Document nNmJMaE0LR96G44VLx3BGNdG1

Industrial Nursing WEDNESDAY AFTERNOON SESSION , October 28, 1942 Presiding:--Joanna M. Johnson, R. N, Supvr, Industrial Nursing Div., Employers Mutuals, Wausau, Wis. Selling Your Program to Management Supervisors and Workers By MARION C. BRITTINGHAM, R. N. F. G. Vogt fttSons, Inc, Philadelphia, Pa. Our modem industrial nurse is prepared cases that will need care after he is gone. to meet all. emergencies--great or smalL She She gives him an insight to die particular is ever mindful' of her oath and practices case.he is treating whenever she knows there loyalty to the employee's confidence as well might be a contributing factor that will help as her doctor and employer. One might call in his diagnosis. She holds in confidence all the dispensary a "faith dink;" for through of the reports that are the outcome of these I rids department many men and women are examinations. She patiently detail^misunderhelped through a crisis. They get sympathy stood directions of routine from (jaunty physi and understanding as well as surgical care. cians, explaining to'the patient'tbe^ reasons ) Many times die nurse can discern the reason for. carrying out instructions. The health why John Brown's work has become inferior programs that our doctors stress must be when only a -short time before he had been simply and dearly explained to the worker. die. best producer in die department John They most often be instructed how to care . Brown,' Idee all die other employees, will for their teeth, eyes, and body--and no one talk to "our nurse" and tdl her his physical, can do this better than the nurse. mental, or* marital difficulties, and dte^fn turn will go quietly about finding a solution Often she is able to help in the establish to his particular problem^so that he will' ment of better relations between employer regain his high rating in ^department and employee-' The industrial nurse has proven hd* worth to the safety engineer. Frequently the nurse is instrumental in re Her knowledge of human nature and the type storing order in chaotic homes. Many times of people dealt with has been most helpful. trouble a^t home will keep the employee's She is ever ready , to urge the employee to mind diverted from his.worie and this invites adhere to safety regulations and explains to and causes accidents. Frequently just a few him the seriousness of partial or complete kindly words or a bit of advice can make. lost time in such a way that he. will realize everything right again. he suffers both a physical injury and a finan The nurse's loyalty to die physician is never forgotten. She clinically systematizes die patients, keeps an accurate up-to-date cial one. Because she knows the cause of many accidents, she is in a position to assist in the reduction of occupational hazards. card system for each one, and has diem ready for doctor when needed She assists with Bigger Health Programs the dressings and carries out orders for the Let us suppose Miss Jane Jones, R. N, 151 i ' PLAINTIFFS | EXHIBIT I uV'atse/s^ V. - v.'>:v\7*v* tr- 152 31st National Safety Congress industrial nurse, Is going Into the office <rf foramination to determine the cause of these die management of her company to ask for^repeated attacks. He reported bade to, the an expanded health program. Her conversa nurse and. told her that he had high Mood tion is probably something like this. "Mr. pressure and a heart.condition too. He was Smith, the average loss of time per employee advised to do tight work and get plenty of per year due to illness is seven days. In oar rest.'. His work was light; hut since we do country there are forty million persons who not police die employee's life at home; he did are losing-two hundred and eighty million not get the required rest; and one- Hobday worlong.days each year because of 31 health. morning he-dropped to die floor while on Stmfifcs. made by die American College of his job. The man toed ofa coronary oedu- Surgeons indicate that illness causes at least sion that was brought on by overexertion fifteen times as much absenteeism as do in and too modi alcohol. Not- only- in major dustrial injuries." illnesses do we benefit by being ifnananed, Now Hr. Smith -begins to listen. Hiss Jones tells him that.in order to.encourage greater production, and moire efficient workers he must take a hand in their personal life. He might even become resentful and tell Hiss Jones that his interests tie only in-see ing that die company is protected so far as' the compensation laws are concerned. { but in mmorones as well. For instance; we have the employee who is a good woricer, but complains frequentlyof headaches; sdrstomach and vertigo. An examination of die eyes wiO often show that glasses are needed. In general,'we might say tint a pre-employment physical examination of employees win tend to make diem more health minded and in this way they will unconsciously become safer No industry, goes die argument,, can -be workers. stronger than its weakest mental and phys ical unit The first step in eliminating mental Supervisors* Cooperation and physical defects is pre-employment examination. We are dins armed withknowl edge and we are in a position tocope with malingerers as well as the chronic complainers. Many tones a man has been paid for an Supervisors and foremen can be.made to reduce that by sending their workers to the dispensary for treatments and care, they will help to improve in the efficiency of their department Sometimes our foremen try' to old condition that he has had for many years, because the employer was hot able to prove to the satisfaction of the arbiters that he did not receive said condition while in their em fisainkate as to whether or not a nan is 3L If they will send the employee to die medical department to have , that derision made, they will be saving fbemsetap time ploy. The only way we can successfully cope and worry, and also be helping hi therestab- with unscrupulous charges is to present toe tisfunent'friendtier relations faweyh die - employee's health record. employee arid toe division heads, ff-the fore There is much less chance for attempted man refuses to permit die'employee to visit \ malingering when we have pre-employment the nurses the employee will probably .return i.} and systematic periodic check-ups. Frequently to Ins job; but under duress.. This- does not these examinations will bring to light chronic tend to. encourage good workmanship. The illnesses. In tuberculosis alone much has been time lost in visiting the dispensary is.gained done to prevent its spread-^mong other em when die man has had his difficulties solved, ployees. In hypertension cases a life has some- . and bis ills cared for. times been prolonged because die condition The supervisors should insist on tbeir em has been recognized and proper treatment ployees reporting; all accidents to.' toe ffis- started. There have been cases where the pensaxyimmeffiatdy. They should encourage condition was not brought to light and die the practice of safety rules-and see to it that employee had a stroke while working. The they are enforced. It is an excellent plan-for company has been hdd responsible because the industrial nurse to meet into the super the man fell while he was at work. There' visors aibd foremen once a month so that toe was toe case of a man hi our own employ, accidents thathave occurred during that time who was constantly complaining of indiges can be openly and franHy ffisaisseidL Thcy tion. He was treated several times