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Industrial Welfare and Medicine

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INDUSTRIAL WELFARE AND MEDICINE, a term used in Great Britain to embrace not only the activities of indus trial medical services but the control of environment and working conditions, the study of the effects of poisons and other occupa tional health hazards and the investigation of the mortality and morbidity experience of occupational groups. In the United States the work is called industrial hygiene. The subject is treated here in two sections : A. Great Britain and B. The United States.

Industrial Welfare.—The movement, which was only embry onic before the World War, received great impetus in Great Britain from the recommendations of the Health of Munition Workers' Committee. The work includes needs within and outside the factory. Within the factory it covers the selection of workers for engagement ; supervision of general behaviour ; of progress and apprenticeship; of transfer and disposal of workers; of general cleanliness, ventilation and temperature; of canteens; of ambulances, rest-rooms and first-aid ; of cloak-rooms, sani tary conveniences and of overalls. Outside the factory it covers housing accommodation, transit facilities, sick visiting, recreation and education. The keeping and studying of personal records of earnings, sickness and accidents is required. Welfare committees composed of workers are found invaluable to the activities of welfare superintendents.

The Home Office obtained powers under the Police, Factories, etc. Act 1916, enabling the Secretary of, State by order to require occupiers of factories to make reasonable provisions re lating to "arrangements for preparing or heating and taking meals; the supply of drinking water; the supply of protective clothing; ambulance and first-aid arrangements ; the supply and use of seats in workrooms ; facilities for washing ; accommodation for clothing; arrangements for supervision of workers." Under these powers more than 14 orders had been made by the beginning of 1928 concerned with the special needs of different industries. At the same time a series of valuable pamphlets have been issued to set forth how the requirements of the orders can be complied with. Action on these lines continues; but already some matters have become of general application, thus drinking water must now be supplied in all factories, while the provision of first-aid has be come generally compulsory under the Workmen's Compensation Act 1923.

Other activities which may be called "voluntary" welfare include housing efforts, recreation grounds, institutes, educational schemes, nurses and sick visiting, canteens and dental clinics at factories; all provide examples of extension of factory welfare without legal compulsion.

In 1872 the Metalliferous Mines Regulation Act called for ac commodation for persons employed in metalliferous mines to dry conveniently and change their clothes. In 1910 the Mines Acci dents (Rescue and Aid) Act gave power to make orders relating to : (a) The supply and maintenance of appliances for use in res cue work, and the formation and training of rescue brigades; (b) The supply and maintenance of ambulance appliances and the training of men in ambulance work.

The Coal Mines Act of 1911 contained, too, an important clause providing for accommodation and facilities for taking baths and drying clothes where the majority of workmen employed in a mine desire such. Unfortunately this clause was a dead letter except at some half-dozen collieries. But under the Mining In dustry Act 1920, welfare work for miners received a great impetus. This Act provides a fund, derived from a levy of id. a ton on the output of each mine every year, to be applied for purposes con nected with social well-being, recreation and conditions of living of workers, and with mining education and research.

The fund amounts to about f I ,000,000 a year ; its allocation is directed by an independent central committee on which both min ers and colliery owners are represented. Four-fifths of the contri butions coming from each coal-field must be spent within that field : the remaining one-fifth of the fund is devoted to welfare matters of mutual interest to the whole industry, such as the pro motion of research into safety and health, and the provision of higher education for miners and their families. Expenditure from the fund is now year by year keeping pace with contributions. The Act of 1920 was due to expire in 1925, but the success achieved by the activities thus instigated led to prolongation of the life of the levy to the fund for a further period of five years. The total credits of the fund on Dec. 31, 1928, amounted to £7,883,105.

The provision of pithead baths has been insured by part III. of the Mining Industry Act 1926, which placed a levy on royalties, "the royalties welfare levy." The sum so raised is made over to the central Welfare committee to be devoted to the pro vision of pithead baths.

The central committee consults with district committees con cerning the amount and purposes of grants in each district. The activities of the fund (with the one exception of allocations for pithead baths) deal with needs outside working hours; while progress in factory welfare made under statutory orders is extend ing with regard to needs within working hours. The contrast is sharp.

