INDUSTRIAL HEALTH 
KOBER AND HAYHURST INDUSTRIAL HEALTH 
EDITED BY 
GEORGE M. gOBER, M.D., LL.D. 
WASHINGTON, D. C. 
AND 
EMERY R. HAYHURST, A.M., M.D., Ph.D. 
COLUMBUS, OHIO 
CONTRIBUTORS 
ANDREWS, IRENE OSGOOD, 
New York City. 
ANDREWS, JOHN B„ Ph. D„ 
New York City. 
APFELBACH, GEORGE L., M. D. 
Chicago, III. 
ASHFORD, BAILEY K„ M. D„ 
San Juan, Porto Rico. 
BLAKE, CLARENCE JOHN, M. D„ 
Boston, Mass. 
BOWEN, JOHN T„ M. D„ 
Boston, Mass. 
DEVOTO, LUIGI, M. D„ 
Milan, Italy 
DITTOE, WM. H., C. E , 
Columbus, Ohio. 
ERDMAN, SEWARD, M. D„ 
New York City. 
FROTHINGHAM, LANGDON, M. D. V., 
Boston, Mass. 
GROENIGER, WM. C. 
Columbus, Ohio. 
HAMILTON, ALICE, M. D„ 
Boston, Mass. 
HANSON, WM. C., M. D„ 
Boston, Mass. 
LEE, FREDERICK S„ Ph. D„ 
New York City. 
LEE, THOMAS S„ M. D„ 
Washington, D. C. 
LEGGE, THOMAS M., M. D„ 
London, England. 
LINENTHAL, HARRY, M. D„ 
Boston, Mass. 
LOVEJOY, OWEN R. 
New York City. 
OLIVER, SIR THOMAS, M. D„ 
Newcastle-Upon-Tyne, England. 
ORDWAY, THOMAS, M. D„ 
Albany, N. Y. 
SAYERS, R. R„ M. D„ 
Washington, D. C. 
SCHERESCHEWSKY, J. W„ M. D., 
Washington, D. C. 
SELBY, CLARENCE D„ M. D„ 
Toledo, Ohio. 
SOLOMON, HARRY C„ M. D., 
Boston, Mass. 
SOUTHARD, ELMER E., M. D„ 
Boston, Mass. 
TELEKY, LUDWIG, M. D„ 
Dusseldorf, Germany. 
TRASK, JOHN W., M. D„ 
Washington, D. C. 
TRUBY, ALBERT E., M. D„ 
Washington, D. C. 
TYZZER, ERNEST E„ M. D„ 
Boston, Mass. 
WELLS, WALTER A., M. D„ 
Washington, D. C. 
WHIPPLE, GEORGE C., S. B„ 
Boston, Mass. 
WRIGHT, FLORENCE S„ R. N„ 
New Haven, Conn. 
WURDEMANN, HARRY V., M. D, 
Seattle, Wash. 
WITH ILLUSTRATIONS, REFERENCE TABLES AND APPENDIX 
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OUR STUDENTS AND FELLOW WORKERS 
IN THOSE BRANCHES OF PREVENTIVE MEDICINE 
COMMONLY KNOWN AS 
INDUSTRIAL HYGIENE 
AND 
INDUSTRIAL MEDICINE PREFATORY 
HISTORICAL REVIEW OF INDUSTRIAL HYGIENE AND ITS EFFECTS ON 
PUBLIC HEALTH* 
GEORGE MARTIN KOBER, M. D.. 
Washington, D. C. 
Edgar L. Collis,1 in his retrospect of prehistoric industry, writes: 
Industry may be considered as an outward and visible sign of the progress of 
the human intelligence and the milestones along the road-the stone age, the bronze 
age, the iron age, the machinery age-gather additional interest when considered as 
stages in the evolution of mind . . . The statement may be made that the intelli- 
gence of a race is measured by its industry, and that the primary raison d'etre of indus- 
try is safety and health. In other words industry is the means human intelligence 
employs to insure the existence of the race. 
It is not surprising, therefore, that the anthropologist should find 
evidences among the "shell mounds and flint heaps" of prehistoric 
man that there were in reality factories for the manufacture of imple- 
ments, which were used for weapons of offense or defense, and that 
some of the best preserved remains of prehistoric man in addition to 
flint also reveal the presence of bronze arrow-heads. Industry, how- 
ever, did not originate solely for offensive and defensive purposes, but 
also to improve living conditions in the life of the race struggling for 
existence. Buecher, cited by Price,2 has classified the methods of indus- 
trial production as follows: domestic production, handicraft production, 
and the modern factory system. 
Domestic production is production in and for the house from raw 
materials furnished by the household itself. In its purest form it pre- 
supposes the absence of exchange and the ability of each household to 
satisfy by its own labor the wants of its members. All that the house- 
hold has it owes to its own labor, and it is scarcely possible to separate 
the operations of the household from those of production. 
Handicraft production, also known as custom production, is carried 
on within or outside of the house, usually by free-workers. The handi- 
*A part of these historical notes appeared in the Jubilee Volume of the American 
Public Health Association, which recorded the history and progress of public health 
work from 1871 to 1921 in this country and is of general interest. The compiler 
greatly appreciates the permission granted to reproduce these notes in this book. 
He also desires to state that his task would have been impossible without copious 
extracts from the writings of Edgar L. Collis, K. B. Lehmann, George M. Price, 
Fielding H. Garrison and numerous other historians mentioned in the text.-Geo. 
M. Kober, M. D. 
VII VIII 
PREFATORY 
craft man always works for the consumer of his production, the region of 
the sale is local-that is, the town and its immediate neighborhood. 
The modern factory system supplies the economic wants of persons, 
communities and nations by wholesale production and the aid of 
machinery and motive power in specially constructed plants operated 
by industrial wage-earners. 
It is very evident that at no time did one method of production exist 
to the exclusion of the other, and that there was a tendency, even in 
ancient times, towards a "localization of human industries." Lehmann3 
tells us that the father of Demosthenes had a knife-factory employing 
30 slave-workers, and that Lysias operated an armor-shield factory with 
120 slave-workers. The Romans during their occupation of Britain, 
according to Cooke-Taylor,4 cited by Collis, established a manufactory 
of woolen clothing for their troops, also a manufactory of pottery, and at 
least one military iron-forge, or fabrica; but on their departure all was 
swept away, and for 900 years no great centers of industry and no factories 
existed. Now and again sprang up a very few notable and apparently 
temporary exceptions, such as the great clothier, "Jack of Newberry," 
who is said to have employed over 1000 persons in the reign of Henry 
VII, but before the eighteenth century, industry as we know it did not 
exist in England. The only factories were the parish water-mills or 
windmills where corn was ground between stones brought from near 
Paris or Andernach on the Rhine. Only here and there was there any 
local industry in the thirteenth century. 
"Manufacturers of cloth are noted-scarlet at Lincoln; blankets at Bligh; burnet 
at Beverly; russet at Colchester (8 weavers are enumerated at this town in the rolls 
of Parliament under the year 1301); produce of linen fabrics at Shaftesbury, Lewis 
and Aylesham, of cord at Warwick and Bridgeport, the latter being cited also for its 
hempen fabrics; of fine bread at Wycombe, Hungerford and St. Albans; of knives at 
Maxstead; of needles at Wilton; and razors at Leicester." (Thorold Rogers.6) 
Space will not permit tracing the rise and growth of domestic and 
handicraft industrial production and its influence upon the health of 
the operatives, which doubtless was very important, the workshops 
of the mediaeval towns and cities being extremely primitive in character. 
There is evidence to show that the factory system began in Italy 
in the fifteenth and sixteenth centuries with the manufacture of silk 
and woolen goods. In France, from the middle of the sixteenth century, 
the cloth, carpet, arms and porcelain industries grew rapidly. Similar 
progress was also made in England, Holland and Germany. According 
to Stieda,6 there was a large sugar refinery at Augsburg in 1573, a gold 
and silver works at Nuremburg in 1592, a soap factory in Augsburg in 
1593, a blue-dye factory at Annaberg in 1649, and a woolen cloth factory, 
with 50 weavers and 300 spinners, at Halle in 1686. Some years later a 
wool and silk factory, with 500 workers, was established in Magdeburg. PREFATORY 
IX 
In 1710 a porcelain factory was established in Meissen, and another one in 
1718 in Berlin. In 1764 a linen factory, with 800 workers, was founded 
in Tournai, Belgium. Prior to 1801 Germany had about 20 factories, 
each employing between 100 and 500 persons. 
The modern factory system started in England in the latter part of 
the eighteenth century. Up to the beginning of that century, England 
was largely devoted to agriculture and sheep culture, and it is quite 
natural that the first mechanical industries should have been devoted to 
the production of material for clothing. The spinning-jenny, invented 
and perfected by High Kay and Hargreaves in 1767, supplemented by Ark- 
wright's spinning machine in 1771 and Cartwright's power loom, patented 
in 1785, laid the foundation for the textile industry on a large scale. 
With the discovery of the steam engine by Watts and its practical appli- 
cation to factories in 1785, a tremendous growth in the mechanical and 
manufacturing industries occurred. This is shown by the fact that the 
importations of raw cotton into England increased from 5,000,000 pounds 
in 1775 to 273,249,653 in 1831 and 775,469,008 pounds in 1849, and also 
by an unusual demand for labor, especially apprentices and child-labor to 
feed the machines. England in 1810 already operated 5000 steam- 
engines, against 200 in France, while Germany introduced its first 
steam-engine as late as 1841. 
With the development of the modern factory system of increased 
production came also a concentration of the population in certain man- 
ufacturing districts, as shown by an increase of the population in the 
Lancashire district from 166,200 in 1700 to 1,336,854 in 1831. But 
most important of all, occupational diseases and accidents came to be 
more and more seriously regarded. It soon became apparent, in countries 
like England, France, Germany and Italy, that death was exacting a 
very heavy toll in many of the industries. Indeed, the workmen in 
these countries began to believe that steam and speed had not improved 
their lot in life, branding their condition as one of slavery, and their 
factories and workshops as "slaughter-houses." 
This was not an unreasonable conclusion, when it is recalled that 
according to Roscher in 1761, 50 per cent, of the English population died 
before the age of twenty. In 1833 in factory towns like Manchester the 
youthful population was physically worn out before manhood, and the 
average age of the laboring classes was only 22 years as compared with 44 
years among the upper classes. Even later there was a period when, with 
a general death-rate for the whole of England of 22 per 1000, the death 
rate in the laboring districts was 36 out of every 1000 per annum. 
In the interest of humanity, and as a matter of social and political 
economy, it became imperative to study the causes of the great mortality 
among wage earners, determine the sources and significance of the dangers 
and the possible means for the prevention and mitigation of the injurious 
effects. X 
PREFATORY 
EPIDEMICS IN INDUSTRY 
Collis, in his chapter on "Industry and Epidemic Diseases," brings 
out a number of interesting facts and shows very clearly that the typhus 
fever epidemics in Great Britain in the late eighteenth and early nine- 
teenth century were generally influenced by a combination of want, 
overcrowding and other economic circumstances. He refers to Tiverton, 
which in the first half of the eighteenth century was a fairly prosperous 
town with 8000 inhabitants mainly engaged in weaving. In 1720 
business began to slacken, and affairs became worse after a fire in 1735. 
Then followed a hard winter in 1739-40, which reduced the inhabitants 
to acute distress. In 1741 spotted fever was epidemic, and one in every 
twelve of the inhabitants died. At the close of the century Tiverton was 
less populous than at the beginning. 
Whether history will repeat itself is a matter of speculation, but in 
the light of recent experience no one can deny that the aggregation of 
human beings as in the industries, in the Army and Navy, has favored 
contact infection, and the epidemic extension of influenza, pneumonia, 
septic sore throat, and other communicable diseases. It is also generally 
recognized that abject want and other economic conditions even now 
play an important role in the spread of typhus fever. 
CHILD LABOR IN ENGLAND 
One of the most baneful effects of industrial development was the 
employment of children. The Hammonds,7 cited by Collis, declare: 
" Child labor was not a discovery of the industrial revolution, but the new 
industry provided infinite scope for the labor of children, and drove the 
workmen to rely on them." When labor was scarce, children were 
imported, and a Yorkshire manufacturer under such circumstances said 
he was driven to the expedient of procuring from the workhouse in London 
500 poor children to be employed in the workshops. Hunt,8 cited by 
Collis has described the practice at the end of the 18th century and the 
commencement of the 19th century. 
"The greater part of the children were pauper apprentices bound by parochial 
authorities to mill owners; others the children of very poor or callous parents. From 
little more than infancy, sometimes under 7 years old, children were condemned to 
labor for long hours, 13 or more a day, at tasks requiring unremitting attention, and in 
rooms badly ventilated, and otherwise injurious to health, they were half starved, 
and cruelly punished when their wearied little arms failed to keep up with the demands 
of the machinery ... Such of them as survived the prolonged misery and torture 
of their early years, grew up more or less stunted and deformed men and women, 
physically unfit for parentage, morally debased, ignorant, and brutalized by ill 
treatment. 
The Hammonds7 declared that "these cotton mills crowded with overworked 
children, were hot beds of what was called "putrid fever," and it was an epidemic at 
Radcliffe in 1784 that first drew public attention to the condition of the apprentices." PREFATORY 
XI 
Notwithstanding these appalling conditions it was not until 1788 that 
the first step in the protection of child labor (chimney sweeps) was taken. 
In 1802, Sir Robert Peel succeeded in securing the enactment of a law 
for the protection of the health and morals of apprentices and others 
employed in cotton and woolen mills. The details of this Act and of 
subsequent legislation will be referred to below. 
HISTORICAL REVIEW OF INDUSTRIAL LEGISLATION 
As pointed out by Price,2 from what is known of Egyptian civilization, 
its industries were founded on slave labor (see the Biblical stories of 
Genesis and the Exodus of the Hebrews). Industry in early Greece 
was carried on by "free men," and only later was it allotted to slaves. 
In Rome associations of "free workers" existed from the earliest times. 
Mommsen refers to eight guilds of craftsmen under Numa Pompilius, 
one of the first rulers,-they were: carpenters, coppersmiths, dyers, 
flute-blowers, fullers, gold smiths and shoemakers, but later much of the 
work was done by slaves. Gibbon in his "Decline and Fall of the Roman 
Empire," Chapter II, points out that by the edicts of Hadrian and the 
Antonines, upon a just complaint of intolerable treatment, the injured 
slave obtained either his deliverance or a less cruel master. 
LABOR LEGISLATION IN ENGLAND 
1349-1351. The first statutes dealing with labor in England accord- 
ing to Collis1 were enacted in 1349 and in 1351 and referred wholly to 
regulation of wages. The next enactment passed in the early years of 
Elizabeth's reign prescribed the hours of labor, not by way of limitation 
but by injunction. Jevons9 cited by Collis says; "Thus from the middle 
of the month of March to the middle of September all artificers and 
laborers hired by time were to be and continue at their work at or before 
5 o'clock in the morning and continue at work and not depart until 
between 7 and 8 of the clock at night. In winter months work time was 
from 5 A. M. until dark. The legal day's work was to be about 12 hours 
at the least." 
1601. A law was enacted in 1601, which provided that substantial 
householders acting as overseers of the poor should in every parish raise 
money by taxation, in order among other things, to set to work and 
apprentice to some trade, destitute children and orphans, and according 
to Hutchins and Harrison10 during the 17th and 18th centuries charitable 
institutions were founded for providing these children with instruction in 
spinning and weaving. Collis very aptly adds "possibly this law was 
the germ from which sprang the widespread employment of children 
previously referred to, which formed so black a spot in the industrial 
development of the latter half of the 18th and the first half of the 19th 
century." XII 
PREFATORY 
The first legislative effort in favor of labor, according to Collis,1 dealt 
with the principle of Truck i.e. payment of wages, not by coin of the 
realm, but by commodities. As early as the reign of Edward IV reference 
is made to payment to workers in "pins, girdles and unprofitable wares" 
and payment is ordained in true and lawful money. This legislation and 
an Act passed in the first year of Queen Anne's reign and re-enacted in 
1726 in the reign of George I appears to have been violated and required 
further stiffening in 1820, 1831 and in 1896. (Anderson.11) 
1788. The first effort of legislation to protect children was the 
Chimney Sweeps' Act of 1788, but according to the Hammonds, cited by 
Collis "it was very modest on paper and absolutely ineffective in 
practice." After years of efforts, in 1834, a law was enacted forbidding the 
binding as a chimney sweep of any boy under the age of ten, and the 
employment of children under 14 years, unless apprenticed or on trial. 
In 1840 the age limit was raised to sixteen and no person under 21 years 
was permitted to climb chimneys. It is stated by Collis that previous 
to these Acts "the children who had to be small to negotiate flues only 
7 in. in diameter, were stolen for the purpose or were sold by 
their parents for a few pounds, were driven up the chimneys and possibly 
made to climb by a straw-fire lighted beneath them, that many, submerged 
in soot in narrow or horizontal flues, were suffocated, and that they usually 
slept in cellars with a bag of soot for a bed and another for a coverlet." 
1802. Sir Robert Peel caused the enactment of a law in 1802 for the 
protection of the health and morals of apprentices. This Act applied to 
cotton and woolen factories and became necessary to correct the abuses 
which had arisen under the parish poor apprentice system authorized by 
the Act of 1601. The chief provisions of this pioneer factory Act are 
stated by Cooke-Taylor4 as follows: 
(1) The first section enjoins the 'master or mistress' of the factory to 
observe the law. (2) All rooms in a factory are to be limewashed twice a 
year and duly ventilated. (3) Every apprentice is to be supplied with 
two complete suits of clothing, one new suit every year, with suitable 
linen, stockings, hats and shoes. (4) The hours of work of apprentices 
are not to exceed 12 a day, nor commence before 6 in the morning, nor 
conclude after 9 at night. (5) They are to be instructed every working 
day during the first four years of apprenticeship in reading, writing and 
arithmetic, by some discrete and proper person and the time so occupied 
to be counted out of their hours of work. (6) Male and female appren- 
tices are to be provided with separate sleeping apartments, and not more 
than two to sleep in one bed. (7) On Sunday they are to be instructed 
in the principles of the Christian religion; they are to comply with various 
religious ordinances during their apprenticeship, and to go to church 
once a month at least. (8) Two visitors are to be appointed by adjacent 
CHIMNEY SWEEPS, CHILD AND FEMALE LABOR PREFATORY 
XIII 
Justices of the Peace, one of whom must himself be a Justice, and the 
other member either of the Church of England or of the Church of Scot- 
land, to enforce the provisions of the Act. (9) In case of infective dis- 
orders prevailing these visitors may require the employer to call in medical 
assistance. (10) Copies of the regulations of the Act are to be affixed in 
conspicuous places. (11) A list of factories situated in his district is to 
be kept by every clerk of the peace. Penalties and the manner of receiv- 
ing them are enacted for breaches of the law. 
1816-1831. The English Parliament in 1816 appointed a Commission 
to inquire into the condition of factories and after much opposition and 
delay in 1819 the age limit of children employed in the cotton mills was 
fixed at nine years, and that any one under the age of 16 should not be 
employed for more than 12 hours a day, exclusive of meal-time. Night 
work was prohibited. In 1825 a statute provided for a 9 hour work-day 
on Saturdays for children under 16 years of age, but it also provided for 
attendance at the factory 13^ hours on all other workdays, making the 
actual work hours 12 with IX hours for meal time. The administra- 
tion of these Acts had been placed in the hands of justices of the peace, 
who were often interested in the cotton industry, and in 1831 a law was 
enacted excluding mill owners and their relations (parents, brothers and 
sons) from hearing cases brought under the Acts. The hours of labor 
for those under 18 years was limited to 69 hours per week, and night work 
for those under 21 was prohibited. In the same year an overseer from 
Dundee gave evidence before a committee presided over by Mr. M. T. 
Sadler of which the following are brief extracts taken from Collis:1 
" There were a great many children in proportion to the number of adults, most of 
them were orphans. There were some of the orphan children from Edinburgh who 
had been in the mill I believe from four to five years. The children were incapable 
of performing their day's labor well towards the termination of the day; their fate was 
to be awoke by being beaten and to be kept awake by the same method. They were 
guarded up to their bothies to take their meals and were locked up in their bothies at 
night and their master took the keys away with him to his bedroom. They were 
not allowed to go to a place of worship on the Sunday . . . The children and young 
persons were sometimes successful in their attempts to escape from labor and con- 
finement. I have gone after them on horseback and brought them back myself. 
Those brought back were taken into the mill, and got a severe beating with a strap, 
sometime the master kicked them on the floor and struck them with both his hands and 
feet." 
While these hearings were in progress (November, 1831) Great Britain 
was, by Orders in Council, restricting the hours of work of adult colored 
slaves to 9 hours a day, and of child slaves under 14 years of age to 6 
hours a day, and, according to the Hammonds,7 Sadler said: "You 
have limited the labor of the robust negro to 9 hours, but when I propose 
that the labor of the young white slave shall not exceed 10, the proposition 
is deemed extravagant." XIV 
PREFATORY 
1833. As a result of constant agitation, a law was enacted in 1833 
limiting the hours of labor of children under 13 years of age to 48 hours in 
any week, and to 9 hours a day. Night work, i.e. between 8.30 P.M. and 
5.30 A.M. or for more than 69 hours per week for persons under 18 years 
of age was forbidden. Certificates of age were no longer to be given by 
the parents, but by a physician or surgeon who had to declare the indi- 
vidual to be of the " ordinary strength and appearance" of a child of not 
less than 9 years of age. The Act of this year extended legislation to 
cotton, woolen, worsted, hemp, flax, linen, tow and silk factories. Legis- 
lation also provided, for the first time, for the appointment of factory 
inspectors paid by the State, and for special rules for the white-lead 
industry, bake-houses, etc. 
1842. At the instance of Lord Ashley, the first Mines and Collieries 
Act was passed in 1842 which prohibited the employment, underground, 
of all female labor, and also of males under 10 years of age, "but," accord- 
ing to Collis, "no medical certificate of fitness was or ever has been required 
for mines." The Act also provided for inspectors of mines, and that no 
steam or other engine could be under the care of any person under 15 
years of age where there were vertical or other shafts. 
1844. The appointment of regular certifying surgeons was legalized 
in 1844; they were required to certify that the children were of such physi- 
que as to justify the probability of their being at least 9 years of age. 
In this act women also were included for the first time with young persons 
in the limitation of hours. The Act also permitted children at the age of 8 
years to be employed for half the day only or on alternate days; it also 
contained for the first time provisions for the fencing in of mill-gearing and 
shafting. 
1845-1850. An Act was passed in 1845 forbidding the employment 
of children under 8 in calico print works; it also provided that no children 
under 13 years of age or women could be employed between 10 P.M. and 
6 A. M. and all children under 13 years were to attend school 30 days in 
each half-year. In 1847 the hours of labor for women and children were 
limited to 10 hours a day. 
1850-1859. The hours of work for women and children in 1850 were 
fixed to be on 5 days in the week either from 6 A.M. to 6 P.M., or from 
7 A.M. to 7 P.M. with 1^ hours for meals within these 12 hours, and on 
Saturdays not after 2 P.M. This Act which determined a normal working 
week of 60 hours in spite of urgent representation did not apply to adult 
males. In the same year an Act giving inspectors of mines broader 
powers and requiring mine-owners to report fatal accidents and to keep 
accurate plans of their mines was passed. In 1855 additional legislation 
was enacted requiring certain safety provisions against accidents; 
mechanical ventilation to render noxious gases harmless and obviate the 
danger of explosions. The Act also improved the inspection service of PREFATORY 
XV 
mines. In 1856 the Act of 1844 providing for fencing of mill-gearing and 
shafts was strengthened. 
1860. The Coal Mines Act was made applicable in 1860 to iron- 
stone mines of the coal measures; it also raised the age at which boys 
might be employed to 12, and the age at which persons might be entrusted 
with the care of steam engines to 18. The provisions of the general 
Factory Act were likewise made applicable to bleach and dye works. 
1862. Night work between 8 P.M. and 6 A.M. in bleach and dye 
works was prohibited for protected persons (females and children). 
1863. Employment of young persons in bakehouses was prohibited 
between 9 P.M. and 5 A.M. The Act also made certain regulations 
relating to sanitation and cleanliness of bakehouses. This Act was 
administered by the local sanitary authorities until 187$, when bake- 
houses were included under factory legislation. 
1864. The following trades were placed within the provisions of the 
Factory Acts: manufacture of earthenware, lucifer matches, percussion 
caps and cartridges, paper staining and fustian cutting. The Acts also 
gave power to masters to make special rules for dangerous trades, subject 
to the approval of the Secretary of State, and prohibited the taking of 
meals in rooms where noxious materials were handled, t 
1867. The following industries were brought within the scope of the 
Factory Act: all metal trades, including blast furnaces and smelting of 
metals, foundries, engineering shops, manufacture of paper and gutta- 
percha, of paper and of glass, the tobacco industry and the printing 
trade. The Act also stiffened the requirements of machinery and shaft- 
guards, declared all places where more than 50 persons were employed as 
factories. Thanks to the scientific investigations on the occurrence of 
disease in the industries published as early as 1861 and 1862 in the 3rd 
and 4th Report of the Medical Officer of the Privy Council, the Act of 1867 
also demanded the removal by mechanical means of dust evolved during a 
manufacturing process, which might be inhaled to an injurious extent. 
The Workshop Act, also enacted in 1867, applied to manufacturing 
establishments in which less than 50 persons were employed. No chil- 
dren under 8, under this Act, could be employed in any handicraft, and 
children from 8-13 could only be employed under the half-time system. 
Young persons and women might only be employed for 12 hours, less 
half an hour for meals and no protected person might be employed after 
2 P.M. on Saturdays. 
1870-1873. An Act relating to danger from spontaneous combustion 
in bleach and dye works was passed in 1870. An Act allowing young 
persons and females of Jewish religion to work on Sundays was enacted in 
1871; also another Act prohibiting the employment of children and female 
young persons in the manufacture of bricks and tiles. In 1872 another 
Mines Act was passed applicable to coal, ironstone, shale and fireclay 
which strengthened the provisions as regards ventilation, safety-lamps and XVI 
PREFATORY 
timbering and placed check weighing on a sounder basis. The Metalli- 
ferous Mines Regulation Act formulated in the same year provided for 
inspection and safety, adequate ventilation, drying and dressing room 
facilities. 
1874. A further Factory Act was passed raising the age for the 
employment of children from 9 to 10 years, and of young persons from 
13 to 14, to prevent the continuous employment of protected persons for 
more than 4^ hours, without hour interval, and to provide for atten- 
dance of children at recognized schools. 
1878. A consolidating Act was passed defining "a factory as premises 
wherein articles are made, secured, repaired, ornamented, finished or 
adapted for sale by means of manual labor, for gain, if mechanical power 
is used on the premises." The employment of children under 10 years of 
age was now prohibited, and children were forbidden to clean machinery 
in motion, and were also excluded from certain sections of the premises in 
the white-lead industry. 
1883. An Act directed towards the prevention of lead poisoning was 
passed, which required every occupier of white-lead factories to draw 
up special rules for official approval. 
1886. A shop hour law limiting the weekly period of employment of 
young persons under the age of 18 to 74 hours, including meal times was 
enacted. Women were not included in this Act. 
1887. The Coal Mining Acts were consolidated, but no new features 
were enacted, notwithstanding the urgent recommendation of a Royal 
Commission in reference to high explosives, safety lamps, electric lights 
and rescue stations. 
1889. Factory Acts were passed and also in 1897 regulating the 
humidity and ventilation of cotton cloth factories. 
1891. A Factory Act was passed in which the employment of women 
within 4 weeks after child birth was prohibited, and the age of employable 
children was raised to 11. Fire-escapes were made obligatory, and 
other provisions for safety especially in dangerous trades were required. 
Sanitary provisions for laundries were included in the Act. 
1892. A "Shop Hours Act" prohibiting the employment of any 
young person for longer than 74 hours including meal times in any one 
week was passed. 
1894. Quarries over 20 ft. in depth were brought under the juris- 
diction of mines. The Act also made reports of accidents and the framing 
of special rules compulsory. 
1895. The local authorities were made responsible for the sanitation 
of factories. The maintenance- of a reasonable temperature in workrooms 
was required; also compulsory notification by physicians of persons 
suffering from anthrax, lead, phosphorus, mercury or arsenical poisoning 
of industrial origin. In 1897 the first medical inspector of factories was 
appointed to handle these notifications. A weekly limit of hours for PREFATORY 
XVII 
laundries was fixed at 30 for children and 60 for young persons and women, 
but permitted children to work 10 hours, young persons 12 and women 
14 hours. 
Under the Factory and Workshop Acts of 1891 and 1895 codes of 
special rules were established relating to the following industries or 
processes. (1) Manufacturing of white lead. (2) Handling of dry and 
dry-salted hides and skins from China and the West Coast of India. (3) 
Vulcanizing of India rubber by means of bisulphide of carbon. (4) 
Chemical works, bottling of aerated water. 
1896. Mining Acts were passed aimed at the prevention of gas or 
dust explosions in coal mines, and in 1900 forbidding in all class of mines the 
employment below ground of boys under 13 years of age. In 1906 an Act 
was passed, which for all types of mines, quarries, factories and workshops, 
extended and made more stringent the obligation to notify the occurrence 
of accidents. 
1899. An Act was passed which called for one seat for every 3 female 
assistants employed in shop rooms, but the principles of this Act were not 
made applicable to factories until 1916. 
1901. All previous Factory Acts of 1878, 1883, 1891, 1895 and the 
two Cotton Cloth Factory Acts were consolidated, increased duties and 
powers were conferred upon medical officers of health, and the Act also 
raised the age of children to 12 years. The procedure for making special 
rules for dangerous industries was simplified and improved. 
1907. Legislation referring to laundries was enacted. 
1908. The use of yellow phosphorus for the manufacture of matches 
was prohibited. In the same year previous acts relating to employment 
of children in agriculture were amalgamated. In the same year the eight- 
hour labor law for miners was enacted to take effect in 1909. 
1910. A Mines Accidents (Rescue and Aid) Act was passed under 
which provision at coal and metalliferous mines may be required by order 
with regard to: 
(a) The supply and maintenance of appliances for use in rescue work 
and the formation and training of rescue brigades; 
(b) The supply and maintenance of ambulances, appliances and the 
training of men in ambulance work. 
It is interesting to note that factory legislation made no provisions for 
first-aid until 1916. 
1911. The present Coal Mines Act was passed which retains most 
of the provisions of previous acts relating to employment underground and 
regulates the employment of women and young persons so that no 
boy between 13 and 16, and no girl or woman may be employed except 
as specially provided for. It also contains a number of health clauses 
providing for baths and drying clothes and the use of a water jet or spray, 
or other equally efficient means to prevent the escape of dust occasioned by 
drilling in ganister, hard sandstone, or other highly silicious rock the dust XVIII 
PREFATORY 
from which is liable to give rise to fibroid phthisis. Section 79 provides 
for the notification of disease occurring in a mine or occasioned by the 
nature of the employment. 
1916. As a result of the report of the Committee on the Health of 
Munition Workers, an Act was passed for securing the welfare of workers 
in factories and workshops. Under the powers conferred by this Act 
provision may be required by orders for " arrangements for preparing or 
heating and taking meals; the supply of drinking water; the supply of 
protective clothing; ambulance and first-aid arrangements; the supply 
and use of seats in work rooms; facilities for washing; accommodations 
for clothing; arrangement for supervision of workers." 
Workmen's Compensation Acts were passed in 1897, 1900, 1906 and 
1918. The Act of 1906 contained a schedule of six diseases for which 
compensation was to be paid on the same basis as for accidents. Twenty- 
six other diseases have been added to the list. The Act of 1918 provides 
in a special way for compensation in cases of silicosis due to the inhalation 
of silica dust and was the direct outcome of a "Report of the Royal 
Commission on Metalliferous Mines and Quarries" published in 1914. 
(For a schedule of diseases for which compensation may be paid and other 
information see Andrew's Chapter, pages 1015-1017.) 
LEGISLATION IN FRANCE AND GERMANY 
France.-In 1810 the French Government issued a decree relating to 
" Establissements dangereux insalubres et incommodes." In 1813 an 
Act was passed prohibiting the work of children under 10 years in mines, 
and made other protective provisions in this industry. In 1839 the 
"Academic des Sciences morales et politiques de France''made an exhaus- 
tive investigation of the working conditions of wage-earners which 
resulted in the enactment of laws in 1841 and 1848 affording some pro- 
tection to children and women, but containing no provisions for the 
supervision of industrial conditions within the factory. Nothing more 
appears to have been done until 1874 when a law was enacted providing 
for a special inspection service and for some standards for the improve- 
ment of sanitary conditions in the workshops. In 1882, 1883 and 1892 
existing laws were amended and stiffened and in 1893 the hygiene and 
security law was enacted which contained many excellent provisions 
for improving the sanitary conditions in industrial establishments. (For 
subsequent legislation see Andrew's Chapter, pages 1007-1018.) 
Germany in 1839 enacted a law regulating the employment of young 
persons, but notwithstanding considerable agitation nothing was done to 
regulate the working conditions in factories up to 1869, when Article 107 
of the "Industrial Code for the North-German Union ' ' contained the follow- 
ing general provision: "Every manufacturer should, at his own cost, 
establish and maintain all necessary appliances for safeguarding 
employes against dangers to health and life." PREFATORY 
XIX 
This provision, according to Price,2 was extended by Article 120 
of the Industrial Code of 1891, which is at present the basis of all factory 
legislation in Germany. The provisions of the Act are general in char- 
acter, but the inspectors and local authorities have power to define 
exactly the provisions of this article, the essence of which reads as follows: 
"Employers are to establish and maintain their establishments, their workrooms, 
machines and utensils so as to protect workers as far as the nature of the industry 
permits, against dangers of life and health. 
"Especially are they to provide for sufficient light, adequate air space and air 
change, removal of gases, dust and fumes arising in the process of the industry. 
They are also to provide such devices as are necessary for the protection of the workers 
against dangerous machinery or parts of machines, or against any other dangers which 
are to be found in the nature of industrial processes, also those dangers which arise 
from factory fires. In establishments where, because of the nature of the processes 
it is necessary for the workers to undress and to cleanse themselves after work, special 
washing and dressing rooms must be established." 
In England, Germany and other European countries, the Secretary of 
State or the Industrial Authorities issue detailed rules and regulations 
to enforce the general intent of the law by a well trained body of factory 
inspectors. (For additional information see Andrew's Chapter, pages 
1002-1019.) 
INTERNATIONAL PROTECTION OF LABOR 
The question of international protection of labor was agitated as 
far back as 1870, but it was not until 1890 that the First International 
Conference was held in Berlin. This was followed by an International 
Congress at Paris in 1900 and the establishment of an International 
Association for Labor Legislation with a Bureau at Basle in 1901. This 
Bureau has an extensive library and receives financial aid from the 
various governments represented in the Union. The object of this organ- 
ization is to secure the enactment of uniform labor laws, to collect and 
publish literature in English, French and German on the cause and pre- 
vention of industrial diseases and accidents, to offer and award prizes 
for the solution of important industrial hygienic problems, and to promote 
generally the welfare of the laboring classes. It is largely due to the 
efforts of this organization that men foremost in the ranks of social medi- 
cine drew up a list of industrial poisons. 
The interest of humanity clearly demands the displacement of par- 
ticularly dangerous labor methods and materials by the introduction of 
less dangerous processes and materials as well as by the employment of 
materials satisfactorily pure, chemically. Until this is accomplished by 
technical experts the prevention of occupational accidents and diseases 
is properly a function of government. Governmental action however in 
promoting industrial hygiene, according to Andrews, "does not signify 
that private or voluntary efforts of the workmen or of their employers, or XX 
PREFATORY 
physicians shall be in any way minimized. On the contrary such volun- 
tary efforts will be vastly encouraged." (See pages 1002-1019.) 
There is no doubt that individual researches, and numerous govern- 
mental investigations have already furnished more accurate information 
relative to the causes of disease and accident hazards, and have provided 
forceful arguments for protective legislation and education. 
EDUCATIONAL METHODS IN EUROPE 
In the way of educational methods, industrial museums of safety 
have been established in 22 European cities. The Berlin Museum estab- 
lished in 1904 and the Vienna Museum founded in 1909 are typical 
examples of what may be done in illustrating the cause and prevention of 
occupational diseases and accidents. In the Berlin Museum, located at 
Charlottenburg, every safety appliance which inventive genius has 
devised can be seen in practical operation. The different labor unions 
appear to profit immensely by the special lectures and demonstrations 
which are given on Sundays or, upon request, at any convenient time, by 
men formerly employed in "dangerous trades." Apart from safety 
devices for machinery and appliances for the removal of dust and injurious 
gases, all improved methods calculated to diminish danger, as for example 
in the manufacture of white lead, etc., are illustrated by models and 
descriptive text, printed leaflets being distributed free of charge. Here 
too may be seen the latest and best types of respirators, wire masks, 
goggles, illuminating appliances, first-aid kits, safety working suits etc. 
Only meritorious objects are displayed, and they are replaced by newer 
and more satisfactory types. One of the most interesting collections 
consist of a series of raw material, a series of bottles containing dust 
evolved from such material, a series of photographs showing the micro- 
scopical character of the dust, and last, but not least, anatomical speci- 
mens and microscopical slides, showing the effect of dust upon the 
respiratory organs of the human subject. Models, plans and photographs 
of sanitary homes for the wage-earners with exterior and interior decora- 
tions have a prominent place in the exhibit. The display of food stuff, 
and data relating to its nutritive and economic value together with 
instructive pamphlets, such as "How to keep well and capacitated for 
work," "Good food at reasonable cost," "The alcohol question," "The 
social evil," etc., form part of this interesting display. In 1906 the first 
International Congress on Occupational Diseases was held in Milan, 
which city has also the proud distinction of establishing in 1910 a special 
hospital and clinic for the treatment, study and prevention of occupa- 
tional diseases.* A report of the activities of this clinic by its dis- 
tinguished Director, Professor L. Devoto, will be found on pages 101-113. 
*In this connection it is of interest to note that, according to Halfort, cited by Lehmann,3 
an "Institute for sick journeymen of artists and handiworkers was established at Wurzburg 
in 1786. Georg Adelmann in 1803 published a report on this"Gewerbe-hygienishe Abteilung" 
consisting of 3 rooms and 19 beds, which had cared during this time for 2741 journeymen. PREFATORY 
XXI 
These measures and the establishment of laboratories in connection 
with the universities for the development of experimental industrial 
hygiene and the formation of research institutes for industrial hygiene 
such as the one at Frankfort on the Main in 1908, and also in Vienna, 
Budapest, Munich and elsewhere with courses for industrial physicians 
and factory inspectors have been most beneficial to the wage-earners. 
In 1913 a special laboratory under the direction of Max Rubner was 
established at Berlin for the study of fatigue, the effects of temperature, 
nutrition, clothing and the care of the body in workers. 
A RETROSPECT OF ROPEAN LITERATURE ON INDUSTRIAL MEDICINE 
In the prevention of the fundamental causes of poverty and distress 
the medical profession has been a helpmate to religion. Men who come 
into daily contact with sickness and sorrow cannot fail to experience a 
deep sympathy for their fellow men, which is all the more pronounced 
when they realize that many of the diseases are preventable and hence 
much of human suffe ing unnecessary. As a result, a special department 
of social medicine has been created with a very satisfactory but by no 
means complete literature of its own. One of the most interesting and 
beneficient subdivisi ons of hygiene is a study of the relations of occupations 
to health and longevity. 
The necessity ■ or devoting special attention to this subject was 
shown long since by observations made by Hippocrates and Galen that 
certain occupations and trades, even in those primitive periods, were a 
menace to health. These authors refer in their writings to diseases 
peculiar to miners, tanners, fullers, bearer of burdens, gladiators, sailors, 
soldiers, chemists : nd professional men. Pliny refers to the dangers of 
workers with sulpl ur and zinc, and even the satirists, Martial Jouvenal 
and Plautus speak )f the "blear eyed smith, " "lame tailors," etc. There 
is a long interval between these writings and the next important contri- 
bution to diseases of occupation. 
According to K. B Lehmann3 the first little book on lead diseases was published 
by Samuel Stockhausen in Goslar in 1556, entitled Lithargyia fumo noxio morbifico 
ejusque metallico frequentiori morbo vulgo dido, "Die Hiittenkatze oder Hiittenrauch" 
cum appendice de montano affectu asthmathico metallico familiari "Bergsucht,"- 
Lehmann, quoting Albrecht v. Haller12 (1777) says, "he describes very well the 
symptoms of hiittenkatze (the old German name for disorders caused by smelter 
fumes) such as colic and paralysis, and emphasizes very distinctly that no other metal 
than lead causes the disease-and not arsenic, antimony, cadmium and sulphur." 
"Bergsucht" is the old German name of a pulmonary disorder peculiar to miners, 
characterized by a dry cough caused by inhalation of dust and fumes of different 
metals. 
Garrison13 refers to a monograph by Paracelsus on miners' diseases (Von der 
Bergsucht, Dilingen, 1567) the result of his observations in Fugger's mines in Tyrol 
giving description of miners' phthisis and the effects of choke-damp as one of the few 
original contributions of the time to clinical medicine. XXII 
PREFATORY 
According to Haller,14 cited by Lehmann, Martin Pansa, a town physician at Anna- 
berg in Saxony, published in 1614 a "Consilium peripneumoniae; or a trustworthy 
counsel in the troublesome 'Berg-und Huttensucht.'" 
The first systematic treatise on Diseases of Occupation, entitled "De Morbis 
Artificium Diatriba," was written by Professor Bernado Ramazzini of the University 
of Padua, in Italy, in 1690, but was not published until 1700. Ramazzini was born in 
Capri near Modena in Northern Italy, November 5, 1633, and died on his eighty-first 
birthday in 1714. He received his doctor's diploma at the age of 26 and practiced 
medicine for several years in his native town. In 1671 at the age of 38 he removed to 
Modena and became connected with the University in 1682. In 1685 he began to 
publish a series of medical and hygienic articles which, according to Garrison,13 opened 
up an entirely new department of modern medicine, the diseases and hygiene of 
occupations. The first edition of his "De Morbis Artificium Diatriba" consisted of 
40 chapters." The second edition contained 12 additional chapters. The author 
emphasized in his introduction the importance of industrial hygiene and the need for 
the physician to enquire into the occupation of the patient. He described very ac- 
curately the processes of various industries and occupations, the injurious influences 
and the special diseases of miners, mirror makers, chemists, potters, glass makers, 
painters, sofa-makers, smiths, lime-workers, fullers, tobacco workers, beer-brewers, 
bakers, millers, starch makers, laundry workers, typographical workers, textile 
workers, wood workers, polishers, brick workers, well-diggers, marine workers, etc. 
Ramazzini was the first after Paracelsus to call attention to such conditions as 
stone masons' and miners' phthisis (pneumonokoniosis). These observations were 
based upon post-mortem findings in 1703 and were confirmed and elaborated by 
Johanes Bubbe in his dissertation "De spadone hypocratic.o lapicidarum Seeber- 
gensium haemoptysin et phthysin pulmonum praecedente Ha ae, 1721." 
Ramazzini described the injurious effects of mercury amalgam in gilders and gold- 
smiths, the effects of antimony and sublimate vapors on chef fists, and the effect of 
lead in painters and potters. He refers to the cadaverous and lead gray countenance 
of potters, describes the symptoms not only of lead poisoning, but also of "potters' 
rot" and the cause of vertigo and sciatica among these workers. While Ramazzini 
was not wholly free from the superstition of the middle ages, he was a keen observer 
and student of the injurious effects of occupations on the heabh of the men engaged 
therein, and published a text book which has secured for him undying fame. It is 
gratifying to learn from Garrison15 that Italy has done eponymi c honor to his memory 
in the medical periodical which bears his name.* 
Ramazzini's book was translated into English in 1705, and a so into French in 1711 
and for over a century was the only text book on this subject. According to Lehmann 
there were not less than 25 editions and translations of this picneer text which, in the 
course of time, was greatly improved by additions and also by eliminations of numerous 
digressions. Among the best revisions of the book are those of Ackermann in 1783, 
and Patissier in 1822 in his " Traite des Maladies des Artisans et de celles qui resultant 
des diverses professions " Paris, 1822. 
In 1782, Uden and Pyl founded in Germany the " Annalen fur Staatsarzneikunde." 
This was followed in 1821 by the Annales d'Hygiene in France, which did more for the 
promotion of hygiene in general, and industrial hygiene in particular, than any other 
publication. Among the early contributors was Jean Baptiste Alphonse Chevallier 
(1793-1879) a distinguished pharmacist and chemist, and Professor at the Ecole de 
Pharmacie. Of his 45 contributions to industrial hygiene, Lehmann and Bauer 
emphasize the great value of his studies on lead, copper, chrome, arsenic, phosphorus, 
iodin, bromin, and fuchsin. 
* Those interested in "Industrial Diseases under Mediaeval Trade Guilds" will find 
copious references to the writings of Ramazzini in Dr. Thomas M. Legge's splendid lectures 
published in the Journal of Industrial Hygiene, February, 1920. PREFATORY 
XXIII 
In 1822 Charles Turner Thackrah (1795-1833) of Leeds, a pupil of Sir Artley 
Cooper, wrote a monograph on " The effects of the principal arts, trades and professions 
and of civic states and habits of living on health and longevity." He was also the first 
to investigate "brass founders' ague." 
In 1839 Tanguerel des Planches (1809-62) wrote an important book on diseases in 
lead workers. In 1847 Bibra and Geist published a monograph on diseases of workers 
in phosphorus match factories. In 1848 Dr. A. Cl. Halfort added an interesting 
tome to this branch of medicine under the title "Entstehung, Verlauf and Behandlung 
der Krankheiten der Kunstler und Gewerbetreibender " (Berlin). This volume 
devotes 548 pages to the general pathology and prophylaxis of diseases of occupation, 
followed by a consideration of the metals, toxic gases, animal parasites, a chapter on 
dust, and a careful discussion of the injurious effects of faulty postures, fatigue, abnor- 
mal temperatures, etc. His commentaries on differential diagnosis, prognosis and 
treatment are of great practical value (Lehmann3). 
In 1849 Francis Melier wrote on "The hygiene of tobacco workers." In 1856 and 
also in 1863 A. L. D. Delpech studied the diseases among workers in the rubber 
industry with special reference to carbon disulphide poisoning. 
In 1861 Adolf Kussmaul (1822-1900) published a monograph on constitutional 
mercurialism and its relation to constitutional syphilis. In the same year Schuchard 
and soon thereafter Letheby, Oliviere and Bergeron published articles on anilin and 
nitrobenzol. 
According to Lehmann,3 G. Pearson as early as 1813 demonstrated that the black 
lung in miners was due to coal dust. Zenker in 1866 described the lesions caused by 
the inhalation of the red oxide of iron, and G. Merkel in 1882, described the lesions 
caused by other forms of dust in Pettenkofer-Ziemssen's "Handbuch der Hygiene." In 
1865 Dr. Hermann Eulenberg published a timely book of 550 pages on injurious and 
toxic gases, based upon quantitative determinations. 
In 1869 Delpech and in 1876 Delpech with J. B. Hilairet published the result of 
their studies on diseases of chrome workers. In 1871-1878 Dr. Ludwig Hirt, Professor 
of Hygiene at Breslau, wrote an extensive treatise on occupational diseases. In 1876 
Eulenberg wrote his "Handbuch der Gewerbehygiene." In 1876 Dr. Alex Layet 
wrote a very satisfactory "Hygiene des Professions et des Industries" of about 356 
pages, which is of great value today for its historical references. This book was 
translated into German by Friedrich Meinel. 
Among other important French contributions following that period mention 
should be made of the books of Poincarg (1886), Thoinot (1903) and Brouardel- 
Chantemesse and Mosny (1908), while more recently, Heim and Hebert have published 
(without date) a number of experimental studies entitled, "Questions d'hygiene 
industrielle." 
Among the noteworthy publications in England from 1890 to 1921 we must not 
forget the classic one by Thomas Arlidge on "Diseases of Occupation, " published in 
1892. Also the monumental work entitled "Dangerous Trades: the historical, social 
and legal aspect of industrial occupations as affecting health;" this volume of 891 pages 
was contributed by English authors under the able editorship of Dr. (now Sir) Thomas 
Oliver. In 1908 Sir Thomas Oliver published his first edition of Diseases of Occupa- 
tions which was revised in 1916 and is sharing a deserved popularity. 
In 1912, Dr. Thomas M. Legge and Dr. K. W. Goadby published an important 
study on "Lead Poisoning and Lead Absorption." Dr. Legge has been an earnest and 
fruitful worker in the field of industrial medicine for many years, and like Sir Thomas 
Oliver is the author of several important chapters in Kober and Hanson's "Diseases of 
Occupation and Vocational Hygiene" used in this volume. The English speaking 
public is also indebted to him for his excellent translation in 1913 of Dr. J. Ram- 
bousek's book on "Industrial Poisoning from Fumes, Gases and Poisons of Manufac- 
turing Processes." This book was originally published in German in 1909 and 1911 XXIV 
PREFATORY 
and is intended, as well expressed by Rambousek, for all who are, or are obliged to 
be, or ought to be, interested in industrial poisoning. 
Much excellent work has also been done by Leonard E. Hill who investigated 
caisson disease in 1912, and the general evils of stuffy atmosphere, and made important 
contributions to the science of ventilation and lighting of workshops, and also investi- 
gated food values in relation to occupations. Dr. J. S. Haldane studied atmospheric 
conditions, dust inhalation and the health of miners. 
Among other English workers in the field of industrial medicine may be mentioned 
Dr. Edgar L. Collis, distinguished for his studies of the physiological and pathological 
effects which follow exposure to compressed air (1908); effect of dust in producing 
diseases of the lungs (1913); housing in relation to tuberculosis and factory life (1914); 
industrial pneumonoconiosis (Milroy Lectures, 1915); eye injuries caused by occupa- 
tions (1915); welfare work in factories, etc. (1919). Major Greenwood has made 
careful researches on cancer mortality in occupations; industrial accidents and fatigue; 
causes of wastage of labor in munition factories employing women; welfare health 
workers; etc. In 1921 Collis and Greenwood published a splendid book on "The Health 
of the Industrial Worker" which deals in a very satisfactory manner from the stand- 
point of hygiene with the profound changes in the lives of civilized people during the 
past century and a half consequent upon the rise and development of modern industry. 
E. W. Hope of Liverpool has written an excellent book of 766 pages on "Industrial 
Hygiene and Medicine," published by Wm. Wood & Co. Jan., 1923. 
From France, in 1918, appeared the splendid treatises by Ju!es Amar on "The 
Physiology of Industrial Organization," and "The Human Motor." 
Among the German text books on industrial hygiene published since 1890 should 
be mentioned the Handbiicher by Albrecht (1896), Theo. Sommerfeld (1898), Emil 
Roth (1900 and 1909). In 1897, German authors, under the leadership of Theodor 
Weyl, completed a volume of over 1250 pages, and in 1908 a "System on Diseases of 
Occupations." These monumental volumes, like Oliver's "Dangerous Trades," were 
written by recognized experts on the various subjects and hence their conclusions 
carried great weight. It must be acknowledged that the value of all the foregoing 
text books, etc., has been greatly enhanced by the splendid work which had been 
accomplished by laboratory and field workers. Max v. Pettenkofer, the founder of 
experimental hygiene, induced Max Gruber in 1881 and Ogata in 1882 to undertake, 
with the aid of the respiration apparatus, investigations on carbon monoxide and 
sulphurous acid. Since 1884 Prof. K. B. Lehmann and his pupils have made quanti- 
tative studies of 35 gases and fumes, based upon animal experiments, observation in 
the industries, and when practicable also upon human control experiments. At the 
same time he has studied the effects of most of the metals by feeding experiments 
with small and increasing doses in animals, and determined the channels and extent 
of absorption of the poisons into the body and thus furnished us with scientific data 
on the relative toxicity of the various poisons employed or evolved in the industries. 
Lehmann's contributions are of striking practical value, and form the basis of the 
best "Lehrbuch der Arbeits und Gewerbehygiene " ever written. (S. Herzel at 
Leipzig, 1919, 468 pages.) 
Prof. L. Lewin of Berlin has also made extensive studies of industrial poisons, 
especially of organic poisons. In his work on "Die Nebenwirkung der Arzneimittel" 
he adduces a vast number of facts showing how the same poisons may produce different 
effects in different individuals, all of which, like his expert opinions on industrial 
hygienic questions, are of great value. Excellent work in industrial hygiene has 
also been done in the German Imperial Health Office by Dr. Wolffhiigel, Renk, 
Wutzdorf, Rost, and by Factory Inspectors Fridolin Schuler of Berne; Ludwig 
Teleky of Vienna; Friedrich Koelsch of Munich, and by a number of Industrial 
Physicians like Grandhomme, Schwerin, Floret, Robert Muller, Bachfeld, F. Cursch- 
mann, Bratt and a host of others, too numerous to mention (Lehmann3). Their PREFATORY 
XXV 
writings will always remain monuments of careful study, accurate observations, great 
industry and faithful devotion to a noble cause. 
PROGRESS OF INDUSTRIAL HYGIENE IN THE UNITED STATES 
As in Europe, so in this country, the mechanical industries had 
their origin in the textile industry. According to Wright,16 the first 
spinning-jenny in this country was exhibited in Philadelphia in 1775. 
The first cotton factory to apply Arkwright's invention was started with 
three cards and 72 spindles in Rhode Island in 1770, by Samuel Slater of 
England. It is reported, however, by a writer in the American Museum 
for July, 1790, that a man in South Carolina completed and had in opera- 
tion on the Santee, ginning, carding and other machines driven by water 
and also spinning-machines with 84 spindles each. Waltham, Massa- 
chusetts, has the credit of having set up the first power loom in 1814, and 
of having established for the first time in history a factory in which all the 
processes involved in the manufacture of goods from the raw material to 
the finished product were carried on in one establishment. 
The wonderful progress in the cotton textile industry in the United 
States is shown by the increase of spindles from 4,500 in 1805 to 1,246,703 
in 1821. The following table shows the growth of the factory system as 
illustrated by the cotton industry in Great Britain and the United States: 
Year 
No. mills 
No. spindles 
No. looms 
No. 
employes 
Great Britain 
1838 
1,151 
9,333,000 
100,000 
237,000 
1878 
2^671 
39^527^920 
514^911 
482,903 
United States 
1831 
801 
1,246,703 
33,433 
57,466 
1880 
756 
10,653,435 
225,759 
172,544 
1899 
1,055 
19,008,352 
450,682 
302,861 
1914 
1,328 
30,815,731 
672,734 
393,404 
1919 
1,496 
33,718,953 
692,169 
446,852 
According to the Department of Commerce17 the number of cotton 
bales (500 pounds to each bale) exported from the United States increased 
from 1,987,708 bales in 1870 to 10,682,758 bales in 1912, and fell gradually 
to 6,316,121 in 1922: The actual supply of cotton and linters in this 
country has increased from 13,358,707 bales in 1908 to 16,674,637 in 1922, 
with even greater quantities in some of the intervening years. 
CHILD LABOR IN THE UNITED STATES 
Both in England and in this country the application of machinery 
resulted in the exploitation of child labor. It cannot be claimed, how- 
ever, that we followed the example of England to the extent of trafficking 
with the poor-law officials in a form not greatly different from the methods 
of ancient slave-dealers. It is reported by Price2 that the first cotton XXVI 
PREFATORY 
mill established in 1770 in Rhode Island began to work with four spinners 
and carders, but five children were soon added whose ages ranged from 7 to 
12 years, and in 1831 the number of children engaged in the cotton mills of 
that state was about one half of the total number of employes. According 
to Miss S. S. Whittelsey's "Essay on Massachusetts Labor Legislation," 
the subject of child labor received attention in 1836. The act provided 
for at least three months schooling during the working year for every 
child employed under the age of 15, and, as amended in 1842, for a ten- 
hour working day for children under 14 years. In 1842 similar legislation 
was enacted in Connecticut. 
According to Price,2 as early as 1827 a bill was introduced in the House 
of the Pennsylvania Legislature which provided that no minor between 
12 and 13 should be employed in the manufacture of cotton or wool 
unless producing a certificate from a schoolmaster or two citizens stating 
that the minor in question could read and write English and German or 
some other modern language, or unless the manufacture should provide 
for instruction of said minor. The bill passed the House but failed in the 
Senate, and nothing more was done until 1837 when the Senate appointed 
a committee to investigate child labor. This committee found that one- 
fifth of the entire number of workers in the cotton mills in the state were 
under 12 years of age, and that the time spent at work ranged from 
11 to 14 hours a day, with an average working week of 72 hours. 
The committee also reported that only one-third of the cotton mill workers 
under 18 years could read or write. In spite of this deplorable condition 
no action was taken until 1848 when a bill was passed which forbade 
the employment of minors in any cotton, woolen, silk or flax factory. 
The bill provided a legal working day of 10 hours in all such factories, 
with a proviso that minors above the age of 14 might be employed more 
than 10 hours by special contract with parents and guardians. In 
1849 the minimum age was raised to 13 years and the law was extended 
also to the paper and bagging industries. 
In New York the first school law was enacted in 1852, and it was 
not until 1874 that the law was framed making compulsory 14 weeks 
of schooling each year. In 1886 the first factory law to regulate 
the employment of women and children in manufacturing establish- 
ments was enacted, and Illinois followed soon with a similar law. Since 
then commendable advance has been made. The compilation of labor 
laws by the Department of Labor in 1892 shows that thirty-four states 
had laws relating to the employment of children and females. Forty- 
three of the forty-five states in the Union in 1892 also had laws relating 
to minors who could be bound out as apprentices. Most of the laws 
required that the apprentice be given an education, good and wholesome 
provisions, and all necessary clothing, washing, lodging and medical 
attention, and also that he be taught the trade to which he was 
indentured. XXVII 
PREFATORY 
NATIONAL COMMITTEE ON CHILD LABOR 
In 1906 by an Act of Congress (Section 2, United States Statutes, 
Number 1180) the National Committee on Child Labor was incor- 
porated. The objects of this corporation are to promote the welfare of 
society with respect to the employment of children in gainful occu- 
pations; to investigate and report the facts concerning child labor; 
to raise the standard of parental responsibility with respect to the employ- 
ment of children; to assist in protecting children, by suitable legislation, 
against premature or otherwise injurious employment, thus to aid 
in securing for them an opportunity for elementary education and physical 
development sufficient for the demands of citizenship and the require- 
ments of industrial efficiency; to aid in promoting the enforcement of laws 
relating to child labor; to coordinate, unify and supplement the work of 
state or local child labor committees, and encourage the formation of such 
committees when not existing. This Committee deserves special credit 
for what has been accomplished in the way of child-labor legislation in 
this country. (See also pages 1020-1027.) 
FEDERAL LABOR LEGISLATION 
The fundamental legal requirements relating to occupational diseases 
and accidents and industrial hygiene are found in the statutes of the state 
and of the federal government, as interpreted in case of disputes by courts. 
These statutes rest upon the "police power" of the government; that is, 
the exercise of public authority to secure the public welfare by restraint 
and compulsion (C. R. Henderson). Federal labor legislation began rather 
late in the history of the United States, and this because all such legisla- 
tion was entrusted under the Constitution to the police powers of the 
various states. It was only after the Government directed the affairs in 
interstate commerce and increased the number of civilian employes that 
federal legislation became more necessary. The following is a chronolo- 
gical list of federal enactments: 
1875. The first federal statute relating to labor which the writer 
found was an Act of March 3, 1875, in Section 2 of which the involuntary 
transportation of any subject of China, Japan or any other oriental 
country is prohibited. The same Act also requires preference to be 
given to all domestic materials and labor for public works. 
1882. The Act of May 6, 1882, as amended July 4, 1884, suspends the 
coming of Chinese labor to the Unites States and the act of September 13, 
1888, prohibits immigration of Chinese labor. Section 7 of the Act of 
May 4, 1882, grants the privilege to any keeper or member of a crew of a 
life-saving or life-boat station disabled by reason of any wound or injury 
received or disease contracted in the line of duty and which unfits him 
for the performance of his work, of being continued upon the rolls of the XXVIII 
PREFATORY 
service and entitled to receive his full pay during the continuance of such 
disability, the period of one year, applicable to this regulation, not to be 
extended unless upon recommendation of the general superintendent. 
Section 4418 of the Act, as amended by the Act of March 3, 1905, 
requires inspection of the boilers and appurtenances in all steam vessels 
before the same shall be used and once at least every year thereafter. 
1885. By a resolution of January 6, 1885, the employes of the Navy 
Yard, Government Printing Office, Bureau of Engraving and Printing 
and all other per diem employes of the government shall be allowed the 
following holidays: the first day of January, the twenty-second of Febru- 
ary, the fourth of July, the twenty-fifth of December, and such days as 
may be designated by the President as days for national thanksgiving, 
receiving on these days the same pay as on other days. 
1886. The Act of June 29, 1886, deals with labor organizations, and 
particularly with the incorporation of national trade unions. 
1887. By a resolution of February 23, 1887, all per diem employes 
of the Government on duty in Washington or elsewhere in the United 
States shall be allowed as holidays each year the day which is celebrated 
as Memorial or Decoration Day and the Fourth of July, and shall receive 
on these days the same pay as on other days. 
1888. The Act of May 24, 1888, prescribes 8 hours as a day's 
labor for letter carriers. By an act of June, 1900, the hours shall not 
exceed 48 during the 6 working days of each week, such number of 
hours, not exceeding 8, to be spent on Sunday as may be required by 
the needs of the service. 
1890. Section 4509 of the Act on August 19, 1890, provides that to be 
apprenticed for sea service a boy must have the consent of his parents or 
guardians, and must be not less than 12 years of age, and of sufficient 
health and strength. 
1890-91. Chapter 564 refers to an Act relating to coal mines, covering, 
among other subjects, inspections, defective conditions, ventilation, 
sprinkling, shot fire, escape shafts, furnace shafts, safety cages and 
accidents. Employment of children under the age of 12 is prohibited in 
the underground workings of mines. 
1892. The Act of August 1, 1892, as amended by Chapter 106, Act 
of 1912-1913, in Section 3738, declared that "eight hours shall constitute 
a day's work for all laborers, workmen and mechanics who may be 
employed by or on behalf of the Government of the United States." 
1893. The Act of March 2, 1893, deals with safety appliances on 
railroads. 
1895. The Act of January 12, 1895, as amended by the Act of August 
24, 1912, fixes the limit of wages, holidays and night work of certain 
federal employes. 
1897. The Act of January 18, 1897, refers to inspection of boats 
propelled by gas, etc., also to tug and freight boats, and the inspection of PREFATORY 
XXIX 
boilers. The Act of March, 1897, refers to inspection of steam boilers on 
foreign vessels. 
1899. By an Act of March 1, 1899, to railway postal clerks whose 
duties require them to work 6 days or more per week, 52 weeks a year, an 
annual vacation of 15 days with pay, may be granted by the Postmaster 
General. Section 4153 of the same Act requires not less than 72 cubic 
feet and not less than 12 superficial feet for each seamen or apprentice 
lodged on vessels. 
1901. Section 1990 of the United States Statutes compiled in 1901 
abolished peonage. Section 2158 prohibits engaging in cooly labor. 
Section 4801 deals with hospital relief for sick and disabled seamen, and 
Section 5344 with negligence of employes on steamboats, causing 
death. Section 4569 requires every vessel of 75 tons or upwards to be 
supplied with a medicine chest, and Section 4572 makes provision for 
clothing and fuel on vessels. Section 4611 prohibits flogging and all 
other forms of corporal punishment on board of any vessel. 
1902-3. Chapter 976 deals with the application of the law of 1893 
regarding safety appliances on railroads. 
1906-7. Section 2, Chapter 1180 of the Acts of 1906 provides for the 
incorporation of a National Committee on Child Labor. 
Chapter 2558 creates a foundation for the promotion of industrial 
peace. 
Chapter 2939' regulates the hours of labor of employes on railroads. 
1908. Chapter 149 of the Acts of 1907-1908 deals with liability of 
railroad companies for injuries to employes in interstate commerce. 
Chapters 200 and 225 deal with inspection and test of railroad safety 
appliances. 
On May 30, 1908, the Federal Government enacted a limited com- 
pensation law for the civilizan employes of the United States applicable 
only to certain hazardous employments. 
1909. Chapter 240 of the Acts of 1909-10 creates a Federal Bureau 
of Mines in the Department of the Interior. 
1910. Chapter 103 of the Acts of 1910-1911 relates to inspection of 
locomotive boilers. 
1911-12. Section 1, Chapter 355 of the Acts of 1911-1912 relates 
to plate printers, rates of wages and power presses in the Bureau of 
Printing and Engraving of the United States treasury Department. 
Chapter 389 of the Acts of 1911-1912 relates to the construction of 
sound and sanitary postal railway cars, and to the provision in these cars 
of sanitary drinking-water containers and toilet facilities. By an act of 
Congress, approved April 9, 1912, the use of poisonous white phosphorus 
matches was abolished in our country by the establishment of a prohibi- 
tive tax of 2 cents per 100 matches. The creation of the Children's Bureau 
by an Act approved the same day was a significant and prophetic action. 
By an Act approved August 23, 1912, Congress authorized the appoint- XXX 
PREFATORY 
ment of a temporary commission on industrial relations, one of whose 
duties is to inquire into matters relating to the health of employes. This 
commission made several important reports. 
1912-13. The Act of August 1, 1892, as amended by Chapter 106, 
Acts of 1912-13, provides in Section 3738 that 8 hours shall complete 
a day's work for all laborers, workmen and mechanics, who may be 
employed by or on behalf of the Government of the United States. 
1916. On September 7, 1916, Congress enacted a model workmen's 
compensation law for the civilian employes of the United States, and in 
1919 Congress extended this law to protect likewise the public employes 
of the District of Columbia. 
STATE LABOR LEGISLATION 
Because of the multiplicity of commonwealths in the United States 
and the lack of uniformity in the laws, it is quite difficult to offer anything 
like a complete historical review of all the laws of the states relating to 
the protection of wage-earners in factories, workshops and mines. 
The first compilation of labor laws enacted in the United States was 
published by the United States Commissioner of Labor in 1892. The 
volume covers 603 pages and includes all legislation in force at the close 
of the year 1890. A revision of this compilation with additions was 
published in 1896. This volume of 1,383 pages includes all legislation 
up to the beginning of that year. The third compilation, covering 1,413 
pages, appeared in 1904. The fourth compilation, covering 1,562 pages, 
was published in 1907. The fifth compilation, covering 2,473 pages, 
appeared in 1915, and includes all legislation up to the beginning of 1914, 
together with orders of the State Industrial Commissions of New York 
and Wisconsin, which under the laws of these states have the force of laws 
LAWS ENACTED PRIOR TO 1890 
It is interesting to note that the laws enacted prior to 1890 deal largely 
with the protection of children and female employes, apprentices, and 
the right of action for injuries in nearly all of the states. The eight- 
hour labor laws as applied to roads and public works existed in 33 
states. Thirty-four states had legislation on female labor. Of these, 
16 states regulated the hours of work for women, and 19 required seats 
for women in certain occupations. 
Only 14 of the states had made provisions for inspection of factories 
and workshops, and 22 states for inspection of mines. Fourteen of the 
states had provisions for reporting accidents in factories and 22 states had 
statutes for the prevention of accidents in mines. Thirteen states 
required fire-escapes and doors swinging outwards; 23 states required 
inspection of steam boilers; 21 states had statutes relating to the health 
of employes, among these being statutes regarding ventilation and sanita- 
tion of workshops in general. (See Table, page xxxviii.) Thirteen states PREFATORY 
XXXI 
had laws requiring guarding of machinery. Three states, New Jersey, New 
York and Ohio, had laws requiring guards for vats containing molten 
metal or other hot liquids. 
The following states had laws prior to 1890 on safety apparatus for 
mine-shafts: California, Colorado, Illinois, Indiana, Iowa, Kansas, 
Kentucky, Missouri, Montana, Nevada, Ohio, Pennsylvania, Washington, 
West Virginia and Wyoming. 
Michigan and New York had laws on safety applicances on railroads. 
Eight states-Massachusetts, New Jersey, New York, Connecticut, 
Pennsylvania, Michigan and Missouri-had laws prohibiting "oiling 
of machinery in motion by women and children." 
The following states had laws guarding elevators and hoistway open- 
ings: Massachusetts, New Jersey, Ohio, New York, Connecticut, Pennsyl- 
vania, Rhode Island, Michigan, Missouri, and Minnesota. 
Massachusetts and New York were the only two states having laws on 
the use of explosives and inflammable material. 
The following states had laws relating to ventilation of factories and 
workshops: Massachusetts, New Jersey, Ohio, New York, Connecticut, 
Pennsylvania, Rhode Island, Missouri. 
Only two states, New Jersey and Ohio, had statutes on the subject of 
heating and lighting. 
New York, New Jersey and Michigan were the only states requiring 
"limewashing or painting of walls of workshops." 
Only five states, Massachusetts, New Jersey, New York, Pennsyl- 
vania and Illinois, had legislation to regulate the "sweating system." 
Massachusetts was the only state requiring approval of plans for 
factories. 
LAWS ENACTED SINCE 1908 
In 1908 and 1909 legislative attention was given largely to the subject 
of employer's liability, the common law defenses having been abrogated 
or modified in a number of states. Fifty-four laws were enacted in 32 
states affecting the employment of women and children. 
In 1910 the subject of workmen's compensation began to claim the 
attention of legislatures, and a number of industrial commissiohs were 
created. Retirement and pension funds also received attention in two 
states. 
In 1911 the workmen's compensation acts continued to occupy the 
center of the legislative stage in 10 states, and occupational diseases also 
received attention in some of the states. The first American law for the 
compulsory reporting of these diseases was drafted by the Association 
for Labor Legislation and was enacted in California in March, 1911. These 
two subjects also held places of increasing importance from 1912 to 1914. 
Accident prevention and accident reporting, and female and child labor 
received attention in a number of states, and the conditions affecting 
employes in mines and on railroads also resulted in additional legislation. XXXII 
PREFATORY 
In 1913 the subject of minimum wages and of support for mothers and 
dependent children was a prominent topic in remedial legislation. 
After these preliminary remarks, a clearer insight into the develop- 
ment of factory legislation may be given by sketching briefly the legislation 
of Massachusetts-the first state in the Union to recognize the fact that 
sanitary inspection of factories is essentially a public health matter. 
FACTORY LEGISLATION 
The bill passed by Massachusetts in 1852 regarding the safety of steam 
machines was the first legislation of this nature enacted by any state. 
An Act of 1870 also required supervision of steam-boilers. The enforce- 
ment of the child labor law had been assigned to the local school authori- 
ties and truant officers. In 1866 a single deputy detailed by the police 
department was entrusted to enforce this law, and only in 1877 was the 
right of entry into factories granted to the inspector. In the same year 
this state enacted a law setting forth certain requirements for the removal 
of dust. In 1879 the Governor was empowered to appoint two or more 
members of the district police to act as inspectors of factories and public 
buildings. The duties of these inspectors were (1) the enforcement of 
laws regulating the hours of labor in manufacturing establishments; 
(2) the enforcement of laws relating to the employment of children, and 
(3) inspection of factories and public buildings. 
One of the inspectors, Rufus R. Wade, in his report made as Chief 
of District Police for 1879 (page 8), cited by Price,2 states: 
In the matter of providing for speedy and safe egress in case of fire or panic, a large 
number of manufacturing establishments were found deficient. The horrors of 
Holyoke and Granite Mill at Fall River and other disasters that have occurred by 
reason of neglect to provide safe means of egress in case of fire or panic should not, 
through negligence or thoughtlessness of manufacturers or owners of buildings, be 
repeated. 
The report also points out that the laws providing for education of 
child workers were not enforced, and that children were below the legal 
age, the youngest being nine years old. The board asked for two addi- 
tional assistants, and, because of the magnitude and importance of the 
problem, recommended that the inspection of factories be made a distinct 
branch of the police service. The Governor in his message in 1880 
approved the recommendation, but it was not put into effect until 1888. 
In the meantime an Act had been passed on March 24, 1887, to secure 
proper sanitary provisions in factories and workshops; another, on 
April 14, to secure proper ventilation and proper meal hours. On March 
10, 1890, the law relating to accidents was amended and made more 
drastic. 
In 1891 the corps of inspectors was increased to 26, two women 
inspectors being added. In 1893 a separate boiler inspection division 
with ten inspectors was created. In 1905 a reorganization of factory PREFATORY 
XXXIII 
inspection was made, by which a number of state health inspectors were 
appointed, who took over a considerable part of the functions of factory 
inspectors. In the same year the State Board of Health submitted a brief 
but excellent report on the conditions affecting the health and safety of 
employes in factories and other establishments in Massachusetts. This 
report was supplemented in 1907 by a more extensive report and 
included a collection of 90 photographs. The photographs, based upon a 
study of dusty trades in Massachusetts made by Dr. William C. Hanson, 
together with charts and a collection of dust and other materials, demon- 
strated in a most effective manner that many of the insanitary surround- 
ings and injurious factors in the leading industries are due to neglect of 
perfect ventilation, and hence are to a great extent avoidable. This was 
in fact the first exhibit in America relating to occupational diseases and 
industrial hygiene. 
The report contained many excellent comments, as, for example: 
In the boot and shoe industry, the inspectors found four conditions which can be 
and ought to be remedied, viz.: poor ventilation, inadequate removal of dust from 
machines, the conditions of water closets, and spit upon the floors. 
In the majority of the factories visited the ventilation was very poor, and in many 
of them distinctly bad. Of the rooms not especially dusty 102 were very badly ven- 
tilated and 25 were overcrowded. Of 84 of the many dusty rooms reported, 40 were 
also overcrowded; 35 were dark, 21 overheated, and 18 overcrowded, dark and over- 
heated. In more than one-third of the factories inspected, most of the water closets 
were dark and dirty to very dirty. In 50 establishments no spitting on floors was 
noticed; in 173 there was some; in 115 considerable, and in 35 much. 
In 85 factories, or 23 per cent, of those visited, a considerable proportion of the 
employes were noticeably pale and unhealthy. 
In the emery and corundum, sand-paper, and all other industries more attention 
should be given to keeping the dust away from the mouth and nostrils of the workmen. 
In the rag industry and cutting rooms of some paper mills very objectionable amounts 
of dust were found and some pale and sickly-appearing operatives, but there are mills 
using the same kind of stock, where the dust is kept away from the employes in a satis- 
factory manner, and much improvement is practicable in the former class. 
In discussing the provisions of the Massachusetts law regarding the 
cleanliness of factories, the report points out that- 
What is clean in an axe-grinding factory would not be so in a silk mill, but the law 
makes no distinction, and the judgment of the officer cannot be received as law . . . 
The Board considers it impossible to specify in any law a standard of cleanliness 
applicable to all industries, and advises that the officer should be authorized to hold 
all factories in any industry up to the standard of cleanliness which he finds main- 
tained in the same industry and using the same grade of stock and which are the 
cleanest. The same method is recommended for the enforcement of standards in 
other directions, subject to an appeal to the State Board of Health.^ 
The writer feels that the pioneer work and methods pursued by 
the State Board of Health of Massachusetts have been of inestimable 
value not only to that commonwealth, but also to the country at large. 
The same agency which investigated the dangers of occupations was 
seeking also to control the evils which arise in the home and community XXXIV 
PREFATORY 
life of the worker. The state inspectors of health were in constant com- 
munication with local physicians who could give information concerning 
not only merely communicable diseases, but also occupational diseases, 
as is brought out in a paper by Dr. William C. Hanson.17 The principles 
upon which the board was proceeding may be found in a paper by Dr. H. 
Linenthal,18 one of the inspectors. 
By a law enacted June 10, 1912, in spite of the good work done under 
the State Board of Health, the duties of the Board were transferred to a 
"Board of Labor and Industries," composed of one employer, one 
laborer, one physician and one woman. This Board was empowered 
to appoint a commissioner of labor, whom it might remove at any time; 
to investigate conditions and to hold hearings; to seek expert advice and 
prosecute violators of the law, and to appoint industrial health inspectors 
and assistants, such persons not being legally required to have a medical 
training. 
Considerable space has been devoted to the state of Massachusetts 
because it has led all other states in labor legislation, except in the enact- 
ment of the law relating to the reporting of occupational diseases. 
Factory Inspection.-There was no legislation in the United States 
for factory inspection prior to May 11, 1877, when Massachusetts led the 
way, followed, in 1883, by New Jersey and Wisconsin, Ohio in 1884, 
New York in 1886, Connecticut, Minnesota and Maine in 1887, Penn- 
sylvania in 1889, Missouri and Tennessee in 1891, Illinois and Michigan 
in 1893, and Rhode Island in 1894. 
The inspection service in 11 of these states included the enforcement of the law- 
relating to child and female labor. In Massachusetts, New Jersey, Ohio, Connecticut, 
Rhode Island, Maine, and Minnesota, the inspection covered seats for female employes. 
In 9 states the inspection law covered fire protection in the way of fire-escapes and 
ready egress by outward-swinging doors. In 10 states inspection applied also to the 
guarding of machinery. In the following states, which had laws providing for the 
removal of dust and objectionable gases by exhaust fans, the inspection covered this 
point, viz.-Massachusetts, New Jersey, New York, Connecticut, Michigan, Missouri 
and Minnesota. Michigan, by Act 136 of 1887, and New York, in 1890, required 
blowers to be provided for emery wheels in factories. 
In 1908 the writer was able to report 12 additional states-California, Illinois, 
Indiana, Iowa, Maryland, Ohio, Oregon, Pennsylvania, Mississippi, South Dakota, 
Washington and Wisconsin-making 17 states which required mechanical devices for 
the removal of injurious dust and gases. Of these states quite a number laid down 
specific rules concerning the construction of work-benches and hoods. The latter 
empty into air-shafts connected with exhaust fans. Of the laws then in effect the 
writer cited the Michigan law of 1899 as the best example of regulation of this 
character. 
The inspection service also covered heating and lighting of workshops in New 
Jersey and Ohio, overcrowding in New Jersey and New York, and the "sweating 
system" in Massachusetts, New Jersey, New York, Pennsylvania and Illinois. In 
8 states factories were subject to inspection in regard to sanitary conditions, including 
toilet facilities. In 22 states the inspection covered safety apparatus for mine-shafts, 
safety lamps, and the like. PREFATORY 
XXXV 
PROGRESS OF FACTORY LEGISLATION, 1890-1920 
We can now say with great satisfaction that all of the states now 
have some form of legislation for the protection of children. In 26 
states there is a provision for the exclusion of children under sixteen 
years from dangerous trades, and three other states besides 12 of the 
26 specify other dangerous trades in which persons under 18 may not 
be employed. Fourteen states prohibit the employment of persons 
under 21, or minors, in a few other trades injurious to morals as well 
as to health, or in trades affecting the safety of others. But in most cases 
the statutes are vague and lacking in uniformity. 
Where one state specifies simply mines and quarries as dangerous, 
the other gives a long list of carefully defined processes or occupations 
dangerous to health or morals, leaving the definition of such occupation 
to the enforcing officials. Almost invariably when a state has such a 
loose statute, the machinery for its administration is so weak that the 
law is practically a dead letter. The only attempt at uniformity in 
such legislation in the United States is the "Uniform Child Labor Law," 
drafted by the National Child Labor Committee in 1911 and 
ater endorsed by the American Bar Association. (See palge 1025.) 
Forty-five states have laws relating to the hours of female labor, and 52 states 
require seats for women in certain occupations. 
It is gratifying to report that in 1920, 50 states had laws providing for inspection 
of factories and workshops, and 36 states required inspection of mines; 21 states 
inspection of bakeries : and 30 states inspection of steam-boilers. 
Thirty-four states require fire escapes, ready egress by outward-swinging doors 
and other methods of fire protection. 
Thirty-six states require guards for dangerous machinery. Twenty-eight states 
make reports of accidents in factories obligatory; and 34 states make reports of 
accidents in mines obligatory. Forty-three states have laws relating to railroad 
safety, and 39 states demand reports of railroad accidents. Twenty-six states have 
laws providing for the protection (in the way of safety scaffolds and the like) of 
employes on buildings. 
Thirty-five states have laws on sanitation of factories and workshops, including 
laws on ventilation, many of which require the removal of injurious dust and fumes 
by mechanical devices and exhaust ventilation. 
Forty-three states have laws referring to toilet rooms and washing facilities. 
The following states have laws relating to the manufacture and 
storage of explosives: Iowa, Maryland, Massachusetts, Missouri, New 
Jersey, Ohio, and Oklahoma. 
Fifty-four states have laws relating to liability of employers for 
injuries to employes. Forty-five of these states and 3 territories have 
abandoned the older idea of employers' liability and adopted the princi- 
ples of compensation for accidents. 
The following states have enacted laws providing for mothers' 
pensions: California, Colorado, Idaho, Illinois, Iowa, Massachusetts, 
Michigan, Minnesota, Missouri, Nebraska, Nevada, New Hampshire XXXVI 
PREFATORY 
New Jersey, Ohio, Oklahoma, Oregon, Pennsylvania, South Dakota, 
Utah, Washington, and Wisconsin. 
The following states have laws providing seats for street railway 
employes: Connecticut, Louisiana, Missouri, New Jersey, Oregon and 
Vermont. 
The following states have laws relating to meal hours: California, 
Delaware, Indiana, Louisiana, Massachusetts, New Jersey, New York, 
Ohio, Oregon, and Pennsylvania. 
The following states require vaccination in certain occupations: 
Connecticut, Maine and Virginia. 
The following states prohibit the employment of women for periods of 
two to four weeks before and after childbirth: Connecticut, Massa- 
chusetts, Missouri, New York and Vermont. 
By an Act of March 14, 1881, a hospital for miners was established in 
the state of California, where indigent miners are charged at actual cost 
for medical attendance, surgical operations, board and nursing, while 
pay-patients, whose friends can pay their expenses, and who.are not 
chargeable upon townships and counties, pay according to the terms 
decided by the trustees of the State Miners' Hospital and Asylum. 
In 1887, by Acts 264 and 265, the state of Pennsylvania established 
state hospitals for the middle coal-fields, the hospitals to be devoted to the 
reception, care and treatment of persons injured in or about the mines, 
workshops and railroads, or any other laboring men. 
New Mexico, in Section 2337 of the compiled laws of 1897, has a 
provision that whenever any employe in smelting works contracts lead 
poisoning, the employer becomes responsible for the medical care and 
treatment of the victim. The same Territory, under Chapter 2, Act of 
1903, established a State Hospital for the treatment and care of resident 
miners of the Territory of New Mexico, who may become sick or injured 
in the pursuit of their occupation, care and treatment to be free, unless 
the patient is possessed of property and means sufficient to pay the actual 
costs and charges incurred. 
Arkansas, by Act 299 of 1909, compelled railway companies who have 
heretofore collected or received hospital fees from their employes to 
"provide hospital facilities in this state of such capacity and equipment as 
will be sufficient for the care, needs and accommodations of their sick and 
injured employes who are residents of the state. Any such employes 
injured while in the service of any such railroad shall not be taken or sent 
out of the state for treatment." 
HISTORY OF WORKMEN'S COMPENSATION ACTS 
Workmen's Compensation in the United States.-The Fourth Special 
Report of the Commissioner of Labor, issued in 1893 under the title of 
Compulsory Insurance in Germany, was the first publication in this PREFATORY 
XXXVII 
country devoted to the subject of workmen's insurance. Before that 
time compensation for industrial accidents had been established in Ger- 
many in 1884, and in Austria in 1887. Norway did not follow until 
1894. The last report, Bulletin Number 126, entitled "Workmen's 
Compensation Laws of the United States and Foreign Countries," dated 
December 23, 1913, shows that 41 foreign countries (including all European 
countries except Turkey) have introduced some form of workmen's 
compensation for industrial accidents. All of these forms, while showing 
great variations in the industries covered, the amount of compensation 
provided, and the methods by which compensation payments are secured, 
recognize the principles of compensation as distinguished from the older 
ideas of employers' liability previously accepted in the civil law of Con- 
tinental Europe, as well as in English and American law. 
It is interesting to learn that the state of Maryland in 1902 provided 
legislation for stated benefits payable without suit in the form of a coopera- 
tive insurance law, and applicable to certain occupations, such as mining, 
quarrying, steam and street railways, and public work. This law was 
declared unconstitutional. 
In 1905 the United States Philippine Commission authorized the 
continuance of wages for a period during disability, but not exceeding 
90 days, in case of injury by employes of the insular government in line 
of duty. In 1908 the Federal Government enacted a law "granting to 
certain employes the right to receive from it compensation for injuries 
sustained in the source of employment." A more comprehensive Federal 
Law was enacted in 1916 and in 1919. (See also page 1043.) 
On March 4, 1909, Montana enacted a statute to take effect October 1, 
1910, providing for the maintenance of a state cooperative insurance 
fund for miners and laborers in or about the coal mines of the state. Con- 
tribution to the fund was compulsory in the case of both of employers 
and employes. 
According to L. D. Clark, of the Bureau of Labor Statistics, the period 
of investigation and education in the United States began somewhat late 
(1909), as compared with European countries. The first American state 
commissions were appointed in New York, Wisconsin and Minnesota in 
1909, and legislation followed in New York in 1910, in Wisconsin in 1911 
and in Minnesota in 1913. Within the period between 1909 and 1913, 27 
commissions (not including one federal commission) have been appointed 
to consider the subject, and compensation laws were enacted in 23 states. 
Following 1914 progress in compensation legislation has been very rapid, 
45 states and 3 territories having enacted laws. (See-Table, p. xxxviii.) 
The laws in the majority of states provide for compensation for 
industrial accident only, but the following 16 states since 1911 have 
enacted laws requiring the notification of certain occupational maladies 
and also provide for compensation in these diseases, viz.: California, 
Connecticut, Illinois, Maine, Maryland, Massachusetts, Michigan, XXXVIII 
PREFATORY 
State 
or 
territory 
Age 
limit 
for 
children 
Seats 
for 
women 
Inspec- 
tion of 
facto- 
ries, 
work- 
shops, 
etc. 
Inspec- 
tion of 
mines 
Inspec- 
tion of 
steam 
boilers 
Fire 
escapes 
Guards 
for dan- 
gerous 
machin- 
ery 
Health 
of em- 
ployes; 
ventila- 
tion and 
sanita- 
tion of 
factories 
Toilet 
rooms 
Report 
of acci- 
dents in 
factories 
Report 
of acci- 
dents in 
mines 
Liability 
of 
employ- 
ers for 
injuries 
to em- 
ployes 
Data of workmen's compensa- 
tion legislation 
Labor 
Bureau 
1890 
1920 
1890 
1920 
1894 
1920 
1890 
1920 
1890 
1920 
1890 
1920 
1890 
1920 
1890 
1920 
1890 
1920 
1890 
1920 
1890 
1920 
1890 
1920 
Prior to 
1900 
After 
1 1920 
Alabama 
♦ 
♦ 
♦ 
♦ 
* 
♦ 
♦ 
♦ 
♦ 
♦ 
* 
♦ 
* 
* 
♦ 
* 
* 
♦ 
* 
* 
♦ 
* 
* 
* 
♦ 
* 
♦ 
* 
* 
* 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
* 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 . 
4 
4 
4 
4 
4 
4 
4 
. 4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
'* 
4 
4 
4 
4 
4 
4 
4 
4 
4 
♦ 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
1919 
1915 
1912 
1911 
1915 
1913 
1917 
1919 
1916 
1915 
1917 
1911 
1915 
1913 
1911 
1915 
1914 
1915 
1914 
1911 
1912 
1913 
1883 
1887 
1873 
1890 
1879 
1879 
1884 
1885 
1876 
1900 
1887 
1884 
1869 
1883 
1887 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
* 
4 
4 
4 
4 
Alaska 
Arizona 
Arkansas 
California 
* 
Colorado 
Connecticut 
* 
* 
♦ 
* 
* 
Delaware 
Dist. of Columbia 
Florida 
Georgia 
Hawaii 
Idaho 
* 
* 
* 
♦ 
* 
♦ 
♦ 
Illinois 
Indiana 
Iowa 
Kansas : 
Kentucky 
Louisiana 
Maine 
Maryland 
Massachusetts 
Michigan 
Minnesota 
* 1 .. 
* ■ * 
TABLE I PREFATORY 
XXXIX 
Mississippi 
* 
♦ 
♦ 
* 
♦ 
* 
♦ 
♦ 
♦ 
♦ 
* 
* 
♦ 
* 
♦ 
* 
* 
* 
* 
♦ 
* 
♦ 
♦ 
* 
♦ 
* 
* 
♦ 
* 
♦ 
* 
♦ 
* 
♦ 
♦ 
* 
♦ 
♦ 
* 
* 
* 
♦ 
* 
* 
* 
* 
♦ 
♦ 
♦ 
♦ 
* 
* 
* 
* 
♦ 
* 
♦ 
♦ 
* 
* 
* 
♦ 
* 
* 
♦ 
* 
* 
* 
* 
♦ 
♦ 
* 
* 
♦ 
♦ 
* 
♦ 
* 
♦ 
♦ 
♦ 
♦ 
♦ 
* 
* 
* 
* 
? 
♦ 
? 
* 
♦ 
♦ 
* 
* 
♦ 
* 
* 
* 
♦ 
* 
* 
♦ 
♦ 
♦ 
♦ 
♦ 
* 
* 
* 
♦ 
♦ 
♦ 
♦ 
♦ 
* 
* 
* 
♦ 
♦ 
* 
♦ 
* 
♦ 
♦ 
♦ 
♦ 
♦ 
* 
♦ 
♦ 
♦ 
* 
* 
* 
♦ 
* 
* 
♦ 
♦ 
♦ 
* 
* 
♦ 
* 
* 
♦ 
* 
♦ 
♦ 
♦ 
* 
* 
♦ 
♦ 
♦ 
* 
* 
* 
♦ 
* 
♦ 
♦ 
♦ 
* 
* 
* 
♦ 
♦ 
* 
* 
* 
♦ 
* 
♦ 
♦ 
♦ 
* 
♦ 
* ■ 
* 
♦ 
* 
* 
* 
* 
♦ 
♦ 
* 
♦ 
* 
♦ 
♦ 
♦ 
♦ 
* 
* 
* 
* 
* 
* 
* 
♦ 
* 
* 
♦ 
♦ 
* 
* 
♦ 
* 
* 
♦ 
♦ 
♦ 
* 
♦ 
♦ 
* 
♦ 
* 
* 
* 
* 
* 
♦ 
* 
♦ 
* 
* 
* 
♦ 
* 
* 
Missouri 
♦ 
* 
♦ 
♦ 
♦ 
* 
♦ 
* 
♦ 
♦ 
* 
♦ 
* 
* 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
* 
♦ 
* 
* 
* 
♦ 
♦ 
♦ 
♦ 
♦ 
♦ 
* 
♦ 
* 
♦ 
♦ 
♦ 
♦ 
* 
* 
♦ 
* 
♦ 
♦ 
* 
* 
* 
* 
♦ 
* 
* 
♦ 
♦ 
* 
♦ 
♦ 
* 
♦ 
♦ 
♦ 
* 
* 
♦ 
♦ 
* 
* 
* 
* 
* 
♦ 
* 
* 
* 
♦ 
♦ 
♦ 
♦ 
* 
♦ 
* 
* 
♦ 
* 
♦ 
♦ 
♦ 
♦ 
♦ 
* 
♦ 
• 
♦ 
* 
♦ 
* 
* 
* 
♦ 
* 
♦ 
♦ 
♦ 
* 
* 
♦ 
♦ 
♦ 
♦ 
♦ 
* 
* 
* 
♦ 
* 
♦ 
♦ 
* 
* 
* 
* 
* 
♦ 
* 
* 
* 
♦ 
♦ 
* 
♦ 
* 
* 
* 
* 
♦ 
* 
* 
* 
* 
♦ 
* 
* 
♦ 
♦ 
1919 
1915 
1913 
1911 
1917 
1911 
1911 
1913 
1919 
1911 
1915 
1913 
1915 
1915 
1912 
1917 
1919 
1913 
1917 
1915 
1918 
1911 
1913 
1911 
1915 
(1908 
*1916 
1876 
1893 
1887 
1893 
1878 
1883 
1887 
1890 
1877 
1872 
1887 
1891 
1898 
1897 
1889 
1883 
1884 
♦ 
* 
♦ 
* 
« 
♦ 
♦ 
♦ 
* 
* 
* 
* 
* 
♦ 
* 
* 
« 
* 
* 
♦ 
♦ 
Montana 
Nebraska 
Nevada 
New Mexico 
New Hampshire 
New Jersey 
* 
♦ 
* 
* 
* 
New York 
North Carolina 
North Dakota 
Ohio 
Oklahoma 
Oregon 
Pennsylvania 
♦ 
Philippine Isl 
Porto Rico 
Rhode Island 
* 
♦ 
South Carolina 
South Dakota 
Tennessee 
Texas 
Utah 
Vermont 
* 
* 
♦ 
* 
♦ 
* 
Virginia 
Washington 
W. Virginia 
Wisconsin 
Wyoming 
United States 
34 
52 
19 
52 
14 
50 
22 
36 
23 
30 
13 
34 
13 
36 
21 
35 
13 
43 
14 
28 
22 
32 
51 
54 
48 
32 
40 XL 
PREFATORY 
Minnesota, Missouri, New Hampshire, New Jersey, New York, Ohio, 
Pennsylvania, Rhode Island and Wisconsin. 
According to Commons and Andrews,20 the earliest of these laws 
called for reports on all cases of anthrax, compressed air illness, and 
poisoning from lead, phosphorus, arsenic, mercury, or their compounds, 
to which were later added brass and wood alcohol poisoning. The 
most recent tendency, however, is to make the laws include any ailment 
or disease contracted as a result of the nature of the patient's employ- 
ment, in which form the laws will probably be productive of more impor- 
tant results. The duty of reporting falls upon the physician in charge of 
the case, who makes his report either to the state labor department or to 
the board of health. (See also Dr. Andrew's Chapter, page 1002.) 
Great Britain under the Workmen's Compensation Acts has a schedule 
of 30 occupational diseases. The Occupational Disease Compensation 
Law of the State of New York, in effect May 5, 1920, covers 23 diseases. 
The Ohio Act, passed April 20, 1921, covers 15 maladies. 
Other Forms of Health Insurance.-K brief reference should be made 
to the excellent health work carried on by the Metropolitan Life Insur- 
ance Company and other insurance companies engaged in industrial 
insurance work. Much good has been done by the so-called "Group 
Insurance" system, and the numerous Employes' Mutual Benefit Associ- 
ations, of which there are over 500 in this country. 
FEDERAL AND STATE ACTIVITIES IN LABOR PROTECTION 
Establishment of Bureaus and Departments of Labor in the United States 
According to Carroll D. Wright, in consequence of some agitation 
started in Massachusetts by the Order of the Knights of St. Crispin, 
in 1869, and as a direct result of the rejection of the petition of this 
Order for an act of incorporation, a Bill creating the Bureau of Statistics 
of Labor was suddenly introduced by some shrewd politician and received 
the Governor's approval, June 22, 1869. "Thus was created by the act of 
the Legislature one of the first offices in the world whose function was the 
collection of information relating to social and industrial conditions." 
The functions of that Bureau were defined by law as follows: "The duties shall 
be to collect, assort, systematize and present in annual reports to the Legislature, on 
or before the first day of March in each year, statistical detail relating to all depart- 
ments of labor in the Commonwealth, especially in its relations to commercial, social, 
educational and sanitary conditions of the laboring classes and to the permanent 
prosperity of the productive industry of the Commonwealth." 
The substance of this language finds a place in nearly every law creating a state 
bureau in this country, and also in the federal law organizing the United States Bureau 
of Labor and subsequently the Department of Labor. 
Efforts pointing toward the establishment of a federal office date from April 10, 
1871, but in spite of repeated attempts nothing was accomplished until out of the 
various bills previously introduced an act establishing a Bureau of Labor in the 
Department of the Interior was framed, and was signed by the President, June 27, 1884. PREFATORY 
XLI 
The Act provided that the Commissioner of Labor shall collect information upon 
the subject of labor, its relation to capital, the hours of labor, and the earnings of 
laboring men and women, and also upon the means of promoting their material, 
social, intellectual and moral prosperity. 
Dr. Carroll D. Wright, a scholar, was appointed the first Commissioner of Labor 
and the office was organized in January, 1885. 
After the Bureau of Labor had been in existence three years and had shown the 
character of its work, which had been largely educational, the "Knights of Labor" 
demanded the creation of a Department of Labor, to be independent of any of the 
general departments. This was done by an Act approved June 13, 1888, without 
however changing its function. In 1903 when an Executive Department of Commerce 
and Labor was established, the department became a Bureau of Labor Statistics of 
said Department, and in 1913, when a separate Department of Labor was created, it 
was transferred to that Department. 
The Bureau, since its creation in 1885, has had but four bureau chiefs-Carroll D. 
Wright, who resigned in 1905; Charles P. Neill, who held office until May, 1913; 
Royal Meeker, who resigned July 31, 1920, and the present Commissioner, Ethelbert 
Stewart, whose appointment took effect August 1, 1920. 
The publications of the United States Bureau of Labor Statistics from 1886 to 
June 15, 1921, consist of 25 Annual Reports (discontinued after 1910); 12 special 
reports; 38 miscellaneous reports; 291 Bulletins; 13 special publications, and 12 
volumes of the Monthly Labor Review. All of these contained items of great educa- 
tional value, and a large number are of special interest to the student of industrial 
hygiene. 
Bureau of Mines.-The Bureau of Mines was created by Chapter 
240 of the Acts of 1909-1910 as amended by Acts of February 25, 1913. 
The object of the Bureau is stated as follows: 
"It shall be the province and duty of the Bureau of Mines, subject to 
the approval of the Secretary of the Interior, to conduct inquiries and scien- 
tific technologic investigations concerning mining, and the preparation, 
treatment and utilization of mineral substances with a view to improving 
health conditions and increasing safety, efficiency, economic develop- 
ment .... to investigate explosives .... and to disseminate 
information concerning these subjects in such a manner as will best carry 
out the purposes of this Act. . . . " 
The Bureau has issued 196 valuable Bulletins, among them a number 
of high grade contributions relating to accident prevention, health and 
sanitation. Space will not permit many details. It may, however, be 
said that the creation of the Bureau has been more than justified, as is 
shown by the following facts. Whereas in 1907, among 680,492 miners 
employed, 3242 men, or 6.19 per 1000 day workers were killed by accidents; 
in 1918, among 762,426 miners, only 2580, or 3.94 per 1000 workers, 
were killed. 
Children's Bureau.--Chapter 73 of the Acts of 1911-12 established 
in*the Department of Commerce and Labor a bureau to be known as the 
Children's Bureau with duties as follows: 
"The said Bureau shall investigate and report to said Department upon 
all matter pertaining to the welfare of children and child-life among all XLII 
PREFATORY 
classes of our people, and shall especially investigate the questions of 
infant mortality, the birth-rate, orphanages, juvenile courts, defectives, 
dangerous occupations, accidents and diseases of children, employment, 
legislation affecting children in the several states and territories. . . . 
The chief of said Bureau may from time to time publish the results of 
these investigations in such a manner and to such extent as may be 
presented." 
This Bureau was transferred in 1913 to the Department of Labor. 
It has done useful work for the benefit of present and future generations 
of American citizens of every class, but more especially for the wage- 
earning community. 
The Bureau has published since its establishment to 1921, 80 special 
bulletins, 10 child-welfare dodgers, 20 leaflets and 2 charts-one on 
"State Child Labor Standards," January 1, 1921, and one on "State 
Compulsory School Attendance Standards Affecting the Employment 
of Minors." 
United States Public Health Service.-By an act approved August 14, 
1902, the name of the Public Health and Marine Hospital Service was 
changed to the "Public Health Service," and this branch was authorized 
to "study and investigate the diseases of man and spread thereof, and 
to publish information for the public." 
Up to this time the Service had been chiefly occupied with the study 
and prevention of communicable diseases and epidemics and the care of 
seamen of the Merchant Marine, although several important investiga- 
tions relating to industrial hygiene were made in 1914. 
In 1915 a Division of Industrial Hygiene and Sanitation was organized under the 
direction of Surgeon J. W. Schereschewsky, now Assistant Surgeon General. The 
office with a research laboratory was established in the Marine Hospital, Pittsburgh, 
Pennsylvania, under the name of "Office of Field Investigations into Occupational 
Diseases." In April, 1917, the name was changed to the "Office of Field Investiga- 
tions in Industrial Sanitation." In August, 1918, the Bureau approved a plan signed 
by the Secretary of the Department of Labor and the Secretary of the Treasury, 
whereby the Service, through the Office of Field Investigation in Industrial Sanitation, 
would cooperate with the "Working Conditions Service" of the Department of 
Labor. 
Following Dr. Schereschewsky's transfer to Washington, D. C., to assume charge 
of the Division of Scientific Research in the Bureau, Dr. A. J. Lanza (then past 
assistant surgeon in the service) became the incumbent of the office. 
In October, 1918, the office and laboratory work were transferred from Pittsburgh 
to Washington, D. C., and the personnel, detailed to the Working Conditions Service, 
became known as the Division of Industrial Hygiene and Medicine. This cooperative 
work was discontinued June 30, 1919, in view of the fact that no funds were appro- 
priated to continue the work of the Working Conditions Service, and the Division 
of Industrial Hygiene and Medicine on July 1, 1919, automatically became the 
"Office of Industrial Hygiene and Sanitation," in charge of Surgeon L. R. Thompson 
of the Public Health Service. 
Dr. Lanza resigned from the Service in January, 1920, and Dr. Bernard J. New- 
man, then Sanitarian in the Reserve Corps of the Service, took charge. Dr. Newman 
tendered his resignation from active duty with the Service and is at present Consultant. PREFATORY 
XLIII 
The laboratory work is now carried on at the Hygienic Laboratory of the Public 
Health Service at Washington, D. C., and also in cooperation with a laboratory under 
Professor Winslow, in which is being made a study of factory ventilation and the 
industrial dust hazards. The Public Health Service has done excellent work in scien- 
tific investigations in a number of occupations and dangerous processes. In March, 
1914, the first publication by the division emanated from the pen of Dr. Schereschew- 
sky, on Trachoma in Steel Mill Workers. Since this time 67 other contributions 
have appeared. (See also pages 95-100 of this volume.) 
Women's Bureau.-By an act approved June 5, 1920, this Bureau 
was established in the Department of Labor. "It shall be the duty of 
said Bureau to formulate standards and policies which shall promote the 
welfare of wage-earning women, improve their working conditions, 
increase their efficiency, and advance their opportunities for profitable 
employment. The said Bureau shall have authority to investigate and 
report to the said Department upon all matters pertaining to the welfare 
of women in industry. The Director of said Bureau may from time to 
time publish the results of these investigations in such a manner and to 
such an extent as the Secretary of Labor may prescribe." 
The Bureau has published 31 Bulletins which will doubtless serve 
the objects for which it was created. 
Exhibit of Safety Devices in Washington, D. C.-In 1915 and 1916 the 
United States Government assembled an excellent exhibit of safety 
devices in the National Museum in Washington. This exhibit was opened 
in February 21, 1916, and continued for a week. It had been the hope 
of those in charge of the exhibit to use it at the end of this period as a 
railway traveling exhibit in the important industrial cities in the United 
States. This plan, however, had to be abandoned for lack of funds. It 
was also hoped that the collection would become the nucleus of a perma- 
nent exhibit in the Museum, but this hope has only been partly realized. 
The exhibit was first suggested by the Bureau of Mines. It was parti- 
cipated in by nineteen Government bureaus, the American Red Cross 
and the Metropolitan Police Department. Many illustrated lectures and 
addresses explanatory of the exhibit were given, and it is remembered 
as one of the most remarkable and interesting Government exhibitions 
ever brought together, proving in every respect most effective and satis- 
factory. The attendance of visitors for the week was 35,447. The 
governors of the various states had been notified of the national aspect 
of the exposition, and one of the results of such notification was the 
meeting of the State Mine Inspectors in the Museum, to which manu- 
facturers and operators from all parts of the country were invited to be 
present.* 
American Association for Labor Legislation.-This Association was 
organized in New York City, February 15, 1906. The objects of the 
COMMUNITY ACTIVITIES IN LABOR PROTECTION 
* While these pages are going through the Press, a large Public Health Exhibit is 
being assembled, and there is reason to believe that the "Safety Devices" will become a 
permanent exhibit. XLIV 
PREFATORY 
Association are stated as follows: (1) To serve as the American branch 
of the International Association for Labor Legislation. (2) To promote 
uniformity of labor legislation in the United States. (3) To encourage 
the study of labor conditions in the United States with a view to promot- 
ing desirable labor legislation. With only twenty-one charter members, 
the Association's growth in membership has been most gratifying, the 
roster at the close of 1920 containing 3124 names. 
In consequence of this growth it became possible to increase the staff of workers 
and to extend the scope of the Association's activities, so that by 1912 the program of 
work covered the following divisions: (1) Organization. (2) Investigation. (3) Edu- 
cation. (4) Legislation. The Association has been active in the promotion of con- 
ferences on special phases of its work, such as the Conferences on Industrial Diseases 
in June, 1910 and 1912, and the First National Conference on Social Insurance in 
June, 1913. 
The Association has published over 52 editions of the American Labor Legislation 
Review, and has done more for the promotion of labor legislation than any other 
agency in this country. 
Much credit for the success of the Association is due to the zeal and the devotion 
of the secretary, Dr. John B. Andrews and the assistant secretary, Irene Osgood An- 
drews, who have been true to the Association's motto, "The fundamental purpose of 
labor legislation is the conservation of the human resources of the nation." 
American Museum of Safety.-This meritorious institution was incor- 
porated by Chapter 152 of the Acts of 1911 of the State of New York. 
The objects are: "To study and promote means and methods of safety 
and sanitation and the application therof to any and all public or private 
occupations .... to establish and maintain a museum, library and 
laboratories and their branches, wherein all matters, methods and means 
for improving the general condition of the people as to their safety and 
health may be studied, tested and promoted, with a view of lessening the 
number of casualties and avoiding the causes of physical suffering and 
premature death; and to disseminate the results of such study, researches 
and tests, by lectures, exhibitions and other publications." 
Dr. William H. Tolman was the first director of the Museum, and he, as well as 
Dr. N. E. Ditman, who had charge of the Department of Industrial Hygiene, has 
rendered a very important service to the country. 
Mr. Albert A. Hopkins, the present acting director, writes me that "The Museum 
of Safety is now known as the "Safety Institute of America." For lack of suitable 
quarters the Museum was closed January 1, 1920, but it is the intention to resume 
this activity. During the past two years the Institute has conducted, under the 
auspices of the Metropolitan Safety Council (a combination of the National Safety 
Council and the Safety Institute of America for the Metropolitan District), lecture 
courses for safety supervisors and foremen in New York City, Long Island City and 
Newark, New Jersey. The purpose of these lectures has been to stimulate and render 
more efficient the safety work in the industries in the Metropolitan District. The 
safety movement is making rapid strides and contributing fundamental values to 
industry. The courses have been well attended, and proved of great interest to 
"safety-men." 
The Institute has published, in book form, the lectures on Safety Fundamentals, 
and also the magazine, Safety, which is a high grade periodical. The Institute main- PREFATORY 
XLV 
tains an excellent library, and has a collection of lantern slides, which are loaned to 
schools and for safety rallies. 
The American Museum of Safety had obtained a lease from the City of New York 
for the occupation of the Arsenal in Central Park, but the matter was contested in the 
courts and was decided by the Court of Appeals in favor of the Parks and Play- 
grounds Association. It is to be hoped that the great metropolis of New York may 
soon erect and maintain at least as good a museum for wage earners as Berlin provided 
as early as 1904 and Vienna in 1909. At the present writing there is only one museum 
of the kind in operation in this country; this one is located in Jersey City, New Jersey. 
The Institute has authority to award six different medals: 
1. The Scientific American Medal, awarded eight times for the most efficient safety 
device invented within a certain number of years and exhibited at the Museum. 
2. The Traveller's Insurance Company's Medal, awarded seven times to the 
American employer w ho has done notable work in protecting the lives and limbs of 
workers. 
3. The Louis Livingston Seamen Medal, awarded six times for progress and 
achievement in the promotion of hygiene and the mitigation of occupational disease. 
(Dr. Alvah H. Doty of New York was the recipient of the medal in 1911 and Surgeon 
General William C. Gorgas in 1914.) 
4. The Rathenau Medal, awarded twice for the best device or process in the 
electrical industry, safeguarding life and health. 
5. The E. H. Harriman Memorial Medals, awarded five times to the American 
steam railroad which during the year has been the most successful in protecting the 
lives and health of its employes and of the public. 
6. The Anthony N. Brady Memorial Medal, awarded three times to that American 
electric railway company which for the year of the award has done most to conserve 
the safety and health of its employes and of the public. 
Organization of the Section on Industrial Hygiene in the American 
Public Health Association.--In 1914 the writer was invited by the presi- 
dent of the American Public Health Association to deliver an address 
on the "History and Development of Industrial Hygiene in the United 
States," at one of the general sessions of the meeting of the Association 
at Jacksonville, Florida, November 30 to December 4, 1914. The other 
contributors to the symposium were Dr. E. R. Hayhurst, chief of the 
Survey of Occupational Diseases, State Board of Health of Ohio, who 
discussed "The Prevalence of Occupational Factors in Disease and Sugges- 
tions for their Elimination." Dr. John B. Andrews, Secretary American 
Association for Labor Legislation, presented the subject of "Health 
Insurance," and Dr. C. T. Graham-Rogers, of the New York Department 
of Labor, delivered an address entitled "Industrial Hygiene the Basis 
of Industrial Efficiency." 
At the meeting of the Executive Committee of the Association, Secretary Gunn 
strongly urged the organization of a Section on Industrial Hygiene, and upon the 
petition of ten or more signers, including the names of Drs. W. A. Evans, E. L. Fisk, 
Di. Alice Hamilton, E. R. Hayhurst, B. S. Warren and others, the Executive Com- 
mittee recommended that the section be organized. At a later period the Executive 
Committee appointed the following officers of the section; Chairman, Dr. George M. 
Kober, Washington; Vice chairman, Dr. Alice Hamilton, Chicago; Secretary, Dr. E. R. XLVI 
PREFATORY 
Hayhurst, Columbus, Ohio. The section met for the first time at the Rochester 
meeting, September 6-10, 1915. 
EDUCATIONAL INSTITUTIONS OFFERING COURSES IN INDUSTRIAL 
HYGIENE 
It is reasonable to assume that all medical schools in this country 
which have courses in hygiene and public health also have eight to ten 
lectures on industrial hygiene and the more dangerous occupations. 
American text-books on hygiene, like Harrington's, Rosenau's and Park's, 
devote special chapters to this subject. 
The writer has pursued this plan of special lectures since 1890, with 
a view to stimulating the interest of his students in one of the most 
beneficient subdivisions of hygiene. He is of the opinion that this is 
about all that can be undertaken in the undergraduate courses of medical 
schools and was therefore greatly pleased when opportunities were 
afforded for postgraduate work. 
Massachusetts Institute of Technology.-Prof. C. E. Turner writes: "It 
appears that instruction in industrial hygiene in the Department of 
Biology and Public Health at the Massachusetts Institute of Technology 
began about 1905, when C.-E. A. Winslow gave instruction in this subject. 
In 1908 Professor Gunn came back to the 'Tech' to teach and continued 
instruction in industrial hygiene until he left the 'Tech' during the period 
of the war. I have been giving this course only since my post-war return 
to the 'Tech' in 1919." 
The Harvard Medical School established in 1910 courses in public 
health in connection with the Massachusetts Institute of Technology, in 
which considerable attention was given to industrial hygiene. In June, 
1918, Harvard University was the first institution in the world to establish 
a course of instruction and research leading to degrees in industrial 
hygiene. Work was begun in the session of 1918-1919 and instruction 
has been offered for each of the subsequent years. Courses leading to the 
Certificate of Public Health in Industrial Hygiene include: applied physiol- 
ogy of industry; methods of air analysis; industrial toxicology; vital 
statistics; industrial sanitation; preventive medicine and hygiene; indus- 
trial health administration; employment management; workmen's com- 
pensation and the legal aspects of industrial disease; nutrition; industrial 
surgery, orthopedic surgery and industrial medicine. These subjects also 
form the work of the first year for candidates for the degree of Doctor of 
Public Health in Industrial Hygiene, the second year being devoted to an 
investigation upon some phase of industrial health. Work in the Occu- 
pational Disease Clinic at the Massachusetts General Hospital is required 
of all students of industrial medicine who hold the medical degree. The 
staff of the Division of Industrial Hygiene of this school published 38 
noteworthy contributions to industrial hygiene from November, 1917 
to May, 1921, many of which were based on laboratory research. Among 
the noteworthy investigations are the following: the dust content of air PREFATORY 
XLVII 
in various industries; new apparatus for dust collection and dust measure- 
ment; effects of mineral dusts; chronic manganese poisoning; poisoning by 
lead, ether, tetrachlorethane and trinitrotoluene; a study of oil folliculitis; 
health in mercantile establishments; etc. It publishes the Journal of 
Industrial Hygiene which is indispensable to all students of the subject. 
The College of Medicine of the Ohio State University in 1915 offered, in its 
Department of Public Health, elective courses in industrial hygiene to 
undergraduate medical and university students. Students in the Grad- 
uate School of the University have also been permitted to specialize 
in industrial hygiene and occupational diseases. The graduate courses 
were dropped during the war, but since 1920 a few students, candidates 
for the degree of Master of Science, have specialized in these subjects. 
Dr. E. R. Hayhurst, who has been an ardent advocate of special courses 
in industrial hygiene for a number of years, says: "There have been over 
100 students for each year since 1919 in the undergraduate 32-hour course 
entitled 'Industrial Hygiene.' " The registration in 1921-22 was 125. A 
full one-year curriculum leading to a Certificate in Industrial Hygiene 
was established in 1921. It is open to medical graduates only. 
Johns Hopkins University.-The School of Hygiene and Public Health 
was opened in October, 1918, under the direction of Dr. Wm. H. Welch, 
and considerable attention is given to industrial hygiene. Important 
studies- of fatigue by Spaeth were published in 1919-20, and a method 
for determining the finer dust particles in air (Meyer, Journal of Industrial 
Hygiene, June, 1921). 
The Rush Medical College of the University of Chicago offers to senior 
medical students a 48-hour clinical and conference course. Another 
course in the Department of Hygiene and Bacteriology is offered on 
dangerous trades, industrial health hazards, and occupational diseases, to 
which also sociological students are admitted. 
The Medical Department of the University of Pennsylvania as early as 
1906 in connection with courses in public health leading to the degree 
of Doctor of Public Health, placed considerable emphasis upon industrial 
hygiene, including inspection of industrial plants, service in first-aid 
stations and emergency hospitals in some of the larger plants, and the 
Occupational Disease Clinic of the University Hospital. This School of 
Hygiene has made studies of: (1) health hazards of cigar manufacturing; 
(2) dust hazards in certain industries; (3) anilin fumes in the air; (4) 
anthrax problem in horsehair; (5) CO2 and CO content of air in a felt- 
hat factory; (6) conditions in an organic color mixing plant; (7) oil 
grinders' furunculosis in a steel ball-bearing factory; (8) condition of the 
lungs of workers in stove foundries, etc. Numbers 1, 2, 7, and 8 were 
made in collaboration with the Clinic for Occupational Diseases of the 
University Hospital. 
The Medical School of Yale University offers to its students in the 
public health courses (begun 1917) opportunities to specialize in industrial XLVIII 
PREFATORY 
hygiene and to carry on research work. The University, in connection 
with the United States Public Health Service, has an experimental 
laboratory for the study of factory ventilation and the industrial dust 
hazards (Shuford). Professor C.-E. A. Winslow and his associates, 
the Greenburgs and Angermeyer, have carried on some of these studies in 
the abrasive industry, polishing shops, grinding shops of an ax factory, 
among sandblasters, etc.; a number of studies of the katathermometer, 
and miscellaneous factory inspections have also been made. (Seepage 18.) 
The Medical School of the University of Cincinnati in October, 1919, 
established courses of one year, open to graduates in medicine and leading 
to a Certificate of Public Health in Industrial Medicine. The program 
includes the training of students in industrial medicine and public health, 
and field work among the industries, also cooperation of the Department 
with the National Safety Council. The training of students in the clinical 
aspects of industrial medicine is provided by an Occupational Disease 
Clinic and the medical departments in local industrial plants. 
The Journal A. M. A., August 13, 1921, in addition to the schools 
already mentioned (except Cincinnati), enumerates the following as having 
graduate courses in public health: The University of Wisconsin, began in 
1910; the University of Michigan, in 1913; Detroit College of Medicine and 
Surgery, 1913; the University of California, 1915; University and Bellevue 
Hospital Medical College, 1916; Albany Medical College, 1919; Howard 
University, School of Public Health and Hygiene, 1922. Two other insti- 
tutions, the University of Colorado and Tulane University, suspended 
their courses in 1918. 
The Ohio State Department of Health, following upon the Occupational 
Diseases Survey of 1913-1915, has maintained a Division of Industrial 
Hygiene under the general supervision of E. R. Hayhurst, which makes 
surveys, investigates occupational diseases, gives advice to employers 
and employes, commissions and other State Departments, does special 
research work and conducts a correspondence-study course in the 
subject for health officials of Ohio. The succeeding Chiefs of the 
Division have been, in addition to Dr. Hayhurst, Drs. R. P. Albaugh, 
E. B. Starr (deceased, June 19, 1922) and N. C. Dysart. 
Recently an Industrial Health Service Bureau has been established in 
Chicago under competent leadership, which offers its services in furnishing 
sources of information concerning the organization of the health work in 
industries, schools and institutions. The Bureau also offers two post- 
graduate courses in industrial medicine and surgery, beginning July 6, 
1921: a three weeks' course of lectures and demonstrations and work in 
clinics and industrial establishments in Chicago; an additional three weeks' 
course of demonstration and observation in industrial plants may be 
taken by those who have completed the first three weeks' course. 
Dr. Hayhurst has furnished me with an elaborate table of medical 
schools which offer courses in public health leading to degrees and which PREFATORY 
XLIX 
presumably give attention likewise to industrial hygiene. Apart from 
those already referred to are the following: University of Iowa; 
Minnesota; Missouri; Chicago; Leland Stanford; Columbia; University 
of Louisville; McGill University, Montreal; Queen's University, Kings- 
ton, Ontario; University of Toronto; Wellesley College; American Insti- 
tute of Medicine. A list given by Eugene C. Howe, American Journal 
of Public Health, Aug., 1918, pages 600-607, includes Chicago Hospital 
College of Medicine. 
According to J. David Thompson, of the medical schools not already 
referred to in detail, the following have done or are carrying on research 
work: University of California, Department of Hygiene: investigations 
in progress by Professor R. T. Legge on "packers' itch," a skin disease 
found among packers using infected straw, and on a peculiar infection 
of the fingers of dried fig packers. The College of Physicians and Surgeons 
of Columbia University, New York, Department of Physiology, under 
the direction of Professor Frederic S. Lee, has made a number of impor- 
tant studies of industrial fatigue. The College of Medicine, University of 
Iowa, Division of Hygiene, published, in 1920, a study of health hazards in 
the pearl button industry, made by Birge and Havens. Stanford Univer- 
sity, California, Department of Physiology, has published "Strength Tests 
in Industry" (Martin) and "Studies of the Effects of Tobacco on Mental 
and Physical Work." In addition to these medical schools, the Henry 
Phipps Institue of Philadelphia has made studies on factors affecting the 
health of garment workers, and various effects of dust inhalation, etc. 
This Institute cooperates with the University of Pennsylvania in indus- 
trial hygiene surveys in Philadelphia. The William H. Singer Memorial 
Research Laboratory, Pittsburgh, has made industrial studies on the pre- 
vention of epidemic influenza, based on about 50,000 steel workers and 
railroad employes; unresolved pneumonia, associated with severe anth- 
racosis; and trinitrotoluene poisoning. The Mellon Institute of Pittsburgh 
has likewise carried on important researches in industrial medicine. 
The Nela Research Laboratory of the National Lamp Works, General 
Electric Company, Cleveland, Ohio, has published results of experimental 
investigations on the physiology and psychology of illumination, glasses 
for protecting the eyes, and industrial medical services, the latter by Dr. 
Ralph W. Elliott. The Psychological Laboratory of Bryn Mawr College 
has made similar studies. The Nutrition Laboratory of the Carnegie 
Institution has made and published studies on the influence of various 
factors upon metabolism, such as variations of temperature, muscular 
work, etc.; on the effect of under-nutrition; ingestion of alcohol as 
affecting skilled muscular performance; etc. The Houghton Research 
Staff (E. F. Houghton & Co.), Philadelphia, has made investigations and 
published in 1920, "Investigations of the Causes of Skin Sores and Boils 
Among Metal Workers." The Cleveland Hospital Council made an 
elaborate hospital and health survey of Cleveland, including an industrial L 
PREFATORY 
survey (1920). The National Industrial Conference Board has issued a 
series of research reports on "Hours of Work as Related to Output and 
Health of Workers" in various industries; also a research report on 
"Health Service in Industry." The Cabot Fund has made investigations 
of the present condition of the iron and steel industry with reference to 
the eight-hour day in Great Britain and the twelve-hour day and the seven- 
day week in the United States (1921) and the ''Twelve-Hour Shift in Indus- 
try," with the cooperation of the Federated American Engineering 
Societies, 1922. The Carnegie Foundation (Americanization Studies) has 
issued a "Study of the Special Medical, Sanitary and Health Problems 
Due to Immigrant Employes" (1921). 
A RETROSPECT OF AMERICAN LITERATURE 
The growth of interest in the United States in the subject of general 
and industrial hygiene and occupational diseases since the birth of the 
American Public Health Association may be judged by the following: 
The Index Catalogue of the Surgeon General's Library shows that prior 
to 1880 there were but 80 subjects indexed by American authors, including 
5 books and monographs, and 75 journal articles, against 166 contributions 
by English authors, of which 16 were books and monographs. 
Among the earliest American contributions should be mentioned Dr. 
B. W. McCready's "On the Influence of Trades, Professions and Occupa- 
tions," the prize dissertation for 1837 of the New York State Medical 
Society. Dr. F. A. Walker, of Boston, in 1869 published a monograph 
on "Occupation of the People." Dr. J. T. Wilson delivered an address 
on "Diseases Incident to Some Occupations," which was published in 
the Transactions of the Medical Society of Youngstown, Ohio, 1879-1880. 
During the period between 1880 and 1900 English authors made 39 
contributions to the literature and American authors but 22. Among 
the American contributions should be mentioned an article on the 
"Hygiene of the Laboring Classes," by William J. Scott, and one written 
by Dr. George H. Rohe on the "Hygiene of Occupations" (1884), followed 
in 1886 by Dr. J. H. Ireland's essay on "The Preventable Causes of 
Disease, Injury and Death in American Manufacture and Workshops 
and the Best Means for Preventing and Avoiding Them," (Lomb Prize 
essay). The Ohio State Board of Health in 1886 appointed a committee 
on Hygiene of Occupations and Railway Sanitation which lead to papers 
by Dr. John D. Jones and Josiah Hartzell, Ph. D. 
In 1895 Dr. J. H. Lloyd wrote an excellent article on "Diseases of 
Occupations." In 1896 a striking editorial on industrial hygiene ap- 
peared in the "Transactions of the American Public Health Association." 
The editorial discussed the report of a parliamentary committee which 
embraced 134 works or factories in Great Britain. The occupations 
included bronzing, steam locomotives, India rubber works, the use of 
inflammable paint, dry cleaning, and aerated waters. PREFATORY 
LI 
From 1900, and more especially from 1908, contributions from 
American authors have increased with wonderful rapidity so that by 
June 30, 1921,702 subjects had been indexed in the Library of the Surgeon 
General's Office as compared with 169 by English authors. These sub- 
jects are indexed under the following headings: occupation accidents; occu- 
pation, diseases incident to; occupation diseases, jurisprudence; occupation 
diseases, legislation; occupation diseases, notification; occupation diseases, 
prevention of; occupation, hygiene of; occupations, hygiene exhibits; 
occupations, statistics; occupation, therapy.* 
Reference has already been made to the early publications of the 
Bureau and Department of Labor, which have been of great educa- 
tional value in stimulating the enactment of labor and factory laws. 
In 1902, Dr. Kober, upon request of the Hon. Carroll D. Wright, Commis- 
sioner of the Department of Labor, recommended his former student, 
Dr. C. F. W. Doehring, for the purpose of making an investigation into 
the manufacture of white lead, paint, etc; the manufacture of linseed 
oil, varnishes, oil cloth and linoleum, tallow, fertilizers, etc. The results 
of this investigation, the first of its kind in this country, were published 
under the title of "Factory Sanitation and Labor Protection" in Bulletin 
44, January, 1903. In 1905 the State Board of Health of Massachusetts 
submitted a brief report on the conditions affecting the health and safety 
of employes in factories and other establishments. This report was 
supplemented in 1907 by a more exhaustive report. 
In 1906, according to Dr. Mock,21 Dr. Frank Fulton of Providence, R. I., began a 
physical examination of employes among the workers in a large saw factory. This he 
did free of charge for the purpose of discovering tuberculous workmen. Dr. Mock 
undertook the examination of the employes of Sears, Roebuck & Co., Chicago, in 
1909, and refers to reports setting forth the benefits of this practice, by Dr. Irving 
Clark, of the Norton Grinding Co., Worcester, Mass.; Dr. Otto Geier, of the Cin- 
cinnati Milling Machine Co.; Wilbur Post, of the Peoples Gas Co., Chicago; Dr. C. G. 
Farnum, of the Avery Company, Peoria, Illinois; Dr. S. M. McCurdy, of the Youngs- 
town Sheet and Tube Co., Dr. D. B. Lowe, of the B. F. Goodrich Co. A splendid 
symposium was presented before the National Tuberculosis Association in 1914, and 
at present writing physical examination of employes, in spite of considerable opposition 
at first, has been found most beneficent to workers afflicted with all forms of diseases, 
which when discovered in their incipiency can be checked.21 
In September, 1907, during the International Congress on Hygiene 
at Berlin, the writer met Dr. E. J. Neisser, who had just completed an 
International Review of Industrial Hygiene covering a volume of 352 
pages. Dr. Neisser deplored his inability to present an extended 
review of the work accomplished in the United States since, with the 
exception of the U. S. Department of Labor and one or two states, no data 
concerning factory sanitation were available. Realizing the impor- 
* Special acknowledgements are due to Mr. Felix Neumann and Sergeant M. 
Katz of the Library of the Surgeon General's Office for valuable assistance rendered 
in this literary research. LII 
PREFATORY 
tance of the subject, not only to wage-earners, but to all interested in 
the conditions under which our fellow men live and work, I returned 
with the determination to do what I could for the promotion of industrial 
hygiene. Fortunately an excellent opportunity was afforded by my ap- 
pointment as Secretary of President Roosevelt's Homes Commission. 
In February, 1908, I submitted, as Chairman of the Committee on Social 
and Industrial Betterment, a "Report on Industrial and Personal 
Hygiene," covering 175 pages. This was followed in December, 1908, by 
a " Report of the Committee on Social Betterment," covering 281 pages. 
It was hoped that this somewhat hasty study of the causes of sickness, and the 
means of promoting industrial efficiency and earning power would direct attention to 
the need of a more critical study and of remedial legislation in the country. This 
hope, thanks to the general publicity given these publications by the lay and medical 
press and the interest aroused among officials, social workers and thoughtful employers, 
has been fully realized, as shown not only by doubling the amount of protective legisla- 
tion since 1907, but also by the gratifying increase in American literature on the 
subject. 
In November, 1908, and May, 1909, Dr. Frederick L. Hoffman's 
valuable monographs on "The Mortality from Consumption in the 
Dusty Trades" were published by the United States Bureau of Labor. 
Dr. George M. Price, a pioneer in public health work and author of a 
Handbook on Sanitation (1901), wrote in 1908 an 80,000-word article 
on "Occupational Hygiene" for Wood's Reference Handbook of Medical 
Sciences. In January, 1910, the epoch-making report of Dr. John B. 
Andrews on "Phosphorus Poisoning in the Match Industry in the United 
States" appeared in Bulletin 86 of the United States Bureau of Labor. 
On June 10, 1910, the First National Conference on Industrial 
Diseases met at Chicago at the call of the American Association for 
Labor Legislation. "The present situation of our Association," said 
Prof. Henry W. Farnum of Yale University, then president, in his open- 
ing address, "is like that of a watchman on a high tower. He does not 
know exactly how the attack is to be made but he knows enough to justify 
him in giving the alarm and in advising that scouts be sent out to ascertain 
more precisely the strength and position of the foe. In this warfare 
against industrial diseases we need the cooperation of many different 
people. This is a warfare in which science, labor, business enterprise and 
government must all unite." 
At this meeting a committee was appointed to present a memorial to President 
Taft on the magnitude and importance of the subject. Although hampered by lack 
of official American statistics on sickness, the committee estimated that among 
33,500,000 occupied persons in this country, there were lost every year 284,750,000 
days through illness, at an economic loss of $772,892,860. Assuming that at least 
one quarter of the sickness was due to strictly preventable causes, it was estimated 
that by deliberate efforts no less than $193,000,000 could be saved to the nation 
annually. Plans were presented for further study of the question by a commission of 
experts representing preventive medicine, sanitary engineering, and industrial 
chemistry. PREFATORY 
LIII 
In 1910, Dr. W. Gilman Thompson, Professor of Medicine in 
Cornell University Medical College, organized an informal committee 
for studying occupational diseases, which was composed of experts in 
industrial chemistry, medicine, economics, social service, insurance, 
and labor legislation. The committee was absorbed in 1914 by the 
American Association for Labor Legislation, which created a Committee 
on Industrial Hygiene, of which Dr. Thompson was made the Chairman. 
In 1910 the Illinois State Commission on Occupational Diseases 
began its labors and on Jan. 1, 1911, published a large number of instances 
of industrial poisoning contracted by wage-earners in the discharge of 
their employment. In July, 1911, the Bureau of Labor published in 
Bulletin 95 the result of an extensive study by Dr. Alice Hamilton, which 
disclosed 388 cases of lead poisoning, of which 16 were fatal in the 
white lead and lead oxide industries in the United States from January, 
1910, to April 30, 1911. The same bulletin also contained a report by 
Dr. John B. Andrews on 60 deaths from industrial lead poisoning actually 
reported in New York in 1909 and 1910. 
The report on "Lead Poisoning in Potteries, Tile Works and in Porcelain 
and Enameled Sanitary Ware Factories," by Dr. Alice Hamilton, and her 
admirable monograph on the "Hygiene of Painters," were published by 
the Bureau of Labor Statistics in 1912 and 1913. These were followed by 
a report on "Lead Poisoning in the Smelting and Refining Industry," 
1914. Since then Dr. Hamilton has made special investigations and 
reports on many industrial poisons. Dr. William C. Hanson's monograph 
on the "Dangers to Workers from Dust and Fumes and Methods of Pro- 
tection," illustrated with 62 photographs, was published by the Bureau in 
1913. Much excellent work of a highly educational character has been 
accomplished by the special commissions for the study and prevention of 
occupational diseases and by numerous official and private investigators. 
In 1911 the National Safety Council was organized and later created 
a Section on Health Service, which held its first session in connection with 
the Fourth Annual Congress of the National Safety Council at Phila- 
delphia in October, 1915. Excellent work has been done in the past, and 
a committee has recently investigated the best modes of preventing and 
controlling occupational skin diseases. This organization was the result 
of joint action by the Association of Iron and Steel Electrical Engineers 
and the Cooperative Safety Congress, and took the name of "National 
Council for Industrial Safety," the fundamental purpose of the organiza- 
tion being the promotion of safety to human life in industries of the United 
States. 
In September, 1912, the Fifteenth International Congress on Hygiene 
and Demography was held in the city of Washington. Section IV of this 
Congress, devoted to the hygiene of occupation, was presided over by the 
writer. The transactions of this section covered 986 printed pages con- 
sisting of 8 English, 2 French, 2 Italian, 8 German, 1 Belgian, 1 Japanese, LIV 
PREFATORY 
1 Austrian, and 41 American contributions. This Congress, as also the 
Sixth International Congress for the prevention of Tuberculosis, held in 
the same city in 1908, with their excellent exhibits illustrating the dangers 
of numerous occupations, stimulated a profound interest in the subject 
of industrial hygiene. 
It is doubtless true that the 64 contributions from distinguished 
experts covering all phases of the subject laid the foundation for a scien- 
tific literature on industrial medicine in this country. Much credit is 
also due to the Section of Industrial Chemistry of the American Chemical 
Society and other national societies mentioned elsewhere. 
In 1912, as already stated, the United States Public Health Service 
created a Division on Industrial Hygiene with Dr. J. W. Schereschewsky 
in charge. In the same year Miss Josephine Goldmark of New York 
published a very comprehensive study of fatigue in its industrial aspects 
under the title of "Fatigue and Efficiency," a book of 890 pages, which 
excerpts and collates much valuable literature. 
In June, 1914, Dr. W. Gilman Thompson's treatise on The Occupational 
Diseases was published. Dr. Thompson, as already pointed out, was 
one of the first among American physicians to appreciate the importance 
of occupational diseases from the medical, social and economic point of 
view. He has made a number of valuable contributions to the literature 
on this subject and his writings and activities have been exceedingly 
fruitful. In the same year, Dr. George M. Price of New York, having 
presented an excellent address on "Medical Factory Inspection" before 
the Congress for the Prevention of Tuberculosis, followed up his good 
work by a splendid book of 574 pages, entitled The Modern Factory. 
In the same year the American Public Health Association created its 
Section on Industrial Hygiene. 
In 1915 Dr. Otto P. Geier, the Chairman of the Section on Hygiene 
and Preventive Medicine of the American Medical Association, and one 
of the most ardent pioneers in industrial hygiene and medicine, prepared 
a splendid symposium for the San Francisco Meeting. Since then these 
subjects have found a place on every program of that Section. 
In 1915 the United States Government assembled an excellent exhibit 
on safety devices in the National Museum in Washington, which was 
opened in February, 1916. In 1915 a "Survey of Industrial Health 
Hazards and Occupational Diseases in Ohio" was published under the 
direction of Dr. E. R. Hayhurst. The report, containing the results of 
the investigation, published by the Ohio State board of Health, constitutes 
one of the most valuable American contributions on the subject to date. 
In 1916 a book entitled Diseases of Occupations and Vocational 
Hygiene, covering 918 pages, was published by P. Blakiston's Son & 
Company. The book was written by 29 experts and edited by the writer 
and Dr. William C. Hanson. In justice to the Publishers, it should 
be stated that the Senior Editor (the writer of this article) declined PREFATORY 
LV 
their request to write or edit a book in the early part of 1911, because the 
scarcity of statistical and other data in reference to disease and accident 
hazards in the various occupations of this country had compelled him in 
his former writings, especially for his monograph in 1908, to gather 
most of his facts from European sources. He entertained the hope that 
with a general awakening in this country and the publication of the Trans- 
actions of Section IV of the Congress on Hygiene (the program for which 
he was then preparing) and Dr. Hayhurst's Report, above referred to, 
valuable material on diseases of occupations as they occur in the various 
states of the Union and in foreign lands would be available. This hope 
has not been idle. 
The notable Brief before the Supreme Court of the United States 
entitled "The Case for the Shorter Work Day," by Felix Frankfurter 
and Josephine Goldmark, was published in 1916. It comprises two 
volumes and contains a valuable list of sources quoted. 
On June 28, 1917, Mr. Samuel Gompers of the American Federation 
of Labor and a member of the Council of National Defense, called in 
Washington a conference of experts to aid him in the formulation of 
recommendations for the promotion of health and efficiency among the 
industrial workers in the United States. This conference resulted in 
the appointment of various committees and the preparation of reports on 
lighting of industrial establishments, dust hazards, sanitation of rural 
workmen's areas, and general welfare work. Most of these reports were 
published by the United States Public Health Service. 
In October, 1917, Dr. Franklin Martin, chairman of the medical 
section of the Council on National Defense organized a subsection on 
industrial medicine. According to Dr. Mock, "This committee pro- 
posed elaborate plans for the supervision of the health of all workers 
engaged in essential war occupations. Few of those in authority were 
familiar with this new field in medicine, and it took weeks and weeks of 
patient endeavor to sell the idea." On May 27, 1918, Dr. Otto P. 
Geier, who was the director of the committee, submitted an excellent 
report on "Industrial Medicine and Surgery as a War Measure." During 
this year also, Dr. C. D. Selby made an extensive survey, under the 
Working Conditions Service, of industrial establishments in both the 
United States and Canada which was published by the U. S. Public 
Health Service as Bulletin No. 99 (1919) under the title of "Studies of 
the Medical and Surgical Care of Industrial Workers." 
On July 1, 1918, President Wilson issued an executive order that "All 
sanitary or public health activities carried on by any executive bureau, 
agency or office, specially created for or concerned in the prosecution 
of the existing war, shall be exercised under the supervision and control of 
the Secretary of the Treasury." The order did not include the Medical 
Departments of the Army and Navy, but designated the United States 
Public Health Service as the Bureau of the Treasury Department respon- LVI 
PREFATORY 
sible for the work. This program could not fail to have had a beneficent 
effect on our war-workers. 
The fundamental principles of Dr. Geier's report should be applied at 
all times, and a careful study of it as well as the writings of Dr. C. E. Ford 
and Dr. C. D. Selby will convince every thoughtful person that much 
remains to be done to prevent the terrific human waste in industry. 
In May, 1919, the Journal of Industrial Hygiene was established 
and the founders and supporters of this excellent Journal may well 
feel rewarded by its glorious achievements in the last four years. It is 
under the editorship of David L. Edsall, a well known American pioneer 
in industrial medicine. He enjoys the support of an able staff of associate 
editors both in this country and in Great Britain, Australia and South 
Africa, with Dr. Cecil K. Drinker as managing editor. 
In the same year Modern Medicine, now The Nation's Health, a 
monthly journal, was established in Chicago, and it can be confidently 
predicted that these two publications will set the pace for all others in the 
subject of industrial hygiene, medicine and surgery. 
In the spring of 1919, the President of the American Federation of 
Labor invited a number of experts to a conference to assist him in the 
consideration of a number of important agenda likely to be presented at 
the International Labor Congress to be held in Washington in October, 
1919. It is gratifying to report that at all these conferences the American 
Public Health Association was largely represented. 
In 1919, Dr. Harry A. Mock of Chicago wrote a very timely and credit- 
able volume entitled Industrial Medicine and Surgery, covering 785 pages, 
published by the Wm. B. Saunders Company of Philadelphia. In 1921, 
Dr. W. I. Clark, Jr., wrote an excellent hand-book on "Health Service in 
Industry," published by the Macmillan Company. 
Garrison.22 in his, "History of Medicine" page 694, says: "In America the inves- 
tigations and reports of George M. Kober (1906-16), FrederickL. Hoffmann (1906-16), 
John B. Andrews (1906-16), and Alice Hamilton (1911-14) on industrial poisons, and 
of William C. Hanson on dust and fumes (1913) have proved of great value. Impor- 
tant monographs are those of Josephine Goldmark on industrial fatigue (1912), George 
M. Price on the "Modern Factory" (1914), W. Gilman Thompson on occupational 
diseases (1914) and the cooperative treatise on the same subject edited by George M. 
Kober and William C. Hanson. . . . " 
Garrison also says, page 775: " The best pioneer work was done by the United States 
Department of Labor, and much was accomplished through the labors of George M. 
Kober, W. Gilman Thompson, John B. Andrews, Alice Hamilton, J. W. Scheresehew- 
sky, S. S. Goldwater, and others." 
INDUSTRIAL SURGERY 
Progress has not been confined to industrial hygiene and medicine, 
for it must be recalled that equally great advances have been made in 
industrial surgery, largely due, as stated by Dr. Mock, to the studies and 
contributions of such surgeons as Moorhead, Clark, Farnum, Corwin, PREFATORY 
LVII 
Harvey, Lauffer, Shoudy, Cotton, Bloodgood, Edward Martin, 
Lounsbury, Warnshius, Richard and Hugh Cabot, Mock, and others. 
In 1914 a "Conference Board of Physicians in Industrial Practice" 
was organized, with headquarters in New York City, and Dr. Magnus as 
Secretary. Its activities were largely focused in the eastern states. 
Many of the leaders in industrial medicine and surgery were numbered 
among its members, some of the greatest contributions to this specialty 
having been made by this group. In the same year great advances were 
also made in the mining and lumber regions of the far west, largely due to 
the efforts of Doctors Corwin of Colorado, Tucker, Philip King Brown, 
and R. T. Legge of California and Dr. Yokom of Washington. 
In 1916 the American Association of Industrial Physicians and 
Surgeons was organized in Detroit. The objects of this Association are 
to "stimulate scientific study and research in all branches of industrial 
medicine, to stimulate industries to adopt a comprehensive health service 
and to raise the standards of the physicians engaged in industrial prac- 
tice." Much credit is due to Dr. Harry A. Mock and Dr. Francis D. 
Patterson and 125 other Charter members for inaugurating this movement. 
The Association has now about 600 members, and we quite agree with 
Dr. Mock that "the combined efforts of this body have undoubtedly done 
more to increase the benefits from this work to both employes 
and employers than any other one agency which has entered the field." 
(For a discussion of the "economic loss from preventable sickness and 
accidents amongthe working population," and "aretrospect and prospect," 
see the body of the Text, pages 79-86.) 
REFERENCES 
1 Collis, E. L. and M. Greenwood.-The Health of the Industrial Worker, p. 2, 
P. Blakiston's Son Co., Philadelphia, Pa., 1921. 
2 Price, George M.--The Modern Factory. John Wiley & Sons, New York, 1914. 
3 Lehmann, K. B.-Kurzes Lehrbuch der Arbeits-und Gewerbehygiene, Leipzig, 
1919. 
♦ Cooke-Taylor, R. W.-History of the Factory System, 2nd Edition. Methuen & Co., 
Ltd., 1912. 
6 Rogers, Thorold.-Six Centuries of Work and Wages, p. 557. Fisher Unwin, 1917; 
cited by Collis. 
6 Stieda, Wilh.-Article "Fabrik" in Conrad's Handworterbuch der Staats-Wissen- 
schaften, cited by Price. 
7 Hammond, J. L. and Hammond, B.-The Town Laborer, Longmans, Green & Co., 
1917. 
8 Hunt, W.-The Political History of England, Vol. X, p. 278. Longmans, Green & 
Co., 1905. 
9 Jevons, Stanley W.-The State in Relation to Labor, English Citizen Series. 
Macmillan & Co., 1882. 
10 Hutchins, B. L. and Harrison, A.-History of Factory Legislation. P. S. King and 
Son, 1911. 
11 Anderson, Adelaide M.-Labor Legislation. Encyclopaedia Brittannica. 
12 Haller, Von, Albrecht.-Bibi. med. pract., Basiliae, 1777, Vol. HI, p. 52. LVIII 
PREFATORY 
13 Garrison, Fielding H.-History of Medicine, 2nd Edition, 1917, p. 192, Wm. B. 
Saunders Co., Philadelphia, Pa. 
14 Haller, Von, Albrecht.-Bibi. med. pract., Basiliae, 1777, Vol. II, p. 434. 
16 Garrison, Fielding H.-History of Medicine, 2nd Edition, 1917, p. 313. 
16 Wright, Carroll D.-The Industrial Evolution of the United States, 1895, Charles 
Scribner's Son. 
17 Bulletin 150. Department of Commerce, 1923, and communication from W. M. 
Stewart, Director, Bureau of the Census, May 3, 1923. 
18 Hanson, William C., M.D.-XVth International Congress of Hygiene and Demo- 
graphy, 1913, Vol. Ill, p. 898. 
19 Linenthal, H., M.D.-Ibid, p. 907. 
20 Andrews, John B.-Secretary, American Association for Labor Legislation, personal 
communication, July, 1921. 
21 Mock, Harry A.-"Industrial Medicine and Surgery, a Resume of its Develop- 
ment and Scope, " Journal of Industrial Hygiene, May 3, 1919. 
22 Garrison, Fielding H.-History of Medicine, 2nd Edition, 1917. Wm. B. Saunders. FOREWORD 
Because of the rapid and continued progress evident in the field of 
health in relation to industry, the determination has been before the 
Editors of the present volume for several years to publish a revised and 
extended edition of Kober and Hanson's " Diseases of Occupation and 
Vocational Hygiene." The paucity of unattached contributors which 
existed when the former volume was brought out no longer obtains, hence 
the opportunity for selecting men with wide reputations in their respec- 
tive subjects has broadened considerably. While most of the contributors 
to the earlier volume have been retained, the reader will welcome the 
addition of some ten new names widely known in their special branches 
of industrial health. Most of them, in fact, bring entirely new subjects 
into the volume, such as Industrial Medical Services, Industrial Nursing, 
Standards in Sanitation, Official and Voluntary Health Agencies, etc. 
The present volume is an extensive revision and amplification of the 
original material by practically all of the respective contributors, bringing 
it up to date and including the more recent literature in a broad way. 
In this latter respect the work will be found somewhat encyclopaedic. 
The aim of the Editors has been to present the basic data of industrial 
efficiency which may be had through personal efficiency and the intelli- 
gent and scientific control of the environment in the workshop and in the 
home. Most industrial applications of today, whether mental or manual, 
result in various kinds of health complaints; much, in fact, in the promo- 
tion of definite ill-health and some in the establishment of true occupa- 
tional diseases. To the informed person, wasteful methods are apparent 
on all sides. Even a high degree of human efficiency, or high percentage 
of output may be bettered. Such is a fundamental biologic law. To 
illustrate, we would consider 90 per cent, efficiency as quite satis- 
factory, but as another has pointed out, 90 per cent, efficiency means 
ten men out of every one-hundred doing nothing. To make the biologic 
law more operative in industry is the chief aim of this work. 
Our method has been to present that which all should know in the 
language of the intelligent lay person, but to leave certain specialized 
material which has been prepared by highly trained and experienced men, 
in the language of the specialist, be he scientist, physician, or other skilled 
person. 
Part I deals with the General Principles of Maintaining Health in 
Industry. It aims to cover all angles of the subject and recognizes the 
fact that reliable guides or standards have now been fairly successfully 
marked out and given sufficient practical usage to warrant advocating 
them for general application. 
Part II considers the Vocational Hygiene of Certain Industries and 
Callings which in themselves, because of their importance in our industrial 
LIX LX 
FOREWORD 
life or in the health relationship of those so employed, deserve special 
consideration and discussion. 
Part III pertains especially to Specific Occupational Diseases, the 
result of exposure to certain poisons, infections, substances, conditions 
and methods of industrial applications. There is a thorough discussion 
of the peculiar health hazards and hygienic oversights or mistakes which 
contribute to the resulting occupational disabilities. Here voluminous 
information is concentrated also in Tables largely derived from Govern- 
mental publications. 
Part IV is of more medico-technical nature and covers the Systemic 
Occupational Diseases, many of which must be carefully differentiated 
from similar disabilities due to other factors than industry. Here some 
of the contributors have seen fit to discuss the various theories and clinical 
experiences dealing with the underlying causes of different types of 
systemic diseases, whether such causes are occupational or otherwise. 
Part V deals with the general Principles of Industrial Health Adminis- 
tration and leads from discussions covering mortality and other vital 
statistical findings to legislative, administrative and compensative 
features. It includes, also, the relationship of such factors as women and 
child labor, emphasizing the best accepted procedures in these matters. 
It is believed that a fairly complete historical discussion is contained 
in the rather extensive Prefatory which covers the evolution of the sub- 
ject in leading industrial countries of the world. The Appendix contains 
certain Tables for analyzing industrial hygiene and occupational diseases, 
as well as addenda to certain Chapters received while the volume was 
in the process of publication. The responsibility for the Index lies with 
the Junior Editor, who with the indispensible assistance of several 
deeply interested technical and professional friends, particularly Dr. N. C. 
Dysart, Chief of the Division of Industrial Hygiene of the Ohio State 
Department of Health, have spared no pains or space to make it complete, 
both as to author citations and subject matter. 
The deaths of three contributors to the earlier work are commemo- 
rated, viz., Dr. Clarence J. Blake, whose Chapter on 11 Injuries and 
Diseases of the Ear" has been revised by Dr. Walter A. Wells; Dr. 
Elmer E. Southard, whose Chapter, with the co-authorship of Dr. 
Harry C. Solomon, on "Occupational Neuroses" has been revised by 
Dr. Solomon; and Prof. Charles R. Henderson, whose untimely death 
occurred just before his Chapter on "Labor and Health Boards and 
Legislative Commissions" appeared in the former publication--certain 
phases of which subject are included in Dr. Schereschewsky's Chapter 
on "Health Agencies," also in the Prefatory, and elsewhere. We 
believe the last production of Miss Florence Swift Wright is the Chapter 
occurring in this volume on "The Industrial Nurse" which was received 
just before her sudden demise and, with slight editorial revision, has 
been used intact. EDITORS 
KOBER, GEORGE M., M. D., LL. D. 
Professor of Hygiene, Georgetown University, Washington, D. C.; President, 
Section on Hygiene of Occupations, XVth International Congress on Hygiene and 
Demography; Chairman, Section on Industrial Hygiene, American Public Health 
Association, 1915, and Vice-President, 1916; President, National Tuberculosis 
Association, 1915. Chairman, Subsection C, Sociological Medicine of the Pan- 
American Scientific Congress-Washington, D. C., 1915-1916. Vice-President, 
Washington Academy of Sciences, 1919-1920. Honorary Member, Association 
of American Physicians, and Association of Military Surgeons. 
HAYHURST, EMERY R., A. M., M. D., Ph. D. 
Professor of Hygiene and Head of the Department of Public Health, Ohio State 
University; Consultant in Industrial Hygiene, Ohio State Department of Health; 
Surgeon (Reserve) U. S. Public Health Service; Chairman, Section on Industrial 
Hygiene, American Public Health Association, 1917, 1923. Member, Pike's 
Peak Physiological Expedition from the University of Illinois, 1903. Special 
Investigator, Illinois Commission on Occupational Diseases, 1910. Fellow on 
Occupational Diseases, Otho S. A. Sprague Memorial Institute, University of 
Chicago, 1911-1913. Chief, Ohio State Survey of Occupational Diseases, 1913- 
1915. 
LXI TRANSLATORS 
FETZER, LEWIS W., Ph. D., M. D., Sc. D. 
Chairman, Committee on Occupational Diseases and Hazards in the Chemical 
Trades, American Chemical Society; formerly, Specialist, Experiment Station, 
U. S. Department of Agriculture, Washington, D. C. (Translation, with 
certain additions, of Section on "Mercury Poisoning," prepared by Ludwig 
Teleky, Dusseldorf, Germany-formerly of Vienna, Austria.) 
RAND, W. H., M. D. 
Washington, D. C. (Translator and reviewer of Section on "List of Mixed 
Industrial Poisons, " prepared by Johann Mueller, Germany, and of Section on 
"List of Industrial Poisons," prepared by Th. Sommerfeld and R. Fischer, 
Germany.) 
LXIII CONTRIBUTORS 
ANDREWS, IRENE OSGOOD. 
Assistant Secretary of the American Association for Labor Legislation. 
ANDREWS, JOHN B., Ph. D. 
Secretary of the American Association for Labor Legislation; Editor of the 
American Legislation Review. 
APFELBACH, GEORGE L., A. B., M. D. 
Physician to the Division of Factory Inspection, Illinois Department of Labor. 
ASHFORD, BAILEY K., M. D., Sci. D. (Georgetown). 
Colonel, Medical Corps, U. S. Army; President of Board for Study of Tropical 
Diseases in Porto Rico, Cooperating with the Institute of Tropical Medicine and 
Hygiene of Porto Rico. 
BLAKE,* CLARENCE JOHN, M. D., O. M. (Vienna). 
Professor of Otology, Emeritus (Harvard); President Ninth International Otolog- 
ical Congress. 
BOWEN, JOHN T., M. D. 
Professor of Dermatology, Emeritus (Harvard). 
DEVOTO, DR. LUIGI. 
Professor and Director of the Milan Clinic for Occupational Diseases; Professor 
of Internal Medicine, Emeritus, Royal University of Pavia, Italy. 
DITTOE, WM. H., C. E. 
Chief, Division of Sanitary Engineering, Ohio State Department of Health; 
Chairman, Conference of State Sanitary Engineers (Ohio); Chairman, Section on 
Sanitary Engineering, American Public Health Association, 1921. 
ERDMAN, SEWARD, M. D., F. A. C. S. 
Associate Attending Surgeon, New York Hospital; sometime Member of Medical 
Staff during construction East River Tunnels, New York City. 
FROTHINGHAM, LANGDON, M. D. V. 
Research Assistant in Comparative Pathology; Harvard Medical School, 
Boston. Formerly Pathologist to the State Department of Animal Industry 
of Massachusetts; Instructor in Bacteriology, Harvard Medical School. 
GROENIGER, WM. C. 
Consultin Sanitary Engineer; President, American Society of Sanitary Engineer- 
ing; formerly Director, Division of Plumbing, Ohio State Department of Health. 
HAMILTON, ALICE, A. M., M. D. 
Assistant Professor of Industrial Medicine, Harvard University Medical School; 
former Chairman, Section on Industrial Hygiene, American Public Health 
Association. 
HANSON, WM. C., M. D. 
Formerly with the Massachusetts State Board of Health. 
LEE, FREDERICK S., Ph. D. 
Research Professor of Physiology, Columbia University, New York City; Senior 
Physiologist, U. S. Public Health Service. 
LEE, THOMAS S., M. D. 
Clinical Professor of Medicine, Georgetown and George Washington Universi- 
ties, Washington, D. C.; Attending Physician, Gallinger Municipal Hospital; 
Consulting Physician, Providence Hospital and Georgetown University Hospital. 
LEGGE, THOMAS M., M. D. (Oxon.), D. P. H. (Cantab.). 
H. M. Senior Medical Inspector of Factories; Lecturer, Factory Hygiene, Univer- 
sity of Manchester; Secretary, Royal Commission on Tuberculosis, 1896-98. 
* Deceased. 
LXV LXVI 
CONTRIBUTORS 
LINENTHAL, HARRY, M. D. 
Physician, Out-Patient Department, Massachusetts General Hospital, Boston. 
LOVEJOY, OWEN R. 
General Secretary, National Child Labor Committee, New York City. 
OLIVER, SIR THOMAS, M. D., F. R. C. P., M. A. (Hon.) and D. C. L. (Hon.); 
LL. D. (Durham); D. Sc. (Glasgow), Sheffield; Consulting Physician, Royal 
Victoria Infirmary, and Professor of the Principles and Practice of Medicine, 
Durham University and College of Medicine, Newcastle-upon-Tyne. 
ORDWAY, THOMAS, M. D. 
Dean and Associate Professor of Medicine, Albany Medical College, Albany, 
New York; Attending Physician to Albany Hospital; formerly Physician-in- 
Charge, Collis P. Huntington Memorial Hospital, Harvard Medical School. 
SAYERS, R. R., A. M., M. D. 
Chief Surgeon, U. S. Bureau of Mines; Surgeon, U. S. Public Health Service. 
SCHERESCHEWSKY, J. W., M. D. 
Surgeon, U. S. Public Health Service; in Charge of Industrial Hygiene, U. S. 
Public Health Service, 1913-1918; in Charge of Division of Scientific Research, 
U. S. Public Health Service, 1918-1922. 
SELBY, CLARENCE D., M. D., F. A. C. S. 
Chief of Staff, St. Vincent's Hospital, Toledo, Ohio; Consulting Hygienist, U. S. 
Public Health Service (during the War), assigned to Division of Industrial Hygiene. 
SOLOMON, HARRY C., M. D. 
Instructor in Psychiatry and Neuropathology, Howard Medical School; Chief of 
Therapeutic Research, Boston Psychopathic Hospital. 
SOUTHARD,* ELMER E., M. D. 
Bullard Professor of Neuropathology, Harvard University Medical School; 
Pathologist, Massachusetts State Board of Insanity; Director, Psychopathic 
Department, Boston State Hospital. 
TELEKY, DR. LUDWIG. 
