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THE JfOURNAL OF 

INDUSTRIAL 
HYGIENE 



EDITORS 

DAVID L. EDSALL, M.D., S.D., United States 
EDGAR L. COLLIS, M.D., M.R.C.S., Great Britain 



VOLUME III 

MAY, 1921— APRIL, 1922 



PUBLISHED BY 

HARVARD MEDICAL SCHOOL 

240 Longwood Avenue, Boston, Mass. 



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EDITORS 

United States . Great Britain 

David L. Edsall, M.D., S.D. E. L. Collis, M.D., M.R.C.S. 

HONORARY CONSULTING EDITOR 
Thomas M. Legge, M.D., D.P.H. 

ASSOCIATE EDITORS 

United States Great Britain 

W. Irving Clark, Jr., M.D. W. F. Dearden, 

Alice Hamilton, A.M., M.D. M.R.C.S., D.P.H. 

Emery R. Hayhurst, Sir Kenneth Goadby, 

A.M., Ph.D., M.D. K.B.E., M.R.C.S., D.P.H. 

Yandell Henderson, Ph.D. Leonard Hill, 

William H. Hovi^eil, M.B., F.R.S. 

Ph.D., M.D., ScD., LL.D. T. Lister Llewellyn, 

Frederic S. Lee, B.S., M.D., M.I.M.E. 

A.M., Ph.D., LL.D. Sir Thomas Oliver, M.D. 

Harry E. Mock, M.D. R. Prosser White, 

J. W. Schereschewsky, M.D. M.D., M.R.C.S. 

C.-E. A. WiNSLow, H. M. Vernon, A.M., M.D. 

M.S., A.M., Dr.P.H. D. A. Coles, M.D. 

South Africa 
W. Watkins-Pitchford, M.D., F.R.C.S. 

Canada Australia 

J. J. R. Macleod, M.B. H. W. Armit, 

M.R.C.S., L.R.C.P. 
MANAGING EDITORS 
Cecil K. Drinker, M.D. Marion C. Shorley, A.B. 



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CONTENTS OF VOLUME III 



MAY, 1921. NUMBER 1 

PAOB 

^ Output Study of Users and Non-Users of Tobacco in a Strenuous Physi- 
cal Occupation. J. P. Baumberger, Edna E. Perry, and E. G. Martin, Lab- 
oratory of Physiology, Stanford University 1 

Survey op Carbon Monoxide Poisoning in American Steel Works, Metal 
Mines, and Coal Mines. Henry S. Forbes, M.D., Division of Industrial Hy- 
giene, Harvard Medical School 11 

Discussion of the Etiology op So-Oallbd Aniline Tumors of the Bladder. 
Alice Hamilton, M.D., Assistant Professor of Industrial Medicine, Harvard 
Medical School, and Special Investigator of Industrial Poisons, U. S. Bureau 
of Labor Statistics 16 

BALTH in Mercantile Establishments. III. Common Sanitary Defects in 
Stores. Arthur B. Emmons, 2d, M.D., Director, Harvard Mercantile Health 
Work, Boston, Mass 29 

)0K Notices 37 

JUNE, 1921. NUMBER 2 

te Pregnant Woman in Industry. Carey P. McCord, M.D., and Dorothy K. 
Minster, Cincinnati, Ohio 39 

Method for Determining the Finer Dust Particles in Air. A. L. Meyer, 
M.D., Associate in Physiological Hygiene, School of Hygiene and Public 
Health, The Johns Hopkins University 51 

tiLiNE Poisoning in the Rubber Industry. Paul A. Davis, M.D., Akron, 
Ohio : 57 

4 Folliculitis. Calvin G. Page, Assistant Professor of Bacteriology, Harvard 
Medical School, and L. D. Bushnell, Professor of Bacteriology, Kansas State 
Agricultural College, Manhattan, Kansas. From the Bacteriological Labora- 
tories of Harvard Medical School 62 

OK Notices 76 

JULY, 1921. NUMBER 3 

Physiological Effects of Automobile Exhaust Gas and Standards of Venti- 
lation FOR Brief Exposures. Yandell Henderson, Howard W. Haggard, Mer- 
wyn C. Teague, Alexander L. Prince, and Ruth M. Wunderlich 79 

The Influence of Fatigue on Health and Longevity. H. M. Vernon, M.D., 

Investigator for the Industrial Fatigue Research Board, London 93 

Syphilis and Industry. Alec N. Thomson, M.D., Director, Medical Department, 
American Social Hygiene Association 99 

rBiNiTBOTOLUENE AS AN INDUSTRIAL PoisoN. Alice Hamilton, M.D., Assistant Pro- 
fessor of Industrial Medicine, Harvard Medical School, and Special Investiga- 
tor of Industrial Poisons for the U. S. Bureau of Labor Statistics 102 

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iv THE JOURNAL pF. INDUSTRIAL HYGIENE 

AUGUST, 1921. NUMBER 4 

PAQK 

Does the Magnetic Field Constitute an Industrial Hazard? C. K. Drinker, 
M.D., and R. M. Thomson. From the Laboratory of Applied Physiology of 
the Harvard Medical School : 117 

The Industrial Physician and the Qualifications Essential to his Success. 
William J. McConnell, M.D., Passed Assistant Surgeon (Reserve), U. S. Pub- 
lic Health Service 130 

An Interchange op Physical Examinatiojns in Industry. Harry Myers, M.D., 

Personnel Superintendent, Ohio Brass Company, Mansfield, Ohio 135 

Physiological Effects of Automobile Exhaust Gas and Standards op Ven- 
tilation FOR Brief Exposures. {Continued') Yandell Henderson, Howard 
W. Haggard, Merwyn C. Teague, Alexander L. Prince, and Ruth M. Wunder- 
lich 137 

Book Notices 1^7 



SEPTEMBER, 1921. NUMBERS 

Fatigue and Error in a Mental Occupation. J. P. Baumberger. From the 

Laboratory of Physiology, Stanford University 1^9 

A Work Chair. Arthur B. Emmons, 2d, M.D., Director, Harvard Mercantile 
Health Work, Boston, Mass., and Joel E. Goldthwait, M.D., Orthopedic Sur- 
geon, Boston, Mass 154 

The Practical Hygienic Efficiency op the Palmer Apparatus for Determin- 
ing Dust in Air. Henry Field Smyth, M.D., Dr. P. H., and Miriam Iszard, 
M.A. From the School of Hygiene, University of Pennsylvania '. . . 15^ 

Physical Education from the Standpoint of the Industrial Physician. Ralph 
W. Elliott, M.D., Manager, Medical Department, National Lamp Works of 
General Electric Company, Nela Park, Cleveland 1^ 



OCTOBER, 1921. NUMBER 6 

He.u)ACHe. Stanley Cobb, M.D., Assistant Professor of Neuropathology, Har- 
vard Medical School, and Assistant Neurologist, Massachusetts General Hos- 
pital, and D. C. Parmenter, M.D., Assistant in Industrial Hygiene, Harvard 
Medical School, and Instructor in Hygiene, Harvard University 1^* 

Medical Supervision in Industry. C. W. J. Brasher, M.D., Bristol, England . • 1^' 

The Framinqham Health Demonstration and Industrial Medicine. D. B. Arm- 
strong, M.D., Executive Officer, Framingham Health and Tuberculosis Demon- 
stration ISS 

Study op Accident Records in a Textile Mill. Prepared under the Direction of 
Amy Hewes by Ruth Fear, Edith Graves, Marjorie Lawrence, Florence Met^, 
and Helen F. Smith, Students in the Course in Statistics at Mount Holvoke 
Colkge ...!... 18'i 

Book Notices 1^^ 



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CONTENTS V 

NOVEMBER, 1921. NUMBER 7 

When Are DisABn^iriEs op the Back Arising out op Pathological Conditions 
Retobtablb Accidbnts? Rufus B. Grain, M.D., and Benjamin J. Slater, 
B.S., M.D., Medical Department, Eastman Kodak Company, Rochester, N. Y. 197 

Picric Acid in Industrial Surgery. Alfred G. Bolduc, M.D., Company Physi- 
cian, The Babcock & Wilcox Company, Bayonne, N. J 202 

SuGOiSTiONs FOB CuspiDORS IN INDUSTRIAL Plants. H. P. Smyth, -M.D., Dr. P. H., 
Assistant Professor of Industrial Hygiene, School of Hygiene, University of 
Pennsylvania 204 

Spray Infection. S. R. Douglas and Leonard Hill. Prom the National Institute 

for Medical Research, Hampstead, London 206 

Carbon Monoxide, Illuminating Gas, and Benzol: Their Effect on Blood 
CoaguLiATION Time. Henry S. Forbes and Louise Hompe. From the Labora- 
tory of Applied Physiology, Harvard Medical School 213 

Book Notices 217 

Notices 218 



DECEMBER, 1921. NUMBER 8 

The 'Problem of Heart Disease in the Industrial Worker. Paul D. White, 

M.D., Boston, Mass 219 

Cardiac Disease and rrs Relation to Industrial Efficiency. Carey F. Coombs, 
M.D., F.R.C.P., Lond., Consulting Physician for Diseases of the Heart, Min- 
istry of Pensions (S. W. Region). From the Department of Medicine, Uni- 
versity of Bristol 227 

Chronic Manganese Poisoning: Two Cases. George G. Davis, M.D., Chicago, 

niinois, and Walter B. Huey, M.D., Joliet, Illinois 231 

Tbenitbotolubnb Poisoning — Its Nature. Diagnosis, and Prevention. Carl 
Voegtlin, Charles W. Hooper, and J. M. Johnson. From the Division of 
Pharmacology, Hygienic Laboratory, U. S. Public Health Service 239 

Book Noticbs 254 



JANUARY, 1922. NUMBER 9 

Dust in Printers' Workrooms. C. B. Roos, B.Sc, F.I.C, H.M. Inspector of Fac- 
tories 257 

Inpluencb of Industrial Noises. D. J. Glibert, M.D., Chief Medical Inspector of 

Factories, Brussels 264 

The Rehabilitation op Employees: An Experience with 1,210 Cases. Fred- 
eric S. Kellogg, M.D., Physician, Western Union Telegraph Company, Pitts- 
burgh, Pa. 276 

PRINrrBOTOLUENE POISONING — ItS NaTURE, DIAGNOSIS, AND PREVENTION. {COU- 

tinued.) Carl Voegtlin, Charles W. Hooper, and J. M. Johnson. From the 
Division of Pharmacology, Hygienic Laboratory, U. S. Public Health Service 280 

Book NoncBs 293 



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vi THE JOURNAL OF INDUSTRIAL HYGIENE 

FEBRUARY, 1922. NUMBER 10 

PAOI 

Modern Views upon the Development op Lung Pibeosis. Cecil K. Drinker, 
M.D., Associate Professor of Applied Physiology, Harvard Medical School. 
Prom the Laboratory of Applied Physiology, Harvard Medical School, Bosj- 
ton, Mass 295 

Investigative Opportunities in the Physical Examination op Large Groups 

OP Individuals. Roger I. Lee, M.D., Professor of Hygiene, Harvard University 304 

A Report on the Brief Neuropsychiatrio Examination op 1,141 Students. Stan- 
ley Cobb, M.D., Assistant Professor of Neuropathology, Harvard Medical 
School, and Assistant Neurologist, Massachusetts General Hospital 309 

Static Equilibrium as a Useful Test of Motor Control. Walter R. Miles, 
Ph.D., Nutrition Laboratory of the Carnegie Institution of Washington, Bos- 
ton, Mass 316 

Notices 332 



MARCH, 1922. NUMBER 11 

Common Colds in Relation to Industrial Hygiene. Harold G. Tobey, M.D., Bos- 
ton, Mass 333 

Infectious Arthritis op the Spine. J. P. Curran, M.D., and S. P. Poster, Statis- 
tician, Norton Company, Worcester, Mass 339 

Some Observations on the Epinephrin Hydrochloride Test (Qobtsch Test) in 

A Group op NcftiMAL Individuals. William P. Van Wagenen 343 

Lighting and Ventilation of Factories, Hours op Labor and Hbai/th. J. S. 
Purdy, D.S.O., M.D., C.H., (Aberd.) D.P.H., (Camb.) P.R.S., (Edin.) P.R.G.S., 
Metropolitan M.O.H., Sydney, Australia 349 

Book Notices 359 

Notices 361 



APRIL, 1922. NUMBER 12 

Adequate Industrial Medical Service for the Small Plant. Carey P. McCord, 

M.D., and Dorothy K. Minster, Cincinnati, Ohio 363 

Metatarsophalangeal Practurbs, vtith a Report op Twenty-Seven Cases. Al- 
fred G. Bolduc, M.D., Bayonne, N. J 371 

The Establishment of a Dental Clinic. L. E. Hastings, M.D., The J. G. Brill 

Company, Philadelphia 376 

Report on an Investigation to Determine the Hazard to the Health 6p Oper- 
ators Using the Spraying Machine for Painting: The Risk of Lead Poi- 
soning. N. C. Sharpe, A.B., M.B. Prom the Department of Pharmacology of 
the University of Toronto 378 

An Appreciation op Sheridan DelSpine 387 

Book NoncBs 390 

Index to Volume III 395 






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THE JOURNAL OF 
INDUSTRIAL HYGIENE 



PUBLISHED MONTHLY 



VaLUMBin 



MAY, 1921 



NnMBKB 1 



AN OUTPUT STUDY OF USERS AND NON-USERS OF TOBACCO 
IN A STRENUOUS PHYSICAL OCCUPATION* 

J. p. BAUMBERGER, EDNA E. PERRY, and E. G. MARTIN 

(From the Laboratory of Physiology, Stanford University) 



Introduction 

IN a previous paper, the first of a series 
of articles dealing with the general 
problem of the significance of the use of 
tobacco in industry, some observations 
were reported on the eflFects of smoking on 
eflSciency in a strenuous mental occupation 
(1). The present paper is concerned with 
the second phase of the general topic: 
namely, the relation of the use of tobacco 
to efficiency in a strenuous physical occu- 
pation. In this investigation, as in our pre- 
vious report, we have adopted output as 
the criterion of efficiency (2). 

An output study requires a routine oc- 
cupation in which the same process is re- 
peated many times during the day and, to 
be wholly satisfactory, requires also that 
the number of repetitions be entirely de- 
pendent on the speed of the individual 
worker, unaffected by the rate at which 
machinery is driven. Obviously tobacco 
effects, if any exist, would be most likely 
to appear in a very strenuous occupation. 
The occupation to be selected for study 
should, therefore, be routine, physically 
strenuous, and dependent on individual 
initiative. 

* Received for publication Dec. 14, 1920. 



After some search we decided on bottle 
making as meeting these conditions satis- 
factorily. Permission was obtained to 
make an output study in a large glass 
bottle manufacturing plant, which operates 
thirty-five bottle-making machines and 
employs 500 persons. We wish to take this 
opportunity of thanking the superintend- 
ent and the personnel of the factory for 
their courteous treatment of us during the 
three weeks of the investigation. 

Process 

The process of glass blowing may be 
briefly described as follows: The old 
method of blowing glass bottles by mouth 
has been largely abandoned except for 
small special orders, and this highly skilled 
work is now done by machinery manipu- 
lated by a skilled "gatherer" and *' cut- 
ter" and inexperienced helpers. In some 
machines the whole process is carried out 
automatically and only an unskilled at- 
tendant is required. In the majority of 
machines, however — and it was with this 
type of machine that our work was con- 
cerned — the gatherer regulates the speed 
of the machine by his own motions. The 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



machines are located at one end of an oval 
tank containing the fused glass, which is 
kept at a temperature of 2650** F. The wall 
of the tank is perforated with working 
holes at intervals of about 12 feet, and foot 
benches of appropriate height for the gath- 
erers are situated at each hole. The ma- 
chine is located at the left of the foot bench 
and consists usually of two revolving tables, 
the first of which bears a number of iron 
blanks in which the neck of the bottle and 
a depression in the center can be formed. 
The second revolving table carries molds 
in whic^ the final form can be given to the 
bottle. The operation is as follows: 

The gatherer stands on the foot bench at 
the working hole with a "punty" in hand. 
This is an instrimient 43 inches long, con- 
sisting of an iron rod with a wooden handle 
at one end and a clay ball on which the 
glass is collected, at the other end. The 
gatherer has his back toward the machine 
and holds the punty handle with both 
hands, allowing the clay ball to touch the 
surface of the fused glass. The iron rod of 
the punty rests on an iron support ("dog 
leg") at the edge of the working hole, 
while the gatherer revolves the punty until 
sufl5cient glass adheres to form a "gob" of 
the size required to make the proper weight 
bottle. The gatherer then turns to the left 
and, suspending the gob over the mouth of 
the blank, allows the glass to drip off. 
When the proper amount has fallen, the 
cutter chps the stream of glass with a pair 
of shears. The gatherer then turns back 
to the hole and again inserts the punty. 
The motions of the gatherer are exceed- 
ingly rapid and acciwate and as many as 
twenty-six 2-ounce gobs may be gathered 
in one minute. 

The cutter sits on a stool at the edge of 
the foot bench and clips off the stream of 
glass from the punty as it falls into the 
blank; he then pulls a lever which brings 
down a plunger into the center of the 
blank, shaping the neck and making a de- 



pression in the glass, revolves the table so 
that the bottle is partially blown auto- 
matically, greases (with a graphite cov- 
ered plunger) another blank, and is ready 
to receive the next gob of glass. 

The "take-out boy" (unskilled) is seated 
on a stool opposite the cutter; he opens 
the blank, removes the half-blown bottle 
by means of pincers, and drops it into a 
mold on the mold table. The second 
helper is seated at the mold table which he 
revolves so that the bottle is fully blown 
by an automatic blower, and passes under 
a torch to smooth the mouth. He then 
opens the mold, places the finished bottle 
on a table, and closes the mold. 

The "carrying-in boy," by means of a 
."carrying stick" (an asbestos-covered, long 
handled implement) transfers the bottles, 
a row at a time, into the "tempering lehr," 
the floor of which moves the bottles very 
slowly through an oven of decreasing 
temperature until the bottles are taken out 
cool at the other end, where they are 
packed. 

In the Lynch machine^ this whole process 
is carried out by a gatherer and a carrying- 
in boy, the gatherer regulating the speed 
of the machine just as he does in the type 
described above. In the Lynch type in 
the process of dripping the gob into the 
blank, the gatherer touches with his punty 
a lever which puts the whole machine into 
motion. Thus, for each gob gathered the 
machine makes one complete revolution. 

Operatives 

The helpers, carrying-in boys, and take- 
out boys are all unskilled, unorganized 
laborers and, though called "boys," are 
usually over 20, the carrying-in being done 
by men of 40 or over, who are not quick 
enough for the other work. During the 
war many women were taken on as help- 
ers, and some white and some colored 
women have continued in this work. The 



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BAUMBERGER, PERRY, AND MARTIN— TOBACCO AND EFFICIENCY 3 



labor turnover among the unskilled em- 
ployees is very high. 

The gatherers alternate every half hour 
in the processes of cutting and gathering. 
On the Lynch machine three gatherers 
operate two machines; one gatherer is as- 
signed to each machine on which he works 
40 minutes, and then rests and oils the ma- . 
chine for 20 minutes; the third man works 
20 minutes on each machine and rests and 
oils the two machines for 20 minutes. The 
gatherers are the only skilled workers on the 
machines and have inherited the pride of 
the craft of glass blowing and are very 
proud of their dexterity and speed. In- 
deed, a speedy man is usually the center of 
attraction for all who happen not to be at 
work at the time. This pride buoys the 
men up and increases their output, as will 
be shown in another paper. The turnover 
for gatherers is very slight, and it is not 
rare to find men who have worked over 
five years in the same plant. 

The average age of the eighty-five gath- 
erers studied was 36 years, of which an 
average of twenty years had been spent in 
the glass industry. A study of the correla- 
tion of age and output gave negative re- 
sults as did also a study of correlation of 
overweight and underweight . and output. 
The men averaged 4 pounds overweight, 
on the basis of the biometric tables of the 
Provideht Life & Trust Co., which seems 
to indicate that the work is not too strenu- 
ous. The men are unionized and work 
under definite regulations as to hours' and 
weeks' work. The shifts are from 7 a.m. to 
3 P.M., 3 P.M. to 11 P.M., and 11 p.m. to 
7 A.M., and the men work for a week on 
each shift. The plant runs from Monday 
7 a.m. to Saturday 12 m. Two weeks' va- 
cation (without pay) between June 15 and 
September 15 must be taken. Apprentice- 
ship is for three consecutive years. A bene- 
fit association is maintained by the Glass 
Blowers' Association of the United States 
and Canada. The gatherers are largely of 



native stock, with little schooling, as the 
average length of experience shows, and 
are, on the whole, a very steady, clean- 
lived group of men. Many expressed the 
belief that their work was so hazardous and 
hard that dissipation could not be indulged 
in without great risk to their health and 
injury to their eflBciency. The men earn 
from $8 to $10 a day, working on a piece- 
work basis except when the machines 
break down, and then they are paid by the 
hoiu". The men claim that they can esti- 
mate their speed closely enough to calcu- 
late their output for the day, but in some 
cases the carrying-in boy scores each load 
of bottles he places in the temj>ering lehr. 

Method 

The output records were obtained by 
passing from one machine to another each 
half hour and counting the number of gobs 
of glass gathered by each man in a period 
of from one to five minutes. The datd, 
therefore, show output rate only and are 
not to be construed as actual output. It 
was found that actual output is not a de- 
pendable criterion of the working capacity 
of the individual, as in this trade machine 
breakdown and minor delays, such as re- 
sult from impurities adhering to the punty- 
head, are a constant and unaccountable 
factor entirely independent of the work- 
ers' eflBciency. It is obvious, however, that 
output would, in general, correspond to 
differences in rate of gathering between 
individuals. 

The counting was done by means of a 
tally register and the timing by means of a 
stop-watch. The records were kept on a 
separate card for each man together with 
the weight of the bottle made and data 
obtained by a personal interview as to age, 
height, weight, marital status, years' ex- 
perience, and smoking and chewing habits. 
All counts were made at times when the 
machinery was working without trouble. 



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4 THE JOURNAL OF INDUSTRIAL HYGIENE 

and in no case was a count made when any conversation. They appeared to be honest 
accidental obstruction to the full speed of and straightforward in their answers and 
the worker was present. The gathering were all on the best of terms with the in- 
had an extremely uniform rate for each vestigator. The following arbitrary classi- 
TABLE 1.— NUMBER OF MEN IN EACH fication seemed logical, on the basis that 
HABIT GROUP about the same amount of tobacco is in- 

Number of men included in habit groups. . . 76 volved in each case. 

Non-users of tobacco 6 Persons who smoked more than ten ciga- 

Non-smokers 13 i i . 

Smokers * * 63 rettes per day, or more than one cigar per 

Chewers 22 day, or more than two pipefuls of tobacco 

Light smokers 23 per day Were called heavy smokers. Those 

Non!^^S^^hochew ^ who smoked less than this Were called light 

Lightsmokerswhochew..............!!. 8 smokers, and chewers and non-users of 

Heavy smokers who chew 7 tobacco were classified separately. Table 1 

Light smokers who do not chew 16 gj^^g ^^^ j^abit groups and the number of 

Heavy smokers who do not chew 33 . , , Vi i ^ # t 

Non-chewers 54 ^^^ ^^ ^*^ class. For lack of adequate 

Non-chewers who smoke 48 data, nine men had to be omitted from the 

. J. ., , , .. ^ , , . habit groups, leaving seventy-six that were 

individual and it was found that one mm- ^^^^^^ q^ g ^^^ ^f ^^^ ^^^ ^^ 

ute was a long ^ough period m which to ^^^ ^ ^^^^^ ^^^ 83 per cent, smoke. 

obtaina comit diaractenstic of the opera- ^g per cent. chew, and 20 per cent, both 

tor. The mvestigation was earned on for ^^^^j^^ ^^ ^^^ 

about three weeks and 1,569 hourly counts 

were made — i.e., an average of 20.3 

hourly coimts per man. Output Rate and Weight of Bottle 

„ In order to determine the eflBciency of 

the men grouped according to their habits. 
The smoking or chewing habits of the it is necessary to compare their actual out- 
men were obtained by questioning them put rates. The men were, however, work- 
directly and by observation and indirect ing on bottles of a number of different sizes 

TABLE 2. — ACTUAL AVERAGE HOURLY OUTPUT RATE AND PERCENTAGE HOURLY 

OUTPUT RATE OF ALL WORKERS 



Hoar 


7-8 


8-« 


^10 


10-11 


ll-l« 


l«-l 


i-« 


%-s 


Actual Output Rat 


*E OF All Workers (m Number of ^4 


Dunce Bo* 


rTLBs PER Minute) 




Mean 


13.6 
2.32 
0.186 

17.1 


13.69 
1.98 
0.141 

14.6 


13.63 
2.02 
0.146 

14.9 


13.76 
1.98 
0.141 

14.4 


13.63 
1.77 
0.156 

13.0 


13.46 
. 1.99 
0.149 
14.8 


13.59 
2.01 
0.16 

14.8 


13.U 


Standard deviation 


1.88 


Probable error of mean * 

Coefficient of variability 


0.14 
14.0 


Percentage Houblt Output Rate of Au 


L Workers 


Mean... 


99.2 
6.0 
0.48 
6.0 


100.6 
5.4 
0.386 
6.0 


100.0k 
4.2 
0.30 
4.17 


100.3 
4.16 
0.29 
4.14 


100.H 
6.4 
0.46 
6.36 


100.01 
6.2 
0.39 
6.29 


100.08 
4.48 
0.35 
4.4^ 


99.3 


Standard deviation 


6.3 


Probable error of mean ^ 

Coefficient of variability 


0.39 i 
6.31 














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BAUMBERGER, PERRY, AND MARTIN— TOBACCO AND EFFICIENCY 5 



and weights. Each machine was assigned 
a particular weight bottle to be made for 
a day, or weeks, as the case might be. It 
requires diflFerent lengths of time to gather 
diflferent weight gobs of glass, but this re- 
lationship is not a direct proportion; thus, 
six and five-tenths 55-ounce gobs can be 
gathered in a minute, while only twenty- 
two and five-tenths If -ounce gobs can be 
gathered in the same time. So that the 
outputs of all the men would be compara- 
ble, they were reduced to output for a 
standard-sized bottle. This was accom- 
plished in the following manner: The aver- 
age output for each individual who had 
worked on a certain weight bottle was 
plotted on co-ordinate paper with the hori- 
zontal axis as the number of gobs of glass 
gathered in a minute, and the vertical axis 
as weight of* the gob in ounces. Having 
plotted ^all the individual average outputs 
for all the diflFerent weight bottles that had 
been handled, the grand average for each 
weight was also plotted. A curve was then 
drawn which coincided as closely as possi- 
ble with the loci of the grand averages. 
Such a smoothed curve can be drawn with 
great accuracy according to Bayliss (3). 
The curve is shown in Figure 1. It was 
then assiuned that the loci of the curve 
represented the relation existing between 
the weight of the gob of glass gathered and 
the number of gobs that could be gathered 
in one minute. The largest number of 
individuals and records had been involved 
in determining the grand average output 
of 8§-oimce bottles, and the locus of this 
point seemed to be in good general con- 
formity with the curve as a whole; it was, 
therefore, selected as a standard. 

An example will best serve to illustrate 
the method used to reduce the output of 
one individual operator to the standard. 
Operator 1 gathered twenty-four l|-ounce 
gobs of glass in one minute. Referring to 
Figure 1 we find that twenty-two and five- 
tenths is the grand average for If-ounce 



bottles, also that thirteen and three-tenths 
is the grand average for 8J-ounce bottles. 
Therefore, Operator 1 would be expected 
to make more than thirteen and three- 
tenths 8 J-ounce bottles in proportion as he 
had made more than the expected number 
of l|-ounce bottles; in other words, the 




Fig. 1. — Relation of gathering rate to weight of gob. 
Hoiixontal axis - number of gobs gathered per minute; 
vertical axis - weight of gobs in ounces; dots - average 
gathering rates; circles - grand average gathering rates; 
crosses <- theoretical7gathering rates. 



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TABLE 3.— HOURLY OUTPUT RATE BY HABIT GROUPS 



Hour 



7-8 



»-• 



»-10 



10-11 



11-1« 



1*-1 



StS 

















Mean 


13.27 
1.25 
0.34 
9.4 


II1.I2 
1.44 
0.27 

10.2 


13.89 
1.45 
0.27 

10.4 


13.96 
1.74 
0.32 

12.5 


H.0 
1.36 
0.29 
9.7 


13.75 
1.87 
0.304 

13.6 


13.96 
1.69 
0.316 

12.1 


UM 


Standard deviation 


1.82 


Probable error of mean * 

Coefficient of variability 


0.34 
13.0 



Mean 

Standard deviation 

Probable error of mean - 
Coefficient of variability 

Mean 

Standard deviation 

Probable error of mean = 
Coefficient of variability 

Mean 
Stand 
Proba 
Coeffi 

Mean 

Standard deviation 

Probable error of mean : 
Coefficient of variability 



All Smokers 



Mean 


U.05 
2.4 
0.23 

17.1 


13.9 
2.33 
0.199 

16.6 


13.95 
2.24 
0.188 

16.0 


U.11 
2.16 
0.18 

15.2 


H.0 
1.91 
0.191 

13.6 


13.89 

2.1 

0.183 
15.1 


13.87 

2.1 

0.183 
15.1 


13.82 


Standard deviation 


1.97 


Probable error of mean ^ 

Coefficient of variability 


0.175 
14.2 



All Chewers 



Mean 


13.3I^ 
1.22 
0.188 
9.15 


13.71 
1.51 
0.208 

11.0 


i3.j^e 
1.21 

0.165 
8.99 


13.71 
1.47 
0.202 

10.7 


U.09 
1.09 
0.177 
7.73 


13.1^6 
1.58 
0.22 

11.7 


13.l^2 

1.39 

0.19 
10.4 ^ 


13.62 


Standard deviation 


1.48 


Probable error of mean ^ 

Coefficient of variability 


0.198 
10.9 



All Non-Users of Tobacco 



13.5 


14.0 


UM 


U.0 


13.9 


14.2 


14.3 


1.0 


L12 


1.07 


1.12 


1.2 


1.48 


1.07 


0.275 


0.308 


0.294 


0.308 


0.357 


0.4 


0.294 


7.4 


8.0 


7.8 


8.0 


8.6 


10.4 


7.45 



All Heavy Smokers 



14.67 
2.68 
0.310 

18.2 



13.92 
2.52 
0.266 

18.1 



14.17 
2.32 
0.236 

16.4 



144 

2.2 

0.224 
15.3 



14.24 
2.02 
0.24 

14.2 



14.29 
2.23 
0.232 

15.5 



I4.U 
1.36 
0.145 

10.0 



All Light Smokers 



Heavy Smokers Who Chew 



14.5 
1.52 
0.42 

10.4 



14.05 

1.9 

0.203 
13.6 



Mean 


13.44 
1.69 
0.288 

12.6 


13.54 
1.29 
0.19 
9.5 


13.22" 
1.29 
0.214 

10.9 


13.5 
1.41 
0.212 

10.4 


13.5 
1.36 
0.256 

10.1 


13.06 
1.55 
0.244 

11.9 


13.31 
1.99 
0.308 

14.9 


13.44 


Standard deviation 


1.99 


Probable error of mean * 

Coefficient of variability 


0.308 
14.8 



13.5 
1.29 
0.35 

12.3 



13.12 
1.22 
0.29 
9.3 



I4.O6 
0.68 
0.152 

4.85 



13.83 
0.9 
0.2 
6.5 



14.07 
1.06 
0.269 
7.54 



14.0 
0.7 
0.167 
5.0 



13.5 
0.7 
0.167 
5.18 



13.83 
0.48 
0.104 
3.48 



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BAUMBERGER, PERRY, AND MARTIN— TOBACCO AND EFFICIENCY 7 

TABLE 3.— HOURLY OUTPUT RATE BY HABIT GROUPS (contintjbd) 



Hour 



7-8 



8-0 



9-10 



10-11 



11-12 



1«-1 



2-8 



Heavy Smokers Who Do Not Chew 



in AZIt 

Standard deviation 

Probable error of mean = 
Coefficient ol variability 



n.67 


IhM 


H.27 


IhM 


U.29 


U.39 


U^kS 


2.92 


2.68 


2.62 


2.44 


2.32 


2.46 


2.30 


0.386 


0.325 


0.306 


0.28 


0.312 


0.292 


0.27 


19.9 


18.8 


18.4 


16.7 


16.2 


17.1 


16.0 



lUl 
2.20 
0.27 

15.5 



Light Smokers Who Chew 



Mean 


13.5 
0.17 
0.047 
1.26 


13.8 
1.42 
0.318 

10.3 


13.0 
1.25 
0.296 
9.6 


13.37 
1.16 
0.276 
8.76 


U^l 
0.65 
0.195 
4.65 


13.38 
1.62 
0.363 

12.1 


13.17 
1.56 
0.35 

11.8 


13.39 


Standard deviation t , . , , t - 


1.67 


Frobable CTroi*of mean ± 

Coefficient of variability 


0.373 
12.5 



Light Smokers Who Do Not Chew 



Mean 

Standard deviation 

Probable error of mean • 
Coefficientof variability 



U.09 


\ 
13.9' 


13.93 


13.93 


13.6 


U.0 


UM 


1.89 


0.95 


1.35 


L45 


1.44 


1.04. 


1.82 


0.367 


0.165 


0.24 


0.26 


0.307 


0.202 


0.34 


13.5 


6.8 


9.7 


10.4 


10.6 


7.41. 


13.0 



13.76 
1.96 
0.382 

14.3 



Chewers Who Do Not Smoke 



Mean 

Standard deviation 

Probable error of mean ■ 
Co^cient of variability 



13.07 


U.S1 


13.21 


13.93 


U.0 


13.3^ 


13.6^ 


1.48 


1.67 


1.39 


2.13 


1.48 


2.12 


1.81 


0.37 


0.42 


0.37 


0.54 


0.445 


0.583 


0.46 


11.3 


11.7 


10.5 


15.3 


10.6 


15.9 


13.3 



13.6^ 
1.96 
0.49 

14.3 



following formula was applied: x : IS. 3 : : 
£4. : 22.5 y and solving for x we have 14.19 as 
the number of standard-sized bottles which 
Operator 1 would make in one minute. 
Individuals who had worked on several 
different weight bottles were found to have 
outputs for the different weights corre- 
spK>nding to our curve, confirming the vaUd- 
ity of our method. Furthermore, as will 
appear in a subsequent paper, the rela- 
tionship of weight of gob to the number of 
gatherings per minute involves the time of 
gathering, of transfer back and forth, and 
of dropping the glass. The last two factors 
vary in an arithmetical progression, and 
the time of gathering, in a geometrical 



progression. The form of our curve is a 
logical outcome of these relationships. 

The formula given above was used to 
reduce the output to terms of a standard- 
sized bottle so that the men could be di- 
rectly compared as to output. The actual 
average output rate of the men in 8J- 
ounce bottles per minute for each hour dur- 
ing the day's work, calculated by the 
method described above, is given in Table 
2. The percentage output is also given in 
Table 2 and serves as a check on the 
former, as the percentage output is deter- 
mined directly from the actual number of 
bottles which each man makes, reduced to 
a percentage on the basis of his average as 



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100. The two sets of figures vary in the 
same manner throughout the day, except 
for minor dififerences which prove to be due 
to the smoothing efifect of the formula 
method, for if the percentage output curve 
is smoothed it approaches the actual out- 
put ciu^e even more closely. 

Output Rate by Habit Groups 

In order to determine the output of each 
group the standardized output records were 
added and the mean output rate per min- 
ute for each hour was obtained. For the 
eighty-five men studied the mean rate per 
minute for the day was 13.56, and for the 
seventy-six men in the. habit groups the 
output was 13.99. The output rate for 
each hour was about the same throughout 
the day (see Table 2), showing that fatigue 
does not affect the output rate to any ap- 
preciable extent. Table 3 shows that all 
the habit groups are equal in this regard. 
The question of fatigue will be taken up in 
a separate paper. 

The mean output rate for the day for 
each of the thirteen habit groups is shown 
in Table 4. The highest output is found in 
the heavy smokers who do not chew, and 
the lowest in the light smokers who chew. 
The difference between these two extremes 
is 1.01 bottles per minute, or 7.2 per cent, 
of the grand average output. Industrially, 
this is an important difference, amounting 
to more than a thousand bottles in a 
twenty-four-hom* day. Statistically, how- 
ever, the difference is so slight that before 
we can draw any conclusions, some statisti- 
cal criterion must be appKed to determine 
whether or not it has any significance. 

The probable error of the mean can be 
used to determine the degree of imreUabil- 
ity of the mean; therefore, if we are com- 
paring two means, the significance of the 
difference between them will be deter- 
mined by the chances that one mean will 
coincide with the other. The chances that 



the difference between the means is signifi- 
cant are 1 : 1 if the probable error of the 
difference is contained once in the differ- 
ence; 4.5 : 1 if contained twice;^ and 21 : I 
if contained three times. It is usually con- 
sidered that, in order to be significant, the 
difference between two means must con- 
tain the probable error of the difference 
twice, and in order to have a degree of 
certainty, must contain it three times. We 

TABLE 4. — MEAN OUTPUT RATE FOR DAY 
BY HABIT GROUPS 



Group 



Heavy smokers who do 
not chew 

Non-users 

All non-chewers 

Non-chewers who smoke. . 

All heavy smokers. 

Mean of all habit groups . . 

All smokers 

Light smokers who do not 
chew 

AU non-smokers 

Heavy smokers who chew . 

Allchewers 

Non-smokers who chew. . . 

All light smokers 

Light smokers who chew. . 



True 
Mean 


Stand- 
ard De- 
viation 


Coeffi. 
cient of 
Varia- 
bility 


14.S8 


2.4 


16.9 


14.24 


1.32 


9.25 


14.24 


2.3 


16.1 


14.19 


2.17 


15.2 


14.14 


2.32 


16.4 


13.99 






13.93 


2.13 


15.8 


13.88 


1.54 


11.0 


13.87 


1.66 


12.0 


13.72 


0.3 


2.2 


13.59 


1.4 


10.3 


13.44 


1.82 


13.3 


13.37 


1.61 


12.4 


13.32 


1.37 


10.3 



Probable 
Error ol 
Mean 



*.101 
=fc.l30 
=*».078 
±.078 
=b.093 

*.065 

=b.099 
*.112 
±.025 
±.066 
±.169 
±.089 
±.114 



have, therefore, arranged in Table 5 the 
diflFerences between groups that can be 
compared and the number of times the 
probable error of the diflFerence is con- 
tained in these dififerences. 

From Table 6 it appears that chewing 
has a marked efifect on output rate, while 
smoking has little efifect. The non-user 
group may be considered as a standard, 
and we find that the whole group of non- 
chewers coincides with it in output rate, 
but the chewers fall far below these two 
groups, the difiference being significant as 
the probable error of the difiference is con- 
tained 2.7 times. The difiference between 
smokers who do not chew and the non- 
users is too small to be of significance; 



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BAUMBERGER, PERRY, AND MARTIN— TOBACCO AND EFFICIENCY 9 



therefore, it appears that smoking has less 
eflFect on output rate than chewing. When 
we separate the smokers who do not chew 
into light and heavy smokers, no significant 
difference appears between the non-users 
and the hght smokers or between the non- 
users and the heavy smokers. The heavy 
smokers who do not chew do slightly better 
than the non-users, but the difference is 
not statistically dependable. The light 
smokers who do not chew, however, do less 



in like manner among the light smokers 
where the difference contains the probable 
error of the difference 1.2 times. These 
comparisons are also given in Table 5 and 
show that chewers have in every case a 
markedly lower output rate. 

Table 6, in which the groups holding the 
highest and lowest hourly records are given, 
shows that the workers who chew in no 
case make a highest output rate record, 
but in seven out of eight of the hours make 



TABLE 5. — COMPARISON OF HABIT GROUPS, SHOWING SIGNIFICANCE OF DIFFERENCES 



G B on PB 


Algebraic 

Mean of First 
Group 


Probable Error 
of Difference 


Number of Timea 
Probable Error U 


First Group 


Second Group 


Difference is Con- 
tained in Difference 


Noii>usei*s 


All chewers 


-0.65 

-0.05 
-0.36 
4-0.00 
-0.77 
-0.61 
-0.56 
-0.45 
-0.40 


0.24 

0.28 
0.34 
0.34 
0.41 
0.33 
0.48 
0.45 
0.37 


2.7 




Non-chewers . 




(• 


Smokers who do not chew 

Light smokers who do not chew. . . 
Heavy smokers who do not chew. . 
All liffht smokers 




« 


1.0 


.. '■ 




All )i«^vy smok^^Tff 


1.9 


Heavy smokers who do not chew 

Li^t smokers who do not chew 


Heavy smokers who chew 

Light smokers who chew 


1.8 
L2 


Heavy smokers who do not chew 

Heavy smokers who chew 


Light smokers who chew 


1.0 
1.1 









well than the non-users, but the chances 
that this is significant are only 1:1. We 
cannot offer tin explanation of the fact that 
the light smokers have a lower output rate 
than the heavy smokers. A difference of 
the same nature, however, exists between 
the output of heavy and light smokers as 
a whole, the probable error of the differ- 
ence being contained in the difference 1.9 
times, and also between the heavy and 
light smokers subdivided into chewers and 
non-chewers, the probable error of the 
difference being contained 1.1 and 1.0 
times, respectively. 

The fact that chewing has a much more 
marked effect on output rate than smok- 
ing is further brought out by a comparison 
of heavy smokers who chew with heavy 
smokers who do not chew, in which the dif- 
ference is large enough to contain the prob- 
able error of the difference 1.8 times, and 



a lowest record. The actual output rates 
are given in Table 3. 

Discussion 

From the foregoing data it appears that 
workers who chew have a much lower out- 
put rate than those who only smoke or who 
do not use tdbacco in any form. The light 
smokers, however, do show some inferiority 
in output rate and the heavy smokers a 
very slight superiority, although these dif- 
ferences are too small to be statistically 
dependable. The difference between the 
light and heavy smokers is apparently 
significant. The fact that light smokers 
have a lower output rate than heavy 
smokers is diflScult to explain but may be 
an indication that insufficient use of to- 
bacco has more deleterious effects than a 
larger use which might confer an immunity 



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10 



THE JOURNAL OF INDUSTRIAL HYGIENE 



that would be lacking in the case of light 
smokers. This explanation is entirely a 
surmise, but should be followed up. 

The low output of chewers may be due 
to a greater absorption of nicotine into the 

TABLE 6. —HABIT GROUPS HOLDING 

HIGHEST AND LOWEST HOURLY 

OUTPUT RATE RECORDS 



Hour 


Highest Average Hourly 
Output Rate 


Hour 


Lowest Average Hourly 
Output Rate 


1 
8 


Heavy smokers who do 

no^ chew 
Heavy smokers who do 

not chew 
Non-users 


1 

3 
4 

5 
6 

7 
8 


Chewers who do not 

smoke 
Heavy smokers who 

chew 
Light smokers who 


4 

6 

6 

7 
8 


Heavy smokers who do 

not chew 
Heavy smokers who do 

not chew 
Heavy smokers who do 

not chew 
Heavy smokers who do 

not chew 
Non-users 


chew 
Light smokers who 

chew 
Light smokers who do 

not chew 
Chewers who do not 

smoke 
Light smokers who 

chew 
Light smokers who 






chew 



system than takes place from smoking. 
Some reason for this is obvious when we 
consider that in smoking at least half the 
nicotine is lost in the smoke from the biun- 
ing point and that a large part of the nico- 
tine in the inhaled smoke may be exhaled 
before it is absorbed. This is quite likely. 



as smoke can be drawn through several 
wash bottles without losing all its nicotine, 
because the alkaloid is probably adsorbed 
on the surface of liquid particles in the 
smoke which are notably diflScult to absorb 
in a wash bottle. (This point will be 
brought out in a paper to follow shortly.) 
In chewing tobacco, on the other hand, the 
saliva of the chewer seems to have ample 
opportunity to absorb the nicotine of the 
tobacco, and from the saliva the mucous 
lining of the mouth may absorb the poison. 
Furthermore, in most chewing a certain 
amount of saliva is swallowed, which gives 
abundant opportimity for absorption of 
nicotine. It is possible, therefore, to offer 
an explanation for the fact that chewers 
have a lower output rate than smokers on 
the basis of the relative nicotine absorption, 
although until actual absorptive studies of 
the two groups have been made, such an 
explanation can be only tentative. 

Conclusions 

1. Smoking has Uttle effect on output 
rate in the strenuous physical occupation 
studied by us. 

2. Chewing markedly lowers output rate 
in this strenuous physical occupation. 

3. Light smokers have a slightly lower 
output rate than heavy smokers in this 
strenuous physical occupation. 



BIBLIOGRAPHY 



1. Baumberger, J. P., and Martin, E. G.: Fatigue 
and Efficiency of Smokers in a Strenuous Men- 
tal Occupation. Joxtr. Indtjst. Hyg., 1920- 
1921, 2, 207. 



2. Florence, P. S.: Columbia Univ. Studies in 
Hist., Econ., and Law, 1918, 81, 8. 

8. Bayliss, W. M.: Principles of Greneral Physiol- 
ogy. New York and London, Longman's 
Green and Company, 1915, p. 40. 



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A SURVEY OF CARBON MONOXIDE POISONING IN AMERICAN 
STEEL WORKS, METAL MINES, AND COAL MINES* 

HENRY S. FORBES, M.D. 

Division of Industrial Hygiene, Harvard Medical School 



THIS report is the result of a survey, 
chiefly in mines and about blast fur- 
naces, to obtain more accurate information 
regarding the clinical effects of carbon 
monoxide. 

In the United States and abroad the 
literature gives many instances of mental 
impairment, psychoses, and paralyses fol- 
lowing acute gassing by carbon monoxide, 
and it is stated that anemia, neuritis and 
other symptoms follow chronic poisoning 
from this gas (1) (2). It undoubtedly 
causes more accidents, fatal and non-fatal, 
than any other gas in industry, and it seems 
important to find out how much crippling 
and how much loss of working time it is 
responsible for. Few accurate data are to 
be found in regard to this, and two definite 
problems, therefore, present themselves: 
(1) How frequent are late sequelae of acute 
carbon monoxide gassing? and (2) What 
effect does the gas have on men frequently 
exposed to small doses? 

An attempt to answer these questions 
has been made by a survey of metal mines, 
coal mines, blast furnaces, and producer 
gas boilers and engine rooms in Montana, 
Colorado, Oklahoma, Arkansas, Alabama, 
Tennessee, Kentucky, and Pennsylvania. 
Data were obtained from mine hospitals, 
mine doctors. United States Bureau of 
Mines ofiScials, superintendents, foremen, 
shift bosses, fire bosses, and individual 
miners, as well as by insi>ection of the less 
well ventilated workings and of drifts and 
stopes near fire areas. In a few cases red 
blood-cell counts were made, and in others, 
tests for carbon monoxide in the blood. 



* Received for publkation Jan. 6, 1921. 



In mines, exposure to carbon monoxide 
usually occurs in one of three ways : (a) after 
explosions or during serious fires; (6) about 
smouldering fire areas; or (c) after blasting. 
Carbon monoxide is the chief poisonous 
element of the miners' "white damp," 
"after damp," and "powder smoke." Its 
presence in 0.025 per cent, is suflBcient to 
cause dizziness and severe heada<9ie; in 
0.2 per cent, it is dangerous (3). 

In Montana the copper mines at Butte 
and the smelters at Anaconda, East Helena, 
and Great Falls were examined. The smelt- 
ers appear to present no carbon monoxide 
hazard under ordinary condition^. In the 
copper mines, the gas does occur frequently 
in small amounts about the fire areas and is 
rather troublesome. Occasionally, also, it 
causes headaches after blasting at certain 
points where the air current is not good and 
where two or three shifts are working. In 
these mines there is no record of lost time 
due to this cause, and only rarely is a man 
overcome for a few hours about the fire 
areas. In the coal mines, especially in the 
South, owing to the danger of explosions 
from natural gas and fine coal dust, there 
is always free ventilation, and the powder 
smoke only occasionally causes symptoms. 
The iron ore mines near Birmingham, Ala- 
bama, are less well ventilated and after 
blasting the carbon monoxide lies in the fine 
dust and is stirred up by the "muckers," 
who often have headaches from it. But 
there is apparently no lost time from this 
cause. 

About the blast furnaces the gas seems 
to cause practically no loss of time among 
the men most frequently exposed to small 



11 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



percentages of it — i. e., the top-fillers, hot 
blast men, or the men tending the boilers or 
engines nm by producer gas. Among the 
pipe-fitters and repair men who encounter 
occasional high percentages of carbon 
monoxide, loss of time is fairly common, 
but the man gassed usually lies down for a 
few minutes and then returns to work. 
Only a small proportion of these cases are 
sent to the hospital, and the company 
office has no record or even knowledge of 
them. In the large plants, such as those at 
Pittsburgh, the number of hours lost in this 
way must be considerable. 

Acute Cakbon Monoxide Poisoning 

Symptoms. — The symptoms of acute 
carbon monoxide poisoning may vary from 
sudden unconsciousness without warning 
to merely a slight headache. The usual 
symptoms, in the order of their occurrence, 
are: dizziness or sense of fullness in the 
head, frontal headache, weakness of the 
knees, nausea, sometimes vomiting, general 
weakness, inabiUty to walk or stand, and 
unconsciousness. The symptoms depend 
chiefly on the concentration (3) of carbon 
monoxide and on the duration of exposure, 
but also vary with the individual and his 
physical condition at the time of gassing. 
Often there is a stage of excitement like 
alcoholic intoxication. Different persons 
react as differently as they do to alcohol, 
and many men are well known to be able 
to stand amounts of the gas which would 
speedily overcome others. The most sen- 
sitive are men with pre-existing pulmonary 
or cardiac disease. Sudden entrance into 
cold air or sudden exertion causes an 
exacerbation of symptoms. Gastric indi- 
gestion and cohstipation seem to make a 
man temporarily more susceptible to car- 
bon monoxide. 

Sequelae. — In severe acute gassing, 
when unconsciousness has lasted minutes 
or hours, the usual after-effects are intense 



headache, fatigue, and muscle pains, lasting 
from one to three days. It is interesting 
that the muscle after-pains appear to be 
worst in those muscles most used during 
exposure to the gas. The temporary char- 
acter of the effects of acute gassing, how- 
ever, are illustrated by the following 
instances. In a mine disaster in Butte, 
Montana, twelve cases were admitted to 
the hospital, gassed. Nine left relieved in 
twenty-four hours, and the other three, two 
days later. No readmissions and no known 
sequelae occurred. In another hospital, in 
the past year ten miners were admitted, 
.gassed in mine accidents. Nine went home 
in twenty-four hours or less. The tenth, 
unconscious at entry, stayed thirty-six 
hours. This patient had always been neu- 
rotic, a state which was accentuated after 
the gassing, but no new condition de- 
veloped. There were no re-entries and no 
sequelae. The same story was told every- 
where by miners, foremen, and mine 
doctors of many years* experience. They 
knew of no men permanently incapacitated 
through mental or physical injury from 
gassing. One Bureau of Mines official, 
however, knew of two men gassed after a 
coal mine dust explosion, who were men- 
tally incapacitated some months later. It 
was not known what their mental or 
physical condition had been before being 
gassed. Another Bureau of Mines engineer 
said that two other men had been partly 
paralyzed after short exposure to mine gas. 
The history given suggested complicating 
disease or hysteria as the probable ex- 
planation, but no clinical details were ob- 
tained. Cases of pneumonia following 
gassing were rare and occurred usually 
when smoke or irritating gases were present. 
About blast furnaces the testimony was 
the same — almost no late nervous or men- 
tal sequelae were known. Two cases of 
mental impairment were reported by com- 
pany doctors, one of which occurred in a 
chronic alcoholic, the other, in a man who 



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FORBES — CARBON MONOXIDE POISONING 



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had a strongly positive Wassermann. Con- 
current disease, and especially cerebral 
arteriosclerosis, seems to be a very impor- 
tant factor in causing cerebral lesions in a 
person severely gassed (4). In fact, if a 
yoimg, healthy adult is severely gassed by 
"white damp'' or by blast furnace gas, he 
either dies in a few days or recovers en- 
tirely — a rule to which there are few 
exceptions. 

Chronic Carbon Monoxide Poisoning 

In r^ard to the question of chronic car- 
bon monoxide poisoning, it was found that 
in certain mines about the fire areas men 
were exposed to "white damp" almost 
daily for months. While at work, these 
men complained of frontal headaches 
which sometimes lasted till they fell asleep. 
Next morning they felt well again unless 
the exposure to carbon monoxide had been 
unusually severe, in which case Ihey suf- 
fered from headache and felt "all in'' for a 
day or two. But at any time if they stopped 
work and stayed outdoors for a day or so, 
all symptoms disappeared. 

Some men notice a certain degree of 
tolerance when working frequently in the 
gas. For example, a mine foreman, whom I 
questioned — a man 50 years old — had 
done mine work since he was a boy. For 
months at a time he had had enough gas to 
cause daily headaches, yet was sure that at 
the end of such a period he could stand 
more gas than he could at the beginning 
and more than a "green" man working be- 
side him could stand. Tolerance to carbon 
monoxide has, moreover, been demon- 
strated experimentally by Nasmith and 
Graham (5), and has been noticed before in 
man by Haldane (6) and others. Most 
miners noticed neither tolerance nor cu- 
mulative ill-eflfects. A few veteran miners, 
however, thought that they had never been 
quite so strong since a series of severe gass- 
ings. Such a man was a fire boss who had 



been under tremendous strain, emotional 
and physical, fighting a fire for eighteen 
months in a coal mine. He had always been 
able to stand a large amount of "white 
damp " and had never been rendered uncon- 
scious by it, though many times men beside 
him had been overcome. He stated that for 
months after this ordeal he was nervous 
and his hand shaky. He believed also that 
his heart was affected,, as he noticed palpi- 
tation and precordial distress on exertion or 
on entering gas, yet he admitted that, even 
now, he could stand as much gas as most 
men. This man had had no careful medical 
examination. The fire in question occurred 
thirteen years ago and he had been at work 
constantly ever since. 

Anemia. — No evidence of anemia re- 
sulting from frequent exposure to carbon 
monoxide was found, either in the reports 
of the doctors or in red blood-cell counts. 
These counts and many more previously 
taken from Illinois blast-furnace workers 
show polycythemia rather than anemia. In 
1911 Karasek and Apfelbach (7) examined 
sixty-eight steel workers. The red blood- 
cell counts in their cases ran between 
5,500,000 and 9,600,000, two-thirds being 
over 6,000,000. The appearance of the red 
blood-cells was normal. Dr. Davis, chief 
surgeon of the Illinois Steel Company (8), 
reports that 175 red blood-cell counts taken 
at Gary and in South Chicago on men who 
had worked in the blast furnace and open 
hearth departments for years showed no 
counts below 4,000,000; 64.1 per cent, over 
5,000,000; and 2.2 per cent, over 6,000,000. 
Physical examinations of these men showed 
no lesions of the nervous system. 

Neurological Symptoms. — No histories 
were obtained from miners or mine doctors 
suggestive of multiple neuritis, mental 
deficiency, or paralysis following chronic 
carbon monoxide exposure. Even with 
illmninating gas, which has been shown to 
be more toxic than pure carbon monoxide 
(9), no serious nervous or mental results 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



seem to be common, at least after acute 
exposure. In the past two years, 134 cases 
of acute illuminating gas poisoning were 
admitted to the wards of the Boston City 
Hospital. Of these, not one patient has 
been readmitted with neurological symp- 
toms or committed to an insane hospital 
imless a definite pathological condition 
existed prior to the gassing. This informa- 
tion was obtained by personal examination 
of the hospital records. 

Tests for Carbon Monoxide in Blood. — In 
the mines it was diflScult to find men 
actually suffering from carbon monoxide 
headaches at the moment and it was useless 
to examine the blood of miners for carbon 
monoxide after they had walked to the 
hospital, for they had then lost the gas 
through respiration. The few specimens 
taken in mines at the working face were 
negative. About blast furnaces, however, 
there was one situation where men inhaled 
carbon monoxide at intervals all through 
the day, and every day. These men were 
the top-fillers on the old style hand-filled 
fiunaces. Blood specimens from two of 
such workmen out of six tested were posi- 
tive for carbon monoxide hemoglobin. The 
tannic acid test was used (10) and the blood 
was taken while the men were actually at 
work on the furnace top. The two patients 
whose tests came out positive had com- 
plained of slight headache at the time the 
blood was taken. Some of these top-fillers 
had done this work for years (one for 
twenty years) without apparent injury to 
their health. 

Treatment 

Carbon monoxide does not form a per- 
manent combination with hemoglobin. 
This has been conclusively shown by Hal- 
dane (11), Henderson (12) and others. The 
affinity of hemoglobin for carbon monoxide 
IS approximately three hundred times that 



for oxygen, but the reaction is reversible. 
As soon as the man breathes oxygen or 
fresh air, the oxygen exactly replaces the 
carbon monoxide in his blood, molecule for 
molecule, at a speed depending on the par- 
tial pressures of the two gases in the 
alveoU. The red blood-corpuscles are ap- 
parently uninjured and are able to take up 
and transport oxygen normally as soon as 
the carbon monoxide has been expelled. 

In the treatment of carbon moi^oxide 
poisoning, bleeding, as Haldane and Hen- 
derson have clearly stated, is harmful. 
Transfusion is unnecessary because under 
proper treatment the blood can be brought 
back nearly to normal within half an hour. 
The most recent advance in treatment has 
been made by Henderson (9), who advo- 
cates administering with oxygen a small 
percentage of carbon dioxide, to induce 
better pulmonary ventilation. Hender- 
son's results are striking. In his experi- 
ments dogs were gassed thirty to forty 
minutes with illuminating gas in such di- 
lution as to give 0.4 per cent, carbon 
monoxide, until they became completely 
unconscious. Untreated, these animals 
took approximately two hours to exhale 
sufficient carbon monoxide from their blood 
to reduce the percentage of this gas to 10 
per cent. With oxygen treatment alone, 
this result was attained in sixty to eighty 
minutes; with oxygen and carbon dioxide it 
took only twenty minutes. 

Another advance of real importance in 
protection against carbon monoxide is the 
perfecting of an efficient respirator by the 
U. S. Chemical Warfare Service (13). The 
cannister of this respirator is smaller than 
the army type and is effective even at zero 
degrees against 1 per cent, of carbon 
monoxide. Its life is approximately three 
hours. Information in regard to it can be 
obtained from the Director of the Bureau 
of Mines, Washington, D. C. 



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FORBES — CARBON MONOXIDE POISONING 



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Summary 

Carbon monoxide as met with in metal 
and coal mines and about blast furnaces 
in this country rarely causes late after- 
effects following acute severe gassing. 
When such effects do appear, there is 
evidence, almost always, of a pre-existing 
pathological condition. 

Frequent exposure to carbon monoxide 
causes headache and malaise, but no evi- 
dence has been found of a cumulative 
harmful effect. 



As was to be expected, owing to the 
compensating increase of hemoglobin and 
red cells from prolonged oxygen want (14) 
(15), it is possible to acquire some tolerance 
to carbon monoxide. 

A recent advance in treatment has been 
made by adding carbon dioxide to the 
oxygen inhalations administered. Recovery 
is three times as rapid as when oxygen 
alone is used. 

An efficient portable carbon monoxide 
respirator has been perfected by the U. S. 
•government. 



BIBLIOGRAPHY 



1. McCombs, R. S.: Clinical Manifestations of 
Illuminating Gas Poisoning. Am. Jour. Med. 
So., 1912, New Series, 144, 577. 

2. Glaister, J., and Logan, D. D. : Gas Poisoning 
in Mining and Other Lidustries. New York, 
William Wood and Company, 1914. 

S. Burrell, G. A., and Seibert, F. M.: Gases Foimd 
in Coal Mines. U. S. Bur. Mines, Miners' 
Circular 14, Washington, 1916. 

4. Hill, £., and Semerak, C. B.: Changes in the 
Brain in Gas (Carbon Monoxid) Poisoning. 
Jour. Am. Med. Assn., 1918, 71, 644. 

5. Nasmith, G. G., and Graham, D. A. L.: The 
Haematology of Carbon-Monoxide Poisoning. 
Jour. Physiol, 190^1907, 36, 32. 

6. Haldane, J. S. : Organism and Environment as 
Illustrated by the Physiology of Breathing. 
New Haven, Yale University Press; London, 
Oxford University Press, 1917. 

7. Karasek, M., and Apfelbach, G. L.: A Report 
of Investigations on Carbon Monoxide Poison- 
ing. Report of Illinois State Commission on 
Occupational Diseases, Jan., 1911, p. 90. 

8. Davis: Personal Communication, 1918. 



10. 



11 



9. Henderson. Y., and Haggard, H. W.: The 
Elimination of Carbon Monoxide from the 
Blood after a Dangerous Degree of Asphyxia- 
tion, and a Therapy for Accelerating the Elim- 
ination. Jour. Pharmacol, and Exper. Therap., 
1920, 16, 11. 

McNally, W. D. : Carbon Monoxide Poisoning. 
Jour. Am. Med. Assn., 1917, 69, 1586. 
Haldane, J.: The Relation of the Action of 
Carbonic Oxide to Oxygen Tension. Jour. 
Physiol., 1895, 18, 201. The Action of Car- 
bonic Oxide on Man. Ibid., 480. 
12. Henderson, Y.: Carbon Monoxid Poisoning; 
Jour. Am. Med. Assn., 1916, 67, 580. 
Lamb, A. B., Bray, W. C, and Frazer, J. C. W.: 
The Removal of Carbon Monoxide from Air. 
Jour. Indust. and Engin. Chem., 190^, 12, 218. 
Manual of Medical Research Laboratory. Air 
Service Division of Military Aeronautics, 
Washington, 1918, p. 18. 
Dallwig, H. C, Kolls, A. C, and Loevenhart, A. 
S.: The Mechanism Adapting the Oxygen 
Capacity of the Blood to the Requirements of 
the Tissues. Am. Jour. Physiol., 1915-1916, 39, 
77. 



IS 



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15. 



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A DISCUSSION OF THE ETIOLOGY OF SO-CALLED ANILINE 
TUMORS OF THE BLADDER* 

ALICE HAMILTON, M.D. 

AssiHant Professor of Industrial Medicine^ Harvard Medical Sehooly and Special Investigator of Industrial Poisons, 

U.S. Bureau of Labor Statistics 



FOR the last twenty-five years the Ger- 
mans have been aware that there is an 
undue prevalence of malignant tumors of 
the bladder in aniline dye workers. The 
first to call attention to this curious fact 
was Rehn (1), who presented before the 
German Surgical Society in 1895 the his- 
tories of three cases of malignant bladder 
tumor in employees of one of the great dye 
works, the men forming part of a force of 
forty-five who were employed in making 
fuchsin. Rehn concluded as follows: 

For the majority of bladder tumors one can only 
assume that compounds excreted by the kidneys and 
existing in solution in the urine are capable of setting 
up tumor formation through chemical irritation. 
So far these compounds have eluded our search. . . . 
The gases produced in the manufacture of fuchsin 
lead to disturbances of the urinary system, and pro- 
longed employment over many years in the fuchsin 
department may cause the development of bladder 
tumors because of continual irritation. The harmful 
effects depend essentially on the inhalation of aniline 
fumes. 

The manufacture of fuchsin consists in 
heating a mixture of aniline, ortho-tolui- 
dine and para-toluidine, with nitrobenzene, 
or ortho-nitrotoluene and para-nitrotolu- 
ene, in the presence of iron and hydro- 
chloric acid. 

This theory of Rehn's was challenged 
immediately, especially by Grandhomme, 
the chief authority on industrial poisoning 
in color manufacture, since he had been for 
many years in charge of the great plant at 
Hoechst-am-Main. Grandhomme admitted 
that aniline was irritating to the blad- 
der mucosa, as shown in observations on 
men and on animals, but as to its being 

* Beoieived fix publication Jan. 88^ 1921. 



responsible for tumor growth, he pointed 
out the fact that, while Rehn had found 
three cases among forty-five fuchsin men 
exposed to aniline fumes, there were in the 
factory at the time about 4,000 men ex- 
posed to the fumes. Eleven years later, 
however, Rehn (2) was able to present to 
the German Surgical Society records of 
thirty-three cases which he had collected 
from German dye works, all malignant and 
all occurring between 1889 and 1906. To 
these, Seyberth added five, others three, 
making forty-one in all. 

In 1912, Leuenberger (3) of Basel pre- 
sented a paper before the same society in 
which he reviewed the whole subject of the 
occurrence and causation of bladder tu- 
mors in aniline workers and added eighteen 
cases from the works in Basel, which had 
then been running for about twenty-seven 
years. He specially urged physicians at- 
tached to dye works to study these tumor 
cases and to try to discover the substances 
responsible for them. The following year 
the German Congress of Industrial Physi- 
cians endorsed licuenberger's request and 
drew up a set of questions to be answered 
in connection with each case of bladder 
tumor. This questionnaire was sent to all 
the German and Swiss dye works. The 
results of the studies made since then are 
now appearing in the German medical 
journals. Many new cases have been 
added to Leuenberger*s list of fifty-nine, 
and in the last article on the subject, by 
Curschmann (4), the final corrected list 
includes 177 cases. 

The statistics on which the Germans 
base their statement that bladder tumors 



16 



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HAMILTON — ANILINE TUMORS 



17 



are strikingly frequent among aniline 
workers are not satisfactory. They are in- 
complete in several respects, and it is sur- 
prising that when so much careful clinical 
and experimental work has been done in 
this field, nobody has troubled to present 
indisputable proof of this basic statement. 
We do not know how many men are ex- 
posed to fumes, and cannot tell, therefore, 
what proportion of the whole such a num- 
ber as 177 is. The number of employees in 
these dye works is estimated at 80,000 to 
100,000 — an estimate which is more de^ 
pendable, owing to the small labor turn- 
over, than would be a similar one in our 
dye works. Nassauer (5) gives the labor 
turnover for one of the plants in the Frank- 
furt region as only 15 per cent, per year. 
That would be more nearly the monthly 
turnover in an American plant. During the 
war, however, there must have been a great 
deal of shifting; indeed, Nassauer speaks of 
the introduction of women workers and 
speculates as to the probable appearance of 
bladder tumors among them during the 
next twenty years. 

The exact number of men exposed to 
what is regarded as the exciting cause of 
tumor growth is not the only missing link 
in the train of reasoning on which the Ger- 
mans base their statement that dye work- 
ers have more than their due proportion 
of bladder tumors. The figures given by 
Rehn for the Frankfiul region are as fol- 
lows: Between 1895 and 1918 there were 
92 cases of bladder tumor in the City Hos- 
pital, 22 of which were unquestionably 
caused by aniline and 24 possibly so caused, 
making 46 or 50 per cent, of the whole 
number. The proof would be much more 
convincing if the records showed what pro- 
portion of the male population of the hos- 
pital was employed in the dye works. The 
same criticism applies to Leuenberger's 
figures from the Basel hospital, which 
cover fifty years. (See Table 1.) Nas- 
jsauer's plant (5) had 32 cases in twenty 



years, with a working force of 105 men and 
an annual turnover of about 15 per cent. 
This is really the most striking record 
offered in the literature, but Oppenheimer 
(6) believes that the proportion is higher 
than that given in any oflScial report. 
According to the tales of his patients there 
was one factory with 60 men in which 
dining twelve years 15 cases appeared; in 
another with 60 men there were 27 cases, 

TABLE 1. — CASES OF BLADDER TUMOR 
tS BASEL HOSPITAL, 1861-1910 





Number 
of Male 
Patients 


Number of Cases of Bladder 
Tumor 


Years 


Id 

HospiUl 


Id Color 
Makers 


Id 
Dyers 


1861-1870........ 


2600 


1 








1871-1880 


3450 











1881-1890* 


4250 


1 








1801-1900 


5500 


4 








1901-1910 


9650 


16 


10 


2 



* The dye iDdustry began ia Basel in 1885. 

9 of which were known to have been fatal; 
and in a third, 29 out of 30 men died of 
bladder disease in ten years' time. 

A typical history of the earlier cases of 
bladder tumor reads as follows: The man 
comes to the plant doctor for treatment 
usually because he has noticed blood in the 
urine. Cystoscopic examination * then re- 
veals a papillomatous growth, more rarely 
a flat carcinoma with a broad base. In 
more recent years, since physicians have 
been on the watch for these tumors, the 
examination is often made before the ap- 
pearance of blood and discloses sometimes 
only a cystitis, with ulceration perhaps, 
then later on, even if the man is removed 
from contact with aniline, a new growth is 
found. Different varieties are described — 
pediculated papilloma, villous polypus, 
wart-like excrescences, or general papil- 
lomatosis of the whole bladder. These 
benign growths may undergo carcinoma- 

* Th^ uafi of the dectric pystotcope was first introduced 
in 1880 in Germany by Nitse, and undoubtedly as its use 
extend^ many early cases of tumors were discovered which 
formerly would have gone undetected. 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



tous degeneration, but there are also 
malignant growths which are quite different 
in appearance and which apparently have 
not passed through the papillomatous 
stage, being solid, with a broad base (6). 
In some instances, a small fresh polyp can 
be seen on one side of the bladder, and a 
carcinoma on the other. The cancerous 
growth may invade the neighboring lymph 
glands or the ureter and kidney, as in one of 
Rehn's cases, or the bones of the pelvis and 
the lower abdominal wall, as in a case seen 
by Czemy. Only one autopsied case has 
shown metastases in liver and lungs. In 
the earlier cases, it was said that the seat 
of predilection was near the mouths of 
the ureters, but later reports showed that 
they might be (situated in any part of the 
bladder. 

A long exposure to the chemical which is 
the exciting cause seems to be necessary. 
The statistics from Hoechst, Ludwigshafen, 
and Greppin (7) show that the cases de- 
veloping in the f uchsin department were in 
men who had been employed on an aver- 
age from twelve years in Greppin to nine- 
teen in Ludwigshafen. Those who worked 
in the benzidine-naphthionic department 
had had a shorter period of exposure, aver- 
aging five years in Ludwigshafen, and six 
years in Greppin. Oppenheimer's patients 
had worked from two to twenty-eight 
years, averaging eighteen years. The two- 
year case, which was far below the average 
— indeed, the shortest exposure on record 
so far — occurred in a man who worked in 
* the benzidine department. 

Both Curschmann and Oppenheimer 
find that there is no connection between 
the length of exposure and the malignant 
character of the growth, nor is there any 
relation between the particular compound 
causing the tumor and the character of the 
tumor. Oppenheimer observed six men 
who had worked together in the same room 
for twenty years; two were healthy, two 
had been operated on for bladder tumor 



and had recovered, and the last two had 
died from bladder tumor. Of Cursch- 
mann's twenty-six cases, one developed 
after five years, six after five to ten years, 
six after fifteen to thirty years, and thir- 
teen after more than thirty years' employ- 
ment. The Basel cases did not begin to 
appear till the industry was 16 to 17 years 
old, and in England the only dye works in 
which information about bladder tumors 
among the men can be obtained is the 
oldest one, more than 20 years old. Cursch- 
mann finds the great majority of cases of 
cystitis among dye workers as reported in 
the literature occurring after 40 years of 
age. Oppenheimer's twenty patients were 
between 34 and 47 years of age, decidedly 
younger than the average for bladder 
tumors in general. 

The histories of color makers who suflFer 
from bladder tumors show that ordinary 
aniline poisoning has nothing to do with 
the condition in the bladder. A man may 
have had repeated attacks of acute aniline 
poisoning or the chronic form of poisoning, 
yet never have even a cystitis; or he may 
never have had typical aniline poisoning 
and yet develop a tumor of the bladder. 

One very interesting feature of this 
variety of bladder tumor was brought out 
by Leuenberger and confirmed by Schwerin 
(7) and by Oppenheimer — namelj^, the 
fact that the tumor may develop long after 
the exposure to the exciting cause has 
ceased. Leuenberger tells of a man who 
worked in benzidine for seven years, had 
cystitis, and was transferred to another 
department where he worked for two years. 
He then left the factory, and two years 
later blood appeared in the urine and he 
was operated on for tumor of the bladder. 
Schwerin of Hoechst reports two similar 
cases: one, a man who worked five years 
in the benzidine-naphthionic department 
and twenty-three years later had tumor of 
the bladder; the other, a man who worked 
eleven years in aniline and eight years after 



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HAMILTON — ANILINE TUMORS 



19 



leaving the factory had a tumor removed 
from the bladder. Oppenheimer saw tu- 
mors develop ten years and seventeen 
years after the men had left the factory. 

It seems from the observations of Nas- 
sauer and of Oppenheimer that an ex- 
tremely slight exposure to the exciting 
cause is sufficient. Oppenheimer had three 
cases which developed in men who never 
came in contact with the chemicals, but 
who worked in rooms adjoining the process 
departments. These cases were slow, the 
tumors developing after twenty to twenty- 
six years. Several of Nassauer's patients 
were employed in departmtnts in which no 
manufacturing was carried on but which 
were next to the departments making 
benzidine. 

In the search for the exact compound or 
compoimds which are responsible, a careful 
study has been made of the history of each 
case so far reported, in order to see which of 
the intermediates used in color manufac- 
ture seem to be connected with bladder tu- 
mors. A great variety of compounds 
emerge as probable agents, compounds with 
different degrees of toxicity and with dif- 
ferent physical and chemical properties, but 
with this feature in common, that they are 
all amido compounds, containing the Radi- 
cal NH2, produced by the reduction of 
nitro compounds. The latter, though dis- 
tinctly more toxic than the amido group, do 
not have this peculiar effect. These are the 
lists which have been submitted: 

List from Hoechst-am-Main (7) 

Naphthylamines 80 cases 

Benzidine and naphthionie acid . 28 ^ 

Fuchsin 21 " 

Aniline ; 8 « 

Black and blue colors 4 ^ 

CurschmanrCa List (-4) 

Beta-naphthylamine 10 cases 

Aniline 5 " 

Fuchsin 8 ** 

Benzidine-naphthionic 8 " 

Other bases 8 ** 

Blue colors 4 ** 



Oppenheimer* 8 List (6) 

Aniline ; . . 3 cases 

Aniline colors 2 ** 

Benzidine 5 " 

Aniline-naphthylamines 3 " 

Aniline-benzene-toluene 1 " 

Benzidine-aniline 1 " 

Benzidine-tolidin 1 " 

Amido-naphthol-cresoldicarbonic 

acid 1 « 

Naphthylamine-cresoldicarbonic 

acid 3 " 

Not directly exposed 1 " 

Nassauer gives the following substances 
in connection with which bladder tumors 
have appeared: aniline, para-toluidine, xyli- 
dines, cumidins, naphthylamines, fuchsin, 
benzidine, tolidin, and blue rosaniline 
coloring matters made from fuchsin by the 
action of aniline in the presence of acetic 
or benzoic acid. 

In trying to determine which of these 
compoimds is the responsible agent, there 
are several difficulties which must be borne 
in mind — difficulties encountered more 
or less in every study of industrial poison- 
ing, but especially in connection with such 
complicated processes as those of dye 
manufacture. In the first place, every 
process involves the use and production of 
more than one compound, so that evfen if a 
man is engaged in only one process it can- 
not be said that he is exposed to only one 
poison. Moreover, it is very common to 
have two distinct processes going on in the 
same room; so that the workmen are ex- 
posed to other compounds than those with 
which they are working. The benzidine- 
naphthionic department, mentioned so 
often in connection with bladder tumors, is 
one in which Congo red is manufactured 
from benzidine, which is a product of nitro- 
benzene, and from naphthionie acid, which 
is a product of alpha-naphthylamine. The 
harmful substance here has sometimes 
been considered benzidine, sometimes al- 
pha-naphthylamine — neither of which is 
markedly toxic — while Nassauer believes 



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that it is the small percentage of aniline 
accidentally formed in the conversion of 
nitrobenzene to benzidine. Nor must it be 
forgotten that certain poisonous substances 
may be formed accidentally in the course 
of industrial processes, and their presence 
not suspected, as when hydrogen sulphide 
is given off in the making of sulphur dyes, 
or hydrogen arsenide in various reduction 
processes. 

Industrial conditions bring about other 
difficulties which are especially evident 
when the form of poisoning to be studied is 
very slow, drawn-out over a great many 
years. Workmen change from one depart- 
ment to another, and each change brings 
new compounds into question, or they go 
from one factory to another, in which the 
processes are diflferent. It is also true that 
the same compound used in diflferent proc- 
esses may be attended with very diflferent 
degrees of danger. Thus, it is said that in 
the making of benzidine there may be more 
actual exposure to aniline vapor than in the 
manufacture of aniline itself. 

These difficulties strike one forcibly 
when one tries to bring into some sort of 
harmony the results of the studies in thp 
diflferent German factories. For instance, 
Nassauer believes that all the cases in the 
Kterature can be traced to one department 
— the manufacture of benzidine. He has 
been very strongly impressed by the dan- 
gers in benzidine manufacture, but then, it 
is obvious that the plant with which he is 
connected makes benzidine chiefly, produc- 
ing before the war 60 to 70 per cent, of the 
world^s supply. It is easy to understand, 
therefore, why he finds that every one of 
the thirty-two cases which occurred there 
were in men who had been working in or 
near or outside of the benzidine rooms. 
Curschmann of Hoechst and Engel (8) of 
Ludwigshafen find a singularly large niun- 
ber of cases in men exposed to beta-naph- 
thylamine, but Nassauer insists that this 
compound could not be responsible since 



he has never seen a case of hematuria or 
strangury in a naphthylamine worker in 
twenty years, and he believes that there are 
other fumes in the naphthylamine depart- 
ments.* 

The Hoechst investigators, Schwerin (7) 
and Kuchenbecker (9), agree with Nas- 
sauer that the greater number of cases 
come from the benzidine-naphthionic de- 
partment. They do not attribute this to 
aniline fumes, however, but to benzidine 
dust. The earlier reports of bladder tu- 
mors placed the danger in the fuchsin 
department. Aniline began to be used on a 
large scale for %he manufacture of fuchsin 
in 1872 and about twenty years later the 
reports of bladder tumors in aniline work- 
ers began to appear. But aniline is not the 
only compound used in fuchsin manufac- 
ture; ortho-toluidine and para-toluidine 
must also be considered. 

The causation of these timiors is a sub- 
j'ect at present occupying most of the 
attention of the German investigators, 
for obviously it is a matter not only of 
scientific but of practical importance, as 
no efficient system of prevention can be 
devised until the dangerous substances are 
discovered. Experiments on animals have 
so far cast very little light on the subject. 
It has been known for a long time that 
irritation of the bladder could be produced 
by injection of aniline and some of its 
homologues, and such dye intermediates 
as tolylenediamine, phenylenediamine, and 
paranitraniline will set up not only irrita- 
tion of the bladder mucosa but also hem- 
orrhage. As soon as the administration 
of the poison is suspended, however, the 
symptoms subside, nothing further occurs, 
and the bladder mucosa becomes quite nor- 
mal again. Nor are these particular com- 

• Hematuria and. stranguiy have been reported, how- 
ev&, in connection with b^ta-naphthylamine by German 
factory iniipeotors and in the one American factory where I 
have seen it used it has been found decidedly more toxic than 
alpha-naphthylamine, causing frequent, burning micturition, 
as if the urine were oVer-acid; as Engel has found it to be 
in dogs which have been fed beta-naphthylamine. 



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21 



pounds connected with cases of bladder 
tumor in dye workers. Oppenheimer tried 
to produce tumors in animals by repeated 
injections of benzidine and tolidin in 
sus|>ension9 but although he continued his 
experiments for eighteen months, there was 
absolutely no result. 

Leuenberger recalls the work done on 
aniline excretion in Schmiedeberg's labora- 
tory (10), which showed that aniline under- 
dergoes in the body hydroxylation to 
para-amidophenol and is excreted in the 
urine in conjugation with ethyl sulphuric 
adjd. He maintains that it is this hy- 
droxyl derivative of aniline and similar 
bodies which sets up proliferative processes 
in the whole urinary tract: first, inflamma- 
tory infiltration and atypical proliferation 
of the mucosa, then, papilloma formation, 
granuloma, carcinoma, sarcoma, and mixed 
forms. He assumes a precancerous stage of 
inflanunation and proliferation, such as 
occurs in arsenical granuloma and epithe- 
lioma, in X-ray lesions, and in the so- 
caUed pitch cancer. The late development 
^f the timoiors he explains by the fixation 
in the body of decomposition products of 
the poisons, with continual damage to the 
bladder cells, or the effect of the chemical 
may be passed on through successive gen- 
erations of cells. He points out the sim- 
ilarity between these aniline tumors, which 
are clearly caused by some chemical irri- 
tant, and other growths which are known to 
be the result of chemical irritants, such as 
the cancer of chinmey sweeps so thoroughly 
studied by the English, and the cancer of 
briquette makers first reported by Volk- 
mann, then by the English, in all of which 
there is, first, irritation of the skin, then, 
the formation of warts, or nodules, or 
sclerodermatous patches. If , the man 
leaves work, nothing more serious may 
occur, but if his exposure is prolonged, slow 
carcinomatous degeneration sets in. 

Nassauer also compares aniline workers' 
tumors to the pitch and tar cancers de- 



scribed by the English, and he speaks of 
a curious observation made among the 
miners of cobalt arsenide ore in the Saxon 
Erzgebirge, who were found to have an 
enormous incidence of limg carcinoma. As 
for the ability of aniline and similar bodies 
to set up proliferative changes in the 
bladder mucosa, there seems to be only 
one observation. Fischer (11) found that 
epithelial growth was stimulated by the 
injection of certain fat-soluble colors in oil. 
"Scharlach Roth" (amidoazotoluene) was 
the most active and has since been used to 
encourage heaUng after extensive burns. 

Oppenheimer believes that there is a 
biological affinity of these poisons (ben- 
zidine, aniUne, naphthylamines, tolidin, 
etc.) for the epithehimi of the excretory 
part of the urinary system. The kidneys 
are not involved but the bladder is affected. 
He suggests that perhaps more than one 
substance is responsible, one sensitizing the 
tissue to the action of the other. The 
length of exposure to the exciting cause 
seems to be a matter of no imi>ortance. 
Oppenheimer agrees with Nassauer that a 
short exposure may set up the process 
which eventuates in a tumor. It is plain 
that the "revolution" in the tissue once 
begun keeps on after the cause is removed, 
cessante causa non cessat morbus. 

According to Nassauer the irritative 
substance is always aniline, mixed with air. 
The condition is always produced by 
fumes, containing a quantity of anUine 
which is too small to set up clinical symp- 
toms of intoxication, but which, dissolved 
in the moisture of the alveoli of the lungs 
(aniUne is 3 per cent, soluble in water), 
penetrates the cells and reaches the lymph 
stream or the blood. A very dilute mixture 
of aniline with air, such as is breathed by 
men working in a room next to the one 
containing the source of aniline fumes, 
causes a more rapid tiunor growth than 
does a larger quantity of aniline in the air, 
and the men who work out of doors, get- 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



ting only minute quantities of fumes from 
the nearby building, have an even shorter 
latent f>eriod. Nassauer considers the ac- 
tion of anihne so powerful that one year's 
exposure to the fumes is too long, and since 
1904, in the factory under his charge, he 
has permitted only three months' employ- 
ment in the benzidine department — in his 
opinion, the danger spot. 

Leuenberger suggested that, since the 
amido compounds which seem to be re- 
sponsible for tumor growth undergo hy- 
drolysis in the body, it should be possible to 
ascertain which of the amido compounds 
used in the dye industry are eliminated in 
this particular form, as para-amidophenol, 
and then to check up the clinical cases and 
see whether they could be linked up with 
these compounds. To this Engel replies 
that there are several compounds appar- 
ently associated with tumor formation 
which do not undergo hydrolysis in the 
body and appear in the urine as para- 
amidophenol. For instance, para-toluidine 
is excreted unchanged, as is also alpha- 
naphthylamine, while diphenylamine un- 
dergoes a complete loss of the amido group. 

Kiichenbecker also imdertook to test 
this statement of Leuenberger 's. Since a 
hydroxyl amido compound, containing as 
it does a free amido group, can be diazo- 
tized in acid solution with a nitrite and 
produce an azo color, it is comparatively 
simple to prove its presence. If aniline is 
administered to animals, a red azo color 
can be obtained in the urine, and the same 
result is obtained with ortho-toluidine, but 
not with para-toluidine. This is because 
aromatic amido compounds undergo such a 
change only if the para position is free, but 
not if it is occupied, as it is in para-tolui- 
dine. Kuchenbecker then fed benzidine to 
dogs and found a substance in the urine 
which was not a hydroxyl compound, nor 
was it benzidine. Practically the same re- 
sult was obtained with tolidin. Alpha- 
naphthylamine is excreted imchanged and 



gives typical reactions with beta-naphthol. 
Beta-naphthylamine is also excreted un- 
changed. It seems impossible, therefore, 
that para-amidophenol should be respon- 
sible for the occurrence of bladder tumors, 
since all the last-named substances are 
apparently as much concerned in their 
causation as is aniline. 

At present, Engel is conducting experi- 
ments with beta-naphthylamine, which 
apparently has been connected with a 
large number of tumors — an especially 
singular fact because it is not particularly 
volatile, and does not cause much ordinary 
industrial poisoning, and because there is 
nothing in the work that brings about un- 
usual exposure. Engel wishes to discover 
whether beta-naphthylamine undergoes 
hydroxylation and, if so, whether amido- 
naphthol is formed or amido-dioxynaphtha- 
lene, and whether these are eliminated in 
conjugation with ethyl sulphuric acid or 
with glycuronic acid. So far he has been 
able to prove that after the administration 
of beta-naphthylamine to dogs, both acids 
are increased in the urine. If the animal is 
on a meat diet, it is the ethyl sulphuric 
acid which shows a marked increase; if 6n a 
carbohydrate diet, the glycuronic acid. 

There the matter rests at present; the" 
problem is no nearer solution than that. 
There is one compound, however, which 
must be considered as having a possible 
bearing on the occurrence of bladder tu- 
mors in dye workers and which is not 
mentioned by the German investigators — 
namely, hydrogen arsenide. The danger of 
arsenical poisoning in f uchsin manufacture 
was well known in the early days of the 
industry, for arsenious acid was one of 
the compounds used for oxidation in mak- 
ing fuchsin, as nitrobenzene is now. That 
method was discontinued about thirty 
years ago, but it is recognized in German 
dye works that accidental arsenical poison- 
ing may still occur from an evolution of 
hydrogen arsenide not only in fuchsin 



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manufacture but in all processes where 
acid and metal are brought together and 
one of them is contaminated with arsenic. 
The chamber sulphuric acid of commerce, 
made from iron pyrites, is frequently thus 
contaminated, as is the hydrochloric acid 
made by the action of such sulphuric acid 
on sodium chloride, while both the iron 
scrap and the zinc dust used in reduction 
processes in the making of intermediates 
and colors may also carry arsenic as an 
impurity, the zinc dust especially. Ger- 
man dye works are so well guarded against 
the escape of fumes of all sorts that acci- 
dental poisoning of this kind is now de- 
cidedly rare, yet that it can occur is shown 
by the history of one of Nassauer's patients 
who suffered from hydrc^en arsenide poi- 
soning while making benzidine. 

It is in the process of reduction that this 
danger is found. Two forms of reduction 
are used in the manufacture of interme- 
diates, acid and alkaline or neutral. Nitro- 
benzene, subjected to acid reduction by 
nascent hydrogen from iron filings and 
hydrochloric acid, yields aniline. Nitro- 
toluene yields ortho-toluidine and para- 
toluidine. If either the iron or the acid 
contains arsenic as an impurity, hydrogen 
arsenide may form in the course of reduc- 
tion, but in a well-managed plant this 
reaction is carried on in tightly closed auto- 
claves, and there is very little, if any, 
escape of fumes. However, when, in going 
through a very excellent German plant, 
I commented on the arrangements for 
fume removal in the aniline reduction 
room, I was told that the rule there was to 
allow no vapors of any sort to escape into 
the room because of the ever-present pos- 
sibility of traces of arseniuretted hydrogen. 
Of course, if the apparatus is not perfect it 
will get out of order and men must go in 
and clean out the sludge and make repairs. 
Five mild cases of arsenical poisoning oc- 
curred in a British dye works from this 
source, but were recognized as such only 



because arsenic was foimd in the urine. 
Tests for arsenic are not made in American 
dye works and if such cases occur they are 
not recognized but are diagnosed as aniline 
or toluidine poisoning. 

Alkaline reduction, used to produce 
benzidine and tolidin, is attended with 
much more danger of arsine poisoning than 
is acid reduction. Briefly, the process is as 
follows. Nitrobenzene, treated with zinc 
dust and sodium hydrate, is reduced first 
to azoxybenzene, then to azobenzene, and 
then to hydrazobenzene, which forms 
colorless crystals. At this point it is cus- 
tomary in Germany and in England to add 
hydrochloric acid, in order to form soluble 
zinc chloride, and get rid of the zinc by 
filtration. The temperature must be kept 
down by means of ice, or brine coils, be- 
cause benzidine will form if it is warm and 
will be lost with the filtrate. In the sum- 
mer of 1918 five cases of severe arsine 
poisoning with two deaths occurred in a 
British dye works where, in order to keep 
down the temperature of the hydrazo- 
benzene - zinc- hydrochloric acid mixture, 
the reducer was opened and a chunk of ice 
dropped in. The fumes of arsine escaped 
from the opening and poisoned the nearest 
workmen. Five cases of severe poisoning 
with one death were caused in a New Jersey 
plant by the fumes rising from an un- 
covered tub. containing hydrazobenzene 
made by this same method of alkaline 
reduction and evidently with arseniferous 
zinc. It was when the hydrochloric acid 
was added and the temperature raised to 
bring about the next stage, the molecular 
change of hydrazobenzene into benzidine, 
that the tub "boiled up," as the men said, 
and the five nearest it were overcome with 
the fumes — three very seriously, one 
fatally. 

Dr. T. H. Wignall (12) of Manchester, 
who is connected with a large dye works, 
has made a very interesting study of the 
occurrence of arsenical hematuria in benzi- 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



dine makers and in workers in certain other 
reduction processes. His attention was 
called to the possibility of mild arsenical 
poisoning by a fatal case of jamidice in a 
benzidine worker, which did not come 
mider his observation early enough to 
allow him to establish the presence of 
arsenic. He began then to have a quanti- 
tative test made for arsenic whenever the 
urine of an employee showed a color as 
deep as porter. When this occurred, not 
only was the urine of the man himself 
examined for arsenic but also specimens 
from all the other workers employed on 
the same process. The tests were carried 
out by Del^pine of the Public Health. 
Laboratory of Manchester. Wignall found 
that the tolerance to arsenic in cases of this 
sort was much greater than it is generally 
stated to be. Men whose urines are deeply 
colored, and contain albumin, blood pig- 
ment, and casts, may not consider them- 
selves sick at all and may not even be 
jaundiced. Examination of those who do 
complain shows symptoms which might 
easily be attributed to aniline or to some 
^milar compound. These symptoms are 
palor, slight icterus, rapid feeble pulse, 
languor, loss of appetite. Hospital treat- 
ment in Wignall's cases was always suc- 
cessful and there were no sequelae and no 
neuritis. It is evident that such cases 
might easily go unrecpgnized for years, 
especially as the absorption of arsenic 
would never be uninterrupted, and there 
would always be periods during which the 
air was uncontaminated and the man's 
system had time to rid itself of the ab- 
sorbed arsenic. The histories of Wignall's 
cases show that in about four to eight 
weeks the arsenic has practically disap- 
peared from the urine. The essential facts 
in his five cases are as follows: 

Case 1. — Icterus, weakness; urine the color of 
dark porter, with methemoglobin and casts; 0.796 
mg. arsenious acid per 100 c.c. urine on Nov. 14; on 



Dec. 12, less than 0.01 mg. and only a trace of 
albumin. 

Case 2. — Porter colored urine with 0.085 mg. 
arsenious acid per 100 c.c. urine on Nov. 9; on Dec. 
20, less than 0.01 mg. 

Cases. — Urine black, sp. gr. 1025, albumin; 
0.2 mg. arsenious acid on Dec. 5; less than 0.01 mg. 
on Jan. 30. 

Case 4. — Abdominal pain, vomiting, icterus; 
urine deep Burgundy red, dear, sp. gr. 1025, acid, 
much albumin, methemoglobin, and oxyhemoglobin; 
0.185 mg. arsenious acid on Jan. 24; less than 0.01 
mg. on Feb. 26. 

Case 5. — No pain or icterus; urine dark brown, 
considerable amount of albumin, sp. gr. 1009; 
0.07 mg. arsenious acid on Feb. 18; less than 0.01 on 
Feb. 27. 

Cases of mild arsenical poisoning have 
developed in English plants, I am told, in 
cleaning out an aniline reducer, and in 
filtering off the zinc chloride from hydrazo- 
benzene in benzidine production. The only 
cases on record in American dye works 
are the five given above. In our large dye 
works benzidine production is not attended 
with this risk, for the hydrazobenzene crys- 
tals are caught in a fine screen and the 
zinc dust filters through and is used again. 

If one examines the histories of the Ger- 
man cases of aniline tumor in the light of 
this theory, that arseniuretted hydrogen 
may be the causative agent, not any aro- 
matic compound, several features emerge 
that seem to strengthen it. 

In the first place, all the products which 
have been held responsible for these tu- 
mors are reduction products, formed by 
nascent hydrogen acting on a nitro com- 
pound.* As we have seen above, such 

* For beta-naphthylamine this is not true. It is made, 
not by a reduction process, but by treating beta-naphthol 
with ammonia water. The only explanation I can suggest 
for the occurrence of tumors in this department is one based 
on the conditions in the one American factory where I have 
seen it made. Here in the beta-naphthylamine department, 
naphthylamine-sulphonic adds are made by the reduction of 
nitronaphthalene-sulphonic acids, and the reducing agents 
used are scrap iron and chamber sulphuric add. At the time 
of my visit, an escape of fiunes directly after reduction was 



very evident. One would have to know just what processes 

phthyla 
ments in the German factories where this has seemed the 



were carried on in or near the beta-naphthylamine depa^- 



danger spot, before one could dedde the question whether 
there was or was not a possible source of hydrogen arsenide 
fumes there. 



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reduction is carried on by means of hydro- 
chloric acid or sulphuric acid with scrap 
iron or zinc dust exactly as if one were 
making Marsh's test for arsenic. The 
compounds produced by alkaline reduction 
with subsequent treatment of the zinc dust 
with hydrochloric acid seem to be more 
productive of bladder tumors than those 
produced by acid reduction, and we have 
seen that there is more danger of escape 
of hydrogen arsenide fumes in alkaline 
reduction than in acid reduction. The 
benzidine department is the one in which 
the largest number of cases are at present 
appearing. Nassauer attributed his entire 
twenty-eight cases to the fumes from ben- 
zidine manufacture. A signijBcant case 
related by him is that of a woman — the 
wife of one of the workmen — who did not 
work in the plant but lived in a room next 
to the one in which benzidine was pre- 
pared. She and her husband both had 
tumor of the bladder. It is shown in the 
statistics from Hoechst and from Greppin 
that benzidine men have a shorter period 
of exposure before the development of 
tumors than do fuchsin men (6), and the 
one of Oppenheimer's cases that developed 
most rapidly was in a benzidine worker. 

That long continued absorption of small 
quantities of arsenic may result in the 
formation of epithelial growths, benign and 
malignant, was established by Jonathan 
Hutchinson and confirmed by dermatol- 
ogists in America, Germany, and France. 
In discussing the chemical bodies which 
have the property of stimulating new 
growth, Leuenberger places arsenic at the 
head of the list. Nutt, Beattie, and Pye- 
Smith (13) have recently collected such 
cases from the Hterature and have added 
another. Thirty-one cases make up their 
list, in three of which, however, the ad- 
ministration of arsenic was not proved. 
Two were industrial in origin; the men had 
been working for years in a factory making 
sheep-dip with white arsenic. Three were 



caused by drinking water contaminated 
with arsenic in the Reichenstein epidemic 
described by von Geyer before the Inter- 
national Congress of Medicine, Paris, 1900, 
and twenty-three were attributed to the 
action of repeated doses of arsenic admin- 
istered as a medicine for many years, 
usually for some skin disease, but in three 
instances for constitutional disturbances. 
In one instance, the lesions developed some 
years after discontinuance of the arsenic. 
Dubreuilh in 1910 described four cases df 
arsenical keratoma, one of which under- 
went carcinomatous degeneration. 

The Germans have commented fre- 
quently on the analogy between aniline 
tumors and those caused by soot, pitch, 
and paraffin. Leuenberger and Nassauer 
have already been quoted to this effect, 
and it is significant to note in this connec- 
tion the findings of the British Royal Com- 
mission on Arsenical Poisoning, with regard 
to arsenic in coal. Delepine found by 
analysis 5.8 grains of arsenious acid, AS2O8, 
per pound of coal in one specimen, and 
28 grains in another. The epidemic of 
arsenical poisoning from beer in Halifax in 
1902 was traced to drying the malt in air 
heated by burning coal which contained 
arsenic. 

Even more significant is a recent study 
made in Belgium of briquette makers* 
cancer, which the authors attribute to 
arsenic present in the coal. Bayet and 
Slosse (14) found in one briquette factory 
three men with skin cancer out of a force of 
only thirteen men, and later two mofe 
cases developed. Inquiry revealed a his- 
tory of warty growths in six more, so that 
eleven out of thirteen men had skin lesions. 
These were not typical keratomatous 
plaques on soles and palms, as described by 
Jonathan Hutchinsonf in arsenical cancer, 
but carcinomatous degeneration of warty 
growths. The likeness to arsenical cancer 
was seen, however, in the fact that the 
cancers were multiple and developed fairly 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



early in life. There was also an extra- 
ordinarily large number of scrotal lesions, 
as in chimney-sweeps' cancer. Except for 
soot cancers this is a very rare location, 
only one among 2,400 malignant tumors in 
males in the Vienna General Hospital 
occurring there. The final proof that ar- 
senic was the cause of the lesions was 
furnished by the detection of arsenic not 
only in the coal, soot, dust, and briquette 
mixture, but in the urine, hair, and finger 
nails of the workmen. Control tests made 
in the villages among other workmen gave 
negative results. Bayet and Slosse would 
attribute also to arsenic in coal the English 
cases of chimney-sweeps' cancer and the 
epithelioma of English briquette makers. 

Finally, an analogy has also been drawn 
between aniline tumors, caused apparently 
by some chemical irritant, and the lung 
carcinoma of cobalt arsenide ore miners. 
The occurrence of malignant lung tumors 
among the miners of the Schneeberger 
cobalt mines in Saxon Switzerland, which 
was brought to light as long ago as 1878, 
has not aroused as much curiosity among 
German pathologists as one would have 
expected. A tumor described by Hurting 
and Hesse (15) in 1878 was examined by 
Weigert and pronounced by him to be 
lymphosarcoma, originating in the bron- 
chial lymph glands. Harting and Hesse 
stated that 75 per cent, of the cobalt 
miners died of malignant lung tumor, and 
they beheved the cause was the arsenic of 
the ore, which consists of cobalt arsenide, 
nickel, and bismuth. Nothing more seems 
to have been heard on the subject till 1884, 
when Ancke (16) reported a second case of 
lymphosarcoma of the lung. In 1913, 
Amstein (17) reviewed the whole subject, 
and found that 44 per cent, of the deaths 
among Schneeberger • miners were attrib- 
uted by the physicians of the region to 
malignant tumor of the lungs, but that the 
diagnoses were not based on autopsy. He 
examined seventy miners and found phys- 



ical signs of lung disease in about half; 
especially indicative of lung sarcoma was 
the parasternal and paravertebral dullness. 
He could secure material for only two 
autopsies, and one of these proved to be 
caseating tuberculosis, but the other was a 
maUgnant tumor — squamous celled car- 
cinoma — originating in the right lung and 
with e^rtension to pleura and pericardium, 
and with metastases resembling lympho- 
sarcoma in lymph glands, liver, and spleen. 
He found that Schmorl of Dresden had had 
two cases of round-celled sarcoma of the 
lungs in Schneeberger miners in recent 
years, and one case of squamous celled 
carcinoma. 

In view of the proof that chronic arsen- 
ical poisoning is capable of producing a 
continual irritation which gradually results 
in cell proliferation, benign or malignant, 
and since the possibility of hydrogen 
arsenide poisoning is admittedly present in 
all the processes with which the bladder 
tumors of aniline workers have been asso- 
ciated, it seems fair to insist that hydrogen 
arsenide is a possible cause which must be 
considered. There is no such proof of the 
power of amido compounds to cause tissue 
proliferation. 

If this explanation is proved true by 
quantitative tests for arsenic in the urine of 
men employed in dangerous departments, 
it will greatly simplify the problem. In- 
stead of a multitude of compounds any one 
or all of which may be the sought-for 
cause of bladder tumors we shall have one 
only, a compound not constantly present in 
any process with which these tumors have 
been connected, but probably present from 
time to time in every one of them. It will 
explain certain puzzling features of the 
problem; such, for instance, as the fact 
that it is only the production of aniline or 
benzidine that gives rise to tumors, not 
their subsequent use as intermediates. As 
Grandhomme pointed out in his contro- 
versy with Rehn, there is no reason why 



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HAMILTON — ANILINE TUMORS 



27 



aniline fumes should cause tumors in the 
men in the fuehsin department and not in 
the other 4,000 men exposed to aniline in 
the rest of the plant. It is also singular 
that, after years of extensive use of aniline 
in rubber compounding and in reclaiming 
rubber in Germany, bladder tumors have 
not appeared as an occupational disease 
among rubber workers. 

It is quite true that no case of bladder 
tumor has so far been traced to slow absorp- 
tion of arsenic. The cases of cancer fol- 
lowing prolonged administration of arsenic 
have been in the skin. Whether the dif- 
ference in the method of administration, by 
inhalation of minute quantities, instead of 
by ingestion, would account for the dif- 
ference in location of the lesions can be 
only a matter of speculation, as is indeed 
this whole discussion. Nor is it a specula- 
tion to which American industrial physi- 
cians can contribute anything positive as 
yet, for the making of dyes and dye inter- 
mediates is too recent in this country to 
lead us to expect the appearance of bladder 
tumors among the workmen for some 
years, if indeed the excessive labor turn- 
over in this industry does not serve to 
protect them against it altogether. For 
the final acceptance or rejection of this 
suggestion as to the etiology of bladder 
tumors in color workers we must look to 
the Germans. 

Summary 

The case for hydrogen arsenide as the 
cause of bladder tumors in aniline dye 
workers may be smnmed up as follows. 

1. The substances, with the exception 
of beta-naphthylamine, which have been 
connected with timior formation are all 
reduction (NHj) compounds, formed by 
reactions in which the accidental produc- 
tion of fumes of hydrogen arsenide is an 
ever-present possibility, and the processes 
in which this danger is greatest are those 



noted as responsible for large numbers of 
tumor cases. Even in the best constructed 
plants minute quantities of the gas may 
escape, especially in the course of filtration 
or of cleaning or flushing out the apparatus. 
It seems far more reasonable to attribute 
such a slow toxic action to small quantities 
of hydrogen arsenide than to high dilutions 
of aniline vapors or to benzidine dust. 

2. No aromatic compound thus far 
studied has been indisputably proved as 
the cause even of the cystitis which pre- 
cedes tumor formation, and none connected 
with clinical cases of bladder tumor has 
been shown to be capable of setting up 
proliferative growth. 

3. Arsenic absorbed from the fumes pro- 
duced by reduction processes is excreted by 
the kidneys, and has been recovered from 
the urine. Since, then, arsenic is known to 
be capable of exciting epithelial prolifera- 
tion in other parts of the body, it seems 
possible that the same effect may be pro- 
duced when ij acts on the mucosa of the 
bladder. 

4. The resemblance between arsenical 
canicer and aniUne tumors becomes plain 
when we study the literature of arsenical 
cancer caused by long continued internal 
administration of small quantities of ar- 
senic as medicine or in drinking water, or 
caused by arsenic in soot and pitch, or by 
arsenic in cobalt ores. In all these growths, 
as in aniline tumors of the bladder, there 
is a precancerous stage of irritation, of 
epitheUal cell proliferation, then tumor 
formation, and then slow carcinomatous 
degeneration. The whole process takes 
years, but the age at which the cancers 
develop is earlier than the average age for 
ordinary cancers. The growths are likely 
to be multiple, and, in the case of the skhi 
cancers caused by administration of ar- 
senic, the cancer may appear some years 
after the drug has been discontinued. The 
same phenomena have all been noted in 
cases of aniline tumor of the bladder. 



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BIBLIOGRAPHY 



1. 



3. 



5. 



Rehn: Ueber Blasentumoren bei Fuchsin- 
arbeitem. Arch. f. klin. Chir., 1895, 60, 588. 
Rehn: Ueber Blasenerkrankungen bei Anilin- 
arbeitem. Verhandl. d. deutsch. Gesellsch. f. 
Chir., 1906, 36, 313. 

Leuenberger, S. G.: Die unter dem Emfluss 
der synthetischen Farbenindustrie beobachtete 
Geschwulstentwicklung. Beitr. z. klin. Chir., 
1912, 63, 208. 

Curschmann: Statistische Erhebungen Uber 
Blasentumoren bei Arbeitem in der chemisehen 
Industrie. Zentralbl. f. Gewerbehyg., 1920, 8, 
145, 169. 

Nassauer, M.: Ueber bdsartige Blasenge- 
schwUlste bei Arbeitem der organisch-chemi- 
schen Grossindustrie. Frankfurt. Ztschr. f. 
Path., 1919, 22, 353. 

Oppenheimer, R.: Ueber die bei Arbeitem 
chemischer Betriebe beobachteten GeschwUlste 
des Hamapparates und deren Beziehungen zur 
allgemeinen Geschwulstpathogenese. MUnehen. 
med. Wchnschr., 1920, 67, 12. 
Schwerin: BlasengeschwUlste bei Arbeitem in 
chemisehen Betrieben. Zentralbl. f. Gewerbe- 
hyg., 1920. 8, 64. 
Engel: Ueber das Schicksal des Betanaphthyl- 



amins im Organismus des Hundes. Zentralbl. 
f. Gewerbehyg., 1920, 8, 81. 
9. Kuchenbecker, A.: Ueber den Nachweis aro- 
matischer Amidoverbindungen im Ham. Zen- 
tralbl. f. Gewerbehyg., 1920, 8, 68. Ueber die 
Umwandlung aromatischer Amidoverbindungen 
im Tierk5rper. Ihid,^ 69. 

10. Schmiedeberg, O.: Ueber das VerhiUtniss des 
Ammoniaks und der primliren Monaminbasen 
zur Hamstoffbildung im Thierkdrper. Arch. f. 
exper. Path. u. Pharmakol., 1877, 8, 12. 

11. Fischer, B . : Die experimentelle Erzeugimg atyp- 
ischer Epithelwucherungen. MUnchen. med. 
Wchnschr., 1906, 63, 2041. 

12. Wignall, T. H.: Poisoning by Arseniuretted 
Hydrogen. Brit. Med. Jour., 1920, 1, 826. 

13. Nutt, W. H., Beattie, J. M., and Pye-Smith, 
R. J.: Arsenic Cancer. Lancet, 1913, 2, 210. 

14. Bayet, A., and Slosse, A. : L' intoxication houill^re 
arsenicale. Bull, de TAcad. roy. de M6d. de 
Belgique, Series IV, 1919, 29, 607. 

15. Harting and Hesse quoted by Amstein (17). 

16. Ancke quoted by Arnstein (17). 

17. Amstein, A. : Ueber dem sogenannten "Schnee- 
berger Lungenkrebs." Verhandl. d. deutsch. 
path. Gesellsch., 1913, 16, 332. 



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HEALTH IN MERCANTILE ESTABLISHMENTS 
III. COMMON SANITARY DEFECTS IN STORES* 

ARTHUR B. EMMONS, «d, M.D. 

Diredor, Harvard Mercantile Health Work, Boston, Mass, 



A RECENT hygienic survey by the 
author of a number of large stores has 
disclosed certain sanitary defects which in- 
fluence the health and productiveness of 
the workers. This paper discusses briefly 
the most common of these defects and sug- 
gests remedies for them. In the investiga- 
tion in question it was encouraging to find 
that several of the newer stores were almost 
perfect in mechanical construction and 
functioning and that some of the firms 
occupying old buildings had spared no 
expense in improving the health conditions 
of their plants. In many of the stores the 
managements had made intelligent pro- 
vision for the comfort of their employees 
not only while at work but also when oflf 
duty at noon. 

Problems Affecting Health and 
Comfort of Workers 

Locker Rooms. — Separate locker rooms 
for men and women, with convenient wash 
rooms and toilets, require considerable 
space and equipment. The most common 
as well as the most satisfactory arrange- 
ment is to have metal lockers set in rows on 
a concrete floor in a well-lighted and well- 
ventilated basement. In a large store the 
locker room usually requires an attendant 
to insure cleanliness, proper lighting, and 
ventilation, and to prevent abuses, such 
as the storage of perishable food, the strew- 
ing of waste, pilfering, and the loss of time 
from unnecessarily prolonged personal toi- 
let. A careful inspection system is always 
necessary. Rigid rules should be made to 
prevent the insanitary practice of keeping 

• Received for publication Dec. 2, 1920. 



clothing elsewhere in the store, especially 
if food is to be handled. To overcome the 
evil of storing perishable food in locker 
rooms an employees' bundle room should 
be provided. 

Lunch Rooms. — The noon lunch, so 
important to the worker's health and vigor, 
is a problem which has been studied and 
solved by many stores. It is essential that 
hot, nutritious food in sufficient variety be 
supplied as nearly at cost as possible, and 
that this food be served in congenial sur- 
roundings, where there is opportunity for 
rest and recreation. 

The employees' lunch rooms at present 
provided grade from the lunch room equip- 
ped with tables and chairs for the use of 
employees who bring their own food, to the 
modern cafeteria which is presided over by 
a trained dietitian, and which supplies an 
excellent variety of food at cost. In every 
store there are always some workers who 
must practise strict economy because of 
dependents at home, and who are conse- 
quently apt to be undernourished. It is to 
the interest of the store that these em- 
ployees receive substantial luncheon. In 
some cases this situation has been met by 
providing at very low rates simple, sub- 
stantial food, such as milk, cocoa, bread 
and butter. Education in regard to a 
balanced diet is much needed. The appeal 
to the individual may be made on the 
score of both health alid economy. 

Recreation. — Suitable recreation at the 
noon hour is second in importance only to 
nourishing food. Good music provides 
relaxation more quickly and for a larger 
group of people than any other single 
means. To some of the more youthful and 



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more energetic workers dancing is an en- 
joyable recreation; to others, who prefer to 
read, a store branch of the public library is 
very acceptable. To still others, in season- 
able weather, a walk in the open air gives 
the needed noon recreation. 

The matter of recreation outside of store 
hours is an important subject, although at 
first it may seem to be beyond the circle of 
store influence. Studies are available to 
show that many shop girls and other work- 
ers lack suitable opportimities for necessary 
recreation and that this lack of diversion 
not only influences markedly their produc- 
tiveness but also may result in frequent 
change of occupation. The employment 
oflSce may some day add to its blank an- 
other heading — namely. Avocation. On 
the answer to this question often depends 
the likelihood of stabiUty ; a good avocation 
favors a settled vocation. Already many 
stores have, unconsciously perhaps, recog- 
nized the importance of recreation outside 
of work hours and have organized clubs, 
athletic teams, bowling teams, and theatre 
parties. Some stores have vacation or rest 
houses, which serve as preventoria for those 
physically below normal, and as club- 
houses for social week-end parties. Such 
adventures in friendship have proved 
acceptable and successful. 

Drinking Water. — The individual drink- 
ing glass which frequently becomes a 
common drinking cup should be replaced 
by paper cups or bubble fountains. To 
be sanitary, however, a bubble fountain 
should be so arranged that the stream of 
water does not fall back on the source and 
that the Hps do not touch the source. 

Washrooms and Toilets. — White enamel 
paint is a great aid in insuring cleanliness in 
washrooms and toilets. The rooms should, 
moreover, be suflSciently well Ughted to 
avoid the possibility of dirty corners and 
should be supplied with some sort of waste 
bucket, preferably with an automatic clos- 
ing top. Some stores have found it neces- 



sary, especially in public toilets, to have 
fixtures which cannot be blocked by waste. 

The matter of providing towels involves 
considerable expense and has not as yet 
been entirely solved. Paper towels are 
hygienic but not altogether satisfactory. 
Individual cloth towels are expensive to 
buy, require laundering and much hand- 
ling, and are too often shared with others. 
From a sanitary standpoint the electric hot 
air drier, which is being tried in many 
stores, is very satisfactory. It can be in- 
stalled for $98 and furnishes a hundred 
dries for 7 cents. No figures are available 
on repairs and upkeep. The chief objec- 
tions to this machine are that it is noisy 
and generally requires from forty to fifty 
seconds to dry the hands thoroughly — 
about double the usual time with a cloth 
towel. 

Common Causes of Fatigue. — For mem- 
bers of the clerical force, who usually sit 
all day at the same desk, working condi- 
tions should be made as favorable as pos- 
sible to reduce fatigue. OflSces should be 
well ventilated without noticeable draft, 
and should not be too warm. The best 
temperature for these rooms is 68°. Higher 
temperatures produce a gradual strain 
leading to fatigue and lower temperatures, 
especially below 65°, are apt to be im- 
comfortably cool. 

The lighting is the next most important 
consideration. Daylight in sufficient quan- 
tity is, of course, the best. If artificial light 
is necessary, indirect or reflected light from 
a favorable ceiling or diffused light from 
ground glass or porcelain globes is very 
satisfactory. The individual adjustable 
shaded light is best adapted for certain 
kinds of close work. It should be so ar- 
ranged that the light falls over the worker's 
left shoulder, and that no shadows are 
cast. Careful tests should be made to dis- 
cover any defects in eyesight and to see 
that suitable glasses are worn to correct any 
errors that exist and to prevent eye-strain. 



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EMMONS — COMMON SANITARY DEFECTS IN STORES 



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Even in the best equipped stores covered 
in the author's sxirvey a lack of proper 
seats for clerks was noticeable. The chair, 
the desk, and the foot rest should be ad- 
justed to the individual and to the work to 
be done. These factors have, perhaps, been 
most successfully worked out at the modern 
telephone switchboard. The best chair* 
available for individual adjustment is 
doubtless the typist's chair. It is essential, 
however, that the worker understand how 
to adjust it in order to secure proper sup- 
port for his back. Often a stool or foot rest 
is necessary for a very short person. 

In one store where adjustable chairs 
were provided, they were most impopular 
among some of the workers simply because 
the girls did not understand how to adjust 
them. Another objection raised was the 
diflSculty of revolving the chairs easily to 
consult files placed at one side. On the 
other hand, a number of the more inteUi- 
gent clerks in this force expressed great 
satisfaction and said that since adjustable 
chairs had been given them they had 
ceased to experience fatigue of the back. 
It would be an admirable scheme if every 
new employee, whether a clerk or a worker 
in a repair room or workroom, had her 
eyesight and her posture determined and 
was then carefully fitted to her place by 
someone famihar with physical require- 
ments. Such a system would prevent un- 
necessary fatigue and ill health. 

As a further aid in preventing fatigue 
among sedentary workers mid-morning 
and mid-afternoon exercises in a well-aired 
room, under the leadership of a physical 
director, have proved to be worth while. 
They furnish relaxation, refresh the workers 
and lead to an increased output. 

