LIV. DISEASES DUE TO WORKING IN COMPRESSED AND STAGNANT AIR…

LIV. DISEASES DUE TO WORKING IN COMPRESSED AND STAGNANT AIR

Caisson Disease.

Caisson disease, or compressed air illness, is a product of modern civilisation. It seizes labourers who are engaged in sinking mines, in excavating the beds of rivers to obtain a foundation for the piers of bridges, and in tunnel making. A caisson is a cylinder composed usually of iron plates riveted together to form a shaft, which, in the case of bridge building, is sunk into a river, for example, so that its open mouth shall rest upon the bed of that river. Down this shaft, when it is properly closed at the top by a perfect fitting diaphragm, men descend, air having been previously driven in under considerable pressure to drive the water out at the bottom of the cylinder and to keep it out. The workmen enter and leave the caisson by a chamber or “lock” close to the diaphragm at the top. The length of the caisson shown in the diagram made for me by Mr Huntley, engineer at the Redheugh Bridge on the Tyne, is 90 feet, and at the time this drawing was made the men were working 77 feet below high-water level mark. In building a caisson it is the lower part that is made first. Thirty feet of circular iron plates are riveted together, care being taken to make the bottom bell-shaped. Before this unfinished caisson is lowered on to the bed of the river, there is placed outside of it a larger cylinder, and the two are united at the rim of the bell-shaped expansion. The space between the two cylinders is filled with cement. Successive lengths of twenty feet of cylinders are added, and subsequently the air lock, or the chamber by means of which men enter and leave the caisson. Two men work as a rule in each caisson, but this number varies with its size. In the lock there is an inner as well as an outer air-tight door, both of which open towards the interior of the caisson. When a labourer has to enter the cylinder that is filled with compressed air, he passes into the workman’s part of the lock by the door A (see Diagram); the other door, B, which opens into the main shaft, is at this time perfectly closed, and kept thus by the great pressure within the caisson. Once he is in the lock and door A closed, also the outlet cock C, the inlet cock D is gradually opened. By degrees the compressed air of the cylinder escapes into the lock, and when the pressure inside the lock comes to equal that inside the cylinder, door B opens of itself. The labourer now enters and descends the internal cylinder by means of a ladder to his work on the bed of the river. On leaving the caisson the process is reversed. The men, while working inside the caisson, shovel the soil and stones into large iron buckets which, when filled, are raised by a chain wound by an engine outside the cylinder. This chain passes through the “material” part of the lock, the sliding doors and cocks of which are moved by men outside who operate very quickly. As the excavation proceeds, the cylinders sink by their own weight and require new lengths to be added, bars of pig-iron being thrown into the space between the external and internal shafts so as to favour the sinking of the caisson.

It was a French engineer, M. Triger, who first employed caissons in order to reach a bed of coal that lay underneath the River Loire. Subsequently he used them for boring wells and fixing piles for bridges. From the first day on which caissons were used, the workmen have complained of pains in their ears and joints. In making the Blackwall Tunnel, several of the men were ill. Dr Snell, the surgeon to the Blackwall Tunnel, has embodied his experience in an excellent monograph. It is to MM. Pol and Watelle we are indebted for the earliest account of the pathological effects of compressed air upon men working in a mine at Douchy in France. Of 64 workmen exposed to the influence of compressed air, 47 stood the work well, 25 gave up their employment, and 2 died. The risks incurred are not so much when the men are at work in the caisson as on entering or leaving it, i.e., when they are passing through the lock undergoing compression before entering the cylinder, or coming out through the lock and undergoing decompression. Of these two, decompression is the more dangerous. If this is not accomplished slowly, the individual may not only experience very unpleasant symptoms, he may become the subject of permanent ill-health. It is because, in our daily life, the ordinary atmospheric air is pressing upon us equally all round that we are unconscious of the 15-lb. pressure to the square inch exerted upon our bodies, also that when we dive under water we are unaware of any superincumbent weight. Engineers have utilised knowledge of these facts, and have tried to imitate nature by subjecting men to pressure equal to two, three, or four atmospheres, or in other words to weights equal to 30, 45, or 60 lbs. to the square inch.

In this country caissons were first made use of by Hughes in 1851 to make a bridge at Rochester over the Medway. Brunel subsequently employed them at Chepstow and at Saltash. At Saltash one of the men died shortly after emerging from the caisson, wherein he had been working at a depth of 87.5 feet below the surface, and under a maximum pressure of 40 lbs. During the building of the bridge of Kaffre Azzyat over the Nile in 1859, five Arabs died from the effects of compressed air. Blood issued from their mouth, nose, and ears. These men had been working at a depth of 85 feet below high-water level mark, and under a pressure of 34 lbs. to the square inch. For several years now, wherever an important bridge has had to be built, caissons have been used. It was thus that the foundations were obtained for such structures as the railway bridge across the Rhine at Strasburg, the Forth Bridge, and the Suspension Bridge at Brooklyn, New York. Descriptions of the illnesses that occurred among the workmen engaged at the Forth Bridge, and at Brooklyn, have been embodied in monographs by Dr James Hunter, in his M.D. Thesis for Edinburgh University, and by Dr Andrew Smith of New York. At the Brooklyn Bridge the pressure varied from 18 to 36 lbs. to the square inch above that of the atmosphere, and the caissons were lighted by gas. Ventilation of the cylinders was attended to as far as possible, but, notwithstanding this, the air frequently contained as much as 0.3 per cent. of carbonic acid as against 0.06, which is regarded as the maximum for a well-ventilated space. Into the caissons 150,000 cubic feet of air had to be pumped every hour to satisfy the respiratory requirements of the labourers. The men worked in two shifts of four hours, separated by a period of rest for two hours, but as the cylinders sank deeper and deeper the working time had to be correspondingly diminished. Dr Smith treated 110 cases of compressed air illness, of which three proved fatal.

In the following brief account of the signs presented, and the symptoms complained of by one of the patients who was under my care in the Newcastle Infirmary, will be found a recital of the details of caisson disease. The man was a sinker, forty-five years of age. He was working in the caissons at the Redheugh Bridge close to the Infirmary, 77 feet below high-water level mark, at a pressure of 31–35 lbs. to the square inch. On leaving work one day he felt numb in his legs, became sick and vomited; shortly afterwards he became giddy and fell to the ground unconscious. His comrades carried him home, where he lay for twelve hours in a state of unconsciousness. When he came to himself he complained of pains all over his body, incomplete loss of power in his legs, headache, and buzzing in his ears. Next morning on getting out of bed his nose began to bleed, but as epistaxis is common among sinkers, he thought lightly of the matter and attempted to go to work. He again lost consciousness for a brief period, and it was in this condition that he was brought to the Infirmary. Subsequently he complained of severe pains all over his body, difficulty of breathing, a feeling of sickness, and profuse perspiration; the pulse was slow and full, there were muscular rigidity, loss of power in his legs, and deafness. The urine was free from albumen and sugar. During the day there was occasionally delirium of a noisy character. Heart, lungs, liver, and spleen seemed healthy. When a few days afterwards the symptoms which have already been detailed had subsided, and the patient attempted to walk, it was observed that there was considerable staggering, and that he tended to fall forwards. On examining his blood microscopically, nothing abnormal was detected beyond the fact that the coloured cells were slightly paler than usual, and did not form rouleaux properly. It was several weeks before patient could walk well, also before he lost the noises complained of in his head, and that his hearing was perfectly restored. During his stay in the Infirmary he had spitting of blood on a few occasions.

At the Forth Bridge, Hunter found that several of the men who worked in the caissons suffered from bleeding at the nose. It is gratifying to know that not one of his cases of compressed air illness proved fatal. The men worked under a pressure of from 15 to 34 lbs. above that of the atmosphere, and from four to six hours at a stretch, but as the caissons sank this was found to be too long. It was observed that the men suffered most in their general health when the soft silt in the bed of the river containing decomposing organic material was being removed.

One of my clinical clerks[156] volunteered to enter a caisson. He observed that the candles burnt more quickly in compressed air than in the ordinary atmosphere, and that as a consequence there was much more smoke. His breathing was at first quickened (40 respirations instead of 16 to the minute), while in the case of Mr Huntley, the engineer who accompanied him, and who was accustomed to the position, the respirations were only 20 to the minute. The pulse-rate was also quickened. Mr Fawcus experienced very unpleasant sensations in his ears, which gradually abated when he swallowed air, and thus inflated the middle-ear through the Eustachian tube. He could speak easily enough, but he could not whistle. There was no difficulty of breathing, although the pressure in the cylinder was 41 lbs. to the square inch; nor was there any sense of fatigue, but rather a feeling of fitness. Another of my students on emerging from the caisson had bleeding at the nose, severe earache and faceache. Pain and unpleasant sensations in the ears are complained of by nearly all on emerging from a caisson for the first time. The pain is apparently a mechanical effect, and is the result of the drum of the ear being forcibly driven in by the compressed air; for when a workman has acquired the faculty of swallowing air and passing it from his throat up the Eustachian tube into the middle-ear, so as to equalise the pressure, the sensation is no longer felt. Under these circumstances, it is unwise for any person who is suffering from a cold in the head or naso-pharynx to enter a caisson. The conditions inside the caisson are unnatural. As the whole body is subjected to an enormous pressure, men can only work therein for a short period at a time. It is a well-known fact that in the ordinary affairs of our daily life, some of our best work is done when we are working under mental pressure; and while the simile does not actually hold good of comparing mental with physical work, also of comparing physical work done under normal and abnormal pressure, yet experience shows that in the caisson the workmen, instead of feeling any bad effects from the compressed air, are so buoyed up by it, that in a given time they do far more and much harder work than when they are on the surface. Besides, as they are unconscious of putting forth extra effort, they do not feel fatigued, they perspire freely, and are apt to rub themselves incautiously, thus causing skin eruptions. Just as candles burn with greater rapidity inside the caissons, so too, it would appear, are the vital processes in the workmen quickened, disintegration of their tissues hastened, and the functions of the eliminating organs heightened. This simply means that all round more work is done by, and more waste formed in, the human body. Unless a caisson suddenly ruptures, as occurred a few years ago in France, the men when working inside run very little danger. It is on emerging from the cylinder, i.e., when he has undergone decompression, that the workman runs the risk of becoming giddy, and of being unable to stand, of having temporary paralysis of the legs, of experiencing muscular pains, called “bends,” all over his body, but particularly in legs and back, of suffering from bleeding from the nose, ears, and lungs, or of becoming unconscious.

That pressure per se plays a part in the production of the symptoms is shown by the fact that as the caisson sinks and the internal pressure is correspondingly raised, the men suffer correspondingly. On the Tyne the men always suffered more when the pressure inside the cylinder was increased so as to keep pace with the rising tide. The condition of the air inside is also of importance. As more smoke is given off by the candles, and the men work harder inside than outside the caissons, the air is rendered very impure. At the Brooklyn Bridge each man was supplied with 1000 to 3000 cubic feet of air per hour, and yet the air inside the cylinders contained as much as 0.3 per cent. of carbonic acid as against 0.06, which is considered a healthy average. It is desirable that the workmen should have not less than 6000 cubic feet of air per hour. At the bridge on the Tyne, where my patients worked, 3000 cubic feet of air per hour were at first supplied to the workmen, but after their breakdown in health, this amount was raised to 5000.

It is difficult to say what amount of atmospheric pressure men can endure with safety. With the object of throwing light upon this subject, experiments have been conducted by Hersent, a French engineer at Bordeaux, and also by Dr Lepine. Hersent tried the effects of compressed air both upon dogs and men. Some of the dogs on leaving the caisson, others the day after having undergone decompression, became paralysed in their limbs. Men similarly treated suffered from severe pains in their limbs and itchiness of their skin. Lepine experimented with guinea-pigs and rabbits. When these animals had undergone rapid decompression after exposure to the influence of compressed air, they became paralysed in their hinder extremities, convulsions supervened, followed by death in a quarter of an hour. On making a post-mortem examination of the bodies, the central canal of the spinal cord was found to be distended by gas which had torn its way into the canal. There were also gaseous bullæ around the blood-vessels of the spinal cord. Several of the small arteries were torn and had bled. In one case where the animal died on the thirteenth day after exposure to compressed air, followed by rapid decompression, Lepine found foci of softening in the anterior horns of grey matter of the spinal cord due to gaseous emboli and to hæmorrhagic infarction or rupture of blood-vessels.

There is a very great tendency for grave accidents to be produced in man when the pressure in the caissons exceeds four to five atmospheres. The greatest risk occurs when the workmen are coming out of the cylinders and are in the lock undergoing decompression. If decompression is effected suddenly, harmful or even fatal results are likely to ensue. One minute for every three pounds of pressure is the time usually given for decompression, or five minutes for each atmosphere, but it is obvious that the longer the labourers are in the caissons and are exposed to very high pressure, the greater is the probability of a larger amount of gas being dissolved in the blood and the greater the time therefore required for decompression.

A caisson has been known to burst. This causes the most sudden decompression possible. It is almost always a fatal accident owing to the rapid disengagement into the tissues of the nitrogen gas of the atmosphere which had been dissolved in the blood of the workmen under very great pressure. Death is often preceded by convulsions. If the workmen rally, their legs are found to be paralysed; this loss of power may be temporary or permanent.

Three theories have been brought forward to explain compressed-air illness: (1) carbonic acid poisoning; (2) mechanical congestion of internal organs; (3) increased solution by the blood of the gases in the cylinder and the sudden liberation of these gases from the blood into the tissues during decompression.

If caisson disease were due to carbonic acid poisoning, we would naturally expect the symptoms to show themselves during the time the men are working in the cylinder, and not after they leave it. Dr Andrew Smith of New York believes that the illness is the result of mechanical congestion, especially of the brain. In several of the men who died the membranes of the brain were found to be deeply congested, a pathological condition that doubtless contributed to the fatal termination.

My own opinion is that caisson disease is due to an increased solution of gases in the blood and sudden liberation of them. The amount of gas capable of being dissolved by a liquid is, as Dalton showed, proportional to pressure. This law holds good for the workman in the caisson. Since under the influence of compression more gas is dissolved in the blood, the excess has to be liberated during the act of decompression. If this is done quickly there is an escape of bubbles of gas from the blood as it circulates through the capillaries in the spinal cord and elsewhere. When Paul Bert, a French physiologist, exposed animals to the influence of compressed air and quickly decompressed them, several of them died suddenly, and at the autopsy free gas was found in the blood and in the right side of the heart. Other animals were paralysed, and in them bubbles of gas were found in the spinal cord, while the subcutaneous tissue was at places emphysematous or filled with air. As to the nature of the gas found in the blood and tissues it is impossible to speak with certainty. It is probably nitrogen, for this gas is the largest constituent of atmospheric air, and it is perfectly passive, so that any effect produced by it would be purely mechanical. If we regard caisson disease as due to the liberation of gases dissolved in the blood during too rapid decompression, we have an explanation of such a circumstance as that of workmen taking ill shortly after they emerge from the lock, also the benefit which they receive by being put back into the cylinder and of undergoing temporary recompression.

Treatment.--Treatment is preventive and curative. The points that above all others demand attention are that the acts of compression and decompression should be very slowly accomplished. Of these two, decompression is the more important. The workman should not be too rapidly pushed through the lock or exposed to any sudden increment or decrement of pressure. One minute for every three pounds of pressure is regarded as the average period, but this length of time might with advantage be lengthened especially for decompression, since it is the more dangerous. At this time too the workman, although he does not feel fatigued, is perspiring freely, and he is exposed to chill owing to a falling temperature. The air inside the caisson should be kept as pure as possible, and the men ought not to work longer than from two to four hours at a stretch. Even the minimum stated here may require to be halved as greater depths are reached. Men should be medically selected for the work, and only healthy men chosen who are free from heart disease, pulmonary and nasal catarrh, and who are temperate. No man who is suffering from a discharge from the ear ought to be allowed into a caisson, for even in healthy men the drum of the ear has been known to become ruptured. There ought to be a warm shelter or cabin at hand in which the men could lie down after coming out of the cylinders, and where hot non-intoxicating drinks can be got if required. If the men on coming out of the caisson are cold and collapsed, warm bottles should be applied to their extremities, medical assistance sought, and if the breathing is impaired a hypodermic injection of liquor strychniæ should be administered. Stimulants should only be given if there is failure of the heart’s action. Subsequently, if there is severe muscular pain morphia may be required. In the view that the symptoms are due to congestion of the internal organs ergot has been recommended. When unpleasant and dangerous symptoms have occurred immediately the workman has emerged from the caisson, good results have been obtained by subjecting him to recompression. Part of the cabin or shelter just recommended might be so constructed that recompression could be carried out therein under careful supervision, with the workman in the recumbent position.

Dangers Incidental to the Making of, and Working in, Tunnels.

The making of tunnels has been carried on from remote ages, there being records of such works as early as six hundred years before the Christian era. In a paper read by Mr Francis Fox, M.Inst. C.E., before the Royal Institution, 25th May 1900, the methods adopted for making tunnels are described at length, and especially the making of the great Alpine tunnels. The dangers of tunnelling the Alps have been considerable, and now that the act has been accomplished, there has been experienced considerable difficulty in ventilating some of the tunnels. The Mont Cenis tunnel is 8 miles in length, and as there is a gradient of 1 in 40 on the French side for the first 7 kilometres,[157] the trains go through with the regulators of the engine full open, so that if the wind is blowing in the same direction, great volumes of smoke practically travel with the train. For the men who are working in the tunnel there are refuges placed at every kilometre. Here when the men shut themselves in they can obtain compressed air, fresh water, and medicines, and by means of the telephone, extending in both directions, they can make their wants known outside. The caretakers of the tunnel work in pairs, so that if one man is affected by want of oxygen or through the density of the smoke, the other can render assistance, or telephone for relief, or they can both retire into a refuge and wait for either the air of the tunnel to clear or for a locomotive to come and remove them.

The St Gothard tunnel is 9.3 miles in length. It is on the railway from Lucerne to Chiaso on the Italian frontier. The north portal of the tunnel has an altitude of 3639 feet above the level of the sea, and the south portal 3757. Ten years were spent in tunnelling the mountain. The work was accomplished at a great sacrifice of human life. In constructing the tunnel there were 580 accidents, of which 177 were fatal. The engineer and contractor lost their lives. There was a great mortality, too, among the horses. This excessive loss of life was attributed to insufficient ventilation, high temperatures in the tunnel, exposure of the men to the rigours of an Alpine climate after leaving their work, carelessness of the men in not changing their wet clothes, the poor character of the food supplied to the men, and defective sanitary arrangements. One of the great difficulties as regards the St Gothard tunnel has been its ventilation. The height of the mountain prevented the sinking of a shaft, but a large ventilating fan placed near the mouth of the tunnel blows air through the annular space between the arch of the tunnel and the gauge of maximum construction, whereby 210,000 cubic feet of air are thrown into the tunnel every minute, or 100 cubic metres per second. Before the fan was brought into operation the temperature used sometimes to be as high as 107° F., with 97 per cent. of moisture, but by artificial ventilation the temperature fell to 81° F., subsequently to 74.5° F. The tunnel can now be kept cool and comparatively free from smoke and vapour. Formerly the engine drivers and passengers were seriously indisposed in going through the tunnel; to-day they can travel without any inconvenience. In the St Gothard tunnel the amount of carbonic acid often exceeded 15 per 1000. There resulted from this and other causes such a corrosion of the rails, that it was necessary at the end of every few years to entirely replace the rails and their connections. The engineers estimated that during three and a half years each rail lost on an average 18 kilos in weight, and at a maximum 28 kilos. Similar metallic corrosion has been observed in the tunnel between Genoa and Turin, and is attributed to the sulphurous acid in the smoke of the coal becoming converted into sulphuric acid. The recent artificial ventilation of the St Gothard tunnel by the Saccardo system has not only made the air purer but increased the longevity of the permanent way.

The Simplon tunnel is now in course of formation. In the first eighteen months three miles were made. When finished it will measure 12.26 miles between the north or Swiss portal on the Brigue side of the Alps and the south or Italian opening at Iselle. Such are the existing engineering and hygienic arrangements that they are believed likely to prevent the heavy death-rate that occurred in tunnelling the St Gothard. Fifty times the amount of atmospheric air is being sent into the tunnel than was forced into the St Gothard, and there are means in use whereby the air is cooled by jets of water. The great difficulty of the enterprise, as Professor Pagliani showed (Revue d’Hygiene, 20 Juin 1900), lies in keeping the temperature low and in renewing the air, so that the work of excavation and construction can be conveniently carried on without undue fatigue to the men. In the centre of the tunnel a temperature of from 107.6° F. to 113° F. is expected to be met with. The best possible means will be adopted to cool and ventilate the passages. The effect of high temperatures upon the men working in the tunnel is to increase the tension of carbonic acid in their blood and to interfere with respiratory exchanges. The moist atmosphere, too, tends to induce both pulmonary and circulatory troubles by preventing elimination of waste material through the perspiration. It is impossible for hard muscular work to be continued for any length of time, and to be efficacious in a temperature equal or superior to that of the human body, and in a close medium saturated with moisture. At 84° F. we know physiologically that muscular effort is considerably reduced. An attempt is being made to keep the temperature of the tunnel at 77° F., and lower when possible.

Two parallel galleries--in other words, two tunnels--are being run into the mountain 17 metres[158] apart, and are reunited by a small transverse gallery every 200 metres. As the entrance into the tunnel, on each side of the mountain, is on a curve, there is at either end a “gallery of direction” to correct errors of alignment direct from the two observatories in the axis of the tunnel. Pagliani found that the amount of carbonic acid at various distances varied from 0.68 to 7.53 per 1000, and the temperature from 75.2° F. to 87.8°, but these amounts vary with the activity of the ventilation, the number of men working, the activity of the machinery, and the moisture of the air, which is nearly always at the point of saturation. It is almost impossible to have a dry atmosphere; besides it is vitiated by the products of dynamite explosions.

The chief feature of the Simplon tunnel[159] “is the much lower altitude of the rails above sea-level than any of the other Alpine tunnels. This altitude is at its highest point 2314 feet, being 1474 feet lower level than that of the St Gothard, 1934 feet lower than that of the Mont Cenis....