In die - have lots of questions that need answers, and dispensary for toe condition and then was it is tq> to dm medical dbecior and mime referred to his family doctor to have an to help diem. It will certahdy ghe toe super- - visor and i Sit lackii be.w shoal This bill W< wbafc pfoye can here safeti are i to re betas jhyw visor a keener Insert as to the conditions and problems of the men working for him. fi it is noticed that a worker seems to be ladcmg inbjs usual efficiency/ or seems to be. worried, or ill.tfae supervisor can, and should, approach the man and offer help; TUs is a kindness that is seldom forgotten and anil certainly reap its rewards in loyalty. Each worker should be treated as :an in dividual and made to feel that we are inter ested ur his personal welfare. He should be encouraged ,to follow through with whatever treatment is indicated and should be com mended on whatever progress is mad&< : . .. Employee Attitudes Workers are usually of the opinion that whatever istftme is fortbe benefit of the em ployer, and they wiQ totally be resentful to suggestions and new rulings. Here the nurse can prove her value. She has it within her power to convince the worker that these safety regtdatioaaand these health programs are for his benefit1 If a man can be node torealize that he is not apt to lose Ids job because of some chronic ailment or some physical defect, he win be cooperative and gfte hrnisdf to treatment Eventually the suspicion subsides.and we find the employee coming voluntarily to the medical depart- ' The majn,purpose of any-indnsmal health programs isto keep theemployeehealdtyand contented. If we-have a high standard of health,: we will unquestionably have a high standard of production' and efficiency..-lire' management can: do this by advocating pre employment and periodic physical examina tion^ by providing an adequate dispensary^to gyve prompt and careful attention to all con ditions necessitating immediate. care, and by employing a nttrse wfeJuffident and sym pathetic; one who can instruct the employee in better healtfrlfebiti; who can advise die employer, and oofrwbo will assist the physi cian. In other words--a nurse should be a cooperative intermediary. \ 13 i* ! Wluxl the Industrial Nurse Needs to Hand andFootinJuries About By FREDERICK W. SLOBE, M. D,, F. A. C. &, Chicago With wounds of the hands and feet die adjacent skin and then the wound itself with same prmciftes apply as in the treatment of a solution, of . mild soap and water. This re wounds in any other part of the body. The. moves the dirt and with it most of the bac nurse shotdd use her influence to see that teria. During this gentle scrubbing thorongh wounds are sent immediately to the! med- .irrigation of tile wound with a soapysoln- kad department. ^Every 'wound is contam- tion is tarrieer^ After that is done; a vw^mated by.bacteria, and it usually takes six sterile dressing. its allied aid over-this hoars' or so:for these bacteria to multiply dressing someflttffed gauze so that firm pres sufficiently and to burrow degily chough into sure is applied'over the wound. the .tissues to the extent that they cause an - X^Wounds so treated vriU. almost invariably infection. . heal. withqut signs of inflaiimationu- Wounds Each hour of dday therefore increases that ard'bntised or jgouged-out; sneff as are the: tiktihoodof infection. Hence; the em caused by grinding wheds; lave the dirt phatic ride, "thei patient- most fc: treated at ground in tbe tissues so deeply that simple oocel" After ti^ -bmirs. tiie .bacteria, can no scrubbing will not deanse the wound suffi- longer be removed by d&ansing as they have dentiy. These roughened areas should be ex penetrated too deeply into the tissues. This cised with a sharp pair of scissors or knife; imtihl deanring should-consist of a thor- the entire area of die wound bring so treated, but gentle; scrubbing of first ifae thus converting the wound into an incised 1l.M\' ... .v.. -. ,. itS'-.-wir!*'. y..! J.t.- i:SrV=i7f 154 31st National Safety Congress wound of the type that will heal readily. If extensive, of course, these wounds should be sent to die physician as local anesthesia facilitates the trimming or debridement of these wounds. If the wound is seen early and carefully cleansed, it should be closed by the insertion of>$mall skin, dips which are so easily applied thartbey lend themselves nicely to use by a nux^e. Flamed adhesive strips are also helpful.in keeping the wound dosed. Obviously, wounds requiring sutures other than a dip or two should be seen by the physidan. Primary dosure of wounds is die ideal method and - results' in far more rapid heal ing, assuming the above procedure has been carried out If, however, the wound is over six hours old or of a nature which can not be well deansed it should be left open and a moist dressing applied. Inddentally, the use of non-absorbable suture material such as cotton and stainless steel wire has been found to be modi more useful than catgut whether buried , in the-tissues or used in the skin. to cake and is harder to use through an atomizer. If a wound is of such severity that it is to be sent to the physician or hospital, it is best to do nothing more than apply a sterile dressing or bandage in order to avoid addi tional contamination of the wound It is best to have all the deansing dime at one sit ting in the hospital as it all has to be done over again by the doctor, anyway. Howew, spraying these^yyotmds with sulfanilamide powder is a good thing as it will aid in keep- - ing the bacteria inactive until the wound is surgically handled'in the hospital. This is especially true when there may be some delay before the physidan can take care of the parent. . * Droplets from the nose and throat are among the most potent sources of wound in fection. No nurse who has a sore throat or cold should handle wounds. If all the nurses wore operating-room masks it would doubt less cut .down the occurrence of Infections definitely. Antiseptics It is quite wdl recognized that an anti septic which will kill most bacteria wilt also harm the tissues. Therefore, if wounds are thoroughly deansed with soap and water an antiseptic is not necessary. However, we have the psychology of the patient to con sider and most patients, perhaps, fed more satisfied if some antiseptic is used. There is very little, if any, harm in applying a few drops of a mild antiseptic by means of a medidne dropper if you wish. However, this antiseptic must be very mild and of an aque ous type. Because of the impracticability of having large quantities of. sterile saline or' sterile water in-the plant dispensary, we like to irrigate these wounds after the soap and water deansing with a'solution of Azochloramid. In this way voluminous irrigations can be carried out as he solution is easily pre pared and is very mild. The sulfonamide drugs have been shown to be very valuable in the prevention of wound infection. An atomizer containing sul fanilamide powder is a very useful way of spraying wounds before dosing them and a very valuable way to prevent infection. Sulfathiazole is also valuable but it tends The control of Needing such as is seen on the hands and feet is usually readily con trolled by the use of direct pressure over the wound. On the fingers it is a simple : matter to apply a temporary tourniquet by means of a rubber;band at the base of the finger. When bleedihg- from the hand is so severe that it cannot be stopped, an elastic rubber tubing tourniquet should be applied halfway