Privat-Dozent for Social Medicine, University of Vienna. Inspector of Indus- 
tries, Dusseldorf, Germany. 
TRASK, JOHN W., M. D. 
Surgeon, U. S. Public Health Service. 
TRUBY, ALBERT, E., M. D. 
Colonel, Medical Corps, U. S. Army; Chief Surgeon, U. S. Air Service (during 
the War); Commanding Officer, U. S. Army General Hospital, Presidio of San 
Francisco, California. 
TYZZER, ERNEST E., M. D. 
George Fabyan Professor of Comparative Pathology, and Director of Cancer 
Research, Harvard University Medical School. 
WELLS, WALTER A., M. D. 
Professor of Oto-Laryngology, Georgetown University, Washington, D. C. 
WHIPPLE, GEORGE C., S. B. 
Gordon McKay Professor of Sanitary Engineering, Harvard University; Member 
of Firm of Hazen and Whipple, Civil Engineers, New York City. 
WRIGHT,* FLORENCE SWIFT, R. N. 
Assistant Superintendent, Visiting Nurse Association, New Haven, Conn.; 
formerly Secretary, Employes' Benefit Association, John Wanamaker Co., New 
York; formerly in Charge of Industrial Nursing, Cheney Bros. Silk Mills and 
Clark Thread Co. 
WURDEMANN, HARRY VANDERBILT, M. D.; Sc. D.; F. A. C. S. 
Lieutenant-Colonel, U. S. Army; Associate Editor, American Journal of 
Ophthalmology. 
* Deceased. CONTENTS 
PART I 
The General Principles of Maintaining Health in Industry 
Page 
CHAPTER I. The Cause and Prevention of Occupational Diseases 
(Kober) 1 
CHAPTER II. Suggested Standards for Ventilation, Sanitation and 
Illumination 28 
Section 1. Ventilation in Work Places, and Tests Therefor (Hayhurst). 28 
Section 2. Sanitation for Places of Employment (Dittoe and Groeniger) 31 
Section 3. Illumination in Work Places, and Tests Therefor (Hayhurst) 38 
CHAPTER III. Personal Hygiene of the Worker (Kober) 42 
The Vitamines, a Summary (Hayhurst) 57-61 
CHAPTER IV. Economic Loss from Preventable Sickness and Acci- 
dents among the Working Population (Kober). ... 79 
CHAPTER V. General Welfare Measures for Wage-Earners (Kober) 87 
CHAPTER VI. Federal, State and Local Health Agencies in Pro- 
moting Industrial Hygiene (Schereschewsky) .... 95 
CHAPTER VII. The Function of the Milan Clinic in the Prevention 
of Occupational Diseases: Its Origin, Purposes and 
Activities (Devoto) 101 
Occupational Disease Clinics in the United States 
(Kober) 112-113 
CHAPTER VIII. Industrial Medical Service (Selby) 114 
CHAPTER IX. The Industrial Nurse (Wright) 136 
PART II 
Vocational Hygiene of Certain Industries and Callings 
K 
CHAPTER I. Mining and Quarrying Industries (Kober) 145 
Air of Mines (Sayers) 146-149 
Special Hazards, Diseases and Mortality of Coal 
Miners (Hayhurst) 150-153 
CHAPTER II. Clay' Products Pottery, Glass and Allied Industries 
(Kober) 163 
CHAPTER III. Iron, Steel and Allied Industries (Kober) 176 
Automobiles, Motorcycles, Etc. (Hayhurst) .... 193-194 
CHAPTER IV. Precious Metals, Jewelry and Plating Industries 
(Kober) ' 196 
CHAPTER V. The Lumber Industry (Kober) 202 
CHAPTER VI. Farmers, Gardeners, Planters and Farm Laborers 
(Kober) 210 
CHAPTER VII. The Industry of Food Stuffs, Etc. (Kober) .... 214 
LXVII LXVIII 
CONTENTS 
Page 
CHAPTER VIII. Rendering, Soap, Glue and Fertilizer Industries, 
Etc. (Kober) 233 
CHAPTER IX. Railway and Transportation Services (Kober) . . . 239 
CHAPTER X. The Printing and Publishing Industry (Kober) . . . 247 
CHAPTER XI. The Textile and Allied Industries (Kober and Hanson). 257 
CHAPTER XII. The Rag, Shoddy and Paper Industries (Kober). . . 269 
CHAPTER XIII. The Button, Horn, Celluloid and Allied Industries 
(Kober) 273 
CHAPTER XIV. The Boot and Shoe Industry (Kober) 278 
CHAPTER XV. Tailors, Garment and Laundry Workers (Kober) . . 281 
CHAPTER XVI. Liberal Professions, Public Services, Etc. (Kober) . . 288 
PART III 
Specific Occupational Diseases with Hygienic Description of 
the Industries in Which They Chiefly Occur 
CHAPTER I. Occupational Intoxications 303 
Section 1. Arsenic Poisoning (Legge) 303 
Section 2. Peculiarities in Arsenic Poisoning (Kober) 315 
Section 3. Copper and the Copper Industries (Hayhurst) 321 
Section 4. Zinc and the Zinc Industries (Hayhurst) 328 
Section 5. Brass and the Brass Industries (Hayhurst and Kober) ... 341 
Section 6. The Health of Brass Workers (Legge) 353 
Section 7. Carbon Bisulphide Poisoning (Hayhurst) 360 
Section 8. Carbon Monoxide Poisoning (Apfelbach, revised by Hay- 
hurst) 369 
Section 9. Lead Poisoning: Sources, Symptoms and Treatment (Oliver) 412 
Section 10. Early Diagonsis of Lead Poisoning (Linenthal) 433 
Section 11. Lead Poisoning in the United States (Hamilton) 440 
Section 12. Lead Poisoning: Notes, Statistics and Preventive Measures 
(Kober) 458 
Section 13. Mercury Poisoning (Teleky) 471 
Section 14. Mercurial Industries (Teleky and Kober) 481 
Section 15. Petroleum and Its Derivatives (Hamilton) 495 
Section 16. Coal Tar Benzene (Benzol) Poisoning (Hamilton) 500 
Section 17. The Petroleum and Coal Tar Industries (Kober) 504 
Section 18. Phosphorus Poisoning: History, Statistics and Prevention 
(J. B. Andrews) 526 
Section 19. Phosphorus Poisoning: Sources, Symptoms and Treatment 
(Hamilton) 531 
Section 20. Poisonings in the Rubber Industry (Hayhurst and Kober) . 535 
Section 21. The Manufacture and Use of Explosives (Kober) 546 
Section 22. Miscellaneous Chemical Poisons and the Relevant Indus- 
tries (Kober) 569 
Section 23. Miscellaneous Metals and the Relevant Industries (Kober) . 583 
Section 24. Alphabetical List of Industries in Which Poisoning May 
Occur and Other Hazards Which May be Present (Kober) . . 606 
Section 25. List of Mixed Industrial Poisons: Composite Industrial 
Poisons (Rand, from Mueller) 627 
Section 26. List of Industrial Poisons and Other Substances Injurious to 
Health Found in Industrial Processes (Rand, from Som- 
merfeld and Fischer) 642 LXIX 
CONTENTS 
Page 
CHAPTER II. Occupational Infectious Diseases 663 
Section 1. Anthrax (Frothingham) 663 
Section 2. The Hide, Tanning and Allied Industries (Kober) 673 
Section 3. Parasites and Occupation (Ashford) 682 
Section 4. Oil Folliculitis, Dermatitis and Furunculosis (Hayhurst) . . 696 
CHAPTER III. Occupational Diseases Due to Dust.-Tuberculosis. . 701 
Section 1. Dust Diseases of the Lungs (Oliver) 701 
Section 2. Tuberculosis in Relation to Occupations (Kober) 720 
CHAPTER IV. Occupational Diseases Due to Fatigue 737 
Section 1. Fatigue and Occupation (F. S. Lee) 737 
Section 2. Occupation Neuroses (Southard and Solomon) 763 
CHAPTER V. Occupational Diseases Due to Abnormal Atmospheric 
Pressures ) 790 
Section 1. Compressed-air Illness (Erdman) 790 
Section 2. Effects of Diminished Atmosphere upon Health (Truby and 
Kober) 814 
CHAPTER VI. Electrical Injuries and Electrical Shock (Oliver) . . 831 
PART IV 
Systemic Occupational Diseases 
CHAPTER I. Occupational Affections of the Nose, Mouth and • 
Throat (Legge) 844 
CHAPTER II. Occupational Affections of the Eye 855 
Section 1. Occupational Injuries and Diseases of the Eye (Wiirdermann). 855 
Visual Power in an Economic Sense (Hayhurst, from Brown) 880 
Section 2. Glass Workers' Cataract (Legge) 883 
CHAPTER III. Occupational Injuries and Diseases of the Ear (Blake, 
revised by Wells) 890 
CHAPTER IV. Occupational Affections of the Skin (Bowen) 905 
CHAPTER V. Diseases of the Blood, Circulatory System and Kidneys 
(Thom. S. Lee) 930 
CHAPTER VI. Cancer and Occupation, X-Ray, Radium 946 
Section 1. Cancer (Tyzzer and Ordway) 946 
Section 2. X-Ray (Tyzzer and Ordway) 959 
Section 3. Radium (Tyzzer and Ordway) 966 
PART V 
The Principles of Industrial Health Administration 
CHAPTER I. Comparative Occupation Statistics (Kober) 970 
The Significance of the Preventable Causes of Death 
(Hayhurst) 984 
CHAPTER II. The Use and the Fallacies of Statistics (Whipple) . 988 
CHAPTER III. The Methods and Scope of Protective Legislation 
(J. »B. Andrews) 1002 
CHAPTER IV. Child Labor (Lovejoy) 1020 
CHAPTER V. Women Wage Earners (Irene O. Andrews) 1028 
CHAPTER VI. The United States Employes' Compensation Act and Its 
Administration (Trask) 1043 LXX 
CONTENTS 
Page 
CHAPTER I. Chart for Analyzing an Industrial Health Complaint 
(Hayhurst) 1067 
CHAPTER II. Chart for Personal Health Data (Hayhurst) 1069 
CHAPTER III. Guide for Chief Diagnostic Signs of Lead Poisoning 
(Hayhurst) 1071 
CHAPTER IV. Addenda on Lead Poisoning: Sources, Symptoms and 
Treatment (Oliver) 1072 
CHAPTER V. Addenda on Dust Diseases of the Lungs (Oliver) . . 1074 
APPENDIX LIST OF ILLUSTRATIONS 
Figure Page 
1. Foot-candle meter 39 
2. Interior details of foot-candle meter 40 
3. Measuring illumination with the foot-candle meter 40 
4. Welding a steel ring with an electric arc 177 
5. Hot saw thoroughly guarded, in beam mill 179 
6. An emery wheel equipped with heavy steel guard 181 
7. Steel dust to which workers are exposed 182 
8. Machine shop workman using movable burlap screen . 185 
9. Grinding iron castings 188 
10. Laundry workers. Ironing machine hooded 284 
11. Laundry workers. Ironing machine not hooded 285 
12. Crude method of drying Paris green (colored plate) 316 
13. Copper mining by compressed air drill 325 
14. Casting yellow brass. Unprotected workers 344 
15. Casting yellow brass. Protected workers 345 
16. Crucible of yellow brass (colored plate) 346 
17. Brass buffing. Well equipped wheels 347 
18. Brass buffing. No dust-removal devices 348 
19. Brass casting. New method of pouring 356 
20. Diagram showing travel of gases from blast furnace to stoves and washers.. 383 
21. Diagram showing travel of furnace gases to boiler house, Theisen washer 
and blowing engine 384 
22. Rate of elimination of carbon monoxide (chart) 403 
23. H.-H.-inhalator with Schafer prone-pressure method of resuscitation 404 
24. Hookworm attached to intestinal mucosa 687 
25. Stages in development of the egg of the hookworm 688 
26. Patient suffering from intense grade of hookworm infection 689 
27. Graphic record of fatigue curve in excised frog's muscle 738 
28. Graphic records compared of two excised frog's muscles lifting equal weights, 
but stimulated at different rates - 738 
29. Graphic records compared of two excised frog's muscles stimulated at the 
same rate, but lifting different weights 739 
30. Graphic record of frog's muscle working in situ 739 
31. Graphic record of voluntary contractions, middle finger lifting a 3 kilogram 
weight-showing progressive fatigue 742 
32. Index numbers showing percentage variations of hourly output from limit of 
possible efficiency 746 
33. Index numbers showing percentage variations of hourly output from limit 
efficiency 747 
34. Distribution of industrial accidents during the working day 749 
35. Diagram of Haldane's decompression methods I and II 808 
36. Expiration; pressure on (in Schafer prone-pressure method of artificial 
respiration) 842 
37. Inspiration; pressure off (in Schafer prone-pressure method of artificial 
respiration) 842 
38. Men at boring mill should provide themselves with goggles 858 
39. Men pouring babbitt should wear goggles or a wire-mesh screen covering 
the face 860 
LXXI LXXII 
LIST OF ILLUSTRATIONS 
Figure Page 
40. A man at an emery wheel should at all times wear goggles even if wheel has 
a permanent glass guard . 863 
41. A fellow workman attempts to remove a foreign body from the eye 867 
42. Hyperplasia in vegetable tissues due to infection with a myxmycete 948 
43. Metaplasia of the epithelium of the biliary ducts in Fiber zibethicus as the 
result of the presence of a species of trematode 949 
44. Irregular proliferation simulating adeno-carcinoma in chronic pancreatitis 
of the cat 950 
45. Coccidium nodule of the rabbit's liver simulating papillary adenocystoma... 951 
46. X-ray work. Photograph of the left-hand and wrist 960 
47. X-ray demonstrator. Photograph of chest 961 
48. X-ray effects on chest, hand, etc 962 
49. X-ray demonstrator. Photograph showing ulceration on chest 963 
50. Radium exposure. Photograph showing effects on fingers, etc 966 
51. Radium exposure. Photograph showing effects on free edge of the nails... . 967 
52. Specific death rates at different ages 998 
53. Diagram showing distribution of deaths from all causes among different ages 
in Massachusetts, 1910 999 PART I 
THE GENERAL PRINCIPLES OF MAINTAINING 
HEALTH IN INDUSTRY 
CHAPTER I 
THE CAUSE AND PREVENTION OF OCCUPATIONAL DISEASES 
Health is the chief asset of the workingman, and no greater calamity 
can befall him than when his earning capacity is impaired or arrested by 
reason of sickness or disability. It means in many instances the utter 
financial ruin of the family, and is doubtless one of the most potent causes 
of poverty and distress. Many diseases are incident to occupation and 
environment and industrial efficiency, and earning power can be pro- 
moted by appropriate safeguards and adequate protection of those 
engaged in gainful occupations. 
Definitions.-Diseases of occupation may be defined as injuries and 
disturbances of health contracted in industrial pursuits, and other voca- 
tions in life, as a result of exposure to toxic agents, infectious organisms 
or other conditions inimical to health. 
These diseases may be acute or chronic and vary in intensity and 
duration from the acute and fatal attacks of asphyxia, caused by suffocat- 
ing gases, to the slow and insidious forms of industrial tuberculosis. 
Classification.-An exact classification of occupational diseases is 
difficult, as we have as yet no standard nomenclature for this class of 
diseases, nor do they differ essentially in the majority of instances from 
the pathology and clinical picture of diseased conditions in general. For 
the present we may divide them into three general classes, viz.: 
(a) Specific occupational diseases, which include all diseases caused by 
industrial poisons or specific organisms which enter the system in the 
course of employment and are traceable to definite materials used, also 
diseases and sequelse caused by exposure to increased and diminished 
atmospheric pressure. 
(6) Systemic occupational diseases include all disorders caused by the 
movements, position of the body, overexertion, dust and fumes and abnor- 
mal working conditions, such as excessive heat, cold, moisture, or sudden 
changes. 
GEORGE M. KOBER, M. D„ Washington, D. C. 
1 2 
GENERAL PRINCIPLES OF MAINTAINING HEALTH IN INDUSTRY 
(c) Occupational diseases of special senses and organs include all affec- 
tions due to exposure to defective or intense light, excessive heat and 
noises, mental and physical strain, repeated motion, mechanical pressure, 
toxic and caustic agents, shock, etc. 
But even a classification according to causes is not exact, as many of 
the diseases contracted in industrial pursuits are due to a combination of 
causes and the so-called predisposing factors play a very important role. 
We will now briefly consider the most important causes of occupational 
diseases: 
Industrial poisons, according to Dr. R. Fischer, are to be defined, in 
general, as those raw materials and products, by-products, and waste 
products which, in their extraction, manufacture and use in industrial 
processes may, notwithstanding the exercise of ordinary precaution, find 
entrance into the body in such quantities as to endanger, by their chemical 
action, the health of the workmen employed. 
Eulenburg's Encyclopedia, published in 1898, under the heading 
" Arbeiterhygiene " gave a list of 31 industrial poisons. This list was 
amplified in 1908 by Prof. Th. Sommerfeld, Sir Thomas Oliver and Prof. 
Felix Putzey, and again amended by Industrial Inspector Dr. R. 
Fischer, in 1910. Sommerfeld's final draft was referred to the perma- 
nent advisory council of hygiene of the International Association for 
Labor Legislation, composed of Dr. R. Fischer of Berlin, L. Teleky of 
Vienna, J. P. Langlois of Paris, Sir Thomas Oliver of England, and Prof. 
Dr. L. Devoto of Milan, by whom it was edited, approved and finally 
published by the International Labor Office (Basle, December 24, 1911). 
A full translation of this list was published by the Bureau of Labor, in 
Bulletin 100, May, 1912. The list deals with 54 poisons. Because of its 
importance it is reproduced on page 642. The advisory council of hygiene 
of the International Association for Labor Protection also approved 
Fischer's definition of industrial poisons. 
Acute and Chronic Industrial Poisoning.-The industrial poisons may 
enter the system through the respiratory organs, the digestive tract, 
through the skin or by a combination of these channels. The effects are 
either acute or chronic and vary in severity from the fatal attacks of acute 
chlorine or aniline poisoning to the chronic intoxications from arsenic, 
ead, mercury, phosphorus, etc. Acute forms of industrial poisoning are 
fortunately becoming less frequent, but many of the industrial poisons may 
produce both acute and chronic effects. In the acute forms we are 
dealing with profound functional disturbances caused by an overdose 
of the various blood and nerve poisons; in the chronic forms, because of 
diminished dosage, the poisons cause disease of a chronic character, by 
producing gradual histological changes of the blood and tissues of the 
body. There are doubtless numerous instances in which minute quanti- 
ties of poison are not sufficient to produce specific effects, and yet bring 
about a general deterioration and diminished power of resistance, as INDUSTRIAL POISONS 
3 
instanced by the undue prevalence of tuberculosis among lead and 
mercury workers. 
It is well to remember that, as in infectious diseases so in the occupa- 
tional intoxications and systemic diseases, dosage, individual suscepti- 
bility, a low state of vitality, previous illness, bronchial and gastric 
catarrh, wounds and abrasions of the skin and the alcohol habit are 
important predisposing factors. Since most of the poisons are eliminated 
by the lungs, liver, kidneys and skin, functional derangement of these 
organs also plays an important role. 
The selective affinity of industrial poisons for certain organs or tissues 
remains obscure. We can appreciate why lead should attack the nerves 
of the overworked muscles of a painter's right arm and cause paralysis, 
commonly called " wrist-drop," or why white phosphorus should show a 
special affinity for a carious tooth and aid the microorganisms in their 
destructive work in bringing about necrosis or the "phossy jaw" of 
match makers. So far, however, no reasonable explanation has been 
offered why "wood alcohol" should select the optic nerve, lead the nerve 
tissue, the tunica media of arteries, and arsenic chiefly the nerves of the 
lower extremities; why hysteria or neurasthenia should develop as a 
result of chronic poisoning from three such widely differing substances 
as carbon bisulphide, manganese and mercury. But after all many 
similar phenomena are found in diseases in general, and the predilection 
of disease germs for certain organs or tissues in particular awaits 
explanation. 
The most important occupational intoxications are discussed in this 
work by recognized experts and this discussion is limited to a statement 
of general facts. 
Prevalence of Industrial Poisoning.-The actual number of cases of 
industrial poisoning cannot be determined until there is a uniform law 
requiring physicians to report certain occupational diseases. In countries 
like England, where reports have been compulsory since 1897, it is quite 
possible to secure, for example, reliable data as to the number of cases of 
lead poisoning. The same may be said of the facilities offered by the 
statistics of the "German Industrial Insurance Institute," which furnish 
not only the number of deaths but also the number of cases treated, 
together with the age period and the duration of the disease. Similar 
data should be collected in all industrial countries. As a matter of fact, 
prior to 1910, in the absence of statistical information in this country 
there was a general impression that American workmen were largely 
immune from the dangers of industrial poisons. The publication of Dr. 
Andrews' report, based upon a study of 15 match factories, disclosed the 
fact that 65 per cent, of the employes were exposed to the dangers of 
phosphorus poisoning, and 82 cases of serious poisoning were found in 
three factories alone. This report and the investigations of Drs. Alice 
Hamilton and Andrews on the prevalence of lead poisoning in the United 4 
GENERAL PRINCIPLES OF MAINTAINING HEALTH IN INDUSTRY 
States, also conducted by the Bureau of Labor, together with the facts 
collected by the Illinois Commission on Occupational Diseases, led to a 
realization of the importance of full and accurate knowledge concerning 
the existence of dangers from industrial poisons and their prevention. 
Thanks largely to the efforts of the American Associationfor Labor Legisla- 
tion, Congress, after two years' delay, by an Act approved April 9, 1912, 
practically abolished the manufacture of poisonous matches by imposing 
a tax at the rate of 2 cts. per 100 matches upon all white phosphorus 
matches manufactured in the United States after July 1, 1913. 
In 1911 six states, California, Connecticut, Illinois, Michigan, New 
York, and Wisconsin, enacted laws requiring physicians to report certain 
occupational diseases in their practice. Since that time 10 other states 
have enacted similar legislation. The lack of uniformity in these laws is 
to be regretted. The most comprehensive law was enacted in Missouri. 
We have as yet no complete tabulated returns from these reports, and 
while it is doubtful whether even one-fourth of all the cases will be 
reported, the returns will at least furnish more accurate knowledge con- 
cerning the existence of industrial hazards in the various states. 
This knowledge will be of great practical value because, as a result of 
preventive measures, factory sanitation and education of the employes, a 
gratifying reduction in the morbidity and mortality of wage earners has 
everywhere taken place. For example, in Great Britain, where notifica- 
tion was made compulsory in 1897, the number of cases of lead poisoning 
had been reduced from 1278 in 1898 to 505 in 1910, and 230 in 1921. 
The economic importance of the subject must be apparent from the fact 
that according to the Leipsic Industrial Insurance statistics of 1910, 1270 
cases of lead poisoning were cared for, with an average duration of 36.2 
days, involving 45,794 days' loss of work. This is all the more lamentable 
since many of these patients are subject to relapses. The Vienna statis- 
tics cited by Koelsch1 show that of 516 painters, during the course of 4 
years, 263 suffered from one attack, 85 from two attacks, 25 from three, 1 
from eight and 1 from nine attacks. According to Kaup's2 statistics the 
morbidity rates among about 5000 Berlin painters between 1905 and 1908 
were 20 per cent, above the average in other occupations, the duration of 
illness 80 per cent, higher, the mortality rates during the productive age 
50 per cent, higher, and the tuberculosis death rate 4 per 1000 higher. 
The Leipsic statistics also reveal an undue prevalence of gout among the 
workers in lead trades. 
The number of cases of mercurial poisoning has also been greatly 
diminished by the employment of less harmful substances and general pre- 
cautionary measures. For example, the number of sick days from mercu- 
rialism, which in 1885 among 160 mirror platers at Furth amounted to 
5463 days, has been wholly eliminated by the substitution of nitrate of 
silver. The number of cases among the miners and smelters of Idria has 
been reduced from 122 in 1896 to 5 in 1908. INDUSTRIAL POISONS 
5 
Similar gratifying reductions are reported in phosphorus poisoning, and 
with prohibitive legislation it is only a question of time when cases of 
necrosis of the jaw, which formerly afflicted between 11 and 12 per cent, 
of match makers, will entirely disappear. 
Importance of the Industrial Poisons from the Medico-legal Stand- 
point.-The question of international protection of labor was agitated as 
early as 1870, but it was not until 1890 that the first international confer- 
ence was held, in Berlin. This was followed by an International Congress 
at Paris in 1900 and the establishment of an International Association 
for Labor Protection, with a Bureau at Basle, in 1901. The object of this 
organization is to secure the enactment of uniform labor laws, to collect 
and publish literature on the cause and prevention of industrial diseases 
and accidents, and to promote the welfare of the laboring classes in 
general. It is largely due to the efforts of this organization that the use 
of white phosphorus in the manufacture of matches has to a great extent 
been prohibited and that so much has been accomplished in the preven- 
tion of lead poisoning, by the substitution of leadless processes in different 
industries. Indeed there are many leaders in the medical profession, 
men like Sir Thomas Oliver, Professor Sommerfeld and others, who 
believe that the interest of humanity demand the substitution of white 
zinc for the use of white lead in paint. It is also due to the efforts of this 
organization that men in the front ranks of social medicine prepared a. 
list of industrial poisons. The care exercised, so that no injustice may be 
done to employes under the liability acts, is shown by Dr. Fischer's 
definition of industrial poison. The question whether the benefits of the 
workingmen's compensation acts, which formerly applied to accidents 
only, should be extended to cases of acute industrial poisoning came up, 
and a number of countries decided to include certain of the occupational 
diseases with industrial accidents. The question now uppermost in the 
minds of thoughtful men is whether it is a social justice to allow damages 
in the case of loss of a limb by machinery accident, and to ignore the claims 
of a workman whose arm is disabled by lead paralysis, and whether it is 
fair that the dependents of a wage earner who perishes from an attack of 
acute industrial poisoning should receive a pension, while those in the case 
of a worker who dies from the chronic effects of the same poison do not. 
Also whether or not a workman who contracts typhoid fever from 
infected drinking water supplied by the employer should receive 
compensation. Already most of the civilized countries have extended the 
original list of notifiable diseases (see page 1002). 
According to Oliver,5 "In order to claim compensation a workman 
must produce: (1) a certificate from the local certifying factory surgeon; 
(2) or prove that he had been suspended from his usual employment on 
account of having contracted one of the diseases scheduled; and (3) in the 
event of death proof will have to be given, by friends or dependents, that 
death was due to one of the diseases mentioned above." 6 
GENERAL PRINCIPLES OF MAINTAINING HEALTH IN INDUSTRY 
It is not improbable that the extension of the liability act to dangerous 
occupations will involve more or less litigation and possibly also lead to 
the practice of malingering. There is already more or less literature on 
this subject, and also on the relation of a traumatic injury received to the 
development of diseases which, sooner or later, incapacitate the individual 
from work. Considerable evidence has been accumulated on chest 
injuries in relation to the development of pneumonia or to the lighting up 
of a latent tuberculous lesion of the lung, on injuries of the knee as an 
exciting cause of tuberculous inflammation of the knee-joint, and on blows 
upon the abdomen as a cause of Addison's disease. Traumatic injuries 
in general are regarded as an occasional cause of malignant growth, and 
the same is true of habitual exposure to anilin, coal tar, paraffine, etc. 
Diabetes insipidus may develop as a result of injury to the back of the 
head, and diabetes mellitus is liable to be aggravated, if not induced, by 
severe physical and mental strain. 
The German Industrial Insurance system appears to reduce the 
chances for litigation to a minimum by securing perfect cooperation 
between the employer, the employes, technical experts, factory inspec- 
tors, officials and physicians. 
Measures for the Protection of Industrial Workers against the Dangers of 
Poison; Compiled by Industrial Councillor Dr. Fischer of Berlin. 
"1. Properly adapted buildings, thick walls of separation for danger- 
ous rooms, good lighting, facilities for keeping the workshops clean and for 
effective ventilation. 
2. Apparatus adapted to its special purpose, whenever possible, clos- 
ing tight in every part. 
3. Appliances for accomplishing the arrest of gases and dust at their 
place of origin, their removal (by exhaust fans), and in a suitable manner 
rendering them innocuous or collecting them, thus preventing their 
entrance in the nose and mouth. 
4. So far as possible, avoidance of direct contact with poisonous 
materials or substances injurious to health in working with them, trans- 
porting or packing them. 
5. The displacement of particularly dangerous labor methods and mate- 
terials by the introduction of less dangerous labor processes and material, 
as well as by the employment of materials satisfactorily pure chemically. 
6. Instruction of workmen, just entering upon an occupation, con- 
cerning the properties of the poisonous substances extracted, manu- 
factured, used or otherwise evolved, and, whenever possible, cautionary 
leaflets should be placed in the hands of the workers. 
7. The repetition of these instructions at frequent intervals. 
8. Posting of precautionary regulations and warning placards, con- 
taining admonitions for the exercise of special caution, and enjoining the 
observance of measures for insuring safety. Constant supervision of all 
dangerous employments by expert and responsible persons. INDUSTRIAL INFECTIOUS DISEASES 
7 
9. Employment of appropriate means for personal protection in the 
way of suitable work clothes, caps, gloves, goggles, and, as necessary 
adjuncts, mouth and nose shields, respiratory masks and the like, in case 
the appliances named in rule 3 are inapplicable. 
10. Practice of bodily cleanliness by the use of wash, bath and dressing 
rooms, the use of special rooms for eating, separate lockers for street and 
work clothes, and frequent non-hazardous cleaning of the clothing. 
11. Immediate report of symptoms of indisposition, attention to 
wounds of the skin caused by the handling of corrosive materials, prompt 
employment of a reliable antidote, and summoning at the same time of 
a physician. 
12. The employment of a healthy working force. Periodical medical 
examination of the workers in dangerous employments. Temporary or 
permanent exclusion of unfit workmen from the dangerous departments of 
the industry. Under certain circumstances there should be a change of 
work in occupations giving rise to chronic poisoning. 
13. The utmost possible reduction of the hours of labor in dangerous 
employments." 
Many of these excellent rules will be extended under specially 
hazardous employments. It is needless to point out that every dangerous 
industry should be provided with a "first-aid outfit." In employments 
involving exposure to toxic gases or electricity, oxygen apparatus and 
instruction in resuscitation are indispensable. 
Rescuing parties must likewise seek protection in the way of forced 
ventilation, breathing helmets, etc. It is cheaper, and certainly more 
humane, for large concerns to provide not only these safeguards, but also 
competent medical service, than to pay compensation under the liability 
act. But after all the chief aim and object must be prevention. 
Industrial Infectious Diseases.-In this class of diseases the germs 
enter the system in the course of employment and are traceable to the 
materials used or to the soil, premises or environment. The most impor- 
tant infections, such as anthrax, uncinariasis, tuberculosis, etc.,- are 
dealt with in special chapters and also under different occupations, hence 
only a few salient facts bearing on general etiology and prevention will 
be presented here. 
(a) Uncinariasis.-This infection is liable to occur among all workers 
in fecally polluted soils, especially in miners, tunnel workers, quarrymen, 
brick and pottery workers, farmers and planters and persons employed 
in lumber and construction camps. The economic importance of hook- 
worm infection must be apparent when, according to Ashford,6 about 
800,000 persons, or 90 per cent, of the laborers in the coffee and sugar 
plantations of Porto Rico, were infected. Stiles6 estimates the number of 
victims in the United States at 2,000,000 and the economic loss from 
inability to work at $100,000,000 per annum. That this disease is 
both preventable and curable is shown by the results achieved in Porto 
Rico and in certain mining districts of Europe (see pages 686-690). 8 
GENERAL PRINCIPLES OF MAINTAINING HEALTH IN INDUSTRY 
(6) Anthrax.-This occupational infection, from the standpoint of fre- 
quency, is insignificant when compared with the hook-worm disease. 
The prevalence of anthrax in different occupations is well illustrated by 
the German statistics of 1910, covering 287 cases with 39 deaths and 
affecting 257 males and 30 females. According to Koelsch,7 in 135 cases 
the infection was traced to live or dead animals, in 142 instances to the 
offal of infected animals, one case was contracted by a laboratory worker, 
and in nine instances the source of infection could not be determined. 
The 257 male cases were distributed as follows: Agriculture, 121; flaying 
establishments, 9; hide trades, 8; tanneries, 92; leather, 3; transport 
laborers, 7; horsehair factories, 11; brush and hair factories, 4; wool 
carding, 1; and glue factories, 1. 
(c) Actinomycosis.-This disease, known as "lumpy jaw" in cattle, is 
caused by the ray fungus, and is generally believed to be transmitted from 
animal to man. Since the natural habitat of the fungus is on grass and 
grain straw, it may possibly be conveyed by placing grass or grain straw 
in the mouth. The majority of cases occur among farmers and stockmen. 
At all events, of the 27 cases studied by Rigler at the clinic of Jena, 18 
affected farmers. The disease is characterized by chronic, generally 
localized, suppurative conditions, accompanied by destructive processes 
of the tissues, and if the seat of the lesion affects some internal organ the 
termination is usually fatal. 
(d) Foot and Mouth Disease.-This affection primarily affects cattle 
sheep, goats, and pigs and is communicable to man. The disease, also, 
known as " aphthous fever," is occasionally observed in persons con- 
nected with the animal industries. After an incubation of from 4 to 5 
days the disease is ushered in by a chill, followed by fever and the forma- 
tion of vesicles upon the tongue, lips and mucous membrane of the buccal 
cavity and pharynx. The vesicles soon break and leave painful ulcers. 
Occasionally also miliary and pustular eruptions are observed on the hands. 
(e) Glanders and Farcy.-This disease affects primarily the horse, ass,, 
or mule and may be transmitted to man through wounds and abrasions, 
by direct contact with the mucopurulent secretions, by droplet infection, by 
the inhalation of dried and pulverized discharges, or through the medium 
of horse blankets, harness, stable utensils, etc. The disease is also com- 
municable from man to man. It is known as glanders when it attacks 
the mucous membranes and as farcy when it affects the skin. In either 
case the course may be acute or chronic and may vary in severity from a 
slight local infection to a profound general pysemic condition. The 
prognosis is extremely unfavorable, as from 50-80 per cent, of the cases 
terminate fatally. Bollinger, cited by Koelsch, has collected 106 cases;, 
of these, 66 occurred in hostlers and coachmen; 10 in veterinarians; 6 in 
horse butchers and 6 in persons employed in flaying dead animals; 5 in 
soldiers; 4 in physicians; 2 in horse dealers; 1 in a horseshoer; 1 in an 
anatomical laboratory worker; and 5 in other occupations. INDUSTRIAL INFECTIOUS DISEASES 
9 
(/) Septic infections (blood-poisoning) are not infrequently observed, 
especially among persons engaged in the flaying of dead animals, the manu- 
facture of artificial manure, glue and tallow factories, the hide, tanning and 
rag industry, in renovating hair mattresses and feathers, in silk workers, 
cannery employes, butchers, game dealers, cooks, physicians, veterin- 
arians, laboratory men, workers in anilin, grease, paraffine, etc. The 
streptococci and staphylococci may enter the system through wounds and 
abrasions, through the medium of biting flies or insects, or through the 
sebaceous follicles, or they may be inhaled. The infection may manifest 
itself by localized affections, such as trachoma, furuncles, or by boils or 
the graver forms of cellulitis, lymphangitis, erysipelas, septic sore throat 
and joint infections, and even by profound general septicaemia. 
(p) Smallpox and cowpox are occasionally contracted by persons 
engaged in handling infected clothing, laundry, bedding, rags, feathers, 
etc. The danger of handling fresh feathers and raw cotton imported 
from countries where smallpox is endemic has recently been emphasized 
by Shablowsky8 and by Corbin.9 The disease may also be contracted by 
nurses and attendants, and by employes of hotels, inns, etc., especially 
by chambermaids. I recall two small epidemics in which the infection 
was evidently carried all the way from Chicago by a traveller who, 
although apparently well himself, left foci of infection in two hotels. 
Cowpox is occasionally contracted by farmers and dairymen, 
especially during the act of milking. 
(A) Syphilis.-The virus of the disease caused by the "spirocheta 
pallida" evidently clings to the secretions of syphilitic ulcers and may be 
conveyed in an extragenital way by kisses, wet nursing, use of infected 
pipes, cigars and cigarettes, by the promiscuous use of glass-blower's pipes 
and the mouth-pieces of wind instruments, by dental and surgical instru- 
ments, and during digital examination by physicians and midwives, in 
case of abraded surfaces, hangnails, etc. Scheuer,10 who collected 297 
cases of occupational syphilis, mostly among physicians, midwives and 
nurses, also reports a series of cases in paper-hangers, cabinetmakers, 
shoemakers, saddlers, painters, dressmakers, who were infected by 
putting in the mouth or between the lips such things as pencils, nails, 
awls, needles, wire, thread and brushes, previously infected by syphilitic 
fellow-workers. According to the same author, clerks, accountants, and 
waiters have contracted the disease by holding infected lead pencils, 
pen holders, and even coins between their lips; he also reports instances 
of transmission in persons employed in the laundry and rag industries. 
(i) Tetanus is a typical soil disease and infections have been reported 
as incident to occupation, not only in workers of the soil but also in the 
jute industry. 
(j) Tuberculosis.-This disease, on account of its importance, is 
discussed in a separate paper. It is not a specific occupational disease, 
except perhaps in some instances where the infection is conveyed in 10 
GENERAL PRINCIPLES OF MAINTAINING HEALTH IN INDUSTRY 
autopsy work, or in the transmission of bovine tuberculosis, as in the 
case of butchers, cooks and dairy employes, who have contracted tuber- 
culosis of the skin by handling infected meat, milk and cream. 
The writer,11 in 1903, collected 12 cases of tuberculous wound infec- 
tion in veterinarians and butchers, and three cases of accidental inocula- 
tion in man by the topical application of cream and milk. Lassar12 
reports 11 cases of verrucose tuberculosis in butchers and abattoir 
employes from wound inoculations. It is also conceivable that the disease 
is occasionally conveyed by infected clothing and foot wear; at all events 
Perlen13 informs us that of 4177 tuberculous subjects treated in the 
Munich clinic 709 were engaged in repair and cleaning shops of foot wear 
and clothing. 
(&) Parasites.-Among other parasites transmissible from animals 
to man should be mentioned cysticerci or the larval form of tapeworm 
and infection with trichina spiralis, which are occasionally acquired by 
butchers, sausage makers, fishermen and cooks, mostly as a result of the 
habit of eating raw beef, pork or fish. 
Scabies and pediculosis are not infrequently contracted in lumber 
camps. Bedbugs and fleas are also great pests in unclean camps. 
The body louse may transmit the virus of typhus and trench fever. The 
pediculoides ventricosis, described by Schamberg and Goldberger, occurs 
primarily in wheat; it persists in the straw for months and may possibly 
survive in flour. The eruption caused by this parasite resembles either 
a severe form of urticaria or erythema multiforme. It is liable to affect 
farm hands, harvesters, packers of the straw and all who may later come 
into contact with the straw, and possibly those who handle the flour 
(Hazen). Among other mites capable of setting up troublesome forms of 
dermatitis are the mower mite, harvest bug, and chicken lice, which chiefly 
affect farmers, gardeners, poultry raisers and feather workers. 
The barbed hairs of the brown-tailed moth, and of its cocoon and cater- 
pillar contain an irritant poison, which not infrequently causes a derma- 
titis, resembling urticaria, in persons engaged in the eradication of the 
pest. 
Lumbermen, rivermen, guides and other field workers frequently 
suffer, not only from the local effects of mosquito bites, but also from sys- 
temic infections such as malaria, yellow fever, etc. They are not infre- 
quently exposed to the bites of moose and deer flies, sand flies, 
chiggers, wood tick, bee stings, fungi and moulds, etc. 
Lehmann emphasizes the fact that quite a number of persons show a hyper- 
susceptibility to the sting of insects, as shown by the presence of fever, dyspnoea, 
twitchings, numbness, etc. 
The stings of bees, according to Neumann have been known to'produce, apart 
from the local reaction such as swelling of the face, also a diminished pulse, pupillary 
reaction, frequent mucous bloody stools and great thirst with convalescence at the 
expiration of the third day. A similar case has recently come to my notice in the 
case of a woman, who was stung by a bee in the mouth, where in addition to the INDOOR OCCUPATIONS AND VITIATED AIR 
11 
above symptoms had also great difficulty of breathing, on account of the swelling in 
the pharynx. 
It is well known that cattle, horses, cats, mice and chickens are frequently infected 
with fungoid organisms known as Favus and Trichophyton capable of producing 
"scald head" and ring worm in various parts of the body, not uncommon among 
persons obliged to handle infected animals. 
Lehmann refers to a peculiar disease caused by mould fungi among pigeon raisers 
in Paris, who were in the habit of feeding the birds from mouth to mouth with mouldy 
rice. The Mucor Corymbifer, a mould fungus, sometimes found in wheat bread has 
also been found in the ear of persons employed in the "sizing rooms" of cotton mills, 
probably due to the lodgment of a drop or two of "sizing." 
Injurious Environments-There is abundant evidence to show that 
the baneful effects attributed to occupations are in large part caused by 
faulty environments and working conditions and hence to a great extent 
avoidable. 
Indoor Occupations and Bad Air.-It is generally held that indoor 
employment is inimical to health, while out-door work in a pure air favors 
health and longevity. This statement appears justified in the light of 
statistics furnished by Kbrosi, who found that out of 1000 deaths 436 
occurred in persons engaged in indoor occupations against 322 employed 
in out-door work. The rate in England (with a standard of 100) was 
55 for fishermen, 61 for gardners, 62 for agriculturists, against 84 for 
grocers, 152 for cloth dealers, 144 for tailors and 233 for printers. The 
U. S. statistics show that the mortality from tuberculosis was 16.1 per 
cent, in agricultural pursuits and 23.1 per cent, among bookkeepers and 
accountants, 23.7 per cent, in tailors and 28.2 in printers, lithographers 
and pressmen. If we stop right here in the comparison the evidence 
would be overwhelming in favor of out-door employment. But when we 
find that the mortality from consumption among merchants and dealers 
(except wholesale) is only 16.1 per cent., exactly the same as in agricul- 
turists, and for draymen, hackmen, and teamsters it is 23.3 per cent., 
almost the same as for bookkeepers, it becomes apparent that in estima- 
ting the hazards of indoor occupations other factors, such as physique, 
habits, exposure to dust, social conditions, standard of living, etc., must 
be considered. One of the chief dangers of indoor life is exposure to 
vitiated air. The air of dwellings and workshops is never as pure as 
the outer air, because it is polluted by the products of respiration, com- 
bustion and decomposition. The presence of individuals also tends to 
vitiate the air with dust, germs and organic matter, from the skin, mouth, 
lungs and soiled clothing. Unless provision is made for the dispersion of 
foul air, and the introduction of pure air there is much reason for assum- 
ing that these impurities play a more or less important role in what has 
been designated as "crowd poisoning," characterized in the acute form by 
symptoms of oppression, headache, dizziness, and faintness, while the 
chronic effects of deficient oxygenation and purification of the blood are 
plainly evinced by pallor, anaemia, impaired appetite, and gradual loss 
of physical and mental vigor. All of these effects are intensified by expo- 12 
THE INFLUENCE OF WORKING ENVIRONMENTS 
sure to excessive temperature and moisture, especially when human beings 
are obliged to occupy a space with an air supply insufficient for the proper 
oxygenation of the blood. As a result of habitual exposure to vitiated 
air we note an undue prevalence of consumption and pneumonia in 
crowded workshops, dwellings, prisons, public institutions, and formerly 
also in military barracks and battleships. Overcrowding naturally favors 
contact and droplet infections from tuberculosis, pneumonia, influenza, 
septic sore-throat, etc. The influence of overcrowding on diseases of 
the air passages, amounting at times to epidemics, was well illustrated on 
the Isthmus of Panama and, as suggested by General Gorgas,14 accounts 
probably for the undue prevalence of these diseases among the gold miners 
of the Transvaal. By scattering the laborers on the Isthmus from large 
and crowded barracks into single huts and small rooms, with not less 
than 50 ft. of floor space, the pneumonia rate was reduced in a single year 
from 18.4 per 1000 to 2 per 1000, and in urging a similar procedure for 
the Rand he predicted a like reduction. Another bad effect of indoor 
occupations is that the work is usually performed in a sedentary and 
stooped position, which, apart from interfering in youthful workers with 
the full development of the chest, limits expansion of the lungs and also 
causes constipation, congestion of the portal circulation and hemorrhoids. 
The baneful effects of vitiated air are of course intensified when the 
occupation is attended with the production of dust and fumes, the foes 
of industrial life. 
Cubic Air-space and Amount of Fresh Air per Hour.-It is evident 
that the question of cubic air-space for each worker plays an important 
role and for the following reason: It is known that carbon dioxide is not itself 
a toxic agent, but an excess of this gas in the air of rooms leads to a defi- 
ciency of oxygen, and also to defective elimination of CO2 from the sys- 
tem, which cannot be eliminated, whenever the tension of CO2 in the 
air exceeds that of the carbon dioxide in the blood. In order that the 
respiratory impurities may not exceed certain limits (6 volumes of carbon 
dioxide per 10,000) it has been found that an average adult requires 
3000 cu. ft. of fresh air per hour, and this amount should be supplied 
without discomfort to the occupant. Experience has shown that the 
air of a room cannot be changed oftener than three times in 1 hour in 
winter without causing a disagreeable draft, hence every occupant should 
have cubic air-space of 1000 ft. This is the ideal standard, and one of the 
factory laws of New York (1906), relating to certain manufactures in 
tenements, provides that the whole number of persons therein shall not 
exceed one to each 1000 cu. ft. of air-space. Such an ideal standard is 
not always obtainable in workshops and it is believed that for practical 
purposes, an air-space of 500-600 cu. ft. per capita will suffice, provided 
the air is renewed sufficiently often and kept in motion. 
A number of states require an air-space of 250 cu. ft. for each employe, 
between the hours of 6 A.M. and 6 P.M., and, unless by written consent of VENTILATION 
13 
the factory inspector, not less than 400 cu. ft. between the hours of 6 P.M. 
and 6 A.M., provided each room is lighted by electricity. This is a 
step in the right direction, but it would be extremely desirable to place 
the minimum amount of cubic-air space at 500 ft. for day work and 600 ft. 
for night work, unless electric lights are used, in which case a uniform 
standard of 500 ft. might be prescribed. At all events the question of 
sufficiency ought not to be left to factory inspectors. Either the cubic 
air-space should be specified, or what is equally effective the carbon dioxide 
contents of the air should be limited to 12 volumes per 10,000. The 
authorities of Great Britain have made a beginning in the latter direction 
by placing the limit of CO2 at 20 volumes when gas or oil is used for light- 
ing (or within 1 hour thereafter) and 12 volumes when electric light is 
used (or within 1 hour thereafter) and 9 volumes per 10,000 at any other 
time. 
Ventilation, which means the removal and dispersion of bad air and 
the introduction of fresh air, is accomplished either by natural or artificial 
means. Natural ventilation is usually sufficient when each occupant has 
1000 ft. of cubic air-space; the walls of the building are porous or contain 
numerous crevices near »the doors and windows, the difference between 
the indoor and outdoor temperature is considerable, and the winds strike 
the walls directly or pass with great velocity over chimney flues and other 
openings. But as the direction and force of the winds, and the other 
factors referred to, cannot be controlled, other means should be provided 
for ventilation. For this purpose open windows, doors, and revolving 
fans answer very well in summer. The objection to this method is the 
cold drafts in winter. In rooms heated with direct radiation the fresh 
air should therefore be admitted above the heads of the occupants, either 
by fresh air register inlets in the walls or by the insertion of louvered or 
swinging windows. Thus an upward direction is given to the air, so that 
it may impinge, on the ceiling, mix with and be warmed by the heated air 
in this situation, falling gently into all parts of the room, being gradually 
removed by means of foul air outlets, aided by exhaust fans. Another 
simple plan is to bore slanting holes in the bottom rail of the window 
sash, or to employ a Pullman or Bury ventilator, or to insert a piece of 
board 4 in. wide across the window sill. The separation of the sashes thus 
caused will provide for indirect fresh air inlets. 
Artificial ventilation, may be secured by providing: (1) suitable inlets 
and outlets; (2) by extraction by heat, or the creation of a decided difference 
between the inner and the outer temperature; and (3) by propulsion and 
aspiration. Space will not permit to enter into details except to say that, 
besides the contrivances already mentioned, any of the ordinary registers 
in which the air passes through the walls by means of a perforated iron 
plate, and is then directed upward by a valved plate with side checks, 
will prove of service. McKinnell's ventilator consists of two cylinders, 
one inside the other and of different lengths; the longer tube, projecting 14 
THE INFLUENCE OF WORKING ENVIRONMENTS 
above and below, serves to conduct the impure air, while the outer 
cylinder, having a larger sectional area, serves as an inlet. The outlet 
is protected on the top by a cowl, and both tubes can be regulated by 
valves. They are especially useful in the ventilation of one story build- 
ings, or the upper story of any building. If gas is used as an illuminant, 
the burners may be placed immediately under the extracting tube. As the 
warm air escapes through the inner tube a corresponding volume is 
admitted through the interspace between the two cylinders. 
Ridge ventilators consist of openings through the ceilings and roof, 
with louvered sides and ends, protected by a small roof. The opening of 
the air shaft in the ceiling is usually provided with suitable registers. The 
fresh air is admitted by the means already referred to, or by registers 
placed behind radiators. If the building is heated by stoves, the fresh air 
may be admitted by inlets running underneath the floor, between the 
joists, and discharging through a register near the stove. 
Extraction of foul air by heat is usually accomplished by placing a 
separate flue next to the chimney flue. The latter, if in use for firing 
purposes, creates an upward current. If this is not sufficient it may be 
promoted by gas jets or a steam coil placed in a separate flue. 
The propulsion and aspiration system is especially adapted for all 
large buildings and factories, and consists of mechanical devices by which 
the fresh air is forced into and distributed throughout the building by the 
use of fans or air propellers. The foul or objectionable air is removed by 
so-called exhaust fans. 
Temperature and Humidity.-It is a well-known fact that the welfare 
and capacity for work of individuals are to a great extent influenced by the 
surrounding temperature. 
There are numerous occupations involving exposure to extremes of 
heat and cold, dampness and sudden changes, the effect of which will be 
briefly stated. The human organism possesses the faculty of maintaining 
a uniform temperature, i.e., it so regulates and harmonizes the produc- 
tion and the loss of animal heat that the normal temperature of the blood, 
98.6°F. is not materially affected. In this the skin doubtless plays the 
most important role. Whenever cold acts upon the skin the irritation is 
primarily exerted upon the nerves which transmit it to the central organs 
of the nervous system (the heat regulating center) and from there it is 
reflected to the nerves of the cutaneous vessels and muscular fibers, which 
promptly contract, and in consequence of a diminished blood supply there 
is less loss of heat. If, on the other hand, heat instead of cold acts upon 
the skin, we have dilatation instead of contraction of the vessels, with an 
increased surface blood supply, and corresponding loss of heat by radia- 
tion and conduction. At the same time the perspiratory glands are stimu- 
lated to greater activity, more sweat is excreted and evaporated, and still 
more heat is dissipated. One of the bad effects of profuse perspiration 
is that the blood is deprived of some of its constituents. The blood is TEMPERATURE AND HUMIDITY 
15 
taken away too long from the internal organs, the proper distribution of 
the blood supply is interferred with, and in consequence the tone and 
nutrition of the stomach, lungs, heart, and other internal organs is 
lowered. We lose our appetite and suffer from indigestion, the red cor- 
puscles are decreased, we experience languor and general enervation, and 
the system in consequence is rendered more susceptible to disease. 
While the human organism endeavors to adapt itself to extremes of 
heat and cold, the facility of the body to maintain the equilibrium is by no 
means unlimited, and the heat-regulating center is liable to fail, or become 
paralyzed if imposed upon too long or too frequently. This is especially 
the case during sudden changes of temperature. It is the abruptness 
which offends the peripheral'nerves, and the greater the abruptness the 
more intensive will be the irritation which is transmitted by reflex action 
to other parts of the body, usually the weakest parts. This may result 
in driving the blood to internal organs, causing congestions and other 
mischief. Then again a cold draft, playing on the skin, may cause 
neuralgia, paralysis, sore-throat, bronchitis, or pneumonia, showing that 
cold applied locally may excite diseases in the neighborhood of its applica- 
tion or in distant organs, and finally it may produce disease by checking 
the secretions of the skin. 
The reason why cold drafts are especially injurious is because usually 
one side of the body is more exposed than the other and the heat regulat- 
ing mechanism of the body finds it difficult to correct this unequal dis- 
tribution of heat and cold. 
Humidity.-The atmosphere always contains a certain amount of water 
in the state of vapor, which varies from 30 per cent, to complete saturation, 
or, according to temperature, from 1 to 12 grains in a cubic foot of air. 
The degree of atmospheric humidity is of special hygienic importance, as 
it influences to a great extent the cutaneous and pulmonary exhalation of 
vapor and, in consequence, also affects the animal temperature. The 
average daily amount of water eliminated by the skin is 2^ lb. and about 
10 oz. by the lungs. It is evident that when the air is damp it lessens 
evaporation, as it possesses little drying power, and the water from the 
skin and lungs is with difficulty evaporated. The evaporation of perspira- 
tion, by which heat is rendered latent, is one of the chief means of cooling 
the body. Consequently when the air is hot and moist the humidity 
tends to increase the effects of the heat, the blood is with difficulty kept 
at its proper temperature, and all the disagreeable effects of a high 
temperature are intensified. This condition may be so aggravated that 
the temperature of the body exceeds the normal degree and causes our 
cases of heat stroke or heat exhaustion, which occur especially on hot, 
sultry days. 
A damp, cold, or chilly air also produces mischief, as it abstracts an 
undue amount of animal heat, lowers the general vitality of the system, 
and favors the development of diseases of the respiratory passages, neural- 16 
THE INFLUENCE OF WORKING ENVIRONMENTS 
gic and rheumatic affections, and aggravates the severity of such attacks. 
We may conclude, therefore, that excessive humidity tends to intensify 
the effects of both heat and cold. On the other hand, excessive dryness 
of the air is also harmful. It increases evaporation, the skin becomes dry 
and chapped, and the mucous membranes of the mouth, eyes and respira- 
tory passages are irritated, causing catarrhal conditions. 
Exposure to excessive heat is especially common in stokers and firemen, 
smelters, puddlers, blast and electric furnace men, steel mill and foundry 
men, blacksmiths, glass-blowers, kiln and pottery men, bakers, cooks, 
miners, tunnel workers, malsters, piano polishers, soldiers, sailors, roofers 
and all out-door workers during hot weather. Exposure to dry heat for a 
short period is sometimes borne without serious effects in temperature as 
high as 140° or 150°F., provided the air is kept in motion, and a tempera- 
ture of 212°F. may be borne by puddlers and electric furnace men, for a 
very brief period, without serious injury. Prolonged exposure, however, 
is usually followed by grave constitutional disturbances already referred 
to. Apart from heat exhaustion, which is not especially common, we 
see more frequently as acute manifestation, cases of colic, concentrated 
urine and muscular cramps, which symptoms are more or less influenced 
by toxins generated within the body; cases of " colds," anaemia and general 
debility are also quite common in this class of workers. The "colds" 
are due to the pernicious habit of the employes in passing suddenly 
from an overheated atmosphere to the outer air during the cold months. 
As already stated, any abrupt change in temperature is liable to cause 
congestion of internal organs; hence the undue frequency of catarrhal, 
neuralgic and rheumatic affections among imprudent workers. These 
congestions not infrequently also result in gastrointestinal and vesical 
catarrh, and pave the way for pneumonia, pleurisy and Bright's disease. 
The men engaged in handling molten metal, and all others exposed to 
radiant heat, not infrequently suffer from dermatitis and pigmentation 
of the skin, inflammatory conditions of the eyes, and even cataract, 
probably induced by a partial dehydration of the tissues. Nervous 
affections, such as headache, dizziness and general irritability, are also 
observed. Exposure to intense solar heat is not uncommon among out- 
door workers, and cases of sunburns and sunstroke occasionally occur. 
Sunstroke is evidently caused by a congestion and inflammation of the 
cerebral membranes, in which not only heat but the ultra-violet rays may 
play a role. Heat combined with humidity is especially trying to workers 
in breweries, laundries, kitchens, hot houses, tanneries, canneries, and 
sugar refineries, but cases of heat exhaustion may occur in all occupations 
involving hard work in a hot and sultry atmosphere. Affections of the 
skin, such as cystic degeneration of the sweat ducts, are not uncommon in 
laundry workers and others exposed to a steaming atmosphere. 
The effects of exposure to excessive cold are usually not so serious, as 
they are generally guarded against by suitable clothing and food rich in VENTILATION, DUST AND FUMES 
17 
fats and carbohydrates. The persons chiefly affected are ice men, cold 
storage workers, butchers, brewery men, in the cooling department, and 
out-door workers such as lumbermen, aviators, farmers, teamsters, coach- 
men, chauffers, etc. In this instance, also, any sudden change of tempera- 
ture is liable to engender internal congestions. Among the local effects 
may be mentioned frost bites and eczema. 
Occupations involving exposure to a cold and humid atmosphere are 
injurious, because a cold damp air abstracts an undue amount of animal 
heat from the body by conduction, lowers the power of resistance, and 
predisposes to catarrhal, rheumatic and pulmonary diseases. 
Abnormal Atmospheric Pressure.-The effect of compressed air upon 
the workmen in caissons and diving apparatus will be presented in the 
chapter on caisson disease, and the effects of rarified air upon mountain 
climbers, balloonists, aviators and workers in high altitudes are described 
on page 814. The effects of air concussion and excessive noises will be 
considered in the chapter on diseases and injuries of the ear. 
Preventive Measures.-The most agreeable temperature for average 
healthy adults performing ordinary light work is between 60° and 70°F., 
but a lower temperature is desirable for persons engaged in hard work. 
Every effort should be made to avoid extremes of heat and cold. Much 
may be done to reduce the temperature of workshops by forced ventilation 
and a supply of cool fresh air. The windows should be kept open and the 
air kept in motion. Special cooling devices, screens, water cooled 
furnace doors, helmets, goggles etc., have been designed for industries 
involving exposure to extreme heat. 
Since an average relative humidity between 55 and 65 per cent, has 
been found most healthful, efforts should be made to maintain such a 
standard whenever practicable. Apart from methods calculated to 
accomplish this result, reliable thermometers and hygrometers are required 
for efficient control. Legislators would do well, instead of making a 
general provision for "sufficient heat, moisture, etc.," to prescribe a 
standard, at least in industries where such standards are practicable and 
can be reasonably enforced. 
The English regulations for the textile industries prescribe that the 
temperature shall not fall below 50°F. and "the humidity of the air shall 
not at any time be such that the difference between the readings of the 
wet- and dry-bulb thermometers is less than 2°." It must be the aim of 
every ventilating engineer to prevent excessive heat and humidity by 
keeping the air in motion. 
Many of the injurious effects of exposure to extremes of heat and cold 
can be guarded against by suitable clothing, avoidance of abrupt changes, 
frequent bathing and systematic hardening of the skin. 
Dust and Fumes.-The relation of dust to occupational diseases 
is extremely important. The influence of dust in causing industrial 
intoxications and infections, will be pointed out in various chapters and 18 
THE INFLUENCE OF WORKING ENVIRONMENTS 
industries. Its effects upon the respiratory organs will be considered 
by Sir Thomas Oliver in the chapter on pneumokoniosis and by the 
writer in the chapter on occupation in relation to tuberculosis (see pages 
701-720). The desirability of differentiating fibroid phthisis, according to 
the nature of the foreign particles or exciting cause, has given rise to 
special designations. So, for example, fibroid phthisis caused by coal 
dust has been called anthracosis, by flinty or silicous particles, chalicosis 
or silicosis, from clay dust, aluminosis, from steel, iron or iron oxide, 
siderosis, from tobacco, tabacosis, from cotton or linen dust, bysinosis, 
and from feather and down dust (Watkins-Pitchford16 has recently 
coined the term) "ptilosis" with special reference to the ostrich feather 
industry in South Africa. 
Ahrens17 found the amount of dust per cubic meter of air in different 
establishments as follows: 
Mg. 
Horse-hair works 10.0 
Sawmill 17.0 
Woolen factory 20.0 
Woolen factory with exhaust venti- 
lation 7.0 
Paper factory 24.0 
Laboratory 1.4 
Mg. 
Flourmill 28.0 
Foundry 28.0 
Foundry polishing room 71.7 
Felt-shoe factory. 175.0 
Cement works 224.0 
Dr. Graham Rogers18 found 70 grains of dust per million liters of air in 
a skirt factory, about the same amount in a pearl button factory, and 75 
grains in the air of a brass foundry. 
Koelsch found as much as 1720 mg. of dust per meter in badly man- 
aged cement works, Dirksen in a coal bunker, 2289 mg., and Hahns in a 
hemp-combing plant, 425 mg. 
Lehmann states that with the just mentioned exceptions the highest 
amount recorded in literature may be placed at 200 mg. per cub. m., that 
5 mg. may be regarded as moderate, 5-10 mg. as sufferable, 10-20 mg. as 
requiring consideration of efforts to remove the dust, and 30 mg. and 
over must be regarded as serious. 
Professor C. E. A. Winslow and his associates, Greenburg, Greenberg, 
Reeves and others have made a number of interesting studies on dust 
determination in different industries which were published in the U. S. 
Public Health Reports Mar. 7, 1919, pages 427-449; May 30, 1919, pages 
1171-1187, and Mar. 5, 1920, pages 518-534. In the selection of dust 
samples they used the Palmer Water Spray Apparatus, and the methods 
of weighing and counting the dust particles were those recommended by a 
committee of the Am. Pub. Health Association. (See Am. Jour. Pub. 
Health, Vol. vii, No. 1.) The highest figures heretofore cited are 218 mg. 
per 100 cu. ft. of air, found by Miller and Smyth in a cement mill, and 
780 mg. by Winslow et al. in an abrasive factory. But in the sand-blasting 
department of a large automobile factory Winslow, Greenburg and Reeves 
determined over 5500 mg. per 100 cu. ft. DUST AND FUMES 
19 
The authors add: "The enormous weight of dust present in the air of 
the sand blasting cabinet is, however, chiefly due to the large particles of 
sand present (average per one standard unit 3,236,000 per cubic foot of air). 
These large particles are of no particular significance in connection with 
respiratory disease since, as the South African investigators have shown, 
it is the particles below 10 microns in diameter which actually enter the 
lungs and produce fibrotic changes. The one-fourth standard unit particles 
in the air of the sand blast cabinet (60,880,000 per cubic foot) may be 
compared with 6,790,000 found by Miller and Smyth in the cement mill 
and with 31,010,000 and 159,780,000 found by Winslow, Greenburg, and 
Greenberg in two abrasive factories. The actual health hazard involved 
in sand blasting, with no protection at all, would be about equivalent to 
that actually existing in the abrasive factories in question. The dis- 
comfort due to the larger particles present would, however, prevent any 
such complete exposure in practice." 
Professor Winslow and his associates submit a table to compare their 
results with those reported for various industries in this country by 
Miller and Smyth (Jour. Am. Med. Assoc., Ixx, 599) and by Higgins and 
Lanza in the Joplin Mines. 
A Comparison of Data Pertaining to Dust Content of Air in Different 
Industries 
Industry 
Observer 
Number 
of 
samples 
Dust 
particles 
per cubic 
foot 
Mgs. dust 
per 100 
cubic 
feet 
Percent- 
age of 
inorganic 
solids 
Good polishing shop 
Winslow, Greenburg, and 
Angermyer 
15 
207,000 
2.37 
77 
Cigar shops 
Miller and Smyth. 
19 
102,600 
8.4 
56 
Pottery. 
Miller and Smyth. 
5 
182,720 
13.0 
60 
Asbestos 
Miller and Smyth. 
6 
494,100 
35.4 
73 
Steel grinding 
Miller and Smyth. 
3 
489,930 
43.3 
96 
Flint 
Miller and Smyth. 
3 
844,040 
45.9 
76 
Blanket, plush, and carpet.. 
Joplin mines 
Miller and Smyth. 
Higgins, Lanza, et al 
Winslow, Greenburg, and 
Greenberg. 
13 
221 
148,950 
50.4 
146.4 
44 
Abrasive factory "B" 
57 
31,010,000 
174.3 
86 
Cement mill 
Abrasive factory "C" 
Miller and Smyth. 
Winslow, Greenburg, and 
11 
6,790,900 
218.5 
72 
Dry grinding shop of an ax 
Greenberg. 
.9 
159,779,000 
780.5 
87 
factory 
Wet grinding in the same 
Winslow and Greenburg. 
10 
154,500 
0.0548 
factory 
Sandblasting department of 
Winslow and Greenburg. 
Winslow, Greenburg and 
32 
15,800,000 
0.414 
an automobile factory 
Reeves. 
10 
3,226,000 
5500. 
Referring to the investigations in the ax factory the writers say: 
It seems clear that the enormous incident of tuberculosis among the grinders and 
polishers in this factory, indicated by Dr. Drury's study, is by no means surprising 
and that it is due primarily to the hazards of wet grinding. 20 
THE INFLUENCE OF WORKING ENVIRONMENTS 
No dust determinations were made in the polishing shops, on account of the 
lack of suitable electrical connections for operating the dust-sampling apparatus. 
The polishing wheels, were, however, equipped with an excellent exhaust system. In 
the case of the dry-grinding shop, which would naturally be much more dusty than a 
polishing shop, a similar exhaust system proved eminently satisfactory as a preventive 
of dust dissemination, the air showing an average of only 154,500 one-fourth stand- 
ard-unit particles per cubic foot. In the wet-grinding shops, on the other hand, only 
one sample, out of 32 showed less than 1,000,000 such particles, and only 12 less than 
10,000,000, the general average being 15,800,000 one-fourth standard-unit particles 
per cubic foot. This is one of the highest values ever recorded in any industrial 
establishment. 
It seems evident that the protection afforded by wet grinding, as compared with 
dry grinding, is in this instance illusory. In order to facilitate rapid work the opera- 
tors are tempted to cut down the amount of water supplied to the wheel; and in 
grinding a heavy object like an ax upon a wheel of soft natural sandstone the worker 
presses so heavily upon the wheel that the superficial film of water is pushed back 
behind the ax and the outer surface of moist stone is ground off, exposing a dry surface, 
which in its turn is abraded and discharged as atmospheric dust. The danger is 
increased by the fact that rapidly revolving wet wheels must be rotated upward 
toward the face of the worker. The principle of using moisture to eliminate industrial 
dust is no doubt a sound one, as exemplified in the measures taken for the protection 
of the miners in South Africa by the use of sprays. The present study merely empha- 
sizes the fact that the efficacy of a process of this sort must be checked up by laboratory 
tests in order to determine its real effectiveness. 
It is evident that wet grinding on sandstone wheels, as practiced at the ax factory 
studied, is an exceedingly hazardous process, and that the substitution of dry grinding 
with an efficient exhaust system (or possibly the use of wet grinding on artificial 
abrasive wheels of a harder nature) is clearly indicated as a measure for the protection 
of the workers against respiratory disease. 
According to Schuler and Burkhardt, cited by Roth,19 the morbidity 
per 1000 workers in dusty trades is as follows: 
Bookbinders 98 
Silk weavers 205 
Cotton spinners 250 
Cotton weavers 285 
Typefounders and typesetters 304 
Paper-factory employes 343 
Mechanical industrial shops 419 
Woodturners 427 
Rag sorters in paper mill 429 
The character and chemical composition of dust is doubtless of more 
importance than the weight and number of the individual particles com- 
posing it. This is particularly true of dust containing toxic substances 
and infectious organisms. But dust apart from this and its relation to 
respiratory diseases, also plays an important role in diseases of the eye, 
ear, nose and throat, as instanced by an undue prevalence of chronic 
inflammatory conditions of these organs in lime, cement and hair workers, 
and by the frequent occurrence of ulcerations of the nasal septum in 
chrome, chlorine and cement workers. It has also been shown that even 
flour and sugar dust, usually considered quite free from danger, may be 
converted into lactic acid in the mouth and possibly increase the virulence 
of disease germs, as evinced by an undue prevalence of caries and pneu- 
monia in flour and sugar workers. The dust generated in the manu- PREVENTION OF DUST FORMATION 
21 
facture of pearl buttons, from the shells of certain mussels, is liable to pro- 
duce a peculiar form of osteomyelitis, involving especially the long bones 
of youthful workers, and other affections noted under mother of pearl 
workers. A combination of dust, sweat and heat, also favors the develop- 
ment of skin diseases, as seen by the undue prevalence of furuncles and 
eczema in persons exposed to mineral, metallic, sugar, flour, anilin and 
other dusts. Since dust and germs often go hand in hand, there is little 
doubt that in many instances occupational infections are conveyed by 
means of infected dust. 
The effects of smoke and soot upon the health of workers and the 
community has been studied by Ascher of Germany, W. C. White of 
Pittsburg, and by numerous antismoke commissions both here and 
abroad. The results everywhere show a distinct relationship between 
the smoke nuisance and diseases of the respiratory organs, especially 
pneumonia. 
The injurious effect of dust in all its forms cannot be questioned and is 
made sufficiently apparent by a study of tuberculosis in relation to dusty 
trades. Fortunately only about 25 per cent, of the dust inhaled actually 
reaches the lungs, the bulk, according to Lehmann and his pupils, Saito 
and others, is sneezed or coughed up or swallowed. But this does not 
imply that the dust which has found its way through the stomach remains 
harmless, for it may reach the lungs by ways of the lymph channels, and 
certainly all poisonous dusts can be absorbed in the gastrointestinal 
canal. 
In addition to the mechanical, irritant and toxic character of dust, 
Haldane very properly points out that "it inevitably tends to lower the 
social status and self-respect of the work people." 
Preventive Measures.-The subject of dust prevention, and its 
removal when its formation is unavoidable, is one of the most important 
problems. Thanks to the efforts of technical experts, most commendable 
progress has been made in the following directions: 
(a) Prevention of Dust Formation.-There are a number of occupa- 
tions in which dust production can be reduced to a minimum by the 
application of oil, sprays of water, or jets of steam. The wet processes 
are especially applicable to the metal, lead and pottery industries, to 
rock drilling, mining, blasting, stone crushing, and cutting, etc. Dr. 
Watkins-Pitchford,16 in discussing the etiology and prevention of phthisis 
among the Rand miners, with a notoriously high morbidity rate, viz., 
32 per cent, and a death rate of 13.8 per 1000, tells us that in December, 
1912, there were 5600 rock drills in operation. He describes in detail 
the present methods of drilling and how the dangerous quartzite dust, 
as soon as it is formed, is converted into mud by keeping the drill hole 
and surroundings wet with water. This may be done by means of a 
syringe or spraying apparatus, while some types of rock drills provide 
for the automatic flushing of the hole. In blasting operations similar 22 
THE INFLUENCE OF WORKING ENVIRONMENTS 
good results, in laying dust, have been attained by the application of 
water spray, or steam, just before the charge is fired. This is not only 
important in the prevention of dust inhalation, but also to prevent dis- 
astrous explosions of coal dust in coal mines. 
Dr. Watkins-Pitchford16 declares, "It is no mere euphemism to say 
that a scrupulous obedience to the spirit of the present Mining Regula- 
tions will result in the total abolition of pulmonary silicosis from the 
gold fields of the Rand." General Gorgas in a more conservative way 
says, "I advise that such measures be generally and carefully enforced 
and extended. I believe they will soon reduce miners' phthisis to a 
minimum." (See also miners, page 145.) 
(6) Prevention of Dust and Fume Diffusion.-Technical experts have 
done much to prevent the escape of dust and fumes at the point of origin, 
by enclosing the machinery or apparatus in air-tight cases. This, 
however, prevents the diffusion of dust and fumes only when no opening 
or hand feeding is required, and hence the attempt to substitute as far 
as practicable automatic feeding machinery for hand labor. There are, 
however, many processes in which wholly enclosed machinery is impracti- 
cable and ineffective, and hence additional methods must be invoked. 
(c) Removal of Dust and Fumes.-This is accomplished by mechani- 
cal devices connected with a system of exhaust ventilation. Fortu- 
nately quite a number of states have made statutory provisions, for the 
removal of dust and fumes, which lay down specific rules concerning the 
construction of work benches and hoods or hoppers. The hoods are 
usually made of metal and so arranged and applied, that the dust will be 
thrown by centrifugal force into the hood and carried off by the current 
of air into a suction pipe attached to the hood or hopper. The suction 
pipes attached to different hoods enter a main suction pipe at an angle of 
30-45°. The main or trunk line is usually below the floor and empties 
into a discharge pipe, connected with an exhaust fan, run at such a rate 
of speed as will produce a velocity of air sufficient to carry off the dust 
and fumes. It is extremely important that the mechanism is so arranged, 
that the dust and fumes are drawn away from the face of the worker, i.e., 
downward and backward. The details of an efficient exhaust system 
must be worked out and adapted to the needs of different industrial 
plants, by a competent ventilation engineer. 
(d) Collection of Dust and Fumes.-In the interest of public health 
and for economic reasons, in certain industries, the dust and fumes 
extracted by the preceding methods should be collected, treated and dis- 
posed of in a suitable manner. In the case of toxic fumes and gases this 
is usually accomplished by (1) condensation, (2) absorption by water or 
chemicals, (3) destructive distillation by heat in a closed vessel, (4) 
combustion of gases that can be burned, and (5) discharge of gases into 
the air at great height. 
The material recovered by condensation and absorption constitutes REMOVAL OF DUST 
23 
often a valuable by-product of the industry. The value of blast-furnace 
and coke-oven gases is evinced by their utilization as fuel for heat and 
power, and the sulphurous fumes evolved in spelter works are converted 
into sulphuric acid. 
In the case of dust which has no special value, it is usually made to 
pass through a tower and precipitated by means of a fine spray of water. 
For the recovery of valuable constituents, as in the jewelry industry, the 
dust is collected in suitable tanks under water for the ultimate recovery 
of gold or silver. The collection of large particles of dust is usually 
accomplished by means of so-called cyclone separators in which, by means 
of centrifugal force and a cone-shaped metallic drum, the dust is deposited. 
A very efficient method is filtration of the air, through jute or cheese 
cloth, woolen sheets or fine wire mesh. The filter devised by Beth is 
supplied with a mechanical knocking device "which shakes the dust from 
the screening material to the bottom of the casing, where a worm auto- 
matically carries it to the collecting receptacle." 
In addition to these methods successful attempts have been-made to 
precipitate dust and smoke by strong electric currents. A method devised 
by Cottrell, in connection with some cement works in Southern Cali- 
fornia, has demonstrated that, by means of a large electrified chamber, 
from 95 to 98 per cent, of the cement dust, from escaping gases during the 
roasting process, can be precipitated and collected. 
(e) Respirators.-There are times when, in the absence of proper safe- 
guards, or because of unavoidable working conditions, the employment of 
respirators becomes necessary. There is an endless variety of these 
devices in the market, all intended to filter out dust and fumes, by means 
of sponge, cotton wool or gauze. It should be remembered that even the 
best respirators, so far designed, are far from satisfactory, and none 
fulfil the indications fully. Indeed some of the respirators improvised 
by the workers, consisting of a piece of sponge, cheese-cloth, jute, etc., 
fastened by means of elastics over nose and mouth are quite as effective 
as most of the manufactured appliances. 
The working conditions should be so perfect so as to obviate the use 
of respirators. Until this is accomplished their employment should be 
encouraged. 
(/) Cleaning of Workshops.-A number of states provide by laws 
that " all factories shall be kept clean." It is difficult to set up exact 
standards, for what is clean in a blacksmith shop would not be clean in a 
shirt-waist factory. But it is well to emphasize the fact, that no amount 
of ventilation can do away with the necessity for frequent and systematic 
shop cleaning. Hygiene demands that there should be no accumulation 
of dust in any part of the premises, and therefore condemns all interior 
finishes, such as exposed girders, cornices, mouldings, cubby holes, 
unnecessary shelves and inaccessible spaces, which will serve as dust and 
germ traps. 24 
THE INFLUENCE OF WORKING ENVIRONMENTS 
Hygiene, on the other hand, approves of hard wood or impermeable 
floors, curves instead of corners and angles, smooth and non-absorbent 
walls-in brief of everything which will prevent the collection of dust 
and germs and facilitate their removal. 
Workshops should be swept daily after cessation of work, the sweeping 
should be done when practicable with damp saw dust, with the upper 
windows opened. In certain industries, cleaning and dusting by the 
vacuum system has been employed and should be encouraged, especially 
where there is exposure to poisonous dust. All work benches and tables 
should be carefully cleansed, and wiped with a damp cloth for the removal 
of fine dust. Feather dusters do not remove but simply displace dust. 
In a number of occupations, cement floors, with a suitable incline for 
drainage so as to facilitate washing with hose, have been found very use- 
ful. The application to floors of so-called "dust oil" cannot.be approved 
since it simply allays dust, but does not remove it, and is therefore espe- 
cially objectionable in industries where poisonous dust is given off. 
Miscellaneous Sanitary Provisions.-In this connection it is desirable 
to point out certain sanitary requisites, which are important in all dusty 
occupations, especially in those involving exposure to toxic dust and 
fumes. 
1. Suitable Work Clothes and Caps.-There is a great variety of 
suitable patterns in the market, of which the snug-fitting duck union 
suit, without many folds, properly buttoned and adjusted is the best. 
Such suits and caps should be furnished at the expense of the employer 
and washed once a week. In occupations involving contact with poison- 
ous liquids, rubber gloves and impermeable overalls or aprons offer the 
best protection. For all wet processes impermeable clothing or aprons 
and wooden shoes should be worn. Asbestos clothing has been recom- 
mended for firemen, etc., but its weight is objectionable, and light 
leather suits or aprons are preferable. Ordinary work suits may be 
rendered practically non-inflammable by chemical treatment. 
2. Dressing-rooms, Lockers, Bath and Wash Rooms.-It is desirable, 
in all dusty occupations, that the workmen should take off all their street 
clothing before beginning work, and this is absolutely essential when the 
occupation involves exposure to poisonous dust. For this purpose 
suitable dressing-rooms, provided with lockers for street suits and sepa- 
rate compartments for overalls, are necessary. Facilities for washing 
and bathing, brushes, soap and individual towels should be furnished. 
In most of the civilized countries statutory provisions have been made for 
these sanitary requisites, in all establishments in which poisonous sub- 
stances are manufactured or used, and the result has been most beneficial. 
It is important that workers should be instructed to wash their mouths 
and teeth before eating and upon cessation of work. Indeed it is a good 
habit to rinse the mouth before swallowing even water, as much of the 
injurious dust lodged in the mouth will find its way into the stomach. DRINKING WATER LIGHTING 
25 
3. Pure Drinking Water and Lunch Rooms.-Hard work and dusty 
occupations produce thirst, and hence the necessity of an ample, easily 
accessible pure and cool supply of drinking water. Sanitary fountains 
are coming more and more in evidence in factories and workshops. The 
health and safety of employes exposed to industrial poisons demand that 
no food shall be taken, or tobacco in any form used, in the workrooms. A 
commendable number of establishments have provided special lunch rooms 
where either their own food can be warmed up, or rolls, sandwiches, coffee, 
tea, milk, soft drinks, fruit juice and hot soups may be obtained at a 
nominal cost. Coffee and tea allay thirst and are stimulants, without the 
depressing effect of alcohol and their use has materially lessened the evils 
of intemperance. Milk is especially recommended for workers in the lead 
and anilin industries and is often supplied free of charge. 
The effects of excessive or defective light are set forth in the 
chapter on diseases and injuries of the eye, X-ray, glass blowers, steel 
workers, etc. and it remains for us to emphasize here the principles 
which should govern the subject of lighting. 
Natural Light.-The natural light in workshops should be sufficient, so 
that the eyes need not be strained even on cloudy days. When the light 
is defective the objects have to be brought too near. The eyes in conse- 
quence converge. The muscular strain thus produced causes a gradual 
elongation of the anterior-posterior axis of the eyeball, and nearsighted- 
ness results. It is believed by specialists that 80 to 90 per cent, of the 
headaches are due to eye strain caused by defective light, also numerous 
cases of backaches, anaemias, and general impairment of health. In 
addition there is good reason to believe that defective lighting influences 
the number of industrial accidents, the efficiency of production, the 
quality of the product and the cleanliness, cheerfulness and healthfulness 
of the shop. 
It has been found by Putzeys15 that the natural lighting in temperate 
climates will usually come up to hygienic requirements when the area of 
windows, exclusive of sash frames, equals one-sixth of the floor space. In 
order that the light may penetrate the deeper portions of the room, the 
windows should reach almost to the ceiling and the glass should be either 
pure white or prismatic, and kept clean. 
The difficulty of securing a sufficient amount of daylight in buildings 
located in narrow streets, surrounded by tall buildings, has been partly 
overcome by glass building blocks 8 by 6 by 2^ in., with an air chamber 
in the center, used instead of bricks or stone, in connection with steel- 
frame construction, but more particularly by the introduction of pris- 
matic glass, which refracts and diffuses the light. 
Artificial light, no matter how obtained, differs from daylight in this, 
that it does not furnish a pure white light, the prevailing rays being red, 
yellow or violet. Whatever difference of opinion there may be as to 
the color best suited to the eye, we know that vision is most perfect under 26 
THE INFLUENCE OF WORKING ENVIRONMENTS 
the influence of white light, and this ought to be a good criterion. One 
of the disadvantages of all low-power illuminants is that the light is never 
as bright as daylight, involving, therefore, closer application of the eyes 
and consequent strain of the muscles of the eyeball. These remarks are 
hardly applicable to the electric arc, the tungsten lamp, and the Welsbach 
gas-burner, the rays of which, like the direct solar rays, may indeed be 
so glaring as to cause undue irritation of the retina. 
Another harmful effect of artificial illumination is the unsteady or 
flickering character, especially seen in the electric arc light, which on 
account of the abrupt changes is likely to irritate the retina. Another 
disadvantage is that the ordinary illuminants, except the electric light, 
tend to vitiate the air by the products of combustion, and also affect the 
temperature and humidity of the air by the heat evolved. 
The requirements of a hygienic light are that it should be as near as 
possible the color of the sunlight, sufficiently ample but not too glaring. 
It should be steady, and instead of deteriorating the air it should as far as 
practicable be utilized to promote ventilation; nor should the heat evolved 
be sufficiently intense to be a source of discomfort to the inmates in warm 
weather. The most common methods of lighting now employed are the 
electric incandescent lamps, arc lights, mercury-vapor lights, tungsten 
bulbs, gas light and kerosene lamps. Of these, electric light, especially 
the indirect system of lighting, is superior to gas or other illuminants, 
because there is little or no danger from fire, and there are no products of 
combustion, hence no pollution of the air. Nor are the temperature and 
humidity of the room affected to any great extent. These advantages 
over gas or kerosene are of special importance to the inmates of buildings 
where the question of fresh air and temperature plays an important role. 
Hence many industrial plants find it profitable to install the very best 
type of electric lighting, and thereby save time and money by the preven- 
tion of sickness and accidents among their employes. Next to the 
electric light, gas, especially in connection with a Welsbach or Siemens' 
burner, or acetylene gas, offers the best choice. In the absence of either 
electric or gas light, kerosene, with a high flashing point, should be pre- 
ferred over other illuminants. Suitable outlets for the products of com- 
bustion should always be provided. 
White, clean ceilings and walls will be of great service, not only in 
solving the question of light but also in general sanitation. A number of 
States require the walls to be limewashed or painted. 
Tenement Factories.-Among the most dangerous forms of workshops 
is one class which most state laws entirely ignore. For example, under 
the laws of the State of New York, relating to manufacturing in tenement 
houses, according to Dr. Anna S. Daniels, 33 distinct industries may be 
carried on in the living rooms of the workers, because they involve hand- 
work or simple machinery. There are over 23,000 licensed home factories 
in the city of New York alone. In addition to wearing apparel for men, TENEMENT FACTORIES-CONSTRUCTION CAMPS 
27 
women and children, including adornment of woman's dress, the flowers 
and feathers for her dress, the hats themselves and neck wear of every 
description, Dr. Daniels found the manufacture of paper boxes, cigars, 
pocketbooks, jewelry, clocks, watches, wigs, fur garments, paper bags, etc. 
The articles are not infrequently handled and stored in infected rooms. 
Of 150 families tabulated by her, 66 continued at work during the entire 
course of the contagious disease, such as tuberculosis, measles, scarlet 
fever, diphtheria, etc., for which she was attending the family. 
Apart from the occupations referred to, numerous bakeries, candy, 
ice-cream, milk and butcher shops, bottling establishments, tailor, cobbler 
and other repair shops are carried on in basements under the most insani- 
tary environments. 
Construction Camps.-It not infrequently happens that mining, lum- 
ber, construction companies, and other large concerns provide board and 
lodging for their unmarried employes. Again, in a number of the smaller 
industries, the employes not infrequently board with the family and are 
obliged to sleep in objectionable rooms. 
The baneful effects of overcrowding as observed in the construction 
camps at Panama have been referred to on page 12. All remedial 
provisions should come up to a reasonable standard as regards salubrity. 
Factory sanitation and the matters just alluded to are after all largely 
questions of public health and should not be left to the discretion of the 
individual employer, but the principles which ought to be adopted should 
be embodied in suitable laws and enforced by competent inspectors. 
REFERENCES 
1 Koelsch, F.-Krankheit u. Soziale Lage, Munchen, 1912. 
2 Kaup, J.-Archiv f. Hygiene, VI, 1910. 
3 Bauer.-Gesundheitsgefahrliche Industrien, Jena, 1909. 
4 Information furnished by letter in 1922 from Dr. Jno. B. Andrews, Secretary Am. 
Assoc, for Labor Legislation. 
6 Oliver.-Diseases of Occupation, London, 1916, page xvi. 
6 Transactions XV. Internal. Congress on Hygiene, Washington, 1913, Vol. Ill, 
Part II, pages 742-768. 
7 Koelsch.-Krankheit u. Soziale Lage, Munchen, 1913. 
8 Shablowsky.-Zeitschft. f. Hygiene, 1911, Vol. LXVIII, page 209. 
9 Corbin, H. E.-Actes des II Congress Maladies Profession, Brussels, 1912. 
10 Scheuer, O.-Die Syphilis der Unschuldigen, Wien, 1910. 
11 Kober.-The Transmission of Bovine Tuberculosis. Trans. Assoc, of Am. Physi- 
cians, 1903. 
12 Lassar.-Deutsche Med. Woch., No. 40, Oct., 1902. 
13 Perlen.-Lungenschwindsucht u. Beruf, Munchen, 1887. 
14 Gorgas, W. C.-J. A. M. A., June 13, 1914, page 1860. General Gorgas was invited 
by the Chamber of Mines of Johannesburg to investigate the causation of 
disease among the miners. 
15 Cited by Munson, Military Hygiene, 1901, page 521. 
16 Watkins-Pitchford.-The Med. Jour, of South Africa, April, 1914. 
17 Ahrens.-Archiv f. Hygiene, 1894, Heft 2. 
18 Graham-Rogers.-Report N. Y. State Comm, of Labor, 1911. 
19 Kompendium der Gewerbekrankh., Berlin, 1904, page 106. CHAPTER II 
SUGGESTED STANDARDS FOR VENTILATION, SANITATION 
AND ILLUMINATION 
SECTION 1 
VENTILATION IN WORK PLACES, AND TESTS THEREFOR 
EMERY R. HAYHURST, M. D„ Columbus, Ohio 
I. PHYSICAL STANDARDS. 
1. Temperature.-The temperature of the air should range from 
68° to 72°F. for sedentary workers; 60° to 68°F. for semi-active workers; 
and below 65°F. for active workers. The temperature should be deter- 
mined by an approved type of thermometer with readings made in the 
clear (the bulb unobstructed) and at 10 to 20 ft. intervals where there 
is doubt as to uniform temperature distribution. 
2. Air Movement.--The air should move (or circulate) at the rate 
of % to 3 ft. per second for sedentary workers; 3 to 5 ft., for semi-active 
workers; and 5 to 15 ft., for active workers. Continuous change in the 
direction of the moving air, or a pulsating effect, should be provided. 
Air movement may be determined by visible tests, such as determining the 
rate at which smoke, or ammonium chloride vapor, moves in the air, using 
a measured distance and a stop-watch. 
3. Humidity.--The relative humidity should lie between 40 per cent, 
and 70 per cent.; or the difference between the readings of the wet and 
dry bulb should not exceed 5°F. provided the wet bulb does not exceed 
70°F. Readings should be made at 10 to 20 ft. intervals and made 
with an approved type of sling psychrometer. 
4. Variation in Temperature, Air Movement and Humidity Desirable.- 
Each of these three physical conditions should change several times per 
hour, preferably from one of the recommended extremes to the other, 
keeping in mind also, the activity of the worker. 
5. Rate of Air Replacement.-The space occupied by each sedentary 
worker should be provided with a complete air replacement of not less 
than 6 times per hour; for each semi-active worker, not less than 10 times 
per hour; and for each active worker, not less than 20 times per hour. 
The breathing air for replacement should come from a pure, out-door 
source. Entering air (that is, via ducts or special openings) should be 
tempered so that upon its ingress to the work room it should not vary 
more than 10°F. from the standards for temperature suggested for 
the different types of workers in Par. 1. Provision for an extra amount of 
28 CORRECT VENTILATION AND TESTS THEREFOR 
29 
air for dilution purposes should be made for extra-human or industrial 
sources of air contamination not otherwise provided for. 
6. Area and Cubic Space.--Each worker should be provided with at 
least 20 sq. ft. of floor space and 200 cu. ft. of air-containing space 
about him. 
7. Dust.-The air of the work place, and particularly that breathed, 
should regularly be free of visible particles of dust when viewed in any 
direction in an illumination of not less than 1 ft. candle at any point. 
(It is probably that air for breathing purposes should at no time have a 
dust content of more than 250,000 particles of standard unit size" per 
cubic foot, as determined by the Palmer Dust Counting method.) 
II. CHEMICAL STANDARDS. 
8. Oxygen and Carbon Dioxide.-The breathing atmosphere should not 
contain less than 20 per cent, oxygen nor more than 0.04 per cent, carbon 
dioxide. These natural amounts usually involve no special concern. 
In special instances, such as in coal mines, other low places, within ship 
holds, and small confined areas, the breathing atmosphere may, within 
the bounds of safety for temporary purposes have its oxygen content 
reduced to 16 per cent, and its carbon dioxide content increased to 1 per 
cent, or 2 per cent, or higher, but in such instances exposure thereto should 
be carefully supervised and made as brief as possible. 
9. Chemical Impurities.-The atmosphere of the work place should 
not contain poisonous particles, vapors, gases, or fumes to an extent 
sufficient to produce acute or chronic symptoms of poisoning in the 
average normal person under any length of time of exposure. (The limits 
for the maximum atmospheric contaminations for the commoner indus- 
trial poisons have now been fairly accurately ascertained-see under name 
of each in Index-while the chemist's services should regularly be sought 
to maintain control.) 
10. Odors.-The air should be kept as free of all obnoxious or nauseat- 
ing odors as possible. 
III. BIOLOGICAL STANDARDS. 
11. The air of the work place should be kept as free as possible from 
animate life, or its products, such as bacteria, protozoa, insects, pollen 
and other animal or plant matters. This should be accomplished by 
means of screens, air-washing, avoidance of dust, etc., and, particularly, 
during epidemics of respiratory diseases by isolation of individuals 
affected with communicable diseases of the respiratory tract. 
IV. PHYSIOLOGICAL STANDARDS. 
12. Primary Sense Impression.-The air of the work place should 
give a favorable sense impression on first entering such place. In case 
of doubt this should be left to the opinions of at least three normal adult 
persons and should take into consideration such factors as odor, "stuffi- 30 
SUGGESTED STANDARDS 
ness," stagnation, temperature, dryness, visibility, and other factors 
affecting the senses. 
13. Room Comfort.-The air of the work place should be such as to 
give a general sense of atmospheric comfort to inmates thereof who have 
been present for hour's time, and any longer time interval, and pref- 
erably while engaged at their regular employments. In case of doubt 
this may be left to the opinions of at least three normal adult persons 
and should take into consideration the same factors as stated in Par. 12. 
As between temperature and air-movement, a quiet coolness is to be pre- 
ferred to draft for all inactive workers. 
14. Health Status of Workers.-There should be a general low 
incidence of diseases, or even health complaints, on the part of workers 
which might be associated with faulty atmospheric conditions such as 
thermic fever, heat cramp, heat stroke, chilling, colds, respiratory afflic- 
tions, faintness, circulatory weakness, digestive disturbances, etc. 
15. Provisions for Supervision.-Some authority should be appointed 
to supervise atmospheric conditions in the work place regularly, as indi- 
cated under the above headings, and at intervals of sufficient brevity 
(depending upon the circumstances of the given work place) to insure a 
maintenance of conditions closely in keeping with the standards recom- 
mended. 
For practical purposes the Physiological Standards are easiest to 
follow as guides, leaving the employment of the other methods for doubt- 
ful or controversial instances. To this end, the person in charge of 
ventilation of the work place should skill himself in physiological impres- 
sions and develop his delicacy of sense appreciations to the utmost. SECTION 2 
SANITATION FOR PLACES OF EMPLOYMENT 
SUGGESTED STANDARDS: (a) WATER SUPPLY SYSTEMS FOR PLACES 
OF EMPLOYMENT 
W. H. DITTOE AND W. C. GROENIGER, Columbus, Ohio 
Item 1. System of Water Supply for Drinking Purposes. 
(a) Quality.-The bacteriological quality should meet the standards 
promulgated by the Bureau of the Public Health Service, U. S. Treasury 
Department. The average, B. Coli content should not exceed 2 per 100 
cc. The water should be free from offensive taste or odor. It should be 
free from noticeable turbidity or color. 
(6) Protection of Source from Contamination.-If the water is 
obtained from a private source, that is, from a source other than the 
public water supply of the municipality, such private source should be 
located at a point remote from contamination. It should be at least 
300 ft. from any source of contamination such as a privy, cesspool, 
sewer line, barnyard, etc. The immediate surroundings should at all 
times be maintained in a cleanly condition. The surface drainage should 
be diverted from the source of supply and the top of the casing or curbing 
should be tightly sealed or capped to render impossible the entrance of 
contamination at this point. 
(c) Distribution.-The supply should be distributed through a piping 
system entirely independent of any piping system conveying another 
water supply. Constant flow through the distributing system should 
be provided. The quantity of water provided should be not less than 10 
gal. per capita per 24 hours. 
Item 2. System of Water Supply for Domestic Purposes Other than Drinking. 
(Lavatories, Baths and General Cleaning Purposes.) 
(a) Quality.-If practicable, the supply should be from the same 
source as the drinking water supply and distributed through the same 
piping system. In special cases due to inadequacy of the drinking water 
to serve all purposes, a secondary water supply for other domestic purposes 
is permissible. Unless such secondary supply meets the bacteriological 
standards for the drinking water supply and is in all respects of satis- 
factory quality for drinking purposes it should be heated and distributed 
as a hot water supply only. 
(b) Distribution.-The supply should be distributed through a 
piping system independent of any other piping system. No connection 
31 32 
SUGGESTED STANDARDS 
between this system and the drinking water supply system or a public 
water supply system should be established. 
Item 3. System of Water Supply for Industrial Purposes. 
(a) Distribution.-Unless this supply is from the same source as the 
drinking water supply it should be distributed through an independent 
piping system not connected to any other piping system. The water 
from this system should be used for industrial purposes and should not be 
used or made available for drinking, laving, bathing or other domestic 
purposes. 
Item 4. System of Water Supply for Fire Protection. 
If the water supply for fire protection is obtained wholly or partially 
from a source other than the source of drinking water supply, and unless 
such water supply for fire protection meets the quality standard for 
drinking water, it should be distributed in an independent piping system 
not connected to the piping system for drinking and other domestic 
purposes. The water conveyed through the fire protection piping system 
should not be made available for drinking or other domestic use. From 
the standpoint of increasing the fire protection afforded it should also 
be independent of the industrial piping system. If an independent 
supply for fire protection is provided, no connection between the fire 
protection system and a public water supply system should be made 
except subject to approval of local and state water works and health 
authorities. The general conditions under which such connection should 
be permitted are as follows. 
1. That the fire protection piping system have no connection to any 
other piping system, the object being to prevent any flow through the 
fire protection piping system except when a sprinkler head, hydrant or 
hose connection is open. 
2. That the connection from the public water supply main shall 
include a device or equipment subject to the inspection of the department 
having in charge the public water supply system, which will effectually 
prevent the flow of water from the fire protection system to the public 
water supply system. While the use of check valves of special type 
with testing and leakage detecting equipment may, in some cases, be 
permissible, it is preferable to provide a tank or reservoir fed by the 
public water supply at an elevation above the overflow of such tank or 
reservoir. 
SUGGESTED STANDARDS: (6) WATER SERVICE IN PLACES OF 
EMPLOYMENT 
(a) Water Service.-The water service of any building should be of 
sufficient size to permit a continuous flow of water at any fixture on any 
floor at a given time. WATER SUPPLY SYSTEMS 
33 
(6) Water Control.-Each fixture or group of fixtures should be so 
connected as to permit of being shut off without interference with any 
other fixture or group of fixtures. 
(c) Water Supplies Indicated on Floor Plan or Plot Map.-The 
relative location and size of all municipal, industrial, fire protection and 
drinking water service pipes and valves should be accurately shown on a 
floor plan of the building or plot map of the area covered by the place 
of employment. 
(d) Identification Chart of Valve Control.-All valves and shut-offs 
should be charted and identified by numbers with description and key 
to their control. 
Plot maps or floor plans and identification charts should be framed and 
hung in office, engine or boiler room and other places, to aid employes 
in emergencies and in making the system fool-proof. 
(e) Identification of Exposed Piping.-Varying colored bands or 
markers one (1) foot long, should be painted on the exposed piping at 
suitable intervals to properly identify the various distributing systems. 
Distinctive colors should be used to indicate the character and quality of 
the water conveyed and lettering should be employed to indicate the 
condition or stage in the handling of the water. The following is 
suggested: 
System 
Initials 
Color of band 
Water for drinking 
D 
White 
Water for other domestic purposes 
OD 
Gray 
Water for industrial purposes 
I 
Blue 
Water for fire protection 
F 
Red 
(J) Hot Water for Domestic Use.-To prevent corrosion of pipes 
and fittings, and discoloration of water, and to eliminate air-binding and 
splashing, approved methods should be employed to remove oxygen 
and other free dissolved gases. 
(g) Water Supply Direct to Water Closets.-No water closet or urinal 
bowl should be supplied directly from a water supply system through a 
flushometer or other valve unless such valve be set above the water closet 
or urinal in a manner to prevent any possibility of polluting the water 
supply by backflow. 
(K) Prevent By-pass Connections at Fixtures.-Connections between 
a drinking water supply system and an industrial system should not be 
made through combination valves or faucets installed to serve showers, 
lavatories or wash sinks. 34 
SUGGESTED STANDARDS 
SUGGESTED STANDARDS: (c) TOILET ROOMS IN PLACES OF 
EMPLOYMENT 
Toilet Room Standards. 
(a) When both males and females are employed, separate toilet and 
wash rooms should be provided. 
(6) Entrance should be clearly marked, "MEN" or "'WOMEN." 
(c) Floors should be of waterproof, indestructible material. 
(d) Separating partitions should be sound-proof, extending to ceiling. 
(e) Interior partitions should be dwarfed. 
(/) Entrances should be screened, insuring privacy. 
(g) Doors should be self-closing. 
(/i) Toilet rooms should not be located in room where food products 
are manufactured. 
(z) Water closets should be readily accessible to persons using them. 
When possible, there should be a number of small installations rather 
than a few large. 
(j) The proportion of glass surface should not be less than one (1) 
square foot of glass to each ten (10) square feet of floor area. 
(fc) Artificial light should be provided whenever natural light is not 
available. 
(Z) Plumbing fixtures should be located in rooms or apartments having 
windows placed in the external wall of building, or provided with a system 
of ventilation which will change the air at normal temperature at least 
six (6) times per hour. 
(m) Ventilation for toilet rooms should be separate and distinct and 
have no connection whatever with other ventilating ducts in the 
building. 
(n) Toilet rooms and wash rooms should be heated to a temperature 
of not less than 58°F. 
(o) Maintenance.-All toilet rooms, wash rooms, dressing rooms, and 
the floors, walls, ceilings and surface thereof and all water closets, urinals, 
lavatories, sinks, should at all times be kept and maintained in good order 
and repair, and in clean, odorless and sanitary condition. All indecent 
writing, marking or defacement should be at once removed. 
(p) Toilet Accessories.-An adequate supply of toilet paper in proper 
holder or container, should be provided. 
The use of the common towel should be prohibited and when paper 
towels are supplied, metal receptacles for used towels should be provided. 
Fixtures. 
(a) Materials.-Water closets, urinals, lavatories and sinks should be 
either glazed vitrified earthenware or china; or cast iron, white porcelain 
enameled on inside. 
(&) Number of Closets.-Water closets should be provided for each 
sex in the ratio of TOILET ROOMS-DRINKING FACILITIES 
35 
No. 
No. Persons Closets 
1 to 10 1 
11 to 25 2 
26 to 50 3 
51 to 80 4 
81 to 125 5 
And for each additional forty-five (45) persons or fractional part 
thereof, in excess of one hundred and twenty-five (125), one (1) additional 
water closet should be provided. The number of water closets provided 
should be based upon the maximum number of persons employed at any 
one time in the area which the toilets are intended to serve. 
(c) Number of Urinals.-Urinals should be provided for male 
employes at the ratio of more than ten (10) and less than twenty (20), 
one (1) urinal; more than thirty-one (31) and less than sixty (60); two (2) 
urinals; and for each additional sixty (60) males or fractional part thereof, 
one (1) additional urinal. 
The individual vitreous, earthenware stall type floor waste outlet 
urinal is preferable. 
(d) Laving Facilities.-Lavatories or wash sinks should be provided 
at the ratio of one (1) lavatory or twenty (20) inches of wash sink for 
every ten (10) employes, based on the maximum number employed at 
any one time. 
When lead, arsenic or other poisonous substances or injurious or 
noxious fumes, dust or gases are present, resulting from trades or 
processes which are dangerous, not less than one (1) lavatory or twenty 
(20) inches of wash sink should be provided for every five (5) employes, 
with running water, soap and individual towels. 
(e) Shower Baths.-Shower baths at the ratio of one (1) shower bath 
for the first five (5) and two (2) for the first seventy-five (75), and one (1) 
for each additional one hundred (100) men or fractional part thereof 
should be provided when men are employed around blast furnaces, soaking 
pits, iron or steel rolling and finishing mills, gas producers, boilers, coke 
ovens, pottery kilns, glass furnaces, forges, fertilizer plants, coal tipples, 
foundries, and some types of machine shop work. 
Shower heads should set at an angle of forty-five (45) degrees at a 
height of five (5) feet from the floor level, delivering the stream at a 
downward angle. 
(/) Drinking Fountains.-A sufficient supply of clean, and safe, chilled 
drinking water, the temperature not to be above 48°F., should be made 
available in readily accessible places through drinking fountains or other 
receptacles. 
Drinking fountains should be provided with a water stream of minimum 
slant to eliminate the possibility of drawing the falling water back into 
the ascending column, as in the case with the vertical stream and still 36 
SUGGESTED STANDARDS 
eliminate the "hose-like" force, causing difficulty in drinking from a 
stream with a decided slant. 
SUGGESTED STANDARDS: (d) DRAINAGE IN PLACES OF EMPLOYMENT 
Separate Drainage Systems.-To facilitate possibility of separate 
treatment and disposal, independent sanitary, storm, and industrial 
drainage systems should be installed in buildings. 
Combined Drainage Systems.-When existing municipal combined 
sanitary and storm water sewerage systems are available and after 
satisfactory treatment of industrial wastes (when necessary), said systems 
should. discharge into the combined sewer outside the foundation walls 
of the building. 
Construction, Size, Accessibility and Cleanouts.-All sanitary, storm, 
and industrial drainage systems should be constructed so as to be per- 
manently water tight; horizontal piping run in practical alignment at a 
uniform grade; of proper size and slope to produce self-scouring action; 
rigidly secured and supported to keep their grade; changes in direction, 
either horizontal or vertical should be made with the appropriate use of 
forty-five (45) degree bends, Y's, TY's, long sweep quarter, sixth, eighth 
and sixteenth bends; with manholes and cleanouts for accessibility 
and inspection. 
Materials.-All soil and waste pipes, vents, traps, roof conductors, 
or leaders should be constructed of selected materials that are durable 
and will insure permanency for the system. 
Drainage below Sewer Level.-In all buildings in which the whole 
or part of the drainage or plumbing system lies below the crown level of 
the main sewer, sewage or other wastes should discharge into sumps or 
receiving tanks and be lifted by artificial means and discharged into 
the drainage system. 
Volatile Oils and Inflammable Wastes.-When gasoline, benzine, 
naphtha or other inflammable oils are used or automobiles are washed, 
cleaned or repaired, the drainage should be so arranged as to intercept 
all oil, gasoline or other inflammable fluids as well as sand, silt and 
other solids for the purpose of excluding same from the sewerage system. 
Grease and Heavy Oil.-Wastes of high content of heavy oil or grease 
such as engine room floor drainage and restaurant kitchen waste should 
be passed through suitable grease and oil traps before entering the 
sanitary sewer. 
Plans-Charts for Accurate Location and Identification.-The rela- 
tive location and size of all sanitary, storm, or industrial drainage pipes, 
traps, catch basins, manholes, and cleanouts, should be accurately shown 
on a floor plan of the building or plot map of area covered by the place 
of employment with 'proper description and key to their service. The 
scheme of identifying exposed piping, by painting various colored bands 
on the pipes, is also applicable to the different systems of drainage. SEWERAGE AND SEWAGE DISPOSAL 
37 
SUGGESTED STANDARDS: (e) SEWERAGE AND SEWAGE DISPOSAL 
Item 1. System of Sewerage for Sanitary Purposes. 
(a) This system should be separate from any sewerage or drainage 
systems for other than sanitary purposes. 
(b) The system should be constructed so as to be practically water 
tight with slopes sufficient to produce self-cleansing velocities and should 
be accessible for inspection and cleaning. 
(c) The system should be used to receive sewage comprising the 
wastes from water closets, urinals, lavatories, baths, kitchen sinks, floor 
drains, laundry tubs. Ordinarily this system should not receive liquid 
wastes from industrial processes unless such wastes are relatively small 
in volume and are not of character to be detrimental to the sanitary sew- 
erage system and disposal features. Surface and subsoil drainage should 
not be permitted to enter the sanitary system. 
(d) Disposal of Sewage.-Wherever possible the sewage should be 
disposed of by discharge into a public sanitary sewer of a municipality. 
Where such a method is impossible independent disposal of the sewage 
should be provided by means of a sewage treatment plant giving suffi- 
cient treatment to permit disposal of the effluent without causing a 
nuisance or contaminating a water supply. Approval of proposed 
methods of sewage treatment by the state health authorities should be 
obtained. 
Item 2. System of Sewerage for Industrial Wastes. 
(a) Unless the industrial wastes are of relatively small volume and 
of character which would not be detrimental to the sanitary system 
they should be conveyed in a system of sewerage independent of any other 
system. 
(6) This system of sewerage should be constructed substantially 
watertight with slopes to produce self-cleansing velocities and should be 
accessible for inspection and cleaning. 
(c) The system should be used to convey industrial wastes only and 
should not receive sewage or surface or subsoil drainage. 
(d) Disposal.-When a public sewer of a municipality is available 
and approval of the municipal officials has been secured, connection 
should be established to such public sewer for the disposal of the industrial 
wastes in their raw state or after such treatment as may be necessary and 
required by the municipality. If such public sewer is not accessible 
independent disposal of the industrial wastes should be provided with 
treatment of the same to an extent to prevent a public nuisance or detri- 
ment to a public water supply. Advice and approval of state health 
authorities should be secured. 38 
SUGGESTED STANDARDS 
Item 3. System of Sewerage for Surface Drainage. 
(ft) This system should be independent of other systems of sewerage. 
(b) Its construction should be substantially watertight and its 
capacity should be adequate to remove the run-off without flooding. 
(c) This system should be used for the removal of surface drainage, 
roof water, cistern overflow, subsoil drainage, clean waste water from 
water motors, elevators, condensers and cooling systems. It should not 
receive any sewage or industrial waste. 
(d) The outlet of the drainage system should be located so as to result 
in no damage resulting from the maximum expected discharge from the 
system. 
SECTION 3 
ILLUMINATION IN WORK PLACES, AND TESTS THEREFOR 
BY EMERY R. HAYHURST, M. D., Columbus, Ohio 
The practical application of science in regard to illumination has 
advanced rapidly in the past few years due to the efforts of such agencies 
as the Illuminating Engineering Societies of Great Britain and America 
and the research divisions of the electric lamp manufacturers as well as 
the work of individuals. A number of states have (for example, Wiscon- 
sin, New York and Ohio) adopted Codes of Lighting for factories, mills, 
mercantile establishments, and other work places among which that of 
Wisconsin is especially full in explanatory details, diagrams, and illustra- 
tions. The physician, however, cannot help but feel that a mistake has 
been made in not calling in the physiologist, especially the ophthalmo- 
logist, for the discussion of the requirements for illumination under 
varying conditions. Practically all factors have been included except 
the human eye and its reaction under various types and experiences of 
lighting. We give below the table for minimum standards laid down by 
Foot-candles at the 
work 
Ordinary 
practice 
Mini- 
mum 
(a) Roadways and yard thoroughfares 
0.05- 0.25 
0.02 
(6) Storage spaces 
0.50- 1.00 
0.25 
(c) Stairways, passageways, aisles 
0.75- 2.00 
0.25 
(d) Rough manufacturing, such as rough machining, rough 
assembling, rough bench work 
2.00- 4.00 
1.25 
(e) Rough manufacturing, involving closer discrimination 
of detail 
3.00- 6.00 
2.00 
(/) Fine manufacturing, such as fine lathe work, pattern and 
tool making, light colored textiles 
4.00- 8.00 
3.00 
(g) Special cases of fine work, such as watchmaking, engrav- 
ing, drafting, dark-colored textiles 
10.00-15.00 
5.00 
(h~) Office work, such as accounting, typewriting 
1 
4.00- 8.00 
3.00 ILLUMINATION IN PLACES OF EMPLOYMENT 
39 
the Divisional Committee on Lighting (section on sanitation, committee 
on welfare work of the committee on labor, advisory commission), 
Council of National Defense, of which L. B. Marks, recently president of 
the Illuminating Engineering Society, was chairman.* This war time 
committee discusses in this code all of the practical phases of the lighting 
question. 
The foot-candle, the common unit of illumination, is the lighting effect produced 
upon an object by a standard candle at a distance of 1 ft.; at 2 ft. the effect would be 
not one-half foot-candle, but one-fourth foot-candle, etc. A lamp which would give 
off 16 candlepower uniformly in all directions would produce a uniform illumination 
of 1 foot-candle at a distance of 4 ft. in any direction. 
Note.-Measurements of illumination are to be made at the work with a properly 
standardized portable photometer. 
The Wisconsin Code, which copies the same table, adds the following footnote: 
The minimum foot-candles specify the lowest illumination intensity with which 
the employes can be expected to work with safety when artificial light is used. It is 
Fig. 1.-Foot-candle meter. 
to the advantage of the employer to provide the intensities of ordinary practice, as 
this results in less eye strain, greater accuracy of workmanship, increased production 
for the same labor cost, less spoilage. When part daylight and part artificial illumi- 
nation must be used together, it is desirable to employ even higher intensities than 
those of ordinary practice in the table above. The intensity requirements for ade- 
quate day lighting are much higher than those for adequate night lighting, because in 
general under daylight conditions, the light coming to the eye from all the surroundings 
in the field of vision is much brighter than at night, and hence'a correspondingly more 
intense light must fall on the object viewed. 
The foot-candle meter illustrated herewith! is designed to measure foot-candle 
intensities quickly and with a fair degree of accuracy. 
It is very simple in operation, so light that it can be easily carried about, and so 
small that readings can be taken in very restricted spaces. It is placed upon or 
* Code of Lighting for Factories, Mills and Other Work Places, U. S. Public Health 
Reports, Vol. XXXIV, No. 4, Jan. 24, 1919, pages 103-123. 
t Manufactured by the National Lamp Works of the General Electric Company, 
Cleveland, Ohio, price $25.00. 40 
SUGGESTED STANDARDS 
adjacent to the surface on which a measurement is desired. The illumination within 
the box illuminates the underside of the screen to a much higher intensity at one end 
than at the other. The illumination which it is desired to measure is, of course, 
practically uniform over the entire scale. Closely spaced translucent dots, which 
serve the same purpose as the grease spots in the simple bar photometer, line the scale 
Fig. 2.-Interior details of foot-candle meter. 
Fig. 3.-Measuring illumination with the foot-candle meter on a machine. 
from end to end. If the illumination on the scale from the outside falls within the 
measuring limits of the meter (1-40 foot-candles) the spots will appear brighter at 
one end of the scale than at the other, and at the point where the spots are neither 
brighter nor darker, than the white paper scale, the illuminations from within and 
from without are equal. The scale is accurately calibrated with the lamp within the ILLUMINATION IN PLACES OF EMPLOYMENT 
41 
box burning at a certain definite voltage. A voltmeter and rheostat permit the 
operator to adjust the lamp voltage to that at which the instrument was originally 
calibrated. The energy is supplied from small dry cells. When the illumination to 
be measured is less than 1 foot-candle readings may be obtained by setting the 
pointer on the mark labeled Ido- When using the Ido setting of the voltmeter, read 
the scale as usual and then divide the readings by 10. The latest model of this 
instrument is used for measuring natural as well as artificial illumination. 
Roughly speaking, natural illumination should be about three times 
as intense as artificial for the same class of work. As ordinary day-light 
varies from 5 to 500 foot-candles at the working plane and sunlight as 
high as several thousand, one cannot help but feel that all the standards 
are set much too low in the various state codes for the welfare of the eye, 
although they may be sufficient for greatly reducing accidents and pro- 
moting production. Also, there is no evidence but that the human eye 
welcomes much higher illumination, other factors being controlled, than 
those provided in these codes. 
Attention is also called to the so-called "day-light light" (a special 
bulb of a transparent blue color manufactured by the General Electric 
Company) which costs only a few cents more than the ordinary "mazda" 
lamp, and, while using a few more watts than the ordinary lamp, is 
especially adapted for all desk and reading work and the finer operations 
named in the table above. CHAPTER III 
PERSONAL HYGIENE OF THE WORKER 
GEORGE M. KOBER, M. D„ Washington, D. C. 
Reference has already been made to the fact that many of the physical 
defects observed in certain occupations have been acquired in early child- 
hood and are naturally aggravated by abnormal postural positions 
and other injurious environments. The writer has felt for years that 
the questions of personal hygiene, physical education and periodic 
medical examination, with correction of defects for the prevention of 
permanent disabilities was of fundamental importance in the develop- 
ment of a happy and efficient race. He realized that many of the 
physical defects, such as defective vision and hearing not only handi- 
capped the child in school but also in its subsequent struggle for existence. 
He was also convinced from his sociological studies of physically and 
mentally defective persons, who contribute such a large contingent to 
our charitable institutions, that many of these partial and complete 
disabilities could have been corrected by proper care and treatment in 
childhood. 
In order to determine the number of physically defective children in the graded 
schools of the city of Washington, the health officer and board of education upon his 
request as Chairman of the Committee on Social Betterment of President Roosevelt's 
Homes Commission in 1908 authorized a general medical survey of the pupils. Of 
43,005 pupils examined 15,304 or 35.5 per cent, showed one or more physical defects. 
Of this number 149 were crippled; 272 deformed; 461 had strabismus (squint); 312 
had discharging ears; 835 defective hearing; 2176 defective vision, 2062 were "mouth 
breathers," 703 were undersized; 727 ill nourished; 934 were anemic and 6698 
pupils had defective teeth. It was not deemed best to conduct examinations invol- 
ving the removal of clothing and hence the number of ruptured children, cardiac and 
respiratory defects could not be determined, but judging from the records of the 
Board of Charities and of hospitals the number is sufficiently large to merit serious 
consideration. 
It will be readily conceded that every crippled, deformed or physically defective 
child should if possible be spared from permanent disability, and no thoughtful 
parent should hesitate to act when attention is directed to the serious consequences 
of neglect. Poverty is no excuse for "the do nothing system" as the medical charities 
afford adequate facilities for persons unable to pay for the same. 
The reports of the United States draft boards show that "47 per cent, 
of the men examined were found to have certain defects, and that 53 per 
cent, were accepted as fully meeting the physical standard with no defects 
recorded." The percentage of rejections varied from 14.13 in South 
Dakota to 46.67 in Pennsylvania. The draft boards rejected 209,304 
42 PHYSICAL EDUCATION HOUSE AND HOME HYGIENE 
43 
men for rupture alone. 0. A. Lauffer {Jour, of Industrial Hygiene, 1920) 
says that hernia is the greatest single frailty of the American worker. 
Three per cent, of the men offering themselves in the industries have 
hernia and 14 per cent, have incipient hernia. There is every reason 
why this defect should receive prompt attention in childhood. Upon 
the writers recommendation 27 ruptured children of poor parents were 
operated upon in the Children's Hospital in 1907, and every child was 
discharged as cured. Since that time 283 operations for the radical cure 
of hernia in children have been performed at that hospital and 66 at the 
Freedmen's Hospital. 
In view of the foregoing facts the writer in May, 1920, strongly urged 
before the U. S. Senate Committee on Labor and Education, federal aid 
for the promotion of physical education. He pointed out that no system 
of education can be considered complete that does not provide for the 
promotion of physical education, including medical inspection and 
the correction of all remedial physical defects. Children are the most 
valuable assets of the Nation, and every movement which makes for 
better health, a temperate, untainted and virile race will be the best safe- 
guard in the prevention of disease, and greatly promote the efficiency 
and happiness of present and future generations. He also advanced mili- 
tary training between the ages of 18 and 20, because of its physical 
hygienic and moral benefits, during which all physical defects of a reme- 
diable character could receive proper treatment. 
Until this is accomplished no opportunity should be lost in the school 
health crusade to emphasize the importance of personal hygiene and 
general sanitation. When we supply our children with healthful school 
rooms and teach them the value of periodic medical inspection, of pure air, 
sanitary homes, proper and sufficient food, physical culture, baths and 
suitable clothing, and the importance of pure clean lives, the lessons 
taught will be applied in the homes and workshops of the Nation, and a 
very important advance in the conservation of life and efficiency in all 
walks of life will be the consequence. 
House and Home.-The writer is fully convinced that insanitary 
environment at home play a very important role in the causation of 
so-called "occupational diseases." As early as 1898 he helped to estab- 
lish a company for the erection of sanitary homes for wage-earners at 
reasonable rentals. 
Special pains should be taken in the selection of living quarters no 
matter how humble they may be. With the excellent motor facilities, 
there is no reason why crowded tenements should be chosen and prefer- 
ence should always be given to individual homes, or apartments, in not 
exceeding two-story tenements. The Germans have an old but true 
proverb-"Where the sun does not enter the doctor surely will;" hence 
dark, gloomy and damp houses should be avoided; mouldy spots on the 
walls or ceiling and a close musty odor indicate dampness; and cheap 44 
PERSONAL HYGIENE OF THE WORKER 
rents should prove no inducement to occupy such quarters. Leaky roofs 
and down spouts, or a pile of ashes against a brick wall, may keep the 
house damp, and the causes should be promptly removed. In all such 
instances, as well as in the occupancy of a recently constructed house, it 
is very desirable to dry out the house by heat and open windows. 
Since we know that the mortality from contagious diseases increases in 
proportion to the number of inmates of the rooms, hygiene requires that 
even the most modest dwellings should afford sufficient room to prevent 
overcrowding. Ventilation is always necessary, but open windows are 
especially indicated at night, as nothing can take the place of pure fresh 
air in small quarters. This may be effectively accomplished without the 
danger of drafts by opening the windows in the bed room from the top, 
and those of the adjoining room at the bottom. 
There are many families who properly insist upon having a sitting 
room or parlor, which is most commendable if the bed rooms are large 
enough to afford at least 500 ft. of cubic air-space for each occupant. 
If they do not it is desirable, after proper airing of the larger rooms, to 
utilize them for sleeping purposes, for it must be remembered that the air 
of habitations is vitiated by the consumption of oxygen and the exhalation 
of carbonic acid. The airing of rooms is even more essential in cold 
weather, because of the additional, pollution by carbonic acid from lights 
and fires. There are families, unfortunately, who for various reasons 
are obliged to live, cook and sleep in one room, and for whom the question 
of fresh air is therefore of vital importance. Such families should not 
hesitate to avail themselves of the benefit of fresh air, especially when 
medical science has demonstrated the advantages of fresh and even cold 
air in the treatment of consumption and pneumonia, provided the body 
is kept warm by sufficient bedclothes. Night air, contrary to popular 
opinion, is not unwholesome. The only danger is from mosquitoes, which 
should be excluded by proper screening of windows and doors. 
Care of the Skin.-The skin is supplied with a network of blood- 
vessels and nerves, and is a sensory, respiratory, excretory and heat-regu- 
lating organ. As a sensory organ, it combines with the tactile functions 
the power of perceiving impressions of warmth and cold. The respiratory 
functions of the skin are limited, to be sure; nevertheless, small quantities 
of oxygen are absorbed and carbonic acid is eliminated. Apart from this, 
the skin of an average adult eliminates, through the sweat glands, about 
2^ lb. of water a day. Human sweat contains about 2 per cent, of solid 
constituents, mostly in the form of waste matter or impurities, and the 
odor varies in different regions of the body and in different races. The 
skin also secretes a fatty substance through the sebaceous glands. As 
the water from the skin evaporates, the solid matter remains upon the 
surface, combines with dirt, harbors germs, and readily undergoes decom- 
position. This, apart from the disagreeable odors so characteristic of 
unclean persons, also tends to macerate the skin and is liable to produce HYGIENE OF THE SKIN 
45 
"galling or chaffing," pimples and boils. The accumulation of 
this matter also tends to close the pores of the perspiratory and sebaceous 
glands and to throw the work of eliminating the impurities upon 
other organs. . 
A normal cutaneous function is doubtless of great hygienic importance 
as shown by the occurrence of many diseases following its suppression, 
because in such an event, in addition to the retention of the waste matter 
in the blood, work is thrown upon the kidneys( and other eliminating 
organs, and these, if already weakened, naturally break down. Since the 
functions of the skin depend not only upon its anatomical intactness but 
also upon cleanliness and a proper tone of the cutaneous vessels and 
nerves, a rational care of the skin demands: (1) That it should be freed 
regularly from the secretory products and particles of dirt; (2) that the 
cutaneous nerves retain their normal excitability or, when impaired, that 
they regain their tone; (3) that we assist the skin in its heat-regulating 
functions, so that it may not be overtaxed-all of which may be accom- 
plished by ablutions, baths, and suitable clothing. 
Ablutions and Baths.-Regular and systematic ablutions with soap 
and water are requisite for reasons already given, and are especially neces- 
sary for persons engaged in dirty work or exposed to poisonous dust. In 
addition to the use of soap, vigorous friction with a brush should be 
employed, not omitting the finger nails, on account of disease germs and 
industrial poisons. The hands should always be washed before meals and 
after going to the toilet. 
The water for general baths should not be too hot, as this would relax 
the skin and increase the susceptibility to catching cold. If the bathing 
is not done in a bath tub, it will be well to wash and dry part of the body 
at a time. In any event the surface should be wiped dry and hard, espe- 
cially the hair, since wet hair is calculated to produce colds. It is always 
a good plan to wash the neck and chest with cold water, so as to harden the 
skin. 
The cold bath is usually taken in a tub or by means of a shower or 
needle bath, at a temperature of about 65° for adults. It should not last 
over 3 minutes. Cool baths vary from 65° to 80°. Tepid baths are taken 
at a temperature of between 80° and 90°, continued from 10 to 15 minutes. 
Warm tub or shower baths vary from 90° to 100°, and are generally 
employed for their cleansing effect. In addition, there are steam or Russian 
baths, Turkish or dry hot-air baths, river and ocean baths, swimming 
pools connected with public baths, medicated baths, etc. Swimming 
baths are particularly useful, as they also afford an opportunity for 
muscular exercise, and, as the temperature of the water is rarely above 80°, 
such baths are both cleansing and stimulating, and therefore an excellent 
tonic for the skin. All baths should be followed by a cool douche, and 
friction with a rough towel should be employed until the skin is in a 
general glow. The value of bathing is so fully appreciated that the 46 
PERSONAL HYGIENE OF THE WORKER 
building regulations of Washington City compel a bath room for every 
apartment offered for rent. No community should fail to make provi- 
sions for public baths for summer and winter. The necessity for washing 
and bathing facilities in connection with industrial plants is pointed out 
on page 24. 
Clothing.-The object of clothing, apart from the moral and aesthetic 
aspect, is to aid the skin in its various functions. It should, therefore, 
afford protection against heat and cold, as well as rain and mechanical 
irritation. Clothing must be adapted to climate and season, and 
extremes should be avoided. As a general rule warm woolen goods are 
best suited for winter wear, and cotton or linen for warm weather. It 
should be understood, however, that flannels absorb more dirt, odors, 
germs and water than linen or silk, while cotton occupies an intermediate 
position. The question of wet clothing, whether from perspiration or 
rain, is important, as the drying of clothing on the body involves an 
expenditure of animal heat, and it is not a matter of indifference whether 
this takes place rapidly or slowly. It is a fact that a wet cotton shirt or 
sweater feels more uncomfortable and colder than a wet woolen garment, 
because the cotton garment dries more rapidly and abstracts during the 
same time more animal heat than flannels. This is not without a practi- 
cal bearing, as it teaches that persons who perspire easily will do well to 
wear flannels next to the skin. This is all the more important when they 
are liable to drafts or abrupt changes in temperature. 
As a protection against cold, wool is superior to either cotton or linen, 
and should be worn for all underclothing. In case of extreme cold, besides 
wool, leather, fur or waterproof clothing, on account of their impermea- 
bility to air, are useful. As a protection against cold winds, for equal 
thickness, leather and India rubber take the first rank, wool the second. 
As a protection against rain, India rubber or oiled canvas clothing is the 
best, but it is an exceedingly hot dress, owing to its impermeability to air, 
which causes condensation and retention of the perspiration. To over- 
come this objection, Dumas suggests a material which is waterproof and 
yet permeable, prepared as follows: The garment is placed in a 7 per 
cent, solution of gelatine, heated to a temperature of 100°F. After 
immersion for a few minutes it is dried in the air and after drying it is 
placed in a 3 or 4 per cent, solution of alum and again dried. 
As a protection against heat in the shade, the thickness and conducting 
power of the material are the only factors to be considered. Texture has 
nothing to do with protection from the direct solar rays; it depends en- 
tirely on color, and white is the best. As a protection against fire, leather 
clothing is generally worn. The fabric can be rendered non-inflammable 
by the addition of 20 per cent, of tungstate of soda and 3 per cent, of 
phosphate of soda to ordinary starch sizing. . Cotton or linen goods may 
be treated simply with starch and borax, in the proportion of a teaspoon- 
ful of borax to pint of starch. (See also special work suits, pp. 24, 567.) CLOTHING HYGIENE 
47 
Clothing as a Cause of Disease.-Clothing may impair the functions 
of the body and cause disease: (1) By improper fitting, which leads to 
compression of blood-vessels and nerves and interferes with the normal 
position of organs and the movements of the body. (2) By improper 
selection of material, affording either insufficient protection or overheating 
a part or the whole of the body; improper material may also produce 
irritation or interfere with the ventilation of the skin. (3) By wet clothing 
which, in drying, may abstract sufficient animal heat to cause peripheral 
irritation and reflex internal congestions. (4) By poisonous dyes, such as 
compounds of arsenic and antimony, chrome yellow, zinc chloride, and 
some of the anilin colors. The toxic symptoms may manifest themselves 
by general impairment of health or by local infections of the skin. (5) 
Clothing may harbor disease germs, and a number of instances are on 
record in which itch, smallpox, tuberculosis and scarlet fever have been 
spread by second-hand clothing and bedding. This points to the neces- 
sity of thorough disinfection. 
The Head Dress.-As long as the head is covered with hair, the head 
dress should be permeable and not too warm, thus less headache may be 
induced; on the other hand, insufficient covering may produce neuralgia 
and rheumatic affections. In the tropics a special type of helmet or 
sun hat is essential for the white man in order to prevent heat stroke 
which authorities state may occur if even a small portion of the crown of 
the head is exposed. 
The head and eyes should always be protected from the direct rays of 
the sun, and for this purpose broad-brim, dark felt hats or caps for cold 
weather and straw or some other light-colored material for summer use 
are the best. 
For the Neck.-Nothing should be worn around the neck which would 
overheat the parts, dilate the blood-vessels, and render the skin sensitive. 
The collar should be loose fitting, so as not to compress the blood-vessels. 
The neck ought to be bared as much as possible, and hardened by frequent 
ablutions with cold water. 
For the Body.-For under garments the union suits are the best. 
They should secure a normal amount of warmth and be so arranged as not 
to interfere with the free movement of the chest, or compress or displace 
the abdominal and pelvic organs. For these reasons corsets and waist 
bands are wholly inadmissable. Suspenders should be worn by both 
sexes, or women may wear a bodice arranged for the attachment of 
skirts, so as to suspend their weight from the shoulders. Steel corset 
stays and tight lacing cannot be too strongly condemned, because there 
is ample evidence that they have caused displacement and disease of the 
abdominal and pelvic organs. The trousers must be sufficiently loose 
around the waist and elsewhere to permit of free circulation of blood. 
Foot Wear.-The stockings should be made of some warm, permeable, 
material such as cotton, merino or wool. Tight elastic bands or con- 48 
PERSONAL HYGIENE OF THE WORKER 
stricting garters are liable to produce varicose veins. Holes and rough 
darning of socks should be avoided. Boots and shoes are intended to 
protect the feet from the uneven and rough surfaces of the ground, from 
cold, wet and even heat, and must be constructed so as to meet these 
requirements. It is needless to insist that they should be patterned after 
the foot. The sole of a shoe should be so constructed that the great toe 
touches it in such a way that a line projected posteriorly through the 
middle of this toe will strike the middle of the heel. The heel should be 
broad and of medium height, so as not to throw the weight on the toes. 
Across the tread and toes the sole should be sufficiently broad to permit 
of lateral expansion. The uppers should be soft and flexible, but not too 
roomy, and should fit snugly around the ankles and insteps. In occu- 
pations involving exposure to wet, the feet should be protected by rubbers 
or preferably wooden shoes. 
Since cleanliness, in body and clothing, is next to godliness, frequent 
bathing and change of underwear are desirable. It is also a good plan to 
use nightshirts or pajamas, so as to afford an opportunity for a thorough 
airing of the underwear worn during the day. 
Care of the Ears and Nose.-These organs should be kept clean. 
There is danger from lodgment of foreign bodies, which may impair the 
hearing for life, especially when injudicious attempts at removal have 
been made. In such instances it is always best to consult a physician. 
The accumulation of dust in the ear may give rise to inflammatory condi- 
tions and favor the development of impacted ear wax. 
The chief function of the nose evidently is to arrest more or less of the 
dust and germs upon its mucous surfaces, and in cold weather to warm the 
inspired air. Much of the dust lodged in the nasal cavities will sooner or 
later find its way into the stomach, and if it contains toxic substances, may 
cause industrial poisoning. In cement workers actual concretions are 
formed in the nasal cavity, hence the importance of cleanliness and of 
breathing through the nose instead of the mouth. In order to do this 
without discomfort, it is necessary that there be no obstruction in the nasal 
passages, and persons suffering from catarrh or other symptoms of difficult 
breathing will do well to undergo treatment. A weak solution of boric 
acid or cooking salt (a teaspoonful to a teacupful of warm water), gently 
snuffed from the palm of the hand or used by means of an atomizer, is 
very useful in the prevention of troublesome and even serious affections of 
the nose. 
Care of the Mouth and Teeth.-It is important that the mouth and 
teeth be kept scrupulously clean at all times, but especially in occupations 
involving exposure to toxic dust and corrosive fumes, such as phosphorus, 
mercury, etc. In addition to the use of the washes just mentioned, with 
which the mouth and throat may be rinsed, the teeth should be well 
brushed before meals, in order to remove any industrial poison which may 
have lodged. Quite apart from this danger, oral hygiene demands HYGIENE OF THE EYES, ETC. 
49 
that the teeth be brushed upon rising, after each meal, and before retiring, 
and the gums rubbed with a soft cloth saturated with a strong salt solu- 
tion. Apart from the corrosive action of fumes and industrial poisons, 
the temperature of food and drink plays an important role in premature 
decay of the teeth. It has been shown that a sudden change in the mouth 
from hot to cold causes the enamel to crack, and leads to decay, because 
the microbes, ever present in the mouth, find these fissures a suitable 
lurking place for their destructive work. Food lodged between the teeth 
naturally offers a suitable medium for the multiplication of these germs. 
Hence the necessity of cleanliness of the teeth, which is best secured by 
brushing them with water and castile soap. In case particles of food 
cannot be thus dislodged, a soft silk thread drawn between the teeth will 
accomplish the purpose more effectively and wisely than a toothpick. The 
temperature of food and drink, in order to avoid cracking of the enamel, 
should not exceed 120°F. or fall below 40°F. This question also plays an 
important role in the causation of dyspepsia. Juicy fruits should be 
eaten at the end of the meal in order that the fruit acids may aid in 
cleansing the teeth. 
If the teeth or gums are already painful or show evidence of decay, 
accumulation of tartar, or the presence of pus, a dentist should be con- 
sulted. Many cases of obscure nerve lesions and septic infections have 
been traced to unsuspected pus cavities in the mouth. It is a wise plan to 
have the teeth examined once every 6 months and will be found much 
cheaper than having the otherwise necessary dental work done every 
few years. 
Care of the Eyes.-The protective measures in the way of suitable eye 
shields for the prevention of accidents which may befall the eyes are 
fully set forth on pages 855-889. Whenever there is any evidence 
of redness, pain, inflammation, watering or "mattering" of the eyes, a 
physician should be consulted. While free bathing with cold water or a 
weak solution of boric acid may exert a tonic effect, especially in dusty 
occupations, the value of good eyesight is too great to trust to domestic 
remedies or even to the services of an optician. Whenever there is any 
difficulty in reading, accompanied by pain or headache, an oculist should 
be consulted. 
Care of the Hair.-From what has been stated in connection with 
industrial poisons, it is apparent that the head, hair, and beard offer a suita- 
ble place for lodgment of dust and condensation of toxic vapors. Apart 
from the local irritant effect, there is a certain amount of danger from 
poisoning by absorption and by ingestion of particles lodged in the beard. 
It is well, therefore, for workers in all dusty occupations, especially 
those exposed to industrial poisons, not to wear beards of any kind, and 
to keep their hair well trimmed. In addition to this precaution suitable 
work caps of some light impermeable material, like oiled muslin, should be 
worn, and the hair thoroughly washed upon cessation of the work. 50 
PERSONAL HYGIENE OF THE WORKER 
Care of the Hands and Nails.-The finger nails should be kept short 
and hang nails properly cared for, so as to prevent absorption of industrial 
poisons and septic germs. One or two applications of tincture of iodine 
is usually sufficient to cure sore hang nails. In addition to frequent 
ablutions, there is need in many occupations for the use of rubber or 
leather gloves. This is especially true of occupations involving exposure 
to strong acid or alkaline solutions, and numerous industrial poisons, 
especially in the coal-tar and dinitro-compound industry. The appli- 
cation of cocoa butter, vaseline, lanolin or cold cream is useful when gloves 
are impracticable, in certain occupations. 
Care of the Feet.-Proper foot wear will prevent corns and bunions, 
which are often a source of great suffering. It is important that the foot 
wear be intact when exposed to industrial poison, such as lead, chrome, and 
dinitro-compounds, etc., in order to prevent absorption. Warm foot 
baths and change of stockings are desirable upon cessation of work, not 
only in dangerous occupations but also when the feet ache from prolonged 
standing and profuse sweating. The application of a weak solution of 
alum or chlorinated soda is useful in case of excessive and offensive per- 
spiration of the feet. (See also page 70.) 
Care of the Bowels.-All sedentary occupations predispose to consti- 
pation, which in turn favors pelvic congestions, hemorrhoids and uterine 
disorders, not to mention the equally important consequences of auto- 
intoxication, which is responsible for the anaemia and disorders of the 
nervous system so common in persons with constipated habits. In some 
instances this condition is due to neglect to answer the call of nature. 
Regularity of the bowels, at least one evacuation a day, is essential for 
health, especially in workers exposed to lead and arsenic. The most 
natural remedy to correct constipation will be persistent effort to secure 
evacuations every day at a fixed hour, aided by the use of succulent vege- 
tables, such as cabbage, spinach, greens, onions, rhubarb, "sour kraut," 
fruits, like stewed prunes, figs, apples, etc., and from five to six glasses of 
water a day. Graham or rye bread, oat meal, wheaten grits, butter or 
butterine, olive oil, are also useful. Milk, cheese, eggs, rice and tea are 
constipating when ingested too exclusively of other foods. 
Exercise, which means muscular activity, yields heat and energy and 
involves a more rapid combustion as shown by the increased elimination of 
carbon dioxide. Exercise leads to increased muscular development, while 
inactivity causes a wasting or fatty degeneration of the muscles. 
The influence of exercise upon the pulmonary functions is well marked 
since, owing to increased oxidation, a larger amount of air is required in 
consequence of which the number of respirations is increased. Moderate 
exercise therefore tends to produce better oxygenation of the blood, 
increased lung capacity and copious ventilation of the air cells. On the 
other hand, if the exercise is violent or done at a rapid rate, the respira- 
tions become shallow and sighing and thereby materially interfere with EFFECTS OF EXERCISE AND OVEREXERCISE 
51 
the circulation in the pulmonary capillaries and the proper oxygenation 
of the blood. 
The effects of exercise upon the circulatory apparatus are also quite 
marked, as shown by increased force and frequency of the heart's action. 
During ordinary exercise the action, although accelerated, is uniform and 
regular, but during violent or long-continued exercise the muscles of the 
heart like other muscles become tired, as shown by a dicrotic and inter- 
mittent pulse. Palpitation of the heart, a rapid irregular pulse and 
inequality of its volume are indications for rest and of danger from the 
continuance of the exercise. 
Exercise increases the cutaneous functions, because the skin in conse- 
quence of the accelerated circulation and heat production receives more 
blood, and in order that the animal temperature may be kept normal 
copious perspiration takes place. 
Owing to the increased elimination of water by the skin, the amount of 
urine is usually lessened, but the solid constituents, especially the inor- 
ganic salts, are increased. The amount of urea is not increased and may 
even be diminished, in which case, however, there will be a compensatory 
increase during the interval of rest. 
Exercise exerts a decided influence on the digestive functions. In 
order to compensate for the increased consumption of carbon and water, 
there is a desire for fatty food and liquids, the digestive functions are 
also stimulated, but exercise immediately before or after meals retards 
digestion, because the muscles, calling the blood from the stomach and 
internal organs, prevent the proper formation of the digestive fluids. 
There is no doubt that the brain and general nervous system partici- 
pates in the benefits of improved nutrition, secured by proper physical 
exercise. This was well illustrated in the person of Mr. Roosevelt whose 
mental and bodily vigor were of the highest order, although as a youth 
he had a delicate physique. Every one is familiar with the fact, that 
trained muscles respond more promptly to volition, a matter of impor- 
tance in many pursuits in life. 
Effects of Overexercise.-If a certain muscle or group of muscles 
undergo severe and protracted exercise, they become tired and it requires 
considerable stimulus and will power to set them again in action. If 
persisted in, the muscular contractions become less uniform, trembling 
and even muscular spasms may ensue, followed by relaxation and soreness 
of the parts. These phenomena disappear upon rest, but increase in 
intensity and lead to complete inefficiency upon continuance of the 
exercise or work. The tired or exhausted feeling of the muscles is 
believed to be due to an accumulation of the waste products of their 
activity (fatigue toxins) and after these products are eliminated or 
neutralized the muscles resume their function. This, however, is prob- 
ably not the only cause, for we know that a certain amount of depriva- 
tion of oxygen and nutritive material, i.e., arterial blood, diminishes 52 
PERSONAL HYGIENE OF THE WORKER 
muscular energy and leads to muscular exhaustion; hence rest is essential 
in order to take in fuel. The elimination of waste products is important 
as their retention renders the blood impure and predisposes to disease. In 
addition it should be remembered that the heart and lungs during hard 
work or exercise are severely taxed, and that the wear and tear from 
increased blood pressure and accelerated respiration involves the expendi- 
ture of considerable nervous energy, which adds to the tired and 
exhausted feeling. Da Costa has described a weak or irritable heart 
especially common, among soldiers and pedestrians which he attributes 
to overexertion and cardiac strain. Aneurysm and rupture of blood- 
vessels and of the heart, though uncommon before middle life, have 
followed overexertion and hypertrophy and dilatation of the cardiac 
muscles are not infrequent results. A person with valvular disease 
should avoid violent exercise by all means. 
General Rules and Kinds of Exercise.-From what has been said it is 
apparently not a matter of indifference as to how we employ our muscles. 
Insufficient exercise not only affects the size and energy of the muscles, 
but also impairs the respiratory, circulatory, cutaneous, digestive and 
intellectual functions, and even the quality of the blood itself. The 
exercise of only certain groups of muscles cannot produce a harmonious or 
symmetrical development of the body and may cause disease as shown by 
the numerous deformities and neuroses in certain occupations. The 
subject of exercise is of less importance to wage earners, whose work 
requires fairly vigorous exercise in the open air; indeed there are many, 
who are already overworked, but to the men and women, including 
brain workers, who lead a sedentary indoor life, with little or no muscular 
exertion, the question of exercise is of the utmost importance. Among 
the many excellent means of muscular exercise are walking to and from 
the work. Professor Haughton has shown that walking on a level surface 
at the rate of 3 miles an hour is equivalent to raising one-twentieth part 
of the weight of the body through the distance walked. The work done 
by a person weighing 150 lb. in walking a distance of 3 miles would be 
equivalent to lifting 52 tons 1 ft. high. Most authors believe with 
Parkes, that a healthy man ought if possible to take a daily amount of 
exercise equivalent to lifting 150 tons 1 ft. high, which would be equal to a 
walk of about 9 miles, but as there is much exertion even in ordinary 
business this amount may be greatly reduced. 
Swimming calls into play all the voluntary muscles, tends to expand 
the chest and causes extension of the vertebral column and is therefore 
especially suited to correct the effects of sedentary habits and as the 
beneficial effects also extend to the skin, this exercise cannot be too 
strongly recommended for both sexes. Dancing and skating also tend to 
expand the chest and develop the muscles of the extremities, and are 
beneficial provided the exercise is carried on in a pure atmosphere and is 
neither too violent or protracted. Rowing develops to a marked degree SPORTS AND EXERCISE-BRAIN WORK 
53 
the muscles of the arms, chest and back, and increases the vital capacity 
of the chest, but in boat-racing the heart and lungs are overtaxed. Golf 
is especially suitable for persons who lead a sedentary or indoor life and 
can be safely recommended to all, where age precludes violent exer- 
cise; the body is gently exercised in all its parts, and there is no danger 
of overtaxing any particular organ. Tennis, football, baseball and other 
out-door sports are more violent forms of exercise; they bring into play 
nearly every muscle in the body and are valuable, but if pushed too far, 
the heart and lungs, especially in football, are severely taxed. Among 
other forms of exercise should be mentioned bicycle and motor riding, 
clubs and dumb bells, swinging on the trapeze, hanging by the arms and 
legs, bowling, military drills and many of the regular gymnastic exer- 
cises. An important point is to vary the exercise in order to call different 
groups of muscles into play and thus produce a symmetrical development 
of the body. Even Celsus advised to swim, ride, fence, sail, row, shoot 
and fish. All these sports will develop the muscles, increase the chest 
capacity, stimulate nutrition and the action of waste eliminating organs. 
But it should be remembered that the greatest good is accomplished by 
moderate and gradual exercise which, several times a day, calls into play 
the full muscular capacity of the part in use, while violent exercise like all 
extreme measures is hurtful. As to the amount of exercise perhaps as 
good a rule as any is laid down by Lynch in his "Guide to Health" that 
the lean should exercise to the glow- point, or until their bodies and spirits 
are heated, for that will fatten them, and the fat should exercise to the 
sweating point. He considers hypochrondriasis and hysteria the special 
punishments of ease, affluence and indolence and that the more luxuri- 
ously a man lives the more exercise he needs. 
When in the course of exercise the body becomes fatigued or the heart 
and respiration embarrassed, rest is indicated. Exercise should not be 
undertaken, when the circulation is already excited, or while important 
organs of the body are performing their functions, as for instance, im- 
mediately before or after meals, or during the menstrual period. It 
would also be obviously wrong to begin with violent exercise, or to allow 
sudden cooling of the body. Attention should also be paid to proper 
clothing, which should not be too warm or tight fitting, as such garments 
result in accumulation of animal heat and interfere with free movements 
of the heart, lungs and muscles. After active exercise the body should 
be washed with soap and water to remove the secretions from the sweat 
and sebaceous glands and the surface should be well dried. If a bath is 
impracticable and the body is in a state of perspiration, a woolen sweater 
is the most appropriate garment to prevent chilling of the body. 
Brain Work.-Our knowledge of the effects of brain work on meta- 
bolism is not at all satisfactory. Hammond, Gamgee and Paton deter- 
mined an increase of urea in the urine, during and after active mental 
labor, but Caceneuve and Speck were unable to confirm these observa- 54 
PERSONAL HYGIENE OF THE WORKER 
tions. A similar difference of opinion exists as to the amount of phos- 
phoric acid elimination. Immermann observed an increased elimination 
of CO2 during brain work, which is confirmed by Speck, but he attributes 
the excess not to the mental efforts, but to the attending muscular 
movements. 
Some authors claim to have observed an increased animal tempera- 
ture, during severe mental labor, but even this is attributed to the 
accompanying muscular activity. In the light of this conflicting testi- 
mony it is evident that the influence of brain work on metabolism requires 
further elucidation. Practical experience teaches, however, that studious 
persons, however well fed, are rarely corpulent, and this at least points to 
an increased consumption of carbon. After prolonged mental effort, 
symptoms of mental fatigue, such as weariness, headache, inability to 
think clearly or to concentrate our ideas, amounting at times to complete 
apathy and disgust may ensue; these symptoms disappear upon proper 
rest, but unless sufficient recreation is taken, this condition is liable to 
increase the intensity of the headache, and produce irritability of temper, 
restless sleep, chasing of ideas, impaired memory, and even symptoms 
of mental exaltation or depression, and other typical symptoms of 
neurasthenia. The reason for this is, that every mental effort involves 
an increased flow of blood to the brain, and unless followed by intervals 
of rest, this physiological hyperaemia may become permanent, interfere 
with the nutrition of the working parts of the brain, and thus lead to 
pathological changes in the brain cells. It is therefore essential not to 
overtax the brain, and to allow a few minutes for the restoration of the 
intracranial circulation, after every continuous mental effort of 50 to 60 
minutes. 
While it is true, that the mind may be stimulated to perform an 
immense amount of labor, it is evident that this involves much danger, 
and neither reason nor common sense can justify the employment of such 
stimulants. Interest in what one is doing is undoubtedly the true mental 
stimulant, rather than extraneous stimulants like coffee, tea or drugs. 
There is no doubt that great mental work can be borne without 
serious effects if hygienic principles of diet, exercise, recreation, and other 
diversions are attended to, not omitting the elements of hope and cheer- 
fulness, which are great aids, while monotony, worry and anxiety have a 
most depressing effect and probably have produced more neurasthenics 
than hard mental work. 
Sleep.-Rest and sleep are Nature's remedy to overcome the effects 
of mental and physical fatigue. We are still in ignorance of the exact 
nature of sleep, or the suspension of the automatic activity of the brain. 
Some authors maintain that it is caused by an accumulation of waste 
products (fatigue toxins) in the blood and central nervous system, and 
that it ceases with the elimination of these products. Others believe that 
sleep results from the exhaustion of the supply of intramolecular oxygen, SLEEP BED AND BEDDING 
55 
while still others attribute it to a temporary ansemia of the brain. On 
the whole, there is much reason for assuming that the refreshing effects 
of sleep are due to the elimination of waste products from the system and 
the absorption of a fresh store of oxygen. Sleep in an abundance of fresh 
air is always more restful. Adults require from 7^ to 8 hours. If the 
amount is materially lessened, languor, pallor and nervous irritability 
may be observed. Excessive sleep is harmful, as it tends to produce 
sluggishness of the bodily functions, lessens tissue metamorphosis and 
favors the deposition of fat. Irregular bed hours are not calculated to 
promote a sound and refreshing sleep, as the human body resents irregular 
habits of all kinds. The objections to all avoidable night work are largely 
based upon the fact that normal sleep is seriously interfered with in day 
time by light, noises and in hot weather also by heat. It is to be noted, 
also, that about the same amount of sleep is required whether one works 
or idles. Also that one sense, like the sense of sight, requires more sleep 
than another, like, for instance, the sense of touch or of hearing. 
Bed and Bedding.-Since about one-third of our life is spent in bed, 
something should be said of this article of comfort and necessity. As the 
object of the bed is to promote a refreshing sleep, it should be long and 
broad enough to permit of the necessary extension of the body; it should 
be elastic, so as not to compress the soft parts unnecessarily, and it should 
be warm, but not too warm. Metallic bed steads are preferable to wood, 
because less liable to be infected with insects; they should be provided 
with a woven wire mattress which admits of free circulation of air. Upon 
this may be placed a mattress of hair, felt, cotton, or excelsior. Pillows 
should be preferably made of horsehair. Feather pillows are too heating 
for the head, unless a layer of paper has been interposed. High pillows 
are objectionable, as the position of the sleeper would impede the move- 
ment of the diaphragm. Sheets and pillow cases of cotton for winter 
and of linen for summer are advisable to prevent irritation of. the skin 
and soiling of the mattress, pillows and blankets. 
The most suitable coverings for a bed are woolen blankets; they are 
warm and their permeability admits the escape of gases. For warm 
weather a cotton quilt or comforter or even a linen sheet is preferable. 
The bedding should be aired every morning and exposed, whenever 
practicable, to sunlight, which is nature's purifier and destroys nearly all 
forms of germs. 
"Featherbeds" and "down quilts" are warmer than blankets, as the 
air contained in the feathers is a bad conductor of heat, but they are 
suitable only in very cold climates, or for anaemic and delicate individuals, 
because they overheat the body, cause dilatation of the cutaneous vessels 
and consequently relax and impair the tone of the skin. 
The sleeper should lie with his head slightly raised, preferably with 
the body inclined to the right side. He should rise rather slowly from 
the recumbent position, since a sudden change to the erect position, not 56 
PERSONAL HYGIENE OF THE WORKER 
only accelerates the heart's action, but also changes the blood distribution 
too abruptly. The bed should be so placed that the occupant is not 
disturbed by the influence of light. A sound, refreshing sleep can be had 
only when the senses are no longer stimulated, and light is a stimulus 
which acts even through the closed eyelids. 
Alimentation and Food.--The human body needs food, air and water 
for its growth and maintenance and the fact that proper nutrition of the 
body is important for efficiency, and the enjoyment of health, has long 
since been recognized. 
The body is composed of about 60 per cent, of water, 19 per cent, of 
protein compounds, 15 per cent, of fats and 6 per cent, of mineral salts, all 
of which are sooner or later consumed, and must be replaced if health and 
life are to be preserved. The chief objects of food are to form the material 
of the body and to repair its waste; also to yield heat, to keep the body 
warm, and muscular and other power for the work it has to do. An 
engine cannot run a machine or draw a train without fuel, which is con- 
verted into energy or power. In the same way the body must have fuel 
in order to generate the power expended in the action of the heart, lungs 
and ordinary muscular movements, and the various activities of man- 
whether it be a mason in laying stone or brick, a carpenter in sawing or 
driving nails, a woman who sweeps or does her household work, children 
who romp and play, or in any of the avocations of life (Langworthy). 
Food stuffs are classified according to their proximate composition as 
follows: (1) Organic, which includes: 
(a) Nitrogenous food material commonly called protein, such as the lean 
part of meat, milk curds, dairy products, eggs, the gluten of wheat and 
other cereals, the legumin of peas, beans, lintels, peanuts, etc. The 
proteids of the human body are made up of the same chemical constitu- 
ents and, hence, the proteids are the chief tissue formers of the body. 
But apart from this purely plastic function they can also take the place 
of fats and carbohydrates, if the body has not enough of one or the 
other for fuel. 
(6) N on-nitrogenous Foods.-These are derived (a) from fats, (5) from 
carbohydrates and (c) from vegetable or organic acids. The fats derived 
from the animal or vegetable kingdom, such as butter, butterine, lard, 
ham, bacon, olives, olive oil, cream, cheese, pecan nuts, walnuts, hickory 
nuts, etc., apart from aiding in the reconstruction of fatty tissue, undergo 
oxidation-i.e., they are burnt up in the body and thus supply heat and 
energy. The carbohydrates, such as starches and sugars, whatever their 
source (potatoes, cereals, bread, syrups, fruits, sweets, etc.) enter the 
blood as sugar. The sugar in the blood is carried to the tissues, where it 
is burned up, yielding heat and energy. The vegetable or organic acids, 
like tartaric, malic, citric, acetic, oxalic, and lactic acid, existing in fresh 
vegetables, fruits, meats and milk, are transformed in the system into 
carbonates, and as such preserve the alkalinity of the blood. In the ALIMENTATION AND FOOD 
57 
absence of these acids in the diet, the blood becomes impoverished, and 
scurvy is likely to develop. The cheapest substitute for fruit-acids is 
vinegar, also tomato juice. 
2. Inorganic Food. Mineral Salts and Water.-The mineral salts 
constitute about 6 per cent, of the body weight and, as certain 
quantities are daily eliminated, they must be replaced. The phosphates 
of lime, potash and magnesia contribute largely to the formation of 
bone, and are also essential for the growth of the nervous system. Iron 
is required for the red blood corpuscles and coloring matters. The chlo- 
rides are the source of hydrochloric acid in the gastric juice, and keep the 
globulins of the blood and other fluids of the body in solution. Potassium 
for the blood cells and solid tissues and sodium for the intercellular fluids 
are essential for the growth and repair of the tissues. The fact that 60 per 
cent, of the body is composed of water clearly indicates that a sufficient 
amount must be introduced to make up the loss sustained by its excretion 
through the lungs, kidneys, skin and feces. It is simply necessary to 
recall the physiological functions of water in the absorption and assimila- 
tion of food, the elimination of waste products, and its role as a heat 
regulator, to appreciate that a deficiency is certain to be followed by 
injurious effects. The above classes of food stuffs are essential for life. 
There is a third class known as food accessories, such as tea, coffee, and 
condiments; these are important as favoring palatability and digestibility. 
THE VITAMINS, A SUMMARY 
BY EMERY R. HAYHURST, M. D„ Columbus, Ohio 
The studies of the past fifteen years upon food and nutrition promise 
to be the outstanding feature of paramount benefit to the health of the 
people thus far in the present century.* Among the discoveries are the 
so-calledwztomns, a name devised for certain food principles by Casimir 
Funk, in 1911, although their existence was biologically proven some 
years previously. 
The vitamins are substances of unknown chemical nature, apparently 
associated with proteins, which are easily demonstrated by feeding tests. 
Some, at least, of them appear to be formed originally by the chlorophyl 
of plants. The green parts of fresh growing plants are rich in them. The 
vitamins are stored in the tissues of animals which feed upon plants and 
are also to be found in fresh milk and eggs. They appear to act similarly 
to catalytic agents, i.e., they bring about nutritive changes without them- 
selves entering into the resulting products to any considerable extent. 
Several of the substances have been identified: Vitamin A, or fat 
soluble vitamin, is found especially in cod-liver oil, in milk, eggs, butter, 
* Reference Works on Vitamins: 
McCollum, E. V.: "Newer Knowledge of Nutrition," Macmillan Co., 1922. 
