Document 6bpDbVDkjr7qarm7702ka1M9E

THURSDAY MORNING SESSION ; October 13i 1938 > The session for the discussion of out- sided. The Chairman emphasized the im- standing problems in the field, of. occupa- , portance of the selected subjects to be pre- tionalj .disease was called to order'by-the sented by eminent speakers,' &n(d .^ropiptly Hon.T\ J. Angsten, Chairman, the Illinois introduced the. first scheduled speaker. Industrial Commission,- Chicago, who pre- s.' The Trend of Occupational Disease Legislation By HENRY D.- SAYER ! *' ; *. Manager of the Casualty Department, Association of Casualty and Surety. Executives ' \ . ^"fA/ Let us consider the differences Kefiveenf^ But sdme will say, truly, not all accidents the-accidental injury' and the occupational happen in the manner described; that not disease. For these distinctions are important always are they held to 'occur rnnly at a. and must constantly be borne hi. mind when specific moment or under circumstances- we. consider either legislatio^bn the .sub wheire they can be visualized and described. ject of disease, or engineering methods of By-administrative arid court decisions, It is prevention decontrol. ' true in some jurisdictions that the definition Generally speaking, accidents occur at a ..specific moment in point of tira^-ahd, from the standpoint of .fixing liability' under sun; policy of insurance, it is in the future; that of""acciden|" has heen greatly broadened. We find -the entrance of disease gerftis.into human system without.visible trauma, resulting .'sickness ..or death,: and even- is' to say, a&ithe moment of the acceptance ::`o~tf Mlia-btMilift*y.-'--undJe--r a--ny in-s--u--r-a-n--c-e- c--o-n*t--ract the accident for! which liability may be as sumed- has not yet. happened. That fre- - specific time. and place not definitely known, except that .it is shown to have probably occurred in the employment,-being held to .be an-accident. quentiy is not so with the occupational dis-1 (Hlersvs. 'Hull, 178 App. DIv. . 350, 164 N.Y. ease. Insurance by its' very ^attire can 767,. an anthrax case; Vennen vs. New Deli Lum-. onlyk assume. liabilities that , have yet; to ' her Co., 161 Wis. 370, a typhoid case; and others.) arise--not those that have already accrued.' Poisoning of the body through the effects Again, speaking generally, the industrial -accident is`something that can be seen--1 even though unforeseen. It^iay be visual ized and described in words, setting forth . specifically the time, place and manner- of happening. It can then be determined, after the happening of . the event, whether it was preverifable or inevitable; blame, if any,'can of a deleterious or tojfic substarice used in the employment, the dangers.of which were ` unknown to the worker, the employer hav ing been negligent in safeguarding properly the use of such substance! has bejen held to be the result of an industrial accident'." (Victory Sparkler & Specialty Co; vs. Francks, 147 ^Maryland, 368;. and'we very recent .case of Btack vi. Creiton Auto Co., Io.wa Supreme *be assessed; the worker involved, or his Court, August -5,- .1938, 281, N.W. 189.) foreman or superintendent, can be shown And where negligence of .the employer the fault,* and effective measures can be has been shown, an Injury- to' health, even taken to . guard against a like future hap though not occurring through a happening pening. ' , . at a given time and place, but by..repeated 21i &. 212 Silver Jubilee Safety Congress exposures over months of time,, has been islatively or administratively. These include . held to be an accident. the well-known metallic and chemical, poi- (McNeely vs. Carolina Asbestos Co., 206, North sons that are so.^definite and characteristic Carolina 568, an asbestosis case.) -a part of some1 industrial processes. Were These and .other cases I' might cite are the exceptions and' not the general rule as to. what constitutes an accidental injury. T think we may fairly assume that the. efforts of administrators of the law and the courts, have, been directly inspired by the diseases arising from the use. of. these substances the only occupational diseases -with which, we' need concern ourselves, the legislative, difficulty would be largely re moved, and we -could safely entrust the. problem to the doctor and. the'engineer,. '. their belief in the.-necessity of finding a remedy for an industrial ill for which, no clear remedy had been, provided by specific language of the statute. May we consider ' But we have seen that 1 the legislative problem is-not so simple. Nor is it simple .'administratively.. We .find ourselves floundering in a veritable morass,' either because' . them as'straws in the wind,, showing a of the inherent difficulties of the situation, trend toward industrial disease liability? or because, we have'not- or cannot agree . lit .may observed that the tendency, of the' on-our objective. If all-parties would rec courts is to construe the term "accident" ognize the difficulties 'and the limitations on in a more limited manner in those states what industry can' do, or can fairly .be ex-' where there is specific provision in the law . pected to' do,.we could much more con . covering occupational ' diseases. Thus, we fidently facethe future. .If we could.agrpe have clear instances of what, has been that provision ;for "occupational diseases"'is termed "judicial legislation," that is, ~ the not synonymous with.general health and life courts broadening the meaning'of .the .law -to cover situations, not clearly, included within the terms of the.law by the duly con-, stituted legislative authorities.. ' Let us now consider .what we mean or in-tend by the term "occupational disease." Here we find a more difficult field--difficult from the standpoint .of administration and judicial interpretation; and difficult from the standpoint of the doctor and-the eh-, gineer:. insurance for industrial workers at indus try's expense, ;then I am sure we could get somewhere very definitely. *- . <>r , But has there not been, too much loose thinking 6n the'subject? We are met with a curious situation.We find the advocates of so-called ."all-indusive" statutory cover-, age deliberately seeking indefiniteness. This is unlike them,-for when they know what their objective' is, and rare , willing to dis close it, they.have not refrained from press What is disease? We. think we know, and; ing, their advantage with definite and spe~. at . least , to laymen the term conjures up cific-purpose, 'and with exact language to in-our .minds something of a rather defi accomplish.that purpose.'That;'at any rate,* nite nature. When we pause to consider it, is correct.legislative.procedure. ' -. .. of course, infinite qualifications, of the term occur to us, and we are confronted with many conditions that, fall into the* zone of doubt--such as, for example, whether her nia is a' disease. At any rate, we.say it is an abnormal condition, and let it go at that. .... But in this field, even where the liability of the employer is made inescapable, the constant suggestion is put forth' that it is* ..futile for the legislature!to...attempt a defi nition-: or delimitation of occupational dis eases, and, therefore, words of the most general character should be employed, leav But when we come, to add to the doubt ing; to the courts the, interpretation of the ful term "disease" the even more indefinite .law as they see fjtv. J submit that it is'hot term "occupational" or "industrial," we find, the functianof the courts to make up the ourselves in an area of highlight sur- . legislative mind; th'at. is the function .and refunded by a vast and increasing, zone of. the-right and the'duty of the legislature.. twilight shading off into. Erebian night. N.or should the legislature seek to avoid Just how then shall we define the term and evade 'responsibility by transferring to "occupational, disease"? courts and commissions'the. determination Some diseases stand out in our minds as .'of questions of liability which the legisla clearly and definitely occupational. As to ture finds too difficult for it to. determine them we have no great difficulty, either leg for itself. ' Occupational Disease 213 -To effect coverage under the. compensa- Add., .to these pneumqnia, asthma, arthritis, tion law, therefore,'by any such general - rheumatism, and a.host'of others; and we-: and vague language.as tk&iterm "any arid' - discern in this the beginning of a system- of all occupational diseaseS;'?,;:'Of'?lby adding to . health' insurance* of the most costly.type-- the definition', of "accidental Injury" the a system .moreover that would discrim phrase, "arid shall-include occupational dis inate ; bitterly against the many millions eases," is to-create an-uncertain liability-^-. who Contract such diseases in, perhaps ac one/ that may: require, endless and perhaps tually the same .way, but who have'no em disappointing litigation--before the meaning. ployment at all against which to assess 11a- of the lawis established; and will most. . bility; Should not the man who falls yic- . certajn!y -be a .disservice' to workers and . tim to', a disease, of ordinal' life while employers, searching for a job be just as much the con ..An excellent rule--a cardinal, rule^-in cern oi the state as. the man who becomes - statutory drafting, -is to use weirds of; defi-. disabled-from the same disease and who nite, certain and understandable- meaning,, is_so.fortunate as to have a job? used in their common acceptance, rather Let us. be: realistic about this thing called than'to' resort to' vague,v uncertain .and health I meaningless words,, or. words the meaning of. which may have'.the effect of distorting the objective that'is sought. Controversy, . 