In the case of factories voluntary effort is forwarding outside welfare schemes ; but in the mines no similar efforts are taking place with regard to such needed inside welfare as the provision of drinking water, improved lighting, or pithead kitchens.

The procedure followed in these two lines of advance is also in contrast. Factory welfare proceeds through statutory orders, compliance with which can be enforced; while mining welfare consists of activities, originated and pursued by the mining com munity, but financed through a statutory levy.

Industrial Fatigue.—The maintenance of health, especially that of women and young persons, has always been a driving force in the code of legislation controlling factories and mines, but its close study is practically a new science, known technically as the study of industrial fatigue. In Great Britain the study is pursued on general principles by the Industrial Fatigue Research board, an integral part of the Medical Research council. This board came into existence in 1918, owing to appreciation of a national need for intensive investigation to which attention was directed during the War by the activities of the Health of Munition Workers' Committee. Problems of interest to particular establishments are tackled by the National Institute of Industrial Psychology (see INDUSTRIAL PSYCHOLOGY). Much practical knowledge as to human activity, embodied in some 5o reports issued by the board, and in the Journal of the Institute, has been placed on a scientific basis.

Certain points may be succinctly stated : work is necessary to health, and health is needed for efficient work; even, steady work is better than spasmodic efforts ; an optimum temperature, which should vary about a mean, exists for each process and is asso ciated with best output, least sickness and fewest accidents; venti lation is to be read in the stimulating effect of air movement, rather than in change of air; rest periods during long spells of work, particularly if posture is changed, may increase output and lessen monotony; monotony in repetitive work, in temperature, in ventilation, in long spells of activity without pauses, and even in food supply, is disadvantageous; good factory canteens im prove health and output; change of personnel; i.e., labour turn over, reduces production and increases lost time due to sickness and accident ; suitable overalls create pride in work and in person; vocational training adds joy to work; vocational selection on en gagement increases output and reduces labour turnover; certain workers exhibit a predisposition to sustain accidents and should be employed where accident-risk is at a minimum; the tendency to sustain accidents is associated with a tendency to fall sick.

Industrial Medicine.--This deals with the prevention of sick ness and the restoration to health of the disabled. Modern research has enabled important protective measures to be adopted, and es tablished the tremendous importance of personal, as contrasted with mechanical, factors; they account for 8o% of industrial acci dents. Further, just as in the case of sickness, the newly employed and those who are not quite well are disposed to sustain accidents. Action should, therefore, aim at interesting workers in accident prevention through the safety-first movement (see SAFETY FIRST), at reducing labour turnover, at maintaining health, and at elimi nating the susceptible. Under the heading of accidents are here in cluded sudden gassings; e.g., from carbon monoxide, nitrous fumes and arseniuretted hydrogen, as well as caisson disease. Information as to the occurrence of certain occupational dis eases; e.g., anthrax, toxic jaundice, chrome and epitheliomatous ulcerations, and poisoning from lead, mercury and arsenic, is ob tained from notification sent by practitioners to the chief inspec tor of factories.

Compensation claims for diseases named in the schedule to the Workmen's Compensation Act 1906 give information concerning the occurrence of other diseases, of which certain troubles which particularly concern coal-miners are the most important; i.e., nystagmus, and miners' beat knee, beat hand and beat elbow. Here recent investigation into causation is ahead of prevention; thus, the distressing trouble, nystagmus is associated with work for long periods in imperfectly lighted galleries of coal-mines. Owing, however, to the danger of explosions from mine-gases, the problem of improving the lighting underground is not a simple one (see COAL AND COAL MINING).

In contrast stands another compensatible eye trouble, cataract, which occurs among glass blowers and furnacemen exposed to glowing heat. Here means for prevention are known ; they con sist in wearing spectacles, the glass of which has been specially de vised for cutting off heat rays, but difficulty arises in getting the workers to use them.