between the elbow and shoulder with towelling or gauze under it to avoid undue pressure on the nerves. This tourniquet should never be left on for more than IS minutes, after which it may be loosened and then reapplied. In the after-care of wounds, it is best to use simple measures and not over-treat them. If a. wound is closed and dean, a dry, sterile dressing is sufficient For. wounds which are open and granulating; a non-adherent vaseline gauze dressing is very effective. In tins ' vaseline tiiere may be incorporated some mild agenf*stick as cod liver oil, xeroform,, or one of the sulfonamides. ' -' One of tiie most important factors in the care of wounds of the hands is the diagnosis of severed tendons. A small incised wound caused by a small sharp object is dangerous. On .tiie dorsal surface the tendon is dose . to . the especial always tendon, the dep hemosts thus a tendon is told i To test patient*: cept tii to ford wardai a sever tivdy. Vafo able as they It bade a remain though partial!: -good ft unsever in a ft patient Excess fete wi should the . to cause s true of tendon nicely i hyper-* weeks, that He the ph) Infec as they ability, minor wounds the uni / X atdy a J- poroqyi appears base a. with a have tc Infec Industrial Nursing 155 . to. the surface and on the palmar surface, especially in the flexion creases, one must ^always be suspicions of a severed flexor tendon. A helpful procedure in ascertaining die depth of a wound is by inserting a sterile hemostat and-spreading the tissues apart; thus a previously obscured pamalfy severed tendon may come into -view whrathe patient is told to bend die finger joints up and down. To test for finger tendon function, hold die patient's finger firmly fixing all die joints ex cept die end and then have the patient try to forcibly bend the end of the finger down ward and upward. Failure to do this indicates a severed flexor or extensor tendon, respec tively. Unfortunately, this test is not entirely reli able as regards die extensor tendons because they have such wide extensions over the bade of the fingers .that enough- continuity remains to allow fairly good function even though much of die tendon is severed. A partially severed floor tendon will allow -good initial functipn also. If left aloof the unsevered portion of the tendon will soften in a few days and may give away if the patient attempts to use tiw finger forcibly. Excess scar wOl form and tins will inter fere with function. Therefore the physician should explore all such wounds to make sure the . tendon is not injured sufficiently to ) cause subsequent trouble. This is particularly true of the flexor tendons. If the extensor: tendon is only partially severed it will ted. nicely if die finger and wrist are kept in a hyper-extention splint for from three to -six weeks. So do not take chances with wounds that He over the tendons but refer them, to the physician. * Infections potentially serious. They are manifested by a tenseness of the tip of the finger, tender ness on pressure, and a painful -throbbing such that the patient cannot sleep.' When these findings are present it means that im mediate surgical incision is necessary and there should be .no delay as it may cause an osteomyelitis of \he finger tip which may be months in healing. This type of infection is so deep in the pulp that one does not get the usual signs of redness and fluctuation. Hence, waiting for these signs to develop means the diagnosis has been made too late. Infections of the tendon sheaths on the flexor'aspect of the hand are. manifested by redness and tenderness with excrutiating pain when the finger is hyper-extended. These require hospitalization and should, be sent to the physician at once. Where red streaks are seen running up the hand and forearm it means lymphangitis. This requires hot packs with tievation of toe part and bed rest The use of sulfonamides is very helpful here. .Surgery is contra-indicated in lymphan gitis, only being done when a localized abscess appears. Small steel particles, if deep and causing no trouble, are best left alone. Copper partides usually cause irritation and should be removed, although if very small and super ficial, tors can often be done best later after a tiny zone of irritation appears. Sometimes flie patient is greatly concerned about a foreign body; when this occurs it is often best to remove it Ordinary graphite lead paid] fragments are rdativdy innocuous but frag ments of indelible lead are very important in that they cause a chemical necrosis of toe adjacent tissues iuid, therefore, should be sent to the physician as he.will wish to excise all toe stained adjacent tissue. Infections of the hand are very important as they are a source of much functional d&> ability. Most hand infections occur from, -minor untreated wounds such as punctured wounds or minor abrasions which proves flie importance of treating wounds immedis atdy as I slated previously. The common paronychia is readily recognized by the angry ' appearance of die flesh just lateral to die base of die nail. If this does not subside with moist dressings, and hot soaks, it will have to be lanced by the-physician. - Infections in the pulp are common and The same applies to splinters'of magnesium metal. Little gas tumors form around the magnesium splinters and cause necrosis of toe adjacent tissues. Hence the fragment should be removed immediately. This applies to pure magnesium; alloys of magnesium may not cause trouble if the - magnesium content is low. Wood splinters, of course, should be removed routindy as they cause irritation and infection. If they are of any length one ' can usually determine their presence by tak ing both index fingers and pressing them opposite one another, placing one of your industrial Nursing %S7 . cast or some type of splint; withfreedom support by bandagingor adhesive strapping fromweigfat-bearing for a moderate period., is effective. Early use inmild sprains is Many cases pf fractured metatarsals can. be . effective but in the tnore severe sprains com* madeambulatory in tea daysafter the swell- plete rest for varying periods is needed; Hot iiig hassubsided by meansof .wearing a soaks, therapeutic heat treatnients, and mas* regtdar sboe.'arith a Gdbaii' foot-piece! ap- sage are helpful. W plied,whkh'jh:fiinpfya bar of arood screwed < across; thesboeabout IKinch in front of The industrial nurse should follow correct, die hed.; ;Thts;fidces the weight off the pain- fundamental principles in handling injuries ftxl area andthesepatients become ambtda- and shotdd avtd hoP^ng.^dd?ctcd to or tory very much earlier. devd^^^toaneritednghn^ifenjctt in certain : pet mttfidtments. Too nia^Jare protie to ' Sprains of thefingers, wrist; foot and ankle forget' that-it is the body itself that supplies joints-aret common. The tenderness in a the healing power. If we .keep dean, use yarn is dimdiy oYcr a joint whereas in a dean materials, andcarefollydeanseall in- .fracture the tenderness is most .marked di- jtired areas promptly, pur body tissues will recfly overthe bone. This sign Tails, of do the rest, He wise nurse will take no course; in joint fractures._^Therefore, the chances; part of her responsibility consists only way tnkjhe sare-isJSy X-ray- and we. in haring the physician see every injury com believe in (vCTyj free nse ov X-rays. Simple cerning windh she is in doubt. - --**>. '" . ' -' ' ` 1,1 1 - " . " - i ;./ ! ^ t^ V.O What the Industrial Nurse Cad Do About Tuberculosis- By FLORENCE B. IfarfNNIS, MJ>. Department of IPoi^ic Health,.Idwaokee; Wii J . Several factsare necessary to a ftdl knowl edge of what the nurse in industry can do about tuberculosis. Age Under 1 1-2 Male 0 1 Tuberculosis is a germ disease; caused hr a micnHMgaaistn, the tubercle bacillus. It is an infectious disease. Every case comes from another. It Is still among the leading causes .of death. In Milwaukee during 1941, die prindpal.canses of death In otderand the rates per 100,000 population were as follows: 24 3-4 4-5 5-9 .10-14 15-19 20-24 1 1 0 0 0 I-/>*r 1. Heart Disease.....