Document reka3oMZrg2DV1KYrEeQL861V

This m9*zin it pubiitiiad to promsit tomd Hiouqlrt upon and eoncaminq industrial madicina and traumatic surqary. To ftiat and it will contain articles, nows items, reports, diqests and other presentations, toqethar with editors' comments. The editorial pol icy is to encourage frank discussion. On this basis contributions are invited. IMelM Req. U. S. Pat. Off. The editors will rrcise care in i inq on the acci. acy of data pi^., but in all other respects ertidee i opinions of which expression is atioU are the opinions of their authors-'^, editors reseryinq in all cases thejifl to comment on the same, in rent or any subsequent issue*,'as may be inclined. \f The Journal of Traumatic Surgery and Occupational Diseases \ , '.l&thi The Law, the Science and the Economics of Industrial j^lealth , Volume 5 JANUARY, 936 "i Jtumbif r.-v Physical Examinations of --An Echo from the Pre-Depression Era; Written by One Executive to Another, in 1930-- .. . ,VS-V:V\|' SERIES of surveys covering in all more they were hired are marked "unfit" and returned; A than 500 shops, showed that 30% require a to the employment manager, not to be potato, medical examination of all new employees work until their condition has been remediedvozv at the time of hiring; while an additional 3% rweork is found that they are well qualified todol* quire a partial examination of all new employees Those found to be unfit to perform any dasslbf' or a complete examination of certain classes. work in the plant, because of personal unclean)!/ Six plants were found which at one time oper ness or communicable diseases, etc.,- are markecT ated medical departments and required physical "rejected" and are not to be put on- the payroll/ examinations of new employees, but for various Reports received indicate that the total numbe?, reasons, generally sharp reductions in working of unfit and rejected applicants varies from 3% to forces, discontinued the practice. Of this number, 10%, (averaging 8.5%) dependent, of course, upon two have since re-established their medical serv individual plant requirements. - . y*. ice, two have medical examinations made by out Many of the larger plants have Mutual Aid side physicians, and two have given up the idea societies or group insurance,1 paying sick and ac entirely. These last two are operating with cident benefits; and in these plants the applicant forces of 85 and 26 people respectively. must be acceptable from an insurance standpoint According to statements made by executives, before he can be put to work. In some of these the purpose of the medical examination at the plants, the age of the applicant might bar him time of hiring is to determine the. applicant's, . from-employment,""while others recognize what physical fitness to do the work reqa red. - This- .. they, call,`a social responsibility for the "unem- does not mean that the applicant*for`a: job'as' pldyable" the sick, the lame, and the blind, tod blacksmith, for instance, must measu e up us `.a* , make; efforts to locate work where such men are certain physical specification such', at "must :Be. \ a&Jq & perform useful duties and earn their livings more than 30 years old, weigh betwt n 200 and One of the objections to the examination, on the 230 pounds, be 70 to 74 inches tall, ha* a 40-inch part of certain state authorities and organizgd[ reach, and be able to strike a 500-- und blow labor representatives, is based on the assumpItjJto with a 6-pound sledge". On the cc crary, the that the primary objective of the examinational examination is to determine whether >r not the to weed out undesirable employees. This idea is applicant can do work of this charac r without erroneous. Only those individuals reach the phy endangering Himself or his fellow wo men. sician's office who are acceptable from every It is obvious that an individual w . a hernia standpoint except that of physical condition. -The should not be employed as a blacks ith, or on employment manager does not hesitate to inform work requiring severe physical straii -he would the undesirable applicant that he cannot be plac be too apt to injure himself seriously, lor should ed. Usually this is done before the physicahedc* the individual with defective eyesigh' iigh blood amination is made. As one executive putsTfcg pressure, chronic heart trouble, or ilepsy, be "There are too many ways of getting rid of un-i employed as an overhead crane ope tor--he is desirable applicants to justify asking the doctor liable to cause an accident involvir injury or to lie about the man's condition. Besides, the do<fi even death to his fellow workmen. tor won't do it." /^ Generally speaking, the medical amination The examination need not be more detailed sorts applicants into three classes: ceptable" than is actually necessary. It accomplishes no "unfit", or "rejected". Those found be quali good purpose to make an elaborate examination fied to do the work for which they w hired are and then file the findings without using them:. marked "acceptable" and put `to v k. Those 41 concerns requiring physical examination':;^ found to be not qualified to do the wc for which new employees: Page 2 INDUSTRIAL MEDICINE January, 1936 28 include complete optical examination; ing to the National Industrial Conference Board, 6 include partial optical examination or vision costs on an average of $5.14 per employee per year. test; The American Management Association, in a 7 do not include optical examination. similar study, found an average cost of $6.89 per The examination of females need not be as employee per year. In this study, an average of strict as the examination of males. This is true $6.02 was found. because females as a rule are not required to Only estimates may be found as to the savings perform the class .of work done by the male. For effected by me'dical service and examinations. instance, hernia in the female is rare, and the These vary from $10 to nearly $500 per employee chance of injury so small as to be negligible. Of per year to the company, and similar amounts to 41 concerns requiring physical examination of the employee. Concrete evidence of value is to new employees: be found in reduced accidents and absenteeism. 17 do not employ females; One concern reports a 50% reduction in absentee 13 require examination of females also; ism, another a 30% reduction, and several be 4 require only partial examination of females; tween 20% and 30%. The National Industrial 7 do not require examination of females. Conference Board reported an accident rate for In the dispensary the choice of male or female 98 plants, requiring physical examination, of 1.56 nurse or physician is not important, but in the pre per employee per year, as against 1.92 for 105 employment examination, the "examination of plants without examination. Five years later the females should be conducted by a female physi Board made a similar study and found an accident cian or nurse. If this is impossible, a nurse or rate for 217 plants, requiring physical examina matron should be present during the examination. tion, of 1.66 per employee per year, as against 1.72 At all times, unnecessary exposure of the body is for 225 plants without the examination. avoided". Twenty-three plants have maintained records Of 41 concerns requiring examination of new of compensation insurance costs over a long per employees, 17 have periodical examinations as iod of years, and from time to time have made follows: studies of the effect of medical examinations upon 2, all employees annually; their insurance costs. The average reduction in 1, all employees biennially; compensation insurance costs reported by these 1, all employees semi-annually; concerns amounts to 20.12% of the annual prem 3, executives and foremen annually; ium, the maximum reduction reported being 60%, 2, voluntary annually. the minimum being .35 of 1%. This average re One employer requires a medical examination of all employees at the time of hiring, at which time a record of the individual examination is made and the workman informed of the findings. Six months later, the employee is again subject to a medical examination. If his condition has continued good or his ailment improved, and his work has been satisfactory, he is then considered a permanent employee and is eligible to join the Mutual Aid society. According to the returns of 370 concerns: 36 employ physicians on a full time basis (Yearly or monthly salary, all work tioneun . plant hospital); : 39 employ physicians on a part time . basis' (Monthly retainer fee, physician- spending ; one or more hours daily at plant, wci-k being ' done either at plant dispensary or else where) ; duction in compensation costs of 20% covers only those items that may be directly measured and does not take into account intangibles; such as, earlier recovery from accidents due to good physical conditions, and less severity due to ab sence of complications, etc. In answering the question: "What effect does medical examination have on your industrial relations?" 40 concerns report as follows: 8, no effect; 6, good effect, satisfactory effect, etc.; 5, helps to place employees in right position; .. 4, prevents a spread of disease; - .4,-.eJimjiates maligners and other undesirables; 3, Welcomed by employees; *.3>.provides.personal touch and boosts goodwill; . ;3, reduces.* compensation cost; ' 2, saves tixh'e and man-power; 2, selects better class of employees. 9 employ physicians on a cooperative basis (Yearly or monthly salary, paid pro-rata by Prevention of Disability several neighborhood employers, work done in local dispensary. Expenses paid by in the Management of Street Injuries physician out of his own pocket); By George L. Apfelbach, MD * 286 employ physicians on a straight time basis. Chicago, Illinois (Employer billed monthly for all work done on his order. Sometimes employer is billed for each case as it is closed. Cases gener ally sent to one selected physician, although a few leave choice of physician up to the em ployee) . The cost of physical examinations varies con siderably, very few concerns reporting this item, and those being employers who use outside physicians with fees varying from $1.00 to $3.00 per examination. General medical service, including all examina- HE old timers' idea of street accidents con Tsisted of horse and buggy accidents, stab and gunshot wounds. Although we now have quite a few window jumpers, most of our street injuries are due to the automobile. Injuries occur more commonly to pedestrians than to the occupants of the auto. In the former we commonly find bumper fractures of the leg whereas in the latter we encounter more com- ' monly trauma to the head, chest, and spine. Frac ture of the pelvis formerly uncommon in females o-\+c eimnlioc calari^Q oto accorfi* * From a Radio Talk by Dr. Apfelbach, S.atiou WAAF, September 27, Vol. 5, No. 1 INDUSTRIAL MEDICINE Page 3 is frequently seen in one of the three ladies on provided with first aid equipment, including blan the back seat. The automobile has made multiple kets. Thomas splints and bandages. Every person fractures common. should carry an identification card requesting that Disabilities following accidents are due not only he be taken to certain hospitals in case of injury. to broken bones with resulting deformity, but also The second weak link in the treatment of street to joint, ligament, muscle, blood vessel and nerve accidents is the lack of equipment. We do not injuries. The more fatal injuries are those of the blame the hospital, for equipment and the care of head, spine an'd spinal cord, and of the organs the injured cost money. Some institutions give of the chest and abdomen, known as internal in this service for tax exemption, others cannot. A juries. Even if death does not occur immediate street accident ends in a liability argument; no ly it may result later from infection, gangrene and one pays, and if there is a settlement the Samari blood clots or embolism. tan services of the doctor and hospital are forgot The ratio of casualties to death in automobile ten. accidents is, no doubt, greater than that of war The medical profession and hospital associations fare. Battle gunshots produce great shattering of have for years advised our legislative solons. that bones, with frequent severe infections such as tet we cannot carry the financial burden of street ac anus and gas gangrene. Street accidents, how cidents; that a lien law would make this possible. ever, have the same hazard in a lesser degree, but Lawyers and undertakers have this protection. A are more often disabling because of multiple frac lien law which guarantees payment to the doctor tures. The medical profession saves many lives and the hospital is only fair. It is, however, more annually by giving tetanus antitoxin and serum important to your interest since it determines the against gas gangrene in street injuries. welfare of your life and limb. A compound fracture is a broken bone with an Even with the best of medical care street injur open wound exposing the bones to street dirt. ies are followed by disabilities. It is our object to Fifty years ago they always became infected, and minimize these. The surgeon thinks first of his ended most frequently in amputation or death. patient's life, then he considers in importance, Medical science has reduced this danger, so that saving the limb, bringing about a good functional we seldom see such a result. The public must learn result, and, lastly and not so important, an exact that a compound fracture is even a greater emer anatomical apposition of the broken bones. Don't gency than appendicitis, and that the wound must become alarmed if you see an x-ray of your frac be cared for and the fracture reduced as well as ture and find the bones not perfectly lined up. possible within four hours of the accident. Every Your result may be very satisfactory. well-trained surgeon realizes this, and that any The important things to remember in case of ac manipulation of the broken bone after this period cidents are: usually brings on infection. 1. Do not allow yourself to be moved in case of I wish to correct a fallacy in the public mind injury without splinting the injured part. that wound infection can be prevented by the use 2. Do not place your faith in iodine, but rather of iodine or other chemicals. The only and best in a competent physician when wounded. antiseptic known in wound surgery is the sur 3. A compound fracture is an emergency which geon's scalpel. Sharply incised wounds are seldom may end in loss of life or limb, and should be infected, contused ragged wounds usually are. taken care of within four hours. No surgeon depends on iodine: he relies entirely 4. Demand of your city government more effi on removing coarse dirt with sterile forceps, and cient transportation of the injured. on turning the wound into one with clean cut 5. Do not lose patience with hospitals in not giv edges by excising all contused and damaged tis ing you all the service you need. They have been sue. imposed upon for a long time, and they need your Before all this is done the injured must have help in obtaining a state lien law to secure just been treated for shock by prompt relief measures. compensation in handling street accidents. To prevent infection the injured part must be kept at complete rest, for further trauma invites infection. The Traumatic Fakir The weak link in handling street accidents is the removal of the injured from the site of the Cases from Personal Experience accident to the hospital. Sir Percival Pott, in 1757, By Frank F. Hammond, M. D.* long before any knowledge of wound infection, Active Surgical Staff, Woodlawn Hospital; refused to be carried to a hospital until his com Traumatic Surgery Dept., Chicago pound fracture of the leg had been splinted. He then was carried to the hospital on a door, show Medical School, Chicago. ing far greater judgment than is shown today by our police ambulances. Eleven per cent of our population die of acci dent, a greater percentage are maimed. You wor ry about your blood pressure and are eating large NE of our rules in detecting a fakir, as O stated in a former article,1 may be worth repeating: When the history does not ring true, when the complaints do not tally with the superficial findings, we doubt the claims. Once quantities of vitamins. Have you ever worried the surgeon has reasons to doubt the claims he how you will fare if injured on the street? Will will use all the ammunition at his command to your leg be properly splinted? Will you be treated determine the facts. A sincere, thorough and . for shock? Will you be transported to the hospital painstaking physical examination, including nec without making your injury still worse? A great essary laboratory tests, culminates in a final cause for future disability is the manner in which diagnosis. Efficiency plus honesty places that street injuries are mauled and hauled about. Page 4 INDUSTRIAL MEDICINE January, 1936 diagnosis above any and all complaints and claims that do not coordinate with the findings reached in making that diagnosis. Is it too arbitrary to state further that, when the complaints do not coincide with the ultimate findings, the claims should be considered false and exaggerated? The fakir in making false and exaggerated claims, though appearing sincere has, as a gen eral rule, an ulterior purpose in view. That ul terior purpose is money. The hysterical patient may only want sympathy, but the fakir wants something more substantial. It is human to sympathize with suffering individuals. Medical men are human. But the doctor should not allow sympathy to run away with his good judgment. His judgment should be based upon history, symptoms and findings, all of which have a back ground of knowledge of physiology, anatomy and pathology of human tissues and their reactions. This total knowledge gives the surgeon a definite opinion as to reactions of trauma and approxi mately the amount of pain resulting. Again, when the complaints of pain do not tally with the surgeon's knowledge of trauma reactions he should doubt the claim. The traumatic surgeon doing any reasonable volume of work meets some of these unreasonable claims every day of his life. By this experience he is best able to cope with them. To avoid criticism that we are prejudiced against the injured in favor of others concerned we must state again, as in a former article,2 that we always give the injured the first consideration in treatment, interpreting symptoms, listening to complaints, and in the final diagnosis and report ing end results. Innumerable examples may be cited. Let me start with a recent one, though minor. Last night a young man. aged 24, while inebriated became rowdy and refractory in a hotel lobby. In order to stop him it appeared necessary for the hotel clerk to "punch him in the face". The result was two "black" eyes, and we were called by the hotel management to attend him. The symptoms: Alcoholism; pain of face, re gion of both eyes. The findings: Inebriation: contusion and ec- chymosis, region both orbits; sub-ocular conjunc tival hemorrhage left eye; cornea and eyeballs intact and uninjured. The treatment: Argyrol and boric compresses. Today (the morning after the altercation): Eyes ecchymotic, left subconjunctival hemorrhage lessened, eye sight not involved; general physical condition good. The complaints: "Cannot see like I did; head ache, chest pains, abdomen sore and painful; must stay in bed". Examination of head, arms, chest and abdomen revealed nothing more than a probable "sick" stomach, due to acknowledged drinking. When told he could be up and about he remon strated that he was unable. When told he would be able to be out and around in a day or two he made it plain that he intended to stay in bed, at least in his room. Before we left he said his law yer would get in touch with us soon if he had not -1,------A.. A-------------- tt our findings to his attorney. Are attorneys prac ticing medicine? Is the lawyer or is the doctor the one to say when an injured man may be up and about? Which one of the three (lawyer, patient, doctor) should be the one to decide the length of disability and when incapacitation ends? It suffices to state that our records will reveal the facts and record the end results, regardless of "pressure" from other or outside sources. Another recent illustrative case is that of W. M. T., age 35, in apparent good general health. Bending forward and limping, he came to our office complaining of severe "back" injury. History: Carrying his own tray in a cafeteria, he slipped on wet food on the floor and fell, strik ing buttocks. Inspection: While disrobing, his actions and body movements, including expressions of pain, appeared unnatural even for a patient with frac tured coccyx. Examination: This was difficult, because co operation was lacking, and it appeared to cause him excruciating pain even to lie on the table or turn on his belly. He flinched and objected at the slightest palpation of the lumbar and buttocks re gions. With a gloved and lubricated finger it was next to impossible to make a rectal examination. Treatment: When it was determined that the coccyx was intact, and recorded mentally that there were no external objective signs of contu sion, he was given radiant heat and massage. Subsequent Events: When he called next day, according to appointment, a casualty adjuster was at the office with a photographer concealed. Within 20 minutes his confession of purposely faking the fall was obtained. The photographer's "flash" was the "shot" that inspired him to leave the city rather than the prospect of boarding at the bridewell. One of the most outstanding cases in recent years of false and exaggerated claims for the sole purpose of obtaining money (insurance) was a colored youngster between five and six years of age. This was outstanding in our experience, be cause a boy of that age is naturally frank, honest and dependable with reference to symptoms of physical ailments, even though parents attempt to create in him the elements of exaggeration. We will only "sentence outline" the high points in depicting the case: He was struck by an auto mobile, injuring his right ankle, and was trans ported to the hospital in an auto. "Brush burn", external malleolus. Two-view x-ray showed no bony involvement. Ankle dressed and bandaged. He was taken home. On residence call, next day, there was no noticable swelling; and there was no infection at the second residence call four days later. We asked the mother to bring the boy to our office a week later. Four days subsequently the mother telephoned: "Boy can't walk; won't you come and treat him?" Forced to respond with another residence call, in our opinion the boy had almost completely recovered. The par- rents were told to bring the boy to our office in a week for a final check-up. When the week was up the father telephoned: "Boy can't get about: he can't walk; he cries with pain," etc. We told the father to bring the boy to the office ----I 1-- . ' *' ... 1936 Vol. 5, No. 1 INDUSTRIAL MEDICINE Page 5 rac- Examination revealed complete recovery. Dur stances should be entirely prohibited, and whether ctoj ing encouraging conversation, we put the boy's it would be possible to use other preparations that shoes on and aided him from the couch to a are free from arsenic (for instance, pyrethrum or standing position on the floor. The boy shrieked nicotine). the with "pain", and crumpled toward the right to the Half of the 50 patients were observed by Prof. ids? floor! During the examination the father now and Ziegler in the polyclinic. The arsenic content of the again injected words into the conversation such the parasiticides amounts to from 4.3 to 7.3%. The of as: "pain"; "cries at night"; "can't walk"; "never most severe symptoms of poisoning occur almost be well again", etc. exclusively in dry, volcanic regions. The disorder W. We must take command! The problem was attacks men almost exclusively. The "house drink," ilth. how? Modus operandi? We spelled these words: which is consumed in large quantities, is obtained our "D-a-d, w-a-t-c-h m-e, s-a-y n-o-t-h-i-n-g. U-n- by hard pressing of the grape husks; it contains d-e-r-s-t-a-n-d? S-a-y n-o-t-h-i-n-g." We attach arsenic and is a contributory factory but rarely ;ria, ed the fluoroscope in next room, lights off; asked the only cause. rik- the father to come in and see the bones' in his The acute symptoms seem as a rule to disappear hand. All interest centered on the fluoroscope within a few days. In some cases, signs of chronic and and its wonders. We took Jack by the hand asenic impairment develop after work is resumed ain, and he walked, for a look at his bones. We with the parasiticides. These are not simply su rac- thought the game was won, but, the excitement of perficial irritations but a vital, universal damaging the fluoroscope gone. Jack reverted to pain-cry of the tissues, resulting from the absorption of co- psychology. Next we asked him if he had a little arsenic. The respiratory tract apparently is the iuse sister at home. He had. "We want to show you most important resorption surface. During this 2 or how to have a lot of fun with her". A strip of stage the most noticeable symptoms are those of the adhesive tape "shackled" his hands together. the skin, characterized by hyperkeratoses on the re- Creating interest and emphasizing the fun he was inner and outer surfaces of the hands, the soles of was going to have, we had him on his feet. With the feet and the toes. Later there usually appears ion. another strip of adhesive attached to the cross a small-flecked melanosis of the skin and other the bar between his hands and leading to a finger of well-known changes. That the nervous system is hat the operator, the boy was led out of the office, involved is indicated by abnormal moods, depres ltulay. down the hallway, down the elevator, and on to the sidewalk--without a limp, complaint or ex pression of discomfort, but on the contrary all sion, disturbances in the memory and polyneuritis, usually of the sensory type, and particularly a hy persensitivity to cold. There are disturbances in f the evidences of enjoyment! the sympathetic and endocrine systems indicated L. There was no subsequent evidence of pushing by loss of tonus, disturbances in the vasomotor ely er's litigation by the father or other interested per sons. regulations, impotence, hyperglycemia and true diabetic glycosurias. ave at ent ole 3a of Why do we announce this as an exceptional or outstanding case within the realm .of Traumatic Fakirs? Because of the immaturity of the in jured and his almost perfect showmanship. The acting in our opinion was vicarious, instigated by the parents or others. In case of cirrhosis of the liver, it is possible that both alcohol and arsenic impair the hepatic paren chyma and that these two damaging factors pro mote each other. The same applies to hemochro matosis. The course of the disease differs in the individual cases. Complete cures have been ob served after elimination of the causal factors. Gen Arsenic Poisoningbe- erally the disease takes an unfavorable course and est may be drawn out over a number of years. The of mortality so far has amounted to 16%. Limitation opt ARSENIC poisoning after the drinking of wine of working capacity is considerable, even in mild i. h\ was reported in J.A.M.A., July 23,1932, page cases. The treatment should begin even in acute nts A X 319. A systematic study of this problem, cases by administering absorptive substances. In -to however, seems to have been conducted only re chronic cases the intravenous administration of ns il", no ed. cently, even though chronic arsenic poisoning of this origin has been observed for years in the wine growing regions of Baden. The disorder is sur prisingly frequent in the wine-growing region of from 10 to 20 cc. of a 5% solution of sodium thio sulphate is advisable. Later, liver preparations, borax baths and sulphur-salicylic ointment may be applied. The protective measures are of especial ay. no iys to tly the Kaiserstuhl. Because some of the cases were considered occupational diseases, the federal min istry of the interior appointed a committee of ex perts, under the directorship of Prof. Uhlenhuth, to make an investigation.* importance.Chemical studies are being made, particularly on the amount of arsenic in the "house drink." As was to be expected, considerable quantities of arse nic were detected in the hair of the patients. P't ind Occupational Disease Report:he f investigation considered the manner in & which the arsenical spraying preparations are em ployed in the vineyards, the famalial hypersensi tivity and also other factors, among which prob r ably the excessive consumption of the wine, with R. A. R. LARRAIN presented the following >ek D=et :tc. ice lat ?d. damaging effect on the liver, plays the most report of the Special Committee on Oc : * important part. The patients are usually strong cupational Disease of the Chicago Medical drinkers and many of them have cirrhosis of the Society to the Council: * hver. According to the lecture by Uhlenhuth be- "An occupational disease as it is defined in the r fore the medical society in Freiburg, it has to be average standard Medical dictionary is one due to determined whether the arsenical dusting sub one's employment. Such definition of necessity Page 6 INDUSTRIAL MEDICINE January, 193( is very ambiguous, and reveals the chaotic state of this important field of medical practice. "Wesley M. Graff, Director of Conservation of the National Bureau of Casualty and Surety Un derwriters, representing 40 casualty companies, said at the last meeting of the State and Provin cial Health Authorities that: `In the last few years occupational disease claims have grown at an alarming rate. They represent today one of the important problems of industry'. "For the past few years, a number of national organizations have become aware of the increas ing importance of the influence of industrial haz ards on the general health of the industrial popu lation and particularly the social, economic and medicolegal aspects of disease inherent or influ enced by occupation. It is the opinion of the Committee that these activities of lay organiza tions if not properly directed, may seriously affect the practice of medicine in the near future. To support this contention we quote the following resolution approved at the last meeting of the American Public Health Association: " `Unhealthful occupational environment con stitutes an important and widespread cause of in creased morbidity and mortality among the large group of wage earners and among the general population. " `Resolved, That it is a function of the depart ment of health to include as an integral part of a complete public health program the protection .of the population against health hazards resulting from unhealthful working environment . . . and recommends to each state health department of an industrial state the establishment of a bureau or division of occupational diseases or industrial hygiene under the supervision of a physician trained in public health and industrial hygiene, with adequate technical and laboratory facilities and personnel, empowered to make investigations of working environment, for the control of in dustrial health hazards and the prevention of oc cupational diseases.' "The Committee seriously questions the ad visability of placing such an important field of medical practice in a Bureau which of necessity will be influenced by the social political activities of the groups in power. "In 1911 the Legislature of the State of Illinois became cognizant of the industrial hazards within the state, and in order to remedy the situation they passed two separate and unrelated acts. These acts being in all probability drawn without active counsel or participation of organized med icine, are known as the Occupational Disease and the Workmen's Compensation. The former gave the right to employees to seek redress by a law suit in a court of common law. The latter made it possible for an employee accidentally injured while at work to receive definitely stipulated amounts of compensation through an industrial commission which was created for the purpose of administering such claims. Under this Act, such claims were automatically recognized and paid, hence the right of lawsuit in a court of common law was not given to these claimants. "Section I of the Occupational Diseases Act provided in substance that every employer en gaged in any work which may'produce illness peculiar to that work shall, for the protection of his employees, adopt and provide reasonable and approved devices, means and methods for preven tion of such industrial or occupational diseases "Section II of the Act specifically named certair kinds of work as being particularly dangerous tc the health of employees, such as the manufacture of brass, the melting of lead, processes using white lead or Paris green, etc., and named definite precautions to be taken by employers in desig nated causes, e. g., the furnishing and use of proper clothing, respirators, ventilators, etc. "In 1923, an amendment was made to the Oc cupational Diseases Act which provided that re dress for employees diseased by the extra-haz ardous occupations specified in Section H would be subject to the same conditions and would re ceive the same amount of compensation as those mentioned in the Workmen's Compensation Act for accidental injuries, and the Industrial Com mission was given jurisdiction over the adminis tration of such claims. "Thus, the right of redress by lawsuit was taken away from all employees diseased while employed in those occupations specifically designated in Section II. "The amendment, however, did not affect those cases which were covered by Section I of the Oc cupational Diseases Act, these retaining their right or redress by lawsuit in a court of common law. "Between 1929 and 1935 a large number of lawsuits were filed by employees claiming dis ability from pneumonoconiosis due to the inhala tion of injurious dusts during employment. These included cases of carborundomosis, anthracosis, bituminosis, siderosis, etc. "Dust diseases, not having been specifically named in Section II of the Occupational Diseases Act, the attorneys for these plaintiffs based their claims on Section I of the Act, which still gave the right of redress by lawsuit. Most of those suits were for amounts up to $25,000. In many cases juries awarded damages up to $24,000, to the point that these claims reached alarming pro portions and threatened to bring financial col lapse of some of the insurance companies and manufacturers. These companies appealed to the Supreme Court of the State of Illinois, and this body on April 25, 1935, rendered a decision in which it held that Section I of the Occupational Disease Act violated the Constitution of the State and the 14th Amendment to the Federal Constitu tion. The Court also inferred that Section II of the Act may constitute an unlawful delegation of legislative power to an administrative body or to courts and juries. Thus there is at present no redress for those suffering from any Occupational Disease not as specifically mentioned in Section II of the Act; therefore, the need for proper legislation on this problem is vital and immedi ate. "At the last session of the Legislature efforts were made unsuccessfully to pass an Occupation al Disease Act. The Committee understands that the present special session of the Legislature will consider a bill which apparently has been drafted by the manufacturers in cooperation with the of ficial labor organizations and which to all in tents and purposes covers fairly this problem. Your Committee has not been able to secure a copy of this bill and understands that it has not been finallv drafted or re)pa.d *** -- Vol. 5, No. 1 INDUSTRIAL MEDICINE Page 7 "In conclusion, your Committee wishes to make ability to do work requiring physical exertion was the following recommendations: greatly diminished, if he could be said to be able to "1. That the Society should take a very active do it at all. Nevertheless, Pemovich's employer interest in the problem of occupational diseases and the company's insurance carrier contended and offer that type of counsel and leadership com that he had suffered no compensable injury in the patible to the best interest of organized medicine course of his employment with the North End and public welfare and to this extent it should Foundry Company. engage through this Committee and in coopera Disability within the meaning of the statute, tion with other committees, affiliated societies said the Supreme Court, occurs when an em and branch organizations in an educational pro ployee is disabled from rendering further service; gram to acquaint the medical profession of this that is, when he no longer has physical ability To State of the various industrial hazards and their perform his work in the usual and customary way. proper recognition. Unless he is so disabled he sustained no compens "2. To make an investigation of the attitude of able injury even though in the course of his em the medical schools located in Chicago to ascer ployment he is subjected to conditions that con tain what their present ideas are concerning the tribute to disability as an end result. The right of teaching of industrial hygiene. Surely it is patent an employee to cqmpensation depends on whether that the young blood coming up to the front con or not, in the course of his employment and be tinually should be exposed to the fundamentals of cause of it, an occupational disease renders him this important field. In no other way can we ex incapable of performing his customary work. pect to develop men who will be properly pre It has been argued, said the court, that if an pared. employee is entitled to compensation, as he is "3. The Committee requests authorization to when he voluntarily ceases work because of physi contact the various organizations and agencies cal incapacity to continue, then an employee who dealing with the occupational disease problem is discharged by his employer because of potential and in general with those related to industrial physical disability is equally entitled to compensa hygiene, that it may be in a better position to en tion. For the latter contingency, however, the lighten the Council with its findings. present law, which, was framed to cover injuries "Respectfully submitted: G. Henry Mundt; M. - resulting from accident, rather than incapacity re C.J. Hubeny; W. Hammond; D. H. Levinthal; A. sulting from occupational disease, affords no re R. Larrain, Chairman. lief. An employee who has been exposed to indus "Motion was carried that the report be adopted." trial hazards, who has suffered no "physical dis ability" that prevents his performing his work in Silicosis and Tuberculosis his usual and customary way, and who is dis charged because an examination discloses that THE NORTH End Foundry Company had to reinsure its employees. The prospective in surer demanded as a condition precedent to the execution of a policy that all emplovees be amined by a physician selected by it. Before the such disability may arise in the future, is not en titled to compensation for "medical dlsabilitv." It has been argued that it is against public policy etwoxhpoehrmasit an employer been exposed to to discharge an employee industrial hazards, in order to anticipate his employee's future disability. examination was made, all employees were dis charged. Only those were reemployed who were That, however, said the Supreme Court, is a prob lem for the legislature and not for the courts. The believed to be physically fit for the duties to be imposed on them. Five employees who were not reemployed, because they were not physically fit, courts can do nothing more than interpret and ad minister the statute. The remedy lies solely with the legislature. were awarded compensation by the industrial Finding no evidence to show that the claimants commission, under the Wisconsin workmen's com pensation act. Thereupon their employer and its suffered disability within the meaning of the law during the period of their employment with the insurance carrier brought actions against the com North End Foundry Company, nor until after the mission and the several claimants to set aside the relation of employer and employee had been term awards. From a judgment modifying and affirm ing the award in each case, the industrial com inated, the judgments of the courts below in the several cases were reversed and remanded with in mission, the several claimants, the employer and the employer's insurance carrier all appealed to the Supreme Court of Wisconsin. structions to enter judgments setting aside the awards of the industrial commission. The Supreme Court based its decision* on the case of one claimant, Pernovich, as the same ques "Error!" tions were involved in all cases. Pernovich, be Afore he was discharged, had worked steadily. He was not aware that he was suffering from any dis FAITH healer's dog fell down the porch steps, hurting his leg a little, and his feelings a lot, ease. The physical examination, however, showed that he had had silicosis for probably five years or more and was in the second stage of that disease and that tuberculosis had already developed. Al though at the time of the examination Pernovich was able to perform at his work, his chance of re covery would be diminished if he remained in the dusty employment in which he had been engaged. Reexamination three months later showed that his . But, as would be expected, he talked himself out of it; all the way down he proclaimed loudly, "Error/ Error/" This is apropos of the fact that we had our own feelings considerably hurt, in our December issue--through one of those inadvert ences which, with the fear that they will happen' sometime, haunt an editor's life. A portion of Dr. James W. Ferguson's article on "Pneumokoniosis and Its Social Effects" was omitted. In justice to r>.. tt____ ______ ____ ____ it. - -.a: -------------- rfi-w- Metatarsal and Phalangeal Fractures --One Splintfor All Fractures of the Metatarsals and Phalanges-- by N AN active indus I trial dispensary, where a consider able number of cases are Geo. G. Davis, M.D., F.A.C.S.