The telephone switchboard has been 
commended for the excellent mechanical 
adjustment of seating and foot rests. Here 
a modified light is used to aid in seeing the 

* A work chair especially adapted for use at tables or 
desks will be described in a subsequent article in this 
JouBNAU Enquire before replacing chairs. 



light signals. In some of the stores sur- 
veyed the ventilation for the telephone 
girls was poor owing to the f a;ct that the 
switchboard had to be shut off by parti- 
tions on account of nearby noises. Tele- 
phone work has a certain fascination and 
requires dexterity, but it tends to keep up 
the nervous tension in an already high- 
tension type of person. To meet the danger 
of fatigue, therefore, frequent short rest 
periods are desirable. A comfortable loung- 
ing chair, with light suitable for reading, 
placed near the switchboard and used in 
turn, has in some instances proved more 
successful than a distant rest room. 

The tube room or cash room, now for- 
tunately becoming less common owing to 
the extended use of the cash register, has 
certain common dangers. It is often in the 
basement and consequently dependent on 
artificial light and air. It is apt to be noisy 
and sometimes overcrowded. The hazard 
of dirty money is also present. Convenient 
provision should be made for moistening 
the fingers for sorting bills, and warnings 
should be given never to use the mouth for 
this purpose. Workers in these places in 
particular should acquire the habit of wash- 
ing their bauds thoroughly before eating. 

Women are becoming more and more 
awake to the comfort and pleasure of 
comfortable shoes. To a girl who must 
stand most of the day a suitable shoe is in- 
valuable. A munber of stores carry good 
looking sensible shoes in their shoe depart- 
ments and, recognizing the importance to 
their sales force of wearing such shoes, 
have offered a substantial discount to 
employees. One buyer of shoes tells me 
that he carries a college girl's shoe, which 
he sells to school girls, who admire college 
girls. In such a way he is able to fit with 
suitable shoes many persons who otherwise 
would be guided entirely by fashion in 
purchasing. 

No one type of shoe is suited to all varie- 
ties of feet. For example, the growing girl 



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and the heavy, middle-aged woman need 
quite different shoes. In the store sm^ey it 
was foimd that some workers kept extra 
shoes in their lockers for store use, and 
changed from their street shoes every 
morning. This practice might be of great 
value if more generally adopted, for it 
would very naturally result in the common 
use of a suitable store shoe. 

Pin Ticket and String Cutter. — Two 
sources of injury which are often respon- 
sible for infected wounds are commonly 
foimd in stores — namely, the pin ticket 
and the string cutter. Pin tickets are used 
for marking a few articles of clothing. Even 
if they are put in by machines, they may 
still be a source of injury to the salesclerk 
and to the customer. They are a not im- 
common source of trouble to the worker 
who inserts them by hand. Some other 
device for marking articles should be sub- 
stituted. The counter string cutter has a 
point suflBciently sharp to inflict wounds. 
It can be roimded or dulled to a safe shape 
without reducing its usefulness. 

Counter Wash Basins. — As the seUing 
of white gloves requires the salesgirl to 
wash her hands frequently, small wash 
basins are usually provided, often below 
the glove counter. A mild soap, preferably 
in the form of liquid or powder, should also 
be supphed. A cake used in common is less 
desirable. Sufficient towels are usually fur- 
nished. It is quite common in winter, how- 
ever, to find that a salesgirl has chapped 
or dried hands, and cannot clean them 
easily. To prevent chapping a hand lotion 
should be provided in a form convenient 
for easy appUcation after each drying. 

Sale of Food. — The public sale of food 
in stores deahng primarily in clothing and 
general merchandise carries certain risks. 
In our survey the soda fountain and ice- 
cream counter in some instances were 
found to be controlled by firms outside 
the store management — an arrangement 
which is always attended by some risk. 



Some of the soda fountains investigated 
were found to be well rim and reasonably 
sanitary; others could not be passed with- 
out considerable criticism. The public 
does not distinguish between managements, 
so criticisms must be borne by the store. 
Similar responsibility is reflected on the 
store in the case of the chiropody, the mani- 
cure, the optical, and the hair dressing 
departments. 

If a store is selling food to the public, the 
food handler must be not only neat and 
scrupulously clean but should also have 
been declared free from communicable dis- 
ease by the store health department. The 
garbage must be systematically cared for 
and frequently removed. Perishable foods, 
such as milk, must be carefully guarded. 
Ice cream may also be a danger if it is not 
properly protected. The handUng of food 
and money by the same person, as com- 
monly happens at candy counters, is not a 
safe procedure. 

Customers' restaurants are found in a 
few stores but in general they have been 
given up. If the management decides that 
a customers' restaurant is desirable, it 
must be made a model of cleanliness and 
attractiveness in order to be successful. 
These restaurants, I am told, seldom pay 
profit equal to the value of the space 
which they occupy. For sanitary equip- 
ment, healthy personnel, and safe practice, 
considerable responsibility is assumed by 
the store, whether or not it assumes the 
financial risk. Failure to maintain a high 
standard reflects directly on the store. 

Conditions Affecting Both 
Workers and Customers 

The customers, the buying public — 
largely women — are directly concerned 
with the conditions in stores. So far the 
questions considered are ones which prin- 
cipally affect the worker. The problems 
discussed below, however, concern equally 
the customer aild the worker. 



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EMMONS — COMMON SANITARY DEFECTS IN STORES 



3S 



The location of the store is favortible 
according to the convenience of approach, 
the breadth of streets or open spaces 
around the store, the amount of sunUght 
and air, and the absence of noise, smoke, 
and dust nuisances. One store has an 
open canal at its rear, which in summer 
emits an odor suflBciently pungent to cause 
shoppers to sniflF the air inquiringly. The 
answer received is "city politics." 

Overcrowding, — The shopping public is 
often ref>elled by overcrowding, which is 
conunon on the street floor of department 
stores. To prevent this undesirable con- 
dition the entrances should be large and 
numerous and easy of access,* the aisles 
should be broad and unobstructed, and 
adequate elevator service should be pro- 
vided. Congestion may be somewhat re- 
lieved by removing to other parts of the 
store goods which are in considerable de- 
mand. The practice of allotting to depart- 
ments space proportional to their earnings 
results, for example, in a whole floor being 
given to the furniture department in which 
may be found a half dozen shoppers, while 
the street floor is overcrowded with pur- 
chasers of small wares. The management 
alone can give due weight to the comfort 
and health of everyone by considering these 
factors in apportioning space. 

Elevator Service, — Suflficient and con- 
venient elevator service may create favor- 
able contact with the public. Three stores 
in particular have strikingly capitalized 
this contact by the neatness and courtesy 
of their elevator operators and by the 
mechanical perfection of the service. The 
chief fault with the older type of elevator is 
that its entrance is so narrow that the time 
needed for filling and emptying is markedly 
lengthened. Thus, its convenience and 
efficiency in transportation are hmited. 
The elevator about 10 feet wide by 6 feet 
deep, with doors folding in six sections, is 
the most eflScient type which I have ob- 
served. To avoid confusion and loss of 



time one store has installed two banks of 
elevators in the cei^ter of the building — 
one side carrying passengers up, the other 
side bringing them down. At first thought 
this might seem ineflScient. Careful ob- 
servation has, however, proved this to be 
the more eflicient service under the con- 
ditions found in this store. It took but a 
short time for the public to become accus- 
tomed to the system. 

The natural tendency of the average 
elevator operator, like a street car conduc- 
tor, is to order about the meek passengers. 
While safety may at times demand this, 
the American pubHc naturally resents it. 
Courtesy here means much to the shopper 
who is often easily confused. 

One store has successfully supplemented 
its inadequate elevator service by an esca- 
lator. Many people wilhngly walk down 
convenient stairways in preference to 
waiting for a crowded elevator. 

Ventilation, — Under-ventilation is the 
common accompaniment of overcrowding, 
a discomfort to which many shoppers are 
very sensitive. Often a day's shopping is 
dreaded for this reason alone. 

The basement store is particularly un- 
popular with some shoppers. This preju- 
dice is often, but not always, justified. It 
is usually possible to supply, suflficient 
artificial ventilation, except perhaps in 
rush times. The practical difficulty dis- 
closed is the fact that the control of the 
ventilating system is in the hands of the 
engineer who has many other duties. 
Some effective check or follow-up system is 
needed to prevent under-ventilation. To 
avoid prejudice a basement store should, 
if possible, be over- ventilated. The prac- 
tice which is now in use in many stores of 
running the ventilating system at night 
and sometimes over Sunday offers one 
solution of the ventilation problem. Fear 
of drafts results too often in under-ventila- 
tion which frequently increases the suscep- 
tibiUty to colds. However good the system 



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of ventflation may be, experience shows 
that a follow-up is necessary. Inspection 
should be systematized and made a regular 
duty if the problem is to be solved, and 
should, if possible, be superintended by 
someone with a medical point of view. 

In large, crowded oflSces and work- 
rooms, supplementary ventilation has been 
satisfactorily obtained by exhaust fans, 
placed in the upper sashes of the windows. 
Air ducts supplying fresh air are necessary 
m some offices where partitions have been 
carried to the ceiling in order to eliminate 
noise. 

Cleaning. — A store cleaning system 
may perhaps be best judged by its results. 
A factor of special importance to the store 
health department is the health of the 
cleaning force who, being largely absent 
during store hours, may easily escape 
notice. 

Vacuum cleaning is by far the most sani- 
tary method of cleaning because dust and 
dirt are removed with no danger to the 
worker. The feather duster is at the other 
end of the scale of cleaning methods, and, 
like the common towel, to be suppressed, 
requires constant watchfulness. The oil 
dust cloth can often be substituted to do 
the same work. 

Flooring is intimately connected with the 
cleaning job. A smooth surface with the 
fewest possible cracks is the best cleaning 
surface. Other factors besides cleaning 
must be considered in selecting flooring, 
such as ap[>earance, cost, comfort and 
durability, including liability to injury 
from desk, chairs and truck wheels. From 
a health standpoint, comfort is a very im- 
portant factor. Two kinds of floors cause 
discomfort to the salesperson, who must 
stand the greater part of the day; concrete 
or stone flooring is cold and hard; carpets, 
especially if they are soft and thick, are 
hot and tiring. 

The flooring which best meets all the 
requirements is battleship linoleum. Es- 



pecially does this meet the sanitary con- 
ditions of comfort and ease of cleaning. 
Cork,- wood, tile and concrete are some- 
what less favorable from a health stand- 
point. Carpets are often necessary and, 
if used, require thorough and frequent 
cleaning. The disadvantage of hardness in 
flooring may be partly compensated for 
by the use of matting and by the wearing 
of suitable shoes with rubber heels. 

Dust Hazards, — Apart from the store 
cleaning system, dust hazards are some- 
times found in certain store work, such as 
silver polishing, fiu* beating, upholstery 
workrooms and packing. The buffing and 
fur beating departments require exhausts 
to protect the employees. The use of paper 
or excelsior instead of hay does away with 
much of the dust in the packing and receiv- 
ing of goods. 

Drafts. — The entrance door problem of 
cold air and drafts during the winter has 
largely been solved by placing a generous 
heating surface either in the vestibule or 
just inside the revolving doors, thus heating 
the fresh air admitted with the customer. 
Glass shields are sometimes necessary to 
protect the worker and the goods on coun- 
ters located nearby in the line of drafts. 

Importance of Proper Industrial 
Relations and Medical Service 

A follow-up system is the key to success 
in all sanitary matters. Experience al- 
ready shows that lack of such a system has 
defeated more carefully prepared plans 
than any other factor. The human ele- 
pient is commonly responsible for poor 
ventilation in the modern well-equipped 
store. The three departments which are 
directly interested in good store house- 
keeping are the management, the engineer- 
ing department, and the health department, 
all of which should be represented in 
formulating instructions and in following 
them through to results. 



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EMMONS — COMMON SANITARY DEFECTS IN STORES 



35 



Thus, industrial relations become prom- 
inent in successful sanitation. One of the 
most satisfactory store sanitary systems 
which has been worked out owes its success 
to the ready welcome of all suggestions or 
reports to the engineering department. 
The chief of this department considers that 
the education of all store workers to report 
trivial matters inunediately and freely is 



means of bulletins, by notices in their pay 
envelopes, or by articles in the store paper. 
Misunderstandings will thus be prevented 
and criticisms may be made which will re- 
sult in wise alterations in the original plan. 
In following up the system of sanitation, 
the health department should be on the 
alert to detect illness arising as the possible 
result of failure in some sanitary feature. 



I 



Figure 1 
HEALTH SERVICE DEPARTMENT 

DAILY REPORT 

DaU 



II 



1 



1% I 
■ I 



Name 



Complaint 



Tbkatmkmt 



DnpoemoN 
or Casb 



the key to success in the functioning of 
his store housekeeping system. All reports 
receive cheerful and prompt attention, 
even though it is recognized that perhaps 
one in four or five such reports needs 
action. 

Proper industrial relations of a store 
require due consideration when any new 
measiure, such as visiting nursing, is intro- 
duced. Publicity within the store, to be 
successful, requires a well-thoughtout plan. 
It should first be explained and discussed 
at the committee meetings of the manage- 
ment and of the sub-management or heads 
of departments, and then should be brought 
to the attention of all the workers by 



A daily record form (see Figure 1) has been 
worked out and tried with success in a 
number of stores. One line only is use<J for 
each case. The monthly report results 
from addition of the columns. From the 
monthly report an annual report can 
readily be made, which will show, among 
many things, where illness is most com- 
mon, and will often reveal a preventable 
cause. Such a daily record will enable a 
store to compare the healthfulness of its 
employees with that of workers in other 
stores, and may thus constitute an added 
attraction for prospective employees. 

In the store emergency room it is a 
common practice for the nurse to give 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



immediate relief. Such relief has only too 
often consisted in drugging; the pill has fre- 
quently become almost the sole reliance. 
Unless medicines are given in accordance 
with standing orders of the doctor, who 
thus carries the responsibility, the emer- 
gency room is not even within the legal 
limits of medical practice. It is a lost 
opportunity to do any lasting good for the 
individual patient and consequently for 
the f utiu-e welfare of the store. 

When patients come for relief, they wish 
to receive good medical advice, which re- 
sults from an intelligent understanding of 
their physical condition, their personal 



hygienic habits, their work, and even their 
play. If the future health of the employee 
is of value to the store, it is a matter of 
economy to furnish high-grade medical 
service. 

To help build up a healthy, stable, and 
reliable personnel is the principal object 
and the chief justification of store medical 
service. It is, therefore, recommended 
that the emergency room be developed into 
a store health department with all that 
this term implies. Those who recognize 
early the importance of sanitary factors 
and adequate nledical service, and who 
build wisely should first reap the benefits. 



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BOOK REVIEWS 



37 



BOOK REVIEWS 



Hygiene of Communicable Diseases: A Hand- 
book for Sanitarians, Medical OfSicers of the Army 
and Navy and General Practitioners. By Francis 
M. Miinson, M.D., Lieutenant, Medical Corps, 
U.SJ^., Retired; Lecturer on Hygiene and Instruc- 
tor in Military Surgery, School of Medicine, George- 
town University; Formerly Listructor in Medical 
Zoology, Georgetown College; Late Brigade Sur- 
geon, and Provisional Brigade, U. S. Marines. Cloth. 
Pp. 793 with illustrations and index. New York: 
Paul B. Hoeber, 1920. 

Dr. Munson has written a book which, in 
spite of the scope and rather minute detail, is 
still compact and physically manageable — an 
item of no small importance in the usefulness of 
a book. Due to the paragraph arrangement 
and an excellent index, the material is avail- 
able for ready reference, so that the book should 
prove of value to all health officers, either civil 
or military, engaged in field work. It makes no 
pretence, I think, of being a laboratory man- 
ual, in which field its value would be much more 
questionable. 

The author begins with a brief consideration 
of the various types of infecting agents and the 
theories of immunity. Chapters are devoted to 
such specific problems of sanitation as mu- 
nicipal, railway, military, prison, and school 
emergencies due to great disasters — i, e,, 
floods, earthquakes, etc. Dr. Munson is per- 
haps at his best when dealing with military 
sanitation, where the wealth of detail as to de- 
lousing, the disposal of hiunan and animal 
excreta imder various conditions, disposal of 
sink water, etc., would be invaluable in plan- 
ning and administering the sanitation of a 
camp. 

In the second part of the book, the diseases 
are grouped according to their mode of spread- 
ing and are considered individually. Parts of 
some valuable documents are quoted at length, 
such as the Interstate Quarantine Regulations 
of the Treasury Department, and War Depart- 
ment Orders and Directions Regarding Vene- 
real Prophylaxis. The consistent use both in 
title and text of the term "communicable" in- 
stead of "infectious" or "contagious" is 
gratifying. 

In spite of the introductory remark that no 
statement is made which is not supported by 
competent authority, we find, to our surprise, 
the imqualified statement that the etiological 
agent of measles is a filterable virus, and the 
etiological agent of influenza, the B. Influenzae. 



True, we read further on that "the consensus 
of opinion is that the bacillus of Pf eiffer. Bacil- 
lus Influenzae, is the specific causative agent, 
but that most cases are mixed infections." 
Even this does not appreciably lessen the sur- 
prise. Then, over two pages are devoted to 
what reads like a modem fairy tale, under the 
heading The Pandemic of Influenza of 1918- 
19y which has to do with a theory that the in- 
fluenza bacillus is metamorphosed from the 
plague bacillus, and that the whole miserable 
pandemic started in China as pneumonic 
plague, and thence was spread into Germany 
by Chinese coolies, and thence all over Europe 
and America as influenza. 

In the chapter on Venereal Diseases^ Dr. 
Munson deals largely with the military and 
naval aspects of the question. He feels that 
"a medical program for civil communities 
equivalent to the military program for preven- 
tion and treatment should be encouraged." In 
so far as the treatment is concerned, Dr. Mim- 
son's recommendation might well be adopted, 
but the prevention in the military sense means, 
besides education and the restriction of prosti- 
tution, alcoholism, etc., the prophylactic sta- 
tion. There lies the difficulty. I know that 
some, and I have been given to understand that 
practically all, of the states have found it im- 
practicable for one reason or another to endorse 
the prophylactic station as a part of their 
venereal program. Theoretically, if such sta- 
tions work in the army, they should at least be 
of some value in a civil campaign against vene- 
real disease. Practically, it is not difficult to see 
the obstacles. 

When considering the control of diphtheria in 
an institution, the author recommends the ad- 
ministration of antitoxin to all the inmates, 
repeated every ten days or two weeks as long as 
cases appear. No mention is here made of the 
use of the Schick test and toxin-antitoxin im- 
munization of susceptibles. True, these pro- 
cedures are elsewhere mentioned for control in 
military organizations, but it would certainly 
be a mistake in an institution to frustrate the 
value of a test like the Schick test by the whole- 
sale administration of antitoxin. 

Under the discussion on measles the author 
argues effectively against closing the schools in 
the presence of an epidemic. He also makes a 
plea for education against the exposing of 
yoimg children. The not at all imcommon prac- 



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lice of exposing yoimg children to measles to 
"get it over with" cannot be too severely con- 
demned, when we consider that about 80 per 
cent, of the deaths from measles occur during 
the first three years of life, while, in 1918 in 
Massachusetts only about 16 per cent, of all the 
cases of this disease occurred in this age group. 

The author states that an attack of yaws 
confers immunity. There seems to be no rea- 
son to suppose that a person cured of yaws is 
any more immune to reinfection than is a per- 
son cured of syphilis. Immunity in syphilis is, 
to say the least, open to question. With the 
almost unquestioned short viability of the 
Treponema pertenue outside the body, there 
seems to be but little need for the thorough dis- 
infection recommended to prevent the spread 
of yaws. 

There are many good points made by Dr. 
Munson, such as the paucity of public comfort 
stations in American cities as compared with 
European cities; the danger from the broadcast 
distribution of raw himian excreta along rail- 
ways particularly when th^ border public 
or private water supplies; that the ordinary 
drip "'disinfecting" machines in toilets and 
urinals are of service only in adding an im- 
pleasant odor to those abeady present; that a 
"school without a playground is an educational 
deformity," etc. He gives regulations that 
should be in force in all barber shops. The 
average barber shop is certainly a sanitary 
nightmare. He also gives points of value in in- 
specting markets, abattoirs, etc., and many 



other suggestions which will, as has been said» 
J)e found of value to the health officer in the 
field. — Oeorge H. Bigdow. 

Organisation Industrielle, M^decine Sociale et 
Education Civique en Angleterre et aux fitats- 
XJnis* By Ren6 Sand, Inspecteur principal au Ser- 
vice m^ical du Travail; Agr^6 de TUniversit^ de 
Bruzelles; Membre correspondant de TAcad^mie 
royale de M^ecine de Belgique; M^ecin de regi- 
ment de reserve k TAmbuliuiee de TOc^an. Paper. 
Pp. 896 with index and table of contents. Paris: 
J.-B. Bailli^ et Fils, 1920; Brussels: Maurice 
Lamertin, 1920. 

Dn Ren6 Sand has recorded in this large book 
the impressions which he received during two 
visits to the United States and one to England 
in 1918 and 1919. 

The title of the volume only suggests the 
multiplicity of subjects of wUch he writes. 
The Taylor system, industrial relations, indus- 
trial safety, the physiology of fatigue, child 
labor, unemployment, settlement houses, public 
health activities and social reconstruction — 
these and many other topics are discussed at 
length. 

The work must be termed superficial — but 
that the author doubtless intended it should be. 
It is, however, in many instances very inexact, 
as any such record must natiu*ally be, when its 
author is a kindly person en tour in a strange 
land and at the mercy of a multitude of individ- 
ual enthusiasts all arrayed in their best official 
robes, each with his best foot forward. — 
Wade Wright. 



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THE JOURNAL OF 
INDUSTRIAL HYGIENE 



PUBLISHED MONTHLY 



YoLuiiB m 



JUNE, 1921 



Number ft 



THE PREGNANT WOMAN IN INDUSTRY* 

CAREY P. McCORD, M.D., and DOROTHY K. MINSTER 
Cincinnati, Ohio 



THE pregnant woman, her physician, 
and her employer, all have need of a 
better imderstanding of pregnancy in rela- 
tion to work. The government, employers, 
and labor bodies are continually seeking to 
surround the woman worker with conditions 
that enhance her economic worth and are 
favorable to the maintenance of her health. 
These agencies have, however, failed prop- 
erly to appreciate the fact that the normal 
pregnant woman is capable of work, and as 
a residt have neglected the specific provi- 
sions that would make it possible and ad- 
vantageous for her to continue at work. 

In the industries of this country about 
five million women are employed, nearly 
one million of whom are married. An un- 
known but obviously large number of 
pregnancies occur every year among them. 
At this time of additional expenses prepara- 
tory to the .child's birth and to after-care, 
an even greater necessity for earning money 
arises. Many times it is of mutual advan- 
tage to the employer and to the pregnant 
employee to allow her to continue her work 
as long as it is not harmful to her or to her 
unborn child. Through lack of dependable 
advice, it is the tendency of the expectant 
mother, especially the primipara, to dis- 
continue work early in her pregnancy. She 

* Received for publication Jan. 14, 1921. 



is influenced in her decision to do so by her 
apprehension lest in some way she harm 
her child; by gossip current among older 
women as to the disastrous effects of work; 
by her fear that in the plant she will be- 
come the butt of idle humor; by the fact 
that the mental and physical discomforts 
of pregnancy are at their height in this 
early period, thus leading her to think that 
she wilt continue to be too "miserable** to 
work. The employer, knowing little about 
the matter, "plays safe" and acquiesces in 
her decision, thus needlessly losing the 
services of a valuable worker. 

There is great need of competent med- 
ical sup)ervision by physicians who are not 
only well qualified as obstetricians but who 
are also well acquainted with trade proc- 
esses, occupational hazards, fatigue and 
I>osture problems, chemical intoxications, 
and the like. Unfortimately, the physician 
serving this group of patients is very often 
wholly unacquainted with industrial med- 
ical matters and therefore incompetent to 
discriminate between suitable and unsuit- 
able plant work. Too much is sacrificed, 
both by the woman and by the employer, 
through this lack of scientific knowledge as 
to the desirable work environment for the 
pregnant employee. 

The approaches to the problem, which 



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THE JOURNAL OF INDUSTRIAL HYGIENE 







TABLE L — MATERNITY BENEFITS 






Date of Law 
inForoe 


Ttpbs or Bbnbtit 


Souree 




COUMTRT OR 

Statb 


Money in 
Lump Sum 


Money 
in Instal- 
ments 


Medical, 

Nursing, 

Institutional 

Care 


Pasrment for 
Breast Feeding 


Amount* 


Australia 


1912 


+ 


•• 








$25 total 


Austria 


1917 


1 


+ 


+ 


i amount format 
temity benefit to 
end of 12th week 


insurance premium 
— i employer, 1 em- 
ployee 


60% of standard rate 
of wage class to which 
insured belongs 


Denmark 


1915 




+ 


if necessary 




insurance society; 
government 


$0.27 daily 




1913 with 

subsequent 

amendments 


to govern- 
ment em- 
ployees only 


+ 


•• 


$2.70 at end of 4 
weeks 


government; mutual 
aid societies 


$0,096 to $0.29 daily 


Germany 


1911 


time meas- 
ure $5.95 


+ 


substitute for 
maternity ben- 
efit if desired 


i cash benefit for 
12 weeks; doub- 
led for twins 


insurance premium 
— 1 employer. 1 em- 
ployee 


$1.19 to $1.43 daily 


Great Britain 


1912 


+ 




cash benefit 
may be used 
in this way 




government insurance 
premium, employer 
and employee 


$7.20 if woman is in- 
sured; $14.40 if hus- 
band is also insured 


Italy 


1912— 
modified 
in 1917 


+ 


•• 






insurance premium 
— i employer, i em- 
ployee 


$7.72 in two instal- 
ments 


Luxemburg 


1902 


•• 


+ 


•• 




insurance premium 
— i empk>yer, 1 em- 
ployee 


cash benefit of i daily 
earnings 


Netherlands 


1913 — not 
in effect on 
Jan. 1. 1918 




+ 


+ 




insurance premium 
— i employer, \ em- 
pk)yee 


70% of average wage 
unta after childbirth; 
then 100% 


New Zealand 


1911 


+ 




+ 




— J government, f 
insured 


not more than $29.20 


Norway 


1915 


+ 


+ 


+ 


* 


insurance premium 
— •/!• insured, Vi« 
employer. */u goVt 


60% of daily wage 


Russia 


1913 


•• 


+ 


+ 




owners of establish- 
ments: insured; do- 
nations, fines, etc. 


i to full wages 


Sweden 


1913 




+ 






government 


$0.24 daily 


Switserland 


1914 


+ 


•• 


+ 


$3.86 if mother 
has nursed child 
for 10 weeks 


dues of membera. 
subsidy of state 


$3.86 lump sum 


Ck>lorado 


1913 


•• 








government 


enough to care prop- 
erly for chiW 


Missouri 


1917 










government 


one chikl, $16 
monthly: $10 for 
each additional child 


Pennsylvania 


1919 


•• 


•• 






government 


one child. $20 
monthly; $10 for 
each additional chUd 



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McCORD AND MINSTER — PREGNANT WOMAN IN INDUSTRY 



41 



TABLE 1.— MATERNITY BENEFITS 



• 


Time Limit 


PsBsONs Included According to 




Stats 


Wt€k9 


After Confinement 
We9k9 


Occupation 


Wage Class 


Remarks 


Australia 






unlimited except for natives 
and Asiatics 


imlimited except for 
natives and Asiatics 


medical certificate necessary to 
exclude stiUbirths and abortions 


Aostria 




6 


establishments using power or 
explosives; under industrial 
code; building trades; trans- 
portation 


workers receiving less 
than $487.20 a year 




Denmark 




10 days, after which 
she is entitled to us- 
ual sick benefit 




workers without in- 
come-bearing property: 
over 16 years of age 


only slight changes in law of 
1892 because of "financial 
straits" 


France 


as indicated for 
mother, not more 
than 4 


4 


all wage earners except rural 
workers 




1917 law provides for wives of 
soldiers regardless of being wage 
earners 


Germany 


2 


medical certificate 
required before re- 
turn to work 


all wage earners 


others if income is less 
than $6.96 yearly 




Great Britain 




4 


manual employment; non- 
manual if income is lees than 
$776.64 


than $778.64 yearly 


pregnancy benefit; British sys- 
tem most complex of all be- 
cause of niuneroua perplexing 
features 


Italy 




4 


industries, factories; private 
telephone companies; govern- 
ment employees excluded 




nursing room for mothers in 
factory; no distinction between 
married and unmarried mothers 


Luxemburg 




4 


wage earners 


salaried employees re- 
ceiving less than $1.93 
daUy 




Netherlands 


unlimited during en- 
tire period of dis- 
ability 




regularly employed 


to be specified later 


no distinction between legiti- 
mate and iUegitimate children 


New Zealand 








all over 16 and under 
than $1,000 yearly 


maternity benefit a part of old 


Norway 


2 


6 


all wage earners and saUried 
employees over 16 years 


than $482 yearly 


admirable provisions for ille- 
gitimate child 


RuBgia 


2 


4 


all wage earners in factories 
using mechanical or animal 
power 




requires owner to furnish hos- 
pital care; present conditions 
unknown 


Sweden 




2 . 






information incomplete 


Switserland 




6 


all industries and occupations 




maternity benefits of this coun- 
try have served as a model to 
many others 


Colorado 






before and after childbirth 


mothers' pension f xmd 


Mlieouri 


3 


3 


unlimited 




mothers* pension fund 








additional sum for unborn child if mother is already 
receiving pension 


mothers' pension fund 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



have thus far been made, have been largely 
blanket provisions without consideration 
of the individual case with its specific prob- 
lems of work environment, health, etc. 
The few measures in practice are chiefly 
the outcome of the activities of govern- 
ments and labor bodies. In accepting some 
responsibility for the pregnant woman in 
industry, these agencies have adopted two 
general methods of procedure: (1) the pro- 
hibition of employment of women on any 
work during specified periods of gesta- 
tion, the prohibition of employment of 
any women in certain trades, and the 
regulation of conditions of employment for 
women at work; (2) the provision of ma- 
ternity benefits, thus making the necessity 
for work less frequent. 

Although these existing measures are dis- 
tinctly helpful, they are palpably inade- 
quate. Obvious shortcomings arise from 
the failure to provide medical guidance 
throughout pregnancy and from the f ailiure 
to determine more definitely the influence 
of specific work conditions upon maternity. 

Maternity Benefits and Legal Con- 
trol OP THE Pregnant Woman's Work 

Is the pregnant working woman jeop- 
ardizing her health by continuing work 
after the onset of pregnancy? Is the well- 
being of her child jeopardized by her work- 
ing? When should the pregnant worker 
discontinue work? Are there certain oc- 
cupations and types of work that are espe- 
cially harmful? Is the fact that she is to 
give birth to a child of such economic im- 
portance that she is entitled to some form 
of comi>ensation? In this country such 
questions have until recently occasioned no 
deep concern and only five states have laws 
definitely pertaining thereto. Fifteen other 
countries are far in advance of the United 
States — namely, Great Britaio, France, 
Italy, Australia, New Zealand, Germany, 
Austria, Hungary, Denmark, Norway, 



Sweden, Roumania, Servia, Switzerland, 
and Russia.* 

Maternity Benefits (1). — In most foreign 
countries, maternity benefits are ioduded 
in systems of social insurance, are usually 
compulsory, and are designed to protect 
the health of the mother and child by pro- 
viding moneys and medical and nursing 
care before, during, and after childbirth. 
By so doing, the financial burden of child- 
bearing is lessened and the mother is as- 
sured freedom from the necessity of exces- 
sive work for a reasonable period of time. 
These insurance systems usually consist in 
one of the following four types or in a com- 
bination of certain features of these types: 

1. A fixed sum is paid at the birth of the 
child — the state supplying the funds. 

2. Insurance systems to which the 
woman, her employer, and the government 
contribute. 

S. The continuation by the employer of 
a portion of the wages of the woman — 
usually from 50 to 75 per cent. 

4. The provision of medical and nursing 
care prior to, at, and after delivery. 

Table 1 is a tabulation of the major pro- 
visions found in the maternity benefit sys- 
tem in force in various coimtries, and in a 
few states within the United States. In the 
coimtries indicated in this table, particular 
features in the treatment of the problem 
are noteworthy. In a few of the countries, 
the maternity bonus is available to every 
mother irrespective of her economic status. 
In others, only urban workers participate 
in the provisions on a compulsory basis. 
In certain countries the type of work or the 
amount of the wage limits the persons who 
are included. The unmarried mother is ex- 
cluded from all benefits in a high percent- 
age of the national laws. In some instances, 
race prejudices lead to the exclusion of 
mothers of designated nationaUties. Dur- 
iDg the war some countries extended their 

* G>nditioiis in certain of these countries may have 
disrupted the application of existing maternity benefit 
measures. 



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McCORD AND MINSTER — PREGNANT WOMAN IN INDUSTRY 43 

TABLE «. — LAWS PROfflBITING EMPLOYMENT OF PREGNANT WOMEN 





Date 


Induftries Included 


Time limit 


State or Coimtry i 


Before 

Conflnemeiit 

We$ki 


After 

ConflnemeDt 

Wuk$ 


Vermont 




mill, cannery, workshop, factory, manufactur- 
ing or mechanical establishment 


% 


4 






Connecticut 


191S 


factory, mercantile establbhment, mill or work- 
shop 


4 


4 






Maffwchflflftttii 


1911 


tablishment 


2 


4 






New York 


1012 


factory, mercantile establishment, mill or work- 
shop 


no 
provision 


4 






Austria 


1917 


ing trades, establishments in industrial code, 
transportation 




6 








1901 


any factory work 




4 






France 


1918 


industrial or commercial undertaking 




4 






Orf^t Brit^vin , . . 


1911 


remunerative employment 




4 






Gennany * 


1908 




% 


6 






Italy 


1907 


factories, agriculture, etc. 




4 






Norway 


1915 


industrial establishments 


4 (must be 

permitted 

to stop 

work) 


6 






Sweden 


1891 


industrial establishments 




4> 






Switzerland ' 


1877 


industrial establishlbents 


>2 


4 







^ Accorcfing to maauthentic information the state of Washington pro- 
Ubits the enqdoyment of nomen 2 months before and weeks after 
oonfinement. 



provisions so as to encourage child-bearing 
and to relieve the wives of soldiers and 
government employees. 

Restrictive Measures. — Practically all 
industrial countries have promulgated laws 
forbidding the employment of women in 
various hazardous trades and restricting 
the hours and time of work. These laws, 
although not primarily designed as protec- 
tive of the pregnant woman, are distinctly 
beneficial to maternity. In addition, a 
limited number of states and countries have 



s Unless she has doctor's certificate. 

* Medical certificate required at end of weeks. 



devised laws applying peculiarly to the 
pregnant woman. ' Switzerland was the 
leader in legislation of this kind. In 1877, 
the National Council prohibited the em- 
ployment of pregnant women in industrial 
plants for a period of eight weeks, a part of 
which was prior to and the rest subsequent 
to delivery. The essential features of this 
type of legislation in various countries are 
grouped in Table 2. 

At the time of the International Labor 
Conference held in Washington, D. C, 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



November, 1919, the following draft con- 
vention with reference to the pregnant 
working woman was adopted: 

Abt. 3. — In any public or private industrial or 
commercial undertaking, or in any branch thereof, 
other than an undertaking in which only members oi 
the same family are employed, a woman 

(a) Shall not be permitted to work during the six 
weeks following confinement. 

(6) Shall have the right to leave her work if she 
produces a medical certificate stating that her con- 
finement will probably take place within six weeks. 

(c) Shall, while she is absent from her work in pur- 
suance of paragraphs (a) and (&), be paid benefits 
sufficient for the full and healthy maintenance of her- 
self and her child, provided either out of public funds 
or by means of a system of insurance, the exact 
amount of which shall be determined by the com- 
petent authority in each country, and as an addi- 
ticHial benefit shall be entitled to free attendance by 
a doctor or certified midwife. No mistake of the 
medical advisor in estiinating the date of confinement 
shall preclude a woman from receiving these benefits 
from the date of the medical certificate up to the 
date on which the confinement actually takes place. 

(d) Shall in any case, if she is nursing her child, 
be allowed half an hour twice a day during hours for 
this purpose. 

Abt. 4. — Where a woman is absent from her work 
in accordance with paragraphs (a) and (&) of Article 
3 of this convention, or remains absent from her 
work for a longer period as a result of illness med- 
ically certified to arise out of pregnancy or confine- 
ment and rendering her unfit for work, it shall not be 
lawful, until her absence shall have exceeded a 
maximum period to be fixed by the competent 
authority in each country, for her employer to give 
her notice of dismissal during such absence, nor to 
give her notice of dismissal at such a time that the 
notice would expire during such absence. 

The shortcomings of all such measures lie 
in (1) the scant provision made for the 
supervision of the health of the pregnant 
woman throughout the gestation period; 
and (2) the lack of investigation seeking to 
determine the eflfects of specific trades and 
occupations upon maternity. 

Hygiene of the Pregnant Woman 

The pregnant woman is admittedly bet- 
ter off in a normal home environment than 
at work in a factory. With the proper 



guidance and supervision, however, it will 
not be harmful for the pregnant woman to 
work if work is an economic necessity for 
her. For those who must work, then, bet- 
ter health supervision and general guidance 
must be evolved. 

Is Work Harmful? — There are many 
opinions as to the harmfulness of work for 
the pregnant woman. Many years ago, 
Jones(2) stated that "the pregnant woman 
should not be employed in industrial oc- 
cupations." More recent opinions hold that 
work of the prop)er sort is definitely good for 
the normal pregnant woman. All books on 
obstetrics and all directions for the hygiene 
of the pregnant woman recommend mild 
exercise and fresh air. Industrial work may 
meet all these requirements. For instance, 
Paradise (3) states that "ordinary house- 
work and many of the chores on a farm af- 
ford mothers the opportunity for necessary 
exercise." This is, of course, not factory 
work but there is much factory work less 
arduous than these domestic duties. In 
the iisual factory there are many occupa- 
tions which are less harmful than some 
housework;, at the same time, it is true 
that there are many processes not at all 
suited to the pregnant worker. On the 
whole, we can accept the principle laid 
down by De Lee (4) : "In a general way the 
gravida should not change her usual mode 
of life unless the physician knows that some 
of her habits are bad." 

Medical Examination. — All these opin- 
ions apply to the normal pregnant woman. 
The crux of the situation, then, is to 
determine whether the pregnant woman is 
normal and to keep a close watch over her, 
so that her work may be regulated to suit 
her limitations. If proper industrial medi- 
cal service is maintained, she should be en- 
couraged to consult the doctor as soon as 
pregnancy is susi>ected. If the doctor con- 
firms her suspicion, a thorough examina- 
tion should then be made. The industrial 
physician is usually not competent to carry 



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McCORD AND MINSTER — PREGNANT WOMAN IN INDUSTRY 45 



out a satisfactory obstetrical examination, 
nor is the average practitioner so qualified. 
Upon detection of pregnancy^ therefore, the 
worker should be referred to a suitable 
clinic or to an obstetrician. It is lumeces- 
sary to describe here the nature of the ex- 
aminations which should be made. After 
the initial examination, however, subse- 
quent examinations should be made when 
recommended by the obstetrician. At the 
very least, a complete examination should be 
made during theeighth month of pregnancy. 

Although the industrial physician may 
not be qualified to make specific obstetri- 
cal examinations, there are many other 
requirements for the general health of the 
pregnant woman which he can fulfil. For 
instance, one obstetrician emphasizes the 
necessity of watching the teeth and bony 
structures which are likely to be affected 
because of the alteration of the phosphates 
of these tissues. 

Full co-operation should exist between 
the plant physician or employment man- 
ager and the specialist. In this way only 
can the obstetrician know of the nature of 
the woman's work and thus be guided in 
his recommendations to the plant physician 
or employment manager. A great respon- 
sibility rests with the plant physician in 
his having a complete knowledge of trade 
processes, occupational and safety hazards, 
and suitable replacement jobs when they 
are necessary. Constant supervision should 
be exercised throughout by the plant phy- 
sician. In a particular munition factory in 
England during the war, the women re- 
ceived very careful supervision and a 
definite routine was adopted. Upon noti- 
fication of pregnancy the women were given 
suitable work, and as pregnancy progressed 
they were changed from time to time to 
work that was even better adapted to their 
needs. At the end of the seventh month, 
the pregnant woman was transferred to a 
particular room known as 'Hhe general 
clothing store and sewing depot." While 



she was at work in this room she was visited 
every week by a physician who examined a 
specimen of the urine and made other ex- 
aminations. The work was so arranged 
that the women could remain at work until 
just before parturition, without harm to 
themselves or to the work (5). 

Aeddent Risk. — By means of such care- 
ful supervision, the risk which an employer 
assumes in keeping a pregnant woman in 
his employ is reduced to a minimum. No 
statistics are obtainable as to the frequency 
of accidents among pregnant industrial 
workers. A knowledge of the physical al- 
teration and the mental preoccupation of 
the pregnant woman, however, makes ten- 
able the assertion that she is much more 
liable to industrial accident than the non- 
pregnant worker. Late in pregnancy loco- 
motion is hampered through the changed 
posture made necessary by her adjustment 
to her shifted center of gravity. This lean- 
ing backward not only alters locomotion but 
is likely to prevent her from seeing where 
she is stepping. Since accidents growing out 
of such circumstances commonly occur to 
the pregnant woman in her home, we may 
expect such mishaps as falling over obstruc- 
tions in passageways and downstairs to be 
no less common in the factory. Accidents of 
this kind frequently result in miscarriage. 
Consequently, the employer is incurring 
some liability in retaining in his employ 
women in an advanced stage of pregnancy. 

Abortion and miscarriage, it must be 
remembered, are more frequent during the 
early stage of pregnancy and are due most 
often to causes in no way connected with 
the work environment. In one factory 
where a study of pregnant women was 
made, among 101 pregnant women in nine 
months, there were fifteen miscarriages, 
thirteen of which were abortiojis occurring 
between the fifth and tenth weeks. Of the 
two miscarriages, one was caused by an 
operation for carcinoma of the cervix, and 
the other was due to syphilis contracted 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



during the sixth month of pregnancy. Of 
the thirteen abortions, one fell out of bed, 
one fell downstairs (the report does not 
state whether at home or in the factory), 
one had tuberculosis, and one had had pre- 
vious miscarriages. There are no facts as to 
the etiology of the other nine, but from these 
six it is apparent that the greater risk arises 
before the employer has been notified — that 
is, before pregnancy is definitely established. 

As is well known, carelessness is the great 
cause of accidents. Continual vigilance on 
the part of all workers is the best safety 
device. In the case of the pregnant worker, 
a concentration on her immediate work 
and its hazard is more difficult, because she 
is continually mulling over her abnormal 
relations with other people and the circum- 
stances attending her pregnancy and an- 
ticipated confinement. The recognition of 
the fact that the pregnant woman is an 
increased accident risk should npt lead to 
her elimination from the plant but rather 
to her placement in non-hazardous occupa- 
tions and to additional education in pre- 
cautionary measures. 

Harmful Occupations. — Throughout the 
discussion of what work is injurious to the 
piregnant woman, it must be remembered 
that any conditions which are bad for the 
normal woman worker are even worse for 
the pregnant worker. This statement ap- 
plies to the hours of employment as well as 
to general working conditions. If the work 
is wearing and the normal woman finds 
eight hours of work a strain, the pregnant 
woman should not be forced or allowed to 
work so long. The pregnant woman should 
never be allowed on a night shift. Night 
work generally means that the woman has 
so much to do at home in the daytime that 
she cannot go out to work. The pregnant 
woman cannot stand the strain of day work 
and night work in addition. There may 
even be certain times of the day when the 
pregnant woman cannot work because of 
her condition. For instance, if she suffers 



from morning nausea, she should be al- 
lowed to remain at home until such time in 
the day as she is able to take up her work. 

A knowledge of what constitutes harmful 
conditions must be based on the individual 
case, that is, the woman and her particular 
job. There are, however, some general 
principles which can help the physician in 
determining suitable and unsuitable jobs 
for the pregnant woman. 

Character of Work. — Generally speak- 
ing, any undue physical strain is bad for 

TABLE 3. — TYPES OP OGCtJPATION SHOWING 

TENDENCY TO PRODUCE BAD RESULTS 

AT PREGNANCY 



Type of Occupation 


Number of 
Women Em- 
ployed during 

Pregnancy 


"bad Cases 


Number 


Percent. 


Active 


213 
88 
30 


83 
23 

2 


390 


Sittinff 


26.1 


Standing 


6.0 







the pregnant woman. De Lee states that 
"jolts, running, sudden motions, lifting 
great weights, going up and down stairs 
quickly, etc., should be avoided." Dorland 
(6) states that "lifting of heavy weights, 
running upstairs and other violent forms 
of exercise must be strictly avoided lest 
miscarriage result." In an article in the 
Monthly Labor Review (7), there are re- 
ported five types of occupation which are 
harmful: (a) Continuous sitting has a bad 
eflfect at delivery as well as on the mother's 
health after confinement; (6) standing con- 
tinuously is less harmful except that it 
tends to induce varicose veins; (c) lifting, 
reaching, and stretching up are universally 
bad during pregnancy; {d) jolting is bad, 
and also {e) work to which muscles are 
not accustomed. 

In Table 3 figures are given which bear 
out this statement of the evil effects of ac- 
tive occupations, sitting occupations, and 
standing occupations on the pregnant 
woman. Bad cases are those which had 
difficulty in some form or other before or at 



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McCORD AND MINSTER — PREGNANT WOMAN IN INDUSTRY 47 



the time of confinement. What the active 
occupations comprise is not stated but it 

> may be assumed that lifting, reaching, and 
jolting are included. The percentage of 
bad cases is remarkably high in this group 
and, indeed, is very little lower in the sitting 
occupations. Although the figures show the 
standing occupations to be far less harmful 
than the other types of work, it must be 
remembered that only thirty women are 
considered — almost too low a number to 
be decisive. In a report on the Proposed 
Employment of Wom£n during the War in 
Industries of Niagara Falls (8) certain con- 
ditions of work were specified which were 
more harmful to women, particularly in re- 
gard to their child-bearing function, than 
to men. Once again reference is made to 
lifting heavy weights, unusual stretching or 
straining, but more especially to contin- 
uous standing, as bad for women because of 
the diflference in their body structure, in 
other words, the structure of their repro- 
ductive organs. If continuous standing is 
noticeably harmful for women in general on 
this account, how much more harmful is it 
for pregnant women in particular, who 
have an additional strain on these organs. 
Indeed, there can be no question that con- 
tinuous standing is as hannf ul for pregnant 
women as any other of the specified forms 
of physical exertion. 

The character of the work may involve 
a nervous strain a^ well as a physical 
strain. The mental attitude of the preg- 
nant woman which causes her distraction, 
referred to above, is due to the fact that her 
whole nervous system is abnormal. She is 
morbid, sensitive, and at times hysterical. 
For this reason any imdue strain on her 
nervous system is felt more than if she 
were normal. Monotony, speeding up, 

* noise, vibration, a high degree of concen- 
tration, all cause a strain on the nervous 
system of the pregnant woman, which 
ought to be avoided. 

Analysis of Work. — Keeping these gen- 



eral principles in mindi, the industrial phy- 
sician or the employment manager must set 
about analyzing his particular industry. 
He should examine each process at which 
women are employed, with a view to deter- 
mining whether the worker is subjected to 
any of the strains enumerated above. 

Si>ecific recommendations in regard to 
occupations to be avoided by women were 
made in the survey of work at Niagara 
Falls. The Woman in Industry Service of 
the Department of Labor demanded the 
prohibition of the employment of women in 
(a) shoveling or wheel barrow work, (6) 
yard work, (c) loading or unloading freight 
cars, {d) lifting weights over 25 pounds. 
The first three types of work are obviously 
harmful but they serve to show a specific 
analysis of an industry. The fourth is of 
especial interest because it established a 
maximiun lifting weight. The permitted 
weight is probably excessive and admittedly 
applies only to some women, and must be 
only an occasional process, not a continuous 
one. The recommendations of the Woman in 
Industry Service were made with reference 
to all women but they may be used as a 
gauge in the case of the pregnajit woman. 

Of more definite value in this regard is 
the survey of the textile industry (9). It 
was found that the mortality rate from 
puerperal infections and childbirth is higher 
in textile towns than in non-textile towns 
where there are not nearly so many married 
women employed. The U. S. Bureau of 
Labor Statistics made an investigation of 
preventable deaths in the cotton manu- 
facturing industry, process by process. In 
the card room the work involves lifting bob- 
bins weighing from 2 to 4 poimds each, and 
placing them on frames 5 to 6 feet high. 
This involves lifting and stretching — two 
of the physical strains to be avoided. The 
eflfect which this work has upon the married 
woman and consequently upon the preg- 
nant woman is very evident when the 
statistics of deaths from various causes ac- 



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cording to conjugal state are examined. 
The deaths from tuberculosis among un- 
married card room workers exceeded those 
of unmarried non-operatives by 93 per 
cent.; the deaths of married card room 
workers exceeded those of married non- 
operatives by 323 p^r cent. The deaths 
of unmarried operatives from non-tuber- 
culous causes exceeded those of married 
non-operatives by 81 per cent. The report 
states that the high death rate of married 
operatives is influenced by the continued 
lifting of bobbins and placing them on 
frames above their heads. This process 
"may quite probably constitute a contrib- 
utory cause of death from prematurely 
terminated pregnancy and from child- 
birth.'' In the spinning room, where the 
work demands constant walking or stand- 
ing in a hot, moist atmosphere^ the per- 
centage of deaths of married operatives 
between the ages of 15 and 44 years from 
causes other than tuberculosis — parturi- 
tion fatalities — is highest. The deaths 
from parturition niunber twenty-eight for 
operatives in this department as against 
five for non-operatives; or the death rate 
per 1,000 from this cause is 4.72 for opera- 
tives as against 0.53 for non-operatives. In 
the weave room, where the women do much 
bending over looms and generally carry the 
cloth weighing from 15 to 18 pounds to the 
scales, the death rate among the married 
women is very high. 

In Table 4 the excess of deaths among 
married operatives over those among mar- 
ried non-operatives is appalling. The re- 
port throws some light on the cause of 
this excess in the following statement: "It 
will readily . be appreciated how much 
fatigue such lifting (15-18 pounds) induces 
and how great is the danger to the expect- 
ant mother, especially during the last half 
of her pregnancy." In the spooler room 
the physical strain resembles that of the 
weave room. There is a great excess of 
deaths of married women over those of 



single women, due almost entirely to partu- 
rition fatalities. The deaths among married 
operatives exceed those of married non- 
operatives from non-tuberculous causes. 

The number of deaths among married 
women operatives in each room was shown 

TABLE 4. — PERCENTAGE BY WHICH DEATH 

RATES OF FEMALE WEAVERS EXCEEDED 

(+) OR FELL BELOW (-) RATES FOR 

FEMALE NON-OPERATIVES 



Conjugal SUte 



Single. . . 
Married. 



Cause of Death 



Tuberculous 



- 5 

+226 



Non- 
Tuberculous 



+ 7 
+160 



to be markedly higher than that of either 
single women operatives or married non- 
operatives. The deaths from parturition 
causes followed this general trend without 
exception. Further figures for the cotton 
industry as a whole show that many deaths 
which were classified as "Tuberculous" 
were "Parturition Complicated." (See 
Table 5.) The character of the work, as it 
is described, can without doubt be held re- 
sponsible for this high mortality. Figures 
for the industry as a whole showing the 
deaths from parturition for operatives and 

TABLE 5. — TUBERCULOUS DEATHS AND DEATH 
RATES PER 1,000 AMONG MARRIED FEMALES 
(16-44 YEARS) BY CAUSE AND OCCUPATIONAL 
GROUP 





Number of Deaths 


Death Rate per 1.000 


Occupational 
Group 


|i 


ParturiUon 
0>inpticated 


Total 


ill 


:|| 




Num- 
ber 


Per 

Cent. 


Total 


Operatives.. . . 
Non-operatives 


88 

77 


37 
19 


30 
20 


125 
96 


3.56 
1.06 


2.0 
0.36 


5.56 
1.42 



non-operatives bear out this conclusion. 
Between the ages of 15 and 24. the death 
hazard complicated with parturition is 
seven times as great for operatives as for 
non-operatives; between the ages of 25 and 
34, the death hazard is three times as great; 
and between the ages of 35 and 44, the death 



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McCORD AND MINSTER— PREGNANT WOMAN IN INDUSTRY 49 



hazard is equal. The condusion of the 
whole report is that "employment in cotton 
mills for mothers of child-bearing age is 
generally inimical to longevity of mothers." 

It must be remembered that this report 
contemplates only the deaths in the cotton 
industry. How many women and how 
many children have been definitely harmed 
but not killed by the employment of 
women during pregnancy was not investi- 
gated. This survey should stimulate addi- 
tional inquiries into the cotton industry 
and into every other industry employing 
women, with a view to bringing to light 
similar race hazards. 

The general conditions in industry, 
which we have discussed, do not constitute 
the only hazards to the pregnant woman. 
There are many industries which utilize sub- 
stances which in themselves are harmful. 
These substances are commonly classed 
as harmful to women in general and are, 
therefore, more especially injurious to the 
pregnant woman. On this account, many 
of the following occupations are prohibited 
to women (10) both in this country and in 
certain foreign coimtries: (1) the making 
of electric accumulators; (2) manufacture 
of paints, varnishes, and colors; (3) brass 
casting, zinc and lead smelting; (4) certain 
processes of glass manufacturing; (5) the 
manufacture of high explosives (previous 
to the war); (6) the curing and tanning of 
skins and hides. In France, lace bleaching 
with white lead, sharpening or polishing of 
metals, and coating mirrors with quick- 
silver are among the many occupations 
prohibited. All the countries prohibit the 
employment of women in any lead indus- 
try. The majority of occupations forbidden 
to women involve the presence of dust, 
fumes, vapors, gases or substances of a 
poisonous character. There are many more 
industries which could properly be included 
in this list, especially when they are con- 
sidered specifically with regard to the preg- 
nant woman; i. e., such industries as the 



manufacture of cordage and twine, enam- 
eling, the rubber industry, and pearl button 
manufacture. 

In a series of articles. Dr. Alice Hamil- 
ton (11) has described the occupational 
effects of many chemicals used in industry. 
There are many which are especially harm- 
ful to the pregnant woman, such as bcH- 
zene, used principally in the manufacture of 
rubber, in paint and varnish removers, in 
making aniline dyes; nitrobenzene, used in 
cleaning establishments; aniline, employed 
in the manufacture of dyes, rubber, and 
black paints, and in printing trades, etc.; 
arsenic, used in a large munber of indus- 
tries, such as in the manufacture of in- 
secticides. Any substance affecting the 
kidneys is particularly dangerous for the 
pregnant woman because of the already 
overburdened renal fimctions at this time. 
The poisoning which results from the use of 
mercury, in processes such as silvering of 
mirrors, making of incandescent lamps, and 
felt hat manufacture, is especially prone to 
affect the pregnant woman. Carbon mon- 
oxide poisoning, which is one of the most 
commonly encoimtered industrial intoxica- 
tions, is a hazard in many laundries, in 
tailoring trades and in bakeries, where gas 
burners are used. When this gas is inhaled 
in only moderately large quantities it has 
distinctly deleterious effects both on the 
normal and the gravid woman. 

The lead industry seems to be the most 
hazardous industry for the pregnant 
woman. Lead poisoning takes many forms, 
for women its most disastrous effect being 
on the generative organs. In her report on 
Women in the Lead Industries (12), Dr, 
Alice Hamilton states that "women who 
suffer from lead poisoning are more likely 
to be sterile or to have miscarriages and 
stillbirths than are women not exposed to 
lead. If they bear living children, these are 
more likely to die during the first year of 
life than are the children of women who 
have never been exposed to lead. This 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



means that lead is a race poison/* Dr. 
Hamilton cites the following statif^ics 
from the report of the British factory in- 
spector for 1897 as striking proof of this 
fact : Out of 62 women who were pregnant, 
16 never bore a living child. There were 
212 pregnancies among these 62 women, 
but only 61 living children resulted; the 
stillbirths numbered 21; the miscarriages, 
90. There are many available proofs of the 
danger to pregnant women from employ- 
ment in occupations that bring them in 
contact with lea^, and many obscure in- 
stances of lead poisoning in addition to the 
well-known cases. For instance, com- 
mercial artists or retouchers use a great 
deal of white lead, thinking that it is zinc. 
Lithotransfer work consists of preparing 
transfer papers with lead colors. There are 
manymoresuch industries wherelead poison- 
ing is common, though seldom recognized. 

Summary 

1. The pregnant woman is better off in 
the normal home environment than at work 
in a factory. 



2. With proper supervision, however, it 
will not be harmfid for the normal preg- 
nant woman to work, if work is an economic 
necessity for her. 

3. All pregnant working women shoidd 
receive careful medical and vocational 
supervision. 

4. The abnormal pregnant woman should 
discontinue work, and shoidd resume it only 
on the advice of a competent physician. 

5. The pregnant woman is an increased 
accident risk for the manufacturer. By 
means of careful supervision, however, this 
risk may be reduced to a minimimi. 

6. Any occupation that is harmful to the 
general woman worker is of greater harm to 
the pregnant worker. 

7. The following types of occupations 
are harmful: (a) continuous sitting; (6) 
continuous standing; (c) repeated lifting, 
reaching, stretching; (d) jolting; (e) any 
work requiring new muscle adaptations. 

8. Certain specific occupations are dis- 
tinctly harmful to pregnancy and to child- 
bearing functions. Lead trades constitute 
the outstanding example of this group. 



BIBLIOGRAPHY 



1. Harris, H. J.: Maternity Benefit Systems in 
Certain Foreign Countries. U. S. Bur. Labor 
Statis., Children's Bur. Pub. No. 57, 1919. 

2. Jones, H. R.: On the Protection of the Health 
of Female Workers, with Special Reference to 
Pregnancy and Wet Nursing. Jour. San. Inst., 
1894-1895, 15, 515. 

S. Paradise: Maternity Care in a Homesteading 
County in Montana. U. S. Dept. Labor, Bull. 
84, 1919, p. 53. 

4. De Lee, J. B.: The Principles and Practice of 
Obstetrics. Philadelphia, 1913. 

5. Adamson,R.H.B., and Palmer-Jones, H.: The 
Work of a Department for Employing Expect- 
ant Mothers in a Munition Factory. Brit. Med. 
Jour., 1918, 2, 309. 

6. Dorland: Modem Obstetrics, General and 
Operative. 2d Edition, Philadelphia and Lon- 
don, 1901. 

7. Effect of Industrial Employment of Women 



upon Maternity. U. S. Bur. Labor Statis., 
Month. Labor Rev., 1918, 7, 1344. 

8. Proposed Employment of Women during the 
War in Industries of Niagara Falls, N. Y. U. S. 
Bur. Labor SUtis., Month. Labor Rev., 1919, 8, 
^1. 

9. Perry, A. R.: Preventable Death in the Cotton 
Manufacturing Industry. U. S. Bur. Labor 
Stalis., Bull. 251, 1919. 

10. Andrews, I. O.: The Protection and Promotion 
of the Health of Women Wage Earners. Kober 
and Hanson's Diseases of Occupation and Voca- 
tional Hygiene. Philadelphia, P. Blakiston's 
Son and Company, 1916, p. 834. 

11. Hamilton, A.: Industrial Poisoning by Com- 
pounds of the Aromatic Series.. Jour. Indust. 
Hyq., 1919-1920, 1, 200. Inorganic Poisons, 
Other than Lead, in American Industries. 
Ibid,, 89. 

12. Hamilton, A.: Women in the Lead Industries. 
U. S. Bur. Labor Statis., Bull. 253, 1919. 



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A METHOD FOR DETERMINING THE FINER DUST 
PARTICLES IN AIR* 

A. L. MEYER, M.D. 

Associate in Physioloffical Hygiene, School of Hygiene and Public Health, The Johns Hopkins Unioersiiy 



IT is well known that a suspension may 
be removed from air by bringing the air 
in contact with water. The more intimate 
and prolonged the contact, the more effi- 
cient will be the removal. One of the 
simplest means of effecting such an inti- 
mate mixture, for purposes of dust anal- 
ysis, is to introduce a small volume of air 
into a syringe containing some water. The 
syringe may then be shaken vigorously and 
a very thorough mixture of air and water 
accomplished. If a drop of the water be 
examined with the microscope by ordinary 
illumination, very few particles, if any, will 
be seen; by oblique illumination, however, 
the minute matter scintillates in the field 
and may readily be coimted. This con- 
stitutes, in brief, the principles of the 
method presented in this paper, a method 
that is concerned chiefly with the minute 
particles. 

In E. V. Hill's method (1) the air is drawn through 
the narrow nozzle of a capsule attached to a metal 
syringe; whereupon some of the particles impinge 
upon a small glass slip covered with a thin layer of a 
transparent adhesive mixture. A variable percentage 
of particles is actually caught, owing partly to the 
fact that the particles differ in inertia. The greater 
the inertia, the greater the likelihood of their being 
directed against the adhesive surface. Because of 
this property of inertia, the rate with which the 
piston of the syringe is withdrawn will influence the 
result. The count is made with ordinary illumina- 
tion. 

Palmer's method (2) consists in the filtration of 
air by means of the water-spray; but here again the 
removal is far from complete. Katz, Longfellow, and 
Fieldner (3) find that the Palmer apparatus retains 
about 45 per cent, by weight of air-floated silica and 
18 per cent, of tobacco smoke as measured by the 
T^dall ^ect. The air passing at the rate of 4 cubic 

* Received for publication March 2, 1021. 



feet per minute is in contact with the water but a 
very short time. 

Aitken devised a method for the estimation of at- 
mospheric dust (4) based on the principle that the 
dust particles serve as nuclei for the condensation of 
water-vapor. In this case all particles, even the 
minutest or those of an ionic nature, are included in 
the precipitation and share in the count. The 
watery envelope makes any determination of size 
diflicult. The coalescence and evaporation of drop- 
lets may easily give rise to erroneous counts. It is a 
method requiring extraordinary care and skill. 

Bill's electric precipitation method (5) is in proc- 
ess of development. The removal of dust particles 
appeared to be greater than in Palmer's method but 
in its present form it is unsuitable for field work. In 
this method, as in Aitken's, all particles of whatever 
size tend to undergo precipitation. The determina- 
tion is gravimetric. 

Procedure 

A Luer syringe graduated to 100 c. c. but 
having a capacity of about 160 c. c. is 
thoroughly cleaned with soap and water 
and alcohol to remove all grease. It is then 
rinsed with freshly distilled water and 
filled with distilled water free from air 
bubbles^ After forcing out all the water, 
20 c. 0. of distilled water are taken into the 
syringe from an Erlenmeyer flask provided 
with a cotton- wool filter (Figure 1). The 
syringe is now ready for the air sample. 
The piston is withdrawn suflBciently to ad- 
mit approximately 100 c. c. The exact vol- 
ume may be read from the graduation. 
While placing the finger tightly against the 
nozzle, a piece of rubber membrane inter- 
vening, the syringe is shaken vigorously for 
one minute with an up and down motion. 
With the syringe in a vertical position the 
water is brought up to the very tip of the 
nozzle and then withdrawn slightly to 



51 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



admit a small bubble of air. This manipu- 
lation is intended to catch the particles 
adherent in the narrow portion of the nozzle 
and bring them into suspension. 

The next step consists in allowing a drop 
to flow from the syringe into the chamber 




mination. It is well to have on hand several 
handkerchiefs of pure linen that have been 
washed several times. Lens paper is useless. 
The ruled surface is thoroughly rubbed 
with the thumb, under a tap of warm water, 
and finally rinsed for a moment in hot 
water. It is then placed upon the table and 
rubbed to dryness with linen wrapped 
smoothly and tightly about the forefinger, 
the latter being applied with considerable 




Fig. 1. — 1. Erlenmeyer flask. 2. Glass tube. 3. Glas^ 
tube containing cotton-wool. 4. Rubber tubing. 5. Pure 
gum connecting piece. 6. Luer syflnge. 7. Metallic con- 
necting piece. 

of a Levy blood counter. This is best done 
with the metal c«mecting piece on the 
nozzle. The particles are counted by 
oblique illumination. The results reported 
in this paper were obtained with the No. 3 
objective of a Leitz Bucroscop>e with a cir- 
cular piece of blue glass below the Abbe 
condenser. A 75-watt Mazda daylight 
lamp was placed in front of the mirror, a 
jar of water intervening to absorb the heat 
rays. Both lamp and jar were covered 
with an asbestos hoodU 

It will require patMft practice in the be- 
ginning to free the rated surface and cover 
of the Levy chamber of dust particles. A 
surface sufficiently dmn for ordinary illu- 
mination will not do at all for oblique illu- 



pressure. The slide should be examined 
with the microscope for cleanliness and 
then, with ruled surface down, supported on 

a tin I |-shaped holder and covered with a 

shallow dish until the cover-slip is cleaned. 
If the sample is taken some distance from 
the laboratory the syringe may be filled in 
the laboratory and the piston fixed in posi- 
tion by attaching a short length of glass rod 
to the nozzle by means of black gum tubing 
free from powder. After the sample has 
been taken, it remains in the syringe with 
the piston fixed. This permits another 
thorough mixture on reaching the labora- 
tory. The entire number of particles in 
two fields, each a square millimeter, are 
coimted. The average of these two coimts 
is used in the calculation. Those fields are 
selected which are divided into sixteen 
smaller areas, each a sixteenth of a square 
millimeter. The particles must be allowed 
to settle before the count is made. 

A Modification of the Forbgoing 
Procedure 

A few determinations have been made 
with a modification of the above method, 
somewhat more complicated, but based on 
exactly the same principle. In this paper 
the steps will be merely indicated. 



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MEYER — DETERMINATION OF FINER DUST PARTICLES IN AIR 53 



A test tube of 150 c. c. capacity, provided 
with a glass stopper perforated by two glass 
tubes, one of which extends to the bottom, 
is filled with distilled water. A filter (Fig- 



Results 

Before proceeding with the actual deter- 
mination of particles present in air, it ap- 



ure 2) is connected with the short tube, peared desirable to test the consistency of 
The syringe being attached to the long the method with a prepared suspension of 




Fig. St. — 1. FUter containing cotton-wool. 2. Test 
tube provided with glass stopper perforated by two glass 
tubes. S and 4. Pu^e gum connecting pieces. 5. Luer 
syringe. 



tube, the contents of the test tube are 
emptied to the 30 c. c. mark. The test tube 
now contains filtered air and 30 c. c. of dis- 
tilled water. An air sample may be taken 
by removing the filter and connecting the 
short tube with the syringe. After vigor- 
ously shaking the test tube, the syringe is 
again connected with the long tube for the 
purpose of bringing into suspension all par- 
ticles adherent in the long tube. This is 
done by moving the piston back and forth 
a short distance. Finally, a portion of the 
water is allowed to remain in the syringe so 
that a drop may be transferred to the 
counting chamber. 




kaolin and another of smoke. It was con- 
ceivable that in transferring a drop of water 
certain factors, such as surface tension, 
might so alter the distribution of the par- 
ticles as to render the counts very irregular. 
Accordingly, a small quantity of kaolin was 
placed in a beaker with water and stirred. 
The coarser particles were allowed to settle 
and the sui>ematant suspension decanted. 
The smoke suspension was prepared by 
blowing a little tobacco smoke into a flask 
containing water. After shaking the flask, 
the contents were p)oured into another 
flask and protected from the room dust. 
The results were suflBciently consistent and 
clearly indicated that no factors operate to 
introduce serious irregularity in this part of 
the procedure. 

Counts made with distilled water alone 
— not prepared with unusual care — 
showed an average number of particles per 
square millimeter of 12 ± 2. This figure is 
used as a correction in calculating the nmn- 
ber «f particles per unit volume of air. The 
distilled water is not entirely responsible for 
this count; some particles unavoidably re- 
main on the ruled surface during the clean- 
ing process. 

The results of the determinations of the 
dust content of outdoor air and laboratory 
air appear in Table 1. The outdoor samples 
were obtained in a street comparatively 
free of traffic; those of indoor air were 
taken in one of the rooms of the laboratory 



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TABLE 1. — DUST PARTICLES IN THE AIR 



Date 



Source of Sample 



Number 
of Sample 



Sue of 

Saoaple 

(cc) 



Time 



Coimt per Sq. Bfm. 



FSeM 



8d 
Field 



Difference 


ATerage 


6 


81 


10 


45 


% 


80 


12 


44 


7 


57 


1 


55 


1 


52 


5 


86 


6 


56 


8 


52 


10 


48 


2 


57 


4 


66 


1 


44 


8 


20 


12 


45 





81 


7 


20 


19 


57 


11 


98 


5 


98 


2 


40 


'8 


87 


2 


85 


8 


69 


6 


70 


6 


65 





60 


18 


62 


1 


65 


10 


48 


4 


54 


8 


66 


10 


56 


18 


61 


12 


43 


14 


88 


8 


9» 


2 • 


84 



Pwticlee 
percc 



October 80. 
November 1. 

November 8. 
November 4, 

November 5 
November 8 



January 5. 



October 28. 



November 9. 



outdoors 



laboratory 



November 10 
December 28 

December 81 

January 4 



closed cabinet 



1 
2 

1 
2 
8 
1 
2 
1 
2 
8 
1 
2 
1 
2 
8 
4 
5 
6 
1 
2 
8 

1 
2 
8 
1 
2 
8 
4 
5 
6 
1 
2 
1 
2 
8 
1 
2 

1 

2 



108 
202 
202 
806 
405 
205 
207 
102 
202 
205 
205 
802 
806 
203 
101 
205 
100 
102 
102 
202 
207 

105 

102 

102' 

204 

202 

202 

202 

204 

202 

205 

206 

206 

206 

205 

102 

102 

102 
101 



10:80 

11:10 

1:80 

2K)5 

8:50 

9:45 

11 KK) 

10:80 

11:40 

4:40 

1:42 

2:50 

10:80 

11:50 

1:25 

2:40 

8:50 

4:80 

^'M 

9:42 

,9:47 

10:45 

11:80 

IKM) 

10:80 

11:09 

1:15 

2:20 

8:00 

3-.50 

10:05 

IKK) 

IKK) 

2:20 

8:85 

10:45 

11:15 

1:10 
2.-05 



84 
40 
81 
88 
6^ 
55 
52 
88 
59 
50 
48 
58 
64 
48 
27 
89 
81 
25 
47 
92 
96 

41 
88 
84 
67 
78 
68 
60 
71 
64 
5S 
56 
62 
61 
67 
87 
45 

81 
S9 



28 
50 
29 
50 
60 
54 
51 
88 
59 
5S 
59 
56 
68 
44 
80 
51 
81 
82 
68 
108 
101 

89 
35 
86 
70 
67 
62 
60 
58 
65 
43 
52 
70 
51 
54 
49 
81 

84 
35 



86,800 
82,600 
17,800 
20,900 
22,200 
41,900 
88,600 
47,000 
43,500 
89,000 
85,000 
29,500 
85,200 
81,500 
83,600 
82,100 
88,000 
88,800 
88,200 
85,100 
82,600 

58,800 
49,000 
45,000 
55,800 
57,400 
52,400 
47,500 
50,000 
52,400 
85,100 
40,700 
52,400 
42,700 
47,800 
60,700 
50,900 

41,100 
48,500 



in which there was generally but one oc- 
cupant. If the dust content of the air were 
absolutely constant, our method would not 
permit us to expect a better agreement 
than the figures in the table actually show. 
With one or two exceptions, the average 
deviation of the number of dust particles 
per cubic caitimeter of air is not more than 
db 4,000 for 100 cc. samples, nor more than 



±2,000 for 200 c. c. samples. The deriva- 
tion of these figures will readily be xmder- 
stood upon recalling that the average count 
for distilled water is 12 ±2. Owing to the 
small number of samples in most of the 
series, there is no significance in the fact 
that in one or two instances the above 
limits are slightly exceeded. 
The residts in the table, therefore, mean 



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MEYER — DETERMINATION OF FINER DUST PARTICLES IN AIR 66 



that the amount of dust present in the air 
on any single day was, in general, practi- 
cally constant iinder the conditions that 
prevailed when the samples were taken. 
When one bears in mind the errors incident 
to enimieration and the possibility of cer- 
tain influences disturbing the dust content 
of the air, the agreement is remarkable. 
There is a variation from day to day and 
the figures for indoor air are on the whole 
higher than those for outdoor air, although 
they are not strictly comparable, having 
been obtained on different days. On the 
morning of January 5, the atmosphere was 
imusually smoky and the coimts are cor- 
respondingly high. The samples of air 
from a closed cabinet free from disturbing 
influences are practically identical in their 
dust content. 

Discussion 

Before the method was actually tested, it 
seemed doubtfid whether one could hope 
for consistent results, partly because of the 
possibiUty of the inclusion of particles be- 
tween the barrel and piston of the syringe 
and partly because of the exposure of the 
piston to the dust particles of the air. But 
experience showed that it makes no dif- 
ference whether samples of 100, 200, or 
300 c. c. are taken; in other words, whether 
the piston is withdrawn once, twice, or 
three times. These factors, then, if they 
operate, do not endanger the usefulness of 
the method. In the modified form of the 
method any error from this source would 
disappear. 

One minute's shaking is sufficient to 
bring the particles into aqueous suspen- 
sion. A more prolonged shaking does not 
increase the count. This is exactly what 
one woidd anticipate from the work of 
Katz, Longfellow, and Fieldner (3) who 
find that Palmer's apparatus in which the 



air is in contact with the water for a very 
brief interval retains 13 per cent, of smoke. 

The same objection applies to this 
method as applies to all methods in which 
water is used as a medium. Water-soluble 
particles will not be included in the coimt. 
In many cases, however, particles lost in 
solution may be determined by chemical 
methods. Bill (5) points out that the par- 
ticulate matter in the Palmer suspensions 
shows a tendency to form small masses or 
clumps. The minute particles in my own 
suspensions have not shown any agglomera- 
tion. Counts made of suspensions that 
were allowed to stand for nearly two hours 
were practically as high as those made in 
the beginning. 

In routine work, such as the examination 
of air in factories, where several samples 
taken at short intervals are desired, the 
contents of the syringe may be emptied 
into small 25 c.c. Erlenmeyer flasks and 
covered with rubber membrane secured by 
an elastic band. In the modified form of 
the method, a series of test tubes each 
provided with a glass stopper perforated 
by two glass tubes (Figure 2) may be em- 
ployed. 

Conclusion 

1. A method has been presented in the 
foregoing pages, based on the enumeration, 
by oblique illimiination, of minute particles 
in a sample of air brought into aqueous 
suspension by shaking the sample with 
water. 

2. Success in the use of the method de- 
mands strict attention to cleanliness. 

3. The method requires but a very small 
sample of air and yields consistent results. 

4. The method ought to be especially 
suitable for the determination of smoke 
particles and should also prove useful in 
determining the efficiency of air-filtering 
devices in ventilation systems. 



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66 THE JOURNAL OF INDUSTRIAL HYGIENE 

BIBLIOGRAPHY 

1. Hill, £. v.: Quantitative Detennination of Air Determining Dust in Air. Jour. Indust. Htg., 
Dust. Heating and Ventilating Magazine, 1917, 1920-1921, 2, 167. 

14, 2S. 4. Aitken, J.: On the Number of Dust Particles in 

2. Palmer, G. T.: A New Sampling Apparatus for the Atmosphere. Trans. Roy. Soc. £din., 1889, 
the Determination of Atrial Dust. Am. Jour. 35, 1. 

Pub. Health, 1916, 6, 54. 5. Bill, J. P.: The Electrostatic Method of Dust 

S. Katz, S. H., Longfellow, £. S., and Fieldner, Collection as Applied to the Sanitary Analysis 

A. C: EflSciency of the Palmer Apparatus for of Air. Jour. Indust. Hyo., 1919-1920, 1, 323. 



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ANILINE POISONING IN THE RUBBER INDUSTRY' 



PAUL A. DAVIS, M.D. 

Akron, Ohio 



ANILINE (CcHsNHa), a primary amide 
±\^ of benzol, is a colorless, volatile oil 
which, when exposed to air and light, is 
very unstable, and rapidly changes in color 
to dark brown and even to black, leaving a 
residue. It can be produced in several ways 
but the most common commercial method 
is by the action of hydrochloric acid and 
iron filings on pure nitrobenzol (CeHsNOi). 
It is used principally in the manufacture of 
aniline dyes, photographic materials, rub- 
ber comiK)unds, and shoe polishes. 

The aniline of commerce is contaminated 
by very small to large amounts of nitro- 
benzol, dimethylaniline, and its nitroso 
bodies, all of which have a predilection for 
action on the blood and nervous system, 
similar to all homologous derivatives of 
benzol. Von Jaksch (1) claims that, as far 
as records show, pure aniline does not pro- 
duce poisoning, but that it is the mixture of 
amidobenzene, meta-toluidine, para-tolui- 
dine and ortho-toluidine and xylidine 
which is poisonous. It is the experience of 
Dr. Alice Hamilton (2), however, that 
"chemically pure aniline produces all the 
symptoms and blood changes characteristic 
of industrial anihsm." The experiments of 
K. B. Lehmanh show that pure aniline is 
very toxic in even smaller quantities than 
carbon disulphide, toxic symptoms follow- 
ing the inhalation of 0.1 to 0.25 gm. of 
aniline, while it takes from 1 to 1.1 gm. of 
carbon disulphide to produce symptoms of 
poisoning. 

Methods of Absorption 

The poison may enter the body through 
the skin, the respiratory tract, the alimen- 
tary tract, and through a combination of 

♦ BeceiTed for publication Dec. SI, 1920. 



these three ways. Aniline oil is readily 
absorbed by the skin, and in a very short 
time produces marked symptoms. One 
case is recorded in which death .resulted 
from poisoning due to absorption through 
the skin of the feet from a pair of shoes 
which had been colored with aniline dye 
and had been put on before the dye was 
dry. A large proportion of the cases which 
I have seen have developed their symptoms 
from skin absorption. 

Respiratory absorption is also very com- 
mon. Individuals working in aniline or any 
of its derivatives in rooms where the venti- 
lation is poor and the aniline bodies are 
subject to heat develop typical aniline 
symptoms after varying periods of time, 
depending on the concentration of the 
gaseous substance. Absorption through 
the alimentary system is the smallest fac- 
tor in producing symptoms of aniline poi- 
soning and one which can be controlled 
largely by education and instruction con- 
cerning the necessity for cleanliness during 
eating and drinking. The most serious re- 
sults and the most acute symptoms are 
produced by a combination of all three 
methods of absorption. 

Clinical Picture 

Symptoms. — The characteristic symp- 
toms of aniline poisoning in the order of 
their appearance as observed in many 
cases are: slight insomnia or drowsy feel- 
ing; neurovascular symptoms, such as 
flushed face, weariness and mental uncer- 
tainty in extreme cases, and sometimes an 
irritable disposition; headache, dizziness 
and nausea; beginning cyanosis, chilliness 
and a sensation of cold; pulse, rapid and 
weak, gradually becoming slower with de- 



57 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



creased blood pressure; loss of appetite, in- 
digestion; irregular respiration; dryness 
and choking sensation in the thipoat, burn- 
ing and stinging sensation of the eyelids; 
joint pains, muscle pains; spots before the 
eyes; hematuria in rare cases; painful urina- 
tion in extreme cases, and hyperacidity; 
con^ipation or diarrhea; skin eruptions, 
macular in rare cases; difficulty in talking, 
accompanied by loss of memory; very deep 
cyanosis followed by unconsciousness; and 
in rare cases, hemoptysis. Each patient 
does not, of course, present all symptoms, 
but he may have had them at some time. 
The marked pallor of the skin, cyanosis of 
the lips, and a history* of work in" aniline, 
together with a characteristic odor of atii- 
line which is usually present, should re- 
move any doubt about the diagnosis. 

There is a dass of men who work in ani- 
line who seem to acquire a tolerance for the 
substance, in that they remain cyanotic 
for years without the development of any 
apparent, seribus symptoms. Through a 
change of work, however, such mild symp- 
toms as do appear clear up, the blood and 
urine return to normal, and we diagnose 
the cases as chronic. These patients have 
some blood changes, of course, yet they 
feel no ill effects except for a sUght tired 
feeling at the end of a day's work. The 
body attempts to maintain an equilibrium 
between intake and output of aniline, but 
there is a surplus amoimt which is ab- 
sorbed and which causes blood changes 
that are responsible for the marked cyan- 
otic condition. 

Laboratory Findings. — The blood 
changes consist principally in the forma- 
tion of methemoglobin and a coincident 
decrease in hemoglobin, with resulting de- 
ficient oxygen supply to the tissues. There 
is also a decrease in the number of red 
blood cells, with anisocytosis and poikilo- 
cytosis, and in very acute cases there may 
be a sUght leukocytosis and basophilic de- 
generation df the red cells. After the 



removal of the patient from contact with 
aniline or its derivatives, the leukocyte 
count returns to normal and in some cases 
even a slight leukopenia is found. There 
frequently occurs a diminution of poly- 
morphonuclears with- a cbrresponding in- 
crease in small lymphocytes, and a slight 
eosinophiUa. 

In very severe cases of poisoning, some 
embryonic forms of red cells appear, the 
hemoglobin (SahU's method) is decreased, 
and there is considerable formation of 
blood dust. Tallqvist's scale cannot be 
used with any success, for as soon as the 
methemoglobin is exposed, the color is 
changed. In the advanced cases, the co- 
agulability and the viscosity of the blood 
are diminished. 

After examining over 100 urines from 
cases ranging from those with marked 
beginning symptoms to those with per- 
sistent symptoms, I am of the opinion that 
no definite rule for urinary findings can be 
formulated, except that in the most severe 
cases, if large quantities of urine are tested, 
there can be found traces of hematin, pre- 
sumably due to blood cell destruction. The 
following is a summary of the urinary find- 
ings from the cases which I have examined: 
specific gravity, 1.005 to 1.030; reaction, 
usually acid, a large amount of uric acid 
being present; albumin, negative, except in 
cases where extreme anemia had residted; 
sugar, negative; aniline or aniline radicals, 
negative; phenol, negative; acetone, nega- 
tive; diacetic acid, negative, except in 
severe cases. Nearly all cases showed 
traces of hematin when twenty-four-hour 
specimens were evaporated. 

Microscopic exanunation generally re- 
vealed large quantities of uric acid crystals, 
urates, and oxalates. One case showed 
marked kidney involvement. It could not, 
however, be proved that this was caused by 
aniline, as this man's condition before he 
went to work in aniline was not known. In 
one case the urine was cloudy and, on mi- 



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DAVIS — ANILINE POISONING IN THE RUBBER INDUSTRY 69 

croscopical examination, no formed ele- on the clothing or the skin; (g) protection 
ments were found, but large quantities of of the hands by rubber gloves, and of the 
fat globiiles were present. In another case, feet by wooden shoes, rubber boots, or rub- 
diacetic acid was found, but no trace of ber-soled shoes in production plants where 
sugar; while in still another, there was pres- the floors are wet with aniline, 
ent diacetic acid with a slight trace of sugar. Some employers furnish milk for their 
Two cases showed bladder involvement employees to drink, but I see no advantage 
which improved under change of work and in this; in fact, rather the opposite, for milk 
treatment. is constipating and thus blocks one of the 
Complications. — In severe cases espe- channels of excretion. One large manu- 
cially, there may appear certain complica- f acturing company gives its aniline work- 
tions such as secondary anemia, which it is ers a teaspoonfid of vinegar (acetic acid) 
difficult to clear up; an irritative cystitis; before they go to work, with the idea of 
and inhibition of the red-cell forming or- producing soluble aniline compounds which 
gans — a condition which gradually re- may be excreted by the kidneys. Per- 
tums to normal when the patient is sonally, I have obtained very good resxilts 
removed from contact with aniline. In from the use of lemonade containing Epsom 
alcoholics a predisposition to glomerular salts. It furnishes the average worker with 
nephritis is often noted. enough citric acid and salts in a day to in- 
Several cases of gastric involvement, crease catharsis and diuresis. The follow- 
especially gastric ulcers, have been re- ing is the formula which I have used: 

ported by German authors, but I have ^^^^^ itoldozen 

never seen a case of gastric ulcer develop. Lemons 2 to 2i dozen 

in which aniline was the cause. I know of Water 8 gallons 

one instance in which a worker with gastric Saturated solution Epsom 

xilcer claimed that it was due to aniline, ^^ ^^ ounces 

but investigation proved that he had been g^"' , , 
exposed to very little aniline and only for a 

period of a few minutes. Sometimes ec- It is advisable that all persons working in 
zematous skin rashes appear, particularly aniline should be examined at frequent in- 
on the covered parts, the scrotum, the arm tervals and a record of the examination 
pits, and inguinal regions, and occasionally made. The form illustrated in Figure 1 has 
we see a pustular eruption resembling a been found to be very convenient for this 
furunculosis. Examination of the pus from purpose. The foreman who has charge of 
one of these furuncles shows staphylo- aniline workers should be instructed con- 
cocci and streptococci. cerning the hazards of the work and should 

report any men who show symptoms of 
rBEVENTioN poisoning. All aniline workers should have 
The most important factors in the pre- short periods to work and longer ones to 
vention of aniline poisoning are: (a) educa- spend in the open air. They shoiild abstain 
tion and instruction of employees working from alcohol as it seems to predispose to 
in aniline; (6) proper ventilation (forced); aniline absorption, particularly in young 
(c) handling of aniline compounds in closed men. 
receptacles; {d) restricted length of time rp^ 
for working in the fimies of aniline; (e) bet- 
ter personal hygiene; (/) an immediate bath Preventive treatment is, of course, the 
if aniline or any of its derivatives are spilled best to piu^ue. When poisoning has al- 



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FlOUBE I 

SPECML EXAMINATION FOR ANILINE WORKERS 

Age Nationality M.S.W. Date 

How long have you worked here? How long in the department? 

Have you felt perfectly well diu*ing the past year? Past six months? 

Have you ever had, or have you now any of the following: 

Muscle weakness, twitching of muscles, or muscle pains 

Large amounts of saliva 

Exhausted or "tired out" feeling 

Fast or slow breathing 

Drowsy or sleepy feeling 

Rapid heart 

Chilliness or cold feeling 

Nasal trouble, catarrh, discharge into back of throat from nose 

Indigestion Constipation Diarrhea Vomiting Nausea 



Nervousness 


Irritability 


Headache 




Joint pains 


1 






Unconsciousness 


Dizziness 


Loss of memory 




DiflSculty in talking 








Spots before eyes 








Spitting of blood 








Cold hands or feet 








Dryness or choking sensation in throat 






BiuTiing or stinging sensation of eyelids 






Painful urination 








Skin eruption 


Duration 






Loss in weight in the last six months 








Physical Examination 


' 


General appearance 








Face and head 




Eye reflexes 




Thorax 


Lungs 


Heart Pulse 


Blood pressure 


Abdomen 


Liver 


Spleen Stomach 




Genitalia 








Reflexes 


Knee jerk 


Babinski Romberg 




Extremities 








Skin 


Areas of anesthesia or hyperesthesia 




Blood: Hemoglobin 


White ceUs 


Red cells Pathological cells 




Urine: Specific gravity 


Albumin 


Sugar Reaction 




Remarks: 









Examining Phi/sician 



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DAVIS — ANILINE POISONING IN THE RUBBER INDUSTRY 61 



ready occurred, however, the patient must 
be treated for oxygen lack and acidosis. 
Very mild cases need free elimination and 
oi>en air, while the more severe ones re- 
quire artificial respiration, injections of 
heart stimulants, and blood transfusion. 

In acute cases the first step is to remove 
the patient to the open air, loosen his cloth- 
ing and examine it as a possible source of 
absorption. If it is found to be saturated 
with aniline f lunes, it should be taken off at 
once. Give oxygen inhalation, if necessary, 
remove the excess of aniline from the siu'- 
face of the skin with soap and water, and 
with a vinegar bath dissolve the aniline 
from the pores of the skin. Use heart stimu- 
lants, such as caffein, camphorated oil, or 
ether, but no tinctures because of the al- 
cohol which they contain and which should 
be abstained from. An enema of soap suds 
and glucose (2 to 3 oimces) may be given. 
If the patient is conscious, give him 1 ounce 
of glucose in water, alkaUnized with sodium 
bicarbonate. Blood letting, transfusion, or 
possibly infusion of normal saline may be 
necessary. Lavage of the stomach has been 



resorted to, but seems to be more hazardous 
than beneficial. It is important to promote 
the excretion of the poison by free diiu'esis, 
catharsis and sweating. The various symp- 
toms should be treated as they appear. 

SUMMAKY 

Aniline and its immediate homologues 
are blood and nervous system poisons 
which produce their effects by internal 
suffocation. They cause destruction and 
hemolysis of the red blood cells and marked 
production of methemoglobin, and, in 
severe cases, acidosis. In acute cases, a 
slight basophilic degeneration of the red 
cells also takes place. Very little effect is 
produced on the white blood cells, the only 
change being a transitory leukocytosis in 
the beginning of acute cases. 

There are very few complications except 
in severe cases. 

Alcohol seems to be a predisposing factor 
for early symptoms. 

Preventive measures should be instituted 
in preference to after-treatment. 



BIBLIOGRAPHY 



1. Von Jakach, R.: Die Vergiftungen. Second 
Edition. Wien u. Leipzig, 1910, p. 828. 

2. Hamilton, A.: Industrial Poisoning by Com- 
pounds of the Aromatic Series. Jour. Indust. 
Hyo., 1919-1920, 1, 204. 

S. Luce, R. v., and Hamilton, A.: Industrial 
Anilin Poisoning in the United States. Jour. 
Am. Med. Assn., 1916, 66, 1441. 

4. Neisser, E. J.: Internationale Uebersicht Uber 
Gewerbehygi^e, nach den Berichten, der Ge- 



werbe-Inspektionen der Kulturltoder. Berlin, 
1907. 

Rambousek, J.: Industrial Poisoning from 
Fumes, Gases and Poisons of Manufacturing 
Processes. Translated by T. M. Legge. Lon- 
don, Edward Arnold, 1918. 
Hayhurst, E. R.: A Survey of Industrial 
Health-Hazards and Occupational Diseases in 
Ohio. Ohio State Board of Health, Columbus, 
Feb., 1915. 



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CALVIN G. PAGE 

Assiatant Prcfeasor of Baderudogy, Harvard Medical School 

AND 

L. D. BUSHNELL 

Professor cf Bacteriology, Kansas State Agrundtural College, Manhattan, Kansas 

{From the Bacteriological Laboratories of Harvard Medical School) 



THE marked increase in our industrial 
population makes a study of the occu- 
pational affections of the skin of special 
importance. These affections will tend to 
increase as greater numbers of persons are 
drawn into the industries, as new industries 
are developed, and as new products are in- 
troduced. This paper is concerned with 
skin affections due to oils, and particularly 
with those due to the use of nlachine oils, 
an investigation of which was undertaken 
to determine the cause of an outbreak of 
furunculosis among the employees of a 
machine shop. 

Affections of the skin due to petroleum 
and its products have long been recognized, 
various terms being used to designate 
them. By some authors they are considered 
as belonging to the eczemas, and by others 
as dermatites or dermatoses. There is, in- 
deed, a considerable amount of confusion as 
to the correct terms to be used for all the 
various skin diseases, and those due to oc- 
cupations are not exceptions. R. P. White 
(1), in discussing the question of termin- 
ology, says "It would seem that, as a term 
intended to express a whole group of these 
disorders, the word * eczema * is both in- 
correct and inadequate. It would, there- 
fore, seem more convenient and logical to 
use the non-committal term * dermatitis.* 
This will embrace all so-called trade ec- 
zemas, as well as other forms of skin dis- 
ease caused by employment, and where 
possible the name of the offending agent 
should be prefixed to it." Following 
White's suggestion, we might designate 

* Received for publication Jan. 12, 1921. 



skin affections due to oils as oil dermatUes. 
This does not, however, clarify the matter 
to any extent, since the different oils pro- 
duce different affections. In the case of 
machine oil, the trouble seems to be largely 
a mechanical plugging, followed by inflam- 
mation and infection of the follicles. For 
this reason we suggest the name oU folr- 
UculiHs. 

Historical Review 

An exhaustive study of skin affections 
due to occupations has been made by 
Knowles (2). In the course of his discus- 
sion, this author says "fully one-quarter of 
all cases of eczema are of definite external 
origin. Almost one-sixth of all cases of this 
affection is caused by the occupation of 
the individual. . . . The largest number 
of cases of the so-called occupation eczemas 
are seen in the workers in the household 
and next most frequently in laborers. Prac- 
tically every occupation and every irritant 
may produce an eczema." Knowles' paper 
reports forty-five cases of eczema in in- 
dividuals, who handled oils, greases, carbon, 
graphite, etc. Oppenheim (3) in Germany 
examined 1,800 operatives who presented 
themselves in his practice, and found that 
400 of the cases, or 22.2 per cent., were due 
to the employment oi the patients. 

The earlier works upon the harmful- ef- 
fects of petroleum and its products upon 
the body were confined largely to the poi- 
sonous or intoxicating action when these 
substances were taken internally. Lewin 
(4) in an article written in 1888 gives an ex- 



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63 



tensive bibliography of the earKer literature 
on this subject, and also reports results ob- 
tained by feeding oils to animals. He refers 
to two early descriptions of skin affections 
due to petroleum, the first (5), designated 
as "eczematous," the second (6), described 
as consisting of small ulcers with erysipela- 
tous red bases, or as consisting of blisters 
with red but not indurated bases. After the 
latter type of ulcer had once been healejd, it 
did not develop again, even though the pa- 
tient continued in contact with the product. 

J. C. White (7), on the other hand, states 
that he has recommended petroleum for 
many years for the destruction of scalp and 
pubic lice, and has never seen the shghtest 
indication of irritation from its use. He 
also states that he has seen teamsters wash 
their faces and hands in the oil without ill 
effects. In conference with the superin- 
tendent of a large refinery. Dr. White found 
that there was very little skin trouble 
among the workmen and that whatever 
irritation there was appeared mostly in hot 
weather, and only among a few of the work- 
men handling paraffin products. The lesion 
in these cases consisted of a mild degree of 
eczematous inflammation on the backs of 
the hands and forearms, which disappeared 
rapidly after the occupation was given up. 

Lewin (4) discusses at some length an 
outbreak of pimples, boils, acne, and black 
comedones on the hands, arms, and other 
parts of the body in a group of workmen 
in the petroleiun industry. This affection 
continued for different lengths of time and 
with varying severity in different individ- 
uals, in some instances continuing as long 
as the men were employed in the work. It 
appeared to Lewin that the inflammation 
went hand in hand with the stopping of the 
hair follicles and sebaceous glands. After 
these were closed, there was a continuation 
of glandular secretion, but excretion being 
inhibited, the condition was gradually 
exaggerated and soon involved all layers of 
the skin. The longer the process continued, 



the more intense the inflammation became, 
finally spreading to neighboring glands and 
hair follicles, or to the subcutaneous tissue. 
In the course of his study, Lewin found 
that the heavier petroleum products, 
particularly those which distill at 250^- 
360^ C, possessed the most marked prop- 
erty of causing inflammation. He tested 
the action of these products by feeding 
them to animals, and considered that the 
action upon the stomach wall was similar to 
that on the skin. He also noted that the 
individuals of most cleanly personal habits 
suffered least from this trouble. Similar 
skin affections have also been described by 
Ogston (8) as due to the paraffin products 
from cannel coal and various other raw 
petroleum products. 

A folliculitis and perifolliculitis of spin- 
ners called boiUon (ThuUe w^ first de- 
scribed by Purdon in Belfast in 1867, and 
by Leloir (9) in Belgium in 1889. This af- 
fection was due to the irritating action of 
the oil used on the machines. In England 
sperm oil was the most common lubricating 
agent; in Belgium, on the contrary, mineral 
oil was largely used. The oils from Russia 
were usually unmixed, as were those from 
America, while the shale oil from Scotland 
was usually mixed with olive or colza oil in 
the proportion of ten to fifty parts per 
hundred. Purdon (10) in his article dis- 
cusses an acneform eruption of "doffers" 
(usually young girls who remove the bob- 
bins and clean and oil them) in flax spin- 
ning mills. The affection is evidently a 
folliculitis due to the sluggish action of the 
sebaceous glands, the orifices of which are 
choked by the oil and irritated by the flax 
water that comes off the bobbins. The 
eruption, which occiu^ usually in persons 
under 20 years of age, of either sex, but 
chiefly in girls who expose their arms by 
wearing short sleeves, may be described as 
follows: The acne eruption commences 
with a small, dull red papule, shotty to the 
touch, occiuring on the forearms and 



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wrists, and when a little matured has a 
small black speck in the center of the pap- 
ule, like a comedo, showing the plugged 
sebaceous fojlide. Next, the papule in- 
creases in size, finally suppuration occurs, 
and the papule disappears. 

In Belfast, Purdon did not find eczema- 
tous conditions of the hands such as those 
described by Leloir in Belgium. In describ- 
ing the trouble, Leloir says that it is seated 
in the hair follicles; these become dilated 
and filled with broken hairs and homy cells 
mixed with dirt and oil, thus setting up a 
perifolliculitis. The corium around the fol- 
licle becomes infiltrated with round cells, 
the vessels dilate, and some of the tissues 
necrose. Eventually the whole follicle may 
be discharged. 

Lefebvre (11), writing in 1888, states 
that skin lesions of the nature described 
above are of fairly common occurrence, and 
are liable to arise wherever dirty oil from 
the joints and gearing of the machinery 
constantly comes in contact with the skin. 
In spinning mills this may be effected 
directly by the fine spraying of the oils 
from the spinners revolving in the oil cups, 
or indirectly from saturated clothing or 
cleaning rags. The condition is easily rec- 
ognized by the stippled ground of minute, 
black, dilated follicles, upon which the 
typical rounded, well-raised, hard papules 
of a dusky red color are irregularly dotted. 
These papules vary in size from that of a 
hemp seed to that of a split pea, and are 
centered by a hair. They may become sur- 
rounded by a zone of erythema, or may de- 
velop into an acute boil. Usually, however, 
they are indolent lesions which form slowly, 
take many weeks to recede, and leave a 
pitted scar. 

Collis (12), in England, reported fourteen 
cases of dermatitis in engineering shops 
among workers whose skin had been much 
irritated by cooling and lubricating mix- 
tures consisting of turpentine and alkaline 
emulsions of mineral oil. This disease failed 



to appear when neither turpentine nor 
mineral oil was used. 

R. P. White (1), discussing the effect of 
petroleum, says that in all instances in 
which raw petroleum is handled, the work- 
ers suffer, whether it be at the mines, re- 
fineries, pumps, or in the manipulation of 
the raw petroleum itself. He states that 
from 1890 to 1893 eighteen cases of petro- 
leum acne were reported in French re- 
fineries, and in the official statistics, which 
included 1,380 petroleum workers in Rus- 
sia, nine were reported to be suffering from 
general symptoms, and fortv-three from 
petroleum acne. Rambousek (13) makes 
the statement that opinion is unanimous as 
to the injurious action of mineral oil on the 
skin, and particularly that the graver con- 
sequences are produced by the petroleiun 
residues. The products of the distillation of 
petroleum and coal appear to have the 
same effect. 

Oppenheim (3) has noted diseases of the 
sweat and sebaceous glands in paraffin and 
petroleum workers, who develop an "acne 
petrolei*' most marked where the clothing 
is satiurated with the heavy oils, especially 
on the "streckseite" of the arms and 
thighs. The heavy petroleum products are 
considered by him to be the most common 
cause of this trouble. He quotes MiUiard as 
stating that half the men employed in the 
j>etroleum refineries in Rouen suffered 
from acne, most of them coming in contact 
with the heavy oils. He maintains that 
"Batschol" and "Juteol" produce the so- 
called "Weberakne," and that machine 
workers may suffer from "Schmier5lakne." 

Weichardt and Apitzsch (14) studied the 
cause of an outbreak, among the workers in 
the metal industry, of a skin disease con- 
sisting of small comedones and pustules 
which developed first on the hands and 
forearms, and later on other parts of the 
body. This disease became very serious 
among the machine workers, usually de- 
veloping within approximately two weeks 



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65 



after employment. The authors consider 
that the characteriitic clinical picture may 
be ascribed to different causes and that 
in the beginning the local trouble may per- 
haps be due to an eflFect of the mineral oil 
which reduces the resistance of the skin 
and allows the entrance of secondary septic 
micro-organisms or their by-products. In 
studying their problem experimentally, 
Weichardt and Apitzsch found that ma- 
chine oils applied to the ear of an albino 
rabbit caused severe inflammation. Olive 
oil rubbed on in the same manner had no 
such influence. Pure liquid paraffin was 
without effect, although the repeated ap- 
plication of pure mineral oil caused some 
irritation. On examination the machine oil 
was found to contain no free acids and 
alkalies. Although it contained 8 per cent, 
of resin, the oil still retained its irritating 
proi>erties after the removal of this sub- 
stance; it also contained a considerable 
amount of easily oxidizable substances and 
imsaturated compounds. The authors used 
several methods of saturating the oil by use 
of halogens but were not able to eliminate 
its irritating action upon the skin of rabbits. 

C. J. White (16) states that "machinists 
of all sorts have a common enemy in dirty 
oil, which is rubbed into and absorbed by 
the follicles of the skin, and if boils don't 
follow, eczema may. The necessary clean- 
ing at the end of the day's work adds its 
quota to the harm to which these men's 
skins are subjected. . . . Paraffin workers 
seem to be particularly prone to skin dis- 
eases. The substance harbors . . . many 
provoking ingredients, mostly mineral oils, 
and constant contact with this medium, 
with the consequent impregnation of the 
clothes, may produce eczema, pustules, 
and in the end cutaneous cancer." 

Allworthy (16) mentions an acneform 
eruption of "doffers" in the flax spinning 
mills of Belfast. He states that the erup- 
tion is probably produced by dirt, sweat, 
and the sperm oil which is used on the ma- 



chinery. In discussing this statement, 
MacLeod affirms that the acneform erup- 
tion is an example of oil acne, or hcvUm 
d'huUe. "In it the follicles become plugged 
with a mixture of dirt and oil which causes 
inflammatory changes and produces the 
acneiform lesions. This condition is met 
with, not only in flax spinners but in any 
form of work in which the skin is liable to 
be bespattered with oil, such as in stokers, 
engineers, mill-hands, etc. It is a milder 
form of the dermatitis from petroleiun, 
shale oil, etc., which tends to go on to 
warty growths and cancer. It occurs on 
the arms from the drops of oil and on the 
legs from contact with clothes saturated 
with oil." 

Oppenheim (17) mentions serious irrita- 
tions of the skin of the face from the use of 
impure vaseline salves which he employed 
in the treatment of lupus vulgaris. The 
skin became rough, harsh, uneven, warty, 
whitish and hard. Some of the softer 
nodules had a yellowish central point. This 
statement was discussed by Sachs (18), who 
affirmed that an acne-like eruption may 
develop alone or associated with eczema 
upon persons in contact with petroleum, 
tar, asphalt or pitch, and that Wacker 
and Schmincke in the Borst Institute had 
found forty-nine different substances (fats, 
oils, paraffin), which by experimental test 
gave rise to epithelial proliferation. 

Deeds (19) investigated an outbreak of 
furunculosis among employees of a steel 
plant and found that "the epidemic ap- 
parently had its beginning in the case of the 
engineer at the plant, who was wont to 
clean his hands daily in tKe barrel of paraf- 
fin oil. Thereafter the cases appeared until 
each of the fifteen workmen had been so 
infected." The work done by these men 
was the handling of steel bars, which were 
coated with a mixture of paraffin oil and 
petrolatum to prevent rusting, and the 
hands of the men were constantly covered 
with this grease. Deeds considered that the 



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pyogenic organisms were carried from. one 
man to another by the grease. Staphylo- 
coccus pyogenes aureus was isolated from the 
hands of the men but not from any of the 
grease used. 

Thibiierge (20) states that the. b&uton 
d^huUe became so serious among the "tour- 
neiurs d'obus" that it made an actual 
dilBference in the functioning of the war 
factories. The lesions occurred in both men 
and women, most conmionly on the hands 
and forearms, or on the face, if directly ex- 
posed to the lubricant, and on parts of the 
body exposed to oil-saturated clothing, 
especially the anterior aspect of the thighs. 
This trouble was generally most pronounced 
and extensive in individuals who had been 
employed for some time, and in the case of 
the "toumeurs d'obus" it became a veri- 
table professional stigma. Necessity re- 
quired the use of products of inferior 
quaUty and irritating nature (oil of petrol, 
etc.), and because of their scarcity it was 
impossible to purify them. They became 
charged with dirt and debris, which were 
deposited upon the skin and which clogged 
the mouths of the glands. The metallic 
particles were retained by the lubricating 
bodies, which in themselves were more or 
less irritating, and a special form of acne 
resulted. At this phase histological exam- 
ination showed nothing of the follicular re- 
action. Finally the products of glandular 
secretion accumulated and became in- 
fected by pyogenic bacteria, and f ollicuUtis 
and perifolliculitis developed. 

Albaugh (21) states that fiunmculosis and 
woimd infection "are unusually common in 
operators of lathes and cutting and milling 
machines, who come in contact with cutting 
compounds and cutting oils, where these 
lubricants are caused, by gravity or force, 
to flow in a steady stream on a job at the 
point of application of the tool. It has been 
observed,, also, that these infections are 
more prevalent during the summer months, 
the exact reasons being xmknown.*' Al- 



bany is not inclined to accept the idea 
that these affections kre caused solely by 
the bacteria which are present on and in 
the skin, and which are allowed to set up 
an infection following •injiu'y by the oil;, he 
believes rather that the oil itself may serve 
as a vehicle of the infectious material — a 
surmise which is further suK>orted when 
the different types of skin affections are 
scrutinized as to their relation with the dif- 
ferent substances. 

Records of a three months' period showed 
forty-one cases of furunculosis and twenty- 
six cases of wound inf ejction occiuring in 
twenty-six departments of a factory em- 
ploying 1,365 men, and - probably many 
more cases were treated outside the plant. 
Few of these men had been troubled before 
coming in contact with cutting compounds 
or cutting oils. The men denied spitting 
into the reservoirs, although several of 
them were observed to do so in spite of in- 
structions to the contrary. As the oils were 
collected from the machines and used 
again, this was an extremely dangerous 
practice. Albaughgoesontosay that "due 
to these exposures, pollution is almost cer- 
tain to follow, especially in those cases 
where employees have acne or where they 
have pus infections of the skin, or mouth, 
or respiratory tract. This is most serious 
where machines are equipped with individ- 
ual oiling systems, and where cuttings and 
shavings are collected from the different ma- 
chines and the oil drained off and filtered. . . . 
This is also true of machined parts which 
are covered with oil and subsequently 
handled by men in other departments." 

In his investigation among lathe workers 
of infections which appeared to be true pus 
infections, Shie (22) states that "a pin- 
prick, if left unattended, developed into a 
severe lymphangitis; a slight scratch in 
twelve hours into a linear mass of pus; a 
slight abrasion into a suppiu'ating ulcer; 
and a laceration into a mass of necrotic 
tissue and pus.'* 



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.67 



Blum (23) has recently submitted an 
article on the . skin affections due to oil 
which he has caUed 4laiokoniose folliculaire 
{bottton cThuHe) . He states that it is not the 
oil which plays the most important r61e, 
but in reahty the foreign bodies carried by 
the oil, metallic particles and dusti which 
contribute to the obhteration of the fol- 
licular orifices. The oil is thus the vehicle 
and not the pathogenic agent. It is to the 
dermatitis of this type that the author at- 
tributes the name ilaiokoniose foUicidaire 
{iXaiovy huile and Kbvios^ poussifere) — 
"a general name used to designate the 
special affection of the pilosebaceous fol- 
licules observed in laborers whose skins are 
greased by lubricating or other oils, or 
whose pores are impregnated and fouled by 
dust in suspension." The trouble appears 
gradually, first generally on the hands and 
postero-internal face of the forearms and on 
the backs of the fingers. It appears occa- 
sionally on the thighs and abdomen as a 
result of wearing clothes saturated with the 
oil, and sometimes on the face and neck of 
attendants on machines which throw the 
oil to some distance. More often the lesions 
on the face and neck are due to scratching 
or to the worker's passing his hands and 
forearms over his face to remove the sweat. 

Type of Lesion Due to Oils 

R. P. White (1) attempts to classify the 
effects upon the skin of petroleum and its 
distillates which, generally speaking, cause 
varying grades of dermatitis, roughly cor- 
responding to the temperatures at which 
they are given off: (a) Benzine, or petrol 
naphtha (boiling point 150^ C. and under), 
causes superficial inflammation of the skin, 
with dry, scaly conditions, or eczematous 
lesions showing fine vesicles, pimples or 
pustules. (6) Lighting oil (boiling point 
150^ to 300® C.) causes papular and pustu- 
lar eczema, miUary f ollicuUtis, with or 
without perifolliculitis (acne), and ab- 



scesses, (c) Residuum (boiling poiut above 
800® C.) causes erythema, keratosis senilis — 
ptmctif orm folliculitis, warts, ulcers, and 
carcinonmta. "These appearances are not 
necessarily sequential the one upon the 
other, and mixed lesions prevail amongst 
the workers, especially in the distillates 
coming off at the higher temperatures." 

Dr. White also states that the existence 
and intensity of a trade dermatitis depends 
upon three factors. In order of importance 
they aire: (1) the potency of the irritant; 
(2) the resisting quality; and (3) the reac- 
tive capacity of the skin. 

According to Besnier, Brocq and Jacquet 
(24), the acneform folliculitis, a pseudo- 
comedo, is uniquely an appendage of trades 
in which are handled tars, petrols and the 
residues of their distillation known as 
heavy oils. They -state that the vesicular 
and pustular dermatites are very frequently 
the origin of lymphangitis and adenitis 
which may result in suppuration. These 
comphcations are rare in spontaneous 
eczema. 

Pusey (25) states that in addition to the 
irritants that produce the usual inflamma- 
tory reactions, there are certain substances, 
that produce lesions in the skin which are 
not of the ^ ordinary inflammatory type. 
The substances which do this especially are 
tar, mineral oils and greases, and their de- 
rivatives, and, perhaps, true fats. The 
commonest lesions which these substances 
produce are boils and large crops of black- 
heads and pustules. Such eruptions are seen 
not infrequently in men habitually exposed 
to these substances in their occupations. 

Bridge (26) divides oil injuries into two 
classes — the first, the injury due to the 
plugging of the small glands at the root of 
the hairs; and the second, the mechanical 
injury produced by metallic particles sus- 
pended in the cutting lubricant. The 
former is primarily mechanical; the mix- 
ture of dirt and oil blocks the opening of 
the glands and, while secretion continues. 



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excretion is prevented and an inflammation 
is caused (folliculitis). The glands may be 
invaded by bacteria and suppuration re- 
sults in a boil. Mechanical injury due to 
particles of metal suspended in the oil 
usually occurs on the hands, where two sur- 
faces are rubbed together, or on the arms, 
from wiping with a cloth or waste when the 
skin is coated with a film of oil in which 
metal particles are suspended. This injury 
allows the entrance of bacteria from which 
infection may result. Often the oils be- 
come infected and thus spread the condi- 
tion among the workmen. 

Hubbard (27) states that an improper 
practice, and one which frequently causes 
skin diseases in mechanics, is that of spit- 
ting into oil receptacles or trade materials, 
which subsequently have to be used or 
handled by workmen. Oil infected by spit- 
tle, especially when used in lathe work, 
quite often causes boils. Grinders fre- 
quently blame the ingredients of prepara- 
tions used by them, when investigation has 
shown that their trouble was due to careless 
workers spitting into the material. 

The bouton d'huUe in its most advanced 
stages is characterized by Thibierge (20) as 
a round pustule 2 to 6 or 8 mm. in diameter, 
generally Uttle raised, with resistant walls 
enclosing a thick pus. This pustule is 
habitually surrounded by a narrow in- 
flammatory, red, slightly infiltrated zone, 
and has little tendency to open sponta- 
neously. Once having been opened, how- 
ever, the orifice remains so for one or two 
weeks and the slight inflammatory zone 
siuTOunding the pustule disappears slowly. 
Besides this type of pustule, there are 
other longer pustules without infiltration at 
the base, which develop more rapidly and 
produce large quantities of pus. These 
tend to multiply by auto-inoculation and 
present many of the characteristics of a 
streptococcic erythema. This latter affec- 
tion is not considered the same as the 
boiiion d'huUe. In many individuab there 



develop large numbers of acne comedones 
usually centered by a hair. 

The affections described chiefly by Al- 
baugh were true f urunculoses and wound 
infections, which are apparently much 
more severe than the oil acne, hovUm 
d^huUe or ilaiokoniose. 

In his description of the houUm d^ huUcy 
Blum (23) states that in the beginning 
there is a slight itching. Little by little 
there develop numbers of black points 
which cannot be removed by washing, 
many of them presenting projections more 
or less pronounced, at the center of which 
the hairs appear old or broken. This stage 
corresponds to the obstruction of the fol- 
licles by dust (konioses) mixed with oil and 
develops into a veritable acne comedo. 
Later infection sets in, generally around 
the follicle, causing a perifollicuUtis which 
clinically has the appearance of a pustule. 
These pustular lesions are red, violet or 
brown, sometimes "jambonn6"; they are 
generally flattened, more rarely conical, 
and represent variable dimensions, from 
the size of the head of a pin to that of a pea. 
Some of the pustular lesions have a raised 
center containing a drop of yellowish pus 
centered by a black point; the papule has 
become a papulo-pustule. In other cases, 
there are vesico-pustules having a vesiculi- 
form aspect. At other points the infection 
is a true folliculitis and more deeply seated, 
and in some cases true furuncles develop. 
There are thus, according to Blum, four 
stages, all of which may appear in the same 
patient at the same time : (1) the stage of the 
black point; (2) the stage of acne comedo; 
(3) the pustular and papulo-pustular stage; 
and (4) the furuncle stage. It is evident, 
then, from the above references, that the 
action of oils will depend upon the type and 
grade of oil, the conditions under which it 
is employed, the length of time it has been 
used, the kind and amount of microbial 
contamination and the kind and amount 
of dirt, dust and metal in suspension. 



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Influences Predisposing to 
Affection of the Skin 

The structure of the skin renders it spe- 
cially able to jesist the action of agents 
likely to injur it and allow the invasion of 
micro-organisms. Its toughness and elas- 
ticity permit it to resist mechanical injury, 
while the chemical nature of its secretions 
prevents to a certain extent the action of 
chemical agents. In discussing this point, 
Jacquet and Jourdanet (28) make the 
statement "that one rarely finds traumatic 
eczema on the palms of the hands, where 
the sweat and grease are abundant and well 
mixed; that eczema is more common in 
winter [when the secretions are apt to be 
deficient]; and that an oily skin is less af- 
fected than a dry skin." This is not true 
in the case of affections due to oil, since 
they are more commonly reported in the 
summer than in the winter. This may be 
due to the fact that in the summer the fol- 
Ucles are more open and more easily clogged 
by the dirt carried by the oil, and that 
micro-organisms more easily penetrate into 
the follicles under these conditions. 

There are certain factors which may pre- 
dispose to infections of the skin, such as 
defective structure or function — congenital 
or acquired, permanent or temporary — or 
unusual environmental conditions. The 
age of the individual is also important. 
In the infant, ordinary soap may cause 
irritation, and in extreme age the skin is 
more easily injured and has less recupera- 
tive pK)wer than at earlier periods of life. 
Sachs (18) has shown, however, that the 
skin of old rabbits is much more resistant 
to the action of certain irritant aniline 
colors than the skin of young animals. 

