Gass lRCQ/„3 Gpiglit'N?_ C0EXRIGHT DEPOSHi HEALTH SERVICE IN INDUSTRY *£2> THE MACMILLAN COMPANY NEW YORK • BOSTON • CHICAGO • DALLAS ATLANTA • SAN FRANCISCO MACMILLAN & CO., Limited LONDON • BOMBAY • CALCUTTA MELBOURNE THE MACMILLAN CO. OP CANADA. Ltd. TORONTO A CENTRAL DISPENSARY Note Good Light, Unit Tables and Simplicity of Arrangement HEALTH SERVICE IN INDUSTRY >»\r BY W. IRVING CLARK, JR., M.D., F.A.C.S. Service Director, Norton Company, Worcester, Mass. Lecturer on Health Administration in Industry, Harvard Medical School; Assistant Surgeon, Memorial Hospital, Worcester, Mass. J?eto gorfe THE MACMILLAN COMPANY 1922 Printed in the United States of America Copyright, 1922 By THE MACMILLAN COMPANY Set up and electrotyped. Published April, 1922 2Jhe iHaksBibt $r?s8 E. E. DONNELLEY & SONS COMPANY CHICAGO §>",LAfio9660 W 19 1922 TO MY WIFE PREFACE The object of this book is to give to those having no actual experience in industrial medicine a short workable plan outlining the administration and methods of a health department in industry. The author has not attempted to discuss more than one approved method of doing a thing. He has not attempted to give methods of treatment except as examples. Everything suggested has been tried and is in use in some large factory. It is presupposed that the reader is either a doc- tor or the superintendent of a factory. Most of the text should be clear to either reader. As it is writ- ten for both doctor and layman, certain sections have been necessarily written with great simplicity. The book is based largely upon a course of lectures given by the author at Harvard Medical School. Vll CONTENTS CHAPTER PAGE I. Industry and Organization 1 II. The Medical Needs of a Small Factory ... 15 III. Organization of a Medical Department in a Large Factory 25 IV. Factory Dispensaries 37 V. The Industrial Physician and the Industrial Nurse 54 VI. The Physical Examination 69 VII. Accidents and Their Treatment 83 VIII. Sickness in the Factory 97 IX. Sanitation Ill X. Special Problems 127 XI. Cost of Medical Supervision 147 AND Economics of Industrial Hygiene IX HEALTH SERVICE IN INDUSTRY CHAPTEE I INDUSTKY AND OKGANIZATION Industry represents one of the large groups of gainful occupations. It numbers millions in its em- ploy. There are few parts of the country in which it does not exist, none to which its results are not vital. Its tendency is always toward growth and expan- sion, thus gathering to itself an increasingly large proportion of the population. The products which are the end result of industry are infinite in variety, and the methods of production are equally varied. Industry is made up of units called factories, very much as the body is made up of units called cells and just as the body grows and maintains its health when the cells are functioning normally, so the coun- try as a whole prospers when factories are running smoothly with maximum production. The country is dependent on industry and indus- try is dependent upon itself. This dependence has developed an interweaving network of interests between factories. The object of industry is to convert crude sub- stances into articles which can be used and to dis- pose of these articles by sale. A factory purchases 1 2 HEALTH SERVICE IN INDUSTRY crude substances and by a series of machine opera- tions produces a finished article. This process of conversion of crude substances into finished articles is known as production. The articles produced must be sold and the business managed and financed. From this simple analysis we see that in every fac- tory there are three great divisions, administration (which includes finance), production and sales. Each one of these divisions is complete in itself, but each is closely allied to both the others. There is, however, a fourth division which is quite separate from the other three. This division deals with personnel and its problems. It is closely allied to the other three divisions, since it has to do with the human factor in each, but inasmuch as it deals most intimately with production it is sometimes classed under this division. It should, however, be considered separately, as will be shown later, and operate as a separate division. The basis of factory organization may be laid down somewhat as follows : A board of directors which controls the policies and development of the company. A division of administration which controls the actual work and development. A division of production which controls all the actual manufacturing. A division of sales which controls all the selling of the completed product. A division of service which controls all matters to do with the personnel of the organization. The above outline is diagrammatic. The organ- ization of large factories is extremely complicated, INDUSTRY AND ORGANIZATION 3 of small factories very simple, but if the plan out- lined above be held in mind as a basic diagram, the complications are more readily understood. In the small factory the same idea exists except that two or more divisions may be represented in the work of a single man. The factory has but one object, to produce. If it fails to produce it dies. Produc- tion may, therefore, be said to be the life of industry. To quote Selby:i "Anything which is capable of facilitating pro- duction is welcome to industry so long as its cost is not excessive. The test is its ability to increase the quantity or to reduce the cost of production without impairing the quality. "Witness the manu- facturer who pays an efficiency engineer $17,000 for three months' work in rearranging the machines in his factory in order that materials may be moved more rapidly from the raw state to the finished product, or the manufacturer who discards a whole battery of smooth-running, though antiquated, ma- chinery in order that he may install improved ma- chines capable of greater output. On the contrary, anything that retards or does not facilitate produc- tion is tolerated by industry only so long as it is unavoidable. ' ' The ideal of production is a continuous output which can be raised or lowered at will to meet the demand and which will at all times be of uniform quality. If all machines were automatic such an ideal could be accomplished but there are many dis- 4 HEALTH SERVICE IN INDUSTRY turbing elements all due to the necessity of employ- ing men and women to run the machines. As soon as the human element enters, uncertainty enters also. When thus considered the personnel assumes great importance and it is generally recog- nized that the more stable and efficient the personnel the closer to ideal is production. The Service Division, as stated, has for its func- tion the selection and care of the personnel. Like any other division it is divided into departments, each department being controlled by a foreman or manager. The departments may be divided into those having to do with the actual care of the em- ploye, and those in which the general factors of wel- fare predominate. Actual care consists mainly of health supervision. According to Mock 2 this division may be made as follows : 1. Health Supervision of Employes. (a) Medical Service (b) Surgical Service (c) Dental Service (d) Nursing Service (e) Safety Service (f) Sanitation Service 2. Adjuncts to Health Supervision (a) Employment Service (b) Restaurant Service (c) Recreation Service (d) Welfare Service (e) Insurance Service (f ) Banking and Loan Service (g) Housing and Community Service INDUSTRY AND ORGANIZATION 5 The interesting point demonstrated is the medical aspect of the majority of the services here men- tioned. The Service Division besides the functions out- lined has numerous others which it is unnecessary to mention. It may be administered by a service director or a service committee, which is usually directly responsible to the general manager or a vice-president. Because of the distinctly medical character of the service department the logical man for its head should be a physician. This, unfortu- nately, is not often the case. Except in a very few factories the service department is controlled by a non-medical man. One of the reasons for this is the difficulty in finding a physician having the requisite administrative training. There is, however, a tend- ency toward appointing physicians to this position, especially since executive training was given many doctors during the war. The medical, or health department, is therefore a part of the service division according to the plan above outlined. It is a complete unit in itself and consists of a medical and surgical service with all ap- purtenances necessary. It is in close contact with the other service departments and must co-operate with them in many ways. Thus the visiting nurses ' service is often a separate department. This depart- ment must, however, work in the closest contact and sympathy with the health department to be of the greatest service. The employment department is in constant contact with the health department through INDUSTRY AND ORGANIZATION 7 the physical examination of applicants and trans- fers, and the placing of subnormal workers at work for which they are physically fitted. In fact every department of the service division is in some way correlated with another department of the same division and all must co-operate to obtain the re- sults desired. Not only must these departments work smoothly together, but they must do their work in such a way as not to interfere with produc- tion. No department can exist which interferes with production unless the value to production of its end result is greater than the loss caused by the inter- ference. Thus the treatment of all injuries at a fac- tory dispensary takes a certain number of workers from production for a few minutes daily, interfer- ing with production. However, the rapidity of heal- ing, lack of infection and satisfaction of the worker altogether represent a factor of time saved and efficiency maintained which more than compensates for the interference with production caused by the visits to the dispensary. The service division may be considered as a num- ber of departments, each governed by a department head, all co-operating, and each endeavoring to ac- complish its desired end with as little interference with production as possible. Each one of these de- partments has to do in some way with the health, welfare or interest of the employe. All are con- trolled by a service director or a service committee and these last are responsible to the general man- ager or vice president of the company. (Fig. 1.) 8 HEALTH SERVICE IN INDUSTRY Since the health or medical department comes in close touch with many of the other service depart- ments it is necessary briefly to outline the functions of the latter. In the majority of large factories they consist of the following departments: Employment Safety Engineering Visiting Nurse Service Commissary Recreation — Games and Athletics Housing Mutual Benefit Associations Banking and Loan Service The employment department has for its function the hiring, transfer and discharge of all employes. Up to ten years ago in the majority of factories all employing was done by the foreman or superintend- ent. When it was done by the foreman each depart- ment hired and discharged on its own account. Experience showed that this method while on the whole efficient, gave the foreman the power of work- ing off personal grudges and hiring men who were personal friends. Moreover, the time occupied in interviewing and entering the applicant was enough to interfere with the foreman's work in production. It was then considered advisable to establish a cen- tralized employment department where all appli- cants were interviewed and then assigned to posi- tions in various parts of the factory. In order to show what positions are vacant each foreman needing a new man, either because one of his regular force has been transferred, discharged INDUSTRY AND ORGANIZATION 9 or left of his own accord, daily sends to the Employ- ment Department a form known as a requisition. This slip states that department number blank is in need of two machinists or whatever are the man power needs. These requisitions await the employment manager each morning and it is his duty and that of his department to fill each requi- sition from the men applying for positions at the factory employment department. Not only must he find a man to meet the requirements but he must select the man who in every way is best fitted for the particular work designated on the requisition slip. Now, it is evident, that men may fail in a certain position for one of two reasons, first, the training and past experience may have been insuf- ficient or second, the applicant may not be in proper physical condition to do the work. While the em- ployment department is competent to judge the former, the latter can be determined only by a doc- tor's examination and it is here that the employ- ment and health departments come into close con- tact. The problems which arise by this contact and the method by which these are handled will be dis- cussed at length later. The employment department also keeps a record of absenteeism. Absenteeism is one of the factors which plays an important role in production. It is determined by daily reports from all parts of the factory to the employment depart- ment, and the tracing of those absent for three days by a special agent of the department. The agent may be a visiting nurse or may be a man specially 10 HEALTH SERVICE IN INDUSTRY trained in this work, but without medical knowledge. In the latter case, when a worker is found to be sick, he is reported to the visiting nurse service which takes the case in hand. The safety engineering department has for its work the protection of the worker from accident. This is carried on in two ways, first, by the guard- ing of machines and appliances, second, by personal instruction of the men and foremen carried on by lectures, conferences and printed matter. The safety engineering department, because of its inter- est in accident prevention, investigates each acci- dent which occurs and endeavors to institute means by which such an accident may be prevented. The health department, therefore, sends a report of all serious accidents to the safety engineering department as soon after occurrence as possible. Compensation for accidents under the Workmen's Compensation Act is frequently in the hands of the safety engineering department. The contact between this department and the health department is, there- fore, a close one. The safety engineer is constantly in conference with the doctors of the health depart- ment on matters of interest to each. Thus, the determination of an employe's ability to return to work rests with the health department, but the actual placing of the man at work and arranging for his compensation rests with the employment man- ager and safety engineer. The visiting nurse service is the connecting link between the employe's home and the factory. It INDUSTRY AND ORGANIZATION 11 is an adjunct to the health department, but is run entirely independently. Its personnel consists of a chief nurse and one or more assistant visiting nurses. The duties of the service are : 1. To investigate all cases reported by the health, employment or safety engineering department and report back to the inquiring department. 2. To advise and assist those who are found in trouble. 3. To do any temporary emergency nursing found necessary. 4. To bring patients to the factory dispensary for dressings. 5. To take up social problems of the home with employes and their families. 6. To co-operate with the private physicians who are caring for employes at their homes. 7. To visit the sick and injured employes when they are at a general hospital and bring them any benefit or compensation or other monies to which they are entitled. The visiting nurse service is in close contact with the employment, health, sanitation and safety engi- neering departments. The detail of its work will be given more thoroughly in another chapter. In large factories a satisfactory restaurant serv- ice is a necessity. This department is always a separate entity and consists of one or more lunch rooms at which cafeteria or served meals are pro- vided at cost. The type of food is usually simple and wholesome and the quantity sufficient. In some factories the service provides merely food to sup- plement the lunch men bring with them. In this case, coffee, milk, soup, fruit, cake and pastry are 12 HEALTH SERVICE IN INDUSTRY served. In other factories a regular lunch of soup, meat, vegetable, dessert and coffee is served at a fixed price. Still another plan consists of providing an elaborate cafeteria similar to those found in busi- ness parts of any city. In all cases the cost of food to the employe is much lower and the quality higher than can be obtained outside of the factory. The lunch rooms vary from simple counters to elaborate and attractive dining rooms. The industrial physi- cian is frequently consulted as to the quality of the food, the health of the kitchen attendants, the clean- liness of the milk and other sanitary matters. Kecreation has become a regular feature in the life of the employe of a large factory. The depart- ment controlling recreation and athletics is often large and is always busy. The work which was done by the Y. M. C. A. in army camps with such success is now being duplicated on the factory grounds, and at the noon hour hundreds of men can be seen playing volley ball, pitching quoits, play- ing basket ball, or passing baseballs. Factories now have their representative teams like colleges, and even rowing has developed with extraordinary rapidity. The athletic interest is good for the mind as well as for the body, and a well regulated athletic program has a great effect in stabilizing labor and overcoming the physical fatigue and lassitude pro- duced by indoor factory work. The difficulty of obtaining satisfactory and hygienic living accommodations for the workers has induced many factories to build small but comfort- INDUSTRY AND ORGANIZATION 13 able houses for its employes. The housing depart- ment is another of the departments which often calls upon the health or sanitation department for assistance and advice. Mutual benefit associations and a banking and loan service while of great importance to the worker are not departments in which the doctor is greatly interested except when he makes the examinations upon which the mutual benefit association settles its claim. It will be seen that the service division covers a distinctly medical field and that while it may not be administered by a doctor, medical advice is needed to some extent in almost every department. It is obvious that the service division only exists in large factories, but many of its principles are carried out even in factories of twenty-five or fifty employes. In fact, the basis of most of these activi- ties originated in the personal interest of the small shop owner in his workers. To quote from the preface of the service book of a large factory : "No work is done which the owner of a small shop would not do himself on a small scale as a matter of duty to his employes. Growth of the shop is almost invariably accompanied by loss of touch between the management and the workman. These departments are simply seeking to re-establish the good feeling and tolerance which have so much dimin- ished under modern management systems. Expe- rience has convinced us that this is an economic 14 HEALTH SERVICE IN INDUSTRY measure entirely aside from improvement in morale, because it costs less to conduct these activities through a centralized department than to accom- plish the same thing by the effort of men whose whole time should be devoted to production." CHAPTER II THE MEDICAL NEEDS OF A SMALL FACTORY From the general discussion in the last chapter, it will be seen that various phases of the practice of medicine play an important part in the organi- zation of large factories. It is equally important in small factories which employ more than twenty- five men, but this importance has either not been recognized or the presumable expense has appeared too great. The overhead expense of running a small factory is frequently greater proportionately than that of a large plant. The absence of one or more employes is more keenly felt and may seriously inter ef ere with production, yet in the great majority no pro- vision for ascertaining or caring for the health of the worker is maintained. This is due partly to lack of knowledge on the part of the employer, partly to the difficulty of the problem, and partly to the insurance companies which cover the accident risk. The value of the doctor to industry has been recognized only recently and this recognition has been confined almost entirely to the large factories. The small manufac- turer has not considered his problems those of the larger plants, although he has without realizing it, 15 16 HEALTH SERVICE IN INDUSTRY in many cases, been personally acting as service manager in Ms factory. Because of his small per- sonnel lie has been able to keep in close touch with all of his workers, place them at the work for which they seem best fitted, and in case of sickness or accident, to see that proper attention was secured at once. With a small force the number of cases of sickness and accident are numerically so few that the regular employment of a doctor or nurse appears unnecessary. Accident insurance, which is now compulsory, in the majority of states, is usually car- ried through private insurance companies. These companies are forced to pay for any surgical treat- ment rendered in case of accident besides a definite compensation following a stated period of disability. In order to fulfill their obligations and obtain the shortest period of disability the insurance com- panies usually appoint selected doctors in each industrial center and ask their insurers to send any cases of injury occurring in the course of employ- ment to these doctors or in case of severe injury to send for one of them. The employer with his accident cases thus provided for feels that except for a first aid outfit at the factory no further pro- vision is required. Although this arrangement appears satisfactory, when stated as above, on closer view it shows many weak points. These can best be shown by outlining the medical needs of a small factory and seeing how well they are cared for at present. Listed they are as follows: MEDICAL NEEDS OF A SMALL FACTORY 17 1. Knowledge of physical condition of employes at time of hiring. 2. Knowledge of physical ability of employe to carry on the work to which he is assigned. 3. Provision of sanitary working conditions, in- cluding light, heat and ventilation. 4. Safeguarding the employes from special health hazards peculiar to the industry. 5. Advising and giving emergency or simple treat- ment to sick employes. 6. Giving prompt and adequate treatment in case of accident. Of these, the last only is provided under the pres- ent system and in this case the doctor is employed by the insurance company, not by the manufacturer. There are two methods which can be applied to carry out a complete system without great expense. The first consists of the employment of a part-time physician by the factory. The physician should live reasonably near the factory and should be at the factory a certain number of hours each week. The second method is a centralized employment depart- ment and dispensary, situated near the center of a group of small factories, which gives service to the group. Each plan will be considered in detail. In the first plan, the selection of the right doctor is most important. He must have knowledge, ability, tact with men, and a sound knowledge of the basic principles of medicine and simple surgery. More- over, he must be interested in the idea and consider his work at the factory as he would a much sought for hospital service. After the selection of a doc- tor he should be taken for a survey of the factory. 