Industrial medicine and surgery

Front matter

/ THE ^ O LIBRARIES ^

HEALTH

Open Knowledge Commons

Preface

In presenting this book to the medical profession, and to those laymen interested in the subject, I am quite conscious of the fact that it is a deviation from the usual character of a text-book on medicine or surgery. Instead of dealing with the pathology, diagnosis and treatment of specific diseases or the individualistic practice of medicine, I have endeavored to sat forth the reasons for, and the methods of a form of group medicine which has stood the test of years, and proven its practicability in many of the large industries of the country.

The conservation of the lives and limbs of the working people and the reclamation of those disabled in the daily strife have become a definite program in the industrial world. The humanizing influence of this work has caused many an employer to consider other means of contributing to the health, comfort and contentment of his working force. Wherever these principles have been adopted, the industry has been rewarded by greater efficiency among its employees, with a corresponding increase in production.

With the growth of this form of medicine the field has extended into the living and home conditions of the working forces, gradually resulting in closer co-operation with the public health authorities. In fact, it has become a vital factor in public health. To-day the achievements of industrial medicine and surgery are one of the strongest arguments in favor of a national health program.

It is less than ten years since the majority of leaders in our profession could see naught but a questionable future, a sort of lowering of the prescribed standards, for those physicians who entered the field of the company doctor. To the pioneers in this new specialty, however, it seemed that these industries offered a veritable human laboratory where the constant supervision of the health of thousands of employees would enable the development of a real system of preventive medicine and preventive surgery. It was their first glimpse of group medicine, a form of practice radically different from that taught in the medical colleges and learned during the one or two years of hospital interneship following graduation.

The comprehensive systems of industrial medicine and surgery established in many industries to-day were the result of a gradual development. The glimpse grew into a vision — the vision broadened with each subsequent year. No one man nor no one establishment can

8 PREFACE

claim the honor of creating this work, for a number of concerns throughout the country engaged competent physicians and surgeons who simultaneously developed these new principles in medicine.

The community of purpose drew together these physicians. By frequent consultations, exchange of ideas and experiences, and by the comparison of results, the vision of each individual broadened and the scope of the work expanded. It would be extremely remiss on my part to refrain from acknowledging with sincere gratitude the great assistance which I have received from many of the leaders, both medical and lay, in this work. Because of our close association, I am especially indebted to Drs. Otto Geier, C. W. Schereschewsky, Francis Patterson, W. Irving Clark, C. W. Farnum, Wilbur Post, Thomas Crowder, C. D. Selby, A. M. Harvey, and James Britton.

During a period of nine years as chief surgeon of one of the largest industries of Chicago, I kept careful notes of the development of this form of medical practice as well as complete records of the results obtained. For the last two years of that period I taught this new specialty to the students at Rush Medical College, where a night clinic on Industrial Medicine and Surgery was established. This afforded an excellent opportunity to study conditions in other industries lacking adequate health services. I am greatly indebted to my associates in this college work and especially to Dr. John Ellis, Dr. John Dodson, Dean of Push Medical College, and Mr. John E. Ransom, Superintendent of the Central Free Dispensary.

This book endeavors to present these various experiences. It is based upon the practical application of every principle herein detailed not only in this one industry but in many of the other large concerns of the country. With the growth of this work of human maintenance in industry, it is becoming more and more apparent that our medical schools must correlate these broad social and economic principles with their teaching of medicine. Therefore, while it will be of value to those physicians engaged in industrial practice, it is felt that such a book will be especially valuable to the coming generation of medical students. As far as possible highly technical language has been avoided in order to extend its usefulness to the layman — to those employers, industrial engineers, social workers, and labor leaders who are honestly striving to improve the condition of those who must produce and provide.

To those pioneer industries having the foresight to establish and stimulate the growth of a genuine health service among their employees, the world is everlastingly indebted. Physicians working in this field could have made little progress without the moral and financial backing of these employers. No one realizes this better than the author.

PREFACE 9

The opportunity of publicly acknowledging this fact cannot be resisted. For all that has been accomplished in their medical department, the greatest credit must be given to the present management of Sears, Roebuck & Company.

To the ten doctors and twelve nurses on their medical staff, I wish to express my deepest gratitude for their loyalty and co-operation during these years of serving together. I am especially grateful to Dr. Edward A. Oliver, my associate for seven years, and to Miss May Middleton, the Superintendent of nurses, both of whom have rendered invaluable assistance.

A number of my colleagues in other industries have been unusually generous in furnishing data and other material and every effort has been made to properly accredit these and all other references.