Abnormal activity of the sebaceous 
glands may predispose to injurious effects 
of certain substances such as oil, tar, and 
I>etroleum. Unnaturally profuse sweating 
is imdesirable in certain industries, since 
there is increased tendency to retain the 



irritant on the skin and to increase its 
solubility. 

R. P. White (1) states that an occupa- 
tional disease once induced may predis- 
pose to recurrences of skin diseases not 
produced by the primary cause. Fordyce 
(29) maintains that in chronic skin dis- 
eases one of the most prominent features is 
the increased susceptibility which the skin 
either presents from the beginning, or 
which develops as the process advances. 
This may be referred to a state of ana- 
phylaxis. Persons who show an increased 
susceptibility to irritants may, perhaps, be 
sensitized to the toxin of pyogenic or- 
ganisms just as patients with tuberculosis 
may be sensitized to tuberculins. Such 
hypersensitive or abnormal skins are sensi- 
tive to small amounts of irritants not affect- 
ing normal skins and this condition may 
pave the way for the entrance of micro- 
organisms normally present on the skin or 
added by contact. 

The French writers attach considerable 
importance to the influence of constitu- 
tional disarrangements in skin diseases. 
Thus, a skin poorly supplied with blood is 
more subject to the action of irritants and 
to invasion by bacteria. It is also well 
known that digestion and nervous dis- 
orders, alcoholism and diabetes mellitus 
affect the resistance of the skin to infection. 
In some clinical investigations in this con- 
nection, Jacquet and Jourdanet (28) found 
that the cure of certain gastric disorders 
was followed by great improvement in the 
severity of local traumatic skin troubles, 
and by the prevention of relapses. They 
claim that the careless bolting of food, espe- 
cially if indigestible, can in itself exercise 
an injurious influence upon occupational 
eczema, proportionate to its severity. They 
also demonstrated that irritable conditions 
of the mucous membranes, and overdis- 
tension of the stomach are associated re- 
flexly with pathological states of the skin. 

Alderson (30), in discussing increased 



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vulnerability of. the skin due to systemic 
conditions, states that "in considering the 
skin, we must not forget that it is an im- 
portant organ intimately connected with 
and influenped.by all the. various bodily 
functions, among which the digestive sys- 
tem plays an extremely important part. 
Various disorders of the nervous system 
and internal gland system are often the 
cause of increased susceptibility of the skin 
to injury." In discussing increased vulner- 
ability due to local conditions he declares 
that "a person whose skin is congenitally 
defective, particularly in the outer layers, 
is very much more liable to develop trade 
dermatoses than one with a normal epi- 
dermis. ... A deficiency in secretion is 
liable to result in lowered tone and lowered 
resistance to chemical and mineral irritants 
as well as to atmospheric and thermal con- 
ditions. On the other hand, an excessive 
sebaceous secretion is prone to clog the 
follicles and the ducts resulting in increased 
irritation and vulnerability. Skin of this 
sort is usually favorable soil for bacterial 
growth. It is particularly sensitive to the 
deleterious effects of various oils, tars, 
paraffin, petroleum and allied substances.'' 

Skin diseases in general, and those due to 
oils in particular, are considerably in- 
fluenced by secondary, invasion by micror 
organisms, and according to Besnier, Brocq 
and Jacquet (24) it is correct to say that 
the secondary micro-organisms determine 
the character of the dermatosis. 

Bender, Bockhart and Gerlach (31) and 
Bockhart (32). studied the influence of sta- 
phylococci and their products upon the 
skin of man., They found that- "toxin" 
obtained from broth cultures, when applied 
to the skin, caused eczema. alone; while 
"plasmin" from the cells pf the organisms, 
applied to the skin, caused pus formation. 
Bockhart states that . the inactive sta- 
phylococci in the sound fqllicles of the skin, 
due ta some inner or. outer condition of the 
body which improves their nutritive con- 



ditions, increase their activity. This results 
in the excretion of the' toxin which diffuses 
into the epidermis giving rise to a serotactic 
action and the formation, of vesicles and 
papules. The tissues in the immediate 
neighborhood of these lesions contain only 
clear serum and no organisms. After a 
time the organisms increase and invade 
these areas. If the organisms contain suffi- 
cient "plasmin," leukocytes wander in and 
the process becomes pustular. 

The fact that non- virulent staphylococci 
from the skin can become virulent has been 
proved by Greisse (33). He obtained three 
strains which were non-virulent, non- 
hemolyzing, nbn-pigment. forming, and 
which would not agglutinate with serum 
agglutinating pathogenic strains. These 
were placed in collodion capsules and 
placed within the peritioneal cavities of 
guinea-pigs. After a passage of three or 
four animab they acquired pathogenic, 
hemolyzing and pigment-forming proper- 
ties and were agglutinated by serum specific 
for pathogenic strains in high dilutions. 

There is no doubt that most of the skin 
affections are due to the staphylococci, 
although Weichardt and Apitzsch (14) 
mention isolating streptococci from the 
lesions of machine shop workers, and Oliver 
and Schwab (34) isolated from a patient 
having funmculosis an organism which 
they considered belonged to the colon- 
typhoid group. 

Bacteriology of Oils 

A review of the literature shows that very 
little attention has been given to the bac- 
teriology of oils. Deeds (19) made a bac- 
teriological examination of oil, petroleum, 
and grease mixtures, and in five out of six 
examinations, he found Bacillus subtilisy or 
air-borne bacteria, but succeeded in isolat- 
ing no pyogenic organisms. He also ex- 
amined these products to determine their 
effectiveness as a medium for bacterial 



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71 



growU^ and as germicidal agents. A twenty- 
four-hour culture of Staphylococcus pyo- 
genes aureus was added and the suspension 
allowed to stand at room temperature for 
ten hours. Each tour a loopf ul of this ma- 
terial was transferred to 10 c.c. of nutrient 
agar and plates were poiu^d. The result of 
this test showed that there was neither an 
increase nor a decrease in the number of 
bacteria during that period. 

Albaugh (21) reported the examina;tion 
of eight samples of oils and cutting com- 
pounds procured from machines, and from 
which cultm'es were made as follows: 
"'slants of glycerine-agar and blood-serum 
were treated with a loop of each sample, as 
were plates of glycerine-agar. A,t the end of 
twenty-f otu* hours all of the cultiures had 
visible bacterial growths. These were 
found to be the usual pus-forming or- 
ganisms. One sample showed as many as 
110,000 micro-organisms per gram of oil 
(estimated from colonies in Petri plates 
after incubation for thirty-six hours) — the 
organism being practically a piure cultiu'e 
of Staphylococcus aureus." 

Experimental Work 

In the present investigation cultiures were 
first made on plain agar, one set of plates 
being incubated at 26® C, and the other at 
37^ C. The types of organisms appearing 
on the plates were the same in both series. 
A few loopf uls of oil were suspended in agar 
and heated at 80° C. for twenty minutes, 
and plates made. No growth occmred. 
Eosin-methylene-blue plates were inocu- 
lated and one set incubated aerobically, 
the other, anaerobically over metallic 
phosphorus. Good growth was observed on 
the aerobic plates in forty-eight hoiu-s, and 
from these Types I and 11 mentioned be- 
low were isolated. Type HI did not appeai; 
<m these plates for several days, but grad- 
ually grew somewhat scantily. This type 
also grew somewhat bette?: at room, tem- 



perature than at incubator temperature. 
The ana&obic plates showed only Types I 
and n. Type I greatly predominating. 

From deep agar shake cultures only 
Types I and 11 were isolated.. No obligate 
anaerobes were obtained by any of the 
methods used. Cultures obtained by en- 
riching in dextrose broth, lactose broth, 
and dextrose broth containing meat, all 
gave rise to Types I and 11. Type HE was 
evidently overgrown in these cases. 

The organisms isolated were as follows: 
Type I, BacUhis aerogenes; Type 11, Bacilr 
lus coli communis; both of fecal type as de- 
scribed in the Standard Methods for Water 
Analysis for 1917. The former gives all the 
typical reactions of the Bacillus aerogenes 
group, is alkaline to methyl red, gives a 
positive Voges-Proskauer reaction and fer- 
ments adonite. Type 11 gives all the typi- 
cal reactions of Bacillus coli communis^ is 
add to methyl red, negative to the Vqges- 
Proskauer reaction, and does not ferment 
adonite. Type III is a Gram-negative, 
non-spore forming, actively motile rod 
with an average of about twelve flagella of 
peritrichic arrangement. It liquefies gela- 
tin, and digests casein and L5ffler's blood 
serum very rapidly. It is very similar to 
the hquefying Proteus vulgaris strains, but 
produces neither add nor gas in any of the 
fourteen carbohydrates tested. The final 
hydrogen ion concentration in Clark and 
Lubs' medium dextrose broth and peptone 
solution was about 8.2. It gives a negative 
Voges-Proskauer reaction and did not 
produce indol. 

Tests were made of the thermal death 
point of these organisms suspended in nor- 
mal saline solution as well as in the oil from 
which they ^ere originally isolated. The 
mixture was drawn into capillary tubes, 
which were sealed at each end and placed 
at temperatures indicated in Table 1. At 
the end of the exposure; the tub^s were re- 
moved, placed in a 5 per cent, solution of 
phenol for fifteen minutes, then in 95 per 



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cent, alcohol for fifteen minutes, and then 
allowed to dry in a sterile Petri dish. The 
ends were then broken off with sterile for- 
ceps and the contents allowed to flow out 
into sterile plates to which agar was added. 
Table 1 shows the results obtained. 

Bacteria seem to be able to retain their 
vitality in oil for long periods of time. The 
sample of oil investigated has been in this 

TABLE 1. — THERMAL DEATH POINT OF 
ORGANISMS 



Time o( Heating 

ateo°c. 


Typel 


Typen 


TVpcin 


ou 


minutM 
5 


+ 
+ 
+ 
+ 


+ 
+ 
+ 


+ 
+ 


+ 


10 


+ 


15 


+ 


80 


4- 


85 




so 









Time ^ Heating 
at 70» C. 


Typel 


TypeH 


Type HI 


OU 


minvtes 
6 


+ 


- 




+ 


10 


+ 


15 




80 









laboratory for eight months and still con- 
tains as many bacteria as when it was re- 
ceived. One interesting point is that while 
there were typical fecal types of bacteria 
present in the oil, yet no spore-forming 
types or staphylococci could be isolated. 

Kurpjuweit (35) studied the length of 
time that bacteria could retain their vitality 
in olive oil and reported the following: 

Staphylococcus aureus not obtained after 12 days 
BaeiUuscdi « « « 14 « 

BaciUwt diphiheriae « " « 9 « 

B€unlltts pyocyaneus " ** " 14 ** 

Micrococcus ureae " " " 11 ** 

BaciUus typhosus « « « 14 « 

Studies on the influence of desiccation in 
air and in vacuum were made by Hammer 
(36) who found that Bacillus coli when 



desiccated in air over sulphuric acid died in 
two days. When desiccated in vacuum it 
lived for fifty-seven days (end of test). 
Staphylococcus aureus gave no growth in 
two days in air and growth after fifty-four 
days in vacuum. BaciUus pyocyaneiis gave 
no growth after four days in air, nor after 
seventeen days in vacuum. 

In the present investigation, tests were 
made to determine the length of time these 
organisms would retain their vitality upon 
the ordinary artificial media. The results 
are shown in Table 2. 

Pathogenicity. — One c. c. of a forty-eight- 
hour broth culture of these organisms was 
injected intraperitoneally into guinea-pigs 
of the following weights: Type I, 564 gm.; 
Type n, 509 gm.; Type III, 539 gm. The 
pig receiving Type I was dead in twenty- 
four hours and a pure culture of the or- 
ganism was obtained from the peritoneum, 
liver and heart blood. The animals receiv- 
ing Types n and HI showed no ill effects, 

TABLE 8— LENGTH OF TIME ORGANISMS 
RETAIN VITALITY UPON ARTIFICIAL 
MEDIA 



Culture 
Medium 


32 Days 


00 Days 


Typel 


TypeH 


Type in 


Typel 


TypeH 


Type HI 


Litmus 














milk 


.+ 


- 


+ 


- 


- 


+ 


Dextrose 














broth. . . . 


+ • 


- 


+ 


+ 


- 


+ 


Peptone so- 














lution . . . 


+ 


+ 


+ 


+ 


+ 


+ 


Agar slant . 


+ 


+ 


+ 


+ 


+ 


+ 



excepting that the Type 11 pig appeared 
sick for about forty-eight hours. 

Relation of Organisms Isolated to Furun- 
culosis. — The particular sample of oil in 
question was submitted to this laboratory 
as it was considered to be the cause of boils. 
All attempts to isolate pyogenic organisms 
failed, and since the oil was drawn directly 
from the supply barrel and was not exposed 
to dust, it is doubtful if any of these or- 



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PAGE AND BUSHNELL — OIL FOLLICULITIS 



7S 



ganisms were present. As it is well known 
that the ordinary staphylococcus types are 
quite highly resistant to external condi- 
tions, it is also doubtful if they would have 
disappeared and left the colon type in such 
large niunbers and such vigorous condition. 
It is indeed diflBcult to understand how such 
tremendous numbers of organisms of the 
tyi>e isolated could have been present in the 
oil without direct fecal contamination. 

From our tests the oil could not be in- 
criminated directly as being the cause of 
the disease. The tests are, nevertheless, of 
considerable significance in showing how 
long organisms can live in oil and still retain 
their virulence. We may here again em- 
phasize the point so often mentioned by 
others, that workers should use great care 
not to contaminate the oils which are to be 
used again, and not to use waste and rags 
with which others have wiped their hands. 

Treatment of Oil to Reduce Danger 
OF Infection 

It does not necessarily follow that infec- 
tion of the skin will result from the use of 
oil contaminated by pus-forming bacteria. 
As was mentioned in the first part of this 
article, certain oils are naturally somewhat 
irritating to the skin, while others may con- 
tain particles of metal which cause injury. 
Also, some individuals are predisposed to 
infections of this type. In order to elim- 
inate possible danger of infection, there- 
fore, the oil should be handled with pre- 
caution. The workmen should be warned 
against spitting into it since pyogenic or- 
ganisms are very common in the mouth 
and saliva, and persons with skin affections 
of any kind should not be allowed to come 
in contact with the oils or cutting com- 
pounds used by others. The heating of the 
oil to 70^ C. for twenty or thirty minutes 
will destroy all the dangerous tyi>es of bac- 
teria, and by allowing it to stand for a short 
time the particles of metal will settle out 
and may be discarded. The individual 



cleanliness of the worker himself and the 
care of his hands will also reduce the danger 
of infection. 

Boils cannot be entirely eliminated, how- 
ever, especially in those who are predis- 
posed to irritation, and whose skins are 
little resistant to the irritating action of 
oil and bacterial invasion, since organisms 
of the type commonly causing boils are 
very common on the skin. Thus, irritation 
or injury merely aids their entrance. 

Summary 

1. Oils of all types are likely to produce 
skin affections if they come in contact with 
the skin for some length of time. 

2. The most serious skin diseases are 
probably due to the oil acting as a carrier of 
infectious material from one individual to 
another. 

3. Individuals of the most cleanly 
habits are, generally speaking, least liable 
to skin affections due to oils. 

4. Special care should be exercised by 
workmen on cutting machines to avoid 
contamination of the oil, especially by 
spittle. 

6. Individuals having skin diseases 
should be transferred to some other type of 
work. 

6. While oils may be placed on the mar- 
ket in a sterile condition and free from 
dust, etc., they will not long remain so after 
being put into use. 

7. By heating the oil to 70® C. for 
twenty or thirty minutes, it is possible to 
destroy all the dangerous pathogenic bac- 
teria likely to be present. 

8. It would seem very desirable to use 
oil which has been rendered free from dust, 
and especially from particles of metal. 

9. Workmen should not exchange waste 
and rags used in cleaning their hands, and 
should not bathe their hands in the oil. 

10. Clothing saturated with oil should 
not be worn, especially if there is an epi- 
demic of skin diseases among the workers. 



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Nois. — After this paper was accepted 
for publication, the Editor called the atten- 
tion of the writers to the repK)rt of an in- 
vestigation by the research staff of E. F. 
Houghton & Company on \he Causes of 
Skin Sores and Boils among Metal Workers 
(37). Data are given in detail and. the re- 
sults of the investigation are summarized in 
non-technical language. These results show: 

1. Ichthyol (0.2 per cent, to 1 per cent.) 
contained in certain oils produces skin 
lesions. 

2. The oils pressed from crude solid 
paraffin also contain an irritating substance. 

8. Lard oil does not irritate but may 
contain bacteria. 



4. Houghton's non-irritating blending 
oil is almost entirely free from idithyol and 
from organically combined hydrocarbon 
sulphonate. It is free from paraffin wax 
and contains no other ingredients which 
would irritate the skin. 

6. Daily filtration of used oil (140^ F. 
for thirty minutes) combined with sterili- 
zation will reduce the number of metal 
particles and the danger of bacterial con- 
tamination from careless workmen. 

6. Germicides added to oil are not effi- 
cient or satisfactory. 

7. The cleanliness of the worker is of 
first importance. Education in cleanliness 
is needed. 



BIBLIOGBAPHY 



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2. Knowles, F. C: The Ext^nal Origiii o! Ec- 
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as Based on a Study o! 4,142 Cases. Jour. 
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8. Oppenheim, M.: Gewerbliche Hautkrankheiten. 
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4. Lewm, L.: Ueber allgemeine und Hautver- 
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5. Prager: Vrtljschr. f. pr. Heilk., 1865, 88, 71, 
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6^ Crucis: Action physiologique et morbide de la 
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7. White, J. C. : Dermatitis Venenata. Boston, 1887. 

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11. Lefebvre, C. J.: De Tecz^ma des fileurs et va- 
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12. CoUis: Annual Rep. H. M. Chief Inspector 
Factories, 1910, p. 188, and 1914. Cited by 
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13^. Rambousek, J.: Industrial Poisoning from 
Fumes, Gases and Poisons of Manufacturing 
Processes. English Trans, by T. M. Legge. 
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14. Weichardt, W., and Apitzsch, H.: Gewerbe- 
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Gewerbebetrieben. Ztschr. f. Hyg., 1918, 85, 
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15. White, C. J.: Certain Occupations as Contrib- 
uting Factors to Diseases of the Skin. Boston 
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16. Allworthy, S. W.: Acneiform Eruption of 
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17. Oppenheim, M,: Drei Falle von Vaselinverlln- 
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20. Thibierge, G.: Le "bouton d' huile" des tour- 
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21. Albaugh, R. P.: Cause and Prevention of Fu- 
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75^ 



28« Blum, P.: L' 61aiokoniose folliculaire (bouton 
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ftS, Bridge, J. C: Memorandum on Cutting Lu- 
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28. Jacquet, L., and Jourdanet, P.: £tude ^tiolo- 
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BOOK REVIEWS 



Public Health and Insurance: American Ad- 
dresses. By Sir Arthur Newsholme, K.C.B., M.D., 
F.R.C.P., Lecturer on Public Health Administration 
at the School of Hygiene and Public Health, Johns 
Hopkins University, Baltimore, Maryland; Late 
Principal Medical Officer of the Local Government 
Board, England; President of the Society of Medical 
Officers of Health and of the Epidemiological So- 
ciety; Examiner in Public Health to the University 
of Cambridge, in Preventive Medicine to the Uni- 
versity of Oxford, and in State Medicine to the 
University of London, Member of the General Med- 
ical Council, of the Council of the Imperial Cancer 
Research Fund, etc. Cloth. Pp. 270 with index. 
Baltimore: The Johns Hopkins Press, 1920. 

In the form of ten lectures Sir Arthur News- 
holme has brought together material presented 
by him in addresses to various public audiences 
in the United States and Canada, and partic- 
ularly to students in the School of Hygiene and 
Public Health of Johns Hopkins University 
during the year 1919-1920. It is fortunate that 
there are thus made available to a larger public 
these expressions of the philosophy and wisdom 
of an able and broad-visioned public health 
administrator. 

The lectures are concerned essentially with 
the development of public health activities in 
England, and it is, therefore, inevitable perhaps 
that there should be extended discussion of the 
relation of public health administration to the 
Poor Law authority and of the interrelations of 
poverty and disease. 

Dr. Newsholme's views regarding the English 
National Insurance Act would undoubtedly 
interest any person who has given thought to 
the problems of compulsory health insurance. 
"The chief justification of a national system of 
insiu<ance against sickness is that it shall be an 
action auxiliary in the prevention of disease. 
. . . Health progress can only be secured by 
preventing preventible illness. . . . In securing 
such a result there will be needed medical prac- 
titioners who are imbued with the ideas of pre- 
ventive medicine in its widest sense. . . . 
There is needed a reconstruction of the training 
of each medical student which will make pre- 
ventive medicine in its widest sense an integral 
part of his training. ..." 

This very readable book well merits the at- 
tention of all who believe that "the real wealth 
of a nation does not consist in its money, in the 
volume of its trade, or in the extent of its 
dominion. These are only valuable in so far as 
they help to maintain a population — and not 



only a portion of it — of the right quality: 
men, women, and children possessing bodily 
vigor, alert mind, firm character, courage, and 
self control "; and that "this ideal can never be 
realized unless and until the medical men of the 
future train themselves for and devote them- 
selves to their essential share in its fulfillment.** 
— Wade Wright. 

Die Kohlenoxydvergiftung. Bin Handbuch fur 
Mediziner, Techniker und Unfallrichter. By 
Professor Dr. L. Lewin. Paper. Pp. 369 and a 
spectroscope chart. Berlin: Julius Springer, 1920. 

This book is by the well-known Berlin tox- 
icologist, who has written many articles on car- 
bon monoxide poisoning in current medical 
literature. The subject is dealt with exhaus- 
tively under the following headings: history; 
sources of carbon monoxide; physical and 
chemical properties; relation of carbon mon- 
oxide to the tissues of the body; qualitative and 
quantitative tests; mode of action on plants, 
cold-blooded and warm-blooded animals; r6le 
of individual susceptibility in poisoning; mode 
of absorption; sources of carbon monoxide in 
industry; acute poisoning and its sequelae; 
chronic poisoning; pathological anatomy and 
medico-legal aspect; statistics; prophylaxis and 
treatment. 

The chapter on history opens with the state- 
ment that carbon monoxide is now and has 
been since the first discovery of fire the most 
widespread poison connected with human life 
and activity. Aristotle mentions coal gas as a 
cause of death. Livy and Valerius Maximus 
describe wholesale executions performed by 
imprisoning the victims in the public baths and 
then starting the fires, and it seems also to have 
been a common method of painless suicide in 
Roman days. Julian, the Apostate, describes a 
very typical case of poisoning which he sufiFered 
when sleeping in a room with a pan of glowing 
coals. Through the Middle Ages the history of 
carbon monoxide poisoning passes from one 
extreme to the other. Sometimes its effect is 
attributed to the work of demons or witches; 
again, an unusually observant and clear- 
headed physician will describe a case with great 
accuracy. Avicenna noted it as a poison which 
weakened the brain. Toward the latter part of 
1500, Donato of Mantua described practically 
all the symptoms of this form of poisoning, the 
rosy color of the face and the appearance of nor- 



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77 



mal sleep in the coma of carbon monoxide 
victims, the fever, bronchial irritation, and 
pneumonia which follow, and the different 
manifestations of damage to the brain. More 
than a hmidred years later, Ramazzini de- 
scribed carbon monoxide as a common indus- 
trial poison, and the eighteenth century saw 
the publication of several very accurate obser- 
vations, notably those of Friedrich Hoffmann 
in 1720 and of Boerhave in 17S2. 

The author gives analyses of smoke and gas 
from all possible sources, and the student who 
wishes to look up ''gassing" in mines, in the use 
of explosives, in blast furnace work, in the use 
of power gas, and in the manufacture and use of 
illuminating gas will find much valuable ma- 
terial here. In the section on the physical and 
chemical properties of carbon monoxide, Lewin 
warns against the fallacy of applying to human 
beings the facts discovered in the laboratory, 
for in this form of poisoning, more than in any 
other, individual characteristics play an enor- 
mous r6le. The outcome of no single case can 
be predicted on the findings with regard to con- 
centration of carbon monoxide or absence of 
oxygen; the man's fate lies essentially in his 
own vital forces. Even the capacity of the 
blood to bind carbon monoxide varies in dif- 
ferent individuals. A practical point brought 
out by test tube experiments is that, although 
the blood gives up carbon monoxide even at 
zero centigrade, the surrender is much more 
rapid at a higher temperature. 

It is impossible to cover nearly all the chap- 
ters of this book within the compass of a review. 
There is space only for the stand taken by 
Lewin on various controversial points. He 
finds carbon monoxide excreted very rapidly 
during the first hour after removal to fresh air, 
then more slowly, but by the end of six hours it 
is usually no longer demonstrable, although he 
has satisfied himself that as little as 0.25 per 
cent, can be shown through the spectroscope. 
He is very skeptical about the instances re- 
ported in the literature of carbon monoxide in 
the blood after more than twenty-four hours in 
pure air. The great variation in the quantity 
found in the blood after death (from 6 per cent, 
in Emile Zola's blood to 83 per cent, in one of 
Haldane's cases) can only be explained on the 
ground of individual susceptibility or perhaps of 
difference in the mode of administration of the 
gas, or the possibility that blood in different 
parts of the body contains different proportions 
of carbon monoxide. 



Lewin takes a very positive stand in the con- 
troversy over the mode of action of carbon 
monoxide, denying that there is any direct ac- 
tion on the cells of the central nervous system 
or of any other organs. All the manifold lesions 
found after carbon monoxide gassing result 
from the injury caused by oxygen privation. 
The whol^error of those who uphold the theory 
of carbon monoxide as a protoplasmic poison is 
that they do not distinguish between the lesions 
of acute poisoning and the later results which 
have no direct connection with the intoxication 
but are secondary and of various origins. It is 
absurd to say, when pneumonia supervenes 
twenty-four to forty-eight hours after the in- 
toxication, that carbon monoxide has injured 
the lung, for it has no chemical or physical effect 
on lung tissue nor does it injure the blood ves- 
sels, producing fatty changes of intima and 
media, any more than does the inhaling of amyl 
nitrite. Carbon monoxide poisoning is a special 
kind of asphyxia which in general corresponds 
symptomatically with other forms of oxygen 
deprivation. This statement rests on the blood 
changes noted and on the impossibility as yet of 
finding any other tenable theory. If the blood 
changes are not the essential and only cause, 
then the action of carbon monoxide on the 
brain must be relegated to the mysterious realm 
of morphine, hydrocyanic acid, cocaine, etc., 
which have nothing in common chemically and 
yet affect the function of the brain in some un- 
explained way. With carbon monoxide as with 
hydrogen sulphide and with the poisons which 
form methemoglobin, there is a causa proxima 
in the blood changes, and this should be ac- 
cepted so long as no more cogent cause can be * 
found. 

Carbon monoxide poisoning is, however, 
distinguished from all other oxygen-deficiency 
or hemoglobin-alteration poisons by the occur- 
rence of sequelae. In all toxicology no known 
body can compare with carbon monoxide in the 
variety and extent of lesions following it, and 
individual susceptibility is not enough to ac- 
count for them. But to assume that carbon 
monoxide acts directly on the brain and other 
organs does not help, for in that case the effects 
would be more uniform and constant. Their 
great variation and extent show that very 
special conditions must be present, not ac- 
counted for by mere oxygen deficiency or other 
poisons, and it is these conditions that are the 
most puzzling elements in the problem of car- 
bon monoxide poisoning. 



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To the unsettled question of chronic carbon 
monoxide poisoning Lewin does not contribute 
very much, although he gives some instances of 
marked* and undoubted slow poisoning. It 
cannot be regarded as a cumulative eflFect of the 
gas in the body which, when it reaches a certain 
degree, gives rise to clinical symptoms. For 
this, one would have to remain in the carbon 
monoxide atmosphere continuously, and that is 
never true; one is always getting rid of the gas 
when one goes out into" pure air. A chemical 
accumulation cannot occur, but a functional 
one can — i.^., a cumulative eflfect of all the 
injuries done to the blood and to the tissues, 
especially the hemopoietic. This injury may be 
simply nutritive — ah anoxemia — but as a 
result poisonous products may be formed and 
exert their own secondary action. As in acute 
poisoning, individual susceptibility varies 
greatly. There is great difficulty in diagnosis, 
for the symptoms are usually only headache, 
anemia, cardiac neurosis, or general nervous- 
ness. The avocations in which this danger is 
present are these: cooks, furnace tenders, pres- 
sers, laimdry workers, gas workers, molders, 
miners, chemists, firemen, garage workers and 
housewives. The symptoms which come on 
usually at the end of the day's work — head- 
ache, dizziness, and distiu-bance of vision — 
pass over quickly at first in the open air, but 
later the natural recuperative powers fail and 
some form of chronic poisoning sets in, the most 
conamon of which is anemia, which may be of 
any type up to the severe pernicious. 

The treatment of acute carbon monoxide 
poisoning must be directed toward the restora- 
tion of normal response to stimuli on the part of 



the* cerebral centers, especially the respiratory. 
The ground for administering oxygen is the 
fact pix)ved by experiment that the dissociation 
of carbon monoxide from the blood takes place 
five times as quickly with pure oxygen as with 
ohiinary air. The administration must some- 
times be prolonged, but it is necessary to re- 
member that with the disappearance of carbon 
monoxide from the blood the symptoms caused 
by its presence do not always disappear. The 
brain symptoms, for instance, may not improve, 
even- after all the carbon monoxide has van- 
ished, and one must assume either that there 
are other toxic substances present in the blood 
which continue to act, or that the degenerative 
changes set up by carbon monoxide progress 
after the cause has been removed. Lewin con- 
demns unreservedly the subcutaneous injection 
of oxygen or hydrogen peroxide. He approves 
of venesection as lessening the danger of hem- 
orrhage, stimulating blood regeneration, and 
also as eff^ting a partial removal of the poison 
(Teilentgiftung), which last is hardly in har- 
mony with his repeated assertion that carbon 
monoxide is not a poison. Normal salt infusion 
is of decided value, especially when preceded by 
bleediag, but Lewin objects strenuously to 
blood transfusion, - apparently imder all cir- 
cumstatices. 

A colored chart of the different spectra of 
oxyhemoglobin and carbon monoxide hemo- 
globin before and after reduction is appended. 
The bibliography is very full, in fact, practically 
complete except for the more recent American 
publications which were probably not acces- 
sible to the author at the time of writing. — 
Alice Hamilton. 



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PUBLISHED MONTHLY 



VOLTTIIB ni 



JULY, 1921 



Ntjhbbr 8 



PHYSIOLOGICAL EFFECTS OF AUTOMOBILE EXHAUST GAS AND 
STANDARDS OF VENTILATION FOR BRIEF EXPOSURES* 

YANDELL HENDERSON, HOWARD W. HAGGARD, MERWYN C. TEAGUE. 
ALEXANDER L. PRINCE, and RUTH M. WUNDERLICH 



CONTENTS 

Introduction 
I. Fundamental Considerations 
II. Experiments on Men in Six Cubic Meter Chamber 
in. Rate of Absorption of Carbon Monoxide and Stand- 
ards of Allowable Vitiation of the Air 
rV. Concordance of the Standard Here Proposed with 

the Observations of Other Investigators 
V, Observations in Large Gassing Chamber 
VI. Observations in Garages and in the Grand Central 

Station, New York City 
VII. Comparative Toxicity of Pure Carbon Monoxide, 
Illuminating Gas, Elxhaust pas from Gasoline, 
Exhaust Gas from Coal Distillate and Gasoline 
Vapor 
Vni. Princifial Conclusions ' 

Introduction 

THE increasing use of the gasoline en- 
gine in a widening diversity of fields 
has brought with it corresponding problems 
concerning the influence of exhaust gases 
upon the health not only of the men in im- 
mediate charge of the machines but of the 

* An abbreviation ot the report to the Chief Engineer 
of the New York State Bridge and Tunnel Commission and 
the New Jersey Interstate Bridge and Tunnel Commission. 
The investigations were carried out under the Bureau of 
Mines at the Physiological Laboratory of Yale University. 
The full reports on both the engineering and the phys- 
iologiGal aspects of this problem will be published in the 
report of the Chief Engineer of the Commissions and by the 
Bureau of Mines. Published here by permission of the 
Director of the U. S. Bureau of Mines and of the Chief 
Engineer of the New York State Bridge and Tunnel Com- 
mission and the New Jersey Interstate Bridge and Tunnel 
Commission. Received for publication Feb. 24, 1021. 



general public as well. Reports upon a 
number of these problems have already 
been published by the United States Bu- 
reau of Mines, but, for the most part, 
recent studies have dealt particularly with 
the use of traction engines and the vitia- 
tion of the air in coal mines, and the de- 
termination of standards for tlie allowable 
vitiation requisite for safety. 

The j)lan to construct tunnels under the 
Hudson River between New York and 
Jersey City for the use principally of motor 
vehicles has raised several problems which 
have previously, however, never been exten- 
sively investigated. Whereas the conditions 
in coal mines and about gas producer plants 
apply only to healthy men, the conditions 
which will prevail in the tunnel under the 
Hudson River will affect the general public, 
>fot only healthy adults but children and 
even invalids on their way to hospitals will 
be transported through it, and at some 
time it may be necessary for soldiers to 
march through. The amount of traflSc is 
likely to be large, even from the beginning, 
and is likely to increase in a few years to the 
maximum capacity of the roadway. The 
total amount of exhaust gas discharged 
from passenger cars and trucks will there- 
fore be considerable. The distance between 



79 



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the ventUating shafts at the pier heads on 
the two sides of the river will be somewhat 
more than 3,300 feet — a distance greater 
than in any existing tunnel used by motor 
vehicles — and the total length of the tun- 
nel about 8,500 feet between portals. The 
ventilation must, therefore, be ample to 
prevent not only danger, but even slight 
discomfort, and must be managed in such 
a fashion as to avoid excessive wind ve- 
locities. The cost of installing ventilating 
fans will, in any case, be an appreciable 
item in the initial construction, and the 
maintenance of artificial ventilation during 
the operation of the tunnel is likely to be 
one of the largest single items of continuing 
expense. 

Accordingly, the commissions of the states 
of New York and New Jersey through their 
Chief Engineer, Mr, Clifford M. Holland, 
contracted with the Bureau of Mines to 
undertake on their behalf the investigation 
of two problems: (1) the amount and char- 
acter of the exhaust gas produced by va- 
rious types and sizes of passenger cars and 
trucks; and (2) the nature of the toxic sub- 
stances in exhaust gas, and their allowable 
concentration — that is, the extent to 
which the gas must be diluted with air to 
become practically harmless. The results of 
these two investigations will together af- 
ford the data upon which plans and designs 
for the ventilation of the tunnel may be 
intelligently based. 

Problem 1 was placed in the inmiediate 
charge of Mr. A. C. Fieldner, supervising 
chemist of the Bureau of Mines at the Ex- 
periment Station of the Bureau at Pitts- 
burgh. Problem 2, of which the results are 
here published, was assigned to Dr. Yandell 
Henderson, Professor of Physiology in Yale 
University and Consulting Physiologist of 
the Bureau of Mines. The work was carried 
out by him with a staff of physiologists and 
chemists employed by the Bureau for this 
purpose in the Physiological Laboratory at 
Yale University. 



The investigations and formulations here 
presented are of a much wider scope than 
the mere solution of the problem raised by 
the Hudson tunnels. Vehicular tunnels are 
being very generally considered both as 
substitutes for bridges and as a means of 
decreasing distances and grades in high- 
ways in mountainous regions. Further- 
more,^ the results of these investigations 
apply almost equally well to conditions in 
garages and fire rooms, to the air around 
gas producers, smelters and blast furnaces, 
to dwellings in which there is an escape of 
illuminating gas, and, in general, to all 
places where men are exposed to the gaseous 
products of incomplete combustion. 

Prior to this investigation, the stand- 
ards of allowable air vitiation with carbon 
monoxide have not been precisely defined. 
The investigations of Dr. J. S. Haldane, 
the eminent English authority, have dealt 
chiefly with questions of the safety of 
miners after mine explosions and fires, and 
his attention has, therefore, generally been 
directed to the amount of carbon monoxide 
which would incapacitate or seriously in- 
convenience a man, rather than to those 
amounts which^are compatible with com- 
plete comfort and eflSciency. For the Lon- 
don underground railways, however, he 
gave it as his opinion that a concentration 
of not more than one part of carbon mon- 
oxide in 10,000 of air was desirable. It is 
noteworthy, nevertheless, that he contem- 
plated a possible period of exposure suflS- 
cient for the blood to approach equilibrium 
with this concentration in the air. The 
standard hereinafter proposed by the au- 
thors appears at first sight distinctly higher 
than that originally suggested by Dr. Hal- 
dane, but when the short time of exposure 
in the proposed vehicular tunnels is taken 
into consideration it will be seen that the 
figures reached by Dr. Haldane and by the 
authors for the amount of carbon monoxide 
absorbable without appreciable injiu-y or 
discomfort are in quite close agreement. 



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HENDERSON — PHYSIOLOGICAL EFFECTS OF EXHAUST GAS 81 



It might appear that the ventilation of 
any closed space should be such as to fur- 
nish virtually as pure air as that of the city 
streets. In that case, this investigation 
would be imnecessary, and a standard of 
not more than one part of carbon monoxide 
in 10,000 of air might have been adopted. 
To have attempted, however, to ventilate 
long tunnels like those imder the Hudson 
River, or any similar closed space, so that 
the air would be virtually free from carbon 
monoxide, would f)erhaps have proved 
scarcely practicable. It- would certainly 
have beeil extremely expensive. The wind 
velocities necessary in moving such a vol- 
ume of air would cause discomfort to pas- 
sengers and might even prove prohibitive 
of traffic. 

The standards here established will re- 
duce the expense of ventilation greatly 
below that required to provide a carbon 
monoxide dilution of one to 10,000, not 
only in the Hudson tunnels, but in all 
similar future undertakings. These stand- 
ards will, it is hoped, prove valuable both 
to hygienists interested in safeguarding the 
public health and to engineers engaged in 
the design of a wide variety of projects 
both above and below ground. 

I. Fundamental Considerations 

Although carbon monoxide is the cause 
of more deaths than the total due to all 
other gases, apart from a single reaction it 
is a physiologically inert and non-poisonous 
substance. This reaction is its combination 
with hemoglobin, the red coloring matter 
and oxygen-carrying element of the blood. 
To whatever extent hemoglobin is so com- 
bined, it is rendered incapable of transport- 
ing oxygen from the lungs to the tissues 
and organs of the body, until the carbon 
monoxide is again displaced. It is highly 
probable that all of the results of inhalation 
o€ carbon monoxide are due directly or in- 
directly to oxygen deficiency. Even when 



other toxic substances are present — as in 
smoke, in fumes from explosives and in 
other incomplete combustions — carbon 
monoxide is usually the chief cause of injury 
or death. It acts wholly through asphyxia. 

The body of to adult man of average 
weight contains enough hemoglobin to 
hold about 600 c.c. of oxygen. If com- 
pletely saturated, it would hold the same 
amount of carbon monoxide, one molecule 
of carbon monoxide replacing one molecule 
of oxygen in the blood. The absorption of 
6 c.c. of carbon monoxide from the lungs 
produces, then, 1 per cent, of saturation 
and abolishes 1 per cent, of the oxygen 
capacity. 

The unit, in which various concentra- 
tions of carbon monoxide are commonly 
measured and expressed for purposes of 
ventilation, is one "part," or a certain 
number of "parts," of this gas mixed with 
10,000 times as much air. A "part" is a 
hundredth of 1 per cent, of an atmosphere. 
A man at rest breathes about 8,000 c.c. of 
air per minute, of which about 6,000 c.c. 
reach his lungs, or 60 liters in ten minutes. 
Let us suppose that this air contains one 
part of carbon monoxide, or 6 c.c. in 60 
liters, and that all of this 6 c.c. is absorbed. 
The blood would then become saturated at 
the rate of 1 per cent, every ten minutes 
per "part" of carbon monoxide in the air. 
Evidently, the duration of exposure is a 
limiting factor in the amount absorbed, for 
one cannot absorb more than one inhales. 

It appears that when a man. begins 
breathing any 1q,w concentration of carbon 
monoxide mixed with air, absorption at 
very nearly this rate does occur, but only 
at .first. Then the rate becomes slower. 
Even if the exposure is prolonged, carbon 
monoxide merely displaces oxygen from 
the blood up to a point of equilibrium de- 
pending upon the relative amounts, or 
mass actions, of carbon monoxide and 
oxygen in the air breathed and the inten- 
sity of the aflSnities of the two gases for 



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hemoglobin. If thereafter the pressure of 
oxygen is high enough and that of carbon 
monoxide is low, or absent as in pure air, 
oxygen can likewise displace carbon mon- 
oxide and thus completely restore the 
twygen^carrying power of the hemoglobin. 
Th% blood is neither directly changed nor 
injIMi by the process. 

Hemcflohia attracts carbon monoxide 
about 300 times as strongly as it does oxy- 
gen. Thus, if Toj and Tco are the pres- 
sures of oxygen and carbon monoxide, and 
Hbo, and Hbco the amounts of oxyhemo- 
globin and carbon monoxide hemoglobin 
in the blood, the relations are expressed by 
the formula: 



Tiv 



. Tcoxsoe* 

percentage Hbco " 



,or 



Hbco' 

TcoXSOO 



To, + (TcoXS»)' 

or more specifically, if there are 1,500 parts 
of oxygen and 2 ^f carbon monoxide, the 
formula works out to: 



2X300 



= 28.5 per cent, satura- 



1500 -j- (2X300) 

tion with carbon monoxide. 

The air in the lungs contains about 1,500 
parts of oxygen in 10,000. (It is actually 
somewhat less than 15 per cent, of oxygen. 
The affinity of hemoglobin for carbon 
monoxide may also be less, or more, than 
300. We are here using round numbers 
merely to illustrate the principle without 
attempting mathematical precision.) We 
may calculate the blood equilibrium for any 
concentration of carbon monoxide in the 
air, and from such data we may obtain the 
carbw jmonoxide dissociation curve of the 
blood as shown in Figure 1. This curve 
indicates that, if air containing two parts of 
carbon monoxide in 10,000 is breathed for a 
time long enough to attain equilibrium, the 
blood should become about 28 per cent, 
saturated; with four parts, 44 per cent.; 
with six parts, 54 per cent.; and so on. 
In the curve it is to be seen that, for in- 



stance, the equilibrium value for ten parts 
of carbon monoxide in 10,000 of air is 60.6 
per cent, saturation, which is a sufficient 
degree of saturation to render a man un- 
conscious and totally helpless. If con- 
tinued, the asphyxia might lead to serious 
f)ermanent injury or even death. 

The question of greatest practical im- 
portance is: How long a time would be 
required to attain this or any other definite 
percentage of saturation? In other words, 
what is the physiological law defining the 
rate of absorption of carbon monoxide into 
the blood? From the simple calculation, 
given previously, regarding the oxygen 
capacity of the body and the volume of air 
drawn into the lungs, it apF>ears that a man 
breathing ten parts of carbon monoxide 
would inhale enough of the gas to become 
66.6 per cent, saturated in 66.6 minutes. 
But; as already indicated, the more carbon 
monoxide the blood contains, the greater 
becomes the force with which this gas tends 
to diffuse out again into the air. The more 
nearly this tendency equals and counter- 
balances the pressure of the gaseous carbon 
monoxide in the lungs, the slower the ab- 
sorption of more carbon monoxide becomes. 
Thus, to attain a condition of complete 
blood equilibrium many hours would be 
actually required; indeed, the time is in- 
determinate. Doubtless other factors also 
play a part in retarding and stopping 
absorption. 

It appeared to us, however, that a d^niie 
quantity for determination would be the time 
required for attainment of a percentage sat- 
uration of one-half the equilibrium values. 
Thus, in an atmosphere containing two 
parts of carbon monoxide, for which the 
blood equilibrium is about 28 per cent., how 
long a time would be required for the blood 
to become 14 per cent, saturated? How 
long with four parts and im equilibrium 
value of 44, to attain 22 per cent, satura- 
tion; or with six parts and an equilibrium of 
54, to reach 27 per cent.? The answer to 



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HENDERSON — PHYSIOLOGICAL EFFECTS OF EXHAUST GAS 83 



this question is the principal practical con- 
tribution to knowledge which we have to 
make — namely, that the time for attain- 
meni of half equilibrium for persons sitting at 
rest and breathing concentrations of carbon 
monoxide up to seven parts is never con- 
siderdbly less than one hour. This fact is, 
we believe, of fundamental importance for 
ventilation engineering. We have estab- 
lished it purely experimentally. It might, 
however, easily be correlated with the ox- 
ygen consumption and the carbon dioxide 
elimination, but we have 
not thought this to be of 
practical importance to 
the immediate object of 
this report. It does not, 
nor does it aim to, express 
what the average person 
does under the conditions, 
for many of our siibjects 
fell much below this rate 
of absorption. The value 
of the rule is that it ex- 
presses the worst attain- 
able, or, so to s{>eak, the 
** maximum load." 

We may here con- 
veniently consider the 
question, often raised, of 
possible extreme individ- 
ual susceptibiUty. Such 
susceptibility might conceivably arise (1) 
from anemia, that is, a subnormal amount 
of hemoglobin; (2) from an unusual avidity 
of the individual's hemoglobin for carbon 
monoxide; (3) from unusual susceptibility 
to the ill eflfects of oxygen deficiency; or (4) 
from a volume of breathing much above the 
ortlinary. The first is unimportant prac- 
tically inasmuch as anemics need not spend 
long periods in ill- ventilated garages, nor 
ride through tunnels on slow moving 
trucks. If, however, they are transported 
at the speed of a passenger car or an ambu- 
lance through a two-mile tunnel containing 
the average concentration of carbon mon- 



oxide here to be proposed, the time of 
exposure will be too brief to allow an ab- 
sorption sufficient for any considerable ill 
effect. The second possibility has been 
investigated by us, but has not been found 
to occur. (Owing to their hi^y technical 
and space-consuming character, these stud- 
ies are omitted here, but will appear in the 
full report.) 

There is reason to believe that there are 
individual differences ixi the degiee of the 
ill effects induced by considerable oxygen 



i 



*j> 



Sj 











































































^^ 
































-'^ 


.^ 


^ 
































r^ 
































/ 




^ 


^ 


































— -^ 


y^ 




































/ 


7^ 




































/ 


/ 


































/ 


/ 




































/ 


/ 




































/ 


/ 






































/ 






































/ 








































L 









































2 



Fio. 1. — Final or equilibrium distribution of hemoglobin between Garix>n 
monoxide and oxygen when various low cx>ncentrations of carbon monoxide in 
air are inhaled for an indefinitely long time. 



deficiency. Aviators and mountain climb- 
ers exhibit such differences, and in our more 
extreme tests headache has occurred in 
some persons at a somewhat lower percent- 
age saturation of the blood than in others. 
We have, however, found no one who ex- 
perienced this effect — the first sign of ox- 
ygen deficiency — under the conditions of 
the standards which we shall propose. 

The volume of breathing is by far the 
most important element in the rate of 
absorption of carbon monoxide and, thus, 
in the individual variations in the ill effects 
of inhalation of this gas. In general, the 
expired air of a healthy man contains 4 or 



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5 per cent, of an atmosphere less oxygen 
than the inspu^ed air, and this percentage 
deficit is nearly the same dm'ing rest with a 
breathing of 8 liters and under physical 
exertion with a respiration several times as 
large. In other words, the volume of 
breathing is roughly proportional to the 
amount of the oxidation and energy libera-/ 
tion occurring in the body. In our observa- 
tions, persons of " vigorous physique and 
large breathing rates have absorbed carbon 
monoxide much more rapidly, as measured 
in percentage blood saturation, than those 
of more sedentary habit and delicate phy- 
sique. As the standard which we shall 
propose is one adjusted to protect even the 
strong, it will therefore afford an extra 
safeguard to the weak and sick, who 
breathe little (except in febrile, cases) and 
who would, accordingly, absorb carbon 
monoxide comparatively slowly. Only in 
the case of children, whose active vitality 
involves a relatively large food and oxygen 
consumption and a corresponding volume 
of breathing, will this rule probably not 
hold. But even for the most active child, 
a period of exposure of only ten or fifteen 
minutes to the concentration of carbon 
monoxide here approved will not be long 
enough for any considerable absorption of 
the gas. 

The particular problem before us — that 
of a standard for the ventilation of the pro- 
posed vehicular tunnels under the Hudson 
River — may, therefore, be thus simply 
expressed : What percentage saturations of 
the blood with carbon monoxide cause ap- 
preciable discomfort in healthy men sitting 
at rest, and what percentage saturations 
do not? The answer to this question, the 
probable duration of exposure of passengers 
through the tunnel, and the law of carbon 
monoxide absorption as above stated, are 
the three considerations on which any 
sound standard must be based. 

In view of the foregoing discussion it is, 
we trust, clear that standards of concentra- 



tion, which will adequately protect men 
exposed for the greater part of an hour, will 
afford an enormous factor of safety for 
persons inhaling the vitiated air for only 
ten or fifteen minutes. We are informed by 
the engineers that all traffic through the 
tunnels will be in. two distinct classes — 
namely, passenger cars, which will make 
the trip in ten or twelve minutes, and 
trucks which may take as Tong as thirty- 
five or forty minutes. The standards which 
we set ourselves to work out are such as will 
afford not only absolute safety but also 
complete freedom from any trace of dis- 
comfort for healthy and vigorous adults 
exposed for periods of forty-five to sixty 
minutes. 

n. Experiments on Men in Six Cubic 
Meter Chamber 

The method of studying the effects of 
various concentrations of carbon monoxide 
upon which we have chiefly relied for 
establishing our standard is illustrated in 
Figure 2. It involves a chamber of 6.4 
cubic meters, or 226 cubic feet, capacity, 
the walls and door of which are covered 
with galvanized sheet iron with soldered 
joints. The door is easily made gas-tight 
by placing long strips of broad (2-inch) 
adhesive plaster over the cracks along lin- 
tel, jambs, and sill. The chamber holds any 
concentration of gas for a day without ap- 
preciable loSs from diffusion through undis- 
covered leaks. A small hole in the door, 
covered by a piece of adhesive plaster, al- 
lows the hand of the subject to be thrust 
outside for the withdrawal of blood. 

Into this chamber are introduced meas- 
ured amounts of pure carbon monoxide, 
made by dripping formic acid into strong 
sulphuricacid and distilling it by gentle heat 
into a large bottle filled with water, which 
ithe gas displaces. The concentration of gas 
desired in the chamber is obtained by run- 
ning into the bottle 640 c.c. of water per 



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HENDERSON — PHYSIOLOGICAL EFFECTS OF EXHAUST GAS 85 



part of carbon monoxide desired, and thus 
displacing this volume of gas from the 
bottle through a tube into the chamber. 
An electric fan in the chamber insures im- 
mediate and complete mixing. In our ex- 
p>eriments, two checks on the concentration! 
of gas in the chamber were 
obtained: (1) by analysis 
of the carbon monoxide, 
before it was introduced, 
by means of a modified 
Orsat apparatus, and 
ignition with an electri- 
cally heated platinum 
spiral; and (2) by analysis 
of a mixed sample of the 
air from the chamber by 
the iodine pentoxide 
method, or by means of 
diluted blood. (For a de- 
scription of these analyt- 
ical methods, see biblio- 
graphical references 
1,2,3.) 

In this chamber, in 
turn, the members of the 
staff of this investigation 
and a few other persons 
spent periods of one hour 
after amounts of carbon 
monoxide from two to 
eight parts, and in one 
case ten parts, had been 
introduced. While the 
subjects sat and read most 
of the time, there were 
a suflScient number of 
acts — such as turning on 
the electric fan, standing up to look out of 
the window for a moment, opening and 
closing flasks to take air samples for later 
analysis, etc. — to correspond fairly well 
with the activity of the driver of a car. 
When we speak of the absorption of carbon 
monoxide by a person "sitting at rest," the 
condition must, therefore, be understood as 
only such moderate rest as this. 



Blood, to the amount of twenty or 
thirty drops, was drawn from a finger be- 
fore the subject entered the chainber; and 
0.02 c.c. were drawn at the middle of the 
period arid at the end, and usrually once or 
twice during the next three hours. These 




iNrrniOft or cnAnseR 

Fio. 2. — Six cubic meter chamber and apparatus for introducing measured 
amounts of carbon monoxide. This chamber consists of a wooden framework 
covered with sheet iron. It contains a chair, table, and electric fan. It can be 
hermetically sealed by applying long and broad strips of adhesive plaster 
over crevices between the door and the chamber walls. The hand hole in the 
door is ^Iso sealed by plaster. Through this hole the subject may thrust his 
hand when samples of blood are required for analysis. 

With the diffusion fan running, measured quantities of water are introduced 
into the funnel. By opening the pinch clamps carbon monoxide is displaced 
from the bottle into the diamber. Samples of air for analysis may be with- 
drawn from the chamber by means of the sampling tube. A rubber bag allows 
for expansion or contraction of the chamber air with changes of temperature. 



blood samples were analyzed for carbon 
monoxide by the carmine method (3). 

After the subject had been out of the 
chamber for a few minutes, the tension of 
carbon monoxide in his lungs, supposedly 
in equilibrium with the blood, was deter- 
mined by breathing back and forth several 
times, during twenty to thirty seconds, 
into a rubber bag. Football or basket ball 



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"bladders" were used for this purpose. 
(A series of check determinations on four 
subjects showed that the maximum con- 
centration of carbon monoxide from these 
bags was reached in five rebreathings dur^ 
ing thirty seconds.) This air was then 
analyzed for carbon monoxide by the iodine 
pentoxide method, or by the blood carmine 
method. The subject's volume of resting 
breathing was determined either in or out- 
side of the chamber by means of a mouth- 
piece, nose clip, double valves, and Douglas 
bag and gas meter; and the volume per 
minute was calculated'. 

In some experiments the respiration was 
increased by exercise, and the increase was 
measured and correlated with the corre- 
spondingly greater absorption of carbon 
monoxide. In these experiments the sub- 
jects did "stationary*' walking or run- 
ning in the chamber by lifting the feet and 
stamping. The exertion involved is con- 
siderable, but with care it can be kept quite 
uniform for half an hour at a time. The 
pulse was counted in the chamber, and 
before and after the test. The eflPects on the 
pulse and respiration of running up and 
down four flights of stairs, each 18 feet 
vertically, were also determined before and 
after the period in the chamber. 

In a few cases the retinal fields were de- 
termined and plotted. With the degrees of 
anoxemia occurring in these experiments, 
however, the eflfects on vision in this respect 
were unimportant. The Romberg test, the 
ability to stand erect with eyes closed with- 
out wavering, was also used, and in some 
cases, after an hour in eight parts of carbon 
monoxide, it showed marked loss of equilib- 
rium* 

But of all signs and tests, both in the ex- 
periments in the small chamber here under 
discussion and in those that are to be 
described in the next section, the typical 
carbon monoxide, or oxygen deficiency, 
headache proved most definite and reliable. 
It is a distinctly localized pain, usually 



frontal, throbbing, intensified by lying 
down or by exertion. It is sometimes ac- 
companied by more or less nausea, readily 
increasing to vomiting. The mind is not 
clear, except with an effort, and one's 
surroundings seem a little strange. The 
temper is easily upset, very much as in 
alcoholic intoxication, and the judgment is 
likely to be bad. There are wide variations 
in the degree of this headache, but in the 
experiments discussed in this section it was 
never extreme. On the border line it 
verged merely into slight lassitude. As a 
criterion of the effect of carbon monoxide, 
however, it is more distinct than any arti- 
ficial test. Concentrations of gas too weak 
and periods of exposure too short to induce 
* this sign in anyone may be . considered 
entirely harmless. 

From Table 1, in which the data of 
thirty-two experiments performed in this 
way on nine men and one woman are given, 
it appears that no one had an appreciable 
degree of headache after a period of one 
hour in the chamber with four parts of car- 
bon monoxide or less, and that with six 
parts the effect, if any, was usually very 
slight. With eight parts there was decided 
discomfort for some hours, although not 
enough to interfere with eflScient work in 
the laboratory or at the desk. After an 
hour in ten parts even an unusually resist- 
ant subject was rather miserable and averse 
to work for five or six hours, and could still 
recognize the effects after twelve hours. 
Examination of these data enables us to 
reach a working rule regarding the rate of 
absorption of carbon monoxide, for we find 
that up to and including concentrations of 
six parts of carbon monoxide in 10,000 of 
air the figures in column 3 of Table 1 do not 
exceed values of about one-half those for 
complete equilibrium given in Table 2 and 
drawn in Figure 1. 

In other words, during one hour sitting at 
rest in such atmospheres, a man's blood 
never absorbs appreciably more than half 



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HENDERSON — PHYSIOLOGICAL EFFECTS OF EXHAUST GAS 87 



the amount of carbon monoxide which it 
would take up if he stayed in the atmos- 
phere indefinitely. Inactive and small 
breathing persons absorb less. At concen- 
trations of eight and ten parts of carbon 
monoxide the figures deviate sUghtly from 
this rule, but the rule of half satiu-ation 
appears to be safe and convenient up to 
seven parts. It appears further that a man 



under exertion even more. These figures 
may be directly apphed to conditions as 
they occur in regard to absorption of carbon 
monoxide. The estimation of the time re- 
quired for half equilibrium must be short- 
ened accordingly. 

Elimination of Carbon Monoxide. — As 
regards the eUmination of carbon monoxide 
after gassing, our data show that the proc- 





TABLE 1. 


— PHYSIOLOGICAL OBSERVATIONS ON MEN IN SIX CUBIC METER 








GASSING CHAMBERS 






Number of 


Concentra- 
tion of CO 
in Air 


Blood CO Percentage 
Saturation 


Alveolar Air CO 
Parta in 10,000 


Puke 




Experiments 


Normal 


After Gassing 


Symptoms 




Parts * 
in 10,000 


After 
One Hour 


One How 








2 


% 


11-12 


• 


70-80 


70-76 


Done 


3 


8 


18, 10, 14 




72,84,74 


72,82,74 


a X 


11 


4 

5 


22,18,17.18,14, 
14,20,21 


1.36, 1.33, 1.30 
0.9 


72,74,72,76, 
76.70,80 


68,76,72.80. 

72,74,82 






6 


21, 16, 16, 25, 26, 


1.30, 1.26, 1.98. 


72,74,80,72, 


72.74,82,72, 


none in seven cases. 






17, 16, 18, 18 


1.20, 1.00, 1.24, 
1.25, 2.30 


74,78 


74 


slight frontal headache 
in two cases 




8 


82,27.8.34,26 


2.3, 1.4, 2.0 


72,76.74 


88.80,84 


decided headache four 
to eight hours 







34 




76 


80 


decided frontal head- 
ache; irritable for six 
hours; insomnia 




10 


38 




78 


90 


throbbing frontal head- 
ache; irritable; at times 
Cheyne-Stokes' breath- 
ing 



1 The figures in column S of the above table are seen to be never more than half the equilibrium values at concentrations of six parts, or 
leas, in 10,000 of air. For equilibrium values see Table 1. 

A number ci escperiments on the influence of exerdae were also carried out in the chamber. When the volume of breathing was thus in- 
creased the rate of absorption of carbon monoxide was proportionally increased. 



who exercises sufficiently to double the 
volume of breathing absorbs as much car- 
bon monoxide in half an hour as he does at 
rest in one hour. We have found in other 

TABLE 2. — EQUILIBRIUM VALUES 
OBTAINABLE FROM FIGURE 1 



8 



10 



ParUofCOmAir 12 8 4 5 6 
Percentage Satura 

tion of Blood . 10.6 28.5 87.4 44.4 50.0 54.5 58.3 61.5 64.8 66.6 
\ 

experiments, which need not be given here 
in detail, that when walking fast a man 
breathes about twice as much air as when 
sitting still and that when hurrying or 
doing rather heavy manual labor he 
breathes about three times as much, and 



ess is not complete until one or two hours, 
or even longer, after return to fresh air. 
Roughly, the rate of elimination is 30 to 50 
per cent, per hour, depending doubtless on 
bodily activity and the volume of fresh air 
breathed. This evidence is summarized in 
Figure 3. 

III. Rate of Absorption of Carbon 
Monoxide and Standards of Allow- 
able Vitiation of the Air 

The essential practical results of the ex- 
periments in the 6 cubic meter chamber, 
and indeed of this entire investigation, are 



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Tine ifi nouR3 

Fio. 3. — The rate of elimination of carbon monoxide after gassing. Solid lines are from analyses 
of blood, and dotted lines from analyses of pulmonary air. 



9 



20 



/5 



/o 



O 



/.O 



a5- 




^7 

^ OAOTS COW 

o.oooorA« 



PEPni62|BLC 
SATUPATlOfI 

rod shOftT 

CXPOSUQC5 



SATURATION 
rOR LONO 
tXPOSURM 



Tine 



rUNUTCS 



SiTTfNO 



¥<ALKtNO 



WOPKINO 



Fio. 4. — Curves showing rate of absorption of carbon monoxide by the blood in persons exposed 
to concentrations up to seven parts of carbon monoxide in 10,000 of air, for periods up to one hour, 
during rest (sitting), and for snorter periods of walking and working. For discussion see text. 



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HENDERSON — PHYSIOLOGICAL EFFECTS OF EXHAUST GAS 89 



summed up in Figiu*e 4, which shows the 
rate at which carbon monoxide may be ab- 
sorbed and the amoimts at which physi- 
ological effects may occur. It is based on 
the data in Table 1, and is confirmed by the 
evidence obtained from experiments on a 
large nmnber^of people in the large gassing 
chamber -r- evidence which is to be pre- 
sented in Section V. The curves are drawn 
to show the rate of absorption of carbon 
monoxide when air with various concen- 
trations from one to seven parts of this gas 
in 10,000 is breathed. They express the 
absorption by the blood during one hoiu* 
of one-half the amoimt of carbon monoxide 
that would be taken up after prolonged 
stay in each of these atmospheres. 

One of the columns of figures at the left 
in this diagram expresses the percentage 
saturation attained by the blood; the other 
column shows the corresponding tension of 
carbon monoxide in the atmosphere in 
parts per 10,000 of air, with which the 
blood would be in gaseous equilibrium. In 
.other words, the figiu'es in column 2 indi- 
cate the amount of carbon monoxide that 
should be found in a pulmonary air sample, 
obtained by the method of rebreathing into 
a rubber bag, when the blood in the lungs 
contains these percentages of carbon mon- 
oxide. The three lines below the base line 
show respectively the (minimum) time re- 
quired to reach these percentage satura- 
tions when the subject is at rest, when he is 
walking at a moderate pace and breathing 
a double volume of air, and when he is suf- 
ficiently active to breathe threefold, as a 
man at even moderate work may do. Hori- 
zontal dotted lines have been drawn at the 
levels of 12 and 18 per cent, blood satura- 
tion, corresponding to tensions of 1.0 and 
1.5 parts per 10,000. The lower line indi- 
cates the amount of carbon monoxide which 
even after an exposure of several hours 
would not induce very disagreeable effects. 
The upper line expresses the level above 
which, in oiu* experiments, slight discom- 



fort and headache have sometimes resulted 
after an exposure of one hour. 

This diagram has a very wide applica- 
tion. One may take off from the curves, by 
means of a pair of dividers, the quantities 
of carbon monoxide which may be ab- 
sorbed by a person passing through any 
variety of concentrations of carbon mon- 
oxide, as may be the case in different parts 
of a tunnel. From the curves, one sees at a 
glance that if the tunnel is ventilated trans- 
versely so as to contain everywhere four 
parts of carbon monoxide in 10,000 — 
corresponding to 2,500 cubic feet of fresh 
air per minute per cubic foot of carbon 
monoxide produced by cars — a passage of 
three-quarters of an hour, the rate for slow 
trucks, would produce no appreciable dis- 
comfort. It is also evident when one plots 
the matter out, as has been done for the 
sake of illustration in Figures 5a, 5b, and 
5c, that if the tunnel is ventilated lon- 
gitudinally and the effluent air contains six 
parts of carbon monoxide, the physiological 
effect will be at least as good as with a imi- 
form concentration of foiu* parts in 10,000. 
In this case the ventilating fans need supply 
only 10,000 cubic feet of air for each 6 
cubic feet of carbon monoxide thrown off 
by the- cars in the tunnel, or 1,666 cubic 
feet of fresh air per minute per cubic foot of 
carbon monoxide. This is true if the air is 
forced in at one end and out at the other, 
and it is also true if the tunnel is ventilated 
in sections so that the air at some points 
contains only a trace of carbon monoxide 
and at others is contaminated progres- 
sively with from one to seven parts in 
10,000 of air. This would be the case, for 
instance, if fresh air were driven in at the 
middle and ends of the tunnel and drawn 
out at the two intermediate points; e. jr., air 
shafts at the pier heads on each side of the 
Hudson River. This is illustrated in 
Figure 5d. 

It is evident from this diagram that if at 
any point the concentration exceeds six 



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Fig. 5a. — Illustration of method for applying absorption curve data to specific conditions arising 
in a vehicular tunnel. Longitudinal ventilation. Subject in a sitting position travelling in direction of 
air current. Duration of passage through tunnel thirty-five minutes. The altitudes of the triangles 
express the increments of saturation of the subject's blood while passing through atmospheres increas- 
ing progressively in their carbon monoxide content. £ffluent air — seven parts carbon monoxide 
in 10,000 of air. 



7 0^13 CO M 
(5 \0,QOO OffiXi 



PQ»1b5IDlC 
5AnjRATlOri 
ro« 5nORT 
CX0O5UPC5. 




Fio. 5b. — Illustration of method for applying absorption ciu-ve data to specific conditions arising 
in a vehicular tunnel. Longitudinal ventilation. Subject travelling against air current. Duration 
of passage through tunnel thirty minutes. The altitudes of the triangles express the increments of 
saturation of the subject's blood while passing from effluent air containing seven parts of carbon 
monoxide in 10,000 through atmospheres decreasing progressively in their carbon monoxide content. 



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HENDERSON — PHYSIOLOGICAL EFFECTS OF EXHAUST GAS 91 




Fig. 5c. — Illustration of method for applying absorption curve data to specific conditions arising 
in a vehicular tunnel. Longitudinal ventilation. Subject walking in direction of air current. The 
altitudes of the triangles as under Figure 5a. 



DlSTHlBUTCD VENTILATION. 
BLOOD SATURATION (t ) Af TCH 

»tfSAoe Of «o nnuTES. 




hk^m sittiri6 "^ 



Fio. 5d. — Illustration of method for applying absorption curve data to specific conditions arising 
in a vehicular tunnel. Distributed ventilation. Subject in a sitting position travelling from A to E. 
Duration of passage through tunnel sixty minutes. The dots indicate the percentage saturation of 
the subject's blo<>d at various stages of the passage. The letters A, B, C, D, and E indicate the 
percentage saturation of the blood when the corresponding points in the tunnel are passed. 



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parts of carbon monoxide in 10,000 of air, 
men doing hard work for even a short time 
will be unfavorably affected. On the other 
hand, the curves show that passengers in 
cars going through the tunnel in ten or 
fifteen minutes will absorb very httle car- 
bon monoxide — a factor of safety which 
is, we believe, suflBcient to afford ample 
protection for children and invalids. The 
standard here proposed for exposures of 
forty-five minutes — four parts in 10,000 
or its equivalent in an average of concen- 
trations from zero up to six in 10,000 — 
affords, in the hght of our experiments, not 
only complete safety but also an assurance 



of freedom from disagreeable effects. Risk 
of considerable discomfort would begin at 
eight to ten parts of carbon monoxide in 
10,000 of air in periods of one hour during 
rest and for shorter periods during exertion. 
Actual danger would begin with concen- 
trations not very much higher and periods 
not very much longer. The point should be 
emphasized, however, that we are dealing 
only with a standard of chemical purity 'of 
the air. Other features of tunnel ventila- 
tion as, for example, wind velocity, mois- 
ture, temperature, etc., are not included in 
the standard here defined, nor is comfort in 
these respects assured by it. 



(To be continued) 



BIBLIOGRAPHY 



2. 



Teague, M. C: The Determination of Carbon 
Monoxide in Air Contaminated with Motor 
Exhaust Gas. Jour. Indust. and Engin. Chem., 
1920, 12, 964. 
Kreisinger, H., and Ovitz, F. K. : Sampling and 



Analysis of Flue Gases. U. S. Bur. Mines, Bull. 
97, 1915, pp. 21 and 32. 

Haldane, J. S. : Methods of Air Analysis. Lon- 
don, Charles GriflSn & Company, 1912, pp. 107- 
122. 



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THE INFLUENCE OF FATIGUE ON HEALTH AND LONGEVITY' 

H. M. VERNON. M.D. 

Investigator for the Industrial Fatigue Research Board, Lojidon 



THE final and most important test of 
the fatigue of a man's calling is to be 
found in the effect which it has on his 
health and longevity. Provided that he 
does not suffer more sickness than men in 
the healthiest trades, and shoWs no greater 
mortality, he has little ground for com- 
plaint even if his occupation is such as to 
induce a considerable degree of fatigue. 
Such fatigue must be within physiological 
limits, and so long as it does not exceed 
these limits and become pathological, it 
does him little or no harm. 

Unfortunately it is a by no means easy 
problem to determine the influence of 
fatigue on sickness and mortality. We 
know that in some occupations, such as 
those of the potter, stone quarrier, and file 
maker, the abnormal sickness and mor- 
tality experienced are due largely to the 
inhalation of dust. In other occupations, 
such as those of lead and arsenic workers, 
they are due to the poisonous action of the 
substances handled; and in others, such as 
sorting wool and hides, they are due to 
bacterial infection. Again, we know that 
industrial workers who have spent all their 
lives in the crowded quarters of town dwell- 
ings have, as a ride, a poorer physique than 
those brought up in more healthy surround- 
ings, and for this reason they may show a 
greater sickness and mortality, apart from 
any occupational effect. For instance, 
I>r. Arkle (1) measured the height and 
DV'eight of the boys in the different grade 
schools at Liverpool, and he found that 
^rhile boys of 14 years of age from the 
higher grade schools were 61.7 inches in 
height and weighed 94.6 pounds, those 
boys of the same age from the council 

* Received for publication Jan. 18, 1921. 



schools, who were the sons of unemployed 
and casual laborers, were 6.5 inches less in 
height and 23.4 pounds less in weight. 
Boys of intermediate social status showed 
intermediate measurements. 

Sickness Records 

It is, nevertheless, of such importance 
for us to determine what effect, if any, 
fatigue may have on sickness and longevity 
that even a prehminary and imperfect at- 
tempt at its estimation is instructive. Such 
an attempt I have recently made in one 
of the heaviest of our industries, the iron 
and steel trade (2). Under the National 
Health Insurance Act the sickness of all 
industrial workers in Great Britain has 
been systematically recorded since 1913, 
and much of this material is in a form suit- 
able for statistical treatment. Working in 
conjunction with Mr. E. A. Rusher, F.I.A., 
an actuary of long experience, I tabulated 
the sickness and mortality records of about 
24,000 iron and steel workers for a six-year 
period, 1913-1918, and Mr. Rusher and his 
staff have worked up this material accord- 
ing to approved actuarial methods. My 
object was to separate the men into clearly 
defined occupational groups, the character 
of whose work was well known to me as the 
result of close observation. Among the 
steel workers, five clearly defined groups of 
skilled men were thereby obtained, while a 
certain number of other skilled men, whose 
numbers were too small tcf admit of their 
consideration as separate groups, had to be 
thrown into the general group of unskilled 
laborers and others. 

The number of days of sickness per year 
suffered by these occupational groups are 



9S 



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recorded in Table 1. On an average they 
came to 6.5 working days i>er year, and in 
addition there was a small amount of time 
(estimated as 0.6 day) which is not com- 
pensated for under the Insurance Act, and 
which is not included in the recorded 
figures. The group of steel milters (on 
open hearth furnaces), teemers, and pit- 
men head the list, and show 23 per cent, 
more sickness than the average of all the 
workers combined. Next come the pud- 
dlers of wrought iron, with a 20 per cent, 
excess; then, the tinplate mill-men with a 



bago, myalgia, and neuritis; (6) pneumonia, 
bronchitis, influenza, pleurisy, catarrh, and 
sore throat (but not phthisis); (c) injuries 
incurred when following employment; (rf) 
sickness due to other causes, and injuries 
incurred apart from employment. 

It will be seen from Table 1 that the ex- 
cess of sickness experienced by the puddlers 
was due entirely to rheumatism and re- 
spiratory diseases, probably resulting from 
the habits of the men. The puddlers gen- 
erally work in couples, and they put in 
alternate periods of about twenty minutes 



TABLE 1. — DAYS OF SICKNESS PER YEAR EXPERIENCED BY STEEL WORKERS AGED 

16 TO 70 (191*-1918) 





Approxi- 
mate 
Number 

of 
Workers 


Days of Sickness per Year Due to 


Percentage Variation from Average of AU 
Workers Combined 


Occupation 


Rheu- 
matism 


Respir- 
atory 
Dis- 
eases 


In- 
juries 


Other 
Causes 


AU 
Causes 


Rheu- 
matism 


Respir- 
atory 
Dis- 
eases 


In- 
juries 


Other 
Causes 


All 
Causes 


Steel melters, teemers, and pitmen. . 
Puddlers 


1,740 

970 

2,090 

2,470 

1,660 
11,740 


1.3 
1.6 
0.9 

0.9 

0.6 
0.8 


2.2 
2.7 
2.1 

2.0 

2.2 
1.9 


1.2 
0.7 
0.8 

0.9 

0.4 
0.5 


3.3 
2.8 
3.5 

3.2 

2.8 
2.7 


8.0 
7.8 
7.3 

7.0 

6.0 
5.9 


+44 
+78 

-33 
-11 


+10 

+35 
+5 

+10 
-5 


+71 

+14 

+29 

-43 
-29 


+14 
-3 

+21 

+10 

-3 

-7 


+23 
+20 


Tinplate mill men 


+12 


Rolling-mill men, soaker men, hot- 
bank in<*n 


+8 


Engine men, crane men, locomotive 
men 


-8 


All other workers Gargely laborers) . . 


-9 


All workers combined 


20,670 


0.9 


2.0 


0.7 


2.9 


6.5 

















12 per cent, excess; and then the rolling- 
mill men, with an 8 per cent, excess. All 
of these men work imder trying conditions 
of high temi>erature, especially the first 
three groups mentioned, while the engine 
men and the general workers, who for the 
most part work imder ordinary conditions 
of temperature, were fomid to show 8 or 
9 per cent, less sickness than the average. 
At first sight, therefore, we seem to have a 
clear relationship between cause and ef- 
fect, but an analysis of the time lost under 
the various categories of sickness does not 
altogether bear out the simplicity of the 
relationship. Sickness was classified under 
(a) rheumatism (acute and chronic), lum- 



of very strenuous work at puddling their 
molten iron, and of comparatively light 
work. They perspire freely during their 
heavy work, and as they sit about a ,good 
deal during their intermediate periods, 
usually in a draft, they render themselves 
very liable to chills. The tinplate mill- 
men, whose work is on the whole as hot 
and heavy as that of the puddlers, show 
no excess of rheumatism and respiratory 
disease. This is due, I believe, to the fact 
that these men work continuously through- 
out their six or eight-hour shift. I kept 
groups of them under observation for sev- 
eral days, and I found that they seldom 
took rest pauses of more than four minutes* 



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VERNON — INFLUENCE OF FATIGUE ON HEALTH AND LONGEVITY 95 



duration, and never rested more than nine 
minutes (3). 

It will be seen that most of the extra sick- 
ness suffered by the tinplate mill-men is due 
to "other causes," and it is possible that 
this is the result of fatigue, which lowers 
their resistance to disease in general. The 
steel melters show, an excess of sickness 
from rheumatism and from respiratory 
diseases, as well as from "other causes," 
and this general excess definitely suggests a 
fatigue effect. The work done by the steel 
melters when fettling (t. e., mending) the 
bottom of their furnaces is more strenuous 
and exhausting than any other kind of in- 



of 55 to 69 years of age, lost 6.3 times more 
time from rheumatism than the yolmg 
men of 16 to 29. This great increase was 
specially observed in the men working at 
high temperatures, and the older steel 
melters and pitmen lost no less than 7.7 
times more time than the young ones. On 
the other hand, the older engine men and 
" other workers " lost only 3 to 5 times more 
time from rheumatism than the young men 
in the same occupations. It is true that the 
total number of days lost by the older men 
in no case exceeded 3.1 days i>er year, but it 
is probable that the efficiency of the men 
would be lowered for weeks every year, 



TABLE 2. — DAYS OF SICKNESS PER YEAR AMONG BLAST FURNACE MEN BY AGE GROUPS 





Days of Sicknen per Year by Age Groups Due to 


OccupAtkm 


Rheumatisin 


Respiratory Diseases 


AU Causes Combined 




19-9S 


84-48 




16-38 


84-18 


40-09 


18^88 


84-48 


49-69 


Batfow fillers 


1.0 
1.8 
0.4 


1.1 
1.0 
1.8 


3.8 
4.0 

2.7 


2.7 
2.8 
2.8 


2.6 
2.6 
2.0 


4.2 
4.9 
8.6 


8.5 
6.6 
4.4 


7.5 
7.8 
7.9. 


12.7 




15.9 


OUier workers 


18.1 






All workers combined 


1.0 


1.1 


8.4 


2.4 


2.4 


4.1 


6.8 


7.7 


18.6 







dustrial labor with which I am acquainted. 
It obliges the men to approach to within a 
few feet of the partly open doors of the 
white hot furnace, and to push away the 
pK)ols of molten steel with a kind of rake 
or "rabble." Subsequently the depressions 
in the bottom have to be filled up with 
dolomite or other material. This heavy 
work is very intermittent, and it lasts, 
on an average, only an hour or less i>er 
shift. After doing it the men not infre- 
quently change their wet shirts. Also, un- 
like the puddlers, they are often provided 
with shelters into which they can retire, so 
there is some reason for thinking that their 
excess of rheumatism and respiratory dis- 
ease may be due not only to chills arising 
from their work, but to lowered bodily 
resistance, the result of fatigue. 

On separating the workers according to 
age groups, it was found that the older men. 



rather than for days, in consequence of 
rheumatic pains. 

Data relating to blast furnace men are 
recorded in Table 2. They were obtained 
from a different "Approved Society" 
(working under the Insurance Act) from 
that of the steel workers, and they are 
classified in different age groups. They re- 
late to 1,002 blast furnace men, and they 
show that men of 16 to 48 years of age ex- 
perienced one to two days' more sickness 
I>ier year than the steel workers, while men 
of 49 to 69 experienced about four days' 
more sickness. The excess of sickness was 
due partly to respiratory diseases, but 
especially to rheumatism. Thus, the men 
of 49 to 69 lost 3.4 days from this cause, 
while steel workers of the same age lost 
only 1.7 days, or half as much. It seems 
highly probable that this excess of sickness 
from rheumatism and respiratory disease 



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was due to exposure to the weather, for it 
was specially marked in the barrow fillers 
and the laborers, who are almost always 
working in the open without any kind of 
protection from the elements. It was less 
evident in the other and more protected 
group of men, which includes the keepers, 
molders, gas men, cleaners, engine men, and 
crane men. 

Mortality Records 

It is extremely difficult to obtain ade- 
quate mortahty records, for though very 



The total deaths recorded among the 
20,670 steel workers in the six-year period 
under observation came to,l,023, and those 
among the blast furnace men, to 337. The 
mortality rates have been compared with 
those of all males (occupied and retired) in 
England and Wales, in the years 1910- 
1912, and the "expected" numbers of 
deaths recorded in Table 3 are calculated 
from the Registrar General's data (4). 
From the final columns of the table it will 
be seen that while 1,018 deaths were "ex- 
pected" between the ages of 25 and 65, 
only 964 deaths were observed. In other 



TABLE S. — TOTAL DEATHS AMONG STEEL WORKERS (1913-1918) COMPARED WITH THOSE 
AMONG ALL OCCUPIED AND RETIRED MALES (1910-1912) BETWEEN THE AGES OF 

25 AND 65 



- 


Bespirmtory Diwases 


Tuberculdeii- 


AUCauMt Combined 


Occupation 


Actual 
Number 


Number 
Expected 


Percentage 
Variation 

from 
Number 
Expected 


Actual 
Number 


Number 
Expected 


Peroentatfe 
Variation 

from 
Number 
Expected 


Actual 
Number 


Number 
Expected 


Percentage 
Variation 

from 
Number 
Expected 


Sted melters, teemers and pitmen 
Puddlers 


35 
30 

22 

36 

22 
165 


16.0 
11.6 
14.8 

16.7 

13.0 
81.2 


+119 
+159 

+49 

+116 

+69 
+103 


15 

7 
7 

11 

10 
55 


20.1 
11.2 
21.0 

24.0 

17.3 
110.3 


-25 
-38 
-67 

-54 

-42 

-50 


125 
66 
69 

114 

77 
513 


104.5 
73.1 
99.3 

112.9 

86.5 
541.6 


+20 
-10 


Tinolate mill men 


-81 


Rolling-mill men, soaker men, 
hot-bank men 


+1 


Engine men, crane men, locomo- 
tive men 


-11 


All other woikers 


-5 






AU woikers combined 


310 


153.8 


+102 


105 


203.7 


-48 


964 


1,018 


-5 







extensive records are collected and pub- 
lished at ten-year intervals by the Reg- 
istrar General, they relate to such large 
occupational groups as to be of little value 
for our special purpose. For instance, the 
iron and steel workers whose sickness has 
just been discussed are placed with iron 
founders and with the makers of iron goods 
(such as stoves and bedsteads) in one com- 
prehensive group, and no separation into 
individual occupations is possible. Ac- 
cordingly, I had to fall back upon the 
mortahty records of the steel workers al- 
ready referred to, but data relating to 
3,540 blast furnace men were obtained. 



words, the steel workers showed 5 per cent, 
less mortality than the general male pK>pu- 
lation. This must not be taken to indicate 
that steel manufacture is a healthy oc- 
cupation, for the group of "all males, 
occupied and retired," includes many 
weaklings who are unfit for any trade, or 
only fit for hght work, while most steel 
workers have necessarily to be healthy men 
of good physique. Men in the healthiest 
occupations have a much lower mortality. 
The comparative mortality figure, which 
gives a death rate in which due allowance 
has been made for age distribution between 
the ages of 25 and 65, is 753 for the steel 



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VERNON — INFLUENCE OF FATIGUE ON HEALTH AND LONGEVITY 97 



workers, as compared with 790 for all 
males, occupied and retired. In the health- 
iest occupations, such as gardening, the 
figure is 457. That of farmers and graziers 
is 495, while at the other end of the scale 
come potters with a mortality figure of 
1,196, and stone getters and masons with 
one of 1,427. 

Again, there can be no doubt that all 
the mortality figures recorded in Table 3 
imderestimate the death rate. In many 
trades, especially in the heavy occupations, 
there is a continual weeding out of some of 
the less vigorous men, who drift into the 
ranks of the casual and unemployed work- 
. ers, and the removal of these weaker men 
• lowers the death rate of those remaining in 
the trade. The records showed that about 
1 per cent, per year of the skilled workers 
aged 54 or less disappeared, while 3 per 
cent, of the older men suffered the same 
fate. Among the "other workers" class 
the proportions were about twice as great. 
It follows, therefore, that it is impossible to 
gauge the effect of industrial work upon 
mortality with any approach to acciu-acy 
unless the history of all the workers can be 
traced after they have dropped out of their 
trade. Nevertheless, the data recorded are 
roughly comparable among themselves, 
and they show clearly that some occupa- 
tions are more harmful than others. We 
see that the steel melters and pitmen head 
the list, and have a mortahty 20 per cent, 
greater than that of all males, or 26 per 
cent, greater than the average of the whole 
group of steel workers investigated. This 
figure corresponds closely with the sickness 
figure, which was 23 per cent, above the 
average, and it suggests that the fatigue of 
the steel melters' work is responsible not 
only for more sickness, but for a loss of 
several years in the average expectation of 
life. It will be seen that the steel melters 
experienced more than twice the usual 
mortality from respiratory diseases, and, in 
fact, every one of the groups of men in the 



various occupations experienced a some- 
what similar excess from this cause. From 
tuberculosis (almost always phthisis) the 
steel melters experienced about three- 
fourths th^ usual mortality, while the other 
groups of men experienced only one-third to 
two-thirds as much. This result was prob- 
ably due in part to the fact that almost all 
the men were working in the oi>en air or in 
sheds. Such exposure tends to reduce 
phthisis, though it may increase the risk of 
respiratory diseases in general. There can 

TABLE 4. — MORTALITY OF BLAST FURNACE 
MEN (1913-1918) 





Perpentage of Deaths per 
Year among 


Age Group 


Blast Furnace 
Men 


AU Males 


16-33 


0.8 
1.3 
2.7 
5.8 


0.4 


34—48 


0.9 


49-58 


2.0 


59-69 


4.4 







be no doubt, however, that many tuber- 
culous workers drop out altogether from the 
strenuous work required in the iron and 
steel trade before death carries them off. 

The puddlers, who showed almost as 
much sickness as the steel melters, had a 
slightly lbwer,mortality than the average, 
but their mortahty from respiratory disease 
resembled their sickness from the same 
cause in showing a maximal value. The 
engine and crane men showed a smaller 
excess of deaths from, respiratory disease 
than any other group except the tinplate 
mill men, presumably because they were 
not so much exposed to the weather or to 
high temperatures. The comparative im- 
munity of the tinplate mill men from fatal 
respiratory disease is presumably due to 
their custom of working continuously dur- 
ing their shift, without any long rest pauses, 
and at the end of the shift going back 
promptly to their homes, which are usually 
situated in the neighborhood of the works. 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



The blast furnace men showed a con- 
siderably higher mortality even than the 
steel melters, as can be seen from Table 4, 
the data in which relate to the whole body 
of blast furnace men. These figures sug- 
gest that moderately heavy work, if carried 
out under ordinary temperature condi- 
tions but with exp^osiu-e to all kinds of 
weather, is more fatal than very heavy 
work, carried out at high temperatures but 
with shelter from the elements. 

Conclusion 

The data as a whole appear to indicate 
that in men of good physique the fatigue of 
heavy work has, as a rule, but little direct 
effect on sickness and longevity. It is 
probable that the excessively exhausting 
work of the steel melters forms an excep- 



tion to this dictum, but it seems highly 
probable that the heavy work of the iron 
puddlers, of the tinplate mill men, and of 
the rolling-mill men has no injurious effect 
on health except indirectly, when it induces 
the men to sit about in damp clothes. The 
men may be working nearly to the limit of 
their strength, but the mere fact that they 
have to continue on the same class of work 
week after week and year after year must 
deter them from overstraining themselves, 
unless they do it unwittingly. At the time 
these observations were made, many of the 
steel melters, rolling-mill men and blast 
furnace men were on a twelve-hour day, 
while the puddlers were usually on an 
eleven-hour day. Since the spring of 1919 
they have all gone on to an eight-hour day, 
so their labor is considerably lightened. 



BIBLIOGRAPHY 



1. Lord Leverhulme: The Six-Hour Day and 
Other Industrial Questions. London, George 
AUen & Unwin, Ltd., 1918, p. 171. 

2. Vernon, H. M.: Fatigue and Efficiency in the 
Iron and Steel Industry. Indust. Fatigue Re- 
search Board, Rep. No. 5, London, 1920. 

3. Vernon, H. M.: The Influence of Hours of 



Work and of Ventilation on Output in Tmplate 
Manufacture. Indust. Fatigue Research Board» 
Rep. No. 1, London, 1919. 
The Registrar Genewa's Report for 191(>-191« 
is not yet published, the data quoted being 
supplied privately. 



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SYPHILIS AND INDUSTRY * 



ALEC N. THOMSON, M.D. 
Director, Medical Department, American Social Hygiene Asaodation 



THE objective of an occasional or pe- 
riodic physical examination is to pro- 
tect against future disease and accident — 
in. other words, to extend life and promote 
eflSciency. From the standpoint of the 
state, this objective may be more specif- 
ically described as the protection of the 
public health, by the recognition of com- 
municable disease at the time of the exam- 
ination, and the safeguarding of the future 
against dependency caused by depreciation 
of health or through injury which may re- 
sult in permanent or transient, partial er 
total, mental or physical disability, and 
which may possibly call for the expenditure 
of public moneys for material relief. 

For the individual, the periodic physical 
examination furnishes a means of protec- 
tion against conmiunicable disease in his 
fellow citizen, as well as a means by which 
defects that may contribute to his own 
health depreciation or liability to injiu-y 
may be recognized. The employer's objec- 
tive, on the other hand, is the protection of 
the community in which his industry is 
located, of the worker as an economic unit, 
aad of the material and equipment of his 
plant, through the early recognition of 
those contributory factors that tend to 
cause health depreciation or accident oc- 
currence. 

Any single factor that is of considerable 
prevalence, easy to recognize, and rela- 
tively sunple to eliminate, and that is, at 
the same time, a known detriment to com- 
mimity welfare, individual health, and in- 
dustrial eflSciency, deserves greater thought 
than has hitherto been given to syphilis. 
No medical argument is needed to prove 
that syphilis is communicable and that, in 
its active stage with open lesions, it is a 
menace to people working in close contact, 

* Received for publication March 7, 19«1. 



with common tools or utensils. Nor is 
proof required that the late disabling mani- 
festations of syphiUs of the nervous system 
cause accidents and contribute to damage 
of property. It is evident, however, that 
attention still has to be called to cardiac, 
nephritic, digestive, and other "diseases'* 
as possible symptomatic indications of an 
underlying syphilis, often overlooked in the 
course of the usual routine examination. 

Any short cut, if not practicable, is of no- 
advantage, and a routine Wassermann test 
as a short cut undeniably has its imprac- 
ticalities. It is relatively expensive. It 
hurts a little to have some one "stick a 
needle" into one's arm. It prolongs the 
examination. Its mere mention still brings 
forth much of the old stigma of "venereal" 
disease. Moreover, it requires careful in- 
terpretation of reports and often frequent 
repetitions. But none of these nor any 
other of its impracticalities is insuperable, 
so why not go around the obstacle instead 
of standing by and saying it cannot be 
done without a short cut through. As a 
matter of fact, the shortest way to the ob- 
jective of recognizing syphilis is to be 
found in the longer procedure of the or- 
dinary physical examination. Greater spe- 
cializing in parts of the routine examination 
for certain occupations makes for easier 
recognition of special defects. Therefore, 
the more value there is attached to ex- 
aminations designed to detect such defects, 
the more important becomes the recogni- 
tion of syphilis. 

The most primitive routine examination 
for employment calls for an "inspection" 
of the applicant, which necessitates, at 
least, looking at the individual. If the in- 
spector looks while the i>erson is walking, 
his gait may suggest locomotor ataxia. 
His eyes, also, by such signs as irregular. 



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100 



THE JOURNAL OF INDUSTRIAL HYGIENE 



unequal pupils, etc., may be of significance. 
Moreover, while conversing with the appli- 
cant, defective hearing may be detected, as 
may also such voice defects as monotony, 
harshness, or low pitch. Cervical glands 
may be palpated or an epitrochlear gland 
felt without actually doing more than a 
simple inspection requires. These danger 
signals, noticed during a very rapid inspec- 
tion, call for further examination for the 
detection of additional signs that may lead 
to a diagnosis of "suspected" syphilis. 

The average routine examination which 
calls for a simple history of past illness, xan 
inspection of the head and neck, listening 
to the heart and lungs, and palpation of 
the inguinal region for hernia, markedly 
enlarges the opportunity for finding signs 
and symptoms of syphilis. Not only the 
obvious signals of abnormal gait, irregular 
and unequal pupils, defective hearing and 
voice abnormality may be detected, but 
also, with practically no consumption of 
time, the observant examiner may note the 
reaction of the pupils to light and accom- 
modation; the presence of interstitial glos- 
sitis, leukoplakia, and Hutchinson's teeth; 
glandular enlargements (particularly epi- 
trochlear nodes); scars (circular, pig- 
mented, depressed, attached to underlying 
bone); and cardiac conditions (especially 
aortic valve disease). The finding of any 
one of these signs calls for f luiJier examina- 
tion; the presence of two indicates the neces- 
sity for a Wassermann test for confirmation 
of suspected syphilis. 

Where mu-sing and clerical help are 
available for such work as the taking of the 
history, temperature, height, weight, eye 
tests, and hearing and voice tests, a com- 
plete physical examination can be made by 
the medical examiner in ten minutes or less 
if his routine procedure is thoroughly sys- 
tematized. With the nurse making the eye 
observations for pupillary irregularity, in- 
equahty, and reaction to light and accom- 
modation, the examiner's observation of 



the applicant's head, nose, and throat may 
detect interstitial glossitis, Hutchinson's 
teeth, leukoplakia, ulcers or scars of the 
nasal septum, cervical adenitis, suggestive 
scars on the forehead, angles of the mouth, 
and alae of the nose, etc. While the ex- 
amination of the heart and lungs is being 
made, the examiner may exercise tiis pK)wers 
of observation to take cognizance of the 
skin of the chest, back, and arms for rash 
and scars not evidently due to injiu-y or 
acne, at the same time that his ears tell him 
whether or not any aortic valve condition 
exists. Likewise, his examination of the 
abdomen enables him to "double up" and 
look for the same signs while palpating. A 
hard, palpable liver is one more signal. In 
e^mining for hernia, the telltale syphilitic 
inguinal glands may be found, as well as 
the testicle that has become harder and 
larger than usual. There are, too, other 
possibilities in the examination of the 
genitalia. Similar skin inspection of the 
lower extremity takes no time, and but a 
moment is required for an investigation of 
the knee jerks. 

In making these observations, only a 
moment or two is added to the examina- 
tion time, and, as syphilis is an important 
consideration for industry, it will be sus- 
pected in a high percentage of cases. In 
most cases showing more than one of the 
above-mentioned signs, the suspicion will 
be confirmed by a further examination, 
including the Wassermann test. If the 
desideratum is a simple examination con- 
suming the least possible amoimt of time, 
it is possible to set down a series of syphilis 
signs that will guide the average examiner 
in culling out those individuals who require 
more detailed consideration and from 
whom it is desirable to procure blood for a 
Wassermann test.* 

* When, as a result of any type or form of physical ex- 
amination, evidence suggestive of lues of the nervous sys- 
tem is ascertained, it should be a routine procedure to do a 
lumbar puncture with a serologic examination of the 
cerebrospinal fluid. 



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THOMSON — SYPHILIS AND INDUSTRY 101 

In summary, it may be said that if any scars not obviously due to injury; cardiac 

one, or any combination, of the following conditions; and altered reflexes, especially 

easily observable signals can be found, knee jerk. 

fiu"ther examination for the detection of The industrial physician is probably 

syphilis is necessary: ataxic gait; mental justified in taking the view that a routine 

slowness; defective hearing; voice defects; Wassermann is not possible at the present 

pupils,, irregular, unequal, or reacting ab- time, but he is not justified in overlooking 

normally to light and accommodation; the easily observable signs and symptoms 

enlargement of the lymph glands, espe- that will promote the health of the em- 

cially of the epitrochlear nodes; interstitial ployee and protect the employer from 

glossitis; leukoplakia; Hutchinson's teeth; responsibility for preventable accidents. 



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TRINITROTOLUENE AS AN INDUSTRIAL POISON* 

AUCE HAMILTON, M.D. 

t 

Assistant Professor of Indtislrial Medicine j Harvard Medical School, and Special Investigator of Industrial 
Poisons for the U, S, Bureau of Labor Statistics 



IN the summer of 1918, the National 
Research Council undertook an inquiry 
into the occurrence of industrial poisoning 
in munition works, and as one feature of 
this study they assigned to six typical 
T.N.T. plants medical students who had 
been trained in laboratory methods and in 
making clinical observations, in order to 
have them collect important data on the 
spK)t. The work was carried on in co- 
operation with the U. S. Department of 
Labor, the Public Health Service, and the 
War Department. The plants which were 
selected manufactured trinitrotoluene, or 
purified the crude, or loaded shell with pure 
trinitrotoluene or with the mixture of am- 
monium nitrate and T.N.T. , known as 
amatol. Six students spent from one to 
two months at the plants assigned them, 
making observations on selected groups of 
the men and women employed there. Al- 
though the results of their studies, coming 
as they did in the fall of 1918, could not be 
put to practical use because of the closing 
down of these plants when the armistice 
was signed, it seems worth while to pub- 
lish them because compounds very similar 
to trinitrotoluene are coming into increas- 
ing use in American industry. It is not 
likely that any other derivative of the 
benzene ring will ever be used on so gigantic 
a scale as was T.N.T. during the war, and 
all the information that was gathered dur- 
ing that great human exi>eriment should be 
made known because of its probable appli- 
cation to the less well known compounds 
which are used in the manuf actiu-e of dyes 
and drugs. 

At the time this study was made we had 
been able to learn a good deal about T.N.T. 

* Received for publication Jan. 19, 1921. 



poisoning and its prevention from the 
British, but several points were still a mat- 
ter of controversy, and it was to these that 
we devoted special attention. A study of 
industrial poisoning in the manufacture of 
explosives, which had been published by 
the Bureau of Labor Statistics in 1917, had 
shown that in American plants, as in the 
British, all varieties of T.N.T. poisoning 
were to be found from the so-called "minor 
T.N.T. sickness" to fatal toxic jaundice 
(1). The first death from the latter in Eng- 
land was reported in February, 1915, and 
the first death in this country came to light 
just about a year later (2). 

T.N.T. is made by the nitration of tol- 
uene either by a continuous or by an in- 
terrupted process. There is little danger of 
exposure to poison for the workmen en- 
gaged in nitration, but the subsequent 
separation and purification of crude T.N.T. 
was, in this country, attended with very 
decided risk of poisoning — a risk actually 
as great as in shell loading. This was ap- 
parently not true in England, for there the 
great majority of cases of poisoning de- 
veloped in the "filling," or, as we call them, 
loading plants. Thus, there were in Great 
Britain, in 1916 and 1917, 370 cases of 
toxic jaundice with ninety-six deaths, but 
only sixteen of the cases and two of the 
deaths were reported from the manufac- 
turing plants (3). The nitration and purifi- 
cation of T.N.T., so prolific a source of 
T.N.T. poisoning in American munition 
plants, was evidently carried on under far 
greater precautions in England than here. 

Commercial T.N.T. is mainly composed 
of the symmetrical isomer, a hard, crystal- 
line powder, pinkish yellow if fairly pure, 
melting and subUming at 82° C. The im- 



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HAMILTON — TRINITROTOLUENE AS AN INDUSTRIAL POISON 103 



purities present in crude T.N.T. and to a 
certain extent in the purified T.N..T. con- 
sist in insignificant quantities of the two 
other isomers and a varying percentage of 
mononitrotoluene and dinitrotoluene, and 
also nitrated methanes. Early in the war 
the question arose whether T.N.T. poison- 
ing was caused by the pure substance or by 
one of the above impurities, and the sug- 
gestion was made that cyanosis and minor 
T.N.T. sickness might be caused by T.N.T. 
but that some other substances might be 
responsible for toxic jaundice and aplastic 
anemia. The British (4) came to the con- 
clusion that pure T.N.T. was capable of 
setting up all these varieties of poisoning, 
while the Germans (5) concluded from their 
experience that toxic jaundice appeared 
only when impure T.N.T. was handled, and 
that tetranitromethane was probably the 
compound responsible for it. With this, 
the French (6) experience harmonized. 

All the early efforts in Great Britain to 
prevent T.N.T. poisoning were directed 
against contamination of the air by fumes 
and vapK)rs. Moore's experiments (4) 
threw doubt on this mode of entrance for 
T.N.T. and showed the importance of skin 
absorption. Indeed, he went so far as to 
declare that there was no need of carrying 
off fumes from melting pots, and that dust 
caused poisoning only because it fell on .the 
skin and on work benches and objects 
which the workpeople had to handle. The 
other British authorities took a more con- 
servative stand on this question, and the 
Home OflSce experts insisted on the pre- 
vention of fumes (3), but the overwhelming 
importance of the skin as a portal of entry 
for T.N.T. was generally admitted. 

A great help in solving the questions of 
absorption, elimination, the relative danger 
of different kinds of work and of different 
mixtures containing T.N.T. was found in 
the so-called Webster test for the urine (4). 
This is a method of detecting in the lu-ine a 
reduction product of T.N.T., dinitrohy- 



droxylamino-toluene, and as it is a color 
reaction varying from a pale pink to a deep 
piu'plish pink according to the quantity of 
this reduction product present, there was 
no difficulty in standardizing it and thus 
bringing the observations of the different 
students into harmony. 

The students assigned to the nitrating, 
piu'ifying, and shell-loading plants were 
asked to make observations on problems 
of a thoroughly practical character, for 
although the United States had been in the 
war for more than a year the government 
had not yet formulated a sanitary code for 
the control of the explosives industry, and 
all attempts to do so met with opposition — 
an opposition which, it was felt, might be 
overcome if the managers of these plants 
were confronted with a body of facts 
gathered from American soiu'ces. The fol- 
lowing questions were assigned to the stu- 
dents: 

1. Can T.N.T. poisoning occiu: as the 
result of breathing fumes or dust, without 
skin contact? 

2. Is susceptibility to poisoning in- 
fluenced by race, sex, age, climate? 

3. How long an exposiu'e is necessary 
before T.N.T. can be detected in the body? 

4. How long does it take to get rid of the 
T.N.T. that has been absorbed? 

5. Which is more poisonous, crude 
T.N.T. or the pure; unmixed T.N.T. or 
amatol? 

6. What are the earliest symptoms of 
T.N.T. poisoning? 

7. What is the practical value of the 
Webster reaction? 

8. Is there any change in blood or urine 
which can be depended on to give warning 
of danger? 

Of the 402 workers who were examined 
in the six plants, only thirty-six were 
women. The conditions under which these 
people worked varied so much that some 
description of the plants will be necessary 
to account for the different results ob- 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



tained by the students. Plants 1 and 2 
were assigned to Miss Alice Hall, a third 
year student at Rush Medical College. 
They were situated not far apart in north- 
eastern New Jersey, in hot, shadeless coun- 
try where the August heat of the summer 
of 1918 was at times excessively trying. 
Methods of work differed somewhat in the 
two plants, but they were both unusually 
neglected and unclean. The floors and 
benches, especially in one of the pouring 
rooms, were covered with drippings of mol- 
ten T.N.T., the rooms were crowded and 
poorly ventilated, and both fumes and 
dust were allowed to escape into the air. 
The washing facilities were very inade- 
quate, and, as they were not conveniently 
situated and time was not allowed for the 
men to bathe, they were not much used. 
Even the men who were cleanly in their 
habits found it very hard to keep clean, 
and naturally the labor tiu-nover was very 
great and the force was for the most part 
recruited from the lowest class of labor. No 
instructions were given the workmen, and 
in neither plant did the physicians have 
anything to do with shop sanitation. Their 
duties were confined to holding office hours 
at stated times when men who fell sick and 
had confidence in the plant doctor could 
seek him out and ask for care. They Hid 
nothing to prevent sickness and not very 
much in the way of treatment, for if they 
thought a man likely to develop a serious 
case of poisoning, they promptly discharged 
him, for the protection of the company. 

Miss Hall saw more cases of severe poi- 
soning than did any of the other students, 
but she was hampered in her study of these 
cases because there was no hospital where 
they could be closely observed and because 
her notes of a case were usually brought to 
an abrupt end by the man's discharge or by 
his quitting of his own accord. She was 
never able to follow a case over a long 
period as could some of the other students. 

In Plant 3, also in northeastern New 



Jersey, shell was loaded with amatol 50-50 
and 80-20.* Miss Jewel Emery, laboratory 
technician from the Michael Reese Hos- 
pital, Chicago, spent a month there. It was 
a U. S. ordnance plant, new, clean, well 
constructed, and carefully managed, except 
that medical supervision was not thorough 
enough and there were no hospital facilities. 
The employees were of a better class than 
in Miss Hall's plants, but there was an un- 
usually large proportion of young men 
among them. 

Plant 4, which was in Virginia, was as- 
signed to Richard TeLinde, a third year 
student in the University of Wisconsin 
Medical School. Shell was loaded in this 
plant with the two varieties of amatol. The 
plant was partly new, clean, large and well 
ventilated; partly old, rather crowded and 
dirty, and in some places very dusty. The 
men employed were negroes and southern 
whites, many of them from the North 
Carolina mountains, of poor physique and 
anemic. The medical care given at this 
plant was by far the best that we found 
anywhere, and included inspection of the 
men and women in their workrooms, the 
shifting of all suspicious cases from T.N.T. 
work to safe work, and the treatment of 
sick men in a well-equipped hospital. Mr. 
TeLinde was able to make observations on 
men for long periods and to follow a case of 
sickness to recovery, but he never saw as 
serious cases as did Miss Hall. 

Plant 5 was in northern Wisconsin near 
Lake Superior. Here D.N.T. and T.N.T. 
were made, and purified and packed. The 
employees were decidedly superior to those 
employed in the other plants. Conditions 
were very good, there were ample facilities 
for washing, and medical care was good 
but insufficient, one physician with a part- 
time assistant not only having about 3,000 
men under his care but also being respon- 
sible for the examination of all applicants 

* Ammonium nitrate 60 per cent., 1*.N.T. 50 per cent., 
and anmionimn nitrate 80 per cent., T.N.T. 20 per cent 



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HAMILTON — TRINITROTOLUENE AS AN INDUSTRIAL POISON 105 



for employment. It was therefore impos- 
sible for the student at this plant to make 
as careful observations as were possible in 
Plant 4, especially as there was no hospital 
on the gromids. Norton EversoU, a third 
year student in the University of Wisconsin 
Medical School, was assigned to this plant. 
The work that was done in Plant 6 has 
already been described by Tracy Jackson 
Putnam and William lierman (7), the two 
Harvard Medical School students who 
spent a month there. Plant 6 was a purifi- 
cation, " finishing'* plant, situated in the 
moimtains of Pennsylvania. It was a fairly 
clean place except in two departments, and 
even those were not excessively bad, but 
the men were not given proper working 
clothes nor were the wash rooms adequate 
or comfortable. The medical care of sick 
men who appUed for treatment was good, 
but there was no preventive work and no 
effort to discover cases of poisoning. Both 
negroes and whites were employed. 

Mqde of Entrance of T.N.T. 

It was impossible for us to obtain as clear 
evidence on the mode of entrance of T.N.T. 
as was gained by the British in their 
carefully regulated factories. No American 
plant was clean enough to make skin ab- 
sorption even a rarity. Everybody em- 
ployed in every department came in 
contact with T.N.T. dust and had his skin 
more or less covered with it. We could 
only make an effort to determine whether 
fumes and contact caused more poisoning 
than contact alone, and whether inhaling 
dust increased the incidence of pK)isoning. 
The reports from certain plants seemed 
to show that fumes and T.N.T.-laden 
steam decidedly increased the risk of poi- 
soning. For instance, the graining, pellet- 
ing, and washing rooms of the purification 
plants, where fumes mixed with steam were 
more or less heavy, gave rise to many cases 
of sickness, especially in cold weather. 



when the doors were closed, and also in 
heavy, hot, summer weather. 

According to Putnam and Herman, the 
procedure most dreaded in their purifying 
plant was cleaning out the bottoms of the 
great tanks in which crude T.N.T. had 
been boiled. The heat, moist lu-e, and fumes 
in the tanks were overpowering and many 
men refused to enter them. Another piece 
of work which, according to the workmen, 
often caused deep cyanosis and fainting, 
was cleaning a room by volatilizing and 
melting with Uve steam the T.N.T. which 
had been spilled and splashed about. As 
for dust, it was found that pure, dry T.N.T. 
dust did not cause poisoning imless present 
in such quantities as to cover the skin of 
the workers. Pressing piu'e T.N.T. into 
detonator charges or demolition blocks 
seemed to be harmless work. On the other 
hand, small quantities of amatol (T.N.T.- 
ammonium nitrate) dust proved, distinctly 
poisonous, although it contained only a 
small proportion of T.N.T. 

A closer study of these findings led us to 
indorse the British view of the overwhelm- 
ing importance of the skin as a portal of 
entry for T.N.T. because the same condi- 
tions that make respiratory absorption 
possible also increase skin absorption, and 
the greater toxicity of amatol as compared 
with piu-e T.N.T. depends on its greater 
absorbability. The instances given above 
of poisoning from steam and fumes can also 
be explained as due to the facilitation of 
skin absorption by heat and moistiu'e. 
Grainers, pelleters and tank cleaners in 
purification works have their hands and 
forearms more deeply stained with T.N.T., 
even after a single day's work, than do 
men pressing charges at the end of several 
weeks' work. The dust of piu-e T.N.T. is 
not very readily absorbed by the skin. If 
one looks at the arms and hands of a man 
who is sifting or pressing dry unmixed 
T.N.T., one can see the powder covering 
the hairs of the skin, but unless the day is 



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hot enough to cause much perspiration this 
powder is dry and hardly stains the skin at 
all. In the graining and i>elleting rooms not 
only is the T.N.T. which the men handle 
warm and wet, but the steam and fumes 
keep the skin moist all the time. 

The same contrast was found by Te- 
Linde between a drilling department where 
there was much amatol dust and a depart- 
ment in which piu-e T.N.T. was sifted. 
There was a great deal of sickness in the 
former department, and almost none in the 
latter. The amatol dust contained 50 per 
cent, of ammonium nitrate, and this, be- 
cause of its hygroscopic natiu-e, kept the 
skin of the workers moist. Tiny droplets of 
water could always be seen on the skin and 
hairs of the men's hands and arms, and on 
all the metallic surfaces in the room. Our 
experience in this country agreed with that 
of the British, who found that there was 
more sickness in connection with 80-20 
amatol, containing only 20 per cent. 
T.N.T., than with pure T.N.T. We also 
found, as the British had, that oily sub- 
stances favored the absorption of T.N.T. 
Two of the earliest American cases of toxic 
jaundice, one of them fatal, were in women 
exposed to very small quantities of amatol, 
but whose hands were smeared all the time 
with paraflSn. 

Although our observations showed that 
the skin is the chief channel of absorption 
for T.N.T., and that the prevention of poi- 
soning means prevention of contact, still 
we were not convinced that T.N.T. fumes 
from grainers, washing tanks and melting 
kettles were harmless. Some of the stu- 
dents' case histories seemed to pK>int quite 
clearly to fume poisoning, as, for instance; 
that of a new employee who was set to work 
on a fairly cool day in June stirring a kettle 
of molten T.N.T. which was poorly hooded. 
He became dizzy and faint, and went to the 
plant doctor who found him cyanosed, with 
weak and rapid pulse. He was susi>ended 
from work that day (Monday) but on the 



following Friday he was still feeling ill and 
his lu-ine was still dark in color. Several 
students reported cases of men who, hav- 
ing once suffered from T.N.T. sickness, 
could go back to work with the substance, 
but if they were exposed to the fumes would 
suffer a retiu-n of the headache, dizziness, 
breathlessness and weakness with which 
they were familiar from their former ex- 
perience. A very interesting report on this 
point was sent by Alice Hall. On two oc- 
casions she remained for two or three horn's 
in the pouring room where the air was 
heavy with T.N.T. fumes, being careful 
not to touch anything during that time. 
After both these exfwsiu'es she was able 
to get a positive Webster reaction. The 
superintendent of a department in one of 
the Navy arsenals, where depth charges 
and mines were loaded, told me that poi- 
soning among his men was practically 100 
per cent., not one of them having been able 
to work as long as three weeks without 
some symptoms of sickness. The fumes 
from poiu-ing and from the cooling mines 
and shell were very heavy. He himself 
hardly ever came in actual contact with 
T.N.T., but he was frequently overcome 
with dizziness, headache and weakness if 
he had to stay in the fumes for many hours 
at a time. It is, of course, by no means cer- 
tain that these fumes contain only T.N.T. 
and not some other substances equally 
toxic or more so. 

Influence of Race 

The only students who had any oppor- 
tunity to observe the difference ^between 
whites and negroes in their behavior to- 
ward T.N.T. were TeLinde in Virginia and 
Herman and Putnam in Pennsylvania. 
TeLinde was much impressed by the 
greater susceptibility of the white men. 
He did not find one case of T.N.T. sickness 
among the negroes. Negroes who were 
working alongside the whites handling 



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HAMILTON — TRmiTROTOLUENE AS AN INDUSTRIAL POISON 107 



amatol sometimes gave a moderate Web- 
ster reaction, but their m'ines were normal 
in color, not dark, as were the m-ines of 
many of the white men in this department, 
nor did they complain of any symptoms of 
poisoning. In sifting pure T.N.T. by 
hand, only negroes were employed, and 
although the dust here was excessive, they 
gave a slight Webster reaction or a nega- 
tive one. It is true that this dust was pure 
T.N.T. but that was also true of the dust in 
the drilling department in one of Alice 
Hall's plants, yet she found decided evi- 
dence of poisoning among the white men 
employed there and always got positive 
Webster reactions. On the other hand, 
Herman and Putnam, who were able to 
watch negroes and whites working together 
throughout the plant, found no diflference 
in susceptibility of the two races. They 
examined thirty-seven whites and thirteen 
negroes. Among the latter were some who 
showed marked poisoning; indeed, the 
most typical case of T.N.T. poisoning that 
came under their observation was in a 
negro. They also found several negroes 
entirely unaffected after comparatively 
long periods of exposiu-e. 

It was apparent from TeLinde's report 
that the negroes in the Virginia plant were 
neither living nor working under the same 
conditions as the whites. They were, on 
the whole, more in the habit of taking 
baths than were the mountain whites em- 
ployed there, and, hving in their own cab- 
ins, they had a diet rich in fresh vegetables 
and fruit, while the white men ate in the 
company canteen where the diet provided 
was largely meat and canned vegetables, 
with almost no fresh food. In the Pennsyl- 
vania plant the negroes and whites not 
only worked in the same departments, but 
lived in company bimk houses and ate the 
same food. Both races had about the same 
standard of cleanliness and both had 
T.N.T. poisoning. There is, therefore, no 
indisputable evidence of racial immunity 



toward T.N.T. as a systemic poison, al- 
though negroes are distinctly less liable to 
T.N.T. dermatitis, as was found in both 
plants.* 

In this respect our experience agrees with 
that of the French in their munition 
plants (8). The French employed three 
races, white, yellow and black, in making 
and loading dinitrophenol, and at first 
were impressed with the greater resistance 
of the Anamites, the yellow race, and the 
high degree of susceptibility of the white 
race. Later, however, they discovered 
that if all conditions were taken into con- 
sideration the theory of racial immunity 
became decidedly questionable. The white 
men were more intemperate, more im- 
cleanly in their habits, and less obedient to 
shop rules than were the yellow men, and 
in addition, the best medical care, which 
means the most careful examination and 
diagnosis, was given to the white men. 
These differences seemed to the French 
enough to account for the difference in the 
numbers of cases of D.N.P. poisoning re- 
ported from the two groups. 

Influence of Age 

Forty per cent, of the employees in the 
six American plants studied were under 
25 years of age, and 22 per cent, under 21 
years. The largest proportion of youthful 
employees — 55 per cent, under 21 years of 
age — was in Plant 3, fortunately one of 
the better plants. Miss Hall reported a 
very marked susceptibility among the 
younger men under her observation. Only 
a few men imder 25 years were employed 
in her two plants, but the few that were 
under that age showed a very low resistance 
to the poison. Three lads of 19 were dis- 

* Marshall, Lynch, Smith, and Williams of the Chem- 
ical Warfare Service tested the susceptibility of whites and 
negroes to mustard gas. A certain degree of resistance was 
displayed by about 20 to 40 per cent, of the whites, and by 
78 per cent, of the negroes. Two per cent, of the whites 
showed hypersensitivity, but none of the negroes. (G. S. 
Derby, Arch, OpfUh., 1920, 49, 119.) 



