HEALTH PROTECTION IN INDUSTRIES MANU- DR. R. P. ALBAUGH, Director, Division of Industrial Hygiene, State Department of Health. Although it is possible to control sickness to a large extent, it is to be expected that the sickness rate among certain classes of people will increase with the advent of the United States into the war. Increased sickness usually follows the movement of large numbers of the population. Persons transferred from one locality to another tend to become ill much more rapidly than usual. The concentration of large numbers of men into military camps offers many opportunities for the spread of disease. The migration of large numbers of laborers and the establishment of industrial camps often provoke severe epidemics. But the enormous increase in the manufacture of materials for use in war with the housing of these industries in temporary quarters, with a floating working force and the absence of sanitary equipment and medical supervision offers a problem of unusual importance at the present time. Because of the pressing need for war materials, manufacturing establishments are being speeded up to the limit and health protective procedures, few as they now are, will probably be disregarded in many instances. Many industries, the explosive industry in particular, are new and unfamiliar in the United States and there are probably more poisons involved in these industries than in any other. Contracts with time limits are being accepted, and because of the shortage of labor and the present inadequate shipping facilities, work is being necessarily delayed, requiring almost continuous operation of plants in order to complete the contracts, resulting in over-time, speeding up, and the lack of facilities for health protection. Physicians as well as chemists and engineers are facing new problems, especially in those localities where new and unusual poisons are being manufactured. Considerable time must be consumed to permit the physician to familiarize himself with these poisons, their occupational origin and their clinical manifestations. For these reasons it would seem that some organized effort should be made to conserve the health of the people employed in these industries. Such a plan would involve the physical examination and medical supervision of employes, the maintenance of proper illumination of work places, the prevention of fatigue, the sanitation of work places and industrial communities, including such features as overcrowding, unsafe water supplies, and insanitary methods of sewage disposal. Proper medical supervision can only be obtained by the all-time physician, who should be expected to make complete physical examinations of all new workers in order to secure proper distribution of the working force and to prevent the introduction of communicable diseases in the plant. He should be expected, also, to re-examine all workers at regular intervals, keeping in mind the hazards present in order to detect early symptoms of industrial poisoning and diseases as well as communicable diseases. He should be expected to be able to render the necessary medical and surgical service to the working force and be willing to keep careful records relating to these services in order that he be in a position to give full cooperation with municipal and state departments of health. Labor turnover and absenteeism should be carefully recorded, as these are very important factors in determining the working conditions within 'an industrial establishment. The importance of adequate illumination may be appreciated from the fact that in a great many accidents defective illumination is given as the cause. Definite standards of illumination should be established throughout the plant, and attention should be paid to the promotion of visual comfort by correct lighting and the avoidance of glare. The prevention of fatigue is necessary to bring about maximum production. The demand for war materials will probably be out of proportion to the amount ever contemplated as needed in this country. Over-time on a large scale and Sunday work will probably become the rule. Past experiences have shown that longer hours do not necessarily increase production, as workers are injured by the long hours and production is really diminished. Hours of labor, speeding-up, monotony, and laborious work must be carefully supervised. The British committee on fatigue has come to the conclusion that Sunday work should be everywhere discontinued, except for the tending of furnaces and other work which must be continuous. Continuous work is, in the opinion of the committee, a profound mistake, not only on social and religious grounds, but also economically, as the output is not increased. Even the administrative officers in industrial plants require definite periods of rest, even more than the manual workers. Fatigue is one of the most common causes of occupational disability and is the prime cause of the fact that bodily development in factory classes remains inferior to that in other social classes. The sanitation of work places would involve the maintenance of a pure water supply, the water conforming, from a bacteriological standpoint, to the regulations of the various health dpartments of the states in which the plants are located. The supervision of the use of ice for cooling purposes and the installation of sanitary drinking fountains are important. All food obtained by workers in industrial plants should be known to conform to certain standards as regards provisions against contamination and care to prevent perishing. Bathing and washing facilities should be provided and maintained in a sanitary condition, especially in those plants where poisonous substances are handled or manufactured, and where workers are exposed to excessive heat. Adequate locker and change house facilities have been found to be valuable adjuncts to any industrial establishment, and are a necessity in plants where the nature of the work requires the changing of clothes when entering and leaving the plant. Toilet facilities and arrangements for disposal of excreta should be such as not to endanger either the health of the worker or that of the public. Adequate sanitary conditions in industrial communities are necessary, as the worker may suffer as much from an insanitary community in which he lives as an insanitary work place. This would require the active cooperation of health departments, the public, the workers. and the owners of factories. The enforcement of the present health laws should not be relaxed but should be even more rigid than ever before, as the enforcement of such laws will now be needed more than ever, owing to the entirely changed conditions brought about by the effort on the part of the Nation to meet the present emergency. RANKING CITIES BY THEIR TYPHOID RATE. For the last five years the Journal of the American Medical Association has issued a yearly report of typhoid fever in the sixty-six cities that have a population of more than 100,000. This should be an index of efficiency in city administration, since typhoid is a preventable dsease, but strangely enough some cities that take great pride in their progressive spirit are far down on the list, while others of which little in the way of civic reform has been heard, are near the top. Cambridge, Mass., heads the list this year, as it did last, with what is probably the lowest typhoid rate for a city of its size in the world. Next is Paterson, N. J., raising