111 healthjs a deviation from the normal. But what is "normal How great a devia- is bred by controversy uncertainty.-of language, and leads to litigatioii in cobrts.' ' tion is abnormal? Disease is of- many and varying degrees.' To what extent does the' Litigation is expensive for all', parties; it causes delay; and it frequently-causes-bitter disappointment. It breeds rancor.' It may, mind'affect-the working status ? Qr what part in the' situation. Fs played by "will - power"? These are not fanciful questions, even breed disrespect .for the law and for they are encountered and-will, -obtrude orderly process of government.;. ' themselves continually in determination of - Why theii .should th.ere.be thjs. continuing demand for the all-incjusive coverage? Is , it .with the vague -hope - that satisfaction compensation-for disease where we, depart' from the known and characteristic occupa tional diseases. may result- in some cases, of misfortune to . From these remarks ^perhaps some will workers who fall victims .of the disease.that say we are-opposed to coverage of `occupa- besets us all and lurks-in' waiting, for .us . tioijal' diseases .under compensation laws. in oUr play, in our homes, yes,- and .even in T -Not -so ! The. stock .casualty ' companies our sleep, as .well as -in our employment? represented in the Association have not op-- Perhaps not--yet`if that were the design,- . posed' and. do hot oppose the principle of 'a'~more simple Way of i succeeding in it; compensation for occupational diseases, if -couid'not otherwise be contrived.' ... thereby, is meant compensation for those Are we to understand that atiy disease of diseases that arise' from a"trade risk," or the most common, and' ordinary risk of . from conditions that are normally ands,usu-life may become, an occupational disease if ally present in the particular. employment, its source or supposed source had its origin as distinguished from those ordinary hu in an incident of the employment or a Con man ills that beset all of us. Our view sof dition there present, or if claim .was made . it is that the polity of coverage' Under the that a pre-existing disease, had 'been ag .. .law is a matter of local concern, to be de gravated by such - condition? That is a. termined- by local legislatures in the light large order. -It would mean that, industry of local demand and with due regard .to - would become liable- for any ordinary dis ' .local opinion of both labor and industry.- ; ease of life, provided that disease could be, No employer .hi. this age can reasonably with a pShow' of plausibility, i related to a object to fair compensation . for disease condition or. incident of the employment. arising from such occupational risks, any Such diseases are'almost too numerous to more than he can object to reasonable com enumerate. . - pensation for disabilities , due to accidental But we know that claims have been made injuries. for -tuberculosis and heart disease, the . two This conception of industry's'obligation . most numerous disease's and the cause .of is, . however, quite different from the con more; deaths than any. two other diseases. ception of a public obligation to - care for 214 Silver Jubilee Safety Congress and compensate for all sickness and death .: acteristically . the obligation of industry,: unden_a form of health ancPJife insurance. . why continually insist- upon the use of lan The latter obligation,'if it'be-a valid one, guage which is susceptible of misinterpre is the obligation of the state and the nation tation ?Be well assured,, if legislatures do - --not the obligation of industry alone. "not perform their duly and-lay down dear The reasonable,, the intelligent,-the sane definitions of liability, industrial boards and' way for industry to discharge its obligation .commissions .cannot in the presence of . the to its workers for conditions of health is widows, orphans, and industrial - cripples;' to provide for the greatest reasonable re be expected to exerdse greater courage quirements for industrial hygierie, and to' than the legislatures: The .law in thp hands provide-compensation-only 'for those con-, of such an administrative body '`will be ditions that arise from specific named dis scanned, and I, fear-'scanned*;in vain, fcir eases that are truly occupational, charac limiting words or language toj&tay; We. teristic of, and peculiar to the processes in hand of industry's self-constituted almoner.. which the worker is engaged. - The legislative trend, I am-happy\to re Industry will, I am sure, meet the chal lenge of' the occupational disease problem, . if it is presented under a law that pre scribes- the liability of industry-in under standable terms. In the early. :, days, the general rule was to include occupational diseases in-the compensation law by specify ing the particular diseases or the particu lar- conditions leading to diseases that are deemed to be occupational and compensable This we call a "schedule" law.. It is the form in which compensation for- ticcupa-' tional diseases is covered in all of the. countries of Europe and of South Amer ica. It is so simple; it is so. sensible; it is so easily .administered, that the wonder is that the acceptance of . the principle is not universal; If- we will keep ever before -us the prin ciple that a disease, to .be deemed occupa tional, huist be "characteristic of and pe culiar to" the occupation, there should be . no great- difficulty' in arriving at a proper statutory setup for the coverage of all true occupational diseases. Metallic poisonings arfe characteristicof.occupations in.which such metals are used: The diseases charac-:.. port; in recent years has been toward the definite, rather than the indefinite. Despite tremendous pressure,* no legislature has, in the past three years, adopted a blind, "all-in clusive" ' occupational, disease law, except New York; of which I shall speak morein' detail presently.. .Michigan,. Rhode Island, Pennsylvania,' - Delaware, North Carolina, and 'Washington, among the states most* recently enactingoccupational diseases laws,. have adopted the "schedule" or specificmethod , of coverage. Two years ago, Ohio . amended, its scheduled occupational disease law'by adding dust diseases to its existing schedule. In two. other states, namely, Illi nois and Indiana, occupational disease laws have, been enacted in general terms. How ever,, in identical language, these two states have undertaken .to limit and defineoccupa tional diseases and. have^attempted therein to safeguard industry against liability for the diseases of ordinary life. . ,,- - Although doubtless familiar to many, the definition in the laws of those two states7 will bear repetition, as. indicating the. ex- . trerae of difficulty in attempting to exactly define an occupational disease. . . terfstic of chemicals, of adds; of alkalies, - "Sec. 6. In this Act the/term `Occupa gases and fumes, are .characteristic of and tional Disease' means a disease arising out' peculiar to . those occupations in which the of and. in the course of tire employment. employees are so exposed. -The diseases of Ordinary diseases of life., to. which the-gen& the respiratory system, due to ..the inhala eral public, is exposed outside of the em tion of dusts, are the natural, accompani- . ployment. shall not be. compensable, except qient and the. characteristic, effect of work where the.-said diseases follow as an in iii such dusts. cident of'an occupational disease as defined When such clear and specific language is- in this section. ' * . available, why should, we be asked to us'e - "A disease shall ;,Se deemed to arise ;out vague, broad terms, the use of which may of the employment only if there is apparent constitute the giving of a blank check, by to tiie rational mind upon, consideration of. industry? If the purpose is not to charge all the circumstances, a . direct causal con industry with diseases which' are not char- . nection between theconditions under which' Occupational Disease 215 the work is performed and' the .occupational new subject; .We. -examined the. existing disease, and which can be seen..to have-, laws in.* other countries .and;. adopted -the followed as. a natural incident of- die work form that seemed best adapted to our con- as a result1 of the exposure occasioned by "ditions, namely, the English-law. on occupa the . nature of the employment and which' tional diseases. The schedule! was, from can be fairly traced to the employment as time to time, enlarged as new -industrial the .proximate cabst and which .does nbt' processes developed new diseases. By 1929, come' from a "hazard to .which.'workmen ; the . schedule had been enlarged to include would have been "equally exposed'outside every-disease that was a potential hazard of the employment The " disease must -be ,.to thegworktrs in New York State, with incidental to the. character of ;the business - the Single exception of the dust diseases and not .independent of the relation of em-: of the lungs. In order" surely and certainly ployer apd employee.. The disease need hot to. bring- such conditions*, within .the .pur to have been foreseen or expected but after view <oi the law, there was 'enacted an ad its contraction it must appear to have had, ditional item in .the schedule, reading "any its origin, ini' a risk connected with the: em and' all occupational diseases." The sched ployment, and to have flowed from .that ule wPs not. repealed, and the administrative, source as a rational consequence.",. provisions in the law with respect to the Under this definition' no industrial man ager