18 HEALTH SERVICE IN INDUSTRY Specially dangerous spots and any poisonous proc- esses should be pointed out to him and he should be given a short talk upon the product manufactured and the machines by which the work is performed. This will give the doctor a chance to size up the sanitary and hazard situation and make his plans accordingly. Next, a small section of the shop should be assigned to the doctor as a dispensary. This space may be a small room formerly used for storage or may be made by partitioning off a sec- tion of floor space where it can be most readily spared. Excellent work can be done in very small quarters. For a factory of between one and three hundred men a room having a floor space of 200 square feet separated into two parts by a partition at least seven feet high is ample. A first aid room of this size is required by law for factories employ- ing 100 or more employes in the State of Massa- chusetts. The equipment of such a room is not expensive. The following items are necessary : (a) A glazed sink with hot and cold water always available. (b) Electric, gas, or other suitable heating device and sterilizer. (c) A table with a smooth top. (d) At least two chairs. (e) A couch or bed, preferably the latter. (f ) Two woolen blankets. (g) Heavy rubber sheet IVz yds. square, (h) Two pillows, rubber covered, washable. (i) Two enamelled hand wash basins. (j) A waste pail. MEDICAL NEEDS OF A SMALL FACTORY 19 (k) Individual drinking cups. (1) A rubber or metal hot water bottle. (m) A simple stretcher. (n) A medical and surgical kit. (o) A supply of individual towels. Having made his survey of the factory, personally met the foremen and the older workmen, and estab- lished his dispensary, the doctor should seek for a competent lay assistant among the workers. In factories employing two hundred or more, a regis- tered, trained nurse having some industrial train- ing should be installed on a full-time basis. In the smaller factories this expense is unnecessary and one of the workers can usually be found who has had some experience and interest in first aid work. This man should be given a course of intensive train- ing by the doctor, in which he is taught the proper method of cleaning a wound with gasoline and iodine, the sterile application of a compress, and proper bandaging. He should also be given a cer- tain amount of general instruction in first aid. Fol- lowing this, the doctor should call all the foremen together and give them a short talk on the ideas of industrial medicine, ending by a demonstration of the prone pressure method of resuscitation for elec- tric shock and a plea for interest and co-operation. The employer or superintendent should be present at this talk to show his support and impress the foremen with his interest in the work. From this time on all cases of sickness and acci- dent should be sent at once to the dispensary to be 20 HEALTH SERVICE IN INDUSTRY treated by the first aid man or nurse. If the case is serious, the doctor is summoned, if not, he is treated simply and returns to work. The doctor pays regu- lar visits to the factory, once, twice, or daily each week, spending one or more hours, depending on the size of the plant. At this time he reviews the sanitary condition of the factory and reports to the superintendent any suggested changes or improve- ments. He next goes to the dispensary where he has sent to him any cases of sickness or accident which have occurred since his last visit, reviews, advises and gives any treatment necessary. After a month of this type of work he should begin the physical examination of the workers then employed, beginning with the foremen and older employes and omitting any who have any objection to being examined. The examination should be com- plete and should give the examined man a feeling of confidence in the thoroughness of the doctor's work. In this way, the workers are gradually exam- ined and each advised as to his physical condition. At the same time the doctor has an opportunity to advise a defective employe as to habits, diet, or any other change in his life which appears indicated. At this time also the doctor can arrange to take men off work for which they are not physically fitted and place them where they will be safer, without loss of wages. After all the regular force has been examined, new men taken on to fill vacancies can be examined shortly after hiring. Unless the doctor is at the MEDICAL NEEDS OF A SMALL FACTORY 21 factory daily it is impossible for him to examine applicants for work before they are hired. Such a system has been carried on in a number of small factories with perfect success. It has been found that the workers appreciate the care they receive and that the prompt attention reduces the time lost from accident and sickness, keeps men at their work and improves the morale of the whole shop. There is no case recorded where a medical service has been dropped when once initiated. The insurance company is usually perfectly willing to co-operate by allowing the company to select its own doctor if he is a man of good standing, knowing that his effort will be to get men back to work early and to give the very best treatment possible. The method of medical supervision by a central- ized dispensary possibly connected with an Employ- ment Department is a method which has been used in the Middle West. The central dispensary is con- ducted by a group of doctors. Someone is always on duty and there are also nurses in attendance. A doctor is sent daily to each of the subscribing plants, supplementing the work of the full-time nurse or trained assistant, and carrying out the duties outlined for the physician by the first plan. When such a group of physicians includes special- ists and the work is carried on in a careful and scientific way there is no better method by which the small factory can supply its medical needs intel- ligently than by subscribing to such a service. Though theoretically such a service should be linked 22 HEALTH SERVICE IN INDUSTRY with a central employment office which would employ for a group of factories, such a central employment office is seldom found. If these two services were grouped it would be possible for the small factory to receive almost as good a form of service as the large factory is now receiving from its own staff. The chief advantage from the medical standpoint would be the physical examination of applicants with proper placing, and the prevention of contagi- ous disease entering the factory. A medical group of the type just outlined is known as a Health Bureau. Shipley 3 gives the following synopsis of the work: "Such bureaus should be prepared to give to in- dustrial and mercantile concerns a well-balanced medical, surgical and sanitary service, which com- bines the emergency and preventive features in such manner as to produce the most effective re- sults at minimum cost. "The field force should be under the direction and immediate supervision of men qualified by vast experience in the fields of medicine and sanitation, in order to insure performance of technical service of the highest character. Furthermore, the staff at headquarters should be constantly analyzing the work performed by the field force, and planning and developing new and more effective means of securing results. This overhead service should be available to all of the establishments for whom the bureau is giving service, thus assuring to the smallest industry all the advantages which the largest corporation can secure through the employ- ment of full-time, high salaried industrial health directors. "The field force should include physicians, sur- geons, industrial hygienists and sanitarians, nurses MEDICAL NEEDS OF A S^IALL FACTORY 23 and nurses' assistants, and home workers. When the needs of a factory have been determined, the service should be arranged so that maximum re- sults are obtained at minimum cost." Selby, in the course of his studies, noted that two factories, one employing 400 and the other 500 work- men, maintained full-time medical services and in one the average number of workmen per physician was about 200. The majority of small employers, however, do not make any attempt to furnish an :_uate medical service, and it is only by a stimu- lation of interest, health bureaus, afi described above, or state bureaus, that the employes of the small fac- tory will receive adequate care. Inasmuch as the number of factories employing under 1.000 workers is approximately 95 per cent of total number of fac- tories in the United States, the need is obvious. To quote from Selby: "In several cities are buildings in which small manufacturing concerns may rent apace and pur- chase power and light. Although the companies that usually avail themselves of these facilities are small, employing but few workmen, rarely more than a hundred, there may be in the aggregate 1,000 or 2,000 employes to a building, a number that certainly justifies the maintenance of a dis- pensary and the employment of one whole-time physician, two nurses and a clerk. By prorating the cost among the companies., pexnans according to the numbers of their employes, the expense would be in proportion to their means, ye: they would have the use of a whole-time medical service and 24 HEALTH SERVICE IN INDUSTRY — t UJ o z . o >- '■ ■< h- Z «s eo 03 -a 3» 3= r ^ Q_ UJ a >» _i _ el- •< o o UJ s' •< 2 — CHAPTER in ORGANIZATION OF A MEDICAL DEPARTMENT IN A LARGE FACTORY In the first chapter it was shown that in large factories the health department is part of the serv- ice division. It is organized in such a way that it is in close contact with other departments of the service division, notably the employment and safety departments. The department is controlled by a chief physician who is responsible to the service director. The chief physician has as assistants one or more physicians and surgeons and a competent staff of nurses. This with clerical assistance comprises the basic per- sonnel. The work of the health department is carried on in one or more dispensaries depending on the size and shape of the factory. The largest of these dispensaries is placed next to the employment department and should be near the rooms assigned to the safety engineering department and the visit- ing nurses' service. The department is divided into three sections, each controlled by the chief surgeon. These sections are the health, sanitation and visiting nurse sections. Each section is separate and separately managed. 25 26 HEALTH SERVICE IN INDUSTRY The function of the health section is to preserve the health of the worker, to treat cases of accident and to prevent, diagnose and, to a certain extent, treat cases of sickness. The function of the sanitation section is to pro- vide and maintain the highest type of sanitation in the factory, co-operating in this with the engineer of the plant. The function of the visiting nurse section is to visit, advise and assist the worker at his home, espe- cially in case of sickness to himself or his family. The organization of these sections is shown on the accompanying chart. (Fig. 2.) The health section will be first considered. The equipment consists of a large, well equipped dis- pensary, centrally located, and, when the plant covers considerable territory, several sub-dispen- saries. The equipment of each dispensary is con- trolled by a registered graduate nurse. In the cen- tral dispensary are all records. Attached directly to the central dispensary or near it are an X-ray room, a dental department, and, if necessary, an oculist's room. The chief surgeon is in charge of the entire sys- tem and has as assistants at least one full-time and one or more part-time physicians and surgeons. In order to make a relatively accurate estimate of the needs of a plant, one nurse, at least, should be allowed to every thousand employes. In addition to the chief surgeon, one full-time doctor should be allowed for each two thousand employes. One LARGE-FACTORY MEDICAL DEPARTMENT 27 dentist can care for about two thousand employes and one oculist can be assigned to four thousand employes, provided that special attention is not required by the hazard of the business. The ques- tion of specialists will be discussed fully in another chapter. The health section records are kept by one or more lay clerks who are to some extent assisted by the nurse or nurses in the main dispensary. The division of the work of the personnel is usu- ally as follows: The chief surgeon has his office in or near the main dispensary. At this dispensary are stationed all assistant doctors, and at least one nurse. As previously stated, all records and files are grouped at the main dispensary. At each sub- dispensary are stationed one or more nurses, de- pending upon the activity of the work. The health department has for its functions : 1. The physical examination of all applicants for positions in the factory. 2. The re-examination of all employes transferred from one department to another. 3. The periodic examination of workers employed in departments where there is a health hazard. 4. A periodic examination of all workers who have physical defects needing following up. 5. The placing of physically defective workmen in departments where the work will not prove in- jurious. 6. The diagnosis and, in certain cases, the treat- ment of workers applying to the dispensary for medical care. 7. Co-operation where possible with the family physician of sick and defective employes. 28 HEALTH SERVICE IN INDUSTRY 8. Diagnosis and treatment of workers injured during employment. 9. Diagnosis and in some cases treatment of work- ers having surgical conditions not the result of employment. 10. Spreading health publicity by lectures, leaflets and similar publications. The effectiveness with which this is done depends largely npon the initiative and vision of the chief surgeon. It is his duty to co-ordinate the work of the health department with that of the contact de- partments mentioned in the first chapter, to stimu- late in his assistants scientific and accurate work, and to co-ordinate and render effective the work of his own department. In addition to this he must do a great deal of actual work, particularly along diagnostic lines. In some very large factories, em- ploying over ten thousand employes, the work of the chief surgeon is largely administrative, but in the average large factory where the number of employes varies between three and five thousand, a great deal of actual work must be done. The management of the health of the employes qf a large factory is carried out somewhat as fol- lows: Each applicant for work after having been interviewed by the employment department is sent to the health department for a complete physical examination. Following this examination the appli- cant is classified by the examining doctor as to his ability to work. The classification is usually con- fined to four groups. A man who is normal in every way is classified in the A group; a man who has LARGE-FACTORY MEDICAL DEPARTMENT 29 several slight defects, none of which are severe, is classified in the B group; a man who has defects severe enough to make his employment in certain departments inadvisable is classified in the C group ; while an applicant whose condition renders it unwise to work in any department is classified in the D group. Few men fall in this classification. Bur- lingame has made it a rule to classify as D all men whose employment would be dangerous to them- selves, to others, or to property, a most satisfac- tory and neat classification. The number of these workers is, fortunately, few. According to Mock, the number amounts to 10 per cent of those apply- ing, but in the average factory, where there is a variety of work and no great hazards, as in a machine shop, the number will be found to be about 2.8 per cent of those approved by the employment department. The disposition of these men can and should be made, whenever possible, by the examin- ing physician. Thus, a case of active tuberculosis is obviously a danger to himself and others in a fac- tory and should be advised to make immediate appli- cation at the nearest tuberculosis clinic for care and advice. To simply reject such a man without telling him of his condition and advising him what to do is a social crime, exposing others to the dis- ease and preventing the possible cure of the affected man. But to return to the physical examination. After the examination has been completed and the worker classified, he is sent back to the employment depart- 30 HEALTH SERVICE IN INDUSTRY ment with his letter classification. If the worker is an A or B class man, he is at once put to work. If his classification is C, he is held at the employment department nntil the doctor is able to confer with the employment manager as to the type of work for which the applicant is best fitted. In some fac- tories besides classifying the applicant when he is in the C class, the doctor writes a prescription for the type of work desired. This prescription the applicant takes with him to the employment depart- ment, and from it the employment manager deter- mines the work at which the applicant shall be put. It is considered advisable that the same relation of doctor and patient be maintained as strictly in industry as in private practice. The doctor should discuss the type of work the patient can and can- not do with the employment manager, but not the physical condition necessitating it. The results of the physical examination are recorded on a special card, envelope, or sheet by the examining physician and this is then filed with the rest of the records. This card forms the basis of all future medical work upon the employe and is frequently referred to. As a result of the physical examination, all work- ers are classed broadly into two divisions, stand- ard and sub-standard. The sub-standard workers are placed at work for which they are physically fitted through the employment department. Their physical examination cards are flagged with a col- ored signal indicating the defect. Once in three LARGE-FACTORY MEDICAL DEPARTMENT 31 months these defective men are re-examined to see how they are standing np under their work, and any adjustments made in their work which appears nec- essary. At this re-examination the examining physi- cian discusses with the worker the condition found and advises him. All men working where there is an industrial disease hazard are similarly managed, each one being called to the main dispensary quar- terly and rigidly examined for signs of industrial disease or poisoning. This also gives the physician an opportunity to discuss freely with the worker the best methods of caring for his health. All workers, standard or sub-standard, are re-ex- amined on transfer from one department to another. This gives the Health Department an opportunity to check up any changes in the workers' condition and prevents a sub-standard worker from being transferred to work for which he is not physically fitted. The applicant having become a worker comes under the medical supervision of the Health Depart- ment. This supervision is carried on as follows : All workers when they start at work are shown the nearest dispensary and instructed to report there for any sickness or injury, no matter how slight. If this is one of the branch dispensaries the fol- lowing routine is carried out in case of sickness or accident : 1. Employe notifies foreman of sickness or acci- dent. 32 HEALTH SERVICE IN INDUSTRY 2. Foreman directs employe to nearest dispensary. 3. Nurse at dispensary takes short history of case and examines into condition complained of. 4. If the condition is simple, as a scratch or con- stipation, the condition is treated and patient told to report back next day. 4a. If the condition is severe the patient is sent to the central dispensary for diagnosis and treat- ment, or a doctor is sent from the central dis- pensary for this purpose. 5. The case is entered on a card or slip which is forwarded to the central dispensary for filing and notation. 6. Patient's name, number and department are entered in a book; and a note made as to the day the patient should return to the dispensary for treatment. 7. Patient returns to work or in case of a serious accident or sickness is sent home or to a hos- pital. 7a. If patient is sent home or to a hospital, the vis- iting nurse service is notified. 8. When patient returns for retreatment, what is done is recorded, another notation is made in the book, and date when patient should return unless discharged is entered. This in brief is the routine used in treating cases of sickness and accident occurring in the factory. In order to obtain uniform results, routine meth- ods of treatment have been adopted wherever pos- sible. This applies more particularly to accidents, but it is also possible in treating minor cases of sickness. The methods adopted and the reason for them will be more fully outlined in a later chapter. Certain routine methods of report to contact de- partments have also been found necessary. These LARGE-FACTORY MEDICAL DEPARTMENT 33 will be considered fully under the chapters dealing with the care of sickness and accident. Sanitation is the second branch of the medical department coming "under the control of the chief surgeon. Sanitation consists of the control of the following plant conditions : Light Water Heat Toilets Ventilation Looker P.xms Dusty Conditions General Cleanliness Each of these will be discussed at length in the chapter on sanitation. The management of sani- tation throws the chief surgeon in close contact with :he plant's engineer, as many of the problems are those of engineering. The control of sanitation in- volves tours of inspection at regular intervals. The Sanitation Department is administered by a foreman who has under him a corps of workers. The organization is similar to that of any factory department. The entire plant is divided into zones, and a certain number of workers are assigned to each zone, each one having a regular task. Thus, one man will take charge of the cleaning of a cer- tain amount of floor space, another will care for the toilets and locker rooms, another will clean win- dows, while still another will collect and clean cus- pidors if these are necessary. The sanitary work- ers in each zone are controlled by a sub-foreman who reports directly to the sanitary foreman.. It is well to supplement the inspections made by the chief surgeon with weekly reports made by the 34 HEALTH SERVICE IN INDUSTRY Norton Company Worcester, Mass. WEEKLY SANITATION REPORT Dept- Date_ LOCATION CONDITION Locker Rooms Toilet Floor Corners Windows Cuspidors Waste Cans Remarks : If everything is satisfactory it is only necessary to write "O. K." in this space Signed. Foreman NOTE : To be filled out and sent to Service Director each Monday Fig. 3. SANITATION REPORT This Is Made Out Weekly by Each Foreman and Forwarded to the Chief Physician LARGE-FACTORY MEDICAL DEPARTMENT 35 production foreman of the various departments. (Fig. 3.) Visiting Nurse Service is the third branch of the medical department. The object of this service is to follow up at their homes, employes who are out because of sickness, accident, or sickness in the family. As soon as a case of sickness or accident is sent home by the health service, the Visiting Nurse service is notified and a visiting nurse visits the patient at his home. The object of these visits is more to render assist- ance than to do actual nursing, though in many large factories where there is a large force of visit- ing nurses, actual nursing is done. When a district nurse service exists in the community, it is not necessary for the factory nurse to do much actual nursing, though she should be prepared to take care of any emergency she finds. Her main function is to see that the patient has good surroundings and improve these if possible; to secure a physician or nurse if the patient is in need of one, or to send or transport the patient to a hospital if the patient is willing and surroundings are bad. The visiting nurse also visits cases of accident who are at the general hospital and reports back their condition to the chief surgeon. In short, the service is a contact between the sick or injured workers and the health department. 36 HEALTH SERVICE IN INDUSTRY Fig. 4. N. A. S. 0. FIRST AID JAR Adopted as Standard by Many Large Factories CHAPTER IV FACTOKY DISPENSAEIES The factory dispensary is the center for all medi- cal work and should be situated as near the geo- graphical center of the factory as possible. Like the base hospital in the army, it acts as the final point for diagnosis and treatment, and is supplied by the sub-dispensaries which correspond to the army field hospitals. The sub-dispensary in turn is supplied from the factory department first aid stations if the factory is large enough to require these. The first aid station will be the first thing con- sidered. It is usually represented by a box or jar which contains a few sterile gauze pads, Tr. of Iodine, burn ointment, and a tourniquet. This box is the equipment of the trained first aid man, usually a foreman or sub-foreman. Up to a few years ago these boxes, usually containing dirty bandages, some patent so-called " antiseptic,' ' and a pair of rusty forceps, probably caused more infection than they prevented. Absorbent cotton was liberally used. Iodine or even soap and water shunned. Of recent years, however, all this has been changed and where the first aid box remains it is usually well kept up. The American Red Cross and the war train- 37 38 HEALTH SERVICE IN INDUSTRY ing received by many of the factory operatives have combined to diffuse a large amount of sane, practi- cal knowledge among the workers of the country, and the results are gratifying. The best first aid outfit at present is that devel- oped by the Conference Board of Physicians in Industry and adopted by the National Founders Association. (Fig. 4.) It consists of a heavy glass jar in a wooden case with the following contents : 1 Tourniquet 1 pair Nickel-Plated Scissors 1 pair Nickel-Plated Tweezers 1 Triangular Sling 1 Wire Gauze Splint 12 Assorted Safety Pins 1 2-oz. bottle Castor Oil 2 3-oz. tubes Burn Ointment 1 2-oz. bottle 3 % Alcoholic Iodine 1 2-oz. bottle White Wine Vinegar 1 2-oz. bottle 4 % Aqueous Boric Acid 1 2-oz. bottle Aromatic Spirits of Ammonia 1 2-oz. bottle Jamaica Ginger (or substitute) 1 piece of Flannel 24" x 36" 1 roll Absorbent Cotton (1.5 oz.) 1 roll 3" x 10 yards Gauze Bandage 1 roll 2" x 10 yards Gauze Bandage 2 rolls 1" x 10 yards Gauze Bandage 1 spool 1" x 15 yards Adhesive Plaster 6 sealed packages 6" x 36" Sterile Gauze 1 Teaspoon 1 Metal Cup 1 Medicine Glass 2 Medicine Droppers 3 Paper Drinking Cups First Aid Record Cards The advantages of a jar are that it is clean, the equipment can be seen at a glance, it can be used LARGE-FACTORY MEDICAL DEPARTMENT 39 to carry water. The instructions are incorporated in the glass cover. The Department of Hygiene of the New York Department of Labor has approved the N. A. S. 0. Standard First Aid Outfit for Employes in the State of New York in lieu of the First Aid Outfit required by the department and similar action has been taken by the Massachusetts Department of Labor and Industries.* The jar or box is in the hands of a trained lay- man who has been carefully taught to do little but do thatrlittle well. The following list of instruc- tions thoroughly understood is sufficient^ Open Wounds — Abrasions, Cuts, Punctures Drop 3% Alcoholic Iodine into wound freely, then apply dry sterile gauze to wound and bandage it. If necessary to cleanse greasy substances from wound, flush it with gasoline. Do not otherwise cleanse wound. Severe Bleeding Place patient at rest and elevate injured part. Apply sterile gauze pad large enough to allow pres- sure upon, above and below wound. Bandage tightly. If severe bleeding continues apply tourni- quet between wound and heart and secure physi- cian's services at once. Use tourniquet with cau- tion and only after other means have failed to stop bleeding. Nose Bleeding Maintain patient in an upright position with arms elevated. Have him breathe gently through mouth and not blow nose. If bleeding continues freely, press finger firmly on patient's upper lip close to nose or have him snuff diluted White Wine Vinegar into nose. *The N. A. S. O. First Aid Jar can be obtained from National Founders Association, 29 South La Salle St., Chicago, 111. Price $7.25. 40 HEALTH SERVICE IN INDUSTRY Bruises, Sprains Cover injury with several layers of sterile gauze or cotton, then bandage tightly. Application of heat or cold may help; other means are unneces- sary. If injury is severe place patient at rest and elevate injured part until physician's services are secured. Eye Injuries — Except Eye Burns For ordinary eye irritations flood eye with 4% Boric Acid Solution. Remove only loose particles which can be brushed off gently with absorbent cotton wrapped round end of toothpick or match and dipped in Boric Acid Solution. Do not remove foreign bodies stuck in the eye. In that case and for other eye injuries drop castor oil freely into eye, apply sterile gauze, bandage loosely and send patient to physician. Splinters or Slivers Embedded in Skin Except Eyes If easily reached withdraw with tweezers, then treat as "Open Wounds"; otherwise let physician attend to it. Eye Burns, Fire and Electrical Burns and Sunburn Do not open blisters. Use burn ointment (3% Bi-Carbonate of Soda in Petrolatum) freely on sterile gauze applied directly to burn. Cover with several thicknesses of flannel or other soft mate- rial, then bandage, but not tightly. Acid Burns Thoroughly flush wound with water, then dry wound, apply burn ointment and bandage as above. Alkaline Burns Thoroughly flush wound with water, then flood with White Wine Vinegar to neutralize (dilute vinegar for alkaline eye burns), dry wound, apply burn ointment and bandage as above. Dislocations In case of dislocation of finger, except second joint of thumb, grasp finger firmly and pull it FACTORY DISPENSARIES 41 gently to replace joint, then place finger in splint and bandage it. In all other cases place dislocated part at rest and promptly secure physician's services. Fractures Make patient comfortable and secure physician's services at once. Avoid unnecessary handling to prevent sharp edges of broken bones tearing artery. If patient must be moved place broken limb in as comfortable position as possible and secure it by splint. In case of severe bleeding apply sterile gauze and follow directions under "Severe Bleeding." Dizziness, Headache, Nausea Give patient teaspoonful of Aromatic Spirit of Ammonia in hot or cold water. Chills, Cramps Give patient 20 to 30 drops of Jamaica Ginger in hot or cold water. If improvement is not speedily obtained send for physician. Frost Bites Rub with ice, snow or cold water, then treat as fire burns. Internal Poisoning Immediately secure physician's services. Make patient drink large quantities of water, preferably warm, and make him vomit by sticking your finger down his throat or by other means. Heat Prostration Give patient teaspoonful of Aromatic Spirit of Ammonia in hot or cold water. In case body feels warm apply cold to it; if necessary give cold bath. In case body feels cold and clammy, apply heat to it and immediately send for physician. Unconsciousness from Fainting Lay patient on his belly and turn his face to one side. Loosen all tight clothing. Remove false teeth, tobacco, etc., from mouth. Apply cold to 42 HEALTH SERVICE IN INDUSTRY head, warmth to hands and feet. If breathing stops treat patient as directed under "Electric Shock." Give no liquids by mouth until patient is fully conscious. Then give teaspoonful of Aro- matic Spirit of Ammonia in hot or cold water. Shock, Following Injury In case shock is due to severe bleeding control it first as directed under "Severe Bleeding" and sum- mon a physician. Lay patient flat on back and keep him warm with blankets, hot-water bottles, etc., and provide plenty of fresh air. Let patient inhale fumes of Aromatic Spirit of Ammonia. If fully conscious give hot drink or teaspoonful of Aromatic Spirit of Ammonia in hot or cold water. Unconsciousness from Asphyxiation by Gas, Smoke or Water Treat patient as directed under "Electric Shock." Electric Shock Immediately free patient from electrical circuit, using every care to protect yourself against electric shock. Then if patient is unconscious, even if he appears dead, lay him on his belly with arms ex- tended forward, turn his face to one side, remove false teeth, tobacco, and so forth, from his mouth and draw his tongue forward. Kneel, straddling patient's thighs, facing his head, and resting your hands on his lowest ribs. Swing forward and gradually bring weight of your body upon your hands and thus upon patient's back, then immediately remove pressure by swing- ing backward. Repeat this movement about twelve times per minute without interruption for hours if necessary, until natural breathing has been started and maintained. The sub-dispensary as already stated is a small dispensary for the treatment of accidents and minor sickness. It is under the charge of a trained, regis- FACTORY DISPENSARIES 43 tered nurse. In small factories it is the only dis- pensary necessary. The dispensary should contain not less than 200 square feet floor space. If it is the only hospital in the factory it should be provided with a partition separating certain portions of the room. This par- tition should be at least seven feet in height and should contain a door. The floor and walls of the dispensary should be smooth, and the floor of some impervious material. The room should be ventilated directly to the outside air by a window or other suit- able opening or approved exhaust system. The dispensary should be centrally located in regard to the territory it is to supply and when pos- sible should be so placed as to guarantee a maximum of quiet and privacy to those requiring first aid treatment or rest, as well as readily accessible to the persons for whose accommodation it is designed. The equipment need not be elaborate. The fol- lowing inventory was taken from a sub-dispensary in a factory which has been maintaining medical supervision of employes for ten years. 