Document NGvE4pn4a6rKDmdGxZkDpLmpD

FILE NAME: DuPont (DUP) DATE: 1936 Apr DOC#: DUP070 DOCUMENT DESCRIPTION: Journal Article - Industrial Medicine and Surgery Industrial Medicine U.U.sr - z-oH-ntn 0*n><0 Industrial Medicine and Surgery Industrial Medicine and Toxicology MODERN civilization demands that we improve the old methods by which workmen were made ill and died by the score, and that we advise adequate methods of preventing occupational poisonings and diseases.* Therefore, it is neces sary that chemical engineers and physicians should become more closely associated in order to develop sufficient knowledge concerning these health hazards, and with this knowledge to institute protective measures which will make all plant operations safe. Industrial medicine is not a new specialty; neither is the recognition of occunational diseases of recent origin. Bernardini Ramazzini, during the 17th century, wrote a treatise on the diseases of tradesmen, in which he recognized many diseases of oc cupational origin. He defined in dustrial medicine when he said, "We must own that some arts entail no small mischiefs upon the respective artisans, and that the same means by which they support life and main tain their families are oftentimes the cause of grievous distempers which hurry them out of the world." Com pare the simple industrial operations of Ramazzini's time with the com plex operations and toxic substances of today and it is obvious that we are facing a complicated problem that must be worked out by the clinician and the toxicologist, as well as the engineer. - What is industrial medicine and how may it be successfully applied? It is not simply the treatment of oc cupational disease and intoxications, but includes that which is more im portant -- medical methods for the prevention of these diseases. Occupational diseases occur as a result of exposure to toxic substances and lack of proper medical super vision. Some of these diseases are the results of years of exposure and cannot be cured; for example, silic osis, a disease in which clinical symptoms do not appear until there has been extensive lung damage. Unfortunately, this damage is pro gressive and incurable. There are industrial diseases that are sudden in onset and terminate in death in a few hours; in this class we have chlorine poisoning, which causes an acute respiratory disease. There are acute occupational diseases which appear almost immediately after ex posure, run an acute course for a period of 12 to 48 hours, and clear up in a few days. Aniline and nitro benzol are examples of substances which cause this type of illness by their action upon the red blood cells, forming methemoglobin, which is followed by the destruction of many millions of the cells. These and other * G. H. G ehrmann, M .D ., F .A .C .P ., Medical Director, E . I. Du Pont de Nemours & Co., W il mington, Del., in Chemical & Metallurgical En gineering, December, 1 9 3 5 ; based on a paper entitled " Industrial M edicine and Industrial T oxicology" presented by D r. G ehrmann, on November, 1 3 , 1935 before the Columbus, Ohio, meeting of the Am erican Institute of Chemical Engineers. examples of industrial intoxications have developed with the progress of industry and have been recognized as the result of bitter human experi ences, inestimable suffering and of ten death. Industry must realize that the previous methods of trial and error are no longer acceptable, neither are they economical Further, we must develop accurate knowledge of health hazards before operations are started. Operative procedures must be de signed to prevent toxic exposure, and industrial health must have adequate medical protection. The toxicologist, by proper methods of animal study, can develop the toxicity of a compound and the mechanism of its action. From these facts he can point out both the pre cautions necessary for safe operation in the plant and the clinical symp toms which indicate the beginning of poisoning. With this information the industrial physician can establish adequate methods of medical super vision, organized on three basic principles; viz, proper selection of all employees, special-medical protective examinations, and treatment of oc cupational diseases. Pre-employment physical examina tion is the only means of making the proper selection of employees. The success of this examination is depen dent upon several factors. The ex aminer must have at least a reason able knowledge of the working condi tions of the plant and the physical and mental requirements of the in dividual jobs. Job requirements have a wide range of variation. For example, the physical effort neces sary safely and efficiently to perform duties may range from physical per fection of 100% down to a very low percentage. The worker who is engaged in lifting heavy materials all day must possess more physical ability than one who maintains tem perature and pressure regulations in a chemical operation. Furthermore, the worker who possesses the physi cal strength to perform laborious work all day may not have the men tal requirements that, would make him an efficient chemical plant op erator. There are many compounds used in industry