“The tunnel enters the mountain at the present level of the railway at Brigue ... but on the Iselle side the connecting line with the existing railway at Domo d’Ossola necessitates heavy work.... The gradient on the northern portion of the tunnel will only be that sufficient for drainage, viz., 1 in 500, but on the southern portion the gradient will be 7 per 1000, or 1 in 142.”

In May 1901, I visited the Simplon tunnel, with the object of inspecting the methods of ventilation, the hospitals, the system of baths, and the houses erected for the working men, married and unmarried. Armed with letters of introduction from Mr Francis Fox, I was received at Iselle, the Italian side of the tunnel, by Mr Sulser-Ziegler, Director of Messrs Brandt, Brandau & Cie, Zurich; also by Dr Volante, the resident Medical Officer, who conducted me over the works, the workmen’s dwellings, and the hospital. From the elaborate precautions taken, it is clear that the Company has made up its mind not to repeat the errors of the St Gothard, and to show to the engineering world and the public generally that tunnel-making can be conducted without greater risk to life and health than occurs in any ordinary enterprise. The large number of deaths in the St Gothard was due to the imperfect system of ventilation, the difficulty of dealing with excessive temperatures in the mountain, and defective sanitary arrangements. Before operations at the Simplon were commenced, Mr Sulser and his colleagues appointed two medical men, one at either end of the proposed tunnel, viz., Dr Volante at Iselle and Dr Pommata at Brigue. Both are Italians, and are most capable men. Before undertaking work the men are all medically examined. By this means, only healthy men have been employed from the commencement. The most important problem has been that of ventilation. The Simplon tunnel, when completed, will be the longest in the world, being upwards of 12 miles in length. So satisfactory have the operations proceeded until now, that unless some untoward and unexpected event happens, the tunnel will be completed with the smallest number of deaths on record.[160] A short description of the work, based upon personal inspection, may well be added here.

Ventilation, as already stated, is the main difficulty. At the Swiss end of the mountain a shaft has been sunk into the tunnel, and up this the foul air is removed by wood fires. Into the tunnel, at each end, by means of large fans, air is introduced to the extent of 19 million cubic feet per day, or 13,200 cubic feet per minute. The air is carried in by one of the two parallel tunnels as far as the most recently constructed cross gallery, thence it is carried to the face by pipes. It returns by the larger tunnel, i.e., the one through which trains will ultimately travel. By this means fresh air is carried to the head of the tunnel where the men are working. At Iselle there are 500 men always at work in the tunnel. There are three shifts of men, and they work 8 hours each, so that 1500 men, roughly speaking, are employed at the Italian end, and a much larger number at Brigue. The average temperature at the head varies from 73° F. upwards. After firing with dynamite it may be as high as 80° F., or 86° F. The air is not only ladened with carbonic acid given off from the lungs of the men and the 15 to 20 horses in the tunnel, but contains materials given off from the bodies of the men during excessive perspiration, and is polluted by the products of dynamite and gelatine explosions. The foul air as it escapes from the mouth of the tunnel is thick and greyish-white in colour; it contains a good deal of smoke from the lamps of the workmen, and is very offensive. Small wonder, therefore, that the men emerge from the tunnel bathed in perspiration, and disposed to be chilled owing to their clothes being wet, for, although they work in tarpaulins, there is a good deal of water in the tunnel. It was, among other things, want of attention to these particular details in the St Gothard that caused so many deaths and illnesses from pulmonary disease.

Close to the mouth of the Simplon tunnel at Iselle, where the railway trucks draw up that bring the men from their work in the interior of the mountain, are large wooden buildings, one of which internally is divided off into, among other things, 32 cubicles, each of which is fitted up with hot and cold water pipes. The railway platform where the men emerge is covered over, so that the workmen can reach this building without being exposed to wet or cold. The building alluded to is not only a bath-house but a vestiary as well. Here the men in going to work in the tunnel put on their working clothes. At first sight, part of the interior of the bath-house is not unlike an old-clothes’ shop, for, on looking upwards, the clothes of the workmen can be seen suspended from the ceiling. There are 2000 strong cords placed 1 foot 6 inches apart. Attached to the free end of each cord are three iron hooks and a soap dish. Upon the hooks the workman hangs his clothes. As every cord is provided with a pulley and is numbered, each man, having had a bath after his day’s work, hangs his wet clothes on the hooks and draws them up to the ceiling. Next morning he finds his clothes ready for him, dry, warm, and comfortable. The bath-house is kept at a warm temperature, and is well ventilated. I was particularly struck with the excellent system of baths, the vestiary arrangements, and the cleanliness of the interior, and am of opinion that prevention of chilling of the workmen after coming out of the hot tunnel has had much to do with keeping them healthy, and has warded off pulmonary and bronchial disease. The supply of drinking water is good, and so far there has been during the three years no case of typhoid fever at Iselle. The workmen’s dwellings are also good, so, too, is the hospital and its administration.

In addition to the ill-health caused by working in the vitiated atmosphere and high temperature of the tunnels, the miners employed in making the St Gothard tunnel suffered from a peculiar form of anæmia, which for long was unexplained. The discovery of the cause of this “maladie des tunnels,” for so it came to be called, was made by Perroncito of Turin, who showed that the anæmia of the miners was caused by the presence of a parasite which fixes itself in the upper part of the small intestine, measures from ¼ to ½ an inch in length, and possesses a mouth and four long hooklets. By its hooklets the parasite fixes itself to the lining membrane of the human intestine, and is thus enabled to suck the blood of its host. The worm is called “Anchylostomum Duodenale,” and is known to be prevalent in Italy. It would appear, therefore, that the ova of this parasite escaping by the fæces of miners who are suffering from anchylostomiasis find in the heat and moisture of the tunnel a medium favourable for their transformation into the larval stage; while in the dirty habits of the miners, and the accidental contamination of their food and drink, lies the explanation of the means of ingress of the ova into the alimentary canal. Anchylostomiasis is not therefore necessarily a disease of tunnels.[161] It was simply introduced into the St Gothard by infected miners. The malady is endemic in Piedmont and Lombardy. Dubini of Milan found in one hundred autopsies made upon the peasantry of these districts, anchylostomiasis present in twenty bodies, so that the disease had been apparently introduced into the St Gothard by Italian workmen. The ravages caused by this parasite show the necessity for miners working in tunnels disinfecting their stools by such means, for example, as sulphuric acid. It is to the careful medical examination of the workmen by Drs Volante and Pommata, before being engaged by the firm, the elimination of all suspected persons, and the repeated inspection of the closets in the tunnel, that anchylostomiasis has not appeared at the Simplon. Since much of the pulmonary disease that affected the miners was consequent upon breathing an overheated and an excessively moist atmosphere, one also vitiated by the products of human respiration and dynamite explosions, improved ventilation in the case of the Simplon tunnel has diminished these evils; while the opportunities given to the men of changing their wet clothes, of bathing themselves, and of receiving shelter when tired, have prevented the acute bronchial and pulmonary catarrhs that were observed in making the other great Alpine tunnels.

Underground Railways.

Of the underground railways in this country the only one I need allude to is the London Metropolitan. In 1897 a Board of Trade Commission was appointed to inquire into the condition of the air in the “Inner Circle” of the Metropolitan. The passenger traffic on this line is enormous. Between Praed Street and Aldgate stations, in one hour, as many as 38 trains were said to arrive and depart from either side of the stations. Welsh coal is consumed. Part of the Metropolitan railway is underground, and part is in the open, so that when the wind is blowing in certain directions passengers have been inconvenienced by the smoke and the insufficiency of the ventilation, despite the numerous escape holes. There has often been an excess of carbonic acid, sometimes, too, of carbon monoxide, in the air in the tunnels. The Commission found that the ventilation could not be adequately assured by the exchange and renewal of the air at the stations and the escape holes. It recognised the necessity for artificial ventilation, and in consequence the centrifugal method was adopted.

Vitiation of the air of a tunnel is caused by the gases that come from the means adopted for illuminating purposes, the products of respiration, and those due to combustion of coal in the furnace of the locomotive. Carbonic acid is only dangerous when it is present in large quantities. Breathed for a very short time at 60 per 1000 it causes headache, at 100 per 1000 respiration becomes extremely difficult, while if present in the proportion of 250 per 1000 it will cause rapid death.[162] It is seldom, however, that carbonic acid is even present to the extent of 10 per 1000; if present, it is as a rule accidental and only for a short period, so that danger from this gas is slight.

It is otherwise with carbon monoxide, a gas much more dangerous and subtle in its influence than carbon dioxide, popularly known as carbonic acid. Carbon monoxide was found to be present in the air of the Metropolitan Railway to the extent of 0.66 per 1000. When present to this amount in air it can, if time is given, paralyse the hæmoglobin or coloured substance of the blood that carries the oxygen to the tissues. Harmful effects can occur when carbon monoxide reaches 0.3 per 1000, but as it requires half-an-hour for the blood to absorb sufficient of this gas to be detrimental to the individual, accidents do not happen owing to the short length of the tunnels and the good speed of the trains through them. The risks to health are incurred mostly by the men who work on the railways. M. Raymond Godfernaux (Génie Civil., Août et Sept. 1899), in reviewing this subject, remarks that the breathing by an individual in repose for one and a half hours (less than this if work is being done) of an atmosphere containing 0.25 of carbon monoxide per 1000 is sufficient to cause unpleasant symptoms; if the air contains 0.5 per 1000 there will be debility and vertigo; if 0.9 per 1000 walking becomes impossible, while death will supervene if there is 1.5 in 1000. To men employed on underground railways, danger from this source only comes when the amount of carbon monoxide passes beyond 0.25 per 1000. The passengers run, practically speaking, no risk.

A heavy sulphurous odour hangs about the tunnels and stations of the Metropolitan Railway due to the combustion of coal. When sulphurous acid is present in air to the extent of 0.6 per 1000 it may cause death. This proportion is never present in the air of the tunnels of the Metropolitan of London.

The sulphurous acid and carbonic acid are believed to be proportional to each other. The amount of sulphurous acid is 440 times less than that of carbonic acid, and as the maximum of carbonic acid was 8.9 per 1000, sulphurous acid is seldom more than 0.02 per 1000.

The Commission established the facts (1) that there was a constant relation between the deleterious gases in the tunnels, and (2) that the proportion of carbonic acid present might be taken as the basis for the aeration of the tunnels. The proportion of carbon monoxide is constant, and corresponds to one-thirteenth the volume of carbon dioxide, while that of sulphurous acid is 440 times less than that of carbon dioxide. The amount of sulphurous acid is regulated by the character of the coal burnt in the locomotive. Some coals contain more sulphur than others. A similar remark applies to carbon monoxide. An Italian Commission charged with a similar function in regard to the composition of the air in the tunnels of its own country arrived at different chemical conclusions to the Commission of the Board of Trade, so that it would be scarcely wise to calculate the purity of the air in all tunnels upon parallel lines.

The amounts of carbon monoxide and dioxide should be estimated separately. The composition of the air of the tunnels of the Metropolitan, accepted for a maximum, is 1.5 of carbonic acid per 1000 (0.3 being regarded as the normal), 0.1 carbon monoxide per 1000, and 0.0027 sulphurous acid per 1000.

It is especially for the sake of the men who are working in the tunnels, and for the drivers of the locomotives, rather than for the passengers who spend proportionally a very short time on the railway, although of course desirable for all, that such artificial means of ventilation should exist as will quickly disperse the smoke and all combustion products.

It has been decided to introduce electric traction in the underground railway. By this means the Metropolitan Railway Company will rid the atmosphere in the tunnels of the impurities alluded to.

Divers’ Paralysis.

Men when clad in proper diving suits and wearing air-tight head-gear can work at very considerable depths under water. At the depth of 33 feet the pressure is about twice that of the atmosphere. It is not exactly known to what depth men may descend with safety, but 201 feet have been reached, i.e., equivalent to a pressure of 87 lbs. to the square inch. It is very desirable that the descent should be made gradually, say about two feet per second. In this country diving is resorted to for making excavations connected with piers, inspecting sunken ships, etc., and abroad for sponge, pearl, and coral fishing. It is not uncommon for the men after having been in the water some time to complain of weakness of the legs and of impaired sensation. A patient of Dr Frederick Taylor (Clin. Jour., April 27, 1898), after diving 162 feet felt sick, and when pulled up into the lighter was found to have lost the power of his legs. Loss of consciousness is a frequent symptom, and as it often takes a man as much as five minutes before he can reach the surface of the water, there is considerable danger attending the occupation. Divers have died without regaining consciousness. Others when rescued, and on coming to themselves, have complained of severe cramp-like pains in the muscles of their limbs and abdomen.

At such depths as 160 to 180 feet men can only stay at the bottom of the sea a very short time. It is only when men work at very great depths that paralysis is likely to supervene. The risk to life and health is regulated by the depth, and particularly is this the case when there are sudden alterations of pressure. Hauling up divers too quickly when the air-tube has become foul is a very dangerous proceeding. Since young men bear the work better than old men, age, therefore, is a circumstance that should be considered, as well as temperance in the use of alcohol. The character of the water and the length of the period of submersion must not be overlooked. Once 150 feet below the surface has been reached, the diver is apt to feel somewhat inconvenienced, and with every increase of two or three feet beyond this, the inconvenience becomes rapidly greater. There are experienced a sense of fulness in the head, buzzing in the ears--often relieved by filling the mouth with saliva and swallowing the secretion--also flashes of light before the eyes. Bleeding at the nose, mouth, and ears occasionally occurs after the men come to the surface; severe muscular pains, called “bends,” are sometimes complained of, followed by loss of power in the legs. There is either complete paraplegia, i.e., the lower half of the body is paralysed as regards motion, and sometimes too as regards sensation, or the loss of power is limited to groups of muscles affecting the wrists and ankles. The paralysis may be permanent, or it may last only a few hours or days, but if a diver has once had paralysis the symptoms are apt to recur on re-exposure.

The cause of divers’ paralysis, like the disease of caisson workers, is the sudden liberation of gas that was previously dissolved in the blood. No hæmorrhages have been found in the central nervous system, but Van Leyden observed fissures in the spinal cord occupied by leucocytes, i.e., cells like the white corpuscles of the blood. The appearance of the fissures suggested that they had first been formed, and that the colourless corpuscles had found their way thither afterwards. When lesions have been present in the spinal cord they usually occupy the lowest third of its length, a circumstance attributed by Moxon to the greater length, tortuosity, and attenuated condition of the small blood-vessels that are present at this particular part compared with the arteries in the upper region of the spinal cord.

Fatal cases of divers’ paralysis fortunately do not occur very frequently. One of the most recent cases was in November 1900, when H.M. battleship Howe was cruising in the West of Scotland; the diver of the ship died after a lengthened immersion in the water. At the post-mortem examination bubbles of gas were found in the blood-vessels, the heart, and brain. The morbid conditions found in this man’s body after death quite confirm the opinion already expressed as to the pathology of the malady.

In addition to the risks to health already mentioned, there are those incidental to the fouling of the air-tubes of the diver; also large stones and other materials occasionally fall upon the tubes, and tend to cause death by asphyxia.

So far as the operations of diving itself are concerned the three things to be avoided are: (1) too great depths; (2) sudden alteration of pressure; and (3) coming up too suddenly. There must necessarily be increased danger when a man who is working at a depth of 150 feet is brought to the surface in one minute instead of five.

Treatment.--If the diver on coming to the surface is found to be unconscious and not breathing well, artificial respiration should be resorted to and kept up till breathing becomes automatic. If he is collapsed, warmth should be applied to the extremities, and, if he can swallow, hot coffee should be administered. The patient should be removed to a hospital, or his own home, when sufficiently revived. If muscular pains are severe, or if there is loss of power, rest in bed, sinapisms to the spine, and later on galvanism should be tried.

THOMAS OLIVER.

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Chapter LV

DISEASES DUE TO DIMINISHED ATMOSPHERIC PRESSURE: PURE AND IMPURE GASES

Mountain Climbers; Military Balloonists.

Increased atmospheric pressure causes unpleasant and sometimes serious symptoms in divers and in caisson workers, but to an extremely rarefied atmosphere can also be traced effects that are nearly equally serious. It is difficult to say at what height above the ordinary surface level of the earth man can live with comparative comfort. The Andes and the Himalayas have been scaled to from 15,000 to 23,000 feet above the sea level, and men are said to have gone as high as six miles in balloons. The difficulties of remaining at great altitudes are the excessive cold and the low barometric and oxygen pressures. In order to compensate for this low oxygen pressure, nature endows men living at great heights by increasing the number of the red corpuscles of their blood. It is these corpuscles that carry oxygen to the tissues. In ascending a very high mountain the individual experiences not only great difficulty of breathing and violent palpitation of the heart, but a sense of great physical fatigue and faintness. A set of symptoms not unlike those observed in sea-sickness occurs, hence the name given to the illness, “mal de montagnes,” although vomiting and nausea are not always present. In climbing mountains people generally put forth a great amount of muscular effort, and in consequence an increased amount of chemical change takes place within their body, a circumstance which reduces the resistance of these individuals to the influences of a falling barometric pressure. Aeronauts do not experience this sense of muscular fatigue, because they are not making any muscular effort, but they ascend to great heights with greater rapidity than climbers, and to this circumstance must be attributed many of the unpleasant symptoms they experience.

Since in the act of climbing it is upon the heart and lungs that the greatest strain is thrown, it is these organs that principally have their functional activity increased. The palpitation of the heart may be very distressing. There is throbbing in the head, accompanied by extreme muscular exhaustion, so that after reaching a great height the individual may be so overcome that he throws himself on the ground, unable to proceed further. He lies there for a time panting, trying to get more oxygen into his system and to rid it of the excess of carbonic acid. He may bleed at the nose or from the gums. He perspires freely, and there is great thirst. There may be deafness and earache owing to the bulging outwards of the drum of the ear. Although it cannot be stated that in man death has been caused by diminished atmospheric pressures at great heights, yet it has been shown experimentally in animals that coma is induced which may end in death. The animal passes into a state of cadaveric rigidity very shortly after death. It is just a question how far the sudden supervention of cardiac and cerebral symptoms in mountain climbers may not be responsible for some of the fatal accidents that we read of from time to time as occurring on the Alps.

Military Balloonists.--In the Archiv. de Med. Milit., February 1900, Dr Maljean reports that in a company of balloonists belonging to the 1st Regiment of Engineers he found several of the soldiers suffering from a toxæmic form of jaundice, the nature of which was obscure. Ultimately he demonstrated that the jaundice was due to poisoning by inhalation of arseniuretted hydrogen gas mixed with hydrogen that had been used for filling the balloons. The hydrogen employed for military balloons is obtained by acting upon granulated zinc with sulphuric acid. The sulphuric acid is generally obtained from pyrites, and this is known to contain sometimes as much as from 2 to 5 per cent. of arsenic combined with iron. Commercial zinc also often contains arsenic. In filling balloons, therefore, it would appear that not only is there frequently an escape of this impure hydrogen from the valves of the balloon, but that during the operation of filling the balloon, the officers and men are in the habit of smelling the tube to ascertain whether by the garlicky odour of the impure hydrogen this gas has replaced the ordinary atmospheric air. At a single filling an officer may smell several times the open tube of the balloon and suffer in consequence.

According to Maljean the symptoms of poisoning commence with a sense of great malaise and nausea, followed later on by jaundice, often of a very pronounced yellow-green tint, urine scanty, and often as dark as coffee, but not giving the reaction of biliary pigment. The urine stains the linen like the blood-coloured urine of patients suffering from hæmoglobinuria, and it may contain both albumen and a few tube-casts. In a few days these symptoms disappear, but they leave behind them anæmia and loss of flesh, which persist. It has for long been known that if animals are given arseniuretted hydrogen gas to inhale, they rapidly become jaundiced and pass a blood-coloured urine. A similar set of symptoms has been observed in men working in chemical and mineral industries in which arsenic is present.

In the balloon service of the French army an endeavour is now being made to use only pure hydrogen. In most of the military balloons the valve which allows the gas to escape is placed in the upper part of the machine. The balloons are filled in the open by hydrogen from metallic cylinders which have been charged under a pressure equivalent to 120 atmospheric pressures. It is stated by some authorities that under such very high pressure the impure gas may be decomposed and rendered less harmful, but this requires confirmation.

Poisoning of aeronauts by arseniuretted hydrogen in connection with military balloons on the Continent is not confined to the French army alone. In the Deutsche Milit. Zeitschrift, 1900, p. 139, is an account of two German soldiers, who, after being poisoned by this gas, died at the end of three days.

Persons ascending in balloons should dress warmly, and they ought to take with them cylinders filled with compressed oxygen.

THOMAS OLIVER.

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LVI. EFFECTS OF CONCUSSION OF THE AIR

Boilermakers and Riveters.

It may be taken as a fact based upon experience, that artisans who are exposed to such loud noises as are made in hammering rivets suffer from deafness. Boilermakers and riveters become deaf at an early age, while their comrades engaged in other kinds of work in the same shipyard do not suffer. Several young boilermakers whom I have examined have stated that they lost their hearing at an early age. Their infirmity dated back to their ’prentice days, when as boys they were sent into the boilers to catch the rivets, and were subjected to the intense noise of hammering inside the cylinder. Workers in sheet-iron factories are sometimes similarly affected with deafness. It is no uncommon thing, as people know, for artillerymen when firing large guns to be rendered temporarily deaf by the noise and force of the explosion, and in some instances for the drum of the ear to be ruptured. In order to prevent such an accident, cotton wadding is sometimes placed in the ear. It is difficult to say exactly what is the cause of deafness in boilermakers, but the extreme vibration of the tympanum, and the intense agitation of the ossicles, cannot but be followed either by a thickening of the drum of the ear, or by a paralytic condition of the minute terminations of the auditory nerve.

There is nothing I know of that will prevent boilermakers’ deafness, short of substitution of machine for hand riveting, and once deafness is established I know of no reliable cure for it.

Boilermakers, Shipwrights, etc.