Further knowledge is drawn from occupational mortality rec ords. They reveal any undue prevalence among a group or groups of workers of some particular cause of death ; phthisis is the most notable example (see TUBERCULOSIS). Recent statistical investi gation has shown that when this cause of death (a) is the only one in excess, its undue prevalence is due to the spread of infec tion among persons whose daily work brings them close together; e.g., in tailoring, printing, and making boots and shoes; (b) is associated with excessive death-rates from other lung diseases, and occurs later in life than usual, as happens among sandstone ma sons, gold-miners, tin-miners, grinders of metal, some pottery workers and others, its excessive prevalence is due to inhaling fine dust of silica, which sets up a condition in the lungs known as silicosis, a condition which takes some years to develop and pre disposes its victims to tuberculous infection; and (c) is associated with excessive death-rates from all other causes of death, and occurs rather earlier in life than usual, as happens among publi cans and inn-servants, its undue prevalence is caused by excessive indulgence in alcohol.

Knowledge of causation in each case points the way to preven tion : (a) Commodious, well ventilated and lighted premises, as sociated with medical examination to eliminate the tuberculous, will rid tailoring, printing and shoe-making from the scourge of phthisis. (b) Reduction to a minimum of risk from breathing silica dust must abolish silicosis; the problem now belongs to the tech nical engineer and is being solved in certain industries. The financial burden of compensation is promoting active attention to dust prevention and control. (c) Limitation of alcohol consump tion, such as has been taking place in this country in recent years, and could be extended, has already reacted not only upon the oc currence of phthisis in industry, but also of ill health from other causes, including accidents.

Another disease to which mortality records have directed at tention is occupational cancer (see CANCER). Workers who handle pitch, a distillation product of gas-tar, and others who mix pitch with coal-dust in the manufacture of briquettes, suffer from warts which appear on the exposed parts of the skin, and also on the scrotum. These warts show a special tendency to become epitheli omatous with the formation of "pitch" cancer. Shale-oil workers coming in contact with crude paraffin, a product obtained by dis tillation, similarly suffer from warts and "paraffin" cancer; but workers manipulating refined paraffin do not suffer. Chimney sweeps have long been noted for their high death-rate from scrotal cancer which originates from exposure to soot, a distillation prod uct of coal. Quite recently an equally high mortality from scrotal cancer has been revealed among mule-spinners in the cotton trade due to contact with lubricating oils, possibly obtained from shale. Cancer of the lips and buccal cavity is nearly confined to males who by smoking expose these parts to the distillation products of tobacco. The evidence here summarized suggests that certain products obtained by distilling vegetable substances can sensitize the skin to cancer.

Evidence from the dye industry suggests that the products in question may possibly be benzene compounds. Workers in this industry exposed to certain amino-benzene compounds, particu larly benzidine and naphthylamine (compounds which, when they gain access to the body, are excreted by the kidneys), have been found to develop malignant tumours of the bladder.

Treatment during the early stages of illness and injuries sus tained in occupation is not peculiar to industrial medicine, even though recent advances in orthopaedic surgery have been of great benefit to those manually employed. But in a few cases treatment is special to the disease; e.g., the onset of caisson dis ease can be met by immediately resubmitting the victim to the high pressure atmosphere from which he has just too rapidly emerged; or, again, persons overcome by carbon monoxide gas can be best brought round by the new method of administering a mixture of oxygen and carbon dioxide through artificial respira tion; while burns caused by acids or alkalis, which must be specially neutralized before ordinary treatment is applied, may be added to the list.

The convalescent stage on the contrary may be profoundly ex pedited by occupation, particularly where recovery is slow and tedious. The industrial convalescent tends either to return to work too soon before he is ready for full employment, when he may quickly break down again, or, by saving himself, develop bad habits ; or to delay—particularly if he is receiving compensation— until he has lost skill, developed some permanent stiffness, or be come neurasthenic. He needs, at an early stage, amusement to divert his thoughts; next, occupational therapy, in which work is performed for wages during limited hours, in order to occupy his mind and assist in restoring lost or weakened function; e.g., a hand stiff after a wound ; or lastly, vocational training for new work when he cannot return to his previous occupation.

At each stage industry can play its part, but with regard to occupational therapy and training it is the only available agency. "After-care" in workshops, and special settlements for those dis charged from tuberculosis sanatoria is pointing the way, which is equally valuable for orthopaedic, mental and other cases. Occu pational therapy and vocational training are rapidly coming to the front both in Great Britain and America.

BIBLIOGRAPHY.-(I) Welfare.