^^..------- 2S&S 2. Cancer--------------------- 1353 3.Apoplexy .......................... .. 8&7 4. AU Acddents------------ ...-- 563 .5. Nephritis --------------------------44.6 . 6. Pnromoma --------------- 353 7. Tuberculosis_____________ ... 353 5. .Diabetes 325 25-29 - 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 8 15 23 13 30 16 6 Tuberculosis may . exist during any age-, 70*74 5 period. A brief coosideratioa of. the ages at 75-79 riddb . dead: .from : tuberculosis .occurred 80 and over "A among males and females in Milwaukee dur l: ing 1941 will bring tbis.fact to light 141 Female 0 0 0 0 0 0 1 4 & 9~ 4 3 6 . 2L7 3 3 4 2 0 69. Total: 210 . . . O' 31st National Safety Congress Most deaths In childhood occur under five years of age. Overwhelming disease in die form of miliary tuberculosis involving most or all organs, or tuberculous meningitis, ac count for these deaths. From die age of five to die teens, few deaths'occur. In the teen age the rate of death is higher among girls.. This is true until the age of 35, when die deaths among men begin to markedly outnumber those among women. The death rate remains higher among men through the age of 65. After this time; die numbers are fairly equal. One hundred and forty-one men died-- twice die figure 69, the number of women who died. The importance of tuberculosis in indus try looms high when we are faced with figures which show a high death rate in women from IS to 35 and among men from 35 to 65--the years for each sex during which they are most likely to be employed. The discovery of tuberculosis in early stages brings about greater and faster prob ability of cure. To now, unfortunately, 80 per cent of sanatorium patients begin treat ment when the disease is moderately or far advanced. The insidious nature of this dis ease which so often progresses without mak ing its host conscious of its presence, is a partial explanation for this fact. The following figures on the stage of dis ease among die cases of tuberculosis reported to the Milwaukee Health Department for 1941, are comparable to those from other cities throughout the United States: Stage of Disease. Number of Cases Minimal ..................... .....81 Moderately Advanced ....119 Far Advanced....... .....138 Unspedfied ................ .....113 Non-pulmonary ........ ..... 16 Primary ..................... .....25 Death Certificate...... .....54 Per Cent . of Total 15 22 25 21 3 4 10 2. Tuberculin skin t^C'v"-) (a) Mantoux--intradermti test is done by injecting a known quantify of a solution of Old Tuberculin or Protein Purified Deriva tive into die outer layer of die skin. The mantoux test is inspected in 48 hours. A raised reddened area, or positive test, in dicates only that tuberculosis germs have, been taken into the body. A negative test usually means no tuber culosis. There are occasional incidences of negative tests in the presence of tuberculosis. All of these are not explainable. Where the individual tested has a history of exposure or suspicious symptoms, he should be checked further in the same manner as ,t&' jreactor. 3. An X-ray of the chest is tite-ritxt step. A well taken roentgenogram interpreted by a physician trained in the reading, of chest X-rays is the most important aid in the find ing of tuberculosis. X-rays, however, show shadows only. From shadows alone one can not always determine whether the disease is active. 4. Careful physical examination of the chest is the next aid. 5. Sputum, blood and temperature studies will help in the determination of the status of the disease. With these basic facts in mind let us con sider the tuberculosis problem which faces the nurse in industry today. War always brings forth significant rises in tuberculosa? rates. Tuberculosis among the armed forces during die fast war has cost the government of the United States $960,000,000. To avoid this in die present war. Selective Service is doing its part in early diagnosis. Definite dicta have been laid down to bar men and women from service on chest X*ray evidence. Those who are rejected should have adequate study to determine theiri status. Many of those rejects are al ready working or will be applying for work in the war industries. Total....................... .....546 100 When tuberculosis exists, if proper search is made, it may be found. The aids to a diagnosis of tuberculosis are: 1. History of the possibility of contact with tuberculosis. /Vigilance on the part of the nurse trill lead to correct diagnosis and solve the probleiniof adequate observation and care of these injtiiyiduals. Some are able to work on a full time basts; others, while non-infectious, are alile> only to do limited work. Many are defi nitely ill and should be hospitalized.. .Inc colds their npl< have In sc are 3 a lai have culin depei roenl In has t year empl Re Tub* dety ploy* shod dude peric It is Pi 1. cnce 2. ctslir 3. tory P< Aca men) divic omn inati Gi empl peat mon ther< T] whil ful< they G| emp dene Industrial Nursing 159 .Industry has been on the alert for tuber Roentgen examination should be repeated' culosis. Many industrial plants have installed at least once a year. their own X?ray equipment In these, preemployment X-rays are mandatory. Others Group C: Those with recorded history of have made use of private X-ray facilities. past tuberculosis' or evidence of arrested In some instances all prospective employee^ '1^01110555 on employment are X-rayed. In other cases, the nurse plays ' ^ Examinations should be made in accord a large part in pocking those who should ance with the history , and findings. have films. Some'industries `use die tuber culin test routinely prior to employment and Pre-employment discovery of active tuber depend upon private or public facilities for culosis in an applicant means that companies roentgenograms and other study. will avoid paying compensation or sick allow ance to that individual when such payment In Milwaukee, the Tuberculosis Division would not be chargeable to the industry. has been called on constantly during the past year.to decide yes or no for a prospective Periodic examinations are also important employee in industry. ^^""^piscbvery of tuberculosis in early stages C: means shorter duration of the disease and a Recently, the Committee on IndustriaL-^fower death rate--profit to' employer and' Tuberculosis of the American Trudeau So- employee: riety, in a report on tuberculosis among em ployees of hospitals, projected a plan which should be helpful in industry. This plan in- Periodic tuberculin testing of negatives wilt' result in: eludes pre-employment examinations and 1.' Early case finding. periodic examinations during employment. It is as follows: 2. Decreasing roentgen examinations. Pre-employment examinations: 1. A history record with specific refer ence to previous tuberculosis contact 2. Mantoux test with standardized tuber culin properly applied .and interpreted. 