Document 0qXoKLeDwyE0j0OGBDGbq5zJJ

FILE NAME: Westinghouse (WH) DATE: 1944 Mar DOC#: WH 112 DOCUMENT DESCRIPTION: Journal Article - Tuberculosis and Industry iiN U IjO i iil-rl-L Alii-L/iOliN -Hi l Jage 239 Tuberculosis and Industry T. LYLE HAZLETT, M.D., F.A.C.P., Medical Director, Westinghouse Electric & Manufacturing Company, Pittsburgh H r-he past quarter of a century is undoubtedly the 5 most important period in the annals of industrial medicine. It is a period which has wrought changes In;,nd the ready conception of the industrial physi ol::;, who performed his task in the first two decades of tl- wntury. From the restricted function of traumatic m iicine to the broad program of preventive medicine is . long step, and those who have participated in the change may well admit that it has been an arduous mv ;o take. It has been well worth it, of course. It ha- brought us to a point of vantage from which we st he greater progress which lies ahead and from w: .:n, if the mood strikes us, we may view our strange ;u : Humble beginnings. The evolution we have witnv an could well be illustrated by what has occurred in a control of tuberculosis in industry. was evident long ago, as many of us will recall, th among the younger age groups in industry tubercri.wis took an immeasurably heavy toll and that it w hr far the greatest threat to the earning capacity of he worker. Management, too, had a painful aware11'.'.- of this fact--largely through the sick benefit a a iations. The age at which benefits began, the ri'w-city of the disease, and the number of cases on tie jicfit rolls produced a drain on the resources of si; associations far in excess of any other individual i:i. ase. A recent review of 400 cases on a disability i"h of a sick benefit association showed 10.51% of the c a w w e r e due to tuberculosis. These represent an accumulation over a period of 10 years in a plant with an average population of 15,000 workers. Ir cannot be said that no effort was exerted to meet this problem. To be sure, well planned and persistent programs were in most places conspicuously absent. But, here and there attempts were made to reduce and control this enormous man-hour loss. We began in our own plants to examine workers prior to their resump tion of work after absences due to upper respiratory diseases. Occasionally, a patient who had suffered from what had been assumed to be a simple bronchitis was found to be tuberculous. Then, too, in those early days, we placed great emphasis on the factor of weight. Bulletin board posters stressed this point alone. Fore men were instructed to send to the medical department for examination workers who were losing weight. At infrequent intervals these men were found to be vic tims of the great plague. Obviously, the early efforts were elemental and crude, but they prove, at least, that the threat was recognized and that something was be ing done about it. It must be remembered, moreover, that in these early J'ears fluoroscopy and roentgenography were just be ginning to enjoy a widespread use. The periodic exam1nation was still largely an unrealized ideal and record systems were more or less haphazard. Inevitably, many cases were detected so late as to preclude the possi bility of recovery. Other difficulties were experienced lu the care of these patients. The fear and prejudice ngainst the sanatoria were both general and deep. En trance into these in stitu tio n s carried a stigma from ^'hich the patient had little hope of ever escaping. Besides, the sanatorium was widely considered not as a significant aid to recovery but as the repository of it ^'1.<ls<in-erl at Joint Annual Meeting of New York Tuberculosis and ^ 'th Association and Tuberculosis Sanatorium Conference of MetroN ew York, February 2, 1944. broken lives about to be ended. Commonly, few people associated hope with sanatorium care; to many it simply meant the close approach of a fatal issue. Overcoming this prejudice among industrial em ployees was one of the essential and monumental ac complishments of the early worker in tuberculosis. And it was a real educational effort. Our own plant was made an induction center to the sanatoria. Our contacts with the State Health Department of Pennsyl vania were intimate and effective. We were supplied with adequate records for the cases we succeeded in placing in the sanatoria and we were, as a result, in a better position to afford needed help in the rehabili tation of cases which recovered. Our interest in the cases was an all-embracing one. To begin with, we did our utmost to popularize the sanatorium. We were enthusiastic in our commendation of institutional care wherever we discussed the patient's problem with him individually or with members of his family. We pre pared literature in which we extolled the virtues of the sanatorium in promoting earlier recovery and in pro tecting the patient's family as well. We used all the assistance we could procure in the form of publications issued by the National Tuberculosis Association. Photographs of the three sanatoria in Pennsylvania were used to visualize in the employee's mind the ad vantages of accepting the opportunity for sanatorium care. We followed up this preparatory work by making periodic visits to patients who were institutionalized. We helped, whenever possible, in eliminating some of the vexations which beset the worker suddenly removed from his accustomed routine of living and plunged into the strict regime of enforced rest and prolonged relative isolation. We believe that many workers re turned to normal life again because these efforts were made. It also aided