which are toxic and un der certain conditions may cause sudden death; examples of-these are HCN and H:S. The latter in high concentrations kills almost instantly and, further, these high concentra tions cause rapid paralysis of the ol factory nerve with a complete loss of the sense of smell. Therefore,' it is possible to walk unaware into a high concentration of H.S, become uncon scious, and die before rescue is pos sible. Concentrations above 500 parts per million are dangerous. Other compounds are toxic to a lesser degree, act more slowly and produce chronic disease--some in a short time and others after years of exposure. Lead is an example of the former. Lead gives rise to acute symptoms, depending upon the amount of the daily exposure, in a few days or a few weeks. Then, as examples of those compounds which require years to act, are certain nitro- and amino-compounds which cause simple tumors and cancers of the ' urinary bladder after an average ex posure of eleven years. Some compounds have a selective action upon certain organs. Carbon tetrachloride interferes with the function of the heart muscle. This action is more severe when the heart muscle is affected by heart diseases. Therefore, an individual with a nor mal heart muscle may successfully withstand the effects of this sub stance, but one with a diseased heart muscle may die with acute cardiac failure. Mercury compounds are eliminated through the kidneys and cause severe irritation with acute or chronic nephritis. Phosgene, nitrous fumes and other irritant gases cause marked inflammation of the lungs and may aggravate a more active pulmonary tuberculosis. Any chronic lung dis ease may be aggravated to such a degree as to cause acute illness, per manent disability, or death. Organic disturbances of the central nervous system may be aggravated by such compounds as carbon bisulphide and those of lead. Lead intoxication produces an encephalitis, which is. almost impossible to differentiate from the mental disease produced by late syphilis. - These are some of the possibilities which must be considered by an ex aminer in order that he may protect an applicant, who has an already established disease, from working with compounds that will aggravate or activate his condition. In 1911, the first compensation laws were passed in this country. Prior to this time there were, to the best of my knowledge, no physical ex aminations in industrial plants. The passage of these laws made industry responsible for accidents and physi cal disabilities, and the physical ex amination was introduced as a pro-' tection against claims for conditions, that existed before employment. At that time applicants were refused- employment for even minor physical: defects. Later, the compensation laws were amended to include oc-, cupational diseases as well as in juries. This necessitated a more, complete employment examination;; and developed the periodic examina-.; tion as a method of detecting the beginning symptoms of occupational-' diseases. Experience indicated that; respiratory diseases were being fre quently missed, the errors in diag-; nosis being reflected in the incidence: of activated lung processes occurring after exposure to irritant gases. Kid ney damage was, in, a like manner, being overlooked, and cardiac and circulatory pathology, either missed entirely or the findings not given the proper interpretations. ' T HERE then came the -realization i that physical examinations for in- . dustry should be of such a naturej as to accomplish two purposes: Firsts to select applicants and place them in occupations that would not ag- -Page 206 INDUSTRIAL MEDICINE April, 1936 . Vol. 5, N( gravate any existing disease; second, fortunate enough, to work through examination that will reveal to the The subj to eliminate the unnecessary exclus the experimental stages of a project clinician the evidence of beginning ] the develc ion of applicants who, although they without any visible damage to them organic changes within the body. ' amount of presented certain physical delects, selves, the compound at hand was The appearance of clinical evidence j ! application were nevertheless able, safely and non-toxic. This assumption is fre of intoxication in a well-controlled ! ficai value. efficiently, to fill properly selected quently erroneous since it is possible operation may mean either a failure jobs. In order to accomplish these' to have degenerative processes started of proper function in the equipment purposes we realized that we must in certain organs without visible or or a careless workman who is not | Selling have more accurate diagnosis -at the clinical evidence. Bor example, de following the rules of hygienic con Indust time of employment. generative process in the liver may trol. Faulty equipment is usually re-1 ' A medical diagnosis is made by be very extensive before there is any fleeted in a group of employees; dis HYSIC; P combining what the patient tells the clinical evidence. Therefore, it is a obedience to rules and regulations in ' doctor with the findings as observed decided advantage, both from the single individuals. In either event requisii tal well-bi by the doctor. Both