Some idea may be formed of the trades included under this heading, by glancing at the reports of the Boilermakers’ Society, and ascertaining from what trades the members of the society are drawn. The members are engaged in the various steel trades, viz., boilermaking, bridge-building, shipbuilding, also in iron and other structural work composed of iron and steel. They mostly come from the boilermaking and shipbuilding industries. As the central office of this Society is in Newcastle-upon-Tyne, I have, through the kindness of Messrs Robert Knight and D. C. Cummings, the past and present secretaries, gained considerable information as to the maladies principally affecting boilermakers, and their death-rate, etc. The work is hard, and as it is mostly carried on in the open the workmen are exposed to all kinds of weather. Under these circumstances, therefore, it would be natural to expect that boilermakers would show a tendency to suffer from acute inflammatory affections, especially of the respiratory organs. Boilermakers as a class are not unhealthy. At the present time there are 48,000 members in the Society. In 1899 there died 436 members, a number equal to 9 per 1000, as against 8 per 1000 of the male population of the country generally. As illustrating the effect of the occupation upon their working powers, members are eligible to be placed upon the superannuation fund at the age of fifty-five years. This is an early age compared with some industries, and yet, at fifty-five some boilermakers are, comparatively speaking, old, a circumstance that is attributed to the arduous nature of their calling. The records of the Society, as of many other trade unions, show that with each succeeding decade in the working life of a boilermaker he is annually on the sick-list an increasing number of days. The average age at death of boilermakers is 46.72 years. Hard and exposed as the work is, it is interesting to know that the average age at death of boilermakers is greater than that of the wives of boilermakers, who are leading an indoor and protected life. The average age at death of members’ wives is 45.47 years, a circumstance which I attribute to many of the wives dying during or shortly after their confinement, and also dying at an earlier age than the members from such other diseases, for example, as consumption.

In the accompanying statistical tables in their present form I am indebted to Dr H. E. Armstrong, Medical Officer of Health, Newcastle-upon-Tyne (see p. 754).

One thousand boilermakers, it will be seen, exhibit a slightly higher death-rate from all causes than 1000 of the male population of England and Wales, the numbers being respectively 9 and 8. They have a slightly higher mean death-rate, too, from all forms of lung diseases, including pneumonia, viz., 3.0 as against 2.9 of 1000 male persons over twenty and under sixty-five years of age; but taking tubercular diseases only, the death-rate from this cause is less, being 1.4 as against 1.6; on the other hand the death-rate for diseases of the heart and circulatory organs is slightly higher, 1.2 as against 1.1.

UNITED SOCIETY OF BOILERMAKERS AND IRON SHIPBUILDERS.

Extracted from the Annual Reports of the Society.

Column headings: 1: YEAR. 2: No. of Members. 3: All Causes. 4: Bronchitis. 5: Pneumonia. 6: Phthisis, not included in cols. 7, 8. 7: Consumption, not included in cols. 6, 8. 8: Tuberculosis, not included in cols. 6, 7. 9: Cancer. 10: Diseases of Heart, Circulatory System. 11: Typhoid Fever. 12: Lung Diseases, including Bronchitis, Pneumonia, Phthisis, etc. 13: Tuberculosis, including Phthisis, and all other forms.

+---------------+--------------------------------------------+----------+ | | DEATHS FROM | TOTAL | | | | DEATHS. | +------+--------+-----+----+----+----+----+---+----+----+----+-----+----+ | =1= | =2= | =3= |=4= |=5= |=6= |=7= |=8=|=9= |=10=|=11=|=12= |=13=| | | | | | | | | | | | | | | | 1896 | 40,776 | 346 | 27 | 35 | 51 | 8 | | 12 | 48 | 5 | 121 | 51 | | 1897 | 42,178 | 379 | 32 | 37 | 43 | 12 | 4 | 23 | 52 | 6 | 124 | 47 | | 1898 | 43,905 | 399 | 25 | 41 | 68 | 6 | 2 | 20 | 53 | 12 | 140 | 70 | | 1899 | 47,417 | 436 | 30 | 53 | 62 | 3 | 7 | 13 | 56 | 25 | 148 | 69 | +======+========+=====+====+====+====+====+===+====+====+====+=====+====+ | Death-Rate per 1000 Members. | +-----------------+--------+--------+--------+--------+--------+--------+ | |Per col.|Per col.|Per col.|Per col.|Per col.|Per col.| | | 12. | 13. | 9. | 10. | 11. | 3. | | +--------+--------+--------+--------+--------+--------+ | | =14= | =15= | =16= | =17= | =18= | =19= | | | | | | | | | | | 3.0 | 1.3 | 0.3 | 1.2 | 0.1 | 8.9 | | | 2.9 | 1.1 | 0.5 | 1.2 | 0.1 | 9.0 | | | 3.2 | 1.6 | 0.4 | 1.2 | 0.3 | 9.1 | | | 3.1 | 1.5 | 0.3 | 1.2 | 0.5 | 9.2 | +-----------------+--------+--------+--------+--------+--------+--------+ |Average for four | | | | | | | | years | 3.0 | 1.4 | 0.4 | 1.2 | 0.2 | 9.0 | +=================+========+========+========+========+========+========+ | [163]ENGLAND AND WALES.--Per 1000 population, 1881–90. | +-----------------+--------+--------+--------+--------+--------+--------+ |Mean Annual }| | | | | | | | Death-Rate of }| | | | | | | | Male Persons 20}| 2.9 | 1.6 | 0.4 | 1.1 | 0.1 | 8.0 | | and under 65 }| | | | | | | | years of age }| | | | | | | +-----------------+--------+--------+--------+--------+--------+--------+

It is noteworthy, as already stated, that the average age at death of the wives of the members of the Boilermaker’s Society is lower than that of members, viz., 45.47 years for the wives and 46.72 for the members. Fewer of the wives die from phthisis and tubercular disease than the members, the numbers being 1 and 1.4 respectively as against 1.6 of 1000 of the population generally, estimated upon the returns of the Registrar-General for 1881–90. The wives of members die at an earlier age from pulmonary consumption than the members, viz., thirty-four and a half years for the wives, and thirty-nine for members, a circumstance possibly explained by two facts--that males show greater resistance to the disease than females, and that during the early part of the disease at any rate the members spend more of their time in the open air than do the wives.

Although boilermakers are exposed to such risks as burns from red-hot rivets, it is surprising how few accidents are traceable to this cause. When Dr Ogle dealt with the statistics of workers in iron, he concluded that of the three classes--(1) locksmiths, including bellhangers and gasfitters; (2) engine and machine-makers, fitters and millwrights; (3) boilermakers--the engine-makers occupied the most favourable position from a mortality point of view, the mean mortality rate being 863 as against 967 for locksmiths, and 994 for boilermakers. According to the same authority, too, the mean annual death-rate of boilermakers is greater at all the ages between twenty-five and sixty-five years.

THOMAS OLIVER.

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LVII. IRON AND STEEL INDUSTRIES

Exposure to High Temperatures, and Severe Muscular Strain.

In iron works the blast furnacemen are exposed to very high temperatures. Passing rapidly from great heat to cold, they are prone to suffer from bronchial and pulmonary affections and from rheumatism. They run the risk of burns, also on a windy day of getting particles of dust or sand into their eyes.[164] Blast furnacemen’s work is hard. When young the men are, as a class, physically strong. Their wages are good; they live well, but at an early age they begin to drink freely. Under the combined influence of their arduous labour, exposure to all kinds of weather, and their intemperate habits, they break down readily and become prematurely old.

The men who work at the puddling furnaces are exposed to excessive heat and to severe muscular strain. Owing to the heat and excessive perspiration, they often work with the upper half of their body uncovered. They imbibe many kinds of liquids, so as to replace what is lost by perspiration. Puddling, which is briefly speaking the rolling about by means of a rabble the huge balls of molten iron in the furnaces, is such very hard work that many of the men develop heart affections, particularly disease of the aortic valves, or aneurismal dilatation of the aorta, owing to the excessive muscular strain and intemperate habits. Puddling is justly regarded as one of the most degrading occupations a man can follow. Fortunately for the workmen it is now very much on the decrease. Steel is rapidly taking the place of iron, consequently puddling is not so much required.

Blast furnacemen are occasionally poisoned by the escape of carbonic oxide from the waste gases used for heating the air of the furnace.

Blacksmiths and Forgemen.

Beyond the extremely arduous nature of this employment, and which necessitates the work being undertaken by men of good physique, whose muscular system develops in proportion to the strain that is imposed upon it, especially in the early years of manhood, and freedom from alcoholic excess, the work of the blacksmith and forgeman is healthy. Formerly a good deal of the heavy work was done by men wielding large hammers. This threw a strain upon the heart and large blood-vessels, and was a frequent cause of valvular disease of the heart, dilatation of the aorta, and possibly too of hernia. Since much of the hard work previously done by hammermen is now done by machinery, we see less of aortic disease among forgemen than two decades ago. The workmen are exposed to heats and colds, to injuries to the eyes, and to burns from flying scales during hammering. Blacksmiths seem to lead a charmed life so far as these risks are concerned, for considering their exposure the percentage of injuries is small. As a consequence of handling the rough iron tools the skin of the hand becomes thick and hard, and the men run the risk of catching bronchial and pulmonary catarrhs on emerging from their heated workshops into the open air. Years ago in Sheffield, when sledge-hammers were more in use than now, there was observed a form of paralysis of the muscles of the arms due to overstrain, and known by the name of hammermen’s paralysis. A considerable percentage of blacksmiths die from phthisis and diseases of the respiratory organs. Out of 872 deaths of blacksmiths Dr Ogle found 194 due to consumption, and 183 caused by other forms of lung disease; while following these came diseases of the heart and circulation, 108; and, lastly, from diseases of the nervous system, 85.

Use of Converters in Steel Works.

This is the proper place to allude to a matter which formed the subject of a special inquiry by, and report[165] from, the Dangerous Trades Committee of the Home Office, on account of a fatal accident to four men in a large iron works in which the Bessemer process of steel manufacture is in use. The Bessemer converter is a pear-shaped metal vessel, about nineteen feet long by seven or eight across at its widest part, into which pig-iron and other ingredients for the manufacture of steel are run in a liquid condition. In the bottom of the converter are openings called “tuyere holes,” through which a powerful blast of air is driven into the molten pig-iron, the object being to burn out such impurities as carbon, silicon, phosphorus, etc., the means employed to do this being sufficient to develop at the same time a degree of heat capable of keeping the purified metal in a liquid state. Before the blast is turned on, the converter occupies almost an upright position. The roar that follows the entrance of the blast of air is succeeded by volumes of coloured smoke and flame, and by myriads of sparks of molten metal. When the flame has become finally white, the blast is withdrawn, spiegel iron is added to the seething mass to restore the proper amount of manganese and carbon required, the converter is lowered and gently turned over so as to allow of the pouring of the liquid steel into a ladle, which distributes it into moulds. It is in the moving of the converter and the ladle into their respective positions, an act usually accomplished by the aid of hydraulic or steam power, that accidents have arisen owing to faulty machinery. The moulds are standing upright in what is called the pit, where there are usually two or three men employed. Should by chance either the converter or the ladle spill its contents a fatal accident is almost sure to occur. It is desirable, therefore, that only experienced men should work the machinery connected with the lowering and turning over of the converter and ladle, and that during the act of distributing the steel into the moulds no men should be present in the pit at all. The Dangerous Trades Committee, in addition to the above, recommended that where an automatic safety apparatus has been introduced into the machinery, the spindle in the valve should be changed every three months, and the valves examined regularly by a competent engineer. Owing to the fact that when molten metal falls into water there is an explosion, it was also recommended that the pits should not be, as they too often are, open to the sky and exposed to all kinds of weather.

Nail and Chain Making.

The small iron industries are located in districts where coal is plentiful, iron close at hand, and labour cheap. It is thus that chain-making has come to be associated with such places as Cradley Heath and Dudley, and has grown up to be a family industry, carried on in these localities by husband, wife, and children in small tenemented properties and outbuildings under the worst hygienic conditions possible. A similar remark applies to nail-making at Bromsgrove. In these trades, as carried on in the Midlands, female labour, assisted by that of children, prevails, a circumstance that tends to pull down wages and to render the conditions of life hard.

As an illustration of how the minor iron industries come to be located in small places, I would mention the manufacture of nails, locks, and angle iron that has been carried on for many years in Winlaton, a few miles from Newcastle-on-Tyne. Here also the work has partly assumed the family type already mentioned. For generations the industry has been handed on from father to sons. It cannot be said that in Winlaton the conditions of labour have been, from a financial point of view, unsatisfactory to the workers or deleterious in its effects upon their health, as is stated to be the case in the “Black Country,” where labour has been ill-requited, recourse had to female and child labour on account of cheapness, the hours of toil long, and the hygienic conditions under which the work is carried on bad. Dr Arlidge, drawing his experience from Staffordshire, was of opinion that for the worker in these trades to earn a living wage, a great amount of physical labour had to be expended in the forging and hammering of the nails on the anvil. To put the head on to a nail a suspended hammer has to be intermittently brought down by pressure of the foot upon a chain. For spike nails the cold iron has to be cut into proper lengths by means of an “oliver” or sledge hammer, worked by two or three men by means of a treddle. In forging a nail a girl works with the hammer on the anvil, and with her foot a small “oliver.” Apart from the small wages received it cannot be said that the industry is unhealthy, but the work is hard, and requires a great amount of physical exertion which ought to be met by good food and adequate physical rest, the former of which is denied the workers by their small wages, and the latter by the long hours of toil required to secure the necessaries of life.

In consequence of the irritation which the palm of the hand is exposed to in handling the hammer, etc., there occurs a thickening and contraction of the fascia in the front of the hand whereby the fingers become crooked and drawn towards the palm. Spinal curvature, too, is not unknown. It is extremely apt to develop in those who engage in the work at an early age. Pulmonary disease is said to carry off the men while still young, and the occupation is one that exposes the worker to the risk of burns. Attention is drawn to this industry, not so much because the trades are unhealthy in themselves, as that the nail-makers at Bromsgrove and Sidemoor, and the chain-makers of Cradley Heath, scarcely earn wages sufficient to buy the proper food necessary for the maintenance of the body, while they are obliged to put forth considerable muscular effort owing to the laborious nature of their calling.

THOMAS OLIVER.

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Chapter LVIII

EYE DISEASES AND EYE ACCIDENTS IN RELATION TO INDUSTRIAL OCCUPATIONS

The subject to be discussed in this article is a very wide one. To treat all industrial occupations and the relations they bear to eye diseases and eye accidents would be impossible in the space at my command. It will, however, be found that the various trades which are brought under notice cover a considerable part of the whole area. They may be regarded as perhaps the most important, and some, at all events, will represent also the dangers arising from cognate or allied industries. For the most part I have treated of occupations in which I have myself been particularly interested.

The subjects to be considered may be conveniently arranged under the following divisions:

1st. Diseases due to occupations involving prolonged use or excessive strain of the eyes, such as nystagmus in miners, and others.

2nd. Diseases due to occupations involving the use of certain poisonous substances, such as dinitrobenzol, bisulphide of carbon, tobacco, lead, etc.

3rd. Diseases due to occupations involving exposure to excessive light or heat, or both, such as burnishers, steel melters, electric welders, etc.

4th. Injuries or accidents amongst grinders, iron and steel workers, masons, coal miners, weavers, etc.

_1. Diseases due to occupations involving prolonged use or excessive strain of the eyes, such as nystagmus in miners and others._

Coal miners, as a result of their employment, are specially prone to a peculiar affection of the eyes called “nystagmus,”[166] which is characterised by oscillations of the eyeball. The sufferer, too, complains of objects dancing before his eyes. In this disease objects appear to move either in a circle or an ellipse. Headache is often present, and especially giddiness, which sometimes causes the miner so to stumble about that he is compelled to leave his work in the mine. The movements of the eyeball are chiefly rotatory; to-and-fro oscillations are sometimes superadded; these are rarely vertical, but the rotatory are seldom, if ever, absent. The rapidity of the ocular motions varies greatly: from sixty to one hundred and fifty motions may be counted in a minute; I have observed them as frequent as three hundred and fifty. Both eyes are affected, but the rapidity of movements may vary in the two eyes. The more rapid the oscillations the less extended is the excursion of the globes. The oscillations are arrested by turning the gaze downwards below the horizontal line, and miners often learn to rest their eyes in this way. Looking upwards, and especially obliquely to one side or the other, rapid movements of the head, lowering of the head and suddenly raising it, are means of increasing the rate of movements of the eyeballs, or, in other cases, of rendering them evident. Placing the patient in the position he would assume at his work is another method. Tremors of the head (noticeable to the hand placed on the head), of the eyelids, and of the muscles of the face or neck, are often associated with nystagmus, and so is torticollis or “wry-neck” in some cases. Night blindness has been alleged to be present, but there is some reason to dispute this; the nystagmus alone is a sufficient cause for any difficulty in seeing in a failing light. Errors of refraction, myopia, hypermetropia, and astigmatism are often present, but bear no causal relation to nystagmus; visual acuity is generally unaffected. Colour perception is good, and, so far as the movements of the eyeballs permit of testing, the field of vision is normal. The onset of the disorder is often brought about by some attack of illness. It is generally met with in men who have worked in the mine for some years. Ninety per cent. of cases occur in persons from twenty-five to forty-five years of age.

Nystagmus is found in miners (coal-getters) engaged at the coal face, who work in a more or less constrained position of body and of eyes. It is desirable to get coal in as large pieces as possible, and, to do this, they undercut, or “hole” the seam. A man sits with his legs crooked up, lying almost on his side, and strikes the coal with a horizontal swing of his pick at the bottom of the coal seam. He will cut away the coal to a height of from 18 inches to 2 feet, and then as he gets deeper in he draws his body under the coal, lying on one side or the other. The process is called “holing,” and sometimes the undermining may be continued from 2 or 3 feet to as much as 7 or 8 feet; the distance varies considerably. As he proceeds with his work the miner applies timber supports to keep the coal from falling. This just described is called “bottom-holing,” but the seam may be attacked in the middle (middle-holing) or at the top (top-holing). A miner engaged at this work will direct his gaze to different parts, as it becomes necessary for him to strike, for the eyes will follow the pickpoint, but the tendency will be for the gaze to be directed upwards (using the ocular elevators) more or less obliquely. He will lie sometimes on one side and sometimes on the other; his legs will be crooked up, his head thrown back and flexed more or less on the shoulder beneath. This position is shown in the photographs, which were taken in the mine with a magnesium flash-light, of a man whilst actually at work. Ninety-eight per cent. of all cases of nystagmus coming under my notice have been in men occupied at the coal face and more or less engaged at this kind of work. The thickness of the coal seam varies greatly in different parts, but work of a very similar nature is done in coal mines in all countries.

There are others working in a mine beside the coal-getters. Among these are those who attend to the roads, fill the waggons (fillers), push these (trammers), or drive the ponies. There are also deputies or overlookers, whose work it is to see to the safety of the places the men work in, both as to freedom from gas and as to the condition of the roof of the mine. These latter occasionally suffer from nystagmus, and a consideration of the work they perform will show that it necessitates the same upward and oblique direction of the gaze. Frequently also these men have previously worked as coal-getters. The photograph shows a deputy examining the roof by striking it with his stick to ascertain its soundness. It must be remembered that the height of the working places and passages in the mine is nearly always so low that this alone compels a constrained attitude. “Onsetters,” whose duty it is to see to the ascent of the full, and descent of the empty coal tubs, sometimes get nystagmus, as do also “timbermen.” It may be accepted as a rule that all cases of nystagmus occur in those who are either working, or have worked, as coal-getters, or that the work in which they have been employed has been one in which an upward direction of the eyes has also been necessitated for more or less prolonged periods. 7 The etiology of the affection must be sought in this constrained position of the eyes by which chronic weariness is induced in the elevator muscles of the eyes. Like effects are found in other muscles of the miner, producing wry-neck, tremors of the head, and quivering of the eyelids. It is thus similar to other occupation neuroses, and in the same category as those met with in writers, compositors, telegraphers, ballet-dancers, and many others.

Nystagmus occurs in miners working with all kinds of lighting. I have met with it in workers with safety lamps, candles, large open lamps, and when the artificial light was really good. There is, however, some reason for believing that the strain is greater the worse the light, and that nystagmus is met with in greater frequency under such conditions. Other things, as to the nature of work, being equal, the disease will probably be most frequent with the worst light.

Nieden says that 5 per cent. of miners suffer, and my observations support this generally; in some parts, however, the percentage is higher. For instance, among men working at a colliery with candles I found that 6 out of a total of 140 were absent from work for nystagmus, and this represented only a portion of those whom an examination would have ascertained to be actually affected with the disorder. Romiée gives the percentage for Belgium as high as 20, but possibly he includes less marked cases.

The prognosis is good, and, even in old-standing cases, if the directions as to work are followed, the nystagmus will usually disappear. Treatment consists essentially of a change of the kind of work. In some cases it will suffice if the patient ceases from coal-getting, without altogether stopping work in the mine, but generally it is advisable, especially if the nystagmus be of high degree and of some standing, to recommend cessation altogether from work underground. After relief has been effected return to the mine is practicable, provided the head can be kept straight, and the upward turn of the eyes avoided. Resumption of the old kind of work is followed, sooner or later, by a recurrence of the symptoms. Medicinal treatment is also of service.

Though so peculiarly an affection of miners, nystagmus is met with, but much less frequently, in other occupations. I have observed it in various employments, and have collected together a series of cases in which it occurred, viz., in compositors, metal roller, plate layer, plank cutter, saw maker, sanitary tube maker, fitter, iron founder, cage worker in the mine, glass manufacturer, youth in confectionery warehouse, and a man engaged in hanging up harness, and in another employed at the screens at the surface of a coal mine. These instances occurred in circumstances closely comparable to the work in the mine as to strain of the elevator muscles of the eyeball, and where, of course, the influence of illumination had no place. They may be held as definitely corroborating the views set forth as to the causation of this affection in miners.

2. Diseases due to occupations involving the use of certain poisonous substances, such as, dinitrobenzol, bisulphide of carbon, tobacco, lead, etc.

Dinitrobenzol is largely employed in the making of explosives, such as roburite, sicherheit, etc., a class of explosives which find special employment in coal mines.

The dinitrobenzol is brought to the factory in slabs, say 15 inches square, and about 4 inches thick. The first process is to grind these to powder in an apparatus with steam rollers. During this process a good deal of dust is given off, and there is a smell of bitter almonds. The next step is to take the powder thus obtained to the mixing shed, where it is mixed with oxidising salts and other materials in a large pan, and heated with steam. It remains there for several hours, and it is then cooled by cold water being pumped on the outside of the shell. When cool, the material is turned out of the mixer. It is during the removal of the material from the mixer that workmen are especially exposed to the vapour, but the dangers are lessened by the adoption of a cowl to the mixer, and also by the use of a fan. The explosive prepared in this way is put away in cylinders and kept until required. The next step is to take it to the filling room, where it is put into cartridges, which are then weighed and stamped, and finally these go to the dipping room, where the cartridges are waterproofed by being dipped in liquid paraffin wax.