1 Table 2 Cupboards 1 Dressing Table — 3 glass shelves 1 Swivel Chair 1 High Chair — Glass Arm (for dressings) 1 Flat Instrument Basin 1 Kidney Basin 1 Large board for folding gauze 1 Electric Sterilizer 1 Saw Horse 1 Pus Pail 44 HEALTH SERVICE IN INDUSTRY 1 Board for Adhesive 1 Army Stretcher 1 Steel Locker (2 coat hangers) 1 Metal Basket 1 Irrigating Can, 5' 2 Small Cupboards, 2 gl. Shelves 1 Solution Stand with 3 gl. Shelves 1 Solution Basin, glass cover 2 Hand Basins 1 Bedside Screen, cover 1 Razor Strap 1 Emergency Jar with sponges 1 Splint, Tourniquet, aro. spts. 1 Cot 1 Mattress 1 Pillow 2 Blankets 1 Rubber Sheet 1 Desk Clock 1 Folding Chair 3 Cane Seated Chairs 5 Bottle Racks 2 Sheets 2 Pillow Cases 5 Eye Bottles and Eye Droppers 1 Razor 2 Scalpels 4 Forceps 3 Scissors 1 Haemostats 1 Bandage Scissors 1 Large Scissors for Gauze 1 Glass Hypo. Syringe and Needles The dressings include the following: Sterile Gauze Bandages Adhesive Plaster, 5 yds. x 1 foot rolls 1 package of wooden splints Sheet Wadding 1 Thomas Splint, U. S. Army Model FACTORY DISPENSARIES 45 Tin Cross Pieces for finger splints Wooden Applicators Tongue Depressors Various boxes and bottles for holding equipment The drugs include the following: Chlorozene Collodion Creso-pinol Gasoline Lead Acetate and Alum Tincture of Iodine Wax Acetanilid Alcohol Alum (powder) Ammoniated Mercury (oint.) Arom. Spirits of Ammonia Bichloride of Mercury Bismuth Subnitrate Blaud's Pills Boric Acid (ointment) Boric Acid (powder) Brown Mixture Browntail Moth Lotion Capsolin Castor Oil Chloroform and Cloves Cocaine (4% sol.) Compound Cathartic pil. Compound Rhubarb pil. Dover's Powder Essence of Peppermint Ether Ethyl Chloride Glycerine Glycerine and Iodine Headache Anodyne Lassar's Paste Rhinitis Tablets Rhubarb and Ipecac Tabs. Rochelle Salts Scarlet Red Ointment Seidlitz Powders Setter's Gargle Silvol Soda Bicarbonate Soap Liniment Sodium Salicylate Special Cough Mixture Special Eye Drops Tartaric Acid Tincture of Benzoin Tincture of Ginger Yellow Oxide of Mercury Zinc Oxide (oint.) Zinc Stearate (powder) The cost of the above equipment was about $250 before the war and now amounts to about $400. With the exception of the drugs and supplies the equipment should last five years before replacements to any extent are necessary. 46 HEALTH SERVICE IN INDUSTRY The equipment standardized and approved by the Conference Board of Physicians in Industry is as follows: 1 metal combination dressing table with drawers to hold instruments and dressings 1 metal chair with head and arm rest 1 metal stool built in combination with metal waste can 1 small wooden or metal examination table with pads, with ends hinged to drop down 1 stretcher of the army type (canvas stretched over two round wood poles) or of the metal N. A. S. O. type 1 small instrument sterilizer arranged for electric, gas, alcohol or kerosene burner Y2 dozen utensils, such as arm and foot basins, 3 or 4-quart ordinary basins, 2-quart dipper, bed pan, etc. 1 portable first-aid outfit (N. A. S. O. standard first-aid jar recommended) Appropriate instruments, including a razor Dressings, splints, drugs Eecently, the American College of Surgeons has been interesting itself in Industrial Surgery and is considering a recommended minimum equipment. The central or main factory dispensary is some- times called the clinic. As has been pointed out, it is the medical center of the factory and is operated by doctors and nurses. It is also the proper place for all records. It should be near the chief sur- geon's office, and close to the X-ray room, pathologi- cal, dental and eye departments. The size and arrangement depends on the size of the factory. In such a great factory as the Ford Motor Company FACTORY DISPENSARIES 47 in Detroit, not only is all emergency operating done at the plant hospital, but wards are ready for the reception of patients. The merging of a ward with the central dispensary is, however, rare and only confined to very large factories or to those which are at a long distance from a general hospital. There are certain general principles concerning factory dispensaries which are of interest. First there should be no waiting room. The object of the dispensary is to return the sick or injured man to work at the earliest moment. It is necessary to give rapid and good service to do this, but it is much better economics to have more nurses or more dis- pensaries than to keep anyone waiting. Six good workmen waiting for dressings can cost the com- pany much more than the nurse's salary in a very few days. The dispensary should, therefore, not only have no waiting room, but be so arranged that maximum speed in dressings and handling cases can be obtained. This is done by using a unit system of grouping. The medical and surgical sections of the dispensary should be separate and distinct. They will be described in detail. The medical section of the dispensary is arranged so that workers may have an opportunity to consult the doctor with a certain amount of privacy, to have physical examinations, and to receive any advice and immediate treatment required. The medical section should therefore contain an office or parti- tioned space with a desk for the doctor and chair for the patient. There should be at least one booth 48 HEALTH SERVICE IN INDUSTRY where the patient may be examined. Connected with this section there should be a recovery room with one or two beds where men who have an acute attack of sickness may rest, or an abdominal examination be made. A medical cabinet or set of shelves is necessary for holding the drugs, ther- mometers, urine bottles, and so forth. The medical section has nothing whatever to do with the physical examination rooms where appli- cants for positions in the factory are examined. It is the purely medical part of the dispensary and should be considered only as a medical and diag- nostic center. The surgical section is separated directly by a partition or indirectly by an open space from the medical section. Its work is divided into several different types and for this reason a careful arrangement by units will greatly reduce and simplify the work. A unit consists of all the appliances, apparatus and dress- ings needed for a certain type of surgical work. Each unit is so arranged that the doctor or nurse can reach the part to be treated, dressings and in- struments, with the least possible lost motion. The usual units consist of 1. Units for dressing clean wounds of the hand and forearm. 2. Units for dressing clean injuries of the foot and leg. 3. Units for dressing infections. 4. A unit for treatment of ear, nose and throat cases. Fig. 5. A UNIT TABLE SET UP FOR HAND DRESSINGS Contents of Upper Shelf Left to Right 1. Bandages 1 in. and 2 in. 2. Tr. Iodine in glass stoppered bottle. 3. Thumb forceps in antiseptic solution. 4. Gasoline. 5. Sterile cotton swabs on wood applicators. 6. Sterile gauze 2x2 in. 7. Bandage scissors. On side of table strips of adhesive. It is better to have these spread on a bread board. FACTORY DISPENSARIES 49 5. A unit for treating eye cases, especially foreign body in the eye. 6. A unit for treating burns. 7. Units for the treatment of back strains. 8. A unit for the treatment of patients who must undress. Unit for dressing clean wounds of the Hand and Forearm. (Fig. 5.) a. One chair for patient, usually built high so that the dresser does not have to bend over. The chair is of the cafeteria type, having a broad arm which is covered with a glass plate or white enamel ware. b. A small glass or metal topped table upon which are the following: Top of Table One wide-mouthed glass stoppered bottle contain- ing Tr. Iodine, U. S. P., Y2 or full strength, four ounces. One wide-mouthed glass stoppered bottle contain- ing Benzene or Gasoline, 8 ounces. One wide-mouthed bottle containing Lysol or other aseptic solution in which one pair thumb for- ceps without teeth is immersed, handle projecting. One wide-mouthed bottle containing sterile cot- ton swabs on wood applicators. One metal box with cover containing folded sterile gauze compressors, 2x2 in. One pair of bandage scissors. Shelf of Table One dozen 1-in. gauze bandages. One dozen 1^-in. gauze bandages. One dozen tin cross finger protectors. The above can easily be contained in a low- sided tray. Standing near or resting on lower shelf of table One bread board covered with strips of adhesive plaster, % in. wide by 2 ft. long, for reinforcing dressings. 50 HEALTH SERVICE IN INDUSTRY Unit for dressing clean injuries of the foot and leg a. One ordinary chair of metal or wood. b. One leg rest of wood, usually horse type. c. One table with same arrangement as clean hand dressing table except that lower shelf should contain a jar of zinc oxide ointment, and adhesive strips should be IY2 in. wide by 2 ft. long. Unit for dressing infections One ordinary chair. One table as before but with following dressings : One bottle Alcohol One bottle Ether One bottle Dichloramin T. One jar of 4x4 in. gauze Sponges soaking in Chlorazene or other antisep- tic solution One package of thin oil, sandwich paper or celu- silk. Assorted bandages Cotton sponges in retainer Instruments Two pair Kelly Clamps One pair Bandage Scissors One pair Thumb Forceps in antiseptic solution Unit for Treatment of Ear, Nose and Throat Cases (This can often be combined with unit for treat- ing eye cases) One table as before One specialist's chair One strong focusing light One head mirror One bottle Tr. of Iodine and Glycerine, equal parts. One bottle Silvol or Argyrol 25%. One set nasal and throat sprays in rack with solutions. One compressed air tank FACTORY DISPENSARIES 51 One metal irrigating can, 2 qts., with attach- ments One pus basin Instruments One nasal speculum One set aural specula One ear curette One ear or nasal forceps Absorbent Cotton Unit for Treating Eye Injuries A dark room 5x5 feet, inner walls painted black Special bracket with light Specialist's chair Shelf for eye solutions in dropper bottles Two cataract knives, eye spuds, etc. Watchmaker's glasses or bifocal magnifying glass Sterile gauze Waste bucket Unit for Treating Burns Table as before One jar Gauze Sponges 4"x4" soaking in satu- rated solution of Sodium Bicarbonate Apparatus for wax treatment Rolls of sheet wadding Units for Back Strains and for Patients who must undress Booths 6x6 feet with a swing door. A hole cut in door enables doctor to see when patient is ready. Each booth should have a table equipped as unit one. In addition there should be an electric plug so that heat-treating apparatus can be connected. The physician should use his own judgment as to the type of apparatus desirable. Broad straps of adhesive ready cut on a bread board for back strapping are desirable. 52 HEALTH SERVICE IN INDUSTRY In addition to the units there must be an adequate number of sinks or basins with running hot and cold water. These sinks can well be placed in the center of the dispensary to be easily reached from all sides. When sinks are used instead of hand basins, white enameled basins placed inside the sink and kept in an antiseptic solution when not in use, are of value. There should also be one or two foot tubs available. The sterilizer should be centrally located and easily accessible from all parts of the surgical section. It should consist of a large dressing sterilizer and a medium sized instrument sterilizer. A container for sterilizing water is unnecessary and occupies valu- able space. Near the sterilizer should be placed the instrument cabinet which contains instruments and frequently needed supplies. The cabinet need not be elaborate nor very expensive. Near each dressing table should be a receptacle for soiled dressings. There are many types of receiver in use. Selby describes an innovation which is strictly clean and not an eye sore. This is a " paper receptacle used in the dispensary of the Erie Forge Company, a cylindrical bag supported by a light metal stand." At each sink there should be a towel shelf and soiled towel receptacle. This may be a cotton bag suspended from a metal ring or a hamper. Many variations of arrangement of these units are now in use and there are numerous modifica- tions. The General Electric Company in its West Lynn plant has a central dispensary with surgical arm and hand units in the form of a long bench with FACTORY DISPENSARIES 53 arm rests covered with glass. Beneath each seat is a board which can be pulled out for a leg rest. On the back of each seat is a coat and hat rack. Many other instances of ingenious arrangements might be cited but the principle of " units for treat- ment" remains unchanged. It has been previously stated that the records of the medical and surgical work done at both branch and central dispensaries should be centralized at the main dispensary. Every factory medical service has its own method of making and filing records. There is no one best method as yet decided on. The record system will be discussed in a later chapter. CHAPTER V THE INDUSTRIAL PHYSICIAN AND THE INDUSTRIAL NURSE The industrial physician must be a good general medical man and have had a hospital training in traumatic surgery. He must have executive ability and be able to handle men. In addition to this he must have interest in and sympathy for his patients, injecting the soul of the family doctor into his work. As a very prominent physician put it, the factory will get more from a 60% trained man with 100% interest and personality than from a 100% trained man with 60% personality. Geier 5 thus describes the industrial physician : ' ' The industrial physician is that man who gives up his private practice to enter industry for the purpose of using his knowledge of medicine and surgery to serve the worker and the management. Here again, just as in private practice, the man is going to be a relative failure or a great success, depending upon his ability and upon the extent to which he now qualifies as a specialist in this new subject. He may be the type of man that is satisfied merely to dress injuries and simply to prescribe for men who appear in his office; or he may make a thorough study of the plant conditions, the sanita- tion, safety, etc., for the purpose of creating a better 54 INDUSTRIAL PHYSICIAN AND NURSE 55 shop morale, raising their level of efficiency, and promoting their health, which will result in increased output. This last is the true industrial physician who really interprets the definition of industrial medicine, which states that it is the knowledge of medicine, surgery, oral hygiene, sanitation, hygiene, safety, economics, and psychology, daily promoted and intensively applied to groups of employes for the purpose of preventing or shortening the disa- bility due to illness and accidents and for the pur- pose of adjusting unhealthful working and living conditions that surround the industrial job, as well as the community life, thereby increasing individual efficiency and mass production.'' Industrial physicians may be whole or part-time men. In a large factory, the chief physician had best be on full time, but his assistant physician or physicians may well be on part time if the factory is in or near a city. A part-time industrial physician is a physician or surgeon in general practice who gives part of his time to industrial practice. A great deal of excel- lent work has been done by men of this type who have seen and grasped the opportunity offered. Without them industry would be greatly handi- capped for over 95% of the factories in the United States employ less than a thousand workers and such factories cannot afford the services of a full- time physician. Part-time physicians are also of great value as assistants to the chief physicians of a large factory. The contact they are constantly 56 HEALTH SERVICE IN INDUSTRY having with private patients and general hospital work keeps their professional interest acute and forces them to study. Moreover it keeps them in tonch with the more advanced forms of the sickness they see beginning in the factory dispensary. An industrial physician who is in charge of a very large staff: of full-time doctors told the author that he wished a high turnover among his doctors as the continuous handling of simple problems had a ten- dency to reduce the initiative and progress of the doctor. The author feels that his summary in another publication covers the ground in a reasonable way. In factories employing under a thousand, one part- time physician ; in factories of between one and two thousand, two part-time physicians; in factories of between two and three thousand, the same number if one is part time and the other full time. Inasmuch as a factory is composed of many de- partments each one specializing in some particular work, it is necessary that the industrial physician have a general knowledge of these departments, and a definite comprehension of the detail work of the departments with which he comes in intimate con- tact. Without this knowledge he is unable to write letters and information to the proper department nor is he able to co-operate with departments with which he is in contact. The doctor has definite authority and in all medical matters his decisions will be accepted without question, but he must be able to show that he is right and produce results in INDUSTRIAL PHYSICIAN AND NURSE 57 order to retain the confidence of man and manage- ment. He must initiate requisitions for all hospital supplies and equipment, and has it in his power to spend large sums of money wisely or foolishly as he wishes. The purchasing of medical supplies requires careful judgment in order that the maximum value may be obtained for each dollar expended. He must be able to inspire his nurses and assist- ants with confidence, and stimulate them to high standards of work, and must be thoroughly believed in by the workers. Beginning slowly he must build up the dispensary service in just the same way as a physician acquires his private practice. The same thought, care and sympathy are required by the patient whether he obtains them from a private or an industrial physician and unless he gets it he will go elsewhere. The records of the factory dispensary should be as carefully guarded as in a doctor's private office and the physical condition of a patient should not be discussed outside of the dispensary. Careful attention to these details has a great deal to do with the ultimate success of the depart- ment. The technique of examination and treatment of patients should be carried on as in a general hospital service. Special emphasis is laid upon these simple details for unless they are carried out with great care the work of the industrial physician will not obtain max- imum results. 58 HEALTH SERVICE IN INDUSTRY One of the greatest privileges of an industrial service is the close and long-continued contact with a large number of men. The doctor has a wonderful opportunity not only for investigation work, but for teaching the worker the rudiments of healthful living. The industrial physician finds that his work nat- urally divides itself into medical, surgical and what may be termed public health work. Owing to the early stage at which many diseases are encountered the factory dispensary probably presents one of the best fields now open for the study of beginning disease and its prevention. As the sanitation as well as the health problems of the factory are under the doctor 's control, he has it in his power to act as a local board of health for the factory and to ob- serve accurately the results of his action. The doctor will always be measured by his results. Factory workers and management are both close observers, and unless the best kind of results are produced, there is bound to be unfavorable criticism. the doctor 's control, he has it in his power to act as of time. In the case of accident, days of disability will be inexorably charted against him, and every infection comes out without possibility of camou- flage. Therefore, careful work, good instruction to nurses, and a follow-up system are obligatory. He will find it necessary to standardize certain forms of treatment, both medical and surgical, in order to study the efficiency of the form adopted and to save time and space. INDUSTRIAL PHYSICIAN AND NURSE 59 The element of time is constantly presenting itself to the industrial physician in some new phase. The length of time allowed for a physical examination, the time it takes for a worker to go to the nearest dispensary to have an injury treated and return to work, the time taken to make a diagnosis, the time taken for taking and filing records, the time lost by workers because of sickness and accident, all pre- sent themselves before him in what at first appears to be a limitless procession. He finds that the installation of an X-ray equipment pays because it saves the time of the worker which would otherwise be spent going to have the picture taken elsewhere, and the time of the nurse who would take him. He finds that men on piece work will not go far for med- ical or surgical care unless sorely in need of it, because of the time they lose from work. He won- ders at first why time is so important and then real- izes that in industry the old adage, "time is money,' ' is the reason. As soon as he realizes this he begins to see that his whole department and many of its results can be measured by a common factor, dollars and cents, which can be understood by everyone. Many things that he does cannot be so measured, but many can, and instead of shrinking from the thought of work being so measured, he should be glad that there is some definite norm which can be applied to measure the results of his department. The good industrial physician is constantly study- ing not only the results in his department, but new methods of diagnosis and treatment. For this rea- 60 HEALTH SERVICE IN INDUSTRY son he should stipulate with the management that he be allowed to maintain any outside hospital con- nections he may have obtained before going into industry, and that he be allowed enough time away from his work to visit clinics and attend medical meetings. In order to obtain good results there must be close co-operation between the doctor and the manage- ment. The interest and backing of the superintend- ent is almost vital to the success of the medical department, and the closer the mutual understand- ing between doctor and superintendent the more effective the work. The foreman has been called the "top sergeant' * of industry. He represents the company to the worker. It is, therefore, of great importance for the medical work to have the sympathy and interest of the foreman. Close co-operation between fore- man and doctor is bound to bring most gratifying results and opens an easy contact with the worker. The worker to a great degree reflects the attitude of the foreman, and enthusiastic support of the med- ical department by the foreman makes the problems of the doctor much less difficult. The industrial physician must be a good team worker and be able to co-operate with the heads of departments with which he comes in contact. He must study the detail of these departments in order to so arrange his work that it will not interfere with their routine or increase their difficulties. The departments in contact with the health de- INDUSTRIAL PHYSICIAN AND NURSE 61 partment have been enumerated in previous chapters and some of the points of contact and co-operation discussed. The Industrial Nurse The industrial nurse may fall into one of two posi- tions, dispensary nurse or visiting nurse. The first of these resembles very closely the position of a nurse in a medical or surgical dispensary of a gen- eral hospital except that in industry her responsi- bilities are usually greater than in general hospital work. While under the general supervision of a doctor there are long periods when the sub-dispen- sary nurse must use her own judgment, and it is this faculty of judging whether or not a patient needs the doctor's care which determines the nurse's ability. If we briefly review the method of dispensaries which we have laid down as a model it will be noted that while the central or main dispensary always has a doctor in attendance, the sub-dispensaries are visited by a doctor only once daily. At this time the nurse is supposed to have ready those cases which need a doctor's attention and advice. At any time she may send sick or injured men to the central dis- pensary to see the doctor there, or may in serious cases send for the doctor to come to the sub-dis- pensary. It is the fifty cases of trivial sickness and accident using the sub-dispensary daily which test her judg- ment. Does the headache this man complains of 62 HEALTH SERVICE IN INDUSTRY suggest eye strain, and should the doctor see him? Is this man's abdominal pain of any significance? Does that cough suggest the need of a complete chest examination? A good nurse who has had experience is very accurate in diagnosis as to whether a patient should be seen by a doctor or not. She should always play safe and err on the side of over-caution. The following general rules may act as guides : 1. Always take the temperature if there is the slightest reason to suspect it. 2. Always take the pulse. 3. In case of headache think of eyes. If headache persists have patient see doctor. 4. In cases of abdominal pain always take tem- perature and pulse. If patient is nauseated or has vomited call doctor. 5. Send to doctor any injury requiring suture or splinting. 