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charged after three weeks' work, because 
the doctor was unwilling to take the risk of 
keeping them longer. One man of 21 years, 
who was imusually careful and cleanly in 
his habits, sickened so seriously at the end 
of the first week that he was discharged. 
Of all the men who were discharged from 
the worst of these two factories during one 
month on account of sickness, one-third 
were under 25 years of age, while only one- 
eighth of the entire force employed were 
imder 25. 

None of the other students had any such 
striking incidents to report; indeed, they 
were not impressed with the oversuscepti- 
bility of the younger men, but a close anal- 
ysis of their records demonstrated it. For 
instance, forty-eight of TeLinde's cases 
were divided into two groups, one consist- 
ing of twenty-nine lads under 21 years; the 
other, of nineteen men over 30 years. The 
period of exposiu-e to T.N.T. before the ap- 
pearance of the first symptoms of sickness 
was noted in each case, and it appeared 
that while the older men had averaged 
forty-nine days of work before sickening, 
the younger men averaged only ten and a 
half days. The young men had for the 
most part reacted to the T.N.T. with great 
rapidity, only five out of the twenty-nine 
working as long as two weeks without feel- 
ing any effect. Similar groups from Ever- 
soU's records gave an even greater contrast. 
The older men averaged fifty-six days* 
exposiu-e, the yoimger men only seven to 
eight days. 

Finally, I selected at random from the 
history sheets of these two plants fifteen 
records of men who had developed serious 
symptoms in a very short time, and on re- 
ferring to the age lists I found that only one 
of these fifteen was over 21 years of age, 
and he was only 24 years old. Yet in these 
two plants the men under 25 years con- 
stituted less than 40 per cent, of the force. 
The early experience with T.N.T. in Eng- 
land showed clearly the greater suscepti- 



bility of the young people. The general 
mortality from toxic jaundice, recognized 
and notified as such, was 25.9 per cent., 
but for persons under 18 years of age the 
proportion was six deaths out of nine 
cases (3). 

Influence of Sex 

The British reports have not shed any 
light on the question of the influence of sex 
in T.N.T. poisoning. Although the mor- 
tality among the women was greater than 
among the men — 28.6 per cent, as against 
20 per cent. — the women were younger 
than the men, and the oversusceptibility is 
attributed by Legge to their youth, not to 
their sex. We could not come to any con- 
clusion at all with respect to the American 
cases, since the employees in our plants 
were almost all men, and the few women 
employed did relatively safe work. It was 
possible to obtain records of only thirty- 
six women employed in four shell-loading 
and detonator departments. These women 
were carefully examined, but the results 
were largely negative. None of them was 
doing any of the more dangero^s work, 
such as preparing the charge, loading shell 
or drilling the hole for the detonator charge. 
Indeed they would have had little or no 
contact with T.N.T. had they all been em- 
ployed in well-regulated plants, but sixteen 
were working in the two plants imder Miss 
Hall's observation where T.N.T. was so 
recklessly spilled and scattered about that 
it was impossible to avoid contact with it. 
Miss Hall examined a group of seven 
women whose hands were stained from 
handling shell smeared with T.N.T. Five 
complained of mild symptoms and three of 
these gave positive Webster reactions, but 
none showed cyanosis, and none had ap- 
plied for treatment, except one married 
woman who complained of nausea and 
vomiting, and whom the physician believed 
to be pregnant. Miss Hall examined an- 
other group of nine girls who were pressing^ 



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HAMILTON — TRINITROTOLUENE AS AN INDUSTRIAL POISON 109 



small quantities of dry, pure T.N.T. into 
detonators. Only one, a girl of 20 years 
who had worked six weeks longer than any 
of the others, had fairly serious symptoms. 
A third gro^ji), under TeLinde's observa- 
tion, working under good conditions and 
expK)sed to small quantities of fume and 
dust had no signs of ill health, although two 
of the women had Webster reactions of 
medium intensity. Miss Emery examined 
ten women who were obliged to come more 
in contact with amatol than any of the 
other women, for they were cleaning the 
outer surface of loaded shell, cleaning the 
threads of the screw necks, and placing the 
finished shell in cars. Six of these ten suf- 
fered from T.N.T. dermatitis and slight 
symptoms of systemic poisoning. One of 
them, a woman of 31 years, seemed un- 
usually susceptible. She had an eruption 
over her hands, arms and legs, and com- 
plained of nausea, loss of appetite, con- 
stipation, sore throat and pains in her 
legs and arms. None of these women was 
cyanosed. 

Sununing up, we may say that it was even 
more impK)ssible to compare the suscepti- 
bility of the two sexes to T.N.T. than to 
compare the susceptibility of negroes and 
whites, for the exposure of the women and 
the men was altogether different. 

Effect of Hot and Humid Weather 

Every manager and foreman interviewed 
said that T.N.T. poisoning was more com- 
mon and severe in hot weather, especially 
if the humidity was also high. The students 
in charge of the inqmry, with the exception 
of Herman and Putnam, worked through 
the intense heat of August, and all of them 
reported that the number of cases of sick- 
ness increased markedly during the hot 
days and for a few days just following. 
Miss Hall wrote that only four men came 
for treatment diu-ing six days when the 
temperature was between 68*^ F. and 89° F., 



but in six days of heat from 90° F. to 
106° F. twenty men repK)rted for treatment, 
and this number did not represent nearly 
all of the sickness, because on the day of 
greatest heat the plant was obliged to dose 
down for lack of men and was greatly ham- 
pered for two days more. 

Curiously enough, heat does not seem to 
increase T.N.T. dermatitis, contrary to the 
general impression that prevails among the 
men. It is true that summer is the season 
for "T.N.T. itch," but the excessively hot 
weather of August did not increase the 
number of cases as it increased the cases 
of systemic T.N.T. poisoning. There were 
quite as many cases in cool summer weather 
as in hot, and the probable explanation for 
the increase of " itch " in summer is that the 
men expose more of the skin by rolling up 
their sleeves and leaving their shirts open 
at the neck, or by working in low-necked 
and sleeveless underwear. 

Period of Exposure before Absorption 
Takes Place 

The Webster reaction may appear very 
early, especially if there is excessive expo- 
sure. Miss Hall reported the most striking 
cases of rapid absorption and elimination of 
the poison and I have already spoken of the 
appearance of a positive Webster in her 
urine after a few hours' sojourn in a badly 
contaminated department. Miss Hall was 
able to get reactions of medium intensity in 
the urines of ten newly employed men at 
the end of their first six hours of work. 
Such excessive exposure did not exist in any 
other plant, but the records of 133 cases in 
which a maximum Webster reaction was 
obtained showed that more than a third of 
the men, 39 per cent., had been exposed no 
longer than three weeks. 

There were plenty of i^cords of men who 
felt the first symptoms of illness on the first 
or second day of their employment, but 
sometimes these symptoms passed away 



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and the men felt quite well again for a 
short time; then, after longer exposure, 
symptoms of anothjsr kind developed. 
TeLinde and Herman and Putnam de- 
scribed in some cases a transitory disturb- 
ance of digestion with loss of appetite, a 
bad taste in the mouth, and usually di- 
arrhea with more or less pain, but no cyano- 
sis or dizziness or headache. The more 
characteristic symptoms were breathless- 
ness, a feeling of tightness in the chest, 
headache, dizziness, dullness and lassitude, 
pains in the limbs, weakness of the knees 
and lividity of the face with blue lips, and 
these usually app)eared soon after the be- 
ginning of T.N.T. work. Even in a well- 
managed plant the men who were at all 
susceptible to T.N.T. felt the first symp- 
toms fairly early, nearly a third of them 
before the first fortnight was over. 

It is the general belief of the men who 
have had experience in T.N.T. work and of 
some plant physicians that T.N.T. derma- 
.titis is quite distinct from general poisoning 
and that a man with "the itch" never need 
fear an attack of serious T.N.T. sickness. 
The students found several exceptions to 
this rule. Nine out of twenty-eight pa- 
tients with dermatitis in the Wisconsin 
plant had fairly serious general symptoms 
of poisoning, as did four out of twelve in the 
Virginia plant. It is clear, however, that an 
attack of dermatitis may occur from a 
purely local action of T.N.T. or its impm^i- 
ties, for the majority of the men with der- 
matitis had negative Webster reactions or 
very slight reactions. 

Persistence of T.N.T. in the Body 

It was, of course, a matter of great prac- 
tical importance to determine how quickly 
T.N.T. could be eliminated from the body, 
and the students were, therefore, instructed 
to make repeated Webster tests on the 
urines of men who had been shifted from 
T.N.T. work or who were in the hospital 



under treatment. They found that the re- 
action tended to disapp>ear from the urine 
within a fortnight after entire removal 
from T.N.T. work, but that there were in- 
stances of delayed elimination quite as 
striking as the instances of rapid absorp- 
tion. One of Miss Hall's |>atients, who was 
seriously poisoned and gave a Webster 5, 
was removed from all exposure to T.N.T. 
but after twelve days it was still possible to 
get a positive reaction. TeLinde reported 
a case with positive Webster reaction five 
weeks after removal from work. 

EversoU and TeLinde were the only stu- 
dents who were able to send full records 
because the plants under their observation 
were the only ones in which there was a 
regular system of shifting men to work free 
from T.N.T., and keeping them under 
observation. The most rapid instances of 
partial and complete disappearance of the 
Webster reaction came from TeLinde who 
was able to observe men in the plant hos- 
pital where a vigorous eliminative treat- 
ment was carried through. The men with 
T.N.T. sickness were given a thorough 
scrub bath, a purge, an enema, and a 
dim^etic, and were encom^aged to drink 
large quantities of warm milk. Under this 
treatment the poison was eliminated fairly 
rapidly. One boy of 18 years, who had 
never been sick before, was first examined 
after he had been expK)sed to fumes and 
dust for thirty-five days. He had a Web- 
ster 3 at that time. Six days later he came 
to the hospital with typical symptoms of 
acute poisoning and a Webster 5. Under 
the above treatment the reaction fell in 
thirty-six hom*s from 5 to 1, and his symp- 
toms had improved greatly, though they 
had not disappeared. Another man with 
much the same symptoms, as well as ab- 
dominal pain and diarrhea, had a Webster 
4 which in twenty-four hours fell to a 
trace. 

Both TeLinde and EversoU found that a 
transfer to work free from T.N.T. would re- 



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HAMILTON — TRINITROTOLUENE AS AN INDUSTRIAL POISON 111 

suit in a disappearance of the Webster re- The negroes in TeLinde's plant certainly 
action, but much more slowly than under showed greater absorption of amatol than 
hospital treatment. One of^EversolPs cases of pure T.N.T., those working with amatol 
was transferred to outdoor work on July giving positive Webster reactions up to 3, 
21 because of slight symptoms of poison- while those working with pure T.N.T. gave 
ing and a Webster 4, but he did not give a negative or 2 as the highest reaction. We 
negative Webster till August 31. Usually were not able to say whether more poison- 
the work to which the man was shifted in- ing resulted from crude T.N.T. than from 
volved some slight contact with T.N.T., in pure T.N.T., or vice versa. According to 
which case the reaction would persist. An the experiments of Voegtlin and his col- 
interesting case reported by EversoU was leagues (9), there is no difference between 
in a boy of 18 who, because of decided crude and purified T.N.T. so far as their 
symptoms of poisoning and a maximum effect on animals was observed. The only 
Webster, was put on outdoor work every positive fact that we were able to establish 
other night. On the morning after such was that crude T.N.T. is more productive 
work the reaction would be Webster 1, but of dermatitis than the pm^ified. We had 
on the morning after his shift of i>ouring looked for the greatest incidence of ec- 
T.N.T. it would be Webster 3. A pelleter zema and other skin lesions in the dirty, 
who had a Webster 4 was transferred to the loading plants in the New Jersey meadows, 
nitrating department, where there is very where heat and humidity, excessive expo- 
little contact with T.N.T. The reaction sure, and poor washing facilities would 
fell to 3 in six days' time, then gradually to seem to favor it. Instead, it was found that 
1, where it persisted. A striking argument those very plants had the smallest number 
in defense of the contention that clean of cases of T.N.T. itch, and the largest 
working clothes, clean gloves, and good number occm^red in the two cool situations, 
bathing facilities must be provided for the nitrating plant in northern Wisconsin 
these men was found in the persistence of and the purifying plant in the Pennsyl- 
the Webster reaction in men who continued vania mountains. Since the Wisconsin 
to wear their dirty gloves after being shifted plant was not only the coolest, but was one 
to T.N.T.-free work. TeLinde had several of the cleanest, had excellent lavatories and 
instances of men with persistent Webster 1 employed an unusually high class of labor, 
or Webster 2 reactions, even after trans- it is plain that there must have been some- 
ference to the empty-shell department, and thing in the material handled that was re- 
he came to the conclusion that they were sponsible for the high percentage of der- 
absorbing small quantities of T.N.T. from matitis. 

their soaked gloves. The following figures show the propor- 

tion of itch among the men and women in 

Comparative Danger of Crude, these six plants. It is evident from them 

Pure and Mixed T.N.T. ^^^^ crude T.N.T. is worse than the pure, 

and that amatol is worse than the unmixed. 
In dealing with this question also we were „ , ., . u 

° ^ . . Percentage of Men with 

greatly hampered by the varying conditions tn.t: Dermatitis 

in the diflferent plants. Miss Hall saw Plants l and 2, loading pure T.N.T. . 3.4 

p . . . 1 J' Plant 3, loadinff amatol 18.0 

severer cases of poisoning m men loading „, ^ /, j. . , ^.aa 

rpxTrp xu T> T- J ' Plant 4, loadmg amatol 20.0 

pure T.N.T. than TeLinde saw m men Plant 5, purifying crude T.N.T 26.0 

loading amatol, but in the one case the ex- pi^nt 6, manufacturmg crude and 
j>osiire was excessive, in the other, slight. pure T.N.T 31.0 



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Early Symptoms of T.N.T. Poisoning 

Most of the students reported that the 
first symptom noted by the men was 
breathlessness on exertion, esf>ecially on 
climbing a hill or going upstairs. A man 
who said that he had not felt the effect of 
his work in any way would almost always 
admit this symptom if he was asked. Next 
in order came dizziness on stooping over, 
and more or less persistent headache, or the 
man complained first of loss of appetite, 
bad taste in the mouth, and a sensation of 
nausea in the morning. Sometimes the men 
who were exposed to dust complained of 
running of the eyes, smarting and burning 
in the nose and throat, and nose-bleed. 
Together with these symptoms, an early 
case of poisoning is characterized by cramps 
in the calves of the legs, fatigue dispropor- 
tionate to the work done, and a feeling of 
tightness in the chest. Very early in the 
course of poisoning the man notices a 
change of color in the urine. It is a clear 
brown, at first about as dark as weak tea, 
then increasing till it may be as dark as 
coffee. 

By the time the man feels ill enough to 
go to the doctor for treatment, he presents 
a very characteristic appearance. He has 
an expression of dullness and weariness, 
heavy eyes, drooping lids, sclerotics slightly 
yellow, lips and mucous membranes of the 
mouth blue, the face a leaden or ashen 
color. In Plant 1, patients with very livid 
color and lips almost inky were described 
by Miss Hall. 

So far as one can judge from the notes of 
the students, there did not seem to be two 
clearly marked varieties of T.N.T. poison- 
ing, the gastric and the cyanotic, such as 
have been described by some of the English 
writers. In Plants 3 and 5 a mild gastric 
form without cyanosis was noted, but these 
cases cleared up rapidly. No serious gastric 
case was free from cyanosis, and almost all 
of the patients with cyanosis, dizziness. 



faintness, headache and pain in the limbs, 
showed gastric symptoms also. 

When no effort was made by the physi- 
cian in charge to discover cases of sickness 
among the men, it sometimes happened 
that by the time a workman applied for 
treatment he was already severely i>oi- 
soned, for apparently serious changes may 
occur without causing enough suffering to 
make the man believe that he is really sick. 
Miss Hall saw a man in the dispensary who 
had not come to complain of sickness, but 
of an infected cut. She described him as 
being strikingly pale, with a grayish yellow 
color, his lips, ears and tongue deeply 
cyanosed, and his sclerotics distinctly yel- 
low. He had dyspnea and a pulse of 100. 
His urine was brownish black and gave a 
Webster 5, yet on questioning him, she 
found that he complained of nothing except 
breathlessness and a slight headache. He 
was told to return to have the cut dressed 
every day, but he did not, and when Miss 
Hall finally discovered his lodging house a 
week later she was told that he had been 
sick in bed for four days a"kid had then left 
for the city^ This is a good illustration of 
the wastefulness caused by poor medical 
supervision. 

The effect of alcohol on T.N.T. poisoning 
was well known to the workmen in the 
plants studied. They knew perfectly well 
that while working with T.N.T. they could 
not drink without risking serious sickness. 
Many stories were told of men turning blue 
in the face and falling unconscious on the 
floor of a saloon after one or two drinks of 
whiskey. So notorious was this that the 
men who wanted to keep on working prac- 
tically gave up drink, or if they decided to 
go on a spree they would deliberately lay 
off work for two or three days before and 
two or three days after. They described the 
effect as a sudden, intense flushing of the 
whole body, with a sensation of heat, a 
rush of blood to the head, blackness before 
the eyes, and then loss of consciousness. 



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HAMILTON — TRINITROTOLUENE AS AN INDUSTRIAL POISON 113 



Bystanders reported that during the period 
of complete collapse, the affected man's 
face was livid and his lips an inky 
blue. 

It was a matter of great surprise to us not 
to discover a single case of typical toxic 
jaimdice nor of aplastic anemia in any one 
of these five plants during the time the 
students were working there. Miss Hall 
was told that a young girl of 16, who had 
been working for three months, left on ac- 
coimt of sickness and was at that time so 
deeply jaundiced as to attract attention. 
She died two weeks later, but it was impos- 
sible to trace this .case or to secure any in- 
formation from the physician. It is difficult 
to explain the absence of toxic jaundice. 
During 1916, I had found records of thir- 
teen deaths from T.N.T., eleven of them 
typical toxic jaundice, and there was a 
much larger number of men employed in 
1918 than in 1916. The only explanation 
that can be given is that in three of these 
plants medical supervision was careful 
enough to make it impossible for a case of 
poisoning to progress to the point of severe 
jaimdice, while in two other plants, all sick 
men were promptly discharged, and no one 
knew what happened to them afterward. 
It must also be remembered that the men 
were usually exposed to T.N.T. for a very 
short time only. Out of 374 men, only 
fifty-seven had worked for more than three 
months, and British statistics show that 
toxic jaundice usually does not appear be- 
fore three months' exposiu-e. In one of the 
plants, the proportion of those employed 
as long as three months was only 4 per 
cent.; in another, 7 per cent.; and in all the 
labor turnover was very great, decidedly 
greater than in 1916. Reports did indeed 
come to me of toxic jaundice and of aplastic 
anemia in other T.N.T. plants. I had rea- 
son to believe that there were twelve or 
thirteen cases during the last year of the 
war, but none were in the factories where 
the students were stationed. 



Significance of the Webster Reaction 

The Webster reaction seems to be an 
admirable test for the absorption of T.N.T., 
a very rapid and delicate one. The worse 
the plant is, the larger is the proportion of 
positive Webster tests. In Plant 1 every 
urine examined was positive, even if the 
man had been at work only one day. In 
Plant 4, which had the best conditions, 
there were only twenty-one negative reac- 
tions out of ninety-eight specimens. As an 
index of absorption it is certainly valuable. 
Repeatedly, the intensity of the reaction 
increased as the days went on. Herman 
and Putnam applied the tests in about half 
their cases before and after work, and in 
about 90 per cent, of these cases the reac- 
tion was more intense after an eight-hour 
shift than before it. The work in this plant 
was continuous, no holidays or Sundays 
being observed, but in the others, where the 
Sunday rest was given, it was repeatedly 
found that the Webster reaction would be 
low on Monday and rise gradually to.be 
high on Thursday, Friday and Saturday. 

Whether the Webster test is of any other 
practical value is hard to say. It could not 
be used as an indication that an acute at- 
tack of poisoning was impending, nor was it 
possible to establish a correspondence be- 
tween the clinical history and the Webster 
reaction. While, as a general rule, the in- 
tensity of the reaction increased with the 
increasing severity of an attack, there were 
too many exceptions to this rule to make it 
of any practical value. Serious cases some- 
times occurred with only a slight Webster 
reaction, while, on the other hand, a Web- 
ster 4 or even a Webster 5 was found in men 
who had no symptoms of sickness at all. 
One man with a negative Webster had 
gastric pain, nausea, vomiting, weakness in 
the knees, cramps in the calves of the legs, 
dermatitis on hands, arms and ankles, and 
general weakness. According to Feldman 
(10), the Webster reaction, indicating as it 



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does elimination of T.N.T., should not in- 
crease with the onset of severe symptoms, 
but should diminish or disappear, and 
Feidman had an opportunity to observe 
just this phenomenon. The students were 
asked to bear this possibility in mind and 
report on it, but Miss Hall was the only one 
who saw a case with a drop from Webster 3 
to 1 as symptoms of poisoning developed. 
A careful analysis of 137 cases failed to bear 
out Feldman's theory, for in general the 
more intense Webster reaction is associated 
with the more serious form of poisoning. 
As a rule Websters 4 and 5 were found 
among the newly employed, those who had 
worked less than a month, while the men 
who had handled T.N.T. for six months 
and more hardly ever had a reaction of 
more than 2 or 3, showing that a gradual 
elimination of the more susceptible men 
takes place, those that absorb the poison 
readily dropping out while the relatively 
immune remain at work. 

Value of Blood and Urine Examina- 
tions IN THE Diagnosis of T.N.T. 
Poisoning 

The examinations made of the blood 
have been described in detail by Dr. George 
R. Minot (11), who found a blood picture 
of enough definiteness and frequency to 
serve as a valuable guide in the diagnosis of 
T.N.T. poisoning and in the estimation of 
the degree of severity of poisoning. As al- 
ready shown, the Webster reaction cannot 
give much aid in this respect, but it seems 
probable that further studies on the urine 
will bring to light other substances besides 
the reduction product of T.N.T. which is 
respohsible for the Webster reaction. Cer- 
tainly it seemed to the students that the 
changes of color in the untreated urine bore 
a closer relation to the clinical history of 
the case than did the varying intensity of 
the Webster reaction. This color was 
usually clear light brown to blackish brown 



and was quite independent of the elimina- 
tion of T.N.T. as shown by the Webster 
reaction. Nineteen specimens of dark 
brown urine, for instance, were either nega- 
tive to the Webster test or almost negative, 
while eight which gave a Webster 3 or 4 
were normal in color. In one of TeLinde's 
patients, a man who was shifted from 
T.N.T. work on account of sickness, the 
Webster reaction fell from 4 to a trace, 
while the dark brown color remained un- 
changed. Two more of his cases dropped to 
a negative Webster with persistent dark 
color, while a fourth had a Webster 4 con- 
tinuously with a normal cojor. As was to be 
expected, the darkest specimens came from 
Plants 1 and 2. Miss Hall reported twenty- 
five very dark urines, some of them the 
color of tincture of iodine. She was never 
able to detect bile in these specimens nor 
were Putnam and Herman able to do so in 
theirs. 

In some cases the urine changed from a 
brown to a clear red color, while in others it 
was red when the first examination was 
made. These red urines were always asso- 
ciated with a high Webster and with clinical 
symptoms of poisoning. Among seventy- 
four specimens, TeLinde found fifteen nor- 
mal, eight red, and fifty-one brown. Miss 
Emery found ten normal among forty- 
seven, nine red, and twenty-eight brown. 
These observations shoul3, of course, have 
been supplemented by chemical and mi- 
croscopic examinations but we did not pur- 
sue them further because the Hygienic 
Laboratory of the Public Health Service 
had undertaken an intensive study of 
T.N.T. urines and we did not wish to dup- 
licate their work. 

Summary 

The studies made by these students 
served to emphasize certain practical 
points in the prevention of T.N.T. poison- 
ing which in all probability apply with 



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HAMILTON — TRINITROTOLUENE AS AN INDUSTRIAL POISON 115 



equal force to those nitro and amido de- 
rivatives of the benzene ring that are used 
in the dye and drug industry. 

T.N.T. is absorbed chiefly through the 
skin and, therefore, the most important 
part of the prevention of T.N.T. sickness is 
the protection of the worker against direct 
contact with it. The methods of manu- 
factm^e, whether or not they necessitate 
hand work, the cleanliness of the work 
benches, apparatus, trucks, etc., and the 
prevention of dust are all of more impor- 
tance even than the provision of good wash- 
ing facilities, because a man can wash only 
at the noon hom* and on quitting work, and 
in the time between these periods he may 
have his hands and arms continually 
smeared with T.N.T. 

Next in importance to cleanliness of the 
premises comes the provision of clean work- 
ing clothes, socks, and gloves. The stu- 
dents' examuiation showed that T.N.T. 
could probably be continually absorbed 
from dirty gloves and dirty overalls. The 
necessity for providing ample washing 
fax^ilities, hot and cold running water, soap 
and towels, and the time to use them, is 
emphasized, not because it is not perfectly 
obvious in connection with such a poison as 
T.N.T., but because it was ignored in sev- 
eral of the T.N.T. plants during the war 
and is ignored in some of the coal-tar dye 
work^ at the present time. 

Fimies from melting pots are apparently 
capable of causing typical T.N.T. poison- 
ing, as is also steam from washing and 
I>elleting, but the more serious forms of 
T.N.T. sickness are probably never caused 
by fmnes alone. 

Hot, humid weather increases general 
T.N.T. poisoning, but not T.N.T. derma- 
titis. This last is more prevalent in summer 
than in winter, but is not increased by very 
hot weather. Its increase in sunmoier is 



probably due to the greater exposure of the 
skin in warm weather. 

Young men are more susceptible to 
T.N.T. than fully grown men. They suc- 
cumb more quickly and apparently suffer 
more seriously. It seems poor economy to 
employ them. 

Negroes are not susceptible to T.N.T. 
dermatitis and may be less susceptible to 
systemic poisoning than whites, but evi- 
dence on this point is not complete. 

The application of the Webster test to 
the urines of approximately 400 T.N.T. 
workers showed that T.N.T. is rapidly 
absorbed, but that it can also be rapidly 
eliminated. Some men could eliminate 
overnight what had been absorbed during 
the day; others could get rid of the week's 
accumulation during Sunday and start on 
Monday with the urine free from the re- 
duction product. The danger of overtime 
work and of the seven-day week was shown 
by these observations and also the value of 
an occasional vacation of two or three days. 

By the use of these same tests it was 
found that the most economical way to deal 
with a worker who had absorbed a large 
amount of T.N.T. was to suspend him al- 
together from work and subject him to 
vigorous eliminative treatment. Simply to 
transfer him to less dangerous work was to 
I>ostpK)ne his recovery. 

No positive aid in the diagnosis of 
T.N.T. poisoning was found in the Webster 
reaction in the inline, but the color changes 
in the untreated urine seemed more signifi- 
cant and worthy of further study. The 
blood changes found by Dr. Minot are im- 
portant enough to lead one to hope that 
careful blood examinations made in work- 
ers who are exposed to other benzene de- 
rivatives may give similar results, and thus 
an important aid be gained in the diagnosis 
of similar forms of industrial poisoning. 



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BIBLIOGRAPHY 



1. Hamilton, A.: Industrial Poisons Used or Pro- 
duced in the Manufacture of Explosives. U. S. 
Bur. Labor Stotis., Bull. 219, May, 1917. 

2. Martland, H. S.: Trinitrotoluene Poisoning. 
Jour. Am. Med. Assn., 1917, 68, 8S5. 

3. Legge,T. M.: Trinitrotoluene Poisoning. Great 
Britain, Ann. Rep. Chief Inspect. Factories and 
Workshops for 1917, p. 23. 

4. Moore, B.: The Causation and Prevention of 
Tri-Nitro-Toluene (T.N.T.) Poisoning. Nat. 
Health Insurance, Med. Research Com., Special 
Rep. Series, No. 11, Londonf, 1918. 

5. Koelsch, F.: Beitrfige zur Toxikolo^t der aro- 
matischen Nitroverbindungen. Zentralbl. f. 
Gewerbehyg., 1917, 6, 60, 65, 98, 109, and 142. 
Die Giftwirkung des Tetranitromethans. Ibid., 

185. 

6. Personal conmiunication from Marcel Frois of 
the Department of Labor, Paris, May, 1919. 



10. 



11. 



Putnam, T. J., and Herman, W.: A Study of 
Fifty Workers in Trinitrotoluene. Jour. In- 
DUST. Hyg., 1919-1920, 1, 238. 
Perkins, R. G. : A. Study of the Munitions In- 
toxications in France. U. S. Pub. Health Rep., 
1919, 34, 2335. 

Voegljin, C, Hooper, C. W., and Johnson, J. M. : 
Trinitrotoluene Poisoning. U. S. Pub. Health 
Rep., 1919, 34, 1307. 

Fddman, I.: Special Discussion on the Origin, 
Symptoms, Pathology, Treatment, and Pro- 
phylaxis of Toxic Jaundice Observed in Mimi- 
tion Workers. Proc. Roy. Soc. Med., 1916- 
1917, 10, Part 1, 67. 

Minot, G. R.: Blood Examinations of Trinitro- 
toluene Workers. Jour. Indust. Hyg., 1919-^ 
1920, 1, 301. 



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PUBLISHED MONTHLY 



VOLUMB m 



AUGUST, 1921 



Number 4 



DOES THE MAGNETIC FIELD CONSTITUTE AN 
INDUSTRIAL HAZARD?* 

C. K. DRINKER, M.D., and R. M. THOMSON 

From the Laboratory of Afylied Physiology of the Harvard Medical School 



MEN achieve undeniable enjoyment 
and comfort from attributing mis- 
fortime and disease to influences which 
they do not understand. Thus, there is a 
large gtoup who tre quite satisfied with 
astrological explanations for an epidemic 
of influensa, and in times past there have 
been even larger groups whose ideas of dis-' 
ease rested np(m a jiunble of electromagr 
netism and fictitious forces of human mag- 
netism, all so vaguely considered as to be 
entirely mystifying and, therefore, entirely 
satisfying. One might write at length of 
individuals who thus are happy in ex- 
planations which are not hampered by 
efforts to seek the truth. 

In view of the frequency with which 
mystifying phenomena have been described 
as causal agents, it is not surprising that 
even within fairly recent years many ex- 
traordinary physiological effects have been 
claimed for the magnetic field; even in 
- serious discussions the possibility that the 
field may effect cures of nervous disease has 
not been overlooked. Our attention was 
drawn to the subject in the course of in- 
vestigations upon chronic poisoning by 
manganese (1) . The affected workmen had, 

* Received for publication March SO, 1921. 



with few exceptions, been exposed to strong 
magnetic fields and the question -7 already 
suggested by Casamajor (2) — arose as to 
whether these exposures might not have 
something to do with causing the symp- 
toms observed. The poisoning in question 
occurred in men working in an atmosphere 
heavily laden with ore dust, much of which 
was strongly attracted by the magnet, and 
the questions arising were of two sorts: 

1. Is it possible that particles of man- 
ganese-bearing mineral deposited in the 
body are caused to penetrate more rapidly 
if the individual carrying them passes in 
and out of strong magnetic fields? 

2. Does the magnetic field alone in very 
great strengths produce any measurable 
physiological effects? 

The first of these questions we have never 
attempted to answer since a progressive 
reduction of dust, in the neighborhood of 
the large magnetic separators used in the 
mill involved, rendered it of no direct im- 
portance. The second question offered an 
opportunity to test the effect of stronger 
magnetic fields, than have ever been used in 
biological work, and we were, accordingly, 
interested in undertaking to find an answer 
to it. The results, though entirely negative, 



117 



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are given in some detail in order to estab- 
lish thoroughly the harmlessness of work 
in the neighborhood of extremely powerful 
electromagnets.* 

Hermann (3), in a paper published in 
1888, discusses previous scientific work 
with the magnetic field, together with the 
vast amount of charlatanry which has 
grown* up around "magnetism" as a result 
of the use of magnetic by hypnotists and 
others, and gives also an account of phys- 
iological experiments carried out by him- 
self. Readers interested in the earlier 
literature on the effect of the magnetic 
field are referred to this paper. Under ap- 
propriate conditions Hermann found that 
certain fundamental properties of muscle 
and nerve were unaffected by exposure to 
magnetic fields. Unfortunately, however, 
he gives ^no information as to the actual 
field strengths operative in his experiments. 
This same criticism applies to other bio- 
logical work with the magnetic field, the 
observations of Peterson and Kennelly (4) 
being excepted. 

In 1892, Peterson and Kennelly made 
experiments with magnets in the Edison 
Laboratory at Orange, New Jersey, in 
order to test out extravagant claims then 
current as to the therapeutic effect of the 
magnetic field. A quotation from the paper 
of these investigators will illustrate the 
degree to which magnetism commanded 
attention at that time (4). 

The status of magneto-therapy in America may 
be inferred from some quotations from the third 
edition of Roberts Bartholow's Medical Electricity, 
1887. Under the caption of Physiological Effects of 
Magnet Applications he says: "We know that a cur- 
rent circulates in a magnet. If a powerful horseshoe 
magnet is brought near to the skin» opposite elec- 
tricities are attracted to the poles and currents are 
induced. About the point of application, therefore, 
the skin will be acted on directly by the magnetic 
current aEnd by an induced current. The production 

* These experiments were made possible by the New 
Jersey Zinc Company through the loan of one of their large 
electromagnets of the type employed in the process at 
Franklin Furnace, New Jersey. 



of physiological effects, which can be recognized, is 
therefore merely a question of the magnetic 
strength." 

He then quotes Dr. Vansant as assummg the body 
to be diamagnetic: ''By applymg north and south 
polarity to different parts, very extensive subjec- 
tive impressions are experienced; they are of two 
classes — of heightened organic activity, and the 
opposite condition." 

He then adds: ''That impressions of a very de- 
cided kind are produced by the application of strong 
magnets is evident in the experience of Dr. Proust 
and Dr. Ballet, who continued a course ot investiga- 
tion begim by Charcot at Salp^tri^re." They ascer- 
tained that magnets could not be applied with 
impunity, for, if applications were prolonged, pains 
were felt in the epigastrium and thorax, making 
respiration painful, digestion was disordered, and 
boulimia brought on. These results were so uniform 
that there seemed to be no doubt of their genuineness 
in the minds of the investigators. 

In their first experiments, Peterson and 
Kennelly employed a magnet with a field 
intensity of 5,000 c.g.s. lines per square 
centimeter. They tested this field upon 
dried hemoglobin, fresh blood, ciliated 
epithelium, and the capillary circulation, 
without observing the slightest eflfect. 
They then placed a dog for five hom*s in a 
field with a strength of 1,000 to 2,000 c.g.s. 
lines per square centimeter without observ- 
ing any change in the animal; and, finally, 
they tested the eflfect of field strengths of 
2,500 c.g.s. lines per square centimeter 
upon themselves. In these latter eflforts a 
variety of types of exposure were used 
but all resulted negatively, justifying their 
conclusion that the human body is appar- 
ently quite uninfluenced by magnetic fields 
of moderate strength. 

PfeflFer (5), in 1903, discussing the pos- 
sible actions of the magnetic field upon 
growth, can find no convincing evidence 
that any eflfect has been obtained. Ewart 
(5), in an editorial note, suggests thai this 
is possibly due to weakness of the fields 
employed and that theoretically one should 
be able to aflfect living protoplasm pro- 
vided strong enough fields are used. 



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DRINKER AND THOMSON— MAGNETIC FIELD AS HEALTH HAZARD 119 



i 



In all the experiments mentioned so far, 
with the exception of several by Peterson 
and Kennelly, a continuous current was 
used and the field strength was steady and 
unvarying. This condition is also true of 
the industrial situation which we have 
cited. In the case of solenoids traversed by 
alternating currents an interesting type of 
actual physiological eflfect was noted first 
by d'Arsonval (6) in 1893, and has been 
commented upon by several later experi- 
menters (7) (8) (9) (10). Many of these ob- 
servations, as for example those of Sylvanus 
P. Thompson (11), are considered by their 
authors to be the first note of the phe- 
nomenon ever made. That a definite and 
easily obtainable physiological effect does, 
therefore, arise in the neighborhood of a 
suflBciently powerful alternating field can- 
not be doubted. If the head is inserted in a 
coil or if it is brought close to a coil through 
which a strong alternating current is pass- 
ing, a flicker of hght is noticed, and this is 
perceived with the eyes open or closed, and 
in a dark or a light room. There is appar- 
ently no doubt that a definite visual sensa- 
tion is induced and that it can be made to 
vary with current strength and the relation 
of the head to the magnet. Dunlap (12, p. 
70) describes the sensation as follows: 

With 480 amperes of 25-cycle current (20 volts) a 
much more striking result was obtained. With my 
bead bdow the level of the coil, and with my eyes 
open, the flicker was strongly noticeable, although 
the room was brightly lighted by afternoon daylight. 
The ^rhde visual fidd quivered as if illuminated by 
a rapidly intermittent light. Several other subjects 
made a similar observation, although in some cases 
the flicker was noticed only in the less illuminated 
parts of the visual fidd, as where shadows fell in the 
room. With the head ioside the coil the flicker was so 
pronounced as to be intensely disagreeable. 

There is no explanation of this eye eflfect 
but at the same time there is no evidence 
that it causes damage. We may sum up, 
therefore, by saying that the scientific 
ht&ratnre upon the physiological eflfects of 
the magnetic field is negative in so far as 



the use of constant fields is concerned, and 
in the case of alternating fields does not 
contain evidence of an eflfect which is harm- 
ful even when the experimenters employ 
much more severe expK)sm*es than would 
ever be experienced in any industrial 
operation. 

Experimental Observations 

a. Magnetic Fields. — The magnet used 
was a very large one. The general config- 
m^ation of the pole pieces and arrangements 
for exposure of experimental material are 
indicated in Figure la. The pole pieces A 
and B are permanent, but C and D are ad- 
justable and when in place enable one to 
secure maximum field strength between 
their tips. In Figure lb a muscle M lies to 
the left of the poles C and D, and the nerve 
N to the muscle passes between the pole 
tips through a gap 1 mm. in width. 

Field strengths were measured by means 
of a bismuth spiral. Table 1 indicates the 
field strengths at points 1 to 10 in Figure la 
with pole pieces C and D in position and 
with diflferent amperages. The breadth of 
the most intense field with its center at 
point 1, immediately between the tips of 
the pole pieces, is indicated in Table 2. 

Two general types of experimental ex- 
posure were employed. In the first of these, 
blood and isolated nerve-muscle prepara- 
tions were exposed to the greatest field 
strengths obtainable, such fields obviously 
requiring use of the magnet under large 
amperages with the pole pieces C and D in 
position. By reference to the positions 
covered in Tables 1 and 2, one can readily 
arrive at a close approximation of the con- 
ditions to which the tissues were subjected. 
For example, if a nerve-muscle preparation 
is placed in a moist chamber K of Figure lb 
with the nerve crossing the small gap be- 
tween C and D, it is clear that the nerve 
impulse set up at the tips of electrodes E 
and F and passing along the nerve to the 



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muscle must, if the magnet is activated by 
a current of 20 amperes, pass a field inten- 
sity of 18,725 c.g.s. lines per square centi- 
meter (Table 1), and that the field strengths 
to which all parts of the preparation are 
exposed may be told provided the lengths 
of the muscle and the nerve are known. 

The second type of experimental ex- 
posure required the use of entire animals 



6. Nerve-Muscle Experiments. — Since 
the nerve, when it conducts an impulse, 
exhibits an electrical change, and since a 
similar change occurs in muscle just prior to 
actual contraction, we examined carefully to 
see whether nerve conduction or muscular 
contraction suffered as a result of exposure 
to the strong magnetic fields we could 
supply. Various tyi>es of experiment were 




Fig. la. — Arrangement of pole pieces A and B, and C and^D, with moist chamber K in place. The 
positions at which magnetic field strengths were determined are indicated by numbers down the center 
of the field. 

b. — Arrangement of nerve-muscle preparation in moist chamber K. M indicates muscle; N, 
nerve; £ and F, stimulating electrodes. 



and is described in detail in a later section 
of this paper. To provide room for these 
exposures C and D were removed, leaving 
a large gap, 12 inches by 18 inches. Under 
these conditions the field strengths ob- 
tainable varied in different parts of the 
gap. Table 3 gives the field intensities at 
15 amperes through the center of this field 
and indicates in an approximate manner 
the conditions to which animals were sub- 
jected over a considerable time. 



employed, the ordinary nerve-muscle prep- 
aration of the frog and the nerve of the cat 
being the test objects used. Several ex- 
amples will suffice to indicate the innoc- 
uous character of the field. 

Jan. 27, 1919. — Two nerve-muscle 
preparations (sciatic-gastrocnemius) were 
made from the same frog. One of these was 
placed in a moist chamber (Figure lb) 
fitted about the pole pieces C and D, which 
had been lightly coated with paraffin, with 



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DRINKER AND THOMSON— MAGNETIC FIELD AS HEALTH HAZARD 121 



the nerve on electrodes E and F and the 
musde clamped in the position shown. 
From the tendon of the muscle a light silk 
thread passed out of the moist chamber to 
a muscle lever lightly weighted and ad- 
justed to write on a large kymograph. The 



electrodes to the two nerves connected in 
series in the secondary circuit of an in- 
duction coil.'' The steadiness of the cur- 
rent used in stimulation was controlled by 
the employment of a miUiammeter in the 
primary circuit of this coil. The thresh- 



TABLE 1. — MAGNETIC FIELD STRENGTHS IN C. G. S. LINES PER SQUARE CENTIMETER 
AT VARYING AMPERAGES IN POSITIONS 1 TO 10, FIGURE la. POLE PIECES 

C AND D IN POSITION 





Amperage 


Field Strengths in C. G. S. Lines in Positions 




1 


2 


8 


4 


5 


6 


7 


8 


9 


10 


10 ,. 

15 


17,450 
18.375 
18,725 
18.975 


8,150 
9,200 


4,825 
5:425 


8,500 
3,900 


2,775 
3,175 


2,400 
2,650 


2.100 
2,375 


1,975 
2,825 


1,825 
1,900 


1,750 


20 


1,800 


22 









TABLE 2. — MAGNETIC FIELD STRENGTHS IN C. G. S. LINES PER SQUARE CENTIMETER 

IMMEDIATELY IN VICINITY OF POLE TIPS C AND D AT TWO AMPERAGES, SHOWING 

DETAILS OF FIELD STRENGTH DECREASE BETWEEN POSITIONS 1 AND 2 



Amperage 


Field Strengths m C. G. S. lines in Positions i 


1 


is 


lb 


Ic 


Id 


i 


10 


17,450 
18,725 


16,875 
17,950 


12,750 
14.200 


10,100 
12,075 


8,400 
9,625 


8,150 


20 


9,200 





^ Distance between 1 and la « 0.25 inches 
« la and lb = 0.25 ** 
lb and Ic = 0.25 « . 



Distance between Ic and Id »< 0.25 inches 
Id and 2 -0.125 « 
1 and 2 -L125 « 



TABLE 3. — FIELD STRENGTHS IN C. G. S. LINES PER SQUARE CENTIMETER WITH POLE 

PIECES C AND D REMOVED 





Amperage 


Field Strengths in C. G. S. lines in PosiUons 




1 


2 


8 


4 


5 


6 


7 


8 





10 


15 


2,800 


2,800 


2,825 


2,825 


2,825 


2,825 


2,800 


2,725 


2,600 


2,400 







control muscle was placed in a second 
chamber lacking the orifices for the pole 
pieces C and D but in other respects en- 
tirely similar, and through a similar muscle 
lever was caused to write upon the kymo- 
graph just above the lever recording the 
magnetic field muscle. Tight-fitting lids 
were placed on both chambers and the 



old stimulus for both preparations was 
then obtainable by breaking the primary 
circuit while bringing ijie secondary coil 
toward the primary. With the first con- 
traction of the muscles the position of the 
secondary coil was read, and this repre- 
sented the minimal or threshold stimuliis. 
Further approximation of the secondary 



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Te Ky9,e^Af.k 




Kp^Os 



\ 






^ 


To Kymcov^ikK. , 


= 





"B^ 










A 



T^^^^ 



f\ 


-y 








N__ 


-^ 








P 




k 







Tp ^y^^^gnpK, 




._i= 



iL 



Fig. 2a. — Experiment of Jan. 27, 1919, showing position of nerve N, muscle M, and pcile pieces 
C and D. Electrodes 3} mm. apart, at a position between 3 and 4; gastrocnemius tendon at 4; and 
body of muscle between 4 and 1. 

b. — Position of nerve after experiment had been in progress four hours. 

c. — Position of stimulating electrodes for the last eight hours of the experiment. 



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DRINKER AND THOMSON-MAGNETIC FIELD AS HEALTH HAZARD 123 



coil increased the strength of stimulus and 
by this means the maximum response was 
rapidly obtained. 

Figure 2a gives the positions of the nerve, 
the muscle, the stimulating electrodes, and 
the pole pieces of the magnet in terms of 
the positions in Table 1. Figure 2b shows 
a slight variation caused by movement of 
the nerve dm^ing the experiment, and Fig- 
ure 2c, the final position of the stimulating 
electrodes. In all cases the positions of 



c.g.s. lines per square centimeter. The 
total period of exposure was from 11.46 
A.M. to 5.29 P.M. on the next day, or twenty- 
nine hours and forty-three minutes. Dur- 
ing this period the threshold for conduction 
of the nervous impulse was tested 116 
times and, although the nerve exposed to 
the magnetic field ceased to conduct before 
the control, the difference is of no conse- 
quence in the face of such a long period of 
survival. It will be noticed by reference to 




Fig. 4. — Fatifcue curves written by companion nerve-muscle preparations under identical conditions 
of stimulation. C indicates control muscle; M, muscle exposed to magnetic field. 



the electrodes on the nerve were duplicated 
in the control preparation. 

Figure 3 (p. 127) shows a series of contrac- 
tions taken simultaneously under identical 
strengths and conditions of stimulation 
during the experiment of Jan. 27, 1919. 
The results of this experiment are sum- 
marized in Table 4. 

Reference to Table 1 and to Figures 2a, 
2b, and 2c will show that the nerve at the 
original point of stimulation experienced a 
magnetic field intensity varying between 
5,4£5 and 3,500 cg.s. lines per square centi- 
meter, that the nerve impulse to reach the 
muscle had to cross a field of 18,725 to 
17,450 c.g.s. lines per square centimeter, 
and that the contracting muscle lay in a 
field varying between 18,725 and 3,500 



49 and 50, Figure 3, that at the end of 
the first twenty-one hours and before the 
stimulating electrodes were moved the 
preparation which had been in the mag- 
netic field was in better condition than the 
control. When the electrodes were moved 
a difference in behavior resulted, but 
throughout the experiment the entire 
course of events was not different from that 
obtained when two nerve-muscle prepara- 
tions are set up under identical conditions. 
In order to be entirely sure that this inter- 
pretation was correct the experiment was 
repeated eighteen times, but no trace of 
magnetic field effect was ever obtained. 

A second type of experiment is illus- 
trated in Figure 4. In this case two nerve- 
muscle preparations were set up as in the 



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TABLE 4. — THRESHOLD STIMULI OF MAGNETIC FIELD AND CONTROL MUSCLES DURING 

THIRTY HOURS 



"fime 



Temperature 



Current in 
Primary Cir- 
cuit Inducto- 
rium 



Magnet 
Circuit 



Observation 
No. 



Threshold Stimulus in Scale Divisions 



Maflietic Field 
Muscle 



Control Muscle 



Januairy ^ 
AM, 

11.80-11.32. , . .* 

11.44-11.46 

11.46 1 

11.51-11.53 

11.58-12.00 



17.2 
17.0 



PM. 



1.48 

2.56-2.58. 
3.11-3.13. 

8.27 

4.10 

4.59. .... 
5.1^-5.20. 
5.25-5.27. 
5.27» 



Arrfperes 

0.075 
0.075 

0.075 
0.072 



0.072 
0.072 



January 28 
AM. 

8.47 

8.47-8.49*.... 



12.2 



10.07. 
10.47. 



PM. 



1.28 

2.07-2.09. 
2.14-2.16. 

2.S0 

3.52-8.55. 
4.00-4.02. 

4.52 

5.20-5.22. 
5.27-5.29. 



0.069 



0.072 
0.072 

0.072 
0.072 

0.072 
0.072 



Amperes 



20.4 



18.6 



18.6 
18.6 
18.2 



10.0 



15.0 



19.2 
18.9 



18.4 



18.2 



18.0 



30 
31 



49 
50 



21.0 
21.5 

21.0 
21.0 



20.0 
20.5 



19.0 
19.5 



29.0 
28.0 

29.0 
28.0 



26.5 
26.5 



23.0 
24.0 



51 



6.5 



No oontraction 
obtainable. 



95 
96 

109 
110 

120 
121 



9.5 
9.5 

7.5 
7.0 

8.0 
8.0 



10.0 
10.0 

9.5 
9.5 

8.0 



^ Magnet turned on. * Magnet circuit reduced to 10 amperes and left for night. 

* Magnetic field muscle continued to show threshold at 6 until 9.40 when it be^me impossible to obtain oontraction 
even with maTimmn stimuli. Electrodes on both nerves were accordingly moved into the positions indicated in 2c. 
Both nerves were slowly drying in spite of moist chamber conditions. 



previous experiment and were compelled 
to contract repeatedly, lifting each time a 
70-gram weight and registering their work 
through two similar work-adders. In this 
particular instance the belly of the muscle 
subjected to the magnetic field was placed 
immediately above the pole tips C and D 
and the magnet was held at 20 amperes. 



The muscle, therefore, was subjected to a 
field intensity of approximately 17,950 
c.g.s. lines per square centimeter (Table 2). 
In this experiment the tracings written by 
the control C and the magnetic field muscle 
M are practically identical, the work done 
by the control being 2,856 gm. cm., and by 
the magnetic field preparation 2,639 gm. 



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DRINKER AND THOMSON-MAGNETIC FIELD AS HEALTH HAZARD 125 



cm. Such results falj within the limits of 
error in comparisons of two normal muscles 
and indicate no harmful 
eflfect from the magnet. 
The same experiment 
repeated ten times never 
gave evidence of any ac- 
tion whatsoever on the 
part of the magnetic field. 
Figure b displays fa- 
tigue curves made by 
two companion isolated 
muscle preparations stim- 
ulated directly, the 
electrodes in each case 
being placed in the capsule 
of the knee-joint and in 
the gastrocnemius tendon. 
During the period of work 
muscle M was subjected 
to a magnetic field of ap- 
proximately 17,950 c.g.s. 
lines per square centi- 
meter, the belly of the muscle lying just 
above the tips of the poles C and D. In 
this case the control muscle C did 3,444 
gm. cm. of work against 3,668 gm. cm. for 
the muscle exposed to the magnetic field. 



Omitting details of other experiments, we 
may sum up our results by saying that in 




Fig. 6. — Fatigue 
identical conditions 
exposed to magnetic 



curves written by companion gastrocnemii muscles under 
of stimulation. C indicates control muscle; M, muscle 
field. 



isolated nerve-muscle preparations we have 
never been able to observe any change in 
irritability or conductivity of nerve nor in 
the contractile power of muscle as a result 
of exposure to the magnetic field. 









0\ 


f 






— U- 




L 


N "^ 


"^/^ 






— L, 
















F 












**• rV'^^^^^^v 


. 








^ 


T 


G 






h 







Fig. 0. -- Diagram of apparatus for recording the action current of mammalian nerve. 
E and F indicate stimulating electrodes; C and D, pole pieces of magnet; L and R, non- 
polarizable electrodes leading to the string galvanometer 6. 



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As a final experiment to test the eflfect of 
the field upon the nerve impulse we placed 
a long section of cat nerve (popliteal) in a 
moist chamber under the conditions given 
in the diagram, Figure 6, in which E and 
F are the stimulating electrodes and L and 
R leading off electrodes to a string gal- 
vanometer.* Figure 7a is a photographic 




Fio. 7a. — Action current of popliteal nerves prior to 
exposure to magnetic field. 

b. — Action current of same nerve after two and 
one-half hours of exposure to a field of 18»725 c.g.s. lines 
per square centimeter* ' 



record of the action current of this nerve 
prior to magnetic field exposure, and Figure 
7b a record of its action current after two 
and one-half hours' ejcposure to a field of 



v/VV 




18,725 cg.s. lines per square centimeter. 
As this record shows, the magnetic field 
produced no change in the action current 
which signals the passing of the nerve 
impulse. 

In addition to these experiments with 
isolated nerve and muscle, a certain num- 
ber of experiments were done with red 
blood corpuscles and blood. It was shown 
that prolonged exposure (two and one-half 
hours) to magnetic fields of 18,725 to 
14,200 c.g.s. lines per square centimeter 
had no effect upon the shape of red blood 
corpuscles nor upon their oxygen combin- 
ing power. In the same strengths and 
conditions of exposure complement and 
hemolytic amboceptors were likewise unaf- 
fected.f 

c. Expervifnents upon Animals. — The 
exposure of living animals to magnetic 
fields for short periods of time and under 
a considerable degree of restraint is easily 
arranged, but, feeling that such a procedure 
gave little promise of interpretable results, 
we endeavored to find small animals of 
active type — certain to make natural 
movements in the field — and to expose 
them under circumstances permitting con- 
stant observation of their condition. 
Dancing mice were finally selected as the 
manmial most stdtable for the experiment. 



3- 



> I I » I .<i I 4 tm 



K 



Fig. 8. — Diagram of apparatus for exposing dancing mice to magnetic field. A indicates aluminum box; 
M, manometer; K, kymogriaph; T, tambour. 

* The observations involving th^ string galvanometer t For these last observations we wish to express our 

were made for us by Dr. Alexander Forbes. thanks to Dr. A. Watson Sellards. 



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I 




5« 





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These animals are small, active, and easily 
cared for during a protracted experiment. 
Accordingly, we exposed dancing mice in 
pairs to magnetic fields, the strengths of 
which are given in Table S. 

Figure 8 indicates the manner* in which 
these animals were studied. An aluminum 
box A, 6 by 12 inches, served as a cage for a 
pair of mice. This box was suspended by a 
light brass spring adjusted to a tambour T 
so that every movement of A acted upon 
the rubber diaphragm in T and by air 
transmission activated the oil manometer 
M which wrote upon a slowly moving 
kymograph JC. The box A was lightly an- 
chored at the comers by brass springs and 
fitted into the large gap in the magnet, 
secured by removing pole pieces C and D. 
A control pair of mice occupied a second 
box, their movements being recorded upon 
the same kymograph through exactly 
similar devices. Mice lived in the box A 
for periods of three months, being exposed 
to fields of approximately 2,800 c.g.s. lines 
per square centimeter for an average of 
fifteen hours daily during this periodr The 
magnet was turned on when we left work in 
the evening and turned off next morning in 
order to avoid the annoyance of having it 
active during working hours in the labora- 
tory. The life of the mice during periods of 
this sort was apparently entirely normal. 
Females became pregnant, and when killed 
near term were found to contain normal 
young. No signs of disease were observed. 
The mice continued sound during the ex- 
periment and their organs, when examined 
microscopically at the close of the experi- 
ments, were found 16 be normal. 

In Figure 9a we have a record covering a 
twenty-four-hour day for the control pair of 



mice and for the pair exposed to the mag- 
netic field. The two lower lines of tracing 
represent the movements of the pairs of 
aninials in their cages during the day 
period, and the two upper longer lines, the 
activity during the night. Figure 9b shows 
a similar set of tracings upon the same pairs 
of mice after three months' exposure of one 
pair to the magnetic field. The top and 
third from the top tracings are those for the 
magnetic field mice and show a normal 
degree of activity. 

As a final type of experiment we fre- 
quently placed our own heads in magnetic 
fields of as great strengths as were obtain- 
able, but were never able to appreciate any 
effect whatsoever — a result which corrob- 
orates the findings of Peterson and Ken- 
nelly (4). With the magnet which we used 
the effects of alternating currents could not 
be tested, and we are, therefore, not in a 
position to speak upon this phase of the 
subject. 

Conclusions 

1. The effect of constant magnetic fields 
varying between 18,725 and 2,800 c.g.s. 
lines per square centimeter has been studied 
in experiments upon various types of nerv- 
ous and muscular tissue, upon blood, and 
upon intact animals. 

2. None of these experiments has-given 
the slightest evidence of physiological ef- 
fects from the magnetic field. 

S. The experiments cited have utilized 
field strengths far greater than those to 
which workmen are subjected, and, since 
the tissues employed were those most 
likely to show vulnerability, it seems cer- 
tain that the magnetic field has no signifi- 
cance as a health hazard. 



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DRINKER AND THOMSON— MAGNETIC FIELD AS HEALTH HAZARD 129 

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THE INDUSTRIAL PHYSICIAN AND THE QUALIFICATIONS 
ESSENTIAL TO HIS SUCCESS* 

WILLIAM J. McCONNELL, M.D. 

Patsed Assistant Surgeon (Reserve), U, S, Public HeaUk Sercice 



OF all the specialties in the medical 
field, perhaps the one which is least 
understood is that of the industrial phy- 
sician. To emphasize the importance of 
this specialty, we have but to recall some 
instances of the past. We are more or less 
familiar with the disastrous effect, during 
the war, of the manufacture of the explo- 
sive, trinitrotoluene, resulting in fatal 
cases of toxic jaundice, as described in the 
report of the Ministry of Munitions, Lon- 
don. Previously, this substance had hardly 
been regarded as toxic; but when the neces- 
sity arose to manufacture it in large quan- 
tities, and at a time when the conservation 
of the life and health of the worker was 
of the utmost import, mortality from its 
poisonous effects became alarming. Had 
it not been for the preventive measures in- 
stituted by a few men with training in the 
hazards of industry, based on previous 
knowledge and experience of the nearest 
analogies, the mortaUty from this poison- 
ing would have been markedly increased; 
and had this branch of medicine been de- 
veloped equally with other specialties, one 
is justified in believing that the mortality 
not only from T.N.T. poisoning but from 
the large list of other recognizable hazards 
would have been appreciably lowered. 

The trend of modern thought is toward 
conserving and preserving human life. 
Science fimctions at its best when it con- 
quers disease and reduces the hazards of 
human existence. Industrial hygiene shares 
its place with other welfare organizations 
designed to give the youth of the nation a 
chance to develop mentally and physically, 
to keep the body strong and well and fitted 

* Received for publication May 7» 192L 



for the tasks and duties of the day, and to 
live long and useful lives. Millions of dol- 
lars are spent, and justly so, in the control 
and prevention of disease, in providing 
pure drinking water and food products 
from healthy stock, and in educating the 
public in health matters. Yet, little indeed 
is to be gained by these activities and by 
the expending of additional enormous sums 
of money in the rearing and education of 
children, and in the promotion of their 
health, if their lives, at the prime, are only 
to be crushed out by the unnecessary haz- 
ards of industry. 

Oliver (1) speaks of lads under 18 years of 
age who were given employment where the 
lead hazard existed. "These youths," he 
says, "all of good physique, well-developed 
and healthy looking, were examined medi- 
cally before entering the factory, and yet, 
notwithstanding this precaution, so great 
was the amount of lead poisoning amongst 
them, and in such a short time, too, that the 
employers were obUged to dismiss them." 
In recent years, however, much has been 
accomplished, both in foreign countries and 
in America, toward eliminating this hazard 
which is perhaps the greatest of all indus- 
trial hazards, and which at one time was 
present in about 150 different industries. 
But the hazards with which the industrial 
physician must cope are still many and re- 
quire constant vigilance. 

Throughout every state and virtually 
every community in this country costly 
machinery is installed and maintained at a 
high degree of eflBciency, for the purpose of 
increasing production. Aside from purely 
humanitarian views, if we conceive of the 
workman as a factor in production, we are 



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McCONNELL— QUALIFICATIONS OF INDUSTRIAL PHYSICIAN 181 



in him dealing with the most potentially 
efficient machine in the universe. 

M. Amar (2) describes the human motor as prob- 
ably an "electro-capillary" engine, the nature of the 
nervous agent and the origin of human power being, 
however, unknown. Man's power is approximately 
1-7 H.P., but the efficiency is about 30 per cent., or 
very high. Compared to a steam engine, the human 
' motor performs its work on half the fuel consump- 
tion. The life of the human motor is greater than 
that of any inanimate prime mover, which is placed 
at a maximum of 20 years unless frequently re- 
paired. Till old age sets in, the human motor is self- 
repairing. Its control is internal. In general: 

"The maintenance of the human machine is as 
difficult and important a matter as the maintenance 
of any inorganic motor. We must do our best to 
eliminate all internal and external conditions tend- 
ing to cause depreciation. Especially must phys- 
iological discomfort be avoided and removed, as far 
as possible. In the due proportion of effort and 
speed, in industrial labor, lies the key to intensive 
production and the well-being of the workman." 

The uninitiated may marvel that a 
science should exist for the purpose of in- 
creasiilg human efficiency and decreasing 
waste; yet it is only by the application of 
the scientific principles of industrial hy- 
giene and sanitation that a man can pro- 
duce an increased yield sufficient to justify 
a larger compensation for his labor, and can 
thus be enabled to live in comfort and to 
find new strength and enjoyment in his 
work each day. It is, therefore, of vital 
import that the public at large should be 
interested in those conditions which ma- 
terially affect the health and welfare of 
approximately one-third of the population 
of enlightened countries — namely, the 
producers of the world. To accomplish 
constructive improvements, organization of 
interests and co-operation with other 
sciences are essential; but as the human 
factor, with which the physician has to 
deal, is the greatest of all factors in the 
activities of life, all other factors should 
revolve around it as a center. 

Unfortunately, the term ''industrial phy- 
sician" has been erroneously applied to 



general practitioners who spend part time 
in treating cases of sickness and injury 
sent to them from industrial plants. Even 
contract physicians have been at times 
classified under the same head. The re- 
stricted conception of the industrial phy- 
sician limits the appellation to the man 
who has speciaUzed in the field indicated 
in this paper. He is no longer the practising 
physician who makes an hourly trip to the 
plant in order to dress minor injuries, or 
who is called when a worker suddenly be- 
comes ill or is hiul:. On the contrary, be is 
a trained specialist in industrial hygiene 
and occupational diseases, and does not 
engage in the general practice of medicine 
nor of surgery any more than does the 
speciaUst in other branches of medicine. 

It is true that little opportunity is offered 
the industrial physician to prepare for his 
specialty, and he must of necessity accu- 
mulate his knowledge from promiscuous 
sources. An attempt has been made to 
merge this all-important specialty, as a 
branch, with preventive medicine or social 
medicine, but the field of industrial hygiene 
and sanitation is sufficiently broad and 
sufficiently well defined to constitute in it- 
self a specialty, and the demand for trained 
men is imperative. A few medical schoob 
are now recognizing the importance of 
training men for this work and are offering 
special courses for it. Much remains to be 
accomplished in this direction, however, 
and a more comprehensive course including 
actual field work is desirable. 

Diagnosis of ordinary occupational dis- 
eases is, to be sure, not difficult, but early 
recognition of them, which is all important, 
is quite so. It is unfortimate that the in- 
dustrial physician must for the most part 
recognize the early diagnostic symptoms 
of many industrial diseases through expe- 
rience and from the perusal of special 
articles, for the reason that textbooks 
usually emphasize only the more advanced 
symptoms. It is obvious, therefore, that 



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to become qualified for his task, the indus- 
trial physician must have special training 
and sp>ecial qualifications as well. 

In the first place, the question arises as 
•to the specific position of the industrial 
physician in industry — whether he serves 
the employees or those who employ him. 
The physician who serves either to the ex- 
clusion of the other fails in the high pur- 
pose of his mission. I. know. of physicians 
who are employed mainly for the protection 
of the management against lawsuits, and 
who are expected, no matter what the 
cause of the ailment or injury, to convince 
the patient that bis trouble is the result of 
his own car^Jessn^s^ . and is in no way 
calised by his working conditions. Such 
policies among physicians are soon recog- 
nized by employees, and have a tendency 
to cause them to resent, and with some de- 
gree of right, the aid offered them by fair 
and conscientious physicians. 

The task of the industrial physician is by 
no means easy. He occupies the position of 
UaisoTty as it were, between management 
and eniployees. His duties toward the 
former are to increase the eflSciency of the 
workers, in order to secure and maintain a 
high rate of production; to prevent wast- 
age; to minimize labor turnover; and to 
interpret the workers to the management, 
by pointing out causes of dissatisfaction 
among them and suggesting remedies for 
it. His duties toward the employees are to 
promote health, sanitation, personal hy- 
giene, and contentment; to maintain clean- 
liness and order; to lessen the possibility of 
accidents and disease; to protect against 
dust, industrial poisons, inadequate ven- 
tilation and' illumination, over-fatigue, 
draught, extremes of heat and cold, danger 
of fire; to advise in the selection of jobs 
suitable to the physical capacity of in- 
dividuals; to improve the morale; and to 
interpret the management to the workers. 

In order to accomplish these ends, the 
industrial . physician should be character- 



ized first of all by fairness, tactfulness, and 
a sympathetic attitude, which will enable 
him to seeing effective co-oi)eration. He 
must evaluate statements of both, em- 
ployer and employed; must discriminate 
between facts, opinions, bias, and prejudice, 
through observation of actual conditions; 
and wherever possible must base his judg- 
ment upon facts instead of upon opinions. 

In making the initial physical examina- 
tion of the worker, the physician should be 
guided by the mental as well as the phys- 
ical fitness of the individual, and should 
assist the management in hiring advan- 
tageously and in giving each new man such 
work as he can best perform. When we 
consider the fact that, as measured by 
mentality tests, the greater number of men 
in the army were of average or less than 
average intelligence — which is probably 
true today of the men of the country as a 
whole — it is evident that, in spite of some 
limitations, each man according to his 
grade of mentality and intelligence may be 
assigned a part in the whole organization 
that will lead to his success and happiness. 

Again, the abiUty of the industrial phy- 
sician and his value to industry are meas- 
ured largely by his knowledge of and 
familiarity with the needs of the plant. 
Before he can recommend or even suggest 
changes for improvement, he must have at 
least a working knowledge of the materials 
used, the products and by-products manu- 
factured, the processes involved, and the 
possible hazards existing. 

The industrial physician's first duty on 
assignment to any plant is to make a com- 
prehensive survey of conditions, including 
an analysis of each department into its 
various jobs and a study of the processes of 
each. The paramount idea of such a sur- 
vey is "seeing with trained eyes" and 
utilizing the collected facts to establish a 
basis for recommendations. No alteration 
or improvement should be recommended 
without suflBicient reason, and the physician 



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McCONNELL— QUALIFICATIONS OF INDUSTRIAL PHYSICL^ 188 



should guard against staggering the man- 
agement with recommendations reqidring 
large expenditures of money. A survey 
likewise fails if the investigator is unable to 
interpret his findings. 

It may be well to review briefly the most 
important factors which may constitute 
hazards in industry and which are of in- 
terest to the industrial physician. Let us 
first consider the subject of ventilation. 
While the task of providing adequate 
ventilation in the larger plants is the duty 
of a ventilating engineer, the maintenance 
of the ventilation system and, in some in- 
stances, the installation of the system rest 
upon the industrial physician. The essen- 
tial factors to be considered in ventilation 
are temperature, degree of moisture, and 
air movement. The air may be vitiated by 
impurities which arise from manufactiuring 
processes, from floors of the rooms, from 
persons, from lights burning, and from ac- 
cidental sources, such as eflBiuvia from 
drains, escape of gas, or impure outside air. 
The industrial physician should know the 
composition of pure air, and its value. He 
should be familiar with methods of remov- 
ing impurities, pollution, dust, and damp- 
ness of surrounding surfaces, and should 
see that there is sufficient cubic capacity, 
with absence of overcrowding, constant 
movement of the air, proper and rightly 
placed inlets and outlets for the air, cross- 
ventilation, and moderate temperature and 
humidity. The objectionable featm-es of an 
inadequately ventilated room are more 
frequently thermal than chemical. 

No less important is the problem of ade- 
quate illumination, and a thorough knowl- 
edge of the subject is particularly essential 
for the successful industrial physician. 
With proi)er illumination over the working 
areas, the safety and skill of the worker 
may be maintained at a high standard, 
and production increased in quantity and 
improved in quality. Distinction must be 
drawn in regard to illumination, surface 



brightness, and glare. The physician 
should not only be familiar with the imit of 
measure for general illiunination and the 
methods employed to test it, but should 
also know the number of units necessary 
for the performance of different kinds of 
work. The ^ectiveness of illumination 
cannot always be measured in terms of the 
vertically downward component of the 
light as it is sometimes of advantage to 
light the work plane from the side. For 
larger plants, at least, the engineer should 
be consulted in order that the fimdamental 
principles of effective illumination — suf- 
ficiency, continuity, and diffusion — may 
be f ulfiUed. 

The problem of illumination is by no 
means solved simply by the installation of 
an efficient system. Indeed, the main- 
tenance of the system is of equal impor- 
tance, because frequently, through neglect 
of proper upkeep, one-half of the light 
which a system is capable of supplying may 
be lost to the worker. The change from 
sufficient to insufficient light is very grad- 
ual and is often overlooked. Dust and dirt 
accumulate slowly, reflectors break, ceil- 
ings become darkened by degrees, here and 
there is an empty socket or a lamp of in-^ 
correct voltage. Thus, it frequently hap- 
pens that the cumulative effect of these 
needed repairs is noticed only after the 
workmen complain of eyestrain. 

The proper method of using Ughting 
equipment so that it may be suitable to the 
needs of a plant is as important as the wise 
choice of a system. Whether direct, in- 
direct, or semi-indirect Ught is best, de- 
pends upon the purpose for which the light 
is to be used. It should also be remembered 
that faulty reflectors may do more harm 
than none at all. 

That certain occupations are more fa- 
tiguing than others is common knowledge, 
and the physician is not interested in fatigue 
in the ordinary acceptation of the term; 
but he is deeply concerned with the effects 



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produced by over-fatigue, the boundary 
line between fatigue and over-fatigue, and 
the length of time necessary to recover from 
fatigue. There is no uniform method of 
treating this problem, and the physician 
must work it out to the best of his abihty 
for each individual industry, for both 
sexes, and for diflferent climates. Other 
problems, with which he is concerned and 
for which he should bear the responsihihty, 
are i)ersonal service facilities, rest periods, 
welfare work, and effective methods of 
cleaning the plant. 

As an aid in predicting the effects of cer- 
tain reactions upon the worker, a knowl- 
edge of chemistry is of great advantage to 
the industrial physician, particularly as the 
substances used in industry are many and 
varied, and their effects multiple. For in- 
stance, it is an interesting fact that there 
are about 300 substances used in industry, 
which cause skin diseases and in dealing 
with which a knowledge of chemistry 
would clearly be exceedingly valuable. 

Too much stress cannot be placed upon 
the importance of careful records. While 
it cannot be expected that every indus- 
trial physician should be^ a statistician, 
he should at least understand the fun- 



damental principles of statistics, and if, in 
addition, he possesses the ability to inter- 
pret them accurately, it is a distinct asset 
to him. For record keeping, he should 
employ a standard form in general use, 
such as that suggested by the U. S. PubUc 
Health Service. 

In conclusion, I wish to emphasize the 
value of the industrial physician in the 
mitigation of industrial imrest, which in 
large part is the reaction to unfavorable 
environment. Insanitary working condi- 
tions lower physical resistance; monoto- 
nous labor, discontentment, and continued 
long hours increase those physical defects 
which are soon acquired when resistance 
is lowered, and in turn the worker who 
has lost his former strength and vigor must 
accept lower wages, and poverty, with its 
many evils, is the result. 

Diminished output is a danger sign of 
diminished physical energy. Desire to 
work cannot exist without good health. 
A healthy and contented laboring force is 
the greatest economic asset that capital can 
have, and such a force should be so pro- 
tected and so guided that the greatest pos- 
sible benefits may accrue to both employer 
and employee. 



BIBLIOGRAPHY 



1. Oliver, T.: Diseases of Occupation. New 
York, £. P. Dutton and Company, 1916, p. 144. 

2. Amar, J.: The Human Motor, or the Scientific 
Foundations of Labour and Industry. New 



York, E. P. Dutton and Company, 1920. 
Quoted from Industrial Informati<m Service, 
Jan. 20, 1921, p. 15. 



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AN INTERCHANGE OF PHYSICAL EXAMINATIONS 

IN INDUSTRY* 

, HARRY MYERS, M.D. 

Personnel Superintendent, The Ohio Brass Company, Mansfield, Ohio 



A GREAT deal has been written con- 
cerning the many advantages of the 
compulsory physical examination in indus- 
try, but only once in a while is anything 
written — and then but a line or two — in 
r^ard to the objections that are advanced 
by the employer or the^employee. The ob- 
jections given by the employer are usually 
concerned with the cost of the service, 
while those of the employee are based upon 
some personal reason, such as his natural 
dislike for anything which he feels is being 
forced upon him and which may in some 
way abuse his private rights, or for any 
procedure which entails extra bother. Or 
perchance, as I have frequently known to 
be the case, "he may object on the ground 
that he has recently been examined by a 
good doctor who said that he was all right, 
and therefore he does not care to be 
examined again. 

We can oftentimes learn something from 
the other fellow even though his training 
may lead us to believe that he really has no 
right to an opinion on the subject in ques- 
tion, and I think that on the subject of 
compulsory physical examination, if we 
care to, we can undoubtedly learn some- 
thing from our applicants. While for the 
most part compulsory physical examina- 
tion is basically right, there are some re- 
spects in which it may be basically wrong, 
and it is on this side of the question that I 
wish to sermonize a Uttle. 

When an order is issued in an organiza- 
tion it is exactly comparable to an order in 
the regular army — it must be carried out, 
right or wrong. When it is ordered, how- 
ever, that "Every man must have a com- 

* Received tor publication May 6, 1021. 



plete physical examination before he can 
be given a job," the order is so general and 
so broad that it may easily include some 
things that are not right, and which give 
rise to unfortunate conditions, as I have 
witnessed many times during the past two 
years. 'Indeed, who has not seen this 
particular incident occur time without 
mention: A great big fellow — the picture 
of health — who has recently been pro- 
nounced physically fit by a regular army 
oflScer or some industrial physician, applies 
for work. By reason of an order in the or- 
ganization, the doctor must make a com- 
plete physical examination before the 
applicant can be accepted. Under these 
circumstances two unfavorable things often 
happen. First, the doctor feels in his own 
mind that the man is normal and that he 
most certainly needs no complete examina- 
tion, and the result is that the work is often 
carelessly doi^e and time is consumed that 
costs the company money without bringing 
any returns. Second, the appUcant himself 
feels that he does not need a complete ex- 
amination, and consequently the procedure 
appeals to him as a mockery, with the result 
that he is annoyed and has a lower regard 
for medicine in industry. 

In order that the many advantages of the 
physical examination may be conserved, 
we should now concern ourselves with im- 
proving its modus operandi by ironing out 
wrinkles wherever possible. In this con- 
nection, why should institutions which re- 
quire physical examinations not adopt the 
policy of giving an applicant a card show- 
ing his physical condition? Within a 
limited time, this card plus an examination 
for a9ute diseases should be accepted in 



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lieu of another compete physical examina- 
tion. These cards could easily be stand- 
ardized and interchanged between, any 
shops carrying on good medical work. 

I can see several excellent results from 
such a system. First, it would rule out 
many of the normal cases that require no 
complete physical examination, and would 
thereby render two distinct benefits — the 
doctor's work would become less monot- 
onous, and much time would be saved. 
I believe that many of the industrial phys- 
ical examinations have degenerated into a 
monotonous routine. Indeed, I know of 
nothing more uninteresting to an intelligent 
doctor than an examination of numerous 
normal cases. The time saved could be 
spent to most excellent advantage in dis- 
cussing personal or organization affairs, 
shop conditions or other subjects which 



aid in determining the employees' ideas of 
life and industry, and help so much in 
establishing pleasant personal relations 
between the dispensary and the plant. 
Second, L think that the importance and 
use of the physical examination would 
appeal much more strongly to the applicant 
if some written statement accompanied it. 
It would help make the intangible benefits 
of the examination more tangible. Do you 
not think that almost any man would re- 
gard with considerable pride a card stating 
that he was in, sound physical condition, or 
can you not easily imagine that the written 
card might help impress upon the applicant 
the seriousness of some existing defects? 
Might it not lend a personal touch that 
would help us immensely in selling medical 
ideas to employees? 



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PHYSIOLOGICAL EFFECTS OF AUTOMOBILE EXHAUST 

GAS AND STANDARDS OF VENTILATION 

FOR BRIEF EXPOSURES 

Continued 

YANDELL HENDERSON, HOWARD W. HAGGARD, MERWYN C. TEAGUE. 
ALEXANDER L. PRINCE, and RUTH M. WUNDERLICH 



IV. Concordance of the Standard here 

Proposed with the Observations of 

Other Investigators 

THE standard defined in Figure 4* may 
seem, from the work of others, espe- 
cially that of Haldane, unduly high, if one 
fixes attention upon the concentration of 
carbon mono^dde in the air breathed; or it 
may appear unnecessarily low, if stated in 
terms of the maximum percentage satura- 
tion — i. e.j complete equilibrium of the 
blood and the corresponding tension. The 
work of Haldane is so pre-eminent in this 
field, alike in amount, thoroughness, and 
practicality, that discordance between the 
conclusions drawn from his investigations 
and the standard here propK>sed would re- 
quire elaborate explanation and defence. 
In fact, however, we believe that when all 
aspects of the question are taken into 
consideration our observations and con- 
clusions, although diffei*ing in detail, are 
essentially concordant with those of Hal- 
dane (4) (5). Briefly stated, his principal 
conclusions were as follows: 

The symptoms caused by carbon mon- 
oxide depend upon the extent to which the 
hemoglobin has been saturated. The symp- 
toms are due solely to the deficiency of the 
oxygen percentage in the blood. 

When air containing carbon monoxide is 
breathed, about half of the carbon mon- 
oxide actually inhaled is absorbed, except 
toward the end of the process when ab- 
sorption is coming to a standstill. 

* For figures, see the first part of this article in the 
preceding issue of the Journal of Industrial Hygiene. 



The rate of absorption and time required 
for symptoms to appear is proportional to 
the respiratory exchange and may be very 
much shortened by the increased breathing 
of exercise. 

The symptoms do not become appre- 
ciable during rest until the blood is about 
a third saturated. An individual in this 
condition suffers from palpitation and 
throbbing in the head and is liable to be- 
come faint or dizzy on any exertion, such 
as that of ascending a stair, or on sudden 
exposure to cold air. 

In experiments on himself Haldane (6) 
foimd that, when 50 per cent, saturated, he 
could scarcely stand and could not walk 
alone without falling down. There was 
giddiness, dullness of the senses, distinct 
shortness of breath, and labored breathing. 
In the course of two or three hours after 
leaving the contaminated air he found that 
nearly all the carbon monoxide disappeared 
from the blood, which had then returned to 
its normal condition. A headache lasting 
for some hours was likely to ensue from the 
exposure if the latter were suflBciently long. 

In reporting on the conditions which 
should be maintained in the Underground 
Metropolitan Railways of London (7), he 
said: 

Roughly speaking, the probable action on a 
healthy person of varying percentages of carbon 
monoxide in the air may be stated' as follows: 2.5 
volumes per 10,000 would suffice after a sufficient 
time (after an hour and a half during rest, but very 
much less during even slight exertion) to cause symp- 
toms just distinctly appreciable on exertion. Five 
volumes per 10,000 would cause marked dizziness or 
fainting on exertion, 9 volumes would cause in- 



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ability to walk, and about 15 volumes might produce 
death. . . . Considering the enormous number of 
people in various states of health who use the rail- 
way, ... it seems desirable that not more than 
one volume per 10,000 of this gas should be present 
in the air. 

To these statements may be added the 
fact that Burrell (8) found that after 
breathing air containing twenty-five parts 
of carbon monoxide per 10,000 of air for 
twenty minutes he had at first only a sUght 
headache, but later became ill. The illness 
lasted for several hours and was accom- 
panied by nausea and headache. 

The agreement of these statements with 
our conclusions is suflSciently close to need 
no further discussion, until the question 
of the allowable concentration of carbon 
monoxide — a concentration producing no 
appreciable effects in any one — is reached. 
On this point Haldane reconunended one 
part in 10,000, while we approve concen- 
trations up to four parts, or, with lon- 
gitudinal ventilation, even six. It is to be 
noted, however, that the conditions to 
which Haldane's recommendations applied • 
were in some respects diflPerent from those 
which will occur in a vehicular tunnel. The 
motive power in the London Undergroimd 
Railways was at that time (1897) furnished 
by steam engines burning coke. The engine 
drivers and train crews and even some pas- 
sengers might be exposed for considerable 
periods of time — much longer than we 
have figured on. Haldane seems to have 
had in mind the possibility that exposure 
might be so long that the blood would come 
nearly into equilibrium with the tension of 
carbon monoxide in the air breathed and 
reach a corresponding percentage of satura- 
tion. We, on the contrary, are basing our 
estimates on times of exposure too short for 
the attainment of more than half the 
equilibrium degree of satiuution. 

The apparent discrepancy between the 
two standards lies in the figures for the con- 
centration of carbon monoxide in the air 



breathed. If, however, we turn to the 
more fundamental physiological condition 
— namely, that of the percentage satura- 
tion of the blood ■ — the discrepancy largely 
disappears. Thus, a glance at Figure 4 
shows that thirty-five minutes in an at- 
mosphere containing four parts of carbon 
moAOxide in 10,000 could induce 12 per 
cent, blood saturation. Now blood which is 
12 per cent, saturated is in equilibrium with 
one part of carbon monoxide in 10,000 of 
air. In other words, a stay of several hours 
in an atmosphere of one part of carbon 
monoxide in 10,000 would involve the same 
percentage saturation as a stay of thirty- 
five minutes in four parts per 10,000. In- 
deed, as the development of symptoms 
from carbon monoxide is wholly a question 
of oxygen deprivation, it is safe to assert 
that a saturation of the blood up to 16 per 
cent, lasting for only a short period would 
involve less physiological effect than a pro- 
longed period of satiutition at 12 per cent. 
On these grounds we have indicated in 
Figure 4 two standards: (1) for the blood at 
12 per cent, saturation, or one to 10,000 
tension, for exposm^s of some hours; and 
(2) at 16 per cent, satiuution, or 1.5 to 
10,000 tension, for brief exposures. The 
whole matter may be even more simply 
summed up in a single expression involving 
the time measured in hours, the concen- 
tration of carbon monoxide in the air in 
parts in 10,000, and a constant for each 
degree of physiological effect. The phys- 
iological eflFects of all concentrations and 
times (within reasonable limits) may be 
then defined as follows: 

1. Time X concentration - S, no perceptible ef- 
fect. 

2. Time X " « 6, a just perceptible 
effect. 

S. Time X ^ " fr» headache and nau- 



4. Time X 



>« 15, dangerous. ' 



Physical exertion and increased breath- 
ing would reduce the constant in the first 



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HENDERSON — PHYSIOLOGICAL EFFECTS OF EXHAUST GAS 139 



equation from 3 to 2, 1, or even less, and 
would aflPect the other equations corre- 
spondingly. Any standard for any special 
conditions of time or concentration, within 
reasonable limits, based on these formulae, 
is suflBciently concordant both with the rec- 
ommendations of Haldane and with the 
siunmary of our observations and con- 
clusions contained in Figure 4. 

Finally, we may here quote from a letter 
recently received from Dr. Haldane, which 
was in answer to a letter from us stating the 
general trend of our observations and find- 
ings and in which Dr. Haldane says: 

In the report on the Underground Railway the 
chemical standard which I recommended if steam 
traction was continued was .15 per cent, of carbon 
dioxide, and I pointed out that this would contain 
about .01 per cent, carbon monoxide. But the stand- 
ard was not based primarily on the carbon monoxide, 
but on the general impleasantness of the air. There 
was no definite evidence of people being upset by the 
carbon monoxide, though there was often .03 to .05 
per cent, at certain parts of the tunnels and stations; 
and I even found .066 per cent, of carbon monoxide 
(with .89 per cent, of carbon dioxide) on the plat- 
form of Gower Street Station (near University Col- 
lege) . Passengers were never exposed long enough for 
ill efiPect, and the men at the stations were probably 
more or less acclimatised. 

At that time I did not know nearly so much about 
small percentages of carbon monoxide as I do now. 
Lorrain Smith and I made a lot of experiments on 
our8dves(to determine oxygen tension of arterial 
blood) (Jour. Physiol., XX, 1896, and XXH, 1897) 
and came to the conclusion that anything less than 
.06 per cent, produced no symptoms after several 
hours' exposure except some shortness of breath on 
exertion. Our blood saturations only went to about 
28 per cent, (in about one and one-half hours), and no 
further absorption occurred up to five hours. About 
a year later we tried a similar experiment and found 
.06 per cent, far too much for us.' I tried again at 
Oxford later, and now found that even with about 
.OS per cent, the saturaticm gradually crept up during 
four or five hours to over 80 per cent. It became 
dear aft^wards that in the first experiments we had 
both got acclimatised and were thus abnormally 
resistant to carbon monoxide. 

What I should now say is that with long exposures 
of several hours anything more than .02 per cent, 
should be avoided. For exposures of less than an 



hour .05 per cent, would not be really objectionable. 
As regards gases from motors, however, the smoke 
and smell might possibly be worse than the carbon 
monoxide.' O^ this point I have no experience, 
though I have run across cases of poisoning where 
there does not seeuL to have been much smoke or 
smell. 

You will see from the above that my ideas about 
carbon monoxide coincide very closely with what 
yoiur experiments point to. Lorrain Smith and I had 
not the least idea that by our daily experiments we 
had become acclimatised and ready to secrete oxygen 
as soon as our blood saturation rose to about 25 per 
cent. The absorption was simply stopped short as 
soon as oxygen secretion began; but an ordinary per- 
son does not secrete at this level, so the absorption 
goes creeping up for hours. 

V. Observations in Large Gassing 
Chamber 

The experiments detailed in Section 11 
involve exact, but rather artificial condi- 
tions. Exhaust gas is not pure carbon 
monoxide and the number of persons who 
could be tested in the 6 cubic meter cham- 
ber was quite limited. It appeared essen- 
tial, therefore, to obtain confirmatory 
observations under as nearly real conditions 
and on as many persons as possible. For 
this purpose a brick building, 30 feet 
square, with walls 12 feet high at the side, 
and a hip roof, was erected. Its cubic 
capacity was approximately 12,000 cubic 
feet of air, which is about the volume of a 
section of the vehicular tmmel which will 
contain one car when the traffic is active. 

A Ford car was installed near the middle 
of this chamber, with a continuous stream 
of water running into and out of its radiator 
to prevent over-heating. The axles were 
supported on a wooden framework so that 
the rear wheels turned clear of the ground. 
Against them were pressed two large 
wooden pulley wheels on a piece of heavy 
shafting, at the ends of which were wooden 
paddle wheels. The engine of the car, 
therefore, ran with a fair load, and the 
power was expended in mixing the air in the 
chamber. The paddle wheels did this so 



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eflfectively that in a number of tests prac- 
tically uniform concentrations of exhaust 
gas were found simultaneously in all parts 
of the chamber. 

The exhaust of the car was connected to 
a 2-inch iron pipe with a T and two valves. 
From one valve a pipe led to a large iron 
can (to equalize pressure) and to a gas 
meter, and discharged close to one of the 
paddle wheels, which drew in and distrib- 
uted the gas. The pipe from the other 
valve led outside of the building. Thus, by 
adjusting the valves, all or any part of the 
exhaust gas could be discharged into the 
chamber, and its volume read on the meter. 
Samples of the exhaust gas unmixed with 
air were taken and analyzed for carbon 
monoxide in an Orsat apparatus, using 
ammoniacal cuprous chloride as the ab- 
sorbent. The percentage ranged between 
5.5 and 6.8 per cent., with an average of 
about 6 per cent. The engine discharged a 
total of about 25 cubic feet of exhaust gas 
per minute, from which we calculated that 
approximately 1.5 cubic feet of carbon 
monoxide were produced by the car per 
minute. 

Diffusion from the chamber through the 
walls and roof, and through cracks around 
the doors and windows, was considerable. 
Whenever the engine was stopped, there 
was thus a drop of about one-third of the 
concentration of carbon monoxide in fifteen 
minutes. Usually the entire exhaust of the 
engine was discharged through the meter 
into the chamber until the desired concen- 
tration of carbon monoxide was approxi- 
mately reached. Thereafter, a part of the 
gas was discharged out of doors, and only 
enough was passed into the chamber 
through the meter to compensate for loss 
by diffusion. Samples of the air in the 
chamber were taken at intervals during the 
period of exposure, and the amount of car- 
bon monoxide determined either by means 
of iodine pentoxide (with a correction for 
vaporized gasoline), or by the blood 



carmine method, or in both ways. Some 
discrepancies will be found in the analytical 
data, but it must be kept in mind that the 
methods are difficult and the amounts of 
the substance are minute far beyond the 
range of ordinary gas analysis. 

With practice, considerable facility in 
controlling the concentratiofi of carbon 
monoxide in the chamber was attained. 
The experimental conditions were quite 
realistic. The car was old and had had 
rough treatment, and the.engine was some- 
what irregular in action. The exhaust gas 
was, therefore, contaminated with at least 
as much gasoline, oil and soot, and other 
substances, in addition to water vapor, 
carbon monoxide and carbon dioxide, as 
may be met with in any well-regulated 
vehicular tunnel. Owing to the fact that 
vapK)rized gasoline and other constituents 
of exhaust gas beside carbon monoxide act 
upon iodine pentoxide, the figure 0.6 was 
determined as the factor by which it was 
necessary to multiply the iodine liberated in 
analysis of chamber air for the estimation 
of the carbon monoxide. 

In this chamber groups of a dozen or 
more persons at a time sat or moved about 
for periods of one hour. In addition to the 
staff of this investigation a number of stu- 
dents of the Yale Medical School served as 
subjects. We take this opportunity to 
recognize the intelligent interest mani- 
fested, and the valuajble service rendered 
by these young men and women. 

After the tests the general condition and 
feelings of the subjects, particularly the 
occurrence or absence of headache, were 
noted. When the subjects had breathed 
fresh air for five minutes after leaving the 
chamber, samples of lung air, obtained by 
having them rebreathe repeatedly into a 
small rubber bag, were analyzed for carbon 
monoxide. In such analyses the gas found 
is that which has diffused out of the blood 
into the lung air, and the analytical data 
indicate, therefore, the tension of the car- 



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HENDERSON — PHYSIOLOGICAL EFFECTS OF EXHAUSt GAS 141 



bon monoxide in the blood. The eflFect of 
running up and down four flights of stairs 
was also noted, as exercise markedly in- 
tensifies asphyxial symptoms. 

Only a few typical protocols of these 
tests can be given in this abbreviation of 
our report, but the whole of the data may 
be sununarized by the statement that, so 
long as the standard worked out in the pre- 
vious section was not exceeded, no appre- 
ciable ill effects were induced in any of the 
numerous subjects. Above this standard, 
however, headache resulted in nearly all 
cases, and in some persons nausea and 
vomiting also occurred. 

Details of Observations in Tunnel 
Gassing Chamber 

Pbotocol 1. — Feb. 4, 1920. The engine of the 
car was started and maintained at a uniform speed 
for twenty minutes. Determinations were made of 
the carbon monoxide percentage in the exhaust from 
the engine (analyzed with Orsat apparatus), and of 
the concentration of the gas in various parts of the 
chamber (by the iodine pentoxide method). For the 

TABLE 8. — EXPERIMENTAL CONDITIONS 
AND PHYSIOLOGICAL DATA {ProlocoL 1) 



^^nic 


Concentrations of 
CO m Positions 


Rem^lu 




1 


2 


Minutes 


ParUin 
10,000 


ParUin 
10,000 







0.5 


0.3 


engine started. 


5 


8.0 


8.0 


exhaust gas « 5.6 per cent. CO 
(by Orsat). 


10 


5.5 


5.0 




15 


6.5 


7.0 


smoke very unpleasant. 


20 


8.0 


8.0 


engine stopped; smoke in cham- 
ber extremely irritating to eyes. 


80 


6.0 


6.0 


pulmonary air of H. W. H., a 
few minutes after leaving cham- 
ber, contamed 8.1 parts CO; se- 
vere headache and some nausea 
for four hours; insomnia later. 


90 


1.5 


. . •• 


gas slowly diffusing out of 
chamber. 



At the end of twenty minutes the smoke in the 
chamber had become quite disagreeable and the 
engine was stopped. The dispersing fans were, how- 
ever, continued in operation by means of an electric 
motor, and air samples were taken at intervals. The 
pulmonary air of H. W. Haggard, who had been in 
the chamber up to this time and who had been 
actively at work on the car, was taken a few moments 
after he left the chamber and analyzed. The data 
obtained are given in Table 3. 

Protocol 2. — Feb. 11, 1920. The procedure 
was similar to that described in Protocol 1. Con- 
tinuous and snap samples of air were taken diuring 

TABLE 4. — EXPERIMENTAL CONDITIONS 

(Protocol ^) 





Concentration of CO in Positions 


Time 






1 


2 


s 


Minutet 


Paris in 10,000 


Part* in 10,000 


Pari* in 10,000 


n 


8.0 


4.0 


S.5 


24 


4.0 


4.0 


4.0 


34 


4.0 


4.0 


4.0 


46 


4.0 


4.0 


4.0 



latter purpose, two positions were chosen: No. 1, 6 
feet to the west of the exhaust; and No. 2, feet to 
the north of the exhaust. 



the period of gassing in three places: position 1, 
northwest comer; position 2, northeast comer; and 
position 3, middle of south side of chamber. 

The number of persons in the chamber was eight- 
een — fifteen men and three women. Foiur subjects 
were seated about position 1, foiur about position 2, 
five about position 3, and the last five were ambula- 
tory. The normal pulse and respiration were ob- 
served on each subject some time before gassing, and 
the same data obtained again soon after gassing. 
The air analyses were made by the iodine pentoxide 
method. The engine was allowed to exhaust into the 
chamber for six minutes initially, and the gas was 
then shunted to the outside for eight minutes. 
Thereafter, the exhaust gas was discharged into the 
chamber for one and one-half minutes in each ten 
minutes. Table 4 gives the conditions in the cham- 
ber as shown by analyses, and Table 5 presents the 
physiological data obtained from eight subjects — 
two typical of each group. 

Protocol 3. — March 13, 1920. The arrange- 
ment of the engine exhaust previously described was 
altered by the introduction of a baffle can and a large 
gas meter into that portion of the piping which ad- 
mitted the gas to the chamber. The volume of gas 
admitted into the chamber was thus more accurately 
contrc^led. A survey experiment, identical with the 
gassing procedure carried out in Protocol 2, was per- 



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TABLE 5.- 


PHYSIOLOGICAL DATA {Protocol 2) 










Sex 


Poationin 
Ch&mber 


Duration of 
Exposure 


CO in Pulmonary 
Air after Gassing 


Pulse 




Subject 


Normal 


After 
Gassing 


Syikk^rtoms 


C. Pepe 


male 

tt 

tt 

female 

tt 

male 
ft 

tt 


1 

1 

2 

2 

8 

8 

ambulatory 
tt 


Hourt 


PtttU in 10,000 
1.12 
0.99 
1.85 
1.16 
1.21 
1.06 
0.99 
1.27 


90 

76 

108 


74 
80 
82 


none 


E. Shorr 


« 


E. Waters 


u 


M. Hotchkiss 


a 


M. BeU 


u 


E. Hilton 


u 


E. Levy 


« 


M. Snow 


tt 







formed. Detennmations were made upon the air in 
the chamber and the pulmonary air of the subjects 
by the Haldane blood method. Observations were 
made on seventeen men and one woman. The sub- 
jects were for the most part quite active during this 
experiment. 

The concentrations found by these methods, those 
estimated from meter readings, and analyses of ex- 

TABLE 6. — EXPERIMENTAL CONDITIONS » 

(Protocol 3) 



Time 


Exhaust Gas 
through Meter 


Exhaust Gas 
by Orsat Analysb 


Concentration of 
CO in Chamber 


MinuU$ 


CvbieFMt 


PtrCmi. 


Parts in 10,000 





800 


6.4 




10 


80 




. . . 


15 






6.8 


20 


75 






80 


82 




9.0 


85 




6.6 


. . . 


40 


78 




8.6 


50 


78 


. . . 


. . . 


60 


... 


... 


9.8 



1 From the figures in column 4, the mean concentration of carbon 
monoxide breathed for one hour may be estimated to have beoi at least 
nine parts per 10,000 of air, and from the Orsat figures, column S, 
perhaps two or thne parts higher. 

haust gas by the Orsat apparatus, allowing for loss 
by difiPusion, are shown in Table 6; the physiological 
data, which were obtained, in Table 7. 

Exposure of Horses to Exhatcst Gas. — A 
few observations were made on two U. S. 
Army artillery horses. They were of the 
Percheron breed and weighed between 
1,400 and 1,800 pounds, one bay and the 
other white. We are greatly indebted to 
Colonel R. E. D. Hoyle, Commanding 



Officer, Field Artillery Unit, R. O. T. C, 
stationed at Yale University, for the loan 
of the animals. 

The car and motor were taken outside of 
the tunnel gassing chamber and the exhaust 
gas piped to the inside. The horses were 
not hitched, but were allowed to move 
about freely inside the chamber. In each 
experiment a blood sample was drawn 
from the ear before and after gassing. The 
results of the three experunents are shown 
in Table 8. 

Owing to the fact that the dispersing 
fans were not in operation we believe that 
the concentration of gas was quite variable 
in diflFerent parts of the chamber; and it is 
probable that the atmosphere which the 
horses actually breathed contained con- 
siderably higher concentrations of carbon 
monoxide than the figures given in the 
table. 

VI. Observations in Garages and in 

THE Grand Central Station, New 

York City 

The occurrence of fatalities in small pri- 
vate garages during cold weather has be- 
come so frequent an item of news that the 
public is becoming aware of the dajiger. 
Evidently if a car, while wanning up, gives 
off 1 cubic foot of carbon monoxide per 
minute in a room 10 X 10 X 20 feet, the 
atmosphere will, apart from diffusion. 



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HENDERSON — PHYSIOLOGICAL EFFECTS OF EXHAUST GAS 143 







TABLE 7. — PHYSIOLOGICAL DATA {Protocols) 




Sex 


COinPul- 
monary 
Air after 
Gunnff 


Pube at Best 




Subject 


Normal 


After 
Gaanng 


Symptoms 


G. Gilderaleve. 

A. Vanderberg 

A. Dreher 


male 
« 

u 

u 

u 

u 
u 
« 
a 
u 
u 

u 
u 

female 
male 

« 


Part* til 
lOfiOO 

2.7 

2.9 

2.2 
1.9 

1.8 
8.0 
2.7 
2.7 
2.7 
2.5 
1.9 

2.5 
1,6 

2.2 

1.8 
2.0 
2.2 
1.8 


Per 
MinuU 

82 

72 

82 
82 

74 
72 
86 
82 
60 
76 
72 

74 
75 
72 

50 
54 
80 

72 


Per 
Minute 

96 
90 

105 
102 

100 
130 
180 
120 

84 

90 
120 

116 

80 

108 

60 

68 

120 


dizziness, extreme headache and some nausea. 

throbbing headache for several hours, general lethargy for 

24 hours. 

headache, nausea, chill. 


J.Olean 

L. Peroflf 


dizziness immediately after gassing, sharp headache for 9 

hours. 

throbbing headache for 9 hours. 

frontal headache for 6 hours. 

severe headache, vomited, in bed 5 hours. 

severe headache for 20 hours, legs weak. 

severe headache lasting 5 hours. 

severe occipital headache for 8 hours. 

severe headache, diz^, nauseated, nnging in ears, for 7 

hours. 

persistent headache and nausea for 8 hours. 

severe headache and nau.<iea for 6 hours. 


M. O'ConneU 

J. ileming 

E. Waters 


M. Glazer. 


H. Farrell 


E. Tolstoi 


E. Shorr 


H. BaUey 


H- T^ngn^r. ...,,, 


pounding in ears, violent headache and nausea, headache 

for 48 hours. 

severe headache, faintness for several hours. 

headache and nausea. 

severe headache and vomiting. 

v^y faint and weak, severe headache for 72 hours. 


£. Wakeman 

A. Wakeman 

P. Susman 


J. Sisal 





reach the dangerous concentration of fif- 
teen parts in 10,000 in three minutes. Ow- 
ing to the insidious and usually accidental 
character of carbon monoxide poisoning in 
such garages, however, nothing bearing 

TABLE 8. — RESULTS OF EXPOSURE OF 
HORSES TO EXHAUST GAS 





Time 


CoDcen- 
trationof 

coin 
Chamber 


Peroentam 
Saturation ofBlood 




Date 


White 
Hone 


Bay 
Horse 


Bemarkf 


3/17/20 
3/17/20 
3/19/20 


Howe 
1 

1 
1 


Parte in 
10,000 

2.5 

5.0 

5.0 


20 
23 


11 
20 
25 


noqnnptoms 



particularly on our problem is to be learned 
from them whjph could not be more ac- 
curately determined in our experimental 
chamber. 

At first it would appear that important 
information might be obtained from the 



conditions occurring in large public garages 
and repair shops. On investigation of a 
number of such places we found that, even 
in those recently built and supplied (usually 
more or less imperfectly) with artificial 
ventilation, the employees frequently have 
slight headaches, while severe headache, 
nausea and emotional disturbances, rang- 
ing from mere unreasonableness up to 
hysterical mirth, anger or grief, or even 
maniacal manifestations, are not very un- 
usual. There seems to be a general recogni- 
tion that "it is not gasoline but the burnt 
gas" which produces these conditions. Our 
inquiries have also elicited information re- 
garding an occasional death in which the 
victim had crawled under a car when its 
engine was running, or when the engine of 
a standing car ahead was "idling." When 
it came to getting samples of air for analy- 
sis from garages, however, we soon found 
that we could get anything that we wanted. 



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high or low, and that the figures had, there- 
fore, little value without more elaborate 
supervision of the personnel than we could 
provide. 

Conditions such as may occur in tunnels 
appear to be aflPorded in the taxicab drive- 
way and stand below the Grand Central 
Railway Station, New York City. The 
general public passes through this place, 
many thousands per day. The taxicab 
drivers sometimes wait half an hour for a 
passenger, and the starters and markers are 
on duty for four or five hours at a time. 

We learned on inquiry that up to a few 
months before this investigation a type of 
car had been in use which produced a con- 
siderable amount of smoke and that at that 
time headache and nausea were conunon. 
Recently, however, another type of car 
producing very little smoke has been intro- 
duced and symptoms of gassing appear 
now to be rare. 

In order to define the conditions at the 
taxicab driveway and stand, members of 
the staff of this investigation spent seyeral 
hours near the starters' position and took a 
number of samples of air for analysis, with 
the following results: 

March 12, 1920. A mild, damp afternoon and 
evenmg. 64SP.M, A sample of air taken soon alter 
a number of cars had gone through contained 0.36 
parts carbon monoxide in 10,000. 

945 P.M. A sample taken alter forty cars had 
gone through in fifteen minutes contained 1.36 parts 
carbon monoxide in 10,000. 

10.35 PM, After three cars had passed in ten 
minutes, the carbon monoxide concentration was 
0.45 parts in 10,000. 

11,30 P,M. Fifteen cars passed through in five 
minutes. A sample taken ten minutes later contained 
1.78 parts in 10,000. 

On another occasion a series of samples were 
taken and yielded the following figures: 0.45, 1.78, 
0.36, 2.12, and 1.47. 

It appears from these data that the air is 
occasionally vitiated for a time with as 
much as two parts of carbon monoxide in 
10,000, but that with the ventilation pro- 



vided by large fans the concentration of 
carbon monoxide soon falls again decidedly 
below one part in 10,000. There are now, 
so far as we can learn, no complaints from 
the public, and the taxicab drivers have 
only an occasional headache, when a line 
of cars stands for a long time with engines 
running. 

Vn. Comparative Toxicity of Pure 
Carbon Monoxide, Illuminating Gas, 
Exhaust Gas from Gasoline, Exhaust 
Gas from Coal Distillate and Gasoline 
Vapor "* 

The general agreement between the ex- 
periments with pure carbon monoxide 
mixed with air in Section II and the results 
with exhaust gas in Section IV indicates 
strongly that in the concentrations occur- 
ring in the large chamber carbon monoxide 
was the only substance of sufficient toxicity 
and present in sufficient amount to have 
any considerable physiological effect. All 
of the data in both of these series of ex- 
periments were, however, based upK)n low 
concentrations of the gas and the deduc- 
tions from them might not apply equally to 
high and lethal concentrations. 

We have, therefore, thought it well to 
check these results by means of observa- 
tions on animals in high concentrations of 
gas. For this purpose dogs were used. The 
animal in each case was placed in a cube- 
shaped plateglass chamber measuring about 
3 feet on a side. The gas to be tested was 
mixed with air in a gasometer of several 
hundred liters capacity, so that the carbon 
monoxide concentration was about 0.3 to 
0.4 per cent., or thirty to forty parts in 
10,000. From the gasometer the gas mix- 
ture was passed into the chamber through 
a tube by a small electrically driven air 
blower. Another tube from the chamber 
led outdoors. Usually the gas was run in at 
such a rate that the animal was at the point 
of death in thirty to thirty-five minutes. 



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HENDERSON — PHYSIOLOGICAL EFFECTS OF EXHAUST GAS 145 

The animal was then removed from the this group of experiments contained at the point of 

chamber and a sample of blood was drawn *^®**'» ^^ following percentages of carbon monoxide: 

for analysis by the carmine titration 8*. 86, 83. 81. 81; average 8S. 

.,1 (o) Experiments wtih Exhaust Gas from a Car 

™^ ,.,...., , . . ^^^9 ^^ Distillate. — For the opportunity to 

The technical details of the analysis of make these tests, we are indebted to the New Haven 

carbon monoxide in air and in blood will be Gas Company which very kindly sent a car charged 

found in the full report. ^^^ coal distillate to the laboratory and allowed us 

to obtain a bag of exhaust gas as in the preceding 

(a) ExperimerUs with Pure Carbon Monoxide experiments. Two dogs were exposed to this gas. 

Mixed with Air. — In this atmosphere the animals exactly as the animals had been exposed in the pre- 

beeame unconscious with no more apparent discoi]^- vious experiments to exhaust from gasoline, and 

fort than if anesthetized with ether. The blood of died with sjrmptoms like, but more marked than, 

five dogs at the point of death contained the follow- those of the dogs poisoned with illuminating gas. 

ing percentages of carbot monoxide: 87, 82, 84, 79, The blood of these two anhnals had a decided brown- 

88; average 84. ish tinge indicating a marked destructive influence 

(6) Experiments with Illuminating Oas Mixed upon the hemoglobin of thie blood. It is known that 

with Air. — In such an atmosphere the symptoms benzol has such an effect. 

during intoxication differed in some respects from the The composition of the coal distillate, according 

preceding group. There occurred in all cases more to figures kindly furnished by the chemist of the Gas 

rapid c<Jlapse and distinctly greater respiratory ex- Company, was: 

citement. Nausea and vomiting, which were lacking Benzol 69.0 per cent. 

in the experiments with pure carbon monoxide, oc- Toluol 15.5 ** " 

curred in all the animals of this second group. These Solvent naphtha 13.5 " ** 

observations and the fact that death ensued though Heavy naphtha 2.0 ** ** 

a lower percentage of carbon monoxide existed in the Total 100.0 ** " 

Wood indicate that illuminating gas contains some ^he blood of the two dogs' used in these experi- 

subetance, or substances, which render it distinctly ^^^^ contained at the point of death the following 

more toxic than an equal amount of pure carbon percentages of carbon monoxide: 60, 64; average 62. 

monoxide. The blood of the five dogs used in these (^) Experiments with GasoUne Vapor. - The 

experiments contained at the point of death the ^^^ ^^ ^^ experiments with gasoline vapor are 

foUowing percentages of carbon monoxide: 74, 67, 76, ^^^^ -^ y^ Anesthetic and Conwlsani I^ecls o/ 

71 ; average 70. Gasoline Vapor, by Howaitt W. Haggard (9). 

(c) Experiments with Exhaust Gas from a Car 
Using Gasoline. — For these tests the three com- 

monest varieties of gasoline sold locally were used ^lll. PRINCIPAL CONCLUSIONS 

sacce«sively. A large rubber hag was attached to the ^he general standards at which we arrive 

exhaust of a car (one m good condition, with an , 0/5 on* j -ioo\ wn^ 4.1. *• 

eflBcient and smooth nmnmg engme), while it was fPP- ^6-89* and 138) are: When the time 

standing with the engine running **idle.*' This gas ^ hours multipUed by the concentration 

was analyzed for carbon monoxide by means of an of carbon monoxide in parts per 10,000 of 

Orsat ^>paratus m the usual way. The gas was then air equals 3, there is no perceptible physi- 

mized with air in the large gasometer to approxi- ological effect. When it equals 6, there is a 

niately the same concentration of carbon monoxide .^^^ perceptible effect. . When it equals 9, 

as in the previous expenments and was then ad- 1,1, • 1 1 ttti 

ministered to animals in the glass chamber. In these headache and nausea are mduced. When it 

eiqieriments the animals were at the point of death in equals 15 or more, the conditions are dan- 

approximately the same time as in the first series of gerous to, life. 

experiments under (a) above. The symptoms were If the volume of breathing is increased by 

shD^ to t^ from pure carbon monoxide and exercise (even by slow walking, and cor- 

nnlike those from illummatmg gas. The percentages j • 1 1 v • i i \ xi. 

of carbon monoxide in the blood were alsTsimili^to ^espondingly more by physical work) the 

the first series, but higher than the second. Evi- f^*^ ^^ absorption of carbon monoxide is 

dentJy carbon monoxide was here practically the only increased propK)rtionally . 

toxic substance. The blood of the five dogs used in ♦ See the preceding issue of this Journal. 



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After return to fresh air, the elimination 
of carbon monoxide through the lungs pro- 
ceeds at a rate of SO to 60 per cent, reduc- 
tion of the blood saturation per hour. 

In the exhaust gas from gasoline, carbon 



monoxide is the only considerable toxic 
constituent. In the exhaust gas from coal 
distillate (benzol, etc.), and in illuminat- 
ing gas, there are present accessory toxic 
substances. 



BIBLIGGRAPHY 

(The following is a list of references which have been consulted during the preparation of this report. 
References 1, 2, and 3 accompany the first part of thi§ article, which appeared in the preceding issue of 

this JOUBNAL.) 



8. 



Douglas, C. G., Haldane, J. S., and Haldane, 
J. B. S.: The Laws of Combination of Haemo- 
globin with Carbon Mcmoxide and Oxygen. 
Jour. Physiol., 1912-1918, 44, 275. 
Haldane, J. S., and Lorrain Smith, J. : The Mass 
and Oxygen Capacity of the Blood in Man. 
Jour. Physiol., 1899-1900, 26, 381. 
Haldane, J. S.: The Action of Carbonic Oxide 
on Man. Jour. Physiol., 1895, 18, 480. 
Report of the Board of Trade on the Ventilation 
of the Metropolitan Railway Timnels. Parlia- 
mentary Paper C8684, 1897. 
Burrell, G. A.: The Use of Mice and Birds for 
Detecting Carbon Monoxide after Mine Fires 
and Explosions. U. S. Bur. Mines, Tech. 
Paper 11, 1912. 



9. Haggard, H. W.: The Anesthetic and Convul- 
sant Effects of Gasoline Vapor. Jour. Phar- 
macol, and Exper. Therap., 1920, 16, 401. 

10. Henderson, Y.: Carbon Monoxid Poisoning. 
Jour. Am. Med. Assn., 1916, 67, 580. 

11. Henderson, Y., and Haggard, H. W.: The 
Elimination of Carbon Monoxide from the 
Blood after a Dangerous Degree of Asphyxia- 
tion and a Therapy for Accderating the Elim- 
ination. Jour. Pharmacol, and Exper. Therap., 
1920, 16, 11. 

12. Haggard, H. W., and Henderson, Y.: Papers 
to appear in Jour. Biol. Chem., Am. Jour. 
Physiol., and Jour. Am. Med. Assn. 



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BOOK REVIEWS 



147 



BOOK REVIEWS 



The Community Health Problem. By Athel 
Campbell Bumham, M.D., Health Service, Atlantic 
Division, American Red Cross; Attending Surgeon, 
Volunteer Hospital, New York City; Lieutenant 
Colonel, Mediod Reserve Corps, U. S. Army; Fel- 
low New York Academy of Medicine. Cloth. Pp. 
149 and index. New York: The Macmillan Com- 
pany, 1920. 

This book is a brief and readable presenta- 
tion of public health material, well suited for 
non-technical courses in general hygiene. The 
author has desired to give his readers a concep- 
tion of the various fields into which preventive 
medicine has crept and the manner and success 
with which it has operated. Industrial hygiene 
is included in this group a^id receives brief but 
discerning treatment. 

It is unf ortimate that a chapter is not devoted 
to the various types of workers necessary in 
the diflFerent branches of community health, 
together with a certain amoimt of information 
as to their training. The practical usefulness of 
the book for elementary students woidd be 
augmented by such an addition. — Cecil K. 
Drinker. 

Human Efficiency and Levels of Intelligence. 
By Henry Herbert Goddard, Director of the Bureau 
of Juvenile Research of Ohio. Cloth. Fp. 128. 
Princeton: Princeton University Press, 1920; Lon- 
don: Oxford University Press, 1920. 

It is no exaggeration to say that this short 
series of lectxu-es, delivered at Princeton Uni- 
versity in April, 1919, enunciates a point of 
view that should not only be understood by 
everyone interested in efficiency and hygiene 
problems, but also by every citizen who wishes 
to east an intelligent vote. Although no original 
work is published in the book, it brings to- 
gether evidence from various sources in such a 
convincing, even dramatic way, that the reader 
finds himself awakened to the realization that 
the doctrine of mental levels is a social conception 
of the first magnitude. 

The doctrine stands mainly on two well- 
established facts: first, that the intellectual 
development is largely independent of what we 
call learning or knowledge; second, that not all 
persons develop to the highest level or even 
near to it; many stop at some one of the lower 
levels of childhood. 

The important thing for us to learn from the 
book is that the number of people of relatively 



low intelligence is vastly greater than is gen- 
erally appreciated, and that this mass of low 
level inteUigence is a menace to democracy 
unless it is recognized and properly treated. 
The data are obtained f rota several sources — 
the experience at institutions for the feeble- 
minded, the Bureau of Juvenile Research in 
Ohio, the statistics of the Department of Labor, 
school statistics from the Department of Edu- 
cation, and the report of the General StaflF on 
Psychological Tests in the Army. The sources 
are authoritative, and the fact that remarkably 
similar figures are obtained from each source 
forces us to accept the statements as proven 
facts, however upsetting these facts may be to 
our preconceived ideas that we are all bom 
equal. The army figures show that 70 per cent, 
of the 1,700,000 men examined were below the 
mental age of fifteen, and that 25 per cent, were 
morons. These figures being from the drafted 
army must certainly be a fair sample of our 
whole male population. The school figures 
from the Department of Education show that 
67 pei* cent, of schoolchildren do not finish the 
eighth grade, and that 26 per cent, do not finish 
the fifth grade — a result remarkably parallel to 
the army figures. The Department of Labor 
tells us that 68 per cent, of wage earners get less 
than $15 a week — at least, an analogous 
observation. 

