I
HEALTH SERVICE IN
INDUSTRY
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THE MACMILLAN COMPANY
NKW 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
rx\'^^?-
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.
THE MACMILLAN COMPANY
1922
Printed in the United States
of America
Copyright, 1922
By THE MACMILLAN COMPANY
Set up and electrotyped. Published April, 1922
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DtC27l972
^■'-^^SW^ OF TO^$V
E. R. DONNELLEY & SONS COMPANY
CHICAGO
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
V'l. 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
CHAPTER I
INDUSTRY AND ORGANIZATION
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 w^ill 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 Mocka 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 ovm accord, daily sends to the Employ-
ment Department a form kno^^^l 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
emplo^inent manager each morning and it is his
duty and that of his department to fill each requi-
sition from the men apphing for positions at the
factory emplojTiient 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-
plo}TQent 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 emplo^Tnent depart-
ment, and the tracing of those absent for three days
by a special agent of the department. The agent
may be a \dsiting 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.
Recreation 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 w^ork.
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 modem 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 emplo}^ 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 interefere
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 ^^ithout realizing it,
15
16 HEALTH SERVICE IN INDUSTRY
in many cases, been personally acting as service
manager in his factory. Because of his small per-
sonnel he 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 1^ 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 tjipe 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, mthout
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.
AVhen 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. Shipleyg 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 SMALL 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
adequate medical service, and it is only by a stimu-
lation of interest, health bureaus, as 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 space 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, perhaps according to
the numbers of their employes, the expense would
be in proportion to their means, yet they would
have the use of a whole-time medical service and
the benefit of its advantages."
24
HEALTH SERVICE IN INDUSTRY
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CHAPTER III
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
LAEGE-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 w^ll 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 upon 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
of 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
LAKGE-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 until 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
LAKGE-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
Locker Rooms
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
the 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. O. FIRST AID JAR
Adopted as Standard by Many Large Factories
CHAPTER IV
FACTORY DISPENSARIES
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 iiave
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. O. 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 that little well. The following list of instruc-
tions thoroughly understood is sufficient u
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 frotn 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 mth 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, arc. 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 tlie 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:
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
Chlorozene
Collodion
Creso-pinol
Gasoline
Lead Acetate and Alum
Tincture of Iodine
Wax
Acetanilid
Alcohol
Alum (powder)
Ammoniated Mercury
(oint.)
Arom. Spirits of Ammonia Seidlitz Powders
Bichloride of Mercury Seller's Gargle
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.
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
tlie 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
V2 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. 0. 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 w^ork. 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
1.
2.
3.
4.
5.
6.
7.
A UNIT TABLE SET UP FOR HAND DRESSINGS
Contents of Upper Shelf
Left to Right
Bandages 1 in. and 2 in.
Tr. Iodine in glass stoppered bottle.
Thumb forceps in antiseptic solution.
Gasoline.
Sterile cotton swabs on wood applicators.
Sterile gauze 2x2 in.
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., V2 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 1% 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
cjdindrical 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. Geiers thus describes the
industrial physician :
"The industrial physician is that man who gives
Lip 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
touch 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 ot
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 manj'' 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 bv 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 lie 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 wdth 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 eniTmerated 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 o^vn 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 I
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 nurses are employed. The
doctor must be always available and must visit each
sub-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 emplojTnent 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 T\T.thout 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 mth 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 YI
THE PHYSICAL EXAMI^TATION
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.s 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-
plo^Tnent 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 Avhere 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 w^ord, 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
TPIE PIIYSICAL 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 tmnors. The patient
is told to swallow and the size and shape of the
thyroid noted.
The examination of the chest is carried ont 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 w^e 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 ing-uinal 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 w^ill 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 neuro-circu-
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 Pennsvlvania Safetv Con-
gress, 1920, reviewed the question of the cardiac in
industiy 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 hj-pertrophy v.-ith or without
endocarditis, dilation, or both of these, adhesions
or mechanical displacement by effusion or new
gro-«i;hs. . . . Ha^-ing 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 pre\-ious rate, but -uithin
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 Walte & Bartlett, 252 West 2Gth
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 which 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 which 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.
CHAPTER 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 tliose 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 w^hich 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:
86 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 stiff 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 acti^dty 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
toS.E.Dept
for Recording
Report Sertt 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
'Lmployinent
Department
Finds Work
Which Patient
.Can Perform,
If Unable to Resume
Old Work at Once
Nearest
Branch Hospital
Immediate
Treatment
Safety
Cnj'.r'g Dep't
Coinpensation
Payments
Main
Tactory Hospital
Intermediate
Treatment
Main
Foctory Hospital
Observations
Dressings
Release
General
Hospital
Home
Final
Treatment
Visiting Nurse
Calls
Report set
immediately
to S. E.for
Recording and
Repairing to
Ind. 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 \\^th
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 he 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 FACTORY
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 w^ork-
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 w^orker 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 dia^osis 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 WorJc
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-
eral practitioner. The method of handling patients
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
HEALTH SERVICE IN INDUSTRY
Norton Company Worcester, Mass.