6. Send to doctor any patient who has coughed a week. 7. Send to doctor any patient with temperature of 100. Many other good rules may be added; the outline above will serve as a guide. There has been some discussion as to the advisa- bility of allowing nurses to take this responsibility. Theoretically, the industrial nurse may have more responsibility than the nurse elsewhere, but unless she is given this responsibility, it will be impossible to achieve real results in industrial medicine. If a doctor is called on to treat every scratch and mild coryza occurring in a factory of five thousand, the cost will prove prohibitive, and the results will be INDUSTRIAL PHYSICIAN AND NURSE 63 no better than when good nnrses are employed. The doctor mnst be always available and must visit each snb-dispensary daily, but he need not see every case treated. The industrial dispensary nurse must be a woman of personality and some physical strength, as the work is frequently arduous. She must have an optimistic temperament, and while being quietly sure of herself must co-operate with and depend upon the doctor in all important points. Her position in a sub-dispensary is one of marked responsibility, and she must know just what she can do and what should be sent to a doctor. Loyalty to her doctors, and team work with them, should be the keynote of her work. The dispensary nurse has four definite duties : 1. The treatment of sick and injured workers. 2. Keeping her dispensary trig and trim. 3. Making supplies. 4. Keeping accurate records. The treatment of sick and injured must be along lines laid out and standardized by the doctor in charge. The work consists in first taking and re- cording an accurate history of the sickness or acci- dent, in the latter case using the technical terms occurring in industry. She should get the history in the man's own words and know enough about the work to realize what these words mean. In order that the history may be intelligent, the nurse should be shown machines, and be given a clear description 64 HEALTH SERVICE IN INDUSTRY of the parts of the machine and the processes of manufacture. The worker who finds his story intel- ligently received has confidence in the work of the nurse. Moreover the nurse must be able to cull out of the story the important facts and construct a con- cise history. In the case of sickness the nurse must always be on the lookout for something underlying the pa- tient's story. She should not accept " headache,' ' "sick stomach/ ' or "cold" without enough investi- gation to be sure she is not in contact with a con- dition more serious than the worker realizes. Intel- ligent questions, common sense, and the use of the thermometer, will prevent mistakes. As the dis- pensary is visited daily by a doctor it is very easy for her to administer a simple remedy and instruct the patient to return at the doctor's visiting hour if she has any question as to the case. The drugs placed in the nurse's hands are always of the sim- plest type. They should not exceed ten in number and should include neither opiates nor poisons. In order that there should be no temptation to elaborate surgical treatment the instruments pro- vided at the sub-dispensary need be no more than a pair of bandage scissors, two pairs of small surgical scissors, two pairs of forceps, and two haemostats. The maintenance of a neat and clean dispensary is obligatory. The effect of neatness and cleanliness upon the patient cannot be overemphasized, and the nurse should take pride in the looks and equipment of the dispensary in her charge. INDUSTRIAL PHYSICIAN AND NURSE 65 A great deal of unnecessary expense can be elim- inated if the nurses during their spare moments make supplies. Gauze bought in large quantity through the purchasing department should be made up into appropriate sized sponges or other forms of dressing. Adhesive plaster should always be pur- chased in rolls five yards long by twelve inches wide, and sheet wadding in bulk. Besides folding gauze, rolling sheet wadding, and cotton tipping applicators, the nurse should cut ad- hesive plaster in appropriate widths and attach it to a bread board, by far the easiest method of han- dling this rather tricky material. All sterilization should be done at the central dispensary by the steam fractional method unless the expense of an autoclave is justifiable. The nurse in charge of the central dispensary should be in charge of supplies, requisitioning them from the general factory stores, and distributing them to the nurses for preparation. She should be personally responsible for sterilization under the instruction and supervision of the chief physician. The keeping of accurate records of work done is one of the most important functions of the dis- pensary nurse. Not only must she take an accurate and brief history of each case, but she must enter a simple diagnosis and treatment on the initial report. All subsequent dressings and sickness must be briefly but accurately recorded and the follow-up sheet previously spoken of must be kept with minute care. A great deal of the value of the records 66 HEALTH SERVICE IN INDUSTRY depends upon the accuracy and conscience of the dispensary nurse, and without her interest and co-operation records will be of little value. The work of the visiting nurse is quite different. It is her peculiar function to act as a connecting link between the health department and the worker in his home. She also represents the company to the employe's family, and by her tact and kindness has it in her power to create good feeling for what is sometimes considered a soulless corporation. In the unique position she holds it is most important that she be a woman of tact, sympathy and judg- ment, as well as having a sound training as a nurse. While the visiting nurse in very large factories often does definite nursing at the employe's home, in the majority of cases she acts more in the capacity of a social worker, investigating the needs of the employe or his family, and advising him how to meet the conditions under which he is suffering. Actual nursing is usually turned over by her to the local district nursing society. She must, therefore, be prepared to meet many social emergencies, and untangle family troubles, for in connection with the worker's sickness are a multitude of perplexing problems which must be solved. The visiting nurse usually receives her list either from the employment department or the health de- partment of the factory. The employment depart- ment sends her the names and addresses of those workers whom the tracer finds to be out because of sickness, accident, or sickness in the family. THE PHYSICAL EXAMINATION 67 The health department sends her the names and addresses of those it wishes visited for special rea- sons or to be brought to the dispensary for dressings. The scope of the visiting nurse 's work is so broad that it can only be outlined. It is limited solely by the time she can give to each case. Thus she may find the employe sick without a doctor, and his wife so harried by household affairs that she is unable to give him anything but scanty attention. It is then the nurse's duty to make the patient comfortable, take his temperature, and advise him to call in a doctor. If he knows of no doctor, being a stranger, she must be able to suggest some one who is competent, but whose charge will be commensurate with the pa- tient's pocketbook. Perhaps it will seem better that the patient go to the hospital or the doctor in charge wishes the patient to go. The nurse then makes arrangements with the hospital and, perhaps, trans- ports the patient there in her car. If it is found that the wife is sick and the husband unable to work because there is no one to care for the children, she must arrange to have them taken care of by neighbors or some association. In cases of death the nurse has been frequently obliged to arrange for the funeral because of sickness among other members of the family. Most visiting nurses have an emergency fund upon which they may draw in order to purchase coal or food for destitute families and tide them over a crisis. The visiting nurse also has a list of cases whom she visits regularly, bringing a word of 68 HEALTH SERVICE IN INDUSTRY encouragement and keeping them in contact with their old associations. Such cases are those who have long-continued sickness, accidents of unusual severity and those who are in the hospital for oper- ative or other treatment. Her function is to help, brighten and encourage, and the amount of real good she does for both worker and company has never been sufficiently recognized and appreciated. CHAPTER VI THE PHYSICAL EXAMINATION The keystone of medical supervision is the phys- ical examination. "The physical examination is the means whereby physicians acquire the information they deem es- sential to the procurement and maintenance of healthy, physically competent working forces. It is consequently the basis of medical knowledge in industry and is fundamental to the successful practice of industrial medicine." (Selby,^ Scope of Physical Examination in Industry. Proc. National Safety Council, 1919.) It represents the first contact of the employe with the health department. It has for its object the determination of the employe's physical fitness for the work for which he has been selected by the em- ployment department, and the recording of his orig- inal condition for the private records of the health department. The physical examination should be given before the employe is actually hired as part of the prelim- inary investigation. The examination is conducted in private by the physician in person, though the weight, height, eye and ear tests may be made by a nurse or trained layman. The method of procedure is as follows : 69 70 HEALTH SERVICE IN INDUSTRY The applicant, having removed his shoes, stock- ings and all his clothes, in a booth, wraps himself in a blanket and steps into the examining room. He is immediately weighed and his height taken. The eye examination follows. This consists in most factories in the simple distance test with the Snellen chart. In some factories where special work requires acute vision, a more complete examination is made. The card test having been made, the exam- ining physician rapidly examines the motion of the eye, the color of the sclera, and the reaction of the pupil. He also notes the condition of the conjunc- tiva. All this takes only a few seconds. The ears are next examined. This may be done as in the Army by asking the applicant to repeat a whispered number or word, or a more rapid test may be made with the standard Ingersoll watch. If deafness is noted the auditory canal should be rap- idly inspected for discharge or impacted cerumen. The examination of the nose is for obstruction or defects. These can be rapidly discovered by press- ing with the finger on one nostril and telling the patient to breathe deeply through the other. If the breathing appears obstructed on either side a more careful examination with a speculum should be made. The patient is now told to open his mouth and with the aid of a wooden throat stick, the con- dition of the teeth, tongue, tonsils and pharynx noted. The lips should be examined on the buccal side for possible mucous patches. It is not considered necessary to chart decayed and THE PHYSICAL EXAMINATION 71 lost teeth, especially if a dentist is on the health department staff. The findings of the examination, as noted thus far, are briefly dictated to a clerk who enters them on the patient's physical examination card. The neck is next inspected and then rapidly pal- pated for enlarged glands or tnmors. The patient is told to swallow and the size and shape of the thyroid noted. The examination of the. chest is carried out as in general or hospital practice. Particular care is taken in the examination of the size of the heart, and the condition of the apices of the lung. Speed in examination is essential so that, though the examination should omit nothing, it must be concentrated on the points of industrial rather than medical importance. By this we mean that we are interested in determining in the shortest possible time the defects which would make it necessary for the worker to be placed in a department other than that already selected for him by the employment department. Thus the examiner is most anxious to determine the functional power of the heart and lungs. A quick method is to run over the apices of the lobes of both lungs with a stethoscope, telling the patient to breathe in, breathe out and then cough. This expulsive cough at the end of expiration is of great service in bringing out rales. In hearts which show enlargement, irregularity, or produce mur- murs, a quick test of function is to have the patient 72 HEALTH SERVICE IN INDUSTRY hop twenty -five or fifty times on one foot. Rapidity of respiration, breathlessness and irregularity of pulse should be noted and, if marked, indicate a myocardium inefficient for hard work. Further tests for the heart will be noted later. The hopping test is also of value in lung cases, as breathlessness is early evidence of tuberculosis. After rapidly reviewing the condition of the heart and lungs and dictating any abnormal findings, the patient is examined abdominally. The examination is made with the patient recumbent, and is to deter- mine the presence of inflammatory conditions or new growths. The patient is then told to sit on the edge of the table and tested for the condition of his knee jerks. He then resumes his upright position in front of the examiner. The umbilical, inguinal and femoral rings are rapidly but carefully examined for hernia. In examining the inguinal ring the patient is told to stand on his toes. The examiner invaginates the scrotal skin and places the tip of the index finger in the external ring, bidding the patient cough. This enables him to appreciate not only the descent of a sac, but the condition of the external ring and tension of the surrounding muscles. Following the examination of the inguinal region in which, of course, any enlarged glands or other abnormalities are noted, the external genitals are rapidly reviewed for venereal or other disease. The examination is now complete except for the extremities, skin and joints. The condition of the skin and extremities can be noted at a glance, but THE PHYSICAL EXAMINATION 73 the joints should be tested out carefully. There are a number of methods equally satisfactory. The one here described is rapid, efficient and has been used for some time in a large factory. 1. Patient stands facing examiner, forearms flexed on arms, hands in supination. 2. Patient spreads fingers apart and brings them together, closes fists, opens fists, apposes tips of thumbs to little fingers, pronates and again supinates. 3. Flex forearms acutely until fingers touch shoul- ders. Raise elbows anteriorily as high as pos- sible. 4. Abduct both arms in this position and rotate shoulders. 5. Raise hands straight up above head as high as possible. 6. Bend over touching ground. 7. Resume erect position. 8. Squat on heels and rise to original position. 9. Abduct first one leg and then the other. 10. Rotate head from side to side. If these motions are gone through rapidly, they can be accomplished in about three minutes, and every important joint in the body will have been tested. It has been found that defective joints are more apt to cause trouble than other apparently more serious disorders in other parts of the body. There is considerable difference between the examination of patients in a hospital and the exami- nation of apparently normal men for work. In the former one knows that some pathological condition exists severe enough to require hospital care. In the latter the patient is applying for work as a nor- 74 HEALTH SERVICE IN INDUSTRY mal man, and the examination is to determine as quickly as possible whether he is physically fitted for the work at which he will be placed. In gen- eral hospital work, time is of no particular impor- tance. In industrial work it is of vital importance. The employment department is anxious to fill its requisitions at the earliest moment, employes object to waiting, congestion must be avoided at all costs. The usual time allotted to the physical examination is, on the average, five to six minutes. It is only by experience and system that an adequate exami- nation can be made in this limited time. The physi- cian must, therefore, concentrate on what may be called the industrial physical defects, expecting to discover those which are less serious at subsequent examinations when the employe is under medical supervision. The vast majority of applicants are standard men. They have numerous slight defects but none of enough severity to require special place- ment or rejection. A second group, much smaller, but still from 8 to 10 per cent, of all applicants are sub-standard and need placing. A third very small group from 2 per cent to 5 per cent cannot be placed anywhere in the factory without danger to them- selves, others, or property. The object of the physi- cal examination is to determine as quickly as pos- sible those who are standard; sub-standard men require a much more careful examination to deter- mine the extent of their defects, and it is usual to complete the examination of these men after the early morning hiring rush is over. THE PHYSICAL EXAMINATION 75 Sub-standard workmen may be divided into three classes: those who are sub-standard mentally, but standard physically; those who are sub-standard physically, but standard mentally; those who are sub-standard both mentally and physically. It is evident that the man who is mentally sub-standard but physically standard can usually be placed at heavy work requiring no particular ability. There are many places of this type open in every indus- try. When the mental condition is standard but the physical condition is sub-standard the problem of proper placement must be solved. When both mental and physical conditions are sub-standard, the applicant is usually unfitted to work in any department of the factory, and it is advisable for his own good and for the good of industry that he turn his work into other fields. The method of classifying these groups of men has already been considered and the method of their placement briefly discussed in Chapter Three. In considering sub-standard workmen alone, those who are sub-standard mentally but standard physically can usually be safely classified as B. When the men- tal condition is standard but the physical condition sub-standard, the applicant is classified as C, and re- quires placement. When both mental and physical conditions are sub-standard the applicant is classi- fied as D. \ Physically sub-standard men usually fall into one of the following classifications : Cardiac, nephritic, pulmonary, hernial, syphilitic, special and general. 76 HEALTH SERVICE IN INDUSTRY Cardiac. — The number of cardiac cases which are unable to work are relatively few. Workers with defective hearts, even though the heart upon exami- nation shows marked murmurs and even irregulari- ties, are able to stand moderate work for a number of years before showing signs of disturbed com- pensation. The industrial physician should deter- mine as much as possible with the stethoscope, but should pay the closest attention to the condition of the myocardium. Though this is an extremely difficult thing to determine in a short examination, a functional test in suspicious cases will usually give a lead in the right direction. The simplest test is that of having the applicant hop fifty times on one foot, examining the heart before and after exer- cise, and noting particularly the effect upon the rapidity and regularity of the pulse, and the time for it to fall to normal. At the same time the reac- tion of the respiration to this moderately violent exercise should be closely noted. A patient who becomes breathless, or shows any signs of abnormal breathing after this exercise as compared with the normal man is one who should be studied with great care and who should not be assigned to work which will throw any strain upon the heart. This point of breathlessness has been emphasized by Lewis in his recent monograph on the Soldier's Heart and the Effort Syndrome. The exercise also brings to the examiner's attention any cases of that mysteri- ous condition known in the army as neurocircu- latory asthenia, the familiar N. C. A. Such cases THE PHYSICAL EXAMINATION 77 are rare in industry, but if met should be imme- diately isolated as they have no business in the hard work of the average factory. Dr. William E. Robertson of Philadelphia in a paper delivered in Harrisburg at the annual Pennsylvania Safety Con- gress, 1920, reviewed the question of the cardiac in industry and outlined the best method of examining a heart from an industrial viewpoint. Some of his points are as follows : "Of first importance are the position and quality of the apical impulse of the heart. Normally in the fifth interspace in the mid-clavicular line, dis- placement means hypertrophy with or without endocarditis, dilation, or both of these, adhesions or mechanical displacement by effusion or new growths. . . . Having marked the outline of the right and left heart, make friction over the epi- gastric area for a minute, then percuss the heart area again. If the area was large and has been reduced, we are dealing with simple hypertrophy. If the area reduces only in part, we have both hypertrophy and dilation, or dilation alone when the area reduces to the normal. Within two min- utes the heart area returns to the original out- line. . . ." "Normally, after moderate exercise, such as hop- ping 100 times on one foot, the rate will increase 10 to 30 beats above the previous rate, but within two minutes will return to the normal. In propor- tion to the degree of deterioration of the heart muscle, the rate will increase and the greater the increase, the slower the return to normal. When to this increase in rate is added dyspnea, with a sense of substernal pressure, the muscle involvement is very definite. In such instances by auscultation the muscle quality of the heart sounds will be found weakened, arrhythmia may be induced, and 78 HEALTH SERVICE IN INDUSTRY not seldom a relative mitral systolic murmur. In the over-acting heart an induced mitral murmur may simulate mitral stenosis. "Morison has shown that inhalations of amyl nitrite will accentuate the organic lesion of the valve. Whenever in doubt as to the possibility of mitral stenosis in any case, this is an excellent di- agnostic aid. When simple tachycardia is present, Benjamin and Brooks have shown that merely bending the head forward at an angle of 45° will promptly retard the heart rate. Fliessinger has reported similar results with respect to respira- tory effort in paroxysmal tachycardia. Sustained respiration, deep inspiration and prolonged expira- tion will often slow the heart rate." Nephritic. — Nephritic workmen can be most rapidly discovered by blood pressure determinations. A good general rule is to make a blood pressure determination on all applicants of forty years or over, and an urinalysis on all those showing a pres- sure of 140 systolic, 90 diastolic or over. Nephritic cases cannot stand the extremes of heat and cold which exist in many departments, nor have they the resiliency against hard work the normal individual has at the same age. The majority of these cases have more or less myocardial degeneration and the cardiac condition should always be investigated. A great deal can be done for the nephritic in the way of advice and diet. If he is hired he should be kept under medical supervision and re-examined at suit- able intervals. Pulmonary. — The most frequent pulmonary con- dition found among sub-standard men is a latent tuberculosis. This may be discovered by a combina- THE PHYSICAL EXAMINATION 79 tion of the patient's general build, physical signs in the chest and breathlessness on exertion. Again we see the advantage of putting the patient through the fifty hops on one foot, and by this simple method we are able to judge two conditions, cardiac and pulmonary. Applicants with latent tuberculosis can be employed in numerous departments in the factory, but should certainly not be put in a dusty, dark or humid workroom. If kept in a bright, dry workroom they are able to do excellent work with- out breaking down. Ee-examination of all workers with latent tuber- culosis is essential. The examination should be made at least twice a year and the worker instructed to report for additional examination if he begins to cough, lose weight, suffers from dyspnoea, or feels unusually tired in the afternoon. Sputum examinations and the taking of temperature in the afternoon should be repeated several times in sus- picious cases. An X-ray is a great help in diagnosing difficult cases. Excellent chest pictures can be obtained with small machines such as the U. S. Army Bedside Unit.* Hernia. — One of the most perplexing conditions which the industrial physician encounters is hernia. A general rule has been to be extremely careful about admitting men with hernias into industry. This is partly on account of the compensation risk in cases of strangulation, partly on account of the *May be purchased from Waite & Bartlett, 252 West 29th Street, New York. $650.00. (1920.) 80 HEALTH SERVICE IN INDUSTRY necessity of repairing the hernia if the man com- plains of pain after lifting, even if there is no increase in the size of the hernia, and partly because where there is a hernia on one side there is usually a tendency for a hernia to appear on the other side.