To the publishers and those others who have so willingly co-operated in the preparation of this book, I will always be exceedingly grateful.

Harry E. Mock.

122 S. Michigan Ave., Chicago, III., August, 1919.

CONTENTS PART I

INDUSTRIAL HEALTH SERVICE

Chapter I Health Supervision Employees' Service Departments

Industrial medicine and surgery, the new specialty, deals with the human maintenance problem in mdustry. Our modern mdustrial concerns have regularly employed experts to study their expensive, comphcated machines in order to preserve their mechanism and obtain their maximum efficiency. The human machine alone has been neglected.

It is true that company surgeons have existed for many years but rarely did the scope of their work extend beyond the repair of injuries. This new specialty in medicine not only furnishes adequate medical and surgical care when necessary, but includes all measures bearing upon the health, welfare and working ability of employees.

Supervision of Health of Employees has become an essential part of the organization of many large mdustries. The past decade has witnessed the birth, in this country, of this one of the most important of human conservation movements, and the last four years have seen it expand into a great, five issue with far-reaching influence. Since its birth, many other issues offering service to the great mass of wage-earners have been created. Chief among these are the Mutual Benefit Associations, the Safety Movement, and Employees' Compensation Acts. The latter still is an ugly child in many respects, but gives promise of a great future. Its brothers, Employees' Health Insurance, Old Age Insurance and Insurance against Non-employment have not as yet been born, but this new specialty is rapidly demonstrating their need.

2 17

A comprehensive system of the supervision of the health of employees must include every branch of preventive medicine and surgery and of remedial medicine and surgery, as well as industrial hygiene and sanitation. These are primarily medical functions and must be administered by the medical department of an industry.

Many other activities have been developed in our best organized industries, however, which have a direct bearing on the comfort, convenience, and state of mind of the employees, and therefore have the closest relationship to health supervision. Recognition of this fact has caused the creation of Employees' Service Departments in several concerns.

or HEALTH or EMPLOYES OP MAINTENANCE DEPART.

SUPO HUMAN

CEIiTRAL MAffAGSR

EneiNEER

CMPLOrfS yismm

NURSe3

Fig. 1. — A successful plan of organization in one industry.

Usually a broad-visioned business man, or occasionally a trained sociologist, has been placed at the head of such a department. It is his duty to co-ordinate all these activities so that the greatest service will be given to the employees. The actual work of the medical department is under the doctor, the safety work is under the safety engineer, the employment manager attends to employment. In other words, the functions of these various services are decentralized as to activities but are centralized under one head as to policy, administration, etc. (Fig. 1).

In at least three large concerns all these functions have been placed directly under the supervision of the chief of the medical staff. The argument in favor of this is that the broadly trained physician, with a proper economic and social sense, because of his close relationship to the employees, is the best manager for such a department.

Time alone will prove which is the best plan. The tendency to give more and more power to the medical director is growing, and certainly demonstrates that all things which increase the health of employees must increase dividends to the employer. It also demonstrates that the vision of the physician in industry must constantly expand, and he must become fully cognizant of those activities which can well be called the adjuncts to health supervision.

This fact is positive, namely, all activities which deal directly with the health and safety of the employees should be placed under the medical director, and those functions which look to the comfort and welfare of the employees, although administered by various lay managers, must be closely co-ordinated with, and often supervised by the health department. In fact, everything about the industry which in any way touches the health problem should be subject to the approval or criticism of the medical staff if the greatest benefits from such a system are to be obtained.

What are the activities of an Employees' Service Department? From a medical standpoint they can be divided into those services which deal directly with health supervision, and those which are adjuncts to health supervision, as follows:

1. Health Supervision of Employees : (a) Medical Service.

(6) Surgical Service.

(c) Dental Service.

(d) Nursing Service.

(e) Safety Service.

(/) Sanitation Service.

2. Adjuncts to Health Supervision: (a) Employment Service.

(6) Restaurant Service.

(c) Recreation Service.

(d) Welfare Service.

(e) Insurance Service.

(/) Banking and Loan Service.

(g) Housing and Community Service.

To the internist, surgeon, or the regular family physician, it is quite evident that this new type of physician, working in industry, is confronted with many problems which have not been included in the usual medical curriculum. Let me assure you, however, that all these services in the working homes of your patients have a decided bearing on their health. Recognition of the relationship between conditions in industry and the health of the people will become more and more essential in the teaching of medicine in the future.