can, with any. assurance; be informed,^ what his' obligation -is- to. his workman, and" assuredly no workman Suffering . from dis ease can surely know whether he is ehr titled to compensation under"that law. Of course; as is to be expected, litigation over the interpretation of this definition is al- - schedule were continued.. One of the first questions that. arose under this new' law .was whetherthe new classification stiper- ! seded the schedule and the limitations set forth therein, or whether it was an addi-; turn-to the schedule and; applied only to those conditions not previously. * included therein. ' ready in progress in both, of these states. The legislature, having evaded tire duty And situations will arise Constantly in the. of defining the' term "occupational disease," future where the .facts will -be such that the Industrial Board, which administers the; only litigation in the courts, will determine law, adopted a defiititidn. .That .definition-' the liability 0? industry, or the right of is well worth repeating: that the Board the worker to be compensated. deems a disease to - be occupational only . The. claims actually filed with- the. In dustrial Commission of Illinois-..already include undiilant fever (a disease:said to be commonly communicated, by- milk.. and meat products), tularemia,.rheumatic fever, arthritis,' rheumatic heart, heart disease, amebfc dysentery, varicose veins, .flat feet, athlete's foot, cerebral hemorrhage alleged, to be due to overwork; syringomyelia, and nerve, disorder. I have not -mentioned the when it is "characteristic" of and peculiar ! to the trade, employment, or. occupation" in which , a worker was engaged. This defi-. - liition was adopted almost verbatim m the -Rhode Island and Michigan Laws. The Appellate-Division of the Supreme Court, however, declined to follow, it^ind by1 a, vote (gjL-three to two, held: that 'any disease that, arises out of a condition incidental .to the employment must be deemed, to be an claims for characteristic,occupational dis occupational disease. eases; -such as silicosis, carbon monoxide poisoning, and the various other toxic con (Bishop, vs. Comer-. & Pollock, 2Si Appellate Division,M92} Goldberg vs. ,9S4 Marcy Corpora tion, .251 appellate Division, 904.) ditions which.dearly come under the Act. Thie`Goldberg case -was appealed to the I have referred to the fact that New. Court oLA^peals--ffte court of last resort York, alone, has in recent years enacted a in New York.-.So completely do the.facts law covering occupational diseases >ingen in the Goldberg case bear , out what, I have eral terms. New York was-.the first state, said about indefinite-liabilities under, an all-' I believe, to. enact an outright compensation. inclusive law,`that they will-bear repetition. law for occupational diseases.'It did so in. Shirley Goldberg - was employed to. sell 1920. The law was a schedule type law. (It tickets - in a moving picture theater. Her' so happens that I had the privilege 6i being .booth was on the sidewalk.. It was kept one .oil those who. collaborated in "the draft heated,- in cold weather, by a small electric ing"of that..law.). We were dealing with a heater,-- operated from a switch in the PL ,} -^4 216 Silver;Jitbilee Safety Congress booth. She contracted what s\vk', described ability. follows immediately, and in which .as blotches or'a rash on her legs. The. prompt!report, to the employer;, is made. .v -blotches or rash she-claimed were-due to ;..the alternate heating and chilling' of her legs when sheswitched on or off the heater. This is- jnot far different from-the rule in ' regard to hernia as an accident. ,But in New York, during the past year/,it has' They did not constitute a disability. How become | somewhat the. fashion to .regard ever, on comprint to her employer, she was almost every hernia as either an accident . told to see her doctor. While on her. way or an occupational disease. . to see her doctor, on her own time, she This followed on a~ decision of the Court - slipped on the sidewalk and fell, fracturing of Appeals, 'sustainingjan award for hernia.- an ankle. Although the day was cold and as an occupational'disease wherein the In - she testified there was ice and snow on the dustrial Board specifically found that no .sidewalk, the claimant alleged that she fell. accident had occurred; 'In' the' case pre- . solely due to weakness resulting-'from Vented, the'' worker was required, in the these blotches, arid the ' Industrial Board course of his employment,.; at' .frequent so-found; and found that the cause, of.the intervals,, to rotate his body.on the.hips.. fall was an .occupational disease, character- This man was-employed in a glass factory.- istic of and peculiar to her-employment. . He gathered molten glass on the end. rif. /The Court of Appeals,' in an opinion that a punby#. which he, irii.rturri, swung about bristles .with logic and sound sense, struck and placed in a. mold. The weight was-not this free-for-all system from the language excessive, being: only a. matter of a few' - of the New' York Act They unanimously pounds. In affirming, this award,, the :Court' refused to concede that this .was an "occu - of Appeals said: - ~' pational . disease. To make every' disease "The finding, supported by -evidence, is - that arose out of and in the -course of em that .the continuous gathering and lifting of ployment compensable as .an occupational . - .glass from a'furnace involved'a .constant disease, they said, would be to make the - twisting and straining of the body. This compensation law ."the. equivalent of life process, from' gradual .stretching, resulted and health insurance." The court further . in a hernia, which is a disease'(Matter of- said that, to -be "occupational," the. disease. . Alpert vs; Bowers. 223 N. Y. 97, .101.) Theye - must be oge which "results from the na . is medieaf testimony that claimant's occu ture of the. employment"; and that-by na- pation would produce this, disease and there ture of the.employment is meant--conditions are judicial decisions in other jurisdictions to which all employees of a class are'subject . holding that hernia ,is an. occupational dis and ..which attach to die occupation--"a ease (Marathon Paper Mills Co. vs. Bid.. ' hazard -which distinguishes' it. from the usual Comm. -203 Wis. 17; Travelers Iris. Co. run of-occupations, and is in excess-of the -vs; Locke 56 Fed. (2nd) 443, '444)." ' ... hazard attending employment hi general." (Goldberg vs. 9S4 Marcy Corporation, - decided , (Foster vs. Gillender Brother? Inc.,. 278 N. Y. 348 16 N.'E. 2nd 36(h) / -January 11,' 1938, and reported in 276, N. Y. . Perhaps the most- controversial question 313 12 N.E. 2nd. 311;) . .. involved, in occupational disease ` legislation Thus; after more than two * years of is the treatment;of;liabilities for' dust. dis> . great uncertainty as to the meaning of the. eases of the lungs.' In -no class'" of cases law, die Court of Appeals.' has eliminated is the marked .difference between accidents , from the New York. Statute, the diseases- arising at a given' time and plate and occu of ordinary Slife which are' only incidental . pational diseases more pronounced. In this or speculatively related to the-occupation. . - category of cases, we find silicosis^anthracor Just a word about hernia'as an occupa silicosis, and asbestosis, all of them- forms tional disease. Never .heretofore regarded of pneumonoconiosis. While these (diseases ' as an occupational disease, but quite gen in some, of''their forms are among' the- erally.j recognized under certain circum most ancient, their ravages having been rec-. stances as an accidental injury--the'Occu pgnized . generations ago, ..little has- been . pational Etis.ease Law of -Michigan,- enacted . known until recent years of their causation, last year, specifically included hernia in of-their pathology, and o,f their complica- die schedule of diseases. Not all herniae, tions- with other diseases. A vast fund of however, are so included, but only those . knowledge of these diseases has been gath- ..clearly of recent origin, as to which dis ered in the .past, ten years; and intensive Occupational..Disease. 217 ' studies of their etiology and pathology.- industry whp_may have in the past in are still going forward. curred some degree of fibrosis of` the lungs. - 'One fact'-stands/out. clearly, and that is, that, these diseases do. not progress to -the..point of-.disability 'until; after many years, of. exposure, to dust./ The.'Jength pf time, varying from five to'twenty-five or more .years, is dependent in large measure . But' ;;itieS, if industry cannot , assume these how. much less- justification -is liabilthere . .-to'!'call upon insurance, out of the premiums of next year, to pay. for disablements ac quired `over, the past fifteen years, and for which.it received no premium? upon the concentration "of .dtist,. the com-, In this - difficult situation, it has been position of the du?t, the time actually ex- found necessary' in many states, if em '-- posed during "working hours, and - the .in-- ployment is to. be continuous and uninter- - dividual' susceptibility, or. resistance', of the rupted, and if men are eventually to. be worker. Another fact that - stands out is'-, .compensated foi: .the. fibrosis acquired due that:-the fibrosis bf. the lungs,' once ac- to-future exposures, to absolve, "to a great- quired, is -permanent: and incurable, and, extent, industry from the obligation of co'm- , - in uncomplicated cases is not .susceptible to : pensation for past'exposures, and to base ',i 'medical *tr*ea*t.m-ent..