Can we hope to have a successful democracy 
when the average mentality is thirteen? The 
answer is that the social efficiency of a group of 
human beings depends upon recognizing the 
mental limitations of each one and of so or- 
ganizing society that each person has work to 
do that is within his mental capacity and at the 
same time calls for all the abiUty that he pos- 
sesses. In short, whenever the 4 per cent, at 
the top of the scale choose to devote their 
superior intelligence to imderstanding the 
lower mental levels and to the problems of the 
comfort and happiness of the other 96 per cent., 
they will be elected the rulers of the realm and 
then will come perfect government. But that 
4 per cent, must have what we call the "human 
quality" and must learn to take seriously the 
responsibility of their position — they must 
have the desire to make all people happy. 
Then, in a' democracy where every person has 
the right to vote for those who shall nde over 
him, the masses will vote for the best and most 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



intelligent if they are made to feel that these 
same intelligent people have the welfare of the 
masses at heart. 

The failure to appreciate the facts upon 
which the doctrine of mental levels is based has 
resulted in a vast amoimt of delinquency, and 
such delinquency impairs the efficiency of the 
total group to an extent little appreciated. It 
is no longer to be denied that the greatest 
single cause of delinquency and crime is low 
grade mentality. Apart from delinquency these 
people, in their present disorganized state, are 
extremely inefficient. It is their history (so 
constant as to be almost diagnostic) that they 
are constantly changing jobs. We have made 
no serious attempt to fit the man to the job. 
No attempt has ever been made to ascertain 
what grade of intelligence is required of any of 



the multitude of occupations. Some progres- 
sive employers in industries have inaugurated a 
sort of tryout system; but this is a crude make- 
shift in comparison to the results of a scientific 
determination of the mental level of the individ- 
ual, coupled with a study of the amount of 
intelligence required for particular work. 

"When one contemplates the enormous pro- 
portion of misfits that must exist in the indus- 
trial world and that such misfits mean dis- 
content and unhappiness for the employee, one 
can but wonder how much of the present unrest 
in such circles is due to this fact. A man who is 
doing work that is well within the capacity of 
his intelligence and yet that calls forth all his 
ability is apt to be happy and contented and it 
is very difficult to disturb any such person by 
any kind of agitation." — Stanley Cobb. 



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THE JOURNAL OF 
INDUSTRIAL HYGIENE 



PUBLISHED MONTHLY 



VoLuiam 



SEPTEMBER, 1921 



NuifBEB 5 



FATIGUE AND ERROR IN A MENTAL OCCUPATION* 

J. p. BAUMBERGER 

{From the Laboratory of Physiology , Stanford University) 



RECENTLY some doubt has been 
thrown upon the use of output studies 
as a criterion of fatigue in industrial occu- 
pations (1). The data reported in this 
paper, however, show that the number of 
errors as well as the output varies during 
the day in a manner typical of fatigue 
curves. Link (2) in his investigations has 
used psychological tests as a method of 
studying fatigue, but although the tests 
were given at various times during the 
day, they showed very little indication of 
fatigue. In this paper output rate and 
error in a normally recurring routine 
operation of short duration are used as a 
measiu-e of fatigue. 

Phocess 

Permission to work in the auditing de- 
partment of a large railroad company was 
obtained through the courtesy of the su- 
peiuntendent, and the records of eighteen 
women clerks were compiled. The proc- 
esses studied were the writing in of names 
on pay checks with pen and ink, and the 
typing in of amounts using a machine, in 
each case the name or amount being ob- 

* The author wishes to acknowledge his indebtedness to 
Dr. E. G. Martin for advice and to Miss Edna Perry for as- 
sistance in connection with this pai>er. Received for publi- 
cation April 26, 1921. 



tained from the payroll. Six women were 
engaged in writing in amounts, and twelve 
in writing in names. Three of the clerks 
worked on both processes. 

It is^he rule in this company that all pay 
checks must be numbered consecutively, 
and that the numbers of all checks on 
which mistakes are made must be re- 
corded. Furthermore, the following data 
are kept in tabular form by the head clerk: 
time consumed in writing and comparing 
payroll vouchers — name of clerk, com- 
mencing number, closing number, number 
of names of payees written in with pen (or 
amounts typed in by machine) — time com- 
menced, time finished, minutes, number of 
checks canceled. 

Treatment of Data 

From the mass of data on the time con- 
sumed in writing and comparing payroll 
vouchers, I copied all the records for each 
of eighteen women clerks for the month of 
September, 1919. The total number of 
checks involved was 114,314. During this 
month the clerks had worked on pay checks 
on about fifteen to twenty days, but only 
for a few hours on each of these days, as a 
transcription from our data clearly shows. 
(Table 1.) The remainder of the time was 



149 



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150 



THE JOURNAL OF INDUSTRIAL HYGIENE 



spent in the routine work of the auditing 
department. 

The data were treated as follows : All the 
output records for one individual for one 
process were grouped together by hours. 
When a period extended into two hours the 



process. The advantage of the data thus 
obtained is its freedom from differences 
due to skill and to the diflferent speeds of 
the two processes of writing names and 
amounts^ The percentage output for each 
hour for the whole group was foimd by ob- 



TABLE 1. — SAMPLE OF DATA SHOWING TIME CONSUMED IN WRITING AND COMPARING 

PAYROLL VOUCHERS 


Name 


Date 


Number of 
Names by Pen 


Number of 

Amounts by 

Machine 


Number of 
Checks 
Canceled 


Time 
Commenced 


Time 
Finished 


Mmutes 


H 


9/5/19 


126 
156 


143 

125 
151 

156 
172 


7 
1 

6 
8 
i 
6 


IKK) 

11:10 

(12)11:55 

SKK) 
(2) 1:40 

2:35 
(4) 3:50 


1:35 
11:40 
IKK) 
3:50 
2:35 
SKK) 
4:30 


35 




30 
25 
50 
55 
25 
40 



record was assigned to the hour nearest the 
center of the period — e. g.y 1.40-2.35 was 
put in the 2-3 hour, and 11.55-1.00 in the 
12-1 hour. The output rate per hour was 
then calculated for each hour of the day and 



• 


- 





• - ^*1 

• i 



t-f f-lO 10-11 ll-U le.l l-ft 2.S f.4 4'» 

Fig. 1. — Solid line = percentage output rate by hours. 
Broken line = percentage error output rate by hours. 

compared with the grand arithmetical 
mean of all the hourly records of the clerk. 
Calling the latter figure 100, by a simple 
proportion the figures of the individual 
hours were reduced to percentages of the 
grand average. This statistical treatment 
was gone through for each clerk and each 



taining the true mean of a frequency curve 
in which the percentage outputs for the 
hour for each individual were the quanti- 
ties, and the number of checks on which 
each quantity had been based were the 
frequencies. This method was followed on 
the assumption that the percentage out- 
puts having the largest number of checks 
as a basis were the most reliable. 

Checks were canceled when errors were 
made; therefore a record of the canceled 
checks for each hour and each individual 
gives the number of errors made. The per- 
centage of error for each individual for 
each process and each hour was calculated 
and compared with the day's average errors 
as 100, and these figures were considered as 
quantities in a frequency distribution with 
the number of checks as frequencies, and 
the true mean obtained for each hour. 

Output and Error 

The percentage output rate by hours is 
shown in Table 2 and Figure 1. It will be 
seen that the output rate starts at 106.8, 
falls to 100.5 in the second hour, goes up to 
111.1 in the third, and falls at noon to 94.2. 
Lunch is had between 12 and 1 with forty 



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BAUMBERGER— FATIGUE AND ERROR IN MENTAL OCCUPATION 151 



minutes allowed, therefore the output rate 
of 94.8 for this hour may not be significant. 
The output rate at 1 p.m. is 96.7 and in- 
creases to 100 by 3 o*clock, falling only 
slightly (to 98.8) at the end of the day. The 
output curve is, therefore, not very typical 



110.3 at noon. At 1 o'clock it starts at 111.8 
(the highest for the day), falls in the 
second hour to 99.9, then goes up to 109.4 
at the end of the day. The morning aver- 
age is 93.6, and the afternoon average 
105.3 Not considering the 12-1 hour, the 



TABLE 2. — HOURLY OUTPUT RATE AND RATE OF ERRORS 



Time 


8-» 


^10 


10-11 


11-12 


12-1 


1-4 


2-8 


9~i 


4-ff 


Hour 


1 


2 


8 


4 


5 


6 


7 


8 





Ordput 

Meftn . . , T , , 


106.8 

22.1 

0.4 


100.5 

11.8 

0.2 


111.1 
8.2 
0.12 


94.2 
7.8 
0.12 


94.8 
7.6 
0.06 


96.7 
4.9 
0.04 


97.8 
15.8 
0.34 


100.0 
16.5 
0.19 


988 


Standard deviation 


10 5 


Probable error of mean 


0.12 


Difference 


6.8 
0.44 

14.S 


10.6 
0.42 

25.7 


16.9 
0.17* 

99.4 


0.6 
0.22 

2.7 


1.9 
0.28 

8.8 


0.6 
0.85 

1.7 


2.7 
0.85 

7.7 




1 2 


Probable error of difference 

Number of times P.E. D. is 
contained in difference 


0.5 

2.4 




A.M. Average 103.1 P.M. Average 97.5 




Error 

Mean 


86.1 
34.2 
0.21 


76.6 

20.0 

0.1 


101.6 
26.4 
0.12 


110.3 
28.4 
0.14 


101.9 
84.1 
0.25 


111.8 
38.8 
- 0.27 


99.9 
25.6 
0.18 


103.7 
28.9 
0.21 


109 4 




878 


Probable error of mean 


0.42 


Difference 


9.5 
0.23 

41.3 


25.0 
0.15 

167.0 


8.7 
0.18 

48.8 


8.4 
0.28 

80.0 


9.9 
0.87 

26.8 


11.9 
0.82 

87.2 


3.8 
0.28 

18.6 




5 7 


Number of times P. E. D. is 
contained in difference 


0.47 
12.1 


A.M. Average 93,6 P.M, Average 105 J 


Quality oj Work 


116.0 


131.0 


98.5 


88.4 


98.2 


84.8 


99.9 


96.5 


91 8 






A,M. Average 108,5 P.M, Average H.l 


Efficiency 


124.0 


181.0- 


109.5 


85.3 


98.0 


86.5 


97.8 


103.7 


903 






A.M. Average 112.li. P.M. Average H.2 



of fatigue; it shows, however, the char- 
acteristic higher output of morning (103.1) 
over afternoon (97.5). 

The percentage output rate of errors by 
hours is also shown in Table 2 and in 
Figure 1. The percentage rate of errors 
starts at 86.1 falls to 76.6, then goes up to 



curve of percentage error output is the con- 
verse of a typical output curve. This is 
shown if we plot the reciprocals of the per- 
centage error output, i. e.y 

1 

percentage error output 
which we will call quality of work. ThLs 



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is shown in Table 2 and in Figure 2. The 
quality is good to start (116), better in. 
the second hoiur (131) » but then falls off to 
88.4 at noon. It starts low in the afternoon 
(84.8), climbs to 99.9 in the second hoiu:, 
and falls off to 91.3 at the end of the day. 
The morning quality average is 108.5 as 
compared with 94.1 for the afternoon. 

The efficiency of the workers for each 
hour is determined by their output and the 



"PT 



<0^ 

r 



XT 



1 



iTnr 



n 



TT 



TT 



§-iO' U-U' 11- if 

Fig. 2. — Solid line = eflBciency by hours, 
line ■■ quality of work by hours. 



Broken 



quality of the work and may be obtained 
by dividing the percentage output rate by 
the percentage error output, for each hour. 
This is called the efficiency curve and is 
shown in Figure 2 and in Table 2. The 
efficiency starts high at 124 and climbs in 
the second hour to 131, then falls by noon 
to 85.3. At 1 P.M. it starts at 86.5, climbs to 
103.7 in the third hour, and falls to 90.3 by 
the end of the day. The morning average 
is 112.4 and the afternoon 94.2. This curve 
has also most of the characteristics of a 
fatigue curve. 

Discussion 

The data in Table 2 show that produc- 
tion is maintained more evenly throughout 



the day than quality. Thus, the difference 
between the highest and lowest percentage 
output hours is only 16.9, as compared with 
35.2 for percentage error output. It is prob- 
able that the writing or typing is an auto- 
matic movement (3) in which the individ- 
ual is unconscious of the figures read but 
conscious of the (voluntary) movements re- 
quired to write the name or the number. 
In order to be aware of errors made, a 
higher form of consciousness — attention 
— is required. It would seem that the out- 
put is maintained by the lower type of 
consciousness, but the quality varies with 
the higher type of attention which is more 
readily subject to fatigue. Attention is 
more easily diverted than unconscious 
volition, and this may explain why the per- 
centage output of error is more variable 
then the percentage output. 

In this connection Spaeth (1, p. 32) says: 

. . . The question now arises as to what light the 
output curve throws on the occurrence of fatigue. 
We may say at once that if by fatigue we mean a 
lowered capacity for work, and the drop in output 
indicates a lowered capacity for work, it must simul- 
taneously indicate, by definition, the presence of 
fatigue. How much of this fatigue is due to the 
work and how much to other conditions, output 
curves do not tell. 

From the data above it would seem that 
even though the percentage output of the 
individual does not follow a fatigue curve 
very closely, the quality of the work does 
so to a very decided degree. It appears, 
therefore, that the decline in output at the 
end of the morning and the lower output of 
the afternoon are really indicative of 
fatigue — that is, if it is admitted that les- 
sened attention is due to fatigue. The fact 
that production is maintained at so near a 
level throughout the day would indicate 
that the workers are endeavoring to keep 
up their output; in spite of this, however, 
the errors increase. It would seem, there- 
fore, that real fatigue is the cause of the 
lowered output. 



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BAUMBERGER— FATIGUE AND ERROR IN MENTAL OCCUPATION 153 



Link (2) made a study of the quaKty of 
the work done in a munition factory and 
concluded that "there was not enough dif- 
ference in the quality of the work done at 
various times of the day to justify reduc- 
ing the number of hoiu^." He gives the 
following table (Table 3) showing the per- 
centage of scrap that had escaped rejection 
by inspectors at various times of the day. 
The figures in parentheses in the table are 
mine and show the percentage of each 



tests are entirely too short for reliability, even if 
carried on five times a day for a period of three 
weeks. Moreover, as has since been discovered in 
connection with the development of psychological 
tests for aviators, the human mind is able to con- 
centrate for short periods even when it is almost on 
the point of exhaustion and render for such a time a 
performance which compares favorably with those 
done under the most favorable conditions. 

From Figiu^ 1 on page 235 of Link's 
paper, however, it appears that the number 
of errors in the 5.40 p.m. test was about 25 



TABLE 8. — PERCENTAGE OF SCRAP FOUND BY REINSPECTION (AFTER LINK (e)) 



Time o! Origmal Inspection 


7-« A.M. 


1H8:80P.M. 


5-9 TM. 


Number of boxes inspected . *. 


47.0 

12.2 (101.0) 

8.9 ( 99.0) 


26.0 

8.5 (70.0) 

2.6 (66.0) 


87.0 


Percentage of total scrap found by reinspection 

Percentage of scrap (based on total number of shells in- 
spected) found by remspection 


15.5 (129.0) 
5.3 (185.0) 







figure of the average for the whole day as 
determined from the three figures given in 
the table. The percentage comparison (in 
parentheses) shows that the inspection work 
in the 5-6 hdur is about 30 per cent, in- 
ferior to that of the morning hour. There- 
fore, Link's conclusion that "this increase 
is comparatively slight" (page 234) seems 
unwarranted. 

Link gave a number of psychological 
tests at different periods during the day 
from which he concludes (p. 237) : 

The results in the tests, in so far as they were in- 
dicative, coincided largely with the results of the re- 
inspection and production study. However, the 
variations in the quantity and quality of the work 
done in these tests were altogether too slight to 
justify using them as an index of fatigue. On the 
other hand, the variations due to practice were so 
marked as to make all other variations seem insig- 
nificant. This is not necessarily a repudiation of the 
psychological method, but rather an indication of the 
diflSculties involved. It would seem that two-minute 



per cent, more than in the 1.10 p.m. test. 
As Link points out, a psychological test 
arouses the individual to unusual concen- 
tration of attention which may mask the 
effects of fatigue. Our use of a normally 
recurring routine occupation of a duration 
of only a few minutes as a measure of 
fatigue is therefore valuable in that it 
escapes the danger of arousing unusual 
attention by its nature. 

Conclusion 

1. Output in clerical work shows signs of 
fatigue. 

2. The error output in clerical work is 
the converse of an output curve. 

3. The eflSciency of clerical workers as 
measured by output and errors made 
varies like a typical fatigue curve. 

4. A normally reciuring routine occupa- 
tion of a few minutes' duration is a valu- 
able criterion of fatigue. 



1. Spaeth, R. A.: The Problem of Fatigue 
Indust. Hyg., 1919-1920, 1, 22. 

2. Link, H. C: A Practical Study in Industrial 
Fatigue. Jottb. Indust. Hyg., 1919-1920, 1,233. 



BIBLIOGRAPHY 

Jour. 3. Grllnbaum, A.: Volont^ et Mouvement. Arch. 



n^erl. de physiol., 1920, 4, 367. 



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A WORK CHAIR * 

ARTHUR B. EMMONS, 2d, M.D. 

Director, Harvard Mercantile Health Work, Boston, Mass. 

AND 

JOEL E. GOLDTHWAIT, M.D. 

Orthopedic Surgeon, Boston, Mass. 



SURVEYS of twenty stores have dis- 
closed a number of hygienic faults, one 
of the most evident of which is unnatural 
seating. Unnatural posture causes fatigue, 
reduces vitality, tends to deformity, and 
always results in reduced production and 
earning pK>wer. A careful search of chair 
salesrooms has disclosed the fact that no 
suitable chair is in stock which can be said 
to meet the anatomical and practical needs 
of the employee whose work is done at a 
desk or table. 

In the past, chairs were evidently de- 
signed for resting, not for working. The 
conunon bent wood chair shown in Figure 
1 supports only the shoulders when one 
leans back, and is an instance in point. 
The cane seat of this chair weakens rapidly 
so that the worker is soon sitting on a 
wooden ring crossing under the middle of 
the thighs. 

A casual glance at any group of clerical 
employees at work will show a large propor- 
tion of them sitting forward on the front 
part of their chairs, as illustrated in Figure 
2. This is an attempt to get comfortable. 
The back of the chair is used only during 
intervals of rest from fatigue produced by 
sitting with no support to the back. (See 
Figures 1 and 3.) Where does one need 
support when sitting at desk work? Try 
this experiment and see for yourself. Sit 
erect, and then gradually relax, letting the 
back bend naturally. You will find at once 
that the small of the back bulges directly 
backward. Here, then, is the need for sup- 
port to maintain the erect position — the 
natural position for work. The weight of 

♦ Received for publication May 31, 1921. 



the body should be supported by a seat 
directly under the body and not at the mid- 
thigh. To meet these requirements of na- 
ture the chair shown in Figure 4 was made. 
It possesses a shallow seat and a back 
curved forward to fit the small of the back, 
and is of rigid construction in order to give 
support and steadiness. This chair has 
proved to be a generally useful work chair 
and considerable search has failed to dis- 
cover any other which approaches it in 
essential requirements. Adjustable chairs 
may still be necessary for special work, such 
as that of the telephone switchboard opera- 
tor, but adjustabiUty is not an immixed 
good. It nearly always results in unstead- 
iness and the chair is rarely correctly 
adjusted to the individual. Moreover, 
adjustability requires frequent repairs and 
results in a short-lived chair. 

To introduce successfully any radical 
change in an individual's working environ- 
ment — and a new work chair constitutes 
such a change — requires tact and care. 
It is suggested that at first a few samples- 
be introduced, with careful explanations as 
to the object of the chair and with the sug- 
gestion that a fair trial be made before 
judgment is passed. 

The work chair, which we have de- 
scribed, was especially designed by a com- 
mittee composed of Dr. Joel E. Goldthwait 
(chairman). Dr. Lloyd T. Brown, and Mr. 
Ford, of Massachusetts Institute of Tech- 
nology, to meet the needs of a large tech- 
nical educational institution. It has proved 
entirely satisfactory, when used at a table 
or desk. Another similar chair, with arm 
rest added, was constructed for ordinary 



154 



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EMMONS AND GOLDTHWAIT— WORK CHAIR 



155 






': 




« 

mm am 


pir 





Fig, 1. — Resting posture in common bent 
wood chair. 



Fig. 2. — Correct working posture in common 
bent wood chair. 




i^ 



I^HM 


[_, 








* 


^T^ 


1 


mA 


m 


^ '^•re'^^ 


'O. 



Fio. 5. — Posture when sitting back in common 
bent wood chair. 



Fig. 4. — Correct working posture in work chair. 



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156 



THE JOURNAL OF INDUSTRIAL HYGIENE 




Fio. 5. — Correct resting posture in work chair. 




•^^B 



1 Va ii|. 
Fio. 7.— Manufacturer's measurements for work chair. 



Fig. 6. — Work chair. 

class room or lecture work. The sturdy 
construction of the chair is testified to by 
the fact that several hundred have been in 
constant use for five years and are reported 
to have received no repairs. Inspection of 
them at the present time shows that the 
glue has given way and needs replacement 
in about one in five to ten chairs; other- 
wise the chairs are in good condition. 

The chair has had industrial use in a 
large clothing factory where many ma- 
chines are used at tables. The personnel 
director of this establishment reports as 
follows: 

We have found that the four different^eights of 
the chair (17", IS*", 19", 20"') we use have'been suffi- 
cient for all but one or two exceptional cases. The 



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EMMONS AND GOLDTHWAIT — WORK CHAIR 



157 





Fig. 8. — Correct working posture in work chair. 



Fig. 9. — Correct resting posture in work chair. 





Pig. 10. — Incorrect working posture in conunon 
o£Bce chair. 



Fig. 11. — Resting posture in office chair. 



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158 



THE JOURNAL OF INDUSTRIAL HYGIENE 



chair has worn very well indeed and is giving great 
satisfaction to the workers. As for its preventing 
fatigue, I cannot furnish statistics on this matter, but 
I do know that any chair which supports the back as 
this one does and which does not interfere with circu- 
lation must have a great deal to do with reducing the 
fatigue of our workers. I have used this chair myself 
ever since we first introduced it in the factory, and I 
wouldn't use any other as a desk chair. I feel that it 
has helped me to maintain correct posture, and that 
I am very much more comfortable in it than in any 
chair I have used as a work chair. 



When we take into consideration the 
fact that many workers in stores, offices, 
and factories spend nearly a third of the 
twenty-four hours of a day in a chair, the 
importance of correct posture in prevent- 
ing fatigue during working hours is evident. 
It is hoped that employees whose work 
must be done at a table or desk may be 
given the opportunity to use the work chair 
described in this article and to enjoy the 
comfort which it insures. 



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THE PRACTICAL HYGIENIC EFFICIENCY OF THE PALMER 
APPARATUS FOR DETERMINING DUST IN AIR * 

HENRY FIELD SMYTH. M.D.. Dr.P.H., and MIRIAM ISZARD, M.A. 

From the School of Hygiene, University of Pennsylvania 



IN view of the recent publication of two 
rather severe criticisms of the eflSciency 
of the Palmer water spray method of dust 
sampling, it has seemed to us that it would 
be advantageous to pubUsh the results of 
some actual studies of dusty air made with 
the Palmer apparatus as compared with 
studies of sections from lungs of animals 
expK>sed to the same dusty air. and with 
counts made directly from samples of the 
dust used in the tests. The criticisms re- 
ferred to were those of Bill in his paper on 
The Electrostatic Method of Dust Collection 
(1) and of Katz et al. on the Efficiency of the 
Palmer Apparatus for Determining Dust in 
AirJ^^). Bill claims a relative eflSciency of 
61.6 per cent, by weight and 59.9 per cent. 
by coimt of the Palmer apparatus as com- 
pared with the electrostatic method, which 
later method he found to retain 82.3 per 
cent, by weight of the dust passing through 
his apparatus. Katz and his co-workers 
claim only a 70 per cent. eflSciency for the 
electrostatic method and an eflSciency of 30 
per cent, or less for the Palmer apparatus. 
It seems to us that the tests used by 
Xatz and his co-workers were entirely too 
severe and not at all comparable to indus- 
trial conditions under which either appa- 
ratus is likely to be used. They start with 
the premise that the finest air-suspended 
particles are the most injurious to the lungs 
— a fact that has never been proved and 
that seems to us to be doubtful. Hoflfman 
in a recent article (3) also conveys this idea 
\«rhen he speaks of "extremely fine dust, the 
ultramicroscopical particles of which are 
most harmful to the lungs." With all mac- 
roscopic foreign bodies, other things being 

* Received for publication April 23, 1921. 



equal, the larger the body the greater the 
irritation produced, and, of course, with 
soluble toxic particles the larger the par- 
ticle the more toxic it is. It would seem to 
us that the largest particles that would 
actually reach the lung tissue would be 
most harmful and the particles that were 
most numerous in the lungs would be those 
most apt to produce gross lesions. Katz 
employed two methods of testing the ap- 
paratus, one with filtered tobacco smoke 
containing particles (droplets) of uniform 
size ranging from 0.2681 to 0.2779 microns 
in diameter. EflSciency was tested by the 
Tyndall phenomenon of luminosity of the 
particles floating in a current of air travers- 
ing a beam of light. Air passed through the 
Palmer apparatus was compared with air 
by-passed around the apparatus, percent- 
age of suspended matter removal being 
calculated from the amount of filtered 
dust-free air required to dilute the latter 
sample so as to make the two beams of 
light of equal luminosity. This is a very 
ingenious method and the complicated ap- 
paratus required to make the test is most 
interesting, but the long, narrow, more or 
less tortuous tubing through which the 
samples are passed offers, as the authors 
state, abundant opportunity for precipita- 
tion of particles on the sides of the tubes. 
The test showed about 13 per cent, re- 
moval of these very minute droplets of 
liquid. Similar tests with finely divided 
dried silica dust showed a removal eflS- 
ciency of 30 per cent, by the Tyndall 
method. 

The second method employed by Katz 
was to collect the silica dust passing the 
Palmer apparatus in a small Cottrell elec- 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



trostatic precipitator. The dust collected 
by the Cottrell precipitator was filtered 
through an analytic fiilter and weighed on 
the fiilter, the dust in the fiiltrate being 
estimated by a turbidity reading of the 
filtrate as compared with the turbidity of 
suspensions of known weights of the finest 
air-floated silica dust. This does not seem 
as accurate a method as that used by Bill 
and by Miller and Smyth (4) for determin- 
ing the weight of dust collected by the 
Palmer apparatus. Just why the suspended 
watar sample was not evapK)rated and the 
residue weighed, does not seem clear from 
the article. No direct measurements are 
given of the size of the silica particles used, 
but it is stated that those that pass through 
the analytical filter-paper average 0.25 
microns in diameter. This method showed 
an efliciency of 45 per cent, by weight with 
this very fine dust. These tests show un- 
doubtedly that the Palmer apparatus 
allows many minute particles to pass 
through, but they throw no light on the 
eflBciency of the apparatus for sampling the 
average industrial dust clouds that contain 
many particles of much larger size which, 
as will be shown later, are still within the 
range of those that reach the lungs and re- 
main lodged in the tissues. 

In Katz's experiments, air was passed 
through the Palmer bubbler at the rate of 
4 cubic feet per minute. Tests at a slower 
rate showed less efficiency, and tests at 5 
cubic feet per minute, as recommended by 
Palmer, carried water through the appara- 
tus. Bill, in his tests, used the same rate for 
the same reason. The work reported by 
Miller and Smyth (4) was mostly done at 
the 5 cubic foot per minute rate, the appa- 
ratus used being moimted in a dress suit 
case as originally designed and described by 
Palmer (5). The collecting bulb in this 
apparatus is larger than that in the later 
designs and has an extra bend in the outlet 
tube, and this is connected with several 
inches of upright and horizontal tubing 



before the fan IS reached. With this original 
apparatus we have never known water to be 
carried over to the fan at the 5 cubic foot 
rate, and we always use this rate of sam- 
pling provided we have sufficient current 
for the fan motor. Many industrial plants 
manufactiuing their own current use a 210 
to 220-volt cmrent, and by the introduc- 
tion of a 110-volt lamp in parallel circuit 
and a four-point switch we have been able 
to use the same apparatus for tests in these 
plants and in plants using the usual 110- 
volt current. 

Bill compared the Palmer apparatus 
with an apparatus of his own design, using 
a small Cottrell precipitator and running 
both types of apparatus for sixty minutes, 
which seems a much better sampling time 
than the one-minute periods of Katz. Bill 
used dusts passing a 100-mesh sieve which 
would much more nearly approach the 
average industrial dust than does tobacco 
smoke or the cotton-filtered silica dust of 
Katz, and would include, as will be shown 
later, the largest particles ever found in 
lung tissue. Bill f oimd an actual efficiency 
of his own apparatus of 82.3 per cent, by 
weight and a comparative efficiency of the 
Palmer apparatus, as compared with his 
own, of 59.9 per cent, by coimt and 61.6 by 
weight, making an absolute efficiency by 
weight of 50.69 per cent. Bill claims that in 
counting particles in Palmer samples he 
was much more troubled by the clumping 
of smaller particles into masses which he 
often counted as units than he was with 
water suspensions of electrically precipi- 
tated dusts. Miller and Smyth and later 
we ourselves foimd that sufficiently vigor- 
ous shaking of samples and sufficiently high 
dilutions with filtered distilled water re- 
sulted in breaking up practically all of these 
clumps. In our counting work we dilute 
very turbid samples from 1 in 10 to 1 in 100, 
so as to have counts of imder 100 particles 
per one-fourth field. This probably ma- 
terially increases total counts and espe- 



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SMYTH AND ISZARD— EFFICIENCY OF PALMER APPARATUS 161 



cially counts of smaller particles, and shows 
a greater percentage efficiency by count 
than was found by Bill, though even the 
approximate 50 per cent, efficiency of the 
Palmer apparatus as demonstrated by Bill 
does not materially aflFect its usefulness 
provided this j>ercentage efficiency is rea- 
sonably constant and provided the ap- 
paratus gives a representative sample of 
particles of the most eflFective size. Bill's 
apparatus, while undoubtedly giving a 
decidedly greater percentage efficiency by 
coimt and by weight than does the Palmer 
apparatus, requires more delicate and skil- 
ful manipulation and more technical knowl- 
edge in order to run it and is as yet far 
from a portable and practical apparatus 
for routine industrial dust sampling. It is 
greatly to be hoped, however, as Bill him- 
self suggests, that these latter difficulties 
may be overcome and that there may soon 
be designed and put on the market a small 
portable apparatus which can be used with 
reasonable facility and accuracy by the 
average field worker. 

Experimental Work 

For over a year we have been doing ex- 
perimental work along the lines followed 
by Mavrogordato (6), exposing groups of 
guinea-pigs to measiu-ed clouds of fine dust 
for given periods at given intervals. After 
given periods of time, the animals were 
killed and the eflFects of dust inhalations on 
the limgs were studied, the method of entry 
of dust to the lung tissue, the location of 
permanent deposits, the rate of invasion, 
and the route and rate of ehmination of 
dust particles from the lungs all being 
noted. It is not the purpose of this paper to 
report on this work other than in one par- 
ticular — that of the size of particles lodg- 
ing in limg tissue. For this work a dust 
box was constructed similar to that de- 
scribed by Mavrogordato, a small electric 
fan being used to keep dust in suspension. 



A hole was so placed in the box that 
samples could be taken by the Palmer ap- 
paratus from alongside the exposed ani- 
mals. Counts were made according to the 
method suggested by one. of us (7), par-r 
tides much over 40 microns in diameter 
being ignored and those coimted being 
divided into three groups based on their 
greatest diameter rather than on their esti- 
mated area. The particles in group I 
averaged 40 microns, being sufficiently large 
so that their area could be easily estimated. 
Group n particles averaged from 5 to 30 
microns in diameter and were large enough 
for their shape to be determined but many 
were too small for their area to be esti- 
mated. Group m particles averaged 1 
micron and appeared imier the low power 
as dots too small to i>ermit us to determine 
their form. 

Table 1 gives the size distribution of 
particles in watery suspensions of samples 

TABLE 1. — SIZE DISTRIBUTION OP PARTICLES 
IN DUSTS USED IN TESTS 



Kiadci 
Dust 


Sisel 
Av.40 
BfkroDS 
DUmeter 


Sixen 

5-80 

Microns 

Duuneter 


Siiem 

Av. 1 

Micron 

Diameter 


Number 

of 
ParticlM 
Counted 


ReUtire 
Weiriitof 
EonaTBuIk 

of Dust 


Coal 


% 


% 
16 + 


% 
81 + 


549 


1.0 


Stone.... 


0.78 


9 + 


90 + 


2,529 


1.8 


Flint .... 


O.S 


2 + 


97 + 


4,885 


1.4 


Average . 


1.3 + 


9 + 


89 + 







of the three dusts used up to the present 
time in these tests — i. a, crushed coal 
used for fuel in cement kilns, crushed raw 
cement rock and crushed flint used in pot- 
tery manufacture. These dusts were com- 
merciail products obtained from a cement 
plant in the Lehigh Valley and from a flint 
mill in Trenton, N. J., and, as will be seen 
in Table 2, averaged smaller particles than 
those entrained in the Palmer apparatus in 
tests made several years ago of air dustiness 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



in the mills from which these samples were 
obtained. Tables 2 and 3 give the percent- 
age distribution as shown in Palmer samples 
of all particles small enough to enter the fine 

TABLE 2. — SIZE DISTRIBUTION OF PARTICLES 

IN INDUSTRIAL DUST TESTS WITH 

PALMER APPARATUS 





Av. 

Number of 

Partidet 

per Cu.Ft 

of Air 


Number 
ofTetU 


Av. 

Weight of 

Dustper 

100 Cu. 

Ft. of Air 


Percentage of Particks 


Kind of 
Dust 


Un<kr5 
Microns 
Sisem 


Overs 
Microns 
SiiesI 
andn 


Coftl.... 


8,881,200 


2 


0.2286 


% 
53 


% 
. 47 


Stone... 


8,609,866 


3 


0.1681 


55 


45 


Flint . . . 


844,040 


S 


0.0459 


65 


35 



bronchioles and reach the lungs. Table 3 
gives the results of counts of samples taken 
from the dusting box in which the animals 
were exposed and shows, by comparison 
with Table 1, that the Palmer apparatus, 
regardless of its total eflSciency, seemed to 
take a fairly representative sample of the 
dangerous sized particles in these dusts. 

Paraffin sections of portions of the lungs 
of guinea-pigs that had been exposed to the 

TABLE 3. — SIZE DISTRIBUTION OF PARTICLES 

IN DUST TO WHICH GUINEA-PIGS 

WERE EXPOSED 

(As Determined hy Patmer Apparatus) 





Av. 

Number of 

Particles 

per Cu. Ft. 

of Air 


Number 
of Tests 

Palmer 


Av. 

Weight of 

Dustoer 

100 Cu. 

Ft of Air 


Percentage of Particles 


Kind of 
Dust 


Under 5 
Microns 
Sisem 


Oyer* 
Microns 
Sixes I 
andn 


Coal.... 


d4,074»000 


6 


gm. 
0.164 


% 
84.0 


% 
16.0 


Stone... 


4,719,000 


12 


0.046 


93.25 


6.75 


Flint . . . 


15,009,000 


6 


0.0504 


96.68 


3.32 



dusts for diflFerent periods and then killed 
by gas immediately after exposure, or at 
increasing intervals after, were stained and 
examined imder the microscope. Simple 



alum-carmine staining permits the dust 
particles in the lungs to be seen clearly. 
The sections were examined under the oil 
immersion lens, and camera lucida draw- 
ings were made of a number of groups of 
intracellular particles. By this means a 
2,000-diameter magnification was obtained 
and particles i micron in diameter and over 
could be measured. Table 4 gives the re- 
sults of the measurement by these means of 
over 1,200 particles of the three dusts used; 
Table 5 gives the percentage distribution of 
particles grouped as over 5 microns (cor- 
responding to sizes I and 11) and under 5 
microns (corresponding to size III). The 

TABLE 4. — SIZE DISTRIBUTION OF DUST 

PARTICLES IN LUNG TISSUE OP 

GUINEA-PIGS 

(Stained Sections) 



Kind of Dust: 


Number 

of 
Partidet 
Counted 


Greatest Diameter of Partidea 
inBiicroiif 




U 


8 


7 


5 


4 


s 


s 


1 


0. 


Coal 


616 


1 


1 


3 


14 


4 


41 


87 


117 


348 






Stone 


378 


•• 






1 




4 


21 


76 


976 






Flint 


295 












3 


19 


61 


2iy. 






Total particles 
counted 


1,289 


1 


1 


3 


15 


4 


48 


127 


254836 



latter are again divided into those under 1 
micron and those from 1 to 4 micnms. This 
division shows that apparently over 64 per 
cent, of the particles are under 1 micron, 
over S3 per cent, from 1 to 4 microns, with 
over 98 per cent, in the third class according 
to the Palmer count, while the dust itself 
showed an average of over 91 per cent, in 
the third class. Tables 4 and 5 show also 
an apparently decided difference in size dis- 
tribution of particles of the lighter coal dust 
and the heavier stone and flint dust. Over 
43 per cent, of the particles of coal dust 
found in the lungs were 1 micron or over in 
diameter, and particles as large as 11 
microns were found, while less than 30 per* 



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SMYTH AND ISZARD — EFFICIENCY OF PALMER APPARATUS 163 



cent, of particles of either stone or flint 
were as large as 1 micron. The relative 
weights of the three dusts are shown in the 
last column of Table 1. 

McCrae (8), in his studies on the lungs of 
South African hard rock miners, found 

TABLE 5. — PERCENTAGE DISTRIBUTION OP 

DUST PARTICLES IN LUNG TISSUE 

OP GUINEA-PIGS 

(Stained Sections) 





Number 

of 
Partkksfl 
Counted 


Peroentege of Particles m Size Groups 


Kind of Dust 


Over5 
Microns 


1-4 
Microns 


Under 1 
Micron 


ToUl 
under 5 
Microns 


CoaI 


616 


% 
8 + 


% 
40 


% 
56 + 


% 
96 + 






Stone 


878 


0.2 + 


'26 + 


78 + 


99 + 


Flint 


295 


0.0 


28 + 


71 + 


100 


Total parU- 
des counted 


1,280 


1.5 + 


88 + 


64 + 


98 + 



that by acid digestion of lung tissue he 
could recover silica particles, 70 per cent, of 
which were under 1 micron in diameter, 
with 30 per cent, ranging from 1 to 10 
microns in diameter. These results com- 
pare very closely with the counts made by 
us, as will be seen by referring again to 
Table 5 in which flint and stone dusts 
averaged 27+ per cent, of particles above 1 



micron and 72+ per cent, under 1 micron, 
as against the 30 and 70 per cent, respec- 
tively coimted by McCrae in miners' limgs. 
Watkins-Pitchford and Moir (9) counted 
the doubly-refracting particles in sections 
of silicotic lungs ranging from 1 to 13 
microns in diameter with a mean size of 
6.13 by 2.18 microns, with particles up to 
13 microns actually seen as intracellular. 
Later, by a method of cold digestion with 
strong nitric acid of the paraffin sections 
fixed on microscopic slides, they found that 
they had overlooked many particles and 
underestimated the size of others. After 
this treatment they counted and carefully 
measured 120 particles ranging from | 
micron up to 5.5 microns in diameter, 35.8 
per cent, being under 1 micron, 48+ per 
cent, from 1 to 2 microns, and over 15 per 
cent, above 2 microns in diameter, 1 micron 
being the most frequent size. 

Sections from some of the same blocks 
of tissue from which stained sections were 
coimted were treated by us according to the 
Watkins-Pitchford method of cold nitric 
acid digestion. Table 6 gives the results of 
these counts which compare closely with 
those of Watkins-Pitchford and Moir. We 
counted more large particles by this 
method than we did in stained sections, as 
did they. Although this method showed a 
surprisingly high percentage of large par- 



TABLE 6.— SIZE DISTRIBUTION OP DUST PARTICLES IN LUNG TISSUE OP GUINEA-PIGS 
AS DETERMINED BY COLD ACID DIGESTION 

{WaikinS'PiU^ford Method) 





ToUl 
Psrtides 
Cmmted 


Greatest Diameter of Particles in Biicrons > 


Per 

Cent. 

ovcrl* 

Microns 


Per 

Cent 

over 5 

Microns 


Per 

Cent. 

1-4 

Microns 


Per 

Cent 


KiMloflhift 


S9 


17 


U 


9 


8 


7 


9 


5 


. 


s 


t 


1 


0^ 


under 1 
Micron 


CoiJ 


506 


•• 


•• 




1 




2 


1 


4 


4 


16 


78 


881 


69 




1.5 + 


84 + 


18 + 


StoDe 


477 


1 


1 


•• 


^ 


•• 


2 


•• 


4 


7 


20 


58 


298 


84 


0.4 + 


1.6 + 


80 + 


17 + 


Flmt 


204 






1 


" 


1 


8 


•• 


8 


4 


11 


20 


115 


47 





8 + 


73 + 


23 + 


Total 


1,187 


1 


1 


1 


8 


1 


6 


1 


11 


15 


47 


156 


744 


200 


0.1 + 


1.9 + 


81 + 


16 + 



i Most frequent siae of all ihree dusts, 1 micron diameter. 



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164 



THE JOURNAL OF INDUSTRIAL HYGIENE 



tides of stone and flint, yet the same rela- 
tive distribution of smaller particles is 
seen. Coal dust showed only 13 + per cent, 
of countable particles under 1 micron, and 
65 + per cent, averaging 1 micron in diam- 
eter; stone showed 17 + per cent, imder 1 
micron, and 62 per cent, averaging 1 mi- 
cron; and flint 23 + per cent, under 1 mi- 
cron, and 56 + per cent, averaging 1 micron. 
With all three dusts the most frequent size 
foimd in the lungs was 1 micron (62+ per 
cent, average), and there was an average of 
81 + per cent, from 1 to 4 microns. The 
same relatively high percentage of larger 



some clumping of very minute unmeasur- 
able particles, yet these clumps were not 
very numerous and evidently were not the 
predominating factor, and hardly seem to 
be the factor apt to be responsible for much 
tissue damage. This would indicate that 
an average of 97 + per cent, of the countable 
particles were among those counted as size 
m in the Palmer method according to 
Smyth's modification, as compared with 
91 per cent, of the same size, counted in 
Palmer samples of the dust to which ani- 
mals were exposed, and 89 per cent, in 
samples taken directly from the dust. The 



TABLE 7. — COMPARATIVE SIZE DISTRIBUTION OF DUST PARTICLES AS SHOWN BY 

COUNTS OF.DUST, OF DUST CLOUDS, OF STAINED LUNG SECTIONS, AND OP 

ACID-DIGESTED LUNG SECTIONS » 



Kind of dust 


Av. 40 Mkroiu 


^-SOMicroDfl 


Av. 1 BCicron 




1 


2 


s 


4 


1 


2 


s 


4 


1 


2 


s 


4 


Coal 


% 
2.9 + 


% 
1.6 


% 



% 



% 
16 + 


% 
14 


% 
8 + 


% 
1.5 + 


% 
81 + 


% 
84 + 


% 
96 + 


% 
98 + 






Stone 


0.78 


1.5 








9 + 


5 + 


0.2 + 


2 + 


90 + 


98 + 


99 + 


97 + 






Flint 


0.3 


0.07 + 








2 + 


8 + 


0.0. 


8 + 


97 + 


96 + 


100 + 


96 + 






Average 


1.8 + 


1 + 








9 + 


7 + 


1 + 


2 + 


80 + 


91 + 


98 + 


97 + 







1 1 >■ Direct oounU from dust. 
2 >■ Palmer samples of dust. 



sized coal particles as compared with 
heavier stone and flint particles is seen 
here as is obtained by the direct counting 
of stained sections, though the difference is 
not so marked. Evidently, in the stained 
sections, many large particles of stone and 
flint appeared to be smaller than they 
really were, or probably were coimted as 
more than one. 

Table 7 is a comparison of percentage 
coimts by all methods and shows a very 
close paralleling of size distribution of the 
countable particles imder 40 microns in the 
original dust, the Palmer sampled dust, 
and the dust in the lungs of the exposed 
animals. While the tissue sections gave 
evidence by both coimting methods of 



S » Stained lung sections. 

4 "■ Add-digested lung sficrionsi 



irregularity of the coimts of particles over 
5 microns in the different methods is ex- 
plained by their relative infrequency in all 
tests. 

These methods seem to indicate that a 
fair efficiency test of a dust sampling ap- 
paratus would include many particles of 1 
micron in diameter and larger, and that 
failure to retain a high percentage of par- 
ticles under 0.5 microns ih diameter does 
not materially reduce its practical efficiency 
as a hygienic test. This is in practical agree- 
ment with and helps to confirm the opinion 
of the American Public Health Association 
Committee on Standard Methods for the 
Examination of the Air (10). 

We are constantly exposed to and inhale 



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SMYTH AND ISZARD— EFFICIENCY OF PALMER APPARATUS 165 



ultramicroscopic dust which is present in 
more or less degree in all air of inhabited 
r^ons. It is this type of particle that 
gives us our diffuse daylight and oiu* 
beautiful sunsets, and that is responsible 
for much mist and doud formation. These 
extremely minute particles remain in sus- 
pension indefinitely, as long as there are 
any air currents, being precipitated ouly in 
perfectly still air. In the bronchioles tiiey 
would be the last particles to be deposited 
on the mucus, would float longest on 
the surface of the mucosa, would jye the 
easiest to be swept up and out by the cur- 
rents kept in motion by the cilia, and would 
be the least irritating when phagocytized. 
Ultramicroscopic particles are more apt to 
be spherical and less apt to be spiculate or 
to have sharp angles, and hard, spiculate or 
angular dusts are generally conceded to be 
most irritating and most apt to cause 
fibrosis. Especially with moderate degrees 
of dustiness, it would seem from the above 
considerations that the largest particles 
reaching the bronchioles would be the most 
irritating, and that of these larger particles 
the most dangerous would be the size oc- 
curring most frequently.. This depends on 
the sj)ecific gravity and nature of the dust, 
and the efliciency of a dust sampling 
method should depend on its ability to re- 
tain a large percentage of these particles 
rather than of those of ultramicroscopic 
size. 

As previously stated, both Bill's and 
Katz's tests with the Palmer apparatus 
were run at 4 cubic feet per minute, while 
we usually employ a 5 cubic foot rate with 
our type of apparatus. Katz states that he 
and his co-workers foimd a SO per cent. 
eflSciency by the Tyndall test when running 
at 4 cubic feet p>er minute, as against a 20 
I>er cent. eflSiciency at 3 cubic feet — a ratio 
of 1.5 for the 4 cubic foot rate to 1 for the 3 
cubic foot rate. Three comparative tests 
were run by us for five-minute periods 
against a very heavy cloud of coal dust 



which at the 5 cubic foot rate showed 
1.3448 gm. of dust per 100 cubic feet of air. 
The tests were all run on the same day, the 
dust being freshly stirred up before each 
test so as to have as nearly as possible the 
same amount of dust in the air. There was 

TABLE 8. — RELATIVE EFFICIENCY TESTS OF 
PALMER APPARATUS WHEN RUN TO SAMPLE 
3, 4, AND 5 CUBIC FEET OF AIR PER MINUTE 



0. By Weight 


Dust 

Employed 


Dura- 
tion of 
Test 


Rate of 
Air Flow 

Blmute 


Total 

Air 

Sampled 


Weight 
ofDbst 
Washed 
from Air 


Calculated 

Weight Dust 

perCu,Pt 

of Air 


Coal 


mim, 
5 


cu.fL 
3 


16 


gm. 
0.1004 


gn, 
0.66264 


u 


5 


4 


20 


0.2012 


1.006 


u 


5 


5 


26 


0.3362 


1.3448^ 


b. By Count 


Dust 
Employed 


Rate of 
Air Flow 

M^^te 


Per Cent 
Sisel. 
Av.40 
Microns 


Percent 
SiseU. 

Microns 


Per Cent 

Size III. 

Av.l 

Micron 


Calculated 

Number 

of Particles 

per Cu. Ft. 

of Air 


Coal 


cu,A 
3 


6.4 


34.4 


69.2 


37.333.300 


u 


4 


1.1 


27.0 


71.ft 


66.800,000 


u 


5 


0.62 


8.6 


90.8 


66.800.000 1 



1 Both count and weight should have been higher for the 5 cubic foot 
rate sample but there was so much coal in the collecting bulb that over 
100 cc. of sample was obtained before the bulb was completely rinsed 
out Some of the coal remained in the bulb and was not included in the 
count or m the weighing test 



absolutely no evidence of any water being 
carried through the apparatus, and with the 
very heavy content of coal dust in the 
water this could not have escaped observa- 
tion. These tests show (see Table 8a) the 
same relative efficiency as that found by 
Katz for the 4 cubic foot rate as compared 
with the 3 cubic foot rate, and a ratio of 
1.38+ for the 5 cubic foot rate as com- 
pared with the 4 cubic foot rate. This 
seems to indicate that if Bill had used 
the older type of apparatus at a 5 cubic 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



foot rate he would have found it to have 
a relative eflBciency of 81.8 per cent, by- 
weight as compared with his apparatus; 
and with the same apparatus at the same 
rate, Katz would have found an absolute 
eflBciency of approximately 59.85 per cent., 
instead of 45 per cent, at the 4 cubic 
foot rate. 

Table 8b shows that the 5 cubic foot per 
minute rate also gives a greater eflBciency 
by count than does the slower rate, and 
that the more active bubbling fountain en- 
trains and holds back a great proportion of 
the smaller particles most apt to be harm- 
ful (size m). 

Summary and Conclusions 

Our findings as to size distribution of 
dust particles in guinea-pig lungs agree 
closely with those of McCrae and of Wat- 
kins-Pitchford and Moir in human lungs. 

The most frequent sized dust particles 
lodging in the lungs of men or animals are 
those about 1 micron in diameter, and 
from 60 to 80 per cent, of the countable 
particles are from 1 to 5 microns in diam- 
eter. There is no evidence of a great ac- 
cumulation of ultramicroscopic particles in 
the lung, and these particles are not so apt 
to reach the lung cells as are those which 
are somewhat larger. 

Dust particles seen in stained sections of 
the lungs are apt to appear smaller than 
they really are, as is shown by the Watkins- 
Pitchford method of cold acid digestion. 

The Tyndall phenomenon, depending 
largely on the presence of ultramicroscopic 
particles in the air, although the best abso- 
lute test of complete removal of particulate 
matter, is too severe a test of the practical 
hygienic eflBciency of a dust sampling ap- 
paratus. EflBciency tests for such apparatus 
should be made with dusts containing 
particles at least as large as 10 microns 
in diameter, and the most frequent size in 



such test dusts should be 1 micron in diam- 
eter. 

With dusts having particles ranging up 
to 40 microns in diameter, and with an 
average of over 89 per cent, of particles 
under 5 microns in diameter, the Palmer 
apparatus run at 5 cubic feet per minute 
collects representative samples with nearly 
the same size distributions. A five cubic 
foot i>er minute rate is the most eflBcient 
for the Palmer apparatus as originally de- 
signed, and does not carry any water 
through the apparatus. At this rate, it is 
at least 1.33 times as eflBcient as is the new 
design run at the 4 cubic foot per minute 
rate, as was done by Bill and Katz. At the 
5 cubic foot per minute rate the Palmer ap- 
paratus should have an eflBciency of almost 
82 per cent, by weight as compared with 
the Bill electrostatic apparatus. At this 
rate the increase in numerical eflBciency 
and the percentage of smallest sized par- 
ticles are both decidedly greater than at the 
4 cubic foot per minute rate. 

The electrostatic method of dust sam- 
pling as used by Bill would undoubtedly be 
the best method, provided a simple, easily 
manipulated, portable apparatus were de- 
vised. 

The clmnping of minute particles in 
Palmer dust samples as objected to by Bill 
can usually be overcome by suflBcient dilu- 
tion and shaking, which will greatly in- 
crease the niunerical eflBciency of the 
method. At present the Palmer apparatus 
is the most eflBcient practical dust sampling 
apparatus at our dispK)sal for hygienic tests 
in industry. 

The Kotz6 konimeter (10) was not con- 
sidered in the above comparisons because, 
regardless of its absolute eflBciency or its 
efficiency for sampling dangerous sized 
particles, it collects too small a sample over 
too short a period to give an idea of the 
amount of dust to which a laborer is ex- 
posed in his daily work. 



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SMYTH AND ISZARD — EFFICIENCY 0;F PALMER APPARATUS 167 



BIBLIOGRAPHY 



1. Bill, J. P.: The Electrostatic Method of Dust 7. 
Collection as Applied to the Sanitary Analysis 

<rf Air. Jour. Indust. Hyg., ldl»-19«0, 1, 323. 

2. Katz, S. H., Longfellow, E. S., and Fieldner, A. 

C: Efficiency of the Palmer Apparatus for 8. 
Determining Dust in Air. Jour. Indust. Hyo., 
19«a-1921, 2, 167. 

3. Hoffman, F. L.: The Mortality from Respira- 9. 
tory Diseases in the Glass Industry. Jour. 
Indust. Htg., 1920-1921, 2, 1. 

4. Miller, T. G., and Smyth, H. F. : The Dust Haz- 
ard in Certain Industries. Jour. Am. Med. 
Assn., 1918, 70, 599. 

5. Palmer, G. T., Coleman, L. V., and Ward, H. C. : 

A Study of Methods for Determining Air Dusti- 10. 
ness. Am. Jour. Pub. Health, 1916, 6, 1049. 

6. Mavrogordato, A.: Experiments on the Effects 
of Dust Inhalations. Jour. Hyg., 1917, 17, 439. 



Smyth, H. F.: Suggested Modifications of the 
Standard Method for the Study of the Dust 
Content of Air. Am. Jour. Pub. Health, 1918, 8, 
769. 

McCrae, J.: The Ash of Silicotic Lungs. Me- 
moirs of the South African Institute for Medical 
Research, March 3, 1913. 
Watkms-Pitchford, W., and Moir, J.: On the 
Nature of the Doubly-Refracting Particles 
Seen in Microscopic Sections of Silicotic Lungs, 
and an Improved Method for Disclosing Sili- 
ceous Particles in Such Sections. Memoirs of the 
South African Institute for Medical Research, 
Vol. 7, Sept. 14, 1916. 

Fourth Supplementary Report of the Com- 
mittee on Standard Methods for the Examina- 
tion of the Air. Am. Jour. Pub. Health, 1920, 
10, 450. 



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PHYSICAL EDUCATION FROM THE STANDPOINT OF THE 
INDUSTRIAL PHYSICIAN* 

RALPH W. ELLIOTT, M.D. 

Manager, Medical DepaHmeni, National Lamp Works of General Eleetrie Company, Nda Park, CUvdand 



ONE of the chief functions of an indus- 
trial medical clinic is that of a "diag- 
nostic clearing house." Yet, too often, this 
real opportunity for service is lost sight of 
in the routine treatment of trivial cases 
and the dressing of minor injuries. Even 
physical examinations are made in a me- 
thodical manned and the cards filed with- 
out any attempt being made to cull out the 
cases which could be benefited by simple 
hygienic measiu'es. An applicant is re- 
jected or employed with little or no thought 
beyond the fact that he is either fit or unfit. 
Too often he is not even told why he is 
rejected, and as a result he drifts from one 
industry to another imtil he finally gets a 
job in a factory that does not require the 
physical examination of applicants. 

In many of our better organized indus- 
tries, physical examinations are required of 
all applicants for employment. Re-exami- 
nations are made at periodic intervals, at 
least once a year, and more frequently 
if it seems advisable to the examining 
physician or to the foremen or super- 
intendents of departments. Re-examina- 
tion is beneficial to the employer because 
it gives him efficient workers; to the em- 
ployee because it serves to keep him in good 
physical condition; and to the examining 
physician because it gives him valuable 
information as to conditions under which 
certain defectives do well. Very often 
applicants and old employees who are 
manifestly physically below par present 
themselves for examination, and yet it 
would be a simple matter to raise them to 
an average standing of physical fitness if 
a physical education department, thor- 

* Received for publication June 8, 1921. 



oughly organized under efficient leader- 
ship, were available, as it were, to fill the 
prescription of the examining physician. 
I believe that one of the most important 
functions of the present day industrial 
physical training department is to carry 
out, imder the direction of the medical 
department, such measures as may help 
to restore the applicant or the employee 
to normal health. Then, too, there are the 
abnormal cases which require special care 
— persons with defective hearts, those 
with arteriosclerosis and high blood pres- 
sure, those who are greatly overweight or 
imderweight, or those who are poorly 
nourished and whose resistance is mani- 
festly low. We industrial physicians are 
comparatively helpless without someone 
to assist us in the upbuilding of these 
bodies which need individual care rather 
than routine work in gymnasium classes. 
It would be foolish to prescribe the same 
drug in all cases of illness with the thought 
that it would be a cure-all. Is it not equally 
absurd to expect the same form of exercise 
to benefit individuals irrespective of their 
physical defects? The physician and the 
physical director should hold a consulta- 
tion over each individual case in order that 
the physical director may be fully informed 
in regard to the condition which he is to 
try to remedy. Otherwise, a heart only 
slightly involved may be permanently 
damaged, or an overtaxed circulation 
broken down by misdirected eflForts. 

In several industrial institutions groups 
of employees are assembled on a gymna- 
sium floor or an adjacent field and put 
through a series of exercises. Calisthenics 
are a bore to the majority of people, and 



16S 



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ELLIOTT — PHYSICAL EDUCATION 



169 



apparatus work is too difficult or monot- 
onous for the average person to approach 
with any degree of enthusiasm. Glowing 
reports of the success of these group classes 
are received but individually the employees 
say: "We have to do it because the boss 
does. We would rather be playing ball." 
Play! That is the answer — the spirit of 
competition, the elemental desire in each 
heart to excel the other fellow. 

The tendency in some industrial phys- 
ical training departmaits is to develop 
teams very closely verging on professional- 
ism. In many of our industrial leagues the 
sole object seems to be to organize such 
teams for advertising purposes. In fact, 
many ex-professional athletes are given a 
nominal place on the payroll merely so 
that they may participate in athletics. 
This is closely analogous to the old cus- 
tom of hiring professional athletes to at- 
tend college and giving them their tuition 
and board in return for their participation 
in certain forms of athletics. In a recent 
conference a group of men engaged in in- 
dustrial physical training deplored this 
tendency and agreed with the physicians 
present that this should not be the sole 
object of physical training in industry. 
On the other hand, there is the human 
factor that must be considered — that is, 
the reluctance which most of us have to 
engage publicly in a sport in which we real- 
ize that we are not very proficient. We 
would rather sit on the side lines and watch 
others play ball or tennis, or engage in 
field events, than to go in and try them 
ourselves and be laughed at because we 
are "dubs." 

There, I think, is the important problem 
to be solved. How are we to get the bench 
w^armers out on the field? Certainly not 
by encouraging the development of so- 
called professional industrial teams, but 
rather, it seems to me, by the development 
of playground activities. In one factory 
ipvhich I recently visited the building was 



locked during the noon hour and all the 
employees went out of doors as soon as 
they had finished lunch. I saw more people 
playing volley ball at one time in: that 
yard than I have ever, before or since, seen 
playing the game. Besides volley ball 
there were several games of indoor base- 
ball and two games of ordinary baseball 
going on, while over in one corner of the 
yard a number of fellows were pitching 
horseshoes. Nearly everybody was doing 
something and but few were looking on. 
Some, it is true, had left the grounds and 
gone for a walk, but no one returned to the 
factory directly after luncheon. 

A point that should be emphasized as 
essential to the success of outdoor recrea- 
tion is that the playground should be close 
to the factory, preferably on the same lot, 
in order that it may be reached with no 
loss of time and in order that there may 
be a feeling of greater freedom among the 
employees because they are, so to speak,* 
playing in their own back yard. If this 
scheme of playground activities could be 
still further perfected by being organized 
under the direction of a playground leader, 
much more might be accomplished than 
under the present system. 

There is one beneficial result of play- 
ground activities that is permanent; when 
the weather becomes inclement these young 
people, who have become accustomed to 
play for a half or three-quarters of an hoiu* 
during each noon recess, will miss their 
play time and will naturally drift into the 
gynmasium during the winter months. 
The gynmasium, therefore, is in this way 
secondary to the playground, and with 
bowling, basket ball and other indoor 
sports will continue the beneficial habits 
formed by play in the open. One serious 
drawback to gynmasium work, however, 
is that so few can enjoy it at one time, 
and therefore oiu* problem is again to make 
the spectator play. This may be accom- 
plished by providing as means of recreation 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



other amusements which require little or 
no equipment, such as dancing, for which 
only a phonograph is necessary; indoor 
quoits; checkers; and singing, which is 
extremely good breathing exercise. Not 
long ago I heard two or three hundred 
young people sing in a factory dining- 
room after lunch. One of the foremen 
acted as leader and one of the girls ac- 
companied them on the piano. And how 
they did enjoy it! Yes, I sang too, as did 
everyone else. 

Practically all outdoor sports and re- 
creational activities that have been par- 
ticipated in by women and girls are but 
adaptations of sports and games indulged 
in by men and boys. Baseball, for ex- 
ample, is not a natural game for a girl to 
play and very few girls make good ball 
players. The same may possibly be said 
of basket ball. It seems, therefore, that 
there is a large field still open for the 
development of games especially applicable 
to the needs of women. 
. It is not the purpose of this paper to go 
into the great subject of fatigue, nor to 
point out the methods of measuring fa- 
tigue, but we must acknowledge that it 
constitutes the most difficult, problem to 
solve in all industrial relations. Fatigue 
is the most common cause of breakage, of 
wastage, of poor quality of product, of 
accidents, and of lessened production. 
Some writers say that there is no such thing 
as fatigue, that it all resolves itself into an 
antipathy aroused by monotonous occu- 
pation. Manifestly this is not so. How- 
ever we may approach this subject, how- 
ever skeptical we may be from a medical 
standpoint, we do see evidences of fatigue 
among workers. This is especially true 
among those, engaged in piecework in shops 
where there is a long working day. If you 
doubt this, try it yourself. Pick out some 
simple manuf actiuing process that is easy 
to learn and then sit down and do that bit 
of work for foiu* successive hours. Then 



eat a light lunch and go back to work after 
half an hour for another four or five hours. 
As a result you will be very tired, nervous 
or imstrung and, undoubtedly, irritable. 
It has been said that, if fatigue causes a 
net loss of five cents a day to each worker 
in the United States, in a year it will 
an\punt to the stupendous sum of $300,- 
000,000. There must be some remedy for 
fatigue, but it is not a universal remedy 
and therefore cannot be applied as a gen- 
eral rule, but must be adapted to each 
process of manufactiu^ after an exhaus- 
tive study of that particular industry. 

Many processes in industry are in them- 
selves fatiguing either because of the 
monotony of the operation or because of 
the physical effort required to do them well. 
Among the workers engaged in such 
processes there are always some who for 
no apparent reason lag behind in produc- 
tion, especially if they are doing piece- 
work. Sometimes this is so apparent that 
it is manifestly due to some inherent de- 
fect in the technic, too long hours or poor 
hygienic surroundings. Personally, how- 
ever, I believe that it is monotony which 
has this effect, and that in order to over- 
come this and thereby decrease spoilage 
and accidents and increase production it 
is necessary to have recess periods during 
the working hours. No definite rule, how- 
ever, can be laid down for these recesses. 
In office work it is a simple matter. All 
that is necessary is an opportimity to move 
about and if possible, under suitable direc- 
tion, to take some simple relaxing or cor- 
rective exercises with the windows open. 
I have seen this experiment tried out in 
one office, and the manager says that ex- 
ercises are now an accepted part of the • 
day's work. Certain trade imions have 
specified in their agreements with their 
employers that a definite amount of time 
be given each day diu*ing the working 
hours for relaxation. They have found 
this necessary because of the nature of the 



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ELLIOTT — PHYSICAL EDUCATION 



171 



process of manufacture. On the other 
hand, there are a vast majority of workers 
who need these recess periods but who do 
not realize their need, and whose employers 
are also obUvious to this cause of fatigue. 
Physical relaxation and exercise during 
working hours are of great importance and 
should be given careful consideration by 
each plant manager after he has made a 
careful survey of physical conditions of the 
operators and processes, with the aid of 
his medical staff. Conditions vary, and 
remedies must, therefore, be chosen to 
meet existing conditions. 

In the large cities where many workers 
must spend from one horn* to three hours 
each day going to and from the factory, 
the question of games and sports outside 
of working hours must often be limited by 
the time available. It is practically im- 
possible to induce anybody to remain for 
an hour or so after work to take up any 
form of recreational activity. A few may 
stay and play baseball or bowl, but the 
majority choose to go home. They are 
tired and hungry, and they want to get 
out of their working clothes. It is appar- 
ent, therefore, that if exercise out of work- 
ing hoiu's is to be indulged in by the 
majority of workers, it must be arranged 
for in the middle of the day. If the work- 
ing day is eight hours long, there should 
be at least one hour at noon for a light 
luncheon and recreation. Again games 
are the best means of relaxation, but these 
games should be simple; first, in order 
that all may play and, secondly, in order 
that they may be completed in the brief 
time allotted. Naturally, the physical in- 
structor should here become the play- 
ground director, and it is his duty to 
arouse the interest of the bench warmers 
and keep thiilgs moving. 

In all of our industries one encounters the 
sad spectacle of twisted hands and fingers, 
ugly deformities and scars with resulting 
contractions. I believe these are a blot on 



a community, a disgrace to industry and 
a shame to the medical profession. They 
should be eliminated, and they can be by 
co-operation between the physical edu- 
cation department and the medical de- 
partment. But you say that methods for 
the relief of these deformities are expensive, 
that the cost is prohibitive for any one 
factory. True, but why should not com- 
bined industry contribute toward local 
. hospitals and see that a ward or building 
is suitably equipped and maintained for 
the care of this class of patients? Imagine 
the tremendous saving not only of dollars, 
but of thousands of dollars, annually if 
the stiffened fingers and hands could be 
treated and kept limber and functioning. 
After it is too late, after adhesions have 
formed and the need is only too apparent, 
a belated attempt is made to correct the 
impossible. Treatment should follow im- 
mediately upon the surgical procedure; 
the injured fingers should never be allowed 
to become stiffened and contraction should 
never be allowed to occiu*. But it is only 
by individual care and by constant super- 
vision and manipulation of these crippled 
members everyday, sometimes every two 
or three hours, that successful results can 
be obtained. In a certain city of a million 
inhabitants, with 3,000 industries, there is 
not even one well-equipped hospital or dis- 
pensary to handle the vast multitude of such 
cases that present themselves each year. 

Perhaps it is not the f imction of a paper 
of this character to mention the beneficial 
effects of preventative measures applicable 
to club feet, flat feet, and other acquired 
or congenital deformities that are occa- 
sionally seen in industrial clinics, and yet 
we know that many of these conditions 
even could be helped or prevented by 
simple measures similar to those which 
have been mentioned above for the treat- 
ment of occupational deformities. 

The chief criticism that has been made 
of this rather extensive program for phys- 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



ical education is that it would be expen- 
sive to put into operation. It would re- 
quire the services of a man well trained 
in gymnasium and playground activities, 
and would necessitate the installation of 
more or less expensive equipment. There 
is no reason why a beginning, however 
small, could not be made in almost all 
industries. The first requisite is a vacant 
lot. The tendency is for young people to 
play wherever there is a vacant piece of 
property. They may be interested in 
baseball or some other outdoor sport, but 
in any event, they tend to gather together 
and to play something. If somebody can 
be secured to direct them, even though it 
be a volimteer from among their own 
numbers, it will be a beginning which is 
sure to bear fruit in the long rim. I do 
not believe it is the province of industrial 
organizations to try to - reach the high 



standard of equipment which has been in- 
stalled in some places and which is so ela- 
borate that the expense is prohibitive to 
most companies. But at any rate let us 
make a beginning. The workers themselves 
will take care of the rest as the spirit of 
play becomes a part of the routine of their 
day's work. 

The industrial executive has three prob- 
lems always before him — production, 
quaUty, and people. He feels that it is the 
function of the medical department to 
provide him with workers physically able 
to give him the maximimi production, and 
realizes that the quality of output, too, 
is inseparable from good health Mid good 
spirits. The medical department and the 
physical education department cannot fail 
to succeed if they will work together and 
strive to co-operate with executives on the 
one hand, and the workers on the other. 



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INDUSTRIAL HYGIENE 



PUBLISHED MONTHLY 



VoLXTlfE ni 



OCTOBER, 1921 



NincBKB 6 



HEADACHE* 

STANLEY COBB, M.D. 

Assistant Professor of Neuropathology, Harvard Medical School, and Assistant Neurologist, Massachusetts Oeneral Hospital 

AND 

D. C. PARMENTER, M.D. 

Assistant in Industrial Hygiene, Harvard Medical School, and Instructor in Hygiene, Harvard University 



HEADACHE" is certainly one of the 
most frequent complaints among 
industrial workers — any physician work- 
ing in im industrial community knows this 
fact in a general way. This paper is written 
to focus our attention on headache as a 
symptom, and, by giving brief data col- 
lected in factories and department stores, to 
stimulate other workers in the field to make 
more extensive studies. 

In a factory industrial unit employing 
12,000 workers, Mock's (1) analysis of the 
cases of time lost in a year showed that in 
approximately 23 per cent, the complaint 

XABLE 1. — NUMBER OF LOST TIME CASES 

DUE TO HEADACHE AMONG 12,000 

FACTORY WORKERS 



Sex 


No. of Cams of 

Lost Time in 

a Year 


No. of Cues 

Due to 

Headache 


Per Cent. Due 
to Headache 


Male 


M20 
15,244 


1,255 

3,778 


19 


Female 


24 



was headache (Table 1). One of us,t work- 
ing in mercantile industrial units, found 

* Received for publication August IS, 1921. 
t D. C. P. 



that from 10 to 15 per cent, of all employees 
asking for medical attention complained of 
headache. One department store had an 
average of 1,500 employees. Table 2 shows 

TABLE 2. — NUMBER OF CASES OF HEADACHE 
AMONG 1,500 DEPARTMENT STORE EMPLOYEES 



Month 


Total Cases 
Examined 


Headaches 


Number 


Per Cent 


1st 


670 


64 


9.5 


2d 


554 


59 


10.6 


3d 


767 


.65 


8.4 


4tli 


1,000 


145 


14.5 


5th 


775 


84 


10.8 


atii 


685 


69 


10.0 



the number of cases seen each month and 
the number and percentage of these cases 
complaining of headache. In a smaller store 
employing about 800, with a greater num- 
ber of women, a tabulation for four months 
showed even a larger percentage of head- 
aches (Table 3). In both establishments 
more women than men were employed, and 
in the smaller store, where there was a larger 
percentage of female employees, the num- 
ber of headaches was greater. Mock's fig- 
ures also showed that more women com- 



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plained of headache than men, in the ratio 
of 24 to 19. This is probably due to sexual 
differences — f pr example, menstrual diffi- 
culties and * * nervous instability " — al- 
though the contention that women as a 
group are less stable than men cannot be 
shown conspicuously by any statistics with 
which we are famihar. 

Francis A. Brugman (2), in the beginning 
of his recent paper. Etiology of Chronic 
HeadacheSy says that there are so many 
factors entering into the causation of head- 
aches, and so many different ways in which 

TABLE S. — NUMBER OF CASES OF HEADACHE 
AMONG 800 DEPARTMENT STORE EMPLOYEES 



Month 


Total Ca«a 
Examined 


Headadiea 


Number 


Percent. 


1st 
2d 
Sd 
4tll 


651 
502 
541 
601 


100 
73 
80 
85 


15.3 
13.9 
13.7 
10.2 



the pain may present itself, that no particu- 
lar pathological, condition can be said to 
cause any particular kind of headache. He 
further says that some idea may be had of 
the problem confronting the diagnostician 
when one observer has given a list of 160 
conditions which may cause headache. 
Hence only- the more common conditions 
can be referred to here. 

Most authors make painstaking classifi- 
cations of the different forms of headache; 
for example, Brugman's division into reflex^ 
congestive, toxic and neurotic is better than 
most classifications; but in all fairness we 
must admit that we know so little of the 
physiological pathology that to use the 
words, reflex, toxic and neurotic, is simply 
to cover our ignorance of the mechanism 
involved with vague names. Congestion 
we can eiasily demonstrate, for we know 
that a tight collar will cause a headache, 
and we can show in the laboratory that 
pressing on the jugular veins causes cere- 



bral congestion and raises intracranial 
pressure. 

Even though we know little definite 
about etiology, clinical experience has 
clearly indicated certain factors in the 
causation of headache, and additional evi- 
dence has been gained by therapeutic ex- 
periments. Therefore we will classify these 
headaches according to their probable eti- 
ology, considering first those causes which 
were most commonly met with in the de- 
partment stores above mentioned. 

The most frequent cause seems to have 
been the onset of an acute infection^ usually 
of the upper respiratory tract — the com- 
mon "cold" or "grippe." A liberal use of 
the clinical thermometer and a few ques- 
tions will make the recognition of this type 
a simple matter. Constipation was next in 
importance. Here the headache is usually 
dull and diffuse, and the diagnosis is gener- 
ally made from the history. But constipa- 
tion is seldom an isolated cause; it is usually 
associated with poor hygiene — e. gr., lack of 
drinking water and other faults of diet, 
lack of sleep, and work at home as well as 
at the store, all contributing to make a 
picture of general fatigue. Frequently this 
is the forerunner of some incipient disease. 
Anemia may be an important factor. 

This class of headaches, however, cannot 
be sharply divided from the great group 
of psychoneurotic headaches, for faulty 
mental hygiene usually leads to bad physi- 
cal hygiene or vice versa, and a vicious circle 
is easily formed, from which the jmtient 
finds it impossible to escape. Advice as to 
regular habits, followed up by supervision, 
is often all that is necessary to break the 
circle. With the physical condition thus 
improved, the mental symptoms may be- 
come inconspicuous. While no one cause 
can be given in such a case, the combination 
of various circumstances at a given time 
burdens the patient to the breaking point. 
For relief it is not necessary to remove all 
the untoward circumstances, in fact it is 



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COBB AND PARMENTER — HEADACHE 



175 



impossible — for we all carry some burdens, 
physical or mental— but a removal of part of 
the burden will usually allow the patient to 
get rid of the symptoms that are interfering 
with economic efl5ciency and happiness. 

Many cases will be encoimtered, how- 
ever, particulariy in department store 
work, where simple rules of hygiene will do 
little good. These cases can be considered 
psychiatric, and a careful study will elicit 
emotional factors, poor adaptations, dis- 
satisfaction with life, worry, or other en- 
vironmental difficulties. For example, an 
employee may be worrying over decreased 
sales and fear of reprimands by sui>eriors; 
another may be having difficulties in his 
home life, causing emotional instabihty; in 
both cases there is a resulting lafck of energy 
and pK)or physical hygiene, for when our 
spirits are depressed our bodies feel "tired" 
and we do not have the energy to follow a 
healthful routine. The headache is a de- 
fence against irksome effort; the patient is 
unhappy, vaguely dissatisfied, and craves 
attention, pity, relief from monotony. A 
slight headache, which in another indi- 
vidual (or in this patient at another time) 
would cause no disability, is seized on as a 
means of escape from the situation and is 
exaggerated until the patient obtains the 
rehef desired. These mental mechanisms 
are largely subconscious, and to tell such a 
patient that the headache is " imagination *' 
is not only to show gross ignorance of the 
psychology involved, but it is bad thera- 
peutics, since the patient is antagonized 
and can never be led to understand the real 
cause. Success is only obtained by sympa- 
thetic investigation of all the mental fac- 
tors, followed by frank talks in explanation 
of the symptoms. In obtaining the facts 
in these cases, which are usually of a per- 
sonal natiu-e, a well-trained and tactful 
social worker is an invaluable adjunct to 
the medical staff. 

Many psychoneiu-otic headaches are di- 
rectly caused by neiu-omuscular tension. 



Whenever we are over-stimulated, uncon- 
trolled and useless energy is likely to be 
spent by contracting the muscles of our 
neck, face, scalp, or even of our extremities. 
Common examples are seen in the set jaw 
and the drawn face. Such muscular tension 
long continued may set up definite head- 
ache; indeed, it is a common cause since 
the over-stimulation responsible for the 
tension may come either from external 
sources, such as continuous noise, or from 
internal emotional conflicts. Perfectly nor- 
mal people subjected to stress often suffer 
thus, but the supersensitive psychoneurotic 
is much more susceptible. 

In our experience, eyestrain was a fre- 
quent cause of headache. Clarke (3) con- 
siders it by far the commonest (quoting 
Lauder Brunton as saying that 90 per cent, 
of all headaches are due to eyestrain), but 
this would seem to be an exaggerated state- 
ment, unless we accept Charles' (4) theory 
that local eyestrain causes headache only 
when the patient is neurotic. These cases 
then would be classed with the great group 
of psychoneurotic headaches, and would be 
best explained by postulating that most 
normal people have slight feelings of pres- 
sure or other cranial discomfort after eye- 
strain, but that it is only in unstable people 
that this degree of pain amounts to dis- 
ability. By what mechanism eyestrain pro- 
duces headache, we do not know. Many 
elaborate theories have been advanced, the 
most reasonable of which seems to be that 
the effort of accommodating with a refrac- 
tive error, or of converging in spite of a 
muscular imbalance, causes a muscular 
tension analogous to those described above. 
Even this theory gives Uttle clue to the 
actual mechanism involved, although the 
fact that those headaches which are most 
reUeved by glasses ar^ usually frontal or 
orbital suggests that local muscular tension 
may be a factor. 

The last group of headaches which could 
be considered common among these em- 



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ployees was the group arising frovpL infec- 
tions of the nasal sinuses. The pain in these 
cases is intense, and tenderness can usually 
be elicited over the offending sinus. The 
history of rhinitis and examinations by 
transillumination and X-ray will aid in the 
diagnosis. 

Before going on to a discussion of the 
kinds of headaches less frequently^ encoun- 
tered in this group of workers, it would be 
well to discuss a vague but important entity 
— the fatigue headache. This is such a mild 
symptom in most people that it seldom is 
brought to the attention of the physician. 
In psychoneurotic patients it is often the 
central symptom. It is a common experi- 
ence that excessive work will cause a feeling 
of pressure about the head, as if the temple 
were clamped in a vice, or as if an iron band 
were pressing about the forehead. The 
precipitating cause of such discomforts may 
be either physical or mental strain. When 
arising from physical strain, fatigue head- 
ache usually occurs in an individual who is 
not accustomed to labor and who leaves his 
sedentary occupation to take a strenuous 
day in the open air. He feels well all day, 
but goes to bed with a slight headache and 
may wake up the next morning with a se- 
vere one. On the other hand, similar head- 
aches arise from excessive indoor work — 
overtime — especially if the worker stimu- 
lates himself to keep up his task with coffee, 
tea, alcohol, or tobacco. These drugs, of 
course, compUcate the picture, as any one 
of them may cause headache with its own 
toxin. Another thing to be considered is 
the environment in which the person is 
working: Is the room stuffy? Is it noisy .^^ 
Is the light trying to the eyes? In fact, 
are there any stimuli which in an ordinary 
eight-hour day would cause no symptoms, 
but which in excess may be important 
sensory irritants? 

It is our experience that persons who 
have unstable vasomotor systems are the 
ones most affected in this way — i. e., those 



individuals who blush and sweat eaaily, 
whose heart rate and blood pressure vary 
quickly, and who in addition show active 
pupillary and tendon reflexes. Rest in- 
variably brings about relief, or a dose of 
"salts" may more quickly cure. These 
facts, taken with the observation that the 
face is usually flushed and the temporal 
artery conspicuously tortuous and tense 
during the attack, direct our attention to 
the vasomotor mechanism, and make us 
believe that cerebral congestion is the prob- 
able cause. The fact that the administra- 
tion of a hypertonic solution in the form of 
a dose of salts gives quick relief corrob- 
orates this theory, because it is known that 
such solutions quickly reduce intracranial 
tension (5). This explanation seems more 
material than the one frequently given 
that "fatigue toxins" cause the headache, 
but it must be admitted that the physi- 
ological products of fatigue in the sensory 
nervous mechanisms and in the muscles 
may well initiate the vasomotor changes. 

Closely allied to these common but mild 
headaches is migraine. This, unlike many 
headaches, is not merely a symptom, but 
seems to be a clearly defined disease entity 
characterized by periodic paroxysmal at- 
tacks accompanied by nausea or vomiting. 
The disease is strongly inherited, 90 per 
cent, of the cases showing antecedents or 
descendants with the same trouble (6). 
The onset is almost invariably during child- 
hood or youth. Less important symptoms 
are the unilateral distribution of the pain 
in about two-thirds of the cases, and the 
ocular prodromal phenomena in about one- 
fourth. At present there is no accepted ex- 
planation of the symptoms, but the most 
satisfactory theory seems to be that vaso- 
motor changes cause an increase in the bulk 
of the cranial contents, thus putting painful 
tension on the dura. 

Three other common causes of headache 
should be given special mention. In the 
first place, syphilis must be thought of in 



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COBB AND PARMENTER— HEADACHE 



177 



cases where the pain is chronic, and a Was- 
sermann test should always be made on the 
blood; even if this test proves negative a 
lumbar puncture and examination of the 
spinal fluid is advisable whenever the case 
is difficult to diagnose. Secondly, brain 
tumor is much more common than is gener- 
ally supposed and severe headache may be 
the first symptom, vomiting, choked disc 
and neurological signs appearing later. The 
third is rheumatic headache, also called "in- 
durative" or "nodular." This type has 
been well described by Patrick (7) and 
Auerbach (8). The cardinal features are 
persistent headache with fluctuations, us- 
ually in people over 40 years of age, and 
primarily located in the suboccipital region 
but radiating to the neck, shoulders, and 
vertex. Changes in the weather often in- 
crefi^e the pain. Palpation of the scalp 
reveals small tender nodules, and in the 
muscles of the neck indurated areas may 
be felt. During an exacerbation, however, 
the neck muscles are so spastic that nothing 
is palpable. General examination may re- 
veal arthritis, low fever, leukocytosis and 
focal infection usually in the head. Massage 
and heat applied to the head and neck give 
relief — procedures which increase the pain 
in most other forms of headache. 
. It is not pertinent to continue enumerat- 
ing the causes of headache, but having 
drawn attention to those types most fre- 
quently met with, we may summarize with 
the following table, modelled on Table 1 in 
Auerbach's book. 

TABLE 4. — CLASSIFICATION OF THE DIFFER- 
ENT FORMS OF HEADACHE 

A. The More Independent Forms of Headache 

1. Migraine 

2. Fatigue headache 

S. Rheumatic headache 

B. Headaches Assodaied with Diseases of Individual 
Organs 

1. Brain disease (meningitis, encephalitis, tu- 
mor) 

2. Organs of special sense (eyestrain, otitis) 



3. Digestive tract (constipation, hunger, gas- 
tric hyperacidity, jaundice) 

4. Kidney (nephritis) 

5. Vascular (congestion from tight lacing, tight 
collars, lumbar puncture, sunstroke or menstruation; 
hypertension J arteriosclerosis) 

C Headache in General Diseases 

1. Acute infections 

2. Chronic infections (syphilis, paresis, rheuma- 
tism) 

3. Intoxications (alcohol, lead, tobacco, ether, 
carbon monoxide, sulphuretted hydrogen, opium, 
iodoform, iodides) 

4. Constitutional diseases (anemia, diabetes, 
endocrine disorders) 

Z). Psychoneurotic 

E, Combinations of Different Forms 

From the foregoing discussion it is ap- 
parent that the diagnosis of headache is 
far from simple; the examination of the 
patient must, therefore, be painstaking and 
prolonged. It would be impossible to out- 
Une a reasonably complete examination to 
cover all cases, but a brief account of what 
should be done in every case can be sketched, 
leaving to the discretion of the examiner 
the "leads" which are worth while follow- 
ing up by special examinations as indica- 
tions may arise. 

In the first place, a careful history must 
be taken, especially in regard to inheritance, 
exact occupation, home conditions and past 
illnesses. The importance of looking into 
the home conditions, such as family and 
marital relations, ' financial worries, etc., 
cannot be over-emphasized, since the group 
of psychoneurotic headaches depends 
largely on these factors; and psychoneu- 
rosis is one of the most frequent causes of 
the symptom. The history of the present 
illness should be taken in detail in order to 
obtain the facts concerning onset, duration, 
periodicity, and precipitating causes. 

Next, the physical examination is taken 
up, and the organism studied in a thorough 
routine way, with special interest in a neu- 
rological examination which should include: 

I. Cranial nerves, with ophthalmoscopic inspec- 
tion of the fundus 



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2. Motor system, with inspection of muscular 
strength, gait, co-ordination and tremor 

3. Reflexes, especially the knee jerks, ankle jerks 
and abdominals 

4. Sensory system — which can usually be judged 
of by asking about subjective sensation, with quick 
tests of the cornea, pharynx and Romberg's sign 

5. Sjmpathetic system — heart rate and pupil- 
lary reflexes to light and accommodation, with in- 
spection of the skin for flushing and sweating 

6. Endocrine system — thyroid, sex glafids, skele- 
ton, skin texture, and hair distribution 

7. Temperature 

8. Urine analysis 

With a brief outline of this sort posted on 
the oflSce wall, it adds remarkably little to 
the time of examination to note the posi- 
tive findings, and in writing up the exami- 
nation afterwards it is a great aid to have a 
list to remind one of omissions. The spe- 
cial examinations which will be found of 
most value are the Wassermann test; lum- 
bar puncture; ophthalmological examina- 
tion with special reference to visual fields; 
blood counts of red and white cells; X-ray 
of the skull, teeth and sinuses; transillu- 



mination; and stool examination. These 
procedures should be advised freely on the 
slightest indication, for the diagnosis is 
difficult at best and success often comes 
from unexpected sources. 

Summary 

Headache is a common complaint among 
industrial workers, causing in some units 
as much as 23 per cent, of the cases of lost 
time, and an average of 10 to 15 per cent, 
in the mercantile establishments studied 
by us. The causes of headache are many, 
but among the employees whom we ex- 
amined acute infection, constipation, poor 
hygiene, psychoneurosis, and eyestrain, in 
the order named, were the commonest. A 
careful history with interest in personal and 
occupational problems is essential to diag- 
nosis. The physical examination must be 
thorough and orderly, with emphasis on 
neiu-ological findings, but it need not be 
time-consuming if carried out according to 
schedule. 



BIBLIOGRAPHY 



1. Mock, H. £.: Industrial Medicine and Sur- 
gery. Philadelphia, W. B. Saunders Company, 
1920, pp. 403 and 422. 

2. Brugman, F. A.: Etiology of Chronic Head- 
aches. Journal-Lancet, 1920, 2, 516. 

3. Clarke, K.: Notes on the Common Causes of 
Persistent Headache and Their DifiPerential 
Diagnosis. Practitioner, 1919, 102, 274. 

4. Charles, J. W.: Ocular Headache. Jour. Am. 
Med. Assn., 1918, 71, 1711. 



5. Weed, L. H.: Experimental Alteration of Brain 
Bulk. Am. Jour. Physiol., 1919, 48, 531. 

6. Moebius, P. J.: Die Migraine. Wien, Alfred 
H6lder, 1903. 

7. Patrick, H. T.: Indurative Headache. Jour. 
Am. Med. Assn., 1918, 71, 82. 

8. Auerbach, S.: Headache, Its Varieties, Their 
Nature, Recognition and Treatment. London, 
H. Frowde and Hodder and Stoughton, 1913. 



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MEDICAL SUPERVISION IN INDUSTRY 



C. W. J. BRASHER, M.D. 

Bristol, England 



MnjjoNB Sacrificed in Lost Time 

An edacational campaign is now being carried on 
to bring home to the large manufacturing employers 
the value of medical supervision in industry. 

The loss to British industry through diminished 
effort due to indifferent health or actual illness is cal- 
culated at something like £2,000,000 a week. It is 
difficult to credit such a stupendous figure, but that, 
I am assured, is the Industrial Welfare Society's esti- 
mate of the fluctuation of labour thus involved. 

Dr. E. L. Collis, late Director of Welfare and 
Health to the Ministry of Munitions, is not, how- 
ever, dismayed by this figure, for he dedares that by 
proper medical supervision it could be reduced by 
70 per cent. — Evening Standard, London, June 25, 
1921. 

THE above paragraphs are of great in- 
terest and importance at the present 
time when the proportion of the physically 
fit of the male population has been reduced 
to a lower point than at any previous period 
by the ravages of the Great War. We are 
accustomed to think of the law of "con- 
servation of energy" in its narrow physical 
sense, but in hiunan life there is also the 
possibiKty of the conservation of energy in 
industry. In the present world-crisis it be- 
hooves us to do our utmost to prevent 
waste in all directions and especially in the 
direction of conservation of human life, in 
which too httle has been done in the past. 

Although the British government, work- 
ing through the local authorities, has done 
much to promote the effective treatment of 
known cases of tuberculosis, no organized 
effort has been made to prevent persons in 
the early stages of tuberculosis, of heart 
disease, and of epilepsy from entering in- 
dustrial life, and, in the case of tuberculous 
patients, to prevent them from infecting 
their fellow-workers. The system of med- 

* Received for publication July 20, 1921. 



ical supervision described in this communi- 
cation has been in use for twenty-one years 
and has been adopted by a number of large 
employers of labor. It has the advantage of 
being easily carried out, and by careful ex- 
amination of all candidates for factory em- 
ployment many early cases of disease may 
be detected and dealt with before irremedi- 
able damage ha$ been done to a growing 
boy or girl, placed in an unsuitable environ- 
ment. 

It has been objected that, by the applica- 
tion of what may be teimed "recruiting 
methods" to candidates for employment in 
large factories, those who are rejected will 
be driven to seek employment m other 
smaller factories or workshops where con- 
ditions are worse. This argiunent would 
apply equally to all attempts to improve 
the hygienic condition of the industrial 
classes. For example, it may be argued 
that because the hygienic standards of 
large cities have not been enforced hitherto 
by the health authorities of smaller urban 
districts and rural areas, these standards 
should be lowered; or, to take another ex- 
ample, because the Overseas Dominions 
and the United States insist rightly upon 
a rigorous medical examination of all immi- 
grants in order to protect their populations 
from the undesirables of Eiu-opc, that these 
barriers should be lowered lest the undesir- 
able and the imfit be driven back to their 
place of birth. 

In the present day, when the Great War 
has caused the death or disablement of sev- 
eral millions of the most robust of the male 
population, the paramount importance of 
conserving the health of the remaining 
workers by protecting them from infection 
and by finding suitable employment for 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



those who show signs of disease which will 
incapacitate them for factory life in a few 
years, will readily be admitted. 

The examination of the greater part of 
the male population of Great Britain be- 
tween the ages of 18 and 41 by medical re- 
cruiting boards during the Great War re- 
vealed a large amount of disease and of 
physical defects among the industrial 
classes. Dr. Carey Coombs has recently 
stated* that "examination of the war 
office records shows that 10 per cent, of the 
total rejections were for ' V. D. H.' " The 
Prime Minister, in characteristically pic- 
turesque language, said a iew months ago, 
"You cannot run an A I empire with a 
C III population." Although school med- 
ical officers and school clinics have done 
much to improve the physique of cliildren 
in th^ public elementary schools, no such 
supervision is exercised generally after 
these children leave school and enter in- 
dustrial life. If they choose factory em- 
ployment, they are examined prior to entry 
by the certifying factory surgeon, and if he 
passes them as fit for employment they 
may have no further medical exammation 
except on applying to a panel-doctor for 
admission to his panel. The choice of em- 
ployment is usually left to the individual 
boy or girl, guided more or less by their 
parents, and, as Dr. Carey Coombs ob- 
serves, there has been no concerted attempt 
to find suitable employment for patients 
who have suflFered from rheumatism or 
from tuberculosis during school life. Many 
of these patients who have reached adoles- 
cence enter factories and may work for a 
few years before they finally break down. . 

There is no system in general use by 
which employers, managers, and heads of 
workshops can be interested in the detec- 
tion of active or latent disease among their 
employees. The system about to be de- 
scribed was introduced in 1900 in some 

* Coombs, C: British Medical Association Branch 
Meeting, Bristol, March SI, 1921. 



large cocoa and chocolate factories in which 
over 4,000 persons of both sexes are em- 
ployed. All candidates for employment are 
examined, as for life assurance, in regard to 
the condition of their teeth, hair, eyes, ton- 
sils, heart, lungs and vaccination. Any de- 
fects are noted on an index card and the 
applicant is referred for treatment to his 
doctor or sent to a hospital. In the case of a 
girl, the mother attends with the superin- 
tendent, and the importance of treatment 
of any defects, such as carious teeth, defec- 
tive sight, or very enlarged tonsils, is. 
pointed out. It has been found that over 
60 per cent, of girls coming from public 
elementary schools have the nits of pedicu- 
lus capitw in their hair, and in these cases 
the mother is instructed in the method of 
removing them. If the parents are willing 
to have necessary treatment carried out, 
the boy or girl is re-examined after this has 
been done, but in case of refusal to undergo 
treatment, the applicant is rejected. All 
persons with serious heart disease or tuber- 
culosis are consistently rejected. 

In addition to this system of medical ex- 
amination, the forewomen or superintend- 
ents are instructed to bring any girl to the 
medical officer for examination, if they 
think she is out of health. To this end, 
periodical short lectures on infectious dis- 
eases, and particularly on tuberculosis, are 
given to the heads of departments and 
workrooms. If an employee develops 
symptoms of tuberculosis he is suspended 
(at full wages) pending admission to a sana- 
torium or hospital, and on discharge from 
the institution patients are assisted to 
obtain suitable outdoor employment, but 
unless there is evidence of complete arrest 
of the disease after repeated examinations, 
and unless tubercle bacilli have disappeared 
from the sputum, they are not permitted to 
return to the factories. 

The adoption of this system of prelimi- 
nary medical examination and subsequent 
supervision reduced the annual death rate 



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BRASHER — INDUSTRIAL MEDICAL SUPERVISION 



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among over 2,000 women and girls from 
6 jjer cent, to less than 1 per cent.,- and dur- 
ing several years no deaths from any cause 
occurred. Prior to the adoption of medical 
examination and sujjervision, four or five 
employees died annually from tuberculosis, 
and before they became too ill to work these 
patients had inevitably infected others in 
their workrooms as well as in their own 
homes. 

On March 23, 1921, the Minister of 
Health stated in the House of Conmions 
that the deaths from all forms of tuberculo- 
sis during the last six years (1915-1920, 
inclusive) reached a total of 311,017 — i. e., 
an average annual death rate of 14.58 per 
miHe. In other words, the deaths from all 
forms of tuberculosis during these six years 
amounted to 141.88 per diem, and if these 
patients had been collected in one center a 
population approximating that of Bath 
would have disappeared every year. 

Dr. Addison observed that the figures for 
the last two years (46,312 deaths in 1919, 
and 42,505 deaths in 1920) were "the most 
encouraging since the inception of the 
scheme for the treatment of tuberculosis." 
It must, however, be remembered that, 
owing to the war and the subsequent wave 
of commercial prosperity, wages were 
high and unemployment had almost dis- 
appeared. Past experience shows that 
all great wars have been followed by 
commercial depression, with an inevitable 
. increase in unemployment and its concom- 
itants, underfeeding, underclothing, and 
overcrowding in ill-ventilated dwellings. 
There is reason to fear, therefore, that the 
annual death rate from tuberculosis will 
quickly reach, if it does not actually exceed, 
the pre-war figure, unless steps are taken 
speedily to deal more effectively with tu- 
berculous patients among the industrial 
classes. 

It must be admitted that, in spite of all 
that has been done during the last thirty 
years, the annual death rate from tuber- 



culosis is a reproach to civilization. Under 
present conditions the majority of tuber- 
culous patients are permitted to be em- 
ployed in factories and oflSces imtil too ill 
to work. When they seek treatment it is 
found usually that the disease has reached 
so advanced a stage that there is np hope of 
cure, while at the same time they have 
frequently infected other members of their 
families and their fellow- workers. The 
following histories illustrate this point: 

Case 1. — Harry P , aged 54, was chief 

clerk to a firm of engineers. His youjagest child 
(aged 12) died of tuberculous meningitis in 1906. 
Although there was a history of tuberculosis on both 
sides, neither he nor his wife nor their two surviving 
children showed any signs of the disease. In 1910, 
a glerk working opposite him died of pulmonary 
tuberculosis after a short illness. Although suffering 
from a severe cough with profuse expectoration, he 
was permitted to work until within a few weeks of 
his death. In 1912, H. P. developed an extensive in- 
filtration of the upper lobe of the right limg with 
pleurby at the right base. He was sent to a sana- 
torium in the Cotswolds for several months, and was 
then pensioned by his employers. A few months ago 
he was reported to be in good health. 

Case 2. — Wilfrid S , aged 26, was a clerk in 

one of the largest stores in London. When seen, he 
had returned to his honie in Bristol in the last stage 
of pulmonary tuberculosis. He stated that three of 
his fellow-clerks working in one office had died of the 
same disease within two years. 

Case 3. — Rose W , aged 17, worked in a 

chocolate factory. She had been examined on leav- 
ing school two years earlier and remained in good 
health until six weeks before she was brought to the 
medical officer by her mother. She had extensive in- 
filtration of the apices of both lungs with typical 
sputum containing numerous bacilli of bovine type. 
Her mother, who was very distressed, stated that her 
father had died recently after being an inpatient at 
the Bristol General Hospital under Dr. George 
Parker, to whom the writer is indebted for the par- 
ticulars of his patient's last illness. 

The father was a butcher employed at Avon- 
mouth Docks. He came to the hospital with a diffuse 
cellulitis of the palm of the left hand, giving a history 
of having scratched himself when cutting up an ox. 
The hand was freely incised but the cellulitb did not 
subside, and a section of tissue showed giant ceUs 
with numerous tubercle bacilli of bovine type. He 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



quickly developed signs of massive infiltration of 
both lungs and was discharged as incurable. Before 
he could be sent to a sanatorium he committed sui- 
cide, when delirious, by jumping from his bedroom 
window. 

Rose W died within three months of the on- 
set of the disease, and, to complete this tragic family 
historjs her brother (aged 14) died from tuberculous . 
meningitis in the Bristol Royal Infirmary in 1913. 
The only satisfactory point in this case was that al- 
though Rose W 's illness proved fatal, she was 

sent home before any of the other persons in the 
room in which she worked became infected. The 
forewoman was instructed to bring anyone who 
showed suspicious symptoms for immediate exam- 
ination, but no other case occurred. 

Although the detection and segregation 
of tuberculous patients has been empha- 
sized on account of the wide distribution 
and serious results of tuberculosis among 
the population at large, it is obvious that a 
system which has proved successful in re- 
ducing the death rate from tuberculosis in 
a factory population of over 4,000 to less 
than 1 per mille per annum will be also ap- 
plicable to the detection of cases of heart 
disease, epilepsy and other diseases, which, 
while affecting seriously the health and 
earning capacity of the person himself, are 
not direct sources of danger to his fellow- 
workers. The method is capable of wide 
application and development. For ex- 



ample, one company, employing over 
10,000 workpeople, has adopted this system 
and insists on all "recruits" being vacci- 
nated before commencing work in their 
factories and requires, in addition, that 
they sign an agreement to be revaccinated 
at any time that the company may require 
their workpeople to do so. x\lthough it has 
been objected that this constitutes a tech- 
nical "interference with the Uberty of the 
subject," it has materially increased the 
percentage of the effectively vaccinated 
among the civil population of Bristol, and 
has thereby assisted the health department 
in preventing the spread of smallpK)x in 
several recent outbreaks which might have 
been serious among an imperfectly pro- 
tected population. 

In conclusion, it is satisfactory to learn 
that steps are now being taken by the Brit- 
ish government to introduce a system of 
medical supervision in industry. Hitherto 
this matter has been left to the imaided 
efforts of a few far-seeing and enUghtened 
employers, but it may be hoped that when 
the system is adopted on national Unes 
those employers who have not hitherto 
realized the paramount importance of this 
subject will fall into line and aid the propa- 
ganda of the government. 



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THE FRAMINGHAM HEALTH DEMONSTRATION AND 
INDUSTRIAL MEDICINE* 

D. B. ARMSTRONG, M.D. 

Executive Officer, Framingham Community Health and Tuberculosis Demonstration 



THE industrial relationships and con- 
tacts of the Framingham Community 
Health and Tuberculosis Demonstration 
have been extremely important in the de- 
velopment of the Framingham tuberculosis 
program. These industrial factors consti- 
tute the chief consideration of this paper. 
Perhaps a preliminary word, however, with 
reference to the character of the demonstra- 
tion in general may be helpful. 

The Framingham experiment, or demon- 
stration, has now been under way for nearly 
five years, under the auspices of the Na- 
tional Tuberculosis Association, financed 
by a special contribution of from $150,000 
to $200,000' to this association from the 
Metropolitan Life Insurance Company. 
This demonstration has aimed to answer 
certain pertinent questions in the tubercu- 
losis field, such as: How much tuberculosis 
is there .f^ What is the best way to treat it? 
How best can a conununity be organized 
for the eventual control and elimination of 
the disease? Naturally, the demonstration 
has had an intense interest in industry, as 
it is in the industrial age group that the 
highest tuberculosis death rates are usually 
foimd. Certainly, tuberculosis is in part, 
at least, an industrial disease. 

The chief activities of the demonstration 
were briefly: 

1. A general and sanitary survey, in- 
cluding a survey of industrial hazards. 

2. Extensive medical examination cam- 
paigns, covering a large fraction of all age 
groups, including industrial workers. 

* Read before the General Session on Health and Sani- 
tation of the National Safety Council, Tenth Annual 
Safety Congress, Bosrton, Sept. 29, 1921. Received for 
publication Aug. 31, 1921. 



3. An expert consultation service for the 
diagnosis of tuberculosis, offered to private 
physicians, factory medical and nursing 
staffs, etc. 

4. The thorough organization of the 
community itself, not only for tuberculosis 
control but for general health and disease 
preventive work, including the fields of 
general community sanitation, infant hy- 
giene, school hygiene, and industrial hy- 
giene. 

Among the most important results of 
these activities, from the general as well as 
from the special industrial viewpoint, the 
following may be mentioned : 

1. The examination of a representative 
population indicates that about 1 per cent, 
is suffering from active tuberculosis. 

2. A thorough search for tuberculosis 
cases indicates that there are nine or ten 
active cases, in an average community, to 
every annual death from tuberculosis. 

3. Adequate medical machinery in 
schools, factories, and elsewhere is essential 
to the detection of tuberculosis. A full- 
time physician for every 2,500 school- 
children or factory workers is essential. 
The first consistent medical examination 
work of the school population of Framing- 
ham (about 3,000) disclosed eleven cases 
of active tuberculosis and sixty-nine sus- 
picious cases hitherto undetected. The 
establishment of adequate medical ma- 
chinery in the factories increased the per- 
centage of new cases annually discovered 
through factory medical machinery from 
to 27 per cent, over a period of three 
years. 

4. The average community does not re- 
port more than 55 per cent, of its active 



183 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



tuberculosis in an early stage. Framing- 
ham exi>erience has indicated that this 
percentage may be raised to 85. 

5. The percentage of active tuberculosis 
cases receiving institutional care has been 
raised from 13 to 42 per cent. 

6. The total health appropriations from 
both public and private sources have in- 
creased from 40 cents to about $2 per capita 
per year, the latter figure being set as an 
approximate standard for adequate com- 
munity health work. 

7. What will adequate machinery ac- 
complish toward tuberculosis control and 
mortality reduction? Starting with a cor- 
rected tuberculosis mortality rate of 121 
per hundred thousand as the average for 
the ten years preceding the demonstration, 
the rate fell to about one-half of that figure 
(64 per hundred thousand) in 1920, and 
present indications forecast a rate possibly 
in the neighborhood of one-fourth of the 
pre-demonstration rate for the current 
year (1921). This would indicate that the 
same measures, applied throughout the 
United States, would result in a saving of 
nearly 100,000 lives a year. 

To retiu'n to the more important indus- 
trial considerations, it may be stated that 
there are in Framingham, at the outside, 
approximately 5,000 industrial workers. 
By far the largest industry, employing ap- 
proximately one-half of this total, is a 
paper products plant where tags, boxes, 
and crepe paper articles are produced. 
Other industrial interests include carpet 
manufacturing, boiler construction, foun- 
dries, and the manufacture of shoes and 
automobile bodies. 

The demonstration's approach to the 
solution of the tuberculosis problem has 
included two main eflForts: first, a thorough 
survey of the industrial hazards of the com- 
mimity, carried out with the co-operation 
of the Massachusetts Board of Labor and 
Industry, jthe former New York Museum 
of Safety, and the New York State Com- 



mission on Ventilation, followed by an 
eflFort to correct the fundamental dangers 
to industrial workers; and second, an effort 
to encourage the local industries them- 
selves, with necessary co-operation and aid 
at the start, to provide an adequate medi- 
cal, nursing, clinic and dental service and 
personnel for the industrial employees. 

On the side of personnel, when the work 
started there were employed by industries 
in the community one nurse and one part- 
time safety engineer. As a result of the 
co-operation which the industrial plants 
have given the demonstration during the 
past four years, it is now safe to say that 
between 70 and 80 per cent, of the indus- 
trial workers are under reasonably adequate 
medical, nursing and chnic supervision. 
The experience in the largest plant in 
the community, employing approximately 
3,000 workers, is particularly illuminating 
from the point of view of employee interest 
in, enthusiasm for, loyalty to, and sym- 
pathy with the purpose and objectives of 
the medical and niu'sing program. This 
plant now employs a full-time physician 
and two nurses, and maintains an ex- 
cellent clinic and first-aid establishment. 
The plant is organized on an advanced 
democratic profit-sharing and manage- 
ment-sharing basis, with considerable par- 
ticipation in control by employees of 
different grades, through industrial part- 
nership, industrial associates, and shop 
committee devices. 

This relationship between management 
and employees introduces certain novelties 
into the development of medical and nurs- 
ing policies which might have seemed to a 
short-sighted view, in the beginning, to be 
obstacles, but which have, in reality, only 
the more firmly established the foundation 
for the program as a whole. Take, for in- 
stance, the matter of compulsory examina- 
tion of new employees. It was not impos- 
sible to convince the manieigement in this 
plant of the validity of the CTiployment of 



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ARMSTRONG — FRAMINGHAM HEALTH DEMONSTRATION 185 



its medical and nursing machinery for this 
purpose. After the management was con- 
vinced, however, it was then necessary to 
convince the shop committee. Fortunately, 
the expert consultant of the health demon- 
stration, Dr. P. C. Bartlett, has always 
worked in close co-operation with the 
members of the medical department in 
this plant, and, with their help, was able, 
by effective case histories of individuals ill 
with dangerous communicable diseases as 
found in this industry,! to illustrate the 
importance of detecting such affections at 
the time of initial employment. The prin- 
ciple of compulsory examination was ap- 
proved and was put through, with the 
backing of the management and of the 
men. 

The members of the shop committee, 
employees in general, and the management, 
are now enthusiastic over the operation of 
this rule. It was not long after its applica- 
tion that the men themselves were asking: 
"If this is good for new employees, why 
isn't it good for all employees on a regular 
basis?*' In fact, the next step has now 
been taken, apd a system of regular 
periodic medical examinations for all em- 
ployees, graded on the basis of age and 
I>eriod of employment, is now being ex- 
perimented with. 

Two or three other clinics with full-time 
nursing and part-time medical arrange- 
ments — in one instance with compulsory 
examination of new employees — have 
been developed in the commimity, and a 
plan promoted for the provision of a co- 
operative medical and nursing service for 
several of the smaller plants unable to pro- 
vide full-time service for themselves. The 
actual establishment of this service is now 
dependent upon the more extensive revival 
of industrial activities. 

While the Framingham experience has 
been on a relatively small scale, it has, 
nevertheless, been an intensive experience 
and may perhaps be legitimately used to 



suggest certain tentative standards for in- 
dustrial medical work at large. It may 
even be possible to propose certain quan- 
titative as well as qualitative standards. 
For instance, for an industrial unit of 
2,500 people it would seem that there would 
be required at least one full-time physician 
and two full-time nurses, an adequate clinic 
equipment, some provision for dental serv- 
ice and at least part-time arrangements 
for safety. While the work of the medical 
and nursing staff may with advantage be 
organized as a fairly autonomous unit, it 
should, of coiu'se, be very closely related 
to certain other factory interests, such as 
the employment management service, the 
personnel division, the insurance or pension 
department, educational work, and welfare 
or recreation activities. Some of the-|unc- 
tions of the medical and nursing staff would 
be: 

1. The routine operation of the first-aid 
facilities and clinic, including the care for 
minor injuries and ills. 

2. The diagnosis of chronic affections, 
with their reference to outside physicians 
of the individual's own choosing for con- 
tinued treatment. 

3. General health education by means 
of literature, lectures, bulletins, etc. 

4. General safety work, machine guard- 
ing, etc. 

5. General plant sanitation, including 
such matters as ventilation, cleanliness, 
water supply, etc. 

6. Special class instruction, as, for in- 
stance, for groups of girls working on special 
types of machines, for whom group teach- 
ing in personal hygiene may be provided, 
covering such matters as posture, diet, 
clothing, and recreation. 

7. Particular medical advice with refer- 
ence to working and living adjustments for 
department heads and more responsible 
employees in the managerial class — a sort 
of local, intensified life extension service. 

8. The regular examination of all new 



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employees, in co-operation with the em- 
ployment department. 

9. The regular periodic re-examination 
of permanent employees. 

As previously indicated, it is oiu* belief 
that medical and nursing facilities in in- 
dustry can only be used to their full ad- 
vantage if they are developed and operated 
in close co-operation with the labor groups 
concerned. These facilities must be used 
with a primary object of fitting the man to 
the job, and not as a device for the rigid 
elimination of the imfit from industry. It 
must be recognized by all that through the 
adaptation or, possibly, the elimination of 
a few will come the protection of many. It 
is probably unnecessary to say that such 
medical and nursing provision is a legiti- 
mate routine charge upon the industry, is, 
indeed, a thoroughly profitable investment. 



and should not be considered at all as a phi- 
lanthropy which the employer provides for 
his employees. 

Properly organized and promoted, an 
adequate medical and nursing service in 
industry will substantially decrease loss to 
the industry as a result of illness prevented, 
labor turnover reduced, etc. If the indus- 
try is intelligently organized on the basis 
of purix>seful service, with the rational 
fimdamental distribution of authority and 
responsibility, and with the necessary con- 
comitant participation of workers in con- 
trol, the medical service will be as useful as 
any other single device for enhancing the 
loyalty and devotional morale of the entire 
industrial group concerned. Adequate in- 
dustrial medicine is an integral part of any 
decent physical foundation for a righteous 
industrial democracy. 



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STUDY OF ACCIDENT RECORDS IN A TEXTILE MILL* 

PREPARED UNDER THE DIRECTION OP 

AMY HEWE8 

BY 

RUTH FEAR, EDITH GRAVES, MARJORIE LAWRENCE, FLORENCE METZ, AND HELEN F. SMITH 

Students in the Course in Statistics at Mount Holyoke College 



UNTIL about thirty years ago, indus- 
trial accidents were regarded as a 
part of the day's work, and, as such, were 
looked upon as largely inevitable. With 
the growth of the workmen's compensation 
laws in the various countries and states, a 
new mass of material on industrial acci- 
dents has been culled from the records 
which the states required to be kept. 
Through the study of this material the 
waste of accidents has been made apparent 
and the safeguarding of life and limb has 
become an industrial issue. In the words 
of Miss Ida M. Tarbell, accident preven- 
tion has become a "gospel which, defended 
as a sound economic policy, is practiced 
with the whole-heartedness and zeal of a 
religion." 

The development of the idea of preven- 
tion of accidents through a study of records 
in which the imderlying causes might be 
discovered followed the appreciation of 
the magnitude of the waste. Accidents 
are expensive. They mean loss of time, 
idle machinery, and retarded production 
to the employer, as well as time out of 
work, suffering, and hardship to the em- 
ployee. The prevention of accidents has 
become a matter of national interest as is 
evidenced by the organization of the 
National Safety Coimcil, the program of 
which is devoted to the stimulating of 
interest in industrial safety work, and by 
the fact that several states and many of 
the leading cities of the country have 
inaugurated campaigns along the same line. 

In 1884, Germany adopted a compre- 
hensive system of accident compensation 

* Beceived for publication June 11, 1921. 



on a national scale. Since it was the first 
country to adopt such a system, and one 
of the first to require the reporting of hours 
of incidence of accidents, it now furnishes 
the most valuable and complete statistics 
of industrial accidents. The Imperial 
Offices in 1887, 1897, and 1907 published 
valuable reports of specific studies of in- 
dustrial accidents. The United States has 
been much slower in the investigation of 
industrial accidents. Among the earliest 
reports in the field is one published by the 
Wisconsin Bureau of Labor in 1909-1910, 
giving a brief table of accidents distributed 
according to the hours of occurrence. To- 
day records of accidents are kept by prac- 
tically all large establishments, but they 
vary widely in the fullness and care with 
which the information is entered. Ex- 
amples of companies foremost from the 
point of view of the accuracy and care 
with which records are made are the In- 
ternational Harvester Company, Cheney 
Brothers, and the General Electric Com- 
pany. 

Scope of the Study 

The material for the present study was 
obtained from the records of the Cheney 
Brothers Silk Mills in South Manchester, 
Connecticut. This company is deeply in- 
terested in preventive measures, and re- 
gards ^wjcident expense as a part of the 
cost of production. It has a comprehen- 
sive system of recording accidents, and 
requires reports made of every accident, 
no matter how slight. 

The study covers 1,221 accidents which 
occurred during the year 1920. This year 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



was considered to be fairly representative, 
and the fact that the numbers employed 
by the company suffered no marked de- 
crease shows a contrast to the general 
depression which was reflected in many 
other establishments as the year progressed. 
The data were transcribed from the com- 
pany's records to the schedule shown in 
Figure 1. The information, except that 
concerning age, marital condition, and 
number of children, was obtained from the 



Labor Statistics Meeker.* The number of 
accidents is therefore related simply to the 
numbers employed on the date specified. 

Character op Accidents 

It is clear that the manufacture of silk 
does not necessarily carry a hazard of 
serious accident. For the most part, the 
accidents listed in Table 1 were of minor 
importance. The majority were slight cuts, 
abrasions, and bruises; the more serious 



FlOUBE 1 



ACCIDENT REPORT — CHENEY BROS. 



Name ^.. Aob.. 

Occupation 

Date houb day month 

Natube and Extent 

Cause 

SuBOicAL Aid Time with Co. 

Accident Due to 

Cabelessnesb of Injubed Pebson 
Hazard of Trade 
Carelessness of Fellow-Workmen 
Defect in Machinert, Toolb or Premises 

During Necessary Performance of Work 



MARRIED NO. OF DEPENDENT 
aiNGLB CHILDBEN UNDEB 16.. 



YEAR . 



Understands Eno Total Expense 



original records made at the time of the 
occurrence of the accident. The data for 
the additional items were transcribed from 
the records of the employment bureau. 
The number of persons injured appears in 
the summaries as smaller than the number 
of accidents — a fact which should be kept 
in mind in studying the tables which 
follow. The scope of the study <Jid not 
permit obtaining records of number of 
man-hours and the total number of days 
worked for all of the employees, and con- 
sequently it was not possible to present 
accident rates according to the method 
advocated by former Commissioner of 



accidents, such as scalp wounds and frac- 
tures, occurred more rarely. The contrast 
in the percentage of men and women work- 
ers who suffered from the various accidents 
is largely attributable to the different oc- 
cupations requiring the use of different 
tools. In 1921 there were 2,891 men em- 
ployed in the manufacturing operations 
in this factory, of whom 30.0 per cent, 
were injured, and 1,819 women, of whom 
only 19.4 per cent, were injured. The 
higher percentage of accidents to men is 
probably largely due to the fact that in silk 

* This method is described in the Bulletin of the United 
Stotes Bureau of Labor Stotistics, Whole Number 2S4, 
1918, pp. 52-^. 