* Chief Surgeon, The United States Fuel Company THE evolution of this splint, originally de signed for fractures of the metatarsals only, is cared for as "new cases" interesting. Dr. F. W. and also as "redressings," a planned program of Merritt, of the Illinois Steel Company, Gary Works treatment of all fractures is desirable. Hospital, and the writer, have modeled and re When a fracture case arrives at the dispensary or modeled and experimented with the application of, hospital it is not the time for a piece of research and noted results obtained with, this splint for work on treatment of fractures, or the time to im over a decade. And we believe that the splint still provise a splint for any special fracture. Treat can be improved, and we are having considerable ment for every fracture should be planned in ad enjoyment striving for that improvement. vance. Incidentally it is noted that the hospital and Fig. 1. Evolution of the splint. In shaping the first splints for metatarsal fractures, (left above) no provision was made for traction. A later splint (right) provided traction, but the arch was too far posteriorly and there was no provision for fractures of individual phalanges Fractures of the metatarsals and their corre sponding phalanges are quite common. A malunion of the metatarsals may cause great disability, and result in a rather painful foot. Angulation and displacement of fracture fragments of the phalanges result frequently from lack of a defi nite plan for caring for such fractures. In crushing injuries of the foot with compound fractures, the wound will need frequent dress ings and re-applications of the splint for care of the fractures. Fig. 3. Dorsal view of the application of the splint, bound to the toes and foot with ad hesive, for multiple fractures of toes or meta tarsals or both toes and metatarsals combin ed. (See Fig. 4) dispensary staff are taking a greater interest in these small but important fractures, that better results are being obtained, and that the amount of permanent disability is accordingly decreased, which from an industrial point of view is impor tant in these days. Fig. 2. Evolution of the metatarsal splint: an early model which lacked the slits for the phalanges and p<`ovd too heavy and cum bersome Fractures of the metatarsals call for a splint that will conform to the concave arc of the plan tar surface of the bones, and also exert extension on the distal fragments, for any or all metatarsals of the foot. Fractures of the foot phalanges re quire a splint that will allow splinting, and hold ing in place by adhesive, of any or all fractures of one or five toes of the foot. Fig. 4. Lateral view of the application of the splint, bound to the toes and foot with adhe sive, for multiple fractures of the toes or metatarsals or both toes and metatarsals combined The first metatarsal srvlint 'Ficr 1 was mndolo/t Vol. 5, No. 1 INDUSTRIAL MEDICINE Page9 This splint helped to correct the position of the fragments and held them in place if there was no great deformity. However, where angulation and especially over-riding of fragments occurred it was evident that traction was necessary to correct that pathology. Accordingly a new model was designed to retain the convex surface and also to provide for traction, Fig. 1, right, (Fig. 2). At about this stage of the development of the tion of the distal fragment of the fractured meta tarsal. To keep up the traction and to prevent the splint from slipping anteriorly, a new model, Fig. 5, was designed. In this splint six slits for passage of adhesive were made; two on either side, to bind the splint firmly to the foot, and two posteriorly for adhesive to tape the posterior end of the splint over the ankle, like a strap at the back of a roller skate, to keep the heel well back on the splint and the splint well forward on the heel. With the modeling of the splint with four slits and five projections, a wider projection was made on the median side of the splint for the big toe, Fig. 6. This, however, made it necessary to have Fir. 5. Evolution of the metatarsal splint: four slits and five projections for binding the phalanges to splint with adhesive: two lateral slits on either side for adhesive: two slits pos teriorly for adhesive to keep the splint tight to the heel that traction may be sustained on the metatarsal fragments splint the question of application of traction of the distal fragments was presented. Traction was then provided by applying adhesive to the toes, like" a Buck's extension of the femur, and bringing the adhesive over the anterior end of the splint. Then it was noted that the frequent association of fractures of the phalanges with metatarsal frac tures demanded attention. A new model, Fig. 3, with four slits and five finger-like splints was de signed. This was a decided improvement, in that Fig. 7. Splint applied to foot with adhesive, for fracture of 1st metatarsal and proximal phalanx of 1st digit two new features were provided: first, fractures of the phalanges of the toes could be splinted with adhesive to these projections; second, the toes could be taped to the projections and then the splint pushed forward, thus exerting extension on the distal fragments of the fractured metatar sal bones, Fig. 4. Adhesive about the splint and over the dorsam of the foot and about the heel holds the splint in place and keeps up the trac Fig. 6. Hallux valgus accompanying frac ture of a phalanx of the great toe or of the 1st metatarsal complicates the method of traction. This is accomplished by using the next lateral digit of the splint to apply the traction in the slanting direction of the toe. two types of splints, one for the right foot and one for the left foot. To overcome the two-splint problem, a new model was designed with five slits and six projections. Thus two projections could be used for the big toe, and one splint could be used for either the right or the left foot. This splint as now used is shown in Fig. 10, with two views giving the dimensions. It is noted that there are five slits and six finger-like projections, two of which may be used on either side for a big toe. This makes one splint do for either foot. FOR metatarsal fractures two points are to be observed in the application of this splint: one, to have the convex surface of the splint pressedwell up at the site of the fracture; two, to apply the extension in such a manner that it will be con tinuous. This may be done by placing adhesive tape about the toes, as in a Buck's extension, and bringing it over the corresponding finger-like pro- page 10 INDUSTRIAL MEDICINE January, 19 Fig. 8. Case 3064, 1923. Fracture of proxi mal phalanx, first dixit: left, dorso-plantar view and right, lateral view before applica tion of splint. ..The' lateral view shows the common deformity .of dorsal displacement of the distal fragment. (See Fig. 9) Fig. 9. Case 3064, 1923. Fracture of proxi mal phalanx first digit, (see Fig. 9): left, dor so-plantar view and right, lateral view after application of splint with traction. The de formity of dorsal dislocation of the distal fragment has been corrected jection of the splint and fastening it. The splint then is pushed forward to obtain traction, and when this extension, has been secured the splint is anchored to the foot with broad bands of adhe sive over the dorsum of the foot, Figs. 3, 4, 6, 8, and also about the heel to keep the splint from slipping posteriorly. For phalangeal fractures, 'the finger-like projec tions offer an excellent splint for any or all frac tures of the toes. Adhesive may be taped over each of the phalanges and, if extension of the proxima. or middle phalanx fragment is desired, the distal phalanx may be taped first to the splint and then by pushing the splint forward, the desired amount of traction may be obtained and the phalanges and foot held in correct position on the splint. Particular attention might well be directed to the fracture of the distal end of the first phalanx of the great toe, Figs. 9, 10, 11, 12. The rotation dorsal-wards of the articular surface of the distal I0| Fig. 10. Two views of the metatarsal splint with its dimensions as now used: below, top surface of splint with five slits and six finger-like projections: two projections can be used for the big top on either foot, thus using one splint for either foot: above, lateral view of splint with dimensions fragment is a deformity often overlooked, espe cially if only a dorso-plantar x-ray view is taken. In the lateral view this displacement is readily picked off. A union of this fracture in malposition causes considerable disability, as the driving pow- Fig. 11. Case 1614, A. S. T. P. 1932. Frac ture of the distal end of the proximal phalanx of the great toe, before the application of the splint: right, the fragments appear in good position; in the lateral view, left, the distal fragment is dislocated dorsalwards, a com mon deformity in this fracture. (See Fig. 12) Fig. 14. Case 5495, L S. C. 1929. Fracture of proximal phalanx of 2nd digit, right foot: after application of the splint: left, extension has corrected the over-riding of the fragments and brought them to 80% apposition: right, over-riding of fragments and plantar dislo cation corrected. (See Fig. 13) ...t. Fig. 12. Case 1614, A. S. T. P. 1932. Frac ture of the distal end of the proximal pha lanx of the great toe, after application of the splint: left, the fragments in excellent position with slight over extension, and right, lateral view showing the correction of deformity of distal fragment. (See Fig. 11) Fig. 15. Case 1714, I. S. C. 1932. Fractures of the proximal phalanges of the 1st, 4th and 5th digits, and of the 3rd metatarsal, close to the head, before splint and traction were ap plied (See Figs. 16 and 17) i Fig. 16. Case 1714,1. S. C. 1932. Fracture of the proximal phalanges of the 1st, 3rd and 5th digits, and fracture of the 3rd metatarsal close to the head, after application of splint and traction. (See Figs. 15 and 17). er of the take-off push of the big toe will be lost. Fig. 13. Case 5495, I. S. C. 1929. Right foot, The combination of fractured metatarsals and 1\ before application of splint. Fracture of prox imal phalanx. 2nd digit: left, lateral disloca tion of distal fragment and over-riding of fragments; right, plantar dislocation of distal fractured phalanges may be treated in the manner just described. The splint is light, and the patient may be up and about the room, and when in bed fragment and over-riding of fragments. (See the projecting finger-like.end of the splint keeps Fig. 14) the covers from pressing over the fractured toes. Page. 12 INDUSTRIAL MEDICINE January, 1936 Flf. 17. Case 1714, I. S. C. 1932. Fractures of the proximal phalanres of the 1st, 4th and 5th digits and of the 3rd metatarsal bone close to the head, four months after injury. (See Firs. 15 and 16) Fir. 20. Case 184, L S. C. 1932. Rirht foot: fracture of 2nd metatarsal: left, dorso-plantar view, the frarments appear in excellent ap position, however, in the lateral view, rirht, the frarments are seen to be 25% off center. (See Fir. 21). This is before application of the splint - Fir. 18- Case 397. I. S. C. 1922. Fractnre of the shaft of the 1st metatarsal, rirht foot be fore application of the splint with extension: left, fractnre 1st metatarsal with anrulatfam: rirht, this appears to be in rood position. (See Fir. 19) Fir. 21. Case 184, 1. S. C. 1932. Rirht foot: fracture of the 2nd metatarsal, after appli cation of the splint: left, dorso-plantar view shows the frarments in excellent position, with slirht over extension, and rirht, lateral view shows the off-center deformity cor rected. (See Fir. 20) Fir. 19. Case 397, I. S. C. 1922. Fracture of the shaft of the 1st metatarsal, rirht foot, af ter application of splint with traction: left, correction of anrnlations: rirht, alirnment rood. (See Fir. 18) Fir. 22. Case 574, L S. C. 1933. Multiple me tatarsal fractures; rirht foot; 2nd, 3rd, 4th, and 5th metatarsals before application of the splint. (See Fir* 27): left, lateral view: rirht, dorso-plantar view VOL. 5, WO. 1 JJNJJUbliUAL, jyittmUUNJi; ; rage u Fir. 23. Case 160, L S. C. 1932. Healed frac tures of the distal ends of the 2nd, 3rd and 4th metatarsals and of the proximal phalanres of the 2nd, 3rd and 4th dirits, three months after injury. (See Fir. 29) Fir. 27. Case 574, L S. C. 1933. Multiple metatarsal fractures: rirht foot: 2nd, 3rd, 4th, and 5th metatarsals after application of the splint. (See Fir. 22): left, lateral view show ing more traction is needed: right, dorso- plantar view Firs. 24 and 25 Fir. 24. Case 12244. C. C. Hosp. 1928. Rirht foot: fractures of 3rd, and 4th metatarsal shafts and slirht dislocation at epiphysis of 5th metatarsal; epiphysial lines of phalanres and metatarsals simulate fractures. Fir. 25. Case 7926, C. C. Hosp. 1927. Rirht foot: fracture of 1st, 2nd, and 3rd metatarsals: the epiphysial lines of the phalanres and me tatarsals simulate fractures Fig. 28. Case 371, L 8. C. R. Fractures of the 2nd and 3rd metatarsal shafts, healed af ter application of splint with extension. (See Fir. 33) Fir. 26. Case 184, 1. S. C. 1932. Fracture of the shaft of the 2nd metatarsal. (See Firs. 32 and 30). Healing of the fracture two months after the injury. Fig. 29. Case 160, I. S. C. 1932. Fracture of the distal ends of the 2nd, 3rd and 4th meta tarsals and of the proximal phalanres of the 2nd, 3rd and 4th dirits with application of the splint and traction. (See Fir. 23) rage n INDUSTRIAL. MEDICINE January, 1936 FIf. 3i. Cue 184. L S. C. 1932. Fracture of the shaft of the 2nd metatarsal. (See Fir. 32 and 26) after traction and splint were applied: right, showinr slight overextension, and left, displacement corrected Fig. 33. Case 371, I. S. C., R. Fracture of the -shafts of the 2nd and 3rd metatarsals: before application of splint (See Fir. 28) Fig. 31. Case 13. I. S. C., R. End result of fracture of shaft of 2nd metatarsal near the head (see Fig. 34) after splint with traction had been applied and corrected the deformity. Fig. 34. Case 13, I. S. C. R. Fracture of the shaft of the 2nd metatarsal bone, close to the head: before application of the splint with traction; displacement of the distal fragment noted in the dorso-plantar view, right; also in the lateral view, left Fig. 32. Case 184, I. S. C. 1932. Fracture of the shaft of the 2nd metatarsal before appli cation of the splint: left, dorso-plantar view: right, lateral view, showing displacement of fragments. (See Figs. 30 and 26) Fig. 35. Cue 1531, I. S. Co., 1935. Fracture of the shaft of the 5th metatarsal bone, be fore splint was applied. (See Fig. 36) J Fig. 36. Case 1531, I. S. Co. 1935. Union of the fracture of the shaft of the 5th metatar sal bone after application of the splint with traction. (See Fig. 35) Fit. 40. Case 2469, I. S. C. 1929. Fracture of the shafts of the 4th and 5th metatarsals with application of the splint and traction. (See Figs. 37, 38 and 39) Fig. 37. Case 2469, I. S. C. 1929. Fracture of the shafts of the 4th and 5th metatarsal bones with displacement of the distal frag ment of the 5th; lateral view, before applica tion of the splint and traction. (See Fig. 38, 39 and 40) Fig. 38. Case 2469, I. S. C. 1929. Fracture of the shafts of the 4th and 5th metatarsals with application of the splint and traction. (See Figs. 37, 39 and 40) Fig. 39. Case 2469, I. S. C. 1929. Fracture of the shafts of the 4th and 5th metatarsals with angulation of the 4th: before splint and traction were applied (See Figs. 37, 38 and 40) Fig. 41. Dislocation of the 2nd, 3rd, 4th and 5th metatarsal bones before application of the splint; and reduction of the dislocated 2nd, 3rd, 4th and 5th metatarsals by application of the splint The splint is simple in application, cheap in con struction, and efficient in caring for the fractures of the metatarsals and fractures of the phalanges and combinations of fractures of metatarsals and phalanges. A series of illustrations, showing the various types of fractures and their displacements is pre sented giving rather complete legends, as it is be lieved that in this manner the subject matter may be presented with the minimum of text. The frac tures are shown in x-ray views before and after splinting. Since this article was handed to the publisher the writer has had occasion to use this splint on a bridge worker on the San Francisco-Oakland bridge. The patient in this case fell from the "cat walk" of the bridge and among other fractures and grief, he sustained the pathology as shown in Fig. 41: a dislocation of the 2nd, 3rd, 4th and 5th metatar sal bones. The splint was applied and all disloca tions of the metatarsals were reduced, as also shown in Fig. 41. INDUSTRIAL MEDICINE f ./ January, 19Zo Personality Disorders in make a fetish of promptness; (3) the sadists, who are forever keeping employees on the "anxious Industry seat" even when there is no real or apparent rea son to do so. .One way of working out the problems of those THE regular monthly meeting of the Indus who have mild mental disorders is by the use of trial Relations Association of Chicago, occur the so-called "personality inventory," which is a ring on Monday evening, January 13, 1936, series of questions that may either be answered had as its main event an address on the above su"ybes," "no," or "not known." These personality in ject by Dr. Robert N. McMurry, Executive Secre ventories are then rated according to a rating tary of the Chicago office of the Psychological scale, and the person can be given a rating as to Corporation. his personality difficulties. Dr. McMurry has not It was stated that, as the result of studies made been very much impressed with the use of these in this country and also in Great Britain, an esti personality inventories as a diagnostic tool for the mate has been made that 20% to 30% of all em chief reason that the results do not check with ployed persons suffer in some degree from mild practical ratings. For instance it has been found mental disorders. The peculiarities of so-called that persons who rate very high in the in problem employees can be roughly classified in ventory have not been found to be efficient em two groups: the first group indudes those who ployees in the practical experience met--and, con have once been rapid and accurate in their work trariwise, those who have sometimes shown low but who have become slow and inactive, and al ratings on the inventory have been found to be though once rated among the best producers, lat very efficient in their actual work. Then, too, a er have become placed at the bottom of the list of great many employees cannot or do not tell the producers; the second group would include those truth in answer to the questions asked on the in who are perennially unsatisfied, those who are ventories. The rating or grading of the question chronically ill, those who are perpetually dissatis naires is also rather difficult, even if done by the fied, individuals who tire easily, those who treat same person on different studies, primarily be their superiors as competitors, those who are giv cause the patterns as indicated by the psychologi en to periodic drinking sprees, insubordination, cal response to the inventories are many times of those who are extremely timid, and those with un a mixed character. governable tempers. It seems, therefore, that the clinical approach is Dr. McMurry stated that it was only a consider the better method of ferreting out the various ation of the important principles that was to be bases for mild mental disorders. The clinical ap given in this outline; that this would include a proach includes: (1) A thorough physical examin consideration of psychology and psychiatry; that ation, as the basis for the mental disorder may in the former, psychometric measurements were be physical or physiological; (2) psychological important and in the latter, abnormalities either tests, which are done for the purpose of finding organic or functional are fundamental. out low well adapted the individual is to his The material considered in this talk was con work and also of the sociological relationships of cerned mainly with the functional types of ab the individual; and finally, (4) the so-called psy normalities, and to illustrate this a story was told chiatric interview. The first three of these items of an individual who had carried over the so-call in the clinical approach provide a rational basis ed "temper tantrums" of childhood into adult be or a background for the psychiatric interview and havior. permit the interviewer to get leads as to where Another common form of the functional abnor difficulties may be found. mality of mental disorders is what is known as The chief types of remedial procedures are some schizophrenia in which day-dreaming is carried to form of mental therapy or change of work, or ad an extreme. justment to work. There are of course all combinations of types of To bring out certain points relative to diagnostic mental disorder, and many times there is no clear- and remedial measures, Dr. McMurry described cut line of demarcation. five illustrative cases, among them a chemical lab Dr. V. V. Anderson in his psychiatric work oratory assistant, 18 years of age, whose difficulty among employees has estimated that approxi was that his work was "over his head," intellectu mately 30% to 40% of industrial and commercial ally; another a woman of 46 with involutional employees may have mild mental disorders. Of melancholia which demanded endocrine adjust such persons there may be mentioned (1) those ment; an Austrian truck driver of 42 who went on who are suspicious and distrustful; (2) the so- periodic drunken sprees, because of his dominat called pathological liars; (3) the neurasthenics ing consort; a book agent of 24 years who enjoyed who are always tired; (4) the introverts; (5) those so-called "flights into illness," because he had been who have chronic ill-health; (6) the hypersensi raised as a "mamma's boy"; and finally a sadistic tive inadequates; and (7) the alcoholics. female supervisor who had charge of a depart Interestingly enough, stated Dr. McMurry, mild ment of 30 women file clerks and who made her mental disorders are not by any means confined to self a perfect tyrant because she was known as a workers or employees, but may exist commonly "dumbbell" at home. among executives and be expressed in the follow In summary, the application of the above des ing ways: (1) the executive given to pedantry, cribed methods may well be made to "ironing out" the employer who is not open to suggestion and dissension among commercial and industrial em who may adopt suggestions made by employees ployees--because of a falling-off of production-- some time before, giving them out as his own; in "labor troubles." It should be thoroughly un (2) those addicted to stinginess, who quibble with derstood that all of these procedures can be justi employees on punching the time clocks, or who fied on a dollars and cents basis. . The Action of Silica --As Modified by the Presence of Alkalies*-- by HE exact manner in which Carey P. McCord, M.D. qualification -- there is a prima T silica acts to produce sili cosis remains undetermin ed. This statement applies not so much to the physiologic re sponses to the presence of silica as to the mechanism that in augurates these responses. Of Cincinnati, Ohio with Harriet Ainslee, Jan Johnston L.Richard Fleming, Detroit, Michigan facie case for attributing the acuteness of these cases to the coating of alkaline soap sur rounding the silica particle. A colloidal alkaline silicate would appear to be slowly formed, and in time to become a `system' of all dusts that enter the lungs, silica hydrosol, sodium silicate, silica and silica alone, with the exception of the and water. Eventually some silica is deposited as magnesium silicate, asbestos, is up to this time known to possess the peculiar property of provok ing the formation of characteristic fibrotic nodules in large numbers. Manifestly this property is not wholly imparted by any condition within the lungs, since typical silicotic structures may be produced experimentally in almost any portion of a gel." The details of several occurrences of acute sili cosis associated with mixed exposure, includ ing alkalies, have been reported by Chapman,5 Kilgore,6 Spilsbury and McDonald,7 McDonald, Piggot and Gilder,8 Kettle,9 and Lennane.10 Such publications have caused a number of workers to the body. The mere presence of siliceous sub regard exposure to mixtures of silica and alkali stances in substantial amounts within the body is dust as unduly hazardous. This is exemplified in not sufficient to assure an injurious action. At a statement attributed to Willis:11 this stage of knowledge it appears that damage "There have recently been a number of contri may be anticipated only from -silica present in butions in the literature which point out the fact some little understood phase, state, or condition. that if there is an alkali in association with silica The literature of silicosis is not lacking in ably dust, the results are likely to be very devastating; conceived publications precisely devoted to ex that an alkali inhaled with silica will stimulate planations of the phenomenon of silica action. the formation of fibrosis to a remarkable degree." Chief among these are the theories of Gye and Since much more of so-called acute silicosis may Purdy,1 Gye and Kettle,2 and Heffernan.3 4 No one be shown to have arisen without concurrent ex may be accepted as conclusive although all have posure to alkalies, the belief is growing that an immensely contributed to the understanding of accelerating action of alkalies is not established. this vexatious problem. Running through many The rapidly developing cases in both the West Vir publications is the concept that silica solubility ginia and New Jersey outbreaks probably may be facilitated by alkalies plays a significant role. This attributed to the presence of gross concentrations has associated certain occurrences of so-called of silica dust in minute particle size. . acute silicosis with exposure to mixed silica and Beginning early in 1933 opportunity has been alkali dust, the latter acting as an accelerator. The provided one of the present authors to investigate present publication is related to the action of al six industrial plants in which certain departments kalies in silicosis and is based upon clinical and provided exposure to silica and alkalies in high experimental observations. dust concentrations. Other departments and oth Clinical Observations er plants provided exposures to silica and alkalies alone, as well as exposures to the dusts of clays, THE colloidal theory of silica action attaches flints, cullet, carbon, iron oxides, tripoli, gypsum, importance to the presence of the weak al limestone, emery, carborundum, etc. These last kalies of the lung fluids as the agents responsibleitems are mentioned only as the source of mater for, or at least participating in, the shift of the ials for comparative purposes. silica (SiO,,) from the solid to the hydrosol (Si (OH) J state, with silicates possibly represent ing a transitory stage. Quite naturally, when a rapidly progressing silicosis appeared in certain industries, such as silica soap plants, unusual sig In the silica-alkali exposure, substances appre ciably present and giving rise to dusts were quartz silica, sodium carbonate, limestone, sodium sul phate, sodium chloride, carbon, and in some in stances small quantities of arsenic, antimony, and nificance was attached to the presence of alkalies iron oxide. The investigations included occupa employed in the soaps. Heffernan's 4 appraisal of tional and medical histories, x-ray examinations, the situation is here condensed: physical examinations, dust counts, chemical an "The existence of an acute form of silicosis in workers handling siliceous soap powders can scarcely be regarded as longer in doubt . . . Sec tions of pathological material of lungs in fatal cases show under the microscope typical whorled silicotic islets ... If we regard freshly formed sili ca hydrosol as the active agent in the causation of silicosis--a belief which, as I shall attempt to show later, now would appear to require some alyses, and in some instances petrographic analy ses and geologic appraisals. At the outset of the work, it was necessary to group the workers into two lots: those who had no other industrial dusty exposure, and those who had been employed in other dusty departments of the same plants and in other dusty occupations. Due consideration was given to the duration of exposure. In no single instance was silicosis found in any From the Industrial Health Conservancy Laboratories, Cincinnati, Ohio. worker whose exposure had been limited to the U11UOLI JVtClUiUIl'IIl January, 1936 silica-alkali-plus mixture. Silicosis was detected serve it was conceived that the rate of solution in three instances of workers previously and ex might be increased and that the quantity of silica tensively exposed respectively in mining, pot mak in the urine might be augmented. The results ob ing and pottery work. No previous medical rec tained were not conclusive. Kettle9 in discussing ords yielded any evidence of suspected silicosis or acute silicosis states: tuberculosis in workers no longer employed, pro "In the affected persons the disease progressed vided their exposure was limited to the one occu with extraordinary rapidity due, it was claimed, pation under inquiry. In all instances long ex to the presence of the alkali which rendered the posed workmen revealed more fibrosis than aver silica more readily soluble in the lungs. On the age for their ages, healed tubeculosis was at times face of it this seems unlikely, for sufficient alkali demonstrable, and the possibility of arsenic poi to alter significantly the reaction of the tissues soning was accepted in a few instances. Charac- - would most probably cause a severe catarrhal in teristic silicosis was signally absent. flammation of the air passages. This, at any rate, It is quite impossible to deduct from the fore is what happened to my animals when I tried to going that the alkalies present in the dust along reproduce the condition experimentally--I could with silica served as any deterrent to the action of not convince myself that the action of the silica silica through facilitating the solution of silica or had been affected in any way by the associated otherwise. The situation is much more complex dust. We still lack proof that anything of the than first appears. The alkalies present so rapid kind can occur." ly dissolved the silica that a grossly dusty atmos In our own experiments the technique of Miller phere in terms of visibility yielded no dust parti and Sayers14 was employed. This same technique, cles in the ordinary dust count procedures. Using only slightly modified by us, elsewhere has been absolute alcohol as the entraining medium, no described.13 The essential feature of the technique known solution took place, but it was impossible is the introduction into the abdominal cavities of to distinguish between silica and other dusty ma guinea pigs of a predetermined amount of the test terials. Petrographic analyses were not effectual. material, usually 0.1 or 0.2 gram in fine particle The chief evidence of a silica exposure resides in size, all passing through a 325-mesh screen or fin the fact that visible clouds of silica dust were er, the particulate material being suspended in created in the operations of the silica shutes. The distilled water or normal saline. After an inter absence of silicosis may in fact result from lack val of 30 days or more the animals were killed of sufficient exposure. and the type of response determined. Although Recognition must be extended to other chemi in many instances the period prior to killing has cals leading to dust utilized along with the silica, been extended well beyond 30 days, Sayers,9 in his soda ash, and limestone. These, however, have remarks on Kettle's paper, has indicated that 30 been relegated to minor consideration in view of days is sufficient to provide distinctive responses. the relatively small quantities employed and to In the case of quartz silica, tripoli, amorphous sili the fact that their physical state was such as to ca, flint, chalcedony and other substances with a minimize dust formation. high content of free silica, the reaction is prolifer A further item to be recognized as conceivably ative, typical silicotic tissues being produced. In standing in relation to the absence of silicosis is the case of emery, carborundum, iron oxides, and to be found in the possibility that the electrostatic carbon (among others) the reaction is one of in charges of various types of dusts may have been ertness. A third response is that of absorption, such as to agglomerate all of the dust into masses and is characteristic of the presence of gypsum, of such size as to hamper entry of the silica into limestone, silica gel, and cement (among others). the lungs. This action has been observed by the In our series, utilizing 300 animals, 29 sub authors in connection with tripoli exposure, and stances have been tested. Among these were com lately has been mentioned by Gardner12 in the binations of quartz silica, of varied particle size, course of experimental work with gypsum and silica gel, tripoli, mixed either with equal quanti silica. However, in the case of the six plants un ties or quantities in chemical combining weights der discussion, this electrostatic action is regarded of alkali substances, including sodium bicarbon as most unlikely. ate, sodium carbonate, limestone, and magnesium The fact remains that amon^ ' ie workers of six carbonate. In other instances the combination of plants employed in dusty operation and regularly silica and these alkalies was further admixed with furnishing exposure to mixed silica and alkalies, kaolin. In some instances the mixture of silica and no silicosis was detectable, whereas prior to the alkali material was injected once only, but in institution of the inquiry, a high incidence of other series additional quantities of alkali were in "acute silicosis" was anticipated as possible in jected at three or four day intervals. For control view of previous publications dealing with the ac purposes silica in its various forms alone was in tion of alkalies entering the body along with silica jected, and likewise the several alkalies alone dust. were injected. Experimental Observations Very early it was established that sodium car bonate either alone or admixed with silica was so THE number of experimental approaches, eith highly irritating as to preclude use. Promptly it er in man or through the use of animals, for was established that limestone administered along the purposes of determining the influence of alw ith silica produced no new reactions, for which kali associated with silica, is limited. With a group reason limestone likewise early was dropped from of men King and Dolan13 sought to accelerate the the series of investigations. output of silica in the urine through the adminis Such quantities of the chemical combining tration of sodium bicarbonate by mouth. Such a weights of the alkalies were admixed with 0.2 process did not change the pH concentration of gram of siliceous material at the outset of the ex the blood, but through increasing the alkali re periments. In such instances, and in those others when equal quantities of the materials, that is 0.2 gram each, were employed, the immediate toxi city, chiefly in the case of sodium bicarbonate in silica mixtures, rather than the mixture of silica and magnesium carbonate, was such that most of the animals did not survive longer than four days. No primary toxicity beyond immediate reaction to injection was noticed either from the siliceous material or the alkalies when alone injected. The high mortality encountered was out of proportion to any expectable 'consequence solely resulting from the doubled mass of material introduced. This high mortality caused the quantity of mater ial injected to be reduced to 0.1 gram of each, or 0.1 gram of the siliceous material together with the chemical combining weight of the alkaline substances. It is noteworthy that silica gel, which led to no proliferative response, was highly toxic when admixed with alkali materials. At the end of 30 days, autopsies revealed a much greater extent of involvement than from silica alone. In addition to the usual nodulation on the anterior abdominal wall--the most pendant por tion of the animal's abdomen--large numbers of nodules were detectable on almost all organs, in cluding the diaphragm, liver, gall bladder, omen tum, intestines, mesentery, epididymides, testes, urinary bladder, seminal vesicles and cremasteric muscles. Although some nodules may be pro duced on some of these organs from the presence of silica alone, the number encountered is custom arily far more in the case of silica admixed with alkalies. This extensive involvement was regu larly observable in the case of all forms of silica, such as quartz, tripoli, chalcedony, etc., but not silica gel, the reaction from the last named sub stance being one of absorption with or without the presence of alkalies. The nodules encountered were typically silicotic as described by Miller and Sayers,14 and as established by us after the exam ination of microscopic tissue preparations. This excessive number of silicotic nodules resulting from the admixture of alkalies with the silica in the intraperitoneal injections has given rise to the use of the term "miliary proliferation" in another publication,1-'' describing the entire series of three hundred animals. TWO summarizing protocols are here introduc ed as representative of the entire lot of ani mals devoted to this phase of our investigation: Composite Record: Sodium bicarbonate and quartz silica, through 325 mesh. Injected five male guinea pigs with 0.2 gram sodium bicarbonate alone. Re-injected 21 days later with 0.1 gram of quartz silica and 0.26 gram of sodium bicar bonate. Two animals killed for examination 51 days after first injection, 30 days after second in jection. Three animals killed for examination 74 days after first injection and 53 days after second injection. Autopsy Notes: (Two groups combined): 1. Site of injection: No markings. 2. Anterior peritoneal wall: Dense fibrous ad hesions extend from proliferative nodules on the anterior abdominal wall and from other portions of the anterior abdominal wall to the liver, gall bladder, testes, intes tines and seminal vesicles. More adhesions in second group of animals. 3. Diaphragm: A few nodules in one instance. Many nodules in one other instance. Ad hesions in others hamper examination. 4. Suspensory ligament: Many nodules in animals in second group. 5. Liver: Extensive nodulation. Silica nodules appearing in lines or streaks rather than discrete, as is usual. 6. Gall Bladder: Not extensively involved, except for adhesions to anterior peritoneal wall in one instance. 7. Omentum: Isolated nodules, but not the same extent of involvement as observed in some other series. 8. Spleen: A few pinhead nodules in two in stances. 9. Mesentery: A few widely scattered nodular deposits. 10. Intestines: Large numbers of nodules on in testinal wall and in second group nodules averaged about one per inch throughout tract. 11. Peritoneum over kidneys: Essentially unin volved. 12. Seminal vesicles: Nodules with many adhe sions to anterior peritoneal wall. 13. Urinary bladder: Nodulation of posterior surfaces. 14. Testes: Nodulation in two instances. Nod ules also found in cremasteric muscles. 15. Posterior peritoneal wall: Extensively nod ulated in second group. Appraisal: Wide distribution of typical silicotic nodulation. The nodules are smaller than usual for silica, but distribution is greater. Composite Record: Magnesium carbonate and quartz silica, air sep arated sample, particle size below 10 microns. Injected five male guinea pigs with 0.2 gram quartz silica and 0.28 gram magnesium car bonate. One pig died within 24 hours. Four pigs killed after 30 days. Autopsy Notes: 1. Site of injection: One instance of an intra muscular silicotic nodule. 2. Anterior peritoneal wall: Characterized by extensive adhesions between nodules and intestines, seminal vesicles, and liver. Ex tensive confluent nodulation chiefly near midline, and many small discrete nodules. Nodules are characteristic cream color, but hemorrhagic in one instance. 3. Diaphragm: A few nodular deposits in two pigs. In one pig, adhesions to liver. 4. Suspensory ligament: Two small nodules in one instance. 5. Liver: Heavy nodulation on all surfaces. No nodules except those superficially locat ed. In three instances, liver is enlarged, hemorrhagic, and friable. Nodules encoun- tered not uniform in size, the largest being dusts may increase the drainage from the lungs several times the diameter of the smallest. and increase the amount of silica detectable in the 6. Gall bladder: In two instances, uniform urine. But this is more speculative than established. nodulation. Likewise, no warrant is known to exist at this 7. Omentum: Rolled up, massive prolifera time for the use of alkalies in the prevention of tion. Some discrete nodulation. Adhesions. silicosis. It is a provocative concept that silicosis 8. Spleen: Uninvolved. might be prevented by the daily dusting of the 9. Mesentery: Nodules in three or four ani lungs by harmless alkalies, during, or before and mals. Adhesions. after exposure to silica dusts. Conceivably these 10. Intestines: Grossly nodulated and many ad coexisting alkali dusts along with the silica dusts hesions between coils of intestines and to in the alveoli might so accelerate the solution of other tissues.' the silica as to prevent or delay the inception of 11. Peritoneum over kidneys: In one instance, silicosis. No substantial fact permits adherence to adhesion to intestine. this conception. 12. Seminal vesicles: Many nodules and adhe sions in all cases. In one instance, seminal Summary Tvesicles are involved in caseous mass size of hazlenut. HE often encountered assertion that coexis tence of silica arid alkali dust in industry con 13. Urinary bladder: Uninvolved. stitutes extra hazardous work conditions, is im 14. Testes: In two instances testes contain a few proved, but not necessarily unfounded. Extensive nodules. investigation of the workers in six plants simul 15. Posterior peritoneal wall: In one instance, a taneously exposed to silica and alkali dusts pro small number of minute nodules. vided no evidence of an accelerator action by al kalies. The entire absence of silicosis suggests the Appraisal: The involvement encountered is possibility of an inhibitor action. constant, but with minor variations. The Animal experiments with guinea pigs in which general picture is characterized by extensive the peritoneal cavities were injected one or more adhesions and miliary nodulation. The chief, times with 0.1 or 0.2 grams each of silica and al point of nodulation, apart from the anterior kali (sodium carbonate, sodium bicarbonate, mag abdominal wall, is the intestinal tract. nesium carbonate, or limestone), yielded no re AUTOPSY findings from the entire lot of ani.IjLm;-.ls in this work might prompt the belief that here i; definite proof of an accelerating action of alkali :s in the production of silicosis. Such ap pears not to be the case. The irritant action of the alkal - seemingly provokes much increased sults proving either an accelerator or inhibitor ac tion of alkalies in the production of silica nodules. The presence of alkalies markedly increased the distribution of silicotic nodules throughout the ab dominal cavity, which action is apparently solely due to the mechanical distribution of the silica by increased motions of abdominal organs, induced by movf . >t on the part of the omentum, intestines alkali irritation. and st vesicles, to the end that the silica The primary toxicity of silica and silica gel mix which . Arise might chiefly lie in the pendant ed with alkalies is much greater than is true for portic. l the abdomen against the anterior peri silica, silica gel or alkalies alone. tonea t all is widely disseminated. Animals kill ed within a few hours or days after injection were found to present a much wider distribution of the siliceous material throughout the abdominal cav Citations: 1. Gye, W. E. and Purdy, W. J.: The Poisonous Properties of Colloidal Silica. I. The Effects of the Parenteral Adminis tration of Large Doses. II. The Effects of the Repeated ity. Wherever deposits of silica were thus mechan ically made, silicotic nodules appeared. In pulmonary tissues it is not known that any comparable mechanical distribution may result from the irritant action of the alkali, so that the Intravenous Injections on Rabbits: Fibrosis of the Liver. lirit. J. Exper. Path. 3, 75, 5, 238, 1922. 2. Gye, W. E. and Kettle, E. H.: Silicosis and Miners' Phthisis. Brit. J. Exper. Path., 3, 241, 1922. 3. Hfffernan, P. and Green, A. T.: The Method of Action of Silica Dust in the Lungs. J. Indust. Hyg. 10, 272, 1928. miliary nodulation regularly found in the abdom inal cavity may stand in no relation to the effect of alkalies on silica dust entering the lungs. 4. Heffernan, P.: Acute Silicosis. Tuherc. 14, 109, 1932. 5. Chapman-, Earle M., Acute Silicosis. J.A.M.A. 98 1439, 1932. 6. Kilgore, Eugene S.: Pneumoconiosis, an Unusually Acute Form. J.AM.A., 99, 1414, 1932. Comment 7. Spilsbury, B., and McDonald, G.: Report of Coroner's In quests, 1928. AT THIS time it appears that the determination . of the influence of alkalies as accelerators or 8. McDonald, G. Piccot, A. P. and Gilder, F. W.: Two Cases of Acute Silicosis. Lancet, 2, 846, 1930. 9. Kettle, E. H.: The Action of Harmful Dusts. Institution inhibitors of the action of silica in pulmonary tis of Mining and Metallurgy, Bull. 357, 1, 1934. sues, through animal experiments, will require 10. Lennane, G. Quin: Some Aspects of Silicosis in Industryi prolonged exposure by inhalation over a period of many months, under conditions establishing the actual entry both of the silica and the alkali into alveoli. None of the shortcuts thus far attempted J. State Med., 37, 602, 1929. 11. Willis, H. S.: Comments. Proc. of Confer. Concerning Effects of Dusts upon Respiratory System, Industrial Com mission of Wisconsin, 127, 1933. 12. Gardner, L. U.: Pathology of Silicosis. Second Symposium offers any prospect of providing fundamental un on Silicosis, (Trudeau School of Tuberculosis), 1935, 44. derlying facts. No justification is now known to exist for the use of alkalies in the treatment of silicosis. At 13. King, E. J. and Dolan, M.: Silicosis and the Metabolism of Silica. Canadian M. J., 31, 21, 1934. 14. Miller, J. W. and Sayers, R. R.: The Physiological Re sponse of the Peritoneal Tissue to Dusts Introduced as For least there is no warrant for any belief that alka eign Bodies. U. S. Public Health Reports, 49, 80, 1934. lies may reduce the fibrosis already created, al though there may be some reason for believing that the dusting of lungs with harmless alkali 15. McCord, C. P. and others: The Measurement of the Harmlulness of Dusts for Humans through the Agency of Animal Reactions; With Special Reference to the Lesions Produced by Silica as a Basis of Comparison. In publication. Central States Society Clinic --All Day Clinical Session of Central States Society of Industrial Medicine and Surgery, Cook County Hospital, Chicago, January 15, 1936-- U DNDER the chairmanship of Dr. Frederick W. R. NELSON gave a review of the surgical Slobe, the following program was given in neurology of spinal cord injuries. The prin an ali-day clinical session of the Central ciple involved is to diagnose the injury from the States Society of Industrial Medicine and Surgenreyu, rological findings regardless of what the x-ray at Cook County Hospital, Chicago, Wednesday, findings may suggest. Comments were made on January 15, 1936: the nerve supply of the various cord segments and 1. "An Important Industrial Injury," by Dr. J. consideration was given to anatomical landmarks. Daniel Willems. X-ray demonstrations were then given of several 2. "Vertebral Injuries," by Dr. Frederick Nel son, of Ottumwa, Iowa. 3. "Injuries of the Female Genitalia," by Dr. W.Channing Barrett. 4. "Injuries to the Male Genitalia," by Dr. Harry C. Rolnick. 5. "Use of Kirschner Wire in Femur Neck Frac tures," by Dr. Frederick Dyas. different cases, including a forward dislocation of cervical vertebra--an unusual instance of forward dislocation of the fifth lumbar vertebra on the sacrum (the probabilities were that the fifth lum bar was not normal before the injury, since there are many anatomical anomalies of this structure) --a demonstration of a compression fracture of one of the dorsal vertebrae. 6. "Chest Injuries," by Dr. Ralph Bettman. 7. "Elbow Fractures and Closed Reduction," by Dr. Frank P. Hammond. 8. "Flange in the Femoral Neck," by Dr. James Callahan. 9. "Physio-Therapy in Traumas," by Dr. Dis raeli Kobak. In the afternoon session, the following demon strations and discussions were given: 1. "Fractures," by Dr. Carlo S. Scuderi. 2. "Interesting Scapula Case," by Dr. J. Beverly Moore, of Benton, Illinois. 