-*. ' i [ -Many thousands.of workers today, under ' nojlaw but the common law, have, been' ..employed in employments ^exposing-them to .moreior less heavy concentrations of-dust '. fOr .matay years. In'the event-of-theeriact- ment of an occupational disease law In- - eluding those<j.diseases, industry will find compensation upoh the extent of exposure : after the' .enactment of an occupational disease law. 'Thus, there has come into acceptance in several states the principle of graduated . compensation benefits for dust diseases, limited , to future-.exposures, and eliminating-in large 'measure the-ex-, posures of.;the pash itself, at the-stroke' of a'pen, liable for Under this system compensation .for dis .conditions already acquired-through long ability.. or death occurring during the..first years of employment^ and which may be- . month under the new law would be only come, disabling'at-any moment In this: sit- `a nominal amount (it has been set as .low - - nation, the best.'.guaranty'.against-disable-' as $500 to start with). 'A person disabled - -ment is. continuous and steady^ employment:- .during'the second or. third month after; Many,, a man, actually ableto work' and- the -enactment, of an occupational disease earn good'wages, while he hhs a . job, .will.; law, will Have'been exposed,, to.a small be able to demonstrate by x-ray- ,and /clin .extent at least, under-that law. The ex-, ical examination, the .presence of. a marked ' posure is ;perhaps . iq itself' insufficient to degree.-pf silicosis,, when his job stops. . actually'result in any harm. But the max . because of depression qr otherwise. imum benefits will be increased, month by Hence arises, the question, of the so-called month by'.small increments, until in the "accrued' liabilities."' -This term.,which has course.'of 'two or three years the full limit come into common use is perhaps 'not an chargeable to industry in the particular exacf term, in .that ."liability".'dqes not.. state will, have been reached. This systein occur until .'disablement, and the liability is not so'COihplicated as it might- seem.- is- only "accrued" at .that. tfme. What we The effect of it is rather to postpone the have; in mind when we discuss'accrued going, into, effect of a dust disease, law for .liabilities is ;the.condition of -fibrosis of a. matter oLtwoqr1 three years, and experi- - the lungs which has accrued, and has been enCe under this law has demonstrated that-, . acquired over a period - of years. This few claims arise, where the compensation . 'condition, being permanent,', remain's,, with'. -benefits- are so. limited, the ...workers pre- ;-the worker,: whatever, and whereyer may be ferring to. stay at work as long as-they.- his;, employment ' Perhaps a more exact can; It may be said that it works harshly expression would. be "potential liabilities," in ' the'.' case of .the= person ` who. becomes and-yet"they'are more than potential ;' the.. really totally ..disabled in the early, months condition gjving rise. to them is riOftfialiy of law. When' measured by the. liability . '. existent . ' ' -.- /"* : with which' the employer' may fairly be Industry-tells us'^uite truly, thai it cah- charged,'it does not, in .fact, work- a-hard / not riow pay full', compensation, out of cur- ship, and when compared with the exist "* rent/income' to a^Pof the "men employed in , ing system in states not now under' occu- 1 /* o 218 Silver Jubtlee Safety Congress A pational disease laws, it not only Is not terest must be given to industriaPhealth. a hardship but is, in (act, a great boon. - The care for the health op the worker The principle pf limited, and graduated must not. be confined to . the .guarding liability oftheemployer (or dust diseases,, against those- conditions that are mentioned has been recognized , by. enactments in' New'-' specifically in the law. The engineer-s re York, Michigan,, Pennsylvania and Ohio.. sponsibility is a broader responsibility than An unusuat'prpvision has been adopted in is the legal liability . for ' compensation. the "state of Washington, providing under' There can be no doubt that the enumeration their, schedule form of law that the cost in. the law of specific conditions for.which of compensation for occupational diseases liability, is absolute will be .of great'ad shall/ be divided equally between the em vantage to the. industrial engineer in seek- ployer and his workers, and deductions - ing to enforce proper health standards. It. shall be made from the employees' wages is far easier for him to obtain approval of- as contributions toward the insurance his. recommendations, if he can point out premiums involved. to management that the use of benzol or But what, you may say, has all this to some benzol derivative is specifically men do with the safety engineer? tioned, and point to the specific paragraph' It has much. The Safety engineer; can . no longer regard ' himself as . doing^his job if he seeks only, ways and means to eliminate the industrial accident The in in: the law that cites the. liability of. the employer for. that condition. No argument is needed to convince, management of its; obligation in such a casei ; dustrial hygienist must become the colleague The same is true with'regards to all of of the industrial engineer. Medical science the metallic poisonings and all of; the other. must give intensive thought and study to wide range of chemical exposures. Psycho-, determining the effects upon the human logically there is great power in the printed system of. various industrial processes, and word, and even the most backward manage exposure to various materials therein. All ment may be made to-respond .when the exposures cannot be eliminated and still - clear mandate is set forth in the law. Not.; have industry perform its functions. Most 'so easy wiil it be, under a general, vague, important, therefore, is the medical deter-', and all-inclusive occupational disease statute, mination of what are safe limits in ex-' to convince management that it has specific posures--the so-called "threshold limits." duties. with regard to the elimination of The engineer cries aloud today for expert .health hazards.. Thus, we see there is an- medical guidance on this subject Armed - other and potent argument for the schedule with such medical opinion and advice, the' law, rather than the all-inclusive law. task of;the engineer then, is to devise prac-. tical ways and means for attaining condi tions where such threshold limits apply. Every industry presents a problem or series of problems in itself. No two in There is perhaps yet another`and even more compelling reason for' applying the rule of sanity and common justice `to leg islative. mandate hi . the complex field of' occupational- disease. Shall employment be dustries are exactly alike. What is toler .^limited to those Who are physically per- able in one may be intolerable in another. feet? Air humans are not examples- of. What is good practice in one industry physical perfection, nor can we by legisla- may be totally inapplicable for. practical . five fiat reverse the laws of nature which' reasons in another. The task of the en immutably decree that we shall grow older gineer then is to find how right' principles with the. passing years. may be made applicable. We have seen and discussed the dangers Industry today, more than at any. time inherent in the. all-inclusive theory- ofi in its history, must bear the burden of stretching the law to cover every. sorf: responsibility for the health as well as for and condition of disease, and* to try-to the safety of; the industrial'worker, and-if make them employment-related. When that his health and his safety are adequately stretching is complete, WhePadministrators safeguarded his happiness and the happiness of the law find it easy and possible to of those about'him will be lncreased. There burden industry with the responsibility of fore, it is of "prime importance in the field health insurance under the guise of an. of safety that intensive and increasing in occupational disease statute, what of those Occupational Disease: 219 who, wanting employment or seeking, to. re-. rider the devastation such a situation would tain it, are not physically perfect yet cer-. produce. -. tainly are not disabled? .In the ,Interest of all workers,, tlieyoung. Much'is.-, heard today of the dread forty-, and the old, the perfect and the imperfect, year-line for employment. Whatever' the .. . let us not embark upon legislative policies facts may be as to that;.is. it not possible-^-." that can-lead only! to enlarging, the : field i.f no.t probable---that industry, in despera?" of unemployment; and to dosing the door tion and against its desire, will ;be forced, of industrial opportunity to those"skilled eventually to accept only those - among . and faithful workers who, having passed .whom the health hazards , are least-uncer- the meridian of life, are subject to those tain--the physically perfect, the, young and . natural infirmities and .ills of the flesh to the strong? We may well pause'to. con- ' which all-men, in time, must bow. ~ Handicaps in the Diagnosis of Occupational Diseases . By CAREYP. MctORD, M.J5. ;" Detroit, Mjch; ' It is a popular medical belief-that occupa- ", undiagnosable occupational diseases, it must tional diseases are far more difficult to fee--. be recognized that many remain utidiag- ognizee,and precisely to class, as such .than nosed, or" more often. misdiagnosed. The any othfer type of disease state. So firmly prime- reason for this is that the usual is this idea rooted in the1 minds of some physician sees only small numbers of any physicians that they argue that occupa-" ope. type of occupational' disease; Taking . tional diseases never, should be made com- . (Dhio as", a typical industrial state, the total .pensable because of extraordinary diag-' number of occupational diseases, cpmjpens- nostic difficulties. ' - able and" Otherwise,! reported to the State Lately, Kettering lias said, "The doctofs Department of Health during the year 1937 tell us there are certain diseases, that are- O* *h.er there,are m incurable. Do you know what ah-incurable ,fhis state 9,200 physicians. Thus, only one disease is? .It is one that the doctors don't . occupational disease arose for. every 5.5 'know anything about. The disease, has no ' doctors in the state.. objection .to-being cured at all." ' * .