us greatly in placing these individ uals at suitable work. The work continues, to be sure. Both through formal study and in casual contact with our workers, the at tempt at prevention and at the restoration of health goes on. The periodic examination is one of the forms which this effort takes. At our East Pittsburgh plant about 5,000 employees are examined annually on a compulsory basis from an occupational standpoint, and early cases are at times detected. The recognition is becoming more general among our workers that the periodic examination hides no ulterior motive and that it constitutes a vital health measure which conceals no threats to job security. But, before terminating our discussion of our earlier work, we should mention a survey made in 1933 of some 450 foundry workers, since this study touched upon a question whose inter est and importance remain undimmed. The time when this investigation was made was, as you will recall, a period of silicosis hysteria, when the foundry was con sidered by some a rather effective route to a state of silico-tuberculosis. It was of great interest, therefore, that not one of the 450 men studied showed any evi dence of active tuberculosis. Some 14% did show evidence of arrested tuberculosis infection but none had to be removed from his work. We explain this ex perience on the basis of (a) careful pre-placement examinations, (b) education on tuberculosis preven tion, and (c) the placement of cases in sanatoria or at home for treatment at the earliest possible moment. Our present efforts in tuberculosis control may be briefly discussed under the headings of the pre-place ment examination, the periodic and transfer examina tion, the care of cases actually found, the study of the sick case resuming work, the casual examination re quested by the interested worker, and our program of health education. Page 2k0 INDUSTRIAL MEDICINE M ardi, llf^ The pre-placement examination opens to us what is cases. The mere cataloguing of records is an academic probably the most fruitful opportunity to control the gesture if proper care for the cases found is wanting. hazards of tuberculosis in industry. Here the suspected Reference has already been made to the receding prej- '' case is either thoroughly studied and carefully placed udice against institutional treatment. Sanatorium or he is haphazardly placed into a type of work in treatment will unquestionably gain progressively in v, which latent tuberculosis lesions will flourish into full popular esteem and provision for such care will be ,, activity. Here, also, is the point of entry for the frank greatly increased in the future. However, in those V" ly tuberculous undetected by a hasty and incomplete cases where treatment is carried out at home, there examination, or here we find the protective wall which should be a well-planned program of supervision in the if the industrial physician interposes between the work conduct of such treatment. Medical management is ers already employed and the tuberculous individual basic, of course. But some supervision of the physical v seeking admission among them. We must insist, at this setting of the household coupled with actual demon- E point, that we are not unmindful of humanitarian con strations of procedure should be an excellent adjunct siderations. But it is a regard of dubious worth both to medical care, and can well be considered a legitimate for the healthy worker and the tuberculous applicant phase of public health nursing. Already, such nursing * to place the two together. The tragedy of such mis aid is available to some degree. It should undoubtedly 'Vi: guided sentimentality is too clearly recognized to war be extended so as to become a part in the management ^ rant even mention. To be sure, the arrested case must of all cases which are confined to their own homes. P" be dealt with on its peculiar merits, and every con No plan for tuberculosis control is complete unless sideration given to proper and safe placement as well education on the subject is continuous and has been' as to systematic follow-up after employment. made a large part of the program. There is much skep The periodic examination I consider second in im ticism in some of the workers as well as in manage portance in the discovery and proper disposition of the ment of the value of educational measures. Yet no one tuberculous case. While it is true that frequently such is willing to deny the insurmountable difficulties which V examinations are limited to those forms of employment obstruct efforts to prevent disease where ignorance of ? where the menace of toxic hazards obtains, it is like the dangers and of the protective possibilities exists. | wise true that among the thousands of workers sub We should probably divorce education as we think of ., jected to this examination an appreciable number it in industry from the purely scholastic training ex having active tuberculosis may be found. These cases ercises which do not always bear an obvious relation-';] are foci for the dissemination of the disease not only ship to practical needs. Our concept of health education among workers at the place of employment but also is one closely allied to tangible and widely recognized.! among the many inevitable community contacts. We need. The objective of such educational effort is to have ourselves found in the past several years an in impart information which will function practically i$j- cidence ranging from one and one-half to two cases the immediate routine of our common daily life. ;`|jT per 1,000 employees. Since the periodic examination There are many forms