McCarrison, R.: "Studies in Deficiency Diseases," Henry Froude, Hodder, Stoughton, 
1921. 
Sherman, H. C.: "Chemistry of Food and Nutrition," Macmillan Co., 1920. 
Lusk, Graham: "Science of Nutrition," W. B. Saunders, 1919. 
Eddy, W. H.: "Vitamin Manual," Williams & Wilkins, 1922. 
Funk, Casimir: "The Vitamins," Williams & Wilkins, 1922. 58 
PERSONAL HYGIENE OF THE WORKER 
and lean meat, and is known as the "growth promoting vitamin," but 
it should not be so designated because no one component of the diet is 
endowed with any such property; Vitamin B, which is referred to as 
the "anti-neuritic vitamin," since it cures or prevents certain forms of 
nervous diseases like beri-beri, and perhaps pellagra, resists heating in 
the usual preparation of food and is found especially in the hulls of grains, 
in the lower layers of the skin of fruits, in the germinal portions of seeds, 
etc.; Vitamin C, which is easily destroyed by heat, and oxidation, occurs 
especially in the green parts of leafy vegetables, and notably in the 
tomato (where it may not be destroyed even by the heat of the canning 
process) and is usually called the "anti-scorbutic vitamin" since it has 
the power of preventing and curing scurvy. It seems, also, that all of 
these vitamins are essential in the diet of both children and adults in the 
directing of metabolism for growth, tissue repair, and resistance to certain 
diseases, if not to diseases in general. It is thought that perhaps the 
progress of such a disease as tuberculosis is associated with the lack of 
sufficient vitamins. There is, closely associated with Vitamin A, an 
"anti-rachitic vitamin," called Vitamin X, which in some way governs 
the metabolism of calcium and phosphorus in the preventing of rickets, an 
unusually common disease in infants, in which connection Hess and Unger 
state that in the Columbus Hill District of New York, 90 per cent, of the 
negro infants have the disease in more or less severe form. 
The investigators in this field of nutrition have found that the Albino 
rat is a most valuable experimental animal for demonstrating the vitamins 
since its food habits and those of man are similar and it has a relatively 
short life cycle. Experiments are conducted for the purpose of identify- 
ing vitamins by placing part of a given litter of Albino rats upon a 
vitamin-free diet, consisting, for example, of purified casein (the curd 
from soured milk), a vegetable oil, cornstarch, milk sugar, and a salt 
mixture, which constituents when mixed in proper portions supply all 
the food factors necessary for growth and maintenance, except vitamins. 
Young animals fed on such diet soon cease to grow, soon become diseased 
and do not reproduce. When testing food for the presence of a vitamin, 
that food is added to the vitamin-free diet for another part of the rats of 
the same litter, after which the two groups are compared in respect to 
growth and the appearance of such signs as sore eyes, leg weakness, and 
emaciation. The group upon the vitamin-free food will show these 
evidences within a week or so, whereas the group fed on a full vitamin- 
containing food will progress normally. As a check, the group on vitamin- 
free food is then fed upon the vitamin-containing food when it, too, begins 
to grow and to recover from the afflictions present. Even quantitative 
experiments on food substances can be made by comparing tRe rates of 
recovery. Other factors such as the amount of sunlight, the space in the 
colony room, temperature, etc., have to be the same for both experimental 
and control groups. ALIMENTATION AND FOOD 
59 
It is usual to compare the method of action of vitamins to the electric 
spark in the gasoline motor, or to the plaster which unites the bricks in 
constructing the house. The one is not considered as entering directly 
into the power produced by the motor, nor the other, as building 
material. 
From the above it is evident that another group of food factors is 
essential for growth, repair, energy production, and quality of resistance 
to certain diseases in addition to the usual food substances heretofore 
considered. Of great importance has been the discovery that it is easily 
possible to fall into habits of living upon food substances which are 
practically bereft of vitamins. An illustration is the so-called "poor 
man's diet" consisting of white bread, canned foods, storage eggs, 
oleomargine, fat pork (lard does not contain vitamins), and dried cereals 
with skimmed milk. 
A summary of food essentials, from the above, may be made as follows: 
1. Nature's food products for man are eight in number: (1) milk, (2) 
eggs, (3) grains, (4) vegetables, (5) fruits including nuts, (6) meat, (7) 
salts and flavors, and (8) water (which is used as a vehicle and solvent). 
Oxygen should also be considered a food but ordinarily it requires no 
special concern for its acquisition. 
2. As nature supplies these foods they are rich in the protective 
substances called vitamins, which substances are easily destroyed or 
removed by elaborating them in such processes as peeling or hulling, 
canning, drying, ageing and otherwise modifying them by heat, cold, 
oxidation, reduction and "preserving." Man therefore should observe 
the following precautions in relation to his diet: (1) Make a generous 
selection of his food from all of the eight natural food products listed; 
(2) eat at least a part of it as fresh as can be obtained; (3) eat a part of it 
in the raw or unprepared state (care here in the matter of infections and 
parasites must be observed); and (4) eat more of certain outside parts of 
it, such as whole grain (so as to obtain the germ part and the inner hull), 
the skin of the apple, of the grape, etc. More thorough mastication is 
also promoted by the "roughage" present. 
3. All the vitamins necessary can be found in great abundance in the 
food substances named and do not have to be obtained from specially 
prepared foods, or medicines or other substances declared to be rich in 
them. 
4. The diet of civilized man has become unusually rich in so-called 
concentrates, for instance, sugar which is a concentrate from the juice 
of the sugar cane, of the beet, etc. When found in its natural form sugar 
is accompanied by the vitamins in the associated juices and tissues of the 
plant, and is, of course, by no means so concentrated. History shows 
that in the year 1700 A.D. the average per capita consumption of sugar 
was 3 lb.; in 1800 it was 9-13 lb.; in 1900 over 80 lb., and, since sweets 
have so largely replaced alcohol following the prohibition enactments, 60 
PERSONAL HYGIENE OF THE WORKER 
it is safe to state that its consumption is over 100 lb. per capita per 
year at the present day. In like manner, white flour is a concentrated 
food, as are coffee, tea, cream, butter, and even salt.* 
5. The diet of civilized man tends to be deficient in many essentials, 
not only in the lake of vitamines, but in mineral salts, cellulose and 
other components of the original juices as well as roughage, bulk, 
toughness, etc., 
6. This combination of concentrated foods with deficient foods is 
alleged by McCarrison to bring about a change in the intestinal flora 
which militates against the health of the individual, so that in the end 
metabolic disturbances and diseases of the glands of internal secretion 
take place. 
7. The natural food substances are cheaper and much more satisfying 
in the end. They satisfy hunger and thirst quicker so that one eats less. 
There is less gormandizing. The appetite proves a better guide with 
them than with elaborated, daintily cooked, "palate-tickling" dishes so 
often seen on the table. For example, fruits and nuts are nature's 
"sugars," and no sugar should be used with any fruit. 
8. Food stuffs in cans, packages, boxes and bottles should be used 
only as auxiliary diet and then only when the natural or fresh forms of the 
food are scarce, or bacterially unsafe. 
9. The researches of McCarrison in India, the observation of 
Schweitzer in Equatorial Africa, and of others, show that native peoples 
living on natural foods, crudely prepared for eating, if prepared at all, are 
remarkably free not only of diseases of the digestive system like cancer, 
appendicitis, ulcer and atonic dyspepsia, but of diabetes, gout, obesity 
and diseases of the endocrinal system. 
The following, adapted from Eddy,f gives the vitamin factor present 
in different foods used by man: 
* Table salt, today, for example, is a purified product of sodium chloride, 96 per cent, 
of which is obtained from inland salt deposits, whereas a century ago it was practically all 
obtained by evaporating sea water and the purification was crude, so that many elements 
other than sodium chloride were retained. Nature provides a very constant mixture, or 
solution, of a considerable number of salts in sea water (which is the ultimate origin of all 
dietetic salt). One of the editors (Hayhurst) finds whole sea water to be an excellent condi- 
ment for use at the table. It is not distasteful in the least. Its non-poisonous character 
may be seen from the fact that it has been used for centuries (Richard Russell, 1754) and 
is still used in hypodermoclysis in the same situations in which normal saline would be 
used. The multiplicity of elements contained in it would appear to make it of decided 
advantage to the animal body. As pointed out by Gaylord & Marsh (Bulletin, U. S. 
Bureau of Fisheries, Vol. 32, Document Number 790, April 22, 1914) it is significant that 
no marine forms, for example, suffer from goiter while in the wild stage, but fish (salmon) 
readily do if land locked, a feature undoubtedly due to the iodine factor. (See also Marine 
& Kimball: Arch. Int. Med., Vol. 25, June, 1920, 661; also Jr. Amer. Med. Assoc., Vol. 77, 
October, 1921, 1068; also E. R. Hayhurst-"Present Day Sources of Common Salt in 
Relation to Health," Jr. Amer. Med. Assoc., Jan. 7, 1922, Vol. 78, pp. 18-21; and J. F. 
McClendon "Are lodids Foods?", Science, April 7, 1922, Vol. LV, 1423, p. 358. 
f Adapted by Williams, J. R.: "Personal Hygiene Applied," W. B. Saunders, 1922. ALIMENTATION AND FOOD 
61 
Relative Amounts of Vitamins in Food-stuffs 
Food-stuffs 
"A" 
"B" 
"C" 
Meats: 
Beef heart 
+ 
+ 
+ _ 
V 
+ 
0 
0 
+++ 
+?+ 
+ 
+ + + 
+ 
+ 
+yellow 
Owhite 
+ 
0 
+ 
+ 
+ ? 
? 
0 
+ 
+ + + + 
++++ 
0 
++++ 
0? 
+ 
0 
0 
+ 
+ + + + 
+ + + + 
+ 
+ + + 
0 
0 
+ 
+ + + 
-t- + 
V 
+ 
0 
+i+ 
+++ 
0 
++ + 
+++++ 
+ + 
+ 
++ 
0 
0 
0 
0 
0 
0 
0 
0 
0 
++ + 
++ + 
+++ 
+++ 
0 
+ 
_++ 
tit 
++ + 
? 
+? 
1 
? 
? 
+? 
+? 
0 
++++ 
+?+ 
? 
++++ 
+ + + 
? 
? 
? 
0 
0 
0 
0 
0 
+ + + 
+ 
+ + + + 
++++ 
■b+++4 
0 
? 
0 
0 
0 
0 
0 
0 
0 
? 
6 
? 
6 
' +? 
+ ? 
0 
0 
0 
Brains 
Codfish 
Fish roe 
Herring 
Kidney 
Lean muscle 
Liver 
Pancreas 
Thymus (sweetbreads) 
Vegetables: 
Cabbage, fresh 
Carrots 
Cauliflower 
Celery 
Chard 
Lettuce 
Onions 
Parsnips 
Peas, fresh 
Potatoes 
Potatoes, sweet 
Spinach 
Cereals: 
Barley 
Bread (white) 
Bread (whole meal) 
Maize (corn) 
Oats 
Rice, polished 
Rice (whole grain) ; 
Other seeds: 
Beans, kidney 
Beans, navy 
Peanuts 
Peas, dry 
Fruits: 
Apples 
Bananas 
Grapefruit 
Grape juice 
Grapes 
Lemons 
Limes 
Oranges 
Pears 
Raisins 
Tomatoes 
Oils and fats: 
Beef fat 
Butter 
Codliver oil 
Corn oil 
Egg yolk fat 
Lard 
Oleo, animal 
Oleo, vegetable 
Olive oil 
Nuts: 
Almonds 
Brazil nut 
Cocoanut 
English walnuts 
Filbert 
Dairy products: 
Butter 
Cheese 
Condensed milk 
Cream 
Eggs 
Milk, powder (skimmed), 
Milk, powder (whole) 
Milk, whole 
Miscellaneous: 
Honey 
Yeast, brewers 
Yeast cakes 62 
PERSONAL HYGIENE OF THE WORKER 
Amount of Food Required.-It is apparent that sufficient food must 
be introduced to make up for the wear and tear of the muscular and other 
tissues, and also sufficient fats and carbohydrates to supply with the 
protein at least 3500 Calories of energy per day, for the muscular and 
other work the body has to perform. By the term Calorie we understand 
the amount of heat required to raise the temperature of one kilo, of water 
1°C.; or if transformed into mechanical power, such as the muscles use 
to do their work, a Calorie represents force which would be sufficient to lift 
1 ton, 1.54 ft. high. According to Atwater, 1 lb. of protein or of carbo- 
hydrates contains 1860 Calories, while 1 lb. of fat yields 4220 Calories. 
For many years it was held that a man weighing 154 lb., and performing 
moderate muscular work, required, during the 24 hours, 118 grams of 
protein, 56 grams of fat and 500 grams of carbohydrates; while a man 
performing hard muscular work should receive 145 grams of protein, 100 
grams of fat and 500 grams of carbohydrates. 
Professor Chittenden's, and Rubner's, more recent determinations 
indicate that the protein ration may be cut in two, provided the fats and 
carbohydrates are introduced in sufficient quantities to bring the full 
value up to 2500 or 2600 calories. Other authorities, however, believe 
that it would be unwise to reduce the protein ration below 100 grams, or 
3.5 oz. a day, or the total Calories of energy below 3500 in 24 hours. The 
whole subject of dietary standards is still in its infancy and the best we can 
do is to make estimates which apply to averages rather than to individual 
cases. In a general way we may conclude that the needs of the economy 
are influenced (1) by the height and weight of the individual, amounting 
to a difference of 40 to 50 Calories for each kilogram (2^ lb.) in body 
weight; (2) by the temperament-nervous and excitable persons require 
more food than those of a phlegmatic temperament; (3) by muscular 
activity, which involves not only an increased expenditure of carbon but 
also increased consumption of protein; (4) age, as during active growth 
there is also a more active metabolism and children consume more for 
each kilogram of their weight than adults; on the other hand, with advanc- 
ing years tissue metamorphosis becomes less active; (5) sex influences 
the amount of tissue consumption only in so far as there is a difference in 
weight and muscular activity-an exception should be noted in pregnant 
and nursing women, who doubtless should receive a more liberal supply 
of proteids; (6) by temperature and climate. The influence of low tempera- 
ture results in increased oxidation of carbon, hence an instinctive craving 
for more fatty food and the carbohydrates (sugar and starches) during the 
winter months and in cold climates. In the summer months, and in warm 
climates, there is a repugnance for fat and a craving for refreshing fruits 
and drinks; hence about 40 grams of fat and between 300 and 400 grams 
of carbohydrates, with a normal protein ration, will meet the requirements. 
A widely stated proportion for the chief constituents of the food is: pro- 
teins 10 per cent., fats 30 per cent, and carbohydrates 60 per cent. ALIMENTATION AND FOOD 
63 
Cost of Food.-In our sociological study of families in Washington in 
1908 we found that 476 families, with an income of $500.00 or less, ex- 
pended 43.68 per cent, of their annual income for food; 159 families, with 
an income of $500 to $600, 43.59 per cent.; 153 families with an income of 
$600 to $700, 41.40 per cent., and 153 families, with an income of $700 to 
$800,40.21 per cent, for food. The question of food, while of importance 
to all classes in its relation to health and efficiency, is of special signifi- 
cance, from an economic standpoint, in families with limited means. It 
has been well said that "half the struggle for life is the struggle 
for food." 
It has been found over and over again, that persons of limited means 
purchase food containing little or no nutriment, or select needlessly 
expensive kinds of food, or prepare a diet altogether too one-sided, and 
lastly, know little or nothing about the art of cooking. They thus impair 
not only the nutritive value of the food, but also the digestive functions 
and general health as well. 
In order to give housekeepers of moderate means an opportunity to 
select suitable dishes I requested Prof. C. F. Langworthy, Expert in Nutri- 
tion of the U. S. Department of Agriculture, to prepare for the President's 
Homes Commission, a chapter on "good food at reasonable cost." He 
also prepared a table for the use of housekeepers who desire to estimate 
the nutritive value of the food they prepare. The table shows the protein 
and energy value of the portions ordinarily served, of the more common 
articles of food. 
This table may be conveniently used by supposing that the food eaten 
by one member of the family will represent in character and amount the 
food for the entire family. To estimate by means of the table the food 
value of the diet, the portions of each article used at each meal should be 
set down in order, together with the protein and energy which each 
supplies and the total sum of the protein and of the energy will represent 
the amount eaten in the whole day. 
The question of adequate and proper food for persons of limited means 
is most important in the present state of high cost of living, and requires 
judgment and experience, which should be obtained in our public schools. 
The foundation of a suitable diet has been stated above. 
Food should be properly cooked, bills of fare frequently changed, and 
relishes and flavors should not be wanting. It has been shown that the 
primary secretion of true gastric juice is the result of a reflex, starting in 
the mouth, and that the relish of the food originates the reflex. This 
explains why certain dishes, however inexpensive, "make our mouths 
water," and why distasteful food fails to cause gastric secretion. Every 
meal should be a feast. It is a good rule to eat slowly, to masticate 
thoroughly, and to avoid overeating, especially of meat and eggs. Hot 
and cold food and drinks hastily swallowed should be avoided. (See 
Teeth, page 48.) 64 
PERSONAL HYGIENE OF THE WORKER 
Approximate Weight and Nutritive Value of an Average Portion of Some 
Common Foods 
Kind of food 
Average 
weight of 
portion 
Average bulk of 
portion 
Protein 
Energy 
Grms. 
Oz. 
Grms. 
Cal. 
1 slice of roast meat 
85 
3 
13 
197 
1 portion of meat stew 
325 
11 
Saucerful 
32 
461 
1 Frankfurt sausage 
60 
2 
11 
170 
1 pork chop 
190 
7 
46 
765 
1 slice of boiled bacon 
100 
15 
432 
1 portion of fried bacon 
50 
2 
11 
252 
1 portion of steak 
100 
26 
411 
1 portion of meat soup 
190 
7 
Cupful 
7 
50 
1 portion of pea or bean soup 
190 
7 
Cupful 
7 
70 
1 cup or glass of milk 
225 
8 
pint 
7 
170 
1 cup or glass of skim milk or butter milk.... 
225 
8 
pint 
7 
85 
1 portion of cream 
65 
2 
Y gill ' 
2 
130 
1 egg 
50 
2 
7 
96 
1 portion of butter 
10 
>2 
1-in. cube 
95 
1 portion of cheese 
20 
2-3 
5 
94 
1 baked or boiled potato 
140 
5 
Med. size 3 in. long 
4 
145 
1 portion of turnip, beet, carrot, or similar 
vegetable 
130 
43^ 
Saucerful 
1 
80 
1 ear of green corn or 1 portion of stewed corn. 
75 
3 
Saucerful 
2 
82 
1 tomato or 1 portion of stewed tomato 
95 
3^ 
Saucerful 
1 
25 
1 serving of cooked spinach, cabbage or other 
green vegetable 
125 
4^ 
Saucerful 
2 
40 
1 portion of baked beans or black-eyed peas... 
200 
7 
Saucerful 
16 
300 
1 slice of bread 
50 
2 
4 X 4 X 1 in. 
4 
175 
1 portion of corn bread 
50 
2 
3 X 3 X 1 in. 
4 
142 
1 slice of cake 
50 
2 
4 X 2 X 1 in. 
3 
190 
1 slice of apple or other fruit pie 
150 
5 
% of a pie 
6 
440 
1 cup of flour 
225 
8 
Y pint 
19 
950 
1 teaspoonful of sugar 
10 
40 
1 cup of sugar 
225 
8 
Y pint 
890 
1 portion of sirup or molasses 
75 
2^ 
About Y gill 
200 
1 portion of cooked cereal 
200 
7 
Saucerful 
4 
170 
1 portion of dry ready-to-eat cereal 
50 
2 
Saucerful 
6 
200 
Milk for cereal 
25 
1 
Y gill 
1 
40 
1 portion of boiling rice 
140 
5 
Saucerful 
4 
155 
1 portion of rice pudding, bread pudding, or 
similar custard pudding 
175 
6 
Saucerful 
7 
300 
1 portion of cherry roll or similar pudding. . . . 
175 
6 
Slice 
8 
460 
1 apple or pear 
100 
3^ 
50 
1 banana 
100 
3^ 
70 
1 orange 
125 
4H 
50 
1 peach or 2 plums 
75 
2J^ 
35 
1 portion of stewed prunes 
100 
3X 
Saucerful 
1 
115 
1 portion of preserves 
2M 
Saucerful 
150 
1 portion of fresh berries 
100 
3M 
Saucerful 
1 
35 
From our knowledge of the proximate constituents contained in 
various food stuffs, bills of fare can be constructed which will meet the 
requirements of the body as well as the purse of the consumer. 
THE ALCOHOL HABIT 
The habitual use of immoderate doses'of alcohol cannot fail to produce 
serious injury to mind and body. One%f the most constant effects is THE ALCOHOL HABIT 
65 
chronic inflammation of the stomach, with consequent impaired diges- 
tion and nutrition. Alcohol in excess also produces fatty degeneration 
of the heart, liver, kidneys and arterial coats, and is one of the most 
common causes of apoplexy, chronic meningitis, insanity and 
affections of the nervous system, such as inflammation of the nerves, 
palsies, epilepsy, etc. 
It is a lamentable fact that while the mortality from the so-called 
preventable diseases has markedly declined in the last three decades the 
death rates from the diseases referred to are very much greater than in 
1900. 
Every physician knows that the alcohol habit not only predisposes to 
tuberculosis, pneumonia, typhoid fever and other infectious diseases, but 
also that these diseases are more fatal or run a more severe course in alco- 
holic subjects, probably because of the impaired digestive functions and a 
general depraved nutrition of the system, with consequent diminished 
power of resistance. 
Alcohol also increases the susceptibility to industrial poisons, and a 
tendency to rheumatism and gout. According to Babcock 11 there is a 
distinct relationship between the incidence of alcoholism, insanity, venery 
and crime." The immoderate use of alcohol leads to mental and moral 
deterioration, characterized by the loss of will power, blunted moral 
sensibilities, and the ruin of character, and saddest of all, these effects are 
often transmitted to the offspring. 
The experience of 43 American Life Insurance Companies1 on alcohol 
in relation to mortality, shows that the mortality of drinkers, who exceed 
two glasses of beer, or one glass of whiskey daily, was 18 per cent, in excess 
of the standard of mortality. In those giving a history of alcoholic 
excesses in the past, the mortality was 50 per cent, in excess of the 
standard, and in the moderate steady drinkers the mortality was 86 per 
cent, in excess of the standard. 
Comparative Mortality of Males 25 to 65 Years of Age 
All causes complete 
All males 
England 
and Wales 
Brewers 
Innkeepers, 
publicans, 
spirit, wine or 
beer dealers 
Mortality figures 
1000 
1361 
1521 
Diseases of the nervous system.... 
119 
144 
200 
Respiratory system 
182 
236 
217 
Urinary system 
41 
55 
83 
Liver 
39 
96 
240 
Alcoholism 
10 
25 
55 
Gout 
3 
9 
13 66 
PERSONAL HYGIENE OF THE WORKER 
Life Insurance Tables Based upon English Statistics Cited by Jewett ("Town 
and. City," Page 87) 
Age 
Average 
expectation 
of life 
Moderate 
drinkers 
Total 
abstainers 
At 20 expect to live to be 
62 
35 
64 
At 30 expect to live to be 
65 
43% 
66% 
At 40 expect to live to be 
68 
51% 
68 ~ 
Alcohol as a Cause of Accidents.-Considerable evidence might be 
adduced to show the relationship of the alcohol habit and accidents. 
Those who are familiar with the effects of intoxicants need no argument in 
favor of sobriety. All railroad corporations and industrial plants realize 
the value of sober habits among their employes, and an increasing 
number insist upon total abstinence at all times, whether on or 
off duty. 
Preventive Measures.-The problem of what Hayhurst calls "indus- 
trial stimulantism " must be solved by educational methods, and hygiene 
offers many valuable suggestions. It teaches that intemperance is a 
vice, the result of a violation of natural laws, and in order to eradicate the 
evil we must remove the primary causes. 
Reference will be made on page 74 to mental and physical fatigue 
as an important predisposing factor. The indications are to regulate our 
life so that we do not burn the candle at both ends, take more rest and 
more interest in general amusements calculated to counteract the influ- 
ence of alcohol. Hygiene has recognized long ago that dust-producing 
occupations, exposure to extremes of heat and cold, the inhalation of toxic 
fumes and devitalized air, etc., are fruitful causes of disease in general, 
and the drink habit in particular, and has also pointed out how the injuri- 
ous effects may be prevented or at least mitigated. Until this is 
accomplished by compulsory factory sanitation, pure drinking water, and 
simple beverages-preferably milk-and good nourishing soups should 
be furnished by the employer. 
Every one at all familiar with the subject knows that badly cooked 
food, especially when consumed from the "cold dinner pail," produces 
derangement of the stomach and a craving for alcoholic stimulants, which 
in turn aggravate the original digestive disturbances and readily lead to 
the drink habit. 
In our sociological survey of 1217 families in Washington, D. C., 
earning less than $1000 a year we found the average expenditure for 
alcoholic beverages to be $16.14 per annum. Of the 750 wage earners 
who carried dinner pails 205 consumed alcoholic beverages with 
their meals. THE TOBACCO HABIT 
67 
Collis and Greenwood (Health of the Industrial Worker, 1921), cite 
the English historian, Lecky, to the effect that alcohol in all forms is of 
only recent occurrence in working men's lives: "It was not until about 
1724 that the passion for gin drinking appears to have infected the masses 
of the population, and it spread with the rapidity and violence of an 
epidemic." 'The fatal passion for drink was the most momentous 
event of the entire 18th century, far overshadowing politics and wars in 
its effect upon the people.' 
Money spent in temperance saloons for warm wholesome food and 
soups, cocoa and chocolate, will be a good health investment. It may be 
stated in general terms that while coffee, tea, spices and condiments in 
moderation, stimulate the nervous system and increase temporarily the 
elasticity of mind and body, their abuse is fraught with danger, and we 
may have "coffee and tea and even coca-cola topers," who suffer from 
diseases of the nervous system. 
The Tobacco Habit.-The per capita consumption of tobacco in the 
United States has increased from 4.98 lb. in 1900 to 6.31 lb. in 1920. In 
view of the fact that our sociological study of 1217 families in the City of 
Washington in 1908 shows an average annual expenditure of $12.19 for 
each family, which at a conservative estimate would amount to $239,655,- 
000 for the annual tobacco bill in the United States, it is important to 
consider the effects of tobacco on the system. 
Tobacco owes its general effects to the presence of toxic alkaloids 
known as nicotin, nicotellin, nicotein, nicotianin and certain bases such 
as pyridin, picolin, collidin and others which are formed during smoking. 
Syrian and Havanna tobacco contain little or no nicotin, while the com- 
mon grades contain from 3 to 4 per cent, and even 10 per cent. The acute 
toxic effects of nicotin are familiar to all who have learned to smoke. 
A yield of carbon monoxide gas is detectable to the extent of at least 
0.1 per cent, in each puff from a cigar, cigarette or pipe. This is simply 
the results of incomplete combustion which must necessarily take place 
in any fuel consuming device in which the air is drawn in through the 
fuel itself. It can easily be demonstrated with the Burrell CO detector 
that this CO is totally absorbed by the system in case the smoker "in- 
hales." Just to what extent smokers suffer from CO poisoning has not 
yet been determined. Strange enough, man becomes accustomed to the 
toxic effects and may even experience an agreeable excitation of the 
nervous system, characterized by increased mental and physical elasticity. 
There is nothing to justify the assumption, however, that the use of 
tobacco is free from danger. 
Dr. Lee has shown that there is an increase in blood pressure during 
smoking. Dr. L. F. Flick a noted expert on tuberculosis has pointed out 
that smokers show a greater susceptibility to consumption and are less 
amenable to curative measures. Lombard from personal experiments 
found that smoking decreases muscular strength. Seavers' observa- 68 
PERSONAL HYGIENE OF THE WORKER 
tion on Yale students appears to show that non-smokers made not only 
the best physical gains in weight, chest measure and lung capacity, but 
that 95 out of every 100 of the best students were not smokers. His data 
were apparently so convincing that Japan in 1900 enacted a law prohibit- 
ing the smoking of tobacco by persons under the age of twenty. Dr. A. 
A. Woodhull, U. S. Army, holds that cigarette smoking by the young is 
harmful as it arrests the natural elimination of waste and hinders the 
utilization of fresh material, thus interfering with proper growth and 
nutrition of the body. He also believes that the habit develops a greater 
tendency to acquire an appetite for alcoholic liquors, premature puberty 
is induced, increasing the sexual propensity and leading to improper 
sexual practices. There is a consensus of opinion among educators that 
the use of tobacco dulls the memory and intellect. When a promising 
pupil begins to decline in his work it is almost certainly found that he has 
begun the use of cigarettes. The excessive use of tobacco produces a 
chronic form of nicotin poisoning, with impairment of vision, nervous 
irritability or exhaustion, a predisposition to neuralgia and a peculiar 
affection of the heart, described by DaCosta as the tobacco heart, 
characterized by irregularity of the heart sounds, accelerated action 
and weakness of the cardiac muscles. Chewing of tobacco is even more 
to be deprecated than smoking, as the injurious elements are dissolved 
by the saliva and not infrequently swallowed. 
In many instances tobacco in any form produces a chronic inflamma- 
tion of the nose, throat and stomach, and acid dyspepsia. Insomnia 
and blindness, or tobacco amblyopia, are not infrequently observed in 
heavy smokers. Tobacco smoke also pollutes the air of the room with 
coal gas and the toxic pyridin bases. 
Some authors maintain that nicotin is decomposed during the process 
of smoking, and that the chief harm results from the pyridin and furfural 
evolved in the smoke. Lehmann,3 however, recovered in the smoke 82 
per cent, of the nicotin contained in cigarettes, and 85 to 97 per cent, in 
cigars. The London Lancet4 cites analyses showing from 3.75 to 84 per 
cent, of the original nicotin contents in the smoke from cigarettes, 77 to 
92 per cent, from tobacco smoked in pipes and 31 to 63 per cent, from 
cigars. The injurious effects of tobacco are also plainly evinced in 
chewers and in workers exposed to tobacco dust, showing that the nicotin 
and not the pyridin bases is the chief toxic factor. Kostial5 has shown 
that 72 of 100 of the female employees in a Vienna tobacco factory suffered 
during the first 6 months from congestive headache, palpitation of the 
heart, precardial anxiety, weakened heart action, intermittent pulse, pain 
in the stomach, heart burn, vomiting, diarrhea, loss of sleep and appetite, 
neuroses, general fatigue and loss of strength. 
These symptoms combined not infrequently, in acute cases, with faint- 
ness, dizziness, pallor of the skin, nausea, vomiting, profuse perspiration 
and diarrhea, are familiar to all who have learned the use of tobacco in ABNORMAL POSITIONS OF THE BODY 
69 
any form, and correspond very closely to those observed in experiments on 
animals which have also shown that nicotin may produce hardening of the 
arteries and other degenerative diseases.6 
Preventive Measures.-The use of tobacco in any form is doubtless a 
fruitful cause of industrial poisoning among wage earners. This must be 
apparent when we recall the many ways in which lead, arsenic and other 
toxic substances may enter the mouth by soiled fingers, chewing tobacco, 
pipes or cigars which have been contaminated with the dangerous agents. 
This element of danger has been recognized and in quite a number of 
European countries the use of tobacco during working hours is strictly 
forbidden. The employment of chewing gum will not obviate the 
dangers referred to. 
On the whole we may conclude that the use of tobacco is not a physio- 
logical necessity, and its abuse, like that of other habit-forming drugs is 
doubtless a frequent cause of a breakdown. It is especially harmful in 
nervous subjects and those of insufficient will power properly to restrict 
its use. A German authority maintains, and no doubt correctly, that the 
danger is greater from smoking cigarettes, because of the ease with which 
the smoke is inhaled. In any event, the practice of inhaling the smoke 
into the lungs, or smoking before breakfast, is a bad one. Pipes, cigar 
or cigarette holders and the mouth should be kept clean. Symptoms of 
shortness of breath, obscure pains around the heart, and nervous 
irritability and cough are indications to reduce or stop the habit 
altogether. 
Abnormal Positions of the Body.-The effects of a constrained work- 
ing position, combined with a sedentary life, have been briefly men- 
tioned in connection with indoor occupations. The effects are especially 
harmful in youthful workers whose osseous system is not fully developed 
and there is little doubt that most of the bone and joint deformities are 
developed in the earlier years of' their work, and aggravated by habit. 
Among the more important should be mentioned the hollow chest and 
round stooped shoulders, caused by a stooped and cramped position, as 
seen especially in tailors, engravers, lithographers, watchmakers, metal 
grinders, shoemakers, and all others obliged to assume a more or less 
bent-over posture. In shoemakers (cobblers) the pressure of the last 
against the breast bone, aggravates the anterior compression and often 
causes a typical depression of the sternum. All thoracic postural defor- 
mities naturally interfere with free expansion of the lungs, and hence with 
the respiratory functions. A stooped or bending posture also interferes 
with the proper distribution of the blood supply, and invites congestions 
of the abdominal and pelvic organs. 
As a matter of fact, a large number of this class of artisans show a 
peculiar predisposition to consumption, many suffer from anaemia, con- 
stipation, dyspepsia, and hemorrhoids, and the majority have a low 
average duration of life. 70 
PERSONAL HYGIENE OF THE WORKER 
Round shoulders and lateral curvature of the spine are quite common 
in bearers of burdens, and in all occupations involving the elevation of 
one shoulder above the other, so that even a clerk by a faulty position, 
or in the absence of an adjustable chair, may acquire lateral curvature 
of the spine. Such deformities are also quite common in blacksmiths, 
locksmiths, cabinet-makers and others, largely because of faulty posture 
and workbenches, and also on account of the unequal development of 
certain muscular groups. 
Among youthful workers, especially apprentices of bakers, barbers, 
waiters, nurses, etc., "flat-foot" "knock-knee," and "in-knee" and vari- 
cose veins of the lower extremity are frequently observed, as a result of 
being on their feet too long. Varicose veins, eczema, and ulcers are also 
quite common in motormen, conductors, machine tenders, and others 
who are obliged to be standing the greater part of their working hours. 
Shultes7 found varicose veins in 12.2 per cent, of German recruits, who had 
pursued an occupation involving a standing position, 4 per cent, in those 
who stood and walked, and 1 per cent, in those engaged in a more sed- 
entary position, and none in those whose occupation was wholly sedentary. 
Abnormal position combined with pressure is responsible for muscular 
cramps, sciatica, and neuralgic affections. The so-called "housemaid's 
knee," which is an enlargement of the patellar bursae filled with fluid is 
notoriously common, not only in scrubber women, but in floor finishers, 
carpet layers, and others who are obliged to be upon their knees for a 
considerable time. This same factor also plays an important role in the 
causation of the miners "beat knee," which is a subcutaneous cellulitis 
over the knee-cap. (See also page 153.) 
Preventive Measures.-Experience has shown that many of these 
deformities can be prevented by teaching apprentices proper posture. 
Indeed in view of the fact that so many of these physical defects have 
been acquired by faulty postural positions in the school and disqualify 
men for military service and the industries, it seems desirable that this 
training should be begun in the school. This can be done by the univer- 
sal use of adjustable seats and desks, correction of faulty positions, and 
exercise of opposing groups of muscles. In the factory or workshop 
adjustable seats and proper workbenches are of equal importance, and all 
persons engaged in occupations involving constrained attitudes should be 
encouraged to engage in well regulated gymnastic exercises. A number 
of states make seats for females obligatory; there is no good reason why 
this provision should not be extended to include men, whenever it is 
practicable. For the prevention of "housemaid's knee" suitable knee 
pads should be used. 
For the relief of varicose veins and prevention of leg ulcers, massage, 
rubber bandages, or elastic stockings are indicated. 
Flat-feet.-Captain J. R. Harris8 of the Medical Corps U. S. A. has 
written an excellent article on this subject and concludes that the prime FLAT FEET 
71 
cause of flat or weak feet is improper posture and gait. For the correc- 
tion and prevention of flat-feet he recommends the following: 
"The habitual position in standing should be the position of 
attention, except that the heels should be 1 or 2 in. further apart 
than the toes. This is a position of muscular tonicity and readiness 
in which the position of the astragalus and the integrity of the arch 
are maintained. 
The stride is changed from the usual waddle gait to the proper gait 
by teaching the Indian stride until the reflex centers in the lumbar cord 
shall have learned the new routine, usually a matter of a few lessons only. 
Then reduction of the exaggeration is permitted, and a set of corrective 
and strengthening exercises prescribed such as the following: 
1. Rise upon the tip toes as high as possible and lower the heels again 
slowly. 
2. Raise the toes as high as possible and relax. 
3. Raise the body by pinching or pressing downward with all the toes, 
an action similar to "grasping" with the hands, endeavoring not to use 
the leg muscles. 
4. Cross the right foot in front of the left and sway, carrying the 
weight alternately from the left to the right foot, with active pushing of 
the toes. Reverse the feet and repeat the exercise. 
5. Stand with the left foot in the hollow of the right knee and swing 
about balanced on the right foot. Change and balance on left foot. 
Continue each exercise from 5 to 10 minutes according to the effect upon 
the muscles. Repeat all the above several times each day. 
These exercises are best taken in barefeet. It will be sufficient in 
many cases to stand with the toes turned well in, draw up the arches and 
then carefully turn the toes out to the parallel position, holding the 
arches and ankles in position, and frequently repeating the maneuver. 
In all cases it is necessary to remember that the ankles must be held 
up over the foot, and the "slump" of ankle and out consciously combated. 
The prejudice against intoeing of children should be strongly com- 
bated, since slight intoeing is the natural and strong position; and the 
exaggerated position or pigeon toe is simply a natural effort to conserve 
arches and muscles not normal in strength." 
Dr. Harris supports Munson's objections to patent devices intended 
to support the foot arch, upon the ground that they relieve the symptoms 
of discomfort at the expense of making the underlying cause of the latter 
much worse, for they splint and restrict the use of the very muscles upon 
the development and strengthening of which the regaining and preserva- 
tion of the foot arch depends. 
Dr. Jay W. Seaver an eminent orthopedist and for many years Direc- 
tor of Physical Culture at Yale considers Dr. Harris's training sugges- 
tions for the prevention and correction of this deformity, eminently 
practical and in accord with the mechanics of the anatomy involved. 72 
PERSONAL HYGIENE OF THE WORKER 
Overexercise of Certain Parts of the Body.-The causes and diseases 
due to the excessive use of certain muscles, to eye strain, and excessive 
noises are fully discussed in the chapters on Occupational Neuroses, and 
Diseases of the Eye and Ear. These affections are of the utmost econ- 
omic importance, since they impair not only the efficiency, but also the 
earning power of the worker, and not infrequently compel a change of 
work. 
Among the affections due to the overuse of the voice should be 
mentioned chronic inflammatory conditions of the pharynx and larynx, 
in public speakers (clergymen's sore-throat), singers, train announcers, 
auctioneers, street criers, etc. In some instances, laryngeal spasm and 
paralysis of the vocal cords, with complete loss of voice, have been 
recorded. 
Constant local pressure, friction, and overuse of the arms and hands, 
is productive of much harm. This is seen in the formation of painful 
callosities in the palms and fingers, inflammation of the synovial lining 
of the wrist-joint and tendon sheathes, and enlarged bursae. These 
conditions not infrequently are followed by septic infections, such as 
subcutaneous cellulitis, as seen in the "beat hand" and "beat elbow" 
of miners. Cysts of the wrist tendons have also been observed, in the 
Government Printing Office, in persons engaged in making firm pressure 
with the hand in folding heavy paper. Contracture of fingers and atro- 
phy of the palmar aponeurosis are also frequently observed, as a result 
of hard manual labor. 
Occupations involving constant jarring of the entire body are con- 
ducive to the development of neurasthenia, insomnia, and gastro-intes- 
tinal neurosis. 
As an example of overstrain of certain groups of muscles should be 
mentioned the distended, yet flabby condition of the cheek, as observed 
in glass-blowers and performers on wind instruments. In these cases 
there is at first a hypertrophy of the muscular fibers, followed later by a 
partial atrophy which not infrequently results in actual rupture. The 
air forced into the salivary ducts causes dilatation and emphysema of 
Steno's duct, which is occasionally followed by rupture and painful 
affections of the parotid gland. 
Emphysema of the lungs is in some instances the result of overstrain 
of the pulmonary tissue, as witnessed by the occurrence of such cases 
among glass-blowers, users of blowpipes, and performers on wind 
instruments. 
Illustrations of the acute and chronic effects of excessive muscular 
strain are seen in the undue prevalence of cases of hernia, among persons 
engaged in hard work, especially in those who lift or carry heavy weights 
on ladders, as in the building trades and in those who operate foot presses. 
Fortunately derricks and lifts are diminishing these hazards. The effects 
of habitual hard work in the causation of diseases of the heart and circula- OVERWORK AND SPEEDING UP 
73 
tory system, which in some instances may result in sudden death from 
cardiac exhaustion or rupture of the blood-vessels will be pointed out on 
page 938. Indeed there is ample statistical evidence to justify the con- 
clusion that persons habitually engaged in hard work are more frequently 
subject to disease and accident and present a higher mortality than 
persons more favorably situated. 
Overwork or Fatigue.-One of the most important predisposing causes 
to disease is overwork or fatigue, because the accumulation of waste prod- 
ucts in the blood, from muscular wear and tear, together with the ex- 
pended nervous energy, combine to render the system more susceptible to 
disease. The subject of fatigue in its physiological and pathological rela- 
tions is discussed by Professor Lee in a special chapter. 
Dr. E. Lyman Fisk very properly suggests that in a survey of fatigue 
it is first necessary to inquire: Does the output fall because the worker is 
tired or because he is physically deficient? Is the worker ill because he is 
tired or tired because he is ill? To which we may add-another im- 
portant factor, viz. the subject of fear, anxiety, worry, and the personal 
habits of the individual such as vice, dissipation, loss of sleep, etc. 
From the view point of prophylaxis it may be well to bear in mind the 
following maxims: 
1. Life without daily purposeful effort is wrong; there are those who do 
too little work, and those who do too much. Some groups of muscles are 
overworked and others are not sufficiently used. The brain worker lacks 
physical exercise, and the physical worker mental exercise and training 
(Fisher). 
2. Habitual hard work and long hours are calculated to diminish 
the general power of resistance and to bring about premature physical 
deterioration. 
3. The more intensive the work ("speeding up") and the shorter the 
interval of rest for the elimination of waste products, the earlier we may 
expect manifestations of fatigue. 
4. Excessive heat and humidity, exposure to vitiated air and toxic 
dust and fumes, violent concussions of the air, and general jarring of the 
body, constrained posture, and overexertion of certain muscles, favor 
premature fatigue. 
5. Insufficient or improper food, long walks to work, vice and dissipa- 
tion and the abuse of alcohol produce premature fatigue. 
6. Monotonous work, employments involving mental strain and 
responsibility, watchful care in machine work, fear about satisfying the 
"boss," anxiety about money and domestic affairs are all conducive to 
premature fatigue, while work done with zest often acts as a tonic. 
7. Night work constitutes a fatigue factor only when it involves long 
hours and loss of sleep. 
"Speeding Up."-Among all the fatigue.factors, none is more potent 
than the pernicious practice of "speeding up." In order to meet the 74 
PERSONAL HYGIENE OF THE WORKER 
demands of competition, lower prices, high profits, and trade supremacy, 
inventive genius is ever at work to increase the speed and output of 
machinery, and employees have to keep pace with the machine. This 
speeding up is manifest in all of the mechanical industries, especially in 
the textile and clothing industry. Some of the sewing machines now 
carry ten needles instead of one, involving correspondingly increased 
strain of the eyes to watch for broken threads, and also increased nervous 
tension and physical fatigue. This high-pressure system had its origin 
in this country and is by no means confined to individual industries. The 
very excellencies of our progress have stimulated the nerves and intellect 
and fired the ambition of men until they overleap the limits of their 
natural powers. Rest and recreation seems impossible to many, and the 
temporary stimulant derived from the tempting cup offers, for the time 
being, relief to our physical and mental exhaustion. It is, however, like 
all so-called "nerve tonics," a dangerous remedy. It is like applying the 
whip to a tired horse and the result is a constant increase in the number of 
prematurely worn-out workers, neurasthenics, alcohol and drug habitues. 
Neurasthenia is by no means confined to mental workers. Of 285 
cases treated by Petren, 189 belonged to the laboring and agricultural 
classes. It is true that certain occupations involving exposure to indus- 
trial poisons, such as coal gas, carbon disulphide, lead and manganese, 
predispose to this disease, as do also occupations involving exposure to 
excessive heat, light and noise. But when we see an increase all along 
the line of industrial workers, affecting, according to Schwab, about one- 
fourth of the garment workers in St. Louis, it is evident that the founda- 
tion is chiefly laid in the "speeding up system," which has also invaded 
Europe. 
Preventive Measures.-The general effects of overwork and chronic 
fatigue are characterized by loss of appetite, anaemia, digestive derange- 
ments, respiratory and cardiac affections, fatigue neuroses, neurasthenia, 
and general deterioration of health. 
In the prevention of the far-reaching consequences it is evident that 
work must be regulated by the capacity of the individual, and hence it is 
desirable at the outset for persons to select only employments for which 
they are physically fitted. After entering upon employment it is im- 
portant that all the fatigue factors should be carefully considered and 
controlled by wise and humane measures. So, for example, a change of 
work to less arduous tasks may often prevent a complete breakdown. It 
is obvious that there must be proper intervals for rest and recuperation, 
hence the necessity of regulating the hours of labor and the enforcement 
of a day of rest. We have referred elsewhere to the high mortality of 
the industrial workers of Great Britain at the beginning of the nineteenth 
century. This was at a time when employes in the cotton mills were 
obliged to work from 14-18 hours a day. Koelsch informs us that after 
the reduction of the hours of labor, from 12-8 hours a day, in the alkali WOMEN AND CHILD LABOR 
75 
works of Norwich, the morbidity rate sank from 10.12 per cent, to 6.1 per 
cent. After the introduction of the 9-hour shift in the English machine 
shops, in 1872, the average span of life of these workers was lengthened in 
the course of 17 years from 38^ to 48^ years. In estimating the general 
efficiency of such commendable laws it is but fair to concede that the 
general health movement in the last four decades, especially the improve- 
ment of the air we breathe and the water we drink, has played an impor- 
tant part in the prolongation of human life. 
The physiological remedy for fatigue is rest, sleep and food, which 
offer an opportunity for recuperation (see Sleep, page 54). 
Hours of Labor.-The enactment of laws limiting actual labor to 8 
hours a day finds ample support in a study of the relation of fatigue to 
accident liability (see page 82) and can also be defended upon general 
health principles. This is especially true of females, who, on account of 
their imperfectly developed muscular system and more delicate physique, 
require special protection. 
No child should be permitted to work in factories and wage-earning 
occupations under the age of 14, and then only upon presentation of a 
medical certificate that it is free from physical defects. Such children 
should not be obliged to work longer than 6 hours, with 2 hours of interval 
of rest after the first 3 hours. Under no circumstances should they be 
permitted to perform night work. The same may be said of individuals 
between the ages of 16 and 18 years, who, however, may be permitted to 
work 8 hours a day, with proper intervals for meals and rest. 
Employment of Women and Children.-In the face of many adverse 
circumstances under which labor is often performed, it is but natural 
that the immature male employes and females should suffer most. The 
former not infrequently inherit a weak constitution, or acquire it by 
insanitary home surroundings and deficient food. Quite a number are 
obliged to enter upon active work long before their bodies are sufficiently 
developed. Apart from the fact that child labor is a menace to education, 
morals and good citizenship, the effects of premature and involuntary labor 
upon the health and physical welfare of the child are extremely detri- 
mental. It has been shown that up to the age of 13 to 14, the muscular 
fibers contain a large percentage of water, and in consequence are very 
tender and weak. Demetjeff, cited by Rubner,9 determined the lifting 
powers of the arm and trunk of the working class, and found that the 
average boy of 14 possesses about one-half the muscular strength of an 
average adult between 35 and 40 years. 
Lifting Power of the Arm and Trunk of the Working Classes at Different 
Ages 
Age 
Kilograms 
14 years 
82 
16 years 
101 
18 years 
128 
20 to 29 years 
140 
Age 
Kilograms 
30 to 35 years 
150 
35 to 40 years 
160 
40 to 50 years 
148 
50 to 60 years 
134 76 
PERSONAL HYGIENE OF THE WORKER 
As a result of imperfect development of muscles and bones it is not 
surprising that a large percentage of young persons engaged in workshops, 
factories, or even at the writing desk, develop lateral curvature of the 
spine and other deformities, such as flat-foot, knock-knee, in-knee, etc., 
not to mention general weakness, and a predisposition to other diseases. 
All of the bad effects are naturally intensified by insanitary environments, 
especially when the occupation involves exposure to dust and fumes. 
In quite a number of European countries minors are excluded from trades 
involving exposure to industrial poisons. During the 1910 Census there 
were 1,752,187 children under 16 years of age engaged in gainful occupa- 
tions; of these over 80,000 were employed in the textile industry; about 
25,000 in mines and quarries; 12,000 in the manufacture of tobacco and 
cigars; over 10,000 in wood industries; 7116 in the glass industry; over 
7000, mostly girls, in laundries; 2000 in bakeries; 138,000 as waiters and 
servants; 42,000 boys as messengers; and 20,000 boys and girls in stores. 
According to Koelsch10 women possess only from six-tenths to seven- 
tenths the strength of men of like weight, and yet, in the struggle for 
existence, quite a number enter the ranks of industrial workers. For 
physiological reasons they are quite sensitive to the effects of physical 
and mental fatigue, and it is perhaps fortunate that, because of marriage 
or inability to withstand the strain of modern industries, the majority 
abandon their strenuous work before permanent injury is done. But even 
as it is, Roth tells us that 75 per cent, of 145 female inmates in a German 
sanitorium suffered from ansemia, chlorosis and neurasthenia, as a result 
of overwork. It is a matter of common observation that women who 
have had to deny themselves proper rest and care during the menstrual 
period, for several weeks before and after confinement, are very liable to 
suffer from chronic uterine diseases and hemorrhages, while miscarriages 
and premature births are not infrequent results of overwork. Statistics 
collected by Neisser indicate that such accidents are quite common among 
farmer's wives, laundresses, seamstresses and women employed in the 
jewelry industry, where foot presses are used. 
The value of proper care and rest during pregnancy is shown by the 
Leipsic statistics, which indicate that the percentage of premature births 
was 0.3 and of abortions 2.3 among the volunteer insured, against 1.7 and 
15.5 per cent, among the compulsory insured. This difference, Koelsch10 
explains, is due to the fact that the volunteer insured mother pays the cost 
of insurance and sacrifices more or less of her wage, in order to protect her 
offspring. The percentage is especially high among workers exposed to 
lead poisoning: 53.6 per cent, in metal polishers, 22.9 per cent, in type 
foundry workers, and 30 per cent, among the tin-foil capsule workers 
of Vienna. 
Rubner, cited by Koelsch, estimates the number of still-births in 
certain harmful occupations as between 150 and 170, against an average 
rate of 33 per 1000 births. WOMEN AND CHILD LABOR 
77 
Strassmann's and Falk's statistics shown an undue prevalence of men- 
strual disorders, inflammatory conditions and displacement of the uterus, 
abortions and diseases of pregnancy among seamstresses using foot-power 
sewing machines. This excess, amounting to between 40 and 50 per cent, 
is attributable to prolonged sedentary and faulty positions, constipation, 
chlorosis, pelvic congestions, and possibly also active hypersemia of the 
pelvic organs caused by overexertion of the lower extremities since the 
difference is not so pronounced in hand seamstress and those using power 
machines. Similar conditions are observed among laundresses, who more- 
over not infrequently suffer from varicose veins and ulcers of the leg. 
Space will not permit of a more detailed presentation of the statistics so 
laboriously collected by Koelsch.10 A few important facts may be 
summarized as follows: (1) The Austrian and Leipsic statistics indicate that 
the mortality rates of female workers between the ages of 15 and 60 are 
distinctively higher than in unoccupied females of the same age period. 
(2) The Leipsic statistics show that, while the death rate is about equal for 
both sexes below the age of 15, between the ages of 24 and 29 it is 1.09 
per 1000 higher in the female workers, and between 30 and 40 it is 0.70 
per 1000 higher than in the male workers. (3) The morbidity rates and 
duration of illness are likewise considerably higher during the same age 
period than in male workers. The number of cases of sickness per 100 
for female workers was 41.8 with an average duration of 24.6 days, while 
the rate for male workers was 39.6 and 21.6 respectively. After the com- 
pletion of the menopause, statistics are in favor of female workers. (4) 
Diseases of the blood, of the nervous system and of the digestive organs 
predominate in all comparative statistics. Tuberculosis is less frequent 
among female workers, 19.2 per 10,000 against 23.2 in the males. During 
the child-bearing period, however, the rates are excessive, especially during 
the ages of 30 to 35 years. This difference is less pronounced in the 
general population and indicates that industrial work combined with 
maternal functions is harmful. 
Dysmenorrhoea as an Industrial Problem.-Dr. Samuel R. Meaker 
(Jour, of Industrial Hygiene, June, 1922) has made an important contri- 
bution to this subject based upon a study of 7876 working girls and 
finds that industrial crippling from painful menstruation may occur in 
three ways: (1) The girl remained at work, but with lowered general 
efficiency; (2) the girl was incapacitated for a short period of the day; 
(3) the girl was absent for a full day or longer. The first group does not 
entail any considerable industrial loss, while in the second group rather 
over 10 per cent, of the girls were found to seek relief at the rest room 
or hospital during any given month. Half of these girls were able to 
return to work after a hot drink and a rest of from 10 to 15 minutes, 
so that the amount of time lost was negligible; somewhat less than one- 
half of them lay down for periods averaging about two hours; about one- 
eleventh of this group were sent home for the remainder of the day, the 78 
PERSONAL HYGIENE OF THE WORKER 
industrial loss in each such case being one day. The third group-those 
absent for a full day or longer-was found to be chiefly responsible for 
industrial loss; it was estimated to constitute more than 1 per cent, of the 
total time of the employees. Dr. Meaker believes that much could be 
effected by providing proper medical care for those seeking relief at 
work (Group 2) and by education among those who had to stay away 
from work (Group 3) and that the greater part of the suffering from 
dysmenorrhoea could be prevented by simple measures, and in most 
cases without pelvic examination. 
REFERENCES 
1 Report of the Medico-Actuarial Investigation, Vol. III. How to Live, Fisher and 
Fisk, 1915, page 235. 
2 Town and City. Jewett, page 14. 
3 Lehmann.-Mtinch. Med. Wochenschft., 1908. 
4 Lancet, London, April 6, 1912. 
5 Kostial cited by Stephani, Weyl's Handb. der Arbeiterkrankh., Jena, 1908, pages 
634-635. 
6 Jour. A. M. A., LXXII, page 461. 
7 Shultes.-Deutsche Med. Wochenschft., 1901, page 546. 
8 Military Surgeon, January, 1914. Also Mo. Bull. N. Y. State Dept. Health, June, 
1920, pages 145-153. 
8 Rubner.-Lehrbuch d. Hygiene, Leipzig u. Wien., 1906, page 709. 
10 Koelsch.-Krankheit u. Soziale Lage, Munchen, 1912. CHAPTER IV 
ECONOMIC LOSS FROM PREVENTABLE SICKNESS AND ACCI- 
DENTS AMONG THE WORKING POPULATION 
GEORGE M. KOBER, M. D„ Washington, D. C. 
Dr. Eugene Lyman Fisk, Medical Director of The Life Extension 
Institute, has rendered an excellent report on "The Problem of Economic 
Loss and Waste in Industry," arising from lowered health conditions, 
sickness and accident among the working population, to the Hoover 
Commission, the perusal of which is urgently recommended. Dr. Fisk 
kindly placed his manuscript at my disposal from which I offer extracts. 
Fisk cites Professor Irving Fisher's report on National Vitality 
for the National Conservation Committee, appointed by President 
Roosevelt in 1909, estimating that there are about 3,000,000 persons 
seriously ill at all times in the United States, and that 42 per cent, of this 
illness was preventable with a resulting extension of life of over 15 years. 
The investigations of the U. S. Commission on Industrial Relations in 
1913-1915, which covered a survey of the sickness prevalent among 
approximately a million of workers of representative occupations, 
revealed an average loss to more than 30,000,000 American wage earners 
of about 9 days per year.1 
The data collected during 1915-1917 by the Metropolitan Life 
Insurance Company covering 637,038 white and colored persons show an 
average loss from sickness of 5.8 days for males and 6.9 days for females.2 
The general death rate in the U. S. Registration Area has fallen from 
17.6 per 1000 in 1900 to 12.9 per 1000 in 1919, so that since Professor 
Fisher's report was issued according to Dr. Fisk: 
A considerable measure of his prediction has been fulfilled. The duration of life 
has probably been extended a period of 5 years and the estimate of 13 days annual 
loss from illness must now be reduced to approximately seven . . . Changes that 
have taken place in the death rates from some of the principal diseases that contri- 
buted to the morbidity rate when the "Report on National Vitality" was issued, 
furnish consistent and confirmatory evidence of the facts suggested by the morbidity 
surveys herein quoted that there is now less disability and sickness present than there 
was even 15 years ago. He also points out the significant fact that the death-rate 
from organic diseases is greater in this country than in England and Wales and that 
the death rate in the middle age of life is now likewise greater, although not formerly 
so, and that there is evident need to combat the chronic maladies like diseases of 
the heart, arteries, etc., that limit the work span and are not now systematically 
attacked as are typhoid, tuberculosis and venereal diseases. 
The general death rate among those employed at ages 15 to 65 as 
estimated (by Dr. Louis I. Dublin, cited by Fisk) on the basis of the 
79 80 
ECONOMIC LOSS FROM PREVENTABLE SICKNESS AND ACCIDENTS 
industrial insurance mortality experience for the year 1920 was 11.46 
per 1000 living. An estimate of 42,000,000 persons gainfully employed 
in 1920 is considered conservative. The application of this death rate 
to such a group would give a total loss for the year 1920 of 483,000 
lives and a probable loss in 1921 of 500,000 lives. 
The sickness rates actually determined in recent studies according 
to Dr. Fisk, show that 2^ per cent, of wage-earners are constantly ill to 
an extent to be incapacitated. This would justify an estimate of approxi- 
mately 2,400,000 people continually ill instead of Professor Fisher's 
estimate in 1909 of 3,000,000. Dr. Fisk estimates that by supervision 
and periodic physical examination a still further reduction amounting to a 
mortality gain of four lives, and the elimination of 8 cases of chronic illness, 
or a reduction of 2920 days of illness, with a net profit of $29,000 to the 
State or community per 1000 of population could be secured. 
Dr. Fisk also estimates that the cost of periodic examinations applied 
to the entire population would amount to $525,000,000, and assuming 
that one-third of the substandard cases or about 10,000,000 revealed by 
these examinations required medical, surgical or dental treatment at a 
cost of $100 per case, the cost of this repair work would aggregate $1,000,- 
000,000, leaving a net margin of $1,520,000,000. 
Specialltems of Loss.-Dr. Fisk cites the losses from the following diseases which 
he considers all theoretically wholly preventable, at least 75 per cent, practically 
preventable: 
Tuberculosis, $500,000,000 annually from death alone,3 $26,000,000,000 in 
this generation from diminished longevity. 
Typhoid fever, $135,000,000 annually. This disease still fills more than 150,000 
sick beds and takes about 15,000 lives annually (Fisk). 
Malaria, $100,000,000 annually.4 
Hook-worm.-Dowling5 estimates the loss from this disease at least $250,000,000 
annually; 33 per cent, increase in industrial efficiency has resulted from hook-worm 
prevention in certain sections (Ferrell6). Ashford,7 based on his experience at Porto 
Rico, writes "it can be truthfully said that treatment and education alone have raised 
the laboring efficiency of the working class by nearly 68 per cent." 
Influenza and Pneumonia.-Fisk informs us that these two diseases even in non- 
epidemic years claim about 35,000 lives in the working ages 20-60 and thus accounts 
for at least 350,000 cases of illness.8 
Focal Infection.-More than 60 per cent, of workers show definite focal infection 
of some degree. This has been confirmed by X-ray examination of over 5000 people 
by the Life Extension Institute. There are more than 130,000 deaths annually 
in the working age from the organic diseases largely due to focal infection and there 
are not less than 14,000,000 people in the industry showing signs of organic impair- 
ment of some degree. 
Increase in Chronic Diseases.-The mortality from diseases of the heart, 
blood vessels, kidneys, apoplexy, insanity and cancer has greatly increased in this 
country during the past 40 years. Unfortunately the exact causes of these and 
other chronic organic diseases, which carry off over 250,000 victims every year are 
still obscure. There is however much reason for assuming that focal infections from 
diseased tonsils, adenoids, infected teeth, middle ear, accessory nasal sinuses, gall 
bladder, appendix, prostate and seminal vesicles are the most frequent cause. It is CERTAIN DISEASES, ACCIDENTS AND INJURIES 
81 
assumed that the continuous absorption and action of these poisonous substances 
on the living cells may bring about degenerative changes. Dr. Frank Billings believes 
that this form of blood poisoning may be a possible causative factor in the following 
diseases: Inflammation of the joints, bone, muscles, goitre, gout, boils, endocarditis, 
pericarditis, myocarditis, arteriosclerosis, pleurisy, pneumonia, bronchitis, asthma, 
neuritis, neuralgia, myalgia, meningitis, inflammation of the kidneys, bladder, 
intestines, stomach, and many chronic skin diseases. 
In reference to the increase of mental and nervous diseases, we know that the 
most frequent causes of insanity are syphilis, alcohol, drug addictions, mental stress 
and overwork. In the light of our knowledge concerning focal infections, there is 
much reason for assuming that the toxic effects, may readily manifest themselves 
in the delicate tissues of the brain and nerves. It is also believed that some of the 
chronic diseases are due to wrong habits of life, the result of nutritive disturbances 
from overfeeding and underfeeding, or an improperly selected diet; while others are 
caused by industrial poisons to which many of our wage earners are exposed. 
In the prevention of chronic organic diseases, much good can be accomplished by 
industrial, social and mental hygiene, and especially by periodical medical exami- 
nations for the early detection of these insiduous diseases, with a view to prompt 
treatment. 
Venereal Infection.-Dr. Fisk in discussing this subject says: "It is impossible to 
give definite figures. Drawing conclusions from the draft figures, 5.6 per cent, would 
be an outside estimate for ages 21 to 31. It may be roughly estimated that 1,500,000 
workers are affected. The Life Extension Institute found less than 1 per cent, of 
syphilis in industry and about 3 per cent, in a mixed population. The Mayo Clinic 
found 4.6 per cent, of syphilis in mixed classes and 10 per cent, among railway men." 
Eye Strain.-Among over 10,000 employes in factories and commercial houses 
examined by the Life Extension Institute, 53 per cent, had uncorrected faulty vision. 
The Institute in its examination of 675 employes in the Underwood Typewriter9 
Company, individuals engaged in close work, found 58 per cent, in need of correction 
by glasses.10 Fisk points out the need of providing adequate illumination for the entire 
industry, and reports the condition of lighting in 446 plants as follows: Excellent 
8.7 per cent.-Good 32.0 per cent.-Fair 29.1 per cent.-Poor 18.8 per cent.-Very 
poor 3.5 per cent.-Partly good and partly poor 7.8 per cent. 
He adduces statistics to show how corrected eye sight increased the productivity 
28 per cent, in the Whiting-Davis Company, where a large amount of close, fine work 
is done.11 
Accidents and Injuries.-The total number of deaths reported from 
accidents during the last census year was 57,513, of which 43,414 were 
males and 14,099 females, and the proportion of deaths from these causes in 
1000 deaths from all known causes was 57.6. In the Registration Area the 
rate was 96 per 100,000 of population. In 1890 the rate was 91.9. 
The rate in the cities was somewhat higher than in the rural districts, and 
the rate for males was about three times as high (125.4) as among females 
(42.2). This is due to the more sheltered position of females and because 
males alone are generally engaged in the more dangerous operations. 
The highest death rates from accidents occur in persons 45 years of age 
and' over, and the lowest in children under the age of 15, which indicates 
that employment in factories, workshops, mines, steel industries, the 
railway service, etc., influences to a great extent the number of accidents 
and injuries. According to the Committee on Public Accident Statistics 82 
ECONOMIC LOSS FROM PREVENTABLE SICKNESS AND ACCIDENTS 
of the National Safety Council,12 there were 76,000 accidental deaths in 
continental United States during 1920. This is 37,000 in excess of what 
we would have if the accident experience of England and Wales were to 
prevail here. The leading cause of accidental deaths is falls, which occurs 
at the rate of 34 a day. Automobile accidents cause 30 deaths a day (a 
total for the year of 11,000). Burns claimed 22 per day (a total for the 
year of 8088). Railroad accidents, 7769; drowning, 6066; gassing, 
3618; firearms, 2767; mine accidents, 2660; machinery, 2260; street cars, 
2128; other vehicles, 2022; and conflagrations, 1277. 
Life insurance and accident policy statistics plainly indicate the danger 
of occupations which involve contact with machinery. This is generally 
attributed to individual carelessness or the negligence of others. It would 
be interesting to know just how much of this so-called carelessness is 
really due to fatigue, which doubtless lowers the power of alertness. Not 
infrequently accidents from boiler explosions, circular saws, planes, 
belting and flying fragments are due to a lack of proper safety devices. 
As might be expected, many of the accidents befall children and inex- 
perienced persons, and take place at night or in badly lighted establish- 
ments. The German accident statistics, cited by Roth,13 clearly indicate 
that accidents increase with mental and physical fatigue. Upon the 
assumption that there is one accident for every three working hours 
during the year, the average number of industrial accidents was as 
follows: 
6- 9 A.M 1.10 
■9-12 A.M 2.26 
12-3 P.M 1.02 
3-6 P.M 2.11 
Saturdays, 3-6 P.M 2.76 
Prof. Imbert at the International Congress on Hygiene at Brussels, 
presented similar statistical material. According to Rubner,14 of 100 
accidents, 41 befell children under 15 years of age, 36.4 befell persons 
between 15 and 25 years, 13.1 befell persons between 25 and 40, and 9.5 
befell persons between 40 and 60 years of age. The upper extremities 
were involved in 87 per cent, of the cases, the lower extremities in 7.5 
per cent., and the head and trunk in 5.5 per cent. 
Swiss statistics show that among 1000 workers accidents occur as 
follows: Cotton spinners 22.2, millers 28.0, paper industry 31.1, carpen- 
ters 35.2, locksmiths 46.9, brewers 66.7, masons 80.5, blacksmiths 93.1. 
metal workers 102.1, moulders 132.2. 
Many of the accidents befall the eye. Magnus attributes 8.5 per 
cent, of all cases of blindness to accidents. Interesting details will be 
found under various occupations. The number of accidents in textile 
mills in this country, considering the large number of fast-running 
machines, is not large,-during a period of almost 5 years at the Pacific 
Mills, Lawrence, Mass., with about 52,000 employes, amounting to 1000. 
Of these, one was killed outright, one fatally injured, 86 seriously injured ACCIDENTS AND INJURIES 
83 
(broken limbs or amputations necessary), 910 slightly injured, and two 
suffered from nervous shock but were physically uninjured. The under- 
lying cause of injury is given as follows: Careless manipulation 539, 
inattention to surroundings 177, taking chances of being injured-■ 
deliberate carelessness, such as cleaning machinery while running, etc., 
164, carelessness of fellow-workmen 51, unforeseen liability 60, unclassi- 
fied 9. 
ECONOMIC LOSS FROM ACCIDENTAL INJURY 
According to the U. S. Department of Labor, cited by Fisk, 875,000 
people are annually disabled 4 weeks or more by industrial accidents.15 
If we assume16 that the cost of turnover or replacement of these people 
is $35 it would mean a direct waste in turnover alone of $30,625,000. 
If we added for those killed $980,000, the increased production cost due to 
industrial accidents amounts to $31,605,00. 
Crum17 estimated the total economic annual loss from public 
accidents in the general population as $2,229,156,000, based on the value 
of human life at various ages and the accident fatalities at those ages. 
This takes into account 45,000 fatal accidents in 1917 and an estimate 
of 5,625,000 non-fatal injuries by public accidents. 
At least 75 per cent, of the accident rate is preventable.18 Even 
greater reduction has been made in some plants by safety measures and 
education. The economic value of these lives on the lowest basis of 
computation is $8000 each and the saving of 20,000 of them (75 per 
cent.) would mean an economic gain in industry of $160,000,000. If we 
apply this rate to the general population on the basis figured by Crum, it 
would mean a saving of $1,671,867,000. 
The industrial Commission of Pennsylvania, cited by Fisk, reported 
that 18 persons lost both eyes in industrial accidents in 1920, the compen- 
sation totalling $63,731.00; 652 workmen lost one eye, the compensation 
totalling $826,674.19 Dr. Fisk also points out how, by the use of safety 
goggles, the eye accidents in the American Locomotive Company20 have 
been reduced from 38.9 per 1000 of full-time-men per year during 1910- 
13 to 15.7 in 1915 and the number of eyes lost during the same period, 
from 10.5 to 2. 
Prevention of Accidents.-Most of the States have taken steps to 
reduce accidents to a minimum. For this purpose they have enacted 
laws concerning employers' liability if they fail to provide safety devices 
for the movable and dangerous parts of machinery. Much has been 
done also in the prevention of accidents in mines, in the railway service, 
in steel plants, etc., by a general "safety first campaign." The National 
Safety Council, 168 N. Michigan Ave., Chicago, has prepared a hand 
book of 72 pages entitled "The Principles and Practice of Safety" for 
technical schools and universities, issued 1919. 84 
ECONOMIC LOSS FROM PREVENTABLE SICKNESS AND ACCIDENTS 
A careful inspection of steam boilers and examination of engines has 
materially lessened the dangers from boiler explosions, so that in England 
there is only about one explosion in 6200 registered boilers. Nearly all 
states require some form of protection in case of fire, by means of fire 
escapes, semi-fireproof buildings, and doors swinging outwardly, while a 
respectable number also provide for automatic sprinklers and other fire- 
extinguishing methods. (For suitable clothing, see page 24. For pre- 
ventive legislation, see page 1002 and the Introduction.) 
Dr. E. L. Fisk presents a table taken from the National Industrial Conference 
Board in its Research Report No. 37 of which the following is a digest of important 
medical work in industry now being carried on. Total number of plants reporting 
207, number of total workers, 764,827; total new injuries 1,034,807. New injuries per 
worker, 1.35. Redressings 2,083,662; redressings per new injury 2.01. Total number 
of medical cases 1,073,731; medical cases per worker 1.40; total number of physical 
examinations 525,818. 
PHYSICAL RECONSTRUCTION OF DISABLED WORKERS IN THE 
INDUSTRIES 
According to H. Mock21 several industries with comprehensive systems 
of industrial medicine and surgery have been practicing the best forms of 
reconstruction of the disabled for many years, although their work was 
not so designated. In fact the medical staff of these concerns have devel- 
oped a more practical co-ordinated system of reconstruction than any 
yet devised by our government or any of the other nations in this war. 
The terms conservation and reclamation more clearly define the scope of 
their efforts in industry than do the terms physical reconstruction and 
rehabilitation. 
But whatever terms are used to designate this work the desired results 
can only be attained by a completely rounded out plan similar to that 
developed in these industries. It includes: (1) Prevention of disease and 
accident. (2) Constant health supervision. (3) Adequate medical and 
surgical care for all disabled. (4) Proper selection of work according to 
the physical qualifications of each individual, including properly chosen 
work for the handicapped men upon recovery. (5) Practical vocational 
training in the plant for men in new occupations, when the disability 
prevents return to the old job. (6) Sufficient compensation for the dis- 
abled man and his dependents to live on while he is undergoing 
reconstruction." 
On July 18, 1918, Dr. W. Gilman Thompson22 established a clinic for 
functional re-education of disabled soldiers in New York City, but it 
has also from the first dealt with civilian cripples. During the first 
year of the clinic's work, 1150 cases were treated of which about 50 per 
cent, were civilians. The clinic conducts departments of electrotherapy, 
thermotherapy, hydrotherapy, mechanotherapy and a social science 
department. Dr. Thompson writes that since February 15, 1921, the RETROSPECT AND PROSPECT 
85 
clinic is known as the Reconstruction Hospital and has treated more than 
3500 patients. It must be gratifying to Doctors Mock, Thompson and 
others that their ideals are being rapidly realized, since we are told by one 
of the leading advocates of the movement. Dr. John B. Andrews, 
Secretary of the American Associztion for Labor Legislation, says that 
since Congress has provided for federal-state cooperation in the work of 
rehabilitating injured workmen nearly half of the states have already 
taken advantage of the provision. 
Retrospect and Prospect.-It is less than 15 years since serious atten- 
tion has been paid to industrial hygiene in this country, but fortunately 
the effects of legislation and factory sanitation, together with the gospel of 
personal hygiene and higher standards of living conditions are already 
strikingly shown by a most marked decrease in the mortality from 
tuberculosis in eight of the most dangerous trades in the State of New Jersey. 
(See pages 733, 734.) 
Progress has crowned the efforts of those interested in the prevention 
of human waste in the industries, but much more remains to be done 
before we can claim that victory is in sight. It is one thing to enact laws 
for the protection of labor, but it is infinitely more important to see to it 
that existing laws are enforced, and if inadequate to secure the enactment 
of better laws. Even now, State laws lack uniformity and proper stand- 
ards for correct ventilation, illumination and sanitation of factories, 
mills, mercantile establishments and other workplaces, and much of the 
criticism the writer offered in his report of President Roosevelt's Homes 
Commission23 in 1908 is to a great extent even true today. 
Industrial diseases and accidents are everywhere assuming more and 
more importance and our knowledge should be based upon accurate data. 
In countries like Great Britain and Germany, where reports of certain 
diseases are compulsory, it is quite possible to secure reliable mortality and 
morbidity statistics. This is all the more important when it is remem- 
bered that even with the most complete statistics, it is extremely difficult 
to determine all the factors which influence the health and longevity of 
operatives. Great differences are found in the conditions under which 
the work is performed, some of which are entirely avoidable, while others 
are not, and it is hardly fair to characterize certain occupations as 
dangerous when experience has shown that no harm results when proper 
safeguards have been taken. In the consideration of this question the 
personal element of the workmen, their habits, mode of life, food, home 
environments, etc., cannot be ignored. 
There are a number of occupations in which the alcohol habit prevails 
to an unusual extent, perhaps because of the character of the work, perhaps 
as a result of association and it would not be just to attribute the ill health 
of the operatives altogether to the character of the employment. (In 
passing we may state that Prof. K. B. Lehmann in his recent text book 
(1919) on the Hygiene of Occupations, considers alcohol the most impor- 86 
ECONOMIC LOSS FROM PREVENTABLE SICKNESS AND ACCIDENTS 
tant of all industrial poisons.) Again many persons are engaged in occu- 
pations for which they are not physically fitted, while others ruin their 
health by vice, dissipation, improper food and insanitary environments at 
home. In addition to all this there are factors, such as water and soil 
pollution, for which neither the industry nor individuals are primarily 
to blame (hookworm, typhoid fever, malaria, etc.). All this indicates 
the need of a thorough study of the conditions affecting health in the 
various occupations, not only to determine the relative health risks, and 
the causes of the. undue prevalence of certain diseases in the industries, 
but also to formulate rules which may remove the causes or render the 
system better fitted to resist them. In this, as in all preventive efforts, 
a hearty cooperation of the parties interested is absolutely essential for 
the attainment of the highest measure of success. In this instance the 
responsibility rests with the State, the employer and employes, and the- 
physician; each have certain duties to perform, and the help of all is- 
essential for the mitigation of existing evils. 
REFERENCES 
1 U. S. Commission on Industrial Relations. Final Report 1913-15, Vol. I, page 124,. 
cited by E. L. Fisk. 
2 Met. Life Ins. Co., 1919, page 28 tab. cited by Fisk. 
3 Dublin, Louis I. and Jessamine Whitney. On the Cost of Tuberculosis. Amer. Statist. 
Assoc. Quarterly; Dec., 1920, pages 441-50. 
4 Hoffman, Frederick L., A Plea for the Eradication of Malaria, etc. Address read 
before the Southern Med. Assoc., Nov. 14, 1916. Reprint Prudential Press, Newark, N. J., 
1917, pages 46-48. 
6Dowling, Oscar, Sociological Aspects of Hook-worm Disease. Am. Jour. Med. Sc., 
July, 1920, pages 595-98. 
6 Ferrell, John A., Hook-worm Disease, Its Ravages, Prevention and Cure. South 
Carolina Board of Health, Columbia, 1918. 
7 Ashford, Bailey K., Parasites and Occupation, Kober and Hanson, Diseases of Occu- 
pation, etc., page 181. 
8Bureau of the Census Mortality Statistics, page 30, 1918. 
9 Fisk, Eugene Lyman, Address Annual Banquet Life Extension Institute. Dec. 3, 
1919. Reprint pages 14-17. 
10 How to Live-A monthly magazine of Health and Hygiene, July, 1919. 
11 Brown, Hal., Factory, July 1, 1920, pages 55-56. 
12 Louis I. Dublin, Chairman. National Safety News, September, 1922, page 14. 
13 Roth, E. Trans. Internal. Congress on Hygiene, etc. Berlin 1907, Band II, page 
618. 
14 Rubner, Lehrbuch der Hygiene Wien 1900, page 701. 
15 Mock, Harry A., Reclamation of the Physically Handicapped. J. A. M. A., Nov. 20, 
1920, page 1046. (Cited by Fisk.) 
16 Drinker, C. K., and K. R., The Economic Aspect of Industrial Medicine. Jour. 
Indust. Hygiene, June, 1920, page 63. (Cited by Fisk.) 
17 Crum, Frederick S., Public Accidents and their Cost. Eighth Annual Safety Congress- 
Proceedings of the National Safety Council, 1919, pages 1061-64. (Cited by Fisk.) 
18 Bach, E. E., 8th Annual Safety Congress Proceedings of the National Safety Council,. 
1919, page 849. 
19 Penna. Dept, of Labor & Industry, Bureau of Workmen's Compen. Report. 
20 National Committee for the Prevention of Blindness. Eye Hazards in Industrial 
Occupations. Publ. No. 12, page 113. 
21 Mock, Industrial Medicine and Surgery. Wm. B. Saunders Co., 1919, page 785. 
22 Thompson, W. G., Personal Communication, July 21, 1921. 
23 Senate Document No. 644, 60th Congress 2nd Session. Government Printing Office, 
1909. CHAPTER V 
GENERAL WELFARE MEASURES FOR WAGE-EARNERS 
GEORGE M. KOBER, M. D., Washington, D. C. 
Sufficient evidence has been adduced and more will be presented in 
subsequent pages to indicate that the laboring classes need special protec- 
tion against the many occupational hazards and injurious environments 
to which they are exposed. This protection should emanate from the 
State, the employers, the community and the employes themselves. 
Each has certain duties and responsibilities, and for success coordination 
and cooperation are essential. The protection of wage earners should 
extend to the work and workshop, and in case the employes are housed 
by the employer also to the living and sleeping quarters, mess rooms, 
etc. (For protective legislation, see pages 1002-1019 and Introduction.) 
What the Federal Government May Do.-Much excellent work has 
been and is being done by the United States Department of Labor and 
Public Health Service, in the collection and publication of facts concern- 
ing every phase of industrial and social betterment. The bulletins issued, 
if carefully read, cannot fail to exert a tremendous educational influence 
upon those for whom they are primarily intended, viz., the wage earners 
and employers. But, while much has been achieved, more remains 
to be accomplished. It has been suggested that apart from establishing, 
in connection with the National Museum, a permanent exposition relating 
to industrial betterment of wage earners, it is clearly the duty of the 
Federal Government to establish and adopt a standard of industrial 
hygiene for all the government workshops. 
President Roosevelt, in a message to Congress, Dec., 1907, has said 
"the National Government should be a model employer. It should 
demand the highest quality of service from each of its employes, and it 
should care for all of them properly in return " 
We regret to say that, with the possible exception of the extraordinary 
precautions exercised to protect the health of the employes in the 
operations connected with the construction of the canal on the Isthmus of 
Panama, the sanitation of offices and workshops for Government em- 
ployes is not even on a par with some of the best private industrial con- 
cerns of this country. There can be no question that model government 
workshops, and efforts for the promotion of the general welfare of the 
employes, would prove a salutary precept and example. The General 
Government is not in a position to legislate for the States, but it can 
at least enact a model labor and factory law for the District of Columbia 
87 88 
GENERAL WELFARE MEASURES FOR WAGE-EARNERS 
and all of the workshops connected with the Army and Navy arsenals 
-gun factories, powder depots, and clothing depots-and for the im- 
mense army employed in the Postal Railway Service, Post offices, and 
other governmental offices, workshops of the Bureau of Engraving and 
Printing, etc. A commendable beginning has recently been in general 
welfare work for employes of the Post Office Department under the 
direction of Dr. Lee K. Frankel of the Metropolitan Life Insurance 
Company. The Federal Government is already doing excellent work 
in the U. S. Public Health Service, the Departments of Labor and of 
Agriculture in general sanitation, disease control, vital statistics, in- 
dustrial hygiene, infant welfare and maternity work, health education, 
housing, pure food and drugs, etc., work which should be coordinated 
in a Federal Department of Health or Public Welfare. (See also 
Chapter VI.) 
Industrial Insurance.-While the Federal Government in 1916 
enacted a model compensation act for civilian employes, there is need 
for a more adequate system of relief in case of disability from disease 
or injuries contracted in the line of duty, and thus initiate a system which 
has proved to be a veritable blessing elsewhere. Under the operation of 
the German law, enacted in 1883, all workmen employed in commerce, 
industries and the handicrafts, whose income is less than 2000 marks (about 
$480), must be insured. By special regulation this requirement may be 
extended to agricultural and household employes. To secure the enroll- 
ment of individuals for "sick benefits," the employers, in the industries 
subject to the law, are required to send to the proper insurance fund the 
name of each person who enters or leaves their service. The income of 
the sick fund is partly derived from the dues of members. The amount is 
fixed by each local association, but cannot exceed 6 per cent, of the 
members' wages. The .employe pays two-thirds of the dues and the 
employer one-third. The employe's share is deducted from his wages 
and paid directly to the insurance fund by the employer, when he remits 
his own share. 
A detailed account of the operations of this system will be found in my 
report as Chairman of the Committee on Social Betterment of the Presi- 
dent's Homes Commission, 1908, page 87, from which the following 
synopsis of practical results is here reproduced. 
1. At the end of 1905, in all 70,000,000 pensioners (sick, injured, 
invalids and their dependents) had received $1,200,000,000 in benefits. 
The workmen have contributed less than one-half of the premiums and 
have received $480,000,000, more than they paid out. Property is 
owned to the amount of $408,000,000, of which $120,000,000 has been 
invested in workmen's dwellings, hospitals and convalescents' homes, 
sanatoria, baths and similar institutions of welfare. 
2. The financial status of the workingmen has been improved at 
least to the extent of the benefits received from the amounts contributed INDUSTRIAL INSURANCE 
89 
by the employers and the Government. Experience has shown that 
employers have not deducted their share of the dues from wages. 
3. The hygienic conditions of the workingmen have been improved, 
both on account of the safeguards which the accident insurance organi- 
zations require employers to use and because of the special efforts made 
by the "sick funds" to reduce the sick rate among the members to a 
minimum. The general knowledge in regard to the preservation and 
promotion of health, which the "sick fund organization" has dissemi- 
nated by means of circulars, monographs, popular lectures, etc., has 
exerted a tremendous educational influence in the promotion of health 
and morals. 
One of the most beneficent features of the entire system has been that 
parts of the funds of these organizations are invested in model houses for 
wage earners, and hospitals and sanatoria for the use of members. It is 
interesting to note that the Prussian "insurance institute and sick funds" 
in 1907 alone maintained 28 hospitals and sanatoria, the latter chiefly for 
consumptives and convalescents. One of the latest features was the 
establishment at Lichtenberg, near Berlin, of a special hospital for sexual 
diseases in the male, and a sanatorium for nervous and anaemic female 
wage earners in Pyrmont (Hannover), all upon the principle that it is in 
the highest degree good economy to restore as speedily as possible the 
unproductive to the ranks of the producers. 
The writer has purposely devoted much space to the German Indus- 
trial Insurance system, because he realizes that sickness and funerals are 
the most potent causes of poverty and distress, and that worry and 
anxiety often retard convalescence. He knows, from personal knowledge, 
that prior to 1883 Germany depended upon employers' liability laws, 
charitable organizations, and private companies for the protection of her 
wage earners, with very questionable results. While much has been 
achieved in other directions for the prevention of disease, the most dis- 
tinct gain in social political endeavors was made by the enactment of these 
laws, and especially the law of June, 1889, authorizing "insurance insti- 
tutes" to invest part of their funds in hospitals and sanatoria, thus 
affording the best possible facilities for speedy recovery, and the preven- 
tion as far as practicable of permanent disability. 
What the Employer May Do.-Social betterment cannot be disas- 
sociated from industrial betterment, and it is here that the employer can 
do much for the welfare of his employes. Apart from a cheerful com- 
pliance with the laws and ordinances which may, from time to time, be 
enacted for the protection of the working classes, it is clearly the duty 
of the employer to promote in every way the efficiency and earning power 
of the wage earner, and to pay such wages as are necessary to improve 
the standard of living among poorly paid employes. 
In occupations involving exposure to industrial poisons it is a doubtful 
policy to employ casual labor or to attempt the instruction of new labor- 90 
GENERAL WELFARE MEASURES FOR WAGE-EARNERS 
ers. It has been shown over and over again that accidents and cases of 
industrial poisoning are less liable to occur in experienced workers. Hence 
it is far better to take precautionary measures in the first place, and in 
case of an impending breakdown to consider the question of 11 change of 
work instead of change of workers." 
There is no doubt that thoughtful employers generally realize that 
they are not only responsible for the proper technical training of appren- 
tices but also for their habits, and a gratifying number of establishments 
have made efforts to surround them with opportunities for mental, 
moral and physical improvement. There is a class of youthful employes, 
both males and females, for whom the writer begs to enter a special plea; 
they are entitled to every consideration, because, either as a result of 
inheritance or faulty environments, they have acquired a general inapti- 
tude; they are perfectly willing to work, but awkward in all their move- 
ments-simply do not know how to work-and special pains should be 
taken to teach them by patient fellow-workmen. 
Industrial Betterment.-Space will not permit to enter into details 
concerning efforts which have been made by employers at home and 
abroad in the promotion of the general welfare of the working classes. 
Every effort in the right direction results in the health and efficiency of 
employes being promoted, the profits of the manufacturer increased and 
the quality of the products improved. 
Among the most important betterments may be mentioned: (1) the 
increasing of industrial efficiency, through industrial schools and manual 
training classes; (2) the care for employees' health and comfort by means 
of bathing facilities, gymnasiums, calisthenics, base ball, bicycle clubs, 
dining and lunch rooms, and the furnishing of hot lunches, free or at 
cost-some establishments even permit dancing during the noon hour- 
improved sanitary conditions and appliances, lectures and demonstra- 
tions, medical supervision; (3) the improvement of domestic conditions 
by means of improved dwellings, instruction in sewing, cooking and house- 
keeping, in landscape and kitchen gardening, and in exterior and interior 
decorations of homes; (4) the care of sick and disabled employes by 
means of rest rooms, emergency rooms, first-aid outfits, medical attend- 
ance and hospital facilities, free insurance, and by the encouragement of 
beneficial organizations; (5) club organizations for social, recreative and 
intellectual purposes, by means of free lecturers, libraries, kindergartens 
and educational classes, social gatherings, summer outings, meeting places, 
game rooms, banquets, dances, etc.; (6) the encouragement of musical 
and dramatic clubs and the promotion of spiritual life by means of Sunday 
schools and general religious work; (7) the cultivation of thrift through 
savings bank facilities, building associations or provident organizations, 
rewards for valuable suggestions of employes, for faithful service, or 
the manifestation of zeal and interest in their employment; (8) the pro- 
motion of employes' personal interest in the successful conduct of the PUBLIC RESPONSIBILITY-HOUSES FOR WAGE-EARNERS 
91 
business by encouraging and assisting them to purchase shares, financial 
aid to employes in case of unusual hardships and distress, and the 
cultivation of cordial and even confidential relations between employer 
and employe. 
What the Public May Do.-It will be conceded that the burdens of 
improving industrial and social conditions should not be carried by the 
employers and employes alone. There are many phases of importance, 
from the standpoint of public health and humanity, which should concern 
every thoughtful man and woman. Reference has already been made to 
the dangerous conditions under which many of the trades and occupations 
are carried on in tenement houses. While this is in part due to the greed 
of the manufacturer, because it means less factory space, less rent, light, 
fuel, and a decidedly smaller pay-roll, the consumer is equally to blame 
because of his constant demand for cheaper goods, quite oblivious to the 
fact that the garments may be a source of danger from infectious dis- 
eases, and are stained with the sweat and blood of helpless women 
and children. 
During one of the Presidential campaigns a clever orator referred to 
Glasgow, and told us that 41,000 of the 100,000 laboring families of that 
manufacturing center lived in one-room tenements, and that this one 
room for a family of father, mother, daughter and sonstold what the wages 
in Scotland were and how they dragged humanity down into bestiality 
and misery. It must be confessed that similar conditions obtain in nearly 
every American industrial city. The effects of such living conditions upon 
death rates will be presently referred to. In the meantime, it will be 
readily conceded that the people do not as a rule live in such quarters 
from choice, but from sheer necessity. Low wages not only compel the 
working classes to find shelter in houses unfit for human occupation, but 
also affect their health and the health of their children by insufficient food 
and clothing; and, last but not least, it means the utilization of child and 
female labor. 
It is to be hoped that public conscience may be sufficiently aroused to 
insist upon adequate wages for all classes, and that the producer and con- 
sumer alike will be willing to assume this responsibility, not as a matter of 
charity, but in justice to the laboring classes. 
Houses for Wage Earners.-In the whole range of social betterment 
and sanitation, especially in our efforts to combat tuberculosis, -no field 
affords better opportunity for philanthropic work than the erection of 
sanitary homes for wage earners, at reasonable rentals, the encouragement 
of cooking schools and the establishment of model lodging and eating 
houses. The Washington Housing Companies have an investment of 
over $1,000,000, have paid 5 per cent, annual dividends, from the very 
inception of the company, and have a surplus fund of over $400,000 to 
provide for physical deterioration. London has more than $100,000,000 
invested in model tenements. 92 
GENERAL WELFARE MEASURES FOR WAGE-EARNERS 
The housing of the working classes has very properly been made the 
subject of legislation in many countries, and is a matter in which factory 
owners, labor unions, and the general public, should be deeply and mutu- 
ally interested. There are several systems of dwellings for artisans and 
laborers, viz., individual houses or cottages, rows of houses under one roof, 
and the so-called "flat." Preference should be given, when practicable, 
to the cottage system, but in large cities, unfortunately, the value of real 
estate frequently compels the erection of large tenements. In such an 
event the State should insist upon hygienic requirements as regards air- 
space, light and ventilation. No home can be considered sanitary where 
one room has to answer the purposes of living room, sleeping room and 
kitchen, or where the water-closet or privy is used by more than one 
family. 
With the present rapid transit facilities, in every city, our voice should 
be clearly in favor of individual homes; and when this is impracticable, we 
should insist upon broad streets and deep yards. No more than 68 per 
cent, of the lot should be covered by the house, and the height of the 
building should never exceed the width of the street. The baneful effects 
of tenement houses should be avoided, as infectious diseases are more 
liable to spread, in consequence of aerial infection and a more intimate 
contact of the occupants. 
Apart from structural defects, there is no doubt that the death rate is 
largely determined by the number of occupants to a room. Russell has 
shown that in Glasgow, when the average number of persons to each 
room was only 1.31, the mortality was 21.7 per 1000, and when the 
number of occupants amounted to 2.05 for each room, the mortality 
reached 28.6 per 1000. 
The death rate at Berlin, in 1885, among the 73,000 one-room tene- 
ments was 16.35 per 1000, against 5.4 per 1000 among 308,000 residents 
occupying four or more room apartments. Neumann, in investigating 
2711 infantile deaths in Berlin, found that 1792 occurred in one-room 
apartments, 754 in two-room apartments, 122 in three-room apartments, 
and 43 in apartments of four rooms and over. 
Insanitary dwellings are to be found everywhere, particularly in older 
cities erected at a time when the principles of sanitation were compara- 
tively unknown. One of the most important municipal problems is to 
correct-existing evils by the enactment and enforcement of suitable laws. 
It requires, however, a strong public sentiment to bring about a complete 
and satisfactory reformation, as evidenced by the housing movement 
everywhere. 
The housing conditions of the least resourceful people have been, and 
are even now, more potent than any other factor in helping to swell the 
frightful mortality from consumption and other so-called house diseases 
engendered by unwholesome environments. The existence of disease- 
breeding habitations is a reflection upon Christian civilization, and there LODGING HOUSES, ETC. 
93 
should be sufficient human sympathy to provide decent, healthful homes 
for our wage earners, who constitute, after all, the bone and sinew of the 
country. This is one of the occasions when we may well act as our 
brother's keeper. 
The history of improved dwellings reveals everywhere a lessened death 
rate, and the experience of the Washington Sanitary Improvement 
Company is equally gratifying. 
The regeneration of the housing conditions for the least resourceful 
people is the great sanitary and social problem of the twentieth century. 
Take away the hovels and filthy places, let sunshine and pure air circulate 
through the homes, and teach them habits of cleanliness and responsi- 
bility, and the first step toward the elevation of the degraded and the 
education of the ignorant will be taken, not only in the warfare against 
tuberculosis and other diseases engendered by insanitary surroundings, 
but also in the battle for a higher moral and social standard. 
Lodging Houses or Homes for Wage Earners.-Those who have read 
"The Long Day" cannot fail to be impressed with the just criticism of our 
present system of homes for working girls. The author makes a strong 
plea for homes designed after the Mills Hotels for working men; no 
charity, but so built and conducted that they will pay a 4 per cent, rate 
of interest upon the money invested. "A clean room and three whole- 
somely cooked meals a day can be furnished to working girls, at a price 
such as would make it possible for them to live honestly on the small 
wages of the factory or store." It is to be hoped that the simple but 
truthful story of the working girl will be read and her appeal for industrial 
and social betterment answered. To supply the need spoken of, together 
with the establishment of cooking schools, and kindergartens, so that 
the children of toil may at least have an opportunity to learn to 
work intelligently, may be regarded as a suitable field for practical 
Christianity, and would do much toward narrowing the breach which 
now exists between the church and wage earners, and between capital 
and labor. 
While the character and variety of the food now served in boarding 
houses is very much better than it was years ago, it is not what it should 
be. The chief fault consists in improper cooking, and the widespread 
error of consuming a cold meal from the lunch or dinner bucket. 
The art of cooking, and how to supply good wholesome food in proper 
quantities, should be made the subject of popular instruction. The 
"Ladies Sanitary Association of England" deserves credit for having 
taken this matter in hand, especially since experience teaches that nothing 
prevents the abuse of alcohol so much as a sufficient and palatable supply 
of food. 
The establishment of public kitchens and eating houses for unmarried 
laborers, conducted upon practical sanitary and economic principles, 
would prove a great blessing. 94 
GENERAL WELFARE MEASURES FOR WAGE-EARNERS 
What the Employe May Do.-It must be conceded that all methods 
proposed for the alleviation of the effects of adverse working conditions 
are prompted by the spirit of humanity and as a social duty. Hence it is 
reasonable to expect that wage earners should in every way cooperate and 
avail themselves of the various safety devices and preventive methods and 
not underrate their importance in the protection of health, life and limb. 
While it is criminal for employers not to provide suitable protection 
it is equally culpable on the part of the operatives to disregard such 
preventive measures. So, for example, it is not a pleasing reflection when 
we are told by the Medical Inspectors of the State Board of Health of 
Massachusetts, that a considerable number of employes remove the 
hoods over emery wheels on the ground that they interfere with their 
work, and that they insist iron enriches the blood. Professor Harrington 
in speaking of respirators says, "Aside from the discomfort caused, the 
operatives have another and a senseless objection to their use, women 
complaining that they are made to look ridiculous, and men being moved 
to discard them by the jibes of their more reckless fellows." Dr. Farrand, 
former Secretary of the National Association for the Study and Preven- 
tion of Tuberculosis, spoke to me of the great difficulties he and others 
had encountered, in New York and New Jersey, in inducing the operatives 
to give safety devices a fair trial. My personal experience and that of 
other social workers has at times been equally discouraging. Time and 
again have the good intentions of employers been frustrated by "self- 
willed" workmen, who professed to know better. Even in Government 
arsenals I have found men working in high explosives without rubber 
gloves and respirators, although provided by the Government. 
With time and patient education these difficulties are surmountable, 
and it is just here that the intelligent worker, the man who appreciates 
the value of his health and his duties to his family, will prove an efficient 
coworker in the prevention of misery and distress. In this connection 
I cannot resist making a strong plea for "economy and thrift," so that 
it may be possible for every family to own their home. It involves much 
self denial, but it can be done with all its resulting blessings, as I know 
full well from personal observation. CHAPTER VI 
FEDERAL, STATE AND LOCAL HEALTH AGENCIES IN PRO- 
MOTING INDUSTRIAL HYGIENE 
J. W. SCHERESCHEWSKY, M. D„ Washington, D. C. 
There is imperative need for a constructive national policy for the 
better protection and conservation of industrial health. What we must 
aim at is the application of the principles of public health science to the 
field of industry so as ultimately to secure for all workers practically 
the same measure of health protection no matter in what part of the 
country they live. It is evident that in attaining this end Federal, state 
and local health agencies must play an interlocking and coordinated 
part in improving health conditions, so that overlapping may be pre- 
vented, no power usurped and yet each governmental agency perform its 
full duty. 
It is my purpose to discuss briefly possible Federal activities in con- 
nection with state and local governmental agencies. It will not be 
possible to discuss the exact scope of the functions of these separate 
agencies of government independently as they are necessarily so related 
and intertwined that this is impracticable. 
Commencing then with the Federal government, this has a most 
important part to play because improvement of industrial health, having 
a profound influence on national welfare, is a national concern. It must 
be borne in mind that the extent to which the Federal government 
may act is limited by the constitution. Under these limitations the 
powers of the Federal government are investigative, advisory, coopera- 
tive, and, to a certain extent, regulatory. So far as regulatory powers 
are concerned, these are not fully defined. Thus, the Federal government 
has certain regulatory powers, particularly in relation to taxation, the 
control of maritime and interstate traffic, the spread of disease through 
interstate channels and matters concerning the national defense. These 
matters involve the exercise of the Federal police power. Yet, we all 
know, that under usual conditions the intrastate enforcement of regula- 
tions for health protection is accomplished by the police power of the 
states. This is a feature of the American system of government, and, 
generally speaking, when the Federal government does exercise sanitary 
police power in intrastate matters, it does so at the request of a state and 
with power voluntarily delegated to the Federal government by the state. 
In reality the regulatory power of the Federal government is coextensive 
with public opinion. If in the future public opinion demands an exten- 
sion of the Federal powers of regulation, in so far as health matters are 
95 96 
FEDERAL, STATE AND LOCAL HEALTH AGENCIES 
concerned, we may expect either a broader interpretation of the consti- 
tutional powers of the Federal government, or such constitutional amend- 
ments as may be needed. 
But I wish to emphasize, in this connection, that in our country, what 
we need is not so much an extension of Federal authority in health 
matters, as the development of a sense of responsibility for good health 
conditions in the people of the state and locality. It is the development 
of this sense of responsibility which will enable the Federal government 
to play its really powerful and useful part in improving health conditions 
generally. 
Taking the existing health powers of the Federal government; these 
in the main are exercised through the United States Public Health Service, 
although, other Federal Bureaus, such as the Bureau of Chemistry in the 
Department of Agriculture, the Children's Bureau and the Bureau of 
Labor Statistics in the Department of Labor, have activities more or 
less related to the public health. 
The United States Public Health Service is already clothed with all 
the power and authority which, under the Constitution, may be given to 
a Federal health agency. The only limitations on its activities are 
constitutional limitations and the extent of the appropriations granted 
by Congress. 
Under these powers the Public Health Service is authorized (a) to 
investigate any and all disease producing conditions; (b) prevent the 
spread of disease through interstate channels; (c) prevent the introduction 
of disease into the country from without; (d) cooperate with and aid state 
and local authorities in carrying out health measures; (e) disseminate 
information to the public. 
With these powers the Public Health Service may perform the follow- 
ing important functions in a national program for improving industrial 
health. This program has already been published in supplement No. 
36 to the Public Health Reports of May 9, 1919, as part of a general health 
program to meet after-the-war-needs proposed by the Public Health 
Service. This program was presented to Congress by the secretary of 
the treasury with an urgent appeal to provide the funds for carrying it 
out. So far, Congress has not appropriated the funds. 
The section of the program dealing with industrial health is as follows: 
(a) Continuing and extending health surveys in industry with a view to deter- 
mining precisely the nature of the health hazards and the measures needed to correct 
them. 
(6) Securing adequate reports of the prevalence of disease among employes and 
the sanitary conditions in industrial establishments and communities. 
(c) National development of adequate systems of medical and surgical supervision 
of employes in places of employment. 
(d) Establishment by the Public Health Service, in cooperation with the Depart- 
ment of Labor, of minimum standards of industrial hygiene and the prevention of 
occupational diseases. HEALTH SURVEYS-MORBIDITY REPORTING 
97 
(e) Improvement of the sanitation of industrial communities through cooperation 
of the Public Health Service, state and local health authorities and other agencies. 
(/) Medical and sanitary supervision by the Public Health Service of civil industrial 
establishments owned or operated by the Federal government. 
Let me supplement this program by the following brief discussion of 
its features: 
Health Surveys of Industries.-While the general enactment of com- 
pensation laws has fostered to a considerable extent the study of indus- 
trial accidents and their causes, and is rapidly fostering a movement to 
inaugurate, on a nation-wide scale, measures for the rehabilitation of 
industrial cripples, even now there is little actual information available 
for the United States of the real occupational hazard, apart from accident, 
and the weighting in order of relative importance of their underlying 
factors. Federal and state agencies have made intensive studies of 
certain industries, for instance, the lead, steel and chemical industries, 
but surveys of truly national scope are still lacking. 
Evidently it is not sufficient to study an industry locally. Surveys 
must be extended to cover all typical geographical locations of the indus- 
try under consideration in order to determine the differences, if any, of 
its essential occupational hazards because of variations in location, type 
of management provisions for health protection, type and degree of local 
health organization and the like. 
Besides the crying need for a comprehensive knowledge of our present 
industrial fabric we must remember that many new industries have been 
established as a result of the war which will become permanent features in 
the United States. It is essential to familiarize ourselves with these 
industries from the standpoint of industrial health. 
Industrial Morbidity Reporting.-It is superfluous for me to dilate on 
the importance of industrial morbidity statistics and their indispensibility 
in any serious attempt to improve the industrial health of the nation. 
While occupational diseases have been made reportable in a number of 
states, the reports secured up to the present are lamentably casual and 
desultory. So long as such reports rest upon the voluntary act of 
physicians, and so long as physicians themselves are interested more 
in the treatment of diseases than in their causes, advance will neces- 
sarily be slow. 
It is evident that the United States Public Health Service may play 
a most useful part here by stimulating and aiding in the collection of such 
statistics and in acting as a clearing house for the dissemination of the 
information so obtained. 
Real progress will only be made, however, when assistance can be 
given directly to states to enable them to collect the information and 
forward it to the central office in Washington. In view of the fact, 
however, that the police power, in the regulation of intra-state health 
matters is exercised by the states, it is most desirable that the primary 98 
FEDERAL, STATE AND LOCAL HEALTH AGENCIES 
collecting agency should be the state, aided and stimulated by the 
Federal agency. 
ADEQUATE SYSTEMS OF MEDICAL AND SURGICAL SUPERVISION OF 
INDUSTRIAL WORKERS 
The keynote of such systems is health service. Above all, health 
supervision of industrial workers is not a means to select the fit, and to 
reject the unfit, but an effective instrument in the proper application of 
national man-power by inducing a positive condition of health in TOO 
per cent, of the workers. As part of such systems of medical and surgical 
supervision, I can foreshadow the general establishment, in industrial 
centers, of industrial clinics to which cases may be referred by the medical 
organizations in plants. 
It is evident that such health services are primarily to be established 
by the industries themselves. By their establishment we sense the 
recognition on the part of industry of their share in the responsibility 
for improving industrial health. The industry helps the worker to keep 
well so that the nation, the industry and the individual are all benefited. 
This sense of responsibility is felt, and health services are actualities in 
large numbers of progressive establishments already. Such projects 
may stand on a permanent and nation-wide foundation only when they 
fill existing needs without superfluity. What the Federal health agency 
may do best here is to study and standardize such systems, outlining the 
best methods, and creating a demand for the qualified personnel neces- 
sary for carrying these into effect. 
States may help by exercising their police power, in framing regula- 
tions for such services, and in cooperating with industrial communities 
in establishing industrial clinics. 
ESTABLISHMENT OF MINIMUM HEALTH STANDARDS 
The necessity for minimum health standards with which to work is self 
evident. Much of state legislation relating to the protection of industrial 
health is vague in its specifications. 
Much research is still required to formulate practicable standards for 
existing industries, and to keep pace with the introduction of new indus- 
tries and new processes. The Federal government is the standard- 
making body par excellence. It is without bias, and desires nothing but 
the truth. So far as appropriations have permitted, some work of this 
character has already been begun by the Public Health Service. If it is 
to become comprehensive in its scope much greater appropriations are 
required than have hitherto been granted by Congress. 
IMPROVEMENT OF THE SANITATION OF INDUSTRIAL COMMUNITIES 
We have seen that, under existing law, the Public Health Service is 
empowered to aid and cooperate with state and local health authorities CIVIL INDUSTRIAL ESTABLISHMENTS 
99 
in improving health conditions. Congress has already made modest 
appropriations to enable the Public Health Service to cooperate with 
these authorities in improving rural health. 
The results in rural districts, where Federal aid has been extended to 
build up a local health organization, have been highly satisfactory, and 
often spectacular. Moreover, instead of increasing local dependence 
upon Federal aid, it has had the effect of stimulating these rural com- 
munities to extend and perfect the health organization the government 
has assisted them to establish. 
I believe that a similar system applied to industrial communities, in 
cooperation with states, will aid greatly in improving the insanitary con- 
ditions all too prevalent in many of our industrial centers. Moreover, the 
cooperation of the Federal government in such enterprises is abundantly 
justified because the benefits reaped are not solely enjoyed by the com- 
munity, but by the nation as a whole. 
CIVIL INDUSTRIAL ESTABLISHMENTS OWNED AND OPERATED BY THE 
FEDERAL GOVERNMENT 
Finally, I should say a word about the medical and sanitary super- 
vision of civil industrial establishments owned or operated by the Federal 
government. During the war the number of these was greatly increased. 
Since the armistice, however, the number, although exceeding that of 
pre-war times, has considerably diminished. While we were at war the 
Public Health Service supervised the sanitation and medical service in as 
many of these establishments as possible, but was much handicapped 
because of the great shortage of medical personnel. 
Since the Federal government is the greatest employer of the country 
it is but fitting that it should be a progressive employer and do for its 
employes what any progressive private corporation would do. Yet it 
must be admitted, up to the present time, the provisions made for the 
sanitary and medical supervision of the civil industrial establishments 
owned or operated by the Federal government fall below the standard 
maintained by numerous private corporations. 
The results obtained by the Public Health Service during the war in 
the sanitary and medical supervision of such establishments are abundant 
justification for their continuation and extension. It is earnestly to be 
hoped that the way will be found to enable the Federal government to 
become a model as an industrial employer for all private corporations. 
Such then is the program of the United States Public Health Service 
for the improvement of industrial health. We have seen that this con- 
sists essentially in investigations, leadership, advice, education, coordina- 
tion of effort and cooperation. The intention is to supplement, not 
supplant state and local government. The authority under law to play 
this important part is already in existence, all that is needed is money and 
the acquisition and training of the necessary personnel. 100 
FEDERAL, STATE AND LOCAL HEALTH AGENCIES 
There is, at present, in the states and communities a great need for 
the coordination of their own health activities, so far as the improvement 
of industrial health is concerned. While general health functions are 
exercised by state health departments, and in communities by local 
health departments, supervision over industrial health is exercised by 
state industrial commissions, state departments of labor or state depart- 
ments of factory inspection. In local health organizations little or no 
provision is made for the improvement of working conditions. There is 
great need for change and improvement here. 
Since the public exercises, as a rule, its police and regulatory powers 
through the state machinery, the pressing need, so far as states and com- 
munities are concerned is to improve and coordinate their organizations 
to this end. The program of the Public Health Service, if carried out in 
the manner discussed, will provide a basic knowledge of conditions 
requiring remedy, and furnish minimum health standards. If states 
and communities will assume their share of the responsibility they will 
provide the funds and machinery to put these standards into effect. 
In this manner, so far as geographically practicable, uniform working 
conditions and effective means for the conservation of industrial health 
will prevail. Yet we must keep ever in mind that the purpose of any 
health organization, Federal, state, or local, is not to multiply upon the 
statute books unnecessary laws, nor to develop political organizations, 
but to become administrative agents of the public purpose, now approach- 
ing realization, to translate into deeds the newly developing sense of 
responsibility for local health conditions, to help realize, so far as possible, 
uniform health conditions, and a favorable environment for the growth 
and development of the present and future generations. CHAPTER VII 
THE FUNCTION OF THE MILAN CLINIC IN THE PREVENTION 
OF OCCUPATIONAL DISEASES : ITS ORIGIN, PURPOSES 
AND ACTIVITIES 
PROFESSOR DR. L. DEVOTO, Milan, Italy 
Since the very first days of the reign of Victor Emanuel III, public 
opinion has been interested in vital hygienic and social problems. Much 
has been said on malaria and the Roman waste-lands; on pellagra and the 
work in the rice fields and in the mines; on woman's and children's work; 
on Government inspection of labor; on accidents in general; and on assis- 
tance to invalids and to the aged poor. The discussions were so wide 
and conclusive as to gain, between the years 1901 and 1902, the approval 
by Parliament of a series of social laws intended to remedy those painful 
conditions. 
It was in that period that the city of Milan elaborated comprehensive 
regulations imposing on the city factories those strict hygienic rules that 
later were highly commended by the Government, and by the adminis- 
tration of other cities. Then followed the foundation of several institu- 
tions in Milan, which afforded physicians the opportunity of perfecting 
and specializing their knowledge; among these is the Clinic for Occupa- 
tional Diseases. 
The purposes of the Clinic are as follows: To study scientifically the 
causes of occupational diseases and to spread its clinical knowledge 
among physicians; to gather in the Clinic all workmen apparently or 
decidedly affected by occupational diseases, whether in incipient or 
advanced stage, for the purposes of diagnostical and therapeutical experi- 
ments, and to examine systematically the health conditions of workmen 
engaged in industries of all kinds, and especially those working in unhy- 
gienic occupations. 
After two years of political vicissitudes the Italian Parliament passed 
a law recognizing the Industrial Clinic Institutions as "Post-University" 
and authorizing them to award diplomas. 
In the year 1906 the First International Congress of Occupational 
Diseases was held in Milan and was a great success. This Congress, 
appreciating the vast importance of the industrial clinic-hygiene problems, 
suggested that the city secure larger ground for the erection of the Clinic 
than was intended and more means to provide it with a stronger scientific 
organization, which caused another delay. Finally in the month of 
101 102 
THE FUNCTION OF THE MILAN CLINIC 
December, 1907, the laying of the corner-stone took place, and the 
building, completely finished, was inaugurated March 20, 1910, The 
administration of the Institutes was entrusted to a Council of Members. 
Calling me to the Directorship of the Clinic in 1906,* the city of Milan 
gave me power to enter agreements for the construction and disposition 
of the building which has since been erected in an area of 5000 square 
meters, actually covering a surface of 1500 square meters in the center of 
the hospital district of Milan, and not far from the leading labor 
establishments. 
The Clinic consists of three buildings: 
1. Eight infirmaries and six isolating rooms of the capacity of 110 
beds with the necessary smaller rooms used for first analysis. 
2. Three physiopathological laboratories and one room for the study 
of experimental fatigue. 
3. Three bacteriological laboratories. 
4. Five chemical laboratories. 
5. Five pathological, histological and microscopical laboratories. 
6. Three roentgenological laboratories. 
7. An auditorium for 200 physicians and three demonstrating rooms. 
Large library. Archives room. Five rooms for the Professional Hygiene 
and Pathology Museum. Refrigerator room. Anatomic museum room. 
Autopsy room. 
The idea of having the autopsy and anatomic museum rooms in the 
same institute is worthy of the highest praise; it makes research easier and 
enables physicians taking the courses or working in the Clinic not only to 
watch the autopsy, but also to follow all the further investigations 
required for the anatomical diagnosis. 
The laboratories have proved to be of great value to the Clinic not 
only for clinical study but also for experimental and anatomopathological 
studies. It is now more and more realized that it would have been useless 
to establish a Clinic which represents a departure from trodden paths, 
and which faces, besides its difficult problems, a considerable amount of 
public diffidence, without furnishing it with an abundance of scientific 
material. Better not do anything than bring into existence an ill- 
appointed institution, especially in a city like Milan, where neither a 
Faculty nor clinical facilities existed, and where there were no laboratories 
available. 
Without counting the services kindly rendered by city officials, engi- 
neers, assistants and by all of the civil service workshops, the Clinic has 
cost over 1,000,000 lires, though the estimated expenditure called for a 
much smaller sum. 
* When in the year 1901 I was a Professor of Internal Pathology at the University of 
Pavia, I initiated a clinical course on Occupational Diseases which proved very successful, 
and started the publication of a review of Industrial Physiology, Pathology and Hygiene, 
by the title: "HLavoro" ("Work"). I left the University of Pavia in 1906 when the opening 
of the Clinic was approaching. DIDACTIC ACTIVITY OF THE CLINIC 
103 
As for me, who took upon myself a part of the responsibility for this 
excessive expenditure in the building of the Clinic, I feel that, if this 
attitude of mine has been wrong, there is but one way for me to make 
reparation, and that is to do all I can to make the Clinic as useful as 
possible to the workers of Milan. 
Ever since the opening of the Clinic I deemed it necessary to establish 
a special and active propaganda of hygiene among the working classes. 
The results obtained are indeed remarkable. 
The work is conducted in the following manner: 
1. By clinical teaching to physicians. 
2. By the treatment of the patients admitted in the Clinic. 
3. By scientific work in the field of occupational pathology. 
4. By consultations with and examinations of workmen; also by exer- 
cising a general control of their health and conditions. 
5. By inspections and investigations. 
6. By a popular propaganda of occupational hygiene. 
Rather than stop to say more in a general way on these activities, I 
will relate how they have been applied in these first few years of the 
existence of the Clinic. 
1. DIDACTIC ACTIVITY OF THE CLINIC 
For the Clinic to undertake the task of teaching physicians the 
treatment and prevention of diseases such as the so-called saturnism, 
mercurialism, anilinism, phosphorism, etc., and of all other occupational 
intoxications, including professional infections (anchylostomiasis, car- 
buncles, etc.) the neurosis due to mechanical work, caissonism, pneumoko- 
niosis, and miner's phthisis, is only natural. But a Clinic establishment 
for the purpose of diminishing the antiphysiologic factors of labor, for 
instructing physicians in that line, and for awarding diplomas has another 
field of action, which is less definite, as yet, but much more important. 
It is the valuation of the occupational factor, often concealed, which must 
be more deeply considered. When this is discovered, then the steps for 
prevention can be more easily taken. Here are some of the points which 
are frequently used as clinical illustrations and which lead us to affirm 
strongly: 
(a) That the relation between continual effort and alteration of the 
heart and of the blood-vessels is closer than generally believed. 
(6) That healthy persons who undertake hard work, without having 
the adequate physical resistance, are bound to suffer alteration or dis- 
placement of some organs. 
(c) That some visceral localizations of syphilis are related to abuse of 
strength; to local traumas. 
(d) That syphilis of unknown origin occurs quite frequently among 
workmen, and causes in those who labor at hard trades, syphilitic aortitis 
and syphilitic myocarditis. 104 
THE FUNCTION OF THE MILAN CLINIC 
(e) That hard labor may hinder, in workmen who have recently 
recovered from infective diseases, the restitution of normal functions of 
those organs which were involved by the infection (myocardium, 
lungs), and the possibility of latent myocarditis in workmen who were 
stricken in their youth by infectious diseases should be given care- 
ful consideration. 
(/) That a loose technical appreciation of the health conditions of 
boys and girls licensed to work, may cause serious disturbances. 
(g) That a wholesome occupation may still cause disturbances if the 
environment is unhygienic (dampness, poor light, insufficient air), that, 
very often, acute nephritis of grave prognosis occurs among workmen in 
places where the atmosphere is moist and cold, and persons who in 
the past, have had scarlatina, tonsillitis, pharyngitis, and perhaps, also, 
nephritis, benign or circumscribed, such cases should not be admitted 
to such occupations. 
(K) That work requiring strained positions must be done in short 
periods, alternated by exercise. 
(i) That occupational infantilism occurs oftener than it is believed. 
(J) That labor is to be considered as a factor capable of forming 
special clinical pictures. 
(k) That periods of labor of at least 90 to 120 minutes without inter- 
ruption very often excite in workmen occupied in hard trades, disorders 
of the digestive tract, just as happens among railway workers. 
Legislators may distinguish between diseases arising undoubtedly 
from work through poison and those due to the diffusion of bacteria, or 
those caused by intermittent or contingent factors, but we, as physicians 
who must look at diseases especially from the viewpoint of their cure, 
and above all of their prevention, and who live outside the pale of mere 
speculation, have no doubt that, admitting the necessity of an institute 
for this specific study and teaching and for the prophylaxis of labor 
diseases, it is the task of such a Clinical Institute to make researches for 
and seek the demonstration of the agent creative of the diseases, inas- 
much as it is centered in antiphysiological and antihygienic work. 
I am also hopeful that, little by little, the Faculty of the University 
Medical Clinics will come to see the necessity of helping their students to 
look at diseases from the point of view of the social influence, and to give 
them, besides the ordinary clinical lessons, those lessons that have far- 
reaching social import. 
The young physician and the student, if taught to analyze, with an 
objective, unbiased criticism, the causes contributing to the pathogenic 
forces, bad surroundings or unhygienical work, will certainly become a 
good clinic physician as well as a good social worker. 
The official lessons of the Director of the Clinic are public. They 
begin November 1, and end June 1. During the fall vacations, and also 
during the school year, rapid courses of professional pathology and ASSISTANCE TO PATIENTS 
105 
hygiene, of tuberculosis, pellagra, diagnosis, and the use of X-rays, are 
given, with the assistance of Professors attached to the Clinic. 
The fees range from 40 lires (without laboratory) to 480 (including 
laboratory) a year. 
To obtain a diploma, the physician must have attended all the courses 
of the Clinic for no less than 12 months, write an original thesis on an 
argument in harmony with the ultimate purposes of the Clinic, and pass 
a practical clinic examination, and a theoretical test as well. 
Out of the funds donated to the Clinic, it is possible for the Adminis- 
tration to award small scholarships to those civil service doctors who wish 
to complete, by clinical observation and laboratory research, the study of 
the cases of professional pathology which they meet in their daily practice. 
2. ASSISTANCE TO PATIENTS 
Workmen affected by direct or contributory causes arising from their 
occupations are taken in the Clinic: (a) To be treated; (&) to establish a 
diagnosis, when it is not possible to do so in the dispensary; (c) for teach- 
ing purposes (and I wish to say here that our working people willingly 
submit to such examinations when requested) although, whenever it is 
possible, we prefer out-patients. 
The Clinic rooms are very well aired, ventilated, heated and dusted 
(vacuum cleaner), and every bed has about 1200 cu. ft. of air-space; every 
ward has its own analysis room. 
It is superfluous for me to enter into the details of the different 
methods of treatment, for, as may be easily understood, they vary so, 
some being of a pharmacologic order, some of a physical order, etc., but 
I wish to say this, that all patients and their relatives are provided with a 
detailed account of the disease, and every person who is discharged from 
the Clinic, besides the better health that it has been possible to give him, 
also has the privilege of taking with him a good knowledge of hygienic 
rules which he may profitably impart to his fellow-workers. 
As a general rule, people affected by pulmonary tuberculosis are not 
admitted. Only for special didactic purposes are patients affected by 
pneumokoniosis and eventual tubercular processes admitted to the Clinic, 
and these are placed in the isolation rooms. 
The most important dispensary cases which have presented them- 
selves during the week are reviewed each Saturday and briefly discussed 
for the benefit of the physicians. 
The Clinic offers to its patients a large garden and several terraces. 
This is not the ideal. Italy, so far, has no convalescence or "Erholung" 
places, as the Germans have it, and something of that sort is needed for a 
Clinic which treats persons affected by apical catarrh, poor blood, states 
of neurosis, alterations of the cardiovascular apparatus, paralysis, etc., 
but I hope that in the near future we may have some ideal climatic 
balneological station on the Lake of Garda (90 minutes from Milan). The 106 
THE FUNCTION OF THE MILAN CLINIC 
owner of the Sirmione Station has already offered the Clinic a large piece 
of ground for that purpose, and if the plan can be carried out, the Station 
will remain open all the year round. In that vicinity there is also a spring 
of chlorosulphuric water, something like that of Aix-La-Chapelle, which 
is very good for cases of lead intoxication. The delightful climate of the 
spot would make the Station all the more beneficial. 
3. SCIENTIFIC PRODUCTION 
The Clinic's scientific production consists of researches, the findings of 
which are made known widely, so as to obtain the views of all physicians 
and institutions working in other fields, as well as those of the city doctors. 
The patients coming to the dispensary or received in the Clinic fre- 
quently offer splendid material for special research. I will here give a 
short account of what has been done up to the present time and of the 
results attained. 
Overexertion has been the object of many laboratory researches which 
are conducted as follows: histopathologically by Cesa Bianchi and by Preti, 
experimentally by Ciovini, immunitarily by Vallardi, and chemically by 
Preti; all these led us to ascertain: 
1. That work, even when very hard, does not produce immunitary 
reactions. 
2. That hard work originates alterations of the cardiac muscular 
fibers which, if not extremely serious, may be repaired by rest and good 
nourishment, but which are otherwise irreparable. The same has been 
observed in the muscular fibers of the papillary fascia. The suprarenal 
capsules are also subject to alteration by hard work. 
3. That hard work generates a conspicuous neutrophilic polynucleosis 
connected with a transient disorder of the blood gases (excess of carbon 
dioxide) caused by a function of the leucocytes versus carbon dioxide. 
4. That from hard muscular work there arises a production of acetone 
and also an increase of the antitryptic power of the blood serum, and that 
in another kind of muscular exertion, in the excitement of persons men- 
tally affected, a remarkable elimination of uric acid is noted. 
5. That periods of great strain in working people (harvest time) lead 
to prostration of the strength and inefficiency of the heart. 
Dusts were made the object of special experimental studies by Prof. 
Cesa Bianchi and myself, and this is our point of view: 
(a) By causing animals to inhale dust we have produced only pulmo- 
nary tuberculosis, regardless of the way in which the tubercular germ is 
introduced, while without the use of dust general tubercular processes 
result. 
(b) Dusty trades frequently produce acoustic reactions of the pulmo- 
nary apexes which look like, but are not, the result of a tubercular process. 
The germ of tuberculosis will later thrive because dusts have prepared 
the soil for it. SCIENTIFIC PRODUCTIONS 
107 
Chronic poisoning derived from lead inhalation has been studied from 
different points of view, and we are in a position to say that the first 
alterations come from disturbances of a chemical order (production of 
uric acid on account of prevented uricolysis or of uric reconstruction) 
and from alterations of cellular elements to which lead adheres more 
durably, both in its passage and during its elimination, and because of an 
attraction of the said cellular elements toward lead, whether alcohol, 
exertion, light, etc., are contributory or not, they prepare the way under 
the progressive march of intoxication, for vasal alterations and, with or 
without these, but aided by other circumstances, as, the habit of unusual 
effort, damp or antihygienic environment, insufficient or irrational 
nourishment, wine, liquors, tobacco, and common diseases, the condition 
progresses and we enter into the realm of real saturnism, that is, into that 
large, complete and complex range of phenomena which has caused lead 
to be called the poison of protoplasm on a large scale. 
Dr. Pier Diego Siccardi, the valiant student of hookworm disease and 
discoverer in Europe of the Necator Americanus, has furnished notable 
contributions upon the pathogenesis of lead-worker's colic. 
In studying pregnancy cases of varnishers' wives in the Clinic, it has 
been ascertained that the mortality of the descendants is 49.7 per cent., 
and the occurrence of abortions has been calculated as 10.3 per cent. 
As to phosphorism, Dr. Vallardi, who had the opportunity to study 
about 50 cases of phosphoric necrosis, made experimental researches that 
lead us to state: 
1. The pathognomonic manifestation of chronic phosphorism in the 
human body is shown by the necrosis of the jawbone. 
2. The other symptomatical manifestations especially frequent among 
workmen who are always in contact with phosphorus have no specific 
characters. 
3. It is not possible to reproduce in animals, poisoned chronically 
with phosphorus, a phenomenon resembling nearly enough that which 
appears in the necrosis of man's jawbone. 
4. On the contrary, chronic poisoning of animals by phosphorus 
through the respiratory or the gastric channels or by both ways simultane- 
ously produces modifications of the blood crasis, injuries of the glandular 
parenchyma, of a degenerative type (especially of the liver), and constant 
alterations of the material exchange. 
None of these manifestations, considered by itself, can be regarded 
as specific. 
The Clinic has had about 130 cases of pellagra in these past years, and 
from the study made of this disease we are led to admit that there is no 
pellagra without maize (corn). Pellagra has diminished considerably in 
Italy during the war. This is attributed to the scarcity of corn, a 
change and variety of food, and the consequent improved nourishment of 
the peasant. 108 
THE FUNCTION OF THE MILAN CLINIC 
We are confident that this grievous disease will not be so prevalent 
again in Italy. 
In conformity with the views expressed by me years ago about the 
paresis appearing in cases of pellagra in those nervous centers of the 
muscles which have been most burdened by work, we have gathered much 
data, proving that intense work reacts back to an isolated or separated 
'center, to which are attracted those factors of diseases which may eventu- 
ally affect this special center or organ: in fact, lead selects the most 
strained parts, to exercise on them its paralyzing power; Spirochaeta 
chooses the aorta in those persons who overstrain themselves; the ectopic 
kidney becomes, in persons who work standing, the seat of unilateral 
nephritis; the radiocarpic articulation, in persons who have an occupation 
limiting their exercise within certain fixed motions, becomes the center 
of arthritis, and the radial and ulnar arteries harden in persons 
making great efforts with the respective joint (stone workers, filers, 
blacksmiths, etc.). 
Under a different aspect persons working in a bended or crouching 
position daily, and for long hours (as brass and tin workers, and others), 
often complain of pains in the lumbar region which, at first, seem to be 
lumbago, but which are really due to an alteration of the spine, a real 
anchylosis induced by work done in one continual position, and by the 
circulatory and trophic disturbances due thereto. 
In order to keep this review within limits I will only note that boys 
who have been engaged in hard work since childhood are frequently 
subject to infantilism. The Clinic has had several cases of infantilism 
which can be used as appropriate illustrations of the above statement. 
A fund for scientific research has been provided by the contributions of 
the King of Italy, of his Government, of several Italian, English and 
American philanthropists, and of the working people of Milan. 
4. CONSULTATIONS WITH THE WORKMEN 
Free consultations are given every day from 10 to 12:30 to those who 
give evidence of being poor and hard-working people. They come: 
1. To be assured as to their personal organic condition and physical 
fitness to learn a certain trade, to keep the one they have, or to enter into 
a new one. 
2. To learn rules and to get medical hygienic instructions about the 
occupation in which they are engaged. 
3. For a periodical medical inspection aiming at an early recognition 
of those preliminary disturbances that, directly or indirectly, arise from 
their occupations. 
4. To have a diagnosis made and methods of treatment suggested for 
diseases already existing. During this free consultation service all the 
physicians on the Staff, each in his laboratory, are at the disposal of the 
consultants, so that whatever examination is called for in the different CONSULTATIONS INSPECTIONS AND INVESTIGATIONS 
109 
cases (blood spitting, urine, X-ray examinations, acute reactions, 
punctures, electro-diagnosis, serum diagnosis, etc.) can be promptly 
performed and all other aids such as measuring, photographs, etc., which 
may be useful to illustrate the case, can be provided for without delay. 
If the diagnosis is made at one sitting the patient is instructed in all 
hygienic or medical rules required by his condition; when the diagnosis is 
not possible at first consultation, and when the treatment cannot be 
followed at home, patients are received into the Clinic. 
Those affected by lead colic are immediately taken in, for the following 
reasons: 
1. In the patient's home there is lead undoubtedly, which, penetrating 
the system, would make the crisis longer and still more serious. 
2. It is necessary to free the patient from his clothes which are usually 
dirty. He is then shaved and his hair and nails, where lead always 
collects, are cut. 
3. Soon after that a very hot bath is given the patient, a treatment of 
pilocarpine is started by hypodermic injections, which through perspira- 
tion and salivation eliminates the lead. In this way the crisis is shortened 
and the pressure on the kidneys, which ordinarily in cases of saturnine 
colic go through a light phase of acute nephritis, is avoided. 
It is the experience of the Clinic that many workmen, in whom lead 
poisoning is taking effect, present three orders of disturbances, viz.: 
paleness, dyspepsia and weakness. Our advice to them is to stop work 
for some days and observe a scrupulous cleanliness. After 10 days a 
remarkable improvement is noted, due to the elimination of lead which 
is not replaced. Another result of the investigations made is that 
persons over 50 years of age should not engage in occupations of any 
kind where there is a possibility of saturnism, because they become more 
easily affected by it, and in very serious forms (as nephritis, arteriosclero- 
sis, paralysis, glandular insufficiency). 
Children of persons affected by saturnism should never attempt to 
work in trades which would put them in contact with lead. 
Our consultation statistics show that 15,000 working people have been 
examined in 9 years. 
5. INSPECTIONS AND INVESTIGATIONS 
The activity of our consultation service extends also to examinations 
of working people in their homes and to investigations concerning certain 
trades, on request of the manufacturers, the State, or the workmen 
themselves. I point out as an example worthy of praise the case of the 
Milanese varnishers who, every two weeks, undergo an examination in their 
meeting place, and that of the printers who also submit themselves regu- 
larly to the professional visit of the professors or assistants attached to 
the Clinic. A fact worth mentioning occurred in connection with the 
strike of the lead capsule and label makers, when the Clinic demonstrated 110 
THE FUNCTION OF THE MILAN CLINIC 
that a large percentage of the strikers were affected by saturnism, thus 
inducing the manufacturers to make them better propositions as to 
wages, etc. 
During the few years of existence of the Clinic, the following researches 
have been conducted by Dr. Carozzi, Chief of the Investigation 
Department: 
"Hygienic-sanitary conditions of the silk industry." 
"Investigation of the polygraphic industry in Italy." 
"Contribution to the so-called ansemia of the photographers." 
"Hygienic protection of workmen engaged in graphic arts." 
"Factory work taken home and its relation to tuberculosis." 
"Infant mortality in relation with parents' occupation." 
By Devoto: 
"Upon the hours of labor in industries using constant fires." 
"Upon conditions of labor among telephone workers." 
"Upon the admission of women to the printing trades." 
By Prof. Allevi: 
"Upon the health conditions of the street-sweepers of Milan." 
A very remarkable investigation is the one conducted by Dr. Pretion 
the "Professional Pathology of Dramatic Artists." 
6. POPULAR PROPAGANDA ON OCCUPATIONAL HYGIENE 
I am very glad, indeed, to have opened the Clinic (which was formerly 
intended only for physicians) to the public in general, and especially to 
the working class. At first we used to give general lectures on the various 
occupational diseases, but now we prefer to speak about each trade and 
profession, because in this way the attention of the workmen is more easily 
attracted and their interest won far more readily; so we try in every 
lecture to illustrate very plainly the pathology and hygiene that varnishers, 
decorators, printers, typists, glove makers, nurses, type founders, etc., 
should know, and for this we draw upon the experience and material 
accumulated by the Clinic, which affords illustrations of actual cases of 
the life and labor environment of the people. It is convincing to them 
to show what a powerful foe to the health and hygiene of workers alcohol 
is, by exhibiting at our popular lectures the bowels and other internal 
organs of hard-drinking workmen who, before dying, donated their 
bodies to the anatomic collection of the Clinic. 
The Museum of Labor Hygiene and Pathology possesses many speci- 
mens (as shown in the hygienic exhibition of Dresden), tables, drawings, 
anatomic pieces and photographs illustrating unwholesome labor environ- 
ments, pathological cases, etc., and these have been drawn upon to great 
advantage in our popular propaganda. This Museum, which is new, is 
open to the public on holidays from 10 to 12 A.M., and I hope that in the 
future it will have sections for general phenomena as strain, fatigue, 
alimentation, alcohol, dusts, and others dedicated to the various categories MUSEUM OF LABOR HYGIENE, ETC. 
111 
of the trades of Milan and its suburbs, so that proprietors, manufacturers, 
and employes may find in each single section all that physiology, pathol- 
ogy, hygiene, statistics and social assistance have to offer in their respec- 
tive trades, occupations and industries. I believe that, by acting chiefly 
upon employers and workmen, we can more easily attain the purpose of 
eliminating from the trades all that is dangerous to the body and some- 
times to the spirit of the laborer. 
The expenses of the Clinic (teaching, laboratories, out-patients and 
assistance to 45 patients) requires a yearly output of 100,000 lire; the 
annual balance shows a deficit of 20,000 lire, which is covered by con- 
tributions. 
This was before the war. During the war the Clinic was converted 
into a military hospital and all the laboratory workers were devoted to 
research work among soldiers stricken with infectious diseases. 
On April 1, 1919, the Clinic again took up its civil activities. 
During the war, the scientific staff of the Clinic while aiding the mili- 
tary authorities either at the front or in the hospitals, had opportunity 
to study a group of actual problems, with the help of the director and all 
his assistants. 
The problems were: 
"The food of the working classes" (Devoto). 
"Alterations of the Heart of Combatants" (Devoto). 
"Nephritis Among Troops" (Devoto, Cesa-Bianchi, Ciovini). 
"Icterhemorrhagic Spirochetosis" (Siccardi, Cesa-Bianchi, Vallardi). 
"Malaria" (Cesa-Bianchi). 
"Typhoid Fever, Cerebro-Spinal Meningitis in Soldiers" (Preti). 
"Diseases by Protozoa" (Vallardi). 
"Scurvy in Soldiers" (Siccardi). 
"Poisoning Among Professionals in the War" (Devoto). 
On December 12, the great physician, Prof. Pier Diego Siccardi died 
in a war hospital. He succumbed to icterhemorrhagic spirochetosis which 
he discovered in the fourth Italian army. The death of this valorous 
scientist is a grievous loss to science and to Italy. Under the auspices of 
the Clinic the "Pier Diego Siccardi" foundation has been created which 
will give a stipend every year to a young physician for the study, in this 
Clinic, of the pathology of occupational diseases. 
Summing it all up in a sentence, the Clinic of Milan, by its work and 
propaganda, is a daily illustration by work and deed of the wisdom con- 
tained in Ramazzini's motto: "Medici munus plebeios curantis est interro- 
gare quas artes exerceant;" teaching to physicians the technic of specific 
exploration, of diagnosis and of prevention, as well as that of treatment, 
it aims at educating them to detect accurately in the infirmities of working 
people what today is to be traced back to trades, and to avoid in the 
future-if not totally, at least in a great proportion-the evil consequences 
of such unwholesome trades; and it works for the extension of education 112 
THE FUNCTION OF THE MILAN CLINIC 
and of class collaboration, availing itself of the cooperation of willing 
workmen and of all who are prompted, by noble feelings, to take an 
interest in the hygiene of work ... I hope that in due time this Clinic 
of Milan, the first established, may become, little by little, the social 
medico-hygienic labor faculty, a mixed international school open to every 
one, physician or not, to ill or healthy persons, to all who are willing to 
contribute toward the realization of healthier and more physiological 
occupations, which is the dream of all who are kindly hearted. 
On the corner-stone of the Clinic of Milan this is carved: in aliis 
vivimus, movemur et sumus. 
OCCUPATIONAL DISEASE CLINICS IN THE UNITED STATES 
BY GEORGE M. KOBER, M. D., Washington, D. C. 
It will be gratifying to Professor Devoto to learn that the first occupa- 
tional disease clinic in this country was established by Dr. W. Gilman 
Thompson in connection with the Cornell University Medical College in 
New York City in 1910. This clinic was discontinued when Dr. Thomp- 
son resigned from that institution in 1916.1 
1911. In July, 1911 the Sprague Memorial Institute of the University of Chicago 
established a special clinic for occupational diseases in connection with the Rush 
Medical College. This was organized and conducted for the first two years by 
Hayhurst. It is now operated as an evening clinic. This Institute in 1913-14 sup- 
ported special investigations (by Bassoe) of compressed air disease, and in 1911-13 
occupational brass and lead poisoning (by Hayhurst). During the world war it 
supported investigations on the toxicity of various explosives or chemicals used in 
munition plants (John D. Thompson). 
1913. According to Dr. Wade Wright,2 the first attempt to study industrial dis- 
ease in the Massachusetts General Hospital was made in 1913 when a social worker 
began work in the out-patient department to whom were referred by the visiting physi- 
cians such cases as they considered of industrial interest or importance. In March, 
1916, a regular industrial clinic was operated. A staff eventually consisted of one 
full-time salaried physician, a full-time industrial social worker, a secretary, and a 
number of volunteer social workers. The importance of careful study of industrial 
poisoning is shown by the fact that during the first year after the establishment of 
this clinic, 148 cases of lead poisoning were diagnosed while in the previous five years 
only 147 cases were reported in the various departments of the hospital. There were 
54 cases of industrial dermatosis, exclusive of anthrax, of which there were 18 cases; 
19 persons were affected by naphtha fumes, usually in the chronic form. There were 
12 cases of caisson disease, none very acute, and 46 cases in the group of miscellaneous 
diagnoses. 
1914. The Hospital of the University of Pennsylvania organized an occupational 
disease clinic more as a center for consultation and investigation than as a place for 
treatment. Apart from the investigations already mentioned in connection with the 
department of hygiene, special studies have been made of pulmonary diseases in 
potters and cement workers; women employes in the textile industry; and compara- 
tive investigations of dust within and without the buildings. 
1915. In 1915 Dr. S. S. Goldwater, the health commissioner of New York City, 
established a clinic exclusively devoted to occupational diseases in connection with OCCUPATIONAL DISEASE CLINICS IN THE UNITED STATES 
113 
the Health Department. Since then the Department has established an occupational 
clinic in each borough of the city. 
In 1915 the Medical College of the Ohio State University inaugurated an occu- 
pational disease clinic which was discontinued with the onset of the war. 
The School of Medicine of Washington University, St. Louis, held each week an 
industrial clinic in its out-patient department. 
The Cincinnati General Hospital established an occupational disease clinic in 
which all the services of the hospital participate. 
1920. The American Hospital, Chicago, established an industrial department. 
The Delray Industrial Hospital, Detroit, has for a number of years also operated 
an out-door department. 
The Joint Board of Sanitary Control of the Cloak and Suit Industry, New York 
City, has established a clinic of workers in that industry which is supported by joint 
contributions from employes and employers. 
1922. The Workers' Health Bureau, New York City, organized the first clinic 
supported by organized labor, July 1, 1922, for the study and correction of occupa- 
tional diseases, although all diseases are considered. It began among the painters' 
unions and, with a capable staff of two lay directors, has a physician, dentist, laboratory 
diagnostician, roentgenologist, nurses, clerks, etc., with a well-equipped clinic head- 
quarters in a downtown building (St. Denis Offices, Broadway and 11th Street). 
It conducts diagnostic and advisory work for the union members, refers its sick to 
ethical practitioners of medicine and dentistry, supplies public health nursing services 
and follow-up work, and prepares lectures, leaflets and other educational material 
on workers' health. It has an Advisory Committee composed of twelve competent 
specialists who are widely known in their respective fields and who guide the scientific 
program of the Bureau. (Emery R. Hayhurst, M. D.) 
REFERENCES 
1 Thompson, Dr. W. Gilman, Personal Communication, July 21, 1921. 
2 Address before Social Insurance Conference held in Washington in Dec., 1916. Monthly 
Review Bureau of Labor Statistics, Dec., 1917, pages 185-193. CHAPTER VIII 
INDUSTRIAL MEDICAL SERVICE 
C. D. SELBY, M. D„ Toledo, Ohio 
Definition.-Industrial medical service may be defined as the science, 
theory and practice of medicine applied to the prevention and alleviation 
of sickness, injury and physical deterioration among industrial workers. 
Although fundamentally the science of medicine, it is also, by virtue of 
its relationship to industry, a specialty in the science of industrial 
management, and its place is similar to those of the employment, safety 
and compensation services of industry. Physicians must of necessity 
view the practice of industrial medicine in the light of this relationship. 
Purpose.-Industry is concerned with the manufacture and distribu- 
tion for profit of salable materials or products. Production, as the 
output is called, is of the highest order of importance. Labor is recog- 
nized as being essential to production. It is a known fact that sickness, 
injury and physical deterioration impair labor's productivity. Industry 
therefore takes measures to avoid and alleviate these conditions. It is 
the ability of physicians to apply such measures that justifies industrial 
medical service and defines its purpose. 
Functions.-In the application of these measures it is necessary that 
physicians (1) assist in selecting employes and assigning them to work, 
(2) exercise hygienic supervision over working conditions, (3) aid employes 
in keeping healthy and to recover when sick or injured, (4) cooperate 
with them in securing better home and community conditions, and (5) 
pursue researches in industrial hygiene and medicine. 
SELECTION AND ASSIGNMENT OF EMPLOYES 
Industry has learned that the most satisfactory workmen are those 
who are healthy and physically capable, especially if they are put on jobs 
they like and know how to do with facility. The obtaining of such work- 
men does not imply the outright rejection of those who are unhealthy 
or maimed, for there is work in almost every plant of reasonable size that 
people of substandard health or body can fill to the profit of their 
employers and themselves. Except under unusual circumstances, it is 
only the obviously unfit and the victims of communicable diseases who 
should be rejected. The essential measures so far as industrial physicians 
are concerned are discussed under four headings, as follows: 
Physical Examination of Employes.-The examination is the means 
whereby physicians acquire the information they need. It is basic not 
114 PHYSICAL EXAMINATION OF EMPLOYES 
115 
only to the proper assignment of employes, but to the preservation of 
their health as well. 
The scope of the examination should be broad enough to enable 
physicians to gather the information that is requisite. It should uncover 
defects and diseases that render a given employment hazardous to the 
one who seeks it or his fellow workmen. It should uncover imperfections 
that contribute to inefficiency. It should uncover disease and sub- 
standard conditions of health and body. In short, it should divulge 
the true condition. 
CASE 
Check No. Name 
Date of Accident M 
Time Office Date 
Dates and Days of Time Lost 
Daily Wage 
Weekly Wage 
Hours Per Day 
Days Per Week 
Weekly Compensation 
Daily Compensation 
Received Wage 
Piece Work 
Day Work 
Work as Usual? 
Present Wage 
Date Returned 
Hour of Day 
Remarks 
Signed 
RECORD 
Although a complete examination, with blood pressure readings, 
urinalysis and other laboratory tests, is a desirable procedure, it is not 
always practical. In the first place, industrial physicians are usually 
pressed for time, and, in the second place, industry has not found so 
complete an examination necessary except in unusual cases. Experience 
has evolved four grades of examination, depending upon the objective 
sought, which in turn is usually fixed by the policy of the company 
immediately concerned. These grades are as follows: 116 
INDUSTRIAL MEDICAL SERVICE 
Department 
Name Check No 
Result 
Claim No. 
THE MANUFACTURING COMPANY 
SUMMARY OF HEALTH RECORD 
Cost 
Days lost 
Date of 
injury or 
illness 
Complications 
Diagnosis HEALTH DEPARTMENT RECORDS 
117 
0 
p 
o 
2 
New 
Com 
(Add 
anuf 
Old 
S 
o' 
tpany 
ress) 
rcturi 
o 
o 
co 
co 
3 
(n 
Respiratory infections 
■ 
Alimentary affections 
Female troubles 
rn 
Headaches 
o' 
Occupational disorders 
o 
co 
1 
1 
o 
p 
CO 
CD 
th 
o 
Total sickness 
New 
Old 
E. 
£ 
o' 
co 
Fingers 
1 
Hands 
1 
Arms 
1 
Eyes 
E. 
co 
1 
1 
o 
co 
m 
o 
1 
1 
1 
1 
Total injuries 
1 
Home visits 
1 
Physical examinations 
1 
Total of new cases 
1 
Total of old cases 
Grand total 
Total 
Number employed 
SUMMARY OF HEALTH DEPARTMENT 118 
INDUSTRIAL MEDICAL SERVICE 
Date of accident 
19... 
1 
2 
3 
4 
5 
6 
7 1 
8 1 
9 | 10 |11 |12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
29 
30 131 
o 
£ 
c 
c 
c 
L. Dressing at Health Office 
Able to do light work 
Able to do usual work 
Unable to work 
Remarks 
z. 
3. 
4. 
5. 
' Residence 
0. xiospirai 
7. Referred to specialist 
8. Operation in health office 
9. Operation in hospital 
"5 
i 
1U. ±bxamination 
Name of attendant 
Children- 
RECORD OF ILLNESS 
The Manufacturing Co. 
-Occupation- 
•Widow 
-Name- 
-Single- 
-Married- 
-Sex- 
Disposal of patient- 
Special treatment- 
Department- 
Treatment- 
Address- 
Illness- 
Age- 
Date- HEALTH SUPERVISION OF EMPLOYES 
119 
Superficial Inspection.--This consists of a hasty survey for obvious 
defects and apparent sickness. It considers height, weight, appearance, 
deformities, distance vision, hearing, hernia and possibly the condition 
of the heart and lungs, (stethoscope applied outside of shirt). Its 
objective is REJECTION of the evidently unfit and exclusion of com- 
municable diseases. 
Inspection.-This consists of a more complete survey. All parts 
of the body are exposed and their conditions noted. Diagnostic instru- 
ments are used when in the opinion of the physician they are needed. 
This is practically an examination without urinalysis and other 
laboratory tests. It gives special consideration to vision, hearing, 
dexterity, size, agility, strength, hernia, heart and lungs and temper- 
ment. Its objective is SELECTION AND ASSIGNMENT of workers. 
Examination.-This consists of a reasonably complete survey of the 
body according to accepted methods and includes blood pressure readings 
and urinalysis. It is virtually the same as the examination required 
by life insurance companies. Its objective is not only the selection and 
assignment of workers, but their HEALTH SUPERVISION as well. 
Special Examination.-This consists of all measures that are neces- 
sary to a thorough study of the body, including intra-ocular observation, 
gastric analysis, rectoscopy, cystoscopy, X-ray interpretation, investiga- 
tion of the nervous system, blood counts, etc. Very few industrial 
physicians are prepared to make such exhaustive examinations, and 
individuals needing them are usually referred to consultants. The 
objective of the special examination is the DIAGNOSIS of obscure 
diseases and conditions. It belongs to the realm of internal medicine 
rather than industrial service. 
The object of the examination can best be served by taking advantage 
of every opportunity that occurs to look an employe over. There are 
many such opportunities, as for example: (a) Prior to employment, 
(6) prior to re-employment if the period of absence warrants, (c) upon 
transfer from one job to another, (d) upon termination of employment, 
if employe has been occupied in process or other hazardous work, (e) 
after absence due to serious sickness or injuries .not under observation, (/) 
when employe does not feel well or appears sick, (g) upon continued 
failure to measure up to the standards of production unless the 
reason is evidently not of a physical character, (h) when employe is on 
process or other hazardous work (monthly at least), (t) when employe 
is a handler of foodstuffs (sufficiently often to safeguard against communi- 
cable diseases) and (j) when pathological conditions have been found 
(sufficiently often to safeguard against further impairment). 
Assignment of Employes.-The physical examination of industrial 
workers has come in for much criticism and in some instances has been 
abandoned, chiefly for the reason that the rejection of the unfit has too 
frequently been the only evident result. This is really a very serious 120 
INDUSTRIAL MEDICAL SERVICE 
criticism. It indicates that physicians, generally considered, have not 
analyzed their findings and have not cooperated with employment depart- 
ments and foremen in placing men on work. In other words, they have 
fallen short of what industry has been led to expect of them in the way of 
fitting workmen to their jobs. 
Applicants for work are usually hired for certain operations. For 
illustration, let it be assumed that a man has been hired as a molder. 
The physician should know what will be exacted of that man, and having 
examined him, must be able to say with certainty whether or not the 
man is physically and temperamentally qualified to do that work without 
impairing his health and with average physical efficiency. If the doctor 
finds the man unqualified, such as having insufficient musculature to 
handle core boxes and castings, then the physician should be able to 
suggest the work this man is capable of doing. To do this in a manner 
satisfactory to all persons concerned, physicians must have intimate 
knowledge of the various operations used in the plants, skill in interpret- 
ing physical values as revealed by the examinations, and a close coopera- 
tion with employing offices and foremen. 
INSTRUCTIONS TO NEW AND TRANSFERRED EMPLOYES 
Sometimes special instructions are necessary in order that workers 
may adapt themselves to their jobs or safeguard themselves against 
hazards that cannot be wholly avoided. This applies, for example, to 
workers in lead, TNT, and other poisons, also to females and handicapped 
workers under certain conditions. Physicians may reasonably be 
expected to offer instruction of this nature at the time of examination, 
which is an opportune time, and to do so they must be (a) familiar with 
hazards of their plants, (b) prepared to offer the necessary instruction, 
and (c) supplied with pamphlets for those employes who are given 
hazardous process work. 
Standards of Job Requirements.-The greatest difficulty physicians 
have in fitting employes to their jobs is due to the lack of standards. 
The development of industrial medicine has not yet reached the stage 
where it provides physicians with knowledge concerning, on the one hand, 
(a) conditions under which women and handicapped workers, and even 
normal workers, for that matter, may labor most effectively and at the 
same time without danger to their health, and, on the other hand, (6) 
the human requirements of the occupations common to industry. In 
other words, industrial physicians have not yet acquired the knowledge 
that enables them to interpret the physical values of the people they 
examine. Individual physicians must therefore study their workmen 
and their plants. They must classify the different types of workmen in 
relation to their jobs and find out, as best they can, the types of people 
that are best fitted to do certain tasks. In no other way can they qualify 
themselves to assist properly in the assignment of employes. SANITARY INSPECTIONS AND INVESTIGATIONS 
121 
HYGIENIC SUPERVISION OVER WORKING CONDITIONS 
Because of their knowledge of the human body, physicians are sup- 
posed to know what deleterious effects, if any, working conditions will 
have on the health of the employes. They may be expected to exercise 
a sufficient amount of supervision to protect the employes from 
unhealthy conditions. 
In connection with this thought a word of caution is not out of place, 
and it is this: Physicians must not let their professional enthusiasm and 
the fact that they have a monopoly on medical knowledge lead them to 
excesses in hygienic supervision. They must not forget that industrial 
medicine is frequently a compromise between the ideals of preventive 
medicine and the necessities of industry. This does not mean that they 
should sacrifice their ideals, but it does mean that they must use judg- 
ment in attempting to achieve them. The measures essential to hygienic 
supervision are discussed under the three following headings: 
Inspection.--Physicians cannot supervise working conditions unless 
they have intimate knowledge of the conditions existing in their plants. 
To obtain this information it is suggested that they or their assistants 
make periodical tours of the establishments. Conditions specially to be 
sought and studied are: (a) Monotony, (6) concentration, (c) isolation, 
(d) speeding, (e) overtime, (/) inadequate ventilation, (g) poor illumina- 
tion, (A) excessive variations in temperature, (2) excessive variations in 
humidity, (j) harmful dusts, (fc) gases and fumes, (Z) poisons, (m) inade- 
quate sewage and waste disposal, (n) inadequate toilet, washing and 
locker facilities, (o) unsafe drinking water, (p) workroom congestion, 
(q) poorly adapted workroom clothing, (r) unnecessary noises, (s) lack 
of mechanical safeguards (if safety service is not otherwise provided for) 
and (Z) workroom disorder. 
Investigations.-Certain processes, operations and methods are known 
to be harmful to health; others are suspected of being so. While investi- 
gations have been made and conclusions have been reached in regard to 
many health hazards, there are yet great opportunities for the enrichment 
of knowledge in this direction. It is devoutly to be hoped that industrial 
physicians will accept their many opportunities to study all hazards, 
particularly those which are not well understood, and to determine means 
for their prevention. 
A Cincinnati manufacturer recently remarked that a process he was forced to 
introduce in his plant in order to supply certain materials for war purposes resulted 
in sickness among the workers. He sought the advice of physicians for a means of 
preventing this sickness without appreciable success. This is one of a number of 
illustrations that may be cited as an indication of the opportunities awaiting the 
physicians of industry and, incidentally, the paucity of general interest in the re- 
searches necessary to make industry safe for the workers. 
Instruction of Foremen and Management.-While production is 
paramount in industry, employers certainly do not wish to jeopardize 122 
INDUSTRIAL MEDICAL SERVICE 
unnecessarily the health of their workers, which is a wasteful policy 
when viewed from any business standpoint. If conditions are such as to 
cause harmful effects, the assumption is that the employers are not 
aware of them, or not informed of their significance, or know of no means 
for their correction. These matters are left very properly to physicians 
and sanitarians, and the initiative in the correction of unfavorable 
conditions must necessarily rest with them. It is suggested therefore that 
industrial physicians take special pains to inform employers and foremen 
tactfully but clearly of (a) the existence of unhealthful conditions, (b) 
their harmful effects and (c) means for their correction. 
HEALTH MAINTENANCE 
While it is true that unfavorable working conditions are capable of 
impairing the health of employes, these are not alone responsible for 
impaired health. Much depends upon the workers themselves and the 
manner in which they live. Although employes are free agents and privi- 
leged to live as they see fit, physicians are able to assist them greatly 
through advice and service in the maintenance of health. As an aid to 
efficiency and production, employers realize the advantage of extending 
their workmen assistance of this nature, and quite naturally they look to 
physicians for this assistance. Activities in this connection are discussed 
under six headings, as follows: 
Health Instruction.-Unfortunately the knowledge imparted through 
our general system of education does not emphasize enough the essentials 
of hygiene and health maintenance, and consequently workers may be 
expected unknowingly to violate the rules of health. In order that they 
may not be so handicapped, industrial physicians should endeavor through 
lectures, personal talks, bulletins, posters, articles in shop papers, etc. 
to instruct them in (a) personal hygiene, (&) proper clothing, (c) proper 
food, (d) recreation, (e) rest, (/) exercise, (g) prevention of the communi- 
cable diseases, (h) personal habits, etc. The personal talks are particularly 
effective. 
Provisions and Facilities for Care of Health in the Plants.-Instruction 
in the maintenance of health alone is not sufficient. Provisions must 
be made and facilities furnished within the plants to induce employes to 
apply the principles of health maintenance during working hours, and 
which will enable them to do so. These concern all activities necessary 
to the prevention of fatigue and the impairment of vitality. They are 
(a) facilities for rest, recreation and exercise, (b) the designation of workers 
who should have the benefits of rest, recreation and exercise, and (c) the 
conditions under which they should avail themselves of these benefits. 
Physicians should also interest themselves in (d) refreshment facilities 
(restaurants, milk stations, etc.) (e) sanitary supervision of restaurants, 
refreshment stations, kitchens and storage rooms for food, and (/) the HEALTH MAINTENANCE-DENTAL ATTENTION 
123 
daily inspection and monthly examination of all food handlers (for preven- 
tion of communicable diseases). 