3. "Trivial Eye Injuries Resulting in Impaired Vision," by Dr. Sidney Walker. DR. BARRETT, in speaking about injuries to the female genitalia, commented that there is a very significant relationship mediocolegally between injury and pregnancy. Absolute aver sion to pregnancy may be transformed into intense desires, subsequent to an injury which may or may not affect a suspected pregnant condition ad versely. In this connection it is important to se cure a sample of urine from the patient, for making the Ascheim-Zondek test. Injuries to the female genitalia may occur rather frequently from falling off a stool or chair, while doing domestic house work, such as hanging pictures and other similar activities; kicks around the vulva, either by hu 4. "Peripheral Nerve Lesions," by Dr. Harold man beings or animals, may produce haematomas; Voris. not infrequently it has occurred that a bull may 5. "Bone Tumors and Allied Lesions," by Dr. rip open the vulva producing extreme lacerations; Chester Warfield. in fact it has been known that serious infections 6. "Interesting Vertebra Case," by Dr. B. V. Mc- have been produced in this manner. In medico Clanahan, Galesburg, Illinois. legal cases, women often claim displacement of 7. "Fractures Around the Shoulder Joint." by the uterus and not infrequently the displacements Dr. William Cubeins. have usually existed previous to the associated in jury; quite similarly fibroids have produced bleed DR. WILLEMS demonstrated a case of a boy ing but have been overlooked until an injury has who had had a series of repeated minor in taken place. In this connection, the famous case juries to the knee over a period of five years' timeo.f Marion Sims relative to retrodisplacement was There had been no physical evidence of any injury mentioned. A case was also described of an injury until a modern amount of swelling became evident that took place on a railroad journey in which dis in the knee a few weeks ago. All of the x-ray placement of the uterus was claimed, but later on films taken on the patient were somewhat confus an operation disclosed a tubal pregnancy, the case ing, although showing no very definite type of terminating in a decision favorable to the defend pathology. An x-ray film of the chest was nega ant railroad company. tive for any evidence of metastasis. An artefact Dwas suspected in one of the films, but was not proved. The case was interesting from the stand R. ROLNICK, in speaking of injuries to the male genitalia, mentioned the use of suction point of difficulty of diagnosis, and suggestions apparatus by males for the purpose of causing erec were sought from the physicians attending the tion and in one such instance tearing off the glans clinic. penis. This case was dealt with successfully by In replying, Dr. Leroy P. Kuhn mentioned that an operation. Two other similar cases were re possibly osteitis resulting from an old abscess membered in Dr. Rolnick's experience. It was also or inflammatory process might be the condition interesting to point out that in some of the earlier with which we were confronted. The probability cystotomies, lacerating injuries to the penis oc is that the condition was not malignant. It might curred, necessitating plastic operations. Another be advisable to do an exploratory operation and remarkable instance was the lodging of a bullet in secure material for biopsy, which might really the corpora cavernosa. A case of shrapnel particles give the solution to the problem. lodged, in the penis has also been a part of Dr. Rolnick's clinical experience in this work. In an ial sacs or upon blood vessels of the heart have other instance, after mutilating injury and partial been found to be a great deal easier in technique amputation of the penis, although the operation than abdominal operations in certain types of gan was successful from a plastic point of view, erec grenous appendicitis. tion was not experienced beyond the point of in Djury, on account of penile circulation not being completely established. It should be emphasized that the regeneration of penile and scrotal tissues R. HAMMOND presented an x-ray demonstra tion of multiple fractures around the elbow joint, successfully treated by closed reduction. In is comparatively rapid. Haematomas are rather this case there were multiple fractures around the common in this type of injury and are predisposing elbow joint, with forward dislocation. The frag factors to subsequent infection. It should be stated ments were properly moulded into position, and that traumatic hydrocele is rare if it does occur, the arm was put up in a cast at approximately the same statement holding good for so-called trau right angle of the forearm with the arm, the resuit matic epididymitis. Traumatic orchitis does occur, being very good. Anther case was demonstrated however. Many so-called traumatic herniae are by Dr. Hammond in which there was a compound really cases of funiculitis. fracture of the elbow and a fracture of the hum erus in the lower third, this fracture after being DR. DYAS, in .discussing the adaptation of properly manipulated being put up in suspension Kirschner wire in fractures of the femoral traction followed by being put into a cast in flexion neck, stated that many cases of fracture of thaend supination. The result now shows approxi femur occur in old persons; that there is poor bone mately 75% of extension. regeneration; that to find a technique which will Dpermit the patient to be up and about in a chair is one of the problems. This apparently is solved in R. CALLAHAN, in discussing the use of a flange in fractures of the femoral neck, the use of the Kirschner wires, several of which stated that after a lot of experience with fractures are put through the femoral neck and into the of this type it was thought best to put the leg up head, being first inserted through the intertrochan in traction, and it was found that good union was teric crest by the special apparatus which is pro obtained in a small percentage. Later experience vided with the Kirschner wire. A case was dem after trying the usual pegs, screws and other im onstrated where such wires were used in an elderly plements did not show what were thought to be woman, with very good clinical .results. Motion good results. At the present time on this service, picture demonstration was also given of the tech use is made of the bone flange, an incision first be nique of putting in the wires and the results which ing made and the muscles split so that the flange were secured in such a case. Apparently this may be inserted with the proper caliper and be method is giving good results and allows of con driven through the greater trochanter, the neck siderably quicker and better function than any and into the head. Traction is then exerted for that has been discovered heretofore. 10 days or two weeks, and then the case is prop erly operated. After this, traction is again used DR. BETTMAN, in commenting on chest in for seven weeks, and then the patient is put into a juries, arranged his remarks around five dif walking caliper for a period of approximately four ferent principles: (1) close every open wound owfeeks. The latter period may vary considerably the thorax immediately; for this purpose one may according to the case. Demonstration was then use any of the ordinary kinds of material close at made of a patient operated in September, 1935, hand and close the wound temporarily because if showing the good result obtained. Dr. Callahan is important for good aeration of the lungs that advises early operation in all of these cases, stat air should be kept out of the pleural cavity, and ing that by early operative interference, preven also avoidance of shock may be accomplished; (2) tion of late cases will be obtained. beware of bleeding from intercostal arteries--stop Dthis by ligaturing the ribs involved; (3) beware of internal tension pneumothorax--this will produce the most distressing symptoms and can be immedi R. KOBAK, in commenting on the use of physio-therapy in traumatic lesions, stated that such procedures are used principally to ob ately relieved; (4) do not aspirate any chest unless tain the restoration of function. There has been this procedure is definitely indicated--there is al a lot of misuse of physical therapy procedures ways the temptation to put a trochar into the chest which are composed mainly of manual operations to see if one gets an effusion or pus--more and or procedures -- passive electrical stimulation -- more chest explorations are being done and there- thermal agencies--and therapeutic exercises. No is relatively little difficulty in doing this operation one of these groups of measures is applicable in successfully; (5) be on the lookout for diaphrag any given case, but a combination of methods is matic herniae--these are far more common than usually found best. An important principle re has been previously suspected. One is liable to garding the application of physical therapy meas have a paralytic ileus following a rib fracture--this ures to the proper treatment of traumatic lesions ileus may account for symptoms which sometimes is to teach the patient to help himself. It is for appear quite unusual in such fractures. Pneumo this reason that corrective exercises must be thorax can occur somewhat later than an injury taught in a rather absolute and dogmatic fashion, but is usually associated with a previous infection because the patient will naturally become lazy causing pleural adhesions, which may be displaced and careless and will not apply himself properly or torn by an injury. Cardiac damage may result when doing exercises away from the supervision from a crushing of the sternum, and this has oc of the nurse or the physician. Physical therapy curred in instances of deformity of the sternum has a very definite place in the restitution of func and produced chronic effects on the heart over a tion and must not be abused--neither must quack period of time. Ordinarily operations on pericard ery enter into the practice of physical therapy. Vol. 5, No. 1 INDUSTRIAL, MEDICINE rage AFTERNOON SESSION dislocation but no neurological symptoms and is now wearing a head halter. R. SCUDERI presented a series of x-ray films showing vertebral injuries. In the first case Dthere was a dislocation of the atlas on the axis Dwith no neurological symptoms; treatment with R. MOORE, in discussing an interesting scap ula case, showed x-ray films of a fracture of the scapula in a coal miner. The history given five pounds of traction was given later on, the pa was that something fell on him while he was on a tient developed a bronchical pneumonia and died. scaffolding. The film showed a fracture through The second case showed no history or trauma, but the lower half of the glenoid process. The nature the patient remembered twisting his head sud of this fracture and separation was such that op denly during a nightmare; the x-ray film showed eration was necessary. The operative incision a forward dislocation of the atlas on the axis; was made over the outer margin of the scapula, later on the patient developed a paralysis and was the muscles split and the fragments wired into also diagnosed as a miliary tuberculosis, which of position. The fragments have stayed in this posi course was incidental. In the third case there was tion, as subsequent films have demonstrated. The a fracture and dislocation of the seventh cervical patient is now confined in bed because of other vertebra after an automobile injury, this being injuries sustained at the same time, but moves treated according to usual routine, with good re his arm for therapeutic exercises. sults. In the fourth case there was a fracture and Ddislocation of the second cervical vertebra; there was a numbness of hands without other definite neurological symptoms; traction of five to eight R. SIDNEY WALKER, commenting on trivial eye injuries which may result in impaired vision, stated that what may appear trivial may pounds was used, a Queen Elizabeth collar ap not be so eventually. Many changes can occur in plied, and the neurological symptoms completely the results of apparently small injuries and ag disappeared. In the fifth and sixth cases, which gravation of other conditions may also intervene. were similar, there were anterior dislocations of In many superficial lacerations of the conjunctiva, the fourth and fifth cervical vertebrae, both oc small wounds may not be apparent except by curring in young boys who had dived, striking the staining with a 1% solution of fluorescein. In head against the ground underneath the water; some instances these small lacerations should be in one instance there was a flaccid paralysis of the drilled out to prevent corneal ulcers. When small left arm with no cutaneous disturbances; a Queen wounds close suddenly as they frequently do, in ElizabetK~'collarwas applied, neurological symp tra-ocular steel may be present and very easily toms disappearedT'afid.-the case was discharged to overlooked. Hence the need for very careful and return again in four months, but was not finally painstaking examination by one who is accustom followed up. In the other case of the boy diving ed to going through these procedures. Electrical there was an extensive paralysis; laminectomy flashes may cause severe retinitis or even catar was done. This, however, was followed by an as act, and it is well to make a thorough examina cending nephritis. In the seventh case, the patient tion for these conditions, especially with a view had fainted striking the head against some ob to ruling out pre-existing conditions. Infection struction; in this instance there was paralysis of is a scourge which is all too common in eye the right deltoid, the usual treatment of traction injuries, and the tear sac itself may harbor and collar being given with good results. The pneumococcic forms. Another point to be re eighth case showed a fracture and dislocation of membered is the eradication of the shop oculist the fifth cervical vertebra on the sixth, the patient and of the plant nurse who oversteps the rights having fallen off a ladder about 15 feet high, of that group. In the matter of liability, blows on after which he was unable to move the left leg the head or jars from jumping a foot or two may for a period of six months; traction was applied cause severe results in the detachment of the and collar fitted, satisfactory results being ob retina, especially in persons of high myopia. tained. but with some involvement of, the grip of Claims for visual losses are continually occurring the right hand at the time of discharge. In the in the face of very slight injuries. There are also ninth case, there was a fracture and dislocation instances of where crossed eye has been ascribed of the sixth cervical vertebra with a crack through to head injuries. It is always a question of how the lamina; traction was used on this case, but it far the plant physician can go in the removal of was not followed up later. Demonstration was foreign bodies; certainly the responsibility for then made of two patients, one having history of thorough examination and treatment of after falling downstairs after partaking too freely of effects is better assumed by the ophthalmologist, liquor; the man presented himself with some although it is always a matter of judgment as to soreness of the neck, the side to side movement the removal of superficial bodies, by the plant being somewhat involved; it was later discovered surgeon. that there was anterior displacement of the sec Dond on the third cervical; reduction is now being attempted with this patient. The second case dem R. VORIS presented a series of cases and clinical demonstrations relating especially onstrated was that of a woman who sustained an to peripheral nerve lesions after injuries. The automobile injury, the diagnosis being an anterior first case was that of an individual injured in an displacement of the fifth on the sixth cervical; 10 automobile accident in which an open reduction pounds traction has been exerted at intervals and of the right arm was done twice; these operations the patient then put up in plaster; this was alter were complicated by radial nerve injury mani nated with traction, it being found that every fested by wrist drop and an anesthetic area over time the patient was put up in plaster there was the dorsal service of the index finger and thumb a return of the dislocation, although traction re --there was also some atrophy of the supinator duced the dislocation; the patient still has the longus and the brachial muscles. Another case of injury due to an auto accident showed a frac (metastatic lesions from carcinoma of the prostate ture of the lower third of the humerus, later com --Paget's disease). plicated by wrist drop and an area of anesthesia; In concluding, Dr. Warfield stated that deeper at the time of operation the nerve showed a specimens should be taken for biopsy, and more neuroma which was divided by multiple long biopsy specimens should be taken than is the incisions, and the patient now has the arm in a rule. cast. In a third case there was a compound Syphilis can produce any kind of bone change fracture of the left elbow with subsequent in in any bone of the body, so that it is well to be fection; wires were placed in the joint, and trac wary of the exclusion of syphilitic infection. tion was exerted and the patient put into a cast; Dthis was an example of a median nerve involve ment, there being trophic changes in the first and R. McCLANAHAN presented an interesting demonstration of a case of a patient who had second fingers and the fingers held constantly in been injured in an automobile accident, a woman a position of semi-flexion. In the fourth case of 27 who had apparently suffered a sudden jerk there had been dislocation of the left shoulder of the spine and was brought to the hospital with complicated by paralysis of all motions of the a kyphosis. Later on it developed by taking x-ray upper extremity after reduction; there appeared films that there was a crushing injury of the body in this case an anesthetic area involving the axil of the first lumbar vertebra. Operation was done lary nerve distribution and also an atrophy of the with a local anesthetic and the patient was put up deltoid. in a hyperextension cast which she wore for a In the fifth case, the result of an auto accident, period of 99 days, meanwhile taking special ex there was a fracture of the lower third of the ercises as demonstrated by the motion picture humerus, complicated by wrist drop; the radial film which was shown. Because of strict adher nerve was freed but it was discovered that the ence to exercise and supervision, the patient was brachial plexus was also involved; there was an in a great deal better physical condition follow esthesia of the hand and the volar surface of the ing this treatment than when she first presented forearm with atrophy of the deltoid; there is now herself with the injury. a small amount of flexion of the hand possible. DDr. Voris then reviewed the nerve supply of the three principal nerves of the hand and arm--the radial, median and ulnar--and also briefly com R. WILLIAM R. CUBBINS gave a very brief summary of his experience with fractures around the shoulder joint, stating particularly mented on motor functional tests. that there are many difficulties in the solution of the problems presented by this type of injury. DR. WARFIELD, in an interesting series of The fracture staff is working now on a modifica x-ray films of typical lesions, presented a tion of methods for the treatment of fractures in review of bone tumors and allied lesions as manaind around the shoulder joint with the hope that fested by x-ray films. There are three guiding standardization of treatment may be made based principles in making classification of bone tumors: on the securing of good functional and anatomic (1) one should decide on one bone or a part of a results. bone involved; (2) grouping should be made un It was felt by members of the society that the der and over 20 years of age; and (3) classification all day clinic was productive of a great deal of should include osteolytic and osteoplastic changes. useful information and that the program chair Following these suggestions, Dr. Warfield showed man, Dr. Frederick Slobe, and the officers of the a series of films using principally a classification society were to be congratulated on arranging a of the different types of changes in the young and very unusual and interesting program. The meet in the old patient: ing was adjourned to reconvene at dinner at the 1. Osteolytic changes in young persons (bone Bismarck Hotel, and later at a joint meeting with cysts--Brodie's abscess and sarcoma). the Chicago Medical Society to hear the program 2. Osteolytic changes in older people, which are of that organization and also the paper of the relatively uncommon (giant cell tumors--benign guest speaker, Dr. John J. Moorhead, of New chondromata of fingers and toes--malignant met- York City, on "Traumatic Surgery Trends," re astases). ported elsewhere in this issue. 3. Osteoplastic changes in young persons (os teoma of the single cauliflower type--sarcoma-- chronic sclerosing osteitis--Ewing tumors). Trivial Eye Injuries 4. Osteoplastic changes in older persons (fib rosarcoma of benign type--myositis ossificans-- ossifying periostitis, usually luetic). By Sidney Walker. M.D., . Chicago 5, Multiple osteoplastic changes in young per HAT may appear at first to be a trivial Wsons (congenital multiple exostoses--osteo-petros- is with many fractures--subperiosteal haematoma with calcification, in scurvy). injury is often of a severe character or may result in a serious condition. More over there is often an underlying pathology which 6. Multiple osteolytic changes in young persons is in no way related to the injury but for which (rickets osteochondritis of lues--osteogenesis im claim is later made on the basis of direct result, perfecta which progresses into fragilitas ossium or from the standpoint of aggravation of the pre after about one year of age). existing condtion. This problem often arises in 7. Multiple osteolytic lesions in older persons industrial ophthalomogy. I shall attempt to (metastatic lesions--multiple myelomata usually enumerate and briefly describe the types of eye of the skull--osteomalacia, somewhat rare in the injuries which are most likely to cause such United States. future trouble. 8. Multiple osteoplastic lesions in older persons The industrial surgeon sees during the year L. -I I VOL. O, JNO. 1 IL'IL/Uoiiuau 1 *-- many superficial lacerations of the eyeball caused blows on the head of a seemingly trivial character by flying chips, some of which imbed themselves or even such slight jars as jumping down a foot or and are easily diagnosed. However many simply two. I have in my records at least a dozen cases lacerate the cornea slightly and do not imbed of detachment of the retina occurring after a themselves. The result is a small, often fine, trivial blow about the head, or a slight jar. The wound which is only diagnosed by staining with facts were that a predisposing factor such as a fluorescein. high myopia existed, and it only needed a slight If cases of this kind are passed on as of little jar to upset the balance of tissue, and detachment importance, a subsequent severe ulcer may of the retina occurred. develop at the site of the wound, and before con Along the same line, but entirely alike, are trol is established the eye is permanently dam those cases in which many kinds of pathology aged to a varying degree. The same thing holds had existed prior to the alleged injury. Claims true for minute emery burns of the cornea. If are often filed on the basis that these conditions these are not properly drilled out, they also break were directly or indirectly aggravated by some down into ulcer and, depending upon the location, trivial trauma, if not directly caused by it. Where result in a specific loss of vision the amount of no evident pathology exists in the eye, and we which depends, in turn, upon the location on the have a condition of amblyopia exanopsia due to cornea. uncorrected refractive errors, claims for visual Intra-ocular steel may be present in some cases loss as a result of some slight injury are not at all which appear to be very trivial trauma of the uncommon. I have seen not a few cases of in cornea or bulbar conjunctiva. I will not go into cipient senile cataract, partially dislocated lenses, the means and methods of making a diagnosis old atrophic choroiditis, glaucoma, optic atrophy, under these conditions, as that is not the scope and, believe it or not. trauchoma. for which claim of this paper. The facts are that a minute wound has been filed. Cross eye is often claimed to be of the cornea often closes so quickly and so per the result of head injury, and certain types may fectly that, unless great care is used in the ex be; but there are many cases of this condition amination, the presence of a deep-hidden foreign found in persons without head injury, the causa body is entirely overlooked. Moreover a severe tive factor being entirely ocular. process is given a good start as the result of the It is, therefore, suggested that unless special lack of proper diagnosis, resulting in the total loss training has been had in ophthalmology, first aid of the eyeball. Infection carried in may result in in eye injuries should not exceed the removal of an all but fatal issue. I submit a case of B. Welchi superficial foreign bodies; also, that the shop ocu Panophthalmitis, the result of a supposed trivial list be put in his place in every plant. injury. It is very nearly an axiom that little credit is While the majority of electrical flashes cause given to the industrial surgeon for the favorable no more than a possible severe conjunctivitis with outcome of an eye injury, and lots of grief if the irritation for several days, there are cases of ap outcome is not good. Therefore little is to be parently trivial nature which result in severe gained by unnecessarily exposing the injured man retinitis and at times a gradually developing and yourself. For the protection of all concerned cataract in one or both eyes. Just what the causa an early examination by a competent oculist tive factor is in cataract electra has not been de should be had in many of the cases of so-called termined, but an examination should be had at trivial injuries. once to rule out pre-existing pathology of the lens or the retina. Such conditions as I have already noted show Dust and Tuberculosis the need of careful methods, but there also often enters the complicating factor of the physical well-being of the patient. We all recognize focal infection as the source of much aggravation, and often as the cause of protracted healing. Trivial wounds of the cornea when infected may spread rapidly or refuse to heal because of infected teeth or because of other foci. I have seen a badly in fected cornea starting from a very slight trauma and carried on to a total loss of vision due to the presence of an infected tear sac harboring the pneumococcus. It seems hardly necessary to stress the damage caused by the shop oculist--so many eyes have been irrecoverably damaged by this handyman with his penknife. He, however, is not alone, as the plant nurse is sometimes at fault in exceeding her duties or capability. Surprising as it is, the first aid in one shop was given by one of the em ployees who was also a student of chiropractic. Before much damage was done, however, the State Board of Registration put an end to his en deavors. To you who examine or come in contact with cases of public liability let me offer a few re AWES believes* that exposure to protein H dusts, some of which may occasionally cause asthma, hay fever or other anaphy lactic phenomena, to the carbohydrate dusts, such as flour, which presumably have no effect, spe cific. irritating or otherwise, and to the inorganic non-silicon-cor`lining dusts, including lime, mar ble, carbon and other elements, in normal amounts and under normal conditions will not reactivate an arrested or quiescent tuberculous process. He does believe, however, that dust in excessive amounts under abnormal conditions, such as street dust in winter and fall or germ laden dust from sleeping cars, which might well cause irritation and infection of throat, trachea and bronchi, is a potential source of harm. Dust that may cause allergic phenomena, such as asthma, bronchitis or hay fever, will not reactivate or harm a tubercu lous process. As to allowing an arrested or quies cent tuberculous patient to take up a trade in which he would be exposed to a harmless dust, the author would be quite willing to allow his patients to take up such dusty work unless the conditions as to dust were extremely bad. marks as to the eye symptoms which may follow Am. Rev. Tubere. June, 1935; Abstr., J.A.M.A., July 27, 1935. Pneumokoniosis; Traumatic Surgery --Review of Papers at Joint Meeting ofthe Central States Society of Industrial Medicine and Surgery and the Chicago Medical Society, held Wednesday Evening, January 15, at the Medical and Dental Arts Auditorium, 185 N. Wabash Ave., Chicago-- \ 5 GUEST of the Central States Society of In- eral surgery in which there was involved the his ZA dustrial Medicine and Surgery, Dr. John J. tory of trauma, and that traumatic surgery had the X A. Moorhead, of New York City, gave a paper following important characteristics: (1) no incu on "Traumatic Surgery Trends," which was dis bation period; (2) no exceptions as to age, sex, cussed by Dr. Harry E. Mock and Dr. C. R. G. color, race, or other personal peculiarities; (3) a Forrester, of Chicago. definite relationship of trauma to disease at vari The Chicago Medical Society had previously ar ous times; (4) greater complications and sequelae; ranged a program on the general subject of "The (5) more frequent contacts with the judiciary; Pneumonokonioses," prepared in the following or (6) malpractice problems; (7) diverse effects; (8) der: fl) "The Problem of the Pneumonokonioses an important relationship to general surgery; and in Industry," by Dr. George G. Davis; (2) "The (9) involvement in the controversy as to proper Clinical Aspects of Pulmonary Fibrosis produced use or abuse of antiseptics. In general, the medical by Dust Diseases," by Dr. Allan J. Hruby; (3) "The profession is responsible for the early care of in Pathology of the Pneumonokonioses," by Dr. jury, and the results are correspondingly better Henry C. Sweany; (4) "Roentgenologic Visualiza the sooner such care is given. The sources of in tion of Lung Fibrosis Produced by Silicosis and jury may be due to transportation facilities, to Other Dust Occupations," by Dr. Hollis E. Potter; industrial accidents, to incidental causes, and to (5) "The Legal Status of Occupational Diseases in sports. The automobile is the most responsible Illinois," by Daniel D. Carmell, Assistant Attorney mechanism in the production of injury. We now General, State of Illinois; and (6) "The Role of appear to be in the "gadget" stage of traumatic the Medical Department of the Illinois State In surgery, and it must be remembered that general dustrial Commission in Connection with Occupa surgery passed through a similar stage. Certain tional Disease," by Dr. Philip H. Kreuscher. of the trends in traumatic surgery at the present time were mentioned by Dr. Moorhead: (1) the DR. DAVIS, in discussing the problem of the universality of compensation laws; (2) early treat pneumonokonioses in industry, first stated ment means less deformity and disability -- by that it was a pleasure to talk on this subject anedarly is meant within the first six hours; (3) use that he had not solicited the opportunity. It is of of soap and water as a reliable method of anti course proper that persons having disability should sepsis; (4) the realization that primary suture is be compensated. The real problem is not in the hazardous--later suture is of distinct advantage; -diagnosis, but in the medicolegal jurisprudence of (5) the importance of early drainage--liberal use the actions which have been brought. Other prob of hot applications and incision after localization; lems which exist are those with reference to: (1) (6) the development of new ideas relative to the legal representatives; (2) x-ray experts: (3) wit methods of treatment of fractures--a general re nesses on medical problems; and (4) the apathy view of the results of various types of treatment of the medical profession in general. The Institute of different fractures--conclusion that fractures of of Medicine in Chicago deserves great credit for the neck of the femur and the os calcis are at the its work in attempting to minimize the amount of present time offering the greatest difficulties; (7) commercialization which has been observed in increasing interest in the relationship of trauma these problems. This paper was prepared from and disease, with especial reference to pneumono knowledge obtained from 182 suits beginning with konioses, cancer, tuberculosis and diabetes--em 1932 up to date. Mention was made of the use of phasis being placed more and more on the medico so-called "triple plays" in this kind of work, the legal aspects of these problems; and (8) the im play being from runner to lawyer to doctor. In a portance of realizing the progress made in various series of lantern slides, Dr. Davis showed that in types of anesthesia. 30 actions there were five cases of tuberculosis, no Dcases of silicosis and no cases of disability from dust exposure. Another important aspect of this problem is the large amount of damages against in R. C. R. G. FORRESTER, Chicago, in discuss ing Dr. Moorhead's paper, emphasized that traumatic surgery was a definite specialty, and dustrial organizations. The ultimate solution of pointed out the need for a chair in traumatic surg the problem depends on the honesty of representa ery in the various teaching institutions. tives of the bar and the medical profession and the Dimmediate elimination of quacks in both profes sions. The speaker repeated his former statement that the real problem of the pneumonokonioses in R. HARRY E. MOCK, of Chicago, also in dis cussion of Dr. Moorhead's presentation, noted that there was a marked increase in surgical inter industry is that of medicolegal jurisprudence. ference on traumatic cases because of the accumu lation of industrial experience and the necessity DR. MOORHEAD, the guest of the evening, of getting men back on the job. Especial reference speaking on traumatic surgery trends, first was made to the contributions of the World War said that traumatic surgery was a branch of gento the technique of traumatic surgery and at pres ent the great increase in public accidents, which tional disease, it is the further duty of the medical, is also greatly developing the experience of the profession to prevent such types of disease and dis traumatic surgeons. The growth of physical ther ability. Mention was made of the recent develop apy, an important adjunct of traumatic surgery, is ments in West Virginia, which emphasized the due in large measure to the war experience and need for the development of accurate knowledge the industrial experience, and is now being, of and the use of specialists in the avoidance of such course, definitely affected by the increasing num situations in the future, in any and all parts of the ber of automobile injuries. country. In conclusion, Mr. Carmell stated that it is not laudable to compensate industrial employees DR. HRUBY, in reviewing the clinical aspects for disease which is not directly associated with of pulmonary fibrosis produced by dust dis occupation. eases. believed that the word "pneumonokoniosis" Dwas a collective term; that the pathology produced in the majority of instances depended upon the silica content of the dust. Experience with indus R. KREUSCHER, in discussing the role of the medical department in the Illinois State In dustrial Commission in connection with occupa trial employees who had previously been coal min tional disease, believed that workmen should be ers was detailed. Mention was made of five cases paid for disability due to occupational disease. The of silico-tuberculosis coming to autopsy at the Commission has had no experience with disability Cook County Hospital in a period of approximately in relation to silicosis. It is generally recognized three years. There has been a change of ideas from that orthopedists or general surgeons do not pos an emphasis put on mechanical effects of dust, the sess the eligibility and experience to pass on such emphasis now being placed on the chemical effects. problems. It is therefore the present plan of those There seems to be a great variability in the period interested persons in the Commission to use three of industrial exposure relative to the production of medical men in the working out of problems rela fibrotic effects in the lungs. The physical findings tive to disability caused by silicosis. This is of in cases of fibrosis are often meager. The diagnosis course assuming that a compensation law will depends mainly on the history of the exposure to eventually go into effect. Of these medical men, dusty occupations and the x-ray findings. one should be versed in the proper examinations of persons exposed to dust and should be a person DR. SWEANY, in discussing the pathology of who "has no ax to grind," so that a non-prejudiced the pneumonokonioses, believed that although opinion may be given; another medical man of this there were many cases of non-occupational fibrosigs,roup would necessarily be a pathologist who is there were industrial instances of where real dam thoroughly acquainted with the pathological find age was done to the lungs. Specific fibrosis is ap ings; the third man would quite likely be a roent parently caused by the solution of silicon dioxide genologist whose experience along this line had and silicates, and also by the plugging of the been sufficient to make him thoroughly conversant lymphatic system by relatively inert dusts. Ap with the roentgenological manifestations. No com parently certain organic dusts sensitize the lungs. ment was made regarding what might be done One of the present day pathological problems is with respect to occupational disease other than the effect of silica compounds on tuberculosis, or- silicosis. Dr. Kreuscher assured the Medical So- the effect of silica compounds when diluted or as cietv that the Commission would be prepared to sociated with other types of metallic dusts or in deal efficiently with the problems of silicosis. organic minerals of non-siliceous type. A series Dof lantern slides was shown demonstrating the histogenesis of silicosis. R. D. C. STRAUS, in opening the discussion, thought the expert witness was the real prob lem in the occupational disease situation. The sug DR. POTTER, in commenting on the roentgeno gestion was made that reports of the roentgen find logic visualization of lung fibrosis produced ings by medical witnesses on both sides of these by silicosis and other dusty occupations, gave caases should be sent to the Chicago Roentgen So general review of the x-ray manifestations at vari ciety for review. It was also proposed that greater ous stages of fibrosis in the production of silicotic activity on the part of official medical groups, and lesions. Especial emphasis was placed on the re the cooperation of these groups, might be instru lationship to tuberculosis, and an excellent demon mental in improving the general situation with re stration of chest films, with a discussion of diagnos gard to medical witnesses. tic points, was made. Tuberculosis ControlR. CARMELL, in speaking about the legal status of occupational diseases in Ilinois, Dcommented that the problem of occupational ease in this state was previously rather serious on Taccount of various court decisions. At the present time the serious problem is what occupational dis eases are really compensable. A real question now is whether silica is a poison, and the legal profes sion must look to the medical profession for the solution of this problem. At the present time va rious representatives of labor and industry are con cerned with a law regarding compensation for dis- abilitj/ in real occupational diseases. Prevention is the key to the situation, and besides being in dis HE important point in this study* is that no matter what people enter a hospital for, the chance for a complete examination is too im portant a matter to be overlooked, and in advising people about themselves all the facts that have en tered into their health problems should be known. Arrested cases of tuberculosis in industry pres ent an important economic problem and only the most intelligent of the arrested cases can be trusted to protect themselves by what they have learned while getting well. The racial differences are shown in the incidence among negroes. terested in the diagnosis and treatment of occupa Philip Kinc Brows, M.D., F.A.P.H.A., in A.J.P.H., June, 1935. unitwry, ivoo , The problem of tuberculosis in the Pacific cident. Compensation is not allowable if death re Southwest was illustrated by the fact that when sulted solely from a so-called occupational disease. the Southern Pacific bought a rival road running The question, then, is whether Morrill's disability through its territory, 11 of the officials who had and death resulted from the accident. The evi been transferred to San Francisco had to be pro dence tended to show that the injuries resulting vided for in their former environment because of from the accident "lighted up," aggravated or conditions of their lungs which had brought them accelerated a preexisting disease and caused death to the Southwest. earlier than otherwise would have been the case. Finally, annual examinations in industry are of It is not apparent that the nature of silicosis from the utmost importance from an economic point of which Morrill was suffering, whether it was an view for industry hnd employees. occupational disease or not, is material to the de termination of the question of compensability. It Significance of Lead in Body cannot be that one who has incipient silicosis is precluded from compensation when injured, be cause the silicosis from which he is suffering, or HE investigation of Myers and his associates ailments consequent on it, might ultimately result Tin 500 cases not known to be associated with in disability or death. The compensation act pre lead exposure has pointed out various syn scribes no standard of fitness to which an employee dromes that may be associated with the "smubust conform, and compensation is not based on chronic" type of lead poisoning.* Common sources any implied warranty of perfect health or immun of poisoning, such as foods, drugs and environ ity from latent and unknown tendencies to disease ment, are discussed. One should be on the alert that may develop into positive ailments if incited for the possible presence of lead in drinking water, into activity by accidental injury. Although Mor fruits and vegetables. People suffering with ob rill's disability and death were due to the de scure gastro-intestinal and cardiovascular dis velopment of a disease that he had in his system turbances should be examined with the greatest when he was injured, if his injuries were a con care. Early symptoms that are of importance are tributing and proximate cause of such develop loss of appetite, nausea, weariness, constipation, ment, the disease, in the opinion of the court, "re headaches, eye symptoms and circulatory mani sulted from the injury" within the meaning of the festations. For the present, the laboratory investi workmen's compensation act and the motion of gator and clinician should certainly give attention the defendant for a directed verdict was properly to all values of more than 50 mm. of lead per liter denied by the trial court. The judgment of the of urine. About 20 mm. per liter is probably some trial court in favor of the claimant, but denying where near the expected limit. In the examina compensation to her children because they were tion of blood, it is believed that 24 mm. of lead per not shown to be dependents of the deceased, was hundred cubic centimeters covers the patients of affirmed. the "subchronic" type, and that 6 mm. is probably a value somewhat nearer that which should be expected. In the case of hair, it appears that lead Industrial Health finds its way with a great deal of difficulty into the hair, and when lead is found it may be of diag nostic significance, depending on the habits of the patient. Under the present mode of living, lead undoubtedly plays a part in many other diseases and should always be given consideration when the clinician is unable to place his finger immedi ately on some definite syndrome. HE ideal concept of industrial relations de Tmands that those conditions and processes that are known to be injurious to the health of workmen must be eliminated*. No industry that prides itself on its industrial relations pro gram can fail to recognize the importance and the urgency of setting up an organization of employees led by engineering and medical groups that will Activation of Tuberculosis attack and eliminate every industrial disease haz ard. Briefly, control of occupational health hazards MORRILL, a granite cutter, while operating depends upon: a silicon carbide saw for the defendant, 1. A complete knowledge by doctors of the phy August 27, fell and injured his left hip, sical effects of all types of occupational exposure side and chest. At the time he was apparentinly tihne industrial unit. . good health and able to work, although he was suffering from silicosis and latent tuberculosis. 