which the educational pro is performed at regular intervals, these cases are gen gram may take in addition to individual contacts,* erally found while still in the early stages of the dis Posters, lectures, films, articles in plant publicatioi ease. Hence their discovery has both great importance and other literature may be utilized. It has been ou! for the individual affected as well as for the group custom for a great many years in our yearly Health, exposed to his presence. This is one of the reasons Education Program to bring to the attention of our^ upon which the general provision of periodic examina workers the necessity of early diagnosis of tuber tions for all workers might be urged. For, important culosis. And in this respect we have taken advantage^ though it is in the control of the hazards of toxic ex of the help which has been given to us by our local posures, it is equally valuable in the control of the Tuberculosis Association which has provided us wi' health hazards which generally plague mankind what literature and displays during the period of-Ear] ever the character of its vocational pursuits might be. Diagnosis Month each year. On the whole, it appear^ that brief, simple and attractively illustrated leaflet 'T 'he transfer examination, though far more limited meet the criteria of acceptability and feasibility. Mans in scope, represents another opportunity for the formal approaches--such as films and lectures--enta discovery of the disease. Such examinations are great difficulties among which time loss, special per^j usually limited to a survey of the particular physical sonnel, equipment, and place are among the more serj requirements of the job to which the worker is trans ous. On the other hand short publications which ar< ferred. Yet, it can be readily extended to include some interesting, readable and scientifically accurate may inquiry into possible pulmonary pathology. If this ap be effective in conveying to the worker a vital health proach be indirect and largely unsystematic it need message. To the criticism that many workers will not nevertheless not be without significant value. What thus be reached because of neglect of these publica ever the circumstance leading to the discovery and tions or indifference to them, we may reply that any^ adequate care of the tuberculous might be, the im disinterested person would be difficult of approach portance of such discovery and such care remains the gardless of the means used. Moreover, repeated is81: same. We should, in fact, urge it as a principle worthy of such material will gradually find a place in the read of general adoption that any opportunity which pre ing of a substantial portion of the recipients. Despite^ sents itself for the physical examination of any worker the fact that any educational procedure will never should be considered an opportunity to find tuber more than partially effective it is necessary to continue^ culosis and to exert every possible effort against its to educate if any improvement in general health prar spread. So strongly are we committed to this principle tices is to be attained. ? that we advocate careful examination--not excluding Because we are committed to this philosophy x-ray films if they appear necessary-- in every case of published last year a series of eight leaflets on the su<* absence due to severe upper respiratory infections. For ject of tuberculosis. The topics covered were: it is well known to all of us that many an apparently 1. What is Tuberculosis? innocuous case of bronchitis on closer scrutiny has 2. War and Tuberculosis. revealed its tuberculous nature. 3. Do I Have Tuberculosis? Only part of our work is done with the discovery of 4. How the Doctor Diagnoses Tuberculosis. h lUk; ademio anting! S prej-i toriur rely will bel i those , there i in thel lent i l l hysicaO demon-p wlj unci itimat mrsing ibtedlj jement 2S. ^ unless^ s beer h skep^ anagejg no one , whichl nee of exists^ link oi ing ex^| latioini icatiopf ignized t is ally re. al _ ntacts cation?! en oui Healt of oui tuber antage1] ir local! is wit EarJ ppear| leaflet Manj --entaif ial pel/; re serilich are te m aj. 1 healtlij will nt publics^ hat any iach re-| d issue] ie read-_ Despite.' ever be. mtinue^ h prac- >hy wer he sub-ji V' : >U. U J.iNJlMj i HIAXj IVliUKJlJS L Paye 2U1 5. Infected Sputum Spreads Tuberculosis. G. Hygienic Living Protects from Tuberculosis. 7. Good Nutrition Helps Prevent Tuberculosis. 8. The Modern Treatment of Tuberculosis. vhe issuance of these leaflets at a time when the stresses of war threaten even more than the usual ravages from this disease lends the quality of timeli ne,'/ and pertinency to our health education program. The number of requests we have received for the ma terial attests to a widespread recognition of the de sirability of health education for the laity. i uberculosis is only one subject out of many which demand treatment. A well coordinated and continuing program is necessary. It may well be assumed that the res',Its will be well worth the effort and the cost even if a measured monetary value cannot be accurately attributed to the ensuing good. o n WR our discussion has dealt with practices as they ^ ii'ect large groups and we may well be reminded that -he problem of tuberculosis is one of individual as ii as of social concern. It would, therefore, be of im- :VSt to review an illustrative case or two of recent oi : in picked from our files to indicate the fate of other similar individuals in whom the disease was folU.d. r first case is that of a young woman of 26 who hr-, been employed by us in a clerical capacity. This fit;:m.