPATIONS 265 2. Provide respirators for all workers who have to handle white lead or other powdered compounds of lead. 3. The floors of the workrooms and the benches at which men work should be cleaned daily after thoroughly moistening them. 4. These regulations should be posted in a conspicuous place in the workrooms." White Lead.- — ^The processes in the production of white lead which create dust are the most dangerous. Chambers should only be emptied by men wearing respirators. Vacuum cleaning apparatus should be used to clean all dusty apparatus. Drying stoves should as far as possible be mechanically charged. Similar measures should be em- ployed in the production of red lead, and lead chromates. The Painters Trade. — The painters trade in all countries furnishes employment for a larger number of men than any other lead trade. Because the men do not always work in shops but, as in the case of house painters, in the various places where painting must be done it is an especially difficult trade in which to control the working conditions. The workers themselves sometimes recognize some of the dangers to which they are exposed as is evidenced by the following reason- able demands made by the Brotherhood of Chicago Painters and paperhangers during a strike in April, 1913: '' No workmen or apprentices shall be required to use any poisonous substance or material injurious to health, such as wood alcohol, varnish remover, oxalic acid, or the sanding of lead, etc., unless they are protected with respirators, gloves, etc., same to be furnished by the employer; nor shall they be required to use any dirty or insanitary waste, rags or drop cloths. There shall be an allowance of five minutes for wash time in each four hours' work, and where lead or other poisonous material is used, the employer shall furnish hot water, soap and towels to the workmen. The officers and members of the organization shall enforce this clause." The German regulations, as quoted by Rambousek, covering the trades of this group are admirable: I. Regulations for carrying on the Industries of Painting, Distem- pering, Whitewashing, Plastering or Varnishing. Regulation — 1. In the processes of crushing, blending, mixing and otherwise preparing white lead, other lead colors, or mixtures thereof with other substances in a dry state, the workers shall not directly handle pigment containing lead, and shall be adequately protected against the dust arising therefrom. Regulation 2. — The process of grinding white lead with oil or varnish shall not be done by hand, but entirely by mechanical means, and in vessels so constructed that even in the processes of charging 266 INDUSTRIAL MEDICINE AND SURGERY them with white lead no dust shall escape into places where work is carried on. This provision shall apply to other lead colors. Provided that such lead colors may be ground by hand by male workers over eighteen years of age, if not more than one kilogram of red lead and one hundred grains of other lead colors are ground by any one worker in one day. Regulation 3. — The processes of rubbing down and pumice- stoning dry coats of oil color or stopping, not clearly free from lead, shall not be done except after damping. All debris produced by rubbing down and pumice-stoning shall be removed before it becomes dry. Regulation 4:. — The employer shall see that every worker who handles lead colors or mixtures thereof is provided with, and wears, during working hours, a painter's overall or other complete suit of working clothes. Regulation 5.' — There shall be provided for all workers engaged in processes of painting, distempering, whitewashing, plastering, or varnishing, in which lead colors are used, washing utensils, nail brushes, soap and towels. If such processes are carried on in a new building or in a workshop, provision shall be made for the workers to wash in a place protected from frost, and to store their clothing in a clean place. Regulation 6. — The employer shall inform workers, who handle lead colors or mixtures thereof, of the danger to health to which they are exposed, and shall hand them, at the commencement of employ- ment, a copy of the accompanying leaflet (not printed with this edition), if they are not already provided with it, and also a copy of these regulations. II. Regulations for the Processes of Painting, Distempering, Whitewashing, Plastering, or Varnishing when carried on in con- nection with another Industry. Regulation 7.- — The provisions of paragraph 6 shall apply to the employment of workers connected with another industry who are constantly or principally employed in the processes of painting, dis- tempering, whitewashing, plastering, or varnishing, and who use, otherwise than occasionally, lead colors or mixtures thereof. The provisions of paragraphs 8 to 11 shall also apply if such employment is carried on in a factory or shipbuilding yard. Regulation 8. — Special accommodation for washing and for dressing shall be provided for the workers, which accommodation shall be kept clean, heated in cold weather, and furnished with conveniences for the storage of clothing. Regulation 9. — The employer shall issue regulations which shall be HEALTH HAZARDS IN OCCUPATIONS 267 binding on the workers, and shall contain the following provisions for such workers as handle lead colors and mixtures thereof : 1. Workers shall not consume spirits in any place where work is carried on. 2. Workers shall not partake of food or drink, or leave the place of employment until they have put off their working clothes and carefully washed their hands. 3. Workers when engaged in processes specified by the employer, shall wear working clothes. 4. Smoking cigars and cigarettes is prohibited during work. Furthermore it shall be set forth in the regulations that workers who, in spite of reiterated warning, contravene the foregoing provi- sions may be dismissed before the expiration of their contract without notice. If a code of regulations has been issued for the industry above indicated, provisions shall be incorporated in the said code. Regulation 10.' — The employer shall entrust the supervision of the worker's health to a duly qualified medical man approved of by the public authority, and notified to the factory inspector, and the said medical man shall examine the workers once at least in every six months for symptoms indicative of plumbism. The employer shall not permit any worker who is suffering from plumbism or who, in the opinion of the doctor, is suspected of plum- bism, to be employed in any work in which he has to handle lead colors or mixtures thereof, until he has completely recovered. Regulation 11. — The employer shall keep or cause to be kept a register in which shall be recorded the state of health of the workers, and also the constitution of and changes in the staff; and he shall be responsible for the entries being complete and accurate, except in so far as they are affected by the medical man. The Printing Trades. — It is undesirable that open metal pots should be in a general room where type-casting and setting and machinery are at work. The pots should be hooded and the fumes carried away by exhaust ventilation. It is important that these fumes shall not be distributed too near factories or dwelling places. In cleaning the flues men should be equipped with breathing apparatus. Local exhaust ventilation should be applied to type cases and letter casting machines. Vacuum cleaning of workrooms and type cases is strongly advised. Several hygienic safeguards against plumbism are of course necessary. The Ceramic Industries. — In May, 1898, in England, the Home Secretary appointed Professor Thorpe and Dr. Thomas Oliver to make special inquiry and ascertain (1) how far the danger (of lead poison- ing in potteries) may be diminished or removed by substituting 268 INDUSTRIAL MEDICINE AND SURGERY for the carbonate of lead ordinarily used, either (o) one or other less soluble compound of lead, e.g., a silicate; (6) leadless glaze; (2) how far any substitutes found to be harmless or less dangerous than the carbonate of lead fit themselves to the varied practical requirements of the manufacturer; (3) what other preventive measures can be adopted. ♦" The recommendations of this committee were: "1. That by far the greater amount of earthenware of the class already specified, i.e., the white and cream colored ware, can be glazed without the use of lead in any form. It has been demonstrated with- out the slighest doubt that the ware so made is in no respect inferior to that coated with lead glaze. There seems no reason, therefore, why in the manufacture of this class of goods the operatives should still continue to be exposed to the evils which the use of lead entails. 2. There are, however, certain branches of the pottery industry in which it would be more difficult to dispense with the use fef lead compounds. But there is no reason why, in these cases, the lead so employed should not be in the form of a fritted double silicate. Such a compound, if properly made, is but slightly attacked by even strong hydrochloric, acetic, or lactic acid. There is little doubt that if lead must be used, the employment of such a compound silicate — if its use could be insured — would greatly diminish the evil of lead poisoning. 3. The use of raw lead as an ingredient of glazing material, or as an ingredient of colors which have to be subsequently fired, should be absolutely prohibited. 4. As it would be very difficult to insure that an innocuous lead glaze shall be employed, we are of the opinion that young persons and women should be excluded from employment as dippers, dippers' assistants, ware cleaners after dippers, and glost placers in factories where lead glaze is used, and that the adult male dippers, dippers' assistants, ware cleaners, and glost placers should be subjected to systematic medical inspection." The danger of plumbism is greatest in small works since the technic necessary for the production of leadless glazes make their production in small quantities difficult and discontinuance of the use of lea glazes necessitates the complete alteration of their equipment for manufac- ture. Furthermore the cost of installation of localized exhaust ventila- tion is far greater in proportion to the cost of production in the small than in the large factory. Teleky, Chyzer and the Dutch Inspector DeVooys,^ have demanded the total prohibition of the use of lead glazes and in Bohemia, at the cost of the state, technical instruction has been given in the preparation of leadless glazes in the districts where the ceramic industries are carried on in the homes of the workers. iRambousek; "industrial Poisoning," p. 320. HEALTH HAZARDS IN OCCUPATIONS 269 Rambousek, contrary to Oliver, does not expect much good from the obligatory use of fritted glazes. In Great Britain the china and earthenware industry is placed under Regulations dated January 2, 1913, which supersede the previous Special Rules. These Regulations- — thirty-six in number — provide, among other usual provisions, (1) for efficient exhaust ventilation in (a) processes giving rise to injurious mineral dust (settling and pressing of tiles, bedding, and flinting, brushing and scouring of biscuit) and (h) dusty lead processes (ware cleaning, aerographing, color dusting, litho-transfer making, etc.); and (2) monthly periodical medical ex- amination of workers in scheduled processes. Zinc, Brass-casting, Metal Pickling, Galvanizing. — Metallic fumes from zinc smelting contain lead, zinc, arsenic, sulphur dioxid and carbon dioxid. These require to be condensed in a specially arranged system. Hoods should be arranged over the fronts of furnaces so that fumes arising during the removal of distillation residues can be conducted into the chimney stock or drawn away by a fan. The residue should be automatically removed from the furnaces into closed receptacles where it is confined until cooled. The mixing of materials for charging as well as the sifting and packing of the zinc dust should be done mechanically under local exhaust ventilation. The regulations to control zinc smelting should be practically the same as those of lead. In brass-casting the development of brass founders' ague is best prevented by the local exhaustion of zinc oxid fumes as they escape from the crucible. Casting is often done in various places throughout the foundry and it is necessary to install small hoods connected to the exhaust ventilation system by flexible hose which can be moved about to cover any region where the casting may be in operation to protect the face of the pourer. In metal pickling dangerous acid fumes are evolved and require that the work be done in isolated chambers with exhaust ventilation. Well adapted for this purpose is a wooden compartment closed in except for a small opening in front exhausted by an acid proof stone- ware fan which leads the fumes through a stoneware pipe to an ab- sorption tower through which water trickles. The water thus charged with acid can often be utilized. In galvanizing and tinning processes acroleic vapors and metallic fumes arise as the metal objects are cleansed and dipped. These fumes must be exhausted as described above. Mercury. — In smelting cinnabar sulphur dioxid and mercury fumes must both be exhausted. The mercury deposit in the flues should only be removed after watering and by workers provided with breathing apparatus and working suits. 270 INDUSTRIAL MEDICINE AND SURGERY The advisability of the substitution of other chemicals for mer- cury in mirror making has been mentioned before. In using nitrate of mercury in the manufacture of felt hats, dust and nitric fumes must be exhausted and strict personal hygiene of the workers insisted upon. In France the following notice is required to be posted in animal hair cutting establishments where mercury is used: "Mercury and its compounds are dangerous. They may enter the body with the air breathed in (dust, vapors), with the food (unclean hands, unclean tables), through the skin (cracks, scratches or cuts). Should you have any cracks, scratches or cuts, please inform the management immediately of the fact. Before eating or drinking carefully clean your hands with soap and your mouth with drinking water. Should you have any pains in the mouth or teeth and excessive quantity of saliva, should you shiver, should you have swelling of the legs, hands or under the eyes, consult the doctor at once." Air pumps should be substituted for mercury pumps in produc- ing the vacuum in electric light bulbs. Careless handling of this volatile metal will endanger dentists, barometer and thermometer makers. In chemical factories calomel and corrosive sublimate, and the other mercury salts should be ground and prepared in closed appa- ratus. The following are general preventive measures for workers in mercury suggested by Dr. George M. Kober: 1. The imperative necessity of providing local exhaust ventila- tion wherever dust and fumes are evolved, as well as a reduction of working hours during the warm weather, should be generally recognized. 2. All processes involving the use of mercury should be carried on in separate rooms, with a northern exposure of the windows, pref- erably at a temperature below 60°, so as to reduce the danger from volatilization of the metal to a minimum. Work should be suspended when the temperature exceeds 78°. 3. Wooden floors and work benches are objectionable as they favor the lodgment of spilled mercury in cracks and crevices. Ena- meled iron benches and smooth asphalt floors, provided with an in- cline and channels toward receptacles in which the mercury may collect should be chosen. The receptacles should be covered leaving only a narrow opening just sufficient for the metal to enter. 4. Absolute care to prevent spilling of the mercury should be exercised. The work benches should be freed from the metal upon cessation of work, the floors should be sprinkled and swept two or three times a day. HEALTH HAZARDS IN OCCUPATIONS 271 5. The workers should be supphed with respirators in all dust producing processes; overalls and a suitable head covering of a per- fectly smooth material should be used and washed weekly. The hair should be worn closely trimmed, preferably no beard; female and youthful employees should be excluded. The use of alcoholic beverages and tobacco should be prohibited. 6. Cleanliness of person and clothing are of the utmost importance. No food should be taken in the workrooms and in no case until after thorough washing of the face and hands with soap and water, using a brush for the finger nails, also washing the mouth and teeth with brush and water, followed by the use of a mouth wash and gargle with a solution of either chlorate or permanganate of potash or phenate of sodium. Heucke recommends the use of akremin soap, containing soluble alkaline sulphides, and believes that the wash water should also contain potassium sulphuratum so as to convert the mercury into insoluble sulphides. 7. The firm should provide not only all the necessities referred to but also the facilities for warm shower and tub baths, suitable lockers for clothing, lunch rooms, and periodical medical examina- tion of the employees, with suspension from work if any are found to present symptoms of mercurial poisoning. Arsenic and Arseniuretted Hydrogen.^ — Since arsenic is a power- ful poison it is very important that the greatest possible care should be taken by all who are engaged in its manufacture or brought in contact with it. Dr. George M. Kober suggests the following regulations : The officials and workmen are requested to strictly observe the following rules, and generally to take every precaution to prevent arsenical poisoning: 1. In the process of de-arsenicating Vitriol, care must be taken to maintain an in-draught in the pipes and apparatus, to prevent escape of arsenical fumes, and should an escape be observed, the brine (or hydrochloric acid) should be at once shut off until the effect is remedied. 2. In the precipitating, drying and packing operations, a clean respirator (Grell's improved pattern) must always be used. A clean one must be obtained every morning from the laboratory, and the one used the previous day returned to the laboratory to be cleansed and prepared for use the next day. 3. Every workman engaged in this process shall be provided by the company with a pair of India rubber gloves and a suit of clothes, which he is to put on in the morning and remove on leaving the works at night, and shall take a bath before putting on his ordinary clothing. These special clothes to be washed by the company and supplied 272 INDUSTRIAL MEDICINE AND SURGERY clean to the workman once a week. Workmen must thoroughly wash their hands before taking food in the works. 4. The buildings in which the manufacture of arsenic is carried on must be well ventilated to remove all fmnes of chlorid of arsenic or dust of arsenious acid from the atmosphere. 5. Any workman having cuts or abrasions on the skin will not be permitted to work in the arsenical department until such wounds have quite healed. 6. Any workman showing the slightest signs of arsenical poisoning must be examined by a doctor and undergo medical treatment. Respirators should be worn by those handling white arsenic and packing or dusty processes should be done under local exhaust ventila- tion. In arsenic work imperviousness of the system is imperative. In technical processes and the trades, substitutes should replace arsenic wherever possible. All workmen in such industries as may necessitate even the pos- sibility of exposure to arseniuretted hydrogen gas such as in soldering with hydrogen, in galvanizing processes, in extracting metals with acids, and in storage battery manufacture, should be made thoroughly conversant with the danger and instructed in the use of first aid methods in the case of emergency. Gold and Silver. — The same precautions apply to the extraction of the precious metals by amalgamation with mercury and volatiliza- tion as are mentioned under the use of mercury. Varnishes and Drying Oils.- — Closely fitting covers should be applied when linseed oil is boiled with oxidizing substances or in dissolving resin and the fumes should be condensed in cooling apparatus. Especial care should be exercised in the use of quick drying paints in the interior of rooms or ships or inside steam boilers, or any other enclosed place as fatalities have occurred from the inhalation of such poisonous solvents as benzin and turpentine. COMPENSATION AND INSURANCE The third class of preventive measures against diseases of oc- cupation is that of compensation and insurance. The principal question involved in the establishment of a method of compensation or insurance is that of ascertaining the per cent, to be borne by the community or state and the per cent, to be borne by the employer. Whether, as the supreme courts of some of the states such as California and Massachusetts have recently held, lead poisoning and other occupational intoxications can be considered as "personal injuries" or not, it certainly is as fair that compensation should be awarded the victim of occupational disease as that it should be given HEALTH HAZARDS IN OCCUPATIONS 273 to the victim of an industrial accident. If the employer is required to bear a part of the burden of providing compensation for the employee disabled by industrial disease, the importance of prevention of such conditions is thereby most forcibly impressed upon him. If, however, the employer has done all that he can to make the occupation of his employees conform with the laws in effect cover- ing such occupations and follows the suggestions made by the agencies especially trained and competent in the prevention of these conditions, there is no moral reason why he should pay compensation for occupa- tional diseases. The state in allowing hazardous occupations to exist and thus acknowledging that the products of such occupations are necessary to the commonwealth thereby tacitly admits that it is responsibe for illness specifically due to such occupation and should bear the burden of compensation. In either case the expense of compensation would prove one of the greatest incentives for adequate prevention of occupational diseases. 18 274 INDUSTRIAL MEDICINE AND SURGERY LIST OF INDUSTRIAL POISONS (Translated by Wm. H. Rand, M. D.) (From Bulletin of the Bureau of Labor, No. 100, May, 1912) Designation of the substance Branches of industry in which poisoning occurs Mode of entrance into the body Symptoms of poisoning ACETALDEHYD ETHYLALDEHYD, CH3COH: A color- less, very volatile fluid, of pungent , odor. Manufacture of vine- gar; silver mirror manufacture. In the form of vapor, through the respiratory organs and mucous mem- branes. Irritation of the mucous membranes of the nose, larynx, and bronchi; irritation of the mucous membrane of the eyes; acceleration of the heart's action; profuse night sweats. ACRIDIN, C13H9N: Crystallizing in col- orless needles; con- tained in anthra- cene. ACROLEIN, C2H3- COH: A colorless, very pungent smell- ing fluid, of fiery taste. AMMONIA, NHs: A colorless gas of sharply penetrating odor. Organic dyes indus- try. In the trying out of fat and fat con- taining material, e.g., in bone ren- dering plants ; oil- cloth and linoleum factories; varnish- boiling shops; tal- low-rendering es- tablishments; soap factories (sulphuric acid process), and stearic-acid factories. Exerts effect in any state of aggregation on skin and mucous mem- branes. Irritation and inflammation of skin and mucous membranes; severe burning and itching of the skin; violent sneezing. In vaporous form, through the organs of respiration and the mu- cous mem- branes. Coke ovens; mirror- silvering _ industry; coating iron plate with tin or zinc; manufacture of solidified ammo- nia, sulphate and chlorid of am- monium (sal am- moniac) from am- monia water; manufacture of the carbonate of soda and of orselle dye- stuffs; dyeing in- dustry; sewer cleaning; manufac- ture of bone black; gas plants ; varnish and lacquer manu- facture; tanning; beet-sugar m a n u- facture; _ manufac- ture of ice; refrig- eration plants. In gaseous form, through the organs of respiration. Seldom pure, mostly in combination with other Immediate effect on the conjunctiva and the cor nea. Itching in the throat; irritation of the eyes, exciting lachrimation, conjunctivitis; irritation of the air passages, bronchial catarrh. A proportion of more than 0.15 per cent, of ammonia in the air imme- diately causes an irritable con- dition of the mucous membranes. Chronic bronchial catarrhs are especially liable to follow long- continued inhalation of small quantities of the gas diffused in the air. From these are to be dis- criminated the acute conditions of transient illness: Intense irrita- tion of the respiratory organs; violent sneezing; lachrimation, redness of the eyes, inflammation of the cornea and of the conjunc- tiva; increased secretion of saliva; burning in the pharynx, and a sense of constriction in the larynx; paroxysmal cough, with secretion of tenacious, viscid, even bloody, mucus; embarrassment of respira- tion, attacks of suffocation; vomit- ing of serous masses; ammoniacal odor of the perspiration; retention of urine, which may last many hours and even two or three days; acute inflammation of the respira- tory organs, and scattered areas of inflammation in the lungs, in severe cases, a fatal outcome. Protracted _ breathing of small quantities is apt to cause chronic bronchial catarrh. Special measures of relief : Immediate removal from the poisonous atmosphere; artificial respira- tion; inhalation of steam; faradic stimulation of the phrenic nerve; free bloodletting; in case of obstinate spasm of the glottis, tracheotomy. HEALTH HAZARDS IN OCCUPATIONS 275 Designation of the substance Branches of industry in which poisoning occurs Mode of entrance into the body Symptoms of poisoning AMYL ACETATE, C6HnCH3C02: Za- pone, a solution of celluloid in amyl acetate and acetone Zapone lacquer used as a lacquering agent in metallic ware and jewelry factories; manu- facture of metallic wire for incandes- cent electric lamps; oilcloth manufac- ture. In the form of vapor, through the respiratory organs. Nervous symptoms; headache; full- ness of the head; Kiddiness; nausea; numbness; flisturbanros of diges- tion; palpitations of the heart. AMYL ALCOHOL, CoHiiGH: A color- less, oily fluid, of very sharp taste and penetrating, disagreeable odor. Manufacture of fruit essences, nitrite of amyl, valeric acid, and anilin dyes; rectification of spirits. In the form of vapor, through the organs of res- piration. Congestion of .the head; headache; oppression of the chest; irritation of the air passages. ANILIN, CrH.^(N- H2): A colorless oil which acquires a tint on exposure to air and light. Like anilin, all other amid compounds of benzol and its homo- logues, as toluol, naphthalin, xylol, etc., are poisons. Especially should be mentioned alpha and beta naphthy- lamin, benzidin, tolidin, paianitra- nilin, the diamins (phenylene and tol- ylene diamin) as well as the alphyl and aryl com- jjounds of anilin, like their homo- logues (dimethyl and diethyl anilin, diphenylamin, etc.). Manufacture of ani- lin and its deriva- tives, as well as of anilin dyes: manu- facture of photo- graphic materials and the like. Absorption through the skin by di- rect contact or by satura- tion of the c lothing; through the digestive or- gans; absorp- tion through the respira- tory organs as volatile particles and impalpable dust. The toxirity of the separate products is very different in degree ; the para compounds are usually more poisonous than the ortho and meta compounds. Acute Poisoning. — (a) Mild cases: Pallor of the skin and mucous membranes, with slight cyanosis; a feeling of weariness and weakness; head symptoms — ver- tigo, reeling, unsteady gait; defi- cient elasticity of movement; slow, labored speech ; irritability (anilin "pip"); condition of slight inebri- ation, with loquacity, gaiety, and defective power of orientation; loss of appetite, constipation, and tense, rapid pulse. (6) Severe cases: Dark blue to swarthy cyanosis; formation of methemoglobin; bounding pulse; "air-hunger," with great frequency of respiration; lowering of sensi- bility; obliteration of the reflexes; sometimes vomiting, strangury and bloody urine. (c) In the most serious cases: Sudden prostration; cold, pale skin, blue lips, nose and ears; diminution and even extinction of sensibility; moist, cold skin; small pulse; death in a comatose condi- tion, sometimes after antecedent convulsions. StTBACtTTE AND ChRONIC POISON- ING. — Anemia; slowing of the pulse; disorders of digestion, such as eructations, loathing of food, vomiting, diarrhea, and eczematous and pustular eruptions on various parts of the body, especially on the scrotum; nervous symptoms, as general debility, headache, ringing in the ears, vertigo, unrestful sleep, disturbances of sensibility, often also of motility; spasmodic muscu- lar pain. Subacute and chronic poisonings are very rare. Anemia and retarded pulse are early symptoms. The blood is of a brownish hue, but microscopically unchanged ; occasionally the urine contains blood. Measures of relief: At the first symptoms of poisoning, immediate removal from the workroom to a cool shady spot; change of clothing; cool affusions; administration of oxygen in connection with artificial respiration; in severe cases, bloodletting with subsequent infusion of physiological salt solution; cooious ingestion of milk; in case of weak action of the heart, stimulants (black coffee, camphor, ether, but no alcohol); caution against the use of alcohol during and immediately after labor; abstinence is advisable. ^ 27G INDUSTRIAL MEDICINE AND SURGERY Designation of the substance Branches of industry in which poisoning occurs Mode of entrance into the body Symptoms of poisoning ANILIN DYE- STUFFS: The ma- jority of the very numerous anihn dyes are non-poi- sonous. Generally the basic dyes are more dangerous than the acid dyes. Regarded as sus- picious or injurious to health are — (a) The various phenol nitrates, di- nitrophenol, dini- trocresol (saffron yellow, _ anilin orange), picric acid (trinitrophenol) . (6) The many naphthol nitrates, dinitronaphthol, Manchester yellow, dinitro and naph- thol calcium; tet- ranitronaphthol. (c) The nitroso dyes. (d) The aurantia — hexanitrodi- phenylamin; im- perial yellow, sodium salt. (e) Ethyl methyl violet. its and (.0 The Meldola dyes, corvulin, in- dulin, fast black. (g) Chrysoidin, fast black. (h) Bismarck blue Anilin dye factories; dyehouses; also manufacture of ex- plosives. Anilin dye manu- factories; dyehouses. Anilin dye manu- factories; dyehouses. Anilin dye manu- factories; dyehouses. Anilin dye manu- factories; dyehouses; manufacture o f colored pencils. Anilin dye manu- factories; dyehouses. Anilin dye manu- factories; dyehouses. Anilin dye manu- factories; dyehouses. Action on the skin; in the form of dust, through the respiratory organs; the digestive or- gans. Action on the skin; in the form of dust, through . the respiratory organs; the digestive or- gans. In the form of dust on the skin. In the tortii of dust on the skin. As dust or fine particles in the eyes. As dust or at- omized solu- tion (in dye- ing by the spraying pro- cess) ; action on the skin and respira- tory organs. In the form of dust; effect on the skin. ANTIMONY COM- POUNDS : Trioxid of antimony, SbiOs; Antimony trichlorid, SbCh (antimon- ious chlorid, butter of antimony, anti- monial ore butter) ; Tartar emetic (tar- trate of antimony and potassium), 2 (C4H4K[SbO]Oc) HoO; Golden sulphid, SbaSs (antimony pentasulphid), an- timony colors. Extraction of anti- In the form of mony and its com- vapor (trioxid pounds; burnish- of antimony, ing of rifle barrels antimonious and steel ware; acid, sulphid manufacture of of antimony) antimony alloys, through the type and stereo- organs of res- type metal, hard piration; irri- lead [ammunition tation of the factories], britan- skin; in the nia, and white form of dust, metal; remelting in the ma- of old and scrap nipulation o f metal; manufac- britannia and ture of anilin type metal, dyes, fireworks ; vulcanizing and red-dyeing of India rubber (antimony pentasulphid) ; mor dyeing and textile printing. Itching, dermatitis, efHorescent erup- tion, yellow discoloration of the cuticle and conjunctiva; sneezing and nasal catarrh; inflammation of the buccal mucous membrane; bitter taste; disturbances of diges- tion; irritation of the central nerv- ous system and of the kidneys. Picric acid is a feeble former of methemoglobin; industrial poi- sonings by it are extremely rare. Blood poisons, forming methemo- globin. The morbid symptoms resemble those in poisoning by amido compounds; ailments of the central nervous system in great variety; paralyses. Intense irritation of the skin, caused, it is asserted, partly by using excessive quantities of chlorid of lime in cleansing the skin. Intense irritation of the skin, caused, it is asserted, partly by using excessive quantities of chlorid of lime in cleansing the skin. Inflammation of the conjunctiva or the cornea. Eruptions; severe irritation of the mucous membranes; uncontroll- able sternutation. Eruptions (probably superinduced by the use of excessive quantities of the chlorid of lime in washing the hands). Intensely itching eruptions of the skin, caused by local irritation and aggravated in the case of a per- spiring skin; inflammation of the mouth, throat, and stomach; con- stipation and intestinal colic; in acute cases, diarrhea, albumin in the urine, loss of strength, weak- ness of the heart, vertigo, and faintness. It appears to be somewhat doubtful, however, whether all of the enumerated compounds of antimony are detrimental to the health of the workers in them. dants and fixing materials in cotton HEALTH HAZARDS IN OCCUPATIONS 277 Designation of the substance Branches of industry in which poisoning occurs ARSENIC COM- POUNDS: Arsenic trioxid, AS2O3 (ar- senic, white arsenic, smelting dust) ; arsenous chlorid, AsCls; arsenic col- ors, e.g. — Scheele's green (Swedish green), arsenite of copper. Schweinfurt green (patent, original, new, moss, moun- tain, oarrot, May, Kaiser, Cassel, Paris, Vienna, Kirchberg, Leipsic, Wiirzburg, Swiss green), compound of the arsenite and the sulphid of cop- per. Brunswick green, oxychlorid of cop- per with cODper oxid and sulphate of lime. Neuwied green. (Similar, only a larger proportion of ars nic trioxid.) Cochineal (Vienna red), arsenic acid with extract of Pernambuco wood. Mode of entrancf into the body Arsenic mining; In the forms of Acute Poisoning. — The first symp- roasting of arsenic- gas and dust, tonis usually appear after half an bearing ores; manu- through the hour or an hour, viz., constriction facture of glass, respiratory of the esophagus, pains in the colored chalk, chlo- organs and stomach and bowels, vomiting, rid of arsenic for mucous mom- diarrhea, debility, cold, bluish etching on brass; branes, the skin, sural cramp, lowering of shot manufacture; stomach, and heart's energy, _ vertigo, headache, metal working; intestinal fajntness, illusions, loss of con- manufacture of canal. sciousness, convulsions; death, arsenic colors; sometimes choleraic symptoms, preparation of or- In mild cases, burning in the ganic dyestuffs, pharynx, vorniting, salivation, colored lights, tex- difficult deglutition and indiges- tile printing, and tion. dyeing; manufac- Chronic Poisoning. — -Constant ture of wall paper and persistent headache combined and colored paper; with melancholia, disinclination tanning; manu- to labor, and sleeplessness, which facture of oilcloth are sometimes the only symptoms; and artificial flow- further, gastric disturbances, such ers; taxidermy as vomiting and diarrhea, which painting (outside result in emaciation and decline of and decorative); strength; persistent symptoms of pyrotechnics (In- catarrh of the mucous membranes, dian white-fire). such as coryza, pharyngitis and It is to be ob- bronchitis; frequently skin diseases served that zinc, in varying form: Frytbematous, silver, lead, bis- papular, and pustular cutaneous muth, copper, and eruptions, which also produce ab- the commercial scesses with infiltrated and indu- acids often con- rated borders; falling out of the tain more or less ha'r and nails; melanosis — -that is, arsenic. - the deposition of a brownish pig- ment, not containing arsenic, on the neck, trunk, and extremities. In severe cnoes disturbances of the_ central nervous system; intense, lightninglike, lancinatre riains; formi- cation; furriness of the skin; impairment of the sensibility; chilliness; weak- ness of the muscles, also unilateral or bilateral paralysis, and often loss of the tendon reflexes; sometimes fever; albuminuria. The paralyses are transient, or they may last for years, leaving not infrequently permanent disturbances. Syrriptfirris of poi.sorjing Special measures of relief: If arsenic has been ingested, thorough gastric lavage is necessary; then administer at once by the mouth five tablespoonfuls of a solution of calcined magnesia (70 g. to 500 g. of distilled water); afterward give a tablespoonful every five minutes until a movement of the bowels occurs; the internal use of lime water also is recommended for rinsing out the stomach and as an antidote; to counteract the exhaustion, cold affusions, rubbing, hypodermic injections of ether and camphor. 1 In case of chronic arsenical poisoning: Electric vapor baths and electrical treatment are in order; the disturbances of the stomach are to be treated with calcined magnesia and unirritating liquid nourishment (milk, milk porridge, rice porridge, salep) ; the cachexia, by fresh air and nutritious diet; in paralyses, use iodin preparations and electricity. ARSENIURETED HYDROGEN, AsHs: A colorless, extremely offensive gas with the odor of garlic. This gas is formed In the form of a everywhere when, gas, through in the use of arsen- the organs of ical acids and met- respiration als, hydrogen is (general! generated for tech- mixed with nical purposes (e. hydrogen). g., the filling of children's toy bal- loons) ; in solder- ing and etching with arsenic-con- taining metals or acids, e.g., enamel ware factories, tin, zinc, and lead plating works; imp'ire iron silicate, by the absorption of water, develops arseniuretted hydrogen. At first no disturbances, or only slight indisposition; after some hours, chilliness, vomiting (food, bile, then blood), pain in the back, giddiness, ringing in the ears, faint-' ness, small pulse, bluish discolora- tion of the mucous membranes; labored respiration; urine at times dark or even black, containing blood or hemoglobin. After twenty-four hours, yellow hue of the skin and mucous rnembranes; from absorption of biliary fluids, fetor of the mouth (resernbling garlic), swelling and sensitiveness of the liver and spleen, headache, delirium, mortal an- guish; death or slow convalescence. Special measures of relief: Fresh air and oxygen; later bloodletting; use of an alkalin solution of common salt; mild alkalin drink; analeptics (coffee, camphor). 1 Hydrated sesquioxid of iron is not mentioned. 278 INDUSTRIAL MEDICINE AND SURGERY Designation of the substance BENZIN : A n\ixture of low-ebiillition portions of petro- leum, known com- mercially under vari- ous names, e.g., petroleum, benzin, ligroin, gasolin. Branches of industry in which poisoning occurs Benzin distillation; chemical cleansing plants, glove clean- ing; removal of fat from bones, fat sol- vent; lacquer, var- nish, and India rubber industries; manufacture of waterproof mate- rials (application of the rubber mass dissolved in ben- zin) ; ornamental feather factories; used as a source of power. Mode of entrance into the body Symptoms of poisoning In the form of vapor, through the respiratory organs; to a less extent, probably , through the skin also. Headache, vertigo, nausea, vomiting, cough, irregular respiration, weak- ness of the heart, drowsiness, and deep sleep with cyanosis of the countenance, coldness of the skin and complete insensibility; on awaking, headache, vertigo and de- pression, fibrillar twitching of the .muscles, trembling, especially of the musculature, as if from chilli- ness. Benzoic acid is found in the urine. Chronic Poisoning. — Head- ache, flashes before the eyes, ring- ing in the ears, psychosis with excitement and a state resembling inebriation, sensory disturbances and hallucinations (but the prq- dromata of chronic benzin poi- soning will also appear). The occurrence of chronic poisoning by benzin has been contested. The symptoms vary greatly be- cause the benzin used technically is a complex mixture and not al- ways of the same composition. Special measures of relief : Removal of the patient into fresh air; in severe cases, stimulants, Uke coffee, camphor; then cold affusions. BENZOL, CrHe. A very unstable, color- less fluid, burning with a bright, very sooty flame) ex- tremely volatile; its homologues, e.g., toluol, xylol, and cumol. Manufacture of ben- zol, its homologues and numerous derivates; technic- al use of these products in the manufacture of colors, in carbur- izing illuminating and water gas, in refining and. dis- solving of caout- chouc, resins, fats, alkaloids, iodin, phosphorus, and sulphur; in the re- moval of grease from materials; dye works, laun- dries; lacquer and varnish factories; the rubber industry. In the form I Benzol, its homologues and the rest of vapor, of the hydrocarbons of coal tar, through the have a specific affinity for the respiratory central nervous system and a gen- orgo grain) subcutaneously to stimulate the pneumogastric. — W. H. R. 284 INDUSTRIAL MEDICINE AND SURGERY Designation of the substance Branches of industry in which poisoning occurs Mode of entrance into the body Symptoms of poisoning HYDROFLUORIC ACID or FLUORIC ACID, HF: A color- less gas, of pungent odor and forming a dense mist in the air. LEAD, Pb: A bluish white, highly lus- rous metal, which on exposure to the air acquires a gray tarnish. Lead alloys. Lead colors, other lead compounds. Lead sulphuret (galena) is held to be nonpoisonous, and some lead polysilioates are regarded as nearly Production in chem- In the form of ical works; glass gas, through factories, etching the respira- laborato- tory organs, ries of the pottery In a fluid industry; extrac- state it has tion of the fluor- an immediate ides of antimony action on the substitute for tar- skin and tar emetic in dye- mucous mem- works); fe r t i li z er branes. factories (extrac- tion of phosphor- ites) ; bleaching of cane for chair seats and extraction of its silicates. Intense irritation of the eyelids and conjunctiva, coryza, bronchial ca- tarrh with spasmodic cough, ulcera- tion of the nostrils, gums, and oral mucous membrane; also painful ulcers of the cuticle, erosions and formation of vesicles; suppuration under the finger nails. Absorption of Industrial lead poisoning appears as lead and lead a rule in the chronic form and compounds arises from continuous absorption occurs — of the most infinitesimal quantities (l)In isolated of lead during a protracted period cases through of time (weeks, months, and even the skin; years). whether The beginning is insidious, with through the disturbances of the general health, uninjured a sense of weakness, decline of skin is doubt- bodily strength; sallow, pale-yel- ful; (2) in the lowish hue of the skin. Distress in form of vapor the region of the stornach, eructa- (very finely tions, lack of appetite, metallic divided oxid taste in the mouth and fetid breath, of lead), and The blue line (blue-gray discolor- as dust, ation of the gums) which, however, through the may be absent, even in the course respiratory of a severe attack; lead colic with organs; (3) most obstinate constipation, reten- by way of the tion of urine; plumbic arthralgia digestive (lacerating, boring), occurring for t r a c t b y the most part paroxysmally, means of con- chiefly in the lower extremities, taminated more rarely in the upper, often in- fo o d a n d terpreted as a symptom of rheuma- drinks (for tism of the joints; frequently, fibril- ex a m p 1 e , lar trembling of the fingers. Typ- cigars, ciga- ical are the lead paralyses, of which rettes, chew- disturbances of sensation (pares- ing tobacco). thesia and anesthesia) take the By inhalation precedence. Paralysis generally the d u st , affects the extensor muscles of the laden with arm and hand, with atrophic mani- lead, finds festations; more rarely, the flexor lodgment in muscles. Sometimes also there are the upper res- paralyses of the extensors and flex- piratory tract, ors of the lower extremities or mus- and, mixed cles of the shoulder. From experi- with saliva, ence it is known that those groups may reach of muscles are especially affected the stomach. which are most used in the occupa- tional activity. Transient blind- ness, but also gradually progres- sive atrophy of the optic nerve; temporary loss of the special senses of smell and taste; violent, often fatally ending disease of the brain (saturnine encephal- opathy), sometimes preceded only by slight premoni- tory symptoms, as irritability and headache, ringing in the ears, insomnia; more often, slowly increasing mental disturbances precede; epileptiform convul- sions, hallucinations; morbid changes in the blood vessels and of the heart and kidneys (contracted kidney); increase of blood pressure and granular degeneration of the red blood corpuscles. Disturbances in the sexual sphere in women; abor- tion, premature birth, low vitality of the children. Measures of relief: Discontinuance of work in lead at the slightest symptoms of lead poisoning. In lead colic, give first, bv the mouth or sul)cutaneously, morphia, opium, or atropin; afterward, cathartics (castor oil or podophyllin) ; in paralysis, electrical treatment, massage and baths; in every case, strengthening diet, iodid of potassium, and sudorifiices. Smelting of lead and lead-bearing ores; manufacture and use of articles made o f metallic lead (sheets, plates, boxes, pipes, wire, cans, flasks, pails, kettles, faucets, re- torts) ; manufacture and use of lead alloys, as type metal, shot (tin foil), for example, in type foundries, tin shops, bottle-cap factories, composing rooms, file-cutting works; manufacture and use of lead colors and other lead compounds, as lith- arge, white lead, Krems white, red lead, lead chro- mates, acetate of lead, lead chloride in lead color works and storage-battery factories, in the trade of painter, house painter and varnisher; plants for installation of gas and water; in the ceramic industry, the textile industry, etc. It is to be ob- served that mate- rials containing lead may occasionally be employed in every industry, and that lead colors and other lead com- pounds are often met with in trade under fanciful names. HEALTH HAZARDS IN OCCUPATIONS 285 Designation of the substance Branches of industry in which poisoning occurs Mode of entrance into the body Symptoms of poisoning MANGANESE DI- O X I D , MnOj: Brown mineral (oc- curring chiefly as pyrolusite) . MERCURY, Hg: A silver-white, shin- ing metal,_ un- changeable in the air, but evaporating at house tempera- ture. Mercury c o m- pounds, amalgams (alloyswith metals) . Cinnabar (HgS) is nonpoisonous. Breaking and grind- In the form of Mn02 produces cumulative efffcts. ing of manganese dust, through After protracted action of the toxin ore; sifting out of the reapira- the symptoms begin with dis- the refuse. tory organs. turbances of the general sensi- bility, general debility, languor, lancinating pains in the extremi- ties, in the small of the back and nape of the neck, creeping sensa- tions in the legs and numbness in the feet; salivation; tremor of the head, tongue, and hands; later, locomotor disturbances with uncertain, stamping gait, and, ultimately, the impossi- bility of safe and sure progression. _ Affections of the voice (low, whispering) and of speech ("indistinct, scan- ning) combined with flatness of tone; forced laughter and weeping and low- ering of intelligence. Sonietimes dropsical effusion into the cellular tissue of the lower ex- tremities. Mining and smelting of quicksilver; oc- cupation of mirror plater, amalgam gilding and silver- ing; manufacture o f thermometers, barometers, and manometers, i n- candescent electric lamps. Roentgen and Hittorf tubes, mercurial vapor lamps; manufac- ture of the salts of mercury, a m a 1- gams, and colors, pharmaceutic prod- ucts, antiseptic dyes, inflammable ma- terials, and explo- sives; employment of the salts of mercury, especially in the hare's fur business and felt-hat manufacture ; pho- tography and steel engraving. Absorption Industrial mercurial poisoning is a through the chronic poisoning occasioned by uninjured work in this metal for a long period, skin;absorbed commonly weeks, months, years, or in the form decades. The first symptom is of vapor and generally increased ptyalism, with dust swelling and inflammation of the (amalgam gums and of the buccal mucous dust, dust of membrane, often with the forma- t h e CO m- tion of rodent ulcers, besides, there pounds o f are, frequently, disturbances of mercury). digestion, lassitude, and pallor. Associated with the further absorp- tion of mercury, "erethism" super- venes — a peculiar psychic excita- bility (timorousness, bewilderment, irritability) aside from the charac- teristic mercurial tremor. In a state of complete repose this tremor is not noticeable, and manifests it- self only on voluntary movement, causing a quite distinctive, irregu- lar tremulousness of the fingers, hands, arms, and finally, also, of the legs and head. In strictly chronic cases the stom- atitis and erethism are absent, and only the tremor is observable. Death may result in the worst cases in consequence of the violent tremor and spasms affect- ing the entire body; in other cases, increasing weak- ness. Cachexia. Special measures of relief: Relinquishment of the employment; nutritious diet; vapor baths; potassium iodid. METHYL AL- COHOL (wood spirit), CH3OH: A colorless fluid, of faint odor. Produced by the dry Ab sorpt ion distillation of through the wood; used in the digestive or- preparation of var- gans, also nish, lacquer, pol- through the ish, and perfumes; skin; in the for the denaturing form of va- of spirits; for the por through production of coal- the organs of tar colors and phar- respiration, maceutical prepay rations; a solvent for anilin dyes in cotton print manufacture; used in combination with shellac for coating the interior of casks; in cabinet- making and furniture polishing. The effect is very persistent; nausea, headache, ringing in the ears, weak- ness of the muscles, insomnia, deli- rium, difficulty of breathing, and sometimes deafness; inflammation of the throat and the mucous mem- brane of the air passages extending to the finest ramifications of the bronchial tubes; finally, death by paralysis of the respiratory appara- tus. Conjunctivitis; also serious affections of the retina and the optic nerve, resulting in blindness, even, from atrophy of this nerve. 1 In chronic cases, fatty degenera- tion of the liver. Special measures of relief: The substitution of innocuous media for methyl alcohol in the denatur- ing of spirits. 1 Perrnanent blindness and even a fatal issue may be caused by the ingestion of small quantites of wood spirit; hence the risk incurred in using cheap essences of vanilla and other flavoring extracts which contain methyl alcohol. — W. H. R. 286 INDUSTRIAL MEDICINE AND SURGERY Designation of the substance Branches of industry in which poisoning occurs Mode of entrance into the body Symptoms of poisoning METHYL BROMID, CHsBr: A colorless, gaseous body of aromatic odor. Methyl iodid, iodin methylate, CH3I: An ethereal, color- less fluid, of some- what penetrating odor, soon becom- ing yellow on ex- posure to the air. Employed in anilin dye factories. In the form of gas, through the respira- tory organs and the mu- cous mem- branes. In mild cases, vertigo, headache, and transient stupor, with diplopia and a sensation of rigidity in the mus- cles of the eyes. In a severe case there was ob- served loss of consciousness continu- ing eight weeks, with staring look, pallor of the skin, retarded pulse, and obstinate constipation. Dur- ing brief intervals of wakefulness there was unrest with increasing excitability. (Grandhomme.) NITRANILIN, C6H4- NH2NO2: Forming long, yellow crys- tals. See Anilin. NITROBENZOL Coal-tar color Indus- (1) Absorption Poisoning by all of the designated (mirbane oil, imita- try and those es- takes place, substances is pretty nearly the tion bitter-almond tablishments in first of all, same, qualitatively; quantitatively, oil), C0H5NO2: A which its interme- through the however, diSerences exist, so that colorless, highly re- diate products are skin, both the the larger proportion they contain tractive fluid, hav- manufactured, as uninjured of the nitro (NO2) groups the more ing an odor like that in explosives works, and e s p e - virulent they are likely to be. The of bitter almonds; perfumery and soap ci ally the nitrochloro compounds are very and all nitro com- factories, pharrna- pathologically rnuch more dangerous than the pounds of benzol ceutical laboratories, altered skin, simple nitro compounds. The and its homologues, etc. particularly first toxic symptoms may ap- e.g., dinitrobenzol, in the case pear within a few hours (8 to 24) dinitrochlorobenzol, of profuse after absorption of the poison, nitrotoluol, nitro- perspira- Acute Poisoning. — (a) In mild phenol, nitronaoh- tion; ( 2 ) cases: Malaise, headache, giddiness, thalene, etc. The through the nausea, loss of api)etite, costive- most of the nitro respiratory ness, burning sensation of the skin and chloro com- organs; (3) and mucous membrane, pounds are the through the (b) In severe cases: A feeling of more poisonous. digestive or- anxiety, disturbances of sensation, gans. like formication on the legs and fur- riness of the soles of the feet, ring- ing in the ears; disturbances of co-ordination (reeling gait, stam- mering speech), increased excitabil- ity of the reflexes, convulsions and a state of general spasm; later, with decline of sensibility, symptoms of paralysis: vomiting; odor of the yomitus and of the exhaled breath like that of bitter-almond oil; ic- terus of the skin ; at first increased, afterward diminished acti\'ity of the heart, with lowered tension of the pulse; visual derangements (amblyopia, optic neuritis) ; blood viscid, brown to deep dun color; diminution^ of the red corpuscles and alterations in their form; in the advanced cases, formation of met- hemoglobin. The course of se- vere cases is exceptionally varied; after intermissions, exacerbations may occur with a finally fatal re- sult. Death may occur also in con- nection with deep insensibility, without other symptoms._ The symptoms which point to blood changes predominate, in severe poisoning, over the nervous symptoms. Subacute and Cheonic PqisoNiNG.-^Icterical skin, which gradually be- comes cyanotic; methemoglobin formation; symptoms of degeneration and regeneration of the red blood corpuscles; general debility, anemia. The clin- ical picture is similar to that of pernicious anemia. In the urine the poi- soned corpuscles are sometimes demonstrable, and finally the presence of hematophorphyrin and of albumin. Measures of relief : Immediate removal from the workroom; inhalation of oxygen; artificial res- piration; eventually bloodletting; stimulants, nonalcoholic; prohibition of the use of alcoholic drinks during working hours; avoidance of the same, also, outside of employment. HEALTH HAZARDS IN OCCUPATIONS 287 Designation of tlie substance mXROG LYCERIN, C3H503(N02)3 glyc- erin trinitrate: An oily, vaporable, colorless fluid, with- out odor. Branches of industry in which poisoning occurs Manufacture of ex- plosives (dynamite, nitro-cellulose) ; in the use of dynamite. Mode of entrance into the body Inhalation of the vapor; absorption through the uninj ured skin, mucous membranes, and wounds of the skin. In the explo- sion of dyna- m i t e the action of car- bon dioxid and nitrous monoxid, as well as that of undecom- posed nitro- glycerin i 8 present. Symptoms of poisoning Extraordinary toxicity, somewhat like effects of prus.sic acid; just a few drops are deadly, and even mere contact with products con- taining nitroglycerin may cause poisoning; severe headache, dis- turbance of the intellect, facile syn- cope, vertigo; burning in the throat and stomach; nausea, vomiting, colic; symptoms of paralysis in the musclesof the head and eyes, as well as in the lower extremities; brady- cardia and retarded respiration, stertorous breathing and dyspnea; cyanosis; coldness of the extremi- ties; injection of the conjunctiva; reddening of the countenance. In the mixing and siftinp of dyna- mite: Obstinate ulcers under the nails and on the finger tips, erup- tion on the plantar aspect of the feet and interdigital spaces of both hands, with extreme dryness and formation of fissures. Explosion of nitroglycerin with little gas: Trembling, determination of blood to the head, vomiting, headache. Explosion of_ nitroglycerin with much gas: Vertigo, asphyxia, cya- nosis, motor paralysis and loss of consciousness; intermittent, sterto- rous respiration, coldness of the skin, small pulse; after recovery of consciousness, debility, nausea, vomiting, headache, intermittent pulse, and finally death. Chronic Poisoning. — Disturb- ances of digestion, trembling, neu- ralgia. Special measures of relief: Absolute avoidance of contact. NITRONAPHTHA- L E N E. C10H7- (NO2): A yellow, friable, crystalline mass of strongly " aromatic odor. (See Nitrobenzol.) 288 INDUSTRIAL MEDICINE AND SURGERY Designation of the substance Branches of industry in which poisoning occurs Mode of entrance into the body Symptoms of poisoning NITROUS GASES (low degrees of oxi- dation of nitrogen, which appear simul- taneously) : Nitro- gen protoxid, NO; nitrogen deutoxid, NO2; nitrogen tri- oxid, N2O3; anhy- drous nitrous acid (HNOj). Red fum- ing nitric acid is a saturated solution of N2O4 in crude NHO3. NO is a colorless gas which under the influence of atmospheric oxy- gen, is readily transformed into brown nitrogen di- oxid. Below —20° C. N2O3 is a blue fluid; at the ordi- nary temperature it separates into NO and NO2. In gaseous form, through the respira- tory organs. Nitrous gases are produced by the action of nitric acid on deoxidat- ing substances of various kinds, prin- cipally on metals (iron, lead, zinc, etc.)> on organic substances (coal dust, wood, straw, paper, textile fab- rics, woolen refuse, etc.) as well as many other substances (pyrites, sulphurous acid and its salts, soda, sediment, hydrochloric acid, iron chlorids, sul- phate of iron, etc.) ; in the preparation of nitric acid, its combinations and salts, among which the nitrous salts also are to be in- cluded; metal etch- ing and metal re- fining; stamp mills and mints; galvano- technics; nitrifica- tion in chemical works and manu- factories of explo- s i V e s ; celluloid manufacture; sul- phuric acid manu- facture: production of picric acid, anilin oolors, nitrocellu- lose (gun cotton, collodion cotton), xyloidin, n i t r o - starch, nitro-.iute dynamite, abelite, nitromannite, n i - trosaccharose, vis- cosin, etc.; nitric acid manufacture and storage; prep- arations of thor- ium and cerium; bleaching materials (oils, etc.) hat mak- ing (maceration of the hair); etching and engraving on copper (etching of the plate); dyeing and printing (fixer I and mordant). Special measures of relief: Immediate removal from the noxious atmosphere; inhalation of oxygen; finally, bloodletting and infusion of normal salt solution. Susceptibility to the effects of nitrous gases fluctuates consider- ably. Persons who suffer from diseases of the respiratory organs are especially susceptible; not in- frequently the continual inhalation of small quantities, for many con- secutive years even, occasions no serious disturbances of the health. A pale, sallow complexion and chronic bronchial catarrh may be deemed, nevertheless, the usual consequences of occupational in- halation of very moderate quan- tities of nitrous gases. Often, however, larger quantities of the poisonous gases are borne for hours together (6 to 8 hours) without discomfort; when suddenly, after a long interval without disturb- ance, ominous symptoms appear. Symptoms of irritation in the air passages are manifest, as a feeling of constriction of the larynx, spas- modic cough, oppression in the chest, labored respiration, anxiety, cold perspiration on the face, pro- trusion of the eyes, gasping speech, paroxysms of coughing, bluish dis- coloration of the countenance, cold- ness of the extremities. Consciousness is at first unim- paired, but with increasing diffi- culty of breathing it becomes dimmed; injury to the teeth. The urine is scanty, brown in color, con- taining hemoglobin and albumin. Death results from edema of the lungs. In very severe cases met- hemoglobin is observed, and then a general systemic poisoning may result. HEALTH HAZARDS IN OCCUPATIONS 289 Designation of the substance Branches of industry in which poisoning occurs Mode of entrance into the body Symptoms of poisoning OXALIC ACID. C2- H2O4: It forms large, pellucid crystals. Manufacture of ox- alic acid; polish- ing of metals, es- pecially of copper and brass utensils; used in dye works, chemical cleansing plants (rust and ink stains) ; straw hat manufacture and straw braiding. In the form of dust, through the respira- tory organs. Opalescent or bluish discolorations (with brittleness) of the nails; blood stasis in the hands; corrosive action on the mucous membrane of the esophagus, of the stomach and bowel; weakness of the heart; convulsions and spasms. However, industrial poisonings by oxalic acid are exceedingly rare. PETROLEUM: _ A Production of oil; re- In the form The vapors of petroleum cause a pro- mixture of various fining of the crude of vapor, found acute poisoning with a con- hydrocarbons of the oil; furniture pol- through the dition of inebriation; shouting, methane, ethyl, and ishing by use of so- respiratory reeling, and prolonged sleep with- aromatic series. called polishing oil. organs. As a out any recollection of what has fluid it has a happened; in severe cases, loss of direct action consciousness, lividity of the coun- on the skin. tenance, staring look and con- tracted pupils, almost impercep- tible pulse, asphyxia. The chronic effect of petroleum vapor causes numbness and irritation of the Schneiderian membrane. In general, the symptoms of the action of petroleum resemble those resulting from the action of ben- zin. By reason of the high boiling point of petroleum there are pro- duced, in the extraction of paraf- fin butter, in the handling of crude paraffin, in the emptying of retorts, and in the filling of casks with petroleum, obstinate inflam- mations of the hand in the form of acne (nodules, pustules, and boils). Special measures of relief : Removal into the fresh air; in collapse, a tepid bath with cold affusions; subcutaneous injections of camphorated oil. PHENOL, CeHsGH (carbolic acid) : A white crystalline mass, and its homologues, e.g., cresol, lysol, and their derivatives. Anthracite coal tar distillation; produc- tion of picric acid and of many organic aromatic c o m - pounds; used in dye- ing, calico printing; manufacture o f lampblack, in photo- gen factories; im- pregnating wood with tar and oil of tar; surgical dress- ing industry. Action on the epidermis and the di- gestive tract. Erosion of the skin, which by great extension may lead to severe inter- nal injuries; symptoms of degenera- tion in the blood and in the inter- nal organs (nephritis) ; gangrene, icterus, collapse. PHENYLHYDRA ZIN, C6H5NH- NH2: A yellowish, oily fluid, shading into brown, of pungent odor. A by-product in the manufacture o f antipyrin from ani- lin; manufacture of organic compounds. Absorption by the skin; ac- tion on the skin. Obstinate vesicular eruption on the skin, with itching and burning; diarrhea, loss of appetite ; granular degeneration of the blood cor- puscles; formation of methemo- globin; a sense of general malaise. 19 290 INDUSTRIAL MEDICINE AND SURGERY Designation of the substance Branches of industry in which poisoning occurs Mode of entrance into the body Symptoms of poisoning PHOSGENE, CO- In the manufacture In the form Until the present time only the acute CI" (carbon oxy- of phosgene and its of vapor, form of poisoning has been recog- chiorid) : A color- use for the produc- through the nized. The first symptoms of ill- less gas, of suffo- tion of organic respiratory ness sometimes appear only after eating odor. compounds. organs. many hours. _ By means of the hy- drochloric acid arising from the de- composition of the gases in the lungs, destruction of lung tissue results, with difficulty of breath- ing, paralysis of the lungs, and pul- monary edema. A fatal outcome is often observed. Special measures of relief: Inhalation of oxygen and medical attendance immediately after breath- ing the phosgene gas. PHOSPHORUS, P: A colorless, trans- parent substance; on exposure to the light, translucent and of a yellowish, waxy luster. In the air it is lumin- ous, and when heated in closed iron crucibles to a temperature rang- ing from 250° to 300°C. it is con- verted into red or amorphous phos- phorus, which is un- affected by the air. The yellow or white phosphorus is very poisonous; the red, nonpoisonous. Extraction of phos- In the form As industrial poisoning it occurs only phorus from phos- o f vapor, in the chronic form, occasioned by phorites and cop- through the the absorption of very minute par- rolites, bone-black respiratory tides of the poison for a period of (refuse of sugar organs; into months, generally, indeed, of years, mills) , bone-ash (ref- the digestive Symptoms of the disease some- use of meat extract canal by times first appear long after relin- manufacture) ; pro- means of food quishment of the occupation, duction of phosphor- contaminated It is doubtful whether chronic bronze, of phos- by the phosphorism occurs (that is, gen- phorus, compounds, fingers; ao- eral systematic poisoning by phos- igniting agents, tion on the phorus). matches, and tar skin. Chronic phosphorus poisoning olors. uniformly affects the bones of the face, beginning with inflammation and sclerosis of the bones and of the periosteum; then, by extension of the suppurative process, necrosis results. This most frequently at- tacks that portion of the alveolar process of the jawbone which is least protected against infection. Swelling and ulcerations on the gums and the buccal mucous mem- brane, pain even in the sound teeth, loosening and falling out of the teeth, infiltration of board like hardness occurs in the soft parts surrounding the jaw; suppuration and destruction of the jawbone (ne- crosis) with numerous fistulous channels which here and there bur- row through the cheek. Hand in hand with the ulcerative processes go osteoplastic formations, so that, while suppurative destruction of tissue takes place at one point, at another the formation of new bone is going on. The under jaw is more often affected than the upper; here the process goes on insidiously without formation of new bone but with local destruction of the part. The palatal and orbital bones may be attacked with ulceration and shrinking of the eyeball. By ex- tension of the inflammation along the sheaths .of the vessels there re- sult meningeal inflammation and cerebral abscess. There is remarkable brittleness of the bones, decline of appetite, pallid complexion, diarrhea, ema- ciation. Sometimes there is amy- loid degeneration of the abdominal organs. Death by sepsis. Special measures of relief: To the utmost possible extent the prohibition of the use of white or yellow phosphorus; exclusion of laborers that have dental caries, after extraction of a tooth at least two weeks' exclusion from the employment; change of occupation; improvement of the general health; there is no specific medical treatment; in appropriate cases, operative intervention. HEALTH HAZARDS IN OCCUPATIONS 291 Designation of the substance Branches of industry in which poisoning occurs Mode of entrance into the body Symptoms of poisoning PHOSPHORUS SESQUISULPHID, P2S3: A grayish yellow, odorless and tasteless substance. In chemical factories. Irritation of the mucous membranes, especially obstinate conjunctivitis. Through the influence of dust in the grinding and sifting of the com- position there appear symptoms of CSz poisoning. To be noticed also is the danger of poisoning by sul- phuretted hydrogen {See under Sulphuretted hydrogen.) Inhalation of sulphuretted hydrogen in the fusion of phosphorus and sulphur as well as in the drawing off of the molten mass from the ket- tles; dust in the grinding and sifting of the paste; bi- carburet of sulphur va- pors in the extraction of yellow phos- phorus and regeneration of CS2. Special measures of relief: Prevention of the contamination of phosphorus sesquisulphid with yellow phosphorus; precautions against injury from the effects of sulphuretted hydrogen. PHOSPHURETED HYDROGEN, PH3: A colorless gas of nauseating odor. In the extraction of phosphorus; in the preparation of red phosphorus and the sesquisulphid of phosphorus; in the reduction of iron silicate con- taining phosphorus by the action of moisture; in the production of acety- lene with calcium carbid that contains an admixture of cal- cium phosphate. In the form of gas, through the respira- tory organs. An anxious, oppressed feeling in the chest, changing to a burning, lan- cinating pain; affections of the head, vertigo, tinnitus aurium; general debility; loss of appetite; great thrist. Death occurs with- out convulsions, through the effect of the poison on the blood. PICRIC ACID, C6H2 (OH)(N02)3: Tri- nitrophenol in a pure state forms pale yellow, bitter tasting, foliate, me- tallic crystals. Chemical works, dye- houses; manufac- ture of explosives and powder (lydd- ite, melinite) ; pro- jectile factories, fil- ling shops. In the form of dust, through the respira- t o r y pa s - sages ; direct action on the skin. Poisonings with picric acid are rare; when they occur there are itching, inflarnmation of the skin, vesicular eruption, yellow pigmentation of the epidermis and of the conjunc- tiva, inflammation of the buccal niucous membrane, bitter taste, disturbances of digestion, epigas- tric pain, nausea, vertigo, diarrhea, and jaundice; picric acid decom- poses the constituents of the blood. By the penetration of dust into the nostrils, sneezing and nasal catarrh are occasioned. PYRIDIN, CsHsN: A colorless fluid of pungent and char- acteristic odor. Its homologues, py- ridin bases. In its manufacture out of coal tar and bone tar; in the use of denaturing spir- its (shops for wood- working, gilding, and hat manufac- ture) . In the form of vapor, through the respiratory organs. In a fluid state it acts on the skin of the hands and arms. Catarrh of the mucous membranes; hoarseness, irritation, and choking sensation in the throat; headache, vertigo, flaccidity and trembling of the extremities; difiiculty of breathing and clonic convulsions; eczema of the hands. Industrial poisoning by pj-ridin is very rare. SULPHUR CHLO- RID, SeCh: A thickish fluid, of brownish color and suffocating odor, fuming on exposure to the "air. Solvent for sulphur and fats; caout- chouc and patent rubber industry. In the form of vapor, through the respiratory organs. In contact with water and atmos- pheric moisture, it is resolved into hydrochloric acid vapor. The vapor of sulphur chlorid is suffo- cating; if ingested, it excites vomit- ing. Special measures of relief : Wearing of rubber gloves; instant removal of the patient from the poisonous atmosphere. 292 INDUSTRIAL MEDICINE AND SURGERY Designation of the substance Branches of industry in w+iich poisoning occurs Mode of entrance into the body Symptoms of poisoning SULPHUR DIOXID, SULPHUROUS ACID, (H2SO3): Its anhydrid is SO2, in the form of gas; condensed, it be- comes fluid. The gas is of pungent odor and suffocat- ing effect. Roasling of sulphur- bearing ores; brick works, ceramic in- - dustry; manufacture of sulphuric acid, of ultramarine; ex- traction of bones, manufacture of glue and gelatine from bones; disinfection; refining of petro- leum; manufacture of candles; bleach- ing of wax, silk, and wool; chromium tanning (two-yat process) ; bleaching of straw hats and bristles; preserving wine and fruits; fumigating hops and casks with sulphur; ice machines; heat- ing plants (burning of pynte-bearing coal). In the form of gas, through the respira- tory organs. In moderate concentration sulphur- ous acid is borne without inconven- ience or injury ; persons accustomed to the gas bear very well a propor- tion of 0.003 to 0.004 per cent, of SO2 in the air. Susceptible persons, at the be- ginning of their employment in an atmosphere containing sulphurous acid, manifest a transient irritation of the mucous membrane of the respiratory organs and of the eyes. In its severe action there is spas- modic cough with secretion of tenacious, often blood-tinged, mucus. The protracted effect of a high degree of concentration is livid discoloration of the mucous membranes, _ bronchial catarrh, croupous angina of the bronchi and their branches, and inflammatory areas in the lungs; disturbances of digestion. Svecial measures of relief: Removal from the noxious atmosphere; admission of fresh air; artificial respiration; infusion of weak alkaline solutions (0.05 to 0.1 per cent, liquor natrii caustici [solution of caustic soda]) . SULPHURETED Blast furnace plants. In the form of HYDROGEN, or in granulating the gas, through HYDRIC SUL- slag; distillation of the respira- PHID, H2S: A col- sulphur waters; tory organs, orless gas, having ultramarine works: as pure hy-^ the fetid odor of Leblanc soda and dric sulphid rotten eggs. chemical factories; gas; often in the manufac- found in ad- ture of the com- mixture with pounds of sulphur other gases and phosphorus; (with COs, N sulphur metals NH4, and (manufacture and carburetted use) ; sulphid of hydrogen) ; di soda and sulphid rect action on of barium indus- the conjunc- try (manufacture tiva. of sulphid colors and dyeing with these) ; the extrac- tion of cellulose (straw and wood) ; in the waste wa- ters of industries which make use of organic _ sub- stances; sedimen- tation tanks of sugar works ; pre- cipitation of soda residua containing calcium sulphid; work in sewers, latrines, and dung pits; illuminating gas plants; flax retteries; tanneries. Svecial measures of relief: Before emptying of dung pits a,nd the like, their contents should be thoroughly mixed with iron sulphate (.5 kg. pro 1 cbm.); the emptying should be effected by mechanical apparatus; safety ropes to be attached to the workmen; prompt hoisting out of the unconscious workmen; removal of the soiled clothing; artificial respiration; administration of oxygen; hypodermics of ether or camphor. In the less violent cases there are gastric distress, _ nausea, fetid eructations, irritation and inflam- mation of the conjunctiva; rarely, erosion of the cornea, formation of vesicles on the lips, irritating cough, headache, and a sensation of giddiness. In long continued in- halation convulsions and paralyses occur. In severe cases there are contrac- tion of the pupils, slowing of the pulse, Cheyne-Stokes respiration, nystagmus, trismus, and tetanus. With a very high proportion of sulphuretted hydrogen in the air a man suddenly falls, becomes un- conscious, and dies without con- vulsions (apoplectic form). Chronic Poisoning. — Conjunc- tival catarrh; a sense of pressure in the head and on the chest; headache, debility, vertigo, nausea, disturbances of digestion; sallow complexion and emaciation; slow- ing of the pulse; tendency to the formation of boils. HEALTH HAZARDS IN OCCUPATIONS 293 Designation of the substance Branches of industry in which poisoning occurs Mode of entrance into the body Symptoms of poisoning SULPHURIC ACID, H2SO4: A colorless, odorless, thick, oily fluid. Manufacture of sul- phuric acid; accu- mulator factories (mold and charg- ing rooms) ; burn- ishing of iron, steel, etc.; textile industry, hat fac- tories; petroleum distillation; facto- ries for the manu- facture of pow- dered fertilizers. In the form of vapor, through the respiratory organs. Inflammatory diseases of the res- piratory organs (acute and chronic catarrh), inflammation of the lungs; anorexia; decalcification of the bones (according to Lewin) ; injury to the teeth through soften- ing of the dentin. As a result of the bespattering of the skin with concentrated H2SO4 there is severe pain, a whitish discoloration of the skin, becoming brownish, with redden- ing and swelling of the surround- ing tissues; in cases of extensive scalds there are, ultimately, de- composition of the blood, forma- tion of ulcers of the duodenum, somnolence, and even death. TAR : A product ob- tained by dry distil- lation, particularly of anthracite coal and lignite. Manufacture of illu- minating gas; coke ovens; tar works; tar product facto- ries; plants for wood preserving; manufacture o f roofing paper; use for concrete pav- ing; painting of metals; as a_ fuel; briquet factories. It acts on the skin; in the form of vapor, on the respiratory organs. Tar itch under the form of diffuse acne, eczema or psoriasis, primarily on the upper extremities, later, also, on the other parts of the body; not infrequently on the irritated portions of the skin there appear cancroid ulcers, especially of the scrotum (among chimney sweepers, paraffin and soot workers and briquet makers). Together with the effect on the greater portion of the skin, there are also general symptoms: Loss of appetite, nausea, diarrhea, head- ache, numbness, vertigo, besides disturbances of the urinary blad- der (ischuria, strangury), also albuminuria and edema. TURPENTINE OIL: A mixture of various terebinthin hydrocarbons, Cicr H16, differing in odor and in com- position according to the botanical species from which they are severally derived. Manufacture of var- nish, cement, lac- quer, sealing wax, colors ; tapestry printing; trade of decorator, lacquerer, and house painter; as a cleansing agent in various industries. In the form of vapor, it acts upon the mu- c o u s mem- branes; in a fluid state, it acts on the epidermis. Irritation of the mucous membrane of the eyes, of the nose (coryza), and of the upper air passages (hem- ming, cough, bronchial inflamma- tion); salivation; besides, there are insensitiveness, giddiness, head- ache. Prolonged action of the oil causes irritation of the kidneys, and then these organs excrete urine having the odor of violets. Severe irritation of the skin is excited, especially by the so-called pine oil (Russian oil of turpentine). 294 INDUSTRIAL MEDICINE AND SURGERY LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR Designation of industrial poison Nitrous gases See Batteries, storage • Lead Phosphuretted hydrogen (From Diseases of Occupation and Vocational Hygiene, Kober and Hanson) Branches o/ industry in which poisoning may occur Abelite, manufacture of Accumulator, electrical works Acetate of lead, manufacture of Acetylene production (if calcium carbid contains admixture of cal- cium phosphate) Acids, commercial manufacture of Acid, hydrochloric, manufacture of Acid, hydrofluoric, manufacture of Acid, muriatic, manufacture of Acid, picric, manufacture of Acid, stearic, manufacture of Acid, sulphuric, manufacture of Acid, valeric, manufacture of Air pollution Alcohol, denatured Alkaloids, manufacture of Amber workers Amalgam Ammonia salts, manufacture of Ammunition, manufacture of Amid compounds of benzol, etc. Amyl nitrite, manufacture of Anatomical preparations AniUn color dye factories: Anilin orange, aurantia, saffron yellow, Manchester yellow, Meldola dyes, corvulin, Bismarck blue, indulin, fast black Antimony alloys, and extraction of Antiseptic dressing, manufacture of Antipyrin, manufacture of Arsenic acid, manufacture of Arsenic mining Arsenical ores, smelting Artificial flowers and leaves Artificial ice and cold storage Asphalt, testing Aurantia dyes Automobilists Babbitting metal, and solder Bakers and confectioners Balloon filling with impure hydrogen gas Barium sulphid, manufacture of Barometers, manufacture of Arsenic Hydrochloric acid Hydrofluoric acid Hydrochloric acid Picric acid Acrolein Nitrous gases, sulphur dioxid Amyl alcohol Carbon dioxid, carbon monoxid Benzol, methyl alcohol, pyridin Benzol Lead | Mercury j Ammonia \ Acrolein, antimony, lead (see also "Ex- plosives") Anilin Amyl alcohol Formaldehyd, phenol AniUn, arseniuretted hydrogen, antimony, hydrochloric acid, methyl bromid, nitro- benzol, nitrous gases Antimony, lead \ Mercury, phenol Benzin, phenylhydrazin Arsenic, arseniuretted hydrogen Arsenic Arsenic Arsenic, lead Ammonia Carbon disulphid Anilin dyestuffs Carbon monoxid, benzin Lead Carbon dioxid, carbon monoxid Arseniuretted hydrogen Sulphuretted hydrogen Mercury HEALTH HAZARDS IN OCCUPATIONS 295 LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR {Continued) Branches of industry in which poisoning may occur Batteries, storage, dry, manufacture of Batteries, storage, wet, manufacture of Beet sugar, manufacture of Benzin plants Benzol Bicycles, manufacture of Bismarck blue, manufacture of Bismuth, manufacture of Black anilin colors Blacksmiths Blast furnace workers Bleacheries Bleaching agents, manufacture of Bleaching agents, for bristles, cane, silk, straw hats, wax and wool Bleaching agents for cotton, linen and paper Bleaching agents for cane and extrac- tion of its silicates Bleaching agents for fats, oil and wax Bone ash, refuse of meat extract Bone-black, refuse of sugar refineries Bone-black, manufacture of Bone, extraction of Bone, rendering plants Bone tar, manufacture of Bookbinders Boot and shoe industry Bottle caps and capsules Box and card factories Brasiers ■* Brass etching Brass instruments, musical Brass foundries Brass polishing Brass lacquer Breweries, fermentation rooms Breweries, fumigation of vats, and disinfection Breweries, shellacing casks Brick kilns, brick and tile makers Designation of industrial poison Benzol, creosote, hydrochloric acid, sulphuric acid, lead, mercury, pitch, zinc chlorid Chromium compounds Ammonia, sulphuretted hydrogen Benzin Benzol Amyl acetate Anilin dyestuffs Arsenic Anilin dyestuffs Acrolein, carbon monoxid, cyanogen compounds Carbon monoxid, cyanogen compounds, lead fumes, if lead is present in iron ore, sulphur dioxid, sulphuretted hy- drogen (in granulating slag) Chlorin, sulphur dioxid Nitrous gases Sulphur dioxid, chlorid of lime Hydrofluoric acid Chlorin, chromium compounds Phosphorus Phosphorus Ammonia, phosphorus Sulphur dioxid Acrolein, benzin Pyridin Carbon monoxid, methyl alcohol Benzin, methyl alcohol, lead, mercury Lead Arsenic, chrome and lead compounds Carbon monoxid Arsenic chlorid Lead Antimony, benzin, carbon dioxid, carbon monoxid, lead, phosphorus, sulphur dioxid, zinc fumes Lead, oxahc acid, sulphuric acid Amyl acetate, methyl alcohol Carbon dioxid Sulphur dioxid, zinc oxid Methyl alcohol Carbon dioxid, carbon monoxid, sulphur dioxid, lead glaze 296 INDUSTRIAL MEDICINE AND SURGERY LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR (Continued) Branches of industry in which poisoning may occur Briquet factories for fuel- Britannia metal Bronze workers Bronzing with nitrate of mercury- Brown mineral mills Brunswick green Brush makers Bullets, dipping Bullets, manufacture of Burnishing of iron and steel Cable wire, manufacture of Cabinet makers Caoutchouc solvent and refining of Caisson work Calcining dolomite, etc. Calico printing Candles, manufacture of Cane factories Canning industry- Carbolic acid Carbonated waters Carbon chlorid, manufacture of Carbon sulphurate, manufacture of Carbonizing of materials Carpet cleaning Carpet dye Cassel green Celluloid manufacture Cellulose, extraction from straw and wood Cements Ceramic industry Cerium, preparation of Chair factories, polishing Chalk, colored Charcoal burning Chemical cleansing establishments Designation of industrial poison Tar Antimony Antimony, lead, zinc, arsenic, acids, phosphorus Mercury Manganese Arsenic Anthrax, lead, methjd alcohol, tar (see also bleaching) Acrolein Antimony, lead Antimony, sulphuric acid Carbon disulphid, lead Anilin stains, chrome lead stains Benzol, carbon disulphid, sulphur chlorid Carbon dioxid Carbon dioxid, carbon monoxid AniUn, chromium, cyanogen and chlorin compounds, hydrochloric acid, lead, methyl alcohol, phenol, antimony, arsenic, carbon monoxid Sulphur dioxid Anilin stains, chlorin, chlorid of lime, hydrofluoric acid, methyl alcohol, sulphur dioxid Carbon monoxid, lead, acid fumes, sulphur dioxid Phenol Carbon dioxid Carbon disulphid Carbon disulphid Acid fumes and arseniuretted hydrogen Benzin Arsenic Arsenic Acetaldehyd, anilin and lead colors, cyanogen compounds, methyl alcohol, nitrous gases, sulphuretted hydrogen. Nitrous gases, sulphuretted hydrogen Turpentine, benzin Hydrofluoric acid, lead, sulphur dioxid (see also Potteries) Nitrous gases Methyl alcohol, petroleum (see also Rattan Industry) Arsenic Carbon monoxid Benzin, benzol HEALTH HAZARDS IN OCCUPATIONS 297 LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR {Cmdinued) Designation of induntrial poison Oxalic acid Branches of industry in which poisoning may occur Chemical cleansing removal of ink and rust stains Chemical industry Chlorid of lead Chlorid of lime, manufacture of Chlorinating process Chlorin, organic products Chloroform manufacture Chromate of lead Chromate tanning Chromium colors and preparations Chromo-lithography Christmas ornaments, manufacture of Ghrysoidin fast black, manufacture Church crosses, gilding Cinnabar Cleaning, dry Coal mines Coal oil Coal-tar anthracite distillation Coal-tar color industry Cochineal Coke ovens Collodion cotton Commercial acids, impure Colors, manufacture of for paints, etc. Colored chalk Colored lights Colored paper Colored pencils Combs, horn-celluloid Compositors Concrete paving Coopers Copper plate etching and engraving Copper polishing Copper smelting Copper workers Ammonia, anilin, carbon disulphid, chlorin, cyanogen compounds, hydro- chloric acid, methyl compounds, nitrous gases, nitrobenzol, phosphorus sesquisulphid, picric acid, sulphur dioxid, carbon monoxid, etc. Lead Chlorin, arseniuretted hydrogen Chlorin Chlorin Chlorid of lime Chromium, lead Chromium compounds Chromium compounds Arsenic, brass, chromium, lead, nitrous gases in etching, turpentine Arsenic Anilin dyestuffs Mercury Mercury Benzin, benzol Carbon dioxid, carbon monoxid (see mining) Petroleum Phenol, pyridin, tar Anilin, formaldehyd, methyl alcohol, nitro-benzol, nitrous gases Arsenic Ammonia, carbon monoxid, tar Nitrous gases Arsenic Benzin, benzol, chromium compounds, arsenic, lead, mercury, turpentine Arsenic Arsenic, antimony Arsenic, chromium, lead compounds Anilin dyestuffs Acetaldehyd, acid fumes, anilin, lead colors (see also Celluloid) Lead, antimony, arsenic, benzin Tar Methyl alcohol shellac Nitrous gases Oxalic acid Arsenic, carbon monoxid, sulphur dioxid Arseniuretted hydrogen, lead, nitric and sulphuric acid fumes 298 INDUSTRIAL MEDICINE AND SURGERY LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR {Continued) Branches of industry in which poisoning may occur Corvulin dye Cowper apparatus Creasote, cresol Cumol Cutlery industry Decorators and painters Decomposition gases Denaturing of spirits Dentists Deoxidating processes Diamond cutting and setting of precious stones Dinitrobenzol, manufacture of Dinitrochlorobenzol, manufacture of Dinitro-compounds, manufacture of Dip for scabby sheep Disinfection Distilleries Dolomite calcining Drying processes by means of open fires Dung pits Dyes, antiseptic Dyes, organic, manufacture of Dyestuffs Dyeing and printing, fixer and mordant Dyeing and dye works Dynamite, manufacture of Electrical accumulator works Electric lamps, manufacture of Electric lamps, incandescent wire Electric line workers Electric meters Electroplating Designation of industrial poison Anilin dyestuffs Carbon monoxid Phenol Benzol Carbon monoxid, acid fumes, lead (see also Brass, Tempering, Tinning) Arsenic, benzin, chromium compounds, lead, mercury, methyl alcohol turpen- tine Ammonia, carbon dioxid, sulphuretted hydrogen Methyl alcohol, pyridin Mercury Nitrous gages Lead, carbon monoxid Nitrobenzol Nitrobenzol Nitrobenzol Arsenic Carbon disulphid, chlorin, chlorid of lime, cyanogen compounds, formaldehyd, mercury bichlorid, phenol, sulphur dioxid Carbon dioxid, sulphuretted hydrogen, sulphur dioxid Carbon dioxid, carbon monoxid Carbon monoxid Ammonia, sulphuretted hydrogen Mercury Acridin Ammonia, chlorid of lime (see also Anilin Dyestuffs) Nitrous gases Antimony, arsenic, anilin dyestuffs, ben- zol, chromium compounds, cyanogen compounds, hydrofluoric acid, phenol, oxalic acid, picric acid, sulphuretted hydrogen (dyeing with sulphid colors), ammonia, lead, methyl alcohol Nitrous gases, nitroglycerin See Batteries Lead, mercury Amyl acetate Carbon monoxid, solder Mercury, lead (see also Brass Industry) Cyanogen compounds HEALTH HAZARDS IN OCCUPATIONS 299 LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR (Continued) Branches of industry in which poisoning may occur Electrotyping Emery wheels, babbitting of . EaameUing works Engraving, steel Essences, fruit, artificial Etching on brass Etching on metals Ether, methyl Ethyl violet Extraction of antimony Extraction of bone Extraction of gold and silver Explosives, manufacture of Farmers Fats, bleaching of Fats, extractions of Fats, solvents Faucets, brass, polishing Feathers, ornamental Fermentation rooms Felt hat industry Ferrosilicon Fertilizers, artificial manufacture of File cutting Fireworks Firearms, manufacture of Firemen Flasks, manufacture of Flax retteries Flowers, artificial Foundries, iron Fluoric acid Fluorides, extraction of Fruit essences, manufacture of Fruit, dried, preservation Fuel briquet factories Fumigation casks, hops, fruit Desiynation of industrial poison Antimony, arsenic, lead, carbon monoxid Lead Hydrochloric acid, lead, benzin, carbon monoxid Mercury Amyl alcohol Arsenic chlorid, nitrous gases Arseniuretted hydrogen, mercury, nitrous fumes, chlorin, phosphoric acid Dimethyl sulphate AniUn dyestuffs Antimony Sulphur dioxid Cyanogen compounds, mercury Anilin dyestuffs, mercury, nitrous gases, nitro-benzol, nitroglycerin, picric acid Carbon dioxid in silos (see also in- secticides) Chromium compounds Benzin, benzol, acrolein, carbon disulphid Benzol, benzin, carbon disulphid, sulphur chlorid Lead Benzin Carbon dioxid^ Mercury, methyl alcohol, nitrous gases, sulphuric acid, nitric acid, arsenic dyestuffs, carbon monoxid Arseniuretted and phosphuretted hydro- gen Hydrochloric acid, hydrofluoric acid, sul- phuric acid, sulphuretted hydrogen, benzin Lead Antimony, arsenic, carbon monoxid, phos- phorus Antimony, carbon monoxid, nitrous gases Benzin, carbon monoxid, nitrous and other acid fumes Lead Sulphuretted hydrogen Arsenic, lead Carbon monoxid, sulphuric acid Hydrofluoric acid Hydrofluoric acid Amyl alcohol Sulphur dioxid Tar Sulphur dioxid 300 INDUSTRIAL MEDICINE AND SURGEBT LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR {Continued) Branches of industry in which poisoning Designation of industrial poison may occur Furnace gases - Carbon monoxid, sulphur dioxid (see also Blast Furnaces) Anilin, arsenic, chrome stains, lead, methyl alcohol, petroleum, phenol, turpentine Lead for dyeing; mercury and nitrous gases for rabbit fur, arsenic, anthrax Cyanogen compounds Nitrous gases Ammonia, arseniuretted hydrogen, hydro- chloric and sulphuric acids, zinc Benzin, carbon monoxid Benzin See Insecticides Anilin and arsenic dyes, carbon mon- oxid from ironing stoves, lead from weighted silk Ammonia, carbon monoxid, cyanogen compounds, tar Arseniuretted hydrogen, lead, nitrous gases Carbon monoxid Carbon monoxid, cyanogen compounds Benzin Sulphur dioxid Mercury Hydrofluoric acid Arsenic, hydrofluoric acid, hydrochloric acid, chromium compounds, carbon monoxid, lead, manganese, phenol (see also Painter) Lead Lead Anthrax, acids, anilin, chrome and lead compounds Benzin Arsenic from impure sulphuric acid Sulphur dioxid, chlorid of lime Nitroglycerin Cyanogen compounds, mercury Cyanogen compounds Benzin, benzene, carbon disulphid Carbon disulphid Nitroglycerin, nitrous gases Antimony, cyanogen compounds, carbon monoxid Anthrax Acrolein, cyanogen compounds and lead Mercury, methyl alcohol, nitrous gases, sulphuric acid, arsenic, dyestuffs, car- bon monoxid Furniture factories, staining and polishing Furriers Galvano-plasty Galvano-techniques Galvanizing with zinc or tin Garage workers Garbage fat extraction Gardeners Garment workers Gas plants Gas and steam fitters Gas machines Gas purification Gasolin Gelatin manufacture Gilding and silvering Glass etching Glass factories Glass polishing Glaze mixing and dipping Glove and mitten manufacture Glove cleaning Glucose, manufacture of Glue, manufacture of Glycerin, trinitrate Gold, extraction of Gold plating Grease removal Gums, solvent for Gun cotton Gunsmiths Hair industry Hardening and tempering steel mag- nets, piano wire, springs, files, etc. Hat, felt, factory HEALTH HAZARDS IN OCCUPATIONS 301 LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR {Continued) Branches of industry in which poisoning Designalion of industrial poison may occur Hat, straw, factory Heating and power plants Hectograph composition Hides and skins Hittorf tubes Hydrochloric acid Hydrogen gas House painting Ice machines Igniting agents Illuminating gas, manufacture of Imitation bitter-almond oil Imitation silk factories Imperial yellow dye, manufacture of Impregnated wood Incandescent electric Ught India rubber industry Indian white fire Indulin dye, manufacture of Ink stains, removal of Insecticides, manufacture and use of Insulated wire, manufacture of lodin, manufacture of Iron chlorid, sulphate, manufacture Iron, deoxidation of Iron, galvanizing with zinc or tin Iron silicate, impure, decomposition of Iron sulphate, manufacture of Ironing Iron sanitary ware Iron and steel workers Jewelry, manufacture of Kaiser green Sulphur dioxid, methyl alcohol, oxalic acid Carbon dioxid, carbon monoxid Chromium compounds, anilin Anthrax, arsenic, sulphur dioxid (see also Tanning) Mercury Nitrous gases Arseniuretted hydrogen Arsenic, benzin, lead, chrome colors, methyl alcohol, turpentine Ammonia, sulphur dioxid Phosphorus Ammonia, benzol, carbon monoxid, car- bon disulphid, sulphuretted hydrogen, tar Nitrobenzol Carbon disulphid, ammonium sulphid, nitrous fumes Anilin dyestuffs Phenol, tar Amyl acetate, carbon monoxid, mercury, methyl alcohol Anilin oil, antimony, benzin, benzol, carbon disulphid, cinnabar (mercury), hydrochloric acid, lead, sulphur dioxid and chlorid, tar, wood, alcohol. Arsenic Anilin dyestuffs Oxalic acid Arsenic, carbon disulphid, cyanogen and mercury compounds, sulphur dioxid Carbon disulphid, lead Benzol Nitrous gases Nitrous gases Ammonia, arseniuretted hydrogen, acid fumes and zinc Arseniuretted and phosphuretted hydrogen Arseniuretted hydrogen Carbon monoxid, chlorin, arsenic Carbon monoxid, lead, acid fumes Carbon monoxid, other furnace gases (see also Cutlery Industry) Ammionia, amjd acetate, cyanogen com- pounds, lead solder, hydrochloric, nitric and sulphuric acids, mercury, carbon monoxid (see also Brass) Arsenic 302 INDUSTRIAL MEDICINE AND SURGERY LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR (Continued) Branches of industry in which poisoning may occur Krems white Lace workers Lacquer manufacture Lampblack, manufacture Lamp shades, coloring purposes Lanolin, extraction of Lard making Latrines Laundries Lead alloys Lead colors Lead, deoxidation of Lead metal Lead smelting Lead plating Leaf metal workers Leather industry Leather sole stitching Leather patent Leblanc soda, manufacture Ligroin Lime chlorid, manufacture of Lime kilns Linoleum, manufacture of Linotyping Litharge Lithographing Litho-transfer work Lyddite, manufacture of Lysol Manchester yellow, manufacture of Manganese mills Manumeters, manufacture of Marble polishers Masonic white leather aprons Mattress, manufacture of Matches, manufacture of Meldola dyes Melinite, manufacture of Mercury compounds, manufacture of Mercury mining Designation of industrial poison Lead Carbon monoxid Ammonia, amyl acetate, benzin, benzol, methyl alcohol, turpentine Phenol Arsenic Carbon disulphid Acrolein, ammonium sulphid, acid fumes Ammonia, sulphuretted hydrogen Benzin, benzol, chlorin, anilin colors for marking ink, carbon monoxid, arsenic from coke burning ironing stoves Antimony, copper, tin, etc. Lead Nitrous gases Arsenic Antimony, arsenic, lead, sulphur dioxid Arseniuretted hydrogen Ammonia, amyl acetate, acetone, benzin, benzol, methyl alcohol, turpentine Arsenic, chromium compounds, lead, mineral acids Mercury Amyl acetate, benzin, methyl alcohol Sulphuretted hydrogen Benzin Chlorin, arseniuretted hydrogen Carbon dioxid, carbon monoxid, sulphur dioxid Acrolein, amyl acetate, arsenical, mercu- rial and lead pigments, benzin and turpentine, manganese, zinc oxid Antimony, arsenic, lead, organic vapors Lead Arsenic, acid fumes, bronze powder, anilin, benzin, turpentine Lead Picric acid Phenol Anilin dyestuffs Manganese Mercury Lead Lead Anthrax, infectious diseases Chromium compounds, phosphorus Anilin dyestuffs Picric acid Mercury Mercury HEALTH HAZARDS IN OCCUPATIONS 303 LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR {Continued) Branches of industry in which poisoning may occur Mercury smelting Mercury vapor lamps Metal dipping Metal burnishing Metal etching Metal lacquer Metal pohshing Metal refining Meters, electric, manufacture of Methyl amines Methyl esters Methyl ether Methyl violet Methylizing of every kind Mining Mineral water, carbonated Mints Mirbane oil Mirror plating Mirror silvering Moulds, drying Monotyping Moulding, picture frame manufacture Mordant in dyeing Mosaic works Muriatic acid Muslin green, color Naphtha, naphthol nitrates Naphthalein Navy Nickel buffers and polishers Nickel platers Neuwied green Nitric acid manufacture, salts and storage Nitrite of amyl Nitrificating in chemical works Nitrobenzol Nitrocellulose Nitroglycerin Nitrojute Nitromannite Designation of industrial poison Mercury Mercury Acid fumes Antimony, acid fumes Arseniuretted hydrogen, nitrous fumes, mercury Amyl acetate Oxalic acid Nitrous gases Mercury, lead (see also Brass Industry) Dimethyl sulphate Dimethyl sulphate Dimethyl sulphate Anilin dyestuffs Diazomethane Arsenic, carbon dioxid, carbon monoxid, lead, mercury, nitroglycerin, nitrous fumes, sulphuretted hydrogen, and other gaseous products of combustion of ex- plosive compounds Carbon dioxid Nitrous gases Nitrobenzol Mercury Acetaldehyd, ammonia; lead, if backed with red lead Carbon monoxid Antimony, arsenic, acrolein, lead Amyl acetate, bronze, methyl alcohol (see also Leaf Metal Workers) Antimony, chromium compounds, etc. Manganese Hydrochloric acid Arsenic Benzin, benzol, nitrous gases Anilin, anilin dyestuffs Carbon monoxid, gun firing, and furnace rooms Lead, nickel-carbonyl Benzene, lime, nickel salts, petroleum Arsenic Nitrous gases Amyl alcohol Nitrous gases Anilin, nitrous gases Nitroglycerin, nitrous gases ■ Nitrous gases Nitrous gases Nitrous gases 304 INDUSTEIAL MEDICINE AND SURGERY LIST OF INDUSTRIES Branches of industry in which poisoning may occur Nitronaphthalene Nitrophenol Nitrosaccharose , Nitroso dyes Nitrotuluol Oil, bleaching of Oil, solvent Oilcloth, manufacture of Oil, vitreol Open fire heating Organ builders Organic dyes, manufacture Organic preparations, manufacture Oxalic acid, manufacture of Oxygen, manufacture of Painters and commercial artists Paper deoxidation Paperhangers Paper mills Paraffin refining Paris green Parrot green Paving material Pencils, colored Percussion caps Perfumes, manufacture of Petroleum industry, distillation and refining Pharmaceutical preparations Phenol nitrates, manufacture of Phenylhydrazin, manufacture of and its use for production of organic compounds Phosgene, manufacture of and its use for production of organic com- pounds Phosphor bronze Phosphorus extraction from phos- phorites and coprolites Phosphorus, manufacture of Phosphorus, red, manufacture of Phosphorus, sesquisulphid, manu- facture of IN WHICH POISONING MAY OCCUR {Continued) Designation of industrial poison Nitrobenzol Nitrobenzol Nitrous gases Anilin dyestuffs Nitrobenzol Chromium compounds, nitrous gases Benzin, carbon disulphid Acrolein, amy lacetate, arsenical and lead pigments Sulphuric acid Carbon monoxid Lead, bronze, methyl alcohol Acrid in, arsenic Formaldehyd, phenylhydrazin, phosgene Oxalic acid Chlorid of lime Arsenic, benzin, benzol, lead, mercury, methyl, alcohol, tar, turpentine, phenol, amyl acetate, carbon disulphid Nitrous gases Arsenic, lead Chlorin, lead, sulphur dioxid, toxic color pigments Carbon disulphid Arsenic Arsenic Asphalt, tar Anilin dyestuffs Mercury fulminate Dimethyl sulphate, methyl alcohol, nitro- benzol Petroleum, sulphuric acid, hydrochloric acid, chlorid of lime, sulphur dioxid, lead, tar Mercury, methyl alcohol, nitrobenzol, etc. Anilin dyestuffs, nitrous gases, phenol Phenylhydrazin Phosgene Phosphorus Phosphorus and hydrofluoric acid Benzol, phosphorus Phosphureted hydrogen Phosphureted hydrogen HEALTH HAZARDS IN OCCUPATIONS 305 LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR {Continued) Branches of industry in which poisoning may occur Phosphorus and sulphur compounds Photoengravers Photogen factories Photographing establishments, material Physical apparatus, manufacture of Pianos, manufacture of Picric acid manufacture Picture frames, manufacture of Plumbers Polish for furniture Polish for metals Porcelain enamelled ware Potteries Printing establishments Preservative fluid for animal tissues Preservative for wood Projectiles, manufacture of, filling shops Putty making Putrefaction processes, gases of Pyridin, manufacture of Pyrites Pyrotechniques Quicksilver Rabbit fur for felt hats Rag and shoddy industry Rattan industry Red lead Refrigeration plants Rendering plants Resin, distillation of Resin, solvent for Rifle barrel, burnishing Rontgen tuber, manufacture of Roofers Roofing paper, manufacture of 20 Designation of industrial poison Sulphureted hydrogen Ammonium dichromate, nitrous fumes Phenol Anilin colors, bromin compounds, cyanogen c,ompounds, mercury, metol, chromium compounds, lead in re- touching high lights. Mercury, arseniureted hydrogen Bronze, lead, methyl alcohol Anilin dyestuffs, nitrous gases, picric acid, phenol Bronze, amyl acetate, methyl alcohol (see Leaf-metal Workers) Arseniureted hydrogen, lead, carbon monoxid Petroleum, methyl alcohol Oxalic acid Lead Hydrofluoric acid, hydrochloric acid, lead, manganese, arsenic, chrome, carbon monoxid (see also Painters) Acrolein, antimony, benzin, lead, carbon monoxid, arsenic, methyl alcohol Formaldehyd, methyl alcohol Arsenical color pigments, phenol, tar Picric acid (see also Explosives) Lead Ammonia, carbon dioxid, sulphureted hydrogen Pyridin Arsenic, nitrous gases Antimony, arsenic, phosphorus Mercury Mercury, nitrous gases Acid fumes, infectious diseases Anilin stains, chlorin, chromium, hydrofluoric acid, methyl alcohol, sulphur dioxid Lead Ammonia Acrolein, benzin, carbon, disulphid Carbon monoxid Benzin Antimony Mercury Lead, solder, tar Tar 306 INDUSTRIAL MEDICINE AND SURGERY LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR {Continued) Designation of industrial poison Branches of industry in which poisoning may occur Roof tiling manufacture Rubber toys industry,' including rubber Rubber tires, assembling of Rugs, manufacture, dyeing Rust stains, removal of Saffron yellow dye Salamanders, drying houses and plaster Sal ammoniac Salts of mercury Sanitary ware factories Schweinfurth green Sealing wax, manufacture of Sewer cleaning Sedimentation tanks Sewing machine manufacture Sheep dip manufacture Sheele's green Shellac, solvent for Shoddy manufacture Shot manufacture Shoe manufacture Silk bleaching Silk imitation factories Silk weighting Silver extraction Silver metal Silver plating Smelting furnaces Smelting lead Smelting mercury Smelting-sulphur bearing ores Soap factories Soda carbonate, manufacture of Soda chlorid, manufacture of Soda sediment, manufacture of Soda sulphate, manufacture of Soda sulphid, manufacture of Soda works Lead, carbon monoxid and other furnace gases AniUn, antimony, arsenic, benzin, benzol, carbon disulphid, and tetra- chlorid, lead, phenol, sulphur dioxid, and chlorid, tar, mercuric sulphid, methyl alcohol, turpentine Carbon disulphid Arsenic and other toxic dyestuffs Oxalic acid Anilin dyestuffs Carbon monoxid Ammonia Mercury Lead Arsenic Turpentine Ammonia, carbon dioxid, sulphureted hydrogen Carbon dioxid, sulphureted hydrogen Amyl acetate Arsenic Arsenic Methyl alcohol Hydrochloric acid, sulphuric acid Antimony, arsenic, lead Benzin, methyl alcohol Sulphur dioxid Carbon disulphid, ammonium sulphid, nitrous fumes Lead Mercury, cyanogen compounds Arsenic, lead, antimony Cyanogen compounds, mercury Carbon monoxide and other furnace gases Lead Mercury Sulphur dioxid Acrolein, nitrobenzol, sulphuric acid, pyridin, ammonia cyanid, sulphur, tar Ammonia Hydrochloric acid, chlorin Nitrous gases Arseniureted hydrogen, hydrochloric acid Sulphureted hydrogen Sulphureted hydrogen, hydrochloric and sulphuric acids HEALTH HAZARDS IN OCCUPATIONS 307 LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR ( Continued) Branches of industry in which poisoning may occur Soldering Staining wood Stannic acetate Starch, manufacture of Stamping designs on embroidery Stamping mills Stearic acid factories Stearin refining Steel engraving Steel burnishing Stereotyping Storage batteries Stone and marble polishers Straw hats, bleaching Straw de oxidation Sugar, beet sugar Sugar plants, saturation vessels Sugar refineries Sulphur, refining of Sulphur metals, manufacture and use of Sulphur extraction in gas purification Sulphur solvent for Sulphur, water distillation of Sulphur and phosphorus compounds, manufacture of Sulphid colors, manufacture and use of Sulphuric acid, manufacture of Sulphurous acid and salts, manu- facture of Surgical dressings Swiss green Tailors Tallow rendering plants Tallow refining Tanneries, tanning and leather dressing Tapestry printing Tar color industry Tar works Taxidermy Telephone wire, manufacture of Designation of industrial poison Arseniureted hydrogen, carbon mon- oxid, hydrochloric acid, lead, nitrous fumes Anilin, chromium, methyl alcohol, phenol Hydrochloric acid See Putrefaction Gases Lead and rosin Mercury, nitrous gases Acrolein Carbon disulphid Mercury Antimony, sulphuric acid Antimony, lead, carbon monoxid See batteries Lead Sulphur dioxid Nitrous gases Ammonia Carbon dioxid Phosphorus, sulphureted hydrogen Benzol Sulphureted hydrogen Carbon disulphid Carbon disulphid, sulphur chlorid Sulphureted hydrogen Sulphureted hydrogen Sulphureted hydrogen Nitrous gases, sulphur dioxid Nitrous gases, sulphur dioxid Mercury, phenol Arsenic See Garment Workers Acrolein, sulphuric acid Carbon disulphid, chlorin, acid fumes Ammonia, anthrax, arsenic, carbon dioxid (in tan pits), chromium com- pounds, lead (white leather), sulphur dioxid, sulphureted hydrogen, acids, benzin, amyl acetate Turpentine, toxic color pigments Anilin, chromium compounds, phos- phorus, etc. Tar Arsenic, carbon disulphid Lead 308 INDUSTRIAL MEDICINE AND SURGERY LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR (Continued) Branches of industry in which poisoning may occur Tempering and hardening, steel magnets, , piano wire, springs, files, etc. Textile fabrics, deoxidation of Textile industry Textile printing Thermometers Thorium, preparation of Tin foil Tin ware and tin shops and tinning Tissue hardening and preserving Toluol, manufacture of Toys, coloring of Toy balloons, filling Transfer chromos Turkey red, mordant for Typefounders Typesetters Ultramarine works Upholstery Valeric acid, manufacture of