* Compulsory use of trusses cannot be enforced, so that in the majority of factories there has been a strong feeling against the man who has a hernia. In many factories, however, men with well-marked hernias have been employed and work for years without trouble. In one factory where a careful record has been kept for nine years, but one case of strangulation has occurred, and this took place while the man was not at work. The great major- ity of these old hernia cases appear to be a fairly safe risk provided they continue doing work of the same type, and are not put on a job which is much heavier. The real hernia risk appears to be among southern Europeans, and among men who having done only moderately heavy work are suddenly put on heavy work. It is very difficult to determine who will develop a hernia, but it is safe to say that all southern Europeans who have previously done light work are very liable to develop a hernia if put on a heavy job. A worker with weak rings and a slight bulge along the inguinal canal on cough is a man who should not be put at heavy lifting. Syphilitic. — A diagnosis of tertiary syphilis is very difficult in the short examination which is given the average applicant. However, if the factory hos- *Moorehead states that 80% of his operated cases show oblique hernia on both sides. THE PHYSICAL EXAMINATION 81 pital is used as it should be, cases are constantly appearing in wliich there is enough to arouse the doctor's suspicion and lead him to take a Wasser- mann. These cases, if the Wassermann is positive, should immediately have salvarsan, following which the type of work at which the patients are placed should be carefully investigated. Special. — There are naturally a number of con- ditions wliich do not fall in any of the above groups, but which, nevertheless, require careful placing. These are too numerous even to mention, but will readily occur to any industrial physician. A typical example would be varicose ulcers of the leg. These cases may be placed at moderately light work, and with protection do extremely well, the ulcer healing up rapidly under daily cleansing at the hospital and proper support. Flatfoot is another condition in which a combination of placing and support gives excellent results. Our own experience goes to show that flatfoot is more a theoretical than a real detri- ment to good work. General. — There are always a number of cases which present a combination of conditions which can only be cited as general. Many of these patients fall under class D group, and really have no busi- ness to work anywhere in the factory. Others may be placed and a moderate amount of good work obtained from them. Proper placement does not finish the doctor's responsibility. These sub-stand- ard men must be examined from time to time to see that their defects are not increasing and that the 82 HEALTH SERVICE IN INDUSTRY placing has been proper. Such an examination should be made as a routine twice a year; and at each examination a record should be made showing the patient's condition. The doctor should take enough time to discuss with the patient his find- ings, and to give advice as to how the patient may maintain himself in good condition. If the patient has confidence in the doctor and medical service, and the symptoms which mean beginning trouble have been thoroughly explained to him, he will present himself for examination long before there are any real signs of breaking down. CHAPTEE VII ACCIDENTS AND THEIR TREATMENT Accidents occurring in a factory may be classified as trivial, moderately severe and severe. Legally, they are classified as trivial, and lost time accidents. Trivial accidents are those in which the worker is able to continue work immediately after treat- ment and which require but two or three dressings. They may be cared for by a nurse or trained lay- man. Moderately severe accidents are those which re- quire a doctor's care. The patient may or may not lose time. Severe accidents are those which require a doc- tor, and usually general hospital care. The treatment of accidents in a factory begins with the first aid treatment and is not completed until the worker is back at his original work or at other work approximating it as closely as possible in earning capacity. First aid may be carried on at first aid stations scattered through the factory, or at factory sub- dispensaries. The first aid station with its equipment has already been described in Chapter IV. As there stated, the equipment is usually in the hands of a 83 84 HEALTH SERVICE IN INDUSTRY trained layman, either a foreman or sub-foreman. The treatment administered should be strictly first aid, that is, just enough to control the emergency features of the case and to prevent infection. By far the largest number of accidents are trivial injuries, and these in turn are most frequently lacerated wounds of the fingers. Every injury in which the skin is broken repre- sents a potential infection, and the prevention of infection is one of the most important services ren- dered by the factory medical staff. The shorter the period elapsing between injury and treatment the more effective the result. Mock has shown the remarkable results obtained by the early use of Iodine, and the Benzene-Iodine treatment of wounds has now become almost stand- ard in industry. The results have been most gratify- ing. Hundreds of consecutive cases have been treated without a single case of infection, and when the working conditions and habits of the average factory worker are considered, the statistics are surprising. In one company employing about 900 machinists there was but one accident in which time was lost from infection out of 4,869 accidents. The period covered was 23 months. The technique consisted in thorough cleansing of wounds and skin with commercial gasoline followed by full strength Tr. Iodine U.S.P. Mock bases the prevention of infec- tions upon three points : ACCIDENTS AND THEIR TREATMENT 85 a. "Immediate application of an antiseptic to an open wound. b. The earliest possible treatment of the wound by a qualified physician. c. Protection of the wound by sterile dressings; regular and uninterrupted care until healed." He goes on to say, "from a careful investigation of the kind of antiseptic used in accident surgery- it is safe to say that at least 80 per cent of the surgeons use some form of tincture of iodine." It will be noted that in Chapter IV in the description of a first aid jar that benzene is not included. This is because the treatment is to be given by a layman and simple flushing with iodine is safer than allow- ing a thorough cleansing with benzene and iodine. Where the first treatment is carried out by a trained nurse or doctor, the wound should always be thoroughly cleansed with benzene or gasoline be- fore iodine is applied. Water should never be used prior to the gasoline-iodine. If the patient has been working in water the wound should be flushed with alcohol and ether before applying the iodine. Whenever possible, the most satisfactory place to give first aid is the sub-dispensary where everything is at hand for proper treatment and where a trained nurse does the work. The first treatment of the more common injuries can be readily standardized and equipment be at hand and ready for the immediate treatment of these cases. Such standardized treatment would be as follows: HEALTH SERVICE IN INDUSTRY Lacerated Incised and Abrased Wounds 1. Cleanse part freely with gasoline, using ster- ile gauze. 2. Wipe out wound thoroughly with cotton ap- plicator dipped in gasoline. 3. Paint wound thoroughly with iodine, using a cotton swab applicator, or spray iodine into and around wound. 4. Apply sterile gauze compress. 5. Bandage. 6. Reinforce bandage with adhesive plaster strips. Sprains 1. Shave. 2. Bandage. 3. Transport to doctor. Burns 1. Cleanse gently with saturated solution of soda bicarb. 2. Apply 3% soda bicarb, ointment or in mild cases powder with Compound Stearate of Zinc. 3. Apply dry sterile dressing held in place by a not too snug bandage. Strains (back) 1. Strap using straps 3" wide. 2. Bake with electric heater. Fractures 1. Put injured part at rest by immediate im- mobilization in appropriate splint. 2. Summon doctor. Haemorrhage 1. Paint rapidly with iodine. 2. Apply mass of 3 in. x 3 in. sterile gauze com- press held snug with bandage. 3. Splint. 4. Apply tourniquet only if absolutely neces- sary. 5. Summon doctor. ACCIDENTS AND THEIR TREATMENT 87 Eye Injuries 1. Flood eye with 4% Boric Acid solution. 2. Wipe out loose particles with sterile cotton swab on applicator. 3. In case injury is severe or if foreign body is imbedded in cornea, drop castor oil freely into eye, apply sterile gauze, bandage loosely and send to physician. Such standardized treatment when used by each hospital worker in exactly the same way inspires the confidence of the worker and rapidly proves to the medical staff the value of the treatment. Any method which does not give good results is imme- diately apparent and can be changed for a better. While trivial cases can be safely treated by a specially trained nurse under the supervision of one of the medical staff, all cases of moderately severe injury should be seen by a doctor at once. The efficiency of the first treatment and accuracy of diagnosis plays a most important part in the rapidity of recovery and the functional end result obtained. As an aid to diagnosis and treatment the value of a small X-ray equipment cannot be over- estimated. All injuries to the extremities of a twist- ing or crushing nature should be X-rayed as should all cases of sprain and strain. The number of slight fractures which occur as the result of industrial accident is striking. If treated by immediate im- mobilization, rest and early mobilization, they do well. If treated as minor injuries they produce prolonged disability. It is always advisable to X-ray the spine and sacro-iliac regions after alleged back strains. The author has found that the great major- 88 HEALTH SERVICE IN INDUSTRY ity of incapacitating back strains are due to either a true sacro-iliac sprain or to an unsuspected chronic arthritis of the spine. When there is an underly- ing pathological condition, a very slight strain of the back is followed by marked spasticity of the back muscles and prolonged disability. In cases of fractures of the fingers, proper reduc- tion and retention are imperative if function is to be required. Fracture of the proximal phalanx, especially if comminuted, is the most difficult finger fracture to treat and the results are usually most disappointing even when good reduction is obtained. The industrial surgeon should study this type of fracture with great care for if a stifi finger results, as is frequently the case, amputation may be neces- sary. Moderately severe crushing and lacerating in- juries require a general anaesthetic and a surgical debridement similar to that used on war wounds. We have found that the French method of flushing the wound with ether following debridement, minutely careful haemostasis, approximation of deep structures in order that dead space be elimi- nated, and the free use of dichloramin T will pro- duce a sterile wound in almost every case. Puncture wounds of the foot caused by nails pro- truding from boards is a fairly common accident which should always be considered as moderately severe. Thorough treatment of the wound by in- jection of gasoline and iodine is usually successful in preventing infection. ACCIDENTS AND THEIR TREATMENT 89 The above are types of moderately severe injury commonly met in industry. In order to treat these and similar injuries properly ,^ the surgeon should have an assistant capable of giving a general anaes- thetic, unless he sends cases of this type to a gen- eral hospital for treatment. Severe accidents require the immediate attention of a doctor. First aid should be given the patient at the point where the accident occurred, but this should be of the simplest type. Transportation should be done only under the doctor's direct super- vision. In each sub-dispensary or at each first aid sta- tion, there should be a stretcher, with blankets, a first aid outfit packed for immediate use and a Thomas hip splint. These three should be brought to the patient as quickly as possible. The patient having been placed on the stretcher is transported to the central dispensary where fur- ther semi-definitive treatment is carried out prior to the patient's final transportation to a general hospital. The arrangement of personnel for handling acci- dents may well be as follows : At each sub-dispensary one or two nurses depend- ing upon the activity and size of the zone covered. Each sub-dispensary is visited daily by a doctor who makes an investigation of all trivial injuries which are not doing well and of all moderately severe injuries under treatment. At the central dis- pensary there is always a doctor and at least one 90 HEALTH SERVICE IN INDUSTRY Report Sent immediately to S. E. Dep't for Recording Report Sent Immediately to S.E.Dept.for Records and Reporting to State and Insurance Co. Fig. 6. (a) Course of a Patient Having a Trivial Accident (b) Course of a Patient Having a Moderately Severe Accident ACCIDENTS AND THEIR TREATMENT 91 At Work Employment Department Finds Work Which Patient .Can Perform . Nearest Branch Hospital Immediate Treatment If Unable to Resume Old Work at Once Safety Eno/.r'gDep't Compensation Payments Main Factory Hospital Intermediate Treatment Main Factory Hospita l Observations Dressings Release Home Visiting Nurse Calls Report set immediately to S. E.for Recording and Repairing to I nd. Ace. Board and Ins. Co. Fig. 6. (c) Course of a Patient Having a Severe Accident (Courtesy of Oxford Loose Leaf Medicine) 92 HEALTH SERVICE IN INDUSTRY nurse in constant attendance. All moderately severe injuries are treated there as well as those cases of severe injury which have been discharged from the general hospital. To recapitulate: 1. All cases of slight injury are treated at first aid stations or sub-dispensaries and re-treated at sub-dispensaries by a trained nurse. 2. All cases of moderately severe injuries are treated at first aid stations or sub-dispensaries for first aid, and are transferred at once to central dispensary for definitive treatment by doctor. 3. All cases of severe injury are treated by doctor who supervises transportation. Semi-definitive treatment is given at central dispensary and final or definitive treatment is given at a gen- eral hospital. Every case of injury establishes a contact with the Safety Engineering Department and whatever department reports accidents under the Workmen's Compensation Act. In many cases this is a branch of the Safety Engineering Department. This contact consists of : 1. An investigation of the accident by the Safety Engineer to determine its cause and possible future prevention. 2. A report of the accident (a) to the proper state authority (b) to the insurance company. 3. Recording the accident from the point of view of time lost and compensation due. 4. Arrangement with employment manager for placement of injured worker, after consultation with doctor as to type of work the injured em- ploye should do when able to return to work. ACCIDENTS AND THEIR TREATMENT 93 Every case of severe injury also establishes a contact with the visiting nurse's service. This con- tact consists of : 1. A report of the case to the visiting nurse with a request to visit the injured man at his home or at the hospital. 2. A series of reports by the nurse to doctor of the progress of the case. This is entered on the worker's medical record. 3. A report to the doctor when the patient is dis- charged from the general hospital in order that the doctor may visit the case if necessary. 4. The visiting nurse frequently brings moderately severe injuries to the factory dispensary for dressings and acts as a transporting agent. At no time should the medical staff lose touch with the injured worker. His exact condition must be known and recorded from the time of the injury until he returns to work, and then any existing dis- ability must be clearly stated. The cycle of a severe type of accident is graphi- cally shown in the accompanying cut. (Fig. 6.) The Workmen's Compensation Act now in force in the majority of states makes accuracy of diag- nosis and a close following of the case obligatory. The importance of a careful history and thorough examination is well shown in the following case of supposed back strain: J-H, 44 years old, married, machinist. Past History: Apparently normal man when hired Feb. 19, 1918. About two years ago severe pyor- rhea for which all teeth removed. About a year ago, noticed he was losing weight and did not feel quite well. At the same time he noticed he was drinking large quantities of water and urinating 94 HEALTH SERVICE IN INDUSTRY freely. He paid no attention to this and did not consult shop hospital or physician. Present History: On November 6, 1920, at 11:30 a. m., while lifting welding tanks, felt a catch in his left back. On November 11 at 4 p. m., he came to the shop hospital complaining of pain in his back. He was strapped and baked. He was treated every other day until November 17, 1920, when he was examined by a doctor whose examina- tion report is as follows: "Patient stands with slight list to left, low dor- sal and upper lumbar scoliosis. Motion: flexion forward, restricted to about one half, to the left about one third, to the right considerably less than one fourth. Diagnosis : Sacroiliac strain with pos- sibly underlying infectious arthritis." Patient sent next day to Memorial Hospital for X-ray of back and application of plaster cast. X-ray was negative. During routine examination urine was found to be four plus for sugar. Diagnosis: Severe diabetes. Transferred medi- cal. Patient put on anti-diabetic diet and further examinations made. Found to be a total diabetic with tendency to acidosis. Acetone and diacetic acid in urine. Examination of abdomen at this time disclosed a feeling of resistance in left lumbar region. Patient since admission ran a low irregular temperature varying between 98 and 100, and a slightly in- creased pulse averaging 90. Blood count showed 24,800 white cells. Differen- tial 90% polys. On November 29, the mass in the lumbar region had become pronounced extending from under ribs to anterior-posterior spine. It was slightly tender on pressure and pressure upon the mass elicited pain down left sciatic nerve. The pain is the same as that complained of since the back strain. The mass feels tense, seems to be present in the lumbar region posteriorily and suggests fluctuation. ACCIDENTS AND THEIR TREATMENT 95 Diagnosis: Perinephritic abscess in left kidney region possibly involving pancreas. Operation of incision and drainage under local anaesthetic advised but refused by patient who left the hospital at own risk. December 6. Accepted operation. Incision re- vealed abscess of left kidney and perinephritic region with about two quarts of pus. December 12. Patient died in diabetic coma. Comment: There seems to be no question but that this patient had diabetes becoming total, fol- lowed by secondary abscess of the kidney which in breaking down caused a perinephritic abscess. The history of back strain was false and the symptoms simulating back strain were due to the condition of the kidney. The error made in the factory medical depart- ment was in not eliciting a complete history before sending the case to the general hospital. A well- taken history would have suggested diabetes at once, and the urine would have been examined. The close association of diabetes with infection might have suggested an infection as the cause of the back symptoms. The importance of confidence in the surgeon and its effect on the psychology of the patient has been well brought out by Mock. Summed up he advo- cates handling each severely injured worker as a private case, explaining fully what is to be done and why, and following operation to constantly main- tain the morale of the injured man by encouraging talks and some form of manual occupation which can be done by the patient while in bed. The after-care of industrial accident cases is one of the most important and difficult duties of the 96 HEALTH SERVICE IN INDUSTRY industrial surgeon, for in many cases the recovery is necessarily slow. No man can do well if lie is worrying over the support of his family and his final ability to work. The industrial surgeon must see that aid is provided the family when necessary, or that arrangements are made by which the wife can add to the income. In this part of the work the services of the visiting nurse are invaluable. As fast as the injured worker is able to resume any kind of work whatever, it should be provided him, not only for the effect on his morale, but also as a therapeutic measure. The war has proved con- clusively that restoration of function is more rapidly obtained by early active motion and consequent mobilization than by any other measure. The inter- est of the injured man in the work he is doing also plays an important part in the final result. A care- ful study by the industrial surgeon of the rehabili- tation methods used in France, England and Canada, during and following the war, will be of great value as a guide. CHAPTER VIII SICKNESS IN THE FACTOEY Sickness is the leading cause of absenteeism in industry. It not only causes absenteeism but also poor work and abnormal fatigue. Its effect upon the working classes has resulted in drastic relief laws in many countries. It is equally disastrous in its effect upon worker and management. The object of the health department in a factory is to prevent as much sickness as possible; to abort be- ginning sickness when this can be done, to prevent contagious disease entering the factory, and if it appears, to prevent its spread, and to instruct the workers in all matters connected with their health and welfare. Its object is also to treat minor cases of sickness which would not otherwise receive medi- cal attention and to give emergency treatment and advice in cases of sudden severe illness. It should endeavor in every way to co-operate with the fam- ily physicians of workers having chronic disease, and to carry out any suggestions made by the family physician as regards change of work or other mat- ters which are under its control. The medical work of the health department may, therefore, be divided into preventive, diagnostic, co-operative and curative. 97 98 HEALTH SERVICE IN INDUSTRY Prevention of Sickness The health department endeavors to prevent sick- ness in the factory: 1. By a complete physical examination of all applicants for positions. 2. By examining all workers who have been out because of sickness before they are allowed to return to work. 3. By examining all cases of sickness applying at the factory dispensary with symptoms suggest- ing beginning sickness. 4. By promptly isolating all cases of contagious disease. 5. By periodic examination of all workers having beginning chronic disease, cardiac, renal or metabolistic and advising them as to work and mode of life. 6. By periodic examination of all workers exposed to any special health hazard or poison in the factory. 7. By inspection and control of ventilation, heat, humidity, light and other general working con- ditions falling under sanitation. 8. By devising and controlling safeguards for special health hazards and poisons in industry. 9. By spreading among the workers simple facts about health and disease prevention by personal talks and leaflets. The majority of these measures explain them- selves. Their reason is obvious and the technique apparent. The physical examination of all workers has been described in a preceding chapter. Workers who have been out because of sickness should be obliged to report at the nearest dispensary before being allowed to return to work. The nurse can then determine whether or not a doctor's examination is SICKNESS IN THE FACTORY 99 necessary. Whenever a worker applies to the dispen- sary for treatment, the nurse should take a careful, concise history and if there is the least suspicion of real sickness being present, the temperature and pulse should be taken and the doctor called or patient sent to him. When a patient presents himself with contagious disease he should, of course,be sent home, the City Board of Health notified, and those work- ing near him examined and advised. Fortunately, contagious disease is rare in factories. In four years' experience of a factory employing 3,600 there were but two epidemics of contagious disease, one of mumps with 73 cases, 56 during the epidemic year, the other German measles with 27 cases about equally divided between two years. During the four- year record there was one case of small pox and 87 vaccinations were done. The initial physical and subsequent examination is pretty sure to reveal any case of chronic disease in the worker. When such a condition is found the patient is given a very complete examination which is entered on a special form usually several pages in length. Following the examination the doctor dis- cusses with the patient the condition found, and in- structs him as to the general rules of life he should follow. If the patient's condition requires it, the doctor then arranges that he put himself in the hands of a private practitioner, and finally by con- sulting with the employment department so ar- ranges the patient's work that he can carry it on with safety to himself and others. 100 HEALTH SERVICE IN INDUSTRY Health ^Safety Bulletin May 1916 Norton Company Health and Sanitation Department Worcester, Mass. Fig. 7. A HEALTH BULLETIN SICKNESS IN THE FACTORY 101 Many factories have in their processes of manu- facture some distinct health hazard. The Metropoli- tan Life Insurance Company has analyzed these and divided them into the following classification: a. Dust, b. Heat, c. Humidity, d. Poisons. When- ever such hazards exist they must be carefully studied by the industrial physician and every effort made to protect the worker against their effects. Not only must the exposed worker be protected but he must be periodically examined to determine whether or not he is being affected by his working conditions. A complete examination once in three months is a good rule to follow. A great deal of good can be done by quiet talking with the worker when he presents himself to the doc- tor at the dispensary. Every case should be treated by the doctor as he would a private patient. Many workers are foreigners and the doctor and nurse must use the simplest language in the kindest way if they wish to make the patient really understand the treatment he should carry out. In the majority of cases drugs play such an unimportant part that they may almost be eliminated, but the patient must be made to understand the importance of simple hygienic measures, diet, sleep and similar subjects. Health bulletins in the form of single sheets or folders written in simple language, easily under- stood and distributed in pay envelopes are of un- doubted value. Many factories have adopted this form of instruction. The subjects cover the com- mon diseases and injuries. (Fig. 7.) 