Prevention of Communicable Diseases.-The necessity of preventing, 
or at least of controlling, communicable diseases among industrial workers 
is evident. The difficulty is in applying the necessary measures. Theoret- 
ically, it might appear that a daily inspection of all employes would 
serve to bring communicable diseases to attention in their incipiency. 
However, in large establishments this is impracticable, although in times 
of epidemics serious efforts should be made to carry on such inspections. 
Under ordinary circumstances physicians should arrange with foremen 
to require all employes who seem to be sick, especially those who have 
eruptions, to report for diagnosis. It is scarcely necessary to mention in 
this connection that all who are found suffering with communicable 
diseases should be excluded and health authorities notified. The rapid 
development of vaccines and other immunizing agents has opened up for 
the industrial surgeon a field prolific in opportunity for the prevention of 
certain communicable diseases, and, similarly to military units, a field for 
controlled research in establishing the efficacy or otherwise of new 
methods. 
Treatment of Trivial Illnesses.-Industrial workers, as well as others 
are prone to neglect non-incapacitating illnesses, such as colds, headaches, 
constipation, etc. As these are sometimes the early symptoms of more 
serious sickness and therefore the forerunners of incapacity and lost 
time, employers have found it beneficial to the workers, as well as advanta- 
geous to production, to have all trivial ailments that appear during 
working hours treated by the physician. In the interest of efficiency and 
for the maintenance of health, physicians should always encourage 
employes to seek treatments of this nature, otherwise some conditions 
may not be treated at all. 
Inasmuch as neglect of teeth, which is quite prevalent, results in a 
variety of infections and disabling diseases, employers are finding it more 
and more to their advantage, and to the benefit of the workers, to provide 
prophylactic and emergency dental treatments. The prophylactic 
treatments are of great educational value, and the treatment of dental 
emergencies, toothache, etc., is usful in giving relief and thereby enabling 
workers to continue employment. Industrial physicians are urged to 
secure personnel and facilities for dental service and to encourage the 
workers to avail themselves of it. 
Surgical Treatment.-The most evident reason for the service of 
industrial physicians is, of course, the treatment of injuries. This is 
mentioned at this time to indicate the fact that the surgical treatment of 
injuries is a function necessary to the maintenance of health, and also to 
emphasize the fact that it is only one of several important functions. 
PROPHYLACTIC AND EMERGENCY DENTAL ATTENTION 124 
INDUSTRIAL MEDICAL SERVICE 
The importance of surgical service is determined largely by its emergency 
features. Measures which obviate the need of surgical treatments, and 
also medical treatments, would seem to be equally essential and of perhaps 
greater importance. Also, reconstructive surgery, which has recently 
come to the attention of industrial physicians, brings to them the sugges- 
tion that they can very well initiate rehabilitative measures early in the 
care, of injured workers. Reconstruction and rehabilitation may also be 
applied to the benefit of workers who are handicapped because of hernia 
and other more or less incapacitating conditions. For the maimed as 
well as in some diseased conditions and during convalescence, functional 
reeducation and occupational therapy come within the field of the industrial 
physician and surgeon. 
BETTER HOME AND COMMUNITY CONDITIONS 
Employers may be exceeding their responsibilities when they endeavor 
to assist workmen in handling their personal troubles and when they 
attempt to improve community conditions, yet employers have a definite 
interest in these matters for the reason that both may cause worry and 
impairment of vitality, two large elements in poor health and inefficiency. 
Social Aid.-The place that physicians occupy in the lives of people 
confers upon them to a certain degree the responsibility of advising 
with them in the solution of problems that are more or less of a personal 
nature, as well as those that relate to community life. It is suggested 
that physicians take advantage of this relationship (a) to advise and 
assist workers in the adjustment of social and financial troubles, (6) to 
encourage thrift, domesticity, sobriety, morality, and (c) to offer instruc- 
tion in health and sanitation. In those establishments which have socio- 
logical departments, physicians may be expected to cooperate with them 
in the foregoing activities. 
Medical Aid.-Sometimes workers are unable to obtain adequate 
medical, dental and nursing attention for themselves and their dependents, 
and although employers may not be responsible, they realize that sickness 
in the families of their workers may be a source of considerable worry and 
therefore, detrimental to production. Because of the knowledge which 
physicians have of doctors, dentists, nurses, hospitals, clinics, and nursing 
relief societies in their communities, it is their reasonable duty to assist in 
providing adequate medical service when the employes are unable to 
procure it for themselves. Actual nursing aid may be given with advan- 
tage for short periods by the visiting nurses of industrial establishments, 
acting under the direction of the patient's own physicians. It is not deemed 
wise, however, for industrial physicians to assume the functions of a family 
physician. 
Community Aid.-Through their professional relations with employes, 
industrial physicians frequently become aware of unhealthful community 
conditions. It is highly desirable that they use this information, when ELEMENTS OF SERVICE 
125 
they can consistently do so, for the betterment of community conditions; 
but in so doing, they should act in cooperation with the health authorities, 
other industrial establishments and social agencies of their communities. 
With respect to the last mentioned, the attention of industrial physicians 
is drawn to the fact that employers are large contributors to charity. 
Any assistance their physicians may be to those charities is undoubtedly 
appreciated by them. 
ENHANCEMENT OF KNOWLEDGE 
Industrial medicine is new. It is not yet out of its developmental 
stage. Only by the contributions of interested physicians can it be 
developed further. Every man who has added something to the knowl- 
edge of industrial hygiene and medicine owes it to industry and to medi- 
cine to make that knowledge known. It is also incumbent upon industrial 
physicians that they make studies of the material which they have at hand 
in their establishments and endeavor to stimulate their own assistants and 
attendants in the pursuit of researches. Unfortunately, industrial physi- 
cians as a rule find their time taken up with routine work and are in danger 
of becoming restricted in the breadth of their knowledge and limited in 
the scope of their activites. To obviate this tendency, it is recommended 
that they hold meetings of the personnel of their own establishments, 
when of sufficient numbers, for the study and discussion of those matters 
that concern the health problems of their industries. It is also suggested 
that they arrange with their fellows in other establishments for conference 
groups for similar studies. 
ELEMENTS OF SERVICE 
In arranging to carry out the foregoing functions of industrial medical 
service, physicians must never overlook the fact that the time of employes 
is valuable. Workmen are hired for limited periods each day, and they 
are expected to utilize those periods in productive work. Injuries or 
sickness are non-productive, and although the greater portion of them 
are not disabling, they require attention which is more or less time con- 
suming. To provide a means for prompt attention in these cases is the 
most evident reason for industrial medical service. This service may then 
be considered as essential; nevertheless, it is unproductive, and physicians 
should bear constantly in mind that the time they require of employes 
is time taken from production. They should, therefore, strive constantly 
to give a prompt, effective service. The elements of this kind of service 
are (1) location of dispensary, (2) arrangement of the rooms, (3) equip- 
ment, (4) personnel, (5) methods and (6) records. 
Location of Dispensary.-The dispensary should be centrally located, 
or so located as to be readily reached by the greatest number of employes 
who are likely to need it. In smaller plants this is not a matter for serious 
consideration.. Tn them the dispensary may be placed near the gate, or at 126 
INDUSTRIAL MEDICAL SERVICE 
the employment office, or anywhere that space is available. But in large 
plants, the location of the dispensary is a matter worthy of much study. 
In very large plants, steel mills for example, it may be wise to establish 
sub-stations at strategic points to supplement the central service. 
Arrangement of Rooms.-The arrangement of the rooms of a dispen- 
sary must be such as will permit (a) accessibility of those rooms that are 
most frequently used, (b) passage of patients without confusion, and, if 
possible, (c) segregation of the various kinds of patients ard visitors. 
Accessibility may be obtained by arranging the rooms around a common waiting 
room, or by providing separate entrances for rooms devoted to special purposes, as for, 
(a) ambulatory patients, (6) ambulance patients, (c) employes for physical exami- 
nation, and (d) visitors to the executive offices of the medical department. The 
latter plan seems to be the better. It avoids confusion, and provides segregation. 
Employes seeking physical examination are not submitted to depressing contacts. 
They do not see large numbers of bandaged fingers, nor limping fellow work- 
men. They do not see mutilated workmen brought in on stretchers. They receive no 
suggestions of the harrowing prophesy that they themselves may some day be injured. 
It is relatively easy to use this principle in the planning of large dispensaries, but 
difficult in the planning of small dispensaries, especially in those of one, two or three 
rooms. Nevertheless, arrangements can be made which will enable patients to avoid 
retracing their steps, such as by having separate doors for entrance and exit. Segre- 
gation can best be accomplished in small dispensaries by having physical examinations 
made at an hour when dressings are light. 
Even though plant dispensaries have become more or less elaborate, the treatment 
of injuries continues to be the most pressing need for medical service, and the dressing 
room remains the center of greatest activity and interest. In small dispensaries, the 
dressing room is frequently the sole center of activity. It should therefore be the 
most accessible of all rooms and so arranged as to enable retiring patients to leave 
by some means other than through the waiting room. 
Equipment.-There is nothing peculiar to the equipment of a plant 
dispensary. It is merely ordinary medical and surgical equipment utilized 
in the care of industrial workers. Association with manufacturers and 
familiarity with their methods have led plant physicians, however, to a 
more effective and economical use of equipment than is customary in 
ordinary medical practice. Efficiency methods have been introduced, 
and patients are given treatments with a minimum of loss in time. 
Attendants also render service with a minimum of lost motion and 
without undue fatigue. And incidentally savings are effected in the use 
of supplies, which is not unimportant to industry. 
Probably the most striking feature in this respect is the grouping of furniture and 
fixtures into units. For example, there is the dressing unit. This consists of (a) one 
dressing table, (6) chairs or stools for the patient and the attendant, (c) a waste 
receptacle, (d) foot and arm rests, and desirably (e) a stationary wash bowl. Upon the 
table are placed such supplies, apparatus and instruments as may be needed for the 
treatment of injured extremities-a finger or a toe, a hand or a foot, an arm or a leg. 
The advantage of this unit is readily apparent. 
For the treatment of eyes, a specialist's unit is appropriate. It consists of (a) 
a specialist's chair, (b) a table for the necessary supplies and instruments, (c) a waste EQUIPMENT OF PLANT DISPENSARY 
127 
receptacle, (d) the essential lighting facilities, and (e) a wash bowl. This unit may be 
also used in the treatment of any condition about the head and face. If desired it 
may be combined in the dressing unit by substituting the specialist's chair for the 
patient's stool or chair in the latter. 
It occasionally happens that patients must disrobe. Facilities should be provided 
for this contingency; at any rate, it is convenient to have them. A separate room is 
desirable. It should contain (a) one dressing table fully equipped, (b) a waste recep- 
tacle, (c) a stationary wash bowl and (d) an operating table of simple design, or 
possibly a bed. This is termed the major dressing unit. 
For ordinary dispensary service a fourth unit is quite necessary. It is for the 
keeping of records. The only essential element in it is a filing cabinet, although a 
desk, typewriter and other office equipment are of advantage. Should it be neces- 
sary to combine the record and dressing units, this can be done very easily by placing 
the filing cabinet within reach of the attendant. For the treatment of trivial ail- 
ments, a medical unit is desirable. It should be set up preferably in a consultation 
room where privacy may be obtained. It might contain, (a) a desk, (b) 2 chairs, (c) 
an examination table, (d) a medicine cabinet, (e) stationary wash bowl, as well as 
the (f) usual diagnostic instruments and possibly (g) a small laboratory outfit. 
This unit is likely to be in considerable demand, not for the treatment of serious 
conditions, but for trivial ailments, usually in the upper respiratory passages, and 
along the alimentary tract. A large supply of drugs is therefore not necessary. On 
the contrary, a few standard remedies are all that are needed. For example they 
may consist of: 
1. A restorative. 
2. A stomachic. 
3. A saline cathartic. 
4. A uterine relaxant. 
5. A cough mixture. 
6. Some 5 grain acetylsalicylic acid tablets. 
7. Some half-strength rhinitis tablets. 
8. A 5 per cent, solution of argyrol for spraying nose and throat. 
9. A mouth wash. 
On the whole, the physician's personal preferences and the special demands of 
his establishment will decide just what this list should consist of, and will cause it to 
be varied from time to time. 
The comments thus far on equipment are appropriate chiefly to 
the small dispensary, the one used primarily for the treatment of trivial 
injuries. Nevertheless, the unit system is applicable to large dispen- 
saries. For instance if the volume of trivial injuries is beyond the 
capacity of a single dressing unit, others may be added. If employes 
are to be examined, an examination unit can be added, or if necessary 
several units. For dental treatments a dental unit may be added- 
and, by the way, the dental unit, which is known to all dentists, is a 
most excellent example of the application of the unit principle. 
As is true with respect to the arrangement of the rooms in a plant dispensary, so 
also is it true with respect to the arrangement of the units; those which are in greatest 
demand should be made the most accessible. As before said, the dressing room 
should be the most easily reached, and of the units in the dressing room, the dressing 
unit should be the most easily reached; other units may be placed with consideration 
to their respective values. If the specialist's unit is next after the dressing unit in 128 
INDUSTRIAL MEDICAL SERVICE 
demand, it should be next in accessibility. In this maimer the relative values of all 
units can easily be determined and the positions they occupy scientifically decided. 
Dispensary equipment, generally speaking, is well standardized-it is not neces- 
sary to describe each article-but there are some points in connection with certain 
articles that merit emphasis. The dressing table should be quite large; say 21J^ X 
43% in. This is none too large to accommodate the essentials. It should be added, 
however, that the essentials must be standardized, and if unusual supplies or instru- 
ments are needed for a specific purpose they should be withdrawn when no longer 
required. 
Standards of dressing table equipment should be rigidly adhered to, otherwise 
much that is useless is gathered, and the table becomes cluttered, a condition which 
militates against clean effective work. Just what the standards should be is pretty 
much a personal matter with each individual physician. The following are merely 
suggested: 
1. One white enamel jar 5 X 6 in. containing 1-in. bandages. 
2. One white enamel jar 5 X 6 in. containing 2-in. bandages. 
3. One white enamel jar 5 X 6 in. containing sterile gauze. 
4. One white enamel jar 5 X 6 in. containing sterile cotton. 
5. One white enamel jar 5 X 6 in. containing sterile wooden blades (used as 
spatulas for the application of an ointment) and applicators dipped with cotton swabs. 
6. One white enamel jar 3 X 4 in. containing a neutral hydro-carbon ointment. 
7. One covered glass dish, 2 X 1 in. containing sterilized rubber tissue cut into 
strips for drainage purposes. 
8. One white enameled tray 4 X 17 in. containing 6 splinter forceps, 6 sharp 
pointed scissors and 6 probes, all sterilized. 
9. One medicine glass containing a 5 per cent, solution of carbolic acid, in which is 
kept a forceps for the removal of sterile instruments from the previously named tray. 
10. One white enameled tray 3 X 8 in. in which are discarded used instruments and 
from which they are gathered from time to time for sterilization. 
11. One hard rubber atomizer containing a 2 per cent, solution of iodine. 
12. One ordinary atomizer containing Dakin's solution, made fresh daily. 
13. One atomizer containing a solution of iodine in hydro-carbon oil. 
14. One atomizer containing benzine or gasoline. 
15. One can of ether. 
16. One jar of solidified liniment. 
17. Several %-in. strips of adhesive plaster 1 in. long. 
18. One bandage shears. 
19. A number of aluminum finger guards. (These, by the way, are very useful; 
they enable men who have lacerated finger tips to continue at work with a great deal 
more comfort than if unguarded.) 
Considerable space has been given to this description of the dressing 
table equipment for the reason that promptness and efficiency in dispen- 
sary service begin with the treatment of slight injuries, and also begin at, 
and radiate from, the dressing table. Let this be repeated for emphasis, 
the most apparent and frequently the only reason for the existence of 
medical service in the vast majority of plants is the accidental injury. 
The injury is the physician's introduction to the plant. If he utilizes 
it to advantage he will be able to assume other duties from time to time, 
and the addition of other units will come as a matter of course. 
Personnel.-Needless to say a physician should be in charge. If not 
present throughout the entire day, he should have definite hours during PERSONNEL OF DISPENSARY SERVICE 
129 
which his attendance can be relied upon. A rather common practice 
has grown up among small industrial establishments of having nurses 
attend all patients and call in physicians only when confronted with cases 
they deem beyond their ability. This is extremely fallacious if for no 
other reason than that under these circumstances nurses are considered 
to be practicing medicine and consequently are in violation of medical 
practice acts. The attending physician is of course responsible for the 
acts of the nurse. He should therefore view all cases. It is not neces- 
sary that he dress all injuries. This duty he may delegate to nurses or 
even untrained assistants so long as he exercises supervision over them. 
One physician can handle a large volume of work each day by viewing all 
patients upon entry and assigning them with definite instructions to 
various attendants. 
Inasmuch as physicians are notoriously negligent in the matter of 
records and busy nurses are not overly competent in this respect, there 
should be a clerk or a stenographer whose duty it is to keep the records. 
As a matter of fact, it is cheaper to employ a clerk for this purpose than 
to require record keeping of physicians and nurses who should use their 
time to better advantage in the actual treatment of patients. 
There is also a distinct need for an attendant who will act as caretaker. The 
cleaning of dispensaries is too often left to a nurse or the regular plant janitor service. 
To require menial service of a nurse is neither dignified nor effective. Nor is the 
ordinary factory janitor service dependable. Nothing reflects so against the quality 
of a plant medical department as an unkept appearance. Clean rooms can be secured 
only through the constant attention of a caretaker. 
The appearance of the various attendants, physicians, nurse and clerk is likewise 
of great importance because of the effect it has upon the employes who visit the 
dispensary. Their conduct is also of exceedingly great importance. 
In selecting assistant physicians and nurses, these points should be 
considered; (1) knowledge, and (2) experience. These weigh perhaps 
equally with the following points; (3) appearance, (4) conduct, (5) loyalty, 
(6) industry, (7) cooperation, (8) initiative, (9) responsibility, and (10) 
regularity. 
Methods.-The fact that a physician has been employed by the 
management of a company to attend injured employes and is given a 
dispensary in which to do so, does not necessarily imply that his service 
will be acceptable to the employes of that company; in the last analysis, 
if the physician will satisfy the management, he must satisfy the employes. 
Plant physicians are therefore constantly face to face with the 
necessity of creating and fostering a demand for their services. This is 
ofttimes quite difficult as employes are discriminating and frequently a 
critical people. They know when they are well treated, and they know 
when results are uniformly bad. 
Unfortunately, physicians cannot always treat patients in dispensary 
practice as they would in private practice. They are forced to delegate 130 
INDUSTRIAL MEDICAL SERVICE 
small duties to others. There is danger in this that the service may- 
become mechanical in nature and the patients thereby get the idea that 
they are being slighted. The methods of rendering service are therefore 
of extreme importance. 
It is very generally known in salesmanship that the introduction, or 
the "approach" as it is termed, may determine the success or failure of a 
salesman. So it is with the introduction of a patient into the plant dis- 
pensary. The manner in which he is received may determine his impres- 
sion of the service he receives. 
There comes to mind an attendant in a small plant who acts also as the safety 
man. Whenever an injured employe enters, this attendant thinks of his safety record 
and scolds bee ause an accident has happened. The condition has become so bad that 
the employes hesitate to seek treatment, and infections are beginning to appear. 
This spirit is quite to the contrary of that which has been built up in a nearby plant 
by the attending nurse. She receives all the patients pleasantly and with a womanly 
dignity that has won their hearts and loyalty. The service in her dispensary is 
appreciated and popular. There is not a man in the plant who does not seek the 
service when he needs it, and there are none who seek it unnecessarily. Although 
a physician visits this dispensary daily and views all patients, the nurse is frankly 
given the credit for effective service. 
One full-time physician has solved the problem of the introduction of patients by 
meeting all of them himself. He takes off their soiled dressings and views the wounds, 
then assigns them to attendants with a few words of instruction. This physician is 
extremely popular in his plant and has the reputation of being a very capable man. 
A group of physicians serves a number of industries, mostly on a 
part-time basis, and its organization is such that the physicians rotate in 
their visits to the various plants. This means that several physicians 
may attend one patient during the course of recovery. The fault of this 
system was brought to attention one day by a patient who remarked 
that every time a different doctor took care of him the treatment was 
changed, with the result that he had become skeptical of all. This has 
been fairly well overcome by standardizing the use of antiseptics and 
medicaments in wound treatment. The standards are as follows: 
Fresh Wound 
1. Remove devitalized tissue. 
2. Cleanse with ether or gasoline. 
3. Spray iodine (2 per cent, solution) into wound. 
4. Pack cavities with gauze. 
5. Dress with dry gauze. 
। Infected Wounds 
(Treat all wounds as though infected after the first eight hours and until the fifth day) 
1. Remove all scabs and loose skin. 
2. Cleanse with ether or gasoline. 
3. Protect adjoining skin with sterile vaseline. 
4. Spray with Dakin's solution or dichloramin-T. 
5. Pack cavities with gauze saturated with Dakin's solution or dichloramin-T. 
6. Dress with gauze saturated with Dakin's solution or dichloramin-T. TREATMENT OF WOUNDS, ETC.-RECORDS 
131 
Clean Wound 
(Treat all wounds as clean on the fifth day and after, unless infected) 
1. Spray with antiseptic oil (a neutral hydro-carbon oil containing iodine). 
2. Pack with dry gauze if necessary. 
3. Dress with dry gauze. 
Indolent Wounds 
1. Cleanse with ether or gasoline. 
2. Spray with argyrol (5 per cent, solution) or swab with Balsam of Peru. 
3. Pack with dry gauze if necessary. 
4. Dress with dry gauze, using slight pressure. 
Burns 
1. Apply hydro-carbon salve, and dress with dry gauze. 
2. This may be varied with antiseptic oil or paraffin. 
3. Or treated as an indolent wound. 
Perhaps these standards are not all that could be desired, but it is 
believed they are a step in the right direction, and they are serving as a 
basis for observation which will probably lead to definite conclusions. At 
any rate, they have solved the problem mentioned. 
All industrial physicians evolve from time to time little things in the way of instru- 
ments, supplies and procedures that help them to improve their service. For example, 
the substitution of the atomizer for the swab has proven very satisfactory. The little 
trick of leaving the beginning of a bandage loose and tying the end to it when the 
application is completed has also proven effective; the bandage stays better. And the 
use of an aluminum guard over the lacerated end of a finger has helped to return many 
a man to work who otherwise would probably lay off. 
Records.-These are of very much importance, not alone from the 
standpoint of compensation but from the standpoint of the physician 
himself. The chief difficulty is to determine what records should be kept 
and how to keep them. Records should be grouped into three classes 
(1) those relating to the individual injury or illness (case records), (2) 
the chronological history of each workman with respect to injury and 
illness, and (3) the summary of the variety and volume of cases treated. 
The case record of illness should show the identity of the patient the 
nature of the illness, the dates and character of treatments and the results. 
When a patient is discharged the record may be filed in a jacket or folder, together with 
other case records which concern the patient, and the record summarized in spaces 
prepared for that purpose on the front of the jacket (see pages 115-116). 
Injury case records should be kept in a similar manner. If they are used to estab- 
lish the validity of compensation and the amount payable, it will be found advanta- 
geous to make them duplicates of the reports required by the compensating agency. 
The chronological history of the illnesses and injuries of each workman may be kept 
on the face of the jacket or folder containing his case histories. This record is of 
tremendous importance in the supervision of health. If a workman becomes a 
repeater or a chronic complainer, that fact becomes readily evident in the chronological 
history and serves as a visual reminder to the physician. It also serves as a key for 
the need of physical examinations and suggests lines of procedure and remedial 
agencies (see specimen record, page 118). 132 
INDUSTRIAL MEDICAL SERVICE 
The summary of the variety and volume of cases is particularly useful 
in keeping a physician informed on conditions in his plant. This record 
can be kept on a sheet ruled vertically and horizontally, the columns to 
indicate the variety of cases and the horizontal lines the volume. The 
record is compiled by adding a line each day. Comparisons are thereby 
permitted at any time and totals may be drawn when desired. If acute 
respiratory infections, for example, increase, it becomes quickly evident, 
and the same is true with respect to the various injuries that occur. 
The summary is really the pulse that enables the physician to keep 
informed on the health of all workers and conditions in general (see 
p. 117). 
It is desirable therefore that six points be reemphasized: (1) Plant 
dispensaries should be accessibly located. (2) The arrangement of the 
rooms should, be such that those which are used most will be most 
accessible. (3) Equipment should be grouped in units and the units so 
arranged that those most used will be most accessible. (4) Dispensary 
attendants should be agreeable and of pleasing appearance as well as 
versed in knowledge and trained in technique. (5) Patients should be 
treated with the same consideration and conscientious attention they 
would receive if private patients. (6) Records should concern individual 
cases (injury and illness), chronological histories of each workman, and 
show in summary the variety and volume of cases occurring. 
RELATIONSHIP OF MEDICAL DEPARTMENT TO PLANT ORGANIZATION 
An industrial medical department may be completely equipped, 
satisfactorily manned and efficiently operated, yet fail to secure the best 
possible results because of a faulty relationship to the general plant 
organization. Such a condition may be avoided by due attention to (1) 
the ranking of the medical department, and (2) the exercise of tact by the 
medical personnel. 
In a study of 155 industrial medical departments, the writer* found 
that 42 per cent, of them derived their authority from officers in charge 
of production, 21 per cent, from officers in charge of compensation for 
injury, 18 per cent, from administrative officers, 15 per cent, from those 
who direct employment and labor relations, and 4 per cent, from various 
other officers. 
These figures do not warrant a conclusion, but they indicate what 
appears to be the favored relationship-medicine and production. The 
reason for this could seldom be given, and in many places it seemed to 
have been chiefly accidental; that is, the superintendent had seen the 
need for medical service and had just started it. As a matter of fact, 
most medical departments have been started in this very way, by officers 
who have seen the need and met it. 
* Selbdy, C. D., Studies of the Medical and Surgical Care of Industrial Workers, 
Public Health Bulletin No. 99, U. S. Pub. Hlth. Service, 1919. MEDICAL SERVICE AND PLANT ORGANIZATION 
133 
There is a tendency to associate medical service with the activities 
of the labor relations or service department, as it is frequently called. 
This appears to be a logical relationship for the reason that medical 
service is closely concerned with employment, safety, compensation, 
and the other functions of a labor relations department, and the associa- 
tion is capable of strengthening all of them. Furthermore, it gives the 
physician some voice in the settlement of questions that effect employes 
and management jointly. Coming into close contact with the workmen, 
as he does, the physician is well fitted to assist in the solution of these 
questions. 
In the final analysis, however, the placing of a medical department in a 
plant organization depends upon conditions. Wherever it can obtain 
the greatest support, there should it be. Cooperation and backing are 
essential. But after all, it is what the physician and his assistants 
do, and how they do it, that really count in securing the recognition and 
standing a medical department should have. 
Physicians are accustomed to issue orders. They have been trained 
to do so. They order their patients to do this or that; they order nurses 
to carry out certain lines of treatment; and they expect their orders to be 
followed literally and without modification. 
Doctors who carry this dictatorial attitude into industry are miserable 
failures. Manufacturing establishments are not institutions for the 
treatment of the sick. Their object is manufacturing. Medical service 
is therefore secondary to production. Compromises between the ideals 
of medicine and the necessities of production are inevitable. Physicians 
must concede to this necqpsity. They must, at least, be considerate of the 
opinions of others and tactful in their endeavors to gain points. In no 
other way, not by means of a relatively high rank, nor even by much 
knowledge, can industrial physicians secure the measure of respect and 
cooperation that enables them to be of the greatest possible benefit to 
industry. 
The cooperative spirit may be fostered by frequent meetings with 
other officers whose work is affected by measures proposed by the physi- 
cian, such as matters pertaining to sanitation, hazardous process work, 
et cetera. The superintendent, engineer, chemist and others should be 
invited to attend these conferences in order that they might consider 
jointly the measures necessary for putting the recommendations into 
effect. Not only is cooperation obtained through meetings of this nature, 
but a dissemination of knowledge concerning health and hygiene as well, 
which is of course a very desirable result. 
In quite a number of plants the medical department provides service 
for a benefit society of the employes. It is not necessary to describe the 
details of service essential to a connection of this kind. The subject is 
merely mentioned to suggest that if the physician meets with the directors 
of the benefit association, as he should, he has a good opportunity to bring 134 
INDUSTRIAL MEDICAL SERVICE 
about a closer relationship between himself and the employes. This 
gives the employes some representation in the management of the 
medical department, a policy toward the adoption of which industry 
seems to be tending more and more. That it is a wise policy, so far as 
the medical service is concerned, is vouched for by the fact that repre- 
sentation in the management does actually promote a better under- 
standing among the employes as to what the physician is trying to do 
for them. 
Employes will usually, accept the recommendations of physicians 
and plant officials will usually cooperate in putting them into effect if 
they see the reasons that have prompted their making. Nevertheless, it 
occasionally happens that a recommendation meets with opposition. It 
may appear to be radical, capable of disturbing some long established 
custom or process, or it may seem to be unwarrantedly expensive, and 
the judgment of the physician is questioned. In such a case it is proper 
and wise for the physician to call in some recognized authority, such as a 
private consultant in industrial hygiene, or an officer of the local, state 
or national governments. The health and labor departments of several 
states, the U. S. Public Health service and the health departments of a 
few municipalities are prepared to render assistance of this character. 
COST OF INDUSTRIAL MEDICAL SERVICE 
The subject of cost of medical service in industry has never been 
worked out very accurately. Some investigations have been made and 
published rather widely, estimating the average annual cost to be some- 
where near $2.50 per each worker. 
This may be a fair reflection of medical cost, but if it is, the amount is 
far too small and a decided reflection against the value of industrial 
medical service instead. Ten dollars a year is too small, and twenty- 
five dollars is more nearly right. This opinion is supported by the recent 
experiences of a number of capable industrial physicians. There is no 
use trying to run a medical department on a small appropriation. The 
physician who does try only succeeds in ultimate failure. He does not 
satisfy either management or men. On the contrary, a well financed 
medical service can be made a feature of pride to the management, of 
benefit to the employes and profit to the stockholders. 
If the management cannot afford to bear the whole cost of a good 
medical department, let arrangements be made to divide the cost with 
the employes. The latter are the direct beneficiaries, why should they 
not pay a portion of its cost? Give them a voice in the management, let 
them share the cost, then give them good, conscientious service, and they 
will be the strongest allies an industrial medical department can have. 
Doctors themselves have often been responsible for small appropria- 
tions because they have not succeeded in impressing their managements COST OF INDUSTRIAL MEDICAL SERVICE 
135 
with the value of the service they give. And too often the service is not 
worth a great deal from the standpoint of the management. Employers 
are very apt to value a given service by the cheapest figure they can get 
it for. Take for example the dressing of minor injuries-a nurse can do 
that, and the salary she asks fixes the value of the service. Why should 
a manufacturer employ a doctor to do dressings when he can get a nurse 
to do them for less, or why should a manufacturer pay a doctor any more 
than he would a nurse if the doctor does not do anything but dress minor 
injuries? 
On the other hand, if the doctor does things a nurse cannot do and 
does them better than any other doctor could do them, he can command 
his own appropriations and, incidentally, he can command a good salary 
for his service. 
The question of salary has always been a serious one. There has been 
a great deal of dissatisfaction expressed by physicians on the ground 
that they have not been appreciated. There is just one answer to this; 
a doctor will receive in industry, as well as in private practice, an honor- 
arium that is proportional to the service he renders. It may take some 
time to convince the management in some cases, but the doctor will 
eventually get what he is worth if he is sincere and sticks to it. 
Industrial medicine is not different in this respect from any other 
profession or business. Good industrial physicians may command as 
high as $12,000.00 but this is very high. They receive more nearly around 
$5,000.00. And the most of them do not get more than $3,600.00 a year. 
No branch of medical practice has come so prominently to the front 
in recent years as industrial medicine. Its rise has undoubtedly been 
due to the fact that it renders a service of value. To the working people 
it has been tremendously beneficial. To industry it has proven satis- 
factory and profitable. To the medical profession it has opened up new 
avenues for usefulness. It is hoped that industrial physicians will con- 
tinue to develop the field in the same dignified, ethical manner that has 
characterized the work of the pioneers of this, the social era of medicine. 
It is hoped that industrial physicians will continue in the full realization 
of their responsibility toward society and in a receptive attitude toward 
the very splendid opportunities they have for doing something that is very 
much worth while. CHAPTER IX 
THE INDUSTRIAL NURSE 
FLORENCE SWIFT WRIGHT, N. R., New Haven, Conn. 
The Origin of the Industrial Nurse.-In this country the industrial 
nurse has probably entered to a greater extent into industry than has the 
industrial physician. For more than twenty years, employers have, to 
a certain extent, availed themselves of the services of graduate nurses 
for the care of workers in their homes. This was a means of expressing 
their benevolent and charitable motives. But with the enactment of 
labor legislation in various states and the accompanying economic 
necessity for preventing accidents and conserving life, industrial nurses 
were employed to a great extent in first .aid rooms within the plants, in 
order that they might dress minor injuries and so prevent infections, and 
that they might give first aid to serious cases pending the arrival of the 
physician or surgeon. 
Employers who have made the experiment of employing a qualified 
industrial nurse are quite unanimous in saying that the industrial nurse 
has prevented infection and that she has reduced the compensation 
liabilities of their companies. 
Her Relation to the Industrial Medical Service.-Nurses in industry, 
however, soon realized their limitations and those who had had the advan- 
tages of a thorough training and the resulting understanding of the ethics 
of their profession insisted at a very early date that the employer must 
also provide for his employes the services of a physician to be responsible 
for the treatment of cases and to direct the work of the nurse in all medical 
and surgical matters. 
This combination of medical and nursing service has in many cases 
led to the installation by the employers of an adequate medical depart- 
ment with a full time industrial physician in charge. 
There are, however, many industries employing nurses which cannot 
afford to obtain the services of a full time physician, where the nurse 
must depend for support and guidance on the part time services of a 
local physician. 
Graduate nurses are being employed in increasing numbers by 
business oganizations to care for sick workers and their families in the 
homes of the workers, especially in those communities which do not 
support a visiting nurse association which serves all classes alike. Such 
a service provided by the industry proves of value wherever the principles 
136 PRINCIPLES OF PUBLIC HEALTH NURSING 
137 
of public health nursing and of industrial nursing are observed. Where 
the service is provided from funds to which the worker contributes and 
in the expenditure of which he has a voice or where the service is provided 
by the employer as a necessary and understood part of his overhead 
expense just as he provides a repair shop, a safety engineer or lubricating 
oil, the work of the nurse in the homes is understood and appreciated by 
the employes and valued by the employer. 
There are, nevertheless, certain fatal errors into which some employers 
and industrial nurses have fallen which make of the industrial nurse, 
instead of the valuable worker she can and should be, a grave potential 
danger to harmonious industrial relations. 
If all the factors leading to error are fully understood by employer, 
physician and nurse, the importance of the fundamental principles of 
public health nursing as applied to industrial nursing will be granted. 
Guiding Principles.-The principles of public health nursing as 
stated by Miss Mary S. Gardner* in her "Public Health Nursing" 
are as follows: 
"1. That only well trained nurses should be employed. 
"2. That the nurses should not be the distributors of material relief. 
"3. That there should be no interference with the religious views of 
the patients. 
"4. That the rules of professional etiquette should be rigidly observed. 
"5. That cooperation in all its forms should be recognized as of 
primary importance. 
"6. That suitable and accurate records should be kept. 
" 7. That patients unable to pay for nursing care should receive free 
service and . . . that those able to pay for it should do so according to- 
their means. 
"8. That the daily working hours of the nurses should be limited 
in order that good work may be done and that they themselves may be 
kept physically fit." 
A ninth principle should be laid down for the public health nurse in 
industry-if she goes to the homes of the workers she should go as a 
helpful friend and co-worker and not as a detective. 
Observance of the first principle is important because a poorly trained 
nurse is a striking illustration of the fact that a little knowledge is a 
dangerous thing. Not understanding the ethics of nursing, it is she who 
becomes the "cheap substitute" for the industrial physician with all the 
attendant complications. It is the untrained or poorly trained nurse 
who cannot or does not try to convince the layman who is her employer 
that he cannot safely or legally expect her to give first aid or other treat- 
ment without the standing orders of a physician. Having little nursing 
skill and lacking an understanding of the principles of hygiene, and there- 
fore unable to teach the workers how to avoid the causes of discomfort, 
* Gardner, Mary S., "Public Health Nursing," The Macmillan Co., page 55. 138 
THE INDUSTRIAL NURSE 
she seeks to relieve what she should try to prevent and falls into the error 
of dispensing medicines, thus bringing criticism upon herself, her employer 
and her profession. 
The treatment of sickness and injury is not within the province of the 
nurse. She may give first aid. She may act in a real emergency. More 
than this she must not do. Her function is that of a public health nurse 
who nurses but does not prescribe for illness or injuries. While doing 
this she seeks their causes and works for the elimination of hazards. She 
continually demonstrates to people to whom she ministers the principles 
and habits which make for health and safety. 
At a recent meeting of industrial nurses this subject was discussed 
and action was taken to determine means for teaching employers the 
limitations of nurses in this respect. Many nurses stated that they felt 
the need for protecting themselves against suspicion of attempting a 
physician's work and so limited their equipment that it would be apparent 
to any observer that medical treatment could not be given. Several 
nurses stated that they did not wish standing orders for medical cases, 
preferring to depend on rest and quiet, and hot drinks, or hot or cold 
application for temporary discomfort; sending all other patients home 
or to a hospital, or, if that were found impossible, securing the attendance 
of a physician in the plant. 
This is a matter in which the nursing profession needs the understand- 
ing and support of employers and physicians in their efforts to maintain 
a proper standard. The nursing profession as well as industry needs to be 
protected against untrained or half trained women who are willing to 
endanger the lives of their patients by usurping functions which are the 
physician's. 
It is often the unqualified nurse who violates the confidence of her 
patients and so finds it impossible to help them. 
The second principle is in accord with the modern democratic spirit 
of industry. While the industrial nurse may occasionally find it neces- 
sary to give relief in an emergency she should not be an almoner. Any 
funds she distributes regularly should be in the form of stated income such 
as a salary allowance, sick or accident benefit or pension. Any smack 
of paternalism in connection with the nursing service must be avoided. 
The service must not be forced on any one. The right nurses will be 
welcome in the homes and will not need to seek out her patients. 
The third principle is seldom violated in these times. 
The fourth principle involves the relation of the nurse to doctor and 
patient. Its observance precludes any assumption by the nurse of the 
function of physician or surgeon and protects the patient from the danger 
which he sometimes fears that facts known to physician or nurse may be 
used to his disadvantage. 
The fifth principle means that the nurse must have full and equal 
opportunities to cooperate with all her fellow workers. PRINCIPLES OF PUBLIC HEALTH NURSING 
139 
It would seem that no one could doubt the importance of proper 
records but the fact that well prepared industrial nurses are sometimes 
not provided with record forms indicates that some employers do not as 
yet realize the value of recording the findings of the industrial nurse.* 
The seventh principle is important in that an industrial nursing service 
is not a charity. It should be either a perfectly free because necessary 
service, used by every employe or, if financed by the workers, it should be 
free to the members of the organization providing the funds. Where the 
industry cooperates with a local visiting nurse association the same 
principles should be observed. The visiting nurse association should 
be reimbursed either by the company or by the employe. 
The eighth principle must not be overlooked because the demands on 
an industrial nurse may be heavy. If she is a real nurse she will see 
needs that are not appreciated by others and she is often drawn into 
seeming duties which leave her little time for the rest and recreation 
necessary to prolonged and increasing usefulness. 
The ninth principle is also involved in the first and fourth. A detec- 
tive must often betray confidence and a well trained nurse does not 
commit this sin. If it is necessary for the wellbeing of the employe that 
intimate personal matters be made known to the general manager, the 
average worker will usually be glad to give the necessary permission, 
especially when he has confidence that his personal affairs are not made 
known without his consent. A reputation for integrity in her confiden- 
tial relationship with her patients is one of the most valuable assets of the 
industrial nurse. 
If the safety of others is involved as in the case of communicable 
diseases the condition must of course be reported to the Department of 
Health and the]nurse has no further responsibility. Continual report- 
ing of conditions is one of the best ways of rousing an indifferent or 
inefficient department of health. Such a stand on the part of the 
nurse in those plants which employ a physician to care for industrial 
injuries only will lead to cooperation between the health department 
and the industry. 
The industrial nurse who is sent out to look up absentees is a travesty 
on the nursing profession unless she goes to serve the employes and unless 
they welcome her as a friend. 
The looking up of absentees by industrial nurses is of great value to 
those firms who see in this contact an opportunity to improve conditions 
in community or plant and who expect from the nurse constructive 
suggestions as the results of her visits. 
The nurse employed by such a firm finds many ways to endear her- 
self to the workers and to promote industrial harmony. Welcomed 
and understood as a nurse she quickly wins her place as a friend. Then 
the real value of the contact begins to show. 
*Wright, Florence Swift, "Industrial Nursing," The Macmillan Co., Chapters IX-X. 140 
THE INDUSTRIAL NURSE 
Mr. T. is reported absent-the nurse calls-Mrs. T. is troubled. Soon her friend, 
the nurse, hears the whole story. Mr. T. has never been able to get on since he worked 
in the "new weave shed." His foreman scolds and he is always docked for "ends." 
The nurse learns that Mr. T. is forty-five years old and has never worn glasses. She 
furthermore discovers that he is away to-day to try for work in the "old weave shed" 
where he and his boss always got on. Mr. T. is glad to call on the nurse in the morn- 
ing. A session with the oculist, a pair of glasses, a word to the foreman of the "new 
weave shed" and all is well. 
Would anyone but the nurse have brought this about so quickly? 
It is needless to multiply instances. 
On the other hand, if the firm looks upon the nurse as a truant officer 
or medical police she cannot do her best work. In fact, a public health 
nurse with vision would hardly accept such a position. Her findings are 
used in getting rid of undesirable help and this soon becomes known 
and is resented. 
If the worker is retained or discharged on his record in the plant; if 
the nurse is given an opportunity to make that record better, this attitude 
will also become known. 
In this connection, it is well to say a word about the many industrial 
nurses who visit the homes and who do not or who are not allowed to 
nurse. They can hardly avoid being medical police. Even though she 
cannot assume the full care of the patient, the nurse should go to his home 
in a public health nurses' uniform, prepared to render any service she 
can when she makes the visit. The actual nursing work of her hands is 
her passport. Without this passport she has nothing tangible to offer 
that can be understood by those she visits. With it her value cannot be 
measured. As she nurses she can instruct and she can also learn-learn 
what is wrong at home-at work-at school-in the town. What she 
has learned she can show her employer. 
Superior Training a Necessity.-To get from her contact with the 
workers all that she should learn in order to be of help to them, the indus- 
trial nurse should have ready sympathies and a quick understanding 
tempered by judgment and patience. She should be a trained public 
health nurse, and she should be able and willing to study and understand 
the particular industry in which she is employed. As a graduate nurse 
she will have been trained to carry on her first aid work. 
As a public health nurse she will have a general understanding of social 
and industrial conditions and a working knowledge of psychology, as 
well as training in public health nursing, as generally understood. She 
will know the importance of informing herself as to the laws governing 
public health and industrial relations. She will know where to look for 
and how to develop cooperation. 
Only the well trained public health nurse is equipped to meet the 
responsibilities of the industrial nurse. 
Her Responsibilities.-The responsibilities of the industrial nurse are 
fourfold-to employer, to employe, to physician and to the community. SCOPE OF WORK OF THE INDUSTRIAL NURSE 
141 
To her employer and to her patients, who are her co-workers, she owes 
loyalty. If this dual loyalty is incompatible in any organization, that 
■organization has no present use for the services of a trained nurse. By 
means of this loyalty the nurse who seeks to understand and to explain 
as well as to serve becomes a strong influence for industrial harmony. 
She should by her work, as the fellow employe who serves with brain 
as well as hand, become an example of true and beneficial democratic 
relations. She can interpret many things to employer and employe 
alike because her service to both gives her an understanding that the 
greatest advantages to both lie in their mutual welfare. To fulfill this 
double responsibility the industrial nurse should study the industry and 
its hazards, the plant and its defects, and should lend her cooperation 
toward improving conditions. She should go about the plant, following 
up accidents to see for herself the cause and tracing illness to discover 
unhygienic conditions. She should study and seek to understand the 
people, their likes and dislikes, their handicaps, their hopes and ambitions, 
so that she may know how to stimulate in them a desire for good health 
and wholesome surroundings. She should work with her patients more 
than for them, leading them to keep the plant clean and safe and them- 
selves fit as their own responsibility. 
To the physician, whether the industrial physician in the plant or the 
family physician in the homes of her patients, the industrial nurse is 
responsible for the exact observation of all medical orders, both on the 
part of the nurse herself and so far as possible on the part of the patient. 
This relationship is so well understood by both physicians and nurses 
that it needs no explanation. 
To the community the nurse is responsible as a citizen who under- 
stands, from her privilege of contact with so many people, better than most 
citizens the community needs. She should not be backward in using all 
her influence to secure better sanitation, an efficient health department, 
schools, recreations, playgrounds, etc. She can best do this by pointing 
out to the people she serves the essentials of wholesome life. She has a 
unique opportunity to plant the seed from which a better community 
will grow; to plant it where it will bear lasting fruit-in the minds of the 
people of the community. 
The Scope of Her Work.*-The scope of the industrial nurse will vary 
with the industry and with the community. She has a good record as a 
health worker in industry. She has oftentimes paved the way for the 
industrial physician by proving that it is an economy to provide an ade- 
quate medical department. In large plants the industrial nurse some- 
times becomes merely the assistant in the work's dispensary, other duties 
being assigned to specialists. In small plants her field is largest. In 
addition to nursing duties she often manages the lunch room and recrea- 
* For discussion of the duties of the industrial nurse, see "Industrial Nursing," Florence 
Swift Wright, The Macmillan Company. 142 
THE INDUSTRIAL NURSE 
tions, looks after the compensation claims, is an officer of the benefit 
association or acts as employment manager as well as nurse. Sometimes 
in small communities she is tenement inspector and health officer. 
She has entered into most forms of social and public health work. 
As industries develop and organize medical departments and as 
communities secure for themselves necessary health and social facilities 
the scope of the industrial nurse may be expected to become more limited 
but there will always be a place in industry for the understanding, sym- 
pathetic public health nurse who can teach health habits while- she 
ministers to those who need her; who can lead her friends and neighbors, 
the workers, to secure by their own efforts wholesome conditions in 
industry, in home, and in community. 
Her Position in the Establishment.-In order that the most perfect 
cooperation shall exist between the industrial nurse and other depart- 
ment heads in the plant, the industrial nurse should be at the head of the 
nursing department whether that department consists of one or twenty 
nurses. She should be a department head and on an equal footing with 
other department heads. She should be permitted to join in their 
councils and to give the benefit of her experience as she receives the benefit 
of the experience of other department heads. It should be her privilege 
to assist in the shaping of any policies which are formed by department 
heads-her privilege on an equal basis with any such privileges enjoyed 
by the Head of the Safety Dept., the Employment Dept., the Medical 
Dept. She should be privileged to attend foremen's councils if such exist, 
in order that she may become acquainted with their difficulties and so be 
in a better position to cooperate with them. 
This plan of having the nurse in charge of the Nursing Department 
is the plan upon which efficiently managed hospitals are run. In such a 
hospital there is a general superintendent or business manager, there is 
also the chief of the medical staff and a director of nursing service. The 
director of the nursing service is responsible to the medical staff for the 
proper carrying out of medical orders and to the hospital management for 
all other matters. 
This is a system of organization to which nurses and physicians are 
accustomed arid which makes for the best efficiency of the nursing service. 
She Must be More than a Graduate Nurse.-The most successful 
industrial nurses are those who have had good public health training 
and experience as well as a thorough hospital course. While the nurse 
should be well grounded in the care of the sick, she needs also an under- 
standing of the principles of public health, a working knowledge of 
psychology and of social and industrial problems. 
Perhaps the most valuable assets the industrial nurse can have are 
the willingness and the ability to learn, to meet changing conditions with 
modified plans, to understand people and to gain their liking, confidence 
and respect. REMUNERATION OF THE INDUSTRIAL NURSE 
143 
The Remuneration of the Industrial Nurse.-The remuneration of 
the industrial nurse should depend on five factors: (1) her duties (2) 
the locality in which she is employed (3) her training (4) her ability and 
(5) her value to the industry. 
The industrial nurse, caged in a first aid room and occupied solely 
with minor injuries and illnesses, is often the nurse who, if lacking in 
vision or poorly trained, takes upon herself more than is a nurse's duty in 
relation to the treatment of workers. However, if a physician is also 
employed on full time she should escape this temptation, and if her 
employers take care to guard their workers as they should the temptation 
will not be great. The nurse whose work is thus limited sees need for little 
more than a hospital training; in fact such a position would scarcely 
attract an efficient, ambitious well prepared public health nurse. 
When the work of the industrial nurse is confined to looking up 
absentees, without attempt at nursing or social service, she can hardly be 
said to be doing nursing. Public health nurses should take a stand against 
the exploitation of their training in work productive of so little result in 
terms of public health. 
It seems to the writer that the two types of service just described can 
be performed by a person who has not had a public health training, thus 
conserving public health nurses for actual instructive nursing work. 
Therefore, in considering the remuneration of the industrial nurse we 
shall refer to only those doing actual instructive and constructive public 
health nursing in industry; to the nurse who goes into the plant to learn 
the conditions of work there and to cooperate with the executives and 
foremen in creating health, safety and contentment, and to the nurse who 
goes into the home with the conscious purpose of aiding in building up 
prosperous, healthy, and contented households. We shall speak of the 
nurse who is anxious to begin in any nursing work which her employer 
has thought of for her but who is also anxious and able to continually 
increase the importance of the nursing service and her own value to 
the industry. 
As such a nurse should be a trained public health nurse her beginning 
salary should be equal to the salary of other public health nurses in the 
locality. Successful experience should have recognition, as should 
maturity when accompanied by proved ability. If an experienced nurse 
is sought to develop a nursing department the candidate's previous history 
and remuneration should be considered. 
Nurses apparently enter industry for one of two reasons-"for the 
easy* work, good pay, and regular hours," or for the opportunity for 
service and the hope of a future. Those with the first aim will unfortu- 
nately look after their own remuneration. At the present time the best 
* Information as to the schools for training graduate nurses for the special field of 
public health nursing may be had from the National Organization for Public Health 
Nursing, 156 Fifth Ave., New York City. 144 
THE INDUSTRIAL NURSE 
paid industrial nursing is not always the best done or productive of the 
best results. 
If the employer seeks a trained public health nurse he can consult 
with a well conducted visiting nurse association in his part of the country 
as to the salaries paid staff nurses and should arrange his schedule to 
correspond. If he pays a higher salary he should demand a better special 
preparation. 
After the nurse begins her work, ability should be recognized and 
increased remuneration should depend on the value of her results. An 
important nursing position should lead to a salary sufficient to attract 
and hold desirable women. Analysis of the work of many a so-called 
industrial nurse would show little of great value or importance. When 
employers learn discretion in choosing nurses, more nurses will find it 
worth while to take advantage of the many opportunities for preparation 
for public health and industrial nursing which are developing in connec- 
tion with universities through the country. 
BIBLIOGRAPHY FOR THE INDUSTRIAL NURSE 
The Public Health Nurse. 
The Nation's Health. 
The Journal of Industrial Hygiene. 
Monthly Labor Review. 
U. S. Bureau of Labor, special bulletins. 
American Labor Legislation Review. 
The Survey. 
Confessions of a Railroad Signalman, J. O. Fagan. 
The Trail of the Immigrant, E. A. Steiner. 
Public Health Nursing, Mary S. Gardner (Macmillan Co.). 
Industrial Nursing, Florence S. Wright (Macmillan Co., 1919). 
Home and Community Hygiene, Jean Broadhurst (Lippincott Co., 1918). 
RECENT BOOKS ON INDUSTRIAL AND PERSONAL HYGIENE 
Physiology of Industrial Organizations, Jules Amar (London Press, Ltd., 1918). 
The Human Machine and Industrial Efficiency, F. S. Lee (Longmans, Green & 
Co., 1919). 
How to Live, Fisher and Fisk (Funk & Wagnails Co., 17th ed., 1922). 
Personal Hygiene, Walter L. Pyle et al. (W. B. Saunders Co., 1920). 
Health Service in Industry, W. I. Clark, Jr. (Macmillan Co., 1922). 
The Industrial Clinic, Edgar L. Collis (Wm. Wood & Co., 1922). 
Personal Hygiene Applied, J. F. Williams (W. B. Saunders Co., 1922). 
The Public Relief of Sickness, Gerald Morgan (Macmillan Co., 1922). 
The Human Factor in Industry, L. K. Frankel and A. Fieisher (Macmillan 
Co., 1920). 
Elements of Hygiene and Sanitation, Hough and Sedgwick (Ginn & Co., 1918). 
The Community Health Problem. A. C. Burnham (Macmillan Co., 1920). 
Health of the Industrial Worker, E. L. Collis and M. Greenwood (Blakiston's 
Son & Co., 1921). 
Industrial Medicine and Hygiene, E. W. Hope, W. Hanna and C. O. Stally- 
brass (Wm. Wood & Co., 1923). PART II 
VOCATIONAL HYGIENE OF CERTAIN INDUSTRIES 
AND CALLINGS 
CHAPTER I 
MINING AND QUARRYING INDUSTRIES 
GEORGE M. KOBER, M. D„ Washington, D. C. 
Miners and Quarrymen.-Mining, even under the best conditions, is 
one of the most laborious and dangerous occupations, and according to 
the German statistics cited by Lindemann1 it occupies the seventh place 
in reference to accident occurrence, and is surpassed only by railroading 
in American statistics. The liability to accidents is very much greater 
than in other occupations, but has been reduced by efficient safeguards. 
The accident fatality rate among German miners has gradually decreased 
from 3.18 per 1000 in 1879 to 2.40 per 1000 in 1914, while the rate among 
American coal miners has unfortunately increased from 3.50 per 1000 in 
1890 to 3.62 in 1920, as compared with (latest available figures) 0.98 
for India, 1.13 for Belgium, 0.77 for France, 0.88 for Great Britain, 2.40 
for Germany, and 2.37 for Japan. Professor Holmes ascribed the greater 
frequency of accidents in the mines of this country to several factors, such 
as the rapid development and still unorganized condition of the industry, 
to unskilled foreign labor of a migratory disposition unable to understand 
the language, to difference in details in the rules and regulations adopted 
by different mining companies, and last but not least to the sharp compe- 
tition, especially in coal mining, as a result of which the average American 
coal miner produces three times as much coal each working day as is 
produced daily by each miner in Great Britain. On the basis of the 
number of men killed for each million of tons mined, the death rate for 
the latest year available was 3.98 for the United States, 4.11 for Great 
Britain, 7.33 for Belgium, 8.44 for Germany, 4.46 for France, 8.99 for 
India, and 22.07 for Japan. During 1919 among 776,569 wage earners 
2317 men were killed in the coal mines. Later figures showing number of 
employees in coal mines are not available but in 1920 the number of 
fatalities was 2271 and in 1921 it was 1973. In the year 1920 among 
136,583 workers in the metal mines 425 were killed, or a fatality rate of 
3.16 per 1000 as compared with 4.45 in 1911, on the uniform basis of 300 
working days per year. In addition to the fatal accidents in metal 
mining there were 8251 serious injuries, such as fractures of arms, legs or 
ribs, and other injuries, causing the loss of more than 14 days' work, and 
24,311 slight injuries involving disability from 1 to 14 days. According 
145 146 
MINING AND QUARRYING INDUSTRIES 
to W. W. Adams2 during the entire period (1911 to 1920) thus far covered 
by published reports of the U. S. Bureau of Mines, there have been 6239 
men killed and 357,299 injured by accidents at metal mines1 and 1642 
men killed and 92,992 injured at quarries.2 For the years 1869 to 1921, 
covered by official State records of accidents, the number of men killed 
at coal mines was 69,289. Disregarding the nonfatal injuries, and valu- 
ing each life lost at $5000, the economic loss due to the 77,170 fatal 
accidents at coal mines, metal mines, and quarries is $385,850,000. 
The causes of fatal coal mine accidents in the U. S. during 1921 are 
given by W. W. Adams3 as follows: Falls of roof (coal, rock, etc.), 46.58 
per cent.; falls of coal other than roof coal, 5.07 per cent.; mine cars and 
locomotives, 17.13 per cent.; gas explosions and burning gas, 4.87 per 
cent.; explosions of coal dust and gas, 0.96 per cent.; explosives, inclusive 
of suffocation by gases from explosives, 7.69 per cent.; suffocation from 
mine gases, 0.46 per cent.; electricity (shock or burns), 4.05 per cent.; 
animals, 0.36 per cent.; mining machines, 0.91 per cent.; mine fires, 
burned, suffocated, 0.46 per cent.; other causes, 3.70 per cent., making a 
total of 92.24 per cent, killed underground;-1.83 per cent, of the total 
fatal accidents occurred in shafts; about one-half were caused by falling 
down shafts or slopes, and one-fourth from objects falling down shafts 
or slopes, and one-fourth by cages, skips, or buckets, 5.93 per cent, of the 
fatal accidents occurred on the surface and were caused by mine cars and 
locomotives, electricity, machinery, boiler explosions, railway cars and 
locomotives and other causes. 
In 351 coal mine accidents in the U. S. up to and including 1921 in 
which five or more men were killed, involving a total loss of 8585 men, 
6689 or about 78 per cent, were killed by gas and coal dust explosions, 
1134 or over 13 per cent, lost their lives by mine fires, 269 were killed by 
explosives, 129 by inrush of water, 118 by falls of roof and coal, 40 by 
mine cars and locomotives, 114 by shaft accidents and 92 by other causes. 
According to Adams,4 the deaths and injuries that occurred in or about 
metal mines in 1920 were caused as follows: Of the fatal accidents 33.41 
per cent, were due to falls of ore or rocks from roof, wall or bank; 13.41 
per cent, to explosives; 9.42 per cent, to falling down slope, shaft or 
winze, and 11.98 per cent, to haulage systems. 
Of the nonfatal accidents 17.19 per cent, were due to falls of roof, wall 
or bank; 12.67 per cent, to car and haulage systems; 9.39 per cent, to 
machinery, and 11.23 per cent, to timber and hand tools. 
AIR OF MINES 
R. R. SAYERS, M. D„ WASHINGTON, D. C. 
The air of mines may be contaminated by gases described below or 
altered by depletion of its oxygen and, as a result, its composition may 
differ from that of normal pure air. AIR OF MINES 
147 
Carbon dioxide, CO2, is a product of decomposition and combustion of 
organic compounds and a result of respiration of men and animals. It is 
naturally increased by the process of breathing, by the burning of miners' 
lamps, by mine fire explosions, and by blasting operations. This gas, 
which is an important constituent of black damp and at least traces of 
which are always present in air, has long been used as a measure of the 
impurity of air but its importance as such has probably been over-empha- 
sized. While in itself it is not toxic, it sometimes occurs in mines in suffi- 
cient quantities to cause symptoms in man or even unconsciousness and 
death. One-half of 1 per cent, of carbon dioxide in normal air causes a 
slight and unnoticeable increase in the ventilation of the lungs, that is, a 
man exposed to of 1 per cent, of carbon dioxide will breathe a little 
deeper and a little faster than when in pure air. If there is 2 per cent, of 
carbon dioxide in the air, the lung ventilation will be increased about 50 
per cent.; if there is 3 per cent, the lung ventilation will be increased about 
100 per cent.; 5 per cent, causes about 300 per cent, increase in the lung 
ventilation and the breathing is laborious; 10 per cent, cannot be endured 
for more than a very few minutes. These results are obtained from 
carbon dioxide air when the oxygen in the air remains about normal and 
the subject is not working.5 
Carbon monoxide, CO, sometimes called "white-damp" or "sweet 
gas," is a product of slow or incomplete combustion of organic material. 
It is produced during mine fires, explosions of gases or coal dust, and 
blasting operations. When mixed with air in proportions varying from 
15^ to 75 per cent, carbon monoxide will explode if ignited. This gas 
causes a great many deaths among miners and workers in the mineral 
industries. It is without odor, color, or taste, and its effects often go 
unnoticed by the victim until too late. The United States Bureau of 
Mines found that a canary bird collapsed in the presence of between 0.2 
and 0.3 per cent, of carbon monoxide, while the members of the exploring 
party experienced no symptoms of distress. The bird quickly revived 
when placed in better air. A chemical apparatus, developed as a result of 
studies made during the World War and known as a carbon monoxide 
detector, has also been found by the Bureau of Mines to be a valuable 
supplement to the canary in the detection of carbon monoxide, as smaller 
percentages of the gas can be estimated by its use than by the effects of 
the gas on small animals. It should be remembered that animals without 
red blood are not affected by carbon monoxide, it having been shown many 
times that such animals can live in high concentrations without harmful 
results. Recently it was demonstrated at the Bureau of Mines experi- 
ment station at Pittsburgh that roaches could be kept for several days in 
an atmosphere of 60 per cent, carbon monoxide and 20 per cent, oxygen 
without lessening their activities. 
Hydrogen sulphide, H2S, called "stink-damp" on account of its odor 
resembling rotten eggs, is usually a product of decomposition of sulphide 148 
MINING AND QUARRYING INDUSTRIES 
minerals in the presence of moisture. It may also be produced by the 
burning of black powder and other explosives. It has been found, 
though rarely, issuing with methane from gas blowers or feeders in coal 
mines. According to Lehmann6 as little as 0.05 per cent, will sometimes 
cause death after long exposure, 0.07 per cent, may produce death in one 
hour, and 0.2 per cent, in a very few minutes. When mixed with seven 
tims its volume of air, it is violently explosive. 
Methane, marsh gas, CH4, also known as light carburretted hydrogen 
and the principal constituent of fire damp, is a product of decomposition 
of carbonaceous matter which has taken place with the exclusion of air 
and in the presence of water. It is one of the characteristic occluded gases 
of coal mines and is occasionally observed in other mining operations. 
Due to its common occurrence and easy explosibility, numerous disasters 
have occurred in coal mines. It is colorless and odorless, but its common 
occurrence in old workings of collieries, where the air may be musty from 
decaying timber, has given the idea to many mining men that it has an 
odor.7 It may be detected by the use of the safety lamp and the approxi- 
mate amount present determined by its action upon the flame. 
This gas has no physiological effect upon men, but it may accumulate 
to such proportions as to make an explosive mixture with the oxygen of 
the air and thus result in disaster or, by diluting the air, may cause a 
man to suffer from oxygen deficiency. 
Ethane, C2H6, Propane, CaHs, Butane, C4H10, and other heavier 
gases belonging to the methane series, are components of natural gas but 
are not normally found in coal mines. They have a pronounced crude 
oil or natural gas odor which gives warning that there is a probable 
leakage from a gas well or oil well in the neighborhood.8 
After-damp and black-damp are one and the same gaseous mixture-- 
carbon dioxide and nitrogen-the first being formed with great rapidity 
by the explosion of fire damp or coal dust or both and the latter by the 
gradual absorption of oxygen and giving off of carbon dioxide by the coal. 
After-damp refers to the gaseous mixture in mines after the explosion. 
It probably always contains more or less carbon monoxide and the pres- 
ence of this gas may distinguish the after-damp from black-damp formed 
in the ordinary way. The untoward physiological effects due to after- 
damp are caused probably by the presence of carbon monoxide or by the 
oxygen deficiency. 
Oxides of nitrogen are given off when nitroglycerine, blasting gelatine, 
dynamite, or other high explosives are burned rather than exploded. 
Haldane found that when nitroglycerine was exploded the gases of 
combustion were 63.2 per cent, carbon dioxide and 31.6 per cent, nitrogen, 
but when burned in the presence of its own gases they contained 35.9 
per cent, carbon monoxide and 48.2 per cent, nitric oxide (NO). This 
latter gas on contact with air is immediately oxidized to nitrogen with the 
production of red fumes. Peroxide of nitrogen is probably the most EXPLOSIVE CONDITIONS IN MINES 
149 
irritating of any of the oxides of nitrogen. The effects on the respiratory 
passages do not usually manifest themselves for several hours after 
exposure, when edema and swelling take place. This irritation may be 
followed by bronchitis or pneumonia. 
MINING AND QUARRYING (Continued) 
BY GEORGE M. KOBER, M. D. 
The undue prevalence of pneumonia among the workers in some of 
the mines, both here and in South Africa, may in part be due to the fact 
that exposure to nitrous gases, apart from engendering pulmonary 
congestion, also produces methemoglobin. It has been noted by Dr. 
Huntington, cited by Dr. Ebright,9 that men engaged in blasting opera- 
tions are inclined to be irritable and pugnacious and that it is unsafe to 
pick a quarrel with them. Dr. Ebright attributes this to the fact that 
alcohol enhances the toxic effects of nitroglycerine, and in support cites 
a case in which acute mania with homicidal impulses developed. 
Explosive Conditions in Mines.-Among the causes which render 
explosive conditions in mines possible are the following: (1) Defective 
ventilation; (2) sudden increase of explosive gases; (3) dry coal dust 
suspended in the air; (4) pressure due to a heavy blast or concussion of 
the air; (5) rapid succession of shots in close workings; (6) discharge of 
an explosive in a dusty atmosphere. The exciting cause may be ignition 
of fire-damp, or fine coal dust, caused by a blown-out shot. 
Preventive Measures.-For the prevention of fire-damp explosions, 
safety lamps, permissible electric lights, copious ventilation and safety 
rules have been found most efficient. Copious ventilation, on the other 
hand, has proved a source of danger by stirring up fine coal dust and 
carrying it to the roofs, sides, bars and props of the mines, and thus 
greatly increasing the dangers from coal dust explosions. 
This danger is generally recognized and recommendations for the pre- 
vention of such catastrophes have been made. Garforth, cited by 
Oliver,10 suggests fixing the dust (1) by water spraying under high 
pressure; (2) by keeping the roadways free from dust for certain lengths, 
thus creating dustless zones; (3) covering or diluting the coal dust with 
stone dust. Ascher and others recommend spraying with calcium and 
magnesium chlorides mixed with silicate of soda, glycerine, water, etc. 
Thornton advocates spraying with soapy water; others advocate the 
removal of coal dust by vacuum cleaners. So far the creation of dustless 
zones and the use of stone dust, urged by Garforth, appear to give prom- 
ise of the most satisfactory results. Water spraying was followed by 
an increase in the number of cases of hook-worm infection among the 
German miners in the Valley of the Ruhr. Joseph A. Holmes, First 
Director of the Bureau of Mines,11 found that there is less danger 
from coal dust explosion in the spring, summer and early autumn months, 150 
MINING AND QUARRYING INDUSTRIES 
as the warm air admitted from without, upon being cooled by contact 
with the cool walls within, deposits its moisture and keeps up a continuous 
sweating. During the cold winter months it has been found that the 
introduction of exhaust steam from the mine power plant in sufficient 
quantities to raise the temperature of the entering air, and at the same 
time to supply it with moisture, offers a simple safeguard. Prof. Holmes 
fully realizes that this method, as well as spraying, is likely to favor the 
development and spread of the hook-worm disease, and also to create 
less favorable working conditions as regards humidity and temperature. 
But happily neither of these evils has appeared after an experience of 
nearly 10 years. 
Diseases of Miners, Tunnel Workers and Quarrymen.-Lindemann's1 
German statistics for 1911, based upon a membership of 357,321, show 
that (1) diseases of the digestive organs lead the list in the order of frequency 
with 39,725 cases or 11.1 per cent.; (2) diseases of the respiratory organs 
28,954 or 8.1 per cent.; (3) neuralgia, 33,991 or 9.4 per cent.; (4) acute 
articular rheumatism, 3482 or 0.97 per cent.; (5) muscular rheumatism, 
30,008 or 8.3 per cent.; (6) pneumonia, 1774 or 0.49 per cent.; (7) 
nystagmus, 1356 or 0.37 per cent.; (8) hook-worm disease, 1166 or 0.32 
per cent.; (9) emphysema and asthma, 689 or 0.19 per cent.; (10) heart 
disease, 449 or 0.12 per cent.12 
Dr. Emery R. Hayhurst12 investigated the health hazards and mor- 
tality statistics of soft coal mining in all the mining districts of Illinois 
and Ohio in 1918 with the assistance of Mr. Paul Skoog* in Illinois and 
Dr. R. P. Albaughf in Ohio: In both Illinois and Ohio, soft (bitumi- 
nous) coal only is mined. The industry in these states is steadily 
increasing; it employed approximately 50,000 workmen in Ohio and 90,000 
in Illinois. The quantity of coal in sight in both states is sufficient 
to- last for centuries. Healthful working conditions in Ohio mines were 
not as good as the average, of most industries in Ohio. On the other 
hand, conditions are good in Illinois mines, which are deep and dry. 
The eight-hour day prevails. 
Housing conditions and harmful forms of recreation, especially 
alcoholism, undoubtedly caused the major amount of sickness. The 
mine itself is not an unhealthful place in which to work. Lack of interest 
in these districts on the part of the population of the rest of the state is a 
potent reason for low standards of hygiene in mining districts. 
HEALTH HAZARDS, DISEASES AND MORTALITY STATISTICS 
[BY EMERY R. HAYHURST, M. D. 
"Dirt" Piles or Gob.-As entries and rooms are extended, the refuse ("bone") 
coal, slate, rock, pyrites, soapstone, clod, timbers, etc., are heaped to either side. 
A certain amount of decomposition takes place in this, occasionally leading to spon- 
taneous fires usually emitting carbon monoxide from incomplete combustion and 
* Director of Surveys, Illinois State Board of Health. 
t Chief of the Division of Industrial Hygiene, Ohio State Department of Health. SPECIAL HEALTH HAZARDS OF COAL MINING 
151 
sometimes hydrogen sulphide gas. The gob crumbles up much and adds to the dust 
in the air and the mud underfoot, also the danger of accidents. 
Dust.-Coal dust itself is regarded as among the least harmful dusts. It creates 
a catarrhal condition which tends to remove it from the respiratory tract. But much 
crystalline and gritty dusts are breathed by the miner as well as acrid sulphur com- 
pounds. The harmful dusts may be listed about as follows in ascending order of 
harmfulness to the miner: coal, timber, clay, soapstone, shale, slate, softer rock, 
sandstone, granite, and sulphur (pyrites). The last three or four dusts are very 
prevalent. When breathed they tend to remain fixed in the lungs and to bring about 
fibrosis, chronic bronchitis, emphysema, and lymphadenitis, the whole characterized 
as "miner's asthma." 
Illumination.-Illumination is no longer a hazard for miners since much of the 
bottom is supplied with electric lights and miners use the modern carbide lamps, 
attached to the caps. Oil lamps are all but gone. Safety lamps, fortunately, with 
their imperfect illumination (the potent cause of nystagmus in British mines) are not 
required for work in Ohio or Illinois mines because these mines, as ventilated, are 
non-gassy so that naked lamps are safe. Occasionally, men complain of the glare 
from brilliant carbide miners' lamps. 
Temperature.-The temperature of mines is very constant. Shallow or wet 
mines are the coolest (temperature falling between 50 to 60°F. at the working 
face). Mines between 300 to 600 feet deep have temperature ranging from 60 to 
70°F. In Illinois' deepest mine (1004 ft.) it runs up to 80°F. Slight seasonal 
variations occur. 
Humidity.-Dripping roofs, mud, and dampness characterize most Ohio mines. 
Dryness characterizes Illinois mines, but the atmosphere of all mines is usually nearly 
saturated with moisture, derived from the strata, by the time it leaves the mine. 
Hence, most of the workers are in a cool moist temperature (highly impregnated 
with dust). The water and humidity greatly increase electrical hazards. 
Fatigue.-Faulty postures while under strain and work of jarring, vibrative char- 
acter, heavy lifting and the employment of a certain percentage of men ill-fitted 
physically for the work, are the chief hazards. The muscular fatigue, however, is 
probably no hazard to normal men of proper build and experience. In some mines 
the competition, to get empty mine cars to fill, leads to much "spurt" work. 
Infection.-The disposal of stools in the gob, as is the prevailing method, can be 
made safe. The extent to which coal mine dust may transport virulent germs, as 
from spitting, has not been investigated; the hazard is probably insignificant. Dis- 
eases from animals, such as anthrax, glanders, and lockjaw (in spite of the presence of 
horses or mules in all mines) do not appear to exist. In the presence of the black 
plague, the rats and mice in mines would be a great menace. Injuries which miners 
receive are at least as free from secondary infections, if not more so, than in most 
classes of workers. Influenza-pneumonia epidemics are particularly severe in mining 
camps (E. B. Starr, Amer. Jour, of Pub. Hlth., Vol. X, No. 4, April, 1920). So, also, 
are small-pox and summer diarrhea. 
Electricity.-In addition to burns and shocks and occasionally electrocutions, the 
witnessing of brilliant electric flashes occasions some electric ophthalmia. Electric 
lights, motors, trolleys, rails, signals and telephones are found in mines and necessarily 
in close proximity to workers. 
Poisons.-These concern mine gases almost solely which have already been 
described on pages 146-149. Sulphur occurs as pyrites and in acid forms; the latter 
dissolved in water is often strong enough to eat holes in clothing or to cause ulcers in 
the eyes if gaining access to them. In dust form it irritates the throat, nose and lungs. 
Questionable water supplies in many instances make miners liable to typhoid fever, 
dysentery, and water-borne diseases. Alcoholic beverages are not permitted while at 
work. 152 
MINING AND QUARRYING INDUSTRIES 
Personal Hygiene.-Miners are in great need of instruction in matters of personal 
hygiene and the prevention of sickness. A large per cent, of miners' illnesses could 
be curtailed by this means. 
GENERAL SUMMARY OF DISEASES 
There is no reason for believing that the usual afflictions, aside from the respiratory 
system and the musculosseous system, are more frequent among miners than among 
other employes. In fact, as a class, they are probably healthier than the average 
type of factory worker. Top workers, exposed to the weather, are said to have more 
sickness than those in the mine. Sickness is much more rampant among the women 
and children in mining districts than among the men. Diseases with occupational 
earmarks are "rheumatism," asthmatic afflictions, and disorders due to alcoholic 
beverages. The "rheumatism" is of the type unassociated with fever, called mus- 
culo-articular, of which lumbago is the chief form, and the so-called "sciatica" 
is next in frequency. Exposure to cool, damp atmospheres, drafts, the weather, and 
straining efforts on the part of men often not physically adapted for same, are under- 
lying causes. The incidence of "miner's asthma" is decreasing. Bad ventilation 
probably still plays a chief part in its cause, but the breathing of dust, and the sus- 
ceptibility of men with weak hearts or other chronic diseases probably account for 
what asthma is found. Asthma rarely occurs in individuals under forty years of age. 
About one or two working men in a hundred are reported as asthmatics, and such con- 
ditions are a frequent cause of temporary absences. Alcoholism is exceedingly 
common, perhaps more so than in other industries, since it seems to be traditional 
among a considerable number of miners to take a day or so off after each pay for an 
alcoholic debauch. Less serious are dust plugs in the ears (of no consequence, but the 
cause of some temporary deafness); eyes flashed by electric short circuits; callosities 
on knees and sometimes elbows, hands and shoulders, mostly in "low coal" districts; 
"gassing" due principally to accidental breathing of white damp after blasting, fires, 
or explosions; and premature ageing. This last is not a marked feature. There is 
some eye irritation due to sulphur (pyrites) dust. 
Tuberculosis and pneumonia have about the same prevalence as elsewhere. 
Venereal diseases are conspicuously less. Several diseases supposedly of industrial 
character among miners, such as hook-worm, nystagmus, and lockj aw^ are practically 
non-existent. 
SUMMARY OF MORTALITY STATISTICS 
1. The annual death rate of Illinois coal miners has steadily increased from 10.03 
in 1913 to 11.85 in 1918. 
2. The percentage distribution of deaths from different causes shows that rates for 
Illinois miners are about the same as for miners and quarrymen in the registration 
area, 1909, and that for this class of employees, external causes (violence') make up 
nearly two-fifths of all deaths, whereas violence for all occupied males makes up but 
one-tenth of all deaths. 
3. As compared with occupied males in general, Illinois coal miners rank (a) 
about the same with respect to cancer and liver cirrhosis; (b) more favorably with 
respect to tuberculosis (although the difference is not great), cerebro-spinal diseases, 
circulatory diseases, other respiratory diseases, and genito-urinary (non-venereal) dis- 
eases; and (c) much less favorably with respect to typhoid fever, pneumonia* and suicide. 
4 Tuberculosis shows its main emphasis in the age-group, 25 to 34 years. Pneu- 
monia shows its emphasis in the age-group, 45 to 54 years. 
5. All the specific causes of death (Table I) show a tendency to increase as years 
go by with the exception of ''other respiratory diseases" and suicide. The causes for 
these tendencies are undoubtedly many and complex. 
'Pneumonia is said to be a common aftermath of carbon monoxide poisoning. (Glaister 
and Logan, Gas Poisoning in Mining and Other Industries, 1916, page 109.) MORTALITY STATISTICS OF COAL MINERS 
153 
Table I.-Mortality of Illinois Coal Miners from Selected Causes of Death 
(February 1, 1912 to July 21, 1918-Approximately 6^ years) 
Cause of death 
International 
list numbers 
Total 
number 
of deaths* 
Percentage 
distribution 
of deaths 
Death- 
rate per 
annum per 
100,000 
employed f 
Typhoid fever 
1 
154 
2.8 
30.8 
Malaria 
4, 4a 
11 
0.2 
2.2 
Tetanus 
24 
6 
0.1 
1.2 
Tuberculosis 
28 to 35 
498 
9.2 
99.4 
Cancer 
39 to 46 
207 
3.8 
41.4 
Cerebro-spinal diseases 
60 to 79 
288 
5.3 
57.5 
Circulatory diseases 
77 to 85 
402 
7.4 
80.3 
Pneumonia 
91 and 92 
491 
9.1 
98.1 
Other respiratory diseases.. 
(86 to 90) 
(93 to 98) 
213 
3.9 
42.6 
Liver cirrhosis 
113, 113a 
88 
1.6 
17.6 
Genito-urinary (non- 
venereal) 
119 to 127 
253 
4.7 
50.5 
Suicide 
155 to 163 
160 
3.0 
31.9 
Violence ft 
164 to 186 
1995 
36.8 
398.2 
All others 
all others 
662 
12.2 
132.1 
Totals 
5428 
100.2 
1083.9 
* From figures compiled by Duncan McDonald, former Sec.-Treas., U. M. W. A., 
District of Illinois (Feb. 1, 1912 to Jan. 31, 1916) and by the Illinois Commission on 
Health Insurance (Feb. 1, 1916 to July 21, 1918) with the help of death claim records 
at office of Walter Nesbitt, Sec.-Treas., U. M. W. A. 
f The average monthly number of employes throughout the whole period of 
approximately six and one-half years was 77,051. The casual reader should not 
compare the rates in this column, which are for adult males only, with the rates of 
death from similar causes in the population at large. 
ft "Violence" includes all external causes other than suicide. 
Miners and tunnel workers may also be subject to compressed-air 
disease and Dr. G. W. Johnson13 has reported 42 cases of gas poisoning 
caused by the fumes of a petroleum motor engine, used in the construction 
of the Montreal tunnel. 
Affections known as "beat hand," "beat knee," "beat elbow" are 
primarily due to friction of tools or contact with hard ground, etc., causing 
callosities of the skin beneath which infection may occur, giving rise to 
subcutaneous cellulitis of the hand, over the patella and elbow. Inflam- 
mation of the synovial lining of the wrist-joint and tendon sheaths is not 
uncommon. 154 
MINING AND QUARRYING INDUSTRIES 
The undue prevalence of diseases of the digestive organs has no 
special connection with the occupation, except in so far as it tends to the 
consumption of cold victuals and of excessive quantities of cold water 
when the body is overheated. Miners as a class, also have a tendency to 
"piece-meal" from their lunch buckets more or less throughout the work 
day, often dispensing with any set lunch hour-a questionable habit 
which may account for much of the digestive derangements reported. 
Nieszytha14 mentions mechanical pressure of the tool upon the stomach 
and liver, the ingestion of dust, the inhalation of sulphureted hydrogen 
and carbon monoxide, and the abuse of alcohol as possible factors, and 
that prohibition of the use of alcoholic beverages during working hours, 
especially in the clay and stone quarries, has had a beneficial effect. 
The respiratory diseases, however, are greatly influenced by the 
character and amount of dust, injurious gases, heat and humidity, abrupt 
changes in temperature, drafts, overwork, etc. The gases in the after- 
damp, especially carbon monoxide and nitrous fumes, doubtless play an 
important role in the causation of acute pulmonary affections. Workers 
in quarries, on account of the additional exposure to the elements, are 
much more liable to pneumonia than miners. The majority of chronic 
respiratory diseases begin as catarrhal affections of the upper air passages 
■-bronchial catarrh-which may terminate in or be complicated sooner 
or later with pneumoconiosis (see page 701), emphysema and tuberculosis. 
The character of dust doubtless plays a more important role than the 
amount. In no other way can we explain the comparative innocuity of 
coal dust, the particles of which are quite free from sharp points and 
corners. Dr. Ogle, in the 45th Annual Report of the Registrar General, 
has shown that coal miners stand at the head of the list as regards com- 
parative immunity from phthisis and other lung diseases in dust-inhaling 
occupations. On the other hand, the Cornish tin miners, who are exposed 
to the inhalation of a sharp angular and most irritant type of dust, fur- 
nish the largest number of cases. This difference in the character of the 
dust is also strikingly illustrated by our American statistics, which show a 
mortality from tuberculosis and pneumonia of 25.8 per cent, among coal 
miners, compared with 31.63 per cent, among metal miners and 43.5 per 
cent, among copper miners. The observations among the gold quartz 
miners of South Africa has already been referred to. Dr. A. J. Lanza 
of the U. S. P. H. S. in an address before the American Public Health 
Association in 1915 first directed attention to the unusual amount of pul- 
monary diseases among the zinc miners of the Joplin district as compared 
with similar miners in southeastern Missouri, and attributes the difference 
to the presence of large amounts of flint dust, which has a silica content of 
over 95 per cent. Nieszytka14 states that salt and sulphur mining, 
and all metal mining involving exposure to dust containing lead, predis- 
pose to tuberculosis; on the other hand, Caryophilis reports only five cases 
of tuberculosis among 1932 Greek sulphur miners. Nieszytka reports DISEASES OF MINERS AND QUARRYMEN 
155 
that 76.5 per cent, of all the deaths among the sandstone workers at 
Hanover are caused by tuberculosis and that their average age is only 
35.1 years. On the other hand, he cites Grab's statistics to show that in 
limestone workers tuberculosis is the cause of death in only 7.5 per cent, 
of the total mortality, with a tuberculosis morbidity rate according to 
Schlokow of only 2.2 per 1000. Koelsch15 confirms Grab's statistics with 
reference to the lime and cement industry and cites the statistics of a 
German Benefit Society to show that among 400 workers, in a German 
plaster-of-Paris establishment, no cases of tuberculosis occurred during 
a period of 17 years, and that of 40,824 deaths from tuberculosis analyzed 
by Fisac in Spain, only 17 or 0.41 per 1000 occurred in lime or gypsum 
workers. Selkirk16 was also unable to find a single case of phthisis among 
lime and cement workers in the vicinity of Edinburgh, nor could he learn 
of any worker in limekilns having died from this disease. He suggests 
that the workingman predisposed to tuberculosis might turn his attention 
to lime and cement working as an occupation, and even hints at the organi- 
zation of lime works as a curative for a tuberculosis colony. All such 
statements deserve painstaking investigations. In our own country 
Reckzeh, as early as 1903 concluded that the statistics in lime producing17 
districts show that pulmonary tuberculosis is rare, and that sometimes 
when present its course is favorably affected. Mr. N. C. Rockwood18 
has recently collected testimony to show that lime dust possesses con- 
siderable preventive and curative properties in pulmonary tuberculosis. 
The tuberculosis death rate among the workers in slate quarries in 
Thuringia amounts to 43.1 per cent, and even to 64.3 per cent, among 
the slate-pencil makers, and this in spite of the fact that dust production 
is not specially excessive. It is also high among the slate workers of 
Wales. Oliver suggests that the bad housing and living conditions are 
important factors. 
The quarrymen and stonebreakers of the Leipsic Sick Benefit Society 
have the third highest morbidity rate, viz., 1496 days per 100 workers, 
and the mortality hazard is 0.88 per cent. 
The undue prevalence of rheumatic and neuralgic affections is doubt- 
less influenced by unfavorable working conditions, such as heat, humidity, 
sudden changes, stooped positions, contact with wet ground, scant 
clothing, etc. Hard work, articular rheumatism and alterations in the 
lung tissue, such as pneumoconiosis, emphysema, etc., naturally favor the 
development of heart lesions. 
The cause of nystagmus is still somewhat obscure. Butler19 believes 
that chronic carbon monoxide poisoning is one of the chief factors. 
Lindemann's experience leads him to conclude that the muscular strain 
incident to an abnormal position of the eyeball, and the glare of the 
miner's lamp, are more important factors than defective light, carbon 
monoxide gas, and other suggested causes. He believes that chronic 
inflammatory conditions of the eyes, opacity of the cornea, visual defects, 156 
MINING AND QUARRYING INDUSTRIES 
anaemia, general weakness and alcoholism also favor the development of 
nystagmus, which, while affecting between 3 and 4 per 1000 miners, is 
rarely of sufficient gravity to prevent recognition of a 2 to 3 per cent, 
fire-damp in the flame of a benzine safety lamp. A case is reported 
(Bull. Bur. Lab. Statist., Mar. 1918, page 193) in which nystagmus devel- 
oped in a German miner after being hit on the right parietal bone by a 
piece of rock weighing about one pound. 
Dr. R. R. Sayers, U. S. Public Health Service, and D. Harrington of the U. S. Bureau 
of Mines,22 made a preliminary study of the physiological effects of high temperatures and 
high humidities in two metal mines. In both mines the data were taken at points over 
2000 ft. below the surface and with surrounding rock temperatures generally in excess of 
90°F. The following is a summary: 
I. In still air in metal mines, with a wet bulb temperature over 90°F., and under 100°F., 
and with a relative humidity of 89 per cent, or higher, the following signs and symptoms 
were found, even when little or no exercise was taken: 
1. Blood pressure, systolic and diastolic, fell rapidly. (2) Body temperature rose; 
in one case it reached 102°F., and this after less than 2 hours having been spent in the hot, 
humid air described. (3) Pulse rate increased and seemed more sensitive to exercise than 
normally. (4) Perspiration was very profuse. (5) Dizziness was a common symptom, 
and sometimes was marked. (6) Physical weakness or exhaustion was marked in some 
cases and present in all. (7) Inability to think quickly or accurately was a very common 
symptom. (8) Nausea was usually found. (9) Headache was also occasionally found. 
(10) Loss of weight was especially marked in men who had been employed under above 
conditions over a period of years, but occurred even after exposure of only a few days. 
II. In still air, with wet bulb temperatures of from 85°F. to 86°F. and a relative humid- 
ity of 96 per cent., there were no marked changes in the blood pressure or body tempera- 
ture, nor were the symptoms dizziness, physical weakness, and inability to think or act 
quickly, mentioned in I, found as long as the subjects remained at rest or took only light 
exercise. When moderate exercise was taken-climbing up and down an 8-ft. ladder 
fifteen times in 5 minutes-the blood pressure and body temperature rose somewhat. 
Hook-worm disease deserves special attention, as the conditions in 
mines, with special reference to absence of privies, temperature, humidity, 
exposed portions of the skin, and the eating of food with unclean hands 
favor the development and spread of the disease. In 1904 hook-worm 
infection was noted in 13,861 Westphalian miners; in 1911 there were 
still 1166 cases or 3.26 per 1000. In the meantime an energetic cam- 
paign had been waged against the spread of the infection by the erection 
of transportable privies for the prevention of soil pollution, disinfection 
of stools by means of milk of lime, and by the administration of thymol 
for the destruction of the parasite in infected individuals. The carriers 
of infection are not permitted to resume work in the mines until found 
free from worms and eggs for a period of 2 weeks after cessation of 
medication; a reexamination is made at the expiration of 6 weeks. 
According to Cumming and White,20 Dr. F. F. Sprague of Jackson, Cal., first 
recognized the prevalence of hook-worm infection in the gold mines of California in 
1906. In 1909, Dr. Herbert Gunn made an investigation and reported that hook- 
worm infected from 50 to 80 per cent, of those working in the mines, and that the 
infection was doubtless present in practically all of the gold mines in California and 
;in those of Nevada just over the border. In 1911, Dr. Endicott, health officer of 
Amador County, related his experience in a paper before the American Medical 
Association. In 1916, Dr. James C. Cumming of the State Board of Health of 
California and Joseph H. White of the Federal Bureau of Mines concluded an investi- 
gation with the following results: Of 1096 men examined 337 or 31 per cent, were PREVENTIVE MEASURES 
157 
infected with hook-worms; the percentage of the 969 underground workers was 38 
and in the 137 surface workers it was only 10 per cent.; moreover nearly all of the 14 
infected surface workers had formerly worked underground. The report is very 
exhaustive and contains excellent recommendations for the prevention and treatment. 
The oil of chenopodium was used. Carbon tetrachloride has proved useful according 
to M. C. Hall; also according to J. C. Allen (cited by G. C. Lake), in dogs, foxes and 
man. Amebic dysentery has been observed in some of the Arizona mining camps, 
following the importation of Mexican labor, and Dr. Lanza fears that hook-worm 
may also gain a foothold there. 
Anaemia has always been quite prevalent among miners and at one 
time the belief that chronic carbon monoxide poisoning and absence of 
sunlight played an important role in the causation of anaemia montana 
appeared justified. It is highly probable, however, that excessive heat 
and humidity, hook-worm infection and chronic pulmonary diseases are 
the most important factors. 
PREVENTIVE MEASURES 
Commendable progress is being made in the substitution of machine 
labor for hand labor. This, together with reasonable hours of work, 
diminution in dust production and its removal by exhaust ventilation, 
will materially aid not only in the prevention of diseases of the respiratory 
and circulatory organs, but also in the prevention of accidents from 
explosions of gases and coal dust. The general use of permissible 
explosives should be insisted upon. The question of adequate ventila- 
tion is of special importance.22 According to Dr. Lanza, in France the law 
limits the regular working temperature to 96° dry and 86° wet bulb. In 
Victoria and New Zealand 80° wet bulb is the limit. In Germany when 
the wet bulb is above 80° the shift is reduced from 8 to 6 hours. The 
undue prevalence of rheumatic and neuralgic affections can be materially 
checked by suitable work suits and avoidance of abrupt changes in 
temperature, and by shower baths and change of clothing upon cessation 
of work. Pure drinking water, sanitary privies below and above ground 
and washing facilities are often lacking for which there is no reasonable 
excuse. Men engaged in quarries should be provided with suitable shelter 
during inclement weather; the employment of respirators and eye pro- 
tectors is clearly indicated. No effort should be spared to improve the 
housing and living conditions of miners and quarrymen, whose natural 
powers of physical endurance are severely taxed by so many injurious 
factors connected with their work. 
Stonecutters and Marble Workers.-These occupations have from 
time immemorial been regarded as inimical to health and even Ramazzini, 
in the first book on Occupational Diseases, calls attention to the fact 
that the inhalation of the dust incident to hewing, cutting and polishing 
of marble or of stone produces a troublesome cough, and that a goodly 
number of the operatives become asthmatic and consumptive. We know 158 
MINING AND QUARRYING INDUSTRIES 
now that the inhalation of mineral dust develops sooner or later pneumo- 
coniosis which may eventuate in pulmonary tuberculosis. It is generally 
held that the liability to diseases of the respiratory passages is less in the 
case of paving stonecutters and slate splitters, and in the sawing, grinding, 
polishing and lathe work which can be conducted by the wet process, 
than in the case of monument or custom work, and particularly in the 
surfacing, carving and cutting with pneumatic tools. The greatest 
amount of dust is evolved by the surfacing machines which are operated 
with compressed air. Of the various tools employed, the bushing hammer 
creates the finest dust.* Unfortunately, work with pneumatic tools can- 
not be done by the wet process, as the pasty material created by a mixture 
of water and dust clogs up the tools. This work is usually done in large 
open sheds or in the yards, but even under such conditions the men are 
exposed to clouds of dust. The sawing of granite and marble into slabs, 
turning in lathes, and the final polishing can be conducted by the wet 
process; soapstone sawing and cutting for joints is frequently done dry 
and is attended with exposure to considerable dust. 
The following is a condensed extract of Mr. W. C. Day's23 description of the 
polishing process: The slabs of stone to be polished are placed upon a rubbing bed 
which consists of a circular cast-iron plate from 8 to 15 ft. in diameter with a circular 
opening about 18 in. in the center, and mounted upon a running gear so that it may 
revolve in a horizontal plane. An abrading material such as sand sometimes mixed 
with "chilled shot" or crushed steel, with a constant supply of water, is fed upon the 
plate. When the process has gone far enough, the slabs are removed to the emery bed, 
which is similar to the one described, fine emery being used for abrasion. The slabs 
are next rubbed down by hand with a fine, evenly grained sandstone, known as "Scotch 
hone," and smoothed off with pumice stone. The final polish is put on by placing the 
slabs upon a buffing bed, which is similar to the rubbing bed but covered with a thick 
specially prepared felt. A small amount of putty powder is fed to give a high polish. 
* A very exhaustive study of the effect of the air hammer on the hand of stonecutters 
was made by Dr. Alice Hamilton and also by Dr. J. P. Leake and Dr. David L. Edsall of 
the U. S. Public Health Service. Dr. Hamilton visited the limestone belt of Indiana, the 
granite cutting centers in Quincy, Mass, and Barre, Vt., the marble shops of Long Island 
City and the sandstone mills of Northern Ohio. She found that the air hammer is employed 
by limestone cutters almost all the time. Marble cutters work more with the mallet 
than do the limestone men, but the greater part of their work is with the pneumatic tool 
and usually the smaller sizes. Granite cutters cannot use the machine for shaping the 
block; as a rule the workers in granite sheds use it only 4.5 or 6 hours a day, while some 
men engaged in lettering and carving use the same sort of air hammer as is found in marble 
and limestone mills and some of these workers use this tool all day long. Dr. Hamilton 
examined altogether 123 workmen and found only 17 who had not had the so-called "dead 
fingers." This condition appears to be caused by three factors-long continued muscular 
contraction of the fingers in holding the tool, the vibrations of the tool and cold. It is 
increased by too continuous use of the air hammer, by grasping the tool too tightly, by 
using a worn, loose air hammer, and by cold in the working place. If these features can 
be eliminated the trouble can probably be decidedly lessened. 
Dr. Leake in his survey of the employment of the pneumatic tool in other occupations, 
such as hot and cold riveting, calking of metal seams, chipping rough projections from cast- 
ings and shells, found that none of the metal workers who used air hammers showed a 
tendency towards vasomotor spasticity or the blanching of the hands. 
Leake and Edsall do not believe that this affection is serious to life or function, but is 
uncomfortable at times and should be remedied. It is believed that this can be done 
without eliminating the tool by the helpful suggestions offered above. (Public Health 
Reports, March 22, 1918, pages 379, 403, and April 5, 1918, pages 488-489.) STONECUTTERS AND MARBLE WORKERS 
159 
The hand process consists in grinding on the rubbing bed as before, and then rubbing 
down by hand, successively with Nova Scotia "blue stone," "red stone," "Scotch 
hone" and pumice stone, after which it is glossed with putty powder, or in case of 
cheaper "onyxes" and common marbles, with a mixture of two parts of oxalic acid 
and one part of tin oxide. 
Of the various kinds of stone dust some are doubtless more injurious 
than others. Reference has already been made to the excessive death 
rates from tuberculosis among workers in sandstone and the low rates in 
limestone workers in Germany. (See page 155.) 
Hoffman24 with his characteristic thoroughness has just completed a 
study bearing on this subject from which we extract the following: 
The average silicotic content of granite is 72.96 per cent., of sandstone, 85.42 per 
cent., and of limestone 1.22 per cent. The evidence is absolutely conclusive that the 
dust hazard depends primarily upon the silicotic content of the dust inhaled. The 
evidence is also conclusive that workers exposed to marble or limestone dust suffer a 
decidedly lesser liability to pulmonary tuberculosis than those exposed to granite or 
sandstone dust, with a high silicotic content. 
No trustworthy statistics are available as to the death rate of marble workers from 
pulmonary tuberculosis but from such investigations as have been made in Vermont, 
the contrast is markedly in favor of the marble workers. Statistics collected in 
Southern Indiana for the limestone industry, show that during the period from 1915- 
1918 the mortality from pulmonary tuberculosis in lime-stone cutters was 425.5 per 
100,000, which is quite a contrast to the death rate from this disease of 1044.3 per 
100,000 for granite cutters and 1029.9 for sand-stone cutters. Hoffman also brings 
out the fact that the incidence of pulmonary tuberculosis is practically proportionate 
to the trade life and that the death rate from this disease among granite workers in 
New England has increased from 432.0 (during the period of 1895-99) to 1056.7 
during the period of 1915-1918. 
It is also stated that in the Southern States where most of the work is done out of 
doors the death rate from pulmonary tuberculosis among granite cutters during the 
period 1912-1913 was only 441.1 per 100,000 of population, against 962.3 for the New 
England States. This may reasonably be attributed to a diminished dust hazard in 
out door work. 
The Inspectors of the State Board of Health of Massachusetts25 
regard granite dust more injurious than marble and soapstone the least 
of all; some varieties of granite yield a much finer dust than others on 
account of differences of texture. It should be remembered, however, 
that cutting of all varieties of stone involves exposure to dust, and that 
the character of the dust, the environments under which the work is 
performed, the social conditions, such as housing, etc., doubtless influence 
to a great extent the liability to pulmonary affections. 
A collective investigation cited by Roth28 shows that of every 100 deaths among 
stonecutters, polishers, etc., 86 were due to diseases of the lungs, inclusive of 55 deaths 
from tuberculosis. 
Of 2013 stonecutters examined by Sommerfeld28 19.7 per cent, were afflicted with 
tuberculosis, 17.98 per cent, with other diseases of the lungs, and nearly all had a 
chronic catarrh of the throat or larynx. According to the report of the State Board 
of Health of Massachusetts25 of 343 deaths which occurred in the city of Quincy among 
stonecutters during a period of 16 years 41.4 per cent, were caused by consumption, 160 
MINING AND QUARRYING INDUSTRIES 
12 per cent, were due to other diseases of the lungs; 12.8 per cent, to diseases of the 
heart; 7 per cent, to violence; and 26.8 per cent, to all other causes. 
In analyzing the statistics of the towns in the State of Vermont, where most of 
the granite and marble industry is carried on, the writer found27 that Barre, Mont- 
pelier, Rutland, Proctor, Dorset, Hardwick, Bethel and Ryegate, with a combined 
population of 34,889, had a tuberculosis death rate of 2.2 per 1000 of population, 
against a rate of 1.3 for the entire State. In the light of Hoffman's recent investiga- 
tions it may be assumed that the granite workers contributed a greater percentage 
of the deaths than the marble workers, although no comparative statistics are 
available. 
Hoffman's28 statistics based upon 534 deaths among stonecutters from all causes, 
show that the principal cause of death was tuberculosis, amounting to 47.8 per cent, 
at the ages between 25 and 44 years, and at ages between 45-62 to 32.3 per cent, of the 
mortality from all causes. According to the recent Ohio Survey by Hayhurst, of 
163 deaths between 1910 and 1912, among the marble and stonecutters, 27.61 per 
cent, were caused by pulmonary tuberculosis, as compared with 7.13 per cent, in 
persons engaged in agricultural pursuits. The Leipsic statistics show a sickness rate 
for marble cutters of 1294 days for 100 members per annum and a mortality hazard of 
1.27 per cent. 
Millstone cutting has always been regarded as a dangerous occupation, 
with special reference to pulmonary diseases. This is due to the fact that 
on account of the very hard character of buhr-stone, which is composed of 
a variety of quartz, there is an unusual wear and tear of the steel tools 
with which the stone is dressed, and the men are exposed to a combination 
of steel and mineral dust. Oliver29 found very few old men in this 
industry, and states that buhr-stone workers are frequently intemperate. 
The same may be said of stone workers in general, who attribute the habit 
to the dryness of the throat caused by the lodgment of dust. It must be 
conceded that all dust-producing occupations are predisposing factors to 
the alcoholic habit, especially when the employer makes no attempt to 
furnish pure water, and when the regulations for the prevention and 
removal of dust are totally ignored. 
Apart from the danger of dust inhalation the liability to accidents is 
not inconsiderable in all stonecutting operations, injuries to the eyes from 
flying chips and fragments of steel from implements are especially 
common. Rheumatic affections and colds, as a result of exposure are 
also quite common. The work is very laborious and none but able- 
bodied men should enter the trade. 
Ganister or silica stone is a quartzite rock found in England beneath 
the lower coal measures and above the millstone grit. It is used in the 
manufacture of highly refractory bricks and linings required for steel and 
other furnaces, and also for silica paint, etc. The lumps of ganister too 
large to enter the jaws of a stone crushing machine are broken up with 
hammers, which involves exposure to a very fine dust, as also the subse- 
quent operation of crushing, even though the stone is wetted. In the 
process of grinding, from 1-3 per cent, of lime in the form of powdered 
lime or hydrated solution of lime is added, the resulting product, of the 
consistency of mortar, being discharged on the floor of the brick making REFERENCES ON MINING AND QUARRYING 
161 
shed, and after tempering, is moulded by hand into bricks. After the 
bricks are dried they are burned at a temperature of 3,000°F. or 
slightly over for several days. 
An investigation under authority of the Chief Inspector of factories 
of Great Britain24 was made of the incidence of respiratory diseases, 
due to the inhalation of dust among the workers employed in this indus- 
try. The inquiry revealed the fact that during 8 years among an average 
not exceeding 60 workers, there occurred 18 deaths from phthisis and 8 
deaths from other diseases of the lungs. A comparative table clearly 
indicates the relatively high risk assumed by those who make silica bricks. 
Preventive Measures.-All the precautions mentioned in the preced- 
ing section for the protection of quarrymen, such as wet processes, general 
cleanliness and copious downward exhaust ventilation, use of goggles and 
respirators are aonlicable for stonecutters and ganister workers. 
REFERENCES 
1 Lindemann.-Trans. 15th Int. Congress Hygiene, Vol. Ill, Part II, Washington, 
1913. 
2 Adams, W. W.-Quarry Accidents in the U. S. in 1920. Technical Paper 295, 
U. S. Bureau of Mines. 
3 Adams, W. W.-Coal-mine Fatalities in the U. S. in 1921, Technical Paper 302, 
U. S. Bureau of Mines. 
4 Adams, W. W.-Metal-mine Accidents in the U. S. in 1920, Technical Paper 299, 
U. S. Bureau of Mines. 
B Hill, Leonard.-Science of Ventilation and Open Air Treatment. Special Report 
Series, No. 52, Medical Research Council, London, 1920. 
6 Lehmann, K. B.-Quoted by Rudolf Robert in Kompendium der praktischen 
Toxikologie zum Gebrauche fur Arzte, Studierende und Medizinalbeamte, 
Stuttgart, 1912. 
7 Peele's Mining Engineers' Handbook, page 1388, quoting George S. Rice. 
8 Coal Miners' Pocketbook, McGraw-Hill Book Company, 1916. 
9 Ebright.-Jour. Am. Med. Assoc., Vol. LXII, Jan. 17, 1914, page 201. 
10 Oliver, Sir Thomas.-Dust and Fumes, General Address Delivered before 15th 
Inter. Congress on Hygiene and Demography, Wash., D. C., 1913. 
11 Holmes, Joseph A.-Diseases and Accidents of Miners and Tunnel Workers in 
U. S., 15th Int. Cong, on Hyg., Vol. Ill, Part II, Washington, D. C., 1913, 
page 691. 
12 Hayhurst, Emery R.-Journal of Industrial Hygiene, I, 7, November, 1919; also 
Modern Medicine, June and July, 1919. 
13 Johnson, G. W.-Jour. Canada Med. Asso., Feb., 1912. 
14 Nieszytka.1-Viertaljahrscht f. Gericht. Medizin, etc., 1912, Vol. XLIII, Suppl. Heft 
1 and 2, page 143. 
15 Koelsch.-Krankheit u. Soziale Lage, 1st Liefg., Munchen, 1912. 
16 Selkirk, Burns.-Brit. Med. Jour., 1908, page 1493 and Jour. Am. Med. Assoc. 
Dec. 12, 1908. 
17 Reckzeh.-Med. Record, N. Y., December 5, 1903. 
18 Rockwood, N. C.-Rock Products, Chicago, Jan. 14, 1912. 
19 Butler Ophthalmoscope, 1912, page 680. 
20 Cumming, James G.-Jos. H. White, Control of Hookworm Disease, etc. Bull. 
139 Bureau of Mines, Washington, 1917. 162 
MINING AND QUARRYING INDUSTRIES 
21 Lake, G. C,-Public Health Reports, May 12, 1922. 
22 Sayres and Harrington.-Public Health Reports, Washington, D. C., Jan. 28, 1921, 
page 116. 
23 Day, W. C.-Report on the Stone Industry, U. S. Geological Survey, 1908. 
24 Hoffman, F. L.-Bulletin, U. S. Bureau of Labor, Statistics No. 293, May, 1922, 
pages 2-4. 
28 Report of the State Board of Health of Mass, upon the Sanitary Condition of 
Factories, Workshops, etc., 1907, page 79. 
26 Kompendium der Gewerbekrankheiten, Berlin, 1904, page 26. 
27 Kober, Geo. M.-Bulletin No. 3, Vol. XIII, Vermont State Board of Health, 
March, 1913. 
28 Hoffman, F. L.-Exhibit of the Prudential Insur. Comp, of America, 1912. 
29 Oliver.-Diseases of Occupation, E. P. Dutton, New York, 1916. 
30 Monthly Review.-U. S. Bureau of Labor Statistics, Apr., 1918, No. 295, page 292. 
Home Office Report on the Manufacture of Silica Bricks, etc., London, 1917, 
page 16. CHAPTER II 
CLAY PRODUCTS, POTTERY, GLASS AND ALLIED 
INDUSTRIES 
GEORGE M. .KOBER, M. D„ Washington, D. C 
The Clay Products Industry.-The brick and tile industry includes 
the manufacture of building bricks, fancy and ornamental bricks, vitrified 
paving brick, drain tile and sewer pipe. 
The preliminary work, such as grinding and mixing of clay involves 
exposure to dust, also to the elements and to wet processes, while in the 
vicinity of the kilns, there is more or less exposure to excessive heat, 
sudden changes in temperature, drafts and to the inhalation of CO, CO2, 
and of sulphurous acid. 
Instances of carbon monoxide poisoning have occurred in men entering 
the kilns for the purpose of filling or emptying, also during the burning 
process, by the escape of gas from defective kilns and flues. Rambousek 
cites the case of a worker who was about to fill a kiln, and upon opening 
the furnace door was overcome by large volumes of CO, which proved 
fatal, in spite of efforts at resuscitation. 
The German statistics, cited by Gottschalk1 show that nearly 21 per 
cent, of all the sickness is caused by muscular rheumatism, mostly lum- 
bago which is frequently accompanied by sciatica and other neuralgia. 
Pneumonia and pleurisy contributed 5.4 per cent., and colds and catarrhal 
affections of the respiratory organs 18.1 per cent, of the general morbidity. 
The catarrhal affections are to a considerable extent induced by inhala- 
tion of dust, and German authors have found a sufficient number of 
"clay lungs" to justify the term aluminosis. During the winter months 
influenza contributes an additional 10 per cent, to the morbidity rate. 
It is evident that the undue prevalence of diseases of the respiratory 
organs paves the way for tuberculosis. Twelve and three-tenth per cent, 
of the morbidity was caused by diseases of the digestive system, probably 
due to sudden changes in temperature, improper food, and the pernicious 
habit of cold drinks while the body is overheated. Hoffman's Industrial 
Insurance statistics show that out of 527 deaths in brick, tile and terra- 
cotta workers 82 or 15.6 per cent, are from pulmonary tuberculosis. 
On account of soil pollution caused by primitive habits at the clay 
banks there is also a certain amount of danger from infection with the 
hook-worm, the small intestinal round worm and typhoid organisms. 
Varicose veins and ulcers are not uncommon. 
163 164 
CLAY PRODUCTS, POTTERY, GLASS AND ALLIED INDUSTRIES 
Callosities of the hands, as a result of hard work, and eczema of the 
hands and wrists from exposure to dust, dirt and moisture are frequently 
observed. Most of the glazing is done by the addition of salt. The 
danger from lead poisoning in the manufacture of fancy ornamental and 
enameled bricks, due to the employment of glazes containing lead, will be 
referred to in connection with the pottery industry. 
Preventive Measures.-The hygiene of this industry has been very 
much neglected and this is especially true with reference to clean, decent 
quarters and sanitary conveniences for unmarried employes, and pure 
drinking water. Persons engaged in wet work should wear rubber boots 
and aprons. Dust production should be reduced to a minimum. The 
men employed about the brick kilns should wear suitable clothing and 
protect their eyes from exposure to intense heat and light, and should 
receive instructions how to avoid injurious gases. Washing facilities 
before each meal, and facilities for a full bath and change of clothing upon 
cessation of work, should be provided. 
The Pottery, Terra-cotta and Fire Clay Product Industry.-The chief 
products of this industry are stoneware, earthenware, porcelain ware, 
fire-brick and terra-cotta products. 
The ordinary stoneware and earthenware is usually made of common 
clay. For the better grades of goods, china clay or calcined bone are 
added; and for the still higher grades of porcelain a mixture composed of 
very fine clay, calcined bone and feldspar is used. The most expensive 
ware like Limoge porcelain is made from very fine white clay peculiar to 
that section. The removal of the different clays from stock bins, the 
crushing, grinding, mixing and sifting processes, and especially the process 
known as "flint dust making" are attended with the evolution of large 
amounts of dust. 
There is also more or less exposure to plaster of Paris dust in the 
manufacture of moulds for forms for china, art ware, etc. 
The chief factors inimical to health in the so-called "slip houses" 
are dust, heat, fatigue and dampness from faulty floor drainage, leaky 
vats and slip-containing machines and the presence of wet clay under foot. 
Sagger Making.-This process which consists in shaping, repairing, baking and 
finishing of clay containers in which the pottery ware is subsequently baked, 
involves similar hazards, and also the risk of lead poisoning, from the red lead solution 
with which the inside of the saggers are painted. The Ohio Survey disclosed four 
cases of lead poisoning among 20 workers in this branch. 
Bisque Making.-In this department the clays previously prepared in the "slip" 
house are shaped on plaster of Paris moulds and potter's wheels. In tile and porcelain 
factories this work is done by machines in so-called press rooms. After the ware is 
shaped, it is carried, usually by boys, into the drying kilns, located in the rear of the 
workers. This process involves exposure to dust, heat and fumes from the baking 
ovens, unless efficient exhaust ventilation is provided. 
Glaze Mixing.-In order to render clay products impervious, and to secure 
a polished surface, they are dipped into a liquid glaze containing finely ground clay GLAZE DIPPING, KILNING AND DECORATING 
165 
and flint and more or less white carbonate or red oxide of lead. Some of the glazes 
do not contain lead, but most of them do, and when used there is naturally considerable 
exposure to lead dust. Of 865 cases of lead poisoning which occurred between 1901 
and 1909, in the potteries of Great Britain, 788 were contracted in glaze processes, 
51 in decorative processes, and 26 in unclassified processes.2 
Glaze Dipping and Kilning.-After drying or bisqueting, and some- 
times even in the green state, the ware is dipped into a glaze solution, or 
the solution is applied by means of a brush or sponge. The glazes used 
for porcelain, stoneware, and some tiles contain usually no lead. The 
colored glazes are rich in lead and the majority of glazes contain lead 
in an unfritted form, but is preferable as "fritted" lead, which is a 
fixed compound with borax and silica, is less soluble and hence less 
dangerous. The dipping is generally done by hand, although recently 
dipping machines specially adapted for tiles and other regular pieces 
are employed and have reduced the handling of glazes very greatly, and 
practically obviated the necessity of "fettling" and cleaning of the glaze 
from the edge of the tile. The process of "fettling" consists in the 
removal of superfluous glaze from the ware prior to placing it in the 
glost kiln, but refers more especially to the removal of little projections by 
means of a small steel knife, and other finishing processes, such as rubbing, 
sanding and dressing after the ware leaves the kiln. 
After glazing, the ware is placed in saggers and fired. Ordinary terra- 
cotta or stoneware is dipped and fired but once, but most of the other ware 
is fired twice. In some branches the glaze is applied to already partly 
glazed ware in the form of lead enamel dust, by means of a cotton pad; 
this method, known as "ground laying," is dangerous and has been to a 
great extent replaced by the aerographing process. For roof tiles and 
bricks the glaze, if used at all, is usually poured on, or applied by means 
of a brush. The last two methods are sloppy and dangerous because the 
liquid is liable to splash over the hands, clothing, floor, etc. Kaup® 
reports that in some roof-tiling establishments nearly all of the workers 
suffer from lead poisoning. 
The work in or about the kilns involves exposure to excessive heat, coal 
gas, dust, abrupt changes in temperature, and lead poisoning. The Ohio 
Survey disclosed about 35 cases of lead poisoning among the 1220 workers 
around the bisque and glost kilns. The chief risk came from handling 
the ware upon which the glaze had just been dried and from which it could 
be wiped off like flour; in some instances, especially in art and colored 
ware,, the dust contained 50 per cent, of lead. 
Decorating Department.-The decorative processes may be carried on 
before or after the glaze is applied and in some instances the glaze itself is 
colored. So for example, Rockingham ware is glazed with a dip contain- 
ing manganese, which results in a brownish or plum colored finish, and 
jet ware is dipped in a glaze containing cobalt which imparts the jet black 
finish. Since cobalt is obtained from arsenical ores there is some danger 166 
CLAY PRODUCTS, POTTERY, GLASS AND ALLIED INDUSTRIES 
from arsenical poisoning. Most of the decorating processes are carried 
on by females and weaklings and consist in the laying on of lithographic 
transfers by means of sizing with turpentine, stamping on impressions, 
"lining" with gold stripes and gilding, color spraying, hand painting, etc. 
The employment of lead containing pigments, such as chrome yellow, 
nitrate of lead or red lead, whether applied by brush, the aerograph or 
decalcomania, naturally involves exposure to lead poisoning. The Ohio 
Survey disclosed three cases of lead poisoning, one suspected case of 
arsenic poisoning and one case from benzine varnish poisoning. 
Summary.-While cases of plumbism in decorative work are now less 
frequent, the sedentary habits and unfavorable working conditions 
predispose to neurasthenia, diseases of the respiratory and digestive 
organs, ocular defects and inflammatory conditions of the eyes from 
exposure to turpentine. 
The danger from dust inhalation in the ceramic industry is plainly revealed by 
the undue prevalence of respiratory diseases, which according to Holitscher's4 German 
statistics were the cause of death in 72.8 per cent, of the potters, and in 62.4 per cent, 
of the decorators. Koelsch8 examined about 1000 workers of both sexes in the porce- 
lain industry in Bavaria and found that the dusty processes were productive of 
catarrhal conditions of the eyes, nose, throat and upper respiratory passages. About 
51.6 per cent, of the male, and 40.2 per cent, of the female workers presented evidence 
of fibroid phthisis, but only 2 per cent, of those examined, 15 males and 5 females, 
were found to be tuberculous. The undue prevalence of gastric catarrah and constipa- 
tion is generally attributed to the ingestion of mineral dust; a similar explanation has 
been given for the occurrence of gastric ulcers by Bogner and Bernutz, in pottery 
workers. The latter, a French author, also refers to the frequency of gastric ulcer in 
stone-cutters. Koelsch while admitting the swallowing of mineral dust as a possible 
cause of gastric ulcer believes that pressure over the stomach in carrying saggers and 
moulds in a bent over position, may likewise play a role. Abrupt changes in tempera- 
ture and some of the wet processes doubtless account for the undue prevalence of 
muscular rheumatism. 
Koelsch refers to denuded finger tips, as a result of smoothing out the moist raw 
ware, enlarged bursa and induration of the skin on the shoulder tips, from the carrying 
of a board, loaded with heavy ware, and also varicose veins, as typical occupational 
afflictions. Females who carry heavy loads frequently complain of pain in the lower 
part of the abdomen and groins. Diseases of the skin with the exception of eczema 
in water workers are seldom seen. Hoffman's American Industrial statistics show 
that 32.2 per cent, of pottery workers perish from tuberculosis. Rheumatic and 
neuralgic affections and obstinate forms of eczema are not uncommon. Cases of 
lead poisoning are still unduly prevalent, especially in this country, and in the smaller 
establishments and home industries of Europe. Chyzer,8 cited by Rambousek, 
refers to the conditions in Hungary where members of the family contract the disease 
from the dust in the living rooms, which was found to contain from 0.5 to 8.7 per cent, 
of lead. The degree of danger depends upon the amount of lead used, which varies 
from 10 to 24 per cent, in the glaze fluxes, and from 60 to 80 per cent, in the enamel 
colors for decorative purposes. 
Oliver7 and Thorpe, who investigated the subject of lead poisoning in the potteries 
of Great Britain, came to the conclusion, as early as 1899, that by far the greater 
amount of earthenware can be glazed without lead, and that in certain branches of the 
industry, in which lead is indispensable, it should be used in the form of a fritted LEAD POISONING IN POTTERY INDUSTRIES OF THE U. S. 
167 
double silicate. It has been found that the danger can be materially reduced by using 
only 8 per cent, of carbonate of lead in the form of a "double fritted silicate" instead 
of the older method, in which from 13-24 per cent, of lead carbonate was employed. 
The English authorities determined that no glaze should be used which upon shaking 
for an hour with 1000 times its weight of a 0.25 per cent, watery solution of hydro- 
chloric acid revealed more than 5 per cent, of its dry weight of lead monoxide. The 
fruits of this splendid work are shown by the fact that in 1898 Great Britain had 
still 457 cases of lead poisoning among pottery workers, and in 1908 only 58 cases. 
Unfortunately, we have not profited by this lesson to any considerable extent, for 
Dr. Alice Hamilton's investigations show that while Great Britain in 1910 had only 
77 cases in a force of 6865 workers, in 1911 we had 144 cases in a force of 
1500. Nothing should be permitted to stop the campaign for leadless glazes, and 
since it has been shown, as pointed out by Oliver,7 that the enameled bricks used in 
Babylon 522 B. C. and the decorative tiles in Egypt, did not contain lead, it is hoped 
that chemistry and technical skill will sooner or later solve the problem. 
Distribution of Lead Poisoning in the Pottery Industries of the United 
States.-Three important surveys have been made in this country to 
determine the lead and other hazards in this industry. The first was 
made by Dr. Alice Hamilton in 1910 and 1911; the second by Dr. Emery 
R. Hayhurst in 1914 and the last by the United States Public Health 
Service in 1919. The following table reproduced from Public Health 
Bulletin No. 116, May 1921, embodies the results of each of these surveys. 
Hamilton, 1910-1911 
Hayhurst, 1914 
U. S. Public Health Serv- 
ice, 1919 
Re- 
ported 
Lead 
cases 
Rate 
Exam- 
ined 
and re- 
ported 
Lead 
cases 
Rate 
Exam- 
ined 
Posi- 
tive 
lead 
cases 
Rate 
Age (years) 
Under 20 
75 
5 
6.7 
218 
2 
0.9 
20-39 
2035 
66 
3.2 
355 
44 
5.1 
40-44 
324 
19 
5.9 
235 
28 
11.9 
45-49 
78 
8 
10.3 
173 
18 
10.4 
50 
55 
11 
20.0 
328 
47 
14.3 
Total 
2585 
109 
4.2 
1809 
139 
7.7 
Exposure (years) 
0-0.9 
38 
6 
239 
3 
1.0 
1-4.9 
36 
35 
392 
17 
4.3 
5-9.9 
63 
25 
294 
19 
6.5 
10 plus 
49 
43 
720 
93 
12.9 
Total 
186 
109 
4.2 
1695 
132 
7.8 
Occupation 
Glaze mixer 
51 
9 
17.7 
112 
11 
9.8 
Dipper 
365 
92 
25.2 
245 
31 
12.7 
292 
46 
15.8 
Dippers' helper 
221 
27 
12.2 
205 
19 
9.3 
220 
10 
4.5 
Ware cleaner . 
311 
2 
0.6 
104 
3 
2.9 
Glost-kiln placer 
464 
19 
4.1 
474 
36 
7.6 
707 
49 
7.0 
Sagger washer 
45 
4 
8.9 
73 
3 
4.1 
Decorator... . 
20 
3 
15.0 
1217 
7 
0.6 
32 
3 
9.4 
Other 
37 
1 
2.7 
269 
17 
6.3 
Total 
1070 
141 
13.2 
2585 
109 
4.2 
1809 
139 
7.7 168 
CLAY PRODUCTS, POTTERY, GLASS AND ALLIED INDUSTRIES 
Dr. R. P. Albaugh summarized the findings of the Ohio Survey 
and called special attention to the fact that only 5.1 per cent, of the 2585 
exposed employes were over 45 years of age, indicating that workers 
leave the industry for some cause before passing middle life. Of those 
over 45 years of age about 15 per cent, were suffering from lead poisoning. 
Another study, which is illustrated in the second part of the above table, 
shows that the evidence of lead poisoning appears in about the same ratio 
as the length of exposure in years thus sustaining the conclusion that 
lead poisoning in pottery workers is a slowly accumulated form of chronic 
rather than acute lead poisoning. The table conclusively shows that 
glaze dipping and glaze mixing are the most hazardous processes in the 
industry. The U. S. Public Health Service in the Ohio study of potteries in 
1919 made an effort to seek out the 109 cases found by Hayhurst in 1914. 
Fifty out of the 109 men were still working in the potteries, forty of whom 
were still definitely leaded. Of the fifty-nine who were not working in the 
potteries no information was obtainable about thirty-five. Of the 
twenty-four others, five were found to have died, cause not stated, and 
the rest to have sought other employment, chiefly in farming, teamstering, 
insurance and iron founding, while two of them found employment in a 
pottery where lead was said not to be used. 
Preventive Measures.-While much of the potter's work is with moist materials, 
it is evident that the handling of all dry and fired products, and the grinding and 
mixing of lead compounds of glazes, involves exposure to dust, which should be 
reduced to a minimum by moist methods. Exhaust ventilation is important in all 
dusty processes such as fettling and pressing of tiles, bedding and Hinting, brushing 
and scouring of biscuit ware.- Exhaust drafts are especially needed in the dusty 
lead processes, such as mixing and grinding of lead compounds, aerographing, color 
dusting, and in ware cleaning. Absolute cleanliness of the workshops, cement or 
inpervious floors, frequently washed, proper air-space, good general ventilation, and 
special lunch rooms are important. Suitable work suits and caps, ablutions before 
meals, baths and change of clothing upon cessation of work, and monthly medical 
inspection of workers exposed to lead processes should be insisted upon. 
Lime Burning.-The risks incident to the quarrying of limestone have been referred 
to and also some interesting statistical data in reference to the comparative danger of 
lime, plaster of Paris and other mineral dusts have been presented. Rossie's9 recent 
investigations tend to show that workers in the lime, cement, procelain and glass 
industries have relatively favorable mortality rates from tuberculosis. The kilns are 
generally loaded from a car, operated by cable from the top of the kiln platform, and 
the dumping involves exposure to dust and more or less CO2 from the open kilns. 
During the roasting process there is exposure to excessive heat and escaping gases, 
while the unloading from the false bottom of the kiln and the subsequent grinding 
and packing of the lime, unless a good suction system is in operation, are naturally 
very dusty operations. As a result, inflammatory affections of the skin especially 
pronounced in the warmer seasons and of the eyes, and of the upper air passages are 
not infrequent. 
Plaster of Paris.-The crushing of gypsum, CaSO4+2H2O, the roasting in kilns 
and subsequent grinding in buhrstones and the terminal processes of handling 
through hoppers, bins, conveyors and sacking involves considerable exposure to dust. 
According to Lehmann,10 the air in different departments of such plants usually MEERSCHAUM, MICA, CEMENT AND ASPHALT 
169 
contains from 75-200 mg. of dust per c.m. involving the inhalation of from 0.7 to 
1 gm. of dust during the shift. Animals subjected in Lehmann's laboratory to daily in- 
halations of 200 mgr. per cubic meter of air for 3 months revealed no harmful effects, 
only a small amount of dust was found in the lungs, and even in the larynx it was 
impossible to detect particles of plaster of Paris with the aid of the polarization 
microscope. The observations of Hebert, Maut6, etc., in France have confirmed 
the contention of the older German authorities that the production of plaster of 
Paris is accomplished without serious injury to the workers. The sackers showed 
evidence of inflammatory conditions of the eyes, nose and throat, and among 158 
workers six were found to be tuberculous. According to the report of the Factory 
Inspector of Great Britain for 1912, no free silica is present in plaster of Paris, and 
the mortality from tuberculosis is not above the normal. (See also interesting 
statistics on page 155.) 
Meerschaum, also known as sepiolite, is a soft white hydrous magnesium clay, 
containing silica, and when dry it will float on water. It is chiefly used for carving 
tobacco pipes and cigar holders and the dust, like that of talc and soapstone, is 
believed by some writers to be a frequent cause of chronic diseases of the respiratory 
passages. 
Mica.-This is a mineral of widely varying chemical composition, but is essentially 
composed of silicates of aluminum and an alkali, such as potassium, sodium or lithium. 
The mineral splits easily into thin flexible colorless transparent plates or scales, known 
as isinglass, and besides window lights for automobiles, etc., is used for a number of 
purposes where glass could not resist the effects of heat. In the powdered form 
it is employed in the manufacture of a giant powder, and on account of the glistering 
character of the dust it is largely used for decorative purposes, chiefly in the manufac- 
ture of wall paper, illuminated designs, postal cards, etc., and is doubtless a frequent 
cause of inflammatory conditions of the eyes and air passages. 
Cement Workers.-The manufacture of Portland cement varies in different 
countries. The raw materials are clay with flint and lime. In England where chalk 
is plentiful this is used in connection with some material containing silica and alumina, 
such as selected clay or river mud. The raw materials are mixed in certain proportions 
and ground together to the consistency of liquid mud. The excess of moisture is 
driven off by heat, and the residue is dried in ovens at a high temperature. The 
preliminary process, while sloppy, is not dusty work, but the subsequent grinding 
between rollers and the sacking and packing of the product is an extremely dusty 
process. Koelsch11 found in the air of the older cement works from 87-1920 mg. of 
dust and in modern plants from 55-450 mg. per cubic meter. According to this 
and other German authors catarrhal affections and diseases of the respiratory organs 
constitute from 30 to 40 per cent, of all the sickness. Diseases of the eyes, and ears, 
impacted ear wax, ulceration of the nose with perforation of the nasal septum, and 
eczema, or cement itch, are also quite common. Hoffman's Industrial Insurance 
statistics show that 47.7 per cent, of the cement workers in this country perish from 
diseases of the air passages, inclusive of 19.3 per cent, from tuberculosis. The Leipsic 
Sick Benefit Society records indicate that cement mixers and hod carriers have a very 
high morbidity rate, viz., 1358 days of sickness per annum per 100 members. 
Preventive Measures.-Wittgen12 has made a gratifying report upon the results 
attained in German cement works by removal of dust. He points out that respiratory 
diseases have been reduced fully one-third within a period of 5 years after the installa- 
tion of exhaust ventilation, and the number of days lost by sickness has been reduced 
from 2742 to 812 days per annum, which means a decided improvement in the general 
health of the operatives. 
Asphalt Workers.-Asphaltum, also known as mineral pitch or hard bitumen, 
is an amorphous brownish-black combustible mixture of different hydrocarbons, and 
is obtained in a natural state from superficial deposits in various parts of the world. 170 
CLAY PRODUCTS, POTTERY, GLASS AND ALLIED INDUSTRIES 
The same name is applied to the pitch or residue of coal tar. The natural asphalt is 
■chiefly used in the construction of asphalt pavements and waterproof roofing and the 
product derived from coal tar is used for the same purpose, and also in the manufacture 
of roofing paper, metal paints and varnishes, artificial fuel (briquets), etc. The 
grinding of asphalt gives rise to large quantities of dust, which may cause serious 
affections of the cornea. The fumes arising from the melting pots are liable to 
produce inflammatory conditions of the eyes and respiratory passages, and a peculiar 
yellowish eruption of the skin. Open pans should be avoided and Leymann recom- 
mends that the fumes should be carried into a furnace, or absorbed by a condenser 
charged with oil. 
Brick and Stone Masons.-Ascher13 reports that among 5695 masons belonging 
to the Berlin Sick Insurance Companies, there were 2181 or 38.2 per cent, cases of 
sickness. The mortality rate from respiratory diseases inclusive of consumption was 
.53 per cent., against 46.1 per cent, in the general population over 15 years of age. 
The mortality from diseases of the heart, digestive tract, kidneys and bladder, is also 
■excessive. Pneumonia is most frequent in the helpers. 
Hoffman's14 Industrial Insurance statistics, based upon 1647 deaths among masons 
from all causes, show a mortality rate of 31.1 per cent, from respiratory diseases, 
inclusive of 17.7 per cent, from tuberculosis. The death rate from urinary diseases 
was 13 per cent.; from heart diseases 10.1 per cent, and from accidents 9 per cent. 
The German accident rate for journeymen was 3.8 per cent, and for apprentices 6 per 
•cent. The Leipsic Sick Benefit records show a sickness rate of 777 days per 100 masons 
and a mortality hazard of 0.70 per cent. 
Dust and exposure to the elements are important predisposing causes to respiratory 
diseases, and the sloppy character of work is conducive to rheumatic and neuralgic 
affections, while lime and mortar accounts for the undue frequency of eczema of the 
hands and wrists. 
Preventive Measures.-Accidents should be prevented by proper construction of 
^scaffold and education of apprentices. Bricks and stones should be moistened to 
diminish dust inhalation. Cleanly habits and the application of cold cream or 
vaseline will aid in the prevention of skin affections incident to cement and mortar 
work. 
The erection of sheds, so as to provide shelter against cold or storms, facilities for 
warming the meals, ablutions and change of clothing is clearly indicated. 
Plasterers.-Plasterers, like bricklayers and cement workers, are exposed to 
unfavorable working conditions, such as damp air, and, in certain stages of the work, 
to inhalation of large amounts of dust containing lime and plaster of Paris. If open 
charcoal fires (salamanders) are used for drying purposes, there is danger from coal gas. 
Opinions differ as to injurious character of lime dust; some authors contend that 
'tuberculosis is less frequent among lime and cement workers than in other dusty 
occupations. Hoffman's Industrial Insurance statistics show that of 1371 deaths 
among plasterers, 300 or 21.9 per cent, were caused by consumption; the degree of 
'frequency was above the average at all ages under 65, and especially at ages between 
25 to 34. The Leipsic Sick Benefit records show a sickness rate of 738 days per 100 
plasterers, and a mortality hazard of 0.46 per 100. Similar conditions would probably 
be revealed among white-washers if separate statistics were available. 
Preventive Measures.-It is important that dust production should be reduced 
■to a minimum, and that the general precautions recommended for masons and cement 
workers should be adopted. 
Paperhangers.-This occupation, especially the process of scraping the walls 
for the removal of old paper, involves considerable dust production, and possibly 
also exposure to lead and arsenical poisoning if the wall paper happens to contain such 
toxic color pigments. A number of cases of arsenical poisoning have been recorded. 
«(See page 304.) EMERY, CORUNDUM AND SANDPAPER 
171 
There is likewise some danger if the room has been occupied by infectious patients, 
and disinfection has been neglected. 
These risks would be more pronounced if the walls were not previously moistened, 
but, even when this is done, the subsequent pointing up and sandpapering of rough 
surfaces results in dust production. Hoffman's Industrial Insurance statistics show 
that of 319 deaths among paperhangers 107 or 33.5 per cent, were caused by consump- 
tion and 11.1 per cent, from other diseases of the lungs, making a combined rate of 
44.6 per cent, from diseases of the respiratory organs, against a normal expected 
proportion of 23.6. 
Preventive Measures.-Wet processes for wall scraping, use of respirators in all 
dusty work, personal cleanliness and all the precautions recommended against lead 
and arsenical poisoning. 
Emery and Corundum.-Emery and corundum wheels are employed as an abrad- 
ing material, for grinding and polishing metals, stone, glass, etc., and the manufacture 
and use of these materials doubtless plays an important role in the development of 
pneumoconiosis. Emery is derived from emery rock, imported from Smyrna and the 
Island of Naxos, and is an anhydrous oxide of aluminum, containing flint, silica, and a 
small amount of magnetite or hematite. 
Corundum is also a very hard granular variety of oxide of aluminum. The 
crushing and grinding of either of these materials, although carried on in inclosed 
machinery, involves like the mixing process, more or less exposure to a very fine and 
extremely irritating dust. The wheels and stones of different sizes are made from the 
powdered rocks, mixed with one or more of various binding materials, such as clay, 
glue, shellac, India rubber, oil, sulphur, and silicate of soda. The mixture is placed 
in a mould and subjected to hydraulic pressure. The mixture with clay is fired in 
kilns and the resulting product is said to be much harder than when other binding 
substances, such as shellac or glue, are used; but the latter binders are more elastic 
and less likely to break. In order to guard against the possibility of breakage, brass 
wire webbing is inserted to prevent fragmentation and resulting injuries. After the 
wheels have been baked they are trued by grinding processes-another very dusty 
procedure. All wheels are or should be finally tested in a metallic compartment at an 
exceedingly high rate of speed, over 7000 revolutions a minute, and those which pass 
the test without breaking may be considered safe. The industry involves not only 
exposure to a very irritant dust, but also to lead from the babbit metal employed in 
fitting the wheels to spindles. 
Oliver18 states that since the introduction of the emery wheel in the Sheffield 
cutlery industry, the cutlers as a class have become even more unhealthy than 
they were in previous years. The Inspectors of the Massachusetts State Board 
of Health16 report that, while the great majority of the employes in this in- 
dustry appear to be well and strong, "a notable proportion present a pale and sickly 
appearance." 
Preventive Measures.-The manufacture and use of emery corundum wheels is 
doubtless dangerous to health, and should be safeguarded by reducing dust production 
to a minimum by adequate exhaust ventilation. 
Emery and Sandpaper Making.-This occupation involves exposure to the inhala- 
tion of considerable quantities of emery powder and sand, derived from "garnet," 
which is a fine variety of gravel, obtained in this country in the Adriondacks. This 
gravel is ground, sifted, and graded, by machinery, and spread on paper covered with 
glue and the product is dried over steam pipes. 
Preventive Measures.-Great care should be exercised to diminish dust produc- 
tion to a minimum, possibly by the employment of moist processes in the grinding, 
sifting and grading processes, for it is reported by the Inspectors of the State Board of 
Health of Massachusetts that in spite of the working of a 48-in. exhaust fan, to which 
the pipes are connected, there was a great deal of fine dust in the air. Workmen are 172 
CLAY PRODUCTS, POTTERY, GLASS AND ALLIED INDUSTRIES 
urged to wear respirators, but it is extremely doubtful whether the inhalation of very 
fine dust is thus prevented. 
The Glass Industry.-The industry includes the manufacture of 
window glass, plate glass, and all varieties of cast and rolled glass, 
pressed and blown glass, such as jelly cups, tableware, tumblers, gob- 
lets, lamp chimneys, lantern globes, electric light bulbs and globes, 
opal ware, cut glass, bottles, jars, demijohns, etc. 
Glass is manufactured by the combination of a fusible alkaline silicate of potash 
or soda with one or more infusible silicates of lime, magnesia, iron, chromium, etc. 
Crown glass, for example, is composed of silica 62.8, lime 12.5, potash 22 and alumina 
2.6. Flint glass contains silica 38.2, lead oxide 48.5, potash 11.7 and alumina 2. 
Optical lenses and imitation precious stones are generally made of the best quality of 
flint glass. Most of the glasses are leadless. Arsenic is used as a de-colorizing agent, 
but cases of arsenical poisoning are comparatively rare, in spite of the fact that dust 
in glass works has been found to contain as much as 1.5 per cent, of white arsenic. 
Chromium, tellurium and manganese compounds and various chemicals are used for 
coloring or decolorizing purposes. 
The mixing of raw materials is usually a very dusty process and the 
fusing and gloss-blowing process involves exposure to intense light and heat. 
Glass-blowing by machinery is largely concerned with the manufacture of 
glass bottles, which are moulded or blown by machines using compressed 
air. Plate glass is cast, and most of the table glass ware is moulded and 
pressed into shape by machines. It is hoped that the machine process will 
come into use before long in the manufacture of large glass carboys. The 
work of blowing large pieces of glass is often so strenuous that the pipe is 
passed in succession from one operator to another, which practice has been 
the means of spreading syphilis. A number of small factory epidemics were 
reported before the Internat. Med. Congress in Paris in 1876. Eysel,17 
in 1896, reported 12 instances and Brosius, in 1904, added to the number 
of wholesale transmissions; isolated cases are not infrequent. Hayhurst 
cites a case in his Ohio Survey on page 261. Cases of heat prostration are 
not uncommon and exposure to intense heat and light is responsible for 
an undue prevalence of diseases of the eye, notably chronic inflammation 
and dryness of the conjunctivae, and most important of all is the large 
number of cataracts observed in glass-blowers. Meyhoffer18 found this 
condition among 506 glass-blowers in 59 men of whom 42 had not yet 
attained the age of 40. Hirschberg attributes this to direct heat absorp- 
tion, others suggest that the loss of bodily fluids on account of excessive 
perspiration, may be a factor. It is probably caused by the combined 
effect of both. In a recent discussion of the subject in London, Mr. Crid- 
land suggested the name of "ray cataract" as a more inclusive term and 
the President suggested the name of "furnace workers' cataract" because 
the affection is not uncommon among puddlers (J.A.M.A., April 3, 
1915, page 1186; see also page 883 of this volume). The tradition that 
glass-blowers are especially liable to develop emphysema of the lungs has THE GLASS INDUSTRY 
173 
been rudely shaken by Prettin and Liebkind,19 who found only five cases 
among 230 glass-blowers who have been engaged for over 10 years in 
this work. Similar observations have been made in German Military 
bands, and we quite agree with Schmidt20 that the elasticity of the normal 
lung tissue may withstand the additional strain. That the buccal cavity 
is taxed to an enormous extent is shown by the great dilatation of the 
cheeks and flabby muscular atrophy, which in older glass-blowers 
occasionally results in hernia of the cheeks and dilatation of Steno's 
duct. 
As a result of exposure to excessive heat and sudden changes, catarrhal 
affections and diseases of the respiratory organs, which are often aggra- 
vated by smoke and dust in badly regulated establishments, lead the list. 
According to Hoffman's statistics 39.4 per cent, of all the deaths among 
glass-blowers were caused by respiratory diseases, inclusive of 30.1 per 
cent, from consumption. The German morbidity rate for respiratory 
diseases was 32.7 per cent. Congestive headaches from exposure to 
heat, and diseases of the digestive organs from excessive use of cold drinks 
are also quite common. Injuries and wounds, painful and inflamed 
callosities in the palm of the hands, from handling rough glass, and 
eczema, caused by glass dust, are not infrequent. 
The workers engaged in dry grinding, sanding, filing, drilling, bevelling 
and glass polishing, especially in the crystal or so-called cut-glass industry, 
are exposed to the inhalation of rouge and putty powder. Oliver has 
found that some putty powder contained as high as 70 per cent, of lead 
compounds. Forty-eight cases of lead poisoning were reported in 
Great Britain from 1900-9 from the use of putty powder. Attempts to 
secure putty powder free from lead have so far failed. In France a 
compound of metastannic acid has been used with success and in this 
country most of the glass polishing and etching is done by means of 
hydrofluoric acid mixed occasionally with other acids such as acetic, 
carbolic acids, etc. This process, however, is not free from danger, as 
the inhalation of acid fumes in injurious, and contact with the skin is 
liable to cause burns in the second degree, and slow healing ulcers, with 
loss of finger nails, etc. Sand blasting is being employed to some extent 
to replace the dangerous process of etching by means of hydrofluoric acid. 
Dr. Hayhurst in his Ohio Survey refers to another substitute for etching, 
in which the design is stamped on the glass with a paste and dusted over 
with zinc oxide. This work is done under a hood, after which the glass 
is heated and the finished product resembles very closely etched ware. 
The different art glass processes, such as assembling in metal frames, 
lacquering, varnishing, etc., involve exposure to the fumes of amyl 
acetate, wood alcohol, benzine and turpentine, and even lead in handling 
and soldering metal composition frames. 
Workers engaged in decorative painting and spraying of glass may be 
exposed to lead color pigments, and persons employed in the silvering 174 
CLAY PRODUCTS, POTTERY, GLASS AND ALLIED INDUSTRIES 
of glass pearls are liable to develop argyria, a shiny black discoloration of 
the skin, caused by the absorption and excretion of silver compounds. 
The danger of glass dust inhalation is plainly revealed by the undue prevalence of 
respiratory diseases. Hoffman's statistics show that 47.4 per cent, of the glass cutters 
perish from diseases of the respiratory organs, inclusive of 34.5 per cent, from tuber- 
culosis. The presence of lead will, as in printers, naturally act as an additional 
predisposing factor. The average duration of life in the German glass polishers is 
given by Anacker as 32.6 years. Dust production is not so great in the manufacture 
of optical lenses, but constitutes nevertheless an injurious factor. (For dangers in 
the manufacture of thermometers, etc., see workers in mercury, page 484.) 
Preventive Measures.-All raw material should be ground and mixed 
in enclosed machinery provided with exhaust ventilation. Appert's 
apparatus, which is operated by compressed air, should replace as far as 
practicable the glass-blower's pipe. Metallic and asbestos screens for 
protection from intense heat should be provided. Dark eye glasses as a 
protection from intense heat and light should be worn. All polish- 
ing processes should be safeguarded by adequate exhaust ventilation. 
Protection of the hands and wrists for men who handle plate glass is 
important. Washing and bathing facilities, special lunch rooms, change 
of clothing, periodical medical inspections, educational methods, and all 
the precautions against lead poisoning are recommended. 
Mineral Wool.-The manufacture of mineral wool is closely connected with blast- 
furnace' operations since it is obtained by subjecting furnace slag, while molten, to a 
strong blast such as steam under pressure. This causes a mass of fine interlaced 
filaments, resembling wool or cotton, which are collected in wire receptacles. The 
operation is naturally attended with the evolution of dust quite as irritant in its effects 
as glass dust. The material is also known as "mineral cotton," "silicate cotton," and 
"slag wool," and is used for covering boilers and steam pipes, and as a filler in ceiling 
spaces to deaden sound, etc. The manufacture and use of this material involves 
exposure to a dangerous kind of dust. 
Workers in Rontgen Tubes and Rontographers.-The men engaged in the manu- 
facture and use of Rontgen tubes are exposed, unless properly protected, to certain 
injurious effects of the Rontgen rays. These effects are especially liable to manifest 
themselves in inflammatory conditions of the skin and burns varying in degree, 
according to the intensity of the rays, duration of exposure, and delicacy of the skin. 
In some instances burns have resulted in extensive destruction of the skin and large 
slow healing septic ulcers. The more commonly observed effects manifest themselves 
in the form of a chronic inflammation of the skin, characterized by hypertrophy of 
the horny layer and a furrowed, dry, rough and parchment-like appearance of the skin. 
Fissures and painful excoriations, hard warts, deformities of the finger nails, felons 
and loss of hair are not uncommon. While most of the damage usually falls upon the 
hands of the operator, the face and other portions of the body may be involved and 
even cases of cataract have been observed in connection with burns of the face. Loss 
of hair and atrophy of the skin not infrequently gives rise to a red shiny disfiguration 
of the skin. In some cases, telangiectases with stellate dark spots have been observed 
on the back of the hands. Cases of cancer, engrafted upon chronic ulceration from 
X-ray burns, have been recorded. Atrophy of the testicles and sterility as a result of 
repeated exposure to Rontgen rays have likewise been reported. Von Jagic21 found 
a marked lymphocytosis (35-52 per cent, in 10 X-ray workers) and also reports three RADIUM-REFERENCES FOR THIS CHAPTER 
175 
cases of lymphatic leukemia in rbntographers and one in a chemist who prepared' 
radium. Animal experimentation led him to the conclusion that both the X-ray and 
radium act upon the bone-marrow cells and stimulate the activity of lymphatic tissue. 
All of these effects are less commonly observed now and will continue to decrease by 
the employment of precautionary measures (see also page 959). 
Preventive Measures.-Formerly the men engaged in the manufacture of the 
Rontgen tubes made the test upon their own hands and thus incurred special risks. 
This danger has been obviated by mounting the skeleton of the hand in a paper machA 
or wax model to which a leaden handle is attached. In modern establishments it is 
now the practice to shield the body by means of suitable sheet-lead screens, and for the 
protection of the eyes lead-glass observation windows and goggles are employed. 
The universal use of these screens together with making the exposure as brief as 
practicable will not only protect the maker, but also the patient and rontgenographer 
and thus eliminate the ill effects of the Rontgen rays, which play a very important 
r61e in modern methods of precision in diagnosis and also for therapeutic purposes. 
Radium.-The effects of exposure to radium apparently do not differ essentially 
from those of the X-ray. So far, probably because of its limited employment and 
briefer periods of exposure, no very serious injuries have been reported. While acute- 
forms of dermatitis, with redness, swelling, itching and burning sensations and even 
deep-seated ulcerations have been reported, the skin lesions are generally of a chronic 
type and characterized by hyperkeratoses of the lateral surfaces of the fingers. 
Preventive Measures.-Sheet-lead screens, lead-glass observation windows and! 
goggles, and careful time limits of exposure have so far afforded the best protection. 
REFERENCES 
1 Gottschalk.-Weyl's Handbuch d. Arbeiterkrankheiten, 1908, page 312. 
2 Oliver.-Industrial Lead Poisoning in Europe. Bull. Bureau of Labor, No. 95r 
Washington, July, 1911. 
3 Kaup, cited by Rambousek.-Industrial Poisoning, London, 1913. 
4 Holitscher.-Weyl's Handbuch d. Arbeiterkrankh., 1908, page 319. 
8 Koelsch.-Zentralb. fur Gewerbehygiene, March, 1920, page 4. 
6 Rambousek.-Industrial Poisoning, London, 1913, page 137. 
7 Oliver.-Industrial Lead Poisoning in Europe. Bull. Bureau of Labor, No. 95r 
July, 1911, Washington, D. C. 
8 Hamilton, Alice.-Trans. 15th Inter. Congress on Hyg., Washington, 1913, Vol. Ill, 
Part II, page 817. 
9 Munch. Med. Wochschft., LXI, 756. 
10 Lehmann, K. B.-Lehrb. Arbeits u. Gewerbehyg, Leipzig, 1919. 
11 Koelsch.-Krankheit und Soziale Lage, 1st Liefg., Munchen, 1912. 
12 Wittgen.-Concordia, 1912, page 37. 
13 Ascher.-Weyl's Handbuch d. Arbeiterkrank., 1908, page 330. 
14 Hoffman, F. L.-Exhibits of the Prudential Insurance Co. of America,^Internal. 
Congress on Hygiene, etc., September, 1912. • 
18 Oliver.-Diseases of Occupation, E. P. Dutton Co., New York, 1916, page 238. 
16 Report of the Massachusetts State Board of Health upon the Sanitary Conditiomof 
Factories, Workshops, etc., 1907, page 77. 
17 Eysel.-Inaug Dissertat., Gottingen, 1896. 
18 Meyhoffer.-Zehender Klin. Monatsbt. f. Augenkrankh. 24, Vol. XLIX. 
19 Prettin and Liebkind.-Munch. Med. Wochenschft., 1904. 
20 Schmidt.-Weyl's Handbuch d. Arbeiterkrank., 1908, page 350. 
21 Von Jagic.-Berl. Klin. Woch., 1911, XLVIII, page 1220. CHAPTER III 
IRON, STEEL AND ALLIED INDUSTRIES 
GEORGE M. KOBER, M. D., Washington, D. C. 
Blast Furnaces.-The operation of reducing iron ore in a blast furnace 
is necessarily continuous and most furnaces operate with two 12-hour 
shifts and work 7 days a week. The operatives, apart from hard work, 
are exposed to excessive heat, abrupt changes in temperature, to injuries, 
burns and explosions, more or less dust and sand and the inhalation of 
toxic gases from leaky furnaces, gas valves or mains which especially 
endanger the men while engaged in cleaning out the furnaces or during 
the process of tapping the slag or the metal. The furnace gases contain 
carbon monoxide and dioxide in large quantities, compounds of sulphur 
and cyanogen and even lead fumes, if lead happens to be present in the 
iron ore. In granulating the slag sulphureted hydrogen is also evolved. 
Falls, asphyxiation and railroad accidents account for most of the fatal 
injuries. 
Preventive Measures.-Great care should be taken to prevent the 
escape of poisonous gases and much has been done toward their utilization 
for heat, power and illuminating purposes in the steel plants, and com- 
mendable efforts are being made in safeguarding the operatives against 
accidents, explosions, etc., by the construction of modern strong furnaces 
with water-cooling jackets and improved methods in the stoking and 
charging of the various materials and in the tapping, pouring and trans- 
portation processes. F. H. Willcox is a strong believer in blast furnaces' 
safety committees. 
Bessemer Steel Works.-In the conversion of pig iron into steel by 
the Bessemer process, apart from the hard work and exposure to intensive 
radiant heat and escape of gases, the operatives are exposed to serious 
injuries from falling scraps from above. Burns are most frequently 
caused by flying sparks of "molten metal" from the converter during a 
blow, from spilling of the hot metal ladles, and from explosions on account 
of the presence of moisture in the converter or from the normally occluded 
gases of the molten metal. 
Electric Welding.-In the electric welding of steel, etc., the light pro- 
duced is extremely intense (equal to about 8000 candle-power) and, as the 
operation has to be closely observed, the workmen must protect their 
eyesight by shields composed of six alternating layers of blue and red 
glass. The light and heat evolved are sufficiently intense to cause a 
condition of the skin comparable to sunburn. 
176 WELDING-OPEN-HEARTH STEEL WORKS 
177 
Hirschberg2 describes a condition of the eyes in persons exposed to 
strong electric light, especially in the electric welding of steel characterized 
by lesions of the conjunctiva, cornea and retina and designated by him 
as "electrical ophthalmia." Crzellitzer3 has reported similar cases. 
Dr. Apfelbach4 cites 50 cases observed by him among workers of the 
Illinois steel plants, caused by electric light, redundant with ultra-violet 
Fig. 4.-Welding a steel ring with an electric arc. The workman's eyes are protected 
from the blinding glare by three panes of colored glass in the helmet, which also defends 
his face and neck from the rays that destroy the skin. (Photo supplied by Wtirdemann, 
taken from The World's Work.) 
rays, causing conjunctivitis, photophobia, profuse lacrymation, tempo- 
rary loss of vision, and rarely keratitis, retinitis, permanent pigment 
changes of the retina and scotomata. 
Open-hearth Steel Works.-The temperature conditions under which 
the men work during particular operations have been studied by the 
Bureau of Labor.5 In spite of the fact that all doors and ports were 
water cooled and furnace fronts partly cooled, the thermometer 6 or 7 ft. 
in front of an open hearth with the door partly open, during the operation 178 
IRON, STEEL AND ALLIED INDUSTRIES 
of rabbling the bottom and stirring heat, registered 120° and 155°; at a 
distance of 2 ft., and while banking doors with dolomite, the workmen 
were exposed for 2 minutes at least to a temperature of 220° and over. 
The excessive heat and exposure to intense light in the various processes 
of steel making and in electric welding must be observed in order to be 
fully appreciated, and naturally calls for special protection of the eyes by 
means of suitable helmets and smoke-colored glasses. 
Puddling.-The process of puddling, the oldest of the purifying 
methods by which iron is produced, is carried on in a furnace supplied 
with a large fire-box on one end, the flames of which are reflected upon the 
pig iron placed in an adjacent chamber. When the mass begins to liquefy, 
the puddler by means of a rabble (a hoe-shaped iron) stirs the molten 
metal and as the impurities are burned out the melting point rises and the 
metal solidifies into smaller masses, which are then gathered into two or 
three huge balls. They are then removed and hammered or squeezed 
for the removal of slag. The work is extremely laborious and attended by 
exposure to intense heat and often reckless exposure to cold draughts. 
Apart from injuries to the eyes, those exposed to the intense heat and 
light are liable to suffer not only from chronic conjunctivitis but also 
from more serious affections of the eye, which may result in retinal and 
choroidal lesions and also in cataract. Dr. de Schweinitz, cited by 
Edsall, states that he could often tell whether iron puddlers were right 
handed or left handed by studying the effect of their work on their eye 
grounds. Quint relates cases of right-sided cataracts in right-handed 
iron workers and cataracts of the left eye in those who were left-handed. 
It is very likely that exposure to intense heat causes dehydrization of 
the lense and other pathological conditions. 
Many of the employes have intemperate habits and as a result of 
combined influences often develop diseases of the respiratory and circula- 
tory system and the kidneys. 
Rolling Mills.-In this department the men are likewise exposed to 
excessive heat, hard work, to burns from flying hot metal and slag and the 
various injuries incident to the moving of large masses. In the hand- 
operated mills the risks from burns and similar injuries incurred in handl- 
ing the heated billets and managing the material with tongs and hooks 
are very much greater than when mechanical means are employed; on 
the other hand, the fatality rates and permanent injury rates are greater 
in mechanical mills, simply because if a man is caught in moving machin- 
ery a severe or fatal injury is likely to result. 
Mechanical Departments.-All steel plants employ a large number of 
mechanics covering a wide range of occupation. Those engaged in repair 
work are liable not only to accidents incident to their own occupation, 
but also those occasioned by the work of others, such as unexpected start- 
ing of machinery; leakage of gas where the work is being done also fre- 
quently adds to these special hazards. ACCIDENTS IN STEEL PLANTS 
179 
Summary of Accidents.-The investigation by the Bureau of Labor,6 
covered all the accidents which occurred during the year ending June 30, 
1910, in 155 steel plants representing a working force of 158,604 employes, 
equivalent to 146,979 300-day workers. The general accident rate was 
Fig. 5.-Hot saw in beam mill thoroughly guarded to prevent sparks from flying 
through the mill, to the injury of the workmen. (Photo supplied by Wiirdemann through 
the courtesy of Carnegie Steel Company.) 
245.2 per 1000; the fatality rate was 1.86; the rate resulting in permanent 
injury was 2.72; and the rate resulting in temporary disability of 1 day 
or over was 240.6 per 1000. In brief, although nearly one-fourth of the 
■employes met with injuries, only 1.9 per cent, of all the accidents resulted 
fatally or in permanent injury. 
A very interesting table on page 69 of the same report, covering 130 plants for 
2 years, ending June 30, 1910, and one plant for 6 years, ending December 31, 1910, 
specifies the nature of the disabling injuries, number of days lost, etc. Of the 18,959 
cases thus tabulated, asphyxia occurred in 710 or 6 per cent, of the cases; fractures, 
497 or 2.6 per cent.; dislocations, 555 or 2.9 per cent.; injuries to the eyes, 1056 or 5.6 180 
IRON, STEEL AND. ALLIED INDUSTRIES 
per cent.; burns, 2842 or 15 per cent.; injuries to the foot, 3306 or 17.4 per cent.; 
injuries to the hand, 4908 or 25.9 per cent.; injuries to other parts, 3968 or 20.9 per 
cent.; all other injuries, 1716 or 9 per cent. It is a remarkable fact that the percentage 
of injuries to the eyes according to the Imperial Insurance Office in 1897 was about the 
same in the German iron and steel industry. Two-thirds of the eye injuries were 
caused by foreign bodies and the remainder by flying sparks. 
The report emphasizes the fact that for a large group of plants in which the work 
of organized accident prevention is well developed the accident rate was found to be as 
low as 167 per 1000, while on the other hand in groups of plants in which safety work 
has not yet been developed it was as high as 506.9 per 1000, and in some of the indi- 
vidual plants in this group considerably higher. 