The most injurious work is that of grinding and mixing, especially the latter. Men are employed in these processes. For the “filling” of the cartridges, and for the “dipping,” women and girls are employed. In the first named, the powder is shovelled into the cartridges and directly handled; a good deal of dust is given off. Respirators and gloves are used, as they are also by the men mixing or grinding. The dippers are apparently the least exposed to the injurious effects, yet they, nevertheless, suffer. The greasiness about the hands from the paraffin may also aid absorption. Here also gloves and respirators are worn. There is not much dust, the powder being confined inside the cases.

Some years ago several patients were under my care whose impaired vision was due to working with dinitrobenzol. An opportunity was afforded me of investigating the manufacture of this material, its effect on vision and the general health of the employés.[167] The eye symptoms may be summarised as follows: failure of sight, often to a considerable degree, to a more or less equal extent on the two sides; concentric contraction of visual field, with, in many cases, a central colour scotoma; enlargement of retinal vessels, especially the veins, some blurring of the edges of the optic disc, and a varying degree of pallor of its surface. The condition of retinal vessels spoken of is observed in workers with the dinitrobenzol independently of complaints of defective sight. Cessation of work with dinitrobenzol tends to recovery. The general effects appeared to be chiefly exerted on the blood and the nervous system. In some cases there were also gastric symptoms. With reference to the blood changes, the occurrence of very marked anæmia in girls, who lived practically in the country, and who worked in well ventilated rooms, was particularly striking. The symptoms and physical signs of anæmia in men, working under the same hygienic conditions, were perhaps still more noteworthy. That some other change, however, in the blood was also present was evidenced by the blueness of the lips and finger tips, which was observed in several cases. The colour of the urine was also remarkable.

The chief nervous symptoms were numbness of the extremities and unsteadiness of gait. The latter was noticed especially at the close of a day’s work in the factory, and was much aggravated by indulgence in alcohol.

Dinitrobenzol may, it appears, either be absorbed through the skin, ingested, or be taken in through the air passages. What the poison then becomes does not appear to have been satisfactorily ascertained, but its action on the blood is definite. Specimens of blood drawn from the fingers of two of my patients were found to be thin and black-looking. Dr MacMunn, of Wolverhampton, very kindly examined some specimens which were forwarded to him, and reported on them (as he did also of the urine, which was dark, almost black like porter), that, spectroscopically, all the specimens of blood sent showed nothing abnormal.

The explosives under consideration are used in coal mines, and cases have been recorded of men who became affected by dinitrobenzol employed underground.

At the invitation of Commander H. P. Smith and Dr Dupré, the following suggestions for preventing the deleterious effects of dinitrobenzol on those engaged in its manufacture were drawn up by me for their report.

(1) That the different processes should as much as possible be conducted in the open air, or in large, well-ventilated sheds.

(2) That in the “mixing,” closed vessels should, as much as possible, be employed.

(3) Fans, which have been adopted in other trades with great advantage, might also in this one be of service.

(4) Respirators are in use, but their employment is, as far as I am aware, optional. Those protecting both the nose and mouth are, up to a certain point, of service. I do not think they are a sufficient safeguard against the fine vapour entering the respiratory system. It occurred to me that during the process of “mixing” especially, it might be possible to shut the workman off from the vapour and fine dust by means of a kind of diving-bell apparatus, with a communication behind open to the air. A mask, such as has been used, I believe, in Germany, might answer the objects desired.

(5) Handling by the bare hand or direct exposure of the skin should be avoided. The filling could, perhaps, be performed automatically. The hand should, moreover, be protected by gloves. These should be capable of being cleaned, and possibly indiarubber might be used by preference. The cleaning of the gloves is an important matter, because those worn with any of the substance clinging to the interior, as would be the case after they had been in use for some time, would allow of absorption taking place under the still more favourable circumstances afforded by the warmth and moisture of the hand. Special clothing should be provided, the workmen and women being compelled to change their clothing on entering and retiring from work. Dressing-rooms should be provided, and washing enforced. Food should only be partaken of away from the sheds where the mixing, filling, etc., take place, and particularly is it important to insist on washing before meals, and removal of the special clothing.

When used in the coal mine it is desirable that means should be taken to prevent any of the powder adhering to the outside of the cartridges, that combustion should be complete, and that the use of cartridges should be restricted as much as possible to well-ventilated places, so that currents of air would speedily dilute and carry away any deleterious vapours.

As a result of the report by Dr Dupré and Commander Hamilton P. Smith, notice to observe the “Special Rules” recommended in their report was served on the different manufacturers.

The effect of bisulphide of carbon in causing impaired eyesight has been shown by many instances. Rubber-making has been the industry in which those suffering have been mostly observed. The bisulphide is a very active and penetrating solvent, and it is used to dissolve and carry into the rubber chloride of sulphur, which is the vulcanising agent. This process is called “curing,” and it is during it that the fumes of the bisulphide are given off and act injuriously on the general system of those exposed to them, as well as in some cases causing injury to eyesight. Some time since I visited rubber-works in which about 200 hands were employed, and witnessed the process of “curing.” The rubber cloth which it was wished to vulcanise was brought into contact with the wet surface of a wood or slate roller, which revolved in a trough in which was the bisulphide holding the sulphur in solution. The shed in which the curing was done was very open, and was well calculated to allow of the ready escape of the fumes. The vapour was a heavy one, and tended very much to keep low, especially in wet or damp weather. Any apparatus to carry off the fumes, therefore, should be one to draw them downwards. Among the workers I saw one man who had evidently two years ago suffered from amblyopia, which appeared to have been characteristic. He changed his work to another part of the factory, and recovered. A considerable alteration has, I understand, been brought about in the vulcanising process, and since attention was first directed to the subject, bisulphide has been much less employed in rubber-works. The sulphur is now mixed with the rubber, and the vulcanising is done by subjecting the otherwise finished article to a high temperature. The bisulphide in the future is even less likely to be required, and therefore in this class of occupation, at all events, it may be expected that impaired eyesight will be more infrequent.

Tobacco was the first agent to be recognised as causing toxic amblyopia. It is doubtful whether it can be classed properly with occupation disorders. Galezowski,[168] however, asserted that visual troubles occurred in those engaged in the manufacture of tobacco in consequence of the absorption of nicotine powder. He further advised that the working places should be well-ventilated, and recommended a change of occupation for those affected. This statement finds corroboration by De Schweinitz, who states that amblyopia may occur in those who do not use tobacco in any form, but who work in tobacco manufactories. He has related a very remarkable case of this character in a young woman. All of the symptoms disappeared when she was removed from the tobacco factory. On the other hand, Shears[169] has related that he visited the large factory of Cope Bros., where 1200 men and women were employed, and that he made careful inquiries in each of the departments of the foremen, but from none could he learn of instances of sight failure. Lee at the same time made observations at a large factory at Chester, with similar results. Sheffield is celebrated for its snuff, the two kinds, Top Mill and Bottom Mill, being well known. There are also several smaller tobacco works about the city, but my attention has in the last twenty years never once, as far as I remember, been directed to a case of tobacco amblyopia in a worker at any of these places. Dowling[170] in America has also gone into this matter. At a factory where 3000 were employed, half being females, he examined 150, or 5 per cent. Ninety per cent. of the males used tobacco in some form or other, and 20 per cent. chewed, in addition to smoking liberally pipe or cigar. These are his conclusions: “When I commenced my examination I was under the impression that the constant inhalation of the dust and the odour of tobacco in the workshops would tend of itself to bring about symptoms of tobacco amblyopia. I am induced to think this hardly takes place, for in my examination I found those who did not smoke were uniformly free from troubles of vision of a toxic nature, and the females were almost universally free from the trouble, that is as far as I examined them.”

Iodoform is largely used in surgical practice. A few instances have been recorded of impairment of vision resulting from its employment as a dressing for large burns, etc. The characteristics of the affection were similar to those met with in tobacco amblyopia, in chronic poisoning by bisulphide of carbon, and other toxic amblyopias. Inquiry addressed to perhaps the largest makers of iodoform in this country elicited the reply, that they had consulted the Medical Attendant of their men, and he confirmed the opinion expressed by the foreman, that they had never known of any injury to the sight from the manufacture of iodoform. If there was carelessness in the manufacture pungent vapours would be evolved; but that was always a sign of something being wrong.

Men employed in dye factories and other manufactories requiring the handling and preparation of the various coal-tar products are reported to be subject to visual troubles, cases having been recorded from time to time.[171] Galezowski gives headache, dizziness, malaise, deficiency in visual acuity, photophobia, and ciliary injection as symptoms from which the workers suffer, but, as is pointed out by Knies, the connection of these ocular complaints with the aniline used is uncertain.

M’Kinlay[172] has recorded a case of intense pigmentation of the cornea and conjunctiva in a man who was a worker in aniline dyes. Reduction of vision was also caused.

Arsenic is extensively used in the arts, and has been the cause of many cases of poisoning, for example, from wallpaper and articles of clothing. Its use for artificial flowers and wallpapers has much abated. Casey Wood mentions that makers of Paris green, painters, and paperhangers, as well as those who take the drug for medicinal or cosmetic purposes, are liable to suffer from visual disturbances, from conjunctival hyperæmia and eczema of the lids, which are regarded as evidences of arsenical poisoning. Amblyopia and optic neuritis have been reported as due to arsenic.

The occupations in which lead or its compounds, in one way or another, are used are multitudinous, and those liable to be affected by lead poisoning belong, therefore, to a numerous class. Among these are painters, plumbers, etc., and, in Sheffield, file cutters. In this latter occupation the file, when being cut, rests on a “bed” made of lead, and each blow of the hammer causes minute particles of lead to disperse and to charge the atmosphere of the workroom. Chronic lead poisoning in file cutters results from inhalation of these particles, and from the uncleanly habit of wetting the hands at the mouth. In acute lead poisoning there are no eye symptoms, but in chronic lead poisoning central and peripheral affections of sight are common. The brain and nervous system are frequently seriously affected in chronic plumbism, and kidney disease is also frequently occasioned thereby. Sight is liable to be affected in association with both these conditions. Apart from them, however, lesions of the eye are often occasioned by chronic lead poisoning. Unilateral or bilateral optic neuritis is met with, and more frequently an affection of the optic nerve (retro-bulbar neuritis) very similar to that occasioned by tobacco and other agents producing “toxic amblyopia.” Recovery from these last-named (peripheral) conditions is frequent. Palsy of one or more of the eye muscles has been met with.

3. Diseases due to occupations involving exposure to excessive light or heat, or both, such as burnishers, steel melters, electric welders, etc.

Silver, either the metal or electro, when finished, has a very highly reflecting surface. The most important for our purpose of the processes by which silver goods have to be brought to the proper polish, is the finishing or burnishing. This is usually done by girls, who brighten the surface with a blunt tool. These girls are frequently the subjects of hyperæsthesia of the retina, by which they are often compelled to relinquish the work entirely. Coloured glasses and correction of refractive errors help in some cases. Those engaged in the process called “buffing” suffer in a similar manner.

Excessive heat associated with intensity of light is met with in iron and steel works in the different processes connected with the making of the iron, and the converting of it into steel. There is, I think, no definite evidence that men exposed to the heat and glare of the furnaces or from the molten metal suffer materially in their eyesight, though some assert that disease of the background of the eye is occasioned in some instances. The men are, in consequence of the heat, prone to sweat a great deal, and frequently wear little clothing above the waist. The temperatures before which they work are, to an outsider, something almost astounding, especially if he remembers that the temperature of an ordinary well-lighted fire in a grate is about 500° F. There would seem to be a very marked difference in the way a temperature is borne, when it is below 2000° F., and when above it. Up to that figure a man can look at the metal in a furnace with comparative ease, but before it gets to 3000° F. he is compelled to wear coloured glasses when doing so. A friend, at some large iron and steel works, gave me the following notes: “In dealing with cast iron, the heat of the metal would be about 1800° to 2000°, and the men employed take no precautions. The heat of the molten metal would be about 2700° to 2800°, while the heat of the gases in the furnace would be about 200° or 300° more. The furnacemen have to wear deep blue glasses to protect their eyes from the glare of the furnace. With this precaution we have not observed their eyes to suffer in any marked degree. The heat of Bessemer metal is about 3000° F. to 3200° F.; in this case there is not the same necessity as in the Siemens to watch the hot metal, consequently the men do not wear glasses. We do not observe any ill effects directly traceable to the heat. In the case of the Siemens men, I should say that without protection the eyes would suffer considerably. After looking at a Siemens’ furnace without glasses, it is several minutes before the eye can see ordinary things again.”

There is, moreover, a further difference between the two processes, viz., Bessemer and Siemens. The former has, as just mentioned, the higher temperature and the more dazzling glare, but the steel is melted and the process completed in about twenty minutes, and it is only necessary for one man to take close observations, and this he does by means of a spectroscope, and is as far as 30 feet from the molten metal. The Siemens process takes ten hours, and during this period the whole of those engaged will, as the door is frequently drawn up, be taking observations to see whether the melting is proceeding properly. This is constant and regular work, and they are obliged to use coloured glasses.

In addition, in these large works, are the castings, forgings, rolling of armour plates, and many other things. A huge forging, of perhaps 60 or 80 tons, is drawn out of a furnace with a temperature of from 2000° to 2500° F., and placed under a powerful hydraulic press of 10,000 tons power, where, with the men all around, it is hammered with as much apparent ease as putty is manipulated by one’s fingers.

The glare and dazzling in the Bessemer and Siemens processes must be seen to be realised. Generally speaking, in fact almost always, it would seem as if the men engaged in these various kinds of work could submit to exposure to the high temperatures and intense lights with impunity, if they will only use coloured glasses when employed with the higher temperatures and the more dazzlingly bright lights. Occasionally, however, one meets with men who appear incapable of continuing to bear these conditions. They feel their eyes painful, and it is some time after cessation of labour before the discomfort passes away. Such as these have sometimes to seek another occupation. On the other hand, the readiness with which, it may be after an accident to one eye, men will often return to their employment before the furnace or fire, is surprising.

Glassblowers are asserted to be frequently the subjects of cataract, and it has been sought to connect this tendency with the powerful heats to which their work exposes them, and also to the sweating which accompanies it. They work around open-mouthed furnaces and close to pots of molten glass, and are thus exposed to intense heat and light. I have, however, seen something of glass-blowers from time to time, and my experience, whilst it does not allow me to support this assertion of the frequency of cataract among these men, may be regarded as too limited to contradict the statements which other observers have made. Should extreme heat and consequent loss of moisture be regarded as sufficient causes for the production of cataract, then it should be found especially among iron and steel workers. My experience does not, however, show that this is the case.

Exposure to Electric Light.--Several instances have been recorded showing the serious effects on the eyes of those exposed to the glare of this powerful light. The following may be mentioned.[173] Two men were employed on an electric street railway. One man thrust a blade of a screwdriver into a motor cylinder and “immediately he was flashed by the powerful light and stunned by the powerful current.” When seen five hours after, the eyelids were closed and he was suffering intense pain, but he was able to resume his work next day. The second man struck a “live electrical circuit” with a steel file, and instantly there was a flash of light and he was rendered unconscious. The eyelashes were singed and the arms burnt, and there was great pain. It was not until the fifth day that he could return to work. A more severe case[174] is reported of a man engaged as engineer in the power-house of an electric car line. He was using a wrench to some machinery, when accidentally his elbow came into contact with another machine forming a short circuit. The whole electrical force--1000 ampères--used to propel the cars several miles, passed down the forearm and out at the elbow. The electrical discharge was succeeded by a loud report following an intense flash of light. The man was knocked down, but only lost consciousness for a few seconds. When seen an hour after, the skin of the arms, hands, face, and neck, in fact, of all exposed parts, was burnt; the effects were like those caused by boiling water; the eyelashes and eyebrows were burnt off. The ocular conjunctiva looked as if a strong solution of nitrate of silver had been applied to it, and the corneæ had the appearance of ground-glass, especially in the centres, so that the impression was given that they were both destroyed. It was, however, found that only the epithelial layers were affected. Ultimately sight was recovered, but photophobia remained for some time.

Of the many ways that the electric light is liable to be injurious may be mentioned that of electric welding. This process is one that is becoming very largely used in iron works, and it effects its purpose so rapidly that it is likely to find still further employment. I have met with many men who have suffered from exposure to the intense light emitted in electric welding. On several occasions the opportunity has been given me of witnessing the process. The heat produced is so intense that metal runs at once like solder. So rapidly, indeed, is this effected that, without seeing the process, it seems incredible. To protect the eyes from the intensity of the light, the onlookers use large shields with glass in the centre arranged in alternate layers of blue and red, there being four thicknesses. The man engaged in working the process in one factory with which I am acquainted, uses a helmet to protect his head and face. In the front of the helmet is a glass window made up of six layers, alternately red and blue. At another place the men stand behind a wooden screen about 4 ft. high, with a sliding top, in which is a glass window for the workman to observe the work upon which he is engaged. The sliding top can be raised or lowered according to the height of the man or the nature of the exact work to be done. The window is made up of four thicknesses of glass, two green and two blue, and there is a plain glass fixed in front of these, as it can be more easily replaced, this being required by the liability of the front glass to be spoilt by deposit on its surface. This arrangement protects the man much more than the helmet. The men’s trousers may be burnt by the metal splashing on them, and this screen gives more protection than the helmet would do. The top part of the screen is narrower than the bottom, to enable the men to get their arms freely round it so as to work on the metal in front, and the broad lower part forms a rest for their arms. Any parts of the body which are exposed to the light may get burnt, and many suffer severely in this way. If the eyes “catch” the light they feel the effects at once, but the worst generally does not come on until some hours afterwards, and most men will say that the most acute stage is during the night succeeding the exposure. The eyes feel swollen and as if filled with burning sand, and the pain is very severe. There is swelling of lids; so much so that they cannot be opened, and there is lachrymation. All night the pain will last, but the next day the worst will be over, and often by a day more the eyes will be quite right again.

Terrier and Malakoff have each published very interesting observations bearing on this subject, as has also Wildmark. The latter especially appears to have settled the point as to whether in these cases it is the heat or chemical rays that act so hurtfully. Taking advantage of the different actions of glass and crystal--the former absorbing chemical rays, the latter, or crystal, allowing them to pass--he showed that if a pencil of light before reaching the skin was made to pass through a disc of glass, in the centre of which was a hole filled with a small disc of crystal, the redness of the skin was observed only in the central area, a proof of its dependence on the chemical rays. Malakoff pointed out that though the light was so intensely dazzling the thermometer was only raised 2° C. at a metre distant, but it must be borne in mind, however, as a workman mentioned to me recently, that the metal acted upon during welding becomes very hot, so that standing close by is hardly possible.

Some idea, also, may be given of the heat involved in electric welding by the following data, supplied to me by an experienced electrical engineer. He stated that, at one works, the temperature during electric welding would measure about 3000° C. (7000° F.), and that it was not an unusual thing to measure 3000° C. in an electric furnace. In the absence of photometric measurements, he assumed the luminosity of the arc for electric welding would be about 8000 candle-power.

The action of the electric light upon the eye is to all appearances confined chiefly to the conjunctival or corneal surfaces. Very possibly, however, it occasions also a hyperæmia of the retina, and one case is on record of a boy who got a central scotoma from looking at an electric light placed in the roof, like those resulting from the action of direct sunlight.

With the prudent use of the protectors mentioned the light can be observed with little risk of injury.

4. _Injuries or accidents amongst grinders, iron and steel workers, masons, coal miners, weavers, etc._

It is difficult to obtain anything like accurate statistics as to the numbers blinded by accident. Magnus, in his tables, makes 8.5 per cent. of all cases of blindness as due to accident. In this calculation no count is made of those blind in one eye only, and the far larger number who have sustained permanent injury in varying degrees short of blindness; and even if such a computation were true for the community generally, the number must be greatly exceeded in large and populous centres, especially in those in which iron and steel are important industries.

A brief reference only to statistics is necessary. Mr Watson, the able Secretary of the Miners’ Permanent Benefit Fund, has given me the following figures as to the proportionate frequency of eye accidents among miners, to other accidents. In all these accidents the miners have been rendered unfitted from continuing their work, at least temporarily. The figures are for fifteen years arranged in periods of five years. The number of non-fatal accidents dealt with is 48,262.

+-------------+------------+-------------+------------+ | Period. | No. of | No. to Eye. | Percentage.| | | Accidents. | | | +-------------+------------+-------------+------------+ |1884 to 1888 | 16,870 | 857 | 5.08 | |1889 to 1893 | 12,768 | 670 | 5.24 | |1894 to 1898 | 18,624 | 979 | 5.25 | +-------------+------------+-------------+------------+ | Total | 48,262 | 2506 | 5.19 | +-------------+------------+-------------+------------+

The average yearly membership for each period was--1884 to 1888, 22,410; 1889 to 1893, 17,876; and 1894 to 1898, 23,005.

The Equalised Druids Society gives to those of its members who are permanently incapacitated from following their employment a grant of £100. The number of cases of all accidents in which this grant was made during the last five years was 57, and of that number it was given seven times owing to eye accidents.

My own infirmary figures also testify to the large number of eye accidents annually occurring in the district with which I am more particularly acquainted. Of the last 2554 patients who have passed through my wards at the Sheffield Royal Infirmary, 2038 were men, and 516 women. Of the 2038 men, 622 were admitted for accident, or 30.52 per cent. This percentage has kept fairly uniform, but at periods of great trade activity the ratio of accidents to other cases admitted has gone up. Of the 516 women, only 36, or 6.9 per cent., were for accidents. The important part occupation bears to the number of eye accidents is well illustrated by these statistics. The men not only exceeded the women very largely in actual numbers, but still more so by percentage, this latter being six times as great as for the women.