Details of this work — the general principles, the purposes and the results of all the functions of industrial medicine and surgery, will be given in subsequent chapters. This discussion will be limited to outhning the scope of health supervision. I want to emphasize that the plan of supervision which I am about to offer is the ideal for which all company surgeons should strive — an ideal to which no industrial concern as yet has fully attained.

The prevention of sickness, accidents and inefficiency among employees is the purpose of all forms of health supervision. A general survey of the component parts is the first step in prevention, be it prevention of fires, accidents, burglaries, war, flood, or what not. Thus, the first step should be a general survey of the working place; the mechanical appliances therein; the employees, individually and in a group; and even the employers and their attitude and state of mind toward supervision of health. The physician entering an industry where this work has not been in vogue will usually have to develop this proper mental attitude on the part of both the employer and the employed.

MEDICAL SERVICE

The medical service in a properly conducted health supervision plan, includes those activities dealing directly with the equation of health in the employees and the treatment of their diseased conditions.

One of the first requirements in the general survey of this field is the complete physical examination of every employee, and, when practicable, a periodical re-examination of these employees, approximately every six months. I qualify the re-examinations, because, whereas in a plant employing only a few hundred people this can be done with a very small medical staff, in one employing ten or fifteen thousand people it would take a staff of four doctors doing nothing else to re-examine the force every six months. Such a plan would interfere with the work of the employees to the extent that few managements would consent to this unusual precaution.

The medical examination should be complete in every case, both male and female. The history in each case can be obtained by a trained nurse, who can also take the temperature, pulse, height and weight of the employee before he is sent in to the doctor. The physical examination can be made while a qualified laboratory assistant is analyzing the urine, the specimen being obtained just before the employee is sent to the examining room. Next, the dentist and the nose-thro at-and-eye specialist examine the individual in turn.

Provided plenty of office space is available and sufficient and efficient assistance is given, this examination can be completed in 25 minutes. This includes the time necessary for disrobing and dressing again, and the short wait for his turn. Unless some condition is found which requires careful study, this examination need not take over ten minutes of any of the doctors' or nurses' time before whom the employee appears for each step in his examination.

Many times a day individual cases will present themselves which require considerably more of the doctor's time; for instance, certain diseased conditions must be carefully explained; advice applicable to each case must be given; the doctor must ascertain if the proper hne of treatment is being followed in a certain case, and, if not, must arrange for it; questions must be taken up with the employees' manager pertaining to change of work, etc.; matters of personal hygiene must be discussed; and numerous other factors deaUng with the personal equation between the doctor and the employee must be met and carefully considered. In no instance should this medical supervision attain such a high plane of efficiency, as regards speed and the number of employees examined per day, as to lose sight of this personal element — the benefit of the personal contact of the employees with the doctor.

Many company physicians may object to such a thorough physical examination of employees as is here outlined, but, remember, this plan is based upon the assumption that the industry wants the same efficiency in its human maintenance department which it demands in all other departments, and efficiency means thoroughness. The inspection of employees and choosing only those for physical examination who seem below par is better than no medical supervision; the physical examinations usually made on girls, namely, the head, neck and chest, have given wonderful results in supervising the health of these female employees, but to obtain the maximum of results a complete survey of the entire body of each individual is necessary in order not to overlook anything which might be detrimental to health.

The pxirpose of a complete physical survey must not be to ehminate the unfit from the working force, but must be done absolutely from the standpoint of supervising the health of the entire group. Thus, it is essential to ascertain the condition of health of each individual to discover diseases in the earliest stages, while still curable ; to find anyone suffering from a communicable contagious disease, and to seek out the employee chronically diseased yet still able to work and recommend for him a position where he can be efficient without hastening the course of his disease.

Until such time as the State takes up its burden, employers should make adequate provision to render proper medical care and sufficient financial aid to him who is forced to stop work because of this system of supervision; otherwise, the very purpose of such a system will be defeated, namely, the restoration to health in the shortest time possible. Lack of money and the worry over debts are great drawbacks to the regaining of health.

Of equal importance with the medical examination and re-examination of the old working force is the thorough examination of every applicant for work; in fact, this is just as essential as keeping the working place sanitary when once you have removed all unsanitary conditions. The examinations of applicants, however, should not be made for the purpose of choosing only the strongest, healthiest workers, but to protect the old working force from any applicant who might have some contagious disease. An excellent means is also given for supervision of the health of these prospective employees by preventing those with serious diseased conditions from going to work, for their own protection; and by choosing the proper type of work for those with chronic diseases which do not totally unfit them for employment.

I have talked with two national labor officials, and they assure me that, if all industries would approach this procedure from as humane a standpoint, as above outhned, they would thoroughly endorse the plan.