Reports of Health of Munition Bibliography.-(I) Welfare:—Reports of Health of Munition Workers' Committee, 1915-18, Cd. 9065 (1918) ; Annual Reports of Chief Inspector of Factories; A. M. Anderson, "Welfare in our Factories and Workshops," Jour. Indus. Hyg., vol. 2 (192o) ; Annual Reports of Miners' Welfare Fund; Industrial Welfare Jour. (2) Indus trial Fatigue.—J. Goldmark, Fatigue and Efficiency (1912) ; Industrial Efficiency and Fatigue, Health of Munition Workers' Committee, In terim Report, Cd. 8511 (1917) ; E. L. Collis and M. Greenwood, The Health of the Industrial Worker (1921) ; H. M. Vernon, Industrial Fatigue and Efficiency (1921) ; P. S. Florence, Economics of Fatigue and Unrest (1924) ; Reports of Industrial Fatigue Research Board; Jour. Nat. Inst. Indust. Psychology. (3) Industrial Medicine.—J. T. Arlidge, Diseases and Mortality of Occupations (1892) ; T. Oliver, Diseases of Occupation (1908) ; E. L. Collis, Industrial Pneumono conioses (1919) ; H. E. Mock, Industrial Medicine and Surgery (1919) ; E. W. Hope, W. Hanna and C. O. Stallybrass, Industrial Hygiene and Medicine (1923) ; G. M. Kober and E. R. Hayhurst, Industrial Health (1924) ; E. L. Collis, Phthisis and Industrialism (1925) ; E. L. Kenna way, "Anatomical Distribution of Occupational Cancers," Jour. Indust. Hyg., vol. 7 (1925). (E. L. C).

Though the specific occupational diseases are numerous, a rela tively small part of the sickness of working persons is due to such ailments. Apart from such disabilities as those due to faulty posture and inadequate or defective illumination, most of the possible ill effects of work and working environment obviously must be exerted upon the body or through entrance to the body by way of the skin, nose or mouth.

Dust, Fumes and Gases.—With little doubt, the most impor tant single occupational health hazard is atmospheric pollution by toxic or irritant dusts, fumes and gases. Most of the industrial poisons are air borne and through inhalation reach the lungs, while certain ones are in part swallowed and thus exert their effects through the gastrointestinal tract. Most dusts are made up of units of a wide range of sizes, from fragments readily discernible by the unaided eye, to microscopic particles measured in fractions of a micron. Probably one-half of the dust inhaled is exhaled; a large portion of the remainder is caught by the moist mucous membranes of the upper respiratory tract, the nose and throat. Some is trapped on the walls of the larger tubes leading to the lungs and much of this is driven back toward the throat and is eliminated with mucose secretion. Only the very small dust particles, those approximately 5 microns (1 m. = 23.000 in.) or less in diameter, can penetrate far into the lungs. Dusts made up of fine particles may not be readily visible. They can be present even in a damp atmosphere.

Not all dust is notably harmful, nor all harmful dusts equally dangerous. Certain dusts, such as lead and manganese, are inju rious because they are definitely poisonous. Others cause a disease of the lungs known as pneumoconiosis. Generally speaking, in organic dusts, as those of metals or minerals, do more damage than organic dusts, as vegetable or animal matter. Not infre quently, dusts are of mixed character, inorganic dust being min gled with organic, or are mixed inorganic dusts, one of which may be harmful and the others relatively harmless, or even slightly protective. Recent research suggests that a mixture of 1 % alumi nium dust in a silica dust atmosphere inhibits the action of the silica on the lung. There are two known harmful dusts, silica (silicon dioxide) and asbestos. Other inorganic dusts are rela tively harmless. Silica is a major constituent of sand, quartz, and granite. It produces a form of pneumoconiosis known as silicosis, characterized by a growth of fibrous tissue in the lungs accom panied by gradual loss of normal lung function and usually, ultimately, is associated with the development of pulmonary tu berculosis. (See MINERS' PHTHISIS.) Asbestosis is a generalized fine fibrosis of the lungs which causes symptoms and disability earlier than silicosis.

Poisons cause perhaps the most clearly defined group of occu pational diseases. The rapid progress of industrial chemistry has led to the introduction of many substances known to be toxic, while new processes are constantly being developed bringing, not infrequently, new hazards in the exposure of workmen to poison ous substances.