In many trades associated with iron and steel in all its varieties, small foreign bodies are very prone to become lodged in the workmen’s corneæ. I take, as an example, the grinders. In the course of the day a grinder may get several “motes,” as he calls them, fixed in his eye, or days may elapse without such a mishap. If the cornea of a grinder be examined carefully with a magnifying glass, it will not infrequently be found to be studded over with minute nebulæ. Although the damage done by each foreign body may often not be serious, yet frequent repetition, by dulling the cornea, will, in many cases, diminish the acuteness of vision. These particles may either be small fragments of stone, or, much more frequently, small portions of steel or emery, which latter is used as a wheel for glazing cutlery, and for other purposes. Of the two varieties of grinding, the dry grinders are more exposed to injury from foreign bodies than the wet grinders. A grinder sits across his bench, or “horse,” and presses the knife or razor blade on the stone. The wet prevents the particles from flying about a good deal, but still a man’s face becomes, as he works, bespattered; nevertheless, a wet grinder seldom gets motes in his eyes. In dry grinding the sparks fly freely, and it is evident that very minute particles of steel or stone are being projected about, and it is the merest chance whether they hit the man’s eye or face, or scatter about the room. The fans, which it is well known have for many years been required in the grinding trade in consequence of its deleterious effects upon the health of the operatives, must be regarded as in some measure a protection. It is interesting to observe the remarkable manner in which a fan draws into it the sparks and particles flying from the wheel. There can, moreover, be no question that the grinder derives considerable immunity from motes by the employment of protective glasses. Grinders admit the protection they afford. If further testimony be needed, it can be found in the condition of the glasses, after having been used for some time by a grinder: they are studded over with small dots occasioned by the impact of the motes.

In the great majority of instances the damage occasioned to the grinder or other operative in which similar mishaps occur is not attended with serious results. The immediate injury may, however, be serious, either directly or indirectly, by the ulceration that ensues. There is another way, also, in which injury results. A man once said to me, pointing to his damaged finger, “This would not have happened if something had not got into my eye, because I could not see my finger on the circular saw.” The operatives, in all the various trades in which iron and steel are used, are liable, though to a less degree than the grinders, to get these motes into their eyes.

In all the large works there are men who have a reputation for their skill in the removal of these motes. The instruments they use are of various kinds--for instance, a blunt lancet, blade of pocket knife, or a pin. Generally speaking, they are unsuitable. In many instances the motes are skilfully removed; in others, there is a good deal of bungling, and not infrequently cases come under observation in which sloughing corneal ulcers have resulted.

It seemed to me not unlikely that septic conditions were set up in consequence of the uncleanly instruments which were so often employed. Dr Shennan of Edinburgh kindly undertook a bacteriological examination of some of these instruments for me. I collected 22 tools used by different men, and Dr Shennan examined the majority of these. Taking all in all, he found nothing pathogenic excepting the staphylococcus pyogenes albus, whose virulence is comparatively slight. Of course there are many sources besides these tools by which a corneal wound may become septic. But good should result if a cleanly and suitable instrument could be made available to the men who remove motes. In some of the works a case, made at my suggestion, is provided, containing iridium-platinum blunt-pointed spuds, together with a small spirit lamp, with directions printed on the inside of the case, saying that before use the extremity of the spud should be sterilised by heating it in the flame of the spirit lamp, or if this be not accessible, in a gas or other flame which may be at hand.

By far the most serious eye accidents happen to men engaged in working iron or steel. The following figures exhibit this in a very lurid light:--

Steel and Iron.

Steel and iron splinters, rivet chips, pieces of drill, file, wire, etc. 173 Nail 5

Burns.

Metal sparks, flashes, etc. 43 Lime 8 Gas explosion 1 Ammonia 1 Gunpowder 4 Cinder 1 Poker 1

Miscellaneous.

Dynamite, and dynamite explosion and cartridge 6 Wood, sticks, and peggy 13 Hook 1 Knife 8 Glass, soda-water bottles, etc. 15 Pick 5 Stone 24 Fork 7 Pin 1 Fist 3 Branch of tree 1 Crane handle 1 Cork 2 Cinder 4 Coal 11 Straw 1 Cat’s claw 1 Sand 1 Ball 1 Pen 2 Firework 1 Boiling oil 1 Tin 2 Band strap 2 Band buckle 2 Chain 1 Kick 1 Brick 1 Thorn 2 Elastic, piece of 1 ---- Total 359 ====

Out of this total of 359 eye accidents to males, taken from the records for this purpose consecutively, which were so serious as to require admission to my wards at the Sheffield Royal Infirmary, no fewer than 173 were caused by iron or steel, pieces of rivet, of drill, wire, and many other means associated with the iron and steel trades. There were also 43 due to burns from molten metal, sparks, flashes, etc. I am not sure, also, whether to the former number should not be added 5 put down as caused by nails, as most, if not all of them, would have occurred to iron or steel workers.

The opportunities for the infliction of severe injuries to iron and steel workers are multitudinous. They occur in all branches of the trade, in the lighter iron and steel industries as well as in the heavy trades where armour plates and heavy castings of scores of tons are made. A very large proportion of the accidents are occasioned by what is called “chipping” and “fettling.” “Dressing” is the name given in some parts to this process. This work consists in chipping the rough edges from iron and steel castings, ingots, and all kinds of steel and iron work, and among other things, even the large armour plates.

Castings of either iron, steel, or brass are the most dangerous to work upon, because the chippings fly about on account of the metal being brittle. It is very dangerous chipping castings in the corners, or where the “chipping” strikes the metal and rebounds. Chippings from the castings are about ¼ inch to ¾ inch long, and very sharp. When chipping thin plates on the edges, the chippings are sometimes 1, 2, or 3 inches long before they break off. All castings are “fettled” at the foundry, that is, the runners are cut off, and the places where the metal has run at the joint of the moulding boxes are trimmed off.

Whatever be the special kind of metal or steel to be fettled, the manner in which it is done is practically the same. A hammer and chisel, or sate, are used, and with these the roughnesses are removed. Frequently, also, whilst one man places the chisel, another, or even two others, called “strikers,” will use a hammer. I understand that at works where say 1000 men are employed, 200 or more will be occupied more or less in “chipping.” Many men are frequently working close to each other, so that the danger is not only to the worker himself, but to those around. Passers-by are by no means infrequently the victims. The chipper himself is often hit by the rebound of the splinter after it has struck some other object. It must be recollected, also, that in the process spoken of, the danger is not merely from the iron or steel which is being operated upon; there are three other places from which splinters may be given off and cause injury, namely, the hammer head, the chisel head, and the chisel point.

It is obvious that men engaged in work which causes the splinters to fly about so freely, should be so placed as not to be chipping against their fellow-workmen, or in a direction from which passers-by may approach. This is managed in some works by getting the men to chip against a wall, though not too close to it, or, again, by interposing a canvas screen between sets of workmen.

The sizes of the splinters spoken of vary from the most minute to others measuring some inches in length, and they may be thick or thin. The injury inflicted differs, of course, in accordance with the size of the missile and the force with which it is projected. The small fragments may be thrown off with such velocity that they penetrate the eyeball and become embedded in its interior, in some instances passing through the eyelid before reaching the globe. The destruction to sight in this way is very large. I have myself removed from the globe, with my electro-magnet, more than two hundred fragments of steel and iron. One was no heavier than 0.0015 gr.; several were as light as 0.0030 gr. and 0.0046 gr. The largest weighed 36 grs., and there were two others 12 and 9 grs. respectively. It would be out of place to refer here to the results of the extraction of this number of foreign bodies with the electro-magnet. It will suffice to say, that many eyes have been saved by its employment which otherwise would have been hopelessly lost. The injury to the eyeball occasioned by the large chippings may be so extensive that the eye is at once irreparably damaged, or so injured that removal of the globe will subsequently be necessitated.

The dangers of chipping may be minimised by adopting a pneumatic chipper. In some works, for chipping ingots I have seen one at work on a large casting. It has the advantage of accomplishing in one hour what, by hand, would take six or seven hours. It certainly prevented the flying about of splinters in a remarkable manner. They merely curled up and rolled over. It more resembled using a cheese-scoop in a fairly soft cheese than running any tool over hard steel. Up to the present these pneumatic tools have not been successful for “chipping” the rough edges from steel castings.

Another class of severe injuries which are of common occurrence are burns from molten metal. Sparks and flashes fly about freely in almost every instance that molten metal is run into the moulds, but on some occasions, of course, more so than in others, and the portions given off vary much also in size. Injuries caused in this manner were no fewer than 43 out of the 359 consecutive accidents in males admitted into the Sheffield Royal Infirmary. In the forgings, also, great or small, when the iron or steel is being hammered either by hand, or, in the case of larger castings, by a steam or hydraulic hammer, portions are given off from the glowing metal, and those working and the bystanders are exposed to danger of burns.

The knowledge which I have acquired from contact with working men who have been injured, and from periodical visits to the principal works, has long since satisfied me that much of the destructive injury to sight is preventable, and that means should be adopted to lessen the risks to sight which are at present associated with important industries. There is less difficulty in enlisting the support of the employers than in gaining the assent of the men to the adoption of precautionary measures. I know of one firm who make it compulsory on men engaged in “chipping,” “fettling,” “turning,” and other work in which iron and steel splinters are liable to fly off and endanger sight, to wear protectors, which are provided at the expense of the firm. This decision was taken in consequence of a workman being blinded by a chipping.

In considering what kind of protectors men should use, it must be borne in mind that the cost must be very moderate, and that sight should be interfered with as little as possible, if at all. Among iron-workers, glass is practically out of the question. Even thick rock crystal, which has been suggested for some kinds of work, in consequence of its thickness and peculiar manner of fracture, would hardly do. Gauze wire, fitting close to the eye like a cup and attached to the head by a string, is employed by stonebreakers and in some ironworks. Complaint is made of such protectors as being hot and interfering with sight, but there is no question that they afford considerable immunity from accident. Another practical point about protectors is that they should not be liable to rust. For this reason galvanised iron wire, or better, aluminium wire, is of service. The mesh should be sufficiently strong and fine, and sufficiently close to prevent, as far as possible, even small chippings passing through it, and yet to interfere with sight as little as need be. I have had experiments made by allowing men engaged in fettling to “chip” against wire gauze which has been suspended for the purpose, to ascertain how far a mesh answered before deciding to adopt a given size. I have had this netting made[175] into protectors which cover the eyes and adjacent parts. The portion over each eye is bulged forward so as to allow very free play to the eye underneath; the convex surface is a greater protection than one merely flat would be. I have supplied workmen with these protectors, who have used them when chipping, steel melting, and in other dangerous iron and steel work. I learn that they are regarded as satisfactory, that they answer their purpose well as protectors, and that the interference with sight is very little.[176]

I would sum up my suggestions as to the means for protection as follows:--

1. The grinder will find that large glasses made of plain glass, or, indeed, his own spectacles, should his refraction require their use, will afford great protection. Or he may use other protectors, made with glass in front, and gauze surrounding it.

2. The use of protectors should be compulsory for those workers in iron or steel whose employment renders them liable to be injured by iron or steel splinters, or who are exposed to danger from molten metal.

The gauze eye-shield I have described will, I believe, answer the purpose well. The cost is low, and it is worth the employers’ while to supply their men with them.

Other means to be adopted are:--

(a) The use of a pneumatic chipper whenever practicable; (b) the proper arranging of the men at their work; and (c) the use of screens, so as to avoid injury to their fellow-workmen and to passers-by.

It is my belief that a consideration of the facts here advanced will lead to the conviction I have myself long held--that very many eye accidents associated with trades are preventable, and to the view that preventive means should be adopted.

In addition to the classes of workmen more particularly alluded to in the foregoing remarks on eye accidents and their prevention, the following occupations may be briefly touched upon.

Coal miners are prone to be injured by portions of coal striking the eye, and either becoming embedded in the cornea (like the grinders’ motes) or causing abrasion of the surface, or wounds of the eyeball. Eye injuries in the miner appear to be more than usually prone to become septic. Injury may also be occasioned by splinters flying from the pick point, and either sticking in the cornea or penetrating and becoming lodged in the eyeball, in a similar manner to that which happens in “chippers.”

Agriculturists are liable to eye accidents in many ways. In “hedging” injury is often caused by the eye being struck by branches or twigs of bushes, or a thorn may wound the surface or penetrate and remain lodged in the interior of the globe. In threshing and chaff-cutting, among other processes, the lodgment of foreign bodies under the eyelids may occur, or abrasion of the surface of the eye be effected. A special form of ophthalmia has been described as occurring among hop pickers. It is characterised by muco-purulent discharge and swelling of the lids. Dr Percy Adams, who has described this affection, considers it is caused by the introduction into the conjunctival sac, or into the cornea, of the small, thorn-like, hairy processes which are found on the hop leaves, bracts, and bines.

It may be generally stated that all engaged in dusty occupations are prone to have their eyes irritated or to suffer from conjunctivitis. This is the case, for instance, in a very dusty coal mine, a dust-laden flour mill, etc.

All workers with stone are liable to eye injury from portions of stone flying off and striking the eye, as they are also from splinters coming from the chisel or hammer. Stonecutters are very liable to have motes in their eyes, and more rarely the injury is much more serious. Stone-masons, masons, bricklayers, and stonebreakers come under this class. Protectors are sometimes used by stonebreakers at their work. Stone “cutting” or “dressing” in the streets is often a source of danger to the passers-by as well as to the workers themselves. Such work should be so arranged that the cutting or dressing is directed against a hoarding or wall.

In the preparation of grindstones there is considerable danger to sight. “Millstone building,” in which buhrstone is used, is only a small and decaying industry. Buhrstone comes from France in blocks, which have to be chiselled into wedges to form sections of the circular millstone, which are joined by cement and bound round with hoops of iron. Pieces of stone or tool are liable, during the process of chiselling, to fly about and endanger eyesight.[177]

The workers in quarries are exposed to dangers to eyesight like the cutters and dressers of stone, but the fragments will frequently be larger. Another danger is added, viz., that of blasting. The gravity of the injury inflicted varies considerably. In some, powder grains are studded about the face and eyelids and embedded in the front of the eyeball, occasioning serious danger to sight. In others, the injury may be so severe that sight is irrecoverably lost. It is unfortunate, also, that not infrequently in these serious accidents both eyes are implicated. The same dangers apply to all kinds of work in which explosives are used for blasting purposes, whether above or under ground, as, for instance, in the latter, coal and ironstone mining.

There are only a few parts of the country where ganister is obtained. The largest works of the sort are situated at Deepcar, near Sheffield. The effect of the fine powder produced in the processes required for making the bricks is recognised as hurtful to the lungs of the employés engaged. Besides this, however, the extreme hardness of ganister necessitates blasting, and this is mostly done by dynamite. Two men, within a short time of each other, came under my observation, who had been blinded from this blasting. This occurrence induced me to pay a visit to the ganister works. I found ganister was obtained by quarrying and also underground, where it is found lying underneath a seam of coal. In “scrapping” or breaking the ganister into smaller pieces there is a danger of pieces striking the face or eye, a greater risk probably than in ordinary stone-breaking. The ganister is afterwards broken, in a machine, into small portions. Fragments not infrequently fly off, and might cause injury. From this machine the ganister goes to another, where it is ground quite small and churned up into a thick pea-soup consistence, whence it is taken and placed where the bricks are made, and afterwards burnt in a kiln heated to 2000° F. The dangers attending the working of ganister are not so great as to call for special notice, and, moreover, the industry is a small one.

Burns caused by lime must be mentioned. All workers with lime and mortar are exposed to this danger from these substances getting into their eyes, resulting sometimes in destruction of the cornea and adhesions of the eyelids to the globe. Masons, plasterers, and bricklayers belong to this class. Besides the actual burning, the irritating qualities of lime and cement may occasion conjunctivitis, with ulceration of cornea, and endanger sight.

In wire-drawing, not infrequently the breaking of the wire is a cause of eye accident. The wire is put on a reel, and passed through the plate, and wound round the wire-drawing block. During this process, the tension is, of necessity, very great, but of course depends on the size of the wire. Generally speaking, it is three-fourths of the breaking strain of the wire. If the wire breaks on this block, the “back-lash” may strike a man on the face or head, and then also the last end of the piece might slip and strike a man. The wire is not likely to break until it has passed through the wire-plate or “wortle.”

In the weaving shops one peculiar danger to which persons working are subject is the liability to be struck in the face, or, more especially, in the eye by flying shuttles. This risk has been known and appreciated for many years. The matter formed the subject of a report ordered by the House of Commons in April 1891.

Since then, greater attention has been paid to the provision of guards to prevent accidents. There are many patterns of guards on the market. In principle they are of two classes: 1st, what are known as wing guards, that is, a wire screen of fine mesh canvas placed between the looms. In this case should the shuttle fly, it would be caught by the wing, and thus danger to the weaver at the adjacent loom is obviated. The other system is to provide a rod on the traversing beam which is always over the beam of the shuttle. Should there be a tendency for the shuttle to rise, this would prevent it. With most guards of this description it is practically impossible for any shuttle to fly, but in less efficient ones the shuttle may escape. If it does so, however, it will always be at a low angle, and instead of striking the worker at the adjoining loom or any passer-by in the face or dangerous part, it will simply strike the clothing, and little or no serious result need be anticipated. Since the adoption of these guards the percentage of accidents has been very appreciably reduced.

In a recent case of serious eye injury to a young girl, it was ascertained that the guard for some reason or other had been left off, and the shuttle had flown up and struck her. The liability to accident among these operatives is shown by the statement of this girl, that she had been struck once before on the eyebrow, and at least twenty times on other parts of the body. All the girls working with her had also been struck several times. She had, however, in five years only known of one serious eye injury similar to her own.

In the manufacture of aerated waters there is danger to eyesight from the bursting of the bottles. The industry is carried on extensively in most of the larger towns. Usually the bottles or syphons are filled by machinery, and, in a similar manner, the cork is inserted, or some other method is adopted for sealing the bottles, whether it be a glass ball or screw stopper. If “wiring” is needed, it is then done and the label attached. In addition the bottles are “sighted,” or held up to the light, to see that they leave the factory clean. Another process consists in cleaning the returned empties. In all these processes, but especially so in “bottling,” there is danger of the bottles bursting, and inflicting serious injury to the eye, or cuts on the face or body from the fragments of broken glass. To obviate these dangers the use of faceguards or eye protectors is absolutely necessary, and all machines used for bottling or corking should be fenced round. The manufacture of aerated waters was reported on by the Dangerous Trades Committee (1896),[178] who recommended that all bottlers, wirers, sighters, and labellers, whilst at work, should be provided with faceguards, masks, or veils of wire-gauze. They also recommended the providing of gauntlets for the arms. They further advised the fencing of all machines for bottling, to avoid the possibility of fragments of a bursting bottle striking any worker.

Bursting of Water-Gauges on Boilers.--Many cases of serious eye injury have come under my notice from the breaking of water-gauges. The liability to danger exists in every description of steam boiler, and breakages frequently occur. Injury may be occasioned by fragments of glass or from scalding, owing to the escape of boiling water and steam. Protection of some sort is necessary. Encasing the gauge in wire netting would suffice to prevent injury from fragments of glass, but it would still allow of the escape of steam and water. Another method is to surround the gauge with a metal casing, in front of which is inserted a window of plate glass to permit of the gauge being visible. A man of considerable experience suggested to me that this metal casing should be left open at the back, so that, in the event of the water-gauge glass breaking, the force of the explosion would be sent backwards. Too frequently no safeguard has been provided, but men occasionally devise means of protection themselves.

SIMEON SNELL.

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LIX. MISCELLANEOUS TRADES

Silicate of Cotton.

The name silicate of cotton is misleading, for the manufacture of this substance has nothing whatever to do with cotton. It is a fleecy, white substance, hence the name. The danger in its manufacture is not from dust but from fluff of a metallic nature. Silicate of cotton is made from the refuse basic slag of ironworks. It is manufactured in Middlesborough, Redcar, Skinningrove, Hazlehead, etc. It is a small industry, and gives employment to very few people. The process of manufacture is simple. It consists in allowing a small, thin stream of molten slag to flow in a special direction, so that at a particular spot the stream is met by a strong blast of steam blown through a narrow pipe. Very minute particles of slag are thus formed, which are driven with great velocity into a collecting chamber in which no person could stand at the time. The small particles of slag are extremely viscous, and as they are blown through the air with very great velocity and meet resistance they become drawn out into very fine filaments like cotton wool, and fall to the ground as a loose, spongy material, not unlike snow or very fine spun glass. The material is then known as silicate of cotton, or slag wool. It contains the ordinary constituents of slag, viz., silica, lime, alumina, with a small percentage of iron and magnesia, etc. As it is a non-inflammable material and a non-conductor of heat, it is used for packing the pipes that come away from steam boilers, and for laying between floors to deaden sound, etc.

The danger to the health of the workmen lies in the inhalation of the fine filaments of slag wool, for they are extremely light, and this occurs mostly during the act of packing the silicate into bags. At this time the filaments are apt to get on to the skin and to adhere to the clothing, particularly where it meets the skin. On account of their sharp needle-like form they cause considerable irritation and induce an itchiness of the skin which is extremely trying, for it endures by night as well as by day, robbing the individual of his sleep, and as he is likely to scratch himself, the inflammation of the skin leads to eczema. Beyond this itchiness or pruritus, the Dangerous Trades Committee, whose description of the process of manufacture I have largely reproduced, did not find anything in the trade that could be considered prejudicial to health. The industry had been previously inspected by Mr Edward Gould, now Deputy Chief Inspector of Factories, but he did not observe anything in the occupation to cause it to be regarded as really dangerous. Yet it is scarcely an industry for growing lads to be sent to, as they seem to suffer more than men, probably on account of being more impatient under the influence of pruritus, and being less able to bear the effects of loss of sleep from it. The working shifts ought to be short, and the men when engaged in packing the slag wool ought to wear a veil or respirator. As it is desirable to cover the ears, nose, and eyes, a loose gauze or muslin veil is preferable. The men ought not to enter the chamber into which the slag wool has been blown until the atmosphere has become clear, through the settling down of the fleecy filaments.

Upholsterers’ Occupation.

As the work of the upholsterer is largely concerned with the manipulation of feather, flock, hair, etc., the subject is indirectly dealt with under Shoddy and Rags. The dust is provocative of respiratory troubles. If the rags, feathers, and hair have not been previously cleaned, the dust not only causes bronchial irritation, but may be the means, owing to morbific germs adherent to these products, of causing infectious diseases such as smallpox and erysipelas, and such intestinal derangements as vomiting and diarrhœa.