Varnish, manufacture and use of Vinegar, manufacture of Vienna green and red Viscosin, manufacture of Vulcanizing and red dyeing of rubber Wall-paper, manufacture of Wall-paper, hangers and scrapers Waste waters of industrial plants making use of organic matter Watch factories Water gas, carburizing Water gilding Waterproof material Wax bleaching Wax refining Weather vane gilding Well gas Whip, factories White lead White metal Window shades, green Wine cellars Designation of industrial poison Acrolein, cyanogen compounds, lead Nitrous gases Arsenical colors, lead, sulphur'ic acid Antimony, arsenic, chromium, lead compounds Mercury Nitrous gases Lead Ammonia, arseniureted hydrogen, chlorin, carbon monoxid, hydrochloric acid, lead sulphuric acid Formaldehyd Benzol Arsenic Arseniureted hydrogen Lead Chromium compounds Acrolein, antimony, arsenic, lead Benzin, lead Sulphur dioxid, sulphureted hydrogen Anthrax and infectious diseases Amyl alcohol Acrolein, ammonia, benzin, lead, methyl alcohol, turpentine Acetaldehyd Arsenic Nitrous gases Antimony, arsenic, carbon disulphid (see also Rubber) Arsenic, lead (see also Paper Mills) Arseniureted hydrogen Sulphureted hydrogen Benzin, cyanogen, compounds, lead for dials, nitrous gases (see also Brass and Tempering) Benzol Mercury See Rubber Chromium compounds, sulphur dioxid Carbon disulphid Mercury Carbon dioxid See Rattan Industry- Lead Antimony Arsenic Carbon dioxid HEALTH HAZARDS IN OCCUPATIONS 309 LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR {Continued) Designation of industrial -poison Branches of industry in which poisoning may occur Wine preserving Wire galvanizing with zinc Wire tempering Wool bleaching Woolen refuse, deoxidation of Wood alcohol Wood deoxidation of Wood impregnating and preserving Wood staining and polishing Workrooms, crowded Yeast, compressed, factories Zyloidin, manufacture of Zylol Zap one lacquer Zinc chlorid, manufacture of Zinc deoxidation of Zinc ore smelting Zinc plating Zinc sulphate, manufacture of Zoological preparations Sulphur dioxid Ammonia arseniureted hydrogen, hydro- chloric acid, sulphuric acid, zinc Lead, acrolein, cyanogen compounds Sulphur dioxid Nitrous gases Methyl alcohol Nitrous gases Arsenical paints, phenol, tar Anilin colors, chromium compounds, lead, arsenic colors, methyl alcohol, alcohol denatured with pyridin, phenol, petroleum Carbon dioxid Carbon dioxid Nitrous gases Benzol Amyl acetate Arseniureted hydrogen Nitrous gases Antimony, arsenic, carbon monoxid, lead, manganese, sulphur dioxid Ammonia, arseniureted hydrogen, hydro- chloric, sulphuric acids and zinc Arseniureted hydrogen Formaldehyd CHAPTER XX \ THE NATIONAL SAFETY COUNCIL "Safety First" is the slogan adopted and made famous by a group of laymen who in 1912 met and formed the great National Safety Council, The work of this association has done more toward preventing accidents among industrial workers than any other single organization. In 1914 a Health Section composed largely of industrial surgeons was incorporated as a part of this association. It was recognized that Industrial medicine and surgery must be a definite part of any successful scheme of accident prevention. The Safety engineer was responsible for the mechanical appliances attached to machines to protect the operator and for other physical conditions in the plant improving safety methods. The Safety Committee could spread the gospel of '' Safety First " throughout the working force. But the doctor was the only one who could inspect the human machine and pick out defects in it which made accidents to the man or to his fellow men more liable to occur. Therefore, with the induction of the industrial surgeon into the ranks of the National Safety Council a complete machine was formed for the prevention of accidents among industrial employees — the Safety Engineer for the correction of physical conditions in the plant, the Safety Committees to spread the educational propaganda among the workers, and the Industrial Surgeon, the Human Engineer, to correct the physical conditions in the employees. Every industrial surgeon should be familiar with the founding and history of this National Safety Council. It has been the means of conserving thousands upon thousands of lives. It has stimulated the medical profession to greater efforts in prevention. "Safety First" is a twin brother of Preventive Surgery. Mr. William H. Cameron, the Executive Secretary of the National Safety Council, a man who has devoted his life to this great humani- tarian movement, has written the following history of this organiza- tion for the author to publish here. "And the end is that the workman shall live to enjoy the fruits of his labor; that his mother shall have the comfort of his arm in her age; that his wife 310 THE NATIONAL SAFETY COUNCIL 311 shall not be untimely a widow; that his children shall have a father; and that cripples and helpless wrecks who were once strong men, shall no longer be a by-product of industry." JUHNKE. '"Accident prevention and health conservation are now firmly established among the institutions of free America. For a score of years individual efforts were made by progressive employers to meet the demands both of production and human conservation. Sporadic efforts sought to gather together the loose ends of the new industrialism, and to fashion an organization which would fit the needs of the twentieth century, but for lack of concentration and co-opera- tion these efforts failed of lasting accomplishment. "With the birth of the American factory system about the time of the civil war, came the doctrine of utility, and, for a time, grace and symmetry in product were sacrificed to unadorned simplicity. The cry was for speed, for production, for machine accomplishment and for 'tonnage,' and constantly increasing 'tonnage.' ''The old tradition of craftsmanship was swept aside and the work- man became a mere part of the shop equipment. Short cuts to produc- tion were the order of the day and the so-called inherent 'risks of the trade' became the doctrine not only of the factory but of the legislative and judicial systems. "But industry, never satisfied with established order, and seeking newer fields, turned from monotonous simplicity and taught the public a new lesson — comfort in living. Following closely in this development came lavishness and magnificence. ''Competition reached a keenness hitherto unknown. Vast capital was required and business management was alert to take advantage of the growing market. The world was scoured for raw materials for our workshops, with the brain centered on production, the drafting rooms became the lungs of industry, the sales force the nerves, the workshops the muscles and tendons. Every member of the industrial body except the heart was working at high tension. "As was to be expected reaction set in. Progressive and thoughtful men began to weigh carefully the costs of operation and maintenance, and the utilization of by-products laid the foundations of fortunes that were not dreamed of under the law of 'tonnage' alone. Economics and efficiencies in operation, studies of costs and closer co-operation in manufacture logically followed. "The Safety idea was born during the period of reconstruction of industry. It is a significant fact that the greatest of American 312 INDUSTRIAL MEDICINE AND SURGERY industries was the first to amalgamate all the forces of production and utility and business experience; was the first, as an organization, to publicly announce a crusade against industrial accidents and occupa- tional disease. The Safety movement owes more to the United States Steel Corporation than to any other single business organization. "The Association of Iron and Steel Electrical Engineers met in Milwaukee, Wisconsin, the week of September 30, 1912, and under the direction and enthusiasm of Mr. Lew R. Palmer, as Chairman of the Accident Prevention Committee of this Association, was launched the first National Safety Congress ever held in the United States. The resolutions announcing the birth of the new order of industrial justice are significant: '' 'Whereas, The Association of Iron and Steel Electrical Engineers, regarding as worthy of particular attention the hazards to life in- volved in electrical operations in steel mills, and appreciating the importance of the general Safety movement, not only in electrical engineering, but also in the steel industry as a whole, and in all the other varied and important industries of our country, and having met with such prompt co-operation in their proposals to establish a national organization devoted to securing increased Safety to human life, has reached the conclusion that such an organization can best be brought about by action at this joint meeting of the Association of Iron and Steel Electrical Engineers and the Co-operative Safety Congress; and it is, therefore, hereby " 'Resolved, That the President of the Association of Iron and Steel Electrical Engineers be requested to take the first steps toward the formation of a national organization for the promotion of Safety to human life by appointing a Committee on Permanent Organization, which shall contain representatives of the Federal and State agencies already established to supervise conditions of Safety in our industries, and shall also contain representatives from the mining, transportation and manufacturing industries of the United States; and be it further " 'Resolved, That the committee so appointed shall be and hereby is authorized by this Congress to organize and to create a permanent body devoted to the promotion of Safety to human life in the industries of the United States; this Committee to have authority to call future Congresses of Safety, increase its membership, if it so desires, and to do such other acts as will promote the object for which it is established.' "The Congress met at the Hotel Pfister and among the delegates we find the following: Dr. L. W. Chaney, Department of Commerce and labor. Mr. C. L. Close, U. S. Steel Corporation. THE NATIONAL SAFETY COUNCIL 313 Dr. Joseph A. Holmes, Director Bureau of Mines. Mr. F. W. Houk, Commissioner of Labor, Minnesota. Mr. John Kirby, Jr., National Association of Manufacturers. Mr. James T. McCleary, Iron and Steel Institute. Mr. Chas. C. McChord, Interstate Commerce Commission. Dr. Chas. P. Neill, U. S. Commissioner of Labor. Mr. L. R. Palmer, Association of Iron and Steel Electric Engrs. Mr. C. W. Price, Wisconsin Industrial Commission. Mr. R. C. Richards, Chicago and Northwestern Railway. Dr. M. J. Shields, National Red Cross. Mr. F. C. Schwedtman, National Association of Manufacturers. Mr. David Van Schaack, Aetna Life Insurance Company. Mr. H. M. Wilson, Bureau of Mines. Mr. H. J. Young, Illinois Steel Company. "Chairman Dr. Lucian W. Chaney, representing the United States Department of Commerce and Labor, opened the meeting as follows: " 'I wish to impress upon those present that the effort in which we have entered in connection with this Congress is distinctly a phase of applied Christianity, and, therefore, it is exceedingly appropriate that we invite Dr. Steiner, Professor of Applied Christianity in Grinnel College, to offer a word of prayer as we begin.' OPENING PRAYER Dr. Edward A. Steiner, Professor of Applied Christianity, Grinnel College " ' Oh Lord, our God, who dost promise to those who meet in Thy name Thine own presence, we have come together not to consider our own weel or wealth; we have come here in Thine own name to consider the well-being of our fellowmen, and we would invoke Thy blessing, ask Thee to meet with us whom Thou hast chosen to be co-workers with Thee. We pray that Thou may be with us and help us not only to light the way, but help us to keep the way, and grant that everything that shall be done at this Congress shall work for the well-being of our fellowmen, for the glory and development of our own country, and for the speedy coming of the kingdom of God. May our consideration of the Safety of labor and the toiler be rewarded by a higher respect for humanity as a whole, a great regard for law, a purer and deeper and higher patriotism; wilst Thou bless this city in which we meet, this Commonwealth, our beloved country, the President of the United States, his Cabinet and all his officers; this great country and all its states from one end to the other, and may it continue to be 314 INDUSTRIAL MEDICINE AND SURGERY the great beacon to the world, Hghting toward Hberty and toward progress, and may the work which we do here this morning be a contribution toward that end. Bless the President of this association, all the officers, all those who take part, and may it be as solemn as it is sacred, and may it be as useful as we try to make it holy. We ask it all in the Master's name, who gave himself for the good of men. Amen.' ''Dr. Chaney's words were prophetic, Dr. Steiner's prayer has borne fruit. To-day Industrial Safety is firmly established as a part of our fabric of government. To-day the gospel of industrial righteous- ness is preached in thousands of workshops, and on the majority of the transportation systems. '' The modest meeting in 1912 developed into the National Council for Industrial Safety. Under the wise leadership of Mr. R. W. Camp- bell, President, and Mr. William H. Cameron, General Manager, and the effective co-operation of an earnest and enthusiastic staff, the Safety crusade took form and substance. The Second Safety Congress at the Hotel McAlpin, New York City, presented a program of activi- ties which commanded the interest of all humane employers and effectively answered the critics of the movement. Two score of the biggest and broadest-minded men in the country accepted invitations to address the Congress, and their allegiance to the Safety movement firmly established the new crusade. About this time the slogan 'Safety First' became popular, welding all forces of the newest gospel into a concrete and effective organization. "The National Council for Industrial Safety grew and prospered. The weekly Safety bulletin service was established and has been continued without a break for 175 weeks, and has grown to a dis- tribution of 75,000 copies per week. Statistical researches were made and tabulated, and practical value given to shop activities never before dreamed of. The innovation of using available data in the simple and effective form of one page illustrated bulletins, rather than in the compilation of massive treatises, proved the value of the Council's services in teaching the lesson in readable form and fresh from the press. The Council doubled its membership and greatly increased its usefulness in this, the second year, of its life. "Then came the Third Safety Congress, held at the Hotel LaSalle, Chicago. This series of meetings was epoch making, both in at- tendance and interest. The roster of speakers contained the names of Royal Meeker, Commissioner of Labor, U. S. Department of Labor; John Price Jackson, Commissioner of Labor and Industry, Penn- sylvania; H. M. Wilson, Engineer in Charge, Bureau of Mines; Dean C. B. Connelly, Ida M. Tarbell, Ahce Hamilton, Dr. Theodore Sachs, Dr. A. M. Harvey, Dr. Geo. W. Price, Martin J. InsuU, William THE NATIONAL SAFETY COUNCIL 315 P. Eno, E. A. Halsey, Fred C. Schwedtman and a host of others, all preaching and advocating industrial Safety and health conservation. "It was at this Congress that the industrial medical practitioner first made his voice heard in unmistakable terms. Plant managers learned that the installation of adequate mechanical safeguards did not comprise their only duty. Sanitation, ventilation, control and eradication of industrial disease, elimination of communicable in- fections, all these and other questions were placed on the program and given a thorough discussion. Tuberculosis, blood poison, hernia, eye strain, and excessive fatigue were handled in a way to awaken the interest and co-operation of the large audiences. "A year of intense activity followed. With the broadened scope of activities the association changed its name to 'National Safety Council.' The program of the Third Safety Congress furnished the text for the activities of the officers and members and the work was carried on with renewed enthusiasm. The membership doubled, and with every mail came scores of experience statements from plant officials to be compiled, digested, and reissued for the information of the whole membership. " Mr. Arthur T. Morey honored the Council by accepting the office of chief executive for the third year, Mr. Campbell retiring as Presi- dent at the end of the second year. It is significant of the interest taken in the work that the master minds of industry have cheerfully and unostentatiously given so liberally of their time and experience for the causes of safety and humanity. "The Fourth Safety Congress was held at the Belle vue-Stratford Hotel, Philadelphia. To meet the demands of the Congress it was necessary to divide the Council into sections, each meeting larger in attendance and more ambitious in program than the first Congress at Milwaukee, The Governor of the Commonwealth, the Mayor of this City, the press, and the public united in a grand rally to further the propaganda of the Congress. "After the great 'round table' gatherings, devoted to general dis- cussion, ten sectional meetings considered the particular Safety prob- lems of their industries. The Cement Section took a leading part in the Congress, as did the Mining, Steam Railroad, Laundry, Paper and Pulp Manufacturers, Public Utilities, Textile, Industrial Hygiene, Safeguarding of Machinery, Foundry and Woodworking Sections. "It was at this gathering that the greatest truth in the Safety Cru- sade was forcibly driven home to the plant managers, the Safety Engineers, and the public, namely, that all the safeguards, all the rule books, all the discipHne, and all other efforts must fail without the earnest and willing co-operation of the workmen themselves. Mil- lions of dollars had been expended by the members of the National 316 INDUSTRIAL MEDICINE AND SURGERY Safety Council in perfecting the mechanical safeguards in their plants; other millions went for sanitation, for ventilation, for preventive measures, yet the men vitally affected too often showed only a per- functory interest in their own welfare. "A scoTe of addresses and lectures were delivered at the Philadel- phia Safety Congress pointing the way to success ?n administering Safety work — ^the way to the hearts of the millions of men and women toiling in the industries. The visiting nurse, the industrial physi- cian, the dentist, and the teacher came forward and joined the social worker, priest and parson in the teaching of applied and practical Christianity. Industrial justice was heard in no uncertain terms. "Another important lesson was taught out of the wealth of digested experience and statistical data furnished through the medium of the parent body — the National Safety Council. Where one accident was prevented through safeguarding three were prevented by the exercise of personal care and caution by the workmen themselves. Where one case of industrial disease was prevented in the shop or factory, two were susceptible of prevention and three of cure in the home life of the employees. ' 'From the date of the Fourth Safety Congress the importance of education, rather than compulsion in Safety matters, was given promi- nent place in the activities of the movement. "The elasticity of the Council was never better exemplified than during the succeeding year. Employers who had held aloof, waiting for the movement to prove itself, came forward in whole-hearted recognition of the justness of the plea for a larger humanity. From an organization struggling to meet the patent demands made upon it in the simple necessities of everyday life, the Council almost in a day, was placed beyond the need of financial worries. "From the Fourth to the Fifth Safety Congresses the membership again doubled in number; the work of the Sections was improved, an increased staff at headquarters facilitated the activities of the officers, and the newer phases of Safety work were pushed with un- relenting vigor. The record of the Fourth Congress is found in the 771 pages of the proceedings of the gatherings — a living monument of service and a text-book on safety of incalculable value. "The Fifth Safety Congress was held at the Hotel Statler, Detroit. Mr. Lew R. Palmer succeeded Mr. Morey as President, Mr. Morey continuing (as in the case of Former President Campbell) as a director and Executive Committeeman of the Council. The proceedings of the Fifth Safety Congress fill a volume of 1541 pages, every page a lesson and an inspiration. "Perhaps the most important constitution for the cause of Safety by the National Safety Council, has been the organization and es- THE NATIONAL SAFETY COUNCIL 317 tablishment of an Information Bureau and Library of every scrap of printed material available in the United States and foreign coun- tries, relating to the work of the Council. This Information Bureau is at present in charge of two trained librarians who are classifying and filing this printed information, and sending it to the hundred of members inquiring for data every month. Every application for membership passes through this Bureau of Information, and the im- portant bulletins and publications of the Council are sent to the new member to properly start him in his new activities. For the year ending April 1, 1917, four million bulletins were distributed to jBf- teen thousand representatives residing in every State of the Union, and in seven foreign countries. "At the present time the monthly pamphlet called "Safe Practices" is in circulation, an encyclopedic work destined to take its place in literature with the foremost handbooks of the world. A modest num- ber on 'Ladders' was followed by others on 'Stairs and Stairways;' 'Boiler Rooms;' 'Crane Construction and Safe Practices;' 'Knots, Slings, Bends and Hitches;' 'Belt Shifters,' etc. In time, it is in- tended to present every phase of industrial education and by rule, illustration and practice, complete a digest of Safe Practices for the prevention of accidents in the industries of America. "In attempting a brief resume of the work of the Council it is weU to digress from its direct accomplishments to point, if only momen- tarily, to the reflection of its activities on other forces in society. Take from the shelf of any Hbrary devoted to law, medicine, pub- lic or private welfare any volume published in the last four or five years and run through the pages. You will find therein, whether in federal enactment, state law, or city ordinance, chapters, phases, and texts first enunciated at the Congresses of the National Safety Council. "In this way is the history of the movement, and the mommaent to its founders and proponents, best perpetuated — in the lives and hearts of Kving men and women; in the healthy bodies and active minds of self-supporting and self-respecting workers, due, in many thou- sands of cases, to the whole-hearted co-operation of their employers in makiag this a better and a safer country." CHAPTER XXI ACCIDENT PREVENTION / Entire volumes have been written in recent years on the subject of accident prevention. In the last decade few topics connected with industry have received more attention or made more rapid progress. And yet the prevention of injuries to our workmen has not reached a high plane of efficiency, and in many concerns it is still more or less neglected. In some nations the conservation of their people has caused high penalties to be placed against those employers who fail to prevent injuries from occurring to their employees. As a result, accident pre- vention has become standardized throughout their entire industrial field, resulting in great saving in life and limbs. In the United States the introduction of employees' compensation laws caused many con- cerns to adopt some system of accident prevention. But thus far these laws have not been drastic enough to place a penalty upon the concerns failing to take proper precautions. In a few states, as for example Ohio, the accident insurance of all concerns is carried by the state government. The amount of premium paid by the employer is raised or lowered each year accord- ing to the number of compensable injuries which his employees sus- tained during the preceding year. This arrangement gave an im- petus to the prevention of accidents among all industries in that state. While some concerns will voluntarily institute this form of prevention, yet it will not become universal until our nation makes it too expen- sive for any employer to allow preventable injuries to occur. It is imperative that every industrial surgeon should drive home this truth at every opportunity — Prevention is much Cheaper than pay- ing Compensation. Many laymen have entered this field of preventive surgery. Safety engineering has become a great specialty. Such an engineer is very essential as the prevention of many accidents depends upon building construction, mechanical appliances adapted to machinery, the rebuilding of some machines, and many other forms of mechanical work. But no surgeon should neglect to familiarize himself with every form of accident prevention. It is impossible to cover the entire scope of this work in a volume devoted to so many other subjects related to Human Maintenance, 318 ACCIDENT PREVENTION 319 but the author would recommend the Transactions of the National Safety Council, and the book, "Accident Prevention and Relief" by Schwedtman and Emery, pubUshed by the National Association of Manufacturers, to every surgeon engaged in industrial practice. In this chapter, however, we will endeavor to show the relationship of the surgeon in industry to all accident prevention work, and point out the responsibilities which are his by many examples derived from actual experience. Industrial accidents may be etiologically divided into three groups : 1. Those due to the physical conditions found in the working place. 2. Those due to certain physical or mental conditions found in the working force. 3. Those due to disaster, as j&res, lightning, explosion, cyclone, etc. The prevention of accidents must be done by : 1. Protection against potential accidents by safety appliances placed about the working place, or worn by the employees. 2. A study of the cause of an accident and protection against a recurrence. 3. Supervision of the physical and mental condition of all em- ployees and correction of any causes for accident found in them; the removal of a susceptible employee to work where no hazard exists; the safeguarding of fellow employees from accidents liable to result from defective workmen. 4. Protection against disaster as far as possible and providing proper means of escape for the employees in case of disaster. To accomplish the above Accident P*revention there must be: 1. Constant study and inspection of the physical conditions of the working place, by the safety engineer, the medical staff, the management and the employees, to discover causes for the potential accidents. 2. Careful study of the cause of each accident by the surgeon and safety engineer to ascertain whether mechanical conditions or condi- tions in the employee, or both, were responsible and how a like acci- dent can be prevented in the future. 3. Educational campaigns on accident prevention by bulletins, lectures, motion pictures, by safety committees among employees, and by developing an atmosphere of Prevention throughout the entire working force (Fig. 39). Before the ''Safety First" movement started the greatest number of accidents were due to the physical conditions of the working place. This is still true in many concerns. But as protective appliances were installed, accidents from these causes decreased, and conditions found 320 INDUSTRIAL MEDICINE AND SURGERY in the employees themselves became more evident as a causative factor. The commonest cause of injury was found in minor accidents, such as those due to splinters, pin pricks, nail wounds, scratches from loose wire, from tools, contusions as from hammer blows, tripping on loose boards, slipping and falling, etc. Even these minor accidents have been greatly reduced. But the greatest benefits have ACCIDENT PREVENTION POSM Number 1 1. 8 Men Killed-Each Death A Preventable Accident I — ^Workman engaged in h»v^ing loail of cut wocxL Load toppled over on him and hd died of hi* iiyurie*. PILE ALL MATERIAL SAFELY. S — Fhre workmen recently killed in different parti of State coming in contact with live wires. PROPERLY PROTECT ALL ELECTRIC WIRES. DO NOT TOUCH WIRES UNLESS YOU KNOW DANGEROUS CURRENT IS CUT OFF. REPORT ALL INJURIES AT ONCE AND RECEIVE PROPER MEDICAL ATTENTION. 1 — Crane lifting plank*. One plank slipped from load and hit workman on head, killing him. KEEP FROM UNDER SUSPENDED LOADS. 8 Persons Unnecessarily Killed. SORROW, SUFFERING, POSSIBLY WANT-ALL AVOIDED BY CAREFULNESS. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY JOHN PRICE JACKSON. Commuiloo.r. Fig. 39. — Actual facts make the best propaganda for prevention. come from early treatment of these conditions thereby preventing any serious complications from arising. The surgeon in charge of the "Human Maintenance" Department of an industry should be most keenly alive to the responsibility of accident prevention. It is one of the most important branches of preventive Surgery. MAJOR ACCIDENTS We will first take up the physical conditions in the working place, which may cause these accidents. ACCIDENT PREVENTION 321 Every building connected with the plant should be thoroughly inspected to see that potential causes of accidents do not exist, or if found, that they are corrected. The building should be strongly constructed so that it can stand the strain placed upon it. This is an engineer's or architect's job, you will say. This is true but wherever the least doubt exists the industrial surgeon should see that this expert advice is brought in to safeguard the employees. Every year severe injuries and deaths occur from the collapse of some building or scaffolding used in connection with industry. The surgeon thinking in terms of prevention should be the first to point out these dangers. He should know at all times if the buildings used by his concern, or any temporary structures which are erected, are safe. Darkness is a Breeder of Accidents. — Every place in the building where employees must work or pass through should be adequately lighted. This is particularly true of all stairways or gangways. All platforms or other elevations should be protected. Unprotected Elevator Shafts are the Cause of Frequent Accidents. — Every known safety device should be placed on elevators. Too -often we wait until an elevator accident occurs before taking proper precautions. Every gate to an elevator should be raised or lowered automatically when the elevator stops or before it can start. Three garages were recently visited in a certain city, in which the elevator gates were not used at all. The elevator was run by any customer who came in and desired to go to the second or third floor for his car. This carelessness is bound to result in accident sooner or later. Laws preventing such carelessness should be enacted and strictly enforced. The prevention surgeon should consider it his duty to report such conditions to the proper authorities. In other words, the prevention instinct in each should react not only for the good of the employees under us but for the good of mankind. Temporary structures such as scaffoldings are notorious as a cause for accident due to collapse. One industrial surgeon persuaded the manager to rule that no temporary structure could be used until it had been thoroughly inspected by the safety engineer and pronounced perfectly safe by him. The Failure to Keep the Building in Repair at All Times Is Often Cause for Accidents.^ — An employee reported to the doctor's office, in a certain concern, with all the flexor tendons of the wrist severed due to striking it against a broken window pane. Inquiry revealed the fact that this window pane had been broken for over six months. In a busy concern, a heavy truck broke one of the boards in the floor. A week later an employee tripped on this broken board and fell 21 322 INDUSTRIAL MEDICINE AND SURGERY striking his head against the sharp corner of a box. He suffered a Pott's Fracture and a skull fracture. The repair of this defective floor would have prevented both. The sharp edge of the box left exposed so near the aisle was a potential cause for accident. Every plant physician can recall many preventable cases which have resulted from, broken conditions left unrepaired. Loose Articles Left on Floors or on Shelves or Other Elevations are Dangerous. — Four employees were assigned the job of moving a heavy machine.' When they had finished, one of them threw his crow- bar down in the aisle. Another employee passing that way stumbled over the bar and fell forward into the pit where the machine had formerly stood. A broken humerus was the result. Like ihese may puncture your feet. Throw old. lumber on scrap pile or turn, boards so nails point DOWNWARD Keep your shoes in good con dition so thai nails or slivers cannot punch through soks Personal Caution is the Greatest Safeguard Fig. 40. — Placards similar to this should be posted throughout the plant. {Courtesy Conference Board Safety and Sanitation.) An employee engaged in opening a crate left the loose boards with nails in them, lying on the floor. A second employee stepped on one of the nails and developed a severe infection which resulted in three months' lost time from work (Fig 40). After a building was completed, a loose brick was left on a cross beam over an aisle. One day, without any apparent cause, it dropped just as the foreman of that department was passing. It gave him a very severe scalp wound. The peculiar coincident about this, ac- cording to the foreman, was that "he had seen that brick there every day for months. " If a keen prevention sense had been developed in the employees of this concern, no brick would have been left in such a dangerous position. ACCIDENT PREVENTION 323 Protection of Employees from Falling Material.^ — The careless stacking of boxes, barrels, filled sacks, jEiles of paper, of lumber, of pipes, and of other, material, often results in the severest kind of accidents. A new employee was assigned to stacking 200 lb. sacks of sugar in a warehouse. He piled them to the roof in a careless manner. Sud- denly the sacks started to roll and an avalanche of them fell upon the employee, breaking his back. The foreman was to blame in this case because he had failed to give proper instructions to his man. Old or broken machinery, broken tools, other appliances in similar condition are frequent causes of accidents. The explosion of old boilers became such a notorious cause of accidents that boiler inspection became a legal necessity. Broken ladders have caused many a broken head or fractures in other bones. > In one concern a cracked emery wheel was left unrepaired for several months as it was not used frequently. One day while in operation it broke into a thousand pieces. One man was permanently blinded and two others lost time on account of injuries. Thousands of examples could be collected of accidents resulting from unrepaired apparatus used by employees. Business men intent upon the larger problems connected with their plants often neglect these smaller leaks which uncorrected are a source of great financial loss to them. The plant physician is the logical person to point out these conditions. In one industry hand infections were very frequent among the employees in the packing room. These usually resulted from minor injuries such as scratches, nail wounds, splinters, etc. Finally the surgeon made an investigation to ascertain the causes of these minor accidents. He found that nails were scattered on the floor and that boards with nails in them were lying about ready to cause naU wound. Goods were brought to the department in large baskets. Some of these baskets were old and the cause of many of the scratches and splinters was discovered in them. The bins where the goods for packing were dumped were lined with tin. In some of the bins this tin was loose and furnished a sharp edge where many small cuts could occur. Many other apparently trivial conditions were found as a cause for these minor accidents. In making this inspection the men in the department were freely consulted as to how these scratches and splinter wounds were caused, and many valuable hints for correction of the same were thus obtained. The spirit of prevention was injected into the men by thus seeking their co-operation. 324 INDUSTRIAL MEDICINE AND SURGEIIY After the management was apprised of these conditions, steps were taken to prevent them. Every employee became a committee of one to keep nails off the floor and out of the way. A man was given the job of keeping all baskets in perfect repair, and the foreman was told to make a daily inspection of all bins and keep them repaired. These precautions, combined with the immediate use of iodin when a minor injury occurred, practically did away with serious infections from this department. This rather detailed report is given as one of the best examples of the work of the surgeon in accident prevention. It also points out the importance of keeping all physical conditions about the plant in repair. Safety appliances on machinery have been the means of reducing major accidents to employees to a very marked extent. Most con- cerns engaged in heavy work such as the steel mills, electrical industries, railroads, and hundreds of others have safety engineers who devote their entire time to safeguarding machinery. The great number of machines that can be safeguarded and the variety of appliances make it impossible to go into detail about this form of prevention. The Safety First movement has made it familiar to all. The few illustrations given will elucidate to every student of the subject the importance of familiarizing himself with the specific appliances. It is a human trait, however, to grow careless. " Familiarity breeds contempt" is too often exemplified by the old workman losing a limb on a dangerous machine with which he was so familiar that he neglected to use the safety appliance. A careful history of the accident taken by the surgeon will reveal this neglect. The doctor should report this to the safety engineer or whoever is responsible for making the men use the appliances. He can also use this history as a text for a bulletin pointing out to the fellow employees how John Doe lost his hand by neglecting to protect his saw with the safety frame. In other words, the doctor is in the logical position to prevent carelessness on the part of the men or on the part of the management when there is a tendency to neglect this form of prevention. It frequently happens that the safety device adopted by the safety engineer is not adapted to the machine and interferes with output. In such a case the men will often deliberately neglect to use it. Or, the safety device itself may be the direct cause of the accident. As an example of this latter condition, I recall two serious accidents which occurred as the result of a safety tread which was placed upon a stairway. It was a stairway which led into a basement and was used chiefly by the women employees. No accidents had occurred here but the safety engineer thought he would anticipate trouble by cover- ing the steps with a new type of safety tread. Shortly after it was installed a girl caught her heel upon the iron tread and fell down the ACCIDENT PREVENTION 325 steps, fracturing her arm. The fact was reported to the safety engineer. His report, however, blamed the cause upon the high heeled shoes worn by the girl. The next day another girl fell down these steps, but no serious consequence resulted. A week later a third girl caught her heel in the same way, falling and injuring her leg. It is needless to say that this "safety device" was removed, but only because the doctor followed up each history and was thus able to point out the cause. Fig. 41. — Properly guarded grinding wheel. {Courtesy General Electric Co.) The high heeled shoe worn by an employee illustrates another cause of accidents — those due to faulty wearing apparel. The shoe with a loose sole often is the cause of falls. Or the worn sole will allow injuries from nails or splinters. A loose sleeve may get caught in machinery, pulling the arm in and causing a severe accident. An employee was oiling a shaft live feet above the floor. He had a loose sleeve, and besides was doing the work while the shaft was in motion- — a condition that should never be tolerated. The sleeve caught and the man was whirled around the shaft three times before the torn sleeve released him. His injuries caused fourteen months lost time and permanent disability. 326 INDUSTRIAL MEDICINE AND SURGERY A safety appliance attached to the employee is another means of prevention. The best example of this is the wearing of goggles in emery grinding or in any work where steel or other material may fly in the eyes. Here again the surgeon will find it necessary to constantly watch the employees to see that they observe this form of prevention. Dr. Irving Clark of the Norton Grinding Works has some wonderful figures showing the almost complete eradication of eye injuries among their employees by not only supplying goggles to the men but by, Fig. 42. — Incorrect way of using goggles. {Courtesy General Electric Co.) enforcing their use. Educational campaigns are the greatest means of securing the co-operation of the men in this form of prevention. Old emery grinders scorned this protection at first. Among these old timers were one or two men very adept at removing emery from the eye — "the eye doctors of the plant." Combined with the use of goggles it was necessary to teach the men to report at once to the doctor if any particles flew in the eye. The dangers of allowing a fellow employee to fool with the eye was impressed upon the men in a dozen different ways until at last this rule was observed by all. One day in a' box factory where old boards, occasionally with nails in them, were sawed up, an employee was struck in the eye by ACCIDENT PREVENTION 327 a flying nail. His goggles were around his neck. He had neglected to use them because his foreman, an old timer, didn't insist upon his men using the "fool things." The loss of the eye resulted. The history of the case was posted throughout the plant by the surgeon as propaganda in favor of goggles. The next day a nail again flew from a board and struck the goggles being worn by the employee. The glass over one eye was cracked in a hundred places but the eye was saved. It was an act of Providence for the broken goggle was shown to every Fig. 43. — Correct way of using goggles. {Courtesy General Electric Co.) employee in that department and this, combined with the recent case of blindness, drove the lesson home. Even the foreman was converted but this didn't save his job (Fig. 44). Whenever goggles are used the glass should be of the best material — that which \\ ill crack but will not fly into splinters. A number of such goggles are made. Many other appliances worn by employees will prevent accidents. The study of each history of accident will enable the surgeon to suggest many such means of prevention. 328 INDUSTRIAL MEDICINE AND SURGERY We will next consider the second class of accidents: those due to some physical or mental condition found in the employees. It is quite obvious, even to some hardened foremen, that if a man who is blind in one eye, or who has lost an arm, or who has some other gross handicap, is placed at certain occupations, he is liable to injure himself or to cause accidents to others. Or, if a man is mentally deficient, it isn't safe either for himself or for others, to allow him to run an engine. These are examples, however, of how certain physical or mental conditions in an employee can cause accidents. H,r.- «.■ lu.v.. .,n i, liirR.r .».:,1,. r,|.r.«l.i.-li..a. . ^;lV,■.i..l•.■„ri.,tl,.■y,,;.rll,,■«,•ar.•^. Tl,.- .rn „«! I, „l 1 1,,-,- kI,,,-,- w ,|„m„ I U-t „,.,l„. „,„l,|l,- p„ ,ur,-. Tl , ,„- .r,. >..„„ >0,, ,„,,| ,„ „,,. fr„,„ thr orifiiKil,. „. thill Ihi- pi,-,-,- ..f ^l.-,-l „.n, „,-(„;, ll> -,i,„-«l,;,l l:,ri:,-r tlum Is M„.>v„i„,l„.,-„t Tl„-mi,„,vl,„«„r,.ll„-lw,ll,„„,.:,ir,v„„l,ll,:,v,-l„.ttmth ' L_;;i;;^, -:"""" "' "" ■ "' '""""'"' '"■ '"" '-"" "" *"' ''>■ ""ij;^ Fig. 44. — A poster which should be displayed wherever goggles for employees are required. (Courtesy General Electric Co.) It is in this field that the surgeon deahng with accident prevention can render some of his most effective service to an industry. While these gross defects are evident as hazardous conditions, yet there are many other things which may exist in employees, making them "accident carriers," that only an experienced physician is able to discover. Just as the frequent inspection of the physical conditions of the plant is necessary to prevent accidents, so is the frequent inspection of the employees essential to discover these physical and mental causes ACCIDENT PREVENTION 329 for accidents. Here is one of the strongest reasons for the Supervision of Employees by medical examinations. Every employee sustaining an accident, except perhaps the minor accidents where the cause is obvious, should be thoroughly examined to discover if any condition existing in him might be the active or predisposing cause. When examining applicants for work, or when examining an old employee, the doctor should constantly be on the lookout for potential causes of accidents in the men. An employee with some physical handicap may be doing work dangerous for him, but the doctor can recommend his transfer to another occupation where he will be efficient and yet not be in danger of an injury. For example, Mr. A, an apoplectic type, short, fat, and with flushed face, was examined. His heart was slightly enlarged and his blood-pres- sure was 200 mm. He felt perfectly well and was able to work. But his work consisted of sawing lumber on a large circular saw. The saw was protected yet if this man had fallen he might have been torn to pieces. This was a hazardous occupation because of his physical condition. A transfer was recommended by the doctor, and he was given the job of measuring and sorting lumber at the same wage. Two weeks later while at work he had a stroke of apoplexy. An employee with epilepsy, or with a pathological condition liable to make him fall, as for instance apoplexy, heart disease, uremia, cerebro- spinal syphilis, etc., should never be allowed to work about machinery, on elevations, or in other places where he could be seriously injured by falling. Such a man may be a potential cause of accidents to others. The hit and miss method of placing men on jobs without a physical examination to ascertain their fitness for the work makes accidents from these causes much more frequent. Epileptics are very hard to discover by examination. A history of attacks or actually seeing the attack are our only means of diagnos- ing this condition. Therefore, these cases often become accident hazards. Whenever an employee is suspected of or found to have epilepsy, the surgeon should carefully study his working conditions and recommend transfer to such work as will be safe. Many in- dustries refuse to allow epileptics to remain in their employ because of this danger of falling and subsequent injury. The state care of epileptics with outdoor employment and proper attention to diet and other habits is one of the most needed social reforms of to-day. Many a sufferer from this disease could be reclaimed by a proper regime of work and care. Mr. B, a new employee m a printing plant, had been examined for work and found O.K. A week later he fell in a fit of epilepsy, 330 INDUSTRIAL MEDICINE AND SURGERY striking his head against the printing press, and suffering a skull fracture. The loss to the concern amounted to several thousand dollars. Four people subject to epilepsy were employed in other departments of this plant. The concern cannot be censured because they immediately discharged these other men who were liable to fall and cause an equal loss. The state, however, can be blamed for not providing some place where these men could go for treatment and work. Mr. C, a ten year employee in a certain plant, who had been periodically examined a number of times, reported to the doctor's office with a scalp wound. He stated that a box had fallen from a shelf and struck him on the head. There had been no- witnesses. Two weeks later Mr. C reported again with a slight contusion on his cheek and a lacerated wound of the nose. This was due to a fall which resulted from tripping on a loose board, according to his statement. Again there had been no witnesses. Some weeks later this man again came to the doctor with another scalp wound. He claimed that he had fallen down stairs but no one had seen him fall. This man was given an examination which was negative. An investigation in his department revealed the fact that an employee had seen him fall while in the wash room. When the man was con- fronted with this statement he confessed that he had fallen while standing in the wash room but didn't know what caused it. The examination was then repeated and included all laboratory tests. These were again negative even to the Wassermann test on his blood. By this time the man had confessed to falling frequently due to "faints" and that his other injuries were due to these attacks. On account of this history a spinal puncture was made and the spinal fluid gave a strong Wassermann reaction. The man was suffering from cerebrospinal syphilis causing epileptiform attacks. During one year the writer found three cases of cerebrospinal syphilis in the same industry. Two suffered injuries due to falling. The third had been diagnosed as lead poisoning by his family physician because the man was a painter. A thorough study of these cases will reveal the cause of the accident, and often of the occupational disease, to be due to the physical condition of the employee. Dr. James Bordley reports a death and a serious accident in a steel mill from an overhead crane, both the result of defective vision in the operator of the crane. This man was given a thorough examination and his vision was found so defective that the man had no idea of perspective. A man with serious heart disease was allowed to operate a dummy engine in a mine. His heart failure and sudden death resulted in injury to several employees who were in the cage being hoisted by this engine. ACCIDENT PREVENTION 331 Innumerable cases of injury to the individual, or to others for whose safety the individual is responsible, could be related due to some condition in the employee, but these examples suffice to point out the lesson. The third etiological group of industrial accidents are: those due to disaster. Of all disasters fire causes more accidents than any other. Therefore, the prevention of fires is one of the most logical forms of preventive surgery with which the doctor can become associated. It is characteristic of our profession's shortsightedness that doctors as a rule have never considered it their duty to enter into a campaign for fire prevention. We have reduced disease by public sanitation but we have not put this same humanitarian effort into the prevention of accidents to the public. Every industry has or should have its fire brigades, fire drills, rules for prevention of fire and means of escape for the employees in case of fire. It is one of the duties of the plant surgeon to point out these needs and to improve in every way these methods of prevention. The National Safety Council has added a section on Fire Prevention to its organization. The transactions of this section, obtainable from this Association, are worth the study of all doctors and especially of industrial surgeons. Specialized industries will have their special dangers for disaster. The surgeon must familiarize himself with these and make certain that proper precautions are taken at all times to safeguard the employees. MINOR ACCIDENTS The same preventive measures outlined for major accidents are applicable to many minor accidents. However, every surgeon con- nected with industry has found it most difficult to prevent a large majority of these minor injuries. As a rule, a slight injury never causes any suffering to the employee nor any lost time from work with its corresponding loss of wages. Likewise, minor injuries occur so frequently to every worker that he becomes accustomed to them. These two facts make the prevention of minor accidents, and the prevention of complications when they do occur, very difficult. An employee will get a splinter in his finger time and again. He removes it himself or gets some fellow employee to remove it. No trouble ever results. But the hundredth splinter results in a serious hand infection. It is often impossible to explain why all the other splinters were harmless and this particular one caused the trouble. For this reason it is hard to make the workman take proper precau- 332 INDUSTRIAL MEDICINE AND SURGERY tions with the ninety-nine spUnters in order to prevent the hundredth one from starting an infection. Nevertheless, the prevention of comphcations from these Httle daily injuries depends upon treating everyone at once as a potential trouble maker. Examples of minor injuries that are almost impossible to prevent and yet frequently result in serious complications, are: Dust, cinders, etc., flying in the eyes. *' Barking" the skin on tools, machines, boxes and other objects. Hang nails, often due to the work. Pin pricks — ^commonest in girls. Wounds from splinters, nails and other penetrating objects. Scratches or slight lacerations from nails, loose wire, loose boards, paper, and a thousand other objects with which the employee may come in contact. Contusions from falling objects, striking the finger with a hammer, being bumped by a door, and other innumerable ways. Slipping on the floor, tripping, and other unaccountable causes for falls. From early childhood we have been receiving such injuries as these and only occasionally has some trouble followed. It is almost sec- ond nature to pay no attention to them. Therefore, it takes years of patient endeavor to educate a group of employees to take pre- cautions when such unpreventable accidents occur. These minor accidents must be combated by preventing compli- cations from developing, as well as by teaching employees the "art of being careful." In 1912 the author published the results of preventing infec- tions among employees due to these miner injuries. For the six months previous to January 15, 1909, the records of the doctor's office showed an average of twenty-six infections per month due to minor accidents. On that date every department was supplied with a bottle of tincture of iodin and another bottle containing applicators (cotton rolled on a toothpick). A letter instructing each employee to paint at once with iodin every wound received, which broke the skin, was sent to every man and woman in the plant. The managers were carefully instructed in the value of this procedure and kept a careful watch over the employees to see that they observed the rule. A daily in- spection was made to see that the iodin bottles were filled and ready for use. Immediately these infections began to diminish. At the end of the year the records showed an average of eight such cases per month, a reduction of 28 per cent. Many of these cases of infection which developed should have reported to the doctor but they thought the iodin treatment alone ACCIDENT PREVENTION 333 made this unnecessary. Therefore, we had to add to our instructions the immediate use of iodin and then the immediate reporting to the doc- tor's office no matter how slight the injury. The importance of this preventive measure is further emphasized in the chapter on Hand Infections (Fig. 45). Some industries may have used iodin previous to the pubUsh- ing of this article but these were the first pubhshed statistics on the results. This procedure soon became quite universal in industrial surgery. Those who fail to get the best results fail to provide tinc- FiG. 45. — Blood Poisoning. John Doe of department 4 scratched his hand on a nail. He failed to paint the wound with iodin and to report to the doctor's office at once. He didn't think such a alight scratch would amount to anything. To-day John is in the hospital with blood poisoning. On all injuries, no matter how slight, use iodin at once and report to the doctor at once. Example of educational bulletin posted in all departments. ture of iodin in a. convenient form and in a place easily accessible to all employees. To be 100 per cent, effective it must be used within two minutes after injury. Also to be 100 per cent, effective it should be followed, as soon as the employee can reach the doctor, with a protective dressing. It is impossible to say which of these is the most important but combined we have the ideal arrangement. Some doctors have discarded iodin, which heretofore has proven our best friend, since the Carrel-Dakin treatment has received so much attention. As Dr. Lauffeur of the Westinghouse Company so forci- bly pointed out — -"iodin has proven its value and is the best prevent- ive measure we have yet discovered for infections." This in no 334 INDUSTEIAL MEDICINE AND SURGERY way refutes the claims of the Carrel-Dakin solution as a treatment agency. The protection of hands by gloves, of the eyes by goggles, of the legs and arms by asbestos covering when slight burns are liable to occur, and other protective methods can be adopted in many industries to reduce these slight accidents. But the best method of preventing both major and minor accidents is by constantly instructing employees how to prevent accidents, how to prevent a recurrence of an accident, and how to prevent com- phcations from developing when an accident has occurred. Com- bined with this there must be the most active treatment of every injury from the very moment it occurs until it is cured by a surgeon skilled in emergency surgery. The spirit of prevention must be developed in the management, in the rank and file of the employees, and in the medical staff, in order to have an efficient human maintenance department. CHAPTER XXII THE SPIRIT OF PREVENTION In this country accident prevention is still in its infancy. It started with a few laws requiring the safeguarding of a few certain well known hazards. Gradually a few industries began to safeguard machinery by safety appliances. This finally led to the Safety First movement inaugurated by the National Safety Council — a volunteer organization. Their work in the beginning consisted of the instal- lation of every known device for preventing accidents. The American Museum of Safety, established several years ago, was among the first to do excellent work along this line by its exhibits of safety devices. These and other safety movements starting with the mechanical prevention appHances all came to the same conclusion, namely, that while these are necessary yet the majority of accidents were due to the ignorance and carelessness of individuals. Therefore, to secure the greatest results, educational campaigns on Accident Prevention must be started and made universal. In some countries such as Switzerland, Germany, and to a certain extent in England, accident prevention has long been a national prob- lem. The governments have their official experts studying the problem from every angle. New laws increasing the safety of the working people are enacted almost every year. Inspectors to in- vestigate and, mark you, to enforce the laws are in the field. And the money paid out in compensation makes both employer and em- ployee more anxious to reduce the number of accidents. In addition, the school children are taught accident prevention and the colleges and universities give courses on this subject. Every means to en- gender a national spirit of prevention is used. The ''Stop, Look and Listen" sign at railroad crossings was the first educational propaganda for accident prevention ever introduced on a universal scale in this country. During the last decade the use of signs or bulletins as a means of spreading the gospel of pre- vention has become very popular. All kinds of signs are posted in trains, street cars, and in many industries, pointing out the means to avoid injuries. In a few states the Departments of Industry and Labor, or the Industrial Boards, or the State Factory Inspector's Office have made the spread of this prevention propaganda one of their duties. 335 336 INDUSTRIAL MEDICINE AND SURGERY One of the best examples is furnished by the State of Pennsylvania Department of Industry and Labor under Commissioner John Price Jackson and his assistant, now acting Commissioner, Mr, Lew R. Palmer. They have formed a corps of experts on disease and accident prevention and the medical phase of the work is under the direction of Dr. Francis Patterson. While stimulating the use of every known safety appliance, yet they have found that the greatest results come ACCIDENT PREVENTION POSTIR Number 17 EVERY person who pays no attention to the UTTLE cut or scratch may think that there is no dzuiger from such a little BIT of a wound. Accident reports show^, hoivever, that those cU'e the ones from which blood poisoning usually develops. FIRSI AID TREATMENT HELPS to stop deaths from this cause. DOirr FAIL TO HAVE MINOR INJURIES ATTENDED TO AT ONCE COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY JOHN PRICE J&CK20N. Commi..ianer Fig. 46. — Placards which spread the spirit of prevention. from educational campaigns. Below are two examples of the placards which are freely circulated to every industry throughout the state, to be posted in conspicuous places for the education of their employees (Figs. 46 and 47). Ohio, Massachusetts, New York, California, and a few other states to a lesser degree, have adopted this method of instructing workmen. It is applicable to the prevention of occupational diseases and many other diseases. It should be used more extensively. In order to secure the co-operation of employers, workmen, safety engineers and plant physicians. Dr. Patterson organized, some two THE SPIRIT OF PREVENTION 337 years ago, the Pennsylvania Chapter of the American Association of Industrial Physicians and Surgeons, and invites, three times a year, representatives of all four of these groups to meet in joint session at the State Capitol to discuss both accident and disease prevention. The American Association of Industrial Physicians and Surgeons are making efforts to persuade every state in the union to adopt a similar plan. ACCIDENT PREVENTION POSTER Number 18 THE country just now needs the services of all GOOD workmen. It wants every one to live to a ripe OLD age. Avoid dangerous methods— do your work carefully and skillfully and thus do your bit for the U.S. A. COMMONWEALTH OF PENNSYT-VANIA DEPARTMENT OF LABOR AND INDUSTRY JOHN PRICE JACKSON, CommUuone* Fig. 47. — Placard which serves a double purpose — prevention, efficiency. In some states the manufacturing associations have quarterly meetings to discuss these safety methods. As a result many employers have adopted the educational plans for prevenbion advocated by the National Safety Council. In some cities the Associations of Commerce have rendered ex- cellent service in teaching accident prevention. The Rochester, New York, Chamber of Commerce has been very active in both disease and accident prevention among the city's industries. Reahz- ing that education must begin in the home they prepared a pamphlet and circulated it throughout the homes of the city. The following is quoted from this pamphlet: 338 INDUSTRIAL MEDICINE AND SURGEEY " ACCIDENTS IN THE HOME" "It is a peculiar thing that accident insurance companies find that the bath tub is responsible for the largest number of accidents that occur in the home. '' On first thought it seems extraordinary that this agent of clean- liness should have destructive features, but the number of people who slip in one way or another and fracture arms or legs or inflict minor injuries upon themselves in this way is surprising. "Falling down stairs is the next most favored method of inflicting injury upon oneself. It is true that the stairways in homes are not so well lighted as those in office buildings, stores or factories, but it would seem that this lack of light ought to be more than balanced by the greater familiarity people would have with their own stairways. " The high heeled shoe is responsible for many falls both in and out of the house, but it is especially dangerous on stairways where the edge of the heel catches and trips the wearer into a headlong fall. " Burns, scalds and fires in the kitchen are responsible for much in the list of accidents. These occur either through carelessness or ignorance of conditions. " The tea kettle, half full of boiling water, is taken to the sink to be filled, the top removed, the water turned on and the hand kept on the handle. The steam may cause her to drop the kettle, thus spilling the boiling water upon her. "^^ The grease employed in cooking some kinds of food is a source of danger because it both spatters and takes fire after being heated above, a certain point. Burning grease is very dangerous and burns deep into the flesh and the wounds heal slowly. Should the grease take fire it is extremely difficult to extinguish the blaze. " Persons who pull down shelves upon themselves, drop heavy weights upon their feet or inflict painful cuts by axes or hatchets, are in a class by themselves. The danger is specific in every respect and it is for the most part a thankless task to impress upon them general rules of carefulness; in other words, it is useless to suggest methods of doing things that should suggest themselves. " It can be taken as a fact that accidents in the home are due to the fundamental causes, haste and carelessness. " Will you, gentle reader, turn your attention upon yourself and upon these quotations? 'If the telephone or door bell rings, do you, in your haste to answer, endanger your life on the stairway or on rugs or waxed floor ? ^ 'Do you mingle caution with your hastie ? ' * Do you, as you go through your daily routine, remember that it is just as important to do each thing carefully as it is to get the thing done?' "If by neglecting precautions for your safety and the safety of others you increase the cost of living by breaking bones, straining STANDARD SAFETY ORGANIZATION INSPECTION AND EDUCATION CHART A SUPERVISOR OF SAFETY WORK (employer, member of firm, manager, superintendent or foreman in charge) who shall: 1. Review and approve inspcciion reports and safely suggestions. A GENERAL Manager, Superi (1) Meet ai (2) Review t monthly and . less than three persons shall be selected from the following; Master Mechanic, Foreman or other employee in a position of agthority and shall: pass on all recommendations to determine their practicability and desirability, and keep records of i (3) Familiarize themselves with tl (4) See that rexv employees are [ practices through the use of b (5) Supervise the safety inspect!© A WORKMEN'S COMMITEE consisting of at I changed at regular intervals, preferably by rotation, and the (1) Make not less than one thorough inspection of the plant each workmen. The personnel of the ( en reports of ' ttie general va|s, preferably by rotation, and the (I) Make at ieast one general inspection of the plant and hold at least one meeting every three months for the purpose of standardizing safety work throughout the plant. A SAFETY INSPECTOR, who shall be a competent person in charge of inspection s 1 shall: A SAFETY ENGINEER who shall devote at least one-half of his entire time to safety and inspection work and who shall . A SAFETY ENGINEER who shall inspection work and who shall: (1) Make tegular weekly inspection ot the plant. (2) FUi out and sign weekly reports showing conditions of the plant and recommendations tor changes, (3) Keep these reports on file in the office tor review by general committee, state authorities- and insurance safety precai carriers, (Standard blanks are furnished by insurance carriers for this purpose.) (3) Keep.complete reco (4) Follow up general lines of outstanding safety work and keep records of same, which indicate progress. (5) Make or arrange ior regular inspections of special equipment, such as elevators, cranes, engine and mot^ each inspection, (6) Look after fire conditions, extinguishers, filling of fire pails (water and sand) and keeping exits clear. (7) , Sec that drawings and specifications for new equipment cover the guarding of dangerous features such Is required herein. ■ stops, etc., and keep ^ conductors, ( (8) Inspect new (9) Investigate a nachinery before placed in operation to : id report to general committee on all ace ^^^^^^ (10) Inspect for and lighting and for obediei that necessary safeguards a safeguards, g gears, sprockets, coupli provided, cral order and arrange; if materials and stock, cleanirnk^ss 1 which safety bulletins (which shall be changed at least mc ,le a RECORD OF ALL ACCIDENTS by preserving duplicates c '' 1 QUARTERLY MEETINGS of not be provided tor these meetii Ihly) safety orders, r mation shall be posted, furnished by state depa safety shall be given. E SAFETY LITERATURE such as operatir ganda, etc., which should be distributed t magazines,, pay envelopes, or special bullet Fig. 48. — (Courtesy of the National Manufacturers Asaociatioa). THE SPIRIT OF PREVENTION 839 muscles, burning the flesh, to say nothing of the cost of replacing destroyed utensils and equipment, are you making yourself the best possible housekeeper ? ' ' Recognizing that accident prevention depends upon Inspection and Education the National Association of Manufacturers has been very active in stimulating employers to adopt these two means of protecting the lives and limbs of their employees. They have pre- pared a plan for a standard safety organization which is now being " ■ ' ' ?^ ■ i Your Eves Are your most valuable asset. ! he above eye was saved by the goggles. Duiinijthe mpnth of May 33 Vj per rent of all major accidents were eye cases beside 89 minor cases. Protect your eyes from flying chips and em- ery chi.st. Ask your loreman for a pair of jioggles and Save Your Eyes I _.. ..:_ ^ Fig. 49. — Example of anti-accident propaganda among the employees of the General Electric Co. followed to a certain degree by many manufacturers. Those who enthusiastically endorse this plan have secured wonderful results because they have adopted it in toto. Others have only half- heartedly installed this system and therefore have not succeeded in reducing their accidents to as great an extent. In this work the re- sults are in direct ratio to the thoroughness of the plan in force. As surgeons should be the leaders in estabhshing this form of prevention in their industries this standard safety plan of the National Manufacturers' Association is set forth in detail (Fig. 48). The fact that compensation underwriters make a 15 per cent, reduction in premiums in those industries where this standard safety organization is installed and rigidly enforced, indicates in a way the 340 INDUSTRIAL MEDICINE AND SURGERY monetary value of this form of prevention. It is impossible, however, to set forth in dollars and cents the great saving to employers, or the increased earning capacity from enlarged production which this or any other form of accident prevention means to a concern. The National Manufacturers' Association, 30 Church Street, New York, has secured one thousand lantern slides illustrating safety first methods, as well as numerous motion picture reels, which it will furnish, free of charge, to those industries desiring to hold meetings for their employees on accident prevention work. The National Safety Council, the American Museum of Safety, the United States Department of Labor, and many of the leading industries of the country are all very willing to supply material for educational campaigns on safety. Among those industries which have excellent material for instruction purposes are the United States Steel Corporation, the General Electric Company, the International Harvester Company, the Brooklyn Rapid Transit Company, and others. The Conference Board on Safety and Sanitation, of which Mr. Magnus W. Alexander of West Lynn, Mass., is Executive Secretary, publishes a monthly periodical called "The Spirit of Caution" which is of the greatest value to surgeons and others interested in spreading accident prevention material. Mr. R. J. Young of the American Museum of Safety has set forth the relative value of the various forms of safety work employed by the Illinois Steel Corporation during a period of ten years. He has . divided their safety work into three branches and estimates the value of each as follows: I. Organization 45 per cent. (a) Attitude of officers 20 per cent. (6) Safety committees 20 per cent. (c) Inspection work 5 per cent. II. Education 30 per cent. (a) Instruction of men 15 per cent. (b) Prizes 9 per cent. (c) Posting of signs 3 per cent. (d) Lectures, motion pictures, etc 3 per cent. III. Safeguarding 25 per cent. (a) Guards 17 per cent. (6) Lighting 5 per cent. (c) Cleanliness 3 per cent Since organizing the safety committees and securing the proper attitude of the officers toward the work is largely educational, it is THE SPIRIT OF PREVENTION 341 quite apparent that at least 70 per cent, of the success in safeguarding employees against accident is the result of well organized educational campaigns against these accidents. It is quite evident that unless the officers of an industry V)ecome personally interested in accident prevention progress in the work will be very slow. Those concerns which are the farthest advanced in the safety movement and whose employees have acquired the spirit of prevention to the highest degrees are the ones in which the president or other executive members of the industry have taken an active part in the work. They have become associated with the National Safety Council and other such organizations. They attend the meet- ings in person and by the giving and taking of suggestions they become thoroughly imbued with the ideals of "Safety First." Such men keep in advance of their medical staffs and safety engineers rather than haK heartedly following the advice and suggestions of them. Of equal importance to securing the co-operation of the employers in such work is to secure the whole-hearted co-operation of the employees. The organization of safety committees among the employees has been a most potent means of spreading prevention propaganda. These committees should be changed every year so that a few new members are added, thus increasing the number of prevention ex- perts throughout the force. Such committees receive suggestions, from the employees as to means of bettering safety arrangements; they are constantly on the lookout for potential accidents; they are: themselves the seeds of prevention from which the great spirit of prevention must grow. Qualified inspectors of safety methods are essential in every large* plant where accidents are prone to occur. These inspectors can be of the greatest value to a concern if their vision is broadened to the extent that they think in terms of prevention from every angle rather than from the standpoint of safety appliances alone. Thus, the in- spector who is ever on the lookout for unsanitary conditions in the working place, or for unhealthy appearing employees, and has the vision of preventing accidents, the result of any cause in the working place or among the workmen themselves, is invaluable to his concern. Such an inspector will welcome suggestions from the medical staff and will work in the closest co-operation with the doctor. If the safety experts could better realize this, the value of Mr. Young's inspectors would be 25 per cent, instead of 5 per cent, as shown in his table. Most of the educational methods have been described. However, the use of ''prizes" is mentioned in the above outline. These prizes refer to the method of giving a bonus, or a prize, to that department having the lowest accident rate — a plan adopted by several concerns. 342 INDUSTRIAL MEDICINE AND SURGERY >- - — ■ --^.^^^ Z ^s^ < \^ o (L \ Z I • 2 / CO \ s \ i fc < :3 *< z tu m a. e 7. \ tu a, / Amou < \^ < CO < J u / i Q y Z 111 — ^ --^ (0 (I) 4 >s «I^£S d J3 . m >, C z (si rto are help e wa ave 1 o DC ^ INGI r helpe as you 't be a s to th may s u. i BC (0 CM > VARN ct you hanlc vouldn ation a e done hof yo 1 V axpe mec he \ plan to b rbol H- ^ ^ Ul ■^H ■^^^^■r b N/ ,. n 3C IIB ^■0 .-^ <« Q - 0, 1- V^ 1 Doti good Isn't, little work to on CO o (/) ft I- «» Q. ti u s o * 111 3 a. 's > s 111 o *1 o «*' n t» .S 4> e •£ TJ <« c bo 1 s > 4> (0 ft o 4m 4) to CU c 'S w 2 « *',« c o -^ — * S * . (« B. i 0.S O flJ 4> 4> * a> ?U4>fl .2-n o oirt •sS:§'S ft -a M- 'c S>€ %{ « ^ .S-g > S 2 S « 6 a * 60? rt JS ;:.£ u ft r - "l O " O (UJ3 •o-o «> V 4) «) X 73 ■s 10 in c Q> U) 0> o Vi o n •o o ■n n c £ n 5- (A ■o n 3 4) O « ® xS THE SPIRIT OF PREVENTION 343 This has been a successful means of reducing accidents and has been a great incentive to the men to be careful. The careless employee who makes his fellow employees lose their bonus because of his care- lessness doesn't usually repeat the experiment. One of the best means of educating the employees m safety precautions is by short, terse statements or warnings printed on the pay envelope. These envelopes are usually carried home, thus extend- ing the scope of their lessons to the family as well. Many concerns have employed this method for disease as well as for accident preven- tion. They have developed their own forms of advice and have ex- Pjq 51._Safety precepts taught by illuminated sign at works entrance. {Courtesy U. S. Steel Corporation.) changed with other concerns until almost every angle of prevention has been covered. The three pay envelopes herewith reproduced illustrate this method (Fig. 50). The United States Steel Corporation has large illummated signs over every gate leading into their plant. Every week some new safety advice is there for the men to read as they go to then- work. This constant educational work is one of the best examples of an m- dustry developing the spirit of prevention among its employees. The following Ust of wordings used on pay envelopes and illummated gate signs was furnished by the management of the United States Steel Corporation and is reproduced here for the benefit it may be to others: 1. The prevention of accidents and mjuries, by all possible means, is a personal duty which everyone owes, not to himself alone, but also to his fellow workmen. 344 INDUSTRIAL MEDICINE AND SURGERY 2. Do not get into dangerous places until you are absolutely- sure they are safeguarded; also prevent anyone from going until this is shown to be a fact. 3. Remember it is better to cause a delay than an accident. 4. Small neglects are apt to cause serious accidents. 5. Let every employee make himself a committee of one, to prevent some one accident. 6. The failure to obey safety rules endangers the life of yourself or fellow workman. SAFETY 7. It pays to think before you act. 8. One man's effort toward safety may seem small, but altogether can do a great deal. 9. Every effort in this direction helps. 10. Be sure everything is safe; then go ahead. 11. Help to prevent accidents. 12. Look out for the other man, you might hurt him. 13. Try to avoid accidents; this means YOU 14. Do not work with unsafe tools. Tell your foreman. 15. Every injury, no matter how shght, should receive medical attention. 16. Never remove or even touch a safety flag, tag or target. Always get the man who placed it to remove same. 17. Safety committees may overlook something. See for yourseK that all is safe. 18. Do not fail to notice all danger signs, and if possible, see that no one disregards them. 19. Safety devices are of little value unless maintained and used as they are intended. 20. Careful men are usually efficient; careless men are not. 21. Use safety devices where provided. Don't take a chance. 22. Replace all guards and safety devices when through making repairs, and before machinery is started. 23. It is your duty to report unsafe conditions to your foreman or superintendent. 24. Every sign in the mill means that the danger pointed out is there. You must obey these warnings. 25. Don't fool with electricity. It is dangerous. 26. Look out for loads carried by overhead cranes and do not stand under them. 27. Employees are cautioned to look out for torn clothing as same is liable to be caught in machinery. THE SPIRIT OF PREVENTION 345 28. Foremen: Carelessness is dangerous. If workmen insist on being careless, discharge them. 29. The proper inspection of tools and machinery by employees using same will help to prevent accidents. 30. The more you insist upon carefulness on the part of others, as well as exercising it yourself, the safer it will be for all. 31. Be careful in doing your work to avoid accidents to yourself and fellow workmen. 32. Warn a man when danger is near. He may know all about it; if so, no harm is done. If not, you may save him from injury. 33. To be careless, thoughtless or reckless means injury sooner or later to yourself or others. 34. Employees are forbidden to take short cuts over dangerous places. 35. Every employee, whose duty requires him to work with appliances of any kind must carefully examine same and report any defects. 36. We will welcome suggestions from employees on anything of a dangerous nature. 37. Keep off railway or crane tracks, except the regular crossings. Before crossing any tracks: Stop! Look! Listen! 38. To avoid accidents to yourself and others, in case of doubt take the safe course. 39. Always be careful and take no risks. 40. The exercise of care to prevent accidents, is a duty which you owe to yourself and your fellow workmen. 41. You are responsible for the safety of others as well as of yourself. 42. Beware of blood poisoning. A wire scratch will cause it sometimes. 43. It is your personal duty to see that all safeguards and signs installed to promote safety are always in good condition, and report all dangers promptly to your foreman or superintendent. The pre- vention of accidents is one of your most important duties. 44. Safety must be the first consideration of all employees. In all cases of doubt take the safe course. When in doubt as to the matter of a rule, or sufficiency of a proposed precaution, take the matter up at once with your foreman or superintendent. 45. Rules and regulations can be adopted, safety devices can be attached to machines, guards can be erected and warning signs posted, but all are useless unless every man is careful to see that they are maintained; unless every man is careful to watch for danger; unless every man is careful to warn others of danger. 346 INDUSTRIAL MEDICINE AND SURGERY 46. Never attempt to make a coupling or work between cars on the short side of a curve. 47. It is as much your duty to comply with safety rules as it is your duty to properly perform your work and it is the desire that you be thoroughly impressed with this idea. 48. Don't swing sledge or hammer that you know is working loose on handle, thinking it won't come off till ''next time. " You may not be hurt but what about the other fellow? 49. Don't expect your helper to be as good a mechanic as you are. He isn't or he wouldn't be a helper. A little explanation as to the way the work is to be done may save injury to one or both of you. 50. At quitting time do not hurry over railroad tracks or through dangerous places. Be on the lookout and take sufficient time to be sure there is no danger ahead. Serious accidents have been the result of not taking this precaution. 51. Indifference to the safety of others may in the course of events sometime place your own life, or that of a member of your family, in danger. 52. A guard is placed on a machine solely for your protection. Don't operate a machine without a guard in place. 53. Stop machine before oiling, wiping or repairing it, and don't try to operate a machine you do not understand. 54. It takes less time to explain why you were late than to make out an accident report. 55. Be sure to warn teamsters and others working in or about cars before coupling to moving cars. Men who are working in cars often want to remain inside while cars are moving. Don't allow this. 56. When you find a highway alarm bell out of order, ticklers in bad condition, or anything that needs prompt attention to prevent acci- dents, make a report of it to the proper person. You may save some- one's life. 57. Don't go between moving cars or engine and car for any purpose whatever. The usual reason for going between moving cars is to turn the angle cock or life pin when the lever does not work. Wait until cars stop. The few seconds' time required is a good invest- ment. Many persons are injured and killed every year by failure to heed this caution. 58. Never try to shift a moving belt by hand. 59. If you know of some machine not properly guarded, don't wait until someone gets hurt and say, "I told you so." Tell the man in charge of the shop before an accident happens, and ask him to supply proper guard. 60. Avoid jumping upon moving cars or engines. Your work does not require it and you cannot afford to take the risk. THE SPIRIT OF PREVENTION 347 61. Never strike tempered steel with hammer or other metal object. Many eyes are injured or destroyed from this cause every year. 62. Watch out for trains. Don't depend on the other fellow. 63. Keep frogs, switches and guard rails properly blocked. This is very important. 64. See that material is kept a safe distance from track, where men on side of cars will not be struck by it. 65. Always bend nails down before throwing boards away. Many serious injuries result from stepping on protruding nails. 66. Look in both directions before stepping on any track, especially in yards. Be particularly careful when crossing track near cars or engines and when about to step from the track containing same upon another nearby track. 67. Cultivate a habit of caution — ^carelessness often leads to loss of life. The medical profession can claim great credit for developing many forms of prevention. The public health departments by safeguarding the milk and water supply, by stimulating proper sewage disposal, by all forms of sanitation and quarantine, have been the means of saving millions of lives from disease. Medical scientists have devoted their time to the study of the causes of certain diseases and thereby made possible the prevention of the same. But our profession has been very lax in their efforts to prevent accidents. Industrial accidents, claiming a greater toll of life than many of these diseases, have been ignored by the majority of physicians. The great preventive surgery movement has been left to the laymen to develop. Even to-day our best surgeons receive injury cases into the hospital, operate and otherwise repair them and finally discharge these patients without giving one thought as to means of preventing a similar accident to other men. ■ - — ^ A surgeon once said, "That factory is a little gold mine for me. I get on the average of two fractures and six hand infections a week from among their employees." When asked if he had ever inspected the factory to see why these accidents were so prevalent, he replied that that wasn't his business. This same doctor had been the most active advocate of cleaning up the city, providing proper sewage disposal, and otherwise reducing the. amount of typhoid in his home town. He wasn't mercenary. His vision of prevention had simply not broadened beyond the horizon of disease prevention. If he had received into the hospital six cases of typhoid a week, he would have moved heaven and earth to discover the cause of the epidemic and would have been very active in securing the removal of the public health officials responsible for such a condition. 348 INDUSTRIAL MEDICINE AND SURGERY It is quite evident that our educational propaganda against acci- dents must extend to the medical profession. Municipal health depart- ments must develop a division of safety as well as one of sanitation. Health officials, municipal and state officers, and factory inspectors must co-operate to secure prevention of accidents in every community. This must become a public fight against a nuisance that heretofore has been tolerated. For over a year I have fruitlessly tried to have ''safety," as is sanitation, included as a part of the work of the medical department of the Army. Yet all of the profession cannot be accused of a lack of vision with regard to this form of prevention. Years before the safety first movement, started by laymen, developed, a few surgeons connected with industry began to point out the need of preventing accidents and the need of preventing serious complications when accidents did occur. When the National Safety Council was organized these doctors pointed out the need of co-operating with the surgeon in industry in order to secure the best results This was the basis of forming the Health Service Section of the National Safety Council, which deals with accident prevention methods from the physician's standpoint. At about the same time the American Public Health Association formed a section on Industrial Hygiene which deals with occupational disease prevention and many other prevention measures including accident. Both of these National Associations have started movements for disease and accident prevention which are directly for the benefit of the people of the Nation. They have raised money and are carrying out many functions that should be recognized by and have the active backing of the National Government. In fact this voluntary machin- ery should be taken over by the Government. Both should be combined under a Federal Health Administration which would make possible the greatest advancement in accident and disease prevention through- out the nation. The surgeon in industry has become the stanchest advocate of a federalized health and safety department. The two must be combined. Just as the doctor is finding it necessary to co-operate with and use the services of the social worker, so he will find it necessary to co-oper- ate with and use the services of the safety expert. The problem as a whole involves the field of preventive medicine and preventive sur- gery and belongs therefore primarily to the medical profession. When will they see the light and grasp their opportunity? In all the literature on accident prevention you will find the problem is handled from the laymen's point of view almost entirely. The outline of the various values of each procedure, as set forth by Mr. Young and quoted in this chapter, assigns the best means of THE SPIRIT OF PREVENTION 349 prevention to organization, education and safeguarding. He has ignored the most effective agent for accident prevention in any industry, namely, the surgeon who is on the job. This is not the fault of Mr. Young or of other safety experts. It is the fault of the surgeon in industry who has neglected to seize the opportunity of becoming the leader in the accident prevention work. The surgeon in charge of the human maintenance department of an industry should feel most keenly the stigma attached to every pre- ventable accident occurring in that industry. Just as he bends every effort to secure the best result in reclaiming an injured employee so should he strive to conserve the employees by every preventive method. It is the duty of every plant surgeon therefore to make the follow- ing methods a definite part of his duties: 1. Secure the active co-operation of the executives of your concern in accident prevention, by pointing out needed changes, by report- ing every accident and how it could have been prevented, to the chief executive, and by enthusiastically telling them of steps taken to safe- guard against recurrences. Make your reports and suggestions in writing, short and to the point. 2. Instruct the employees individually and in groups in safety methods. Use every injury as a text for instructing that employee in prevention while furnishing him surgical attention. Every pre- ventable accident should be posted on the bulletin boards through- out the plant, thus: John Doe, of Department 15, is in the hospital with a skull frac- ture. One of his fellow employees carelessly shoved a crate from the top of a pile of boxes to the aisle below without looking to see if anyone was walking in the aisle. The crate fell on John's head causing a bad scalp wound and fracture of skull. Always look before letting any- thing fall and avoid injuring others. Or, in case of a minor accident that later becomes infected, post a bulletin similar to the one shown in the illustration. The picture of the infected hand and the warning to use iodin at once and to report to the doctor at once makes an indelible impression upon most employees (Fig. 45), 3. Make frequent inspections of the plant, first to pick out possible accident causes, and second to pick out the employee who because of his general appearance, his methods of working, or his mental attitude, might be a potential cause for accidents to himself or to his fellows. The surgeon, drawing on his experience of dealing with accidents, can be invaluable in spotting these possible causes. 4. Assist in the formation of safety committees, meet with them, and thoroughly instruct them in every angle of accident prevention — 350 INDUSTRIAL MEDICINE AND SURGERY especially call their attention to the types of employees who can cause accidents. Make them inspectors of both the mechanical appliances and the human machine. 5. Secure a careful history of every accident and follow it up to see that the proper precautions are taken to prevent a recurrence. 6. When inspecting an employee either at work or when he reports to the office for any cause observe whether his clothing such as im- proper shoes, loose sleeves, etc., might be the potential cause of accidents. 7. Examine every injury case to ascertain if the cause for the same lies in the physical or mental condition of the employee himself. 8. Use physical selection of employees for work so that the pre- disposed cases will not be placed in hazardous positions. This applies to both applicants for work and old employees. 9. Use every educational method which will drive home the les- sons of safety and will cause each employee to be alert to prevent accidents to himself or others. 10. Eat, sleep and breathe Prevention. With the growth of industrial medicine and surgery these pre- ventive methods are extending to all branches of industry and to the community life of every industrial center. Preventive surgery has been born. The fathers of this branch of medicine are rendering a service to humanity equal to that of the leaders in preventive medicine. The field has just been touched, however. Before us lies the oppor- tunity of spreading these principles to the entire nation. CHAPTER XXIII THE INFLUENCE OF NEW EMPLOYEES AND "SPEEDING- UP" ON ACCIDENT RATE Many industries in this country were forced to take on great num- bers of new employees and to "speed-up" production on account of the great demand made upon them by war conditions. Since our nation entered the world war this ''speeding-up" process has been especially pronounced. Such a condition invariably results in an increase in the number of accidents, no matter how thorough is the system of prevention which has been developed. Under average conditions the taking on of new employees simply means extending to them at once every facility to become acquainted with the accident prevention methods. They are taught the use of the safety appliances; instructed in preventive measures such as the use of tincture of iodin, and the reporting to the doctor at once when injured; they receive more personal attention from everybody. But when there is a universal speeding-up of most industries sev- eral conditions conspire to frustrate these established methods. The labor market is so scarce that concerns feel forced to be more lax in the choosing of employees. The ease of securing work causes a larger floating labor population. Men jump from job to job seek- ing higher wages and other inducements. The short time on the job tends to unfamiliarity with the prevention rules. The medical staff is unable to examine these applicants as thoroughly as formerly, and men are assigned to jobs for which they are physically unfit. The green hand in an unfamiliar occupation is always more prone to injury. Every surgeon connected with an industry has witnessed the great increase in both accidents and sickness among new employees, espe- cially the ''floaters," when speeding-up of production has occurred. In an industry where every possible safeguard was used, the working force was suddenly increased and every department was speeded-up. The following statistics illustrate the resulting accident disability increase: 351 352 INDUSTRIAL MEDICINE AND SURGERY Table 8 Jan. 1 to Sept. 30 Oct. 1 to Dec. 31 1915 1916 Per cent, relative increase or decrease 1915 1916 Per cent, relative increase or decrease Average employees per month 10,649 4,628 4.83 12,485 5,213 4.64 + 17.0 - 3.6 - 3.8 11,937 2,203 6.16 15,238 2,712 5.92 + 27.6 — 3 6 Per cent, injured - 3.9 Accidents causing time loss 343 3,439 640 3,411 + 32.6 -15.1 185 1,622 411 2,915 + 74.2 +41.8 Accidents causing more than seven days' 117 2,784 123 2,005 -10.0 -38.4 45 1,250 104 2,279 + 61.6 Days lost from above +43.0 409 566 469 450 - 2.1 -32.0 157 241 241 366 + 20.3 + 19.2 It is only after a few years of experience and after keeping careful records for comparison that the surgeon in charge of the Human Maintenance Department comes to realize that these new employees, often the transients, are the greatest factor in a high accident rate. The author once exhibited great pride in his low infection rate, the result of injuries. For weeks there had been no hand infections of any moment in spite of the slight, practically non-preventable, minor injuries. Then at the Christmas rush many new employees were taken on. In one week three very serious hand infections developed which caused great loss of time and much expense. Two histories will illustrate the point in mind. Miss B., employed on November 30, stuck her palm, right hand, on a spindle. She thought it was not serious and so did not mention the fact. She knew nothing of the rules about painting every injury with iodin and reporting to the doctor at once. Two nights later the hand became very swollen and painful. Instead of calling the plant surgeon (she said she didn't know that she could call him). Miss B. went to a doctor near her house, who made a slight incision in the palm and put on a dressing. Two days later the nurse called when this girl was reported home on account of sickness. The plant surgeon after three days took charge of the case and had to deal with a serious middle palmar abscess which caused eleven weeks of lost time from work. Mr. C. was employed on November 27. Just before noon he scratched his finger on a nail. As the plant closed down at noon be- cause of Thanksgiving holiday on the twenty-eighth, Mr. C. decided not to follow the foreman's order to report to the doctor. The foreman THE INFLUENCE OF NEW EMPLOYEES 353 who was supposed to see that iodin was applied simply told the man to use it. The next day the finger was badly inflamed. Instead of calling at the doctor's office (open at all times), Mr. C. saw a doctor who temporized with it. The next day this doctor took him to a hospital and opened the finger. This man failing to show up after the hohday and neglecting to report any reason, was considered a "floater. " A week later, however, his doctor called the plant surgeon in con- sultation as the infected finger had to be amputated. The patient lost eight weeks time and became a compensable case. In both of these examples it is quite evident that the prevention regime which should have been in force had fallen down. First, the foreman in the case of Miss B. failed to instruct her in the means of protecting the spindle point to prevent injury. She was not told regarding the use of iodin or reporting to the doctor at once. Neither was she instructed as to the means of reaching the doctor in case of injury or of complications from same arising after she reached home. Again in the case of Mr. C. the foreman neglected to follow instructions in regard to preventing infection. He also forgot about this slight injury when he dropped the man from the pay roll without investigating the cause of his absence. In both cases the fact that they were new employees made it possible for these conditions to develop without any special blame being attached to anyone. These cases happened years ago. With such experiences as a teacher, it soon became evident that every effort must be made to educate at once every new employee in every preventive procedure in operation in the plant. The following steps have been taken to accomplish this early instruction of new employees in accident prevention in this concern: I. Every applicant for work must be examined in the doctor's office. The nurse and the doctor seeing each case must, as a routine, tell him of the purpose of the office and especially instruct him that in case of an injury he is to report to the doctor at once. II. The employment manager hands each new employee a little leaflet telling of the various activities of the plant looking to the welfare of the employees. In this he is told of the purposes of the doctor's office and his share in the accident prevention methods in vogue. III. In the department and elsewhere he sees signs telling him to use iodin at once and report to the doctor at once in case of injury no matter how slight it may be. IV. The foremen have standing orders to carefuUy instruct every new employee in every form of accident prevention connected with his work in particular, and with the plant in general. Recent statistics gathered from the iron and steel trades by the 354 INDUSTRIAL MEDICINE AND SURGERY U. S. Department of Labor illustrate this relation between labor turnover and industrial accidents as follows : 1. Accident frequency rate per one thousand, 300 work days, of six months' experience and under 111.3 2. Accident frequency rate per one thousand, 300 work days, of three to five years' experience 42.4 It is evident that every industry must resort to more strenuous educational campaigns with new employees along lines of disease and accident prevention in order to accomplish greater results in this direction. Constant appeals to the old employees to help educate the new workmen and develop the spirit of prevention among them is one of the best methods which can be adopted. Part III INDUSTRIAL MEDICINE CHAPTER XXIV MEDICAL EXAMINATION OF EMPLOYEES The constant supervision of the health of employees leads the physician into many and varied activities. He must meet many of the problems of the pubhc health officer, the general practitioner, as well as those of the speciaKsts. But above all else he must be a thorough diagnostician. Early in his work the alert industrial physician realizes that he is in the most strategic position to diagnose disease early and, by insti- tuting proper treatment at once, to prevent many conditions which ordinarily would become serious. This is due to the fact that he sees great numbers of cases at the very beginning of their troubles. As a rule, a man or woman taken sick at work goes home, tries home reme- dies, and lies around for a day or two before calling in the family phy- sician. This delay often allows the disease to develop to such an extent that many days are lost from work. But when doctors in whom the employees have confidence are at hand they will be con- sulted at once. It behooves these doctors therefore to be constantly on the alert to discover any threatened conditions. The prescribing of drugs without a thorough examination to ascertain their need, or the care- less examination without carefully weighing every symptom, will sooner or later result in some preventable mishap which will cause both suffering and financial loss to the employee and will reflect seri- ously upon the ability of the physician. Through centuries of scientific investigations our profession has developed more and more exact means of diagnosing disease. Three basic principles form the very foundation of all diagnostic effort; namely, the history, the physical examination, and the various labora- tory examinations. To be thorough all of these must be carefully weighed in every case where the least suspicion of disease exists. The physician dealing with diseased patients, or curative medi- 355 356 INDUSTRIAL MEDICINE AND SURGERY cine, must utilize all of these methods in practically every case. But the physician supervising the health of large groups of people, dealing largely in preventive medicine, where he is in a position to study the normal human mechanism in thousands of cases, must constantly watch for suspicious symptoms or signs and submit those individuals to the most thorough examination. This routine examination of large groups of people in order to discover the diseased individuals among them develops a different type of medical man from the one who is brought in constant contact with the diseased patient. It is a common observance among indus- trial physicians that the new doctor on their staff discovers many more cases of tuberculosis, of heart disease, and of other conditions, when making routine examinations of employees, than the doctor trained in this work. This is due to the fact that the average physician is trained by examining diseased people where findings are usually present and where these findings can be interpreted as the cause of the symptoms. But when a man is examined who has no symptoms and yet presents a few adventitious sounds in his lungs, or a peculiar heart tone, it is difficult for this doctor not to explain the same in pathological terms. It is very essential therefore for the industrial physician to develop a keen sense of the normal in the human body. He must recognize that certain changes, the result of previous disease, or of certain working conditions, or of numerous other causes, may occur in the human organism which will give signs and even symptoms and yet are not incompatible with a normal, healthful existence for that indi- vidual; while other signs of changes in the body, even when the man complains of no symptoms, may be the earliest warning of a pathological state. In the latter case the patient must be submitted to a most thorough examination, the cause of the sign discovered, and the proper steps taken to abort a condition which if neglected may result seriously. It is utterly impossible to lay down hard and fast rules whereby the beginner in industrial medicine can know v/hen to submit an em- ployee to a complete examination which involves all laboratory tests, or when to feel satisfied with the routine physical examination with the ordinary laboratory tests. Neither can one definitely say just what physical handicaps are sufficient cause for rejecting an applicant for work, while others are not of a nature to interfere with employ- ment. Nor will rules always explain why a certain employee should be sent home for some minor condition while another employee with a similar trouble can be allowed to remain on the job knowing that his resistance will overcome the condition. None of these problems is solved by rules. It is only after years of experience that one becomes expert in weighing these matters and solving them with accurate judgment. The best rule is to always MEDICAL EXAMINATION OF EMPLOYEES 357 give the employee the benefit of the doubt and meet each problem in the safest manner for the individual concerned. In a large industry hundreds of employees come to the doctor's office every day; and the more reporting the greater is the opportunity for health supervision. It is impossible to examine all of these people and further it is not necessary. Certain ones come for their routine examinations; others because of accidents, or because of some slight symptom; while others report for various kinds of advice. The medical staff, including the nurses, must be so thoroughly trained that it is constantly on the alert for that sign, symptom or even casual remark on the part of each employee which indicates the need for an examination and study of his case. Others who are examined must be put in one of three classes: normal, no findings; pathological, definite findings; suspicious, in- definite findings. Those in the first group require no further con- sideration until some condition arises which indicates another ex- amination. Those in the second group must be diagnosed and placed under observation and proper treatment. In the third class fall those cases which reveal findings which must be studied before the employee can be definitely assigned to either the normal or patho- logical groups. The latter make up the great bulk of re-examination cases. Many employeees are found with some suspicious finding which on re-examination has disappeared. For example: The case which shows a sugar reaction should be examined at least three times before pronouncing it diabetes as many of these are only transient glycosuria. If every medical staff of an industry will develop a keen sense of detecting the employees needing examinations, plus the routine examination of certain groups, and then will place every employee examined in one of the above classes, it will have estabHshed a firm foundation for an efficient system of health supervision. The medical examination of employees necessitates engaging the services of a greater number of physicians, and enlarging the emergency doctor's offices to include examining rooms and laboratory facilities. All of this means a greater expense to the industry. Therefore, in order to expect industries to adopt such a plan the industrial physician must be able to present a feasible system backed up with the strongest evidence that it is a good business proposition. The arguments in favor of an examination of all employees of any industry are based upon the following facts: 1. That for greater efficiency an employer has the right to demand a healthful, physically and mentally normal, working force. 