According to Rbpke,7 during 1909 among 165,470 insured employes in the 
"Rhein" steel plants of Germany 27,895 accidents were reported or 169 per 1000 
workers; of these, 183 resulted fatally, 198 in total and 1630 in partial permanent 
disability, and 513 in temporary disability. It should be stated, however, that 
according to the Report of the Bureau of Labor the German accident figures include 
no temporary disabilities of 13 weeks and under. According to the same report, 
more than half of the accidents during a 6-year period in one of the American steel 
plants were due to four causes; viz.: flying and falling objects 25.2 per cent.; falls of 
the worker 10.5 per cent., hot metal explosions and spills 8.9 per cent.; and the opera- 
tion of cranes 8 per cent. 
It was also found that there was a distinct excess in the number of accidents 
during night work amounting to 11.6 per cent, over the day rates. The data in 
reference to the influence of long hours on the accident rates were not sufficient to 
justify positive conclusions, but appear to indicate a tendency to greater frequency of 
accidents during the "long turns." A study based upon 26,839 accidents show that 
for the forenoon of the 10-hour shift the greatest number of accidents occur in the 
fourth hour and for the night shift during the second and third hours of the work. 
This is contrary to the general expectation that accidents increase with increasing 
fatigue of the workers. Several reasons for this contrast are suggested in the report, 
viz., that during the early hours of the night turn much repair work is done necessi- 
tating overtime work of the day mechanics, hence also a larger working force during these 
earlier hours, and that because of the fatigue of these overtime workers and a tendency 
to hasten their work in order to get home or because of the exigencies of the case, the 
liability to accidents is increased. Another and quite reasonable explanation offered 
by the superintendents is that the men on the night shifts do not secure the same 
amount of restful sleep and that this less satisfactory physical condition tends to bring 
about a greater number of accidents during the period when "they are getting into 
the swing of the work." 
A study of the seasonal distribution of accidents appears to justify the conclusion 
that both extremes of heat and cold have an influence, the heat condition being the 
more potent. 
Prevention of Accidents.'-A most gratifying reduction in the number of accidents 
peculiar to blast furnaces and rolling mills has been accomplished since 1905 by the 
application of safety devices. The rates for permanent injuries were reduced from 
2.2 per 1000 in 1905 to 0.5 per 1000 in 1910; injuries to the eyes from 19.7 to 4.7; 
bruising injuries to the hands from 58.7 to 27.2; similar injuries to the feet from 46.4 
to 22.8; bruises to other parts of the body from 72.6 to 26.6; and burns from hot metal 
from 16.5 to 6.8 per 1000 workers. A chart on page 118 of the Government Report8 
shows a reduction in one of the large steel plants in the accident rate from 370 in 
1900 to 109 in 1910. 
Comparative Morbidity Rates.-We know that the morbidity rates 
are higher in the large steel and iron plants than in the manufacture of OCCUPATIONAL DISEASES IN IRON AND STEEL INDUSTRY 
181 
machinery and other mechanical departments of this industry. So, for 
example, the average number of men taken sick in the large steel plants 
at Solingen in 1905 was 476 per 1000; in the cutlery industry 404; and in 
the sword, bicycle industry, etc., only 302 per 1000 (Ropke9). 
Hayhurst10 gives a synopsis of the chief occupational diseases in the 
iron and steel industry as follows: 
1. Heat stroke (apoplexy), heat exhaustion, heat cramps, heat anaemia 
and heat diarrhea, premature senility in older employes. 
Fig. 6.-An emery wheel equipped with heavy steel guard. Guard on pulley and 
belt and permanent glass guard to prevent injury to the eyes. (Photo furnished to Wiirde- 
mann by the U. S. Steel Corporation.) 
2. Asthma, bronchitis, tuberculosis and hemorrhages while at work, 
due to dust, sand, gas and fume inhalations, grinding processes, etc. 
3. Gas poisoning, producing chronic symptoms such as headaches, 
dizziness, vomiting, coated tongue, anaemia, palpitation, insomnia, gen- 
eral debility, mental dullness, and later depressive insanity. 
4. Conjunctivitis, injected or bloodshot eyes, due to heat, sand and 
dust; cataracts among those exposed to white heated metals. 
5. "Sunburn" of arms, hands, and face, due to exposure to heated 
metals. Small hemorrhages under the skin of the face; blistering, foot 
calluses, due to walking over hot iron plates, etc. Severe callusing of the 
hands. 182 
IRON, STEEL AND ALLIED INDUSTRIES 
6. Rheumatism and lumbago, due to great temperature variations. 
7. Heart disease, perhaps evinced by sudden deaths while at work. 
8. 11 Hammermans' paralysis" of arms, due to the use of heavy sledges, 
pneumatic tampers and other pneumatic tools, particularly with long 
strokes. 
9. 11 Strikers' arthritis" of wrist and elbows, due also to hammering or 
holding vibrating tools. 
Fig. 7.-Steel dust to which steel workers are exposed. Particles magnified 40 diameters. 
(Photo furnished by Hanson.) 
10. Boiler-maker's deafness. 
11. Ferrosilicon poisoning. 
The U. S. Census for 1910 gives the percentage of the chief causes of deaths for 
workers in this industry as follows: Tuberculosis 16.3; accidents 16.2; pneumonia 
10.8; heart disease 10; Bright's disease 6.6. 
The morbidity statistics in a very sanitary steel plant employing 5602 workers, 
presented by Hayhurst and based upon the records of a sick benefit association, but 
excluding accidents and venereal diseases, show that there were 1444 claims by workers 183 
MORBIDITY IN AN IRON AND STEEL ESTABLISHMENT 
sick for at least 5 days, or an annual percentage of 7.2. The claims for systemic 
diseases were as follows: Respiratory 391; digestive 285; communicable 218; musculo- 
osseous, mostly rheumatism and lumbago, 184; nervous, mostly neuralgia, sciatica, 
neurasthenia and neuritis, 79; skin 65; circulatory 63; urinary, mostly nephritis, 45;, 
strain, mostly hemorrhoids, hernia, and heat prostration, 41; auto-intoxication and 
diabetes 27; chronic infections 18; special senses 17; lymphadenoids and neoplasm 11. 
Average (Yearly) Morbidity in the Various Departments of an Iron and Steel. 
Establishment During a Period of 3 Years-1911 to 1913 Inclusive 
(Hayhurst) 
(The greatest variation of numbers employed did not exceed 15 per cent, in any one 
department) 
Departments 
Average 
number of 
employees 
Average 
number 
sick 
Average 
per cent, 
sick 
(a) Heat exposed: 
Bessemer 
393.3 
33.0 
8.39 
Open hearth 
145.3 
7.0 
4.81 
Rail and shape mill 
500.0 
43.3 
8.66 
Blast furnaces 
261.0 
35.0 
13.41 
Foundry 
163.3 
12.7 
7.77 
Skelp mills 
348.3 
33.3 
9.56. 
Pipe mill 
1764.7 
162.0 
9.18 
(6) Weather exposed: 
Police 
35.0 
2.7 
7.62- 
Railroad (yards) 
156.3 
9.0 
5.76 
Section hands 
110.0 
10.0 
9.09- 
Yard labor 
468.0 
28.7 
6.13 
Ore docks 
90.3 
8.3 
9.19. 
Bricklayers 
72.7 
2.7 
3.66. 
Building construction . . 
106.3 
9.7 
9.07 
(c) Indoors (mostly): 
Mechanical 
472.3 
47.7 
10.09 
Electrical 
181.3 
4.3 
2.37 
Miscellaneous 
351.6 
11.3 
3.21 
Total 
5619.7 
460.7 
8.20 
Foundries.-The metal is reduced to a molten state either in a cupola, 
by combustion of coke, or in "open-hearth furnaces" heated with gas. 
flames; in either case the operations may involve exposure to intense heat 
and the inhalation of carbon monoxide. In tapping the molten metal 
there is considerable danger from explosions and flying sparks; in fact 
most of the serious burns occur in tapping either the slag or metal or 
during the transportation of the metal to the moulds and the process of 
pouring; other injuries are contracted in the moving of heavy castings, etc.. 184 
IRON, STEEL AND ALLIED INDUSTRIES 
Accident Liability.-Among 16,480 foundry employes reported upon by the 
Bureau of Labor11 there were 2198 accidents or 133.4 per 1000 workers. Of these, 
8 proved fatal, 37 resulted in permanent disability and 2153 in temporary disability 
of 1 day or over; all of these rates are much lower than in the other departments of the 
large steel plants; injuries of the eyes were the most frequent accidents, next came 
bruises. 
Hayhurst's Ohio Survey12 supplies statistics for 1913 showing that the 
chief causes of death among foundry workers are pneumonia, heart 
disease, tuberculosis and violence. Sick benefits were distributed as 
follows: Accidents and burns 24.2 per cent.; rheumatism, sciatica and 
neuritis 21.8 per cent.; respiratory diseases 16.7 per cent.; gastro-intestinal 
diseases 10.4 per cent.; heart, kidney, liver, bladder 3.7 per cent.; tubercu- 
losis 1.1 per cent., and the remainder for miscellaneous diseases. 
Casters.-Apart from dust inhalation and the injurious factors already 
referred to, the casters are also exposed to organic vapors on account of 
the material of the cores, which are made by mixing sand with a "core 
binder" such as flour, sour beer, molasses, starch or some other sticky 
substance. The cores when completed are covered with a thin layer of 
pulverized coal or graphite which forms a vitreous layer while the metal is 
being poured. Contact of the hot metal with these moist moulds natur- 
ally causes combustion of the organic material with evolution of gases 
and steam. 
The men engaged in casting generally wear smoked glasses to protect 
their eyes from the brilliancy of the light and sputtering of the metal. 
Core and Moud Makers.-These employes are exposed to the inhala- 
tion of large quantities of dust, especially in sifting the sand for the cores 
and in dusting the completed moulds with powdered charcoal and 
graphite. 
Female labor is often employed in the making of cores for small 
castings. The men engaged in breaking up the hot moulds naturally 
inhale large quantities of dust. 
Ahrens13 determined the presence of 28 mg. of dust per cubic meter in 
the air of the foundry room, and Hesse,14 71.7 mg. per cubic meter in the 
air of the cleaning and polishing room, which amount according to his 
calculation would subject each operative to the inhalation of 42 grams of 
dust per annum. 
Apart from these dangers, foundries are notoriously dirty and gloomy 
workshops and the walls and windows are generally covered with dust and 
soot, shutting, out light; very few are properly heated and in winter the 
mould and core makers who work in wet material often suffer from colds 
which are aggravated by drafts. 
It is by no means infrequent to observe red hot cast-iron stoves giving 
off deadly coal gas or, what is even worse, open wood or coke fires, pro- 
vided not so much for the comfort of the workers as for the drying out of 
the moulds and repaired fire-clay linings for the "pouring metal pots." CLEANING AND MILLING OF CASTINGS 
185 
Cleaning and Milling of Castings.-In the removal of scales dilute sul- 
phuric acid is used, the fumes of which are irritating. The subsequent 
processes of smoothing the castings by means of sand blasts, tumbling- 
mills, emery wheels, etc., are all dust producing and have already been 
referred to on page 18. 
In the department in which the castings are sand-blasted the air is 
frequently impregnated with flying sand which gets into the eyes, nose 
Fig. 8.--Machine shop workman using the movable burlap screen while chipping a 
piece of steel at bench vise. (Photo furnished Wiirdemann by the U. S. Steel Corpora- 
tion.) 
and mouth of the operatives, the effects of which few can resist for any 
length of time; most of the men have to quit within a year or two. Much 
of this unnecessary suffering is now prevented by thoughtful employers 
by providing in the center of the room a large flaring hood with upward 
suction draft, the operatives wearing helmets with fine wire inserts to 
protect the eyes, and cloths underneath the helmet for the protection of 186 
IRON, STEEL AND ALLIED INDUSTRIES 
the nose and mouth. The latest pattern of helmets is provided with a 
tubing through which fresh air is supplied from the outside. 
Preventive Measures.-There can be no question that the factors 
referred to render employment in foundries more or less injurious to health. 
It should be remembered, however, that bad working conditions are 
responsible for much of the ill health. In the polishing room the emery 
wheels are usually provided with hoods and exhaust ventilation, but the 
men ignorant of the dangers habitually remove the hoods, maintaining 
that the hoods interfere with their work and that "iron dust is strengthen- 
ing as it enriches the blood." 
It is gratifying to note that thoughtful foundry owners15 appreciate 
that health and efficiency can be promoted by providing suitable work- 
rooms, properly heated and equipped with mechanical devices for the 
removal of dust, gases and fumes; they also furnish pure drinking water 
and good washing and bathing facilities. All others should be required 
to do likewise, and when thus provided the workmen should be obliged 
to avail themselves of these safeguards. 
Blacksmiths and Forgemen.-Space will not permit a consideration 
of all the occupations connected with the iron industry, and hence only a 
few of the more hazardous trades can be considered. 
Blacksmiths and forgemen, apart from hard work and exposure to 
intense heat and abrupt changes in temperature, are also exposed to the 
inhalation of coal dust, smoke, fuel gases and the fumes evolved during 
the tempering and case hardening with lead, potassium cyanide and oil. 
There is also danger from flying scales which not infrequently affect the 
eyes. 
Wounds, contusions, burns, fractures and hernia are not infrequent. 
They are also liable to conjunctivitis and skin affections caused by 
exposure to radiant heat and deposits of dust. Lumbago and acute 
rheumatism are frequently met with. According to Sommerfeld16 
66.6 per cent, of all the deaths in this class of workmen are caused by 
consumption and 8.4 per cent, by other diseases of the lungs. 
The tuberculosis death rate, while very high in Germany, is not exces- 
sive in this country. According to U. S. Census, 11.4 per cent, of black- 
smiths died of pulmonary consumption, 8 per cent, of pneumonia, 13.8 
per cent, of heart disease, 10 per cent, of apoplexy and 9.7 per cent, of 
Bright's disease. Layet cited by Lehmann was perhaps the first to 
associate lumbago in blacksmiths with kidney diseases. Six per cent, of 
his hospital cases were diseases of the kidneys which he attributed to 
congestions caused by abrupt changes in temperature. 
Hypertrophy of the heart, diseases of the aortic valves and of the 
kidneys are not uncommon. When most of the heavy work was done by 
manual labor instead of machinery, rupture of muscular fibers of the upper 
arm and shoulder and cases of so-called "hammer's paralysis" caused by 
overfatigue of the muscles of the arm were frequently met with. Even VARIOUS IRON AND STEEL PROCESSES 
187 
now occasional cases may be observed in forgemen, and likewise instances 
of "strikers' arthritis" which is a painful inflammation of the wrist- 
and elbow-joints. 
The men engaged in handling sledge hammers, chisels, files and other 
tools are also liable to develop disagreeable callosities and thickening of 
the fascia with consequent contraction of the finger toward the palm of 
the hand. Faulty positions, stooping over anvils, work benches, etc., are 
a frequent cause of lateral spinal curvature and of genu valgum ("knock- 
knee") in youthful workers and should be prevented by teaching appren- 
tices at the outset correct positions. 
Boilermakers, Riveters, Structural Iron Workers, Etc.-The work 
of boiler makers and structural iron workers is also laborious and attended 
with considerable danger from accidents.* As a result of hard work and 
exposure to abrupt changes in temperature they are liable to the develop- 
ment of rheumatic, neuralgic and catarrhal affections and diseases 
of the respiratory and circulatory organs. In riveters using a hand 
hammer spasm and paralysis of the muscles of the hands are liable to 
occur, while the constant jarring of the automatic hammer has been 
known to produce occupational neuroses. Progressive impairment of 
hearing is by no means confined to boiler makers and riveters since 
Gottstein and Kayser17 found that fully 61 per cent, of the blacksmiths 
and locksmiths examined suffered from partial deafness. 
The Cutlery and Tool Industry.-This extensive industry involves a 
number of processes, such as iron and brass founding, forging, blacksmith- 
ing welding, tempering, grinding, polishing, buffing, pickling, acid 
dipping, enameling, etching, electroplating, tinning, wood working, 
painting, varnishing, etc. The health hazards are peculiar to the different 
processes named. 
Steel Grinding and Polishing.-In the grinding and polishing proc- 
esses of the metal industry in general, and in the manufacture of cutlery, 
tools and steel implements in particular, immense quantities of dust are 
evolved, not only from the metallic surfaces but also from the numerous 
grindstones, revolving wire brushs, emery and corundum wheels and other 
buffing material. Professor Roth18 estimates that a grindstone 2 meters 
in diameter and 10 cm. in width after 4 months' constant use is reduced 
fully one-half, and the various metal implements lose from 20 to 30 per 
* According to the Bull. U. S. Bureau of Labor Statistics, Feb., 1918, there were 239 
or 4.2 per cent, of accidents among the Bridge and Structural Iron Workers' Union No. 1 
of Chicago, against 2.2 per cent, among painters; 5 of the accidents proved fatal. Fifty- 
two per cent, of the accidents were caused by being struck by machinery or falling objects. 
The report of the Union very properly insists that no work should be allowed to proceed 
where the workmen are exposed to falling objects from men working above them, unless 
a safety floor or netting has been provided. Such provisions would also decrease the dan- 
ger for the 18 per cent, of men, who slipped and fell. Accidents due to defective scaffolding 
of which there were 8.7 per cent, could be prevented by a more efficient inspection and 
supervision. 188 
IRON, STEEL AND ALLIED INDUSTRIES 
cent, of their original weight during the grinding process. This affords an 
approximate idea of the amount of dust production, which is not always 
wholly avoidable, even by the employment of hoods and exhaust ventila- 
tion or by the wet process. But even with the wet process, the possibility 
of droplet, or spray inhalation cannot be ignored. 
It is well known that the inhalation of the hard, sharp and angular 
particles of steel, sand, and emery dust produce a very intensive irritation 
Fig. 9.--Grinding iron castings. Employe is wearing goggles to prevent injury to his 
eyes. (Photo taken by Hanson for the Mass. State Board of Health.) 
of the mucous membranes of the nose and air passages, causing not only 
catarrhal conditions, but also more serious chronic inflammations of the 
respiratory organs, such as bronchitis, peri-bronchitis, fibroid pneumonia, 
also spoken of by the workmen as "grinders' asthma" and "grinders' 
rot." The chronic inflammatory conditions thus produced, together 
with exposure to dampness and other injurious factors, naturally favor 
infection with the tubercle bacillus. 
Hirt gives the percentage of consumption in the total number of sick among differ- 
ent classes of "metal workers as follows: Needle polishers 69.6 per cent.; file cutters 
who are also exposed to lead poisoning 62.2 per cent.; grinders 40 per cent.; and nail 
cutters 12 per cent. STEEL GRINDING AND POLISHING 
189 
Beyer19 found that of 196 needle polishers at Remsheid only 24 were over 40 years 
of age. The reason why this occupation is especially dangerous is because the "wet 
process" cannot be employed for small objects, which moreover have to be brought 
more closely to the eyes, and thus the chances for the inhalation of dust is increased. 
During 1850-1874, according to Oldendorff quoted by Ropke,21 the mortality 
among the grinders and polishers over 20 years of age of Solingen, the seat of the 
cutlery industry in Germany, was 25 per 1000, as compared with 12.6 in the general 
male population. From 1885-1895 the relative figures were 20.63 per 1000 among the 
grinders and polishers and 13.6 in the general male population over 20 years of age. 
According to Dr. Scurfield, Medical Officer of Health of Sheffield in England, the 
mortality rate of the steel grinders over 18 years of age between 1901-1909 was 30.4 
per 1000 and in the male population over 20 years of age only 16.4 per 1000; the tuber- 
culosis death rate was 15.1 and from other diseases of the lungs 5.4. Most commend- 
able progress has been made at Solingen, where according to Ropke the mortality has 
been reduced from 20.63 in 1885 to 9.3 per 1000 in 1910 and the mortality from diseases 
of the respiratory organs from 12.82 in 1885 to 6.72 per 1000. 
In addition to the dangers referred to, the "grinders" not infrequently 
sustain injuries from bursting grinding stones and polishing wheels while 
in motion, for which adequate protection has been found in the case of the 
smaller wheels by a strong hood which incloses the wheel except at the 
point where the grinding is done, while for the larger wheels a special form 
of wheel with a safety collar is used. 
The "wet process" in addition to the danger of spray inhalation 
involves other risks. While dust production is reduced to a minimum, 
the constant throwing off of water saturates the clothing, floors and air 
and predisposes to "colds" and rheumatic conditions, especially when the 
operatives are careless about their clothing. 
Some of the grinders also assume a faulty position, crouching over 
their work, which interferes with the free expansion of the lungs. 
Study of the cutlery industry at Northampton and vicinity20 shows 
that the dust hazard is greatest in 3 departments (1) handle, sawing and 
milling, (2) grinding and (3) polishing and glazing (including buffing). 
Fumes and gases present a serious hazard in the forge department, where 
carbon monoxide is present, and in the hafting department, where lead 
and antimony, copper and tin are used. The report also points out that 
the placing of the machines at right angles to the line of windows would 
not only guarantee adequate illumination, but remove the necessity for 
pushing aside the hoods. 
Preventive Measures.-Apart from securing general sanitary working 
conditions, every effort must be made to diminish the amount of dust 
production to a minimum. In Solingen the "dry grinders" furnish 13.7 
per cent, of the lung diseases, the "wet grinders" 11.3 per cent. In all 
"dry grinding processes" forced ventilation by means of hoods connected 
with a system of exhaust fans or blowers to carry away the dust from the 
operator should be installed and their faithful use insisted upon. 
Unfortunately, in this country at least, a large proportion of grinders, 
preferring freedom of movement, remove the hoods and thus expose them- 190 
IRON, STEEL AND ALLIED INDUSTRIES 
selves unnecessarily to this especially dangerous form of dust. This state 
of affairs can be overcome only by general education and legislation. 
Scrupulous cleanliness of the person, clothing, tools and work benches 
should be observed. The employes should be taught from the outset 
proper positions and the habit of breathing through the nose. Abnormal 
conditions such as adenoids, enlarged tonsils, etc., necessitating mouth 
breathing, should be removed. 
The results of ameliorating efforts are strikingly shown not only by the 
decreased mortality rates at Solingen, but also by the fact that morbidity 
and loss of work among the insured grinders has been reduced from 38.5 
per cent, in 1886-1898 to 22.6 per cent, in 1902-1904. Grindstones 
should be inspected in order to detect flaws, properly mounted and 
secured by means of plates and bolts and the safety devices already 
referred to. (For general and individual hygienic measures see also 
pages 17-24.) 
Tempering.-The process of tempering or hardening of metals is 
carried on very extensively in the metal industry, especially in the manu- 
facture of cutlery and tools, springs, files, foundry and machine-shop 
products, automobile and bicycle parts, sewing machines, stamps and 
stencils, cash registers, electric apparatus, etc. This process is not 
dangerous to health when it involves simply heating and cooling, or 
heating and dipping into water or brine. On the other hand, the dipping 
into hot bed of lead, oil, or potassium cyanide, or the application of 
potassium cyanide, and subsequent heating in an oven, involve serious 
risks unless done with special precautions and adequate exhaust ventila- 
tion. A patented preparation advertised recently as a harmless substi- 
tute for "case hardening" is said to yield the poisonous cyanide radical 
when melted for use. 
File Cutting.-It is to be regretted that machine work has not wholly 
supplanted the dangerous process of hand file cutting. It is claimed that 
the best files are cut by hand, and as long as there is a demand, manufac- 
turers will continue to supply it regardless of the health of the workers. 
This occupation appears to be the most dangerous of all dusty occupa- 
tions; the comparative mortality rate in England is given by Dr. Tatham22 
as 1810, practically three times higher than that of agriculturists. This 
excessive mortality is due to a combination of causes, viz.: (1) The 
laborious character of the work incident to the use of the steel hammer, 
which weighs from 8 to 20 lb., and during an average day's work amounts 
to lifting over 150,000 lb. weight. (2) The work is performed in a stooping 
position, which interfers with normal respiration. (3) Both the smoothing 
process of the blank files and the process of cutting the lines by means of 
a chisel and hammer involves the inhalation of steel dust. (4) While the 
file is being cut it is usually held upon a leaden bed to prevent slipping 
and a sharp recoil and also to protect the already cut surface from injury. 
During this process particles of lead may be inhaled or swallowed with GUNSMITHS, ETC.-AGRICULTURAL IMPLEMENTS 
191 
the dust, or they may be taken up by the fingers in brushing off the file, 
or in handling the bed, and carried to the mouth in licking the fingers and 
left thumb to secure a firmer grip of the chisel. Teleky in 1913 described 
a paralysis and atrophy of the muscles of the thumb, which he attributed 
partly to lead poisoning and partly to pressure from the hammer. 
Another source of lead poisoning is that the files are hardened by passing 
them through kettles of molten lead. From 3 to 6 per cent, of lead have 
been revealed in the dust of file-hardening establishments. 
The Ohio Survey of 1915 disclosed cases of lead poisoning, occupation 
neurosis from hammering, rheumatism, stiff wrists, diseased gums and 
teeth, and inflammation of the margin of the eyelids. 
According to Sprenger, cited by Ropke,23 5.24 per cent, of the file 
cutters in Berlin using the lead bed suffer annually from plumbism. 
Preventive Measures.-Efficient exhaust ventilation and adjustable 
seats and work benches are indicated. All sorts of substitutes for the 
lead beds, such as pads of paper, wood, clay, sand, gutta percha, etc., 
have been tried and finally block tin has come into use, which Ropke 
declares to be free from objections both from the hygienic as well as 
technical point of view. 
Gunsmiths, Firearms, Weapons.-The mortality figure of gunsmiths 
according to Tatham24 is 1228, or 100 in excess of that of metal workers in 
the aggregate; the mortality from phthisis is 324 as compared with 206 
among other metal workers, and 185 for all other occupied males; the 
death rate from other diseases of the lungs and the heart is also excessive. 
Tatham regards most of the processes in which they are engaged as 
injurious, especially the exposure to the inhalation of metallic and mineral 
dust during the filing and polishing of the metal. The occupation is 
often carried on in insanitary shops, and the employes in England, 
otherwise high-grade men, appear to suffer from the alcohol habit. 
The men employed in the manufacture of firearms in the metal depart- 
ment, apart from the inhalation of metallic dust, not infrequently are 
exposed to nitrous gases evolved in the etching process, to vapors of 
antimony compounds in the burnishing of rifle barrels, and in the steel 
bluing room to the fumes of charcoal, giving off carbon monoxide. In the 
manufacture of gun stocks, large quantities of fine black walnut dust is 
evolved. 
In the manufacture of swords, sabers, bayonets, etc., apart from the 
dangers incident to steel grinding and polishing, the men engaged in fire 
gilding are exposed to the risk of mercurial poisoning. 
Agricultural Implements.-In the manufacture of these goods various 
processes are involved; some are characteristic of the metal industry, such 
as brass and iron founding, blacksmithing and forging, welding, bronzing, 
tempering, grinding, polishing, buffing and dipping, electroplating, etc. 
There may also be more or less woodworking and painting, with all of the 
hazards attending these operations. 192 
IRON, STEEL AND ALLIED INDUSTRIES 
Iron Sanitary Ware Factories.-The dangers to the workers employed 
in the manufacture of so-called porcelain or vitreous enameled iron ware, 
such as bath tubs, sinks, basins, gas stoves, hollow ware, iron plates for sign 
boards, etc., are the elements of overfatigue, excessive heat, and exposure 
to dust containing poisonous lead compounds. This industry, as con- 
ducted at present in this country, must be regarded as extremely danger- 
ous. In Germany the enamel employed is leadless, while in this country 
it contains from 2^ to 25 per cent, of lead. (See also page 449.) 
The Wire Industry.-When the ingots are ready in the "open-hearth 
department" of wire mills they are rolled into long rods and placed upon 
large spools or reels, from which the rod is carried through the drawing 
block and thence to another revolving drum drawing the rod through the 
block. This process is repeated until the desired size of the wire is 
reached. The workmen are protected to a certain extent from the heat 
by metallic screens over which water trickles, but cases of heat exhaustion 
are not uncommon, especially in summer. The process is quite dusty 
from the lime which is put on the wire to prevent rusting. The occupa- 
tion also involves considerable liability to accidents as a result of the 
fingers getting caught between the wire and the drum in drawing from 
the block. It not infrequently happens that in passing to the block the 
moving wire becomes tangled and the operator is caught and drawn 
toward the block. Unless the machine can be stopped the workman is 
likely to be seriously injured, the loss of a hand or a foot being often 
recorded. To guard against this possibility an automatic stop has recently 
been introduced and proved to be an effective safeguard.25 
After the wire is hardened by being run through crude oil it is passed 
through kettles of molten lead inside the tempering furnaces, and the 
men who feed and tend the furnaces not infrequently suffer from chronic 
lead poisoning, a danger wholly avoidable by efficient mechanical ventila- 
tion, which would carry these fumes to the outer air. 
Other sources of danger in the manufacture of wire are the employ- 
ment of sulphuric acid for annealing and pickling purposes, and the 
coppering process by the employment of sulphate of copper. The dangers 
from carbon disulphide and lead incident to the manufacture of insulated 
wire and cable should also be mentioned. 
In the process of galvanizing wire it is first passed through diluted com- 
mercial sulphuric acid, next through a weak solution of hydrochloric acid 
and finally through molten zinc (see page 337). 
Preventive Measures.-It is needless to insist that adequate provisions 
should be made to carry off the acid and metal fumes rapidly into the 
outer air. The workmen should be instructed to avoid the fumes as much 
as possible and to annoint the lips and nose within and without several 
times a day with lanolin. 
Wire Cloth, Netting and Fencing Material.-In the manufacture of 
these materials the wire is first rolled on spools and drums to form the warp AUTOMOBILES, MOTORCYCLES, ETC. 
193 
and is then woven by means of heavy looms. There is no special danger 
in this industry unless the japanning is done without adequate exhaust 
ventilation. The latter process is usually carried on in a suitable tower, 
the cloth passing from the rolls through a vat of japan, and as it emerges 
is subjected to the action of a blower, then passing upward through several 
stories, where it is dried by steam heat, and finally descends on another 
side to be wound again into rolls.26 
AUTOMOBILES, MOTORCYCLES, ETC. 
EMERY R. HAYHURST, M. D„ COLUMBUS, OHIO. 
Automobiles.-The automobile industry is an illustration of the fact 
that great plants employing thousands of men in a special branch of 
manufacture, may yet have no special processes peculiar to themselves. 
This industry is made up of several common processes which are more or 
less health hazardous, viz., Iron Founding, Brass Founding, Core Making, 
Metal Grinding, Forging and Blacksmithing, Machine Shopping, Braz- 
ing, Soldering, Welding, Polishing and Buffing, Acid Dipping, Pickling, 
Furnacing, Tempering, Electroplating, Woodworking, Painting and 
Varnishing, Japanning, Enameling, Lacquering and Shellacing. In the 
Ohio Survey, 34 firms were covered in 10 cities, employing 17,783 wage 
earners, of whom 17,404 were males, and 379 were females. The occupa- 
tional diseases and disability found were classified as follows:* 
Trade process 
Disease or disability 
reported 
No. of reported cases of 
disease disability by type 
of case 
Posi- 
tive 
Tenta- 
tive 
Probable 
total 
Varnishing 
Conjunctivitis 
1 
XX 
Tempering 
Cyanide ulcer 
XX 
Machine shopping 
Dermatitis (lard oil) 
1 
XX 
Welding 
Eye strain 
1 
XXX 
Adjusting carburetors 
Gas poisoning 
1 
X 
Carpentering on primed work. . . 
Lead poisoning 
2 
XX 
Painting, sanding, etc . 
Lead poisoning 
72 
5 
XXXX 
Tempering 
Lead poisoning 
2 
1 
XX 
Not specified 
Lead poisoning 
3 
XX 
Metal grinding, polishing 
Siderosis 
3 
XX 
Painting, varnishing 
Turpentine poison 
XXXX 
Various processes 
Tuberculosis 
17 
XX 
* Of those so engaged, x = 1-5 per cent., xx = 5-10 per cent., xxx = 10-15 per cent., 
and xxxx = 15 per cent.+. 
In the total survey there were reported 544 positive cases, and 138 
tentative cases, of lead poisoning (in a total of 1040 establishments, 194 
IRON, STEEL AND ALLIED INDUSTRIES 
employing 235,984 wage earners), hence it will be seen that the automobile 
industry, not including the manufacture of rubber tires nor the local 
repair shops and garages, supplied more than its proportion of lead 
poisoning cases. As also seen in the above table, this lead poisoning is 
a special feature of the painting and sanding processes. In a number of the 
largest plants men were still engaged in the primitive methods of dry 
sandpapering of automobile bodies following the drying of each coat of 
paint or enamel. It is to be noted that not only new work is hazardous, 
but repair work on old machines in which holes and scratches are filled 
with molten lead, and then filed or sandpapered smooth; also the scraping 
off and sandpapering of old enamel and paint. Some of the worse cases 
of lead poisoning come from these repair shops, many of which employ 
less than half a dozen men. 
Another hazard not shown in the above table is the testing out of 
motors, both in new work and inrepairshops where workmen are subjected 
to the breathing of fumes, from the mufflers or exhausts, which are often 
rich in carbon-monoxide and carbon-dioxide gases and other products 
of incomplete combustion. 
Motorcycles, Bicycles, Sewing-machines, and Cash-registers.-These 
industries simulate the automobile industry in consisting of a number of 
the same general processes, although dealing with smaller parts. In the 
Ohio Survey there were noted the following diseases and disabilities of 
occupational character: Brass chills (from bronzing and brass founding), 
and lead poisoning from painting, varnishing and tempering. 
1 Report on Conditions of Employment in the Iron and Steel Industry in the U. S. 
Senate Document No. 110, 62d Congress, 1st Session, Washington, D. C., 
1913, Vol. IV, page 29. 
2 Hirschberg.-Berliner Klin. Wochenschft., No. 6, 1898. 
3 Crzellitzer.-La Presse Medicale, December 8, 1906. 
4 Apfelbach, Geo. L.-State of Illinois Dept, of Factory Inspection Bull., April, 1914, 
page 18. 
6 Report on Conditions of Employment in the Iron and Steel Industry in the U. S. 
Senate Document No. 110, 62d Congress, 1st Session, Wash., D. C., 1913, 
Vol. Ill, pages 289-332. 
6 Report on Conditions of Employment in the Iron and Steel Industry in the United 
States, 62d Congress, 1st Session, Senate Document No. 110, Washington, 
1913, Vol. IV, page 11. 
7 Ropke, Friedrich.-Trans. 15th Internal. Congress on Hygiene, Vol. Ill, Part II, 
page 729, Washington, D. C., 1913. 
8 Employment in the Iron and Steel Industry in the U. S., Vol. IV, 62d Congress, 1st 
Session, Senate Document No. 117, Washington, D. C., 1913. 
9 Ropke.-Transactions 15th Internat. Congress on Hygiene, Washington, D. C., 
1913, Vol. Ill, Part II, page 730. 
10 Hayhurst, E. R.-Industrial Health Hazards and Occupational Diseases in Ohio, 
February, 1915. 
11 62d Congress, 1st Session, Senate Document No. 110, Vol. IV, Washington, 1913. 
REFERENCES REFERENCES (IRON, STEEL, ETC.) CONCLUDED 
195 
12 Hayhurst, E. R.-Industrial Health Hazards and Occupational Diseases in Ohio, 
February, 1915. 
13 Ahrens.-Archiv fur Hygiene, Bd. XXI. 
14 Hesse.-Vierteljahrschft. f. gerichtliche Medizin, Bd. XXXVI. 
16 Second Report of the Factory Investigating Commission, State of New York, 1913, 
Vol. I, page 256. 
16 Sommerfeld.-Handbuch d. Gewerbekrankheiten, Berlin, 1898. / , 
17 Gottstein and Kayser.-Breslauer Artzliche Zeitschft., 1881, No. 9. 
18 Roth.-Gewerbehygiene, Berlin, 1906, page 71. 
19 Beyer.-Die Fabrikindustrie d. Reg. Bez., Dusseldorf, 1876. 
20 Mass. State Board of Labor and Industries, January, 1917. 
21 Trans. Internal. Congress on Hygiene at Washington, 1913, Vol. Ill, Part II, page 
721. 
22 Oliver's Dangerous Trades, 1902, page 138. 
23 Ropke, F.-Trans. 15th Internal. Congress on Hygiene, Vol. II, Part III, page 722, 
Washington, 1913. 
24 Tatham.-Oliver's Dangerous Trades, 1902. 
25 Senate Document No. 110, 62d Congress, 1st Session, Vol. IV, page 232, Washing- 
ton, D. C., 1913. 
26 Report of the State Board of Health of Mass, upon the Sanitary Condition of 
Factories, etc., 1907, page 91. CHAPTER IV 
PRECIOUS METALS, JEWELRY AND PLATING INDUSTRIES 
GEORGE M. KOBER, M. D„ Washington, D. C. 
Gold Mining.-The dangers of gold mining do not differ from those of 
metalliferous mines in general; indeed they are probably less in alluvial 
and placer mines. In quartz mines, however, the men are exposed to a 
very irritant dust as shown by an alarming prevalence of pulmonary 
diseases, especially in the gold fields of the Transvaal and at Bendigo. 
The dust is generated not only during the drilling and blasting of the hard 
quartzite rock, but the men are exposed also during the transport of the 
conglomerate to the surface and the subsequent crushing in the stamp 
mills. (See dust prevention, page 21.) 
Extraction of Gold and Silver.-After repeated washing of the crushed 
ore the gold is extracted by amalgamation with mercury, which takes 
up the gold and from which it is recovered by raising the temperature to 
400°C. This involves danger from mercurial poisoning, especially during 
the retorting process. Silver is likewise recovered from crushed ore by 
amalgamation with mercury, and considerable quantities are obtained 
from lead ore during the roasting of which there is a certain amount of 
danger from lead, arsenic and antimony poisoning. (See also pages 
485, 486.) 
The MacArthur-Forrest cyanide of potassium process is now generally 
employed for the extraction of gold and silver from low-grade ores as a 
substitute for the more dangerous mercurial process. In this process the 
crushed ore is placed in vats containing a 0.05 to 0.5 per cent, solution of 
cyanide of potassium, where it remains from 12 to 24 hours or longer 
according to the character of the ore. The liquor is then passed over 
pure metallic zinc shaving, upon which the gold is deposited as a slime. 
This slime is roasted and smelted and pure gold is obtained. Work with 
cyanide solution, however, involves exposure to cyanogen and arsenical 
vapors. According to Dr. Noble W. Jones (J. A. M. A., 1907, Vol. 48, page 
1099), cited by Dr. Alice Hamilton, arseniureted hydrogen is evolved when 
a hot solution of potassium cyanide and powdered zinc acts on a reducible 
compound of arsenic, which is commonly present in the ores and in the 
zinc. Two of the 5 cases reported by Jones had complete suppression of 
urine before death and autopsy revealed hemorrhagic inflammation of the 
liver and kidneys. The dangers must be avoided by copious ventilation, 
the employment of cold cyanide solutions, respirators and the use of 
rubber gloves in order to avoid troublesome eczema of the hands and 
arms. 
196 GOLDSMITHS 
197 
Gold and silver apparently possess no serious toxic properties. Cases 
of argyria, i.e., a brownish-black discoloration of the skin as a result of 
ingestion or penetration of silver dust, have been reported in silver 
workers. Koelsch1 describes two cases in silver leaf workers. Most of 
the cases have been observed among workers in the glass-pearl industry, 
who employ a solution of nitrate of silver for silvering purposes and 
apply suction by the mouth. This danger has been obviated by the use 
of air pumps. Cases of local argyria have been observed in photog- 
raphers and mirror platers. 
Goldsmiths.-The manufacture of jewelry affords employment to a 
large number of persons, including females and minors; of 5753 persons 
employed in various jewelry establishments in Massachusetts2 there were 
3504 males and 2219 females, including 442 girls and 260 boys. The 
Sanitary Inspector found, what is quite generally the case, a tendency to 
overcrowding; this together with a stooped position over bench work, in 
the absence of adjustable seats, and a high temperature of the room con- 
stitute in themselves injurious factors, aggravated by dust, acid fumes and 
other conditions, such as fatigue due to eye strain incident to the various 
processes which will be briefly alluded to. The mortality rate from 
diseases of the lungs in the Berlin goldsmiths3 from 1886-1893 was 42.5 
per cent., inclusive of 40.2 per cent, from tuberculosis. 
The basis for all kinds of jewelry is what is known as "flat stock," 
which is made by sweating on bars of gold by means of silver solder to 
bars of brass of the same width in a gas furnace to a cherry red which 
results in a firm fusion. This process is necessarily attended with expo- 
sure to excessive heat and should never be carried on in the general work- 
room. The bars are then rolled to any desired, thickness, the gold 
spreading equally with the brass, and from this "flat stock" both tubing 
and wire maybe made suitable for bracelets, slides, watch chains and orna- 
ments of every description. The patterns for the flat ware are struck by 
means of a steel die and cut out in steel presses. The several parts are 
then soldered together usually by female labor; the process involves the 
use of Bunsen burners and blowpipes, and although an ingenious sub- 
stitute for the blowpipe operated by compressed air has been employed 
in Germany, the work which is done within 16 in. from the eyes, involves 
not only eye strain, but also exposure to heat, inhalation of the products 
of combustion, and possibly of coal gas from defective rubber tubings 
and burners. After soldering, the piece is placed in a 5 to 20 per cent, 
solution of sulphuric acid for the removal of borax and is then polished 
with cotton cloth wheels and bristle brushes. The polishing wheels are 
provided with efficient hoods and exhausts so that the dust may be 
collected under water in suitable tanks for the ultimate recovery of the 
gold and silver. The final finish consists in the application of a weak 
solution of potassium cyanide and gold; this is applied steaming hot in 
open crocks or sinks, not infrequently located in the center of the room. 198 
PRECIOUS METALS, JEWELRY AND PLATING INDUSTRIES 
Cheap Jewelry and Electroplating.-The manufacture of cheap 
jewelry, ornaments, etc., is a growing industry both here and abroad; 
suffice it to say that most of these trinkets are merely plated brass goods, 
which are first cleansed by means of an acid bath containing nitric or 
muriatic acid, although sulphuric acid is sometimes used. This dipping 
process in hot acid solutions, apart from being a frequent cause of eczema 
of the hands and arms, also exposes the workmen to injurious fumes. 
The goods are then washed off in ammonia solutions and dipped in the 
electroplating bath consisting usually of gold or silver dissolved in a 
solution of potassium cyanide, the fumes of which constitute the chief 
element of danger. 
Plated goods are not polished but they are subjected either to the 
so-called scratch brushing process, or various enamels and lacquers are 
employed to prevent tarnishing. Zapone lacquer is quite generally used 
and the observations of employes of the State Board of Health in Massa- 
chusetts as to its effect upon the health of some of the female employes 
indicate the wisdom of placing it in the list of industrial poisons. (See amyl 
acetate, page 644.) Holtzmann cited by Lehmann has called attention 
to the danger of lead poisoning from the enamel employed in the manu- 
facture of jewelry from "Tula or Niellosilver." The blackening of silver 
goods by means of a bath in a solution of arsenious acid, iron sulphate, 
sulphuric acid and zinc shavings, according to Bayer cited by Lehmann 
involves exposure to arseniureted hydrogen. (See also copper, nickel, 
tin and zinc plating.) Occasional cases of lead and mercurial poisoning 
have been observed in galvano-plastic operations and also in the refinement 
of gold and silver. 
The machinery used in the jewelry industry includes power presses, 
foot presses, stamps, rolling mills, large and small lathes, milling and 
grinding machines, planers, grindstones, small sand blasts, emery and 
cotton wheels. Occasional injuries to the fingers occur in operating the 
stamp and pressing machines. Dr. Baum,4 a woman Medical Inspector, 
has called attention to the fact that miscarriages and premature births 
are quite frequent among the women employed in the Pforzheim jewelry 
industry and attributes this largely to the use of the foot power presses. 
The writer feels disposed to raise the question whether the constant han- 
dling of brass goods may not cause a subtle form of lead poisoning to 
which the embryo is peculiarly susceptible. 
The materials employed in the manufacture of jewelry besides those 
mentioned also includes aluminum, precious and imitation jewels, cellu- 
loid, glass and pearls; in fact quite a number of establishments are also 
engaged in the manufacture of pearl goods. 
Silversmiths.-The hygiene of silversmithing does not essentially 
differ from the industry just described; both occupations are sought by 
weaklings and the working conditions tend to produce not only pul- 
monary diseases but also visual defects, because much of the work is done WATCHES AND CLOCKS LEAF METAL WORKERS 
199 
at close range and unless the light is sufficiently ample, eye strain results. 
On the other hand, if the light is too glaring, or the persons handle highly 
reflecting surfaces, irritation and hyperaesthesia of the retina is apt to 
develop. This condition is by no means uncommon in polishers of silver 
or silver-plated ware. 
Preventive Measures.-The most injurious factors in these industries 
are exposure to vitiated and often overheated air, dust of a mixed charac- 
ter, acid fumes, the vapors of cyanogen compounds, ammonia, zapone 
lacquer and of glacial acetic acid, while the odor of sour beer, solutions of 
soda, bran and shorts and soap tree bark employed in the " scratch-brush- 
ing" process are also more or less offensive. All these dangers can be 
reduced to a minimum by efficient exhaust ventilation, separate rooms 
for the "dipping" department, provided with suitable hoods and suction 
apparatus. The persons engaged in the "dipping process" should either 
handle the goods with wooden tongs or protect their hands with zinc 
ointment or rubber gloves in order to avoid troublesome affections of the 
skin. 
Manufacture of Watches and Clocks.-In this industry there is 
likewise a tendency to overcrowding, and failure to provide adjustable 
seats for bench work. The lighting of the rooms is often defective, caus- 
ing eye strain in about 10 per cent, of those engaged in the work (Cohn). 
The injurious factors, apart from exposure to dust derived from gold, 
silver, steel, copper, brass and the material used for enamel, are the fumes 
of nitric acid evolved in the enameling process of dials, etc. The latter 
process and the tempering of watch and clock springs, and the casting of 
leaden weights also involve exposure to lead. The fumes of benzine and 
of cyanide evolved in cleaning the small parts are likewise inimical to 
health. The Berlin statistics5 from 1892-97 show that 50 per cent, of all 
the deaths in this industry were caused by tuberculosis and the average 
age was only 27.8 years. This may in part be accounted for by the fact 
that many persons with feeble physique enter this industry, but the bad 
working conditions are also important contributory factors. 
Preventive Measures.-Most commendable efforts are made in 
modern establishments to provide proper safeguards in the way of air- 
space, light and ventilation, with mechanical devices for the arrest and 
removal of dust and fumes at the point of their origin. In one of the 
German establishments the tempering furnaces are supplied not only with 
exhaust ventilation but also with a pyrometer, in order that the operators 
can observe the color of the steel without exposure to the vapors. 
Leaf Metal Workers.-The metal employed for gold leaf, silver, 
bronze, aluminum, or other composition, usually an alloy of copper and 
zinc, is first rolled into thin sheets and subsequently hammered into the 
finest sheets inclosed in parchment paper. The hammers weigh from 6 
to 24 lb. and the workmen lift this weight about 90 times every minute, which 
involves a hard day's work. Recently special beating machines have 200 
PRECIOUS METALS, JEWELRY AND PLATING INDUSTRIES 
been invented which it is hoped will obviate excessive muscular efforts, 
exposure to intensive noises and accidents from hammer blows. 
Leaf metal is employed in the manufacture of mouldings, picture 
frames, gilding and silvering of furniture, art goods, etc. The leaf metal 
or other gilding materials are generally applied by means of a size con- 
taining benzol or benzine, acetone, pyroxylin, wood alcohol, amyl acetate 
and ammonia. Apart from exposure to these agents and leaf metal dust, 
more or less white lead and acetate of lead are used in this industry and 
add an element of danger. The work is generally done in closed rooms 
to avoid draughts and hence the air is charged with the odors of glue, 
varnish, oil, turpentine, shellac and the other agents mentioned. In 
the manufacture of gold-threaded textiles, a very fine metallic dust6 is 
evolved which has been known to produce catarrhal conditions of 
the eyes. 
According to Hirt,7 the leaf metal workers are peculiarly liable to 
diseases of the respiratory organs and especially to tuberculosis. 
The gold leaf workers in Vienna7 have a very high morbidity and 
mortality from chronic bronchitis, emphysema, and tuberculosis of the 
lungs. The morbidity of this class of workers in Austria, according to 
Jehle,8 is 42.5 per cent, against an average of 27.5 per cent, in other 
pursuits. 
The vital statistics of leaf metal workers in this country are extremely 
meager. Hoffman's statistics are based upon 25 deaths from all causes; 
of this number 7 were from consumption and 5 from pneumonia and other 
diseases of the lungs. 
Diamond Cutters and Polishers of Precious Stones.-This industry 
is to a great extent centered in a few cities of continental Europe, notably 
Amsterdam, Antwerp and Oldenburg. There are only about 400 men 
employed in the diamond-cutting shops of New York as compared with 
9000 in Amsterdam.* The rough diamond is usually cut by another 
diamond and is then embedded in a mass of molten metal, composed of 
about 60 parts of lead and 40 parts of tin, to which a handle is attached. 
The same method, although with variable proportions of the alloy, is 
also employed with other precious stones, and greatly facilitates the 
polishing process, which is done by hand, but mostly by means of rapidly 
rotating small iron wheels or leaden discs. In either case there is exposure 
to dust and lead, and the danger from lead poisoning is all the more 
pronounced if revolving lead discs, or a lead-containing grinding powder, 
are used. Some authors maintain that during the melting of the alloy 
there is also exposure to lead fumes. The "setters" who prepare the 
diamond or gem for the cutter by soldering are exposed to coal gas when 
charcoal fires are used to prepare the solder. 
* According to the Scientific American Supplement (Oct. 7, 1916), since the War New- 
York is now the center of this industry, but there are no published morbidity or mortality 
statistics. DIAMONDS AND PRECIOUS STONES--REFERENCES 
201 
Tracy, cited by Hoffman9 found 73.5 per cent, of the setters in 
Coster's factory at Amsterdam pale and anaemic; 57 per cent, had palpita- 
tion, giddiness, precordial distress; 56 per cent, chronic headache; 36 per 
cent, asthma, etc.; 90 per cent, had phthisis, and 30 of 90 men examined 
showed traces of lead poisoning. Oliver10 reports that wrist-drop and 
colic are the prevailing forms of plumbism. Koelsch11 found among 
50 diamond polishers sixteen cases of suspected lead poisoning, six of 
which revealed slight traces of a gum lead line. 
The same danger is observed in the cutting and polishing of other 
precious stones, which industry, in some parts of Bohemia, is not infre- 
quently carried on in the homes of the artisans. 
The undue prevalence of plumbism among the diamond cutters in the 
Netherlands induced the Dutch Government to offer a prize for a suitable 
substitute for lead in the alloy, which has not yet been awarded. 
It is reported by Oliver that some of the gem polishers in Oldenburg 
use an alloy of tin, copper and bronze, and Rambousek, in referring to the 
industry in Bohemia, states that the authorities have required substitu- 
tion of silicon carbide for lead discs. 
The work, apart from danger of lead poisoning, involves eye strain, 
and is often carried on under unfavorable environments as regards 
light, ventilation and heating. A combination of factors, such as bad air, 
sedentary habits, inhalation of dust, and ingestion of lead are doubtless 
responsible for much of the ill health. According to Tracy, 52 per cent, 
of the cutters or polishers employed in Coster's factory at Amsterdam 
were thin and pale, 40 per cent, were asthmatic, and 33.75 per cent, 
suffered from headache, etc. Cases of lead poisoning are doubtless as 
common among the cutters as among the setters. 
Preventive Measures.-Since it has been shown that an efficient sub- 
stitute for lead exists, the use of lead discs should be prohibited. All 
polishing processes should be carried on by the wet process and guarded 
by hoods and efficient exhaust ventilation. Frequent ablutions and all 
the safeguards against lead poisoning should be invoked. Good general 
ventilation, adjustable work benches, and improved working conditions 
as regards light, air-space, and heating, are recommended. 
1 Koelsch.-Munch, med. Wochenschrift, January-February, 1912. 
2 Report of the Mass. State Board of Health, 1909, pages 25, 53. (See also report on 
sanitary condition of factories in Mass., 1907, page 95.) 
3 Koelsch.-Soziale Lage u. Krankheit, Munchen, 1st Liefg., 1912, page 219. 
4 Baum-Neisser's Internat. Ubersicht uber Gewerbehygiene, Berlin, 1907, page 126. 
s Zadek.-Weyl's Handbuch der Gewerbekrankheiten, Jena, 1908, page 151. 
6 Walther.-Weyl's Handbuch der Gewerbekrankheiten, Jena, 1908, page 663. 
7 Hirt.-Die Krankheiten der Arbeiter, 1871, I, page 89. 
8 Jehle.-Zeitschft. f. Gewerbehygiene, 1895, page 24. 
9 Hoffman.-Bull. Bureau of Labor, No. 79, Washington, D. C., 1908. 
10 Oliver, Sir Thomas.-Bull., Bureau of Labor, No. 95, Washington, D. C., 1911. 
11 Koelsch.-Zentrbt. f. Gewerbehygiene, 1914, page 91. 
12 Lehmann, K. B.-Arbeits u. Gewerbehygiene, Leipzig, 1919. 
REFERENCES CHAPTER V 
THE LUMBER INDUSTRY 
GEORGE M. KOBER, M. D„ Washington, D. C. 
The Lumber Industry.-According to the U. S. census an average 
of 695,019 wage earners, inclusive of 7959 females and 5933 children under 
16 years of age, were employed in this industry. The merchant saw mills 
afforded employment to 547,178 persons, the independent planing mills 
employed 112,392 wage earners, and the wooden packing box factories 
employed 35,449 persons. Most of the women were employed as cooks, 
etc. The U. S. Statistical Abstract (1921) gives an average of 839,008 
employes in lumber and its remanufacture for the year 1919. 
According to the report of the Washington State Industrial Insurance 
Commission, 47,400 men are employed in the logging camps and lumber 
mills of that State alone. During the period from October 1, 1911 to 
September 1, 1913 there were 9661 accidents with 251 fatal injuries; 
990 of the injuries resulted in permanent partial disability, and 8420 in 
temporary disability. Among the causes of accidents may be mentioned 
the following: Falling trees, timbers, lumber, "kick-backs," etc. Rolling 
and moving logs, log carriages, handling chains, cables, blocks, lumber, 
timbers, etc., flying fragments, explosives, axes, hatchets, adzes, crosscut 
saws, splinters, power-driven saws, planes, and wood-working machines. 
During the year ending October 1, 1913, there were not less than 7465 
awards in this industry in that State amounting to $668,793.84. 
Preventive Measures.-The accident liability is sufficiently appalling to have 
induced Miss Boardman on behalf of the American Red Cross to arrange for first-aid 
instruction in our American lumber camps. According to W. Graham Cole, (Safety 
Engineer, December, 1920) the men need education in modern preventive methods. 
In addition to accidents the men are exposed to hard work, long working hours, 
inclemency of the weather and very frequently also to typhoid, dysentery and hook- 
worm infection, vermin, and other avoidable insanitary conditions of camps, food 
supplies, kitchens, disposal of refuse, etc. 
Saw and Planing Mills.-In these occupations, hard work, exposure 
to drafts, high temperature in the drying kiln department, the effects of 
incessant noise upon hearing, the inhalation of dust from planing and 
sandpapering machines and accidents are injurious factors. 
Accident Liability.-Of 3464 accidents requiring workingmen's compensation in 
Austria collected by Sternberg,1 1074 were caused by planing machines, 283 by 
ripping machines, 1975 by circular saws and 132 by straight saws; 3029 of the injuries 
involved the fingers, resulting often in complete loss of one or more members; 268 
involved the hands and forearm, and 46 the eyes, mostly from flying fragments from 
the circular saws. 
202 WOOD WORKERS AND TOXIC WOODS 
203 
Wood Workers.-Apart from accidents, intense noises, from ripping 
and planing machines, constrained position, causing the so-called "car- 
penter's stoop" and exposure in certain processes to industrial poisons, 
the chief occupational risks are unfavorable hygienic environments, 
exposure to wood dust, sandpaper and sanding belts. The amount and 
character of dust depends upon the process in which it is evolved and the 
character of the wood; the dust from hard wood is finer, harder and doubt- 
less more irritating to the respiratory passages. Sommerfeld2 gives the 
mortality rate from tuberculosis among wood workers as 6.6 per 1000. 
According to Roth3 61.7 per cent, of all the deaths among the wood 
turners in Berlin were caused by consumption; inflammation of the skin 
and mucous membranes are also quite common in this class of workers 
on account of the use of bichromate and anilin stains, wood alcohol, 
varnishes, etc. 
Toxic Woods.-Workers in "sequoia wood," especiallyrecent employ- 
ees, are liable to suffer from catarrhal symptoms, such as sneezing, water- 
ing of the nose, smarting of the eyes, irritation in the throat, coughing, 
difficult breathing and oppression in the pit of the stomach.4 
"Cocobola wood" is extensively used in the manufacture of tools and 
implements, especially for handles, and also for bowling balls. This 
wood evolves a very pungent and irritating dust productive of inflamma- 
tion of the eyes and skin. Some persons become accustomed to its effects 
while others are obliged to discontinue work in that department. Similar 
observations have been made in Austria in connection with the manufac- 
ture of walking sticks from "cocobola" and other exotic, colored hard 
wood. The Factory Inspector4 also observed an undue prevalence of 
diseases of the respiratory organs and insisted upon the introduction of 
mechanical devices for the removal of dust. 
Dr. Neisser5 refers to a tool factory at Strassburg which in 1904 
furnished 15 cases of sickness out of the 20 employes, with 288 days loss 
of work; among these were six cases of diseases of the lungs, three of the 
nose and throat and one of the eyes. In this instance the authorities 
likewise insisted upon effective removal of the dust. Dr. A. Nestler6 
has studied the toxic principle of cocobola wood and believes it to be an 
ethereal oil, soluble in alcohol and benzol and to a less extent in water. 
Sabicu wood, a product of Cuba, is said to produce a "snuffy dust" 
and catarrhal symptoms of the eyes and nose. The same is said of the 
Japanese hard wood "tagayasa" which in addition also causes dermatitis 
and a dark brown gunpowder-like pigmentation. The toxic action is 
attributed by Iwakawa to a substance closely allied to chrysarobin and 
like the latter agent also affects injuriously the digestive and renal functions. 
Satin Wood.-The Medical Inspector of Great Britain5 in 1904 reports 
a few cases of a peculiar inflammation of the skin affecting cabinet workers 
engaged in handling "satin wood" panels for decorative purposes in the 
smoking room of a steamer. The dust from this wood (Cloroxylon Swien- 204 
THE LUMBER INDUSTRY 
tenia) affected only the unprotected portions of the body, face, neck, ears, 
hands and wrists. The first symptoms consisted of an intense irritation, 
followed by heat, redness, swelling and pain; at a later stage the skin 
became moist and peeled off. Some of the workmen doing the same work 
experienced no unpleasant symptoms. The wood from East India was 
found to be more irritating than the West India variety. According to 
Lehmann7 similar cases have been reported in Germany; in some instances 
tolerance was established in others the susceptibility increased to such an 
extent as to produce toxic manifestations in persons, who simply handled 
the tools used in the manipulation of the exotic wood. In another variety 
of satin or amber wood derived from the Liquidamber stryaciflua and 
which produces more intensive irritant effects, Nestler8 succeeded in 
extracting the active principle consisting of a stearin-like substance solu- 
ble only in ether. A small quantity of it placed in contact with the skin 
of the forearm produced in about 5 hours a tensely swollen yellowish 
blister surrounded by a red area of inflammation. After the bursting of 
the blister an ulcer remained which required 4 weeks to heal. Satin 
walnut appears to be harmless. Wechselmann cited by Lehmann7 
isolated from the Australian Moa wood an oil and an alkaloid and found 
that the latter produced toxic symptoms when present even in minute 
traces. The dust of "cokus" wood, ebony, teak and Mexican "blue 
gum" is also liable to cause inflammatory skin affections. Teak wood 
also produces constitutional symptoms such as nausea, and vomiting. 
Sternberg10 refers to "Indian rosewood" as a cause of inflammatory affec- 
tions of the skin of the face, forearms and hands in the employes of one 
of the Vienna store fixture factories. 
African Boxwood (Gonioma Kamassi).-In 1905 the Medical Inspec- 
tor of Great Britain11 reported a number of instances with toxic symp- 
toms occurring among persons employed in the manufacture, especially 
during the sandpapering process, of weaver shuttles made from African 
boxwood. Investigation revealed the presence of an alkaloid in the wood 
which acts as a heart depressant, producing a slow and intermittent pulse, 
also headache, watering of the eyes and nose, feeling of sleepiness and 
difficulty of breathing. Some of the men were pale, weak and jaundiced 
and had precordial pain, nausea, cold sweats and a camphor-like odor of 
the breath. Oliver12 states that Dr. Young described in 1902 symptoms 
such as inflammation of the eyes, dilatation of the pupils, dryness of the 
throat and catarrhal conditions, lasting 2 or 3 days in men making rulers 
from Marcaibo boxwood. Poisoning by African boxwood is subject to 
compensation under the British Compensation Act. 
Pneumoconiosis and Asthmatic Attacks in Woodworkers.-There is 
very little concerning wood dust in the literature of pneumoconiosis. 
P. Pincherle (Il Lavoro, Oct., 1921) cites Kurt Gade of Rostock who, 
examining wood dust under the microscope, found particles rich in sharp 
points capable of injuring the epithelium of the nose, trachea and bronchi. WOOD PRESERVATIVES, STAIN'S AND POLISHES 
205 
It is chiefly this mechanical effect that is of importance, although there 
is also a chemical action in the case of such woods as mahogany, satin 
wood, sandal wood, and teak. 
The author reports a case of asthma following the aspiration of wood 
dusts. The sputum did not show the findings pathognomonic for asthma, 
i.e., Curschmann spirals, Charcot-Leyden crystals, nor was there any 
reason to suspect the presence of a toxic agent or of bodies provoking 
anaphylaxis. The cause of the asthma was a chronic bronchitis provoked 
by the breathing of wood powder. Twenty wood workers were then 
examined, fourteen of whom showed morbid conditions of the respiratory 
tract, viz., seven with bronchial catarrh more or less intense, and seven 
with asthmatic attacks.-Curschmann spirals were found twice, Charcot- 
Leyden crystals once. (Alice Hamilton, Jour. Ind. Hyg., Mar., 1922. 
Abst. No. 251.) 
Wood Preservatives.-Persons engaged in the impregnation of rail- 
road ties, shingles, etc., with tar or creosote are liable to suffer from 
vesicular and other skin eruptions not necessarily confined to the hands 
of the worker. In recent years solutions of corrosive sublimate and 
sulphate of copper have also been used. According to Schlauf cited by 
Lehmann,7 sublimate eczema and catarrhal conditions of the mucous 
membranes of the head are fairly common. Respirators and other special 
precautions are necessary for the men preparing the mercurial solutions; 
a change of work every two months has been recommended. 
According to McCord and Kilker9 the principal chemicals used in 
this country are: tars and creosote because of their ability to render the 
wood weather-proof and water proof; and zinc chlorid because of its 
action as a fungicide and a fire repellant. 
Tar dermatitis was observed in only 2 instances; tar acne was present 
in nearly all the workers examined, and tar cancer was strongly suspected 
in two cases. In addition, all patients presented multiple lesions of the 
fingers, hands, forearms and rarely of the legs and thighs, which the 
authors attributed to burns from the chloride of zinc solution. Ante- 
cedent injury to the skin appears to be necessary to cause these lesions. 
Preventive Measures.-McCord and Kilker found that, since the use of an overall 
impervious to water and acid zinc chlorid solution and of flexible "linoleated" canvas 
gauntlets and prompt treatment of all trivial injuries, the zinc chlorid burns have 
disappeared from the plant. 
Wood Stains and Polishes.-Reference has been made on page 203 to 
the use of bichromates'for wood stains, and on page 514 to the toxic effects 
of red anilin used for staining purposes in imitation of mahogony, or to 
impart to this wood a richer color; similar instances are doubtless quite fre- 
quent. In a recent investigation at Budapest it was found that the pro- 
longed working with stains containing wood alcohol may cause optic 
neuritis, simply by the evaporation of the spirit and several workmen in a 
cabinet factory were suffering from incipient atrophy of the optic nerve. 206 
THE LUMBER INDUSTRY 
As a result of Dr. Daifis'13 investigation, which also revealed the presence 
of wood alcohol in a few of the most expensive liquors, monthly inspec- 
tions of the workmen have been ordered, and it is expected that more 
stringent legislation will be enacted. 
The so-called "polishers' itch," an eczematous condition of the hands 
and arms, is quite common among wood polishers, the causative agent 
being either petroleum, paraffine oil, shellac dissolved in wood alcohol or 
in alcohol denatured with pyridine bases or wood alcohol. The use of 
varnish may give rise to occasional cases of plumbism, and Sternberg14 
reports that old topers not infrequently drink the shellac mixture leading 
to the formation of shellac concretions in the stomach. 
Furniture Carpenters, Cabinet and Furniture Makers.-According to 
Sternberg14 of 10,071 male workers in Vienna during the year 1904, 5341 
were taken sick; of these 1506 or 28.1 per cent, suffered from tuberculosis 
and other diseases of the respiratory passages. The death rate from tuber- 
culosis in the registration area in the U. S. for 1909 was 10.1 per cent. Apart 
from dust inhalation this class of workers are liable to suffer from callosities 
and contracted tendons of the palm of the hand from the use of the chisel 
and those using hand planes involving rotary movements of the wrist and 
forearm not infrequently develop occupational neuroses and peculiar 
inflammation of the tendons of the dorsal surface of the thumb. Workers 
in parquetry and scrapers of floors are very liable to develop inflammation 
of the bursa in front of the kneecap, with accumulation of fluid therein 
(housemaid's knee). Faulty positions and unsuitable work benches 
naturally favor the development of spinal curvature and other deformities. 
Continuous standing predisposes to varicose veins, ulcers and "flat-foot," 
affecting especially the left side. (See also wood stains and polishes.) 
Robinson and Wilson16 found among 270 employes engaged in the 
manufacture of furniture, only three cases or 1.1 per cent, to be tuberculous. 
Much of the work, i.e., sawing, planing, turning and belt-sanding is dusty, 
but powerful blowers eliminate this hazard to a great extent; 58.1 per 
cent, of the employes were over 35 years of age. The sanitary condition 
(toilets, wash rooms, and general cleanliness) was fair in three and dirty in 
one of the factories. 
Carriage and Wagon Makers.--Robinson and Wilson16 examined 230 
persons employed in this industry in Cincinnati and found only one case of 
tuberculosis. This is attributed to the fact that 79.6 per cent, of the 
workers were over 25 years of age and 42.6 per cent, over 35. The 
blowers attached to the dust producing machines (belt-sanding) removed 
a large part of the dust; steady work and fair wages also played a role. 
Only a small percentage of metal grinding is done in carriage factories. 
Varnishing usually has an injurious effect upon health, but no sickness due 
to the process was found. 
Piano and Organ Making.-These industries include a great number 
of separate processes; of hygienic interest are those connected with dust WOOD WORKING PROCESSES 
207 
production, the inhalation of bronze and exposure to wood alcohol in the 
varnishing and polishing department. Cases of lead poisoning have been 
reported among solderers, varnishers and bronzers of piano frames and 
also in men who work on pipe organs or temper piano wires. Other 
hazards are acid dipping and electroplating, brazing and welding. Among 
664 employes (94 females) engaged in the manufacture of pianos, seven 
cases of tuberculosis, or slightly more than 1 per cent, of those examined, 
were found by Robinson and Wilson. A powerful blower system carried 
away all dust produced by the machines. The factories were provided 
with good toilet facilities, wash room, sanitary drinking fountains, lunch 
rooms, etc. Two of the active cases of tuberculosis were employed in the 
varnishing department and exposed to the fumes of naphtha and dust 
produced in sand papering, but both were also addicted to the use of 
alcohol. The reporters do not consider the occupation hazardous as 
regards tuberculosis. 
Chair and Rattan Factories.-The splitting and sorting of rattan is a 
very dusty process and extremely irritating to the respiratory passages. 
There is more or less danger from exposure to the fumes of sulphur, quick 
lime and chlorine employed for bleaching the rattan, and likewise from 
hydrofluoric acid, which is used not only for bleaching purposes, but also 
for the extraction of its silicates. Italian observers (Il Lavoro, Jan. 31, 
1921) report cases of dermatitis of the forehead, cheeks, eyelids, neck, 
back of the hands and scrotum, which is attributed to a black dust, 
which forms on the mascerated cane stalk. (See also wood stains and 
polishes.) 
Whip and walking stick makers employ a variety of material such as 
rattan, wood, rawhide, glue, cotton thread, anilin dyes, varnishes, etc. 
There is always considerable production of dust in the splitting and turn- 
ing of rattan and wood. Other injurious factors are bad working condi- 
tions, the employment of chrome and other toxic stains, which together 
with impure varnishes and polishing materials not infrequently cause 
inflammatory and even suppurative inflammation of the hands. Neisser15 
also reports cases of suppurative skin affections in persons employed in the 
curving of walking-stick handles, which had been treated with a solution 
of acetate of iron, although the older employes appeared to be exempt 
from such effects. 
Furniture Repair Shops.-The work is generally carried on in insanitary 
shops, and the persons engaged in renovating old furniture and upholstery 
are exposed to the inhalation of dust of a mixed character possibly con- 
taining disease germs. (See also Upholstery, page 680.) 
Moulding and Picture-frame Makers.-In this branch of industry, the 
various processes are dusty and often carried on without adequate ventila- 
tion, while in the bronzing and gilding department there is danger from 
the inhalation of bronze, wood alcohol and amyl acetate and so-called 
"banana oil." Leadless paints are almost exclusively used for picture 208 
THE LUMBER INDUSTRY 
mouldings. Koelsch found 5.8 per cent, of hard wood picture frame 
polishers afflicted with "polishers itch." 
Coopers, like wood turners, have a high mortality rate from consump- 
tion and diseases of the respiratory system, in which the inhalation of 
hard wood dust probably plays an important role. There is also exposure 
to metal dust, blacksmithing, sand blasting and painting. The men 
engaged in shellacing the interior of casks are exposed to the toxic effects 
of the wood alcohol. (See Breweries, page 225.) 
Among 273 workers engaged in cooperage and the manufacture of 
bungs and cigar boxes, seven cases or 2.56 per cent, examined by Robinson 
and Wilson16 were tuberculous. The blowers attached to dust producing 
machines were not always successful in removing all of the dust. The 
investigators point out other unfavorable conditions, such as tempera- 
ture, humidity, alcoholism, dissipation, bad housing and family histories, 
as possible predisposing factors. 
Miscellaneous Wood Workers.-In the tub and pail industry the 
employees, many of whom are youthful wage earners, are exposed to the 
inhalation of fine wood and sandpaper dust. In the cutting, trimming, 
turning and polishing of shoe lasts large amounts of dust are evolved and 
inhaled. 
Ruler Makers.-In the manufacture of measuring rules, numerous 
cases of lead poisoning caused by chromate of lead have been recorded. 
Tuberculosis is also quite common among the workers, probably due to 
the subtle influence of lead poisoning. 
Basket Makers.-There are no published American morbidity and 
mortality statistics. The Leipsic Insurance statistics show excessive 
tuberculosis rates and also high rates for diseases of the digestive organs. 
Layet and others have observed that rheumatism, wound infections after 
injuries of the hands, inflammation of the gums and vesicles of the lips are 
quite common. Lehmann7 attributes the lip and gum affections to 
the introduction of willow switches into the mouth, as the willow bark 
contains a toxic substance. 
Charcoal Burners.-This class of wage earners are exposed to the 
hardships and discomforts incident to the primitive life of lumbermen. 
There are no special morbidity and mortality statistics. According to 
Rouget cited by Lehmann, catarrhal and rheumatic affections, gastro- 
intestinal diseases, inflammatory conditions of the eyes and hemeralopia, 
i.e., a condition in which objects are seen better at dusk or at night than 
during the day, are not uncommon. 
Preventive Measures.-Since dust inhalation and accidents constitute the most 
important risks, it is evident that all machines should be properly guarded and 
mechanical means be provided for the removal of dust; for the latter purpose, hoppers, 
suction pipes and blowers have proved quite efficient especially in connection with 
turning and sanding machines. Some of the workmen claim that the exhaust flues 
Cause disagreeable drafts and rheumatism of the finger joints, but this is a minor INSECT POWDER-REFERENCES ON LUMBER INDUSTRY 
209 
objection and could be prevented by wearing suitable gloves. It is also evident that 
persons handling toxic woods, and stains and polishes should protect their hands and 
resort to frequent ablutions. All processes should be carried on in well-ventilated 
rooms, and the vessels containing wood alcohol should be kept closed until used. 
Insect Powder Makers.-One of the most popular household insect 
powders, also known as pyrethrum (Dalmatian or Persian insect powder, 
or buhach) is made from the flowers of three varieties of Chrysanthemum 
or pyrethrum. Drs. Cary P. McCord, C. H. Kilker and Dorothy K. 
Minster17 have described several types of skin reactions among workers 
in this industry, viz., erythema venenatum, vesicular dermatitis, papular 
dermatitis and an anaphylactic type. In discussing the substances 
responsible for the hazard, reference is made to pyrethron, a neutral 
ester isolated by Fujitani and a " pyrethrotoxic acid" found by Reeb. 
In addition to these insecticidal substances, the presence of pyrethrum 
camphor, an acrid resin, known as pelletorin, essential oils, an alkaloid 
inulin, tannin, etc. have been demonstrated. These ill classified resins, 
oils, camphors etc. are accepted by the authors as irritants contributing 
to the etiology of the skin lesions. 
Preventive Measures.-Dust proof grinding and automatic filling and weighing 
devices have resulted in the prosecution of this work without contact between the 
workers and pyrethrum materials, and has proved satisfactory in the prevention of 
these skin lesions. Re-exposure frequently leads to a reoccurrence of the disease. In 
the absence of such machinery, the authors recommend scrupulous personal cleanli- 
ness, adequate workrooms, frequent change of work garments, and general cleanliness 
of the workrooms. 
REFERENCES 
1 Sternberg, Max.-Weyl's Handbuch der Arbeiterkrankheiten, 1908, page 435. 
2 Sommerfeld.-Handbuch der Gewerbekrankheiten, Berlin, 1908. 
3 Roth.-Gewerbehygiene, Leipzig, 1907. 
4 Oliver's Dangerous Trades, 1902, page 791. 
5 Neisser.-Internal, Ubersicht uber Gewerbehygiene, Berlin, 1907, page 115. 
6 Nestler.-Ber. d. deutsch. bot. Ges., 1912. Prometheus, Berlin, 1913. 
7 Lehmann, K. B.-Arbeite u. Gewerbehygiene, Leipzig, 1919, page 352. 
8 Nestler.-Arb. d. deutsch. bot. Ges., 1911. 
9 McCord and Kilker.-Zinc Chlorid Poisoning, J. A. M. A., Feb. 12, 1921, pages 
442-443. 
10 Sternberg.-Weyl's Handbuch d. Arbeiterkrankheit, 1908, page 433. 
11 Neisser.-Internal. Ubersicht uber Gewerbehygiene, 1907, pages 79, 80. 
12 Oliver.-Diseases of Occupation, New York, 1916, page 258. 
13 Journal A. M. A., August 16, 1913, page 502. 
14 Sternberg, Max.-Weyl's Handbuch d. Arbeiterkrankh., 1908, page 432. 
15 Neisser.-Internal. Ubersicht, Berlin, 1907, page 101. 
16 Robinson, D. E., and Wilson, J. G.-U. S. Public Health Bulletin No. 73, March, 
1916. 
17 McCord, Kilker and'Minster.-J. A. M. A., Aug. 6, 1921, pages 448-449. CHAPTER VI 
FARMERS, GARDENERS, PLANTERS AND FARM LABORERS 
GEORGE M. KOBER, M. D., Washington, D. C. 
Farmers, Gardeners, Planters and Farm Laborers.-The general death 
rate for 1910 in the manufacturing and mechanical industries of the 
United States was 13.8 per 1000 and the consumption rate 2.6, or 18.8 per 
cent, of the mortality from all cases. The farming population furnished 
a mortality rate of 17.6 per 1000 and a consumption rate of only 1.5, or 9.5 
per cent, of the mortality from all causes. Other diseases of the lungs 
were also less frequent. The same is true of diseases of the circulatory, 
urinary, digestive and nervous system; and the accident liability was also 
below the average. While this serves to emphasize the advantages of an 
out-door life, it cannot be said that this occupation is wholly free from 
danger and this is especially reflected by the higher mortality rates in 
agricultural laborers. The long working hours and hardship and exposure 
to all kinds of weather cannot fail to prove injurious, and as a result 
colds, catarrhal affections of the eyes, nose, and throat, rheumatism, and 
neuralgia are by no means infrequent, especially in men who work in 
green houses and are exposed to abrupt changes in temperature. Much 
of the work, such as transplanting, grafting, weeding, and cultivation with 
hand tools, is performed in a stooping or kneeling position, which is 
liable to cause lumbago, congestive headaches, nose bleed and distortion 
of the femur. Of 58 cases of coxa vara observed by Bernhart1 49 belonged 
to the agricultural classes. (For American mortality statistics see 
page 972.) 
Apart from general diseases, farmers are often victims of hay fever, 
hemp fever and quite a number are extremely sensitive to the dust from 
oats and clover, probably due to protein intoxication. 
Loth2 states that while on the whole the morbidity rates are more favor- 
able, the diseases are generally more acute, the illness more severe, and 
the mortality rate, except from consumption, is actually above the 
average of most of the other occupations. 
It is generally held that cancer of the skin is more common among 
farmers and gardeners, but Loth could not confirm this from his ex- 
perience with the truck farmers of Erfurt. The industrial mortality 
experience of the Prudential Insurance Company 1907-1912 shows the 
mortality from cancer for farmers and plumbers to be 6.94 per cent, and 
for gardeners 8.43 per cent, as compared with 5.49 per cent, in the general 
population. Among the diseases communicable from animals to men, to 
210 AFFLICTIONS OF FARMERS, ETC. 
211 
which farmers and stockmen are exposed, should be mentioned, foot and 
mouth disease, glanders, anthrax, bovine tuberculosis, cow-pox and lumpy 
jaw or actinomycosis. Since tetanus or lock jaw is a typical soil disease, 
wounds and abrasions are more liable to infection in this class of workers. 
Diseases of the skin caused by contact with poison ivy, sumach, 
asparagus and the primrose, and the affections produced by the mower 
mite (leptus autumnalis), the pediculoides ventricosis (or wheat bug), the 
acarus hordei (or barley bug) and the harvest bug or mite (leptus irritans) 
which burrow under the skin, causing itching and irritation, are occasion- 
ally met with. (See also Diseases of the Skin, page 919.) Some of the 
mites infest especially goose-berries and hyacinth bulbs and may also 
cause conjunctivitis by dust infection. Among other parasitic infections 
mentioned by Lehmann5 are: the wood tick (Ixodes ricinus) from dogs 
and other smaller animals, pigeon tick (Arcus reflexus), chicken lice 
(Dermanyssus avium), the itch mites (Sarcoptes or Acarus scabiei) from 
dogs and pigs; the fungus of ringworm (Trichophyton) and of scald head 
(Favus) from cattle, horses, cats and mice. 
Hernias and accidents are by no means infrequent and serious eye 
injuries may result from beards of grain, spears of grass, twigs, leaves, 
chaff, distribution of artificial manure, caterpillar hairs and fine hair-like 
processes from hop leaves (hop-pickers' ophthalmia). Some of these 
injuries become infected and result in blindness. G. Gherardi (Il Lavoro, 
Jan., 1921) reports an infection of the cornea produced by the sharp 
points of rice leaves which are blown about during the processes of reap- 
ing and winnowing. The evil is a very real one in the rice-growing 
districts. Of the infected cases 10 per cent, suffer total loss of vision, and 
43 per cent, diminution of vision. The author recommends protective 
eyeglasses and first-aid stations. (Jour. Ind. Hyg., Sept., 1921, Abst. p. 
103.) Cases of arsenical poisoning have been reported from the use of 
Paris green and lead arsenate employed in the form of a spray for fruit 
trees, and also from sheep dip, as an insecticide. 
Statistics cited by Neisser appear to indicate an undue prevalence of 
miscarriages in farmer's wives. Harrington calls attention to the fact 
that monotony of life is a potent factor in mental breakdown, as evi- 
denced by the frequency of insanity in farmers and farmers' wives in 
sparcely settled regions. 
Among the diseases spread by means of human fecal matter or night 
soil should be mentioned typhoid fever, dysentery, and other infectious 
intestinal diseases. 
We have learned only in recent years what an important role uncin- 
ariasis, or hook-worm infection, plays in the loss of life, impairment of 
health, efficiency, and earning power of the tillers of the soil in almost 
every part of the globe. 
A correct idea of the economic aspect of this disease may be gained 
by reference to the chapter on Animal Parasites written by Dr. Ashford, 212 
FARMERS, GARDENERS, PLANTERS AND FARM LABORERS 
who, in 1899, was the first to demonstrate that the hook-worm is the 
cause of the anaemic, dropsical, and debilitated condition, and the high 
death rate, of the peasant population of Porto Rico. In 1902 Professor 
Stiles pointed out that the same parasite is likewise crippling the South. 
Mr. Rose3 of the Rockefeller Sanitary Commission, through the 
courtesy of the Department of State, has been enabled to show that the 
hook-worm infection belts the globe, in a zone about 66° wide, extending 
from about parallel 36° north to about parallel 30° south, and that about 
940,000,000 persons live in 46 countries where hook-worm is prevalent. 
It is estimated that 90 per cent, of the inhabitants of certain parts of 
Columbia are infected; 50 per cent, of the total population of British 
Guiana, with a higher percentage among the laborers on the sugar 
plantations. In Dutch Guiana the infection on many plantations runs 
as high as 90 per cent. 
It is further stated that 50 per cent, of the coolie laborers on sugar and 
tea estates in Natal, and the same percentage of the laboring population 
in Egypt, are infected; that on many plantations in Ceylon the infection 
runs as high as 90 per cent.; and on the rubber plantations in the Malay 
States from 47-74 per cent.; that of the 300,000,000 people in India 
from 60 to 80 per cent, harbor this parasite; that the population of the 
southern two-thirds of the Chinese Empire in involved, the infection 
among the farming population running as high as 70 to 76 per cent.; 
and that about 70 per cent, of the entire population of American Samoa 
are infected. 
Danger from Carbon Dioxide in Silos.-While cases of fatal asphyxia 
from carbon dioxide evolved as a result of intramolecular processes in 
the disintegration of plant substances have been reported among vint- 
ners, distillers, brewers, yeast and vinegar makers, in the holds of grain 
vessels and in peat pits, the four cases described by Hayhurst and Scott4 
are the first on record in connection with workers in silos. Here green 
corn silage yielded enormous quantities of CO2 (probably 50 per cent, of 
the air present) within twelve hours of its placing in the silo. It is not 
improbable that such accidents have occurred before and death has been 
attributed to other causes. 
These four cases of sudden death clearly indicate the necessity of 
greater precaution in the way of ventilation of silos, either by open doors 
above the level of the silage, or as suggested by Hayhurst and Scott by 
the use of unhinged doors, which fall in as the silage settles below them, 
in addition to open roofs. The authors state that the gas can be driven 
out easily by using an open umbrella, bunch of hay, or a leafy branch of a 
tree to promote diffusion. The extinguishing of a candle or lamp flame 
indicates the presence of a dangerous decrease in O. In such cases 
oxygen inhalation and artificial respiration should be resorted to. 
Lehmann5 cites the case of a deserter, who secreted himself in hay for 
two days and was found almost unconscious with a flushed face, restless REFERENCES ON FARMERS, GARDENERS, ETC. 
213 
limbs, nausea and intensive hay odor in his breath; he recovered on the 
third day. The same author refers to two other obscure diseases one, 
designated as 11 slime or mire fever" occurred in the Province of Posen, 
the symptoms of which appear to the present writer to be similar to those 
observed in trench fever during the World war. The other disease 
described by Antonelli affected workers in artificial fertilizer and was 
characterized by fever, swelling of the upper eyelids, which gradually 
extended to the forehead and face; in severe cases there was also delirium. 
The temperature became normal in about ten days. 
Preventive Measures.-When we consider the vast number of persons engaged in 
agricultural pursuits, it is evident that greater attention should be paid to their 
hygiene. The working hours at present are excessive and should be reduced to ten 
hours a day, which would offer also opportunities to vary the monotony of life. The 
diet is often faulty, especially the hot biscuits and greasy fried dishes, and should be 
improved. The clothing should be adapted to climate and seasons, and farm labor 
should not be done in bare feet. Personal cleanliness, frequent ablutions of soiled 
hands, and prompt disinfection of wounds and abrasions with tincture of iodine are 
indicated. More attention should be paid toward securing cheerful, airy, sunny, and 
healthful homes, the proper disposal of house wastes, and a pure water supply. 
No farm should be without sanitary conveniences. The Department of Agri- 
culture has published directions for the construction of suitable privies. On account 
of the possibility of infecting the water supply, wells and privies should not be danger- 
ous neighbors. The undue prevalence of typhoid fever in rural districts could be 
materially checked by prompt disinfection of the stools of the typhoid patients. This 
is all the more important, since infection is often conveyed through the milk supply, 
and through vegetables and strawberries raised in beds which have been fertilized with 
infected night soil, which may thus infect consumers residing elsewhere. 
REFERENCES 
1 Bernhart, cited by Koelsch.-Krankheit u. Soziale Lage, 1st Liefg. Munchen, 1912 
2 Loth.-Weyl's Handbuch d. Arbeiterkrankh., 1908. 
3 Rose.-Trans. 15th Internat. Congress on Hygiene, Washington, D. C., 1913, 
Vol. Ill, Part II, page 762. 
4 Hayhurst, E. R., and Scott, Ernest.-J. A. M. A., Vol. LXIII, pages 1570-1572. 
Also Bull. Ohio State Board of Health, October, 1914, and Indust. Health 
Hazards & Occup. Diseases in Ohio, 1915, pages 394-399. 
6 Lehmann, K. B.-Arbeits u. Gewerbehygiene, Leipzig, 1919, page 444. CHAPTER VII 
THE INDUSTRY OF FOOD STUFFS, ETC. 
GEORGE M. KOBER, M. D., Washington, D. C. 
The Grain and Milling Industry. Grain Threshing.-It is well known 
that even the modern threshing process has not materially diminished the 
liability to dust inhalation. Fortunately, the exposure to this mixture of 
dust of an organic and inorganic origin is usually for a short duration, but 
even as it is, we not infrequently observe acute bronchial catarrh and 
inflammatory conditions of the eyes, nose and throat and quite commonly 
also intense itching of the skin. In the acute attacks characterized by 
chilly sensations, headache and high fever there is reason to suspect 
protein intoxication while the chronic lesions are doubtless caused by 
inorganic dust, which is always present in grain. Dreissbach (Munch. 
Med. Wochschft., 1913, No. 11) cited by Lehmann described a peculiar 
disease in threshers of mouldy oats; some of the men felt sick during the 
work, others developed symptoms soon after quitting time, such as chilly 
sensations, high fever, great depression, headache, pain in joints, total 
loss of appetite and a violent dry cough. The attack resembled brass 
founders' ague and lasted several days; in one instance acne and furuncles 
developed. The exact cause is still obscure, but here also the present 
writer suspects protein intoxication. 
During the season of 1914 numerous fires occurred in the State of 
Washington in connection with the threshing operations, especially in the 
threshing separator. These fires were of an explosive character and 
numerous persons were seriously injured, usually by fire, and in a few 
cases, by the force of the explosion. Investigation rendered it reason- 
ably certain that the cause of the fire was an unusually large amount of 
stinking smut (tilletia tritici} in the wheat which contains from 4-5 per 
cent, of inflammable oil. An exceedingly dry season increased the 
amount of organic dust from broken grain and straw, and also increased 
the combustibility of both smut and dust, and the amount of static 
electricity.1 While the source of ignition has not been positively proved, 
it would appear that static electric sparks, which are generally present in 
the cylinders of the separator, are the cause in the majority of instances, 
and hence it is urged that the cylinders of the separator be grounded by 
means of an electric brush connected to the ground by wire, attached to 
an iron peg driven a foot or two into the ground. 
Workers in Grain Elevators.-The amount of dust is very much less 
in handling grain after it leaves the threshing machines. More or less 
214 FLOUR MILLING 
215 
dust is, however, gathered in transport and is also produced by the attri- 
tion of the individual grains during shipment. The dust from rye and 
wheat grain on account of the sharp particles of the husk is more irritating 
than that caused by oats, but the latter give off a larger volume. The 
dust from corn usually contains large quantities of mineral matter and 
fragments of husks. The construction and equipment of modern 
grain elevators reduce exposure to dust to a minimum; nevertheless the 
men engaged in shovelling the grain toward the mouth of the elevators 
and those who work in the bins, turning over corn or grain to prevent 
heating, are exposed to clouds of dust. Most of this work is done by 
casual labor and the injurious effects would be more pronounced if the 
employment were constant instead of seasonal. No extended statistical 
material is available to determine conclusively the unhealthful character 
of this occupation. Hoffman2 found that of 24 deaths from all causes 
among grain handlers and elevator men 5, or 20.8 per cent, died from 
consumption, as compared with 14.8 per cent, in the general male popula- 
tion in 1906. 
Preventive Measures.-While much has been done to reduce the dangers from dust 
inhalation by automatic processes, no effort should be spared to render the devices 
for the arrest and removal of dust more effective. In the meantime the workers so 
exposed should protect their nostrils and mouths by handkerchiefs as the ordinary 
respirators soon become clogged and embarrass respiration. 
Flour Milling.-In spite of the tremendous growth of commercial mills, 
there are still a large number of custom mills, where the facilities for the 
arrest and removal of dust are not nearly so good as in the large patent 
rolling process establishments. But even in modern mills where the 
cleaning, grinding and bolting is done in inclosed machinery, there is always 
more or less exposure to grain and flour dust, while the men engaged in 
dressing the buhrstones which are still in use in some of the custom mills 
are also exposed to mineral and metallic dust. If statistics were available 
it would probably be found that these men, and those connected with 
the cleaning of the grain preliminary to the milling, furnish the highest 
percentage from diseases of the respiratory system; the flour and bran 
packers, counters, sweepers and warehouse men would probably come next 
in frequency. The inhalation of flour dust, in spite of the smooth and less 
irritating character of the individual particles comprising it cannot fail 
to prove injurious to the respiratory organs. Indeed there is much reason 
for assuming that the lodgment of flour dust in the minute ramification of 
the bronchial tubes and air vesicles apart from clogging up the air 
passages and acting as an irritant, may result in collapse of a small area 
of the lung (atelectasis) or in a dilatation of the vesicles and an abnormal 
collection of air in the lung tissue, technically called emphysema, and 
popularly known as "miller's asthma." Other diseases of the lungs 
are even more common. According to Hirt, 20.3 per cent, of all the 
diseases affecting millers are pneumonia; 9.3 per cent, bronchial catarrh; 216 
THE INDUSTRY OF FOOD STUFFS, ETC. 
10.9 per cent, consumption; and 1.9 per cent, emphysema, a total of 42.4 
per cent, from diseases of the respiratory passages. These rates are 
about 11 per cent, in excess of the statistics furnished by Hoffman2 who 
found that of 256 deaths in millers, in this country, 31.6 per cent, were 
caused by diseases of the lungs, inclusive of 40 deaths, or 15.6 per cent., 
from consumption and 29 deaths or 11.4 per cent, from pneumonia. The 
statistics of Hirt cover an older period and the difference is largely due to 
the less harmful processes employed in modern mills. But the New York 
State Bureau of Labor reports for 1906 a very high death rate from pneu- 
monia in millers. 
Cases of chronic indigestion are not uncommon among millers, which 
the writer feels disposed to attribute to the swallowing of flour dust. 
Since uncooked starch is not readily digested, it is very liable to undergo 
fermentation and thus injure the gastric mucosa. Millers occasionally 
suffer from inflammatory conditions of the skin, impacted ear wax and 
partial deafness. Other sources of danger in connection with flour milling 
are exposure to sulphurous acid fumes when used for bleaching purposes, 
accidents from moving belts and machinery, fire and explosions. 
According to the report of the Miller's Committee of Buffalo3 in 13 explosions 
investigated in recent years in the milling industry in this country, 78 men were 
killed and 119 injured and the total damage to the property exceeded $2,000,000. 
Dr. H. H. Brown's laboratory studies have shown that grain dusts, especially from 
oats and yellow corn, are even more inflammable than standard coal dust and develop 
higher pressure on explosion. Apart from the generally recognized source of ignition 
such as the use of open lights or naked flames, the committee mentions electric sparks 
from motors, fuses, switches and lighting systems, static electricity produced by fric- 
tion of pulleys and belts, and the introduction of foreign material in grinding machines. 
The Committee found the latter in recent years a very frequent cause and expresses 
the hope that some system may be devised by which the foreign material might be 
removed before it reaches the mill. 
Preventive Measures.-Since cork dust explosions are often caused by particles 
of iron producing sparks in passing through the mill, a like cause may be surmised in 
this instance, and Doehring's recommendation that the cork be passed through a 
magnetic separator before being placed in the comminuting machine would be equally 
applicable for the prevention of explosions in the flour industry. The recommen- 
dations of the Committee may be summarized as follows: Complete lighting systems, 
portable electric lamps instead of lanterns and naked lights, the inclosing of the electric 
light bulbs in strong wire guards; the possible use of vapor proof globes, and the 
locating of all fuses, switches, starting boxes, motors, etc., at points where no dust is 
present. The receiving bins from the grinding machines to be as small as compatible 
with the operations, as increased size gives increased space for dust clouds and there- 
fore opportunities for more violent and destructive explosions. Above all else dust 
should be prevented from escaping into the air of the workrooms. 
Bakers, Confectioners and Pastry Cooks.-The preceding remarks 
concerning the inhalation of flour dust apply equally to this class of 
workers, except that there is a less intensive exposure and that millers 
are also liable to the inhalation of grain dust. At all events Hirt's Ger- 
man statistics are somewhat in favor of bakers, whose mortality rate from BAKERS, CONFECTIONERS AND PASTRY COOKS 
217 
diseases of the lungs was 28.2 per cent, against 42.4 per cent, in millers; 
their consumption rate was 7 per cent, against 10.9 per cent, in millers, 
and 11.6 per cent, in confectioners and the pneumonia rate was 8.4 per 
cent, against 20.3 per cent, in millers. Hoffman's4 statistics based upon 
1357 deaths among bakers in the United States, from all causes, are not 
so favorable as they show a death rate of 34 per cent, from disease of the 
lungs and air passages, inclusive of a consumption rate of 20.4 per cent., 
while the confectioners reveal a mortality rate of 39 per cent, from diseases 
of the lungs inclusive of a consumption rate of 22.2 and a pneumonia rate 
of 13 per cent. (For other mortality statistics see page 975.) The 
excessive American rates may be due to more unfavorable environments 
of our smaller bakeries. 
The excessive rates in confectioners may be due to several factors: 
first, because it is quite common for delicate individuals to engage in this 
work; second, certain operations, for example the dipping of chocolate 
candies, involve a temperature between 66° and 68°, which in summer is 
secured by refrigerating pipes and the exclusion of the outer air, with 
corresponding pollution of the air of the workshops; lastly, confectioners 
either inhale or ingest more or less pulverized sugar. It is known that 
lodgment of flour and sugar dust upon the teeth and gums, unless removed 
by frequent cleaning, favors fermentation processes and decay of the 
teeth so common among bakers and sugar workers, and there is much 
reason for assuming that such a condition may likewise favor the prolifera- 
tion and virulence of disease germs, such as the pneumococcus, which is 
quite frequently found in the buccal cavity of normal individuals. 
Other factors prejudicial to the health of bakers are exposure to heat, 
coal gas, impure air, long hours and hard work; this is especially true of 
city bakers whose mortality is very much higher than in towns and 
villages. Apart from disease of the respiratory passages, anemia, prob- 
ably caused by chronic gas poisoning and excessive perspiration, acute 
infectious diseases, digestive disorders, and diseases of the heart are quite 
common. 
Bakers, and all others engaged in handling dough, are liable to suffer 
from eczema of the hands and arms ("bakers itch") and also evince a 
peculiar susceptibility to scabies, pimples and boils. Conjunctivitis is 
likewise quite common and youthful employees frequently develop 
hernia, "in-knee," "knock-knee" and "flat-foot." 
Fractures, burns and scalds are always common. Other accidents, 
such as contusions and incised wounds, have increased with the intro- 
duction of modern mixing, kneading and cutting machines. 
Preventive Measures.-While health boards have been quite active in their 
efforts to secure better sanitation of bakeries, it is evident that more should be done in 
the way of legal requirements. There is no good reason why bakeshops located partly 
below ground should be tolerated, and why the manufacture of the "staff of life" 
should not be carried on under more favorable sanitary environments, as regards air- 218 
THE INDUSTRY OF FOOD STUFFS, ETC. 
space, light, ventilation, general and personal cleanliness, with benefit to the pro- 
ducer and consumer alike. It is to be hoped that machine labor will displace at least 
the "drudgery" of all bakeshops and that day work with reasonable hours will take the 
place of night work. Italy passed a law in 1908 for the abolition of night work in 
bakeries. 
Manufacture of Glucose and Starch.-Starch is made chiefly from 
corn, although wheat and potatoes are also used. There is no statistical 
data upon which to base conclusions as to the injurious health factors in 
this industry. It is evident, however, that the work around the steeping 
tanks is connected with exposure to dampness and inhalation of putre- 
factive gases, especially in the "alkaline process," in which the corn is 
steeped in water at a temperature of 70° - 140°F., from 3-10 days. The 
handling of -the corn or wheat, preliminary to maceration, involves 
exposure to grain dust; while the drying of the starch, which is done in 
rooms with a temperature between 125° -170°F., involves exposure to 
starch dust and abrupt changes in temperature, all of which cannot fail to 
affect adversely the health of those exposed. As in the case of flour mills 
there is also danger from explosion of dry starch. 
Glucose is made commercially by treating starch with diluted sul- 
phuric acid. The resulting solid product is called grape sugar, and the 
syrup, glucose. In this process the workmen, in addition to the other 
injurious factors, are also exposed to sulphuric acid fumes, and arsenical 
poisoning if the acid is made from arsenical pyrites. 
Preventive Measures.-Provisions should be made for the removal of dust and 
obnoxious gases. The employes should not be obliged to remain in overheated 
rooms any longer than is necessary; and actual work in storing and removal of the 
starch from the drying departments should not be done until the temperature is 
below 90°F. 
The Sugar Industry practically covers three industries, viz., the manu- 
facture of "beet sugar," "sugar and molasses," and "sugar refining." 
The total number of persons employed in the United States in 1919 was 
36,084, of whom 32.6 per cent, were engaged in beet sugar, 16.9 per cent, 
in cane sugar and 50.5 per cent, in sugar refining, not including beet 
sugar. 
The work, like the manufacture of starch, involves exposure to damp- 
ness, excessive heat, humidity and steam, especially during the condensa- 
tion process where the atmosphere of the room is generally above 95° 
and the relative humidity about 96°, with corresponding dangers incident 
to abrupt changes in temperature. The Leipsic statistics show a mor- 
bidity rate of 1443 days per annum per 100 workers in sugar refineries. 
Headache, vertigo, heat-stroke, rheumatism, diseases of the respiratory 
and digestive organs and accidents, lead the list. The employes not 
infrequently work stripped to the waist, and, as a result of moisture and 
contact with the sticky substances, develop eczematous conditions of the 
skin. Cases of inflammation of the lymphatic vessels, caused, according SUGAR INDUSTRY-FISH INDUSTRY 
219 
to M. Gaillot by the staphylococcus pyogenes aureus found in the residue 
of molasses, are occasionally observed. In his opinion this organism 
may produce virulent toxins and fatty acids by the conversion of sac- 
charine material into lactic, acetic and butyric acids, and the solu- 
ble poisons, as well as the microorganisms, may enter through the hair 
follicles. A number of the processes also involve exposure to industrial 
poisons, such as ammonia, sulphurous fumes, carbonic acid, sulphuretted 
hydrogen, and the inhalation of bone black dust. There is also a slight 
liability to phosphorus poisoning from the bone black refuse of sugar mills. 
The regeneration of animal charcoal involves exposure to offensive gases, 
including the products of putrefaction and fermentation. In the beet 
sugar industry, especially when the diffusion method is employed, an 
explosive mixture probably containing carburetted hydrogen, has proved 
a source of danger to the operatives. The refuse waters from such plants 
have been regarded for some time as a source of stream pollution and are 
therefore subjected to treatment before discharge into open water courses. 
The men employed in connection with the sedimentation tanks are 
exposed to the inhalation of sulphuretted hydrogen and other impure 
gases. 
Preventive Measures.-Adequate provisions should be made for ventilation 
and general cleanliness. Prof. Roth5 points out that only strong men with an active 
skin should be employed. Ample washing facilities for the prevention of eczema 
should be available. The water-closets should be so located as not to involve exposure 
to abrupt changes in temperature. It is gratifying that, according to Neisser,6 these 
recommendations are being complied with in a number of plants. 
Fish Industry.-The occupation of fishermen necessarily involves 
exposure to the inclemency of the weather, but it cannot be said that the 
occupation is dangerous to health, since it occupies the eighth rank in the 
comparative mortality of 22 occupations tabulated in England and 
Wales. 
The work of fish curing has some special interest because of the employ- 
ment of a large number of females, and also because during the herring 
season it involves long and irregular working hours and even night labor. 
Miss Mary M. Patterson7 in discussing the herring, cod and haddock cur- 
ing industry with special reference to female labor, points out that as a 
result of long hours and exposure, rheumatism, bronchitis and diseases 
of the lungs are not uncommon. Severe cuts, slow healing and septic 
wounds are not infrequent. In speaking of injurious environments she 
observes, "the very ground they stand on is often a menace to health, for, 
in the absence of proper paving and drainage, the earth becomes impreg- 
nated with decaying organic matter, which 'smells to heaven ' and creates 
a constantly foul atmosphere, not completely counteracted by the open- 
air surroundings." 
The hygiene of this industry has been very much improved since the 
establishment of modern canneries, and, while the primitive conditions 220 
THE INDUSTRY OF FOOD STUFFS, ETC. 
still prevail in the curing of herring and cod fish in different sections, the 
handling of most of the sea food is now carried on under more favorable 
working conditions. 
Diseases of Fishermen.-H. Muir Evans (Lancet, March 5th, 1921) describes 
the accidents and diseases in fishermen, chiefly due to the dogfish, the sting ray and 
the greater and lesser weerer. The most common injury was caused by the poisonous 
spine of the weevers, which possesses a perfect double grooved exploring needle on 
either gill cover. At the root of the spine is a definite poison gland. When alarmed, 
the fish erects its gill cover and bends itself round, driving the poisoned spine into any 
adjacent body, which at once receives some grumous drops of a highly poisonous 
nature. The pain is very intense, swelling follows, which may subside within a few 
hours, or terminate in phlegmonous inflammation with local gangrene. The limb may 
be partially paralyzed for a time. Applications of ammonia, of heated vinegar, or of 
the liver of the fish itself to the injured part are popular remedies. Dr. Evans states 
that fish venom, just as snake venom, is destroyed by potassium permanganate, 
chloride of lime and chloride of gold, and suggests that a "Lauder Brunton snake- 
bite lancet" be carried by all drifters and smacks so that a really efficient remedy may 
be at hand. The toxin contained in the tentacles of the jelly fish after a sting also 
causes much burning pain followed next day by intense itching. After the summer 
fishing, while mending the nets, the men suffer very greatly from lachrymation and 
sneezing to such an extent that this work has to be stopped. Evans suggests that the 
trouble is caused by the toxin which clings to the strands and which, when dry, is 
liberated with the dust from the nets. 
Boils on the forearm sometimes spreading to form large suppurating areas are 
common during the autumn and winter, believed by Evans to be due to rubbing by the 
edges of the "oilies," seawater and dirt. (Jour. Ind. Hygiene, August, 1921. Abst. 
p. 66.) 
W. A. Clemens records a peculiar dermatitis occurring in the fishermen handling 
nets in Lake Erie which may be due to hydra. (Science, April 28, 1922, p. 455.) 
Preventive Measures.-Special attention should be given to the construction 
of the buildings; cement floors, wooden lattice work for the employes to stand on, 
suitable tables so that the water will drain away from the workers, rubber aprons 
and boots, good ventilation for the removal of bad air or steam and suitable dressing 
and lunch rooms should be provided. Much of the work is now done by machines, 
and the methods for the collection and utilization of the offal have been perfected, 
so as not to constitute a menace to public or private health. 
The Slaughtering and Meat-packing Industry.-The average number 
of persons engaged in this industry during the census year 1919 was 
160,996. During the census year 1910, the total number of animals 
slaughtered for food was 88,358,815; hogs represented 60.2 per cent., 
sheep and lamb 16.7 per cent.; beeves 15.4 per cent.; calves 7.4 per cent.; 
and goats and kids %o 1 per cent. This tabulation does not include 
the retail trade. The hygiene of this industry has been materially im- 
proved in modern establishments, but is still quite unsatisfactory in the 
rural districts and wherever primitive methods are in vogue. The 
employment involves hard work, exposure to dampness, and a liability 
to infection from diseases communicable from animals to man, such as 
anthrax, bovine tuberculosis, glanders, tetanus, actinomycosis (lumpy 
jaw), and septic conditions of cuts and abrasions. Butchers who are in OLEOMARGARINE 
221 
the habit of eating raw meats may become infected with tapeworm and 
trichina. 
According to Leiser,8 of 4200 male butchers in Berlin, during the 3 
years from 1902-1905, an average of 2125, or about 50 per cent., came 
to the attention of the Sick Insurance companies. Of these 38.6 per cent, 
were treated for injuries and scalds incident to the trade; 19.2 per cent, for 
sexual diseases; 7.2 per cent, for diseases of the respiratory organs; 
5.4 per cent, for rheumatism; 4.7 per cent, for skin diseases, chiefly 
eczema (the last two groups are largely influenced by exposure to wet and 
drafts); 4.6 per cent, for diseases of the digestive system; and 3.7 per cent, 
for "flat foot" and varicose ulcers, probably caused by standing too long 
on their feet. The excessive rates from sexual diseases may be due to 
more frequent exposure, especially as animal food stimulates the sexual 
appetite and butchers are proverbially well fed. (For American mortality 
statistics see page 975.) 
Preventive Measures.-Since Federal meat inspection covers only inter-state 
trade it is clearly the duty of each State to exercise a strict sanitary supervision of this 
important food industry, for the protection of the producer and consumer alike, and 
this supervision should extend to the smaller establishments in the country, and the 
numerous meat and sausage shops in the city. Wherever unsatisfactory conditions 
are found, they should be removed and brought up to the standard which prevails in 
clean, decent, and properly managed establishments. 
Manufacture of Oleomargarine.-The manufacture of oleomargarine 
originated in 1868 with Mege Mouries, a chemist, who at the instigation of 
the French Government undertook a series of experiments for the purpose 
of securing a substitute for butter, at less cost, which might be used by 
the army and navy and the wage earners of France. The original process 
of Mouries was patented in the United States in 1873. 
The product consists of oleo oil, neutral lard, butter, cream, milk and 
salt. Refined cotton-seed oil is sometimes used in limited quantities in 
the cheapest grades. Oleo oil is made from the choicest fat of the beef. 
It is taken out of the animal, washed in several changes of water and 
placed in a vat of ice water to stand until the next day. It is then cut up 
and transferred to large steam-jacketed kettles in which it is boiled under 
constant stirring. It is next piped to kettles on the floor below, where it 
is clarified, after which it is conducted into tanks on the floor below and 
allowed to stand until the stearin separates. It is then placed in linen 
cloths and the oil is extracted in a hydraulic press and barreled. The resi- 
due in the cloths after pressing, commercially known as stearin, is utilized 
for the manufacture of candles. 
Neutral lard is obtained from the leaf lard of the pig and after 
thorough washing is placed in cold storage for 24 hours; it is then cut up 
into shreds and cooked and after steaming presents a snowy white 
appearance. The oleo oil and neutral lard in the proportion of about 27 
per cent, of the former and 35 per cent, of the latter, are churned with 222 
THE INDUSTRY OF FOOD STUFFS, ETC. 
cream or milk, salted, run through cold water, worked in a butter worker, 
placed in suitable packages, and labelled according to the U. S. Laws, 
"Oleomargarine." The product is subject to an internal revenue tax of 
1 ct. per pound, and if colored to resemble butter it is subject to a tax 
of 10 cts. a pound. 
Lard Making.-Another important industry carried on in connection 
with slaughtering and packing houses is the production of lard, of which 
there are several kinds. In rendering leaf lard, part of the fat separates 
at a temperature between 105° to 120°F., and constitutes, after washing 
with a trace of sodium carbonate, common salt or dilute acid, the choicest 
and richest part of lard known as neutral lard-referred to in the preced- 
ing paragraph. Leaf lard is obtained by steam heat under pressure from 
the residue, after the neutral lard has been piped off. "Choice" kettle 
lard is derived from the remaining portions of the leaf and from the backs 
of the hogs. Other grades of lard are derived from the head, the fat of 
the small intestine and other viscera, trimmings and other fatty parts and 
is sold under the euphonious names of "prime steam" or "refined" 
lard. 
These occupations are of importance as the process of rendering 
animal fats is attended with the evolution of fatty acids, such as palmitic, 
stearic, oleic, margarine acids, and at higher temperatures necessary for 
the melting of tallow, the so-called acrolein vapors. Under certain con- 
ditions acetic and butyric acids, and also ammonium sulphide, sulphu- 
retted hydrogen, pyridin, picolin and lutiosin may be evolved. Acrolein 
produces itching in the throat, irritation of the eyes, lachrymation, con- 
junctivitis, irritation of the upper air passages and bronchial catarrh. 
Dr. Grim9 believes that ingestion of fatty acids is liable to produce gastric 
catarrh, and that many of the diseases of the stomach in this class of 
workers are primarily caused by excessive consumption of scraps of fat 
meat fished out of the rendering kettles. 
Injuries from moving machinery, burns and infected wounds are not 
uncommon, and erysipelas occurs sufficiently often to justify reference 
by some of the German authors to such terms as "margarine" and 
"tallow erysipelas" and "zoomotic erysipeloid," meaning thereby that 
the infection is conveyed through the raw products. The wound infec- 
tion is characterized by inflammation of the lymphatics and glands, and a 
moderate temperature. It can scarcely be regarded as a typical strepto- 
coccus infection, but nevertheless suggests prompt antiseptic treatment 
of all wounds and abrasions. 
Dairy Industry.-The exact number of employes in this industry as 
a whole cannot be stated. During the census year 1919 there were 
17,641 persons engaged in butter factories; 3997 in cheese factories, and 
13,675 in condensed milk factories. The average number of female wage 
earners, in 1910, was 1420, of whom 987 were in the condensed milk 
factories. DAIRY INDUSTRY-CANNING AND PRESERVING 
223 
The hours at dairy farms if not long are unseasonable and involve 
more or less night work. The milkers suffer in rare instances from 
infected callosities of the palm of the hands and spasm of the flexors of 
both hands and fingers. Instances of infection from cowpox, tubercu- 
losis, from handling diseased udders or infected milk or cream, ring- 
worm from leaning the face against the flank of an affected animal, and 
occasional cases of infection with the germs of foot and mouth disease 
and actinomycosis, or lumpy jaw, have been reported. Most of the 
milking on large dairy farms is now done by machines. 
The employes in dairies, especially those engaged in the pasteurizing 
and bottling departments, are exposed to a damp and steamy atmosphere 
and the work under foot is sloppy. The strong borax and other alkaline 
solutions used in the cleaning of bottles, utensils, etc., and also employed 
to renovate rancid butter, quite frequently produce eczematous condi- 
tions of the hands and arms, unless guarded against by the employment 
of machinery and rubber gloves. The hygiene of persons employed in 
the manufacture of butter, cheese, or condensed milk does not materially 
differ. 
Preventive Measures.-Fortunately education, legislation and competition 
have done much to reduce the dangers to a minimum. Nevertheless watchful care 
is still needed to prevent the transmission of disease through the medium of milk 
and dairy products. This is true not only of the diseases already mentioned, but 
also of scarlet and typhoid fever, diphtheria and septic sore-throat, in which infection 
takes place from handling of the milk by bacillus carriers, or by washing the utensils 
in infected water. In our present state of knowledge nothing short of pasteurization 
will confer immunity from so-called milk-borne diseases. 
The Canning and Preserving Industry.-The average number of per- 
sons engaged in this industry during the census year 191010 was 71,792 of 
whom 59,968 were wage earners; of these over one-half were females, and 
4246 or 7.1 per cent, were children under 16 years of age. The census 
for 1919 gives a total of 89,923 in four classes of establishments, viz.: 
(1) Plants whose chief products are canned and preserved fruits and 
vegetables, including dried and packed fruits put up in packing houses 
(60,865); (2) establishments whose chief products are canned and cured 
fish, including pickled, smoked and dried fish (11,248); (3) establish- 
ments whose chief products are canned oysters and clams (1189); (4) 
establishments whose chief products are pickles, preserves, jellies, sauces, 
etc. (16,621). 
A large number of the establishments are located in rural districts. 
The working hours are irregular and often very long. The work itself is 
sloppy and involves exposure to dampness, and in the cooking and pack- 
ing department a steamy atmosphere prevails, which upon condensation 
helps to saturate the clothing of the workers. The surroundings are 
sometimes quite insanitary, especially in the jam and jelly industry, and 
in the rural districts the temporary camps are often a distinct menace to 224 
THE INDUSTRY OF FOOD STUFFS, ETC. 
the health of the people. The work of lifting and carrying buckets or 
baskets weighing from 40 to 60 lb., from the supply court to the peeling 
room and from there to the canning department, is not an easy task for 
women and children, who receive but 4 cts. for skinning a 40-lb. basket of 
tomatoes and a similar wage for peeling apples and fruit, averaging 
about 6.3 cts. per hour. The amount of work and exposure can be 
readily judged when it is remembered that during the rushing season some 
of the employes have weeks of 72 and even 81 working hours.11 
As a result of long hours and exposure, catarrhal affections of the 
respiratory passages, rheumatism, and ansemic conditions are by no means 
infrequent, and sore hands, cut fingers, and infected hang nails are not 
uncommon sights. The soldering process involves exposure to lead and 
acid fumes. According to the National Canners Association the intro- 
duction of the present style of can with rolled cover seams in the canning 
of fruit, vegetables and fish, and the use of modern mechanical sealing 
appliances in case of milk and meat canning has practically done away 
with this danger. Two large plants visited by Hay hurst (November, 
1922) convinced him that lead poisoning is no longer a hazard in the 
modern canning establishment. The men employed in the preservation 
of evaporated fruit are also exposed to the fumes of sulphurous acid; 
this agent is also employed for the fumigation of hops. Cases of derma- 
titis have been reported in workers who had been handling dried figs and 
dried plums. The primary cause was traced to a light brown fine powder, 
composed of live and dead mites, identified as carpoglyphiis passularum. 
(Jour. Ind. Hyg., Aug., 1921. Abst., p. 71.) 
Preventive Measures.-The recommendations referred to in the fish industry are 
equally applicable to canning establishments. There is no reason why mechanical 
conveyors and machine labor should not supercede much of the hand labor. Health 
authorities should insist that hoods and exhaust drafts for steam and fume processes 
are provided and that the equipment and sanitary arrangements observed in some of 
the establishments are made compulsory for all others, in which the conditions are 
unsatisfactory. Special attention should be paid to the sanitation of the working 
camps in rural districts. 
Breweries, Distilleries, Etc.-A number of operations connected with 
this industry involve hard work and exposure to extremes of heat and 
humidity. This is especially true of the malting and brewing processes. 
The work of turning the malt, performed in a temperature between 158- 
176° is laborious and should be displaced by automatic machinery. The 
men engaged in the brewing department are exposed to the combined 
effects of heat and humidity, and those employed in the cooling rooms to a 
temperature between 38° and 40°; hence rheumatic affections are quite 
frequent, amounting to 20-22 per cent., against 15-16.5 per cent, in 
other occupations. Work connected with the fumigation of hops, vats 
and casks involves exposure to sulphurous acid fumes, and the employ- 
ment of "salufer" as a preservative and antiseptic may prove injurious BREWERIES, DISTILLERIES, ARTIFICIAL ICE 
225 
as it contains about 2 per cent, of silicofluoric acid. (See also Arsenic, 
page 312.) The men employed in the fermentation vaults are exposed to 
large volumes of carbonic acid, unless special care is taken for the liberation 
of these gases. This is likewise true of wine cellars, champagne factories, 
and carbonated water bottling establishments. Another source of danger 
in breweries and distilleries is the employment of wood alcohol as a solvent 
for the shellac to coat the interior of large storage casks and vats. Quite 
a number of fatal cases from this cause have been reported in recent years 
in New York, Buffalo and Chicago. A peculiar affection of the finger 
nails due to contact with yeast has been described by Villaret. 
The death rate, of brewers, distillers and rectifiers in this country 
during the 1910 census year was 19.7 per 1000, which is far above the 
average of other occupations. Tuberculosis and other diseases of the 
lungs, heart, kidneys, nervous system and of the digestive organs lead 
the list. This we find also to be the case in Great Britain and Germany. 
The number of deaths from tuberculosis and other diseases of the lungs 
among brewers in Great Britian was 518 per 1000, against an average of 
416 in the general population. Sommerfeld calculates that 52.4 per 
cent, of all the deaths of brewers are caused by pulmonary diseases, 
inclusive of 47.2 per cent, from consumption. According to Weihrauch12 
36.4 per cent, of all the deaths among Munich brewers were caused by 
tuberculosis, 19.7 per cent, by heart disease, 11.1 per cent, by accidents, 
8.02 per cent, by diseases of the kidneys, 7.4 per cent, by tumors, etc., 
4.9 per cent, by pneumonia and 3.1 per cent, by typhoid fever. The 
average duration of life is about 32.6 years (Koelsch).13 
The Leipsic statistics show a morbidity rate for brewers and malsters 
of 1106 days annum per 100 workers and for workers in yeast factories 
863 days. 
The undue prevalence of rheumatism, diseases of the lungs, heart and 
kidneys may in part be due to exposure incident to the work, but the 
intemperate habits doubtless play even a more important role in their 
causation. (See also the alcohol habit.) 
Preventive Measures.-In all fermentation processes cases of asphyxia may occur, 
on account of an excess of carbon dioxide and deficiency of oxygen. Such instances 
have been reported in breweries, distilleries, yeast factories and bottling establishments. 
Hence copious ventilation should be provided near the floor level for the removal of 
CO2. There is also danger from carbon monoxide and arsenical fumes if the products 
of combustion are allowed to pass into the malt or other drying chambers. 
Modern hot air kilns and automatic malt-turning machines should be provided. 
Special precautions are necessary in the sulphuring process of malt and hops, so 
that no one enters until after thorough ventilation of the premises, the efficiency of 
which can be tested by holding a moistened strip of blue litmus paper into a partly 
opened door which will turn red, if sulphurous acid fumes are still present. 
Artificial Ice.-The manufacture of artificial ice by the ammonia and 
brine process is quite generally carried on in connection with breweries 
and cold storage plants. The work is wet and sloppy and involves 226 
THE INDUSTRY OF FOOD STUFFS, ETC. 
exposure to very low temperature (0-50°F.) with abrupt changes. In 
most of the modern plants the ice is handled and stored by machinery, but 
injuries are by no means infrequent, and cases of poisoning from ammonia 
fumes are not uncommon. 
Cold Storage.-A temperature of between 32° and 40°F. combined 
with excessive humidity is inimical to health. In all cold storage plants, 
where ammonia is used for refrigeration purposes, special precautions are 
necessary to prevent leakage and also to provide helmets or an oxygen 
breathing apparatus, suction pumps, etc., for the safety of the workers in 
case of an accident. 
Vinegar.-In the manufacture of vinegar there is frequently escape of 
acetic acid fumes, alcohol, acetaldehyde, acetic acid ether and other low 
oxidation products of alcohol. These may not only prove injurious to the 
health of the workers but constitute an economic loss, which can be pre- 
vented by the employment of an hermetically closed automatic apparatus. 
Cases of asphyxia occurred in a vinegar plant at Alexandria, Va., in 
the fall of 1922, among workers engaged in a fermentation vat. 
Manufacture of Carbonated Waters.-This occupation, apart from 
exposure to large quantities of carbon dioxide, involves considerable 
risk of injuries from bursting bottles, as a result of gaseous pressure 
during the bottling, wiring or capping process. The injuries from flying 
glass fragments may involve the loss of an eye, or serious wounds of the 
blood-vessels. The work is often carried on under unfavorable environ- 
ment, and involves standing in the wet and working in wet clothes, with 
its attending consequences. 
Preventive Measures.-Copious ventilation, cement floors properly drained; 
wooden slat floors, wherever wet processes are carried on; water-proof clothing 
and rubber boots; and, last but not least, suitable wire face guards and gauntlets. 
Spices.-The grinding and packing of mustard, pepper, allspice, 
nutmeg, vanilla, etc., involves exposure to irritant dust owing to the 
presence of essential oils and alkaloids, which may give rise to catarrhal 
conditions of the eyes and upper air passages, and also in some instances, 
notably in the manipulation of " vanillon," an impure specie of the vanilla 
bean, to irritation and inflammatory conditions of the skin. 
Chloride of Sodium.-The manufacture of chloride of sodium or table 
salt involves exposure to a moist steamy atmosphere, during the evaporat- 
ing process, which is productive of catarrhal conditions of the upper air 
passages. The effects of exposure to chlorine are evinced by the fact that 
Muller14 in examining 165 salt workers, mostly packers and grinders, 
found 45 cases of nasal catarrh, 45 perforations of the nasal septum and 9 
recent ulcers. 
A peculiar form of dermatitis characterized by the appearance of acne, 
redness, and oedema of the face, eyelids, and tips of the ear is frequently 
observed among workers in the drying process. This, together with THE TOBACCO INDUSTRY 
227 
catarrhal symptoms of the upper air passages, loss of appetite, and diges- 
tive derangements, is attributed to the irritant vapors of hypochlorites 
and should be guarded against by hoods and copious exhaust ventilation. 
The Tobacco Industry.-The cultivation of tobacco and its subsequent 
storage in well-ventilated barns for the purpose of "curing" may be 
regarded as purely agricultural pursuits. Robert C. Frederick (Jour. 
Ind. Hyg., Oct., 1920, 205-207) found under certain conditions and 
after elapse of sufficient time, tobacco stored in an unventilated space, 
provided there is 10 per cent, or more of moisture present, converts air 
into a mixture of gases entirely incapable of supporting human life. 
The stripping of the leaves from the stalks, the sorting, drying and pack, 
ing and unpacking involves more or less inhalation of dust and the pun- 
gent odors of tobacco. The work in the "tobacco dryers" involves 
occasional exposure to excessive heat and the inhalation of fine tobacco 
dust and a certain amount of risks from dust explosions due to the greasy 
and inflammable character of the dust. But on the whole none of these 
preliminary processes, according to the Austrain statistics, appear to be 
as detrimental to the health of the wage earners as the manufacture of the 
final product. This is probably accounted for by the fact that the pre- 
liminary processes are seasonal in character and the exposure of a com- 
paratively short duration. 
Manufacture of Tobacco, Cigars, Cigarettes, Etc.-This industry 
during the 1910 census afforded employment in the United States to 
159,408 wage earners* of whom 57,174 or 42.2 per cent, were females and 
5274 or 3.9 per cent, were children under 16 years of age; 135,318 or 85 
per cent, of the workers were engaged in the manufacture of cigars and 
cigarettes; 23,044 in the manufacture of chewing and smoking tobacco; 
and 946 in the manufacture of snuffs. Quite a number of authors state 
that the manufacture of snuff involves the greatest amount of fine dust 
production but this is an evident error as the tobacco for snuff is ground 
up in a moist state. The manipulation of tobacco in a dry state results, 
however, in more or less dust production; this is especially the case in the 
unpacking, the separation and sorting of leaves and subsequent cutting 
process and also in the manufacture of cigars. It is a source of satis- 
faction that the use of machines has to a considerable extent displaced 
hand labor in a number of the processes. It is estimated by the Bureau of 
Census, that fully 85 per cent, of the cigars and nearly all of the cigarettes 
are now manufactured in this country by machinery; a similar revolution 
has taken place in the manufacture of smoking and chewing tobacco, 
where granulating, shredding and packing machines perform the work 
formerly done by hand. There is no doubt that these modern methods, 
quite apart from the hygienic aspect of doing away with the objectionable 
and nasty practice of finishing cigars with the aid of saliva, will result in a 
distinct improvement in the health of the employes. On the other hand, 
it must not be forgotten that the preliminary processes and even the use of 
* The U. S. Statistical Abstract gives 157,097 wage earners in 1919. 228 
THE INDUSTRY OF FOOD STUFFS, ETC. 
machinery unless provided with dust-removal devices will still involve 
exposure to dust containing more or less nicotine. This, together with 
exposure to volatile, pungent tobacco odors incident to the various 
processes of selection, blending, fermentation, flavoring and saucing 
of tobacco, cannot fail to prove injurious. 
Heucke15 examined the dust in different establishments and found 
63 mg. of dust per cm. of air and that the dust contained 0.56 per cent, 
of nicotine; Stephani15 calculates tht a cigar maker in turning out 
between 5-600 cigars, each weighing 10 grams, manipulates in close 
proximity to his mouth and nose every day about 5 kg. of tobacco, 
containing over 100 grams of nicotine and adds that when it is considered 
that the Hoodooo part of this amount subcutaneously injected is liable to 
produce serious symptoms of nicotine poisoning, even a minimal per- 
centage in the dust may suffice to produce specific toxic effects. In 
proof of this he presents Kostial's observations, showing that 72 of 100 
of the female employes in a Vienna tobacco factory suffered during the 
first 6 months from congestive headache, palpitation of the heart, pre- 
cardiac anxiety, weakened heart action, intermittent pulse, pain in the 
stomach, heart-burn, vomiting, diarrhea, loss of sleep and appetite, 
neuroses, general fatigue and loss of strength-a clinical picture which 
corresponds to that observed in animal experimentation with nicotine. 
Much has been said and written concerning the health injurious 
factors in this occupation and opinions differ. Some authors doubtless 
overestimate the risks; others deny all dangers; indeed some authors 
maintain that tobacco dust exerts a protective influence against infective 
organisms, and instance the fact that during the cholera epidemic of 
Hamburg in 1892 there were only 8 cases among the 5000 resident cigar 
makers. Be this as it may the statistics of the U. S. Census Bureau shows 
that among 23 occupations tabulated, cigar makers and tobacco workers 
occupy the second rank in the mortality from tuberculosis, the first place 
being held by marble and stone cutters. 
Hoffman's16 Industrial Insurance statistics based upon 141 deaths 
from all causes show a mortality of 34.8 per cent, from consumption and 
9.9 per cent, from other diseases of the lungs, which is far in excess of the 
rates for bakers, confectioners and others exposed to the inhalation of 
vegetable dust. The Austrian statistics cited by Professor Roth17 and 
based upon the morbidity and mortality statistics of 35,000 tobacco 
workers show that among the causes of deaths, tuberculosis occupied the 
first place, other diseases of the lungs came next, followed by diseases 
of the circulatory and digestive organs. 
As evidence of the specific irritant properties of tobacco dust Professor 
Roth17 refers to the frequency of inflammatory affections of the skin, eyes, 
throat and of dental defects. Brauer was the first to point out that the 
sharp angular fragments of tobacco dust are very liable to produce 
lesions of the mucous membranes. Oliver has never seen any ill effects THE TOBACCO INDUSTRY 
229 
associated with the manufacture of cigars and cigarettes, at least in so far 
as tobacco dust is concerned and this conclusion is shared by Landis, 
Funk, Smyth and Miller, who inspected numerous cigar factories in 
Philadelphia and noted the absence of tobacco dust, as for economic 
reasons the tobacco leaves are kept in a moist and pliable condition. 
Dr. H. R. M. Landis, (Jour. Ind. Hygiene, July, 1920) while admitting the 
presence of dust, which has been carried in on the shoes of the workers or 
sifted in through the window declares that amongthe cigar makers studied 
roentgenologically, none of them showed changes in the lungs which 
differed in any way from those of the city dweller and in some instances 
they had followed the trade for 25 years or more. 
Among the surgical diseases Stephani18 mentions felon and cellulitis; 
he also points out a very low accident rate in tobacco workers. Neuralgia 
is not uncommon and a peculiar form of neuritis affecting the right 
forearm has been described by Kostial.18 Galezowski19 found cases of 
amblyopia in tobacco workers who did not use tobacco in any form. 
De Schweinitz20 reports the case of a young woman suffering from loss of 
vision whose symptoms disappeared when she left the tobacco factory. 
Dowling21 reports a case of tobaccoamblyopiaina woman who had worked 
in the factory for 5 or 6 years, but who had never used tobacco. Such 
instances are doubtless quite rare. Dr. de Schweinitz writes me that the 
woman's work involved immersion of her arms for several hours a day in 
a rather strong solution of tobacco. Diseases peculiar to women were 
twice as frequent as among workers in the textile industry; chlorosis 
and anaemia are also frequently observed. 
According to Kostial, Rosenfeld and Picraccini, female tobacco workers 
are more liable to miscarry. While this confirms the conclusions reached 
by Dr. Roger S. Tracy of New York as early as 1873, it is at variance with 
the results of an investigation made at Giessen, a German tobacco town, 
in 1906, and hence more extended investigations are called for. The 
latter inquiry revealed, however, a greater frequency of post-partum 
hemorrhages and a tendency to profuse menstruation among this class of 
workers. The statistics presented by Stephani18 covering some tobacco 
towns in Baden from 1889-1901 indicate an undue prevalence of tuber- 
culosis. In 1893 the German government promulgated regulations cover- 
ing the installation and operation of tobacco factories and provided a 
minimum air-space of 7 cubic meters which was increased in 1907 to 10 
cubic meters (353.16 cu. ft.) for each worker. Rules concerning ventila- 
tion, the removal of dust and the exclusion under certain conditions of 
female and child labor were also enacted. 
The undue prevalence of consumption is in part explained by the fact 
that many weaklings enter upon this work; while this must be conceded, 
as well as the fact that in the absence of adjustable seats and work benches 
the constrained position of the workers favors a predisposition to pul- 
monary diseases, yet the same is true of youthful confectioners and candy 230 
THE INDUSTRY OF FOOD STUFFS, ETC. 
makers, and, although likewise exposed to the inhalation of organic dust, 
these latter show a much lower death rate from diseases of the-lungs. All 
of this tends to the conclusion that we are dealing in some of the processes 
not only with the inhalation of irritant vegetable dust, but also with a 
toxic agent, viz., nicotine, the combined effects of which probably account 
for the lower general resisting power to disease. 
Tobacco Testers.-Men who are in the habit of sampling different 
brands of tobacco by smoking and chewing have been known to suffer 
from the effects of nicotine poisoning, and like tea tasters have been 
obliged to limit their work or give it up all together for the relief of 
nervous symptoms and visual defects. 
Tea Testing.-The testing of tea is done by experts in the tea business. 
For this purpose the taster sits at a revolving table with several samples of 
infused tea before him; he takes a sip of the tea to determine its aroma, 
and after rinsing his mouth with it, expectorates it. In spite of the latter 
precaution, possibly because of the numerous tests in any one day, more or 
less of the beverage is swallowed or absorbed through the mouth and may 
produce chronic "thein intoxication." The general symptoms of this 
condition vary with the dosage and susceptibility of the individual and 
are characterized by loss of appetite, gastric catarrh, flatulent dyspepsia, 
constipation, insomnia, irritability, restlessness, muscular tremblings, 
and gradual emaciation and in some cases also discoloration of the finger 
nails. Similar symptoms are observed in so-called tea and coffee topers, 
but fortunately the effects, like those of alkaloidal beverages in general, 
appear to be functional in character and pass off by removal of the 
cause. 
Dr. A. Castellani (U. S. Naval Med. Bull., Oct., 1920, 669-670) 
reports a case of chronic bronchitis in an assistant of one the Ceylon tea 
firms. The sputum contained some mycelial filaments and yeastlike 
bodies. Tea tasters, it is stated, not only taste infusions but often fill 
their hands with tea leaves and bury their noses in them and snuff them 
up. A certain amount of dust is thus inhaled. The tea dust of Ceylon 
constantly contains fungi of the genus Monilia and frequently those of 
the Aspergillus and Penicillium and sometimes fungi of Oidium genera. 
A peculiar streptococcus also occurs, and it is believed these organisms 
are factors in the causation of tea tasters' cough, which may also affect 
other workers. 
Hotels, Restaurants, Saloons, Etc.-These occupations include a 
large number of employes, both male and female, from bell boys of the 
age of 14, to veterans in the army of waiters, cooks, porters, housemaids, 
etc. 
While we have no statistical data in this country which would serve 
to emphasize the injurious effects on the employes as a whole, the sta- 
tistics of Great Britain and of Berlin clearly indicate that this class of 
workers has an unusually high morbidity rate. HOTELS, SALOONS, ETC. DOMESTIC AND PERSONAL SERVICE 
231 
Dr. Gast22 informs us that of 18,133 members of the Berlin Union, 
including the various classes of employes, there were 19,856 admissions a 
year on the sick report, with an average duration of 28.9 days, which is 
considerably higher than among other occupations. 
Of these there were 2308 cases of diseases of the digestive organs, 2087 
cases of diseases of the respiratory organs, 204 of tuberculosis, 2074 cases 
suffered from diseases of the motor system inclusive of 1031 cases of mus- 
cular rheumatism, and 318 cases of "flat-foot" and deformities of the 
knee; 1585 suffered from accidents; 1417 from sexual diseases; 1016 from 
mental and nervous diseases; 1011 from chlorosis and angemia; 660 from 
blood poisoning and cellulitis; 564 from diseases of the heart and 
blood-vessels, inclusive of 228 cases of varicose veins; 314 contracted 
occupational eczema; 212 had ulcers of the legs; and 45 suffered from 
chronic alcoholism and delirium tremens. 
The general mortality rate was 7.16 per 1000; 45.4 per cent, of all the 
deaths were caused by diseases of the lungs, including consumption. The 
deaths from diseases of the heart and kidneys were in excess of those in 
other occupations. The three principal causes of death and also the 
undue prevalence of these diseases are doubtless influenced by the alcohol 
habit. (For American mortality rates see pages 727-729.) 
The occupation, in general, involves long and irregular hours of work 
in a vitiated atmosphere, often contaminated by tobacco fumes. Many 
of the employes are weaklings and have inferior sleeping quarters. Pro- 
longed standing and walking naturally favor the development of "flat- 
foot" and "knock-" and "in-knee" in the young, and of varicose veins and 
leg ulcers in the older class of employes. Schultes 23 has shown that of 
14,000 recruits examined 12.7 per cent, suffered from flat-foot and varicose 
veins, mostly waiters or salesmen, while occupations involving sedentary 
habits furnished practically no cases. Cooks in general are exposed to 
excessive temperatures and this is especially true of men connected with 
the dining-car service, where cases of heat exhaustion are not uncommon. 
Preventive Measures.-It is evident, from general observations that the lot of 
this class of employes is far from satisfactory and shorter working hours, not exceed- 
ing 8 out of 24 hours, better working conditions and pay, so as to enable them to enjoy 
their much needed rest, is certainly indicated. 
Copious ventilation in cafes and restaurants, which permit smoking, and general 
sanitation of the kitchens and serving departments, will benefit the patrons and 
employes alike. Persons under the age of 18 should not be employed for night 
duty. 
Domestic and Personal Service.-The United States mortality 
statistics of this class of wage earners including barbers, bartenders, 
janitors and sextons, servants and waiters and laborers not specified, 
show high rates from tuberculosis and pneumonia. (See pages 728, 729.) 
The rates are especially excessive in janitors and sextons, barbers, 
servants and waiters. The general servant, as a result of long hours and 232 
THE INDUSTRY OF FOOD STUFFS, ETC. 
indoor life, becomes anemic, and is liable to suffer from headache, con- 
stipation and digestive derangements, including gastric ulcer. Varicose 
veins and ulcers of the leg, and "flat-foot" from prolonged standing are 
not infrequent. 
Barbers and Hair Dressers.-In view of the fact that many weaklings 
engage in this employment, it is not surprising that the tuberculosis death 
rate of barbers is rather high. Catarrhal affections of the upper air 
passages, digestive disorders, "flat-foot" and eczema, the latter as a 
result of contact with hot water and toilet preparations, are not uncom- 
mon. Razor cuts of the fingers occur occasionally, but on the whole it 
cannot be said that the occupation is inimical to health. The Leipsic 
Insurance statistics show a morbidity of 395 days per 100 members per 
annum and a mortality hazard of only 0.32 per cent. 
REFERENCES 
1 State College of Wash. Agric. Exper. Station, Pullman, Wash., Bull. No. 117, 
November 3, 1914. 
2 Hoffman, F. L.-Bulletin Bureau of Labor, No. 82, May, 1909, page 502. 
3 Editorial, J. A. M. A., December 12, 1914, page 2137. 
4 Hoffman, F. L.-Bulletin Bureau of Labor, No. 82, May, 1909, page 534. 
5 Roth.-Gewerbehygiene, Leipzig, 1907, page 132. 
6 Neisser.-Internal. Ubersicht d. Gewerbehygiene, Berlin,. 1907. 
7 Oliver's Dangerous Trades, 1902. 
8 Leiser.-Weyl's Handbuch d. Arbeiterkrankh., Jena, 1908, page 442. 
9 Grim, Heinrich.-Weyl's Handbuch d. Arbeiterkrankh., Jena, 1908. 
10 Statistics for Canning and Preserving. Census of the U. S., 1910. 
11 Bulletin of the Bureau of Labor, No. 96, Sept., 1911, pages 353-356, Washington, 
D. C. 
12 Weihrauch.-Inaugural Dissert., Munchen, 1905. 
13 Koelsch.-Krankheit und Soziale Lage, Munchen, 1913, 1 Liefs, page 215. 
14 Muller.-Vierteljahrschr. f. Ger. Med., Bd. Ill, IX, page 381. 
15 Heucke, cited by Stephani.-Weyl's Handbuch d. Arbeiterkrankheit., Jena, 1908, 
pages 634-635. 
16 Hoffman, F. L.-Bulletin of Labor, No. 82, Washington, May, 1909, page 569. 
17 Roth, E.-Gewerbehygiene, Leipzig, 1907. 
18 Kostial, cited by Stephani.-Weyl's Handbuch d. Arbeiterkrankh., 1908, page 637. 
19 Galezowsky.-Des ambly op. et Amauroses toxigues, 1897. Cited by Oliver. 
20 The Toxic Amblyopias, etc., 1896, pages 59-79. 
21 Cincinnati Lancet Clinic, 1892, Vol. XXX, pages 585-590. 
22 Gast.-Weyl's Handbuch der Arbeiterkrankheiten, Jena, 1908, page 445- 
23 Schultes.-Deutsch. Med Wochenschrift, 1901, No. 32. CHAPTER VIII 
RENDERING, SOAP, GLUE AND FERTILIZER INDUSTRIES, 
ETC. 
GEORGE M. KOBER, M. D., Washington, D. C. 
Occupations Involving the Inhalation of Organic Gases, Etc.- 
Whether the effluvia from sewers, stables, stock yards, rendering estab- 
lishments, glue, candle and soap factories, hide depots, fertilizer plants, 
etc., are injurious to health remains an open question. Some authors 
insist that the olfactory organs are alone offended and point to statistics 
which indicate that the duration of life of such employes is above the 
average, quite forgetful of the fact that weaklings rarely engage in such 
occupations. It is reasonable to assume that the effluvia, consisting as 
they do of ammonia, hydrogen and ammonium sulphide, are fully as 
injurious as foul sewer air, which, judging from animal experimentation, 
appears to increase the susceptibility to infectious diseases by diminishing 
the power of resistance. 
In unventilated privy pits and sewers the danger is intensified by an 
excess of carbonic acid and corresponding deficiency of oxygen in the air. 
Special precautions should be taken to exhaust the foul air before sewer 
employes or scavengers are allowed to descend. The general effects of 
foul odors upon those unaccustomed to do work in the so-called "offen- 
sive trades" are nausea, vomiting, headache, loss of appetite, diarrhea, 
general depression, and weakness.* 
Flaying and Bone Yards.-Every community provides for the collec- 
tion and disposal of dead animals, which is usually done by contract. 
The animals are taken to some establishment beyond the residential 
limits, flayed and worked up, so as to utilize the skin, hair, fats, bones, 
horns, etc. After the animal has been skinned and the mane, tail, hoofs, 
and horns removed, the carcasses are cooked in a boiler for the recovery 
of fat and bones and the fleshy residue is used for the manufacture of 
artificial manure. Apart from exposure to extremely offensive odors 
* The inhalation of even fragrant odors is by no means free from danger; the toxic 
effects in some individuals of turpentine, copaiba, camphor, esther, ketone, nitrobenzol 
and the oil of rose have been recognized. But there are many other substances, which in 
specially susceptible individuals, may produce local and systemic effects. This is true of 
coumarine, the odoriferous principle of Tonka bean, woodruff, sweet clover, etc.; myristicin, 
from the oil of nutmegs and cloves; safrol, found in the oil of sassafras, and other essential 
oils. There are dlso instances on record in which the exhalation of flowers and of oranges, 
etc., have produced toxic and in some instances fatal symptoms. It is evident therefore 
that we have much to learn regarding the anaphylactic action of some of these fragrant 
substances. According to Lehmann1 based upon the testimony of the owners of a large 
establishment engaged in the manufacture of essential oils and perfumeries, toxic symp- 
toms rarely develop, and the workers acquire a gradual tolerance. 
233 234 
RENDERING, SOAP, GLUE AND FERTILIZER INDUSTRIES 
there is more or less danger of the transmission of infectious diseases 
communicable from animals to man, such as anthrax, glanders, tetanus, 
tuberculosis, and hence all such work should be done under strict sanitary 
control. Moreover, during the fly season there is distinct danger from 
septic infection, by biting flies, in all occupations involving the handling 
of decomposing animal matter, and every effort should be made to abate 
the fly nuisance and protect the workers by suitable screens. 
Rendering Plants.-In some establishments the refuse from dead ani- 
mals and garbage, such as fat, meat trimmings, bones, etc., is treated with 
benzine, carbon disulphide, or by heat for the extraction of fats. The 
products are oils, grease and tankage. When heated in tanks the fat 
separates and is drawn off into barrels and sold for the manufacture of 
soap, wagon grease, etc. The tank residue is subjected to pressure and 
the meat scraps are converted into feed for poultry, or utilized for the 
manufacture of artificial manure. The bones are either cleaned and 
dried and sold for the manufacture of buttons, etc., or are ground up and 
converted into fertilizers. The tanks are usually provided with ventilat- 
ing pipes which carry the odors and gases to the furnaces, where they 
pass through the fire and are destroyed. In spite of this provision there 
is much reason for assuming that the evolution of volatile fatty acids and 
acrolein are responsible for the undue prevalence of catarrhal affections 
of the eyes, air passages and of the stomach. 
The Manufacture of Tallow.-Tallow is a mixture of olein, stearin and 
palmitin, chiefly the first two, and melts at a temperature of between 100° 
and 120°F. The better grades are obtained by rendering beef or mutton 
fats, but inferior qualities used for soaps are secured from the refuse fats 
already referred to, and even from whale or fish oil. Dr. C. F. W. Doeh- 
ring2 has described in detail the methods employed in the manufacture of 
tallow: 11 There are a series of cylinders of 1200- to 1500-gal. capacity 
employed in rendering the fats when the tissues are not required in a 
condition otherwise than is suitable for manure. The cylinders are filled 
above a false bottom with the crude fat and steam is admitted by a foot 
valve and perforated pipe at 50- or even 100-lb. pressure After 
10 to 15 hours the steam is cut off and the cock and safety valves are 
opened, and after settling, the layer of tallow is drawn off through a 
series of cocks. The cover of a discharge hole in the bottom of the 
cylinder is then raised by a rod, and the residue falls into the tub beneath. 
To remove the last traces of tissue it is necessary for the tallow to be 
washed, melted and strained. This process extracts more tallow from the 
fat than any other. Sometimes the fat is rendered at the atmospheric 
pressure by boiling a mixture of the fat with one-fourth of its bulk of 
water, containing 2-3 per cent, of sulphuric acid." 
Several processes are employed for bleaching and purifying tallow. 
Apart from subsidence, mechanical filtration and aeration, various chem- 
icals have been used, such as potassium carbonate, or potassium perman- THE SOAP INDUSTRY 
235 
ganate, or bleaching powder in the proportion of 1 per cent, or potassium 
chlorate in the proportion of 0.03 per cent, with the addition of hydro- 
chloric and sulphuric acid. In some establishments, the tallow is purified 
by heating with soda and salt solution and boiling the unsaponified por- 
tion with a 2j^ to 3 per cent, solution of alum. It is very evident that 
the workers are exposed not only to very offensive odors but also to a 
number of toxic fumes. 
The Soap Industry.-During 1919, reports show 20,436 persons were 
employed in the United States in soap making. The manufacture of 
soap and candles is usually carried on in the same establishment, and 
because of the offensive odors evolved the occupation has been considered 
unwholesome. The inspectors of the State Board of Health of Massachu- 
setts do not share this opinion and report that the employes as a class 
appear to be in good health. The Leipsic statistics for female tallow and 
soap workers show 1085 days of sickness per annum per 100 members and 
a mortality hazard of 1.14 per cent. 
In the manufacture of soap, animal fats or oils, such as olive, cocoanut 
or palm, containing the fatty substances olein, palmitin and stearin, are 
heated with either caustic potash or soda. This converts the fatty 
substances into oleic, palmitic and stearic acids, which combine with the 
alkaline base and form oleate, palmitate and stearate of potassium or 
sodium, while glycerine is set free and saved as a by-product. Hard soap 
results when soda is used ^s a base, and soft soap is the product when 
potash is employed. 
In addition to the materials mentioned various coloring matters are 
employed. For example, the marbled or mottled appearance of castile 
soap is produced by the addition of ferruginous matter. Toilet soaps 
are frequently colored with harmless anilin dyestuffs and scented with 
essential oils and artificial perfumes which may cause headache. The 
most dangerous agent employed is nitrobenzol, which not infrequently 
produces malaise, headache, giddiness, nausea and other symptoms of 
nitrobenzol intoxication. Dr. Grim3 suggests that some of the chronic 
affections of the kidney and bladder may be caused by the perfumes and 
chemical dyestuffs employed. The manufacture of medicated soaps 
containing sulphur, tar, etc., like toilet soaps, involves more complicated 
processes. 
Apart from exposure to volatile fatty acids, acrolein vapors and soap 
dusts, the employes may sustain injuries from machinery, burns from 
caustic alkalies, and eczema from exposure to acids. Wounds and abra- 
sions are not infrequently followed by erysipeloid infections. It is 
generally believed that exposure to the vapors of fatty acids is productive 
of catarrhal affections of the upper air passages, and Grim accounts for 
the undue prevalence of acute and chronic gastric catarrh among soap 
makers by the fact that they swallow a sufficient amount of alkaline 
vapors and dust to neutralize the hydrochloric acid of the gastric juice, 236 
RENDERING, SOAP, GLUE AND FERTILIZER INDUSTRIES 
and that fatty acids ingested also act as chemical irritants. All of these 
hazards can be reduced to a minimum by hoods and exhaust ventilation. 
Robinson and Wilson4 in examining 581 employes in different soap 
factories in Cincinnati found 10 cases or 1.7 per cent, of tuberculosis. 
The manufacture of soap powder is attended with the production of much 
dust containing soda ash, which in addition to the blowei' system fre- 
quently compels the employment of respirators. Apart from this, long 
working hours, "speeding up" and low wages are referred to as deleterious 
influences. 
Glue Makers.-Glue is usually an impure gelatine derived from 
boiling animal substances such as fleshings, scraps of sea food, hide, hoofs, 
horns, etc. The material is first washed and then soaked for a few days 
in lime water in suitable tanks for the purpose of loosening the hair. 
This is removed and dried by steam heat and sold for plastering pur- 
poses. The residue is washed for the removal of lime and exposed to the 
action of steam in suitable tubs. The liquid glue is drawn off from 
below and allowed to solidify in pans to a hard jelly, which is then cut 
into slices, transferred to screens and thoroughly dried. Glue is gener- 
ally sold in thin, hard and brittle cakes, although sometimes it is ground 
up in the factory. This involves more or less dust production. The 
residue in the tubs is further treated for the extraction of fatty matter. 
The glue manufactured from by-products of the fish-preserving indus- 
try is usually evaporated to the required consistency and sold in a liquid 
form. In the manufacture of so-called Cologne glue, which is a pale 
strong glue, considerable chloride of lime is used for bleaching purposes. 
The manufacture of gelatine for dietetic purposes is carried on along 
the same lines, except that none but pure and wholesome stock is used, 
and the entire process is conducted with special regard for cleanliness. 
Preventive Measures.-While it is true that the workers in these so-called offen- 
sive trades generally appear to be in good health, it should be remembered that, as a 
rule, only men of rugged physique engage in these disagreeable occupations. As 
already indicated the inhalation of organic gases and of volatile fatty acids and 
acrolein is not free from danger and should be guarded against by copious ventilation 
and exhaust flues. Personal cleanliness is likewise important and all wounds and 
abrasions should be treated with antiseptics. 
Basic or Thomas Slag.-In the manufacture of steel by the Gilchrist- 
Thomas method a slag is formed, which contains from 10-25 per cent, of 
soluble phosphoric acid and naturally led to its utilization as a fertilizing- 
agent. This involves crushing and grinding operations of a very dusty 
character, and hence diseases of the respiratory organs are quite common. 
In some of the workers ulcerations of the mucous membranes have been 
observed and the undue prevalence of pneumonia among this class may 
reasonably be attributed to the fact that the pathological changes, pro- 
duced by the corrosive action of quicklime present in the dust, favor 
infection with the pneumococcus. BASIC OR THOMAS SLAG-ARTIFICIAL MANURE 
237 
Foreign statistics show an undue morbidity rate especially from 
pneumonia, conjunctivitis, and eczema. In recent years a process of 
granulating basic slag, under the influence of a stream of water, has 
been introduced, which, while it obviates the dangers of dust production, 
is attended with the evolution of sulphuretted hydrogen. This should 
be guarded against by copious ventilation. It should be stated that 
granulated slag, apart from being used as a fertilizer, is also utilized in 
the manufacture of cement, artificial stone, etc. 
Karl Opitz (Zentralbt. f. Gewerbehyg., T)ec., 1920) informs -us that the typical 
sickness of workers with Thomas slag is a non-specific inflammation of the lungs. 
The sharp dust and the resulting injury to the lung fabric makes access of a morbific 
agent easy. Before preventive measures were adopted the mortality was as high as 
28 per cent, of those employed in one factory. After 1911 the figure dropped to 1.2 
per cent, annually, which is twenty times that in other industries. For the sixty 
German plants with about 2500 workers there occur about 35 deaths annually. Dur- 
ing the war women were employed to the extent of about 20 per cent, in one plant; 
excluding the influenza epidemic, serious respiratory diseases caused absence from 
work in 36.8 per cent, of the women, and 27.9 per cent, of the men. During the 
influenza epidemic, July to December, 1918, the incidence of the disease in the whole 
plant was 31.1 per cent, among the men and 66.4 per cent, among the women suffered 
from the disease. In the Thomas slag department 73.3 per cent, of the men and 93.0 
per cent, of the women suffered from the disease. Pneumococci are especially 
common organisms in the lung cases among the slag workers. Opitz suggests the 
employment of optochin and its derivatives as a prophylactic measure against infec- 
tious pneumonia (Jour. Ind. Hygiene, July, 1921. Abstr. p. 51.) 
Artificial manure is also made from various materials rich in phosphate 
of lime. For this purpose phosphorites, cuprolites, bone dust, guano, etc., 
are employed. The grinding of the raw material involves exposure to 
caustic dust and should be carried on automatically in enclosed ball mills. 
The material is then mixed with sulphuric acid which renders the insolu- 
ble phosphates soluble. During this process, hydrofluoric, silico-fluoric, 
hydrochloric and carbonic acid vapors are evolved and also sulphur 
dioxide and sulphuretted hydrogen. These gases should be promptly 
removed by acid proof exhaust fans and condensed. Cases of poisoning 
from nitrous fumes may occur in the manufacture of fertilizers in mixing 
Chili nitre with strong acid superphosphates. When ground bones are 
used, the fats are first extracted by means of benzine, which contributes 
an additional element of danger. (See also Farmers, page 211.) 
My former student, Dr. C. F. W. Doehring,2 has described the condi- 
tions observed in some of the fertilizer plants, and emphasized the danger 
from biting flies, and the clouds of dust and exposure to acid fumes in 
some of the superphosphate factories. 
In addition to the materials already referred to, the following are 
sources for artificial manure. The deposits of native guano consist of the 
excrement and carcasses of sea fowl, but many of these deposits are now 
exhausted and artificial guano is made from the tank refuse of dead 
animals, garbage, carcasses of whale and fish, after extraction of the fats. 238 
RENDERING, SOAP, GLUE AND FERTILIZER INDUSTRIES 
Other sources for artificial manure are seaweed, soot, damaged oil cakes, 
nitrate of soda, sulphate of ammonia, the latter chiefly a by-product of 
gas works, also dried blood, refuse of hoof, horns, leather, wool, calcium 
cyanide and calcium nitrate. 
REFERENCES 
1 Lehmann, K. B.-Arbeits u. Gewerbehygiene, Leipzig, 1919. 
2 Doehring, C. F. W.-Factory Sanitation and Labor Protection. Bull Bureau of 
Labor, No. 44, January, 1903. 
3 Grim, Heinrich.-Weyl's Handbuch d. Arbeiterkrankh., Jena, 1908. 
4 Robinson, D. E., andJWilson, J. G.-U. S. Public Health Bulletin No. 73, March, 
1916. CHAPTER IX 
RAILWAY AND TRANSPORTATION SERVICES 
GEORGE M. KOBER, M. D., Washington, D. C. 
Railway Service.-The employes in the railway service, apart from 
liability to accidents, lead a life full of responsibility and hardships. 
This, together with irregular habits as regards work, sleep and meals, and 
exposure to dust, drafts, etc., increases their liability to sickness in spite 
of the fact that generally only able-bodied men are employed. 
According to Rudlin1 of 280,098 employes in the Prussian-Hessian 
system in 1905, the morbidity rate was 41.97 per cent, with an average 
duration of 26.69 days. The German statistics prior to 1890 show a 
morbidity rate of 48 per cent. The train hands, dispatchers, switchmen, 
track walkers and gatemen show the greatest amount of sickness and the 
station and office force the least. Diseases of the digestive organs, 
diseases of the respiratory system, rheumatism and diseases of the nervous 
system appear to predominate. 
Schwechten2 reports a notable decrease in the tuberculosis death rate, 
which has declined from 34.8 per 10,000 of employes in 1878-82 to 16.3 
per 10,000, a reduction of 53 per cent. While organic diseases of the 
nervous system, railway spine, insanity and apoplexy have decreased, an 
increase in functional disorders, such as neurasthenia, hysteria, etc., is 
noted. * 
The undue prevalence of rheumatic, catarrhal and neuralgic affections 
is probably accounted for by sudden changes in temperature to which 
train hands are especially exposed during the cold months. 
Dr. Edsall3 upon the authority of Dr. Latta, Railway Surgeon of the 
Penna. R. R. Co., calls attention to the frequency of right-sided cases of 
sciatica in locomotive engineers. This was traced to the fact that some 
of the men are in the habit of sitting sidewise on the bench of the right- 
hand side of the engine cab and, in the constant jolting, the weight of the 
body is continually thrown violently on the right thigh and buttock. 