factors are ex health and economic viewpoints, to the evidence indicates that employees tremely significant and probably of know how to start new operations are being poisoned, and the source pi essential t recognitioi equal importance. Patients present themselves to their personal physician with safety. There are today many operations which should be improved. contamination should be corrected. The correction of faulty operative sponsibilit ` Recently to be cured of an illness and naturally Some can be made safe with reason conditions is necessarily an engineer tell of all their complaints. On the able changes; others will require a ing problem. The matter of proper some 25 informatic other hand, applicants for employ complete change of operating equip handling of an individual who is ment present themselves to the ex ment. showing signs of toxic absorption is programs, survey th; aminer with hopes of passing their examinations and, therefore, have an The question may well be asked, "Why do we need periodic medical entirely medical and in each in dividual case the physician must de-1 ers are n the idea o incentive to cover up any existing ill examinations if our factories are cide whether it is safe for the em ness and conceal many pertinent facts equipped with operative devices that ployee to continue in his operation or a real in\ health pr< concerning their medical history. This places the examiner at a disadvant eliminate exposure to health haz ards?" My answer is: First, I have whether he must be removed from! found th source of further intoxication and ! larger err age, and so in order to detect lung yet to see the mechanical equipment, given special treatment. pathology, liver disfunction, nephritis, no matter how perfect, that will con Industrial toxicology offers the: complete doing a cardiac diseases, circulatory disturb ances and central nervous involve tinue to remain so, and very often the first knowledge of its faulty function means of avoiding frequent repetition j I. larger pi of our past experiences of human suf H< and thei ment, he must have at his command all the modern diagnostic equipment is the appearance of toxic phenomena in the employees.^ Secondly, there fering, acute illness, chronic illness(1 and death. With the aid of the toxi- f : smaller e; 10 and 1 for making urine analyses, blood ex aminations (including blood chemis frequently arise new sources of con tamination, sometimes from within cologist and the pathologist, we can"! no progr; eliminate from our industries occupa- ] livery lim try), blood counts, serum examination the operation and sometimes from tional diseases and toxic processes.; without. Thirdly, the human flesh We can start all new operations with*,, There ; this: (1 for syphilis, x-ray films of the chest and, in special cases, electrocardio is heir to many ills, some developing adequate protective measures and aJ | :tion with grams and basal metabolism tests. slowly, others rapidly, many in scientific understanding of the toxic; sidiously. There are many chronic symptoms to expect, based upon our;: a progr) knowledf Unfortunately, there are too many industries today giving little or no ailments that are never suspected un knowledge of the mechanism of their ; ft, lack of ; consideration to such an examination til far advanced. Many of these can production. be detected early and at least im The toxicity of a compound may | push the . It is e and many others making no examina tion at all. They consider this work proved by removing the individual from any source of possible toxic ir vary with the conditions under which' it is used. Substances which giveg: ' grams m ment. S unnecessary as long as their insur ance carriers give them adequate cov ritation. little or no trouble at ordinary tem- _ peratures become extremely toxic at der the health 1 erage. Many are unaware of the haz T ards that exist in their factories, HE frequency of periodic ex higher temperatures; some substances aminations should be determined decompose and give off poisonous": and that cern hin others show no interest until they are forced to become interested, either by the toxicity of the compound in products when heated. Carbon tetra-s volved and the rapidity with which chloride brought into contact with ] employe value of because of compensation experiences, civil suits, or insurance rates that it may enter and attack the human hot metal or an open flame is oxidizedj of their |i citated ; have increased to such an extent as to body. Lead, for example, may pro duce symptoms in a few days or it and phosgene is liberated, which has^ a destructive action on lung tissue. an awk be reflected in higher production costs. Too many are satisfied with a may take years, depending upon the In order fully to understand the toxic-.