2. That an employee is justified in demanding a healthful, sanitary working place, uncontaminated by diseased fellow employees. 358 INDUSTRIAL MEDICINE AND SURGERY 3. Good business, as well as a humanitarian spirit, demands the conservation of the life and health of employees. 4. That the medical staff of an industry is employed to act as experts in accomplishing the above results. In the past the care of accidents has been the chief duty of the company surgeon, with very little attention paid to the health and working ability of the individual employee. Likewise, concerns having company surgeons failed to realize the great advantage at their disposal for increasing efficiency by utilizing the expert knowledge of these men. Conditions are changing. To-day we see many of our industries employing safety engineers, experts on ventilation, visiting nurses to care for the sick employees and to better their home conditions, and a staff of physicians trained to diagnose diseases in their incipiency, endowed with a great enthusiasm for results, and a knowledge sufficient to master every detail that could possibly lower the resistance of the working force. Frequent inspections of employees and their work-rooms, instruc- tions in hygiene, sanitation, and health by personal talks, lectures, and printed articles, will increase the standards of health. But the systematic medical examination of employees is the method par excellence in this fight for better health among our working people. By this means the doctor comes in touch with each employee, giving advice and instructions where necessary and estabhshing thereby a personal contact between the medical staff and the working force. Many diseases are discovered in their incipiency while still curable, thus involving the least expenditure of time or money and therefore directly benefiting both the employee and the employer; whereas, otherwise, the employee would continue at his work with an inestimable, gradual loss in efl&ciency, until his disease had become incurable, or,at best, could only be controlled. Again, by this system of physical examinations a great many communicable diseases, for example, tuberculosis, are diagnosed and eliminated from the working force, protecting thereby healthy employees frona an imminent source of infection — their diseased fellow worker. Every employee, male and female, from the head of the concern down, should be examined. Naturally, the greatest interest should center on the present working force, and here the physical examination of employees should begin — there should be a general house cleaning. This, of course, will take a great deal of time, depending on the size of the working force and number of doctors employed. The best method is the systematic examination of employees department after department until all have been examined. But the examination and re-examination of the old working force is inadequate unless the MEDICAL EXAMINATION OF EMPLOYEES 359 portals of the industry are guarded. Therefore, an examination of all new employees is the second essential in raising the health standards; likewise, it is the first essential in protecting the concern from workers who are unfit because of disease. When to examine these new employees must be determined by each industry. The ideal time is before beginning work. From a practical basis, however, this is frequently impossible; for instance, when a large number of people are employed, often temporarily, and upon very short notice. Therefore, a flexible rule must be adopted so that, where possible, every applicant for work shall be examined before employ- ment. Otherwise, they shall be examined the first week or month of their service. Another ideal arrangement in this scheme of medical supervision would be the repetition of these general examinations at stated inter- vals — say, every six months. Again, this in not practicable, especially in our larger industries, owing to the number of doctors necessary at all times to accompUsh this. A comprehensive yet workable system which the writer has gradually evolved during the last ten years for the examination and re-examination of employees in a large industry of Chicago having over 14,000 men and women, is adaptable to any concern. This consists of a constant, careful watch for employees below par by the medical staff, nurses, managers, floor bosses, division heads, and even the employees themselves. Any employee who at the first examination is found to have the least suspicious findings of any disease is filed under the heading of "Re-examination." In the course of a week, month, or three months, according to the doctor's decision, he is recalled and again examined. This is repeated as often as his condition warrants. Other types of suspicious cases are assigned to a nurse to have temperature and pulse watched morning and evening for stated periods. If any abnormal condition is found in the temperature chart of such an employee, he is relieved from work until a final diagnosis is made and his future care outlined. Again, when an employee re- turns to work after some chronic disease has been cured or arrested, he is frequently examined to guard against a recurrence. AU employees who become sick while at work are sent to the doc- tor's office for a ''pass" before going home. And all employees ab- sent on account of illness, of even one day's dm-ation, must secure a permit from the physician before returning to work. By this rule, the medical staff is enabled to watch those employees most fre- quently absent on account of sickness, and thus quite often some incipient disease is revealed as the cause of this decreased working capacity. 360 INDUSTRIAL MEDICINE AND SURGERY When a concern has a benefit association the examination of every employee joining this organization furnishes another source of secur- ing re-examinations. The visiting nurse is one of the best adjuncts to the doctor's office. While visiting a sick employee, she often discovers conditions at home that enable the physician to arrive at the true nature of the employee's trouble which might have been overlooked in a routine examination. Letters and personal talks by the medical staff, backed by the influence and instructions of the management of a concern, will soon arouse all sub-managers, floor bosses, and division heads to take a great interest in the health of workers under them. In time they learn to recognize the early signs of disease and are constantly send- ing employees for re-examinations. This educational system does not stop with those in positions of authority, but soon extends to the employees in general, and if their confidence is once gained, these become "medical missionaries, spread- ing the value of the examination throughout the working force." Periodical examinations for occupational diseases, as prescribed by certain State laws, where thoroughly made, furnish another opportunity for supervision of health. Concerns which are forced to employ men in dusty, dark places, or where disease is more prone to develop, should always provide frequent medical examinations. To recapitulate: the various channels through which re-examina- tion of employees can be obtained are: Those found at first examination to be below par. The repeated examination to guard against recurrences. Those becoming sick while at work. Those returning to work after an illness. Those found by the visiting nurse needing examinations. Those referred by managers or others in authority. Those referred by fellow employees. Those examined for benefit association. Those examined for occupational diseases, or where their work indicates the necessity. The following table shows the great number of examinations of employees which can be made during the course of a year, and the number of re-examinations made possible by adopting the above sys- tem. The examinations of old employees were in practically every case re-examinations as the old working force had been thoroughly "house cleaned" six years before at the time the system of examina- tions of all applicants for work was adopted. The statistics were secured from the records of this same concern which, as stated, em- ployed approximately 15,000 men and women. MEDICAL EXAMINATION OF EMPLOYEES 361 Table 9 Examinations and re-examinations were secured through the fol- lowing channels: Examined for employment 17,742 Old employees completely examined (including laboratory tests). . 7,088 Old employees partially examined 37,906 Total 62,736 Re-examinations Found at first examination to be below par. 4,871 Examined to guard against recurrences 4,251 Reporting for pass home on account of sickness 8,272 Reporting for pass back to work after sickness 18,800 Referred by the nurses or others of medical staff 1,983 Referred by managers, fellow employees, or reporting of own accord 4,264 Examined for benefit association 1,299 Examined because of occupational disease hazards 1,254 Total 44,994 The partial examinations referred to in the above table were those where some local condition was being followed up and where repeated thorough examinations were not necessary after they had once been made. Through these same channels a repeated inspection of employees can be made: for instance, every complaining employee who comes to the doctor's office should have his temperature, pulse, and weight taken. If these are normal and his history is negative and his record shows an examination within the last year, further examination will not be necessary. Whenever an employee with a contagious disease is found working in close contact with others, a careful examination of every man and woman in this department should be made, to ascertain if any have been contaminated. To make such a system possible, every concern must provide a suitable doctor's office at the plant. This should consist of waiting rooms, history, examining, and consultation room, and a general office, as well as an operating room (the care of the injured must always form a large portion of the company surgeon's work), and a well equipped laboratory. The size of the medical staff naturally depends upon the number of employees and the nature of their employment. For the system of medical examinations above outlined, in a concern employing 5000 people, at least two physicians and four nurses would be necessary to accomplish the work. Careful history sheets and records with an adequate tickler system should be kept on every case. 362 INDUSTRIAL MEDICINE AND SURGERY THE EXAMINATION This should consist of the following, and is applicable to both sexes, with only a few exceptions, which are noted. 1. History of patient on regular blank. (a) Personal and family history. (&) Home conditions and financial conditions. 2. Temperature, pulse, height, and weight. (These can be obtained by nurse.) 3. General inspection — color, nutrition, any deformities or co.ngenital malformations, gait, etc. 4. Inspection of mouth, teeth, throat. 5. Inspection of eyes — Snellen's test. 6. Inspection and palpation of neck. 7. Thorough examination of bare chest, (o) Lungs. (b) Heart. 8. Examination of abdomen, genitalia, and extremities in men. (a) Hernias. (&) Venereal disease. (c) Varicosities or flat-foot. Where history of case indicates some abdominal or other trouble in the female employee, the services of the doctor for a further and more thorough examination, in the presence of the nurse, or the next day when the mother can come with patient, are offered. If refused, send to family physician. 9. A routine urinalysis in all cases — albumin, sugar, and microscopic. 10. Blood-pressure and blood examinations in all cases where history and examination show they are indicated. 11. Other laboratory tests such as bacteriological examinations, stomach analysis, Wassermanns, a;-ray examinations, etc., should be provided when needed, either at the plant office or at an outside hospital. 12. Examination of the teeth of employees by a dentist who recommends treatment when needed, is a valuable adjunct. 13. Examination of eyes by a specialist is indicated in all cases of defective vision found at routine examination. Routine Procedure for examinations The applicants for work and those employees reporting for routine examinations can be handled rapidly and efficiently by the following system. 1. Each patient enters with a pass from the employment depart- ment or from his foreman. A girl punches the time of entrance MEDICAL EXAMINATION OF EMPLOYEES 363 to the doctor's office on this pass. This prevents employees from becoming lost and spending too much time in the office. It also gives a check to the foreman on the length of time spent in going and coming from the doctor's office. 2. Sits in waiting room until a record girl finds and brings employee's history sheet to the nurse in charge. The records are pulled in turn from names on the passes (2 minutes). 3. Enters one of the history rooms where nurse takes history, secures pulse, temperature, weight and height record, makes eye test (Snellen) and records all these on the employee's history sheet (5 minutes). 4. Messenger takes employee to dressing room where he disrobes, urinates in specimen jar (boy marks and places in compartment basket), and then goes into the examining room. The physician stays here constantly, the cases coming to him. By handling ten employees at a time the messenger boy is able to keep ahead of the doctor and to take specimens in batches of ten to the laboratory where they are examined and recorded before the examination is made (5 minutes). 5. Employee dresses and goes to dentist or other specialists for special examination (10 minutes). 6. Passes out before a nurse who inspects his record to see that it is complete and to note whether he has been referred for some special test or examination. Records are collected by this nurse. 7. Girl punches time of leaving on his pass which she has retained. By such a plan the employee that needs no special conference, no consultation with others, no treatment or advice can have his ex- amination and record completed and leave in 22 minutes. Other employees meanwhile are seen by the nurses, the surgeons in charge of dressings and the chief of staff who acts as a con- sultant, without interfering with these examinations. Eight hundred and seventeen patients have been seen and cared for by eleven doctors, spending from three and one-half to four hours each at the office, and assisted by twelve nurses in the morning and five nurses in the afternoon. The examination of girls is conducted in the same way except their examination only includes head, neck and chest. Careful history is obtained in each instance however to ascertain if she should be referred for more thorough examination. The question of the history sheets and other records used in these examinations is dealt with in Chapter XII. Some Statistics of Examinations It is to be deplored that physicians engaged in this work have been entirely too busy to keep careful statistics. Managers of industry 364 INDUSTRIAL MEDICINE AND SURGERY often cannot see the value of assigning the necessary clerks to compile statistics. Valuable information is contained in the records of these industrial dispensaries which should be combed out and contributed to medical literature. Recognizing the need of some uniform method of keeping records in order to facilitate this compiling of statistics, Dr. Warren of the U. S. Public Health Service is working on a record sheet which he hopes to have adopted by all physicians in industry. Dr. Tucker of the Conference Board of Industrial Physicians is also preparing a record card. It is to be hoped that within the next year a simple, uniform system of record keeping will be adopted by all industrial dispensaries. I have collected the number of diseased conditions found by medical examinations in twelve different industries, representing almost every type of work. The total number of examinations made was 276,420 during a period of five years. The relative incidence of diseased conditions found is divided for purposes of comparison into the follow- ing groups: Group I. The author's findings in 112,000 examinations among employees : engaged in clerical work, 35 per cent. ; skilled light occupa- tions, 20 per cent.; heavy manufacturing and laboring work, 45 per cent. The proportion of female help was about 42 per cent, and of male 58 per cent. The average age was twenty-six years. Group II. The findings of the U. S. Public Health Service in 936 steel workers. Group III. The findings of the U. S. Pubhc Health Service in 2086 male garment workers. Group IV. The average findings of ten surgeons in ten different industries representing clerical, light manufacturing, heavy steel, electrical, rubber and other forms of manufacture. In going over these statistics from the various industries one is impressed with a number of facts: 1. The majority of industrial physicians are not paying sufficient attention to foot conditions and deformities of the extremities. Un- doubtedly more careful selection of work for employees so handi- capped would improve efficiency. 2. Only a very small number of these physicians are making care- ful tests of vision, otherwise the percentage of eye conditions found would have been higher. In Group IV under defective vision I have reported the average percentage of two concerns only. 3. One is impressed with the small number of blind or partially blind men that are being employed by these industries. Is this be- cause of the compensation laws? MEDICAL EXAMINATION OF EMPLOYEES 365 Conditions found Group I, per cent. 1. Tuberculosis, active. . . 2. Tuberculosis, sus pected or arrested . . 3. Other lung conditions. 4. Organic heart disease. Functional heart conditions Arteriosclerosis 5. Nephritis 6. Albuminuria 7. Rheumatic conditions 8. Hypertrophied or dis- eased tonsils 9. Hernia Unprotected by truss Varicocele, hydro- cele and undescended testicle 10. Varicosities 11. Flatfeet 12. Amputated members 13. Deformities 14. Epilepsy 15. Defective vision Blind one eye Blind both eyes. . . . 16. Deafness 17. Skin diseases 18. Defective teeth Anemias Diabetes Contagious diseases Venereal diseases 01.7 02.10 03.10 02.20 03.00 03.10 00.80 01.70 05.00 40.00 03.20 02.50 00.80 01.00 04.00 02.50 Group II, per cent. Group III, per cent. 00'. 04 35.00 00.40 04.00 04.00 93.00 03.10 00.06 00.30 00.60 00.92 07.17 02.90 00.00 05.00 06.60 26.80 12.60 09.63 32.80 04.28 21.90 00.30 3.00 02.00 10.10 01.80 00.50 02.^0 00.25 13.00 07.50 03.00 29.00 03.00 00.80 00.05 00.66 Group IV, per cent. 01.40 05.30 02.25 00.20 03.90 06.20 03.90 04.40 03.20 05.20 Average, per cent. 01 01 ,30 ,90 00.02 33.90 00.10 00,01 02.30 02.40 56.90 01.20 01.7.55 01.025 08.418 02.288 00.3.50 03.225 04.512 20.925 06.925 04.208 17.750 02.740 06.150 00 . 028 17.225 00 . 365 00 . 003 03 . 100 03 . 200 37.475 4. The percentage of tuberculosis cases is higher among the garment workers of New York. These figures were taken before the working conditions of this group of employees were improved. I am told by different physicians famihar with this group of employees, that their tuberculous incidence has decreased in the last five years. 5. The circulatory conditions among employees cause much ineffi- ciency and lost time unless these individuals are carefully supervised in which case they become, on selected duty, very efficient. The incidence of this organic condition is in proportion to the number of rheumatic conditions found among employees and from the great number of diseased tonsils and bad teeth found both of these condi- tions can be accounted for. 366 INDUSTRIAL MEDICINE AND SURGERY 6. The hernia figures are most interesting. In the industries with the heaviest occupations the rate is usually highest — one physi- cian in a steel mill reporting 14 per cent. Dr. Schereschewsky's fig- ures show a much higher rate in the steel employees than he found in garment workers, or than I found among employees whose work was of a lighter nature. This would seem to bear out the contention of some that if hernia is not a traumatic condition it can certainly be classed as an occupational condition, being more frequent among those submitted to continuous, arduous work. 7. The venereal incidence is smaller than that found in the army. Employees with venereal disease do not seek employment as a rule where physical examinations are conducted, and they avoid paying visits to the doctor's office for fear of losing their job if their disease is discovered. A more generous policy toward these cases by em- ployers would be of the greatest help in discovering them and safe- guarding all concerned. No exhaustive studies have been made as to whether all these efforts in supervising the health of employees have resulted in a marked reduction in morbidity or mortality. Many examples, however, can be given to prove that they have. The author found forty-five cases of tuberculosis in 1909 working in a plant. Five of these died from the disease because they were dis- covered in an advanced stage. In 1913, five years later, one hundred and one cases of this disease were found with only two deaths resulting. This reduction in the death rate has been constant ever since the general house cleaning took place, eight and nine years ago. In 1915 there was an increase of 28 per cent, in the member- ship of the Benefit Association of this same concern, as compared with three years previously. In spite of this increase there was a decrease of 20 per cent, in the amount of sick benefits. About the time we were feeling unusually happy over these figures there was an epidemic of so-called grip which soon destroyed this showing. It will only be after years of careful comparison that the real benefit of these efforts can be shown in actual figures. During the epidemic referred to above the death rate from pneu- monia greatly increased in this community. In this concern how- ever out of thirteen hundred cases of "grip" during a period of three months there were only three deaths from pneumonia. The measures taken to discover the disease early and to free the plant at once of the infected cases accounted for this reduction. Two of the largest industrial insurance companies of the country, the Prudential and the Metropolitan have prepared an interesting table showing the reduction in the mortality rate from a few specific causes. As all those engaged in improving the health conditions of MEDICAL EXAMINATION OF EMPLOYEES 367 employees are responsible to some extent for these results the table is herewith reproduced. INDUSTRIAL MORTALITY EXPERIENCE Reduction in Mortality from Specific Causes, 1911 to 1914 Causes of death Prudential Death rate per 100,000 '911 1914 Per cent, reduc- tion Metropolitan Death rate per 100,000 1911 1914 Per cent, reduc- tion Typhoid fever Measles, scarlet fever, diph- theria, whooping cough .... Tuberculosis, all forms Bronchitis (acute and chronic) Pneumonia All external causes Cirrhosis of liver Total above causes 18.5 58.9 201.4 17.2 124.1 102.8 17.2 12.5 47.7 182.2 14.0 110.3 95.3 17.1 540.1 479.1 32.4 19.0 9.5 18.6 11.1 7.3 0.6 11.3 19.3 62.7 195.3 14.4 108.4 95.6 16.9 512.6 13.6 51.3 176.1 11.0 95.0 85.9 13.9 446.8 29.5 18.2 9.8 23.6 12.4 10.1 17.8 12.8 These data are based upon exceptionally accurate statements of cause of death and upon very close approximations to the number of the living exposed to the risk of death. The two experiences are strikingly similar, they both represent large exposures of industrial workers and both show a quite remarkable reduction in mortality from the causes specified, all of which are largely preventable. The examination of employees is demonstrating a great social and economic problem which sooner or later must be faced: that is, what is to be done with those diseased workers who are refused positions in one concern after another because they cannot pass the physical examination? Some arrangement must be made by the States, by industrial insurance, or by the corporations themselves, to care for these unfortunate men and women who are found below par and not desirable as employees. The problems which are unfolding because of this new line of medical work in our industries are many and serious. This work has surely demonstrated the great human wastage which has been going on since the birth of our nation, and the appalling need for some means of salvaging the disabled employee whether his disability is the result of industrial conditions, or otherwise. When an industry adopts this system of examination, the number of employees found suffering from incipient disease will be excessive. For in the first year or two the ratio of those found diseased increases directly with the number of examinations. After fom* or five years, 368 INDUSTRIAL MEDICINE AND SURGERY however, the number of diseased employees in the working force will be smaller compared with the number of applicants and six month em- ployees found diseased (Fig. 52). The attitude of the employee toward this medical supervision of his health is very gratifying, as a rule. He recognizes its great value to himself and his family. Very rarely, and usually only in the very ignorant class, does an applicant or an employee refuse to be ex- amined. If the management is standing firmly behind the doctor, even these few cases can be persuaded. DECREASE IN TUBERCULOSIS AMONG THE OLD EMPLOYES 1909 15.5/ 1 5 3" 1 5.5% 13.3* 11% SJ* 6.s% Q. CL < 2.2% 45 CASES OF TUBERCULOSIS 27.1^ Z3M^' 4.S% 155 CASES OF TUBERCULOSIS RESULTS OF INCREASED MEDICAL EXAMINATIONS OF EMPLOYES NO 5 YR EMPLOYES-iaoa-SlO NO 5 YR E:MPL0YES-|3H^2Q49 Fig. 52. — Medical examinations caused a marked reduction in the tuberculosis rate among the old employees even though the number of these was four times as great in 1914 as in 1909. This is true of many other chronic diseases. Medical work is growing rapidly in favor with employers as their education along these lines is progressing. Labor unions are also in favor of this work, providing it is done from a humanitarian stand- point. But if done for the purpose of picking only the healthiest, most fit employee without any regard for the welfare of those begin- ning to wear out under the strain, then they are opposed to it. Five years ago it was my experience to find family physicians opposed to all industrial medical systems. A diagnosis of incipient tuberculosis, for instance, was often the cause of a severe arraign- ment from the family physician and the enmity of the employee and MEDICAL EXAMINATION OF EMPLOYEES 369 his family. If, however, the company physician has thoroughly diagnosed his case by repeated examinations and careful laboratory study, he is in a position to stand his ground, and the subsequent course usually justifies his position. In time the family physician comes to recognize the great value of this careful supervision of his patients while they are at work, especially if the employee is referred to him for treatment, independently or in co-operation with the com- pany physician, 24 CHAPTER XXV MEDICAL EXAMINATION OF APPLICANTS FOR WORK In the various armies of the world one of the functions of the medi- cal officers has always been the physical examination of new recruits. This was done for the purpose of picking only the physical fit as it was felt that only such men could stand the hardships of a soldier's life. But the economic demand for man-power in all the countries engaged in this world war has forced them to adopt a plan of physical selection for work of those men not quite fit for general military duty. In our own country after the course of a year we are utilizing this class of men. Soldiers unfit for general military duty are being as- signed to development battalions where they are given training ac- cording to their physical ability to stand it, and then are carefully classified, by qualified medical officers, and assigned to selected duties where they can be efficient in spite of their physical handicaps. Draft- ees with physical handicaps are also being sent to camps for Hmited duty men and, after their physical classification, are assigned to properly selected occupations. Tens of thousands of able-bodied soldiers will thus be freed from lighter duties for the heavy combat service. This radical change in the practices of the army, which has enabled them to utilize man-power to a greater extent than ever before, will have a far reaching influence in the employment practices of our industries. Henceforth the new recruit in the industrial army will be classified physically, as well as technically, and assigned to work by considering both qualifications if industry desires the most effi- cient system. Long before the war a few of our industries had begun a thorough, systematic physical examination of applicants for work. In fact, the experiences of some of these industries, where this procedure had proven both practicable and profitable were influential in establishing these new standards in the army. There are isolated examples of the examination of appHcants for work prior to 1912 but it was about this date that the practice was introduced to any extent in industry. It is often stated that ex- amination of applicants and of employees did not start until after certain states had enacted employees compensation acts. True the 370 MEDICAL EXAMINATION OF APPLICANTS FOR WORK 371 enactment of these laws gave a marked stimulus to the method be- cause many concerns felt that it was necessary to rule out the defectives in order to protect themselves from liabilities. The chief surgeon of one of the largest industries in the country expressed it thus: '•No such examinations were conducted by us prior to the com- pensation act. It was thought best to let every man apply for a job, try himseK out, if he could stand up under the work and wished the job, it was his. At the present time physical examinations are being conducted so as to fit defective men into such posts in our industry as will interfere least with existing defects. The physical examina- tions also disqualify many men seeking employment. The compen- sation Hability is too great. The industries do not like to discriminate against men seeking employment, as their services are much needed. A man with one eye is often a good man for his post yet such a defect at present disqualifies. 'Everybody is doing it,' and it was not until we were convinced that we were getting only the refuse of the rail- roads and steel mills, men who could not qualify in competitive phys- ical examinations, that our company began such physical examina- tions in May, 1916." But those concerns which really initiated medical examinations did so before any such laws were enacted, and the basis for so doing was not selfish, but solely for the protection of their working forces. Few of us in the beginning realized all the ramifications this procedure would have in the economic and social existence of our country. Some of these ramifications have been for good and some for evil but an equitable adjustment for all concerned is gradually taking place. And it is an efficiency measure which both employers and labor unions now recognize as here to stay. In Chapter XXI I have referred to the old system of throwing men into jobs without knowing their fitness for the same and the human waste and financial loss to employers which such a system involved. This hit or miss method of employment is still in vogue in the majority of industries. It is one of the chief factors in the high percentage of labor turn-over. Inefficiency on the job, needless premature break- downs the result of overwork, unnecessary accidents, misunder- standings between boss and workman, and the discontent of labor can more often be traced to poor health conditions than to any other one cause. The physical selection of men for proper work combined with proper health supervision is the cure for many of these difficulties. WHEN TO EXAMINE The only proper time to examine an applicant for work is before he is employed. No working force is sufficiently protected from con- 372 INDUSTRIAL MEDICINE AND SURGERY tagious diseases in applicants if these are allowed to work for a number of days before being examined. The defective new employee may cause an accident to himself or others during those early days of work before he is examined. The loss in inefficient labor, in breaking an employee in to a job and then losing him, and the uncertainty on the part of the the employee as to whether he will be retained or not, all point to the importance of making this examination before he goes to work. Above all it is a gross injustice to employ a man and then a month later, because he has some physical defect which is found at the examination supposed to be given to applicants, dis- charge him because of physical disability. Rightfully he asks if he hasn't been doing his work efficiently in spite of that handicap. An exception to this rule may be made in the case of employing a large number of men at one time for temporary work as before the Christmas rush. But that concern is the wisest, and after all the most frugal, which employs more doctors at such a time and main- tains its standards. This true example can be given illustrating the bad effects of post- poning this examination of applicants. J. B. was employed by an electrical concern as a mechanic. Phys- ical examinations of applicants were required by this industry but the doctors were three months behind in their work. Finally J. B., after 3 months of efficient work as a mechanic, was examined and it was discovered that he was blind in his left eye. This did not interfere in his work but it added to his liability to the concern in case of an injury to his good eye. Therefore he was dismissed. The doctor who handled this case was ashamed of it and framed up an excuse with the man's foreman in order to fire him. If this was sufficient reason for not accepting the man for work then he should have been examined and refused employment when he applied. As it was a great injustice was done the man and his future was jeopardized. REASONS FOR EXAMINATION The industries adopting this system did so for one of the following reasons. You will note that some of them are altruistic, good busi- ness reasons, while others have a selfish basis only. 1. To maintain the standards of health among the old employees. 2. To enable the selection of work according to the physical quali- fications of the applicant. 3. To pick only the physically fit. 4. To protect the concern from employees who might add to their accident liability, thus increasing the insurance premium. MEDICAL EXAMINATION OF APPLICANTS FOR WORK 373 5. To keep out the labor agitator and other undesirable employees (claimed by opponents to the plan). In most concerns where examinations of applicants are conducted the old employees have been thoroughly examined, industrial hygiene methods are in vogue, and all forms of health supervision established. It is only logical therefore that as far as possible they desire to maintain these standards of health. The more comprehensive their standards are however the more broad-minded, as a rule, are they toward employing handicapped individuals. Applicants with contagious conditions are not employed because of their danger to fellow employees. During the course of one year in an industry conducting physical examination the following conta- gious diseases were found by the author and his associates among 8000 appHcants and were a cause for rejection: Tuberculosis 102 Syphilis (active) 10 Gonorrhea 16 Diphtheria 8 Scarlet fever ,. , 2 Measles 6 Mumps 6 Streptococcic sore throat 18 Small-pox r. . 1 Traucoma 1 Total 170 It is self-evident that the health of employees in this industry was greatly protected by preventing these applicants from going to work. The financial saving to the concern by preventing at least five pos- sible epidemics among their working force cannot be estimated. In spite of new theories in regard to the absence of danger from mingling with tuberculous patients I contend that it is a much safer business policy to protect the employees from intimate contact with this disease in their working rooms. Other appUcants are rejected because they have some diseased condition that makes work of any kind dangerous for them. No health standard can be maintained if a man with a broken compen- sated heart, or a girl with an advanced exophthalmic goitre is allowed to go to work. The occupation, no matter how carefully selected may be detrimental to their health and cause much lost time from work on the one hand and great physical damage to them on the other. This does not mean, however, that all organic diseases are causes for rejection. 374 INDUSTRIAL MEDICINE AND SURGERY The second reason for examining applicants, namely, to enable the selection of work according to their physical quaHfications, is one of the most logical business reasons which can be advanced for this procedure. Every efficiency engineer recognizes the value of placing "round pegs, in round holes." No method of picking these pegs is complete that does not include a physical examination. Examples have already been given illustrating the human danger and the financial loss that can follow the usual system of throwing men into jobs without any thought given to their physical qualifica- tions. The example of the man who was employed as a crane operator and whose crane was responsible for the death of one man and the injury of another is one of the best illustrations we can use. These accidents were attributed to other causes but when the crane operator was finally examined he was found to have an eye condition which destroyed part of his vision, especially his perspective. The mental qualifications of a man for types of work must also be considered in this selection of the round hole for the round peg. The employment manager usually becomes a practical psychologist and is able to select these jobs properly. But the physician can often detect mental conditions not apparent to the employment man. For this purpose he should talk with every employee and applicant, asking questions and observing his manner of responding to certain requests in order to determine the mental attributes of each. When deemed advisable the suspicious cases should be referred to a practical psychiatrist for a decision as to their mental fitness for work. Every industrial physician can develop this ability of diagnosing mental troubles even though he cannot subdivide the conditions into the many types of nervous and mental diseases. Even after an applicant has been examined and accepted these mental cases will be cropping out. The majority of them are only functional or temperamental. Often incompatible work will bring the temperamental condition to the foreground. One employee was recommended for discharge on account of inefficiency by his foreman. Before this was done the employment manager sent him to the doctor for another examination. The man was sullen, morose and above all disheartened. He had been working as a packer during the day and studying as a violinist in the evenings. The fellow employees were rude to him and he could not understand their ways. Physically he was perfect. Mentally he was temperamental. A conference between the doctor and employ- ment manager resulted in the man being transferred to the position of assistant foreman over a department of girl typists. He was told to fix up their working room, make it home-like, give the girls a little recreation for ten minutes in the morning and afternoon. In MEDICAL EXAMINATION OF APPLICANTS FOR WORK 375 six months he had a glee club developed among these employees and other activities started which made the girls enthusiastic about their department and most loyal to their foreman and the concern. The output of work increased over 50 per cent. This man is now manager of a department and is happy in his work. Often the nervous energy behind a temperamental employee can be used as a great dynamic force if directed in the right channels. Those concerns which adopt this system of examination for the pur- pose of picking only the physically fit employees may be playing a long stroke of business but they are not assuming their share of responsi- bihty toward society. The handicapped employee is ever in our midst. While he has his brain power left he is able to be efficient in some selected capacity. Unless this opportunity is given him he becomes a non-productive agent and a drain on society. Every concern is benefited by all things which improve the social and economic conditions of their community. Refusal to assume their share of this burden reacts on them as well as on the other industries. From a recent questionaire sent out in regard to the employment of handicapped men the writer discovered that many concerns, even where physical examinations of applicants were conducted, were employing such men. Those with diseased conditions unfitting them for their work were rejected, but the disabled men, the armless, the legless, the bhnd in one eye, were being employed. This may be due to the fact that man-power is at such a premium now, but the testi- mony of most of these concerns would indicate that, where jobs are properly selected, these handicapped individuals make better employees than the able-bodied, and that as far as they are concerned these are permanent employees. One concern reported that it employed all legless and one armed men who appHed and that it had carried out this pohcy for five years. To-day forty such men work here. Five of these have advanced to the position of foreman, one to a manager. Their reasons for favoring this type of a man were purely business reasons and can be stated as follows : 1. Lessens labor turn-over. These men hesitate to change jobs more than do the ablebodied. 2. Make more loyal employees. They appreciate the opportmiity given them to work in a world that has heretofore tried to place them in the scrap heap. 3. Lessens troubles from labor agitators — because of loyalty. 4. Have a greater output. They stick closer to the job, do not move about the plant as much as one with two legs.j 5. Are more punctual and have less absenteeism. As a rule they 376. INDUSTRIAL MEDICINE AND SURGERY take a more serious view of life, do not use alcohol, stay home of nights, and avoid exposures that lead to sickness. 6. Take a pride in their accomplishments. The reaction from those days when they thought they were cripples makes them strive the harder to make good. As one of them said: "It takes a lot of extra effort at first to overcome your handicap and then when it is overcome this extra effort ought to push you away ahead of the other fellow." One employer was quite proud of the fact that he had a number of "cripples" working for him. His chief argument in favor of employ- ing such men was "they worked a lot cheaper than the other fellows." His plant was visited and the lack of incentive for these employees which was witnessed there accounted for them still being "cripples." The handicapped man who has overcome his condition and made good is never a "cripple." So, the concern which is picking only the physically fit employees may not possess such a strong business sagacity after all. Usually such a one is selfish in other matters and sooner or later this selfishness will be their undoing. The lack of loyalty on the part of employees who cannot respect their employer is an ever present, incalculable loss to any industry. With the enactment of employees' compensation laws a great stimulus was given to examinations of applicants. Many concerns adopted this measure as a means of protection against the employee who might increase his accident rate. Practically all the state compen- sation laws hold the employer responsible for total disability when subsequent injury to an already handicapped individual renders him totally disabled. For instance if a one eyed man is employed and by accident he loses the other eye the concern must pay compensation for the loss of both eyes, that is, total blindness. The tendency of all industrial boards to call most hernias traumatic, and therefore compensable, placed a ban on the employment of men with hernias. Insurance companies began to raise the premium rate for concerns employing men who were potential accident liabilities. This added greatly to the discrimination against handicapped individuals and forced many to employ doctors to make physical examinations of applicants from this standpoint of protection alone. No other one thing has caused greater criticism of physical examina- tions of employees than this attitude on the part of employers and insurance companies. Few could see that neither physical examinations, nor the doctors, were to blame, but rather the compen- sation laws which placed this injustice on the employer and the handicapped applicant for work. MEDICAL EXAMINATION OF APPLICANTS FOR WORK 377 During the last year the government's plans for the reconstruction, re-education and re-employment of the returned disabled soldier has injected a new issue, a new viewpoint into the question of employees' compensation. All agree that these disabled soldiers must be employed by industry. All agree also that the employer should not be held responsible for the increased liability due to the handicapped condition of these men. Therefore committees, congressmen and state senators are considering means of so modifying all compensation acts that this injustice will be eliminated. When it is so modified it must include the disabled of industry as well in its interpretation. Thus will the last excuse for using physical examinations of applicants as a means of discriminating against the disabled man be cast aside. Many union labor leaders at first bitterly opposed the examina- tion of employees. They contended that it was only a means of discrimination against the labor union men; of keeping men who were radical in their views out of the working force by claiming that the doctor had found them physically unfit. I doubt if any industry has ever used this as an excuse to so dis- criminate. But there is evidence that the doctor has been asked to use sickness as an excuse to get rid of some undesirable employee. Often it is hard to fire a man and the doctor's office will offer an easy solution to this difficulty if the the doctor will only follow directions. Knowing this to be a fact we can conceive of these fears, of the labor union men, as having some foundation. It is imperative that the medical staff of an industry be absolutely square at all times with both the employee and the employer. He can- not favor one against the other. His decisions must be made altogether upon the evidence of the case. Subterfuges which could reflect upon his professional honesty will soon rob him of the respect and confidence of all. REJECTION STANDARDS It has often been suggested that a list of diseases and the subnormal conditions for which men should be rejected should be prepared by a representative group of industrial surgeons. The standards for re- jection in the army have been offered as a basis. Such a plan would work great injustices on thousands of individuals. The variations in occupations, hours of labor, plant conditions, attitude of employers toward employees and many other things on the one hand, and the variations in the seriousness of specific conditions in different individ- uals and the interpretations of the different conditions by the medical men on the other hand, make such a standardization of specific causes for rejections impossible. The case of each individual must be considered separately, and the 378 INDUSTRIAL MEDICINE AND SURGERY decision as to his fitness for work must depend upon his individual physical and mental quahfications and the nature of occupations available in the given industry. The Ford Motor Company claims to have the policy of "No Rejec- tions for Work." Every applicant is given a thorough examination, his physical defects noted, and then he is assigned work where he can be efficient in spite of his handicap. Naturally contagious cases would not be accepted at once. This careful fitting of the job to the man has resulted in the greatest efficiency in this plant. Even men who are bHnd have been found useful and more efficient than others especially on the finer electrical work, as winding of armatures. There is no attitude of charity in this policy but it is placed on a straight business basis. For a large concern where many kinds of occupations are represented this policy is logical. But a smaller industry perhaps could not find employment for every type of handicapped individual without introducing the element of charity. Representing the other extreme are a few concerns which have definite standards for rejection. These reject: all cases of blindness, one eye or both; deafness in both ears; badly infected teeth; cases of tuberculosis or suspicious lung findings; organic heart disease; nephritis; diabetes; all cases of hernia; varicose veins; marked deform- ities of extremities; epilepsy; any degenerative nervous conditions; syphilis or gonorrhea. These conditions raise their rejection Ust to approximately 15 per cent, of all applicants. They accept many employees with minor handicaps and therefore cannot be placed in the class of those concerns picking only the most fit material. The latter concerns reject from 18 to 20 per cent, of all appHcants In between these two extremes of accepting all comers and of rejecting all with specific conditions, we find a large group of industries that have adopted the plan of individual selection for proper work. No definite standard of causes for rejection can be outhned for these concerns but their policy can be stated in general as follows: 1. All contagious cases must be rejected — later they may return for examination. 2. Cases of total bHndness are not accepted as a rule. A job may be found for some specific case. One eye blindness is accepted but assigned to work where the hazard to the good eye is reduced to a minimum, 3. Locomotor ataxia, paresis and general nervous conditions are not accepted as a rule, although the milder forms may be placed at selected work. 4. Epileptics are not accepted by the majority. A few concerns MEDICAL EXAMINATION OF APPLICANTS FOR WORK 379 find suitable work for these individuals where the danger of injury resulting during an attack is obviated as far as possible. 5. Tuberculous cases are rejected. Some of the concerns assume the duty of seeing that these rejects are placed under proper treat- ment by the city, county or with their family physician. 6. Other lung conditions are decided on their merits. An asth- matic may be rejected because the only work available for him is in a very dusty occupation. Careful selection of proper work is neces- sary for these cases. 7. Organic heart disease with broken compensation is a cause for rejection — ^for the good of the applicant. Other applicants with heart disease can be very efficient in selected positions where excessive physical strain is not demanded. In a large group of applicants ex- amined for work 3 per cent, were found with heart disease but only one-half of 1 per cent, was rejected. The others, in selected jobs, made excellent employees, were very loyal because they ap- preciated the fact of being employed, had a decreased sickness rate because they were more careful and were supervised more rigidly, and decreased labor turn-over by staying on the job where these advantages were afforded them. 8. Hernias are a cause of rejection in most of these concerns. This is largely because of the legal liabiUties assumed by employing these cases. This fear has been exaggerated, however. Men with hernias are undoubtedly less efficient on all jobs demand- ing physical exertion. Even when a truss is worn they unconsciously protect themselves by lessened exertion. Some statistics show a lessened rate of 20 per cent, in these cases. Considering the large number of hernia cases and the small number of men suitable for sedentary occupations it is obvious that many of these cases must be rejected. Wherever possible, suitable work should be provided for them. Some arrangement should be made where men with hernias could undergo operations. The writer has operated a great many of these rejected cases free of charge and then the concern, with which he was associated, would employ them after recovery. Such men were able to do heavy work and were usually a very loyal group of employees. But this plan smacks too much of charity. As an economic responsi- bility the state should provide some means of remedying these, as well as other, conditions which have an occupational etiology, or, because of their existence, have an occupational hazard. Undescended testicle, varicocele, hydrocele and similar conditions have often formed a basis for rejection on the ground that they pre- dispose to hernia. Such conditions should not interfere with employ- ment except where they form a definite hazard and no proper work 380 INDUSTRIAL MEDICINE AND SURGERY can be selected. Many a man with an undescended testicle lying in the abdomen has been rejected, who is just as safe and as capable an employee as any other able bodied man. 9. Varicose veins, especially with ulcers of the legs, often so incapacitate a man as to make him unfit for emplojrment. Again, a large varicosity adds to the hazards of certain occupations. Many such cases must be rejected. But these men on properly selected jobs, which do not involve the combination of heavy work and con- tinuous standing, can make efficient employees. A concern, however, always assumes the liability of a shght injury to the varicose leg causing a serious ulcer and prolonged disabihty. Relief from this hability on the part of the compensation act, would enable more men and women with varicosities to secure employment. 10. Severe deformities, even the loss of a leg or an arm, should not be a cause for rejection if the industry has work of any kind that could be done by such men. All concerns who have employed such individuals testify to their efficiency. 11. It takes a very broad minded employer who will consent to the employment of venereal cases. The active syphihtic and acute gonorrheal are a menace to the old working force. Therefore they should be temporarily rejected. But some plan must be formed whereby these cases can be reported and forced to take proper treat- ment, and other forms 'of protection of society from this menace made. It is a duty of the state to take up this problem at once. A few industries have provided proper care for their employees who contract these diseases but none have assumed responsibihty for the diseased applicant. 12. Infected teeth, diseased tonsils, defective vision, lack of pro- tection by vaccination and other remedial conditions are not causes for rejection by most employers. Some, however, have made arrange- ments, either in their own medical departments, or with outside medical and dental clinics, for the correction of these conditions. Employ- ment is granted on the understanding that the apphcant will at once seek proper treatment. Some concerns even arrange a loan of money to these individuals, so that they can obtain this treatment; the loan to be repaid in small weekly payments taken from their wages. No greater efficiency measure, nor better pubhc health act, has ever been initiated in this country. One establishment has extended the same policy to venereal cases. SHOULD DISEASED CONDITIONS BE EXPLAINED? When an apphcant is examined for work and a diseased condition is found should he be told about it? This is a question that has caused considerable dispute among physicians in industry. MEDICAL EXAMINATION OF APPLICANTS FOR WORK 381 If we are working solely for the interests of the employer, and are willing to forget our responsibility toward society, then we may take the narrow view of this question. But, if we are making these ex- aminations solely for the good of the old employees and the applicants themselves and if we are thorough and prove beyond a doubt that the conditions really exist, we need have no hesitancy in informing the individual of his trouble. Some concerns forbid their physicians to ever tell an applicant when a diseased condition is present. The appHcant is rejected by the em- ployment manager and does not know that it is on account of health reasons. He may have a beginning pulmonary tuberculosis which has not yet forced him to seek medical advice. The doctor kills the professional instinct that urges him to warn this man of his danger. The emploj^er rejects him for work. The man seeks employment else- where, exposing others to the disease and allowing it to progress as surely as a smouldering fire. He obtains employment in a dusty loft and finally is forced to quit work because of consumption. The disease is now incurable. Doesn't a considerable responsibility for his death lie at the door of that physician, and the concern who failed to warn him when the trouble was still curable? Many applicants with kidney disease, a heart condition, or other incipient organic disease, of which they were not cognizant, will thank the doctor for telling them of the condition and will seek proper medical advice at once. But if they are not told they will go elsewhere and seek employment, usually where physical examinations are not required, and the work here will do the damage from which' you saved them in your concern. There can be but one answer to this question. Every applicant and every employee examined must be kindly and diplomatically told of his condition and given the advice that will enable him to seek the proper remedy. In order to be sure of his ground the physician may have to request the appHcant to return for two or three re-examinations and careful laboratory tests. This should be done in every doubtful case until the diagnosis is made or the suspicious findings proved false. A concern whose doctors work thus carefully need never fear the consequences of telling an individual when a diseased condition is present. DO APPLICANTS OBJECT TO EXAMINATIONS? The fear of hampering their labor market was the chief objection to introducing this system into the plant of the first concern in Chicago that started it on a comprehensive scale. To their surprise, however, they found that applicants seldom objected. A radical labor journal made quite an attack upon the system but even this did not increase 382 INDUSTRIAL MEDICINE AND SURGERY objections. Frequently the remark was heard that "this must be a good place to work if the boss looks after the health of his employees this carefully." The clean, comfortable doctor's office, the smiling nurses, the courteous, diplomatic way in which the doctors explained the pur- poses of the examination to each one, soon impressed the applicants that this practice was done for their good as well as for the good of the old employees and the employer. They told their friends about it and soon the labor supply for this industry was increased rather than limited. As one mother, who had brought her daughter here for a job, said: "I would rather my girl worked in a place like this, where she is protected from disease, for $5 a week than to mingle with people with no telling what's the matter with them, for $15 a week. " Out of 9000 applicants examined the first year there were six who refused the examination. In 1917 when jobs were plentiful there were forty refusals for examination out of 17000 applicants. Sixty others refused or failed to return for a re-examination when some condition was found that needed study. The fact that so many concerns have adopted the physical ex- aminations for appHcants is sufficient proof that it does not limit the labor supply. This procedure must always be done from an un- selfish standpoint, and governed by altruistic principles, however, or it will in time fall into disrepute. FITTING DISABLED TO JOBS The subject of fitting disabled men to proper work for which they are qualified would fill a volume in itself if the entire field of occupations were covered. But from a practical standpoint it in- volves just three things which must be considered by both the physician and the employment manager jointly. They are: 1. The nature of the man's disability. 2. His previous training and occupations. 3. The finding of the occupation in the industry for which the above qualifications fit him. If the doctor pays no attention to the occupations to which handi- capped men are assigned, or if the employment manager or foreman pay no attention to the remarks of the doctor concerning the man's physical condition, then no efficient system of fitting disabled to jobs is in vogue. The actual selection, therefore, is a matter of considering each individual case in each industry. Every physician when dealing with the problem in its relation to his specific industry will shortly find MEDICAL EXAMINATION OF APPLICANTS FOR WORK 383 a number of positions where handicaps must not be employed. For instance : Never put men who have been poisoned with lead, or other occupational poisons, back where the same hazard exists. Never place men with organic heart disease in occupations where; overexertion could make it worse; where a fainting spell could cause injury to them; or where they are responsible for the lives of others, as in engineering or elevator operating. Keep the men with infected teeth, diseased tonsils and other pre- disposing rheumatic conditions out of dark, damp rooms; where exposed to extremes of heat and cold, and similar positions. Keep the men with hernias off the heavy lifting jobs. A long list of these prohibited jobs for men with handicaps should be prepared by the physician after a thorough study of his industr^^ and should be given to the employment manager and every foreman in the plant with instructions from the head of the concern that these rules must be obeyed. When a handicapped person has once been assigned to a job he should never be transferred to another occupation without the consent of the physician and the employment manager. To make sure that this rule is observed every transfer of men should be made only after conference with the employment department where each man's record is kept. As a result of the return of so many war disabled to industry, England has had a commission studying this problem for the last two years. This commission has considered each occupation in the majority of industries in England, and has described the jobs which handicapped men can do, the training necessary to make them com- petent in this work, and what special appliances are necessary on the machines or on the men. These reports are set forth in several pamphlets which can be obtained from His Majesty's Stationery Office, London. They are entitled "Openings in Industry Suitable for Disabled Sailors and Soldiers." WHAT BECOMES OF REJECTS? The problem of what is to become of these men, who because of disabilities are refused work in industries, was becoming very acute before the war. With the increased demand for labor, the result of war production, almost everybody could get a job, including these diseased individuals who in normal times would have been rejected. It is impossible to estimate how many of these have sickened and died, how many accidents they have been responsible for, how much they have added to the labor turn-over situation, and to what extent they 384 INDUSTRIAL MEDICINE AND SURGERY have slowed up production. But as industry settles into its normal stride it is evident that the physical selection of men for work is an efficiency measure which is to be utilized more than ever. How- ever, as the economic demand for man power increases even these handicapped individuals will be used, but they will be carefully as- signed to work in which they can be efficient without adding to their disabilities. Thus the country is learning its lesson. Undoubtedly these disabled men will be provided for in the future. These acts on the part of the government are necessary to meet this problem : 1. Provisions for proper medical treatment for all diseased and injured workmen^ — their physical reconstruction. 2. Provisions for proper vocational training in. occupations which they can safely and efficiently perform in spite of their disabilities. Corporation schools, continuation schools, vestibule schools, and other vocational centers are already meeting this problem in some places. 3. Disability, insurance to provide for their maintenance and that of their families during these periods of treatment and training. Adequate insurance and proper care in case of permanent disability. 4. Repeal, by an executive order in case of disabled soldiers, or by state legislatures, of those portions of the various state compensa- tion acts which now cause employers to discriminate against handi- capped man. During the present emergency our government is making these provisions for our disabled sailors and soldiers. A wise, far visioned Congress surely will provide these same advantages for the industrial army. Industry which is so essential to victory is disabling five times as many men and women as the war. What will we do with them? PERCENTAGE OF REJECTS Figures were obtained from eleven industries of the country repre- senting many and varied occupations, whose medical staffs are re- puted to make very thorough examinations and where all apphcants are said to be examined. The first five of these concerns are known to base their causes for rejection on these two points: first, whether the appHcant has any condition that would make his presence dangerous to the old em- ployees; second, whether he has any condition that would make work of any kind dangerous to himself. Their percentage of rejections vary from none to 3.9 per cent. The remaining six concerns consider the above points in reject- ing men plus the additional factor of the added compensation lia- MEDICAL EXAMINATION OF APPLICANTS FOR WORK 385 bility if they employ handicapped individuals. Their percentage of rejections vary from 9 per cent, to 16.76 per cent. These percentages give a fairly accurate index of the number of industrial workers in the country who would need to take advantage of this opportunity for physical reconstruction and perhaps train- ing for proper selected work. As these examinations of applicants for work represent the ap- proximate number of new men employed it is noteworthy that those concerns who have the lowest rejection rate as a rule have the lowest labor turn-over rate. The attached table gives the percentages of both rejected and de- fective applicants as well as the nature of the business conducted by these concerns. Table 10 Kind of industry Number applicants examined in 1916 Per cent. having disabilities employed Per cent, rejected because of disabil- ities Automobile factory ■Garment industry Mail order house Gas company, includes shops, street gangs and office force Grinding industry Engine and boiler foundry Electrical manufacturing and muni- tion plant Rubber industry Implement foundry Electric power plant and city office force Lamp foundry and electric company . . Total number of employees 5,000 33.0 0.0 7,877 0.5 17,642 25.0 3.4 2,802 28.0 3.6 (6 months) 2,618 98.0* 3.9 4,475 9.0 24,000 40.0 14.0 33,000 64.9 14.1 1,082 35.0 15.0 3,645 5.0 15.0 2,756 16.76 35,000 21,800 16,000 4,500 6,000 6,500 18,000 14,000 3,300 5,100 * Includes defective teeth. 25 CHAPTER XXVI EXAMINATIONS AND CORRECTION OF EYE CONDITIONS With the adoption of a thorough physical examination of em- ployees and of all applicants for work it soon became apparent that a great number of the cases had faulty vision. At first the examin- ing physicians would explain this defect to the workman, pointing out the lowered efficiency and the resulting handicap to his advance- ment due to lessened acuity of vision, and recommend that he consult a recognized eye specialist. Some followed the advice but the majority failed to do so because "they couldn't afford it," "didn't know where to go," "didn't want to lose time from work," or "could get just as good glasses at the department store or the corner drug store." In order to meet this situation we arranged the following plan for the employees under our care: 1. All with vision below 20/25 should be referred to a competent eye specialist for examination and necessary correction. 2. Those needing glasses would be furnished the same at cost. 3. The doctor's fee and the cost of glasses would be paid for by the firm in every case, the employee repaying the firm in easy installments. 4. The eye specialist would charge a very nominal rate, and could afford to do so because of the bulk of work. After adopting this plan it was comparatively easy to persuade employees with defective vision to take advantage of this opportunity of securing proper care. Other concerns have had a similar experience and have met it in various ways. Practically all agree that some plan similar to the above is necessary to meet the great economic waste due to this com- mon condition among employees — faulty vision. Dr. Earle B. Fowler, who has been associated with the author in the night clinic on Industrial Medicine and Surgery, at Rush Medical College, and has had wide experience in this form of industrial prac- tice has prepared the following brief: "Primarily the examination of the eyes and correction of defects found has been taken up with the purpose of increasing efficiency. We have felt that the employer would benefit by selection; by the increase in accuracy and quantity of the work; and Dy justice in the 386 EXAMINATIONS AND CORRECTION OF EYE CONDITIONS 387 settlement of damage claims. The employee would, of course, be helped by the same factors; by a careful placing so that a defect does not mean a handicap; by increased wage earning ability and dependability; and by just recompense when injury causes disability. "In the examinations of all applicants for acuity of vision a nurse or assistant can carry out the routine accurately. The distance must be definite and uniform; the test card evenly and brightly lighted with no direct light in the applicant's eye; the vision must be taken with each eye singly, using the utmost care in the covering of the unused eye; there must be two or three test cards to avoid memorizing in questionable cases. The covering completely of the unused eye without causing pressure on the globe has given the most difficulty, and it has been found that the palm of the patient's own hand (not the fingers), with the margin pressed closely against the nose gives the best results provided the applicant is forced to keep his head absolutely straight. (A black card may be used in the same manner.) This is easy to control and he must not be allowed to turn even slightly to right or left. Twenty feet is the arbitrary distance and in places where this cannot be obtained a mirror at ten feet (fourteen inch square plate) and reversed test type over the applicant's head is very satisfactory, in fact the ad- vantage of being able to control the position of the head (keeping it straight) and at the same time to point to the letters, leads some to prefer this arrangement. The eyes must be at a uniform distance from the card (or mirror); sitting forward in the chair results in marked inaccuracy. The record is kept in terms noted on the margin of the test card opposite the line of smallest type read. A little urging will often demonstrate the vision to be better than indicated by the ap- plicant's statement that he can read no farther, for many are nervous and feel hurried or have waited long and are tired. " The requirements applied to this selective test must vary as judg- ment dictates. It has been found satisfactory to arbitrarily turn over to the surgeon all applicants unable to read the 8/10 (20/25) line with either eye alone and leave it to his judgment whether without cor- rection they will get the best results in the work they are going into. The surgeon may carry out his work at the plant, making the com- plete examination and prescribing glasses when deemed necessary' or the applicant may be referred to his office provided it is reasonably accessible. The problem of commercial supply of glasses may in- fluence in the choice of arrangements, the object being to complete Fig. 53. — Snellen's vision test card. 388 INDUSTRIAL MEDICINE AND SURGERY the whole process with the least delay in starting the employee at work. If there is a reliable optician in the immediate neighbor- hood or one can be located at the plant during certain hours either plan for the surgeon's work will be satisfactory, otherwise time can be saved by the trip to the office as there will have to be a day spent in going for the glasses anyway. It is most important that the frames be fitted individually with care and accuracy. As we are caring for people of small salaries it is hard to require an employee or applicant for work to spend the amount necessary for glasses, and in the at- titude of the patient toward this we meet one of our hardest problems. Some firms arrange to buy the glasses and charge the amount against the employee for repayment in installments. Ordering uniformly from one concern will often materially reduce the price. From the point of view of the surgeon the use of mydriatics, necessary in at least a percentage of the cases, would require much time if working at the plant and if there are too many cases referred time can be saved by sandwiching these in at the office. Most of these problems work themselves out and the method most advantageous to all is reached in time. "Another group of referred cases is made up of those employees reporting disability from headache, or eye fatigue. In most instances a general physical examination is made including nose and throat and then they are referred for the correction or elimination of visual defects. In a large proportion of these the vision at 20 feet is normal or better but varying degrees of hyperopia or hyperopic astigmatism are re- sponsible for the symptoms. Muscle balance is carefully examined in all of these. Added to this group are the employees, most often from the correspondence or clerical departments, typists or comp- tometer operators, reported for repeated errors. Though not a large number the results obtained with this class have been most important. "Cases of injury and inflammation will be discussed later. "The question of visual requirements after correction with glasses must be left to the judgment of the surgeon. Definite abnormal- ities must be emphasized in the record so as to be noted in case of transfer from one class of work to another. Poor distant vision does not handicap for close work if the near vision is good, but would be a menace for one doing truck driving. Great reduction in the one eye, a condition very frequently met with, would lead to a designation as "unsafe" for elevator operator or similar occupation while not in- terfering in another fine. Some famiharity with the work in all de- partments is a necessary part of the surgeon's training if he is to make these decisions with the best results for all concerned. "During the first year of this eye work at Sears, Roebuck & Com- pany, eye tests were carefully made and the record of vision kept, but EXAMINATIONS AND CORRECTION OF EYE CONDITIONS 389 it was left to the judgment and choice of the employee whether to follow the advice given regarding proper correction. As a result out of 2000 cases of defective vision found among the applicants and old employees only 327 placed themselves under proper treatment. "The second year, April 1, 1916 to April 1, 1917, there were 1834 referred of 20,507 applicants, otherwise acceptable, and in the first eight months of the third year, April 1 to January 1, 1918, 1028 cases were referred. "A brief summary of these cases gives some idea of the need for this work. The results are based on the examination of 2652 em- ployees, during a period of one year and eight months, referred be- cause of defective vision or symptoms of eye strain. The records total as follows: 1. Both eyes less than 3^ vision 763 Of these 289 were improved to normal, 307 to better than '^'2, with a prospect of further improvement as glasses were worn, and 12 were not improved. 2. One eye less than 3^^ vision 662 Of these 225 were improved to normal; 318 improved, but not to normal; 119 not improved. In most instances re- corded " not improved " the other eye was normal and either the prospects of improvements even with glasses were not . good, or it was felt the patient would not wear glasses even if supplied. As the one good eye was sufficient for all re- quirements of work the wearing of glasses could not be forced. This most important group will be referred to in the last part of the chapter in reference to damage suits. 3. Headaches and eye strain 764 Of these 493 had normal vision, 271 with reduced vision are included in the above. "Although detailed records of cases and results at the time of fitting have been kept the above is sufficient here. The hardest statis- tical work comes in the follow up. In the opinion of department man- agers there has been a distinct value to the work. In all instances they have accepted our decisions in regard to placing or transferring em- ployees. The results of this selection must be speculative ; conclusions in regard to those in which vision was bettered must also be judged by opinions of work improvement. Those in charge give many instances of marked increase in quantity and quality of the work of these em- ployees either as groups or individuals. It is comparatively easy to judge of those reporting for eye strain or headaches. These results have been most gratifying as marked improvement or complete rehef is very definite. The loss of time is reduced at once to a minimum. 390 INDUSTRIAL MEDICINE AND SURGERY "Just how much the employer or the employee profits by this branch of the work covered in this report we cannot measure, but we feel sure it is sufficient to more than balance time and money spent. Reports from other firms confirm this in so far as results can be judged from observation purely. "Since the employees' compensation laws have gone into effect it has become important for all concerned that an accurate account of vision of every employee be kept. In the group above in which the vision in one eye was less than 1/2 normal 60 per cent, were unaware of the fact until the routine test brought this out. Without a record the possibihty of an unfair settlement following a very slight or imagined injury in any of these cases is evident. "This year a young man applied for a position. Three months previous he had passed the vision test for the navy. When he came to us a low grade neuritis had reduced vision to right eye, left eye 6/10. How easily it would have been to convince a jury that a blow on the head two weeks after going to work caused blindness. Good vision, a blow on the head, proven blindness; our peers do not require that pathology be presented. "Fortunately the accidents are few. We try to look after all foreign body cases and injuries immediately and follow up the treatment until the condition is healed. Of course it is optional with the patient whether he accepts treatment from the surgeon employed by the com- pany or goes immediately to his own. Our only insistence here being that he sees someone we know to be thoroughly rehable. "If we only take and record vision carefully we have done something toward bettering our judgment of an employee's capabihties, also we have shown him his deficiences. We do more if we urge or demand a correction of these deficiencies, and still more if we help in the securing of the correction." CHAPTER XXVII MEDICAL TREATMENT OF EMPLOYEES The amount of medical treatment afforded sick and injured employees in concerns having medical staffs varies considerably. Most of these take complete charge of the treatment of all injured employees when accidents are directly the result of occupations or plant conditions. Likewise if a disease results from occupation they will assume the medical care. Some refer all sick employees to their family physicians, refusing even first aid treatment. Others render treatment in certain diseased conditions referring all other cases to their family physicians, but maintaining some form of supervision over th? treatment given these employees. Still other concerns furnish complete medical and surgi- cal care to all. In the majority of cases most plant surgeons have been con- scientiously referring the sick employees to their family physician. As a rule they receive excellent care. But in a number of instances these cases are neglected, their time loss from work is greatly in- creased, and there is a very decided financial loss to both the employee and employer. More and more the physician in industrial practice is being called upon to assume the entire medical care of the employees. These physicians feel a professional obhgation toward their fellow practitioners and usually are very conscientious in meeting this obhgation. Nevertheless, they are often placed in an embarrassing position because of their other obhgation to both employer and employed. The physician responsible for the human maintenance department in an industry must be absolutely honest and fearless. Professional ethics in its truest form must he his guide. But the old false standard of ethics, which prevents a physician from interfering in another doctor's case when he sees the patient is being neglected, or which prevents him from giving an honest opinion to a patient in order to protect another physician's dishonesty, should not be confused with true professional ethics. SUPERVISION OF MEDICAL TREATMENT The advance which has been made from the days when the company surgeon paid no attention to the medical diseases of the employees 391 392 INDUSTEIAL MEDICINE AND SURGERY to the present systems of supervision of their medical treatment marks one of the most progressive movements in industrial medicine. Its influence presages almost revolutionary changes in the practice of medicine. In the well organized medical departments of industry no employee can remain away from work on account of sickness without the doctor's knowledge. This knowledge is obtained through these channels: 1. An employee becoming sick at work must secure a pass from the doctor's office before going home. He is then reported on sick leave every morning, by his foreman, until he returns when he must obtain a pass back to work from the doctor. 2. Every employee who cannot come to work, must send word to his foreman the morning of his first day of absence. Those who are home on account of sickness are reported to the doctor's office. In the case of an employee who fails to notify the foreman there are many ways of ascertaining the causes of absence. After twenty-four hours, if no word has been received, the foreman should send a trusted employee to investigate. When an employee is home on account of sickness, the visiting nurse calls on him within the first three days of his absence and as frequently thereafter as his condition indicates. It is her duty to learn the nature of the sickness by talking with the family physician and the family. She must make sure that the doctor is on the job and that every possible care is being given the employee. These nurses even render such nursing aid as bathing the patient and preparing certain foods (thus teaching the wife or another), cleaning up the room and changing the linen on the bed. This is always done with the consent of the family physician. These nurses soon develop a keen perception regarding the serious- ness of the case and the kind of treatment the patient is receiving. When, in her judgment, the case is not progressing properly or there is evidence of neglect she reports the same to the chief surgeon. Some member of the medical staff then phones the family physician and arranges to visit the employee in consultation or alone. Any suggestions, such as the employment, by the industry, of a nurse for the patient, or the sending of the employee to a hospital, or the need of special consultation, or special treatment, are then made to the family physician. This is done diplomatically, with the knowledge that the concern will pay, or loan the needed money to the family, for this additional care. As a rule, the family physician welcomes this interest in his patient. Only seldom is it necessary to tell the family that the case is being neglected and offer the services of the medical staff. The following examples illustrate this method of supervision: MEDICAL TREATMENT OF EMPLOYEES 393 Mr. J. was reported absent on account of sickness by his foreman. The next day the nurse called at his home and found that he was very sick but had not yet summoned his family physician. The nurse secured his wife's consent and asked this doctor to call. The following day the nurse again visited the patient and learned that he had pneu- monia. The sick room was badly ventilated and dirty. The wife had four small children and no help, arid could give very little attention to her sick husband. The doctor had only called once and was not to return unless requested. The patient's condition seemed very serious, so the nurse reported the state of affairs to the chief surgeon. One of the medical staff, after arranging with the family physician, met the latter at the patient's home within a few hours. As a result of this consultation, the patient was removed into an airy front room, a nurse was put on the case, the industry paying the cost, and in ten days the man had passed his crisis. With the care this man was receiving, and would have received in the days prior to such super- vision, the chances are he would have died. He was a valuable employee, was receiving two-thirds of his wages while away from work, and in case of death, would have received a death benefit from the benefit association. It is evident that from an economic standpoint this was good business on the part of this concern. Example 2. — Jennie J. came to the doctor's office on account of a severe pain in her right side. Examination revealed marked tender- ness over the appendix region. The blood count showed 16,000 leukocytes. A diagnosis of acute appendicitis was made. The family physician was called on the phone and asked if he wished the case sent direct to some hospital. He preferred to have her sent home, and promised to call there Very shortly. A taxi cab, therefore, was ordered, and Jennie was sent home with a card giving the result of our laboratory examination and the diagnosis. A nurse called the next day and reported back that Jennie seemed better, and that her doctor had laughed at our diagnosis as she was suffering only from gastritis. The attitude of the family was hostile as they felt we had made a serious mistake. The following day the nurse reported that Jennie was much worse. The family doctor had sent some other medicine out to the house, but the family did not think it necessary to have him call. When the nurse called the next day she found Jennie suffering great pain, and the abdomen hard and distended. She reported over the phone to the chief surgeon that the patient was being woefully neglected, and would die unless some active steps were taken at once. The chief surgeon phoned the family physician and explained the situation to him. The latter still contended that it was only a case of gastritis. He acknowledged that he had made no further blood- 394 INDUSTRIAL MEDICINE AND SURGERY count. He refused to meet the surgeon in consultation, and stated positively that we had no right to interfere- with his patient. A request to call on Jennie was then made direct to the family. As she was receiving benefits from the association they could not very well refuse. The examination made by the company surgeon at this time showed a large appendiceal abscess had developed. The blood-count was 24,000 leukocytes. The condition was carefully explained to the family, and finally their consent gained for an operation. The fact that the surgeon would operate free of charge, and that only the hospital expenses need be met by them, influenced their decision. While the girl was being sent to the hospital the father got in touch with the family physician. Just before the operation this doctor appeared on the scene and strenuously objected. Consultation was called and agreed that it was an extreme case and immediate operation was necessary. The father then consented. At the operation a large appendiceal abscess was found filling most of the right side. Thorough drainage resulted in recovery after some six weeks. A year later it was necessary to operate on this girl a second time and remove a gangrenous appendix which could not be found in the presence of the large amount of pus at the first operation. The neglect of this case resulted in an avoidable operation and eleven weeks of unnecessary lost time from work. This is not an unusual example, for every medical staff which is properly super- vising the treatment of their employees has had similar experiences. No physician believing in true professional ethics, which must react to the welfare of both the patient and the doctor, would condemn this form of interference in a case receiving such neglectful treatment. The number of different forms of quackery which the medical staff of a large industry meets is appalling. Some of these practices are carried on by known quacks and others by presumably reputable physicians. If the plant doctors are honestly supervising the treatment, they must meet these various forms of quackery with outspoken condemna- tion and must use every argument to have the patient seek proper medical care. A sharp distinction must be drawn between quackery and certain legitimate forms of treatment which may not exactly agree with the views of the medical staff. In the latter case the physician should never belittle the work of the family doctor nor make any disparaging remarks about his diagnosis and form of treatment in the presence of his patient. The profession soon learns to know if the medical staff of an industry is at all times square in its judgment and statements MEDICAL TREATMENT OF EMPLOYEES 395 to their patients and the degree of respect and co-operation given by the physicians in a community is influenced accordingly. This is important as no system of treatment supervision can be ade- quate where co-operation with the family physicians does not exist. The following are examples of pure or near quackery which the physician in industry is daily called upon to meet and correct. 1. The Venereal Quack. — The methods of these so-called specialists for men's diseases are notorious. The extent to which their perfidious practices reach out and rob the working classes of our country surely is not known, otherwise a government interested in the welfare and protection of its people would long ago have eradicated this nuisance against society. Cases of so-called gonorrhea have been found at examinations of employees, who have been under the care of these quacks for months, paying a dollar per treatment and receiving the same nightly from a lay assistant. Bacteriological examinations of the discharge failed to reveal gonococci. Careful inquiry revealed the fact that injections of strong solutions of silver nitrate, or of nitric acid had developed a marked urethritis thus keeping up the discharge. Many legitimate cases of gonorrhea are treated by these special- ists and "cured" in two weeks for $25 paid in advance. The cure consists of a drying up process. When the recurrence appears they can be "cured" again for $20 paid in advance. Often these men are convinced that the recurrence is a new infection and must therefore pay the usual rate of $25. Men who fear they have been exposed to syphiHs, or have con- tracted the disease go to these quacks. Heavy doses of potassium iodid are administered until the typical iodid rash appears and then it is easy to convince the patient that he has the disease. Many cases have been reclaimed from the treachery of these robbers and have been relieved of the terror created in their minds, by the "museum" maintained by these quacks and the line of talk handed out by them. Employees with harmless varicoceles often consult these specialists and are led to believe that the condition is serious. Electrical treat- ments, expensive "imported" lotions and even more expensive trusses or suspensories are sold to them. The efficiency of empleyees, hounded by the fears created by quacks, and worry over the debts the treatments involve, is bound to be affected. The economic loss to industry from this source cannot be estimated. 2. Patent Medicine Quackery.' — This is a more insidious form of quackery and often very difficult to cope with. An emploj^ee begins to lose weight and feels badly. He reads an advertisement 396 INDUSTRIAL MEDICINE AND SURGERY describing symptoms that correspond to his, or the corner druggist suggests that " swampy-root " or " S.S. " or some other patent medicine is just what he needs. Secure in the behef that this medicine will cure him he takes a vacation to' rest up and get in shape again. In spite of the four bottles of the medicine he has consumed he grows worse and finally returns to the city and consults the physician at the plant. Examination shows an advanced tuberculosis. If he had consulted a doctor in the beginning instead of an ''ad," or a druggist, the disease could have been discovered in its incipiency and cured. As it is the cure is now accomplished only after a great loss of time from work, or oftener he may not be cured at all. Such patent medicines, frequently containing a high percentage of potassium iodid, have been known to break down tubercles and cause a rapid spread of the disease. Many examples of the misplaced trust of patients in patent medicines, and even in drugs prescribed by physicians, are constantly brought to the attention of the medical staff of an industry. This leads up to the third type of quack. 3. The Non-examining, Non-diagnosing Type of Physician who prescribes drugs without knowing whether they are indicated or not. Many highly respected family physicians would be shocked to be placed in this category of "quacks." Yet is is hard to distinguish between some of their practices and those of qualified quacks. When an employee reports that he has been home for the last month on account of stomach trouble, taking three kinds of medicine from Dr. J., his family physician; when on careful inquiry you find that this doctor has never examined the patient; and, when your examina- tion reveals a pulmonary tuberculosis as the true condition, it is only human to condemn such a hit and miss method of prescribing drugs. One of the commonest examples of this type of quackery is the giving of medicine to a patient for "kidney trouble." The physician at the plant examines the urine but finds no sign of kidney disease. On inquiry he learns that the family physician has never even secured a specimen of the patient's urine. Frequently an employee reports to the office with a severe attack of appendicitis. He gives a history of having had a severe pain in his abdomen the night before. He went to his family doctor and was given some powders to relieve the pain and was ordered to take a dose of salts. No, the doctor did not examine him. When this physician is called on the phone and told that his patient has an acute appendix, he often replies, ''Well I was afraid that was the trouble last night." I never hesitate to frankly tell such a doctor that his neglect to examine the case, and the drugs which he prescribed, jeopardized his patient's life. Neither do I hesitate to take this MEDICAL TREATMENT OF EMPLOYEES 397 patient away from his doctor and either refer him to some competent surgeon, or, if he is not able to pay for proper service, to perform the operation myself free of charge. The examples of this blind treatment of disease without a thorough examination and diagnosis are so frequently bjought to the attention of the surgeon who is supervising the health of employees, that too much emphasis cannot be laid upon this treacherous and dishonest practice. Whenever such a case presents itself it is the duty of the plant surgeon to tell both the employee and his physician that examina- tions are essential to the proper treatment of disease. This frankness has been known to influence some family physicians to improve their standards. Every teacher of medicine should impress his students with this great need of proper diagnosis of every case before prescribing drugs. A state law providing for the thorough examination of every sick person by a physician before drugs are prescribed and further pro- viding that no kind of drugs can be dispensed except on the prescrip- tion of a physician, would be one of the greatest measures for the conservation of man-power which could be adopted. It would at once do away with "counter prescribing" by druggists, with the sale of patent medicines, and would eliminate the doctor who sits at his desk and hands out prescriptions or medicines with barely a glance at his patient. To-day with so many physicians in the army it behooves the government to take adequate steps to prevent the increase of quackery and of patent medicine sales which is bound to flourish because of the scarcity of competent medical men. This should be a war measure for health conservation. 4. Hernia Quacks. — In many cities there are so-called specialists who cure hernias by a bloodless operation. The men who patronize such quacks are most often met among employees in our industries. This operation as a rule consists of the injection of paraffin into the inguinal canal. I have later operated on a number of such cases. This form of treatment of hernia is a failure and a waste of the employee's money and every man with hernia should be warned against this method. 5. Belts, supports, braces, plates and other appliances make up another form of quackery which is frequently perpetrated on workmen as well as others. Too often after abdominal operations expensive belts are sold to these people who can ill afford this additional expense. Experience in hundreds of cases of abdominal operations has proven that only in exceptional instances are these belts needed. When used they tend to make the patients over-cautious about exercising or exerting themselves, and frequently prolong the length of dis- 398 INDUSTRIAL MEDICINE AND SURGERY ability, I have found a belt necessary in only two out of three hundred cases of herniotomy. The majority of surgeons would undoubtedly scorn accepting a commission for belts sold their patients, yet we all know that the prescribing of these post-operative belts is too often done for the 25 per cent, commission paid the surgeon or the hospital, instead of offering real service to the patient. The need for braces and supports should be carefully determined before a physician prescribes these expensive appliances. In a few cases employees have applied to the Employees Service department for a loan in order to buy some such appliance. The case is examined thoroughly by the plant physician and then the question of the need for this brace is taken up with the employee's doctor. Several times this has resulted in a saving to the employee of $40 or more for the apphance. Plates for flat-feet are often sold to people without any effort being made to correct the faulty type of shoes worn. Often these plates are bought on the suggestion of some shoe salesman or of a druggist*. In too many cases this is a needless expense as the type of plate bought does not correct the trouble. The useless expenditure of money by employees for these various appliances is one of the commonest conditions which the medical staff encounters. Electric belts, electric pads for the shoes, porous plasters, flannel jackets, chamois vests and innumerable other con- traptions come in this category of appliance quackery. A large mail order house, which installed this comprehensive system of health supervision of employees, including condemnation of all forms of quackery and of patent medicines, gives an excellent example of a concern ''practicing what it preaches." The writer was told to go over their drug catalogue and cross off every patent medicine and every appliance which they were selling which could in any way be detrimental, or of no value, to the buyer. As a result this concern dehberately ceased to sell patent medicines thereby cut- ting off profits amounting to $180,000 a year. It retained for sale only those drugs commonly used as household remedies such as castor oil, Epsom salts, soda bicarbonate, etc. If all manufacturers and retailers of the obnoxious types of patent medicines would voluntarily adopt such a principle the effect on the health of the nation would be incalculable. In the absence of voluntary action some legal action should be taken. The medical staff which is responsible for the supervision of the medical treatment of employees must in every case, first, determine if the best possible treatment is being given; second, if all adjuncts which will help hasten the patient's recovery are being used and if not, see that the concern provides these when the family cannot afford to do MEDICAL TREATMENT OF EMPLOYEES 399 so; third, if interference in the treatment of the case is necessary; fourth, advise the employees against the wrong Une of treatment, against quacks the use of patent medicines and all other forms of quackery; and fifth, use every means of educating the employees to a knowledge of what constitutes proper medical treatment. The employee who once learns this will demand more scientific care from his physician. WHAT CASES SHOULD BE TREATED? Granting that the medical staff of an industry is to refer all cases of sickness that rightfully belong to the family physician, then what cases should this staff treat? The real purpose of an industry in establishing an expensive med- ical system is to reduce the amount of sickness and injuries among its employees, and to reduce the amount of lost time from work to a minimum when these do occur. It is purely a business proposi- tion with them. However, due largely to the influence of their physi- cians, they recognize the claims of the family physician and the rights of employees to choose their own doctor. But in many cases better results are obtained and there is less financial loss to the concern if they take complete charge of the treat- ment. Again they feel that their responsibility toward the working force and society in general has a greater claim on them than the rights of any individual physician and for this reason they assume the care of certain types of cases. In other instances they demand that em- ployees undergo certain forms of treatment in order to improve their health and make them more efficient, and therefore it is the employer's duty to see that proper treatment is rendered them. As the medical staffs, by their work, have demonstrated the value of proper treatment in these various types of cases, it is only natural for the management to demand that this treatment be given. This is not written in defense of the practice but rather to show the pro- fession at large why it is done. 1. Treatment is given by the company surgeons to all injured employees when their work is responsible for the injury. The sur- geon, trained in emergency surgery, and responsible to the manage- ment for results, as a rule gives more active treatment, gets the em- ployee back on the job quicker, and strives to return him with the best possible restoration of function. The cost of this surgical care is less to the concern than if these cases went to outside surgeons. It has proven a good business proposition to the industry. A great number of employees are injured at home. Many would neglect the injury if compelled to pay a doctor's fee for the dressing of what seems to them a trivial wound. These cases can be treated 400 INDUSTRIAL MEDICINE AND SURGERY in the doctor's office and complications with loss of time from work avoided in many instances. 2. Employees with certain diseased conditions are dangerous to the rest of the working force. The tuberculous, the syphilitics, and those with acute contagious diseases are examples. Some concerns seek out these tuberculous employees and forbid them working in the plant. It would be an injustice to these sick employees, and to society at large, if they were discharged outright. Therefore these concerns have assumed the responsibility of giving such cases proper sanitorium care, paying all their expenses, and often providing an allowance to the family during the absence of the wage earner. No better safeguard to the public health of a community can be conceived, and certainly no family physician should object to the treatment of these cases. Most employers discharge all active venereal cases on the ground of protecting the old force. One or two concerns have adopted the same policy in these cases as for tuberculosis, and are providing proper treatment for them, while at the same time steps are taken to protect others from infection. Careful treatment combined with proper selected work, hastens their recovery and prevents compli- cations. This is a direct financial gain to the employer whereas the old plan meant undue loss of time or expensive labor turn-over. Close co-operation between the municipal health departments and the medical staff in the case of acute contagious diseases has resulted in better control and better care for these. 