2. A thorough understanding by doctors and en gineers of the industrial factors which produce ' On the day following the accident he went to bed, harmful conditions or substances. where he remained until his death, October 8, from acute pulmonary tuberculosis. His widow brought proceedings under the workmen's compensation act of Vermont to recover compensation for her self and her children. From an award in her favor, but denying the compensation to her children, con firmed by the county court, she appealed to the Supreme Court of Vermont, as did also the em ployer. There is no question, said the Supreme Court,* but that Morrill sustained personal injuries by ac- 3. The development by engineering methods of effective means of protection for every exposed workman. 4. Complete organization of the entire person nel of each industrial group for the purpose of educating every one in the avoidance of occupa tional disease. This problem is difficult and complicated, but it can be solved. Long years of practical experience make me absolutely certain that the doing of this job will pay for the expense and effort by in Nrw York State J. Med., 352579; Abstr. August 3, 1935* creased efficiency of the working force, improved Morrill v. Charles Burnthi & Sons, Inc. (Vt.) 176 A. 416. J.A.M.A. i Medicolegal (October 19, 1935). James A. Britton, M.D., in National Safety Netus, July, 193s. quality of product, and (that which is the most important of all) more cordial relations between men and management. Infectious Diseases As Vulnerating Forces Under Workmen's Compensation Acts By Kurt Garve, M. D.,* Member of California Bar *N EMPLOYEE was sent upon a business trip /\ in the course of which he was to visit a JLA. number of eastern cities. In pursuance thereof he left San Francisco, the place of busi ness, and called on dealers in different localities. Finally he landed in New York. A month later while homebound he found himself sick, and con tinued to be so when he arrived at San Francisco. He was suffering from typhoid fever. Proceed ings ensued before the Industrial Accident Com mission on the ground that the claimant had con tracted his ailment by reason of his employment while in New York. The Commission found that there had been an epidemic of typhoid fever in New York at the time of the claimant's stay there; that he had eaten oysters, but that they did not cause, or ag gravate, the epidemic. And, since all other people in New York had been subjected to the contact with the disease in the same manner and degree as the claimant had been, no connection between his stay and his disorder was proved. His duties had not been so peculiar or hazardous in regard to the contagiousness of the epidemic as to intensify the risk which was common to all. Compensation was denied. Appeal was taken. Infectious diseases are often contracted outside of the employment as well as by reason thereof. Their relation to the workman's job may be difficult to trace. Intensification of danger of in fection by reason of industry marks compens ability. In some situations the infection can clearly be tracked down to the employment. An industrial tool, laden with virulent germs, pierces the intact skin. Stepping on a tack, receiving a scratch from box cars while unloading bags, a fall on a dirty floor with resulting fatal erysipelas or blood poisoning are, therefore, compensable accidents. Employment may also furnish contact by germs with a pre-accidental open wound due to employ ment or otherwise. There is an aggravation of a pre-existing infirmity. A cold sore, infected by rubbing while handling carbon paper, wading with an old open wound through infested water, or cleaning urinals after having received a cut, warrant compensation whenever complications result. Blisters, callosities, felons are often considered occupational rather than accidental, unless em ployment causes an additional infection. On sim ilar principles rest vaccination wounds: they are not regarded as incidental to the employment, though the employer may have required vaccina tion as a condition precedent to giving, or per mitting to continue, work. Since vaccination wounds may easily become infected from sources other than industry, proof of connection between * Condensed from Dickinson Law Review, vol. XXXVIII, January, 2934. infection and job would have to be rather clear and convincing in order to hold the employer liable. Certain occcupations. however, suggest at first blush causal connection between infection and work. The place of employment, or materials or tools handled, are veritable breeding places of microorganisms often of the highest virulence. In "embalmers' cases", for instance, the inference of compensability becomes strong when the species of germs, found in the body of the em ployee and identified as to strain, dovetails with that in the corpse. Awards have also been up held in litigations involving anthrax, actinomy cosis, blastomycosis, and similar ailments, though in some decisions compensability could not be sustained because of strong possibility of extra industrial inoculation. No visibly open wounds need be proved. It is, however, important that the manifestation of the disorder be not postponed too long so as to indi cate recuperation or illness from sources not connected with industry. Yet it cannot be denied that a period of incubation may be comparatively protracted in industrial infections. Contagious diseases are more difficult to trace to the job. The genesis and source of the disease, such as sleeping sickness, may be obscure. In North Dakota compensation was denied. In ty phoid fever, on the other hand, the etiology is well-established. Where the employer supplies the workman with polluted water at the place of work and while he is in the line of duties, many courts have held that his contracting the disorder constitutes a compensable accident. In other jurisdictions non-compensability, however, was upheld upon the ground that there was no injury to the physical structure at the time the water was consumed, or that there was nothing, fortuitous, as the interpretation of the word "acci dent" requires. Where the disorder is considered to be acci dental, compensation would also be granted when the employer is aware of a source of infection within the reasonably immediate neighborhood of the place of work so as to be able to warn the workman, and when the employer fails to do so. Vice versa, the source of infection being 'some distance from the place of work, causal connec tion between employment and disease must be denied. In another type of cases, germs are already in or on the body. But, they were of weak viru lence prior to the accident. Lowered vitality, local or general, caused by industry, contributes to the infection. A severed spinal cord and loss of sensation below the seat of infection, followed by a bed sore and resulting in blood poisoning, warrant compensation. Similarly, the complete rupture of the skin making the employee, who is suffering from arteriosclerosis, more susceptible to blood poisoning and gangrene than normal persons would be. does not exempt the employer from liability when industry contributes to the septicemia. But a kidney infection, due probably to a dropped kidney, a tipped womb, and the wearing of a pessary, is too remote in connection with an industrial accident. Suffering from a disease in the stage of incuba tion and at that time sustaining an industrial trauma, also makes out a case of compensability. j uwuiry, imo since the disorder is aggravated by reason of low vical vertebrae or at whatever level may be in ered vitality. dicated for fractures of other regions of the spine. Finally, "carriers" may be reduced in their An air mattress, preferably eight inches thick, is vitality by an industrial injury. Pulmonary tu then placed on the bed over the blanket roll and a berculosis, pneumonia, pleurisy, when originated strip of adhesive tape, eight inches wide if the frac by accident, are compensable. Diphtheria has ture is in the cervical region or from 12 to 14 been held to be non-compensable. As to typhoid inches wide if the fracture is in the thoracic or fever, judicial doubt exists. the lumbar region, is applied to the mattress be To come back to the "traveler's case". The ginning at the line of the blanket roll. The mat reviewing court in its majority-opinion sustained tress is covered with a soft woollen blanket or a the commission. Yet, a dissenting opinion sheet and the patient is placed on the bed. The pointed out that "it is axiomatic that to go from adhesive strip is then drawn as tight as possible, as a place of safety to one of danger is to incur a much force being used as is necessary to obtain special risk. If one's employment requires him the proper degree of angulation of the air mat to incur such risk, any injury resulting therefrom tress. It is then fastened to the bottom of the foot certainly arises out of the employment." piece of the bed either directly or to a movable There is another reason why compensation bar attached to the foot end, a ratchet being vised ought to have been awarded. There was a change to tighten as needed. The air mattress must not of climate, of diet, of air, and so on, incidental to leak and must be kept pumped up, and the ad traveling from the West coast to the East. When hesive strip must be tight at all times. A pillow is such a trip is made, a temporary revolution in then rolled and placed beneath the patient's knees the metabolism, and consequently some sort of' so as to flex the lower extremities slightly. A lowered vitality, exists. Amenorrhea follows im small folded blanket is placed beneath the calf migration from Europe into the United States. muscles, reaching to within four inches of the in Why not apply corresponding reasoning to the sertion of the achilles tendon. The heels are thus male? Natives do not undergo this stage of ad kept off the bed by resting the calves on a wide justment to the new surroundings and to the new surface and pressure sores of the heels are thus living conditions. It is submitted, therefore, that avoided. Any abnormal position of this sort is there was an intensification of hazard in regard naturally uncomfortable and the author has found to the epidemic of typhoid fever ip New York by it advisable to relieve the patient's discomfort reason of employment. This is also somewhat during the first few days by medication. If each substantiated by another decision of the same of the details is carefully observed, he believes reviewing court holding that typhoid fever was that the foregoing method will be found satisfac compensable under similar circumstances, the tory for the reduction of incomplete vertebral only difference being that the business trip ex fracture dislocations, especially in the cervical tended into a foreign country. There the court region, and for the reduction of compression frac thought that the natives were less affected by the tures of the whole spine. epidemic than newly arrived people. The major ity of the justices do not seem to have grasped the import of the essential facts in the "traveler's Death from Tuberculosis case". Activated by Silica Dust as Accidental Injury EAVER entered the employ of the Morrison- Vertebral Fractures . Reduction of Dislocations B Knudsen Company in 1928. At that time he had tuberculosis in an arrested stage but otherwise seemed to be in good physical condi tion. He was able to carry on regular manual la TOOKEY presents a method for the reduc bor. In the course of employment he was sub S tion of incomplete fracture dislocation that jected to clouds of dust, containing from 80 to 85% may be employed immediately after the. in silica, and, was more or less bothered by coughing, jury, can be maintained as long as may be dewhich became more frequent as time passed. In sired, and is available in any hospital having an 1931 he became ill with active tuberculosis and air mattress. Reduction of the dislocation is ac filed a claim under the Workmen's Compensation complished without manipulation and usually no Act of Idaho. After the hearing before the indus special skill is required. With slight modifications trial accident board Beaver died, and his adminis .the principle of the method may be used for tratrix was substituted as claimant. From a judg transporting patients with acute spinal cord in ment of the district court affirming a decision of juries by substituting a stretcher for the bed and the board disallowing compensation, the claimant using an air mattress. appealed to the Supreme Court of Idaho.* The technique used is as follows: It seems clear from the evidence, said the Su A fracture board is placed on the springs in the preme Court, that the inhalation of silica dust ac usual manner. The foot end of the bed is placed tivated a latent tuberculous condition in the em on low blocks elevated slightly in order to raise ployee's lungs, which in 1931 suddenly lighted up the relative position of the patient's head to his and resulted in death. No one was able to testify trunk. In order to have the head easily acces as to the specific time when the injury was re sible, the foot end of the bed is made the head of ceived, or when the fatal draft of dust was inhaled. the bed. Two ordinary mattresses are placed over Who can in truth and fairness say that there was the fracture board. A blanket is then rolled and not a compensable "accident?" All accidents are placed on the ordinary mattresses at the level of preceded by a cause; in some cases that cause may the shoulders for fracture dislocations of the cer- have operated instantantaneously; in others it may Da. B. Stooket, in Amer. Jour, of Surgery, (December 1934). Abrtr. J.A.M.A. (February 9, 1935)- * Beaver r. Morrison-KufuUen Co. (Idaho) 41 F. (ad) 605. J.A.M. Med icolegal, (October 19, 1935). have been operating for days, months or years, and ultimately the accident occurs and the "blow up" happens. A workman works for years on a given job in which he regularly has to lift a con siderable weight. In the course of time his heart grows weaker. Eventually he lifts a similar load, his heart fails and he dies. He has overstrained himself in lifting the load and it is said to be an "accident" arising out of his employment. In re Larson, 48 Idaho 136, 279 P. 1987. Strain may im pair or rupture some other part of the body so that the final `effort at labor accomplishes the breakdown, and it is held to be an "accident." Hanson vs. Independent School District 11-J, 50 Idaho 81, 294 P. 513. In principle, said the court, the cases cited are not dissimilar from the one here under consider ation. In view of the facts and circumstances bear ing on the injury in this case, said the court, and of the uniform purpose of the court to give the workmen's compensation law a liberal construc tion in favor of the injured workman, we are con strained to hold that the workman in this case met with an "accident" in the course of his employ ment and was entitled to compensation. The judgment of the lower court was reversed. Pneumokoniosis and Its Social Effects By James W. Ferguson, M.D., duces a severe form of pneumokoniosis, called silicosis, which is characterized by fibrosis within the lungs, and which disease can completely in capacitate or render the victim susceptible to other respiratory diseases. Silica in its different forms comprises better than half of our earth's composition. It is found in all animal and vegetable life; it gives form to the hulls and husks of different grains, and to the leaves and stocks of the various grasses, weeds, and vegetable plants. It occurs as almost pure silica in opal and amethyst. Quartz and flint contain a very large amount of it, and it is found in all sand stone, gravel, and granite. Since it is found so abundantly in its various forms and combinations and is so widely distrib uted over the surface of the earth and throughout our constructive and destructive enterprises, it is obvious that people who work with the different products of nature are more or less exposed to dust which contains silica; and this explains the reason for so many industries being concerned with it. Throughout the various stages of industrial de velopment, dust has been somewhat of a hazard and a hygienic problem for the industries. The use of modem machinery for rapid cutting, pul verizing, and polishing has produced dust in enor mous quantities and this, along with the present trend of economical and social conditions, has so widely introduced the subject of pneumokoniosis that it has become the outstanding hygienic prob lem of the day. HE physiological aspects of pneumokoniosis T Tin relation to its effect on the present eco HE length of time an employee works at a nomical and social status of the employer and dusty occupation before pneumokoniosis de employee have become a very important problem. velops to a dangerous stage, or before it is severe Many studies have been made of diseases of the enough to warrant a change in occupation, depends lungs caused by dust; and extensive work has been upon the amount of dust inhaled, the chemical done in an effort to determine the etiology, path composition of the dust, the fineness of the dust, ology, and diagnosis of the lung conditions; but the susceptibility of the person, the anatomical very little attention has been given to the effects condition of the upper respiratory tract, and the of the degree of disability on the industry, the em working conditions. Formerly it was thought that ployee, the employee's family, and society. 15 to 20 years were required to produce a serious The ill effects of inhaling dust while working at condition, but recently, by investigations and the a dusty occupation are not a recent discovery; the study of cases by the roentgen rays, it has been earlier medical writers1 knew something about the found that under certain conditions some cases harmful effects of dust. may take several years and under others, where The importance of this subject is emphasized by the dust is very fine and in large amounts, and the the number of commissions lately formed to study employee has little resistance, the time may be the conditions dealing with dust and health and by reduced to a few years. the number of articles on pneumokoniosis11--sili For a long time physicians have been advising cosis, asbestosis, anthracosis, etc.--that have ap certain patients to work in less dust. In recent peared recently in medical literature. It is also years some industries have shown a willingness to interesting to note that in cases concerning dust ills cooperate with them by installing, from time to brought before the courts of several states, indus time, modern preventive measures. But. on the try has received a verdict of adverse character. other hand, it is impossible entirely to eliminate All this reflects the trend of social thought, and, in the dust, fumes, gases and mists from all industries turn, points out that disease due to the inhalation and still carry on the business of the enterprises. of dust at one's occupation concerns not only the This means that many industries contain more or employee and his dependents, but also the industry less hazardous occupations and, therefore, it re and society. mains for society, the industry, and the employees The severity of the diseases varies somewhat to cooperate for the best interests of all. with the different kinds of dust, fumes, gases, and When society considers the preventive and com mist in the atmosphere, and, on account of the pensative measures it should also consider the fact wide distribution of the industries which subject that the more the protection and the greater the one to these hazards, the diseases vary in different compensation offered, the greater the burden on localities and in different industries. the industry. Since the states, instead of the fed Investigators now agree that various kinds of eral government, make the compensation laws, dust, fumes, gases, and mist are capable of causing occupational diseases are not similarly recognized pathological conditions of the respiratory appara by the various states. Some do not recognize oc tus but that an inhalant that contains silica pro cupational diseases at all. Others award compen- sation or benefits according to the degree of dis will do so in the future. This will prevent many of ability and the amount of suffering of both the the exposed unemployed from obtaining employ worker and his dependents. Those states that do ment in the states where occupational diseases are not recognize occupational diseases teach little or compensable, leaving them to seek employment no protective health measures and employ little or elsewhere, which will add to the perplexity of the no preventive and protective measures. This cre problem, with many of them on the verge of pov ates an unequal cost of production in some indus erty and dependency. Some will find their way tries and in different states. The incentive to pro into similar industries, some into dissimilar indus tection and preventive measures is, and always tries--factories, mills, and mines. This unfortu will be, in direct proportion to the difference be nate situation will result in disaster to the self- tween the first cost of the preventive measures and insuring industries if they do not protect them the consequences .-- the costs and culpability -- selves by carefully examining the applicant before which are determined by the amount of the ver hiring. They will be very likely to receive in their dict as a measure of damage awarded by juries employment some very dangerously-exposed per under common law suits, the workman's compen sons with pneumokoniosis, possibly tuberculosis, sation law, or by society attempting to legalize or both, for which they may be required to assume preventive measures. responsibility for all of the exposure whether or In some states industry recognizes the impor not the worker received it while in their employ. tance of healthy employees in its plants because it For this reason it is strongly recommended that means more efficiency and fewer accidents. Many a roentgen examination be given at the time the have been teaching first aid and accident-preven applicant is being considered. tive measures. Through this teaching, the average The industries that depend upon outside com worker, though he himself might not be injured or pensation coverage may find it very expensive, if get sick as a result of his working conditions, re not impossible, to obtain proper coverage for cer gards the accident and preventive measures as his tain occupations. At the present time some insur own immediate concern and often places the cul ance companies are unwilling to cover certain oc pability of the whole scheme of hygiene upon his cupations. There seems to be an increasing con employer, the industry. These acts are often evi fusion concerning the unstable condition of the denced by the demands upon industry for protec subject of pneumokoniosis. Recently a company2 tive measures or compensation for injury received found it necessary to reinsure all of its employees. by the employee or one of his fellow workers in All were discharged and re-employment took place the course of employment. after a health survey was made. Some affected In the past, fatal accidents, because of their in were not re-employed. Legal proceedings were evitable publicity, have been given more thought commenced against the company. The Supreme and attention than occupational diseases, especially Court ruled that it was a matter for legislation and those which develop insidiously like pneumoko- not for the courts, and further ruled that no dis niosis, which as a rule occurs little by little, day by ability was suffered by the employees within the day, out of sight and mind of the public. There meaning of the law during the period of their em fore, society has been slow to adjudge industry and ployment nor until after the relations of the em make demands for preventive measures in this ployer and employee had been terminated and, particular condition. But, recently, on account of therefore, the employees were not compensable. the present social and economical trend, society is Tstrongly asserting itself by awarding court verdicts against industries in cases of pneumokoniosis from HE last occupation is not always the one ac tually responsible for all of the trouble. The occupational dust exposure. person may have had pneumokoniosis when he was An important condition from an economical and hired. He may have contracted it during some oc social standpoint is the fact that the present eco cupation of short duration, and on account of fre nomic depression has caused considerable reduc quent changes in occupation the one that caused tion in employment, especially in the constructive the exposure was forgotten. But if the industry industries that are always attended with dusty oc does not know the condition that existed when it cupations. A large number of the unemployed hired him, it may be required to assume responsi have been exposed to dust. Since some states do bility for all the existing conditions. not recognize occupational diseases they have not A radiogram, made when the applicant is being employed very many protective and preventive considered and kept as a record, appears to me to measures and, therefore, in these states exposure be a decisive way to show the condition that exist has sometimes been very extensive. ed when the worker was hired and the progress of With the return of prosperity, the labor influx the condition during employment. in the various factories, mills, and mines will carry Subsequent roentgen examinations will show more or less hardship for the industry, the oper when the danger point has been reached. Roent ators. and society. It is questionable how many genograms will also aid in detecting tuberculosis, of these unemployed will return to their former and, by eliminating the tuberculars, the other occupations and how many will be compelled to workers within the plant will be protected. Ro seek employment in other industries of their own entgenograms may be the means of detecting tu state or of other states. The moving from one state berculosis at a time when the applicant does not to another expecting to find employment will add know that he has the disease, and may give him a to the social problems. Many will not be accepted chance for recovery by receiving early treatment. because of their physical conditions. Because of Furthermore, he may be enabled to protect his the present social and economic unrest, with so family by affording them information so that they ciety demanding more protective measures for its can use preventive means against infection. Ro workers, some states that do not now recognize oc entgenograms can be used in the future as a de cupational diseases as a compensative condition ciding evidence to aid in the establishment of the degree of disability compared to the amount of cupation really did cause the condition, or to show pneumokoniosis that the applicant had at the time that an occupation made an existing condition he entered employment. worse, should also aid the compensation adminis The day of specialization is here. The com trators. panies wish experienced operatives. In gaining Roentgenograms of the claimant's chest made at experience the worker, while learning, may have the time he began the occupation and at the time been subjected to exposure to dust which resulted he left the occupation, or at the time the exposure in his contracting a corresponding amount of pneu was stopped, should, along with other information, mokoniosis. Hence, one of my reasons for recom aid in settling the dispute. mending an examination of all applicants who ex But it must be remembered that stopping'the ex pect to work in dust or who give a history of work posure by removing the worker to a dustless occu ing in dust, or when tuberculosis is suspected and pation does not always stop the progress of the dis when a history is given which reveals contact with ease. As a rule it does, but it has been proved that tubercular patients. sometimes it does not.6 The disease may keep on Tubercular applicants who expect to work in progressing, especially if the person is subject to dust should be ruled out. The inhalation of silica frequent attacks of bronchitis or if he falls ill of dust can activate tuberculosis,3 and those suffering pneumonia or influenza. This has been proved in from this disease have fewer chances of recovery the writer's experience. if silicosis is present along with the tuberculosis. Whether or not certain occupations aggravated a Some courts have ruled that tuberculosis activated previously-existing condition is difficult to deter by silica dust is compensable.4 mine unless there is some record of the condition As a rule, a person with silicosis continues at his which existed when the worker began the occu occupation without knowing that he has the disease pation. Whether or not a condition developed while until he ultimately contracts tuberculosis or pneu at a certain occupation is also difficult to determine monia which causes the condition to become pro unless a record of the condition that existed at the gressively worse and probably incapacitates him time the worker began the occupation can be for further work.5 Frequently an acute respira shown. tory condition such as bronchitis or influenza ag Wgravates a silicosis condition that has been lying dormant for several years, and the worker does not HEN we consider that silica is capable of producing a severe form of pneumokonio recover as quickly as he should, with the result sis, and that other dusts and mixtures of dust that silicosis is for the first time discovered and cause somewhat different pathological conditions, usually is accredited to the last occupation of the and that silica and mixtures of silica and other patient. Society should not adjudge an industry dusts vary in amounts throughout our various in for wrongdoing until it has been shown that the dustries which are widely scattered throughout industry is at fault. If damage to the worker's the country, it becomes obvious why one author lungs has occurred, the source of exposure should ity said: "Even clinicians experienced in ex be definitely established, because, as has been pre amining cases from one industry may not be qual viously explained, an employee may have worked ified to express opinions upon cases in other dusty in a dangerously dusty industry for only a few industries,"7 and explains a reason for differing years, and have developed silicosis and, because of testimonies being offered in these cases. Those his frequent change of occupation or its short dura interested in testimony may be interested in tion, the occupation is forgotten or is not consid knowing that many who have had special train ered important by those in charge of employment, ing and experience in roentgenology have a certi and the applicant is hired. The new occupation ficate from the American Board of Radiology may be silica-free and in no way responsible for which was formed in 1933. The board is made up silicosis, but still, if there is dust present, the in of 15 members, all recognized authorities on ra dustry may be adjudged responsible for all dam diology who were appointed by the various radio age. Again, a worker who has been exposed to logical societies. The board conducts examina silica dust at a certain occupation, either knowing tions for those who wish to qualify as to their ly or unknowingly, applies for similar employment ability and competency to practice radiology or in another industry which has the necessary pre one of its branches. A diploma from the board in ventive measures, or possibly on account of its dicates that the holder thereof has had certain location may have a silica-free atmosphere, and training and experience and has satisfactorily again an innocent industry may be adjudged and passed the examinations of the board and satisfied held responsible for all of the damage. them as to experience, training, competency, and other qualifications which they deem necessary BEFORE an industry, an insurance carrier, or in order to practice radiology or one of its the courts can render compensation measures, branches. certain facts necessarily must be established. They The physical suffering of one afflicted with the must be furnished with decisive information, so disease, and his inability to work, with the result they can award the compensation as prescribed by ing reduction in his wages, and, perhaps, the pos the compensation laws. They must be shown that sible destitution of his dependents, plus the fact actual damage to the lungs has occurred, and what that the afflicted worked at a dusty occupation, damage has been done. Also, the degree of dis usually furnishes grounds or reasons for claims ability that is present and the amount that is likely for compensation; but, frequently, lack of evi to continue permanently must be determined. The dence by those in charge of the case, including the condition of the claimant's chest at the time he be industry, the physician, and the employee or his gan the alleged responsible occupation should be dependents is the cause of compensation disputes. offered as a deciding influence to those administer Sometimes claims are filed against an innocent in ing compensation measures. To show that the oc dustry by some unscrupulous person, and there fore it behooves the insurance carrier to seek all eases which may cause him to die earlier in life the information possible so as to aid in awarding than his fellow workers who do not develop sili the compensation as provided for by the compen cosis. It can also, by causing a partial disability, sation laws. Sometimes, when the insurance car result in a reduction in earning power with a cor rier, the industry, or the courts request sufficient responding amount of suffering to himself and his information to justify them in settling a claim, or family. Silicotics are subject to frequent attacks to aid them in awarding a fair and adequate com of upper respiratory colds, bronchitis, and other pensation, a just claim is insufficiently presented diseases, but the most common danger is an ex and the claimant suffers, the blame being shifted traordinary susceptibility to tuberculosis which onto those attempting to administer the compen completely incapacitates the worker and usually sation. Hence, another reason for keeping rec progresses rapidly towards death. Seventy-five ords, histories, and roentgenograms as outlined percent of those afflicted with silicosis ultimately herein, and considering them along with the clini develop tuberculosis.8 cal aspects of the dispute between the claimant In the year 1916, when the Pennsylvania Com and the defendant. pensation Law went into effect, this writer made a health survey of several hundred employees for MOST of the records of physicians, hospitals, a large self-insuring corporation. The chests of and industries pertaining to pneumokoniosis the employees were examined both clinically and do not usually give the information necessaryrotoentgenologically. Many of these people were settle a compensation dispute. The value of good stricken with influenza in the epidemic which oc records is evidenced by the inconvenience often curred in the fall of 1918. A number of them were experienced when an attempt is made to obtain again examined in 1921, and just recently some records after the claim has been entered for trial. were further examined, and others will be as they Physicians' records are generally kept for their are located. The results of these examinations are own therapy requirements and not for tracing the of value, but out of the scope of this paper. I ex cause or origin of the disease. The same thing pect to report them later. However, evidence was may be said of hospital records. They give gen sufficient to indicate that influenza caused some eral information, but not enough detail as to the of the cases of pneumokoniosis, "which were not amount of dust inhaled or the kind of dust en interfering with their health and ability to work," countered in the occupation, the hours of expo to flare up and become progressively worse and sure, and the various occupations that the patient cause a few to become incapacitated. Other phy had, with the exact duties of each one. sicians have reported similar conditions. Often pneumokoniosis is obscured by tubercu Elosis or pneumonia for which the patient was ad mitted to the hospital, and these often appear on death certificates because they are considered the VEN though it is impossible to remove all the dust from some industries it appears that it is up to the industry to meet the increasing de active causes of death. For these reasons it is pos mands that are being made upon it in this respect sible that there may be considerably more cases of by society or to accept the consequences. While pneumokoniosis in our country than our records it is impossible to eliminate entirely the dust from indicate. certain occupations, industries can do much to I believe that records made when an applicant wards preventing pneumokoniosis from develop is being considered can be made to be of consid ing among their employees to a dangerous stage. erably more value both to the employer and the They can make a health survey of their workers employee. to determine the condition of their chests, deter Records should be made of the various previous mine how many have pneumokoniosis, how many occupations, not just what company the applicant have tuberculosis, and how many have both dis worked for; the exact duties of each occupation, eases. A roentgen examination will show the not the name of a general occupation; the num amount of fibrosis, and its anatomical location. It ber of working hours per day in the dust, and the will show the design or pattern of the fibrosis. exact number of days--not just how many years of Roentgenograms will aid in the segregation of the work and whether or not the occupation was a tubercular from the non-tubercular, so that those dustv one: the kind of dust, if possible, and the who have silicosis may not be subjected to the location of the plant; not just the name of the com dangers of contagion. A health survey will aid in pany; the hygienic conditi<"-- of the occupation determining whether or not more exposure will be and, if possible, whether respirators were used harmful, and if the worker should be transferred and what kind of respirators. All this will, when to some other work. It will show the exact state the time comes, help to arrive at a fair settlement of affairs, so that more serious trouble may be of compensation disputes, and will be useful when guarded against. Subsequent examinations will considered along with the roentgenological exam show the progress or development of the condition ination and clinical findings. after the survey was made. After the general health survey of the employ SILICOSIS is characterized by irritation, con ees the question arises of what to do with those gestion, and fibrosis within the chest; as the having silicosis or pulmonary tuberculosis, or sili fibrosis develops it encroaches on the air cells, aircosis and tuberculosis. Discretion must be used in passages, and lymph and blood vessels, with a cor handling these cases. To discharge all of them responding decrease of or interference with lung would invite litigation2, but, on the other hand, ventilation and a reduction in constitutional cap those having pulmonary tuberculosis become a ability for muscular activity -- "exercise and hazard to their fellow workers. It would not be work." Uncomplicated silicosis rarely kills the wise to allow a tubercular person to continue person unless the exposure has been extensive, working among other employees, especially if but it usually leaves him susceptible to other dis some of them have silicosis, because it has been irrefutably proved that silicotics are susceptible to ployee. They will aid in detecting early tuber tuberculosis, and tuberculosis contracted by a sili culosis and pneumokoniosis; they will aid in de cotic usually means the beginning of a rapidly- termining whether the applicant has suffered ex progressing disability and a premature death. posure or whether he should be allowed to work To tell tuberculars of their condition may invite in more dust; and they will aid the employer in some criticism, but not to tell them would deprive placing the applicant according to his physical them of necessary treatment and the chances of condition. Roentgenograms will also show the recovery. It would also deprive their families of condition of the applicant's chest at the time he precautionary preventive measures. If tuberculars became an employee, and when kept as a record, continue at employment for the industry, medical along with other data, as previously outlined, they treatment should be started at once. Periodic ex can be used for comparative study purposes at fu aminations are advised. Roentgenograms offer re ture examinations, and in this way control the de liable aid in determining the progress of the dis velopment of pneumokoniosis and tuberculosis ease. Follow-up roentgenograms ought to be of and other conditions within the industry which similar density, detail, and distance technique for are not considered in this paper. comparative purposes. A fluoroscopic examination does not make a Those having only silicosis in the early stages, permanent record, and it usually does not reveal without pulmonary tuberculosis, present a differ the minute structural design or pattern of the fi ent problem. They will not infect their fellow brosis and air cells as clearly as when they are workers, but they have a strong tendency towards depicted on a film, but it often becomes useful in the contraction of pulmonary tuberculosis, pneu determining the excursion of the diaphragm and monia, and acute respiratory colds.- the gross aeration of the lung and gives informa As a rule, silicotics who have not as yet contract tion as to the size, shape, and position of the car- ed pulmonary tuberculosis are healthy looking and dio-vascular structures. It is also useful in indi-= able to carry on the duties of their occupation. eating the technique needed or the quality of the More exposure to dust may or may not be harmful, exposure necessary. Thick masses of fibrosis re but here it should be remembered that removal of quire more penetration to depict their structural the exposure does not always stop the progress of features than does air-filled lung tissue. Frequent the disease.0 A transfer to a less dusty occupation ly several roentgenograms of a chest are necessary may be indicated. to depict the areas of fibrosis, or the small patches A careful study of the roentgenograms as to the of emphysema, or the small areas of atelectasis amount of fibrosis, the anatomical location of it, which often occur in silicosis. One image may and its structural design may aid in determining show an air-filled lung, but the same image usu whether or not the patient should be transferred ally does not show the structure of a denser sha to a non-dusty occupation or be allowed to remain dow. The structural pattern of the shadows or de at his regular one. sign of the fibrosis offers means towards establish Those having tuberculosis and silicosis present a ing the diagnosis and the origin of the kind of dust still somewhat different condition. They are not that caused the fibrosis. Sometimes stereoscopic so infective as persons with primary pulmonary roentgenograms are indicated to show space and tuberculosis, probably because tubercular germs distance around and between the various shadows are not so frequently found in their sputum as to determine their design or contour and loca they are in tuberculars where silicosis is not pres tion, with reference to other structures within the ent, but these people require treatment and it is chest. imperative that a dusty occupation be eliminated. The similarities of the symptoms of pneumo Such cases usually progress rapidly towards in koniosis and those of pulmonary tuberculosis, and complete incapacitation, and finally a fatal termin other conditions not due to the inhalation of dust, ation is reached. Frequently some acute condi and the differing opinions of physicians and roent tion. such as pneumonia or a cardiac complication genologists, plus the fact that the claimant work fatally terminates the condition9. ed at a dusty occupation, and the inability to de A person with a well-defined case of advanced termine the condition of the chest at the time the silicosis presents a serious problem. He may at claimant entered the employ of the industry--to any time develop tuberculosis or become ill with gether with the possibility that some, or all, of the pneumonia or bronchitis, and from that time on exposure may have occurred outside the industry, he may be totally incapacitated, with a resulting and the further possibility of it not being due to more or less depressing effect on his family, and dust at all--make it very difficult for the compen with the possibility of his family and himself be sation administrators to administer compensation coming a burden on society. If he is permitted to according to the laws of the statute. continue at his work he probably will develop tu Matters would be somewhat simplified if the berculosis. with its resulting incapacitation, and various states were to pass laws containing uni the industry will be left to assume the resDonsi- form, fair, and adequate compensation coverage of bility for all ensuing trouble, whether he devel occupational diseases, establish uniform and spe oped the disease in the course of his last employ cific preventive and protective measures, and for ment or while at some other occupation. Those mulate a health standard for dusty occupations. who develop tuberculosis on a well-advanced case However, at the present time, such a step appears of silicosis usually do not continue to work long to be remote. after the tuberculosis is established; their condi In the meantime each state should create a tion invariably becomes rapidly worse.9 board of control.7 It is here suggested that this board, under an already-existing department, be Roentgenograms made of the applicant's appointed, or that a new medical board be creat chest will give valuable information which ed, with representatives in districts for the great will be helpful both to the employer and the emest convenience of all concerned. This board snoiua nave me aurnority and power to investi gate occupational hazards, to determine the de gree of disability, and to decide upon the alloca tion of work according to physical conditions. The power of the board may be broadened so as to provide for study of dust hazards and dust dis eases, to point out defects, and recommend cor rections of the system in order to accomplish ef ficiency with the least possible cost. It may in clude occupational injuries, whether they be due to accidents or hazardous conditions -- "occupa tional accidents and occupational diseases." The board should pass on the physical condition of the applicant or appraise the applicant for certain dusty occupations and have the power to pass fin al judgment on all cases applying for compensa tion. At the present time, since each industry must answer to its own state, I therefore recommend that each industry: 1. Make a clinical and roentgen examination of its applicants who expect to work in dust; 2. Make a physical and chemical examination of the dusts in the industry; 3. Formulate a health standard for applicants to dusty occupations; 4. Make periodic health surveys of the opera tives; 5. Allot the work according to the physical con dition of the employees; 6. Keep records as outlined herein; 7. Insist on efficient respirators where needed. (See standards for tests)10; and 8. Obtain more exact information as to previ ous occupations as suggested herein. Bibliography: 1. Georcius Agricola: "De re Metallica" (1557) ; Ramazzini: "Diseases of Tradesmen"; Ahrens: Arch }. Hyg. (1894). 