3. A chest roentgen examination satisfac tory to a critical expert 1 Periodic examinations during employment According to the results of the pre-employ ment examinations, applicants should be divided into three groups for which the rec ommendations for subsequent periodic exam inations differ: Group A: Those tuberculin negative on employment Tuberculin test should be-.re-:, peated every, three months. (Every six months may be sufficient in an industry where there is no special tuberculosis hazard.) T|tose who become tuberculin positive while employed-should be kept under care ful clinical observation for at least two years --with repeated chest roentgen examinations; they may then be transferred to Group B. Group B: Those tuberculin positive on employment but no history or roentgen evi dence of significant tuberculosis. 3. The provision of a sensitive index of where and when infections are occurring. The nurse in industry who is familiar with the baste principles of tuberculosis and with this plan, is in a key position to make a big contribution to tuberculosis control. In plants where no tuberculosis facilities exist, the nurse whip knows her employee, who has taken an adequate medical history, can* find some way to have him examined thoroughly. The horse in one. Milwaukee industry, which employs about 1,000 men and women/ , by taking a good history promoted the dis- , covery of six cases of tuberculosis inj/.sjbclmonths. This was followed by a survtijj^bf the entire plant in which all employees were . X-rayed. Five additional cases, of tuber culosis were discovered. The X-rays were done in the photofluoragraphic trailer unit of the Wisconsin Anti-Tuberculosis Associa tion. Now that all of the employees have been checked, all prospective employees with a history of possible contact are required to have a tuberculin test and if positive a chest roentgenogram. This is one example of what has been done. Similar stories may be told of nurses in many industries. Corresponding opportunities are open to every nurse in industry. 160 31st National Safely Congress < THURSDAY NOON SESSION October 29, 19^2 Pretiding:--Mrs. Christian Sbabsook, R.N., Local Field Supvr., Metropolitan life In surance Company, Chicago . The Mental Health of Workers By MEYER BROWN, M. D* Ph. D. Consultant to the Industrial Welfare Department of die Zorich Insurance Companies, Chicago Unless one has had experience in dealing with persons affected by nervous and mental disorders he is apt to have' an incomplete and often a distorted conception of the vast social, economic and industrial problem which these patients offer for solution. Persons 2! enough to be in a hospital or asylum for mental cases do not, of course, concern us in industry but the much larger number of people with mild or early cases of tills nature are an industrialproblem of major importance. Furthermore, no one with experience in .dealing with large numbers of employees will deny the great significance of the so-called psychologic fac tors among workersw^pm everyone regards as mentally normaj?5^ It is a competing fact that there are ac tually more hospital beds in the United States that are occupied by patients with nervous or mental diseases than by patients with all other kinds of diseases combined, and we should keep in mind that for every neuropsychiatric case actually occupying a hospital bid there are probably several who are not In tins vast army of persons, who are usually not ill enough to ever reach an institution, we shall find our workers. It is not my intention to imply that a large portion of industrial employees are insane, but that mild nervous disorders and the early stages of serious ones occur far more often than is generally rea lized. , ' The obviously insane person can be detected by any intelligent layman but it is the duty of' the industrial physician and nurse to detect that person at the beginning ofphis disorder before he causes serious acridents or spoilage at work and if possible to prevent his enter ing a place of danger. To the borderline mental cases, to persons with mild nervous disorders, to the emotionally unstably to. the persons with limited intelligence and to others that we may label as mental misfits in In dustry we can attribute an impressive share of accidents, frequent layoffs, errors,spoilage, slowed, production and damage to that precious ingredient of our war effort, which we call morale. Mental Misfits As the present war progresses industry will be saddled to an Increasing extent with tiie mental misfits in our population for the simple reason that they are being rejected by tiie armed forces. At the present time it is generally recognized that such men are far more trouble to the military servioes than they are worth, and they are being excluded for the very same reasons that wppld cause them to be a source of difficulty in industry. Many of these persons, as a matter of fact, give a history of being unable to give satis factory service on a job for any appreciable length of time. They commit errors, are not dependable, do not adapt themselves to`the conditions of work, show a high rate of short, voluntary absences from work andimpair tiie' working morale .of their fellow employees by their poor example, bickering and complain ing. ' f ) ., In tiie present stagevof ccmflict the armed services find it wiser to simplj\ reject these men than to attempt to correct tbeirpecufiarities or adjust to their shortcomings. Because of labor shortages industry mil be forced to cope with the shortcomings of these men tally unstable men, whether it wishes-to . do so or not We shouldn't leap to the eon- dusl to it by < viro to v carat infir fron Tod imtu ably prot F< emp prot thre pers to 3 to si wori fectl and the act t The ride a si so s pleb It mor `plac alws ava . havi - who pea wor men fron the be; prai reef whe tiori of : thet natt win . as f com E me phy Industrial Nursing. wi elusion that these men are entirely useless nervous system. Like diseases of other organs to industry as they are now considered to be in the body the diseases of the nervous system by the armed sendees. In the proper en present many insoluble problems,to the physi vironment, with suitable attention being given cian and also present problems with which to what they can do as well as what they our medical science of the present can cope cannot do and with an understanding of their fairly adequately. The causes of some of infirmities valuable work can be obtained these mental illnesses are dearly understood, from these individuals and is being Obtained. general paralysis of the insane, for example, Today those who are concerned with max bring due to tfie same organism tint causes imum production at the factory may profit- syphilis. Other fitnesses in tins group have abljrtum their attention to such psychologic causes which are as poorly understood today problem cases and try to understand them. as is the cause of cancer. As a rule, a patient with a disorder of the nervous system which For the purposes' of the present paper the falls into this first groups comes to the at employees who present nervous or mental tention of an industrial physician or nurse or problems in industry can be divided into .' to'the attention of his private physician rela three basic groups. First, there are. those tively early in the course of his illness. This persons whom everyone considers noqual up is true bemuse bis sickness has canted him to a certain point in time when they begin some distress for which he series relief or to sbowsigns of mental abnormality. 