= ..'Here then ..is the foremost handicap to This 'may .be paraphrased by saying": . the recognition-and.'diagnosis'of occupa-. There" are no undiagnosable occupational - tional diseases and at. the same .time, -..a diseases. The'only ones-.that appear undiag- back-handed compliment to industry. In- nosable are the ones, the physicians have dustry, because of'its prevention. achieve- not.. learned how. to diagnose. No occupa? , ments, has so limited the number.-of oc- tional disease has ever offered any resis-- cupational diseases that day .by . day the tance of its own to being diagnosed. The" physician is ordinarily not spurred to the disease is perfectly filling to be diagnosed, possibility that any-worker who seeks his At least one-half- of all occupational di- ` professional guidance may have a disease of seases are almost self-diagnosing, particu- occupational origin. Here, too, is tne ftfnda- la'rly when arising in groups; the remaining mental reason why more medical schools half present' no greater difficulties than do not develop training departments m this attend the diagnosis of.Vbme other classes *!eId or organize special hospital services of diseases; To maintain that occupational *or care" f occupational disease pa- . diseases ..arc&beyond the. diagnostic skill of hents. the physician is pure defeatism. With equal While there are reasons for rejoicing that propriety, it might: he suggested that all there are comparatively so few occupational neurology be abandoned because the ma-. diseases, we should recognize that there jority-of conditions arising in 'this field, are specific situations which introduce diag- maynot .be diagnosed with ease. nostic. difficulties, A number of these are While it may be said that there are no now presented, as separate entities. '220 ' Silver Jubilee Safety Congress .Definition arid Terminology. uncertainty that this condition represents a Much confusion is - caused by ' lack of ' characteristic occupational disease. . uniformity and' clarity in.definition. Scarcely' Between these extremes, there is (|b;me any two states in their-statutes accept the .point at which difficulties yrould . arise in: same definition-of an. occupatiorwl disease. distinguishing occupational diseases' from, In a few states, hernia is by la^specified accidental injuries! 'his same situation ap as an occupational disease.. However, in the plies to many other , substances and many majority of states it is, when related to in . other, occupational diseases. There is per dustry as a cause, classed as a traumatic haps no warrant for anjr^attempt at a hard fnjuiy. In a few states,^tHe, definition,of and fast demarcation tiniterms of time,.in an occupational disease provided by statute dicating where an. accidental injujry expo is such that certain items later appearing oh' sure leaires off and an occupational disease schedules themselves do not., conform'.to. exposure begins. the definition furnished.- However, there may be some justification Well meaning legislators might enact a : fpr the practice of many physicians, -who law declaring that two and two make seven, hold that if~the exposure-leading to damage but the mathematical facts. still might re is less than one work period,, the ensuing main otherwise. So with legislation, -in injury should be recognized as an accident volving occupational disease diagnosis, th'ere Conversely, if the exposure period extends may be demands for legal acceptan^*!pf ^ for.'more.ffian. one work. period, then the - certain conditions as occupational diseases,^ ) resiiltingroajnage may wiffirpriopriety- b^^- when elementary medical facts poibt other- ' cepted^aS'afi occupationalWisgaW. In gn.- wise. One group of physicians may reserve eral,-it ifnay be claimed tfiat.one of the the term "injury";-.for exclusive use in con- disturbing handicaps to .uniformity, clarity,s nection with trauma* while another .with, and. precision in -cpnnection with occupa propriety may a$sen that occupational dis tional disease diagnoses stands in delation eases of many natures represent. "injury" to awkward legal situations, inadequate defi to the same extent-implied by the . tenn nitions, unsuited- classifications arid such. "traumatism." , . --Let us consider,-,for example, the'occur Fallacious-Medical Histories ` rence of an accidental injury on. the one As'a result of careful training, every hand and a clear-cut occurrence of an oc physidan is disposed to attach significance cupational disease on ffte other, both caused, to the history statements. given by a pa- from one and-the same substance, but under ' tient .or members of his'family with re-, different circumstances. Itmight come gard to any disease." The less a physician about in a given factory that a workman may know about the possible etiologic.facts. entered a tank car, lately emptied of ben-. in any situation, the-more consideration he zol, and in the absence of suitable protec- ' -is likely-.to give to history statements.' It ' tive and precautionaiy 'measures might,. is. human- nature to associate all .o.f our- within ten minutes, become asphyxiated as -ilis with some-particular happening or series a result of breathing benzol vapors.' 'Man of happenings. A;.cold may be` associated ifestly, such .ah occurroice as this would with a particular periPd of. sitting in a' be accepted as an accidental injury' and ho draft A gastr'd-intestinal upset is-prone to . J. compensation board would ever fai.se ; a be-associated with' some particular alco ^ question tfiatsuch was not the case. ' holic bout or food-engorgement : , On; the . other hand, this' same benzol, ' .In'-the case of industriaT workers, there- taken from tins',tank'car, might-be utilized - is aii especial proneness- to' associate any. in this sanie factory in some- productive . .bodily ailment with some aspect of work.- operation, giving rise to bcnzol.vapors. Day - . Inasmuch as almpst .every workman hopes, by day, another workman might inhale some openly dr secretly, that any and. all dis- of these vapors. In due course, this work . eases. from which, he may suffer inay be exposure might produce the< usual and , laid at .the door of his employer, he is characteristic features'of . that occupational * ` mdst likely-to stress and emphasize.the high ..disease known as benzol ppisoning. Here probability that this `condition unfailingly again it. is most unlikely'that any physician - was produced by the chemicals, gases, .va or compensation board would entertain any pors, dusts, eta that attend his work `oper-. ations. This does hot necessarily repre is to be appraised until long after that sent dishonesty or cupidity on the part of time within which the disease might have the patient and only may involve those, hu been diagnosed with precision. Withoutt man frailties shared by all of us. any purpose of condemning or finding fault, : No less, the history Statement may un the fact must be .faced that in many in duly influence the physician in his diag stances the decision of a patient to blame .- nosis, may lead to misdiagnosing,, may pave his ailment on work causes , was not made - . the way for unwarranted claims or law suits within that period when some or .all of without any evil intent on the part, of -the the characteristicmanifestations were pres physician.. It: is_mpst; unfortunate that die ent V " physidan is all tod'Joften unable to appraise. .Then, at some Jatertime, a physician the worth of work history statements pro qualified in occupational disease work may vided by a patient,. Let us, for the moment; - be-called upon to . examine die claimant or assume that* a specialist in ear diseases is'-4 to reach a decision'based upon.'the exam visited by a patient*on account of. deafness.