3. Employees with bad teeth, diseased tonsils, uncorrected defect- ive vision and many other conditions are often inefficient workers because of the undermining of their health. When these are found the medical staff offers to take care of them free of charge, or provides for their care by some specialist employed for the purpose. Often money is loaned to employees to pay for this service and the company dentist or the doctors arrange for some specialist in the community to give the necessary treatment at a stipulated fee, usually less than would ordinarily be charged. The correction of these conditions is good business on the part of the industry, and better results demand that the medical staff take charge or supervise this treatment. 4. In a large industry many employees will be found with conditions which are being neglected because of lack of funds to provide proper treatment. Many of these concerns have arrangements with hospitals whereby cheaper hospital care can be obtained. Such cases are there- fore sent to these hospitals and operated free of charge by the com- pany surgeon rather than sending them to the city or county hospitals for free treatment. 5. The types of medical cases requiring treatment which predomi- MEDICAL TREATMENT OF EMPLOYEES 401 nate are the minor ailments which develop while at work. The employee, after being examined and ruling out a more serious condi- tion, can often be relieved by prescribing some medicine and a few hours rest in the rest rooms provided for this purpose. Others must be sent home. Whenever medicine is prescribed for cases going home a statement as to the drug used should be sent with the patient for the family physician. 6. In certain industries there are specific diseases the direct result of the occupations, as for example lead poisoning, occupational dermatitis and furunculosis. These are treated by the company physicians the same as all accident cases, or at least should be. The treatment of these six different groups of cases combined with proper supervision over the treatment afforded by the family physi- cians make up the bulk of the remedial work which the medical staffs of most industries carry on. COMPLETE MEDICAL TREATMENT For many years we have had examples of the medical staffs of certain industries rendering all medical care to employees and to their families. This practice has chiefly been in vogue in the mining and lumbering companies of the west. It is also a common practice in northern Michigan. Practically all of these plans involved the payment of from $1 to $5 a year, by the employee, into the medical fund. This assured him free treatment for a, year. It also included free treatment for the family with the exception of certain operations and obstetrical cases for which a small additional charge was usually made. This type of practice in many instances was excellent. The best qualified surgeons took the positions and developed an efficient staff of assistants. Unfortunately in too many places the doctor tried to increase his income by cutting down on the number of assistants. It was impossible for him to render the most efficient, scientific treatment to the great number of people depending on him. A very mediocre form of medicine was practised. This lowered the reputa- tion of this form of contract work. Fortunately some of these concerns have awakened to the value of the best preventive measures combined with the best treatment. They have provided excellent hospital facilities and have very com- petent staffs. In such places the treatment afforded to the employees and their families is of the best. The old type of contract practice, which is condemned by all, is being eradicated by this new era of industrial medicine. The Brooklyn Rapid Transit Company affords an example of a concern that has adopted all the modern principles of industrial 26 402 INDUSTRIAL MEDICINE AND SURGERY medicine and surgery and has extended it to include free medical care for its employees. They claim that practically 95 per cent, of their people use their medical staff altogether and that time loss on account of sickness has been reduced to a large extent. Above all, they assert that these measures introduced for the welfare of their working force have paid the greatest dividends in increased loyalty on the part of em- ployees. As an example of loyalty the men of this concern were the only ones who refused to walk out during the street railway strike in Greater New York a few years ago. TYPES OF CASES CAUSING TIME LOSS The diseases which cause loss of time from work, and therefore need medical treatment, will vary considerably. In a plant where no health supervision has been conducted many more cases of chronic disease will be found. For instance tuberculosis made up from 1.5 per cent, to 2 per cent, of the total causes for lost time, whereas after several years of careful supervision this disease only accounted for 0.3 per cent, of the causes, in the author's experience. The reduction of lost time on account of heart disease after health supervision, proper selection of work, and adequate treatment is pro- vided for such employees, is a striking example of the benefits of this work. The minor ailments which cause loss of time are the most difficult to control. Nevertheless in these cases improvement in sanitary conditions, plenty of recreation for the employees, good water supply and the training of employees to drink plenty of water, educat- ing them to correct their diet and depend upon food rather than cathartics to keep their bowels active, and steps to prevent fatigue, have all caused a reduction in loss of time. In a working force of twelve thousand, divided approximately into five thousand girls and seven thousand men the annual time loss on account of sickness was estimated at six days per employee. There were fifteen thousand two hundred and forty-four cases of lost time from work among girls and six thousand four hundred and twenty cases of lost time among the men. The ailments which caused this lost time can be classed as minor and serious. The minor ailments were often undiagnosed, as the employees simply remained at home and on their return gave some in- definite symptom or homely diagnosis which they had made them- selves. These common, everyday bad feelings which you and I have, and for which a doctor is seldom consulted come under this group. The attached table is of interest as it shows the diseases in a large industry most responsible for time loss. MEDICAL TREATMENT OF EMPLOYEES 403 Table IL DISEASES CAUSING TIME LOSS Number of Employees Male 7,000 Female 5,000 Total 12,000 Cases of Lost Time Male . . . Female . 6,420 L5,244 Total 21,664 Minor conditions Female Per cent. Male Per cent. 1. Headache 2. Dysmenorrhea 3. Colds 4. "Grippe" 5. Tonsillitis 6. Nausea 7. Other stomach conditions 8. Nervousness 9. Neuralgias, myalgias and pains in joints. 10. Backache 11. Stiff neck 12. Eye conditions 13. Ear conditions 14. Fever 15. Diarrhea 16. Constipation 17. Fainting 3778 2935 2251 1354 974 750 403 355 188 153 99 172 102 110 130 92 132 24.0 18.9 14.0 08.0 06.0 04.8 02.6 02.3 01.3 01.0 00.6 01.2 00.6 00.7 00.8 00.6 00.8 1255 19.00 1313 956 883 203 331 42 123 111 30 56 36 107 74 41 13 20.40 14.80 13 . 70 03.10 05.00 00.60 '01.90 01.80 00.40 00.87 00.50 01.80 01.10 00.60 00.20 Serious conditions Female Per cent. Male Per cent. 18. Appendicitis 19. Bronchitis 20. Heart trouble 21. Kidney disease 22. Pleurisy 23. Pneumonia 24. Paralysis 25. Rheumatism 26. Anemic and generally run down . 27. Acute contagious diseases 28. Typhoid fever 29. Tuberculosis 30. Miscellaneous 48 27 8 4 9 2 1 90 34 32 1 19 1281 0.300 0.180 0.050 0.020 0.060 0.010 0.007 0.600 0.200 0.200 0.007 0.140 8.400 35 45 2 4 24 12 1 122 4 32 1 15 505 0.50 0.60 0.03 0.06 0.40 0.20 0.01 1.74 0.06 0.50 0.01 0.23 7.80 404 INDUSTRIAL MEDICINE AND SURGERY An industry with its large group of employees forms a great human laboratory— a veritable physician's paradise. Here he can study aU varieties of pathological conditions, every type of preventive measures and the best lines of treatment which will afford the quickest and surest results. He also gains an insight into those social and economic conditions which are constantly playing a greater part in all medical work. CHAPTER XXVIII / WOMEN m INDUSTRY THEIR EMPLOYMENT, SUPERVISION OF THEIR HEALTH, AND OTHER PROBLEMS The fact that a separate chapter is devoted to the problems related to women employees does not indicate that a different standard of health supervisio-n must be established for them. All that has been written in other chapters relative to industrial hygiene, physical examinations, treatment of disease and accidents — in fact, the entire field of industrial medicine, is applicable to women as well as men employees. Their employment in industry, however, presents a few problems which must receive special consi.deration. The present world war has focused public attention on, the question of woman's work as nothing else has ever done. In the pre-war days the women were employed in rather limited fields, every industry having certain positions which were recognized by men as rightfully belonging to them. Whenever an employer endeavored to place women on work carried on by the male employees labor troubles usually ensued. A few women were able to overcome these preju- dices and enter a broader field of endeavor, but the majority con- tinued to work on jobs suitable to their weaker strength and paying a wage far below that earned by the men. Many labor leaders to-day still contend that it is not necessary to extend the scope of woman's work, that the proper mobilization of man-power in this country would result in keeping production at a maximum. Nevertheless, as our millions of men are being absorbed by the army we see women taking up the work of these men and in most instances carrying on with equal, or even greater efficiency. England, France, Canada and other nations, have been forced to utilize women on occupations heretofore thought of only in connection with men. It is only logical to foresee that our country must do the same. In every nation the slogan "equal pay for equal work" has been adopted by the industries, and many of the old injustices toward women employees are being corrected. Exploitation of women in industry is becoming a thing of the past. This is truly a "War for Democracy." In many of our well organized industries, for years previous to the 405 406 INDUSTRIAL MEDICINE AND SURGERY war, the women employees have been enjoying comforts and con- veniences, every means for the protection of their health have been provided, and a good living wage has been paid to all. But in many other concerns, the most deplorable conditions existed and still exist. Let us make a comparison. The writer once worked in two different factories where great numbers of women were employed. One was a shoe factory, the other a glass factory. In both these the girls worked in the same rooms with the men. No effort was made to supervise the relationship between the sexes. Vile stories and obscene jokes were bandied back and forth, the foreman often taking the lead in these pastimes. Proper toilet facilities were unknown. Privies, one for men and one for women, but in close proximity, were in use and were filthy and unsanitary. I recall that the pits were so unprotected that a drunken man fell into one of these one night and was found dead the next morning. There were practically no washing facilities. Everybody, girls included, carried their lunches and ate them in the working places. When a girl became sick at work she usually had to stop for the day and go home, often walking a considerable distance. There was a cot in the corner where the girls kept their wraps, which could be used for resting purposes, but a rest room as we understand it to-day was unknown. One of these factories operating day and night employed a force of girls for the night shift also'. The use of suction fans or other means of removing the injurious dusts was unheard of. Only the poor girls who had to work could have endured such conditions. And the wages they received for ten hours' work were far below those paid the men. It was such standards as these that caused the gkl who must work to lose caste. Humane employers who im- proved the working places for our girls and protected them against those influences which undermined their moral and physical well- being were great benefactors to the race. Some ranks in society still retain their early impressions of the girl who must work. For men to work is honorable. Work is just as "honorable for women. And to-day all classes of women, from the poor who must work to the rich who work for patriotic reasons, are entering all kinds of industrial occupations. New standards are being set and a new viewpoint is being obtained by society concerning woman's work. Compare with the conditions in the two factories described above the conditions in factories in England to-day. We are told that modern factories have been built in England to produce many of the essentials for war;, and that if these factories were joined together they would make a building twenty-five miles long and forty feet in width. WOMEN IN INDUSTRY 407 Women make up a large proportion of their working forces. Partly to induce women to work, and partly because they found that such things helped production, these factories are equipped with everything which will add to the comfort, convenience and health of the employees. Men and women work in the closest proximity. But in each depart- ment there is an intelligent forelady whose character and personality is such that she is a constant stimulus for good. The moral standards in these industries are of the highest. Women are honored and re- spected just as much, although they must often dress in trousers in order to do men's work. Fig. 54.- -Every industrial sanitary measure has been provided in these new working laomes in England. The sanitary conditions of these plants have been perfected to the highest degree possible. Every method for the protection of the employees, both male and female, against the dangerous poisons found in munition work and all other occupational diseases have been provided. Every modern washing and toilet facility has been installed. Restaurants and canteens are a definite part of the organization. Comfort rooms where the girls can lie down and rest when neces- sary, and where they can go to relax during the noon hour and rest periods is now recognized as one of the most important provisions in the working place. Arrangements have been made for suitable homes for all employees, and when girls must room, the management has 408 INDUSTRIAL MEDICINE AND SURGERY supervised the selection of these rooming places. Many concerns have provided dormitories for their girls. Suitable recreation for the employees is now a definite part of all programs seeking to improve the conditions of the working force. The communities have entered into this angle of war work and provide all kinds of entertainments for the girls similar to our entertainments for the soldier boys. The question of hours of labor has been settled in England because it was essential to find the best solution of this problem in terms of maximum production. That country found the greatest output ob- FiG. 55.- -A good forelady makes segregation of men and women employees unnecessary. tained when the standard of eight hour shifts was adopted. This has even been divided so that employees work two hours, rest fifteen minutes; work two hours, thirty minutes for lunch; work two hours, fifteen minutes rest; work one hour and quit. Not only is such a standard good for girls but it produces the best results when applied to men. England was not always thus kindly toward her women employees. The same deplorable exploitation of women workers existed there as has existed in this country. But the need for greater production for war purposes, and the presence of many women who demanded better conditions, forced both employers and the government to adopt those measures which both Industrial Medicine and Industrial Engineering have been urging for years. WOMEN IN INDUSTRY 409 England will never go back to the old conditions. To-day the women in America who are so gallantly taking their places in the industrial army are unconsciously forcing many changes in our working conditions. Social and economic improvements are being advanced fifty, yes, a hundred years under the stress of war. America will never go back to the old conditions. Many individuals, committees, organizations, and government agencies have been concentrating their studies and efforts on this problem of "women in industry" since our country entered the war. The reports of all these bodies should be bound and given to every employer throughout the land and if he is wise he would read them as faithfully as he should read his bible. If he has a keen business sense he would learn his lesson. Every physician in industrial practice should hkewise become familiar with these reports if he desires to keep up with the rapid advancements which are taking place these days. Two of the most valuable contributions on this subject are, " Women in Industry" by Mr. C. E. Knoeffel, which can be obtained from the Society of Industrial Engineers; and "War-time Employment of Women in the Metal Trades" published by the National Industrial Conference Board, 15 Beacon Street, Boston, Massachusetts. That the industries of America will meet this problem of emploj^- ment of women as thoroughly as England has done is indicated by the following report of a committee on Standards appointed by the Standard Practice Executive's Club of Detroit, Michigan, which repre- sents forty different concerns : "In order to protect the women who may enter industry at our solicitation and to provide for them fair working conditions, the Com- mittee on Standards of Working Conditions submits the following recommendation : "l. That the Recruiting Committee investigate the applications from married women with children to ascertain if the children are properly cared for. Results of investigations to be filed with the Central Bureau. ''2. That women be given equal pay for equal work. While learn- ing they shall be paid the flat day rate paid men for the same work or operation. This recommendation has the endorsement of the Detroit Division of the Women's Committee of the Council of National Defense, as they passed a resolution to this effect on May 14, 1917. The committee understands that the Buick Motor Car Company, of Flint, Michigan, is at present paying women on this basis. "3. Because of the experience of England, where it was found that shorter hours resulted in more and better work, we suggest that the working day for women be limited to eight hours and that the maxi- mum weekly hours be limited to forty-eight. 410 INDUSTRIAL MEDICINE AND SURGERY "4. That the following working conditions are essential: " (a) Separate entrances to be provided for women if practicable; if not, that women be allowed to report for work fifteen minutes later than men and leave fifteen minutes earlier. " (h) That separate workshops be provided if possible; if not, that there be both a man and woman supervisor stationed in the mixed departments. '' (c) That rest rooms and toilets adjoining workshops be provided with a matron in charge. " (d) That a sufficient number of drinking fountains be installed in each department. '' (e) That the period for lunch be at least forty-five minutes. " (/) That if possible a restaurant be operated on the premises; if not, at least a counter maintained where a box lunch with hot coffee and tea and milk can be purchased at cost. *' (g) That provision be made for rest periods during working hours, their frequency and duration depending on the nature of the work. " (h) That seats be provided wherever possible to avoid injury to women by standing all day at their work. " (i) That sickness insurance be provided to care for workers absent because of sickness. " (j) That workers on monotonous and tedious operations, to avoid undue fatigue, be transferred from time to time as seems advisable. " (k) That there shall be provision for first aid attention to all workers. " (l) That there be first class supervision of working conditions with particular reference to safety, sanitation, ventilation and lighting. "(m) That some person be delegated to act as welfare supervisor for the plant, to whom women shall have access and whose duty it shall be to have general oversight over welfare conditions. This position might be given to some woman already in the employ of the company, in addition to her other duties, but if possible a trained person should be secured for this work. "In setting up these standards the committee feels that its work would be useless and ineffective unless a permanent committee was appointed by the executives to investigate working conditions in each plant employing women to be recruited by the special committee organized for the purpose. Such a committee should not only make an investigation before placing the women, but should further make periodic visits to ascertain if the standards are being maintained according •to agreement. Since it is almost impossible to set standards for first aid and safety provisions, without an intimate knowledge of the size and kind of plant and hazard of the work, we deem it advisable that this permanent inspection committee treat each plant individually WOMEN IN INDUSTRY 411 adjusting requirements in each case according to the conditions found on visitation. ''It is further believed that a physical examination should he made of each applicant." Every physician familiar with the occupational hazards to health that exist in industries realizes that the methods of prevention of many occupational diseases have not yet been perfected. Most of these diseases have been studied from their effect on men. With women entering these new fields new problems will undoubtedly be presented. Lead poisoning is known to be more injurious to women than to men. Will not the same be found true of other occupational poisonings? Industrial accidents have been more common among the male employees but this is due to the more hazardous occupations they have been engaged in. With women entering these new jobs the accident rate is bound to increase. The fact that they are "green" at the work will be an etiological factor in increased injuries. Is it not possible that complications following these injuries will be more serious and more prevalent? These and many other problems will follow the employment of women in men's work. While the management and the lay forces are preparing to increase the comforts and conveniences and other- wise improve working conditions so that women can be employed, the medical staffs of these industries must become more rigid in their efforts to supervise the health of these workers. The doctor must carefully study the effect of every new occupation upon women work- ers and determine as soon as possible what jobs they are fitted for and what jobs they must be absolutely barred from. The future of the race depends upon these women. No war emer- gency must allow the wastage of our woman-power else defeat will ultimately be ours. A new responsibility rests upon the physician in industry because of the increased activities of the women workers. Women have always been employed in many occupations where medical supervision was indicated but where it did not exist. The small employer has used his women on work entirely too arduous for them. The heavy farm work which many women used to perform has been responsible for thousands of premature deaths. What workers needed more careful supervision, or provisions for then' comfort and welfare, than the hard working scrub women slaving every night, in wet and filth, in our large office buildings in the cities? Veiy little attention has been paid to their home condition^, to the hours of labor which they must work. Every medical dispensary has known this prematurely old woman, broken in health, but very few doctors have sought the source of her trouble in her occupation. So, during this first year of war, we have witnessed women enter- 412 INDUSTRIAL MEDICINE AND SURGERY ing many positions where medical supervision is unknown. Con- ductors on street cars, elevator operators with long, closely confined hours, janitor work, railway section hands, loading of junk, coal, coke and other material on flat cars, piling of lumber, firing stationary boilers, working in machine shops, and shoe stores, in cellar and lofts, these are some of the new occupations which these pioneer women workers in men's jobs have entered. Fig. 56. — Women have replaced men in many occupations in the munition factories. Can they stand the work; what are its hazards for them; what of the factor of fatigue and other conditions which will predispose to sickness? How are we to answer these problems without the most careful medical supervision? The time has arrived when our federal government must demand the most thorough supervision of the health of all workers— men and women. After one year of war the nation has learned that this great industrial army is just as essential to the winning of the war as our military army. The men and women in this second line of defense must be medically supervised, furnished with the adequate medical WOMEN IN INDUSTRY 413 and surgical care when necessary, and otherwise conserved the same as the first hne of defense. In those industries where medical departments are maintained they should not be disrupted by the demand for physicians in the army. But such industrial clinics should be extended and made a center for medical supervision of all workers in that neighborhood. For those industries where no medical supervision has been in vogue and for the employees in small concerns, and on the isolated jobs, there must be established industrial clinics in every community where employees must be forced to report for proper supervision. Other physicians must be placed in the field as inspectors to supervise the working conditions. All the recognized essential features of industrial medicine must be summoned for the protection of this industrial army, and especially for the protection cf the women who are braving these unknown dangers to help win the war. A federal plan of public health service is the only solution of these and the other health problems confronting our civil population to-day. With the medical forces of the nation so depleted by the demands of the army provisions must be made to utilize to the greatest advantage the remaining civilian physicians. The prevention of disease and accidents among the industrial employees of the country and their families will reduce the amount of curative medicine which must be practised. The medical forces of the country must be mobilized there- fore and a certain percentage of the physicians must be ordered to duty in the industrial army. Prevention must become the slogan of the medical profession. Choosing Occupations for Women Already women workers have upset our preconceived ideas of what jobs they are capable of holding. Throwing off the hampering in- fluences of sex and inexperience woman has stepped forth into the fields of work hitherto belonging only to the realm of man. From every source testimony is coming that she is making good. But this new freedom must be controlled. She must not be allowed to enter work which in time will destroy her or mean a premature breakdown. Therefore every woman worker should receive a careful physical examination and the occupation should then be chosen according to her physical qualifications. In every case the question of whether she is physically and mentally fit to do the work and whether the occupation will be unduly hazardous for her must be answered. Some have suggested that a survey should at once be made of all positions available for women and then a board should decide which of these jobs she could enter and from which she must be debarred. This boaYd might lay down some general principles on this subject 414 INDUSTRIAL MEDICINE AND SURGERY but the real selection of proper occupations can only be made by con- sidering each individual case as she presents herself. Some women will be found perfectly able to enter occupations requiring heavy lifting or constant standing, while others must be assigned to seden- tary work only. The Physical Examination How thoroughly should this examination be made? There is no question but that women should be examined from head to foot, the same as men are examined; a complete analysis cannot be made in any other way. But to do this women physicians must be employed and the number of these is not sufficient to meet the demand. One large industry employed two women physicians and subjected every girl employee to a complete examination. For three years they kept careful records of these examinations. The number of pathological conditions discovered by this thorough system were only slightly more than those found by the partial examinations in other concerns. They have since discarded the method as it was very dis- tasteful to their girl employees. The conditions usually found in healthy males by examining below the waist are hernia; venereal disease; hydrocele, varicocele and undescended testicle; varicosities, deformities of the extremities; flat-feet and other foot conditions. Remember most employees ex- amined are apparently healthy and the examination is not made for the purpose of discovering some acute disease. The proportion of these conditions found by examining women below the waist are small compared with men. Hernia is rare in women — even the femoral type which is the commonest form found in this sex. Dr. Schereschewsky states that he found one hernia in five hun- dred examinations of female garment workers. In two thousand examinations of girl employees, where the history of the case indicated a more thorough examination, the author found three femoral and one inguinal hernia. In five hundred consecutive examinations in a gynecological dispensary the author found only five femoral or in- guinal hernias whereas umbilical and ventral hernia were common. These were chiefly found in older women who had borne children. Therefore the need of examining female employees for hernia is not sufficient to warrant subjecting them to the naked examination. Questioning as to whether they have a lump or swelling in the groin will usually be answered in the affirmative by a woman em- ployee if a hernia does exist. Venereal disease is often hard to detect in women. I have been told by the physician in charge of the work in the concern referred WOMEN IN INDUSTRY 415 to above that the percentage of venereal cases found by their complete examinations were very few. In our clinic we have discovered cases of syphilis among the girl employees but this was done by the detection of mucous patches in the throat or the rash on the body. Varicose veins are common among older women -or among the married women who apply for work. These do not object to the physician examining their extremities. But the average girl employee has been protected from the type of occupations which have made varicosities more prevalent among the male workers. Flat-feet and other foot deformities can often be detected by the gait of the employee. As girls have been employed on sedentary occupations, sitting most of the time, it has not been so important to examine their feet. But in our clinic questions have been asked concerning foot troubles and when indicated they have been examined. Because of the rarity of conditions found below the waist Hne, influencing woman's fitness for work, most physicians in industry have limited their examinations to the head, neck and chest coupled with a careful history in each case which develops the need for a more complete examination in certain cases. This partial examination can be made by a male physician, always, however, in the presence of a nurse. In order to make sure that a nurse was always present and to safeguard the physician in case some employee raised a disagreeable question. Dr. A. M. Harvey initiated the plan of having the nurse initial every examination record in the presence of the woman just examined. For years the author had no woman physician on his staff in a plant where approximately 5000 girls were employed and were fre- quently examined. There was seldom an objection raised to one of the male physicians examining a girl. All abdominal examinations were made by either the chief of staff or his first assistant. Girls needing this more thorough examination were referred to the chief nurse who explained how and why it was made and then prepared the girl. She covered the girl's body with a sheet and the doctor was then called into the room. He was very careful not to unduly expose the girl, examining by moving the sheet slightly to one side. No girl was ever unnecessarily embarrassed and she usually explained to her friends how considerate the doctor had been. Vaginal examinations were never made except when the history or symptoms indicated the need. In married women these were done as described for abdominal examinations. In the case of single girls they were told by the chief nurse of the need and were asked to bring their mother next day, or a note giving her consent, when the chief surgeon would make the regional examination. Usually if a girl had never been examined vaginally she reported with her mother 416 INDUSTRIAL MEDICINE AND SURGERY or a close friend to the hospital in the city where the surgeon made the examination under a light gas anesthetic. This facilitated the examination and relieved the girl of the embarrassment. New physicians, fresh from hospital or dispensary practices, enter- ing this field for the first time will often make the mistake of handling these cases as so much material for study. They will order a girl to submit to a regional examination as though she was a dispensary patient (a practice which should likewise be condemned). They are even careless about unduly exposing her. Such methods will always place the doctor in a wrong light before these employees and will soon destroy the usefulness of the doctor's office. In fact such methods should not be tolerated in a dispensary. My first advice to every new assistant is, "handle every case as though a hundred dollar fee was at stake." When a lady physician was finally employed on my staff she had considerable difficulty in gaining the girls' confidence. Often they insisted on one of the male physicians making the examination. However, this doctor because of her skill and her wonderful person- ality won a place for herself in the hearts of all the girls, which makes her services invaluable now. Whenever a competent, diplomatic woman physician can be employed for the examination of girl em- ployees the same should be done. The professional standards should never be lowered, however, just to employ a woman doctor and certainly never in the case of your male physician. Men or women who have not sufficient training to make a good income at the practice of medicine should never be employed in industry just because they can be obtained at a cheap salary. The routine examination of girl employees should be done as follows: 1. Secure careful history by the nurse. Only the positive points need be recorded. 2. Nurse takes temperature, pulse, weight and height and tests the vision by Snellen method. Records these findings on the card. 3. Girl is then taken to lavatory (best if next to dressing room) and a specimen of urine is obtained. This is placed in a compartment basket with other specimens, duly marked, and carried to the labora- tory for analysis. 4. Girl removes waist and under vest and is covered with a cape made from a sheet. 5. She then goes into the adjoining room, where the doctor and nurse remain constantly, and is examined. As there is no undue exposure of these girls two can be waiting while the doctor is examin- ing one; a sheet suspended between the waiting girls and the one being examined will add to the privacy. WOMEN IN INDUSTRY 417 The cape worn by these girls (see Fig. 57) has a large neck opening and can be pulled down over either breast for the purposes of examina- tion, the other breast remaining covered. Either side of the back can be similarly examined. The sides of the chest can be examined through the side openings of the cape. This permits of examining the entire chest as far as the waist hne without exposing any large area at one time. The nurse who is present moves the cape for the doctor. This examination consists of (a) reading nurse's findings on the his- tory card and also urinalysis; (h) examining eyes, nose, teeth, tonsils "e-a,rT.-9>^ m Fig. 57. — Illustrating type of cape used to cover chest of girls during physical examination. and pharynx; (c) palpating glands of neck and thyroid; (d) examining heart by auscultation (palpation, percussion and blood-pressure are only done when some indication is found) ; (e) percussing lungs and then ex- aminmg by auscultation; (/) recording all findings on history card. While examining the lungs and heart both breasts can be inspected for suspicious swellings and the girl questioned about these. When indicated the breasts should be thoroughly palpated — usually through the thin cape. While the nurse is standing over the girl she can carefully inspect the hair and if signs of pediculosis are present 27 418 INDUSTRIAL MEDICINE AND SURGERY she will then thoroughly examine the employee. Many cases of pediculosis have been discovered by this method. The doctor asks questions regarding abdominal and extremity conditions. If in the examination, history or the urinalysis show the need of a more complete examination she is referred to the chief nurse. In questionable cases the chief of staff is called into the examining room at once for consultation. Many girls have an anemic appearance and these should always be referred to the laboratory for a blood count. Those with bad teeth are referred to the dentist. Defective vision cases are sent to the eye specialist and proper glasses fitted or other corrections made. Fig. 58.— Examining a girl applicant for work. Note how cape covers the chest, also that nurse is present. In the routine examination room all that is needed is a stool for the doctor, a piano stool for the girl being examined (this facilitates her turning around quickly), a chair for the nurse, and a table by the side of the doctor for his instruments, and for writing purposes. All necessary appHances should be arranged close at hand for the doctor, namely his stethoscope, wooden tongue depressors, which are used only once, the nasal speculum and the blood-pressure outfit. Many of these girls are found with conditions which need careful study, or further examination. They are told to report for re-exami- nations and the time and type of examination needed is recorded on their cards. The record room keeps a tickler system on all such cases and makes sure that they report. This same plan is used for the men. When drugs are necessary to relieve symptoms or conditions a note to this effect is made on the history cards and the nurse sees that these girls are sent to the drug room where a nurse gives the medi- cine needed. Prescribing of drugs has been reduced to a minimum. WOMEN IN INDUSTRY 419 Which Girl Employees are Examined? All girl applicants for work should be examined for the same reasons set forth in the chapter on examination of applicants for work, namely, proper physical selection for the work and protection of old force from contagious diseases. The type of work the employ- ment department intends to employ the girl on should always be shown on her history card so that the doctor can size up her physical qualifications with this work in mind. Girls who later are to be tran."?- ferred to an altogether different occupation should be re-examined. Girls taken sick while at work should come to the doctor's office for a pass home. Their case should then be carefully analyzed and when indicated an examination should be made. Likewise, many girls will report to the oflfice sick who can be later returned to work by a few hours rest in the rest room. Many of these must be examined. On returning to work after an illness employees must report to the office for a pass back to work. Those whose history indicates the need should be examined. In a large industry this plan may cause much lost time from work due to the congestion in the doctor's office from so many reporting, and the long distance between the office and some departments. To obviate this loss a number of substations have been provided in various parts of the plant with a nurse in charge. The employees, especially the girls, can report to these for their passes. Most of the girls have been absent one or two days on account of some minor ailment and these can be sent direct to work by the nurse. Others the nurse will send to the doctor's office for examination before the pass is issued. All women employed in fatiguing occupations or hazardous work from the standpoint of occupational poisonings, should be periodic- ally examined. This is one of the most important features of proper health supervision. Rest Rooms Wherever women are employed clean, airy rest rooms removed from excessive noises should be provided. They should be furnished with single beds, instead of hard cots, with clean pillow and sheets and warm blankets. A nurse or some qualified matron should always be in charge. Screens should separate the beds so as to furnish privacy to each girl. Talking and other noises should be prohibited. The room should be kept cool and well ventilated. Its very appearance should be restful. In the author's early experience the rest room was a dark back room of the doctor's office. Hard cots, provided only with a blanket under and over the girl, afforded the means for rest. When a sick girl reported to the office and the nurse suggested that she lie do^Ti in 420 INDUSTRIAL MEDICINE AND SURGERY the rest room instead of going home she refused oftener than accepted the invitation. It was only an emergency room used by the girls when too sick to refuse. Later this concern provided a large, airy room furnished with beds as described above. The girls with temporary sickness would report to the office and were always glad to go to the rest room, remove only their shoes, or perhaps loosen their skirts and corsets and crawl in between the clean sheets and under the warm blankets. The nurse would then bring them a hot water bottle and often a hot drink. Many were given a glass of malted milk or a cup of hot tea. After an hour or so these girls would feel better and would return to work (Fig. 59) . Fig. 59. — Rest room for women employees. Nurse always in charge. (From Doctor's Office, Sears, Roebuck & Co.) In the old days girls who had fainted, had severe cramps with their periods, had headaches, nausea, diarrhea, pain in their side, or other minor ailment, usually went home losing the greater portion of the day and often longer because the exertion of going home had made the condition worse. With this new rest room these girls were restored to work in a short time, and often more serious conditions were aborted. No greater efficiency measure can be installed by a concern than a properly located, adequately equipped rest room. Sitting Positions and Rest Periods Most state laws now require that women shall be furnished seats while at work. None of these laws seemed to take into account the deleterious effect of this constant sitting. Our good law makers seemed to think they had met their obligations toward those of the gentler sex, who must work, by gallantly providing them seats. Constant standing is undoubtedly fatiguing tomost women workers, WOMEN IN INDUSTRY 421 but of the two evils constant sitting is the worse. The congestion of the pelvic organs by this practice, and the tendency toward con- stipation because of lack of exercise, causes many pathological con- ditions to develop in the generative organs of women. The congestion and constipation also tend to develop hemorrhoids. Backaches, pains in the legs and many ill-feelings can be traced to constant sitting. The ideal work for woman will enable her to stand part time and sit part time. If she can move about while at work it is even better. In the departments where the work permits this I have found at least 50 per cent, less absenteeism on account of dysmenorrhea than in those departments where the girls sat constantly at their work. Fainting, nervousness and signs of fatigue were also less. Even before state laws demanded it, many occupations for girls necessitated constant sitting. For these, and in fact for all workers, rest periods should be provided. Ten or fifteen minutes in the middle of the morning, and the same time in the middle of the afternoon furnish these workers the opportunity to walk about, relax from the tension of work, do their visiting and gossiping and get rid of the stored up products of fatigue. The windows of the working room should be opened up during such a period, and marching, calisthenics, games and other forms of exercise indulged in. Music at these periods from a victrola will stimulate dancing, and that in itself is restful. The f orelady should devise means to make these rest periods of the greatest benefit to the girls. Clothing The new occupations women are entering are having a marked influence on their manner of dress. Overalls and trousers are common wearing apparel for many women workers to-day. Common sense, thick soled low heeled shoes are necessary in many of these positions. If this influence will extend to her sisters in the ordinary occupations of woman great benefits and increased efficiency will result. The constant sitting regulations were largely necessary because of the illogical shoes girls wear when working. It is obvious that the high Cuban or French heel, with the thin turned sole, or the low pumps, were never made to work in, especially if the work require standing. If women can be persuaded to wear shoes modelled after those recommended for soldiers they will develop strong feet and will be able to qualify for many more positions than have been opened to them in industry in the past. The high heeled shoe, loose skirts, flowing sleeves and other peculiarities of dress are hazardous in occupations about machinery, tending to increase the accident rate. 422 INDUSTRIAL MEDICINE AND SURGERY In departments where men and girls work together great difficulties in ventilation are presented during the winter months, because of the flimsy waists worn by girls. They are easily chilled when a window is opened and demand more heat than is wholesome in the departments. One of the best services the nurses or the woman advisor or welfare worker can render- to a concern is to correct these faulty dress habits among the girl employees. Food Every employee should get out of the working room for the lunch hour, during which time it should be thoroughly aired out. This is especially appHcable where girls in sedentary occupations are employed. A cafeteria or restaurant should be provided where warm, whole- some food can be obtained. If the number of employees does not warrant this then some suitable place for the eating of lunches should be provided. Here hot tea or coffee or soup should be sold at a small price. Drinking and Toilet Facilities Every recommendation for improving the hygienic conditions of the working place made in other chapters should be adopted wherever girls are employed. Special mention is made here of the drinking and toilet facilities because there is a tendency to neglect their importance. When employees are engaged on piece work, and especially in the case of girls, one often finds that insufficient water is consumed and the requirements of nature are neglected. The girls will simply not lose the money involved by taking time off for these things. The only solution for this is that the employer will give ample time, without loss to the employee, to attend to these essentials. Bubbling fountains should be located near the working places and every employee should be thoroughly educated in the importance of water drinking. No better remedy is at hand for the prevention of fatigue than frequent flushings of the body organs by water. For every hundred girl employees there should be provided close at hand at least five toilets. The toilet rooms should be kept clean and well ventilated. Washing facilities should be in the room, or an adjoining room. Receptacles for refuse are necessary. Means for obtaining sanitary napkins should always be present in these rooms. Minor Diseases Common to "Women Employees From an analysis of 15,244 cases of absence on account of sickness (see Chapter XXVII) the author found that headaches caused 24 per WOMEN IN INDUSTRY 423 cent, of the absenteeism. Headaches are more common among girls than men and cause a great loss to every concern employing girls. The plant doctor should make a careful study of every case to ascertain the cause. The condition is usually indicative of some other trouble, the correction of which will stop this drain on efficiency. Constipation is present in many cases and the cessation of head- aches on curing this condition is a common result. Diseased tonsils, defective teeth, and other foci of infection about the nose and throat, as well as defective vision, are frequently the source of headaches- These should be carefully examined, the teeth even being x-rayed and any infected foci removed. Glasses should be provided whenever needed. The author has operated free of charge over one hundred cases of infected tonsils in order to relieve employees of headaches and thus improve their value to the concern. Over a thousand cases of defective teeth have been corrected for the same purpose and has resulted in at least 50 per cent, of the cases being relieved. Fatigue poisoning, faulty diet especially at the lunch hour, insuf- ficient water drinking, night work at home and many other conditions either in their work, in their living conditions or in their bodies, have been found as the cause of headaches. The physician will find that in a large percentage of the cases he can run the cause to earth by diligently studying all possible sources. The value of this work to the employer cannot be estimated, but must result in great financial saving in labor tutn-over and great gains in output. Dysmenorrhea came second in the causes for absences, 18.9 per cent. This condition as a cause for reducing eflaciency and making irregular attendance at work has not received sufficient attention from the medical profession. The subject is dealt with in detail further on in this chapter. Rest periods, with relief from constant sitting, the urging of plenty of outdoor exercise, the relieving of constipation by proper diet, and a suitable rest room for a few hours rest when the period starts, have all resulted in a decrease in this cause of absence. Here again the doctor's ingenuity will be tested in finding the cause of the trouble. Colds ranked third, or 14 per cent., in the causes of absence. This condition was 20.4 per cent, of the causes among men. It is a very difficult condition to control and is undoubtedly infectious. As- sociated with it are mild forms of tonsilhtis and other respiratory infections. It is much better to send employees with colds home than to leave them in the department to spread the disease. But employees with mild ''colds" will not report to the doctor's oflSce remaining in the department as sources of infection to others. Educational propaganda on the infectious nature of "colds," "grippe," and tonsillitis will help reduce this source of absenteeism. 424 INDUSTRIAL MEDICINE AND SURGERY The following "Don'ts" should be spread by letters, pamphlets, bulletin boards and other means throughout the working force: 1. Colds, grippe, tonsillitis and often causes of coughs are infectious and you can spread these to your fellow workers. 2. DonH continue to work when you have these but report to the doctor at once. 3. Don't talk, sneeze, or cough into another person's face especially when you have a cold. 4. Don't jerk your handkerchief from your pocket and carelessly shake it before or after using. 5. Don't sneeze or cough without covering your mouth with a handkerchief. 6. Don't spit on the floor. 7. Don't use a common towel, drinking cup, utensils or anything that might be the means of spreading your cold to others. 8. Don't put pencils, pens, envelopes or like things in your mouth. If you haven't a cold maybe the other fellow had. 9. Don't fail to report to the doctor early. Colds can often be stopped by proper early treatment. All employees reporting to the office on account of these respiratory conditions must be scrutinized thoroughly to discover if he has this contagious type. The temperature will often be 99^° to 100° while the employee insists "outside of a bad cold I am well and able to work. " Those with temperature should always be sent home. The throat which is inflamed, often covered with very small pearly papules, is suggestive of this so-called grippe. A severe headache and aching all over associated with a slight sore throat or a "cold" is sufficient evidence to warrant sending the employee home to protect the old force. Often painting the nose and throat with a 10 per cent, solution of argyrol or using an alkaline spray and repeating it several times during the day, with hot drinks, combined with a few hours rest in the rest room, the bed being isolated and thoroughly cleaned after- ward, win serve to abort these "colds." When an employee, who is hardly sick enough to call his or her doctor, is sent home instructions such as the following should be given : 1. Go home and rest. 2. Take a hot bath and a hot lemonade. 3. Take a dose of salts or castor oil. 4. Go to bed and cover up warmly. 5. Gargle a solution of one teaspoonful of baking soda (Soda Bicarbonate) to a glass of water every two hours. 6. Drink plenty of water ; also drink a hot lemonade every 2 hours containing the following: WOMEN IN INDUSTRY 425 Baking soda 1 oz. Cream of tartar 1 teaspoonful Sugar f^ oz. Lemon juice 1 oz. Hot water 1 pint 7. If the cold has disappeared after twenty-four hours you can report to the doctor's office — otherwise you should summon your family physician. Many a serious illness with prolonged disability has been aborted by these methods. The plant physician should ever be on his guard against these epidemics of "colds" or so-called "grippe" which have frequently disrupted the working forces in many industries. Grippe and tonsillitis made up 8 per cent, and 6 per cent, of the causes for disability among the girls and 14.8 per cent, and 13.7 per cent, of the causes among the men. Thus "colds" and these two conditions rank higher in the causes for absence than any other minor ailments. Stomach trouble, nausea and cramps, and pain in the side cause considerable of the lost time from work. Girls will get up in the morning and because they "don't feel like it" or because they are late will rush off to work without eating. About the middle of the morning they become weak, sick at their stomach and are forced to report to the doctor's office. Many of these can be relieved and sent back to work. Often a little food or a glass of malted milk is the best treatment you can render. These stomach conditions, fainting, and nervousness are the com- monest manifestations of fatigue. When a girl reports three or four times with these conditions a careful investigation of her working conditions will usually reveal the cause. Constipation. — Constipation is one of the commonest complaints among girl employees and undoubtedly plays a very important part in the minor illnesses which cause short periods of lost time from work. In over a thousand consecutive records of working girls, ap- proximately 33 per cent, give a history of constipation and at least 20 per cent, of these were more or less habitually constipated. The cathartic habit among girls is more extensive than would generally be believed. This is especially true among the foreign element and the less educated, and is undoubtedly stimulated by the extensive advertisements of various kinds of laxatives in foreign and cheaper newspapers. Girl employees are more prone to use the doctor's office than are the men and one of the most frequent causes for their visits is con- stipation. The easiest way for the doctor to handle these cases is to give them a Seidlitz powder or a pill but such a method will only 426 INDUSTRIAL MEDICINE AND SURGERY serve to increase the trouble. For several years I have met this prob- lem by giving every employee who complains of constipation, a printed diet sheet containing anticonstipation foods which could readily be purchased at the restaurant, could be carried in the lunch basket, and which could be served at home. In addition each case was given a prescription for a fruit mixture as follows: Figs M lb. Dates M lb. Seedless raisins ^ lb. Cooked prunes yi lb. Senna leaves 3^ oz. Grind through a meat chopper or chop up finely, mold into a loaf and keep in a cool place. Take one or two teaspoonfuls every night. In one department employing twenty girls, I found that 70 per cent, of these suffered from constipation and approximately 50 per cent, had dysmenorrhea. Efforts to overcome these two conditions were concentrated on this group. The forelady secured a table in a res- taurant where they could all eat together and insisted on the mana- ger of the restaurant serving the girls with at least two of the articles mentioned in the constipation diet list. She also saw that the girls made up the fruit mixture and used it. In addition, they were stimulated to take plenty of exercise outside of working hours. With- in one month the constipation was completely overcome in every case, and within three months the ten girls who had been accustomed to report to the rest room for their sick time or to remain away from their work for a day, ceased this practice. Proper diet, sufficient exercise and considerable educational propaganda a ainst the habit of taking cathartics will decrease the amount of constipation among all employees to a marked extent. Such efforts are of the greatest economic value to the industry. Dysmenorrhea. — Among concerns employing great numbers of girls, this condition of painful menstruation causes an incalculable loss of time from work and decreased efficiency before and after as well as during the periods. The causes of this condition are many. A small percentage are due to anatomical displacements or some pathological change in the generative organs. The majority of the cases, however, are traceable to other conditions more or less remote from the pelvis. Of these, con- stipation, and the conditions predisposing to this, such as improper food, lack of exercise, etc., is the commonest cause. A few years ago, many state legislatures endeavored to improve health conditions among working girls by enacting laws making it necessary for them to sit while at work. In my opinion constant sitting during the long WOMEN IN INDUSTRY 427 working hours is as bad, if not worse, than constant standing. This sitting posture causes more or less congestion of the pelvic organs which is increased by constipation so often associated with constant sitting. If girls could be persuaded to dress properly and then could be gradually trained to standing and walking for several hours, much healthier employment could be found for them than the sedentary occupations to which they are now condemned, chiefly by legislature. Under the existing conditions, occupations which allow part time sitting and part time standing, or if this is impossible, frequent rest periods which will allow the girls to stand and move about, will be found of the greatest benefit in overcoming dysmenorrhea. The next commonest cause for this condition can be found in an unstable, nervous mechanism. A large percentage of the girls who reported to the doctor's office because of painful menstrual periods also reported at other times because of various nervous manifestations, such as fainting, hysteria, "nervousness" and many neurasthenic symptoms. I have submitted hundreds of these girls to thorough physical examinations (not including vaginal) and many of these have shown the signs of neurocirculatory asthenia, the long narrow chest with the acute intercostal angle (Stiller type), movable or even floating kidneys especially of the right side, and exaggerated abdominal reflexes. These cases are so common that the nurse who was present at the time of examinations voluntarily remarked about the similarity of the findings. Many girls suffer from neurasthenic symptoms during their periods which are based upon the teaching or on the lack of teaching of the mother. Instead of being told of this normal condition in their sex, they are suddenly frightened to death by its appearance. They are then told to keep quiet, avoid excitement, never bathe and similar instructions all of which stimulates fear of consequences and tends to develop the neurasthenic state at each subsequent period. It is imperative that our girls be taught that this is a normal condition and should not be regarded as a ''sick time," I have submitted girls to vaginal and rectal examinations, usually under gas anesthesia, whose dysmenorrhea could not be accounted for by the above conditions or cured by the correction of the same. Only about 10 per cent, of these oases showed definite pathologic changes which could account for the dysmenorrhea. Of these, an acute retroflexion of the uterus was the commonest finding, marked retroversion being the next commonest condition. In many of these cases the rectum was found impacted with fecal matter even when constipation was not complained of. Care of the bowels and proper exercises, such as assuming the knee chest position for several minutes, three times a day, relieved many of these while in a few an opera- tion was necessary. The operative cases gave uniformly good results 428 INDUSTRIAL MEDICINE AND SURGERY chiefly because such radical treatment was not instituted until all other sources of the trouble had been eliminated except, perhaps, some due to neurasthenia. The number of girls suffering from dysmenorrhea in the working force can be greatly reduced by systematic efforts directed toward this end by the medical staff. Here the nurse and intelligent foreladies can be of greatest assistance, in fact they must often take the lead in directing the routine measures suggested by the doctor. The first essential is to decrease the number of cases of constipation to a minimum. Directions for this are given above. Next, every in- dustry employing girls should provide the means for healthful recrea- tion including games which afford plenty of outdoor exercise. Lectures will be found of great value, but better than this is a careful study of each case of dysmenorrhea followed by individual instructions con- cerning the methods of overcoming it. The nurses can give these instructions by many intimate talks with the girls. Hot drinks, especially those containing certain food values, combined with a short rest in the rest room, will enable many to return shortly to work whereas medicine given to relieve the pain only tends to create a habit. This short resume concerning this, one of the most important problems in industry, is given with a view of stimulating more con- certed action on the part of both physicians and nurses in industry in order to overcome a condition which has hitherto been tolerated. In correcting dysmenorrhea, many of the faulty conditions surrounding women in industry will likewise be corrected. CHAPTER XXIX / THE TUBERCULOUS EMPLOYEE Tuberculosis has been a greater enemy of the human race than almost any other disease. Its devastation has surpassed the wanton destruction of savages. The pulmonary type is the commonest form of tuberculosis, but it also involves glands, bones and joints, the serous linings of cavities, as the pleura, peritoneum, and meninges, and attacks other organs of the body as the kidney or the testicle. In dealing with the problem of the tuberculous employee the pulmonary type only will be considered, but the principles herein set forth are applicable to practically all forms of this disease. Tuberculosis is not a disease of industrial life alone. It existed even more extensively among the American Indians and other aborigines, where our modern industrial conditions were unknown. The more favored in life, from the standpoint of wealth and social position, have succumbed to its ravages. Among the agricultural class, where outdoor life and abundance of food prevail, the disease has been very common. But unquestionably it has caused the greatest destruction among the poor working classes in our industrial centers. In all nations as the tendency to concentrate in certain communities increased, and as small shops grew into factories, and these into great congested industries, the working people were more and more crowded together. Small homes were replaced with flats and these in turn with large tenement buildings. Not only were the working places overcrowded and unhygienic, but the families of these workers were forced to live in congested quarters, ill-ventilated, unclean and in- sanitary to the extreme. Tuberculosis has reached its highest morbidity and mortality rate among these poor working classes. They become centers of infection and spread the disease to all other walks of life, even reaching the homes of the landlords who are responsible for such community conditions. This disease has become so prevalent that autopsy statistics show that from 70 per cent, to 85 per cent, of all people have at some time during their life been infected. Healed or inactive areas of the disease have been found in a large percentage of those dying from some other 429 430 INDUSTRIAL MEDICINE AND SURGERY cause. It is hard to explain why more do not succumb to tuber- culosis but undoubtedly the fact that our working and living condi- tions do not tend to lower our resistance is the saving factor for many. Some of our modern tuberculosis specialists contend that this disease is not infectious to adults. They argue that the focus of infection is contracted during childhood and in later life some under- mining condition so lowers the resistance as to cause the disease to light up. These teachers have caused some to doubt if it is necessary to protect the working forces from the tuberculous employee in their midst. They even argue that the husband sleeping with the tuberculous wife cannot contract the disease from her. There is abundance of proof of this infection of children but this fact does not refute the arguments that overcrowding, unsanitary living and work- ing conditions and even certain occupations are equally responsible for the spread of tuberculosis. Therefore while tuberculosis may be classed as an industrial disease yet many conditions in industry have been responsible for maintaining and spreading it. Granting that the infection is one of childhood yet certain occupations and certain insanitary industrial conditions are responsible for the lowered resistance and the lighting up of the in- fection. Even if the presence of the tuberculous employee is not dangerous to his fellows yet these same working conditions can in- crease the activity and dangers of the disease for him and therefore this fact makes it imperative to remove him from the working place until he has recovered. The irrefutable proof of these statements exists in the fact that in those industries where an active fight against this disease has been made the tuberculosis rate has rapidly decreased. With improved living conditions and plant sanitation, even though not directed espe- cially at the prevention of tuberculosis, the disease has decreased. In those occupations, which have been directly responsible for lung trouble even crude preventive measures have decreased phthisis to a remarkable extent. And the seeking out of the tuberculous employee and removing him from the presence of his fellows, placing him under proper conditions for recovery, have resulted in decreasing both the morbidity and mortality rate. The extent to which tuberculosis may be classed as an industrial disease may be disputed, but no argument can exist against the fact that improving industrial conditions decreases the tuberculosis rate. But the employer alone cannot be blamed for these deplorable con- ditions which make the disease so prevalent. Society at large is responsible to a certain extent. And society, through the official agencies of the state and federal governments, should improve all conditions tending to lower the nation's resistance and should in THE TUBERCULOUS EMPLOYEE 431 addition provide the machinery for discovering and properly curing the tuberculous people among us. A concerted fight on the part of the nation against this disease would in time eradicate it completely and at the same time would solve most of the social evils coincidental with it. The tuberculous, whether he is the single employee of a small shop or one of a hundred thousand working force in an industry, must be sought out and cared for. The conditions in his working place or in his home that made the disease possible must be removed. All who come in intimate contact with him must be examined for possible infection. In fact each individual case must be thoroughly studied and the possibilities of the spread of the disease from this source must be followed out in all its ramifications. Such a machinery will not only reach the tuberculous in adult life but will reach into childhood as well. Under the incentive of war we have seen the nations mobilize their forces and concentrate their every effort against the common enemy which was spreading death and degradation among us. The medical forces, sacrificing personal wealth and aggrandizement, have responded gloriously in this fight. If we could maintain this same great war machine, and the civilian agencies, such as the Red Cross and all government agencies, after the war, to concentrate their efforts against tuberculosis, and all the other social diseases, devastaling our people even more than war has done, it would result in a more glorious, far reaching victory than we are gaining over the Huns. PREVALENCE OF TUBERCULOSIS IN INDUSTRY It is not our purpose to classify all tuberculous employees as the victims of an occupational disease and thereby add to the liability of the employer in these cases. But rather to show that in some cases there is a legal responsibility and in many others a moral responsibility which must be assumed by the employer at this time in the absence of any state responsibility for these sufferers. And the physician in industry is in the strategical position to attack this disease where it is the most prevalent. The causes of tuberculosis in industry can be divided into pre- disposing etiologic factors, the active cause being the bacillus of tuberculosis itself, discovered by Koch in 1880. The relationship to industry of some of these predisposing conditions is very remote, while others are so closely connected with certain industries that they represent almost an active causal agency. In the latter cases tuber- culosis should be classed as an occupational disease, the emploj^er being held liable for the condition. Only in this way will the proper 432 INDUSTRIAL MEDICINE AND SURGERY preventive measures be taken where these more or less active causes exist. These predisposing factors to tuberculosis among employees are as follows : 1. Hereditary predisposition and family infection. 2. Poor housing and living conditions and other community conditions. 3. Alcoholism and other excesses.. 4. Unsanitary working places and working conditions. 5. Tuberculous employees among the working force forming "foci of infection." 6. Prevalence of other diseases. 7. Injuries to chest and other injuries. 8. Specific occupational hazards. The relationship of industry to hereditary predisposition and to family infection is indeed very remote and yet it exists. In cer- tain industries, as for instance the textile workers of New England, or in the copper mines of Montana, the children often follow the parents into the mills or mines. Physicians in these communities have told me of members of families, for at least three generations, dying of this disease. Heredity and family infection have undoubtedly played their part but the working conditions have been responsible to a cer- tain extent for these deaths. In some of these families where each succeeding generation has followed the occupation of the parents the signs of a hereditary predisposition to tuberculosis have in- creased in each group of children. The smaller stature, the narrow chest and the stooped shoulders of these children point to industries' responsibility toward them and toward society. Improved working conditions, with every preventive measure installed, would stop these family infections. Poor housing and living conditions increase the number of tuber- culous employees. Some industries have even provided long rows of tenements for their employees and their families. These poorly built homes, with their insanitary arrangements, and their dark, ill- ventUated sleeping rooms, have reduced the efficiency of their workers and caused disease to become more prevalent. Poverty among em- ployees has forced them to dwell in unhygienic surroundings and to live under conditions which have been proven by many investigators to predispose to tuberculosis. The employer should see that the community, responsible for fur- nishing him his labor supply, is cleaned up and kept clean; that his employees are paid a living wage and are subtly educated to proper living environments. All his efforts to improve health conditions in his plant can be undone by unhealthful community conditions. THE TUBERCULOUS EMPLOYEE 433 Good business, as well as a certain moral responsibility, should force every concern to remove these predisposing causes. Alcoholism, venereal diseases and many other forms of excesses, are acknowledged predisposing factors to tuberculosis, as well as a direct cause of inefficiency. Beer drinking during working hours has increased at an alarming rate among the workers of hundreds of different industries. Some of these employees will drink at least two gallons of beer during the day. This is encouraged by some employers, and not prohibited by others for the fear of losing these men. Other concerns have increased alcoholism by paying in checks and allowing the corner saloon to cash these checks. In many communities the saloon offers the only club facilities for the working class. They can go here and eat their lunches in warmth, and in the evening can find a warm place to congregate where facilities for games and amusements are freely furnished. In such communities the cheap dance hall is the only source of entertainment for the girls. Alcoholism, venereal dis- eases and late hours prevail, and result in tuberculosis and inefficiency. Society and the industries that do not provide the means of combat- ing these conditions are responsible. Dr. Wilbur Post recognized the deleterious effects of alcoholism on the employees of a large industry in Chicago. These men were in the habit of "rushing the growler" during working hours, and to have their beer at the noon hour with whiskey in the morning and evening. He arranged through the management, to meet small groups of employees each day for a twenty minute talk, on the company's time. He gave these talks until every man in the concern had heard them several times. In a snappy, subtle way he drove home the undermining influences of this constant use of alcohol, and in time decreased the sale of beer among these men over 75 per cent. Buttermilk was advocated as a substitute and the concern saw that opportunity for buying buttermilk was provided. The environments of the working place are frequently the cause of tuberculosis, and here the industry is more directly responsible for the disease. Overcrowding of working places was best exemplified by the sweat-shops among garment workers so prevalent a few years ago. Doctors Price and Scherechewsky found in 2000 garment workers in New York a tuberculosis rate of 5 per cent., whereas among 1000 steel workers they only found .9 per cent, affected with this disease. Poor ventilation usually is coincident with overcrowding. Vitality is practically always reduced by ill ventilated, contaminated working rooms. The presence of inorganic dust and of pathogenic bacteria thrown off from the workers in the room add greatly to the disease hazard. Lack of facilities for the proper removal of dust is another hazard 28 434 INDUSTRIAL MEDICINE AND SURGERY for tuberculosis. Dry sweeping in the rooms, where people are employed is one of the most dangerous practices. Dust created in many occupational processes is known to be especially predisposing to respiratory conditions. Ventilators, fans and artificial means of remov- ing dusts are imperative; where such appliances are neglected there is a direct responsibility on the employer for the cases of tubercu- losis which develop. Forcing employees to work constantly in dark, damp places is a cause for lowered vitality and a predisposition to tuberculosis. That such working places cannot be avoided at times may be granted, but no man should be forced to work there day in and day out. These employees should be changed frequently, say every three weeks, to outside employment. They should also be subjected to more frequent physical examinations and other forms of health supervision to prevent the incipient development of this disease. Exposure to extremes of heat and cold, and other forms of poor temperature and humidity provisions, is another predisposing factor in industry which is responsible for many cases of phthisis. Industrial sanitation is the means of removing all these factors and that industry which neglects the environments of its working force should be held liable for its tuberculous employee. Employees working in intimate contact with each other, are constantly exposed to the diseased fellow employee in their midst. This is true of tuberculosis as well as all contagious diseases. These men with tuberculosis, where proper supervision does not exist, wiU continue to work as long as they are able, and meanwhile the dis- ease is advancing and the number of germs thrown off by their coughing and spitting increases daily. The author found twenty-six cases of tuberculosis among a large nu-mber of packers in two years. The sources of infection were removed and in the next seven years only seven cases of this disease developed among this force. While proper supervision accounted for part of these results, yet the segregation of these sources of infection undoubtedly removed the cause of contamination. Ten years ago when the physical examination of employees in industrial concerns was first advocated, it was met with every form of objection. But today it is recognized as one of the greatest efficiency measures, as well as the most advanced public health movement, which can be adopted. It is the greatest means of health supervision, and health supervision of employees forms the very foundation of all common-sense efforts at so called welfare work. Every employer should see that his working force is carefully supervised in order to discover and remove these foci of infection^ — -the tuberculous employees. THE TUBERCULOUS EMPLOYEE 435 Certain industries, due either to unsanitary conditions, or the nature of the work, or the location of the plant, seem predisposed to other respiratory diseases These diseases are often the cause of the lighting up of a case of tuberculosis. It behooves every concern, therefore to combat these antecedent diseases. When the causes for them exist in either the working place or in the community, every effort should be made to remove the same in order to prevent the worst disease — tuberculosis. Following the epidemic of so called grip, in the winter of 1915, the author found eighteen cases of tuberculosis in the month of March among employees who had been working in a concern where careful medical supervision was in vogue. Twelve of these employees had been thoroughly examined during the preceding year, and no evidence of tuberculosis was found. This epidemic was responsible for light- ing up tiie disease. Our efforts, which resulted in controlling the "grip" epidemic, and in reducing the sick rate among these employees to a much lower percentage than that in the community at large, undoubtedly reduced the number of tuberculosis cases which followed in its wake. Overcrowding, poor ventilation, fatigue, and lack of immediate medical care, are directly responsible for the increasing number of so called grippe, or epidemics of streptococcic res- piratory conditions among employees. These epidemics are becoming more and more a cause of immediate high absence rate among employees. The extent to which they are contributing to absenteeism in the following months, chiefly because of tuberculosis cannot be estimated. Cigar makers are more subject to these milder respiratory conditions, and they are also known to have a higher tuberculosis rate than many other employees. Protection against these milder condi- tions would result in a lowered tuberculosis morbidity. These two examples are sufficient to point out the responsi- bility of the employer in protecting his working force from those influences which cause these antecedent diseases which often result in consumption. Sir Thomas Oliver, in his book on Diseases of Occupation, has devoted considerable attention to the relationship between traumatism and tuberculosis. He describes several cases of injury to the chest in men who later developed tuberculosis. Some of these had been examined previous to the injury and no sign of tuberculosis was dis- covered, neither was there any family tendency to this disease. One case, a previously healthy male, two weeks after a severe blow on his chest, developed a pleurisy. This man continued to lose weight and grew rapidly worse. A few weeks later his physician found tubercle bacilli in his sputum. Under proper treatment the man finally 436 INDUSTRIAL MEDICINE AND SURGERY recovered. The conclusion was reached that the trauma was responsible for the disease. In my experience, I have had twelve cases of traumatic pleurisy. All of these followed a direct injury to the chest wall; none had evidence of fractured ribs. One of these developed the signs and symptoms of tuberculosis, but the germs were never found in his sputum. After three months of treatment which corresponded in every respect with the treatment of tuberculosis, the man recovered. At the time of the injury a stethoscopic examination of his chest revealed none of the signs which later developed. This stethoscopic examina- tion of every injury to the chest wall is very important, and will often enable the physician to prevent an injustice being done to either the employer or employee. One of the above cases was struck in the lower side of his left chest by a falling box. He reported to the doctor's ofl&ce at once. The routine examination with the stethoscope was made and signs of tuber- culosis were found in both apices. His sputum was immediately examined and found to contain the germs. An a;-ray examination showed no fractured ribs, but revealed large areas of calcification and fibrosis in the lungs. The condition was explained to the boy and his family. It was carefully pointed out that this disease was already existent and active and that the blow had nothing to do with it. This concern followed its usual custom and sent this employee to a sana- torium for treatment, paying all of his expenses. He recovered and left the sanatorium in seven months and was again employed. The injury to his chest wall did not seem to increase his lung trouble. A case similar to this is described under the medicolegal chapter. Another employee received a nail wound of the hand and developed a severe streptococcus infection. At his first general examination, made one week after the injury, no signs of tuberculosis were found. There was no family history of this disease. The infection in the hand persisted for several weeks and required extensive drainage under a general anesthetic. He finally recovered from this, but remained emaciated and did not regain his strength. About three months after the injury he began to cough and expectorate. Dullness and rales developed in the lungs and tubercle bacilli were found in the sputum. My opinion was demanded as to whether the injury was responsible for this pulmonary condition. The fact that there was no evidence of the disease one week after injury, and that his lowered resistance followed directly as the result of the severe infection, making it possible for this disease to develop, caused me to give the opinion that his injury was the predisposing factor, and the employer should be responsible. There is no doubt but that injuries can predispose to tuberculosis, THE TUBERCULOUS EMPLOYEE 437 * and it is essential for industry to recognize the fact and take the neces- sary precautions against accidents, and provide the best of care for all injured in order to prevent this complication. OCCUPATIONAL HAZARDS Tuberculosis follows so frequently in the wake of certain occupa- tions that these have come to be recognized as definite predisposing causes for the disease. Just as plumbism is a definite occupational disease for which employers may be held legally liable, so tubercu- losis should be classed as an occupational disease when it develops in certain industries. Frederick S. Crum in his treatise on "The Mortality from Diseases of the Lungs in American Industry," Hoffman and other excellent, authorities, have definitely demonstrated that certain occupations are directly responsible for this pulmonary condition. Those industrial processes which contaminate the atmosphere of the working place with inorganic or organic dusts are especially pre- disposing to pulmonary tuberculosis, as well as to other respiratory diseases. It is estimated that approximately 5,500,000 wage earners of both sexes, or 12.5 per cent, of the total wage earning force of the country work under conditions where this atmospheric pollution is very prevalent, and of known hazard to the employees. A careful investigation in many of the smaller concerns, and of the more ob- scure occupations, would undoubtedly reveal a higher percentage of workers exposed to dust hazards. The metallic dusts, with their millions of jagged, angular micro- scopic particles floating in the atmosphere, are probably the most hurtful to the lung tissue. The constant irritation from these particles causes a fibrosis which is a favorable garden spot for the tubercle bacillus, or may cause death from some other respiratory disease. Mr. Crum based his study on the experience of the Prudential Life Insurance Company which for years has kept careful statistics on the causes of death among policy holders engaged in these dusty occupations. He says, "In the Prudential experience the group of occupations exposing the workmen to metallic dust shows the most disastrous results, as evidenced in the mortality returns from both tuberculosis of the lungs and other respiratory diseases. At ages 25 to 34, taking the group as a whole, of the total deaths 53.9 per cent, were caused by tuberculosis of the lungs and 8 per cent, were from other respiratory diseases. Respiratory diseases at this age period together caused an excess mortality of 25.3 per cent, if comparison is made with the mortality from these diseases in the non-dusty oc- cupations. At ages 35 to 44, tuberculosis of the lungs caused 44.7 438 INDUSTRIAL MEDICINE AND SURGERY per cent, of the total deaths and the other respiratory diseases caused 9.7 per cent. In other words, respiratory diseases, tuberculous and non-tuberculous, caused 54.4 per cent, of all the deaths of occupied males, ages 35 to 44, in the group of occupations exposing to metallic dusts, in the Prudential experience. This represents an excess mortality from these causes of 22.2 per cent, as compared with the non-dusty occupations in the same experience. Specific occupations in this group with exceptionally high mortality from lung diseases are cutlery makers, file makers, metal grinders and polishers, brass workers, printers, engravers, tool makers, gold beaters, etc. Metal grinders, polishers and buffers invariably show a high mor- tality from respiratory diseases as a direct result of their inhalation of metallic dust particles. The peculiar effect on the lungs of metallic dust is described by some writers on occupational diseases as ''grinders' rot." In the Prudential experience, metal grinders and polishers show an excess mortality from tuberculosis of the lungs at ages 25 to 34 of 60 per cent, and at ages 35 to 44 an excess of 107.1 per cent. The mortality of this class of workmen from other diseases of the lungs was practically the same as ages 25 to 44 as in the non-dusty occupations. The oft quoted figures from the medical officers of health of Shef- field, England, show that for the period of 1889 to 1910 tuberculosis caused 43 per cent, and other respiratory diseases 24.9 per cent, of the deaths among grinders. Most mineral dusts cause a high mortality rate from tuberculosis. During the period of 1907 to 1914 in Montana the mortality report among copper miners shows that out of 1614 deaths, for ages of 15 and over, 611 or 37.9 per cent, were due to tuberculosis, and 364 or 22.6 per cent, resulted from other respiratory diseases. In this registra- tion area the riiale 'deaths for the same age period showed 14.1 per cent, due to tuberculosis and 10.8 per cent, to other respiratory causes. These figures certainly demonstrate that copper mining is especially hazardous and results in excessive mortality from consumption. Coal miners and cement workers seem to suffer the least from the dust created by their occupations. In fact colliers in well ventilated coal mines were found to have a comparatively low mortality rate from this disease according to F. A. R. Russel of the Smithsonian Institute who wrote on this subject in 1896. Quoting again from the Prudential experience among stone and marble cutters,- planers and polishers, we find these occupations par- ticularly hazardous if we are to judge from their mortality returns. •The excess mortality from tuberculosis of the lungs at ages 25 to 34 THE TUBERCULOUS EMPLOYEE 439 among these workmen was 40 per cent, and at ages 35 to 44 it was 34.4 per cent. This experience is confirmed by other data and it has long been a well known fact that stone cutters are very liable to a fibroid form of pulmonary tuberculosis. In Washington County, Vermont, the general mortality returns are available for the six year period, 1900 to 1905. These statistics show that pulmonary tuber- culosis caused 46.2 per cent, of all the deaths among these workers and other respiratory diseases caused 14.7 per cent, of the total mortality. Diseases of the respiratory system, tuberculous and non-tuberculous, were, therefore, responsible for 60.9 per cent, of all the deaths of stone and marble workers in Washington County, Vermont, during 1900 to 1905. Such terms as "grinder's rot, " pneumoconiosis, silicosis and others, prove that both the laity and medical profession have recognized the existence of these conditions among employees subjected to metal and mineral dusts. The cotton and linen textile workers, wood workers and paper makers are exposed chiefly to vegetable dusts. The mortality rate from tuberculosis among these employees has been excessively high. Cotton spinners at ages of 35 to 44 were found to have an excess mortality of 90 per cent, when compared with non-dusty occupa- tions for these ages. Animal and mixed fiber dust has also been found very injurious to the lungs. For example, among hat-makers the mortality rate from tuberculosis was 60 per cent, for ages 25 to 34, according to Mr. Crum. The death rate from lung diseases among leather workers, especially boot and shoe employees, has been notoriously high. In Oxford, Massachusetts, a boot and shoe factory showed a record of one death out of every six of its employees due to tuberculosis. Car- pet weavers, upholsterers, silk and woolen mill employees, furriers, workers in hair and hair goods, mattress makers, garment workers and employees in many other occupations, are exposed to this animal and mixed fiber dust. Workers exposed constantly to street or municipal dusts were found to have a high tuberculosis mortality rate, judging from the Prudential experience. Street car conductors and street cleaners were especially affected by this form of dust. This should be given more thought as many physicians have been in the habit of recom- mending teaming or the occupation of chauffeur to the arrested case of tuberculosis. The occupations where general organic dust was prevalent aU showed an increased mortality rate from tuberculosis. For instance, bakers, candy-makers, millers, harness and shoemakers, tanners, button makers, glove makers, tobacco workers, celluloid workers, 440 INDUSTRIAL MEDICINE AND SURGERY and grain handlers, showed a death rate of 51.8 per cent, from this disease according to the Prudential statistics. These examples of the occupational hazard of dust caused Robert Hessler (Dusty Air and 111 Health) to say, "Tuberculosis is really a protest against bad air conditions, just as typhoid is a protest against bad water." In England, Sir James Crichton Browne summed up his experiences on ''The Dust Problem" as follows: "Industrial dust, 'per se, apart from poisonous or pestilential mixture, is a sufficiently interesting theme from a sanitary point of view, for the returns of mortality re- veal that notwithstanding the highly successful crusade against it, which has been and is being conducted by our factory inspectors, nobly assisted now by local authorities, intelligent employers, and awakened workpeople, it is still responsible for an appalling amount of suffering, disablement and death. "The mortality of the principal dust producing occupations, com- pared with that of agriculturists who live and work in what is prac- tically dustless atmosphere, is excessive to a startling degree. It is not suggested that this excess is to be ascribed to dust alone ; no doubt various factors contribute to it, but the facts that it is due mainly to respiratory diseases, that it is distributed among the several occupations pretty much in proportion to their dustiness, and that it has diminished in some instances where dust has been effectually dealt with, justify the conclusion that it is largely dust-begotten." Many other occupations have shown a high mortality rate from tuberculosis among the employees. This field has only been scratched, and it behooves all physicians in industry to seek out those occupations which are especially deleterious to the lungs and make comprehensive reports on the same. One of the earliest contributions to the relationship between phthisis and occupation was that of Perrond in 1875. This writer drew attention to the prevalence of this disease among the sailors on the Rhone, and attributed it to the fact that these men pressed their chest wall on the pole of the rudder in steering the ships. Schereschewsky has repeatedly pointed out that the cramped, stooping posture which employees must assume in certain occupations, is responsible for many of the lung conditions which they develop. For example, the posture of the garment workers has the effect of Umiting lung expansion with a consequent poor nutrition due to sub- oxidation and a resulting lowered resistance to respiratory diseases. Again, the grinder and polisher presses the object he is working on against the chest, reducing thereby his respiration, and thus adds this factor to the hazard of dust. Dr. James Britton of Chicago found a much higher rate of tuber- THE TUBERCULOUS EMPLOYEE 441 culosis among the 1000 clerks of a large industry located in the city than among the factory employees working at the outskirts of the city. The former had far better environments in their working places than the latter. But the sedentary work and the posture assumed when sitting at the desk evidently lowered the resistajice of these clerks. The author's experience was quite similar to that of Doctor Britton. In 300 cases of tuberculosis among employees of a large industry 31 per cent, were among the clerical force, which constituted about 30 per cent, of the entire force. Packers and allied workers made up about 10 per cent, of the force, and furnished 13 per cent, of the cases of phthisis; approximately 3 per cent, of the employees were truckers and 6 per cent, of the cases were found among these. Their work, as a rule, subjected them to considerable exposure to dust. A com- paratively small force of porters were employed, yet 3 per cent, of the tuberculosis cases came from this group. This bears out ^he experience of other authorities that porter work is particularly hazardous as regards phthisis. Better measures must be adopted for sweeping and the handling of cuspidors and other refuse in order to protect these porters against infection. Among the clerical workers the stenographers showed a greater tendency to the disease. No better argument can be advanced for rest periods with exercise, especially deep breathing exercises, and for educational campaigns on the need of proper recreation at the noon hour and in the evening, for these stenographers and other sedentary workers in industry. Old paper gathered up in the various departments and old paper bought up from rag pickers is put through paper cutting machines and used by many concerns for packing purposes. The dust from this paper is undoubtedly contaminated with pathogenic organisms to a marked degree. Straw used in packing is also very dusty. These materials add greatly to the hazard of this occupation. When this fact was pointed out to one large concern they immediately built a factory in Northern Michigan and made excelsior to be used for packing purposes. This clean material, with its decreased dust, plus the fact that the sources of infection were removed, by discovering and eliminating all tuberculous employees in their working force, has been the means of reducing phthisis among their packers. These examples of the tendency of certain work to predispose to tuberculosis are sufficient to prove that the employer who fails to take proper precautionary measures to prevent this disease among his employees, engaged in these hazardous occupations, should be held responsible for this the same as for any other occupational disease. 