The manufacture of mattresses is an unhealthy occupation, for the dust that escapes from wool and horsehair during the operation of carding often causes cough, difficulty of breathing, and retching, and if these have not been previously sterilised, the dust may cause blood-poisoning. Ramazini alludes to the ill-health of the Jews in Italy who undertook this work, and to the fact that they became emaciated.

Mattresses that have been lain upon by persons who have died of infectious diseases occasionally find their way into third-rate upholsterers’ shops, where their contents are picked and mattresses are re-made. It is very dusty work when the picking is done by hand, and besides, there escapes an unpleasant, sickening odour which causes headache and a feeling of malaise. When mattresses have become fouled in places by discharges from patients suffering from infectious diseases, considerable risk is incurred by those who by hand teaze the contents of such bespoiled bedding.

A short while ago a Commission in France dealt with the subject of the cleansing of bedding. It reported that used mattresses often harboured the germs of smallpox, scarlet fever, measles, diphtheria, and typhoid fever. Before any old mattress is picked, it ought to be exposed to a very high and dry temperature, say 100° C. or 212° F. Woollen and other flock materials should be previously exposed to superheated steam and afterwards to sulphurous acid vapour, which can be got from burning sulphur. In ordinary medical practice, particularly in large towns, many of the municipal authorities not only provide the means for sterilising, but require that the bedding that has been used in infectious cases shall be disinfected. It is desirable in the interests of the public that the Sanitary Authorities should also offer facilities to furniture dealers for the disinfection of second-hand mattresses, and that upholsterers who re-make these mattresses should not be allowed to have their contents picked by hand until they have been dry stoved. Cardage by machinery is fortunately replacing hand-picking, but in places where hand-picking is still carried on the workers should wear respirators, and the ventilation so arranged whereby the dust may be carried away from them.

From feathers dust of a suffocating character is also given off. Sometimes it induces ophthalmia, also diseases of the bronchial tubes and lungs, but as feathers can be very readily disinfected by means of steam, and the industry is a small one and offers work only at irregular intervals, the number of people who actually suffer in health from feather dust is not large.

Joiners and Carpenters: Workers in Sequoia Wood.

The occupation of joiners and carpenters is on the whole healthy. Beyond a greater amount of exertion required in some branches of the trade than in others, and greater exposure to the weather, the industry calls for very little consideration here. The removal of timber in dockyards is heavy work, but it is undertaken by labourers. A few years ago, when sawpits were more in use than now, the act of sawing imposed a considerable strain upon the men, and as the sawpits were often out of doors or at the best very imperfectly covered, the sawyers often suffered from rheumatic affections, bronchitis, and asthma. Thirty years ago, before machinery had so generally supplanted hand-sawing, sawyers occasionally came to the Newcastle Infirmary suffering from disease of the aortic valves, and presenting such other signs of cardio-vascular degeneration as are found in men whose work is hard, and who have been exposed to all kinds of weather. Beyond the large but diminishing number of surgical accidents caused by the circular saw, the use of this implement, especially when acting upon soft wood, cannot be regarded as the cause of ill-health to men employed in the joiner’s shop.

Carpenters are said to suffer from contracted tendons of the hand, owing to the protracted use of the chisel, and in men who plane much the hands become enlarged. As these workmen stand on their feet all day they run the risk of suffering from hernia and varicocele, but I am not disposed to admit that their liability to these affections is very much greater than in men in other trades, nor have I noticed to any extent, in turners, the depression of the left shoulder, the bulging of the shoulder-blade, and protrusion of the left hip, through the individual throwing the weight of his body upon the left leg when at work, to which some authors allude as of common occurrence.

Sequoia Wood.--A short while ago my attention was directed by Sir James Russell of Edinburgh to a series of symptoms said to be experienced by joiners when working with sequoia wood. To Councillor Telfer of the same city I am indebted for a short account of the supposed effect of the sawdust on those who saw and chip the wood, also for samples of the sawdust. The symptoms produced resemble those of a bad cold in the head and chest. There is a running at the nose, with frequent fits of sneezing, irritation in the throat and chest, followed by coughing, laboured breathing and quickened pulse, and later on by a sense of oppression at the pit of the stomach and a smarting sensation in the eyes. The symptoms usually last for only twenty-four hours, and are especially pronounced in men working for the first time with the wood. By next morning the unpleasant symptoms just described have, as a rule, disappeared. A kind of tolerance comes in time to be established, although in the case of men who are the subjects of asthma and throat affections, their experience is painful and the effects enduring. I am informed that if a splinter of the wood penetrates the skin to any depth the wound almost invariably suppurates. The sequoia tree is a conifer, and is found in California. It requires a good deal of moisture, grows well in fog, which is said to be essential to its life, for on passing through the fog belt into clearer air no sequoia trees are to be found. It is a wood not unlike mahogany in appearance, and is used for house panelling. Dr R. A. Bolam and myself have examined sequoia sawdust both chemically and microscopically without finding in it anything definite to explain the symptoms attributed to working with the wood. It can be kept mixed with water without giving an acid reaction. I covered the floor of a rabbit’s hutch with sequoia sawdust instead of ordinary sawdust, but the rabbit confined in the cage, although thus exposed to it for several weeks, took no harm. Rats, on the other hand, seemed susceptible to sequoia sawdust; they suffered in a few instances from running at the nose. That the dust of some kinds of wood are more irritating than others has long been known. Rosewood, for example, has had a bad reputation in this respect. The presence of a large amount of inorganic matter in wood causes the sawdust to be much more irritating than that obtained from wood in which such inorganic matter is, comparatively speaking, absent.

Manufacture of Celluloid.

In the manufacture of celluloid two risks are incurred: (1) fire, and (2) inhalation of harmful vapours.

Celluloid is a complex product formed from pyroxiline, camphor, and alcohol. It was invented by an American named Hyatt in 1869. When rolled and compressed after having been very gently heated, it forms a hard, elastic, transparent substance, capable of taking a beautiful polish, and as various pigments can be added to it, celluloid can be made to resemble coral, ivory, ebony, malachite, etc. Heat quickly softens it. If brought into contact with a naked light it is readily ignited, producing a smoky flame and a disagreeable camphor-like odour. Several explosions and burns have been known to occur when hairdressers have been using celluloid combs in close proximity to a naked light. Celluloid is used for making billiard balls, knife and umbrella handles, combs, frames for eyeglasses, also washable imitations of linen,--for example, American cuffs and collars, etc.[179]

One of the principal dangers in regard to using celluloid is fire. No naked lights, therefore, should be allowed near at hand, nor should there be any open hearths where celluloid is being manufactured or stored. Should celluloid by any chance become ignited, sand and water will extinguish the fire.

There are also dangers incidental to its manufacture. Pyroxiline is prepared from vegetable cellulose by treating it with nitric and sulphuric acids. Apart from the burning accidentally caused by these acids, the workpeople breathe while in the factory an atmosphere charged with nitrous vapour, which causes cough, a feeling of suffocation followed at times by bloody expectoration and signs of pulmonary congestion. No mixing and pounding of the celluloid should be done in open tubs, but in hooded receptacles, so that the irritating fumes are carried away from the workmen. Gloves ought to be worn. No young person should be employed in the industry.

Tobacco and Cigar Manufacture.

Medical opinion is divided as to whether the manufacture of tobacco and cigars really exercises any injurious influence upon the workers. As far back as 1846 this subject was carefully investigated by Dr Melier at the request of the Academy of Medicine of Paris. In the manufacture of tobacco for smoking it is generally conceded that during the chopping up of the leaves and their subsequent exposure to a high temperature in shallow vessels, certain fumes are given off that are obnoxious to the workmen engaged in this operation, also that during the grinding of snuff irritating gases and dust are evolved. Apart from these, however, the industry is on the whole a healthy one. Some people have an idiosyncrasy which causes them to be easily affected by tobacco. New hands on entering a tobacco factory for the first time often experience a good deal of nausea, headache, and giddiness, and they sometimes too have a sense of faintness, but by degrees they become accustomed to the odours. At the Newcastle Dispensary I am occasionally consulted by female tobacco-spinners on account of persistent headache, nausea, dislike to food, anæmia, and muscular feebleness. I have never observed the transient loss of sight nor the pharyngeal catarrh alluded to by some writers. Melier held the opinion that working in tobacco arrested tuberculous disease, but this is simply an opinion, and is uncorroborated by the experience of others. Poisson and Eulenburg take the opposite view, and maintain that tuberculosis is a very frequent disease indeed in tobacco workers, especially in females. In the lungs of tobacco-workers, both at home and abroad, there have been found pigmentation and patches of brown induration. Similar lesions have been observed in the lungs of animals experimentally exposed to tobacco dust; but at the best these changes in the human subject must be regarded as of extremely rare occurrence, and are more than likely due to the inhalation of vegetable and mineral dusts which dry tobacco often contains. Given a healthy man or woman, and a well-ventilated factory provided with the proper means for removing dust and foul air, there is nothing in the manufacture of tobacco or in the making of cigars to cause the occupation to be regarded as one very prejudicial to health. Anæmic girls and those with an idiosyncrasy to tobacco are not good subjects. As to the work causing excessive menstruation and producing sterility, confirmation is required; and the same remark applies to the supposed frequency with which pregnant tobacco-workers and cigar-makers are said to miscarry. In Poisons Industriels, p. 201, it is stated that the midwives who attend the female tobacco-workers of the Rue Jean-Nicot in Paris often remark upon the readiness with which pregnant cigar and cigarette makers abort, and that the only way by which it is possible for a pregnant tobacco-worker to carry her child to term is to give up her employment for the time being. It is also stated that the infants are either born dead or die soon after birth. Out of 100 pregnancies in female cigar-makers, Dr Jacquemart observed 45 miscarriages. Personally I do not attach much importance to these statements, nor to that regarding infants suckled at the breast, who are said to suffer from colic after a meal, and to die from inanition. In Madrid infants are taken at certain hours of the day to the large cigar factories to be suckled by their mothers. While I am far from countenancing the practice, I must admit that, having examined as many as 30 and 40 infants being thus fed at a time, the children looked plump and healthy; so, too, did the mothers. Tobacco is not an emmenagogue. Its abortifacient properties, it seems to me, have been exaggerated; and in this I am supported by Poincaré, and also by Ygonin, who found in 750 female cigar-makers that miscarriages were by no means more frequent than in women engaged in other occupations.

The subject of amblyopia or loss of vision in tobacco-workers is dealt with in another part of this book by Mr Simeon Snell.[180]

An interesting contribution to the subject of the manufacture of cigars, from the social and hygienic standpoint, appears in the Economic Journal, December 1900, from the pen of Miss Grace Oakeshott. It is the result of an inquiry undertaken by the Women’s Industrial Council. Smokers need hardly be reminded that two kinds of cigars are made, the machine or moulded, and the handmade cigar, nor is it necessary to do more than mention the superiority of the latter over the former. A woman requires rather a long apprenticeship, nearly five years, before she becomes an adept in making handmade cigars. Miss Oakeshott had several opportunities of coming into close contact with female cigar-makers, from whom she learned that they themselves believe there is nothing in the work that is unhealthy nor in any way trying to an ordinarily healthy woman. The occupation is decidedly sedentary, and it is more than probable that the women sit too long. As to a supposed protection to the workers from epidemic disease afforded by tobacco, I am not in a position either to support or contradict the statement. I doubt it. In 1862 a Parliamentary Report was published on the tobacco manufactories of Lancashire. It dealt especially with the female workers in Liverpool. The medical men gave it as their opinion in the report that tobacco had no permanent effect upon the health of the workers, and that “though at first the women were attacked by sickness and faintness due to the smell of tobacco and to insufficient ventilation, they soon grew accustomed to this, and that, moreover, at the time of a cholera epidemic the cigar-makers in the town were free from the disease altogether.”

Women, taken all in all, are slower cigar-makers than men. Men will make from 800 to 1270 cigars in a week, and women from 400 to 800, and yet it occasionally happens that a woman who is an exceptionally quick worker will beat the best male worker. The cigar trade is one that requires deftness and skill in manipulation, and as both of these are possessed by women’s fingers, the occupation is one particularly suited for women. The work is neither hard nor laborious; it is quiet, and on the whole it is well paid.

Engine-Drivers and Railway Employés.

What strikes one most in dealing with the subject of workmen employed on railways is the large number of accidents that befall them. It is a general opinion that engine-drivers are a healthy class of men. The records of their Insurance Societies show this, and medical experience confirms it. The wages that drivers receive enable them to buy good food. As they have few opportunities of getting much physical exercise, several of the men become rather obese. My own professional knowledge of engine-drivers is limited. Most of those whom I have had medically to deal with have suffered from acute inflammatory affections of the chest, or from dyspeptic troubles due to their long and irregular hours, their long journeys, and lengthened absence from home. These irregularities oblige drivers and firemen to take with them on the engine food already cooked, and often to eat it when they can. Their duties are of an anxious nature, and are accompanied by a considerable amount of nerve tension, which may cause them to break down in health. Dr Alexander Scott, of Glasgow, at the meeting of the British Medical Association at Cheltenham, August 1901, expressed the opinion that most of the accidents on the line are the result of nervous tension on the part of railway servants. He cited instances of signal-men becoming paralysed through fear, and of experienced engine-drivers losing their head and suffering from temporary mental aberration. Nervous tension causes headache, weariness of brain, and sleeplessness. Whether it is in consequence of this nerve strain that engine-drivers as a class suffer more frequently from diabetes than men engaged in other occupations, I am not prepared to say. Dr Atkinson, of Crewe, states that engine-men are usually long lived, but that they are subject to bronchitis in winter, while their common complaints are indigestion, varicocele, and varicose veins, the latter in consequence of their prolonged standing. Out of 4000 men employed at Crewe, not more than 6 die annually from phthisis.

Through the kindness of Dr Atkinson, of Crewe, I have been furnished with the Annual Reports of the London and North-Western Railway Insurance Society for Drivers and Firemen for the last six years. The average number of men in the society has been 10,817. The average annual number of deaths during these six years has been 91, and the average annual number of deaths from accidents 9.6; that is to say, one-tenth of the deaths is due to accidents received when at work. On looking over the causes of death, it is noticed that the largest number of men die from old age, and that pneumonia, heart and kidney diseases, also the combined influence of these two latter, carry off by far the next largest proportion. I am struck, however, by the number of deaths from diabetes. They vary from one to four per annum; no age period is spared, but the maximum rate of mortality is above fifty years of age. More of the men die from pneumonia than phthisis, probably in consequence of exposure. Dr Atkinson concludes a letter by remarking that drivers and firemen “are very long lived and healthy, and fewer of them suffer from hernia than the public generally.”

Stokers are said to suffer from pulmonary anthracosis, a form of consumption like coal-miners’ phthisis, but I am doubtful of the prevalency of this ailment among stokers, just as I am of their becoming deaf owing to the soundings of the whistle. Men employed in the sheds cleaning the engines with soda and potash often become thin and anæmic, but if they are given outside work they rapidly regain the appearance of health.

Labourers on the railway employed to look after the transport of living cattle, or who have to handle the carcases of dead beasts, skins, and hides, run the risk of contracting blood-poisoning. As the identity of human and bovine tuberculosis has recently been disputed by Koch, the following fact is of considerable importance. Two labourers employed on an American railway to clean and repair cars used for transporting cattle, suffered from local tuberculosis of the skin, following a slight injury to the hand caused by a splint of wood. One of the men died a year afterwards from tuberculous disease of the lungs. There is every reason, therefore, why infected cattle and carcases should not be allowed to be carried by rail. In our own country we know how often anthrax has been traced to the importation of diseased hides and infected hair (see “Anthrax”). While people may thus become infected, not only on the railways but in the factories, it is absolutely necessary that diseased cattle should not be allowed to travel either by road or rail. In the event of infected animals having been conveyed by rail, complete disinfection of the waggons is an absolute necessity. This is sometimes done by washing out the interior of the waggons and brushing them with quicklime. Superheated steam is by many believed to be better than antiseptic solutions, for if these are to be of any service they must be used strong. Pasteur taught that all disease-causing germs were destroyed at a temperature of 110° C., or 233° F., and that moist heat is superior to dry. A few minutes’ exposure to superheated steam kills even the most resistant microbes, so that where vehicles have been employed in the transport of infected cattle, patients suffering from enteric fever, and in warfare of soldiers with discharging wounds, disinfection should be resorted to immediately after discharge of the cargo.

(For further remarks on disinfection, see article “Anthrax,” p. 642).

Drivers of Public Vehicles.

Drivers of public vehicles suffer and become prematurely old in consequence of their exposure to inclement weather, late hours, and irregularity in getting their meals. Alcoholism and exposure to cold are responsible for their tendency to develop gout and rheumatism, and through these disorders to secondary affections of the kidneys, heart, and respiratory organs. They die at the rate of 1482 to 1000 of the male population generally.

Cooks.

The average age at death of cooks is fifty-four years. Heat affects cooks differently; some become extremely stout and unhealthy looking, while others, in consequence of the heat, working in cellar kitchens by artificial light, and deprived of the fresh air, become pale, suffer from headache, lose their appetite, and have occasional bleedings at the nose. Many of them suffer, too, from varicose veins, owing to standing so long on their feet. Others suffer from eczema of the hands. Subterranean kitchens are bad from a hygienic point of view. Every kitchen should be well ventilated and have good daylight. The introduction of gas stoves into kitchens has not improved matters. They are very convenient, but ventilation is interfered with, and the atmosphere is liable to be contaminated when the gas stoves are not provided with adequate means for carrying off the products of combustion. Often, too, the indiarubber tube that carries the gas emits an unpleasant odour. The tube may become cracked, allowing coal-gas to escape, and as arsenic has been found in some indiarubber tubes, this substance may enter into combination with the gases that are of themselves harmful, and thus further help to undermine the health of those working in the kitchen.

Confection Makers.

Confection makers suffer from caries of the teeth, and from ophthalmia and headache, and from the effects of great heat.

Domestic Servants and Housemaids, etc.

Domestic servants in well-to-do and upper middle-class families are not unhealthy. They are well fed, but either do not get or take as much open air exercise as they ought. It is in the maid-of-all-work, and in servants employed in the smaller houses where there are large families, and in lodging-houses, that we find the worst indications of the effects of domestic service. The sleeping accommodation for servants, even in large houses, is not always as good as it should be. Their rooms, which are at the top of the house, are small, badly lit, often without a fireplace, and therefore badly ventilated. Their hours of toil are long, and the demands made upon domestic servants are numerous, often exacting, and frequently protracted well on into the evening. Small wonder that, owing to their deprivation of fresh air, the monotony of their work in many instances, the conflict of tempers, and the imperfect food obtainable in poorer families and lodging-houses, many young women break down in health, become anæmic, suffer from headache and derangement of the digestive and pelvic organs. There is one illness domestic servants seem to be very prone to, and that is ulcer of the stomach. It used to be stated in medical text-books that cooks were more liable than any other class of female servants to ulcer of the stomach, a circumstance that was attributed to their frequently tasting very hot foods. My own experience at the Newcastle Infirmary is that housemaids suffer in at least as large a proportion as cooks do from ulcer of the stomach, but why I cannot say, unless it be that as a class they are more anæmic, and anæmia is a predisposing cause to gastric ulcer. It is an opinion held by several asylum physicians and others, that domestic servants form a very large percentage of the inmates of asylums. I have taken pains to ascertain the facts upon which this opinion rests, by applying to Dr McDowall, of the Northumberland County Asylum, and to Dr Calcott, of the Newcastle-upon-Tyne Asylum at Cox Lodge. The total admissions of women into the Northumberland County Asylum for five years, 1886 to 1890 inclusive, were 415. Of these, 48, or 11.3 per cent., were domestic servants, 15 were housekeepers, and 189 housewives, by which is usually meant married women. The area from which these patients are drawn is agricultural and mining. Taking outdoor work as a healthy but often badly paid occupation as a contrast, I find that 11 field-workers were admitted as against 48 domestic servants. Dr McDowall does not think “there is an excessive amount of insanity among domestic servants.” It is only right to add that in addition to the above there were 101 females admitted classed under “no occupation,” and that many of these were young women who were at home and helped in housework.

The Newcastle-upon-Tyne Asylum, on the other hand, draws its patients from the city, where the typical domestic servant is more likely to be found than in the districts that supply the County Asylum. Dr Calcott has been good enough to send me a table showing the occupation of female patients received into the Newcastle City Asylum during the past twenty years, and embracing 1000 cases. The following is the percentages:--Housewives, i.e. married women, widows, and daughters acting as housekeepers to fathers, brothers, and relatives, 47.7 per cent.; domestic servants, 14.60, or, including women keeping house for artisans, 2.03, a total percentage of 16.63. This is a large percentage for domestic servants compared with 0.46 for shop girls. The Whittingham Asylum, near Preston, Lancashire, draws patients from a different class of occupations to those in Newcastle. I find in the Report of that Asylum of 1899, that there were 196 females admitted during the year. Of these, 26 were domestic servants; housekeepers and housewives numbered 102, contrasted with 24 mill hands and factory operatives. Next to housekeepers, which includes married women, domestic servants stood highest in the list of admission.

“Housemaids’ Knee” is an inflammation of the bursa in front of the knee-cap, and is caused by pressure and friction.

Barmen and Dealers in Alcoholic Drinks.