2. North End Foundry Co. v. Industrial Com. (Wis.) 258 N.W. 439. 3. Gardner, L. U.: J.A.M.A. (May 5, 1934). 4. Beaver v Morrison Knudeson Co. (Idaho) 41 P (2D) 605; J.A.M.A. (October 19, 1935) ; Morrill v Charles Vianchi & Sons, Inc. (Vt.) 176 A 416. (Activation of tuberculosis by iniurv compensable). 5. Irvine, L. J., So. African investigator (1928) ; Pitcher Clinic Report of 7722 Emplovees. 6. Clark, \V. I., Investigator; Hawes, J. B., and Moses, J. S.: Neva England J. Med. (De cember 20, 1934) : Bloomfield: J.A.M.A. (January, 1935). 7. Pancoast, H. K., and Pendergrass, E. P.: J. Indust. Hyg. (May, 1933). R. Gardner, L. U.: J.A.M.A. (May 5, 1934). 9. International Conference, Johannesburg (1930); So. African Miners Phthisis Prevention Committee (1914-1916); British Roval Com. on Metals and Quarries (1914) ; Miners Phthisis Med. Bu. (1928) ; Pitcher Clinic Report of 7722 Employees. 10. U. S. Bureau of Mines, Bulletin No. 21. 11. Gardner, L. U.: Acute Silicosis, J..4JM.A. (1932) Chapman, E. M.: Acute Silicosis, J.A.M.A. (1932) Sampson, H. L.: Acute Silicosis, Am. J. Pub. Health (De cember, 1933); Sayf.rs, R. R.: J.A.M.A. (August 19, 1933) ; Gardner, L. U.t and Cummincs, D. E.: J. Indust. Hyg. (May, 1933); Lanza, A. J.: J.AM.A. (August 19, 1933); Hope, Indust. Hyg. and Med. (1923) ; McNally, W. D.: J.AM.A. (1933); Dye and Kettle, British Investigators: Meller, H. B.: Bureau of Smoke Regulation, Pittsburgh, Pa.; Drinker, Phiup: J. Indust. Hyg. Industrial Poisons I SENSCHMID and Kunz1 report the history of a man. aged 56, whose occupation caused him to inhale trichlorethylene. He developed a severe retrobulbar neuritis with pupillary disturb ances, paralysis of the hypoglossal nerve of the left side and polyneuritis of the nerves of all the ex tremities, with abolishment of the reflexes and re duction of the cutaneous sensitivity in the region of several peripheral nerves. The symptoms proved to be rather persistent and the vision seems to be permanently impaired. The authors call at tention to the wide use of neurotoxic trichlorethy lene, pointing out that it is employed as a fat sol vent in industry as well as in cleaning fluids and other preparations that are marketed for home use. Hypertension NOUGH has been said to emphasize the com plexity of the problem presented by hyper tension and, therefore, the difficulty in set ting any definite standards for the employment of those showing the condition.2 Certainly no arbi trary standard can be set up, based simply on a blood pressure determination. Wychgel's classi fication furnishes probably as satisfactory a basis as any suggested. Our own experience has been chiefly in connection with the examination of older employees, and the question chiefly involved is determination of suitable work. Generally speaking, the basis is as follows: In hypertension with early myocardial changes, lighter physical work is indicated; with arteriosclerosis, not only lighter physical work, but usually work involving less responsibility is indcated. Arteriosclerotics are placed also where any such thing as a cerebral or oronarv accident would not be likely to en danger others. Those showing only an unusually high systolic pressure, with freedom from signs of accompanying disease, and with no tendency to ward steady increase of pressure, may often con tinue with apparent safety at their usual work. All cases showing any noticeable increase above the usually accepted standards are urged to con sult their own physician. Our great difficulty has been in persuading such patients, who are often symptom free, to give their condition proper at tention. One of the most important practical points in the hypertension case is continuing supervision. Response to treatment must be noted at intervals to insure continued safe relation between work and the patient's capacity. Sometimes suitable work may be available for several years. In other cases leave of absence must be given for a time, and in a few cases not responding to treatment, or showing other serious changes, retirement must be arranged. As far as possible we try to co-oper ate in the treatment of these cases by providing suitable work and environment. Hypertension is probably more common in in dustry than is generally supposed. Care must be taken to avoid error in the detection of cases. It self only a symptom, associated conditions must receive the greatest consideration. From point of 1. Schweis. Med. Wchnschr., Basel, 65:530, Abstr. J.A.M.A., July 27, 1935. 2. A. G. Cranch, M.D., ih Ohio State M. J-, XXXX:676, September, 1335. VOL- O, 1NO. X ilVUUOlXVLrtJLl IV.LCUJlV^ll'i.E, rage a/ view of capacity for work, myocardial and arterio sclerotic changes are most important. Standards based primarily on blood pressure determinations are not satisfactory. Successful placement of hy pertension cases is only possible through continu ing supervision. Eye Hazards IN THE discussion of health hazards in indus try,1 at the annual meeting of the American Public Health Association. Dr. R. A. Jewett stated: "For years, I have been impressed by the great amount of relief obtained from physical symptoms by proper treatment of the eyes." A survey of the vision of men employed in one oil company showed that 30% had subnormal vision, and 7% had pathological eye conditions. A special eye hazard for filling station attendants is the ir ritation to the eyes, of acids used in cleansing car springs and lubricating racks. Refusal of Employee To Submit to Medical Treatment IN THE course of his employment, on Decem ber 23, Haill ran a file into his hand. A clerk of the employer, who had charge of the em ployer's first aid station, washed the wound, ap plied certain preparations, and rendered "medical attention" to the employee daily for the succeed ing three days. Until January 2, the workman's wife bathed his hand every morning in hot water in which she put "some sort of antiseptic". The hand seemed to be improving and. according to lay testimony, was healed from the outside. On January 2, however, there was a swelling and the workman went to a physician. On January 4, a fever developed and he was taken to a hospital where he died January 7 from septicemia. His widow was awarded compensation by the work men's compensation commission. The employer then appealed to the St. Louis circuit court, con tending that the workman had unreasonably re fused medical attention. To sustain that conten tion, he relied on the testimony of the clerk in charge of the plant's first aid station and of the plant foreman that they had suggested to the workman on several occasions that he go to a physician, but that on the workman's assuring them that he did not believe the injury was ser ious enough to warrant that they refrained from insisting that he do so and at no time named any particular physician for him to see. Two medical witnesses, one called by the plaintiff and the other by the defendant, testified, in effect, that even if the workman had been treated by a physician from the inception of his injury, septicemia might still have developed. The court affirmed the award of the commission and the defendant appealed to the St. Louis court of appeals. It cannot be said as a matter of law, said the court.2 that under the facts of this case the work man unreasonably refused to submit to medical treatment. It does not conclusively appear that he refused at all. While the defendant's witness- x. The Sight-Saving Revirvi, V:i48, June, I93S. 2. Haiti v. Champion Shoe Machinery Co, (Mo.), 7r S.W. (2d) 146. J.A.M.A. (February 9, 1935). es testified that the workman refused to go to a physician, though repeatedly told to do so, they further testified that they merely suggested that he go to a physician or advised that he ought to do so. A mere negligent failure on the part of the workman to obtain or accept medical treat ment, though advised or urged to do so, does not bar a recovery of compensation. To bar a recov ery, an unreasonable refusal to submit to medical treatment must be shown and the burden of prov ing that refusal is on the employer. The court held that the commission was warranted in hold ing that the employer had failed to offer the re quired proof. The ward of compensation was accordingly affirmed. The Arsenic Problem REUTER cites a probable case of arsenical dermatitis caused by wearing a black wool- lensuit.1 Arsenic was found in the urine and hair of the patient, and in the suit. Recovery oc curred when the patient discontinued wearing the suit and when local treatment of the skin was in stituted. The presence of arsenic in excretions is discussed. There are no definite criteria by which to identify arsenic as a cause of disease in a given case. At present the diagnosis in obscure cases of arsenical poisoning rests on presumptive evidence. A general rule regarding the behavior of arsenic within the body is of little value, because in many persons the biochemical reactions are exceptional. Patients who suffer from symptoms of arsenic poi soning are exceptions in that they manifest a hy persensitivity to arsenic. Legally, it is difficult to state whether or not arsenical poisoning has been the cause of death, even though the amounts of arsenic found in the tissues and excretions are the same or less than those cited as "normal" values. The use of arsenic as a contaminating factor in foods and drugs should not be permitted, since no limit of tolerance for arsenic can be established for all persons. Total and Permanent THE NEW YORK Life Insurance Company issues to the plaintiff an insurance policy providing for the payment of certain benefits on receipt of "due proof. * . . that the insured. . . . has become wholly disabled by bodily injury or disease so that he is and will be presumably there by permanently and continuously prevented from engaging in any occupation whatsoever for re muneration or profit." The plaintiff, 40 years old, became afflicted with phlebitis and a blood clot formed in the vein in the thigh of his right leg. Contending that he was totally and permanently disabled, be applied for the benefits payable under the policy. The insurance company denied li ability. In a suit to collect the benefits, the trial court gave judgment for the plaintiff and the defendant appealed to the Supreme Court of Michigan. The medical testimony, said the Supreme Court,2 established the fact that the plaintiff could not pursue any suggested vocation with a i, Arch, Dermal, & Syph31:811, June, 1935; Abstr. J,A.M.A,t 105:313, 93S- 2. Forman v. Neio York Life Ins, Co, (Mich.), 255 N.W. 222. J.AJA.A. (February 23, 1935). xcaoonuuie degree oi regularity or length of time and without hazard of relapse. The physicians who attended the insured stated that he was not able to engage in any occupation for gain except under circumstances so favorable and fortuitous as to be outside the range of probabilities; that his disability was probably permanent. The insurance company contended, however, that "due proof" of total disability had not been submitted to it, as required by the policy. Of course, said the Supreme Court, the policy cannot fairly be construed to constitute the de fendant insurance company the sole judge of dis ability or to mean that the fact of permanent disability is foreclosed in favor of or against either party by the proof made to the company by the insured. Actionable disability ultimately, said the court, is a question of fact for trial. "Due proof" can mean no more than that reasonable evidence of disability within the terms of the policy shall be submitted to the company. Where such evidence is submitted in a good faith attempt to comply with the provisions of the policy, the company should point out particularly any de fects therein if it intends to rely on them. The insured in this case submitted the reports of four attending physicians covering treatments from July 26, 1928, to June, 1930, showing the character of his ailment and that he was totally disabled continuously during that time. The physicians who early treated him made a prognosis that his disability would extend into the future-but did not then express an opinion that it would be perman ent. However, they became progressively doubt ful of his recovery as time passed and the condi tion did not yield to treatment. The physician who attended him in 1930 stated: It is my opinion that as much collateral circulation has been es tablished in the right leg as is possible and that condition now is one of total and permanent dis ability as far as pursuing occupation is concerned. Having before it proof of the nature of the dis ease, concluded the Supreme Court, of the results of treatment for two years, of the fact of past and present total disability, and medical opinion that it would be permanent, the defendant insurance company had such reasonable showing of total disability as constituted "due proof" and required it to pay the benefits or to be prepared to defend on the fact of disability. The judgment in favor of the insured was consequently affirmed. Protecting the Eyes THERE are four things to consider when furn ishing protective glasses to workmen: ultra violet, infra-red, glare and color.* In the past a number of types and kinds of glass have been used to give supposed protection: brown, red, combinations of three or four glasses, and blue--this latter being predominant. Little or no thought was given in the past to harmful rays, the workman simply choosing a pleasing color and a density sufficient to cut down the glare. Work men in various industries and different localities learned to judge temperatures, heats and flame characteristics with their predecessors' or fellow workmen's glasses. Makeshift standards and den sity numbers were set up, and a feeling now exists W. T. Camekon, in Nashnal Safely News, 31: pp. 17, 18, 62, 193s. among these operators that they cannot change from one color to another, or from one type of glass to another, without losing the ability to make the above-mentioned determinations. Now, glass does not give protection by virtue of its color, but from the chemicals used in its manu facture. Ultraviolet and infra-red have no color, therefore color does not affect them. Two pieces of glass of exactly the same appearance often have entirely different properties. Blue glass, most commonly used, gives little or no protection. The United States Government, through the Bureau of Standards and the U. S. Navy, has set up a definite standard covering the amount of ab sorption necessary for protective glass; and has standardized a set of shade numbers based on the density of the glass. Table "A" is from Federal Specification No. GGG-G-541, covering the lighter* shade lenses, and No. GGG-H-191, covering the darker shades. Glasses made to these specifications assure the workmen of complete protection from ultraviolet and infra-red, it being only necessary to pick a shade of glass which cuts down the glare to the point where the eyes will function normally when looking into the flame or arc. All lenses in these specifications transmit the visible rays in the green or vellow-green portion of the spectrum. Glass meeting these requirements is available from several manufacturers, in a number of types and kinds of goggles, in helmets or hand shields; also in plates of any size required for use in peep holes, observation windows, etc. The following table in suggested shades for va rious industrial operations is recommended by the leading manufacturers of specification glass: Shade No. Suggested Use 14 Carbon arc welding and cutting. Electric furnace operation. 12 Metallic electric arc welding 250 amperes or more. 10 Metallic electrie arc welding 75 to 250 am peres. 8 Heavy acetylene cutting and welding. 6 5? 41 3 Extra Dark "Calobar" or No. 2 Acetylene welding set-up work on electric welding. Fire box observations. Acetylene burning, cutting and brazing. Light brazing. Bull ladlemen, spot, flash and seam welding. Dark "Calobar" or No. 1 1 Employees in area of electric welding, stray I or reflected light, low temperature fire box | observations, rivet heaters, ladleman, hand ` pourers. }Medium "Calobar" IN INDUSTRIAL medicine, particularly rail roading, the attitude toward hypertension in employees should be one of extreme conserva tism. No matter at what age hypertension mani fests itself, it should be looked upon as a degen erative process--an expression of senility. Re sponsibility and senility are incompatible. A policy based on such a conclusion may work a hardship, or even prove unjust in individual in stances. And there may be exceptions made, yet in the long run experience and physiology have proved that such an attitude is fair." patient obtains the money to pay the doctor, in full, at the time the services are rendered, so that the obligation of repayment of the amount in volved does not remain any concern of the doctor himself. The credit union is useful in this respect. Likewise, such institutions as those which lend to an employed person on a signature and co-signa ture basis, are equally valuable. Delayed collec Th Journal of Traumatic Surgery and Occupational Disease* tions, as between a debtor individual on the one hand and a creditor bank or credit union on the Published Monthly other, do not involve the personal relation be For the Physician and Surgeon in Industry tween doctor and patient with any extraneous Publication Offices exigencies of financial obligations, and do not 413 Pleasant Street, Beloit, Wls. antagonize where antagonism does too much Editorial Offices damage. The employee won't get very mad at 844 Rasta Street, Chicago, ILL the credit union; he can't afford to get too mad at the bank. Editors: James T. Case, M.D., F.A.C.S. Volney S. Cheney, M.D., F.A.C.S. Geo. G. Davis, M.D., F.A.C.S. Joseph Jordan Eller, M.D. There is much in this for the. doctor to think about. The tactful suggestion that there are ways and means, organizations, agencies, banks, which may be thus called to assistance, may very often Hart E. Fisher, M.D., F.A.C.S. John G. Frost, M.D., F.A.C.S. Otto P. Geier, M.D. Burke C. Hamilton, M.D. --indeed, more often than is quickly realized-- preserve for the doctor both his pay and his patient. LeRoy P. Kuhn, M.D., F.A.C.S. David Shapiro, M.D. Frederick W. Slobe, M.D., F.A.C.S. Industrial Medical Trends Charles D. Squires, M.D. Consultant: C. O. Safpington, M.D., Dr.P.H. Managing Editor: A. D. Cloud N OBSERVING the development of traumatic I surgery, the fact cannot be avoided that the World War experience and industrial injuries have contributed greatly to the material which has VOLUME 5 JANUARY, 1936 been of vital use in developing this specialty. NUMBER I Industrial injuries, however, have been reduced considerably and according to some authorities to Opening for a Bank! an almost irreducible minimum, during the past 10 years. The fact is that most traumatic surgeons at WHEN the average individual begins to suf the present time are depending for their clinical material very largely upon the results of public fer from interference with the normal body processes of the human temple of accidents, especially automobile accidents. That this source has provided an abundance of clinical his alleged soul, the doctor is the first to be cmallaetderial is well known among traumatic surgeons; and the first to respond. Where this occurs in the and the types of injuries are somewhat different region outside of compensation cases--employee from those seen in industry, thus affording a dif family matters, for example--there follows, as it ferent type of experience. were, a transference of suffering; the individual It may be assumed that for some time to come recovers from his physical disability, whatever it there will be a considerable number of public ac may be, and the doctor begins to suffer from the cidents resulting from the misuse of the automo queer quirks of human nature as it is manifested bile--although in some quarters this is vigorously in that same individual. All too often the doctor denied. Granting that there have been many im is never paid in full; much too often he is only provements in making roadways safe, providing partly paid, and that grudgingly; and many more adequate and properly working traffic signals and times than is good for the economic integrity of traffic supervision, and in making the automobile any social equation, he is never paid at all. But as a mechanical unit as foolproof as it is possible to even these eventualities are not the end. Wholly do, there will still be what is called the "human or partly unpaid, he isn't called again: "I'll go to element." And probably this factor will be the Dr.-------------- . I don't owe him anything." Too cause of a great number of casualties for many familiar to be repeated; almost too painful to be years to come. remembered. "Human nature" at its rather ugly Nevertheless, it is quite sensible to believe that average! there will be a material reduction in the number A thousand schemes have been devised to cor of public accidents during the next five years, for rect, or at least reduce, the hardships of this con the public is becoming thoroughly aroused to the dition from the doctor's standpoint. Most of them, necessity of cutting down the enormous number however, have proved unworkable; where per of casualties and deaths from this source. More sistence in collection is their chief element they over, it is not impossible that "things may become are almost inevitably unworkable. Even when so bad before they get better," that the amount of the patient's financial condition improves, so that automobile travel may be materially reduced, this he could keep up at least with current needs, the in itself having a desirable effect upon the decrase old resentment lingers. of automobile casualties and deaths. For any plan of this kind to be really successful, It may be assumed therefore, that the material it is necessary to interpose a third party. And the afforded for traumatic surgery may reasonably ideal third party is the agency through which the suffer a considerable decline and, with the increas- mg number of traumatic surgeons developed, will dustry from the sociological viewpoint, but, need accordingly cause a disproportion of material and less to say, it has not been observed as a part of men. the reactions of the great number of persons who Granting that such events may occur, the real object or have objected to this measure. opportunity for medical service in industry will Although these remarks are only a brief review exist through the avenues which have previously of the past and present situation, the physical been most neglected, namely, the hygiene of indus examination at the present time is not in need of try and its employees, including preventive meas justification; it is and will continue to be in the ures against injury and disease, and, more con future an accepted method of classifying indiv structively, the promotion of health among indus idual employees according to physical status, and trial groups. upon such classification so selecting, placing and With the emphasis upon occupational diseases supervising, that the best possible use may be over the entire country, with the attention given made of the physical capacity of each individual by legislatures to the consideration and final pas concerned--and further, and more important, sage of laws compensating for disability from oc so that the possibility of the occurrence of injury cupational disease, and with the increasing concern and disease may be minimized. manifested by employers and insurance companies, It is with this last application of the physical one natural effect will be a general stimulus of the examination in industry that many an oppor development and application of preventive and tunity has been overlooked. control measures. No less important will be the Ordinarily in the use of the physical examina by-products of this stimulus to new activity--in tion only the gross defects and abnormal condi vestigations as to the causal relationships of ab tions are actually recorded (or made use of), al normal conditions both in industrial environment though in a few scattered instances special adap and in the bodies of employees, which, when asso-^ tations have been made to unusual situations. ciated, tend to bring about occupational disease or Since occupational disease has come to be an to aggravate previously existing conditions which ever present problem and one of most vital socio may be associated with disease difficulties. economic importance, one would naturally reason Such natural developments will further give rise that the physical examination in industry would to the critical study of the various problems as be important in working toward the prevention sociated with the subjects of preventive medicine of occupational disease. Such, however, has not in industry and industrial health. For many years a small group `of specialists in industrial medicine and industrial hygiene have continued to advocate the more extensive use of teaching material relating to the problems of in dustrial medicine and industrial hygiene. It would now be a wise move on the part of the large uni versities in the industrially developed areas of this country to establish industrial clinics in connec tion with the hospital facilities already afforded, for the specific purpose of developing clinical ma terial, both out-patient and hospital types, to be adapted to the teaching of medical students in reg ular courses, and also the development of postgrad uate courses especially designed for those physi cians who are already in industrial practice. been the case so far as the general experience of industry is concerned. It would seem that few people have heretofore realized that the indus trial physical examination can well be a preven tive procedure. For example, Sappington has previously mentioned in this magazine that when an industrial physical examination is made on an employee who is going into an occupational dis ease exposure the physicians might well take int account three things: (1) the nature and severity of the exposure into which the prospec tive employee is going--meaning as accurate as may be possible to do, a measurement of the kind and severity of exposure and a rating of the occupational disease hazard; (2) with the nature and severity of the exposure in mind, an appraisal Physical Examinations of the physical condition of the employee, taking into account especially those defects or abnormal conditions which might be aggravated by the oc O MUCH has been said and written about cupational exposure or which might in time pro S physical examinations in industry, but so duce occupational disease; and (3) a scientific much has been left unsaid and unwritten! knowledge of the type of protection afforded the Aside from the more or less obvious personal employee during his occupational exposure and reasons, the chief objection to physical examina the efficiency of this protective mechanism. tions on the part of prospective employees has Aside from detecting gross abnormalities or been the fear that the procedure may be used as defects which are due in most instances to non- a discriminatory measure. That physical ex occupational disturbances, one might well ask the aminations have been so used in a small number question as to why the physical examination is of instances probably is true; but those who are justifiable unless Sappington's suggestions are fol conversant with the facts are aware that their lowed. Of course it is to be acknowledged that in wide and general use is as an instrument of selec the general physical examination the recording of tion, placement and supervision. It must be vision and the condition of the inguinal rings are recognized that if a man has a physical defect or either one worth the amount of money it takes to abnormal condition which is dangerous for him make a physical examination, even if nothing else or for his fellow employees, or which may become is done. a liability to the company, the condition should In the working out of occupational disease re certainly be recognized and proper steps taken to lationships in industry, however, it appears alleviate it or to place the person having it in an reasonable that, to make the most of the indus environment where the effects are most likely to trial physical examination, physicians should lay be least hazardous. This principle is the rationale much emphasis on securing the type of informa of the proper use of physical examinations in in tion indicated above. Industrial Medicine and Surgery Compensation for Occupational their harmful results. In silicosis Diseases* FROM its beginnings the work men's compensation law has there may be an interval of as much as 20 or 30 years between the first exposure and disability or death. In the meantime many causes covered all injuries to health resultfor disablement or death, other than ing from occupational accidents. the occupational disease --e.g., bad Further it has now, in many juris habits, bad living conditions, con dictions, in this country and abroad, traction of other diseases, old-age, been extended to cover many speci etc.--may have operated. It follows fied diseases, not resulting from ac that it is commonly a matter of ex cidents, classified as "occupational". treme difficulty to determine whether And in a few states in this country disability or death really has result and Latin America it has been in ed from an occupational disease or considerately extended indefinitely from other causes or from a variety further to cover "all inclusively" all of causes. Medical diagnosis of the injuries to health "arising out of and mere existence of a particular dis in the course of the employment" or ease is often uncertain; yet for the all "occupational diseases", undefin proper operation of compensation for ed. "arising out of the employment". occupational diseases it is essential In this country, peculiarly, there to obtain true medical diagnoses not is strong political pressure in favor merely of the existence of the disease, of this "all inclusive" coverage of but also of its causes and conse injuries by disease based upon the quences. This, manifestly, calls for contention that there is no difference practices and procedure, limitations in principle between "injuries by ac and conditions, different from those cident" and "injuries by disease" which suffice for the operation of and, therefore, that industry ought to compensation for accidents. be liable for both classes of injuries A further difficulty from the time on the same terms and conditions. element is that, where the disease is .This contention is fallacious. The of slow contraction, it may be con fundamental principles of the com tracted by a workman under several pensation law are that industry shall or many different employers or in be held responsible and liable to surance carriers or both. In such compensate for the losses from those cases it is essential for the protection injuries only which are caused by of the workman that some one exis "trade risks", that is, risks resulting tent employer or insurance carrier from the employment and which the shall be directly liable for the entire employer can control; and that the compensation. Manifestly that is a liability for such risks shall be "in highly vicarious and harsh liability surable". that is, shall be sufficiently to impose upon an employer or in well defined as to be insurable at surer--whether or not accompanied practicable and equitable rates, fixed by a right to claim contribution from in advance. The standard compen earlier employers and insurers--and. sation laws have been framed to in all fairness, should be subject to carry out those principles in applica strict limitations. tion to injuries by accident. But the Moreover there is a further diffi factual conditions relative to injuries culty incidental to the initiation of a by disease are so different from novel law or the provision of new those relative to injuries by accident insurance for compensation for such as to necessitate different treatment, progressive diseases of slow con that is, different terms and condi traction as silicosis. Under such con tions in the provisions governing li ditions. the liability imposed upon ability, in order to carry, out the the employer or assumed by his in same principles and effect equally surer includes a liability for dis salutary results. ability or death in the future in The crucial difference between ac those cases of disease which may be cidents and diseases is the time fac the result of exposures during long tor. An accident is a sudden event, years in the past--in other words, a happening at a definite time and liability, not merely for future risks place. Generally the causal relation but also for the cost of a volume of between the employment and acci physical impairments already incur dent and between the accident and red, though the liability therefore is the resulting injury or injuries can not yet matured. In insurance par be traced with reasonable certainty. lance these are loosely termed "ac Generally the employer responsible crued liabilities". Such accrued li is automatically identified. And abilities--the impending cost of past there is a clear-cut event from the exposures--under a law newly im date of which time-limits on notices, posing a liability to compensate for claims, etc., can be measured. In silicosis, would, it is estimated, in a contrast, many diseases attributed to state such as New York, amount in occupational risks are of slow con the aggregate to many millions of traction, some very slow; and they dollars. This cost is additional to may be of equally slow progress to the cost of losses from current risks; and how to meet it and how to fix Excerpts from an Address, ,bv F. Robertson Jones, General Manager, Association of Casually and Surety Executives, delivered at the 24th An nual Safety Congress and Exposition (Industrial reasonable charges for insuring it is a complex financial problem of the first magnitude. Manifestly a law Diseases Section), Louisville, Kentucky, October i3, 1935; published in the Bulletin of the Association of Casualty and Surety Executives, November, 1935* initiating compensation for such dis eases as silicosis needs to be so shap ed and tempered as to enable em ployers and insurance carriers to ad just themselves to such novel bur dens. The situation, then, in my opinion, is this; The principle of compensation, re gardless of fault, may well be ex tended to cover those disabling dis eases that are characteristic of and peculiar to and have their origin in the occupation or process in which a person is engaged. This would ex clude, of course, the diseases of or dinary life, and would be applicable only to the specific hazards which arise out of and because of industrial processes and occupations, but upon terms and conditions and with pro cedures differing quite radically from those applicable to compensa tion for injuries due to accidents and differing, of course, for different categories of diseases that present peculiar problems. The provisions for such coverage should be separate and distincT from the provisions of law applicable to compensation for accidental injuries, and these dis tinctions should be kept constantly to the fore and emphasized. The problem of formulating such pro visions is relatively simple with ref erence to those recognized diseases that have been generally included in the schedules set forth in the older occupational disease laws, since such diseases are reliably diagnosable, of quick contraction and non-progres sive. But it is more difficult in respect to such progressive diseases of slow contraction as silicosis and asbestosis --now generally regarded as being truly "occupational". Fortunately, in respect to the coverage of these latter diseases; there are promising models for our guidance in some of the foreign compensation laws, whereas experience under indefinite, "all inclusive" coverage in Connecti cut, Massachusetts. Wisconsin and California is helpful with lessons of faults to avoid. In my opinion, a law for the compensation of occupa tional diseases should contain pro vision to the following effect: 1. The diseases to be made "com pensable" should be distinctly speci fied--by listing in a "schedule" or otherwise. They should include all those diseases, but only those dis eases, to be found in the state, which, according to prevailing medical op inion, can be traced, in individual cases, to origins in "trade-risks"-- i. e. risks, not of ordinary life, but created by special practices or pro cesses in industrial occupations. 2. There should be a special re gime for expert adjudication of medical questions in occupational disease cases. 3. There should be definite periods of exposure required as a condition to the right to compensation for var ious occupational diseases; the time within which, in order to be com pensable. disability or death must follow exposure should ' be limited; and cases resulting from exposures entirely prior to the effective date of the compensation coverage, or in industries wholly outside the partic ular state, should be excluded. 4. Prompt notice either of the first manifestation of symptoms of the disease or of disablement--the time of such event to be determined as a medical question--should be strictly required; and every presumption should be against the validity of a claim not made as promptly as prac ticable. 5. In case an occupational disease merely aggravates, prolongs or ac celerates disability or death due primarily or proximately to a nonoccupational disease or infirmity or, above all, to old age, the compensa tion should be reduced to be pro portionate to the degree to which the occupational disease contributes to the disability or accelerates death. 6. The employer as of the time of the workman's last substantial ex posure to hazards of the disease and the insurance carrier then on the risk should be liable for the entire compensation--with or without right to contribution from earlier employ ers and insurers. But all such li abilities, whether directly for com pensation or for contributions to the compensation payable by others, should be subject to brief time limit ations. 7. In respect to incurable diseases, especially silicosis, the obligatory medical benefits should be specially limited in time and kind. 8. In respect to silicosis and other diseases of slow contraction, there should be special provisions for limited compensation to workmen laid off before actual disablement because of manifestations of first symptoms of the disease, with the alternative, under some conditions, of waiver of compensation by such workmen for aggravations resulting from being allowed to continue in the hazardous occupation. 9. A law newly imposing liability to compensate for silicosis and other diseases of slow contraction should leave a substantial interval for pre paration between the date of its en actment and the date when it shall take effect; and the compensation for such diseases should be specially re duced and limited substantially be low what would otherwise be ap propriate until the ``accrued liabili ties" are worked off. 10. Compensation for occupational diseases should be insurable separ ately from compensation for acci dents; and, in the initial .stage, at least, of a regime of compensation for such diseases as silicosis, the rat ing practices now imposed upon in surance carriers by public regula tion need to be radically modified and liberalized. Compensation for occupational diseases involves dangers, difficul ties and uncertainties which call for more careful study in advance of legislation than political impatience is apt to concede. Political impatience indeed is the chief obstacle to a just and equitable settlement of the occupational dis ease problem. If those thoroughly informed as to this intricate and THE BULLETIN ................. ........... .... ^ The American Association of Industrial Physicians and Surgeons THE object of this Association 1st Vice-Pres.: Dr. Samuel R. Benedict. shall be to foster the study and discussion of the problems Alabama Power Company, Birmingham, Ala. peculiar to the practice of indus 2nd Vice-Pres.: Dr. Donald Guthrie, trial medicine and surgery; to Lehigh Valley Railway, Sayre, Pa. develop methods adapted to the conservation of health among Sec'y-Treas.: Dr. Volney S. Cheney, Armour and Company, Chicago, 111. workers in the industries; to promote a more general under standing of the purposes and re sults of the medical care of employees, and to unite into DIRECTORS 1935-1937 one organization members of the medical profession specializing Dr. Edward C. Holmblad, Railway Express Agency, in industrial medicine and sur Chicago, 111. gery for the mutual advance Dr. Cassius H. Watson, ment in the practice of their American Telephone & Telegraph profession. Co., New York, N.Y. Volney S. Cheney, M.D. Secretary-Treasurer, Chicago PUBLICATION COMMITTEE Dr. Alfred H. Whittaker, Insurance Companies, Detroit, Mich. Dr. McIvor Woody, Standard Oil Company, New York, N. Y. W. A. Sawyer, M.D. Rochester, New York L. A. Shoudy, M.D. Bethlehem, Pennsylvania Dr. Andrew M. Harvey, Crane Company, Chicago, 111. Dr. Daniel L. Lynch, New England Telephone & Tele graph Co., Boston, Mass. J. Rollin French, M.D. Los Angeles, California T. R. Crowder, M.D. Chicago, Illinois 1934-1936 Dr. Don B. Lowe, B. F. Goodrich Company, Akron, Ohio E. C. Holmblad, M.D. Chicago, Illinois Dr. A. Girard Cranch, National Carbon Company, Cleveland, Ohio OFFICERS Dr. Royd R. Sayers, U, S. Public Health Service, Washington, D. C. President: Dr. Floyd E. Shaffer, Bethlehem Steel Company, Sparrows Point, Md. Dr. Loyal A. Shoudy, Bethlehem Steel Company, Bethlehem, Pa. President-Elect: Dr. Robert P. Knapp, Cheney Brothers, South Manchester, Conn. Dr. William A. Sawyer, Eastman Kodak Company, Rochester, N. Y. complex subject who have sincerely at heart the welfare of workers act ually suffering from or exposed to real occupational diseases could be delegated the authority to devise a solution, some progress might be made. But when political propagan da is injected into the situation and when campaign issues are developed from it, there is little chance for an adjustment which will be satisfac tory to alt concerned. This is a highly technical subject. It cannot be solved by political methods, by passing resolutions or by damning employers as a class. On the other hand it requires care ful study of all the factors involved and especially the incidence of occu pational disease legislation upon em ployment, That the passage of acts without proper limitations as to benefits may be highly detrimental to labor apparently has not been considered by' the labor leaders who are promoting these measures. The same is true of the politicians who have taken their cue from the labor organizations. The average worker knows nothing whatever of the sub ject, and consequently his only opin ion is that he should be compensated if he gets sick while at work from any cause whatever. He does not comprehend the ultimate effect of such legislation, either upon him or his fellows, and therefore easily is misled by the agitators who claim they are trying to help him. The greatest need today in this field is the divorcement of occupa tional disease legislation from poli tics or political considerations. Until that is done, the many problems confronting us never will be proper ly solved. Workmen's Compensation changes. Between 1923 and 1933, the sufficient to ensure voluntary retire Problems average loss cost increased from $.52 ment. As a result there are now to $.62 for each $100 of payroll, an 2,600 separate schemes in existence, THE cost of insurance to Massachu increase fully accounted for by law covering some half-million workers setts industries can be largely con changes. In 1928. the loss cost was of all grades. trolled by the buyers of insurance3.63, in 1933 $.62. Non-Contributory Schemes: Pen themselves.