442 INDUSTRIAL MEDICINE AND SURGERY PREVENTION What measures therefore are necessary to prevent tuberculosis among employees? They are (a) eliminate the tuberculous from the working force ; (6) protect the employees from the predisposing causes ; (c) supervise the physical condition of the workers by medical examinations. The examination of all applicants for work furnishes the only means of preventing these foci of infection, the tuberculous, from mingling with the old working force. Likewise, the constant super- vision of the health of the old employees by medical examinations will reveal those who have developed this disease and who must also be eliminated from the working place. There is sufficient evidence of the spread of tuberculosis from one individual to another by close daily contact, especially when predisposing conditions in the work lower the resistance of the employees, to warrant the segregation and even the isolation of these cases. Protection of the workers against the predisposing causes is the duty of every employer and should be made legally compulsory. This is not a hardship or an unjust demand on any concern for protection against this disease always means an improved working environment, a healthier more contented working force, decreased labor turn-over and therefore increased production. An enlightened business world should grasp these facts and voluntarily protect the labor market from this and other destructive diseases. These preventive measures have been set forth at length in numerous other places in this book, especially under Industrial Hygiene. In combating tuberculosis the ventilation including dust removal, temperature and humidity and cleanliness of the working rooms are the three most important conditions for industry in general to consider. Overcrowded, dark, damp, ill ventilated, stuffy rooms have been responsible for hundreds of thousands of deaths from phthisis. These condilions plus dusty occupations are the great allies of the tubercle bacillus. So easy to prevent, and yet what an economic waste they have caused during the centuries. In the best conducted business these faults will creep in. The primary object of the management is to maintain production. The employees are directly absorbed with their work. Therefore, it is necessary for the physician in industry to concentrate his efforts on these preventive measures. Frequent inspections of the working places must be made; tests of the ventilation, of the temperature and humidity of the atmosphere must be made a routine part of his work. In a large concern it is well to assign this duty to one doctor who must be held responsible for maintaining health standards in the working place. His recommendations should be made to the THE TUBERCULOUS EMPLOYEE 443 highest authority in the management and repeatedly made until faulty conditions are corrected. In those occupations where dust or fumes are created, especially when of a known hazard to the lungs, every facility must be provided for the proper removal of the same. These consist of hoods, large conducting pipes, suction fans and other apparatus. In some concerns where great attention has been given to this hazard, practically all dust is eliminated from the rooms. Instead of throwing this dust into the outside atmosphere it is often collected in bags or rooms provided for the purpose and salvaged. This salvaging process alone has paid many times over for the expense of installing the necessary system. The removal of dangerous fumes is just as essential for often these fumes, as for instance, lead, will predispose to tuberculosis even with- out causing the specific occupational disease. A factory, with both hazards of dust and of fumes, was recently inspected. The management was very proud of the fact that it had provided protective measures for the employees. The hoods, which cost $50,000 to install, were pointed to with pride. But these hoods were some four feet over the lead vats; other hoods for dust removal were covered on their exterior with the fine metal dust. The dust that was collected discharged from a pipe just outside the building and much of it was blown back into the room through an adjacent, open window. The physician should always demand the services of an expert industrial engineer to take charge of installing ventilation and dust and fume removal systems. Concerns will meet the problems more thoroughly and will save needless expense by employing such engineers. The use by employees of a non-irritating, simple respirator, should be enforced in all occupations where dust and fumes prevail. Such respirators are often furnished by the employer, but no effort is made to compel their use. Educational campaigns among the employees is the greatest means of securing their co-operation in all these preventive measures. Excellent reports on the reduction of disease in certain hazardous occupations by the use of these various devices, coupled with educating the employees to their use have been published by the Pennsylvania and New Jersey Departments of Industry and Labor, as well as by the United States Department of Labor, These furnish irrefutable evidence that tuberculosis can be controlled in these occupations. The next step for these governmental agencies is to provide means of punishment for those industries which continue to neglect precautions. The benefits derived from a healthful working place may be com- 444 INDUSTRIAL MEDICINE AND SURGERY pletely nullified by faulty home conditions and insanitary community surroundings. While the employer cannot be held legally responsible for these, yet it behooves him to see that they are corrected. This is another duty for the medical staff. CoHDperation with the city and state health authorities will improve community conditions which should always include housing conditions. By the aid of the visiting nurses, and by subtle suggestions from the doctors and often by actual assistance from the employer better home conditions can be obtained for most of the employees. The third great preventive measure which every industry, and every small employer should adopt is the constant supervision of the physical condition of the employees by medical examinations. The method of doing this is dealt with in other chapters. To reiterate though, some system must be established whereby every employee will be examined and re-examined whenever necessary. Those working in dusty occupations, in rooms which must perforce be dark or damp, or where other hazards exist, should be examined at stated intervals, preferably every month, and certainly every three months. These examinations will enable the discovery of all tuberculous cases in an early and therefore curable state. Combined with the examination of applicants they furnish the means of eliminating these cases from the working force. After a man has been cured of tuberculosis he should be allowed to return to the industry to work at his old occupation, if no hazard for the disease exists there, or in some allied occupation. These apparently cured cases therefore furnish another group of employees who should be periodically examined to guard against a recurrence. TREATMENT OF THE TUBERCULOUS EMPLOYEE The elimination of the tuberculous employees from the working place means excessive hardships for them and their famihes, and often is a very decided contributing factor to their deaths, unless provisions are made for their proper care, preferably in sanatoria, and the adequate support of their dependents during the period of treatment. Until recent years no such provisions were made for the treatment of these cases, resulting therefore in a high death rate particularly among the poor. To-day, chiefly because of the efforts of the members of the National Tuberculosis Association and the various state and municipal tuber- culosis institutes, there are numerous sanatoria scattered through- out the country where free, or very reasonable, treatment can be given to these sufferers. Massachusetts has established such sana- toria in several counties and plans to have one in practically every THE TUBERCULOUS EMPLOYEE 445 county of the state. A few other states are planning similar pro- visions. Several state sanatoria have been established and a few county and municipal sanatoria. Chicago's Municipal Sanatorium is one of the most representative of the latter. Adequate provision for the support of the families during the period the wage earner is under treatment has not yet been made. The reports of any United Charities Organization in the country will show that they have furnished relief to hundreds of such families. The motive back of this relief has been noble and it was necessary, but charity in any form should not be a part of the social and economic mechanism of our country. Charity, when interpreted as brotherly love, should provide sick insurance or some other self-respecting means for the support of these dependents. Even with the establishment of these sanatoria no state has yet provided the machinery for the early discovery of the cases of tuberculosis. All authorities agree that the disease is usually curable when treatment is started in the incipient stage. In spite of this knowledge the death rate still continues high in most sanatoria because the cases were not admitted until the disease had reached the second or third stage. The medical profession is responsible for this condition in many cases. Lack of ability to diagnose the disease in its incipiency, fail- ure to thoroughly examine each patient, and temporizing with the condition by trying ambulatory or home treatment are the three most appalling mistakes which the family doctor makes with his tuberculous patients. The patients themselves often pay no attention to the early symptoms, dragging about their work, trying patent medicines and home remedies, and when finally forced to consult a physician the disease is in an advanced form, often incurable or entailing a heavy financial loss to both the patient and the state because of the longer period of treatment necessary. Even more essential than the establishing of sanatoria is for the state to provide the necessary machinery for the early detection of the consumptive and to make treatment compulsory during this early stage. The work of many industrial medical staffs has demonstrated the value of periodical medical examinations as the best means for detecting the early cases. Also many concerns have provided sanatorium treatment, free of charge, for their tuberculous employees and have thus reduced the length of treatment and the death rate on account of this disease to a most marked degree. Sick insurance, based on the fundamental principle of 'prevention first, would undoubtedly provide for the periodical exarrJnation of all workers. If the prevention idea is to be the basis, sick insurance 446 INDUSTRIAL MEDICINE AND SURGERY should be compulsory for everybody. The machinery established to carry on this work would be the means of finding the tuberculous in our midst in this early, curable stage. Many municipal health departments provide consultants who visit every contagious case reported, to ascertain if the diagnosis is correct and if proper precautions are taken. Physicians who fail to report these cases early are legally responsible. A similar plan should be adopted in regard to tuberculosis. Early reporting, com- petent consultants to visit these cases or centers where they could be referred for examination combined with sanatorium treatment for all positive cases, and suitable provisions for the suspicious ones, would be one of the greatest life saving measures which the state could adopt. Punishment for the doctor failing to report his tuberculous patients early would soon eliminate the majority of these second and third stage cases which now seek sanatorium care. It is quite evident that tuberculosis has so many predisposing causes that in the majority of cases it is impossible to say which one has been responsible. Most of these causes however are found in the social and economic fabric of our every day existence. It can really be classed as a social disease, the prevention and cure of which is a state duty. In the absence of the state assuming this responsibility we have many examples of wonderful provisions for the care of the tuberculous by various organizations, by philanthropic citizens, and above all by certain individual industries. These latter have provided every means for prevention in the plant, and, when an employee is assailed, every opportunity for the best of treatment. No chapter on the tuber- culous employee would be complete without setting forth in detail examples of this care on the part of certain concerns. In 1906 an effort was made by a few of the large manufacturers of Providence, Rhode Island, to exterminate tuberculosis in their factories. Large placards were placed in conspicuous places advis- ing all employees with suspicious lung symptoms to report to Dr. Frank Fulton, who offered his services gratis, for examinations. The object was to diagnose the disease, if possible, in its early stages. Some eighteen cases were discovered and proper home and sanatorium treat- ment established. As a result, all of these workmen recovered and were able to return to work. A few years ago in Hartford, Conneticut, 10,000 employees of various factories, mills and other industries organized to protect them- selves and their families from the ravages of tuberculosis. The owners of these industries agreed to give a sum equal to that raised by the working men and women to fight the disease. Adequate medical aid was called into service, and by means of home and sanatorium THE TUBERCULOUS EMPLOYEE 447 treatment they were able to greatly reduce the death rate from consumption. In Oxford, Massachusetts, a boot and shoe factory showed a record of one death out of every six of its employees due to tuberculosis. In 1904 a systematic educational campaign was organized among the workers in this factory, its purpose being to instruct them as to the nature, cause and prevention of consumption. Also the owners paid for free treatment for three months in a sanatorium for those employees afflicted with the disease. As a result the deaths greatly diminished, and in 1907, three years later, only four people died of consumption in Oxford. A similar movement started in Worcester, Massachusetts, showed equally marked results. In 1909 the author started a system of medical examination of employees in one of the large industries of Chicago employing at that time about 10,000 people, and now having approximately 15,000 employees. A great many different types of occupations were repre- sented here, including clerical work of all kinds, printing, packing, warehouse work, all kinds of merchandizing and approximately forty different manufacturing processes. Examples of a majority of the occupational hazards could be found in this plant. The medical examinations were first made for the purpose of dis- covering the tuberculous employee, but it soon extended into a thorough examination in order to discover all other physical defects. After three years, in 1912, the medical examination of all applicants for work was introduced, and now is one of the most vital functions of the medical staff of this industry. From January, 1909 to the end of December, 1917, 869 cases of tuberculosis were discovered among these employees or applicants for work. Since 1912, 245 of these cases were found among the appUcants, 0.7 per cent, of all examined. About sixty of these cases were not posi- tively diagnosed, but had such unmistakable signs of the disease that they were rejected. Others with suspicious findings in the lungs, yet apparently healthy, were employed but were re-examined at frequent intervals until the signs cleared up, or a positive diagnosis could be made. This policy accounts for the fact that the highest percentage of cases found in the old working force has been among the three to twelve months employees. So rnany suspicious cases clear up how- ever that a great injustice would be done these applicants if they were rejected for lung trouble. This also accounts for the lower tuberculosis rate among these applicants (0.7 per cent.) as compared with the rate among the total examinations made (1.7 per cent.). The medical staff reported all of these applicants to the City Health authorities and to the Chicago Tuberculosis Institute. The 448 INDUSTRIAL MEDICINE AND SURGERY visting nurse followed up all cases to see that they were under some form of supervision. It is a waste to all industries to throw these tuberculous cases back into society without endeavoring to place them under proper treatment. If every concern would adopt this system they would protect one another from the contamination of their employees by the diseased employee of some other plant. Your tuberculous employee may occupy the same boarding house, may even sleep with one of the force of another plant. The ramifications of the spread of the disease are so intricate that a good business sense should dictate a policy of joining hands against this common enemy. The 624 cases of tuberculosis among the old employees were divided as follows: Table 12 Suspected tuberculosis 94 Pulmonary tuberculosis first stage 321 second stage 128 third stage 44 Tuberculous glands 23 Tuberculous bones 6 Tuberculous spine 3 Tuberculous meningitis Tuberculous peritonitis Tuberculous kidney Tuberculous eye Tuberculous tonsil 624 The 94 suspected cases gave the clinical findings of tuberculosis, but were never positively diagnosed. These cases, however, were sufficiently suspicious to be eliminated from the working force and placed under active treatment until they had recovered. The ma- jority of these were given home treatment, and later, when it was safe to stop more careful medical supervision, they were often sent to the country. Hundreds of cases, not shown in the above table, were found with symptoms indicating a threatened tuberculous condition. For instance, many employees would become anemic, lose weight, complain of night sweats or stomach trouble, and other symptoms, pointing to a generally run down condition. No definite diagnosis could be made, but nevertheless vacations were secured for them, and they were placed on a general building up regime, many going to the country to rest and recuperate. Unquestionably a number of such employees would have developed an active tuberculosis if they had not been detected at this stage and these precautions taken. THE TUBERCULOUS EMPLOYEE 449 From the very beginning of this work this concern provided free treatment for 4 tuberculous employees. While their occupations were not responsible for the condition, except in a very few instances, yet the fact that these people were forced to quit work for the protection of the rest of the employees, caused the management to feel a certain moral responsibility for their care. The first two years this free treatment was given only to those employees who had worked for the concern more than one year, but since then every case was offered the free treatment. Except in a few of the early stage cases Fig. 60.- -A tuberculous employee under treatment at home. • her bi-weekly call. The visiting nurse on with unusually good home surroundings, or where the employee was from the country and it seemed advisable for him to return there, sanatorium treatment was advised for all. Many at first refused to go to a sanatorium, but each succeeding year made it easier to persuade the tuberculous employee to accept this form of treatment. For those who refused to go arrangements were made for proper treat- ment at home, either directly under the care of the medical staff or under their family physician. The visiting nurse was of the greatest help in supervising this treatment in either plan. (See Fig. 60.) Often the home conditions were totally unfit for the proper treat- ment of the case; or were not suitable for the patient to return to 29 450 INDUSTRIAL MEDICINE AND SURGERY after completing the sanatorium care. The doctor reported these conditions to the management and in almost every instance the family was persuaded to move to better surroundings. Money was furnished, whenever necessary, to stand the expense of moving and of preparing a suitable sleeping porch for the patient. At first consider- able difficulty was encountered with many family physicians, but of recent years these doctors have co-operated in the work chiefly Fig. 61.- -A tent erected in the rear of a flat building where a tuberculous employee after returning from the sanatorium continued his treatment. because they know that every facility for properly diagnosing the case is used by the medical staff and that the treatment afforded by them gives better results than any home treatment which they can offer. The 530 cases which were positively diagnosed were treated in the following places: Table 13 In sanatorium 370 At home 108 In the country 40 Lost track of 12 Total 530 THE TUBERCULOUS EMPLOYEE 451 The first two years of this experience only thirty-four cases out of one hundred and sixteen consented to sanatorium treatment, whereas in the last two years, one hundred and twenty of the tubercu- lous employees accepted the offer of free sanatorium care out of one hundred forty-two cases. This proves the value of educational work among the employees and also is positive proof of the good results obtained. The sanatoria chiefly used were Edward Tuberculosis Sanatorium at Naperville, Illinois, the Winifield (Illinois) Sanatorium belonging to the Chicago Jewish Aid Society, the Chicago Fresh Air Sanatorium, the Valmora Sanatorium of Watrous, New Mexico, and others. All but sixty of the cases were treated in home climates. There was practically no difference in the results obtained between the local climatic conditions and those afforded by the high altitude and climate of the West. The greater willingness of the employees to go to a sanatorium near home and the happier frame of mind on the part of both the patients and their families has caused us to favor treatment in their home territory. The results of this treatment are shown in Table 13. Table 14 Cured 236 Arrested 67 Improved 44 Unimproved 5 Deaths 30 Lost trace of 113* Still under treatment 33 Total 530 The average length of treatment for patients in sanatoria was six months; and for those receiving non-sanatorium treatment ten and two-third months. Of the total number of employees who have received treatment approximately two hundred fifty have returned to work in the same concern, at their old occupations or in some other position less hazardous. There have been twenty recurrences among those cases kept under observation and in all but three of these the disease has again been arrested. This is a far lower recurrence rate than is usually found in this disease, thus demonstrating the value of health supervision. The use of short vacations when threatening symptoms developed prevented many of these employees from break- ing down. Twenty-nine out of the forty-four third stage or advanced cases were found during the first two years of this work. Ten of the deaths *Since their discharge from treatment. 452 INDUSTRIAL MEDICINE AND SURGERY occurred during the first two years the remaining twenty deaths were scattered through the last seven years. (See Fig. 62.) These two facts substantiate the claim that physical examination of employees enables the discovery of tuberculous cases in the earlier stages, thereby reducing the death rate, and shortening the time of treatment necessary for a cure. Yio, 62. — Reduction in number of cases of tuberculosis found and in the death rate as number of employees examined increases. 1, Per cent, of employees examined from total number. 2, Per cent, of tuberculous employees found among number examined. 3, Per cent, of deaths among those found tuberculous. The age periods at which these tuberculous cases were found were as follows: Table 15 Age 15-20. 20-25. 25-30. 30-35. 35-40. 40-45. 45-50. 50 or ( Per cent, of cases ... . 21.0 . . . , 34.4 . .. . 23.9 .. . . 8.0 .... 5.0 4.1 .... 3.0 .... 0.5 While the tuberculosis rate decreased markedly after the age of 35, yet the discovery of this disease among the applicants and new employees resulted in a very noticeable reduction in the incidence among the older force. For example in 1909 there were only five hundred ten employees- who had worked at the plant for five years or more, but 33 per cent, of our tuberculous employees were found among these. Six years later, in 1914, there were two thousand THE TUBERCULOUS EMPLOYEE 453 W Sears shack, Edwards Sanatorium, Naperville, 111. '■ — -^ I " ' '•■' --^^ 1 -- |lhHW!Hl ffllFflfflL-. 1 ^.^ ^^..^ 1 1 Fig. 63. — Plan of sleeping shack for six patients. 454 INDUSTRIAL MEDICINE AND SURGERY forty-nine people who had worked here for five years or longer, and only 13.8 per cent, of the tuberculous were among this number. This result was obtained by constant health supervision, by eliminating the tuberculous applicant and by improved working conditions. Fig. 52 illustrates very graphically this decrease in tuberculosis among the older employees and also shows the great advantage to the concern of examining applicants for work. There were only eight hundred thorough examinations made in 1909 when one physician was employed, whereas in 1914, with six physicians, twelve thousand three hundred eighty complete examinations were made. The results obtained from discovering and reclaiming the tuber- culous employees in this concern has been one of the most gratifying features of the medical work. The co-operation of the manage- ment has at all times been of the greatest aid, and their example has influenced other industries, especially in Chicago, to adopt a similar program. In 1910 because of the limited capacity in Sanatoria great difficulty was experienced in securing prompt admission of our patients. The result was that the management erected a shack at the Edward Sanatorium for the accommodation of more patients. Since then the Chicago Telephone Company, the International Harvester Company, Montgomery Ward and Company, and Swift and Company have each built shacks at this sanatorium for the use of their employees. (See Fig. 63.) In 1911 thirty of Chicago's largest industries contributed the funds for the establishment of a sanatorium at Watrous, New Mexico, where their employees could receive treatment at the lowest possible cost. This is known as Valmora Sanatorium. Over four hundred employees of these concerns, or members of their families, have received treatment at Valmora during the last nine years and the results have been most excellent. This was one of the first sanatoria to adopt graduated exercise, in the form of work, for its patients. (See Fig. 64.) In 1915 the Ford Motor Company introduced this plan of giving free sanatorium care to every tuberculous employee. It has even extended this policy to the tuberculous applicant for work. A sana- toriuni near Detroit has been developed where these employees are sent until the disease is arrested. They then return to the plant, are put to work in some outside occupation and are carefully supervised by the medical staff. Most of these cases have been placed on the work of salvaging the scrap iron which previously was sold as junk. This salvaging process, done by salvaged employees, netted this concern a profit of $78,000 in one year. Large dividends from a simple humanitarian effort! The profit to these employees and their families cannot be shown in dollars and cents. (See Fig. 65.) THE TUBERCULOUS EMPLOYEE 455 ,fe a^ ^'^ . .^ ,456 INDUSTRIAL MEDICINE AND SURGERY The Jewish Tuberculous Association of New York City has introduced an entirely new idea into the treatment of this disease. After years" of combating tuberculosis among the Jewish people of New York they were impressed with the great economic waste which fol- lowed in the wake of this disease. During the perod of sanatorium care it was necessary to give large sums of money to maintain the family while the bread winner was absent. After his discharge from treatment months and often years elapsed before he could support his family. Investigation showed that most of these patients on Fig. 65. — Tuberculous employees at work. (Courtesy of Ford Co.) discharge from sanatoria were warned against returning to inside employment. They sought work on farms, as teamsters and at other outside occupations, positions for which they were untrained and physically unfitted. Jobs were frequently changed because they were not able to do the work. Exposure to the elements, worry and other undermining conditions caused a high percentage of recurrences. In order to overcome this economic waste and unnecessary loss of human life this Association, through the magnificent efforts of Mr. Stein and Mr. Hockhauser, developed a postsanatorium factory. This factory is located in Hoboken, and is engaged in the manufacture of garments. Here under the best hygienic conditions, and constantly supervised by a competent doctor, over two hundred tuberculous employees have been given graduated work until they were finally THE TUBERCULOUS EMPLOYEE 457 able to return to full time employment when they graduated from the factory. Tinsmiths, clerks, jewelers, junk men and many others have learned to be garment makers and are drawing larger salaries now than they made previous to their sickness. This factory has demonstrated that the garment industry when properly conducted is not a hazardous occupation predisposing to lung trouble. (See Figs. 66 and 67.) The summary and chart — taken from a paper by Mr. Hockhauser on this experiment is one of the most enlightening contributions to all tuberculosis literature. Fig. 66. -Model garment factory for tuberculous employees. Tuberculous Association.) {Courtesy Jewish "An investigation in 1912 reported a waste of 45 per cent, due to relapse of sanatoria patients six months to one year after discharge. In a three year experiment we have reduced it from 45 per cent, to 15 per cent. "The sanatorium treatment is but a part — a large part it is true — of the treatment of the tuberculous. "After-care of the patient in his home is vital to any scheme which tries to conserve the gains made in the sanatorium and to protect the family from infection. "Carefully selected patients can be treated at home with as good results as at a sanatorium. Some patients improve at home and at work even though they do not do well at an institution. 458 INDUSTRIAL MEDICINE AND SURGERY "To provide 'industrial convalescence' or a scheme of gradually returning patients to ordinary economic life we maintain a special factory where the doctor is the ' boss. ' "Over 90 per cent, of the families of the patients at the factory were under the care of relief agencies. Of 58 who received relief from three months to five years 17 are partially self-supporting and 41 are entirely self-supporting. Patients, whose families were granted from $40 to a month by charities and relief agencies, are now earning from to $160 a month. Fig. 67. — Dining room in model garment factory for tuberculous employees. "Periodic examination of the patient is the price of keeping the tuberculous at work. The doctor must know his patients to guard against the malingerer or the patient too anxious to work to be truthful. Generous constructive care and supervision can cure dependency as well as tuberculosis. " All surgeons in industry as well as the tuberculosis worker have been impressed with this great waste of human energy as well as of human Ufe and its resulting financial losses to the patient, his family and the state, which has been connected with the treatment of 4 tuberculous people. Not only is it essential for the states to provide adequate Sanatoria care for all tuberculous but it should see that these people are placed in proper employment and carefully supervised after their treatment ceases. The prevention of recurrences is equally as essential as the cure. THE TUBERCULOUS EMPLOYEE 459 T-, ^ o o o oo ^ CO rH ^ CO M >! io"^ci •H T3 M — a (N ■* ^ o 3 a q oo CO lO ■ ^ CO CO -r '^" : °2 rH rq £>> o OO 1-4 C<) • T-H I— ( Th Oi IM rH -f d^'S i-< §^§ (M CO CO oi"ii S o 2§ I— ( , 1 h S p 23 — a) u2 9* si m m 03 (M CO 1— 1 ffi & 03 CI o — O o — rt _ o < aiq'Buoi:>sanl) o CO CD o a CO - : Tfl ^ o O - +J O o . T-( CO lO iH ^ ' 'O o o a o 03 O o o3 O o 03 — o o3 S5 pa^eajjB ddy < Tt4 CO ,-1 < »c ; -1^ < CD »o "3 : ^ Ph o ■ i^ ajno ddy (M CO : .- CD H < ^ o g »— I CO CO O lO lO ^ .-H - tH o M a) i-i CD 1—1 "* CO H " CO "3 cc : i-l 1—1 ^ : t^ ;?^ 1— 1 anioq ,_, 1—1 1—1 (N IC ^■B pa:jBaj^ 9omg H < Plh ninijo^'Bu'BS i> O T-H ^ T— 1 Tt< 1-1 CO Tl< Oi rH 03 rl en £ • 2 s =« s? o • 0! if\ ^ £ 03 s 03 03 0) >> & ^ a ,£3 fl & H H E^ C Eh Eh O Eh O Eh -a (d hr o3 Cl 03 a; 03 -tJ rA OI 3 ■n tPl crt 03 bX) a c d O tj ^ o at d t^ fl 1—1 03 -o l=! a> lA rrt ii m Tt< cj »o (U m OI Tl rt a> ^ +-> it! (4-) a o 03 rr 0) «J-. C n 03 > 460 INDUSTRIAL MEDICINE AND SURGERY The establishing therefore of industries in certain centers where these ex-sanatoria patients could be sent for graduated employment under proper medical supervision is a duty which should no longer be neglected. Those states which are providing sanatoria for the tuberculous should at once provide these state industries where they can work until such time as it is safe for them to return to private employment (F g. 68). It is a fallacy to recommend outdoor employment such as farming for all arrested or apparently cured tuberculous patients. Many of Fig. 68. — Every state should provide these model factories for the tuberculous in connection with the state sanatoria. these are not vocationally trained or physically fit for the strenuous out- side work and to others it is abhorrent. Experience in caring for the tuberculous employee has proven that the majority of these can return to their former occupations providing there are no known hazards connected with it. Society owes an everlasting debt of gratitude to those industries which have provided the means of Prevention, Discovery and Treat- ment of the Tuberculous Employees. CHAPTER XXX RECLAIMING THE TUBERCULOUS SOLDIER FROM THE MILITARY AND INDUSTRIAL ARMIES The army is a great military industry made necessary by the pres- ent struggle of right against might. Its medical problems are very similar to those found in the industrial army. The solution of these problems for the soldier is destined to carry over into civilian life. Therefore, in considering the reclamation of the tuberculous at this time it is only logical to deal with the entire man power in both armies. The war has brought to public attention a great many disabilities which overtake the soldier as the result of military service. Some of these disabilities and our efforts to overcome them are in the lime- light more than others. ' Thus, the reconstruction of the badly crip- pled, the deformed, and those suffering severe facial disfigurations, is wonderful and quite spectacular to the general public; the retrain- ing of the limbless and of the blind likewise appeals to our minds and imaginations. But just as wonderful work is being done for those soldiers disabled because of disease and the number of these far exceeds those who are crippled or blinded. These same disabilities existed before the war, but the busy pub- he paid very little attention to them except when they or their friends were the victims. But our efforts to prevent disease among the soldiers, and when disabilities overtake them, to reconstruct, and when necessary retrain them for a Hfe of usefulness, are gradually awakening the public con- science to the need for the same efforts among the civilian disabled. The disease which is causing the most disability among the sol- diers of all the nations is tuberculosis. We have not been in the war a sufficient time to realize the terrible ravages of this disease among the military and civilian forces alike, but the experience of our allies is sufficient warning to point out the importance of our preparing to combat tuberculosis and its complications. It is difficult to obtain exact statistics concerning the incidence of tuberculosis in the warring nations. A conservative estimate re- cently made by one of our greatest tuberculosis experts, Dr. Briggs, who studied conditions at first hand in Europe, showed that there are at least 500,000 active cases of tuberculosis in France. England 461 462 INDUSTRIAL MEDICINE AND SURGERY shows an increase of 16 per cent, in the death rate from pulmonary tuberculosis as compared with the rate of 1914. The Canadian forces have already sent 2500 cases of tuberculosis back to the sanatoria in Canada for treatment. Fifty per cent, of these were discovered among the soldiers before they had been sent overseas. Many cases of tuberculosis have been discovered among our own soldiers. The epidemics of measles, grip and pneumonia which have been so prevalent throughout the cantonments, will increase the tuber- culosis rate materially. In the light of the above facts and figures it is imperative that the plans of the medical department of the army be formed along three distinct lines: prevention, reclaiming, and coordination with civilian plans. As a result of the work of the National Tuberculosis Association during the last fifteen years the national conscience has been stirred, the public has been educated to means of prevention and cure of tuber- culosis, and the soil has been generally prepared. A great harvest of results awaits the reapers. In addition to this publicity and missionary work almost every large city of the country now has its tuberculosis institutes, many county institutes have been formed and much valuable machinery in the way of medical experts and visiting nurses has been established for the purpose of fighting this disease. A number of municipal and state sanatoria have been erected. A few states like Massachusetts have made elaborate plans for a sanatorium in practically every county or group of counties and have many of these in operation. Large appropriations by some of the states have been made. Meanwhile, the medical profession has made great advances in the treatment of this disease. No longer is it considered fatal. No longer do we think it necessary to send the tuberculous patient out west or far from home in order to accomplish a cure. Homesickness and want have ceased to be the great allies of Death in treating these cases. Climatic treatment, many different drugs and serums, and other specifics have come and gone during these years. Theories as to modes of infection and as to the spreading of infection have been advanced and discarded, and some remain for the proverbial bone of contention. Absolute rest for months has been advocated by some, and early exercise and work is the criterion of others as adjuncts to various forms of treatment. But a few sound, common sense principles have been evolved and have withstood the acid test of time and criticism, and will remain as the fundamentals in our crusade against this disease. These are: RECLAIMING THE TUBERCULOUS SOLDIER 463 1. Prevention. (a) By combating unsanitary home and working conditions, child labor, inadequate food, alcoholism, and venereal diseases. (6) By preventing the spread of the disease from one infected person to another, (c) By active and thorough treatment of those respiratory diseases predisposing to tuberculosis. 2. Diagnosis. (a) The importance of an early diagnosis. (6) The value of the periodical medical examination as a means of early diagnosis, (c) The importance of medical examination of other members of the family when a case is discovered. 3. Treatment. (a) The instituting of early sanatorium treatment. (b) The value of isolation of the case from free intercourse with society. (c) The established routine of Rest, Fresh Air, Proper Diet combined with graduated exercise later on. (d) The importance of supervision of the apparently cured c'ase for many years. All of these things with many additional details the tuberculosis expert and his lay and nurse assistants do to-day. The treatment laps over into the social and economic field. Thus, the tuberculosis institutes, and other groups of workers in this field, have banded -to- gether to efficiently handle the medical, social and economic aspects of this disease. They treat not only the individual but society at large. A wonderful work has been accomplished by these organizations all over the country but the surface has only been scratched. Their cases have come to them voluntarily or been referred by charitable organizations. The weakness of the system has been the absence of some form of governmental control — federal and state. The discovery of approximately two hundred thousand cases of tuberculosis among the first ten million men between twenty-one and thirty-one examined for the draft army showed the enormity of the task before us. Thousands upon thousands of young men have been thrown back into civilian life suffering from tuberculosis. Some have been referred to the proper authorities for treatment, but many remain loose in society to combat the disease according to their individual desires — sources of infection to their fellowmen. What an economic waste of man-power in this day when man-power is at such a premium. 464 INDUSTRIAL MEDICINE AND SURGERY . Therefore, the first contact that should be established and cemented most firmly between the military and civilian forces is apparent — the reporting of every man rejected from the army because of tuberculosis to an authorized civilian agency. This agency must provide in every state suitable sanatoria and proper medical attention for the treatment of these cases until cured. The state should make such a course of treatment compulsory. The mistake of our allies in allowing them to go untreated, spreading the infection to others, must not be repeated by us. Such a mistake has already been made but it is not too late for correction. For years we have dreamed of a nation striving constantly to prevent tuberculosis. We have dreamed further of an elaborate system, of sanatoria scattered throughout the nation for the cure of these cases. To-day the demand for the conservation of our man-power makes it absolutely essential that our dreams become realities. This is a national emergency and all things looking to the winning of this war, either by sacrifice or by saving, can be established now. This is the time to get together and do it. All tuberculosis associations should cooperate with the United States Public Health Service, the National Defense Council, the American Red Cross, the organized medical profession, and all other agencies capable of contributing to the effort, and institute a great drive against tuberculosis now rather than two years hence when the increased number of cases will force cognizance of conditions as it has done in France and England. There is still another civilian force that has been doing excellent work in the tuberculosis field — a force that has made itself felt more and more during the last decade in both the medical and economic world. I refer to the industrial physicians and surgeons of the country. Not the oldtime company doctor who constantly thought of the interests of the employer alone, contenting himself with the emergency surgery that arose in the plant, but the new industrial medical man who speaks the language of preventive medicine and preventive surgery, who is the employees' physician, and who has become a great efficiency expert for the employer by constantly thinking of the interest of the employee. About ten years ago the medical examination of employees became a fixture in a few industries. Gradually it became apparent that for the protection of the old working force and for the new workmen alike the examination of all applicants for work must be included in this system of health supervision. Whereas, ten years ago only three or four industries in the country had established some system of health supervision, the foundation RECLAIMING THE TUBERCULOUS SOLDIER 465 of which is the medical examination at stated intervals, to-day we see a very comprehensive and thorough system in operation in at least one hundred industries and approximately five hundred concerns have inaugurated some health system. It is impossible to estimate the results of the work of these surgeons upon the health of the industrial workers of the land. Neither can we say to what extent the death rate from both accidents and disease has been reduced by their efforts. But that the results have been immense is a certainty. I have obtained the figures from ten industries where the best form of Industrial Medicine and Surgery is practised, where the medical examinations are thorough and complete and where careful statistics of results are kept. These figures show that last year 104,066 employees were given medical examinations; that during the last five years 276,420 employees have been examined thoroughly. Some of these industries have examined " their workers only during the last year, while others have had the system in force for the entire five years. During these five years examinations have resulted in the dis- covery of 4423 cases of tuberculosis, or 1.6 per cent, of all examined had the disease. Approximately one-third of these were cared for by the industries where they were employed. With a hundred industries carrying on a comprehensive system of Industrial medicine to-day it is conceivable that during the next five years 27,642,000 physical examinations of employees may be made and 442,300 cases of tuberculosis discovered. If the states will only provide adequate sanatoria care for these cases, the greatest advance will be made in eradicating this greatest plague of humanity. The Industrial Surgeons' Committee of the Council of National Defense has proposed a program for the complete supervision of health of the industrial army during this crisis through which the nation is now passing. Recognizing that the industrial army is of equal importance to the military army in winning the war, this committee is endeavoring to devote its energies to keeping the standard of health at the highest level among all workers in the industries neces- sary to the continuance of the war in order to keep production up to the highest mark. Healthful workers are as essential to production as the most effect- ive machinery — both must be supervised. To attain these results the committee proposes to establish in all industries the following program : 1. Supervision of physical condition of employees by medical examinations. 30 466 INDUSTRIAL MEDICINE AND SURGERY 2. Industrial sanitation. 3. Sanitary home conditions. 4. Prevention of disease. 5. Prevention of accidents. 6. Early and proper medical and surgical treatment when needed. To carry out this program the industries must not be depleted of physicians. Other medical men must be persuaded to enter this field. By concentrating upon a large group of people in this way the doctors can supply the demands of the civilian population much more efficiently, which is very desirable at this time when so many of our profession are in the army. In addition to this force of physicians the committee intends to secure the greatest co-operation between the United States Public Health Service, the Department of Labor, the state and municipal health departments, and all other agencies which must be depended upon to do a part of this great work. It is hoped, and there is reason to believe, that the federal govern- ment will throw its influence behind this movement in order to have the war industries at least adopt this program. This is one of the greatest war measures that has been undertaken during this national emergency. With such a system of health supervision established in industries throughout the country, millions of people will be given periodical medical examinations and thousands of cases of known and unknown tuberculosis will be found. Experience in this line of work has proven that over 85 per cent, of these cases will still be in the curable stages. What will become of these tuberculous Industrial Soldiers? How will the civilian forces handle them? What provisions have the states made to adequately treat these cases? How will the Federal Govern- ment meet the problem? By co-operation and co-ordination the medical department of the army and the various civilian agencies can meet this situation. God grant that we may arise to our opportunity! The immediate problems for the civilian forces are: 1. Providing in every state several sanatoria where these cases can be treated. 2. Laws making sanatorium treatment compulsory until the disease is arrested. 3. Co-operation with the Industrial program in order to discover the tuberculous employees. ' 4. Co-operation with the machinery of the army to have the tuber- culous draftee referred to the proper civilian authority. 5. A National program of Health Supervision carried on along lines similar to the Food Conservation work, whereby the EECLAIMING THE TUBERCULOUS SOLDIER 467 entire population of the country would be induced to enter into a great, common-sense health movement, as a patriotic duty. This could be accomplished by an educational campaign which has the moral and financial backing of the Federal government. The medical examination of everybody could be made a fact, and the correction of the diseased conditions would naturally follow. The present tuberculosis problem has been facing the medical department of the army for over a year now. Those found at the draft examination with this disease and even many of those discovered within three months after induction into the service have been thrown back into civilian life. Unfortunately only those cases which were found at the examination at the cantonments were referred to civil- ian authorities. Some of the states have provided for the care of these but others have failed to meet the problem. The first great advance in the army program was made the first of this year (1918) when the Surgeon-General issued an order that all cases of tuberculosis found at the cantonments after the men had been inducted into the service would hereafter be considered "in line of duty." This stopped the discharge of many of these cases. Sanatoria treatment was offered to all regardless of "line of duty" or not, but refusal to accept it meant their discharge. For those in line of duty the War Risk Insurance Bureau took up the case and arranged for compensation. The treatment was left to the individual's desires and arrangements. Any of these line of duty cases could apply for treatment in one of the army sanatoria if they so desired. This was not generally known by the men, however, and the busy army doc- tors did not always take the opportunity of urging sanatorium treat- ment to them. In 1918 the War Risk Insurance Bureau through the United States Public Health Service arranged for sanatorium care for many of these discharged cases. About nine months ago (August, 1917), the Division of Physical Reconstruction and Rehabilitation of Disabled Soldiers was organized in the Surgeon-General's Office. The purpose of this Division was to provide the machinery for completing the cure of certain types of disabled soldiers returning from overseas and arranging for their re-education and vocational training when it was necessary for them to learn a new occupation because of the nature of their disability. At first it was thought this work would be limited largely to the surgical cases, especially orthopedic and severe facial disfigurements. Gradually the plans for Physical Reconstruction have unfolded, however, until to-day it includes every type of medical or surgical case requiring prolonged treatment, and instead, of referring only to 468 INDUSTKIAL MEDICINE AND SURGERY the disabled from overseas, all cases in this country or from the expe- ditionary forces abroad are included in its scope. It is realized now that the tuberculous patients will make up a large proportion of those needing reconstruction and in many instances vocational retraining. In December, 1917, and again in January, 1918, a new policy was submitted by the Surgeon-General to the Secretary of War for his approval. The Army Regulations provided that when a soldier was unfit for full military service he was to be discharged from the Army. Medical and surgical treatment was rendered to these men but often they were discharged before a cure had been accomplished. This new policy, however, provided that in the future no disabled soldier should be discharged from the Army until from a physical, func- tional and mental standpoint he had been cured as far as it was humanly possible. It further provided that the medical department of the army should employ all therapeutic adjuncts necessary to attain such a result, including physiotherapy, bedside occupations, and cm-ative therapy in workshops. This policy was approved by the Secretary of War the first of May, 1918. This will prove to be one of the greatest advances ever made by the medical department of the army and is another notable achieve- ment of our illustrious chief. General Gorgas. The far reaching re- sults of such a policy are only vaguely comprehended by the majority of men as yet. It means the death knell of our old soldiers' homes where disabled men in the past have been prematurely relegated to the scrap heap. To complete this process of reclaiming the disabled soldiers Con- gress is providing the machinery for their vocational retraining when necessary, assistance to* complete their educations, replacing in occu- pations where they will have as great or a greater earning capacity than before they were handicapped and the proper soc al and eco- nomic supervision to see that their rehabiHtation is completed and so remains. This portion of the work will undoubtedly be delegated to the Federal Board for Vocational Education after the man is dis- charged from the army. Co-operation between this civilian agency and the medical department of the army will enable much of this vocational training to begin during the final stages of the man's convalescence. Already the War Risk Insurance Act has been placed in operation and it provides excellent compensation for these men — a compen- sation based upon a debt which the nation rightfully owes her dis- abled soldiers and not given to them as a charity. No matter how proficient these men become as the result of vocational training, this compensation will not be reduced. RECLAIMING THE TUBERCULOUS SOLDIER 469 The tuberculous soldier is included in this far reaching plan as well as all other types of disabilities. Sanatoria are being established in various parts of the country where these tuberculous soldiers can be sent and retained until cured. The order has already gone forth mak- ing it compulsory to send all cases of tuberculosis to these sanatoria, both from the home and expeditionary forces before they are dis- charged. Some will demand their discharge on arriving at the sana- torium and will bring political influence to bear to secure it. But the majority will be subtly persuaded to remain until their disease is apparently cured. The prolonged course of treatment necessary for these men will enable many of them to be vocationally trained for better positions in life before they are discharged. Now that the army has provided this improved arrangement for the tuberculous soldier it behooves the civilian forces to make equally elaborate preparations for the physical reconstruction and rehabili- tation of the tuberculous industrial soldier and in fact for all civiHan tuberculous patients. This can only be accomplished by federal and state provisions for the discovery of these patients and the necessary sanatoria for their treatment. Combined with this must be a nation- wide educational campaign to arouse public opinion in favor of such a program. The treatment of both the military and civilian tuberculous should be for the combined purpose of accomplishing their complete physical and mental cure. Instead of returning them to their communities as hospitalized individuals they should be returned as more useful economic units of society. This can be attained by introducing curative work and vocational training into the routine sanatorium treatment. The following outline is a suggested plan for the physical recon- struction and rehabilitation of the tuberculous from both the mili- tary and industrial armies. In reclaiming those in the military and industrial armies who have contracted tuberculosis and in securing their complete rehabilitation, the following requirements must be considered : I. The best medical treatment with certain adjuncts to secure the most rapid recovery. II. Certain occupations in connection with this treatment, to prevent hospitalization and to refit for employment. III. Suitable employment after the disease is arrested or apparently cured, combined with proper medical supervision I. The best medical treatment with certain adjuncts to secure the most rapid recovery. A. Prevention. 1. By periodical physical examination to discover early signs of the threatened disease. 470 INDUSTRIAL MEDICINE AND SURGERY 2. By prompt and proper medical care of all colds, grippe, bronchitis, pneumonia, and other respiratory diseases. 3. By proper care of certain complications predisposing to tuberculosis which remain after these act ve diseases are cured. For instance, pleurisy following grippe and pneumonia, or the small patches of unresolved pneumonia following the latter disease predispose to tuberculosis. B. Sanatoria Care, Medical Treatment and Adjuncts. 1. When tuberculosis develops, the case should be sent to a sanatorium at once. 2. The medical care should be under specialists in tuber- culosis work. 3. During the active stage when temperature, weakness, and aggravated symptoms demand absolute rest in bed, the men should be entertained, but all mental and physical work should be barred. 4. Light mental and physical work can become an adjunct to the medical treatment when the patient reaches the stage of treatment which permits his sitting up in bed or spending a few hours in a reclining chair on the porch. a. Purposes: * 1. To stimulate hope and desire for recovery. 2. To occupy patient's mind, to remove his thoughts from his disease, and all outside worries. Encom- aging reports from home that his family is all right and being properly cared for are essential to help put patient in proper mental attitude. 3. To gradually prepare him for a more elaborate course of study and work as soon as his condition warrants. h. Types of Mental and Physical Work: 1. These must be arranged after a careful study of each individual with a view of accomplishing the purpose desired. 2. The studies should be arranged along the Knes of the man's former occupation, with the idea of making him a better employee or employer. For instance, if a farmer, his studies should be along the Knes of agriculture. If he were a dry goods clerk, his studies should be the "textile industries," the ''manufacture of silks and dress goods, "" business management," "human engineering," etc. 3. Most cured tuberculous cases can return to their former occupations, except those employed in dusty work, as coal miners, certain types of packers, etc.; RECLAIMING THE TUBERCULOUS SOLDIER 471 in occupations with disease hazards, as lead workers, phosphorus workers, etc.; in jobs with great ex- posure to elements, combined with heavy work, as teamsters. For these there must he training in new occupations. Here again the individual equa- tion must be carefully studied. After the man has decided what line of work he intends to follow, his studies should be along that line. 4. Light occupations should be provided for these bed and chair patients as soon as their conditions warrant. (1) Embroidery, pottery, light jewelry, and the usual arts and crafts work commonly employed heretofore are not practical nor .appeal- ing to the average man. They may well be used for the female patients. (2) Curative work should always be made of the most practical character. 5. Examples of light work : (a) Knitting socks, wristlets, sweaters, etc., not by hand, but on the light machines now provided for this purpose. (6) Making dressings for hospitals. (c) Making various kinds of splints. {d) Wrapping armatures. Arrangements can be made with nearby electrical concerns to have this done by piece-work. (e) Sign painting. (/) Typewriting and learning shorthand. ig) Toy making by hand. {h) Book binding (^) Careful analysis of light occupations will reveal many more with a practical trend. 6. Moving pictures, lectures, and other forms of enter- tainment, both amusing and instructive, must be combined with this medical, mental and occupa- tional therapy, as a definite part of the cure. II. Various studies, heavier and more continuous occupations, and retraining for work. After the patient's disease becomes quiescent and his temperature remains normal, and his strength returns; and in the opinion of the physician the patient can have a certain number of hours of exercise per day, his course of study can be increased and he can be permitted to do heavier work. When necessary to retrain for new occupations, this can now begin. The doctor must at all times decide the number of hours of study 472 INDUSTRIAL MEDICINE AND SURGERY and work which it is advisable for the patient to pursue. This must be increased and decreased according to the patient's daily condition. A. Purposes: 1. Same as purposes for Hghter occupations and study, plus. 2. To prevent laziness, dependence, and hospitalization so prevalent in all sanatorium treatment. 3. To refit for employment in his old or a better posi- tion than he had previous to the war. 4. To increase productivity and earning capacity. B. Types of Study and Work: 1. His studies started during his earlier days can be con- tinued, increased, and supplemented by classroom work and by special lectures and note-taking. Lectures in almost any line of study can be procured gratis from our large industrial establishments. 2. His work can now be increased to give productivity and wages; and thus develop a sense of independence and usefulness. 3. Examples of occupations: a. Carpentry. h. Mechanics — especially acetylene welding, lighter motor mechanics, inspector work, as of small shells, and other lines, especially valuable for war industries. c. Agriculture — bee husbandry, poultry raising, stock rais- ing, gardening, and lines suitable to those who were farmers and to the few suitable cases who will be re- trained for farming. Every sanatorium should have its own poultry yards, bee hives, and dairy, and these can be utilized for teaching purposes. d. Tailoring — this work is especially fitted as a form of occupation for the tuberculous when he can first begin to return to work. It is not heavy, can be performed in airy rooms, is done by machines, for the most part easily manipulated, and pays good wages. Every sanatorium could make suits and uniforms for our soldiers and sailors, such as are being made by the factory in New York which is run by 150 arrested " tuberculous cases. e. Shoe repairing: Old shoes from the army could be sent here for repair, which would give productivity and wages. /. Commercial work should be provided. g. Every occupation represented by a patient should be RECLAIMING THE TUBERCULOUS SOLDIER 473 represented in some way at the sanatorium to improve the patient along his line of work. h. The idea that all tuberculous cases after leaving a sanatorium must return only to outside work is er- roneous. With very few exceptions they can return to their old employment. Therefore, our idea should be to improve their condition by education, by a broader insight into their work, and fitting them to advance into better positions. III. Suitable employment after the disease is arrested or apparently cured combined with proper medical supervision. A. No tuberculous patient should be discharged from a sana- torium until the disease is arrested or apparently cured. In some cases this may mean two years or more of sana- torium treatment. However, if he is discharged before this goal is obtained, the benefit of his sanatorium treatment may be lost. Exceptions may have to be made to this rule, but as a general principle this standard should be adhered to. In some cases arrangements for suitable work under medical supervision can be made, thus allowing the cure to continue while the patient is earning part or all of his liv- ing. State industries should be established for this purpose in connection with state sanatoria. B. These men should be placed at work under the best sanitary conditions possible. If their old jobs were in unsanitary plants, sweat-shops, etc., similar jobs should be secured for them in suitable working places. C. Definite arrangements should be made whereby these patients will have medical supervision and periodical ex- aminations, in order to make sure that their disease remains arrested and continues into a permanent cure. The effective plans for the salvaging of the tuberculous from the military army should awaken us to the immediate need of reclaiming the tuberculous from the industrial army and from the entire civilian population. If we arise to our obligation and strive to conserve our manpower in this period of national emergency, the result will be one of the greatest and most beneficial by-products of this terrible war. Part IV INDUSTRIAL SURGERY CHAPTER XXXI THE SURGICAL DISPENSARY, STAFF AND EQUIP- MENT; PREVENTIVE SURGERY The physician engaged in accident surgery for an industry is naturally trained, by the very character of the work, to view every case from its economic standpoint. An accident occurs, and at once he plans the subsequent treatment with four fundamental principles in mind: 1. How to aid recovery the quickest. 2. How to prevent permanent disability. 3. How to avoid a fatal termination of the case. 4. How to prevent a recurrence of the accident. The welfare of the patient, the protection of the other employees, and the interests of the employer, all demand the careful con- sideration of these principles. Unfortunately such a conception of accident surgery did not obtain until of recent years. Like the man in Robert Burdette's lecture, "Acres of Diamonds," our best surgeons were seeking the newer and rarer conditions in other fields while the real, constructive surgery, ever present in their midst, as the result of accidents, was more or less neglected. But more and more during the last ten years expert surgeons have been attracted to this field of industrial surgery and their writings and teachings are awakening the profession to its duty in regard to the careful treatment of the victims of accidents. With the enactment of compensation laws greater demands have been placed on the sm-geon by industry, by the employees, and by the legal profession. He is frequently forced to give a prognosis of the expected results and occasionally the line of treatment adopted by him is reviewed and criticised by others before the compensation board. Not only must the injured part be cured, but it must be functionally restored so that the patient can again become a productive unit. If such a result 475 476 INDUSTRIAL MEDICINE AND SURGERY is not obtained, then a very definite reason for the failure is often demanded by these lay forces. These facts have caused all surgeons, and especially those engaged in industrial surgery, to recognize more fully their responsibility toward the accident cases. They are thinking less of the surgical end-result and more in terms of the economic end-result. Industrial surgery consists in the prevention and treatment of all injuries, the result of accidents, arising in the course of employment. These are usually divided into minor and major accidents. The subject can best be treated under the subheads of: (1) Preventive Surgery; (2) First Aid; (3) Emergency Treatment; (4) Subsequent or Permanent Treatment. Before entering into a discussion of these subheads, consideration should be given to the necessary arrangements for the proper care of accident cases in industry. The Surgical Staff. — Industrial surgery, in its best, most complete interpretation, is now based on the principle of bringing the surgeon to the injured instead of the injured to the surgeon. In other words the surgeon must be constantly on the job in industry to render immediate and proper treatment to all injured employees. This principle is the greatest advance which has been made in accident surgery during the last decade. Moorhead, Corwin, Clark, Hudson, Farnum, Mock, and other surgeons in industry, and Bloodgood, Edward Martin and others, have emphasized this point at every opportunity. For adequate treatment of injured employees every industry should provide the services of a qualified surgeon. The smaller plants cannot perhaps afford to keep a surgeon on the premises at all times and the best plan for them, therefore, is to combine with others for the employment of a surgeon. A central office in the neighborhood of several industries, at which a surgeon is always in attendance, affords the best solution for these smaller concerns. Well trained assistants must be instructed to render the necessary first aid care. The large industry, especially if accidents are frequent, should have a surgeon near at hand at all times so that prompt care can be rendered. Three plans may be adopted to meet the situation, namely : 1. The doctor should spend a part of each day at the plant dressing the minor cases which report to the doctor's office, and caring for the injuries that may arise during this period. After two or three hours he leaves the plant to visit the major accident cases in their homes or at the hospital. He may care for the injured employees in one or two other plants by a similar arrangement. He must keep the plant posted at all times concerning his whereabouts. An associate must be arranged for who can respond to an emergency call when he cannot. THE SURGICAL DISPENSARY STAFF 477 During his absence from the plant a well trained first aid man, or preferably a nurse, should be in attendance to render emergency care to any injured. This person must develop clear judgment as to when to call the surgeon or when to send an employee to his office, or to the hospital, to see him. This plan is in force in many industries and gives fair results. It is indeed, a great improvement over the old method of leaving an injured employee without any care until some doctor — any doctor — could be summoned, or until the ambulance could be called and the injured party sent to the hospital. 2. The second plan consists of employing an all time physician who remains constantly at the plant during working hours giving immedi- ate emergency treatment to all injured employees and attending to the daily dressings of the ambulatory cases. The major accident cases are sent to the hospital or to their homes under the care of some other surgeon. Usually the management arranges with this surgeon to treat these major cases, which is preferable, or the injured employee, or his family, chooses the doctor he desires. As a rule such company surgeons become expert at emergency care but are not qualified to carry the treatment of serious injuries through to their completion. This plan has been in vogue in many of our large industries for years. It has given good results but not the results obtained by plac- ing the full responsibility for the best and quickest possible cure on the surgeon connected with the industry. 3. The third plan is more often found in those plants employing part time surgeons but it is also applicable, and in use, among the full time surgical staffs when two or more doctors are employed. One physician, the surgical assistant, is thoroughly trained in emergency treatment and the subsequent dressings of all injured employees reporting to the plant dispensary. The chief surgeon spends a part of his time at the plant supervising the emergency work, as well as all the other angles of the industrial medical practices. The remainder of his time is spent at the hospital and at the homes of injured employees rendering the necessary permanent treatment. In the part time staff such a surgeon usually has time to teach and develop a private practice. He has two surgical assistants each spending a half day at the plant. I always insist on one of these living near the plant so that he can quickly be called at night in case of an accident. Where a large night force is employed a surgeon should be on the job all night. This third plan, involving as it does the combination of an experi- enced emergency surgeon at the plant at all times, and the supervision of all the work and the permanent care of the major accidents by 478 INDUSTRIAL MEDICINE AND SURGERY another qualified surgeon, has given the best possible results in indus- trial surgery. Every industry employing men or women in work where accidents are prone to occur should adopt one of these systems. The best plan necessitates the employment of good surgeons at all times. Cheap surgery usually gives poor results. Employers will find that expert surgery, while costing more in the beginning, is by far the cheapest method in the long run. Such surgery will reduce law suits, lessen compensation, and add greatly to the loyalty and confidence of the employees. Surgeons employed by industry must become thoroughly imbued with the fact that proper treatment rendered immediately after an Fig. 69. — Surgical room for men. (From Doctor's Office, Sears, Roebuck & Co.) accident occurs is one of the greatest principles of preventive surgery, surpassed only by the prevention of accidents. They must study the local situation so that someone absolutely qualified to give this imme- diate treatment is always close at hand. Theirs is one of the most responsible positions in the medical profession. The surgical nurse is the most valuable assistant the surgeon in industry can have. Some employ a male nurse for this position but I have found a well trained, carefully uniformed female nurse is a more efficient assistant. Her presence, if she is adept, conscientious and tactful, adds to the confidence of the employees and increases the morale among them when they visit the office. This nurse should remain in the plant dispensary continuously during the working hours. She should be thoroughly trained in her relations to emergency surgery and able to take charge of a case and render first aid care until the surgeon arrives if he should be absent from the plant. Such nurses become quite skilled in this work and THE SURGICAL DISPENSARY STAFF 479 undoubtedly have saved the hves of employees in more than one serious case. The nurse sterilizes the dressings and keeps a supply on hand at all times. She keeps the instruments sterilized and ready for immediate use. She prepares the patients for minor operations performed in the plant dispensary and assists at these operations. In fact she is a versatile operating room nurse and surgical dispensary nurse combined. In one plant dispensary where an average of one hundred injured employees received emergency treatment or reported for subsequent dressings daily between the hours of 8 a.m. and 12 noon, one emer- gency surgeon and two surgical nurses were able to efficiently handle this work. Miss Mabel Liddel, one of the pioneer industrial surgical nurses of the country, was largely responsible for developing this system. Just outside the surgical room a girl clerk was stationed. As the employees left she collected their passes and recorded on their permanent records the penciled notations made on the passes. His- tories of new accidents were obtained and recorded in the same way. The doctor questioned every new accident case carefully and brought out all important points which would help in preventing the recurrence of a similar accident. (See Chapter 12 for records of Accident Cases.) This clerk kept a tickler system on each employee and if he failed to report promptly at the designated hour for, his dressing would phone to the department and have him sent to the office. Occasion- ally it happened that an employee remained at home because of his injury without notifying his department or the doctor. This tickler system enabled the detection of all such cases. One of the surgical nurses would call on the absent employee in the afternoon and either bring him to the office for treatment or would summon the surgeon to his home. This constant watchfulness is necessary to prevent complications developing in these accident cases, as employees are frequently careless about their dressings or prefer to try some home remedy, as a bread and milk poultice, thus adding greatly to the danger of infections. The Surgical Office. — Every plant of sufficient size to warrant a doctor's office should set aside one room for the surgical cases. It is unsightly, arousing fears in the employees, if the sick and those reporting for examinations must witness the dressings of the injured. Furthermore such an office should be kept as clean and as aseptic as any operating room. This is often difiicult where workmen must report in their dirty, greasy working clothes, but nevertheless clean- liness can be maintained even under these conditions. Where women are employed a separate surgical room should be provided for them, or if only one room is available, men should 480 INDUSTRIAL MEDICINE AND SURGERY be barred while an injured woman employee is receiving her dressing, even though it is only an injured finger. As much segregation of the sexes in the doctor's office must be maintained as possible. The more nearly conditions can be made to correspond to a well regulated private office the better, for only in this way can the absolute confidence of the employees be secured. The office should be well lighted, well ventilated, and kept as free from drug and wound odors as possible. The walls should be white enameled and the floors made preferably of tile or of one of the cement-like preparations so commonly used in hospitals. Cracks and other places where dust can collect must be obliterated. The furni- ture and equipment should be of white enamel. Fig. 70. — Surgical dressing room for women. Instruments, especially knives and other terrifying paraphernalia, should be kept out of sight. The same is true of bloody or pus- saturated dressings which hav,e been removed. These should be thrown in a can covered with a lid which can be raised by a foot pedal. When a wound, which may appear frightful to others is to be dressed the office should be cleared of all other patients. Too much attention can- not be paid to these details which, if not observed, tend to have a bad reaction on the employees. The equipment of this office should be simple but adequate. The various illustrations show the ideal arrangement in some surgical dispensaries in industry. It should consist of: 1. A stationary wash stand with hot and cold water faucets with a foot pedal control. 2. A stationary foot tub and another for hand or arm baths. These facilitate the work greatly as many cases will need a prolonged hot bath for some sprain or chronic infected part. THE StTRGICAL DISPENSARY STAFF 481 3. At least two basins in a rack should be provided for hand solu- tions for the use of the surgeon. 4. One or more white enameled chairs, depending on the size of the room and number of patients accommodated at one time. 5. One white enameled stool on which the patient can sit while he rests his arm on a table for hand dressings. 6. One or more white enameled foot stools of sufficient height to facilitate foot dressings. 7. One white enameled surgical table for the patients who must lie down for treatment. This table will often be used for patients showing signs of fainting. 8. One recHning chair, somewhat similar to a dentist's chair, for use in eye injuries, especially in removing foreign bodies from the eye. 9. One small dressing table for use in hand and arm cases. 10. One white enameled, glass topped table on which instruments, jars containing sterile dressings, bandages, medicines and other things needed in the dressings of all kinds of cases can be placed. 11. One instrument cabinet. The number and type of instruments must be determined by each surgeon according to the local needs. All of the above equipment may not be needed in many plant dispensaries while others may need a more elaborate equipment. This, however, forms an average for most surgical offices. Sterilizing Room. — As an adjunct to every surgical dispensary in industry there should be a well equipped sterilizing room. This should consist of at least one large steam sterilizer for the steriHzation of all dressings and one instrument sterilizer. The rubber gloves worn by the surgeon, the basins for solutions, the dressings and in- struments and in fact everything coming in contact either directly or indirectly with the injured parts should be as scrupulously steril- ized as when used in an operation. In a well organized office this can be done without any undue loss of time. Dressings, Supplies and Bandages. — Surgical gauze should be used for the dressing of all open wounds. Absorbent cotton which is at times applied by some is not suitable because of the difficulty of removing this after it has become adherent to a wound. I have found the following procedure the most economical and most efficient in preparing dressings for at least a hundred cases per day. 1. Surgical gauze is bought by the bolt. 2. Nurses cut this into different size dressings : (a) Small, three layer piece of gauze for finger dressings (1" by 2"). (6) Slightly larger, three layer piece of gauze (2" by 4") for 31 482 INDUSTRIAL MEDICINE AND SURGERY hand dressings, or for small wounds about the head or other surface of the body. (c) Three layer, folded piece of gauze (4" by 6") for the larger wounds. (d) Four layer, rolled piece of gauze (4" by 10") suitable for encircling the arm or covering considerable surface of the body. (e) Large hemorrhage pads consisting of cotton covered with two layers of gauze folded with edges turned in (6" by 10") . (/) Larger hemorrhage pads (12" by 18") made about two inches thick for use in severe crushing wounds or to cover a stump where the Hmb is completely severed. 3. Each of these dressings is rolled separately in a piece of thin paper carefully twisted at either end so that the dressing is completely and thoroughly covered. 4. These are then placed in a small sack the size of a ten pound meal bag and put in the sterilizer for one hour. 5. These sterile dressings as needed are put in large covered glass jars kept on the dressing table. In using them the nurse or doctor tears off the tissue paper, unrolls or unfolds the dressing without touch- ing the portion which goes next to the wound and lays it over the in- jured part. All dressings in the first aid kit are similarly prepared. Towels, cotton tampons, sponges and similar materials are also covered with paper and sterilized. Basins are put in cloth bags which are then carefully tied with draw-strings and sterilized in the same manner. Rubber gloves are rolled in pieces of cloth and sterilized. Bandages are among the most expensive items in the dispensary if bought already cut in 1", 2", 3", etc., sizes. Very good gauze bandages can be obtained in long, solid rolls, wrapped in paper, and cut as needed with a knife into the various sizes. Strong cotton band- ages are also necessary especially in applying splints. Flannel bandages are used frequently about swollen joints or as supports in varicose veins of the leg. All of these materials can be bought in bulk and the nurses can cut and roll the bandages in the sizes needed. Cotton applicators play a very important part in minor surgery about an industry, lodin is best applied to surface wounds by means of these applicators. Also applicators and a bottle of iodin should be placed in every room about the plant so that employees can paint iodin on their wounds at once. These applicators are made by rolling a small piece of cotton on the end of a toothpick. Adhesive plaster is used extensively in dressing injured parts. This should be bought in bulk, rolls 14" wide and approximately three feet long. The small strip used so commonly to hold bandages in THE SURGICAL DISPENSARY STAFF 483 place, or often to replace bandages, can be cut and stuck to a piece of glass the size of a window pane, thus being quickly available for use. Employees with minor injuries, not sufficiently serious to prevent their working, can have their efficiency greatly increased or diminished by the type of dressing that is applied. This is especially true in in- juries about the hands. Often one sees a small cut on a finger band- aged until the whole hand and wrist are encased. The psychological effect of such a dressing on an employee is bad. Therefore the smal- lest possible dressing should be applied and a minimum amount of bandage used to hold it securely in place. As few joints as possible should be restricted by the bandage. Wire cages or protective strips of tin are very useful in protecting injured fingers and adding to the comfort and efficiency of the em- ployee. These are placed next to the sterile dressing and held in place by a bandage or adhesive plaster. (See Fig. 71.) Fig. 71. — Tin strips which act as a protection to the injured finger allowing the em- ployee to continue at work. Splints of all sizes should be prepared and always ready for im- mediate application to all fracture cases. The delay in preparing a sphnt for the immobilization of a fracture is annoying to the patient and often shows a lack of efficient management in the office. Before leaving this question of dressings the author desires to re-enforce what has been said regarding the use of sterile dressings. About two years ago he visited five surgical dispensaries in plants and five private offices where the doctors attended many minor injury cases for insurance companies. In only three of the plants dispen- saries and only one of the private offices were sterile dressings used. In the others gauze was bought from drug stores in the commercial, 484 INDUSTKIAL MEDICINE AND SURGERY so-called sterile, five yard rolls. The doctors would cut off the neces- sary amount of gauze needed for the dressing by pulling it out on a table and cutting it with unsterile scissors. Perhaps the first piece used was sterile but certainly none of the remainder could be. In- fections are bound to be more prevalent if these methods are used. One doctor never used gauze but simply covered the -wound with the ordinary commercial bandage. Every surgeon should strive to make the minor surgery carried on in industry as ideal, from an aseptic standpoint, as the surgery done in our best hospitals. Such methods have wonderful educational value in teaching the employees pre- vention. Sources of Accident Cases. — The great bulk of accident surgery naturally is derived from injuries received directly as the result of occupations or of conditions in the plant. However, many employees receive injuries outside the plant or while at home. These outside accidents have come to be known as "home accidents" in contradis- tinction to those received while at work. Major home accidents like serious illnesses are usually treated by the family physician or the surgeon he calls in. Often when the visit- ing nurse reports neglectful treatment of such cases the plant surgeon is forced to take charge. But minor home accidents are frequently neglected by the employees. They lie around the house for days with a swollen ankle, the result of a sprain, or with an infected hand due to some slight abrasion, trying home remedies and otherwise temporizing with the condition rather than consult a physician. Time lost from these slight injuries is excessive. But if the employee knows that he can report to the plant dispensary and receive free treatment he usually comes to work in order to see the doctor. Proper treatment can be instituted and the case supervised, and many times the employee can be assigned to work which will not interfere in his recovery. For three years it was the policy of the plant with which the author was connected to refer all home accident cases, even the slight in- juries, to the family physicians. We limited our care of these cases to emergency treatment only. Many who were thus referred failed to see a doctor but simply remained away from work until the injured part healed. Undue loss of time from work resulted. Gradually we began to treat these home accidents when they called at the office. More and more of the employees took advantage of this until in 1916 there were 4570 home accidents cared for by the plant surgeons. Approximately 95 per cent, of this number lost no time from work, except that due to reporting to the office for their daily dressing. With the old policy at least 50 per cent, of these cases would have remained at home, many because it was necessary to go THE SU'RGICAL DISPENSARY STAFF 485 to their family physician for dressings and naturally they would not report for work for a part of the day. Proof of the value of this system is seen in the following extract from the safety engineer's report to the general superintendent: ''The number of home accidents treated by the hospital has risen from 2896 in 1915 to 4570 in 1916, an absolute increase of 57.8 per cent., or a relative increase of 32 per cent. The reason that the em- ployees are making more use of the hospital in cases of accidents occurring outside the plant is due to the more liberal policy of the hospital in treating home cases, which was adopted with a view of reducing time loss in these cases. That this new policy has produced most satisfactory results there is no doubt." Occasionally one of these injured cases, for which the concern is in no way responsible, will develop complications which adds greatly to the expense of continuing this free treatment. However, if the surgeon has started free care, when the case seemed only a minor affair, he must continue the same policy when it becomes serious. The expense connected with the treatment of these minor home accidents, even with the occasional serious case arising, is more than compensated by the increased efficiency of these employees and the diminution in time loss. Schedule for Dressings. — Much loss of time from work can result from lack of system in the reporting of employees to the hospital for their dressings. If employees are simply told to "come back to- morrow for a dressing" most of them will report the first hour of work with the result that the congestion in the office interferes greatly in the surgeon's work and unnecessary delay in treatment. To avoid this a small hospital card, or pass, can be given to each in- jured case on which the date and hour for the next dressing is marked by the nurse at each visit. By our system ten patients . reported every twenty minutes. PREVENTIVE SURGERY Preventive surgery is a direct outgrowth of human maintenance in industry. It is still a new science in the medical field but the time is coming when it will receive the same recognition as is now allotted to preventive medicine. In practical operation in industry it in- cludes the following: 1. The prevention of accidents. 2. The prevention of complications when accidents occur. 3. The prevention of undue loss of time. 4. The prevention of permanent loss of function. 5. The prevention of threatened illnesses, premature breakdowns, lowered efficiency, etc., by adopting certain surgical procedures. 486 INDUSTRIAL MEDICINE AND SURGERY The prevention of accidents has been thoroughly dealt with in Chapters XXI and XXII. The following letter written by the author, early in his career as a plant surgeon, to the general superintendent of an industry will illustrate some of the preventive methods success- fully adopted since then by this and many other concerns. Surgeons entering this new field of medicine will find that the recommendations ^ submitted in a memorandum such as this do not always receive the prompt approval of the management, but patience and perseverance will usually result in the final adoption of these methods. *'Mr. : Safety first appliances installed last year prevented a great number of accidents. An excellent example is afforded by the reduction of accidents due to conveyors. In 1912 there were 101 accidents directly due to the new conveyors, while last year only four accidents could be traced to this cause. "A careful study of all the machines and processes in the plant would reveal many other places where safety appliances would reduce the accident rate. While the medical staff and the safety engi- neer are constantly striving to anticipate accidents by installing these appliances, yet the man on the job is in the best position to perceive hazardous conditions, especially if he is trained until he is imbued with the spirit of prevention. "I wish to recommend that the doctors, the safety engineer, the management and all the employees be urged this year to put forth a great effort to prevent both major and minor accidents and compli- cations, especially infections. "The first step in this direction is to appoint an accident 'prevention man in every department or two or three such men in the larger departments. Their duties would be: "l. To report the need of any new safety appliances to the Safety Engineer. Quite often the necessity for some safety appliance is not recognized until after a serious accident has occurred. This prevention man would constantly study conditions in order to foresee such a need. "2. To study the causes of minor accidents and endeavor at all times to remove these. For example this man would soon develop the habit, and spread it to others, of picking up every loose nail from the fioor or of removing obstructions which might cause falls. "3. To see that every employee who receives an injury, no matter how slight, paints it at once with iodin and then reports to the doctor. "4. To prevent employees from rendering first aid to one another, as for example the removing of foreign particles from the eye or extract- ing slivers. "5. To receive reports from the doctor concerning injured employees who fail to report at once, or concerning accidents in his department which apparently could have been prevented. THE SURGICAL DISPENSARY STAFF 487 "6. To receive periodical instructions from the safety engineer and from the doctors on all matters of prevention and on certain first aid methods which will make them competent to render the same if occasion arises. "The number of safety appliances which have been installed follow- ing suggestions from the employees demonstrate how valuable these men can be in this respect. "Last year 610 cases of infection developed after injuries. Twelve, or 1.9 per cent., of these used iodin and reported to the doctor at once. Twenty-four, or 3.9 per cent., reported at once without using iodin. "These thirty-six cases were only slightly infected and none of them required opening nor lost time from work. The remaining 574 cases reported from one day to two weeks after receiving their injuries; 520 of these required opening and all of them lost time from work, with an additional decrease in their efficiency while working with a finger or hand bandaged. Of this number 42 per cent, used iodin sometime later, while 52 per cent, failed to use it at all. From our past experience we know that the immediate use of iodin and then reporting to the doctor at once would have reduced this number of infections at least 90 per cent. An alert prevention man in the department would be one of the best means of training all employees to observe these rules. "It is a common practice for some man to try to remove a sliver from a fellow employee's hand. Often the part is so lacerated that an entrance for infection is the result; or only a part of the sliver is removed, the remainder being discovered a few days later when the member becomes infected. Great damage is often done to the eye by similar attempts to render first aid by an employee. Our preven- tion man could forestall these misdirected efforts. "Our figures are very striking in regard to wounds from splinters. Two hundred and eighty employees reported to the doctor on account of sliver wounds last year. One hundred and twelve, or 40 per cent., of these reported late with the part infected. All had either success- fully or otherwise endeavored to remove the splinter themselves or the same effort had been made by a fellow employee or some member of the patient's family. None of the cases reporting early to the doctor, who removed the splinter under aseptic precautions, become infected. "Occasionally a very serious accident occurs where first aid must be rendered at once in the department. In those departments where these major accidents are liable to occur we have placed first aid kits and two men have been carefully instructed by the doctor in the various first aid methods. This system should be extended so that the 488 INDUSTRIAL MEDICINE AND SURGERY prevention man in every department is a thoroughly trained first aid expert. These serious accidents may occur in the most unex- pected places. "Each prevention man should have at least two understudies who can in turn take charge of this prevention work if occasion arises. Such a system would give us missionaries who would spread the spirit of prevention throughout the working force, "I would further recommend that each department be given arating according to their percentage of accidents per employee last year and. that a contest be developed to see which department will have the greatest percentage of reduction in accidents each year. To further stimulate this effort a bonus should be given to the first, second and third most successful departments in carrying out this program of prevention." The above letter surely demonstrates that this branch of prevent- ive surgery is only limited by the vision of the responsible workers in this field.* The prevention of undue loss of time from work is best attained by treating every case of injury as serious from its inception until completely cured. Temporizing with slight infections, or with sprained backs; neglecting to diagnose early every case of frac- ture, or by considering some cases of apparent sprains as trivial, and later discovering that a true fracture is delaying the recovery; or sending some injured cases home when they really should have the advantages of the best hospital treatment, are all examples of- undue loss of time from work by injured employees which it is within the power of the surgeon to prevent. Early diagnosis, the adoption from the very first of the best line of treatment, constant watchfulness for compHcations, and starting early to restore function in an injured part are the best means of preventing permanent deformities. In order to accompHsh this the surgeon must be constantly on the job. He cannot leave impor- tant dressings, or the decision as to when massage or passive motion shall begin in an injured member, nor any other important point of judgment to some inexperienced interne. He must feel the full responsibihty of the case and act quickly and wisely if he is to be a true preventive surgeon. The constant supervision of the physical status of a large group of people, such as is carried on in certain industries, reveals many con- ditions which need surgical interference. Some of these offer oppor- tunity for classical operations but are not really essential to the health or efficiency of the employees. Others, which apparently cause no inconvenience to the employee at the time, urgently need surgical care in order to prevent future illnesses or premature break-downs. THE SURGICAL DISPENSARY STAFF 489 Frequently these conditions are causing an unknown loss of efficiency to the workmen which could be relieved by surgical interference. This type of surgery requires the most careful judgment on the part of the surgeon. It is not so difficult to convince a patient suffer- ing from some acute surgical condition causing intense pain to undergo an operation, but excellent arguments must be presented in order to persuade an employee in apparently good health to submit to one of these preventive surgical operations. The economic result is the best argument which can be advanced. If an employee can be shown that the removal of some condition, to which he has paid little attention in the past, will tend to improve his health, will prolong the period of his working capacity and will give him an immediate increased effi- ciency he will usually welcome such surgical procedure. The surgeon must be sure of his results before recommending operations on these grounds. One of the most classical examples of this type of preventive surgery is afforded by the work of our oral surgeons. A few years ago Billings and others called our attention to the part played by focal infections in rheumatism, arthritis, endocarditis and similar conditions. In order to relieve people suffering with these diseases, search for foci of infec- tions was made and the same were removed. The eradication of focal infections to prevent the occurrence of these diseases followed in logical sequence. The majority of up-to-date industrial surgical dispensaries now have their dental departments where this type of preventive surgery can be practised. (See Chapter V.) Diseased tonsils is one of the most common conditions found among employees. The condition is equally prevalent among males and females. They seem to cause more time loss and complications among the girl employees, however, than among the men. Recurring attacks of tonsillitis seem to occur with equal frequency among both sexes but headaches, nausea and backaches, all of which have been relieved by the removal of the diseased tonsils, caused the greater loss of time Among the girls. In 1914 the author began to recommend the removal of tonsils to all employees who showed signs of definite diseased conditions, with resulting loss of efficiency, due to the tonsils. As an inducement to the employees to have this operation performed, the surgeon offered his services free of charge. For those who could not afford to pay for a bed at the hospital arrangements were made for free hospital care; the others were charged only a nominal hospital fee. Approximately 250 tonsillectomies were performed for the employees by the sm-geon and a far greater number had the operation performed, by the surgeon of their choice, on the recommendation of the medical staff. These 490 INDUSTRIAL MEDICINE AND SURGERY operations, which the author performed, were always done in the hospital under the most aseptic precautions and the patients were required to remain there at least 24 hours. All cases recovered without any comphcations except two who had severe hemorrhages. In every case it was carefully explained to the employee that the operation was offered on the sole responsibihty of the surgeon and not as an activity of the concern. In practically every instance this preventive surgery has given the most excellent economic results. Male employees who frequented the doctor's office, complaining of sprained backs, lumbago and backache were reheved of these troubles in many instances. The girl em- ployees who reported to the office on account of headaches, attacks of nausea and fainting, signs of fatigue, frequent colds and other con- ditions traceable to this focal infection, seldom called at the office on account of these conditions after the tonsillectomy. Many of these employees were absent four or five times during the course of a year on account of acute tonsilHtis. The lost time averaged from two days to a week in each attack. Where the tonsils were completely enucleated all of these employees ceased to lose time on account of this disease. In only two of the author's series, due to small tags of tonsils, did subsequent attacks occur. In 1915 the records of 28 employees, on whom the author had operated for diseased tonsils, were carefully scrutinized to ascertain whether or not the desired economic results were actually being obtained. This scrutiny showed that for the two years previous to the tonsillectomies these employees had made 160 visits to the doctor's office, chiefly on account of tonsillitis, colds, sore throat, headache, conjunctivitis, nausea, pains in back, pains in joints, swollen glands and general fatigue. During the same period this group of employees had remained at home 71 times on account of sickness. Their chief illnesses were tonsillitis, colds, headache, rheumatism, neuralgia, influ- enza, and a few other conditions which seemed to have no connection with the tonsils. For the two year period following their tonsillectomies this group made 68 visits to the doctor's office and were absent from work only 33 times. A reduction in both instances of over 50 per cent, in time loss. The conditions causing these absences were as follows: 4 on account of colds 4 on account of stomach trouble 4 on account of rheumatism 5 on account of influenza 6 on account of dysmenorrhea 2 on account of bronchitis 2 on account of sore throat and earache THE SURGICAL DISPENSARY STAFF 491 3 on account of headaches 1 on account of pleurisy 1 on account of appendicitis 1 on account of cholecystitis The war interfered with the obtaining of complete statistics on all of the tonsillectomies but I am positive that the removal of dis- eased tonsils among employees, as well as among any other group of people, will result in greatly improved health and is a measure of the greatest economic importance to industry. It is amazing with what ease a small epidemic of tonsillitis will spread among a group of employees working in the same department. To avoid these epidemics, if the employees will not submit to the opera- tion, I have made it a point to recommend their transfer to work which segregates them as far as possible from their fellow workmen. Under the chapter on "Hand Infections" the relationship between these and diseased tonsils is pointed out and affords another example of the importance of this type of preventive surgery. The presence of an unsightly birth mark or nevus on an employee's face, or of a hairy mole on the lip, or of a large sebaceous cyst on the scalp is often the cause of lowered efficiency in an employee. The condition may make one self-conscious or backward, or it may re- sult in a foreman forming a wrong judgment concerning the ability of the workman. The surgeon can gain the confidence of these employees and explain the resulting damage which these condi- tions are causing them. After their confidence is gained most em- ployees will welcome the opportunity of having these unsightly growths removed. The gratitude of these patients and the energy they dis- play in overcoming the prejudice which existed either in their own minds, or in the minds of others, well repays the surgeon for his in- terest in them. Surgery performed for the purpose of preventing decreased efficiency is perhaps a new viewpoint but it is a field which every surgeon in industry has an opportunity to thoroughly investigate. The above examples of the scope of preventive surgery are suffi- cient to demonstrate that this field is comparable in importance and interest to the older and well-recognized work of preventive medicine. CHAPTER XXXII FIRST AID First aid, as used in industrial surgery, consists of such surgical or medical procedures as may be given to a patient by a layman pend- ing the arrival of a physician or during the transportation of the patient to the physician. Untrained individuals often render first aid care on their own responsibility. Such assistance is often necessary, but to be of the greatest value it should be administered by a thoroughly trained first aid expert. During the last ten years many advocates of first aid care sprang up throughout industry. Lay associations were formed and doctors, without sufficient training or experience in industrial surgery, were called in to lecture on first aid. First aid diplomas have even been issued, giving the layman a sense of great confidence in his ability to care for the injured. Many have advocated a national first aid movement which would train millions of our civilian population as to just what to do immediately for the injured man or woman. If the teachings of such an association were Hmited to three or four simple but essential p'rin- ciples, and the rest of their energy was devoted to "What Not to Do," there is no doubt but that such a movement would result in the saving of thousands of lives during the course of a year. But if the efforts of these half-trained first aiders were allowed to go unbridled among minor injury cases many of them would not see a doctor until some serious complication had developed. Recognizing the importance of standard first aid care to the injured civihan forces, many different individuals and associations have en- deavored to work out a logical system of standardization. Dr. Joseph Colt Bloodgood's questionnaires and investigations on this subject have resulted in stimulating these efforts, even though, as Bloodgood himself says, this work resulted only in the expenditure of considerable sums of money and the accumulation of so much material that he alone could not arrive at any logical conclusions. The committee on Standardization, under the leadership of Dr. Rucker, of the United States Public Health Service, took over the data which Dr. Bloodgood had collected and started a further investiga- tion on this subject. The war interfered with this study, but it is hoped that when conditions once more become normal much valuable informa- tion will be presented to the country as a result of the work of this Com- 492 FIRST AID 493 mittee. The Conference Board of Industrial Physicians, The National Electric Light Association, The Bureau of Mines — Department of the Interior, The National Safety Council and other organizations have brought out valuable contributions on the subject of first aid. While excellent results have been obtained by many of these standardized first aid methods when properly supervised by physicians, yet one outstanding criticism is applicable to the majority, viz., they are too extensive and tend to make embryo physicians out of the trained first aid assistant. r ■"'^1 Fig. 72.- -First aid station at Colorado Fuel & Iron Co. attendance. A trained nurse is always in In organized industrial surgery three first aid systems have been developed which deserve mention: 1. The best system is found in a few industries which employ a sufficient number of doctors and nurses on the premises at all times so that immediate emergency treatment by a qualified physician can be given to all injured employees. The only first aid care needed in such industries is: the application of some antiseptic at once by the employee himself or by some fellow employee to open wounds; the resuscitation of employees who have been overcome by gas, elec- tric shock or similar conditions; the control of hemorrhage by the ap- pHcation of hemorrhage pads or the tourniquet; and the removal of the injured party from a position to preclude further injury. Thus in those industries where a doctor can be summoned to a department within four or five minutes certain employees should be taught these simple first aid methods. Above all every employee should be warned 494 INDUSTRIAL MEDICINE AND SURGERY against unduly moving of the injured, against manipulation of broken parts, against ever touching the open wounds and certainly against endeavoring to remove foreign bodies. If the surgeon, on his arrival, needs assistance in these maneuvers he will request it from some in- telligent employee in the department. The majority of persons injured in the plant can be brought to the doctor's office at once where proper emergency care can be given. For these the only' first aid needed is the application of some antiseptic to the open wound; this can usually be done by the employee himself or by some fellow em- ployee. In these plants the nurses often respond to calls from de- partments and they become quite expert in rendering the necessary first aid. They take charge of transporting the patient to the doctor's office or summoning the physician if they think it unwise to move him at once. Fig. 73. — A first aid station in the Ford automobile factory. 2. The second method in vogue in some industries consists of first aid stations in various parts of the plant, with a well trained first aid man or a qualified nurse in charge. Injured employees are taken at once to these first aid stations, or the attendants are called to them when the injured party cannot be moved. These assistants render the necessary first aid care and then transport the injured to the doctor or immediately summon the physician to the case. In one industry medical students are employed for three hours a day on this work, so rotating that it does not materially interfere with their studies. FIRST AID 495 Here again the first aid is limited to the apphcation of antiseptics and a sterile dressing, checking of hemorrhage, combating shock and resuscitation. All manipulations or direct treatment of the wound is left to the physician who is close at hand. (Fig. 73.) 3. The third method is employed in industries engaged in unusually hazardous occupations and where the employees are scattered over a large territory, as, for example, in mines, in large steel plants, ship- building yards, etc. While physicians are employed by these con- cerns, yet they are usually stationed at the plant hospital which may be a haK mile or a mile away from the point where some of the work- men are employed. The best organized medical work in such con- cerns has recognized the need of competent first aid assistants scattered throughout the working forces. To meet the situation the physician has trained first aid teams in every department. The teams are taught how to immediately apply an antiseptic to open wounds and then cover them with a sterile dressing; how to check hemorrhages and combat shock; how to give artificial respiration; how to apply splints to fractured limbs and the best means of transporting the injured employee to the doctor. In some instances the medical staff depends altogether on these teams to render first aid care and to bring the pa- tient to the hospital, while in others the doctor is summoned from the hospital by one member of the team while the others are rendering the necessary care. The latter plan is better, as the physician can thus take charge of the case earlier than if he waits for the seriously injured to be conducted to him. During the early popularity of the first aid movement many more elaborate schemes than the above were promulgated. In 1914 the author visited a number of industries in order to study this question of first aid. He was astounded at the extensive preparation for this work which some concerns had made. For example, one industry had provided a very pretentious first aid kit, which contained a complete set of instruments, all varieties of commercial splints, six different sized bandages but no sterile dressings; one compartment of this kit was set aside for medicines and in this was found such drugs as castor oil, Epsom salts, whiskey, aromatic spirits of ammonia, morphin, cocain. Sun cholera tablets, a cough mixture, Jamaica ginger and several others which would enable the layman to treat medical cases as well as to render a questionable first aid to the injured. One can see at a glance that such power as this placed in the hands of a layman was dangerous and would tend to eliminate the physician from a field where he was most urgently needed. The very best types of first aid work were found in those industries where the doctor insisted on seeing the injured employee just as soon after the accident oc- curred as it was possible to bring the patient to the surgeon or the 496 INDUSTRIAL MEDICINE AND SURGERY surgeon to the patient. In those plants where the hazards of the occupations necessitated first aid kits the contents were Hmited to the necessary bandages and sterile dressings, a few splints, an antiseptic, a tourniquet and aromatic spirits of ammonia to be used when a stimulant was necessary. Short, terse instructions went with each kit and limited the layman in what he could do for the patient and impressed upon him the importance of getting the physician on the job at once. The first aid methods consisted only of preventing in- fection, checking hemorrhages, combating shock and resuscitation. All other treatment was left to the surgeon. Fig. 74. — The contents of the best first aid kits are limited to: a, Tincture of iodin and applicators; b, bandages and sterile dressings; c, some form of tourniquet; d, a few splints; e, aromatic spirits of ammonia. As a result of this study the author has adopted the following first aid rules: 1. All injured employees, no matter how slight the injury, must report to the doctor's office at once. 2. If the employee is so injured that he cannot walk to the doctor's office the physician must be summoned to him at once. 3. Every open wound which penetrates the skin, no matter how slightly, must be painted with iodin at once. The foreman or the selected first aid man in the department must pour iodin into the extensive open wounds at once. For this purpose a small rack, containing a bottle of iodin and a bottle of applicators must be placed in a conspicuous spot in every department (as many as twelve of these racks have been placed in the larger departments). Instructions on each rack and on the bulletin boards warn the employees to use iodin at once in the case of injury and then immediately to report to the doctor. (See Fig. 75.) 