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HEWES — TEXTILE ACCIDENTS 



189 



manufacture, as in most other industries, 
men are employed in more hazardous oc- 
cupations than women. 

The minor character of the accidents is 
shown in another way in Table 2, which 
gives the amount of time lost through 
accident. There were only ninety-six cases 
reported in which any time was lost, and 
fifty-seven of these incapacitated the 



expense ($807.58) was a compensation 
case following the amputation of an index 
finger injured by a picker stick. 

Table 4 indicates that more than three- 
fourths (79.5 per cent.) of all the accidents 
which occurred in the mill were injuries 
to the hands (including fingers and thumbs) 
and arms. This obviously results from the 
greater exposm-e of these members in 



Ti^LE 1. — NATURE OF ACCIDENTS 








Number of Accidents 


Nature of Accidents 


Total 


To Men 


ToWdmen 




Number 


Per Cent. 


Number 


Per Cent 


Number 


Per Cent. 


Total 


1,221 


100.0 


868 


100.0 


358 


100.0 






Cuts 


288 

196 

175 

188 

91 

77 

68 

62 

85 

25 

21 

10 

10 

7 

7 
6 
5 
4 
8 
48 


19.5 
16.1 
14.8 
11.8 
7.5 
6.8 
5.2 
5.1 
2.9 
2.0 
1.7 
0.8 
0.8 
0.6 
0.6 
0.5 
0.4 
0.8 
0.2 
8.9 


152 

155 

104 

108 

61 

59 

57 

41 

26 

28 

7 

8 

10 

4 

6 

6 

5 

4 

8 

84 


17.5 
17.8 
12.0 
11.9 
7.0 
6.8 
6,6 
4.7 
8.0 
2.6 
0.8 
0.9 
1.2 
0.5 
0.7 
0.7 
0.6 
0.5 
0.8 
8.9 


86 
41 
71 
85 
80 
18 

6 
21 

9 

2 
14 

2 

8 

1 

14 


24.4 


Lacerations 


11^ 


Abrasions 


20.1 


Bruises and abrasions or lacerations 


9.9 


Incisions 


8.5 


Strains and snrains 


5.1 


Foreim bodies in eves 


1.7 


Punctures - 


5.9 


Splinters and slivers 


2.6 


Bums 


0.6 


Infections 


4.0 


&*]>otpllP4 • 


0.6 


Fractures 




Blisters 


0.9 


Swellings 


0.2 


Inflammations ,,.,,, 




Scab) wounds 




Abscesses 




Hernia 




Miscellaneous 


8.9 







worker for less than two weeks. In 945 
cases, or 77.4 per cent, of the total, there 
was no loss of time. The majority of acci- 
dents studied were of minor importance 
from a financial standpoint as well as from 
the point of view of the amount of time 
lost (Table 3). In the case of nearly one- 
half (581) of the whole number of accidents, 
no financial outlay or compensation was 
reported. More than one-third (38.9 per 
cent.) of the 640 involving expense 
amounted to less than $5, and nearly two- 
thirds (65.6 per cent.) to less than $10. 
The case which resulted in the maximum 



operating the tools and machines. When 
one considers that the weaver's hands may 
at any moment come in contact with the 
knife of the loom and the picker stick, 
that agility is required of a doflFer to keep 
from injuring his hands in changing the 
bobbins, and that many times a day a 
knife must be used to clean the silk waste 
from a bobbin, it is not surprising that 
the hands and arms bear the brunt of the 
injuries. The number of accidents to the 
eyes is large, but is explained by the fact 
that even a tiny particle of dust lodging 
there was reported as an accident, though 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



TABLE 2. — LENGTH OF TIME LOST 
BECAUSE OF ACCIDENTS 



TABLE S. — EXPENSE OF ACCIDENTS 



nmeLort 


Number of 
Accidents 


Total 


1,221 




No time lost 








945 


Less than 1 \ 


(reek 

Ql< 






29 


Lesstha 
1 day . . 


day. 




2 




4 


2 days 


7 


S days 


7 


4 days 


2 


5 days 


6 


6 days . . 


1 


1 week and 


less 

a 
u 
u 
a 
a 
u 
u 
u 
a 
u 
u 
u 
u 
a 
a 
u 
a 
a 


thai 

« 

a 
tt 

u 
u 

u 
a 
tt 
u 
u 
u 
u 
u 
u 
tt 
u 
tt 


i 2 


28 


2 « « 


S 


9 


3 a « 


4 


9 


4 a « 


5 


4 


5 a « 


6 


s 


g « « 


7 


4 


7 ** '« 


8 


s 


g « a 


9; 





^ a « 


10 


2 


10 " " 


11 





11 " " 


12 


1 


1« ** « 


13 


1 


IS « " 


14 





14 « « 


15 


1 


15 « " 


16 





16 « « 


17 





17 « « 


18 


1 


Ig « a 


19 





19 " ** 


20 


1 


Not reported 




180 



it may have occasioned discomfort for a 
few moments only. 

Cause and Responsibility 

A large proportion of the accidents oc- 
curred in connection with the use of ma- 
chinery, a fact which is a natural conse- 
quence of the extensive employment of 
machinery in textile industries. More than 
one-third (36.0 per cent.) of the accidents 
were so classified (Table 5). Hand tools, 
including such instruments as knives, 
scissors and hooks, were responsible for 
one-fifth of the whole ^number, but it 
should be remembered that the majority 





Ezpenac 


in Dollars 


Acadents 




Number 


Per Cent. 


Tc 


tal.. 






640 


100.0 










1 and 


lessl 
tt 

u 
tt 
tt 
tt 
tt 
tt 
tt 
tt 

over 


than 

tt 

tt 
tt 
tt 
tt 
tt 
tt 
tt 
tt 


5 


249 

171 

75 

40 

20 

17 

7 

12 

4 

5 

40 


38.9 


5 « 


10 


. 26.7 


10 « 
15 ** 


15 

20 


11.7 
6.3 


20 « 


25 


3.1 


25 « 


30 


2.6 


30 « 


35 


1.1 


35 " 


40 


1.9 


40 « 


45 


0.6 


45 « 


50 


0.8 


50 and 




6.3 











of these were slight injuries. This is also 
true of the remainder of the accidents, 
many of which were not hazards pecuhar 
to the manufacture of silk. 

In Table 6 the accidents are shown classi- 
fied as they were reported in the factory 
record according to the responsibility for 
their occurrence. Two-thirds of the acci- 
dents (67.1 per cent.) were attributed to 
hazard of irade^ and include such accidents 
as injuries to the hands incurred while 
putting belts on rollers, cutting the hands 
when working with reed wires, or contact 
with moving bobbins. The carelessness of 

TABLE 4. — PART OF BODY INJURED 



Location of Injury 



Injuries 



Total 

Hands 

Fingers 

Thumbs 

Palms and backs 

Anns 

Head and face 

Eyes 

Other 

Feet 

Torso 

Legs 

Shoulders 

Miscellaneous 




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HEWES — TEXTILE ACCIDENTS 



19r 



the injured person was the source of a 
second large group (24.7 per cent.). In 
order to show the full extent of individual 
responsibility as a factor, there must be 
added to the above the cases caused by 
the carelessness of the fellow-worker and 
the cases in which carelessness, together 
with defective machinery, was responsible, 
making a total of 335 cases, or 27.5 per 

TABLE 5. — CAUSES OF ACCIDENTS 



Cause 

Total Accidents 

Machinery 

Tools 

Falling, tripping, and slipping . . 

Slivers, nails, tin, etc 

Lifting and moving 

Flying particles 

Rolling and falling bodies 

Collisions with stationary bodies 

Materials 

Liquids '. 

Glass 

Miscellaneous 

Not reported 



Per Cent 




cent. There is often disagreement as to 
whether carelessness has actually been 
shown. In the above case the judgment 
taken was that of the foreman reporting at 
the time of the accident. The large number 
of accidents due to these causes indicates 
roughly the extent to which the accidents 
might be prevented by the education of 
the worker in the importance of safety 
methods. 

Time of Occurrence 

Practically all studies of accidents have 
shown a marked clustering in the latter 
part of the morning and afternoon periods. 
In the accidents grouped according to hour 
of occurrence, in Table 7 and Figure 2, 
peaks occiured between 10 and 11 o'clock 
in the morning, and between 3 and 4 in 
the afternoon. Similar peaks have usually 



been attributed to the fatigue of the worker 
which brings with it increased hazard in 
the worker's failing alertness. In the 
present instance, an explanation, which 
has not been hitherto emphasized in the 
literature of fatigue, was suggested by an 
official of the company and commeAded 
itself to the writers as an extremely 
reasonable one. He said: 

The facts are that the foremen are so rushed with 
supervisory duties in the early hours of the morning 
and afternoon, and the employees are so bent upon 
getting their work started and well in hand, that 
the minor accidents, which constitute a very large 
proportion of the whole, do not get attention until 
the breathing spell comes, about half past ten and 
half past three. 

In the last hoiu*s of both periods fewer 
accidents occurred. A similar recovery has 
been noted in other accident studies and 
is attributed by Miss Josephine Gold- 

TABLE 6. — RESPONSIBILITY FOR ACCIDENTS 



Reqx>iuibility for AcddenU 



Per Cent 



Total 

Hazard of trade 

Carelessness of injured person 

Defect in machinery 

Carelessness of fellow-workman 

Defect in premises 

Carelessness of injured person and de- 
fect in machinery, tools, or premises . 

Carelessness of injured person and of 
fellow-workman 

Defect in tools 

Not reported 



100.0 




mark* to the decreased number at work 
during the last hours and to the fact that 
the worker, having reached a high point of 
fatigue, imconsciously slows down in the 
last hour and in this way decreases the 
risk. Anticipation of the coming rest 
period has also been suggested as a cause 
of decrease in the number of accidents 

* Goldmark, J. : Fatigue and Efficiency. New York, 
Russell Sage Foundation, 1912, pp. 77, 78. 



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during the last hour of work. Conversely, 
the large number of accidents at the peak 
hoiu-s has been attributed to the fact that 
as the work progresses the employee be- 
comes more accustomed to it and works 
at a higher speed, and when this high 
speed is attained, the increased repetition 
of an act gives increased opportimity for 
accident. A slightly different point of 
view was held at the Cheney Mill, where 
the rapid falling off toward noon and 4 
o'clock was attributed to the imwilling- 
ness of the workers to take time off just 
before they were going home. This, and 
"not any psychological state of mind or 
condition of fatigue," was advanced as 
the cause of the character of the ciu^es 
noted. 

The accident risk does not appear so 
great in the first and last horn's of the 

•eci4«nt« 
«80 



TABLE 7. — OCCURRENCE OF ACCIDENTS BY 
HOURS 



Hour 


AcddeoU 


Number 


Per Cent 


Total 


1,221 


100.0 






7- 8 A.M 


48 
102 
184 
154 
118 

15 

90 
123 
130 
107 

15 

7 

183 


3.8 


8- 9 


8.4 


9-10 


11.0 


10-11 


12.6 


11-12 


9.3 


12— 1 Lunch Hour 


1.2 


1- 2 p.M 


7.4 


2-3 


10.1 


3- 4 


'10.6 


4-5 


8.8 


5- 6 


1.2 


6 and after 


0.6 


Not reported 


15.0 








'A.n. 



Fig. 2.- 



flli» 

- Occurrence of acdde&ts by hours. 

morning and afternoon because it is usu- 
ally not possible to make allowance in the 
first hour for the number who are late, 
and in the last hour for the employees 
who usually spend the last few minutes 
In getting ready to go home and who are, 
consequently, not exposed. The first hour 



of the afternoon has a higher percentage 

than the first hour of the morning, which 

may be partly due to the 

fact that the fatigue is 

then greater. 

In a similar investiga- 
tion* of accidents in 
textile mills covering the 
calendar years 1918 and 
1919, the peak hours were ' 
found to be 9 in the 
morning and 3 in the 
afternoon. The author 
suggests that regularly 
recurring psychological 
and physiological cycles, 
such as mid-morning and 
mid-afternoon drowsiness 
as a consequence of eat- 
ing, may also be impor- 
tant factors, as well as 
the increased risk with 
the higher speed following the low mental 
period. 

A marked variation in the number of 
accidents on diflFerent days of the week is 
probably accounted for as much by out- 

* Gates, D. S.: A Statistical Study of Accidents in the 
Cotton Mills, Print Works, and Worsted MiUs of a Textile 



F.ML 



Company. Jour. Indust. Hyg., 1920-1921, 2, 287. 



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HEWES — TEXTILE ACCIDENTS 



193 



Vuaiber ct 

aeci dents 

300 



side factors causing fluctuation of the 
attention as by diflfering degrees of fatigue. 
In a study of the accidents in th^ Bur- 
roughs Adding Machine factory for the 
years 1919 and 1920, the distiu-bing eflFect 
of pay day is stressed. 

In the year 1919 the factory day force was paid 
Saturday 'noon and the night force Friday evening; 
consequently, it is found that more accidents re- 
sulted on Fridays and Saturdays than on any other 
day of the week. In 1920, pay day was so arranged 
that certain sections of the factory were paid on 
different days of the week; a lowering of accidents 
per day was at once noticed.* 

In the present study, Monday, Wednes- 
day and Friday stand out as days when 
more accidents occurred. (Table 8 and 
Figure 3.) The high percentage on Mon- 
day may be occasioned by the fact that it 
is difficult to settle down 
to the routine of work 
after the Saturday after- 
noon and Sunday break. 
Possibly the Wednesday 
peak is to be attributed 
to the facts that Tuesday 
is pay day and the stores 
in the town are open on 
Tuesday night.* The 
sequence is repeated on 
Thursday and Friday. It 
is reasonable to assume 
that many of the workers 
go out on Thursday eve- 
nings since that is the 
night for the change of 
feature at the moving 
pictures. After Friday 
the drop in the Saturday 
accident rate is not so 
great as the drop from 
the high rates of Monday and Wednesday, 
when the fact that Satm-day is only a 
half-day is allowed for. Saturday morning 
is a period of anticipation of Saturday 

* Stote fd Mind the Largest Contributor to Safety. 
Burroughs Magazine* Apjil, 1921, p. 5. 



TABLE 8.— OCCURRENCE OF ACCIDENTS 
BY DAYS 



Days 



AocideiiU 



Total... 

Monday. . . . 

Tuesday 

Wednesday. . 
Thursday . . . 

Friday 

Saturday ^ . . 

Sunday 

Not reported 




1 Saturday is a half-day. 

afternoon good times; the worker's mind 
is occupied partly with plans for th^ after- 
noon and is not wholly devoted to his 
work. Another cause for the accumula- 




FiG. 8. — Occurrence of accidents by days. The dotted line is carried to a 
pomt which indicates twice the numJber of accidents which actually occurred^ 
since Saturday is a half-holiday. 



tion of accidents near the end of the week 
is probably the haste of the pieceworkers, 
in their attempt to catch up after "taking 
it easy*' at the beginning of the week. In 
their haste they are liable to become care- 
less and are subject to a greater accident 



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risk. Added to these causes is the cumu- 
lative fatigue of the week's work. 

Age and Sex of Injuked Person 

The findings of this study show clearly 
that age is an important factor in the 
accident rate. The employees imder 20 
years of age met with a larger proportion 
of accidents than did those in any other 



than one injury is ignored in the table 
itself. The strikingly larger proportion of 
men than women amoiig the injured, 
already noted, holds for almost every age 
group. 

Table 9 shows not only the high accident 
rate for the younger employees, and especi- 
ally the younger men, but also the signifi- 
cant fact that the decrease of risk with 
increasing age is to some extent regular^ 



TABLE 9. — ACCIDENT EXPOSURE BY AGE AND SEX 





All Employees 


Men 


Women 




Number! 


Acadrats 


Number 


AcddenU 


Number 


Accidents 


Age of Injured 


Number 


Rate per 

100 
Workers 


Number 


^ISo^ 

Workers 


Number 


^1^00^ 
Workers 


Total 


4,710 


1,221 


25.9 


2,891 


868 


30.0 


1,819" 


353 


19.4 






Ijtss than 15 


85 
671 
772 
768 
681 
5S8 
884 
305 
241 
157 
114 

54 


13 

288 

216 

161 

136 

120 

78 

64 

41 

29 

12 

6 

57 


37.1 
42.9 
27.9 
21.1 
19.9 
22.5 
20.3 
20.9 
17.0 
18.4 
10.5 
11.1 


7 
305 
393 
474 
458 
343 
257 
211 
182 
122 
92 
47 


8 

181 

145 

113 

109 

98 

66 

47 

29 

24 

10 

5 

83 


114.3 
59.3 
36.9 
23.8 
23.8 
28.6 
25.7 
22.3 
15.9 
19.7 
10.9 
10.6 


28 

366 

379 

289 

223 

190 

127 

94 

59 

35 

22 

7 


5 

107 

71 

48 

27 

22 

12 

17 

12 

5 

2 

1 

24 


17.9 


15 and less than iO 


29.2 


20 " " " 25 


18.7 


25 " " " 30.... 


16.6 


80 " ** " 85 


12.1 


85 ** " " 40 


11.6 


40 ** " " 45 


9.4 


45 ** ** " 50 


18.1 


50 « « « 55 


20.8 


55 « ** « 60 


14.8 


60 " " " 65 


9.1 


65 and over 


14.3 


Not rcDorted 









1 Number of persons employed January 1, IMO. 



age groups — a fact which supports the 
statements in the study of textile accidents 
made by Mr. Donald S. Gates, referred 
to above, to the effect that the younger 
employees (in the latter instance those 18 
years of age) were subject to the greatest 
accident risk. 

Table 9 and Figure 4 show the age dis- 
tribution of the injured persons and the 
relationship of the number of injuries in- 
curred by employees of the various age 
groups to the total numbers of those ages 
employed. It must be remembered that 
the accident figures used in this table refer 
to the number of accidents^ and the fact 
that numbers of individtuds suflteyed more 



with the exception of the fact that the 
employees from 30 to 35 years fared better 
than their fellow-employees who w^re 
slightly older. The numbers of employees 
who were past middle age were so small 
that no attempt can be made to interpret 
the figures which pertain to them. 

The peculiar susceptibility of young 
people to accidents is probably due to a 
combination of influences, of which in- 
experience and unfamiharity with the 
work and the necessary precautions, care- 
lessness and a form of bravado, lack of 
attention and concentration due to lack 
of training, as well as possible greater 
exposure to the objective dangers of their 



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HEWES — TEXTILE ACCIDENTS 



195 



per 100 employed 
SO 



40 



trades play a part. For the most part, the 
accidents to the younger persons were not 
disabling. 

An examination of the individual records 
also showed that the yomig people tended 
to encounter more than one injury to a 
greater degree than did older persons. 
Approximately one-half 
(47.2 per cent.) of the 212 
persons who had more 
than one accident were 
between 14 end 25 years 
old, though this group 
constituted less than one- 
third (31.4 per cent.) of 
the whole number of em- 
ployees. The individual 
who had the maximum 
number of accidents dur- 
ing the year — eleven — • 
was also a member of this 
younger group. The fact 
that the majority of the ac- 
cidents were of small con- 
sequence prevented the 
experience from having 
much of the quality of a 
warning which would teach 
more caution next time. 

The study offers evidence to prove that 
a carefid system of reporting accidents and 
immediate care of injuries are effective 
factors in a program of accident preven- 
tion. There is little room for doubting that 
the practice of giving prompt attention to 
even the slightest injiu*ies is one of the 
best reasons why so few accidents at 
the Cheney plant entailed serious conse- 
quences. It is safe to say that treatment 



of an insignificant cut has many times 
prevented serious infection. 

Accident rates in many states have been 
reduced by laws compelling the guarding 
of machines, but the passing of state laws 
can do little to eliminate human , careless- 
ness. In the study of accidents made at 



IT 



>5 



^ ts Jo 35 io ti 

Me inyeere 

Fig. 4. — Accidents according to age. 



the BiuTOUghs Adding Machine factory it 
was contended that "state of mind*' was 
the largest contributor to safety. Since 
evidence of carelessness is particularly 
marked in the workers under 20 at the 
Cheney plant, it becomes apparent that 
special attention should be directed to the 
younger workers and perhaps particularly 
to the young men in a campaign for the 
further prevention of industrial accidents. 



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BOOKS RECEIVED 

Books received are acknowledged in this column, and such acknowledgment must be regarded as a 
sufficient return for the courtesy of the sender. Selections will be made for review in the interests of our 
readers and as space permits. 



Goyemment Control and Operation of Industry 
in Great Britain and the United States During the 
World War. By Charles Whiting Baker, C.E. 
Carnegie Endowment for International Peace. Pre- 
liminary Economic Studies of the\ War, No. 18. 
Edited by David Kinley, Professor of Political 
Economy, University of Illinois; Member of Com- 
mittee of Research of the Endowment. Paper. Pp. 
138 with index. New York: Oxford University Press, 
1921. 

Goyemment War Contracts. By J. Franklin 
CrowelJ, Ph.D., LL.D. Carnegie Endowment for 
International Peace. Preliminary Economic Studies 
of the War, No. 25. Edited by David Kinley, Pro- 
fessor of Political Economy, University of Illinois; 
Member of Committee of Research of the Endow- 
ment. Paper. Pp. 357 with index. New York: Ox- 
ford University Press, 1920. 

The Control of Sex Infections. By J. Bayard 
Clark, M.D., Fellow of the New Ywk Academy of 
Medicine; Fellow of the American College of Sur- 
geons; Member of American Urological Association; 
American Association Genito Urinary Surgeons; 
International Surgical Society; Sometime Major 
Medical Corps U. S. Army, etc. Cloth. First Edi- 
tion. Pp. 132 without index. New York: The Mac- 
millan Company, 1921. 



Neryes and the Man. A Popular Psychological 
and Constructive Study of Nervous Breakdown. By 
W. Charles Loosmore, M.A., Brown Scholar at Glas- 
gow University. Cloth. Pp. 223 with index. New 
York: George H. Doran Company, 1921. 

Epidemic Respiratory Disease. The Pneu- 
monias and Other Infections of the Respiratory 
Tract Accompanying Influenza and Measles. By 
Eugene L. Opie, M.D., Colonef, M.R.C., U. S. Army; 
Professor of Path<Jogy, Washington University 
School of Medicine; and Francis G. Blake, M.D., 
Major, M.R.C., U. S. Army; Associate Member of 
the Rockefeller Institute for Medical Research; and 
James C. Small, M.D., Formerly First Lieutenant* 
M.C., U. S. Army; Bacteriologist, Philadelphia Gen- 
eral Hospital; and Thomas M. Rivers, M.D., For- 
merly First Lieutenant, M.C., U. S. Army; Associate 
in Bacteriology, Johns Hopkins University. Cloth. 
First Edition. Pp. 402 with illustrations, index, and 
appendix. St. Louis: C. V. Mosby Company, 1921. 

Henley's Twentieth Century Formulas^ Recipes 
and Processes. Containing Ten Thousand Selected 
Household and Workshop Formulas, Recipes, Proc- 
esses and Money Saving Methods for the Practical 
Use of Manufacturers, Mechanics, Housekeepers and 
Home Workers. Edited by Gardner D. Hiscox, M.E. 
Cloth. 1921 Edition, Revised and Enlarged. Pp. 
807 with index. New York: The Norman W. Henley 
Publishing Company, 1921. 



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INDUSTRIAL HYGIENE 



PUBLISHED MONTHLY 



Volume HI 



NOVEMBER, 1921 



NUMBEB 7 



WHEN ARE DISABILITIES OF THE BACK ARISING OUT OF 
PATHOLOGICAL CONDITIONS REPORTABLE ACCIDENTS?* 

' RUFUS B. CRAm, M.D.. and BENJAMIN J. SLATER, B.S., M.D. 

Medical Department, Eastman Kodak Company , Rochester, N. Y. 



OF all the problems that confront 
the mdustrial surgeon there is none 
more diflScult to handle than the famiUar 
"strained back." Osgood (1), in his article 
read before the meeting of industrial sur- 
geons at Atlantic City in June, 1919, has 
shown a very proper conception of the 
I)erplexity of the situation, and his article 
represents as good a medical resume of the 
subject as may be found. 

Almost every day the industrial surgeon 
is consulted by a workman who says, "I 
believe I have strained my back." Broadly 
speaking, such cases fall into two groups, 
the first of which is composed of strains 
which date from a definite experience, such 
as a slip or a fall, or the lifting of some un- 
usually heavy object. These cases usually 
conform to our conception of what is meant 
by an accident as set forth by the Work- 
men's Compensation Law of New York 
State. When a workman is able to point 
to a particular trauma at a certain time of 
the day, which is unusual and not a part of 
his routine work, there is no problem in- 
volved. The case is always reportable, pro- 
vided there is loss of time or more than 
first-aid treatment. The second class, how- 

* Received for publication Sept. 1, 1921. 



ever, is far more numerous and difficult to 
handle. Cases in this group differ from 
those in the first in that they are referable 
to no definite time or unusual experience. 
The workman presents himself foi an ex- 
amination complaining of "lumbago" or 
"rheumatism," with or without some rise 
in temperature. His usual statement is, 
"Doc, I believe I have strained myself lift- 
ing boxes in Department X." 

"When did it happen?" 

"Two or three weeks ago, I can't say 
exactly when." 

"Did anything unusual happen?" 

"No^ I was simply stooping over (or 
lifting some boxes) and felt no pain at the 
time." 

"When did the pain develop?" 

"It came on today." 

Further questioning will generally reveal 
the fact that the workman was doing his 
regular work in a routine manner without 
the occurrence of a single incident which 
might be thought to be apart from the ordi- 
nary routine of his work. We have found 
that the onset in this particular type of 
case is not so dramatic as that in class one." 
The consequences, however, may be, and 
frequently are, quite as serious. It was 



197 



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formerly our custom to report all of these 
cases as accidents. They have, however, 
become so serious and so numerous, and 
have shown such a large variety of etio- 
logical factors, when carefully studied, that 
we now hesitate before reporting them as 
accidents. Fortunately, under the existing 
state compensation law we are permitted 
ten days in which to report an accident, and 
it is during this time that we investigate 
through the workman's department the 
circumstances attending the disability and 
make a thorough medical examination of 
the case, including X-ray examination, 
Wassermann, and a thorough physical ex- 
amination. 

It is our opinion that of this latter type 
of case each has developed from some focus 
of infection. Only occasionally have we 
been unable to demonstrate such a focus. 
Certainly, nine cases out of ten are, in our 
opinion, not reportable accidents within 
the mejining of the workmen's compensa- 
tion law. The most common causes in this 
group of cases have been thought to be 
faulty posture, infected teeth or tonsils, 
syphilis, tuberculosis, weak feet, etc. In- 
deed, it is really surprising to find the num- 
ber of cases of chronic disease which are 
encountered, in which a workman feels that 
his condition is due to some slight injury, 
and it is in the handling of these chronic 
diseases that we are confronted with our 
most serious problems. Often the only com- 
plaint which a workman will have is a 
strained back, and upon thorough exami- 
nation some other condition will be dis- 
covered. It is not uncommon to hear a 
workman say, "I have not been so well 
since I was hurt," when he is really siiflfer- 
ing from advanced tuberculosis, syphilis, 
or some other chronic disease. A great 
many workmen are entirely unfamiliar 
with the workmen's comi>ensation law and 
regard themselves as victims of an acci- 
dent without any consideration of what is 
really wrong with them, or of the manner 



in which their disability has developed. 
The following three cases taken from a 
much larger group are illustrative of the 
pK>ints imder discussion : 

Case 1. — L. H., female, 37 years of age, and 
weighing 140 pounds, at 3 p.m. on April 6, 1918, in 
the course of her ordinary employment, reached to 
pick up from a basket placed on the floor a small 
object weighing about S ounces. This was a part of 
her routine work. On this particular occasion, she 
felt something slip in her back, became unable to 
move her right leg, and three or four days later be- 
came almost completely disabled. She did not slip 
or fall, and there appeared to be nothing unusual 
about the manner in which her disability developed. 
The case was reported as a right sacro-iliac strain, 
and the woman was referred to a specialist who ap- 
plied a cast and, later, a brace. Her case dragged 
along for two years, during the greater part of which 
period she did not work. In her particular case, it 
seemed as though there was some malingering, inas- 
much as she was often seen to walk in a perfectly 
normal manner, whereas, before the Industrial Com- 
mission, she would appear almost a complete invalid. 
A contest was raised, after two years, that an acci- 
dent was never sustained. The Industrial Com- 
mission closed the case on the ground that there was 
no accident. 

The interesting feature, which this case 
illustrates, is that an employee may de- 
velop a disabled condition of the back 
which is not a reportable accident and 
should not be reported as such. 

Case 2. — E. M., male, 46 years of age, and 
weighing 186 pounds, on December 12, 1918, leaned 
forward in the course of his ordinary employment 
and lifted from one stall to another a jar of liquid 
weighing about 50 pounds. The vertical lift was 
2 feet, and the horizontal, about 1^ feet. He had 
been performing this particular operation for many 
years, but on this particular occasion was seized with 
a terrific pain in the region of the right sacro-iliac 
joint, became incapacitated, and was taken home. 
There is no record, in this case, of the man's having 
slipped or fallen, or of his having been struck. He 
was apparently performing a routine operation in a 
routine way. His case was reported as a sacro-iliac 
strain. During the course of treatment by a spe- 
cialist, he developed a phlegmasia alba dol^ois and, 
later, cystitis and varicose ulcers of the right leg. 
He has drawn compensation at intervab since the 
period of injury. While the final award has not he&i 



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GRAIN AND SLATER— BACK STRAINS AS REPORTABLE ACCIDENTS 199 



made in this case, it is easy to see that the amount 
involved is very considerable, and it is difficult to 
understand how this can be called an accident even 
though it was so ruled by the Industrial Commission. 

This case differs from that of L. H. in 
only one respect, namely, that the weights 
lifted were diflferent. Nevertheless, very 
considerable compensation has been paid 
and the case is still on the- calendar. It is 
not micommon to have three or four such 
cases a month — cases in which there is a 
sudden seizure in the region of the sacro- 
iliac joints with disabiUty for a short time. 
It is not often, however, that cases are as 
prolonged as was the case of E. M., but 
they are occasionally seen. The third case 
is somewhat diflferent from the two which 
we have already described. 

Case 3. — G. A., male, 36 years old, weighing 
146 pounds, was reported to have Sustained an acci- 
dent at 4 p. M. on January 4, 19^1 in the following 
manner. Previous to the accident he was trans- 
ferred from inside machine work to the yard. The 
weather was rather severe and at this particular time 
there were high winds. On the day mentioned, 
while he, with three other men, was using a crowbar 
to roll a heavy pipe into place, he felt a sudden pain 
below the angle of the left scapula. He was pulling 
rather hard at the crowbar, but was not using his 
full strength nor working harder or in a more strained 
position than his assistants. On the following day 
he did not report for work, and on visiting his home 
we found that his temperature was 102°, and his 
pulse 106. He was perspiring profusely. His tem- 
perature gradually came down and in three weeks 
he came back to work. The only local physical sign 
was tenderness in the angle of the scapula. There 
was no redness and no swelling. Motion of the right 
arm was limited but only in so far as the scapular 
action was brought into play. It was evident that, 
this was not altoge^er an accident, but just how 
much of the syndrome was accident and how much 
disease, is very difficult to say. The patient de- 
manded a diagnosis, and when he was informed that 
it was "lumbago" he remarked, "Doc, I cannot 
coUect on an accident policy for that." The case 
was r^K>rted as an accident and so carried by the 
Industrial Commission even though we felt that 
disease played perhaps the most prominent r6le. 

In this case we have a disabled back due 
to an acute febrile condition. In all proba- 



bility the strain was nothing more than a 
coincidence, yet this case was reported as 
an accident. During certain seasons of the 
year, mostly in the spring and autumn 
when there are frequent changes in the 
weather, we have "crops" of cases similar 
to the last two. Following an abrupt 
change in the weather from warmer to 
colder we are always certain to find such 
cases. 

In each of the three cases cited, the em- 
ployee felt that he was hurt and was willing 
to hold the employer responsible. Indeed, 
there appears to be a growing tendency on 
the part of employees to hold the employer 
responsible for all manner of cases. 

A review of BuUetm 272 of the U. S. 
Bureau of Labor Statistics (2), covering 
compensation cases in various states of the 
United States and in Canada, shows the 
greatest diversity of opinion in parallel 
cases as to what constitutes an accident, 
and how and when subsequent disease or 
death may be considered a result of acci- 
dent. The tendency seems to be gradually 
to broaden the classification of conditions 
for which compensation may be paid. Out 
of the confusion which has arisen, as to 
what are really reportable injuries, we 
have adopted the following rule of action: 
As soon as possible after the injury, real or 
imaginary, we fill in a blank similar to the 
questionnaire shown in Figure 1. This will 
tell exactly what happened, and it will later 
be found of very great value to have re- 
corded the exact statement of what actually 
happened as given by the employee at the 
very earliest moment following examina- 
tion by the doctor. Lacking this clear, 
definite statement from the patient, the 
industrial physician will find himself at a 
very great disadvantage when presenting 
the case before the Industrial Commis- 
sion. The borderline between accident and 
disease is so indefinitely drawn that, when 
a contest is arranged and the employee has 
been instructed by his attorney, he may 



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easily, intentionally or unintentionally, by 
inserting a few simple words such ^as 
"slipped" or "fell," change the entire 
complexion of the case. 

It seems highly desirable that the em- 
ployer, before assuming responsibility for 
the many questionable injuries, should 



instance of G. A. {idde supra). Because of 
the fact that the physician who has done 
much industrial work will not care to go 
frequently before the Commission to testify, 
it is not desirable to hold too paany hear- 
ings, since they tend to break down the 
close co-operation which should exist be- 



FlGUBE 1 

QUESTIONNAIRE REGARDING INJURY 

Name 

Address Dept 

How long with company? When did accident occur? 

What happened? : 



What were you actually doing when the accident occurred? 



Is this your regular work? 

Did you slip or fall, or were you struck? 

If you lifted an object, what was the weight? 

Did you have any assistance? 

Witnesses to accident 



Did anything unusual happen which you believe caused this injury?.. 



Whom do you blame? 

Have you ever had any injuries or accidents before? ... 

Did you report accident to anyone? 

Date 

request a hearing before the Industrial 
Commission in order to determine the re- 
sponsibility in the particular case in ques- 
tion. This is a long, tedious and tiresome 
method, and one which we seldom employ 
because of the fact that it tends to destroy 
the. confidence of the patient in the phy- 
sician if there is any contest before treat- 
ment is undertaken. 

The nature of the case often makes it 
diflBcult or impossible to request a hearing 
before the Industrial Commission, as in the 



M.D. 



tween a physician and his patient. There 
. is also a great deal of diflBculty due to the 
fact that it may take weeks or months for 
the Commission to arrive at a decision after 
the case has been given a hearing. During 
this time the patient is without treatment 
unless the employer wishes to assume re- 
sponsibility before the decision is made. If 
he adopts this method, it really oflFsets the 
purpose of having a hearing. 

In answer to the question, "When are 
disabiUties of the b^ck arising out of patho- 



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GRAIN AND SLATER— BACK STRAINS AS REPORTABLE ACCIDENTS 201 



logical conditions called reportable acci- 
dents?" we are frank to admit that in 
many instances we are unable to decide. 
It is oilr belief, however, that many cases 
now ref)orted as accidents need not be so 
carried. We feel that, by the application 
of the methods already outlined, we have 
been able to diminish the jiumber of re- 
portable cases. • Inasmuch as in this state 
the power of determining what is an acci- 
dent lies in the hands of the Industrial 
Commission, the logical thing to do seems 
to be to bring the case early to the atten- 
tion of the Commission and ask for a de- 
cision. The physician who has at hand a 
careful detailed record of the events attend- 
ing the so-called "accident," together with 
his physical findings, will always be in a 
better position to furnish satisfactory testi- 
mony before the Commission than the 
physicians who fail to have such a record. 
When an employee has gone on record as 
having stated that the disabiUty developed 
in this or that way, he is not so apt to 
change his mind later, especially if he 
knows that his physician has a typewritten 
sheet at hand on which is contained the 
statement which he made at the time of 
injury. It is only reasonable to feel that 
such a statement must have some weight 
before the Commission, in view of the fact 
that it was taken at the time of the injury. 
Before reporting any borderline cases, 
however, it is of greatest benefit to have a 
thorough physical examination and labora- 
tory study of the case. As pointed out 
above, these studies will frequently reveal 
some chronic condition as the underlying 
cause of the disability. It is much more 



satisfactory and conclusive to have at 
hand the information which these studies 
bring to light, than to report a borderline 
case to the Commission as an accident and 
be compelled to furnish such information 
at a later date. 

•Under the existing compensation law in 
New York State, the employer will gradu- 
ally be compelled to have a complete physi- 
cal survey of all new employees. There 
would be many fewer deaths from syphiUs 
aggravated by back injury if there were 
more routine Wassermann tests; X-ray 
studies of the chest would help to reveal 
pulmonary tuberculosis; and urine exami- 
nations would disclose diabetes and ne- 
phritis. These chronic diseases contribute 
to the greatest number of death claims in 
our experience. Each one, we believe, 
could have been avoided if our preliminary 
entrance examination had been sufficiently 
thorough, and often enough repeated. 

If the employer will, by job analysis, 
inform the medical department what is 
expected from a new employee, and will 
supply the department with adequate per- 
sonnel, laboratories and other facilities, he 
may hope to cut down the number of death 
claims and borderline back injuries. In 
this way only can he succeed in reducing 
these cases to a minimum. Laboratory 
examinations can necessarily be done more 
cheaply and more ^ectively in great num- 
bers of cases than they can be done by a 
physician working on an individual case. 
It is in such work as this that the industrial 
physician can make his greatest contribu- 
tion to the employer, the employee, and 
the community. 



BIBLIOGRAPHY 



Osgood, R. B. : Back Strain — An Accident or 
a Disease. Proc. Fourth Ann. Meeting Am. 
Assn. Indust. Physicians and Surgeons, June 9, 
1919, p. 88. 



2. Clark, L. D., and Frincke, M. C, Jr.: Work- 
men's Compensation Legislation of the United 
States and Canada. U. S. Bur. Labor Statis., 
Bull. 272, Jan., 1921, pp. 106-1S5. 



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PICRIC ACID IN INDUSTRIAL SURGERY* 

ALFRED G. BOLDUC, M.D. 

Company Physician, The Babcock <fe Wilcox Company, Bayonne, N. J, 



PICRIC acid, CeHs (N02)3 (OH), or 
trinitrophenol, is an odorless substitu- 
tion product* of phenol, and occurs in light 
yellow crystals or needles. Heretofore, it 
has had very limited use in the practice of 
medicine, being chiefly employed in a 1 
per cent, aqueous solution as a dressing for 
superficial burns, for erysipelas, and as an 
anthelmintic. During the World War, 
however, the British Army Medical Corps 
(1) used a 5 per cent, solution of picric 
acid in 95 per cent, alcohol as an antisep- 
tic in open wounds and for preparing the 
skin preceding minor and major operations, 
and had very gratifying results. \ 

. During the last two years I have treated 
approximately 4,000 cases of minor cuts, 
severe lacerations, punctured wounds, com- 
pound fractures (principally of the bones of 
the hands and feet) and other cases com- 
mon in an industrial plant, and have used 
as the antiseptic, in all these cases, a 5 per 
cent, solution of picric acid in 95 per cent, 
alcohol. In fact, I have entirely discarded 
tincture of iodine. Practically all wounds 
that were sutured healed by primary in-* 
tention and without infection, and better 
results were obtained with the use of picric 
acid in cuts and lacerations than were 
formerly obtained with the use of iodine. 
The wound, as a rule, remains clean and 
heals more quickly. From my experience, 
I think that I am justified in saying that 
picric acid (5 per cent.) can be applied to 
any part of the body, excepting the eye, 
without any untoward results. It can be 
used as an antiseptic for any condition for 
which iodine is used, and with better re- 
sults. It is less irritating to the skin than 
iodine; it has mild anesthetic qualities; 

* Received for publication Aug. 17, 1921. 



it is staple; it is less toxic; and last, but 
not of least importance, it is comparatively 
cheap. 

It has been demonstrated that the pene- 
trating power of picric acid on the skin is 
about the same as that of other germicides, 
i. e.y it penetrates only as far as the stratum 
comeum. The tanning qualities of picric 
acid are an important factor in the treat- 
ment of wounds. Pedicles of tanned skin 
form over areas which are painted with it, 
and in this tanned area are emmeshed the 
bacteria, which are prevented from enter- 
ing the wound and spreading over the ad- 
jacent area of skin. This is theoretical, of 
course, but the principle is sound and plau- 
sible. The main fact is that in the cases 
mentioned above picric acid was an efficient 
antiseptic. 

I have prepared the skin preceding minor 
op>erations with the alcoholic 5 per cent, 
picric acid, and have seen very few cases 
of infection. In at least one large New 
York hospital (2) picric acid is used ex- 
clusively in preparing the skin preceding 
major operations. Gauze saturated with 
a 5 per cent, aqueous solution of picric acid 
has the advantage over sterile gauze in 
that it is ^.ntiseptic and cp^n be made abso- 
lutely sterile by live steam sterilization. 
If the gauze is then allowed to dry, an ideal 
surgical dressing results. 

There is, however, one great objection to 
picric acid which should be mentioned 
here — namely, the tenacity with which 
the stain clings to the skin. I have as yet 
found no reagent that will entirely remove 
it from the skin, although it is easily re- 
moved from clothing and dressings by 
simply washing them in water. As picric 
acid in the crystal state is highly inflam- 



202 



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BOLDUC — PICRIC ACID IN INDUSTRIAL SURGERY 



203 



mable, care must be taken to keep it away 
from open flames. 

In conclusion, I wish to give the follow- 
ing list of the advantages of picric acid over 
iodine and other similar antiseptics, as ob- 
served in my clinical experience and as 
substantiated by laboratory findings: 

1 . Its comparative cheapness 

2. Its mild anesthetic qualities 

3. Its stability 



4. The fact that it does not irritate the 
parts to which it is applied 

5. Its non- toxic qualities (even when 
used in large ajnounts over extensive 
areas) 

6. Its power of hastening healing, the 
wound resulting in a smooth cicatrix 

7. The fact that it can be applied to any 
part of the body, excepting the eye, with 
absolute safety. 



BIBLIOGRAPHY 



1. Fair, C. E.: Picric Acid in Operative Surgery. 
Ann. Surg., 1921, 73, 13. 



Ochsner, A. J.: General Surgery. Vol. 
Chicago, The Year Book Publishers, 1920. 



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SUGGESTIONS FOR CUSPIDORS IN INDUSTRIAL PLANTS^ 

H. F. SMYTH, M.D.. Db.P.H. 

Assistant Professor of Industrial Hygiene, School of Hygiene, University of Pennsylvania 



WHILE attending the recent annual 
meeting of the National Association 
of Industrial Physicians and Surgeons the 
author was asked by an industrial phy- 
sician for a large rolling mill if he could 
give him any suggestion for solving the 
problem of cuspidor location in the mill. 
There seems to be no suitable place for the 
ordinary metal cuspidor; it is always get- 
ting in the men's way and becoming bat- 
tered and banged beyond usefulness, or 
being upset and its contents spilled. If 
no cuspidors are provided, however, the 
workmen are constantly expectorating pro- 
miscuously on the roUing floor or in ac- 
cumulations of dirt and dust, and the 
partially dried sputum, if it contains infec- 
tious micro-organisms, becomes a menace 
in the form of dust. As the suggestion 
given by the author seemed to the plant 
physician to be a practical solution of this 
problem, it is given here in the hope that 
it may be of service to others and adapt- 
able in other industrial locations. 

The suggestion made was to have the or- 
dinary trumpet-mouthed metal cuspidor or 
a modified two-piece fiber cuspidor set in 
a concrete pit (Figures 1, 2 and S) so that 
its top is level with the floor and conse-' 
quently does not offer an obstruction to the 
worker nor get in the way of working ma- 
terials or tools. A location can certainly be 
found for the placing of such pits not too 
far from the place of work and yet where 
the open mouth of the cuspidor will not 
offer an accident hazard to the worker's 
heel or toe. If this cannot be done, the top 
of the opening may be covered with a 
coarse grating which can be swabbed off 
periodically with a disinfectant. 

* Received for publication July 22, 1921. 



The opening for the cuspidor should be 
in the center of a S-foot circular or square 
steel or concrete plate which should be kept 
free from dust or clutter and should be 
swabbed off daily when the cuspidors are 
removed for cleaning. Removal of the cus- 
pidors for cleaning can be conveniently and 




Fig. 1. — Cross section of metal cuspidor in concrete pit. 




Fig. 2. — Top, view of Figure 1. 

safely accomplished, without touching any 
contaminated surface, with the use of ex- 
panding metal tongs. If a two-piece fiber 
cuspidor is used, the flare top must extend 
s^v'eral inches beyond the sides of the bowl 
so as to give a surface to engage the edges 
of the pit. 

For many other shop locations the same 
idea can be used of having a stationary, per- 
manent location for a cuspidor so placed as 
to be free from any danger of upsetting or 
denting. Where feasible, the cuspidors can 
be sunk in a raised concrete block just a few 



204 



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SMYTH — CUSPIDORS IN INDUSTRIAL PLANTS 



205 



inches larger in diameter than the opening 
for the cuspidor, or possibly, better still, the 
cuspidor can rest in an iron ring attached to 
the side of a press, lathe, or other machine. 
(See Figure 4.) 

Where many cuspidors are used in a large 
plant, the question of a safe and eflBcient 
means of cleaning them is not an unim- 
portant one. Cuspidors should contain a 
small amount of liquid, preferably some 
cheap disinfectant as lysol, creolin, or other 
cresol preparation. They should be col- 
lected daily, if much used, and should be 
thoroughly cleaned before replacing. In a 
large plant, a hand truck Can be provided 
to carry clean cuspidors and remove soiled 
ones for cleaning. This truck may also 
' have a place for a jar of disinfectant with 
a swab for cleaning the surface surrounding 
the pits and the gratings, when these are 
necessary. Cuspidors can be easily and 
simply sterilized by inverting over a steam 
jet such as is used in many dairy farms for 
steriUzing large milk shipping cans. They 
may be placed over hoppers draining into 
the sewage system. 

In some instances the removable cuspi- 



■ dor may be dispensed with entirely and re- 
placed by metal or concrete funnels set in 
the floor and draining into the sewage sys- 




FiG. 3. — Two-piece fiber cuspidor in its pit. 




Fig. 4. — Strap iron ring to be bolted to machine as' 
support for metal cuspidor. 



tem or into sand pits. The funnel should be 
swabbed out regularly and thoroughly with 
disinfectant solution. 

The accompanying drawings may, per- 
haps, give a clearer idea than the text of 
some of the suggestions made above. 



.4 w 







SPRAY INFECTION* 

S. R. DOUGLAS and LEONARD HILL 

{From the National Institute for Medical Research^ Hampgtead^ London) 



IN the crowding together of human beings 
in factories, public conveyances, restau- 
rants, cinemas, etc., one of the factors that 
tells against health is massive infection 
with organisms sprayed out from the 
mouth and nose by the carriers of patho- 
genic germs. In the open air such infection 
is neghgible and good ventilation and 
proper spacing out can largely mitigate 
the massiveness of infection in places where 
people congregate indoors. The following 
research has been directed toward finding 
out how certain conditions aflfect the mas- 
siveness of spray infection. 

I. The Effect of Humidity of 
THE Air 

Trillat and Mallein (1) compared the 
influence of humidity and dryness of the 
air on the duration of the suspension of a 
spray of microbes by spraying into bell 
glasses 4 eg. of an emulsion of microbes. 



tion of the culture medium which coated 
the dishes. Their figures show a greater 
number of colonies in air with 60 per cent, 
humidity than in dry air, a much greater 
number in supersaturated air, and a still 
greater number in air sprayed with some 
food substance, such as bouillon. They 
suggest that the microbes grow and mul- 
tiply in the droplets of bouillon when sus- 
pended in air. The method is obviously 
open to error, as there is no .guarantee 
that the spray in each bell glass is of the 
same order and distribution. We have 
failed to confirm their results in the case 
of relatively humid and dry air. 

The method which we employed in our 
experiments was as follows: Two bell 
glasses were selected of equal size and with 
a ground flat edge at the bottom, and a 
tubulure at the top. The edges were vase- 
lined and brought into apposition, and 
the nozzle of a spray inserted through one 
of the tubulures (Fig. 1). The bell glasses 





Fig. 1. — Diagram showing the two bell glasses held in apposition horizontally, and nozzle of spray inserted 

through one of the tubulures. 



the emulsion being made by diluting 1 eg. 
of a solid culture with 50 c.c. of water. 
Petri dishes were ejtposed after three and 
ten, or fifteen and twenty minutes, and the 
number of colonies counted after incuba- 

* Received for publication July 5, 1921. 



were placed in a horizontal position. Three 
strokes of the spraying pump were then 
made and the tubulure closed. The two 
bell glasses, now held in apposition verti- 
cally, were inverted four times at intervals 
of thirty seconds, so as to mix the suspen- 



206 



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DOUGLAS AND HILL — SPRAY INFECTION 



207 



sion equally. They were then gently sep- 
arated and each one placed on a glass 
plate (Fig. 2) for transport, and then over 
the central orifice in the cover of one of 
the two chambers in which the Petri 
dishes were exposed (Fig. 3). These 
chambers were cylindrical and made of 
glazed earthenware. The Petri dishes were 




u=£\ 



I 
I 

I 



bi. 



I 



Fig.' 2. — Bell glass on a plate ready for transport. 

placed on a stand about 6 inches from the 
bottom of the chamber. The covers of the 
cylinders were glass and their apposition 
secured to the flat-topped edge by vaseline. 
A central circular orifice cut in the glass 
cover was closed by another glass plate 
curved on one side to fit the edge of the 
bell glass and so arranged that it could be 
pushed aside when the bell glass was sl'd 
into position. To the cover of each Petri 
dish was aflBxed a lump of hard wax to 
which a string was attached. The strings 
passed through pinholes in the glass cover 
closed by plasticine, so that by pulling on 
the strings the lids of the Petri dishes were 
raised and the culture medium exposed. 
One of the diambers was dried by a cur- 



rent of dry air, and basins of sulphuric 
acid and phosphorous pentoxide were 
placed on the floor in order to keep the air 
dry. In the other chamber which had been 
kept closed with a basin of water on the 
floor, the air was damp. 

In the first experiment of this kind plates 
were exposed for two, five, and ten minutes 
after the bell glasses had been put in posi- 
tion. The result was that crowded colo- 
nies developed all over the plates in both 
the wet and the dry chambers In the 
next experiment we exposed the plates 
for two minutes at times shown in Table 1, 
with the result that the difference between 
the wet and dry chambers was found to 
be insignificant. The temperature of the 
chambers was 13^C. and the relative hu- 
midity of one 90 per cent., of the other 44 
per cent., taken by wet and ^y bulbs in- 
troduced 9.t the end of the observation. 

II. The Effect of Cold 

Trillat and Mallein found that mice were 
much more readily infected when placed 
in a cold chamber and exposed for from 
one to three minutes to a suspension of 
the infecting microbes, than was the case 
when the chamber was warm. Moreover, 
they carried out the following experiment: 

A chamber A of 50 liters' capacity was 
connected to a chamber B of 20 liters' 
capacity by a tube 10 m. long and 2 cm. 
in diameter. Into A the spray of microbes 
was made; in B mice were placed. If B 
were cooled the mice became infected, but 
no infection occurred if B were kept at 
the same temperature or warmer than A. 
Obviously the infection was due to con- 
densation by cold of the air in fi, and con- 
sequent drawing of the infected air from 
A into B. 

We spread a microbic spray uniformly 
through two bell glasses A and B as in our 
previous experiment, and, after separating 
them, placed them on glass plates so that 



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208 



THE JOURNAL OF INDUSTRIAL HYGIENE 



they could be carried about without dis- 
tiu-bmg the contained spray. Bell glass A 
was then placed over the perforated cover 





Fig. 3. — Diagram showing bell glass placed over the orifice in the cover of 
a chamber in which Petri dishes containing culture media are exposed. 

of a chamber which had been placed in 
the hot room at S7.5®C. some hours pre- 
viously, while B was placed over a chamber 
in the cold room at 3°C. Table 2 gives the 



results. We suggest that more microbes 
became at once aflSxed by the cold walls, 
together with the moisture which was con- 
densed out, but the few organisms which 
escaped contact with the walls continued 
to float for a long time. 

To test the suggestion of Trillat and 
Mallein in regard to condensation, we 
twined an iron wire in a series of bands 
round the outside of each of several test 
tubes, which were then sterilized inside 
paper covers. Some of the tubes were then 
filled with water at body temperature, and 
some with iced water, and after the paper 
covers had been removed 
were placed on a stand 
near the bottom of the 
chamber. A microbic 
spray was then made in 
a bell glass as before, and 
the spray allowed to 
settle from this into the 
chamber. After exposure 
for five minutes, a piece 
of wire was cut from each 
test tube and dropped 
into melted agar medium, 
and this, being shaken 
with the wire, was floated 
out into Petri dishes. 
Figures 4 and 5 show the 
difference in the results; 
many less colonies grew 
from the warm wires than 
from the cold wires. 

In order to obtain a 

more exact idea of the 

difference in the number 

of organisms settling on 

the warm and cold wires, 

the following method was 

employed: After the 

tubes had been exposed, 

the wires were carefully removed with sterile 

forceps and dropped into a known volume 

(20 c.c.) of broth. The broth containing the 

wire was then thoroughly shaken so as to 



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DOUGLAS AND HILL — SPRAY INFECTION 



209 



loosen the organisms from the wire and dis- 
tribute them in the broth. Measured quan- 
tities of the broth were then added to melted 
agar which, after thorough mixing, was 
poured into Petri dishes. These plates were 
incubated at S7°C. and the colonies were 

TABLE 1.- RESULT OF EXPOSURE OF PLATES 
IN WET AND DRY CHAMBERS 



DiyAir 


Humid Air 


Eiponre after 


No. of Colonies 


Exporare after 


No. of Colonies 


hom 




hours 




1 


17 


1 


33 


i 


S 


2 


11 


8 


5 


8 


5 


4 





4 


1 


5 





5 





6 2 


6 


1 



counted after forty-eight hours. Taking 
the average of several experiments, the 
number of organisms (staphylococcus) 
found in a cubic centimeter of the broth, 
after it had been shaken with the wire, was 
29 per c.c. in the case of the warm wire, and 
120 per c.c. in the. case of the chilled wire. 
It seems probable, then, that on coming 

TABLE 2. — RESULT OF EXPOSURE OF PLATES 
IN WARM AND COLD AIR 



Warm Air 


CoUAir 




No. of Colonies 


Exposure after 


No. of Colonies 


AoMff 




hours 






400 


1 


26 




20 


2 


6 


3 





3 


2 


4 





4 


3 




1 


5 


3 







6 






into a crowded, warm room on a frosty 
day, hair, moustache, clothes, etc., will, 
owing to their lower temperature, affix 
microbes upon their surfaces in greater 
numbers than would be the case if the 
temperature were higher. Thus, too, Tril- 
Ut's mice may have been more massively 
infected in the cold chamber. 



The effect of a cold surface on suspended 
particles is shown in the following experi- 
ment: We took a glass tube S cm. in 
diameter and 1 m. long and inserted into 
either end of it a short U-tube through 




Pig. 4. — Number of colonies growing from warm wires 
after five minutes* exposure to microbic spray. 




Pig. 5. — Colonies growing from cold wires after five 
minutes* exposure to microbic spray. 

which circulated in one case iced water, 
and in the other case water at body temp- 
eratm^e. We then drew tobacco smoke 
through the tube so as to fill it with a cloud 
of smoke from end to end. We found the 
smoke cleared round the end fitted with 
the cold U-tube and particularly round the 



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end of this tube, leaving a space as shown 
in Figure 6. Smoke eddies could also be 
seen at this place. At the end fitted with 
the test tube containing warm water no 
change appeared. The condensation of 
moisture of the air by the cold surface 
leads to many more particles, such as 
smoke and microbes, coming in contact 




Fig. 6. — The smoke-free space at the end of the U- 
tube shows the eflFect of the cold surface of the U-tubc on 
the suspended particles of smoke. 

with the surface, and they become fixed 
thereon, whether because they are carry- 
ing an opposite electrical charge, or other- 
wise, we cannot say. 

m. The Effect of a Current of 

Saturated or Dusty Air on 

Transport of Microbes 

Trillat and Mallein state that either 
water-saturated or dusty air carries away 
from the surface of a culture many more 
organisms than does dry air. This state- 



ment we have confirmed. Dry air from a 
compressed air cylinder was passed over 
a culture of staphylococcus, which grew 
along the floor of a tube A placed horizon- 
tally. In sequence to this tube was another 
tube B lined with sterilized agar culture 
medium. Air flowed through the two 
tubes for two and one-half minutes at the 
rate of 10 liters per minute. Only one or 
two colonies grew subsequently in B. The 
experiment was repeated, but this time 
with air first bubbled through warm water 
to saturate it. Some of the water condensed 
in B; this was grossly infected. 

In a third experiment, the dry air passed 
through a bottle in which some dry sterile 
talc was shaken to make a dust. Many 
more colonies ajppeared in B under these 
conditions than when dry air alone was 
passed over the culture. In a fourth ex- 
periment, saturated and dusty air was 
passed over the culture and this caused 
gross infection in B. We conclude, there- 
fore, that particles of water or dust in 
moving air on hitting infected surfaces 
carry away the microbes from these sur- 
faces and in this manner help to spread 
infection. 

IV. Experiments Made to Investigate 

THE Effects of Ventilation in Rooms 

Massively Infected with a Spray 

OF Culture 

We made a spray in an empty room 
(21 by 16i by 13^ feet) heated by steam 
radiators, and exposing Petri dishes, usu- 
ally five for each observation, compared 
the number of colonies formed, first, when 
the room was comfortably ventilated by 
open windows so that it felt fresh, and 
secondly, when the windows were all shut 
and the room felt close. 

Seven and a half c.c. of a broth culture 
of a coliform bacillus (from a rabbit's in- 
testine), diluted 1 in 5, were sprayed 
across the blast from a fan directed toward 



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DOUGLAS AND HILL — SPRAY INFECTION 



211 



TABLE s. — AVERAGE NUMBER OF COLONIES closely; the average number of t^olonies 
RESULTING FROM EXPOSURE IN FRESH being shown in Table 3. The area of cul- 
AND CLOSE ROOMS ^^^ media exposed was very nearly equal. 

Figures 7, 8, and 9 are from photographs 



Nao( Plate 


Exposure for 

Two Minutes 

after 


No. of Colonies 


Fresh Room 


Close Room 




mintdu 

immediate 

5 


1,593 
446 


1,468 
634 




10 


54 


272 




15 


38 


118 




20 


1 


76 



the ceiling so that the organisms might be 
equally distributed throughout the air. The 
original culture contained about 300,000,000 
living organisms per cubic centimeter, and 
it was found that by the above technic a 




Flo. 7. — Photograph of plate 1 after exposure, imme- 
diately after spraying, in close room (upper half), and in 
ventilated room (lower half). 

very even distribution of the organism 
was obtained. In the fresh room the dry 
bulb read 17.2°C., the wet bulb 12.8°C., 
and the dry kata-thermometer reading 
was 6°. In the close room, the dry bulb 
read 21.4°, the wet bulb 15.5°, and the 
dry kata-thermometer 4.2°. The Petri 
dishes were exposed for two minutes im- 
mediately, and at intervals of five, ten, 
fifteen and twenty minutes after making 
the spray. The number of colonies in the 
five plates after each exposure agreed very 




Fig. S. — Photograph of plate 3 after exposure ten 
minutes after spraying, in close room (upper half), and in 
ventilated room (lower half). 




Pig. 9. — Photograph of plate 5 after exposure, twenty 
minutes after spraying, in close room (upper half), and in 
ventilated room (lower half). 

of plates 1, 3, and 5; the close room plate 
being shown in the upper half in each case. 
It is clear, then, that opening the window 
enough to change close conditions into 



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, those which feel fresh lessens massive spray 
infection greatly. 

We next repeated the experiment in the 
close room, first, with the fan running so 
as to keep the air in constant movement, 

TABLE 4. — AVERAGE NUMBER OF COLONIES 

RESULTING FROM EXPOSURE IN CLOSE 

ROOM WITH FAN RUNNING AND WITH 

FAN AT REST 



No. of PUte 


Exposure for 

Two Minutes 

after 


No. of Colonies 


Fan Off 


Fan On 




minutea 






1 


immediate 


1,750 


1,700 


2 


5 


680 


510 


3 


10 


425 


230 


4 


15 


200 


84 


5 


20 


97 


40 



and, secondly, with the fan at rest. With 
the fan at rest the dry bulb read 22.5*^, 
the wet bulb 14.5°, and the dry kata- 
thermometer 4.1°. With the fan running 
the readings were 22°, 14°, and 5.6°. 
Table 4 gives the . average number of 
colonies formed. This experiment shows 
that the movement of the air, caused by 
the fan, takes away more than double the 
number of microbes, probably by bringing 
them in contact with walls and other sur- 
faces and by driving them out of the room 
through crannies. 

Lastly, we tried the experiment in the 
relatively dry close room, and in the same 



room made moist by a number of baths of 
water kept boiling by Bunsen burners, 
and by water scattered over the floor and 
walls. In the dry close room the dry bulb 
read 21.2°, the wet bulb 12°, and the dry 
kata-thermometer 4.3°; in the moist close 
room the readings were 23.5°, 20.5°, and 
4.0°, respectively. The nimiber of colonies 
is recorded in Table 5. In the moist room 
the number of microbes was notably more 
reduced, partly, we suggest, owing to their 
condensation together with water vai>or 
on the walls and other surfaces, partly 
owing to stronger outward currents being 
set up through crannies because of the 
greater lightness of the moist air, and 

TABLE 5. — AVERAGE NUMBER OF CX)LOXIES 

RESULTING FROM EXPOSURE IN DRY AND 

MOIST CLOSE ROOM 



No. of PUtc 


Exposure for Two 
Minutes after 


Drv Close 
Room 


Moist Close 
Room 




minuttt 






1 


immediate 


1,540 


2,610 


2 


5 


690 


1,025 


3 


10 


540 


452 


4 


15 


215 


157 


5 


20 


121 


68 



partly owing to the fact that a large num- 
ber of organisms must have been de- 
stroyed by the twelve or more Bunsen 
burners which were employed in heating 
the water used to saturate the air. 



BIBLIOGRAPHY 



1. Trilkt, A., and Mallein: Sur le sort des pro- 
jections microbiennes dans Tair. Influence de 
rhumidit^. Compt. rend. Acad. d. sc, 1920, 
170, 1291. Experiences de transmission d*une 



6pid6mie chez les animaux par rinterm^iaire 
de I'air. Influence de la temperature. Ibid., 
1529. 



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CARBON MONOXIDE, ILLUMINATING GAS, AND BENZOL: 
THEIR EFFECT ON BLOOD COAGULATION TIME* 

HENRY S. FORBES and LOUISE HOMPE 
From the Laboratory of Applied Physiology, Harvard Medical School 



IN carbon monoxide poisoning, pathol- 
c^sts describe hemorrhages in the 
brain, muscles, Imigs, and other organs (1). 
Some authors state that the blood post- 
mortem remains fluid in the vessels much 
longer than usual and does not readily clot 
-when withdrawn (2). Others say that car- 
bon monoxide favors coagulation (3). On 
account of these diverse findings and be- 
cause of differences of opinion regarding 
the mode of action of the gas, it seemed 
worth while to determine earefidly the 
coagulation time of the blood of animals 
gassed with carbon monoxide and to note 
any evidence of blood destruction (e. jr., 
hemolysis). 

Convincing proof has been brought for- 
ward by the physiologists that this gas has 
no direct harmful action upon nerve cells or 
other tissues, but injm^es solely by robbing 
these tissues of oxygen through the forma- 
tion of a compound with hemoglobin which 
is not stable but which can be replaced by 
oxygen under suitable tension (4) (5). 
Many of the cases described in the liter- 
ature as carbon monoxide poisoning are 
in reality, however, due to illuminating gas. 
The pathological pictures in poisonings by 
these two gases may well differ. Illuminat- 
ing gas is complex and has been shown to be 
more toxic than is piu^e carbon monoxide, 
the chief additional poison being benzol (6) 
(7) . The other toxic constituents — xylene, 
ethylene, etc. — appear to be much less 
important so far as is known at present. It 
has been shown by Hurwitz and Drinker 
(8) that repeated subcutaneous injections 
of benzol can cause delayed coagulation, 

* Tbe auUiors wish to express their thanks to Dr. Cecil 
K. Drinker and Dr. Kathffine R. Drinker for valuable sug- 
I and help. Received for publication Sqpt 1% 1921. 



but this does not happen immediately. 
According to their figures, the change is 
slight after four days from the first injec- 
tion, and is not marked till the tenth day; 
therefore, a change is hardly to be expected, 
even from intensive gassing, within the 
time hmits of the present exi>eriments. We 
have tried to find out in these experiments 
whether or not, under controlled condi- 
tions, pure carbon monoxide, illuminating 
gas, and pure benzol have any measurable 
effect on coagulation time. 

Method 

Cats anesthetized with urethane or 
ether supplied control samples of blood. 
With urethane the dosage was 10 c.c. of a 
25 per cent, solution per kilo weight of cat 
given by stomach tube. One carotid was 
exposed and 2 c.c. samples * were drawn 
directly into a cannula-tipped pipette. 
This was previously coated with a sat- 
urated ether solution of vaseline, the ether 
being afterwards carefully expelled. From 
the pipette 1 c.c. of blood was delivered 
into the bottom of each of two test tubes, 
which were thoroughly clean and dry, and 
of uniform diameter. These tubes were 
kept in a water-bath at 31*^ to 32*" C. After 
standing ten minutes, they were tilted 
slightly once every five minutes. The end 
f)oint was the firm holding of the clot so 
that the blood did not run down the side 
when the test tube was inverted. Time was 
taken from the moment the blood entered 
the pipette. A few determinations were 
made on blood oxalated and recalcified 
after the method of Howell (9). 

* Occasionally 3 cc samples were taken and put into 
three test tubes. 



21S 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



After control samples had been taken 
from the urethanized animal, the gas was 
given from a Douglas bag by a tracheal 
cannula, fitted with inspiratory and ex- 
piratory valves. In the different experi- 
ments the duration of gassing varied from 
thirty minutes to seven and one-half hours. 
For the longer periods, instead of being 
permitted to inhale the gas by tracheal 
tube, the animal was placed in a box of 
760 liters* capacity, to which a measiu*ed 
amount of gas was added. An electric fan 
kept the air in motion, and the excess of 
carbon dioxide and moisture was absorbed 
by soda lime. 

The carbon monoxide, which we used, 
was made from formic acid and sulphuric 
acid heated to 70*" to 80°C., and the gas 
passed through strong sodium hydrate 
solution and collected in a bottle by dis- 
placement of water. The illuminating gas 
was taken from the laboratory gas jet. It 
was suppUed by the Boston ConsoUdated 
Gas Company, and the figures giving the 
average monthly percentage of carbon 
monoxide were 6btailied through tlie coiu*- 
tesy of the chief chemist of the company. 
The benzol used was "Benzene (Benzol) 
Merck." The percentage of vapor inhaled 
by the animals was not determined but was 
of sufficient concentration to keep them 
unconscious. 

Experimental Data 

Eleven experiments have been chosen 
from the total number performed. A num- 
ber were discarded because of lack of 
uniformity among the controls before a 
constant temperatiu*e bath was used. In 
the prothrombin tests, uniformity was 
obtained without the use of a water-bath, 
and it was, therefore, omitted. 

The accompanying protocols show the 
extent of the individual variations in 
coagulation time. 



Protocol 1. — Cat 1. Weight 3.1 kg. Urethane 
81 C.C. 25 % solution given 2 hours and 22 minutes 
before gas started. Gassed 82 minutes with 0.5 % CO. 



Sample 






Normal Blood 


Tube f Tube « Tubes 
wtin, 9un, mm. 


A 










25 
20 


25 25 


B 










20 26 








CO Blood 






A taken 21 minutes after starting 
B « 88 « 


gas 

a 


20 
20 


20 25 
20 


C « 


55 


u 


tt u 


a 


20 


20 


D « 


72 


a 


tt a 


tt 


20 


20 


E « 


82* 


tt 


a tt 


tt 


20 


20 



* Heart had stopped when sample was taken. 

i 

Pbotocol 2. -r- Cat 2. Weight 2.9 kg. Urethane 
29 c.c. 25% solution given if hours before gas 
started. Gassed 61 minutes with 0.5 % CO. 



Sample 




Normal Blood 


Coagulation Time 

Tube 1 Tube t 

wan, tma. 


A 






. 85 85 


B 






. 80 26 






CO Blood 




A taken 10 minutes after starting gas 


80 80 


B « 24 


tt 


U tt tt 


85 81 


C « 40 


tt 


tt U tt 


80 26 


D ** 48 


tt 


U tt tt 


25 20 


E « 56 


u 


tt tt tt 


SB S5 


F « 61* 


tt 


U tt tt 


20 80 



* Heart stopped i minutes before sample was taken. 

Protocol 3. — Cat 3. Weight 8 kg. Urethane 
80 c.c. 25% sohition given li hours before gas 
started. Gassed 47 minutes with 0.6 % CO. 





Prothrombin Test 




Ozalated Blood 
drop» 


1% CaCh 
drops 


CoagulaUon Time 
Control CO Sample 
min. mta. 


5 


1 





8 


5 


2' 





10 


5 


8 


11 


11 


5 


4 


12 


11 


Oxalated Plasma 
drops 


l%CaClt 
drops 


Control 
mtn. 


COSampli 


5 


1 


20 


22 


5 


2 


21 


20 


5 


8 


20 


20 


5 


4 


20 


20 



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FORBES AND HOMPE— EFFECT OF CO ON COAGULATION TIME 215 



Protocol 4. — Cat 4. Weight 2.2 kg. Urethane 
18 C.C. 25% solution given 2i hours before gas 
started; Gassed 39 minutes with 0.7 % CO (in two 
periods with two 69-minute intervals). 





Prothrombin Test 


bted Blood 
dropi 


l%CaCh 
iropi 


Coagolation Time 

CoDtroT CX) Sample 

msft. ffttn. 


6 


1 


4 S 


6 


2 


5 3 


6 


8 


5 4 


6 


4 


7 4 



Pbotocol 5. — Cat 5. Weight 2 kg. Urethane 
20 c.c. 25% solution given 2| hours before gas 
started. Gassed 30 minutes with 0.6 % CO. 





Prothrombin Test 


Oxalated Blood 
dn>p. 


Coagulation Time 
1% CaCli Control CO Sample 
dropt nUn, vdn. 



Pbotocol 8. — Cat 8. Etherized 35 minutes be- 
fore taking control samples. Exposed to benzol 
vapor in box for 3 hours. Unconscious. 

Norm^ Blood 

Coagulation Time 
Tubel Tubes Tube 8 
Sample min. min. min. 

A... 25 20 

B 25 20 20 

Benzol Blood 
A taken 3 hours after starting gas 30 20 

B ^ 3hrs. and 5 m. after storting gas SO 30 

C* « 3 « « iQ « « a « 4Q 4Q 50 

* Taken 1) minutes after heart stopped. 

Autopsy, — Blood as dark in arteries as in veins. 
Right lung congested, hemorrhagic, edematous; in- 
testinal vessels appear contracted and pale, showing 
marked contrast to those of CO animals, which are 

always greatly dilated. 
5 1 6 5,. 

g g 7 5 Protocol 9. — Cat 9. Etherized before taking 

5 4 6 control samples. Exposed to benzol vapor in box 

for 3 hours. Unconscious. 

Protocol 6. — Cat 6. Weight 2.5 kg. Urethane Normal Blood 

30 c.c. 25 % solution given 1 hour before gas started. Tubc^*^ Tu^T 

Gassed 34 minutes with 2% illiuninating gas (con- Sample min. min, 

taining approximately 0.5 % CO). A 20 25 

Normal Blood Benzol Blood 

Coagulation Time 

Tube 1 Tube t A taken 3 hours after startmg gas 15 15 

Sample min. min. ^ ** R ** *^ u u j^ 25 

A 30 30 

B 25 30 Prothrombin Test 

Coagulation Time 
Illuminating Oas Blood Oxalated Blood 1% CaCb Control Benzol Sample 

, ^ . , . ^, ^« dropt dropi min. min. 

A taken 8 minutes after starting gas 21 25 

B«15««««2025 ^ \ \ \ 

C«23««««2525. ^ * I \ 

D«28««««2530 ^ \ I \ 



Protocol 7. — Cat 7. Etherized 40 minutes till 
gas started. Gassed 5 hours in box with 0.5 % illu- 
minating gas (containing approximately 0.12 % CO). 









Normal Blood 








^Coagulation Time 
Tube 1 Tube « 


Sample 






^ mxn. mxn. 


A 






15 10 


B 






20 10 


c 






15 15 








lUuminaiing Oas Blood 




B « 


4i 


tt 


« « « .... 20 10 


C « 


4J 


tt 


« .... 25. 10 


D « 


5 


u 


« « « .... 20 20 


E « 


5 


u 


" .... 20 10 



Protocol 10. — Cat 10. Etherized before taking 
control samples. Chilled by wetting and exposure to 
fan for 53 minutes. Rectal temperature reduced to 
29.5^C. Exposed to benzol Vapor in box for 3i hours 
after being warmed. Rectal temperature 33.5*'C. 



Normal Blood 



Sample 

A 25 

B after exposure to cold 20 

Benzol Blood 

A token after 1 hour of gas 20 

B « « 1 « «« 20 

C « « Si ** " ** 17 

D " **3J" **** 20 



Coagulation Time 
Tube 1 Tube 2 



25 

20 



30 
15 
17 
20 



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Protocol 11. — Cat 11. Gassed preceding day 
for 7f hours with benzol vapor. Unconscious most of 
that time. Appears normal on day of experiment; 
no sign of paralysis. No ether or urethane given. 
No control samples taken. Exposed in box to benzol 
vapor for 7i hours. Red blood count 8,000,000; 
white blood count 13,000; blood smear shows poly- 
nuclears and platelets increased. 



Coagulation Time 

Tube 1 Tube « 

min. mtn. 



Bensol Blood 
Sample 

A taken after 6 hours and 24 minutes of gas 25 25 
B« «6««45« ««20 15 
Q u «6**"54" ***25 25 
D*** u J a «3Q a tt u 2020 

* Tkken ht>m abdominal ararta 2 minutet after heart stopped. 

Discussion 

The experiments which we have re- 
ported show no constant change of coag- 
ulation time in the blood of cats gassed 
with any one of the three gases tested, and 
the prothrcMnbin content was apparently 
unaltered. Evidence of hemolysis was 
lacking. Clear serum was always obtained 
unless mechanical injury to the red cells 
had occurred. The urine was never dark or 
smoky. Since no hemorrhages were found 
postmortem, it is apparent that the exact 
conditions of human poisoning were not 
reproduced, even by five hours of deep 
coma in the gas. The one possible excep- 
tion is seen in Protocol 8 where the lungs 
showed some extravasation of blood. This 
animal's blood showed a lengthening of 



coagulation time in the last sample, 
though it is doubtful if this is significant, 
for the sample taken only five minutes 
before showed a normal time. Protocol 9, 
on the other hand, with the same duration 
of exposure to benzol showed a slight 
shortening of coagulation time, but this 
again can be disregarded because the 
prothrombin test taken at the same time 
was normal. 

In fatal human cases of illuminating gas 
poisoning the patient often Ungers in coma 
for one or two days before death. This 
condition we were unable to duplicate in 
animals. They either died in the gas or 
recovered entirely. The most probable 
explanation of this failure to reproduce 
hemorrhages or prolonged coma after re- 
moval from the gas is either that it aflFects 
animals differently from human beings or, 
more probably, that the period of gassing is 
shorter in these experiments than in the 
human cases. 

Conclusions 

Under the conditions of these experi- 
ments no measurable effect upon the coag- 
ulation time of the blood was found in cats 
gassed with carbon monoxide, illuminating 
gas, or benzol. 

No evidence of hemolysis or of blood 
destruction was observed. 



BIBLIOGRAPHY 



1. Kober, G. M., and Hanson, W. C: Diseases of 
Occupation and Vocational Hygiene. Philadel- 
phia, P. Blakiston's Son and Company, 1916, 
p. 57. 

2. Glaister, J., and Logan, D. D.: Gas Poisoning 
in Mining and Other Industries. New York, 
William Wood and Company, 1914, p. 340. 

3. Rambousek, J. : Industrial Poisoning. London, 
EdwArd Arnold, 1913, p. 199. 

4. Haggard, H. W. : Effects of Carbon Monoxide on 
Neuroblasts. To appear in Am. Jour. Physiol. 

5. Haldane, J. S.: The Relation of the Action of 
Carbonic Oxide to Oxygen Tension. Jour. 
Physiol., 1895, 18, 201. 

a. Henderson, Y., and Haggard, H. W.: The 



Elimination of Carbon Monoxide from the 
Blood after a Dangerous Degree of Asphyxia- 
tion, and a Therapy for Accelerating the Elim- 
ination. Joiu*. Pharmacol, and Exper. Therap.» 
1920, 16, 11. 

7. Henderson, Y., and Haggard, H. W.: Personal 
Communication. 

8. Hurwitz, S. H., and Drinker, C. K.: The Fac- 
tors of Coagulation in the Experimental Aplas- 
tic Anemia of Benzol Poisoning, with Special 
Reference to the Origin of Prothrombin. Jour. 
Exper. Med., 1915, 21, 401. 

9. Howell, W. H.: The Condition of the Blood in 
Hemophilia, Thrombosis and Purpura. Arch. 
Int. Med., 1914, 13, 76. 



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BOOK REVIEWS 



217 



BOOK REVIEWS 



The Assessment of Physical Fitness by Corre- 
lation of Vital Capacity and Certain Measure- 
ments of the Body. By Georges Dreyer, C.B.E., 
M.A., M.D., Fellow of Lincoln College, Professor of 
Pathology in the University of Oxford, Corresi>ond- 
ing Member of the Royal Danish Academy of Letters 
and Sciences, and George Fulford Hanson, Late Lieu- 
tenant U.S.A. Medical Corps, Air Service. With a 
foreword by Charles H. Mayo, M.D., Rochester, 
Minn. Cloth. Pp. 127 with illustrations and index. 
New York: Paul B. Hoeber, 1921. 

This book is a collection of tables through 
the use of which it is held possible to arrange 
individuals in the order of their physical fitness. 
The author has established certain relations be- 
tween weight, sitting height, chest circum- 
ference, and vital capacity, which are indicative 
of good health. He does not include any of his 
data upon the validity of these relations but in- 
cludes references to previous papers in which he 
has discussed the development of his concep- 
tions. 

The reader is given a series of tables with 
thorough directions as to their use for the fol- 
lowing purposes : 

**1. The determination of what are the nor- 
mal proportions between the weight, the trimk- 
length, and the circumference of the chest. 

"2. To gain evidence as to underfeeding or 
malnutrition during different stages of adoles- 
cent or adult life, as well as in various classes 
and occupations of the population. 

**3. For the study of the different aspects of 
physical fitness as measured by vital capacity 
in its relation to weight, trunk-length, and 
chest-circumference; for the comparison of 
adolescents with adults, and of the male sex 
with the female; for the comparison of different 
trades, occupations, and classes one^with an- 
other, referring all to a definite common 
standard. 

**4. The application of these various mea- 
surements to patients with organic disease — 
e.g.y pulmonary tuberculosis — as well as to per- 
sons with functional disorders — e, g,, indus- 
trial fatigue, the fatigue of aviators, and so on." 



Since the usefulness of Dreyer's tables can 
only be established through experience with 
them, no opinion can be expressed as to the 
soundness of these contentions. The whole 
subject is of such vital interest to industrial 
physicians that it is hoped they will at once 
begin to utilize and criticize the methods and 
standards which the author has furnished. — 
C. K. Drinker, 



Occupational Affections of the Skin. Their Pre- 
vention and Treatment, with an Account of the 
Trade Processes and Agents Which Give Rise to 
Them. By R. Prosser White, M.D. Ed., M.R.C.S. 
Lond., Life Vice-President, Dermatologist, Senior 
Physician and Enthetic Officer, Royal Albert Ed- 
ward Infirmary, Wigan; Vice-President Association 
Factory Surgeons; Life Fellow London Derma- 
tologists' Society; Member Manchester Medical and 
Dermatologists' Societies; Hon. Life Member St. 
John Ambulance Association; Associate Editor, 
Journal of Industrial Hygiene. Cloth. Second Edi- 
tion. Pp. 360 with illustrations and index. New 
York: Paul B. Hoeber, 1920. 

The first edition of this book, published in 
1915, proved itself of great worth in a compara- 
tively neglected and diflScult field. In this, the 
second edition, which is greatly amplified, use- 
ful material has been added to almost every 
chapter. Deserving of especial mention are the 
chapters on dermatitis venenata and the der- 
matoconioses. The added illustrations are 
excellent and the numerous references, which 
have been carefully and painstakingly com- 
piled, will prove a great help to investigators in 
this line of work. 

It is a book which fills a long felt want and 
deserves a prominent place in the library of 
every worker in industrial hygiene, while the 
dermatologist who reads it will soon discover 
that to him it is not a luxury but a necessity. 
It is to be hoped that in the future there will 
follow other editions to add to the literatiu^ 
in this complex and ever-widening field. — 
E, Lawrence Oliver, 



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218 THE JOURNAL OF INDUSTRIAL HYGIENE 

HEALTH INSTITUTE OE THE AMERICAN PUBLIC 
HEALTH ASSOCIATION 

One of the features of the Fiftieth Annual Meeting of the American Public Health 
Association is to be a Health Institute which will be held in New York City from Novem- 
ber 8 to 11, the convention itself taking place the following week, November 14 to 18. 
The Institute is open to non-members of the American Public Health Association. 

Among the demonstrations tentatively included in the program for the Industrial 
Hygiene Section of the Institute are: 

Industrial Hygiene and Welfare Work of the New York Telephone and Telegraph 

Company. 
Industrial Hygiene Work of the New York City Health Department. 
Industrial Hygiene Work of the American Telepihone and Telegraph Company. 
National Industrial Conference Board Exhibit of Charts and Discussion of Cost of 

Industrial Welfare. 
Industrial Welfare Work of the Metropolitan Life Insurance Company. 
Industrial Hygiene Work of the New York City Health Department. 



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y 



THE JOURNAL OF 
INDUSTRIAL HYGIENE 



PUBLISHED MONTHLY 



Volume III 



DECEMBER, 1921 



NUMBEB 8 



THE PROBLEM OF HEART DISEASE IN THE 
INDUSTRIAL WORKER* 

PAUL D. WHITE, M.D. 

Boston, Mass, 



HEART disease and industry are not 
incompatible. An individual may be 
productive even while bedridden with 
heart trouble a large part of the time. The 
active trained mind of a cardiac cripple 
may be more valuable in industrial prog- 
ress than a body in perfect health con- 
trolled by a dull intellect. In general, we 
have been inclined to shelter too much 
our young patients with heart disease. 
They can usually do more than we have 
permitted. An example of the interest ex- 
pressed in their own future as a group is a 
letter which I received recently from a 
young man 20 years of age who has been 
crippled since childhood by rheumatic 
heart disease, and for that reason imable to 
obtain all the education which he desired, 
and who is now facing the need of support- 
ing himself without the best training for a 
clerical job. He is unable to do hard phys- 
ical work and cannot obtain even light 
work because of the stigma of his heart 
disease. His plea for the future of the 
whole group of young people with heart 

* Read before the Health Service Section at the Tenth 
Annual Meeting of the National Safety Council, Boston, 
Mass., Sept 29, 1921. Received for publication Oct. 17, 
1921. 



disease overshadows all the rest of his let- 
ter. He is a champion of their cause. 

There are two problems of heart disease 
in industry: first, that of the individual 
worker; and second, that of the attitude of 
industry in general. My subject is con- 
cerned particularly with the problem of the 
individual, but in closing I shall discuss 
briefly the general relation of industryto 
heart disease. 

The Individual Worker 

Every industrial worker with heart dis- 
ease is a problem in himself. The solution 
of each problem depends on the answers to 
two short questions: How much work can 
the individual do? What is his future? If 
we can puzzle out the answers to these 
questions, we can solve the problem of 
heart disease in the individual industrial 
worker. The first question is a relatively 
easy one — to be ascertained at once by 
questioning the subject, by suitable tests, 
or by observing the subject while at work. 
The question would be better put as fol- 
lows: How much work can the individual 
do without discomfort? — for sometimes a 



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person will force himself to do work often 
very distressing and even injiu^iousHo him- 
self. 

The other question at times is a very 
diflScult one to answer for the futiu*e of the 
individual depends oa a number of factors. 
In the first place, a correct diagnosis is of 
prime importance, and yet is very often 
neglected. Symptoms of heart distiu*b- 
ance, such as palpitation (that is, the 
disagreeable sensation of the heart beat), 
pain in the region of the heart, and short- 
ness of breath, do not by any means al- 
ways signify heart disease. Nor do fainting 
attacks or weakness indicate heart disease. 
Nor do murmurs or rapid heart action 
mean a diseased heart. And yet 1 have 
often seen patients diagnosed by them- 
selves, by their relatives or friends, or, not 
infrequently, even by their physicians as 
having heart disease, when to all methods 
of examination their hearts appear normal. 
This has been true in 60 out of 250 cases 
which 1 have seen in consultation (24 per 
cent.) in the last two years. To be siu-e, 
some of these people are incapacitated by 
their symptoms even though their hearts 
are normal; the nervous system or thyroid 
gland may be at fault. Though it may be 
impossible for such individuals to carry on 
ordinary work, the heart should not be 
blamed and treated, and cardiac statistics 
padded by these thousands of cases. The 
very first step in our problem, therefore, is 
to make a proper diagnosis. This having 
been made in its entirety, the rest, even the 
forecast of the future, is not dijBScult. The 
other important point in answering the 
question as to the future of a given case is 
the study of the individual's reaction to 
medical treatment or to a definite test of 
work over a given interval of time. An 
hour, a day, or a week may suffice to answer 
this. 

Diagnosis. — Let me now take up these 
two steps — diagnosis and reaction to 
work — in more detail, since they are so 



vital in judging a case. Recently, diagnosis 
in heart disease has been put upon a 
sound basis, and I shall discuss briefly the 
system as it is now in use in the Heart 
Qinic at the Massachusetts General Hos- 
pital and, in somewhat similar form, in 
some other hospitals and cities. Because it 
is not widely used and because it has 
proved so useful, I wish to emphasize it in 
its value in the industrial health problem. 

In former times, and not so far back 
either, as any one who received his medical 
diploma ten years or more ago will testify, 
heart disease consisted of mitral regurgita- 
tion and other such valve damage. A Uttle 
was said about enlargement, myocarditis, 
and pericarditis. Disturbances of rhythm 
were beginning to be recognized in a hazy 
way, very shortly to flash up and take the 
lead for a while, with such diagnoses as 
heart block and aiu*icular fibrillation (abso- 
lute arrhythmia) sufficing as diagnoses of 
heart trouble. At this same time Mac- 
kenzie's teaching of myocardial capacity 
was filtering in here and there, taught in a 
very disjointed way, unconnected with 
structural or etiological condition. Now, 
more than ever before, we see the tremen- 
dous importance of the cause of heart dis- 
ease as a vital part of our estimate of the 
heart's condition and particularly of its 
future. Finally, at the present moment the 
best diagnosis we can make comprises all 
three factors — the cause of the trouble (or 
etiology), the degree of anatomical dam- 
age, and the extent of functional impair- 
ment. Unless all these three points are 
studied and stated, I consider the diagnosis 
of a case of heart disease inadequate. By 
using this method not only do we have a 
clear picture of the individual at the pres- 
ent time but also a very solid foimdation 
for a prophecy as to his future. 

Each diagnosis should include, then, aM 
available information as to etiology, struc- 
ture and function. If the cause of the 
heart disease is unknown, it should be so 



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221 



stated. Such a declaration of our ignorance 
will stimulate us to study the individual 
further and to search more deeply into the 
causes of heart diseases in general. 

The most common causes of heart dis- 
ease are arteriosclerosis and rheumatic 
fever with its allied infections, such as 
chorea and tonsillitis. Syphilis and thyroid 
disease are other important causes. It is of 
much value in estimating the future of a 
person with heart disease to know what 
caused the disease. For example, given 
three hearts with organic defects of equal 
degree, the future is as a rule much brighter 
if the cause is rheumatic fever than if it is 
arteriosclerosis or syphilis. Until recently 
syphilitic heart disease carried with it an 
especially bad outlook — indeed, it was 
often only a question of a few more months 
of life.- Now, under better treatment, the 
future is not quite so dark. 

The next step in diagnosis is the deter- 
mination of the actual degree of anatomical 
change so far as possible — the size of the 
heart, the valve changes, the involvement 
of the pericardium and the presence of dis- 
ease in the aorta. Careful physical ex- 
amination, supplemented if necessary by 
X-ray and electrocardiographic studies, 
will give a fairly good answer to this part of 
the problem. 

And then finally we come to a very vital 
part of the diagnosis — the functional con- 
dition of the heart. Are there actual signs 
of heart failiu-e, such as swelling of the 
feet, or is there severe heart pain or short- 
ness of breath in the presence of a dam- 
aged heart? If so, there is heart failiu-e — 
that is, decrease in cardiac capacity far be- 
low what it should be. We speak of the 
type of failure with the shortness of 
breath and edema as the congestive, and the 
typ)e of failure with heart pain as the 
anginal. .Both are significant of serious 
heart damage and weakness. Of coiu-se, 
there may be much heart disease without 
failiu'e, but sooner or later in such hearts 



failure is apt to appear. All gradations of 
functional limitation of the heart's capac- 
ity exist, and following more or less one of 
the classifications of the New York Asso- 
ciation of Cardiac Clinics we may speak of 
five groups of individuals with heart dis- 
ease as follows: 

1. Those able to carry on their habitual activi- 
ties (without symptoms of distress) ; 

2. Those able to carry on slightly curtailed ac- 
tivities; 

S. Those able to carry on moderately decreased 
activities; 

4. Those able to carry on only greatly di- 
minished activity; 

5. Those unable to carry on any of their habitual 
activities. 

Finally, under the heading of functional 
diagnosis are to be included the disturb- 
ailces of rhythm, rate and pressure, such as 
heart block, auricular fibrillation, hyper- 
tension and pulsus altemans. 

A few examples will suflSce to show the 
usefulness of this scheme of diagnoses. 
Take first a man 35 years of age who has a 
crippled heart following tonsilUtis and 
rheumatic fever twelve years before. His 
heart condition has been diagnosed as a 
leaky valve. After he has been carefully 
examined the following diagnosis is made: 
"Rheumatic heart disease with aortic 
regurgitation and slight mitral involve- 
ment, cardiac enlargement, with normal 
rhythm and able to carry on habitual ac- 
tivities without symptoms." Now such a 
young man, although he has a loud mur- 
miu*, may. be able to live an active, useful 
life of many years; only late in life may 
symptoms of heart failure appear. The 
fact that rheumatic fever was the cause of 
his disease, the fact that his aortic valve is 
involved with Uttle damage to his mitral 
valve (mitral stenosis would be more 
serious), the fact that he has a regular 
pulse, and, finally, the fact that he has no 
symptoms of heart failure make such a 
young man a good risk for the f utiu-e. The 
only things which we must do with regard 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



to him are to be sure that his tonsils are 
removed if they are in the least diseased or 
if there is the slightest doubt as to their 
condition, and to avoid so far as possible 
further rheumatic infections (as a matter of 
fact best done by the tonsiUectomy itself). 
There are many young people with heart 
trouble who are. now being condemned as 
invalids and useless because they happen 
to have loud murmurs, about whom one 
may be as optimistic as I have indicated 
above. 

Take another man, 42 years of age, who 
is beginning to have heart pain on exer- 
' tion. He boasts, perhaps, that he never 
was sick in his life, but on careful ques- 
tioning he admits that he had a venereal 
sore fifteen years before. On examination 
one finds his heart enlarged, with a sUght 
but definite degree of aortic regurgitation, 
and a positive Wassermann reaction. His 
case is diagnosed as, "Syphilitic heart dis- 
ease with aortitis, aortic regurgitation, 
cardiac enlargement and normal rhythm, 
able to carry on slightly limited activity.** 
In spite of the fact that he may appear to 
be a robust man and may have only a slight 
aortic murmur, his future is very serious 
at the present stage of our medical knowl- 
edge. This is all due to the fact that syphilis 
is the cause in this instance, and not rheu- 
matism. Once upon a time both of these 
men, the one of 35 and the one of 42, would 
have been classed simply as cardiacs with 
aortic regurgitation, the younger man with 
more marked valve damage than the older. 

Finally, let us suppose another man, one 
27 years of age, with shortness of breath 
and palpitation on moderate exertion and 
occasionally when excited. His symptoms 
are worse than those present in either of the 
two cases already cited. He gives a past 
history of the usual children's diseases 
without rheumatic fever or chorea. He has 
always been high-strung as his father was 
before him. His father is alive and well at 
the age of 64 years. The patient broke 



down at the front during the war after a 
long bombardment of his trench by the 
enemy. He was said at the time to have 
"disordered action of the heart," and has 
been more or less incapacitated since. 
People are afraid to give*him work because 
of his symptoms and history; yet he is well 
educated and bright. His diagnosis is, 
"Nervous heart with no evidence of heart 
disease." He has a rapid heart beat at 
times of examination, and under strain is 
unable to x^arry on his ordinary activities as 
well as normally. Now such a man may be 
very valuable in industry. He is apt to be 
very quick to learn some delicate or intri- 
cate work and may accomplish much more 
in the end than his husky, stoUd comrade 
who can do a hard day's work with the pick 
and shovel but who rarely has an idea pass 
through his brain. Let us remember this 
large group of keen, nervous individuals 
who cannot stand a hard strain but who 
are able none the less to accomplish a 
great deal. Such young men and women, 
in spite of their symptoms, will im- 
doubtedly outUve the men with syphilitic 
and rheumatic heart disease. Our chief 
concern in such cases is to protect the sen- 
sitive nervous system. The heart is sound 
enough. 

These three examples are, I believe, 
enougti to show the great importance of 
establishing a correct and complete di- 
agnosis in each employee with heart dis- 
ease. Sometimes a case is baffling, but if 
so, let us confess it and closely follow th^ 
individual until we can arrive at the correct 
conclusion, if it be possible. 

Functional Tests. — After the diagnosis 
has been determined, the other essential 
point in the proper estimation of a person's 
capacity and future is the actual test. 
Many articles have been written about 
testing the heart's function and some facts 
of value can be extracted from them. We 
must realize, however, that in a given case 
it is not the cardiac function that we riieas- 



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223 



ure with all our tests but the physical fit- 
ness of the individual as a whole. His 
nervous system plays a part in his response 
to the tests as well as his heart and other 
muscles. The reaction of the pulse rate, 
blood pressure, respiratory rate and gen- 
eral condition to measured exercise, such 
as stair climbing, hopping on one foot, 
running a given distance and swinging 
dimib-bells, has been studied and all these 
exercises have their advocates. Dr. May 
Wilson (1) of New York has been attempting 
to find the "equivalent of ordinary exer- 
tion*' by standard tests — particularly 
dumb-bell swinging. Two iron dumb-bells 
swimg from the floor to full stretch of arms 
overhead and back again between the legs 
at a constant rate of two seconds for eafch 
swing were used in testing children from 6 
to 15 years of age. The weight of the dumb- 
bells varied from 3 to 20 pounds, and the 
number of swings from ten to thirty. Thus, 
in her classification, mild exercise for the 
children of from 6 to 8 years consisted in 
swinging two IJ-pound dumb-bells ten 
times, while strenuous exercise for chil- 
dren of from 12 to 15 years consisted in 
swinging two 10-pound dumb-bells thirty 
times. Now by carrying this or some 
similar test a step further we may roughly 
correlate it to industry. If the measure- 
ment of physical action in a certain occu- 
pation can be figured in foot-pounds or 
kilogram-meters per unit of time, we may 
be able to arrive at some sort of estimate of 
the cardiac ability, always included in the 
general jitness of the individualy by the test 
of a like amount of work in a unit of time 
in dumb-bell lifting. 

Papers by Barringer (2) (3), Rapport 
(4), and Mann (5) have in the last few 
years taken up the question of the signif- 
icance of blood pressure kad pulse rate 
changes in man after exercise tests, par- 
ticularly the dumb-bell test.* Conclu- 

* Lifting a 25-pound bar over the bead is a useful varia- 
tion of tbe dumb-bell test. 



sions to be drawn from their work are that 
the pulse rate changes following exercise 
are unrehable as evidence of circulatory 
condition, but that the systoUc blood pres- 
sure ciu^e is of some value in judging 
hmitations of physical capacity, not of 
cardiac capacity. Rapport, in working 
with Lewis, showed that "as an immediate 
sequence of accomplished exercise, whether 
that exercise is moderate in degree, or 
whether it calls forth a full effort on the 
part of the person who performs it, there 
is a rise of systolic blood pressiu-e." In 
criticizing Barringer's reUance on a de- 
layed rise as indication of limitation of 
cardiac capacity. Rapport quite rightly 
says: 

To speak of the rise ("delayed rise") itself as an 
index of a change in the circulatory reaction is» in the 
light of our experiences, unsound; to speak of a delay 
in the full development of the rise ["delayed sum- 
mit**] with severe effort, is usually to speak cor- 
rectly. . . . The work done by the heart in the 
intact and sentient animal at rest has never been 
accurately computed; still less has the capacity of the 
heart for work in circumstance of overload. It has 
become fashionable, nevertheless, to express the 
capacity of the heart for work in terms of measure, 
terms which do not measure that capacity, but some- 
thing which is quite different. ... A curve of 
syst61ic blood pressure during or following exercise 
may be an exact expression of real events; but these 
events are blood pressure events and the measure is 
of blood pressure and not of cardiac work [or cardiac 
capacity]. 

Nevertheless, it is true that as the degree 
of exercise done approaches the limit of an 
individual's physical capacity, whether he 
be normal or affected with heart disea^se^ the 
rise in blood pressure following the test 
shows a more and more delayed summit. 
With the extreme in delayed summit in a 
given person go symptoms of distress — 
dyspnea and exhaustion. Right here it 
should be said that a healthy person un- 
trained may show this sign and these 
symptoms with considerably less exercise 
than a person with heart disease who shows 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



no failure and who has excellent reserve 
power. 

Two examples of the systolic blood pres- 
sure exercise test will make clear some of 
the points just mentioned. The man 35 
years of age (and 150 pounds in weight) 
with rheumatic heart disease and aortic 
regurgitation, whom we have already cited, 
is examined at rest for fifteen minutes 
before the exercise. His blood pressure, at 
first 130 mm. Hg. systoUc, becomes on the 
second measurement 120 mm., and is 
thereafter fixed at 120 mm. His pulse rate 
before the exercise is steady at 76. He is 
then put through the test consisting of 
swinging two 10-pound dumb-bells thirty 
times from the floor above the head at the 
rate of one swing every two seconds. He 
shows shght breathlessness and weariness 
at the end of the exfercise; his pulse rate is 
108 and his systolic Wood pressure 140 mm. 
Hg. thirty seconds after the exercise is 
stopped. (Ten seconds after the exercise the 
systolic pressure is 130 nmi.) One minute 
after the exercise the blood pressiu*e be- 
comes 135 mm., and the pulse rate 90; and 
at the end of two minutes the pressure is 
125 mm. and the pulse rate 70. This is 
quite a normal reaction. 

For the second case let us take the man 
42 years of age Vith the syphilitic heart 
disease and aortic regurgitation, whom we 
have also cited. He is put through exactly 
the same exercise as the previous man but 
complains of considerable precordial pain 
and is very breathless at the end of the 
exercise. His systohc pressure has gone up 
from his normal pressure of 130 mm. to 
145 mm. at the end of one-half minute, to 
160 mm. at the end of one minute, a^d 
stays at that point after one and one-half 
minutes. At two minutes the pressure is 
150 nmi., and at three minutes 140 mm. 
His pulse rate, at first 80, becomes imme- 
diately after the exercise 160, at the end of 
one minute 140, and at the end of two 
minutes 100. It is obvious that the test 



more than taxed the strength of this man. 
The delayed summit of the systolic blood 
pressure is here well marked. 

Certain factors enter into such exercise 
tests, however, that render them imper- 
fect. In the first place, muscles may be in 
use quite different from those exercised in 
the particular occupation; secondly, there 
is an added strain due to nervous excite- 
ment at the time of the test; and, thirdly, 
the test lasts but a few minutes at the most, 
while the job in question lasts several hours 
every day. Thus, only a very rough esti- 
mate of individual physical and cardiac 
ability can be made from such tests. Stair- 
climbing, running and hopping are all open 
to the same objections. 

There are no short cuts to determining 
the heart's power that I know of which are 
of universal value. Respiratory tests have 
been suggested, such as the length of time 
the breath can be held, the height to which 
a mercury column can be blown, the length 
of time the mercury column can be main- 
tained at a certain height, and the vital 
capacity. As in the case of the exercise 
tests, if these are normal the individual's 
heart cannot be in a very bad condition. 
The vital capacity test, which is the meas- 
urement of the amount of air that can be 
expired after a full inspiration, and the test 
of holding the breath are useful measures of 
the degree of heart failure present. Vital ca- 
pacity and the power of holding the breath 
are also reduced in marked psychoneurosis 
(6). Similarly in these conditions the car- 
bon dioxide rebreathing test shows a 
capacity below normal. But the only sure 
way to determine whether a man with 
heart disease can stand a certain job is 
actually to try him out at it. No two jobs 
are exactly alike and no two individuals 
have exactly the same kind or degree of 
heart disease. A few minutes, a few horn's, 
or a few days at the most will answer our 
question. Having by observation, exam- 
ination and some simple test roughly deter- 



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mined the fitness of the mdividual, the 
exact measurement of his strength, cardiac 
and general, in relation to a certain job 
must come from the job itself. We must 
remember, moreover, that it is possible to 
train a man for a job physically as tvell as 
mentally though he appear incapable at 
the first trial. There are occupations for all 
kinds of cardiac cripples. A man unable to 
climb a flight of stairs without shortness of 
breath is obviously unfit to work as a 
freight handler, but he may prove very 
useful in keeping the office files. A concise 
folder has been published recently by the 
Association for the Prevention and Relief of 
Heart Disease (7) giving Usts of occupa- 
tions — both skilled and unskilled — gen- 
erally suitable for people with heart disease. 
This folder can, I believe, be obtained on 
request from the office of the Association at 
325 East 57th Street, New York City. 

General Relation of Heart 
Disease to Industry 

Having finished this brief discussion of 
the problem of heart disease in the individ- 
ual worker, I should like to conclude with a 
few remarks on the problem of the relation 
of heart disease to industry in general. In 
the first place there is not, so far as I know, 
any industrial heart disease. There is, of 
course, effort syndrome, but for that indus- 
try is not to blame. The relation of indus- 
try to the production of arteriosclerosis is 
still a question to be solved. Arterioscle- 
rosis is a very important cause of heart dis- 
ease as I have said, and if years of hard 
work produce arteriosclerosis, then indus- 
try may be accused of causing heart disease. 
The factors of the individual's suscepti- 
bility to arteriosclerosis, of the exciting 
effect of hard physical or mental work, and 
of the time element of hours of work per 
day or week must eventually be studied and 
weighed before we can point out how indus- 
try may be reUeved of the possible blame of 
inducing arteriosclerosis. 



In helping to eradicate heart disease, in- 
dustry should insist on the proper physical 
examination of the worker. If the tonsils 
are diseased, their early removal may pre- 
vent rheumatic heart disease or prevent 
the increase of such disease if already pres- 
ent. It is very worth while to try to eradi- 
cate rheumatic fever for it is one of the 
serious scourges of the youth of the land. 
If there is a history of syphilis, or if the 
Wassermann reaction is positive, proper in- 
tensive treatment may prevent syphilitic 
heart disease. Proper education and cam- 
paigning against venereal disease (including 
the adoption of prophylaxis if necessary) 
will also help, for syphilitic heart disease, 
as I have already said, is a very serious 
matter. Early recognition and treatment 
of thyroid disease may avert thyroid heart 
compUcations. Avoidance of long-sus- 
tained excessive physical or mental effort, 
and the insistence on regular periods of 
relaxation should reduce the degree of 
presenile arteriosclerosis. 

People should, on the average, live far 
longer than they do, though the 300 years 
of age advocated by the Barnabas Brothers 
in Shaw's Back to Methuselah is a bit too 
great a jump from our modest three score 
and ten to accomplish at the moment. To 
increase the average life, infectious disease 
must be eradicated, cancer overcome, and 
accidents and the strain of work reduced. 
There is, in general, too high a tension in 
American life, both in work and in play. 
We do not sit long enough at the breakfast 
table or over the teacups' — we might do 
well here to take a leaf from the leisurely 
ways of the European. An engine nm at 
high speed all the time wears out too 
quickly. The human machine, too, is 
Uable to break down eventually with ac- 
cident to the heart or brain. 

Not only may industry do its share in the 
prevention of heart disease but it may also 
do its part in the prevention of heart failing 
in the individual worker who has heart dis- 



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ease. The tremendous improvement in the 
care of the health of workers carried out by 
industrial concerns all over the country 
makes it possible to check up frequently the 
physical condition of the worker with heart 
disease. By examinations given weekly or 
monthly or at intervals as circumstances 
demand, the earliest symptoms or signs of 
failure may be detected and proper recom- 
mendations as to treatment given. Rest in 
bed for a day or two at such a time may 
.save the individual weeks of illness and loss 
of income later. It may prove to be very 
valuable insurance. Some of the cardiac 
clinics in New York meet on Friday even- 
ings so that their patients may be advised 
to stay in bed for the week-end if necessary, 
with little or no loss of time from their work. 
A word should be added concerning the 



need of special vocational training of 
young people with heart disease so that 
they may be able to support .themselves 
comfortably later in life in occupations 
which will not involve physical or mental 
strain.* Special classes have already been 
instituted in connection with the pubUc 
school system of New York City with this 
aim in view. 

Finally, let me repeat that heart disease 
and valuable productive ability may co- 
exist in the same individual. We must 
know the kind and degree of the heart 
damage. Knowing this, we should be able 
properly to place the worker by using our 
common sense, by tests for a rough esti- 
mate of the physical capacity of the 
individual, and, finally, by the actual test 
of the work itself. 



BIBLIOGRAPHY 



3. 



Wilson, M. G.: The Equivalent of Ordinary 
Exertion. Jour. Am. Med. Assn., 1921, 76, 1213. 
Barringer, T. B., Jr., and Tesclmer, J.: The 
Treatment of Cardiac Insufficiency by a New 
Method of Exercise with Dumb-Bells and Bars. 
The Circulatory Reaction to Exercise as a Test 
of the Heart's Functional Capacity. Arch. Int. 
Med., 1915, 16, 795. 

Barringer, T. B., Jr.: The Circulatory Reaction 
to Graduated Work as a Test of the Heart's 
Functional Capacity. Arch. Int. Med., 1916, 
17, 363; Studies of the Heart's Functional Ca- 
pacity as Estimated by the Circulatory Re- 
action to Graduated Work. Ibid,^ 670. 



4. Rapport, D. L.: The Systolic Blood Pressure 
Following Exercise; with Remarks on Cardiac 
Capacity. Arch. Int. Med., 1917, 19, 981. 

5. Mann, H.: Circulatory Reactions to Exercise 
during Convalescence from Infectious Disease. 
Arch. Int. Med., 1918, 21, 682. 

6. White, P. D.: Observations on Some Tests of 
Physical Fitness. Am. Jour. Med. Sc., 19«0, 
169, 866. 

7. Occupations for Cardiacs. Ass<2ciation for the 
Prevention and the Relief of Heart Disease, 
New York. 



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CARDIAC DISEASE AND ITS RELATION TO 
INDUSTRIAL EFFICIENCY* 

CAREY F. COOMBS, M.D., F.R.C.P. Lond. 

Consulting Physician for Diseases of the Hearty Ministry of Pensions (S. W, Region) 

{From the Department of Medicine, University of Bristol) 



[ 



AT a time when we are taking stock of 
jLjL our resources and looking for means of 
increasing the national output by reducing 
our losses from disease, it behooves us to 
study not only the mortality records but 
also such figures as are available to tell us 
what diseases cripple men and women and 
lower their standard of eflBciency. The 
best figures to which we can turn for such 
information are those supplied by the 
Ministry of National Service and drawn 
from their recruiting experiences. From 
the tables which they have published, it 
appears that about 10 per cent, of the men 
rejected as unfit for military service were 
rejected on account of valvular disease of 
the heart. In some districts, indeed, this 
kind of disability was responsible for more 
rejections than any other. This figure is to 
some extent discounted by the fact that 
cardiac murmurs were too readily received 
as evidence of valvular disease by recruit- 
ing authorities, the result being that many 
men who might have made eflScient soldiers 
were rejected on inadequate grounds. On 
the other hand, we have to recollect that of 
the foiu* great causes of organic heart dis- 
eases — to wit, rheumatic infection, syph- 
ilis, high arterial tension, and "senile** 
arteriosclerosis — the first alone finds a 
large proportion of its victims among per- 
sons of military age. The others fall with 
heavier incidence on men past the age of 
40. Moreover, it must be remembered that 
rheumatic heart disease attacks women 
rather oftener than men. It is therefore 

* Received for publication May 2» 1921. 



clear that cardiac disease is responsible 
for a very great wastage of the nation*s 
strength. 

It is scarcely necessary to impress upon 
the medical profession the need for a more 
concerted plan of attack upon these dis- 
eases. Already, in America at all events, 
there are signs of such a movement. Nor 
should we expect or wish the profession to 
regard this attack on disease primarily 
from the commercial standpoint. Our 
chief motive for such an attack is, and al- 
ways ought to be, the prevention and relief 
of suffering. But it is nevertheless needful 
to impress upon those who must find the 
money essential to such a campaign, that 
the study of disease and its causes will pay 
its own way, not at once, of course, but as 
the years and decades go by, with unfailing 
certainty. 

What, then, is to be our plan of cam- 
paign? Let us first review the objectives, 
and then pass to a brief consideration of 
strategy. In any attack upon disease the 
first objective must always be out-and-out 
prevention. Where prevention is not pos- 
sible, we must fall back upon plans for the ^ 
arrest of disease. Finally, in cases of severe 
and established disease, we must have plans 
for treatment, and these must include 
economic treatment. 

First, how is cardiac disease to be pre- 
vented? There is no disease that needs 
more time and energy devoted to the study 
of its causes than does cardiac disease. 
Even if the belief, which I share, in the 
streptococcal origin of rheumatic heart dis- 



227 



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ease be accepted, we are still far from 
knowing much about the influence of such 
matters as climate, soil, density of popula- 
tion, and so forth, on its initiation. Thanks 
to a grant from the University of Bristol 
Colston Research Society, and to the help 
of Dr. D. S. Davies and his clerk, Mr. W. 
N. Brown, I have been able to make an 
investigation into the incidence of rheu- 
matic heart disease, based on the mortaUty 
records of Bristol. The results of this re- 
search have already been published,* and 
I am looking forward to an extended in- 
quiry into the same matter on a basis of 
data more reliable than those f imiished by 
death certificates. Even in cardiac syph- 
ilis, where so much is known as to the excit- 
ing cause, how little is known as to those 
factors which predispose to the incidence 
of the infection on the heart rather than on 
some other organ! And when we turn to 
those forms of cardiac disease wWch are 
related to high arterial tension or arterial 
degeneration, or both, it must be confessed 
that our study of their causation is Uttle 
better than a mass of conjectures. 

I do not beUeve that we can get far in 
these researches into the factors predispos- 
ing to disease without enlisting the help of 
every medical practitioner. Before this can 
be done, however, medical men must be 
trained to think etiologically in the matter 
of heart disease. If we consult any of oiu* 
textbooks of medicine, we find that the 
pages devoted to cardiac disease are divided 
into paragraphs on "mitral regurgitation," 
"heart block," and so forth — titles which 
describe symptoms, not diseases. Not until 
they are replaced by such headings as "car- 
diac rheumatism," "cardiac syphilis," and 
so forth, shall we get students and practi- 
tioners to think of cardiac disease as 
something with a tangible beginning, a 
plant which ought not merely to be nipped 

* Coombs, C. F.: The Incidence of Fatal Rheumatic 
Heart Disease in Bristol, 1876-1913. Lancet, 1920, 
2,226. 



in the bud, but actually to be prevented 
from getting any place whatever in the 
ground. 

This kind of description of cardiac dis- 
ease can only be built up on a systematic 
study of the whole subject. What is wanted 
is exhaustive examination of a large num- 
ber of cases of cardiac disease, with careful 
records of the features of each, and classifi- 
cation into such etiological groups as I have 
already indicated. For example, we ought 
not to be content with recording such cases 
of cardiac syphilis as manifest evidences of 
heart block; every case of the disease ought 
to be studied with the electrocardiograph, 
and the presence or absence of block in its 
various grades noted. When all such in- 
formation has been duly collected, it will 
be possible to write a connected account of 
each of the forms of cardiac disease, classi- 
fied under headings which bear reference to 
causation. Then the medical profession will 
be armed with the information essential to 
a study of factors predisposing to cardiac 
disease, and we shall be able to get on with 
oiu* task of finding out what those causes 
are. As I have already said, this can only 
be carried out by the general co-operation 
of the whole profession, and some better 
plan must be devised than the present one, 
by which family doctor, laboratory worker, 
and medical oflBcer of health work sepa- 
rately from each other. 

As to the second line of objective — 
arrest of disease in an early stage — there 
is Uttle enough to be said, with one excep- 
tion, and that relates to rheumatic heart 
disease in its childhood stage. The course 
of this disease is one of progress, not sus- 
tained or interrupted, but marked by a 
series of active phases, each lasting a few 
days or several weeks. In a certain per- 
centage of cases the child is killed by the 
first of these phases. In a very few there is 
but one such phase, from which the child 
recovers, without further recurrence. In 
most cases the active phase of the disease 



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COOMBS — CARDIAC DISEASE AND INDUSTRIAL EFFICIENCY 2129 



recurs from time to time, each attack leav- 
ing the heart more damaged than before, so 
that the patient, if fortmiate enough to 
sm^ve into adolescence or adult life, finds 
himself handicapped at the outset of his 
wage-earning career by a crippled heart. 
Only too often his education has been so 
interrupted by the active phases, which 
keep him away from school, that he is fit 
for nothing but general labor. HI equipped 
in mind, and dangerously crippled in body, 
he has Kttle chance of doing any useful 
work. It would be weU worth while to 
make some provision for his education to be 
carried on quietly during his periods of ill- 
ness or, at aU events, of convalescence — 
such provision as is being fiumished in the 
analogous case of the tuberculous cripple. 
There is no reason why the same building 
that houses the latter, providing both 
treatment and education, should not be 
used for the rheumatic child also. Indeed, I 
believe that this is actually done at the 
Liverpool Country Hospital for children. 
The number of beds needed in each large 
city would not be great; one might begin 
. with a dozen in Bristol, for example. 

Arrest of pther forms of cardiac disease 
in an early stage does not at present seem 
practicable, though it is possible that closer 
study of cardiac syphilis might discover evi- 
dences earHer than those at present known 
to us. Unfortimately, this and the arterial 
types of cardiac disease attack the patient 
when he has already reached or passed the 
watershed of life, so that his chance of ef- 
fecting successful repair is smaU. 