The number of cases was reduced and the special tendency to right-sided 
cases eliminated by simply cutting off the forward part of the bench, so 
that the engineer had to sit squarely facing forward. 
Disorders of the digestive system are doubtless influenced by irregular 
meal hours, and the character of food and drinks. Iced or very cold 
drinks are especially harmful, and since the months of July and August 
furnish the greatest number of cases of gastric catarrh, this causative 
factor may at least be assumed. 
239 240 
RAILWAY AND TRANSPORTATION SERVICES 
Hedinger4 called attention to the fact that only 8 per cent, of the 
German locomotive engineers have normal hearing, while 67 per cent, of 
the engineers and 30 per cent, of the firemen, and 14.5 per cent, of the 
track walkers had defective hearing. The percentage in all increased 
with the length of service. The most common affection was catarrh of 
the Eustachian tube, and internal ear, probably caused by frequent 
exposure to abrupt changes in temperature. 
Hoffman's5 statistics based upon 537 deaths among brakemen show a 
mortality from accidents of 63.3 per cent., from tuberculosis 11.9 per cent., 
pneumonia 3.2 per cent., digestive diseases 3 per cent., heart disease 2.6 
per cent., nervous diseases 2 per cent., apoplexy and paralysis 1.5 per 
cent. (For other statistics see pages 977-981.) 
Railway Accidents.-The fatal accidents to railway employes had 
been gradually reduced from 9.52 per 1000 in 1890 to 4.78 per 1000 in 
1909. The following tables compiled by the Prudential Insurance Com- 
pany of America are of special interest: 
Causes of Fatal Accidents to Trainmen, 1901-1909 
(Employes exposed 1 year 2,363,077) 
Cause 
Total accidents 
Rate per 10,000 
Falls from trains 
3710 
15.7 
Collisions 
3202 
13.6 
Struck by trains 
3104 
13.1 
Derailments 
1974 
8.4 
Coupling or uncoupling 
1874 
7.9 
Other movements of trains 
1624 
6.9 
Jumping on or off 
943 
4.0 
Overhead obstructions 
634 
2.7 
Breaking down of equipment 
199 
0.8 
Parting of trains 
154 
0.7 RAILWAY ACCIDENTS 
241 
Number of Passengers, Employes, and Other Persons Killed or Injured in 
Reportable Steam Railway Accidents of All Kinds for the Years 
1920-1905* 
Year ending 
Passengers 
Employes 
Other persons 
Total persons 
Killed 
Injured 
Killed 
Injured 
Killed 
Injured 
Killed 
Injured 
Dec. 31, 1920 
229 
7,591 
2,578 
149,413 
4,151 
11,304 
6,958 
168,308 
Dec. 31, 1919 
273 
7,456 
2,138 
131,018 
4,567 
10,579 
6,978 
149,053 
Dec. 31, 1918 
471 
7,316 
3,419 
156,013 
5,396 
11,246 
9,286 
174,575 
Dec. 31, 1917 
301 
7,582 
3,199 
174,247 
6,587 
12,976 
10,087 
194,805 
Dec. 31, 1916 
246 
7,152 
2,941 
176,923 
6,814 
12,647 
10,001 
196,722 
June 30, 1916 
239 
7,488 
2,687 
160,663 
6,438 
12,224 
9,364 
180,375 
June 30, 1915 
199 
10,914 
2,152 
138,092 
6,270 
13,034 
8,621 
162,040 
June 30, 1914 
232 
13,887 
3,259 
165,212 
6,811 
13,563 
10,302 
192,662 
June 30, 1913 
350 
15,130 
3,715 
171,417 
6,899 
13,761 
10,964 
200,308 
June 30, 1912 
283 
14,938 
3,635 
142,442 
6,667 
12,158 
10,585 
169,538 
June 30, 1911 
299 
12,042 
3,602 
126,039 
6,495 
12,078 
10,396 
150,159 
June 30, 1910 
324 
12,451 
3,382 
95,671 
5,976 
11,385 
9,682 
119,507 
June 30, 1909 
253 
10,311 
2,610 
75,006 
5,859 
10,309 
8,722 
95,626 
June 30, 1908 
381 
11,556 
3,405 
82,487 
6,402 
10,187 
10,188 
104,230 
June 30, 1907 
610 
13,041 
4,534 
87,644 
6,695 
10,331 
11,839 
111,016 
June 30, 1906 
359 
10,764 
3,929 
76,701 
6,330 
10,241 
10,618 
97,706 
June 30, 1905 
537 
10,457 
3,361 
66,833 
5,805 
8,718 
9,703 
86,008 
Preventive Measures.-Every effort which will promote the health and comfort 
of passengers and employes in the way of temperature, ventilation, light and miti- 
gation of the dust evil, cannot fail to prove beneficial to a large number of employes. 
The sanitation of passenger coaches is still defective, in the matter of cleaning, which 
should be done more frequently and thoroughly, but not while occupied by passengers. 
The vacuum system is especially indicated for upholstery. Leather or some imper- 
meable material should replace plush covers. The temperature in cars during the 
cold months should be maintained between 70° and 75°. 
It is generally conceded that safety in railroad operation is the result of: (1) 
Properly constructed and maintained track signals and rolling stock. (2) Careful 
rules and regulations. (3) Carefully selected and trained employes, of sober habits, 
who faithfully discharge their duties. (4) Intelligent and comprehensive supervision. 
These cardinal principles are carried out by the management of the 
Pennsylvania Railroad Lines, with the result of having the best record 
in accident prevention. The Company maintains its rolling stock with a 
large percentage of steel cars in a high state of efficiency, and has introduced 
safety devices in the shops and roundhouses where over 41,000 men are 
employed. In 1911 the Company appointed 35 "safety first" committees 
who made 17,333 formal recommendations, of which 13,861 were acted 
upon, one of the results being that by the expenditure of $99,753 for 
safety guards, mainly in shops, the serious accidents to shop employes 
had been reduced from 5.4 per 1000 to 3.2 in 1912. The Company main- 
tains 105 hospitals, and employs an efficient medical corps not only for 
♦Figures for years 1915-1911 include industrial and other nontrain accidents to employes 
only; and for years 1910-1908 do not cover switching and terminal roads, otherwise the statement 
covers all reportable accidents. 242 
RAILWAY AND TRANSPORTATION SERVICES 
emergency and hospital work, but also for the instruction of all employes 
in first aid. Lectures and demonstrations are given, particularly at the 
larger shops. All stations, shops, engine cabs, cabin cars, etc., are 
equipped with "first-aid" kits. 
Street Railway Employes.-The hygiene of this occupation does not 
materially differ from that of the general railway service. The working 
hours of the traffic force are unusually long, the shifts are irregular and 
involve both night and day work. 
Professor Weyl,6 with his characteristic thoroughness, presents 
statistical data bearing upon the accident and morbidity liability of this 
class of workers in Germany. 
In 1905 there were reported among 60,940 employes, 4253 accidents 
or a rate of 69.73 per 1000 full-time workers. Of this number 31 proved 
fatal, 35 resulted in permanent total disability, 293 in partial permanent 
disability, and 104 in temporary disability. A majority of the serious 
injuries were caused by falls and being run over. 
The inspectors and overseers of the traffic lines furnished the largest 
percentage; next came the employes in the mechanical department, 
followed by the motor men and conductors. The same relative frequency 
was noted in the morbidity rates, except that the "extra force," which is 
made up of inexperienced men, furnish the highest rates. 
The morbidity statistics, which are based on a membership of 8523, 
show that there were 6471 cases of sickness with 88,149 days' loss of work. 
Colds, influenza, tonsillitis and rheumatism were the cause of illness in 
2411 cases; digestive disorders furnished 1248 cases, diseases of the 
respiratory system, inclusive of consumption, 611. The mortality rate 
from consumption, which was especially high in the office and temporary 
force, was 22.6 per cent. There were also 265 cases of mental and nervous 
diseases; 376 cases of skin diseases; 222 cases of ear, nose and throat affec- 
tions; 161 cases of diseases of the eye; 89 cases of heart disease; and 54 
cases of varicose veins; cases of "flat-foot," hernia and frost-bite are not 
uncommon. 
In view of the fact that the employes are primarily picked men, the 
morbidity rates appear to indicate that the same injurious factors pointed 
out in connection with the general railway service also operate in this 
branch. 
Dr. Schwarze7 emphasizes the strain upon the eyes and ears, the 
development of "flat-foot" and varicose veins from prolonged standing 
and the undue prevalence of chronic conjunctivitis, from exposure to dust 
and drafts as incident to the occupation. While the occupation predis- 
poses to nervous affections, the real cause of neurasthenia is often not at 
all connected with the service. Motormen who almost constantly stamp 
on the gong pedal often develop neuroses of the right leg. Schwarze 
refers to occasional cases of burns from the electric current, and to the 
comparative rarity of injuries from electric shock, having observed but SUBWAY EMPLOYES-AUTOMOBILISTS 
243 
one case during 10 years. As causes of hernia he mentions the faulty 
position of the motormen in the use of the brake, and the habit of the 
conductors in leaning too far back over the rear platform, to which may be 
added the muscular strain involved in jumping on and off the cars. 
Preventive Measures.-While it cannot be said that this occupation is intrinsically 
dangerous to health, much could be done to diminish exposure to the elements and 
dust by inclosed platforms. Adjustable seats for the motorman should be provided. 
The clothing should be adapted to climate and seasons. The establishment of 
reasonable working hours, and of lunch rooms, where hot soups, coffee, tea, etc., are 
served, would do much toward the prevention of the alcohol habit and of accidents. 
Subway Employes.-We have as yet no statistical datato justify posi- 
tive conclusions as to the injurious effects of employment in the subway 
service. Dr. Sutherland determined that the proportion of carbon diox- 
ide in the air of subway stations and cars varies from 4 to 20 parts per 
10,000 volumes as compared with 2.8 in the outer air. 
Dr. G. A. Soper8 of New York has shown that the subway dust con- 
tains 61.3 per cent, of iron, mostly in the form of fine platelets; 21.9 per 
cent, of organic matter of animal and vegetable origin; 15.6 per cent, 
mineral matter, mostly silica; and 1.3 per cent, of oily matter. 
The average amount of dust was 61.6 mg. and the maximum weight 
was 204 mg. per 1000 cubic meters of air. The excess of dust in the sub- 
way air over the outer air averaged 47 per cent. Dr. Soper found that 
magnets hung up in the subway, collected more particles of iron than mag- 
nets of the same size and strength hung up in an iron foundry or in a dry 
grinding and polishing establishment. From samples taken it was 
estimated that in every month 25 tons of iron and steel are ground off the 
rails, brake-shoes and wheels on the 21 miles of subway. The greatest 
wear and tear falls upon the cast-iron shoes of the powerful brakes, amount- 
ing to 1 ton per mile a month. 
The physical examination of the men9 revealed an excessive amount of 
dry pleurisy without pain or other physical discomfort, the proportion 
being 53 per cent, against 14.5 per cent, among men not engaged in sub- 
way work. Congestion and inflammation of the upper air passages were 
also prevalent. The drafts and changes of temperature at or near the 
stations and the character of dust are doubtless injurious factors. 
Preventive Measures.-It is reasonable to assume that the factors mentioned are 
inimical to the health of employes, who are exposed for several hours daily to the 
inhalation of dust which is known to produce structural changes in the lungs. No 
effort should be spared to reduce dust production and to mitigate its effects by venti- 
lation and copious oiling of the road beds. 
Automobilists.-The hygiene of automobilists is still in its infancy and 
we have no statistical data to justify positive conclusions as to the 
influence of exposure to fine road dust, smoke, and other products of 
gasoline combustion upon the habitual users of automobiles. Dr. 
Delavan10 has pointed out that dust and smoke, temperature, air pressure 244 
RAILWAY AND TRANSPORTATION SERVICES 
and winds are fruitful causes of inflammatory conditions of the nasal 
cavities, pharynx, larynx, trachea, bronchi and lungs. It can be readily 
understood how these causative factors are intensified during speeding, 
since a speed of 30 miles will create, even in a calm atmosphere, currents 
equivalent to a stiff breeze. This alone is calculated, especially in cold 
weather, to abstract an undue amount of animal heat and predisposes to 
congestions of the internal organs, while dust and fumes will serve to 
aggravate the evil effects. 
Cases of gasoline poisoning were reported as early as 1908 by Dr. 
Box11 in chauffeurs who were maneuvering a motor car in a closed garage. 
Similar cases are mentioned by Oliver12 and also cases of carbon monoxide 
poisoning, from defective exhaust pipes. 
Affections of the eyes and skin, caused by exposure to the sun and dust, 
are not infrequent. Sciatica, neuralgia, muscular rheumatism and 
numbness in the lower extremities are prevalent, and attacks of pseudo- 
angina have been observed after violent efforts in cranking. Constant 
and excessive pressure with the right foot has been known to produce 
sciatica and lumbago. "Chauffeur's knee" (partial ankylosis) is also 
reported. It is highly probable that the nervous strain, combined with 
constant and rapid concussions, tends to produce similar diseases of the 
nervous system as are observed in locomotive engineers. 
Borattaue13 mentions that injurious effects are produced in all per- 
sons suffering from diseases of the respiratory, circulatory and female 
genital organs; and Paul le Gendre14 reports cases of sudden death in 
chauffeurs from heart lesions. The liability to accidents from collisions 
and otherwise is also very great in this age of speed. Colles' fracture 
the result of back fire while cranking the motor is notoriously common. 
According to the "National Safety News," Dec., 1921, automobile accidents have 
increased from 0.4 in 1906 to 9.4 per 100,000 of population in 1919. This same 
paper gives charts showing the proportion of decrease in accidents from various 
causes for the years 1906-1919, and states that 23,000 lives were saved by safety work 
in 1919. (Jour. Ind. Hyg., April, 1922. Abst. by M. Dent., p. 275.) 
Of 55 garage employes, mechanics and garage men, 36, or about two-thirds, were 
shown to have absorbed in their blood carbon monoxide in demonstrable quantities. 
Of the remaining 19 only 9 had been at work inside the garage for more than an hour 
when the test was made. (Dr. Alice Hamilton, U. S. Bur. Labor Statis., Ind. Acci- 
dents-Hyg. Ser., No. 291, Dec., 1921, p. 47.) 
Preventive Measures.-Dustless streets and roads, rules limiting the speed to 12 
miles or less per hour in cities, and to 30 miles on country roads, careful traffic rules 
in cities, proper clothing and protection of the eyes by suitable glasses, wind shields, 
and the habit of breathing through the nose, are all important safeguards, while 
automatic sparking blocks will diminish the number of Colles' fractures. Copious 
ventilation in all garages while motors are running is essential. 
Draymen, Hackmen, and Teamsters.-During the last census year 
the number of drivers and teamsters in the U. S. was 532,632; the mor- 
tality rate from consumption was 2.6 per 1000, and the death rate from other 
diseases of the lungs was 1.7 per 1000. (See also page 976.) MISCELLANEOUS TRANSPORTATION WORKERS 
245 
The industrial insurance statistics cited by Hoffman15 include 3850 
deaths, of which 999 or 25.9 per cent, were caused by consumption, 483 
or 12.5 per cent, from pneumonia, 56 or 1.5 per cent, from bronchitis and 
93 or 2.4 per cent, from other diseases of the lungs making a combined 
death rate of 42.4 per cent, from diseases of the respiratory organs, against 
an expected rate of 26.5 per cent. 
The mortality rate from diseases of the heart and arteries was also 
excessive. While exposure to road and municipal dust, inclement 
weather, and hard work, especially in the draymen and teamsters, are 
doubtless important predisposing factors, the effects of the alcohol habit 
cannot be ignored. 
The death rate from accidents and injuries in this class of employes 
in 1910 was 1.33 per 1000. Only six of the other 27 occupations tabulated 
furnished a higher rate. 
Preventive Measures.-The undue prevalence of diseases of the respiratory organs 
plainly indicates that dust plays an important role; hence no effort should be spared 
to reduce the amount of road and street dust, primarily by proper construction of the 
highways and next by frequent cleaning of streets and oiling of roads. 
Street Cleaners, Ice, Coal and Ash Men and General Day Laborers.- 
Although these occupations are carried on largely in the open air, foreign 
statistics show that this group is subject to the highest morbidity and mor- 
tality rates, especially from diseases of the respiratory organs. The acci- 
dent rate is also excessive, and diseases of the heart and arteries as a result 
of hard work are likewise quite common. 
The dirty character of the work predisposes to diseases of the skin and 
septic infections. Rheumatism as a result of exposure to the elements is 
not infrequent, and the undue prevalence of diseases of the digestive system 
is doubtless influenced by the scale of wages and character of food. Our 
American statistics are limited to street cleaners and the evidence 
gathered by Hoffman16 from medical journals indicates that about one- 
third of the 5000 street cleaners, in 1907, in New York, were infected with 
tuberculosis, in spite of the fact that these men, previous to employment, 
were examined by Civil Service Surgeons and pronounced free from 
organic disease. The men employed on the East side, where the streets 
are in a more filthy condition, suffered more from diseases of the nose, 
throat and lungs, than the sweepers of the West side. 
The more accurate data furnished by Hoffman16 are based upon the 
industrial insurance statistics, which deals with 180 deaths among street 
cleaners; of this number 33 or 18.3 per cent, died from consumption, and 
a like number perished from pneumonia and other diseases of the lungs, 
making a combined mortality rate of 36.7 per cent, from diseases of the 
respiratory organs. The Bavarian statistics cited by Koelsch17 show that 
the tuberculosis death rate in this group of employees is 83.1 per 1000 
living, or 27 times higher than in the average occupied male population. In 246 
RAILWAY AND TRANSPORTATION SERVICES 
England it is 5-6 times higher. On the other hand, we have the studies 
of Augustus Gay, cited by Edsall18 on nightmen, scavengers and dust men 
showing that they presented an unusually good average health. The 
observations made in the so-called dust women of London, who are 
engaged in picking from the city refuse such articles as rags, twine, paper, 
old leather and rubber, bones, coal, cork, broken glass, etc., led Oliver19 
to conclude that, in spite of the extremely dusty character of the work, 
the women become apparently immune to its possible evil effects-all of 
which indicates that more intensive studies are needed. Kryz20 has 
called attention to the sharp, angular and irritant character of dust from 
ashes. 
It is difficult to determine how much social economic factors have to 
do with the excessive rates of the German day laborers, but they are 
perhaps no more potent than in the same group of laborers elsewhere. 
Exposure to the elements, dust, and tubercle bacilli are predisposing 
factors everywhere. While the danger of infection from street dust has 
probably been overstated, because the tubercle bacilli perish under the 
influence of sunlight, they have been found in street dust by Dr. Robertson 
in Birmingham and Martin of Leipsic. Kristen of Breslau has shown that 
they may survive from 3-8 days in such material. 
Preventive Measures.-It is hoped that anti-spitting ordinances and the modern 
system of cleaning streets, by means of sprinkling and sweeping machines, will be 
generally adopted and thus reduce the dangers of dust inhalation to a minimum. The 
wet process is equally applicable to the unloading of coal, the collection of ashes, etc. 
All dry refuse should be moistened and removed under cover. A higher scale of 
wages, better food and better housing conditions are indicated, and will do much 
toward the prevention of the general misery of this class of wage earners. 
1 Archiv f. Eisenbahnwesen, 1907, Heft I. 
2 Schwechten.-Wey's Handbuch der Arbeiterkrank., 1908, page 593. 
3 Edsall, D. L.-J. A. M. A., Vol. LIII, 1909, page 1876. 
4 Hedinger.-Zeitschf't d. Vereins d. Eisenbahnverwaltg, No. 27, page 25. 
5 Exhibits of the Prudential Insurance Company of America, 1912. 
6 Weyl, Theo.-Weyl's Handbuch d. Arbeiterkrankheiten, Jena, 1908, page 595. 
7 Weyl's Handbuch d. Arbeiterkrankh., Jena, 1908, page 598. 
8 New York Medical Record, April 21, 1906, page 614. 
9 Scientific American, Aug. 31, 1907, page 146. 
10 Delavan, D. B.-Med. Record, N. Y., 1910, LXXVIII, pages 305-309. 
11 Box, Dr.-British Medical Journal, Apr. 4, 1908, page 807. 
12 Oliver.-Diseases of Occupation, London, 1908, page 386. 
13 Borattaue, H.-Gesundheit, Berlin, 1905, pages 688-695. 
14 Le Gendre.-Wiener Mediz. Presse, 1907, pages 586-590. 
15 Hoffman, F. L.-Bull. Bureau of Labor, No. 82, May, 1909, pages 481-485. 
16 Hoffman, F. L.-Mortality from Consumption in Certain Occupations. Bull. 
Bureau of Labor, No. 82, May, 1909, pages 475-481. 
17Koelsch.-Krankheit, Soziale Lage, ist Liefg., Munchen, 1912, page 212. 
18 Edsall, D. L.-Journal American Medical Association, Vol. LIII, 1909, page 1878. 
19 Oliver's Dangerous Trades, 1902, page 279. 
20 Kryz.-Zeitschrift f. Gewerbehygiene, etc.,.1912, Vol. IX, page 62. 
REFERENCES CHAPTER X 
THE PRINTING AND PUBLISHING INDUSTRY 
GEORGE M. KOBER, M. D., Washington, D. C. 
Printers.-During the year 1909, the printing and publishing industry 
in this country afforded employment to 388,446 wage earners. Of these, 
77.7 per cent, were males and 22.3 per cent, females. The average 
number of wage earners under 16 years of age was 6333, of which about 
one-sixteenth were girls. These figures cover the industry as a whole, 
which includes music-printing, book binding, and blank-book making, 
engraving on steel and copper plates and printing from such plates, and 
lithographing. In the U. S. Statistical Abstract for 1921 the figures for 
printing and publishing (only) were 245,098 wage earners. 
The morbidity and mortality of printers is everywhere very high. 
The statistics of German printers based on a membership of 54,000 from 
1891-1904 gave a sickness rate of 461 per 1000 as compared with 375 in 
the occupied male population.1 According to Schuler, of 1000 Swiss 
typesetters and founders 304.7 are annually taken sick, and of printers 
250. Diseases of the digestive organs predominate (78 per 1000). 
Diseases of the respiratory system come next (75 per 1000). 
The death rate per 1000 employes engaged as compositors, printers 
and pressmen in the United States was 12.1. Among 27 occupations 
tabulated by the Census Bureau these workers occupy the third rank in 
the number of deaths from tuberculosis, and in 38 occupations tabulated 
by Professor Sommerfeld the German printers occupy the fifth rank. 
Albrecht2 reports that the statistics of the Berlin Sick Benefit Insurance 
Companies, covering a period of 33 years, show that 48.13 per cent, of all 
the deaths among printers prior to 1887 were caused by consumption. 
The statistics collected since that time by Sommerfeld and Silberstein3 
are more favorable, since only about one-third of the deaths among the 
Berlin printers in 1903-1905 were caused by consumption. This gratify- 
ing reduction is doubtless the result of improved sanitation in the work- 
rooms as required by regulations of the Federal Council of the German 
Empire which went into effect July 31, 1897. At all events, in a total 
membership of 44, 236 among the printers of Germany in 1905 only 134 
or 3.03 per 1000 died from pulmonary diseases (tuberculosis not being 
separated in the tabular presentation). The corresponding death rate 
among compositors in New York City was 7.17; in the State of New York 
4.04; total of New York State 6.34; Chicago 5.04; Philadelphia 4.70, total 
United States 5.02 and London, England 5.50. See interesting study of 
247 248 
THE PRINTING AND PUBLISHING INDUSTRY 
the health of printers by George A. Stevens.4 Statistics compiled from 
the record of the International Typographical Union cited by Hamilton 
and Verrill,11 covering about 12,000 deaths between 1893 and 1915 show 
a decided lowering of the death rate from tuberculosis and an increase in 
the expectation of life. 
The undue prevalence of consumption among printers may be due in 
part to the fact that many weaklings engage in this occupation, but the 
work itself is doubtless an important predisposing factor, as it is often 
carried on under unfavorable environments and in an atmosphere rendered 
impure by the products of respiration, combustion and the presence of 
lead type metal, plumbago dust and benzine vapors evolved for cleaning 
purposes. 
Type metal is an alloy containing about 75 per cent, lead, 23 per cent, 
of antimony and about 2 per cent, of tin, copper or zinc. According 
to Dr. E. B. Phelps5 of the U. S. P. H. S., the proportion of antimony 
used in the type of the Government Printing Office varies from 16 percent, 
for monotype casting to 3 per cent for electrotype. During the wear 
of the type more or less dust is given off which generally collects at the 
bottom of the type cases. One gram of this dust upon analyses revealed 
the presence of 57.5 mg. of lead, 186.8 mg. of antimony and traces 
of arsenic.6 
According to Fromm7 the dust collected from type cases contained 
38.77 per cent, of lead, the dust deposited in compositors rooms contained 
1.95 per cent, of lead and the floating dust in such establishments revealed 
the presence of 0.54 to 1.55 per cent, of lead. Other investigators like 
Panwitz8 detected only traces of lead in the atmospheric dust of com- 
positors' rooms. 
In addition to this, more or less plumbago is used in electrotyping 
which is not always sufficiently removed before the type is redistributed. 
It will be readily understood that the inhalation or ingestion of this 
metalliferous dust not only predisposes to diseases of the respiratory 
organs but also causes lead poisoning in various degrees, resulting at 
least in such a general deterioration of the health of the workers as to 
render the system susceptible to the invasion and effects of tubercle 
bacilli. At all events, Professor Hahn9 points out that the workers 
both in Berlin and Vienna between 1901 and 1907, who are most exposed 
to plumbism, viz., the printers and type founders, also show the highest 
mortality from tuberculosis. Cases of pronounced lead poisoning are not 
very common. According to Sir Thomas Oliver10 only 200 cases were 
reported in printers in Great Britain between 1900 and 1909. Conditions 
are, however, worse in Germany as in Leipzig in 1 year alone 132 typists, 
25 type founders and 9 music typists suffered from lead poisoning. In 
Vienna, between 1891 and 1900, 1308 cases were reported with 41,838 
days of sickness and 8 deaths, exclusive of about 400 cases of a milder 
type which did not incapacitate the individuals for work. Females and TYPE FOUNDING AND TYPESETTING 
249 
youthful employes are especially susceptible to lead poisoning. Dr. 
Alice Hamilton11 states that Dr. J. D. Ellis of Chicago and W. W. 
Palmer of Boston examined 200 printers and found 18 cases or 9 per cent, 
of plumbism, and only 93 or 46.5 per cent, were free from noteworthy 
symptoms of ill health. The significant symptoms in the remaining 107 
were abdominal pain, constipation, articular pains and headache. The 
processes in which the workers are especially exposed to injurious fac- 
tors are the following: 
Type Founding.-It was held for a long time that the old process of 
casting type involved exposure to lead and arsenical fumes, as the anti- 
mony frequently contains arsenic. This, however, according to Stern- 
berg,12 is not the case as the melting point of lead is 326°C. and the 
vapor is over 1000°C. and that the latter point is never reached in this 
process. Sommerfeld and Lewin of Germany and Legge and Goadby 
of England cited by Hamilton and Verrill5 and 11 maintain that the 
addition of antimony to lead up to a certain proportion results in a 
mixture which has a lower melting and volatizing point than pure lead 
itself. 
Dr. Phelps11 of .the Public Health Service, believing that the con- 
tradictory results obtained by different experimenters might be due to 
the fact that lead when stirred, skimmed or ladled gives off fumes at a 
temperature at which lead at rest may not give off enough to be recogniz- 
able, reproduced in the laboratory the conditions present in the various 
processes and determined, that while in stereotyping and electrotyping 
the temperature may be high enough to give rise to fumes when the lead 
is agitated, in linotyping and monotyping there is neither enough 
agitation nor a high enough temperature to allow of the escape of lead 
fumes. The discomfort experienced by linotypists when working at 
machines with no provision for carrying off fumes is to be explained by the 
fumes from the gas used to keep the lead hot, and possibly also as pointed 
out by Schuler, cited by Silberstein,13 by acrolein vapors, due to the 
presence of wax, fat or oils used in fluxing, the metals. (See Acrolein.) 
Dr. Emery R. Hayhurst found the proportion of lead poisoning in his 
Illinois survey among linotypers was 3^ per cent, against 7.6 per cent, 
among stereotypers. The polishing of the type by means of files and 
machines is usually done by female labor and youthful employes and 
involves exposure to lead dust, and the sorting and packing, also largely 
done by female labor, involves at least the risk incident to the constant 
handling of a lead-containing metal. 
Typesetting.-The compositor is chiefly exposed to the inhalation and 
ingestion of the dust from the type cases; the absorption by the skin is 
probably insignificant as only the apex of the thumb and index-finger are 
brought into contact with the metal in setting up or distributing of the 
type; the skin of these fingers soon becomes hardened, rendering the 
chances of absorption quite remote. On the other hand, it should be 250 
THE PRINTING AND PUBLISHING INDUSTRY 
remembered that some compositors, especially youthful members, are in 
the habit of moistening their fingers in order to get a better hold of the 
type, and of holding the type between their teeth while correcting proof. 
This, together with smoking and an equally pernicious habit of eating 
fruit and lunches with unwashed hands, is a frequent mode for the inges- 
tion of lead. Prof. Van Eyk, cited by De Vooys and quoted by Oliver,10 
requested a number of printers, after several hours' work with type, 
to wash their hands in a weak solution of hydrochloric acid and found on 
an average from 6 to 15 mg. of lead in each wash basin. 
The danger from type case dust could be materially reduced by proper 
construction of the cases. Strasser, nearly 40 years ago, suggested a type 
case with a perforated tin bottom, placed within another case; the dust 
would naturally drop from the upper to the lower case, and if the latter 
was provided with a concave and rounded bottom its collection and 
removal would be materially facilitated, especially since the introduction 
of vacuum cleaners. In spite of this practical suggestion, the writer has 
never seen such cases in use, and even in the Government Printing Office 
in Washington, an otherwise high-grade institution, the old style of cases 
are still in use, but are now cleaned by the vacuum system instead of by 
bellows as formerly. 
Monotyping and Linotyping.-Both of these processes, the former 
casting single letters and the latter an entire line, have superseded in all 
large printing establishments the old methods of type founding and type- 
setting. The work is nearly all done automatically by machines and 
hence the danger from dust, or handling of the type, has been greatly 
reduced. For reasons already given there is no danger from lead or arsen- 
ical fumes from the melting pots. The operatives, however, may be 
exposed to gas fumes and irritating acrolein vapors from materials used 
in fluxing the metal, such as wax. In monotype machines which operate 
directly over the metal pots, oil from the machine is liable to drip into 
the molten metal and aggravates the offensive acrolein vapors. All of 
this should be obviated by suitable hoods and exhaust flues connected 
with each pot; this method, however, must be regulated so as not to pro- 
duce an excessive draft and thereby overheat the metal. 
Of 47 linotypists in a newspaper plant where the gas from the lead pots is not 
carried off by an adequate suction apparatus 8, or over one-sixth, showed the pres- 
ence of carbon monoxide in their blood. The actual effect of such constant absorp- 
tion of small quantities of this gas should be studied further. (Alice Hamilton, U. S. 
Bur. of Labor Statis. No. 291, Dec., 1921.) 
Stereotyping.-In the process of stereotyping the type forms are 
placed in steam or gas, or preferably electric heated presses, for the pur- 
pose of making a negative impression upon paper specially prepared for 
the purpose. The impression or matrix is placed in suitable moulds, into 
which the molten metal is either poured by a ladle or pumped auto- ELECTROTYPING, LEAD MELTING, ETC. 
251 
matically, until the desired thickness of the slab has been attained. This 
process, as well as the preliminary act of melting, necessarily involves 
handling of the lead and exposure to its toxic effects. 
The formed plates are subsequently trimmed. Dr. Manning of the 
Government Printing Office believes that the finishers of the plates, who 
handle only the smooth, hard, bright slabs run the least risk of lead 
poisoning. 
Electrotyping.-In this process an impression of the set-up type is 
made upon a layer of wax, both the form and the wax having previously 
been covered with plumbago to prevent adhesion of the surfaces. The 
wax matrix is then placed in a closed box and more plumbago is blown 
on it by means of compressed air, which is an extremely dusty process. 
Recently modern establishments have adopted a wet method which 
consists in the application of a liquid graphite-paste by means of a hand 
brush, or by having the matrix move automatically upon an incline, back 
and forth through the graphite mixture. Dr. Manning informs me that 
by this method the dust production has been reduced fully 90 per cent, in 
the Government Printing shop. Iron filings, followed by a solution of 
sulphate of copper, are next applied to the wax impression to form a plate, 
which is then immersed in the electrotyping solution to secure the desired 
thickness of copper deposit. When this is attained the copper plate is 
removed from the wax and thoroughly cleaned. It is then placed face 
downward in a tray and backed by pouring electrotype metal lead on it; 
all of which necessarily involves considerable handling of lead and expo- 
sure to irritating fumes. 
Lead Melting.-The men engaged in melting the new metal and old 
slugs are exposed to the risk of plumbism from handling the metal and 
breathing its toxic fumes under conditions referred to on page 249. The 
temperature of the room in which this process and type founding is carried 
on is also frequently above 86°F. 
In the Government Printing Office the melting is done in special rooms 
after the usual working hours and the men are shifted to other work at the 
expiration of one week. The melting pots are placed between open 
windows so as to insure copious ventilation, aided by revolving fans. 
It is said that the hoods interfere with the stirring of the metal. 
Summary.-The chief occupational diseases in the printing industry 
are tuberculosis, other diseases of the respiratory system, and plumbism. 
Diseases of the digestive organs are also quite common, and compositors 
and proofreaders not infrequently develop neurasthenia. Compositors, 
and all others obliged to maintain a standing position, are liable to develop 
flatfoot, varicose veins and ulcers. There is also evidence to indicate that 
the married women employed in this industry, probably as a result of 
lead intoxication, miscarry more frequently than women engaged in other 
occupations. According to Silberstein13 the percentage in Berlin in 
1905 was 2.4 and 1.7 respectively. According to the same author 252 
THE PRINTING AND PUBLISHING INDUSTRY 
inflammatory diseases of the skin are also more common in the printing 
industry, viz., 20 per 1000 against an average of 13 in other occupations. 
Eczema of the hands and forearms in the workmen who handle the type 
forms is evidently caused by the irritation of certain agents such as tur- 
pentine, petroleum, benzine, lye, etc., employed for the removal of 
printer's ink. Zellner and Wolff14 have called attention to the undue 
prevalence of these skin affections, and attribute them to trade sub- 
stitutes for the oil of turpentine, which was formerly almost exclusively 
employed. Among the substitutes were found inferior benzine, lye, 
poorly refined petroleum, and impure turpentine, called "pine oil." 
Of 37 samples of "pine oil" and other cleaning materials^examined 32, or 
87 per cent., contained impure benzine or lye, and the turpentine used 
was also found to be adulterated with impure benzine. It is well known 
that even pure oil of turpentine and refined petroleum may prove irritants 
to sensitive skins. According to an article in the J. A. M. A. (Nov. 26th, 
1921, page 1760), inquiries made of the larger printing and engraving firms 
of this country disclose the fact that although neither oil of turpentine 
nor a substitute is used, still the arms and hands of the pressmen develop 
skin lesions which vary from slight erythema to ulcerations. Some of 
the lesions present a dry and scaly appearance, while others are moist 
and vesicular. Some have a tendency to coalesce and spread, others are 
discrete. A study to determine the possible relationship of the dermato- 
sis to the use of inks was made by W. J. McConnell, (U. S. P. H. Reports 
36, 279, May 6,1921). 
The investigation disclosed the significant fact that the persons without eruption 
had oily skin, and all those afflicted were found to have dry skins. The fact that 
the inks retard healing after abrasion of the skin indicates the presence of some 
ingredients, perhaps of chromates, which aggravate an otherwise simple dermatosis. 
There is reason to believe that the driers in the inks, such as benzol may extract the 
oil from the skin, and if used also for cleaning purposes without gloves cause intensive 
irritation. The degree of the inflammation apparently depends on the dryness of the 
skin and the method of removing the ink. 
Preventive Measures.-Dr. McConnell recommends the following: 
Pressmen and all those who handle the inks or clean the plates-should be required 
to rub into the pores of the hands and arm lanolin or a mixture of equal parts of lanolin 
and olive oil supplied by the plant in the wash room. If the skin feels too greasy 
after thorough rubbing, the excess may be wiped off with a clean cloth. At the 
luncheon period these workers should be supplied with a mixture of saw dust and 
liquid soap (the saw dust should be moistened with the soap) which, together with 
warm water, will readily remove the ink without injury to the skin. The hands and 
arms should then be rinsed in plain warm water and thoroughly dried. Before 
entering the press-rooms, the first process should be repeated, and at the end of the 
shift the second or cleansing process should be repeated. The skin lesions respond 
readily to the treatment with calamin paint: Zinc ore (calamin and a silicate of zinc) 
pulverized and passed through a 100 mesh sieve) 3 parts; gelatin, 4 parts; glycerin, 
5 parts, water 6^2 parts. They were also given a copy of the following directions for 
using the calamin paint: Melt and paint over the part affected with a single thin layer 
of paint and before it has set, tap lightly all over with a piece of absorbent wool, so as BINDING ROOM PROCESSES-CHROMO-LITHOGRAPHY 
253 
to form a feltwork with the paint. Allow it to set completely before putting clothes 
over it. Leave it on until it begins to come loose; then peel off and apply more in the 
same manner, until the lesions are healed. 
Binding Room Processes.-The work is generally carried on in 
unfavorable surroundings, as regards light and air. Dust, heat and 
exposure to wood alcohol, from the shellac employed, constitute the chief 
injurious factors. Persons employed in folding heavy paper with their 
hands are liable to develop cysts of the wrist tendons in consequence of 
constant local pressure. 
Preventive Measures.-In view of the foregoing it is evident that the 
utmost precaution should be taken to reduce the dangers in printing 
establishments to a minimum. All processes involving the handling of 
molten metal should be carried on in the upper stories or in separate 
buildings, to facilitate the removal of injurious fumes by means of hoods 
and exhaust ventilation. 
Cleaning of electrotype plates for the removal of caked plumbago 
should be done by means of steam in a "boiling chamber" and the plates 
lifted in and out by hooks. This method, in vogue in the Government 
Printing Office, has reduced dust production to a minimum and also 
secured a thorough removal of the graphite. Perfect cleanliness of the 
establishment aided by vacuum cleaners should be observed. 
Light, air space, general ventilation including the stimulating effects 
of fresh outside air admitted to the rooms about once hourly, temperature, 
humidity, spittoons and facilities for personal cleanliness should be in 
harmony with modern ideas of factory sanitation. 
Chromo-lithography.-This growing industry affords employment to 
a large number of persons, including females and minors. The work is 
often carried on under unfavorable hygienic conditions as regards light, 
air space, and ventilation, which is all the more regrettable as some of the 
processes involve the employment of injurious agents, such as arsenic 
pigments, chromium, lead and bronze powder. In the room where the 
prints are made the air is usually charged with vapors of turpentine and 
benzine. 
The lithographic process varies in different establishments; the design 
or picture may be engraved by means of a diamond or steel needle upon a 
fine grained sandstone, generally imported from Bavaria, or the drawing 
may be made upon the stone with a greasy composition. In photo-lithog- 
raphy the printing surface is largely prepared by a photographic process. 
In all of the processes of chromo-lithography the stone is dampened on 
those portions of the design which are no't to appear in the first printing; 
this prevents taking the ink or colors. The actual application of colors, 
and press work, is performed by another set of operatives. 
According to Leiser15 in a total membership of 11,807 employes in this industry, in 
Berlin during 1904, 2002 males and 1840 females, or 32.6 per cent.,were reported sick, 
with 90. deaths; of the sick about 12 per cent, suffered from tuberculosis; 11 per 254 
THE PRINTING AND PUBLISHING INDUSTRY 
cent, had skin affections, especially obstinate forms of eczema caused by contact with 
acid dips, bronzing powder, toxic color pigments, impure turpentine, etc.; 10.5 per 
cent, of the sick suffered from disorders of the digestive system and 19 per cent, of the 
females were anaemic. There were 356 accidents, mostly contusions of the fingers con- 
tracted in press work. Cohen estimates that about 45 per cent, of the lithographers 
suffered from near sight or other visual defects. 
The operation of bronzing may be done by the dry or wet method by hand or 
machinery. The wet process by inks has not proved satisfactory from the artistic 
standpoint and machines are rapidly displacing the dry bronzing by hand. The 
machines print the designs in sizing and the sheets are fed into the bronzing machines 
from which, however, according to the Massachusetts Report of the State Board of 
Health,16 "in spite of their metallic coverings and exhaust ventilation the bronze 
powder escapes freely into the air. The boys who run the five machines wear hand- 
kerchiefs over the nose and mouth. They look pale and unhealthy and all show the 
characteristic green perspiration due to contact with bronze. The great majority 
of the employes appear to be healthy." (See also bronzing powder, page 350.) 
The danger from lead poisoning is quite pronounced in the manufac- 
ture of so-called lithographic transfers intended for decorative purposes on 
porcelain ware, ornamental glass for windows, art and enameled goods, 
etc. In this process metallochrome powder, often containing 50 to 60 
per cent, of white lead, is used. The work of rubbing the powder over the 
sheets of paper is usually done by females, many of whom show evidence 
of chronic lead poisoning; indeed it was not until several deaths from 
acute lead poisoning were reported in this industry that the real cause 
was discovered. 
Between 1895 and 1905, 46 cases were reported in Great Britain, and in the latter 
year 21 cases with 355 days of sickness occurred in one of the German establishments. 
Several cases were reported by the Illinois Occupational Diseases Commission in 1910. 
Since that time the dangers have been materially diminished as the "laying on" of 
the powder is now done on tables covered with a glass case, the hands protected with 
rubber gloves perform the work through suitable openings, and the dust evolved in the 
glass case is rapidly removed by exhaust ventilation.17 
Neisser18 points out another source of danger in this industry by 
reporting a case of double cataract in a man who melted over an open 
flame a color mixture composed of wax, stearin, Venetian soap, asphalt, 
pitch, turpentine and oil of lavender, mixed in the order named. The 
affection was attributed to the inflammable character of the vapors 
evolved during the melting process and the manufacturer has guarded 
against a recurrence of the evil by providing suitable exhaust ventila- 
tion and eye protectors. 
Engraving.-The work of engraving upon steel, copper or other 
material involves not only considerable eye strain, but also, in the 
absence of suitable work benches, a faulty position which interferes with 
the respiratory movements. Steel and copper plate engravers are also 
exposed to mercury, and makers of stamping devices and seals, to lead 
and the fumes of nitric acid. The latter agent is likewise employed in 
mints in connection with the coinage of money. According to Sommer- PHOTO-ENGRAVING, METAL ETCHING, PHOTOGRAPHY 
255 
feld, cited by Zadek,19 73.6 per cent, of all the deaths among this class of 
workers in Berlin were caused by diseases of the respiratory system, inclu- 
sive of 62.1 per cent, from tuberculosis; this is in part accounted for by the 
fact that so many weaklings engage in this pursuit. Visual defects, 
neurasthenia, and diseases of the digestive system are also quite common. 
Plate printers who have to look constantly at bright plates, suffer not only 
from eye strain but occasionally also from conjunctivitis and even 
retinitis. / 
Photo-engravers.-/-Photo-engravers handle benzol for dissolving- 
rubber films; alcohol and ether, in coilodium films; and strong acetic acid 
for the removal of films; they are also exposed to gas fumes and ammon- 
ium dichromate in sensitizing copper plates, and to ferric chloride and 
nitric acid fumes in etching. The Report of the Photo-engraver's Union 
for 1914, cited by Hayhurst,20 discloses the fact that out of 217 deaths 
since 1903, 88, or nearly 41 per cent., were due to tuberculosis. ? During 
the year 1914, five cases of bichromate and one case of cyanide poisoning 
were reported. Metol dermatitis is a characteristic occupational disease. 
In fact photo-engravers as a class are probably exposed to the greatest 
number of poisonous substances to be found in any single industrial 
calling. Metol is the trade name for methylamidophenol (see page 516). 
It is possible that some of the black or brown anilin colors are also used 
in printer's ink. 
Metal Etching.-In the etching process of zinc or copper plates nitric 
acid in the proportion of one part to four of water is used, evolving large 
volumes of nitrous fumes, which are distinctly injurious, unless the proc- 
ess is carried on under hoods equipped with efficient exhaust ventilation. 
There is also exposure to mercury in some of the processes, and etching on 
brass involves the use of chloride of mercury. 
Neisser21 reports that in one of the establishments at Nancy chromic 
and phosphoric acid was employed as a secret process in the etching of 
zinc plates, causing characteristic chrome ulcers on the hands, arms, neck 
and face in seven of the 45 persons engaged in the work. 
Photography.-Workers in photographic establishments, especially 
those engaged in the developing process are exposed to bad air and light 
and also to a number of industrial poisons, such as the bromine, chro- 
mium, metol, cyanogen, platinum, uranium, vanadium, anilin, and mer- 
curial compounds. They also handle more or less iodin, nitrate of silver, 
gold and copper sulphate, oxalic and pyrogallic acid. 
In an examination of 40 studios in Chicago by Dr. Karasek22 platinum 
paper was found to be the cause of eight cases of poisoning, characterized 
by "pronounced irritation of the throat and nasal passages, causing 
violent sneezing and coughing; bronchial irritation, causing such respira- 
tory difficulties as to preclude the use of the paper entirely for some 
individuals, and irritation upon contact with the skin, causing cracking, 
bleeding and pain." Metol poisoning characterized by an erythematous 256 
THE PRINTING AND PUBLISHING INDUSTRY 
rash of the hands and arms, occasionally involving other parts of the body 
and giving rise to ulcers, were found in 31 cases in this same study. Other 
interesting cases have been reported. (See J. A. M. A., Feb. 19, 1921, 
p. 540.) 
The developing process very frequently gives rise to inflammatory 
conditions of the hands (eczema) ulcers and pigmentation unless pro- 
tected by rubber gloves. 
Chrome compounds and anilin colors are also used in the composition 
of hectograph inks, and hence are a possible source of danger to the 
makers and users of the ribbons. 
REFERENCES 
1 Professor Martin Hahn.-Die Gesundheitsverhaltnisse im polygraphischen Gewerbe 
Deutschlands, etc., Berlin, 1910. 
2 Albrecht.-Roth's Compendium der Gewerbekrankh,. Berlin, 1904, page 56. 
3 Sommerfeld, cited by Silberstein.-Weyl's Handbuch der Arbeiterkrankh., 1908, 
page 255. 
4 Twenty-fourth Annual Report of the Bureau of Labor Statistics, New York. 
5 Hamilton, Alice, A. M. M. D. and Verrill, Charles H.-Hygiene of the Printing 
Trades, Bull of Bureau of Labor Statistics, No. 209, April, 1917. 
6 Roszahegyi.-Arch. f. Hygiene, Munchen and Leipzig, Vol. Ill, page 522. 
7 Fromm.'-Uber den bleihaltigen Staub der Setzereien. Hgg. Rundschau., 1898. 
8 Arbeit, aus d. Kaiserl. Gesundheitsamtes, Bd. XIII. 
9 Hahn.--Op. cit., pages 22, 58, 59. 
10 Oliver.-Bulletin Bureau of Labor, No. 95, July, 1911, Washington, D. C., pages 
65, 71. 
11 Hamilton, Alice.-Jour, of Industrial Hygiene, May, 1919, page 12 and June, 1919, 
page 93. 
12 Sternberg.-Med. Reform, 1906, Nos. 49, 50. 
13 Silberstein, R.-Weyl's Handbuch der Arbeiterkrankheiten, Jena, 1908. 
14 Uber die Ursachen der Hauterkrankungen in Buchdruckereien Ztschft. f. Hyg. and 
Infectionskrank., 1913, LXXV, page 69. See also page 1815. J. A. M. A., 
November 15, 1913. 
15Leiser.-Weyl's Handbuch der Gewerbekrankheiten, 1908, page 339. 
16 Report on the Sanitary Condition of Factories, Workshops, etc., 1907, page 80. 
17 Oliver's Dangerous Trades, London, 1902. 
18 Neisser.-Internal. Ubersicht fiber Gewerbehygiene, 1907, page 123. 
19 Zadek.-Weyl's Handbuch d. Arbeiterkrankh., 1908, page 141. 
20 Hayhurst, E. R.-Industrial Health Hazards and Occupational Diseases in Ohio, 
February, 1915. 
21 Neisser.-Internationale Ubersicht fiber Gewerbehygiene, Berlin, 1907, page 94. 
22 Report of the Illinois State Commission on Occupational Diseases, January, 1911. CHAPTER XI 
THE TEXTILE AND ALLIED INDUSTRIES 
BY GEORGE M. KOBER, M. D„ Washington, D. C„ and WILLIAM C. HANSON, M. D., 
Belmont, Mass. 
The Cotton Industry.*-According to the Statistical Abstract of 
the United States for 1921, there were 446,762 wage-earners in cotton 
mill operations. The work of cotton-mill employes involves more 
or less constant confinement in a dusty atmosphere even in the best 
regulated mills. The presence of dust in the air of cotton workrooms, 
however, does not appear to be a prominent feature except in the first 
few processes which cotton undergoes after being taken from the bales. 
The intrinsic danger in the industry in this respect lies chiefly in the open- 
ing, picking, and carding processes, the danger varying with the construction 
of the mill, the amount of dirt and other impurities in the stock, the means 
of removing the dust, and some other factors.1 A careful consider- 
ation of other factors than cotton dust which affect injuriously the health of 
the workers shows that too little attention has been given to the evil con- 
sequences of poor light (especially in certain departments), excessive heat, 
nauseating odors, irritating gases, the products of gas combustion, the lack 
of proper means of ventilation, the failure to regulate properly the intro- 
duction of artificial moisture, and want of cleanliness. 
By eliminating the avoidable dangers and the associated unnecessary 
conditions of the cotton processes the exact danger caused by the cotton 
dust can be more accurately judged. 
Light.-Poor light may itself reduce the physiological resistance to dis- 
ease, or it may be a concomitant of a number of insanitary influences 
which affect the health of the worker. A detailed study by the writer of 
several hundred cotton mill buildings in Massachusetts showed con- 
clusively that too little thought had been given, in mill construction, to 
providing for light in accordance with the kind of work to be done in a 
given room. Some of the finer goods mills were remarkably well con- 
structed, however, and a few very old buildings where coarse and colored 
goods were manufactured were operated under commendable conditions. 
Many buildings had rooms of old construction, with low ceilings, small 
windows and small panes of glass. Some of these rooms were narrow and 
admitted fair light from the sides; but some were wide, and some were 
basement rooms which lacked both an ample supply and an even dis- 
tribution of light. 
* By Wm. C. Hanson, Belmont, Mass. 
257 258 
THE TEXTILE AND ALLIED INDUSTRIES 
Aside from the question of mill construction, two important factors 
may contribute to poor light viz.: (1) neglect to keep the ceiling and walls 
clean and white; and (2) infrequent washing of windows, allowing them to 
go unwashed in some instances for several years. It is often the case that 
prismatic glass of different kinds and sizes is introduced into poorly lighted 
rooms; but unless this glass is kept reasonably clean, it is of little value. 
In poorly constructed and neglected rooms, with or without prismatic 
glass, artificial light is not uncommonly used even on bright, sunny days 
in the late morning or early afternoon hours; and in such rooms incandes- 
cent bulbs or gas jets are likely to be found. Even if artificial light is not 
used until the late afternoon hours, there is then much variation as to the 
time and method of lighting and the kind of light in use. In some 
instances the light should be turned on half an hour, or longer, before the 
engineer sees fit to do so; yet the employes during this time are supposed 
to continue their work with the same degree of accuracy and rapidity as 
with good light. 
It is a well-established fact that either the overuse of the eyes, or the 
use of eyes under bad conditions, may give rise to eye fatigue or to eye 
strain; and many eye specialists believe that at least 80 to 90 per cent, of 
headaches are dependent upon eye strain. 
With these facts in mind, it is impossible to ignore the probability that 
many individuals working by gaslight, or even electric light, in dirty, un- 
painted, overheated rooms, with impure air and excessive moisture, for 
10 hours a day or merely for the last 2 hours during the day, use up a great 
deal of nervous energy, and suffer from eye fatigue, or eye strain, and its 
consequences. 
In the weaving and spinning departments there are two distinct 
causes of possible injury to the employes, viz., (1) insufficient light and 
(2) dust. 
Some employes may be exposed to both sources of injury, although 
it is not usual to find much dust in a weave room. The department where 
reasonably good light is important, in which most commonly there is con- 
siderable dust, is that of ring spinning. Here, on account of the character 
of the machinery and the way in which it is placed, there are very com- 
monly dark alleys, so that the work of "finding the ends" becomes some- 
what trying to the eyes, particularly in rooms that are poorly lighted.* 
In both weaving and spinning departments there are a number of 
other insanitary influences which may affect the health of the workers, the 
effects of any one of which are not susceptible of correct measurement. 
The spinning rooms are often excessively hot; the temperature in the 
* T. C. Bridge, in the Ann. Rep. Chief Inspect. Factories, etc., of Great Britain, 1919, 
calls special attention to the frequency of twisters' cramp in the cotton industry. Weak- 
ness and loss of power of the thumb (inability to finish twists of the ends) is the prominent 
symptom with pain generally referred to the base of the thumb. Fifty per cent, of the 
men examined showed an unusual flattening or apparent wasting of the muscles of the 
ball of the thumb. (Jour. Ind. Hyg., Feb., 1921, Abst., p. 191.) COTTON WEAVING AND SPINNING 
259 
winter months is commonly above 90°F., and occasionally above 100°F. 
The heat generated by the friction of the machinery in a ring-spinning 
room is at least sufficient to keep the room at a good spinning temperature 
in the winter months, provided the room is at a proper temperature on 
starting in the morning. 
Although in the majority of the ring-spinning rooms some means of 
introducing artificial moisture is adopted, the methods of introducing the 
moisture vary considerably, while in some rooms no artificial moisture is 
introduced. In a considerable number of spinning and a large number of 
weave rooms the means of introducing moisture is by the old steam vapor 
pot, which many agents say is a detriment to a mill, both because it 
permits excessive steam and heat, and because the regulation of humidity 
is practically impossible. In addition, therefore, to poor light and some 
dust in many of the weave rooms and to considerable dust and poor 
light in many of the spinning rooms, there is commonly an excess 
of moisture with unnecessary heat in weave rooms, and excessive heat 
with frequently undue moisture in spinning rooms. Some spinning 
rooms have no means of artificial moisture; the air in these rooms is, as a 
rule, very dry. 
A weave room with poor light, unnecessarily high temperature, with 
some dust and an excess of moisture, is not, from a sanitary point of view, 
a desirable room to work in; neither is a spinning room with considerable 
dust flying about, together with excessive heat and either undue moisture 
or no artificial moisture whatever. Add to these unhygienic influences 
two prominent factors which enter into health conditions of both weave 
and spinning rooms, viz.: (1) want of cleanliness and (2) lack of provision 
for a plentiful supply of fresh air, and an exceedingly undesirable class of 
rooms is represented which is conspicuously common everywhere among 
weaving and spinning mills. In short, the conditions commonly met 
with in weave and spinning rooms are: (1) Poor light. (2) Presence of 
carbon dioxide and carbon monoxide in the air. (3) Non-regulation or 
unscientific and unsatisfactory regulation of artificial moisture: (a) 
excess of moisture, undue heat; or (6) no artificial moisture, excessive 
heat. (4) Dust from the cotton and from "sizing," etc. (5) Want of 
cleanliness. (6) Want of provision for a plentiful supply of fresh air. 
The presence of dust in the air of workrooms is a prominent feature in 
its influence on health. Aside from dirt and other impurities which may 
be in the stock, the vegetable dusts are inimical to health. Those opera- 
tives in cotton mills who are peculiarly sensitive to unhygienic influences 
may become seriously affected through the constant irritation of cotton 
dust in the upper air passages, giving rise first to dryness of the throat and 
later to cough and expectoration. There are many departments in which 
processes are conducted which expose the employes to dust, but the 
weaving, spinning, carding and waste rooms illustrate the important 
unhygienic conditions commonly associated with this disturbing element. 260 
THE TEXTILE AND ALLIED INDUSTRIES 
In estimating the effects of dust upon health, the following considerations, 
among others, are to be borne in mind: 
1. Grade of stock used, e.g., quality of cotton. (2) Quantity of 
dust in a given room. (3) Whether the dust is constant. (4) Type of 
■construction of the room. (5) System of management. (6) Number 
and kinds of other unhygienic influences present. (7) Means of ventila- 
tion. (8) Health and susceptibility of the individual. 
In some weave rooms the air is so filled with minute bits of dust as to 
present a hazy or "smoky" appearance throughout the room, and parts 
•of the room are covered with the small particles which have settled there- 
on; while other weave rooms are practically free from such dust, there 
being merely a slight amount of lint or dust of microscopic fineness. 
Dust in ring-spinning rooms is more constant and is greater in amount 
than in weave rooms. In a fine-goods mill, in which a high quality of 
cotton is used in a properly constructed and well-regulated room, the 
amount of dust present is comparatively unimportant, from the point of 
view of health. On the other hand, in a coarse-goods mill, where waste 
stock is used in a low-studded and generally neglected room, the amount, 
constancy and character of the dust is such as to suggest the probability 
of real danger. 
While in both weave and ring-spinning rooms there are many unhy- 
gienic factors, the principal features of the card room are (1) the amount 
of dust and (2) lack of proper ventilation and effective means of removing 
the dust. Cotton dust in the card room varies greatly both in quality 
and quantity. It is always considerable, owing to the carding process of 
freeing and cleaning the material. In some mills it is enormous in amount, 
with considerable dirt as a concomitant. The quantity of dust is com- 
monly sufficient to cause a distinct cloudiness of the atmosphere, which, 
in a room lacking proper ventilation, is a serious menace to the health of 
the operatives. 
In the assorting or waste-room "sweepings" are picked over and the 
different grades separated. Here may be found numerous kinds of waste 
and dirt, including that which comes from the floors of the card and spin- 
ning rooms, and, of most importance, sputum in large quantities, which 
may contain the exciting causes of infective diseases of the respiratory 
tract. 
A comparison of the important constant or possible unhygienic 
influences in the ring-spinning and carding departments, with emphasis 
upon the dust in these rooms, is as follows: 
Ring-spinning.-(1) Considerable dust (constant). (2) Infectious 
dust (dried sputum). (3) Excessive heat (with artificial moisture). 
(4) Excessive heat (without artificial moisture in some rooms). (5) 
Want of provision for a plentiful supply of fresh air. (6) Poor light. 
(7) Carbon monoxide gas, and excessive amounts of carbon dioxide from 
respiration and combustion. COTTON CARDING, ETC. ARTIFICIAL MOISTURE 
261 
Carding.-(1) Dust (abundant and continuous where old methods of 
card shipping are in use). (2) Infectious dust (dried sputum). (3) Want 
of provision for a plentiful supply of fresh air. (4) Carbon monoxide 
gas, and excessive amounts of carbon dioxide from respiration and com- 
bustion. 
Card Stripping.-The introduction of the 11 dustless cotton card 
stripping apparatus,"2 invented and placed on the market in 1911, 
prevents an unusual and excessive amount of cotton "fly" and fine dust 
(not yet removed from the cotton) from flying in the air of the carding 
room. In fact, the stripping device is fitted so perfectly to the card on 
the one end and to a dust-tight patented machine on the other that 
practically no dust escapes into the air of the workroom. The use of 
the apparatus requires a little more time than the ordinary stripping 
roll consumes, but the extra time is more than offset by the improved 
sanitary conditions in the workroom and by the better health of the 
employes. This card stripping apparatus is now in use in many cotton 
mills in Massachusetts and throughout New England and the Southern 
States. 
Artificial Moisture.-Reference has been made to the introduction 
and use of artificial moisture. In England certain localities have yielded 
climatic conditions which have been very favorable to the manufacture of 
textile fabrics. In this country within recent years systems of artificial 
humidification have been installed in most of the mills less favorably 
located in order to increase the moisture in the air of the rooms. While' 
a certain amount of moisture gives an elasticity and smoothness to the- 
fibers which may then be carded, combed, spun and woven more easily 
and evenly, too much moisture is not only detrimental to many of the' 
operations but is also injurious to the workers. 
The two simplest but practically obsolete methods of introducing 
moisture into mill rooms are (1) the water sprinkling or "digging" 
method, by sprinkling water upon the floor and (2) the use of steam.. 
The methods now generally in use are evolved from one or the other of' 
these practices. They include the spray moistures in a large variety of' 
patterns. The types most commonly found in Massachusetts mills are 
those in which a spray is projected directly into the air in the room. A 
discussion of the bacterial condition of the air in picker, carding, spinning 
and weaving departments of certain cotton mills, with tables showing 
average results of examination of air in these departments, is contained 
in a report by H. W. Clark to the Massachusetts State Board of Health 
in 1913 on "A Study of the Hygienic Condition of the Air in Textile Mills 
with Reference to the Influence of Artificial Humidification." 
In spite of the modern method of humidification the writer found, 
from an investigation of a very large number of cotton mills, that the 
raising of humidity was done in a very unworkmanlike manner. Scarcely 
any effort was made on the part of most manufactures to ascertain the; 262 
THE TEXTILE AND ALLIED INDUSTRIES 
definite conditions with respect to heat and moisture favorable to weaving 
and spinning, by the use of accurate thermometers and hygrometers. 
In the great majority of instances where hygrometers were used the instru- 
ments were untrustworthy. The writer is of the opinion that most of the 
men in mills, who have the care of the ordinary stationary wet and dry 
bulb thermometer for determining the atmospheric humidity, either 
neglect to keep them in order or fail to take accurate records. 
A few agents or superintendents of mills have made extensive inquiries 
as to what degree of humidity for a given temperature constitutes the 
best working conditions. These men have used the self-registering hygro- 
meter, or psychrometer, and the "sling hygrometer" with very promising 
results; and one of them stated that "for quickly and accurately deter- 
mining the actual moisture and temperature conditions of a room, the sling 
hygrometer leaves little to be desired for mill use." 
The diseases with which cotton mill operatives appear to be most 
commonly afflicted, and from the effects of which become seriously 
impaired in health are: Pulmonary tuberculosis, pneumonia, asthma-■ 
frequently with bronchitis, influenza and rheumatism. In Massachusetts 
the reduction in the death rate from pulmonary tuberculosis during recent 
years has been much less in the four textile centers, Fall River, Lowell, 
New Bedford, and Lawrence, then in the State in general. Other factors, 
however, enter into the question as to the harmfulness of the cotton indus- 
try to health and its effects on length of life. The sanitation in all of 
these cities is not on the same plane. The homes and immediate sur- 
roundings of the workers are not alike. The personal characteristics, 
nationality, physique, educational opportunities and habits, differ; 
moreover, we have no accurate statistics covering the illnesses of cotton 
workers in connection with the particular kind of work done and the 
length of time spent at that kind of work. There is probably no industrv 
today that we know less about in its effects on health and longevity than 
the textile industry, of which the cotton industry is a principal part. 
While we may reason from death returns that tuberculosis and pneumonia 
are the diseases most prevalent among mill operatives, does it follow that 
these diseases, known to be prevalent among so many different types of 
workers in various industries, are the direct result of mill life and work? 
The writer considers this one of the most important and far-reaching 
problems in the study and researches of occupational hygiene. (For 
mortality statistics see page 982.) 
Woolen and Worsted Manufacture.*-This industry includes the 
manufacture of woolen and worsted goods, the production of wool felt 
goods and of wool hats. During the 1910 U. S. census 175,171 wage 
earners were employed of whom 13 per cent, were spinners, 22.2 per cent, 
weavers and 64.7 per cent, in other capacities. The number of wage 
earners included 75,869 females and 9576 children under 16 years of age. 
* By George M. Kober. WOOLENS AND WORSTEDS-CARPETS AND RUGS 
263 
U. S. Statistical Abstract for 1921 gives a total of 166,787 wage earners 
for woolen and worsted manufactures. The general processes employed 
in the manufacture of woolen and worsted goods are very much of the 
same character as in the cotton textile industry. 
The most important hygienic features are connected with the sorting, 
carding, combing, spinning, weaving, dyeing and finishing processes. 
The wool is usually sorted by females on benches with perforated tops 
or on tables covered with wire mesh, through which dust and dirt falls into 
a box beneath. This operation is of special interest, not only on account 
of its dusty nature, which gives rise to catarrhal affections, but also 
because of the danger from anthrax infection. Of 261 cases of anthrax 
infection tabulated by Dr. Legge 88 occurred in this industry. The 
disease was formerly even more common than now and was commonly 
spoken of as "woolsorter's disease." Those engaged in wool scouring 
especially in the extraction of oil by means of sulphur chloride, carbon 
disulphide, benzine, benzol, etc., are exposed to these industrial poisons. 
Sulphuric or hydrochloric acid are also used in the cleaning process. 
Manufacture of Carpets and Rugs.*-The weaving of carpets and 
rugs involves many of the same dusty processes incident to the textile 
industry in general. The materials employed differ, however, more 
widely as wool, cotton and hemp or jute are used singly or in combination. 
The wool used in this industry in generally of a short and coarse fiber, and 
it is quite probable that the amount of dust is greater in carpet and rug 
mills than in other branches of the textile industry. In some establish- 
ments the raw materials are picked, carded, twisted, and spun, while in 
other factories the yarns have been prepared elsewhere. The bales of 
yarn are opened and the yarn is dusted by machinery, which gives rise to 
considerable dust and is especially injurious if poisonous dyes have been 
used. The State of Massachusetts in 1900 limited the use of arsenical 
pigments to 0.10 grain per square yard, and anilin dyes have superseded 
the use of chrome lead dyes to a great extent. (See also dye-works, 
page 267.) The operation of carpet weaving is not only a very dusty 
process but requires great care in the prevention and detection of flaws 
and skips. After leaving the loom the carpet or rug is carefully inspected, 
sheared and brushed. The shearing process is especially a dusty operation. 
The work of carpet weaving is hard, but the death rates compare favorably 
with those of other textile workers. The English statistics show that the 
comparative mortality was 873, which is 8 per cent, below the standard. 
Consumption was 22 per cent, in excess of the normal and other diseases 
of the respiratory system were 11 per cent, in excess. Hoffman's statis- 
tics based upon 155 deaths among carpet and rug makers, show that 23.9 
per cent, were from consumption, and 16.9 per cent, from other diseases 
of the respiratory organs. Thompson has seen a few cases of anthrax 
among weavers of rugs and carpets in eastern New York. 
* By George M. Kober. 264 
THE TEXTILE AND ALLIED INDUSTRIES 
Dr. Alice Hamilton in her studies of lead poisoning in the textile industry cites Edsall 
to the effect that he had only seen one case of plumbism in 5 years, in a woman, though 
thousands of them work in the great textile mills of Kensington. Of 98 industrial cases in 
men, only one was a weaver and he had probably not contracted the poison from his work. 
The only case of plumbism from lead dyed textiles that Dr. Hamilton heard of was sent 
her by Dr. D. J. Miller of Atlantic City. He saw a woman with profound neuro-retinitis 
as one symptom of a bad case of lead poisoning, and her father also had typical lead poison- 
ing though without eye involvement. The woman tore old window shades into strips and 
wound the rags into balls, and her father wove them into rag rugs. 
Flax and Linen.*-Employes in flax textiles are apparently more 
exposed to dust and various diseases of the respiratory organs than those 
in woolen mills. This is especially true of the men or boys who attend the 
"heckling" machines. 
The work, especially the spinning, is often carried on in a hot and 
humid atmosphere, which predisposes to diseases. According to Oliver3 
recent employes suffer from so-called "mill fever," which lasts from 2 to 
3 days and is characterized by rise of temperature, malaise, nausea, 
vomiting and headache. This affection is attributed to the disagreeable 
odor given off by the oil, and the combined effects of heat and humidity. 
According to Lehmann,5 a febrile affection, accompanied by cough and asthma, among 
weavers in English cotton mills, has been attributed to the inhalation of mould-fungi 
(Aspergillus) as the disease appeared coincident with the abandonment of treating the 
weft with a solution of zinc chloride. Koelsch cited by Lehmann appears to think that the 
mill fever in flax textile workers is probably caused by a similar organism. The symptoms 
described as " mill fever" are usually ushered in by chilly sensations; muscular pains, fever, 
bronchial and nasal catarrh have also been observed in hemp, shoddy, jute and flock 
workers, and we are inclined to believe with Landis that they are the effects of protein 
poisoning in extremely susceptible persons. This may also be true of the asthma observed 
by Collis and Greenhow cited by Oliver3 among cotton carders and the asthma and bron- 
chitis caused by dust formed from the husk of vegetable fibers referred to by Collis and 
Greenwood.13 
The Mucor corymbifer, a mould fungus sometimes found in wheat bread has also been 
found in the ear of persons employed in the "sizing rooms" of cotton mills, probably due 
to the lodgment of a few drops of "sizing" (starch and dextrin solution). Lehmann5 states 
that the fungi are readily destroyed by a 2 per cent, solution of silver nitrate, or salicyl- 
spirit. 
Accidents from machinery, "flat-foot," varicose veins, and ulcers 
from prolonged standing, are not infrequent. Flax workers are very 
liable to suffer from eczema and also from a peculiar ulceration of the skin, 
caused by the irritant effect of lactic and butyric acids which are used in 
some establishments, in a solution, during the spinning of the thread. 
The drippings from this solution sometimes get on the barefeet of the 
employes and produce similar effects (Hazen). These ulcers have been 
repeatedly observed by Glibert in Belgium, but not by Dr. Purdon of 
Belfast, indicating that the process very likely differs in different countries 
and establishments. Dr. Purdon describes a peculiar skin eruption which 
affects the arms and face of the workers who remove the full bobbins from 
the spinning frames. The eruption resembles smallpox and is attributed 
to the irritant effects of flax, water and oil. Callosities on the index- 
* By George M. Kober. SILK AND LACE WORKERS 
265 
fingers of "hecklers," and painful affections of the nails of the great toe in 
men who work barefooted, are not infrequent. 
The phthisis death rate in Belfast4 with its 30,000 persons engaged in 
the linen industry was 4.1 per 1000, against 1.4 for the whole of England 
and Wales, and 2.1 for Ireland. According to Schuler and Burkhardt 
1000 linen spinners furnish annually 221.6 cases of sickness; 1000 weavers 
202.7. Female operatives suffer even more, the sick rate being 249.5 and 
334.4 for the respective occupations. 
Silk Workers.*-According to Lehmann5 the culture of silk worms 
apart from disagreeable odors is without hygienic interest. The opera- 
tives engaged in spinning the raw silk from the cocoons owing to the 
softened condition of their hands contract the so-called "mat desbassines" 
characterized by an erythema covered with small vesicles which later 
become pustular and extremely painful. The affection usually runs 
about 40 days and is believed to be caused by a poison similar to can- 
tharidin, which is present in nearly all chrysalides, and which possibly 
is also responsible for the swelling of the face and inflammation of the 
eyes observed in some of the female workers. A certain degree of 
immunity is acquired after a moderately severe attack, and treatment is 
usually more successful after the affliction has reached its height. 
I was surprised to find that silk weavers in this country have an unusually high 
tuberculosis death rate, viz. 44.5 per cent, f The rate for lace workers is 49.2 per 
cent. Since acetate of lead is used for "weighting" these fabrics, it is possible that 
an insidious form of lead poisoning is an important predisposing cause. The per- 
centage of deaths from tuberculosis according to the experience of the Prudential 
Insurance Co. in knitting mill workers is 22.1, in carpet weavers 32.7, in other weavers 
34.7 and in spinners 42.5. The Metropolitan Life Ins. Comp, reports a percentage 
of 22 for male and 35.5 for female textile workers against an average of 14.8 per cent, 
in the general population. 
The process of sucking thread into the weaver shuttles as an agency in the 
transmission of communicable diseases became known in this country as the kiss of 
death. In 1911 Massachusetts forbade the use of any form of shuttle which requires 
the employe to place it to his or her lips or mouth in threading it (Andrews). 
(For artificial silk see page 276.) 
Lace Workers.*-An excellent description of the manufacture of lace 
by machinery will be found on page 746, Bulletin of Labor No. 79, 1908. 
This industry, which is chiefly carried on in Nottingham, consists of lace 
making proper, finishing, including dressing, gauffering, bleaching and 
dyeing. Arlidge considers the process of "gauffering" as particularly 
injurious, chiefly because the machines employed are heated by 
gas. Excessive heat and humidity are injurious factors in some of 
the departments. 
* By George M. Kober. 
t Dr. L. B. McBrayer, after making a survey of a Silk Mill Village (Am. Rev. Tuber- 
culosis, Feb., 1921), concludes that "the silk mill per se was not responsible for the tuber- 
culosis, but that it was a matter largely if not wholly of contact infection." 266 
THE TEXTILE AND ALLIED INDUSTRIES 
This occupation involves little or no exposure to dust and the death 
rate from consumption among lace workers in Great Britain in somewhat 
below the average frequency in other branches of textile manufacture. 
But they show a marked excess in the mortality from cancer, alcoholism, 
diseases of the liver, nervous and circulatory diseases. The Leipsic sta- 
tistics show a sickness rate of 620 days per 100 male workers and 910 for 
female workers, with a low mortality hazard of 0.35 per cent, and 0.54 
per cent, respectively. 
Manufacture of Cordage, Twine, Jute, Etc.*-This industry includes: 
(1) the manufacture of rope, binder twine, cordage; (2) gunny cloth and 
other goods in which jute is the principal material; (3) crash towelling, 
linen thread, etc., made chiefly from flax; and (4) the manufacture of 
cotton belts, nets and seines. During the 1910 U. S. census 27,214 per- 
sons, including 1763 children, were engaged in this industry, of whom 
51.8 per cent, were males and 43.2 per cent, females. In 1919, the 
census reported 17,622 wage earners in the cordage and twine industry. 
Rope Makers.-Diseases of the respiratory organs have always been 
excessive among rope makers. Ramazzini over 200 years ago declared 
that hemp and flax breakers and combers suffered from a peculiar cough 
and were short winded, which he attributed to the inhalation of dust. 
According to Hirt 42.3 per cent, of all the sickness in rope makers were 
diseases of the respiratory system. It will be well to look out for symp- 
toms of heckler hemp fever, closely resembling brass founders' 
ague, bronchial asthma and other signs of protein intoxication. The 
primitive methods of rope making have been displaced by machine work, 
but it is very doubtful whether this has been of an special benefit to 
the operatives, as most of the dusty work was formerly done out-doors. 
The raw material arrives at the factory in bales, which on opening and 
shaking apart, emit considerable quantities of dust. After shaking, 
ordinary jute and hemp are run through softening machines, in which, 
according to the Massachusetts State Board of Health,6 "they are mois- 
tened with an emulsion of oil and water, preparatory to carding. Old 
rope, gunny bagging and twine are run through machines which pick the 
fibers apart as a preliminary to other processes. Opening, picking, soften- 
ing and carding are exceedingly dusty processes, and the dust is very irri- 
tating to the air passages. A fairly large proportion of the operatives 
show the effects of their employment, looking pale and sickly." 
Apart from dust inhalation, the employment of boiling tar in the 
manufacture of rope and oakum, may produce tar itch. Skin rashes, 
caused by the oil and coloring matter employed, are not uncommon. 
English statistics show that the mortality from consumption among 
cordage makers is excessive at ages 20-34 and 55 years or over. The 
general death rate is also in excess of the normal mortality of occupied 
males. Hoffman's7 statistics based upon 109 deaths from all causes 
*By George M. Kober. ROPE MAKERS-DYE WORKS 
267 
among cordage makers, show that 25.7 per cent, were caused by consump- 
tion and 8.3 per cent, by other respiratory diseases. The statistics of the 
Infirmary at Dundee which is the seat of the jute industry in England 
show an undue prevalence of lobar pneumonia among the operatives. 
Oliver8 states that deafness caused by excessive noises, and impacted 
ear wax, is a common complaint. He also refers to the dwarfiness and 
anemic condition of the Dundee employes, and justly dwells upon the 
baneful effects of female and child labor in this industry. The same 
author mentions the fact that several cases of tetanus were traced to the 
raw material imported from India, the organism having been recovered 
from the machinery dust. 
Franz Kazda (Zentrbt. f. Gewerbehyg., May, 1922) describes a heretofore 
unknown occupational disease in a rope maker who had to swing a heavy knife with 
the right hand and developed, after he began this work, a large mass on the left 
thoracic wall. This was composed of connective tissue.. . . There was a history of 
peptic ulcer, followed by symptoms of pyloric stenosis. Operation confirmed the 
diagnosis and a gastro-enterostomy gave relief. The trauma of the strain on the 
thoracic wall from swinging the heavy knife suddenly is thought to have caused 
undue motion of the stomach about the pylorus at a fixed point, with resulting 
irritation and predisposition to ulcer formation. (E. L. Sevringhaus, Jour. Ind. 
Hyg., Jan., 1923, Abst. p. 140.) 
Dye Works.*-Cases of poisoning by dyes are becoming less frequent 
in this country on account of educational methods and proscriptive regu- 
lations against the employment of arsenical coal-tar dyes. Occasional 
cases still occur from arsenite of sodium, which is used for fixing coal-tar 
dyes in Turkey red dye works, and also from orpiment dyes, which give 
off arseniureted hydrogen gas and are likewise productive of eczematous 
affections of the skin. Much harm also results from the employment of 
lead salts, especially in calico printing, and from the use of chromate of lead 
in dyeing yarns, etc. Cazaneuve9 has found 10 per cent, of chromate of 
lead in cotton yarn and as high as 18 per cent, in woolen yarn, and in the 
dust of rooms where the yarn was worked up 44 per cent. The women 
who handle and pull the yarn are literally covered with yellow dust, and 
quite a number suffer from the combined effects of lead and chrome. 
Clayton10 has described a number of cases of lead poisoning in this 
industry. Among other injurious mordants are antimony and tin 
compounds. Ammonia, oxalic acid, picric acid, sulphuric, hydrochloric 
acid and chloride of lime are also used' in dye works. Cases of poisoning 
in anilin black dyeing have been reported by Deardon11 of Manchester. 
Neisser12 cites the Report of a Medical Inspector in England upon the 
effect of anilin oil in black dyeing works, and also the effects upon the skin of 
chromic acid and the bichromates in these establishments. He examined 
200 employes, many of whom suffered from anemia, headache, digestive 
derangements, heart-burn, dizziness, palpitation of the heart, loss of will 
* By George M. Kober. 268 
THE TEXTILE AND ALLIED INDUSTRIES 
power, excessive mucous secretions and grayish discoloration of the lips, 
all of which symptoms were attributed to the toxic effects of anilin. Of 
82 persons employed in the padding, washing and drying processes, 34 per 
cent, had gray lips, 20 per cent, were anemic and 14 per cent, suffered 
from the effects of chrome. 
Apart from exposure to industrial poisons, the work is exhausting 
especially in summer on account of the heat and humidity; it is also sloppy 
work and hence colds, catarrhal, rheumatic and neuralgic affections are 
not uncommon. 
Preventive Measures.-The use of all poisonous dyes and mordants 
should be prohibited. Until this is accomplished the following safe- 
guards recommended by the British Medical Inspector should be carried 
out. (1) Mechanical suctional ventilation, (a) at the machines where the 
cloth is being dyed, (&) at the machines where the cloth passes through the 
bichromate solution and (c) at points where there is danger from chromate 
dust. (2) Protective clothing and frequent washing of the working suits. 
(3) Dressing-rooms and lockers for street clothing. (4) Suitable wash 
rooms. (5) Special lunch rooms. 
The use of respirators in dusty processes and of vaseline to the skin 
are indicated. All dye works should have cement floors, well drained, 
wooden slats to stand upon during wet work, protective clothing, wooden 
shoes and good overhead ventilation. 
REFERENCES 
1 For illustrated description of processes in Cotton Industry, see Bull. U. S. Dept, of 
Labor, Bureau of Labor Statistics, No. 127. 
2 For illustration see Practical Hygiene, Harrington-Richardson, page 650. 
3 Oliver.-Diseases of Occupation, London, 1916. 
4 Ferris, G. H.-Journal of State Medicine, March, 1895. 
6 Lehmann, K. B.-Arbeits. u. Gewerbehygiene, Leipzig, 1919. 
6 Report of the Massachusetts State Board of Health upon the Sanitary Condition of 
Workshops, Factories, etc., 1907, page 46. 
7 Hoffman.-Bulletin Bureau of Labor, No. 79, 1908. 
8 Oliver.-Diseases of Occupation, E. P. Dutton & Co., New York, 1916. 
9 Zeitschft. f. off. Gesundheitspfl., cited by Rambousek, London, 1913, page 58. 
10 Clayton.-Brit. Med. Journ., 1906, Vol. I, page 310. 
11 Deardon.-British Med. Jour., 1902, Vol. II, page 750. 
12 Neisser.-Internal. Ubersicht uber Gewerbehygiene, Berlin, 1907, pages 74-75. 
13 Collis and Greenwood.-The Health of the Industrial Worker, P. Blakiston's Son & 
Co., Philadelphia, 1921, page 300. CHAPTER XII 
THE RAG, SHODDY AND PAPER INDUSTRIES 
GEORGE M. KOBER, M. D„ Washington, D. C. 
The Rag Industry.-Rag sorting is an old industry and the work is 
generally performed by women, whose duty is primarily to divide the 
rags into linen, cotton and woolen rags after which they are baled. All 
bales of rags are opened at the mill and the contents are placed in a beating 
or thrashing machine which separates the rags and shakes them thor- 
oughly. This process is attended by the escape of more or less dust and 
the quantity naturally varies with the cleanliness of the stock. 
The rags are conveyed from the duster or thrasher through a chute to 
the sorting room, where they are picked over by women who sort out all 
cotton, linen and silk mixtures, and remove buttons, whalebones, rubber, 
buckles and other foreign matter. The sorting tables have a box-like 
top, lined at the bottom with wire meshing through which dust and fine 
particles escape to receptacles below. 
It has been held for a long time that the germs of infectious diseases, 
like smallpox, anthrax, cholera, scarlet fever, tuberculosis, diphtheria, and 
septic germs may cling to body and bedclothes and prove a source of 
danger to employes in the rag and paper industry. The danger, while 
perhaps overrated, is nevertheless real and would be much more evident, 
if federal legislation did not prevent the importation of rags without pre- 
vious disinfection. Some of the states also require evidence of successful 
vaccination in persons engaged in the rag industry, or those employed 
in the manufacture of paper from foreign and domestic rags. 
We have no published morbidity and mortality rates for the rag 
industry in this country. Wittgen (Zentr. Gewerbehyg., 1915, page 245), 
cited by Lehmann1 gives an average of 26 sick days per annum. A Ger- 
man firm by introduction of mechanical exhaust ventilation reduced the 
amount of sickness from 20 per cent, to 5 per cent, and increased the 
output of the sorters fully 10 per cent. 
Shoddy is made from woolen rags. For this purpose the rags are 
treated in a large vat with dilute sulphuric or hydrochloric acid, which 
destroys whatever vegetable or cotton fiber there may be present and 
leaves the wool fiber intact. This process is known as carbonizing and 
may cause injury from exposure to acid fumes, unless the process is 
carried on in so-called carbonizing stoves which are ventilated and con- 
nected with coke condensers. Rambousek2 considers it essential that 
only acids free from arsenic be employed on account of the danger from 
269 270 
THE RAG, SHODDY AND PAPER INDUSTRY 
arseniureted hydrogen. The rags are next drained, spread over steam 
pipes and dried in a confined space, at a temperature of 100°. This 
involves exposure to acid fumes, which are generally guarded against 
before the removal of the dried rags by thorough ventilation and exhaust 
fans. The rags are next washed and run through "pickers" which 
reduce them to a wool of short fiber, which is mixed with new wool, spun 
into yarn and manufactured into cheap cloth. The grinding or picking 
process is extremely dusty and persons new to the work are liable to 
develop so-called "shoddy fever," which clinically resembles "mill fever" 
(see page 264). Chronic affections of the upper air passages are 
however quite common. 
The Paper Industry.-During the 1910 census the paper and wood pulp 
industry afforded employment to 81,473 persons of whom 10,557 were 
females and 154 children under 16 years of age. The material from which 
paper is made includes rags, burlap, old paper, and wood pulp. The 
U. S. Statistical Abstract (Dept, of Commerce) for 1921 gives a total of 
113,759 wage earners in the paper and wood pulp industry. The rags 
are subjected to a number of processes for the purpose of cleaning and 
disintegration, some of which have already been alluded to. The beat- 
ing, thrashing and chopping process is carried on by machines. In the 
observation of about 80 establishments, the Massachusetts Board of 
Health found that where the cleanest grade of rags were being handled 
practically no dust was observed, but with the usual grade of stock, no 
matter what kind of duster or thrasher or chopper is used, a considerable 
amount of dust is evolved and in spite of exhaust fans and dust flues some 
dust will escape. The men engaged in the collection and baling of this 
dust are usually provided with respirators. The material, after passing 
through the chopping machines, is conveyed by an endless belt to the 
kettle room where it is boiled, with the addition of lime, usually in a "rag 
rotary," by means of steam under pressure. After thorough cooking the 
material is placed in the "washer;" it is then bleached by means of chlo- 
ride of lime and placed in a draining vault. When sufficiently dry it 
goes to the "beater," with perhaps some wood pulp, where it undergoes 
further comminution; it is then transferred to a large tank known as 
the "machine chest," where it is thoroughly mixed, diluted, and stored, 
and from which it passes as needed to the paper-making machines. 
The occupation is evidently inimical to health. Of 4857 German 
operatives reported by Uffelmann3 2437 or 50.2 per cent, were annually 
taken sick; the morbidity fluctuated from 9 per cent, to 112 per cent, in 
different establishments; there were 287 injuries; about 34 per cent, of 
those engaged in the handling of dry rags suffered from diseases of the 
respiratory organs, and only 21.9 per cent, of those engaged in other proc- 
esses. Chronic bronchitis and emphysema of the lungs, impacted ear 
wax, and granular inflammation of the eyelids are not uncommon among 
the older employes. In addition to the danger from dust inhalation PAPER INDUSTRIES 
271 
including also alum and resin dust the possibility of infection with the virus 
of smallpox, and other diseases already mentioned cannot be ignored. 
There is also danger from the use of chloride of lime for bleaching pur- 
poses, from the employment of toxic colors, containing lead or arsenic, and 
the addition to the paper pulp of lead-containing substances. In the 
production of wood pulp by the sulphite cellulose process there is danger 
from escape of sulphur dioxide from the sulphur stoves or from the boilers. 
Preventive Measures.-Greater attention should be paid to the con- 
struction and interior arrangement of establishments for the rag, paper 
and shoddy industry. All dusty processes should be carried on in sepa- 
rate rooms partitioned off tightly from adjoining rooms where less dusty 
processes are carried on. Efficient exhaust ventilation is of the utmost 
importance for the removal of dust and fumes. The addition of poison- 
ous color pigments and lead-containing substances to paper pulp should 
be prohibited. Disinfection of rags and revaccination of employes, 
suitable work suits including in the wet processes rubber boots and 
aprons, and facilities for personal cleanliness should be insisted upon. 
Manufacture of Wall-paper.-In making wall-paper the paper is first 
passed through troughs containing colored solutions for the ground work, 
it then passes through machines to receive patterns and different colors. 
Formerly there was considerable risk from the employment of arsenite of 
copper and lead pigments; their use has been prohibited in some countries 
and replaced by vegetable or anilin colors. The employment of bronz- 
ing powders, mica and wool dust involves exposure to irritant forms of 
dust which must be guarded against by exhaust ventilation. The tem- 
perature in the printing department often ranges between 90° and 100°F. 
even in cold weather. Rheumatism and diseases of the digestive system, 
and accidents are above the average in other occupations. 
Cardboard and Paper-box Workers.-The Leipsic insurance statistics 
show that this class of workers has the highest morbidity rate among 84 
occupations, viz., 1574 days of sickness per 100 workers per annum and a 
mortality hazard of 1.06 per cent. There is nothing in the manufacturing 
process which explains these hazards, unless the work is carried on as a 
home industry by youthful workers and without special precautions. 
Apart from machine accidents and dust the character of stock employed 
is important. If the paper happens to be colored with arsenical, lead or 
chrome pigments there is danger from metallic poisoning, especially in the 
practice of sticking on labels or loose edges, after licking them with the 
tongue. This pernicious habit was formerly quite common not only in 
paper-box factories, but in many other industries in which adhesive labels 
are used. As a result the so-called "stamp licker's tongue," characterized 
by a polished tip and small ulcers on the tongue and mouth, was quite 
common. 
Since much of the adhesive material used is of animal origin, it is pos- 
sible that the ulcers are of septic origin; at all events they offer an excellent 272 
THE RAG, SHODDY AND PAPER INDUSTRY 
portal of entry for septic germs and hence account for the frequent 
involvement of the submaxillary glands. Hayhurst4 believes that there 
is danger from lead poisoning, in labelling fresh paint cans.* 
Much of this label licking is done by frail little girls, and the loss of 
saliva and its effect upon the digestive functions can be judged by the 
fact that, according to Miss Squire,5 Factory Inspector of Great Britain, 
the little girls employed in labelling reels of sewing silk and skeins and 
balls of embroidery "moisten the adhesive labels by the mouth, sometimes 
to the number of 30 gross a day or more." 
Preventive Measures.-It is evident that the use of mechanical con- 
trivances and dampers to replace the dangerous process should be made 
obligatory. 
REFERENCES 
1 Lehmann, K. B.-Arbeits u. Gewerbehygiene, Leipzig, 1919. 
2 Rambousek, J.-Industrial Poisoning, London, 1913, pages 156, 336. 
3 Uffelmann, J.--Handbuch der Hygiene, Wien, Leipzig, 1890, page 824. 
4 Hayhurst, E. R.-Industrial Health Hazards and Occupational Diseases in Ohio, 
February, 1915. 
5 Squire.-Oliver's Dangerous Trades, London, 1902. 
* Here thumb prints of lead paint left on the cans from the can filling operation are 
next handled by employes (girls) who put the labels on the cans. While the labels are 
moistened by sponges or other mechanical means, as a rule, the workers have a habit of a 
"thumb-lip movement" in picking up the labels which they do with the same hand and 
fingers which come in contact with the thumb prints (Hayhurst). CHAPTER XIII 
THE BUTTON, HORN, CELLULOID AND ALLIED INDUSTRIES 
GEORGE M. KOBER, M. D„ Washington, D. C. 
Button Manufacture.-Buttons are made of all kinds of material, 
such as vegetable ivory, metal, celluloid, compositions of casein, potatoes 
and mixtures of fossils and vegetable gums combined with pulverized 
carbonate of lime, feldspar, etc. According to the U. S. census of manu- 
facture 10,567 persons were employed in this industry; of these 5085 were 
engaged in making fresh water pearl buttons and 1001 in the manufacture 
of vegetable ivory buttons. For lack of space, reference can be made 
only to these two classes and to the manufacture of horn buttons as likely 
to affect the health of the wage earners. 
Vegetable Ivory.-The seed of the fruit of the South American ivory 
palm (phytelephas marcrocarpa) commonly known as the "ivory nut" is 
about the size of a hen's egg, and resembles in texture and color genuine 
ivory. In sawing the material into suitable sizes and shapes, the work- 
men are exposed to large amounts of coarse sawdust, which is difficult to 
remove by suction. The Report of the Mass. State Board of Health 
Inspectors for 1908 (page 85) states that one plant had spent a large 
amount of money in trying to adapt a blower system to its sawing 
machines without success. A much finer dust is produced by the 
machines which cut out the buttons and drill the holes, and during the 
polishing process, all of which can be adequately removed by suitable 
suction devices. The inhalation of this dust, like that of horn and genu- 
ine ivory dust, with their sharp and angular fragments, predispose to 
diseases of the respiratory organs, while the dust from bone is classed by 
Professor Roth1 among the less offensive varieties of dust. Since vege- 
table ivory is especially adapted to the application of colors, there is an 
element of danger if toxic pigments or dyestuffs are used. 
Pearl Buttons.-In the manufacture of pearl buttons, studs and orna- 
ments, the shells of mullosks are used; after cooking, the shells are freed 
from the fleshy parts, sorted into three sizes and soaked for several days 
in water to render them less brittle. While still wet the shells are sawed 
into suitable blanks; this as well as the subsequent processes such as 
cutting out the discs, boring, planing, facing, grinding, polishing and dom- 
ing are all attended with the production of dust. The wage earners 
include a large number of females and minors. The inhalation of this 
273 274 
THE BUTTON, HORN, CELLULOID AND ALLIED INDUSTRIES 
dust produces dyspeptic conditions and catarrhal affections of the respira- 
tory passages, such as chronic bronchitis which may eventuate either in 
fibroid phthisis or in pulmonary tuberculosis. 
Of 390 deaths among the button workers in Vienna between 1895 and 
1905, no less than 272 or 69.7 per cent, perished from consumption, and 
Teleky2 in an examination of 150 pearl button workers in 1907 found 
only 93 with normal lungs. 
Professor Roth states that mother-of-pearl dust is largely composed of 
carbonate of lime and, as such, less offensive. Reference should be made 
to a peculiar inflammation of the bones (osteomyelitis) which most fre- 
quently affects the bones of the forearm and hand and occasionally also 
the shoulder blades, jaw-bone and the bones of the lower extremities, 
especially of youthful workers. This disease, first described in 1869 by 
Englisch as attacking "pearl turners," was subsequently studied by Gus- 
senbauer, Weiss, Fischer and others, and in all about 31 cases have been 
recorded. Teleky observed only one case among 150 pearl workers in 
Vienna. The etiology still remains obscure, it is generally attributed to 
the absorption of some of the constituents of the shell dust, causing 
embolic processes in the bone. Levi suggests that it may be caused by 
pyogenic organism contained in the water of the grinding trough. What- 
ever the factors such as the grinding process, water or air may be, which 
predispose to this affection in Germany and France, the only two coun- 
tries in which cases have been reported, the disease does not exist accord- 
ing to Oliver3 among the pearl workers in the shops of Sheffield where the 
grinding is done by the wet process. 
Neisser4 refers to instances in a pearl factory in France of severe nose 
bleed, pricking in the eyes, bronchial and even gastric irritation, caused 
by the dust of shells from certain mollusks, the symptoms differing so 
radically from those produced by the genuine mother-of-pearl dust that 
the employes promptly stop work in these shells. 
The mortality statistics of button makers in the United States from 
1897 to 1906 collected by Hoffman5 are based upon 127 deaths from all 
causes reported in only one of the Industrial Insurance Companies; of 
these 48 or 37.8 per cent, died from consumption as compared with 14.8 
per cent, for males in the registration area; there were also 14 deaths or 
11 per cent, from other diseases of the lungs. 
Preventive Measures.-The mortality statistics from diseases of the 
respiratory system sufficiently indicate that the occupation as at present 
carried on is injurious to life and health, and that every effort should be 
made to reduce dust production to a minimum by wet processes and to 
provide for its removal by effective exhaust ventilation. This at present 
appears to be not wholly possible, since, "notwithstanding the best pro- 
tective devices found in the way of hoods and exhausts, there was some 
escape of dust, as evidenced by the fact that the fine white pearl dust 
covered the belts, machines, walls, ceilings, clothing and often the faces of HORN, COMB, HAIRPINS, CELLULOID GOODS 
275 
the workers in those establishments which provided the most improved 
methods of protection."6 
The State of Massachusetts since 1910 excludes boys and girls under 
18 years of age from all processes involving the evolution of dust. In the 
prevention of the pulmonary affections social and industrial betterment 
will play an important part, and as a preventive measure against inflam- 
matory affections of the jaw Dr. Ritter, a Berlin dentist, recommends care 
of the teeth and astringent mouth-washes. 
Horn Industry.-Horn is extensively used in the manufacture of 
mouthpieces for pipestems, handles for carving sets, buttons, combs, 
hairpins, ornaments, frames for eye-glasses, etc. 
In the manufacture of horn buttons, the hoofs of cattle are generally 
used; after boiling to soften them they are cut by machines into pieces, 
while still other machines shape them into buttons; they are then stamped 
into the desired pattern by means of hydraulic presses; all of these mani- 
pulations are less dusty than the subsequent drilling of the holes and the 
polishing process. 
Combs, Hairpins, Etc.-In the manufacture of combs, hairpins and 
similar ornaments, various materials such as horn, bone, tortoise shells, 
celluloid, ivory, composition material and different metals are used. 
Reference can be made here only to those materials involving the inhala- 
tion of dust. Apart from the liability to mechanical injuries during the 
process of cutting the horn into laminae by means of circular saws, all of 
the manipulations such as sawing and turning of the horn, and especially 
the process of rounding and pointing of hairpins and subsequent rubbing 
and polishing, are attended with considerable production of dust. There 
is also an element of danger during the coloring of the goods with a mix- 
ture containing anilin dyes, red lead, lime and saleratus. Dr. Power7 
refers to the liability of horn workers to anthrax infection, but cites no 
specific instances. According to Hirt the inhalation of dust of animal 
origin is more conducive to the development of consumption than dust 
of vegetable origin, the consumption rates being respectively 20.8 and 
13.3, and for workers in non-dusty trades only 11.1 per 1000. 
Manufacture of Celluloid Goods.-The use of celluloid in the manu- 
facture of combs, pins, frames for eye-glasses, knife and umbrella handles, 
billiard balls, buttons, collars, cuffs, etc., is rapidly growing. Celluloid, 
also known as fiberloid, invented by Hyatt, an American, in 1869, is a 
mixture of pyroxiline, camphor and alcohol. Pyroxiline is primarily 
obtained by treating vegetable fiber, usually cotton or tissue paper, with 
nitric acid and sulphuric acid in stone jars. This process gives rise to the 
evolution of nitrous fumes and sulphureted hydrogen, to which the work- 
men are exposed, even though the process is well guarded by hoods and 
exhaust ventilation. After maceration in the acid solution, the material 
is freed of most of the acid and washed; it is then dried and mixed with 
wood alcohol and camphor and the final mixture is kneaded and moulded 276 
THE BUTTON, HORN, CELLULOID AND ALLIED INDUSTRIES 
or rolled into sheets of suitable sizes for manufacture of celluloid combs 
and other goods. 
The manufacture of celluloid combs, especially the process of "shap- 
ing" and "pointing" the teeth, and the rubbing and polishing, involves 
more or less dust production, which can be removed to a great extent by 
efficient exhaust ventilation. 
In recent years in order to obviate much of the hand polishing proc- 
esses a dip containing glacial acetic acid and other unknown constituents 
has been employed, the fumes of which are, however, very irritating to the 
mucous membranes of the eyes and to a less extent to the nose and throat. 
Fortunately, good blowers are required by fire insurance companies 
on account of the extremely inflammable character of the celluloid dust. 
There is some danger of injury to the eyes, from flying chips of celluloid 
caused by the circular saw employed in "shaping" the bottom of the 
teeth and also in the "pointing" of the teeth by sand wheels or steel 
burrs, unless glass fronts and efficient blowers are used. 
Artificial Silk Workers.-One of the great achievements in the celluloid 
industry is the manufacture of artificial silk, which is accomplished by 
several methods, the basis of all being cotton wool. In the 1st 
process described by Lehmann8 the cotton is nitrated (see Gun cotton) 
and dissolved in a mixture of alcohol and ether; the resulting collodium 
is pressed through capillary openings into water, which congeals the 
threads and after being treated with ammonium sulphate to render the 
material non-inflammable the threads are spun out on spools and dried. 
In the 2nd process the cotton and wool is dissolved in copper oxide- 
ammonia, and pressed into diluted sulphuric acid. In the 3rd process 
the cotton is dissolved in a solution of caustic soda and carbon disulphide 
which forms Viscose and is pressed into sulphuric acid. The employ- 
ment of carbon disulphide has given rise to a large amount of sickness in 
certain plants. In the 4th process the acetate of cellulose is employed 
with tetrachlorethane as a solvent, and this agent has produced indus- 
trial poisoning in persons engaged in making the solution, and also 
among those who were spinning out the thread on spools and drying it. 
(See tetrachlorethane, page 576.) In the various processes, besides the 
poisons mentioned, the following may be encountered: amyl acetate, 
methyl alcohol, nitrous gases and sulphureted hydrogen. 
Preventive Measures.-The chief elements of danger in the horn and 
celluloid industry are exposure to dust, acid, and toxic fumes and numer- 
ous industrial poisons, there is also great danger of fire and explosions. 
The obligatory installation of exhaust ventilation is not only a fire 
but also a health protection; in addition some underwriters require 
a thermostat system of automatic sprinklers. A recent inspection 
of one of the Brooklyn establishments satisfied the writer that the 
horn and celluloid industry can be carried on under favorable hygienic 
conditions. REFERENCES ON BUTTON, HORN, CELLULOID INDUSTRIES 
277 
REFERENCES 
1 Roth, E.-Gewerbehygiene, 1907, page 119. 
2 Teleky, L.-Weyl's Handbuch fur Arbeiterkrankheiten, 1908, page 326. 
3 Oliver's Dangerous Trades, page 276. 
4 Neisser.-Internal. Ubersicht uber Gewerbehygiene, 1907, page 132. 
6 Hoffman, F. L.-Bull. Bureau of Labor, No. 82, May, 1909, page 515. 
6 Report of the Massachusetts State Board of Health upon the Work of State Inspec- 
tors, 1909, page 29. 
7 Oliver's Dangerous Trades, 1902, page 244. 
8 Lehmann, K. B.-Arbeits u. Gewerbehygiene, Leipzig, 1919. CHAPTER XIV 
THE BOOT AND SHOE INDUSTRY 
GEORGE M. KOBER, M. D., Washington, D. C. 
The Boot and Shoe Industry.-The old-time occupation of shoe and 
boot making has assumed a different character during the last three or 
four decades by the establishment of large factories, many of which are 
model workshops. But even now this occupation, and certainly all 
repair work, is still carried on in a primitive way as a home industry, and 
when thus conducted we may expect to find an undue prevalence of 
diseases of the respiratory organs, and other affections engendered by 
unfavorable working conditions. Faulty position is responsible for the 
round shoulders, and pressure of the iron last against the chest in the 
operation of burnishing, etc., is the cause of a peculiar deformity of 
the chest, characterized by a marked depression of the breast bone and 
cartilaginous ends of the ribs. Callosities of the upper surface of the 
right thigh caused by pressure of the clamps and strap are of frequent 
occurrence. 
Diseases of the heart, according to Sternberg,1 are unusually common, 
15.5 per cent, against an average of 10.8 per cent, in other occupations. 
Both he and Koelsch2 attribute this to venous congestions caused by the 
stooped position and also to intemperate habits. Injuries followed by 
septic infections and diseases of the skin are not infrequent. Scabies 
appear to be unusually prevalent among the shoemakers of Vienna 
amounting to 38.9 per cent, against 10.8 per cent, in other occupations. 
Among 399 cases of tetany described by v. Frankl-Hochwart1 179 
occurred in shoemakers. This affection is characterized by bilateral 
tonic spasms of the muscles of the hand and wrist and often assumes an 
epidemic character, which Koelsch2 attributes to unclean habits and 
close sleeping quarters. Cases of plumbism and injury to the incisor 
teeth caused by the pernicious habit of holding tinned tacks in the 
mouth and between the teeth have been reported. Prolonged standing 
may develop flat-foot and varicose veins; sedentary habits tend to induce 
constipation and hemorrhoids. The Leipsic statistics show a sickness 
rate of 642 days per 100 shoemakers and a mortality hazard of 0.68 per 
cent. (For American mortality statistics see page 974.) 
In the manufacture of boots and shoes in large establishments the 
working conditions are generally speaking more favorable. There are a 
number of processes, some of which are less harmful than others. The 
following is a condensed statement from the Report of the State Board 
of Health of Massachusetts.3 
278 BOOT AND SHOE PROCESSES 
279 
Cutting Department.-In this department the first process of 
making the shoe is begun. The men who cut the leather and lining 
material for the uppers with sharp knives by hand or machines, are more 
or less exposed to injuries. The work calls for good light. 
Fitting or Stitching.-The re-enforcement of parts with cotton 
cloth is done by machine work, usually by boys and girls who may occupy 
a standing or sitting position. The same is true of cutting tongues and 
eyelets stays, and the perforation of tips. The work of joining the linings 
to the uppers is done by machines operated by women. The edges of the 
vamps, quarters and tips are covered by girls and women with a cement 
of rubber, dissolved in naphtha, to the fumes of which the operators are 
exposed, especially when open cans, instead of patent closed containers 
with automatic emitters are used. The machines for eyelets are usually 
operated by men, and the buttonhole machines by women. The vamps 
are stitched to the quarters by men and women; the latter usually work 
in lighter stock. 
In the sole leather and stock fitting department the stock is cut out 
by men and channelled and the soles and uppers are ready to go to the 
making department, which includes lasting, heeling and finishing and 
numerous subdivisions. Most of the work is performed by men and 
boys in a standing position. 
Lasting.-In this department the upper part of the shoe and inner 
sole are fitted over a suitable last and the outer sole is stitched on. 
Among the injurious factors should be mentioned the possibility of 
mercurial poisoning in persons attending the sole leather stitching 
machines, if mercury is employed, as a lubricant, as it frequently is, in 
the Blake machines. Several mechanical processes connected with the 
lasting department also involve exposure to heat from the warming racks 
and the possibility of wood alcohol and benzine poisoning from the shellac 
and cement employed. After stitching on the outer sole the shoe is ready 
to receive the heel. 
Bottoming and Finishing.-In the manufacture of shoe heels the 
workers are exposed to the inhalation of considerable quantities of leather 
dust and also to the fumes of wood alcohol and naphtha, from the shellac 
and cement which are employed. The heels are usually rough and larger 
than the required size, and are turned over to the heel trimmer or shaver. 
The heel-trimming machine requires watchful care to avoid injury or a 
spoiled product. Painful callosities frequently develop in the outer and 
upper surface of the last two joints of the left fore-and middle fingers of 
the operator. In heel scouring a felt wheel faced with carborundum or 
sand, moulded paper and cloth is used. 
Edge trimming of the sole of a shoe is also done by machine work and 
involves exposure to considerable fine dust which should be removed by 
exhaust ventilation. 280 
THE BOOT AND SHOE INDUSTRY 
Bottom Scouring and Finishing.-In this process the sole and face 
of the heel receive a smooth surface by me^ns of a wheel covered with 
sandpaper or carborundum. In the process of Naumkeag-Buffing the 
sole and shank is brought into contact with a revolving wheel covered 
with emery cloth, or carborundum, and involves exposure to a mixture of 
animal, mineral and vegetable dust. The same is true of heel and breast 
scouring. In the final polishing process, blacking is applied, and revolv- 
ing bristle brushes and cloth wheels are employed. Wax is also put on 
the polishing wheels. Apart from exposure to dust, the process is very 
liable to produce inflammatory conditions of the hands. 
As a result of exposure to dust composed of leather, sand, emery, car- 
borundum, bristles, lint, shellac, resin and wax, it is not surprising that dis- 
eases of the respiratory passages should be quite common. According to 
Dr. J. Beatty,4 Medical Officer of Health of Northampton in England, the 
phthisis death rate for boot and shoemakers was 2.59 per 1000, against a 
normal average of 2.08 for the whole population. In the City of Brock- 
ton, Mass., out of 167 deaths among shoemakers 42 or 25.1 per cent, were 
caused by pulmonary consumption and 11.4 per cent, by other lung dis- 
eases. In Lynn in 297 deaths among shoemakers 21.9 per cent, were 
caused by consumption and 10.1 per cent, by other respiratory diseases. 
Hoffman's statistics,5 based upon 1930 deaths among boot and shoemakers, 
371 or 19.2 per cent, were caused by consumption and 14.4 per cent, by 
other diseases of the lungs. The excess was most pronounced at ages 
between 25 to 34 when out of every 100 deaths from all causes 50.3 per 
cent, were from consumption against a normal expected proportion of 31.3. 
Preventive Measures.-No state board of health has accomplished 
better results than that of the State of Massachusetts which, by frequent 
exhibits of photographs contrasting sanitary and insanitary processes, has 
stimulated most gratifying improvements in the working conditions of 
this and other industries6 (see Hanson's Monograph). There is every 
reason to believe that all the health hazards connected with this industry 
can be removed by efficient factory sanitation, with special reference to 
the removal of dust and fumes. 
REFERENCES 
1 Sternberg, M.-Weyl's Handbuch der Arbeiterkrankh., Jena, 1908. 
2 Koelsch.-Krankheit und Soziale Lage Munchen., 1912. 
3 Report of the State Board of Health upon the Sanitary Condition of Factories, 
Workshops, etc., 1907. Hygiene of the Boot and Shoe Industry in Massachu- 
setts, 1912. 
4 Hoffman, F. L.-Bulletin Bureau of Labor, No. 82, May, 1909. 
5 Exhibits of the Prudential Insurance Company of America, 1912. 
6 U. S. Labor Bulletin No. 154, 1914. CHAPTER XV 
TAILORS, GARMENT AND LAUNDRY WORKERS 
GEORGE M. KOBER, M. D., Washington, D. C. 
Tailors and Garment Workers.-This occupation, like that of shoe 
and bootmakers, has also undergone marked changes as regards general 
working conditions, and the old-type tailor shop can be found only in 
small towns and villages and in connection with repair shops. It is well 
known that weaklings generally seek this occupation, and it is not sur- 
prising that the constrained position of the body, which interferes with 
free expansion of the chest, should not only favor the development of 
skeletal deformities, but also predispose to pulmonary diseases. While 
most of the work is now carried on in large establishments, the shops are 
frequently not much better than the homes, or tenement shops, as regards 
air-space, ventilation, lighting and general sanitation. According to 
Dr. Geo. M. Price, of 1800 shops in the cloak and suit industry examined 
in New York in 1911, only 3.83 per cent, had any special means of venti- 
lation. The efforts of the Joint Board of Sanitary Control to improve the 
conditions and the health of the workers in this industry, in New York, 
have attracted the attention of the United States Public Health Service 
and the authorities promptly conducted a special examination of the work- 
ing conditions and the effect on the employes. A similar investigation 
was carried on by Dr. Linenthal of the Board of Health of the State of 
Massachusetts as early as 1908.1 He investigated the manufacture of 
men's ready-made clothing, the manufacture of men's custom made 
clothing and the manufacture of ladies garments. The result of the 
inspection showed that the industry was carried on for the most part in 
neglected buildings. Stairs and hallways were as a rule dirty and in 
many instances the water-closets were foul and filthy. The working 
rooms were found unclean, the walls and ceilings dirty and in need of a 
coat of whitewash, and the windows were often so dusty as to be almost 
opaque. The disgusting and dangerous habit of spitting on the floor or 
on heaps of rags was observed in almost every establishment visited. Dr. 
Linenthal very justly attributes the main cause of the insanitary con- 
ditions in the clothing industry to the contract or sweat shop system. 
The competition among the contractors being extremely keen, their earn- 
ings often less than that of the employes, it is but natural that little or no 
attention is given to matters of sanitation. The shops operated directly 
by the manufacturers were generally in a very satisfactory condition, and 
281 282 
TAILORS, GARMENT AND LAUNDRY WORKERS 
efforts toward improving existing conditions in the insanitary shops of 
Boston have been fruitful. 
Conditions are, if anything, worse when the work is carried on in tene- 
ment homes, where one room often serves as a workroom, living room, 
dining room and kitchen, and long hours and child labor are the rule, in 
order to eke out a mere existence. The effects of overcrowding, overwork, 
"speeding up," underfeeding, constrained position and exposure to dust, 
and carbon monoxide from ironing stoves and leaky gas tubing are plainly 
evinced by the pallor and anaemia of the operatives and the undue 
prevalence of tuberculosis and neurasthenia. 
Epstein2 states that 43.7 per cent, of the morbidity among tailors is 
caused by pulmonary tuberculosis, and that of 266 post-mortem examina- 
tions in 118 male and 148 female tailors, performed at the Munich 
Pathological Institute, 123 or 46.2 per cent, died from consumption. The 
records of the Milan Clinic and of the tuberculosis clinics in this country 
likewise show an undue prevalence of tuberculosis in garment workers. 
In this country the percentage of deaths in tailors between 25-64 years is 
31.50. Hayhurst reports 228 deaths from tuberculosis among 18,793 
wage earners in the clothing industry of Ohio between 1910-1912. Landis 
believes that the undue incidence of tuberculosis is due to the presence 
of infected individuals, whose carelessly expectorated sputum on the 
floor of workshops becomes a constituent of the organic dust. He also 
points out some of the contributory factors. In a study of 743 garment 
workers made by him and Reed it was shown that among those workers 
who had irregular meal hours, inadequate food and insufficient sleep, the 
incidence of tuberculosis was three times higher than in those leading a 
regular life and obtaining sufficient nourishment. According to Schwab3 
fully 25 per cent, of 7000 garment workers in St. Louis suffered from neu- 
rasthenia. Cases of gastric catarrh, hemorrhoids, varicose veins, and 
ulcers and diseases of the female genital organs are also quite common and 
are probably caused by improper food and pelvic congestions, incident to 
sedentary habits, constrained positions, foot-power sewing machines, etc. 
Lateral curvature of the spine, occupation neuroses and visual defects are 
likewise frequently observed. 
Cases of industrial lead poisoning from the use of silk thread, which 
had been weighted by a solution of sugar of lead have been reported by 
Eulenberg and Teleky. Cases of eczema contracted while handling silk 
fabrics and tarlatan dyed with arsenic-containing anilin colors, picric 
acid, Schweinfurth green, etc., and even symptoms of systemic poisoning 
from arsenic, have been reported by Layet and Epstein. Hayhurst in 
his Ohio Survey of 1914 refers to the use of benzine in association with 
cleaning and cementing processes, carried on in the same quarters. 
The investigation by the U. S. Public Health Service10 based upon 
a physical examination of 2107 male and 1000 female garment workers in 
the City of New York, shows the following: Among male garment work- TAILORS AND GARMENT WORKERS 
283 
ers, the pressers have the most robust physique, but many had a low 
hemoglobin count. Among female garment workers no striking physical 
differences were observed in the various classes of workers. Tuberculosis 
is the most prevalent disease; a postural influence may be discerned, since 
finishers (among males) show the greatest percentage of faulty postures. 
Apart from tuberculosis, the number of cases of emphysema of the 
lungs, chronic bronchitis and chronic catarrhal conditions of the naso- 
pharynx indicates that the presence of suspended matter (woolen "fly") 
in the air of the workshops may be a factor in the development of these 
diseases. Other defects and diseases were defective vision, flat feet, 
defective teeth and pyorrhea, nervous affections, particularly neurasthenia, 
defective hearing, digestive derangements and habitual constipation due 
to dietetic errors and faulty postures. Only about 2 per cent, of those 
examined were free from defects, but a large part of these defects are 
believed to be due to ignorance or neglect of personal hygiene. 
While no vocational diseases peculiar to garment workers existed, it 
was suggested that low wages and irregularity of employment were 
important factors in causing certain conditions of ill health as for example: 
tuberculosis and neurasthenia. This has been confirmed by a subsequent 
study of the health of garment workers, the relation of economic status 
to health,11 which conclusively shows that "the greatest number of poorly 
nourished, anemic, tuberculous workers in an extremely seasonal industry 
were in that group composed of the lowest paid and the least regularly 
employed." Another investigation confirmed the conclusion that the low 
hemoglobin content in the blood of the pressers is due to chronic carbon 
monoxide poisoning from defective gas tubing, gas connections, and defec- 
tive gas irons. Samples of air for analysis were secured from 244 shops, 
the average amount of carbon monoxide present was 55.4 parts per 
million, near pressing irons and 7.4 parts for the window samples. In 30 
per cent, of the shops the odor of gas was perceptible. Fifty per cent, of 
the shops used ordinary gas irons, 41.8 per cent, used irons heated 
by a mixture of gas and air under pressure, and only 2.4 per cent, used 
electric irons exclusively. A study of the gas tubes used showed that 
none were gas-tight. The findings are clearly in favor of electrically 
heated pressing irons. 
The Leipsic Insurance statistics show a sickness rate of 715 days per 
100 workers per annum and a mortality hazard of 0.88 per cent.; for dress- 
makers and seamstresses the sickness rate is 993 days, and the mortality 
hazard 0.50 per cent. 
Preventive Measures.-The fact that during the 1910 census year 
393,439 persons, including 230,395 women and 6252 persons under 16 
years of age, were engaged in the clothing industry in the United States 
indicates sufficiently that every effort should be made to improve the 
working conditions of this class of wage earners. This can be done only 
by absolute prohibition of all manufacturing in tenement houses, the 284 
TAILORS, GARMENT AND LAUNDRY WORKERS 
abolition of the contract system and sweat shops, and the enactment and 
rigid enforcement of laws concerning factory sanitation. Even the small 
establishments and repair shops should be placed under sanitary control, 
not only to safeguard the health of the employes, but also for the preven- 
tion of communicable diseases which may be spread through the medium 
of infected clothing. 
Laundry Workers.-We have no statistics of the number of persons 
actually engaged in laundry work. The 1910 United States census shows 
that 124,214 persons were engaged in the steam laundry industry, of 
Fig. 10.-Laundry workers. The flat-work ironing machine is provided with an ex- 
cellent overhead hood connected by suction pipes with an exhaust fan. (Photo supplied 
by Hanson for the Mass. State Board of Health.) 
whom 81,833 were females and 675 persons under 16 years of age; about 
75 per cent, of the wage earners were engaged in laundries in which the 
hours of employment ranged between 54 to 60 hours per week. 
Those who have read "The Long Day," "The True Story of a New 
York Working Girl as Told by Herself," or who have critically studied 
the working conditions in steam laundries, realize the hardships incurred 
by this class of workers. The work naturally includes a number of 
operations. Some of the employes are engaged in opening the various 
bundles and marking each piece, if not already marked, and in separating 
the "flat " from the "starched " work. This work is regarded as quite dis- LAUNDRY WORKERS 
285 
agreeable, as every piece has to be handled. The Medical Officer of Stock- 
port,4 in England, refers to the use of anilin oil in laundries as a source 
of poisoning to the females engaged in marking the clothes. 
After being sorted, the clothes are placed in washing machines and 
churned for about 20 minutes in hot water with soap or washing powder. 
The bleaching powders are quite irritating to the skin and eczema of the 
hands and arms is not infrequent. The washing machines are generally 
run by men, and only a small proportion of the washing is done by hand 
in open tubs. After removal from the washing machines the clothes are 
placed in a centrifugal machine, commonly called the wringer, which 
Fig. 11.-Laundry workers. The flat-work ironing machine is not protected by an 
exhaust system and the steam disposes through the room causing excessive heat and 
humidity. (Photo supplied by Hanson for the Mass. State Board of Health.) 
quickly removes the excess of water, and the articles are placed on racks 
and rolled into the steam-heated drying chamber. From the dryer 
the flat work goes directly to the mangles, where it is ironed and folded; 
the "starched work" is generally machine starched, and the ironing is 
done partly by machine and in part by hand. The work in summer is 
especially exhausting on account of the combination of heat and humidity. 
The temperature in the mangle and ironing department is often over 100°F., 
but much commendable progress has been made in the alleviation of 
these conditions, certainly in this country, by the introduction of high 286 
TAILORS, GARMENT AND LAUNDRY WORKERS 
studded rooms and forced ventilation. The watery vapors from the 
drying chambers are speedily carried away by exhaust fans, and in nearly 
every well-appointed laundry we find good overhead ventilation and 
revolving fans. 
Cases of arsenic and gas poisoning have been reported as a result of 
exposure to the fumes of coal-burning ironing stoves, or defective gas 
connections. Accidents in American laundries are not very common, as 
the machines are all well guarded. According to the Medical Inspector 
of the State of Massachusetts,5 in 1907 in one establishment employing 
95 persons, two accidents occurred in 5 years; in another employing 54 
persons two slight accidents due to carelessness had been recorded in 15 
years. Sir Thomas Oliver6 states that in 1906, 301 accidents were 
reported in England-46 males and 255 females. He also cites two fatal 
cases of tetanus which occurred in workers apparently in the same laundry: 
one, a girl of 15, ran a splinter in her finger while washing up the floor of 
the lunch room; the other was a man who received injuries while trying 
to start the engine. Oliver thinks it probable that the floor of the mess 
room was infected by the soiled boots of the workers. 
It is rather remarkable that recent literature makes little or no 
reference to the possibility of contracting infectious diseases in the laundry 
business. The Massachusetts investigation5 on this point, even among 
"markers" proved negative, and the general health conditions among the 
employes were also found to be very satisfactory. Uffelmann7 in dis- 
cussing the spread of typhoid fever and cholera mentions a number of 
instances where the disease was conveyed to washerwomen, apparently 
through infected bed and body linen. It is quite possible that the danger 
referred to is greater in hand or home laundries and hospitals. 
Much of the work in laundries is carried on in a standing position; 
hence varicose veins, leg ulcers and flat-foot are quite common. In 
plants where one-foot lever machines are used for ironing and pressing, 
there is more or less complaint of side-ache. There is some evidence that 
new workers on foot-lever machines may develop acute appendicitis; 
also hernia. Among other prevalent diseases should be mentioned 
chlorosis, diseases of the digestive organs, gastric catarrh, gastric ulcer, 
cardialgia, constipation, enteroptosis, retroflexion of the uterus, dys- 
menorrhea, rheumatism, hysteria and neuralgia, while catarrhal affec- 
tions and diseases of the respiratory organs, including pulmonary tuber- 
culosis, are also quite common. The percentage of deaths from tuber- 
culosis in 238 laundry workers observed by Landouzy was 75 in male 
and 56 among the female workers. In this country the percentage for 
both sexes in this occupation is only 16.3. As a typical occupational 
disease Margoniner8 describes a synovitis of the long extensor tendons 
of the right arm, beginning about the medial end of the metacarpal of 
the thumb and extending midway up the forearm; another favorite loca- 
tion of this affection is in the shoulder-joint. The women engaged in LAUNDRY WORKERS REFERENCES ON TAILORS, ETC. 
287 
ironing and washing by hand are most frequently afflicted. Parsesthesia, 
or a peculiar tingling itching of the fingers, and also an affection of the 
finger nails, is occasionally observed. Among 165 female employes 
under observation for 3 years in Brooklyn, N. Y., there were 1876 cases 
of sickness-among them 436 cases of gastric diseases, 328 of dysmenor- 
rhea, 124 of colds, 55 of sore-throat, 36 of neuralgia and 31 of rheumatism.9 
The Leipsic statistics show a morbidity rate of 979 days per 100 ironers 
and washers and a mortality hazard of 0.71 per cent. (See page 978.) 
Preventive Measures.-These include reasonable working hours and 
all the precautions already pointed out in reference to ventilation and 
safety devices for moving machinery, sloping concrete floors, good drain- 
age, slatted platforms or mats, rubber aprons and boots for all sloppy 
work. 
REFERENCES 
1 Report of the Work of State Inspectors of Health, Nov., 1908. 
2 Epstein.-Weyl's Handbuch d. Arbeiterkrankh., Jena, 1908, page 410. 
3 Schwab, Sidney I.-Am. Labor Assoc. Review, Vol. I, No. 1, 1911. 
4 Neisser.-Internal. Ubersicht uber Gewerbehygiene, Berlin, 1907, pages 72-75. 
6 Report of the Massachusetts State Board of Health upon the Sanitary Condition of 
Factories, Workshops, etc., 1907, page 143. 
6 Oliver, Thomas.-Diseases of Occupation, Dutton & Co., New York, 1916, page 387. 
7 Uffelmann, J.-Handbuch der Hygiene, Wien und Leipzig, 1890. 
8 Weyl's Handbuch der Arbeiterkrankh., Jena, 1908, page 426. 
9 Klink, Jane S.-Proceed. Ac. Polit. Science, N. Y., Jan., 1912, Vol. II, No. 2. 
10 Shereschewsky, J. W.-U. S. Public Health Service, The Health of Garment 
Workers, Bulletin No. 71, May, 1915. . 
11 Warren, B. S., and Sydenstricker, Edgar.-U. S. Public Health Service Reports, 
May 26, 1916. 
12 Wiseman, Charles, Sanitary Chemist, U. S. P. H. S.-The Effects of Gas-heated 
Appliances on the Air of Workshops, Bull. No. 81, Public Health Service, 
January, 1917. CHAPTER XVI 
LIBERAL PROFESSIONS, PUBLIC SERVICES, ETC. 
GEORGE M. KOBER, M. D., Washington, D. C. 
Liberal Professions.-These include clergymen, lawyers, physicians 
and surgeons, teachers, nurses, artists and musicians. The morbidity 
and mortality statistics in all these occupations, considering the indoor 
and sedentary employment, are quite normal. Mortality statistics very 
generally indicate that clergymen have the greatest expectation of life. 
(For mortality statistics in the United States see pages 975-980.) Accord- 
ing to the statistics cited by Koelsch, protestant ministers enjoy a higher 
longevity than priests, who however, have about the same morbidity 
and mortality rates as bachelors of the same age periods. Among 
the principal causes of death among clergymen are diseases of the heart, 
kidneys and apoplexy. The tuberculosis death rate in 1908 in Bavaria 
among this class was 1.84 against 3.07 per 1000 in the occupied male 
population. 
The mortality of physicians, surgeons and veterinarians is generally 
higher than in the other liberal professions, but not in excess of the occu- 
pied male population of the same ages, except in diseases of the circulatory 
and nervous system, and the infectious diseases. This is in part due to a 
life full of exposure and responsibility, contact infection, and Koelsch 
suggests that in some instances the tobacco and drug habits may play a 
role. Veterinarians are also exposed to diseases communicable from 
animals to man, and to injuries from kicks and bites. The tuberculosis 
death rate in Bavaria among physicians is quite low, viz., 1.92 against 3.07 
per 1000 in the occupied male population. There are no published 
morbidity and mortality statistics referring to dentists. It may be 
assumed that the occupational risks are similar to those observed in 
surgeons. Edsall reported some years ago two cases of mercurial poi- 
soning contracted from working up the amalgam in the palms of their 
hands. Guy Lane (Arch. Dermat. & Syph., Mar., 1921) describes 
three cases of dermatitis caused by the use of procain, a cocain substitute 
employed extensively by the dental profession. The cases reported all 
cleared up with protection by rubber gloves but relapsed when that care 
was discontinued (Jour. Ind. Hyg., Aug., 1921, Abstr., p. 71). Accord- 
ing to Bertillon cited by Lehmann1 the mortality of directors and teachers 
of public institutions at the age period 30-39 years is 8.5 per 1000; for 
architects 5.2; physicians and surgeons 11.3; clergymen 8.2; lawyers 
11.6; government officials 15.8, against 14.9 in the general male popula- 
tion. We have no mortality statistics concerning "trained nurses," 
288 LIBERAL PROFESSIONS 
289 
and even the German statistics cover chiefly religious orders of those 
who consecrate their life to the care of the sick. According to Cornet 
and Koelsch from 55-66 per cent, of the sisters of Charity perish from 
tuberculosis, as compared with a rate of 39.6 per cent, in the general 
female population. Among the chief predisposing causes are doubtless 
the indoor life, insufficient exercise in the open air, deficient air-space of 
sleeping quarters, contact infections, night duty and frequent fasting. 
The condition of the sisters who devote their lives to teaching is almost 
as unsatisfactory as regards the prevalence of tuberculosis. 
The mortality rates among school teachers, the majority of whom are 
females in this country, are quite favorable, and among the German male 
teachers approximate very closely to those of the protestant clergy. The 
tuberculosis death rate in Bavaria was 1.3 for males and 1.55 per 1000 for 
female teachers, which is far below the average rate. Higher rates have 
been reported by Schmidt of Dusseldorf, and our American statistics also 
indicate that school teachers are more liable to tuberculosis than members 
of the other learned professions. 
This is doubtless due to indoor life, confinement in badly ventilated 
school rooms and the presence of dust. Diseases of the nervous and 
digestive system and of uterine organs are also quite common, and 
teachers will do well to insist upon proper seats, absolute cleanliness of 
the school room, fresh-air schools, or at least copious ventilation, and 
substitution of wet for dry methods of removing chalk markings. 
The mortality rates of lawyers are quite favorable, although not quite 
as good as those of ministers, teachers and artists; their consumption rate 
in the British statistics is 11.6 as compared with 27.2 among their office 
employes. In this country the rates are 7.5 and 28.3 respectively. 
The office assistants, in addition to indoor work, are doubtless exposed 
like so many other bureau and library employes to the inhalation of 
very fine dust, and as a protection against this the general introduction 
of dust-proof file cases and cleaning by the vacuum system should be 
invoked. 
We have no published morbidity and mortality rates of artists in this 
country. The Prussian statistics cited by Lehmann1 show that their 
tuberculosis death rate in 1908 was 63.78 per 10,000 against a rate of 15.4 
in miners and 16.44 in stone workers. Lehmann cites A. Peri (H. 
Ramazzini, 1913, No. 4-8) who apart from tuberculosis also mentions 
anemia, chlorosis, alcoholism, arterio-sclerosis, hemorrhoids and digestive 
disorders (from irregular habits), conjunctivitis from powder and paint, 
visual defects (from intensive and deficient lighting), affections of the 
larynx, nervous and hysterical affections and venereal diseases as the most 
prominent afflictions. 
Public speakers, clergymen, singers, auctioneers etc., are liable to 
suffer from chronic affections of the throat and paralysis of the vocal 
chords. 290 
LIBERAL PROFESSIONS, PUBLIC SERVICES, ETC. 
Musicians.-In this country 23.4 per cent, of musicians and teachers of 
music perish from pulmonary tuberculosis, 6.8 per cent, from pneumonia, 
9.6 per cent, from heart disease and 2.2 per cent, from diseases of the 
digestive system. As with artists we are dealing with a class of people 
subject to great differences in social conditions, and there are doubtless 
a goodly number, who have, as suggested by Koelsch, a precarious exis- 
tence and a "life full of temperamental conditions." Pianists and violinists 
not infrequently suffer from spasm and fatigue neurosis of the fingers and 
forearms; flutists have been known to suffer from laryngeal spasm, and 
performers on wind instruments from spasm of the tongue and laryngeal 
muscles. Formerly it was held that emphysema was quite common in 
military musicians, but Fischer did not find a single case among the 500 
brass instrument performers examined by him, and Professor Gairdner 
never saw a case among the Scotch bagpipe players. 
Aldrich has described a peculiar neurosis, characterized by a cramp- 
like and burning pain, fatigue and a sense of constriction in the muscles of 
the right leg below the knee, caused by operating a " trap drum " by means 
of a pedal, which gave him free use of both hands to play other drums, 
triangle and "traps." The pedal mechanism required a pressure of from 
5 to 25 lb. for each stroke; to play the drum required at times 180 strokes 
per minute, and it is perfectly conceivable how the excessive use of certain 
muscular groups of the right leg should be responsible for this type of 
fatigue neurosis. Von Wurthenau, cited by Dr. J. R. Hunt,2 has collected 
62 cases of "drummers' paralysis," which is an extensor paralysis of the 
distal phalanx of the thumb, occurring usually in beginners and exclusively 
on the left side. The condition is the result of a chronic tenosynovitis 
induced by a peculiar method of holding and using the left drumstick, 
causing a mechanical irritation of the long extensor tendon of the thumb, 
and subsequent pathologic alterations in the tendon and its sheath 
and eventually a rupture during a paroxysm of drumming or more rarely 
quite spontaneously. 
Dr. Hunt2 has recorded a case which occurred in a tailor in whom the 
daily use of a coarse heavy needle and pressing irons evidently induced 
the pathological change. 
Preventive Measures.-The learned professions, whose work is to a 
great extent mental, need physical exercise, such as golf, lawn tennis, 
etc., which are calculated to counteract the evil effects of a sedentary and 
indoor life. The benefits derived from office and house sanitation, general 
cleanliness, and ventilation, personal health rules as regards food and 
drink, and temperate habits in all things should not be underrated. (See 
also brain work, page 53.) 
Soldiers.-The hygiene of soldiers, sailors, and members of the Police 
and Fire Departments is not without interest as they are usually able- 
bodied men and have to undergo a physical examination prior to enlist- 
ment. The health of the United States Army has steadily improved SOLDIERS 
291 
during the past four decades, as shown by a reduction in the mortality 
rate from 7.54 per 1000 in 1885 to 6.51 per 1000 in 1920 (having reached 
the low rate of 4.55 in 1912). The majority of the men are recruited from 
the rural districts and in point of physique and morale compare most 
favorably with any army in the world. The percentage of rejection for 
physical defects is only 12, which is far below the average in other coun- 
tries. The food, clothing, quarters and general sanitation in the United 
States public services are very satisfactory. The medical officers have 
realized long since that their chief function lies in preventive medicine, 
and profiting by the experience that many soldiers are lost in the making, 
there is no disposition to overdo the training of the recruit. The ten- 
dency is in the direction of steady physical gains and the percentage of 
recruits who break down during the first year of enlistment is very small. 
The prevention and correction of flat feet has received attention not only 
by proper shoes but also by proper posture and proper gait (see flat-feet). 
The mortality of the enlisted men, American troops in the United 
States Army according to location between 1911-1920, is given by the 
office of the Surgeon General U. S. Army as follows: 
Locality 
Mean strength, 
exposed 1 year 
Deaths 
Rate per 
1000 
Philippine Islands 
14,447 
49 
4.70 
United States 
268,615 
3,929 
14.63 
Panama Canal Zone 
4,211 
17 
4.01 
Alaska* 
981 
6 
5.78 
Hawaii 
6,379 
226 
3.54 
The morbidity and mortality rates are very satisfactory, except that 
the admission rates for venereal diseases and alcoholism are still excessive. 
The primary cause may be looked for in idleness, and while much has 
been done by athletic sports, educational methods and genteel amuse- 
ments, calculated to counteract the evil effects of saloons and prostitution, 
more may be done by the employment of trained soldiers on extra duty 
for mechanical work. The admission rate for alcoholism has been 
reduced from 35 per 1000 in 1907 to 6.97 per 1000 in 1920, and for venereal 
diseases from 168 per 1000 in 1912 to 62.6 in 1920. The typhoid fever 
rate, the scourge of all armies has been reduced from 5.46 in 1903 to 0.03 
per 1000 in 1920. This is the result of improved sanitation, but chiefly a 
direct effect of anti-typhoid vaccination, introduced in the United States 
Army in 1909. 
The tuberculosis and pneumonia death rates in the United States 
Army were reduced respectively from 0.95 to 0.48 in 1901 to 0.49 and 
0.28 in 1913. This is largely due to the increased cubic air space in 
* From 1911 to 1916 inclusive. 292 
LIBERAL PROFESSIONS, PUBLIC SERVICES, ETC. 
military barracks. Sir Thomas Oliver8 states that the phthisis death rate 
in the British Army was reduced from 7.82 to 2.5 per 1000 in the course of 
5 or 6 decades. 
If is of interest to note that the ratios of deaths from accidents, suicides 
and genito-urinary diseases in the army during the war were lower than 
in peace time, while the ratios for respiratory diseases rose from 4.9 per 
10,000 in 1916 to 17.5 in 1917; 65.7 in 1918 and fell to 20.9 in 1919 and 
to 9.4 in 1920. This increase was doubtless due to influenza and pneu- 
monia epidemics of a virulent type. The influence of hardships and 
exposure upon tuberculosis is shown by a rise from 3.8 per 10,000 in 1918 
to 22.0 in 1919. It was still 13.9 per 10,000 in 1920 and has fallen to 4.8 
in 1921. 
Col. H. M. Dean of the British Army Medical Corps, cited by Oliver,8 
believes that the soldier's irritable heart, first described by Da Costa of 
this country, is largely the result of standing "at attention," with his chest 
advanced, walls fixed and the abdomen retracted. Such a position 
naturally impedes inspiration and expiration, and the blood tends to 
accumulate in the right side of the heart and venous system. The pulse 
rate is often increased from 80 to 100 and even 132 per minute, and he 
believes that "the mischief done to the recruit on the parade ground can 
be stopped by abolishing the present position of 'attention' and giving 
short plain instructions as to how to stand erect without constraint." 
Navy and Marine Corps.-The hygiene of the public services is quite 
satisfactory, as shown by the following comparative mortality statistics 
of the United States Army and Navy: 
Principal causes of death 
Army rate per 10,000 
Navy rate per 10,000 
1911 
1920 
1913 
1920 
Accidents 
18.9 
19.0 
14.2 
18.8 
Tuberculosis 
5.2 
13.9 
4.5 
5.8 
Respiratory diseases 
4.5 
9.4 
3.6 
5.6 
Digestive diseases 
2.2 
2.2 
2.5 
2.2 
Circulatory diseases 
4.0 
2.1 
2.2 
1.1 
Suicides 
5.9 
2.4 
2.1 
1.9 
Genito-urinary diseases 
1.4 
1.3 
1.9 
1.7 
The sailors' greatest enemies are darkness, dampness, insufficient air- 
space in the sleeping quarters, exposure to extremes of heat and cold, 
irregular sleeping hours, hard work and accidents, especially during storms. 
As a result we see an undue prevalence of injuries, diseases of the respira- 
tory organs, rheumatic and neuralgic affections. Cases of heat 
exhaustion are not uncommon in stokers and engineers, especially in the 
tropics. Venereal diseases and alcoholism are still quite frequent, NAVY AND MARINE CORPS 
293 
although the admission rate from alcoholism has been reduced from 5.28 
per 1000 in 1907 to 2.01 in 1920. The admission rate for venereal diseases 
in 1920 was 126.1 per 1000, for tuberculosis 4.52 and for typhoid fever 
0.20 per 1000. Tropical diseases naturally help to swell the general 
mortality rate, which, however, has been reduced from 11.85 per 1000 in 
1885 to 7.10 in 1920. 
Among the occupational risks in the United States Navy, Surgeon 
General Stokes refers to the injurious effects of carbon monoxide, which 
develops in gun firing in the turrets of battleships, and believes that this 
gas in the furnace rooms gives rise to acute poisoning, often mistaken for 
heat prostration. He has also called attention to the serious injury 
inflicted upon the retinas and optic nerves of men who have to operate 
strong search-lights, and has further pointed out that gunners, who use 
telescopes, to point the big guns in the turrets, soon fall 8 or 10 below 
normal vision. 
Fiske presents tables of occupational distribution of physical disability in the 
personnel of the U. S. Navy.3 In a personnel of 62,251 officers and men for a period 
of six years the non-effective rates per 1000 caused through sick days, invaliding or 
death are as follows: Officers 31.88; midshipmen 35.01; electricians 32.61; engine 
room force 37.74; fire room force 45.02; all other artificers 40.23; clerical force 31.16; 
culinary force 40.50; hospital corps men 48.90; marines 58.17; musicians 26.15; 
prisoners 16.20; apprentice seamen 110.84; ordnance 26.75. All other in the seaman 
branch 35.55. Practically over 11 per cent, of apprentice seamen and nearly 6 per 
cent, of the marines were unavailable for duty, while all the other groups show a 
disability rate of less than 5 per cent.. 
The admission rate for affections of the eye varied from 10.97 for the whole service to 
154.60 for midshipmen. The admission rate for diseases of the ear was especially high 
in apprentice seamen, marines and coal passers. The admission rate for mental 
diseases was relatively high for apprentice seamen, fire room force, hospital corpsmen 
and marines. The rates for neurasthenia were 8.84 for officers, 4.95 for yeomen, 3.58 
for hospital corpsmen and 3.05 for musicians. The admission rate for skin diseases 
was lowest (16.56) in hospital corpsmen, next (19.16) in yeomen and highest 177.36 
for midshipmen. In the latter class Surgeon Fiske believes that the swimming pool, 
carelessness in using others towels, soap, athletic clothes and infected gymnasium 
apparatus deserve attention. The admission rate for respiratory diseases for appren- 
tice seamen was 103.07 per 1000 against an average of 22.80 for the service at large. 
The admission rate for tuberculosis for apprentice seamen was 7.04 per 1000 against 
5.26 for the whole service. The death rate from all respiratory diseases for apprentice 
seamen (years 1909-1914) was 7.58 per 1000, approximately 50 per cent, higher than 
for any other occupational group of the Navy. In addition to unfavorable climato- 
logical naval training stations, mentioned by Fiske, it is possible that close quarters 
favor contact infections. 
Midshipmen have a very high injury rate, 204.52. The fire room force shows a rate 
of 100.93; engine room force 83.52; electricians 62.87; Surgeon Fiske believes that these 
rates warrant remedial measures in athletics and safety devices in shopwork, etc. 
Rheumatic and heart affections are especially high in recruits, coal passers, marines and 
apprentice seamen. 
Medical Director J. D. Gatewood and Surgeon T. W. Richards4 have both made 
exhaustive studies in relation to light on shipboard and conclude that there is need 
for a higher general illumination, and deprecate the use of bare lamps in living spaces 294 
LIBERAL PROFESSIONS, PUBLIC SERVICES, ETC. 
which should be provided with suitable shades or frosted bulbs. Dr. Gatewoods' 
study is not limited to ships. Surgeon R. C. Holcomb5 made an exhaustive study of 
the atmosphere and its relation to the human mechanism with special reference to the 
Naval Service in aviation and submarines. 
Surgeon D. N. Carpenter6 presents an able resume on the dangers of smoke and 
powder gases in naval warfare, especially the asphyxiating character of the smoke 
from trinitrotoluol and other high explosives which provide the bursting charge of 
modern armor piercing shells. 
Naval Gun and Machine Shops.-Dr. W. A. Bloedorn of the U. S. 
Navy,7 presents studies of industrial accidents which occurred in the Navy 
Yard at Washington, D. C., covering a period of two years beginning 
January 1, 1914. The average number of men employed was 3202. 
Of the 4711 injuries reported, 2988 or 63 per cent, involves the upper 
extremities; 742 or 16 per cent, the eyes; 527 or 11 per cent, the lower 
extremities; 319 or 7 per cent, the head; 70 or 1.5 per cent, the lumbar 
region; 31 or 0.7 per cent, the chest; hernia 21 or 0.6 per cent.; abdomen 
13 or 0.2 per cent. 
The nature of injuries is stated as follows: lacerations of all grades 
1256; contusions 871, foreign bodies in the eye 680; incisions 558; abra- 
sions 480; punctures 372; burns of varying degrees 232; sprains 166 and 
fractures 93. 
The work was carried on in 27 different shops and the report shows that the sight 
shop, cartridge case, gunners workshop, miscellaneous, primer and erecting shops 
had the highest percentage of injuries. The gun shop, public works, buffing, gunners 
workshop, pattern shop and foundry had the greatest loss of time per man as a result 
of injury. 
Causes of Accidents.-Bloedorn from a study of the injuries in the various shops 
emphasizes the following chief causes: (1) Falls; (2) Falling, rolling and flying objects; 
(3) Power driven machinery; (4) Hand tools and simple apparatus; (5) Carrying, lifting 
and transportation; (6) Dangerous substances, such as molten metal and electric wires. 
Falls was the cause of injuries in one of the five fatal cases and of disabilities lasting 
for more than a year in three other cases. Falling and rolling objects caused many 
of the fractures, and three of the five fatal injuries. Flying objects were responsible 
for the great percentage of the eye injuries, which to a great extent may be pre- 
vented by the use of properly fitting goggles. 
Power driven high speed machinery, such as grinders, circular and band saws 
and lathes are a fruitful source of injury and require the use of safety devices. The 
heavy, slow speed machines, such as planes, shapers, slotters and slow speed lathes 
are comparatively less hazardous. 
Hand tools and simple apparatus are responsible for the majority of wounds of the 
fingers and hands. Carrying, lifting and transportation, resulted in such injuries as 
muscular strains and sprains. Contact with dangerous substances such as molten 
metal, live wires and various caustic solutions was responsible for a small number of 
injuries. 
The highest percentage of injuries occurred among employes between 16 and 20 
and decreased steadily to those between the ages of 50 and 59, from which point there 
was a slow but constant rise with advancing age. The injury rate was much higher 
among colored than the white employes although engaged in less hazardous work. 
The single employes showed a higher injury rate than the married employes. The 
injury rate was markedly higher during the first six months of employment. Skilled ACCIDENTS IN NAVAL WORKS-THE MERCHANT MARINE, ETC. 
295 
employes showed the lowest percentage, whereas the helpers and apprentices showed 
the highest, and laborers standing about midway, between the two. The day of the 
week had a very slight influence, Monday, contrary to general belief compared very 
favorably with other days. Fatigue factors appear to have played very little influence. 
As a matter of fact in the eight hour shift, Bloedorn found the greatest percentage 
of injuries occurring during the first two hours of work with a steady decline for each 
two hour period thereafter. He believes that the first two hours constitute the period 
of adjustment of the workmen to his machinery or tool during which he is more 
susceptible to injury. The 4 P.M. to 12 midnight shift showed the highest percentage 
of injuries, and the 12 midnight to 8 A.M. showed the lowest percentage, while the 
8 A.M. to 4.30 shift occupied the intermediate position, although only slightly below 
the rate of the 4 P.M. to 12 midnight shift. Bloedorn believes that the difference in 
the character of the work performed by these three shifts accounts in a great measure 
for the difference in the injury rates. It is interesting to note that of the 4711 injuries 
received by 2178 men, 1263 were received by 188 men, in other words 8.6 per cent, 
of the total number of men received over 26 per cent, of the total number of injuries. 
The author also determined that individuals differ greatly in their susceptibility to 
injury, although engaged in the same class of work, and that this susceptibility varies 
in the same individual from time to time. All of which indicates the existence of 
physical or mental predisposing causes. 
Preventive Measures.-Bloedorn's recommendations for lowering the number of 
industrial accidents may be summarized as follows: 
1. Special attention must be given to new employes largely made up of appren- 
tices and minors, who are learning their trade, until they become thoroughly 
accustomed to the machine or tool and their fellow workmen with whom they must 
cooperate in performing their daily task. That they must be instructed in the risks 
and the manner in which these risks may be avoided. 
2. Special efforts should be made to avoid accidents during the first two hours 
shift, which appears to be the most dangerous period of employment; and that partic- 
ular attention be given to shops which show a high percentage of injuries and those 
that show a high loss of time per man. 
3. Employes who evince a peculiar susceptibility to injury should receive special 
attention with a view of correcting any physical and we may add mental defects, by 
instruction and education along the lines of accident prevention. 
4. The large percentage of inj uries of the eyes from flying particles could be pre- 
vented by the compulsory employment of suitable and properly adjusted goggles so 
that they may fit the orbital margin snugly and offer complete protection against 
entrance of foreign bodies. All lenses which have become damaged and interfere 
with vision should be promptly replaced. All dangerous machinery, exposed shafts, 
belts, pulleys, flywheels, gears, circular and band saws, emery wheels, grindstones, 
etc., should be provided with guards. 
Merchant Marine Service, Etc.-We have no separate statistics for 
sailors in this country. The United States census gives the death rate for 
"sailors, pilots, fishermen and oystermen" at 22 per 1000 in 1890, and 
27.7 in 1900; for "boatmen and canalmen" the rates were 20 in 1890, 
18.8 in 1900 and 22.9 per 1000 in 1909. Of 14,469 cases treated in the 
Marine Hospitals during the fiscal year ended June 30, 1914, there were 
2579 general and local injuries with 25 deaths, and 11,890 cases of sickness 
with 431 deaths. In addition 38,757 cases were treated in the dispen- 
saries, of which 6816 were for injuries and 31,941 for diseases. Of the 
total number there were 8601 cases of venereal diseases, 7219 cases of 296 
LIBERAL PROFESSIONS, PUBLIC SERVICES, ETC. 
diseases of the digestive system, 3104 cases of diseases of the respiratory 
system, 2731 cases of rheumatism, 1361 cases of nervous diseases, and 870 
cases of diseases of the circulatory system. 
Ratio of Deaths from Specific Causes in the IL S. Merchant Marine Service* 
1906 
1914 
General diseases 
51.52 
48.23 
Diseases of the nervous system 
4.87 
6.39 
Diseases of the circulatory system 
11.16 
14.53 
Diseases of the respiratory system 
9.13 
9.25 
Diseases of the digestive system 
5.88 
5.28 
Genito-urinary system 
6.09 
7.93 
Injuries 
9.13 
5.52 
From all other causes 
2.22 
2.86 
* Surgeon General Cumming informs me that owing to the assumption of greatly 
increased work for veterans it has been impracticable to tabulate the returns in recent 
years suitable for detailed information. The following memorandum was prepared for 
his annual report: 76,991 American seamen were treated in Marine Hospitals and relief 
stations of the United States Public Health Service during the fiscal year ended June 30, 
1921. Of these 466 died; 18,483 American seamen received hospital treatment for a 
total of 649,186 days, and office relief was given to 58,508 patients of this class, the total 
number of times office relief was furnished being 133,879. 
The mortality rate of the British Merchant Service given by Oliver8 
for 1898-99 was 9.6 per 1000, of which 7.4 were caused by injury and 2.2 
from disease. The corresponding rate in the Royal Navy for 1899 was 
4.9 per 1000 made up of 1.35 from injury and 3.56 from disease, showing 
what can be done by rigid discipline, and prompt medical attention in 
the prevention of fatal accidents. The same author states that cases of 
thoracic aneurism, as a result of hard work, sudden strain and syphilis, 
also of violent knocks and bruises of the chest received during gales, are 
quite common. 
The occupational hazards of pilots, fishermen and oystermen do not 
differ essentially from those of sailors. Exposure to all kinds of weather, 
long hours, irregular meals and accidents from sudden squalls naturally 
render an otherwise healthful out-door occupation dangerous. 
The members of the Life Saving Service9 encounter even greater 
occupational risk than pilots and fishermen. The average age of station 
keepers in 1910 was 51 years and of surfmen 38 years. The fatal accident 
mortality in 1880, in a force of 1167, was 5.14 per 1000 and in 1910 with a 
mean strength of 2204 it was only 0.45 per 1000. 
Fire and Police Department Employes.-The men employed in the 
fire department, like all other workers, exposed to excessive heat, sudden 
changes in temperature, wet and cold are predisposed to rheumatic, 
neuralgic and catarrhal affections, muscular cramps and diseases of the 
respiratory organs. 
In addition to the injurious factors common to all firemen they are not 
infrequently exposed to the inhalation of hot smoke, carbon monoxide and 
illuminating gas, nitrous fumes and other toxic vapors from acids, chemi- FIREMEN, POLICEMEN, STATIONARY ENGINEERS, ETC. 
297 
cals, celluloid, benzine, turpentine, etc. Cases of asphyxia, pulmonary 
oedema and pneumonia are not uncommon. Accidents and electric 
shocks, are also quite frequent. The fatal accident rates of the chiefs of 
batallion in the New York City Fire Department between 1902-1911 ac- 
cording to Hoffman,10 was 8.4 per 1000 and that of the firemen 2.4 per 
1000. The men employed on the police force are engaged in out-door 
work and the duties are not unlike those of soldiers in time of peace. 
The chief occupational risks are exposure to inclement weather, long 
hours, irregular sleep and meals. 
The following comparative mortality statistics are compiled from data 
furnished by Hoffman: 
Principal causes of 
deaths 
New York Fire Dept. 1902- 
1911, force exposed per 
annum, 37,526, rate per 
10,000 
Chicago Police Force 1901- 
1910, force exposed per 
annum 34,087, rate per 
10,000 
Accidents 
23.2 
17.6 
Pneumonia 
9.3 
15.5 
Tuberculosis 
6.9 
12.9 
Urinary diseases 
5.3 
10.0 
Heart diseases 
4.8 
14.7 
Digestive diseases 
3.7 
6 5 
The mortality rates from pneumonia and tuberculosis in the Chicago 
Police Force are especially excessive, which is doubtless due to climatic 
and racial conditions in that city. 
Stationary Firemen and Engineers.-The men employed in power 
plants, notably the firemen, coal heavers and laborers, are exposed to 
excessive heat and sudden changes in temperature, especially when the 
workmen step out-doors to cool off. There is also more or less exposure 
to dust from ashes and coal, and escaping gases and steam. The work, 
unless automatic stokers are employed, is fatiguing and is often carried 
on in dark, damp and dirty quarters. The mortality from tuberculosis 
is about 11 per cent, and the accident rate about 12 per cent. (For other 
statistics see page 977.) 
The men engaged in attending furnaces in connection with foundry 
work, kilns and drying rooms, enamelling, japanning, baking ovens, etc., 
are exposed to similar occupational risks. In some industries there is an 
added danger from poisonous dust and fumes, and exposure to intense 
heat and light. 
Working conditions should be improved by adequate exhaust fans, 
movable screens, mechanical contrivances, eye protection against intense 298 
LIBERAL PROFESSIONS, PUBLIC SERVICES, ETC. 
heat, light and foreign bodies. Shower baths and facilities for personal 
cleanliness are essential. 
Commercial and Mercantile Pursuits.-There are two groups of 
employes in commercial pursuits which deserve consideration. The 
first group, according to Chajes,11 includes the office employes, book- 
keepers, cashiers, stenographers, typists, travelling salesmen, clerks, 
stockclerks, floor walkers, etc.; the second group includes porters, shipping 
clerks, delivery wagon drivers, messengers, laborers, etc. 
The German Insurance statistics from 1903-1905 show that of 215,981 
male employes there were 76,334 cases of illness or 35.38 per cent, per 
annum. Of 114,824 female employes there were 48,733 cases of illness, 
i.e., or 42.44 per cent. The average for both sexes was 38.8 per cent, 
which is about 3 per cent, higher than the general average in other occupa- 
tions. The prevalent diseases among the male employes were diseases 
of the respiratory and digestive organs and diseases of the nervous system. 
Among the female employes, anemia and chlorosis came first with a 
morbidity rate of 30 per cent.; next diseases of the respiratory and of 
digestive organs; followed by diseases of the nervous system. About 
29.5 per cent, of those reported sick had sustained accidents, which are 
especially common among the porters and packers and in the stock and 
shipping departments. Near-sight, caused by defective lighting, and 
deformities of the knee, flat-foot, and varicose veins are not uncommon. 
About 19 per cent, of the morbidity among the office and store force 
was due to diseases of the lungs; the percentage among the porters, pack- 
ers, etc., was between 21 and 29, probably on account of additional expo- 
sure to dust; 41 per cent, of all the deaths were caused by tuberculosis. 
Among the diseases of the digestive organs with a morbidity rate of 
7-11 per cent., gastric and intestinal catarrh, chronic constipation, 
gastric ulcer, and hemorrhoids were the most frequent. Rheumatism, 
anemia, neurasthenia, and other nervous affections are not uncommon. 
Occupation neuroses are occasionally observed in stenographers and 
typists. 
Travelling salesmen often contract the alcohol habit. Peddlers and 
small shopkeepers have a very high tuberculosis death rate in Bavaria, 8 
per 1000 against 3.07 in the occupied male population (Koelsch).2 (For 
mortality statistics in this country see pages 979-980.) 
' The long hours, indoor life, exposure to vitiated air, uneven tempera- 
ture, drafts and sedentary habits in the office force naturally favor the 
development of pulmonary disorders. These same factors, together 
with the mental strain in accountants, typists and stenographers, also 
predispose to anemia, chlorosis, malnutrition and diseases of the nervous 
system. Cold lunches, improper food, hasty eating, sedentary or standing 
habits and many of the conditions incident to indoor occupations, are 
doubtless responsible for the undue prevalence of diseases of the digestive 
organs. MERCANTILE, POSTAL, RADIO, TELEPHONE SERVICES, ETC. 
299 
Preventive Measures.-Commendable progress has been made in the 
sanitation of mercantile establishments, but much more needs to be done 
in the way of ventilation, heating, lighting and general cleanliness. All 
sweeping and dusting should be done by the vacuum system. Vestibule 
doors should be provided in winter to avoid cold drafts. The law usu- 
ally makes provisions for seats for female clerks and they should be 
encouraged to use them. 
Stores should not be open for over 9 hours a day with 1 hour for lunch 
and rest. Large establishments should provide rest rooms and hot 
lunches at reasonable prices. Female employes deserve special considera- 
tion; they are usually underpaid, and as a result the home environments 
are not conducive to health. 