* ination of inadequate records of another physician who himself did not carry out any examinations with particular reference forge.operator,' The. physidan , may w to that...occupational disease for which a aheadlana make many-careful examinations, claim later has' been filed. This is asking , looking for the cause of the' deafness, from too much' of the 'diagnostic ability of any infection; from syphilis, .from heredity, etc.' good physician. If; .howev<eir,'-he had'obtained a .complete-- Oh the-'witness stand,, the.charlatan al work history,' and was m position to evalu ways . makes the better-impression on a ate this work history,-he might come at once jury, . because -he is unhampered by- the- to know that this. drop, forge, operator, is. . caution and -reserve that guide the up . perhaps exposed to as much noise and cbn- right.witness. Being positive is often merely. Jcusdon- as ever arises inordinary indus .a matter 6f-being-wrong in a loud voice. _. trial work and that the deafness present - The point is that the-time to make . a .diag- dearly is an occupational disease, '.resulting ; nosia of . an occupational .disease is' that - from sustained noise exposure. ' period during'which the . disease exists..... . It may be asserted* that well meaning .Otherwise, the. most* accomplished physi physicians, without any evil,intent through cian may. be placed in an unfortunate po their misunderstanding of patients' descrip sition in the reaching of his decisions. tions of work operations, have become re sponsible for a., high percentage- of the. Insufficient Training and Experience... large. number -qf unwarranted suits' that Ah outstanding, drawback to. the. proper have flooded the country in recent years. . . diagnosis of occupational-diseases may-be In short pile of the handicaps to the proper 'found /iri-ina'dequate training in medical* diagnosis of Occupational diseases is to be schools for this aspect of medical work. found in the attaching, of undue significance . This is' not a thrust at the doctor, nor may to^e-patientY Statements'as to work con c'any .complaint be made;against medical ed ditions, when the physician himself i?' un ucation today. It *mayfhot-be expected that . able to. appraise thfeir reliability and merit medical schools will markedly enlarge an Some physicians heed to.;make thejhselves already over-crowded' curriculum *to pro more remote -to. the'fajlacy that just because'; vide extensive'instructions with reference a -workman is employed in a dangerous to .occupational diseases when the number trade,-meVitably any ailment , must neces of .cases yearly .is. so . small as to proVide sarily-be the,,.'result of work exposure.. only, one for every-five or- six physicians. . There still .may':fte a few. persons who'may Realizing his own. .Shortcomings in -this believe that lead poisoning may arise from" ' field; a good general practitioner may'hon- . work in making lead pencils.. ` * estly shun this type'of-work, but this,step . Time as a Handicap in Diagnosis . on .hfs part'may eventuate in. even more ' undesirable- situations. Too often'the physician well qualified in :. The patient, instead of being referred* the field of occupational diseases, does. hot. to a better , qualified physician in this field, see the patient or claimant whose condition. is given; no." advices, whereupon he gravi 222 Silver Jubilee Safety Congress- * ,- -'T ; ' tates toward an inferior physician, Jess con^ of- the chest of -this workman may. strongly - cemed with the lack of qualifications. The suggest the. possibility`of silicosis,'nowhere extent to .which lack of qualifications in oc . on the,work record may it be shown that cupational-disease work may go Is-reflected - for a .period of -seven yearn at some'much in the fact that recently a duly, licensed earlier time tins.'workman was' employed as physician in the State of Michigan reported "intestinal peristalsis" as a diagnosis of an occupational disease. a laborer in apottery. ... - - ' - '. i'* ' Iti this same connection it should be cm- t phasized that one of the--many handicaps, While the unwillingness of a physician to to-the physician'in making an accurate . accept responsibility for pathologic states diagnosis is to be found -in the widespread with which he is not conversant is~com practice of hospitals, of. clinics, insurance mendable, there still remains a duty to di records,- etc, in merely naming the trade of rect his patient into channels wherein ade a workman rather than describing his exact quate services may be procured.. occupation.' <-Xt is quite insufficient for med- Industrial Terminology. . - deal purposes `for a record merely to show, .' - for example,-, that the patient was employed One of the most annoying handicaps;-^ as an "automobile .worker." Under: this:, establishing'the exact etiology of a possible heading, there are perhaps not less than :. occupational disease resides ixi the wide spread practice ,of industry hi. using code symbols in the designation of its substances. 200 different and dissimilar types of emiployment leading to different .exposures ; such for example as to silica in the foundry, . On inquiry, the patient may .state to his cyanidein. th^heat treating room, chromium physician that his work consists of filling in the plating department, lead in body fin containers with "B-72." But; inquires the ishing) and-on and on. physician, "What is B-72?" The patient * ; . continues, "B-72 is a mixture of M-20 with Lack of)Library Facilities H5W and L-97." Completely the physician With some temerity the - statement, is is. left in the dark, but if the-truth were made that regardless of many book publi- -v known it might be shown that this patient cations in .the field of industrial .hygiene -was engaged in the filling of cans -with -a - and occupational diseases,' Special maga varnish remover, which consists of a mix- zines, and - articles appearing in general 1 tureJof wood alcohol, benzol and a syn - medical magazine publications, there is,'-at thetic wax. this time, no condensed, informative ma-. ' Such situations may. become so confus terial on occupational .diseases wejl suited ,. ing that .it may be almost impossible for to the needs of the faniily practitioner. . ^ the physician to obtain' proper information It is of course impossible and undesirable as to work exposures. Medical, safety, so that any attempt should'be. made to reduce cial service or insurance departments: all alj the lore of occupational diseases to . may have difficulty in obtaining full in some thin book to which' th practitioner formation as to actual chemicals and mix may refer and1 with certainty obtain all the tures of chemicals designated in production guidance needed in the.treatment and man operations only by code numbers. agement of occupational diseases; Granting - The Absence of Records The majority of-N industrial plants fail to maintain sufficient,1 medical and work records to serve the physician properly in connection with occupational disease work; In a given instance an afflicted, workman may give as his occupation some innocu ous job as "elevator operator." He may re all this, there still- is occasion to assert .that a real need now. exists for.a book publica tion on occupational diseases designed for services to the neighborhood physician who - 'in the aggregate sees far more occupational disease cases, than , the small number of specialists in this field. . , , Attitude Toward. Industrial Medicine member that the job' before that was as In times long ago, when mine .workings, . L a "truck driver." There his memory may sawmills, and railroad' construction camps fail. His work "record mayfshow no items were established in remote sections of the . as to transfer within.' the factory of his country, far removed from the usual sources last employment and no record of any pre of. medical services} it became neoossary vious employments. -- Although the x-ray that the management bring into these iso-....  " Occupational Disease 223 lated work places a physician who might New Chemicals carry out'all manner of medical services. '-A further deterrent , to. ..accurate diag-. These physicians - set the. broken arms of . nosis of occupational diseases is linked up injured miners** .delivered the babies of the - with an almost endless flow of new chem- miners' wives; treated^the miners' children itijds into industry's processes.:. Year by' for measles and mumps and otherwise at- : year* a/far greater number of new-chem tempted to meet the medical needs'of these, icals:.are introduced than the-number of. detadhed communities. Usually the com investigations, referable, to their toxicity. panies coiitribhted^to ;the' income of these* . It is often true that nowhere in the entire physicians and every ' family - and. every literature' concerned with - industrial tox- - single man was taxed. a stipulatedsum each, . icology may any word be found aiding the month in. order toCoyer the physician's physician in. determining, if a given chemical salary. Thus arose' the term "Contract -inight.be responsible for a series of objec . Physician." This perhaps., did- not .always tive and subjective symptoms in any patient. represent the best of, medicine and' not in One' of the most desirablegjhanges, needed all instances were' these contract'physicians * in* connection with worker" health protec of the highest type..- . tion is .the requirement that no new sub Later some of these communities became . stance ~ be introduced into industry on a . larger towns, or.-cities,. and other physi production basis' until .it shall'have..been, cists- sought to gain- a livelihood, only to established ; to the extent-possible,' through find that-the contract.-physician was in-the animal^,experimentation,- that such a sub-. saddle. This gftve rise -to complaint - and '. stance is without daitgerous'potentialities. out of .this'`Tahdo'ra's box'yhave come in numerable. evils that even t<? this, day at . Significance'of Handicapsin Diagnosis tend the: highest type of indusfrial medical'' -A*, recital of the ..type just presented supervision-, under., the ` most \ ethical.' and. ' might- be continued almost indefinitely* but commendable.', circutnstances.. It has'be-* ' perhaps without profit. The entire, situa- come a tradition on the ,part *of many of tion may be summarized by stating that . the medical profession to' blame almost any.' .- whereas. occupational. diseases themselves manner of their economic dfficultiesupon .are-'probably as diagnosable as any other,. industrial ^physicians.. So real if this -dis difficult -class of .diseases, just about every affection 'that some- organized medical stumbling block tfiatimay be produced is- groups have sought to> legislate against 'al- laid at -the door of the; physician. sincerely, most .any 'form: o.fiindustrialmedical `prac seeking to .acquire sufficient evidence upon.. tice and in some - instances to deny- mem which to make exact diagnostic decision. bership.' in medical societies to*, industrial .The greater number of these stumbling physicans. As -a result, industrial .physi-. blocks represent ho willful desire to hamper. dans in-some respects have been-, branded . the. physician, .but instead arise .from-the with a. scarlet letter. ' * . results of - peculiar circumstances that in .