4. First aid kits must be placed in all departments where machinery FIRST AID 497 is used or where other hazardous processes obtain. A wooden box, 15" X 9}4" X 7" fastened by a strong clasp and equipped with one handle, wh ch acilitates carrying is to be used as a conta ner for the first aid material. This box is divided into four compartments: a large one for the various sized dressings, a smaller one for bandages, the tourniquet and a spool of adhesive plaster, a third compartment just large enough to hold the container for the iodin and applicators 1 Fig. 75. -Rack used by author to hold bottles of iodin and applicators, placed in conspicuous places throughout the working place. These are and a fourth small compartment into which is placed the aromatic spirits of ammonia. (See Figs. 76 and 77.) (a) The dressings are placed in three cloth bags, according to their size, as follows: Small sterile dressings, rolled individually in tissue paper for finger bandages or other small wounds. Middle sized sterile dressings, rolled individually in tissue paper for the larger wounds. Four large sterile hemorrhage pads, 12" X 18" (see Chapter 32 498 INDUSTRIAL MEDICINE AND SURGERY Fig. 76. — Author's first-aid kit. Fig. 77. — First aid kit with four compartments packed. FIRST AID 499 XXX) rolled individually in tissue paper, to be used as com- presses in case of hemorrhages or as dressings for large wounds. (6) The bandages consist of l'\ 2" and 3" gauze bandages (four of each) and four strong cotton bandages 3" by 10 yds. (c) A spool of 3" adhesive plaster must be included in every kit, to be used to hold dressings in place when bandages cannot be applied. (c?) The tourniquet consists of a 3" X 5 yd. rolled, strong, cotton bandage, plainly marked ^''To he used in case of hemorrhage '' (the author discarded the use of the rubber tourniquet in the hands of lay assistants because of the dangers arising from its use. The first aiders were instructed to place a compress over the artery above the bleeding point and to bandage the same as tightly as possible with this cotton bandage). (e) lodin is supplied for the purpose of immediate application to all open wounds, no matter how extensive. This is either to be painted on with an applicator when possible without touching the wound with the fingers, or to be quickly poured on directly from the bottle. (/) The aromatic spirits of ammonia is to be used in case of fainting or shock. On the inside of the lid of this first aid box the following legend is printed in large type : (See Fig. 77.) READ CAREFULLY This is a first aid outfit only. It is not to be used for subsequent dressings. The purpose of the first aid man is not to replace the doctor. Send every injured employee to the Doctor's Office at once, no matter how slight the injury. Use these supplies for temporary dressings until proper medical care can be obtained. DIRECTIONS lodin and Applicators. — Apply iodin at once to all injuries, small or large, that break or penetrate the skin. Paint over only once. Do not wash injured part with soap and water, hydrogen peroxid, nor any other antiseptic. Simply paint over with iodin. It kills the germs and renders all dirt in the wound inactive. Small Dressings. — To cover cuts or bleeding wounds. Remove tissue paper and unfold gauze. Avoid touching that portion of the dressing which goes next to the wound; bandage. Hemorrhage Pads. — To be used on large wounds or bleeding sur- faces. Unfold the pad without touching the surface applied next to the bleeding area. With bandage bind on sufficiently tight to con- trol bleeding. 500 INDUSTRIAL MEDICINE AND SURGERY Constrictor or Bandage Tourniquet. — When severe hemorrhage occurs in any part of the arm or leg wrap the constrictor about the extremity a short distance above the point of hemorrhage and tie sufficiently tight to control the bleeding. Aromatic Spirits of Ammonia. — To be used in case of fainting or shock. One-half teaspoonful in one-half glass of water and give to patient to drink, or let the patient inhale the fumes from the bottle. In case of fainting lay person flat on back either on the floor or on a table until the faint is over. 5. In every department where accident hazards exist, two or more intelligent employees must be trained in the following first aid methods : (a) To Prevent Infections. — lodin is to be applied immediately to every open wound as already described. Foreign bodies are only to be removed when the same can be done without in- serting the finger into the wound. The proper sized sterile dressing is then removed from the tissue paper covering and applied to the wound without touching the inner side, which goes next to the wound, with the fingers. The dressing is to be held in place by a bandage or by adhesive plaster. Care must be observed at all times not to unduly move the injured part. Washing with soap and water or other manipulation of the wound is absolutely prohibited at all times. In case of a compound fracture (a broken bone accompanied by an open wound) the wound is simply to be covered with iodin and a sterile dressing applied. Leave manipulation for the surgeon when he arrives. In wounds about the eyes exercise great care to prevent the iodin entering the eye. (h) Checking Hemorrhage. — In case of excessive bleeding from a wound a hemorrhage pad is to be applied without touching the surface next to the wound and the bleeding is then to be checked by a firm pressure being made over the pad with the fingers. After two minutes of strong pressure if the bleeding continues apply the tourniquet; if the pressure has checked the hemorrhage, bandage the hemorrhage pad snugly in place. In applying the tourniquet a small compress should be made from a middle-sized dressing and the cotton bandage, marked for hemorrhages, should be bound about the member as tightly as possible and tied in place. All of these maneuvers must be done as gently as possible. In case of hemorrhage do not administer aromatic spirits of ammonia unless absolutely necessary. (c) Combating Shock. — ^Every seriously injured person must be immediately placed in a prone position. To do this he should FIRST AID 501 not be moved any great distance. Whenever possible he must be protected from extremes of heat and cold, especially the latter. He must also be protected from a damp ground or a cold cement floor. If he cannot be moved to a dry, warm spot, then several coats should be placed under him. All of the body, except the wounded part should be immediately covered by blankets or overcoats. The head must be on the same level with the rest of the body except in case of hemor- rhage or fainting, when it should be at a lower level. In the case of shock these precautions must be doubly observed. Heat should be applied about the body. This can be done by filling dinner pails, bottles or jars with hot water or by the use of hot water bottles or hot bricks placed near the body under the coverings. Precautions must always be taken not to burn the patient. Half a teaspoonful of aromatic spirits of ammonia in a half a glass of water should be given at once if patient is conscious. Never give an unconscious person water or other liquid as it may enter his windpipe and strangle him. If conscious give the patient all the water he wants in small amounts at frequent intervals. In case of vomit- ing turn the head to one side so that he will not swallow the vomited matter and strangle himself. Loosen all tight clothing. Avoid undue movement of the body. Do only what is neces- sary to make him comfortable and keep him warm. (d) Resuscitation. — To be used in cases of electric shock, suffocation or asphyxiation or other conditions which have apparently caused cessation of breathing. Artificial respiration by the Schdfer or prone method should be employed as follows: Place the person on his abdomen; remove from his mouth all foreign bodies, such as false teeth, tobacco and gum; pull and keep the tongue forward; turn his head to one side and rest it on his forearm, so that the mouth and the nose will not come in contact with the ground and extend the other arm forward. If the person is thin prepare a pad of folded clothing, blankets, or other material and place it under the lower part of his chest. Do not make this pad too thick. Do not wait to loosen the victim's clothing but begin artificial respiration without delay. An assistant may remove all tight clothing from the victim's neck, chest and waist; blankets, hot water bottles, safety lamps, or hot bricks well wrapped in paper or cloth should be placed about the person by an assistant. Kneel, straddHng the person's thighs and, facing his head, rest the palms of your hands on his loins — on the muscles of the small of his back — with your thumbs nearly touching each other 502 INDUSTRIAL MEDICINE AND SURGERY and your fingers spread over his lowest ribs; with arms held straight swing forward slowly so that the weight of your body is gradually brought to bear on the person. This operation, which should take three or four seconds, must not be violent, lest the internal organs be injured. The lower part of the chest and also the abdomen are thus compressed and air is forced out of the lungs. Now, immediately swing back slowly so as to remove the pressure, but leave your hands in place, thus returning to the original position. Through their elas- ticity the patient's chest walls expand and his lungs are thus supplied with fresh air. After two seconds swing forward again and repeat deliberately, 16 to 18 times a minute, the double movement of compressing and releasing — causing a complete respiration in about four seconds. If a watch or clock is not available, follow the natural rate of your own deep breathing, swinging forward with each expiration and back- ward with each inspiration. Continue artificial respiration, if necessary, for at least three hours without interruption until natural breathing has been restored, or until a physician arrives. Even after natural breathing begins carefully watch that it continues. If it stops, start artificial respiration again. Do not give aromatic spirits of ammonia or other liquids by mouth until the patient is fully conscious. Keep all by- standers away from the patient in order to give him plenty of air. (Various machines to assist or compel artificial respir- ation have been invented. Only an expert in the manipulation of such a machine should be allowed to use them.) (e) Fractures. — In case of fractures never move the patient, unless it is to free him from further danger, until the part has been thoroughly immobilized with a splint. The injured limb should be immobilized with the least manipulation possible. A sphnt can be made by using a thin board slightly wider than the injured member and covering it with one or two of the hemorrhage pads. It is then firmly bound to the member with one or more of the cotton bandages. These same principles hold in the case of dislocations. Leave the manipulation of the broken or dislocated parts to the surgeon. (/) Burns. — In case of burns the patient is to be brought as rapidly as possible to the doctor's office or the doctor immediately summoned to the patient, the nature of the case always being explained in the summons. Cotton rags and other material are not to be placed on burns. If the patient is in shock, treat these symptoms until the doctor arrives. FIRST AID 503 The above rules and methods are sufficient for the first aid care of any injured employee when a doctor can be summoned very shortly. I wish to again emphasize the fact that the ideal system of industrial surgery is based upon the immediate treatment of a wound by a qualified surgeon. A few years ago no one question in accident surgery caused more discussion than the application of proper antiseptic to an open wound. Many good surgeons decried the use of any antiseptic and advocated thoroughly washing with soap and water. Some instructed their first aid assistants to immediately wash a wound with hot water and soap. Such a method is no longer recommended as a first aid procedure and very few surgeons to-day apply soap and water to any wound. The danger of grinding infected material deeper into the injured parts by such a washing process is greater than if the wound was left absolutely alone. The pendulum then swung to the other extreme and it was advocated to thoroughly wash the wound with bichlorid of mercury or hydrogen peroxid and then paint it with carbolic acid, followed by alcohol. It is still a common sight to see a wound washed, anti- septicized and otherwise picked at for ten or fifteen minutes before the dressing is applied. Even then the dressing may be frequently soaked with bichlorid or some other antiseptic. The replies to the questionnaire sent out by the Committee on Standardization of First Aid Methods, as well as the investigations of Dr. Bloodgood, show that at least 90 per cent, of the surgeons in industry advocate the use of some antiseptic as a first aid measure. Approximately 80 per cent, of these advocate tincture of iodin as the best and most logical antiseptic to be used. The majority of these are in favor of the patient, or a fellow workman, painting the part at once with tincture of iodin, but some of these surgeons fear that such a procedure gives a false security to the employee and lessens the chances of his reporting to the doctor for proper treatment. My own experience has absolutely convinced me that the immediate use of tincture of iodin to an injured part by the employee himself or by a fellow employee is the most important first aid procedure which can be adopted in industry. In 1909, when I first used iodin in every department of the industry with which I was connected, there was an immediate reduction of 28 per cent, in the number of infections the first month after this plan was installed. To counteract the danger of the injured employee thinking that the use of iodin was all-sufficient, bulletins, letters and constant warnings were scattered throughout the working forces to the effect that "Every injury — no matter how shght — must be painted with iodin at once and then the employee must report to the doctor immediately." Some claim that the report- ing to the doctor at once is sufficient. Every year, however, has more 504 INDUSTRIAL MEDICINE AND SURGERY clearly demonstrated that the combination of the use of iodin and the reporting to the doctor at once is superior to the method of only reporting to the doctor at once. The nature of the work in this in- dustry was such as to cause a great many minor accidents from such conditions as pin pricks, nail wounds, slivers, abrasions, etc. The following table clearly demonstrates that the double procedure gives better results than the single method of reporting at once : Table 17 TABLE ILLUSTRATING THE VALUE OF "USE OF IODIN AT ONCE AND REPORTING TO THE DOCTOR AT ONCE" Total number of infections ilodin used in Dept. reported at once 1 Iodin not used in Dept. reported at once. Rules not observed 1913 710 18 28 668 655 16 28 611 586 5 12 569 1916 610 10 12 588 The degree of infection in those cases where iodin was used or where they reported to the doctor's office was very slight and consisted only of redness and a small degree of swelling about the wound or a drop of pus. The fact that none of these lost time from work or required an incision clearly points to very mild infection. The large number of infected cases that failed to observe these rules came from the following groups : (a) New employees who had not yet learned their lesson (one year 80 per cent, of the infected cases came from this group). (&) Employees who failed to report to work and who could not be located by the visiting nurse, and otherwise neglected their dressings. (c) Employees who removed their dressings at home and applied some home remedy. (d) The employee who "didn't believe in doctors." (e) Christian scientists. Such figures plainly show that no matter how extensive your preventive measures are, or how extensive an educational campaign you wage, these careless employees will always be a source of trouble. During these four years there were 39,672 accidents cared for in this industry. These include the infected cases shown in the foregoing table. Out of this total number of accident cases, even including the very serious crushing and mutilating wounds, where the employees observed the first aid rules and continued under the constant care of the plant surgeon the infection rate was only 1.2 per cent. 1 None of these required incision nor lost time from work. FIRST AID 505 Bloodgood, as a result of his investigations concerning the various methods used by several hundred industrial surgeons, summarizes his conclusions concerning various uses of a first aid antiseptic by saying: "As far as can be ascertained from the industries the answer is practically uniform: that an antiseptic is of immense value in the wounds in industry in preventing infection. Whether that antiseptic should be applied by the individual or by the doctor who sees the wound quickly is a question on which I can get very little evidence. The great majority of surgeons in industries, however, agree that iodin is the best antiseptic to be used." Many of our best industrial surgeons advocate a much mxore extensive system of first aid than that outlined by the author. This is partly due to the fact that these doctors have fewer assistants so that it is impossible for a physician to always render the emergency treatment at once; or because the employees are so scattered that fifteen minutes to one or two hours must elapse before it is possible for the doctor to see the patient. Naturally, under these conditions, they must depend more upon lay assistants. Bear in mind, however, that even these reasons are not sufficient to permit of too much leeway being given to the first aid man. Doctor Loyal Shoudy of the Bethlehem Steel Company has developed a very excellent first aid system, which is constantly supervised by the doctor and his assistants. This consists of teams of six or eight men, who are thoroughly trained in a great many different first aid methods. Every large department has its team. He has extended this system to include not only the home plant but all of the subsidiary organizations. In order to stimulate enthusiasm and expertness among the various first aid teams he holds an annual First Aid Meet. The teams enter intensive training for several weeks, solving many theoretical problems of first aid care to the injured. A preliminary interdepartmental first aid meet is held and the winning teams then represent the various plants at the final meet. The prob- lems for the contest are selected from the records of actual injuries which the various first aid teams attended during the preceding year. In the recent first aid meet held at Bethlehem the following problems were selected for execution by the contesting teams: 1. Dress compound fractures of leg, L., lower third, splints. Eight triangular bandages. One tourniquet. One dressing. Use im- provised stretcher. Blanket. Time Allowance 10 minutes. 2. Dress fracture of knee cap, R., crush of foot, R., and laceration of scalp. Two splints. Eight triangular bandages. Two dressings. Time allowance 8 minutes. 3. Dress hums of foot, R., calf of same leg, fracture of lower jaw, 506 INDUSTRIAL MEDICINE AND SURGERY R., and laceration of chest, L. Five triangular bandages. Three dressings. Time allowance 8 minutes. 4. Dress dislocation of shoulder, L., hum of hack of hand, L., and crush of foot, R. Five triangular bandages. One piece I" roller band- age. Two dressings. One splint. Time allowance 8 minutes. 5. Dress fracture of the hack. Splints. Fourteen triangular bandages. Two blankets. Time allowance 10 minutes. 6. Dress lacerated shoulder, R., and opposite fractured forearm. Seven triangular bandages. Two splints. One dressing. Time allowance 8 minutes. 7. Patient found in unconscious condition from prolonged inhalation of hlast furnace gas, rescue (one man method). Resuscitate (demon- strate Schafer and Sylvester methods). Two blankets. Stimulants. Time allowance 5 minutes. 8. Dress burns of entire head, face, back, chest, shoulders, and hack of both hands. Six triangular bandages. Four dressings. Blanket. Time allowance 8 minutes. 9. Dress fracture of lower jaw, R., and sprain of ankle, R. Two triangular bandages. One 2" roller bandage. Time allowance 8 minutes. 10. Rescue from electrical contact. Instructions Dress the most serious injury first. Do not allow fingers to come in contact with underside of dressings. Grasp artery and use tourniquet in all cases of compound fracture. Watch for symptoms of shock in all injuries. Treat for shock in all problems where blanket is indicated. In dressing patients, kneel on knee next to patient's feet. While the above were theoretical cases arranged for purposes of the field meet, yet they illustrated the exact nature of the injuries which these first aid teams were called upon to treat during the course of their work. Dr. Shoudy's paper before the 1918 Convention of the National Safety Council thoroughly explains his methods of training these teams. There is no question but that better results could be obtained if emergency treatment by quahfied physicians could be rendered at once in such extensive injuries as these, but in the absence of a suffi- cient number of physicians to meet the situation, this elaborate plan in a hazardous industry is worthy of great commendation. One of the greatest functions of these teams is the constant study of works conditions in order to prevent accidents. It is very essential that every first aid man should be first, last and all the time a preven- tion man. FIRST AID 507 The N, A. S. O. First Aid outfit is the result of numerous confer- ences of surgeons from different industries, held under the auspices of the Conference Board of Industrial Physicians. Dr. Lauffer, of the Westinghouse Company, who helped standardize this outfit, de- scribes it as follows: "The container is glass, the contents include (1) drugs and (2) dressings; and are: 1 tourniquet. 1 pr. nickel plated scissors. 1 triangular sling. 12 assorted safety pins. 1 wire gauze splint. 1 two ounce bottle castor oil. 2 three ounce bottles burn ointment. 1 two ounce bottle 3 per cent, alcoholic iodin. 1 two ounce bottle white wine vinegar. 1 two ounce bottle aromatic spirits of ammonia. 1 two ounce bottle 4 per cent, aqueous boric acid. 1 two ounce bottle Jamaica ginger. 1 piece of flannel 24" X 36". 1 roll absorbent cotton. 1 roll 3" X 10 yd. gauze bandage. 2 rolls 2" X 10 yd. gauze bandage. 1 spool 1" X 5 yd. adhesive plaster. 4 rolls 1" X 10 yd. gauze bandage. 6 packages 6" X36" sterile gauze. 1 teaspoon. 1 medicine glass. 2 medicine droppers. 3 paper drinking cups. 12 first aid record cards. 11 finger splints. 12 wooden applicators. 1 instrument box, 1 cotton box. This detailed list of contents were regarded as the best item^to include in the outfit in the year 1915, in the collective judgment of the Con- ference Board. "The special requirements of particular injuries are cared for by adding to or subtracting from the standard contents of this jar. "The rules of procedure for the instruction of laymen were agreed upon by the Conference Board in advance of the selection of the con- tents of the jar, and it will be observed that the first aid taught is preliminary, not final treatment, and that it is designed that the pa- 508 INDUSTRIAL MEDICINE AND SURGERY tient be given reasonable first aid attention, pending the care of the case by a physician." Dr. A. W. Colcord, of the Carnegie Steel Company, is one of the pioneers in the instruction of the layman in the application of first aid. He states "I believe we have overdone this work; I feel that we have undertaken to teach too much and to allow the layman to do too much. After three years of lecturing to forty special groups on this subject I have boiled down instructions on this subject to just four things: 1. How to treat hemorrhages. 2. How to treat shock and asphyxia. 3. How to transport the injured man with a maximum of speed and a minimum of trauma to the proper place. 4. What not to do: To keep away entirely from the wound; not to administer a dressing; and get to the emergency hospital as quickly as possible. I believe attempted treatment of wounds by a layman has done in- finite harm and that we cannot condemn it too strongly." In 1917 the Bureau of Mines, Department of the Interior issued a small book on "First Aid Instructions for Miners; a Report on Standardization. This was compiled by a Committee of surgeons consisting of G. H. Halberstadt, A. F. Knoefel, W. A. Lynott, W. S. Rountree and M. J. Shields. Every surgeon in industry should read this book as it is pregnant with excellent ideas, not only on first aid care but on emergency surgical treatment. The following summary shows the extent of the first aid work advocated by these authorities for mine employees: FIRST AID EQUIPMENT (Surface First Aid Dressing Station) "At a suitable place on the surface and near the mine opening there should be a first aid dressing station, which also can be used as a storeroom for first aid suppHes. In this building should be a stretcher, woolen blanket, waterproof blanket, and sphnts, all of which except the splints should be suitably protected from moisture and air in a sealed tin case, or its equivalent. Also there should be first aid packets in germ proof and waterproof wrappings suitably protected in sealed metal boxes, and first aid cabinets. Contents of First Aid Cabinet "Each cabinet should contain: 12 sterile triangular (unprinted) bandages. 12 small bandage compresses, each 1" square when folded upon itself about 15 times, with mushn tails }i yard long, the center being sewed to compress. FIRST AID 509 12 medium-size bandage compresses, each 2^'^" square when folded upon itself about 18 times, with muslin tails 1 yard long, the center being sewed to compress. 6 large bandage compresses, each 33^^" square and folded upon itself about 20 times, with muslin tails 2 yards long, the center being sewed to compress. 6 packages of sterile picric acid gauze, each containing a piece of gauze 1 yard square. 6 yucca splints or similar material. 1 two ounce bottle aromatic spirits of ammonia. 6 paper cups. 1 teaspoon (horn). 1 tourniquet. 1 pair of scissors. (From First Aid Instructions for Miners.) Underground Dressing Stations " First aid dressing stations should be maintained near the bottom of the shaft or slope and at a central sidetrack. One first aid cabinet should be available for every 100 men or less. At least one man out of every 10 employees should carry a first aid packet which should be refilled when necessary. Surface Hospital Room " Where a large number of men are employed, there should be avail- able on the surface a room provided with suitable hospital facilities, and having a surgeon in attendance. The building should be as close to the entrance of the mine as possible and should be supplied with the necessary articles, all furniture and utensils, except perhaps the chairs, to be covered with heavy white enamel. " Suggestions The authors of this report make the following suggestions : "1. That as far as possible first aid training be given under the immediate supervision of a regularly registered and qualified physician. "2. That there be close co-operation with the first aid department of the American National Red Cross in first aid work. ''3. That all examinations for first aid certificates be held by a qualified physician and conform with such standards as may be laid down by the Bureau of Mines. "4. That it be an imperative rule that in all first aid contests the judges shall be regularly qualified physicians trained in first aid work. "5. That where it is possible every employee in a mine be trained in first aid work but if this is impossible that at least 1 out of every 10 employees, both underground and on the surface, receive such training." 510 INDUSTRIAL MEDICINE AND SURGERY CONCLUSIONS This chapter on first aid clearly indicates that the question as to what extent laymen should be permitted to treat injured employees is still unsettled. Practically every worker in this field agrees that a certain amount of first aid care is necessary. They further agree that the extent and method of first aid care should be standardized. The war interfered with the work of standardization, undertaken by the American Association of Industrial Physicians and Surgeons and also by the Committee on Standardization of the U. S. Public Health Service. It is hoped that these two organizations will get together as soon as the present emergency permits and work out this standardization. The author believes that all first aid methods should include and be limited to the following: 1. The immediate application of tincture of iodin to all open wounds. 2. The appointment of a responsible person among each group of employees to see that the injured employee reports to the doctor at once. 3. The instruction of two or more responsible persons among each group of 100 employees in the best first aid methods of (a) Controlling hemorrhages. (6) Combating shock. (c) Resuscitation by artificial respiration. (d) Immobilization of fractures. (e) Transporting the injured when necessary Every report on this subject should point out most emphatically the importance of having a qualified surgeon on the job in industry at all times in order to render immediate emergency treatment. CHAPTER XXXIII EMERGENCY SURGERY Emergency surgery is the first treatment rendered to an injured person by the surgeon. An emergency operation is one performed to relieve some sudden emergency as, for example, the opening of an abdomen to relieve a hemorrhage or a tracheotomy performed because of a foreign body blocking the larnyx. As used in industrial surgery first aid is rendered by a layman but emergency surgery is always rendered by the surgeon. On the battle- field and in some industries the expert first aid man has been so well trained in his work that often the first aid treatment rendered by him is sufficient. Col. Frank Billings, reporting on the work which he saw at the front in France, stated that frequently the enlisted medical man applied the splint so thoroughly to a fractured limb that it was unnecessary for the surgeon to redress the fracture for several days. Dr. Shoudy has found that quite often his first aid men have executed their work so thoroughly that he was able to send the patient direct to the hospital for permanent care, without giving any emergency treat- ment. As a general rule, however, it would be a dangerous practice for this first aid care to replace the emergency surgery rendered by a quali- fied surgeon. This view is gradually becoming universal and as a result surgical dispensaries are being established in many of our large industries and a surgeon is kept at the plant at all times in order to render immediate emergency surgery and thereby obviate as far as possible the need for the less efficient first aid work. In fact, well organized medical staffs within our industries, with facilities for treating injured employees immediately after the occurrence of an accident, have made first aid superfluous in the ma j ority of instances. These physicians insist on seeing patients at once before first aid measures have been applied. This limits the need for trained first aid workers to those departments where hazardous processes are carried on and where the employees are so far removed from the dispensary as to render immediate care impossible. Even here the injured employee and the surgeon can get together so quickly that emergency surgery is preferable. The surgical dispensary, its equipment and the necessary surgical 511 512 INDUSTRIAL MEDICINE AND SURGERY staff have been fully described in other chapters. (See Chapter XXXI.) Therefore this chapter will be devoted to those conditions commonly arising in industry which require emergency treatment and to a description of the practical methods which have been found most efficacious under the different circumstances. Two great . slogans have developed in connection with accident surgery in industry. One deals with prevention in the pre-accident stage and is known as '^safety first;" the other deals with the post- accident stage and is represented by "report at once." This reporting to the doctor at once when an injury is received, always qualified by ''no matter how slight" is the universal preventive measure adopted by all surgeons in industry. As a result the great proportion of their work consists of the emergency treatment of minor accidents and their subsequent dressings. In the author's experience a hundred of these minor cases report to the doctor's office for every five of the more seriously injured em- ployees. In the combined major and minor accidents about one injury out of twelve is sufficiently disabling as to require actual lost time from work, providing the injured parties' report at once to the doctor. Approximately one of these disabling accidents out of every fifteen causes a disability exceeding fourteen days. In the major accidents, fractures are the chief cause of dis- ability, averaging 42.8 days per case. Sprains and dislocations were second and hernias came third in this class of accidents causing the greatest amount of disability. Thus, in major accidents, the cause of disability can usually be traced to the severity of the injury as these employees are under control and therefore their treatment is uninterrupted. The greatest cause for disability among the minor acci- dent cases was infection. These occurred commonly among two classes, namely, those who failed to report to the doctor at once and those who were careless about their dressings or their return visits. Thus the majority of disability cases in this class can be traced to carelessness and neglect on the part of the patient. Accidents in the general industries involve chiefly, the fingers and hands, the toes and feet, the eyes, the lower extremities, upper extremi- ties, the back, the head and the abdomen, named in their order of frequency. The most frequent minor wounds are: (a) abrasions; (b) contusions; (c) lacerations; (d) puncture wounds; (e) blisters; (/) brush-burns; (g) foreign bodies in the eye; (h) foreign bodies penetrating the soft parts; (?') strains; (j) sprains; (k) tenosynovitis; (I) swallowing foreign objects. Complications oftenest arising from these wounds are infections, ulcers, keloids and scar contractures. EMERGENCY SURGERY 513 The chief major wounds met with in accident surgery are: (a) fractures; (6) crushing wounds; (c) dislocations; (d) penetrating wounds; (e) burns; (/) loss of members; (g) avulsions; (h) injuries of nerves, blood-vessels and viscera; (i) brain injuries; (j) special traumas, as traumatic hernias, traumatic orchitis, traumatic pleurisy, traumatic appendicitis and traumatic neuroses. These severe wounds may have any one of the complications common to minor injuries and in addition the immediate complications of shock and hemorrhage, and the more remote complications represented by systemic conditions occurring as the result of lowered resistance. Naturally permanent deformities more frequently follow these major accidents. Every variety and degree of the above minor and major injuries may occur singly or in combination and any one or several regions of the body may be involved. The complications which may arise are so numerous and often so surprising in their occurrence that the alertness and skill of the surgeon is taxed to the utmost. No field of surgery is more varied, and therefore more interesting, than this accident work. In addition to the above, emergency surgery in industry must contend with certain conditions not causing visible wounds but which nevertheless are injuries resulting in the course of employment. These include such cases as suffocation, asphyxiation, acute poisoning, freezing, heat stroke and sun stroke. The emergency care of any of these accidental conditions involves in every case consideration of a logical sequence of treatment : 1. Prevent complications. 2. Combat immediate complications. 3. Temporary or permanent relief. 4. Apply dressings. In 95 per cent, of injured cases the line of treatment can follow the above sequence and the expert emergency surgeon automatically considers each of these steps in turn. However, in a small number of cases he is forced to forget every other step and exert all his energies .toward combating the worst complication: impending death. There- fore, in 5 per cent, of the cases, steps one and two may be forced to exchange places in the sequence of treatment. PREVENT COMPLICATIONS Infections. — In all accident surgery the commonest and most feared complication is infection. In its wake follows many other complications, notably deformities, loss of members, systemic diseases and even death. The prevention of infections is the earliest lesson learned by the surgeon in industry. The majority of these surgeons 33 514 INDUSTRIAL MEDICINE AND SURGERY have learned by experience that the best methods of prevention consist of three things: (a) Immediate application of an antiseptic to an open wound. (h) The earliest possible treatment of the wound by a qualified physician. (c) Protection of the wound by sterile dressings; regular and uninterrupted care until healed. Surgeons may differ as to the kind of antiseptic, or regarding some minor points in the treatment, or as to the type of dressing to employ and the frequency of redressings, but no experienced worker in this field differs as to the prime importance of these three steps in prevent- ing infections. From a careful investigation of the kind of antiseptic used in accident surgery it is safe to say that at least 80 per cent, of the surgeons use some form of tincture of iodin. In the chapter on First Aid and again in the chapter on Hand Infections the author has advanced the strongest arguments in favor of the efficacy of tincture of iodin as a preventive agent. The fact that it is used so universally by the majority of surgeons is only another argument in favor of it as the antiseptic of choice in emergency surgery. The strength of the tincture of iodin advocated varies from 3 per cent, to the 10 per cent, tincture. The majority seem to use a 5 per cent, strength diluted with alcohol. Some have urged the use of glycerin with iodin (one part of glycerin, three parts of iodin) as a means of preventing irritation of the skin or the severe burning complained of by many patients when the application of iodin to a raw wound is made. The antiseptic should be applied to the open wound as soon after the injury is received as possible. In order to meet this requirement, tincture of iodin with applicators should be kept at regular stations throughout the working place where the injured party or some fellow employee can apply it at once to the injured surface. This method is fully described elsewhere. Iodin can be applied by cotton apphca- tors, by pouring on the wound, by applying with a camel's hair brush, or by using some of the commercial tubes which are so made that the iodin exudes through a gauze stopper, making combination container and applicator. Another excellent commercial tube on the market is sealed with paraffin, the tip of which can be broken off allowing the iodin to escape slowly. After using it the opening in the paraffin can be sealed by heating with a match. I have not found these commercial tubes as practicable, however, as iodin and applicator, chiefly because in large wounds one desires to quickly pour the iodin over the surface. When employees are allowed to use the iodin them- selves they should be warned against rubbing great quantities of the EMERGENCY SURGERY 515 antiseptic into the skin or against .soaking a dressing or cotton with it and binding same on the wound. The only cases of burning of the skin which the author has noted have been in the few instances where excessive amounts of the iodin have been used in this way. This use of the iodin in the departments by the employees has not caused them to cease reporting to the doctor at once for minor injuries, an argument which is often advanced against this system. When the patient reports to the dispensary, even though iodin has been applied in the department, the surgeon should again apply the antiseptic, making sure that every portion of the wound is treated. In the severer injuries this will often be very painful but the momentary pain is much better than the prolonged suffering following a later in- fection. Where active bleeding is present, this should be stopped by pressure with sterile gauze before the iodin is applied in order to be assured that the bottom of the wound is reached. The application of this antiseptic should be done quickly and deftly and nothing is gained by subjecting the patient to repeated applications. However, in severe crushing wounds a second treatment with the iodin should be made after the patient is anesthetized and before any operative procedure is undertaken. Other antiseptics used on wounds for the prevention of infection include carbolic acid followed by alcohol, alcohol alone, bichlorid of mercury (1 to 1000), hydrogen peroxid, turpentine, salt solution and recently Dakin's solution or some modification of it and dichloramin- T. Carbolic acid is not a safe routine antiseptic to use and really is only indicated in bites or other places where cauterization is needed. Its use should be followed by alcohol. Bichlorid of mercury was for- merly used quite extensively in emergency surgery but nevet accom- plished the desired result as tincture of iodin has done. Hydrogen peroxid is of very little value as an antiseptic for the prevention of infections; in fact in wounds with small external openings the forceful expansion of the peroxid may carry foreign infected material deeper into the wound. Turpentine has been commonly used by employees themselves to prevent blood poisoning. It is very painful and not as efficacious as iodin. Since war surgery has demonstrated the value of Dakin's solution and dichloramin-T a few surgeons have adopted the use of these as preventive antiseptics in lieu of iodin. Dr. Lee feels that the immediate application of dichloramin-T would prevent all infections and would be a cheaper antiseptic than iodin. Experimentation is now being conducted to prove whether or not this is true. Some surgeons have advocated the use of Dakin's solution in the same way and often give their patients a bottle of this solution to pour on the dressings covering the wound at stated inter- vals. More actual experience is necessary before either of these 516 INDUSTRIAL MEDICINE AND SURGERY methods can be recommended and certainly before many surgeons would be willing to discard their old standby, tincture of iodin. One of the strongest exponents of this new antiseptic reported two years ago 77,000 wounds treated by the old methods with only 90 infections, while one of his colleagues reported 3500 wounds treated by the old methods with no infections. They are now using Dakin's solution and claim that it is producing splendid results. Certainly it would be hard to conceive of any better results in accident surgery than those reported by these two men when using the tincture of iodin. It is interesting to read of the different antiseptics advocated by the various surgeons operating at the front in this war. The English speak first of carbolic acid or diluted carbolic acid, while the French extol iodin. After a year or two of the war, Wright, the English surgeon, urged the use of salt solution while Carrel, operating with the French, proclaimed Dakin's solution as the antiseptic of choice. In the fourth year of the war many surgeons have swung back to the use of tincture of iodin as the best emergency antiseptic which could be used. Every first aid kit of the enlisted medical personnel of the American Army contains tincture of iodin. There is no question but that war wounds have developed extremely serious infections which are seldom seen in industrial surgery. These soldiers have been subjected to more terrific traumatisms, have had their filthy clothes ground into the flesh and in a great many cases have not reached the surgeon until several hours afterward, often with the parts badly infected. Some heroic method of treatment was necessary to check these infections and to overcome the excessive period of hospital treatment which was so common in the early days of the war. The reports of Dr. Carrel and other enthusiastic users of the Carrel-Dakin solution convinced practically the entire pro- fession that the continuous use of this antiseptic in these infected areas has been one of the greatest advances made in war surgery. Recent American reports show that, as the hospitals have been pushed nearer the front and the transportation of the wounded to the surgeon has been expedited, the number of serious infections has been decreas- ing. It is conceivable that if these patients could be treated immedi- ately by the surgeons, the elaborate Carrel-Dakin method would be needed only in the exceptional cases. In accident surgery in industry the injured either receive this immediate care by the surgeon or medical care is very shortly given. If, combined with this, tincture of iodin is applied to the injured part, no matter how excessive the injury, these severe infections seldom occur and the Carrel-Dakin treatment is correspondingly rarely needed. These wounds, receiving the immediate surgical attention and the early application of an antiseptic, have been successfully closed in the EMERGENCY SURGERY 517 majority of cases without subsequent infection developing. This treatment, with its accompanying careful repair, is certainly much wiser than to insert a number of tubes into the wound and start the constant irrigation with the Carrel-Dakin solution, for, as stated above, experience has proven that the majority of such cases healed rapidly and with primary intention. I do not believe that Dr. Carrel himself, would advocate any other line of treatment. However, when any of these wounds show signs of infection or when, because of neglected early care, the surgeon is confronted with a seriously in- fected case, the Carrel-Dakin solution may very wisely be employed. The point I am trying to make is that the judgment of the surgeon in industry must not be warped by the new methods developed for the more serious war injured. On the other hand, war surgery has developed many new measures which will improve the technic and efficiency of all accident surgery and the surgeon in industry must develop a keen judgment in deciding which of these measures is an improvement or is essential and which of them is unnecessary when the nature of the case and the quicker methods of handling it are 'Considered. In this connection the author desires to publish a report of three cases with comments on each, which emphasizes the value of tincture of iodin, which Dr. Charles A. Lauffer of the Westinghouse Company gave to him recently: " 1. Charles W., L6-42. ''Injured 6/18/17, resumed work 10/15/17. "Mode of Accident. — While standing on a ladder to repair a line, reaching to the right, patient threw out his left foot to balance himself. This foot came in contact with a 36" fan, driven at high speed, employed for ventilating, located near the roof in P-2. "Extent of Injury. — Patient was on the operating table at Braddock General Hospital within an hour of the injury. He was reluctant about giving his consent for the amputation of the first and second toes, until a mirror was provided, enabling him to see for himself the extent of the damage on the plantar surface of the foot, and the com- minuted fractures of these toes. Not only were all the tissues ground from the plantar surface of these two toes, but from the sole of the foot two inches beyond the insertion of these toes. "Surgical Treatment. — Tincture of iodin was used at once. Very tenacious black dirt was inground, making it necessary to use the scissors, in addition to gasoHne and tincture of iodin in abundance, in cleansing the lacerated tissues. It required an hour to clean the wound, and another half hour for the operative procedure. The bones were sacrificed from the big toe and the second toe, and the dorsal and lateral skin of these toes, as much as remained of it, was employed to 518 INDUSTRIAL MEDICINE AND SURGERY cover in the defect on the sole of the foot. Tincture of iodin was employed to excess and an iodoform drain was inserted at the time of operation. "Comment. — We expected to employ Dakin's solution subsequently, should infection set in, but this was not required. A staff member, a railroad surgeon, present when we operated the case, remarked: ' What an excellent case on which to try out Dakin's solution. Put in tubes, do no washing nor cleaning, just bandage it up; continue the Dakin solution until the slough has separated.^ " This recommendation was abhorrent; by cleansing and closing the wound, we avoided the implantation of infection, and within 24 hours, had a comfortable, well pleased patient on the high road to recovery; results justified the procedure followed. " X-Ray No. 1025 exhibits fractures of all five metatarsals, and the middle phalanx of the third toe; it was this extreme traumatism, not suspected at the time we operated his toes, that retarded his complete recovery. '2. John P., SK-323. Injured 7/17/17, discharged cured 8/7/17. Patient was a Greek, joined the army, and is now in camp. He is fully recovered. ' ' Mode of Accident. — Patient loaded sheet iron on small cars, drawn by motor trucks. The sheets in this instance extended out beyond the end of the car on which it was loaded. The motor truck slid in crossing slippery dinkey tracks, and the end car was switched around, the sheet iron striking the patient, while he stood in a narrow doorway where he could not escape. "Extent of Injury. — The external ham string tendons and muscles were completely severed in two places about an inch apart, in the popliteal area and the outer aspect of the thigh; the wound was very dirty, so was the patient's skin. The large vessels were not cut. ' ' Surgical Treatment . — Tincture of iodin was applied and the patient was removed at once from the Works Dispensary to the Westinghouse Ward in the Braddock General Hospital, Braddock, Pa. Vicinity of the wound was carefully shaved, and cleaned with gasohne, then tincture of iodin was lavishly used in and about the wound. Severed tendons, muscles, and fascia were approximated with catgut sutures, which also controlled the bleeding. The fascia lata could not be en- tirely approximated, but nature evidently filled in the defect. Iodo- form gauze drain was inserted, to care for oozing, and leg was dressed in fixation dressings, at approximately 10° flexion. There was no infection at any time, and the patient was comfortable; heahng was nearly as rapid as in a surgical, non-traumatic wound. "Comment. — We are of the opinion that the immediate use of tincture of iodin gave us superior results, and the preliminary use of EMERGENCY SURGERY 519 Dakin's solution before closing the wound would not have been justifiable. "3. Alfred Jackson, K20-107. "Injured 9/20/17, still under treatment. "Mode of Accident. — First day at work, had been onthe job just 33-^ hours. A terminal fell behind the carriage of a milling machine. Without stopping the machine, he reached behind the carriage for the terminal; the carriage drew his forearm against the saw. Extent of Inj ury . — The saw lacerated the soft tissues of his forearm, severing all the muscles and other structures, exposing both bones of the forearm. Severe arterial hemorrhage. " Surgical Treatment. — Tincture of iodin applied. Tourniquet applied to the arm did not adequately control the squirting arteries. Four bleeding points were sutured in the works dispensary. Tincture of iodin was freely used, and he was sent to the Westinghouse Ward in the Braddock General Hospital, Braddock, Pa. " Foreign matter was removed from the wound, the muscles and fascia were approximated with catgut sutures; the median nerve was also sutured. The surgeon was too busy suturing to count the number of muscles that had to be united, nor did he count the number of buried sutures. "The wound has healed kindly, there has been no pus. He has a fair functional recovery of the use of the hand, but he has not yet sufficiently recovered strength in the hand to be able to resume work. " Comment. — When such a wound can be treated the hour of the injury, the use of tincture of iodin as an antiseptic permits of closing the wound. Even should infection arise, which is always a possibiHty, — though infection is a rare occurrence, when rubber gloves are used and antiseptics are freely employed — the wound can be opened, drained, and Dakin's solution resorted to, to control the infection." The general and local measures employed in the immediate emer- gency care of the patient have a very direct bearing on the prevention of infections. Rest is one of the most essential preventive measures. By rest the body is enabled to overcome the shock and general injury which it has received when an accident occurs and can thus more rapidly recuperate those body forces necessary to combat the invading bacteria. Thus the gentlest manipulation of the injured member with early immobilization is required to give this needed rest. In the severer injuries rest for the entire body should be afforded as soon as possible. Comfort, warmth and nourishment are necessary adjuncts to the rapid recuperation of the body forces. When it is necessary to remove the clothing to expose the injured 520 INDUSTRIAL MEDICINE AND SURGERY region the same should be cut away rather than the slower and more painful method of undressing the patient. The cleansing of the wound is another important preventive measure. No injured part should be unnecessarily handled in securing this cleansing. Neither should any method be employed which would tend to grind dirt or other infected material deeper into the wound. For this reason, washing the wound with soap and water or with bichlorid solution, or other lotion is practically obsolete. The author has frequently seen nurses and surgical assistants, especially the latter when they are lay assistants, and even the enlisted medical personnel in the army wash open wounds with water, then with bichlorid, then with alcohol, dabbing at them and otherwise abusing the injured tissues until it is no wond:r that in ections occur. One of the most essential things to teach these assistants is to leave these wounds alone. Even many surgeons have yet to learn this lesson. Bleeding should not be checked immediately in any wound as this usually is nature's method of washing it out. After painting the injury with tincture of iodin the adjacent skin can best be cleansed with gasoline, benzin, or alcohol. If the dirty skin about the wound is thoroughly painted with iodin even this cleansing is not necessary. However, the patients often feel that their injury is neglected if the adjacent surface of the body, especially that portion immediately under the dressing, is not cleansed. I never dress a fresh wound without carefully explaining to the patient my reasons for not washing it with soap and water, or otherwise insulting the . parts. Taking the patient into your confidence and explaining such details as this is one of the best ways of securing his co-operation and is a procedure in emergency surgery which is too often neglected, especially by the young surgeon, fresh from hospital or dispensary training. When a wound occurs in the hairy parts of the body, shaving should be a routine cleansing meas- ure. Before shaving the hair next to the wound it should be painted with iodin. A sharp razor should be used so that dry shaving can be done. Always shave away from the wound. Any loose hair falling into the wound should be carefully removed with sterile forceps. All foreign material which has entered the wound should be removed. This should not be done until the wound has been treated with tincture of iodin and then should be accompanied with the least possible manipulation of the injured tissues. The probing of wounds with the finger is a dangerous practice and in the few cases where necessary a sterile rubber glove should always be worn. When the entering wound is small and one is convinced that infected material has been carried into deeper tissues the opening should be enlarged and the foreign material carefully removed by sterile forceps. When small pieces of steel or bullets penetrate the body these should be EMERGENCY SURGERY 521 carefully located by rc-ray before an effort is made to remove them, unless their location is so evident that the operation can be readily performed. Many such small pieces of foreign material enter the body and never cause any trouble if proper sterihzation of the tract is accomplished. In fact, meddlesome interference in these cases is often more harmful than if the part was left absolutely alone. Here again the keenest surgical judgment is necessary and is only developed by experience. In accident surgery in industry the foreign materials usually penetrating the tissues are splinters, particles of clothing, pieces of steel or pieces of a tool which broke off after penetrating the body, such as a needle — so common among garment makers. The removal of these materials is usually -essential to the prevention of infections. All loose tags of skin or other soft tissues so damaged that they are bound to become necrotic should be trimmed away. If the wound is seen after several hours and has been caused by an object which undoubtedly will cause the tissue to become infected, the tract of the wound may be thoroughly dissected, sterilized and closed as is being practised in war surgery to-day. As a general rule, however, every effort should be made to save all of the soft parts so as to better facilitate closing and healing. When loose particles of bone which have been deprived of periosteum are scattered about the wound these should be removed. Bone adherent to the periosteum should be replaced. Drainage is a very essential factor in the prevention of infections and when to and when not to insert drainage into a wound requires most careful consideration on the part of the surgeon. As a general rule, incised wounds which have been treated with iodin or similar reliable antiseptic can be closed without drainage. Extensive lacer- ated wounds even though treated immediately with an antiseptic can be closed but only after drainage is established. Severe crushing wounds or deep penetrating wounds after sterilization should only be partially closed, sufficient opening being left for the introduction of good drainage. Wounds already showing signs of infection should never be completely closed and thorough drainage is usually indicated. An exception to this may be in the case of small incised wounds, mildly infected, which can be thoroughly sterilized and then closed with only small drainage provided. Many kinds of drainage material are used. In large wounds rubber tubing or a section of tubing, twisted rubber or gutta percha are best adapted for drainage. In many cases, especially if hemorrhage is profuse, gauze is required but as a rule gauze drainage tends to act as a pack and defeats its own purpose. Plain sterile gauze is now used for drainage just as often as iodoform gauze, formalin gauze or other such chemically treated material. In smaller wounds a small rubber 522 INDUSTRIAL MEDICINE AND SURGERY band, or two or three strands of silk gut twisted together, affords excellent drainage. The question of closing the wound often plays an important part in infection prevention. Many wounds which were formerly left open are now treated with iodin and then carefully closed without ever becoming infected, whereas if left open healing is delayed and the dangers of subsequent infection increased. Careless coaptation of the tissues, leaving dead spaces in the tissues below the skin have frequently resulted in infections. Over-zealousness in coaptation may shut off the blood supply and cause necrosis of the edge of the wound followed by infection. Frequently one sees a good surgeon, who otherwise has the most perfect technic in the operating room, suturing one of these emergency cases without observing any of the finer points in asepsis. A wound which is to be closed by sutures in the office or the dispensary should be carefully sterilized, surrounded by sterile gauze or a small sheet, resembling a miniature laparotomy sheet, and treated only after the hands and instruments have likewise . been sterilized. Sterile suturing material should be used and should not be allowed to drag across unclean portions of the patient's body while being inserted. Tetanus (Lockjaw). — This infection, due to the Bacillus tetani is one of the most feared complications following injuries. In order to prevent this infection some surgeons have advised the injection of an immunizing dose of tetanus antitoxin in all punctured or lacerated wounds. Ten years ago this prophylactic measure was used quite extensively in industry. However, with the increased use of antiseptics and the more immediate treatment of wounds by the surgeon antitoxin has become less necessary. In the first year of the war many soldiers died of lockjaw. To combat^this, antitoxin was administered at the first aid station farthest front. The wonderful results obtained by the use of this prophylaxis proved the great value of antitoxin. These wounds were practically all soil infected. In industry it is only the occasional wound which is soil infected. The patient whose foot is crushed by an automobile or a truck on the street is a logical case for antitoxin but the foot crushed by machinery or falling timber in the plant or even by the locomotive on the raih-oad track where the dirt consists chiefly of cinders, is very seldom in danger of developing lockjaw providing thorough steriHzation with iodin can take place within the first hour. We must not think it necessary to give every industrial wound an immunizing dose of tetanus antitoxin when we once more return to our private work. Here again the judgment of the surgeon must not be warped by our experience in war surgery. Nevertheless we will all be more faithful EMERGENCY SURGERY 523 in administering it in the suspicious cases where soil infection makes' lockjaw imminent. In the author's experience, antitetanic serum as a prophylaxis was only administered routinely during the first year of his emergency surgery. No cases of lockjaw developed during that year and neither have any cases developed among the employees under his care during the succeeding nine years. His predecessor in the same industry used tetanus antitoxin on every puncture wound due to nails and on all severe lacerated wounds. The records show that three cases of tetanus developed during the period he was in charge. I am convinced that in this industrial work the thorough sterihzation of the wound by tincture of iodin makes the need of the immunizing dose of anti- toxin practically unnecessary, thereby limiting its use to the occasional soil infected case. When the immunizing dose is given it consists of from 500 to 1000 c.c. of antitoxin injected subcutaneously above the wound. Some insist on injecting it directly into the nearest nerve trunk. Hemorrhages. — Hemorrhage is another complication, especially in extensive wounds, which it is always necessary to prevent. This is accomplished by firmly packing the wound or by applying a thick sterile gauze dressing and firmly binding in place or by clamping the bleeding vessels with clamps left on for several hours, or by the direct apphcation of ligatures to the bleeding points. When ligatures are necessary in the emergency treatment of these extensive wounds it is well to leave their ends long in order to easily locate the bleeding vessels in case of subsequent hemorrhage. At times it may be neces- sary to use a tourniquet for two or three hours in order to control and prevent subsequent hemorrhage. Such a continued use of the tour- niquet should always be under the direct supervision of the surgeon and great care should be exercised to prevent subsequent gangrene. Deformity.— Deformity naturally is more often due to the severity of the wound and to that extent is beyond the control of the surgeon. But in every case the physician must begin thinking of the prevention of undue deformities at the time he administers the emergency treat- ment and must continue to constantly think along these lines during the subsequent treatments. Many a case of deformity can be prevented by immediately restoring the limb to its proper position whereas if this is left for 'some future treatment permanent damage may have occurred. In preventing infections one is likewise pre- venting the dangers of deformity. COMBAT IMMEDIATE COMPLICATIONS Impending Death. — In emergency surgery the physician faces some of his greatest battles against impending death and many a case is 524 INDUSTRIAL MEDICINE AND SURGERY saved by the experienced surgeon who does nothing with the wound in such a crisis but devotes his entire attention to assisting the patient to overcome the terrific shock which is threatening his hfe. On the other hand many a case is lost in this critical moment by manipulating the injured part or attempting surgical procedures before this shock is overcome. This can best be illustrated by two cases which the author observed in two different hospitals during the same day: Case One: A man was carried into the hospital after being run over by a street car. His left thigh was crushed to the hip-joint and was held in place only by the gluteal muscles. There was a warm bed in the receiving ward held in readiness for such shock cases. After cutting the trouser leg away from this wound the surgeon simply clamped the femoral vessel which was exposed but not bleeding and then covered the wound with a large sterile pad and immediately placed the man, with his clothes on, in the warm bed. No further attention was paid to the injured part, but by means of salt solution intravenously, hot coffee per rectum and stimulants the shock was combated for the next ten hours. The wound was watched carefully for possible hemorrhage following the use of the stimulants and salt solution but only once was it necessary to apply an additional artery forceps. After the immediate danger of death was over- come the wound was sterilized by pouring iodin over it but no other effort was made toward repair until all signs of shock were over- come. Twelve hours later the patient was subjected to a hasty amputation at the hip-joint under ether anesthesia but no time was consumed in endeavoring to carefully coapt the various layers of tissue. This was left for a subsequent operation when the patient's condition warranted it. This man made an excellent recovery without infection. Case Two: That night the author was called to another hospital to see a man who had been run over by a nearby street car and who was immediately carried to the hospital. This patient had likewise suffered a severe crushing wound at the hip-joint and in many respects was almost identical with the other case. The patient had been immediately carried to the operating room and the physician who was called in to give emergency care had started combating the shock but at the same time had proceeded to give surgical attention to the wound. The patient's body and right limb were covered with blankets and hot water bottles were in place. Normal salt solution was being administered intravenously, stimulants had been given. While the patient was being anesthetized with ether, the physician had pro- ceeded to cut away the mangled limb and was carefully coapting the various tissues. I arrived at this stage and recommended the imme- diate application of a large sterile pad to the stump, leaving subsequent EMERGENCY SURGERY 525 repair to some future date if the patient recovered. This was doubtful considering his condition at that moment. Before this recommenda- tion could be acted upon the patient died. Too much emphasis cannot be placed upon the importance of combating these severe shock conditions before attempting any- radical emergency treatment of the wound itself. The surgeon must have the patience of an obstetrician in such cases and stick by the patient; biding the time till it is safe to proceed with the repair work. Shock and Hemorrhage. — Shock and hemorrhage, either singly or combined, play an important part in the complications which an emergency surgeon must combat immediately following an accident. There are all grades of both shock and hemorrhage and both may occur immediately (primary) or late (secondary or delayed). Both may gradually lead to a condition spoken of as "collapse" and death may follow this state. Previous to the war these conditions were most thoroughly de- scribed by Crile and his methods of treating them have played an im- portant part in the treatment of our soldiers affected by these con- ditions. During this period of war surgery, research in the field of shock and hemorrhage have added considerably to our knowledge of these subjects and the emergency surgeon in industry should famil- iarize himself with these various reports from the war zone in France. One of the interesting contributions of the physiologic changes which take place in the body during traumatic shock has appeared recently in the report from the Central Medical Department Labora- tory of the American Expeditionary Forces in France, under the title of "The critical level of a falling blood-pressure and the modifications of hemorrhage. " "Clinical and experimental observations have shown that death after severe hemorrhage is not immediate, but may occur after the la.pse of some hours. This fact is explained by the gradual damage of essential organs by partial anemia until they fail to perform their functions. If hemorrhage is repeated, non-volatile acid (lactic) will appear in the blood. Other conditions which markedly lessen the oxygen supply to the tissues (CO poisoning, rebreathing expired air), have the same effect. Lactic acid thus produced unites with the sodium of the sodium bicarbonate in the blood, drives off CO2, and thereby produces a reduction of the "alkali reserve" (indicated by a diminished capacity of the plasma to take up CO2). When the CO2 capacity is reduced to less than 50 volumes per cent., under standard conditions, "acidosis" is said to be present. Reduction of the alkali reserve in such circumstances, may be taken as an in- dication of insufficient oxygen supply to the tissues. 526 INDUSTRIAL MEDICINE AND SURGERY "As arterial blood-pressure falls, the rate of circulation of the blood decreases. Then, though the red blood corpuscles leave the lungs normally laden with oxygen, they may not carry a normal supply to the tissues because they move too slowly. In that case the condition would be similar to other conditions in which oxygen want exists; non-volatile acid would result, and the alkali reserve be lessened. "In traumatic shock the blood-pressure is low and the circulation is therefore sluggish. For therapeutic purposes, it is important to know at what point in a falling blood-pressure, the oxygen supply begins to be insufficient, as indicated by a lessening of the alkali reserve. "Experiments in the Laboratory of Surgical Research at the Central Medical Department Laboratory have shown that if arterial pressure is lowered to 80 mm. of mercury for an hour, the alkali reserve is not reduced; but if lowered to 70 mm., the reserve begins to fall; and if lowered to 60 mm., it falls still faster {i.e., the oxygen supply is less adequate, and the production of non-volatile acid is more rapid). A critical level of oxygen supply to the tissues is reached, therefore, when the arterial pressure is experimentally lowered to less than 80 mm. of mercury. Average figures from 43 cases of shock and hemorrhage studied last summer at Bethune reveal in human beings similar relations : Systolic blobd-pressure, . mm. mercury Average CO2 capacity, vols, per cent. No. of cases 90-100 49 12 * 80- 90 49 5 70- 80 43 10 60- 70 36 11 50- 60 24 5 "As these figures clearly show, a reduction of the alkali reserve below 50 volumes per cent. CO2 capacity, or a condition of "acidosis," occurred when the systolic pressure was lower than 80 mm. of mercury; and the reduction of the reserve was progressive as the pressure was progressively lower. It appears, therefore, that the critical level for proper oxygen supply to the tissues is approximately 80 mm. of mercury, systohc arterial pressure. The lower the pressure below that level, the less is the circulation able to meet the needs of the tissues. "Experiments show, as might be expected, that if hemorrhage complicates a low blood-pressure, the critical level is higher than if no loss of blood has occurred. Thus, if 20 per cent, of the blood has been lost, the pressure cannot be lowered to 80 mm. without indica- tions of insufficient, oxygen supply to the tissues. "In the treatment of shock and hemorrhage, the persistence of EMERGENCY SURGERY 527 arterial pressure below 90 mm. of mercury for more than a half hour, without sign of improvement, though the patient has been warmed and rested, should call for treatment by transfusion of blood or the infusion of acacia solution. If the pressure is much below 90 mm., e.g., 50 or 60 mm., such treatment should be instituted immediately." The symptoms of shock are most graphically described by John J. Moorhead as follows: "A typical case presents rather a characteristic appearance in that the patient immediately after the accident is unconscious or nearly so; the surface of the body is pale, cold and sweaty; the expression is anxious; the eyes are shut or widely open; the pupils are dull, usually dilated, and slowly responsive; respiration is shallow and feeble and often intermittently sighing; the pulse is weak, compressible and ir- regular, and often slow and inactive; if very arousable, mental tor- pidity is the rule; sometimes the sphincters are relaxed and nausea and vomiting may occur; the temperature is subnormal or sHghtly elevated at first. After some minutes, or later, these patients grad- ually become aroused, the color returns, the mind clears, the pulse and respiration strengthen, and they recover." Other much more severe grades may remain in a state of mental and physical depression or mental torpor for many hours and even die in deepening coma from shock alone, although death from this source independently is quite rare and should not be accepted as a sole cause in the absence of an autopsy. In some instances a condition of apathy is replaced by one of ir- regular activity of a somewhat dehrious type, this occurring especially with head injuries and with alcoholics; this is a so-called erethistic as distinguished from the apathetic or ordinary form, and it is very closely allied to traumatic delirium. Secondary or delayed shock may appear from several hours to two or three days after an accident. It is most frequently due to hemor- rhage or may appear after an anesthetic operative procedure has been undertaken. Hemorrhage gives almost the same symptoms of shock especially as the two so often occur together. A patient without much shock, however, who is hemorrhaging, will gradually develop these symptoms. Increasing pallor is noticed; the pulse becomes soft and compressible, at first rapid but gradually becoming slower and irregular; the patient yawns frequently and complains of thirst; the blood-pressure be- comes lower and lower. Unless the condition is checked a state of collapse gradually develops, followed by coma and death. Secondary or delayed hemorrhages frequently occur in accident surgery and in severe injuries the surgeon should constantly be on the lookout for the above symptoms. 528 INDUSTRIAL MEDICINE AND SURGERY When shock and hemorrhage are coincidental as is so often the case in those accidents diagnosed as internal injuries, it is often very diffi-. cult to differentiate between the two. It is very important to make this differentiation, however, as the treatment must frequently be modified where the two exist together. For instance, when shock alone is present; the repair work may be postponed until the patient's condition is improved, but if shock and hemorrhage are both present or if the shock is solely due to hemorrhage, the finding and checking of the source of bleeding is the paramount consideration. Often the stimulation and especially the transfusions which are administered in case of shock may increase or even create a hemorrhage. Therefore, in combating shock, one must constantly be on the lookout for hemor- rhage and ready to immediately check the same. As Moorhead so aptly states, "shock patients get better, while bleeding patients often get worse during treatment and lapse of time." The treatment of these conditions is similar after the hemorrhage is controlled. . In fact the treatment of both must often be instituted while endeavoring to check the hemorrhage. The ordinary shock patient will recover from this state very shortly by the simple methods of rest; keep thoroughly warm; no manipulation of the injured part or if necessary, the very gentlest; lowering the head, and stimulation. The severe cases demand all of the above and in addition, transfusion or infusion of normal salt solution with or without adrenalin, the infusion of acacia solution, or the transfusion of blood. The delay in administering the more heroic methods has caused a fatal termination of many a case which otherwise might have been saved. As one observer in the war zone has said, ''Necessity for transfusion or infusion in cases of shock with or not the further cause of low pressure resulting from hemorrhage can be detected earlier and with greater certainty by a series of blood-pressure obser- vations than by other means. A warmed, rested patient showing a persistent arterial pressure below 90 mm. of mercury needs help at once and the help he needs is infusion or transfusion." In industrial surgery the majority of these shock and hemorrhage cases will or should receive their emergency treatment in the plant dispensary. They are the type of cases which formerly so frequently died in the ambulance on the way to the hospital. The bringing of the surgeon to the front line trench in industry has prevented many such deaths. The time is coming when a very hazardous industry must provide this immediate treatment. Every plant surgeon should be thoroughly drilled in the follow- ing treatment of a patient brought to the dispensary on account of severe injuries: 1. Immediately place on a bed or on the dressing table and cover EMERGENCY SURGERY 529 all parts of the body except the injured portion with warm blankets, and surround the body with hot water bottles. Elevate the foot of the bed. (My surgical nurse carries out this procedure in all cases of injury whether shock symptoms are present or not, automatically attending to the comfort of the patient without any directions from the surgeon.) 2. If shock symptoms are present, administer at once a hypo- dermic of morphin. If the condition of shock is mild, this may be replaced by aromatic spirits of ammonia. 3. While this treatment is being carried out, carefully inspect the injured part, clamp all bleeding points, sterilize with iodin and cover with a sterile pad. Don't take time to carefully bandage. Direct the rest of your attention to combating the shock, meanwhile watching the wound carefully for a recurring hemorrhage. 4. If the condition of the pulse or the lowered blood-pressure (the nurse or an assistant has already taken the blood-pressure and continues to do so at frequent intervals) show the need of cardiac stimulation, strychnia one-thirtieth of a grain may be given, or better, adrenalin or camphor. The author keeps two things constantly ready for shock cases, namely, a sterile glass irrigation jar containing sterile tubes with sterile needles attached for the infusion or transfusion of normal salt solution; and a fountain syringe with a large size catheter attached for the administration of hot normal salt, six ounces, and whiskey, two ounces, per rectum. While the above procedures are being carried out, the surgical nurse and her assistant sets up this apparatus and fills the first with the sterile normal salt solution and the latter with the normal salt and whiskey solution. They do this even though later their use may be found unnecessary. 5. If the shock is severe and the blood-pressure indicates its need, an infusion or transfusion of normal salt solution should immediately be given, at the same time starting the rectal stimulation. The body must not be unduly exposed but must be kept warm during this entire treatment. 6. Do not move the patient from the dispensary to the general hospital until this condition of shock has been overcome. As a rule, after three or four hours, even these extreme cases can be moved to the hospital. Gentleness and great care must attend this transpor- tation and the surgeon should stay constantly by his patient, even riding in the ambulance with him. Unless the danger of delaying an operation is of greater menace to the patient's life than the shock condition, all operative procedures should be postponed until the latter is overcome. The need for an immediate operation may cause the patient to be rushed to the hos- 34 530 INDUSTRIAL MEDICINE AND SURGERY pital at once. Contrary to the opinions of many, such a case usually stands the effect of an anesthetic very well, the patient's condition seeming to improve after the anesthetic has started. Frequently the symptoms of shock return and the condition becomes critical during the operative procedure. Crile's method of blocking the nerves above the site" of the injury by injection will often prevent this re- currence of shock during an operation. Blood transfusion has usually been considered an operative pro- cedure suitable only for the hospital. Recent experience has proven that quick methods of blood transfusion by the use of a large hypo- dermic syringe containing 2 per cent, solution of sodium citrate, so that when the syringe is filled there will be one part citrate to ten parts of the donor's blood, can be administered with good effect to these hemorrhage and shock patients. Undoubtedly, one of the ad- vances in surgery as a result of the war will be a commoner use of blood transfusion. Resuscitation. — The method of artificial respiration for com- bating certain types of shock, suffocation, asphyxiation and similar conditions has been fully described in the chapter on First Aid. In addition to this, many industrial dispensaries, especially in those in- dustries where electrical shock, gas poisoning or asphyxiation are liable to occur, have included pulmotors as a part of their equipment. Many surgeons claim excellent results from the use of these pulmotors. Universal approval of the various devices for automatically forcing respiration has not been given, some authorities claiming that this procedure is dangerous. There is no question, however, but that this method has been very successful in many cases of gas asphyxiations. Circulatory artificial stimulation is another means of resuscitation which should be employed. Rhythmic pressure over the heart area, the tongue being drawn out, combines circulatory with respiratory stimulation, according to Crile. Some have advocated the digital rhythmic compression of the heart itself but the success of this method is very doubtful. Freezing or Frost-bites. — Third degree frost-bites, that is, those with deep ulcerations, destruction of tissue and even gangrene, are not usually seen in industrial practice. Frost-bites of the first degree producing redness and swelling of the skin are not uncommon and some even show the blebs or blisters of the second degree frost-bites. The combating of immediate complications in frost-bites aims at the res- toration of circulation. Such patients should not be taken into a warm temperature at once but gradually. Friction and cold applications afford the greatest relief. Cracked ice applied direct to the frost- bitten member and rubbed back and forth with increasing vigor is the best method. EMERGENCY SURGERY 531 The patient that has suffered an extreme case of freezing should be placed in a cold bath in a cold room and friction applied by cold towels. Gradually the temperature of the bath and the room is in- creased until the appearance of the body indicates that circulation has been re-established. Heat Exhaustion. — Heat exhaustion is not uncommon among employees during the summer months when they must work in hot places. Heat exhaustion is really a collapse from the effects of neat. Such a patient develops an extreme pallor; the skin is covered with a clammy perspiration; his pulse is weak and rapid, and respira- tion is rapid and shallow; the patient is never unconscious but may be in a state of collapse; the temperature is rarely over 103°F. and may be subnormal. The patient should be immediately removed to a cool room, should lie down with the head lowered, the body should be covered with a blanket and aromatic spirits of ammonia administered. In extreme cases, rectal stimulation with normal salt and whiskey and hot coffee, is beneficial. Such patients usually require rest, comfort and mild stimulation to early overcome this condition. Sunstroke. — This condition is usually caused by prolonged ex- posure to the direct rays of the sun or it may be due to excessive heat indoors. The symptoms develop suddenly. The face is flushed and the skin of the body is hot and dry. The temperature of the body is greatly increased, ranging from 103°F. to as high as 109°F., even more in fatal cases. The pulse is rapid and bounding, later followed by a weak, irregular pulse. At first the respiration is stertorous, later becoming rapid and shallow. The treatment in this condition consists in reducing the temperature of the body as quickly as possible. It is done by ice water sponging or by placing the patient in a cold bath the temperature of which is gradually decreased by the application of ice. This is kept up until the body temperature is lowered and consciousness returns. On the first indication of the return of high temperature this treatment should be repeated. After the patient is placed in bed ice bags should be placed on his head. A very sudden drop in temperature usually indicates a fatal termination. At the same time the collapse must be treated by cardiac stimulation, strychnia and caffein being most commonly employed, and by the use of salt solution and whiskey per rectum. Every industrial dispensary should be equipped for the emergency treatment of both heat exhaustion and sunstroke. After a fatal case of sunstroke, the author had a bath tub installed in both the men's and women's toilets in connection with the doctor's office. 532 INDUSTRIAL MEDICINE AND SURGERY These have only been needed in two cases of sunstroke since their in- stallation but both cases were saved. The combating of the immediate complications in the three last named conditions makes up a definite part of the emergency surgeon's work in industrial practice. • TEMPORARY AND PERMANENT RELIEF The majority of emergency surgery in industry consists of the im- mediate permanent treatment of wounds, the patient returning to work, and reporting to the doctor's office for his subsequent treat- ment. In some cases the permanent relief will be given at the dis- pensary and the patient is then sent to his home or to a hospital for the subsequent treatment. Many employees receiving fractures, severe lacerations, crushing wounds and loss of members will be given temporary relief at the dispensary and then sent to a hospital where the permanent repair is given in surroundings better adapted to major work. Emergency surgery administered for either the temporary or permanent relief usually involve the following methods: Closure of Wounds. — Consideration was given to this procedure under the subhead of preventing infections. As a rule, the incised wounds and the majority of lacerated wounds received by employees can be closed after sterihzation has been done. Many of these cases will require a small rubber band, a wick of gauze or two or three strands of twisted silk gut for drainage, the same to be removed after twenty-four or forty-eight hours. The majority of penetrating wounds and even the severe, crushing wounds, after sterilization, the removal of all foreign bodies, and the repair of the deeper tissues, can be closed providing the doctor receives these cases early. In many of these, small drainage is often indicated. As a general rule, the compound fractures should be sterilized, thoroughly drained, and not completely closed. The treatment of such wounds, as developed by war surgery, is described under the chapter on Fractures. The commonest method employed for the closure of wounds is that of suturing with catgut, horsehair, silkworm gut, or silk and linen, all thoroughly sterilized. Catgut is almost universally used in the repair of deeper tissues. Some use it in the skin but a majority of the surgeons prefer non-absorbable material. The author has used cat- gut for the closure of many skin wounds and when iodin was used religiously, has never" had any difficulty with infections. As a routine measure, however, silk, linen and horsehair are best employed in emergency work. During the last five years, the author has not employed suturing in more than 10 per cent, of his cases. Narrow strips of adhesive EMERGENCY SURGERY 533 |j! Fig. 78. — Strip of adhesive plaster sterilized with iodin at point of con- tact with wound. Used in place of suture. plaster will coapt the skin edges of a wound as thoroughly as suturing, except in those regions where considerable tension is brought to bear upon the skin as in the movement of a joint. The method for the closure of wounds by adhesive plaster is as follows: 1. Adhesive plaster is cut in one- quarter inch strips and in lengths varying from one inch to eight or ten inches depending on the location of the wound. 2. That portion of the adhesive plaster which comes in direct contact with the wound is thoroughly painted with tincture of iodin and allowed to dry. Care is exercised in not touching the middle portion of the strip thus sterilized. (See Fig. 78.) 3. The wound which has pre- viously been sterilized with tincture of iodin is held together by the sterile fingers of the left hand while each adhesive strip, which has previously been attached to the skin on one side of the wound, is drawn snugly across and attached to the skin on the other side. Additional strips are thus ap- plied until the wound is completely closed. A quarter of an inch space is left between each strip. This allows for the natural oozing of the wound. (See Fig. 79.) 4. Tincture of iodin is now painted over the adhesive strips. 5. A sterile dry gauze dressing is placed over the wound and adhesive strips. 6. In large wounds with consider- able gaping where it is difficult to coapt the edges or where tension would ordinarily indicate the use of tension sutures, a small roll of sterile gauze can be placed on either side of the wound and a longer and wider strip of adhesive plaster can be drawn tightly over these so as to cause inward pressure on the wound by the gauze rolls. Fig. 79. — A cotton bandage, cut to the circumference of the limb, edges bound with adhesive plaster into which eyelets are fixed, and a tape for lacing affords a rapid method of bandaging. 534 INDUSTRIAL MEDICINE AND SURGERY Adhesive strips are of no value when moist dressings are to be apphed to the wound. The greatest value of adhesive strips over the old method of suturing is in the psychologic effect on the employees. Previously, workmen, especially foreigners, would stay away from the doctor's office for fear their incised wound would be stitched. Some time ago the author overheard an employee who had just received this adhesive plaster treatment, remark to a fellow employee, ''Say, those docs, up there are all right. They don't butcher a fellow all up or stick a needle through every little cut like that doctor at the mill used to do. I won't be afraid to go up there any more." Such favorable propaganda as this, spread throughout the working force, increases the usefulness and value of the doctor's office. Metal clamps of the Michel type are used by some plant surgeons but even when not painful, they have an unfavorable psychologic effect upon the employee. The closure of wounds by sealing them up with collodium is a dangerous practice. The wound secretions, clogged up under the collodium dressing, often form a favorable seat for infection. One foreman objected to his men losing so much time in going to the doctor's office to have minor wounds properly attended to. He procured a bottle of hydrogen peroxid and another bottle of col- lodium and some cotton, and proceeded to care for these minor cuts and abrasions himself. Two serious infections shortly occurred among the employees treated by him. He was not discharged but the management published his folly broadcast throughout the plant and such individual efforts as these immediately ceased. Further, foremen were more keenly alive to the importance of sending these minor cases to the doctor's office. Great care should be exercised in the closing of wounds to prevent scar formation, especially on the face or exposed portions of the body. In linear wounds, the adhesive strips will cause healing with less of a scar than where sutures are used. However, in jagged wounds on the face, stitches should be employed in order to secure less of a scar. In such cases, fine horsehair is the best material. Fainting. — Fainting is very prone to occur during this minor emergency surgery. It is best to have patients he down when their wounds are being closed. If they are allowed to sit up, they should be carefully watched, and if pallor, clammy perspiration, dilated pupils, yawning, or a complaint of dizziness or blindness is made, they should immediately lie down. Often when the dressing can best be accom- pHshed by the patient sitting up, if any of these signs are noted, the faint can be avoided by having the patient lean over with his head between his knees. A few whiffs of aromatic spirits of ammonia or even a EMERGENCY SURGERY 535 drink of water will prevent many faints. Such patients should be given plenty of fresh air. When a person faints in the dispensary, the other patients must be carefully watched as frequently two or three of these may topple over. I have seen several ugly scalp wounds received by patients allowed to fall in faints and for this reason caution should always be taken to prevent them. I have always insisted that the patients who faint in the dispensary, must lie down for a few moments in the rest room before returning to work. Immobilization. — The importance of the immediate immobiliza- tion of fractures is brought out in the chapter on the same. For this purpose, several different types of splints should always be on hand. In severe incised, lacerated wounds or crushing wounds near joints, the member should be immobilized with a light splint in order to put it absolutely at rest. This will not only prevent the wound from being torn open by movements but is an excellent means of preventing infection. All sprains should be immobilized. This can be accomplished by the use of spHnts, but often binding by two or three layers of adhesive plaster will afford the necessary rest for the part. In applying adhesive plaster to the skin, all hair should be carefully shaved away. It is inexcusable for any surgeon to apply adhesive plaster over a hairy area, even though it be the few hairs found around the foot and ankle, and cause thereby the needless pain to the patient when the same is removed. In some cases a cotton or flannel bandage can first be applied over the sprained joint and this can then be reinforced by adhesive plaster strips. If swelling of the part is anticipated the adhesive strips should not meet in the middle line. In extensive injuries to the soft parts of the upper extremity both immobilization and rest can be gained by the use of the tri- angular sling. Often, rest in bed » ith sand bags placed on either side of the injured member, affords the best method of immobihzation and rest. This is well illustrated in the case of hand infections where immobilization of the entire upper extremity is very important for rapid recovery. The patient should be put to bed with the arm ex- tended at an angle of 45 degrees from the body. A rubber sheet is placed under the arm and hand to protect the bedding from the moist dressings. A folded woolen blanket is placed under the arm and hand, hot dressings are then applied from the hand to the elbow, or if in- dicated, completely to the axilla. Sterile bath towels soaked in hot boric solution make an excellent hot dressing and can be readily wrapped around the entire arm and hand. The woolen blanket is then folded over the hot dressings. Two or three hot water bottles can be placed about the blanket, and the rubber sheet- is then folded over the entire dressing so that the arm and hand are thoroughly 536 INDUSTRIAL MEDICINE AND SURGERY encased. This usually accomplishes complete immobilization but if necessary, a sand bag can be placed on either side of the member to hold it more securely. The various things commonly used for immobilization are band- ages, adhesive plaster, various sized pasteboard or wooden splints carefully padded, plaster of paris splints or casts, blanket splints, pillows and specialized splints as the Hodgen arm or leg splints, or the commercial splints. Dressings. — The rule "report to the doctor's office no matter how slight the injury" brings many cases with such minor injuries that a dressing of any kind is unnecessary. The doctor should not make light of these cases but carefully paint with iodin and explain to the patient why no dressing need be applied. Fig. 80. — A severe laceration of the hand closed with adhesive strips after first steriliz- ing the wound with iodin. Fifty per cent, of the dressings will consist of a dry sterile gauze applied and held in place by a gauze bandage. The surgeon must remember that the smaller the dressing and the fewer the joints covered by same, the less is the efficiency of the worker interfered with. Absorbent cotton should not be applied next to wounds for reasons already given. Moist dressings are chiefly indicated in infected wounds or in abrasions where they are used to prevent the dressings from adhering. The commonest moist dressings are boric, saline, bichlorid of mercury or alcohol. Recently moist dressings of Dichloramine-T or of the Carrel-Dakin solution have been advocated by different emergency surgeons. It is unwise to use strong antiseptic moist dressings on any wounds as the adjacent skin will invariably become irritated and more prone to infection. Occasionally a physician will apply a moist dressing of weak carbolic acid solution with the result that when the dressing is removed the underlying skin has a characteristic pallor EMERGENCY SURGERY 537 and the capillary blood supply is destroyed. Or a physician or a patient may pour iodin on a gauze dressing and bind it on the wound. Severe burns often result from such treatments. In fact, iodin applied to a wound should be allowed to dry before applying the dressing. In threatened wound infections, especially about the fingers or toes, and for moist dressings in ambulatory infected cases, the author relies especially on equal parts of alcohol and glycerin. For example, the finger has been punctured. The employee neglects the wound but reports the next day with the finger slightly swollen, reddened about the injury and very tender. No sign of pus is present and it is not indicated to open the area. A fairly large pad of sterile gauze Fig. 81. — Paraffin treatment of burns: a, Sponging wound with Dakin's solution. is soaked in the alcohol and glycerin and immediately wrapped around the finger. This is covered with gutta-percha so that the dressing is practically air tight, and is then bandaged in place. Such a dressing is reapplied every twelve hours. Usually by the next day the threatened infection has been aborted. Another moist dressing which is very valuable especially in am- bulatory cases is composed of a solution of magnesium sulphate and glycerin. This is expecially adapted to abrasions or old chronic, ulcerated areas where granulation must be stimulated. Dusting powders are chiefly used in abrasions, small first degree burns, or when the skin has become irritated. Bismuth subnitrate is the most soothing powder which can be used. The wound area may be gently covered with sterile olive oil and the bismuth powder 538 INDUSTRIAL MEDICINE AND SURGERY applied over this. Bismuth subiodid, powdered oxid of zinc, boric powder, powdered calomel and iodoform are powders most frequently- used by surgeons. Fig. 82. — Paraffin treatment of burns: b, drying with hot-air blast. Fig. 83. — Paraffin treatment of burns: c, spraying melted and medicated paraffin on wound. Ointments are occasionally applied to the irritated skin or more frequently to large, denuded areas after ''weeping" has ceased. Dr. EMERGENCY SURGERY 539 A. I. Bouffleur advocates the use of equal parts of balsam of Peru and castor oil as one of the best ointment dressings which can be used over these chronic, denuded areas. It stimulates granulation and prevents the dressing from adhering. Chronic abrasions over the shin bone where ulceration so easily occurs, require such a dressing. Unguentine, although a proprietary ointment, is one of the most use- ful about the dispensary. It affords an excellent dressing for recent abrasions or burns and also stimulates heahng in these chronic con- ditions. Mercurial ointments, such as white precipitate, is an excel- lent dressing where antiseptic action is desired. Fig. 84. — Paraffin treatment of burns: d, applying thin cotton over the paraffin film. CarboUc salve is chiefly used by the laymen. Every patient should be warned against applying carboHc salve to a wound and covering it with a dressing. Some very serious cases of necrosis have followed this practice. A girl employee scratched her little finger and it be- came shghtly infected. She reported to the doctor's office where a moist dressing was applied. That night her mother removed the dressing and put on a large quantity of carboHc vaseHn, then again bandaged the finger. She kept the girl home the next day under the same treatment. The following day the patient reported to the doc- tor's office with the finger blanched and shriveled. Within twenty- four hours, a dry gangrenous condition developed and continued until the first two joints of her finger practically dried up. This young lady has a perfectly useless fifth finger as a result of the car- bolic ointment. 540 INDUSTRIAL MEDICINE AND SURGERY The open treatment of wounds is becoming more and more popular. Abrasions and burns, chronic ulcerated conditions and old infections will often yield more rapidly to this open treatment. A cage can be made from wire screening, the edges of the cage being bound with adhesive. This can then be sterilized with heat and apphed over the wound. A thin gauze covering is placed over the wire cage, and adhesive strips are used to hold the entire dressing in place. Free access of air and sunHght seem to hasten the heaUng process. Protective devices are often necessary, especially where employees return to work after the dressings are apphed. These consist of wood spUnts, tin sphnts, wire cages and other such measures. They are usually retained in place by the use of adhesive plaster. Fig. 85.- -Paraffin treatment of burns: e, painting paraffin over the cotton, to 76 from clinic of Dr. Corwin, Colorado Fuel & Iron Co.) (Figs. 72 CONCLUSION The following points are so vital in emergency surgical work that their repetition is justified: 1. Always sterilize open wounds no matter how sHght or how ex- tensive and no matter where located. Tincture of iodin is the best antiseptic to use. 2. The surgeon must begin his emergency treatment immediately after the accident occurs. 3. The same asepsis must be observed as in operative surgery. Only sterile dressings must be applied to the wound. EMERGENCY SURGERY 541 4. Immediate immobilization of the injured member whenever indicated. 5. Shock and hemorrhage, whenever present, must receive first consideration. 