Medical treatment of diseased employees is still a mooted question.

The treatment of conditions directly the result of occupations, for which the employer is considered responsible, is almost universally recognized as a logical part of the work of the company surgeon ; but the care of the workman injured outside the plant, or whose sickness has no connection with his work rightfully belongs in the opinion of many to the family physician. To give the best results to both employees and employer, complete remedial measures must go hand in hand with the work of investigation and supervision.

This medical and surgical treatment has already been instituted in a few industries, and the results are proving its worth. Most medical staffs furnish complete surgical care to those injured while at work and the more rapid recoveries, fewer permanent disabilities, and lower death rate furnish the strongest arguments in favor of such a plan. Every company surgeon has seen the most deplorable surgical treatment given to workmen injured while at home. Many of these home accident cases are neglected by the employee himself until some severe infection or other complication finally forces him to consult his family doctor. Even then, many family doctors, untrained in emergency surgery, will give inadequate treatment, for example, making a small incision in an infected area when a wide-open incision is indicated. As a result, the disability of the outside accident case is often prolonged and frequently a permanent deformity occurs which could have been prevented by the prompt, early treatment of the accident by the surgical mechanism of the industry. Many surgeons are daily interfering in the care of some home accident case in order to prevent these dire results.

Almost the same situation exists in the medical cases. When a diseased condition is found, the employee is advised as to the best line of treatment and then is referred to his family physician. Often he receives the very best of care from the latter, again only mediocre care, and occasionally he neglects to follow the advice to consult his doctor, waiting until the condition becomes so serious that he is forced to do so. In many instances the case is treated without any effort at a diagnosis being made. Time and again a blood examination or a stomach analysis would show the true state of affairs and would indicate the proper line of treatment, whereas the employee is taking pills from a "bhnd doctor," or is receiving electrical treatment from a quack.

Daily the medical staffs of industries are interfering in the treatment of sick employees. They are operating more and more on employees who have some surgical condition, when careful inquiry shows that they cannot afford to obtain proper surgical and hospital care, or when it is apparent that the condition is being neglected by the family physician.

A few industries have assumed the care of all cases of tuberculosis found among their workmen. Most of these are sent to sanatoria. Some refuse this care and choose home treatment under the family physician. A comparison of the results between this home treatment and sanatorium treatment proves that these concerns have saved Hves by taking complete charge of the tuberculous employees.

Some industrial medical staffs are now treating all syphilitic and gonorrheal cases, with the result that scientific care is curing the early cases, and, best of ?il, society is protected. The old plan of firing the venereals and leaving many of them to the mercy of the quack is no longer practiced.

Those with defective vision are now being cared for by competent ophthalmologists, instead of allowing the employee to go to the corner optician for their glasses. In 1915 the writer found 799 cases of defective vision, and cared for 179 of these, the remainder going without care or to whomsoever they saw fit. In 1916 he found 1014 cases of defective vision and corrected 930. Supervision of these shows that they have remained corrected, and the increased efficiency resulting therefrom has far more than paid for the cost of this service.

These examples therefore prove that, hand in hand with the supervision of the health of employees, there must be proper medical and surgical treatment rendered — the two are almost inseparable. I do not mean to insinuate that the medical men of an industry are better physicians than the average family physician, but I do knowthat systematic care by a unit of medical men, each trained especially in some particular line, will give the surest, quickest and best results.

NURSING SERVICE

One of the chief aids in the supervision of the health of employees is a well-trained staff of industrial nurses. Special training is necessary before any nurse can learn all the ramifications of the work of an industrial nurse. Through her the employers can show their friendly interest in the force. The small merchant, with five or six employees, can personally visit and offer aid to one of his men when the latter is sick or in trouble; but the large employer, with several thousand workmen, must depend upon some other agency in order to show his friendly interest in their welfare.

Thus, every industry should have a sufficient number of these nurses to visit each sick employee; to render nursing aid when necessary; to report on his condition and whether or not he is receiving proper medical care. She also diplomatically ascertains whether or not financial aid is needed; if the sick one is worrying over accumulating debts; if the home environments and housing conditions are such as to interfere in his rapid recovery; in fact, she is able to supervise the health of the employee, to a certain extent, while at home.