102 HEALTH SERVICE IN INDUSTRY Accurate diagnosis is the basis of all good medi- cal work. Poor diagnosis is more frequently due to carelessness than to lack of knowledge. In in- dustrial work as in hospital dispensary work, there is a temptation to inaccurate hasty diagnosis be- cause of the number of cases and the fact that many of the conditions presenting themselves are trivial. The industrial physician must always remember that he is in a unique position in medical practice. To him as to no one else is open the chance of study- ing disease in its earliest forms often before any pathology can be demonstrated. The general prac- titioner, according to MacKenzie, has the best op- portunity of studying early changes in heart disease and following cases through long periods of time. The industrial physician has an even better oppor- tunity for early diagnosis and continued study of cases. While it is true that there is a large turnover in every factory, it is also true that about fifty per cent of the workers remain employed over periods of from five to twenty years and can be re-examined and studied at any time convenient to the doctor. This opportunity for study should be used to its full extent. It is not as yet recognized by the pro- fession at large. The great opportunities of indus- trial medicine from the physician's standpoint con- sist of facilities for the study of disease in its very early manifestations and the ability to follow defi- nite pathological conditions over long periods of time. In order that definite diagnosis may be read- ily made, certain laboratory and diagnostic equip- SICKNESS IN THE FACTORY 103 ment must be on hand, but this is never very ex- pensive nor does it occupy much space. Except in isolated communities a general hospital is usually available at not too great a distance where the more intricate chemical and X-ray examinations can be made. Co-operative Work In order to in any way do adequate medical work, the health department and its personnel must co- operate with the foreman, the worker and the gen- done away with. The worker must receive prompt must be modeled upon private practice, and yet the interminable waiting of private practice must be done away with. The worker must receive prompt attention, thorough examination, clear advice and be able to return to work in a minimum time. If the worker is given service of this kind he will use the dispensary freely and report back for further examination willingly when called for by the doctor, even when he is a piece worker. The doctor must co-operate with the foreman by not calling a man away from his work for an exami- nation unless the foreman says he can be spared. He must also obtain the co-operation of the foreman in changing the work of men who are handicapped by some physical disability. A foreman who is thor- oughly in sympathy with the health department and its ideals is a constant source of help to the doctor. Last and most important is co-operation between the industrial physician and the general practi- tioner. This relationship has only recently been 104 HEALTH SERVICE IN INDUSTRY recognized. There has been a tendency in the past for the general practitioner to look askance at the industrial physician and the industrial physician to consider very little the problems of the general prac- titioner. For the good of the patient there should be close co-operation and this can easily be estab- lished if the problem is understood by both. If the practitioner is really interested in maintaining the health of his patient who is suffering from some chronic condition, or who has some physical defect, he can obtain very great assistance from the in- dustrial physician at whose factory his patient works. A short letter or telephone conversation puts the industrial physician in touch with the wishes of the patient's physician and he is able to assist by arranging the patient's work and, perhaps, by giving certain forms of treatment at the factory dispensary. For instance in a case of chronic ar- thritis, the industrial physician can arrange that the patient's work shall not be in cold or damp work rooms, that he receive systematic baking of the affected joints, and that his mouth be kept in good condition by the factory dentist. Moreover, if the patient does not seem to be doing well, he can send him back to his doctor with comments of value be- cause of his intimate knowledge of the patient's working conditions and reaction to environment. The industrial physician should use specialists outside of the factory with great freedom. It is his duty to see that patients needing special work be urged to have this attended to. Here, again, co- SICKNESS IN THE FACTORY 105 operation is of the greatest value. The specialist frequently has certain changes of work to suggest or treatment to be given which can be carried out at the factory dispensary. In factories which exist in small towns the factory dispensary may easily become a medical center at which X-ray and laboratory work can be done at a trifling charge for the doctors in the community. Such work is now being done in a number of fac- tories and does a great deal not only to promote co- operation but to help the local practitioners obtain diagnostic data which they could not otherwise ob- tain. Curative Work This is confined entirely to the treatment of trivial sickness in an effort to prevent something more serious from developing. The most common diseases occurring in factory practice are those of the upper respiratory tract. This is the universal experience of industrial phy- sicians. In the author's clinic an analysis of the sickness covering a period of four years resulted as follows : Number of Cases of Sickness per 100 Employes 1916 1917 1918 1919 Respiratory 74 68 139 140 Digestive 35 35 68 88 Infection, Inflammation and Skin Disease 26 24 40 53 Nervous 15 13 35 45 Muscular 14 9 17 21 Eyes 15 12 17 15 106 HEALTH SERVICE IN INDUSTRY Ears 3 2 3 5 Miscellaneous 6 23 26 26 Total 188 186 345 393 The predominance of respiratory and digestive diseases is noteworthy. The startling increase in number of cases during 1918 and 1919 is due largely to the influenza epidemic following which not only respiratory but digestive and nervous conditions seemed to increase in number. During the period the two leading diseases of the upper respiratory tract were rhinitis and tonsilitis. Influenza though epidemic and very severe in its effects ranked third in number of cases. The figures representing the total number of cases treated dur- ing the four years are as follows : Rhinitis 5052 Tonsilitis 2654 Influenza 2356 In spite of the large number of cases of tonsilitis the number of cases of acute rheumatism and car- diac conditions was small, only 150 cases of acute rheumatism and 92 cardiac cases having been re- ported. The number of these which could be attrib- uted to tonsilitis has not been ascertained. Of the diseases of the digestive tract, constipation was by far the most frequent condition with gastritis a poor second. The complete list is as follows : Constipation 3060 Gastritis 1569 Indigestion 1426 Gastro Enteritis 493 SICKNESS IN THE FACTORY 107 Enteritis 855 Hemorrhoids 53 Gastric Indigestion 115 Appendicitis 28 Miscellaneous 119 The leading diseases in each of the other groups were: Infections, etc. Caries of teeth . . . 872 cases Skin Diseases Furunculosis 1028 cases Nervous Disease Headache 2976 cases Muscular Disease Myalgia 1360 cases Eye Disease Conjunctivitis . . .1271 cases Ear Disease Impacted Cerum. 229 cases Miscellaneous Disease Dysmenorrhea . . . 2269 cases On going over these diseases and figures it is evi- dent that except for influenza the majority can be more accurately classed as ailments than as diseases. It is also evident that they are of a character not only to cause considerable discomfort and disability but also to be in many cases forerunners of future more serious conditions. When the large number of these cases is con- sidered and the anxiety of both doctor and patient to arrive at a rapid but accurate diagnosis and some form of treatment recognized, it is evident that anything which will reduce time both in recording and dispensing is desirable. It has been found that a printed form, such as is shown (Fig. 8), is con- venient and time saving, the history, physical exami- nation, diagnosis and treatment being checked off with a pencil. The full advantage of this form of record will be shown when the general question of record keeping is discussed. In order that forms 108 Name Address HEALTH SERVICE IN INDUSTRY Norton Company Worcester, Mass. SICKNESS SLIP Health & Sanitation Department Time Treated No. Dept. Age M. S.W. Date Duration D. W. M. Phy. Exam. Diagnosis Treat Resp. Resp. Resp. Ac. Comp. Running Nose Coryza Coryza Bismuth Subnitr Cough Spts. on tons. Tonsilitis Brown Mixture Chills Crepitant r. Chr. Bronch. Rhinitis Expectoration Negative Ac. Bronch. C. C. & C. R. Sore Throat Sub. crep. r. Subac. " Castor Oil Feverish Granular Phar. Pharyngitis Hoarseness Dry pleurisy Chloroform & cloves Night Sweats Influenza Capsolin or liniment Laryngitis Dovers Powders grs. Dermatitis Abd. Abd. Abd. Sod. Salicylate Nausea Distended Gastritis Local anodyne Dizziness Tympan. Enteritis Paint I. & G. Vomiting Tender Ap Gastro ent. R. &I. Diarrhoea Mass in caecum Constipation Setter's Garg. Constip. Rash Appendx. Seidlitz Pulv. Abd. pain Indigestion Strapped Gen. Gen. Gen. Sputum Box Toothache Cavity Caries tooth Sent home Earache Impacted c. Otitis Media Silvol Conj. Chr. Rheum. Therap. lamp Nose bleed Ulcer of sep. Nose bleed Tr. Ginger Malaise T. Malaise Wash ears Gen. Pains P. Myalgia Massage _; . Rt. Chest Pam Lt. Chest Headache Headache Remarks: Fig. 8. A SICKNESS SLIP Filled in by Nurse or Doctor with a Series of Checks and Used to Record Cases of Minor Sickness. More Serious Sickness Is Noted in a Full Report SICKNESS IN THE FACTORY 109 such as this may be used and that dispensing be uniform, a certain amount of standardization must be employed. Every doctor has his own standard treatment for minor sickness, but the general proposition of stand- ardization can be carried out in any dispensary pro- vided every one in the department uses the same method of treatment, and only a certain number of drugs are provided. At the author's factory clinic the following is the regular practice and is given in order to suggest the basic idea: Respiratory System Pharyngitis Tonsilitis Local Treatment Systemic Treatment Paint with Tr. Pil. Rhei Comp. Pil. Iodine and Glycerin Cath. Comp. aa 1 pill equal parts. at night. Soda Sal- icylate gr. v q. 3.h. Coryza Trachitis Mild Bronchitis without Systemic Symptoms Advise warm cloth- Pil. Rhei - Pil. Cath. ing and protection Co. aa 1 pill at night. of feet. Alboline Pulv. Doveri gr. 10 spray for nose. Ar- with hot lemonade gyrol 15% instilled with above. Tab. in eyes S. 0. S. Belladon. Dover's Powder Co. (Dela- field) one q.h., for 4 doses then q.2.h. or Tab. Glyc. Co. for cough q.2.h. S. 0. S. Digestive System Indigestion Gastritis (Mild) None Pil. Rhei et Ipecac No. 3 (Roosevelt Hospital). 2 after meals with a cup of hot water. Very light diet. 110 HEALTH SERVICE IN INDUSTRY Gastro Enteritis (mild) Enteritis (mild) Constipation Advise mustard Very light diet. Bis- paste to epigastrium muth Subnit. gr. 10 at night. stat. with Tr. Zingi- ber dr. 1 in hot water. Bismuth Subnitr. gr. 5 q.3.h. or each time bowels move. Castor oil oz. ss at night if no vomiting. Advise regularity Anti-constipating and special exercise, diet. Seidlitz Pulv. stat. Pil Rhei Co. Pil Cath Co. aa 1 pil at night follow by Extr. Cascara gr. 5 q.n. Nervous System Headache Paint forehead with local anodyne. Pil Acetanilid Co. gr. 1 every hour for 3 doses. Treat con- stipation if present. There are standard forms of treatment for other conditions which are common but the above should give a clear idea of the method. All standard forms of treatment should be at the doctor 's hand and the pills and tablets should be ready in envelopes labeled with the name and amount of the drug and full directions as to use. Only a minimum number of tablets should be dispensed not only for economy but in order to have the patient return to the dis- pensary for further attention if a cure is not im- mediately effected. CHAPTER IX SANITATION The control of sanitation is the third function of the health department. Sanitation comprises the use of sanitary appliances, and deals with the con- trol of the external factors of environment which effect the health of the worker. The conditions re- quiring control are ventilation, illumination, tem- perature, humidity, drinking water, dust, and nuis- ances, especially those which may produce disease. The setting up of sanitary appliances and their maintenance in good working condition is the duty of the engineering department. The selection of the type of appliance, the study of its efficiency, the maintenance of cleanliness and the study of the effect of environment upon the health of the worker are sanitary duties. The purely health side of this work must be carried out by the industrial phy- sician, but the laborious portion should be placed in a separate sanitation department in charge of a sanitary foreman or inspector. The sanitary foreman is directly responsible to the chief physician. He has in large factories sub- foremen, and each sub-foreman is in charge of the sanitation in a certain section of the plant. For the cleaning of this section he has under his control a 111 112 HEALTH SERVICE IN INDUSTRY number of workers who give their full time to the work. It is the duty of the industrial physician to in- vestigate, and by co-operation with the engineering department, control: 1. Ventilation. 2. Illumination. 3. Heat and Humidity. 4. Dust. 5. Drinking water. 6. Disposal of sewage. Each of these will be discussed in detail. It is the duty of the sanitary inspector to control by the work of his force : 1. Cleanliness of toilets and locker rooms 2. Cleanliness of windows and electric lights 3. Cleanliness of all floor space in order that dust hazard may be reduced 4. Setting out and cleansing cuspidors 5. Collection and disposal of litter and refuse 6. Trapping of flies and extermination of vermin Ventilation When a number of individuals breathe air in a confined space certain chemical changes in the at- mosphere of the space occur. There is a reduction of oxygen, an increase of carbon dioxide, and an in- crease of possibly slightly toxic protein substances which are emanated from the skin and lungs. There are also physical changes consisting of increase of heat and humidity. The reduction of oxygen and increase of carbon dioxide, which occur in the aver- age factory even when poorly ventilated, are of no harm to the healthy worker. The carbon dioxide SANITATION 113 content is, however, frequently used as an indicator of the general condition of the air in a given space. The protein emanations are the substances which cause the unpleasant odor, "stuffiness" and head- ache. The exact nature and degree of toxicity of these substances is as yet unknown. Physiologists lay special stress upon heat and humidity, the two physical factors, as being the true dangers of an overcrowded workroom. Combined they lower effi- ciency and are distinctly prejudicial to health. The object of ventilation is, primarily to reduce abnormal heat and humidity and to remove the pro- tein emanations. Secondarily, it acts as a stimulant by breaking up the warm stagnant air film which forms about the body, and by initiating currents of air which strike the skin at varying angles. This motion of air has been found to be most important, but must not be confused with the direct current of air which causes a " draught." The latter is uncom- fortable and unhealthful. There are three methods of ventilation in general use; by windows, doors, elevator shafts and other openings which occur in every building; by artifi- cially sucking air from the part to be ventilated ; and by forcing fresh air into the part to be ventilated. Frequently the last two are combined. Whatever method is used the industrial physician must see that it is efficient and that the air conditions in all departments of the factory are satisfactory. In those departments where there is question in his mind as to the efficiency of ventilation, carbon diox- 114 HEALTH SERVICE IN INDUSTRY ide readings should be made, and where there ap- pears to be an abnormal amount of heat and humid- ity an hygrodeik should be installed and changes instituted following its readings. The special duties of the industrial physician in industrial ventilation consist of : 1. Routine inspection to detect poor ventilation. 2. Conference with the engineering department on questions of ventilation especially the installa- tion of new ventilation when this is contem- plated or repair of the old system. 3. Routine temperature and humidity readings in special departments and co-operation with the engineering department in reducing this hazard. 4. Inspection of hoods, suction apparatus, etc., for the removal of fumes or dust when these are in operation. 5. Special attention to the ventilation, and the elimination of offensive odors, in toilets and locker rooms. To sum up factory air should not contain more than six parts of carbon dioxide in 10,000. , This means a supply of 3,000 cubic feet of pure air per person per hour. The temperature whenever pos- sible should not exceed 68° and the humidity should not exceed 72° wet bulb. Illumination There are two means of illuminating a factory, natural and artificial. Both are always employed. Natural illumination is obtained by windows, sky- lights, etc. It varies in different factories and in different parts of the same factory. The cause of variation is the amount of window or other lighting SANITATION 115 space, the size of the floor space to be lighted, and the neighborhood of obstructions to light in the form of neighboring bnildings, wings, and so forth. Where there are no obstructions there is little trouble provided the builders have allowed an ade- quate amount of window space. Where there are obstructions the angle of incidence of light, that is, the angle formed by the admitted beam of light and a horizontal line passing through the window, is greatly increased. The result of this is increasingly poor illumination as the center of the room is ap- proached. This angle of incidence may be reduced by the use of ribbed glass or in extreme cases by the use of prism glass. During the "greater part of the working day in the winter months, and during some part of every day artificial lighting must be used. This is obtained from electric or mercury vapor light. Most factories prefer the former, using the Tungsten bulb and a proper reflector as a standard unit. The placing of the artificial lighting is arranged by the engineering department. Its maintenance should be controlled by the industrial physician. Illumination is measured in foot candles by a special apparatus called the photometer. ' ' One foot candle is the intensity of illumination produced on a surface one foot distant from a lamp of one candle power, the surface being at a right angle to the light rays." (Shop Lighting, National Safety Coun- cil No. 22.) 116 HEALTH SERVICE IN INDUSTRY Certain standards of lighting have been agreed on as good practice. The National Safety Council recommends these as follows: Roadways and yard thoroughfares %o to % foot candles Storage spaces % to 1 foot candles Stairways, passageways, aisles 1 to 2 foot candles Toilets and washrooms 1 % to 3 foot candles Rough manufacturing, such as rough ma- chining, rough assembling, rough bench work, foundry floor work 2 to 4 foot candles Rough manufacturing involving closer dis- crimination of detail 3 to 6 foot candles Fine manufacturing such as fine lathe work, pattern and tool making, light colored textiles 4 to 8 foot candles Special cases of fine work, such as watch- making, engraving, drafting dark col- ored textiles 10 to 15 foot candles Office work such as accounting, type- writing, etc 4 to 8 foot candles There are three fundamental items of artificial lighting; intensity, distribution and absence of glare. Intensity can be measured, and to a certain degree controlled, by the industrial physician. This is carried out by controlling the maintenance and seeing that lights and reflectors are regularly cleaned, that burned out bulbs are replaced, and that dingy paint on the walls and ceilings is cleaned or renovated. Distribution of light is in the hands of the engi- neering department, but the industrial physician should see that the distribution is sufficient for the field to be illuminated. Most factories are under- illuminated. Absence of glare is most important SANITATION 117 and can be controlled by the proper placing of shades and by selecting the proper type of reflector. There are three types of artificial illumination, direct, semi-direct and indirect. The first is almost universally used and is present in some part of any factory. It consists of the shaded electric bulb light. Semi-direct light is produced by placing the bulb in a semi-transparent bowl surrounded by a reflector. A small part of the rays of light pass through the bow], but the majority are reflected up to the ceiling and thence reflected about the room. Indirect lighting is when the bulb is hung in an opaque bowl lined with a reflector. The rays of light are directed or reflected to the ceiling and thence throughout the room. Both semi and indirect methods of lighting are employed in factories, the former more than the latter. The advantage of in- direct lighting is the absence of shadow, the disad- vantage is the high wattage lamps needed and num- ber of rather expensive fixtures plus the difficulty of cleaning. Indirect lighting requires a great deal of cleaning to be kept efficient. While many modern factories are using general lighting for all illumina- tion, the majority still use local lights for machine illumination. When these are used special care should be taken that the operators ' eyes are shielded from direct rays of light. The three dangers to be avoided are over-illumination, causing over-stimula- tion of the retina and contracted iris, under-illumi- nation producing eye strain, and reflected light from brightly polished metallic surfaces which tends to 118 HEALTH SERVICE IN INDUSTRY confuse and to produce the effect of over-illumina- tion. Heat and Humidity The importance of this problem has been pointed out under ventilation. In many parts of most fac- tories heat considerably above 68° Fahr. is unavoid- able. Coupled with this is, frequently, excessive moisture making the working conditions most un- satisfactory. The more heated the air, the more moisture it will hold, and the greater the amount of moisture in the air, the more difficult it is for the human body to maintain its temperature equilib- rium. The temperature of the body rises under these circumstances, causing an artificial fever, and resulting in a distinct menace to health. Every effort should be made to keep the air in such depart- ments in active motion, using electric fans if other methods cannot be applied. The industrial phy- sician must meet the particular problem as it pre- sents itself and solve it to the best of his ability. In- asmuch as heat and humidity, far above the health limit, are necessary to many processes, attention must be paid to the personnel in these departments, and they should be re-examined and considered as men working in any department where there is a dis- tinct health hazard. Dust Many industries have dust as a health hazard in some part of production. Dust may be organic or inorganic. The former, though irritating, is not SANITATION 119 seriously harmful, that is, it does not produce per- manent change in the lung as is frequent after long periods of inhalation of inorganic dust. Inorganic dust is harmful, producing, if inhaled over a long enough period of time, a connective tissue infiltra- tion of the lungs, closely resembling fibroid phthisis. The symptoms are those of phthisis without fever, there being cough, a gradual loss of weight and strength and rather marked dyspnoea on slight exertion. Except in special trades there does not appear to be a very serious danger from dust as it requires years of constant exposure to produce definite lung changes. Inasmuch as only those dust particles of 10 microns or less reach the lung, and as these fine light particles are for the most part removed by the exhaust system used in dusty trades, the hazard is further reduced. It is also important to note that the turnover is usually high in dusty de- partments, the workers preferring work elsewhere. This naturally prevents prolonged exposure. The most dangerous types of dust are the siliceous and zinc, of much less danger are dusts of softer substances as plaster of paris or coal. While fibrosis of the lungs is not common it is far from being a rare condition, and is prevalent in cer- tain trades especially among miners and stone cut- ters. Where the dust even when very hard can be removed by suction apparatus, the disease is seldom found. However, there is a tendency to an increase of respiratory disease in dusty departments as com- pared to non-dusty, and an irritating hard dust even 120 HEALTH SERVICE IN INDUSTRY in small quantities will undoubtedly excite the light- ing up of an old tubercular lung process. The responsibility of the industrial physician in regard to dusty departments consists in an estimate of the hazard, a dust count if advisable, advice as to need of installation of an exhaust system, inspection of dust removing apparatus to determine its con- tinued efficiency, periodic examination of men work- ing continuously in dusty departments, and transfer to other departments of any who show a tubercular tendency even when no disease is manifest. Drinking Water The importance of a copious supply of clean drinking water in any industrial plant is self-evi- dent. In those plants where the factory receives its water through the city water supply, there is nat- urally no problem except when city water is con- taminated, a very rare occurrence. When the factory is isolated and has its own water supply, the industrial physician should test or have tests made of the water at regular intervals. In some cases where the water supply is impure, chlorinating the water will be necessary and fre- quent routine examinations should be made. The type of drinking fountain used is important. It is now considered advisable, when putting in a new installation, to use the type in which the stream forms an arc. The straight up and down fountain stream is not considered as clean, but it is more con- venient to use and, therefore, generally preferred by the workers. The temperature of the water [3 1 l*w/| \Pr<,nfZ | | Plgni-3 \ E U*^-3| ^«>«- HSmptr iSPIoor SS~„p», Wfhor As~tef*r 1 Z-j> ■ / •• 2* J - \z*. & ■■ \ ?=?■ • ■ # - 3* ■ 1 ■■ ^^ wm«~ • LTr g< " t»»2- ' kbjAftK*.*-; O/KV* C/«m Cc/lecf.nff' Fig. 9. ORGANIZ SANITATION 121 should be between 45° and 50° F. when possible. Too cold water is very apt to cause gastro-intestinal up- sets when freely used by overheated workers in warm weather, while tepid water is unsatisfying and nauseating. Disposal of Sewage Here again the problem arises only in special con- ditions where there are no sewer connections. The industrial physician must co-operate with the engi- neering department in the installation and mainte- nance of any septic tank or other apparatus neces- sary. The actual work of the sanitary department, as previously stated, is carried out by the sanitary foreman and his force of workers. The organiza- tion of this work is often elaborate as shown in Fig. 9. The industrial physician will usually find a com- plete installation of toilets and locker rooms in the factory. These usually vary in quality in different parts of the works depending on the age of the in- stallation. His first work will therefore be to get the already existing appliances clean. This is often very difficult. After continued use with improper attention — for the care of sanitary appliances is usually nobody's business — he will find much of the equipment in need of minor repairs and the bowls covered with a yellow scale which is responsible for the unpleasant odor. The preliminary cleanup given by the force under the sanitary foreman should be very thorough. Plenty of soap and water Fig. 9. ORGANIZATION CHART OF SANITATION DEPARTMENT IN A FACTORY OF 4,000 EMPLOYES 122 HEALTH SERVICE IN INDUSTRY for floors, walls and partitions, and a weak sulphuric acid solution to remove the scale from the bowls is the first step. After this preliminary cleaning the bowl should be washed daily with a soap powder, special atten- tion being given to the under side of overhanging edges beneath which scale collects. The condition of these places can only be seen by holding a small hand mirror in the bowl when many unsuspected catch places can be found covered with scale. After the washing, a spray of 1% Formalin should be used in the neighborhood. After a week's treatment fol- lowing this routine, a daily wash up with soap and hot water is all that is needed. If this routine is carried out a sanitary toilet is maintained such as is lacking in most factories. It is not the type of toilet but care and cleanliness which gives the sanitary result. Where new in- stallations are contemplated the Engineering De- partment should consult the doctor before deciding on the type of toilet to be installed. The National Safety Council makes the following recommendations : "Closets: Water closets should be of the in- dividual bowl type with individual water seal and should be made of white vitreous china or porcelain and not of enameled iron. Flush range closets which have been more or less extensively used are quite unsanitary and should under no condition be installed. The seat of each water closet should be made of wood or other non-heat-absorbing material SANITATION 123 coated with varnish or water-proof paint to make it impervious to water. Seats made of enameled iron ware, porcelain or other heat absorbing material should not be used. For sanitary reasons it is recommended that the bowl be of the extended lip type and that the seat be open front and back. ' ' There is qnite a difference of opinion regarding the best flush valve arrangement. Some companies which had installed seat-acting flush valve closets now favor a type in which the valve handle is placed alongside of and convenient to the user. A valve which may be tripped by foot-treadle has also been suggested. ' ' 1 ' One closet for each 20 employes on the same shift is generally regarded to be sufficient. Where only a few are employed it is advisable to increase this ratio. ,, ' ' Urinals : An adequate number of urinals should be placed throughout the plant convenient to work places to avoid loss of time required for men to walk to the toilet rooms. One urinal for each 40 males, or fraction thereof, is considered sufficient. Where- ever urinals are provided they should be in a suit- able enclosure. Provisions should be made for flush- ing out the rooms and keeping them in a sanitary condition. In each toilet room urinals should also be provided, the number depending upon their con- venience to workshops, and the number provided elsewhere in the plant. "Although the trough and basin urinals are used 124 HEALTH SERVICE IN INDUSTRY in many plants, the vertical slab (individual stall) urinals are now recognized as best." The equipment of locker rooms is usually some type of steel locker. The best type provides good ventilation and a slanting top on which articles can- not be placed. The lockers should always be on legs raising them from the floor in order that the floor beneath them may be readily flushed with a hose. A bench between rows of lockers is a convenience for those changing clothes. The locker room is often used for a washroom as well as for lockers. (Fig 10.) The type of wash basin depends on the age of the installation. The National Safety Council recom- mends as follows: "The most desirable type of washing fixture for plant usage is a trough over which are placed hot and cold water pipes with faucets for washing, spaced not less than 24 inches apart, thus giving each man sufficient space for washing without splashing his neighbor. Double width troughs hav- ing faucets facing each side are in common use. Many companies place the single width troughs back to back; this arrangement providing a partition be- tween washers on the two sides. The troughs or basins should be made of porcelain enamelled iron or other impervious material which may be kept clean easily.' ' The sanitary force should clean locker rooms daily and keep metal work on washing appliances well cleaned and shining. Each locker room should be provided with at least one large waste can for Fig. 10. A GOOD LOCKER AND WASH ROOM Note 1. Good light and ventilation. 