Publicans and licensed victuallers are notoriously a short-lived class. The modern tendency of brewers to buy out the smaller publicans and to form “tied” houses is causing the older type of landlords to disappear, and is replacing them by men often drawn from an inferior rank of life. In large industrial centres the men who are placed in charge of bars or who take over public-houses for themselves have frequently been previously engaged in the ordinary trades of the district. As subsequent events too often show, the life adopted, however gilded it may appear, is attended with considerable danger. The occupation of the publican is sedentary. Without any exercise in the open air, his long day is too often spent in an atmosphere reeking with the odour of spirits, tobacco smoke, and emanations from the men and women who lounge at the bar; and this, coupled with the numerous temptations to drink, and his irregular meals, sooner or later induces structural alterations in the liver, lungs, and heart, that bring life to a premature close. According to Ogle, innkeepers and publicans have a comparative mortality figure of 1521 as against 1000 of the general population, an unenviable position, which is corroborated by the statistics of the Scottish Amicable Insurance Society, which show that dealers in intoxicating drinks have a mortality of 68 per cent. in excess of the Actuaries’ or healthy Male Tables, and 49 per cent. in excess of the English Life Tables. The mortality is 51 per cent., roughly speaking, above that for all males. In no other class of men, as might be expected from the opportunities offered, is the mortality from alcoholism so high as in innkeepers and publicans. It is from five to seven times higher than the average. The only occupation that approximates to it from a mortality point of view is that of cabmen. There is a belief that the mortality among publicans from alcohol is diminishing, but Dr Tatham’s statistics for 1890–92, which appeared in the British Medical Journal for January 1898, do not confirm this. Some barmen, it is true, are teetotallers, and many are extremely temperate, but all are living under conditions of great temptation. The dangerous nature of the occupation lies not so much in the fact that barmen may get repeatedly drunk and run the risk of delirium tremens, but in the opportunities that are offered of continually nipping. It is the frequent nipping, begun early in the day and continued through it, often without food and an increasing distaste for it, that slowly undermines the physical and mental health of the publicans, is the cause of the large number of suicides among them, and of the large number of barmen that are carried off by cirrhosis of the liver and kidney disease before they reach the age of forty.

Working brewers are also unhealthy. They have, according to Ogle, a mortality figure of 1361 as against 1521 for publicans, but while they present a lower mortality figure and greater freedom from alcoholism, they have a higher mortality from heart and lung diseases, especially consumption, a circumstance which is attributed to their greater exposure to varying temperatures and to wet, their figures for phthisis being 334 as against 295 for publicans. Brewers and their assistants are more liable to accidents; these, like all alcoholic subjects, they bear badly. Dr Tatham’s statistics are more recent than Ogle’s, and they show that all occupations connected with the liquor traffic have even a higher mortality rate than those furnished by previous decennial reports. The figures are for brewers 1427, innkeepers and publicans 1642, and for inn and hotel servants, 1725. Taking 100 as representing the mean mortality among all occupied males for each of the subjoined causes of death, the comparative mortality figures for publicans, innkeepers, and their servants are 723 from alcoholism, 600 from gout, 271 from diabetes, 644 from diseases of the liver, 210 from urinary diseases, and 207 from suicide.

Sewing-Machine Workers.

If seamstresses and tailors in days gone by suffered, in consequence of plying the needle for many hours a day, from contracted fingers and rheumatic swellings of the joints; and tailors, owing to their cross-legged position when at work, from atrophy of the muscles of the limbs, bandy-legs, and deformities of the chest, the introduction of the sewing-machine about 1855, while removing these evils, was at first believed to have introduced others of its own. To sit working a sewing-machine, as thousands of anæmic women in this country are doing six days in every week, is to aggravate the physical conditions upon which their bloodlessness depends, to court neuralgia, and to encourage lethargy of some of the eliminating organs, but beyond exaggerating certain functional disorders, I do not think that to working the sewing-machine can be traced any real organic disease. It has been asserted that the vibration to which the spine is subjected is a cause of spinal-cord disease, and of such a disorder as locomotor ataxia. There is no truth in this statement. I know of no instances, nor is it likely that the jolting of the spine could cause locomotor ataxia any more than the movements of the knees induce disorders of the genital organs and encourage immoral practices, which some medical men claimed for the sewing-machine on its introduction. The one statement is just as unfounded as the other. Working the sewing-machine too long may be followed by muscular cramps, and even by loss of power in the limbs, due to irritation of the flexor and extensor muscles of the legs. The principal effects, however, are vague muscular pains in the limbs and loins, and a sense of fatigue, but I question whether these pains are more pronounced in sewing-machine workers than in shop girls and women who are doing other kinds of work. It is a sedentary occupation, but given a good constitution to start with, well-ventilated workrooms, and not too prolonged hours of toil, coupled with such open air exercise as a reasonable walk twice a day, between the home and the workroom, provides, along with good wages to get sufficient food, it cannot be said to be unhealthy. Women, recognising that the work is sedentary, ought themselves to take the necessary means to keep the bowels open, for obstinate constipation is not only a cause of anæmia, it ladens the blood with impurities that induce headache, the too frequent recurrence of which obliges the individual to give up her employment.

Label-licking.

In thread mills young girls are often employed to put labels on the bobbins. This they do by licking the labels, and as a consequence children are known to have suffered from swollen submaxillary glands, as reported in 1895 by Miss Anderson,[181] Principal Lady Inspector of Factories. This unwholesome practice is not confined to thread mills, it prevails in many industries in which small packets are being labelled for sale. The work is generally given to young persons and children. It is undertaken, therefore, at an age when growth is active, and the system is in need of all its digestive juices. The practice entails an enormous loss of saliva daily. Quite apart from this circumstance weakening the digestive functions, there is always the risk of the coloured labels containing, as Professor Thorpe’s[181] analysis showed, copper and lead. Besides, there is the risk that the adhesive part of the label owes its sticking properties not to gum, but to substances of an animal nature, such as serum, to the presence of which have been traced some minor forms of blood poisoning, and the painful affection known as “stamp-lickers’ tongue.” As a consequence ulcers in the mouth sometimes develop, and from these ulcers poisonous material is absorbed and carried by the lymphatics to the glands underneath the jaw, setting up an acute inflammation or adenitis.

Stamp-lickers’ tongue is an infective process which generally yields to antiseptic treatment, such as a weak carbolic, boric, or hyposulphite of soda mouth-wash. It is not so generally known as it ought to be, that the licking of stamps may be followed by tubercular disease. The following fact is therefore worthy of being more publicly recorded. Dr Busquet,[182] a surgeon-major in the French army, and engaged in the Bacteriological Laboratory attached to the military hospital at Dey, in Algiers, received into the hospital a young soldier far advanced in tubercular disease of the lungs. He was a collector of foreign stamps. Unused stamps he generally fixed in his album by licking them. In order to test some stamps, Dr Busquet bought three hundred for his patient, many of which were for the purpose of exchange. These stamps were placed in sterilised water. At the end of twenty-four hours, Busquet inoculated guinea-pigs with the water. Of eight animals thus treated all became tuberculous, and at the post-mortem examination they showed various tubercular lesions in their internal organs. School boys and girls form the larger number of philatelists, and as they often wet the stamps with their tongue the danger incidental to this practice is apparent. What has been said of foreign stamps may not apply equally to label-licking, and yet labels are often lying about in a factory exposed to the dusty atmosphere of the workroom in which microbes of disease are known to abound. We cannot always be sure too that the solution of gum was sterile to commence with, and that it was spread upon the labels by healthy persons. There is no wish to exaggerate the importance of microbes in causing disease; all that is here insisted upon is that label-licking is an unhealthy and an unpleasant occupation, one that can be better and just as cheaply done by mechanical contrivances than by wasting children’s saliva. That large quantities of saliva are used up in the process is shown by the fact that half-timers will lick as many as forty to fifty gross of labels in one day, and an adult woman as many as ninety gross. Where factory owners have introduced the use of dampers, they have found that by such artificial means the fixing of labels on bobbins can be just as expeditiously performed.

Glass Manufacture: Glass-Blowing.

The manufacture of glass is a very old industry. The Egyptians made glass more than 4000 years ago. Probably they learned the art from the Phœnicians or Jews. When Rome was at its zenith the number of Jewish glass-makers was so great that a special quarter of the city was set apart for them. These men turned out beautiful works of art, as the specimens in the Vatican and the British and French Museums show. Glass is supposed to have been introduced into England in the year 676 A.D., but the first glass works in London were not established until 1557. Two centuries ago Lancashire led the way in making plate glass. British sheet glass began to be made in Birmingham in 1832. So far as plate glass for mirrors and windows is concerned the British-made article is bad to beat. St Helens in Lancashire is the home of the manufacture of this particular kind of glass, which is composed of sand, soda salt, lime, felspar (quartz), and occasionally red lead and black oxide of manganese. These when melted together form a silicate, the sand supplying the silicic acid. Boric can be substituted for silicic acid. These substances are all fused together at an extremely high temperature in circular furnaces, with several small openings through which the workmen, wearing blue-tinted spectacles, can view the molten mass. Boys dip the end of a long hollow iron tube into the lake of molten material and, removing a blob on the end of the tube, take it to the men standing close by, who blow down the iron tube and cause the glowing mass to become globular. They fix and regulate the shape of the globe by occasionally rolling it on a small iron table. As the mass at the end of the iron tube cools further expansion of the glass by blowing becomes impossible, and so it becomes necessary to again replace the unfinished product at the end of the rod in the furnace. This is in time removed and again blown, restored to the furnace and manipulated until a completely finished article is evolved. This has still to undergo a process of annealing or toughening so as to prevent it cracking or breaking readily. The process consists in again exposing the glass to a high temperature, gradually raised and just as gradually lowered. Frosted glass is made by forcing a jet of sand under very great pressure upon particular parts of the glass. Sheet glass, on the other hand, is formed from a large mass of molten material adherent to the end of a blow-pipe, which, when it becomes large enough, is swung round and round in the air until it becomes oblong. It is then cut and the mass is allowed to fall flat. In order to flatten it still more the sheet is put into an oven; when rendered pliable by the heat it is removed and smoothed out by wood. In the manufacture of plate glass no blowing is required. A pot of molten glass is carried by a travelling crane to the casting-table, which is made of smooth iron with an elevated rim. Upon this table the liquid is poured. By means of rollers the workmen spread the layer out equally until it is of uniform thickness. After cooling, the glass is annealed in the manner already described. It is subsequently ground with sand and water, and afterwards polished with emery or putty powder.

The risks to health incurred by makers of glass are mainly those due to exposure to excessively high temperatures, e.g. bronchial and pulmonary affections; many of the men die from phthisis. They bear pneumonia badly owing to their intemperate habits. Dr Scheele, in the Berlin. Klinische Wochenschrift, March 1900, has drawn attention to what is known as “glass-blowers’ mouth.” Large swellings like air-cushions can be seen and felt in some glass-blowers, extending from the angle of the mouth to below the ears. The swellings look like mumps. They involve the parotid gland only. They crepitate under the finger, and by pressure can be made to disappear. It is only recently that these swellings in the cheeks of glass-blowers have attracted attention, and especially in France. The relaxation of the cheeks, the joues casées of French glass-blowers, is by some attributed to a faulty method of blowing. From glass-blowers under my care in the Newcastle Infirmary I have ascertained that the malady is not unknown among the men in the works on Tyneside. Dr Scheele found that it was present in only 2.5 per cent. of blowers, some of whom had worked for years. In those who had thus suffered the duct that leads from the interior of the mouth to the parotid gland had become dilated owing to the repeated entrance of air into it under considerable pressure: the mucous membrane of the inside of the cheek, too, showed thick pale patches, plaques opalines, which Guinard regarded as the result of the great pressure and straining the buccal mucous membrane was exposed to during the act of blowing. Under ordinary forced expiration the pressure inside the closed mouth is equivalent to from 6 to 9 millimetres of mercury, but in glassblowing it may rise to 90 and even as high as 110 mm. In the course of an ordinary day a good workman will blow as many as from 600 to 700 bottles.

In consequence of the strain experienced by glass-blowers other defects are occasionally observed; one is deafness due to increased internal pressure in the middle ear, and the other is a painless deformity of the fingers (main en crochet) due to the manner in which the blow-pipe is grasped.

Glass-workers are exposed to other dangers. Dr Pröbsting,[183] an oculist in Cologne, has found that in 12 per cent. of the factory operatives in Ehrenfield who are upwards of forty years of age, the crystalline lens of the eye becomes opaque. One of the most frequent causes of this form of cataract is exposure to the intense heat on the part of glass-makers, especially the workmen who remove the molten material from the furnace. Owing to the manner in which they handle their implements these men generally stand with the left side of their face towards the furnace. It is generally the left eye that becomes the seat of cataract. Meyhöfer believes that the excessive perspiration of glass-makers plays an important part in producing this change in the lens. A third cause may be the brilliant white light that dazzles workers in glass, and which, by fatiguing the retina of the eye, reflexly influences the lens. Mr Simeon Snell’s experience does not quite corroborate that of Dr Pröbsting.[184]

A new method of making hollow glass ware, e.g. tumblers, etc., has lately been introduced. The blowing is no longer done by men exhaling air from their lungs, but by driving in compressed air by means of machinery. One machine managed by four men and seven boys can turn out 500 tumblers in an hour, or 5000 in a day, whereas the same number of operatives working under old methods can only throw off 40 tumblers in an hour. In large glass factories the work often goes on night and day in double shifts, particularly on the Continent. The use of compressed air in glassblowing is very desirable, for by its use many of the ill effects consequent upon the present methods of blowing would soon disappear. The more frequent wearing of blue-tinted spectacles by the workmen, too, would tend to lessen the frequency of cataract.

Glazed Ware Poisonous from other Causes than Lead.--Cyanide of Potassium.

The United States Consul at Mayence, in December 1900, uttered a word of warning to purchasers of silvered glass and porcelain, which is deserving of notice. In order to apply the silver by the galvano-caustic method in use, the ware has to be dipped in a bath highly charged with cyanide of potassium. However carefully treated, the surface is never perfectly smooth, but conceals innumerable fine cracks. The cyanide lies in the minute fissures and cannot be removed during manufacture. As a consequence both the use and the handling of the ware may be followed by poisonous effects. Cyanide of potassium contains the well-known poison, prussic acid. Owing to the danger to health incurred by the workmen and the public, some large firms have abandoned the manufacture of goods by this process, but the ware is still exported from Frankfort, Stuttgart, and Berlin. Attempts are being made to devise non-poisonous methods of plating these goods.

Coal-heaving, Coal-trimming, and Chimney-sweeping.

Men employed in the first two of the above occupations are much exposed to the weather and to dust given off during the tipping of coal, while in the case of chimney-cleaning the sweep is exposed to the effects of soot that has been formed during the combustion of coal. The men who perform the rough, heavy labour on quays and staithes, loading and unloading ships with coal, or who fill sacks with the fuel, are called coal-heavers, while the men who are in the holds of vessels, shovelling and distributing the coal therein, are known as coal-trimmers. Usually the men are well developed and of good physique, but as a class they are extremely intemperate. On Tyneside they earn good wages, but a large part of them goes in drink. Owing to the many delays to which steamers are exposed the work of these men is rather irregular, a circumstance which does not conduce to steady habits. Beyond the risk of accidents, and the hard and exposed nature of the calling of the coal-heaver, there is nothing that is particularly dangerous in it, if the men themselves are careful. The trimmers when in the further recesses of the holds of vessels work in a dusty atmosphere, but the dust readily escapes. On coming out of the holds they often bring up a black spit, but this is mostly pigmented mucus from the bronchi. Phthisis and pulmonary disease carry off a large percentage of coal-heavers and trimmers. It must be admitted that neglect of common colds, and the indifference to health created by intemperate habits, are to a large extent responsible for these maladies.

Chimney sweeps form pretty well a social class by themselves. Their occupation cannot be regarded as a healthy one. To pulmonary, cardiac, and kidney diseases sweeps are particularly liable. Soot has a peculiarly irritating effect on the skin. It induces eczema, and is apt to cause inflammation of the eyelids, hence the “blear” eye exhibited by many sweeps. Occasionally the soot enters the skin, and is transported by the cells along the lymphatic vessels to distant parts of the body. A short while ago the question was raised in the pages of the Lancet, Do coal miners suffer from cancer? In a paper which I read at the Sanitary Congress in Newcastle-on-Tyne five years ago, I showed, from statistics of admissions into the Newcastle and Sunderland Infirmaries and the Durham County Hospital, that coal miners were anything but exempted from cancer. It is interesting to note, too, that while coal dust when inhaled is followed only by an inflammatory reaction in the pulmonary tissue surrounding the entangled particles of dust, coal when burnt undergoes some peculiar chemical change, whereby soot has conferred upon it properties of a specially irritating nature, for only thus can we explain the prevalence of cancer in chimney sweeps, a disease with which hospital surgeons at home, particularly in London, have been long familiar. Taking Dr Ogle’s statistics of the deaths of 242 chimney sweeps, 49 were due to malignant disease. Expressed in other words, Ogle found that while among all males in England and Wales between twenty-five and sixty-five years of age the proportion of deaths from malignant disease was in the ratio of 36 per 1000 deaths from all causes, it was in sweeps 202. Reference may here be made to the opinions expressed by Dr Tatham in this book, vide “Dust-Producing Occupations,” upon the mortality of sweeps from cancer. His statistics, which are more recent than Ogle’s, indicate that the mortality from different forms of cancer amounts to 156, compared with 44, the figure for occupied males in the aggregate. Chimney sweeps have a liability to cancer eight times greater than other persons. The disease tends to locate itself in the scrotum more than in other organs. To this subject Mr Henry T. Butlin, F.R.C.S., Surgeon to St Bartholomew’s Hospital, has given considerable attention, and has embodied his experience in a series of lectures delivered at the Royal College of Surgeons.[185] There is a widespread opinion that chimney sweeps’ cancer is seldom met with in any other part of the civilised world than in Great Britain; also, that during recent years, in this country, it is becoming rarer. Statistics show that it occurs very infrequently on the Continent. Many French hospital surgeons say they have never seen a case of cancer of the scrotum in a chimney sweep. In Vienna during eleven years, 1874 to 1884 inclusive, only one case of scrotal cancer was reported, and in that instance the patient was not a chimney sweep. During the years 1878 to 1885 not one case occurred in the large town hospitals of Berlin, and yet in four of the large London hospitals in one year, 1884, there were five cases of chimney sweeps’ cancer admitted; during 1881, into a similar number of Metropolitan hospitals there were received four patients suffering from this affection. It is sometimes stated that cancer in chimney sweeps has practically disappeared in Britain. This is not so. As Dr Tatham has shown in his article on “Dust-Producing Occupations,” there has been within the last twenty years a considerable decrease in the mortality of sweeps from this cause; but that it still claims annually a large number of victims in this trade is, unfortunately, too true. During a recent period of twenty years, there were admitted into St Bartholomew’s Hospital alone 39 cases of cancer of the scrotum, and of these patients 29 were chimney sweeps. So far, then, as London is concerned, there are every year in its hospitals one or two cases of chimney sweeps’ cancer in the wards. In Newcastle it is only rarely met with.

There is a theory that the supposed decline of sweeps’ cancer is due to the prohibition of “climbing boys,” to the use of machinery, cleaner habits of sweeps, and the abolition of passing soot through sieves for agricultural purposes. That the disease we are alluding to is cancer there is no doubt. It often commences in the form of a wart or warts on the scrotum, and as these are very frequently followed by cancer, what is called the “soot wart” becomes the “soot cancer.” These warts may exist for years. In many instances they never take on malignant action at all. The warts are liable to be rubbed and irritated by the dirty clothes of the sweep and by soot, and in consequence they become larger and ulcerate, the ulceration extending superficially along the skin or penetrating deeper into the testicle. The glands in the groin become enlarged at first from irritation, but ultimately they assume the malignant characters of the original ulcer. Under any circumstance, even when the disease is far advanced, death comes but slowly; emaciation does not progress rapidly, strength is gradually lost, and the general health is undermined by the profuse and sickening discharges from the open sores. On post-mortem examination of the body secondary disease, as might be expected, is frequently found in the peritoneal cavity, liver, and lungs. On microscopical examination of the scrotal ulcer the appearances presented are those met with in epithelioma or squamous cell cancer.

Although the dirty clothes of chimney sweeps and their want of personal cleanliness have been regarded as causes of the cancer, there is a feeling that the real cause resides in the soot itself, for there are many trades that are as dirty as chimney sweeping, and yet the men engaged therein do not suffer from scrotal cancer. Gardeners, who have been in the habit of using soot for the protection of plants from slugs (see paper by Mr D’Arcy Power, page 237), are known to have developed cancer in the hand. How soot causes cancer it is difficult to say. By some pathologists the sulphurous acid present in soot is blamed, by others, the ammonia compounds. The parasitic causation of cancer is still only a theory and requires confirmation. At any rate there is no proof of the existence in soot of a cancerous element. Soot when repeatedly applied to the skin causes it to become thickened, or harsh and dry, and just to the extent that it is capable of altering the structure of the skin, so may it predispose to cancer. The disease is most rife in chimney sweeps between the ages of forty-five and fifty. Whether the soot from one particular kind of coal has a greater influence compared with another it is not easy to say. The coal that is used for heating dwellings is of four kinds: (1) anthracite or smokeless coal; (2) hard coal or stone coal; (3) brown coal; (4) coke, wood, peat, and charcoal are also used. There is very little soot formed during the burning of anthracite. In England the fireplaces are open, but on the Continent stoves for heating purposes are more in evidence. At home there is a much larger quantity of hard or stone coal burnt in the dwellings than on the Continent, and to this fact has been attributed the greater freedom of chimney sweeps from cancer across the Channel. Butlin made extensive inquiries into the question of chimney sweeps’ cancer abroad, and elicited a good deal of information as to the personal habits of the men who follow this particular calling. In Belgium, for example, sweeps are in the habit of washing themselves to the waist daily, and of washing the whole body from head to foot once or twice a week. The chimney sweeps of Hanover wear special kinds of clothes, and after each day’s work they wash themselves with soap and warm water. In the North German towns several of the sweeps have baths fitted up in their own houses, and where this is not the case the fraternity own a bath-house, fitted up with all the necessary requirements, and to which the sweeps pay a daily visit. They also wear special garments, and a handkerchief over their mouth. Swiss chimney sweeps take a bath every evening. In some of the towns of France the precautions taken in regard to preventing the contact of soot with the body are not so good. It was found, however, that in Amiens, Lille, Rouen, etc., the sweeps wore blouses, and that they washed themselves thoroughly all over once a week. In Paris, sweeps’ cancer is practically unknown. Chimney-sweeping in Paris is relegated to companies known as fumistes (stove makers, menders, etc.). One establishment employs 100 men; these men dress in a linen blouse or jacket buttoned in front, trousers made from the same material, a coarse shirt and boots. After a day’s work the men take off their clothes in the workshop, wash, and on reaching home wash themselves again. Their working clothes are washed once a week.

“Climbing boys” are still employed by sweeps on the Continent for cleaning chimneys. It is several decades since they were prohibited in Britain. In the north of Germany, boys from seven to fourteen years of age are employed for this purpose, and in Belgium Mr Butlin found that even still younger boys were engaged to do the work.