6. Keen judgment, carefulness and alertness, adeptness and ingenuity, and a constant enthusiasm are the necessary attributes of a good emergency surgeon. CHAPTER XXXIV THE SUBSEQUENT OR PERMANENT TREATMENT OF CERTAIN INJURIES In previous chapters on industrial surgery, consideration has been given to preventive surgery, to first aid care, and to the immediate or emergency treatment of injuries the result of accidents. The remain- ing function of the physician practicing industrial surgery is to render subsequent or permanent treatment to the injured employees. These four functions are so closely interrelated that to be a successful in- dustrial surgeon one must be expert in all of these four lines. Some of the best surgeons of the country are capable of doing excellent repair work in accident surgery but would make poor industrial surgeons because they are not trained to think of their surgical results in terms of the man's work. Both preventive and emergency surgery are based upon the economic end-results. The subsequent surgery and the permanent treatment involve the same economic considera- tions — the quickest possible recovery, the restoration to full func- tion or as nearly so as is possible when the nature of the injury is con- sidered, and the placement at suitable work compatible with the function attained. The best emergency surgery is rendered in those industries where a surgeon is on the job to give immediate treatment to every accident case. The majority of injured employees are able to report to the plant dispensary for their subsequent treatment or in the absence of such a dispensary, to the surgeon's office. The success of these ambulatory cases depends upon frequent dressings, careful supervision to see that the dressings are not removed and proper assignment of the injured to such work as will not delay the healing process. Work is one of the best therapeutic adjuncts which the surgeon can employ and in every case he should get the employee back to some occupation in the industry as soon as possible. In a certain number of accident cases, the injuries will be so serious as to confine the employee to his home or to the hospital and arrange- ments must be made to carry on the permanent treatment in one or the other of these places. When subsequent operations are neces- sary the patient should always be sent direct to the hospital. As a general rule closer supervision can be maintained and better results obtained by rendering the permanent treatment of these serious injuries in the hospital rather than in the home. Much of the success 542 TREATMENT OF INJURIES 543 of the industrial surgeon will depend upon his powers of per- suading patients to accept this hospital care. The majority of dis- satisfied patients belong to those receiving home treatment and these are the ones who usually enter damage suits in the courts or claim excessive compensation. A few of our largest industries have their own hospitals adjacent to the plant where both the emergency and permanent treatment can be carried on. Two industries have a ward in connection with its doctor's office where the serious cases can be kept for twenty-four or forty-eight hours and then removed to one of the outside hospitals in the community. In these concerns, the surgeons do most of the operative work at the plant, even operating hernia cases, and then placing them in the ward for twenty-four hours. At the end of that time they are taken in an ambulance to one of the city hospitals. This plan saves a certain amount of expense to the management but is rather a dangerous procedure from the standpoint of the safety of the patient. As a general rule major operative work requiring an anesthetic should not be performed in the plant dispensary. Such work requires considerable time and ties up both the staff and the doctor's office so that the other medical and surgical functions are neglected. Again it sometimes happens that a patient dies during the anesthetic. There may be many excellent reasons for this death but the working force always blames it on the anesthetic. The morale of the employees is lowered and their confidence in the doctor's office is shaken by the depressing news of a death occurring there. Years ago in one in- dustrial dispensary the surgeon attempted to remove some diseased tonsils from one of the employees. A light anesthetic was given and before the operation commenced the patient suddenly died. The news of this death spread rapidly throughout the plant. Following this accident it was almost impossible to persuade injured employees to report to this dispensary for treatment. I am told that a drastic rule was immediately made by the management that no anesthetic should ever be administered in the plant. In the author's experience it has only been necessary once to give a general anesthetic at the plant dispensary. A patient needing operative work requiring an anesthetic can usually be transferred to a hospital where every facihty is at hand to meet any emergency that may arise. By careful emergency surgery and rapid evacuation of serious cases to an outside hospital, we have been able to avoid death in the dispensary for the last ten years and as a result the confidence of the working force in the doctor's office has never been shaken. Neither did any one of these patients die as a result of being moved. It is very essential that the best and most up-to-date hospital 544 INDUSTRIAL MEDICINE AND SURGERY in the community should be chosen for the care of injured employees. The surgeon should endeavor to have certain wards and private rooms set aside in this hospital for his cases and he should become a recog- nized member of the staff. Only in this way can he obtain the best nursing and interne service for his patients, both of which are absolute essentials in accident surgery. These serious cases should not be turned over to a disinterested surgeon, for employees are much better satisfied if they are in the hands of a quaUfied surgeon directly re- sponsible to the management of their industry. Such a one becomes a connecting hnk between the employer and employee and in a hundred little ways is able to convey the personal interest of the former to his injured workmen. To be successful the permanent treatment of these seriously in- jured employees must include: first, the actual surgical treatment and subsequent dressings; and second, the psychotherapeutic treatment. It is not the intention of the author to write a treatise on the sur- gical treatment of specific injuries following accidents, but rather to deal with certain general principles involved in industrial surgery. Many standard surgical works and such books as Foote's "Emergency Sur- gery," Moorhead's "Traumatic Surgery," Cotton's book on "Frac- tures and Dislocations," and other of the more recent writings on war surgery, will give the student the necessary information on special lines of treatment. The psychotherapeutic treatment of the injured, however, has been woefully neglected by the majority of surgeons, and consideration of this important phase of the care of injured employees is indicated. The psychology of a workman who has received injuries the result of his employment, is pecuhar and has an important bearing on the successful outcome of the treatment. In the first place, he feels that his employer is responsible for his suffering and disabihty and should be made to pay dearly for the same. He is then forced to- accept the administrations of a surgeon chosen by this employer rather than by himself or his family. He is carried directly to a hospital and if conscious, usually frets a great deal over how the news of his accident will be broken to his wife or family. His surroundings are strange, the experience is entirely new and he is in the hands of strangers. An immediate operation may be necessary and how does he know whether the doctor will amputate the injured member or otherwise leave him permanently disabled. In case of such permanent disability, how will he ever make a hving again and what will become of his family? These and a thousand other, fears prey on his mind and unless im- mediately dispersed by the surgeon may interfere with his recovery. During the days and weeks which follow, such a patient can easily become discouraged or dissatisfied and as a result he develops a neuro- TREATMENT OF INJURIES 545 sis which usually greatly delays his recovery. If his daily dressings are extremely painful, another factor for the development of neurosis is introduced. Or if pain and discomfort accompany the use of an injured member he may resist all efforts to regain function in the part and delay of ' this kind frequently results in permanent disability. During these days while lying in bed slowly recovering, his mind will have time to dwell upon the thoughts of compensation. The desire for excessive compensation may become so great as to cause him to feign certain conditions, while in other cases he may resist all efforts for a rapid recovery in order to receive his weekly compensation over a longer period. This latter is often the case when, in addition to his accident compensation, he is receiving benefits from his lodge or union. All of these various mental states play such an important part in the recovery of these injured employees that the industrial surgeon must constantly be on the alert to counteract their influence. With this in mind, let us consider the various methods necessary to meet these conditions. Better results can be obtained if the surgeon employed by an in- dustry, providing he is capable, takes complete charge of every accident case. In the majority of instances when employees choose their own doctor, their period of disability is prolonged and the functional re- sults are not uniformly good. On the other hand, if the employer arbitrarily chooses the surgeon for his employees, he should pick one whom he, himself, would trust in every emergency. The reputation of such a surgeon soon spreads throughout the working force so that when an employee sustains a serious injury, his confidence in the doctor is already estabHshed. The surgeon, however, must endeavor to gain the complete confidence of every injured workman from the very minute he takes charge of the case. EstabUshing confidence, therefore, is the first link in the psycho- therapeutic care. If the surgeon enters the dressing room without paying much attention to the patient, becomes excited at the sight of the wound, and cries out orders and counterorders to his assistants, starts one line of treatment then switches to another, handles the injured member roughly or otherwise causes unnecessary pain, he soon has the patient and all those about him completely bewildered. On the other hand, if the surgeon takes time to speak to his patient while sizing up the extent of his injury, learns the patient's first name and addresses him by it, cheers him up and endeavors to overcome any antagonism which may exist, then gently but deftly renders the neces- sary treatment, quietly issuing liis orders to his assistants, he im- mediately establishes an atmosphere of calmness and efficiency which impresses and reassures the injured. Such a surgeon is not only the mechanic called in to repair the broken parts but at once becomes a 35 546 INDUSTRIAL MEDICINE AND SURGERY friend and that confidence between doctor and patient, so necessary in accident surgery, is established. Reassuring the patient that his wounds are not as serious as he may think must be stated as soon as the surgeon has had the op- portunity of inspecting the condition. The more serious the wound the more essential it is for the surgeon to smile and not betray by the least sign his fears of a fatal outcome. Such remarks as "internal injuries," ''high amputations," ''gangrene," and other equally terrifying terms should not be made in the presence of the injured. If the friends or relatives excite the patient they should be kept from the room. While combating death with your every effort, if the patient is conscious, cheerfully reassure him and stimulate him to put up a fight. Notifying the relatives about the accident must be thought of at once. No employee should be taken to the hospital without im- mediately sending someone to notify his family. No worse seeds of dissatisfaction can be sown than to leave the wife worrying all night over the non-appearance of her husband after his day's work, or even allowing several hours to elapse before notifying her. The author trained two of his nurses in the best and most tactful way of approach- ing the family and telling them of the injury. These nurses were given the authority to call a taxicab whenever necessary and bring the wife or other members of the family to the hospital as soon as possible. By the time the wife has reached the hospital such a nurse usually has her trained to approach the husband without unduly ex- citing him. Surgeons who neglect the family miss their greatest opportunity of establishing friendly relations with the patient. Explaining the whys and wherefores of every step in the treatment of his case is the best means of securing the co-operation of the patient. If a part must be amputated explain the reasons to the patient and show him the futility of endeavoring to save the member. On the other hand, if there is a possibihty of saving the part and yet later it may become necessary to amputate, explain the condition and get him interested in the fight. If it becomes necessary to amputate two weeks later, he will fully understand the delay and will not criti- cise you for neglecting to operate at once. Avoid unnecessary pain during the daily dressings. When severe pain is inevitable the surgeon should employ nitrous oxid gas during the dressing. This anesthetic can be administered similar to the use of gas in an obstetrical case. Such details hasten the recovery and win the everlasting gratitude of the patient. Study the mental attitude of the patient and strive to overcome all those stimuli for the development of traumatic neuroses. If the . man is fussy and given to complaining it may be necessary to coddle him. Again, such a patient may best be treated by the surgeon taking TREATMENT OF INJURIES 547 a firm stand and scolding him; and in still others, this mental state may be overcome by carefully explaining its effect on the final recovery. Every injured employee has his moods and each must be handled individually. Mental idleness is the greatest drawback to a quick recovery. The patient who lies all day with nothing to do has time to worry and become dissatisfied. Therefore, the surgeon must counteract in every case this mental idleness. Bedside and ward occupations are the best means of accomplishing this. In the past, nurses have realized that their patients are better satisfied and require less personal attention if they are employed, and so have given them light duties to perform, Fig. 86. — Incline in the Minnequa hospital. (Grade 1 foot in 6.) Serviceable for the sick and lame. Can also be used for giving graduated exercises to heart cases and other convalescents. {Colorado Fuel & Iron Co.) such as rolhng bandages, preparing dressings, making appHcators and other light or useful employment. The busy surgeons have neglected this form of psychotherapy. The author has been in the habit of learning the exact occupation of each of his patients and then tactfully stimulating him to study and work along lines which will improve his status on returning to his job. I have found many of these patients greatly interested in improving their education during the long days of convalescence. Some who have not had the opportunity of going to school will welcome the chaince of studying the three R's. Others will enter into the study of chemistry or of stenography, bookkeeping, commercial lines and similar studies, and will develop ambitions during these days of convalescence which they never dreamed of before. 548 INDUSTRIAL MEDICINE AND SURGERY Still other patients will respond more readily to manual diversions. They will spend hours working over puzzles or at basketry or at weaving, or even playing games with some fellow patient. In many instances I have found problems connected with their occupation in the plant, have brought these problems to them and have suggested that they might improve their standing as an employee by working out some improved method during these days of idleness. Many of these employees will take a draughting board, drawing paper and pencil, and with rulers and compasses will study out many ingenious, often im- practical, contrivances. The chief point is that they have become interested in Ihoir work and are anxious to return to the job in order, Fig. 87. — Aiuputation case learning typewriting during his stay in the liospital. pliance on typewriter enables making of duplicate copies. Ap- to try out some of these experiments. When an employee has lost an arm or a leg or even an eye as a result of his accident, he is greatly discouraged and feels that his future is damned. A good surgeon will immediately conceive methods of awakening ambition in such patients. If they cannot return to their old job he will suggest lines of study or work which will prepare them for a better position in some aUied occupation. The employer can often be interested in these efforts and will be of the greatest help in suggesting the means of preparing the patient for his future. This rehabilitation of injured employees is one of the most fertile fields of endeavor open to the surgeon. Every hospital should provide TREATMENT OF INJURIES 549 some qualified person who can assist in these forms of psychotherapy. Often the manual work which is given the patient will be such as will help him to regain function in an injured member. For instance, con- tractures following a hand infection often result in stiff and useless fingers. Early employment of the fingers by typewriting, by weaving, by grasping a hammer or a saw, and similar methods will be of the greatest aid in preventing undue contraction and restoring function. OCCUPATIONAL THERAPY This use of work as a means to help restore function and as an adjunct to the usual surgical treatment, employed as a form of psycho- FiG. 88. — An amputation <;ase learning to use his stump by doing wood-carving. therapy, is called occupational therapy. It can be used during the hospital treatment or the home treatment as above described. Small shops should be estabhshed in connection with each hospital where various kinds of occupational therapy can be administered. As soon as possible, however, patients should be removed from the influence of the hospital. Every surgeon knows the great patience and time that is often required to overcome the hospitalization which follows a prolonged sojourn there. But patients leaving the hospital and allowed to remain in idleness around the home frequently develop even a worse state of mind. Therefore, as soon as possible after 550 INDUSTRIAL MEDICINE AND SURGERY leaving the hospital every injured employee should be returned to some light occupation in the plant. Foremen must realize that this is a definite part of the treatment and that such employees are not expected to turn out an average day's work. To successfully carry on such occupational therapy, industries would find it greatly to their advantage to establish schools and ex- perimental shops in some portion of the plant where every injured man, or woman, could spend the days of convalescence in some form of occupation. This would not only hasten recovery but would make a better employee when he returns to work. Every efficient manage- ment is anxious to fill the better positions in the plant, such as foremen, chief clerks, etc., from the ranks of its working force. Many foremen and future managers could be developed in these schools and shops maintained for injured employees. The following example illustrates to what extent light occupations about the plant can be employed by the surgeon to assist in restoring function to disabled parts. C. W., forty, male, Polish nationality, was severely burned about his right arm, right leg and back. After three months the wounds had healed but wound contractures were threatening to cause perma- nent deformities. During his stay in the hospital this patient was given passive motion and as soon as possible active motion, and certain work and exercises to prevent these contractures. In spite of these precautions the right knee had considerably flexed and the right wrist was greatly restricted in motion. During this period of his disability, C. W. had received his full weekly wage from the concern. Arrangements were now made for his return to light work as we recognized that he was neglecting to exercise these parts while remaining at home. The patient objected to returning, however, and so it was explained to him that from that time on he would only receive two-thirds of his wages which was the amount required by the compen- sation law. On the other hand, if he would return to light work for a few hours every day at first, he would continue to receive his full wages. This argument as usual prevailed and C. W. reported for duty. He was given a light paint brush and a bucket of paint and assigned the task of painting the steam pipes and radiators. In order to do this, it was necessary for him to ascend four steps on a ladder while painting the overhead pipes, then he stood on the floor for a portion of the time and in order to paint the pipes near the floor he was forced to stoop and bend the knee. At first he persisted in using his left hand in wielding the paint brush but the surgeon got him interested in the game and bound up the left hand so that it was impossible to hold the brush. Naturally he was very awkward during the early days and accomplished very Httle work but gradually he began to TREATMENT OF INJURIES 551 use the wrist and knee more and more. After one month the knee was perfectly straight and could be flexed or extended at will. It took three months to restore perfect function in the wrist but at the end of that time C. W. was an expert painter and the management decided to keep him permanently on this job. His wages were in- creased commensurate with this work, whereas before the accident he had been a day laborer about the power plant earning some $16.00 a week. He had now learned a trade and for the first time in his life had developed an ambition. When at the end of three months he received his first weekly pay check for $22.00, C. W.'s Americanization was completed and he began at once planning to buy his own home. Two years later this employee told the surgeon that his accident was the best thing that had ever happened to him. PHYSIOTHERAPY Massage, Hydrotherapy, Electrotherapy Industrial surgeons as well as all others have devoted almost their entire attention to standardize surgical methods and have neglected many of the therapeutic adjuncts which are of the greatest assistance in restoring function and securing rapid recoveries. The idea of bed- side occupations and later the application of occupational therapy as described above has developed during the last few years and has lately been especially stimulated by the reconstruction of disabled soldiers in the European and Canadian hospitals and now in our own hospitals. The use of massage, electricity and the various forms of hydrotherapy as definite therapeutic methods have been known for years but these excellent means have been left chiefly to a few enthusiasts in the profession or have been relegated to the realms of quackdom. Many a surgeon has been chagrined by having a patient over whom he has labored for months, seek relief at the hands of some osteopath or other type of physiotherapist, and return to him completely cured in the course of a month. The reason for this is that the surgeon has depended entirely on the old classical Hues of treatment taught him in medical school and failed to take advantage of some of these most excellent methods used by the other man. Instead of condemn- ing these therapeutic measures because they are used chiefly by the so-called quack, we should condemn those practitioners who claim a cure-all by these means. The whole field of physiotherapy has played such an important part in the surgical work during this great war that these methods will undoubtedly become a definite part of the therapy practiced by surgeons in the future. Major R. Tait McKenzie, M. D., professor of physical training at the University of Pennsylvania, has covered this field very 552 INDUSTRIAL MEDICINE AND SURGERY thoroughly in a book entitled "Reclaiming the Maimed." Every industrial surgeon should become familiar with the methods therein described. Under many different conditions he points out the great value of massage, hydrotherapy and electrotherapy as a definite part of the permanent treatment. For instance, in the case of injuries to peripheral nerves, all the way from bruising of a nerve trunk to its destruction and restoration by surgical means, he states: ''These cases are accompanied by weakness, or paralysis, muscular wasting, and contractures. They are treated by wet or dry heat to exalt the local circulation; supported in proper position by splints to prevent the overstretching of weakened muscles, and the resultant permanent contraction of those that are unimpaired ; galvanic, and afterward faradic, stimulation to the affected muscles; massage to keep up or improve their nutrition; passive move- ment to prevent contraction and limitation of the normal range of the joint; progressive active movement, joint by joint, to bring back and strengthen voluntary power; ending with gymnastic and occupational therapy for skill to fit the patient to take his place in civil life again." In regard to scar tissue with contractures and in extensive scar tissue following old septic wounds, McKenzie says: ''Such wounds are treated by the warmth of the whirlpool bath, which in twenty minutes changes the cold purple of the painful hand into a warm crimson, and enables the masseur to stroke, knead, and move a joint in a way that no amount of persuasion would have made tolerable without it. "The hastening of repair in these scars by diathermy and ionization and the stretching of beginn'ng contractures by careful manipulation, taking care to avoid the breaking down of scar tissue in course of organization, are among the triumphs of these methods." This war has greatly increased our knowledge of functional neuroses and many a surgeon, as a result of his war experience, has developed the necessary patience to successfully handle these cases. These neuroses take the form of paralysis, contractures, areas of anesthesia or hyperesthesia, loss of sight, speech or hearing and many other pecuhar phenomena. Many miraculous cures have already been accomplished by our physiotherapists working in the war hospi- tals. In these cases massage, hydrotherapy and electro-therapy combined with the personaHty of the operator furnish a combination of hypnotism, suggestion and encouragement and results in the cure of many conditions which would not otherwise yield to the ordinary treatment. Unfortunately thousands of soldiers will be thrown back into civil life who have been cured by this form of physiotherapy and they will more than ever before depend on these methods as eure-a!ls for every condition. "Quacks" will take advantage of this TREATMENT OF INJURIES 553 to extend their profiteering on the human credulity. In order to prevent this, surgeons must standardize these methods and apply them in every case where they can hasten or assist recovery. Several industrial surgical dispensaries have already adopted these methods. A quahfied masseur is employed on the medical staff to give massage under the direction of the surgeon. Arm baths and leg baths have been added to the equipment of the dispensary where hot and cold hydrotherapy can be administered when necessary. McKenzie advocates the whirlpool bath in all cases of painful stumps, painful scar tissues, partial paralysis, injuries to nerves and to any condition which lowers the circulation and nutrition of the part. "The arm or leg is thrust into a vessel containing water at a temperature varying from 105 up to 115 degrees. This water is Fig. 89. — Adjustable electric cabinets suitable for local heat bath. (Burdick.) Fig. 90. — Same as Fig. 89. circulated by means of jets set at an angle or by a propeller. Air is also introduced, so that the limb is immersed in a swirhng, bubbling current. In this way the part is flushed with blood, and the full effect of heat is obtained in a way that is impossible if the water is still." The author has recently used radiant light and heat in the treat- ment of strains, backaches, muscle pains and other conditions of obscure origin but undoubtedly having a neurotic basis. Such cases report to the doctor's office frequently and continue to report for days and weeks complaining of the pain which does not yield to the ordinary methods. If such patients receive proper attention the first day they report and are put in the rest room and given a course of treatment with the radiant heat followed by massage, the condition is usually cured at once, or within two or three treatments, thus saving these cases much loss of time from work and the accompanying inefficiency which goes with such conditions. Figures 89 and 90 554 INDUSTRIAL MEDICINE AND SURGERY illustrate two types of local light and heat baths which can be used in the surgical dispensary. Dr. B. F, Lounsbury in his railroad accident surgery at the Wash- ington Boulevard Hospital, Chicago, keeps a physiotherapist in constant attendance at the hospital. In practically all major acci- dent cases he employs faradic and galvanic electricity, heat and light baths, hydrotherapy, massage and gymnastic exercises as a definite means of restoring function and hastening recovery. All these methods can be applied in the large industrial dispensary and the results obtained justify the additional expense. FUNCTIONAL RE-EDUCATION ^ Functional re-education aims at the restoration of lost or restricted function in a disabled member. It is based upon the principle of Fig. 91. — A hospital bed with frame and sling attached. This enables patient to move himself and facilitates exercising in bed. letting each patient be his own doctor. During the early days of convalescence an operator must give the massage and passive move- TREATMENT OF INJURIES 555 ments necessary to prevent complete loss of function, but as soon as possible active movements by free exercise or with apparatus should be instituted in order that the patient himself can re-educate the part and cultivate strength and endurance. This re-education can be made so interesting for the patient that it takes his mind off of the dis- ability and, therefore, has an excellent psychotherapeutic value. While a limb is still in a splint, or otherwise immobilized, a patient may learn certain muscle resisting exercises by a process of mental control over different groups of muscles. In this way muscle twitch- ing without moving the joint can be commenced weeks before the splint is removed. When final and free motion of the joint can begin, the muscles having become strong instead of atrophied, the patient Fig. 92. — A bed table suitable for games or bed-side occupations. Corwin.) {Courtesy of Dr. is able to raise the dropped wrist or to bend the stiffened knee. The period of disability can be greatly reduced by this type of functional re-education. The greatest value of functional re-education, however, is found in those cases of scar contracture, stiff joints following long spUntage or following extensive injuries with scar formation, in paralysis follow- ing injuries of the nerves or in those cases of lost tendon and muscle tissue. The value of occupational therapy as a form of functional reeducation has already been pointed out and wherever it can be ap- plied in a practical way it is certainly of more value than any other form. However, during the hospital days and the convalescent period before the patient is able to take up practical work this reeducation can be greatly facilitated by the use of certain appliances. 556 INDUSTRIAL MEDICINE AND SURGERY -»"--C-^-- 1^ MECHANOTHERAPY The use of apparatus for functional re-education is called mechano- therapy. Its principles are best described by Dr. McKenzie who has invented several different types of apparatus which are now in use in practically all the Canadian war hospitals and several of the army hospitals in this country. "Apparatus is necessary to bridge the gap between free movement and the more complicated and skillful co-ordination of gymnastics and occupation, and it can be constructed so as to give a graduated and measurable i'S,,^ load, to be increased as strength returns. N. Muscles work better against resistance than free, and the necessary resistance may be given by the hand, by friction, forming a brake on the^ turning of a wheel or handle, by stretching elastic cords, or by stretching, or compressing springs. In these devices, it is difficult or impossible, to measure accurately the work done. They vary at different stages of the movement, are un- even, and the patient quickly tires and becomes discouraged, because he cannot see a definite and measurable improvement. The best principle to use is the raising of graduated weights, either by a lever or by a rope and pulley. In the former, the weight is clamped on a lever at points in- dicated on a scale, the lengthening of the lever increasing the force necessary to raise it. This is the principle employed by Zander in most of his machines, which, however, are expensive, complicated, cumbrous, require much space, and need an engine to supply motive power for some of them. Appliances can be constructed to produce accurately the same effects at one-tenth the cost, by making use of the weight and pulley. " Figure 93 shows diagrammatically an arrangement by which the direction of the resistance may be upward, downward, or from the s'de. Machines combining these three movements are called triplex, or triplicate machines, but, in addition to these, special devices are necessary for exercising certain joints. The following set of appli- FiG. 93. — The triplicate pulley weight. (McKenzie, "Reclaiming the Maimed." The Macmillan Co., Publishers.) TREATMENT OF INJURIES 557 ances are designed to combine simplicity, cheapness, and efficiency. They can be easily multipHed to any extent by a good carpenter and blacksmith who has the pattern before him. "Their use should have a place in a definite sequence; treatment begins with the preparation of the limb or joint by electricity, radiant heat, or hot baths, then massage and passive movements, as already described, followed by active movement. A mirror is of great value Fig. 94. — Protractors for measuring angles of movement in the shoulder, elbows, wrist, knee and ankle. Hart House. (McKenzie, "Reclaiming the Maimed.") The Macmillan Co., Publishers. to teach accuracy and associate the feeling of the movement with its appearance. "Before beginning the re-education of a joint, the range of move- ment should be carefully measured. This is done by means of pro- tractors of cardboard, or galvanized sheet iron, with the scale marked in degrees. The illustration shows the method of measuring move- ments of the shoulder forward and backward, the protractor being set with zero perpendicular to the joint as checked by a plumb Hne. The movement in either direction is marked in degrees. The elbow, wrist, knee, and ankle are measured by the second protractor made 558 INDUSTRIAL MEDICINE AND SURGERY Fjg_ 95. — Adduction and abduction of wrist. Note the scale to measure the angle of movement. {From McKenzie, "Reclaiming the Maimed.") Fig. 96.— Measuring atreugtli of grip by the tycos sphygmomanometer. F. W. Harvey. {From McKenzie, "Reclaiming the Maimed.") TREATMENT OF INJURIES 559 Fig. 97. — Wrist abduction in action. E, beginning of wrist extension. F, correct position of arm in pronation. {From McKenzie, "Reclaiming the Maimed.'") Fig. 98. — Rotation, flexion and extension and lateral movements of the wrist. {From McKenzie, " Reclai?ning the Maimed.") 560 INDUSTRIAL MEDICINE AND SURGERY of galvanized iron strips, hinged, and with a scale pasted on to a side plate. "Most of the appliances about to be described have protractors at- tached, so that the range of movement can be watched by the patient rG ° :^ 3 o o ^•S fl S 3 2 sr rH O •2 « weeks it reached normal and remained there. On the third day, a 588 INDUSTRIAL MEDICINE AND SURGERY stock streptococcus vaccine was injected, and on the fourth day, a small dose (50 million) of autogenous vaccine, which had been pre- pared, was administered. A slightly larger dose of autogenous vac- cine was given on the sixth day, and again on the ninth day. These vaccines were repeated every four days for four more doses. She left the hospital at the end of three and one-half weeks, and recovery was complete at the end of five weeks. The neglect of this minor injury and the late reporting after the trouble had started were the chief reasons for this girl's serious sickness. Mr. E., an old employee, received a slight contusion of the hand on March 4, 1912. The cause of the accident was unknown. He had been under the care of his family physician because he did not think his work was responsible for the injury. The hand at first became swollen, then the forearm, which was badly inflamed and very Fig. 123. — A deformed hand following a cellulitis of the forearm. This man was- treated in his home by his family physician for two weeks. Numerous small incisions were made without adequate drainage. Recovery did not occur until he was taken to the hospital and the deep abscesses drained. This temporizing treatment caused four months disability and the permanent loss of function in the hand. tender. This swelKng increased until his family physician was called on the fourth day. Three small incisions were made on the flexor surface of the forearm and were extended through the skin to the fascia. A little serous exudate was found, but no pus. These incisions became infected, and superficial abscesses developed on the forearm during the next ten days. These were opened and drained by small incisions. The swelhng in the arm increased to an immense size and the entire forearm assumed a dark-red, brawny appearance. The patient came under my care March 18 and was taken to the hospital. A diagnosis of diffuse cellulitis of the forearm was made, with large collections of pus in both the ulnar and radial bursse and the intramuscular spaces. Under a general anesthetic, large incisions were made at each side of the forearm, just above the wrist- HAND INFECTIONS 589 joint, and the ulnar and radial bursse drained by through-and- through drainage. A large incision was then made through the upper two-thirds of the forearm, shghtly to the ulnar side of the middle of the flexor surface. From this incision, all intramuscular abscesses were opened and drained. Infection was found to be a staphylococcus pyogenes aureus, and autogenous vaccines were made and used for several weeks. This man ran a temperature from 99° Fig. 124. — Deformed hand following severe hand infection from nej^lected pin prick. to 102°, with a weak thready pulse of 110 to 130 for at least six weeks. He gave the typical picture of sepsis. Acute nephritis developed, but gradually disappeared with recovery from his infection. For several days we despaired of this man's life. Recovery was prac- tically complete about the middle of June, some three months later. Permanent deformities remain in this case. His four fingers are -Hi - ■p^ Fig. 125. — Same as Fig. 115 three months later. This deformity was overcome by the constant use of a hammer. flexed about 25 per cent, and cannot be completely extended nor closed. This man's long disabihty, loss of function in the fingers, and the narrow escape from death were all the result of neglecting a simple injury, trying ambulatory treatment when hospital treatment should have been instituted together with inadequate drainage during the early course of the disease (Fig. 123). 590 INDUSTRIAL MEDICINE AND SURGERY The remainder of the cases in this group all neglected prophy- lactic measures at the time of the minor injury; a few were given first aid by fellow employees, as attempted removal of a splinter from the hand, in which case a portion of it was left in ; all reported to the doctor from three days to one month after receiving their injuries; and four were given office treatment by their family physicians for a few days before being sent to the hospital. The five cases of permanent deformities, two with loss of fingers, are the direct result of the above negligence. ECONOMIC VALUE OF PROPER DIAGNOSIS OF LOCATION OF PUS AND PROPER SURGICAL INTERFERENCE IN HAND INFECTIONS Many cases of prolonged disabihty and also of permanent defor- mities result from a wrong diagnosis of the type of infection, a lack of understanding as to the location of the pus, and inadequate sur- gical interference — either too small incisions, or at times too large Fig. 126. — A lateral incision, instead of on the flexor surface, over the tendon, fur- nishes better drainage and prevents deformity. or too many incisions. Some of our cases of serious deformities come under this heading. Kanavel has demonstrated conclusively that there are certain definite spaces where infection, entering at various points on the hand, tends to spread. The most important of these spaces are: 1. The synovial sheaths about the tendons — the commonest site for the more serious forms of hand infections (Fig. 126). 2. The lumbrical and subaponeurotic space at the edge of the palm,, where the so-called ''collar-button" abscesses form. HAND INFECTIONS 591 3. The thenar space. 4. The middle palmar space. 5. The hypothenar space. 6. The radial bursa. 7. The ulnar bursa. Through the last two spaces, infections usually spread from the hand to the forearm. A knowledge of these spaces and the location of injuries that usu- ally lead to their involvement should be had to properly open and drain these most serious types of hand infections. To know the re- lations and boundaries of these various spaces is just as important as it is to know where to enter the abdomen for the appendix or to reach the gall-bladder. In other words, infections about the fingers and hand have too long been considered of rather minor importance and FiG. 127. — A "collar-button" abscess from a neglected infected callous. have been treated accordingly, whereas they must be recognized as very grave, serious conditions and must be studied and treated by the most approved surgical procedure. Every possible adjunct, both locally and constitutionally, must be employed to hasten re- covery and prevent a spread of the infection. A classification of the various types, as to location, of the 411 cases of hand infections which were serious enough to cause disability will give the relative frequency of the involvement of these different spaces. 592 INDUSTRIAL MEDICINE AND SURGERY I. The types of hand infections, named in their order of frequency, which were given ambulatory treatment: (o) Paronychia 90 (b) Superficial or subepithelial abscesses 72 (c) Abscesses in superficial connective- tissue spaces — cellulitis of hand 45 (d) Carbuncular infections 20 (e) Lymphangitis of arm from hand injury 13 (f) Felons 10 (g) Collar-button abscesses (distal edge of palm) 3 Total •....: 253 II. The types of hand infections, named in their order of frequency, which were given hospital treatment: (a) Lymphangitis of arm from hand injuries. . . . . : 59 (b) Felons 24 (c) Tenosynovitis 24 (d) Abscesses in superficial connective-tissue spaces — cellulitis of hand 14 (e) Collar-button abscesses 7 (/) Carbuncular infections 5 (g) Middle palmar space infections 5 {h) Paronychia 3 (i) Thenar space infections 3 (j) Hypothenar space infections 2 Total 146 III. The twelve very serious cases where active treatment was adopted late were characterized by having more than one space involved, or some other form of complication, as follows: a) Diffuse cellulitis of hand and arm and general sepsis. b) Middle palmar space and ulnar bursa. c) Tenosynovitis and necrosis of bone of index finger. d) Tenosynovitis and multiple abscesses of arm. e) Diffuse cellulitis of hand and arm. /) Tenosynovitis, middle palmar abscess, and necrosis of bone. g) Thenar space, middle palmar space, and ulnar bursa. h) Tenosynovitis and middle palmar space. i) Superficial abscess of hand, lymphangitis, and axillary abscess. j) Superficial abscess of hand, lymphangitis, axillary abscess, and subclavicular and subscapular abscess of chest wall and general sepsis. k) Lymphangitis, axillary abscess, and subclavicular abscess of chest wall. I) Lumbrical space abscess and necrosis of bone. Besides definitely ascertaining the location of the pus, a differ- ential diagnosis of the type of infection should be made in every case showing signs of becoming serious. In this way complications which may be expected from more virulent organisms can be anticipated and guarded against. Again chronic infections which have resisted all treatment may be found due to some obscure condition or rare organism. For example, a young man scratched his forearm upon a HAND INFECTIONS 593 piece of tin nailed to a bin. It became infected and resisted all treat- ment for a period of two weeks. The first cultures were reported as negative. Finally cultures were again made and were reported as *'no growth" after forty-eight hours. After seventy-two hours, how- ever, the laboratory assistant reported that we were dealing with a case of Sporotrichosis caused by the Sporothrix Schenkii. The line of treatment was modified accordingly and recovery resulted shortly afterward . (See Fig. 1 28 . ) Fig. 128. — Case of sporotrichosis (sporothrix Schenkii). Failure to diagnose the cause of this infection delayed recovery at least two weeks. The operative procedures and the general and local treatment required for hand infections is dealt with in detail by Kanavel in his book on " Hand Infections. " Likewise many interesting contributions on this subject have been made to the medical literature as a result of the various experiences in war surgery. The reader is referred to these sources. Both Dr. Sherman of the Carnegie Steel Company and Dr. Corwin of the Colorado Fuel and Iron Company have introduced the Carrel- Dakin method of combating infections into their industrial surgery 38 594 INDUSTEIAL MEDICINE AND SURGERY S^l>fc4 . ill Fig. 129. — Cellulitis of the arm from an industrial injury being treated by the Carrel- Dakin method. Fig. 130. — Sterile instruments and tubes are handed to doctor by nurse with sterile instruments. HAND INFECTIONS 595 and claim most excellent results. These two surgeons visited France and made personal studies of this method of treatment which may- account for their results. It is quite evident that many of the un- FiG. 131. — Smear of wound being taken for bacterial count. favorable reports concerning the Carrel-Dakin treatment are due to lack of familiarity of applying the method (Figs. 130 to 135). The Dichloramine-T treatment of infections has also come into Fig. 132. — Wound with Carrel tubes inserted ready for external dressings. prominence since the war. Dr. Lee of Philadelphia has published numerous reports concerning its use. In my own chnic this has proven very efficacious in securing the more rapid recovery of many 596 INDUSTRIAL MEDICINE AND SURGERY chronic infections, as for instance the infected abrasions or a periostitis with ulcer formation over the shin bone. It is an excellent method of treatment for old chronic hand infections. Fig. 133. — Gauze taken from sterile package with sterile instruments. Many surgeons treat these hand infections by the continuous hot boric dressing method. Results depend upon the frequent changing Fig. 134. — Sterile gauze applied to the wound. of these dressings otherwise they soon become saturated with the infected pus — truely pus dressings instead of boric dressings. HAND INFECTIONS 597 Adequate drainage, hot dressings frequently changed, with immo- bilization of the infected part have proven very beneficial in the past. Careful records and comparison of results between this and the newer principles regarding infection treatment are necessary before determin- ing which will give the desired end — the quickest recovery with the least loss of function. Fig. 135. — Bandaging wound over the tubes and dressing. {Clinic of Dr. Corwin.) CONCLUSIONS The treatment of hand infections, therefore, in order to give the best results from every viewpoint must include: 1. The proper preventive measures, especially the prophylactic use of tincture of iodin and the early reporting of all minor injuries. 2. The treatment of hand infections as a serious surgical condition from their inception, and whenever indicated the adoption of hospital treatment early. 3. The proper and early diagnosis of the type and nature of in- fection and the exact location of the pus. 4. A proper incision of the abscess in order to establish adequate drainage and yet not spread the infection to other spaces. 5. The immobilization of the infected part and the frequent changing of the dressing whatever method is used. CHAPTER XXXVII i FRACTURES ^ Prior to the war industrial surgery furnished one of the greatest opportunities for advancement in the handhng of fracture cases. If we combine with our past experiences the vast material concerning fracture treatment which has accumulated during these four years of war, still greater advances in this branch of surgery will be made. Fractures undoubtedly contribute more to the absentee rate among injured employees than any other type of injury. The claims for permanent disability are also more frequently the result of fractures than from any other cause. Thus it is evident that greater attention must be paid to the handhng of fracture cases from the standpoint of, first, their prevention, and second, their treatment from an economic point of view. The number of fracture cases can be greatly reduced in any industry by the methods described for preventing accidents. In addition to this the spirit of prevention must invade the entire working force so that every employee will be on the lookout for obstructions and pit- falls which can cause a fellow employee to fall and injure himself. In my experience falls have been responsible for 70 per cent, of the fracture cases presenting themselves for treatment. During the first 'year of the war out of 24,000 injuries due to accidents from industrial causes in the army, 12,626 were due to falls, and of this number 2,147 sustained fractures. Therefore, a campaign directed toward the removal of obstructions, the protection of high places, the fencing in of excavations, the testing of ladders and elevations before using them, the repair of broken floors and sidewalks, the proper attention to the shoes of employees, and the eradication of ah other things making falls possible, will certainly prevent at least 50 per cent, of the fracture cases. The following are the high hghts in the economic treatment of fractures : 1. The use of the a;-ray. Every .fracture should be a;-rayed before and after it is "set" and always from two or more different angles. This is often neglected because of the expense attached to the procedure, but one cause of faulty functional result will cost more than a;-raying every fracture case for a year. The reduction and coaptation of many broken bones can be facihtated by the use of the fluoroscope. Every 598 FRACTURES 599 industry where a fair number of fractures occur among the employees should have a surgical dispensary equipped with an a;-ray apparatus. 2. The immediate immobilization of the fractured member. The improved results in fracture work in many industries has been due to the presence of a surgeon on the job, who could properly immobilize the part before transportation was attempted. This principle has been further strengthened by the work of the regimental surgeons at the front. When ^ surgeon is not available then first aid assistants should be thoroughly trained in these methods of fixation and transportation. Major Horace Allen (The MiHtary Surgeon, April, 1918) has made a suggestion relative to the proper stretcher for severe fractures of the Fig. 136. — A stretcher table. {Allen, from The Military Surgeon.) Such a stretcher would enable the transportation of a severe accident case to the" doctor's office where emergency treatment could be rendered, and later transported to the hospital — all without unnecessarily disturbing the patient. spine, pelvis or femur which can very well be adapted to industrial surgery. It has been customary to carry these severe fracture cases to the surgical dispensary where emergency care is rendered. When the ambulance arrives the patient is transferred to the ambulance stretcher and on arriving at the hospital he is again transferred to the hospital bed. These movements are exceedingly painful to the patient and are liable to interfere with the best functional results. Alien suggests using a padded stretcher with legs which can be used to transport the patient and also as his bed in the hospital for a few weeks. He claims that the patients find the stretcher bed more comfortable than a hospital bed. It would undoubtedly facihtate the handling of the case 600 INDUSTRIAL MEDICINE AND SURGERY by the doctor and nurse. Major Allen thus describes the accompany- ing illustrations : "A Htter resting on four sticks passed through rectangular holes in the tread into the sockets at the top of the stirrups. At the head and foot of the Htter are adjustable extensions. Near the head end is a head rest which is automatically locked in place when the spreader bars put the canvas on the stretch. In the middle is the bed-pan, attached to the canvas in such a way that it has to be open when attached and has to be closed in order to be detached. Near the foot end is a substitute for the Balkan frame, namely, a swinging traveling Fig. 137. — The practical use of a stretcher lied in an army hospitaL (From a Painting by Thayer.) crane, balanced or unbalanced, capable of giving any variety of move- ments, or standing stationary. It can be attached or removed in less than one minute. The attachment piece crosses underneath the poles of the htter." Some of the possibilities of such a stretcher bed are well illustrated in the painting "Why Not" by Sergt. Thayer, of the Army Medical Museum (Fig. 137). Quicker and better results will be obtained if more attention is paid by surgeons to the prompt immobiUzation of fractures and to the proper facihties for their transportation. FRACTURES 601 3. The use of an anesthetic for reducing and fixing the fracture. 4. The early use of passive motion, massage and muscular ex- ercises in all fractures. In the majority of broken bones after they have once been properly set and fixed it is perfectly safe to gently loosen the splints and give massage. The sooner passive motion and then active motion can be estabhshed the better will be the functional result. For this reason I avoid as far as possible the use of the circular plaster cast which prevents these methods of maintaining tone and function in the adjacent muscles. The surgeon treating fractures must not be content to put them up in a cast and not see the case again for a month or six weeks when the cast is removed. These patients require almost daily attention to obtain the best results. 5. The therapeutic adjunct of "keeping these patients busy" is of the greatest importance in shortening their period of disability. If the fracture is of such a nature as to confine the patient to bed, then "bedside occupations" should be provided. He should be given regular exercises in bed and taught how to exercise the muscles in the injured member without moving the adjacent joints. For the ambu- latory cases work is the best medicine. These men tend to develop habits of loafing and postpone as long as possible their return to work. If, however, they are assigned easy tasks at the plant they can often return to work within a week after the injury, before the habit of loafing has developed. Thus I seldom allow my cases of fractured arm to remain away from work until recovery is completed. Dr. Farnum states that 80 per cent, of all his fracture cases are placed at some light, useful work within a week after the accident and the period of disability and the actual time the patient is under treatment have been greatly reduced thereby. 6. The judicious and early use of massage, mechanotherapy, and hydrotherapy will be found of the greatest value in overcoming the sweUing and sluggish circulation in the extremity which has been im- mobilized for some time. We have followed a very uneconomical practice in allowing these conditions to gradually disappear of their own accord. Proper active treatment of a fracture throughout will eHminate the chronically swollen extremity which worries the patient so much and tends to prolong his disabiHty weeks longer than is necessary. For the treatment of specific fractures the reader is referred to any one of the excellent text-books on this subject. Nevertheless so many advances have been made in the treatment of fractures during the war that it is desirable to point out the most important improvements which are apphcable to industrial surgery. Dr. Irving Clark, of Worcester, Mass., had an unusual experience in fracture work during his eight months service with the American 602 INDUSTRIAL MEDICINE AND SURGERY Red Cross in France. He is also familiar with the problems which confront the industrial surgeon. Therefore, the author per- suaded him to write the following article which is pregnant with suggestions applicable to this field of surgery: "The treatment of fractures in industrial surgery may be divided into the treatment of simple and compound fractures. The treatment of simple fractures is divided into emergency and permanent treatment. "Fractures occurring in industry are more severe than in ordinary practice because of the frequency of direct violence as a cause. EMERGENCY TREATMENT "Emergency treatment, while it can be carried out by a foreman trained in first aid, can in most cases be done better by the industrial surgeon. "The emergency treatment consists of immediate immobilization in approximate alignment. This is obtained by traction, and fixation, the fixation being so managed that the patient may be transferred to the hospital with a minimiim of pain and shock. The permanent treatment consists in complete reduction and immobilization. In the treatment of fractures, there are four basic rules which are always safe to follow : Always have a good a;-ray. Always use a general anes- thetic. When reducing endeavor to obtain an interlocking of the fragments end to end, and immobilize in the position which will hold them in alignment with the least strain. When one of the fragments is held in a certain position by muscular spasm, the other fragment should be approximated to it and held in alignment with it by thesphnt. "In a brief chapter such as this, it is impossible and unnecessary to consider the classic fractures, their reduction and the various forms of spHnts which can be used for their retention. Information of the most complete kind can be obtained in such text-books as Scudder's 'Treatment of Fractures,' Moorhead's 'Traumatic Surgery,' Stim- son's 'Fractures' and Cotton's 'Fractures of the Joints.' Our efforts here will be to point out slight modifications of standard dressings and splints, and particularly to bring out the most recent work done in the war hospitals where fractures play a very important part. "The industrial surgeon will do well to hmit his emergency splints to as small a number as possible and not only know himself, but have trained his assistants, in the rapid application of each type. The fol- lowing Hst of splints may prove useful as a basis :^ 1 At the beginning of the war over 200 different types of splints were used by the English. A committee on standardization first reduced this number to 112 and later to less than 50. The medical department of the A. E. F. early stand- ardized the fracture work in our army so that eight varieties of splints made up the total used. (Author's note.) FRACTURES 603 " 1. Six basswood splints cut in 16-inch lengths — trade width. It is well to have these all ready thickly padded with sheet wadding. For use in fractures of forearm. " 2. Two Thomas hip spUnts, army pattern. For use in fractures of the femur. The sphnt consists of a padded ring, slightly ovoid in shape, set upon two iron wire rods at an angle of 55 degrees with the outer rod. The rods are three-eighths of an inch in diameter. At the inner and shorter of these two rods the ring is twice as heavily padded as at the outer, and the ring is symmetrically depressed at either side of the inner rod to form a concavity which hugs the ischial ramus and fits snugly around the ischial tuberosity. The long and short diam- eters of this ring vary since the splint as used by the British army comes in several sizes, but a ring of average size -measures across the long diameter 93=^^ inches, and across the short diameter 9 inches. The outer rod descends from the ring vertically for 2}^^ inches and Fig. 138. — Thomas splint. then incKnes toward the inner rod. At the starting point of the in- ner rod the two wires are 83^^ inches apart and at the bottom they are continuous in an indented or notched end, 33^^ inches in width, about which the traction bands are wound and knotted. The out- side rod is 47 inches in length and the inside rod 42 inches in length, The space between the rods may be varied by bending them outward and inward. If desired the splints may be bent at the knee (Fig. 138) . " 3. Twelve wooden tongue depressors, thickly padded. For frac- tiu-ed fingers. "Supphes for use in emergency treatment of fractures. " 1. Twelve bandages 3 inches wide — 6 gauze, 6 musHn, "2. Six packages large safety pins. "3. Two folded pillow cases for axillary pads. "4. Four triangular slings, army design. " 5. One roll of Z. 0. adhesive plaster, 5 yards X 12 inches. For fracture of clavicle and for retention of basswood splints. "6. Two pillows with pillow cases. For leg fractures. 604 INDUSTRIAL MEDICINE AND SURGERY '' The standard methods of applying these splints and suppUes to the most frequent fractures will be found in the Red Cross First Aid Manual. "There are certain points about their application which are im- portant. Little difficulty will be experienced with the emergency treatment of fractures of the clavicle and humerus. These can be treated in the classic way with slings and bandages. "Fractures of the forearms should always be splinted with double boards and the forearm should be supported at right angles to the humerus. Fig. 139. — Strapping of chest for fractured ribs. Note that plaster extends two-thirds around the body and that the straps overlap, being applied from below upward. "Fractures of the ribs should be at once immobilized with adhesive plaster. The strips should be four inches wide, and long enough to encircle two-thirds of the chest (Fig. 139). "The strapping should be applied from below upward, each strip overlapping the one below. Too much snugness cannot be obtained. The strap should be put on with pressure. "Fractures of the thigh should be treated by the Thomas hip splint. The method of applying this is as follows: With the patient lying in a comfortable position apply traction to the injured leg. 'Adequate and comfortable traction can be secured with a bandage, which is al- ways at hand and, therefore, most strongly recommended. Various ingenious substitutes have been suggested and employed and are wor- FRACTURES 605 thy of mention. A screw-eye may be inserted in the heel of the boot ; a nail or skewer may be pressed through the shank of the shoe and cords attached to its projecting ends; a horseshoe shaped wire with inward facing prongs can be hooked over the welt of the shoe on both sides and a traction cord be attached to the ring of the horseshoe. These methods demand special articles sure to be lost or mislaid, while bandage traction is always available.' "The technic of the application is important. Take a double length of four-inch bandage a yard and a half long. Place the middle of this traction band back of the shoe just above the counter. Wrap both ends across the instep and round under the sole in the usual figure-of-eight manner. Bring each end up on its respective side and carry its under the lateral part of the bandage behind the malleolus, then over this bandage and directly downward, thus providing two Fig. 140.- -Thomas splint hastily applied for emergency, for traction. Note hitch in region of ankle lateral traction bands. The loops should be well back of the malleoli so that the line of traction is behind the ankle-joint. A generous pad should be placed over the instep beneath the crossing of the bands to prevent pressure. It must be borne in mind that grave injuries of the leg interfere with its circulation and that pressure sores develop from incredibly slight trauma. "Slip the Thomas splint on gently and fit the ring well at the ischial bearing. Carry each traction band half around the corresponding uprights, passing one over and one under its upright, and then bring each one in opposite directions once about the notched iron piece at the lower end of the splint and tie with square half bow-knot. A nail or bit of wood slipped between the bands below where they have been brought about the uprights may be twisted as in a Spanish windlass to increase the traction at will (Figs. 140 and 141). "A bandage about the whole splint completes the dressing. For 606 INDUSTRIAL MEDICINE AND SURGERY speed, this may be applied from above downward, as there is no danger of constricting the hmb with a bandage carried outside the uprights of the sphnts. "A coaptation «plint is often used as a posterior spKnt to increase the support of the thigh. This is desirable but by no means necessary, as the dressing as above described gives adequate and comfortable support. "Transfer to the Stretcher. — The stretcher should be provided with a heavy spHnt support which springs on to the side bars. The patient should be carefully lifted on to the stretcher by four bearers. The end of the splint should be slung to the cross bar of the splint support by a bandage, so that the leg clears the stretcher, and also tied to each upright of the sphnt support to prevent side sway.^ Fig. 141. — Thomas splint further applied before the application of bandage. Note bandages tied around leg in the region of fracture to set leg on sphnt. A further bandage may be apphed over the whole for additional security, but the rigging as shown is sufficient for transportation for short distances. "Fractures of the leg can usually be comfortably immobiUzed by a pillow sphnt. When the fracture is very severe and there is much pain and displacement the Thomas sphnt should be used. "Pott's fracture and fractures of the foot can be best treated by using the pillow sphnt. PERMANENT TREATMENT Fractures of Upper Extremity "Fractures of Clavicle. — In applying the classic Sayre adhesive plaster dressing, the foUowing shght modifications have been found of advantage. The first consists of a pad of one thickness of Saddler's felt having a hole cut in it and apphed over the olecranon. This prevents the cutting of the adhesive plaster which is so disagreeable. 1 Major Kendall Emerson, British Jour, of Surgery, September 12, 1918. FRACTURES 607 The second modification consists of a strip of adhesive 1^^" wide which surrounds the wrist and then passing over the affected clavicle, sticky side down, and is attached to the broad arm strap behind. A pad of felt over the affected clavicle helps to hold the fragments in position and avoids adhesive plaster pressure (Fig. 142). "Fractures of the Surgical Neck of the Humerus. — This fracture is a fairly common one and has received considerable attention due to the difficulty of its retention. Jones describes its reduction and retention as follows: ^^^ Treatment. — Traction on the arm in the axis of the humerus, gradually abducting and rotating outward till the arm is at right Fig. 142. — Modification of Sayre dressing for fractured clavicle. Note pads at elbow and over clavicle and additional strap extending from wrist over clavicle. The elbow strap is not put on in this case in the classical way as enough raising of the shoulder can be obtained without carrying the strap across the back, and the dressing is more comfortable for the patient. Note raising of right shoulder in cut. angles to the body or even straight upward parallel to the side of the head, will disengage the lower fragment from the inner side of the upper fragment. In this position the Hne of traction of the pectorahs major, latissimus dorsi, and teres major is in the axis of the shaft, so these muscles no longer exert a lateral distorting force. " 'While an assistant is extending the Kmb in this way the surgeon with his hands feels when the bones have completely disengaged. He then asks the assistant to relax the tension on the hmb, while he tries to guide the ends so that they engage end to end. 608 INDUSTRIAL MEDICINE AND SURGERY '"If they do engage, they can often be gently pressed together and made to lock sufficiently to allow the arm to be brought down to the side slowly and gently, and with a pad in the axilla the arm is securely fixed to the body, with the elbow bent to an angle of forty-five degrees and the wrist slung from the neck. These movements should be performed with gentleness and judgment to avoid injury to nerves and vessels. "'Experience has shown that once this maneuver is successfully accompUshed the ends are not likely to disengage, and all that is neces- sary is to wait for union and then gradually commence movement. " 'If the shape of the line of fracture is such that the fragments will not lock properly and, therefore, disengage when the arm is brought Fig. 143. — Thomas arm extension splint for severe fractures, usually compound, of the humerus. Note method of suspension and traction, the same as used in the Thomas leg splint. {Manual of Splints and Appliances for the Medical Department of the United States Army, 1917.) down to the side, the arm must be fixed in the abducted position. In this position the line of traction of the pectorals and latissimus is practically the axis of the limb, and, therefore, will only pull the two ends toward each other and not laterally, and usually the fragments will not slip. " 'The whole arm, shoulder and upper hmb, is swathed in one layer of cotton-wool. It is best to roll up a whole length of cotton-wool and apply it like a bandage. Over this plaster bandage is applied to the arm and upper part of the chest, rubbing it firmly round the shoulder and axilla and again firmly round the bony points about the elbow. A proper grip of the condyles of the humerus prevents shorten- ing of the limb; to make sure of the external rotation the forearm should FRACTURES 609 be included; if the elbow is bent till the hand is behind the head, the position is not in any way uncomfortable, and the success of the functional result is assured. ** 'Two lengths of strong webbing, like horse-girths or something not quite so wide, one round the axilla and fixed on the opposite side of the table, and the other over the top of the shoulder and fixed to the bottom of the table, give an excellent resistance against which to pull. A roller towel or folded sheet will do, but being more bulky is more apt to get in the way of the surgeon's hands when mani- pulating the shoulder.' '■ ''The aeroplane splint devised at the former American Ambulance, Neuilly, France, is extremely good in these cases, allowing motion Fig. 144. — Suspension traction method of treating compound fracture of the humerus by means of the Balkan frame, h, Plate or hook; w, weights; a, arm suspen- sion band ; h, glued traction band. {Manual of Splints and Appliances, Medical Depart- ment, U. S. A.) of the forearm on the arm. It is, however, bulky and does not seem necessary in the case of simple fractures. "If the fracture is very severe with much comminution there is no better form of treatment than that of suspension in a Balkan frame. Continuous traction in abduction can be maintained by means of a Thomas arm splint or by the Blake method of suspension (Figs. 143 and 144). "The writer when visiting the large fracture center of the French Army at Chateau Thierry was told that all fractures of the humerus were treated by a simple triangle of wood which fitted snugly in the ^ Jones, " Injuries to Joints, " Oxford War Primer, 1918. 39 610 INDUSTRIAL MEDICINE AND SURGERY axilla and to which a single forearm splint was fixed by a hinged piece of strap iron. Continuous extension was maintained by a bag Fig. 145. — Wood triangle splint ueed in French army hospitals. of sand suspended from the humerus or forearm when extension was necessary. The results with this simple apparatus were excellent (Fig. 145). Fig. 146. — Delbet arm extension apparatus. {Techniques des Operations et Pansements Plates de Guerre, D"" Dupuy c?e Frenelle, Aide-maj or-V I" armee.) Among the more recent appliances is the Delbet apparatus for continuous extension. In this splint the force of extension is adjusted FRACTURES 611 by a movable pin as seen in cut. The method of application is well shown (Fig. 146). "An excellent splint for fractures of the humerus and one adopted by the United States Army is the Jones elbow extension splint. This splint may be used for continuous extension of either the humerus or forearm (Figs. 147 and 148). "There are two methods of applying traction to the humerus; first, by the Hennequin band, second, by glued traction bands. The Hen- FiG. 147. Fig. 148. Figs. 147 and 148. — Jones arm extension splint. Method of application. {Injuries to Joints, Second Edition, Oxford War Primers.) nequin band is a band made of Canton flannel, four inches wide and eighteen inches long. It is appHed over several thicknesses of non- absorbent cotton wound snugly about the lower part of the arm just above the elbow. Over this pad the band is applied from behind forward, crossed in front and pinned at the sides so that there is a direct pull along the arm. "The glued traction bands are also made of flannel of shape similar to cut (Fig. 149). 612 INDUSTRIAL MEDICINE AND SURGERY ^/^ es ho//? yS^me pc9/^fn "The glue with which these bands are applied is made as follows: "Resin and Turpentine Glue:^ Resin 50 Alcohol. 50 • Benzine (pure) 25 Venice turpentine 5 "Powder the resin, then add half the alcohol, then the Venice turpentine and benzine, washing the measure into the bottle with the remaining alcohol. This glue may be removed with alcohol or ether. The bottle containing the glue should be kept tightly stoppered else the proportions of the constituents may change, and the glue become irritating to the skin. This glue does not require heating before use, and should not be applied too thickly. "Moderate traction may be safely insti- tuted with this form of glue in from 5 to 10 minutes after application, and as much trac- tion as is required in 20 minutes. "Fractures About the Elbow-joint. — Jones makes the following statement which should always be remembered: " 'There is one golden rule regarding frac- tures of the elbow : they should all be treated with the elbow fully flexed and the forearm supinated, with the single exception of fracture of the olecranon, which requires full extension.' "The method of putting up an elbow in acute flexion is shown in Fig. 150. "After a few days, four or five, it is safe to relax the acuteness of the flexion and shng the wrist of the affected arm close under the chin. The shng may be lengthened from day to day, and the patient urged to try active motion. War surgery has developed the fact that in injury to the joints active mo- tion should be started at the earliest possible date, but this motion should be done at first under the careful supervision of the surgeon and if any stiffness or severe sweUing appears as a result, acute flexion should be resumed for a few days. 1 Formula from Manual of Splints and Appliances, Medical Department, U. S. Army. Fig. 149. — Flannel band for traction. To be applied to skin witb special glue painted on with paint brush. FRACTURES 613 "Fractures of Forearm. — Fracture of both bones of the forearm are notoriously difficult to reduce and hold in position. There appears to be nothing especially new in the treatment developed by war except in the case of compound fractures of the forearm. "A double board splint with imm9bilization of the elbow by a tin right angle splint, as described by Scudder, or the moulded anterio- posterior plaster splints, described by Moorhead, are prObably the best methods of holding after reduction by traction and manipulation. Fig. 150. — Elbow put up in acute flexion. Forearm supinated and elbow in flexion. Note heavy padding on arm and forearm, as well as protective padding in inner side of arm and forearm where this comes in contact with chest. "The French use forms of crinohne to make their molded splints. These forms consist of ten thicknesses of crinoline basted together. The forms are immersed in plaster bouillon immediately before using with vasehn. The method of making the plaster bouillon is given under the treatment of fracture of the thigh and with description of the Delbet plaster forms. "This method of application of plaster is rapid, accurate and the form can be cut to suit the case and surgeon. After appHcation it is held in place by a gauze bandage until the plaster sets. 614 INDUSTRIAL MEDICINE AND SURGERY "So much has been written on the reduction and retention of Colles' fracture that it seems unnecessary to repeat what is already known. "There are two points which are worth bearing in mind. First, complete reduction has not been obtained until the styloid process of the radius is well below the stj^oid process of the ulna. Second, the tearing of the internal lateral ligament of the wrist is frequently more troublesonie than the fracture of the radius. Fig. 151. "After reduction both anterior and posterior sphnts should be kept in place, except during massage, for three weeks, and the anterior splint for one week longer (Figs. 151 and 152). "Fractures of the carpal bones are very troublesome and give rise to considerable disability in the wrist. It is almost impossible to ap- pose the fragments and in order to get a useful wrist the open opera- tion is often necessary. This is particularly true in fracture of the scaphoid. Fig. 152. Figs. 151 and 152. — Jones cock-up wrist splint. For use in injuries where dorsal flexion of the wrist is advisable. (Injuries to Joints, Second Edition, Oxford War Primers:) "Fractures of the metacarpals are fairly common. Reduction is difficult but should always be attempted. It is more likely to succeed if a general anesthetic is given and the position of the fragments checked up with a fluoroscope during reduction. The reduction can usually be well held if the hand is strapped over a roller bandage, the principle being the same as that of acute flexion in the elbow. Ex- tension by means of traction on the finger of the injured metacarpal is rarely successful and is difficult to manage. "In industrial surgery fractures of the fingers and thumb are most FRACTURES 615 important and much of the worker's skill may be lost by a poor result. The greatest care should be used in setting these fractures and after reduction the result should be checked up by an a;-ray picture. The wooden tongue depressor splint is clumsy and inefficient except as a first aid dressing. "The best method of retention is probably the Marsee block tin r- — . - . Fig. 153. — Marsee's tin finger splint. finger splint made as follows : A strip of tin is cut 14 in. long and 23^^ in. wide. This is to be folded upon itself lengthwise and hammered flat so as to make a three-ply strip ^ in. in width. Upon one end of the strip, a piece of thin leather or canvas 4 or 5 in. long and 3 in. wide is to be riveted in order to give the strip stability when bandaged to Fig. 154. — Method of application of Marsee's finger splint before bandage is applied. Note natural curve of finger. the forearm. The strip is then shaped to suit the curved outline, in which position the fingers should be immobilized (Figs. 153 and 154).^ "By means of this spKnt anterior bowing can be overcome and sad- dle-shaped deformity controlled. For fractures with Httle displace- ment there is nothing better than a strong hair pin which when wound ^Sluss, "Emergency Surgery," Third Edition. 616 INDUSTRIAL MEDICINE AND SURGERY with adhesive plaster makes a light and easily adaptable splint. An- terior and posterior hair pin spHnts hold the fracture well with a mini- mum of bulk and weight. "For crushes of the terminal phalanx no splint is required but great comfort is obtained if the Manning tin cross piece is applied over the dressing. These have been used in many factory dispensaries with universal success and no industrial surgeon should be without at least a dozen always on hand. Fractures of the Lower Extremity "Fractures of Femur. — Fractures of the neck of the femur are di- vided into impacted and non-impacted fractures. If there is firm im- paction with httle shortening, httle need be done beyond sand bags to steady the leg and hght traction by weight and pulley, or better sus- pension in a Balkan frame. A description of this method of handling fractures of the femur will follow. "Whitman beheves in breaking up the impaction under anesthesia and setting the leg in wide abduction with some internal rotation holding the position with a plaster cast extending from the toes to the axilla. "The Kmb is reduced by extension and gradual abduction to an angle of forty-five degrees, in the meantime supporting the upper end of the femur and rotating the leg inward. "In this position, the limb is well covered with cotton batting, all the bony points especially well protected and a flannel bandage smoothly applied. A plaster spica is now applied extending from the lower ribs to and including the foot. The plaster fits the pelvis snugly and is molded close to the trochanter and posterior aspect of the joint. It is also molded to the patella and condyles, and to the foot to pre- vent rotation. This dressing permits the patient to rise up in bed without much discomfort. "The advantage of abduction is that it makes the capsule tense and thus ahgns the displaced fragments, that it directs the surface of the outer fragment toward that of the inner; that it relaxes the muscles that produce distortion by their traction; that it opposes the trochan- ter to the side of the pelvis and thus checks upward displacement. Repair in these fractures is slow and can hardly be completed with- in a year; thus prolonged after-treatment is necessary for restoration of function. ^ "In cases of non-impaction three methods are open to the surgeon: first, the Whitman method as outHned above; second, suspension and. traction in a Balkan frame and Thomas sphnt; third, open reduction and nailing the fragments in alinement. Jones has developed a frame which holds the femur in abduction, altows traction and affords an 1 Jour. Am. Med. Assoc, February 20, 1909 (Sluss). FRACTURES 617 easy means of transport. It is of particular value in the case of compound fractures (Fig. 155). "In war hospitals all thigh and many leg fractures are being treated by means of the Balkan frame, suspension and traction. This method, now almost unknown in civil surgery, will probably be largely used after the war. The Balkan frame consists of a head frame and a foot frame of wood united by longitudinal bars. The wood is white pine, % by 2 inches. The head and foot frames consist of two uprights slightly slanted to form a truncated A. The cross bars which hold these Fig. 155.- -Jones abduction frame for high fractures of the femur. Second Edition, Oxford War Primers.) {Injuries to Joints, uprights together are the width of the bed, at top extending beyond uprights on either side, while the lower joins the uprights at the level of the mattress. "The longitudinal bars are two in number, resting on the upper cross bars and retained in any desired position by reciprocal notches (mortise joint). "The exact measurements are as follows: height of side bars, head and foot frame, 6 ft. 6 in.; length of upper notched transverse bar, 3 ft. 3 in.; length of lower transverse bar, width of bed at top of mattress; length of longitudinal frame connecting bars, 8 ft. 8 in. "The head and foot frames are set up and attached to the bed with rope; they are then joined by the two longitudinal bars which lock by their reciprocal notches in the upper cross piece of the head 618 INDUSTRIAL MEDICINE AND SURGERY and foot frames, making the whole frame firm and rigid. One of these bars can be brought out at an angle so as to produce abduction and additional cross bars of varying width can be added to the foot frame for the support of pulleys. The Thomas or Hodgen sphnt (Fig. 156) is suspended from three pulleys set in a block of wood 16 inches long which in turn is supported by the longitudinal bar. The set-up frame and arrangement of pulleys is well shown in the accom- panying cuts from the Red Cross Splint Manual of the United States Army. "The method of apphcation is as follows: The frame having been set up with all bars arranged for the proper amount of abduction and the pulleys having been placed, the Hodgen or Thomas splint is pre- .^a=^ Fig. 156. — Balkan frame. Suspension method of treatment of fractured femur. Note method of obtaining abduction by additional bars on frame; to compare with figure of Hodgen splint. (Manual of Splints and Appliances for the Medical Department of the United States Army, 1917.) pared as shown in the photograph. The sphnt is then attached by cords to the three-pulley block. Glued bands are now applied to the leg which has been previously shaved and washed with alcohol and ether. The glued bands extend a little above the site of the fracture as their pull is exerted through the skin and fascia lata before reaching the muscles and bone (Figs. 157 and 158). "The splint is now dropped over the leg and the shngs brought under the thigh and leg and fixed to the outer bar of the sphnt with paper chps, usually more slings are used than are shown in the cut. FRACTURES 619 The whole leg is then gently raised and the suspension weight adjusted. This should exactly equal the weight of the leg and splint. Sand or buck shot may be used in the weight bag. A second cord with about four pounds of weight passes from the upper end of the splint over a Fig. 157. — Hodgen sjplint. pulley set at the opposite side of the head of the bed. This acts as a countertractor. "The extension bands are now attached to a spreader and the proper amount of weight attached to the rope after it has passed through the Fig. 158.— Method of suspension with Hodgen splint in Balkan frame, a, Slings which hold in splint, held in place by paper clips; h, foot piece of flannel glued to foot; c, hand grips so that the patient may help raise and lower himself in bed; W, weight; H, pulley hooks. {Manual of Splints and Appliances for the Medical Department of the United States Army, 1917.) pulley. Last of all a flannel band is cut the shape of the sole of the foot and glued in place. The tape is tied to a piece of cord which is carried over the middle block pulley and to which a one-pound weight is 620 INDUSTRIAL MEDICINE AND SURGERY attached. This allows free movement of the ankle, exercise of the muscles of the leg and prevents foot drop (Fig. 159). "The advantage of the suspension method of treating fractures is as follows : "l. There is no pain. "2. There is no edema. "3. There is no motion of all the joints without displacement of the alignment of the fragments. "4. The patient can move around in bed. "5. The leg may be easily examined and massaged. "It will be noted that this method of treatment completely upsets the time honored belief that a fracture must always be treated by a Fig. 159. — Application of Thomas splint for suspension and traction. (Manual of Splints and Appliances for the Medical Department of the United States Army, 1917.) sphnt which immobihzes the joints above and below the site of injury. Where considerable traction is needed, two sets of glued bands can be used, one attached to the thigh as described above, a second pair attached to the leg. To each of these traction weights are apphed. When the traction is so great that it tends to pull the patient down in the bed, the foot of the bed may be elevated on blocks. "When much traction is needed, the Steinman pin, 'ice tongs,' or the Finechette stirrup may be used. In the case of the pin much less traction weight is needed than when the glued bands are used. Blake recommends the use of the Steinman pin in all cases of fracture just above the knee joint. TRACTURES 621 "In a resume such as this it is impossible to go into the necessary- details. For a full and detailed account the reader is referred to the excellent paper by Blake in La Presse Medicale, November 19, 1917. "Fractures of the middle of the femur can be treated in two ways: first, by the suspension and traction method just described; second, by plaster cast extending from the toes to the chest. If a plaster cast is used, proper reduction can best be secured by the use of the Hawley table or similar apparatus for producing mechanical traction. Where the Hawley table is not available, and it is considered advisable to use plaster, the following method may be used. This is the method Fig. 160. — Type of fracture bed used in Colorado Fuel & Iron Co. Hospital. {Clinic of Dr. Corwin.) which is now in use in a great many hospitals in France where expense prevents their having up-to-date tables and apparatus. "The patient is supported on an ordinary table by a box under the shoulders and chest, while the pelvis is supported by a tin can or a couple of bricks under the sacrum. The affected leg is extended by- means of a clove-hitch of wide bandage which is appUed over several layers of cotton wound around the ankle. The ends of the muslin bandage used in making the clove-hitch are carried over a tin can or bottle, and then over the end of the table. To the bandage ends a bucket is attached which can be filled with water or sand to produce traction. Countertraction is obtained by a loop of pillow case or 622 INDUSTRIAL MEDICINE AND SURGERY sheet which passes under the crotch and is attached to a rope or to the leg of the table near the patient's head. This method is well described by Calot in his recent 'Orthopedic et Chirurgie de Guerre,' third edition. Calot describes the apphcation of a plaster case for fracture of the femur about as follows. I have not used his words but have abbreviated to make the matter more condensed. "Two types of plaster appHances are used. First, five plaster band- ages 3 or 4 inches wide, and second, four atteles, oblong strips of crinoline, five thicknesses each, two cut long enough to extend from the toes to the hip, both in front and behind, and wide enough to slightly overlap when wrapped around the leg, one wide enough to extend from pubis to sternum and long enough to surround the abdomen, and a fourth about four inches in width and long enough to encircle the hip obliquely. The method of application is as follows : After the patient has been placed in the proper position and traction apphed, the leg and abdomen are completely enveloped in one thickness of sheet wadding, stockingette or ordinary drawers, extending from the toes to the ribs. Two bandages are then dropped in cold water in a large basin holding three quarts without salt. About three minutes later three other bandages are dropped into this water. As soon as possible the first bandages are wrung out and handed to the surgeon who appHes them from the toes to the hip in the usual manner. While this is being done, another basin of plaster bouillon is being prepared by an assistant. This plaster bouillon which is used very widely by the French in the use of their plaster forms of various types is made as follows : "Three glasses of water are poured into a basin to which is added rapidly five glasses of plaster, the plaster being shaken in httle by little rapidly while the left hand of the operator agitates the water to obtain an homogeneous bouillon. This should be obtained in about one minute. "The atteles of crinoline are then plunged into the bouillon and worked through it rapidly absorbing the mixture. These are then appHed to the anterior and posterior of the leg extending from the toes to the groin. Immediately following this apphcation, another attele is apphed around the pelvis and abdomen. This attele has been cut wide enough to extend from the. pelvis to the base of the chest and forms a broad belt around the abdomen and pelvis. The ends overlap in the region of the groin. The fourth attele is next prepared and is applied over this. This attele consists of a band about 4 inches wide, five thicknesses of crinohne, which is long enough to completely en- circle the hip and extends up over the groin. The exact method of the arrangement of these atteles appears in the accompanying cut. Immediately after having apphed these atteles, the three remaining plaster bandages are apphed from the toes well up to the base of the chest, completing the cast. It is well after putting on the atteles to FRACTURES 623 cover them with a thick layer of plaster bouillon taken from one of the basins in which the atteles have been prepared, and after the last plaster bandage is applied, the whole cast may be gone over with this same material. The application of such a cast requires assistants in order to achieve it quickly. Calot states that the entire application can be done in five to six minutes, or eight at the most. He advocates practice in team work between the nurses and the doctor. Immedi- ately after the cast has been applied, it should be carefully moulded in the region of the knee, ankle and the crest of the ihum. This point is most important and has been brought out not only by Calot but by Whitman. Great care should be taken that the foot is at right angles to the leg and slightly inverted. Such a cast can be readily split if it Fig. 161. -Application of cast as described by Calot and used in the French war hospitals. appears to be too tight. If it is probable that such sphtting will be necessary, a long piece of tin can be incorporated beneath the sheet wadding so that the knife will have a firm base to cut upon, and there is no danger of injuring the patient (Fig. 161). "Fractures of the Leg. — Fractures of both bones of the leg can be treated either by suspension and traction, or by plaster cast. The cast in this case does not have to be as heavy as that described for the thigh fractures, but should extend from the toes well above the knee. Particular care should be taken that there is no anteriorposterior bowing. After a fracture has become consolidated, if the callous is still soft, the French are accustomed to apply a Delbet plaster appareil de marche. The French also use this method of treatment for simple fractures of the fibula and for Pott's fracture after reduction. The 624 INDUSTRIAL MEDICINE AND SURGERY patient is able to hobble around on this splint, and it apparently causes no bending or weakening of the callous. It will be seen that the weight of the leg is borne largely on the lateral and longitudinal atteles, and that the bone is still further protected by the bands around the ankle and below the knee which prevent strain upon the callous by transmitting the weight to these same lateral atteles. The atteles are DELBET FORMS (CRINOLINE.) OupplcmcntsJ To dcscriptiorvTurnisned py Dr. W' Ir-ving Cl&rly To Xn« CTonTarcnca Bo^rd oi Pnysicie-n^ in Inouslriivl r^ractice tkl jfa mficiing Ju g June 29. 1918 (?.»-) <3:„0 to™) (z™-; l6 thickne 22 tdickr (?5i ■■'■=■■> ^(4 iB.J 22 iklcL l6 tliickne ^^Lrxi 4 oelowncel' Fold back. Grips Lad of fitula anj iubarosity of Jitia- J. inta ripscxtenop.and. inwripr rnalleoli. Fbld back.. Fig. 162. — -Diagrammatic description of Del bet forms. {Dr. W. Irving Clark.) made of crinoline, as indicated in the cut, and are prepared by being rolled through plaster bouillon (Fig. 162). "This plaster bouillon, which as I said before is greatly used by the French, is usually made as follows : "The basin is filled with about a quart of cold water. To this is added plaster little by little, the plaster being shaken in while the FRACTURES 625 water is being gently agitated by the left hand of the surgeon. When the withdrawn hand appears as if it was covered with a thick white cotton glove, the proper consistency has been reached. "The trick of preparing a proper bouillon is one which requires a little practice, but when it has been acquired the surgeon will find his ability to handle certain types of fractures greatly increased. "Simple fractures in the region of the ankle, such as Pott's fracture, can probably be best treated by reduction in a classical manner, and a plaster cast, the foot being held in exaggerated inversion. After about a week, Delbet's appareil may be tried if the swelling is not too severe. "The French frequently apply the Delbet even on complete fracture of both bones, making traction by means of a weight over a tin can, as described before. When reduction has been obtained the Delbet forms are apphed and held in place by a Scultetus, many-tailed bandage which remains on for twenty-four hours. The traction is of course removed as soon as the plaster has set. The patient should be able to walk with the Delbet and a cane the day following the application of the splint. An important point which is sometimes neglected in the after treatment of cases of Pott's fracture is the necessity of keeping the foot in inversion, and supporting the arch with a pad, or flat-foot plate. Every case of Pott's fracture, or of fracture of the ankle, excepting the phalanges, should be supported by a firm foot pad and adhesive plaster strapping when the patient is up and around. "Compound Fractures. — The treatment of compound fractures is exactly the same as that of simple fractures with the exception of the treatment of the wound. The treatment of the wound consists of the primary treatment and the secondary, or operative treatment. The primary treatment which occurs immediately after the injury should consist of painting the wound rapidly with tincture of iodin, and applying a sterile dressing consisting of many folds of gauze in the form of a thick pad, held in place by a bandage. The operative treatment is the same as is now used in the war hospitals of France. This consists of a careful dissection of all of the injured tissues, a knife being used to cut out the skin in a fine elliptical incision. Where there is some question as to whether the tissue is viable or not, no chances should be taken, but the tissue unless of great value should be removed. In short, the entire wound tract should be treated as if it were a new growth, and removed enbloc if possible. "The following quotation from Major Poole is an exact description of the methods now being employed in the treatment of compound fractures, caused by accidents, at La Panne, and should act as a guide in the treatment of compound fractures in industrial work: " 'These are operated upon as routine at La Panne and when it is 40 626 INDUSTRIAL MEDICINE AND SURGERY possible the following procedure is followed : The edges of the wound are excised, contaminated or lacerated tissues are carefully excised, the fracture is exposed and as far as possible the fragments are reduced. Foreign bodies such as plates, screws and wires are not employed except in rare cases for the reason already given under "Treatment of Com- pound Fractures ' caused by Projectiles." The wound is closed by layers without drainage.'^ "It is evident that the chance of infection is less in industrial work, and wherever possible the tissue should be saved and not sacrificed. With the facilities for prompt treatment, it would seem possible to convert the majority of compound fractures into simple fractures by Fig. 163. — Treatment of an infected compound fracture by Carrel-Dakin irrigation method. Inserting the tubes. {Dr. Corwin.) primary suture. Any loose bone which is apparently free of periosteum should be removed but care should be taken to leave in place all bits of bone to which the periosteum is adherent. In cases where there is much contamination, especially where this extends to the bone, it is better to follow the tactics of war surgery and not attempt primary suture. It should be noted here that owing to the dangers of special infection and lack of immediate treatment, the French do not dare to practice primary suture in compound fractures, except in very special cases. After the wound has been treated, the fracture should be treated by one of the methods outlined in the treat- ment of simple fractures. However, the use of plaster is contra- 1 Poole, Surg. Gyn. and Obs., Sept., 1918. FEACTURES 627 indicated where one expects to have to deal with a suppurating wound, and if this condition is considered probable, the suspension method of treatment should be adopted. "Infection in a compound fracture is a common occurrence in France, and the usual method of combating it is by the use of the Carrel-Dakin method. This has been so fully described that the technic will not be entered into here. It may be of interest to note that by the Carrel method other solutions than Dakin's are used. Those which have proved most successful in the American Red Cross Military Hospital No. 2 are appended. For further information as to the method of suspension treatment of compound fractures, Fig. 164. — Compound fracture of leg due to industrial injury treated by Carrel-Dakin method. {Dr. Corwin.) the reader is referred to Major Blake's paper in La Presse Medicale, November 19, 1917." Dressing Solution Formulas. — American Red Cross Military Hospital No 2, Paris. Dressing solution for fresh wounds: 1. Quinin hydrochlorid 1 Acetic acid (90%) 5 NaCl 8 H2O 1000 2. Acetic acid 5 NaCl 8 H2O 1000 628 INDUSTRIAL MEDICINE AND SURGERY Dressing solutions for granulating wounds : 3. B. Naphthol 1 Sod. hvdrox 1 H,0.;. • ■ 1000 4. Daufresne's modification of Dakin's solution. 5. Sodium bicarb lO NaCl : 8 H,0 1000 CHAPTER XXXVIII OPEN TREATMENT OF FRACTURES The growing tendency among surgeons to operate upon many cases of fracture which hitherto gave good functional results by the closed method of treatment makes it seem timely to illustrate many of the bad results which occur by open treatment. The various figures rep- resent cases collected in one of our best hospitals and the operations were performed by surgeons with the best of reputations. Cases of recent fractures and many cases of old fractures, bony defects, bone cysts, etc., do arise, however, in which open operative treatment is surely indicated. The purpose of this chapter, there- fore, is not to condemn such operations but rather to stimulate a more conservative attitude toward selecting the types of fractures so treated and the methods employed. The bone graft has become a fixture in surgery. A great amount of experimental work on animals has been reported and has made pos- sible the advances in this branch of surgery. However, it is only by the reporting of many and various results on humans by the rank and file of surgeons that the indications and technic of this operation will become fully established, and, above all, that the autogenous bone graft will become recognized as the safest and surest method of repairing cer- tain bony defects — far superior, in most cases, to any foreign material which can be used, such as Lane's plates, silver wire, nails, ivory pegs, magnesium plates or tubes, aluminum plates, and even the hetero- geneous bone plates, screws and bone chips. Many discussions and controversies have arisen during the last few years in this field of surgery, a history of which would make an interesting paper in itself. Three questions especially have formed the nucleus of this discussion, namely: 1. The comparative value of bone grafts and Lane's plates, and other foreign materials in the open repair of fractures, and in the re- pair of certain bony defects. 2. The indications for the open treatment of fractures. 3. Does the bone graft have osteogenetic power, and if so, does the periosteum alone possess this power, or does the graft simply form a bridge between the ends of the bone to be repaired, over which re- generation by conduction occurs? 629 630 INDUSTRIAL MEDICINE AND SURGERY Lane plates, ox-bone plates, silver wire and many other foreign materials have been chiefly used in the past; and even by many of our best surgeons to-day, for the open treatment of fractures. Good re- sults have obtained in many cases, but, unfortunately, many others Fig. 165. ' Fig. 166. Fig. 165. — Lane plate applied to recent fracture. Fig. 166. — Three weeks later — plate loosening due to liquefaction. have been very discouraging. These bad results can be summarized as foUows: 1. Delayed union: The presence of the foreign body causing a deficient callous formation and may even cause some liquefaction and absorption of the healthy bone to which the plate is attached. fjj~^ J Fig. 167. Fig. 168. Fig. 167. — Ends of fragments absorbed allowing plate to become detached with dis- placement of lower fragment. Fig. 168. — Sclerosis of ends of fragments prevented union. 2. The wound is more prone to infection because of the foreign body. When infection does occur, the above mentioned necrosis of the healthy bone is the rule. 3. Non-union may occur: (a) Due to hquefaction, the plate may loosen and not hold the fragments in firm apposition (Figs. 165 and 166). OPEN TREATMENT OF FRACTURES 631 (6) Due to infection or the presence of foreign body, the ends of the fragments may absorb and not have coaptation (Fig. 167). (c) In old un-united fractures, the ends of the fragments of bone may have undergone sclerosis. It is the rule to fresh- en these ends, but the sclerotic process may extend far- ther than the surgeon expects. Thus a plate attached to these fragments will give fixation, but no union occurs (Fig: 168). 4, Subsequent operations are often necessary: (a) For the purpose of replacing a loosened screw or readjust- ing a plate which has slipped. (6) For the removal, later on, of the foreign material because it has become a source of irritation, (c) To resort to some other plan of operation, because of non- union. As a substitute for this foreign material method, which has all of the above dire results to its credit, we have the autogenous bone graft, which, in the hands of most operators accustomed to its use, has given practically 100 per cent, good results in the repair of fractures and other bony defects. From both a practical and a scientific stand- point, living bone grafts are more logical, chiefly for these reasons: 1. There is no foreign body present which later may have to be removed or may cause some of the above described complications. 2. Infection does not destroy the graft, as was at first supposed; in fact, I have seen the growth of a graft apparently stimulated in the presence of infection. ■ 3. Union is more rapid than where ox-bone plates or Lane plates, or other foreign material has been used. 4. Non-union in the old un-united fractures, because of sclerosis of the ends of the fragments, need never occur, especially if Albee's inlay method of bone grafting is used, as the transplant always extends a sufficient distance above and below the ends of the fragments to reach into healthy bone. For this reason, the intramedullary graft is not always adaptable to these cases, as the sclerotic process may extend a considerable distance into the medullary canal. 5. A Hving bone graft will conform itself to the shape and func- tion of the bone into which it is grafted (Wolff's law). The next question, ''The indications for the open treatment of fractures," likewise forms the nucleus for a very lengthy discussion. McAusland, in Surg. Gyn. and Obs., September, 1914, advo- cates the open method on most fractures, in order to secure perfect alignment and coaptation. He thinks there is less danger to the soft parts by this procedure than by so much manipulation. 632 INDUSTRIAL MEDICINE AND SURGERY In opposition to this doctrine, B. S. Campiche, ^ writes a plea against unnecessary operations for fractures which is very timely. So many articles have appeared in the last few years, and so many clinical cases have been demonstrated on the open treatment of fractures, that the student and the profession at large are almost led to believe that with some of the very best surgeons this is really the treatment of choice for the majority of fractures. We know, however, that during the last century the treatment of fractures by the closed method has been satisfactory in most cases. Especially in the last decade this conservative treatment has been so vastly improved, due to the aid of the x-ray, that bad results are compara- tively few. In every case of recent fracture, therefore, conservative non- operative treatment should be tried thoroughly and conscientiously, and the operative treatment reserved for those few cases — not over 3 per cent, where the closed method has failed. The only indications for open treatment in recent fractures are: 1. Interposed soft tissues which prevent coaptation of the fractured ends. 2. Two or more fractures of a long bone, where it is impossible to secure coaptation and fixation of each fragment. 3. Certain fractures of both bones of forearms or leg, where, by every known manipulation, it is impossible to secure coaptation and fixation of both fractures at the same time. 4. Certain fractures into joints, where loose fragments will interfere with the function of the joint. 5. A few atypical fractures, where muscular action has displaced 'a fragment to such an extent that coaptation and resulting function can only be secured by operation. In recent fractures, the appHcation of internal splints is not always necessary as the ends may be held in apposition by chromic gut, or kangaroo gut, or even by external splints after coaptation has once been estabhshed. However, in many recent fractures, where opera- tion is necessary, a bone graft of the inlay type, made from the longer fragment, will give the surest fixation and the quickest results. In old fractures, the chief indications for open treatment are : 1. Non-union. 2. Faulty union with very marked deformity or loss of function. 