Postal, Radio, Telephone and Telegraph Service.-We have no pub- 
lished mortality statistics of persons engaged in these pursuits. Railway 
mail clerks are doubtless subject to the same hazards as conductors and 
trainmen, with an added mental strain incident to their work. A 
study of German Postal Officials and employes by Eisenstadt cited by 
Lehmann1 shows that diseases of the nervous system, tuberculosis and 
heart disease predominate. The work of mail carriers not only involves 
considerable mental strain, but also physical exertion, in walking, stair 
climbing (heavy loads), sudden variations in temperature, and exposure 
to all kinds of weather. In 1921 the U. S. Post Office Department 
inaugurated a much needed system of welfare work under the super- 
vision of Dr. Lee K. Frankel of the Metrop. Life Insurance Company. 
Physical examinations of all employes are now being conducted. 
Radio operators on board of ships are exposed in their compart- 
ments to confined air and an excess of ozone, but no injurious effects from 
electric waves have come to Lehmann's attention. 
The telephone service is rapidly growing and is of special interest 
because it affords employment to a large number of females. The occupa- 
tion involves indoor life, concentration and alertness of mind, and many 
vexations which cannot fail to exert an injurious affect upon the operators. 
Statistical data is still lacking, but general observation indicates that 
the switchboard service predisposes to the development of neurasthenia 
and hysteria. Opinions as to the effect of the occupation upon hearing 
differ very widely; some authors hold that it leads to impairment, while 
others contend that the sense of hearing is rendered more acute. 
A few cases of paralysis of the vocal chords have been reported and 
attributed to the excessive use of the voice and constrained position in 
telephoning. A more important group of injuries is caused by sudden and 
violent acoustic effects upon the auditory nerve of the person using the 
receiver. This phenomena may be caused by entrance of a high-tension 
current into the telephone circuit, by breakage of a power or light cable, 
or during an electric storm. According to Bernhardt13 in some instances 
these violent acoustic bangs have produced rupture of the ear-drum. 300 
LIBERAL PROFESSIONS, PUBLIC SERVICES, ETC. 
This accident must be very rare, however, as I have been unable to find 
similar cases in the literature. In the majority of cases, a slight shock 
from low voltage simply produces a psychic shock and the frightened 
operators sometimes become quite hysterical. 
M. Capart's14 extended experience leads him to conclude that the 
normal operations of the telephone produce no injurious effects. But 
abnormal acoustic effects are very liable to develop profound symptoms 
of hysteria and aggravate chronic affections of the ear. The presence of 
impacted ear wax was found by Castaneda15 to be the cause of frequent 
attacks of nausea and dizziness in a telephone operator. Koelsch16 
informs us that in Germany during the year 1907, eight telephone opera- 
tors were injured by the transmission of high-tension currents, seven by 
the induced current, and two others by the effects of lightning. 
In the Chicago Telephone Co., according to Dr.- J. D. McGowan,17 
there were in 1 year 473 cases of shock reported, two of which resulted in 
death. Most of the serious cases occurred in linemen. 
Dr. McGowan also refers to the accidents liable to befall linemen, 
such as fractures, dislocations, sprains, wounds, contusions, and nail 
punctures, and the frequency of septic infections of wounds, caused by 
copper wire. It is difficult to conceive why copper or verdigris, which is 
so much feared by the workmen both here and abroad, should be held 
responsible for septic conditions of wounds which are of bacterial origin. 
This class of employes is especially liable to electric shock, burns and 
other injuries from crossed wires, etc., which will be considered in 
another chapter (see page 831). Hoffman's statistics based upon 205 
deaths among electric linemen show a mortality of 48.3 per cent, from 
accidents, 18.5 per cent, from tuberculosis, 6.3 per cent, from other lung 
diseases, 6.3 per cent, from heart disease, 3.9 per cent, from digestive 
diseases, 3.4 per cent, from urinary diseases. Workers in cable vaults 
are also often exposed to gas poisoning. 
Bacterial Content of Telephones.-C. C. Saelhof made this investigation with 
special reference to respiratory pathogens and isolated hemolytic streptococci in 
15.9 per cent., the diphtheria bacillus in 2 per cent, and the pneumococcus in 1 per 
cent, from the transmitters and receivers of 94 telephones. Saelhof recommends 
thorough sterilization by means of soap and warm water, followed by the applica- 
tion of a solution of mercuric chlorid, compound solution of cresol, etc., and that in 
speaking, the mouth should not come in direct contact with the transmitter. 
The occupation of telegraphers involves many of the risks already 
referred to, except that the telegraph operators, as a result of over- 
exercise of certain groups of muscles, are liable to develop a fatigue 
neurosis of the muscles of the hand and forearm, which is analogous to 
"writers' cramp." 
Preventive Measures.-There is no doubt that the occupation of both 
telephone and telegraph operators involves a severe strain upon the 
nervous system, which can be greatly mitigated by favorable working TELEGRAPHERS ELEVATOR EMPLOYES 
301 
conditions, shorter working hours, and by kind and considerate treatment 
on the part of the general public. The female operators, because of the 
strenuous character of the work, are entitled to special protection and 
should not be obliged to work over 8 hours out of the 24, with reasonable 
intervals for rest, which should be taken in cheerful, airy and comfortable 
rest rooms. 
In the matter of accident prevention, Dr. McGowan states that, while 
shocks are common, severe shocks causing deaths are now rare in com- 
parison to what they were 10 years ago, owing to the various safety devices, 
the greater care in supervision and greater caution on the part of the 
employe. 
The large number of accidents from electric shock in Chicago, as 
compared with the German statistics, shows that more remains to be done 
to prevent the transmission of high-tension currents by the abolition of 
overhead wires, and the general introduction of safety devices for the 
prevention of the entrance of strong currents of atmospheric electricity. 
Operators and all others using the long distance wires during electric 
storms should handle the receiver with a silk glove or handkerchief. 
Excellent safety devices have been introduced for the prevention of slight 
shocks from a low voltage, caused by the old-time method of violent 
ringing. 
The majority of telephone operators in the central station in the City 
of Washington are females; they are on duty for 9 out of 24 hours, with 
1 hour for complete rest, and intermissions of 10 minutes after 2 hours of 
work. 
The company has provided rest rooms, lunch rooms and an emergency 
room. The working conditions are favorable, and all vexatious patrons 
are promptly switched over to a calm and tactful operator, who adjusts 
the difficulties and thus spares both parties from a nervous strain. Most 
large exchanges now provide similar arrangements. 
Elevator Employes.-A large number of persons are employed as ele- 
vator conductors. The accident liability in this occupation is by no 
means insignificant and numerous fatal injuries, the result of carelessness 
or direct violation of rules, such as open doors or sudden starting, are 
constantly recorded. 
Among the non-fatal injuries may be mentioned fractures of the lower 
extremities, pelvic bones and spine, the result of falls through an open 
door down the elevator shaft, while crushing injuries of the foot are not 
infrequently caused by being caught in starting between the door and 
shaft. Fatal injuries and contusions of the chest often result from care- 
lessness during the oiling or inspection of the running gear, and the head 
injuries are usually caused by falling objects from above. Minor injuries, 
such as contusions and fractures of fingers or bones of the hand, may result 
from being caught between the doors in the attempt to close them. 
Lacerations of the hand may occur as a result of a slipping wire rope, which 302 
LIBERAL PROFESSIONS, PUBLIC SERVICES, ETC. 
is also the cause of painful callosities and contracted tendons in the palm 
of the hand. 
"Flat-foot" and varicose veins, the result of prolonged standing, and 
catarrhal, rheumatic and neuralgic affections, caused by drafts and uneven 
temperature, are frequently observed. 
Preventive Measures.-Reasonable working hours and strict enforce- 
ment of the rules governing the elevator service. 
REFERENCES 
1 Lehmann, K. B.-Lehrbuch der Arbeits u. Gewerbehygiene, Leipzig, 1919. 
2 Hunt, J. R.-Journal A. M. A., Apr. 3, 1915, page 1139. 
3 Fiske, C. N.-Surgeon, U. S. Navy, Naval Med. Bulletin. Vol. X, No. 2, 1916. 
4 Gatewood, J. D., Richards, I. W., U. S. Navy, U. S. Naval Med. Bulletin, January, 
April and July, 1916. 
6 Holcomb, C. R., Surgeon, U. S. N. U. S. Naval Medical Bulletin, 1916, Vol. X, 
page 430. 
6 Carpenter, D. N.-Surgeon U. S. N., The Military Surgeon, Nov., 1916, page 
461. 
7 Bloedorn, W. A.-Surgeon U. S. Navy, U. S. Naval Medical Bulletin, October, 
1916, Vol. X, p. 585. 
8 Oliver.-Diseases of Occupation, E. P. Dutton Co., New York, 1916. 
9 Hoffman, F. L.-Exhibits of the Prudent. Ins. Co., Washington, 1912. 
10 Hoffman, F. L.-Exhibits of the Prudent. Ins. Co., Washington, 1912. 
11 Chajes, Benno.-Weyl's Handbuch d. Arbeiterkrankheiten, Jena, 1903, page 578. 
12 Koelsch.-Krankheit und Soziale Lage, Munchen, 1912, 1st Liefg., page 211. 
13 Verletzungen des Gehdrorgans, 1903. Die Betriebsunfalle der Telephonistinen, 
1906. 
14 Capart.-Annales d'hygiene pub., Vol. XVIII, page 711. 
15 Castaneda.-Boletin de laringologia, Apr.-June, 1912. 
16 Krankheit und Soziale Lage, Munchen, 1912, 1st Lief., page 212. 
17 Trans. 15th Intern. Congress on Hygiene, Washington, 1913, Vol. Ill, part II, 
page 711. 
18 Saelhof, C. C.--Am. Jour. Hygiene, March, 1921, No. 2. p. 234. PART III 
SPECIFIC OCCUPATIONAL DISEASES WITH 
HYGIENIC DESCRIPTION OF THE 
INDUSTRIES IN WHICH THEY 
CHIEFLY OCCUR 
CHAPTER I 
OCCUPATIONAL INTOXICATIONS 
SECTION 1 
ARSENIC POISONING 
Industrial arsenic poisoning occurs in two distinct ways: (1) from the 
dust of salts of arsenic, through inhalation or contact; and (2) from arseni- 
ureted hydrogen gas. 
The principal poisonous salt is white arsenic, or arsenious acid (As2O3). 
Pure metallic arsenic (As) is considered to be innocuous. 
Arsenic: How Obtained; Its Important Uses.-In order to obtain 
white arsenic (arsenious acid) the ore is roasted and the arsenic so vola- 
tilized is collected in flues and chambers. This so-called " arsenic soot," 
in the collection of which elaborate precautions in the shape of overalls 
and respirators are necessary to guard against the effects on the skin, 
is again submitted to heat in a refining furnace and the fumes again de- 
posited in flues as white as a "hound's tooth." Subsequently, the 
material is ground and packed in barrels usually by automatic arrange- 
ments preventing dust. Use of emerald, Paris or Schweinfurt green 
(aceto-arsenite of copper, Cu(CH3CO)2CuO2As2Og) depends on its value 
as an insecticide in preserving fruit trees. In its manufacture the workers 
run little risk until the precipitate of emerald green (made by mixing 
solutions of arsenite of soda with sulphate of copper) is dried. All subse- 
quent processes of sifting and packing, unless carried on in closed-in 
apparatus from start to finish, cause the greatest distress to the workers, 
owing to the very irritant nature of the exclusively fine and light dust 
which "flies" readily. 
Use of Scheele's green (arsenite of copper) in the preparation of artificial flowers 
and wall papers has only a historical interest because anilin colors have almost 
T. M. LEGGE, M. D., Home Office, London, England 
303 304 
ARSENIC POISONING 
entirely taken the place of arsenic in their manufacture, and a host of other articles 
(notably children's toys), as a consequence of the injury traced to their action several 
years ago. When arsenic colors were used, as much as from 1 to 50 or 60 grains was 
found per square foot in different samples of wall papers examined for a committee of 
the Medical Society of London. The progress made since then is well illustrated in a 
Report of the United States Department of Agriculture in 1904, following on the law 
passed in 1900 by the State Legislature of Massachusetts limiting the amount of 
arsenic in wall papers and woven fabrics, other than dress goods, to 0.10 grain per 
square yard, and in dress goods and articles of dress to 0.01 grain per square yard. 
Thus, of 537 samples of paper examined only four contained more than 0.10 grain per 
square yard and 90 per cent, of them contained less than 0.046 grain. The importance 
of the matter in relation to wall papers is that symptoms of coryza and conjunctivitis, 
gastro-intestinal catarrh and obscure nervous symptoms, all suggesting arsenical 
poisoning, are found to be associated with residence in rooms the wall papers of which 
contain arsenic. How the arsenic came to be disengaged from such papers remained a 
mystery until it was discovered that certain moulds and fungi (notably penicillium 
brevicaule) while growing upon the adhesive paste split up the arsenic compounds, 
liberating them in the form of a gas, di-ethyl-arsine AsH(ET)2. Thus technical 
improvement in processes due to progress in chemical knowledge is shown in the case 
of arsenic colors. In some of the anilin colors themselves, as of fuchsin red, the use 
of arsenious acid in the original method of manufacture has been dispensed with by 
adoption of the nitrobenzene process. 
In its effects on the workers by reason of the lightness and readiness 
of the dust to "fly," manufacture of sheep-dip-a mixture of solutions 
containing white arsenic, caustic potash or soda to which flowers of 
sulphur are added-closely resembles that of emerald green. 
Other important uses of arsenic are of the oxide as a preservative of 
hides, skins and furs, and of red orpiment (AS2S2) as a depilatory in tan- 
yards. After the liming process the hides are pasted (on the flesh side) 
with a mixture of red arsenic and lime. About 5 lb. of arsenic and a 
bushel of lime are mixed to a thin paste with water in a tub and the mix- 
ture applied to the hides with a piece of sacking tied to the end of a pole. 
Each hide, after pasting, is folded once, and the hides are then piled 
in heaps for about 12 hours, when the depilatory action is sufficiently 
advanced to allow of removal of the hair by scraping the hair side of the 
hides on the beam. In 1912 three men employed at the London docks 
suffered from sharp attacks of sore throat and diarrhoea as a result of 
unpacking bird skins. From seven of the boxes it was stated that 16 lb. 
of arsenious acid were recovered. 
Salts of Arsenic.-In the form of the salts arsenic acts as a local irri- 
tant or escharotic on such portions of the skin or mucous membrane as it 
may alight, whereas absorbed as a gas it acts hemolytically, destroying 
the red blood corpuscles and throwing the hemoglobin into the blood 
stream. 
If poisons are described as (1) having a superficial action on the skin, 
(2) being absorbed by the blood, changing its constitution, and (3) having 
an internal, remote effect after absorption on organs or tissues such as the SYMPTOMS OF ARSENIC POISONING 
305 
heart or nervous system, then arsenic, in a way in which no other sub- 
stance does, displays all three modes of action. 
Symptoms.-The symptoms caused by dust of salts of arsenic show 
themselves on the skin, on the mucous membrane of the upper air passages, 
and in the gastro-intestinal tract. Dust alighting and remaining on the 
skin, especially where there are folds as around the nose and mouth, or 
where surfaces are moist as in the armpits or on the scrotum, sets up an 
acneiform eruption or an eczematous condition which, if not treated, will 
lead to extensive ulceration. Indeed the discomfort produced by this 
so-called "arsenic pock" is very great. On the other hand, a slow 
undermining of the health such as is commonly caused by lead poisoning 
is not evident. Associated with the skin eruption are conjunctivitis 
with oedema of the eyelids, coryza, injection with dryness and soreness of 
the throat, hoarseness (a very noticeable symptom), and depression. In 
severe cases the gastric symptoms become pronounced-vomiting, 
abdominal cramp, and purging. In former years workers were known 
to be sometimes so seriously collapsed as the result of the cramps as to 
require removal to their homes in cabs. 
Peripheral neuritis showing itself in parsesthesia and anaesthesia ("pins 
and needles " feeling) is much commoner in my experience than paralysis 
of the muscles of the extremities. 
Brown pigmentation of the skin is present in those who have worked 
for years'in contact with arsenical dust. In slight cases it is seen best on 
the upper and lower eyelids, round the temples, on the neck, the areolae of 
the nipples and in the folds of the axillae, while in marked cases there may 
be an intense bronzing of the chest, abdomen and back. 
The most characteristic lesion produced on the upper air passages is 
perforation of the septum of the nose varying in extent from a circular 
hole % to 1 in. in diameter. Perforation may be complete in a month 
from the time of commencement of work. The anterior and lower mar- 
gins of the cartilage, and the bones to which they are attached, never 
become involved in the ulcerative process so that deformity is absent, thus 
distinguishing the condition easily from that due to syphilis. Once the 
perforation is complete no further inconvenience is felt; not a few of the 
workers are ignorant of the existence of the condition. 
Sir Jonathan Hutchinson has laid stress on what he believes to be rela- 
tively frequent occurrence of cancer in those who have taken arsenic 
for long periods. A list of 31 published cases collected by Pye-Smith 
includes two in which the persons had been employed in a sheep-dip 
factory. 
The following table shows the number of cases of arsenical poisoning 
(other than those due to arseniureted hydrogen) reported to the Chief 
Inspector of Factories, London, during the years 1900-1919 inclusive and 
their distribution according to industry: 306 
ARSENIC POISONING 
Industry 
Total Cases 
Manufacture of emerald green 
47 
Manufacture of arsenic trichloride 
18 
Extraction of arsenic 
8 
Manufacture of sheep-dip 
6 
Paint and color works 
4 
Chemical works 
4 
Smelting of metals (lead, copper) 
3 
Sorting bird skins 
3 
Wall paper manufacture 
2 
Shot making 
1 
Scraping paint off ship 
1 
Tanning 
1 
Unloading white arsenic 
1 
Indefinite. • 
9 
Total - 
108 
The symptoms described are those which inevitably result from the 
manufacture of, or contact with, the dust of salts of arsenic where hand 
labor is relied upon, even when protection is sought by the usual precau- 
tions of the wearing of overalls and respirators, locally applied exhaust 
ventilation, washing and bath accommodation and periodical medical 
examination. Fortunately progress in adoption of automatic methods 
involving no handling of the materials in a dusty condition has robbed the 
emerald green industry of danger. 
Thus, in a large factory where this has been achieved I examined 25 workers in 
1900 of whom 20 had worked for 3 months or less (a short duration of employment 
generally signifies an unpleasant occupation with unskilled labor ignorant of the risk) 
and found only two free from signs of the discomfort and injury caused. As late as the 
year 1908 out of an average of 33 workers examined weekly 5.4 per cent, had to be 
suspended, as compared with 0.6 per cent, in 1913, the weekly average exposed to risk 
having been reduced to 14, owing to the improvements effected in the process. The 
dried material is here placed in an enclosed hopper connected with a powerful exhaust 
fan. When the door is shut the material is tipped over into a receptacle from which 
it is elevated into a sieve (also under negative pressure) and from there again passed 
automatically by means of a worm into the packing hopper and so into the tin canisters. 
Only as the green falls into the cans is there possible exposure to dust, and the man 
placing the cans in position is completely protected by the exhaust draught immedi- 
ately behind them. No dust is visible from start to finish-a condition very different 
from that of a few years ago when the effect of the dust on the eyes and nose made one 
glad to get out of the atmosphere after 5 minutes. Splendid washing accommodation 
and douche baths now make the conditions wholly satisfactory. At the same time 
the wise precaution of periodic medical examination at weekly intervals has not been 
relaxed. 
The 18 cases included in the figures from the manufacture of arsenic trichloride 
(for purposes of chemical warfare) were not due to dust but to vapour which permeated 
the air near the place where the men were working. The effect was to produce an 
intense irritation showing itself in eczematous ulceration of the face, nose, hands 
and other parts of the body. The mucous membranes were attacked in the same 
way. None who came into contact with the vapour can have escaped and the cases 
are, therefore, only to be regarded as samples. ARSENIURETED HYDROGEN GAS 
307 
In one case death was due to an accident in the manipulation of the apparatus 
which led to a burn on the leg extending from the knee to the ankle and half way round 
the leg, in a man, aged< 46. Professor Del6pine, who made the post mortem exami- 
nation, and examined the tissues, reported that death was due to absorption of arsenic. 
The microscopical examination of the organs showed that the heart, liver, kidneys, pan- 
creas, and the gastric and duodenal glands were in a state of granulo-fatty degenera- 
tion. Arsenic was also found in considerable quantities in the various organs. It 
was impossible to determine to what extent arsenic absorption had taken place 
through the skin, but Professor Deldpine expressed the opinion that the amount of 
arsenic found in all the organs examined indicated that some soluble compound of 
arsenic had been freely distributed through the body, in all probability by the blood 
and lymph. Examination of the hair and urine of other men working on the same 
plant showed the presence of material quantities of arsenic and indications of degenera- 
tive changes in the kidneys. 
Arseniureted Hydrogen Gas.-The subtle poisoning from this occurs 
mainly in the chemical metalliferous industries, but occasionally isolated 
cases will naturally occur in any chemical action of acid on metal when 
either one or both are arseniferous. The workman, therefore, absorbs the 
poison in operations in which as a rule the possibility of poisoning is not so 
much as imagined. Fortunately this form of poisoning is rare. Such cases 
as have come to my knowledge have been frequently due to work carried 
on in confined spaces or where the means for the removal of the gases 
evolved were inadequate. 
The following table shows the number of cases reported by medical 
practitioners to the Chief Inspector of Factories in the years 1900-1919 
and the industries in which they occurred: 
Industry 
Cases 
Chemical works 
28 
Galvanizing works 
7 
Bronzing of art metal 
5 
Dyeworks 
4 
Paper manufacture 
2 
Shale oil works 
2 
Bullion refining 
2 
Zinc white manufacture 
1 
Gas works 
1 
Tin plate manufacture 
1 
Total 
53 
Professor John Glaister of Glasgow in his interesting monograph on 
this form of poisoning has classified 127 cases as follows: 
I. Chemical operations in laboratories 8 
(a) Operations with known arseniferous materials 1 
(&) Operations with unknown arseniferous materials 14 
(c) Operation not known 7 
II. Trade processes. . 73 
III. Military ballooning 16 
IV. Domestic environment (wall papers) 6 
V. Causes not known ; 2 
Total 127 308 
ARSENIC POISONING 
The professions and occupations exposed to risk are classified thus: 
I. Professional chemists: (a) medico-legal analyses in cases of arsenical 
poisoning; (6) in preparation of AsH3 for demonstration purposes; (c) 
researches in anilin colors and in arsenical compounds. 
II. Physicists and physiologists, from inhalation of arseniferous hydrogen in 
experiments on the voice or as to pulmonary capacity, or other like 
experiments. 
III. Workers in anilin colors, from preparation of arsenic acid (a process now 
obsolete). 
IV. Chemical workers: (a) manufacture of iron sulphate; (6) manufacture 
of zinc chloride and sulphate; (c) zinc smelting; (d) roasting and extraction 
of mineral ores; (e) manufacture of bleaching powder (calcium hypo- 
chlorite); (/) manufacture of soda sulphate by treatment of soda-lye with 
arseniferous sulphuric acid. 
V. Ballooning for military and other purposes. 
VI. Plumbers in brazing operations. 
VII. Galvanizers. 
The essential factor for the production of arseniureted hydrogen gas 
is the presence of nascent hydrogen in solutions containing arsenic; hence 
its occurrence when hydrogen is generated from zinc, tin, copper, or iron, 
and sulphuric or hydrochloric acid when either or both show a proportion 
of arsenic. These substances and the acids, unless the sulphuric acid has 
been prepared from sublimed sulphur or has undergone a de-arsenicating 
process, are always more or less contaminated. Samples of sulphuric acid 
have been found to contain proportions of arsenious acid varying from as 
high as 0.045 to 0.140 per cent, and hydrochloric acid from 0.0014 to 0.691 
per cent. 
Koelsch, basing his view on experiments on animals by Dubitzki, considers 
0.3 gram AsH3 (equivalent to 86.1 cc. ) as a fatal dose for an adult man, or less-0.1 to 
0.15 gram AsH3-if the haemolytic action of the gas on different kinds of blood is made 
the basis. An actual instance where death followed inhalation of 0.6128 gram 
(equivalent to 175 cc.) AsH3 suggests a much larger amount as the lethal dose, and 
Wignail, from analyses of the amount of arsenic excreted in the urine of workmen suffer- 
ing from AsH3 poisoning, comes to the same conclusion. Dubitzki (quoted by Koelsch) 
considers that a concentration of 3 parts per 100,000 would cause symptoms in time* 
Symptoms.-The symptoms set in generally a few hours after inhala- 
tion, with nausea and sickness. Interesting and exact details of 30 slight 
cases are given by Dudley in his account of submarine crews poisoned by 
the gas generated from the lead plates of the batteries which contained 
0.2 per cent, of arsenic. The symptoms were vomiting-a constant 
feature-albuminuria, oedema of the face and eyelids, conjunctivitis, 
headache and insomnia, neuritis (numbness "pins and needles" sensation 
and the like) and slight jaundice. In more severe cases in addition 
there is feeling of great lassitude, pain in the region of the liver, haemo- 
globinuria or haematuria with strangury, while the jaundice becomes, 
after 48 hours, of an intense coppery hue. A fatal termination is usually 
brought about by suppression of urine. ARSENIURETED HYDROGEN POISONING 
309 
Prognosis turns largely on the amount of urine passed-the smaller 
the quantity the graver the case. Death does not usually supervene in 
less than seven days. The fatality of recorded cases (and perhaps there is 
a tendency for them to be recorded more than the recoveries) is from 25 
to 30 per cent. All the symptoms are referable to the haemolytic action 
of the gas upon the red blood cells, which are thereby rendered incapable 
of supplying the colouring matter necessary for the internal respiration of 
the organs and so cause a condition of tissue suffocation. The functions 
of the liver and kidneys break down in the effort to eliminate the products 
of the disintegrated corpuscles. As a result of the effort of the liver to 
dispose of the dissolved haemoglobin much more, and a more inspissated, 
bile is formed. The liver cells degenerate and as a consequence the bile, 
unable to be removed, arrives in the general circulation by the hepatic 
veins, giving rise to the jaundice and bile in the urine. The jaundice 
is, therefore, of a haemo-hepatogenous character. 
Delepine gives details of the post mortem appearances and microscopical change 
in a case of AsH3 poisoning, from which the following is taken-"The liver was 
large, weighing 1757 grams (3 lb. 14 oz.) and appeared as if in a state of cloudy 
swelling or early fatty degeneration . . . the tissues adjacent to the large vessels 
were purplish black as if stained by altered blood pigment. Microscopically the 
liver was found to be in a state of dropsical degeneration, with considerable atrophy, 
pigmentation, some necrosis, and very slight fatty degeneration of the secreting 
epithelium. 
"The kidneys were enlarged-in the cortex and medulla were a number of spots 
and straight sinuous dark brown lines, as though the vessels were distended with dark 
blood. Microscopically the epithelium lining the tubules was much degenerated and 
the lumen of the cortical straight tubes distended with round granules of yellowish 
brown pigment. The renal epithelium was in a state of incipient necrosis." 
Chief interest lies in the action of AsH3 on the blood. Dudley examined the blood 
in all his thirty cases. In every case the red blood cells were below 5,000,000 per 
cubic millimeter-in two they were under 2,000,000, in twelve between 2 and 3,000,000, 
the number increased rapidly for the first fortnight. Only three of the patients, 
however, were seen within 48 hours of leaving their boat. The white cell count 
showed little divergence from the normal. Haemoglobin was much reduced. He 
points out the close resemblance to pernicious anaemia. In the two with most marked 
blood changes-less than 2,000,000 red cells, a high colour index, advanced degenera- 
tive changes in the reds, erythroblasts, megaloblasts more plentiful than normoblasts, 
and bile stained serum. 
Several of the cases enumerated in the list of reported cases occurred in 
groups. Reference to some of them will serve to illustrate the circum- 
stances under which nascent hydrogen was generated in arseniferous solu- 
tions and the kind of precautions which should be carried out in chemical 
works where there is risk of evolution of the gas. In some instances 
knowledge of them only slowly filtered through in consequence of the 
bizarre symptoms of jaundice suggesting yellow fever, acute yellow 
atrophy of the liver, or acute phosphorus poisoning. Doubtless some cases 
are never recognized. 310 
ARSENIC POISONING 
In a works for the manufacture of bleaching powder a man engaged in the cleaning 
out of a Weldon chlorine still at the usual three weekly period was reported as suffering 
from "constant vomiting, coppery jaundice, lividity of the body, the mucous mem- 
brane of the lips almost black, suppression of urine-what little was drawn off 
consisting almost of blood." He died 6 days afterward. It transpired that a fellow- 
workman was affected in the same way though less severely, and that a few months 
previously another man had died after a similar cleaning operation. Of such stills 
there are throughout the country several thousands, and as no other cases were 
recorded there had obviously been unusual circumstances at work. The still in 
question differed from most similar stills in not having a trap-door at the base through 
which the residue could be discharged outside. Instead the residue was placed in a 
bucket and drawn out through the manhole above. The Weldon mud-acid calcium 
manganite-is run into the still which is then filled to a height of 2 ft. with hydro- 
chloric acid. After the chlorine has been evolved the manganese chloride liquor 
is withdrawn, but a certain amount of residue remains behind. A probable source 
for the production of the gas lay in the hydrochloric acid made on the premises from 
pyrites. The deceased had used a new galvanized iron bucket and iron shovel for the 
removal of the residue. A sample of the liquid containing the deposit was found to 
contain 0.45 per cent, of arsenic acid and the hydrochloric acid used 0.292 percent, 
of arsenious acid. This the analyst described as "highly arsenical." It evolved, 
when iron or zinc was placed in it, arseniuretted hydrogen rapidly and abundantly. 
This acid I find to be very much more arsenical than the crude acids of commerce. 
Similarly he said that to immerse zinc or iron implements in the liquid containing the 
deposit in an imperfectly ventilated still would involve great risk to life. In 11 oz. of 
the viscera which had been preserved in formaldehyde (equivalent to about 24 oz. of 
fresh viscera) ^50 grain (0.0028) arsenicum was found and on this the analyst reported 
that "assuming the arsenic was uniformly distributed through the body, and that the 
deceased was a man of average height, the whole body would have contained 0.28 
grain (rather more than a quarter of a grain) arsenicum. One and a half grains of 
arsenicum in the form of white arsenic taken by the mouth, has caused the death of an 
adult, and less than half that amount has, in my experience brought life into great 
peril; 2 cu. in. of arseniureted hydrogen gas contains 1)^ grains arsenicum. Arsenic 
is quickly eliminated in the excretions. I am of opinion that the presence of arsenic in 
the viscera is quite consistent with death from arsenic, the man having survived 2 days." 
To render occurrence of another such fatality impossible the firm took steps to substi- 
tute wooden utensils in the cleaning out of the stills for the metal ones previously used. 
A few months later 10 cases of poisoning by AsH3 were reported in the manu- 
facture of zinc chloride. Zinc oxide-the waste from galvanizing pots-was treated 
with hydrochloric acid made on the premises in a vat situated in open air upon a 
platform. To protect the men from the weather a lean-to roof had recently been 
erected about 10 yd. away from the vat above a gangway along which the workmen 
wheeled the barrows of zinc oxide waste. This shelter played an unexpectedly 
important part in influencing the poisoning. On the occasion in question the men 
were eager to get through a certain amount of work by noon. The day was warm 
and unusually sultry. The fumes must have been drawn in the direction of the shelter 
by the indraught of a furnace situated in the building against which it was placed. 
The men working nearest to the vat itself suffered least of all; those in a well under 
the vat most; but seven men engaged in shovelling from a cart and never at any time 
within 10 yd. of the vat all suffered more or less severely, one dying on the seventh 
day after. The hydrochloric acid admittedly contained arsenic. Very decided infor- 
mation was obtained by Dr. Clayton of Accrington, who investigated the cases, that 
others had previously occurred from time to time. 
A similar case was reported in the manufacture of zinc sulphate in an uncovered 
vat in the open air which had only been used experimentally a few times. Subse- ARSENIURETED HYDROGEN POISONING 
311 
quently the process was removed to a position whence all fumes could be conveyed 
to the main chimney stack. The necessity of carrying away gases likely to contain 
AsH3 into the main chimney stack is emphasized by Dr. Dixon Mann after an investi- 
gation of five cases arising from the manufacture of zinc chloride. The sulphuric 
acid contained 0.309 per cent, of metallic arsenic. 
Galvanizing is a process where cases of AsH3 poisoning might be expected in view 
of the quantities of commercial hydrochloric acid and zinc and iron used. Reported 
cases, however, are few. Seven cases with indefinite symptoms of headache, giddi- 
ness, sickness, weakness of the limbs and tremor having been notified, I visited the 
factory. The acute symptoms had passed off, but I satisfied myself that jaundice 
and hematuria had been present in some while others showed keratosis of the skin on 
the hands resembling the condition seen in poisoning from arsenic in beer. The only 
men who had been attacked were those engaged in dipping the iron sheets in the acid 
solution. The amount of arsenic in the acid used was stated to have been 0.035 per 
cent.-a rather small amount to account for the cases. 
In the year 1912 an Inspector of Factories was summoned by telegram from the 
proprietor of a paper works who stated that a workman had been seized with symp- 
toms resembling yellow fever. His work was to dissolve block tin after granulation 
in strong hydrochloric acid. After the pots were charged, steam was turned on to 
raise the mixture to boiling point. When solution was completed the pots stood for 
12 hours to cool and the contents were then ladled out. During this last operation 
some gas was disengaged. The symptoms were typical-jaundice and hematuria. 
Samples of the acid, tin and zinc, and a sample of the urine also, 6 oz., were submitted 
to the Government Laboratory for analysis. The results as to the proportions of 
arsenic calculated as arsenious oxide were as follows: 
Liquor from preparation bath Practically nil. 
Sheet zinc Practically nil. 
Block tin ' 0.03 per cent. 
Feathered tin 0.05 per cent. 
Precipitated tin 0.011 per cent. 
Strong hydrochloric acid 0.20 per cent, or 159 grains per gallon. 
Urine 0.07 grains per gallon. 
The proportions of arsenic in the samples of block and feathered tin are those 
usually found in commercial tin, but the quantity in the hydrochloric acid is very 
high. The absence of arsenic in the preparation bath liquor (tin solution) indicates 
that the arsenic is given off in the form of gas or vapor during the process of solution 
of the tin in the acid, and direct experiments with the samples have shown that con- 
siderable quantities of arseniureted hydrogen are evolved in this way. It is probable 
that most of the arsenic is given off as arseniureted hydrogen. Assuming the samples 
to represent the materials generally used, the total amount of arsenic (calculated as 
arsenious oxide) evolved during each operation in which 132 gal. of acid are used is 3 
lb., equivalent to upward of 10 cu. ft. of arseniureted hydrogen. 
The amount of the arsenic (0.07 grains per gallon) found in the sample of urine 
is much higher than that normally present in men employed in alkali works who may 
be supposed to run the chance of slight absorption and in whom the amount has been 
found to vary from 0.0011 to 0.0035 grain per gallon. At the works in question there 
were 700 earthenware vessels used in the room where the tin foil was extracted and fan 
ventilation was installed at the opposite end of the room to that where there are two 
open doors. Question of discontinuing the process altogether was under considera- 
tion. Use of de-arsenicated acid would remove the possibility of such accidents and 
should be pressed. Three cases occurred in a process for the recovery of copper, the 
men attacked being employed at the time in emptying vitriol from the depositing 312 
ARSENIC POISONING 
tanks. A fatal case was that of a man employed in a poorly ventilated room in dipping 
"store plates" composed of zinc with a small proportion of copper into a "bronzing" 
solution-essentially a solution of the chlorides of arsenic and iron dissolved in strong 
hydrochloric acid-to give the appearance known as "art metal." 
Treatment.-The only form of treatment holding out any hope of 
success for the inhalation of arseniureted hydrogen gas is prolonged 
inhalation of oxygen. Where there are facilities in a hospital, transfusion 
of blood from the artery of the giver into the vein of the sufferer and saline 
injections have been advocated. 
Arsenical Poisoning from Consumption of Beer and Other Articles.- 
Brief note should be made of the circumstances attending outbreaks of 
arsenical poisoning from consumption of beer and other articles. 
On this subject the Report of the Royal Commission in England and Wales in 1901, 
following on the epidemic mainly in Manchester, Salford and Liverpool which affected 
certainly 6000 persons of whom at least 70 died, has given valuable data. The disease 
was characterized by paralysis and wasting of certain muscles, principally those of 
the extremities, and derangement of function in certain sensory nerves, closely resem- 
bling in these respects the peripheral neuritis associated with alcoholic poisoning. 
In addition, a great proportion of the cases exhibited various affections of the skin, 
such as erythemata, herpes, pigmentation, bullae. In some the alcoholic type pre- 
dominated and in others the arsenical. Beer contaminated with arsenic was account- 
able for all the symptoms. Analysis of some samples yielded as much as 1^ grains 
per gallon but usually the proportion found was from 1 to to of a grain per gallon 
or less. The introduction of arsenic into the beer was made in the form of "brewing 
sugars"-glucose and "invert sugar"-which are extensively used as adjuncts to, or 
partial substitutes of, malt, and as "priming" solutions added after the fermentation 
of the wort. But both the glucose and the invert sugar derived their arsenical con- 
tamination from the acid used in preparing the former from starch and the latter 
from cane sugar. In the acid, responsible for the majority of the cases, as much as 
1.45 to 1.9 per cent, of arsenious acid was detected. Sulphuric acid made from 
brimstone, or in the usual way after a de-arsenicating process effectively applied, 
may be practically arsenic free. This is not the only way, however, in which arsenic 
may contaminate beer. It may be introduced with the malt as the result of the 
arsenic in the coal or coke burnt in the drying of the malt. When the fuel is burnt 
the arsenic is volatilized and becomes deposited as arsenious acid on the surfaces of 
the kiln. Part remains in the ash and this also, if carried up by a draught of air, may 
settle on the malt. As bearing on this, six remarkable cases of arsenical poisoning 
caused by fumes from a coke stove in an ironing room of a laundry have interest. 
Vomiting and loss of power in the legs-in one case almost complete paralysis of them 
with complete paraesthesia below the knees, and loss of patellar and plantar reflexes- 
were the prominent signs without any changes in the skin. Two leaky coke stoves 
were used to heat the irons and while no carbonic oxide could be detected in samples 
of the air of the room there was a noticeable proportion of sulphur dioxide. The 
analyst suggested that as sulphur dioxide was present in the coke used arsenic was 
present also. He found ^4 grain per pound (0.001 per cent.). Arsenic was detected 
in the urine of the two worst cases. Since coal only has been used in the stoves and 
leakage thus readily detected, there has been no more trouble. 
The Royal Commission recommended that no substance should be used 
as an ingredient of food which contains a larger proportion of arsenic than 
Moo grain per pound, or, in the use of solutions, Moo grain per gallon. ARSENIC IN URINE AND HAIR-REFERENCES 
313 
The amounts of arsenic likely to be found in the urine during life or in 
the viscera post-mortem in cases of suspected industrial poisoning by 
arsenic are so small that, for its detection, recourse must be had to compari- 
son of mirrors obtained preferably by the Marsh-Berzelius method after 
the material to be examined has been subjected to appropriate treatment 
by which any arsenic present is obtained in a solution suitable for the 
proper application of the test. By its means the Royal Commission 
state in their report that arsenic will be detected in amounts well below 
Hooo grain per pound or (in the case of a liquid) well below Hoo grain 
per gallon. For an account of this method as also of the other recognized 
tests-Reinsch, Marsh and Gutzeit-reference must necessarily be made 
to standard works on toxicology. 
An interesting point elucidated by the Royal Commission, and one of 
great value in obtaining indication of the past history of a patient in regard 
to arsenic, was the fact that persons taking comparatively small quanti- 
ties of arsenic habitually excrete the poison in their hair to an extent readily 
appreciable by chemical tests. Thus men taking 3 minims of liquor 
arsenicalis three times a day (about Ho grain of arsenic daily) at the end 
•of 2 months showed amounts of arsenic varying from Ho grain to H grain 
per pound in hair which had grown during the interval, whereas out of a 
total of 41 control cases the hair of 38 was either free from arsenic or 
showed no more than Hso grain of arsenic per pound of hair. 
REFERENCES 
Annual Reports of the Chief Inspector of Factories, 1899-1919. 
First and Final Report and Minutes of Evidence of the Royal Commission on Arsenical 
Poisoning from Beer and Other Articles. Eyre & Spottiswoode, 1903. 
"Poisoning by Arseniureted Hydrogen or Hydrogen Arsenic," by John Glaister, 
M. D., F. R. S., Ed. E. & S. Livingstone, 1908. 
"Industrial Poisoning," J. Rambousek. (Translated by T. M. Legge) E. Arnold, 
1913. 
"An Investigation as to the Danger of Poisoning from Lead and Arsenic in Industries 
outside Greater New York," by C. T. Graham-Rogers, M. D., and John H. 
Vogt, B. S. (containing a suggested code of regulations and bibliography). 
J. B. Lyon Company, Albany. 
Sir T. Oliver in Albutt and Rolleston's System of Medicine. Vol. II, Part 1. Mac- 
millan & Co., 1906. 
"Arsenic in Paper and Fabrics," by J. K. Haywood and H. J. Warmer, U. S. Depart- 
ment of Agriculture Bulletin 86, 1904. 
"Arsenic Cancer," by R. J. Pye-Smith, Lancet, Vol. II, page 210, 1913. 
"Forensic Medicine and Toxicology," by J. Dixon Mann, M. D. C. Griffin & Co., 
London. 
"Toxsemic Anaemia from Arseniureted Hydrogen Gas in Submarines," by S. F. 
Dudley, M. B., Journal of Industrial Hygiene, Vol. I, page 215. (Sept., 1919). 
■"Report on Certain Organs in a Case of Fatal Poisoning by Arseniureted Hydrogen 
Gas," by Sheridan Delepine, M. B., Journal of Industrial Hygiene, Vol. I, 
page 356 (Nov., 1919). 314 
ARSENIC POISONING 
"Gewerbliche Vergiftungen durch Arsenwasserstoff," by H. Koelsch, Zentralblatt 
fur Gewerbehygiene und Unfallverhiitung, 1920, Vol. VIII, page 121. 
"Poisoning by Arseniureted hydrogen," by T. H. Wignail, M. B., British Medical 
Journal, June 19th, 1920. 
"Arsenic Trichloride," by S. Delepine, Journal of Industrial Hygiene, Dec., 1922. SECTION 2 
PECULIARITIES IN ARSENIC POISONING 
GEORGE M. KOBER, M. D„ Washington, D. C. 
Lehmann1 refers to "arsenic eaters" who began with very small doses 
and increased them until 0.1 to 0.3 gram once or twice a week were reached, 
and attributes their apparent immunity to gradual incapacity of the 
gastro-intestinal tract to absorb the poison. He also points out the 
interesting fact that arsenic is quite generally and successfully employed 
as a therapeutic agent for the relief of symptoms it is capable of producing 
in chronic arsenical poisoning-such as anemia, nervous disorders, and 
diseases of the skin and that the toxicity of organic arsenic compounds 
like atoxyl, cacodylic acid, salvarsan, etc., is remarkably slight. 
Schwartze,la in charge of the U. S. Pharmacological Laboratory 
(Dept, of Agr.) offers a very acceptable explanation of the so-called tolera- 
tion or habituation to "arsenic." He determined experimentally, upon 
rats, rabbits and chickens, that the toxicity of preparations of arsenious 
oxide administered undissolved per mouth varies markedly owing to the 
coarseness or fineness of their subdivision. "The finer the particles of a 
preparation, the more potent it is and vice versa." The toleration of 
large doses may be due, not to any attribute inherent in the consumer 
(i.e., an immunity), but to the preparation's relatively slow solubility, 
which has been further decreased due to its coarse state of subdivision. 
Mining.-Arsenic is usually mined in the form of arsenical pyrites, 
and when thus obtained, the mining process is believed to be free from 
danger as regards arsenical poisoning. It has been suggested that the 
inhalation of dust in mining of an arsenite of cobalt may be responsible 
for the undue prevalence of cancer of the lungs.in the mining district of 
Schneeberg in Saxony.2 
Roasting of Ores.-The men engaged in the smelting of other ores 
containing arsenic as an impurity, such as tin, copper, nickel, lead, iron 
and silver ore, are liable to suffer from arsenical poisoning, generally in 
the form of troublesome skin affections, but according to Dr. Hamilton,3 
cases of arsenical multiple neuritis have also been reported from smelter 
works and some physicians have seen mixed cases of arsenical and lead 
poisoning and declare that except for the ulcers, it was not possible to 
say which symptoms were attributable to lead or arsenic. Dr. Lawrence 
G. Dunlap gives an account of the hazard from arsenious oxide to which 
many workers in copper smelting plants are exposed, with special reference 
to perforations of the nasal septum, for the prevention of which he found 
315 316 
PECULIARITIES IN ARSENIC POISONING 
the habitual application of camphor-menthol ointment and a "bag house 
salve" (ferri hydroxidum cum magnes: oxido) quite efficaceous, (J. A. M. 
A. Feb. 26, 1921, pages 568-569). Cases of arsenical poisoning have 
likewise been reported in a metal refinery at Perth Amboy, N. J. which 
works up Western and Mexican lead and copper bullion, both containing 
arsenic. 
Metallic arsenic is used to impart luster and to harden metal alloys 
and in the manufacture of shot to harden the lead. 
Paris Green and Lead Arsenate.-According to Dr. Hamilton3 the 
most important arsenic industry in the United States is the manufacture of 
insecticides: Paris green and lead arsenate, chiefly carried on in Brooklyn, 
N. Y. and Chicago. Analysis of a sample of dust secured in a room where 
Fig. 12.-Crude method of drying Paris green. Note dust on walls. 
(Illinois Factory Inspection Bulletin, Vol. 1, No. 1.) 
Paris green was boxed revealed the presence of 0.093 gram of arsenic per 
cubic meter of air, and Dr. Graham-Rogers4 reports that as a result of spend- 
ing several days at the plant the mucous membrane of his nose as well as 
that of Inspector Vogt was inflamed for some time after their visit. 
Lester Roos examined 14 men in 2 Paris green factories and found 3 
with inflamed eyes, 2 with ulcers and 4 with scars of old ulcers and furun- 
cles and 2 with marked anemia. The Illinois Factory Inspection Depart- 
ment, between 1912 and 1916, reported 6 cases of poisoning from Paris 
green and 2 from lead arsenate, and 20 cases in another year, in a force that 
varied from 16 to 178. Scrotal ulcers were fairly common, also ulcers of the 
nostrils, perforation of the septum, ulcers at the corners of the mouth and 
even on the feet from wearing leaky rubber boots; others suffered from ARSENIC COLORS-ARSENIURETED HYDROGEN POISONING 
317 
conjunctivitis and sore throat, colic and constipation. Dr. Apfelbach in 
1913 performed an autopsy on a rapidly fatal case of arsenical poisoning, 
the man dying after less than two weeks exposure in the Paris green 
industry. Dr. Hamilton3 emphasizes the fact that the rapid labor turn 
over in this industry makes for the protection of the men. 
In the manufacture of artificial flowers, Sheele's green is powdered 
over the leaves, which constitutes a very objectionable method. Accord- 
ing to Morris,6 from 1 grain to 50 and 60 grains of this pigment have 
been found per square foot in green wall-paper. This author has also 
called attention to the fact that stockings, gloves, etc., dyed with anilin 
colors often cause severe irritation of the skin, because of the presence 
of arsenic which in his opinion should never pass into the finished dye, 
if the process is rightly carried out. 
It is a remarkable fact that the number of cases of industrial 
arsenical poisoning, apart from skin affections, is comparatively small. 
H. K. de Hass,6 reports an affection of the retina and optic nerves caused 
by arsenical poisoning. Slosse,7 reports occupational poisoning by 
arsenobenzenes in varying manifestations and degrees of intensity in 
physicians and attendants administering. Sheridan Delepine,8 before 
his untimely death, made observations upon the effects of exposure to 
arsenic trichloride in a workman at a chemical plant who died following 
the accidental spilling of this fluid over his right leg. 
Arseniureted Hydrogen Poisoning.-Of 39 cases reported by Prblss,9 of which 19 
proved fatal within from 3 to 24 days, 12 were chemists, 11 were engaged in filling 
toy ballons, 7 were anilin workers, 5 lead smelterers, 3 were balloonists, and in one the 
occupation is not stated. Cases have also been reported, apart from the processes 
already named, among solderers, in smelter works in the refining of silver from zinc 
crust with impure hydrochloric acid, and in the formation room of accumulator fac- 
tories. Three cases occurred in England in an electrolytic process for the recovery 
of copper. Several cases have been reported3 from Colorado and Utah mining 
districts, in connection with the MacArthur-Forrest cyanide process for working up 
low grade gold and silver ores. 
Rambousek10 reports five cases which occurred at Breslau in 1902, of whom three 
died from inhalation of this gas in filling toy balloons. In such instances the hydrogen 
gas employed is usually generated by the action of sulphuric acid upon granulated 
zinc or iron which frequently contains arsenic. The cases reported as having occurred 
in paper-hangers, wall scrapers and even in occupants of rooms decorated with arsenical 
wall-paper are in part caused by arsenical dust, as well as by the inhalation of 
hydrogen arsenide gas, evolved by the growth of moulds in starch paste acting 
chemically on the arsenical salt. 
Preventive Measures.-For the removal of arsenic Wentzki, cited by Lehmann,1 
recommends passing the hydrogen gas through a cylinder filled with two parts 
of dry chloride of lime and one part of moist sand. By adopting this method cases of 
arseniureted hydrogen poisoning among solderers, using the solderer's hydrogen flame, 
have ceased. Lehmann adds that a method has recently been proposed by Francke to 
remove arsenious acid from hydrochloric acid by means of coke-baskets charged with 
mineral oil, which reduced the arsenious acid contents to 0.01-0.02 per cent, at an 
increased cost of 2.5 per cent. 318 
PECULIARITIES IN ARSENIC POISONING 
The following rules for the officials and workmen engaged in the Arsenic Recov- 
ering Process have been in force for a number of years in large alkali works in Great 
Britain: 
1. In the process of De-arsenicating Vitriol, care must be taken to maintain an 
in-draught in the pipes and apparatus, to prevent the escape of arsenical fumes, and 
should an escape be observed, the brine (or hydrochloric acid) should be at once 
shut off until the defect is remedied. 
2. In the Precipitating, Drying and Packing operations, a clean respirator 
(Grell's improved pattern) must always be used. A clean one must be obtained every 
morning from the laboratory, and the one used the previous day returned to the 
Laboratory to be cleansed and prepared for use the next day. 
3. Every workman engaged in this process shall be provided by the Company with 
a pair of India-rubber gloves and a suit of clothes, which he is to put on in the 
morning and remove on leaving the works at night, and shall take a bath before putting 
on his ordinary clothing. These special clothes to be washed by the Company and 
supplied clean to the workman once a week. Workmen must thoroughly wash their 
hands before taking food in the Works. 
4. The buildings in which the Manufacture of Arsenic is carried on must be well 
ventilated to remove all fumes of chloride of arsenic or dust of arsenious acid from 
the atmosphere. 
5. Any workman having cuts or abrasions on the skin will not be permitted to work 
in the Arsenical Department until such wounds have quite healed. 
6. Any workman showing the slightest signs of Arsenical Poisoning must be 
examined by a doctor and undergo medical treatment. 
In other occupations much may be done by the substitution of harmless colors for 
arsenical pigments. Until this is accomplished special attention should be paid to the 
employment of wet processes; so, for example, the dusting of green arseniferous pig- 
ments, in the manufacture of leaves for artificial flowers, etc., from a dredging box, is 
wholly unjustifiable. Strict cleanliness of the skin and clothing are essential and 
the rules for prevention of lead poisoning are applicable here. The possibility of 
arseniureted hydrogen poisoning in the various occupations referred to emphasizes 
the fact that such operations should never be carried on in confined spaces without the 
aid of efficient mechanical ventilation. The manufacture of the salts of iron and zinc 
should be carried on in closed chambers connected with exhaust flues. In the employ- 
ment of hydrogen gas every effort should be made to secure pure reagents and to avoid 
close proximity to the communicating nozzle and escape valves, and to make sure 
that the valves and hose are not leaky. 
Ferrosilicon.-Prof. Glaister11 reports a series of interesting cases of 
poisoning caused by the combined action of arseniureted and phos- 
phureted hydrogen during the transportation by sea or water ways of 
ferrosilicon. This material is an alloy of iron and silicon and is chiefly used 
for the manufacture of electrodes and in the production of steel, and 
thousands of tons are annually shipped from France and Germany to 
Great Britain and the United States but in recent years most of our 
supply is manufactured at Niagara Falls. 
Ferrosilicon is prepared by melting together iron ore, or iron or steel turnings, with 
coke, lime, sand or quartz at a temperature of 2000°C. in electrical furnaces. The 
coke reduces the quartz and ore to silicon and metal with the production of ferrosilicon. 
Iron and quartz often contain arsenic and phosphorus as impurities, which are not 
removed, but are converted in the presence of carbon from the coke into calcium phos- 
phide and calcium arsenide. The grades containing 30 per cent, or less, or over 70 
per cent, of silicon are comparatively innocous, but those containing between 40 and FERROSILICON 
319 
60 per cent, are liable to decompose on exposure to air, especially in the presence 
of moisture, with the evolution of arseniureted and phosphureted hydrogen. These 
gases are not only fatal to animals when present in the proportion of to 1 per cent., 
but have also given rise to explosions. Most of the cases of poisoning have so far 
occurred in confined air spaces on board of ships and canal boats. 
The symptoms usually develop quite suddenly, and are characterized by general 
and abdominal pains, nausea, vomiting, diarrhea, hemorrhages, loss of consciousness, 
dilated pupils, cold clammy perspiration and death from coma. Cases of poisoning 
have been mistaken for cholera, gastro-enteritis, ptomaine poisoning and pneumonia. 
In January, 1905, 50 steerage passengers on the S. S. "Vaderland" en route from 
Antwerp to New York, and lodged over the hold containing a consignment of ferro- 
silicon, were seized with an obscure illness and 11 died. The deaths were certified 
to have been caused by pneumonia, but on account of suspicion of plague, the ship 
was quarantined until further investigation led to the conclusion that toxic gases 
evolved from the ferrosilicon caused the illness and deaths. In October, 1905, Dr. 
Robertson reported similar cases which occurred on a canal boat in England, whereon 
part of the cargo consisted of ferrosilicon. The brief history given by Glaister shows 
that the whole family on board suffered from a feeling of sickness and giddiness on 
getting up in the morning after leaving the port, that these symptoms passed off during 
the day, but reappeared next morning, and in addition there was also pain in the body, 
headache and vomiting. On the third day the symptoms were about the same in the 
parents, but had assumed a very grave aspect in the two children, aged 3 and 4 
respectively. Dr. Robertson was called and on arrival found one to be dead and the 
other unconscious, pupils somewhat dilated, skin covered with a cold clammy per- 
spiration, pulse almost imperceptible, respiration slow and shallow, with crepitant 
rales all over the chest. This child also died soon after his arrival. Post-mortem 
examination revealed nothing beyond congestion of the lungs, and analyses of the 
viscera showed no trace of poison. 
In December, 1908, the deaths of five Jewish emigrants during their voyage from 
Antwerp to Grimsby on the Steamer "Aston," first attributed to cholera and then to 
ptomaine poisoning, were finally traced to the gases of ferrosilicon, of which the ship 
carried 9 tons. In another instance cited by Glaister four patients died on a Swedish 
steamer from the same cause. Thiele12 reports the death of three persons from expos- 
ure to ferrosilicon which had been stored in a wet state on the ground floor of the house. 
(For treatment see Arsenic and Arseniureted Hydrogen, page 312.) 
Preventive Measures.-Rules governing the transport of ferrosilicon were formu- 
lated in September, 1910, by the Prussian Government. It is required (1) that ferro- 
silicon be packed in strong water-tight cases of wood or metal; (2) that the words, 
"ferro-silicon," "to be kept dry," "with care," be legibly and indelibly inscribed on 
the case; (3) that the substance be delivered dry and in dry cases; (4) that the cases 
be stored in airy places on the deck of the ship in such a manner that they are protected 
from wet. 
Dr. Copeman, Medical Inspector of the British Local Government Board, suggests 
the following international regulations for the ocean transport of ferrosilicon. (1) 
Ferrosilicon should be first broken up into pieces of the size in which it is usually sold, 
and should be stored under cover, but exposed to the air for at least a month before 
shipment. (2) Manufacturers should be required to mark in bold letters each barrel 
or parcel of ferrosilicon with the name and percentage grade (Certified by chemical 
analysis) of the material; the name of the works where it is produced; the date of 
manufacture; and date of despatch. (3) The shipment of ferrosilicon on vessels 
carrying passengers should be prohibited. When carried on cargo boats it should, if 
circumstances permit, be stored on deck. If it be considered necessary to store it 
elsewhere, the place of storage should be capable of being adequately ventilated, and 
such place of storage should be cut off by airtight bulkheads from the quarters 320 
PECULIARITIES IN ARSENIC POISONING 
occupied by the crew of the vessels. (4) This regulation should apply to the 
transport of ferrosilicon on river or canal barges as well as on sea going vessels. (5) 
Storage places at docks or at works where ferrosilicon is used should have provision 
for free access of air, and should be situated at a distance from workrooms, mess 
rooms, offices, etc. 
A Committee of which Dr. Copeman was Chairman investigated the accident on 
the steamer "Aston" and stated, "the proprietors of iron and steel works making use 
of ferrosilicon will assist in the protection of their work-people and at the same time 
act for the public benefit by restricting their orders to grades of this material, either 
not exceeding 30 per cent., or of 70 per cent, and upward, according to the special 
nature of their requirements." 
REFERENCES 
Lehmann, K. B.-Arbeits u. Gewerbehygiene, Leipzig, 1919, page 177. 
10 Schwartze, Erich W.-Jr. Phar. and Exper. Ther., XX, No. 3, Oct., 1922, pp. 
181-203. 
2 Henry Louis, Oliver's Dangerous Trades, 1902, page 538. 
3 Hamilton, Alice.-Journ. of Industrial Hygiene, June, 1919, page 92. 
4 An investigation as to the danger of poisoning from lead and arsenic in industries out- 
side of Greater New York, by C. T. Graham-Rogers, M. D., and John H. Vogt, 
B. S., Report of the New York State Commissioner of Labor, 1911. 
6 Morris Malcolm.-Oliver's Dangerous Trades, 1902, page 381. 
6 de Haas, H. D.-Arch. Opthal., 1919, 99, p. 16; Jr. Ind. Hyg., July, 1921, Abst. p. 
53. 
7 Slosse-Bull, de l'Acad. roy. de Belgique, 1921, I, 416-428; Jr. Ind. Hyg., Sept., 
1922, Abst. p. 66. 
8 Delepine, Sheridan-Article begun in Jr. Ind. Hyg., Dec., 1922, p. 346. 
8 Prblss, F.-Bl. f. Gerichtl. Med., 1901, page 171. 
10 Rambousek.-Industrial Poisoning, London, 1913, page 145. 
11 Glaister.-Actes du II Congress Internal, des Maladies Professionelles, Brussels, 
1910. 
12 Thiele-Zentralbt. f. Gewerbehygiene, May, 1921; Jr. Ind. Hyg., Nov., 1921, Abst. 
p. 158. SECTION 3 
COPPER AND THE COPPER INDUSTRIES 
E. R. HAYHURST, M. D„ Columbus, Ohio 
Copper and zinc, at least in toxic forms, are so infinitely bound up 
with the brass industry that it is well to consider them in this relation. 
The founding and casting industry in general is divided into two great 
divisions-iron and brass. Although the processes, except the manner of 
melting metals, are quite identical, still managements and tradesmen 
remain quite distinct. The brass worker, however, has an acquaintance 
with a great many more metals and alloys than the iron worker. 
While nearly all metals may enter the brass crucible, copper and 
zinc are the primary ones and, with tin, constitute the ternary metals. 
COPPER 
Copper is mined extensively in various parts of the world, particularly the United 
States, China, Japan, the Ural Mountains and Sweden. The United States controls 
the supply of the world, her total gain in output for the five years ending 1918 being 
51.7 per cent., the extra demand being largely due to the war when the total (1917) 
reached 753 million pounds of semi-fabricated copper articles.1 Commercially there 
are four kinds of copper: electrolytic (99.93 per cent, pure), casting (with traces of 
precious metals), pig (free from precious metals) and Lake or native metallic copper. 
The chief articles fabricated are in descending order, wire, rods, sheets, tubing and 
castings. It is practically the only metal which occurs pure,2 as in the Lake Superior 
region. Usually it is in the form of various ores. The copper mines of the United 
States produce half of the world's product and employ close to 80,000 men. The 
richest centers are Montana and Arizona, but Michigan mines employ the most men.3 
California and Utah are also important centers. Copper is worth in normal times 
about 15 cts. per pound but reached 26% cts. in 1917. Copper melts at 1080°C., 
which is 300°C. higher than the point where zinc becomes a gas. Copper assumes a 
gaseous form at something over 2300°C. 
An excellent series of descriptions of the various processes through which copper 
goes "from ore to metal" is to be found in "The Anode," published by the Anaconda 
Copper Mining Co., Butte, Mont.-Monthly-beginning November, 1919. 
Toxicity of Copper.-Whether copper per se is toxic or not is as yet 
unestablished. It is therefore well to sum up the evidence upon this 
point. Literature is replete with reference to the relative harmlessness 
of copper upon the human organism. Certain vegetable organisms 
are extremely sensitive to the poisonous action of copper and its salts. 
Experimentally, it causes chronic poisoning when given in large amounts 
to animals.4 "Copperman's chest5 is a pulmonary fibrosis, due purely to 
mechanical irritation. "Copper colic" and the rare cases of polyneuri- 
321 322 
COPPER AND THE COPPER INDUSTRIES 
tis, affecting especially the lower limbs, reported6 as occurring among 
brass polishers and coppersmiths and even those presumably working 
with pure copper, are rare complaints considering the large numbers so 
employed, and are probably due to lead,7 arsenic, heat-fatigue toxins8 or 
other factors. Arlidge and Blaudet9 have held for a long time that copper 
workers are liable to a specific intoxication, characterized by colic, 
vomiting and purging. Dr. Simon9 admits the possibility of such 
effects in men, who by reason of unclean habits are liable to swallow 
copper dust with their food, especially those who work in old copper and 
brass covered with more or less copper carbonates. 
Zadek10 on the other hand cites a number of authorities to support 
the opinion that copper itself is not a toxic agent, and that the symptoms, 
such as colic, etc., are caused by alloys, chiefly lead, and the green dis- 
coloration of the teeth and hair has no pathological significance. Leurin,11 
while questioning the possibility of chronic copper poisoning, concludes 
that acute intoxications may occur after ingestion of considerable quan- 
tities of the metal. Animal experimentation, conducted by Baum and 
Seeliger12 would appear to establish the possibility of chronic copper 
poisoning. Extensive experiments* were made on the effects of small 
amounts of copper in man and animals by Taylor, Long and Chittenden, 
with pathological investigations by Theobald Smith and clinical observa- 
tions by Alfred Stengel. The work was done in connection with the 
mooted question of the influence of vegetables greened with copper salts 
on the nutrition and health of man. Experiments were carried out on 
human beings, on dogs and on monkeys. In Long's experiments the 
daily mean ingestion of copper in human subjects varied from 15.94 to 
19.52 milligrams, the whole period of observation being 120 days, includ- 
ing certain periods of no ingestion. The results proved the retention 
of copper by the animal body, principally in the liver, with considerable 
evidence of gastro-intestinal disturbances in some of the individuals in 
the nature of nausea and diarrhea. However, none of the findings proved 
general constitutional effects. While the investigators reasoned that 
retention of a metal like copper must have some deleterious effect anal- 
agous to lead or mercury, there was no definite data to substantiate the 
same. Two of the four dogs exposed presented an interstitial inflamma- 
tion of the kidneys localized in the cortex, apparently due to the copper 
salts ingested, while in none of the monkeys did microscopical examina- 
tions reveal differences between the controlled and the treated monkeys. 
In all of the animals as well as the human subjects there was no elimina- 
tion of copper via the kidneys, the urine remaining constantly free from 
copper. 
Peigney,13 who studied the afflictions of copperworkers in a large French plant 
during the war where fusees were made and where 2000 women and 700 men were 
* Report of the Referee Board of Consulting Scientific Experts, Report No. 97, U. S. 
Dept, of Agr., June 16, 1913, 461 pages. TOXICITY OF COPPER COPPER TRADES 
323 
employed, found that about one-third of the younger women, in particular, suffered 
at intervals from attacks of gastro-intestinal disturbances of irritative character due 
largely to ingestion and perhaps skin absorption of copper particles and copper salts, 
and slightly worse in oily processes than in dusty ones. Nausea, vomiting, diarrhea, 
sweating, pain on urination, all lasting perhaps for several days with a slight hyper- 
globulia and a leucocytosis of 15,000 to 19,000 were characteristic. He concludes that 
copper, unlike lead, is not toxic in the sense of destructiveness, but is simply irritative 
to the organism even to the extent of arousing the hematopoetic tissues. Immunity 
seemed established in about two years. * Rambousek14 considers all chronic industrial 
copper poisoning as due to admixtures of other metals. 
Copper dust, or alloys rich in copper, generally produce in workers 
green-stained hair, greenish deposits on the teeth and in the gums, and a 
green tint to the perspiration, which may persist even after a thorough 
bath, while the skin may be actually bronzed. Some dentists have 
reported a peculiar purple color and swelling of the gums with pyorrhoea 
and more or less stomatitis in copper workers. Copper has been found 
accumulated15 in all of the organs of the body, in the various excretions,16 
and in the bones of former copper workers17, which have shown a green 
color when subsequently removed from graves. Dogs fed copper pass 
it on to the suckling young,18 in whose livers it may be found, without 
apparent effect. While not a normal constituent of the human body, 
copper is found in the liver in practically all autopsies because of the mani- 
fold opportunities of the human being to ingest copper. It is a common 
constituent of vegetables and various plants.19 
Workers in various copper processes are often thought to be "copper 
poisoned." While copper miners have various afflictions, none can be 
charged to any peculiar toxicity of copper itself. Zadek's20 tables show 
that coppersmiths suffer above the average in most forms of sickness, but 
as stated, he discountenances copper poisoning. Seventy-five copper- 
smiths interviewed in Chicago21 were uniformly healthy men, some of 
whom had been at the trade as long as 40 years. There was no evidence 
of "copper poisoning" among bronze or copper founders. 
In copper smelting, sulphuric and other fumes must be acknowledged 
as obnoxious and very destructive to surrounding vegetation. The toxic 
* Under the title, "Poisoning by Copper Fumes," Dr. W. H. T. Hamill, of Providence, 
R. I., describes the afflictions of workmen who attend rolls which ruff copper bars under 
high temperatures and while subjected to a continuous flow of water. Lake, or electrolytic, 
copper is used. At first a white cloud arises which gradually turns dark brown as the tem- 
perature mounts from 1500°F. upwards. This cloud contains copper oxide scale and fumes 
of arsenic. On humid days all who inhale this so-called "copper dust" are subjected to 
sudden attacks of " copper chills" which come on in from 30 minutes to 5 hours and strongly 
resemble malaria. However, there is no fever, the skin assumes a light yellow color with 
pinkish lips and nails, the taste is sweet, headache is severe, there is no vomiting although 
the blood pressure is lowered. Relapses do not occur. "The only lasting effect is a light 
persistent attack of gastro-enteritis during the summer months and then only periodically." 
Hamill suggests that the headaches are due to the lodgement of particles of copper on the 
mucous membranes of the turbinate bones " after the fumes of arsenic have spent them- 
selves." The copper scales stick like glue to the membrane and he uses a piece of mag- 
netized steel to remove them. A hypodermic of atropine ^50 gr- and morphine X gr> 
"stops the chill in about three minutes." "For the rash which resembles measles witch- 
hazel is very effective."-Bull. State Board of Health, Rhode Island, Aug., 1918, IV, 3, 
28-30. 324 
COPPER AND THE COPPER INDUSTRIES 
vapors which escape from the electrolytic refining of copper (an important 
American industry) are acidic in character, and cannot be considered as 
copper poisoning. While copper volatilizes to a slight extent below its 
boiling point (probably the surface temperature of the molten mass 
actually reaches above the boiling point), the metal is rarely boiled, as is 
zinc, in any industrial process. In an instance in which this did occur 
(electric furnace),22 those who inhaled the vapors suffered from severe 
influenzal-like symptoms, quite similar to those experienced after inhaling 
zinc fumes. Perhaps the severe symptoms experienced by those who 
breathe the fumes arising from pots of German silver (copper 60, zinc 
24, nickel 16) are due to some extent to volatilized copper, as well as to 
zinc, since the melting point of nickel (1500°C.) approaches the boiling 
point of copper. Certain salts of copper are astringent, or even caustic, 
and, in chemical industries and copper plating, may produce contact 
poisoning. The idea that copper workers are immune to typhoid fever 
was exploded years ago. Corper23 disclaims any therapeutic value of 
copper in tuberculosis. 
COPPER INDUSTRIES 
Copper Mining.-Copper miners and those who handle ores, as at 
milling, are liable to arsenic poisoning and also plumbism, providing lead 
is present in a soluble form. The ore dust itself produces digestive, 
respiratory, skin and conjunctival disease. Miners' boils,24 occurring in 
Michigan mines, are probably due to the action of the hard alkaline 
character of the water upon the skin, thus predisposing to infection. 
Miner's cramps^ occur especially among trammers in deep mines, and 
appear to be due to heat-fatigue toxins. These cramps may involve 
the whole body, last for hours or days, and perhaps end fatally. The 
exhaustive character of work in setting up one-man drills,25 powder fumes, 
ore dusts, high humidity, the lack of artificial ventilation, temperatures 
ranging from 85° to over 90°F. in the deeper shafts (some Michigan mines 
have the deepest shafts in the world-5300 ft. vertical depth) crude 
or absent sanitary arrangements and drinking water supplies, and high 
accident and fatality incidence are the chief hazards reported for copper 
mining.* Hook-worm disease is a great factor in older mines, or where 
foreigners are employed (including Cornishmen), or where temperatures 
reach over 70°F. In California mines 50 to 80 per cent, are so affected 
with a loss in efficiency conservatively estimated at 20 per cent, of the 
working force.26 According to Hoffman,27 mortality rates among copper 
miners for 1911 ranged from 3.32 to 3.54 per thousand, with tuberculosis 
* Those particularly interested in the industrial and health features of copper mining 
should get the report upon the Michigan Copper District Strike, Bull. U. S. Bur. Labor 
Statistics, whole No. 139, Feb., 1914, 183 pages illustrated. Furthermore, Miners' Cir- 
cular 20, U. S. Bureau of Mines, 1916, by Lanza and White explains "How a Miner Can 
Avoid Some Dangerous Diseases." COPPER MINING AND SMELTING 
325 
claiming about one-third of the deaths, and accidents a close second. 
Metal miners and smelterers are declined or considered extra hazards in 
life insurance.28 
A special study of 1614 deaths in the Butte district, Montana, 1907 to 1914, 
showed 37.9 per cent, due to tuberculosis of the lungs, 14.6 per cent, to pneumonia, and 
8 per cent, to other respiratory diseases. There was also evidence of silicosis and 
short work-life. 
Fig. 13.-Copper mining. Compressed-air gang at work on face of ore, Butte, Montana. 
(Photo furnished Wurdemann by Dr. Donovan.) 
Copper Smelting.*-The smelting of the ore is carried on in reverbera- 
tory furnaces and involves exposure to sulphurous! and possibly arsenical 
fumes, and also to the products of combustion which sometimes contain 
25 per cent, of carbon monoxide. In the electrolytic process of copper 
refining there is exposure to acid fumes. Hard work, exposure to exces- 
sive heat and sudden changes are likewise injurious factors and help to 
account for the pale and ill-nourished condition of the workers. 
* Prepared by George M. Kober. 
t Those interested in the effects of smelter fumes should read the Report of the Selby 
Smelter Commission, U. S. Bur. of Mines, 1914, Bull. 98, 528 pages, illustrated. See also 
Bull. 81. The Smelting of Copper Ores in the Electric Furnaces, by Lyon and Kennedy 
(1915). 326 
COPPER AND THE COPPER INDUSTRIES 
In most of the modern smelters steps are taken to utilize the monoxide 
of carbon for fuel, and the sulphurous fumes are condensed in leaden 
chambers for the purpose of making sulphuric acid. 
The dangers incident to the smelting operation can be materially 
diminished in this as in all other similar processes by high stacks and well- 
constructed furnaces, proper ventilation and sprinkling of the flues and 
chambers before they are cleaned out and the employment of respirators 
by the men engaged in this work. It is equally important that during 
the pouring of the metal the employes should be protected from the toxic 
fumes by hooded exhaust ventilation. 
Coppersmithing.-The coppersmith's trade resembles blacksmithing 
and boilermaking, except that copper is the metal dealt with and various 
machine processes of drilling, boring, shaping, beating and pounding, 
soldering, grinding, polishing and buffing are included. The metal, while 
never actually melted in the forges and furnaces, is often heated to a 
slight volatilization point. Heat, noise from hammering, and copper dust 
are the chief hazards. 
While Dr. Tatham9 found mortality rates from respiratory diseases 
high for copperworkers and Arlidge considered this trade hazardous, 
Simon and Knyvett9 considered it less dangerous than brassworking. 
Since the trade employs no large group of workers at one place, it is 
difficult to study them separately and recent statistical studies fail to 
particularize them. Acute bronchial catarrh, rheumatism, gastro-enteric 
catarrh, tonsillitis, neuralgia, eczema, diseases of the veins, contusions, 
fractures, burns and wounds and lead poisoning are prevalent affections 
among the coppersmiths of Berlin. The average age at the time of death 
was 47.4 years.29 Coppersmiths, like boiler makers, are liable to develop 
progressive deafness. Cases of oxalic acid poisoning contracted during 
the polishing of copper or brass utensils have been reported. The men 
engaged in soldering of copper are exposed to lead and the inhalation 
of acid and possibly arseniureted hydrogen fumes. Copper is also used, 
in connection with gold, silver and mercury, in water gilding and in the 
manufacture of bronzing powder. The sulphate of copper is used for 
coppering wire. Many of these processes involve not only the inhalation 
of dust, but also of acid fumes and therefore engender diseases of the 
respiratory and digestive organs. Much of the danger of dust inhalation 
has been eliminated by the substitution of acid dips for polishing but the 
acid dipping solutions expose the operatives to the inhalation of irritating 
fumes and hence all operations involving the evolution of dust or fumes 
should be carried on with adequate provisions for hood and exhaust 
ventilation. REFERENCES ON COPPER 
327 
BIBLIOGRAPHY 
1 Aldrich and Schmuckler.-Bull. No. 34, U. S. War Industries Board, 1919, History 
of Prices during the War. 
2 Molinari.-General and Industrial Chemistry (Inorg.), 1913, has been consulted 
for many of the mineral and chemical statements. 
3 13th U. S. Census Abstract. 
4 Robert.-Lehrb. der Intox., 1904-1906. 
"Latimer.-Lancet, 1887, 1, 1126. 
6 Rohrer.-Klin. Vortage, Bd. 1, Heft 3. 
7 Zadek.-Weyl's Handb. der Arbeiterkr., 1908, 112. 
8 Lee.-Am. Jr. Pub. Hlth., Nov., 1912, 863. 
9 Oliver's Dangerous Trades, London, 1902. 
10 Zadek.-Ref. 7 (page 112). 
11 Leurin.-Deut. Med. Vchschft., 1901, 689. 
12 Baum and Seeliger.-Arch. f. Wischftl. u. prak. Tierhkde, 1897, XXIII, 6. 
13 Peigney.-Rev. d'Hyg., 1918, XL, 66-85. 
14 Rambousek.-Industrial Poisoning, 1913, 188. 
15 Lewin.-Lehrb. d. Toxik., 1897. 
10 Rost and Weitzel.-Arb. Reichsgeshamt, 1919, LI, 494. Also E. Rost, Die 
Umschau, 1920, XXIV, 201-2. 
17 Baum and Seeliger.-Dtsch. Tierarztl. Woch., 1896. 
18 See Raoult et Breton. Jr. de Pharm. et de Chern., 1878, XXVII, 118. 
19 Rost, E.-Die Umschau, 1920, XXIV. 201-2. Also Liberi, Cusmano and Zay 
(See Bull. Agr. Intell., 1916, VII, 662-4). Also Schmidt, Jr. Amer. Chern. Soc., 
1914, XXXVI, 132-6. 
20 Zadek.-Ref. 7. 
21 Hayhurst.-Am. Jr. Med. Sc., May, 1913, 723-739. 
22 Hanson.- Metal, and Chem. Eng., 1911, IX, 2, 67. See also foot-note, Dr. W. H. T. 
Hamill, Rhode Island (above). 
23 Corper.-Jr. Infect. Dis., 1914, XV, 518-40. 
24 Warthin.-Public Health, Mich., 1st qt., 1912, 67. 
25 Taylor.-The Survey, Nov. 1, 1913, 131. 
26 Gunn.-Jr. Am. Med. Assoc., Jan. 28, 1911, 259. 
27 Hoffman.-Exhibits of the Prud. Ins. Co., Sept., 1912. Also Bull. U. S. Bur. Labor 
Stat., Whole No. 231, June, 1918, 366-70. 
28 Prud. Ins. Co., Rate Book, 1919. See also National Union (Fraternal) Ins. Co., 
June, 1912, III, No. 2, 4-6. 
29 Zadek.-Ref. 7, (page 149). SECTION 4 
ZINC AND THE ZINC INDUSTRIES 
E. R. HAYHURST, M. D., Columbus, Ohio 
Zinc occurs in nature principally as the sulphide (blende, sphalerite, "jack"), 
the carbonate (calamine), and the silicate. Its ores are widely distributed. It was 
first smelted in England in 1743, in Europe in 1807, and in the United States in 1873.1 
In 1918 the United States produced 545,000 tons of the metal (spelter) which is 
estimated as about one-third of the world's output. This was about double the out- 
put in 1911 in the United States when the zinc mining industry engaged 21,000 men, 
or 2 per cent, of all American miners.2 
The Western ores contain3 lead, iron, cadmium, and occasionally arsenic. The 
New Jersey ores are free from arsenic, practically so from lead, but contain manga- 
nese.4 The price of zinc, or "spelter," was about 5 cts. per pound before the war. 
During the war it was quoted as high as 37)^ cts. Zinc melts at 417.6°C. and boils 
(volatilizes) at 730°C.; hence it is, with the exception of cadmium, the only supposedly 
innocent metal boiling under 1000°C., an important point to remember since metal 
workers are thus industrially liable to the volatilization products of but one metal- 
zinc. In fact zinc volatilizes at temperatures as low as 500°C.B similar to the well- 
known evaporation of water at temperatures far short of its boiling point. The use of 
chlorides (as in galvanizing) still further promotes the volatilization of zinc. It is 
important to remember that all metals distill to a limited degree far below their boiling 
points, and if the metal is intrinsically poisonous its mere molten condition becomes a 
health hazard, which increases with temperature. Lead, for instance, distills even 
more readily than zinc, although its boiling point is 900°C. higher. 
Zinc is the most wasted of all metals.6 Conservation of tin, copper, aluminum and 
brass is effected by the use of zinc. It is also the most impure of all metals used 
industrially and, on this account, retains its old name "spelter."7 There is usually 
present a trace of lead (less than 0.1 per cent.) as well as iron, and sometimes manga- 
nese, cadmium and arsenic. But these impurities are very rarely the cause of indus- 
trial poisoning. Plumbism in this relation is usually due to the fact that lead is 
subsequently added to spelter alloys. 
Tests for Zinc.-Qualitatively Ganassini's8 test is very delicate. The substance 
to be tested, preferably in the form of zinc sulphide or calcium zincate, is exposed 
for a moment to the fumes of boiling hydrochloric acid arising from a test tube. The 
substance is then heated briefly to drive off chlorine fumes. A uric acid reagent is 
made by dissolving 2 grams of uric acid in 100 cc. of 5 per cent. KOH. Streak the 
substance with this reagent, using a fine glass filament. Then touch the moistened 
streak with a crystal of KjFeCng, or with a freshly prepared 10 per cent, solution of the 
same. In a moment a beautiful azure-green color will appear. Avoid excess of the 
uric'acid reagent. In verifying test reagents try them directly upon a piece of zinc 
or galvanized iron. Slight modifications render the test still more delicate and micro- 
chemical in character. The test may be applied directly to washed mucous mem- 
branes and sections of organs. The most delicate quantitative test9 is the calcium 
zincate method which, however, is a little too extended for the general practitioner. 
Its delicacy is claimed to be one in 30,000,000 parts, even in the presence of other 
metals and salts. Recent workers describe other methods, and also caution against 
zinc-containing glassware in making estimations.10 
328 USES AND TOXICITY OF ZINC 
329 
Principal Uses of Zinc.-Zinc has the following principal uses from the 
sanitarian's viewpoint: (1) Processes involving the manufacture of brass 
and bronze alloys; (2) galvanizing (by far its chief industrial use); (3) 
manufacture of German silver and white metal; and (4) the manufacture 
of zinc oxide (zinc white), used especially in the rubber and paint indus- 
tries and in the making of zinc salts. Other uses of zinc are as lithopone, 
a lead substitute in paints and enamels; in the manufacture of oilcloth; 
the manufacture of galvanic battery plates; the desilverization of lead; 
etching and lithographing plates; and the manufacture of parchment 
paper. 
Toxicity of Zinc.-Zinc per se is non-poisonous.11 In this, practically 
all recent authorities are agreed. 
Michaelis12 claims zinc to be a normal constituent of human tissues (probably in 
very minute quantities). Zinc exists in a large number of plants in which it probably 
has a definite physiological function.13 Bodansky (Jour. Biol. Chern., Nov., 1920,. 
399-407; Jr. Ind. Hyg., May, 1921, Abst. p. 15), found zinc present in the tissues of 
twenty species of marine animals and concludes that it is a normal constituent of the 
tissues. In animal tissues, zinc causes precipitation in unusual dilution,14 forming 
an inert (?) albuminate. Zinc ions markedly activate metabolic processes.15 When 
taken internally, zinc as oxide or salt can be detected in the blood and practically all 
tissues of the body.16 Given subcutaneously, the same obtains. In rabbits, its 
intravenous injections produce albuminuria with hyper-glycemia and glycosuria, the 
latter probably of renal origin similar to that of other heavy metals.17 Zinc does not 
accumulate to any extent in the system, but any excess is stored temporarily in the 
liver. It is found normally in the bile, urine, milk and other excretions. As with other 
metals, it is more largely excreted by the intestines, and perhaps the stomach, than by 
the kidneys.18 Zinc albuminate does not affect red corpuscles or other tissues, except 
possibly the heart muscle (frogs).19 
Certain salts of zinc, as the sulphate and chloride, are well-known astringents 
and caustics, and industrial poisoning (dermatitis, conjunctivitis) occurs from these 
as the result of carelessness in their handling. Zinc chloride burns or "sores" among 
workers in a wood preserving industry are described in detail by McCord and Kilker 
(J. A. M. A., Feb. 12, 1921, 442-3). All patients gave a history of slight injury, some- 
times only crevices or chapping. There was no evidence of infection, and little swelling, 
but pain might be exquisite at times. Treatment consisted of removal of overhanging 
scar tissue with sodium bicarbonate, alone, or with petrolatum. Prevention through 
the use of "lineoleated" canvas gauntlets proved entirely satisfactory. Seiffert20 
claims that the gastro-intestinal attacks which occur among zinc smelterers are not due, 
as commonly thought, to lead poisoning, but to swallowed zinc ore dust, rich in zinc 
sulphate and zinc carbonate [and undoubtedly changed to zinc chloride in the gastric 
juice]. The writer cannot agree that this is chronic zinc poisoning, as claimed by 
Seiffert, any more than the similar condition described by Peigney in copper workers, 
v. s. It would seem, rather, to be a local irritative reaction, due to the zinc salts men- 
tioned. (See also Cadmium, page 585). Investigating the use of cadmium solder in 
food containers Schwartze and Alsberg (studies about to be published on the Pharma- 
cology of Cadmium and Zinc with Particular Reference to Emesis-from the U. S. 
Bureau of Chemistry) determined that, on oral administration, the lethal dose of zinc 
(as sulphate and chloride) for animals (rats, rabbits, cats and dogs) is from five to 
seven times that of cadmium-cadmium, calculated as a metal, being eight to nine 
times more effective as an emetic than zinc. 330 
ZINC AND THE ZINC INDUSTRIES 
In the manufacture of zinc compounds arsenic poisoning may occur from impurities. 
Zinc chloride is used for denaturing alcohol, as a preservant for wood, for preparing 
parchment paper, and for weighting goods. The fumes of zinc chloride which form in 
soldering zinc, previously cleansed with hydrochloric acid, are an occasional com- 
plaint (proteid resorption poisoning?). Zinc sulphate is used in varnishes and as a 
mordant for the production of colors on calico. It is also applied with a brush, in 
saturated solution, to plaster and cement surfaces as a preparation for subsequent 
painting. 
The Lancet (London, Feb. 3, 1923, p. 242) reported a sudden outbreak of ill- 
ness amongst the inmates of a large institution where, within a few minutes, about 
200 out of the 400 persons who were served at tea with hot stewed apples, cooked 
in galvanized iron vessels, complained of dizziness, sickness, colic and tightness in 
the throat. After the administration of an emetic of bismuth and chalk mixture, 
most of the sufferers recovered in short order, and all were able to carry out their 
ordinary work the next day. Chemical examination of the stewed apples showed 
that each person had received approximately 18 to 20 grains of sulphate of 
zinc, undoubtedly produced by the action of vegetable acids in the apples on the 
galvanized stewing vessels. 
But there is something which occurs in association with the immediate 
products of zinc fumes which causes acute intoxication. 
Molten zinc when slightly overheated produces a greenish-yellow flame, and yields 
to the air a whitish smoke, composed of the flaky oxide of zinc ("philosopher's wool"). 
This is usually encountered in the making and pouring of brass. There is also pro- 
duced some zinc dust, due to incomplete oxidation. Obviously the fumes themselves, 
being at high temperature, cannot be inhaled or at least absorbed as such. Experi- 
mentally, zinc dust, zinc oxide and zinc carbonate are all harmless,21 whether ingested 
or inhaled. Lehmann,22 however, proved that the symptom-complex known as 
"brassfounders' ague" could be produced in every feature in man by burning pure 
zinc and inhaling the oxide therefrom. He believes that the zinc oxide produces 
proteid destruction in the respiratory membranes with resorption of the destroyed 
cell contents into the system, and that these dead proteids acting as toxalbumins 
produce the symptoms. Experimental animals do not develop the same symptoms, 
but after such exposure show a more or less violent congestion and reddening of the 
respiratory mucous membranes with zinc demonstrable in the lung tissues and, later, 
in various organs (guinea-pigs and rabbits).23 To our mind, the phenomenon may be 
explained as due to the hygroscopic action of the hot, almost nascent oxide just formed 
in the foundry atmosphere. Thus the usually inert oxide is in such a condition that it 
not only dries but actually sears the epithelium (ciliated, simple and parenchymatous) 
of the respiratory mucous membranes.* An analogy is seen in the fact that zinc 
chloride may even carbonize organic substances in its demand for moisture, and the 
resultant symptoms (as seen in intra-uterine cauterizations25 with zinc chloride) are 
similar to, and also explainable as, proteid resorption phenomena. There are many 
things in the composite picture of "zinc ague" which tend to bear out the above 
"anaphylactic" explanation: (1) Pharmacologists have proven the harmlessness of 
non-caustic zinc compounds;26 (2) the quick immunity to subsequent attacks, which is 
similar to all foreign-proteid poisonings; (3) no poisonous metal is known to produce 
a rise in temperature; (4) metallic poisons act accumulatively; (5) infection is negatived 
since ulcerations, septicemia, pyemia, and fatalities never occur; (6) fumes of other 
metals, whether such metals are poisonous or not per se, produce similar symptoms 
* Subsequent to my suggestion23 that it might be due to zinc in the temporary form of 
zinc carbonyl (ZnCOd, similar to Armit's explanation for the toxicity of nickel fumes, 
Gillett (Bull. 73, U. S. Bur. of Mines) claims this explanation to be untenable upon the 
grounds that the existence of zinc carbonyl is unknown. ZINC AGUE 
331 
(copper,27 nickel,28 iron,29 cobalt,30 cadmium31); (7) that the symptoms are invariably 
associated with zinc (or brass) only is simply a trade-process circumstance, due to the 
low boiling point, excessive volatility, cheapness and therefore waste of zinc to the air. 
A more explicit explanation comes from Drinker,24 a metallurgist, who gives an 
excellent bibliographic review, with critical comments, and states the following: The 
difference between the zinc oxide which produces the ague and that which does not 
is that in the freshly burned state it is made up of dispersed particles which have not 
yet absorbed moisture, while, in the usual state in which it is handled without unto- 
ward effects, "it is largely flocculated, undoubtedly lower in temperature, and contains 
some adsorbed moisture." 
ZINC AGUE 
Synonyms.-Brassfounders' ague, brass chills, zinc chills, smelter 
shakes, metal shakes, zinc asthma, braziers' disease. 
Definition.-"Zinc ague," or "brassfounders' ague," may be defined 
as an acute malaria-like syndrome of chill, fever (sometimes) and sweat, 
appearing a few hours after the inhalation, for a few minutes or longer, of 
zinc fumes, whether pure or, as is the usual rule, in the form of brass 
fumes, affecting only, or mostly, those unaccustomed to such exposure; 
further characterized by the development of a form of temporary im- 
munity, and absence of immediate serious or fatal consequence. Definite 
chronic symptoms due to the presence of zinc probably do not occur, but 
the morbidity and mortality rates of workmen constantly exposed to 
the breathing of the fumes are high, with respiratory diseases especially 
in evidence. 
Occurrence.-Of the different classes of workers, the symptoms of the 
"ague" do not occur among the miners, nor in the handling of zinc or its 
compounds at ordinary temperatures; they may occur, though rarely, 
among galvanizers and infrequently among zinc smelterers and oxide 
makers; they occur very commonly among workers in brass foundries, 
casting shops and in brazing processes, also among refiners of junk metal 
and dross. 
Symptoms.-At the end of a few hours' exposure,'or even less, to the 
breathing of the metallic smoke which arises during the melting or pouring 
of brass or zinc, the nose, throat and substernal region have a sensation of 
dryness, soreness and burning. The conjunctivae feel irritated. There 
may be a metallic taste in the mouth, an unproductive cough, a feeling of 
constriction in the chest, lassitude, headache and loss of appetite, followed 
sometimes by nausea and vomiting. Within one to several hours after 
the exposure the vision may become blurred, the headache worse, the 
cough more productive and the sputum blood-streaked.32 Chilly sensa- 
tions begin to appear and the victim usually takes to his bed. The shiver- 
ing rapidly increases into a distinct rigor, which may last from to to 2 or 
3 hours. No amount of external heat or friction appears to lessen the 
chill and shaking. There is a great desire to imbibe hot drinks and stimu- 
lants. During this stage there are usually muscular cramps and sharp 332 
ZINC AND THE ZINC INDUSTRIES 
joint pains. The victim feels that he is deathly sick. These symptoms 
end almost by crisis and are followed by a most profuse perspiration, in 
which some claim there is an odor of zinc. There is an immediate sensa- 
tion of great relief. Sleep supervenes and the victim awakens the next 
morning with no remaining symptoms of his recent experience other than 
a little exhaustion, perhaps a metallic taste, and a temporary loathing of 
food. The entire attack lasts from a few to 20 hours, seldom longer. 
In many cases there is a distinct rise in temperature during and follow- 
ing the chill, but it is not constant and may be subnormal. It does not 
usually mount high. The pulse during the chill is small and rapid- 
120 to 130 per minute (zinc effect upon the heart?). The respiratory 
rate is not much affected. The blood findings during and after a chill 
have been reported as normal, although some have found a slight leucocy- 
tosis, and Arnstein, in experiments with brass fumes on men, found a 
constant leucocytosis to 16,000, in which neither the per cent, of lympho- 
cytes nor of eosinophiles was affected, thus differing from an infection. 
Sigel33 proved the absence of carbon monoxide hemoglobin as an etiolog- 
ical factor by spectroscopic examination of the blood. The urine after 
a severe chill invariably shows albumen and casts which clear up within 
a day or so, and zinc is usually present, although much more of this metal 
is to be found in the feces. Arnstein was struck by the fact that these 
symptoms were evoked by very minute traces of zinc in the air (0.007 gram 
of zinc oxide in 30 liters of air). Graeve34 reports an enlargement of the 
spleen noticeable after a few days. 
There are many conditions which seem to influence the onset and 
severity of zinc chills. The newer workmen, or those who have returned 
to work after a week's vacation, perhaps only after a day or so off, as over 
Sunday, are the most liable. Unless the exposure to the metallic smoke 
and vapors has been unduly severe, the workman continues at his vocation 
all day without noticing untoward health effects. It is usually after leav- 
ing work at night that the sickness comes on. Many state that as soon 
as the cold outside air strikes them or when removing the clothes at 
bedtime the chill is inaugurated. Hence chills are far more common in 
winter than in summer. This seasonable influence is due mostly, how- 
ever, to decreased ventilation through closing of doors, windows and 
skylights in foundries. Following a snowstorm, such a large per cent, of 
workers have been seized with chills that the condition has been mis- 
taken for an epidemic (some form of influenza). The worst complaints 
in my experience have come from so-called bronze foundries where 
journals are cast for car wheels. Although the bronze contains only a 
small per cent, of zinc, it is melted and poured by the ton so that the 
amount of fumes becomes excessive. Lead poisoning from babbitting is 
very frequent here too. The chills occur rarely in shops where pouring 
is done but once or twice daily. The frequency of the chill, other condi- 
tions remaining the same, is almost in direct ratio to the percentage of ZINC AGUE 
333 
zinc contained in the alloy. Furnace men, casters and helpers are rather 
more exposed than moulders. Deep breathing while under strain is a 
most important factor. About 70 to 80 per cent, only of workmen seem 
susceptible; hence some natural immunity seems to exist. Also a 
tolerance occurs in about 70 to 75 per cent, of workmen who work steadily 
at the trade. A further 20 to 25 per cent, sicken more or less regularly, 
but usually not severely. Only in very rare cases do these attacks occur 
so frequently that a change of occupation is necessary. Still many older 
workmen prefer to lay off in the winter season. The workers consider 
the chills so commonplace and matter-of-course that they do not go or 
send to the physician on account of them. All factors which tend to 
lower natural vitality are predisposing to zinc chills, especially alcoholism,35 
poor quality of food, as is consumed by a large proportion of the foreign 
workmen, irregular hours, and excesses of all kinds. In addition, weak, 
anaemic individuals, young persons and women are more subject to 
zinc fumes than are robust individuals. 
Unlike lead, zinc probably does not produce chronic poisoning (but 
see Seiffert's claims above). This is best explained by the fact that it has 
very little tendency to accumulate in the system. The chronic neuritic 
symptoms, described by older writers as affecting the lower extremities 
particularly, were quite probably due to impurities in the metals, such as 
arsenic and lead. However, the continual occurrence of zinc chills pro- 
duces, in from 5 to 20 years' time, the same results as described below in 
brass poisoning. 
Diagnosis.-As just stated, the physician must get away from the idea 
of attempting to diagnose chronic zinc or brass poisoning, as there prob- 
ably is no such condition. Rather, look to lead, arsenic or manganese for 
the specific causes of such conditions. Every complaint of chill, fever 
and sweat, lasting a few hours' time, and with absence of interval symp- 
toms, should cause inquiry to be made as to exposure to metal fumes, the 
more so if the symptoms occur after the work period, or during inclement 
weather, or the winter season. 
The worker himself may consider the symptoms due to malaria, 
especially if he has even been so afflicted. Zinc ague attacks must be 
differentiated from influenza, or la grippe, as there are respiratory com- 
plaint, aches and pains, and a subfebrile movement in all three, but the 
"ague" shows a minimal character of catarrhal symptoms with pain, 
soreness and constriction symptoms in the throat and substernum promi- 
nent. The chills are usually unduly severe, while the recovery from 
subsequent malaise after the sweating period is quick, and there is an 
entire absence of sequellae. Acute bronchitis, onset of tonsillitis, or of 
septic processes may confuse for the first few hours. The repetition of 
the chills and fever of irregular type may be confused with the course 
of tuberculosis, Hodgkin's disease and leukemia, while, on the other hand, 
the physician often comes to the erroneous conclusion, particularly if 334 
ZINC AND THE ZINC INDUSTRIES 
no fever can be detected, that he is dealing with a case of auto-intoxica- 
tion, neurasthenia, hysteria, or malingering. 
THE ZINC INDUSTRIES 
Zinc Mining.-While zinc is mined extensively throughout the world, the United 
States is the chief producer (Missouri, Montana, New Jersey, Colorado). It is nearly 
always mined with lead. The chief form of both metals is the sulphide, but near the 
surface the ores are often oxidized and acidified to carbonates and sulphates. The 
Missouri district has been the best studied from a hygienic viewpoint.36 It presents 
the extreme conditions of rock-drill mining with the well known result, miners' 
phthisis (which see). Most of the ore is found in hard or so-called "sheet" ground.37 
Shafts are sunk up to 400 feet in depth. The ore occurs in beds of flint (chert) 
often 40 feet thick and lying horizontally. Mining is on a modified "long wall" 
type (circular extension in all directions from the foot of the shaft), with about 30 
per cent, of rock left in for pillars, so that constantly extending chambers are pro- 
duced. Unlike coal mines practically all material blasted is taken to the surface. 
New shafts are sunk, to facilitate working and ventilation, about 300 feet apart. 
Water under foot and seeping in during the rainy season is a handicap, especially in 
soft-ground mines. The latter are usually slope or drift mines and, in distinction to 
the former, require much timbering. Mining methods and structures seem crude, but 
this is due to«the lack of necessity for permanency, so that, after all, a good grade of 
efficiency is maintained. Within the mines the chief work consists in drilling holes 
into the rock, blasting with dynamite, shoveling material into half-ton buckets and 
tramming same by hand, mule or motor power to the hoisting shaft. On the surface, 
the ores are milled and concentrated38 to about 30 per cent, zinc content after which 
they are binned or shipped to smelters which are usually located in coal regions (even 
400 miles away). The refuse or "tailings" accumulates at the mines in huge mounds 
but may be used for railroad beds. About 15,000 workmen are in the Missouri 
district-mostly native-born Americans. Wages are considered good. A strong 
miners' union exists. 
The chief health hazards are as follows: (1) The breathing of siliceous 
dust of flint character, very angular and jagged and constantly suspended 
in the mine air during work; also found in the coughed-up sputum of 
the workers. 
These range in size from 2 to 5 microns down toparticles of colloidal dimensions, the 
numbers countable being perhaps the highest dust counts on record, while the weight 
ranges from 1 to 5 mgms. per 100 litres of air at breathing points. The dust is pro- 
duced chiefly by the blowing out of cuttings, by means of compressed air, from the 
drill holes and by "bowlder popping," or the blasting asunder of bowlders too large 
to handle; also by "squibbing" (enlarging drill holes by powder blasts), drilling 
without water in the holes, shoveling, loading the tram buckets, tramming, and trim- 
ming down of roof and pillars. It is made worse through careless personal habits of 
the workers, unnecessary exposures and, oftentimes, holding the head low while 
shoveling. Furthermore, all blasting raises settled dust by throwing the mine air 
into violent vibrations. Of 720 men physically examined by Lanza, 472 were 
suffering from pulmonary disease, and "60.4 per cent, suffered from diseases 
of the lungs directly due to rock dust." Tuberculosis invariably follows in time, being 
rooted in the district, so that "practically no cases die without its being present." 
The infected miner easily infects the members of his household. Control consists in HEALTH HAZARDS OF ZINC MINING 
335 
water spraying and the enforcing of wet methods throughout, blasting only outside of 
work hours, increasing shafts or installing fans for ventilation, limiting shoveling to 
those of 20 years of age or over, adopting physical examinations, and much personal 
instruction such as the limiting of spitting. Compensation for "miners' phthisis" 
on the Witwatersrand, South Africa, where,up to the end of January, 1914, $5,659,740 
had been granted in awards in spite of serious difficulties chiefly on the grounds of 
malingering, but also of actual diagnosis, has resulted in "the conditions underground 
inimical to health and life gradually being brought under sanitary and medical 
control."39 
2. Poisoning.-Plumbism, while rare among Missouri miners and 
mill men, may occur in developing new mines due to working the oxidized 
ores near the surface. Galena (lead sulphide) causes no poisoning (Lanza), 
but Alice Hamilton40 doubts the same, from St. Louis Hospital records. 
Arsenic and "metallic" poisoning41 are reported from abroad,42 and, 
where the ores contain manganese, those exposed to the dust develop 
peculiar nervous symptoms.43 Powder gas released in shoveling, and 
volatilized oil improperly used in air compressors, cause complaint. The 
use of gasoline motors in some mines may occasion exhaust-gas poisoning. 
The use of natural gas for power purposes has its attendant hazards. In 
many quarters the mine waters are acidulous (H2SO4) and therefore caustic. 
Where the flotation process is used in concentrating ores, warm sulphuric 
acid, creosote, coal-tar, pine oil, turpentine and rosin may be used. 
3. Ventilation.-Natural air currents are chiefly depended upon in the 
mines. These are effected through shafts and air holes to the surface as well 
as cross openings. Circulation often stagnates at working faces, although 
vitiating factors (mine gas as in coal mines, breathing of men and animals, 
lights, combustion of explosives, and timber decay) may be negligible 
according to some air samples. Only a few mines use fans. Respirators 
(little used) are not recommended because they do not retard the fine dust 
while they give a false sense of security. The state mine inspectors look 
especially after ventilation. Temperature in the Missouri mines ranges 
from 52° to 65°F., with relative humidity from 82 to 100 per cent, and 
both stable the year around. 
4. Illumination is by the miners' carbide lamps and by electricity and 
is good. 
5. Fatigue is a feature especially emphasized. The 8-hour shift 
prevails for miners with a 20-minute dinner period, and 10-hour shift for 
mill men, except where three 8-hour shifts prevail. 
The average shoveler handles 22 tons per day at piecework rates. Many workers 
are youths and at 25 years of age find themselves able to do hardly half the work they 
accomplished 2 to 6 years earlier. They work incessantly the entire shift, "the whole 
picture furnishes an example of burning the physical candle at both ends that is 
attested by the figures quoted at the beginning of this report" (Tech. Paper 105, 
U. S. Bur. of Mines, 1915). Placing a limit to the tonnage shoveled daily is the 
suggested remedy, with an age requirement of 20 years or over (the laws permitting 
boys 14 and over to work underground). 336 
ZINC AND THE ZINC INDUSTRIES 
6. Tuberculosis Cross-infection.-"The risk of conveyance of tuber- 
culosis from infected to healthy persons underground is by no means 
negligible. Out of 205 specimens of sputum collected underground, 15.2 
per cent, contained the tubercle bacillus. Infection is more likely to 
arise from contamination of the hands and subsequent ingestion. All 
water for sprays, as well as drinking, should be pure. There should be 
disfection of ladders and traveling ways, also change houses and living 
rooms."44 
Hoffman45 says that in the Prudential Company's experience "out of 96 deaths 
from all causes (lead and zinc miners) the extraordinary number of 47, or 49 per cent., 
are caused by deaths from pulmonary tuberculosis, in contrast to the expected pro- 
portion of 13.9 per cent. 
7. Sanitation and Other Features.-Lanza dwells on the primitive 
■standards of living, of sanitation, water supply and refuse disposal within 
the mines, at the surface workings and in the housing districts, but at the 
close of his work he describes the improvements following upon recent 
mining laws and the educational propaganda, such as the abolishing of 
the common drinking cup, the erection of change houses, washing facilities 
and shower baths, and improvements in the disposal of human wastes. 
Still, Wright,46 a mining engineer, proclaimed in 1918 that health and 
safety should be given more attention to insure efficiency. 
Mrs. Norma Seibert, who is now in the writer's department at Ohio State University, 
■conducted public health nursing work in the zinc mining district for the Extension Depart- 
ment of the University of Missouri in 1919 and attributes the low standards of living 
to the uncertain future which confronts almost every mine with its possible shut-down, as 
well as tq lack of instruction in better ideals. The workers make good wages but spend 
it on foibles. While the existence of hookworm infection is probable (Lanza says none 
was found among the miners, which fact he lays to their working largely in rocky instead of 
sandy ground), the people have great fear of it and are careful in wearing shoes. Malaria 
is no factor, but trachoma is believed to be common. Rheumatism is a very common 
complaint. Water for domestic purposes is often at a premium and it is no uncommon 
thing to see it sold on the streets. An interurban system furnishes good transportation. 
Several hospitals exist and some of the union locals as well as companies employ nurses. 
There are no tuberculosis sanatoria, but county infirmaries provide a room or annex for 
the care of the indigent sick. Following the war considerable inertia settled over the district. 
C. M. Mills (Survey, Feb. 5, 1921, 657-666) describes industrial conditions in the 
Joplin district which, he says, comprises 1000 square miles and is the home of 12,000 
miners. The territory is peculiarly barren and hideous in its outlook because of the 
ravages caused by mining. In the leading towns 94 per cent, of the miners are American 
born of American parentage. They are entirely unorganized. Accidents of all kinds have 
a high rate. While watercore drills have come into general use in the district and resulted 
in much improvement, the silicosis problem still remains. The whole industry "stands in 
a pre-Victorian period of social development." The short lived character of the average 
productive area and the "small capitalists" explain in part the conditions. In'his opinion 
the operators are responsible for the conditions and change must come through them. 
Zinc Smelting.-American ores are usually smelted by the Belgian 
process in which the ore is first roasted to drive off the sulphur (sul- 
phuric acid is an important by-product), then volatilized in clay retorts 
having muffles attached in which the fumes condense.* The escape of 
* An interesting series of articles descriptive of American zinc smelting plants, by E. H. 
Leslie, is to be found in Mining and Scientific Press, 1914, Vol. CIX, pages 44, 136, 204, 280, 
395 and 475. During the Illinois survey of occupational diseases, the writer investigated ZINC SMELTING GALVANIZING 
337 
zinc fumes which sometimes contain also the fumes of antimony, arsenic^ 
cadmium, lead and manganese is rendered almost negligible. 
Zinc smelting has certain forms of occupational complaints: (1) "zinc 
chills" (see above) which are of infrequent occurrence because from 
industrial economy the escape of fumes is limited; (2) lead poisoning, where- 
lead occurs in the ores, is of greater frequency than among brass moulders- 
(the lead-burners or solderers who work in the acid tank houses are also- 
very liable to plumbism); (3) "summer colics," probably due to heat- 
fatigue toxins, plus the drinking of cold water (note Seiffert's claims under 
"Toxicity of Zinc"); (4) heat prostrations; (5) "zinc asthma," which is 
very prevalent and shows winter exacerbations; (6) gas poisoning, from 
the producer-gas made and used; (7) industrial alcoholism, due to a tradi- 
tion among the workers that alcoholic liquors are antidotal to zinc and 
other metallic poisonings, but heat, dust, gases and fatigue also contribute 
to it; (8) rheumatic affections-very common-especially lumbago; (9) 
dermatitis and boils, due to the ore dusts; (10) a rare possibility of arsenic 
poisoning, in American works, and (11) night blindness,47 probably a 
zinc effect, but may be due to looking at zinc flames. It contributes 
to accidents. Colored glasses should be worn by furnacemen. 
Rambousek's48 summary of the afflictions of zinc smelter workers shows that 
among 4789 men there were 50 cases of lead colic, 18 of kidney diseases, 223 of gastric 
and intestinal catarrh, 40 of anaemia, and 612 of rheumatism in 1 year's time. (For 
insurance risks see "smelting," under Copper.) According to Dr. Krautz49 the num- 
ber of cases of lead poisoning in the German zinc-smelting industry has been reduced 
by hygienic methods from 819 cases among 1200 employes in 1879-1885 to 78 cases 
per 6400 workers in 1910. According to Tatham the mortality of zinc workers in 
Great Britain was 1198, as against 602 for agriculturists. Consumption and diseases 
of the respiratory and circulatory organs predominate. 
Galvanizing.-Sheet iron or metal to be galvanized is first cleansed in 
a "pickling" bath of hot dilute mineral acid, and then dipped into a bath 
of molten zinc, which is kept from overheating by sprinkling sal ammoniac 
upon its surface. A layer of melted lead forms the bottom of the zinc 
bath, its heavier specific gravity keeping it down, where it helps to prevent 
overheating. The occupational afflictions of this industry may be 
summed up as follows: (1) Inhalation of acidic steam and vapor from 
pickling, causing rhinitis, frontal headaches, conjunctivitis, bronchitis, 
and asthma, dental caries, reddening and softening of the gums, hyper- 
acidity, mucous gastritis, and attendant disturbances, also the immersion 
of the hands in acid baths whitens and hardens the skin which tends to 
three of these plants, one of which, the Nassau Zinc Works at DePue, Illinois, Leslie 
describes as the largest and most modern American zinc smelter (see Report of the Com- 
mission on Occupational Diseases to His Excellency, Gov. Chas. S. Deneen, Jan., 1911, 
pages 73-79). The largest plant at present is probably one of the Bartlesville Zinc Com- 
pany's located at Collinsville, Oklahoma. W. R. Ingalls describes the new large plant of 
the American Steel & Wire Company, located at Donora, Pa., in the Pittsburg district, in 
the Engineering Mining Journal, 1916, Vol. CH, 648-54. A list of the 56 chief smelters 
with their respective capacities is given in Bull. 154, U. S. Bureau of Mines, 1918, 124-5. 338 
ZINC AND THE ZINC INDUSTRIES 
crack; (2) sal ammoniac "smoke/' which when inhaled at first causes 
coryza, with perhaps epistaxis, nasal sores and dyspnoea, but workmen be- 
come rapidly inured to it; (3) rheumatism and lumbago, from alternations 
of heat and cold exposures, especially when combined with occasional 
heavy lifting or straining; (4) dermatitis, from the chemicals used; (5) 
arsenic poisoning as a rare possibility, from the spelter; (6) "zinc chills"80 
(see above), which can occur only when the metal becomes overheated; 
and (7) lead poisoning, infrequent and probably due to handling the 
metal rather than from any escape of lead as fumes. 
Manufacture of Zinc Oxide.-Ores of second grade, as a rule, are 
smelted and the zinc fumes condensed in long air-cooled pipes under nega- 
tive pressure, which convey the zinc oxide formed to bag houses. Here 
the oxidized coal gases and other gases escape through the meshes of the 
muslin bags, while the flaky oxide is caught. The afflictions of the 
furnacemen are practically the same as those of smelterers, but zinc chills 
are less common because of less exposure. However, they may occur.51 
Bassett52 states that they have been a very serious factor in securing and 
retaining labor, particularly in the bag rooms. This is probably a question 
of the completeness of the oxidation and the cooling of the oxide before it 
reaches the bags. In the new and model plant which I once visited 
at Palmerton, Pa., bronchial afflictions were said to be the only complaint 
among the bagmen, this from the escaped dust. Packers were more 
troubled even than bag-house men.53 Zinc dust (pulverized zinc) and zinc 
oxide may also produce dermatitis,* conjunctival and digestive distur- 
bances, similar to other metallic dusts, and workmen should be protected 
as well as possible. Zinc dust may be a constituent of "bronze" powders. 
Zinc oxide may be used in brewing to assist in disinfection and preservation. 
Zinc white (zinc oxide) is used in great quantities to mix with dried 
rubber to secure the physical properties necessary for pneumatic tire 
casings. 
Zinc Paint.-Zinc white and lithopone (the latter is zinc sulphide and 
barium sulphate) are the best substitutes for lead in paint. Lithopone 
makes an excellent marine paint. Sir Thomas Oliver54 says that zinc can 
certainly be used for all interior decorations, and that reformers maintain 
that the slight advantage of white lead over zinc for exterior painting 
is not worth the cost to human life. The French and British laws which 
greatly curtail the use of soluble lead compounds have undoubtedly 
extended the use of zinc paints. 
* John A. Turner (U. S. P. H. Reports, Nov. 4, 1921, 2727) investigated the "oxide 
pox " among workers in a zinc oxide plant where 14 of 17 men gave a history of it, and 
considers that the disease is primarily due to a clogging of the skin glands with the dust and 
secondarily to infection, so that the papules become composed chiefly of zinc oxide. Free 
perspiration greatly favors the disease. The freshly made oxide is very hydroscopic, so 
that after storage the moisture content was found to be increases 122 per cent. While 
traces of other metals were present, the zinc oxide was 99.199 per cent. pure. He considers 
it non-toxic but capable of acting as a mechanical conveyor of bacteria. Personal cleanli- 
ness, special work clothes often washed, limiting of dust, and bathing facilities are recom- 
mended in its prevention. REFERENCES ON ZINC 
339 
REFERENCES 
1 See Molinari, Ref. 2, under Copper. 
2 See Bull. 34, U. S. War Industries Bd., and U. S. Census (Ref. 1 and 3, under 
Copper). 
3 Ill. Comm. Rep. on Occ. Dis., 1911, 74. 
4 Casamajor.-15th Int. Cong, on Hyg. and Dem., Ill, pt. 2, 574. 
6 Bassett.-Jr. of Ind. and Eng. Chem., March, 1912, 164. 
6 Parsons.-Jr. of Ind. and Eng. Chem., March, 1912, 165. 
7 Encyc. Brit., 11th Ed.. 1912. 
8 Ganassini.-Bol. d. Soc. Med. Chir. di Pavia, 1909, XXIII, 72-90. 
9 Bertrand et Javillier.-Compt. Rend. Acad. d. Sc. 1907, CXL, 924-6. 
10 Birckner.-Jr. Biol. Chem., 1919, XXXVIII, 191-203. Also, Weitzel, Arb. 
Reichsgeshamt, 1919, LI, 476. 
11 Rambousek.-Industrial Poisoning, trans, by Legge, 1913, 151. 
12 Michaelis.-Quoted from Hill in Ref. Handb. of Med. Sc., VIII, 339. 
13 Javillier.-Ann. de 1'Inst. Past., 1908, 721. 
14 Kisskalt.-Ztschr. f. Hyg. u. Infect., 1912, LXXI, 472. 
15 Knauer.-Ztschr. f. med. Elek. u. Rontg., Leipsig, IX, H. 12, 1907. 
16 Matzkewitch et al.-Ref. 10, above. 
17 Salant and Elsberg.-Jr. Biol. Chem., 1918, XXXIV, 447-62. Also, Salant, 
"The Pharmacology of Heavy Metals," Jr. Ind. Hyg., June, 1920, II, No. 2, 
72-78, (a summarizing statement). 
18 Arnstein.-Wien Arbeit, a. d. Gebiete d. soz. Med., 1910, I, 49-50. Also Moore- 
Oldershaw-Williams, Brit. Med. Jr., Aug. 2, 1913, 217. 
19 Sacher.-Arbeit, d. Pharm. Instit. zu Dorp., 1893-4, 88-152. 
20 Seiffert.-Off. Gschtpflge., 1918, III, 44, 85, 116. 
21 Sacher.-Loc. cit. See also Hirt (1882), Lehmann (1910). 
22 Lehmann.-Arch. f. Hyg., 1910, LXXII, 358-381. 
23 Hayhurst.-Am. Jr. Med^Sc., May, 1913, 723-739. 
24 Drinker, Philip.-Jr. Ind. Hyg., Aug., 1922, pp. 177-197. 
25 Buttersach.-Mntschr. f. Geb. u. Gyn., 1909, XXIX, 11-22. See also Clin. Mod., 
Zarogoza, 1908, VII, 343. 
29 See also Lander and Edwards, Jr. Comp. Path, and Ther., Edin, and Lond., 1912, 
XXV,. 319-321. 
27 Ref. 22, under Copper; also Peigney, Rev. d'Hyg., 1918, XL, 66-85. 
28 Armit.-Jr. Hyg., 1911, VII and VIII. 
29 Layet (1877), Homann (1903), and Armit (1911). 
30 Armit.-Loc. cit. 
31 See Homann. Also Kisskalt, ref. 14, above. 
32 Zadek (ref. 7, under Copper) mentions coughing of blood in certain instances. 
33 Vrtjschr. f. gerichtl. Med., July and Oct., 1906, 174, 384. 
34 Weyl's Handbuch, footnote, page 113. 
35 See Laureck, Weyl's Handbuch, 57. 
36 Wright, C. A.-Mining and Treatment of Lead and Zinc Ores in the Joplin District, 
Missouri, Tech. Paper 41, Bureau of Mines, 1913, p. 40. Lanza and Higgins, 
Pulmonary Diseases among Miners in the Joplin District, Missouri, Tech. 
Paper 105, Bureau of Mines, 1915, 47 pages. Lanza and Childs, Miners' 
Consumption with Roentgen Ray Findings, Pub. Hlth. Bull. No. 85, U. S. 
Pub. Hlth. Ser., 1917, 39 pages. Higgins, Lanza, Laney and Rice, Siliceous 
Dust in Relation to Pulmonary Disease among Miners in the Joplin District, 
Missouri, Bull. 132, Bur. of Mines, 1917, 116 pages. 
37 Wright, C. A.-Mining and Milling of Lead and Zinc Ores in the Missouri-Kansas 
-Oklahoma Zinc District, Bull. 154, Bur. of Mines, 1918, 134 pages. Also 340 
ZINC AND THE ZINC INDUSTRIES 
by the same author, Mining and Milling of Lead and Zinc Ores in the Wisconsin 
District, Wisconsin, Tech. Paper 95, Bureau of Mines, 1915, 39 pages. 
38 Lyon and Ralston.-Recovery of Zinc from Low-grade and Complex Ores, Bull. 
168, Bureau of Mines, 1919, 145 pages. 
39 Hoffman, F. A.-Mortality from Respiratory Diseases in Dusty Trades, Bull. 231, 
U. S. Bureau of Labor Statistics, 1918, 354. 
40 Hamilton, Alice.-Lead Poisoning in American Industry, Jr. of Ind. Hyg., May, 
1919, I. No. 1, 9. 
41 Murgia.'-La. Clin. Mod., 1906, XII, 316-19. 
42 Mangold, G. B.-Cited from the Survey, Jan. 17, 1917, 470. See also U. S. Labor 
Bulletin No. 95, 3. Also Hoffman, F. A., Bull., 231, U. S. Bureau of Labor 
Statistics, 1918, 356-58. 
43 Casamajor.-XVth Int. Cong, on Hyg. and Dem., Ill, part 2, 574. See also his 
Chapter in Kober and Hanson's Diseases of Occupation and Vocational 
Hygiene, P. Blakiston's Son & Co., 1916, pp. 119-125. And Edsall, Wilbur 
and Drinker, Jr. of Ind. Hyg., Aug., 1919, Vol. I, No. 4, 183-93. 
44 Miners' Phthisis Prevention Committee, Pretoria, Union of South Africa, 1916, 
quoted from Rice's article in Bull. 132, Bur. of Mines, 1917, 91. 
45 Hoffman, F. A.-Loc. cit. (Bull. 231), 359. 
46 Wright, C. A.-Loc. cit. (Bull. 154), 124. 
47 Roth.-Komp. der Gewerbekr., 1909. See also Laureck, in Weyl's Handbuch. 
48 Industrial Poisoning. Trans, by Legge, 1913, 130. 
49 Krautz.-Sozial Technik, IV, No. 2, 1912. 
50 The author has encountered a number of such cases. 
61 Bouchut.-Cited from Arlidge's Diseases of Occupation, 1892, 449. Also Hohmann, 
1913. 
52 Jr. of Ind. and Eng. Chem., March, 1912, 154. 
63 Dr. Luther, Company Surgeon. 
64 The Survey, Aug. 30, 1913, 662. SECTION 5 
BRASS AND THE BRASS INDUSTRIES 
BY E. R. HAYHURST, M. D„ Columbus, Ohio, and GEORGE M. KOBER, M. D. 
Washington, D. C. 
Brass is an alloy of copper with a base metal, usually zinc, but sometimes tin, and 
contains varying quantities of other metals. Fine brass or red brass consists of 
copper 2 and zinc 1. However, as these two metals combine in practically all pro- 
portions, many alloys are possible. "Cheap yellow brass" is very rich in zinc. The 
making of brass was known to the Phoenicians before Solomon's time. Pliny describes 
brass fumes. The brass of the Bible was probably bronze. From % to 13 per cent, 
of lead is contained in brass alloys. 
Bronze is an alloy consisting of copper 9 and tin 1. In the industry, however, 
red brass is very often styled "bronze," although zinc is the other component instead 
of tin. Many metals and metalloids are added to brass and bronze to convey certain 
physical properties. Aluminum, copper and German silver castings are other 
products.1 
Usually, in foundry work, scrap metal, consisting of all sorts and compositions of 
(non-ferrous) metals, makes up one-third or more of the alloy; then copper, zinc, or lead 
ingots are added, to arrive at an approximate composition. Consequently it will be 
seen that the brass manufacturing industry, or more properly the non-ferruginous 
metal-working trade, is engaged in the handling of large amounts of copper, zinc and 
tin, while it must not be overlooked that lead, antimony, nickel, aluminum, cadimum, 
manganese, iron, phosphorus, arsenic and sulphur may enter the brass crucible. In 
subsequent processes of cleansing, plating and finishing, dangerous acids and cyanide 
solutions are used. 
Pseudo-brass Poisoning.-Wounds due to brass objects and similar 
alloys are of traumatic and infectious significance only. Brass dust 
(grinders, polishers and buffers) does not produce 11 brassfounders' ague," 
and has only the harmful effects of metallic dusts in general. The lead 
in the alloy-dust may produce its symptoms in very susceptible persons(?). 
Brass in any condition short of the recent vaporous state of its compo- 
nents produces no intoxication peculiar to itself. 
The essential health-hazard from brass is the inhalation of the metallic 
fumes. Analyses of brass fumes show: 
Substance 
Deposits from 
flues2 
Analysis of fumes3 
Bench-settling4 
A 
B 
C 
D 
Zinc oxide 
32.13 
24.74 
28.82 
(zinc) 44.9 
Lead oxide 
0.31 
1.92 
0.00 
(lead) 0.8 
Iron oxide 
2.43 
2.78 
Copper oxide 
2.85 
2.50 
(copper) 1.71 
Cadmium oxide 
1.56 
0.89 
(moisture) 9.64 
341 342 
BRASS AND THE BRASS INDUSTRIES 
Insignificant traces of arsenic, nickel and manganese may be present, and 
Sigel found the chills where copper was absent in the fumes. Symptoms 
traceable to phosphorus in phosphor-bronze and manganese in mangan- 
ese-bronze have never been reported. Antimony poisoning occurs, 
however, among type-metal refiners and melters, and dermatitis and 
"biting" nasotracheitis from this should be distinguished from "brass 
itch" and "zinc asthma" respectively. Braziers and hard-solder 
workers, especially where electric welding or the modern blow pipes 
(oxy-acetylene, oxy-hydrogen) are used,* may suffer greatly from metal 
chills due to volatilization of the alloys worked upon.5 
Brass Poisoning.-"Brassfounders' ague" is the only condition which 
can be recognized under this heading and this has been described under 
zinc where it properly belongs. The condition was first mentioned by 
Thackrah in 1832,6 who considered it periodic because seasonal; the zinc 
factor was recognized by Greenhow7 in 1862; the earliest American cases 
were cited by Oppenheim8 in 1894, while later references are Moyer and 
Lavin,9 also Pietrowiecz,10 Chicago, 1904, Sicard,11 New York, 1905, 
Hayhurst,12 Illinois, 1910 and 1912, and Reisman and Bolis.13 
Chronic Effects of Brass Poisoning.-In Chicago14 the fact that 85 
per cent, of 1761 foundry workers were under 40 years of age, and only 1 
per cent, over 50 years, was explained by employers as due to "slowing 
up," or beginning increpitude, and by workmen, as gradual incapacitation 
from the inhalation of brass fumes and the strain of the work. The 
constant intake and elimination of unusual amounts of zinc and copper 
from the system along with the repetition of brass chills or the constantly 
forced immunity to the same are enough to cause degenerative diseases 
in themselves even though the immediate afflictions above mentioned are 
overlooked. Chronic bronchitis or "asthma," emphysema and pul- 
monary tuberculosis are very common. Older workers invariably com- 
plain of dyspepsia, "biliousness," occasionally of gall-stones and they are 
often icteroid. Constipation is the rule among them and hemorrhoids 
are frequent complaints. Pyorrhea alveolaris, carious teeth, gastro- 
enteritis, sallow complexion and anaemia, ill-nourishment and emaciation, 
chronic alcoholism, Bright's disease, nervous and heart diseases are all 
above the average.15 
Remedial Measures.-No specific treatment for zinc or brass ague has 
been discovered. Mild emetics, hot milk, and stimulants are used. A 
good purge seems as beneficial as anything. To counteract the effects of 
* Autogenous Welding.-Jennie Adler-Herzmark (Zentralbt. f. Gewerbehy., May, 
1921), investigated a number of small industries in which autogenous welding is done and 
found that acute attacks resembling brassfounders' ague, and probably identical with it, 
are always associated with the use of hot brass or zinc. Zinc vapors were often visible. 
It is proposed to determine experimentally whether the corrosive action of zinc oxide is so 
extensive that after a few hours the absorption of the damaged tissue may cause a fever. 
Is the more severe gastric part of the attack to be associated with zinc chloride formed in the 
stomach? (Jour. Ind. Hyg., Nov., 1921, p. 157). In this connection see Seiffert, under 
"Toxicity of Zinc," above. BRASS AGUE THE BRASS INDUSTRIES 
343 
the sublimed fumes which are swallowed, the drinking of milk before and 
after "pouring," and of water containing sodium bicarbonate, magnesia or 
lime water, is recommended. For such as is inhaled, particularly if a 
chill is anticipated, a dose of Epsom or Glauber salts should be taken at 
once, and to relieve the respiratory membranes an expectorant, such as 
ammonium chloride, combined, perhaps, with brown mixture. During 
the course of the chill, hot lemonade, hot milk, hot milk with pepper, seem 
welcomed. The use of whiskey, or any alcoholic liquors could be of 
value only because of their narcotic action, and according to the state- 
ments of the more observing workmen are of no more benefit nor relief 
than the hot drinks above mentioned. Further, alcohol increases the 
subsequent malaise, and adds to the liability of sequellae. Alcoholic 
beverages are especially to be discouraged because of the development 
of industrial alcoholism, that is, the worker who has come to believe 
that alcohol is a true antidote to the metal fumes, rapidly becomes a 
chronic alcoholic as a result. Many such cases are seen. This condition 
only lays him more liable than ever to the "ague." In fact many work- 
men claim that abstainers are the last to succumb to the chills, and have 
them the mildest. The prostration usually compels one to take to bed, 
where plenty of covering and external heat, especially to the feet, are 
very comforting. Antipyretics and antiperiodics are useless, while the 
symptoms do not usually warrant opiates. Finally, any physician may 
consider himself lucky who has been called to see a case of "zinc ague" 
at its height, especially in an informed worker, since the victim usually 
knows what he has got, and also its cause, and immediate prognosis, and 
hence does not see the need of the services of a physician. But the 
physician will see many cases of tuberculosis, pneumonia, chronic 
degenerative diseases and pre-senile conditions if in practice much among 
zinc or brass workers who are concerned with the hot processes. 
THE BRASS INDUSTRIES 
Founding and Casting.-In the brass foundry the metal is poured into sand moulds 
according to certain patterns. In brass casting the metal is poured into iron moulds 
in the shape of bars, tubes or rods which are subsequently rolled or drawn out into 
sheets, tubes or wire. In both instances the brass is melted, as a rule, in crucibles 
which are heated each by itself in a submerged cylindrical furnace, although many 
types of furnaces, less objectionable from a health point of view, are beginning to be 
used. Scrap metal is dumped into the crucible first, then copper. Just before remov- 
ing the crucible from the furnace (a period of about 3 hours from the beginning), the 
zinc ingots are shoved well under the surface of the molten copper mass and, after 
removal of the crucible, but just before pouring into the moulds or casts, lead is usually 
added. The workmen are divided into furnacemen, moulders and casters, coremakers, 
grinders and laborers. Moulders and casters are skilled men except in cases where 
machines are used. In America unskilled men are largely Eastern and Southern 
Europeans. Coremakers are often foreign women, who work in separate rooms from 
the foundry and make fair wages at piecework. 344 
BRASS AND THE BRASS INDUSTRIES 
During melting and pouring, zinc fumes arise, and, unless provisions 
are made for confining or removing them, they fill the atmosphere and are 
inhaled by all those in the vicinity. These fumes cause the affliction 
called "brassfounders' ague," or "zinc ague" (see above). Other imme- 
diate afflictions of brass founders are: (1) lead poisoning, usually from 
auxiliary processes; (2) nausea, vomiting and mucous gastritis from sick- 
Fig. 14.-Casting yellow brass. When the molten metal is poured into the moulds, 
fumes of zinc arise and are precipitated by the cool air of the room into fine gray powdered 
flakes. In the room shown these are unavoidably inhaled by the workmen who are thus 
exposed to the disease known as brassfounders' ague. (Photo taken by W. C. Hanson 
for Mass. State Board of Health.) 
ening oil furnace fumes; (3) heat prostrations and heat colics due to grave 
metabolic disturbances; (4) gassing; (5) fatigue and strain; (6) rheuma- 
tism and lumbago; (7) acute bronchitis; and, until recently at least, (8) 
industrial alcoholism (see zinc smelterers). 
Various Poisons.-The investigators of the Ohio Survey reported 
■exposure to the following industrial poisons in brass foundries: zinc fumes, BRASS FOUNDING AND CASTING 
345 
lead, antimony, carbon monoxide, carbon dioxide, sulphur dioxide, ben- 
zine, phosphorus and "salamander gases." 
Preventive Measures.-The brass industry needs a close scrutiny and 
usually much improvement in all branches of industrial hygiene before 
workers so engaged can be freed of the risks of degenerative diseases and 
an abbreviated span of life. 
Fig. 15.-Casting yellow brass. Brass workers are here protected from zinc fumes 
by an adequate exhaust system. (Photo taken by W. C. Hanson for the Mass. State 
Board of Health.) 
A well-arranged foundry16 is a roomy, one-story building or top floor, with imper- 
vious flooring, ceiling vents, large windows and unhampered by high surrounding 
eminences. It is divided into: (1) furnace room, or at least partial partitions provide 
adequate up-and-down ventilation in the furnace area; (2) casting room, or an area 
covered by broad spreading exhaust hoods beneath which pouring is done; (3) mould- 
ing shop, where moulds are made (an entirely cold process); (4) core room, which has 
the core-baking ovens well apart; (5) chipping, grinding and sand-blasting rooms, 
equipped with exhaust ventilation, where rough castings are smoothed down; (6) 
washing facilities consisting of a sanitary trough, for small places, with hot and cold 
water and an open outlet, and, for larger places, a change house, or quarters provided 346 
BRASS AND THE BRASS INDUSTRIES 
with lockers on one side for street clothes, shower baths in the center, and lockers or, 
better still, ceiling hangers for work clothes on the other side; (7) sanitary drinking 
water devices, preferably angle-stream bubbling fountains; and (8) luncheon quarters. 
At present, very few foundries in America approach this standard. In most instances 
all or nearly all the above processes are carried on in the same room, often low-ceilinged, 
while doors and windows with perhaps a few small openings in the roof-most of which 
are closed in the winter time-are depended upon for ventilation. 
Furthermore, prophylaxis consists in selecting workmen through 
physical examinations, regulating their habits and work, then limiting, 
confining or removing the fumes. The adoption of the electric furnace 
promises much in this respect. Aerial dilution of the fumes is not enough. 
All furnace areas and pouring areas should be provided with hoods and 
stacks to draw off vapors. The Germans use flexible exhaust ducts which 
Courtesy of Crane Co. 
Fig. 16.-Crucible of yellow brass. Approved method of handling. 
(Illinois Factory Inspection Bulletin, Vol. I, No. 1.) 
are locally applied during pourings.17 In addition, the foundry rooms 
need air-agitators (fans), and arrangements for vertical (floor-ceiling) 
ventilation which is most apt to be efficient irrespective of weather and 
wind conditions. The wearing of respirators although a help will not 
prevent the inhaling of gas or fumes. The more zinc oxide in the air 
the more imperatively are regulations and improvements needed. Illu- 
mination is often most inadequate in founderies due to insufficient light- 
ing units, absence of reflectors, dirty windows and lamp bulbs, and 
obstructions in general. Foreign countries have adopted extended regu- 
lations for smelting and founding industries (see article by Legge, pages 
357-359) and marked results have already been produced according to their 
statistics.18 OPERATIONS ON BRASS 
347 
Fortunately the vast majority of brass workers are employed outside 
of the foundry in finishing processes, such as polishing and buffing (very 
dusty work, but in the past 15 years rendered practically harmless by 
exhaust systems locally applied), machinery and assembling work, plating, 
lacquering, etc. Among assemblers of brass parts, as chandelier makers, 
lead poisoning occasionally occurs due to the careless use of white or red 
lead paste in hermetically sealing joints by testing them with the mouth. 
Finishing of Brass Castings.-Rough Finishing.*-This process is 
accomplished in several ways. One method is by chipping the rough 
Fig. 17.-Buffing brass. The buffing wheels shown are well equipped with hoods and. 
blowers and give off practically no dust or lint. (Supplied by W. C. Hanson for the- 
Mass. State Board of Health.) 
castings with pneumatic chisels (an extremely noisy process) or by means 
of "sand blasting." In some of the factories the smaller castings are 
cleaned by hand with steel wire brushes, or with mechanical revolving 
wire brushes, or by being mixed with small pieces of scrap iron and then 
rotated in "tumblers" or "rattlers." The constant friction of the 
castings upon each other and the scrap iron removes the sand and all 
rough surfaces. 
Polishing and Buffing. *-This is usually accomplished by the employ- 
ment of emery wheels and the final burnishing of brass is done on "buffing. 
* By Geo. M. Kober, M. D. 348 
BRASS AND THE BRASS INDUSTRIES 
wheels " covered with leather or circular pieces of cotton cloth. All of the 
processes referred to are extremely dusty and expose the operatives to 
the inhalation of a conglomeration of dust and also to injuries of the eyes. 
The wearing of goggles should be imperative. 
A strong international union exists in this trade and, according to Hayhurst, 
laws are now nearly universal in the requiring of hoods over the wheels connected to 
"blower" (suction) pipe systems. But few of these are entirely satisfactory and 
they are hard to keep in order so that many thoughtful workers still use respirators. 
A number of cases of plumbism are annually reported among the polishers or 
buffers of brass goods, especially of spiggots. Gun and pot metal contain usually 
from 5 to 6 per cent, of lead, but the Medical Inspector of Great Britain19 has reported 
Fig. 18.-Buffing brass. No dust-removal device is here provided for the protection of 
employes. (Supplied by W. C. Hanson for the Mass. State Board of Health.) 
instances of lead poisoning in brass polishers in which analyses revealed the presence 
of only 2.4 to 2.9 per cent, of lead. The Factory Inspector of the State Board of Health 
of Massachusetts20 also points out that many of the brass polishers are pale and emaci- 
ated, their teeth in a bad condition and the gums showing the characteristic bluish 
discoloration. Dr. Wm. Murray21 was the first to point out that the cases of lead 
poisoning in "chandelier makers" are contracted by the habit of fitting the joints 
with lead and then testing them by closing one end and sucking the other end of 
the bracket. 
Acid Dipping and Plating.-Many castings are further subjected to 
plating for which a cleansing dip in acid solutions is preparatory. The BRASS SPECIALTIES 
349 
hazards and precautions are thus summed up in the Illinois Report on 
Occupational diseases (pages 71-82): 
1. Acid Fumes.-These arise when the castings are dipped into mixed mineral 
acids for cleansing them. A hood and vent pipe to a window or stack should be pro- 
vided. (2) Hot Potash Solutions.-These stand usually in large vats. Breathing 
over them causes a dryness of the throat and an irritating cough. A low hung hood 
with connection to proper stack should be suspended over such vats. (3) Cyanide 
Solutions.-Potassium cyanide is the compound used in these solutions which are hot 
and stand in open vats. These should be provided with hoods and vent pipes (if 
solutions are strong enough to emit the characteristic hydrocyanic odor. Also dipping 
the hands and arms in such solutions causes the intractable cyanide ulcers. Poison 
signs should be conspicuously dispbyed). 
Shellacing and Lacquering.-Final protection and gloss is given to 
castings, tubings etc. by varnishing methods: (1) Shellacing.-The vapors 
from the solvents used (wood alcohol, amyl acetate, benzine, etc.)22 cause 
irritation to the eyes, the respiratory tract and occasionally the chronic 
forms of sickness usually ascribed to these poisons. If the hands are kept 
free of the solutions, the brushing and dipping processes are less harmful, 
but all spraying and atomizing processes are deadly and demand cabinets 
with exhaust fans.23 (2) The use of Japan mixed with wood alcohol and of 
Zapone lacquer (amyl acetate) as a final finish to chandeliers, art goods, 
etc., is injurious to the health and calls for special protection in the way of 
exhaust ventilation and steam-heated drying chambers. (See page 644.) 
CERTAIN BRASS SPECIALTIES* 
Instruments, Professional and Scientific.-The most important unhy- 
gienic processes involved in the manufacture of such instruments are those 
already referred to, such as machine shopping, soldering, welding, polish- 
ing, buffing, electroplating, etc. In the manufacture of optical lenses, 
microscopes, etc., there is also exposure to dust from glass and rouge 
(iron peroxide) during the grinding and polishing processes, and in the 
manufacture of barometers and thermometers there is exposure to lead 
and mercury. Makers of musical instruments often acquire lead poison- 
ing by filling the instruments with molten lead before the shaping process. 
Electrical Machinery, Apparatus and Supplies.-The manufacture of 
electrical switch boards, meters, telephones, registering devices, etc., 
involves hazards common to the brass industry, except that the workers 
on electric meters and electrodes are also exposed to mercury. 
Storage Batteries.-The occupational risks in the manufacture of 
storage batteries, from lead poisoning, are referred to on page 462. 
The dangerous process consists in the casting, dressing and polishing of 
perforated or grooved lead plates, the connection of these plates by the 
use of solder and blowpipe and the employment of lead oxide paste and 
* By Geo. M. Kober, M. D. 350 
BRASS AND THE BRASS INDUSTRIES 
sulphuric acid. The rapid solder employed in storage battery work also 
contains mercury. In many establishments fully 50 per cent, of the 
workers have been known to contract lead poisoning, some of them within 
10 days after beginning the work. 
Dry Batteries.-The manufacture of dry batteries involves exposure 
to a number of industrial poisons, such as benzol, creosote, hydrochloric 
acid, lead during the soldering process, mercury during the amalgamazing 
process, pitch and zinc chloride. Inflammatory conditions and fissures 
of the skin and chloride of zinc and acid burns are not uncommon. 
Cancer of the skin, attributed by some authors to carbon dust, the use of 
pitch and chemicals, has been reported but is rare and probably unrelated. 
Incandescent Lamps.-One of the chief characteristics of this industry 
is the overwhelming number of female employes and the "speeding-up" 
incident to piecework. Much of the work is done in close quarters and 
involves exposure to industrial poisons. Commendable progress has been 
made, however, and the Ohio Survey reports that none of the employes 
were exposed to mercury, which was used in closed containers to produce 
a vacuum, and that red phosphorus was used instead of the white or yellow 
variety in painting. The chief hazards in each of the different depart- 
ments found by the Ohio Survey in 1914 were as follows: Filament making: 
wood alcohol, gas fumes, heat, inadequate ventilation. Tubulating, 
sealing and painting: the hazards already mentioned, also exposure to 
glass dust, foreign bodies in the eyes, small cuts and burns. Vacuum 
production, photometry and aging: gas fumes, heat, eye strain from bright 
and flashing lights. Finishing processes: gas and solder fumes, wood 
alcohol, some eye strain, troublesome callosities of hands, caused by the 
use of wire cutters. Amyl acetate is used in some establishments as a 
lacquer. Most of the hazards have' been eliminated in recent years. 
The larger plants also conduct excellent medical services. 
Bronze Powder.-The manufacture of gold, silver, bronze and copper 
powder is attended with the evolution of considerable quantities of very 
fine dust even though the process of grinding, powdering and drying is 
carried on in inclosed machinery. 
The ordinary gold bronze powder is composed of copper and zinc, with 
traces of lead, tin, arsenic and iron. Simon and Knyvett24 call attention 
to the possibility of lead poisoning because in a case brought to their 
notice the bronzing powder contained 7 per cent, of lead. Popoff, cited 
by Casamajor,25 described a case of general muscular atrophy and gastro- 
enteric symptoms in a bronze worker which he attributed (we think 
wrongly) to zinc poisoning. Quite a number of persons engaged in handl- 
ing bronzing powder complain of a coppery taste in the mouth, but not 
many cases of plumbism have been reported. Catarrhal affections of the 
eyes and respiratory passages, headache, and gastric derangements are 
not infrequent and Oliver26 refers to the process of "dry bronzing" as a 
cause of inflammatory conditions of the skin. On the other hand, Woll- BRASS WORKERS-BIBLIOGRAPHY 
351 
ner27 maintains that the bronze workers at Furth are a comparatively 
healthy class. Bronzes are often suspended in benzene, acetone, pyrox- 
ylin, wood alcohol, amyl acetate, etc., with consequent menace to 
health.* (See also pages 207 and 254.) 
Gilds.-Analyses by the Ohio State Board of Health22 of six leaf gilds 
(gold, silver, copper, aluminum and white finish) made by several manu- 
facturers failed to show the presence of either lead or arsenic. 
Workers in Junk.-In a number of cities special establishments exist 
where the process of sorting rags, paper and metal is carried on in large 
sheds and warehouses, and where the non-ferrous metals are melted down. 
The various processes are usually carried on under the most insanitary 
conditions and are doubtless inimical to health. Hayhurst in his Ohio 
Survey reports four cases of lead poisoning and also believes there is 
considerable risk from brass or zinc poisoning where some of the soft 
metal alloys are handled and melted. He also reports that several cases 
of lock jaw had come from one of the large plants. 
Mortality Rates.-The death rate from tuberculosis among brass 
workers is twice that of iron and steel workers.28 Of 201 brass workers, 
31.3 per cent, died of pulmonary tuberculosis, 9.4 per cent, of Bright's 
disease, 9.0 per cent, of pneumonia, 8.4 per cent, of cancer, 8.0 per cent, 
of accidents. Hoffman's figures29 for 1897 to 1914 cover 633 deaths, 
the consumption rate being 36.7 per cent. He says, "The proportionate 
mortality from pulmonary tuberculosis is decidedly excessive at all ages 
under 65," and most so at 15 to 24, when out of every 100 deaths from all 
causes 58.2 per cent, are from consumption, against a normal expected 
proportion of 27 per cent.-Insurance premiums on brass founders, 
molders and casters are considerably above the usual rates. Those 
in finishing processes, including grinders and polishers, have more 
privileges or are not super-rated at all. 
BIBLIOGRAPHY 
1 See New International Encyclopedia for list of various products. 
2 Bassett.-Jr. Ind. and Eng. Chem., March, 1912, 164. 
3 Oliver.-Dangerous Trades, 1902, 456. The mention of moisture excludes fresh 
fumes. 
4 .Report, Ill. Commission on Occ. Dis., Jan., 1911, 74. 
6 Pfender, C. A.-Jr. Am. Med. Ass., Jan. 24, 1914, 296. Our investigations in Ohio 
have also amply confirmed Pfender's observations upon "brazier's" disease. 
See Ref. 22 below. 
6-7 Cited by Arlidge, Diseases of Occupations, 1892, 447. 
8 Johns Hopkins' Hospital Bull., No. 48, Oct. 9, 1894. 
9 Medicine, Detroit, 1904, 335. 
10 Jr. Am. Med. Ass., 1904, XLIII, 465. 
* Specifications for the safe use of dry metallic (bronze) powders in letterpress printing, 
lithographic printing and coating of metal sheets are given in the British Regulations on 
Bronzing, April 11, 1912 (Factory and Workshops Acts, page 125; and reprinted in Special 
Bulletin 76 of the N. Y. State Industrial Commission, March, 1916, 7-8). 352 
BRASS AND THE BRASS INDUSTRIES 
11 Medical Record, N. Y., Aug., 1905, 209-217. 
12 Hayhurst.-Am. Jr. Med. Sc., May, 1913, 723-739. 
13 Reisman and Boles.-Am. Jr. Med. Sc., March, 1917, 376. 
14 Report, Ill. Commission on Occ. Dis., Jan., 1911. 
16 Zadek.-Ref. 7, under Copper, Also Roth, Komp. der Gewebekr., 1909, 61. 
16 See Sharp, Modern Foundry Practice, 1900, 632. 
17Rambousek.-Industrial Poisoning, Trans, by Legge, 1913, 323. 
18 Frey.-Vrtljschr. f. gericht. Med., Berl., 1912, 3, F., XLIII, I, S. H., 113-141. 
19 Neisser.-International tTbersicht, etc., 1907, 17. 
20 Massachusetts.-Report of Sanitary Inspectors, 1909, 41. 
21 Murray.-Brit. Med. Jr., June 2, 1910. 
22 Hayhurst.-Ill. Report on Occ. Dis., Jan., 1911, 72-82. Also Survey of Industrial 
Health Hazards, etc., in Ohio, Feb., 1915, 172-3. 
23 Albaugh.-Ohio Pub. Hlth. Jr., Nov., 1915, Vol. VI, 5, 512-14. 
24 Oliver's Dangerous Trades, 1902, 468. 
25 Trans. XVth Inter. Congr. on Hyg., and Dem. Wash., D. C., 1913, III, Pt. 2, 578. 
26 Oliver's Dangerous Trades, 1902, 268. Also Indust. Lead Poisoning in Europe, 
Bull. 95, U. S. Bur. of Lab., July 11, 1911, 83. 
27 Wollner.-Verl. d. Naturforschervereins, Nurnberg, 1893, II, 2, 426. 
28 U. S. Cens. Mort. Stat., 1909. 
29 Hoffman.-Bull. Whole No. 231, U. S. Bur. Labor Stat., June, 1918, 158. SECTION 6 
THE HEALTH OF BRASS WORKERS 
T. M. LEGGE, M. D., Home Office, London, England 
In the year 1902 detailed inquiry into the health of brass workers in 
Birmingham-the center of the industry-was undertaken by the Factory 
Department of the Home Office because not only was there ignorance of 
the real prevalance of so-called brassfounder's ague among them, but 
also because the view had been expressed that a definite clinical picture 
was associated with filing, polishing or otherwise manipulating brass, of 
which the prominent symptoms were a green line on the teeth, anaemia, 
and emaciation. 
In order to obtain accurate information as to illness attributable to 
poisoning by brass I undertook the examination of 233 casters (among 
whom were included metal mixers, casters proper, and casters' helpers), 
and 210 polishers and others (including polishers proper, dressers, turners 
and burnishers). The object throughout was to make comparison 
between those exposed to fumes and those not so exposed. 
In addition to the filling in by each one of the men of a printed form as to the state 
of his health while working in brass note was made of the height, weight, chest meas- 
urement and strength of grasp as tested by a dynamometer; the heart, lungs, gums 
and teeth, were examined; and the condition as to anaemia, paresis, general health, 
and prevalence of brassfounder's ague, was ascertained. The inquiry was carried 
out in 21 factories in Birmingham in all of which, with one exception, both zinc and 
copper entered largely into the metal poured. Subsequently I visited the principal 
foundry in the Royal Arsenal, Woolwich, and examined 89 persons of whom 58 were 
engaged in casting gun metal into the composition of which zinc hardly enters at all. 
Tabulation of the results as regards age, duration of employment, height, weight 
and chest measurement, showed differences so slight that generalization from them 
revealed nothing of importance. 
The strongest evidence perhaps obtained in the inquiry that the 
operation of casting is more trying than other brass work and came from 
the replies to the question: Do you consider that your health has been in 
any way injured by working in brass?-since 22.7 per cent, of the casters 
as compared with only 11.6 per cent, of the polishers said they had 
suffered. 
Of 193 casters interrogated as to brass founders' ague 123 or 63.7 per cent, stated 
that they had suffered more or less frequently from the train of symptoms-malaise, 
sense of weakness, shivering with chattering of the teeth and extreme feeling of cold- 
characteristic of this complaint. There could be no doubt as to the extreme preva- 
lence of the affection. The frequency of the attacks in several cases-often once 
353 354 
THE HEALTH OF BRASS WORKERS 
a week-was remarkable, the attack, as has so frequently been described, following 
on return to work after temporary absence for a day or two. 
There was general censensus of opinion that the greater the proportion 
of spelter in the metal mixture the greater was the liability to attack. 
The strongest evidence I obtained on this point was at Woolwich Arsenal. Among 
the 58 casters of gun metal where conditions of ventilation in the past would have 
led one, if anywhere, to expect heavy incidence of brassfounders' ague six only nar- 
rated indefinite symptoms suggesting the possibility that they had suffered. In 
another foundry at the Arsenal, however, where zinc entered largely into the com- 
position of the metal, of the 10 casters questioned all but one gave a history of frequent 
attacks. 
It was impossible not to be struck by the less satisfactory appearance 
of the casters as compared with the polishers. By the sallowness of the 
complexion the occupation as a caster could often be correctly guessed. 
Evidence of lead absorption-showing, itself in a blue line on the gums-was 
noted in four casters and in 16 polishers. In one man engaged in polishing on an 
emery wheel unprovided with exhaust ventilation paralysis of the wrists was found. 
Analyses of two samples of brass dust made in the Government Laboratory showed in 
the one case 2.9 per cent, of lead and in the other 2.43. I have no doubt that inhala- 
tion of brass dust containing so small a percentage of lead as these samples show can 
in the long run give rise to plumbism. 
A green line on the teeth from formation of basic carbonate of copper was noted 
in at least 65 per cent, of the polishers and 16 per cent, of the casters. It is, there- 
fore, more an indication of work involving exposure to dust rather than to fumes. 
Greenish coloration of the hair was noted twice. 
The conclusion at which I arrived from the inquiry was that work in 
the casting shop was more trying and attended with greater injury to 
health than work in polishing. Apart from brassfounders' ague and the 
occasional development of lead poisoning among chandelier fitters and 
polishers, I did not find symptoms of illness which suggested to my mind 
that they could possibly be due to absorption of copper or brass. If, 
therefore, so-called brass poisoning were made notifiable in the same way 
as poisoning by lead, arsenic, mercury and phosphorus, the result would 
be the reporting of any ill-defined sickness in persons showing a green line 
upon the teeth or even of persons working merely in brass. Mortality 
statistics, however, as for instance those contained in the Decennial 
Supplement of the Registrar General, show that there is undue incidence 
of phthisis among those employed in brass working. What was wanted 
in casting shops, I said, was removal of the fumes and in polishing shops 
removal of the dust. At the time I investigated the subject there were not 
more than three or four out of the 900 casting shops in Birmingham in 
which attempt was made to remove the fumes locally by exhaust ventila- 
tion and in the polishing shops only one. 
Subsequently in 1907 the Home Office issued Draft Regulations in 
accordance with the requirements of the Factory and Workshop Act, 
1901, which it was proposed should apply to factories in which the process BRASSFOUNDERS' AGUE PREVENTION 
355 
of casting was carried on. Numerous objections from manufacturers 
were received (in consequence perhaps of ambiguous wording in the Draft) 
and a Commissioner was appointed by the Secretary of State to hold a 
public inquiry in regard to the same under section 81 of the Act. At the 
inquiry strong evidence from casters as to the effect of the fumes on 
themselves was heard, but perhaps the most striking evidence was that of 
the Commissioner's own experience as stated in his report: 
On the occasion of one of my visits to Birmingham, after several visits to casting 
shops and seeing some pourings, I inspected toward the close of the day a strip casting 
shop, where the ventilation proved to be extremely bad. I witnessed four crucibles 
of brass, containing 120 lb. each, poured in succession into strip moulds, the doors 
and windows being meanwhile closed for reasons hereinafter referred to. The time 
occupied was some 15 minutes. On coming out into the air I felt a sense of stifling 
oppression on the chest, which passed away in about an hour, a strong taste of the 
fumes, however, remaining. At about 10:30 P.M. the same night symptoms 
corresponding exactly with those of the "brassfounders' ague" or "fever" showed 
themselves: shivering and chattering of the teeth followed by what appeared to be a 
considerable degree of fever, which lasted for perhaps 2 hours, then a most profuse and 
long-continued perspiration, followed at last by sleep. In the morning, however, 
I rose at the usual hour with only a slight headache and a taste of the fumes in my 
mouth. Mr. Thornton Lawes, who had been with me throughout the previous day 
on my tour of inspection, and had witnessed the casting to which I have referred, 
had a similar attack of the "ague" or "fever" the same night. On that or the next 
day I began to feel pains in the shoulders and chest, and for over 2 months I have 
suffered from these and from asthmatic and bronchial symptoms which have been 
sufficiently severe to compel me to give up my work and seek a cure in the country. 
As the outcome of this Inquiry the Regulations which are appended to 
this article were issued by the Secretary of State in 1908 and now govern the 
industry. 
In Birmingham alone they apply approximately to 860 casting shops of which 
about 320 are exempted by reasons of the exception with regard to air space per 
person. Most of the casting shops are ground floor rooms with lean-to roofs made of 
slate. Many small and unsuitable shops have been discontinued during the past 
few years. The most popular method by which compliance with the Regulations as 
to exhaust ventilation has been secured is provision of a large hood fixed about 6 or 
7 ft. above the floor connected up with a power-driven volume fan. The moulds 
are placed in a leaning position against a shelf or "spilling hearth" 10 in. or more 
above the floor directly under the hood and, whilst pouring, the pot is rolled along 
this shelf behind the moulds. Another device in use--the most successful form of 
locally applied exhaust ventilation by heat which I know-is that invented by 
Messrs. Rainsford and Lynes, Ltd., brass casters, of Birmingham. In this case a 
small cap is attached to the crucible containing the molten metal and connected by 
a flexible pipe some 3 or 4 in. in diameter to a fixed tube running into the furnace 
chimney. With this apparatus no fan is necessary and yet, in the act of pouring, at 
least 85 per cent, of the fumes never enter the workroom at all. Unfortunately its 
use is limited to sand casting as it is alleged that it cannot deal with the enormous 
volume of zinc oxide fume given off in strip or tube casting. The illustration shows 
the mode of application. Progress, however, in regard to exhaust ventilation 
has been so rapid in recent years that all manner of devices now enable occupiers 
to comply with the requirement as to removal of the fumes. 356 
THE HEALTH OF BRASS WORKERS 
While the exemption from the Regulations allowed on the ground of 
ample cubic space per person was necessary, there cannot be question 
that, in comparatively small casting shops, work is carried on under 
healthier conditions where there is a fan to induce a constant current of 
fresh air through the room while pouring is going on than where, owing to 
the exception, reliance is placed on natural means of ventilation only. 
Commencing in 1902 and from that year onward the inspectors of fac- 
tories in Birmingham and elsewhere had been pressing, in brass-polishing 
shops, for action in pursuance of section 74 of the Factory and Workshop 
Fig. 19.-New method of pouring in brass casting; 85 per cent, of the fumes are taken away. 
Act, 1901, which states.that if polishing on a wheel is carried on so that 
dust is generated and inhaled by the workers to an injurious extent, and it 
appears to an inspector that such inhalation could to a great extent be 
prevented by. the use of a fan, the inspector may direct that a fan be pro- 
vided within a reasonable time. A spirit of emulation among the employ- 
ers was set up and it is now safe to say that exhaust ventilation is applied 
at all benches where polishing is continuously done. Although from time 
to time I had when in Birmingham seen admirable instances of the success 
of the Regulations, it was not until the beginning of the year 1914 that I BRITISH REGULATIONS FOR CASTING BRASS 
357 
had opportunity of revisiting the factories in which I had made my origi- 
nal inquiry. I then found in every casting shop, not exempted by reason 
of air space, suitable provision made, in one or other of the ways described, 
for speedy removal of the fumes. Several of the casting shops were small 
and incidence of brassfounders' ague had been severe, but the same men 
whom I had examined under the old conditions were insistent as to the 
striking improvement in the conditions of work which had resulted. 