SICKNESS SLIP
Health & Sanitation Department
Name
Address
No.
Age
M. S.W.
Time Treated
Dept.
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
ChiUs
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
Seller'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
SUvol
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
Pain 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
Coryza
Trachitis
Mild Bronchitis
without Systemic
Symptoms
Digestive System
Indigestion
Gastritis (Mild)
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.
Advise warm cloth-
ing and protection
of feet. Alboline
spray for nose. Ar-
gyrol 15% instilled
in eyes S. 0. S.
None
Pil. Rhei -Pil. Cath.
Co. aa 1 pill at night.
Pulv. Doveri gr. 10
with hot lemonade
with above. Tab.
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.
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 v/ith
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-
mediatelv 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
conlined 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, skj''-
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 buildings, 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 Vio to Vi foot candles
Storage spaces V2 to 1 foot candles
Stairways, passageways, aisles 1 to 2 .''oot 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
bowl, 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. AVhile many modem
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 Hmnidity
The importance of this problem has been pointed
out mider 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 reconsidered 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.
T\Tiile 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
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Fig. 9. ORGANIZATION CHART OF SANITATION DEPARTMENT IN A FACTORY OF 4,000 EMPLOYES
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 sho^\^l in
Fig. 9.
The industrial physician Avill 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
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-
lomng 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 quite 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."
^ ' 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 easih" 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 duty 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 PROBLEMS
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. GenitoUrinary,
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 PKOBLEMS 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. Follovdng 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 vdth 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
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
Time
Amount
Gravity
Excretion
Excretion
8-10
280 c.c.
1008
10-12
85 c.c.
1020
12- 2
440 c.c.
1006
2- 4
140 c.c.
1018
9.7 grs.
13.8 grs.
4- 6
225 c.c.
1012
6- 8
270 c.c.
1012
8- 8
625 c.c.
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 manganeses and cadmiumg 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
az2>e-20-2;oo
Health & Sanitation Department, Norton 0>mpany, Worcester. Ma
Name Age
Address
Dept.
No.
Date
Gen. Appearance
Eyes: Vision Dist 1 0 Ft.
JR.
IL-
Ears: Hears Watch
JR.
Inches
Inches
Nose
Throat
Tongue
Teeth
Neck
Chest Contour
Heart
Pulse
Blood Pressure
Lungs
Ahdomen
(Upper
cjctrem. \ ,
(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
514 by 814 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 outside
physicians, specialists' reports or other medical
information. Thus 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. 8 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.
When more detail is needed in special cases the back
of the slip is used for full long-hand notes.
138
No,
Name
Address
Location
HEALTH SERVICE IN INDUSTRY
Norton Company Worcester, Mass.
ACCIDENT SLIP
Health & Sanitation Department
Age Dept.
M. S. W. Date
Time Accident
Exp.
Occ.
What patient was doing
Time Treated
What happened
—
Injury
Site
—
Treatment
—
Condition
Return
Lac. wnd.
—
Rt. Lt.
G. &L
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, 3i 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 -j 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 PEOBLEMS 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 B. Strenuous
Pulse rate and character
One minute after exercise
Cyanosis
Breathlessness
Pain
Other symptoms
No. of hops No. of lifts
Rating (degree of tolerance)
Good Fair Poor Good Fair Poor
Final Diagnosis:
Prognosis :
Treatment :
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
Experience therein
and previous experience
in handling lead
Health
good
fair
poor
Appetite
good
fair
poor
Digestion
good colic
fair eructation gas and
poor regurgitation of fluid
Bowels
regular
constipated
or loose
alternating constipation
or diarrhea
Strength
vigorous
weak
Swelling of
ankles
present
absent
144
HEALTH SERVICE IN INDUSTRY
Physical Examination
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 SUPERVISIOIT AND ECONOMICS OF
INDUSTRIAL 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. Initial
No. of No. of No. of of Cost Total
No. Pull- Part- Cost Full- Cost Dis- of Dis- Cost of Medical
of Em- Time Time of Time of pens- pensary Supplies Cost
ployes Doctors Doctors Doctors Nurses Nurses arles Equipment 1 Year Per Tear
200 0 1 $360 0 0 1 $250 $240 $1,200
500 0 1 540 0 0 1 500 700 3,000
1000 0 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 medical 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 : ' ' 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."
Drinkerio 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 value. Mock2
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.
Howeii 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:
"In a 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 Mocko 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 mth-
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 Boardi upon investigation of a large
number of industries found not only that the ma-
jority were providing medical ser\dce, 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 reco^ized.
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 1916.12
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, O. 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. 0 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. 0. 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
Sevv^age, 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
In Large Factories 30
Substandard Workmen —
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
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