3. To restore or supplant dislodged or destroyed fragments. It is in these last conditions that the bone graft is of the greatest value and far superior to any foreign material. The third question regarding bone grafts concerns the viabihty or non-viabiHty of the graft. Murphy, Barth, et al., claim that the graft ^ Jour. Am. Med. Assoc, Vol. Ixiv, No. 20. OPEN TREATMENT OF FRACTURES 633 is not osteogenetic. They contend that osteoblasts form from either end of the sectioned bone and circulate through the Haversian canals of the transplant, and that as they multiply, they cause absorption of the bone cells of the transplant, the latter acting only as a scaffold or osteoconductor — a process of substitution. Axhausen and others claim that the inner layer of the periosteum is the only portion of the transplant that has osteogenetic powers, and that the bone in the graft dies. MacEwen, of Glasgow, states that the periosteum has no such power, but is simply a limiting mem- brane for the osteoblasts, regenerating from the osteoblasts of the graft itself, and that this membrane prevents the spread of these osteo- blasts into the surrounding tissue. Many of our more recent investigators, Albee, Johnson, Phemister Lewis, et al., claim that the graft has osteogenetic powers in all three of its layers — periosteum, cortex and endosteum — but more pronounced in the periosteum and endosteum, and especially more marked at either end of the graft, because here the new blood supply to the graft is the richest. In fact, the osteogenetic power of any of these layers depends absolutely on the blood supply. A portion of the graft near the center, and especially in the denser cortex, becomes necrotic and absorbs and is replaced by the osteoblasts from the living portion of the transplant — the process of "Creeping Substitution" of the old bone by the new. From studying the a;-ray findings in a large number of cases I feel that we have conclusive proof of : 1. The osteogenetic abihty of the periosteum. 2. The osteogenetic powers of all three layers of the graft. 3. The death of a certain portion of the graft and the substitution of osteoblasts from other portions. 4. And that the transplant is not simply a scaffold. Autogenous bone grafts have become of paramount value also in repairing many bony defects, such as those resulting from complete loss of bone due to : 1. Destructive infections, septic, tuberculosis, lues, etc. 2. Defects of development. 3. Benign tumors, as bone cysts, myeloma, etc. 4. Encapsulated malignant tumors, as giant-cell sarcoma and chondrosarcoma. These conditions are extremely important in industrial surgery as fractures from very slight injuries sometimes occur due to the presence of these pathologic conditions. I have had two cases of fracture and one case of alleged injury to the finger in which the accident was really coincidental, the real cause being the presence of a bone cyst in each case. 634 INDUSTRIAL MEDICINE AND SURGERY Bone cysts are the small, single or multiple cysts found in the body of the bone and usually destroy most of the cortex, the periosteum often serving as the cyst wall. They are the end-result of a low-grade Fig. 169. — Mviltiple bone cysts, osteitis fibrosa, of hands discovered in an ap- plicant for work. Under present compensation laws the employer could be held responsible for subsequent fractures. inflammatory affection of the bone and medullary tissues, known as osteitis fibrosa. Fig. 170. Fig. 171. Fig. 170. — Bone cyst in little finger. This girl employee claimed her work was responsible for the condition. Fig. 171. — Same as Fig. 170. Three days after bone from tibia was transplanted. Cortex only was transplanted. Fragments of periosteum from wall of cyst were left intact and growth first took place in these and in ends of transplant. Osteitis fibrosa causes a destruction of the bone, and this is gradually replaced by granulation tissue, which, in time is converted into connective tissue, with or without the formation of these bone OPEN TREATMENT OF FRACTURES 635 cysts. Any of the long bones may be affected by this condition, especially the upper end of the humerus; also, the small bones of the foot and hand are often involved. The bone, if a cyst is present, increases in size very slowly, as compared to a bone affected by Fig. 172. Fig. 173. Fig. 172. — Same as Fig. 170, eight months after operation. Note that transplant now has the normal contour of metacarpal bone. (Wolff's Law.) Fig. 173. — A bone cyst of upper end of humerus. A fracture followed a slight collision between trucks. malignant disease, and often a fracture through the cyst is the first evidence of the disease. In small cysts, where the cortex of the bone is not completely destroyed, simply opening and thoroughly curetting will often cure Fig. 174. Fig. 175. Fig. 174. — Same as Fig. 173, three weeks after bone transplant; arm at right angles held by plaster cast. X-ray shows growth taking place from periosteum, chips of bone inserted about transplant and in the ends of the transplant. Fig. 175. — Same as Fig. 173, six months after operation. Note how transplant has assumed the natural contour of the humerus. the condition, but in multiple cysts, where the shaft of the bone is completely destroyed for a distance, the periosteum should be stripped off and the entire cyst excised; then the resulting bony defect should be 636 INDUSTRIAL MEDICINE AND SURGERY repaired by the insertion of a bone graft taken, preferably, from the patient's own body. In repairing fractures or these bony defects by the autogenous graft, the technic of the operation is practically the same. I will pass over the actual steps of these operations, but here are a few facts which should be emphasized : 1. The bone work is best done with a motor and the various shaped saws, as outhned by Albee, Hogrin, et al., especially the twin saws for inlay work; a chisel and mallet may be used, however. 2. The greatest asepsis must be observed. Some advocate the extreme methods of never touching the graft except with instruments. 1 Fig. 176. Fig. 176.^ — Same as Fig. 173 normal motion in shoulder joint. Fig. 177. — Large bone cyst of humerus Fig. 177. Eight months after operation patient had practically (Clinic of Dr. A. I. Halstead.) The graft should not be placed in normal salt solution, as this washes away the blood on the graft which nourishes its cells. 3. The smaller the graft, the better its growth. When necessary to use a large graft, save every small fragment of bone and pack about the graft, as these become centers of osteogenesis. 4. Transplant all three layers and coapt periosteum to periosteum, cortex to cortex, and endosteum to endosteum. This is not essential for growth of the graft, but gives better blood supply and quicker growth. It is a far superior method to the intramedullary grafts. 5. Attach the soft tissues singly about the graft and suture muscle attachments to the graft as near their normal position as possible. 6. As early as possible, allow slight movement in the part, so that OPEN TREATMENT OF FRACTURES 637 the graft will not only grow, but will conform itself to meet its new mechanical functions (Wolff's law) . The x-v&y should be the guide as Fig. 178. — Same as Fig. 177, two weeks after transplant was made. Dr. A. I. Halstead, St. Lukes Hospital, Chicago.) (Operation by to when to allow this motion, and it should not be done until the graft has become firmly fixed. Pig. 179. — Same as Fig. 177, eight months after operation. Patient is developing good function. Illustrates process of "creeping substitution." 7. It is preferable not to transplant in the presence of infections, but, contrary to earher teachings, experience has taught us that in- 638 INDUSTRIAL MEDICINE AND SURGERY fection, even when great amounts of pus are present, does not, as a rule destroy the graft. Thus, in compound fractures, much time can be gained, instead of waiting until the wound is perfectly healed. 8. No foreign material, such as silver wire or ivory pegs, should be used to hold the graft in place. Kangaroo gut is my choice of material for this purpose. • Figures 165 to 179 illustrate the various points brought out in this chapter. CHAPTER XXXIX AMPUTATIONS Amputations the result of injuries occurring in industry have de- creased materially during the last ten years but they are still suffi- ciently prevalent as to make this one of the most important problems confronting the industrial surgeon. Their decrease has been due chiefly to : 1. More prompt attention by the surgeon. 2. Preventive measures reducing the number of infections. 3. A more conservative attitude on the part of surgeons toward seriously injured extremities. 4. The "safety first" movement which has materially reduced the number of serious accidents in hundreds of our largest industries. In a large steel mill prior to the employment of a surgeon con- stantly on the job and before the introduction of accident preventive measures, amputations were very common. The commonest cause of these amputations was severe crushing wounds followed by infection. After a surgeon was employed, prompt emergency treatment was rendered to all of these cases with the result that the number of infec- tions decreased rapidly. This surgeon claimed that the reduction was due chiefly to the use of tincture of iodin which was immediately applied to wounds no matter how extensive the injured area. This concern was one of the first to adopt the measures advocated by the National Safety Council and immediately these serious accidents became less frequent. This is the history of hundreds of other industries. The cost of installing these accident prevention measures, plus the cost of employing the best surgical talent to render proper and immedi- ate surgical care to injured employees is far below the cost of paying indemnities for permanent disabilities especially when involving the loss of members. For a decade this doctrine has received nation wide publicity but still there are industries so short-sighted as to refuse to adopt such a straightforward business proposition. Neither the economic nor the humanitarian viewpoint seems to appeal to them. It is high time that both the States and Federal governments awake to their responsibilities and legislate most drastically with a view to preventing loss of members and loss of life from industrial accidents. In civil practice surgeons have become far more conservative with regard to amputating injured members than they were previously. 639 640 INDUSTRIAL MEDICINE AND SURGERY This is undoubtedly due to the fact that our present day methods of combating infections are superior to the old methods; the transplan- tation of skin, fascia and bone has enabled the repair of wounds which formerly were considered hopeless; and there has been a growing tend- ency to delay amputation to some subsequent date, trying the re- parative work first and later amputating if this failed. The severe infections, especially from the gas bacillus, following war injury has necessitated the more radical operations on the part of the army surgeon. Many wounds occurring on the battlefield have made amputations necessary which if received in industry would have yielded to conservative treatment. The opportunity of giving more prompt attention to the wounds and the absence of these extremely virulent infections make the latter course possible. Medical officers returning to the accident surgery of civil life must constantly bear these facts in mind. Through the courtesy of Dr. Royal Meeker, Commissioner of Labor Statistics, United States Department of Labor, the author was able to obtain the most recent figures concerning industrial accidents in the United States for the year 1917. Of the 875,000 non-fatal in- dustrial accidents causing disability of over four weeks, 68,820 resulted in amputations of some member of the body. These were distributed as follows: Loss of one finger or part of finger 52,050 Loss of two or more fingers 9,100 Loss of one hand or arm 2,880 Loss of one foot or leg 1,220 All other specific losses (including multiple) 3,580 Total 68,830 When we consider the thousands and thousands of amputations which result yearly from accidents received on the streets, oh the farms and in the homes which are not included in the above figures, we obtain some conception of the size of this problem. The estimated number of amputated cases for all the nations participating in the present war is thought to be between 400,000 and 500,000, approximately 100,000 a year. The number of amputated cases from industrial accidents in the United States during one year closely approaches the yearly rate from this terrible war. It is evident, therefore, that the treatment of injuries necessitating amputations is one of the most important problems in industrial surgery. Every country participating in the present war has made an intensive study of this problem in all its aspects with a view of obtain- ing the very best economic end-results for the soldiers thusly disabled. As a result of these studies, many valuable principles appUcable to AMPUTATIONS 641 industrial surgery have been conceived. If the surgeon in civil practice will take full advantage of these great principles the unfortu- nate patient in the future who loses a limb should have many more opportunities for a happy existence than has been afforded to these individuals in the past. Finger Amputations. — In industry, the majority of finger am- putations result from crushing wounds in machinery; from saws, heavy shears, presses, etc., cleanly severing the finger from the hand; from lacerations, nail wounds, splinters, scratches and abrasions which, through neglect, become seriously infected. Statistics obtained from several accident insurance companies and from a number of industrial surgeons showed a surprisingly high percentage of amputated fingers resulted from infections of minor wounds. In order to eradicate the great loss of fingers from industrial accidents two things are necessary : 1. Proper protection against these machinery accidents; 2. Immediate antisepsis and proper emergency treatment of all finger accidents with a view of preventing these infections. Formerly I followed the usual procedure in amputating these injured fingers, namely, removing a sufficient portion of the bone to enable the formation of an anterior and posterior skin flap which could be approximated and sutured. This practically always resulted in a loss of a greater portion of the finger than actually occurred at the time of the accident. Like most surgeons, it was felt that quicker healing and a more sightly result could be obtained by such reparative work. The great majority of finger injuries requiring amputation which report to the surgeon are of the following types: 1. The tip of the finger crushed off with loss of only a slight portion of the bone. 2. Most of the distal phalanx removed with a small portion of the bone exposed and the soft tissues lacerated for a short distance above the point of severance. 3. The distal phalanx and the lower third of the middle phalanx crushed off leaving the bone splintered and exposed and the soft tissues lacerated. 4. Complete loss of the finger often including the end of the metacarpal bone and the soft tissues about the lower portion of the palm lacerated. One or more of the fingers may be thusly injured. For the last five years I have treated such finger injuries as follows: 1. Immediately paint the wound with tincture of iodin. 2. With sterile gauze make gentle but firm pressure upon the in- jured part until the bleeding ceases. When necessary, a bleeding artery is grasped with forceps and ligated. 3. If the bone is splintered and protrudes below the soft tissues, 41 642 INDUSTRIAL MEDICINE AND SURGERY it is snipped off even with the rest of the wound by means of a bone forceps. If it does not protrude it is left entirely alone. 4. Loose shreds of tissue deprived of sufficient circulation are removed. No other effort is made, however, to trim up the soft parts. 5. Narrow strips of adhesive plaster one-eighth to one-fourth of an inch in width are now apphed over the wound directly on the skin. These adhesive strips extend up the finger from one inch to two inches above the wound. They are first apphed on the flexor surface, pulled down snugly over the wound and then back over the extensor surface. They should not overlap but a small space should be left between each strip to allow for oozing and drainage. One or two strips should next be applied over the wound from side to side. The portion of the adhesive plaster which comes in contact with the wound can be sterilized by painting it with tincture of iodin before applying it. After the strips are in place, they should be lightly painted with tinc- ture of iodin. Next a sterile gauze dressing is applied and the injured member bandaged. 6. This dressing should be changed daily but the strips need not be removed for at least four days unless infection makes it necessary which is rare. Adhesive strips should be reapplied every four to six days. By this method no more of the finger is lost than actually occurs at the time of the accident. The adhesive strips prevent retraction of the soft tissues from the bone, pull the skin edges inward, form a bridge for the new granulations, and finally cause a complete approxi- mation of the soft tissues over the end of the bone with excellent closure of the wound. The advantages of this fine of treatment are : (1) A greater portion of the member is saved; (2) it can be carried out without an anesthetic and the necessary operative work required by making flaps and suturing; (3) better drainage is afforded in case of infection; (4) the patient is more pleased because at each subsequent dressing he can see that the maximum saving of tissue is being attained. The only disadvantage is that in clean cases the length of treatment is usually prolonged over the period required for healing when the skin is immediately approximated by the flap method. The manager of one of the departments once reported to the doctor's office complaining of a slight pain in his abdomen. One of the surgeons placed him upon a new operating table in order to exam- ine the abdomen. This table was a new-fangled contraption which could be made into a chair. After the examination, as the patient was arising from the table, the footpiece fell forward. The manager's right index finger was caught in the hinge in some way and the tip completely cut off at the middle of the distal phalanx. Naturally AMPUTATIONS 643 the manager was very outspoken in his criticisms of such an office and the surgeon was extremely chagrined. I was immediately called and endeavored to explain that the table was new and the ac- cident was not the fault of the doctor (this case afforded the example that "safety first" methods must be applied in the doctor's office and in the hospitals). I explained to the manager that we could remove the remaining portion of the bone back to the joint, coapt the flaps and secure a good result with only the loss of his distal phalanx; or by prolonging the treatment somewhat we could treat it by the adhesive strip method and most of the finger would grow back into place even including a portion of the nail. The latter plan was adopted and in six weeks the wound had healed. At the time of the accident careful measurements of both index fingers were made and the right one was just a half inch shorter than the left. Three months after the accident comparison of the two fingers showed only one-fourth of an inch difference in length. The injured finger had a natural tapering and a well-formed nail which required close inspec- tion to show that it was somewhat shorter than the other nail. The excellent result obtained removed all criticism concerning the accident. The removal of bone and soft tissue in order to attain well-formed flaps which can be sutured over the end of the severed finger is wasteful surgery — not only wasteful to the employee but necessitating greater compensation on the part of the employer for the loss of the member. This adhesive plaster treatment is also appHcable to many cases suffering loss of a portion of the palm or a portion of the foot. I have also used it to approximate the flaps in amputations of the leg and arm where haste in operating is indicated. Amputations of Upper Extremity. — The emergency treatment consists in antisepticizing the wound with tincture of iodin and com- bating hemorrhage and shock. The subsequent indications are: (1) to secure the safety of the patient, and (2) to secure the best functional result. The best functional result will depend upon the amount of the member saved, the location of the scar and especially the absence of a painful scar, and the adaptability of the stump to the artificial hmb which must be worn. When infection is present the safety of the patient can best be conserved by estabHshing good drainage without endeavoring to form and approximate flaps. The InteralHed Surgical Congress has re- quested that amputation for infection should be flapless or with short flaps held apart. When it is necessary to leave the incision open traction should be applied to the skin just as soon as possible in order to overcome retraction (see Fig. 180) and thus Hmit the size of the resulting scar. After the infection has subsided a ream put ation, in order to secure a proper closure, may be necessary but quite frequently 644 INDUSTRIAL MEDICINE AND SURGERY approximation can be secured by the adhesive piaster method out- lined above especially in the smaller extremities. The location of the scar in arm amputations should either be posterior or preferably across the end of the stump as in using the stump pressure is usually exerted laterally and not on the end. A wrist stump, however, requires frequent end pressure and for this reason a long palmar flap with the scar at the back of the wrist is preferable. In all other locations the short anteroposterior flaps will be found the most useful. Whenever possible the muscles and deep fascia should be sutured over the end of the bones in order to prevent an adherent scar and to give sufficient bulk to form a cushion. Fig. 180. — Traction applied to skin to prevent retraction. Stump extension with a modified Thomas splint. (Adapted from Sinclair.) "A Thomas knee splint is cut down and a 9-inch square riveted on to the side bars 12 inches beyond the end of stump. An 8-inch circle of aluminum is attached by gauze and glue to the skin of the stump so as to be 6 inches distal to the cut surface. Extension is made from the ring to the square either by tapes or rubber bands. The square acts as a pedestal and also for the attachment of the extensions." (Courtesy, " The Military Surgeon.") Redundancy of tissue affording excessive motion is to be avoided as in this case the skin may become irritated from rubbing against the socket of the artificial appliance. In amputations of the forearm ^oft tissues must be carefully sutured between the ends of the ulna and radius to prevent union between these bones as such union interferes with pronation and supination. The Division of Military Orthopedic Surgery of the Office of the Surgeon General of the United States Army has made an extensive study of the preferable sites of amputation as related to the future requirements of the artificial appliance. These favorable sites are graphically shown in Fig. 181. AMPUTATIONS 645 I. PREFERABLE SITES of AMPUTATION from ARTIFICIAL LIMB STANDPOINT (UPPER EXTREMITY) >t :>' , Leave Humeral Head.if possible as it la of advantage in filling Glenoid Cavity Lfpp')>i'\\ iitiii8 Totals 1,157 186 455 2,360 324 237 236 "On the other hand, the amputations in warfare are probably more serious in degree than the amputations in industry. According to the official bulletin of the Canadian Department of Soldiers' Civil Ee-estabhshment for March, 1918, a classification of the amputation cases in the Canadian Army shows that of the men returned to Canada, 328 had lost arms and 723 had lost legs. A further classification shows that virtually twice as many arm amputations were made above the elbow as below the elbow and about twice as many leg amputa- tions were made above the knee as below the knee. "After almost four years of war, with an army, at present, of between 400,000 and 500,000, Canada's experience shows that less than 50 soldiers have been blinded. It has been stated that the number in the Spring of 1918 was 34. "In the shorter period of only two and one-half years — from January 1, 1916, to July 1, 1918 — there have been 29 workers blinded through accidents in the industries of Pennsylvania. The total number of eyes lost through industrial accidents in Pennsylvania during those two and one half-years is 1157. "Of the twenty-nine men blinded by industrial accidents in Penn- sylvania during two and one-half years, one worker also lost a left hand, one a right arm, and one both hands in the accidents that blinded them. During those same two and one-half years, five workers lost both hands, one of whom also lost one eye; six workers lost both legs; three workers lost both feet; four workers lost both an arm and a foot; five workers lost both an eye and a hand ;' two workers lost a leg and a foot; two workers lost an arm and leg and two workers lost both arms. "During the two and one-half years from January 1, 1916, to July 1, 1918, there were 159,659 industrial workers injured in Pennsylvania and disabled for a period exceeding fourteen days. Those workers received workmen's compensation payments as provided by the state law and, in addition, dependents of 4636 workers killed in industry likewise received workmen's compensation payments. The difference between the number of 577,053 industrial workers reported as injured and those receiving compensation payments represents cases where the disability did not exceed a period of fourteen days. 792 INDUSTRIAL MEDICINE AND SURGERY "Workmen's compensation awarded and paid for fatalities in Pennsylvania from January 1, 1916 to July 1, 1918, amounted to $11,539,352.46 of which $1,393,616.76 had been paid to depend- ents. Payments for disability cases during the same period amounted to $5,378,207.14. The gross total of workmen's compensation awarded and paid in Pennsylvania for fatal and disability cases from January 1, 1916, to July 1, 1918, amounted to $16,917,559.60." Figures from other states would indicate that considerably over 100,000,000 dollars a year are disbursed in payment of accident com- pensation claims throughout the United States. One-half this sum intelligently spent by the government in prevention of accidents would reduce the number of persons needing physical reconstruction, and the other half of this huge amount would vocationally train and other- wise reclaim the smaller number receiving permanent handicaps, as well as pay their compensation. It must be remembered that adequate surgical care and proper training will always reduce the number of compensable cases. No less an authority than Dudley M. Holman, recently President of the International Association of Industrial Accident Boards and Commissions, explains the size of the problem of the permanently disabled worker, and the value of prevention as a means of reducing this problem, in the following words: "It is a very conservative estimate to state that annually 250,000 workers are, under present conditions, permanently thrown out of employment through accident or preventable disease in the United States alone. These men and women must be supported somehow. Part of them receive whole or partial support under the provisions of the workmen's compensation acts, and while this solves in whole or in part their individual problem of existence, it does so in most states only for a limited period, and after six or ten years of idleness, when their compensation ceases, they are left in a most pitiful condition. "Yet there are a few of these men and women who could be put back into industry and have a place found for them where they could support themselves in part at least. "This economic waste caused by the apparently enforced idleness of this vast army of men and women exceeeds $100,000,000 a year of added burden, and amounts to not less than half a billion dollars annually, a figure that is constantly being increased by the addition of a quarter of a million cripples each year. "Much of this burden is primarily borne by the insurance companies, but they pass it along so that in the end the burden falls on society in general. This waste is a by-product of industrial inefficiency, for by prevention of accidents and disease 50 per cent, of these men and women would never become disabled." CONSEEVATION AND RECLAMATION OF THE DISABLED 793 Interwoven with and contributing to the wastage of human hfe and human energy on the part of industry and of society is the inade- quate medical care so often afforded these victims of accident. They are admitted to our wards in the hospital and the immediate treatment or operation is performed properly and well. This is followed by the daily dressing. For the remainder of the day, for weeks and weeks to come, the patient is left to his own devices. Lying there in idleness, with worry and melancholy his chief companions, is it any wonder that traumatic neuroses develop? Satisfied with a good surgical end-result, as usually interpreted, very little thought is given to the man's future economic usefulness. As a consequence efforts to restore Fig. 210. — A typical scene in the average hospital. Nothing to do but play cards, checkers, or read cheap novels for weeks upon weeks of convalescence. This period should be utilized to improve their future social and economic conditions. Suitable ward occupations will hasten recovery. function in the disabled member receive only secondary consideration. And when the patient must finally leave the hospital, to make room for other unfortunates, neither the surgeon nor the insurance company nor the responsible employer strive to place him in a position where the best economic end-result can be attained (Fig. 210). Every surgeon will recognize the truth in the following statement made by a layman, Mr. A. Gwynne James, County Court Judge under the Workmen's Compensation Act, in Bathj, England: ''On my circuit the large majority of injury cases arise from acci- dents in mines and from machinery, and the lack of proper and ade- quate medical treatment and training is simply appalling. There is 794 INDUSTRIAL MEDICINE AND SURGERY practically no exception to the following routine : On the workman re- ceiving his injury he is sent to the hospital, where he receives the best of treatment, and a Hmb is amputated or other treatment given, but as soon as it is possible to remove him he is discharged to make room, for others. He then becomes an out-patient or goes home. In the former case (the hospital is often some way from his home) he attends a few times for dressings, after which all treatment ceases; in the latter case he is attended by his club doctor, often a young and inexperienced medical practitioner, who has had no communication with those who have treated his patient at the hospital, and these attendances invariably cease in a short time, and from then the injured man has 'to fake for himself.' He cannot in most cases carry on his former trade and has no means of being trained to another. As regards artificial limbs, although I have had hundreds of cases before me involving loss of a limb, I have never known a case when an artificial limb has been sup- plied except the old-fashioned leg stump. The workman does not appreciate or understand the advantage of an artificial limb, and, if he did, has not the means to buy one. Of the cases which come before me perhaps the most numerous and difficult to deal with are those acci- dents which result in a permanently stiff limb. The insurance company asks the judge for a diminution of payment to the workman on the ground that if he had followed the doctor's advice the limb would not have become stiff, and, therefore, the incapacity to work arises from the negligence of the workman. The treatment advised is generally massage and certain manual exercises; the former (in most cases) the man is totally unable to obtain, either because there is no one living near him who can administer it, or because he has no means to pay for it; as regards manual exercises there is no institution where they can be given and where he can be instructed, and if he tries to exercise the limb himself this involves in most cases very conside 'able pain, especially to begin with, and the exercise is discontinued. This, in the case of a poor and ignorant man, cannot be held to be negligence, especially as the doctor invariably admits that had the patient been a well-to-do one he would have advised the treatment of exercise being done in the first instance by a medical man. The result is a stiff limb for life, a continuance of weekly payments by the insurance company (probably for life), and a loss to the country of the man's earn- ing powers. "Another class of case, occasioned by accident arising out of and in the course of the workman's employment, is stiff limbs arising from traumatic neurasthenia. In many instances under proper treatment the neurasthenia need not have developed, and under existing circum- stances when it has occurred there is no provision of any kind whatever for medical treatment such as is now given to soldiers suffering from CONSERVATION AND RECLAMATION OF THE DISABLED 795 'shell shock.' I have only dealt with a few instances of the lack of medical and orthopedic treatment of our injured workmen and not with his re-education, although the latter is of signal importance. "I sincerely trust that the institutions and training which are now being founded for our injured soldiers may become permanent after the war and available to the English workman. As regards the work- men's compensation acts, the law would probably have to be amended by introducing a slight amount of compulsion as regards treatment. I do not think there would be much difficulty as to this; for example, if the workman's doctor and the insurance doctor agreed that a certain treatment was necessary, then if the patient refused to undergo it his weekly pajnments might be docked or varied. "Another question would arise in respect of accidents under the above acts as regards the cost of this extra treatment and on whom it should fall. In my opinion this cost should fall mainly if not entirely upon the insurance companies, although in the case of an injured workman having no dependents he might be called upon to pay a small amount from his weekly payments. I cannot think that the insurance companies would make any objection to this course, as the extra cost to them would be more than covered by the smaller weekly payments they would have to pay owing to the increased power of wage earning, and the earlier date at which their Hability to make weekly payments would cease. Co-operation and help should be ob- tained from the Trades Unions, without whose sympathetic assistance the success of the workmen's compensation acts would not have been attained." Every thoughtful physician and surgeon in this country should be stirred to the utmost endeavor to overcome existing conditions by these eloquent words from the pen of John Mitchell: " We are casting valuable workers needlessly on the scrap heap. In my experience as chairman of the New York Industrial Commission, which administers the workmen's compensation law, I am brought face to face every day with the tragic consequences of our failure to make some provision for restoring to economic usefulness, self assur- ance, and renewed interest in Hving, those victims of industry whose injuries have maimed or disabled them beyond ah possibility of return- ing to their usual occupations. . . . For a time workmen's compen- sation comes to the aid of the family. Then these benefits are ex- hausted. The little savings of years are swallowed up. The unfortu- nate man is entirely cut off in the prime of manly vigor from the work he knows so well how to do. He sees no occupation open to him. . . . His special knowledge of working processes gone to waste, he sinks under the weight of his misfortune . . . watching . . .the black shadows of destitution fall over his home." 796 INDUSTRIAL MEDICINE AND SURGERY The Solution of the Problem The accident cases — the armless, the legless and the blind — form the most spectacular group of those needing physical reconstruction. But those employees suffering from "invisible wounds" — the tuber- culous, the heart case, the nephritic, the mental defective and the victims of occupational diseases — demand the same care. The problem of the disabled from industry can only be solved, however, by considering every angle of human conservation and reclamation. It involves more than the physical reconstruction and vocational training. Every year recently has witnessed the enactment of laws by the different states tending to meet some portion of this problem. But these laws show a woeful lack of intelligent understanding of the exigency and are very inadequate. Proof of this statement has just been furnished in the pages dealing with the size of this problem as it confronts us to-day after several years of legislative effort. The first real advance in labor legislation in this country was the enactment of certain laws regarding industrial sanitation and the es- tablishment of state factory inspectors in practically every state. These have been followed by acts concerning hours of labor, employ- ment of women and children, periodical examinations for occupational diseases and, in 38 states, employees' compensation acts. The Federal government has passed similar laws for the government employees. At present there is a bill before Congress for the vocational rehabilita- tion of industrial cripples. The trouble with all this legislation and the reason that it has not been more successful is this piecemeal method of meeting the requirements. Certainly the time is ripe for uniform labor legislation which will adequately solve the problems of conserving human life, reclaiming the disabled, sufficient compensation for disabilities sustained, insurance against sickness, old age, and unemployment, and better living and working conditions. Instead of Congress enacting another law applying to only a small angle of this great question it would be much wiser for it to appoint a commission, and provide sufficient funds, in order that the whole situation could be studied and a standard law submitted to the Federal and state governments which would furnish a comprehensive solution of the whole problem. Such a law, couched in simple but unmistakable language, and enacted in every state, must provide for the following: 1 . Prevention of Disease and Accidents. — All possible methods of preventing occupational diseases must be standardized and their use made compulsory. Protection of fellow employees from communicable diseases, in- CONSERVATION AND RECLAMATION OF THE DISABLED 797 eluding the discovery of such diseases, must be provided, as well as adequate supervision of health in order to detect all disease in its incipiency. The effective accident prevention measures now being used in many industries must be applied to all. Provisions must be made to include the farmer, the small employer, the employer of domestic help, and every community activity in the scope of this law. Above all it must provide for better living and housing conditions, better working conditions, shorter hours of labor and better wages so that "the gaunt spector of poverty will be removed from the doors of those who toil, and will give to them a part of the day for rest and recreation in order to repair the bodily wastes that sap the energy and consequently reduce their output through fatigue and overwork." 2. Adequate Medical and Surgical Care. — It must provide for the best and immediate medical and surgical care for every sick or injured employee. Whenever occupational conditions are responsible for the sickness or injury the employer, should furnish this care. Adequate care must be clearly defined and must include every therapeutic adjunct which will enable the physical reconstruction, the functional re-education and the maximum restoration to useful employment of every disabled individual. State and community hospitals, convalescent centers, and human repair shops must be provided where this treatment can be furnished under proper environment and supervision. Suitable artificial appliances and training in their use must be considered a definite part of treatment. No longer should such an important branch of medicine and of social economy be left to the uncontrolled commercial interests of the country. 3. Training and Emplo3anent. — The recent provisions for the vocational rehabilitation of disabled soldiers and sailors and their return to civil employment must be extended to the disabled in industry. Centers must be provided in every state where disabled men made unfit by disease or accident for their usual vocations can be retrained for useful employment. Federal, state and local employment agencies must be provided for the intelligent placing of these men in suitable occupations. Employers must be required to train their disabled employees for better or just as good positions as they formerly held instead of relegating them to the usual jobs for cripples such as watchman, messengers, etc. 4. Compensation and Insurance. — Thirty-eight states have already enacted employees' compensation laws. None of these covers 798 INDUSTRIAL MEDICINE AND SURGERY all employments; the amount of compensation paid for disabilities has a very wide range; and the methods of insuring the risks and administering the acts differ materially in the various states. The crying need is for a uniform, standardized compensation law in every state. Insurance against sickness, accidents, invalidity, unemployment and old age must be provided as a definite part of a conservation and reclamation program. 5. Machinery for Carrying Out the Act. — Each state should have a central administrative body with sufficient administrative and police powers to execute the intentions of the Act. Health, sanitation, food, housing, employment, education, insur- ance and both industry and labor should be represented on this central commission. As far as possible these should be removed from the appointive realm of politics and should be considered honor positions. The activities of the different state departments should be co-ordinated so as to avoid the present duplication and inefficiency existing in the Federal and state governments. Qualified medical men and laymen must be appointed to supervise every angle of this work including even the medical and surgical treatment afforded the disabled, the type of health supervision mam- tained, as well as the living and working conditions of all coming under the Act. 6. Remedial Measures for Existing Conditions. — ^Laws requiring compensation for injuries without providing for accident prevention have proven how wasteful partial legislation to meet a given situation can be. Therefore, remedial legislation for the purpose of removing or correcting all things which prevent the complete fulfillment of the proposed law is essential. No longer should inadequate medical and surgical care be tolerated or protected by the unwritten laws of the profession generally included under the term medical ethics. Those hospitals notorious for their lack of high standards and responsible for many a case of permanent disability must be abolished. Patent medicines, fake appliances, and quackery of every form, acting as a snare and delusion for millions of employees, must be eradicated. Child labor and every other form of exploitation of labor must cease. Above all such a law must be absolutely just, based upon the rights of both industry and labor, and tending to weld into a close partnership those who employ and those who must work. The new viewpoints gained from the sacrifices of this war must lead our country into a true democracy with equal rights for all. CONSERVATION AND RECLAMATION OF THE DISABLED 799 It is not to be expected that these great social, economic and indus- trial problems will be solved immediately. Great progress has been made during the short time we have been in the war. But years of effort, propaganda and example are yet required before these ideals can be attained. With immigration ceasing to a large extent and with the increased demands upon our industrial resources it will be necessary for the nation to conserve its man-power if we intend to maintain America's economic supremacy and to take our rightful place in the great commercial struggle confronting the world. Industrial medicine has already blazed the trail in this the greatest conservation movement ever inaugurated. It has played a most important part in helping win the war by maintaining the health and efficiency of our second line of defense — the industrial army. It must now forge ahead, extending its principles to every industry in every community of the land. It must now become the pioneer move- ment for the socialized medicine of the future. With a broadened vision and a greater capacity for service let us strive for this ideal — Human Conservation and Reclamation of all Disabled. BIBLIOGRAPHY A very complete bibliography on Industrial Medicine and Surgery prior to 1916 can be obtained from the following sources: United States Department of Labor, Bureau of Statistics. Books and period- icals on accident and disease prevention in industry, Washington, 1915. KoBER & Hanson. "Diseases of Occupation and Vocational Hygiene," Philadelphia, 1916. SiE Thomas Oliver. "Occupational Diseases from Social, Hygienic, and Medical Points of View," Cambridge University Press, 1916. The following bibliography includes practically all the articles, reports, special bulletins and transactions published on this subject since 1916. The names of all contributors are not included, in this list as their articles appear in the various reports and transactions referred to. Adamson, R. a. E. Workshop for the handicapped. Survey, New York, 1916, xxvi, 392-393. Adler, Eleanor. An experimental employment bureau for cripples. Work gives the afflicted a new lease on life. Changed attitude on the part of employers. Modern Hospital, Chicago, 1918, xi, 402-405. Albaugh, R. P. Health protection in industries manufacturing war materials. Ohio Public Health Journal, Columbus, 1917, viii, 300-302. . Peculiar poisoning in construction camp (carbon monoxide). Ohio State Board of Health Bulletin, Columbus, 1917, viii, 195-200. Alberti, E. J. H. Twee gevallen van schadelyke werking door den electrichen stroom. Nederlandsch Tydschrift voor Geneeskunde, Amsterdam, 1918, i, 232-234. Albrecht, a. E. Industrial accidents and the education of immigrants. School and Society, New York^ 1917, vi, 652. Alexander, M. W. Measuring the workman's physical fitness for his job. Industrial Management, New York, 1917, lii, 493-502. . The physician in industry. Dominion Medical Monthly, Toronto, 1916, xlvi, 97-105. -. Health supervision in Industry — Conference Board of Physicians in Industrial Practice, 1917. Allport, F. State legislation concerning shop lighting, shop accidents, shop conditions, the common towel, etc. Ophthalmology, Seattle, 1916-1917, xiii, 48-117. Amar, Jules. Organisation physiologique du travail. Paris, 1917. . The physiology of industrial organization and the re-employment of the disabled. Translated by Bernard Miall. London, 1918. Andrews, J, B. Industrial hygiene and health insurance. American Journal of Public Health, Concord, 1916, vi, 959-963. Andrews, J. B. New Federal workmen's compensation law. Survey, New York, 1916, xxxvi, 617. . Physical examination of employees. American Journal of Public Health, Concord, 1916, vi, 825-829. . A timely brief for health insurance. Boston Medical and Surgical Journal, 1916, clxxv, 539. Andrus, C. S. The responsibility of industrial boards to employer and employee SI 801 802 INDUSTRIAL MEDICINE AND SURGERY as influenced by the opinion of the medical officer. Journal of the American Medical Association, Chicago, 1918, Ixxi, 508-511. Anthony, F. W. Industrial health legislation. Boston Medical and Surgical Journal, 1916, cLxxv, 911-913. Appelbaum, S. J. Compulsory health insurance. Journal of the American Medical Association, Chicago, 1917, Ixviii, 1338-1339. Armstrong, D. B. Social aspects of industrial hygiene. American Journal of Public Health, New York, 1916, vi, 546-553. Ashe, S. W. Organization in accident prevention. New York, 1917. Atherton, Sarah H. Survey of wage-earning girls below 16 years of age in Wilkes- Barre, Pa. Nail Consumer's League, New York, 1915. B., A. Lo stabilimento tipolitografico Antonio Vallardi nei rapporti della igiene e della sicurezza. Rivista di Ingegneria Sanitaria, Torino, 1916, xii, 1, 13. Bacon, J. E. Traumatic hernia. Southwestern Medicine, El Paso, 1917, i, No. 9, p. 9-12. Baldy, John M. What constitutes reasonable surgical, medical and hospital services under compensation act. (Second Conference Industrial Physicians, Harrisburg, 1916.) Baker, V. C. Dusty occupations. Journal of the American Medical Associa- tion, Chicago, 1916, Ixvi, 1453-1456. Bangert, George Schuyler. Occupational mercury poisoning. New York, 1918. Reprinted from New York Medical Journal, June 22, 1918. Bargeron, L. L'hygiene dans la reconstruction des usines apres la guerre. Annales d'Hygiene Publique et de Medicine Legale, Paris, 1916, xxvi, 257-273, 321-345; 1917, xxvii, 213; xxviii, 57. Bargoni, Foscolo. The insurance of the disabled against industrial accidents. In: Inter- Allied Conference on the After-care of Disabled Men. Pi,eports, London, 1918, p. 71-82. Baskerville, C. The American chemist and occupational diseases. Medicine and Surgery, St. Louis, 1917, i, 767-771. . Occupational diseases in the chemical trades. Journal of Industrial and Engineering Chemistry, Easton, 1916, viii, 1054. Batjvallet, H. Note sur un nouveau modele de casque recepteur pour radio- telegraphie et telephonie. Bulletin de I'Academie de Medicine, Paris, 1917, Ixxviii, 101-103. Bentley, J. R. Welfare work of Montgomery Ward & Company. Journal of Ophthalmology, Otology and Laryngology, Lancaster, 1917, xxiii, 529-545. Beyer, David Stewart. Accident prevention. Annals of the American Academy of Political and Social Science, Concord, 1917, Ixx, 238-243. Billings, Frank. The program for the physical reconstruction of disabled soldiers, Jour. A. M. A., July 1, 1918. BiRKS, M. Mine accidents at Broken Hill and their treatment at the Broken Hill and district hospital. Medical Journal of Australia, Sydney, 1918, i, 507-510. Blanchard, R. H. Liability and Compensation insurance. New York, 1917. Block, E. Resume of health conditions of a modern department store. New Orleans, Medical and Surgical Journal, 1917-18, Ixx, 724-733. Bloedorn, W. a. Studies of industrial accidents which occurred in the Navy Yard at Washington, D. C. U. S. Naval Medical Bulletin, Washington, 1916, X, 585-625. Bloodgood, J. C. How the industrial surgeon can best co-operate with the government during the war. Southern Medical Journal, Birmingham, 1918,^ xi, 543. BIBLIOGRAPHY 803 Bloodgood, J. C. Medical preparedness in the great drive for democracy-. Southern Medical Journal, Birmingham, vol. x, No. 7, 544-546. BOLAND, F. K. Traumatic rupture of viscera without external wound. Journal of the Medical Association of Georgia, Augusta, 1917-1918, vii, 74-78. Bonnier, J. W. Statistique de I'hygi^ne professionnelle. Bulletin Manitaire, Montreal, 1916, xvi, 81-86. BoRDLEY, James, Jr. The re-education of the blind. Jour. A. M. A., July 7, 1918. Borne, and Kohn-Abrest. Le bouton d'huile des ouvriers metallurgistes. Revue d'Hygiene et de Police Sanitaire, Paris, 1916, xxxviii, 1077-1093. Bouquet, H. Le travail industriel des femmes et I'Acad^mie; la propagande francaise par les medecins. Monde medical, Paris, 1916-17, xxvi, 170-174. Bowers, A. P. Tuberculosis as it affects the worker. Monthly Bulletin of the Pennsylvania Department of Labor, Harrisburg, 1917, iv, 106-108. Brock, L. G. The re-education of the disabled. Nineteenth Century, New York, 1916, Ixxx, 822-835. Brocx, D. De organisatie van het reddingwezen in onze steenkolenmijnen. Reddingwezen, Rotterdam, 1917, vi, 203; 231. Bromberg, R. (Occupational diseases and their social importance.) Medisch Weekblad, Amsterdam, 1916-17, xxiii, 205, 217, 231, 241, 253, 265, 277, 289, 301, 313, 325. Bulletins. National Founders Association on Safety and Sanitation. West Lynn, Mass. Carmichael, H. B. The method of examination and results in sight, hearing and colour vision for one year on the Grand Trunk Railway system. Canadian Medical Association Journal, Toronto, 1916, vi, 210-227. California. Report of Industrial Accident Commission — 1915 to 1916. Gary, Harold. Keeping employees happy. Music, rest and recreation contrib- ute to the success of a button factory and the content of its employees. Modern Hospital, St. Louis, 1917, viii, 232. Cause and prevention of furunculosis and wound infection among machinists. Ohio Public Health Journal, Columbus, 1918, ix, 145-152. Certifying factory surgeons. British Medical Journal, London. Chaney, Lucian W. and Hugh S. Hanna. Accidents and accident prevention in machine building. Washington, 1917. . Can serious industrial accidents be eliminated? Monthly Review of the U. S. Bureau of Labor Statistics, Washington, 1917, v, 201-216. The safety movement in the iron and steel industry 1907 to 1917. Washington, 1918. (U. S. Department of Labor. Bureau of Labor Statis- tics. Bulletin No. 234.) Chubb, Irene Sylvester. Some problems of the partially disabled, in war and industry, American Labor Legislation Review, New York., 1918, viii, 294-305. CiAMPOLiNi, A. Rischio professionale e rendimento utile degli operai invalidati che si riadattano al lavoro. Ramazzini, Firenze, 1916, x, 137-160. Clark, Lindley D. Workmen's compensation legislation of the United States and foreign countries, 1917 and 1918. Bulletin of the United States Bureau of Labor Statistics, No. 243, Washington, 1918. Clark, W. I. Adjustment of physical defectives to employment. Boston Medical and Surgical Journal, 1917, clxxvii, 578-580. . Medical supervision of factory employees. Journal of the American Medical Association, Chicago, 1917, Ixviii, 5-8. . Nail puncture wounds of the foot. Boston Medical and Surgical Journal, Apr., 1917. — Physical examination and medical supervision of factory employees. 804 INDUSTRIAL MEDICINE AND SURGERY In: Proceedings of the Conference of Social Insurance, 1916, Washington, 1917, p. 317-326; 335-347. Clark, W. I. The protection of the health of the worker in war. Journal of the American Medical Association, Chicago, 1917, Ixix, 1124-1129. Clegg, J. G. Ophthalmic occupational affections as described by Prof. Ramaz- zini, of Modena and Padua, at the end of the seventeenth century. Ophthal- moscope, London, 1916, xiv, 290-300. Clewell, C. E. Natural lighting in shop work spaces. Metal Worker, Plumber and Steam-fitter, New York, 1918, Ixxxix, 162-166. Clinical study of lead, turpentine, and benzine poisoning in 402 painters. Monthly Labor Review, Washington, 1919, viii, No. 3, p. 227-229. Close, C. L. Economic saving of human resources. Scientific Monthly, Garri- son, N. Y., 1917, iv, 428-437. Clough, F. E. From kindergarten to library. Welfare work of the Homestake mining company, Lead, S. D. Modern Hospital, St. Louis, 1917, viii, 74-75. CoBURN, C. O. Industrial medicine. Transactions of the New Hampshire Medical Society, Concord, 1918, cxxcii, 85^100. , CoLCORD, A. W. Hernia; should it be classed as a compensable injury or a disease? Pennsylvania Medical Journal, Athens, 1917-18, xxi, 672-684. CoLLis, E. L. The protection of the health of munition workers; with special reference to the work of the health of munition workers committee. Journal of State Medicine London, 1917, xxv, 203-213. Compulsory health insurance. Journal of the American Medical Association, Chicago, 1917, Ixviii, 292. CoNCTJLMER, P. Neurosi traumatiche. Rivista Medica, Milano, 1916, xxiv, 17. Cottingham, C. E. Occupational neuroses; report of seven cases of a new type. Journal of the Indiana State Medical Association, Fort Wayne, 1918, xi, 297-302. Cotton, F. J. A consideration of workingmen's accident and sickness insurance in their relation to the medical profession. Boston Medical and Surgical Journal, 1916, clxxv, 893-897. CouiLLARD, E. L'inspection medicale de I'industrie. Bulletin medical de Quebec, 1916, xviii, 145-158. — . Bulletin Sanitaire, Montreal, 1916, xvi, 92-103. Crandall, E. p. Industrial welfare nursing. Public Health Nurse Quarterly, Baltimore, 1916, viii, No. 2, p. 32-47. Cronin, Herbert J. Administration of the Workingmen's compensation act by the city of Cambridge, Massachusetts. Boston Medical and Surgical Journal, 1916, clxxv, 906-911. . The establishment of a first-aid hospital in industry. Boston Medical and Surgical Journal, 1917, clxxvii, 580-583. The physician and the prevention of industrial accidents. Boston Medical and Surgical Journal, 1916, clxxiv, 870-874. Crosby, John C. Workingmen's compensation act. Boston Medical and Surgical Journal, 1916, clxxv. 883-892. Crown Mines, Limited. Annual report of the Chief Medical Officer, 1916. Crown Mines, 1917. Crum, F. S, Facts showing the correlation between tuberculosis and industry. Journal of the Medical Society of New Jersey, Orange, 1918, xv, 181-183. . The mortality from diseases of the lungs in American industry. Penn- sylvania Medical Journal, Athens, 1916, xx, 33-48. Cunningham, W. P. Health insurance. New York Medical Journal, 1917, cvi, 683-686. BIBLIOGRAPHY 805 CtTRRAN, J. F. Relation of industrial surgeon to industry and to society. Boston Medical and Surgical Journal, 1918, clxxviii, 215-217. Curtis, W. G. Economic disadvantages of compulsory health insurance (and comments). New York State Journal of Medicine, New York, 1917, xvii, 75-81. Cutler, R. W. Physical examination of factory employees; two thousand con- secutive cases and the defects found. Boston Medical and Surgical Journal, 1917, clxxvii, 627-631. Dangers of the airplane industry from a hygienic standpoint. Monthly Review of the W. S. Bureau of Labor Statistics, Washington, 1917, v, 284. Darlington, Thomas. Address on prolonging the lives of busy men. New York, 1918. . Physiological principles applied to industry. International Clinics, Philadelphia, 1916, 26, s., iv, 142-146. Present scope of welfare work in the iron and steel industry. Modern Hospital, St. Louis, 1916, vii, 91-94. Davin, J. P. Compulsory health insurance. American Medicine, New York, 1917, xii, 188-193. Dawson, M. M. Contribution of health insurance to improvement of public health. Public Health Journal, Toronto, 1917, viii, 313-317. . What will health insurance do for the insured? American Journal of Nursing, Philadelphia, 1917, xvii, 937-942. Delphey, E. V. Arguments against standard bill for health insurance. Journal of the American Medical Association, Chicago, 1917, Ixviii, 1500-1501. . Compulsory health insurance from points of view of general practitioner. New York State Medical Journal, New York, 1916, xvi, 601-604. Devoto, L. I problem! igienici davanti al nuovo industrialismo italiano. Pen- siero Medico, Milano, 1917, vii, 181-184. DiCKERMAN, C. Cigarmakers' neurosis. National Eclectec Medical Association Quarterly, Cincinnati, 1918-19, x, 58-66. Disabled (the) in industry. Hospital, London, 1918, Ixiv, 511. Disabled men in productive work. Educational motion picture entitled: "An object lesson in the employment of war and industrial cripples." Produced by the Ford Motor Co., American Industries, New York, 1918, xix. No. 1, p. 24-25. DoANE, P. S. Health and sanitation in the shipyards. New York Medical Journal, 1918,- cviii, 880. Dobbins, R. B. Putting the industrially disabled back at work. 100 per cent. Efficiency' Magazine, Chicago, 1918, xi. No. 3, p. 76-84; No. 4, p. 68, 70-90. DoDsoN, J. M. Preventive medicine in railway work. Journal of the Minnesota State Medical Association and the Northwestern Lancet, Minneapolis, 1918, xxxviii, 91-97. . Medical Insurance and Health Conservation, Dallas, 1918, xxvii, 219-222. DoNNET, E. H. Making of rates for workmen's compensation insurance. Journal of Political Economy, Chicago, 1917, xxv, 961-983. DoNOGHUE, Frances D. The history and operation of the Massachusetts workingman's compensation law. Boston Medical and Surgical Journal, 1916, clxxv, 897-902. . The rehabilitation of crippled workmen. In: Massachusetts Industrial Accident Board. Annual report No. 3, Boston, 1916, p. 82-101. — . Restoring the injured employee to work. Boston Medical and Surgical Journal, 1916, clxxv, 457-461. 806 INDUSTRIAL MEDICINE AND SURGERY Doty, A. H. The value of examination of applicants for industrial employment. Medical Record, New York, 1916, Ixxxix, 952-954. Double Duty Finger Guild. Steady, remunerative work for the blind. Ampere, N. J., 1918. Douglas, Paul H. An after-care clinic in Oregon. American Lavor Legislation Review, New York, 1919, ix, 134-136. Dublin, L. I. Occupational mortality experience of 94,269 industrial workers. American Journal of Public Health, New York, 1916, 663-670. Dublin, L. J. and Jacobs, P. P. Tuberculosis as a war problem. Journal Out- door Life, vol. xiv. No. 12. DucLOT. Quelques considerations sur le travail des f emmes dans les establessement, de la marine. Archives de Medecine et Pharmacie Navales, Paris, 1917, civ, 5-11. Duncan, Jambs P. The aims of industrial welfare. Modern Hospital. St. Louis, 1916, vii, 127-128. Eaton, J. M. Industrial welfare work a factor in modern management. Modern Hospital, St. Louis, 1916, vii, 104-109. Edsall, D. L. The bearings of industry on medical practice. Boston Medical and Surgical Journal, 1917, clxxvii, 575. . Medical-industrial relations of the war. Johns Hopkins Hospital Bulletin, Baltimore, 1918, xxix, 197-205. The prevention of disease in war industries. Extent and importance of the problem. Medical Record, New York, 1918, xciii, 611. . Supposed physical effects of the pneumatic hammer on workers in Indiana limestone. Public Health Reports, Washington, 1918, xxxiii, 394- 403. Edwars, J. W. Industrial diseases prevailing amongst iron and steel workers in Middlesbrough. British Medical Journal, 1916, ii, 97-99. EisENBERG, A. A. Visceral changes in wood alcohol poisoning by inhalation. American Journal of Public Health, New York, 1917, vii, 765-771. EisENSTADT, H. L. Bcitrage zu den Krankheiten der Postbeamten. Berlin, 1916. Emmons, A. B. Industrial Medical supervision. Boston Medical and Surgical Journal, 1916, clxxiv, 495-499. Employment results in Philadelphia, American Journal of Care for Cripples. New York, 1916, iii, 42-44. Employment of crippled in a large industrial plant. Monthly Labor Review, Washington, 1918, vii, no. 6, p. 85-86. Erdman, S. Standards for the prevention of compressed air illness. American Journal of Public Health, Concord, 1918, viii, 431-434. EsTES, W. L. Compensation laws of the potent factors in the prevention and treatment of occupational diseases and industrial accidents. Transactions of the College of Physicians, Philadelphia, 1917, 3 s, xxxix, 439-455. Evans, William A. Industrial physicians and the returning soldier. Survey, New York, 1918, xl, 354. Eve, D. a discussion of seven thousand industrial injuries. Journal of the Ten- nessee State Medical Association, Nashville, 1918-19, xi, 269-276. . The necessity of making blood pressure examinations of engineers over 60, at stated intervals. Railway Surgical Journal, Chicago, 1917-18, xxiv, 265-270. . Experiment (an) in fair dealing Modern Hospital, Chicago, 1919, xii, 144-146. BIBLIOGRAPHY 807 Farnam, Henry W. The Seaman's act of 1915. 9th annual meeting — American Assn. for Labor Legislation — Dec. 28, 1915. Farnum, G. G. Modern industrial medicine. Journal of the American Medical Association, Chicago, 1918, Ixxi, 336-338. . The relationship of impaired physical condition to accidents. American Journal of Public Health, New York, 1916, vi, 470-473. The Ideal Industry from the Standpoint of Health and Safety — Nail Safety Council, Chicago, 1917. Fay, a. H. Metal-mine accidents in the United States during the calendar year 1915. American Journal of Public Health, Concord, 1916, vi, 1235. Feiss, R. a. Scientific management and its relation to health of worker. Ameri- can Journal of Public Health, New York, 1917, vii, 262-267. Ferretti, U. Ill Convegno degli industriali del freddo, nei riguardi igiemici. Annali d'Igiene, Roma, 1917, xxvii, 38-41. First-aid equipment for industrial plant. Modern Hospital, St. Louis, 1918, x, 305-306. Fisher, I. Need for health insurance. New York State Journal of Medicine New York, 1917, xvii, 81-84. Fisher, Hart E. Now adhering surgical gauze — used in Emergency Surgery. Jour. A. M. A., vol. Ixvi, pp. 929. First aid system — (Interstate Med. Journal, vol. xxii, No. 10, 1916. FisKE, C. N. Suggested use of combined table of occupational distribution of physical disability. U. S. Naval Medical Bulletin, Washington, 1916, x, 199- 213. Fleischer, Alexander. Welfare service for employees. Philadelphia, 1917. Reprinted from Annals of the American Academy of Political and Social Sciences, January, 1917. Florence, P. S. Methods for field study of industrial fatigue. Public Health Reports, Washington, 1918, xxxiii, 349-353. Floret. Erfahrungen mit verschiedenen Handereinigungsmitteln bei Arbeitern in der Chemischen Industrie. Zentralblatt fiir Gewerbehygiene, Berlin, 1915, iii, 238-240. Foley, Edna L. Visiting nurse in industry. Modern Hospital, St. Louis, 1916, vii, 125-127. Ford, James S. Employment of persons in the arrested stage of tuberculosis. Medical Record, New York, 1916, xc, 1154-1155. Forrester, C. R. G. The prevention of disability following fracture of the OS calcis. Illinois Medical Journal, Chicago, 1916, xxx, 385-388. Frankel, Lee K. Systematic health service for employees. Modern Hospital, St. Louis, 1916, vii, 87-90. . Welfare work of the Metropolitan Life Insurance Company for its employees. New York State. Journal of Medicine, New York, 1917, xvii, 38-40. Freeman, J. W. Fractures of the different bones occurring in the gold mining industry; end-results and economic study of 311 consecutive cases. Annales of Surgery, Philadelphia, 1917, Ixvi, 193-200. Freiberg, A. H. The casualties of War and Industry and their relation to Orthopedic Surgery. Jour. A. M. A., vol. Ixxi, No. 6, p. 417. French, W. J. Accident prevention in California. In: Proceedings of the Conference of Social Insurance, 1916, Washington, 1917, p. 267-272, 283-291. . Cooperative methods to promote industrial safety. Proceedings of the International Association of Industrial Accident Boards, 1916, Washington, 1917, iii, 145-151. 808 INDUSTRIAL MEDICINE AND SURGERY Fronczak, F. E. Modern chemical industries and public health. American Journal of Public Health, New York, 1917, vii, 268-272. FuLLERTON, HuGH. Make men as well as goods. Modern Hospital, St. Louis, 1916, vii, 346-347. Gana, V. Q. La industria de curtidos en las Islas Filipinas. Actas, Memorias y comunicaciones de la 3. Assemble a regional dm6e dicos y farmaceuticos de Fihpinas Manita, 1917, 498-521. Geier, O. p. Health of working forces. Industrial Management, New York, 1917, liv, 13-19. The human potential in Industry. Jour. American Soc. Mechanical Engineers, N. Y., 1917. Gentry, J. A. Medical supervision of employees in large industries. Southern Medical Journal, Birmingham, 1918, xi, 115-119. Gesundheitlichen (die) Verh altnisse in den vergoldereien. Zentralblatt fiir Gewerbehygiene, Berlin, 1915, iii, 280-284. Gesundheitsverhaltnisse der Arbeiter in englischen Munitionsfabriken. Deutsche medizinische Wochenschrift, Leipzig, 1917, xliii, 1269. Gewin, W. C. The relation of the surgeon to industrial corporation. Interna- tional Journal of Surgery, Nev/ York, 1917, xxx, 109-111. Gibbons. Work, principles and problems of industrial accidents. California State Journal of Medicine, San Francisco, 1916, xiv, 470. Gilberti, p. Ernia da infortunio. Pensiero Medico, Milano, 1915, v, 523, 537, 562. GiLBRETH, Frank B. and Lillian M. Gilbreth. Creating the cripple's oppor- tunity. Iron Trade Review, Cleveland, 1918, Ixii, 268-269. . Fatigue study, the elimination of humanity's greatest unnecessary waste ; a first step in motion study. New York, 1916. Measurement of the human factor in industry. (To be presented at the National Conference of the Western Efficiency Society, May 22-25, 1917). N.p., n.d. Gilson, M. B. Recreation of working force. Industrial Management, New York, 1917, liv, 13-19. GoLDMARK Josephine. Women workers in new occupations. Manufacturers' News, Aug. 8, 1918. GoLDWATER, S. S. The conservation of the health of industrial workers. Modern Hospital, St. Louis, 1917, vii, 124-125. Great Britain, Ministry of Munitions. Health of Munition Workers Committee. Health of the munition workers. London, 1917. GuTON, L. Conditions d 'insalubrity des etablissements industriels. Bulletin Sanitaire, Montreal, 1916, xvi, 86-92. Haldane, J. S. Dust inhalation and the health of miners. Medical Officer, London, 1918, xx, 146. Haldt, W. a. Welfare work in the modern factory. Cleveland Medical Journal, 1915, xiv, 757-761. Hall, H. J. and M. M. C. Buck. Handicrafts for the handicapped. New York, 1916. Hambrecht, George P. Industrial experience of handicapped workmen in Wisconsin. American Labor Legislation Review, New York, 1919, ix, 117-125. Hamilton, Alice. Dangers other than accidents in the manufacture of explo- sives. Journal of Industrial and Engineering Chemistry, Easton, 1916, viii, 1064-1067. BIBLIOGRAPHY 809 Hamilton, Alice. The fight against industrial diseases; the opportunities and duties of the industrial physician. Pennsylvania Medical Journal, Athens, 1918, xxi, 378-381. . Industrial poisons encountered in manufacture of explosives. Journal of the American Medical Association, Chicago, 1917, Ixviii, 144.5-1451. Prophylaxis of industrial poisoning in the munition industries. American Journal of Public Health, Concord, 1918, 125-130. Hamilton, Alice and Charles H. Verrill. Hygiene of the printing trades. Washington, 1917. Harford, C. F. Visual neuroses of miners. British Medical Journal, London, 1916, i, 434. Harrington, T. F. Health in war industries. Boston Medical and Surgical Journal, 1918, clxxviii, 453-458. . Industrial health. American Journal of Public Health, New York, 1917, vii, 322-330. Occupational diseases in Massachusetts. 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Some fallacies of compulsory health insurance. Scientific Monthly, Garrison, N. Y., 1917, iv, 306-315. Some theoretical and practical aspects of industrial medicine. Transac- tions of the College of Physicians, Philadelphia, 1917, 3 s., xxxix, 421-438. Holden, O. The effects of electric arc welding upon the eyes and skin. British Medical Journal, London, 1918, I, 454. HoLMAN, Dudley M. Educational work in accident prevention. Proceedings of the International Association of Industrial Accident Boards, 1916, Washing- ton, 1917, iii, 128-144; 151-157. . The problem of the handicapped man. Bulletin of the United States Bureau of Labor Statistics, No. 212, Washington, 1917, p. 348-357. HooKSTADT, Carl. Comparison of experience under' workmen's compensation and employers' liability systems. Monthly Labor Review, Washington, 1919, viii, No. 3, p. 230-248. . Probability of an industrial cripple sustaining a second injury. Monthly Labor Review, Washington, 1919, viii, No. 3, p. 79-84. . 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Health insurance and the hospital. American Hospital Associa- tion, Atlanta, Sept. 27, 1918. Landry, L. H. Intracranial hemorrhage due to traumatic rupture of arteria meningea media, report of six operated cases with one death. Southern Medical Journal, Nashville, 1916, ix, 157-166. Lanza, A. J. Hazards of metal mining. Medical Record, New York, 1918, xciv, 394. . Miner's consumption: a study of 433 cases of the disease among zinc miners in southwestern Missouri. Wisconsin Medical Journal, Milwaukee, 1917, xvi, 64-66. Lauffer, Chas. a. Inguinal hernia viewed as an anatomical defect. Second Conference Industrial Surgeons, Harrisburg, May 18, 1916. Leake, J. P. Health hazards from the use of the air hammer in cutting Indiana limestone. Public Health Reports, Washington, 1918, xxxiii, 379-393. BIBLIOGRAPHY 813 Leclercq, J., Mazel, and R. Dujarric de la Rivi£;re. R61e du m(5dicin dans I'industrie apres la guerre; orientation et utilisation physiologiques de I'ouv- rier. Annales de Hygiene et de M6dicin Legale, Paris, 1917, xxvii, 345-390. Lee, Frederic Schiller. The human machine in industry. Columbia Alumni News, New York, 1918, ix. No. 14, pp. 1-10. . Industrial efficiency; the bearing of physiological science thereon; a review of recent work. Public Health Reports, Washington, 1918, xxxiii, 29-35. . Industrial service in tire factory. Modern Hospital, St. Louis, 1917, viii, 353. Periodic examination of employees. Modern Hospital, St. Louis, 1916, vii, 350. Lemon, C. H. Medical supervision of street railway employees. Journal of the American Medical Association, Chicago, 1917, Ixviii, 95-98. . Social medicine in the industries. Wisconsin Medical Journal, Mil- waukee, 1917-1918, xvi, 453-459. Lesieur, C. Hygiene des travailleurs. Du role des adjoints techniques dans la surveillance hygienique et epidemiologique des travailleurs francais indigenes et etrangers employes dans les ^stablissements travaillant pour la guerre. Archives de Medecine et de Pharmacie Militaires, Paris, 1917, Ixvii, 76-96. Levings, a. H. Traumatic hernia and traumatic orchites in relation to workmen's compensation. Wisconsin Medical Journal, Milwaukee, 1915, xiv, 273-276. Levy, E. Workers in compressed air; precautions adopted by the N. Y. Public Service Commission for protecting their health. Scientific American Supple- ment, New York, 1917, Ixxxiv, 73. Light, A. B. Thresher's fever. Therapeutic Gazette, Detroit, 1918, xxxiv, 615- 619. Little, R. M. Who shall bear the extraordinary compensation cost of total disability caused by successive injuries ? American Labor Legislation Review, New York, 1919, ix, 141-149. Lord, C. B. Athletics for working force. Industrial Management, New York, 1917, liv, 44-49. LovEJOY, F. W. Big benefit fund basis of welfare work. Modern Hospital, St. Louis, 1916, vii, 349. Lowman, J. B. Value of physical examination as a factor in the prevention of industrial injury. Pennsylvania Medical Journal, Athens, 1916, xx, 48-55. Lynott, W. A. Bureau of mines' studies of occupational diseases. Journal of Industrial and Engineering Chemistry, Easton, 1916, viii, 1062-1064. Lyons, Barrow B. Northeastern hospital of Philadelphia to serve corporations on a co-operative basis. Modern Hospital, St. Louis, 1917, ix, 306-307. McAllister, J. B. How the workmen's compensation act may be made satisfac- tory to the profession. Pennsylvania Medical Journal, Athens, 1916, xix, 736-739. McCleery, Agnes P'. The value of employees' medical and social service depart- ments. Modern Hospital, St. Louis, 1916, vii, 208-210. MoCoMAS, R. T. Welfare work of Cincinnati and Suburban telephone company includes country home where girls go to rest. Modern Hospital, St. Louis, ^ 1917, viii, 75-77. McCiTLLOUGH, J. W. S. Hours of work in relation to efficiency and output of munition workers. American Medicine, Burlington, 1917, xxiii, 402. McCttrdy, S. M. The industrial dispensary in preventive medicine. Journal of the American Medical Association, Chicago, 1917, Ixix, 1318. 814 INDUSTRIAL MEDICINE AND SURGERY McCuRDY, S. M. Physical examination and regeneration of employees. Journa of the American Medical Association, Chicago, 1915, Ixv, 2050-2054. Macdonald, J. S. Man's mechanical efhciency in work performance and the cost of movements involves (treated separately) . Proceeding of the Royal Society, London, 1917, Ixxxix, 394-410. McKendrick, Archibald. Back injuries and their significance under the work- men's compensation and other acts. Edinburgh, 1916. • McKenna, H. Infections of the hand; their diagnosis and treatment. Kentucky Medical Journal, Bowling Green, 1917, xv, 290-292. Mackey, Harry A. Employment opportunities for rehabilitated men in Pennsyl- vania. American Labor Legislation Review, New York, 1919, ix, 130-133. . Medical questions in the Pennsylvania compensation act, New York, 1916. Reprinted from New York Medical Journal, April 22 and 29, 1916. . Pennsylvania's compensation law and the docter, Pennsylvania Medical Journal, 1916, xix, 725-730. . Reclamation of the human scrap heap. 1919. Reprinted from North American, January 5, 1919. McLeod, Norman. What sick and crippled men are doing for the Ford Motor company. Modern Hospital, Chicago, 1919, xii, 1-3. McMuRTRiE, Douglas C. The rehabilitation of the disabled civilian. Testi- mony submitted to the Joint committee on education and labor of the Senate and House of Representatives in hearing on the Bankhead-Smith bill, December 10-12, 1918. New York, 1918. Marks, L. B. Practical standards for factory illumination. American Journal of Public Health, Concord, 1918, viii, 363-367. Marriott, R. H. Engineering precautions in radio-installations. Scientific American Supplement, New York, 1917, Ixxxiii, 266. Marsh, B. C. Economic foundations for health. New York State Journal of Medicine, New York, 1917, xvii, 184-187. Marshall, William A. Rehabilitating the disabled victims of industry. Oregon Voter, Portland, 1918, xiii, No. 13, p. 13. Massachusetts. Board of Education. Special report of the board of education relative to training for injured persons. Boston, 1917. (House Document No. 1733.) . House of Representatives. An act to establish a division for the training of crippled and injured persons in the department of the industrial accident board. Boston, 1918. House No. 1529. . Legislature. Resolve directing the board of education to investigate the subject of special training for injured persons. Boston, 1916. Marquis, S. S. The factory doctor. Transactions American Association of Industrial Physicians and Surgeons, Chicago, 1916. Massachusetts laws for training disabled soldiers and persons crippled in industry. Monthly Labor Review, Washington, 1918, vii. No. 1, p. 50-51. Massey, G. B. Electrodiagnosis in industrial accidents, war wounds, and affec- tions of the motor apparatus. Journal of the Medical Society of New Jersey, Orange, 1918, xv, 146-148. Maximum temperature in which a workman can work. Heating and Ventilating Magazine, New York, 1917, xiv. No. 4, p. 46-47. Mead, J. E. Rehabilitating cripples at Ford plant. Iron Age, New York, 1918, cii, 739-742. Medical Research Committee, London. A report on the causes of wastage of labor in munitions factories employing women, London, 1918. BIBLIOGRAPHY 815 Medical examination of employees. Report of Committeee on Factories, Chicaf^o Tuberculosis Institute, 1915. Mengel, S. p. Some medical and surgical problems and their solutions : from the point of view of the mining surgeon. Proceedings of the Conference of Industrial Physicians and Surgeons, Athens, Pa., 1918, v, 1-6, 13. Mercade. Large Eventration inguine-abdominale cons6cutive ilune plaie de guerre. Restauration de la parol par myoplastie au d6pens du couturier. Bulletins et Memoires de la Society de Chirurgie de Paris, 1916, xlii, 414. Merian, L. 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Ramazzini, Firenze, 1916, x, 89-98. . Delle Asimmetrie delle regioni esterne del corpo umano in rapporto alia patolagia del lavoro. Lavoro, Milan, 1915, viii, 237-245. . La Patologia dei cavatori di alabastromarmai di Castellina Marittima Ramazzini, Firenze, 1916, x, 99-136. Morrison, M. L. Employment certificates. New York City Dept. of Health Bulletin, 1917, vii, 73-77. MoscHcowiTZ, Alexis V. The relation of hernia to the workmen's compensation law. The Medical Record, Apr. 3, 1915. MuLREADY, E. The activities of a labor department. Boston Medical and Surgical Journal, 1917, clxxvii, 576-578. MuNSON, E. L., CoL. "The Soldier's Foot and the Military Shoe." Collegiate Press, Menasha, Wis. National Civic Federation. The problem of pensions, Washington, Jan., 1916. National Industrial Conference Board. Sickness insurance or sickness prevention, Boston, 1918. (Research report No. 6.) . Workmen's Compensation acts in the U. S. — the legal phase, Boston, Apr., 1917. Wartime employmentygiene, industrial. medical office serving several indus- tries, 48 medicine, 355 and surgery, practical system of, detailed outline of, in large in- dustry, 67 nurse, conserves physicians' time, 57 daily routine of, 53 at plant and in homes, 54 for tuberculous cases, 58 number employed in plant, 93 qualifications of, 51, 58 report of request to call, 124 responsibilities of, 52 Nurses' Club of Chicago, 69 nursing, 51 plant, accident prevention in, 138 fire prevention in, 139 prevention in relation to physical conditions of, 137 poisons, arsenic, 219 classification, 211 definition, 210 important role in, 211 laws requiring reporting of cases of, 212 lead, 213 list of, 274-293 mercury, 220 phosphorous, 221 zinc, 218 sanitation, 125. See also Sanitation. surgeon's place in americanization of foreign employee, 769 surgery, 475. See also Surgery, in- dustrial. Industries, activities of, prevention as related to, 139 in which poisoning may occur, 294- 309 nurse in, 51 Industries, prevalence of tuberculosis in, 431 preventive medicine and surgery in, 133 respiratory infections in, 178 women in, 405. See also Women in industry. Inefficiency among employees, 30 Infections following injuries, reduction of, by medical department, 85 from minor accidents, prevention of, 332 hand, 574 active treatment, 581 early hospital treatment for, 584 economic value of diagnosis of location of pus and surgical in- terference in, 590 prevention of, 577 iodin in, 578 removal of predisposing causes in employees, 579 r61e of tonsillitis in, 580 in emergency surgery, prevention of, 513 closure of wounds in, 522 drainage of wounds in, 521 iodin in, 514 prevention of, 500 respiratory, in industry, 178 teeth a source of, 61 Influence of new employees and speed- ing-up, on accident rate, 351 Influenza, 180 Information record of applicants for work, 117 Ingrowing nails, treatment of, 662 Inhalation of dust, pathological effects of, 204, 432 Injured, mental idleness drawback to, 547 psychotherapeutic treatment of, 544 subsequent or permanent treatment of, 543 Inspection and education in accident prevention, 339, 340 sanitary, of plant, 26 restaurant by medical staff, 111, 112 Inspectors of safety methods, 341 Insurance, 667 and compensation, 272 health, 740. See also Health insurance. INDEX 837 Insurance service of employees, 31 Inversion and eversion of ankle, 561 lodin and applicators, rack for, 497 immediate use of, first aid procedure, 503 in emergency surgery, 514 strength employed, 514 use of, 499 preventive measure in minor acci- dents, 332 Iron works, health hazards in, prevent- ive measures, in, 250 Jaw, phossy, 221 Jewish Tuberculous Association of New York City, 456 Joint, re-education of, 557 Jones' abduction frame for high frac- tures of femur, 617 arm extension splint, 611 cock-up wrist splint, 614 Knee, rotation of, 560 Labor turn-over, estimates of cost of, 88 reduction of, by medical depart- ment, 84, 85 Laboratory in connection with doctor's office, 73 in hospital, 40 in medical department, 39, 40 Lay assistants, number needed in med- ical department, 93 Lead colic, 215 compounds, danger of, 216 health hazards of workers in, preven- tive measures for, 251 industries in which used, health regu- lations of European governments for, 252, 254 paralysis, 216 poisoning, 213 colic in, 215 dangerous trades found in, 216 diagnosis of, Gower's three postu- lates in, 214 examination for early diagnosis of, 214 paralysis in, 216 symptoms, 213 smelting, advice to employees in, 264 to employers in, 264 Lead smelting, duties of occui)icr in, 260 of persons employed in, 263 general regulations for, 256 health hazards in, German Imperial Regulations for, 256 preventive measures in, 255 regulations for clothing, overalls, and lavatory accommodations in, 258 for employment of workers in, 258 special regulations for distillation of zinc skimmings, 257 for lead colors preparation, 257 trades, dangerous, 216 white, production of, health hazard regulations in, 265 works, poisoning in, 217 Lectures and individual instruction to employees on dental hygiene, 63 Leg, fractures of, 606, 616, 623 Licensing, 232 Lime, chlorinated as disinfectant, 161 milk of, as disinfectant, 161 Liquid disinfectants, 160 Liquor cresolis compositus, 160 Loan and banking service of employeeSj 31 system for dental care of employees, 66 Location of medical department, 33- 37 Locker and dressing rooms, 164 room, cafeteria, dining room and commissary, floor plan of, 114 Lockjaw. See Tetany^. Loss, financial, due to employment of physically unfit, 87 Lumbago, 179 Lunch of employees, deficient in calo- ries, 110 where eaten, 110 Machinery, broken, cause of accidents, 323 safety appliances on, 324 Major accidents, preventive measures in, 320 Malingering, 732 absolute faking in, 735 medicolegal aspects of, 732 true, 732 838 INDEX Managerial staff, diplomacy in medical treatment of, 99 periodical medical examination of, 99 recreation and exercise for, 100 sets example for employees, 99 supervision of health of, 98 Manures, artificial, manufacture of, health hazard regulations for, 242 Marsee tin finger splint, 615 Massage, 551 Mechanotherapy, 556 Medical and surgical care for employees and their families, 49 supervision of employees, cost of, 84 department, 33 and service room plan, 34 benefits and profits of, 79 city health department and, close cooperation between, 1 13 cost of, 90 caliber of physicians employed, 90 number of employees, 94 of hours physicians are en- gaged, 90 of industrial nurses employed. 93 of lay assistants employed, 93 of physicians needed, 93 on staff, 92 total, 94 dental office of, 42 estimate of financial returns due to, 79 examining room, 38 food of employees a responsibility of, 109, 110 general office, 38 history room, 39 laboratory of, 39 location of, 33-37 minimum requirements of, 36 offices of, 37 prevention of spread of epidemic diseases by, 178 preventive work of, 133 private office of physician in charge, 39 records, 116 doctor's office pass, 118 record, 116, 119 Medical department records, em- ployee's pass home, 120 filing of, 116 information, of applicants for work, ]17 report of accident, 121, 122, 123 request for nurse's call, 124 return to work pass, 120 rest rooms of, 42, 582 rooms for eye, ear, nose and throat work, 42 sanitary inspection of plant res- taurant, by. 111, 112 sources of profit from, 84 sterilizing room of, 41 success of, confidence of employees necessary to, 80 supervision of physical exercises by, 107 of plant restaurant by, 111 surgical room of, 40 toilet facilities of, 42 waiting room, 38 x-ray laboratory of, 41 director, 44 as head of employees service de- partment, 18, 19 examination of applicants for work, 22, 27, 86, 87, 134, 359, 370 do they object to examinations, 381 fitting disabled to jobs, 382 percentage of rejects, 384 reasons for examination, 372 rejection standards, 377 should diseased conditions be ex- plained, 380 what becomes of rejects, 383 when to examine, 371 of employees, 355 attitude of employee toward, 368 classes divided into, 357 female, 38, 416, 427 in plant restaurant, 111 new, 359 of lead process, 262, 263 present working force, 358 problem of physically unfit, 367 reasons in favor of, 357 re-examination of, 359, 360 routine procedure for, 362 statistics of examinations, 363 steps of examination, 362 INDEX 839 Medical examination, periodical, for managerial staff, 99 office, industrial, serving several in- dustries, 48 service of employees, 20 staff, 43 duties and size of, 43-50 treatment of employees, 22, 391 complete, 401 supervision of, 391 types of cases causing time loss, 402 what cases should be treated, 399 Medicine, industrial, 355 preventive, in industry, 133 Medicolegal phases, 667 Men's rest room, 582 Mental idleness, drawback to injured. 547 Mercurialism, 220 Mercury, bichlorid of, as disinfectant, 161 health hazards in use of, regulations for, 269 poisoning, 220 symptoms, 220 Metacarpal bones, fractures of, 614 Metal handling trades and smelting, preventive measures in, 250 pickling, health hazard regulations in, 269 shakes, 218 Metallic dust, 206 mortality from occupations in. 437 Milk of lime, 161 Mineral dust, 206 Minor accidents, preventive measures in, 331 diseases common to women em- ployees, 422 Misfits among employees, 30 Model cafeteria for employees, 113 office room, 146 Mortality in dusty occupations, 437 Motion picture shows for employees, 105 Mouths, unclean, prevalence of, 61 Municipal health boards and commis- sioners, 232 Munition factory in England, 170 Mutual benefit associations, 31 Nails, ingrowing, treatment of, 662 National Safety Council, history of, 310 Neck, stiff, 179 Nervousness among employees, 30 Neuroses, traumatic, medicolegal as- pects of, 721. See also Traumatic neuroses. Nitric acid and explosives, health haz- ard regulations for, 238 Nurse, industrial, 51 Club of Chicago for, 59 conserves physician's time, 57 daily routine of, 53 at plant and in homes, 54 for tuberculous cases, 58 number employed, 93 qualifications of, 51, 58 report of request to call, 124 responsibilities of, 52 surgical, 478 Nursing service of employees, 24 Occupational diseases, prevention of and vocational hygiene, 222 compensation and insurance in, 272 measures ia smelting and metal handling trades, 250 special measures for workers, 232 regulations for chemical in- dustries, 237 three legislative measures for, 225 hazards in tuberculosis, 437 therapy, 549 Occupations, dusty, mortality in, 437, 438 health hazards in, 201. See also Health hazards in occupations. ward, for convalescent soldiers, 780 Office, doctor's, 33 of medical department, 37 surgical, 479 equipment of, 480 Ointments in emergency surgery, 538 Orchitis, traumatic, medicolegal aspects of, 738 Organization, successful plan of, in one industry, 18 Outdoor athletics for employees, 107 840 INDEX Painters' trade, health hazard regula- tions in, 265 Painting and allied trades, lead poison- ing in, 217 Paraffin treatment of burns, 537-540 Paralysis in lead poisoning, 216 Patent medicine quackery, 395, 398 Pathological effects of inhalation of dust, 204, 432 Pay envelopes, prevention propaganda on, 342, 343 Permanent or subsequent treatment of injuries, 542 Permanganate-formalin method of evolving formaldehyd gas, 158 Personal hygiene in handling of poison- ous materials, 234 Petroleum in industry, health hazard regulations for, 244 Phalanx, terminal, crushes of, 616 Phosphorus in industry, health hazard regulations for, 245 poisoning, 221 Phossy jaw, 221 Physical examination of applicants for work, 22, 27, 86, 87, 134, 359, 370 of employees, 20 before entrance into physical ex- ercises, 107 for prevention of accidents, 328, 329 purpose, 21 exercises conducted during working hours, 105 or mental condition of employee, acci- dents due to, 328 selection of employees for work, source of profit from medical de- partment, 86 Physically unfit, employment of, 86, 87, 374-377 Physicians, number needed in medical department, 93 of hours employed, 92 on staff, 92 Physiotherapy, 551 Placards for spread of spirit of preven- tion, 336, 337 Plan of sleeping shack for six patients, 453 Plant hospital, 33 industrial, accident prevention in, 138 fire prevention in, 139 Plant, industrial, prevention as related to physical conditions of, 137 physician, duty in regard to hygiene of plant, 141 in detection and prevention of health hazards, 201 should inspect drinking fountains, 162 supervision of plant disinfection by, 156 restaurant, 110 medical examination of employees of. 111 sanitary inspection of by medical staff. 111, 112 supervision of, by medical depart- ment, 111 surgeon leader in spirit of prevention, 339, 349 walls, finish of, 164 Plaster bouillon for casts, method of preparing, 622 Playgrounds, 105 Plumbism, 213. See also Lead poisorir- ing. Pneumonia, 180 Poisoning, arsenic, 219 in American trades, 220 in English trades, 219 industries in which may occur, 294- 309 lead, 213 colic in, 215 dangerous trades found in, 216 diagnosis of, Gowers's three postu- lates in, 214 examination for early diagnosis of, 214 paralysis in, 216 symptoms, 213 mercury, 220 symptoms, 220 phosphorous, 221 trinitrotoluene, 238 causation, 239 prevention, 240 symptoms, 240 treatment, 241 zinc, 218 Poisons, industrial, arsenic, 219 classification, 211 definition, 210 INDEX 841 Poisons, industrial important role in, 211 laws requiring reporting of cases of, 212 lead, 213 list of, 274-293 mercury, 220 phosphorous, 221 zinc, 218 Pott's fracture, 606 Power gas works, health hazard regula- tions for, 245 Pox, 198 Practical system of industrial medicine and surgery, detailed outline of, in large industry, 67 Predisposing factors to tuberculosis among employees, 432 Prescription for fruit mixture for con- stipation, 426 Prevalence of unclean mouths and de- cayed teeth, 61 Prevention, 133 among employees, 134. applicants for work, 134 old employees, 134 physical examination of old and new, 134 as related to activities of industry, 139 to physical conditions of plant, 137 in employees home conditions, 137 in industrial hygiene, 137 in relationship between employee and fellow employees, 136 and his work, 135 m.easures rendered employee, 136 of accidents, 318, 319, 486 and recurrences of, 25 depends upon inspection and edu- cation, 339 due to disaster, 331 due to physical or mental condition in employee, 328 employees' co-operation in, 134, 341 in plant, 138 inspectors of safety methods in, 341 major, 320 minor, 331 safety appliances attached to em- ployee, 326 on machinery, 324 Prevention of complications when ac- cidents occur, 487 of disease, employees' co-oporation in, 134, 341 of fire, in industrial plant, 139 of infection in hand injuries, 577 of occupational diseases and voca- tional hygiene, 222 compensation and insurance in, 272 measures in smelting and metal handling trades, 250 special measures for workers, 232 regulations for chemical indus- tries, 237 three legislative measures for, 225 of permanent loss of function of in- jured part, 488 of premature breakdowns, 488 of spread of epidemic diseases by medical staff, 178 of tuberculosis among employees, 442 of undue loss of time from work, 488 propaganda, 135 on pay envelopes, 342, 343 spirit of, 335 inspection and education in, 339, 340 plant surgeon leader ia, 339, 349 Preventive legislation, lack of, 127 measures for workers, special, 232 in smelting and metal handling trades, 250 medicine and surgery in industrj^ 133 surgery, 475, 485 Printing trades, health hazard regula- tions in, 267 lead poisoning in, 218 Private office for physician in charge of medical department, 39 Privies, specifications for, 165 Prizes, in accident prevention methods, 341 Problems of industrial hygiene, 141 Production and industrial hygiene, 167. See also Hygiene, industrial and 'pro- duction. Profits and benefits of medical depart- ment, 79 sources of, from medical department, 84 842 INDEX Propaganda, anti-accident, 339 prevention, 135 Protractors for measuring angles of movement in shoulder, elbows, wrist, knee and ankle, 557 Provision of individual wash basin or trough, 163 of washing faucets in toilet rooms, 165 Psychotherapeutic treatment of injured, 544 Psychrometer, SUng, 153 Pulley weights for exercising fingers in flexion and extension, 562 triplicate, 556 Quackery, in hernia treatment, 397 in surgical appliances, 397 in venereal diseases, 395 patent medicine, 395, 398 Qualifications of industrial nurse, 51, 58 Quickhme as disinfectant, 161 Rags, sorting and shredding, health hazards in, 209 Rattan, splitting and sorting, dust haz- ards in, 209 Reclamation of disabled, 776 physical reconstruction in army, 778 in industries, 785 size of problem, 787 solution of problem, 796 usual method in industry, 786 Reconstruction, 769 Records, medical department, 116 doctor's office pass, 118 record, 116, 119 employee's pass home, 120 filing of, 116 information, for applicants for work, 117 report of accident, 121, 122, 123 request for nurse's call, 124 return to work pass, 120 Ree»eation and exercise as related to supervision of health of employ- ees, 102 for managerial staff, 100 for employees, 102 room for employees, 104, 105 service of employees, 28 Re-education, functional, 554 of injured joint, 557 Report of Committee on Factories, 36 Resin and turpentine glue for fracture traction bands, 612 Respiratory infections in industry, 178 Responsibility of industrial nursing service, 52 Rest, essential preventive measure, 519 periods for women employees, 420 room for men employees, 582 for women employees, 419, 420 of medical department, 42 Restaurant, plant, 110 medical examination of employees in. 111 sanitary inspection of, by medical staff, 111, 112 supervision of, by medical depart- ment, 111 service of employees, 27 Resume of growth of industrial health service, 125 Resuscitation, use of, 501 in emergency surgery, 530 Ribs, fracture of, 604 Rotation, flexion and extension and lateral movements of wrist, 559 of hip, 560 of knee, 560 Routine, daily, of industrial nurse, 53 at plant and in homes, 54 Safety appliances attached to em- ployee, 326 on machinery, 324 committees among employees, 341 engineer, 25 first, 310, 341 methods, inspectors of, 341 organizations, 339, 340 service of employees, 25 Salt cake, hydrochloric acid and soda industries, health hazard regulations for, 237 Sanatoria for treatment of tuberculous employees, 444 Sanitary inspections of plant, 26 of restaurant by medical staff, 111, 112 Sanitation, industrial, 125 movements, employees' co-operation in, 134 service of employees, 26 INDEX 843 Sanitation, state labor laws in relation to, resume of, 125, 126 Schafer method for artificial breathing, 249 Sears shack, Edwards Sanatorium, 453 Service departments of employees, 17 banking and loan, 31 dental, 60 employment, 26 housing and community, 32 insurance, 31 medical, 20 nursing, 24 recreational, 28 restaurant, 27 safety, 25 sanitation, 26 surgical, 24 welfare, 30 Sheet or spray method of evolving f orm- aldehyd gas, 159 Shipbuilding yards, industrial hygiene in, 132 Shock and hemorrhage in emergency surgery, 525, 528 combating, 500 in emergency surgery, 528 treatment, 526, 528 symptoms of, 527 Shoddy, production of, health hazards in, 209 Showers for employees, 163 Shredding, rag, health hazards in, 209 Silver and gold extraction, health haz- ard regulations for, see Mercury. Sitting positions for women employees, 420 Sling psychrometer, 153 Small-pox, 195 Smelter shakes, 218 Smelting and metal handling trades, preventive measures in, 250 lead, 255. See also Lead smelting. Soap holders for employees' toilets, 163 Soda, salt cake and hydrochloric acid industries, health hazard regulations for, 237 Soldiers, disabled, reclaiming of, 467, 468 War Risk Insurance for, 468 tuberculous, provision for, 469 reclaiming of, from military and industrial armies, 461 Specifications for urinals, 165 Spocding-up and new employees, influ- ence of, on accident rate, 351 Spirit of prevention, 335 Splint, Hodgen, in fractures of femur, 618, 619 Jones' arm extension, 611 cock-up wrist, 614 Marsee tin, for finger, 615 necessary in emergency surgery, 603 Thomas, 603 for suspension and traction, 620 method of applying, 604, 605, 606 wood triangle, used in French army hospitals, 610 Sprains, treatment of, in emergency surgery, 535 Spray or sheet method of evolving formaldehyd gas, 159 Sputum examination, plan used in large industry, 73 Staff, medical, 43 surgical, plans for, 476 State labor laws in relation to sanita- tion, resume of, 125, 126 Sterile dressings, importance of, 483 Sterilizing room, 481 of medical department, 41 Stiff neck, 179 Stomach analyses, plan used in large industry, 74 troubles, 425 Stove factory, medical attention in, 44 Strained backs coincidental with disease, 715 Stretcher bed, use of in army hospital, 600 table, 599 Subsequent or permanent treatment of injuries, 542 Successful plan of organization in one industry, 18 Sulphur as disinfectant, 157 dioxid, 159 Sulphuric acid industry, health hazard regulations for, 237 Sunstroke, treatment of, in emergency surgery, 531 Supervision of health of employees, 17 recreation and exercise related to, 102 of managerial staff, 98 Supplies, surgical, 481 844 INDEX Surgeon, industrial, duties of, in rela- tionship to compensation, 682 place in americanization of foreign employee, 769 Surgery, accident, sources of, 484 emergency, 611 accidents and wounds in, 512, 513 cleansing wound in, 520 closure of wounds in, 522, 532 combat immediate complications in, 523 combating shock in, 523 drainage of wounds in, 521 dressings for, 536 fainting in, treatment, 534 frost-bites in, treatment, 530 heat exhaustion in, treatment, 531 hemorrhage and shock in, 525, 528 immobilization of fractures in, 535 impending death in, 523 infections in, 513 iodin as antiseptic in, 514 other antiseptics used in, 515 prevention of comphcations in, 513 of deformity in, 523 of hemorrhage in, 523 of tetanus in, 522 removal of foreign bodies from wound, 520 rest in prevention in, 519 sequence of treatment in, 513 shock and hemorrhage in, 525, 528 sprains in, treatment, 535 sunstroke in, treatment, 531 temporary and permanent relief in, 532 industrial, 475 a;-ray in, 568 preventive, in industry, . 133, 475, 485 Surgical and medical care for employees and their families, 49 supervision of employees, cost of, 84 dispensary, 475 dressing room for men, 478 for women, 480 dressings, schedule for, 485 suppUes and bandages, 481 nurse, 478 office, 479 equipment of, 480 room of medical department, 40 Surgical service of employees, 24 staff, plans for, 476 Sweaty feet, treatment of, 661 Syphilis, 198 cerebrospinal, accident prevention in, 330 Syphilitic cases, care of, 23 Table, bed, suitable for games or bed- side occupations, 555 stretcher, 599 Tailors and garment workers, tubercu- losis among, 208 Tar, coke and gas, production of, health hazard regulations for, 245 products, from distillation; health hazard regulations for, 248 Taylor hygrodeik, 153 Teeth, diseased, prevalence of, 61 examination of, part of physical ex- amination, 60 Temperature, 153 Tent in rear of fiat building for tubercu- lous employee, 450 Tetanus, prevention of, in emergency surgery, 522 Thigh, fractures of, 604 Thomas arm extension splint for severe fractures, 608 splint, 603 for suspension and traction, 620 method of applying, 604, 605, 606 Tin strips for protection of injured fin- ger, 483 Tobacco industries, health hazards in, 209, 210 Toilet and drinking facilities for women employees, 422 facilities of medical department, 42 Toilets in plant, 164 number of installations, 164 provision of washing faucets in, 165 specifications for closets in, 165 for urinals in, 165 urinals in, 165 Tonsillitis, 180, 425 role in hand infections, 580 Tonsils, diseased, 489 Tooth-brush drill conducted by com- pany nurse, 62 Torticollis, 179 Trades, dusty, chief, 205 INDEX 845 Transfusion, blood, in shock in emer- gency surgery, 527, 530 Traumatic apoplexy, medicolegal as- pects of, 736 appendicitis, medicolegal aspects of, 736 displacements of uterus, medicolegal aspects of, 738 neuroses, age and sex in, 726 desire for gain in, 724 exciting cause of, 726 fear and suggestion in, 725 medicolegal aspects of, 721 moral instability in, 722 neurasthenia and hysteria recog- nized types of, 726 psychic impressions in, 726 race influence in, 726 treatment of, 727 orchitis, medicolegal aspects of, 738 Traumatisms and tuberculosis, relation- ship between, 435, 436 with medicolegal aspects, 719 Treatment of conditions directly the result of occupations, 22 of home accidents, 22 Trinitrotoluene poisoning, 238 causation, 239 prevention, 240 symptoms, 240 treatment, 241 Triplicate pulley weight for mechano- therapy, 556 Tuberculosis, 429 and traumatisms, relationship be- tween, 435, 436 cases, care of, 23 decrease in, among old employees, by medical examinations, 368 occupational hazards in, 437 predisposing factors to, among em- ployees, 432 prevalence of, in industry, 431 prevention among employees, 442 problem in army, 467 pulmonary, among tailors and gar- ment workers, 208 Tuberculous employees, 429 at work, 456 examination for discovery of, 128 model garment factory for 457, 458 nurse for, 58 treatment of, 444 Tuberculous employees, treatment of, at home, 449 by certain organizations, 446 by Ford Motor Company, 454 by Jewish Tuberculous Associa- tion of New York City, 456 detection of disease in early stage, 445 free, 449 industrial convalescence in, 458, 460 periodical medical examinations for, 445 sanatoria for, 444, 451 from military and industrial armies, plan for physical reconstruction and rehabilitation of, 469-473 industrial soldiers, problems in care of, 466 soldier, provision for, 469 reclaiming of, from military and industrial armies, 461 Turpentine and resin glue for fracture traction bands, 612 as antiseptic, 515 Typhoid fever, 178, 195 from unsanitary toilets, 135 inoculations, 49 Unfit, physically, employment of, 86, 87, 374-377 Unjust compensation and litigation, re- duction of, by medical department, 85, 86 Upper extremity, fractures of, 606 Urinals, number of, in plant, 165 specifications for, 165 Urinalyses, plan used in large industry, 72 Uterus, traumatic displacements of, medicolegal aspects of, 738 Vaccinations, 49 Valmora Industrial Sanatorium, 455 Varnishes and drying oil industries, health hazard regulations for, 272 Vegetable dust, hazards of, in textUe production, 207 Venereal diseases, 196 beware of advertising specialists, 198 J prevention, 198 propaganda, 197, 198 846 INDEX Venereal diseases, what to do in, 198 quack, 395 Ventilation, adequate, 155 principles of, 151, 152 Vicious circle, 30 Vision, defective, care of, 23 Vocational hygiene and prevention of occupational diseases, 222 Waiting room of medical department, 38 Wall paper production, health hazards in, 209 Walls of plant, finish of, 164 Ward occupations for convalescent soldiers, 780 Washing facihties, for employees, 163 clothes hooks, 163 hot and cold water, 164 location of supply pipes, 164 number of faucets, 163 provision of individual wash basins, 163 showers, 163 soap holders, 163 spacing of fixtures, 163 Waste, financial, due to employment of physically unfit, 87 Welfare service of employees, 30 Wet and dry bulb for temperature of plant, 153 White lead production, health hazard regulations in, 265 Whitewash as disinfectant, 161 Women in industry, 405 choosing occupations for, 413 clothing of, 421 drinking and toilet facilities for, 422 food for, 422 medical supervision for, 411-413 minor diseases common to, 422 colds, 423 constipation, 423, 425 dysmenorrhea, 423, 426 grippe, 425 headaches, 422 stomach trouble, 425 tonsillitis, 425 physical examination of, 414 problems of, 411 Women in industry, question of hours of labor for, 408 recommendations by Committee on Standards of Working Con- ditions, 409 rest rooms for, 419 routine examination of girl em- ployees, 416 sitting positions and rest periods for, 420 which girl employees are examined, 419 Wood working industries, dust from, 209 Work and benefits of human mainte- nance department, 81, 82 Workroom, cleanliness of and purity of air in prevention of industrial poi- soning, 236 Worry among employees, 30 Wounds, cleansing of, in emergency surgery, 520 closure of, in emergency surgery, 522, 532 drainage of, in emergency surgery, 521 removal of foreign bodies from, in emergency surgery, 520 Wrist abduction in action, 559 adduction and abduction of, 558 rotation, flexion and extension and lateral movements of, 559 X-RAY in discovering foci of infection about teeth, 60, 63 in industrial surgery, 568 types of injury requiring exami- nation by, 569 in treatment of fractures, 598 laboratory of medical department, 41 machine, portable, for accident sur- gery, 572 room in doctor's office, 568 Y. M. C. A. in connection with large industry, 103 Zinc ague, 218 poisoning, 218 skimmings, health hazards in distilla- tion of, regulations for, 257 smelting, health hazard regulations in, 269 '4 1^:. '*■ ' *-w COLUMBIA UNIVERSITY LIBRARIES 0055756921 'iJAHnW'Wi^ Demco, Inc. 38-293