2. Steel lockers raised from floor. 3. Shower baths at end. 4. Faucets arranged for washing under stream of water. 5. Cement floor and drain allowing hose washing. SANITATION 125 papers, soap tins and other refuse and this should be emptied daily. Lockers should be cleaned once a month and whenever one is vacated. Each employe should have an individual locker. Ventilation, heating and daylight should be adequately provided. All these items require a certain amount of supervision and checking up by the industrial physician in addition to the actual work done by the sanitary force. The importance of keeping windows and electric lights clean was pointed out in discussing illumina- tion. The sanitary force should contain a certain number of window and lamp cleaners who should have a regular schedule of cleaning. They should also see that broken or defective lamps are replaced. In addition to cleaning toilets, locker rooms and lighting, the floor space of the whole factory should be thoroughly cleaned in order that dust may be reduced and tripping hazards eliminated. A certain amount of floor space should be assigned to each sweeper and he should be held responsible for his district. The same man should be responsible for the care and cleanliness of any cuspidors, drinking fountains, or other sanitary appliance. In most factories cuspidors must be installed. They may be of cardboard, but a large earthenware cuspidor with an inside glazed surface, half filled with a mixture of sand and chlorinated lime, is probably the most satisfactory. These cuspidors cannot be overturned, are easily collected on a hand truck, and can be rapidly washed out with a hose. The sanitary force 126 HEALTH SERVICE IN INDUSTRY is also responsible for the collection of paper and refuse in the factory and the disposal of the same. It is often necessary to trap flies and rats. This is again a dnty which must be divided through the sanitary force. The sanitary foreman is responsible for the carry- ing out of these duties by his force and receives his authority from the chief physician. In small factories no such elaborate system is necessary; one or two men can be assigned all the sanitary work, these men reporting to one of the foremen or to the doctor. The important point is that sanitation, to be properly and economically carried out, should be the definite work of one or more individuals who have no other work to do. The advantage is that better work is done, the cost of sanitary work can be exactly figured, and some one is responsible for the sanitary condition of the whole plant. In many large plants sanitation is coupled with safety and both are controlled by an inspector of safety and sanitation. CHAPTER X SPECIAL PKOBLEMS There are three special problems which the health department has to consider. 1. The physical condition of the higher executives. 2. The study of health hazards peculiar to the in- dustry and their effect upon the health of work- men. 3. The study of early manifestations of disease in workmen. The health department has excellent facilities for studying all three and if earnest in its efforts has an opportunity for some very interesting clinical research. In any factory the higher executives are the guiding hands which control the success of the business. If these men can be kept in good physical condition their work will always be the best they can turn out. If one or more is laboring under a physical handicap, work when kept up produces a nervous strain which eventually requires a pro- longed rest. Each member of the executive force should have a physical examination. This should be much more searching and complete than that given the work- men. The order of examination should be as follows : 127 128 HEALTH SERVICE IN INDUSTRY 1. History — past and present. 2. Physical examination — special attention to (a) Organs of special sense. (b) The heart — functional tests — electro-car- diagraph if necessary — blood pressure. (c) The lungs — X-ray all suspicious chests. Temperature every afternoon for a week. Three sputum examinations. (d) The digestion — special care to eliminate ulcer of stomach. (e) The kidneys — careful, complete, urin- alysis one twenty-four hour specimen, further examinations if necessary. (f ) The prostate and rectum. (g) The blood — in any cases where blood smear indicated. Wassermann when in- dicated. 3. Check up any abnormal findings one month later. 4. Re-examination and advice as often as indicated. Naturally special conditions found indicate special examinations. The value to the company of routine examina- tions of this type is evident. The loss of a single executive may cause considerable difficulty in the management of any department. The knowledge that all executives are in first-class physical condi- tion is a great asset, while it is equally important that a valuable executive who is physically slipping should appreciate his condition and co-operate with the doctor in warding off a breakdown. The Life Extension Institute, through its writings, has called attention to the large number of men at or about middle age in whom degenerative proc- esses of serious nature are just starting. These processes, if discovered, can usually be checked or SPECIAL PROBLEMS 129 their progress greatly delayed by intelligent advice and management. The industrial physician is in a position to make examinations as often as they seem to be needed, and to supplement them by special examination at a general hospital if this seems neces- sary. This point, if no other, shows the great advan- tage of having the chief physician, or one of his assistants a member of the visiting staff of a neigh- boring general hospital. Vexed problems of diagnosis can be rapidly solved by sending the patient to the hospital for twenty- four hours where special X-ray, chemical, or other clinical investigations can be made. If there is enough evidence of trouble to indicate such an exam- ination the patient will readily assent. The records of the examination of executives should be kept in a special file by the chief physician and no one else should have access to them. Each case should be handled like a private case and rec- ords should be as inaccessible as in a practicing physician's office. The following examinations taken from the rec- ords of a large factory show the type of work which should be done. Mr. A. Date of examination, December 7, 1920. Physical findings: Mouth and throat, mild pyor- rhea. Several crowned teeth. Tonsils enlarged and ragged, no pus. Lungs, few coarse rales heard at left base, no change in breath sounds or in frem- itus. Heart, sounds of rather poor quality. Pulse 120. Rhythm regular. Apex 1 cm. outside of 130 HEALTH SERVICE IN INDUSTRY nipple line. Blood pressure 180/80. Rectum, small internal hemorrhoids. Slight pruritis. History: Complains at present of a slight pain in the small of the back. Pain worse after he has been on his feet for any length of time. Cardio- Respiratory — takes cold fairly easily, and notices he has a cough which hangs on following any slight cold. Frequent attacks of tonsilitis when young, none of late. Dyspnoea on exertion. Palpitation at times. Gets excited rather easily and at these times the palpitation is worse. Occasionally has a feeling of substernal distress. Genito-Urinary, Nocturia occasionally. Laboratory: Blood tests, hemoglobin 90%. Was- sermann negative. Blood urea nitrogen 12 mgm (normal). Two hour test for fixation of specific gravity, results given below. Tests show a ten- dency toward fixation of gravity in the afternoon, and it also shows a moderately increased night amount of urine. There was no albumen in any of the specimens and no blood, pus or casts in the sediment. Specific Salt Nitrogen Gravity Excretion Excretion 1024 1022 1006 1009 13.1 grs. 10.7 grs. 1013 1014 1015 Comment: This is a case of hypertension and apparently it is hypertension without any known cause. For lack of a better term these cases are called essential hypertension. As time goes on we can look for degenerative processes in the kidney, heart muscle or brain. A low salt, moderately low protein diet was outlined for this patient, and at the end of two weeks on such a diet his blood pressure was 140/80. It seems to me that he Time Amount 8-10 70 c.c. 10-12 110 c.c. 12- 2 465 c.c. 2- 4 490 c.c. 4- 6 315 c.c. 6- 8 200 c.c. 8- 8 585 c.c. SPECIAL PEOBLEMS 131 should stick to this sort of a diet over a long period of time. Furthermore, he should be cautioned and should if possible rest for at least a half hour dur- ing the middle of the day. Examination of the heart should be made every few months. It is im- possible to say whether or not the degenerative processes can be delayed. Mr. B. Date of Examination, November 9, 1920. Physical Findings : Teeth — Considerable den- tistry, few carious roots. Chest — Funnel shaped breast. Lungs — Slightly increased, normal signs right apex, no rales. Extremities — Knee jerks not obtained. Evidences of old infantile paralysis. History: Complains particularly of nervousness associated with headaches. Unable to think straight. Condition getting worse. Mother died of Melancholia. Cardio-Respiratory — Occasional palpitation at night. No tendency to colds. Genito- urinary — No nocturia. Neuro-Muscular — Head- aches are frontal in type, more on the right side, not relieved by sleep, usually present upon awaken- ing. Sleeps poorly. Nervousness began one year ago. Following a two weeks' vacation May, 1920, felt better for four months. Attacks of nervous- ness and headache generally come together. No gastric upsets. Slightly depressed mentally. In addition in 1912 had an attack of so-called sciatic rheumatism. Has an occasional twinge of rheu- matic pain now. Twelve years ago slight inguinal hernia right, no trouble at present. Laboratory — Urine, Specific Gravity 1010. Other- wise normal. Blood hemoglobin 90%. Smear nor- mal. Blood Urea — Nitrogen 15 mgm. Blood Salt — 645 mgm. Blood Uric Acid — 1.5 mgm. These findings are normal with the exception of the Blood Salt which is somewhat elevated. On the supposition that some of the symptoms might be due to kidney changes, in addition to the above mentioned blood tests, a 2-hour test was done Time Amount 8-10 280 c.c. 10-12 85 c.c. 12- 2 440 c.c. 2- 4 140 c.c. 4- 6 225 c.c. 6- 8 270 c.c. 8- 8 625 c.c. 132 HEALTH SERVICE IN INDUSTRY for fixation of specific gravity. The results of the 2-hour test are given below. It will be noted that there is a good variation in Specific Gravity but that there is a fairly large night amount of urine, somewhat higher than we normally expect. Specific Gravity fixed during late p. m. and night suggest- ing kidney fatigue. Specific Salt Nitrogen Gravity Excretion Excretion 1008 1020 1006 1018 9.7 grs. 13.8 grs. 1012 1012 1014 Totals.. 2065 c.c. Slightest possible trace of albumen was found in two of the samples. The examination of the sedi- ments was negative. (1) Note that the mother died of Melancholia, and that the patient is mentally depressed. (2) It is possible that some of these cases are due to kidney changes and for this reason a moder- ately low protein (60 grams) low salt diet was outlined for this patient with the hope that if adhered to over a period of time it might have some effect on the symptoms. (3) A careful neurological examination is, it seems to me, indicated. Each industry has its particular hazard and each factory has its share of these hazards. Processes are common in which toxic or mechanically injurious substances are used and frequently the signs and symptoms which the patient presents make an abso- lutely unknown picture. The harmful agents of these various processes are rapidly being eliminated SPECIAL PROBLEMS 133 wherever possible, but the industrial physician must be constantly on the watch and investigate any group of symptoms which suggest poisoning. Usually the hazard is already known and the symp- tom complex recognized. It is then necessary to watch for early symptoms and to endeavor to pre- vent definite disease or poisoning by recognition of early pathological changes. Thus among lead work- ers absorption of lead can be discovered by urine and blood examination long before the appearance of symptoms. Occasionally a group of cases will present a symp- tom complex suggesting a new disease. These cases should be very carefully noted, the symptoms classi- fied, and an attempt made to determine whether there is some substance in the process which is caus- ing the trouble. Thus obscure types of toxicosis such as manganese 8 and cadmium 9 poisoning have been recently investigated, their cause identified, and the method of their prevention determined. The industrial physician is placed in a unique medical position. He has an opportunity as afforded nowhere else in medicine to study the effect of work upon the human organism, and to observe the very beginning of disease. Workmen will avail them- selves freely of a well-conducted medical service consulting the doctor for a multitude of small ail- ments. As each visit to the factory dispensary and as at least one physical examination is recorded, the development of numerous diseases can be watched and an effort made to check them in their 134 HEALTH SERVICE IN INDUSTRY early stages. There is also the opportunity for the observation of chronic disease conditions over periods of years, and the study of groups of similar conditions can be readily made. The amount of material and the ease with which this can be gathered together at any time is a thing as yet unap- preciated by the majority of the profession. Thus, if the chief physician wishes to investigate the effect of work on hearts having a mitral systolic murmur, he can have the entire group sent to the dispensary at ten minutes notice. If he wishes to find out the end result in a series of fractures it is equally easy. A large factory with which the author is connected, is now reviewing the end result of all serious acci- dents of the previous year, and is making re-examin- ation of all defective hearts, paying special attention to the functional power of the mycocardium and its reaction to different forms of work and exercise. Following this an investigation of hernia cases will be made, determining the end results in all operated cases and the condition of workers who have not had operation. The same factory will shortly start an X-ray lung examination of a number of its employes who have been exposed to abrasive dust over a period of years. It will be seen from this that the opportunities for investigation are almost limitless, and that lack of a sufficient force of medi- cal workers is the only handicap. It is to be hoped that some of the problems of medicine will in future years be solved through the industrial medical department and laboratory. SPECIAL PROBLEMS 135 The work of the health department will be incom- plete without a good record system. In previous chapters the record system has been mentioned and its importance indicated. Unless very complete records are kept the mass of information which is being obtained is valueless. Every factory health department has a different system. In many ways they are similar but none are exactly alike. The important points in a system are : 1. Accuracy. 4. Elasticity. 2. Brevity. 5. Economy. 3. Availability. It is hardly necessary to dwell on accuracy. The exact position of injuries must be stated and the exact result of the injury recorded. Similarly physi- cal examinations and special investigation must be recorded with detail and accuracy. Brevity means getting in all necessary facts in the fewest possible words. Positive findings only need be recorded. Date and time as well as name of the doctor, or the nurse, treating the case should be entered. Availability means that a record can be found in one minute or less. Elasticity means that the record system can be enlarged or contracted at will and that individual records can be added to indefinitely. Economy means running a record system with the least trouble and clerical work, using the small- est number of clerks possible. As there are many systems some good, and some 136 HEALTH SERVICE IN INDUSTRY " "\ Health & Sanitation Department. Norton Company, Name Worcester. Mass. Age Address DepL No. Date Gen. Appearance i p Eyes: Vision Dist 1 Ft. "\ . Ears: Hears Watch I . Inches Inches Nose Throat Tongue Teeth Neck Chest Contour Heart Pulse Blood Pressure Lungs Abdomen | Upper Lxtrem. N , , 1 Lower Ing. Reg. G. U. Spine ' Skin Height Weight Joints Fig. 11. PHYSICAL EXAMINATION ENVELOPE SPECIAL PROBLEMS 137 bad, we will describe a simple system which is the result of ten years' actual experience and which has proved satisfactory and economical. The unit of the system consists of a single manilla envelope 5% by 8% inches on the face of which are printed the physical examination headings. The back con- tains space for recording transfers and date of dis- charge. Within the envelope, which opens end up, are placed the cards bearing the sickness and acci- dent record of the worker, any letters from ontside physicians, specialists' reports or other medical information. Thns each envelope has on its face the physical examination of the worker on entrance to the factory with his complete subsequent record within. (Fig. 11.) The method by which the sickness and accident record is built up is as follows. In each sub-dispen- sary as well as in the central dispensary, there are two forms, one for sickness and one for accident. (Figs. S and 12.) Each form is so arranged that after the history is taken, the doctor or nurse can, by a series of checks, designate the injury, its site, diagnosis and treatment, or in case of sickness the history, physical examination, diagnosis and treat- ment. These forms are in a block and torn off as needed. Every dressing is thus recorded and initialed by the doctor or nurse treating the case. TVhen more detail is needed in special cases the back of the slip is used for full long-hand notes. 138 HEALTH SERVICE IN INDUSTRY Norton Company Worcester, Mass. no. ACCIDENT SLIP Name Address Location What patient was doing Health & Sanitation Department Age Dept. M. S. W. Date Time Accident Time Treated Exp. Occ. What happened - Injury Site Treatment Condition Return Lac. wnd. Rt. Lt. G.&I. - Healing - Today Abrasion - Eye. O'Clock - D.D. Infected Tomorrow Contusion Hand W.D. — Clean D. after T.M. Puncture Wrist F. B. R. Coc. Improved See Doctor - Incised - Elbow - Sp. Drops No Change Report Sprain Forearm Silvol Lost Time R. to work Strain Foot Strapped Released Days Burn Ankle Splint Main Hosp. Weeks Foreign Body - Knee Sutured - Advised Xray - Months Fracture 1.2,3,4.5 Sutures rem. Discharged - F. B. Conj. Finger T. Lamp Toe Massage Back Wax Fig. 12. ACCIDENT SLIP For the Quick Recording of Accidents. It May Also be Used for Recording Treatments SPECIAL PROBLEMS 139 Each nurse brings to the central dispensary at noon and at night, the forms she has filled ont. These are immediately arranged in alphabetical order by the clerk. She then goes to the central file and takes from the physical examination envelope the last record card on each case. Upon these she transcribes the record on the form slips. These cards are then filed in a drawer near her desk as "live" cases. In case of redressing or retreatment the card is simply taken from this live file. When a case is discharged the card is transferred from the live file to the main file being replaced in the physi- cal examination envelope. The main file is cleared weekly from a list of dis- charges sent to the health department by the employ- ment department. Monthly reports can be readily made from the cards in the live file by not re-filing until the monthly report statistics have been taken off. Forms for special examinations as heart, lungs, special industrial diseases or poisoning, clinical reports, X-ray reports and similar data are filed in the individual envelope as received. It has been found that the space on any general physical exam- ination form is much too small for detail. In order that adequate records may be made, there should be special forms for recording heart, lung, and special examinations. 140 HEALTH SERVICE IN INDUSTRY Heart Questionnaire for Recording All Cases of Diseased Heart Name Age No. Address Dept. Date Present Complaint Family History Past History Date and duration of Illness Rheumatic fever Tonsilitis Influenza Typhoid fever Other illnesses Habits Appetite and digestion Bowels Kidneys Alcohol (amount) Tobacco " Food " Tea " Coffee " Sleep " Physical exercise ("Gardening other than that of <[ Walking occupation [Dancing, etc. Venereal History Gonorrhoea Date of Infection Syphilis Duration and nature of treatment History of Heart Trouble Present Condition Shortness of breath Palpitation Dizziness or giddiness Precordial pain Fainting Swelling of ankles Fatigue Nature and Description of Present Work How does it agree with patient SPECIAL PROBLEMS 141 Physical Examination Thyroid 1. Before exercise (a) Inspection Respirations — Normal — Increased Chest — contour Cyanosis Pulsations Bulging precordium Apex beat visible Sweating (b) Palpation Pulse rate and character Apex beat palpable Thrill (c) Percussion (d) Auscultation (Breath to be held in expiration) Heart sounds Murmurs present Effect of posture Before Ex. After Ex. Blood Pressure Systolic Diastolic Pulse Pressure 2. After Exercise A. Simple Pulse rate and character One minute after exercise Cyanosis Breathlessness Pain Other symptoms No. of hops Rating (degree of tolerance) Good Fair Poor Final Diagnosis: Prognosis : Treatment : B. Strenuous No. of lifts Good Fair Poor 142 HEALTH SERVICE IN INDUSTRY Lung Questionnaire for Recording All Cases of Diseased Lungs Name No Dept Date S. M. W Age Residence Family History of Tuberculosis or other Lung Disease Previous History Diseases of Childhood Lung or Gland Disease Other Severe Diseases Venereal Disease Habits Tea Appetite Coffee Bowels Tobacco Catamenia Alcohol Present illness Date and Mode of Onset Cough Expectoration Haemoptysis Pain Loss of Weight Weakness Afternoon Fever Shortness of Breath Chills Sore Throat or Hoarseness Night Sweats Insomnia Physical Examination Height Weight Best Weight General Appearance Adenopathy Contour of Chest Symmetry Expansion Lungs Tactile Fremitus Percussion Resonance SPECIAL PROBLEMS Auscultation 143 Vocal Fremitus Rales Description of Sputum Positive Negative . Heart Blood Urine Diagnosis Lead Questionnaire for Recording All Workers Ex- posed to Lead Poisoning Name Age Address Department Health good fair poor Experience therein and previous experience in handling lead Appetite good fair poor Digestion good colic fair eructation gas and poor regurgitation of fluid Bowels regular constipated or loose alternating < or diarrhea constipation Strength vigorous weak Swelling of ankles present absent 144 HEALTH SERVICE IN INDUSTRY Physical Examinati on General appearance robust frail Pallor present absent blue line present absent Mouth teeth good fair poor Heart Murmurs present description of absent Arteries rate of pulse sclerosis present degree absent systolic Blood pressure diastolic pulse pressure distended Abdomen level scapheid Peri-umbilical tenderness present absent Extremities extensor weakness present or wrist drop absent oedema ankles present absent Blood stippling present absent Urine lead present absent nephritis present absent The unit envelopes with their contents are filed alphabetically in a central file. Wherever the record notes a serious defect a colored marker or flag is attached to the upper edge of the envelope. Differ- ent colors indicate different defects. In this way SPECIAL PROBLEMS 145 the clerk can rapidly gather the whole group of defective hearts, lungs, hernia or whatever is called for. As men are being constantly discharged and fre- quently rehired, a large "dead" central file is needed in which are filed the envelopes of those men who are discharged each week as determined by a weekly list from the Employment Department. The investigation of sickness and accident cases at their homes by the visiting nurse service has been noted. The record of these cases coupled with the record of individual time lost, as recorded by the cost department from the time clock cards, forms the basis of many interesting medical statistics. In a large factory the following statistics were worked out in detail, charted and curved last year. 1. Report on sickness for 1916, 1917, 1918, 1919 presenting the record analysis of data covering the cases of illness reported as having occurred among the plant force during those periods. The extent of the disability discussed both with reference to the comparative amount from year to year and in regard to the measurement of the occurrence by disease groups within each year. These groups also compared for the four- year period. 2. Report on absence from sickness July, 1919, to July, 1920, presenting a record of the absence occasioned by illness during the year relative to extent of disability, nature of illness, period of absence, and comparative prevalence of cer- tain ailments among departments where similar physical conditions attend the occupations. Data 146 HEALTH SERVICE IN INDUSTRY also shows the occurrence of disability by months and the rate of return to work by those affected. 3. An analysis of the data pertaining to the dusty departments to derive the relation between the period of employment and liability to sickness. 4. Analysis of cases of hernia operated during past year, giving etiology, duration of stay in hospital, duration of inability to work, and end results. Different problems of this type are constantly arising which can be rapidly analyzed, producing extremely interesting data. CHAPTER XI COST OF MEDICAL SUPEKVISION AND ECONOMICS OF INDUSTKIAL HYGIENE The cost of a health service in industry must be divided into the cost of the dispensary system, the cost of the visiting nurse service, and the cost of sanitation. Each will be considered in order. The present cost of maintaining a complete, well- running medical department is approximately six dollars per position in the factory per year. Thus in order to find the cost, the average total number of employes for the year should be multiplied by six dollars. This is less than the most expensive medical services, but it is higher than many which are now being carried on so that it is a safe conser- vative figure. This figure does not cover the initial expense of dispensary equipment. It can only be used when considering the force as one in continuous operation. That is, if a force of 3,000 is suddenly reduced to 1,000 it takes quite a long time to make the corresponding reduction in medical department expense. On the other hand the force may usually be considerably increased before added expense is incurred. In other words it is easier to expand without added expense than to contract with reduc- tion of expense. 