'These persons around him, at home- or .at Wbrk; workers are similar to those who are per notice that he is not writ and urge him to fectly healthy op to a certain point in time- get medical attention. The early detection and then develop disease in other ports of and proper treatment of such cases is almost the body. Thor arer healthy^ work wdl and : as greet a. responsibility of industrial medi act normally oral mental illness strikes them. cine as the detection and treatment of tuber- f The severity of their illness can vary con ctdosts. ' siderably from being barely. noticeably like a slowly developing ntild deafness, to being . To describe all the disorders of the nervous so Severe as to incapacitate their victim com system which fall within tilts first group-, pletely just as a paralytic stroke will da would mean to write a text book of psychia Into the second group, which, is a much more numerous . one than the first, we may place employees who have always been and try and neurology. For purposes of fitastra? tion perhaps a brief description of one com mon nervous disorder will suffice. always will be considered different from the average person as far as> their mental be- . Types of Disorders t havior is concerned. They are like persons- The depressed phase of manic-depressive who have always been unusually tall or have , psychosis, an illness which is commonly peculiar shaped features in the face. In other known as melancholia, is a disorder with words,' from birth or early childhood the which industrial physicians; and nurses will mental makeup of these persons is* different7 have to cope frequently. Tim cause of tins from that which is considered .normal. From illness Is not known and its appearance in a the discussion which appears below, it will. worker-cannot be attributed to the living' be apparent that industry must learn to ap- conditions in which he finds himself. Up to - praise the defects in these persons, to cor- the time- lfats Alness begins the patient is . rect them when possible and to place them very apt to be a valuable employee because where their defects are not costly to produc quite often It affects those persons who have tion. The third and largest group consists . been particularly conscientious, intelligent, of persons we call' normal. * Among them industrious and of excellent character. For there are problems of a mental or psychologic no discernible reason tins worker (men and nature, which appear from time to tune and women are affected with about equal fre- which industry finds are often as important ; quency) begins to show many symptoms that . as the problems of buying and selling, their . impair his working efficiency and are respon commodities. , ~ sible for many absences from his -job.:; : Employees in the first group are obviously The patient begins to complain of fatigue medical problems and can best be handled by With little or no provocation for this. He physicians who understand diieases of the loses his previous keen interest in his job, in 162.. 31sf National Safety Congress his friends and even in his family. Severe There.are of course, dozens of illnesses in insomnia appears, especially the variety in - this group, some of which resemble die ex- which the patient is unable to sleep in the ample dted very closely, while others do not early morning hours. . The appetite falls off . resemble it at all. Some nervous disorders badly and with this there may be a marked disable a patient completdy and pennanendy loss in weight. The patient becomes appre . as well as quickly, whereas with; others a hensive and worries excessively about many long and useful industrial life is possible if things of little or no consequence. the case is properly handled. As in the case He develops many fears which .are often absurd in die light of the factsThut which are nevertheless real to the patjatt'andex'tremely disturbing. For example, he can be obsessed with the idea that he is about to lose his job or that he is going insane despite of tuberculosis or syphilis, the problem in these cases is to recognize diem .early and treat diem correcdy. That is..primarily the responsibility of industrial physicians and nurses but in a lesser degree of the commun ity and employer as well. die fact that everyone with a right to an opinion assures him that this is not true. A The "Dumb" and "Peculiar" very common complaint of these patients is that they cannot concentrate on their work and' that they find it difficult to keep up. They slow down in their rate of work and make many errors. A patient with this illness becomes depressed or sad for- no ap parent reason; he will weep on litde or no provocation; his feelings are hurt much more easily than usual; he becomes irritated and impatient much more quickly than in his nor mal condition. The second group of problem cases, of a,- -psychiatric nature within industry constitute a much more troublesome situation. The people who fall into this category are much more numerous in industry than die first group and their'shortcomings are very dif ficult if not impossible- to correct in many instances. These are die persons who from early life and as long as they live present abnormalities in their intelligence or per sonality traits. To put it into the language To complete their misery these patients of the streets, they have always, been and, develop numerous aches and pains in any or always will be "dumb" or "peculiar" or both; all parts of their body, winch are very dis how dumb and how peculiar they are varies tressing despite our inability to demonstrate greatly. It is these persons who are not . a basis of organic disease for them- Hcadache, sharply demarcated from normal persons. palpitation, dizzy spdls, indigestion, numb-, ness in the arms or legs, pain in the heart, and choking sensations in the throat can all : occur in this disorder and even be more alarming to the patient than his mental symp toms. . Just as it is impossible to say with finality y how tall a man must be before he is con sidered abnormally tall so we cannot say, . without resortmgto an artificial limit, how stupid a man must be before he is considered feebleminded. Again, like aU Gaul, we must On the other hand, this illness never leads to insanity as the average man uses this terms. The memory, judgment, reasoning ability and understanding of these patients suffer little or no impairment as a result of die disorder.' When it is over the patient can usually resume his old job with equal skill and reliability as was present before he became sick. The illness has its ups and downs. For no apparent reason it comes, for no apparent reason it gets better or worse for a few days or weeks and for no apparent reason it will disappear. The doctor's prob divide this group into three subdivisions, namely: the feebleminded, the.neurotic and die psychopathic. The' feebleminded or men tally deficient can'be dismissed here , with a few words. They are simply persons whose ; mental powers.remained at a childhood level while the rest of their body, matured to an adult level. The judgment; reasoning power, memory, initiative and knowledge of such persons is no greater than that of a normal child of 12, of eight or of four, depending on how severely retarded their mental develop ment has been. lem is to recognize this disorder to distinguish The neurotic group of persons, more ac it from many others which it may resemble curately spoken of as psychoneurotic, are and finally to offer