* atmospheric concentrations. Benzol ity of a compound, we must know I dare s tune al superficial examination which costs comparatively little money, does not may cause chronic poisoning in a few how the material is handled, the tem-j : Years a accident supply adequate information or pro days and I consider monthly examina tions necessary in both lead and ben peratures to which it will be sub-j jected, physical changes in the opera-J realize tection, gives a false feeling of security and, in truth, is wasted time, zol operations. Nitro- and amino- tion, the various conditions undhrl Lproblen 1 compen. money'and effort. All too frequently compounds are all more or less toxic and workers in these compounds which it will be handled and thel possible chemical changes which mays them in the physicians making these examina tions have little or no knowledge of should have an examination at least occur. rJ every three months. Chemical plant There must be a very careful studyj dimply ` S&nake v factory conditions, job requirements, and health hazards that exist. workers who are not exposed to any of the effect of a compound upon f "fportant | that ur Selection is the first step toward the known hazard should be examined once a year. \ body organs. What does it do? How does it do it? What organs of th$ ` st us successful application of industrial medicine and the second is adequate Periodic examination should be de body are affected and what clinic)" geents, v them, protection. Adequate protection is provided by two means--properly de signed to bring out the physical signs and symptoms to be expected with the symptoms are to be expected as " result of intoxication? There are cei gfe- Thret health signed operative, protective measures exposure to certain substances and need not necessarily include a gen tain substances which produce diseai mechanically and in themselves Jplant 1 and equipment, and periodic medical examinations. Protective equipment eral physical examination. 1Beta not poisonous. Silica dust is an exj gjhysicf leutives is an engineering problem that should naphthylamine, alpha naphthylamine and benzidine, for example, cause cellent example of this type of terial. Fine silica dust when inhale) leuliar never be planned until the toxicol ogist has pointed out all the health tumors of the urinary bladder, and in eventually becomes .imbedded in th| pon t fearly hazards that may exist, and before he so far as we know, do not affect other organs. Therefore, it is only essential lung tissues, setting up an irritatia which is followed by the formation tfhe w( can do this he must make a careful toxicological study, which should be to make a careful search for these fibrous tissues. The physical eba Tim; fall of completed while prospective opera tumors. Benzol, by its action upon the blood-forming elements, causes a acteristics of the lung change. ; loses its elasticity and its function? pouch tions are in the experimental stages. By the time they have reached the primary anemia which can be detected interfered with, depending uponJ" gjnembt phould semi-works, it is usually too late be by certain blood examinations. Thus, the entire field of periodic examina stage of the disease. This is the c ease known as silicosis. Silicosis i ysic cause the equipment for production has been selected. tions should be based upon the clini chronic, progressive, incurable, In the past, many chemical engin cal signs to be expected. Here again the toxicological study of a compound often leads to total and permana disability. When complicated wi| " nestii lento eers have assumed that because they have been able, or more frequently makes it possible to design a type of tuberculosis it is usually fatal. ' usm 4 'No.. 4- INDUSTRIAL MEDICINE P age 207 ie subject oi toxicology requires development of an extensive unt-of knowledge, otherwise its ication to industry is of no prac- value.' ------- AMERICAN ASSOCIATION OF fling Management on an ndustrial Health Program RAILWAY SURGEONS iYSICAL well-being is a preequisite to emotional and menwell-being.* These, in turn, are ntial to an alert and enlarging gnition of opportunities and reisibilities. ecently a survey was made of e:25 industrial firms to secure rmation in regard to their health /rams, and it is evident from this eythat the majority of employare not yet sufficiently sold on idea of industrial health to make ad investment in a well defined ith program. It is true we have id that a great many of our er employers have established a iplete medical program and are ig a real job. However, these ;er plants are in the minority, ; there are vast numbers of iiw establishments, with between and 1,000 employees, who have program at all, or one which is y limited. here seem to be three reasons for (1) lack of detailed informa i with regard to organizing such program; (2) lack of definite iwledge of its economic value; (3) < of some promotional agency to h the thing into action, t is evident that our health pro ms must begin with the manageat. Some employers are still un - the impression that a worker's dth is his own personal problem i that the employer need not con11 himself with it. Many of these ployers will not fully realize the ioe'of a worker's health until one their key men is suddenly incapaifcd and they find themselves in awkward position. Even then, lire say, they may lay the misfor-K at the door of Providence, ars ago it was chiefly the cost of ddents that made employers alize that the accident prevention iftlpm demanded attention, and nipensation laws spurred many