* This is true of fire in Since 1912, the losses in relation to sion funds maintained and adminis surance, automobile insurance, work payroll have nearly doubled and the tered entirely at the discretion of the men's compensation insurance, and statutory benefits have likewise been firm and invested in the firm's capi practically all other kinds of insur nearly doubled. tal or as a special trust. ance which business concerns buy. I know that some employers are The inadequacy of such schemes There are important differences in wondering whether it is not less ex accounts for the preponderating the methods open to insurance buyers pensive to reject the compensation growth of in controlling costs and in the extent law; that is, to substitute the old com Contributory Schemes: Fund man to which costs can be controlled, but mon and employers' liability laws for aged by a special trust or insurance they can be controlled to a very great the compensation law, and substitute company with uniform and accepted extent in any kind of insurance. the jury for the industrial accident scales of contribution and benefit. In the Factory Mutuals, in the board. Survey of Main Types of Contribu decade from 1870 to 1880, the average What would have happened to the tory Schemes: Scope: Salaried and/ fire loss was some $.25 annually for cost to employers for industrial acci or wage-earners included--very often each $100 of value insured. During dents if Massachusetts had never had confined to male employees only. the past decade, the loss has been a compensation act? Of course, we Employees'Contributions: (1) Scale under $.02, a reduction of over 90%. can only guess, but we may gain some based on amount of salary or wage; The average rates paid for fire in indication from the experience in (2) Flat rate, e.g. lOd. to 1/3; Both surance generally have likewise been those states which have continued up may be variable to adjust for age of going steadily down for many years, until now without compensation laws. entry into the scheme. reflecting successful efforts in the re There are only two states now with Benefits: (1) Sliding scale--bene duction of fire losses. Fire insurance out compensation laws -- Mississippi fits some percentage of wage or sal costs have been reduced and can be and Arkansas. In South Carolina, a ary; (21 Flat rate--commonly 1 per further lowered by decreasing the compensation law became effective annum for each year of contributions. number of and the seriousness of for the first time on September 1, fires.' 1935. It is interesting to note that There is a very fundamental dif the standard or manual insurance Silicosis ference between fire insurance and rate for a cotton mill in South Caro Tworkmen's compensation and other lina was $1.04 under the old common HE question of silicosis* last week caused a wrangle in San Fran forms of liability insurance. The and employers' liability law, and for cisco, where doctors, lawyers, min number and seriousness of injuries to workmen's compensation under the ers, mineowners, insurance men, leg workmen, the number of accidents .new law $.71. The rate for furniture islators, public health agents and caused by automobiles can be con manufacturing was $2.08 and it is fuss-budgets met to argue the pros trolled, but the cost of the injuries now $1.59. The rate for boot and and cons of a disease which has lately which are not prevented is deter shoe manufacturing was $.75 and it taken the public spotlight as the sub mined by persons outside your con is now $.59. ject of bitter industrial controversy. trol. These common law rates, that were Silicosis is due to inhalation of fine, Workmen's compensation statutes, in effect prior to September 1. were sharp particles of sand, sandstone or administered by industrial accident not the rates in effect in 1912, but the quartz, all of which contain silica, by boards or commissions, determine the cost of settling claims of employees miners, sandblasters, quarrymen, tun amounts to be paid for injuries. The had increased in South Carolina with nel borers. The silica particles erode amount to be paid for automobile and out a compensation act even more the delicate lining of the lungs, make other public liability accidents, as than it has in Massachusetts with a them vulnerable to the germs of well as for injuries to employees of compensation act, and the passage of pneumonia and tuberculosis. If those employers who have rejected the pro a compensation act has actually re diseases do not kill, the silica victim visions of the Workmen's Compensa duced insurance rates for South Caro usually wastes away to death because tion Act, is determined by a combina lina employers. The experience in his clogged lungs transmit insufficient tion of common and statutory laws states still without compensation laws oxygen to his blood. interpreted and administered by jur is similar to that of South Carolina. Because silicosis may terminate ies assisted by plaintiff and defendant It is entirely possible that costs fatally as long as 40 years after silica attorneys. might have increased more rapidly inhalations, the California Supreme In Massachusetts, the law, which in Massachusetts without a compen Court last year declared that there is became effective in 1912, has been sation law than with one. no time limit to bar a silicotic em liberalized by amendments year after The problem of increasing injury ployee from bringing a damage suit year until the law, as it now stands, costs is not peculiar to industrial in against an employer. Industrial in pays almost double the benefits of juries. Juries and plaintiffs' attor surance companies immediately the original law. I have seen state neys largely determine what is to be wanted to increase their rates. Oper ments that compensation losses had paid for automobile injuries. I do ators of deep California gold mines, increased eight or ten times since not need to tell you that in the past which are difficult to ventilate, would 1912. They have increased, but not 20 years the meaning of "negligence" be obliged to pay $22.25 instead of the to any such extent. For 1913, the has greatly changed. The percentage current $11 premium for every $100 first full year under the Act, the aver of all automobile accidents for which they pay their men. Some mines of age losses for all Massachusetts in the driver is held responsible has in low-profit margin have already shut dustries were $.35 for each $100 of creased tremendously. The amounts down. Others threaten to do so. payroll. In 1933, the cost was $.62, juries are awarding has likewise Mineowners and miners, who face loss not quite doubled. greatly increased. Lest anyone think of employment, were last week be Is there a constant upward trend this is peculiar to Massachusetts, be seeching California's insurance com in compensation costs? During the cause it has a compulsory insurance missioner to forbid any such rate early years of a compensation act law, let me assure you that in many upping on account of silicosis hazards. there is always likely to be a definite states juries are much more generous Last March the West Virginia Leg upward trend. People become fa in spending your money than they islature passed a silicosis compensa miliar with its benefits; its maximum are in Massachusetts. tion law as the result of an unholy limits are determined by numerous industrial condition from which the legal tests; and almost always such Pensions in Great Britain U. S. radical press last week was be laws are interpreted more broadly than originally expected. There is, however, little evidence in the Massachusetts experience that there is any continuing upward trend in cost except that resulting from law TtdpreiitanioHphslnaliEoovpayneelymsneuaiseapncirnoocsGtnnerofnreofsteaulcldtoathierBteweepmmrdrinieeteagstshnsinteithob,*neennaceoaGareernudrdsaenefraouoettnrsctWehtoiamnenatdeyrusltbfWlaaeoerbtreIgneenoseudstrsn,lt1ys-V9fb.r2aitlirr9antgycgiiankGneidgawaau,anNtledotweeywriwd-thpBihRsoirttiwiceivdlhle,egerrnefaraiptonutaimnotlsornnoanmeaunglltsohwibueethainnrtnes-t * S. Bruce Black, President, Liberty Mutual In surance Oj., in Industry, December, 1935. * Abstr. in Labour Management, January, 1936, of an article in Internet. Labour Rev. Time, January 6, 1936. tain districts as far away as Georgia. ing sickness as distinguished from in ered by the reporting organizations. The tunnel went through white sand juries of non-industrial origin. The influenza mortality rate likewise stone and quartz which were 99% In the second quarter of 1935 the increased sharply, but the mortality pure silica. Every blast of dynamite frequency of disability from respira from this disease in 1935 was con puffed deadly silica dust down the tory diseases exceeded the average siderably below the average for in throats of sappers who wore no pro rate for such illnesses during the five fluenza during the winter and spring tective masks over their mouths and years 1930 to 1934 inclusive. The av seasons.1 This result suggests that noses. Rapidly men began to die of erage rate was exceeded in each of the the influenza fatality rate (percentage silicosis, pneumonia and tuberculosis. respiratory disease categories shown of cases terminating fatally) may When workmen refused to go into in table 1 with the exception of res have been unusually low during the the tunnel heads, foremen, according piratory tuberculosis which occurred first half of 1935. The rise in the to subsequent court testimony, often at average frequency in the second influenza morbidity rate was accom clubbed them on. But the foremen dutifully followed, their gangs into the dust, and many of them died too. According to the People's Press. Rine hart & Dennis, tunnel builders for New-Kanawha Power Co., contracted with a distant undertaker to bury casualties at $50 per head. When he had buried 169 of them on his mother's farm at Summersville, W. quarter of 1935. For the six months as a whole, each numerically import tant respiratory disease, tuberculosis included, occurred oftengr than in the first half of 1934. Influenza which was recorded at less than average fre quency in the first three months of 1935 was found at greater than av erage incidence in the second quarter among the industrial employees cov panied by an increase in the fre quency of pneumonia among the in dustrial workers under consideration. The mortality from pneumonia, how ever, as reported by the Metropolitan Life Insurance Company, differed lit tle from that in the first half of 1934.2 1. Statistical Bulletin, Metropolitan Life Insur ance Company, Vol. 16, No. 7, July, 2935, p. 3. 2. Ibid., p. 7. Va. she planted the cemetery to com. Digging of the Gauley Bridge tun nel ended in 1932. By that time about 500 silicosis deaths had spread terror throughout the territory. A smart Kentucky lawyer went over the Table 1. Frequency of disability lasting 8 calendar days or longer in the second quarter of 1935, compared with the same quarter of preceding years, and in the first half of 1935 as compared with the corresponding period of 1934. (Male morbidity experience of industrial companies which reported their cases of the United States Public Health Service).1 mountains, instigated damage suits against Rinehart & Dennis. Some Diseases and disease groups which caused Annual number of disabilities relicts won. Some derelicts won. Many lost or sued too late to accom plish anything for themselves. But as a result West Virginia passed its silicosis compensation law. which in disability. (Numbers in parentheses areper 1000 men disease title numbers from the Interna- Second quarter of First half of tional List of the Causes of Death, Fourth1 Fiveyrs. Revision, Paris, 1929). 1935 1934 1930-34 1935 1934 turn prompted the radical press to dig up the Gauley Brideg skeleton and rattle its bones. Sickness and non-industrial injiirip.<r, 85.2 Non-industrial injuries ........................ 9,5 Sickness- ...............................................75.7 72.8 9.6 63.2 84.9 11.1 73.8 92.9 9.9 83.0 82.4 10.6 71.8 Sickness Among Male Industrial Employees During the Respiratory diseases ......... ...................... 29.1 Bronchitis, acute and chronic (106) 3.8 Disease of the pharynx and tonsils 20.9 2.5 25.4 3.0 37.9 4.2 28.2 3.6 Second Quarter of the (115a) .............................................. 6.5 5.2 5.6 5.8 4.8 First Half of 1935* Influenza, grippe (11).......................... .11.1 7.2 9.9 19.0 12.2 Pneumonia, ail forms (107-109) 2.4 1.9 2.0 3.1 2.4 ONE has to go back to the fourth quarter of 1932 to find an increase Tuberculosis of the respiratory system (23) .................................. . 1.1 .8 1.1 1.0 .8 in the frequency of sickness and non Other respiratory diseases industrial accidents as large as that (104, 105, 110-114) ............................ 4.2 3.3 3.8 4.8 4.4 which occurred in the second quarter Non-respiratory diseases ........................ 46.6 42.3 48.4 45.1 43.6 of 1935 in comparison with the cor Diseases of the stomach, cancer responding quarter of the preceding excepted (117-118) .......................... 3.1 3.2 3.9 3.3 3.3 year. Cases causing disability for Diarrhea and enteritis (120)................. .8 1.1 1.1 .9 1.0 more than one week occurred 17% Appendicitis (121) ................................ 4.2 4.1 4.0 3.9 4.0 oftener than in the second quarter of Hernia (122a) ....................................... 1.4 1.6 1.6 1.4 1.5 1934. After two years of below-aver- Other digestive diseases age sickness incidence rates, the fre (115b, 116, 122b-129)........................ 3.0 2.7 3.0 3.0 2.8 quency of disability in the second Rheumatic group, total........................ 9.9 8.9 10.9 9.8 9.4 quarter of 1935 increased to a figure Rheumatism, acute and chronic approximately the same as the av (56, 57) .......................................... 4.9 4.3 5.8 4.6 4.6 erage rate for this period of the five Diseases of the organs of loco- preceding years. motion (156b) ................................ 2.5 2.8 3.1 2.7 2.9 In the first three months of 1935 Neuralgia, neuritis, sciatica (87a)........ 2.5 1.8 2.0 2.5 1.9 only a slight increase in sickness fre Neurasthenia and the like (part quency occurred over that recorded of 87b) .............................................. 1.4 1.1 1.3 1.1 .8 for the same months of 1934. The Other dis. of the nervous sys- fairly sharp rise in the second three tern (78-85, part of 87b)................... 1.2 1.4 1.3 1.2 1.5 months of 1935 brought the rate for Dis. of the heart and arteries, and the half year to a level 13% above nephritis (90-99, 102, 130-132)...... 3.7 3.2 4.1 3.8 3.5 the corresponding rate for the same Other genito-urinary diseases period of 1934. (133-138) .......................................... 2.9 2.3 2.4 2.7 2.5 These findings emerged from an Diseases of the skin (151-153).............. 2.3 2.2 2.8 2.3 2.3 analysis of reports from a group of 33 Epidemic and endemic diseases except corporations having sick-benefit or influenza (1-10, 12-18, 33, 37, 38, ganizations covering approximately part of 39 and 44).............................. 4.0 2.5 2.8 3.3 3.2 158,000 male industrial workers in the Ill-defined and unknown causes (200) 2.1 1.7 1.8 2.0 1.8 periods under consideration. All other diseases (19-22, 24-32, part There was very little change in the of 39 and 44, 40-43, 45-55, 58-77, 88, frequency of non-industrial accidents 89, 100, 101, 103, 154-156a, 157, 162).. 6.6 6.3 7.4 6.4 6.0 in the second quarter and in the first half of 1935 as compared with the Average number of males covered corresponding periods of the preced in the record.........................................158,959 158,875 150,777 158,310 152,300 ing year. The increase was due to a Number of companies included_________ 33 33 36 33 33 greater frequency of cases of disabl 1. In 1934 and 1935 the same companies are included. The rates for the sec * Dean K. Brundace, Statistician, Office of In dustrial ffysicne and Sanitation, 0. S. Public ond quarter of the years 1930-1934 include 19 of these companies which employed an average of 120,666 men during these months or 80 percent of Health Service. The report for the first quarter of 193s was published in the Public Health Reports for August 23, 193j, Vol. 50, No. 34 pp. 1125- 1127- the 150,777 men representing the sample population for the five years. Exclusive of disability from the venereal diseases and a few numerically unimportant causes of disability. For non-respiratory diseases as a whole the rate was 10% higher in the second quarter, and 3% higher in the first half than in the corresponding periods of the preceding year. There was practically no change in the fre quency of digestive diseases. The rise in non-respiratory diseases was due to a combination of small increases in the rate for the rheumatic group of diseases, neurasthenia, diseases of the heart and arteries, and diseases of the genito-urinary system and annexa. The rate for diseases of the skin remained virtually unchanged from the low incidence to which this group of diseases has declined during the past few years. Although the sickness experience of the group of male industrial workers under consideration was not so favor able as in the corresponding periods of 1934. no disease group with the exception of epidemic and endemic diseases occurred at a rate which was appreciably above its five-year aver age. The down trend in sickness fre quency which has been manifested during the past five or six years, how ever, 'may have reached its nadir, at least for the time being. Progressive increase in the proportion of workers employed on a full time basis may re sult in slightly higher sickness rates on account of increased exposure to occupational health hazards. That a relationship exists between the health of industrial workers and the rate of business activity seems ap parent from the changes which have occurred in sickness frequency among industrial employees from 1921 to date. The comparison of rates in 1935 with those in 1934 is based on the re ports of identical companies and the five-year averages are based on the experience of almost the same em ployee groups. The number of com panies included may be insufficient to afford an adequate sample of the sickness experience of industrial workers in the country as a whole although the reporting companies em ploy persons in nearly all parts of the'eountry. A majority of the work ers covered in the record are located north of the Ohio and east of the Mis sissippi river. The illnesses reported are those for which sick-benefits are paid (for cases causing disability last ing longer than one week) from funds to which payments are made either by the employee, by the employer, or by both. United States Bureau of Mines approves Willson No. 400L Bag Respirator for LEAD DUSTS The Bureau of Mines has approved No. 400L "for protection against the inhalation of mechanically generated dusts whose main harmful constituent is lead, such as lead dusts generated in manufacturing storage batteries; enameling; pottery making; rubber compounding; sandpapering and chipping painted surfaces; paint making; preparing lithotransfers; and mining, milling and processing lead ores; and for protection against the inhalation of pneumoconiosis-producing or nuisance dusts, as quartz, asbestos, iron ores, cement, limestone, gyp sum, coal, coke, charcoal, wood, cellulose, flour and aluminum." The accumulated experience with bag respirators of our many good user friends plus the findings of our own Research Laboratories, have made the bag respirator for lead dusts possible. In back of everyone that leaves the plant is proof of worth built up by countless tests of materials and trials in various dust conditions in plants and factories of dozens of trades. Sealed Air Passage There is a sealed air passage between the filter bag and rubber face piece, making it impossible for even the fin est dusts to gain entrance. Low Breathing Resistance Weighing only 5',' ounces and having 40 square inches filtering area, these respiratoi-s are comfortable and very easy to breathe through. Low Service Cost Filter disc replacement problem is solved by the Approved Long Life Fil ters which in most cases last as long as the respirator. Positive Action Intake Valve Rebreathing of used air is prevented by an intake valve which closes auto matically the moment exhalation starts. WILLSON PRODUCTS, Inc., Reading, Pa. Broken Bones and Wasted Money DR. E. W. HEY GROVES (Emeri ers. maternal and infantile mortality. tus Professor of Surgery, Bristol Figures have been collected by a University) gave a very arrestingCommittee of the British Medical paper* on the treatment of fractures Association, and from these we have and the waste of money and time reason to believe that there are more caused by unorganized methods of than 150,000 cases of fracture in a dealing with accidents. In the first year, and that very wide differences place he found a great deal of diffi exist in periods of disability experi culty in arriving at an accurate esti enced for a similar fracture at dif mate of the number of fracture cases ferent centers. which occur in this country and of For example, one firm reports an the number of different bones affect average disability period for Colies' ed, the length of disability, or the fracture above the wrist of 27 weeks percentage of cases of permanent dis which should recover in seven weeks. ability. Fractures do not come under Another company was so impressed any government department, and no by similar differences that it arranged statistical evidence is collected as is for all cases of fracture among its done in the case of tuberculosis, fev- employees to be treated at one clinic, Abjtr. in Labour Manaaement, London. Octo ber, 1935; paper presented at Congress of Na which reduced cost per case from 117 to 19, and the incapacity period tional Safety First Association. from 23 weeks to five weeks. There is an organized clinic at Crewe for the L.M.&S. Railway which has wonderful results even from patients with old injuries of many kinds who were seemingly incapable of improvement; from this and frac ture clinics in Manchester and Liver pool, remarkable figures have been collected for comparison with un organized treatment. The period of disability has been reduced from 22 weeks to five weeks (clavicle) and from 57 weeks to 26 weeks (patella) with a permanent disability of only 1% as against 37%. With regard to compensation, to take one special fracture, namely Potts' fracture of the ankle, 100 such cases treated at the organized clinic would involve a payment of 1,650; the same number treated haphazard would cost 7,050. Another point is mates more or less to the condition posure in an effort to make an ac- the great loss suffered by the patients of ankylosis of all three joints of the curate adjustment of accrued liabil in wages and the unnecessary pain fingers, and of the two joints of the ity and premium rates. and loss cf morale. thumb. The lumbrical muscles may (c) propose recommendations of a These striking differences between the results of organized and unor ganized treatment of fractures are not special or peculiar to this time or this country. It was first demon strated on a large scale by the ex periences of the war. In the early months no less than 80% of gunshot fractures of the femur died, while in the last year of the war this mortality was reduced to 10%. No new dis covery was made in treatment, and the improvement was entirely due to the standardization of methods and continuity of treatment. In Vienna the insurance company, which is a state institution, has proved that it pays to treat cases of accident by an organized system. The mainte nance cost of a complete hospital was saved on only 124 cases of fractures of the long bones in 1929, so that the rest of the cases were practically treated for nothing. (Total treated, 1,792 in-patients, and 6,936 out effect some movement at the metacarpo-phalangeal joint, but their ac tion is too weak to be of any prac tical value. Again, so often the in flammatory reaction has involved and immobilized the lumbrical muscles themselves, and has produced periar ticular adhesions. Imbert, Oddo and Chavernac, in their "Guide pour 1'Evaluation des Incapacites," give the following useful figures in the assess ment of the disabilities sustained. Complete stiffness of the digits at both the interphalangeal and the metacarpo-phalangeal joints:-- Thumb-- Right In extension _____ __ 30% Moderation flexion ....25% Index finger ................. 18% Middle finger ......... .... 15% Ring finger .............. --15% Little finger ................. 10% Left 25% 20% 14% 12% 12% 8% Lesser degrees of stiffness can be merit system to the Compensation Rating Board whereby premium rates will be based upon the degree of prevention in respective plants. (d) revise present Industrial Code rules on injurious dusts, fumes and gases. (e) make specific recommendations for control of dust hazards. (f) plan and inaugurate a vigorous campaign for the prevention of sili cosis in collaboration with industry and labor. "It is obvious that the success of a study such as the one upon which we are now engaged depends in large measure on the cooperation we re ceive from certain groups outside the Department of Labor," Dr. Green burg commented. "It is essential that we have the cooperation and backing of industry and labor. Also, it may be desirable to ask the cooperation of certain unofficial as well as official patients.) The Vienna Hospital is assessed accordingly from this table. health groups." under the control of one man, whose Should the finger be completely methods are used throughout, where stiff following sloughing or fixation Medical Service in Office as in most of our hospitals every surgeon on the staff has a few acci dents and different methods may be used even in the same ward. Many examples may be given of cases that have been sent from one medical man or hospital to another, where no one person takes the re sponsibility, or where the patient is first seen by a junior house surgeon, and wrong diagnosis and treatment result in total disability. In an organized clinic three prin ciples must be aimed at: unity of con trol, continuity of treatment, and an eflicient follow-up. The provision of a fracture service consisting of three surgeons, sister, nursing, massage, and x-ray assistants, would not be very expensive, and if all cases of fracture within the radius of the - hospital were treated in the same way and gave the same average re sult, about 4 million a year in com pensation could be saved. In any given city, if the leading insurance companies united to finance such a scheme they would be far more than repaid by the saving of compensation. If such centers could be founded in, say, 10 of the leading cities of this country, a good start would be made towards general re organization. At the end of a few years accurate figures would be avail able, showing how much money has been saved at these centers in com parison with that spent on cases still treated in an unorganized way. Such demonstration would soon lead to the spread of the system to all great towns in the country. of the tendon, amputation at the Management metacarpo-phalangeal joint should be advised. Suppurative arthritis of the proximal interphalangeal joint may be present, and affords an addi tional indication for amputation. This does not, of course, apply to the thumb, all of which, or as much as possible, should be preserved. Even a completely stiff thumb can be ren dered useful by affording something against which the fingers can oppose themselves. Often the patient him self requests that amputation should be done, as he finds the stiff finger a constant hindrance at his work. Am putation at the metacarpo-phalan geal joint is assessed by the same writers in the following manner:-- WHILE the value of an industrial medical service is receiving at tention from industrialists of vision, the importance of such a service in office organization has perhaps been less well recognized.* This may be due to the fact that medical service for employees was originally estab lished to minimize the obligations of the employer under the Workmen's Compensation Act. It was later real ized that it had a wider sphere of in terest, to promote the health of the worker and produce a substantial re duction in sick absenteeism. The most important duty of an of fice medical service is the exmaination of all prospective new employees. Right Left It should be as thorough as that for Thumb ...... 30% 25% life assurance, though many people Index finger ..................15% 10% with even grave physical handicaps Middle finger ..............10% 8% are able to work with profit both to Ring finger......................10% 8% their employers and to themselves. Little finger .............. 8% 6% The proportion rejected should be It is interesting to note that apart from the case where a thumb is stiff in moderate flexion, the percentage disability of amputation at the met acarpo-phalangeal joint is substan tially less than complete stiffness of the corresponding finger. somewhere near 3%. The Medical Officer must have an intimate knowledge of the nature of the work and of the environment in which this work will be performed. Most employers pay staff salaries during periods of sickness. This is a burden which a medical service Industrial Hygiene can reduce, by the exclusion of those applicants whose sickness absentee DR. LEONARD GREENBURG, Ex ecutive Director of the Division ism is likely to be much above normal. In a large number of applicants of Industrial Hygiene, who is conthere are minor defects which, if left ducting a series of studies on the untreated, will result in invalidism. need of the Division, with special The medical service can confer a emphasis on the problems presented double benefit on such applicants by Synovial Whitlow by silicosis and other dust disease recommending them for employment hazards in industry, in a partial re on condition that they agree to have SYNOVIAL whitlow causes the loss port on the progress of the studies of many working days, and is the presents an outline of their purpose.* source of much litigation under the Workmen's Compensation Act.* Thus, it would perhaps be helpful to give The dust hazard phase of the studies. Dr. Greenburg reports, is "designed to obtain fundamental data in a rep an outline of the "percentage disa resentative number of plants." bilities" which can be sustained in Using these data as a basis, it will this condition. The stiff finger which be possible to: cannot be flexed, and which so often (a) determine the incidence of sil follows synovial whitlow, approxi- icosis in its various stages. (b) present factual evidence of ex- the necessary medical treatment-- examples of such conditions are carious teeth, pyhorrhoea, chronical ly infected tonsils, defective vision. The Medical Officer should be in attendance at certain specified times each week, so that both management and staff may know when he is avail able. By referring any member of the staff whose health does not ap pear to be satisfactory many ail- From an article by J. Cosqie Ross. CilM. (Liverp.), F.R.C.S., in Liverpool Medico>Chirurg. * Indust. ButtDecember, 1935, State of New * T. E. A. Stowkll, Chief Medical Officer, J., VoL XUII, Part 3, 1935. York Department of Labor. I.C.I., in Labour Management, December, 1935. ments are discoverable in the early stages, and not infrequently cases of grave communicable diseases are thus discovered. The most common cause of absen teeism is that of influenza, the com mon cold, and their sequelae. The re Central States Society of Industrial Medicine and Surgery sults of a large scale experiment of inoculation with vaccine were dis appointing, as also that of using Official Proceedings vitamins to increase resistance. Every sufferer from a cold should be re garded as a leper and sent home and kept away from work until such time as the M. O. certifies him free from infection. Spraying offices in the Editor: Volney S. Cheney, M.D. Frank P. Hammond, M.D. Secretary-Treasurer Associate Editors: Don Deal, M.D. Frank P. Hammond, M.D. hope that this will keep down in fection is a waste of energy; there is, however, an excellent fumigator which has proved itself effective. Another common cause of lost time among female members of office staffs is painful menstrual periods. This is in a measure due to a com bination of superstition and ignor ance. The modem girl, in her sane outlook on life, is an improvement on her mother, and a far greater im provement on her grandmother, but the superstition of the taboo still lin gers. Medical supervision and the en couragement of a sane outlook on life can almost entirely banish this par OFFICERS President, Dr. Geo. L. Apfelbach, Chicago Secy-Treasurer, Dr. Frank P. Ham mond, Chicago BOARD OF GOVERNORS 1936 Dr. Ralph M. Carter. -- ---------------------- Green Bay, Wis. Dr. Frederick W. Slobe_______ -- ----------------------------Chicago, III. Dr. Flint Bondurant.__ Cairo, 111. 1937 Dr. John J. Grant.__ Freeport, 111. Dr. Don Deal-------- Springfield, 111. Dr. J. B. MooreBenton, III. 1938 Dr. James Finch--Champaign, 111. Dr. F. J. Otis--------------- Moline, 111. Dr. W. E. Wolcott -- ---------------------- Des Moines, la. ticular bogey. In a recent letter to The Times Mr. Hyde, of the I. W. S., wrote: "One wonders how the employer today can afford to do without the services of a medical man, whose main task is the prevention of sickness." I have fig ures showing a reduction of 50% in sickness absenteeism in a very large group of office workers, due to the institution of a staff medical service. Such a service need not entail great expense. All the offices in one building can share the cost in pro portion to the number of their em ployees. Waiting accommodation is necessary, and a consulting room with examination couch, sterilizer, cabinet with the essential instru ments, a plentiful surely of hot and cold water and the necessary dress Chicago Society of Industrial Medicine and Surgery Officers and Board of Governors President------------------------------------------- John G. Frost Vice-President-- -------- --------------------Frank E. Schram Secretary-Treasurer.__________ Frank P. Hammond Office: 6308 Cottage Grove Ave., Chicago, Illinois Term Expiring 1938 0. W. Rest Frederick W. Slobe E. A. Degenhardt Term Expiring 1937 Georcb L. Apfelbach Fred G. Carls James A. Valentine Term Expiring 1936 Hugh W. Mullins Felix M. Jansey Fred M. Miller ings. A fully-trained nurse is another essential. To place nursing responsi bilities on the shoulders of a welfare worker who is not so trained is un fair both to her and to the patients. It is to be remembered that nurses, Behind Mercurochrome (dibrom~oxymercuri*fiuoresceia>so<iium) by qualifying, do not lose their na tive common sense and intelligence thereby. They may profitably fill in time by filing or doing various other is a background of clerical jobs. The scale of fees for the medical officer should be approximately 60 guineas per year for a half-day ses sion every week. For office staff it is more satisfactory to have part time Precise manufacturing methods insuring uniformity Controlled laboratory investigation medical officers than whole time. The cost of such a service, therefore, is not great, and the return will be a substantial reduction in absenteeism, improved health and happiness, and therefore increased efficiency. A booklet sum marizing the im Chemical and biological control of each lot produced Extensive clinical application Corporate Practice portant reports on ABOMBSHELL opinion* was hand ed down on October 21, by Judge Mercurochrome and describing its D. F. Wright, of the Thurston Countyvarious uses will Superior Court of Washington (state) be sent on request. to the effect that the Olympia Lum berman's Clinic was illegal. It was Thirteen years' acceptance by the Council of Pharmacy and Chemistry of the Amer ican Medical Association * Medical Economics* HYNSON, WESTCOTT & DUNNING, Inc., Baltimore January, inso medical aid an ambulance or any physician may be called to give first aid treatment. 4-- Homeopathic and osteopathic societies and boards should receive applications from and recommend Published under supervision of the Wavs and Means Committee of the Nneew Ytoorrsk Ssttaarte Ssoocciety orf Ixnndauustrial Medicine. Editorial office, F. E. Redmond, Managing Editor, 406 Root Building, Buffalo, N. Y. Articles appearing herein ao not neecceessssarily reflect the opinion or policy of for authorization to treat workmen's compensation cases only homeopaths and osteopaths. this journal nor of the New Yorrk State Society of Industrial Medicine. 5-- All specialists, consultants, etc., should submit a report of their find Editorial Board ings in triplicate to the attending B. J. Slater, M.D. . Willis C. Templer, M.D. M. W. Stofer, M.D. E. T. Wentworth, M.D. Chas. P. Hutchins, M.D. D. C. O'Connor, M.D. M. S. Bloom, M.D. A. M. Dickinson, M.D. F. N. C. Jerauld, M.D. Edw. S. McDowell, M.D. Chas. D. Squires, M.D. E. MacD. Stanton, M.D. P. K. Menzies, M.D. Richard S. Farr, M.D. E. A. VanderVeer. M.D. A. R. Grant, M.D. C. W. Woodall, M.D. E. S. McSweeny, M.D. Raymond C. Almy, M.D. Francis J. Ryan, M.D. W. D. Ward, M.D. Paul B. Jenkins, M.D. Frank E. Redmond, Managing Editor physician who referred the case to them. It is not necessary that these specialists file a 48-hour report. The completion and filing of all reports is the duty of the attending physician. 6-- A registered physiotherapist may treat workmen's compensation cases at his own office or bureau when the case is referred to him by an authorized physician. The author ized physician should, however, give The New York State Society of Industrial Medicine a written .direction to the physio OFFICERS Charles W. Woodall, M.D. E. A. VanderVeer, M. D. President 2nd Vice-President Willis C. Templer, M.D. Raymond C. Almy, M.D. 1st. Vice-President Treasurer Frank E. Redmond, Executive Secretary therapist as to the kind of treatment to be rendered and the number of treatments to be given. This direc tion must be given in writing by the physician and shall constitute a part of the record of the case. 7-- Removal of physicians from Directors Dr. Raymond C. Almy, Auburn Columbia Rope Co. Da. A. R. Grant, Utica 321 Genesee St. Da. Eovc. S. McDowell, Plansburg Saranac Pulp Company Da. E. S. McSweeney, New York New York Telephone Co. Da. P. K. Menzies, Syracuse 5x1 Medical Arts Bldg. Da. Chas. D. Squires, Binghamton 2ft Conklin Ave. Da. Willis C. Templer, Corning Corning Glass Works Da. C. P. Hutchins, Syracuse Aetna Life Insurance Company Da. Francis I. Ryan, Syracuse New York State Railways Dr. B. J. Slater. Rochester Eastman Kodak Company Da. A. M. Dickinson, Albany New York Central R. R. Da. Edw. T. Wentworth, Rochester Da. M. W. Stofer, Norwich Norwich Pharmacai Company Da. M. S. Bloom, Binghamton Dunn & McCarthy Da. E. MacD. Stanton, Schenectady American Locomotive Company panels. Section 13-D. (a) The doctor accused of mis conduct shall be notified of the charges in writing by the medical society or board as to the date and time of the hearing. (b) Careful records shall be kept of the minutes of the hearing. (c) These records, together with the report of the Board of the medi cal society with its findings, shall be submitted to the Commissioner. Da. Beverly L. Vossrurch, Schenectary Da. F. N. C. Jerauld, Niagara Falls Appeal by physicians to the Indus General Electric Co. Da. William D. Ward, Rochester 20 Grove Place Da. C. W. Woodall, Schenectady Da. Donaid C. O'Connor, Buffalo Internationa) Railwavs American Radiator Co. Da. Richard S. Farr, Svracuse trial Council to be referred to a sub committee to report findings to coun cil. 146 Barrett St. Consulting Orthopedist (a) The doctor appealing and the medical society or its board shall be notified in writing as to the date of soon followed by Judge Wright's New York state, to their detriment in the hearing. statement that he would issue an competing with business from other (b) The doctor may be represent order to compel the outfit to dissolve. states, was stressed by several speak ed by counsel. Many lumber mill operators and ers. It was reported that a number (c) Accurate stenographic or logging companies have been using the clinic's services to provide medi cal care for their employees. The judge's decision followed charges by Prosecutor Smith Troy that the O.L.C. was actually a cor poration engaged in the insurance business and therefore could not be licensed to practice. This action is expected to have a far-reaching effect on similar organ izations that flourish throughout the country. already had to lay off many employ ees because of the additional ex penses under the amendments, and that expenses will increase when the full effect of the occupational disease amendment is felt. A resolution was proposed from the floor that all groups agree to amendments to the present law, to be presented to the 1936 legislature.- This motion was heartily endorsed. N. Y. Regimentation stenotype minutes of the hearing shall be kept for the files of the Com missioner and Industrial Council. (d) Findings of the committee shall be submitted to the Industrial Council for final action. 8-- Arbitration Committee on med ical bills: A panel of physicians is to be appointed by the president of each county medical society, who shall submit the names of the physicians on the panel to the Industrial Com missioner. The Commissioner shall, when arranging hearings on medical INew York Employers Oppose NDUSTRIAL Commissioner Elmer bills, select two members of each F. Andrews recently promulgated arbitration committee from this Occupational Disease Compensation the following set of rules and regula panel for each arbitration session, the tions governing the application of Industrial Commissioner to set the Chapter 258 and 930 of the Work dates for all hearings and notify all AlMASS meeting was held at the men's Compensation Law, familiarly interested parties. The arbitration Hotel Astor in New York on No known as the "Free Choice of Doctor" committee shall submit to the In vember 21, 1935,* to crystalize sentiamendment: dustrial Commissioner its decisions ment among employers against the 1--All doctors whose applications on a form prescribed and provided by medical practices and occupational have been disapproved by the vari the Industrial Commissioner, who disease amendments to the Work ous county medical societies may will then forward notice of decision men's Compensation Law of New continue to treat workmen's com to all interested parties. In the event York, which were enacted by the pensation cases until a final decision of disagreement as to the value of 1935 legislature. The meeting was called by a joint-committee of the five brokers' organizations in Great er New York, and many of the indus trial groups in the state participated. The additional expense imposed by the amendments on industries in is rendered by the Industrial Coun cil. (Rule No. 1 not effective after November 1st, 1935). 2--All C-4 reports filed by attend ing physicians should be verified to insure their value as prima facie evi dence in a compensation case. 3--In the event of a serious acci medical services rendered a hearing shall be held in the county in which the doctor practices or in which his main or principal office is located. Notice of this hearing shall be sent to the doctor or hospital who rendered the services, the employer and the insurance carrier, any of whom may * Jour. Am. Insurance, December, 1935. dent requiring immediate emergency appear or be represented if they so The Journal of cia mrnmR n*Q. U. . FAT. OFF. Occupational Diseases and Traumatic Surgery for Physicians and Surgeons in Industry Its Field: The Medical Science, the Law, the Economics, and the Statistics of INDUSTRIAL MEDICINE and TRAUMATIC SURGERY Industrial Hygiene Occupational Diseases Traumatic Surgery Medical Departments Medicolegal Relations Workmen's Compensation EDITORS: James T. Case, M.D., F.A.C.S___________________________________ Chicago, 111. Volney S. Cheney, M.D., F.A.C.S.------Medical Director, Armour & Company Geo. G. Davis, M.D., F.A.C.S------------Chief Surgeon, The United States Fuel Co. Joseph Jordan Eller,.M.D.Dermatologist, New York City Hart E. Fisher, M.D., F.A.C.S___ !___ Chief Surgeon, Chicago Rapid Transit Co. John G. Frost, M.D., F.A.C.S Chief Surgeon, Chicago & Eastern Illinois Ry. Co. Otto P. Geier, M.D., Director Employee Service, Cincinnati Milling Machine Co. Burke C. Hamilton, M.D--------------Medical Adviser, Aetna Life Insurance Co. LeRoy P. Kuhn, M.D., F.A.C.S., Chief Surgeon, LumbermensMutual Casualty Co. David Shapiro, M.D.