> This queer, situation, strange .to say, .some measure separate industrial diseases 'may serve as a handicap in the diagnosis^ .. from the general run of afflictions, ' v of occupational ;diseases,, since some of the . As a consequence,, iaige numbers of un best physicians, and*'particularly the more warranted diagnoses &i occupational dis-- timid ones, fear lest they, may become.be- "eases haye been:made and are being made. -, smirched by cooperating iii. this type of Scores of * suits have' been instituted and .medical endeavor .and'to some extent`shun ' some- have- been woh by .claimants. whose any dose affiliation that might lead to lifted - claims possess no whit of merit, chiefly be- 'eyebrows' by those .regarded as the leaders . cause wcll;` meaning physicians unhappily of the profession. ; .**.*' implanted the seed, of-possibility that his' Now that the American Medical Asso- . disease, might -have' been caused, by' work ciation. is somewhat alert to this- situation . and-.that the. responsibility might be laid and has organized a Coundl on . Industrial . , at the door of.the Employer. While there** Health, including^ some members: with. in-'. sultf may have appeared-to* work afi^in- dustrial: medical"experience, it is..to he ' justice arid -monetarytoss; upom the em hoped that after alL the - industrial physi-1 ployer, 'm ,the- long-run . the- interests of cian may become respectable. ; the worker himself are. not .served by these c. 224 Silver Jubilee Safety Congress ''spurious claims predicated upon improper badly heeded under postgraduate auspice^. medical advices. .The usual trial of an oc .(b) In' every industrial, community, or cupational disease-case is a travesty. The bombastic statements of some physicians, unattended by any iota. of fact, bring into -disrepute the entire medical profession and take away its time honored traditions of integrity and skill. ... at leaft in' every industrial state, there should be available for cooperation withthe . general, medical, profession, a number of much experienced .and highly sldlled occu pational disease consultants/ who, through limiting their professional activities to this A further significance in the misdiagnosis one aspect of medicine, may become highly of occupational; diseases on die part of proficient in the. solution of occupational physicians is. to be found in unwarranted disease enigmas. ' . , "hardships imposed upon employers. Re cently a, physician made a diagnosis of silicosis'in two workmen in a given depart ment As a result; widespread apprenhensions arose among the remaining workers, strikes were threatened, talk developed as to 'demands for high wages because of un usual exposures and the expectancy or a short work life. The employer was com pelled to spend some $85,000 in the installa tion of an elaborate dust control system. . As .a matter of fact these two workmen did not suffer from silicosis,- were-not'in any wise disabled, had never been exposed to silica; ho silica or any other harmful dusts - were created. There was no need for the expensive installation made and contrariwise other departments did present practical exposures for which this $85,000 might have been spent to better advantage in procurement of needed protection. (c) In every state and in some of the larger industrial cities, there should liemaintained public institutions., devoted to industrial . hygiene and ' occupational, dis eases-whose technical services may.be avail- * able. to . the physician in charge of patients . who may; be. suffering from - occupational _ diseases, and. these public bureaus should^-yj ' serve, as fact finding bodies, equally inter-.', ested in the worker and his employer.. .. ; (d).Much wiU be-gained if all physicians responsible fqr^ the health of industrial /.y porkers in any capadty may make greater ' -effect to Qbtain~precise work histories, both present and past, ana* may seek to gain an. . adequate understanding as to the work en vironment, Ats materials', machinery and possible exposures. (e) Controversies should be eliminated in the largest possible measure from occu pational 'disease work. Many abler physi . The Road to. Betterment cians eschew all . connections with this type This entire discussion would bejwithout any. value if present day practices and sit uations only were condemned. .More ac curate diagnoses as to occupational diseases are badly needed. These better diagnoses' of medical practice because of the. sad ex- ' perience that nearly every case. may be so . involved in controversy, litigation, disaf fection, until the good physician may fed that he may be-degraded; will come in proportion to the extent that. ' (f) A need .exists- for greater disclosure the changes now listed are brought to ac to physicians of the chemical nature of tuality. work materials to the harmful nature of ' (a) The general level of knowledge of occupational diseases' on the part- of the medical profession should be increased through the introduction into medical col lege training of a practical amount .of in struction on industrial hygiene antLoPu- p^tional diseases furnished' byf.men.who have had first hand experience in tHi field and. agre not wholly dependent upon textbook - which employees may be - subjected. In dustry may have excellent reasons for hid ing the nature of .'some of its chemical ma terials under code terms, but more oftenthese .code terms are designed only} for rcqnvenience mid not for secret fbrinulae tjnirpqses.} A greatefPi|<p[;ee of cooptation - on the part of the maqufkcturer wilFeirSn- tuate in'the. better health, protection of his kgfi.0 However,; it!, is emphasized . that in workers through' the more, intelligent min- ^undergraduate smedical training this form istrations of the patient's physician.. -.. t ' ... ' 'of instruction necessarily' must .be sharply (g) Lastly, it. may be pointed but that limited because of a crowded curriculum;' better- diagnoses , of occupational - diseases'' but conversely more extensive, instruction is wiU come when the general ' medical pro- . Occupational Disease '.22Sb- fession, through its organizations, shall to almostjsye^.spScalty .In medicine. The alter its. attitude toward .industrial medi- organized';medical profession'Whole-heart- cine, shall recognize this type of work, as edly should render its'approval and. support just .the antithesis of the undesirable . as- to'the efforts' of the. physicians; '.earnestly pects of state medicine, and may;come to seeking to protect workers.from the many realize that industry, under the . guidance ' dangers Connected^with-industry's thousands of able medical directors, is the meritorious - of substances and work conditions. ^ source of numerous cases to be referred- ' , Necessity-for UniformAbsenteeism Record In the Industrie Health Ingram ^ By MILTON H. KRONENBERG, M.D. Chief, Division of Industrial Hygiene, Department of Public Health, State of .' .Illinois, Chicago - You are all. aware of the value of acci These, excessive rates are especially not dent statistics. You know that without fre able for-unskilled workers as shown in - quency and seveHty rates there would be the accompanying table. no solution .of the. safety problem arid we These death -rates, could, only have been would hg groping, in the dark.. But, since prepared by- statistical .methods of analy-r;-, they, are available, we know where correc sis and, therefore, deafly point out where tive measures are. needed and this affords one phase of our probIem/2ies. If Mold us an; opportunity to correctly judge the nothing more than this we. "Would nave -value' of one' method o,.prevention over plenty to do trying to uncover the .menaces another. . to health among the pinskilted group' of ` Today, the'grip'-of statistical Methods workers. . ' . o- ' "is dosing, down upon industry, medicine, The morbidity and mortality data laid public health and .safety. .Vital statistics,- down by uniform and adequate reporting; howevqr imperfect, are one of , the chief ;6f cases can also- serve as -a`basis for pre1- means now available for measuring health,. yention and health' education among work longevity and the progress- of medical ers, the same as is. and. has been." done for- services in the battle against, diseases. - accidents. -- . So well recognized is this fundamental principle that the effectiveness of a- city or state health' department, is judged, in a large measure, by .the accuracy and com pleteness of its morbidity and mortality reports and records. . The same principle obviously should*hold true; for the groups of workers employed in: a-factory, qlifi^ quarry, public utility or department store;4' ^It may- interest-you to know.- that the Eastman Kodak,Company, Edison Electric Illuminating* Company, Hood Rubber Com pany, Westinghouse,' Metropolitan Life, Gen-' eral Motors,, and several others have for years .-made, sickness. studies' iwith fhe aid .of statistical methods. Itf tins . Way .- they were able to evaluate the different sickness problems confronting them and those need ing'.attention, and at the.