Lead is used in most paints, in floor coverings, in many sorts of glass, commonly in brass and in solder; in plumbing installa tions, in the storage batteries which furnish power or light for motor cars, railroads and aeroplanes, in the rubber of tires and in much of that used for other purposes, in modern high com pression gasoline, in the type and plates from which books and newspapers are printed and in scores of other articles of common use. Inevitably, the men and women who produce, use or market many of the articles containing lead may be affected by this very toxic substance. Reports of deaths attributed to lead have de clined relatively in recent years, but such reports do not accu rately reflect the actual influence of lead poisoning. There is abundant evidence that lead reaching the lungs is more readily toxic than that ingested. Some individuals are extraordinarily susceptible to poisoning and when exposed for even a few days to considerable quantities of lead may be seriously affected. This occasional personal idiosyncrasy appears in groups of workers ex posed to any industrial poison. Acute poisoning is very rare. Most of the cases of chronic type recognized have been exposed to lead over a period of months or years. Death may be due di rectly to severe poisoning, but in most cases is in part attributable to other causes, with lead as a secondary factor. The disease ad mits of prevention and control. It is quite impracticable to list all of the recognized industrial poisons, which number several hundred. The most important are lead and its derivatives, the volatile solvents, of which benzol is one of the most important, and carbon monoxide. There are others scarcely less important, such as mercury, arsenic, and hydrogen sulphide (q.v.).

Skin Affections form a very large and important group of occupational diseases involving a multitude of industries and proc esses. A list of skin irritants would be almost as long as that of the industrial poisons. Prominent, however, among the industrial dermatoses are the superficial cancers produced by coal tar, soot and a number of petroleum products (see DANGEROUS TRADES), chrome sores, a great variety of burns by powerful acids and alkalies, the dermatitis of candy workers and chocolate dippers, that of masons and plasterers and the folliculitis or infection of the hair follicles of the arms common among machinists. The causes of the many industrial skin diseases are so diverse, the conditions differ so greatly and so many simulate dermatoses of non-industrial origin that most cases call for the investigation and care of a dermatologist. A form of bladder cancer occurs among workers in the aniline dyes. This type of cancer is very difficult to cure and methods of prevention have not yet been perfected.

Ventilation.—Wholly apart from risks of atmospheric poisons, of increased or diminished atmospheric pressure and of extremes of temperature and humidity, good working conditions entail proper ventilation. The criteria of good ventilation are that air should be (1) pure rather than polluted by dust or other foreign matter, (2) cool rather than warm, (3) moist rather than dry and (4) moving rather than still.

A temperature of approximately 68° F is sufficiently high for persons engaged in sedentary or very light work and too high for those engaged in more active exertion. At 68° F the relative humidity for sedentary work should be about 45%.

Light.—A great part of the work men and women perform under modern conditions must be done in buildings dependent for light upon sources other than the sun. The aspects of indus trial lighting which warrant particular consideration are its char acter, its adequacy and the location of the source in relation to the eyes of the worker. Apart from the question of general or focal illumination of work, a discussion of light involves consideration of the hazard of such light rays as the ultra-violet rays and of the kindred rays known as Roentgen rays or X-rays and those ema nating from radium. Ultra-violet rays given off in arc welding, in arc flashes on electric switchboards and from various other sources, may produce a very distressing dermatitis or ophthalmia, the latter a congestive reaction of the conjunctivae or lining mem branes about the eye. Workers with X-rays and radium or with certain other radio-active substances may develop a severe derma titis or even cancer of the skin.

Industrial Medical Service.—The mutual interest of em ployer and employed in the maintenance of the health of workers has led to the establishment in the United States of hundreds, per haps thousands, of industrial and mercantile health services, vary ing greatly in purpose, in degree of elaboration and in standards of professional service, but all contributing in some measure toward the furthering of the physical well being of the working men and women who utilize them. Many of the industrial medical activities found their origin in an effort to meet the need for furnishing the prompt and adequate medical care demanded of employers by the operation of workmen's compensation acts which most of the several State legislatures passed between 1912 and 1920. Many of the industrial clinics, dispensaries or plant hospitals continue to limit their activities largely to emergency surgery. There is, however, rapidly spreading a realization of the fact that sickness is more important as a cause of working incapacity than are accidents, that from io to 15 days are lost from work on account of illness for one lost from injuries, and that economic self-interest, if not humanity, calls for intelligent consideration of the ill health of workers and of means for its prevention or remedy.