The third line of objective — better 
treatment of established disease — comes 
within the scope of this article only in its 
relation to the patient's capacity for 
work. One of the lessons of the war has 
been that many people with severe cardiac 
lesions can nevertheless do a surprising 
amount of work with impunity. Unfor- 
tunately, however, it is difficult for such 
people to compete in the open labor mar- 



ket with those whose hearts are sound. 
Employers are surprisingly considerate in 
such cases, but it is impossible, imder the 
industrial conditions of the moment, to 
arrange for the interrupted work of these 
cripples in workshops and factories that are 
geared to run continuously at a high rate of 
efficiency. On the other hand, during the 
periods which many of them spend in the 
hospital, under observation, they have 
nothing to do, and this does no good to 
their morale. They would be better in 
every way if they had some kind of occupa- 
tion. Workshops, similar to those provided 
for crippled ex-service men, ought to be 
attached to the hospitals so that these pa- 
tients might be given an opportunity of 
combining productive work with institu- 
tional treatment. 

In order to bring into being these pro- 
posals, Kttle or no expenditure on building 
would be needful. All that is required in 
each large city, in each imiversity city at 
aU events, is that there should be such a 
rearrangement of the existing resources as 
to provide the team of practitioners spe- 
cially interested in cardiac disease with a 
consultative out-patient department, hos- 
pital beds for the treatment of severe cases, 
and premises for the housing and treatment 
over long periods of such cases as I have 
alluded to in the two preceding paragraphs. 
The team must also have at its disposal 
such electrocardiographic and other appa- 
ratus as is needful for the careful and 
systematic study of cardiac disease. By 
this means knowledge will be gained which 
will be imparted to the students — the 
practitioners of the immediate future. 
Last but not least, this central organization 
must be in touch with the practitioners of 
the area. This will confer benefit in both 
directions — on the cardiac specialists, 
who would gain the breadth of view and 
sense of proportion that close attention to 
one branch of medicine is apt to impair; 
and on the general practitioners, who 



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230 THE JOURNAL OF INDUSTRIAL HYGIENE 

would assimilate and apply each new dis- but also to eflFect such an economy of man- 

covery as it was made. power as amply to repay the moderate 

As an outcome of such co-operation it outlay necessary for the initiation and 

should be possible not only to diminish ap- maintenance of the organizations pro- 

preciably the sum total of human suffering, posed in this article. 



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CHRONIC MANGANESE POISONING: TWO CASES* 



GEORGE G. DAVIS, M.D. 

Chicago, lUinois 

AND 

WALTER B. HUEY. M.D. 

^Joliel, lUinoU 



IX is the purpose of this paper to call at- 
tention to two cases of manganese poi- 
soning occurring in steel workers who were 
engaged in handling manganese in the 
Sessemer process of making steel. 

M^anganese poisoning, though a com- 
paratively rare finding, presents a symptom 
complex, definite and constant enough to 
l>e readily diagnosed, and should be sus- 
pected in workers handling manganese. 
Xhis metal is used in the chlorine industry 
and to aid in Uberating chlorine gas, in the 
liberation of oxygen, in dyeing, coloring 
glass, charging galvanic cells, in making 
lacquer, varnish and oil paints, enamel 
and linoleum, and in marbling soap. Man- 
ganese i>oisoning is also noted in workers in 
industries dealing with other metals or 
their ores, in which manganese exists as an 
impurity, and it was under such conditions 
that Casamajor (1) met his cases. Man- 
ganese is used extensively as an alloy with 
nickel and steel. 

The niunber of cases of manganese poi- 
soning is not large nor is there an extensive 
literature on the subject. Couper (2), in 
1837, described characteristic symptoms in 
workmen in a chemical factory where man- 
ganese dioxide was ground in the manu- 
facture of chlorine for bleaching powder. 
In 1901 (October 7), R. von Jaksch (3) 
described similar symptoms in three work- 
men employed as grinders of manganese 
dioxide, but diagnosed the findings as 
atypical cases of multiple sclerosis. H. 
£mbden (4), in an article also published in 
1901 (October 15), described characteristic 

^ R«ceiTed for publication Sept. 19, 1921. 



symptoms in men employed in grinding 
manganese dioxide, and correctly di- 
agnosed chronic manganese poisoning. In 
1903 and 1904, respectively, Friedel (5) and 
Seiflfer (6) reported cases which presented 
characteristic symptoms. Several years 
later von Jaksch (7) (8) and Seelert (9) 
summed up the fiif teen cases of manganese 
poisoning in Euroi>e described in the above- 
mentioned articles, and in 1913, Casa- 
major reported nine cases occurring in this 
country. In 1919, Edsall, Wilbur and 
Drinker (10) summarized the literature to 
date and reported the details upon three of 
the thirty cases which they examined. 

Etiology 

The chief etiological factor by means of 
which manganese enters the system is un- 
doubtedly coarse dust, though in the 
writers* cases fumes must have played a 
r61e. It has been pointed out by OHver and 
others that most of our industrial poison- 
ings are taken in the form of dust, and not 
so much the dust which is inhaled as that 
which is swallowed in the saliva. In his re- 
ports, von Jaksch stated that no new cases 
developed when the dust was abolished. 
Embden likewise ascribed his cases to 
manganese dioxide dust, as did also Casa- 
major and EdsaU, Wilbur, and Drinker. 

In order to supplement these clinical 
findings by analytical data, Reiman and 
Minot (11) made a study of the absorption 
and elimination of manganese ingested as 
oxides and silicates, in which they came to 
the following conclusions: 



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Ores containing manganese as oxides and silicates 
are soluble in gastric juice. Manganese is absorbed 
in the blood stream causing in most cases a slight 
temporary rise in manganese concentration fol- 
lowed by a quick return to normal. In none of the 
cases studied was the manganese content of the 
blood mcreased by the ingestion of manganese ores 
to a value more than double the normal level, and in 
some of the subjects no increase was noted. We sug- 
gest that individuals of the first group would prob- 
ably be more susceptible to manganese poboning 
than those of the latter. 

Even prolonged feeding of large amounts of 
manganese ore to dogs failed to produce significant 
changes in manganese content of blood and tissues 
or to cause any pathological symptoms. Manganese 
ores are thus very non-toxic and in order to produce 
symptoms of poisoning must be ingested by individ- 
uals who are peculiarly susceptible. Clinical expe- 
rience [10] has demonstrated that such persons are 
extremely rare. 

Symptoms 

Edsall, Wilbur and Drinker (10), who 
have made a careful review of the subject 
of manganese poisoning and have reported 
cases of their own, summarize the symp- 
tomatology thus: 

As we have seen chronic manganese poisoning the 
following findings make the syndrome. We have 
numbered them in the most common order of ap- 
pearance. It is difficult to emphasize in any written 
description the clearness with which the symptoms 
come out and the ease with which the diagnosis can 
be made. 

1. A history of work in manganese dust for at 
least three months. 

2. Languor and sleepiness. 

3. Stolid, mask-like facies. 

4. Low monotonous voice. Economical speech. 

5. Muscular twitching, varying in degree from 
a fine tremor of the hands to gross rhythmical move- 
ments of the arms, legs, trunk and head. 

6. Cramps in the calves and a complaint of 
stiffness in the muscles of the legs, the cramps usually 
coming on at night and becoming worse after a day 
of exertion. 

7. Slight increase in tendon reflexes. 

8. Ankle and patellar clonus. Frequently by 
stretching any of the muscles of the body it is pos- 



sible to elicit rhythmical contractions. Romberg 
sign is inconstant; there is no incoordination. 
9. Retropulsion and propulsion. 

10. A peculiar slapping gait. The patient keeps 
as broad a base as possible, endeavoring involun- 
tarily to avoid propulsion. The shoes are worn 
.evenly and we have not been able to convince our- 
selves of the pronounced tendency to walk on the 
region of the metatarso-phalangeal joints, a feature 
strongly emphasized by von Jaksch [7]. 

11. Occasionally, uncontrollable laughter; less 
frequently, crying. 

12. Uniformly absent are any disturbances of 
deep or superficial sensation, eye changes, rectal, 
genito-urinary or gastro-intestinal disturbances, re- 
actions of degeneration, blood, urine, and spinal 
fluid alterations* It is significant that, unlike lead, 
manganese produces no life-shortening degenei^- 
ticms. Seriously poiscmed men are long-lived cripples. 
The metal apparently makes a very definite attack 
upon some non-vital portion of the neuromuscular 
system, destroys it thoroughly, if time for action is 
permitted, and leaves the victim quite well in every 
other respect. 

We have never seen either the salivation or edema 
described in foreign cases. 

Pathology 

The pathology of this condition is not 
clear. Von Jaksch reported that he never 
found any pathological lesions postmor- 
tem, but he does not state the details of his 
investigation. Casamajor had an autopsy 
in but one of his cases. He reported the 
appearance of degeneration in the longitu- 
dinal fibres of the pons in isolated bundles 
lying mostly close to the raph6. This degen- 
eration was seen only-in the pons. He was 
imable to reproduce it in rabbits or dogs. 

Further autopsy studies of these cases 
would be desirable, but as the patients do 
not die of manganese poisoning per se^ and 
as cases of the poisoning are comparatively 
rare, little is known of the pathology. 

Treatment 

Prophylaxis is the only hope in the treat- 
ment of chronic manganese poisoning. In- 
asmuch as dust was the means by which 



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DAVIS AND HUEY— CHRONIC MANGANESE POISONING 



IK>isoning occurred in the writers' cases, it 
is clear that, in order to remove all possibil- 
ity of poisoning, dust must be eliminated 
from processes in which workers handle 
manganese. If this cannot be accomplished, 
the process should be rearranged or discon- 
tinued, as it was in the plant in question. 

General eliminative measures by means 
of the kidneys, skin and intestines, etc., are 
indicated, but little is to be looked for in 
the way of improvement imder such treat- 
ment. 

Prognosis 

In patients manifesting minor symp- 
toms, recovery may take place. If, how- 
ever, the patient has progressed to more 
advanced stages, the disease may be ar- 
rested, but a cure will not be forthcoming. 
The disease is not fatal, and the condition 
of the patient continues for months or 
years without change. 

Report of Cases 

The writers' two cases occurred in work- 
men who were occupied in the process of 
making manganese steel. A few words con- 
cerning the process may elucidate the en- 
vironment in which they worked. 

In the Bessemer process for making steel, 
molten iron from the blast furnaces is car- 
ried in large ladles to the converters, which 
are retorts shaped like an egg with a por- 
tion of the small end cut ofiF. These con- 
verters are pivoted near the center and are 
so made that there are openings in the 
lower end from which heated gases may be 
blown through the molten jron, for the 
purpose of oxidizing a part of the carbon 
which is in solution in the molten iron. 
When this carbon is oxidized to a certain 
point, the resulting mixture is known as 
steel. 

The molten iron from the blast furnace is 
poured directly into the opening in the top 
of the converter, after which the blast is 



turned on and the gases are forced through 
the molten iron. When the oxidation has 
progressed suflBciently, the blast is shut off 
and the converter is tilted so that the mol- 
ten steel, which remains, runs from the 
opening in the top into a large ladle which 
is suitably placed to receive the steel as it 
pours from the converter. From this ladle 
the steel is withdrawn into moulds, and, 
after cooling, forms what. is known as an 
ingot. The ingot is then made into the 
various shapes desired. 

In the process of making manganese 
steel, manganese is added to the steel in a 
definite proportion and it immediately dif- 
fuses through the mass of steel. When the 
manganese is fused in the electric furnace, 
a definite amount of molten manganese is 
added to the steel and there results a prod- 
uct, the composition of which is uniform. 
Previous to the use of the electric furnace 
the solid manganese was added to the 
molten iron as it came from the blast fur- 
nace, and in the oxidation process a portion 
of the manganese was also oxidized, so that 
the resulting composition of the steel was 
not so definite nor so imiform. 

In the operation of the electric furnace 
there are three large carbon electrodes, and 
the electric arc between these electrodes 
generates the heat which causes the fusion 
of the manganese. The electric furnace in 
use at the plant in question, when the two 
cases of manganese poisoning occurred, was 
a large steel chamber lined with firebrick 
and provided with two openings — one a 
sliding door (Figure la) through which the 
solid chimks of manganese were shoveled 
into the interior, the other a small opening 
connected with a spout (Figure 16) from 
which the molten manganese was poured 
into a small ladle. The molten manganese in 
this small ladle was poured into the molten 
steel which had just been poured from 
the converter into the largeladle. When the 
sliding door was open for recharging the 
furnace, the heat within the furnace was 



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, so intense that a considerable quantity of 
brown manganese fumes from the furnace ' 
escaped from the door into the surrounding 
atmosphere and entered the mouth, throat, 
and lungs of any person who was in the 
vicinity. Mr. S., .superintendent of the 




Fig. 1. — Electric furnace which was located in a room 
about 25 feet square. 

(a) Charging door, into which the manganese was 
shoveled. At each charge the door was open long enough to 
allow 150 pounds to be shoveled in — about fifteen seconds 
— and during this time the fumes escaped freely. 

(6) Spout from which liquid manganese was poured and 
from which fumes escaped in large quantities. 



Bessemer department, stated that there 
was the same taste to the smoke that he had 
experienced when manganese had pre- 
viously been ground and the dust had en- 
tered his mouth, and he believed that there 
was a considerable amount of manganese 
in the smoke which escaped. At his sugges- 
tion, therefore, the fumes from the electric 



furnace were analyzed, and were found to 
contain a high percentage of manganese, 
as did also the dust on the ledges in the 
same room. (See Table 1.) 

TABLE 1. — ANALYSIS OF COARSE DUST AND 
FUMES FROM ELECTRIC FURNACE 



Substanoe 



SiO, 

Si 

Carbon 

Fe,0, 

Al A 

Mn 

CaO 

MgO 

Phosphorus! 
As J 



Analysia of Coane 

Dust from Electric 

Furnace 



17.14 

17.18 
9.46 
6.S6 

S8.16 
1.40 
5.28 

0.13 



Analysis of Fumes 

from Electric 

Furnace 



% 
23.38 

8.87 
19.30 

2.26 

6.54 
18.72 

4.56 
15.50 



Such was the environment in which were 
employed the two workmen whose his- 
tories are given below. 

Case 1. History. — N. V., an Italian, 25 years 
old, was examined first on Feb. 1, 1916, and 
subsequently at various times during the early 
months of that year. He gave the history of always 
being well and never having had any accidents or in- 
juries or bad habits. He did not drink or smoke. He 
had been in this country ten years. He had been 
married four years; his wife had been previously 
married but had never had any children. He began 
working for the Steel Company on Sept. 25, 1912, as 
a laborer, and continued as a laborer until Feb. 16, 
1914, when he was transferred to work as a charger 
at the electric furnace where ferro-manganese was 
fused before it was added to the converter to make 
manganese steel. He continued in this work until 
the time of examination when his foreman foiuid it 
necessary to change his employment on accoimt of 
increasing menlaJ dullness. 

Conversation with the patient and his wife brought 
out the facts that early in October, 1915 he began 
to be sleepy and indifferent, and that during Christ- 
mas week he took no interest in the festivities, Mrhich 
he had greatly enjoyed in previous years. Shortly 
after Christmas his wife noticed that he was often 
tremulous, especially at the table, that this condi- 
tion persisted during sleep, and that he was rather 
disposed to stagger on his feet as though he Mrere 



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DAVIS AND HUE Y — CHRONIC MANGANESE POISONING 



235 



drunk. Moreover, about the same time he would 
walk backwards and occasionally would fall back- 
wards. Two or three times in succession, while try- 
ing to put up some window shades, he lost his bal- 
ance, finally falling backwards to the floor. 

Sometimes his wife noticed that his face was very 
red, and she said that it looked different — meaning 
that his expression was different. She also noticed 
that he would laugh frequently without any appar-* 
ent cause, contrary to his former way of doing. 
Sometimes he would laugh at whatever was said to 
him. She noticed, too, that he had difficulty in 
coughing and that he did not seem to be able to 
cou^ up the accumulations in his throat. 

The patient complained of weakness in his hands 
and legs since Christmas of 1915, and noticed that 
when going downstairs his legs trembled and he felt 
insecure. He always staggered backwards when he 
lost his balance. He made no complaint of loss of 
sphincter control or of sexual disability. 

His wife said that his memory was all right. She 
noticed that his neck gradually became larger and 
that, although formerly he had worn a size 15 collar 
with comfort, a number 16 now seemed rather tis^ht 
for him. He did not complain of headache, and his 
appetite remained good and his bowels were regukur. 
She stated that at times his speech was normal but 
that olten it was necessary to ask a question several 
times and even to speak sharply before an answer 
was obtained. She also noticed that in friendly 
scuffles she was stronger than her husband, whereas 
fonnerly the reverse was true. His disposition, she 
said, was becoming ugly and he had attacks of vio- 
lent temper which were quite short in duration. In 
one of these fits of anger he threw a piece of soap at 
her, striking her side and bruising it. Inunediately 
after this he showed that he was sgrry that he had 
hurt her. 

Exannnaiion of PatierU. — The patient was a very 
strong muscled, thick-set Italian. His face was ex- 
pressionless and mask-like. (Figure 2.) Over the 
nose and each cheek, somewhat in the conmion dis- 
trihuUcm of lupus, there was distinct etythema, 
which whitened to finger pressure, and on the left 
cheek there was some scaliness. He closed his eyes, 
moved all his facial muscles, protruded his tongue in 
the middle line, and the tongue was not tremulous. 
He held bis lips firmly under expiratory effort. He 
gave a short whistle but no longer whistled con- 
tinuously as he had been m the habit of doing. He 
had difficulty, apparently, in taking a deep inspira- 
tion; repeated efforts failed of the desired result, and 
daring the examination he seemed to be disturbed at 
times with an accumulation of mucus in his throat. 
Rngcr to nose test was accurate but irregularly 



tremulous. The patient stood well with his eyes 
closed, but not so well on his left foot as on his right. 
He walked in a rather uncertain fashion, though not 
in a definitely atypical way. Reflexes were normal 
throughout. 

The patient signed his name and wrote his street 
number with comparative readiness, but his writing 




Fio. 2. — (Case 1.) Showing the characteristic expres- 
sionless and mask-like facies. 



was cramped and his wife said that it was different 
from what it used to be. His arterial pressure was 
70-98, with a pulse of 80. His tremor was not much 
exaggerated on volition; he poured water from one 
test tube to another fairly well. There was no body 
tremor, no tremor at rest. He articulated every, word 
but not clearly, and his speech was muffled and 
difficult to understand, seemingly because of the 
motionless condition of his lips and mouth parts in 
the effort of speech. At times during the interview 



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he did a little laughing without its being apropos, 
and at other times he laughed at something that was 
said which he may have considered amusing (Figure 
S). Voluntary strength and grasp and resistive 
movements at the elbow and shoulder and in the 




Fig. 3. — (Case 1.) Unmotive laughter was a prominent 
symptom in this case. 



lower extremity seemed to be very great, in spite of 
his complaints of weakness. 

During the examination the patient stepped off the 
scales backward and was unable to. stop until he had 
walked backward to the opposite wall, a distance of 
About 12 feet. Then it was noted that if he were 
given a slight push in a backward direction he would 
walk back several steps before recovering his bal- 
ance. He expressed no sense of fear of falling and 
smiled as he walked back. 

While the patient was in the hospital for observa- 



tion it was noted that he slept a great deal during the 
day as well as at night. His pulse, temperature and 
respirations were normal. 

An X-ray examination failed to reveal any pa- 
thology in the lungs or gastro-intestinal tract. His . 
urine was normal. His feces and urine were examined 
for. traces of manganese, but none was found.. A 
Wassermann test on the patient's blood gave a frank 
negative reaction. Blood examination showed 
hemoglobm 85 per cent., white cells 7,250, red count 
5,640,000. As a probable explanation of this un- 
usually high erythrocyte count, it should be under- 
stood that there was added to the ferro-manganese at 
intervals a certain amount of limestone and coke, 
and it is possible that there was a sufficient amoimt 
of carbon monoxide given off from this coke — there 
being no air supply to the interior of the furnace — 
to produce a mild form of carbon monoxide poisoning. 

Case 2. History, — S. K., a Hungarian, aged 32, 
a married man, without children, had been in the 
employment of the Steel Company since Feb. 17, 
1906, but he was laid off on account of lack of em- 
ployment on March 6, 1908, and he returned to work 
on Oct. 20, 1908. During this time he was employed 
as a runner in the converter until May 7, 1918, when 
he became a weigher at the electric furnace, weigh- 
ing the manganese in the ladle as it was poured from 
the furnace. He was doing this work until the latter 
part of 1915, when he found that he was unable to 
continue. On Jan. 31, 1916, Mr. S., the superintend- 
ent of the Bessemer department, stated that this 
man had for some time past been a very able axid 
efficient workman but that he had noticed a gradual 
decrease in his energy and mental acuteness, and 
had thought that he was becoming lazy. Mr. S. said 
that the man seemed to be dull mentally and that his 
movements were sluggish, and that when asked 'why . 
his work was so poor he responded that he did not 
know, and seemed indifferent. ^ 

This patient was examined first on Feb. 1, 1916, 
and has been under observation at various times 
since. Wlien questioned, he stated that he never had 
any serious illness, accidents, . or dissipated habits. 
A little over a year before the first examination, he 
began to notice that he was having some difficulty in 
walking — a tendency to trot forward or badrward 
when first starting off, and a little trouble in going 
down hill or downstairs. He had no feelings of 
dizziness, however. He said also that he had some 
numbness in his fingers and his toes. About tlus 
time his speech became muffled and indistinct. He 
became weak, and had continued so up to the time of 
examination. 

Examination qf Patient, — At the time of the first 
examination, the patient presented a peculiar f aeial 



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DAVIS AND HUEY — CHRONIC MANGANESE POISONING 237 



expression, a mask-like face (Figure 4), commonly 
with the contours and appearance of a fixed smile 
which showed his teeth. This was not invariable, but 
was frequently present and tended to be rather per- 
sistent. He walked fairly well, but said that he had 




Pig. 4. — (Case SL) This patient presented a peculiar 
facial expression, mask-like face, with the appearance of A 
tfight, contmual, fixed smile. 

an inclination to hurry ahead and he did, as a matter 
of fact, walk with rather short, hastening steps. He 
also indicated that at times he ran backwards. He 
said that he slept well, had a good appetite, good 
digesti(Hi, good bowel action, entire control of the 
Wadder, and a reasonable amount of sexual ability. 
He said that he had no sensory disturbance, but his 
hands were cold and cyanotic, and the nutrition of 
the cutkJe about the nails did not seem to be good — 
that is, there was a suggestion of glossiness about 
the skin. 



Cranial nerves seemed to be all normal as to vol- 
untary control and as far as reflexes were concerned. 
The deep reflexes were also all present and about 
normal, certainly not at all exaggerated. This was 
true of heel jerks, knee jerks, wrist and elbow jerks. 




' Fig. 6. — (Case 2,) Unmotive laughter was a prominent 
symptom in this case also. 

f The patient's writing was small and cramped and 
attempts to write a larger script even with a pencil 
failed. He wrote, however, with readiness and even 
with a fair amount of speed for a laboring man. He 
said that he could read and write but that he did not 
spend any time in reading. His speech was par- 
ticularly peculiar. He talked with lips slightly re- 
tracted and motionless, teeth almost together, tongue 
apparently inunobile, and his voice was low and 
monotonous, the enunciation deliberate and ob- 
scured. He tended to answer in monosyllables, and 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



seemed to have great difficulty in fonnulating a sen- 
tence. When asked how long he had worked on the 
furnace, he undertook to say that he had worked two 
years and eight months, and after a long pause one 
could understand the "two," and he drawled "aaaa" 
for a long time until it seemed that it would be im- 
possible for him to enunciate anything at all, and at 
the end of a continuous drawling "a," dropped out 
''eight months" rather abruptly. It was impossible 
to understand him when he -attempted to explain 
anything, and anything besides ''yes" and "no" 
could be understood only with considerable uncer- . 
tainty and guessing, yet he seemed mentally dear 
though apathetic. 

No decided tremor was observable, but upon hav- 
ing the patient extend his fingers one could see and 
feel a tremulousness in the hands and arms, with 
some lack of co-ordinate control of the phalanges of 
the fingers. He poured water from one tube to an- 
other with steadiness and precision. He made all 
sorts dP indicated voluntary movements with readi- 
ness. His grasp was greatly weakened in both hands, 
and his ability to resist passive movements com- 
municated to his arms, especially at the elbows by 
the contraction of the biceps, was reduced. The leg 
muscles also seemed somewhat weakened. The eye 
grounds were normal. 

Examination of the blood showed hemoglobin 90 
per cent., leukocytes 8,000, erythrocytes 6,400,000. 
This unusually high red cell count was the result of 
a mild form of carbon monoxide poisoning, the ex- 
planation of which is noted in the preceding case. 
A Wassermann examination of the blood was nega- 



tive. A chemical analysb of the urine and feces 
showed no trace of manganese. The urine examina- 
tion was otherwise negative. An X-ray examination 
of the limgs showed no evidence of manganese in- 
filtration. The patient's temperature, pulse and 
respirations were normal. A tendency to sleep and 
unmotive laughter were marked symptoms (Figure 

5). 

In May, 1917, it was noted that there was a 
marked falling out of the patient's hair, and on the 
right side along the hair line above and behind the 
right ear for a length of 5 inches, there was an area 
about 1 inch wide which was entirely denuded of 
hair. The hair in other parts of the scalp was easily 
removed by slight pulling. 



The 'diagnosis of chronic manganese 
poisoning in these two cases was fij'st made 
by Dr. Huey. The neurological examina- 
tions were later made by Dr. Archibald. 
Church who confirmed the diagnosis. 

The operation of the electric furnace, 
which was used to melt the manganese 
compounds, was discontinued when it was 
established that these men were suffering 
from chronic manganese poisoning. This 
was done because no practical way was 
found to eliminate entirely the dust and 
fumes from the furnace when it was in 
operation. 



BIBLIOGRAPHY 



1. Casamajor, L.: An Unusual Form of Mineral 
Poisoning Affecting the Nervous System: Man- 
ganese? Jour. Am. Med. Assn., 1913, 60, 646. 

£. Couper: Jour, de chim. med. de pharm. et de 
toxicol., 1837, 3, Second Series, 223. 

3. Von Jaksch, R.: Ueber gehttufte diffuse £r- 
krankungen des Gehims und RUckenmarks, an 
den Typus der multiplen Sklerose mahnend, 
welche durch eine besondere Aetiologie gekenn- 
zeichnet sind. Wien. klin. Rundschau, 1901, 
15,729. 

4. Embden, H.: Zur Kenntnis der metallischen 
Nervengifte (Ueber die chronische Manganver- 
giftung der BraunsteinmUller). Deutsch. med. 
Wchnschr., 1901, 27, 795. 

5. Friedel: Ztschr. f. Med.-Beamte, 1903, 16, 614. 

6. Seiffer: Manganvergiftung. Berl. klin. Wchn- 
schr., 1904, 41, 371. 



7. Von Jaksch, R.: Ueber Mangantoxikosen und 
Manganophobie. MUnchen. med. Wchnschr., 
1907, 64, 969. 

8. Von Jaksch, R.: Die Vergiftimgen. Second 
Edition. Wien u. Leipzig, Alfred Haider, 1910, 
p. 231. 

9. Seelert, H.: Ein Fall chronischer Manganver- 
giftung. Monatschr. f. Psychiat. u. Neurol., 
1913, 34, 82. 

10. EdsaU, D. L., WUbur, F. P., and Drinker, C. K. : 
The Occurrence, Course and Prevention of 
Chronic Manganese Poisoning. Jouk. Indubt. 
Hyo., 1919-1920, 1, 183. 

11. Reiman, C. K., and Minot, A. S.: Absorption 
and Elimination of Manganese Ingested as 
Oxides and Silicates. Jour. Biol. Chem., 1920- 
1921, 46, 133. 



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TRINITROTOLUENE POISONING — ITS NATURE, DIAGNOSIS, 

AND PREVENTION* 

CARL VOEGTLIN, CHARLES W. HOOPER, and J. M. JOHNSON 

Ftxm the Division of Pharmacology, Hygienic Laboratory, U. S, PMie Health Service 



Introduction 

WITH the entrance of the United 
States into the World War, the pre- 
vention of poisoning among American 
mimition workers presented a public health 
problem of considerable importance. Pre- 
vious experience in other countries had 
demonstrated that the productiveness of 
noiimition plants was dependent, to a large 
extent, on the prevention of such poisoning. 
Protection of the health of thousands of 
workers engaged in this industry was also ^ 
matter of much concern. Our allies. Great 
Britain in particular, had fortunately given 
this matter serious thought and consider- 
able scientific work had been done with a 
view to reducing the health hazards in 
munition plants. 

The most impK)rtant explosives used for 
the manufacture of shells l^elong to the 
group of nitro derivatives of aromatic hydro- 
carbons, aniline and phenol. Among these 
nitro -compounds, trinitrotoluene (com- 
monly called T.N.T., triton, or trotyl) was 
predominantly used in this country and in 
England on a very large scale. Inasmuch as 
the experience with this explosive in Great 
Britain had caUed attention to the serious 
health hazards connected with its manu- 
facture, and especially its handling in the 
filling of high explosive sheUs, there ap- 
peared soon after the entry of the United 
States into the war several articles dealing 
with this subject. 

In the Public Health Report of Nov. 16, 
1917, Surgeon J. W. Schereschewsky (1), of 
the United States PubUc Health Service, 
gave an expose of the practical aspects of the 

* The details and the methods used in this investiga- 
tion will be found in Hygienic Laboratory Bulletin No. 126. 
Received for publication Sept. 21, 1921. 



problem as ascertained by an inspection of 
the plants where T.N.T. was manufactured 
or used in the fiUing of shells. W. G. Hud- 
son (2) (3), medical director of the Du Pont 
Company, and Alice Hamilton (4), of the 
United States Department of Labor, ako 
contributed papers dealing with T.N.T. 
poisoning in factories in this country. 
H. S. Martland (5) described the first fatal 
case of T.N.T. poisoning which had oc- 
curred in the United States. 

Although no accurate statistics were 
available on the incidence of T.N.T. poison- 
ing in this country, inspection of various 
factories engaged in this industry had 
shown that the health of a considerable 
number of workers was aflFected by the con- 
stant contact with T.N.T. * Being charged 
by Congress with the safeguarding of the 
health of the civil population, it became the 
duty of the United States Public Health 
Service to undertake an investigation of 
the best ways and means for the prevention 
of T.N.T. poisoning, inasmuch as it was 
evident that the available information was 
not adequate enough to lay down safe rules 
for this purpose. For instance, no satisfac- 
tory data were known as to the production 
and characteristics of T.N.T. poisoning in 
animals, data which were obviously needed 
to serve as a firm basis for the understand- 
ing of the nature, diagnosis, and prevention 
of T.N.T. poisoning in man. Accurate ob- 
servations were also lacking in regard to the 
degree of contamination of factory air with 
T.N.T. undfer various conditions, data 
which are essential for purposes of proper 
ventilation of these plants. For these rea- 
sons the Hygienic Laboratory imdertook a 
co-operative investigation, the Division of 
Chemistry concerning itself with (1) the 



2S0 



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determination of the vapor pressure of 
T.N.T. at various temperatures and the 
amount of T.N.T. present in the air of 
various parts of a shell-filling plant, and (2) 
the quantitative determination of T.N.T. or 
its derivatives in the urine. The Division of 
Pharmacology was charged with the study 
of the pharmacological aspects of the prob- 
lem, with particular reference to (1) the 
elaboration of reliable and simple tests for 
the diagnosis of mild poisoning, (2) the in- 
vestigation of the channels of absorption to 
the poison by the animal body, (3) th,e dis- 
covery of prophylactic methods, etc. It 
was in the nature of the problem that the 
practical aspects deahng with the recogni- 
tion and prevention of T.N.T. poisoning 
should receive the major attention, al- 
though a number of very interesting obser- 
vations were made which, as will be seen, 
have an important bearing on the subject of 
blood destruction and regeneration. 

The data included in this report deal 
with the work done by the Division of 
pharmacology. They are divided into two ^ 
parts, the first one dealing with experi- 
mental T.N.T. poisoning as produced in 
dogs, and the second with the investigation 
of T.N.T. poisoning in a large shell-filling 
plant. The results obtained by the Division 
of Chemistry will be published elsewhere. 

Experimental T.N.T. Poisoning in 
Animals 

As previously stated, the literature con- 
tains little satisfactory information con- 
cerning the production of typical T.N.T. 
poisoning in animals. White and Hay 
(6), on the basis of a few experiments on 
cats and rabbits, considered T.N.T. "as 
not poisonous under ordinary use.'* Moore, 
Webster, and Wyon (7) state that they 
were not successful in producing toxic symp- 
toms in guinea-pigs exposed for several 
weeks to T.N.T. fumes in factories, whereas 
kittens under similar conditions showed 



evidence of poisoning (cyanosis). The 
animal work of these investigators was 
largely confined to rabbits and guinea-pigs, 
which were given one or a few large doses, 
ranging from 10 to 9,000 mg. per kilo body 
weight. The British report, while contain- 
ing extremely valuable information, does 
not include any really satisfactory informa-* 
tion on T.N.T. poisoning in animals. This 
is due to the fact that the species of animals 
selected for the work happened to be highly 
resistant to the toxic action of T.N.T. It is, 
of course, possible to kill even a highly re- 
sistant animal with massive doses of the 
poison, but it is questionable as to whether 
the symptoms and pathological changes 
thus produced correspond to those found in 
T.N.T. workers who, according to clinical 
observers, must be exposed to T.N.T. for at 
least four weeks. 

During the progress of our work a brief 
abstract of the work of Kramer and Meier- 
hof (8) appeared, in which these authors 
reported some experiments dealing with 
T.N.T. poison in dogs. They noted the 
following symptoms: vomiting, diarrhea, 
depression, and weakness. Examination of 
the blood revealed the presence of a leuko- 
cytosis, polychromasia, and an increase in 
nucleated red blood cells. The necropsy 
findings were negative, with the exception 
of a moderate degree of central degenera- 
tion in the liver and an increase of blood 
pigment in the bone marrow, lymph nodes, 
and spleen. They called attention to the 
absence of any lesions which might explain 
the death of the animals, particularly the 
absence of acute yellow atrophy of the 
liver. 

It was therefore necessary to find a 
highly susceptible animal. 

General Plan of Investigation 

Preliminary experiments with guinea- 
pigs and albino rats confirmed the pre- 
viously noted statements of the British 



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VOEGTLIN — TRmiTROTOLUENE POISONING 



241 



investigators that these animals are highly 
resistant to T.N.T. That the animals ab- 
sorbed the poison was evident from the 
change in the color of the urine and the 
positive Webster test. In rats the urine 
contains a bright pink pigment after 
T.N.T. is given either by mouth or sub- 
cutaneously. The first few experiments 
with dogs and cats, however, showed that 
these animals jievelop the typical symp- 
toms which are seen in T.N.T poisoning in 
man. Dogs were finally chosen for this in- 
vestigation as these animals seemed to be 
sensitive to T.N.T. and as they were of 
suflBciently large size to permit the frequent 
withdrawal of small quantities of blood for 
examination. 

In view of the fact that T.N.T. poisoning 
in munition workers is essentially of a 
chronic nature requiring several weeks or 
even months for its full development, it was 
desirable to produce an analogous condition 
in dogs by the repeated administration of 
relatively small doses of T.N.T. over a long 
period of time. A small number of experi- 
ments dealt with a study of acute poison- 
ing. For this purpose a single large dose 
(100 mg. per kilo) of the poison was given. 

For the production of chronic poisoning 
the doses ranged from 5 to 33 mg. per kilo 
body weight given every day except on 
Sundays and holidays. The T.N.T. used in 
this investigation was obtained from va- 
rious shell-filling plants and represented a 
product of average purity. A chemically 
pure T.N.T. was prepared for us by Dr. 
Marcus of this laboratory. In most of the 
experiments the poison was administered 
either by mouth in the form of gelatin 
capsules or subcutaneously dissolved in 
olive oil. A small number of animals re- 
ceived the T.N.T. in the form of fine dust 
directly into the lower air passages. For 
this purpose the animals were anesthetized. 
A smaU catheter was inserted through the 
trachea into the left bronchus and the fine 
T.N.T. dust was then blown into the lungs. 



this being followed by the immediate with- 
drawal of the catheter, care being taken 
that none of the poison should come into 
contact with the animal's mouth. A few 
animals received the poison dissolved in oil 
intrai>eritoneally. 

The condition of the animals was care- 
fully watched and the kind and severity of 
symptoms observed were recorded daily. 
A specimen of urine was secured each day 
(except Sundays) by means of catheter- 
ization, and these urines were submitted to 
various tests for the presence of abnormal 
constituents, such as sugar, protein, bile 
pigment, and T.N.T. and its derivatives. 

Particular attention was also paid to 
changes in the blood in this condition. For 
this purpose the blood of each animal was 
carefully examined prior to and following 
the administration of the poison. In a con- 
siderable number of the animals a complete 
blood study was made, including a quan- 
titative estimation of the hemoglobin, the 
total blood volmne, plasma volume, and 
pigment volume, the number and char- 
acter of the red cells, a leukocyte and dif- 
ferential count, the number of reticulated 
and nucleated red cells, the coagulation 
time of the blood, and the presence or 
absence of bile pigments and T.N.T. de- 
rivatives in the serum. 

In view of the fact that the work of 
Hunt (9), of Opie and Alford (10), and of 
Salant and Swanson (11) had shown that 
the character of the diet has a marked in- 
fluence on the toxicity of various sub- 
stances, and as Hooper and Whipple (12) 
had demonstrated that blood regeneration 
is materially influenced by the composition 
of the diet, it seemed important to study 
the effect of various diets on the course of 
the T.N.T. poisoning. Three diets were 
chosen for this purpose: (1) a bread and 
milk diet, composed of approximately 
equal parts per weight of pasteurized milk 
and white bread; (2) a meat diet, consist- 
ing of medium fat beef witE or without the 



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addition of calcium phosphate; and (3) a 
naixed diet containing white bread, pas- 
teurized milky and medium fat beef in the 
proportion ofS, 3 to 1. The relative propor- 
tions of protein, fat, and carbohydrates in 
these three diets were as foUows: 

Protein Fat Carbohydnta 

Bread and milk 15 7 78 

Mixed «0 14 66 

Meat 45 65 

These figures show that the bread and 
milk diet is rich in carbohydrates and rela- 
tively poor in fats and proteins. The meat 
diet, on the other hand, is rich in fat and 
protein, and the mixed diet occupies an 
intermediate position. 

Inasmuch as the British report had called 
attention to the probable conversion of 
T.N.T. within the body into certain re- 
duced compounds, particularly a hydrox- 
ylamine derivative, a number of reduction 
and oxidation products of T.N.T. were pre- 
pared, and their pharmacological action 
compared with that of T.N.T. The solu- 
bility of these compounds in oil and water 
was also determined. This phase of the 
work is of interest with respect to its bear- 
ing on the fate of T.N.T. in the body and 
the mechanism of the toxic action of the 
substance on the tissues and particularly 
the red blood corpuscles. A careful necropsy 
was made on all animals which died and 
all the tissues, with the exception of the 
central nervous system, were subjected to 
histological examination. 

Explanation of Charts. — The charts and 
their legends contain the essential informa- 
tion relating to and the results obtained by 
the experiments. The number and time of 
administration of the doses of T.N.T. are 
indicated by the arrows at the bottom of 
the charts. The figures immediately above 
represent the number of nucleated red cells 
per 200 white cells counted. The curves 
were obtained by plotting the initial value 
obtained before the animal received T.N.T. 
as 100 per cent. The curves therefore 



represent the percentage fluctuations and 
give a clear picture of the course of the 
poisoning as determined by the body 
weight and the blood changes. 

Discussion 

(a) Symptomatology. — In mimition 
workers various symptonas, such as derma- 
titis, gastro-intestinal pain, constipation, 
bleeding from the nose, giddiness, cyanosis, 
breathlessness after slight exertion, anemia, 
and jaundice, have been attributed to the 
toxic action of T.N.T. The symptom-com- 
plex varies with the individual. In the 
milder form of poisoning, which is spoken 
of as "minor T.N.T. sickness," there may 
be present: cyanosis, dermatitis, nose bleed- 
ing, constipaticm and giddiness. The severer 
forms of poisoning have been divided into 
toxic jaundice and aplastic anemia. 

Doses of T.N.T. ranging from 5 mg. to 
100 mg. per kilo body weight produced a 
more or less severe grade of intoxication, 
the severity of the latter being somewhat 
dependent on the size of the dose. After the 
larger doses the animals showed marked 
symptoms within a few hours, whereas the 
lowest dose used (6 mg. per kilo) did not 
always lead to recognizable clinical mani- 
festations. 

The striking feature of T.N.T. poisoning 
in dogs is the fact that individual suscep- 
tibility plays a very important part. Cer- 
tain animals receiving a fairly large dose 
may not show as marked symptoms as 
others receiving 50 to 75 per cent, less 
T.N.T. This difference in individual suscep- 
tibility is very probably not due to differ- 
ences in the rate of absorption of the poison^ 
as T.N.T. is absorbed fairly rapidly. It is 
more likely that different individuals deal 
differently with the poison after the poison 
is absorbed, a point which will be dealt 
with later on. 

Most of the animals developed within 
the first day after the administration of the 
T.N.T. a very pronounced cyanosis^ a 



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VOEGTLIN — TRINITROTOLUENE POISONING 



243 



symptom which is very common in T.N.T. 
workers. The mucous membrane and 
tongue of the dogs assumed a dark purplish 
color. This cyanosis was observed in some 
dogs as early as four hours after the admin- 
istration of a fairly lai*ge dose. In a few 
animals which had received one large dose 
or repeated small doses this symptom was 
entirely lacking, in spite of the fact that 
these animals finally died from the effects 
of the poison. In animals receiving the 
poison over a long period of time the 
cyanosis usually cleared up after the first 
two weeks, giving place to an anemic ap- 
I>earance of the mucous membranes. At 
its height the cyanosis may be associated 
with a marked dyspnea, and the blood 
always contains considerable methemoglo- 
bin and is chocolate-brown in color. Oxy- 
gen inhalation has no eflFect whatever on the 
cyanosis, a fact which proves that the latter 
is essentiaUy due to the large amounts of 
methemoglobin of the blood.* It is, how- 
ever, possible to lower thie increased pulse 
ratie and respiration observed in this condi- 
tion by allowing the animal to breathe a 
mixture of air and oxygen. 

In some of the experiments a very 
marked incoordination was noted, which 
first appeared on the second or third day. 
When this occurs, the animal staggers and 
is apt to fall when attempting to walk 
downstairs. The incoordination is usually 
associated with a marked cyanosis and dis- 
appears in the later stages in chronic poi- 
soning. It appears as if this symptom is 
due to a temporary functional abnormality 
of the cerebellar centers. 

Vomiting and salivation were observed in 
a number of animals during the stage of 
acute intoxication. Constipation was some- 
times noted, though as a rule the animals 
suflfered from diarrhea. The body loeight 

* This methemoglobin formation is due to the reduction 
of T.N.T. to a hydioxylamine derivative, the latter acting 
on the hemo^obin. Letsche (18) in Ztschr.f. physiol. Chem., 
1912, Vol. 80, p. 419, has shown that hydroxylamine con- 
yerts ozyhonoglobin completely into methemoglobin. 



and nutrition were maintained in a satis- 
factory manner in a considerable number 
of experiments of long duration. 

All animals developed an anemia, the 
principal features of which, and its causa- 
tion, will be discussed separately. In six 
dogs a marked icterus was observed, this 
being preceded by the excretion of a con- 
siderable amount of bile pigment with the 
urine. Dermatitis occurs in T.N.T. work- 
ers, but was never observed in these ani- 
mals. Ulceration of the mucous membrane, 
which was observed in the dogs on a bread 
and n^ilk diet, has no relation to T.N.T. 
poisoning, but is due to a dietary defect. 

(6) Paths of Absorption of T.N.T.— 
From a practical point of view it was im- 
portant to determine by what channels 
T.N.T. can gain access to the blood and 
tissues. Under the conditions prevailing in 
the factories, the T.N.T. workers may come 
into contact with both T.N.T. vapor and 
dust, thus exposing the skin and the respira- 
tory and gastro-intestinal tracts to the 
poison. It was, therefore, necessary to 
determine whether these organs absorbed 
T.N.T. 

Experiments which are not reported in 
detail have shown that dogs and cats 
which had received T.N.T. dust directly 
into the lower air passages developed a 
marked cyanosis within twelve hours, and 
their urine revealed the presence of a 
T.N.T. derivative. T.N.T. is evidently 
very readily absorbed by the epithelial cells 
of the bronchi. On account of the proba- 
bility of producing a pneumonia by this 
method of administration, no attempts 
were made to cause chronic poisoning in 
this way. 

T.N.T. is also very readily absorbed 
from the gastro-intestinal tract when it is 
given in the form of gelatin capsules. As 
T.N.T. is very readily soluble in fat, it 
might be expected that fat would favor its 
absorption. The comparison of the results 
obtained in animals fed either on a diet 



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poor in fat (bread and milk) or on a fat-rich 
diet (fat meat), however, shows that the 
presence of a considerable amount of fat in 
the food does not favor the absorption in 
any way. Within six hours after the feed- 
ing of T.N.T., the urine yields a positive 
test for the presence of a T.N.T. derivative 
(Webster test), and cyanosis, incoordina- 
tion and dyspnea are observed. 

The poison is also absorbed with great 
ease when injected subcutaneously in the 
form of a 3 per cent, solution in olive oil. 
These injections, even when repeated daily 
over several weeks, do not seem to lead to 
any local irritation at the site of injec- 
tion. Kramer and Meierhof (8) state that 
they have been able to produce T.N.T. 
poisoning in dogs with great regularity by 
means of skin immction. We have not used 
this method, principally on account of the 
impossibility of ascertaining the amoimt of 
T.N.T. actually absorbed. T.N.T. is also 
readily absorbed from the peritoneal cavity. 
In conclusion, it is safe to say that T.N.T. 
is readily absorbed from the respiratory 
and gastro-intestinal tracts, the subcu- 
taneous tissue, the peritoneal cavity, and 
the intact skin. 

(c) Fate of T.N.T. in Body. — Moore 
and his associates of the British Medical 
Research Committee (7) briefly state in 
their report that T.N.T. is reduced, within 
the animal body, to 2, 6-dinitro-4-hydroxyl- 
aminotoluene, which is readily converted 
into 2, 6-dinitro-4-azoxytoluene. The 
chemical relation of these thr^ compoimds 
is brought out by the following formulae: 

CH, CH, CH, CH, 

21 .i^w, NO^ANOt NOjAnO, N^ANa 



NOjAnG, 



NO, 



NHOH 



N 



N 



The hydroxylamine derivative is then 
conjugated with glycuronic acid and ex- 
creted in this form in the urine. Although 
the announced paper on this subject has 
not appeared up to this date,* it seemed of 

* See British Medical Research Coiuncil, Special Report 
Series, No. 58, 19«1. 



considerable interest to consider this ques- 
tion of the fate of T.N.T. From previous 
work on the metabolism products of toluene 
and aromatic nitro-compounds, it is a priori 
possible that both oxidation and reduction 
might play a r61e in the modification of 
T.N.T. According to Nencki and Giacosa 
(14) toluene is oxidized in the body to 
benzoic acid. Jaffe (15) isolated from the 
urine of dogs which had received large 
doses of paranitrotoluene a substance 
which he identified as paranitrobenzoic 
acid, part of which was conjugated with 
glycocoU to nitrohippuric acid. Meyer (16) 
was able to isolate paraaminophenol from 
the urine of a case of nitrobenzene poison- 
ing. He also confirms some older obser- 
vations of Lewin (17), who claims that 
azoxybenzene occurs in the urine of ani- 
mals poisoned with phenylhydroxylamine. 
Wajko (18) reports experiments which in- 
dicate that picric acid is reduced in the 
body to picramic acid. 

That trinitrotoluene does not occur as 
such in the urin^ of T.N.T. workers was 
shown by Moore and confirmed by us in 
the case of the urine of dogs poisoned with 
T.N.T. The so-called Webster test, which 
is used for this purpose, is based on the fact 
that an ethereal solution of T.N.T. as- 
sumes a purplish-red color after the addi- 
tion of an alcoholic solution of potassium 
hydroxide. This test is always negative in 
the dog's lu-ine if the fresh urine is directly 
extracted with ether. According to Web- 
ster it is essential to acidify the urine with 
20 per cent, sulphuric acid before the ether 
extraction. The ether extract so obtained 
then yields a dark purplisji-red color upon 
the addition of an alcoholic potash solution. 
When carried out in this latter way, the 
test is usually positive in the extract ob- 
tained from the urine of dogs which have 
received T.N.T., indicating that unchanged 
T.N.T. is absent, but that a derivative 
giving the same test is present. This de- 
rivative, according to Moore, is the above- 



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mentioned hydroxylamine compound which 
has to be split off from its combination with 
gylcuronic.acid by the acid treatment. We 
fomid that the only derivative of T.N.T. 
which yields the same color as T.N.T. itself 
is the hydroxylamine compound. It is, 
therefore, very probable that the hydroxyl- 
amine compound is one of the metab- 
olism products of T.N.T. We have 
repeatedly examined the feces of our ani- 
mals for the presence of T.N.T., but have 
never been able to get a positive Webster 
test. The bile, however, very often yields 
positive tests. Here also, as in the case of 
urine, it is necessary to add acid before 
carrying out the ether extraction, a fact 
which indicates that T.N.T. as such is not 
present and that, therefore, the test is prob- 
ably due to the hydroxylamine derivative. 

As to the quantity of the hydroxylamine 
compound which is excreted with the urine 
very little can be said, except that the 
miethod described by Elvove (19) when 
applied to dog's urine accounts for only 
from 9 to 42 per cent, of the T.N.T. given 
to the animals. 

An important fact which we wish to em- 
phasize particularly is the absence of any 
relation between the urinary Webster test 
and the severity of the intoxication, as 
determined by the clinical symptoms and 
the grade of the anemia. The data pre- 
sented in this report conclusively show that 
the Webster test may be persistently nega- 
tive in spite of the presence of marked 
cyanosis and incoordination, and that, on 
the other hand, it may be strongly positive 
in animals in which the symptoms are not 
especially pronounced. 

We have also frequently made the ob- 
servation that during the first month of 
chronic poisoning the lu-ine of the dog 
yields a very marked Webster test, but 
that this test nearly always becomes nega- 
tive in the later stages of poisoning, and 
this in spite of the fact that the animal still 
receives the poison and shows evidence of a 



progressing anemia. We believe that this is 
an indication of a change in the disfK)sition 
of the poison by the body, in the sense that 
the hydroxylamine compound is further 
reduced to the mono or diamino derivative 
of T.N.T., substances which do not give 
the Webster test but which possess the 
same pharmacological action as T.N.T. 

It is also possible that part of the T.N.T. 
is oxidized to trinitrobenzoic acid, which 
would combine with glycocoU to form 
trinitrohippuric acid. We have been able 
to show that trinitrobenzoic acid, when 
given in doses of the same order as those 
required for the production of T.N.T. poi- 
soning, has no evident effect on dogs. This 
substance is, to say the least, much less 
toxic than either T.N.T. or its reduction 
products. This difference in toxicity of 
T.N.T. and trinitrobenzoic acid is very 
likely due to the greater water solubility of 
the latter, a fact which favors its rapid re- 
moval from the body through the kidney. 
It is quite possible that the difference in the 
resistance of different individuals to T.N.T. 
poisoning may be explained by assuming 
that the more resistant animals oxidize the 
methyl group of T.N.T. more readily than 
the more susceptible individuals. 

There remains much to be learned about 
the fate of T.N.T. and other aromatic nitro 
derivatives in the body. May it suflSce here 
to state that the marked variation in the 
resistance to the poison may be easily ex- 
plained on the basis of the assumption that 
the reactions involved in the transforma- 
tion of T.N.T. in the body may differ both 
qualitatively and quantitatively in dif- 
ferent animals of the same and different 
species. 

Trinitrotoluene or some of its deriva- 
tives are retained in the tissues for a con- 
siderable time, as shown by the progressive 
anemia observed in dogs after a single dose 
of the poison and the slow recovery after 
the animal is taken off T.N.T. This reten- 
tion of T.N.T. or its reduction products is 



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probably due to the fact that these com- 
pounds are very insoluble m water, render- 
ing their eKminationwith the urine difficult. 

(d) Necropsy Findings. — All of the ani- 
mals that died from chronic T.N.T. poison- 
ing were anemic and showed the following 
characteristic pathological changes which 
must be attributed to the action of this 
poison: 

The endothelial phagocytes of the spleen 
pulp, bone marrow, and liver contained 
engulfed red cells and a varying amoimt of 
granular hemosiderin. These pigment 
granules were frequently as large as red 
corpuscles. The pigmentation was most 
striking in the spleen and bone marrow. 
(Fig. 1.) The liver pigment was usually 
confined to the swollen Kupffer cells within 
the liver capillaries. At times groups of 
hemosidefin-containing phagocytes were 
found about the portal spaces. The liver 
cells rarely contained even a small amount 




subcutaneous fat and the intima of the 
aorta yielded a positive test for bile pig- 
ment. 

A myeline degeneration of the sciatic 
nerve occurred in the majority of the ani- 



f Fio. 1. — Spleen pulp in chronic poisoning containing 
maximum amount of hemosiderin. PerKs reaction. 



of finely granular hemosiderin. (Fig. 2.) 
The mesenteric lymph glands occasionally 
contained a few hemosiderin-holding phag- 
ocytes. 

A mild icterus was found in six of the 
thirty-nine animals. In these cases the 




Fio. 2. — Liver in chronic poisoning showing the hemo- 
siderin in the swollen Kupffer cells within the liver capU- 
laries. The liver cells do not contain hemosiderin. Peri's 
reaction. 



mals in which this nerve was examined 
histologically, irrespective of diet. 

In some of the dogs fed on medium fat 
beef the liver showed a definite fatty change 
chiefly confined to the liver cells surround- 
ing the eflPerent veins. Hyaline necrosis 
was not foimd, although in a few cases 
small areas of focal necrosis were detected. 

Animals sacrificed within a few days after 
administration of relatively large doses of 
T.N.T. showed a varying degree of splenic 
tumor. In these animals the endothelial 
phagocytes of the spleen pulp, bone mar- 
row, and the Kupffer cells of the liver con- 
tained many engulfed red corpuscles, ap- 
parently intact, and a small amount of 
granular hemosiderin. (See Figs. 3, 4, 5.) 

A hyperplastic bone marrow was found 
in all of the animals except those sacrificed 
within a few days after the administration 
of the first dose. 

In addition to the above changes a num- 
ber of the animals with a complicating in- 



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tercurrent infection showed bronchopneu- 
monia, acute nephritis, cloudy swelling of 
the liver, and splenic tumor. Two dogs of 
the mixed diet series and five dogs of the 




Fio. S. — Mononuclear phagocytes with engulfed red 
cells from the spleen pulp in acute poisoning. 




Fig. 4. — Kupffer cells containing red cells and pigment 
from the liver capillaries in acute poisoning. 

bread and milk diet series showed an ex- 
tensive superficial ulceration of the oral 
mucous membrane, changes brought about 
by the deficient diet and not by.T.N.T. 

{e) Pathogenesis of Anemia and Icterus. 
— The salient feature of chronic T.N.T. 



poisoning in dogs is the anemia so con- 
stantly present and the mechanism of this 
red cell destruction. On reviewing the 
Uterature on physiological blood destruc- 
tion it is evident that a certain proportion 
of the erythrocytes are continuously broken 
down and replaced. Ashby (20) showed 
that the length of life of transfused blood 
corpuscles in man is thirty days and more. 
As to the fate of the erythrocytes, present 
knowledge is still inadequate. 

As long ago as 1901, Hunter stated that 
two diflPerent processes of blood destruction 




Fig. 5. — Bone marrow in chronic poisoning. Note the 
amount of hemosiderin within the phagocytic cells. Perl's 
reaction. 



may be distinguished — one in which the 
red corpuscles are phagocytosed without 
loss of hemoglobin, the other in which the 
red corpuscles undergo hemolysis with the 
liberation of hemoglobin within the blood 
stream. The first process is characterized 
by a gradual decay of the red corpuscles 
while still circulating. They become 
spherical, deep>er in color, and retain their 
hemoglobin until they are enclosed within 
the active cells of the spleen, or leukocytes 
of the blood, and are stored up within the 
spleen or in the capillaries of the liver. 
Within these cells the whole of the hemo- 
globin of the corpuscle is converted into 



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hemosiderin. The pigment so formed is 
characterized generally by the varying size 
of its granules, some of which correspond in 
size to that of the original red corpuscles. 
In the liver, the pigment is found within 
the capillaries and never within the liver 
cells. The second process is marked by the 
liberation of hemoglobin from the red cell 
within the blood stream. The hemoglobin, 
escapes from the corpuscle, either alone or 
in combination with the albuminous stroma. 
It is carried to the liver and is broken up by 
the liver cells. 

Recently Rous and Robertson (21) 
showed that a hemolytic process, in the 
ordinary sense of the term, at most plays a 
very minor part in normal blood destruc- 
tion. They state that phagocytosis will not 
suffice as a general explanation of normal 
blood destruction and that the red cor- 
puscles, in those species in which phago- 
cytosis is negligible, are fragmented one by 
one, while still circulating, to a fine hemo- 
globin-containing dust which is eventually 
removed from the blood by the spleen, and 
imder exceptional conditions by the bone 
^larrow. 

In certain anemias, on the other hand, 
such as those produced by hemolytic im- 
mune serum and by certain poisonous sub- 
stances (toluylenediamine, sodiiun oleate, 
phenylhydrazine, arseniated hydrogen, 
etc.), the destruction of the red corpuscles 
takes place by hemolysis within the cir- 
culating blood. The hemoglobin escapes 
from the corpuscles into the plasma and a 
hemoglobinemia ensues. If* the concentra- 
tion of hemoglobin in the plasma is great 
enough, it will escape through the kidneys 
into the urine. The liver cells contain an 
excess of hemosiderin in consequence of 
hemolysis, not of phagocytosis of red cells. 
The hemosiderin granules so arising are 
small and more or less uniform in size. 

According to Pearce, Austin, and Eisen- 
brey (22), hemoglobin escapes into the 
urine of normal dogs when the concentra- 



tion of free hemoglobin in the blood plasma 
is approximately 0.06 gm. of hemoglobin 
per kilo of body weight. The blood of the 
dog contains approximately 16 per cent, of 
hemoglobin, so that it would require the 
hemolysis of the red corpuscles contained 
in only 4 c.c. to cause a hemoglobinemia in 
an animal weighing 10 kilos. 

The anemia produced in dogs by T.N.T. 
is characterized by a very rapid destruction 
of the red corpuscles. The percentage of 
hemoglobin in the unit of blood diminishes. 
The pigment volmne, representing the total 
amount of hemoglobin in the circulating 
blood at the time of the blood volume de- 
terminations, drops in certain animals to 
50 per cent, or less within fifteen days, 
especially in those on a bread and milk diet. 
Coinciding with this decrease in pigment 
volmne there is a marked diminution in the 
total blood volmne corresponding roughly 
to the extent of the reduction of the red 
blood cell volume. This rapid blood de- 
struction is not accompanied by the ap- 
pearance of hemoglobin in the blood 
plasma or urine. In many cases there is 
also a complete absence of bile pigment in 
the blood plasma and urine. The number 
of .red corpuscles is usually markedly de- 
creased. In a few cases, however, the 
erythrocytes have fragmented to such a 
degree that their actual number per cubic 
millimeter of blood is considerably in- 
creased above normal, while the total pig- 
ment volume and red blood cell volume 
show a very marked decrease. (See Fig. 6.) 
Fragmentation of red cells has been most 
marked in dogs on a bread and milk diet. 
Anisocytosis, poikilocytosis, and polychro- 
matophilia were common findings, the 
degree of such abnormalities usually cor- 
responding to the degree of the anemia. 
The detailed examination for disintegrating 
red corpuscles in dogs acutely poisoned re- 
vealed the presence of considerable num- 
bers of these cells in the blood, spleen, bone 
marrow, and liver. They were often small. 



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Sometimes they were as large as and even 
larger than the normal red cell. Most of 
them were characterized by a translucent 
blister-like elevation extending from a por- 
tion of the cell and having at times a 
somewhat irregular outline. The hemo- 
globin mass within these cells stained 
uniformly and deeper than the surrounding 



scopic examination. The methemoglobin 
is confined exclusively within the red 
corpusdes and does not occur in the 
plasma. 

As stated above, in the necropsy findings, 
the spleen pulp, bone marroW, and, at 
times, the mesenteric lymph glands con- 
tain numerous large mononuclear phago- 




A/UMBOn UtTH %'» NtfCLMMTtO MKO eottPUSCLBS. 



Fig. 6. — Adult male. Slight cyanosis, salivation, and incoordination. Food consumption fair, ^ight icterus of 
conjunctivae between the 464 and 65th days and between 88th and 93d days, accompanied by an increase in bile 
pigments in the urine. Leukocytes varied between 4,200 and 22,400. Reticulated cells 12 to 95 during the first 71 
days. Nucleated reds from none to 7. Anisocytosis and basophilia. 

A\dop9y, — Emaciation. Extensive superficial ulceration of oral mucous membranes. Bone marrow hyperplastic. 
Spleen pulp, liver capillaries, bone marrow, and mesenteric lymph glands contain hemosiderin-holding phagocytes. 

liaU the increased fragmentation of erythrocytes between the ISth and dJfth days. 



red corpuscles. Other cells were found in 
which the hemoglobin was apparently 
divided by a clear portion. (See Fig. 7.) 
Hemolyzing red corpuscles or red cor- 
puscle shadows were not encountered. 

Blood, aspirated from the external jugu- 
lar vein within a few hours from animals 
given a moderate dose of T.N.T., is choco- 
late-brown in color and contains large 
amounts of methemoglobin on spectro- 



cytes loaded with granular hemosiderin — 
some of the granules are as large as the red 
corpuscles — and in acute poisoning, esj)e- 
cially, the phagocytes contain engulfed red 
corpuscles. The KupflFer cells of the liver 
are swollen and contain hemosiderin and 
red corpuscles. At times there are groups of 
hemosiderin-containing phagocytes about 
the portal areas. The liver cells rarely 
contain hemosiderin. 



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A further important observation in de- 
termining the mechanism of the blood de- 
struction is that T.N.T. does not produce • 
hemolysis in vitro when added directly, or 
dissolved in olive oil, to defibrinated 
blood, citrated blood, or washed red cor- 
puscles. From these experiments it is 
evident, however, that T.N.T. is absorbed 
by the red corpuscles, since part of the 




Fio. 7. -^ Disintegrating red corpuscles from the blood 
of an acutely poisoned T.N.T. dog. Wright's stain. 



oxyhemoglobin is changed into methemo- 
globin within twenty minutes at ST** C. 

On the basis of these observations the 
following explanation may be made of the 
mechanism responsible for the blood de- 
struction in T.N.T. poisoning. T.N.T. or 
some of its derivatives^ being lipoid soluble^ 
are absorbed by the red corpitscles and change 
part of the oxyhemoglobin into methemo- 
globin. Disintegration of the red corpuscles 
follows without the liberation of hemoglobin 
or meihemoglobin into the blood plasma. The 
injured cells are then engulfed by the en- 
dothelial phagocytes of the spleen^ of the bone 
marrow y of the lymph glands, to a certain ex- 
tent, and by the endothelial Kupffer cells of 
the liver. The engulfed red cells are in turn 



broken down within the endothelial phago- 
cytes with the formation of bile pigment and 
hemosiderin. 

The bile pigment which at times occurs 
in the urine of dogs poisoned with T.N.T. 
without the appearance of icterus can be 
easily explained when it is remembered 
that the dog's kidney excretes bile pig- 
ment very readily and that normally the 
blood plasma does not contain any bile 
pigment. A trace of bile pigment in the 
urine of normal dogs is conmionly found, 
especially when the animals are consti- 
pated or during fasting periods. On the 
other hand, the threshold value of the 
human kidney for bile pigment is relatively 
high and plasma contains a considerable 
amount of bile pigment before it appears in 
the urine. Gilbert and Herscher (23) 
shoyved that the normal himian serum 
contains from 25 to 35 mg. of bilirubin per 
liter. Panton (24) studied the blood of 100 
munition workers exposed to T.N.T. and 
found that 20 per cent, had an increase of 
bile pigment in the serum without its ap- 
pearance in the urine. The increase of bile 
pigment found at times in the urine of 
poisoned dogs corresponds to the increase 
of bile pigment in the plasma of muni- 
tion workers — probably brought about in 
either case by the increased destruction of 
red corpuscles by the endothelial phago- 
cytes and the consequent formation of bile 
pigment within these phagocytes. 

Six dogs out of thirty-nine showed slight 
but definite clinical icterus of the mucous 
membrane of the mouth and conjunctiva, 
accompanied by the appearance of bile 
pigment in the blood plasma and consider- 
able amounts in the urine. In four of these 
dogs the icterus appeared several days be- 
fore death. At necropsy the intima of the 
aorta and the subcutaneous fat were def- 
initely bile stained and gave positive tests 
for bile pigment. The kidneys in two of the 
animals were normal. The slight fatty 
changes occasionally found in the liver can- 



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^ ~0 '-^ <3 dj 






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not be held responsible for the icterus. The 
bile in all four cases was very dark and 
viscous. Special attention is called to the 
transient nature of the icterus observed in 
two of the dogs. In these animals the 
icterus coincides with periods of very ac- 
tive blood destruction. Furthermore, five 
out of the six animals that developed icterus 
were fed on meat, a diet which stimulates 
blood regeneration. On this diet the num- 
,ber of red corpuscles formed, and i>ossibly 
the number undergoing disintegration, is 
greater than on a bread and milk diet, 
which, as already pointed out, is not as 
satisfactory for blood regenwation. 

Possibly the icterus of these animals was 
of an obstructive type and hepatogenous 
in origin due primarily to the viscid bile 
which led to obstruction in the smaller bile 
ducts, with consequent absorption of the 
bile by the hepatic capillaries and without 
definite Uver injury. Another possibility is 
a functional disturbance of the liver cells, 
rendering them incapable of dealing with 
the bile pigment, as normally 

The primary rapid blood destruction ob- 
served in the dogs chronically poisoned is 
followed by an evident blood regeneration, 
as seen by the increase in the niunber of 
nucleated and reticulated * red corpuscles 
in the circulating blood and by a polymor- 
phonuclear leukocytosis in most cases. In 
some animals blood regeneration tem- 
porarily overcame blood destruction, fol- 
lowed by a partial return to normal of the 
pigment volume and the total blood vol- 
ume. (See Fig. 8.) Then, unless the 
T.N.T. was discontinued, a recidivation 
followed the period of active blood regen- 
eration which was associated with a grad- 
ual fall in the pigment volume and a 
reduction in the niunber of nucleated and 
reticulated red corpuscles. 



All of the animals which had received the 
poison up to the time of death invariably 
showed a hyperplastic bone marrow at 
necrospy in spite of the presence of a very 
severe anemia. 

(/) Influence of Diet. — On account of 
the considerable difference in the individual 
susceptibility to chronic T.N.T. poisoning, 
it is rather difficult to determine the exact 
influence of various diets on this intoxica- 
tion. The number of experiments which 
would have to be carried out in order to 
obtain reliable data on this point would of 
necessity be. very large. For this reason, 
the results obtained in this investigation, 
while not absolutely conclusive, are at 
least highly suggestive. It is seen that the 
animals on a mixed or meat diet seem to be 
more resistant than the dogs fed on bread 
and milk. The animals belonging to this 
latter group as a rule show a more acute 
and severer anemia, and die sooner. 

(g) Importance of Impurities in Crude 
T.N.T. — The T.N.T. used for the manu- 
facture of high explosive shells is not a 
chemically pure substance, although it is a 
fairly pure product consisting of approx- 
imately 99 per cent. 2, 4, 6 trinitrotoluene 
(T.N.T.).t 

Various writers have attributed the toxic 
action of T.N.T. to the impiuities con- 
tained therein, among which may be men- 
tioned traces of j8 and y trinitrotoluene and 
especially tetranitromethane. 

The results reported in this paper clearly 
demonstrate that there is no qualitative 
nor quantitative difference in the phar- 
macological action of the ordinary T.N.T. 
obtained from shell-filling plants and chem- 
ically pure 2, 4, 6 trinitrotoluene. This 
latter substance was prepared by Dr. 
Marcus of this laboratory. Dr. Marcus also 
tried to isolate the impurities, but suc- 



* An increased number of reticulated red corpuscles in 
the circulating blood is considered by Vogel and McCurdy 
(25), Lee, Minot, and Vincent (26), and Robertson (27) to 
be very good evidence of increased activity of the eiythro- 
blastic system. 



t For literature relating to the manufacture of T.N.T., 
the reader is referred to Arthur Marshall's ''Explosives,*' 
J. & A. Churchill, London, EnglaDd; and G. Smith's 
"T.N T. Manufacture," New Yoric, Van Nostrand Com- 
pany, 1918. 



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ceeded only in obtaining a few milligrams 
of P trinitrotoluene from 785 gm. of the 
commercial product. The fact is, there- 
fore, well established that the toxic action 
of the commercial product is essentially 
due to 2, 4, 6 trinitrotoluene. 

Summary 

The results obtained in this work may be 
briefly summed up as follows: 

A condition may be produced in dogs 
which in the most essential respects very 
closely resembles T.N.T. poisoning in the 
hmnan. The symptoms observed are 
cyanosis, methemoglobinemia, choluria, 
dyspnea, inco-ordination, and salivation. 
An anemia appeared in all animals and in 
six a definite icterus was noted. The blood 
destruction is due to an injury of the red 
blood corpuscles leading to increased phag- 
ocytosis of these cells in the spleen, liver, 
and bone marrow (phagocytic anemia). 
Blood regeneration usually proceeds very 
slowly after the withdrawal of the poison. 



The icterus is caused primarily by the 
enormously increased breakdown of hemo- 
globin within the phagocytic cells of certain 
organs and in this respect is hematogenous 
in origin. Acute yellow atrophy of the hver 
was never observed in any of the animals. 

The toxic action of T.N.T. is essentially 
due to 2, 4, 6 trmitrotoluene! T.N.T. is 
changed in the body and is not excreted as 
such. Reduction and oxidation may take 
part in this transformation. The reduction 
products have the same pharmacological 
action as T.N.T. Trinitrobenzoic acid, the 
only oxidation product studied, is much 
less toxic than either T.N.T. or its reduc- 
tion products. A marked variation in in- 
dividual and species susceptibility was 
observed, which is probably dependent on 
the nature of the change undergone by 
T.N.T. in the body. A definite tolerance to 
the poison was never estabUshed. 

The composition of the diet seems to be a 
factor influencing the susceptibility of the 
animals to T.N.T. poisoning. 



(To be continued) 



BIBLIOGRAPHY 



1. Schereschewsky, J. W.: Trinitrotoluol: Prac- 
tical Points in its Safe Handling. U. S. Pub. 
Health Rep., 1917, 32, 1919. 

2. Hudson, W. G.: Explosives-Industry Poisons. 
Med. Rec., 1917, 91, 89. 

8. Hudson, W. G.: Medical Supervision of Trini- 
trotduol Workers. N. Y. Med. Jour., 1918, 
107, 728. 

4. Hamilton, A.: Causation and Prevention of 
Trinitrotoluene (T.N.T.) Poispning. U. S. 
Bur. Labor Statis., Month. Labor Rev., 1918, 
6,1285. 

5. Martland, H. S.: Trinitrotoluene Poisoning. 
Jour. Am. Med. Assn., 1917, 68, 835. 

6. White, R. P., and Hay, J.: Some Recent In- 
quiries and Researches into the Poisonous Prop- 
erties dp Naphthalene and the Aromatic Com- 
pounds. Lancet, 1901, 2, 582. 

7. Moore, B., Webster, T. A., and Wyon, G. A.: 
The Causation and Prevention of Tri-Nitro- 
Toluene (T.N.T.) Poisonmg. Med. Research 
Com., Special Rep. Series, No. 11, 1918. 



8. Kramer, R., and Meierhof, H.: Experimental 
Tri-Nitro-Toluene Poisoning. Proc. Soc. Exper. 
Biol, and Med., 1917-1918, 16, 134. 

9. Hunt, R.: The Effects of a Restricted Diet and 
Various Diets upon the Resistance of Animals to 
Certain Poisons. Hyg. Lab. Bull., No. 69, 
Washington, Govt. Printing Office, 1910. • 

10. Opie,E.L.,andAlford,L. B.: The Influence of 
Diet on Hepatic Necrosis and Toxicity of 
Chloroform. Jour. Am. Med. Assn., 1914, 62, 
895. Influence of Diet on the Toxicity of Sub- 
stances which Produce Lesions of the Liver or 
the Kidney. Ibid,, 1914, 63, 136. 

11. Salant, W., and Swanson, A. M.: The Protec- 
tive Action of Diet against Tartrate Nephritis. 
Jour. Pharmacol, and Exper. Therap., 1918, 11, 
43. 

12. Hooper, C. W. and Whipple, G. H.: Blood Re- 
generation after Simple Anaemia. I. Curve of 
Regeneration Influenced by Dietary Factors. 
Am. Jour. Physiol., 1917-1918, 46, 573. 



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IS. Letsche, E.: Ueber die Einwirkung von Hy- 
droxyUmin aiif den BlutfarbstofiP. (Ein Beitrag 
zur Kenntnis des Meth&noglobins.) Ztschr. f. 
physiol. Chem., 1912, 80, 412. 

14. Nencki, M., and Giacosa, P. : Ueber die Oxyda- 
tion der aromatischen Kohlenwasserstoffe im 
Thierk5rper. Ztschr. f. physiol. Chem., 1880, 4, 

15. Jaffe, M.: Ueber das Verhalten des Nitro- 
toluols im 'thierischen Organismus. Ber. d. 
deutsch. chem. Gesellsch., 1874, 7, 1673. 

16 Meyer, E.: Ueber das Verhalten des Nitro- 
benzols und einiger anderer aromatischer Nitro- 
' k(5rper im Organismus. Ztschr. f. physiol. 
Chem., 1905-1906, 46, 497. 

17. Lewin, L. : Die Wirlamgen des PhenylKydroxy- 
lamin. Ein weiterer Beitrag zur Kenntnis der 
Blutgifte. Arch. f. exper. Path. u. Pharmakol., 
1894-1895, 36, 401. 

18. W^ko, K.: Ueber Reduction und Wirkungen 
aromatischen Nitrokbrper. Arch. f. exper. 
Path. u. Pharmakol., 1901, 46, 181. 

19. Elvove, E.: The Detection and Estimation of 
Small Amounts of Certain Organio-Nitro Com- 
pounds with Speciid Reference to the Exam- 
ination of the Urine of T.N.T. Workers. Jour. 
Indust. and Engin. Chem., 1919, 11, 860. 

20. Ashby, W.: The Determination of the Length 



of Life of Transfused Blood Corpuscles in Man. 
Jour. Exper. Med., 1919, 29, 267. ' 

21. Rous, P., and Robertson, O. H.: The Normd 
Fate of Erythrocytes. I. The Findings in 
Healthy Animals. Jour. Exper. Med., 1917, 26, 
651. 

22. Pearce, R. M., Austin, J. H., and Eisenbrey, 
A.B.: The Relation of the Spleen to Blood De- 
struction and Regeneration and to Hemolytic 
Jaundice. 11. The Relation of Hemoglo- 
binemia to Hemoglobinuria and ^Jaundice in 
Normal and Splenectomized Animals. Jour. 
Exper. Med., 1912, 16, 375. . 

23. Gilbert, A., and Herscher, M. : Sur la teneur du 
sang normal en bilirubine. Compt.rend.Soc.de 
biol., 1905, 68, 899. 

24. Panton, P. N.: The EflFect of Trinitrotoluene 
upon the Blood. Lancet, 1917, 2, 77. 

25. Vogel, K. M., and McCurdy, U. F.: Blood 
Transfusion and Regeneration in Pernicious 
Anemia. Arch. Lit. Med., 1913, 12, 707. 

26. Lee, R. I., Minot, G. R., and Vincent, B.: 
Splenectomy in Pernicious Anemia. Studies on 
Bone Marrow Stimulation. Jour. Am. Med. 
Assn.. 1916, 67, 719. 

27. Robertson, O.K.: The Effects of Experimental 
Plethora on Blood Production. Jour. Exper. 
Me^., 1917, 26, 221. 



BOOK REVIEWS 



The Human Motor or the Scientific Foundations 
of Labor and Industry. By Jules Amar, D.Sc., 
Director of the Research Laboratory of Industrial 
Labour at th^ Conservatoire National des Arts et 
Metiers, Paris. Translated by Elsie P. Butterworth 
and George E.Wright. Cloth. Pp. 470 with illustra- 
tions and mdex. London: George Routledge & 
Sons, Ltd.; New York: E. P. Dutton & Company, 
1920. 

Before the publication of the present volume 
in English, Amar's work had already become 
well-known in this coimtry through his Phy- 
siology of Industrial Organization and the Re- 
employment of the Disabledy which appeared in 
1919, and in which frequent references were 
made to his more fundamental work, The Hu- 
man Motor. The present volume is thus re- 
ceived with great interest. 

Since the book is addressed to the practical 
man in industry as well as to the investigator, 
the author's wisdom is at once evident in be- 
ginning with a consideration of the general 
principles of mechanics most obviously con- 



cerned in the movement and work of the human 
machine. In the subsequent chapters which 
comprise the first part of the book, the following 
subjects are considered: the structure of the 
body; neuromuscular action and the energy 
exchanges in rest' and work, and the relation of 
diet thereto; human energy, including the con- 
sideration of speeds, loads, and effort; fatigue; 
the internal environment and the physico- 
chemical conditions within the body; and ex- 
ternal environment. The second half of the 
book is' devoted to experimental methods of 
measurement applicable to industrial labor and 
to the results that have been obtained by these 
methods. 

There is suflScient reason for devoting a large 
section of the volume to general physical and 
physiological principles as a matter of conven- 
ience for the general reader. Opportunity inay 
thus be taken to emphasize aspects of the sub- 
ject more directly related to industrial' physi- 
ology. Amar's treatment of general physiolog- 



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255 



ical matters bearing upon work is stimulating 
and suggestive, but it is questionable whether 
the general reader would obtain an adequate 
conception of the subject in such a brief treat- 
ment. 

Any reviewer would perhaps find objections 
to some, views of any writer upon the general 
subject of physiology, and it should not, there- 
fore, detract from the merit of the work as a 
whole to criticize certain statements and con- 
ceptions. The work quoted on the systolic 
blood pressure for the diflFerent ages does not 
agree with the general views at the present 
time as regards normal blood pressure, the 
average pressure for the ages between 20 and 40 
being given by Amar as 170-190 mm. Hg. 

As to the chemical phenomena occiuring in 
fatigue, the statements that toxins are pro- 
duced in the muscle, and that "the blood by 
circulating more quickly during work washes 
the poisons out of the tissues and carries them 
to the suprarenal glands which secrete adrenalin 
by which they are neutralized; it oxidizes them 
itself by the oxygen which it contains," do not 
represent the best opinions on the subject. Of 
the same type is the following statement: 
"... sweat is a toxic waste and is produced 
during fatigue. The poisons which it eliminates 
in 24 hours would be sufficient to endanger an 
adult subject. Poisoning sometimes takes place 
in a hot, humid atmosphere if the sweat has not 
been able to leave the body." This erroneous 
view is frequently encountered among people in 
industry. The statements that the blood of 
obese subjects is less rich in red corpuscles; that 
senile decay affects tall people most; that one of 
the effects of an electrified environment, as 
after a violent thimder-storm, is anemia; that 
the application of a moderate current appears to 
increase the power of muscles for several days; 
that "chloride of sodiiun intervenes in the 
metabolism of the body to protect the pro- 
teids," should not be allowed to pass without 
question. Reference is made to creatinin in 
connection with muscular activity, but evi- 
dently creatin is referred to. 

The translation is not altogether good, and 
as a result imcpnventional expressions are 
occasionally used, and the author's meaning is 
sometimes obscure. As an example of the 
former, we find in the index a reference to 
"renal force," with a test for renal force illus- 
trated, the test being a measure of the strength 
of the limibar muscles by means of the dynamo- 
meter. As an instance of obscure meaning, the 



following sentence, which occurs in the discus- 
sion of nerves, may be cited: "They emanate 
from determined centers, these centers being 
cellular, but the 'nervous cell' emits a very 
long prolongation to the centrifugal fimction, 
the cylindric axis, and short appendices, *the 
dendrites,' which connect it with the neighbor- 
ing cells" (p. 99). Moreover, through some 
mistake of labeling or shading the drawing of 
the knee joint, an entirely erroneous impression 
of this structure is given (p. 103). 

The author makes several references to dif- 
ferences associated with sex, but does not im- 
dertake a general discussion of these differences 
as bearing upon fitness fbr various kinds of 
work. The female suflFers in the conventional 
manner through comparison but it seems a bit 
unfair to her to draw attention to slight dif- 
ferences in the water content and density of her 
nervous matter. She is found to possess less 
muscular strength, and this is more important. 
In view of more recent results pf Martin, how- 
ever, and the same criticism applies to com- 
parisons of the strength of different races, the 
eflFect of occupation probably has not been duly 
taken into accoimt. 

The real contribution of Amar is in pointing 
out the applications of physiological methods to 
the study of labor, the results obtained, and 
those to be expected. His own work has con- 
sisted of investigations of pressure and speed of 
movements by means of Marey tambours and 
recording devices, following the lead of Imbert 
in this technic, and of correlating these re- 
sults with observations upon the oxygen con- 
sumption, respiratory rhythm and heart beat. 
By means of this technic he has determined 
the work accomplished in relation to the energy 
expended in several kinds of labor, at various 
time rates. Interesting and valuable results are 
given. 

Amar's chief incentive is apparently found in 
the shortcomings of the methods of Taylor and 
his followers through their failure to take into 
account the physiological principles concerned 
in human work. The same criticism has been 
frequently made, and indeed with justice. 
Industrial engineers have frequently stated 
speeds, loads and percentage of time in func- 
tional activity in relation to lengths of rest, 
without taking into account the physiological 
factors already known, and without making 
physiological research where such knowledge is 
inadequate. While Amar must siu^ly convince 
even the practical engineer of the richness of 



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this field of investigation he demonstrates, per- 
haps more than he realizes, its present short- 
comings. He is least of all to be criticized in 
this respect since he is actively working in this 
field. In making this criticism it is not my pur- 
pose to defend any continued neglect upon the 
part of industrial engineers to ignore physi- 
ological facts and methods in their studies, but 
rather to stimulate greater eflfort on the part of 
physiologists. 

The two salient deficiencies, in so far as 
scientific management is concerned, are briefly: 
first, inadequate methods of determining and 
stating the work of the human machine; and, 
secondly, inadequate means of determining the 
eflfects of work upon the human machine, u e., 
fatigue. In the determination of work, Amar em- 
ploys the customary methods used in the past. 
For example, a man uses both hands in filing 
and makes both vertical and horizontal pressiu^ 
upon the file. The pressure in both directions is 
determined in kilograms. He moves the file a 
certain distance in the horizontal plane. The 
work which he accomplishes is determined by 
multiplying the horizontal pressure by the dis- 
tance through which the file b moved. The 
downward pressure is disregarded. From a cer- 
tain standpoint this may be of value — pos- 
sibly, in comparing the efficiency of the human 
machine with other types of machines — but from 
the standpoint of determining quantitatively the 
I^ysiological activity involved in the work as a 
basis of reckoning daily functional activity, it is 
inadequate. Total muscular activity, however, 
may be inferred from studies on oxygen con- 
sumption. This was done in the case of filing. 
It must be recognized, however, that the oxygen 
consumption gives no indication of the de- 
mands made upon particular muscle groups 
and, furthermore, that it does not indicate the 
demands made upon the special senses and 
nervous system. Our technic must, therefore, 
be extended to include measurements of the 
physiological activity of particular muscle 
groups and other structures concerned in work, 
if we are to obtain measurements indicative of 
the demands made upon the human machine. 
In connection with muscular activity it has long 
seemed to me that more fruitful results would 



be obtained by expressing this in terms of ten- 
sion multiplied by time rather than of weight 
times distance. 

In the matter of determining the effect of 
work upon the himian organism, Amar offers 
little assistance to the engineer. In the ex- 
amples given, he recognizes fatigue produced in 
the work, by irregularities in respiration, pain 
in a muscle group, unusually high performance 
in terms of kilogrammeters, and by oxygen 
consumption, and as we know these are not 
reliable criteria of fatigue. His contribution to 
the energy exchanges in the work of an appren- 
tice as compared with a skilled worker is an 
additional plea for a detailed study of move- 
ments in occupation and standardization of the 
most efficient movements, which, it should be 
noted, may not be those of the shortest paths or 
necessarily those requiring the lowest oxygen 
consumption. The method suggested, which 
involves a study of the movements of the most 
efficient workers, is likely to prevent falling into 
such errors. 

Amar indicates the advantages to be gained 
through proper selection of workmen but does 
not discuss this aspect of the subject. His 
classification of men into four types — the 
digestive, the muscular, the respiratory, and 
the nervous types, each suited especially to cer- 
tain types of activity — seems far-fetched; also 
the statement that subjects with a stronger will 
have more endurance hardly admits of practical 
application. 

Under external environment there is a brief 
discussion of atmospheric pressure, the effects 
of gases and vapors, etc. In connection with 
high altitudes the work of English investigators 
is not mentioned, and in connection with cais- 
son sickness the advantage of gradual decom- 
pression of the air pressure is not referred to. 
Moreover, the work referred to in connection 
with the occurrence of diabetes following 
exposure to aluminum fumes should be ques- 
tioned. 

Amar is a pioneer and his excellent book 
should stimulate both the practical man in in- 
dustry and the laboratory worker to a fuller 
realization of the fruits which may be reaped 
through endeavor in this field. — A. H. Ryan. 



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THE JOURNAL OF 
INDUSTRIAL HYGIENE 



PUBLISHED MONTHLY 



Volume m 



JANUARY, 1922 



Number 9 



DUST IN PRINTERS^ WORKROOMS* 

C. B. ROOS, B.Sc., F.I.C. 
H, M, Inspector of Factories 






DISCUSSION having arisen in the 
press as to the possible relationship 
between tuberculosis in printers and inhala- 
tion of silica dust, I was instructed to in- 
vestigate the quantity and nature of the 
dust in the air of workrooms in which 
printing processes are carried on. Some 
silica is foimd in "printer's list," a black 
fluffy substance which collects in com- 
positors' cases, and its existence there has 
*>een attributed to: 

J. Sand used in casting and moulding 

jf^oxx "chases" (the metal frames into which 

^/^o type is locked). When these rust, the 

sj0UOL€3i is loosened and on releasing the type, 

siXic^^ and oxide of iron are shaken out. 

^ • Silica shaken off the chases by vibra- 
tioxifc. in machines. 

^- The "dross" which arises from the 
"li^f when used type is melted down. 
Tla^i^ dross is skimmed off and often stored 
in^ <:>pen chests in workrooms for months 
^a^til sold. 

I^t was suggested that the silica was car- 

^^<1 from the compositors' cases into the 

^^^ ^y floating vegetable fibres produced by 

lvi« paj)er. The pai>er fibre was clogged 

^^•o the type in the machines; when the 

Xteprinted from the Annual Report of the Chief In- 
*y^5|tor of Factories for 1920 by permission of the Con- 
iwslier of His Majesty's Stationery Office. 



type was released, the fibre was distributed 
with the silica into the cases, then thrown 
out into the air, and inhaled while the 
compositor was picking out the type he 
wanted. 

It appeared therefore that to test these 
theories information on the following points 
would be useful: (1) quantity of dust in the 
air of printers' composing and machine 
rooms, and particularly as to whether the 
amount was in excess of that found in the 
air of ordinary rooms; and (2) nature and 
size of dust particles. 

Determinations of the dust were made 
both in old-fashioned works, where con- 
ditions of air space and ventilation were 
usually indifferent, and in ui>-to-date 
works, under the best conditions obtain- 
able. Altogether eight works were visited, 
four "good," and four "indifferent." In 
every case the air was drawn in at the 
breathing level of the workers, either in the 
centre of the room, or in the most crowded 
part. 

These determinations were made by a 
special apparatus designed by Mr. G. E. 
Duckering (1). Briefly, the method con- 
sists in drawing a measured volume of the 
air of the workroom through a weighed 
filter-paper and weighing the dust col- 



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lected on the paper. From these results a 
figure representing the dust content of the 
air, known as the "dust figure," is calcu- 
lated, and can be used for purposes of 
comparison. The dust figure is the number 
of milligrams of dust in 10 cubic metres of 
air, this being a convenient standard to 
adopt. 

The dust collected on the filter was sub- 
mitted to microscopical examination (with 
polarised light) with a view to determining 
the size and character of the constituent 
particles. The results of these determina- 
tions are given in Table 1. The dust 
figures may be compared with those in 
Table 2, which were obtained (1) in the 
open air; (2) in a laboratory. 

In view of the different suggestions as to 
the sources of the silica, samples of dust 
were collected from (a) fluff and dust from 
compositors' trays and cases; (6) dross 
from melting pots in casting rooms; and 
(c) paper fibre from machine rooms. Dur- 
ing the investigation another possible 
source of dust was evident, namely, the 
French chalk used in the moulding process; 
a sample of this was also taken. These 
samples were analysed at the government 
laboratory, and the results of the analysis 
appear in Table 3. They can be compared 
with an analysis of a "domestic" dust. 

Conditions in Printing Works 

Composing Rooms. — In general, these 
rooms are not particularly well ventilated. 
Although in most cases plenty of windows 
(to open) are provided, they are usually 
foimd to be closed. The workers seem to 
prefer a warm atmosphere and object to 
windows being open. In some rooms, espe- 
cially those used for newspaper work, there 
is much traffic, and in such cases the dust 
figure is higher than in rooms where traffic is 
restricted. 

The dust in the trays is a woolly, felted, 
fluffy substance; but if the type is removed 



there is also found a fair quantity of fine 
black dust underneath the fluff. It is only 
to be expected that the trays, which are 
divided into small compartments, and only 
occasionally cleaned, will accumulate dust. 
When not in use the trays are stored away 
in a sort of cabinet, into which they fit like 
drawers. When an old case is taken into 
use after being disused for some length of 
time, an attempt is usually made to clear 
the dust from the small compartments. 
The old method of doing this, still used in 
many works, is to take the tray into the 
open air and blow the dust away with 
hand bellows. The more modem firms 
have installed dust extractors for this pur- 
pose. These are of two kinds: 

1. A closed box with a fan and duct, 
known as the "Clements' Case Dust Ex- 
tractor." The tray is placed inside the box, 
and the motor started. The action is three- 
fold; the tray is agitated so as to stir up the 
type, the dust is blown up into the air in- 
side the box, and drawn away by the fan 
through the duct into a special compart- 
ment, from which it can be cleared. The 
time taken to clear a tray by this method is 
about thirty seconds, as against fifteen to 
twenty minutes by the hand bellows, be- 
sides which there is no chance of the worker 
breathing the dust. Each compositor 
usually clears his own trays, as he requires 
them. 

2. A vacuum cleaner, similar to those 
used for domestic purposes. A special 
worker is employed to go round the com- 
posing room, and keep all trays clean. Its 
disadvantages, as compared with the Clem- 
ents' Extractor, are that there is no 
device for shaking up the type and so re- 
moving the dust underneath, and that 
light, thin pieces of tyi)e are liable to be 
lifted up with the dust by the suction, and 
carried inside the cleaner. 

Machine Rooms. — Conditions in these 
rooms vary within very wide limits. Some 
are large and well ventilated, on the ground 



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floor, with good natural or mechanical 
ventilation. In many cases, however, the 
machine rooms are in the basement with . 
artificial light constantly in use. They 
often appear to be overcrowded with ma- 
chinery, their free ventilation being thereby 
restricted. 

A certain amount of paper dust is usually 
found on the machines, the quantity vary- 
ing with the kind of paper used. The prin- 
cipal varieties of paper met with are as 
follows, in the order of their dustiness: 

1. Antique wove. — This is the dustiest 
pai>er on the market. It is used almost en- 
tirely for printing high-class novels. 

2. Antique. — Used for cheap magazine 
work. 

3. News. — Used for cheap newspapers, 
weekly periodicals, etc. 

4. Thin antique. — Used for books. 

5. Smooth or calendered antique. — Used 
for high-class newspapers, books, etc., and 
for the outside of weeklies and cheap maga- 
zines. A fairly smooth paper giving only a 
little dust. 

6. Calendered. — Good smooth surface, 
giving very little dust. 

7. Super-calendered. — Gives practically 
no dust. 

In machine work where a dusty paper is 
used, the type has to be wiped frequently, 
as a bad impression is made in printing if 
the dust collects. The "clogging" of the 
type by dust and ink is therefore kept 
down to very small limits, to avoid spoiling 
the work. Moreover, after type is finished 
with and while it is still in the frame, or 
chase, it is usually washed with strong 
caustic potash solution, to remove the ink 
and paper fibre, before being broken up. 

McnUding Rooms. — The chief character- 
istic of these rooms is the high temperatiu'e 
from the steam presses in use. The only 
possible source of dust is the French chalk 
used for dusting forms before and after 
moulding. Most firms use very little 
French chalk; in one case where a fair 



amoimt was used a suction fan was pro- 
vided to assist in keeping the room clear of 
dust. 

Casting Shops. — The processes carried 
on in these shops are: 

1. Melting down of type (old and new). 
This is done in large pots, provided with 
hoods and ducts to carry off the fumes. 
The dross rises to the surface and is skim- 
med off. It is generally left until the next 
day to cool, when it is either placed in 
sacks or in a special closed metal bin, kept 
outside the workroom. -It is disposed of to 
lead smelters (for recovery of the metal) 
and carted away weekly. Table 3 shows 
that dross contains no siUca. 

2. Pouring of molten type into moulds. 
This process gives rise to no dust. 

3. Various trimming processes, e. g.y 
"routing," "shaving," etc. None of these 
is a dusty operation. 

Linotype and Monotype Machine Rooms. 
— The machines give rise to little dust; 
the fumes given off by the melting pots are 
in most cases efficiently removed by ex- 
haust ventilation. 

Consideration of Results 

In Table 1 the results have been ar- 
ranged so that the amounts of dust in the 
air for the various processes are grouped 
together. 

Composing. — Table 1 seems to show 
that the following factors have a deter- 
mining influence on the size of the dust 
figiu-e: 

1. Size of room, in relation to the num- 
ber of workers, i. e., amoimt of cubic space 
for each worker. 

2. Amount of traffic in room. 

3. Amount of ventilation, i. e., rate of 
change of air in the room. 

Number 100 has the highest figure 
(24.4) for all composing rooms, the room 
being rather crowded, with much traffic. 
Number 107 is next, with a figiu-e of 19.5; 



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ROOS — DUST IN PRINTERS' WORKROOMS 



261 



the ventilation was poor, and the presence 
of platen machines raised the dust con- 
tent of the air. Number 115 (18.2) was a 
well-ventilated room, but was somewhat 
crowded, and much traflSc was going on. 
Numbers 99 and 105 have the same figure 
(14.6) ; in one case all windows were closed 
and there was no traflSc, and in the other 
case there was good' ventilation and much 
trafl5c. The lowest figure of all is 7.3, ob- 
tained in two cases in which all the factors 
contributed to a low dust content. The 
average figure for the eight samples is 14.1. 

Machine Work. — Here, besides the air 
space and ventilation, the kind of paper in 
use is seen to influence the figure. Number 
108 is highest (31.7), the ventilation being 
indifferent and the paper dusty. Number 
112 was taken in the least satisfactory 
room encountered, but the paper used was 
of a smooth, calendered type, so that the 
dust figure (18.3) is moderate. Number 
114 was taken under what might be termed 
ideal conditions — a large, lofty, well- 
ventilated machine room, and a smooth 
calendered paper. The dust figure (1.0) is 
practically negligible. The average figure 
for the seven samples is 13.1 

Moulding and Casting. — The dust figure 
in these rooms (24.4) is somewhat in excess 
of the average figure for machine and com- 
posing rooms. This is explained, in the 
case of the moulding room, by the quantity 
of French chalk in use, and, in the case of 
the casting room, by the relatively large 
amount of traflSc at the time of sampling. 

Results of Microscopical Examination 
{Table 1). — This examination was carried 
out by Dr. H. H. C. Thomas, D.Sc, at the 
Geological Survey and Museum, Jermyn 
Street. The results show that, in all print- 
ing processes, the quantity of silica in the 
dust of the air is extremely small — in 
some cases so small as to escape detection. 
It appears, therefore, that the workers 
breathe very little, if any, silica. The dust 
consists for the most part of vegetable 



fibre and carbonaceous matter. In one case 
(No. 108), in which a rough "news" paper 
was being used, the vegetable fibre is de- 
scribed as having "good vegetable tissue 
with cell structure. The tissue and struc- 
ture indicate straw . or grass particles." 
Possibly some variety of straw or grass had 
been used in the manufacturing of the 
paper. In all cases the vegetable fibre is 
described as being "not such as would be 

TABLE 2. — RESULTS OF DETERMINATIONS OF 

DUST IN AIR AND IN ROOMS WHERE 

ATMOSPHERE WAS NOT DUSTY 



Point at Which Determinations Were Made 



Centre of garden, Edgbaston, after three fine 

days 

Same point after four days of fine weather . . .' 
Same point after thirty-six hours of heavy rain 

Centre of study, Edgbaston , 

Open air outside laboratory. Stoke, centre of a 

manufacturing district 

Centre of laboratory. Stoke 

Side of laboratory. Stoke 

Side of laboratory, Oxford 



Milligrams 

of Dust in 

10 Cubic 

Metres of 

Air 



2.1 

2.8 
0.7 

7.7 

9.4 
18.5 
10.8 
12.6 



yielded by filter paper," i. e., by the ma- 
terial on which the samples were collected. 

Table 2 shows the results of determina- 
tions of dust in the open air and in rooms 
where the atmosphere was not dusty. 

The dust figure of the atmosphere ap- 
pears from these determinations to vary 
from 0.7, imder ideal conditions (open air 
after heavy rain), to 18.5, this being the 
figure in a laboratory in a manufacturing 
town. Out of eight samples taken in com- 
posing rooms, in only two cases is this latter 
figure exceeded, and out of seven samples 
taken in machine rooms, in only one case, 
while the average figure for both these 
classes of work (14.1 and 13.1 respectively) 
is well below. Moreover, the figure 18.5 
represents the dust in the air of an empty 
room with no traflSc of any sort. A com- 



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262 



THE JOURNAL OF INDUSTRIAL HYGIENE 



parison of Tables 1 and 2, therefore, shows 
that printers' workrooms are by no means 
dusty. 

Table 3 shows the results of analyses 
made at the government laboratory of nine 
samples of dust taken from printing works. 
This table gives the analysis of the sources 
from which it has been alleged that silica 
may geX into the dust of the air. The high- 
est percentage of "free" silica found is 6.31, 
the average being 3,35. Silica dust is com- 



metal and occasionally a little metallic 
oxide. 

"Total silica" in dust from printing 
works, when compared with that of Lon- 
don "domestic" dust taken from the top 
of a wardrobe,* comes out much the lower 
of the two. 

Conclusions 

1. Printing cannot be described as a 
"dusty" trade. The average quantity of 



TABLE 3. — RESULTS OF ANALYSES OF DUST SAMPLES FROM PRINTING WORKS 



Sample 
No. 


Firm 
No. 


Where Taken 


Organic 
Matter 

and 
Moittuie 


Lead 


Other 
Heavy 
Metals 


Total 
Sifica 


other 
Inorganic 
Substances 


Total 


"Pwe" 

Sifica 
(Indaded 
in Total 

SUica) 


1 
2 
3 
4 


1 
1 
2 
2 
2 
6 
9 
4 


Type cases, composing room 

Inside Clements* dust extractor . . 
Inside Clements* dust extractor . . 
Machine room 


66.00 
59.00 
40.00 
71.00 
47.00 
68.00 
56.00 
74.00 


2.80 

8.92 

23.75 

0.51 

4.68 

4.39 

traces 


3.20 
4.08 
6.25 

traces 
0.49 
1.32 
1.61 

traces 


8.95 

9.96 

8.63 

11.45 

13.23 

8.48 

13.72 

12.00 


19.05 
18.04 
21.37 
17.55 
38.77 
17.52 
24.28 
14.00 


100.0 
100.0 
100.0 
100.0 
100.0 
100.0 
100.0 
100.0 


4.33 
6.31 
1.32 
2.50 


5 
6 

7 


Inside fan in moulding room 

Type cases, composing room 

Inside dust extractor 


3.16 
3.21 
4.24 


8 


Machine room 


1.78 









paratively heavy, so that the percentage 
of silica actually breathed by the worker is 
probably much lower than this. The re- 
mainder of the silica in the samples, in- 
cluded from the heading of "total silica,'* 
is present in the combined form, as silicates, 
in which form it is considered to be in- 
nocuous (2). 

The ioUo wing is an analysis of a sample 
of "dross": antimony, 16.49; lead, 68.23; 
tin, 12.50; copper, 0.12; iron, 0.09; zinc, 
0.26; arsenic, 0.09; oxygen, 2.22; total, 
100.00. It shows that dross, which is one of 
the alleged sources of silica, is entirely of 
metallic constitution. When type is melted 
down, the oil and other organic matter rise 
to the surface and are vaporised, the 
vapours passing into the hood above the 
casting pot. A certain amoimt of the metal 
separates from the alloy in a granular con- 
dition and is skimmed off. These skim- 
mings are the dross and consist entirely of 



dust in the air is no higher, and in some 
cases considerably less, than that in the air 
of many occupied rooms. 

2. The dust in the air contains very 
little silica — in some cases a negligible 
quantity. 

3. The dust in comFK)sitors' cases, in 
machine rooms, and in other dust-produc- 
ing sources contains less silica than dust 
collected from a living room. 

4. On the grounds of the presence of 
lead alone in the dust of the type cases, it is 
desirable that some apparatus, such as the 
Clements' Case Dust Extractor, should be 
used, particularly in large works, for re- 
moving the dust from the trays and cases. 
Such apparatus should be so constructed 

* The analysis of this is given by Sir J. Ciichton- 
Browne in the Times of Nov. 3, 1920, as foUows: moisture^ 
4.4; organic matter, 52.6; silica and insoluble silicates, 21.0; 
iron oxide and alumina, 9.7; lime (CaO), 6.2; carbonic add, 
with traces of sulphuric and phosphoric adds, 6.1; total, 
100.0. 



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ROOS — DUST IN PRINTERS' WORKROOMS 263 

that the dust does not escape into the air me at the South Western Polytechnic In- 

during the process of removal. stitute, Chelsea, and the thanks of the 

The laboratory work in connection with Department are due to the authorities for 

the dust determinations was carried out by the facilities given. 



BIBLIOGRAPHY 

Duckering, G. E.: Methods of Determination 2. Collis, E. L.: Industrial Pneumonoconioses, 
of Dust and Lead in the Air of Workrooms. with Special Reference to Dust-Phthisis. Mil- 
Ann. Rep. Chief Inspect. Factories, 1910, p. roy Lectures, 1915, p. 32. Pub. Health, 1915- 
201. 1916, 29, 16. 



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INFLUENCE OF INDUSTRIAL NOISES 

D. J. GUBERT, M.D. 

Chief Medical Inspector of Factoriee, Brussds 



THIS memoir — a resum6 of all that 
was known in 1914 in regard to the in- 
fluence of industrial noises — was originally 
written at the request of the Third Inter- 
national Congress on Occupational Diseases 
due to be held at Vienna in the later half of 
August, 1914, and was intended to open 
the debate on the subject. As the author 
lived in the occupied part of Belgium dur- 
ing the war, he had no access to new 
work, but nothing new appears to have 
been discovered, except that we have 
since learned of the idea that deafness fol- 
lowing an explosion is usually temporary 
except when the auditory nerve is affected. 
It seems wise, however, to re-introduce so 
important a subject in order to stimulate 
research on the part of ear specialists. The 
influence of noise, which is at times deafen- 
ing, has been little studied in spite of the 
fact that it is present in nearly all indus- 
tries. The author, although not an ear 
specialist, feels justified in writing this 
resume because it states the present po- 
sition; because there is confusion among 
ear specialists; and because of his twenty 
years' experience in factory work which 
has enabled him to bring out the etiological 
factor in questions on which industrial 
doctors require a solution from ear spe- 
cialists. 

Deafness as an Occupational 
Disease or Accident 

Deafness as an occupational disease 
should be studied separately from deafness 
caused by traumatic lesions due to explo- 
sions, gim fire, blasting, etc., which cause 

* Translated from BuUetin du Service Midical du Tra- 
vail, J^n., 19«0, No. 1, by Dr. S. A. Henry, H. M. Medical 
Inspector of Factories, Manchester, England. Received 
for publication May 2, 19£1. 



immediate lesions, although the difference 
is perhaps somewhat subtle. Save in spe- 
cial cases where initial lesions are clearly 
recognized as immediate, it is only after 
repeated injuries that ear affections be- 
come obvious, and therefore it is nearly 
always convenient to classify the deafness 
of gunners and firers of mines among occu- 
pational diseases rather than among acci- 
. dents. Consequently, for practical purposes 
we may include the affections caused by 
injurious action of the air during firing 
among ear injuries caused by noise proper. 

Outline of Previous Investigations 

Classic writers on occupational diseases 
are generally reticent on the subjectof disor- 
ders caused by noise in industry. Layet (1) 
points out that the deafness of copper- 
smiths was known of old and that sheet 
iron workers, coppersmiths, blacksmiths^ 
and coopers are nearly always hard of hear- 
ing and become more so the longer they re- 
main at their trade — a perversion of hear- 
ing shown by increased perception of high 
notes or loss of perception of low notes. 
Layet observed an old foreman who ap- 
peared to hear only in the midst of the 
greatest noise, while at other times he com- 
plained of continual buzzing in his ears, so 
that he was an example not only of the 
phenomenon of WiUis but of other ear 
trouble. This phenomenon of Willis (hear- 
ing better when a certain sound is present 
than under ordinary conditions) is frequent 
in noisy industries, where another phenom- 
enon is also observed which must not be 
confounded with that of Willis — namely, 
the power of certain workers to converse 
together in a nearly normal voice when a 



264 



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GLIBERT — INFLUENCE OF INDUSTRIAL NOISES 265 

stranger is at the time deafened and inca- closed space. Delia Vedova of Milan, at 

pable of making himself heard without the Seventh Itahan Congress of Laryn- 

raising his voice. In factories for removal gology and Rhinology, insisted on good 

of coarse hair from furs by machinery or ventilation in enclosed spaces and pointed 

in works where hatters furriers' processes out among the causes harmful to hearing, 

are carried on amid intense noise, I have dust, irritating gases, high temperature, 

often observed the workers laughing and dampness, and variations of atmospheric 

talking together when I could not hear the pressure, and cited as a proof of the injuri- 

sound of their voices. Is there a special ous influence of a confined space the fact 

adaptation of the worker's voice or a par- that among soldiers inflammatory condi- 

ticular accommodation of the organism of tions of the ear are less frequent during 

the ear, or both.'* Be it as it may, this manoeuvres than during life in barracks, 

phenomenon is not necessarily accompanied As far back as 1877, the replacement on 

by a diminution of hearing in a quiet at- railways of shrill toned whistles by those of 

mosphere. a deeper note or by other signals, such as 

According to Roosa, workers in a noisy bells, was suggested. Hedinger, in 1882, 
atmosphere get a true nerve lesion; they tested the hearing of 1,100 railway em- 
hear less well and do not recover their acu- ployees and found only 48 per cent, of hard- 
ity of hearing except by staying off work ness 6f hearing among engine drivers and 
for some time, and eventually the auditory stokers as against 95 per cent, among the 
trouble becomes permanent. According to other employees. He concludes that in- 
Dr. Moure of Bordeaux, the more the noise temperate habits are much more the cause 
produced in a small, closed and resounding of catarrhal affections of the ear than is 
space, the more rapid is the damage to the the engine whistle. Guterbock states that 
auditory nerve; that is why he considers hardness of hearing among engine drivers 
as the most exposed young persons- who increases in proportion to the length of 
are employed in coppersmiths' workshops service, as the following table shows: 
to assist riveters in the interior of boilers y^^^^ ^j ^^^^ PercerUage of DefecUve Hearers 

in holding rivets in place during hammer- Less than 5 5.8 

ing. It is necessary to class with this From 5 to 9 7.3 

group young persons who enter the boilers From 10 to 14 8.0 

for the purpose of removing the deposit ^^°^ 15 to 19 31.8 

(boiler cleaners) . My personal experience ^^ 

confirms the fact that these workers at Dr. G. Boval likewise states that the 

times leave this noisy atmosphere abso- deafness of engine drivers and stokers in- 

lutely dazed, deaf, and in a state of vertigo creases with age and years of service from 

which lasts for several minutes. These 11.7 to 62 per cent, according to age, and 

facts may be compared with those ob- from 18 to 75 per cent, according to years 

served in ironclads after a sea battle and of service. Barr makes similar observa- 

in this connection De Merrys reports that • tions on 100 persons; after seventeen and 

on the Cesarewitsch, twenty-four hours one-half years' service none heard a watch 

after the engagement, many men com- normally, fifty could not hear the low voice, 

plained of headache, loss of memory, and thirty-three perceived it with both ears, 

deafness. and eight with only one ear. 

Other influences, however, than that of It is surprising that observations in tex- 

a resoimding medium can be cited to ex- tile industries are rare. Ropke (2) refers to 

plam auditory lesions of workers in an en- the examination of twenty spinstresses, 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



fourteen of whom were hard of hearing, 
and of fourteen weavers, none of whom 
heard normally. Dr. E. Coosemans, at the 
Sixth International Congress of Otology 
held in London in 1899, read a paper on 
hearing among "beetlers," who, after ten 
or twelve hours of daily labor, exhibit more 
or less marked deafness, which diminishes 
after a few hours, and which becomes nor- 
mal after a Simday's rest. 

Another injurious occupation is that of 
telephone workers. Capart (3), reporting 
upon the telephone industry, stated that: 
(1) Occupational use of the telephone is a 
cause of fatigue to the ear, which may be ag- 
gravated too far by certain circumstances, 
such as production of induction currents, 
sudden opening and shutting of the circuit, 
etc.; and (2) fatigue and overwork of tele- 
phonists are at times the cause of various 
neuroses, neurasthenia, hysteria, etc. How- 
ever, others, as Dr.N.R. Blegvad (4) are less 
pessimistic and do not think that telephone 
work hastens, or makes active, pre-existing 
ear affections. Generally the power of per- 
ception of high soimds is little altered. Of 
854 telephone employees examined with 
regard to the lowest sound perceptible to 
the normal ear (sixteen vibrations), seventy- 
five could not perceive it on one or both 
sides. Blegvad admits that among certain 
individuals employment can cause earache, 
buzzing, vertigo, or Meniere's syndrome. 
Recently Dr. Tretrdp of Antwerp (5) re- 
ported two ear accidents, one to a telephone 
girl, and the other to a merchant speaking 
on the telephone, which he attributed to 
the too sudden breaking of a current of 
which the voltage had lately been increased 
to 20 volts. 

Attention was first drawn to the action 
of reports and explosions on the ear when 
the use of gunpowder was introduced. Am- 
broise Pare taught us that heavy artillery 
could cause ear lesions and cerebral con- 
cussion. Layet (6) mentions the investi- 
gations of Percy who j!>ointed out hem- 



orrhages following a ruptured tympanum, 
with persistent severe headache, more or 
less pronoimced disturbances of hearing, 
and refractory otitis following on the 
non-cicatrization of the rupture. He also 
recalls Barthelemy*s remarks on a momen- 
tary hardness of hearing with hissings, 
buzzings, and "still noises,'* (proof of 
nerve trouble) met with among gunners 
after firing. These observations, however, 
were made before war was brought to 
a fine art, and require re-investigation to 
prove whether or not they are true. 

Delsaux has analyzed all the work on 
the noise of explosions and firing, and re- 
calls the work of R. MUller who examined 
fifty-one gunners, noting the extent of their 
hearing before firing and three days after. 
Six were excluded because their ears were 
plugged with wax; of the remainder ex- 
amined before firing, thirty-four were nor- 
mal and all the others had symptoms of 
actual disease or signs of old cicatrices. 
After firing, fifty-two ears remained in 
statu quo and all the others showed tym- 
panic congestion. There were seven cases 
of hemorrhage of the tympanum but none 
of rupture of the membrane. The duration 
of perception of the tuning fork by bone 
conduction was shortened. On the subject 
of air conduction, the author is reticent 
and calls for further investigation. It ia 
the experience of Cheatle, in England, that 
naval oiBBcers are more affected than their 
men and that the very high tone of guns 
of small calibre and of machine gims is 
more injurious than that of big gims. In 
addition, autopsies as well as experiments 
on animals corroborate the fact that occu- 
pational noises are capable of seriously in- 
juring the organs of hearing. 

Elementary Knowledge 

In reading works on the subject of the 
influence of industrial noises, one is con- 
stantly meeting vague expressions, such as 



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GLIBERT — INFLUENCE OF INDUSTRIAL NOISES 



267 



"muffled sounds," "light sound," "great 
noise," etc., which it is necessary to define 
uniformly. 

It is generally admitted that a:ll sounds 
and noises which the ear receives can be 
referred to musical soimds. Noise proper 
is composed of a rapid and irregular suc- 
cession of different auditory sensations. 
Sound, on the contrary, is uniform, calm, 
and without variations in its component 
parts. It possesses three principal quali- 
ties which are peculiar to it: intensity, re- 
sulting from amplitude of vibration and 
diminishing by distance in proportion to 
the square of the distance, from the fact 
of the diminution of the amplitude of vi- 
brations transmitted; height, which in- 
creases with the number of vibrations; and 
tone, which depends on the harmonics, 
"superior or inferior," of the fundamental 
sound. Certain authorities add to inten- 
sity, height, and tone the idea of duration. 
To these intrinsic qualities of sound must 
be added an extrinsic quahty described 
thus by Helmholtz: "In the main, in 
sounds of equal strength the sensibility of 
the ear changes with the height of the 
sound." Zwaardemaker (7) formulates 
the following conclusions as to this variable 
sensibility of the ear for different sounds: 

1. The maximum sensibility of the human ear 
responds to 3,072 double vibrations (g4 of the Ger- 
man no^tion, sol 6 of the French notation). 

2. The zone of very distinct sensibility extends 
from 256 double vibrations to 6,144 double vibra- 
tions. 

3. Outside this zone to the limits of the scale, 
sensibility diminishes considerably. 

There are three principal theories of the 
way in which sound is perceived: 

1. Helmholtz' s Theory. — The organ of 
Corti vibrates in concert. The elements 
of the internal ear are attuned to different 
heights of sound; low sounds are perceived 
by the part fiui:hest from the base of the 
cochlea, while sharp soimds are perceived 
nearest this base. 



2. Hydrodynamic Theory of Bonnier (8). 
— The liquid of the cochlea moves in bulk 
and rubs the sensory epithelium. Bonnier 
compares the organs of the ear not to res- 
onators, but to registers. 

3. Pressure Theory of Mar age. -The 
perception of sounds is due to differences 
in the pressure of the endolymph, with no 
definite auditory localization. 