Workers in tar and paraffin are also liable to cancer of the scrotum, and men employed in the production of anthracene, which is the last product of the distillation of gas-coal tar, are specially prone to suffer from warts and skin eruptions. Distillers of benzine and creosote suffer in a similar but slighter degree from warts. Tillmanns[186] of Leipzig, who made an inquiry into the health conditions of the men employed in the tar manufactories, stone coal tar distilleries, pine soot, or lampblack factories in Saxony, Hanover, and Holland, etc., states that “in lampblack factories, and in stone coal tar factories cancer of the skin and severe dermatitis do not appear to have been hitherto observed, as in the workers in the brown coal tar and paraffin industries.”

Having reviewed this subject at considerable length, I reproduce the conclusions that Butlin arrived at--(1) That it is possible to prepare the skin for the occurrence of cancer by the constant or repeated application to it of certain substances during a period of years; (2) that the nocuous substances in this relation of which we have the most information are hard or stone coal soot, brown coal tar, and crude paraffin; (3) that there is evidence to cast grave suspicion on certain other substances, such as stone coal tar, but that those are far less to be feared.

In order to prevent the occurrence of this malady in chimney sweeps, the individual should have his skin protected as far as possible against contact with the soot, and he ought to have a warm bath daily after his work. In the special clothing worn by Dutch, Belgian, and German sweeps, and in their practice of covering the mouth with a handkerchief, may possibly lie one explanation of their freedom from the disease compared with English sweeps, while in the use of the daily bath there assuredly lies protection.

* * * * *

Acts of Parliament relating to the Employment of Boys in the Sweeping of Chimneys in England:--

George III., 28, chap. 48 (1788).--To compel the masters to provide proper clothes for the climbing boys and to cause the boys to be washed and cleaned from the soot and dirt at least once a week. Also that the boys shall attend public worship on the Lord’s Day, on which day they are not to wear their sweeping clothes. The masters are not permitted to take more than six apprentices at one time, and no apprentice of less than eight years of age.

William IV., 4 and 5, chap. 34–35 (1834).--The age of the apprentices is not to be less than ten years.

Victoria, 3 and 4, chap. 85 (1840).--To provide that from and after July 1, 1842, no sweep under the age of twenty-one years shall climb a chimney, and that no apprentice of less than sixteen years shall be taken.

Manufacture and Use of Emery Wheels.

Emery wheels are used for grinding steel goods, knife and fork smoothing, etc. A large proportion of the wheels run in this country are imported from the Continent and from America, but many are made at home. When serving on the Dangerous Trades Committee I had the opportunity of inspecting their manufacture in Manchester and elsewhere. The Departmental Committee was invited to report upon emery wheels,[187] less on account of danger to health in their manufacture than their breakage when running at great speed, and of their splinters, which are hurled with great force, dealing sad havoc in a crowded factory. The wheels are made from crushed emery stone. Emery rock,[188] which is imported from Smyrna or from the Island of Naxos, is an anhydrous oxide of aluminium with a large percentage of flint, silica, and iron. In Canada a similar kind of wheel is made from a stone called corundum, which, while quite as hard as emery, is also an oxide of aluminium. The rock in either instance is crushed by means of heavy rollers into a very fine powder, which is sifted and then blown by a fan into a dust chamber, where it is collected. A considerable amount of dust is generated at this particular stage, but as the processes are conducted in encased machinery there is little or no risk to the workmen who superintend the crushing of the rock. Nor did it appear to me that any risk to health was incurred by the men who built up the emery wheels. These are made of crushed emery rock, with such binding substances as shellac, indiarubber, oil, sulphur, and silicate of soda, all pressed together in a mould under great hydraulic power. Into some of the wheels brass wire webbing is inserted, so that in the event of one of them breaking when running there would be less chance of the whole wheel sundering.

The danger commences during the running of emery wheels, a circumstance that can be readily imagined when it is known that a small wheel of 3 inches in diameter will often make as many as 7400 revolutions in a minute, and a large one, 3 feet in diameter, 600.

The Departmental Committee recommended that guards should be used in connection with the running of emery and corundum wheels. These should cover as much of the wheel as possible without interfering with the operations of the workman. During grinding a considerable amount of dust is given off. A suction pipe and fan should therefore be provided to draw the dust away from the face of the workman. Mr Archibald Newlands, H.M. Inspector of Factories, has invented a guard which not only protects the workmen from portions of broken emery wheel, should such an accident happen, but is so arranged as to aspirate and remove by suction the dust that is generated. In addition to the mineral and metallic dust that is given off during the operation of grinding, sparks are sometimes thrown off which might injure the eyes of the workman, hence the necessity for powerful suction.

THOMAS OLIVER.

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Chapter LX

OCCUPATION DISEASES DUE TO EXCESSIVELY REPEATED MUSCULAR ACTIONS.

Fatigue Neuroses: Scriveners’ Spasm, or Writers’ Palsy.

Under the head of occupation or fatigue neuroses it is customary to include affections characterised by spasm or paralysis of the muscles which prevent the individual performing certain muscular actions, by means of which he has hitherto earned his livelihood. The affection is met with in various occupations, usually, but not always, in those in which delicate movements--as, for example, those of the fingers--are required; hence as writing is one of the commonest of this class of occupations, it occurs as writers’ palsy. Accompanying the spasm or sudden contraction of the muscles that takes place, there is frequently pain, but there may be pain without spasm. Gowers, in his Diseases of the Nervous System, speaks of a motor and a sensory, or a spasmodic and neuralgic, form of scriveners’ palsy. Seventy years ago the affection was first described by Sir Charles Bell. The infirmity affects males oftener than females, and the weakness shows itself mostly between twenty and thirty years of age. While the repeated muscular movements required in writing become through fatigue the cause of the loss of power, there are other circumstances in operation, notably the inheritance of a weak nervous system, family worries, and financial difficulties. Excessive use of tobacco and intemperance in alcohol also favour its development. Since over-use of the muscles is a cause of the palsy, the malady naturally occurs in those people who earn their living by writing, e.g. clerks, copying-clerks particularly, and it would seem to be caused less by the amount than by the manner of writing. Steel pens have been blamed for causing scriveners’ palsy, because they have to be grasped more firmly and adjusted more exactly than quills. Doubtless the malady has become more general since their introduction, but the disease was previously not unknown in persons who only used quills. Besides, the number of people who are employed as clerks is greater now than formerly, and the conditions of life have materially altered. Quick writers do not suffer so much as slow and laborious toilers of the pen, owing to the greater range of their muscular movements. Sharp-pointed pens are more liable to cause paralysis than stub-pointed, because they have to be held more tightly, and require more and finer muscular adjustments.

Once the malady is established, it is when any muscular effort is made that the defect is observed. An individual, for example, may feel nothing wrong with his hand until he begins to write, and then the muscles that control the movements of the fingers are thrown into a state of involuntary spasm, or there is pain which prevents him writing. I have at present under my care a schoolmaster whose right arm is perfectly still, and its muscular movements normal, until he attempts to write. In the middle of writing a word the fingers will be unexpectedly thrown into a state of spasm, so that the pen is more firmly gripped than before, and yet he is unable to lift the pen off, or move it further on the paper. He has no difficulty in writing on the blackboard owing to the wider range of muscular movements of the elbow and shoulder. In scriveners’ cramp there may be, in addition to spasm and pain, violent tremor, or there may be what is still rarer, actual paralysis. When the muscles during the act of writing are thrown suddenly into a state of spasm, the individual is conscious that he is grasping the pen too tightly, but he cannot help it. Any voluntary attempt to relax his hold of the pen makes no difference so far as his ability to finish the writing is concerned. The act is accomplished slowly: the letters and figures which he makes are irregular, while the handwriting resembles that which is attempted by a person riding in a jolting carriage or on the railway. The power of writing may be lost gradually or quickly. The presence of spasm either prevents the individual writing at all, or if the spasm is intermittent and accompanied by tremor, the handwriting is jerky and rather illegible. It is the attitude assumed by the muscles in the act of writing that induces tremor, for where no effort is made there are no tremulous movements. It is an interesting fact too, as showing how the affection is limited to a distinct group of muscles concerned in a particular act, that while a person who is the subject of scriveners’ palsy cannot write, he may be able to paint quite well or even to print various letters and words. The grasp of the affected hand is usually unimpaired, or there is just the slightest loss of power. In grasping the affected hand in scriveners’ spasm, I have noticed that if there is prolonged contraction of the muscles concerned in grasping, the act is sufficient to bring on tremor. The muscles of the fingers seem to be incapable of sustaining any effort without being thrown into a state of spasm or tremor. If there is any atrophy or loss of muscle substance it is generally slight. Usually there is very little alteration in the response of the nerves and muscles to electrical stimulation. In some persons it is increased, in others it is diminished. The patients complain of the arm and hand feeling tired, and of a general sense of languor and fatigue to which they have hitherto been strangers. They are easily fatigued and retire to rest early, for they feel the need of repose, and are conscious of the benefit that comes from it. Their general health remains on the whole good. They are, however, apt to suffer in consequence if they are unable to take their accustomed out-of-door exercise, and there is a degree of mental depression that comes from the disablement caused by their infirmity. The individual feels that he cannot earn his living as he used to, and so he worries. It is not that he is overcome by pain, although in some instances this is acute and of a severe neuralgic character, especially in the muscles of the thumb, the finger, and the forearm. It is mental anxiety that drags him down.

Various theories have been put forward to explain writers’ palsy. According to Gowers these are--(1) weakness of groups of muscles with over-action of antagonists; (2) a reflex spasm due to stimulation of the sensory nerves in writing; (3) structural changes in those particular parts of the central nervous system that superintend the muscular movements concerned in this act. Writing is an acquired act learned by education, and it never becomes automatic. We require to concentrate our attention while writing, and so the fatigue is really as much, if not more, cerebral than muscular. Each of the above theories has its supporters, but it is difficult to make any one of them harmonise with all the facts. My own belief is that the malady is primarily central rather than peripheral. Spasm is one of the initial facts in the illness, and in writers’ palsy, as in all occupation neuroses, spasm and paresis overtake those muscles that have been trained to accomplish particular movements, especially movements of a complicated and delicate character. Altered nutrition of cerebral nerve centres is in all probability responsible for the defective muscular movements, while any pain that is felt is due to compression of the sensory nerve endings in the muscles during spasm. If there is any structural alteration in the nerve fibres it must be slight. This indicates that we are not dealing with a neuritis but a functional condition of the nerve fibres, such as occurs in neuralgia. Although the primary seat of the trouble is probably located in the cortex of the brain, there is a marked absence of headache and of impairment of intelligence. A recent author has thrown out a hint that, in cases of great nervous exhaustion and extreme fatigue, in which during life no physical signs of disease of any organs can be detected, and in which after death no gross structural changes are found, the cause in all probability resides in some obscure pathological condition of the large nerve cells in the cortex or grey matter of the brain. It is to such a condition that we are disposed to look for an explanation of the early symptoms of writers’ palsy.

Scriveners’ spasm per se is distinguished from the inability to write that is observed, for example, in hemiplegic patients who have had an apoplectic stroke, by its history, the limited extent of the spasm and loss of power.

So long as the individual, the subject of scriveners’ spasm, insists upon writing, the more pronounced does his difficulty become. He must give up writing for a lengthened period if he wishes to get well. Should he, however, persist in following his occupation, the weakness may extend to other muscles, and he will then be thrown further hors-de-combat, a circumstance that will only tend to deepen still further his mental depression and make him more anxious with regard to his future. Feeling himself baffled, he may educate himself to write with his other hand, but in time this too may become affected. More than that, when he attempts to write with his left hand tremors may be induced in his right. In one of my patients a sudden involuntary act, such as sneezing or yawning, will sometimes induce violent tremor of the affected arm when the muscles are perfectly still. Absolute rest from the use of the pen and freedom from all worry are necessary to establish a cure, which unfortunately is readily broken by too early return to work.

Prevention and Treatment.--All are agreed that the less cramped the handwriting and the more that shoulder muscular movement can be brought into operation, the less is the likelihood of scriveners’ spasm arising. Writing is a matter of education, hence children should be taught to use the muscles of the arm more freely. Pens should not be too fine-pointed if much writing is to be done, while the encircling of the lower part of the penholder by indiarubber obviates to some extent the necessity for taking too firm a grip of the pen. Lewis (Twentieth Century Pract. Medicine, vol. iii., p. 471) recommends that the pen should be held between the index and middle fingers, as this requires less muscular effort than the ordinary method, but at the best it must be admitted that this is an awkward position, and although initial difficulties can be overcome by education, it is still doubtful whether the muscular movement required under those circumstances is, after all, so very much less. Quills and stylographs may be substituted for steel pens, and, as already mentioned, the non-affected hand may be taught to write. Type for hand writing might be substituted, since this brings a new set of muscles into play, and the movements are not so fatiguing. Once symptoms of the malady begin to show themselves, absolute cessation of all handwriting is necessary. The work should cease at once, for it is in the early stages that rest is beneficial and a cure possible.

Internally, nervine tonics may be administered. Drugs as a rule do only a limited amount of good. I have got the best results from arsenic and bromides. Strychnine is recommended by some. If there is much pain such sedatives as morphia or belladonna may be required, but their use should be avoided as far as possible. Electricity, too, is worthy of a trial, especially in the voltaic rather than the faradic form, combined with massage or rubbing.

Telegraphists’ Spasm, or Cramp.

Mal télégraphique, or telegraphic spasm, was first described by Onimus, a Frenchman, in 1875; by Robinson in this country in 1882; and by Fulton in 1884, who described in detail the movements involved in the use of the Morse instrument. Twenty-five years ago the disease was a rarity. In the succeeding decade it was pretty prevalent. Probably it is now less frequent, owing to the telephone having been in many instances substituted for the telegraph. Dr Vivian Poore (Allbutt’s System of Medicine, vol. viii., p. 131) examined 400 cases of professional ailments, but he only found two patients who were telegraphists, and they had worked the Morse instrument. Telegraphists’ spasm differs in no material way from what has been described as writers’ palsy. Since it is to working the Morse machine that the largest number of cases of telegraphists’ cramp has been traced, it is necessary to remind the reader that the Morse alphabet is composed of a series of dots and dashes, and that the transmitting instrument consists of a lever surmounted at one end with a knob, which when depressed by the hand of the operator makes an electrical connection with, or completes the electrical circuit between, the transmitting apparatus at one end of the telegraph wire and the receiving apparatus at the other. On each occasion that the lever is brought down by the hand of the operator, and an electrical connection is made, a bar of soft iron in the receiving instrument becomes magnetised and attracts an armature which is fastened at one end of a lever, while an inscribing point at the other end reproduces on a slip of ribbon or paper, kept moving by clockwork, the dots and dashes made by the transmitter. As the knob is generally held between the thumb, index, and middle fingers of the right hand, the elbow meanwhile being supported, it is clear that most of the movement is made by the extensor and flexor muscles of the fingers and of the wrists, including the adductor and opposing muscles of the thumb. Since each letter, with the exception of E, which is a single dot, and T a single dash, consists of more than one dot or dash, while some require as many as four, the amount of sustained and co-ordinated movement is necessarily very great, and as the transmission is generally very rapidly effected, the operation when repeated for a great length of time, as in the transmission of speeches delivered in Parliament, must be followed by a considerable amount of fatigue. Fulton calculated that an operator might make between thirty and forty thousand muscular contractions in one hour, and since many telegraphists work eight hours a day, the strain on their muscles is necessarily very great. While the excessive use of tobacco and alcohol doubtless favours the development of telegraphists’ spasm, as of other occupation neuroses, there is not the least doubt that cerebral fatigue and muscular overstrain are the causes of it. In America, men have not been found to be more predisposed to it than women, or vice versâ. Once the symptoms of the malady have shown themselves, an operator when transmitting a message may be suddenly seized with muscular cramp, so that his hand cannot be quickly enough raised, and in consequence of this involuntary spasm, the pressure on the lever by the fingers is so long maintained that what ought to have been dots become dashes, or he transmits dots and dashes in such an abnormal sequence that the message received reads quite differently to that which it was intended to send. Mistakes of this kind have a distressing mental effect upon the operator, and they tend still further to derange the functional activity of his nervous system. There may be tremor of the hand as well as cramp of the muscles, but pain as a rule is absent. The muscles respond to electrical tests and do not waste to any extent. A telegraphist feeling that the muscular spasms are unfitting him for his daily duties may train his other hand to do the work. Conscious that by this means he will retain his appointment, he becomes more cheerful, and is able to rise to some extent above his infirmity. Whenever possible, such an individual should have a lengthy respite from his labours, for muscular rest is of very great importance. The treatment of telegraphists’ spasm is the same as that described under writers’ palsy. Prevention is better than cure. Learners are encouraged to practise with both hands, and as a consequence of this ambidexterity, not only are the cases becoming fewer every year, but they are seen and treated earlier by the Post Office Medical Attendants, whose experience is, that by causing the patients to desist there and then from keying for a few months recovery invariably follows. After all, it is but a small percentage of telegraphists who have “spasm,” probably not more than 1.3 per 1000.

Pianoforte Players’ Cramp, etc.

Pianoforte players’ cramp affects principally professionals, women more frequently than men. Like the infirmities mentioned in the preceding pages, there is muscular spasm, which may or may not be associated with pain. If the cramp is painful the individual cannot go on playing. Usually the spasm affects one or more of the fingers.

Spasmodic muscular contraction is also met with in violin players, in violincellists especially in the fingers of the left hand that are brought down upon the strings of the instrument, and in seamstresses, in whom once the affection is developed any attempt at sewing is followed by cramp of the fingers, so that sewing becomes impossible. Seamstresses’ cramp bears a resemblance to shoemakers’ spasm mentioned a little further on.

Spasms of various trades have been described, e.g., type-setters’, milkers’ spasm, which is said to occur in the cowherds of the Tyrol, and hammermen’s spasm. Workers in almost any trade, but especially those trades in which excessive muscular effort is combined with mental concentration, are liable to spasmodic seizures such as have been described, and to which in a general way the remarks already made on prevention and treatment may be said to apply.

Shoemakers’ Spasm.

In Vienna and Heidelberg there have occurred on several occasions epidemics of “idiopathic tetany.” Tetany is a disease characterised by muscular spasms involving the hands and feet, and sometimes, too, the muscles of the trunk, the face, neck, eyes, and larynx. Of 399 cases of idiopathic tetany collected by Frankl-Hochwart, 174 occurred in shoemakers and 95 in tailors, mostly between the ages of sixteen and twenty-five years. The epidemics have generally prevailed during the months of March and April. Risien Russell, who alludes to this subject in Allbutt’s System of Medicine, vol. viii., p. 51, says that probably some general toxic condition is in operation. If so, then idiopathic tetany would be caused by something on, or in, the thread that is used, since this material is common to the two occupations, and the illness should therefore be regarded as accidental, and not as incidental, to either the trade of the shoemaker or the tailor.

Boot and Shoe Making.

The last few decades have witnessed great changes in many trades that were formerly conducted as home industries, but perhaps in none more than in boot and shoe making. A few years ago it was no uncommon thing to find a cobbler working alone in his home, or in a small shop, assisted by one or two workmen. All boots and shoes were then handmade, the leather being cut and the pieces sewn together on the premises, so that a completely finished article was turned out by one person. The application of machinery has changed all this. It has flooded the market with ready-made boots and shoes, which, since they can be made more quickly, and in larger numbers, are cheaper than those made by hand, although not so enduring. In boot and shoe making, as in all factory production, subdivision of labour prevails. To one man is assigned the guidance of a machine which cuts the “uppers” or the “soles” of the shoes; another stitches the uppers, or “closes” them; while to yet another is given the harder task of “making” the shoe, i.e., of attaching the soles to the uppers. The extent to which machinery has already displaced handmade boots and shoes is depriving us of a class of workman who was capable of doing all that machinery now accomplishes, only he required much longer time. In rural districts cobblers will still be required, but their occupation in the future will be that of boot-menders rather than of boot-makers.

In reproducing the accompanying picture of one of my patients--a shoemaker--who was in the Newcastle-upon-Tyne Infirmary, I am wishful to give some literary permanence to a deformity which was very prevalent in workers in the trade a few years ago, a deformity known by the name of shoemakers’ chest, and which, as time goes on, will probably cease to exist. At his work the old type of shoemaker would sit on a low bench, with his thighs and knees tightly drawn towards each other, clasping the last with the boot upon it. His trunk would be bent down over his work, so that during the act of stitching and drawing the waxen threads through the holes made by his awl in the leather, his arms would be forcibly separated from his sides in order to tighten each stitch, while any beneficial expansion of the chest that this movement created was unfavourably counterbalanced by the increased pressure of the last upon his chest bone. As a consequence of this repeated pressure applied to the front of the chest, especially on younger men, the chest bone and ribs were driven in so as to form a deep hollow, such as is depicted in the lower part of the chest in the illustration (Fig. 89). The work, too, was sedentary, consequently the men suffered from indigestion, constipation, and piles, the latter being often aggravated by excessive indulgence in alcohol, to which shoemakers as a class were much addicted. It has sometimes been stated that they also suffered from cancer more than men engaged in other trades, but it is difficult from available statistics to prove or disprove this.

In modern boot factories, instead of the “uppers” being stitched to the “soles,” they are often riveted. When bootmaking is carried on by this process at home, the workman is often found sitting in the attitude of the shoemaker described higher up. During the act of burnishing and filing the rough edges of the boot, there is a considerable degree of pressure exercised by the heel against the front of the chest. In the bootmaking trade the men who cut out and shape the leather to be made up are known by the name of “clickers.”

Shoemakers formerly suffered from bronchitis and pulmonary phthisis in fairly large numbers, but much of this was due to the sedentary character of their occupation, their want of exercise in the open air, and their intemperate habits. The introduction of machinery, and the bringing of shoemaking under the Factory Acts, may to some extent effect an improvement in the health of shoemakers, but in many of the factories which I have visited, and where large numbers of persons are employed, the overheated rooms in which the work is carried on and the vitiated atmosphere rather predispose the workpeople to pulmonary catarrh, and tend to make the women anæmic. In addition, mercurial poisoning has been known to occur in the men employed in shoemaking factories, whose duty it is to mind the American or Blake machines. The mercury is placed in a well in the machine, to act as a lubricant, and as the metal is extremely volatile, poisoning may readily arise.

THOMAS OLIVER.

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