a whole list of unanswered questions. Why should this city, associated chiefly with turbulent labor disputes, handle its health problem so much better than Dayton, with its commission government, or Detroit, or Kansas City or Washington? Why should New Haven have almost twice as high a rate as New Bedford? Why should Toledo and Indianapolis be among the worst sinners, while Cincinnati and St. Paul have reached the honor roll? Among those that have undergone conviction of sin and seen the light are Pittsburgh, which now has its place in the second class; and just beside it another conspicuous convert, Philadelphia, also for decades one of the worst American cities in this respect. Even Baltimore is improving, though her place is far down in the third class. The South stands worse than East, North or West. All but two of the eight cities in the lowest class are southern, and none of the sixteen in the first class. The difficulties in the way of improvement are decidedly greater in the South, but that they are not insuperable is shown by the great advance made by Louisville and by the strenuous efforts which have moved Nashville up from the very foot of the class where she stood formerly. On the whole there is progress to be recorded. In 1916, 33 cities had a lower typhoid rate than for the preceding year and only 26 a higher, and if 1916 is compared with 1910 the improvement is decided a rate of 7.61 per 100,000 in 1916 as against 19.59 in 1910. — The Survey. LATENT TUBERCULOSIS: ITS IMPORTANCE IN MILITARY PREPARATION.* EDWARD R. BALDWIN, M. D. It is very important to interpret wisely the events of the past three years to learn the lesson taught by the war in relation to latent tuberculosis. In one aspect the conflict assumes the character of a huge experiment to disclose the prevalence and importance of latent tuberculosis. Enough has been published already to energize all our forces, both public and private, to prevent so far as possible the unnecessary sacrifice of many young men who have recognizable tuberculosis or a fairly clear history of it. The opportunity now before the Army medical examination boards may be made a blessing by the discovery and rejection of early or unsuspected disease. On the other hand, those who have the so-called "predisposition" and to whom camp. life and training would be of vast benefit, ought to be placed under continuous medical observation for future decision as to the duties they can safely perform. Let us take a glimpse of the nations as war and see in what way we can profit thereby. England, France and Germany have given some account of tuberculosis in their services, but I have no information about the others. Sir William Osler, in an address in July, 1916, gave a rather optimistic account of the British Army. During 1915 only 2,770 soldiers were treated for tuberculosis. The proportion of the total enlisted force was not given, but Osler considered it less than the general incidence in the country. He looks for no great increase among the soldiers, as these men would likely have broken down in civil life. Many enlisted with well-marked disease and were passed by the examining physicians. Others concealed their histories to avoid refusal, or made light of symptoms. In a Welsh hospital during the first six months after its establishment the Medical Officer, Harries, received 109 tuberculous soldiers, 51 of which he classes as having had positive or probable evidence of tuberculosis when enlisted. The same thing occurred in Germany, but to the greatest extent in France, where the disease is far more prevalent in the army. It is interesting to compare the mortality and invalidity of the armies of the three nations during times of peace. In 1906 the British lost 2.57 per cent from tuberculosis, a decrease of 60 per cent since 1860. Germany, in 1907-08, lost only 1.51 per cent, while France from 1905 to 1909 had an average of 6.8 per cent. The exigencies of the sudden mobilization of reserves in Germany and France left no time for careful selection and many cases of tuberculosis in a fair state of health were enlisted. Up to March, 1915, the German * Abstract of paper read before the Alpha of Ohio Chapter of the Alpha Omega Alpha Fraternity, Western Res erve University, May 14, 1917, being the Annual Oration, and printed in full in The Cleveland Medical Journal, June, 1917. authorities dismissed 3,500 soldiers for tuberculosis. It was also reported that 16 per cent of illness among the troops was due to tuberculosis. The reports for the past two years are not accessible, but the number must have greatly increased as the struggle has advanced. We have only estimates of the French situation, but it is appalling. In a symposium, "Tuberculosis and the War," in the Paris Medicale, one writer mentions 30,000 as the probable number. During the winter, press reports gave figures from 90,000 to 100,000. Very recently (May, 1917), the report of Dr. H. M. Biggs, after an investigation for the Rockefeller Foundation, gives 150,000 already dismissed from the army, but an estimate of the total nearer the truth of 400,000. Without pursuing figures further there are some important facts already evident in which the British and German reports agree. I. In the first place, little or no tuberculosis was acquired from infection in the army service. As Osler expresses it, "the germ enlists with the man." There was no particular type of tuberculosis due to the war, as it was merely reactivated. 2. In nearly one-half the cases the history indicated the presence of the disease before entering the service. Presumably a careful examination would have shown its presence. The remainder belong to those whose infection may have been of prior date but previous to enlistment and probably difficult or impossible to discover. 3. Chest wounds were infrequently followed by an outbreak on tuberculosis. An inquiry by Moritz of 190 sanatoria in Germany, Austria and Switzerland, disclosed only 27 cases that yery likely could have been aggravated by wounds, while 51 were questionable. In view of the large number of chest wounds the number is considered very unimportant by the author. 4. Wetting and cold were the most frequent causes ascribed for the outbreak. Overstrain and trauma came next, especially severe wounds with large loss of blood. 5. Anti-typhoid vaccination in German soldiers was followed in 46 out of 62 cases observed by Schroeder by signs of active tuberculosis. This was doubted as a predisposing cause by other observers, who saw no connection. It cannot be regarded as a specific factor, alone sufficient to activate tuberculosis. The ultimate history of the war in the light of modern knowledge on tuberculosis should add much more of interest and value. At present one cannot state whether the sub-standard individuals improved in health will not exceed the number whose latent tuberculosis is aroused to activity who otherwise might never develop it. The urgent need for our medical men to meet in the near future is to make as careful selection as possible when the large numbers of recruits are to come up for examination. It may be asked: What criteria are we to take in order to recognize the clinical latent tuberculous subjects? Are there any practical methods by which we might accomplish it? In the first place, a careful history, if candidly given, is of prime importance. This may involve some difficulties, as in life insurance examinations. |