SURGICAL SERVICE

The Surgical Service is one of the most vital branches of the medical department. The company surgeon, working in the front Line trench of industry, is in the strategic position to develop the most comprehensive system of preventive surgery. His first duty is to study and enforce every possible form of accident prevention. In the minor accidents, such as pin-pricks, bruises, and the like, which are almost unavoidable, he must devise means of preventing comphcations such as infections. When an accident occurs he must be close at hand to render the earliest possible treatment, and must continue to treat the case from the standpoint of preventing undue loss of time from work, preventing permanent disability, and, above all, to prevent the death of the patient. The restoring of the most perfect function in an injured member must be his aim. Such a surgeon is constantly striving for the best economic-end result, as well as for a medical-end result.

Every industry should have on its medical staff a surgeon competent to handle every type of surgical condition. Even where a specialist is required for certain operations this company surgeon should continue to supervise the treatment. Employees sent to a hospital for surgical care usually receive more prompt attention and more careful after-treatment from the surgeon who is directly responsible to the management of an industry. Many an employee has been referred to one of the large hospitals in a city for operation when his occupation was not responsible for the condition. Often three or four days elapse before the hospital surgeon finds time to operate, except, of course, in very acute conditions. After the operation the treatment is left largely to the interne. Unfortunately, many internes have not yet developed the proper social sense, or do not consider the great economic loss due to keeping the patient in the hospital longer than is necessary. These employees leave the hospital dissatisfied with the treatment which they have received. Their statements are often exaggerated, but nevertheless it is apparent to the management that the cases cared for by the company surgeon are expedited, while too often those referred to the general staff of a hospital sustain an unnecessary loss of time. This condition is resulting in the company surgeon being requested by the management to operate more and more often on workmen with conditions other than injuries, especially when the early return of a man to his work is vital to the production of the plant.

In many industries the workmen are so scattered that it is often impossible for the surgeon to render prompt treatment when an accident occurs. In this case he must arrange for proper first-aid treatment by some competent fellow-employee. First-aid stations in some plants have been established at regular intervals throughout the buildings with trained laymen in charge to render first-aid to every injured employee. In others three or four intelligent employees are chosen in each department and are carefully drilled in every form of first-aid treatment by the company surgeon. When an accident occurs in that department these men take charge of the case and render the early treatment indicated. This first-aid work, however, should never replace the doctor. Practically every injury, no matter how slight, should be sent or taken to the central office at once where a competent surgeon can take charge. In many places this first-aid service has been developed to such a high degree that it is one of the most important features in their plans for health supervision.

SAFETY SERVICE

No system of supervision of health of employees is complete imless suitable provision is made for the prevention of accidents. Therefore, a safety engineer is essential in making the general survey of mechanical conditions of the working place and in adding every appliance known for protection. After this is done he must make daily inspections of the plant to see that these safeguards against accidents are used by the employees. He must also investigate every accident in order to devise some means to prevent its recurrence.

There must be the closest co-operation between the safety engineer and the company surgeon; in fact, he should be directly connected with the medical department. The surgeon must report every accident promptly with all data pertaining to its cause which he obtains from the injured employee. By talking freely with an injured man during the period of caring for him the doctor can learn many apparently insignificant facts, even from the most ignorant employee, which are invaluable in this work of prevention. Likewise, the company surgeon is the safety engineer as regards the human mechanism. By thoroughly examining the injured man he often finds some physical or mental defect as the cause for the accident.

SANITATION SERVICE

Sanitary conditions of the plant have a very definite bearing on the comfort and health of the employees. Industrial engineers are constantly pointing to the relationship between industrial sanitation and maximum production. There is no doubt but what unsanitary conditions about a plant cause more sickness, more discontent among the employees, greater labor turn-over, and a very definite slowing up of production. From a medical standpoint the sanitary inspections are almost of equal importance as the inspections of the force by physical examinations. The medical staff should see that every unsanitary condition is removed and the plant is made as healthful and comfortable as possible. To accomplish this the cleanliness of the building, the ventilation, the lighting, the temperature and humidity, the disinfection of toilets and cuspidors, the installation of proper washing and bathing facilities, the removal of dangerous gases and dusts and the fumigation of departments or rooms where contagious cases have developed must be made perfect and kept so by frequent inspections.

EMPLOYMENT SERVICE

The question may well be asked by those unfamiliar with this work, why the employment service should be included as an adjunct to health supervision. The very fact that some employment managers in certain industries are endeavoring to have the medical departments placed under them demonstrates that there must be a very definite connection between health and employment. But the employment problem is only a small portion of the health program in any industry, and it is bound to curtail the work of the medical department if it is made subordinate to the employment department. As a means of health supervision it would be more logical to place employment under the medical director. The majority of concerns, however, consider it best to have the closest co-operation between these two departments, but to have them operate under separate heads.