________ Medical Director, Lumber Mutual Casualty Co. Frederick W. Slobe, M.D., F.A.C.SChicago, 111. Charles D. Squires, M.DBinghamton, N. Y. CONSULTANT: C. O. Sappington, M.D., Dr. P.H- Consulting Industrial Hygienist OFFICIAL PUBLICATION MEDIUM OF: American Association of Industrial Physicians and Surgeons Association for Advancement of Industrial Medicine and Surgery Netv York State Society of Industrial Medicine Central States Society of Industrial Medicine and Surgery Chicago Society of Industrial Medicine and Surgery A MEDICAL MAGAZINE--PROFESSIONALLY EDITED (Conforming, in its advertising, to the standards of the Council on Pharmacy and Chemistry of the A. M. A.) Published Monthly jidSSSk Bag. U. & Pat. Off. 844 Rush Street, Chicago, Illinois Subscription $5.00 per year 2 Years for $9.00 J rage ou INDUSTRIAL MEDICINE January, 1936 IDEAL FRACTURE TREATMENT for INDUSTRIAL SURGEONS Bohler--TREATMENT OF FRACTURES By DB. LORENZ BOHLER, Director of the Hospital for Accidents, Vienna; Lecturer on Surgery, University of Vienna. Translation from the fourth enlarged and revised German edition by Ernest W. Hey Groves, M.S., F.R.C.S., Emeritus Professor of Surgery, University of Bristol. Buckram binding, gold stamped, 6ftxl0ft, S88 pages, 1059 il lustrations, $12.00. LORENZ BOHLER has long been internationally famous for his many successful developments in methods for the treatment of all kinds of fractures. The German editions of his book are well known in Amer ica, but their use has naturally been restricted by the limitations of lan guage. Even a fair ading knowledge of German is not sufficient for a complete grasp of r .'inciples or a reliable unaerstanding of details of technique. Many American surgeons have wished for a complete and reliable English translation of Dr. Bohler's work, and one is now ready. Not only a complete translation of the fourth German edition, but add ed material, not previously published, from Dr. Bohler's latest experi ence with Fractures of the Spine and of the Neck of the Femur. Not a dull machine-like translation by an uncomprehending literary hack, but a work of appreciation done by a man who is himself a well known master-surgeon. Ernest Hey Groves, editor of the British Journal of Surgery, an authority on fractures, who deliberately postponed revi sion of his own excellent book on the treatment of fractures in order to pay tribute to the Viennese master of the art, and make his work bet ter available to all English-speaking surgeons. It has been well said that Dr. Bohler's book reveals he hats that quality of genius which con sists in the infinite capacity for taking pains. All of his painstakingly acquired knowledge and experience is now available to every American orthopedist and general surgeon. Bohler's methods are not experiments but a carefully compiled and developed system, superior to that commonly in use, covering many years' experience with a large number of cases. Many American prac titioners have visited his hospital where thirty to forty visiting sur geons from all countries watch his work daily. In fact the Bohler ex perience and methods have been for several years increasingly used in many American cities with success and satisfaction. In the words of a well-known California surgeon, "These methods, applied in the treat ment of injuries, result'in a lessened disability period, an earlier return to the proper industrial status of the patient, a shortened period of hos pitalization, and the least possible impairment of function. The mor ale and physical well being of the injured are enhanced and economy to society ensues." No surgeon should rest content until he has a copy of Bohler on his bookshelf for reference, for comparative purposes to aid him in im proving his own methods and technique. The book is a liberal educa tion in fracture treatment. WILLIAM WOOD & CO. (Division of the Williams & Wilkins Co.) BALTIMORE Massachusetts Division desire. The arbitration Board shall of pass upon the matter in dispute in Occupational Hygiene accordance with Section 13-D of the 23 Joy Street, Boston amended law. Careful records of the Manfred Bdwditch, A.BDirector hearing shall be kept in the office of Hievey B. Elejns, Ph.D--------------------------- Cheroiit the county society. Eowaid C. Riley, M.ScEngineer i 9--In the event of the rejection of Louise E. Buenham--------------------------Senior Clerk I| a physician by a county medical soci Evelyn BeonskiJunior Clerk ety the jurisdiction of the County "IT SHALL be the duty of the Division to investigate conditions of occupation with reference to hazards to health and to determine the degree of such hazards, to investigate and evaluate methods for the control of such hazards to assist in the preparation of rules and regulations for the preventing of occupational accidents and diseases, and, in cooperation with the department of public health or otherwise, to promote occupational health and safety education."--Sec. 11A of the law creating the Division, effective 1934. Lincoln-Belmont X-Ray and Clinical Laboratory COMPLETE X-RAY Service Hours: 9 A.M. TO 5 P.M. -- 7 P.M. TO 9 P.M. Sunday by Appointment 3166 Lincoln Ave. Wellington 2277 Medical Society has terminated and it cannot reconsider its action. Each county medical society must pass upon the application of each physi cian within thirty days of the receipt of the application and notify the In dustrial Commissioner of its action. 10-- Bills for x-rays and other consultants should be made out separately and submitted by the doc tor in charge of the case and paid directly by the employer to the doctor rendering the service. 11-- A hospital may not secure a license to operate a medical bureau to render care to compensation cases. 12-- No insurance company or selfinsurer may reduce the size of notice to employees (form C-105) which is to be placed in all places of employ ment covered by the act, unless such permission is granted on application to the Industrial Commissioner. 13-- Physicians treating claimants in hospitals may secure signature of claimants for authorization of copies of any necessary hospital records. 14-- The physician in attendance in public hospitals must be the judge as to when the "emergency status" of the case has terminated. 15-- Methods for identification of medical inspectors of insurance com panies wishing to visit claimants in hospitals must remain in the hands of the hospital themselves. 16-- No license is necessary to operate a first aid station for'emerg ency treatments, but no 'subsequent visits are to be made by claimant to the first aid station. 17-- The physician in attendance must seek authorization for a special ist first from the employer; if unable to secure it, he may apply to the In dustrial Commissioner if necessity for operation or ability of specialist designated is questioned, in accord ance with Section 13 A-5. 18-- The interpretation of Section 13 A-5 shall be to the effect that the authority of an employer for the services of a specialist in excess of a $25.00 fee applies only to the neces sity for such services but that the choice cf such specialist is entirely within the jurisdiction of the injured worker and the doctor in the case. 19-- All medical bureaus and labor atories in operation on July 1st, 1935 shall be charged a license fee, effec tive from July 1st, 1935 to and in cluding June 30th, 1936. 20-- When it is in the interest of the injured employee and where an x-ray is required and it is impossible to secure the services of a qualified x-ray specialist the Board of the Local County Medical Society may designate a specially qualified in dividual to take x-ray pictures under the supervision of the attending physician. The attending physician however, shall render a bill for such service to the employer. This in no way however, deprives the employer or insurance carrier from having other x-ray pictures taken if they so desire. 21-- No advertising matter of any nature on compensation work will be allowed by authorized physicians, medical bureaus or laboratories. 22-- That all County Medical Socities be instructed first to investi gate all complaints submitted to them and if the evidence warrants it, charges should be preferred against the physicians after which the physi cians should be notified in writing of i v Vy ^ The Association for the Advancement of Industrial Medicine and Surgery INDUSTRIAL Inc. Executive Office - 370 Lexington Avenue, N. Y. (Room 904) MEDICINE Purpose: To disseminate accurate medical knowl edge in reference to the diagnosis and treatment of all conditions arising out of and in the course of employment. OFFICERS i --A New, Important ! Contribution to i Medicine i President: Anthony Avata, M. D., 110 William St, New York City Vice-President: J. J. WlTTMER, M.D. 4 Irving Place, New York City Recording Secretary: David Shapiro, M. D. 41 East 42nd St., New York City Treasurer: Joseph L. Ramirez, M. D. 30 Fifth Ave., New York City Executive Secretary: J. J. Blackford, 370 Lexington Ave., New York City (CAledonia 5-9753) Robert F. Coleman, Inc. just oft the press-- by W. Irving Clark, MJ)., and j Philip Drinker, Ch.E. Har vard School of Public Health. --Edited by Morris Fishbein, M.D. To most general practi EXECUTIVE COUNCIL tioners Industrial Medicine is an unknown held, although Dr. J. Hudson Blauvelt.. .Fidelity & Casualty Insurance Co. much of their private prac Dr. T. Wallis Davis___ Dr. Lyle Ellis__________ Dr. Halcyon HalsteadTM _________________Borden Company --Travelers Insurance Co. ____ Globe Insurance Co. tice embraces industrial acci dents and industrial diseases. Dr. Burke C. Hamilton... -Aetna Life Insurance Co. This book is written as a Dr. George A. Koenic..... Dr. Willis W. Lashf.r...... Dr. Frederick L. Mosser.. ( Dr. Arthur R. Tilton.... _____ National Biscuit Co. .Employers Liability Insurance Co. ______ Third Ave. Ry. Sc Bus Lines _________ Travelers Insurance Co. handbook for the practitioner who either is going into in dustrial medicine or who may have industrial medicine the charges, as well as given a bill of more or less indefinite causes. The particulars so that they may be in a mental conditions that result in error thrust upon him. It assists I position properly to defend them are lack of knowledge, inattention, selves at the hearings. confusion, and often an unwarranted ; sense of superiority typified by the j him in understanding the con ditions under which his pa Mental Hygiene as Applied to "it-cannot-happen-to-me" attitude. ' tients work, his contacts with Industrial-Accident Prevention These terms, of course, overlap and [ are dependent for their existence on i a number of things, such as experi plant departments, with so cial service and insurance OUR present methods of accident ence, training, worry, fear, fatigue, agencies, and informs him of 1 prevention* are based on the exhilaration, or some mental subnor- ! presumed need of awakening emmality, all of which tend to expose j ployees to a sense of responsibility the individual worker to hazard. standard remedial and pre ventive practice. for their own safety. To do this, we Accident investigation and analy spend considerable time trying to scare them into looking out for them selves. Posters showing the horrible results of accidents are promin" My displayed. Speeches are made in sis usually stop at the first cause, in i as much as most plants are not , equipped for further analysis and ] their executives believe it imDracti- ] cable to go into psychological causes | NATIONAL MEDICAL BOOK CO. 119 W. 41 ST. NEW YORK which the suffering at home as a re further than to note that the man ; t t sult of loss of income is vividly ex was inattentive, disobedient, or, per plained, and articles are written tell haps, careless. 280 pages -- 34 illustrations ing large groups of workers to "do Cloth -- S3.00 net. J this" or "do that" to avoid dreadful New Chrysler Laboratories Tconsequences. A number of the in dividuals for whom this propaganda is prepared pay complaisant atten HE Industrial Hygiene Labora tories of the Chrysler Corporation ! began operation on January 1, 1936. j National Medical I.M.-I-3* Book Co., } tion--and then apply the lesson to These laboratories, located at the | some one else. Our general educa Dodge Main Plant of the Chrysler i tional campaigns are, no doubt, leav Corporation, in Detroit, are devoted ! 119 W. 41 St., New York, N. Y. ing many things undone. to the study of occupational diseases I Send me, carriage prepaid, one According to the best authorities, and their sources, together with other j at least 85 or 90% of all accidents agencies and conditions of work lead- copy of "INDUSTRIAL MEDICINE" by Clark and Drinker. have as their proximate causes the ing to industrial health hazards. The j Enclosed find check for 43.00 mental conditions of workers. This Laboratories are under the direction Q Send C.O.D. estimate relegates the remainder of of Dr. Stewart F. Meek, as industrial j the accidents to machine or material hygienist, with Dr. Cordon C. Har- i failures, "acts of God," and various rold, as chemist; they were planned I Name ............................................. . Edward R. Oravniss. Travelers Insurance Company, Hartford, Conn., in Menial Hygiene, July. 1935- under the direction of Dr. Carey P. | McCord, who remains associated in j the capacity of adviser and consultant. | Address --------------------------------------------- -IF YOU BUY BOOKS -and Who Boesn't? The American Public Health Association has been operating a Book Service for years. Its cus tomers are loud in their praises of its convenience. If you buy books -- any books -- perhaps it can be useful to you as well. The Book Service rend ers expert advisory help. It will recommend the most generally approved books, old and new, on any public health specialty, and in dustrial medicine is such a specialty. It will under take the furnishing -- and guarantee satisfaction -- of anything from a "Five-Foot Shelf of Health Books" to an entire library. The Book Service ren ders its most valuable aid when it turns detective. It sleuths down the pub lisher, if you know only the title of the book you want, or it searches out the title and the author on such slight information as "some publishing house in New York brought out a book on occupational dis eases a few years ago." There is no charge for advice and detective work. Books are sold at publish ers' list prices; and the Book Service pays the post age if you send cash with your order. Use the Book Service for any book you want to add to your personal or pro fessional library. It will save time and temper. You, too, will become a Book Service fan. THE BOOK SERVICE AMERICAN PUBLIC HEALTH ASSOCIATION 50 West 50th Street, New York, N. Y. Occupational Morbidity and It is anticipated that a number of Mortality Study interesting by-products will arise from this study: as, for example, the TepisdrotHiPijennhrEecoitgtcsUraoae.otnstspasaSteuit.nAirdoamPdynti,emuaonbntlihntl"ieichswoetorfHiatabhletjtseihaoicclntkttihhn,neovehSfesaseWnwsrtvhooiainirrccnkycehds"l,udcsrwameotsaielrctatdharutiesbsivduemerodfelaonymrrtrhoheiseeniigndatthghltleohpedfeepafraasenetorchdfsnfteoosrlcnoartsntsferogaefseuoqvscfusiuoteeymamlne.lpltcaylaytrTiroirtehenaides.l mortality rates in relation to occu pation.* From Census data it is estimated Injuries to Workers in Ohio Cthat the health of approximately 40% of the total population is affected in UTS and lacerations furnished the basis for more occupational in varying degrees by their working en jury claims last year than any other vironment. Thus among the 14 mil form of injury, as they have in pre lion persons employed in manufactur ceding years.* The claims due to this ing and mechanical industries in 1930, class of injury numbered 68,271, or more than 900 different occupational 15,228 more than in 1933. exposures to hazardous materials and Crushes and bruises, with 29,810 conditions have been found. Many cases, were second in frequency. of these exposures undoubtedly affect Sprains and strains gave rise to 21,- health adversely. This supposition is 834 claims, puncture wounds 12,930, substantiated by the finding of life fractures 10,168, burns and scalds 10,- insurance companies that the life ex 987, dislocations 651, traumatic am pectancy of industrial workers is six putations 570, concussions 169, as- to seven years shorter than that of phyxiations 175, drownings 3, and un non-industrial workers. It is the pur classified 3,680. These figures repre pose of the Occupational Morbidity sent increases over 1933, with the ex and Mortality Study to obtain sick ception of concussions, drownings and ness and death rates for each numeri unclassified cases. cally important disease or disease An analysis of the record shows group according to occupation. that the fingers of workers in Ohio Sources of this information are the industries are more susceptible to in records of sick benefit associations jury than other parts of the body, 41,- and the records of personnel depart 749 claims being based on injuries of ments of companies having sick bene this nature. Eye injuries were sec fit societies. Information also is be ond with 27,195 cases, the trunk had ing obtained as to raw materials han 22,604, legs 15,565, arms 15,841, hands dled, the nature of the end product 12,898, head and face 10,192, feet 7,- of each process, and the working con 739 and toes 5,465. ditions surrounding each occupation. Included in the 10,168 fractures re The schedule is so arranged that sick ported in claims for compensation ness and death rates can be computed were 1,945 of fingers, 1,883 of toes, for groups exposed to such specific 1,349 of arms, 1,354 of ribs, 1,063 of potential health hazards as arsenic, legs, 834 of feet, 390 of hands. 294 of lead, quartz dust, mercury, chrom the skull, 348 of teeth, 261 of verte ium, extreme temperature changes, brae. 144 of the nose, 136 of the pelvis dampness, etc. Thus, from a statisti and 88 of the jaws. The extent of cal analysis of the schedule, the ef the incapacity due to this one type of fects of industrial exposures are accident alone, is shown in the fact measured in terms of occupational that workers sustaining fractures suf morbidity and mortality rates. It is fered a time loss of 1,782,790 days, or expected that several hundred thou more than 22 per cent of the total for sand of these schedules will be ob all injuries. tained by May 1, 1936. * 1934 Annual Statistical Report. Industrial * AJ.P.H., December, 193s. Commission of Ohio. ii i RETINOSCOPIC REFRACTIONS I[ i j Form Fit Lenses to Your Individual Features | We Maintain Our Own Lens Grinding Laboratory j METRONOSCOPIC TRAINING j Improves Your Reading Speed 50 to 100% ! PHOTO ELECTRIC CELL j "The Electric Eye" For Proper Light Determinations i I Call On Us and See the OPHTHALMOGRAPH j A Motion Picture Film of Your Eyes j The Only Machine of its Kind in Professional Use in Chicago DIAGNOSES:--Muscular Imbalances--Refractive Errors--Faulty Eye Movements-- I Stress and Strains--Fixations-- Regressions and Reading Speed J INDUSTRIAL EMERGENCY OPTICAL SERVICE Call Monroe 3375 j Temporary Glasses Supplied at the Plant Permanent Repair and Return within 2 Hours i THE YOUNGDAHL OPTICAL LABORATORIES 1 1526 West Madison Street Chicago,. Illinois FEBRUARY od: D 56) and suitable for use as an illuminant when burned in a wick lamp. Gas Oil: A liquid petroleum distillate having a viscosity intermediate between that of kerosene and lubricating oil. Fuel Oil: Any liquid or liquefiable petroleum product burned for the generation of heat in an industrial or household furnace or firebox, or for the generation of power in a Diesel engine, exclu sive of oils with a flash point below 100F. Tag Closed Tester, and oils burned in a cotton or woolwick burner. Fuel oils in common use fall into one of four classes (not here specified). Tar, Pitch: These terms shall not be applied to petroleum products. Petroleum Lubricating Grease: A combination of a petroleum product and a soap or a mixture of soaps, suitable for certain types of lubrication. Oil-Shale: A compact rock of sedimentary ori gin, with an ash content of more than 33% and containing organic matter that yields oil when destructively distilled but not appreciably when extracted with ordinary solvents for petroleum. Enctne Distillate: A refined or unrefined pe troleum distillate similar to naphtha, but often of higher distillation range. Tops: The unrefined distillate obtained in top ping a crude petroleum. Gasoline: Motor, United States Government OTOR gasoline shall be of one grade only. Federal specifications for certain of these substances are abstracted as follows: Gasoline: Motor, U. S. Government6--This gaso line shall be of one grade only. It shall be vola tile hydrocarbon fuel free from water and sus pended matter, and shall be suitable for use as fuel in internal combustion engines. Distillation range--When the thermometer reads 75C. (167 F.) not less than 10% shall be evaporated. When the thermometer reads 200C. (392 F.) not less than 90% shall be evaporated. When the ther mometer reads 140C. (284F.) not less than 50% shall be evaporated. The vapor pressure at 37.8C. (100F.) shall not exceed 12 pounds per square inch. The vapor pressure shall not exceed eight. pounds per square inch in tropical countries:, in termediate pressures in warm weather. Used as fuel for automobile, tractor, motor boat, and "sim ilar engines. Motor-Fuel V7--Motor-Fuel V shall be of but one grade--a highly volatile hydrocarbon liquid. When the thermometer reads 70C. (158F.) not less than 10% shall be evaporated; at 125C. (257 F.) not less than 50% shall be evaporated; at 180C. (356F.) not less than 90% shall be evapor ated. The vapor pressure at 37.8C. (100F.) shall not exceed 10 pounds per square inch. This speci fication covers a grade of motor fuel which is suit able for ambulances, fire engines, emergency ve hicles, military and naval equipment, and for oth er equipment under adverse conditions 'of starting and acceleration. Ether: Petroleum8--Petroleum ether shall be of two grades, A and B, respectively. Grade A should be composed solely of low boiling hydrocarbon distillates. It shall distill completely between 30 and 80C. (86 and 176F.). Grade B shall distill completely between 30 and 65C. (86 and 149 F.). Neither grade to contain benzene hydrocar bons. Thinner: Paint, Volatile Mineral Spirits9--This specification covers that grade of petroleum distil late known as "mineral spirits," or "petroleum spirits" for use in paint. Distillate below 130C. (266F.) shall not exceed 5%. Distillate below (230C. (446F.) shall not be less than 97%. It is frequently used in place of turpentine in thinning oil paints. Thinner: Paint (for) Semipaste Paints10--This specification covers one grade of composite vehicle which contains, in one liquid, drying oil, drier, and volatile thinner. When mixed in any proportion with pure raw linseed oil (also specified), the re sulting mixture shall be clear and shall show no separation of precipitation on standing 18 hours. Non-volatile matter not less than 50% by weight. Such preparations are sometimes called "thinning mixtures for paint," "japan oil," "paint oil," "lin seed oil substitute," etc. Drier: Paint, Liquidu--Type I, for general use, containing lead. Type II, for special lead-free paint, containing no lead. This specification ap plies both to straight oil drier, that is, material free from resins or "gums," and to "japan drier," that is, material containing resins or "gums." Drier containing lead is to be preferred for gen eral use. SERIES I--Leading case: White, male, Ameri can, aged 48 (1923), married, two children (none dead), painter by trade. Parental history negative. Patient was the oldest of six children, viz., four brothers and two sisters. Only the his tory of two brothers, who were also painters, is significant and will be referred to below. Patient passed employer's entrance examina tion February, 1919, for job in painting depart ment of automobile assembly plant. His work was to take off fenders and small parts from traveling chain which had carried them through a tank of black enamel (specifications: Asphaltum 16-17%, linseed oil 22-24%, lead oleate drier 1-3%, petro leum distillate 62%). An analysis by the Labora tories of the Ohio Health Department showed the petroleum distillate or "mineral spirits." used both as a cleaning fluid (degreaser) and enamel thin ner, to be composed of "hydrocarbons similar to gasoline, .95%. by volume distilling below 203C., the residue being heavy mineral oil"12. (See 12 Circ. No. 98, U. S. Bureau of Standards, Federal Specifications No. 16, For Volatile Mineral Spirits for Thinning Paints, revised January 2, 1923). Five men were employed in work similar to that of patient. A mechanical ventilation system was in operation but did not obviate strong odor of dis tillates. The work quarters were rather small, while the amount of output was large and con stant. Soon after first employment the patient was put to cleaning small parts in a tank of the cleaning fluid. After some months he was returned to the enameling process again. He was next put into the finishing room for one and one-half years, where vapors of the same distillate were much worse be cause the temperature was kept from 98 to 104 F. The work-day was eight hours throughout, with a half-hour lunch period; frequent overtime up to four hours--six days per week. The patient often worked eight hours at a time with his hands and forearms in the cleaner or enamel fluid sev eral times a minute. He worked fairly steadily to April 26, 1922, when he was forced to quit, owing to ill-health. Early in the work (1919) he developed a series of boils, other employees being similarly affected. The chief symptoms while at work were: smart ing and running eyes, burning sensation in nose and throat, headache, dizziness, anorexia, nausea, sometimes vomiting, "naphtha jags," nervousness, prostration, muscular twitchings, loss of strength (it became difficult to lift parts weighing as little as 25 lbs.), and gradual loss of weight from 138 to 121 lbs. The patient's physician had known him for years, and attested to his previous good health, Series L Leading: Case--Left: Appearance at Aye 25--Right: Same: Appearance at Age 40 (Central figure); Weight 138 lbs. habits and steadiness. The patient visited the physician early in the above mentioned work, com plaining of "rheumatism" starting in the back. Some other findings (above listed) began to ap pear. Patient failed to respond to tonics, and one year after quitting work (i.e., in March, 1923) the physician reported: "He is little better--has lost his original vigor, slowed up, has an earnest desire to work and has tried several simple jobs but can't do it. He is mentally depressed and worried. Prognosis unfavorable." One of the patient's former foremen, who had gone into business for himself, gave the patient a job for a few days (March, 1923) painting automo biles, but found he could work no more than 15 to 20 minutes at a time, then he would stop and have to be reminded what to do. He was also too weak to work for more than a few minutes at a time and was uncertain of himself. He stated he could not make his hands go, his back got too weak to sup port him upright, he "got so tired had to give up." When I first saw the patient, March 26, 1923, he appeared listless, fagged out--a thin, rather pale man. He added to the above coterie of symptoms as follows: stiffness and pain in back, cold sensa tions, attacks of diplopia, hearing poor and be coming worse, cough with much sputum (several recent sputum examinations reported "negative"), hot flashes, pains about heart, ankles swollen at times (but not at present). His weight was then 121 lbs., temperature 98F., pulse 104, regular, equal both wrists; hemoglobin 95%, Wassermann test negative. Four months after this time the pa tient was allowed state compensation at total dis ability for 44 weeks (already lost), for occupa tional naphtha poisoning. After History: On July 22, 1923, patient took up a part-time job as an assembler in a motor fire- truck factory, where he was not exposed to paints in any way. He was carried by state compensa tion on a wage impairment basis for the next five and one-half years, or until Aug. 6, 1928. During this time his new employer permitted him to work as he felt able, which was usually about three to four days per week with, often, incomplete days. The Commission's physician reported on Aug. 27, 1928: "He gets weak spells, and has to lay off and loses much time. He is small and appears stupid and dull. He weighs 118 lbs. He is mentally in competent and unstable, and is still partially dis abled." He continued to work part time until De cember 31,1929, when he was laid off, and has not worked since except about the house. Present Findings: I examined patient August 24, 1933, at his home in an outlying suburban dis trict. He is now approaching 60 years of age, height 5 ft. 7 in., weight 107 lbs. (with light clothing), ap pearance very thin, but appears agile; gait slow, measured; mentally fairly alert, well poised; some what hard of hearing. Patient has been a home owner; used alcohol sparingly, never drunk; smoked cigarettes more or less since 25 years of age; used patent "tonics" off and on. No note worthy illness prior to his exposure above de scribed. Present Complaints: Has frequent chilly sen sations, usually when in bed; more or less palpita tion with pain in heart region; had a syncopal at tack about two months ago which however was the first for years; becomes blinded on stooping over or on sudden rapid movement. Has a per sistent cough and raises a good deal of morning sputum (has never suffered from hay fever or functional asthma). Has more or less headache with dizziness; likewise, tinnitis, especially at night. Weight has been as low as 104 lbs., with Same: Appearance at Axe 59, or 10 Tears after Last Exposure; Weight 107 lbs.; Picture taken Au gust 24, 1933 corresponding weakness and loss of strength. No particular indigestion, but has some nausea with gurgling in bowels and pains in lower abdomen. Suffers from constipation with hemorrhoids, al though without bleeding. Nocturia once per night for the last three years. Sleep is disturbed and not refreshing. Able to work about the house and yard and to use street cars alone. Present Physical Findings: Hair thin. Vision 20/30th each eye (wears bi-focals), pinguecula and pterygium right eye, conjunctivae slightly yellowish; senile puffiness of both lower lids. Hearing, right ear, nearly gone; left ear impaired; drum reflexes normal. Several molar teeth miss ing; one pre-molar carious; lower incisors show a blue discoloration (on teeth, not in gums), some tartar, also breath odor; gums moderately re tracted, somewhat purple in color; possible focal pyorrhea, but no tenderness or bleeding. Tongue rather coated. Pharnyx somewhat congested. Temperatime 99.4 (outdoor temperature 88). Neck, thin, and shows moderate carotid pulsations. The chest is emaciated, the skin showing several scattered red moles and prominence of veins below the left breast. Lung examination reveals nothing of significance; heart is rapid; the patient becomes dizzy and says he is made blind by holding his breath (by test) for 20 seconds. The abdomen is scaphoid but presents no abnormalities. Each in guinal ring admits one finger tip. The skin of the buttocks is quite scaly; old hemorrhoidal tags pres ent. The lower and upper extremities are less emaciated than the trunk. There are small super ficial varicose veins in the legs. Both hand grips (dynamometer test) low normal. There is slight ataxia. The pulse is 106, soft, compressible and equal in both radials. The blood pressure (seated), with out special exercise, is 123/82 in the right arm and 132/90 in the left arm. The patellar reflexes are normal, but the abdominal and cremastaric are absent; there are no abnormal reflexes. Urine negative. Blood findings show hemoglobin 90%. gross appearance and clotting time normal; differ ential count (%)--polymorphonuclears 70, small lymphocytes 15, large lymphocytes 12, transition- als 1, eosinophiles 1, basophiles 1. Sputum exam ination for tuberculosis negative. (a) The manOther Cases, Similar Exposure: whose place patient took (1919) had quit, so pa tient said, because of "stomach trouble"; he later died. A fellow employee died with pneumonia within two days after ceasing work; another, who was a large, well-developed man, is now (March, 1923) "skin and bones." During the three years and two months which patient worked here, there were five different foremen of the enameling divi sion, all of whom complained of symptoms similar to, but less marked than, the patient's. Two of these foremen, when seen, reported that men often got into "trances" while working. The workmen rarely stayed long, because of the health com plaints suffered and the ill-repute of the job as a health hazard,-but the pay was very good and on day-work basis. However, "work was speeded up to the limit." The plant manager (March, 1923) told the writer that this work was an acknowl edged health hazard, but that several experts had so far failed to solve it. However in May, 1923, a letter was received from the chief surgeon of the corporation stating that a new system for doing this work had been perfected which would "rem edy all occupational hazards now existing." (b) One of the patient's younger brothers (mar ried, three children), who was also a painter, worked for five years (1916-1921) at the same plant, but in the- color varnish division where va pors of turpentine and mineral spirits were the chief hazard (there being no material skin-wet ting by same). This man died in 1929 at the age of 54 years after being completely disabled for the last two years. His impaired health seemingly be gan with this exposure but was later contributed to by lead poisoning in another plant where he worked several years in the paint department, painting and sanding lead coats. His case was carried as one of total permanent disability due to "lead poisoning" by the Industrial Commission until his death, when further benefits were awarded his dependents. (c) In July, 1924, my attention was called to another case of exactly similar character to the leading case herewith in another employee of this same enameling process using petroleum naphtha as a cleaner and enamel thinner. Here the work man was exposed less to skin wetting, but had the added exposure of inhalation of spray. The work was carried on only at night in a rather small room which also contained the endless chain-dipping ap paratus as above described. The men were still ap plying the first coat by dipping the parts by hand in a tank of enamel at a temperature of 88-90F. The parts were next baked in an oven heated to 500F. Thereafter the parts were sprayed while still heated to 150-200F. This produced exces sive smoke and odor, chiefly due to the linseed oil and asphaltum content of the enamel. Despite a powerful system of artificial ventilation, this work man found it necessary to discard his mask because his glasses became so obscured that he could not see. The chief hazard again was the dipping of the right hand and forearm into the black enamel solution for one to three hours at a spell. The chief symptoms began with respiratory com plaints: coughing, spitting up of black chunks, and pains in the chest. There were attacks of dizzi ness, frontal headaches, occasional "jags" (which were common to all the men), loss of 15 pounds in weight and progressive weakness so that, al though he was transferred to lighter jobs, he had to quit because of loss of strength. When seen, this patient appeared somewhat anemic, with a yellowish tint; several sputum examinations were negative. He had considerable dyspnea but no rales. His temperature was normal. He com plained of dizziness and headache. His physician, who had known him for 30 years, vouched for his previous good health. Of the five men on the job, two had worked one year, one had worked two years, one had worked three years. The patient under investigation had worked one and one-half years. SERIES II--Leading case: White, male, Ameri can, aged 31 (1931), married, three children (none dead), shingle-stainer by trade. Family history negative (?). Patient's work consisted in submerging wood shingles up and down by hand in a tank of shingle stain, varying as to pigments* used (never in dust form), but (of interest here) the vehicle consist ing of petroleum naphtha one part, and kerosene two parts. In the case of darker colored stains, creosote might be added in the proportion of 1% quarts to 10 gallons of total mixture (therefore about 4%). The hands and arms, nearly to the el bows, were soaked in the mixture, and the vapors arising were directly inhaled. While the building was of brick construction and the workroom was large, there was no artificial ventilation of any sort, no hoods or other protection. Even room ventilation was by windows and a door on one side only. There was no heating in the winter time. Four or five men worked at this process on * Zinc oxide, tamp black, burnt umber, chromium oxide; lithophone; also linseed oil might be added. a piecework basis. Three or four others applied pensation reduced by one-third to November 27, stain, similarly prepared, by a brush method. The 1932. work hours varied from six to 14 per day, depend November 18, 1932: Patient seen by internist ing on orders to be filled. sent by the Commission who reported as follows: Patient worked at trade in present plant for 11 his arms and legs give out; occasional attacks of months when about August 15, 1931, he began to dizziness; he feels peculiar at times; symptoms are suffer from diarrhea, prickling of the skin, numb in the main subjective; suggest that patient be ness attacks, vertigo, gastric disturbances, weak placed on reduced compensation and urged to se ness and loss of weight. He continued to work un cure suitable employment. Accordingly, compen til October 17,1931, when he was compelled to quit sation was reduced to $5.00 per week. The patient because of ill-health, and called in a physician who still continued to insist on his inability to work, al recorded on that date: Pulse, 110, temperature though he admitted his condition was much im 100F., respiration increased, paresthesia, lumbar proved. Reason: syncopal attacks upon all work pain, restlessness, insomnia, diarrhea, gastric up efforts. set, cardiac disturbances and headache. His color April 18,1933: Patient called at my office, when was rather sallow. Urine examination negative. I found his weight to be 160 pounds. He was appar The patient told him that soon after he started ently normal in appearance, but comDlaining of work he began to have irritation and rashes on night sweats two or three time a week, faintness his hands and arms, also inflammation of the eyes, attacks, knees giving out, coughing at night but followed after about three months with headaches, no expectoration, soreness in chest and over liver sore throat, bleeding gums and diarrhea attacks. region, dyspneic attacks, nightmare, headaches His fingers, hands, and forearms would get numb. "all the time," aching in legs, could not stay in one He had lost weight from about 170 to 130 lbs. He position any length of time, weight varying had enjoyed good health previous to the present from 142 to 160 pounds within three to four weeks' employment. He reported that other employees at time, bowels varying between constipation and di the same plant were similarly annoyed. His em arrhea, nocturia three or more times nightly, eas ployer at this time claimed that the patient was ily irritated, etc. Patient considered that he was at really suffering from an attack of flu; there was, his best now. Physical examination revealed slight however, no epidemic of same in the vicinity at the cough at intervals, heart rates 120 per nr uite in time. creased to 144 on moderate exercise, retu ning to I first saw the patient on October 21, 1931, at 112 after three minutes, respirations 28-30, oreath- which time he did not apear sick. However, his holding 25 seconds, sensitiveness of abdor en, pa pulse was 92, temperature 99F., respiration-rate tellar reflexes absent, blood pressure befo:e exer normal. He had a slight cough, tongue coated, cise 124/80, after exercise 118/78; mental condition mouth condition in general good, throat injected calm. A very complete laboratory investigation (possibly from cigarettes), tonsils negative. There was ordered, which was carried out at the Uni was complete absence of knee jerks, but the pu versity Hospital. This included electro-cardio pillary reflexes were normal. He complained of graph, blood findings, basal metabolism, mine, and pain in the abdomen with cramps at intervals al x-ray of the chest. These were reported April 23, though local examination was negative. His wife 1933, as entirely negative except that the heart said that he slept little, and kept talking and rate was 90, regular. shouting in his sleep. He had little appetite, was In the meantime I examined the patient at his very nervous and worried, particularly about los residence, where he was working a small home ing time from work. Hemoglobin 90% and differ garden on April 20, 1933. Noted an occasional un ential count (%): polymorphonuclears 66, lymph productive cough, blood pressure (after rest 116/ ocytes 20. mononuclears 7, eosinophiles 6, baso- 70, pulse 104, breath-holding 23-24 seconds. He philes 1. No stippling. complained of weakness in the knees and blind October 28,1931: Condition the same. Temper spells on work effort. ature 99o-10(FF. April 27,1933: Patient called at my office. Pulse October 29, 1931: Patient developed marked 110 (after rest). He was still drawing $5.00 per heart irregularity, which stopped promptly upon week compensation, and wanted to go to work if administration of digitalis. That same afternoon I he could but feared he could not. Despite his com called at the patient's residence and found him im plaints and rapid pulse, I advised outdoor work proved but still complaining of weakness, some without heavy lifting or prolonged strain, cessa coughing, occasional pain in the abdomen, sharp tion of compensation, family care by Red Cross, pains in the liver region, an indifferent appetite, and tried to convince him of the necessity of self- with two or three nights of fair sleep followed by confidence. I considered him a complete neura a night of restlessness. No headache remained, sthenic at the time--left that way, however, by bowels normal. Pulse was 88, temperature 97.4, the effects of prolonged absorption of petroleum respiration normal, circulation in feet poor, ten distillates. derness over gall bladder region, tongue badly October 3, 1933: Patient has been slumping for coated, skin slightly jaundiced. the past several weeks. His physician sent him to During November, 1931, an internist was called a radiologist who, September 20, 1933, reports: in, who reported a continuance of the same symp "Considerable fine infiltration of both lungs which toms and physical findings. Laboratory tests looks mighty suspicious of beginning tuberculosis." proved essentially negative. His diagnosis was Patient has lost some weight, complains of numb guardedly given as chronic naphtha poisoning. ness and prickling sensations in hands and arms, February 2, 1932: Patient still disabled, general general skin sensitiveness, rather marked short weakness, no material increase in weight. State ness of breath, chilly sensations with night sweats, compensation had been allowed. considerable cough with some expectoration (re July 3, 1932: Patient has slowly improved. Has peatedly reported negative for tuberculosis), been caried as a total disability to this date. Com weakness in the knees in attempting fairly long walks, so that had to give up an attempt at squirrel hunting. Other Cases, Same Exposure: (a) The above case could not stand by itself as an occupational disease. It is particularly important, however, because it brought out the following: The patient's father-in-law, aged 49 (1929), formerly a farmer and carpenter in good health, worked for six months at the same plant as a shingle-stainer when he quit, so he claimed, because of ill-health which he laid to the absorption and inhalation of the staining solution. He was working in the darker stains containing a low percentage of creo sote in the naphtha-kerosene mixture. His symp toms were constant skin itching, occasional rashes and nervousness. No bowel disturbances. After some months he again went to work in the same plant (1930), when he quit after two months be cause of the more marked return of the same symptoms. During this period he worked on lightcolored stain containing no creosote. After a few weeks' lay-off he again tried the same job but worked only one and one-half days when he quit because of marked dermatitis. This disappeared in the main, very promptly, but was followed by gen eralized pruritis and frequent recurrence of a low macular dermatitis on the arms. I saw this patient first October 18, 1931, when he was still complaining of the same symptoms, although he appeared normal. He had been put on State compensation. From superficial observa tion I discovered the case as one of malingering or neurasthenia. This man again called on me, September 26,1933, having, in the meantime, made the rounds of eight or 10 physicians, including several specialists. He had drawn a small amount of State compensation to September 3, 1932, when this was stopped. His symptoms were still typically neurasthenic, with a great deal of complaint of generalized pruritis and restlessness. (b) Son of the above case (a), aged 27 (1930), single. Worked at the same place for one and one-half years, when he quit because of general ill-health, principally insomnia, nervousness, pru ritis, parethesias and occasional skin rash. No bowel disturbance. While the pay had been good he had preferred to take up insurance work at which he was now employed. He had not filed claim for compensation. I next saw this young man on January 27, 1933, when he called upon me, stating that he had been employed in the same plant for the past four and one-half months but that he had just quit because he was suffering from sleeplessness, chronic head ache, pain in the eyes, loss of appetite, constipation, "crawly" skin, and nervousness. He was next em ployed for a time by the City Relief Division. On September 26,1933, he was still complaining of the same symptoms, and claimed loss of weight from 165 to 145 pounds. He is now under State compen sation. (c) Another employee, aged 27 (October, 1931), married, no children, still at work as a brusher, was complaining of the usual protean symptoms. He continued to work until December 23, 1931. when he quit because of symptoms described by still another physician as "weakness, gastric cramps, eye strain, vertigo, insomnia, constant headache, cramps in legs, dental caries, very nerv ous, and anorexia." On August 1, 1933, this patient had not worked since quitting his job December 23, 1931. He had been seen by several physicians and an internist employed by the Commission. He has been carried on partial State compensation to date. He claimed loss of weight from 155 to 134 pounds. He did not appear materially sick on first observation, but he had the usual complex of neurasthenic symptoms, which in themselves fluctuate greatly from week to week. "Whenever he thinks he is well, he suf fers a prompt relapse." It was noted that his hand was very moist in shaking hands. On this date, August 1, 1933, he was seen by another internist to whom he was referred by the Series IL (Case C); 22 Months after Qnijtini Job; Still Disabled; Picture taken October 2, 1933 Industrial Commission. I am indebted to this in ternist for the following additional report: Age 29; cold, sweaty hands and feet; reflexes moder ately exaggerated; diarrhea two to four times daily; tender abdomen; potential inguinal hernia: sensory system tests normal; gums recessed and tonsils badly infected, throat injected, teeth in fair condition; urine negative (two specimens); Wassermann negative; blood pressure 112/72; hemoglobin 80%, red cells 4,100,000, white cells 6.200, differential count: Polys 54, small lymphs 42, large lmphs 2, mononuclears 2. Heart and lungs negative. Reflex emptying of stomach about normal. His physician reported his findings to the In dustrial Commission, August 14, 1933, as: gastric cramp (not from indigestion), anorexia, conjunc tivitis, easily exhausted, weak, lost weight, in somnia, constant headache, dental caries (low resistance, gums easily infected), diarrhea at va rious times, secondary anemia, hands and feet per spire. vertigo, pruritis. On September 12, 1933, the same symptoms prevailed, as well as dizzy spells; "patient is becoming cachectic." On this same date his physician reported the findings of many blood cells in the urine which, he said, had not been a constant finding. And on the same date, an outside laboratory reported hemoglobin 68%, red cells 3,705,000, white cells 11,700, differential count (%): polys 70, small lymphs 20, large lymphs 6, mononuclears 1. October 2, 1933: I saw patient at his residence on this date. He was seated on the front porch and apparently in no immediate distress. He felt that he was improving, but stated he could maintain no continued effort at anything. The palms of his hands were very moist. His complaints were: chilly sensations with sweats, cardiac pains, and Vol. 5, No. 2 UNJ-UOXVLrtJj A Ul/c %f%t pains in the back and legs, pruritis, continued headaches with dizziness, some recent painfulness of urination, about one good night's sleep per week. His appetite varied greatly. He stated that he had worked about two years at brushing the stain on shingles, not dipping shingles, so that this ex posure had been chiefly to the inhalation of vapors. His work varied from six to 14 hours per day. His onset symptoms had been headache, dyspepsia, pains in the calves of the legs, general pruritis. (d) September 26, 1933: Another employee, brother to (b) above, aged (about) 33, has worked at this plant for several years, but has been in the shingle staining process for only the past year. He presents the same complaints, but has less expos ure because work has been more irregular. He is still so employed. (e) Another employee, aged about 50, was simi larly disabled in 1930, after about six months' employment. He was given State compensation, and left the state. eral tired feeling. Laid off January 1 to 3, 1932, with acute throat, "different from any she had ever had." Returned to work January 4; remained to January 7, when severe headache, weakness, nervousness, involuntary muscular twitching and near-collapse compelled cessation from work. Four physicians who saw her, one until about February 7, 1932, were told of gasoline or naphtha exposure but hesitated to diagnose the case. The consensus SERIES III -- Leading case: Female, aged 20 (summer, 1931), single, born in Ohio, of na tive parents. Height 66 inches, weight 158 lbs. Completed second year high school. "Always pre viously healthy." Stock-clerk in art works about two years, then assigned, with five other girls, the task of cleaning metal trays with petroleum naph Same: at Age 21; Picture taken August 27, 1933, or Five Months after Recovery Began; Health Appar tha to free same of dirt and grease preparatory to ently Restored; Weight 140 lbs. enameling. The trays were dipped in a can con taining several gallons of the naphtha where the of medical opinion seemed to be that the girl had patient scrubbed them with a cloth. She was thus developed an acute psychosis--possibly post-infec exposed to skin absorption and inhalation of va- tious (following sore throat). The family physi cian reported that she lost her mental faculties after a few days and remained so until he was dis missed from case (February 7). Her parents then removed her to a "rational living" rest home in a neighboring city because, they said, medical opinion was that rest and proper food offered the only hope in the case. Here she was without medical care. She grew worse, but remained at the place until about May 1, 1932, when she was brought back home and another physician saw her. He found her greatly emaci ated, weight 92 lbs., with severe headaches, insom nia, extreme nervousness, mentality "somewhat affected." She also complained of sore mouth and throat; she had continual spitting of slimy saliva with occasional vomiting of large quantities of mucus. The bowels were very loose. She had involuntaries when she stood up. She was unable to eat or drink while standing or to take nourish ment except while lying down; anorexia was marked. Some temperature at times. Urinary Series TTI. Leading- Case--Left: at Age 19, Before Exposure, Summer 1931; Weight 158 lbs.