-yee presented herself to the medical department in nber, 1941, with the complaint of severe pain in tin; right chest. An x-ray was taken at once but no pndmlogy was detected. She was sent home with in structions to consult her family physician and the la;;rr hospitalized her for study. No diagnosis was rearned even after a period of two weeks during which she was observed under controlled hospital conditions. She returned to work and again later we took chest x-rays. On these films there was evidence of a peri pheral involvement of the right upper lung, and a diag nosis of minimal A tuberculosis was made. In January, 1942, she was admitted to the State Sanatorium where she was confined for 14 months, the first six of which "ere spent in complete bed rest. Following her sojourn at Uie sanatorium she was considered a healed case of tuberculosis and she was permitted to return to work. She performed the duties of her job without difficulty and decided, one month after her return, to apply for membership in the Women's Army Corp. She passed her physical examination and was accepted. Among the noteworthy facts in this case is the establishment <'f a diagnosis of tuberculosis only through careful study and observation. A superficial survey of this vase would certainly have failed to reveal her true vendition until such time as her lesions would have ad vanced to the point of frank and total disability. Should diagnosis have been delayed so long, obviously, the vourse of this case might have had an unnecessarily t*'agic termination. Our second case is that of a young man who reported fe the medical department for a routine periodic ex amination. Chest examination revealed a questionable area at the upper left apex. A detailed history was ob tained and among the salient facts disclosed was a progressive weight loss amounting to about 20 pounds in a period of approximately three months. The genvral physical findings with the exception of a tempera ture of 99 were largely negative. Chest x-rays, however, revealed an incipient tuberculosis. He was advised to enter a sanatorium and was admitted a few "'eeks following the original examination. He remained at the sanatorium for six months at the end of which time he was declared healed. Upon advice of the at tending physician he remained at home, virtually at complete rest, for two additional months. Shortly thereafter he was well able to resume his work with out symptoms or signs of the disease and a gain of 22 pounds. Recently he was inducted into the army and is now in service. Again we illustrate the desirability of early and thorough study. It would be possible to cite cases found in the ad vanced stages of the disease in which the outcome was far less favorable. But it seems appropriate to empha size unremittingly what is possible of accomplishment with adequate and early medical care. In any attempt to outline the major procedures in the tuberculosis program of an industrial plant some details must always be evolved on the basis of the specific needs and potentialities. Thus it has been con sidered more logical to discuss the general problems that may well arise anywhere. There are certain con clusions which we may draw from this discussion and, inasmuch as they constitute the essence of this paper, they may be mentioned at this point by way of sum mary. These conclusions are submitted, at the same time as recommendations of procedure. 1. The pre-placement examination should include a careful study of the chest. Fluoroscopy and roentgen ography should be done routinely on all applicants. 2. Periodic examinations should repeat the complete study of the pre-placement survey and should also in clude x-ray films of the chest. 3. Systematic health education programs should be conducted giving due emphasis to the subject of tuber culosis at regular intervals so as to maintain the worker in a state of alertness relative to the disease. Health education material should be so distributed as to reach the family of the worker. 4. Careful and adequate follow-up of all cases, by competent agencies, should be insured. Industry should assist in the placement of cases discovered among its workers, and should aid in pursuing the follow-up measures required. 5. The rehabilitation of the arrested case should be an important objective of industry in its follow-up. Thorough job analyses should be made available to aid in the proper placement of the many eases which re turn to employment. It is the one indispensable mea sure in the prevention of recurrences. We are not in the realm of untested theory when we propose these recommendations. They have been tried and found to constitute our most effective approach to a solution of the problems of tuberculosis in industry. Perhaps, as health measures and as health knowledge improve, the battle against tuberculosis will bring nearer the victory which mankind has sought so long. We are undoubtedly contributing to the defeat of this ancient enemy when we continue the assault against him according to the strategy we have just described. Endocrine Disorders -- and low Back Pain - JAMES H. HUTTON, M.D., Chicago IT is said that endocrinologists are prone to study endocrinopathies per se and that they sometimes overlook other disorders that may at the same time victimize the patient. The converse of that idea is un doubtedly true. Workers in other fields of medicine tend to overlook endocrine disorders or to recognize them only after treatment of some other syndrome has failed to bring relief to the patient. Perhaps all of us would do our jobs better if we kept in mind the very