Musical sounds proper are met at times 
in industry, as in hammering deep-toned 
metals, but these more or less pure sounds 
are rarely isolated. More usually noise 
proper is heard, but that also has its in- 
tensity, height, and tone. It is compara- 
tively easy to determine experimentally 
the relative intensity of an industrial noise 
when it is regular and more or less continu- 
ous and can be compared to another noise, 
a short distance away, of constant intensity 
and suflScient to rise above it; The meas- 
ure of the displacement required would 
give the relative intensity. Exact estima- 
mation of the height of noises is much more 
difficult, and we must, for the most part, 
rely on a few observers for this information. 
Although a well-trained ear learns by prac- 
tice to grade the tone of noises by compari- 
son with a known height of tone, it would 
be more satisfactory if the ear specialist 
would furnish a precise method of deter- 
mining as nearly as possible the notation 
of different noises. Tone, on the other 
hand, can be described with sufficient 
precision for practical purposes. It char- 
acterizes the source of noise; it enables 
one to distinguish various machines in 
action, without seeing them; and, in com- 
bination with height, it gives to certain 
noises that disagreeable character which 
is peculiar to them — e. g., the rasping 
noise in the finishing off of white stones, or 
the grating of saws or files. When it has 
this unpleasant character, tone is important 
in observations, as it inevitably has an ill 
effect on persons of nervous temperament. 
It is also necessary to pay attention to the 



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rhythm, and the continuity, regularity, or 
irregularity of a noise essentially uniform 
are also factors to be dealt with. The un- 
expectedness of certain short, loud noises 
bursting forth at rather long intervals has 
a disagreeable eflFect on the nervous system. 
Finally, it is necessary to have comparative 
information on the subject of intensity of 
vibration communicated to the ground and 
to the body of a worker by the vibrating of 
noisy machines. This information is not 
difficult to obtain. 

Noisy Trades 

It would be wrong to imagine that all the 
employees in a brass foundry, in large iron 
works, or in shipbuilding yards are equally 
exposed to noise in their work. We must 
have a reasonable classification' which will 
serve to show that it is necessary in each 
group to take into account accessory cir- 
cumstances. Take, as an example, flax 
spinning which must be carefully dis- 
tinguished from weaving of linen, just as 
it must not be confounded with "steeping" 
and "stripping" or "scutching," — the 
operations which precede it. 

In a linen factory one meets all the scale 
of noises: there are quiet processes, as 
winding, or reeling, and heckling; less 
quiet processes, as drying and packing; 
noisy ones, as combing by machinery, 
carding; and, finally, very noisy ones, as 
in the preparing rooms and spinning rooms 
where the noise is so great that orders have 
to be given by means of a shrill whistle. 
Hence, one sees the inaccuracy of medical 
observation which is limited to describing 
the examinees as workers in the linen in- 
dustry. Carding, preparation, etc., irritate 
the nasopharynx by dust, and spinning 
gives rise to similar trouble because of the 
humidity and heat which may cause 
"chills." Combing by machinery exposes 
the young worker to dust and muscular 
strain. 



In many factories the noise is great in 
certain places and not in others, as in metal 
stamping, especially in making metal boxes. 
Very often in these works there are quiet 
comers, also the noise of one stamping 
machine varies from another, and curiously 
enough it is npt always the stamper who is 
most exposed to the noise of his own ma- 
chine. Certain other occupations are quite 
unknown to aurists. How many of them 
suspect that in the preparation of little 
rubber objects such as nipples for feeding 
bottles and toy balloons, there exists at 
times noise comparable to that of the 
loudest hammering. These examples are 
sufficient to prove the necessity for medical 
inspectors of factories to draw up a list of 
noisy industries which would serve as far 
as possible as a basis of comparison, and to 
point out all the other peculiarities which 
may influence health. The ear specialist 
ought to be in possession of all the facts 
before he pronounces on the etiology of a 
lesion, and he should take into account all 
the causes other than noise which could 
explain in part or in whole the malady 
observed. 

In addition to information in regard to 
noise, the aurist should know in detail the 
peculiar health conditions of certain trades. 
Lesions of the middlie ear or nasopharynx 
are in themselves a menace to the int^- 
rity of hearing. Noise being equal, trades 
which specially expose a worker to these 
lesions are more harmful to hearing than 
others; hence, the necessity of paying 
attention to different accessory risks, such 
as mercury, carbon bisulphide, and espe- 
cially lead, which is a poison to the internal 
ear. Irritant vapors, or acid fumes, and 
toxic gases, such as carbon monoxide, in 
the form of slow chronic poisoning attack 
hearing as well as memory. In the same 
way, it is necessary to note the influence of 
heat, humidity, and dusts. Moreover, the 
influence of fatigue, muscular and intellec- 
tual, must be remembered. Fatigue in. 



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itself lessens auditory acuity even when 
not excessive. For example, examination 
of twenty-four bicyclist^ who had ridden 
50 kilometers showed that air perception 
was diminished, especially for sharp sounds 
(9). After a few hours' rest hearing had 
already improved. Finally, it must be re- 
membered that ear lesions are often accom- 
panied by loss of sense of space (vertigo, 
M^nifere's syndrome), and in this connec- 
tion I wish to note the occupational risk 
on ladders, scaffolding, and work in par- 
ticularly dangerous places. 

Nature of Lesions 

According to Layet, most authors think 
that noise is a determining factor in caus- 
ing a true lesion of the auditory nerve. At 
the autopsy of an old coppersmith aflSicted 
during life with occupational deafness, Hab- 
ermann found degeneration of the organ 
of Corti and other nerve elements at the 
base of the cochlea. Similar lesions were 
found by the same author at the autopsies 
of several other subjects afflicted with deaf- 
ness which was considered to be due to 
occupation. Moure, of Bordeaux, is of the 
opinion that, when the occupational dis- 
ease is established and, in spite of rest, 
hearing does not retiun, it is a question of 
deep-seated trouble — a labyrinthine af- 
fection, of which the diagnosis is certain 
and proved by acoustic tests, before the 
absence of lesions of other parts, such as 
tympanum, tubes, and ossicles, is objec- 
tivdy proved. 

Wittmaack has made considerable prog- 
ress in the question of lesions caused by 
noise. He has demonstrated that animals, 
subjected under certain conditions to the 
action of a noise of varied duration, with 
or without rest, show profound lesions. On 
microscopic examination the middle ear 
appeared intact, as did also the vestibule, 
while obvious changes were seen in the in- 
ternal ear in the region of the cochlea. 



Wittmaack's work has been controlled by 
Professor Siebenmann and his pupil. Dr. 
Yoshii, with varied intensities of sound. 
These authors constantly f oimd visible and 
characteristic anatomic lesions of the organ 
of hearing. These lesions, varying with the 
sound used, took effect on the organ of 
Corti, and the nerve fibers and cell ganglia. 
It is useful also to recall that, with a pure 
sound, always the same, Wittmaack found 
a lesion of the cochlea peculiar to itself in 
each case. 

H. Marx, of Heidelberg, experimenting 
on guinea-pigs under conditions similar to 
his predecessors, obtained similar results, 
at least in the main points. The degenera- 
tion of the organ of Corti, however, was 
foimd to be situated a httle further from 
the base of the cochlea than that f oimd by 
Wittmaack. Von Eicken, studying the 
action of deep sounds produced by organ 
pipes, states that, when the middle ear is 
normal, certain deep sounds cause altera- 
tions of the cochlea at the level of the 
second tiun of the spiral. Other deep 
soimds, on the other hand, appear harmless. 
Delsaux summarizes the conclusions to be 
drawn from the patient, and extremely 
careful, researches of Haenli. Violent ex- 
citation of hearing, or reports, attack at 
first the terminal organ which they destroy 
in a certain way and it is only later that 
the neurones atrophy. Later still, there 
appear alterations in the membrane of 
Reissner. 

A good synopsis of the results of Witt- 
maack's, Siebenmarin's and Yoshii's ex- 
periments is found in the very instructive 
work of E. J. Moure and P. Cauzard on 
functional examination of the labyrinth 
(10). The authors of this work are in- 
clined to consider the exp)erimental results 
as proved definitely, and allow the follow- 
ing assertions of Wittmaack: (1) the in- 
tegrity of the vestibule in lesions due to 
noise; (2) the destruction or alteration of 
the same section of the cochlea by soimds 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



of the same instrument (whistle). In a 
personal communication to these authors, 
Siebenmann expresses himself thus: "It 
follows (from the experiments of Witt- 
maack and his school) that a pure soimd 
only affects a single point of the cochlea and 
that the lower the sound is, the higher the 
point is foimd in the cochlear region." 

From the analysis of twenty principal 
clinical works on the results of reports and 
explosions, Delsaux concludes that the dis- 
orders of hearing or the lesions of the ear 
arising from these causes may be classified 
as: (1) lesions of the tympanum; (2) le- 
sions of the drum; (3) disturbance of the 
labyrinth; (4) progressive deafness; and (5) 
diverse nervous disorders. He states that 
all experiments tend to show that, apart 
from ruptures of the tympanum and lesions 
of the drum, and, in rare cases, lesions of 
the ossicles, injury to the ear by detona- 
tions gives rise in the internal ear to tem- 
porary or progressive or definitive lesions, 
situated mostly in the tympanic slope of 
the cochlea and rarely and temporarily in 
the vestibular slope or in the static appara- 
tus of the internal ear. Finally, it is well 
to keep in mind the views suggested to 
Layet by Dr. Moiu-e, namely, that when 
the organs are intact the principal indus- 
trial noises act on the labyrinth, while re- 
ports and explosions may also act directly 
on the organs of the middle ear. 

Transmission of Noise by Air and 
BY SouD Substances 

Must one blame noise transmitted at the 
same time by air and bv solid bodies? 
Must one, on the other hand, consider air 
vibration alone as practically harmless and 
blame chiefly vibrations and tremors which 
are communicated to the bony skeleton? 
This is a necessary point in prophylaxis. 
It is a problem, the solution of which, if it 
can be obtained, will revolutionize the 
methods of protecting the worker and the 



legal measures formulated by different 
governments. 

The accidental results of great explosions 
or a sudden change of pressure among 
workers in an atmosphere of compressed 
air must be excluded. These are cases of 
"superior force," the effects of which can- 
not be used as a proof for or against the 
theory as to the cause of it. Would it not 
be wise also to exclude the results of re- 
ports and explosions knowingly caused? 
Truly, the deafness of gunners is an occu- 
pational one, but the conditions producing 
it are not met with in industry, except 
quite exceptionally among those employed 
in shooting galleries or attached to depots 
for testing firearms. In firing a mine, it 
is obviously wise that workers who start 
the fuse should^be as far away as possible, 
and consequently lesions of the ear among 
them ought to be much more often in the 
category of occupational accidents than of 
occupational diseases. In addition, the 
violent disturbances which occur from the 
deflagration of explosives singularly com- 
plicate the principle of the problem. Hence, 
it would perhaps be wise to limit the sub- 
ject to industrial noises, properly so called, 
which are far more frequent. In return, it 
would be useful to compare the influence 
of vibrations where the noise is dominant, 
with the action of vibrations when shaking 
is the principal cause of trouble. 

There are a great number of workers on 
trains, trams, and vehicles of all kindd, 
whose whole bodies are for many hours, ex- 
posed to an energetic vibratory shaking, 
without which, howevei*, the noise to which 
these workers are exposed would still be 
considered as excessive. Whatever the 
value of these previous remarks may be, 
let us examine the main sources of infor- 
mation at our disposal. 

Castex, in 1897, speaking of engine 
drivers and stokers, pointed out the harm- 
ful influence of vibration: ''shaking acts 
on the labyrinth and causes sclerosis, as 



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seen in the occupation of hammering/' 
This is the conclusion, aptly expressed, to 
which Wittmaack came in his remarkable 
experiments, be^n in 1903, on both ears 
of ninety guinea-pigs. Six guinea-pigs 
were subjected night and day, without in- 
terruption, to the noise of an electric bell, 
freely suspended above their cage. The 
animals were killed in succession after 5, 
10, 20, 30,. 40 and 60 days, and no lesion 
was found in any part' of the auditory 
apparatus. This negative result gave rise 
to the idea that ear affection caused by 
noise must be due to something more than 
the simple transmission by air. He there- 
fore modified his experiments in such a 
way that the vibrations of the electric bell 
were communicated to a tin plate on the 
floor of the cage. Very different results 
were then obtained; rapid emaciation of 
the animals was observed and two died 
after 14 days. Controlled experiments led 
to the same results and although, as be- 
fore, the middle ear of animals killed after 
various intervals appeared intact, the 
nerve terminals in the cochlea, especially 
the organ of Corti, were degenerated. 
Analogous experiments, in which suflScient 
rest was allowed to resemble the normal 
conditions of human industry as far as 
possible, furnished similar results. Witt- 
maack tried also the influence of other 
noises, especially that of a whistle, as well 
as air disturbance caused by firearms. 
As a conclusion to his researches, he ad- 
mits the preponderating influence of vi- 
brations, of soUd substances on lesions of 
the ear, due to sounds, and he calls atten- 
tion to the fact that among workers most 
frequently afflicted with occupational deaf- 
ness one finds nearly always the possible 
transmission of vibrations by the bony 
skeleton, especially among blacksmiths, 
in whose work they are transmitted by the 
arm. In noisy factories the constant vibra- 
tion of the ground is frequently observed. 
According to Peyser, Wittmaack's first 



statement is of minor importance; the 
second on the other hand is of capital in- 
terest. The elasticity of the soft parts and 
articulations of the wrist and of the arm 
appeared to him to be a good non-con- 
ductor while the heavy body of the worker 
resting on vibrating ground, and especially 
the bony frame, from feet to head, would be 
favorable conductors for the transmission 
of vibration. An intermediate condition 
would be that of boiler riveters, who sup- 
port their mechanical hammers by prop- 
ping their elbows against their chests. In 
corroboration, Peyser cites the authority 
of Friederick of Kiel, who thinks that the 
deafness of naval officers is at least par- 
tially attributable to vibrations of the ship 
during firing. Finally, with the object of 
studying the influence of conduction al- 
most exclusively by air, Peyser examined 
the builders of hulks made of curved 
iron sheets which have to be riveted. 
During construction the hulk is placed on 
the ground, with the keel in the air, and 
supported on wooden blocks which rest on 
a mass of concrete 30 centimeters thick. 
The worker crawls under this metallic arch 
and proceeds to rivet by means of per- 
cussion hanmiers worked by compressed 
air. Of twelve workers engaged for two 
years at this work, none had become hard 
of hearing at the time the examination was 
made. Peyser concludes that this con- 
firms the theory of Wittmaack on the in- 
fluence of vibrations. Neither the number 
of observations, however, nor the length 
of time of service allow final conclusions 
to be drawn. Peyser concludes with the 
following statements : 

1. Continual, but moderate noise, exclusively 
transmitted by air, has little or no action on the 
organ of hearing. 

2. Short, but intense and shrill sounds, especially 
when repeated, injure the organ of hearing in a 
temporary or a permanent way. 

3. Simultaneous conduction of noise by air and 
by the bony skeleton, and above all by the vibration 
of the ground, affects hearing finally and seriously.. 






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Everyone does not admit the opinions 
of Wittmaack and Peyser. Reinking of 
Hamburg, at the last German Congress of 
Otology, made a conmiimication tending 
to show the importance of the harm of air 
conduction. Delsaux could not agree en- 
tirely with Reinking concerning the minor 
importance of bone conduction and rightly 
put forward a statement, easy to prove, 
that it was not sufficient in normal con- 
ditions to stop up the nose, mouth and 
ears in order not to perceive any longer at 
a meter's distance words uttered in a high 
voice. One must admit in this case that 
sound is transmitted by way of a solid 
substance. On the other hand, Delsaux 
observed that the statements of Coose- 
mans on "beetlers" in a linen factory con- 
tradict the conclusions of Wittmaack and 
Peyser. In fact, Coosemans has not found 
really serious lesions among workers whom 
he has examined and who were subjected 
at the same time to a muffled soimd and 
to continual vibrations of the groimd. He 
concludes that: (1) Every noisy trade is 
not necessarily harmful to hearing. (2) In 
order that it may be harmful, it is neces- 
sary (a) that* the worker should be predis- 
posed to affections of the ear, by the pres- 
ence of lesions in the nose or pharynx; 
(6) that the noise should be intermittent; 
and (c) that it should be of a relatively 
high tone. 

From the foregoing, it must be con- 
cluded that a certain amount of doubt 
still exists as to the extent of harmful- 
ness of transmission of sound by air. Let 
us hope that futiu^e research may procure 
definite results on this point so important 
to industrial hygiene. 

Prophylaxis 

Choice of Worker. — Only yoimg people 
fitted to undergo the normal consequences 
without damage should be allowed to work 
in noisy industries. Young persons with 
ear affections or predisposed to them by 



lesions in the neighborhood of the ear 
should be prohibited. This conservative 
method must, however, be used with 
great prudence. Statistics show that the 
number of persons with deficient hearing 
is considerable. According to Ely, 8.5 
per cent, of conscripts were refused for 
this reason — a percentage which repre- 
sents only the worst cases. Weill reports 
30 per cent, of 5,905 children, whom he 
examined, as hard of hearing; Moure re- 
ports 17 per cent, out of 3,588; Bezold 
reports 20.75 per cent, out of 3,836, with 
ear trouble; Lausi shows 10.8 per cent, of 
deaf scholars; Sexton 13 per cent.; Gelle 
and Von Riechardt 22 per cent.; Ostman 
36 per cent.; Nager 40.3 per cent.; R5pke 
23.6 per cent.; Cronenberg 44.1 per cent.; 
Hansberg 50 per cent.; Felix 31 per cent.; 
Courtade 37.5 per cent.; Malherbe and 
Stackler 35 per cent. If these large num- 
bers of deaf or partially deaf children were 
excluded from noisy industries, factories 
would soon be empty, for other groups of 
sick or puny children would also have to 
be excluded, one for deficiency of vision, 
another for poor development, and another 
for some physical disabiUty. Also the law 
of work is imiversal and the weak and in- 
firm must work for their living; but as a 
defect such as an ear lesion may be an indi- 
cation of a more general disease, those who 
are excluded from noisy industries because 
they are partially deaf may find that they 
are refused entrance to any work at all. 
Great discretion must therefore be used, 
and only those most liable to harm should 
be prevented from entering the most in- 
jurious industries. This tolerance, how- 
ever, requires a safeguard in the form of 
periodic medical supervision of young 
persons. In the same way it will be neces- 
sary to have a methodical periodic exami- 
nation of the ears of adults working in 
noisy industries. At first one would 
imagine that an essentially defective ear 
would be an indication that the subject 



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GLIBERT — INFLUENCE OF INDUSTRIAL NOISES 



273 



should not work in a noisy atmosphere. 
But if Eicken and de HoessU are correct 
in their assertions that the chains of 
ossicles conduct sound and do not damp 
it, as Zimmerman thinks, in certain cir- 
cumstances a state of relative deafness, 
while not advantageous, would at least be 
harmless in certain industries where there 
is a loud or rackety noise. 

When choosing workers for a noisy in- 
dustry (and in doubtfid cases this should 
be done by an ear speciaUst), the doctor 
must keep in mind the other peculiarities 
of the industry. For instance, a deaf man 
is more exposed to accidents in the vicinity 
of belts, gearing, etc., because very often 
when a machine is going wrong an unusual 
soimd is emitted which acts as a warning. 
In the same way workers with alterations 
in the auditory apparatus associated with 
vertigo and loss of sense of space should 
not be exposed to falls from heights, such as 
from scaffolding, timber works, or bridges. 
In the medical examination a fixed imit of 
measurement should be employed through- 
out the coimtry, so that absurd and unfair 
situations may be avoided; better still, 
there should be international uniformity to 
enable us to meet hostile criticism on pro- 
phylactic measures. At present, tests of 
hearing lack uniformity and even precision; 
the whispered voice, the murmured voice, 
the voice of conversation and the tick of a 
watch are very variable quantities. Still, if 
judiciously employed, these simple methods 
seem to suffice in ordinary examinations. 
A definite criterion is, however, needed for 
determining whether or not a more com- 
plete examination by an ear specialist is 
desirable. 

As a means of securing uniformity in ear 
examinations, the following methods of 
estimating hearing in terms of the distance 
at which a watch is heard by the normal 
ear have been proposed: 

1. Let M be the distance at which a watch is 
heard by a normal ear; 



Let d be the distance at which a watch is heard by 
the examinee; 

Let A be the auditory acuity of the examinee; 

Therefore^ ='17; 
M 

Therefore, if if is 1 meter and d is 10 centimeters, 
^=0.10 meter. 

%, Let D be the maximum distance at which the 
normal ear hears the instrument of measurement; 

Let d be the maximum distance for the ear ex- 
amined; 

Let -4 be the auditory acuity of the examinee; 

Therefore ^^(jC) since the intensity of sound 
is in inverse proportion to the square of the distances. 

Ear specialists must aid us in drawing 
up examinations which will be uniform as 
to tests, signs and terms, and must deter- 
mine for us the best methods to use, and 
at precisely what stage hearing is suffi- 
ciently diminished (a) to warrant refusing a 
young person work after a complete ear 
examination; and (6) to require an exami- 
nation by an ear specialist of workers 
(young persons or adults) employed in 
noisy industries. It will be the particular 
field of ear spedahsts to do research on 
"the sense of space" and "the organ of 
equihbrium," and on such diseases as 
nystagmus, while the factory doctor can 
hmit himself to finding the degree of vertigo 
or incoordination by the ordinary clinical 
means, and can pass on to the specialists 
the most interesting patients. 
. Individual Means of Protection. — The 
means of self-protection tend to muffle 
sound, and plugs of cotton wool and cover- 
ing pads, and especially helmets and similar 
apparatus, are makeshifts disliked by the 
workmen on account of their weight and 
pressure, and because they are contrary to 
their habits. Such objects are often a hin- 
drance to hearing orders and are also a 
cause of accidents, as they diminish the 
perception of unusual sounds or cries of 
appeal fromfellow-workers in danger. They 
must therefore be reserved for special cir- 






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THE JOURNAL OF INDUSTRIAL HYGIENE 



cumstances where it is impossible to do 
without them, and as these circimistances 
are rather numerous, it is necessary to 
make a detailed examination of the pro- 
cedure to adopt. As regards the ear plug 
there is no agreement on the best method 
of application. Should it be slack or com- 
pressed into the ears or should the ear be 
stopped as completely as possible by a 
tight plug impregnated with an 6ily sub- 
stance? Ignorance on this subject is due 
to the imcertainty in regard to the re- 
spective rdles played by air and solid sub- 
stances in sound transmission. 

It is certain, however, that as far as 
fatigue is concerned the vibrations of the 
soil are an important, harmful factor. 
Hence, the use of anti-vibratory footgear 
or mats is to be recommended in all cases. 
An individual method, frequently extolled, 
is change of work, but this can easily be 
carried too far. Although excellent in it- 
self when recommended for workers in a 
particularly imhealthy trade, it loses all 
its value in a well-defined trade. Take, for 
instance, the case of a flax spinner. Her 
work is of a special kind, requiring an ap- 
prenticeship of from three to four years at 
least, and consequently commands rela- 
tively high wages. What would a spin- 
stress do if she were put to winding or 
reeling? But if a change of occupation is 
often impossible, a change of place in the 
same occupation is often easy, and with 
differences of intensity, resonance and 
height of noise in various parts of the same 
room or in different departments or build- 
ings of the same industry, it is advisable 
and possible by a simple change of posi- 
tion to improve conditions for a suscep- 
tible person. 

Protective Measures Applicable to Work- 
ing Conditions. — Extensive and pains- 
taking researches should be made in order 
to discover the best means of lessening in- 
dustrial noise. The origin, intensity, 
lieight and rhythm of noise, the local cir- 



cmnstances which increase it, the vibra- 
tions which accompany it, etc., must be. 
examined in detail. It is necessary to re- 
duce the intensity as well as height and 
resonance. Among causes which aggra- 
vate are carelessness, lack of room, wrong 
use of apparatus, lack of upkeep and re- 
pairs, abuse of glass partitions, insufficient 
natural ventilation. But if it is true, as is 
sometimes claimed, that the internal ear is 
organized in such a way that each of its 
parts corresponds to a soimd of definite 
height, it would be of value to vary as 
often as possible the tone of soimd in a 
factory, and this is practicable in many 
cases. It has been observed that a sudden 
intermittent, and more or less irregular 
noise is more disagreeable to the ear, other 
conditions being equal, if produced in a 
quiet atmosphere than in a noisy one. 
Here we have practically the action of the 
natural organic defences still imknown as 
regards the ear. It is useful at times to 
compare certain machines making a con- 
tinuous moderate noise with those making 
a loud noise when thrown out of gear. But 
before we can successfully apply pro- 
phylaxis to objects, we must know how 
far air conduction is harmful to the ear. 
If it were shown to be powerless to create 
alone a serious organic ear lesion, the prac- 
tical means to apply would be principally 
against vibrations, and it would be neces- 
sary to have special regulations for the 
supporting structiu*e of machines and foun- 
dations of factories, special platforms for 
the use of workers, etc. 

Conclusions 

1. It is desirable that careful observa- 
tions be made in order to remove the exist- 
ing uncertainty in regard to the following 
points: 

(a) Are lesions due to noise so localized 
that high and deep sounds act on different 
parts of the cochlea? 



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(6) Is air conduction in itself sufficient 
to cause in time lesions of the internal 
ear? 

(c) What are the extreme limits of de- 
ficient hearing compatible with work in a 
noisy factory without examination by an 
ear specialist? 



2. 'An international commission com- 
posed of doctors having access to all the 
factories of the country ought to decide 
the basis of an inquiry into industrial 
sounds, for the purpose of preparing a de- 
tailed account of the principal noisy in- 
dustries. 



BIBLIOGRAPHY 



1. Layet: Sixth volum^ of the EncydopMie 
d'Hygi^e de Rochard. 

2. R(5pke, F.: Die Berufskrankheiten des Ohres 
imd der Ohren Luftwege. Wiesbaden, 1902. 

3. Capart, A., Jr.: Report to Belgian Society of 
Otorhinolaryngology, Feb., 1911. 

4. Bl^vad, N. R.: Effets professioneb du tel6- 
phone sur I'appareil auditif et sur I'organisme. 
Ann. d'hyg. pub., 1907, Series 4, 8, 375. 

5. Tr6tr6p: Troubles auditif s d'origine t^l^pho- 
nique. Fresse Otolaryngol, beige, 1914, 13, 275. 



6. Layet: Hygiene des professions et des indus- 
tries. Faris, 1875. 

7. Zwaardemaker: Commimication to the Royal 

Academy of Sciences of Amsterdam, Feb. 25, 
1905, 

8. Bonnier: L'Oreille. Encydop^die des aide- 
m6moire, Leaut^. 

9. Poli: Arch. ital. di otol., 1894. 

10. Moure, E. J., and Cauzard, P.: Examen fono- 
tionnel du labyrinthe. Fratique m^., 1909, 28» 
97. 



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THE REHABILITATION OF EMPLOYEES: AN EXPERIENCE 

WITH 1,210 CASES* 

FREDERIC S. KELLOGG, M.D. 

Physician, Western Union Tdegrafk Company, Pittsburgh, Pa. \ 



A LTHOUGH the custom of making a 
±\. physical examination as a prelimin- 
ary to employment has become very com- 
mon in recent years, there has grown up 
on the part of the employees a great deal of 
opposition and even hostility to this re- 
quirement. The object of the work here 
described has been to extend and make 
practical use of these examinations for the 
reconstruction of the employee — a pro- 
cedure by which we believe that inmiense 
gains, both economic and in point of health, 
will be secured, and a kindlier feeling es- 
tablished. 

The subject of salvage in general has be- 
come a matter of vast and recognized im- 
portance and the savings thus seciu'ed are 
enormous. We may, for example, see this 
process being carried on daily in the dis- 
posal of city waste: A broad, endless belt 
carries the waste down a long room. Work- 
ers on either side take off various articles 
for reclamation, and what is left is then 
swept on to the furnace. If, instead of city 
waste, this endless belt were carrying men 
and women, more or less disabled, and if, 
instead of ordinary workers, there were 
stationed by the sides physicians and 
specialists, would such wholesale human 
salvage be possible.'^ Or would it be better 
merely to make a selection here and there 
of the best? 

The results submitted in this article were 
secured from the analysis of 1,210 examina- 
tions made among the employees of a large 
department store. There are in all 2,000 
etnployees in this estabUshment, 85 per' 
cent, of whom are women. The average 
age is 27 years. The method of medical 



service in use in this store has been fully 
described in an earlier paper,t and there- 
fore it is enough for the present to say that 
the physical examination has been supple- 
mented by reports from specialists or from 
laboratory experts whenever such reports 
were needed. The general physical condi- 
tion of these men and women, as disclosed 

TABLE 1. — DISTRIBUTION OF DEFECTS IN 
OLD AND NEW EMPLOYEES COMPARED 



CUn 


ll 


< 
1 


1 


i 


1 


i 


k 


New employees apply- 
















ing for work 


582 


23J 


U 


78 


152 


288 


97.8 


Old employees 


678 


«7 


7 


118 


217 


841 


98.9 



• Received for publication Oct. 10, 1921. 



by the study of the examination records, is 
shown in Table 1, new employees and old 
employees being grouped separately by 
way of comparison. In Table 2 the workers 
are arranged in groups by decades, in order 
to show more clearly the progressive de- 
terioration suggested by the figures in 
Table 1. From the schoolchildren group to 
the group of workers over 40 years of age 
there is a steady deterioration from 75 to 
99.3 per cent., the causes of which, in the 
experience of this service, are as follows: 
infection from fellow employees, persistent 
bad hygiene, and neglect. 

As to infection, it may be said that in the 
examinations analyzed the following dis- 
eases have been found: scarlet fever, diph- 
theria, measles, whooping cough, impetigo 

t F. S. Kellogg: Medical Siq>ervision of Employees. 
Penn. Med. Jour., 1920, p. 667. 



876 



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contagiosa, scabies, pediculi, gonorrhea, 
syphilis, pneumonia, erysipelas, tubercu- 
losis and an immense number of cases of 
diseased tonsils, acute and chronic, and an 
equally large number of foul teeth and 

TABLE 2. — DISTRIBUTION OF DEFECTS 
BY DECADES 



Group 


No 
DefecU 


Defective 


Percent 
Defective 


Schoolchildren 






75.0 






Under 20 years 


17 


600 


96.7 






20 to 80 years 


10 


871 


97.4 






80 to 40 years 


2 


167 


98.8 






Over 40 years 


1 


142 


99.8 







septic mouths. Infection is very real and 
ever present; yet medical inspection has 
been limited to the schools. 

Bad hygiene — that is, bad habits which 
will cause disability in time — is very 
common. Out of 425 cases which were in- 
vestigated 359, or 85 per cent., were in- 
stances of bad hygiene. (Hygiene here 
does not include housing.) Neglect is even 
more common, indeed it is often the rule, 
as is evidenced by the fact that none of the 
forty-two cases of tuberculosis noted among 
the employees examined was on treatment, 
and also by the habitual disregard of treat- 
ment as shown by the figures given later in 
this paper (see Table 4). 

The gravity of the defects noted in the 
examinations under discussion canT)e seen 
by reference to Table 3, in which are given 
the requirements in time f6r the rehabilita- 
tion of these employees. In contrast to the 
requirements and needs of these cases are 
the facts as to the actual treatment which 
the patients receive. The facts are ascer- 
tained as follows: On the completion of an 
examination and after reports from special- 
ists have been received, it has been the 



custom to refer the patient for treatment to 
a hospital or to a specialist. In order that 
authentic reports of treatment may be re- 
ceived, the patient is given a report card 
with a stamped and addressed envelope. 
If treatment is secured, the report is re- 
ceived and noted on the patient's health 
record. If the report card is not returned, 
the patient is called again to the oiBBce and 
his case is followed up imtil he has received 
proper treatment. The amount of follow- 
up work needed is instructive: There were 
thus given to patients 1,054 report cards, 
after a . complete physical examination, 
frequently supplemented by a careful ex- 
amination by a specialist. The results were 
as follows: 

Number securing treatment without follow-up 
work. 62 

Percentage securing treatment without follow- 
up work 5.9 

Number who had to be called to office re- 
peatedly 992 

If, after a full examination and with ex- 
pert advice, only 6 per cent, are led to se- 
cure treatment from competent hands, 

TABLE 8. — REQUIREMENTS IN TIME 
FOR TREATMENT 



^ of Cases 


Per Cent. 


No stopping of work required 


473 


89.0 


From 1 to 10 days of hospital care 


578 


47.8 


From 10 days to 1 month at hos- 
pital 


107 


8.8 



More thafl 1 month at hospital or 
sanatorium 


65 


4.5 






Incurable and unable to work . . . 


% 


0.1 



what percentage would seek treatment 
when left entirely to their own initiative — 
the condition of general practice.'^ Cer- 
tainly it would be much less than 6 per 
cent. And of this small number what per- 



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centage would place themselves in com- 
petent hands? Or, being fortunate enough 
to find themselves in good hands, how 
many would remain on treatment long 
enough to secure any permanent benefits? 
It is evident that constructive treatment, 
such as is necessary for the rehabilitation 
of these employees, exists, if at all, in only 
a very small fraction of cases, and the 
progressive deterioration of the employee 
which has been shown is evidence of this 
fact. 

The most impressive single fact brought 
out by the present study is the almost uni- 
versal neglect of life and health. And yet 
the only means used at present for the 
reclamation of the disabled employee is the 
treatment which he secures upon his own 
initiative. The plan of leaving the sick or 
disabled employee to his own resources and 
trusting to his initiative is, therefore, a 
failure. If anything is ever to be done for 
the employee we have, then, as an alterna- 
tive, medical supervision, either by the 
company or by the state. 

Experience with Medical 
Supervision 

The experience here given covers a 
period of about two years, and includes a 
very great variety of diseases and dis- 
abilities. Treatment has not been made 
compulsory except in cases of tubercu- 
losis and contagious diseases, including 
veneral diseases. Moreover, a case is con- 
sidered and counted as having been treated 
only when the patient has been placed in a 
hospital, or in other thoroughly competent 
hands, and a report has been received on 
one of the cards already mentioned. 

To report all the diseases and disabilities 
occurring among the employees of the de- 
partment store under consideration would 
require an unduly long list. A few classes 
of diseases have, therefore, been selected in 
order to show the percentage of cases secur- 



ing treatment. (Tables 4 and 5.) The low 
I>ercentage attained in certain cases, such 
as diseases of the nose and throat, is to be 
explained by the fact that a very large 
niunber of operations have been recom- 
mended. Many of the cases which have 
not been treated as yet will, as a result of 
further work, have their defects corrected. 
It is to be noted, also, that although only 

TABLE 4. — CASES TREATED UNDER 
MEDICAL supervision 



Diseaw 


Number 
ofCasefl 


Number 
Treated 


Per Cent 
Treated 


Diseases and defects of eyes . 


813 


117 


37.8 


Diseases of ears 


76 


81 


41.8 






Diseases of nose and Uiroat . 


691 


?1 


18.1 


Bad teeth 


717 


176 


24.5 






Diseases of digestive tract . . 


94 


24 


26.5 


Orthopedic (employees stand 
at work) 


607 ^ 


18 


S.6 






Diseases of skin 


67 


24 


86.8 






Gynecological cases 


186 


48 


28.2 


Appendicitis 


11 


7 


68.6 






Diabetes 


2 


2 


100.0 






Diseases of nervous system . . 


6 


8 


60.0 



forty-two cases were diagnosed positively 
as tuberculosis, there were 141 cases of 
suspected tuberculosis. Many of these, 
seventy-three in all, left the service of the 
company without allowing a careful study 
of their cases to be made. If all these 
cases had been carefully studied, it is cer- 
tain that there would have been many 
more cases diagnosed as positive tuber- 
culosis. 

Although the general average of cases 
treated is not so high as we would hope to 
have it or so high as we expect to have it in 



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KELLOGG — REHABILITATION OF EMPLOYEES 



279 



the future, it is to be noted that it is about 
19 per cent, more than it would have been 
without medical supervision. And how- 
ever, earnestly we may desire a higher per- 
centage of cases placed on constructive 

TABLE 6. — TREATMENT COMPULSORY 



Disease 


Number 
of Caaes 


Number 
Treated 


Per Cent. 
Treated 


(Jenito-urinary diseases 


12 


10 


83 


Syphilis (6 cases untreated) , 


6 


5 


83 


Tuberculosis (diagnosis posi- 
tive) 


42 


30 


71 






Suspected tuberculosis (di- 
agnosis not made) 


141 






Contagious diseases 


a 


6 


100 


Pregnancy (including 1 case of 
toxemia of pregnancy) .... 


6 


6 


100 


Total defects noted 


2,906 


577 


19.8 



treatment, we cannot secure these best re- 
sults without educating the employees. 
They must be taught new and higher ideals 
of health. The very existence of a medical 
service, such as the one considered in this 
report, is the best way to teach these ideals. 
The constant contact with the medical de- 
partment and the transformation eflfected 



in the lives of many of the patients will 
teach lessons which can be learned in no 
other way. The relief of recurring head- 
aches and of the exhaustion of chronic ill 
health, the rejuvenation of the consump- 
tive, the development of ability and talent 
bhghted by disease — these benefits will 
give new standards of health, and secure 
hearty co-operation on the part of the 
employee. 

Conclusions 

There is a progressive deterioration of 
physique in the group of employees here 
studied and presumably among working 
people in general. This deterioration is 
found to be due to infection from associates, 
to persistent bad hygiene, and to continual 
neglect. 

The initial or sporadic examination can- 
not supply a healthy body of employees 
nor can it arrest thjs strong tendency to 
deterioration. 

Medical supervision offers an effective 
means of securing the rehabilitation of 
employees, and salvage of large groups of 
men and women is thus practicable. 

The time, therefore, is surely past when 
employer and physician, content to make a 
selection here and there, can watch with 
indifference the endless stream of more or 
less disabled men and women sweep by. 



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TRINITROTOLUENE POISONING — ITS NATURE, DIAGNOSIS, 

AND PREVENTION 

CorUimied 

CARL VOEGTLIN, CHARLES W. HOOPER, and J. M. JOHNSON 

From the Division of Pharmacology, Hygienic Laboratory, U, S, PuUie Health* Service 



FiBLp Investigation 

THE principal purpose of the field inves- 
tigation was to apply the knowledge 
gained from the study of T.N.T. poisoning 
in animals to the conditions prevaihng in 
the factories. This work was done in a 
large shell-filling plant employing from 
7,000 to 8,000 workers, and was made pos- 
sible through the co-operation of both the 
management and the workers. The work- 
ers were employed in three shifts of eight 
hoiu*s each. The general sanitary conditions 
of this war settlement, such as housing, 
sewage disposal, water and food supply, 
were excellent. A hospital with a compe- 
tent staff of physicians and nurses looked 
after the sick workers. On account of the 
high wages paid, the labor tinrnover was not 
large, a fact which made it possible to ex- 
amine workers who had been expK)sed to 
T.N.T. for a long time. The workers of 
each factory unit were sometimes shifted 
from one job to another, but on the whole 
a considerable number were continuously 
exposed to T.N.T. The following brief re- 
marks are intended to familiarize the 
reader with the conditions under which the 
T.N.T. worker is exposed to the poison. 

Manufacture of High Explosive Shells 

The manufacture of high explosive shells 
varies with the type of explosive used. At 
the beginning of the war, T.N.T. was ex- 
tensively used as the main charge. With 
the tremendously increased demand for 
these shells, it became necessary to supple- 
ment the deficient supply of T.N.T. by 
using a mixture of ammonium nitrate and 
T.N.T., commonly called amatol. 



If T.N.T. alone is used, it is melted in 
large steam kettles at a temperature of 
about 85^C., and the molten explosive is 
then poured into the shells. Amatol is pre- 
pared by mixing from three to four parts of 
dry ammonium nitrate with T.N.T. at a 
temperature of approximately 90®C. The 
mixture, while still warm, is pressed into the 
shells by machinery (extruding machine). 
In order to understand the process of filling, 
the following description of the various 
parts of a high explosive shell ig here given.* 

The shell proper is made of hollow steel 
and fits snugly into the top of the cartridge. 
The bursting charge is contained in the shell 
and consists either of T.N.T. or amatol. A 
circular opening in the top of the shell is 
threaded so as to allow the adapter and 
booster to be screwed down into it. 

The adapter is a device holding a narrow 
tube which in tiu*n contains a narrower 
tube. The two tubes together constitute 
the booster. The adapter and booster are 
loaded witji a mixture of tetryl (tetrani- 
troaniline) and T.N.T. The fuse which is 
loaded with a sensitive explosive (mercury 
fulminate) is inserted at the top of the 
shell. The fuse is not inserted at the filling 
plant, but is put in before the shell is fired. 
The bottom of medium and large caliber 
shells contains a mixture of T.N.T., am- 
monium nitrate and ammonium chloride. 
This mixture ("smokemix*') is used to pro- 
duce smoke for the purpose of range ob- 
servations. 

The method of filling the shells in use at 
the plant where this investigation was car- 
ried out is essentially the following: The 

* See "Ordnance and Gunnery" by Tshappat, Wiley & 
Sons, 1917. 



280 



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VOEGTLIN — TRINITROTOLUENE POISONING 



281 



empty shells are first painted in the empty- 
shell room. After this they pass to the 
pouring house containing three steam ket- 
tles in which the T.N.T. is melted. These 
kettles are provided with a hood connected 
with a vertical ventilating pipe which 
passes through the top of the roof. The 
hood has a window which permits the filling 
and emptying of the kettle. The workmen 
on this job are exposed to T.N.T. fumes and 
dust. The molten T.N.T. is poured into 
large ash cans, from which the shells are 
filled by means of hand dippers. The 
T.N.T. in the shells slowly crystallizes. 
The crust which is formed on the top is 
broken up in order to prevent cavity for- 
mation. This work is usually attended to 
by women. After all of the T.N.T. has 
crystallized the shells are put on trays and 
moved on rails to the finishing room, where 
the booster cavity is formed. This last 
process is done by pouring T.N.^T. around 
a steel form inserted into the top of the 
shell. After coohng, the form is removed 
and the cavity is blown out with com- 
pressed air. The finishing room contains a 
steam kettle of the same construction as 
those in the poiuing room. Finally the 
booster, containing the mixture of T.N.T. 
and tetryl, is inserted into the top of the 
shell. The loaded shells are transferred to 
the stenciling room, where they are labeled, 
weighed, and examined. From the stencil- 
ing room the shells pass to the magazine. 

The booster plant is separated from the 
filling plant. The mixture of dry T.N.T. 
and tetryl is pressed into the booster by 
means of hydrauUc presses. Amatol was 
used as the main charge imtil two months 
before this work was begun. 

Incidence of T.N.T. Poisoning 

In the time at our disposal it was impos- 
sible to examine all T.N.T. workers in this 
plant. For this reason, 237 workers were 
selected at random and subjected to a 
thorough examination, special attention 



being given to the presence or absence of 
clinical manifestations of T.N.T. poisoning, 
such as cyanosis, icterus, and dermatitis. 
A specimen of urine was obtained from each 
worker, and this was examined for the 
presence of T.N.T. derivatives (Webster 
test), bile pigment and albumin. The blood 
was tested for its hemoglobin content by 
means of a Sahli hemoglobinometer stand- 
ardized against a standard solution of 
hematin. The hemoglobin figures are 
therefore very reliable. The number and 
character of the red blood cells was deter- 
mined. A white cell count and differential 
coimt were also made, and the number of 
nucleated red cells per 200 white cells 
counted. Information as to the length of 
exposure to T.N.T. and the type of work 
performed by each worker was obtained. 
The data pertaining to this work are com- 
piled in the accompanying tables. Before 
proceeding to a discussion of these results, 
it is desirable to review briefly the work of 
other investigators interested in this sub- 
ject. 

Livingstone-Learmonth and Cunning- 
ham (28) relate their experiences in a shell- 
filling plant in Great Britain and call atten- 
tion to the frequency of poisoning among 
thirty-six women workers as determined by 
clinical symptoms. They also report the 
blood and necropsy findings of a case of 
toxic jaundice. The "blood in this case 
showed 4,400,000 red corpuscles, 9,320 
white cells, 60 per cent, hemoglobin, ab- 
sence of methemoglobin and nucleated red 
cells, no abnormaUties in white cells. 

Panton (24) examined fifty T.N.T. work- 
ers, some of whom had mild symptoms but 
were perfectly fit for work, with special 
reference to the blood changes. He stated 
that the red cells and hemoglobin were not 
adversely aflFected, with the exception of a 
shght degree of poikilocytosis. A moderate 
leukocytosis with a relative increase in the 
polynuclear neutrophils was noted in many 
cases. The blood serum often contained an 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



abnormal amount of bile pigment. Panton 
furthermore examined twenty-eight eases 
of toxic jaundice and six cases of so-called 
aplastic anemia. In the former group only 
four cases showed blood changes, these 
being characteristic of aplastic anemia. 
Panton suggests that moderate doses of 
T.N.T. might lead to a stimulation of the 
blood-forming organs. 

Stewart (29) reports fourteen cases of 
toxic jaundice, in some of which the blood 
revealed an anemia of various grades. In 
nine cases a neutrophil leukopenia with 
lymphocytosis was noted. 

Smith (30) examined twenty-five work- 
ers exposed to T.N.T. dust. A few showed 
slight cyanosis and complained of ab- 
dominal pains, but were otherwise perfectly 
fit for work. The lowest hemoglobin esti- 
mation was 75, and the red cell count was 
never below 4,400,000. No abnormality 
was noted in the character of the red cells. 
Most of the cases showed a moderate 
leukocytosis and increase in polymor- 
phonuclear neutrophils. The platelets ap- 
peared normal. 

Harrington (31) and Gregorson and 
Taylor (32) also report a small number of 
cases of T.N.T. poisoning. 

Recently a paper appeared by Minot 
(33) in which the blood changes found in 
233 T.N.T. workers are reported in great 
detail, as follows: 

Red cell abnormalities were found to be very 
frequent. The most interesting abnormality was the 
frequent finding of fragmented or fragmenting red 
cells which have a definite histologic character. 
These cells appear to afford evidence of a rapid in- 
creased destruction of the red cells. Evidence shows 
that distinct increases of these cells are to be looked 
on as a significant sign of a considerable degree of 
poisoning; and probably when they occur in large 
numbers, they indicate some degree' of toxic jaundice. 
Among other red cell abnormalities noted were the 
following: Polychromatophilia occurred in 83 per 
cent, of the cases, often to a marked degree. Howeil- 
Jolly bodies, stippling and blasts were found, and in* 
creased numbers of reticulated red cells. The red cell 
count averaged in the mildest cases 4,500,000, and in 



the severest 3,800,000. It was found that there was 
usually a definite relationship between the total 
amount of red cell changes and the symptoms. 
Methemoglobin or some form of changed hemoglobin 
is apparent in these cases. 

The white blood cells do not furnish as much in- 
formation concerning the workers* condition as do 
the red cells. Slightly increased white cell counts 
were common. The observations showed that an 
individual may become distinctly and severely poi- 
soned with a normal, or an absolute or relative' in- 
creased lymphocyte count, or with an increased or 
normal polymorphonuclear count. However, lym- 
phocytosis is to be looked on as an undesirable sign, 
but does not necessarily indicate that significant 
poisoning will occur or is occurring, except when there 
is a leukopenia. Slight eosinophilia (more than 5 per 
cent.) occurred in 10 per cent, of the cases. It was 
more conmion in cases with slight s^^mptoms than in 
those with marked. 

The blood platelets were usually slightly in- 
creased. Their diminution was observed twice and in 
both cases there was a relative lymphocytosis. Such 
a condition should certainly be regarded as evidence 
of a severe effect on the marrow, indicating aplasia. 
Webster's test for changed trinitrotoluene in the 
urine was found to be less valuable than blood ex- 
amination to indicate the worker's condition. 

Minot (33) (34) does not give much in- 
formation as to the change in hemoglobin 
content of the blood. The few hemoglobin 
estimations referred to were made by the 
Tallquist method, which is very imreliable. 

In its final report the Health of Mmii- 
tion Workers Committee of the British 
Ministry of Mimitions (35) makes the 
following reconmiendalions concerning the 
detection of the milder forms of T.N.T. 
poisoning: 

. . . Care must be taken to avoid confusion with 
digestive disturbances due to other causes. Accoimts 
given by patients may be unintentionally misleading. 
The yellow staining which normally occurs with 
T.N.T. cannot be taken as in itself a sign of poison- 
ing. The following points are the more important 
indications of T.N.T. poisoning: 

(a) Pallor of face and an ashen grey colour of the 
lips, tending to disappear if the worker becomes ex- 
cited, as by medical examination. Sometimes the 
lips and tongue are purple in colour; the tongue is 
generally free from fur. 



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VOEGTLIN — TRINITROTOLUENE POISONING 



283 



{b) The character and situation of the stomach 
pains. 

(c) The presence of constipation and stomach 
distention. 

The literature, therefore, shows that, 
with the exception of Minot, all writers 
rely principally on the presence of clinical 
symptoms for the diagnosis of T.N.T. poi- 
soning. We cannot share this view, as our 
work has clearly shown that marked blood 
changes may be present in some workers in 
spite of the fact that they do not exhibit 



however, abnormal, showing anisocytosis 
and poikilocytosis. This relatively high 
number of red cells is due to fragmentation 
and proves that a red cell count alone, in 
the absence of a hemoglobin estimation, is 
a very unreliable diagnostic index. Nu- 
cleated red cells were found in the circulat- 
ing blood in 18 per cent, of the anemia 
cases. As regards the leukocytes, 4 per 
cent, of the cases with anemia showed a 
leukop)enia, 22 per cent, a leukocytosis 
(coimt above 10,000), and 49 per cent, a 



TABLE 1. — CLASSIFICATION OF CASES WITH ANEMIA 
[Data compiled from an examination of 149 male and 88 female T. N. T. workers.] 



Degree of 
Anemia 



Number of Cases 



"I 



1 






Hemoglobin in 
Per Cent 



BAales 



Females 



Erythrocyte Counts 



Males 



Females 



I 



i 

<3 



II 



Leukocytes 



u2 




Slight... 
Moderate 
Severe... 



50.2 

21.5 

0.4 



53.7 

«1.5 

0.7 



19 



44.8 



21.6 



97-71 

70-61 

57 



I 
91-71 i 

70-621 



4.306,000 
4.181,000 
2.986,000 




4.210.000 
4,064.000 



' 5,440,000 1 

2.888.000 J 

4.704.000 1 
^ 3,224,000 / 



2,936,000 



% 
46 



61 
100 



any cyanosis, pallor, or icterus. Table 1 
reveals the significant fact that 72.5 per 
cent, of the workers showed an anemia of 
various grades. These cases are grouped 
into three classes as follows: (1) slight 
anemia, men with less than 84 per cent, 
hemoglobin or a red cell count below 
4,000,000, and women with less than 80 
per cent, hemoglobin or a red cell coimt 
below 3,700,000; (2) moderate anemia, 
workers with a hemoglobin content of 
from 60 to 71 per cent.; and (3) severe 
anemia, workers in whom the hemoglobin 
was below 60 per cent. According to 
Table 1, most- of the anemia cases belong to 
the first and second groups, and only one 
case revealed the presence of a severe 
anemia. The red cell count of the anemia 
cases is very often normal or even above 
normal. The red cells of these cases are. 



relative lymphocytosis (mononuclearis 
above 40 per cent.). 

Both sexes show approximately the same 
percentage of anemia cases, a fact which in- 
dicates that sex has no influence on the 
susceptibility to T.N.T. poisoning. The 
same holds true in regard to the relation of 
the age of the workers to the susceptibiUty 
to anemia, as the latter appears in young, 
middle-aged, and old persons, the average 
age of the workers included in the three 
grades of anemia being approximately the 
same. (See Table 2.) In passing, it should 
be mentioned, however, that the British 
reports refer to the greater susceptibihty of 
persons under 18 years of age. We were 
unable to verify this observation as the 
factory regulations prohibited the em- 
ployment of persons below 18 years of 
age. 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



There is no consistent relation between 
the time of exposure and the susceptibility 
to anemia, a fact which is probably best ex- 
plained by variations in the individual 
susceptibility of the workers to T.N.T. 
poisoning. It will be recalled that a very 
marked difference in individual suscepti' 
biUty was also observed in dogs, and there 
is no reason to doubt that it may likewise 
occur in man. Moore (7) attributes this 
difference in susceptibility to differences in 
the permeabiUty of the skin to T.N.T. We 
beheve that this factor may partly account 
for these differences, but not entirely. It 
cannot be denied that the skin of various 



that cyanosis of the oral mucous membrane 
is often absent in spite of the presence of a 
moderate to severe degree of anemia. Pal- 
lor of the skin was noted in 39 per cent, of 
our cases showing anemia. 

A considerable number of the workers 
without anemia exhibited certain blood 
abnormaUties and the presence of cyanosis 
or pallor. (See Table 3.) This would indi- 
cate that TvN.T. was absorbed by these 
workers, but obviously not in sufficient 
quantity to produce an anemia or toxic 
jaundice. In these cases blood regenera- 
ticHi was able to overcome any increased 
blood destruction caused by the poison. 



TABLE 2. — RELATION OF ANEMU TO AGE, TIME OF EXPOSURE TO T. N. T., AND CYANOSIS 

[Data compiled from an examination of 149 male and 88 female T. N. T. workers] 





Age in Years 


Time of Exposure 
in Days 


Number of Cases with Cyanosis 
and Anemia 


Number of Cases with Pallor 
and Anemia 


Class 


Average 


Eixtremes 


Average 


Extremes 


Per Cent, 
of Total 
Number 
of Cases 


Males 


Females 


Per Cent 
of Total 
Number 
of Cases 


Males 


Females 


Slight anemia 

Moderate anemia 

Severe anemia 


28 
30 
20 


18-70 

18-53 

20 


122 
102 

24 


8-545 

8-300 

24 


45 

55 




46 

21 




8 
7 



33 

49 




28 

16 




11 
9 




individuals shows a considerable variation 
in permeability to certain poisons. This 
was very well proved in the case of a num- 
ber of war gases. It is to be kept in mind, 
however, that it was shown in the previous 
section of this report that dogs exhibited a 
marked difference in susceptibiUty, even 
when differences in the absorption of 
T.N.T. were completely excluded. Under 
these conditions the variation in individual 
susceptibility is very likely due to dif- 
ferences in the methods of dealing with the 
poison on the part of the body, in the 
manner indicated in the experimental 
section. 

Only 48 j>er cent, of the anemia cases 
showed the presence of cyanosis of the lips. 
This observation is in conformity with the 
observations made on dogs with chronic 
T.N.T. poisoning. Here it was also shown 



The urine of these workers never con- 
tained even traces of bile pigment, and 
icterus was always absent. In no case did 
the urine contain sugar, and in a few cases 
only, a moderate amount of albumin was 
found. The urinary Webster test was made 
in a large number of cases and was nearly 
always positive. There was no relation be- 
tween the intensity of the test and the 
anemia. The detailed account is therefore 
omitted. The Webster test has no diag- 
nostic value beyond showing that T.N.T. 
is absorbed and excreted in a modified 
form. A few of the workers complained of 
shortness of breath and palpitation follow- 
ing slight exertion. Others complained of 
itching of the skin of the forearms and 
face, and in a few workers a typical papillar 
dermatitis was observed. The skin of the 
hands often shows a yellow staining due to 



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T.N.T. The hair of some workers as- 
sumes a reddish-yellow discoloration. 

To smn up, it can be said that nearly 
three-fourths of the workers examined 
showed definite signs of poisoning. For the 
detection of poisoning the physician can- 
not rely altogether on symptoms, but he 
should also make a blood examination. 
Much valuable information can especially 
be gained from an accurate hemoglobin 
estimation. A standardized Sahli hemo- 
^lobinometer is recommended for this 
purpose. 

Preventive Measures 

In the manufacture of T.N.T. and in the 
fiUing of shells with this substance, it is 
almost impossible to prevent all contact of 
the workers with this poison. A certain 
amount of vapor is always formed in the 
heating of T.N.T. , and unless rigid pre- 
cautions are taken this vapor escapes to 
some extent into the workrooms, where it 
condenses to a fine dust which settles 



by the skin of the workers, it is impossible 
to estimate the relative importance of skin 
absorption and absorption by the respira- 
tory and gastro-intestinal tracts. Moore 
and his colleagues are inclined to attribute 
all T.N.T. poisoning to skin absorption. 
This view is altogether too one-sided, as 
the estimation of the air contamination 
made by Professor Phelps and Mr. Cassel- 
man of this laboratory plainly proves that 
under certain conditions the workers take 
in a considerable amount of the poison 
with the inspired air. For this reason it is 
safer to take the necessary precautions 
against both methods of absorption. The 
same position in regard to this matter is 
taken by the British Health of Munition 
Workers Committee in its final report. 

Absorption of T.N.T. by Skin 

In view of the importance attached to 
skin absorption in the production of T.N.T* 
poisoning, it appeared desirable to deter- 



TABLE 8. — BLOOD CHANGES AND SYMPTOMS IN WORKERS WITH AND WITHOUT ANEMIA 





Cases 


PoDdlocy. 

tosisor 

AmsoKT- 

tosis 


Nucleated 
Red Cells 


Leukocytes 


Cyanoms 






Below 
6.000 


Above 
10,000 


Relative 

Ljnnpho- 

cytosis 


Pallor 


With anemia 


171 
66 


% 
S9 
82 


% 

18 

6 


% 
4 




% 
15 


% 
49 
52 


% 
48 
86 


% 
39 


Without anemia 


27 







slowly. It is also impossible to prevent 
completely the spilling of either the molten 
or solid explosive, with the result that the 
floor, machinery, and the outside of the 
shells are more or less conj:aminated with 
T.N.T. Hence the workers may absorb 
the poison through the skin or the poison 
may enter the body with the inspired air. 
In this latter case part of the substance 
may be swallowed and absorbed from the 
gastro-intestinal tract. On account of the 
absence of a method for the determination 
of the absolute amount of T.N.T. absorbed 



mine the skin area actually exposed to the 
poison. 

Several hundred workers, both men and 
women, were examined by testing the skin 
of the various parts of the body with alco- 
hohc sodium hydroxide (Webster's reagent) 
and noting the intensity of the color so ob- 
tained. This varied from a very deep 
purple to a negative finding, and diflFered 
considerably on the same body surfaces in 
diflPerent individuals. As a general rule the 
reaction is most intense on the palms of the 
hands and about the ankle region. Next in 



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line comes the dorsal surface of the hand, 
the wrist, the foot below the ankle, the 
forearm, the neck, and the face, in the 
order named. The reaction is rarely posi- 
tive on other parts of the body. 

The skin area exposed to T.N.T. in fe- 
male workers was as a rule not so extensive 
as that of male workers, which is due to the 
facts that the former are more particular in 
wearing clean overalls, underwear, and 
gloves, and that they bathe more fre- 
quently than the average male worker. 
This conclusion was reached from informa- 
tion volunteered by the workers, and from 
inspection of the change houses and living 
quarters. 

The important practical point brought 
out by these tests is that the clothing and 
overalls protect the coveied skin very 
efficiently against contact with the poison. 
The only exception in this respect concerns 
the ankle region. The poison gained access 
to this skin area on account of the fact that 
overalls of these workers did not cover the 
upper part of the shoes, and thus permitted 
T.N.T. dust to penetrate the stockings 
above the shoes. In order to avoid this the 
worker should be required to wear overalls 
which cover not only the legs but also the 
ankles. 

The use of leather gloves seems to be 
of little protective value, as most of the 
workers remove them from time to time, 
thus allowing the inside of the gloves to 
become covered with T.N.T. Under these 
conditions skin absorption is probably 
favored instead of reduced, especially dur- 
ing the warmer seasons when excessive 
perspiration might aid it. The use of 
gloves should therefore be discouraged. 

The British official reports refer to the 
failure experienced in the use of skin 
varnishes in the prevention of skin absorp- 
tion. In several cases varnishes gave very 
unsatisfactory results. Dr. George F. 
White of this laboratory has experimented 
with a shellac castor-oil varnish which ap- 



pears fairly satisfactory for this purpose, 
but its trial in the factory was impracti- 
cable. 

Further work was done in order to dis- 
cover an inexpensive, harmless, and ef- 
ficient skin wash which might prove 
satisfactory in removing T.N.T. from the 
skin of the workers before they left the 
factory. It is. obvious that such a skin 
wash might considerably reduce, possibly 
by two-thirds, the amount of T.N.T. ab- 
sorbed by the skin, as the worker would no 
longer absoft> the poison after leaving the 
factory. The regulations in this plant re- 
quired that the workers should wash their 
hands and faces very thoroughly with soap 
and water after stopping woik, and they 
were also advised to take a shower bath. 
Excellent wash houses were available for 
this purpose, but the instructions were only 
partially carried out. It was furthermore 
found that soap and water do not remove 
all the T.N.T. from the skin even after 
thorough and repeated washing. Nimier- 
ous experiments were then carried out to 
determine the solubihty of T.N.T. in vari- 
ous solvents. The most promising solvent 
seemed to be a 10 per cent, sodiimi sulphite 
solution. This .wash- was tested out on 
T.N.T. workers in the following manner: 

Thirty-six workers volunteered for this 
experiment. They were asked to wash their 
hands and forearms very thoroughly, first 
with soap and water, and then with 10 per 
cent, sodium sulphite in water. The pres- 
ence or absence of T.N.T. on the skin 
previous to and after the washing with 
soap and the sulphide was determined by 
means of alcoholic sodium hydroxide (Web- 
ster's reagent). The results are illustrated 
by Table 4. It is evident, then, that wash- 
ing of the skin with soap and water re- 
moves only a relatively small portion of 
T.N.T. After washing in the sodium sul- 
phite, however, the test for T.N.T. became 
negative in practically all cases except where 
the washing had not been very thorough. 



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In order to gain some information as to 
the actual amount of T.N.T. removed by 
the sulphite wash, the following experiment 
was carried out: Four T.N.T. workers 
were asked to wash their hands and fore- 
arms thoroughly with soap and water. 
After this they washed a second time in a 
liter of 10 per cent, sodium sulphite, care 
being taken to prevent spilling of the solu- 
tion. The sulphite solution assumed a dark 



made inquiries as to where they could pro- 
cure it. The reason for the great interest on 
the part of the workers is that the deep red 
color which appears on the skin after treat- 
ment with sulphite clearly proves to the 
worker the presence of T.N.T. on his skin, 
and the fact that the color passes into the 
solution visualizes the removal of the poi- 
son from the skin. There is no objection to 
the use of the sulphite solution for washing 



TABLE 4. — RELATIVE EFFICIENCY OF SOAP AND WATER AND SODmM SULPHITE 
SOLUTION IN REMOVING T. N. T. FROM SKIN 



No. of Worker 


Webster Test before 
Washing 


Webster Test after Soap 
and Water 


Webster Test after 
Sulphite 




Hands 


Wrist 


Forearms 


Hands 


Wrist 


Forearms 


Hands 


Wrist 


Fore- 
arms 


Bemaiks 


M.K.471... 
M. D. 647. . . 

L. L 358 

L.E.543.... 
M.K.85.... 
L. D. 314 .. . 
L.K.401 ... 

L, K. 192 . . . 
L. 1. 562 ... . 
L.L488.... 
L. 1. 276 ... . 
L. H. 615 .. . 
X 


+ + + + 
+ + + 

+ + + + 
+ + + + 
+ + + + 

+ + + + 
+ + + + 

+ + + 
+ + + + 
+ + + + 

+ + + 
+ + + + 


+ + + 
+ + 

+ + + 
+ + 
+ + 

+ + + 
+ + 
+ + 

+ + + 

+ + + 
+ + 

+ + + 


+ 
+ 

+ + 

+ 
+ 

+ 

+ 

+ 
+ + 
+ + 

+ 
+ + 


+ + 
+ + 
+ + 
+ + 
+ + 
+ + 
+ + 

+ + + 
+ + + 
+ 
+ + 
+ + 
+ + 
+ + 

+ + + 


+ 

+ 

+ 

+ + 

+ 
+ 
+ 

+ 
+ + 

+S1 

+ + 

+ 
+ 
+ 
+ 
+ + 


+S1 
+S1 

+ 

+S1 

+ 

+S1 

+ 
+ 

+S1 

+ 
+ 
+ 
+ 


+S1 
+S1 

+S1 

+S1 


*+si 




End of shift 

a u u 

a u a 
u a u 
a a ' u 
tt u tt 

Had been off T. N. T. 
two weeks; worked on 
day of test 

End of shift 

u a a 

Did not wash thoroughly* 

tt u u u 
tt tt tt « 

a « « u 


X 


tt a a u 


L. 1. 591 ... . 
L. 1. 505 ... . 


tt tt tt u 

tt tt a tt 



red color and was analyzed for T.N.T. in 
the following manner. The solution was 
acidified with dilute sulphuric acid and ex- 
tracted twice with ether. The ether ex- 
tract was washed twice with distilled water 
and the ether evaporated to dryness. The 
crystalline residue, after drying to constant 
weight, weighed 148 mg. and consisted of 
T.N.T. It is, therefore, evident that at 
least 37 mg: were removed from the hands 
of each worker. 

The workers who used the sulphite wash 
were enthusiastic over the efficiency of this 
chemical for the removal of T.N.T. and 



the face and neck, as animal experiments 
have demonstrated that this solution has 
no injurious eflfect on either the skin or the 
eyes. 

Absorption of T.N.T. by Lungs and Gastro- 
intestinal Tract 

In order to prevent as much as possible 
the absorption of T.N.T. by the lungs 
and gastro-intestinal tract, the workrooms 
should eliminate the possibiUty of air con- 
tamination with T.N.T. In the factory in 
which this work was carried out, three 
operations exposed the workers to badly 



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contaminated air. First of all the melting 
of T.N.T. in the steam kettles led to the 
escape of a considerable amount of the 
vapor into the workroom as the kettle 
hoods were not provided with forced draft. 
The workmen engaged in melting were 
therefore breathing air more or less satu- 
rated with T.N.T. vapor, which, according 
to the analyses reported by Professor 
Phelps and Mr. Casselman,* contained 
0.006 mg. of T.N.T. per liter. The worker 
would therefore breathe at least 16 mg. of 
T.N.T. during seven and one-half hours. 
Another operation which led to air con- 
tamination was the sweeping of the floors, 
which was done three times during the day 
while the workers were at work. The dust 
suspended in the air by means of this opera- 
tion is very light and settles slowly. As the 
result of the sweeping, each worker would 
breathe in approximately 9.1 mg. of T.N.T. 
during a day. The third objectionable 
operation consisted in blowing out the 
booster cavity with compres^d air. This 
was done very frequently in the finishing 
room, and the persons on this job may take 
in 2 or 3 mg. of T.N.T. with each breath. 
These serious health hazards could easily be 
eliminated by the use of exhaust ventila- 
tors for the melting kettles and an appro- 
priate vacuum system for the cleaning of 
the floors and the booster cavity. 

The figures given in the report of Pro- 
fessor Phelps and Mr. Casselman are con- 
vincing enough to emphasize the impor- 
tance of preventing air contamination^ The 
method used was much more accurate than 
the one used by Moore and his colleagues, a 
fact which explains the higher values thus 
obtained. 

As a further precaution, the workers 
should be urged to wash their hands 
thoroughly before eating their meal during 
the working hours. The protective value of 
respirators has been tested out extensively 

. ♦ The report by Professor Phelps and Mr. Cassehnan 
will be published elsewhere. 



in this coimtry and abroad, and has been 
found to be very unsatisfactory. 

This investigation, therefore, clearly 
proves the necessity of guarding the worker 
against absorption of the poison by the 
skin as well as by the lungs and gastro- 
mtestinal tract. 

Diet 

In the first part of this paper attention 
was called to the relation between diet and 
T.N.T. poisoning. It was pointed out that 
dogs on a meat diet are more resistant to 
the action of T.N.T. than dogs fed on 
bread and milk. In view of this observation 
it was important to make inquiries concern- 
ing the diet of the workers. 

The company operates two mess halls, 
one principally for women, the other for 
men. In both of these a fixed menu is 
seived. There is also a "short-order" 
restaurant where the workers can choose 
their menu from a large variety of foods. 
The portions served in these mess halls are 
fairly Uberal. The menus vary but little 
from week to week. 

A relatively small number of the workers 
live in family cottages and procure their 
provisions from the coinpany's commissary 
store. 

It was evident that the diet of the work- 
ers was varied and that it included a 
considerable amount of meat, vegetables, 
cereals, bread, butter, and fruits. The 
good quahty of the diet consumed by the 
workers may be one of the factors which 
accounts for the evident absence of severe 
T.N.T. poisoning in this plant. 

Toxic Jaundice and Aplastic Anemia 

The first cases of toxic jaundice at- 
tributed to T.N.T. were reported in 1915 
by the medical inspectors of factories to the 
British home oflBce, which in turn issued ' 
instructions to physicians to report all such 
cases. According to O'Donovan (36) there 
occurred in England, in 1916, 181 cases 



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with 50 deaths; in 1917, 189 cases with 44 
deaths. In addition there were reported 
during this period 14 cases of at)lastic 
anemia, these cases being regarded as rep- 
resentatives of another extreme form of 
T.N.T. poisoning. No statistics are avail- 
able as to the prevalence of these two con- 
ditions in the United States. Martland (5) 
and Haythorn (37) report two fatal cases, 
giving also the pathological findings at 
necropsy. Hamilton (38) (39) reports 13 
deaths from T.K.T. poisoning in the 
United States, but fails to state the nature 
of the clinical picture, whether toxic jaun- 
dice or aplastic anemia. 

It is very significant that the occurrence 
of toxic jaimdice and aplastic anemia in 
T.N.T. workers is relatively rare when it is 
considered that Great Britain alone em- 
ployed over 100,000 persons in the manu- 
facture of munitions. It is also to be 
remembered that the diagnosis of toxic 
jaundice depends largely on the icterus, 
which of course is not characteristic of this 
condition only, and the association of the 
worker with T.N.T. Syphilitic icterus, or 
true yellow atrophy of the liver, may occur 
in T.N.T. workers and may thus lead to a 
diagnosis of toxic jaundice. The same holds 
true for aplastic anemia, a disease which 
also occurs in persons not exposed to 
T.N.T. It is therefore possible that the 
figures given by O'Donovan are somewhat 
too high. 

The question naturally arises as to why 
most of the T.N.T. workers should be im- 
mune to toxic jaundice and aplastic 
anemia. The following considerations may 
assist in the solution of this problem. 
From the results obtained in the study of 
T.N.T. poisoning of dogs, it is evident that 
T.N.T. often causes the appearance of a 
very severe anemia. The bone marrow of 
these animals is hyperplastic without ex- 
ception, and for this and other reasons the 
anemia as observed in these animals cannot 
be regarded as a true aplastic anemia. The 



blood destruction was therefore attributed 
to a primary injury of the red cells leading 
to fragmentation and eventually to phag- 
ocytosis of the injured red cells by the 
phagocytic cells of certain organs. The 
examination of the T.N.T. workers has 
furthermore revealed the fact that a con- 
siderable number show a moderate anemia. 
Minot has also called attention to the frag- 
mentation of the red cells in many T.N.T. 
workers. 

We therefore believe that the available 
evidence clearly shows that the mechanism 
of the blood destruction caused by T.N.T. 
is essentially the same in dogs and in man. 
Previous writers on this subject insist, how- 
ever, that T.N.T. anemia is caused by the 
toxic action of T.N.T. or some of its deriva- 
tives on the hematopoietic organs, espe- 
cially the bone marrow. Our data do not 
permit us to exclude this possibiUty alto- 
gether, although they do show that T.N.T. 
anemia is essentially a phagocytic anemia. 
The bone marrow was examined only in six 
cases of so-called aplastic anemia in T.N.T. 
workers. The marrow of the femur was 
described as gray in one case,' fatty with 
pink spots in two cases, and pale pink in 
two cases. Turnbull (40) from the micro- 
scopic examination of the bone marrow in 
one case, claims that it showed a relative 
excess of erythroblastic activity and a de- 
crease in the number of megalokaryocytes; 
numerous plasma cells and large phag- 
ocytes containing pyknotic nuclei, eryth- 
roblasts, erythrocytes, and iron-containing 
pigment. It is possible to conceive that in 
the later stages of the anemia the function 
of the bone marrow may be seriously de- 
pressed on accoimt either of the oxygen de- 
ficiency or of other metabohc abnormalities 
resulting from the severe anemia, or as the 
result of the direct action of the poison on 
this organ. We believe, however, that these 
factors are of minor importance in the pro- 
duction of T.N.T. anemia. 
. As to T.N.T. icterus, the experimental 



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vork plainly shows that this condition may 
often occur in the absence of liver necrosis 
or atrophy, in which case the icterus is 
probably due to the inability of the Uver 
cells to excrete the increased amount of bile 
pigment resulting from the destruction of 
erythrocytes. Some of the cases of toxic 
jaundice reported by Panton (24) may pos- 
sibly be explained on this basis. The blood 
of these patients showed a normal hemo- 
globin content and red cell count. On 
account of these findings some writers ex- 
plain T.N.T. icterus as being primarily due 
to the injurious action of the poison on the 
liver cells, a view which is not necessarily 
correct as it is quite possible to conceive 
that T.N.T. may lead to a considerable in- 
crease in red cell destruction and conse- 
quently bile pigment formation, without 
causing a reduction in the hemoglobin 
content or number of red blood cells. The 
hemoglobin content and red cell count are 
not an absolute index of the degree of blood 
destruction, as increased blood regenera- 
tion may temporarily compensate the in- 
creased disintegration of red cells. Some of 
Panton's cases which he observed for sev- 
eral weeks showed a gradual decrease in 
hemoglobin and the number of red cells, 
this finally resulting in the appearance of a 
severe anemia. It is very likely that in the 
early stages of the jaundice the increased 
blood destruction was compensated by 
regeneiation, and that later on, when this 
compensation failed, the anemia appeared. 
It is therefore possible to attribute the 
icterus in some of the toxic jaundice cases 
to the increased blood destruction caused 
by T.N.T. In other cases, however, the 
icterus is associated with a marked reduc- 
tion of liver dullness during life, and at 
necropsy the liver shows extensive necrosis 
and atrophy, which, according to Turnbull, 
Haythom, and others, cannot be dis- 
tinguished from acute yellow atrophy. The 
hver was examined in thirty of these cases 
and in all a greater or less degree of acute 



yellow or red atrophy was present. The 
Uver cells of some areas were completely 
destroyed. Some observers also found a 
moderate amount of cirrhotic change. It is 
diflBcult to determine whether or not 
T.N.T. alone is responsible for these Uver 
changes. We are rather inclined to explain 
these ca^es by assuming that certain pre- 
existing pathological conditions affecting 
the functional capacity of the Uver, such as 
cirrhosis, syphiUs, alcoholism, etc., may 
predispose some T.N.T. workers to toxic 
jaundice in an abnormal degree. Under 
these circumstances, it is possible to con- 
ceive that T.N.T. or its reduction products 
may exert a more deleterious action on the 
Uver cells than in persons with normal 
Uvers. This explanation would account for 
the fact that in numerous experiments with 
dogs it was impossible to produce even the 
sUghtest degree of Uver atrophy, and this 
in spite of the fact that these animals are 
highly susceptible to necrosis of the liver 
when exposed to poisons with k more or 
less specific action on the organ, such as 
chloroform, phosphorus, and arsenicals. 

The fact that toxic jaundice sometimes 
appears in T.N.T. workers several weeks 
after their removal from aU contact with 
T.N.T., agrees with the observation made 
on dogs, viz.y that T.N.T. is very slowly 
eliminated from the body, and therefore 
continues to exert its toxic action for a long 
period of time. 

If the correctness of these considerations 
is taken for granted, the prevention of toxic 
jaundice and so-caUed aplastic anemia in 
T.N.T. workers should concern itself prin- 
cipaUy with the eUmination of aU persons 
with evidence of Uver disease and anemia 
from contact with T.N.T. Moreover, all 
T.N.T. workers should be frequently ex- 
amined by the factory physician, special 
attention being given to the occurrence of a 
sUght icteric change of the conjunctiva or 
skin, the presence of this symptbm being 
regarded as sufficient reason to put the in- 



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dividual on work where he is no longer ex- 
posed to T.N.T. An accurate hemoglobin 
estimation should also be made on each 
worker every week, or at least every two 
weeks. A nurse or specially trained labora- 
tory assistant could easily attend to this 
work. Any workers with icterus or severe 
anemia should be admitted to a hospital. 
The treatment should consist first in the 
removing of all T.N.T. from the body sur- 
face by means of a 10 per cent, sodium 
sulphite solution. The anemic patients 
should receive a nutritious diet containing 
a fair amount of fresh meat. The patients 
with jaundice should be treated with laxa- 
tives and. should be fed on a meat-free diet 
containing milk and fresh vegetables. 

The prognosis of cases with an extreme 
anemia is grave. A considerable number of 
cases with jaundice recover, although the re- 
covery proceeds very slowly and requires 
six months or more. See Crawford (41) 
and Bower (42). 

Summary 

The principal results obtained in the 
field investigation are the following: 

The examination of 237 T.N.T. workers 
in a shell-fiilling plant showed that 72 per 
cent, of these workers were anemic. This 
anemia exhibits the same features as the 
anemia observed in dogs poisoned with 
T.N.T., viz.y a reduction in the hemoglobin 
percentage, the presence of anisocytosis 
and poikilocytosis, polychromatophilia, 
fragmentation of red cells, and the appear- 
ance of nucleated and reticulated red cells 
in the circulating blood. The anemia may 
or may not be associated with a leukocy- 
tosis, leukopenia, or relative lymphocy- 
tosis. 

Cyanosis, pallor, and dermatitis were 
frequently seen in these workers, and indi- 
cate that the poison is absorbed. The 
absence of these symptoms, however, is 
not proof of the absence of poisoning. A 



marked anemia may exist without clinical 
symptoms. 

Examination of the urine nearly always 
reveals the presence of a derivative of 
T.N.T. (hydroxylamine compound). The 
presence or absence of this substance in the 
urine, as determined by the Webster test, is 
of no prognostic value. The examination 
of the blood, with particular reference to its 
hemoglobin content, the character of the 
red cells and the appearance of a slight 
icteric discoloration of the skin or conjunc- 
tivae, is recommended as a reliable guide 
for the diagnosis of T.N.T. poisoning. 

No cases of toxic jaundice or aplastic 
anemia were found among these workers. 
It is suggested that the so-called aplastic 
anemia observed in T.N.T. workers repre- 
sents the final stage of the anemia so com- 
monly found in persons exposed to T.N.T., 
and that in the earlier i§tages of poisoning 
the blood destruction is essentially due to 
the injury of the red cells which secondarily 
leads to phagocytosis of the injured cells 
by the spleen, liver, and bone marrow. In 
toxic jaundice the hemoglobin and red cell 
count may be normal or reduced. In the 
first case blood regeneration probably 
compensates for blood destruction. The 
liver lesions found at necropsy may be due 
to a pre-existing fimctional or histological 
abnormality of the liver cells which has 
been aggravated by the T.N.T. intoxi- 
cation. 

The poison n^ay be absorbed through the 
skin, the lungs, or the gastro-intestinal 
tract. Means of prevention should be 
strictly observed. Skin contact and air 
contamination should be reduced to a 
minimum. The principal measures for 
skin protection should consist in wearing 
clean overalls and head dress, and in using 
sulphite solution for the removal of T.N.T. 
from the exposed skin surface before the 
worker leaves the factory. Personal clean- 
Uness in working and in the care of the 
body should be emphasized. Gloves and 



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respirators are of no value. There should 
be eflScient ventilation of the workrooms; 
the floors, booster cavities, etc., shoiftd be 
cleaned by means of an induced draft. The 
workers should be instructed to eat a 
nutritious diet containing a fair amount of 
meat. They should be examined at least 
every week or two for the presence of 
clinical symptoms and anemia. Intermit- 
tent employment on T.N.T. work reduces 
the health hazard somewhat, but does not 
necessarily insure against poisoning be- 
cause the system retains T.N.T. for a con- 
siderable length of time. Prehminary 
medical examination should insure, as 
nearly as possible, that no person is em- 
ployed who shows the sUghtest evidence of 
liver disease or anemia. 



ACKNOWLEGDMENTS 

The authors are greatly indebted to 
Misses K. Dorothy Wright, M. Crane, M. 
A. Connell, Mr. Henry B. Mulholland and 
Mr. Lewis D. Hoppe for assistance in the 
blood examination of the experimental 
animals and T.N.T. workers. Dr. Walter 
L. Mendenhall, of Dartmouth Medical Col- 
lege, rendered valuable assistance diu-ing 
the first three months of this investiga- 
tion. We also express our grea£ apprecia- 
tion to Dr. W. G. MacCallum and Dr. 
Henry Christian for their examination of 
part of the histological material obtained in 
the experimental work. The vital red used 
in the blood volume determinations was 
secured through the courtesy of Dr. C. L. 
Alsberg, Chief of the Bureau of Chemistry. 



BIBLIOGRAPHY 

(For bibliographical references numbered less than 9S, see Part I of this article in the preceding 

issue of This Journal.) 



28. Livingstone-Leaarmonth, A., and Cunningham, 
B.M.: Observations on the Effects of Tri- 
nitro-toluene on Women Workers. Lancet, 
1916, 2, 261. 

29. Stewart, M. J.: Toxic Jaundice in Munition 
Workers. Lancet, 1917, 1, 158. 

30. Smith, L. H.: The Blood of Workers in Trini- 
trotoluene. Jour. Am. Med. Assn., 1918, 70, 
231. 

31. Harrington, T. P.: Tri-Nitro-Toluene Poison- 
ing in Massachusetts. Boston Med. and Surg. 
Jour., 1917, 177, 838. 

32. Gregorson, A. W., and Taylor, F. E.: On 
Trinitrotoluene Poisoning, with Records of 
Five Cases. Glasgow Med. Jour., 1918, 90, 65. 

33. Minot, G. R. : Blood Examinations of Trinitro- 
toluene Workers. Jour. Am. Med. Assn., 1919, 
73, 714. 

34. Minot, G. R.: Blood Examinations of Trinitro- 
toluene Workers. JouB. Indust. Hyg., 1919- 
1920, 1, 301. 



35 



36 



37. 



Final Report of Health of Munition Workers 
Committee. London, 1918, p. 78. 
O'Donovan, W. J.: The Epidemiology of Tri- 
nitro-toluene Poisoning. Proc. Royal Soc. Med., 
1917-1918, 11, 149, 

Haythom, S. R. : The Pathology of Trinitrotol- 
uene Poisoning. Intemat. Assn. Med. Mu- 
seums, Bull. No. 7, 1918, p. 103. 

38. Hamilton, A.: Industrial Poisons Encountered 
in the Manufacture of Explosives. Jour. Am. 
Med. Assn., 1917, 68, 1445. 

39. Hamilton, A.: Trinitrotoluene Poisoning. Med. 
and Surg., 1917, 1, 761. 

40. Tumbull, H. M. : Discussion on Toxic Jaimdice 
in Munition Workers. Proc. Roy. Soc. Med., 
1916-1917, 10, Part 1, 47. 

41. Crawford, B.G.R.: Tqxic Jaundice, with Atro- 
phy of Liver, followed by Regeneration and 
Recovery. Brit. Med. Jour., 1918, 1, 450. 
Bower, W.: Toxic Jaundice: Atrophy of Liver: 
Regeneration and Recovery. Brit. Med. Jour., 
1918, 1, 508. 



42 



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BOOK REVIEWS 



The Health of the Industrial Worker. By Ed- 
gar L. Collis. B.Ch., M.A., M.D. (Oxon.), M.R.C.P. 
(Lend.), M.R.C.S. (Eng.), Mansel Talbot Professor 
of Preventive Medicine, Welsh National School of 
Medicine; Member of Industrial Fatigue Research 
Board; late H.M. Medical Inspector of Factories; 
^iember of Health of Munition Workers Committee; 
Milroy Lecturer, R.C.P. (1915); Director of Welfare 
and Health, Ministry of Munitions; and Major 
Greenwood, M.R.C.P. (Lond.), M.R.C.S. (Eng.). 
Member of Industrial Fatigue Research Bosgrd; 
Reader in Medical Statistics, University of London; 
late Statistician to Lister Institute; Head of Medical 
Research Branch, Ministry of Munitions; Arris and 
Gale Lecturer, R.C.S. (1908). Containing a chapter 
on Reclamation of the Disabled by Arthur J. 
Collis, M.A., M.D. (Cantab.), M.R.C.S. (Eng.), 
D.P.H. (Durh.), Medical Superintendent, Ministry 
of Pensions Hospital, Leicester; late Temp. Lieut. - 
Col. R.A.M.C. With an introduction by Sir George 
Newman, K.C.B., D.C.L., M.D., F.R.C.P. Illus- 
trated. Cloth. Pp. 450 with illustrations and index. 
Philadelphia: P. Blakiston's Son & Co.. 1921. 

Sir George Newman in his introduction to 
this book gives the point of view which it so 
forcibly presents: "While at first sight acci- 
dents, poisoning, and a high occupational death 
rate are impressive, it cannot, I think, be 
doubted that the less dramatic side of the prob- 
lem is, in fact, the more important — namely, 
the lost time and incapacity due to ill-health. 
For this is so widely prevalent as to be almost 
universal, in all districts, at all ages, in all 
trades, there is this vast mass of wasted life and 
energy due for the most part to preventable 
maladies — in their turn largely attributable to 
remediable conditions of industry, or to neglect 
of hygiene." 

After reading this introduction one is not sur- 
prised to find an absence of chapters upon in- 
dustrial toxicology and upon the minutiae of 
industrial medicine and surgery. We are of- 
fered instead a view of a new field in preventive 
medicine, a field which covers the working life 
of a large portion of our population. Such a 
book places industrial hygiene in its proper 
place, displays its possibilities of growth, and 
removes it from the position of a rather feeble 
adjunct to pharmacology and to the estab- 
lished practice of medicine and siu'gery. 



The chapter headings will give the best idea 
of the scope of the work: I. Industry' and 
Health — A Retrospect; II. Review of In- 
dustrial Legislation; III. The Utilization of 
Statistical Methods in Industrial Preventive 
Medicine; IV. The Effects of Industrial Em- 
ployment upon Health as Indicated by Vital 
Statistics; V. Industrial Activity and Fatigue; 
VI. Tuberculosis and Industry; VII. Cancer 
and Industry; VIII. Causation and Preven- 
tion of Accidents; IX. Industrial Employment 
of Women; X. The Feeding of the Industrial 
Worker; XI. Food at the Factory; XII. The 
Use of Alcoholic Beverages by the Industrial 
Worker; XIII. Reasons for and Methods of 
Ventilation; XIV. Lighting; XV. Washing Ac- 
commodation — Sanitary Accommodation — 
Drinking Water — Working Clothes — Cloak 
Rooms — Seats; XVI. Labour Turnover or 
Industrial Wastage; XVII. Supervision of In- 
dustrial Health; XVIII. Reclamation of the 
Disabled. 

The treatment of these subjects is of high 
order and the difficulty of handling them is 
great because in the main they are at the be- 
ginning of their development. Of particular 
merit are the chapters upon fatigue, ventilation 
and tuberculosis. The addition to each chapter 
of well-selected groups of references is an addi- 
tion of value and especially useful in a develop- 
ing subject. 

While to the American reader it may seem 
that the treatment should have extended out- 
side British experiences to a greater degree than 
occurs, this does not seem of importance to the 
reviewer. The book is an exposition of prin- 
ciples, of a modern point of view upon which 
schools may be founded. In such an effort the 
experiences recounted are necessarily inter- 
national in their applicability and significance. 

It is a pleasure to recommend the work to 
forward-looking readers, and it is hoped that 
those who have seen the subject of industrial 
hygiene as the weak handmaid of medicine and 
surgery will find a stimulating refutation of 
their views in this volume. — Cecil K. Drinker. 



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BOOKS RECEIVED 

Books received are acknowledged in this column, and such acknowledgment must be regarded as a 
sufficient return for the courtesy of the sender. Selections will be made for review in the interests of our 
readers and as space permits. 

Principles of Hygiene. A Practical Manual for 
Students, Physicians, and Health-Officers. By D. H. 
Bergey, A.M., M.D., Dr. P.H., Assistant Professor 
of Hygiene and Bacteriology, University of Pennsyl- 
vania. Dlustrated. Cloth. Seventh Edition, thor- 
oughly revised. Pp. 556 with illustrations, preface, 
index, and appendix. Philadelphia and London: W. 
B. Saunders Company, 1921. 



Textbook of Surgical Nursing. By Ralph Colp, 
A.B., M.D., Instructor in Surgery, Columbia Uni- 
versity, New York; Lecturer in Surgical Nursing, 



Presbyterian Hospital Training School for Nurses, 
New York; Adjunct Visiting Surgeon, Volunteer 
Hospital, New York; Chief of Surgical Clmic, Beth 
Israel Hospital, New York; Formerly Lectiu^r in 
Nursing and Health, Teachers College, Columbia 
University, New York; and Manelva Wylie Keller, 
B.S., R.N., Formerly Chief Operating Room Nurse, 
St. Luke's Hospital, New York, and Anesihetist, 
St. Luke's Hospital, New York, and Mobile Hos- 
pital No. 2, A. E. F., France. Cloth. Pp. 453 with 
appendix, illustrations, and index. New York: 
Macmillan Company, 1921. 



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INDUSTRIAL HYGIENE 



PUBLISHED MONTHLY 



Volume hi 



FEBRUARY. 1922 



Number 10 



MODERN VIEWS UPON THE DEVELOPMENT OF 
LUNG FIBROSIS* 

Cecil K. Drinker, M.D. 

Associate Professor of Applied Physiology, Harvard Medical School 
{From the Laboratory of Applied Physiology, Harvard Medical School, Boston, Mass.) 



I. New Aspects of the Problem 

T N 1918 Haldane (1) published a short 
-*- and very suggestive paper on the 
cause of serious lung injury from dust. 
He pointed out that silicious dust had 
been thought to be harmful if present 
in the air in any considerable amount, 
but that he had become acquainted with 
certain instances in which this did not 
seem to be true, work in high percent- 
ages of silicious dust being apparently 
uninjurious. He then discussed the fact 
that coal miners who breathe coal and 
shale dust remain comparatively free 
from serious lung disease. This he har- 
monized with experimental work done 
by Mavrogordato (2), who caused gui- 
nea-pi^s to breathe air laden with 
six different dusts: coal, shale, quartz 
from the Transvaal, flint, material 
from flues, and pure precipitated 
silica. He found that high concen- 
trations of any of these dusts re- 
sulted in heavy deposition in the 
lungs, with marked congestion and 
cellular proliferation. His observations 



^Received for publication Oct. 18, 1921. 



did not continue long enough to permit 
the widespread development of fibrous 
tissue, but there is apparently no doubt 
that it would have occurred. 

The significant fact of the experi- 
ments was brought out by moderate ex- 
posures, when it was found that "While 
coal dust and shale dust enter the lung 
with great readiness they do not pro- 
duce, under these conditions, permanent 
lesions; and the lung might pass for 
normal after a twelvemonth. Flue dust 
and crystalline silica are not eliminated 
with such readiness." The important 
suggestion of the experiments is, then, 
that dusts which do harm are those 
which for some reason or other are not 
eliminated. Carbon particles, according 
to Haldane and Mavrogordato, cause 
rather a violent reaction when they 
reach the pulmonary alveoli, which re- 
sults in their quick seizure by phago- 
cytes and their elimination ; while crys- 
talline silica, a notably harmful dust, 
enters the lung with equal readiness, 
causes little reaction, remains in the 
lung tissue and slowly induces fibrosis. 

It will be shown later that Mavrogor- 



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dato makes many claims as to the man- 
ner in which cki^t i? removed from the' 
lungs, which are out of accord with the 
observations of other investigators. But 
analytical disagi:eements have nothing 
to do with his most important conten- 
tion, namely, that rate of dust invasion 
is not more important than rate of dust 
elimination. When dust reaches the 
lung alveoli there are three ways by 
which it may get out : 

1. By the bronchi — ^the route taken 
on coming in. The sputum of individ- 
uals who have worked in coal dust in- 
variably shows particles, and a fair per- 
centage of these have probably been 
down in the lungs and up again. They 
are noticed clinging to bits of mucus or 
within large cells which are constantly, 
but apparently erroneously, thought to 
be desquamated epithelial cells from the 
pulmonary alveoli. Later on the real 
origin of these cells will be discussed, 
but at this point it is enough for us to 
realize that dust particles in the alveoli 
may be seized by phagocytes which, by 
ameboid movement, find their way up 
into the bronchi and then, through the 
activity of the bronchial cilia, are driven 
up into the mouth. No doubt, also, the 
alveoli may fill with semi-fluid exudate 
which carries particles up on to the cilia, 
and thence they may be slowly passed 
on to the mouth. 

2. The particles may get through the 
alveolar walls, reach the lymphatics of 
the lun.RS, and be slowly moved toward 
the lung roots. Present indications 
point to this second possibility as of 
most importance. 

3. The particles may be taken up 
from the alveoli by phagocytes which 
wander into the blood capillaries sur- 
rounding the alveoli, and then be car- 
ried to various points of elimination. 
Permar (3) mentions this possibility and 
feels that it does not occur. While we 



must admit that there is no direct proof 
of the removal of ^foreign material by 
the Blood, there Is a certain amount of 
analogous evidence which is worth con- 
sidering. Winternitz. ^nd Smitji (4) 
have shown that physiological salt so- 
lution may be poured into the alveoli 
of the dog at a rate as high as 3,000 c.c. 
in 30 minutes. Undoubtedly, removal 
of this fluid is accomplished by the blood 
stream. So far as we know there are 
no direct attempts to ascertain whether 
solid particles may be removed by the 
same route. In 1916 Shipley and Cun- 
ningham (S) performed experiments 
which are most suggestive in this direc- 
tion. They immersed the omentum of 
the decerebrate cat in a suspension of 
finely divided carbon, and within a short 
time were able to detect carbon parti- 
cles free both in the capillaries of the 
liver and upon the phagocytic endothe- 
lial cells which line them. These parti- 
cles could not have reached the liver ex- 
cept through the blood stream. By some 
process, the nature of which is not 
known, carbon particles pass into the 
blood capillaries of the omentum and 
drift up to be arrested in the capillaries 
of the liver. The situation within the 
lung alveoli is possibly similar, particles 
within them being very close to the 
blood stream and quite as well able to 
get into these capillaries, as in the case 
of particles which enter the omental cir- 
culation. 

If now we review these three methods 
of removal, it is apparent that phagocy- 
tosis plays an exceedingly important, 
indeed an indispensable part in the pro- 
cess. 

II. The Alveolar Phagocytes 

Mavrogordato describes the phagocy- 
tosis of carbon in the lung of the guinea- 
pig in the following summary : 



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(i) The dust cells, mostly cells derived 
from pulmonary epithelium, take up coal 
dust with great avidity and are very readily 
shed. Dust is seen in fixed cells as well as 
m free cells, but the former are for the 
most part isolated, and one does not meet 
islets of dust-loaded cells to any extent. 

In the text leading up to this sum- 
mary he makes such statements as: 
"Many cells — of large and small endo- 
thelial type and dust laden — were to be 
made out free in the alveoli, but there 
was also much dust in the fixed cells." 
And later, in describing experiments 
with the Transvaal silicious dust, he 
again speaks of cells of "endothelial 
type." One cannot decide whether Mav- 
rogordato recognizes the possibility of 
phagocytosis by actual endothelial cells 
or uses the term to describe the appear- 
ance of cells of epithelial origin. This 
view, that the alveolar epithelium is re- 
sponsible, is in agreement with that of 
many investigators, but it is not con- 
firmed by recent observations ; and since 
the origin and original position of lung 
phagocytes is of considerable practical 
importance it is necessary to review the 
data which have been presented. 

The idea that the large flat cells, seen 
to contain dust in properly exposed ani- 
mals and persons, are derived from the 
epithelium is singularly easy to hold. 
By ordinary methods of staining practi- 
cally all the cells containing particles, 
which are found either inside, clinging 
to the alveolar walls, or within adjacent 
lung tissue, are indistinguishable from 
lining epithelial cells. Knauff (6) pre- 
sented this view many years ago. Rup- 
pert (7), Schottelius (8), Wainwright 
and Nichols (9), Briscoe (10) and Se- 
well (11) agree with him. Arnold (12), 
Oliver (13), Beitzke (14), Watkins- 
Pitchford (15), and Willis (16) believe 
that a variety of cells may be responsi- 
ble. Haythom (17) and Klotz (18) 
were the first to hold substantially that 



the endothelial leukocyte is of import- 
ance. Such cells must be derived from 
the lining of blood capillaries of lymph- 
atics or from the circulating blood. 
They are, therefore, out of contact with 
dust as it reaches the alveoli. A definite 
migration through the lung tissue into 
the alveolar spaces is necessary in order 
to bring them into action. Haythorn's 
identification of the lung phagocytic 
cells as endothelial depended upon the 
.facts that they were identical in size and 
appearance with endothelial leukocytes, 
that they were phagocytic for blood pig- 
ment, carbon, and all kinds of cellular 
debris, and were apparently the same 
type of cells as were found in tubercles. 
Gardner (19) studied nearly one hun- 
dred dusted guinea-pigs, and during the 
stage of phagocyte formation failed to 
find a single mitotic figure within alveo- 
lar epithelium. He says : 

. . . Moreover, no trace of dust has been 
found within an attached alveolar epithelial 
cell. One of Miller's great contributions 
to our understanding of pulmonary anatomy 
has been the distention method of fixation. 
By its use it is possible to determine with 
a considerable degree of accuracy the rela- 
tion of one structure or cell to another. If a 
collapsed or undistended lung be examined, 
it seems indisputable that dust particles are 
lying within attached epithelial cells. If, 
however, the lung be fixed by the distention 
method, the dust cells, although they may 
be near the wall, will always be super- 
imposed upon the epithelium or lying at a 
little distance from the wall. It would seem 
that the employment of this technical pro- 
cedure has enabled us to eliminate one of 
the proposed sources of the intra-alveolar 
phacrocyte. 

No definite conclusions on this disputed 
question are possible at this time. The evi- 
dence would seem to have reduced the ques- 
tion of the orierin of the alveolar phagocyte 
to a consideration of the local vascular en- 
dothelium in the lung and to studies on the 
transitional cell of the circulating blood. 

Neither Haythorn, Klotz, nor Gardner, 
however, employed staining reactions 



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wl\ich identify endothelial phagocytes. 
Their conclusions depend upon analo- 
gies, or upon attempts to eliminate the 
alveolar epithelium from consideration. 
Slavjansky (20) practically accom- 
plished the identification of endothelial 
cells as the important agents in 1869. 
He gave intratracheal injections of indi- 
go followed by intravenous injections of 
cinnabar, and shortly after he found 
phagocytic cells, containing cinnabar 
particles and indigo, free in the alveoli. 
He considered that these cells were 
mononuclear elements derived from the 
circulating blood. Tchistovitch (21) 
used a somewhat similar technic in 
1889. Recently Sewell (11) attempted 
the same sort of experiment but, for 
technical reasons which need not be out- 
lined, failed in the proper execution of 
his task. 

Foot (22) and Permar (3)— the lat- 
ter in a very beautiful and conclusive 
series of observations — have carried 
through the same type of experiment 
and leave little doubt as to the final con- 
clusion. The technic used by Permar 
depends upon the following facts. It has 
been known for some time that the en- 
dothelial leukocyte will take up certain 
vital stains. Thus, if rabbits or guinea- 
pigs receive intravenous injections of 
trypan blue, isamine blue and a num- 
ber of other dyes, it is found that after 
a few days certain large cells in the liver, 
spleen, lymph nodes, and bone marrow 
are filled with the dye. In the normal 
animal practically no stained cells are 
found in the lung. The uninjured en- 
dothelium of the blood capillaries and 
lymphatics does not take up the dye. 
It has, however, been shown that in- 
jured or irritated vascular endothelium 
very readily becomes phagocytic (23). 
If, now, the animals are injected intra- 
venously with isamine blue and intra- 



tracheally with finely ground carmine,, 
the injections being repeated for several 
days, one is soon able to find numerous • 
blue-stained endothelial phagocytes in 
the lung, and these clearly identified 
cells may then be followed in relation to 
the phagocytosis of the intra-alveolar 
carmine. 

On examining animals so treated Per- 
mar never found the epithelial cells of 
the alveolar lining either vitally stained 
or carmine containing. He discovered 
that the number of blue-stained cells in 
the lung increased with intratracheal 
carmine injections and sums up his 
work as follows : 

. . . The large mononuclear phagocyte 
of the lung is derived by proliferation from 
the vascular endothelium, and in large part 
that of the capillary network in the walls of 
the air sacs. This proliferative activity is 
accomplished by mitosis. The point of 
origin in the pulmonary capillaries is indif- 
ferent and determined only by the proxim- 
ity of an irritant in the lung tissue. The 
proliferating cell is endowed with an ameboid 
motion, and once free, migrates directly to 
the site of the irritant, in the air sacs and 
bronchial tree. The point of entrance of the 
wandering cell into the alveoli is equally in- 
different, the cell passing directly between 
the epithelial plaques to gain the free air 
space where it at once proceeds to collect 
within its cytoplasm the foreign substance 
which has called it forth. Ordinary pulmon- 
ary anthracosis, now accepted as almost a 
physiological process, illustrates how slight 
an irritant may give rise to a proliferative 
endothelial reaction. 

If we return to Haldane's paper we 
find the following paragraph : 

It is highly probable that insoluble dust 
particles are attractive and stimulating to 
dust-collecting cells in proportion to the solu- 
ble substances absorbed in the dust particles; 
and that the particles containing little of 
these substances will be correspondingly un- 
stimulating. This, at least, seems to me the 
most probable explanation of why some kinds 
of insoluble dust stimulate the cells and 
others do not; and the facts so far known 



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299 



seem to be consonant with this explanation, 
though far more work on the whole subject 
is required. 

Haldane then seems to explain the dif- 
ference between the effects of insoluble 
carbon dust, which is harmless, and the 
most dangerous sort of insoluble sil- 
icious dust, by the suggestion that the 
carbon particle, which has to a high de- 
gree the power of adsorbing material 
upon its surface, upon reaching the al- 
veolus becomes coated with material 
which renders it not only highly irritat- 
ing so that many phagocytes at once 
begin to concentrate upon the scene but 
also highly desirable for phagocytosis. 
Silica, which is notably non-adsorptive, 
owes its tendency to remain in the lungs 
and to resist elimination to the fact that 
absence of adsorbed material renders it 
less irritant and less readily phagocy- 
tized. In another paragraph, however, 
he makes the statement that all the dif- 
ferent sorts of dust used by Mavrogor- 
dato were apparently taken up by pha- 
gocytic cells with the same degree of 
readiness, and the difference between 
them lies in the fact that cells which 
have ingested carbon are able to move 
steadily out of the lung, whereas the re- 
verse is true with silica. In Mavrogor- 
dato's words : 

1. Coal and shale are taken up by cells 
which are quickly shed, and consequently do 
not set up processes which block lymphatics. 
These cells frequently break down, and 
masses of dust are to be seen on the surface 
of the alveolar walls. 

Flue dust and crystalline silica are taken 
up by cells which tend to remain in situ and 
form plaques, which appear early and per- 
sist. Tbev are the only site of fibrosis made 
out in this investigation. 

Dusts which form plaques are not readily 
eliminated. 

Mavrogordato apparently believed 
that carbon particles reaching an alveo- 
lus stimulated the alveolar epithelium 



near by to proliferate and to ingest them. 
Permar, however, has shown that the 
particle must arouse proliferation in the 
capillary endothelium with subsequent 
detachment of cells and migration 
through the wall into the alveolus. 
While it is true that such cells have 
their origin very close to the air space, 
the actual process involved is somewhat 
more formidable than that conceived by 
Mavrogordato, and gives better play for 
differences in physical characteristics of 
foreign particles. 

On considering this entire situation 
it seemed wise to attempt an analysis 
of all the possibilities raised by Haldane 
and Mavrogordato, keeping in mind 
their fundamental contention that rate 
of dust elimination is as important as 
rate of inhalation, and subjecting the 
different phases of the process to experi- 
mental procedures. One step in this 
work has been accomplished. It was first 
desired to find out whether all dusts 
really were taken up by phagocytic cells 
with equal degrees of readiness. Fenn 
(24) has prepared suspensions of car- 
bon and quartz and has shown that the 
polymorphonuclear leukocytes of the 
rat ingest carbon four times as readily 
as quartz. He has recently extended 
this observation to phagocytes obtained 
by scraping the surface of the lung — the 
method employed by Briscoe for obtain- 
ing similar material — and thus has 
shown that in the very first step of the 
process of removal of foreign material 
silica lags behind carbon. 

III. The Disposal of Foreign 
Material 

In the last section the lung phago- 
cytes have been identified, and the char- 
acter of the discussion has made it evi- 
dent that phagocytosis is an extremely 
important early step in ridding the al- 



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veoli of foreign material. In early ob- 
servations upon lung fibrosis investiga- 
tors (25 ) advanced the view that parti- 
cles might pass between the alveolar 
epithelial cells or actually pierce them 
to reach the lung tissue. These ideas 
are apparently entirely discounted to- 
day. Though there may be differences 
of opinion as to the cell responsible, 
there is unanimity that particles leaving 
the alveoli must first be ingested by pha- 
gocytes. 

The questions which next arise relate 
to the length of time i;equired by phago- 
cytes to collect a load of foreign ma- 
terial and their subsequent movements. 
Haythom (17) gave soot inhalations to 
rabbits for eighty-seven days and found 
pigment-bearing cells, "only in the al- 
veoli and interalveolar spaces and there 
was no evidence that any had migrated 
as far as the large lymphatics. All these 
points seem to indicate that the phago- 
cytic cells are not transient scavengers, 
but in a more leisurely manner gather 
their pigment-load and transport it to 
the tissue spaces." Willis (16) also feels 
that the '^absorption [of alveolar phago- 
cytes] must be relatively slow, since in 
these normal animals [caged guinea- 
pigs in the laboratory unsubjected to 
dust inhalations] increments of dust are 
taken into the lung only very slowly and 
gradually, yet the dust cells are always 
seen." 

Permar (3), using powdered carmine 
by intratracheal injection, showed that 
this material begins to be taken up at 
once by the few endothelial phagocytes 
in the alveoli at the time of injection 
and that, while all the material intro- 
. duced had not become intracellular in 
five hours, by the end of twenty-four 
hours even if the injections were large 
all the foreign particles were intracellu- 
lar. He says : 



. . . These cells take on the most extra- 
ordinarily heavy loads of pigment, even when 
the particles are relatively coarse.* As a re- 
sult, they increase enormously in size, and 
the nucleus becomes completely masked by 
the quantities of granules with which the- 
cytoplasm is packed. 

This author verifies the observations 
of Haythorn and Willis on the slowness 
with which cells which have taken up 
dust leave the alveoli. He states : 

^Though the foreign pigment is entirely 
intracellular at the end of a twenty-four hour 
period, the endothelial phagocytes do not 
leave the alveolus at a rapid rate. On the 
contrary, there is often very little diflPerence 
in the picture, even at the end of five or si'^c 
days. In four animals killed after this in- 
terval, the alveoli still seem equally crowded 
by the same groups of large, heavily loaded 
cells. This is borne out by the relatively 
slight change in the number of cells found 
migrating along the lymphatics after six 
days as compared with that found after 
twenty-four hours. In fact, in some animals 
there seems to be a slowing down after the 
first acute reaction, and the migrfttinpr oells 
are even fewer in three to five days than 
after twenty-four hours, indicating a less- 
ened activity after the acuteness of reaction 
is gone. The actual time period required to 
effect complete clearing of the alveoli could 
only be estimated by experiments coverinjr 
long periods of time, possibly even running 
into months. 

It should be pointed out that the ob- 
servations so far quoted, Haythorn, Wil- 
lis, and Permar, have been made (1) by 
the use of carbon dust, (2) upon ani- 

♦t^nn (24) has shown that in vitro carbon par- 
J:leles 4.7 M- in diameter are ingested as readily as 
3.2 M- particles. It has been held rather gener- 
ally, apparently as a result of lindinars in South 
Africa (20), th«t only very small particles are re- 
sponsible for dainnge to the lunsr. The great 
majority of slliclous particles recovered from the- 
lung postmortem were found to have a diameter 
lees than 1 ^. Particles as large as 12 m were- 
found In the lung but were very few. The question 
as to the size of particles which may actually reacht 
the alveoli has never been investigated from a 
careful quantitative point of view. If large par- 
ticles do r(^a<^h the alveoli there Is no apparent 
reason why they should not be picked up by 
phagocytes and carried into the lung tissue. 



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301 



mals acquiring a normal degree of lung 
pigmentation while living under labora- 
tory surroundings, and (3) upon ani- 
mals receiving intratracheal injections 
of carmine suspension. The results aire 
in agreement but this does not assure us 
that flint dust, organic dusts, etc., will 
bring about similar states of affairs. 

Many investigators have reported 
that dust falling upon the ciliated epith- 
elium of the bronchioles begins to move 
toward the mouth at once, and after a 
single moderate dusting these upper 
passages may become quite clean before 
material begins to leave the alveoli eith- 
er in cells which pass through the wall 
or which move up on to the ciliated sur- 
face and are then carried away. 

Permar has found, and others are in 
agreement with him, that phagocytes 
containing dust tend to accumulate near 
the alveolar entrance and apparently 
move through the wall in this neighbor- 
hood to enter the terminal lymphatics 
of the lung which arise about the alveo- 
lar ducts. After reaching a lymphatic 
the dust-carrying phagocyte, partly 
through its own ameboid activity and 
partly through the lymph flow, moves 
toward the lymph nodes at the root of 
the lung. Twenty-four hours have been 
found necessary for the traverse of this 
distance in the case of carmine by Per- 
mar, and twenty hours for manganese 
dioxide by workers in our own labora- 
tory. Whether this rate of travel is re- 
duced after foreign material begins to 
accumulate, is not known. Permar re- 
cords a decreased rate of migration from 
the alveoli five or six days after intra- 
tracheal injection of carmine. Since the 
lymphatics of the lung are found about 
the blood vessels and bronchi, it is na- 
tural to see cells containing pigment, 
and foci of cellular debris and pigment 
at such points. Willis has commented 
upon the fact that in the young guinea- 



pig there is practically no lymphoid tis- 
sue in the lung, but as life goes on lym- 
phoid accumulations begin to appear. 
These masses are prominent along bron- 
chi and blood vessels, and Willis pre- 
sents a very beautiful reconstruction of 
one such fusiform collection about a 
small artery and comments upon the 
fact that "Irvine and Watt (27) de- 
scribed an irregular periarterial thicken- 
ing as one of the early lesions in pneu- 
mokoniosis and remarked that the thick- 
enings are not 'nodular' formations." 

While dust may naturally be found 
scattered long the lymph passages from 
their origin to the peribronchial nodes, 
a good deal is usually seen in such 
lymphoid collections, and as they con- 
tinue to enlarge in the face of steady 
dusting a definite mottling of the lung 
is produced and areas of lymphoid pro- 
liferation begin to be found immediately 
outside alveoli at the very beginning of 
lymph channels. Fibrosis apparently 
takes place in close relation to the 
lymphatics and to such collections of 
lymphoid tissue, and it seems probable- 
that both increases in lymphoid collec- 
tions, through which lymph must flow 
to reach the root of the lung, and C9n- 
nective tissue encroachment upon lymph 
channels must combine to slow lymph 
drainage and to arrest more and more 
dust-laden phagocytes before they reach 
their final destination in the lymph 
nodes at the lung root. It should, how- 
ever, be remembered that while a cer- 
tain amount of data exists as to lymph 
movement out of the peritoneal cavity 
and out of the limbs, there is no direct 
knowledge upon the rate of lymph flow 
in the lungs and upon the factors which 
bring it about. 

Mavrogordato has contended that al- 
veolar phagocytes may wander out of 
lymphatics and through the walls of 
large bronchi. His data on this point are 



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THE JOURNAL OF INDUSTRIAL HYGIENE 



insufficient and are unconfirmed by- 
other observers. The reader will recol- 
lect that he distinguished between 
carbon and silica by the fact that 
cells containing carbon were elimi- 
nated more readily than those con- 
taining silica. The cells containing 
carbon he believes to be quickly shed, 
apparently chiefly by moving up onto 
the ciliated epithelium. Silica-con- 
taining cells, on the other hand, do 
not tend to move but are apt to aggre- 
gate and form plaques which become 
foci for fibrosis. Mavrogordato believes 
that the rate of silica removal can be in- 
creased by adding carbon to the air 
breathed, thus inducing a more vigorous 
reaction and getting rid of some of the 
silica as a result of the intense drive at 
the carbon. He implies that where air 
has contained silica but workmen have 
experienced no harm there has been an 
admixture of carbon or of some dust 
with similar properties which has kept 
the silica on the move. Haldane goes so 
far as to suggest that such mixtures be 
made artificially in work which demands 
inhalation of silicious dust. 

These are contentions which are not 
verified experimentally, and, as has been 
pointed out, the ground upon which they 
rest seems frequently to be insecure. 
They are peculiarly susceptible to ex- 
perimental attack and should either gain 
our confidence or be cast aside in a few 
years' time. 

IV. Some Final Aspects of the 
Problem 

Collis (28), in his classical lectures 
upon the pneumokonioses, calls atten- 
tion to the innocuous character of coal 
dust, of limestone and plaster of Paris, 



and speaks especially of crystalline sili- 
ca as being the principal source of real 
lung damage. He calls attention to the 
fact that in the amorphous form this 
substance is not known to do harm, and 
that silicates such as clay (aluminum 
silicate) are also harmless. He remarks : 

Silica dust, then, possesses certain quali- 
ties: — (1) physical, (a) such smallness as 
permits the particles to be carried into the 
alveoli, and (b) such hardness and angular- 
ity as suggest that the particles can act as 
centres of irritation; and (2) chemical, 

(a) acidity which, owing to the presence 
of the element silicon, may render the parti- 
cles capable of entering into and modifying 
the colloidal structure of protoplasm, and 

(b) smell, possibly due to a vapour, as yet 
undetermined, given off when silica is 
fractured. 

We do not know which or whether 
any of these properties is responsible for 
the harm done by silica. To them Hal- 
dane has added another, the non-ad- 
sorptive power of silica. We call atten- 
tion to these statements only in order to 
show how little fundamental explora- 
tion of the field there has been. With the 
exception of Fenn's observations, which 
deal with carbon and silica alone, we 
have no data on differences in rate of 
phagocytic intake, and with the excep- 
tion of Mavrogordato's somewhat un- 
supported contentions, no data upon dif- 
ferent rates of movement of different 
dusts which reach the alveoli. While 
silicious dust is the most deadly, even 
carbon dust produces some lung damage, 
and the whole question as to whether 
pure organic dusts can do significant 
harm may be regarded as unsettled. For- 
tunately, the field is one which can be 
explored throueh animal experimenta- 
tion, and it is probable that a period of 
more exact quantitative investigation is 
at hand. 



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DRINKER— DEVELOPMENT OF LUNG FIBROSIS 30» 

BIBLIOGRAPHY. 



20. 



21. 



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4. Winternitz, M. O., and Smith, G. H. : Prelim- 
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INVESTIGATIVE OPPORTUNITIES IN THE PHYSICAL EXAMINA- 
TION OF LARGE GROUPS OF INDIVIDUALS* 

Roger I. Lee, M.D. 

Professor of Hygiene, Harvard University 



T^ HE physical examination is, or 
^ should be, the foundation upon 
which any plan for supervision of health 
is constructed. It is, of course, entirely 
possible to accomplish something with- 
out physical examination, but positive 
results depend upon the amount of real 
information obtained concerning the in- 
dividuals whose health is supe