* same time With These records are of value not' so much to'indicate what has been . done, although ..this is' important enough in demonstrating ;:to management the value of certain. Work ^land, therefore, the advisability of.contin'i-uing'it, as .they are to chart-.future action. these-Sickness records properly ..appraised and-evaluated, .they were able to educate their employees regarding ; digestive dis eases,. colds, pneumonia, tuberculosis, can cer,- skin disorders,, as' well' as other ail ments.- 4 *. ., - , Insufficient .data have, thus far prevented "the recognition :of some health - problems peculiar :tq.wage-earners and there is simple evidence to indicate- that .morbidity' and. Furthermore) studies. conducted in spe cific Industrial Undertakings1 have shown the value of...statistical methods in revealingthe inadence. of such diseases as pneu mortality rates are .higher 'for some,groups. monia,' tuberculosis, and degenerative dis- 226 Silver Jubilee Safety Congress Death Rate* by Occupation \ Occupation Professional men Skilled-worker Semi-skilled worker Unskilled worker All Causes 670.5 .' 828.9. . 1009.3 . . 1447.7 Tuberculosis ofthe Lungs : 26.2 72.1 102.1 184.9 Pneumonia '38.8 , S9.7 ' '71.6 135.9 ' Cancer and . Tumors 70.3 ' 85.4 -90.8 . ' 106.* Rates per 100,000 occupied males, based on U. S, Census data in ten selected States. seases to be higher,;than the average, tor dents,:. the quality' df, bis work is of ..a the entire industrial 'popblation. This was " lower grade, team work is disrupted, fac clearly demonstrated in a'pneumonia study tory processes are dislocated, undue burdens among steel workers which was. conducted are placed on other workers and the worker by the U. S. Public Health Service. himself becomes dissatisfied. If he is oc : Drury, some years ago, was able to show cupied with weighty-matters o. policy and a high rate of tuberculosis among workers ` production then : someone in that .organiza in the ax-grinding industry, and the Barre, tion must assume thie -leadership and . ac Vermont; study revealed -a high tubercu quaint him with the problem by understand losis rate among granite workers. No doubt, able and intelligent facts and figures..,' other occupational undertakings would re veal data for prevention, control and edu cation were it possible to have adequate statistical records as revealed in the slide . just shown you. There are progressive industrial organ izations who may and-.have- spent large sums, of money for the improvement of working conditions and for the care-, of-, workers who become .ill,- but without cur Dr. Selby, of General Motors, in calling rent plant information about* the human attention to his statistics shows that about factor much-of this money and effort has 0.6 of a day per annum is lost due to oc been, spent-on "general .principles" or per cupational injuries and that includes occu haps; concentrated .upon the elimination of. pational diseases as' well, whereas, eight, ..only one or .two -publicized health hazards, nine or ten days per year is the total and only from-the-standpoint of existing lost time from all illnesses. In Dr. New- compensation laws, as for . example; sili quist's report for the American College of cosis. But the extent of the health problem Surgeons, the figures are about the same. in a plant necessarily may not end here,- This shows us that our industrial illness problem is approximately fifteen times the size of our accident problem.' With.the progress of industry especially on the chemical side, new' health .problems . will arise : resulting in . physiological and?? It is evident that industry r could well pathological upsets.' The effect .oh health- afford to concentrate on itlnesses among will, therefore, have to be measured and. wage-earners, other than the occupational evaluated. We must have data in order diseases, because they are the ones that- for one to judge...the efficacy of methods cause the greatest amount of absenteeism employed 'to combat- disease; so we must and are the biggest drain on industry, . ' ..first know wherediealth is being menaced, - In jthe recent National Conference on 'the relationship of occupation to these dis health Conservation, it was estimated that eases and the causative factors responsible. the'nation's bill for illness and-premature The records you keep will be.a guide to ac deaths amounts to approximately ten bit tion as well as a record of action. 's lion dollars annually, and that on every '-average day about four million persons in the United States are incapacitated by ill ness. No doubt many industrial workers are in that last figure; Therefore, I Say, prove your value to industry .since many a skilled industrial medical department has been; limited in its budget ana activities because it overlooked the necessity' and value of absenteeism re The industrialist of today should recog ports and records which could have been nize that a sick worker is prone to acci used to enlighten management regarding its  . Occupational Disease - . 227 . 'J-'1 healthproblems.Pefhaps .in some cases up and maintaining records of sickness in the industrial establishment may .find'it dif- their particular ^plants.' .An analysis and ficult to undertake a complete record system . evaluation of. these reports and records is -of absenteeism. I do urge you, though,-tb another service offered by them to manage- make a start somewhere. It need not be ment. . -.i . - too elaborate; ! ' Before' showing you. a . form on which to .. I have heard it said that the best'way. collect your absenteeism data, and which can ' to detect illnesses" which are causative of. be termed the "master sheet," I should like `.absenteeism from work'is by periodic phys- to acquaint you with several important . ; ical Examinations. l am not fully in accord items that must be had for your records withe .jthis type of ` prevention; It may . be before they can lend themselves to* analysis .helpful where the illness .lasts longer than arid evaluation The form is self explana-` a week or ten days, but something should , tory except for a few. general remarks. be done about the. frequent oiiSj $wo .or A card should be made out for each and three day absences, and T. fear. thal?pmSodic every employee, on the. payroll, regardless physical examinations will not help- tre of vvhether he or she-gets sick, or not . This'' mendously. This, of course, does hot mean is necessary in order to ascertain the ratio ..that industrial me,dical services should aban of those sick tb the number on the payroll. don; or minimize.-that phase of health serv The workers' age, sex, color and occupation . ice. . * - ``v, . . The industrial hygiene divisions of State Health" Departments and that of the United are. important tb record since they will have to be' related, to the specific exposed popu lation. '. State Public Health Service are urging the Under "occupation" state the work in . employment and use of a uniform code for which the employee was engaged when his recording and reporting absenteeism of the ` sideness began. The "date disability began" 'worker due/to* sickness. Forms and meth- ..should'only' be recorded for one full day - . ' ods have-been) developed' after, a study of. or longer. In the column "work days lost" some twenty years by,.-the Public Health' . we refer to calendar days and. this is neces .' Service-and also as a result of the recent sary to put lost time on a comparable basjs. .-National Health;Inventory of chronic dis- for all employees. For "diagnosis" one . ease affecting'wbrkers., The aforementioned 1 should list the sickness or injury when defi .health agencies, will gladly assist' and co-` nitely known; if there is any doubt about operatefwith industries desirous of setting the correctness bf the diagnosis, a statement 4 * ' * , `Slekatu Record Bora. Name or Clock No. \ ' Dole.. ' - Dale Dipt. Occupation Ate Sex Color Dis Dis ability ability Began.- 'Ended. Work Days Lost.(Cal endar days). Diag* ' HOSTS By Whom Diag. nosed Termination of.Case . -... * bfc, * *' , .* V, ' "- . i /.fV - v-i` t 4 -.. ` < : * ` r /"N \ \ .. -' . rr Ul jr Ai V 228 Silver Jubilee Safety Congress1 of the symptoms experienced by the patient given disease for the entire plant, individual should be recorded.' The point is that facts departments or occupations. , should be recorded and not guesses. It is more important, for example, to. know that ten men in a given occupation were dis abled by "pain in the stomach" than to get - 2. The time lost due to any given dis ease or to all diseases combined in the en tire plant or by departments or occupation: ten different guesses of the disease or ail ' 3.`The mortality rate, ment causing , the pain. Another item of importance on the record is "by whom . 4. The' case fatality rate,. expressed as diagnosed," and should show whether the the .percentage , of cases of a given disease diagnosis was made by the family phys which terminates fatally. : ician,, plant physician, nurse or the patient himself. Under "termination" of case, one should'record whether the illness terminated in recovery, death, relapse or ended in a chronic condition. The following statistical information and data are, therefore, possible if the items listed in the slide just shown you are care fully prepared. .. The intelligent application of .preventive . measures, of control, of health preservation must have statistics and. they will always be an integral pa.rt in jthe solution of any problem. That it holds true in industrial hygiene is represented in my next slide which'shows that the strength of any wheel is . dependent on each and every spoke and each is dependent upon the otiier, otherwise 1. The frequency or severity rate of any your structure is unbalanced or-coliapses. r'- ADJOURNMENT r \ Ui O r> P: *.f