of an into action. I do not mean to inly that we need legislation to ike us realize that health is imtfent to industry, but it does seem rf.unless these problems actually itijis money in visible dollars and nfiFwe are very apt to disregard ai* v three .special problems that the alth department of an industrial ait has to consider are: (1) the usical condition of the higher exejfives; (2) the health hazards peiiar to industry and their effect poothe workman; (3) the study of ajy manifestations of disease in ^workman. me will not permit discussion of Mof these problems, but I will h briefly on the first. Each ^gober of the executive force Wold have periodically a complete tjsical examination. This should S n , p. Schilling, R.N.,. Industrial Nurse, J L j e Coke Corporation, Fail-mount, W . V a .: aid at the Annual Mtetinfc of the National i Council, Louisville. Ky., October, 19 15 ; bed in Pub. Health N ursing, April,-1936. 1935 - 1936 ' Officers President-. D r. D on D eal, Springfield, 111. Vice-Presidents-. Dr. W. A. M cM illan, Charleston, W. V.; Dr. M. A. T inley, Council Bluffs, Iowa; Dr. H. A. Brennecke, Auro ra, Illinois. Treasurer: Dr. S. C. P l u m m e r , Chicago, 111. Secretary: D r. D. B. M oss, Chicago, 111. . Phone: WAB 2345 Executive Board: D r. S. C. P lummer, Chicago, 111., Chairman, D r. S. B. T aylor, Columbus, Ohio; D r. W. L. H artman, Detroit, Mich.; D r. J. R. G arher, Atlanta, G a.; D r. G. G. D owdall, Chicago, 111.; D r. J ohn R. N illsson, Omaha, Neb. be just as searching and complete as that given to the workman. In any factory the higher executives control the success of the business. If these men can be kept in good physical condition, their efforts will be the more fruitful. The loss of a single executive in any department may cause considerable difficulty. The Life Extension Institute has called attention to the large number of men, at or about middle age, in whom degenerate processes of seri ous nature are just starting. These processes, if discovered, can usually be checked, or their progress greatly delayed, by the industrial physician. When we have sold the management on the value of physical examination for themselves and their executives, then, and then only, will we be able to sell the management on a health program. , , , The average cost of health work in industry is approximately $6.00 a position, per year. There is consid erable difference in this price as re ported by various firms, the range being from $2.47 to $22.00 per em ployee per year. The plant haying the $22.00 cost employed full time medical service, three nurses in the plant and one full time visiting nurse, a fully equipped industrial hospital, eye room, dental room, x-ray and physical therapy room, and required a careful physical ex amination of all employees with per iodic health examination. This plan reported that in two years the aver age lost time illness had been reduced from 8 days to 3.4 days per employee, and that no days were lost from infection. The benefits of a health program may be divided into those which af fect the management and those which affect the worker. All who have written on the subject agree on the economic value of medical supervision to the management, but state difficulty of showing this in figures. Mock sums up these bene fits to management as follows: 1. Reduces the time loss due sickness and epidemics. 2. Reduces compensation for ac cidents, disability, deformities, and death. 3. Increases output by steadier working force. 4. Decreases hiring of new em ployees at a great financial saving. 5. Increases general efficiency of force. 6. Secures good will of employees. Many employers have asked, "What size must a plant be before a health service can be established?" The number of employees is not necessarily the criterion for justifi cation of a plant physician or nurse. Health and safety work is important in all plants, regardless of the num ber of employees. In referring to a recent list of small plants which provide health service, there were a number of instances of employment of part time physician and nurses where there were fewer than 500 employees. In one instance, how ever, there was a part time physician employed in a plant having only 167 employees; in another, a full time physician was employed where there were 310 employees. Any plant, no matter how small the number of employees, can ar range a definite part time health program. The deciding factor is usually the interest of the manage ment in providing protection for its workmen, the character of work done in the plant, and finally, the desirability of maintaining healthy workers. I believe you will agree that it is just as absurd for a plant having a few electric motors and elevators not to employ safety in spection as it is for the plant with a few employees to be without a health service. The safety engineer who has made a study of accident reports can read ily recall numerous cases of longdrawn-out disability caused from in fected gums and teeth. The "back" case has long been the Waterloo of the claim man; any doctor will tes tify that prolonged disability in this toclass of cases is usually due to focal infection.