The most simple effort to meet the medical needs of industrial workers lies in the provision of the "first-aid kits" found in most industrial establishments throughout the country. From this elemental installation, plant medical services range far in com plexity of organization. In many industrial dispensaries a trained, registered nurse is on duty the full working day, who usually works under the direction of a part-time or full-time physician. Few full-time physicians are engaged in plants employing less than a thousand, but many such plants employ part-time physi cians. In larger establishments a reasonable ratio for adequate health protection is one physician to every 2,000 employees and one nurse to every i ,000.

Where plant medical departments serve a large organization the variety of activities may include certain or all of the following: Physical examination of labour applicants and the subsequent periodic examination of employees; re-examination of individuals transferred from one department to another; emergency treatment of minor injuries and illnesses; diagnostic aid in involved and obscure clinical conditions with guidance in the seeking of further medical counsel and care and a well-trained and competent visiting nurse service. In addition, there may be an eye clinic for the treatment of eye injuries and diseases as well as for refraction; dental clinics for the examination of the teeth of labour appli cants and for the supervision of the dental hygiene of employees; psychiatric clinics for the study and guidance of cases of mental abnormality, and physiotherapy units with facilities for the care of such cases as old fractures, burns, bruises, sprains and arthritis, by baking, massage or diathermy.

A few establishments maintain sanatorium facilities for tuber culous employees, either through a private institution or through the support of beds or cottages in semi-public sanatoria. A few railroads or isolated groups operate excellent private hospitals. More frequently, industrial organizations maintain in local hos pitals beds or wards, for the care of injured employees. In most instances these various services are conducted at the cost of man agement ; in others, the cost is shared by employees, perhaps through a mutual benefit association. The problem of adequate medical service is largely confined to small manufacturing estab lishments. Nearly 62% of the industrial wage earners are em ployed in such plants.

The prime purpose of these varied industrial medical activities is not to replace or supplant the personal physicians of employees, but rather to meet emergency needs without loss of working time, production and wages; to stimulate an intelligent interest in the maintenance of health and to offer guidance in the efforts of sick or defective individuals seeking competent medical care at prices they can afford to pay. Through the study of the clinical records of the all too small portion of plant medical departments which keep trustworthy and accurate records, there is coming to light knowledge of the nature and extent of sickness among the great portion of the population engaged in industries. Such important organizations as the National Association of Manufacturers and the National Industrial Conference Board are interesting them selves in the establishment, the cost, and the accomplishments of industrial medical services throughout the country.

The Governmental Control

of industrial and mercantile work ing conditions is not uniform throughout the States. In most of the larger industrial States, departments of labour or industrial commis sions maintain inspection forces and issue regulations for the sup pression of unhealthful conditions and the encouragement of safe practices in operation. Subsidiary or separate boards administer the workmen's compensation acts. Forty-six States have some form of workmen's compensation act and 22 States provide compensation for one or more occupational diseases. There are 23 States and four municipal departments of health that provide industrial services, giving advice and making examinations of occupational hazards where they may exist. The U. S. Public Health Service, through its office of in dustrial hygiene, has for years made many notable contributions to the subject.

BIBLIOGRAPHY. Journal of Industrial Hygiene (1919 seq.) ; The Bibliography. Journal of Industrial Hygiene (1919 seq.) ; The Journal of Industrial Medicine (1932 seq.) ; J. C. Aub and others "Lead Poisoning" Medicine Monographs, vol. 7 (1926) ; Y. Henderson and H. W. Haggard Noxious Gases (1927) ; R. P. White, The Der matergoses ; A. Hamilton, Industrial Toxicology (1934) ; W. I. Clark and P. Drinker, Industrial Medicine (1935) ; Symposium: The environment and its upon man, published by Harvard School of Public Health ; Medical Research Council—Report No. 8o "Toxicity of Industrial Solvents" (1938) ; C. K. Drinker Carbon Monoxide Asphyxia (1938) ; A. J. Lanza and others, Silicosis and Asbestosis (io.8). (W. WR. W. I. C.)

workers, health, medical, lead, occupational, dusts and activities