147 148 HEALTH SERVICE IN INDUSTRY Moreover these figures can be generally consid- ered only as prices, salaries, etc., vary in different parts of the country. In the accompanying table an effort has been made to indicate the more important items of expense at the average of nineteen twenty- one. Estimate of Expense of Medical Personnel, etc., 1921. No. of Em- ployes No. of No. of Full- Part- Cost Time Time of Doctors Doctors Doctors No. of Full- Time Nurses Cost of Nurses No. of Dis- pens- aries Initial Cost of Dis- Cost of pensary Supplies Equipment 1 Tear Total Medical Cost Per Tear 200 1 $360 1 $250 $240 $1,200 500 1 540 1 500 700 3,000 1000 1 1,200 1 $1,560 1 1,000 1,200 6,000 3000 1 2 5,400 3 4,680 3 2,000 3,600 18,000 5000 1 3 10,400 6 9,360 5 4,000 6,000 30,000 The cost of establishing and equipping a dispen- sary, and its running cost, are very difficult things to figure owing to the constant change in prices. The figures here given are decidedly estimates. Salaries of Doctors There is more variation in the salaries paid in- dustrial physicians than in any other item. Part-time Doctors When working on a basis of two or three visits to the plant per week the average fee is three dollars a visit, each visit being about one hour. A special fee of three dollars is paid for calls to plant outside of visiting hours. When the part-time doctor visits the plant daily, spending approximately three hours a day, he receives $1,200 to $1,800 a year for his services, but if he is a highly-trained man, specially desired, his salary may go much higher. COST OF MEDICAL SUPERVISION 149 Full-time Doctors A doctor giving full time to industry receives from $1,800 to $5,000 a year depending on the size of the factory and the importance of his position. Thus a man just out of inedical school or hospital, starting in industrial medicine, receives much less than a fully qualified industrial physician. In the large plants employing over four thousand employes the chief physician 's salary may be $10,000 or more. It must always be remembered that salaries in in- dustrial medicine are net, that is, all equipment, transportation, supplies, etc., are without cost to the physician. He has no expenses whatever. The salaries of industrial nurses, whether dis- pensary or visiting, seem to average about $30 per week. This figure applies especially to the eastern states. It is said to be higher in the middle-western states. In March, 1920, an investigation of nurses' sal- aries in twenty large factories in New England and elsewhere found the average wages as follows : Yearly Average for Female Dispensary Nurse $1,438.00 Yearly Average for Female Visiting Nurse 1,441.00 Yearly Average for Male Dispensary Nurse 1,858.00 (Made by Secretary of New England Conference Board of Industrial Physicians.) The dispensary nurse usually has the added per- quisites of uniform, laundry, and expenses to any nurses' conference she attends. All nurses receive two weeks vacation per year with pay and indefinite sick leave when necessary. In all cases graduate nurses only are considered. 150 HEALTH SERVICE IN INDUSTRY Each visiting nurse has in addition the use of a company automobile during working hours. The cost of the visiting nurse service will, therefore, be $1,441 per year for each nurse plus the cost of office space and fixtures, and automobile expense. The most satisfactory type of car has been found to be the Ford coupe which costs about $800 delivered. The cost of sanitation is impossible to estimate for industry as a whole. At a large factory employing about 4,000 workers, it amounted to twenty-one dol- lars per year per position in the factory in 1920. This included every cleaning expense, floor sweep- ing, paper baling, etc. The expense in this factory was somewhat greater than the average because of the large floor area and the dusty character of the business. The average factory superintendent will be surprised to find how great is the expense of cleaning when it is separated from general depart- mental expense where it is usually carried and buried. In the past four years three comparatively com- plete surveys of the cost of Health Supervision in industry have been made. The first was made by M. W. Alexander for the Conference Board of Phy- sicians in Industrial Practice in 1917. This survey of ninety-five factories found the average annual cost of medical and surgical supervision per em- ploye to be $2.21. The majority of these factories were not, however, carrying on medical supervision as outlined in this book, and costs have mounted steadily since the above statistics were compiled. COST OF MEDICAL SUPERVISION 151 The second survey was made by Selby, in 1918. One hundred and seventy industrial establishments were visited. Though making a very complete in- vestigation and discussing numerous costs found, no compilation of expense is made. The third survey was made by Wright in 1920 for the Cleveland Hospital and Health Survey. "Wright investigated 1,521 factories. He found 72 had some type of medical service. He says : l ' There are sev- eral plants in Cleveland efficiently applying cost accounting to medical departments and it is in these few plants alone that there is definite knowledge of the total outlay for medical work. Other firms may roughly calculate the cost by guessing at the value of medical supplies purchased or on hand and add- ing to that amount the salaries of personnel. A number of firms stated the cost to be in the neigh- borhood of five dollars a year per employe." Wright rather doubts the accuracy of the above for reasons previously stated. He goes on to say: "In one large establishment the cost is $10.92 a year per employe and in another $11.23. Such amounts are probably not excessive at the present time if the service is comprehensive and of a high order.' ' Drinker 10 in a review of the economic aspects of in- dustrial medicine in 1920 says: "At the present time we know of two establishments where the cost is between $6 and $7 per employe, and there is cer- tainly no disposition to curtail the service offered in either instance. It is probable that a figure of $5 per employe more nearly represents the average 152 HEALTH SERVICE IN INDUSTRY total cost of well-administered industrial medicine at the present time. ' ' From an economic point of view it is interesting to compare the figure of $6.20 per position in the factory, a rate of actual experience for the year 1920 in a large Worcester factory, with the expense of medical care estimated by the National Industrial Conference Board in its table of the average mini- mum cost of living at a fair standard for a single man in Worcester, Massachusetts, in June, 1920. Medical supervision in factory one year includ- ing— Physical examination on entrance and subsequent examinations. Treatment (complete) of all accidents. Treatment of all minor sickness. Pathological and X-ray work $6.20 Medical care of single man in Worcester living at minimum cost at a fair standard, one year $18.20 The factory medical work which is very complete costs $12 per year less than average medical care for the same period in the same city. Having considered the costs of medical super- vision, what are the benefits ? They may be divided into those which affect management and those which affect the worker. All authors who have written on this subject agree on the economic value of medical supervision to management and the difficulty of showing this in figures. Mock sums up the benefits to management as follows : 1. Reduces time loss due to sickness and epidemics. 2. Reduces compensation for accident, disability, deformities and death. COST OF MEDICAL SUPERVISION 153 3. Increases output by steadier working force. 4. Decreases hiring of new employes at a great financial saving. 5. Increases the number of old employes with their constantly increasing value. 6. Increases general efficiency of force. 7. Secures good will of employes. It will be readily seen how few of these advan- tages can be translated into monetary valne. Mock 2 collected " statistics from ten large industries, hav- ing excellent medical staffs, which examine all ap- plicants for work." These statistics show that 9.7% of all applicants (118,900) were rejected for work because of disabilities and that by this rejection alone $144,155 was saved. He bases these figures on Alexander's estimate of the cost of turnover at $35 per employe, believing that each rejected em- ploye would have left the company within six months of being hired. Howen using the same figures has attempted to show the exact saving to a factory of 1,000 employes, resulting from a well-organized medical depart- ment. He bases his figures of saving on Mock's 10% rejection figure and Alexander's estimate of $35 per employe as the cost of turnover, and his ex- pense figures on the investigation of the Conference Board of Physicians in Industry on the cost of medi- cal supervision in 95 large factories. His balance sheet is as follows: u Ina Typical Plant of 1,000 Employes, Suppose the Value to the Employer of each Employe-Day, above "Wages Paid, is $2. 154 HEALTH SERVICE IN INDUSTRY A conservative calcula- A careful investigation tion places the in 95 representative plants places the Saving from lessened ill- Cost of Medical Super- ness due to Medical vision at $2.21 per Examination of Appli- Employe per Year, or cants at $ 683 for this plant of 1,000 Saving due to Prevention Employes $2,210 of infection at 2,442 Saving in Workmen's Compensation Insur- ance Premiums 1,105 Balance Saved 2,020 $4,230 $4,230 And besides this there are the many intangible savings due to such causes as lessened illness through dissemination of health literature, and through prompt treatment at the beginning ; greater output through increasing physical vigor; and in- creased goodwill on the part of the employes.' ' The author believes that 10% is too high a figure for rejections and that rejections should not be used as a basis of determining the economic value of medical supervision. The real value should rest upon: 1. Reduction of absenteeism as a result of (a) Prevention of sickness. (b) Prevention of infection following in- juries. (c) Proper treatment of serious injuries. (d) Assurance of worker in cases of exag- geration or imaginary illness. 2. Reduction of accident insurance rate as a result of a well-equipped medical service. 3. Preservation of the health of valued workers and executives. COST OF MEDICAL SUPERVISION 155 4. Prevention of "unhealthy working conditions" and "lack of medical care" being used as a basis for strikes or other labor disturbances. 5. Increased "good will" of worker for company. Considering each in a little more detail. 1. The experience of industrial physicians is that absenteeism due to sickness and accident can be reduced between 25% and 50% as the result of a well-run health department. 2. A definite reduction of rate is made by accident insurance companies when the policy holder maintains a health department. 3. The preservation of the health of valued workers and executives cannot be measured in dollars and cents. The early discovery of be- ginning disease and its prompt cure in the case of an important executive may be of more value than the entire cost of the health department for a year. 4. A well-run health department inspires confi- dence among the workers and content with their surroundings. No cause of dissatisfaction from working conditions is likely to arise. This is worth a great deal to the company. 5. A good medical service is always a source of satisfaction to the worker and a firm bond be- tween man and management. The benefits of medical supervision to the worker according to Mock 2 are that it : 1. Discovers disease early — more rapid and surer cure. 2. Discovers organic disease which can be con- trolled. Prevents overwork and hazardous occupations for these. 3. Prevents disease by discovering focal infections and danger signs. 4. Provides protection from contagious disease. 156 HEALTH SERVICE IN INDUSTRY 5. Provides suitable work according to physical condition. 6. Prevents accident by removal of cause in em- ploye. 7. Provides better medical care when sick. 8. Provides better surgical care when injured. 9. Reduces suffering, permanent disability and death rate. When we consider the results as a whole we see that the entire community benefits by the improved conditions of the worker, that the local board of health is assisted in its work, and that the lessons learned by the workers are carried to their homes and have a definite effect on the health of their families. There are few manufacturers who, if they realize the all-round advantages of maintaining a pro- gressive factory health service, will begrudge the six dollars per employe per year necessary to put it into operation. It is the author's belief that a well- run health service returns yearly a cash dividend from time saved and disease prevented alone with- out considering in any way the great value of many of the less easily estimated but none the less definite benefits. One of the strongest proofs that this is a reasonable statement is that the National Industrial Conference Board 4 upon investigation of a large number of industries found not only that the ma- jority were providing medical service, but that the service was being enlarged. To quote the conclu- sion: "Judged by the experience gathered among New England industries, the value of certain phases COST OF MEDICAL SUPERVISION 157 of industrial medical work is quite fully recognized. With few exceptions plans were under way for an expansion of the work, either by adding to the quarters, the staff, or the character of the work." In the majority of states a Workman's Compensa- tion Act is in force. This requires carrying of com- pensation insurance by the factory. One of the largest insurance companies in the East in a pam- phlet entitled, "Surgical Service for Plants having Fifty to Fifty Thousand Employes' ' makes the fol- lowing statement : "The advantages to be gained by employers through the installation of a plant hospital or first- aid room are : 1. An increased production through: a. Saving in time by having injuries dressed and redressed at plant instead of at office of private physician or at public hospital. b. Practical elimination of lost time and labor turnover that result from neglected or im- properly treated injuries. c. Saving in time by having doctor and nurses prescribe for slight illnesses that might otherwise take employes off the job. d. Improvement in physical condition of em- ployes through advice of doctor and nurses. 2. A substantial reduction in compensation prem- ium.* 3. A reduction in the amount of compensation pay- ments, which under "Experience Rating" means a reduction in future insurance cost. 4. The promotion of friendly relations with em- ployes through the services rendered by the hospital staff. Credits on premium are graduated according to equipment and surgical service, and the amounts vary in different states. Specific information on this point will be gladly furnished by our Underwriting Department. 158 HEALTH SERVICE IN INDUSTRY It is quite certain that no such statements would be made unless the maintenance of a factory dis- pensary were of financial benefit to the insurance company and if to the insurance company, surely doubly so for the factory in which the service exists. The true effect of medical efforts can be determined accurately by the insurance companies who have the ability to make statistical studies of the effect of new work. The Metropolitan Life Insurance Com- pany in an open letter to members of its field force makes the following statement: "The reduction in the mortality from typhoid fever among Industrial policy-holders between 1911 and 1919 was 69%. The acute infectious diseases of childhood showed a reduction of 46.7%. The death rate from tuberculosis of the lungs was re- duced 33.1%; from organic diseases of the heart, 23.1%; from Bright's disease, 25.8%; from diseases relating to child-bearing, 6.5% and the external causes, including accidents, showed a reduction of 7.9%." This reduction is ascribed largely to the work of the company's nursing service and "represented a saving of $2,605,625 in 1919 to the company. ' ' Finally it is interesting to note the action taken on the industrial medical department by the British Health of Munition Workers Committee in 1916.i 2 At this time Great Britain was making her greatest effort in production. The committee closes its re- port with the following : "The committee have received evidence and re- ports from all parts of the country of the economic and industrial value of the proper organization of COST OF MEDICAL SUPERVISION 159 a medical service within the factory, and they are convinced that both on grounds of health and of securing improved output this subject demands the immediate attention of employers, and that ade- quate schemes of treatment, especially of minor injuries, are an important means of preventing loss of time and efficiency among the workers. They recommend, therefore, that provision for or- ganized treatment should be made in every muni- tion factory." REFERENCES 1. Selby, C. D. Studies of the Medical and Surgical Care of Industrial Workers. Public Health Bulletin No. 99. Washington, D. C. 2. Mock, H. E. Industrial Medicine and Surgery. W. B. Saunders & Co., 1919. Philadelphia, Pa. 3. Shipley, H. E. Health Service for Industries of Moderate Size. The Modern Hospital. April, 1920. Vol. XIV, No. 4. 4. National Industrial Conference Board Health Service in Industry. Research Report No. 34. 5. Geier, 0. P. Modern Medicine, December, 1920. Vol. II, No. 12. 6. Selby, C. D. Scope of Physical Examination in Industry. Proceedings National Safety Council, 1919. Health Service Section. 7. Dublin, J. J. and Lieboff, P. Occupation Hazards and Diagnostic Signs. Proceedings National Safety Council, 1920. Health Service Section. 160 HEALTH SERVICE IN INDUSTRY 8. Edsall, Wilbur & Drinker. The Occurrence, Course and Prevention of Chronic Manganese Poisoning. Journal Industrial Hygiene. Vol. I, No 4. 9. Stevens, G. A. Cadmium Poisoning. Journal Industrial Hygiene. Vol. II, No. 4. 10. Drinker, C. K. Economic Aspects of Industrial Medicine. Journal Industrial Hygiene. Vol. II, No. 2. 11. Howe, G. L. Why a Factory Doctor's Salary Costs Less than Nothing. Factory, March 1, 1920. 12. Newman, G. Sickness and Injury. Memorandum 10, British Health of Munition Workers Committee, 1916. INDEX PAGE Abdomen, Examination of 72 Abrasions, First Aid Treatment of 39 Treatment of 86 Accident Record 137 Accident Slip 138 Accidents, After Care of 95 Classification of 83 Compensation for 10 Course of Patient With 90, 91, and see Injuries First Aid Treatment of 39 Moderately Severe 83 Personnel for Handling 89 Routine in Large Factories 31 Severe 83 Treatment of 89 Trivial 83 Acids, Burns from, First Aid Treatment of 40 Air, 112, and see Ventilation Supply of, in Factories 114 Alkalies, Burns from, First Aid Treatment of 40 Asphyxiation, First Aid Treatment for 42 Bleeding, First Aid Treatment of 39 Treatment of 86 Bronchitis (Mild) , Standard Treatment of 109 Bruises, First Aid Treatment of 40 Burns, Treatment of 86 Burns, from Acids, First Aid Treatment of 40 From Alkalies, First Aid Treatment of 40 Carbon Dioxide, Amount allowed in Air in Factories 114 Cardiac, and see Heart. Cardiac Substandard Men 76 Centralized Dispensary Service for Small Factory 21 Chest, Examination of 71 Chills, First Aid Treatment for 41 161 162 INDEX PAGE Closets, Care of 121, 122 Number Required 123 Type Recommended 122 Compensation for Accidents 10 Constipation, Standard Treatment of 110 Cooperation of Health Department with Others 103 Coryza, Standard Treatment of 109 Cost, of Health Supervision 150 Of Medical Supervision 147 Of Sanitation 150 Cramps, First Aid Treatment of 41 Crushing Injuries, Treatment of 88 Cuspidors 125 Cuts, First Aid Treatment of 39 Diagnosis, Accurate, Value of 102 Dislocation, First Aid Treatment of 40 Dispensaries 37, 46 Equipment 43, 46, 49 Units 48 Dispensary Nurse 63 Duties of 63 Dispensary Service, Centralized, for Small Factory 21 Dizziness, First Aid Treatment of 41 Doctors, Salaries of 148 Full Time 149 Part Time 148 Draught 113 Drinking Fountain, Type of 120 Drinking Water 120 Dust 118 Dangerous Types of 119 Effects of Inhaling: 119 Ears, Examination of 70 Economics of Industrial Hygiene 147 Electric Burns, First Aid Treatment in 40 Electric Lights, to be Kept Clean 125 To be Replaced 125 Electric Shock, First Aid Treatment for 42 Employes, Health Supervision of 4 Adjuncts to 4 Management of Health of in Large Factories 28 Employment Department, Functions of 8 INDEX 163 PAGE Enteritis (Mild) , Standard Treatment of 110 Examination, Physical 69, 128 Executive Force, Examination of 127 Extremities, Examination of 72 Eyes, Burns, First Aid Treatment of 40 Examination of 70 Foreign Bodies in, First Aid Treatment of 40 Injuries of, First Aid Treatment of 40 Treatment of 87 Factory, Carbon Dioxide in Air of 114 Factory Dispensaries 37, 46 Equipment of 46, 49 Units of 48 Factory Organization, Basis of 2 Factory, Hazards in 101 Sickness in, See Sickness in Factory. Statistics of 145 Fainting, First Aid Treatment of 41 Fibrosis of the Lungs 119 Fingers, Fractures of, Treatment 88 Fire Burns, First Aid Treatment of 40 First Aid Jar, N. A. S. 38 First Aid Station 37 First Aid Treatment 39 Flies, Trapping of 126 Foreign Bodies in Eye, First Aid Treatment of 40 Foreman and Physician, Cooperation between 60, 103 Fractures, First Aid Treatment of 41 Treatment of 86 Fractures of Fingers, Treatment of 88 Frost Bite, First Aid Treatment of 41 Gas, Asphyxiation, First Aid Treatment of 42 Gastritis (Mild) , Standard Treatment of 109 Gastro-enteritis (Mild), Standard Treatment of 110 Hazards in Factories 101 Headache, First Aid Treatment of 41 Standard Treatment of 110 Health Bulletins 100, 101 Health Bureau for Small Factories 22 Health Department 5 Functions of 127 164 INDEX PAGE Health Department — Relation to Other Departments 8 Organization Chart of 24 Specific Problems of 127 Health Section in Large Factories, Equipment of 26 Function of 26, 27 Health Supervision 4 Adjuncts to 4 Benefits of 152 To Employers 157 To Workers 155 Cost of 150 Heart, and see Cardiac. Examination of 71 Questionnaire 139 Heat, in Factories 118 Heat Prostration, First Aid Treatment of 41 Hemorrhage, First Aid Treatment of 39 Treatment of ' 86 Hernia, Examination for 72 In Substandard Men 79 Housing 12 Humidity, in Factories 118 Illumination, 114, and see Lighting. Measurement of 115 Indigestion, Standard Treatment of 109 Industrial Hygiene, Economics of 147 Industrial Medicine 55 Industrial Nurse 54, 61, 63 Rules for 62 Salary of 149 Industrial Physician 54 And Foreman 103 And General Practitioner 103 And Specialist 104 Cooperation with Management 60 Part-time 55 Results and 58 Salaries of 148, 149 Time and 59 Industry 1 And Factories 1 And Organization 1 Infection, Prevention of 84 INDEX 165 PAGE Injuries, and see Accidents. And Safety Engineering Department 92 And Visiting Nurse's Service 93 Course of 92, 93 Joints, Examination of 73 Kidneys, see Nephritic. Lacerations, Treatment of 88 Large Factories, Accident Routine in 31 Health Section in, Equipment of 26 Function of 26 Management of Health of Employe in 27, 28 Organization of Medical Department in 25 Sanitation Service in 33 Administration of 33 Function of 26 Sanitation Service in 26 Sickness Routine in 31 Standards in 30 Visiting Nurse Section in 35 Functions of 26 Lead Questionnaire 142 Lighting, and see Illumination. Artificial, Fundamental Items of 116 Types of 117 Direct 117 Indirect 117 Semidirect 117 Standards of 116 Lockers 124 Care of 125 Locker Rooms, Care of 124 Equipment of 124 Lung Questionnaire 141 Lungs, and see Pulmonary. Examination of 71 Fibrosis of 119 Medical Department 5 Relation to Other Departments 8 Medical Supervision, Cost of 147 Mouth, Examination of 70 166 INDEX PAGE N- A. S. O. First Aid Jar 36, 38 Nausea, First Aid Treatment in 41 Neck, Examination of 71 Nephritic Substandard Men 78 Nose Bleed, First Aid Treatment of 39 Nose, Examination of 70 Nurse, Dispensary 63 Nurse, Industrial 54, 61, 63 Rules for 62 Salary of 149 Nurse, Visiting 26, 35, 66 Organization Chart of Health Department 24 Paper and Refuse, Collection of 126 Part-time Physician for Small Factory 17, 148 Patient with Accident, Course of 90, 91 Pharyngitis, Standard Treatment of 109 Photometer 115 Physical Examination 69, 128 Physician, Industrial, see Industrial Physician. Poisoning, Internal, First Aid Treatment of 41 Prevention of Sickness 98 Production 2 Pulmonary, and see Lungs. Substandard Men 78 Punctured Wounds, First Aid Treatment of 39 Of Foot, Treatment 88 Questionnaire, Heart 139 Lead 142 Lung 141 Rats, Trapping of 126 Receptacle for Soiled Dressings 52 Record System 135 Important Points in 135 Sample 137 Recreation 12 References 159 Refuse and Paper, Collection of 126 Restaurant Service 11 Safety Engineering Department 10 Relation of Injuries to 92 INDEX 167 PAGE Sanitary Appliances Ill Sanitary Force of Factory, Duties of 125 Sanitary Foreman Ill Sanitary Inspector, Duties of 112 Sanitary Section in Large Factory 33 Administration of 33 Functions of 26 Sanitation Ill Conditions Requiring Control Ill Cost of 150 Report 34 Service Division, of Factories, Functions of 4, 5 Layout of 6 Sewage, Disposal of 121 Shock Following Injuries, First Aid Treatment of 42 Sickness in Factory 97 Curative Work in 105 Effects of 97 Prevalence of 105 Prevention of 98 Sickness Record 137 Sickness Routine at Large Factory 31 Sickness Slip in Minor Ailments 108 Skin, Examination of 72 Slip, Accident 138 Slivers in Skin, First Aid Treatment of 40 Small Factory, Centralized Dispensary Service for 21 Health Bureau for 22 Medical Equipment of 18 Medical Needs of 15, 17 Part Time Physician for 17 Smoke, Asphyxiation from, First Aid Treatment for 42 Splinters in Skin, First Aid Treatment of 40 Soiled Dressings, Receptacle for 52 Sprains, First Aid Treatment of 40 Treatment of 86 Standard Treatments 109 Strains, Treatment of 86 Sub-Dispensary 37, 42 Equipment of 43, 46 Substandard Workmen, Cardiac Cases 76 Classification of 75 General Cases 81 Hernial Cases 79 168 INDEX PAGE Substandard Workmen — In Large Factories 30 Nephritic Cases 78 Physically 75 Pulmonary Cases 78 Re-examination of 81 Special Cases 81 Syphilitic Cases 80 Sunburn, First Aid Treatment of 40 Supervision of Health of Employes 4 Syphilis, in Substandard Men 80 Tonsilitis, Standard Treatment of 109 Trachitis, Standard Treatment of 109 Tuberculosis, Latent 78 Unconsciousness, from Asphyxiation, First Aid Treat- ment of 42 From Fainting, First Aid Treatment of 41 From Gas, First Aid Treatment of 42 From Smoke, First Aid Treatment of 42 From Water, First Aid Treatment of 42 Units of Factory Dispensaries 48 Urinals 123 Number Required 123 Ventilation 112 Duty of Physician in 114 Methods of 113 Visiting Nurse, Work of 66 Visiting Nurse Section in Large Factories 35 Function of 26 Visiting Nurse Service 10 And Injuries 93 Washing Fixtures 124 Water, Asphyxiation from, First Aid Treatment of 42 Weekly Sanitation Report. 34 Windows to Be Kept Clean 125 Wounds, First Aid Treatment of 39 Treatment of 85, 86, 88 Wounds, Punctured of foot, Treatment of 88 X-Ray Examination, Value of in Diagnosis 79, 87, 129 s LIBRARY OF CONGRESS 022 216 239 7 m I Hill , ill III!! 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