--Right: Same: at Age 20, Four Months after Ceasing Ex suppression two or three days at a time. June 25, 1932: A record on an official form re ported: sore throat, and mouth, headache, no con posure of Five Weeks, November-December, 1931; Weight 92 lbs.; Picture taken May, 1932. (Patient lost about 25 lbs. more weight in the course of the next four months, or down to 67 lbs.) trol of muscles, complete loss of appetite; sore hands. July 18, 1932: Her physician reported (in addi tion): constant working of phlegm from stom pors. Patient was the only "washer," the other ach. vomiting, marked loss of weight. girls doing the drying. Patient worked eight and August 2, 1932: Her physician reported: spit one-half hours daily, Saturday five hours; over ting and vomiting of mucus continues; mouth and time to 7:30 P.M. "quite a number of evenings." throat have exceedingly foamy spittle. (The Began such work the latter part of November, mother later stated that long tough strings, or 1931. Work was in closed room without ventila bands, of mucus were pulled out of mouth and tion. Total exposure, about five weeks. throat "every little while" by wrapping same on Symptoms began with eyes smarting, throat a cloth). Diarrheic stools, three to eight times a burning, drowsiness, loss of appetite. Noticed head day, often involuntary. Choreiform movements ache almost from first day, also nausea and gen at times; strong sedatives to produce sleep; must Uc c<ucu lor uKe a ctald; has recently had large June 15, 1933, where she is now employed except gatherings of pus on face and hands which are now that the NRA has reduced hours of work to eight peeling off with large patches of skin. Patient's per day and maximum of 40 hours per week. She weight 85 lbs. sews wristbands on cotton gloves, using an electric September 5, 1932: Diarrhea, six to eight invol sewing machine, piece-work. untaries daily. Eating better, but weight decreas Now feels entirely normal. Weight 140 lbs. (was ing; can't be moved for trip to hospital. 142 lbs. a few weeks ago). Only remaining com On September 15,1932,1 examined patient at her plaints: skin of hands sensitive; feet swell at home, securing additional findings as follows: times; six teeth have had to be filled, while a low- Family History: The patient was the older of grade abscess about a lower right molar has been two children--the other a brother of 17, living and lanced three times and is still under observation. well. Father and mother living and well. Father's Teeth, however, appear excellent, none missing. father died at 50 years (typhoid fever); father's Further examination shows tonsils more or less mother living at 80 years. Mother's parents both visible with slight anterior cervical adenitis (no living and well. tenderness). Lungs, heart, abdomen negative. Past Illness: Usual children's diseases without Patellar reflexes slightly exaggerated. Pulse 68, complications. Had pneumonia of moderate sever regular and equal in both wrists; normal response ity when 7 to 10 years of age. Always well, and to (light) exercise. Hand grips, breath-holding in robust health otherwise. and other strength tests normal. Blood pressure: Present Illness: Menstruation stopped Decem right arm 112/72; left arm 110/78. Hemoglobin ber, 1931; appeared only once or twice to date; 100%. Blood smears show reds and whites normal. Wassermann (and associated tests) negative; in Differential count (%): polymorphonuclears 50, recent past, unable to talk for weeks or to sign large and small lymphocytes 41, large monocytes her mark to official papers. Hair came out mark 6, eosinophies 1, basophiles 2; clotting time normal. edly. Diarrhea, which began July 4, 1932, is now Urine negative. Mentality tests entirely negative. much better; abdomen formally tender; hands Similar Cases, Same Exposure: (a) The five burned. other girls working with patient during her five Present Condition: In bed, greatly emaciated, weeks of naphtha exposure also complained of weight about 70 lbs. (it decreased to about 65 lbs. symptoms similar to patient, but not so marked. in the next few weeks). Skin dry, shriveled; heal They did not have their hands and forearms wet ing scars of recent infections on face, hands, and in the naphtha. Their task was to wipe, arrange left shin. Answers questions in monosyllables, and stack up the trays after patient scrubbed them mentally semi-stuporous. Complains that feet in the naphtha. They were also not directly over bum, but are not tender; hands bum only slightly. the can of cleaning naphtha, and evidently did not Headache all the time. breathe the vapors in equal concentration, but pa Scalp and hair normal; desquamation on hands tient said the whole room smelled strongly of the and neck. Pupils somewhat dilated (eyes not tested vapors of naphtha. for vision); coular reflexes normal; lids pale. Ears, (b) A young man, aged 19, who was put on to mastoids and nose negative. Lips pale. Teeth take the patient's place, when she was forced to show some caries with marked tartar deposit (had quit (January 7, 1931), worked for two weeks, fine teeth before present illness); some dental in when he experienced similar symptoms which be lay noted. Gums somewhat retracted, some pyor came so marked that he was compelled to give up rhea. Tongue coated, fissured, slightly tremulous. the work at the end of that time. He was disabled Tonsils somewhat enlarged, but not inflamed. for about two months, but was up and around Pharnyx somewhat injected; voice husky (only most of this time during which, according to wit able to talk for past six weeks). Neck negative nesses, he frequently acted and talked as though (except emaciation and skin desquamation). he were drunk. He eventually recovered and re Chest flat, spices sunken; there is great emaci turned to work at another job in the same factory. ation of thoracic wall; also limited expansion- The job in question--washing metal trays in naph breath sounds barely audible; breasts appear com tha--was discontinued when this young man be pletely atrophied. Heart rapid, normal otherwise. came disabled. Abdomen and pelvis scaphoid; normal otherwise. SKidneys now functioning normally (several urine examinations reported negative). Slight inguinal adenitis. Rectum somewhat prolapsed; old tags ERIES IV--Significant Cases: 1. This case has been referred to me by Dr. Ira S. Wile, New York City. Male, white, American, aged 26 of hemorrhoids; healing bed score scar on right (1933), single, weight normally 148, height 5 ft. 10 buttock. in., no previous illnesses save grippe (tonsils were Lower extremities greatly emaciated; arches removed in 1911), no accidents, habits normal, high but some foot-drop (disuse). Hands, wrists family history negative. and fingers show scaling with redness; nails nega Employed four years in an oil refinery, where tive. Radial pulses equal, rate 120. was subjected to distillates escaping from petro Reflexes: patellar exaggerated; balance nega leum stills, more exposure last two years. The pe tive or absent. troleum stills were under cover and the patient March 16,1933: Her physician reported: skin on was busied in a supervising capacity, being called entire body, especially hands to elbows, still very to "trouble" points where the distillates were na dry and scaly; mental condition still impoverished. turally more prevalent. Once, when transferred Later History (from patient and parents), Aug. to another place, there was more than the usual 27, 1933: Began to mend rapidly in March, 1933. exposure over a period of a few days (followed Appetite became voracious, strength and weight by breathing difficulty and substemal pains). Ap increased rapidly, was able to do light work about parently some other employees had mild' symp house in April. Went to work, nine hours daily toms of poisoning, which had been recognized and (50 hours per week), in a glove factory about no doubt overlooked in a few instances of men who felt incapable of continuing the work. No other workers, however, developed a symptoma tology as complete as the patient's. Symptoms began about the beginning of the sec ond year of employment arid involved lethargy, fatiguability, some embarrassment of respiration, interference with gait, some loss of attention, in terest and capacity for prolonged mental applica tion, and later muscular twitchings. There was some throat irritation, along with enlargement of glands at various times. The case went unrecog nized by physicians for more than a year. In the spring of 1933 this patient was subjected to appendectomy because of tenderness in ab domen. Later he was referred to a neurologist who, after a thorough examination, reported no organic causes for his condition. Among the features re ported by the neurologist (June 1, 1933) were re current attacks of pain in the left shoulder and neck and. later, extending to the right side. After getting up from the appendectomy, which was performed under spinal anesthesia, it was noted that his left calf muscles were smaller than the right. However, there was no change in the ankle jerk on that side and the motor power of that group of muscles was perfectly normal, from which it was concluded that this condition was lo cal in the muscle itself. Extensive laboratory ex aminations proved negative. The red cell count was: R.B.C. 5,200.000; W.B.C. 7,900; hemoglobin 90%; platelets 240,000; polynuclear staff 2%; poly nuclear segment 61%; eosinophiles 1%; lympho cytes 30%; monocytes 5%. The metabolic rate was minus 16 on June 22,1933, at which time his weight had increased four lbs. from a previous loss of about 20 pounds in less than two years. At the height of the affliction (April and May, 1933) patient's weight had fallen from 148 to 132 pounds, but he was apparently in good health, al though thin appearing. The physical findings of significance were: occasional cough accompanied with pain and rarely a little red tinged expectora tion; physical examination of chest negative (no x-rays taken). Tenderness over the appendix later resulted in operation as above stated. There was complaint of difficulty in walking, with perhaps tendency to steppage gait. Basal metabolism was minus 24. later minus 16. There had been no skin involvement at any time. The patient's complaints were, very occasionally, slight febrile disturbances (T 99.2 mouth), palpitation on slight exertion, headache (at times quite severe), "having to drag self to work," some anorexia. Sleep was varied ac cording to work shift. September 14, 1933: Patient's general condition improved, weight 140 lbs. This case is of interest because of general re semblance in its principal features to the group cases reported elsewhere in this paper. By itself, and unassociated with its history of industrial ex posure to petroleum distillates, it would be entire ly anomalous. It will be watched with interest. Is there a definite relationship? Case 2. White, male, aged 27, American, mar ried, rubber worker, engaged in preparing dry rubber stock with benzine, from 1927 to August, 1932. Had previously worked in another rubber company (occupation unspecified). Noticeable symptoms appeared August 12,1932, with bleeding from nose and gums, headache, dizziness, numb ness of hands and feet, weakness, loss of weight, loss of appetite, nausea, dryness of throat and loose teeth. Anemia and weak pulse were also noted. The doctor reported that the teeth became loose with occasional bleeding as far as six months pre viously and that stiffness of joints had been noted in the interim. Laboratory tests were negative for syphilis and tuberculosis. August 19, 1932: Patient quit work. Up to about one year previous he had "used a lot of benzine" in swabbing bands. September 27, 1932: Employer reported that the patient's exposure was only to high test gaso line and in no way to benzol. Also that he was not using such at present but it was used in the department in which he was employed. October 24, 1932: Hemoglobin 60%, red cells 3.760.000, color index 0.8, white cells 10,700. Differ ential count: polys. 75 (non-seg. 18, seg. 57, shift 1-3.2), small lymphs. 24, eosinophiles 1. November 14, 1932: The physician wrote that all the teeth had been x-rayed showing a necrotic process going on in the jaw bones, and that the teeth had become very loose and very brittle. Ap parently there was nothing other than benzine in his occupation to which he was exposed, and the question arose whether the persistent anemia was the cause of the mouth condition or vice versa. March 10, 1933: Is showing marked improve ment. Still has secondary anemia, epistaxis and asthenia April 27, 1933: Hemoglobin 75%, red cells 4,- 210.000, color index 0.9, white cells 12,200. . Differ ential count: polys. 76 (non-seg. 27, seg. 49 and shift 1.8), small lymphs. 22, large lymphs. 1, eosin ophiles 1. August 6,1933: Weakness, bleeding from gums, anemia, and dizziness. September 13, 1933: Nose bleed persists. Ner vousness, weakness, has lost weight from a claimed original 147 pounds to present 121 pounds. Anor exia, weakness, anemia, heart rapid and irregular. All of upper teeth and several of lower teeth have been extracted. In general appearance is a tall, thin individual who is an anemic in aspect. Case 3. White, female, aged 41, Polish, divorced, occupied for two months in "building" rubber tubes by moistening the ends of the tubes with a benzine soaked sponge prior to July 7, 1933. She had been previously employed at "flipping" tires, from 1931 to 1932. The chief symptoms and condi tions began July 7, 1933, with weakness, dizziness and tired feeling, dryness of nose and throat, dry cough, nervousness, loss of appetite, nausea, loss of weight, drowsiness, some bleeding from nose and gums. Anemia also was noted. There were no complicating diseases such as alcoholism, tuber culosis, syphilis, etc. An inquiry of the Medical Director of the plant where this woman worked disclosed that she was exposed to high test gasoline only. She handled a swab dampened with the gasoline for a period of about two seconds out of every minute. The gaso line was kept in a container with a perforated top, and the swab rested on this top when not in use. The fumes of the gasoline could not be detected by smell 15 inches from the perforated top. The room was very spacious, with windows opened on two sides. The operation had been in effect for five years with no other reported cases. Our laboratories analyzed a specimen of the gasoline used, with the following findings: Spe cific Gravity 0.705; Refractive Index 1.3980; Dis tillation 10% at 73C., and 95% at 131C--from _______ woo cuuoiucicu iu o a. mixture of hydrocarbon oils similar to naphtha." Case 4. White, female, aged 39, American, sin gle, occupied at "flipping" beads in a rubber tire factory--specifically taking wrinkles out of beads with benzine--for a period of about three years to July 24,1933. Prior to that she had been employed for three years in making paper boxes. Her symp toms came on gradually with weakness, dryness of nose and throat, dry cough, anorexia, nausea, vomiting, tired feeling, bleeding from nose and gums, nervousness, drowsiness, headache, dysp noea, and loss of weight. The physician noted an increased bleeding time. There were no compli cating diseases such as alcoholism, syphilis, tuber culosis, etc. A laboratory check-up on this case showed the exposure to be due to petroleum with distillation points indicative of gasoline. July 25, 1933: Hemoglobin 68%, red cells 4,- 040,000. white cells 8,900. Differential count: polys. 50, small lymphs. 28, transitionals 2, eosino- philes 20. Platelets 100,000. The doctor explained the eosinophilia by stating that the patient at that time had asthma. Subsequent blood findings were as follows: (a) August 31, 1933: Hemoglobin 83, red cells 4,200,000, white cells 12,900. Differential count: polys. 71, small lymphs. 24, large lymphs. 3, transitionals 2. (b) September 6, 1933: White cells 12,500. The patient ceased work about Aug ust 25, 1933. September 12, 1933: I saw the patient at her home in company with several physicians, includ ing her own physician. She was in no apparent distress and stated that she had ceased to* work because she felt too weak, that she had lost 30 pounds (although she now looked well-nourished and of proper weight for her height); she possibly appeared somewhat anemic. The gums looked normal. She fell down that morning and scuffed the skin below both knees while on a trip to a neighboring store. She did not remember having tripped or whether she slumped without apparent -reason. She stated that she was also nauseated, had little appetite, was nervous and drowsy, But could not sleep. She complained of nearly con stant headaches, and dizziness. She thought she was better now than she had been. Case 5. 'White, female, aged 20, occupied at washing parts of household appliances, in an elec trical manufacturing company, in naphtha to which her bare hands were exposed. The period of employment was one month. The room where patient worked was not provided with windows and had only one air duct. She had had no prior employment, and her previous health was report ed as good. Her symptoms began July 20, 1933, and consisted of dizziness, fainting, anorexia, loss of appetite and nausea. Her hands became red and swollen, and the skin came off over the entire surface. A marked injection of the pharyngo- mucosa was noted. There were no complicating diseases such as alcoholism, syphilis, tuberculosis, etc. The reporting physician stated that at about the time he saw this patient quite a number of other girls were carried out unconscious from the plant. The patient also showed conjunctivae red. We referred the situation to the local health officer, who reported, August 7,1933, that the girls in this department were cleaning off a tar-like sub stance from refrigeration units prior to final in spection. The process was carried out in a main room of the factory with a fair amount of ventila tion. There was a very noticeable saturation of the air with naphtha fumes on entering the quar ters, and no doubt on a very hot day with no out door breezes, such would become very disagree able. He was also informed by one of the em ployees that during the hot weather it was no un usual thing for as high as seven girls to be carried out, but that this disability apparently was only temporary, as most of them immediately returned to their positions. It is interesting to note that the company physician who saw the above case at the time of the skin eruption did not consider it a case of naphtha poisoning. Summary THREE series of cases of chronic poisoning with petroleum distillates, each representing two or more cases, and a group of six significant indi vidual cases, from as many different places of em ployment, are presented. 2. Periods of exposure have ranged from five weeks to three or four years before employmentdisability began. 3. Onset symptoms were pre-eminently subjec tive, also manifold -- chiefly complaints of head ache, dizziness, loss of appetite, dyspepsia, itching of the skin of the hands and arms, burning of the eyes, restlessness at nights with insomnia; pains in the back, legs and cardiac region; slight cough and shortness of breath, a feeling of weakness, and im pending ill-health. Intercurrent mouth and throat infections were common. 4. The typical picture associated with disability came on with a complaint of loss of weight, worry, a feeling of "slipping" in physical and mental well being, accompanied by a bizarre neurasthenic and psychasthenic symptomatology. The objective findings may be grouped as follows: (a) loss of weight from 10 to 60% over months of time with periods of partial recovery nearly to normal: (b) pulse rate increased, sometimes notably; (c) blood picture showing moderately severe secondary ane mia--hemoglobin 60 to 90%, red cells decreased 2035%. color index less than 1, slight leucocytosis-- 10,000 to 14,00 (secondary infection?) and trend toward eosinophilia in some cases; (d) skin irrita tion with tendency to rashes, furunculosis, local abscesses, etc., followed by a persistent if not per manent generalized pruritis; (e) mouth infection --especially tonsils and gums; (f) diarrhea, often persisting over weeks of time, sometimes alternat ing with constipation; (g) mental depression and even slowed mentality extending perhaps to semi stupor and complete disorientation; (h) muscular twitching and bodily tremors, slight ataxia. 5. Great variability of both subjective com plaints and objective findings occurred over pe riods of months and years. A chronic case invari ably gives the impression at first of malingering or extreme neurasthenia following upon mouth or throat infection (which is commonly a part of the history just before quitting work). 6. Great chronicity has followed the onset of actual disability. The duration of disability has appeared to be related to the period of exposure as (a) in one case, two weeks' exposure followed by two months' disability, (b) five weeks' expo sure followed by 15 months' disability; a year or more exposure followed by years of partial or complete disability. 7. There appears to be a question about com hicles; Marketing Petroleum; Modernizing Police plete recovery, although ability to do part time Methods; Small Plants; Handling Materials; Han work returned as a rule. Normal weight was never dling Traffic Violations; Aeronautical Problems; fully recovered. Safety Training; Hotels and Restaurants; Home 8. Actual skin-wetting, as by having the hands Safety; Accident Prevention Equipment; Mercan and forearms in petroleum distillate mixtures, has tile Problems; Public Employees; Training Drivers produced the most marked cases. Inhalation cases in the High Schools; Industrial Health; Child Ed have shown a lessened degree of symptoms and ucation; The Highway and The Pedestrian; First findings, but such warn of the necessity of forced Aid; Building Operation and Maintenance. or controlled ventilation. Of particular interest to industrial physicians 9. The loss in weight appears to affect chiefly and surgeons will be the session on Occupational the fatty tissues, since there are no actual paral Disease to be held Tuesday afternoon, March 3rd, yses. Likewise, the reflexes are retained (one at 2:15 p.m. The chairman is Dr. Donald B. Arm case excepted). It seems logical to assume that strong, Third Vice-President, Metropolitan Life the dissolving effect of the distillate upon the fat Insurance Company, New York City, and the fol of the central nervous system, the medullary lowing subjects will be presented: sheaths of peripheral nerves, the heart muscle, "Dust Inhalation: Its Effects upon the Respira liver, and elsewhere in the body is the explanation tory System," by Dr. Leroy U. Gardner, Director of of the disability. the Saranac Laboratory at Saranac Lake, N.Y.-- Conclusions discussion will be opened by Dr. A. J. Lanza. "Volatile Solvent Hazards," by Dr. Henry Field WORKERS should not be exposed to skin wet Smyth, Director Laboratory of Hygiene, Univer ting by petroleum distillates under any pro sity of Pennsylvania School of Medicine--discus longed condition of employment; they should aslsioon is to be opened by Dr. Leonard Greenburg. be protected from unusual or protracted inhalation "The Menace of Industrial Skin Disease," by of the vapors of such distillates. Dr. C. Guy Lane of Boston--discussion is to be [Editor's Note: A subsequent paper will be de opened by Dr. Samuel M. Peck, New York City. voted to the presentation of the details of addi Another session of interest will be what is called tional cases, and to a critical consideration of the "Occupational Disease Forum," of which it is ar literature related to the toxicity of solvents de ranged to have two sessions, one on Wednesday. rived from petroleum.] March 4, at 10 a.m., and the other on the same day Bibliography: 1.Spencer. Octavies M.: Pub. Health Repts., XXXVII. 38: 2291-2307 (September) 1922. 2. Hayhurst, Emery R.: Some Common Industrial Health Haz at 2:15 p.m. The chairman of this session is Lewis A. DeBlois, Consulting Engineer, New York City, and arrangements have been made to have a "panel" of various well informed persons who will ards. C. S. Bureau of Labor Statistics, Bull. 557:190-205 answer questions on different phases of occupa (April) 1933. 3.Rambousek, J.: Industrial Poisoning. Translated by Thomas M. I.egge. London, Edward Arnold, 34, 69, 268, 275 (1913). 4. Lehmans', K. B.: Fuhrt die technische Verwendung von tional disease problems. The panel selected is as follows: Ray Caverly, Vice-President, Fidelity & Casualty Co. of N.Y.; Warren A. Cook, Industrial Tetrachlor Kohlenstoff zu hygienischen Gefahren ? Zentralbl, Hygienist, Bureau of Occupational Diseases, Con f. Gevierbehyg. u. L'nfall., Berlin. 123-133 (May) 1930. 5.American Standard Association, American Tentative Stand ard (No. Z tl.28-1932), Tentative Definitions of Terras Re lating to Petroleum (A.S.T.M. Designation: D288-31T), necticut State Department of Health; Dr. R. R. Sayers, Medical Officer in charge of Industrial Hy giene and Sanitation, U. S. Public Health Service, Revised. 1931. Washington, D.C.; Dr: Leonard Greenburg, Exec 6.Federal Specifications Board: Gasoline: Motor, L'nited States Government (VV-G-101), July 21, 1931. /......................... : Motor-ruel V (VV-M->71), July 21. 1931. 8. ___ ________ : Ether; Petroleum (O-E-751), jan. 6, 1931. utive Director, Division of Industrial Hygiene, New York State Dept, of Labor, New York City; Leonard E. Hatch, Past-Member, Industrial Board. 9................ ........ : Thinner; Paint, Volatile Mineral Spirits New York Dept, of Labor; Dr. Wm. J. McConnell, (TT-T-291), March 31, 1931. 10......................... : Thinner; Paint, (For) Semipaste Paints (TT- T-271), March 31, 1931. 11. : Drier; Paint, Liquid (TT-D-651), Mar. 31, Asst. Medical Director, Metropolitan Life Insur ance Company, New York City; Leon S. Senior, General Manager, Compensation Insurance Rating 1931. Board, New York City; and Dr. William P. Yant, 12. T. S. Bureau of Standards, Circ. No. 98, Federal Specifica Supervising Engineer, Bureau of Mines Experi tions No. 16; For Volatile Mineral Spirits for Thinning Paints. Revised (January 2) 1923. See Gardner, Henry A., Physical and Chemical Examination of Paints, Varnishes, and Colors. Paint Mfg. Ass'n., Etc. 1922. ment Station, Pittsburgh, Pa. A session on Industrial Health will be held Thursday, March 5, at 10 a.m., Dr. C. H. Watson, Medical Director, American Telephone and Tele New York Safety Conference graph Company, and President,. National Safety Council, presiding. In this session, the following papers will be given: HE Seventh Annual Greater New York "Personal Experience in Health Betterment TSafety Conference will be held at the Hotel among Organized Groups," by Dr. William R. P. Astor, New York City, Tuesday, Wednesday, Emerson, Boston, Mass.; Thursday, March 3rd, 4th and 5th, 1936, under the"Physical Examination and Health Supervision auspices of the Metropolitan Chapter of the Amer as an Aid to Transfer and Promotion," by Dr. Wil ican Society of Safety Engineers, the Engineering liam A. Sawyer, Medical Director, Eastman Kodak Section of the National Safety Council and other Company, Rochester, N.Y.; and cooperating organizations. "Shall We Promote Industrial Health and Effi There will be sessions on Occupational Disease; ciency or Only Industrial Safety," by Dr. C-E. A. on the Safety Problem of Hospitals; Construction; Winslow, Prof, of Public Health, Yale School of Marine Hazards; Recreation; Organizing a Com Medicine, New Haven, Conn. munity Street Safety Program; Commercial Ve A First Aid session will also convene on Thurs- day, March 5, at 2:15 p.m., Mrs. William Kiimicutt of disability, except where the disability exists Draper, Chairman of Board of Directors, New York for more than 35 days. It is held that to make the Chapter, American Red Cross, presiding. Dr. Cary proposed change will invite fraud by encouraging T. Grayson, Chairman, American National Red malingering and will unduly burden the employer Cross, Washington, D.C., will present the subject with a mutiplicity of unjust claims. "Highway First Aid Stations." The subject of H"Practical First Aid," will be discussed by Dr. W. R. Redden, Director First Aid, New York Chap ter, American Red Cross. First aid demonstrations ENRY FORD has to provide an average of $9,007.37 capital to set up a job for each worker--$2,008.55 for land and buildings, $2,670.- will be given by teams from the Volunteer Fire 59 for machinery and tools, $664.78 for materials, Department, Westchester County--Boys from New and $3,663.45 "to maintain materials, power and York School for'the Deaf--Girls from the Bronx machine replacement." Of every dollar of Ford Vocation School, these demonstrations taking the Company income, 94 cents goes to its own and oth nature of the practical solution of three problems er employees. The company gets only 1% cents.4 by first aid teams composed of five persons. Music Twill be furnished by the Band of New York School for the Deaf. HE Westinghouse Relief Department, es tablished in 1907, was the outgrowth of an employees' sick benefit association formed some Comment Obvious! years before at the East Pittsburgh Works. Bene fits for lost time due to illness or to accident off SYPHILIS and gonorrhea cost employers mil lions of dollars a year in compensation relief and medical attention, especially in cases characterized by delayed convalescence and longed disability, plus the difficulties of labor turnover and temporary substitute employees, and the decreased efficiency or ven accidentproducing illness of the workmen. A locomotive engineer who was responsible for a bad wreck explained that one of his "spells" had come on him and he had run by a siding. Examination showed that he was suffering from dementia paralytica, softening of the brain due to syphilis, which might have been prevented had treat ment been given in time.1 duty, and death, are supported by employee con tributions. The company contributes the cost of administration and matches death benefit pay promdeerntths.isDpelaanthsginrcaetuiittsieisncpeapidtiobnytothtael company $477,864. un The organization at present includes 25,263 employees. Benefits, exclusive of the death benefits paid by the company, totaling $8,616,103 have been paid since 1907. Several subsidiaries not participating in the Relief Department carry health and accident cov erage to which employees contribute. During the period these several contracts have been in effect, disbursements under them have totaled approxi mately $390,000. With the establishment of the Relief Department came the need for a Company Physician to examine new applicants. This be BETWEEN 20 and 30C* of all employees of busi ness concerns are mildly crazy, Dr. Robert N. McMurray, head of the Chicago office of Psychological Corporation, told executives at tending the meeting of the American Manage ment Association at the Palmer house (February 6, 1936).2 "Among the rank and file." Dr. McMurray said, "these conditions manifest themselves by such symptoms as: seclusiveness or a tendency to too much day-dreaming; insubordination; chronic ill health without demonstrable organic basis; oversuspiciousness of associates and superiors; extreme defensiveness and oversensitivity to ginning became the foundation of a comprehen sive medical program. At present there are 25 thpWehhysileiciaitnsfuanncdtio2n0snpurrsimesarinilyWfeosrtitnhgehocuasree clinics. of em ployees who may be injured while at work, im provement in safety records is permitting the Medical Department to devote more of its at tention to a program of keeping employees fit. Several plants have gone an entire 12 months without a single lost-time accident; and today reliable statistics show that every Westinghouse plant has a safety record better than the average of all industrial plants in the state in which it is. located. ) W*Q4X-^K+4</..AT { jfrwnftaW* V * r f slights; easy fatiguability and overtendency to errors and accidents. "And," said Dr. McMurray, "the same tenden Sulphur flf l V* * cies are prevalent among executives at about the OIT and Schmidt direct attention to studies Vsame ratio as among employees." Dr. McMurray said that such disorders can be profitably studied and treated in an industrial conducted by Vita and Salmoiraghi.* In ani mal experiments on the action of colloidal sulphur in carbon monoxide poisoning, these in 1 1KMT1 concern, improving the efficiency of the employees vestigators were able to show that guinea pigs and general morale and reducing the tendency treated with sulphur survived carbon monoxide toward labor disputes. poisoning and recovered in a relatively short time, while the control animals died. When the animals THE Merchants' Association3 has re-affirmed at were exposed to fatal doses, those which had re Albany its past action in opposition to meas ceived prophylactic injections of sulphur survived ures of the character of the McCaffrey bitlhl ree times as long as those which had not. In amending the workmen's compensation law by spectroscopic studies on the detoxication mechan providing compensation from the date of dis ism in experimental carbon monoxide poisoning it ability. The present law provides that no com had been determined that at the time the signs of pensation shall be allowed for the first seven days 1. From "Venereal Disease--The Modem Plague," by Mason Giesu, in 4. B. C. Forbes, in Chicago Herald-Examiner, 5. "Note* on Fifty Yean of Industrial Relations," Wesringbouse Electric Hygeia, January, 1936. Sc Manufacturing Company--1886-1936. a. Chicago Daily Newt, February 6, 193d. *Munchen metL fFchnschr., Munich, 'August 30, 1935; abstr., J.AMJt., 3. Greater New York, February it, 1936. October 26, I9S5 poisoning disappear there appears a blood spec to provide compensation for injury or death, re trum that greatly resembles the spectrum of car gardless of fault; and in which an injured person bon oxysulphide in the blood. From this observa may seek damages by action at law, where there tion it was deduced that carbon oxysulphide is has been fault...." formed in the blood during carbon monoxide poi soning and that this is a detoxication process. It was thought that the injection of sulphur might Rejection Percentages accelerate the formation of carbon oxysulphide. EVERAL attempts have been made to estab The authors decided to investigate whether the prophylactic treatment with sulphur would pre vent the development of erythrocytosis, leukocy S lish averages as to the relative number of men applying for work in industry who are physically unfit. tosis and hyperglycemia, which frequently de These averages, however, have not been very velop in the course of carbon monoxide poisoning. satisfactory, except in purely local instances. The They studied the action of sulphur on acute as well most elaborate study was made by the National as on chronic cases. They found that the injection Industrial Conference Board in 1926. In its in of sulphur prevents the development of hypergly vestigation of the practice of physical examination cemia and erythrocytosis. The observation of Vita of workers in 255 plants, 20 reported that no em and Salmoiraghi that the animals treated with sul ployees were rejected on account of the physical phur have a greater resistance to carbon monoxide findings. These were large organizations with a poisoning could be corroborated in the majority of variety of occupations providing considerable op animals, but not in all. portunity for the placement of persons not so seri ously incapacitated as to be unable to carry on any Decision on Silicosis productive work. Rejections in other plants var ied from less than 1% to 50% or more; only one THE plaintiff sought damages* from the de fendant because of the contracting of silicos is while employed in the latter's factory. It was alleged that the disease was due to the fendant's failure to exercise reasonable care and to perform its statutory duties in the operation of its factory. Silicosis was not an "injury" or "personal in plant, however, reporting more than 50%. The higher percentage occurred in those plants en gaged in specialized work in which there were spe mdcieaelnhacozaurldds which only successfully physically perfect work avoid. The number of plants reporting on this question, together with the range of their rejection percentages,.was as follows: jury" compensable under the workmen's compen sation law, nor was it included among the occupa tional diseases named in such law as being com Plants Rejections 38 reported 0 to 2% 28 reported 2 to 3% Plants Rejections 5 reported 7 to 8% 5 reported 8 to 9% pensable. The workmen's compensation law, among other things, provided that the liability of an employer, prescribed by the statute, for injury or death, 18 reported 6 reported 29 reported 5 reported 3 to 4 to 5 to 6 to 4% 5% 6% 7% 2 reported 9 to 10% 23 reported 10 to 20% 3 reported 20 to 30% 2 reported 30 to 50% should be exclusive and in place of any other li The defects which were the most common causes ability whatsoever "on account of such injury or of rejection for employment were: tuberculosis, death!" venereal disease, hernia, heart disease, blindness The defendant's motion to dismiss the complaint in one eye, amputation of members, mental defi was denied in two lower courts, and the matter for ciency, defective hearing, varicocele and hydro decision was stated by the Court of Appeals as cele, epilepsy, contagious and infectious diseases, follows:1 ". . . . The question now arises whether kidney disease, rheumatism, arteriosclerosis, the right to compensation for disability or death chronic alcoholism and drug addiction, spinal trou resulting from accidental injury under the work ble, goiter. men's compensation law is the sole right which The exact percentage of rejections for hernia an employee now has against his employers for in alone is almost impossible of determination, and it jury suffered in the course of employment and ex is not much easier to find out the prevailing fig cludes and takes the place of all common law rem ures on hernia and herniotomies. An examination edies, not only for compensable injuries but for of 900 men ranging from 50 to 76 years of age em injuries entirely outside the scope of the act." ployed in one situation indicated that 21% of all This conclusion reached by the court was that examined had varicose veins, and 16% had hernia. the action could be brought. The following are This is probably the highest average found in any brief excerpts from the opinion: "___ Here, as we study. have said, the action is brought for an industrial Another company, in pre-examining 547 appli injury entirely outside the scope of the statute. cants for employment, identified various degree^ The statute provides that the statutory liability for of hernia in 55 of them, approximately 10%. Since injury or death shall be exclusive and in place of the average age of these people differed materially any other liability `on account of such injury or from the ages of the men examined in the other death.' situation mntioned, it is probable that comparisons "By no other construction, even though forced, would be worthless. In another instance, there can these words be found to mean that the right was a prevailing rate of hernia among applicants to compensation in case of certain injuries should for employment of about 4%%. This figure was be exclusive and in place of liability for other in based upon a comparatively small number of ex juries. ... There still is a field in which the statute aminations. fails to impose liability on the part of an employer, Later, when the number of examinations ex Public Health Reports, V. 50, No. 39, September 27, 1935. 1. Barrencotto v. Cocker Save Co., Inc., 194 N.E. 61. ceeded 120,000, indications of complete or incom plete hernia dropped to about 2%.