medical aid, which fre persons with normal intelligence but their quently is very helpful. personality traits are such that they are often problem common the high teristic excited fended t formatk highly s pleasant woiksp such as the nob ded insi When easily" group. ^ he worl he may change errors a motherforeman very sex tng and accident summar of perse expend 1 that he When s one of t person' waysgc acts. P pulsrver thinks, enstome gained about h that hn dearly, .think th day. St He is ft intolera table, ir His i trial fat differen time^ tr He "bo ("; " ;> [j Industrial Nursing r. 163 I: ' problems inan Industrial establishment. We often with fittie intention of rqaying his f jcommohly call dim the excitable type or debts. He-clamours loudly about the mis thehigh strung sort of person. It is charac- treatment he receives from everyone and is i , .teristic for such an individual to become indignant if anyone intimates that he is none ; excited easily, to find fault easily, to be of- too perfect Boasting, lying, cheatmg, loaf fended easily and to be swayed easily in die ing, gambling, drinking^ fighting, and gram* formation of their opinions, dat is to be bling are a few of die acts by virtue of which highly suggestible. They bear strain or un- he is a burden to his family and a monkey pleasantness badly. They are upset and their wrench in the gears of industrial production. work spoiled by trivial unpleasant experiences such as a cross word from a gruff foreman, Often such a person is talented and simply j the noise of a gum dewing partner or a fan* must be tolerated. Occasionally work or ded insult home conditions can be so arranged that. Ids shortcomings.are overbalanced by his con When we say that a- man "goes to pieces ' tributions to an industrial establishment It easily" we mean that he. belongs in this is'also true that the milder instances of this groups As long as the circumstances in which type of person often become less troublesome he works, lives, and plays are to his liking as they pass from early adult life to middle be may be a valuable worker but if they life. To put it simply however, die psycho change his efficiency may suffer-`and his path is somebody's headache almost all the errors and accidents may increase. Let his time; ^ mother-in-law move into his bouse and his foreman may notice a change in his work . There are numerous facets to the problem very soon; let bis wife scold him one mom* of the psychopathic /personality which must mg and he is more apt to be cardess and be left unmentioned because of the limitation accident prone on that day. .Ibis may be of staTce'but all in ill they constitute a fas summarized by saying that th^ncqrotic type cinating,and challenging problem in society " of persoriis more easily upsetby unpleasant today. In industry,* m these times, we may experiences than one who is not neurotic add not be able to just discharge this kind of an i that he finds many more things unpleasant. employee; we may find' it necessary to learni 'j When morale has to take a 'pounding he is to get the best he can give and to pnt him in one of the weak finks inthe chain. a position where he can do die least harm. -The last type of individual in this trio is difficult to describe; bat be is trouble- : nonetheless. Typically the psychopathic ividual, or to give him bis full name, die person with a psychopathic personality is al ways getting into trouble because of his own acts. Perhaps his most constant trait is impulsiveness; he acts and speaks before be. thinks.' He talks bade to the foreman or customer first and later realizes that he has gained nothing thereby. He boasts or lies about his accomplishments and later learns that his lie has cost bun or bis company dearly. He gets drank before he stops to dunk that he won't be able to work die next day. Such a person is.often a troublemaker. He is frequently vain; extremely selfish, crud, intolerant; lazy, moody, not dependable, irri table; irresponsible or lacking in perseverance. IBs past record is often a series ofindnstrial failures; he has held many jobs at many different kinds of work for short periods of time; until he was fired or quit in' disgust HerTwrrows money indiscrimioatdy and The Noiibal Worker The problems presented by the feeble minded, neurotic add psychopathic are very difficult to solve in industry. Because of practical necessity industry cannot concern itself with die causes of these mental difficul ties but it .will pay. to understand these people better, to know- their limitations as well as their usefulness, to ascertain where possible changes can be made and to do die best with what we have. To successfully five and work with persons in this group is similar to learn ing to five and work in a war torn country. We don't like it; we can't understand how it happened; we didn't choose it; but we have just got to malm the best of it because that is the wisest course to follow. ^'Before leav ing this group it*should be pointed out that there are persons who show more or less of the traits found in all. of the three subgroups discussed. Transitions and combinations of defective intelligence, neurotic personality and psychopathic trends are not infrequently found in die same person. 31st National Safety Congress The last group of workers left to discuss are die normal ones. Again, we 'most realize that die psychologic or mental factors re lating to . the working' performance of die normal man or woman is a most complicated situation. The productivity of a worker may be said to rest upon or be determined bya triangle of forces. First, there is the per sonality and intelligence of the employee or put in another way, what kind of a man or woman we are dealing with. Is he smart or stupid, is he energetic or indolent, is he am bitious or contented, is he meticulcrasor care less and so on. How these various character traits came to be is a theoretical problem which does not concern die foreman or plant manager when John Jones walks in for a job, because the man is there in his tally molded state. But die kind of work he can entrust to- John Jones does depend on these traits for obvious reasons. enable him to understand ideas that increase iris health, safety, well being or his effitiency at work. They contend that employees are suspicious of employer sponsored education. The effect of an education program is said to be that of a "shot in die arm," brief and temporary. All in all they maintain that an educational program for employees is not worth die expenditure of tune ornwney that is entailed. An eloquent rebuttal to all these points is die mere fact that all employee groups, almost without exception, own or aspire to own a radio. They indulge in well known cigarettes or smoking or diewing to bacco and today they are buying war bonds or stamps. Advertising does it, most of us will agree, but what else is advertising but education of a potent nature. It is potent because it implants ideas by a simple, attrac tive and most important of all, by a con tinuous technique. The second force in the triangle is die en vironment to which die employee is exposed when he is away from his job af"home or at play, die combination of influences acting upon him through his wife, his children, his friends, his recreation, his diet, his state of health. iris-financial status, etc. Progressive employers would willingly pay good money to insure adequate sleep, proper recreation, adequate diet, freedom from economic wor ries, freedom from mental strain and free dom from illness in their employees because they are learning that these things are just as important to acddent free, high perform ance on the job as safety catches or dean washrooms in the factories. It is slowly be coming apparent to many that ignoring these factors in a large industrial establishment can cost as much as ignoring die quality of ma terials going into the manufactured product Effective education among employees must borrow the techniques of advertising. We must tax our ingenuity to sell ideas and at titudes to employees by malting diem attrac tive, interesting, and understandable to die particular group concerned. The program must appeal to die self interest of tbe em ployees mid it cannot be successful unless it is a continuous and well coordinated effort A continuous and well coordinated program of education sldllfuUy assembled can go a long-way toward assuring better physical and mental hygiene among employees, more ade quate rest and less harmful recreation, more consciousness and pride-in safe practices, both at work and away from work and more in terest in doing a certain job welL The pro gram, however, most be continuous and .coordinated, not sporadic and ill conceived and it must be genuinely directei toward the welfare of the employee. More than a year's In this connection it may be well to'digress experience with such a program has . amply for a few moments to discuss the value of sustained these opinions. education among employees as a means of controlling important off die job factors as well as those within the plant Education, ' Environment propaganda, or advertising:, depending on Returning to the third angle of forces your point of view, is without doubt one of - upon which worker performance depends,' /man's most potent weapons for getting some we come to those conditions to which he is - people to do as other people want them to. exposed at his . place of work. By these is In some quarters, however, die value of edu meant a complex web of all die things, per cation among industrial employees is looked sons, and attitudes he comes in contact with. upon as either useless or hopeless. Their These include his fellow workers. Iris super belief is that die intelligence of die average iors, his equipment or materials, his salary laborer is not such as to interest him or to and opportunity for improvement, his se $ curity in Iris the w and i other far m far fe these an al emplt irnfivi An or qt or ev not a or ar comp tadd from are * Tfc awaj atten their thee creal it n To i ness Pre. ai H Wh Con ice, nritl in i T tee die sisti nur vise this and Industrial Nursing 165 t corfty of tenure on die job, the interest shown in Ins initiative or efforts, the cleanliness of die workroom, its temperature and humidity' and its lighting equipment and dozens of other factors, some of which have teemed far more stress don they deserve and others far too little. -The extent to which each of these factors can be altered or the*effect such an alteration will have^in a specific place of employment varies, a great deal and is an individual problem for the management Any program intended to boost the amount or quality of sendee rendered by employees or even to decrease accidents and errors can not afford to ignore any of die three aspects or angles mentioned above. Most can be acr. complisbed in the way of correction by at tacking the last two angles, conditions away from work and conditions at work and both are equally important The importance of the second aspect, the away from die job factors, is receiving more attention from employers today. It is to their advantage they are finding to look into the dietary habits, personal problems and re creational habits of their employees because it means dollars and cents to their business. To put it in another way, progressive busi ness is concluding that what is good for its employees, either intide or outside of die plant; is also good for itself. The mental health of workers, we may summarize, offers many interesting prob lems whose ramifications are very wide. An understanding of these problems and at tempts to solve them means rewards in die form of more efficient industrial production, with less accidents and waste, from happier and healthier employees. Common sense as well as professional skill are needed. Fancy theories and confusing explanations will re tard die application of sound knowledge in industrial psychiatry. General principles have been stressed here rather than concrete solu tions for specific problems, because the topic is too large for such treatment and conditions vary from plant to plant and industry to in dustry. If the present discussion has stimu lated a desire to understand these problemsmore, fully and has shed , some light in what is still a dark corner of industrial medicine, its purpose is amply rewarded. The opinions or assertions contained herein are the private ones of the ivriter and are not to be construed as official or reflecting the views of the Navy Department or die naval service at large. THURSDAY AFTERNOON SESSION October 29, 1942 Presiding:--Christian Seabcook, R. N- Local Field Supvr., Metropolitan Life Insur ance Gx, Chicago Mrs. Seabrook introduced Miss Olive M. Whitlock, Associate Public Health Nursing Consultant of the U. S. Public Health Serv ice; told of some of the findings of the com mittee for the study of die duties of nurses in industry. The survey was done by a special commit tee of die Public Health Nursing Section of the American Public Health Association con sisting of several industrial and public health nurses. Before die* survey was begun an ad visory group laid out die plans for it and this advisory group is continuing its work and will prepare recommendations based on the findings of the survey. ' In 716 industrial establishments employing approximately 2,000,000 workers nursing ac tivities were carried bn by 2^257 full-time , registered nurses, 38 part-time registered ' nurses, and 567' non-professional people. The non-professional people were practical nurses, medical students, and first aid workers. Nineteen per cent of the plants employed fewer than 500 workers. Fifty-five per cent employed from 500 to 2,500 and 23 per cent employed over 2,500. Full-time physicians were employed in 23 166 J 31st NatiowI^Shfety Congress per cent of the plants, part-tune physical in 35 per cent and physicians on-call in 42 per cent. At least one full-time registered nurse was employed in 93 per cent of the establishments surveyed. Nursing services were established for the first time in 31 per cent of the establishments surveyed during the period from 1940 to 1942. Of 1,900 full-time registered nurses, 70 per cent began employment sometime during 1940 to 1942. In only 33 per cent of the plants where a .physician serves part-time or is on-call does the nurse have the guidance of written orders outlining the procedures to be fol lowed. r A wide variety of duties, professional and non-professional are performed by nurses. In 35 plants nurses are responsible for inspection of the cafeteria arid give dietary advice to cafeteria managers in 20 plants. Nurses in 12 plants manage the cafeteria of lunchroom. Miscellaneous non-professional duties in clude, .'clerical work, secretarial work, and personnel work. c ''l Prcsii Me l' ; V. ( Tht largeical : amoni ailmei to th crush: bodies above result ical c of th< Exj chemi break and t tion < .or im ing < pounc and c of d acrid* invar: body proce plays Ac! and s rives