Brassfounders' ague in their experience had become, practically speaking, 
a matter of historical interest only. The amelioration in health, so I was 
informed, was reflected in the lessened amount of sickness claims made 
on their Society. The single instance of complaint brought to my notice 
was in a large casting shop where attempt had been made to arrange a 
hood and fan over spilling hearths in the center of the room. Here natur- 
ally cross, currents at times defeated the draught induced by the fan and 
explained the partial failure. 
REGULATIONS, DATED JUNE 20, 1908, MADE BY THE SECRETARY OF 
STATE, GREAT BRITAIN, FOR THE CASTING OF BRASS 
Whereas the casting of brass or any alloy of copper with zinc has been certified in 
pursuance of Section 79 of the Factory and Workshop Act to be dangerous, I hereby 
in pursuance of the powers conferred on me by that Act make the following Regula- 
tions and direct that they shall come into force on the 1st day of January, 1910, and 
shall apply to all factories in which the casting of brass is carried on, with the follow- 
ing exceptions: 
(i) The Regulations shall not apply to a sand-casting shop having an air-space 
equivalent to 2500 cu. ft. for each of the persons employed nor to any 
other casting shop having an air space equivalent to 3500 cu. ft. for each 
of the persons employed. Provided- 
(a) that provision is made for the egress of the fumes during casting by 
inlets below and outlets above of adequate size, and 
(6) that a notice in the prescribed form, giving the prescribed particulars, 
shall be kept affixed at or near the entrance of the casting shop and that a 
copy thereof shall be sent to the Inspector of the district, and 
(c) that the conditions of exemption stated in such notices are not 
departed from. 
(ii) So much of Regulation 1 as requires that exhaust draught shall be main- 
tained during the process of casting shall not apply in the case of strip or 
solid drawn tube casting or any other class of casting which the Secretary 
of State may certify on that behalf, provided that- 
(a) the exhaust draught cannot be so maintained without damage to the 
metal (proof of which shall be upon the occupier); and 
(6) the exhaust draught is put into operation immediately after the 
casting; and 
(c) provision is made for the egress of fumes during casting by inlets 
below and outlets above of adequate size. 
(iii) Where it is proved to the satisfaction of the Chief Inspector of Factories that 
by reason of exceptional features in the construction or situation of a cast- 
ing shop or by reason of the infrequency of the casting or the small quan- 
tity or the nature or composition of the metal cast or other circumstances 358 
THE HEALTH OF BRASS WORKERS 
all or any of the Regulations are not necessary for the protection of the 
persons employed he may by certificate in writing (which he may in his 
discretion revoke) exempt such casting shop from all or any of the pro- 
visions of the same subject to such conditions as he may by such certifi- 
cate prescribe. 
In these Regulations (including the above provisions and exceptions)- 
"Brass" means any alloy of copper and zinc. 
"Casting" includes the pouring and skimming of brass. 
"Casting shop" means any place in which casting of brass is carried on. 
"Sand-casting" means casting in moulds prepared by hand in sand or loam or 
sand and loam. 
"Sand-casting shop" means a place in which no kind of casting other than sand- 
casting is carried on. 
"Pot" includes any crucible, ladle or other vessel in which the brass is skimmed or 
from which it is poured. 
"Employed" means employed in the casting shop in any capacity. 
"Persons employed" means the maximum number of persons at any time 
employed. 
It shall be the duty of the occupier to observe Part I of these Regulations, and the 
conditions contained in any certificate of exemption. 
It shall be the duty of all persons employed to observe Part II of these Regulations 
Part I 
Duties of Occupiers 
1. Casting of brass shall not be carried on unless the following conditions are 
complied with: 
(a) There shall be an efficient exhaust draught operating by means either of (i) 
a tube attached to the pot, or (ii) a fixed or movable hood over the point 
where the casting takes place, or (iii) a fan in the upper part of the cast- 
ing shop, or (iv) some other effectual contrivance for the prompt removal 
of the fumes from the casting shop and preventing their diffusion 
therein. The exhaust draught shall be applied as near to the point of 
origin of the fumes as is reasonably practicable, having regard to the 
requirements of the process, the maintenance of the exhaust draught 
during the process of casting, and (as regards casting shops in use prior 
to January 1st, 1908) the structure of the premises, and the cost of 
applying the exhaust draught in that manner. 
(&) There shall be efficient arrangements to prevent the fumes from entering 
any other room in the factory in which work is carried on. 
(c) There shall be free openings to the outside air so placed as not to interfere 
with the efficiency of the exhaust draught. 
2. There shall be provided and maintained in a cleanly state and in good repair, 
for the use of all persons employed, a lavatory, under cover, (i) with a sufficient 
supply of clean towels, renewed daily, and of soap and nail brushes, and (ii) with 
either- 
(a) A trough with a smooth, impervious surface, fitted with a waste pipe with- 
out plug, and of such length as to allow at least 2 ft. for every five such 
persons, and having a constant supply of warm water from taps or jets 
above the trough at intervals of not more than 2 ft.; or 
(fe) At least one lavatory basin for every five such persons, fitted with a waste 
pipe and plug or placed in a trough having a waste pipe, and having 
either a constant supply of hot and cold water, or warm water, laid on, REFERENCES, HEALTH OF BRASS WORKERS 
359 
or (if a constant supply of heated water be not reasonably practicable) 
a constant supply of cold water laid on and a supply of hot water always 
at hand when required for use by persons employed. 
3. No female shall be allowed to work, in any process whatever, in any casting 
shop. 
Part II 
Duties of Persons Employed 
4. No person employed shall leave the premises or partake of food without care- 
fully washing the hands. 
5. No persons employed shall carry on the pouring of brass without using appara- 
tus provided in pursuance of Regulation 1 (a). 
6. No person employed shall in any way interfere without the knowledge and 
concurrence of the occupier or manager with the means provided for the removal of 
fumes. 
H. J. Gladstone, 
One of His Majesty's Principal 
Secretaries of State. 
Home Office, Whitehall, 
20th June, 1908. 
REFERENCES 
Brassfounders' Ague, by D. H. Greenhow. Medico-Chirurgical Transactions, Vol. 
XLV, 1862. 
Brass Workers' Diseases, by D. Hogben. Birmingham Medical Review, 1887. 
Chronic Brass Poisoning, by W. Murray. British Medical Journal, Vol. I, page 
1334, 1900. 
Copper and Brass, by R. M. Simon, M. D., and S. H. Knyvett. Article in Oliver's 
"Dangerous Trades," page 455, 1902. 
Untersuchungen an Kupfer Arbeitern, by Prof. L. Lewin. Deutsche Medicinische 
Wochenscrift, No. 42, 1900. 
Annual Report of the Chief Inspector of Factories for the year 1905, pages 388-397. 
Report on the Draft Regulations for the Casting of Brass, by W. Wills. (Cd. 4154.) 
1908. SECTION 7 
CARBON BISULPHIDE POISONING 
E. R. HAYHURST, M. D„ Columbus, Ohio 
Historical Notes.-Bisulphide of carbon was discovered by Lampadius, the 
German chemist, in 1796. Pazen1 seems to have been the first to call attention to it as 
an occupational poison (1851) and to have counselled caution in its use. Duchenne2 
(1853) mentions its paralyzing effects. Delpech3 (1856, 1863), with description of 
cases, gave the first comprehensive picture of its symptomatology. Tavera4 (1865) 
first studied the blood changes. Since these dates much experimental work and the 
study of special signs of intoxication have been reported by various investigators. 
Chemistry.-Bisulphide of carbon is a constituent of coal tar. It is made com- 
mercially when red hot carbon, contained in a retort, is treated with sulphur vapors. 
It is an endothermic compound and, therefore, formed only on heating. The 
carbon bisulphide gas is condensed to liquid form, purified and, when pure, is prac- 
tically colorless, has a chloroform-like odor, is very limpid, mobile, volatile, refractive, 
insoluble in water, but soluble in all proportions in alcohol and ether and to 60 per 
cent, in oil. It dissolves all resins except shellac.22 It does not dissolve vulcanized 
rubber. It dissolves nearly its own weight of sulphur at 38°C. When impure it has 
a repulsive smell and a yellow color. Impurities are usually H2S, sulphur, and sulphy- 
drates of carbons. H2S cannot be demonstrated in its vapors,10 at least, in sufficient 
quantity to produce poisoning.17 
When passed through a red hot tube, with chlorine, it yields carbon tetrachloride 
(CCD and sulphur monochloride (S2C12) two substances much used as rubber sol- 
vents. Carbon bisulphide is more inflammable than ether and burns with a bluish 
flame yielding CO2 and SO2. In America it is practically all made by the Taylor 
electric-process, Penyan, New York, and is a rather cheap substance, averaging from 8 
to 12 cts. per pound. It has a specific gravity of 1.262 and boils at the low tempera- 
ture of 46.5°C. Its vapor is heavy; density 2.6. If evaporated rapidly, as by pass- 
ing a current of air through it, its temperature is reduced to - 60°C.; hence it may be 
employed to produce low temperatures. 
Uses.-According to Molinari,26 besides its principal use of vulcanizing and 
dissolving rubber, 
"Attempts have been made to use it for the extraction of sulphur from poor ores. 
It is used for extracting aromatic oils from drugs. It is also used in large quantities 
for the extraction of oil from seeds and from oily seed residues and rags. It is also 
used for degreasing vegetable and animal residues, such as rags, bones, meat, hides, 
wool, etc. It is used for preparing solutions of wax for coating plaster casts, and for 
the preparation of waxed paper. It is also used for dissolving out the tar from many 
industrial products [and in gas purification to remove sulphur],27 for preparing various 
chemical products, for making Greek fire (phosphorus dissolved in CS2), for killing 
insect pests, and more especially, in large quantities, for destroying phylloxera in 
vineyards by injecting it into the earth with suitable pumps. ... In 1906 it was 
used with good results for destroying the nematodes which attack beet root." 
It is used in the preparation of cellulose for artificial silk; in cleaning establish- 
ments to remove grease spots; as a disinfectant; and by the Public Health Service 
in destroying rodents in their natural haunts.23 
360 INDUSTRIAL FACTORS IN CARBON BISULPHIDE POISONING 
361 
In the Parke's process of vulcanizing it is used to carry the sulphur into the 
rubber "in the cold." It is practically never used pure, but combined with S2C12, 
CCL or with benzol (C6H6). It renders rubber more elastic, malleable, resistant and 
long-lived. It is a better solvent for rubber than benzine and even better than ether, 
and is likely to be the principal solvent used in all rubber and gutta-percha cements 
which are to dry quickly. 
It was once advocated for the treatment of tuberculosis (all forms) by hypo- 
dermic injections and by inhalations of the vapor.15 
Lehmann10 has shown that 1 part per million in the air will produce mild symp- 
toms, while Iki parts will produce severe symptoms. As much as 2 to 3 parts per 
million have been found in work places^. 
Classes of Workers Most Liable to Carbon Bisulphide Poisoning.-(1) 
Rubber workers; (2) oil and grease extractors; (3) those using cements 
dissolved in CS2; and (4), rarely, those concerned with its manufacture 
and various other uses mentioned above. 
Predisposing Factors in Industry.-Among these are hot weather or 
overheated rooms, also working in low places and close to the floor. Poi- 
soning occurs through breathing the vapors, or getting the fluid on the 
skin, or having it splashed upon the clothing. Good ventilation in recent 
times has greatly decreased cases and usually only milder symptoms show.16 
In Belgium, Galet18 says it causes "le plus grand" per cent, of injuries 
and incapacities for work. Repairers of belts in factories who use cement 
dissolved in CS2 are affected, Briau25 finding as many as 8 of 30 to be 
mentally "off." It is the cause of "folie du cuir" or leather-workers' 
insanity. It is used by shoemakers in applying invisible patches. Shoe- 
makers may be very easily poisoned because of their close quarters, sitting 
near the floor, lack of precautions and ignorance of the poisonous charac- 
ter of the gutta-percha solvent used. The most susceptible persons are 
the ill-nourished, neurotic, alcoholic, female and young persons. 
In Ohio where over 75,000 workers were employed in the rubber 
industry (1920), less than per cent, came into contact with CS2. The 
classes usually exposed: (1) Rubber cement makers (exposure usually 
quite limited since the mixing is mechanically done in close up containers). 
(2) Cement tube- and can-fillers (more exposure, but boys and men so 
engaged were a rapidy changing lot or rotated with other work. Mild 
symptoms were a frequent complaint, however). (3) "Cold curing" of 
drug sundries (gloves, caps, nipples, bags, cots, etc.), and splicing ends of 
inner tubes for tires (exposures varied in plants, but some form of local 
exhaust ventilations was usually present, or a more or less complete 
confinement of the odors within cupboards, or, finally CC14 was largely 
substituted for CS2. Some moderately severe cases were previously 
found). (4) Transmission belt makers. Balata is the kind of rubber 
usually employed (exposure varied but quarters were spacious and not 
many employes thus engaged. Reports of acute cases in the past were 
all that could be found). (5) Water-proofing and spreading of rubber 
onto fabrics (CS2 used very limitedly, if at all, for this purpose, since 362 
CARBON BISULPHIDE POISONING 
benzine seems to be the usual solvent). In almost no processes were 
females exposed to CS2.29 
Jules Blain32 shows a diagram of a filter for removing sulfur-carbon compounds 
from the air by means of crude petroleum and CaCL 
Pharmacology and Animal Experiments.-Lehmann found experimentally that 
men absorbed on the average 22 per cent, of all the CS2 emanations they inhaled, and 
animals a little less (20.6 per cent.).10 Oliver21 found that CS2 was a very deadly 
poison to animals, and a more powerful anaesthetic than chloroform and more lasting 
in its effects. A rabbit which inhaled the vapor for a short time showed intense 
excitement, intoxication, impulsion, followed by a deep sleep, and on regaining 
consciousness its hind limbs were paralyzed and so remained for 1 hour. Animals 
exposed more slowly died within 3 to 21 days, during which time they lost flesh, 
showed tremors, were easily fatigued, became paralyzed in the hind limbs and died 
convulsed. The urine was excessive, no albumin was present, there was but little 
urea, although considerable sugar at death. 
The cells of the motor areas of the cortex showed, by Golgi's method, cytoplasm 
stained unequally and axis-cylinders distorted. Oliver states that it is a fairly safe 
anaesthetic, but the odor is too repulsive for use and it produces too much muscular 
jactation. Red cells are not disintegrated (dog and rabbit); spectroscopic findings 
are all negative. 
There occur extravasations in the lungs (Poincare5) and stomach walls;28 pneu- 
monia,13 degeneration of liver cells, of splenic pulp, and sometimes nephritis, and 
gastro-enteritis. The myelin substance of the nervous system is broken up into fatty 
droplets,5 and emboli occur in the blood-vessels of the brain. The blood findings in 
animals have been well investigated and do not differ materially from those in man 
(see under Pathology). 
Pathology.-Persons poisoned by bisulphide of carbon, in the course of 
conducting occupational processes, usually show atrophy and fatty degen- 
eration of muscular and connective tissues with loss of normal fat. There 
may be dryness and contraction of the skin due to the fatty solvent 
action of CS2 (Perrin).27 The urine in acute cases may give a dark-brown- 
ish color (Galet) with Fehling's solution, due to the presence of hematin 
from destroyed red cells. Hydrobilirubin and indican, as well as albumin 
and casts occur in older cases. Its essential action on the blood is hemoly- 
sis. Cenci20 carefully studied 12 afflicted workers who had been exposed 
for long periods, while engaged in the extraction of oil from olives, and 
obtained blood findings as follows: (1) chloransemia, (2) hypoglobulia, 
(3) white cells not affected, (4) alkalinity of the blood reduced in all cases, 
(5) red corpuscle resistance greatly increased, (6) no apparent effect upon 
coagulation time. All of these conditions returned to normal after with- 
drawal from the work and within a period of a few weeks or months. 
Jump and Cruice14 report hemoglobin 40 per cent, with red and white 
cell count normal. Galet18 found no granulations in the cells in either 
acute or chronic cases in six men. Laboulbene6 was the first to cite cases 
showing cutaneous "taches ecchymotiques," later followed by pigmen- 
tation. These appeared upon the limbs and thorax. Vesicles may 
appear. SYMPTOMS OF CARBON BISULPHIDE POISONING 
363 
Symptomatology.-Two types of industrial cases are recognized, acute 
and chronic, the latter with two stages, excitement and depression. Acute 
industrial poisoning is rare to-day. Extensive users of the substance 
appear to be well informed of its dangers. However, in Ohio in the first 
6 months of the year 1914, two instances came to our notice, which may 
have been due to carbon bisulphide, in one of which sudden paralytic 
attacks occurred on each of two times the patient returned to work, while, 
in the other, puzzling symptoms, which lasted a few days, were followed 
by death with hemorrhages from the various orifices. In rubber workers 
symptoms of carbon bisulphide poisoning are apt to be accompanied by 
those due to benzine, benzol, sulphur monochloride and carbon tetra- 
chloride, which are usually employed, one or all, with the bisulphide. 
The acute cases have as chief symptoms: (1) circulatory disturbances, 
pallor, headaches, throbbing of temples, pains in nape of neck and crown 
radiating to temples and frontal region, palpitation, fainting; (2) drowsi- 
ness; (3) digestive disturbances, especially nausea, anorexia, repeated 
vomiting, perhaps diarrhea, but sometimes colic and constipation; (4) 
pervous manifestations, especially incoordination, weakness in legs, signs 
of great fatigue, unsteady gait, impulsive acts, as throwing one's self 
under vehicles, into machinery, out of windows, etc.-mania with homi- 
cidal and suicidal results are known. There are also marked hallucina- 
tions of sight, hearing, taste and smell. Death may follow during a 
convulsion or during coma. The breath has the fetid odor of sulphides. 
Chronic symptoms are the usual ones and the onset may appear within 
a few weeks or months, or only after years in the work.24 The stage of 
excitement comes first, and is usually evinced while at work as exhilara- 
tion, loquaciousness and undue jollity. Following this comes faintness, 
giddiness, drowsiness, exhaustion and headache. At home the patient is 
irritable, depressed, tastes the bisulphide in everything, sleeps in daytime, 
cannot sleep at night, and has bad dreams. Return to work temporarily 
invigorates again. Cases investigated in Ohio complained of feeling 
"drunk," when fellow-workers would take them into the open air (with 
little concern). Usually new men were the ones most afflicted. Hysteri- 
cal manifestations7 are particularly common, and more so in females. 
There are all manner of psychical phenomena, from "crazy," excited 
talk, to ravings and acute mania. Workers complain of dysthesias, 
which assume geometrical distributions; numbness and tingling; anaes- 
thesia of parts; "that contact of the hand with the body seems that of 
some other person's;"18 cramp-like pains; spasms of face muscles; and 
trembling. There is a drunken gait, exaggerated reflexes, and a Romberg 
sign is usually present. A violent explosive temper with symptoms resem- 
bling delirium tremens21 may prove puzzling in diagnosis. Peripheral neuri- 
tis, mostly motor in type, is easily demonstrable. Digestive disturbances 
include vomiting, especially in females, loss of taste, subjective rotton odors, 
and diarrhea, which may alternate with constipation. Delpech3 cites an 364 
CARBON BISULPHIDE POISONING 
instance where a capricious appetite showed that " he spent 10 francs to each 
6 sous' worth." The pulse is rapid and there may be abundant nose bleed 
at times. Menorrhagia and miscarriages occur, while a violent sexual 
passion possesses males.25 Hearing is early impaired, and more often 
than sight. Disturbances of sight11 come later on-dimness of vision, 
blind spots, disturbances of color fields-and appear to be a retrobulbar 
neuritis* with changes, later, in the retina and choroid.19 
In the stage of depression, which follows the above in the course of a 
few weeks, there is noticeable nutritive disturbances, atrophy and emacia- 
tion, or sometimes just softness of the muscles and tissues, with fibrilla- 
tions and relaxation. Pallor and weakness may develop into actual 
cachexia. Functional troubles are very common, and include paraesthe- 
sias (itching, formications), great depression, weakness of memory for 
words, puerile enunciation, melancholia, hypochondria and torpor. 
Organic nervous symptoms are almost equally common, and consist of 
partial and complete paralyses, especially of extensor groups of muscles 
(arms, hands, feet), leading to wrist drop, steppage gait, and, later, con- 
tractures. The fingers which come into contact with carbon bisulphide 
are apt to become extended, stiff and numb.13 There is often tremor of the 
extended hands and tongue, exaggerated on use. The lips tremble, and 
quite violently so, when attempting to whistle.14 Absent knee-jerks and 
other deep reflexes, with loss of sensations caused Berbes (1885) to speak 
of the condition as pseudo-tabes.16 There is constipation most of the 
time. Skin pigmentation may be present. The patient cannot read 
because of dim vision; fingers may, with difficulty, be counted.12 Pupils 
appear normal, there is no diplopia; the examination of the fundus shows, 
at first, a congested disc with hypersemia of retinal vessels, and, later, 
pallor, said to be more marked in the temporal half. Deafness may be 
marked. Sexual power is entirely lost; atrophy of testes may be plainly 
discernable. Sterility obtains in females. Ten cases (all males) dis- 
covered among the rubber workers in Ohio, lay between the excitable 
stage and this chronic depressive type, with some symptoms especially 
well-marked. 
Diagnosis.-Carbon bisulphide gives no characteristic sign or syn- 
drome. Peripheral neuritis, hysterical symptoms, and history of expo- 
sure usually suffice for diagnosis. Physicians in rubber districts are so 
confused with the multiplicity of poisons used in that industry that they 
usually style all patients "rubber poisoned." An attempt is here made 
to distinguish between them. Acute cases are to be distinguished from 
poisoning due to: (a) Anilin-sudden weakness of legs, sudden swooning, 
cyanosis of lips, pale or suffused face, air-hunger, strangury, bloody urine, 
* Terrien31 reports two cases of central scotoma with notable reduction of the visual field 
in two persons who had been exposed to the vapors of carbon disulphide for eight hours 
while spreading a solution of rubber in benzine and carbon sulphide on paper in order to 
make mustard plasters. A retrobulbar neuritis was found similar to that caused by nico- 
tine and alcohol. DIAGNOSIS OF CARBON BISULPHIDE POISONING 
365 
methemoglobin, stupor, apt to continue for 24 hours or longer, and, if 
death does not occur, bladder irritation and skin eruptions may follow. 
(&) Benzine-usually begins with foolish prattle, laughter, shouting, 
trembling and jerking-"the benzine jag"-collapse, pallor changing to 
cyanosis, syncope, all with quick recovery in fresh air. (c) Benzol-is 
more of an irritant, shows slight flushing of face, followed by pallor, 
watery eyes, nasal discharge, coughing. When unconscious, lips are of 
scarlet hue, blood is bright red and thin, tonic and clonic spasms are 
present; symptoms are much worse and more prolonged than those due to 
benzine, (d) Sulphur monochloride-harmful only when it is broken 
up by moisture (steam) into SO2 and HC1 vapor, (e) Carbon tetra- 
chloride-rarely poisonous industrially, but will produce symptoms 
similar to chloroform, with nausea, coughing, headache and pronounced 
excitement.* Around tar and gas works: (/) Hydrogen sulphide-an irri- 
tant, producing watery eyes, running nose, coughing, herpes on lips, con- 
tracted pupils, slow pulse, Cheynes-Stokes respiration, tonic spasms, 
delirium and coma; breath smells of sulphides, also, (g} Carbon mon- 
oxide and illuminating gas poisoning-may, rarely, be confused with car- 
bon bisulphide poisoning. Finally, (A) Acute alcoholism-the patient 
is rather less impulsive, and there is a different odor to breath; uncon- 
sciousness is not coma as a rule. 
Chronic poisoning shows itself principally in the history of the case. 
A period of several days or weeks of drunken jollity and excitement, 
followed by depression, with paralytic, digestive and nutritive distur- 
bances, is quite characteristic. The condition is to be differentiated from 
(a) Lead poisoning, which is more common in rubber-tire and hard-rubber 
factories than bisulphide poisoning. Here the predominance of colic, 
constipation, vomiting, with peculiar pallor and blue line on gums, and lead 
in urine are diagnostic. (6) Mercurialism-trembling, salivation, gingivitis, 
diarrhea, and foul breath are characteristic, (c) Duchenne2 declared 
that time only would separate bisulphide poisoning from paresis, since 
death is not frequent in the former. This condition and (d) locomotor 
ataxia, however, have characteristic pupil, reflex bladder and rectal dis- 
turbances and specific blood and spinal fluid tests, (e) Progressive mus- 
cular atrophy presents no digestive disturbances, while mental faculties 
remain good. (/) Hysteria probably cannot be differentiated sympto- 
matically, but note especially signs of peripheral neuritis of toxic origin. 
(g) Many mild cases probably pass as neurasthenia. (A) Chronic alco- 
holism with neuritis exhibits cutaneous and muscular tenderness, features 
usually absent in CS2 poisoning. Also eye symptoms are not promi- 
nent. (i) The dulled mentality, muscular weakness and slow movements, 
which accompany or follow severe CO poisoning must be thought of. 
* The late Dr. E. B. Starr,33 my lamented associate in office, summarized the literature 
on the systemic effects of carbon-tetrachloride, and writes that its action is similar to that 
of chloroform, though more depressant to the circulation and respiration, while Waller and 
Veley (Lancet, 1909, 2, 369) considered it more toxic. 366 
CARBON BISULPHIDE POISONING 
Prognosis.-Of the eight cases studied by Brian,25 two had mental 
alienation, one had presenile involuntaries, one was profoundly stupid, 
three suffered paresis of legs, with pains in limbs, and one, brutal genital 
excitation. Except the first three, all recovered, with the possible excep- 
tion of full capacity for work. Delpech3 says, " He who has worked in 
sulphur is never again a man." Usually cases lightly affected, or only 
acutely affected, and who get out of the work, are not harmed. Chronic 
poisoning rarely results in death, except through cachexia. Eye symp- 
toms usually recover, hearing recovers more slowly, while memory for 
words seems to be one of the last functions to be reestablished. 
Peterson8 reports recovery in three cases of mania within 9 to 17 
months. Bard9 reports cases of homicide and suicide, and another case 
which recovered from mania. 
Treatment.-Prophylaxis is usually easy. Workers should stand on 
raised platforms, not down in pits or low places. They shouTd'be selected, 
instructed, alternated, and allowed only short applications at this work. 
They should wear impervious clothing, rubber gloves, and boots. Local 
exhaust systems; slatted floors with powerful exhausts beneath; fresh air 
from windows stirred up by electric fans; the process confined within 
special cupboards with apparatus for subsequently drying the goods, all 
handled mechanically-these are some of the various means employed to 
prevent poisoning. It should be remembered that clothes, hands, walls, 
floors, etc., become impregnated with CS2 and that all need thorough and 
frequent cleaning. Especially should the hands and fingers be kept out 
of CS2 solutions. 
Carbon tetrachloride is the natural substitute, having many advan- 
tages, but is more expensive. Yet it is extensively used in Ohio. Some 
patent harmless substitutes are also on the market.22 Substitution of 
other curing processes (steam, vapor cures with sulphur monochloride 
alone, sulphur chloride with carbon tetrachloride, etc.) have largely 
replaced the old "acid" or "cold" cure in rubber districts. Outside of 
extraction purposes and special cements manufactured for the trade 
(when "Poison" labels should be attached), the use of carbon bisulphide 
could probably be substituted advisedly in industry in general, because 
of its toxic properties. 
In case of acute poisoning, remove to fresh air, give warm bath or cold 
affusions, accordingly, as excitement or stupor prevail. Artificial respira- 
tion may be necessary. For subacute or chronic symptoms the patient 
should quit the work at once. He should be given nitrogenous food to 
prevent muscular atrophy, with such drugs as strychnine, quinine, phos- 
phorus, iron, iodides and arsenic. For the muscular conditions, elec- 
tricity (galvanism), vapor baths and massage are indicated. 
The British Factory and Workshops Acts30 specify the duties of employers thus- 
(1) exclusion of children or young persons from rooms where carbon bisulphide is used, 
(2) limit of 2^ hours' work per spell with not over 5 hours per day total (with certain REFERENCES ON CARBON BISULPHIDE POISONING 
367 
exceptions) and at least an hour between spells, (3) self-feeding troughs, automatic 
conveying machines (with certain exceptions) and hoods with suction fans, (4) 
exclusion of persons from drying chambers during ordinary course of work, (5) outside 
eating, (6) monthly examination by district certifying surgeon, and (7) maintenance 
of a register of visits, examinations and findings: and of persons employed, thus- 
(1) exclusion from drying chambers, (2) compulsory use of boxes with suction fans, 
(3) eating outside of work rooms, (4) exclusion from work contrary to directions of 
certifying surgeon, (5) compulsory physical examinations by certifying surgeon, and 
(6) immediate reporting to employer or foreman of defective protective devices. 
REFERENCES 
1 Pazen.-Chemie industrelle, 1851. 
2 Duchenne de Boulogne.-Memoires sur la paralysie generale. Arch. gen. de Med., 
1853. 
3 Delpech.-2e Memoire. Acad, de Sc., 1861, publie in Ann. d'Hyg. et de Med. leg., 
1863, IX, 65. 
4 Tavera.-These Paris, 1865. 
6 Poincare.-Arch, de phys., 1875. 
6 Laboulbene.-Soc. Med. d. Hop., 1876. 
7 Marie, Pierre.-Bull, de Soc. Med. de Hop. de Paris, 1888, V. 
8 Peterson.-Boston M. & S. J., 1892, XXVII. 
9 Bard.-Cal. Pract., 1892, VII. 
10 Lehmann, K. B.-Arch. f. Hyg., 1897, XX, 894, 26. Also, 1908, LXVII, 57-98. 
11 Friedenwahl, H.-The Newer Pathology of the Retina. Jr. Am. M. A., 1901, 
XXXVII, 1443. 
12 Heath, F. C.-Amblyopia from Carbon Bisulphide Poisoning. Ann. of Ophth., St. 
Louis, Jan., 1902. 
13Hauft, Hans George.-Beitrage zur Kenntnis der Schwefelkohlenstoffvergiftung. 
Arch, intern, de Phar. et de Ther., 1903, II, 155-200. 
14 Jump, H. D., and Cruice, J. M.-Chronic Poisoning from Bisulphide of Carbon. 
Univ, of Penn. Med. Bull., July-Aug., 1904, 193-196. 
15 Coronulas (Athens, Gr.).-Chicago Med. Soc., Jr. Am. M. A., 1904, XLIII, 1657. 
16 Pigeon, L.-Du sulfo-carbonisme professionel. Paris Thesis, March 23, 1905. 
17 Aitoff, Vladimir.-Effects du sulfure de carbone. Paris Thesis, 1905. 
18 Galet, O.-Empoisonnement par le sulfure de carbone et sulfocarbonisme profession- 
nel. La Clinique (4 illustrations), Brus., 1906, 501. 
19 Offret, Alfred.-Essai sur l'amblyopie par le sulfure de carbone. Paris, 1906, 62 p, 
1 pl., 8°. 
20 Cenci, Francesco.-Sull 'anemia da sulfuro di carbonio. Ann. d'ig. sper., Roma, 
1907, 17. 
21 Oliver, Sir Thos.-Allbutt and Rolleston's System, 1909, II, pt. I, 1021. 
22 Pearson, H. C.-Crude Rubber and Combining Ingredients, 2nd Ed., 1909, 227. 
Also "Rubber," Philip Schridrowitz, Methuen & Co., London; and Heil and 
Esch: "The Manufacture of Rubber Goods," Chas. Griffin & Co. 
23 Rucker, Wm. C.-Rodent Extermination in "The Rat and Its Relation to the 
Public Health." Special Bull. U. S. P. H. & M. H. Ser., 1910, 158. Also 
McClinitic, Thos. B., Killing of Wild Mammals. P. H. Reports, 1912, 
XXVII, pt. I, 736. 
24 Sommerfeld & Fischer.-List of Industrial Poisons. U. S. Labor Bull. No. 100, 
1912. 
25 Briau (de Creusot).-Hygiene Industrielle. Y-a-til une "Folie du cuir"? Empois- 
sonement chronique par le sulfure de carbone. Lyon Med., 1912, 119, 897- 
901. 368 
CARBON BISULPHIDE POISONING 
26 Molinari, Ettore.-General and Industrial Chemistry. Trans, by E. Feilmann, 
1912, I, 395, P. Blakiston's Son & Co. 
27 Rambousek, J.-Industrial Poisoning. Trans, by T. M. Legge, 1913, Edward 
Arnold, Lond. 
28 Luig, Bruno.-Beitrage zur Schwefelkohlenstoffvergiftung und Benzol in Akuten 
und Chronischen Versuchen. Wurzburg, 1913, E. Monnich, 53 p., 8°. 
29 Hayhurst.-A Survey of Industrial Health Hazards and Occupational Diseases in 
Ohio, Ohio State Board of Health, Columbus, 1915, pages 219-228. 
80 British Factory and Workshop Orders, 1914 edition, page 217. See copy of these 
in Special Bulletin No. 76, New York State Department of Labor (Industrial 
Commission), published in 1916. 
31 Terrien.-Il Lavoro, Sept. 30, 1920, 12, No. 5, 147; Abst. Jr. Ind. Hyg., Feb., 1921, 
200, from Paris Medical. 
32 Blain, Jules.-Industrie Chimique, 1920, 7, 311-313; Abst. Jr. Ind. Hyg., July 21, 
1921, 61. 
33 Starr, E. B.-Poisoning by Benzol-Carbon Tetrachloride Cement, Etc., Jr. Ind. 
Hyg., Vol. IV, No. 3, Sept., 1922, 203-212. SECTION 8 
CARBON MONOXIDE POISONING* 
BY G. L. APFELBACH, M. D., Chicago, Ill., Revised By EMERY R. HAYHURST, M. D„ 
Columbus, Ohio 
Introduction and Definitions.-Lewin1 states that CO is now and has 
been since the first discovery of fire the most widespread poison connected 
with human life and activity. Widely discussed in ancient literature, its 
effects in the middle ages were attributed to the work of demons and 
witches. 
Glaister and Logan2 devote an entire text-book to the subject and 
are well recognized authorities. Alice Hamilton (Bull. 291, U. S. Bur. 
Lab. Stat., Dec., 1921) gives an excellent discussion and statistical 
summary and notes that its incidence as reported in European countries 
is much higher than in America which implies that a more thorough 
study of it should be made here. 
The unusual prevalence of domestic mishaps with CO was demon- 
strated during the winter months in Ohio, 1922-1923, when a careful 
record kept by the State Department of Health showed approximately 
50 deaths and at least 150 partial asphyxiations attributed to CO gas 
from the use of gas heating stoves and water heaters set up without flues 
or vents to the outside air. These were in living rooms, and occasion- 
ally in offices and store buildings. 
As stated by Apfelbach,3 the subject of CO poisoning is an intricate 
one. It is not difficult to find that workers in certain industries are 
being "gassed," either by appreciable quantities or by small continuous 
doses of this gas. It is, however, difficult to determine the sequelae or 
subsequent effects of CO gassing. Many factors make a scientific con- 
clusion of the effects of CO prohibitive. These are syphilis, alcoholism, 
poor nourishment, insanitary home conditions and surroundings, and the 
elements of fatigue and high temperature. These factors had to be 
considered in the investigation of 1910 by the Illinois Commission on 
Industrial Diseases. 
In 2062 authentic occupational diseases reported to the Ohio State Department of 
Health in eight years (1913-1921), CO poisoning stood fourth in order with 101 cases. 
Sudden severe gassings, which come under the compensation law for accidents were 
* Much of the fundamental and historical matter prepared by Dr. Apfelbach has been 
retained under his name and the general arrangement of the discussion follows his original 
plan. His material bears the reference number "3" throughout. 
For the sake of brevity as well as ease of comprehension, chemical symbols of the simpler 
elements and compounds are used throughout this Section. 
369 370 
CARBON MONOXIDE POISONING 
not included in this group. The figure, also, represents but a small proportion of the 
total cases occurring, due to incomplete reporting. 
Acute CO poisoning3 is that condition in which the person affected has 
been subjected to such a toxic dose of the gas as to produce either coma 
or such a train of subjective and objective findings as to be readily 
attributed to "gassing." Chronic CO poisoning is the result of subjection 
to repeated or continuous small doses of CO, not, however, producing at 
any one time a marked symptom-complex. 
Before going into the industrial medical importance of this toxic agent, we must 
pause to consider with what temerity we use this most poisonous gas in our everyday 
life.3 During childhood the writer (Apfelbach) became acquainted with the subject 
of CO poisoning when the kindly grandmother warned her grandchildren to keep the 
stove door closed, especially at such times during which the blue flames skipped about, 
between and on the surface of the burning coals. We permit our houses, even our 
sleeping rooms, to be surrounded by a network of pipes containing this deadly gas, 
making us the victims of accidental leakages. Our illuminating gases vary in CO 
content, the toxic agent of the gas. Carburetted water gas is used extensively 
throughout the United States for illuminating purposes with contents of about 30 
per cent. CO. Since 0.5 per cent, to 1.0 per cent, of CO or 1.5 per cent, to 3.0 percent, of 
illuminating water gas is rapidly fatal, accidental leakage of this gas in our bedrooms 
often causes death. Accidental "gassing" was more common during the introductory 
period of illuminating gas than at present. Many cases have also occurred from neg- 
lect of closing stove doors, from back draught of hearths or fireplaces, from old-style 
bake ovens and charcoal braziers. The use of any form of carbonaceous fuel, such as 
charcoal, wood, coal, kerosene, gasoline.and gas, is dangerous in any room without an 
adequate method of drawing off the products of combustion. 
For the first few minutes following the "turning on" of a gas stove (Hayhurst) in 
which the flame touches metal, there is escape of large quantities of unburned gas which 
continues until the metal contact surface becomes heated to the point of igniting all 
the gas. Even here if the inner cone of a blue flame (i.e. Bunsen type of burner or one 
having a shutter or opening for mixing air with the gas just previous to burning), or 
any yellow flame continues to impinge on metal a constant yield of CO is produced. 
It is safest to consider that all carbonaceous flames yield CO whenever they impinge 
against metal. The more heat conductive the metal C-Q- copper), or other substance, 
the more the yield of CO since the point- of impingement may not be fully heated to 
the ignition point of CO. Hence it can be seen that instantaneous hot water heaters 
(changing cold to hot water) with gas burners are a veritable menace in a bath room 
unless adequately flued to the exterior. 
Harris4 cites an instance of CO poisoning in a factory on the top floors of a twelve 
story building, given over to the manufacture of men's clothing. Of 125 employes, 
73 became suddenly ill at about 2 P.M., being seized with nausea and vomiting, head- 
ache, dizziness and weakness. Several were overcome, but none died. After aid 
was rendered nearly all recovered in a few hours. The source of gassing was puzzling, 
but was eventually found to be due to chimney gases from the roof coming down a 
rear stairway and through the open doors of workrooms. Hence, contrary to first 
interpretation, "open doors" here "caused the gassing." 
McNally5 states that people nearest the doors or windows in a room into which CO 
gas is escaping suffer the least, and those nearest the floor the most. He cites cases to 
show this. Cellars are especially bad. 
Police records3 of almost every city show numerous cases of gas poisoning, often 
proving fatal, attributed to intentional suicide. The Paris records, for the 9 years PREVALENCE OF CO POISONING-CHEMISTRY 
371 
from 1834 to 1843, show a total of 4595 deaths due to suicide, of which 1432 were 
accomplished by means of CO. The charcoal brazier became the popular means of 
suicide in France, so much so that we find frequent reference to it even by writers of 
fiction such as Dumas, Victor Hugo and Eugene Sue. With each decade this practice 
increased, until the records of 1891 in Paris disclose the surprisingly large number of 
848 suicides by this method. 
At Cook County Hospital,5 Chicago, in 1916, there were 501 cases of 
CO Poisoning, or 8 per cent, of all coroner's cases. They stood fourth 
place in numerical order of different forms of death for the year. Mc- 
Nally found such deaths to be increasing annually, due to the suicide 
factor. He calls attention, incidently, to CO in inhaled tobacco smoke 
of any source (0.014 per cent, to 0.027 per cent.). The habitual tobacco 
smoker may show as much as 6 per cent. CO-Hb saturation of his blood 
(Hartridge: Proc. Physiol. Soc., Jan. 31, 1920; Jr. Physiol., 53). 
Additional accidental poisonings3 from CO, other than industrial, 
have occurred in many different ways, chiefly from fires made with 
briquettes, used in heating cabs; from chemical laboratories; among 
persons living in the neighborhood of gas-producing industries; from 
gasoline automobiles and launches; and to gas heating stoves (Hayhurst), 
usually of the cheaper radiant types, having air-and-gas mixers of im- 
proper design, or requiring practically expert supervision to maintain 
the proper mixtures, or subject to producing improper combustion 
because of fluctuations in the gas pressure which often varies daily from 
50 to 150 per cent.,-as from 3 oz. in the day time, when many are using 
their burners, to as high as 7 or 8 oz. after midnight when domestic and 
industrial use is greatly reduced. The gas mixers on such stoves when 
set for the lower pressures may become CO generators on the higher 
pressures. (See Tech. Paper 257, by S. S. Wyer, U. S. Bur. of Mines, 
1920, p. 14). 
Reference3 is made to the numerous stories about tramps expiring 
in the warmth of a brick or lime kiln. This gas is often formed 
by smouldering timbers after large conflagrations in factories, theatres, 
and other buildings. 
Surgeon General Stokes, U. S. N., found that the pulse rate of men rose rapidly 
from 72 to 120 within 10 minutes after firing guns in the turrets on battleships. He 
also observed that the socalled "heat prostrations" in the stoke rooms are often due 
to CO and other gases. 
CHEMISTRY 
Carbon monoxide is seldom found in a free state. Contrary to pop- 
ular opinion, natural gas, which is obtained from gas wells sunk usually 
in coal bearing areas, does not contain CO and is practically nontoxic, 
although it will not, of course, support life if breathed in very high con- 
centration because of its lack of oxygen. Therefore suicide, homicide and 
even accidental death by inhaling it are almost unknown. It is no excep- 372 
CARBON MONOXIDE POISONING 
tion, however, to the general rule for carbonaceous materials, i.e. it will 
yield CO if not burned with enough air (oxygen). A typical analysis 
(Burrell) of natural gas shows: 
Gas 
Per Cent. 
Carbon dioxide (CO2) 
Trace 
Methane (CH4) 
84.7 
Ethane (C2H6) 
9.4 
Propane (C3H8) . . . . 
3.0 
Butane, etc. (C4H10) 
1.3 
Nitrogen (N2) 
1.6 
Carbon monoxide may occur in the chemical laboratory and in old gas 
mains where it lies inert in brick, flue dirt, soot, oil, and pools of water. 
During the world war, Rutherford6 found it might be held in the porosity 
and fissures of shelltorn ground for hours and days, and thus caused many 
deaths. Changes in the barometric pressure and in the subsoil water 
levels would force it out, this condition being most noticeable in chalky 
soils and least so in clay soils. Georgine Luden7 calls attention to the 
tenacity with which CO clings to objects, as furniture, bedding, clothing, 
as if it were dust. She states that in American training camps, troops 
were instructed in "shovelling CO out of the trenches" with canvas 
shovels as if it were snow. 
The gas is colorless, tasteless, non-irritating and without odor. It burns with a blue 
flame, at 650°C. (1100°F.), but does not maintain combustion. Its flame is extin- 
guished in air containing less than 13.4 per cent, of oxygen; it is explosive if ignited 
when it makes up from 15 to 73 per cent, of air mixtures (Burrell). It has a specific 
gravity of 0.967. One liter weighs 1.25 grains. It is very diffusible, yet readily 
held inert by dust and oils. Claim has been made that it is able to diffuse through 
red hot iron; however, proof is not clear. It is readily taken up by an ammoniacal 
or hydrochloric acid solution of cuprous chloride,8 with which it forms a crystalline 
compound, 2CuCl.CO + 2H2O. 
Carbon monoxide production is quite invariably the result of incom- 
plete combustion of carbonaceous materials.3 As a rule wherever com- 
bustion of carbon-containing material occurs, we are apt to find CO as a 
by-product. Complete combustion is the rarer occurrence, as observed 
in our furnaces and stoves. The amount of CO formed, however, may not 
be perceptibly noticeable. Combustion depends on the presence of 0, 
or in a practical way on the draft, which is greatly influenced by weather 
conditions. When a flame strikes a cooling surface, such as a metallic 
plate, combustion is incomplete. The complete combustion of carbon- 
aceous material results in CO2, the incomplete, in CO, plus other by- 
products. 
Carbon monoxide may also be formed by the de-oxidation of CO2, when the latter 
is passed closely over red hot coals or metal. Carbon monoxide, formed by incomplete 
combustion, is found in our stoves between and beneath the coals; when formed by 
de-oxidation, on the surface of the red hot coals. Carbon monoxide is also found in 
the after-damp of mine explosions (see Index). TOXICOLOY OF CO POISONING 
373 
The ultimate end of CO discharged into the air is discussed by a 
writer in Science9 who says chlorophyll and hemoglobin both fix CO in 
the air. Also sunlight and halogen elements and the fluorine of mountain 
districts, during storms and lightning, convert CO to carbonylhalide 
or CO2. 
Fortunately, CO occurs usually in composition with other gases 
imparting an odor which makes the presence of CO presumable, although 
in stoves burning natural gas, which gas may be nearly odorless and is 
usually free of CO, an improper air-gas mixture may result in producing 
CO, CO2 and H2O all of which are odorless and practically non-detectable 
in the amounts generated, except that the characteristic symptoms of CO 
poisoning may occur and be mistaken for sickness or indisposition from 
other causes until unconsciousness develops and the victims die during 
sleep and apparently without a struggle. Formaldehyde may be a by- 
product of incomplete combustion and, when present, imparts a smarting 
sensation to the eyes and causes the inspired air to "bite." 
TOXICOLOGY 
Tests for Carbon Monoxide.-A mechanical CO detector and a simple 
type of CO gas mask were perfected by members (Frazer, Lamb, Hoover, 
and others10) of the Chemical Warfare Service during the world war which 
are adaptable to industrial use. The detector comprises a small metal 
barrel with a rubber bulb on one end and a means for quickly inserting a 
glass tube filled with a special chemical in a space on top of the barrel. 
The detector substance "hoolamite" contains fuming sulphuric acid, 
iodine pentoxide and powdered pumice sealed in a glass tube. The 
chemical used changes color from a light grey to a green when air con- 
taminated by CO is forced through the tube by the rubber bulb, the 
amount of color changes depending upon the percentage of CO in the air 
so that an accompanying calibrated color scale enables one to estimate, 
in a few seconds, amounts varying from 0.05 to 1.0 per cent. CO. The 
instrument is entirely mechanical and any one can operate it. It is far 
more sensitive than a canary bird and can be carried through gaseous 
zones. It has been thoroughly tried out around blast furnaces, steel mills 
and coal mines with most satisfactory results. The instrument readily 
shows the presence of CO in cigar, pipe or cigarette smoke [and also the 
effects of "inhaling" while smoking in which case the CO seems to be 
absorbed into the system for it can barely be detected in the exhaledbreath 
when the smoke remnant is blown through the detector-Hayhurst]. 
The Burrell instrument, however, will not detect the condition of " 0- 
want" in an atmosphere, which condition may be so marked in mines and 
similar places as to cause sudden collapse without previous warning signs. 
McNally5 also describes in some detail the usual tests for CO under 
different conditions and those interested should consult his original article. 374 
CARBON MONOXIDE POISONING 
In conclusion he states that he relies on the tannic acid test, basic lead 
acetate test and palladium chloride test, and says that if these are positive 
all other tests are superfluous. The palladium chloride test will show 0.05 
parts of CO in 1000 parts of air. The spectroscopic test is less used than 
formerly by recent workers. Sayers and Yant (U. S. Pub. Hlth. Reports, 
Vol. 37, No. 40, Oct. 6, 1922, p. 2433) have made a modification of the 
tannic acid test which they consider the best for all around purposes as it 
is very delicate and especially valuable for quantitative estimations: 
PROCEDURE FOR MAKING STANDARDS 
"Using a modified Keidel tube or any intravenous means, 5 cc. or more of human 
blood is drawn and kept from clotting by the addition of 0.5 gram of potassium citrate 
(K3C6H6O7), or 0.02 gram sodium fluoride (NaF) per 10 cc. of whole blood (the 
advantages of each will be discussed later). The blood thus obtained is divided into 
approximately equal parts, one of which is immediately diluted 1 in 10 with distilled 
water, while the other is saturated with 3 to 5 per cent, of CO gas, then diluted 1 in 
10 with distilled water." 
"From these solutions of approximately all oxy-hemoglobin (O2Hb) and carbon 
monoxide-hemoglobin (CO-Hb), respectively, mixtures are made which total 1 cc. 
but vary from none to 100 per cent CO-Hb in steps of 10. These are contained in 
test tubes of approximately inch inside diameter, and of clear, thin, glass. To 
each standard thus prepared is added 1 cc. of a mixture consisting of equal parts of a 
strictly fresh solution of 2 per cent, pyrogallic acid and a solution of 2 per cent, tannic 
acid, after which the tube is inverted twice to insure thorough mixing. Immediately 
after adding the acid, the tube should be sealed by pouring a little melted paraffin 
on top of the contents, the tube being immersed in cold water as a caution against 
overheating. This temporary seal will- be sufficient to exclude the air until the walls 
of the tubes have become dry, after which a tight, permanent seal can be made by 
placing a disc of cardboard on top of the paraffin and filling the remainder of the tube 
with ordinary sealing wax. Care should be taken to have no air inclosed between the 
disc and the paraffin, or between the disc and the sealing wax. Standards thus pre- 
pared develop their full color in from 10 to 15 minutes, and if properly sealed will 
remain in a suitable condition of permanency for several weeks. 
TECHNIQUE OF DETERMINATION 
"In making an estimation of the CO in the blood of a supposed victim of poisoning, 
the technique is, in principle, quite similar to that of making the standards. Measure 
into a test tube of the same size and glass as used for the standards, 1 cc. of a 0.05 per 
cent, solution of potassium citrate or 0.03 per cent, solution of sodium fluoride, depend- 
ing on the anticoagulant used in preparing the standards. Then, by the aid of a hemo- 
spast, make a small puncture wound in the tip of the sterilized finger of the subject, and, 
with a capillary pipette, draw up 0.1 cc. of blood. Quickly discharge this into the 
solution in the test tube, and add 1 cc. of the mixture of pyrogallic and tannic acids 
as previously described. After inverting twice to mix constituents thoroughly, and 
allowing to stand from 8 to 10 minutes, a comparison with the standards can be made 
and the percentage noted. It is very good practice to prepare a similar sample from 
an unexposed subject, thus insuring against spoiled reagents or change in standards. 
Any differences noted' in this control should be considered in estimating other 
samples." TESTS FOR CO IN THE BLOOD 
375 
"In making the comparison, the observer should stand with his back to the light, 
viewing the tubes by reflection, and should change the position of the tubes several 
times to note if any differences occur that are due merely to unequal lighting effect. 
Also, holding the tubes against a black background, such as a coat sleeve, seems to 
facilitate the observation." 
The comparison of the tannic acid with the spectrophotometric method shows a 
"evariation which is less than 3 per cent, which is negligible for practical work in the 
determination of CO in the blood." 
"It is evident that an occasional analysis by one man might be incorrect by 5 per 
cent., but the error is generally less." 
"In view of the simplicity of the procedure, and the reliability of the results, this 
method should be well suited to the determination of CO poisoning. It can also be 
used to estimate the CO-Hb in samples which have been collected in the field and 
shipped to the laboratory." 
"For nearly all ordinary work, potassium citrate will be quite suitable" (as the 
preferred anticoaglant.) 
"Probably the most important item of the entire analysis is to have strictly fresh 
prepared solutions, especially the mixture of tannic and pyrogallic acids." 
Henderson, Haggard and Scott62 have modified the above method as 
follows: 
"A finger is wrapped with a rubber band, a deep prick is made with a stiletto, and 
0.1 cc. of blood is drawn into a pipet. This blood is immediately delivered into a test 
tube in 0.4 cc. dilute ammonia (1 cc. of strong ammonia in a liter of water). It is 
essential that the blood and ammonia be immediately mixed so as to lake the sample 
completely, but the mixture must not be shaken or caused to foam. One and five- 
tenths cubic centimeters of tannic acid (1 per cent, freshly prepared) is then added 
and mixed. It takes several hours for the color to develop, or rather for all color not 
due to carbon monoxid to be converted into the dull brown of the tannated blood 
proteins. Such samples are read against a scale which must be prepared at practically 
the same time. For this scale dog's blood is generally used: Five cubic centimeters of 
the undiluted blood was thoroughly exposed to illuminating gas in a flask by bubbling 
the gas through the blood until it was completely in foam. One cubic centimeter of 
this blood was then laked in dilute ammonia. An equal amount of the original blood 
without carbon monoxid was similarly mixed with ammonia. By taking proportional 
amounts of these two solutions, mixing them and adding tannic acid solution, a scale 
was then prepared in a series of test tubes to show 10, 20, 30, 40, 50, 60 and 100 per 
cent, saturation with carbon monoxid. 
"The blood from the patient was compared with such a scale the day following. 
The comparison was always made independently by at least two observers, generally 
with close agreement in their estimations of the degree of saturation." 
Oxygen and Carbon Dioxide.-It seems very advisable at this point 
to give the percentages of the gases CO2 and O which, in man, produce 
symptoms (from "Science of Ventilation and Open Air Treatment," 
by Leonard Hill, Medical Research Council, Special Report Series No. 
52, 1920, Part II, pp. 136-142.): 
"In the case of people at sea-level, when the partial pressure of oxygen in the air 
is made to fall quickly to 14-12 per cent, of an atmosphere, hyperpnoea begins to be 
noticeable; at 10 per cent, it'becomes distinct, capacity for mental action and acuteness 
of sensation are lowered, the reaction time lengthened, cyanosis becomes evident, the 
pulse-rate increases, and there is a rise in systolic and fall in diastolic pressure, with 376 
CARBON MONOXIDE POISONING 
increased throbbing of the heart and arteries. Anoxaemia causes increased secretion 
of adrenalin and formation of sugar by the liver, these effects being brought about by 
stimulation of the splanchnic nerves. At 5 per cent, cyanosis is very marked and 
consciousness lost. 
"On breathing deoxygenated air consciousness is lost in some 45 seconds, and with- 
out warning. Convulsions follow with a temporary rise of blood pressure, followed 
quickly by a fall, cessation of respiration and of the heart beat. 
"Animals may live in an atmosphere, by gradual acclimatization, in which the 
proportion of oxygen has become so low and that of carbonic acid so high that a similar 
animal, brought from fresh air into it, dies almost at once. The degree of this immu- 
nity to oxygen-want varies with individuals. 
"Haldane found that men became acclimatized to 9.5 per cent, oxygen by 56 
hours spent in the sealed atmosphere of a submarine. Those coming in fresh from the 
outside air suffered from oxygen-want." 
"When the CO2 percentage rises over 3 per cent, hyperpnoea begins to be trouble- 
some, and there may be slight headache. On breathing 5-6 per cent, the hyperpnoea 
is exhausting, the face flushes, and there is sweating and headache. Breathing 10 
per cent, of CO2 cannot be endured for more than a minute or so; there results headache 
sweating, dimness of vision, and tremors. 
"On inhaling 5 per cent, it is possible to exhale 6 per cent, and keep up a respira- 
tory exchange by great hyperpnoea; beyond this point symptoms of poisoning from 
CO2 rapidly increase as the output from the body is checked." 
"Cadman and Whalley reported a place in a coal mine where a quantity of black- 
damp was given off and where a light would not burn 1 ft. 6 in. from the floor, or in 
the waste, but the men had no fault to find with the air. The foreman said it was 
better than usual. 
"Analyses of samples taken (1) at the floor, (2) at the coal face, showed: 
Per Cent. 
(1) C02 4.56 
(2) CO2 1.21 
Per Cent. 
02 13.13 
02 ' 18.97 
"Men in submarines are willing to remain submerged until the CO2 rises to 3 
per cent. 
"Men in breweries work for years in places where the CO2 may be 1-2 per cent, 
and retain excellent health. 
"Two per cent, increases the pulmonary ventilation about 50 per cent., 3 per cent, 
about 100 per cent., 5 per cent, about 300 per cent. Such increases lessen the working 
power in so far as the limit of hyperpnoea is sooner reached. 
"Divers constantly do heavy work in air with more than 1 per cent. CO2. It is 
important to bear in mind in the case of divers and compressed air workers that it is 
the partial pressure which matters, not the percentage. One per cent, at a pressure 
of three atmospheres equals 3 per cent, at one atmosphere. At two atmospheres 
(33 feet) the ventilation of the diver's helmet must be double that required at one 
atmosphere, at three atmospheres treble, and so on (Haldane)." 
Effects of Breathing Combustion Products.-In the middle west where so many 
persons breathe combustion products of industrial and domestic heating appliances, 
like gas stoves which are not flued or vented to the outside air, one feels that he can 
note three types of afflictions which possess many of the inhabitants during the 
winter season: (1) an anemic group which also complains of much headache, (2) a 
group with constantly recurring "colds," especially in the upper respiratory tract, 
associated with oft-repeated sensations of chilliness, and (3) those who have an 
unaccountable lack of energy developing as the day wears on. Combinations of these 
afflictions are also common. In view of the fact that Vaughan and Palmer (High COMBUSTION PRODUCTS-TOXICITY OF CO 
377 
Mortality from the Acute Respiratory Diseases in Winter, Am. Jr. Pub. Hlth., Dec., 
1922, 1022), state that cities suffer fully one-third more from pneumonia than country 
districts, and that one city, like Pittsburgh, has a rate of 275 as compared to Cleveland 
with a rate of 140 [and an enforced regulation against smoke production as well as 
flueless stoves], or that in Pittsburgh pneumonia represents 16 per cent, of all deaths as 
contrasted with San Francisco where pneumonia represents but 8 per cent., the 
assumption can hardly be otherwise than that the question of combustion products in 
the atmosphere, even without CO, may be a significant factor in the high rate of res- 
piratory afflictions in general. 
Detection of Combustion Products.-Experience shows that persons may breathe 
poisonous combustion products up to the point of sudden unconsciousness, followed 
by death, unless rescued, without suspicion of the dangers at hand. The following 
general rules for guidance under these circumstances may be laid down. A person 
should take warning and perhaps extricate himself at once from an atmosphere in 
which a fire is burning when there is (1) an odor of "burnt gases" in a confined place 
(unfortunately often detected only by one who happens to enter the premise and not 
by the occupant), (2) a precipitation of moisture on window panes and other cold 
surfaces, (3) a slight irritation of the eyes and perhaps nasal mucous membranes 
(formaldehyde as a by-product), (4) listlessness of any domestic animal present, 
(5) failure of a match to burn perfectly, or the fact that oil lamps or candles burn low 
or strangely, and (6) any sudden weakness experienced on arising from a quiet posi- 
tion, or starting some activity. On account of explosion hazard, one should never light 
a match in such a premise, however, as a test if a fire is not already burning therein. 
In summary it may be said that in unfavorable mixtures of these gases, 
lack of 0 is the important factor in extinguishing lights, also in the un- 
favorable effects on men, (and on the explosibility of CH2-air mixtures), 
while increased CO2 is far less important. The flame of a match or an 
oil lamp becomes extinguished when the 0 in the air falls to about 17 
per cent.; an acetylene lamp is extinguished when the 0 falls to about 12 
or 13 per cent. Burrell et al. (Bull. 105, U. S. Bur. Mines, 1916, p. 80) 
found that 0 might fall to 16.3 per cent, before the oil-fed lamp became 
extinguished, while the presence of 10 per cent. CO2 only raised the 
extinguishing percentage of O to 17.1. But while an atmosphere which 
will not support a flame is hazardous for human occupancy (because of 
the 0-want condition), "a lamp flame may burn fairly well in an atmos- 
phere that contains a fatal proportion of GO. The presence of fatal 
proportions of this gas is not indicated by the appearance of the flame." 
Toxicity of Carbon Monoxid.-From the view point of the industrial 
hygienist,3 or occupational disease physician, CO is the most important 
toxic gas, being not only highly toxic, but used extensively in our various 
industries. Gertz11 states that the toxic action of CO develops slowly at 
first. With 20 normal respirations-about one minute's time--there is no 
risk of asphyxia or loss of consciousness unless the air has unusual quanti- 
ties of CO. Gruber12 says that the limit of toxicity is 0.2 per cent. A 
volume of air containing 0.01 per cent, may cause distress, headache, 
nausea, and other phenomena. Others say that symptoms will not be 
produced until 0.05 per cent, of the gas is present. The point of toxicity 
will vary in individuals. This has been accurately proved by Haldane13 378 
CARBON MONOXIDE POISONING 
in humans and animals. The blood is capable of carrying 1 liter of 0 or 1 
liter of CO. As a matter of fact such will never occur, since we never find 
a saturation of the hemoglobin over 83 per cent, in fatal cases. It is well 
known that an air volume containing 1.0 per cent, of CO is considered as 
having moderately rapid fatal tendencies. In the Snaefell Mine Disaster14 
Dr. J. S. Haldane and his co-workers observed that the mine air contained 
1.07 per cent. CO. 
Henderson et al. (for ready description and brief pertinent bibliog- 
raphy see Nation's Health, IV, No. 10, Oct., 1922, p. 607-9) announce 
the following rule for practical use: 
"When the time is expressed in hours and the concentration in parts 
per 10,000, there will be no appreciable physiological effect when the 
product of the time, as multiplied by the concentration, equals 3; when 
the product of time by concentration equals 6 there will be in some persons 
slight effects; when it equals 9 there will be in nearly every one a distinct 
effect; when it equals 15 the condition is dangerous. A concentration 
of carbon monoxide not exceeding 4 parts in 10,000 (that is four cubic 
feet of carbon monoxid in 10,000 cubic feet of air) is therefore recom- 
mended as a practical standard for vehicular tunnels. This involves 
an enormous ventilation and force to maintain it, but is said by engineers 
to be entirely feasible." 
It is claimed that women are more resistant than men to CO. In 
Harbitz' cases15 (poisoning in a motorboat) the girl recovered while the 
young athlete died. He states that in Paris, of 19 cases of man and wife, 
the 3 survivors were women. 
The gas acts rapidly with no irritation to the respiratory tract,3 and 
also because of its inodorous quality its presence is often unknown. A 
case is recorded by Sonnenschein of a chemist, who by a single inhalation 
of an atmosphere laden with the gas, fell backward as if struck by 
lightning. 
The effect of CO gas varies in animals, causing convulsions in rats and other 
animals, while birds die failing to show such signs. Apfelbach3 mentions its use in 
killing vagrant dogs in Chicago; also for killing guinea pigs quickly. 
The striking unreliability of animals (rats, canaries, and guinea-pigs) for detecting 
the presence of CO gas was observed by the writer (Hayhurst), Berry, Dysart, Ei 
and another associate in the investigations of the Lancaster, Ohio, tragedy in Nov., 
1922, where a family of six persons,-father, mother and four small children-were 
killed by CO gas from defectively operating stoves in the course of one night's exposure 
in a small cottage. Here, after an 8 hour exposure with conditions including weather 
simulating as nearly as possible those on the night of the fatalities, only 2 out of 4 
young white rats, 1 out of 4 canaries, and none out of 4 guinea-pigs succumbed, 
although at the end of the 4th hour the CO concentration in the air had reached'0.2 
to 0.3 per cent, and at the end of the 8th hour 0.5 to over 1.0 per cent. (Burrell 
detector, partly checked by air-gas analyses.) This, at first, seems very inconsistent 
with usual reports, as, for instance, "canaries collapse in atmospheres containing 0.15 
per cent, carbon monoxide in 18 minutes, and show distress in 3 minutes." (See 
Burrell's "Chart of Properties of Mine Gases," U. S. Bur. of Mines). However, the TOXICITY OF CO 
379 
phenomenon of acclimation was probably operative: In the usual test the animal is 
suddenly placed in the deadly atmosphere with the usual results as reported. In our 
experiments there was a gradual accummulation of the gas beginning from zero. 
Recently Haldane reported a similar observation on himself when he found himself 
able to endure up to 0.6 per cent, without symptoms, as a result of getting acclimatized. 
This is in keeping with the experience of gas house workmen. Haldane regards that 
the lowest portion of CO in the air which would endanger life in about 12 hours, is, 
according to the susceptibility of the person, from 0.15 to 0.3 per cent. (British Med. 
Jr., Feb. 26, 1921). Oliver also reports unusual acclimation to CO in the case of 
a rabbit ("Diseases of Occupation," 1916, p. 417). 
While certain lower animals (mice, canaries, etc.) are more susceptible 
to CO than humans, their use for detecting the gas has much decreased in 
favor of better and more dependable methods. 
The gas is toxic* to the human whether it is inspired, swallowed or 
injected into the peritoneal cavity.3 The CO rapidly unites with the 
hemoglobin, replacing the 0 and forming a compound known as carboxy- 
hemoglobin. The affinity of the hemoglobin for CO is 300 times greater 
than the affinity for O (Haldane). This substitution of CO for O 
deprives the blood corpuscle of its O carrying power. Lewin1 is very 
skeptical about the instances reported in the literature of carbon mon- 
oxide in the blood after more than 24 hours in the pure air. He finds it no 
longer demonstrable after 6 hours by the spectroscopic method which 
shows as little as 0.25 per cent. 
Henderson and Paull state:16 "In six successive cases in which a sample of blood, 
was taken and examined not more than two hours after the patient had been removed 
to fresh air from the room in which asphyxia had occurred, the elimination of carbon 
monoxide was found to have been so rapid that in only a single case was the presence 
of a small amount in the blood still demonstrable. In all of these cases the blood had 
undoubtedly been saturated beyond the danger point of 60 per cent., yet two hours in 
fresh air had served to reduce the carbon monoxide to less than 15 per cent., the 
amount which the small pocket spectroscope employed was capable of distinguishing. 
Four of these cases died within 24 to 60 hours after the asphyxiation. One, which 
oddly enough was the case above noted in which a small percentage of carbon monoxide 
was detected two hours after removal to fresh air, recovered completely. Another 
still exhibited profound nervous impairment a month later." 
Henderson, Haggard et al.17 state: The elimination of CO is not 
complete until one or two hours, or even longer, after return to fresh air. 
Roughly, it is 30 to 50 per cent, per hour, depending doubtless on activity 
and volume of fresh air breathed. 
There is still a difference of opinion3 as to whether CO merely causes 
internal asphyxia by reason of having deprived the blood corpuscle of the 
hemoglobin element and, therefore, its O carrying power, or whether the 
gas also has a distinct toxic action on tissue. Haldane refers all toxicity 
of the gas to the lost O carrying power of the hemologbin, pointing out 
that a saturation of 20 per cent, will cause dizziness and dyspnoea; 50 per 
cent., loss of consciousness; 80 per cent., death. He points out that such 
is due to an internal asphyxia and explains that even such pathological 
♦"Toxic," here, is used in the sense of "shows its effects" (Hayhurst).) 380 
CARBON MONOXIDE POISONING 
sequelae as fatty degeneration of vessels and other organs are due to the 
impoverished red blood corpuscle. To sustain his point he proves by 
experiment that animals will live much longer and will tolerate a greater 
quantity of CO in an atmosphere of 0 than of air. Henderson finds:18 
(1) that CO is a physiologically harmless gas, except for its affinity for 
hemoglobin. Its toxic affects are wholly due to inability of the blood, 
combined with CO, to transport 0 to the tissues. That (2) CO does not 
form a permanent compound with hemoglobin. In presence of 0, or 
even pure air, CO is rapidly given off and the 0 carrying power of the Hb 
is restored. That (3) the continuance of coma, tissue degenerations, etc. 
are results of injury from lack of 0 and not from presence of CO. That 
(4) bleeding and. transfusion are probably both harmful. And that (5) 
"fresh air-with oxygen inhalation for a short time as early as possible- 
symptomatic treatment and good nursing are the only measures to be 
recommended. Practically the die is already cast for death, permanent 
defects, or complete recovery at the moment when the patient is brought 
out of the asphyxial atmosphere." Henderson, Haggard, et al.17 state 
that the body of an adult man contains enough Hb to hold about 600 cc. 
of 0. If completely saturated it would hold the same amount of CO. 
The absorption of 6 cc. of CO produces, then, 1 per cent, of saturation 
and abolished 1 per cent, of 0 capacity. 
Older writers leaned to the theory of a specific toxic action of CO,19 
based on the rapid narcosis produced, the early muscular weakness 
occurring in the lower limbs, gangrene as a complication, and damage in 
the lenticular nucleus (Poelchen, 1888). Hill and Semerak,20 also cite 
Lanossier as finding that animals die sooner and with different symptoms 
in an atmosphere of CO than when asphyxiated with nitrogen. Karasek 
and Apfelbach,3 however, who demonstrated that humans, subjected 
continuously to this gas, have a compensatory polycythemia and no 
physical disturbances, are inclined to Haldane's views. Lewin1 denies 
that there is any direct action on the cells of the central nervous system or 
of any organs. All of the manifold lesions found after carbon monoxide 
gassing result from the injury caused by oxygen privation. It differs 
from all other oxygen-deficiency or hemoglobin-alteration poisons by the 
occurrence of sequelae which have the greatest variety and extent known 
in all toxicology, and individual susceptibility is not enough to account 
for them. Gorn (Zntrlblt. f. Gewerbehyg., Apr., 1922, 10, 14, 97-107; 
Abst. Jr. Ind. Hyg., Nov., 1922, 103) argues at length that the damage 
caused by CO is a direct intoxication of the nerve cells, and is not merely 
due to replacement of O. 
Henderson and Paull16 state further that "When a man breathes an atmosphere 
containing even a trace of carbon monoxide his blood in time becomes partly saturated 
with this gas, the extent of saturation depending on the relative amounts of carbon 
monoxide and oxygen present, multiplied by the affinities of these gases for haemo- 
globin. The rate at which the saturation proceeds depends upon the amount of BLOOD RETENTION OF CO 
381 
breathing. In a man at rest the tissues consume little more than one-third of the 
oxygen that the blood brings to them, whereas during muscular exertion nearly two- 
thirds is utilized. Accordingly the blood of a man at rest may become nearly one- 
third saturated with CO without his realizing that anything is wrong. If, however, 
he tries to make any considerable exertion the fraction of his haemoglobin uncombined 
with carbon monoxide is insufficient to transport the oxygen needed, and he may 
collapse. When his blood is more than half saturated he is liable to collapse even at 
rest. If he remains for a considerable time in this condition the delicate nerve cells of 
the brain, and less often other organs also, are injured by the continued lack of oxygen, 
and unconsciousness (coma) results. 
As a rough estimate it may be stated that a man who has breathed air 
containing 0.2 per cent. CO for four or five hours or 0.4 per cent, for one 
hour will die. In air containing 2 to 5 per cent, of CO, as after an 
explosion of coal dust, nearly all of the haemoglobin is combined by 
the first few breaths drawn, and death follows almost as quickly as in 
drowning." 
How Long May CO be Found in the Blood after Exposure Thereto?- 
Henderson and Paull16 state: "If the breathing is slow and irregular, 
or has stopped entirely, as may be the case in sudden exposure to con- 
centrated carbon monoxide, artificial respiration by the Schaefer method, 
but with administration of oxygen, should be performed. The stronger 
the oxygen the sooner the CO is displaced and the oxygen-carrying capa- 
city of the hsemoglobin restored. Even when only pure air is breathed 
the mass action of its oxygen is usually sufficient to displace the greater 
part of the CO in an hour or even only half an hour, so that the oxygen- 
carrying power of the hsemoglobin is restored sufficiently to meet the 
patient's needs. Practically all of the CO is eliminated and the haemo- 
globin fully restored in three or four hours. This is facilitated by the 
rapid breathing, usually 30 to 45 times per minute, which such cases exhibit 
during recovery and which is probably caused by incomplete combustion 
products formed in the tissues during the asphyxia and circulating in the 
blood for sojne hours thereafter, or by some long-lasting effect on the 
respiratory center." 
McNally5 found CO in blood submitted to him after 2 and in one 
case after 4 days; he has had over 100 cases of over 4 hours standing in 
which he could detect CO by definite color tests and the palladium 
chloride (Fodor's Test) method (Henderson et al to the contrary). 
However, he agrees that in a large number of cases he could find no CO 
in blood where respiration of pure air or air and oxygen had taken place 
a few hours. He cites Gaglio (1887) who found inhaled CO to be all 
recoverable from exhaled breath down to 2.8 per cent, (this loss due to 
experimental conditions). While Fodor in Paris found CO in blood of 
normal dogs and human beings, McNally failed to find any. 
Legry and Lermoyez21 state that the blood in the cerebrospinal fluid 
may reveal CO long after it has disappeared from the blood stream. A 
lumbar pucture in a case also showed the fluid to be almost pure blood, 382 
CARBON MONOXIDE POISONING 
confirming assumptions of a congestive and hemorrhagic process in the 
cortex and meninges as part of the reaction to CO. 
ACUTE CARBON MONOXIDE POISONING 
The greater number of CO "gassing" cases occur from producer and 
blast-furnace gas.3 Those not thoroughly acquainted with the subject 
are confused when such a variety of gases are mentioned as coal gas, 
producer gas, water gas, blast-furnace gas, power gas, suction gas, Monde 
gas, and others. It should be constantly kept in mind that they all 
contain CO in varying quantities, and that it has been fairly well estab- 
lished that CO is the toxic agent in all these gases. Their toxicity will 
vary because of the different methods of production. 
The Home Office (British) experience in industrial CO poisoning is 
summed up, including types of industries, precautions for each, symptoms 
and after-effects, methods of blood examination and of resuscitation, and 
types of protecting masks, in Form 287, July, 1921, Factory Department, 
London. We follow here with a description of the usual American indus- 
ries of chief import. 
THE STEEL INDUSTRY 
The blast-furnace gas as produced in the average American stack will run an 
average composition as follows:3 
Per Cent. 
CO 26.0 
CO2 11.12 
H 3.5 
C2H2 0.3 
Per Cent. 
ch4 1.0 
N 57.0 
0 0.2 
This gas is produced in the blast furnace by the smelting of iron ore, coke and 
limestone, in the proportion of 2000 lb. of ore, 2000 lb. of coke, and 800 lb. of limestone. 
After combustion has begun, the mixture is blasted by means of heated air, which 
is heated in the adjoining stoves, four to one furnace (Figs. 20 and 21). The air in the 
stoves is heated by means of blast-furnace gas. The gas which is produced in the 
blast furnace goes up the stack to the top from where it is led by a pipe, through a dry 
cleaner or dust catcher. From here it goes to the gas washer, which allows the gas 
to ascend through screens of dropping water, removing thereby that dirt not caught 
in the dry cleaner. It is then piped in an over-head main to two points, the stoves, 
and the boiler and engine houses. There are four stoves for each furnace, two only 
being used at one time. In these the gas derived from the blast furnace undergoes 
combustion, heating the air which is also drawn through the stoves. That portion 
of the gas which is piped either to the boiler houses or to the gas engines, goes through 
an overhead main to its destination. Some steel companies use the gas in boiler houses 
to produce steam; others explode it in gas engines. Both methods produce power, 
wherewith the converters, rail mills and other machinery is operated. Changes in the 
operation of the blast furnaces are constantly occurring. 
There are certain places along the gas route3 where "gassing" is liable to occur:22 
(1) The top of the blast-furnace in old-style furnaces without an automatic filler. 
Formerly three to four men were constantly required at the top of a furnace. At 
present only "cleaners" or "sweepers," "sailors" and "riggers," needed in urgent 
repair work, are required to ascend to the top while the furnace is in operation, and 
then only for 20 minutes every 12 hours. Before going up on a furnace, the foreman is THE BLAST FURNACE 
383 
Clean-gas 
main 
Fig. 20.-Diagram showing travel of gases from blast furnace to stoves and washers. (Willcox, Fred. H., Technical Paper, 106, 
U. S. Bur. Mines.) 
Clean-gas 
main 
to boilers 
and 
I Theisen 
washer 
to 
Water 
seal valve 
Gas scrubbers 
Clean-gas main 
to stoves. 
Water 
seal valve 
Dirty 
gas main 
Stove chimne/ 
Hot-blast stoves 
Water 
seal valve 
Centrifugal 
whirler 
Dust catcher 
Blast furnace 384 
CARBON MONOXIDE POISONING 
Fig. 21.-Diagram showing travel of furnace gases to boiler house, Theisen washer, and blowing engine. (Willcox, Fred. H., Technical 
Paper 106, U. S. Bur. Mines.) 
Gas-driven blowing engine 
Exhaust stacks 
Inlet valves 
Water seal 
Gas holder 
- H-4 
Water''- 
seal valve 
>[ Motor 
Theisen 
washer 
Clean-gas 
main 
Stack Water 
seal valye 
Boiler house, gas fired CO POISONING IN THE STEEL INDUSTRY 
385 
notified and attends to all proper safety precautions. No man is ever allowed alone on 
the furnace. (2) The "mantle" above the bustle pipe is nearly as dangerous as the 
top. It seems impossible to prevent leakage of gas through the walls of the furnace 
which generally occurs in a belt around the furnace about 12 ft. from the ground, 
If the gas remains unignited, especially on rainy days, it affects those below on (3) 
the casting floor. (4) The great danger about the stoves is at the enormous burners, 
from adverse draft or puff-back of unconsumed gas and also from leadage. (5) 
Another source of "gassing" is in cleaning out cold mains or pipes, because the gas 
remains inert in the flue dust and is liberated in the atmosphere upon being disturbed. 
This is done less frequently at present, because of newer methods of flushing the mains 
with water. (6) In the boiler house the same danger of puff-back is present as at the 
stoves, except in the later make of boilers, which have the entering flue burners sealed 
into the brickwork, and receive air from a point about 2 ft. below. During Apfel- 
bach's investigations many flues with large leaks or rents were noticed, either dis- 
charging the gas under pressure into the boiler room, or plugged indifferently with clay 
stoppers. Cleaning out the boilers frequently gives rise to "gassing." (7) The dry- 
cleaner is opened daily. "Gassing" may also occur from this procedure. (8) 
Accidental leakage usually occurs in the basement of the gas-engine house. The men 
who work above the engines, such as oilers, often complain of headache, especially 
after having worked above the engines for a prolonged period. In one steel mill an 
engineer was found dead on the bed of an engine. The coroner's verdict was CO 
poisoning. (9) A great many cases occur during cleaning operations, when the furnace 
and mains are not in operation. Even after air has been driven through these mains, 
CO lying inert in the flue dirt is liberated when cleaning operations are conducted. 
(10) In fact, "gassing" may occur anywhere along the gas route. Structural iron men 
have been "gassed," while rigging up a smoke stack over an open-hearth shed or 
building, or while working on buildings in the vicinity of the furnace. Men in sup- 
posedly safe places are sometimes overcome by vagrant whiffs of gas due to peculiar 
atmospheric conditions. Men have taken stolen naps alongside the blast-furnace 
stoves with fatal consequences. Then there occur freak "gassings" which even the 
most expert safety man would never anticipate. (11) The majority of steel mills, 
while obtaining most of their gas from the blast furnaces, find it necessary to operate 
one or more producer gas furnaces for the purpose of supplying power to parts of their 
plant where blast-furnace gas is not available. Most of these furnaces are located in 
the open air, however, and seldom cause acute CO poisoning. 
In this connection it is well to state that "gassing" is not only the cause of such 
disturbances as drowsiness, coma, and other signs of gas poisoning, but is also the cause 
of serious accidents, such as falls after having been overcome by gas, and also burns. 
The following table illustrates the result of our Illinois investigation concerning 
the incidence of "gassing" and also the gas route: 
Source of gas 
No. of men 
employed 
Fatal 
cases 
Severe cases 
per year 
Mild cases 
per year 
Blast furnaces 
900 
13 during 
past 4 years 
65 
216 
Boiler houses 
212 
1 
55 estimated 
from findings 
Gas engine 
42 
1 in 1910 
4 
Variable 
Open hearths 
24 
1 
Variable 386 
CARBON MONOXIDE POISONING 
GAS ROUTE 
Leakage in 
Loading 
"Stoves" 
Bustle 
I Gas 
■.Scrubbers 
Gas 
Washer 
Gasom- 
eter 
Blast 
Furnace 
and other 
pipes 
Boiler House 
Engines 
Gas poisoning and accidents due to gas in steel mills have in the past 
decade or two shown a decided decrease for the following reasons: New 
and modern types of furnaces; automatic charging of furnaces, which has 
eliminated those men who formerly were stationed at the tops of the 
furnaces; the modern furnace is of more substantial and heavier construc- 
tion with a view of accommodating more plates and fire-brick; overhead 
mains have replaced underground mains; and underground pits have been 
done away with. Safety organizations of the steel companies have adopted 
suitable safety rules, which incorporate the following ideas: No man 
is allowed upon any furnace alone; repairs must be undertaken by two 
or more men; a watcher must accompany every workman in any place of 
hazard; special placards and transportable danger signals are placed in 
the danger zone. 
ILLUMINATING GAS INDUSTRY3 
Two distinct types of gas are used for illuminating purposes, water and coal gas. 
Following is an average of tests made of the composition of water and coal gas: 
Water gas 
(carburetted), 
per cent. 
Coal gas, 
per cent. 
co2 
3.00 
6-7.0 
co 
30.00 
0.0 
Light oils 
12.00 
5.0 
H2 
31.5 
46.0 
ch4 
18.0 
40.0 
0 
0.5 
0.5 
n2 
4.5 
2.0 
The use of water gas is prohibited in many cities, necessitating the use 
of coal gas. In certain cities of England the use of a gas containing over 
14 per cent, of CO is forbidden for illuminating purposes. A review of gas 
poisoning shows a considerably greater number of "gassings" occurring 
in cities using water gas than where coal gas is used. 
In order to give a clear understanding of the dangers of "gassing" the process of 
manufacture is described here. A charge of coke is blasted in the generator, this part ILLUMINATING GAS PRODUCER GAS 
387 
of the process being called the "blow." Steam is then blown in, forming what is then 
known as "blue water" gas, which has 43 per cent. CO. The gas is next carbureted 
by the addition of pre-heated gas oils, reducing the CO content to about 30 per cent. 
After being carbureted the resulting gas is passed through what is known as the 
superheater, which consists of a checker work of brick, heated so as to fix the constitu- 
ents of the gas. From here the gas is lead through a main to a condenser, which cools 
and to a certain extent mechanically cleans the gas. From there the gas passes to the 
shaving scrubbers, which removes most of the remaining tar. From here the gas is 
passed through large boxes, containing hydrated FeO2, which removes sulphur com- 
pounds and all remaining tar. Having been purified, the gas is metered and passed 
into large tanks, a common sight in larger cities, where it is ready for distribution to 
the consumer. 
Up to this point accidental leakages may occur, causing "gassing." Again the 
men are sometimes gassed while cleaning, especially about the generators, mains and 
oxide box. 
Gas mains are often laid in our streets parallel to a sewer or an electric 
conduit. Therefore, "gassing" occurs not only to the men who work on 
the gas mains, but also to the municipal sewer and water pipe extension 
crews, and to members of telephone, telegraph, and electric lighting gangs. 
Also, to workers in compartments under side walks which face street 
mains. 
PRODUCER GAS3 
Producer or power gas is used in the industrial world (1) to generate power by 
means of a gas engine, (2) to be used as fuel in producing steam and electricity, or (3) 
for heating purposes. The industrial use of producer gas is increasing rapidly. 
Therefore, various types of this gas are manufactured. Any kind of carbonaceous 
material can be used for making producer gas. The most commonly used material is 
coal. In some types straight distillation occurs while, in others, steam is used as part 
of the manufacturing process. Thus the composition of the gas will vary depending 
upon the method of manufacture. According to some methods the gas is produced 
by suction, in others by blasting the air. Common names for producer gas are: 
power gas, suction gas, Monde gas, and wood gas. An average composition of pro- 
ducer gas is as follows: 
Peb Cent. 
CO 23.0 
CO2 8.0 
H 11.0 
C2H4 0.2 
CH4 0.2 
N 57.1 
0 0.2 
The reports show a large number of "gassings" from producer gas. 
The accidents depend on the situation of the generator, on whether suc- 
tion or pressure is used in making the gas, and on the general safety rules 
followed. A producer in an out-door location is naturally not as danger- 
ous as one placed in an inclosure. Producer gas is used in metallurgical 
plants; by glass makers; for heating sterotype, linotype and monotype 388 
CARBON MONOXIDE POISONING 
kettles; sad irons in tailoring establishments for pressing clothes; in laun- 
dries, book binderies, smelters, laquering stoves; and numerous other 
fields of industry. 
INDUSTRIES USING OVENS 
Ovens are used in various trades for divers purposes, such as in the 
melting of ore, enameling of procelain and plumbing supplies, and enamel 
ware, in bakeries, chemical companies, and in other industries. Carbon 
monoxide poisoning is not common, because of the ease with which a 
discharge of gas into a room can be prevented. The prerequisites of 
preventing CO poisoning from an oven are a good draft through an effi- 
cient chimney, and care in keeping the stove door closed. Weather con- 
ditions, such as a low barometric pressure, demand extra care in operating 
an oven. Most cases on record have been due usually to gross care- 
lessness. 
FIREMEN, BOILER OPERATORS, AND OTHERS 
The United States Navy Surgeons3 have found symptoms indicative 
of carbon monoxide poisoning among firemen and stokers on warships, 
but have failed to ascertain whether caused by high temperatures or CO 
gas. The location of boiler rooms on large sea-going vessels below the 
water line makes ventilation and fresh air a tedious problem. Again it 
might be said that CO poisoning in this line on land is usually due to 
negligence in operation. 
Mild forms3 of "gassing" occur where fuel is burnt in small quanti- 
ties without an outlet to the outside air. We find this to be true of sala- 
manders, which are used for drying the plaster and paint in new buildings. 
Other instances to be classified under this caption include electroplating, 
electrotyping, stereotyping and linotyping, machine casting of metal, 
can manufacturing and soldering. One case of severe "gassing" was 
brought to the attention of the writer, as Medical Director of the Illinois 
Department of Factory Inspection. A painter, upon entering the room 
in which he intended to work, was suddenly overcome by the fumes of a 
salamander. His companion made a prompt rescue, but became parti- 
ally affected by the gas, producing headache for several days, nausea and 
malaise. Fire extinguishers of the carbon tetrachloride and foamite and 
other types yield CO in dangerous amounts so that their use in confined 
quarters should be attended with great care.* 
Albaugh23 investigated a series of cases at a construction camp in Ohio alleged by- 
attending physicians to be due to "ptomain poisoning." The same sequence of 
events was repeated on three separate occasions, each with one fatality and several 
severe intoxications occurring among laborers who were bunked in what appeared to 
be a rather model, frame camp-building which they had occupied without event for 
* U. S. Bur. Mines. Reports of Investigations, Series No. 2262, June, 1921. CO POISONING IN CAMPS, MINES AND FROM MOTORS 
389 
three months. While a review of the evidence pointed toward carbon monoxide 
poisoning, there was at first no clue available of any exposure to same as there were 
no fires left burning at night and no gas pipes in or about the building. Also some 
windows were said to be left open for ventilation. However, it was found that the 
building was located on an abandoned fill composed of slag, scrap and cinders from a 
near by steel mill. This dump was 10 to 15 feet in depth, a couple of acres in extent, 
and appeared to be quiescent. No cinders or other fuel material had been added for 
over six months. The cases occurred in the winter time when the upper two feet 
of the ground had frozen over, except under the kitchen part of building. Here 
the sink drains emptied directly upon the ground causing some odor and several of 
the workers declared the trouble to be "sewer gas" poisoning. This warm place 
seemed to form a flue for the whole dump, whose accumulating, pent-up gases, which 
were odorless, passed up through the kitchen and pervaded the sleeping quarters 
in the wings of the building. Trenches dug along side of the building disclosed hot 
smoldering cinders five feet below the surface of the ground, and therefore the true 
cause of the condition. Workmen, while digging the exploratory trenches, and 
Albaugh himself, while investigating, experienced the classical symptoms of carbon 
monoxide poisoning. 
MINES 
Carbon monoxide poisoning, severe and often fatal, is found in mines 
(1) after accidental explosions, (2) after blasting or "shooting," (3) in 
slow smoldering "gob" fires, and (4) as an accompaniment of all mine 
fires. Often the men cannot escape rapidly enough from the poison- 
ladened atmosphere. Characteristic of mine CO is that it is usually 
inodorous. It is called "white damp." It never occurs naturally, i.e. 
as a natural constituent of mine gases, but is always the result of some 
form of incomplete combustion set up by fire. 
FROM THE EXHAUST OF GASOLINE ENGINES 
With the growth of the gasoline engine for motive power,3 as in the 
automobile and the gasoline launch, has arisen another source of industrial 
CO poisoning. J. N. Schumacher, chemist for the city of Chicago, upon 
making a series of gas analyses of gas collected from the exhaust pipes of 
motor cars in collaboration with Apfelbach, obtained the information 
that an average composition of exhaust gas is as follows: 
Peh Cent. 
C02 6.7 
CO 9.3 
0 1.4 
Illuminants 0.3 
N 82.2 
H 0.0 
These analyses were not made from the first sample in the morning, but 
after the motor was warmed, which condition is even less productive of 
CO gas than when the motor is cold. 390 
CARBON MONOXIDE POISONING 
Burrell and Gauger24 found CO present in air of small garages, con- 
taminated by automobile exhaust fumes, to be as high as 1.98 per cent, in 
10 minutes and 3.2 per cent, in 35 minutes. An engine running idle 
produces more CO than when under a load. Retardation of the spark 
and "warming up " greatly increase the amounts present. 
Upon investigation, the writer3 found that headaches, dyspnoea, attacks of vertigo, 
nausea and other symptoms were common in chauffeurs of large taxicab garages. The 
chauffeurs unaccustomed to continuous doses of the exhaust gas become more readily 
affected than the machinists and others, who were constantly in the garages. The 
physician for one of the larger concerns informed me that this condition is more 
prevalent during the cold weather season. 
One morning the writer's3 chauffeur observed that his companion, who had been 
standing near the back of the car while the engine was running, staggered about the 
garage, whose windows and door were closed. The chauffeur opened the door and 
resuscitated his companion. Although not in coma, stupor was present for 2 to 3 
minutes. The victim said that he noticed first a pressure in the temples, then a weak- 
ness in the legs, and blurring before the eyes. Cases of death too frequently occur in 
private garages, where the occupant, being alone, is unable to escape from the CO gas. 
PATHOLOGY 
The post-mortem findings3 will depend on the length of time elapsing 
between death and autopsy, and also on the suddeness of death. Follow- 
ing a very quick and rapid death, the cadaver may be pallid and cyanotic, 
with swollen face and neck, similar to death from CO2 gas. Victims of 
CO gas at other times present a life-like picture, sometimes with rosy 
cheeks, and a calm, undisturbed face, as if there has been no death struggle. 
Red blotches are seen on the face and body, more frequently on the former. Such 
findings at once suggest a spectroscopic, Haldane or other examination of the blood for 
CO. These blotches are hypersemias of the skin, having occurred with vasomotor 
paralysis, though sometimes they are due to hemorrhages into the tissue. 
It has been said that the odor of gas can be detected from the mouth of the corpse. 
If this does occur, death must have been recent, and the gas must have had other 
constituents, as so to impart an odor. This may be true of illuminating gas poisoning. 
Where death results from CO poisoning the body is usually remarkably well 
preserved and retains its heat for an unusually long time. In a mine explosion at 
Whitehaven,26 England, 136 were killed and found 5 months later in a well-preserved 
condition. The spectroscopic characteristic of CO-hemoglobin was obtained in the 
blood of 36 of the victims. (In these instances there evidently had been no oppor- 
tunity for displacement of the CO by O, ante- or post-mortem.-Hayhurst.) 
In the interior of the body, attention will be attracted to the bright, cherry-red 
color of the blood which flows freely. This blood is one of the most characteristic 
post-mortem signs of CO death. This blood will keep in excellent condition for 
months, for purposes of examination, if placed without shaking or undue opportunity 
for aeration, in a well-stoppered completely filled bottle. Strassman,26 found the red 
corpuscles remarkably well preserved even seven to eight weeks after death from CO 
although a part showed crenation, change in size and certain colorless areas. He 
found the white cells to be swollen and vacuolated, but the differential counts normal. 
Nicloux (Abstr., J.A.M.A., Oct. 15, 1921, 1289 and Nov. 11, 1922, 1722) emphasizes 
that the blood corpuscles even saturated with CO are not devitalized at all, but are 
ready to resume function with a little aid, that is, when supplied with 0. PATHOLOGY OF ACUTE CO POISONING 
391 
Carbon monoxide often causes a rapid fatty degeneration. This may be observed 
in the heart-muscle, liver, kidneys, vessel walls, and other tissues. 
The heart upon being opened shows bright red blood, sometimes fatty degeneration 
in the musculature and in the walls of the large vessels. 
Broncho-pneumonia is common in those having died from the effects of CO one to 
two weeks after the "gassing," the pneumonia being a complication. Upon cutting 
the lungs, the characteristic color of the blood can be observed. 
The gastric and intestinal mucosa may show small punctiform hemorrhages. 
Kidneys: fatty degeneration, and necrosis in the convoluted27 tubules. 
Skin: herpes, blebs, pemphigus and gangrene. (Several days after 
death the superficial vessels, especially those of the legs, may stand out 
as bright red bands or streaks.-Hayhurst.) 
Carbon monoxide frequently causes pathological changes in the brain. 
Changes have been observed in those who have died from the immediate 
effects, and among those who have died from psychoses. Cerebral 
hemorrhages and thrombosis in cerebral vessels are not uncommon. 
The hemorrhage may.be extensive or there may be numerous punctiform 
hemorrhages. Mott28 records in one post-mortem that he found various 
congestive patches about the external and mesial surfaces of the hemi- 
spheres, with all indications of subpial hemorrhages. Autopsy on cases 
from psychoses of CO gas shows a predilection for degenerations, throm- 
bosis, encephalitis29 in the lenticular nucleus and the optic thalamus. It 
is held that the encephalitis and hemorrhages sometimes observed in 
gas autopsies are due to the rapid fatty degeneration, which occurs in the 
vessel walls. Kolisko30 states that symmetrical softening in the brain, 
especially the lenticular nucleus, is such a common finding in those having 
died of illuminating gas that it is of great medico-legal importance. Hill 
and Semerak31 examined 32 brains from CO autopsies at Cook Co. 
Hospital, Chicago, and state: "CO produces a characteristic lesion of the 
brain, a bilateral ischemic necrosis of the lenticular nucleus, especially 
the globus pallidus," and that the CO in circulating blood produces a 
thrombosis with degeneration of vessel walls; the necrosis varies from slight 
perivascular lesions to gross visible softening of the entire lenticular 
nucleus and internal capsule. If death occurs within a few hours there is 
found cherry-red blood, pink hue of brain substance, petechial hemorrhage 
in skin, mucous and serous surfaces, and CO-hemoglobin (spectroscope). 
These evidences later disappear and the diagnosis depends on the charac- 
teristic lesion in the lenticular nucleus. 
Spontaneous hemorrhages in leptomeninges and punctiform hemorrhages through- 
out the white matter are part of any profound picture. The nerve cells themselves 
have a high degree of resistance (tolerance). Edema and hyperemia and internal 
hydrocephaelus are frequent. Cerebral arteriosclerosis cannot be attributed to CO, 
but it renders the victim probably more vulnerable. These authors further cite 
McGurn who says CO poisoning has been said to simulate almost every variety of 
nervous disease and multiple softening may produce the picture of insular sclerosis. 
Gunther (Abst., J.A.M.A., Feb. 4, 1922, 396) found evidence of polyneuritis in about 392 
CARBON MONOXIDE POISONING 
1 per cent, of 215 cases and hemorrhagic polymyositis in 3 cases accompanied by a 
peculiar pigment in the urine in the one fatal case. 
Another common finding3 in post-mortems upon "gas" cases is extensive hemor- 
rhage into the serous tissues, pleura and peritoneum. 
In summary we find that: 
1. Carbon monoxide produces a characteristic blood finding, both in 
gross appearance and as seen by the spectroscope and special tests. 
2. That pathological changes in the tissue outside of the brain are not 
constant. 
3. That broncho-pneumonia is a frequent pathological complication. 
4. That CO causes fatty degeneration in the blood-vessels and other 
tissues, and extensive hemorrhage into the serous tissues. 
5. That CO has a predilection for causing degenerations in the brain, 
including the characteristic necrosis described above in the lenticular 
medic, also thrombosis, encephalitis, and hemorrhages-. 
MEDICO-LEGAL QUESTIONS 
1. May carbon monoxide leave the body and death still result after 
a few hours? 
Bock32 reports a case of poisoning from a defective stove. The body of the 
husband was found on the floor near the stove, and two-thirds of the hemoglobin in 
his blood had been transformed to carbon monoxid hemoglobin. The baby near 
him showed no signs of poisoning. The body of the wife was in the closed adjoining 
room and only one-fifth of her hemoglobin had been thus transformed, and she had 
evidently survived the man for several hours. Bock assumes that originally her 
blood had been as deeply poisoned as her husband's but that she sought the bed room 
when she felt sick and her blood gradually threw off the carbon monoxid gas. It 
would in another half hour or two have thrown it off altogether, and nothing would 
have been found to explain her death. Bock experimented on animals in connection 
with this case, and found that the animals died even although all the carbon monoxid 
had been thrown off. Evidently the central nervous system becomes irreparably 
injured from the after-effect of the protracted asphyxia. In the medicolegal case 
described, the baby must have been kept in the adjoining room, as was known to be 
the custom, and was not brought out into the room with the stove until late, and was 
then placed near a window. Bock remarks that if the woman's body had not been 
found till all the hemoglobin had been thrown off, and if she had been living alone with 
her baby, the cause of her death might never have been cleared up. 
2. May CO enter the body after death? 
The interesting question has often been raised whether the detection of CO in the 
blood is unmistakable evidence that poisoning by the gas had taken place, or whether 
death resulted from other causes, and that, by reason of the corpse having been placed 
in an atmosphere containing CO a sufficient quantity of the gas had been absorbed 
to cloud the diagnosis of suicidal or accidental poisoning or death from some other 
cause. Whenever CO is found in the blood the general supposition is that it was 
inhaled into the lungs during life and entered the circulation in that manner. In 1902, 
experments by Wachholz and Lenberger33 who placed the bodies of stillborn children 
in an atmosphere of pure CO, showed that within a half-hour the deep livid patches SYMPTOMS OF ACUTE CO POISONING 
393 
observed in the skin of the cadavera had turned to a red-rose color. The presence of 
CO in the blood was determined by the spectroscope, even as late as 7 days after 
the immersing process, especially in the blood removed from the heart. In permitting 
a long period of time to elapse between death and the placing of the cadaver in the 
gas the chances of absorbing CO lessen. Some German authorities, as Strassman and 
Schultz, venture the opinion that CO enters the skin and external coverings of a dead 
person and penetrates into the blood, and that the quantity of CO in the superficial 
and more exposed blood and tissues is always greater than that found in the deeper 
and more central parts. Thus, it is stated that, in the post-mortem diffusion of the 
gas, there is a well-defined difference between the anterior portion of the liver, whose 
CO contents is plentiful, and the posterior portion, which contains less CO and is of 
a deeper color. In a case of poisoning by inhalation of CO such a difference would not 
occur, since the blood would be equally affected all through the body. 
Oliver33> 3 reports a German case of a woman who was found dead in her room, 
with one end of an India-rubber pipe in her mouth and the other attached to a gas 
pipe, the valve of which was open. The room smelt strongly of coal gas. Everything 
seemed to favor the theory that death was suicidal, but at the last moment the father 
of the dead person intervened and asked for a delay in the interment as he believed an 
operation for the induction of abortion had taken place at the instigation of the hus- 
band, and that in order to raise the question of suicide the tube had, in order to mis- 
lead, been placed in the woman's mouth. An inquiry was ordered, and Strassman 
and Schultz found that no abortion had taken place, and that there were present all 
the typical signs of poisoning by CO. 
May CO be found in the blood and tissues of the body without ex- 
posure to the gas? 
Curschmann says:84 "Animal experiments as well as the findings in one patient 
known to have taken methyl alcohol demonstrate that after poisoning with methyl 
alcohol carbon monoxide may be found in the blood." 
SYMPTOMATOLOGY 
An acute CO poisoning will vary in intensity with the amount of 
CO which enters the blood, and upon the rapidity with which it enters. 
Other determining factors are the susceptibility of the person "gassed" 
and whether pathological accidents, such as hemorrhage, occur with the 
initial result. The primary pharmacological effects are these: 
"If CO gas is administered in sufficient concentration and in sufficient quantity to 
an individual in good physical condition, there is always noted, first stimulation and 
then depression of the medullary centers in the following order of sensitivity: res- 
piratory center, vaso-motor center and cardio-inhibitory center. The degree of 
stimulation is determined by the rate at which the blood becomes saturated with CO, 
the degree of this saturation, and the condition of the centers at the time. If the 
blood becomes saturated very slowly, there is no stage of stimulation, and the better 
the condition of the centers at the time the more marked will be the degree of stimula- 
tion." See, The Mechanism of Stimulation of the Medullary Centers by Decreased 
Oxidation-H. S. Gasser and A. S. Loevenhart, Jour. Pharmacology and Experi- 
mental Therapeutics: 5, 239 (1914). (Dr. A. S. Loevenhart, Sigma Xi Lecture, 
Ohio State University, Jan. 19, 1923.) Compared with CO, the stimulating and 
irritant effect of CO2 gas is more prolonged so that, unless large quantities (over 394 
CARBON MONOXIDE POISONING 
10 per cent.) are encountered, the victim usually has sufficient warning to put up a 
*'fight" and to extricate himself. 
Among four workmen who seemed exposed to equal quantities of the 
gas, Appelbach3 observed that one was in deep coma, whereas the others 
were simply in stupor. 
Prodromata.-In some cases3 of "gassing" the victims succumb as 
rapidly as if struck by lightning, with no apprehension of its presence 
and with no prodromes. The coma and even death may be almost 
immediate. Out of about 300 cases of industrial gas poisoning comas 
observed, the writer would say that about one-third occurred without 
prodromes. Absence of prodromes is especially true of blast-furnace 
gas intoxication. 
Following3 are the more common prodromes of CO poisoning: a 
throbbing or feeling of pressure in the temples; tinnitus aurium; distress 
in the epigastrium; nausea, sometimes vomiting; weakness in the legs 
together with sluggishness of movement; hallucinations and wild mental 
pictures; sometimes convulsions; a severe or even bursting headache; and 
blurring before the eyes. 
The most common prodromes are:3 the pressure and throbbing in the temples; 
the epigastric pain; and the weakness in the lower limbs. The latter is often described 
as a "caving in" at the knees and an inability of movement. Some of those "gassed" 
are able to move away and escape, others seem "glued" to the spot, and are unable 
to conduct locomotion. 
Harbitz,15 states there was a stiffness of body in all four of his cases-"an actual 
rigor mortis in the living body." Henderson and co-workers35 state: "But of all signs 
and tests (on persons in an experimental chamber) the typical CO, or O deficiency, 
headache proved most definite and reliable. It is a distinctly localized pain, usually 
throbbing, intensified by lying down or by exertion. It is sometimes accompanied by 
more or less nausea, readily increasing to vomiting. The mind is not clear, except 
with an effort, and one's surroundings seem a little strange. The temper is easily 
upset, very much as in alcoholic intoxication and the judgment likely to be bad." 
"The borderline (of this headache) verged merely into slight lassitude." The border- 
line CO concentration (for 1 hour's exposure at rest) is 7 parts per 10,000 of air (or 
0.07 per cent.). Exercise shortens the time. From the prodromes, if they occur, the 
patient lapses into somnolence, then into coma.3 
A medico-legal instance in point is a case which came before the Ohio Industrial 
Commission for compensation. A young man, with previous history negative, was 
•engaged for several days repairing a tramway above some coke ovens. He complained 
■of the "gas" and developed the usual symptoms, gradually progressing each day, 
which characterize subacute CO poisoning. The evidence in the case showed both 
■CO and COa present in the escaping gas to which he was exposed. At the end of the 
4th or 5th day he went home more incapacitated than usual, became semi-delirious 
with varying degrees of stupor, passed into coma with fever, and spells of excito-motor 
states and partial paralyses (especially ocular) which lasted 8 or 10 days when he died 
in coma. In spite of the occupational history indicated, his death, after a medical 
consultation, was pronounced due to "encephalitis lethargica," due to the failure to 
recognize that CO may undoubtedly cause symptoms of encephalitis in itself. 
Dr. C. LeNeve Foster,36 makes some interesting statements concerning the 
sensations and symptoms experienced upon being "gassed" in mine air containing CARBON MONOXIDE COMA 
395 
about 1.07 per cent. CO. "The poison took effect most suddenly ... I felt 
decidedly queer when I reached the level and thought that a drop of brandy might 
revive me. I took out my little brandy flask, but already my fingers seemed incapable 
of doing the work properly . . . Everything seemed in a whirl, and the atmosphere 
seemed to be a dense white fog ... A curious fact is that we all sat without moving 
or trying to escape; the foot of the ladder was close by, yet none of us made any effort 
to get to it and even ascend a single rung." In writing a note of farewell to his family, 
he states:-"I frequently wrote the same sentence over and over again." This 
reiteration of words and syllables is occasionally observed among the early symptoms 
of gas poisoning. 
Other prodromes sometimes observed are: a dryness of the throat, 
backache; heart fluttering or palpitation; and sensations of chilliness. 
CARBON MONOXIDE COMA3 
When the narcotic action of the gas continues, the victim becomes 
comatose. The usual text-book pictures of gas coma do not always 
occur. We are taught to look for rosy cheeks and bright red lips. On 
the other hand, cyanosis, palor and distorted facial expressions are 
frequently met with. Nevertheless, in a great number of cases, red 
blotches and areas of hypersemia form upon the skin, and the lips and 
conjunctiva are a bright red. (Confusion with erysipelas is possible as 
in a case in Ohio.-Hayhurst.) The writer has observed that these typical 
gas comas are more often found in illuminating and coal-gas poisoning 
than in those which occur from the other industrial gases. 
The coma in the average industrial "gassing" is milder than those 
observed by physicians in the average illuminating gas poisoning where 
such has occurred accidentally or with suicidal intent. That a far lesser 
number of "gassings" accompanied with coma take place may be gathered 
from the fact that out of 281 "gassings" about a blast furnace only 65 
were actually comatose, whereas 216 never entertained more than a 
stupor or the prodromal symptoms. 
The pulse is at first full and slow with a rise of blood pressure. Later as the coma 
deepens or as the patient survives, the pulse becomes feeble and rapid. Rapidity of 
pulse, or tachycardia, will continue for several days after recovery from the coma. 
The respirations are at first deep, stertorous: later weak and rapid. (Aleucocytosis 
up to 25,000 may exist.37 Thompson38 reports that it was above 18,000 in 18 of 29 of 
his cases in which a general blood count was made.-Hayhurst). 
Hyperpyrexia occurs most commonly, the temperature ranging from 100°F. 
to 104° and 105°. Temperature is often an indication of pneumonia. If the rise is 
sudden after the patient has recovered from the coma, or if it occurs during the coma 
it is suggestive of brain insult such as hemorrhage, or thrombosis. Dr. W. Gilman 
Thompson states that in nearly all comatose cases observed by him there was an 
elevation of body temperature, lasting from a day to a week or more. In some cases 
there was a preliminary fall to 96° or 97°F. The writer3 observed that, similar to fatal 
cases of brain injury such as cerebral hemorrhage, sunstroke and skull fracture, there 
is, in^fatal cases of gas comas, an ante-mortem rise of temperature in many cases from 
107 to 110°F. 396 
CARBON MONOXIDE POISONING 
The odor of gas can sometimes be detected on the breath early in the 
coma. This occurs more often in illuminating gas intoxication than with 
those "gassed" industrially. The odor is not that of the gas, but rather 
of a characteristic odor familiar to the physician meeting frequently with 
gas comas. 
Nervous phenomena observed are initial convulsions, twitchings of 
muscles during the coma, and absence of the deep reflexes (depending on 
the depth of the coma). Rare signs are nystagmus and strabismus. 
Other incidents of gas coma are involuntaries, Cheyne-Stokes respira- 
tions, local oedema, and hemorrhages in the sclera and conjunctiva. 
No diagnostic aid is given in a urine analysis. Albuminuria is of no value nor 
is melituria. Four out of five successive "gassing" cases reported by a German clini- 
cian had a glycosuria. Dr. Herbert S. Carter, who made urine analyses for Dr. W. 
Gilman Thompson39 in five non-fatal cases, found an increase of chlorides and urea. 
(The question of whether an acidosis or alkalosis exists appears to be controversial.40) 
The duration of a coma varies from a few minutes to several days. 
Comas lasting over 48 hours are usually fatal, either directly or from a 
complicating pneumonia. Of course this is the probability, not the rule. 
A positive diagnosis of gas cannot be made from any of the above- 
mentioned symptoms and physical signs. The clinical observations of a 
comatose patient may disclose a bright redness of the blood, cherry red 
lips, faint to bright red blotches on the skin, and the odor of gas on the 
breath. Still, the most determining factor in the diagnosis is the history 
and especially the examination of the blood. (See under Toxicology.) 
The writer (Apfelbach) at this point presents a partial representation 
of work done on acute "gassing" in the period from 1910 to 1914: 
Table I 
Case 
Duration 
of coma 
Red count 
Red count 
third day 
Red count 
sixth day 
HB (Dare) 
White 
count 
1 
per 
cent. 
2 
per 
cent. 
3 
per 
cent. 
Female, illuminating gas.. 
Male, 42 years, illumi- 
10 hours 
4,876,240 
5,200,400 
4,906,403 
80 
90 
90 
19,460 
nating gas 
Male, 47 years, illumi- 
23 hours 
5,267,000 
5,640,300 
5,602,100 
90 
100 
100 
18,760 
nating gas 
Male, 31 years, blast-fur- 
3 hours 
5,100,800 
5,706,060 
5,980,760 
95 
95 
95 
16,600 
nace gas 
Male, 39 years, illumi- 
6 hours 
4,878,410 
5,146,700 
5,317,000 
95 
100 
100 
12,860 
nating gas 
27 hours 
5,163,700 
6,821,300 6,251,000 
95 
100 
100 
9,791 
Late Symptoms.-When a person wakes3 from gas stupor or coma, it 
usually takes from 2 to 3 days, and sometimes longer for restoration to a 
normal condition. SEQUELAE OF ACUTE CO POISONING 
397 
The coma leaves the patient3 with a severe headache which lasts the 
entire day or persists for one or more days. This is even true of mild 
industrial "gassings." Moreover, anorexia, sometimes nausea, pains in 
the limbs and even neuritis follow a "gassing." 
Twenty-seven men3 were critically observed for one week following a blast-furnace 
intoxication. One man who had been hardly "gassed" suffered a coarse tremor, 
anorexia and insomnia for three days. Tremor of the tongue and fingers was a com- 
mon aftermath. One was markedly neurasthenic for a week, and also complained of 
anorexia and insomnia. 
Forbes41 considers that CO poisoning in metal and coal mine exposures and about 
blast furnaces in this country rarely causes late after-effects following acute severe 
"gassing." He claims that when such effects do appear, there is evidence, most 
always, of a pre-existing pathological condition. Most sensitive are men with pre- 
existing lung or cardiac disease. Also gastric indigestion and constipation. In fact, 
" If a young healthy adult is gassed he either dies in a few days or recovers completely." 
Zondek42 says, in regard to the heart findings, that the constant symptom 
complex which results is (1) pronounced fall in blood-pressure, lasting about a 
week: (2) early tachycardia on third to fourth day changing to bradycardia and 
arrythmia: (3) acute dilatation or, in strong functionally active hearts, decrease of tone. 
This usually disappears on third or fourth day, but may not appear until the 3rd day 
(delayed dilatation). Thus the degree of cardiac enlargement is an index of its 
efficiency and resistance. 
SEQUELAE OF ACUTE CARBON MONOXIDE POISONING 
Among the sequelae3 of CO poisoning are: (1) pneumonia, (2) psy- 
choses, (3) paralyses, (4) skin eruptions, and (5) gangrene. 
Pneumonia.3-Broncho-pneumonia frequently terminates a gas 
poisoning. It occurs both during the coma and often when the patient 
seems entirely recovered. Thus we find pneumonia is commonly of the 
"schluck-pneumonia" type. The inordinate use of oxygen has been 
thought by one of the physicians of a large illuminating gas company to 
be a respiratory irritant and, therefore, a predisposing cause to pneumonia. 
The Psychoses.3-Psychoses must not be interpreted to mean those 
milder phenomena which follow "gassing'' immediately, such as neuras- 
thenia, muscular twitchings, insomnia and other mild neuroses. Definite 
mental disorders have been reported from various sources in the literature 
following CO poisoning. Sibelius43 and Stierlin44 have presented this phase 
of the subject most thoroughly and in admirable detail. Others who have 
treated of CO psychoses are Zangger,45 Giese,46 Mott,47Libin,48 Weidner,49 
O'Malley,50 and Abrahamson.51 Sibelius classifies this complication as 
(1) psychoses directly due to CO, (2) psychoneuroses, (3) emotional 
psychoses, (4) traumatic or mixed psychoses. 
It must be emphasized that some CO psychoses follow "gassing" 
immediately; others have a lucid interval of from two to three weeks. 
How commonly do we find psychoses following industrial "gassing?" 
The literature,3 rich in descriptions of psychoses, fails to show any attempt 398 
CARBON MONOXIDE POISONING 
at separating those cases which occur industrially from those chargeable 
to neurotic individuals with suicidal tendencies. The writer believes 
that if an investigation were made, few cases of psychoses following indus- 
trial "gassing" would be discovered. Dr. James Burry, Surgeon in Chief 
of the Illinois Steel Company, in his extensive experience with "gassing" 
has never observed one single case of psychosis undisputably attributable 
to CO. 
In comparing the reported psychoses subsequent to CO poisoning, 
no two cases present the identical clinical picture. McGurn52 says these 
gases are capable not only of producing many diseases and conditions 
peculiar to themselves, but also of simulating nearly every disease 
known to modern neuro-pathology, as well as many of the so-called 
"idiopathic" and "functional" disorders. He gives a list of 105 varying 
pathologic conditions known to have been caused by this gas. 
He suggests that the compound first formed with hemoglobin is slowly liberated 
and reabsorbed by brain and nerve tissues so that irritative and permanent degenera- 
tion changes often result which lead to an increased susceptibility to the gas. We find3 
that they simulate dementia prsecox, acute mania, general paresis, Korsakow's 
syndrome and other forms of dementia. O'Malley's case had amnesia, apathy, 
stupor, delirium and confabulation. Giese18 reports a case having amnesia, stupor, 
and a resemblance to Korsakow's syndrome, terminating fatally. Dr. Alex Scott 
quotes a case of dementia with acute mania, of eight day's duration, with recovery. 
Dr. Sanger Brown, of Chicago, also reports a case with both retrograde and antero- 
grade amnesia following a "gassing." The patient never recovered entirely and died 
suddenly eight months after exposure to the gas. Hitchcock53 adds more evidence of 
cases of amnesia, following CO poisoning, both retrograde and anterograde. Amnesia, 
or a loss of memory, is the most common finding in gas psychoses. 
The majority of the psychoses recover, and no prognosis can be devised 
from the character of the psychoses. 
Cerebral Hemorrhage.3-Cerebral hemorrhage with hemiplegia is sometimes the 
result of an acute CO poisoning, due to the rapid fatty degeneration of the blood- 
vessel walls, also to the rise of blood pressure at the onset of the coma. Such hemor- 
rhages also cause other forms of paralyses or motor disturbances. The English 
Factory Inspector reports the case of a fatal cerebral hemorrhage in a man 24 years 
old, who while cleaning a main, was "gassed." In connection with the paralysis occur 
disturbances of sensation, as parsesthesias, analgesias, and hypersesthesias. 
Neuritis.3--Actual neuritis is not as commonly seen as with other occupational 
poisons, such as from lead, mercury, and arsenic. Nevertheless, we find neuritis 
reported in the literature. Lancereaux mentions a paralysis of the leg due to CO 
neuritis. Krantz54 refers to a polyneuritis following gas poisoning. 
Other nervous complications3 to be enumerated are deafness, amblyopia, and 
diplopia. The English Factory Inspector reports a case of diplopia lasting 22 days 
following CO "gassing." 
Gangrene.-Alberti55 and McLean56 reported upon this condition. In the former's 
case there appeared soon after "gassing" blebs containing a brownish fluid material 
showing a CO spectroscopic picture. Later, extensive gangrene of the elbow, lower 
limbs and the neck, with a lethal termination, developed. In McLean's case, which 
came on after one week, there were scattered areas of moist gangrene in the legs. PROGNOSIS AND TREATMENT OF ACUTE CO POISONING 
399 
Briggs57 describes, in an illustrated article, two cases of gangrene following upon coma 
due to CO exposure in a motor boat. Large tense blebs formed the second day on both 
hands and feet resembling second degree burns. The type of gangrene differed from 
anything he had ever seen. It later become a dry gangrene necessitating amputation 
of several fingers. One died later from the gangrene. In McLean's case the gangrene 
did not appear for a week and was of moist type. The pathological basis of gangrene 
with CO poisoning is uncertain, some considering it due to thrombosis, others to 
trophic and degenerative changes in the tissue itself. 
PROGNOSIS 
Henderson and Paull16 state: "There is no known method of restoring 
tissues to normality after parenchymatous degenerations have once been 
initiated. Left to itself nature does all that can be done to stop the 
abnormal processes. The man recovers completely if the asphyxia has 
not been too intense and prolonged, although in many cases men who 
have once been 'gassed' exhibit a muscular weakness of the heart per- 
manently thereafter. More severe cases recover only with the loss, 
partial or complete, of vision, power of speech, or with come other nervous 
defect." 
TREATMENT OF ACUTE GAS POISONING 
Prophylaxis.-The prevention of industrial "gassing" is dependent3 
on (1) the employer, (2) the employe, and (3) the state. 
The employer is responsible for the placing and operating of gas- 
producing machinery, and the administration of safety rules for his em- 
ployes. The larger companies have been on the alert to adopt every 
modern appliance for preventing gas poisoning. 
Burrell16 states that a protective gas mask, developed by the Chemical 
Warfare Service has now been perfected. It weighs 3 to 4 pounds and 
has a canister containing "hopcalite," a combination of metallic oxides 
which catalytically convert CO into CO2 at ordinary temperatures. 
While it cannot be used where there is a deficit of 0 (as occasionally 
occurs in mines), still, being catalytic in action, it is not subject to exhaus- 
tion by use and is invaluable around furnaces, mills, mine fires, etc. It 
is regarded as one of the great chemical achievements of the war. (These 
appliances are purchasable from the Mine Safety Appliances Co., 
Pittsburgh, Pa.) 
Lamb10 et al. state: 
"The 'hopcalite' absorbant functions indefinitely against any concentration of 
carbon monoxide, provided the effluent air is adequately dried, and hence the life of 
the canister is limited solely by the life of the drier." It was found that the net gain 
in weight of the canister was sure criterion of its condition. By tests, the average gain 
in weight was 54 grams before signs of leakage occurred; therefore they recommend 
to discard any canister which has gained more than 35 grams above its original weight 
(stamped on it). They present a table which shows the estimated time-service of 400 
CARBON MONOXIDE POISONING 
canisters to be from 3 to 60 hours for men at rest under air conditions varying respec- 
tively from 100° Temperature and 100 per cent, relative humidity to 32° Temperature; 
and 25 per cent, relative humidity and % to 32 hours for men in action under the same 
conditions. 
The following methods3 have decreased gas poisoning in steel mills to a minimum 
in the opinion of the writer. First, the adoption of automatic top-filling furnaces; 
second, the use of overhead mains instead of underground; third, reduction of leakage 
by improved methods of lining and riveting the furnace and pipe walls; fourth, by 
enforcing adequate safety rules. 
Katz and Allison58 have investigated the problem of adding various stenches to 
gas in the mains for detecting its leakage. The two cheapest stenches are amylacetate, 
which costs $0.0095, and nitrobenzene, which costs $0.0053, for imparting a strong 
odor to 100 cu. ft. of gas. Ethyl mercaptan and pyridin (extremely disagreeable 
odors) cost $0,040 and $0,043 per 1000 cu. ft. respectively. Others might be used 
if made up commercially: Amylthioether and phenyl isocyanide. They suggest that 
savings from gas leakages in the use of stenches would probably total more than the 
cost of the stench. 
The employe also shares responsibility in his work of prevention.3 
He must learn to recognize the danger of gas and its sources. Of dan- 
gerous occupations it might be said that familiarity breeds contempt. 
Alcohol should be abstained from during or before working hours. Some 
men have gone to sleep under the influence of alcohol alongside the 
comfortable warmth of a furnace to be found by fellow-workers fatally 
"gassed." 
The state is advancing in factory regulation.3 Nearly all govern- 
ments have adopted laws for the prevention of industrial accidents and 
diseases, which provide for safe machinery, necessary ventilation and the 
safe removal of obnoxious and poisonous dusts and gases. 
The following laws are from those enforces by British Factory Inspec- 
tors :3 
1. Notices are exhibited at different parts of the works calling attention to the 
dangers of the gas. 
2. Men engages in flue cleaning are never permitted to work single handed nor are 
both men permitted to enter the tube at the same time. Each can watch his mate, 
this by turn. 
3. No workman is allowed to enter the tube until it is cleared of gas. External 
work, such as raking out the dust from the bottom doors, is always completed first. 
4. During cleaning, a cylinder of compressed oxygen, is kept on the spot. Various 
persons have been instructed in artificial respiration. 
5. Attendants are supplied with ropes for rescue purposes, and a smoke helmet 
with bellows and piping, which the attendants would use in order to enter the tube to 
tie on the rope to any one "gassed," and assist him out of the tube. 
Following are regulations adopted by the Illinois Steel Company 
pertaining to "gassing."3 
1. Never go into a gas-engine house or electric motor room unless your duties 
take you there, and you have special instructions from your foreman. 
2. Work around blast furnaces is very dangerous, because of excaping gas, the 
possible breaking out of the side of a furnace, explosions, and the blowing of hot 
stock out of the top of the furnace. These dangers cannot always be guarded against PREVENTION OF "GASSING" RESUSCITATION 
401 
by those in charge and every one near a furnace must be watchful for his own 
safety. 
3. Gas May Kill You. Dangerous gas may be found anywhere. Sometimes 
you cannot see or smell it. It may make you unconscious before you know gas is 
present. Sometimes gas makes you feel dizzy, or gives you a headache, or stiff neck 
or weak legs. When you feel any of these symptoms, get into fresh air. 
4. Employes are forbidden to go to top of furnace without the permission of 
the General Furnace Foreman. 
5. Before working around the explosion doors, bell rods or hangers, or doing any 
work between the big bell and gas seal, see that the gas valves are closed, that the 
gas escaping from the stock is lighted and that the man operating the bells is notified. 
6. Before changing tuyeres, notice should be given the party in charge filling the 
furnace to stop filling until he gets notice that the tuyeres have been changed. This is 
to prevent gas from blowing out on the men through the tuyere openings of the furnace. 
7. Keep away from valves under dust catchers and down legs, especially when a 
furnace slips. There is danger from gas. 
8. You must not go anywhere above the floor, around a blast furnace (around 
bustle pipes, water trough, valves, roofs, stoves, etc.) without first telling the General 
Foreman on the Blower of that furnace. 
9. Stove Cleaner Foreman must order men out of stoves when the wind is off the 
furnace or when a furnace is slipping badly, as there is danger of gas from the Furnace 
backing into the stoves and igniting. 
10. Keep out of the engine rooms unless your duties take you there. There is 
danger from gas. 
11. Never work in the basement alone-always have a helper with you. Gas may 
kill you. 
12. If you find a man "gassed," get him into the open air and call foreman at 
once. 
13. Gas may be found anywhere; never go into holes or out of the way places 
alone. 
Resuscitation.-The above mentioned regulations show clearly3 how 
the workman is removed from a gas atmosphere without "gassing" more 
men. Resuscitation is then begun. This must be conducted at the site 
of the "gassing" up to the point where the patient can be safely removed 
to a hospital or his home. Many industrial "gassings" do not demand 
much more treatment than removal to pure air. Not all are deep comas; 
in fact the majority are mild in which the patient is only in a simple 
stupor. 
Artificial respiration should be begun at once and the Schafer prone- 
pressure manual method used with arms well extended beyond victim's 
head and persisted in for at least two hours or until rigor mortis (stiffen- 
ing) has set in.59 
In treatment, Lewin1 says pure oxygen inhalation causes dissociation 
of the carbon monoxide from the blood five times as quickly as ordinary 
air. Tanks of oxygen3 and resuscitation apparatus are kept close to the 
furnaces in many companies. 
Nicloux60 says one volume of CO acts like 220 volumes of O. Hemoglobin in the 
presence of 1 part of CO and 220 parts of O takes up equal parts of each, half of the Hb 
becoming oxygenated and half carbon-monoxated. Air contains only 21 per cent. O; 402 
CARBON MONOXIDE POISONING 
therefore the proportion would have to be 1: 1000 when air instead of pure O is used. 
In animals deeply intoxicated with CO he found nearly the whole amount of CO had 
disappeared from the blood by the end of an hour of O breathing. 
Henderson and Paull16 state: "In many instances the victim never 
recovers consciousness and dies a day or two later. Many physicians 
still hold to the belief (now completely disproved) that the prolonged 
coma is due to retention of the carbon monoxide, and advocate bleeding, 
infusion of oxygenated saline solution, transfusion of blood from some 
healthy person, and other active efforts at restoration. None of these 
procedures nor any known procedure aside from careful nursing and 
symptomatic treatment has been demonstrated in practice to be of any 
benefit. Recovery when it occurs is not due to them, but in spite of them." 
"Theoretically there is no treatment that would seem more likely 
to diminish a patient's chance of recovery than treatment by bleeding." 
Henderson61 describes the preferred treatment as follows: 
"Obviously, the first step in any treatment must be the restoration 
of spontaneous breathing if it has stopped. For this purpose the manual 
prone-pressure method of artificial respiration is to be recommended 
above any apparatus, for it is as effective or even more effective than 
apparatus and it can be applied instantly, while the bringing and adjust- 
ment of apparatus involves delay. A delay of even a couple of minutes 
after breathing has stopped may sometimes be fatal and a quarter or 
half an hour always fatal. This delay has probably cost more lives than 
such apparatus has ever saved and many such lives might be saved if 
everyone were trained to perform the manual method. 
"The next step after restoring spontaneous breathing is to accelerate 
the elimination of carbon monoxid from the blood. For this purpose 
the inhalation of oxygen has long been recognized as the specific pro- 
cedure, but the difficulty arises that after a long exposure to an atmos- 
phere containing carbon monoxid, respiration is very much depressed 
and the inhalation of oxygen has no stimulating effect upon the volume of 
breathing. It occurred to us to utilize the stimulating action of carbon 
dioxide, . . . ." "Asphyxiated patients who were reached within half 
an hour-and the utmost speed at this time is essential for success-and 
who were given an inhalation of oxygen containing 5 per cent, carbon 
dioxide were practically freed from all but the merest trace of carbon 
monoxid in their blood within twenty-five to thirty minutes. Frequently, 
also, consciousness returned within this time and within a few hours the 
patient was practically well again. It is also noteworthy that not a 
single patient thus treated developed pneumonia, which is so common 
after gassing, nor any of the other distressing sequelae sometimes asso- 
ciated with poisoning by illuminating gas or the exhaust gas of 
automobiles. 
"There are thus solid reasons for the expectation that with the general 
introduction of the oxygen, and carbon dioxid inhalation, fatalities from ELIMINATING CO FROM THE BODY 
403 
■carbon monoxid may be very considerably decreased and its after effects 
largely eliminated." 
An apparatus for this purpose62 has been perfected which includes an 
improved inhaler, a device for the control and measurement of the flow 
of gas, and the sylphon bellows reducing valve, invented by Mr. W. E. 
Gibbs, for the U. S. Bureau of Mines, and patented by the government 
for general use. Using these three features the apparatus is to be had 
from the Mine Safety Appliance Company, 908-912 Chamber of Com- 
merce Bldg., Pittsburgh, Pa. 
Percent oj Hb Combination With CO. 
Time in Minutes. 
Fig. 22.-Elimination of carbon monoxide. 404 
CARBON MONOXIDE POISONING 
"This treatment is highly effective, inducing rapid and completely recovery, if 
applied early enough. It requires merely general medical supervision, and may be 
safety and efficiently carried out by intelligent men of the type composing the emer- 
gency crews of a city gas company. 
"Until more definite knowledge has been obtained regarding the conditions in 
the lungs, brain and elsewhere, subsequent to gassing, and until treatment can be 
based on such knowledge and has been tested experimentally, it is inadvisable to 
apply any specific treatment in postasphyxial gassing cases. The evidence here 
reported indicates that oxygen + CO2 inhalation and rapid elimination of carbon 
monoxid greatly decreases the liability to nervous and pulmonary asphyxial sequelae." 
"The apparatus consists of a steel tank or bottle charged to about 120 atmospheres 
of oxygen and 6 atmospheres of carbon dioxid, that is, 5 per cent, with an allowable 
variation of +0.5 per cent, carbon dioxid. The bottle is connected with the reducing 
valve, which automatically delivers any quantity of gas that may be drawn at a 
uniform pressure of about 1.5 pounds per square inch. The gas then passes through 
the graduated needle valve, which serves both as a control and as a meter for estimat- 
ing the volume of breathing, so that the supply to the patient can be adjusted to any 
volume from 0 to 30 liters a minute. From this needle valve the gas flows into a bag 
of rubber and cloth of 4 or 5 liters capacity. Beyond this bag is a pair of disk valves 
arranged on a T so that the upper one, which has a very light disk, allows the patient 
to inhale the contents of the bag at the beginning of a respiration, while the lower 
valve with a heavier disk only opens to admit outside air after the bag has been sucked 
empty. From the upper disk valve a hose of 0.8 inch bore leads to a snout mask. 
On the mask is an expiratory valve. This apparatus has been given the name of the 
H.-H. inhalator. 
Fig. 23.-H.-H. inhalator with Schafer prone pressure method of resuscitation. 
The following sheet of instructions is put into each of the inhalator boxes: 
I. Open valve at top of tank. 
II. Put mask on victim. 
III. Turn pointer on dial to 10. 
IV. Keep advancing pointer as victim breathes more. 
V. Use for from twenty to thirty minutes. 
Detailed directions accompany each apparatus. 
DIRECTIONS IN BRIEF CHRONIC CO POISONING 
405 
"Note.-It has come to our attention that an attempt has been made to sub- 
stitute, in place of the special inhaler which we have developed, one of the common 
artificial respiration devices, namely, the pulmotor. The pulmotor, like all other 
such devices, is, however, entirely unsuited to this purpose, and such use of it can do 
no good and may even do a patient serious harm. The inhaler which we have used 
was invented by us for the special and peculiar condition of the oxygen +CO2 inhala- 
tion. No other apparatus now available is capable of functioning as it does, and for 
the present at least no other should be used on our responsibility." 
CHRONIC CARBON MONOXIDE POISONING 
Sommerfeld and Fischer63 state that chronic CO poisoning produces: 
"frequent headaches, dizziness, nausea, vomiting, coated tongue, weak- 
ness of memory, anaemia without chlorosis, hot flushes, formication, 
palpitation of the heart, insomnia, general debility, and feebleness of the 
psychic functions." It is true3 that many persons who are continually 
subjected to small continuous doses of the gas are sometimes afflicted 
with the symptoms mentioned above. The writer has personally seen 
undisputed cases of chronic CO intoxication, confirming such by means 
of a method which will be mentioned later. Nevertheless, upon critical 
examination of 240 men, in 1910, together with Dr. Matthew Karasek, 
and upon further investigation since then, the writer must conclude that 
certain workers acclimate themselves to CO within certain limits. 
The cases appear to divide themselves into two groups (Hayhurst): 
those who for some reason or other, become acclimated and those who 
do not. It is probably, fundamentally, a question of cardiac condition 
at the time, and analogous to experiences in mountain climbing by the 
inexperienced: Some become rapidly inured and others suffer continu- 
ously from the start. The acclimated group in CO poisoning are those 
who compensate by an increase in red corpuscles, hemoglobin, etc., as 
detailed for the 240 men examined by Karasek and Apfelbach and whose 
findings follow (under Pathology). The other group has symptoms 
which simulate hystero-neurasthenia and accounts for the vast number of 
symptom complexes reported for chronic carbon-monoxide poisoning. 
Gas men who are professional investigators often experience gas 
poisoning. Undoubtedly some of them fail to thoroughly appreciate the 
dangers which they take. The reviser was once asked to go to a southern 
state to see what could be done for a man who had been "gassed." He 
was surprised to find that the victim was a prominent investigator and 
inventor in this field who had been subject to chronic gassing in his 
laboratory in New York City for years paying no particular attention 
to his exposures, although on two or three occasions he had been found 
partially unconscious. He was 39 years old at the time of my visit and 
had been compelled to give up his work for a matter of eight months, and, 
in brief, had the symptoms of a fully developed neurasthenia. His 
personal habits were good but he had gotten into a state of irritability 
and changeability which practically nullified his endeavors. After 406 
CARBON MONOXIDE POISONING 
telling him that there was no such thing as carbon monoxide gas remaining 
in his blood I referred him to a neurologist. During the subsequent two 
years he got no better in spite of sanatorium treatment, etc., became a 
great burden to himself and family and finally succumbed to an attack 
of influenza during the 1918 epidemic. In this connection I would also 
mention that an official of a large steel company stated they had a couple 
of men on the pay roll who had been severely gassed and it had affected 
their efficiency to the extent that they were now employed at purely 
menial labor of light character whereas they had been skilled workmen 
theretofore. 
In making quantitative analyses on air collected in various establish- 
ments, Apfelbach3 found a great variation in the CO present, at different 
times and in different parts of the same room. 
In five analyses made in motor garages the CO content of the air was 
as follows: 
Per Cent. 
1. CO 0.02 
2. CO 0.13 
3. CO 0.04 
4. CO 0.00 
5. CO 0.02 
The average for the above five samples was 0.042 per cent. CO. 
Pathology.3-The pathology of chronic CO poisoning does not refer 
to post-mortem findings, since there exists no cause of death from chronic 
intoxication, but to the clinico-pathological examination of the blood. 
During the Illinois investigation of 1910, a critical examination was 
made of 240 men who had either recently been "gassed" or who had been 
subject to frequent "gassings." During this work the blood of 68 men 
was examined by Dr. Matthew Karasek and the writer, with the following 
observations: 
1. There existed a polycythemia in these cases of 5,500,000 to 9,676,000 
-66 per cent, being over 6,000,000 cells per cu. mm. 
2. No cells such as poikilocytes, normoblasts, microblasts, etc. No 
embryonal red cells. 
3. Hemoglobin estimated from 95 per cent, to 125 per cent., more 
estimations being over 100 per cent, than under. Whites 7000 to 10,000. 
4. Color index under five-sevenths. 
5. Eosinophiles in about two-sevenths cases from 5.5 per cent, to 8.5 
per cent., myelocytes in one-third cases as high as 3 per cent. Basophiles 
rare. 
Similar work was done by Drs. Nasmith and Graham64 on guinea-pigs. They 
allowed the animals a saturation of 25 per cent, of the coloring matter of the blood, 
with CO. The guinea-pigs inhaled this gas daily for several weeks. Although their 
blood was saturated with 25 per cent. CO, they did not lose weight, become anaemic, 
nor show any signs of disturbance from the gas. They state: "With 25 per cent, of PATHOLOGY OF CHRONIC CO POISONING * 
407 
its blood rendered useless for O carrying purposes, by its union with CO, the guinea- 
pig is capable of compensating and will manufacture new red blood corpuscles until 
it has reached a total of 8,000,000 with a corresponding hemoglobin content of 105 
per cent. The normal number of erythrocytes in the peripheral circulation of guinea- 
pigs is about 6,000,000 with 88 per cent, hemoglobin. The animal with true com- 
pensation has three-fourths of 8,000,000 or 6,000,000 erythrocytes and three-fourths 
of 105 per cent, or 79 per cent, hemoglobin still available. Thus there is only a total 
loss for O carrying purposes of 9 per cent, of its hemoglobin." 
The following were their conclusions of their entire experiments with CO: 
1. "Carbon monoxide acts as a poison solely by its ability to prevent the normal 
supply of oxygen from reaching the tissues, and thereby deranging the normal metab- 
olism of the body cells. 
2. "Guinea-pigs living continuously in a dilute atmosphere of CO, so that the 
carrying power of the blood is reduced, are able by increasing the quantity of hemo- 
globin and number of erythrocytes to compensate for this loss and maintain an O 
carrying capacity approximately equivalent to that of the original blood. 
3. "Carbon monoxide poisoning is followed by a leucocytosis of the eosinophile and 
"pseudo-eosinophile forms. A moderate saturation produces a moderate toxaemia 
involving an eosinophila like nearly all moderate toxaemias. A high saturation 
causes a severe toxaemia in the course of which the eosinophiles disappear, as in all 
severe toxaemias. A high prolonged saturation brings about the appearance of 
erythroblasts and myelocytes, indicating hyperactivity on the part of the parent cells 
in the bone marrow. 
4. "The effect of CO in increasing the number of erythrocytes in the blood is, in 
many respects, similar to those of high altitudes, in the peripheral circulation at 
least." 
Apfelbach3 presents a second table showing work done on chronic 
"gassing" (1910-1914). 
Table II 
Sex 
Occupation 
How long 
employed, 
years 
Red blood 
count 
Symptoms noted 
Female 
Tailor shop 
6 
5,762,100 
Headaches 
Female 
Laundry 
1 
6,432,130 
Headaches 
Male 
Can manufacturer 
22 
7,611,310 
Headache, anorexia 
Male 
Can manufacturer 
10 
6,421,140 
Neurasthenia 
Male 
Can manufacturer 
4 
5,280,710 
Neurasthenia 
Male 
Salamander 
3 
8,497,600 
Headaches, anorexia 
Male 
Salamander 
5 
6,311,000 
Nausea 
Male 
Salamander 
5 
6,131,000 
Headaches 
Male 
Salamander 
12 
4,376,000 
Headaches 
Male 
Tailor 
5 
6,378,000 
Headaches 
Male 
Tailor 
6 
5,810,000 
Headaches 
The above table gives reason for saying that the blood forming organs, 
tending to compensate a loss of O carrying power in many individuals, cause 
an increase in the number of red cells and the quantity of the hemoglobin. 
Symptomatology.-Since acute "gassing" may occur3 in so mild a 
manner so as to produce only a headache, it is easy to confuse acute and 408 
CARBON MONOXIDE POISONING 
chronic CO poisoning. When mention is made of certain symptoms as 
being so-called chronic CO poisoning, such a person is continuously 
exposed to small quantities of this gas, or is "gassed" frequently in a 
very mild manner. 
Forbes41 says: There is no evidence of a cumulative harmful effect 
from frequent exposures. On the other hand it is possible to acquire 
some tolerance to it. 
Persons who do not acquire a tolerance3 to the gas will become 
anaemic, irritable, neurasthenic, and complain of headaches, anorexia, 
loss of weight, backaches, vertigo and gastro-intestinal disorders. To 
this list Watkins,65 who investigated the conditions in the steel industry, 
adds: nausea, vomiting, lack of coordination, muscular weakness, rapid 
fatigue, palpitation and cardiac distress, irregular pulse, neuritis with 
ensuing paralysis, and melancholia or hallucinations. There is occasion- 
ally albumin and sugar in the urine. From the point of the view of the 
employer: mental alertness is gone, while judgment, strength and 
coordination are impaired. Air analyses from places where men worked 
showed CO always present in the breathing atmosphere and ranging 
from 0.01 per cent, to 3.43 per cent., but usually under 0.10 per cent. 
Wilmer66 gives in great detail the symptoms and impressions recorded by a very 
intelligent patient whose whole family was subjected to slow poisoning by the gas 
escaping in an old house into which they had moved which was said to be "haunted" 
due, plainly, to hallucinations of sight and hearing which all occupants experienced, 
and which turned out eventually to be due to CO poisoning. There were, also, peculiar 
changes in temperament so that the persons became just the opposite of what they 
were before. The picture looked like hysteria. Wilmer describes the optic neuritis, 
scotoma and other disturbances in the field of vision of two of the children, one of 
whom had not entirely recovered after a period of four years. 
Georgine Luden7 of the Mayo Clinic gives, in great detail, the symptoms in 
herself and several others which were due to a faulty furnace in the residence and 
caused disturbances extending over a year or so. These symptoms she divides into 
three periods. Those of the first period simulated Sommerfeld's picture given above. 
Those of the second period were many and included varied subjective symptoms, but also 
the following objective symptoms: sudden drowsiness; shivering attacks; muscular 
spasm (short), extreme thirst (satisfied with lots of tea), great craving for sugar; 
transient bronzing, pinched face for 24-36 hours (one looks old); low blood pressure 
with normal pulse pressure; transitory "uncomfortable" heart action; irregular flat- 
tening pulse; respiratory oppression after the intake of food, sometimes with slight 
shivering attacks; and low blood-sugar values. Third Period: Hypersensitization 
to minute amounts of CO, as a whiff of exhaust gas from a passing auto, smoke 
from a chimney; transient, acute nausea; numbness of feet; scalp felt too tight, 
etc., etc. Veins in scalp seem to bulge in certain areas; "coal-gas headache" for 
several hours which is characteristic, localized, sore to touch, intense, no effects 
from the usual remedies (aspirin, phenacetin, pyramidin, etc.); dull headache at 
times. 
The Lancaster, Ohio, victims (above mentioned) mistook, for several days if not 
several weeks prior to the fatal night of their demise, obvious CO poisoning symptoms 
for food poisoning perpetrated either by outside enemies, or, as the authorities at 
first feared, by the mother herself. Some alleged labor threats exercized the father REFERENCES ON CO POISONING 
409 
while peculiar actions at times by the mother, undoubtedly due to daily inhalations 
of CO gas, confused the evidence presented to the coroner. 
Whether the compensating power3 of the blood-forming organs in those persons 
living with a polycythemia will ever exhaust itself, as in the case of a hypertrophied, 
leaky heart, is yet to be determined. The writer has not been able to find a greater 
incidence of pernicious anaemia among blast-furnace workers. 
McGurn67 details two cases of multiple sclerosis due to repeated inhalations of 
CO in house furnace gas. Each occurred in a young man. As time went on the 
typical symptoms of multiple sclerosis gradually developed. Both became pitiable 
sights to behold. One died after ten years of invalidism. The prognosis for the 
other after about five years is no better. 
Symptoms of chronic CO poisoning undoubtedly always cease upon withdrawing 
from exposure. Sequelae following coma or other severe gassing exposures should 
not be called chronic CO poisoning (Hayhurst). 
The diagnosis of chronic CO poisoning was once made by Apfel- 
bach3 in the following manner: A person engaged as mechanician in a 
can-factory occupied himself for certain periods every day over a solder- 
ing machine, during which time it was possible to inhale CO fumes. 
The patient complained of a symptom-complex very much like that 
usually mentioned under chronic CO poisoning. Upon excluding tuber- 
culosis, as far as my ability permitted me, nephritis, and especially lead 
poisoning, a red count was obtained in the neighborhood of 7,000,000 
red cells. The diagnosis of chronic carbon-monoxide was made. Upon 
changing his manner of work the patient obtained relief. 
A loss of muscular power3 seems to occur in those subjected to CO 
poisoning. This should be referred to as a sign of chronic intoxication. 
Dr. Matthew Karasek and the writer made comparative tests on the 
workmen about a blast furnace, and on those working in non-gas pro- 
ductive industries, selecting as much as possible workers of the same 
nationality and habits. Diminution in strength, as noted by the hand 
dynamometer, was noted in those subjected to the gas. 
REFERENCES 
1 Lewin, Prof. Dr. L., Die Kohlenoxyd vergiftung, Ein Handbuck fur Mediziner, Tech- 
niker and Unfalberichter. Berlin (Julius Springer, publishers), 1920. Reviewed by Alice 
Hamilton, Jour. Ind. Hyg., June, 1921, Vol. Ill, No. 2, pp. 76-78. 
2 Glaister, John, and Logan, D. D.: Gas Poisoning in Mining and Other Industries, 
1914, Wm. Wood & Co., 471 pages. 
3 Apfelbach, G. L.: See Kober and Hanson: Diseases of Occupation, Etc., page 43, etc. 
4 Harris, Louis I., Clinical Types of Occupational Diseases. J. A. M. A., Vol. LXXIII, 
No. 12, pages 880-886, Sept. 20, 1919. Mo. Lab. Rev., Vol. IX, No. 5, Nov., 1919, pages 
263-4. 
6 McNally, William D.: Carbon Monoxide Poisoning. J. A. M. A., Vol. LXIX, No. 
19, Nov. 10, 1917, pages 1586-1590. 
6 Rutherford, W. J., CO Poisoning in Warfare. Lancet (London) No. 5030, Jan. 24, 
1920, pages 184-188. 
7 Luden, Georgine, Chronic CO Poisoning. Mod. Med., Feb.-Mar., 1921. Vol. Ill, 
Nos. 2 and 3. 
8 The reader should consult such works as Thorpe's "Outlines of Industrial Chemistry" 
or Molinari's "Industrial Chemistry (Inorganic)" for a full discussion under this head. 
9 W. M., Carbon Monoxide. Science, Vol. LI, No. 1322, Apr. 30, 1920, page 437. 
10 Lamb, Arthur B., Bray, Wm. C. and Frazer, J. C. W., The Removal of Carbon Mon- 
oxide from Air. Jour. Ind. and Eng. Chem., Vol. XII, No. 3, pages 213-221 (Mar., 1920). 
Also, Burrell, Capt. Guy H., Carbon Monoxide Gas. Proc. Nat'l Safety Council, 9th 
Am. Safety Congr. (Milwaukee), 1920, pages 751-3. Also, Hoover, R. C., Jr. Ind. and 
Eng. Chem., Sept., 1921, No. 9, 770-772. 410 
CARBON MONOXIDE POISONING 
11 Gertz, H., To Calculate Speed of Intoxication with CO. Nordiski Medicinski Arkiv., 
Vol. LI, Mar. 10, 1919, page 227, Stockholm. (J. A. M. A., Oct. 11, 1919, page 1122.) 
12 Peterson and Haines, "Text-book of Legal Medicine." 
13 Haldane, J. S., "The Disassociation of Oxygen Hemoglobin, in Human Blood, during 
Partial Carbon Monoxide Poisoning." Proc. Physiological Soc., Lond., 1912, pages 
xxii-xxiv. 
14 Haldane, J. S., Sir C. S. Foster. "The Investigation of Mine Air." 
15 Harbitz, F., CO Poisoning in Motor Boats. Nnisk Magazine for Laegevidenskaben 
Christiania, Vol. LXXVIII, No. 4, pages 383-504, Apr., 1917. (J. A. M. A., Nov. 17, 
1917, page 1746. 
16 Henderson, Yandell and Paull, James W., Tech. Paper 82, U. S. Bur. Mines (1917). 
17 Henderson, Y., Haggard, H. W., et al., Physiological Affects of Automobile Exhaust 
Gas and Standards of Ventilation for Brief Exposure. Jr. Ind. Hyg., July, 1921, (pages 79- 
92, and Aug., pages 137-148), 1921, Vol. Ill, Nos. 2 and 3. 
18 Henderson, Yandell, CO Poisoning, J. A. M. A., Vol. LXVII, 8, 580-83, Aug. 19, 
1916. See also: Resuscitation Apparatus. J. A. M. A., Vol. LXVII, I, 1, July 1, 1916. 
19 Robert, "Lehrbuch der Intoxicationen," II, d, s, 870. 
20 Hill, Emory and Semerak, C. B., Studies from Otto S. A. Sprague Memorial Institute 
(Chicago Univ.), Vol. VI, 1918. 
21 Legry and Lermoyez, CO Poisoning, Presse Medicale, Paris, 28, No. 83, Nov. 13, 1920, 
page 816. (J. A. M. A., 1, 1, 21, page 72.) 
22 For a more detailed description see Willcox, Fred H., Asphyxiation from Blast 
Furnace Gas. Tech. Paper 106, U. S. Bureau of Mines (1916). 
23 Albaugh, R. P., Peculiar Poisoning in a Construction Camp. Jour. Amer. Med. 
Assoc., Vol. 68, No. 14, April 7, 1917, page 1033. 
24 Burrell, G. A., & Gauger, A. W., Vitiation of Garage Air by Automobile Exhaust Gas. 
Technical Paper 216, U. S. Bur. Mines, April, 1919. 
25 Harris, " Note on Carbon Monoxide Poisoning at White Haven Pit Disaster." Lancet, 
Lond., 1910, Vol. II, page 1693. 
26 Strassman, C., Hematologic Studies of the Dead with Special Reference to CO poison- 
ing. Vrtljhrschrt. ger. Med., 1919, LVIII, pages 50-73. 
27 Hektoen and Reismann, "American Text-book of Pathology," 1902, page 377. 
28 Mott, F. W., "Carbon Monoxide and Nickel Carbonyl Poisoning." Arch. Neurology, 
Lond., 1910, Vol. II, page 1693. 
29 Libin, " Hsemorrhagische Encephalitis bei Kohlenoxyd Vergiftung." Kcenigst. I. 
Pr., 1913, F. Heise, page 22. 
30 Kolisko, " Die symetrische Encephalomalachie in den Linsenkernen nach Kohlenoxyd- 
gasveriftung." Beitrage zur gerichtlichen Medicin, 2, 1914, pages 1-16. 
31 Hill, Emory and Semerak, C. B., Changes in the Brain in Gas (CO) Poisoning. 
J. A. M. A., 71, 8, 644-48 (Aug. 24, 1918). 
32 Bock, J., Carbon Monoxide Poisoning, Hospitalstidende, Copenhagen, Vol. LXI, 
No. 1, page 1, Jan. 2, 1918 (J. A. M. A., Mar. 16, 1918, page 820). 
33 Oliver, Thos., "Diseases of Occupation," pages 59-68. 
34 Curschmann, Medical Discretion in Industrial Poisoning. Zentralbl. f. Gewerbehyg., 
1919, 7, pages 131, 245, 171, 191. (Abstracted verbatim by J. Ind. Hyg., June, 1921, 
Vol. Ill, No. 2, pages 24-25.) 
35 Henderson, Y., Haggard, H. W., et al.: Physiological Affects of Automobile Exhaust 
Gas and Standards of Ventilation for Brief Exposure. Jr. Ind. Hyg., July, pages 79-92, 
and Aug., 1921, pages 137-148, Vol. Ill, Nos. 2 and 3. 
36 Haldane, J. S., Sir C. S. Foster, "The Investigation of Mine Air." 
37 Williams, John R., The Blood in CO Poisoning. Letter in J. A. M. A., Jan. 12, 1918, 
pages 119-120 (Vol. LXX, 120, 2). 
38 Thompson, W. Gilman, "Occupational Diseases," 1914, page 323. 
39 Loc. cit. 
40 See Ref. 37. Also Ref. 62. 
41 Forbes, Henry S., A Survey of Carbon Monoxide Poisoning in American Steel Works, 
Metal Mines, and Coal Mines. Jour, of Ind. Hyg., Vol. Ill, No. 1, May, 1921, pages 11-15. 
42 Zondek, H., Heart Findings in Illuminating Gas Poisoning, Deutch. Med. Wchnschr., 
June 19, 1919, 45, No. 25, 678-680; abstr., Jr. Ind. Hyg., I, 8, Dec., 1919, p. 126. 
43 Sibelius, "Die pschischen Stoerungen nach akuter Kohlenoxyd Vergiftung." Monat- 
schr. f. Psch. u. Neurol., Bd. XIII, 1906. 
44 Stierlin, "Ueber psycho-neuropathische Folgezustaende bei den Ueberlebenden der 
Katastrophe Courrieres." Inaug. Diss., Zurich, 1909. 
46 Zangger, Heinrich, 1874, "Ueber die Beziehun gen der technischen und gewerblichen 
Gifte zum Nervensystem." (In Ergebnisse der Inneren Medicin und Kinderheilkunde.) 
Berlin, 1910, Vol. V, pages 335-410. REFERENCES ON CO POISONING (CONCLUDED) 
411 
46 Giese, G., "Zur Kenntniss der psychischen Stoerungen nach Kohlenoxyd Vergiftung. 
Allegemeine Zeitschrift fur Psychiatrie und psychisch-gerichtliche Medicin." Berlin, 1911, 
804-851. 
47 Mott, F. W.,"Carbon Monoxide and Nickel Carbonyl Poisoning." Arch. Neurology, 
Lond., 1907. 
48 Libin, "Hsemorrhagische Encephalitis bei Kohlenoxyd Vergiftung." Koenigst, I, 
Pr., 1913. F. Heise, page 22. 
49 Weidner, "Ueber die Schaedigung des Nervensystems nach Kohl Kohlenoxyd." 
Leipzig, 1910. 
60 O'Malley, "A Psychosis following Carbon Monoxide Poisoning with Complete 
Recovery." Am. J. Med. Sc., Phil., Vol. CXLV, 865-69, 1913. 
61 Abrahamson, A., "A Case of Acute Dementia or Mental Stupor Following Illuminating 
Gas Poisoning." Jour. Nerv. and Ment. Dis., 1905, XXXII, 332. 
62 McGurn, Wm., Chronic Carbon Monoxide Inhalation and Some of its Untoward 
Results. Boston Med. & Surg. Jour., CLXXVI, 7, 231-235, Feb. 15, 1917. 
63 Hitchcock, Chas. W., CO Poisoning: Its Nervous and Mental Symptoms. J. A. 
M. A., Vol. 71, No. 4, pages 257-269 (July 27, 1918). 
64 Krantz, "Ueber einen Fall von Kohlenoxyd Vergiftung mit nach folgenden Poly- 
neuritis." (Muenchen) Aachen, 1913. 
66 Alberti, " Gangrene der Halsmuskultur und Laehmung des rechten Beins nach 
Kohlenoxyd Vergiftung." Deutsche Zeitschr. f. Chir., 20, 1884, page 476. 
66 McLean, "Carbon Monoxide Poisoning with Gangrene in Both Legs." J. A. M. A., 
Chicago, 1911, Vol. LXI, pages 1455-57. 
57 Briggs, J. Emmons: Gangrene Following Carbon Monoxide Poisoning. J. A. M. A., 
Vol. 73, No. 9, pages 678-9 (Aug. 30, 1919). 
58 Katz, S. H., and Allison, V. C., Stenches for Detecting Leakage of Blue Water Gas 
and Natural Gas. Technical Paper, No. 267, U. S. Bur. Mines, 1920. 
69 U. S. Bureau of Mines, Tech. Paper No. 77, 1914. 
60 Nicloux, W., Importance of O in Treatment of CO Poisoning. Presse Medicale, 
Paris, Mar. 15, XXV., No. 16, page 153. (J. A. M. A., May 19, 1917, Vol. LXVIII, No. 20, 
page 1511.) 
61 Henderson, Yandell: The Nation's Health, IV, No. 10, Oct., 1922, 607-9. 
62 Henderson, Haggard and Scott: J. A. M. A., Sept. 30, 1922, 1137-1145. See also, 
Drinker, Cecil K., Drinker, Katherine R., Shaw, Lewis A., and Redfield, Alfred C., Carbon 
Monoxide Asphyxia: Artificial Respiration; and Final Report of the Commission on Resus- 
citation from Carbon Monoxide Asphyxia: The Treatment of Carbon Monoxide Asphyxia, 
Jour, of Ind. Hyg., V, 4, (Aug., 1923), pp. 109-124, and 125-129, respectively. 
63 See "List of Poisons," page 649. 
64 Nasmith & Graham, "Hematology of Carbon Monoxide Poisoning." Jour. Physiol., 
Lond., 1906-1907, XXXV, 32. 
65 Watkins, J. A., CO in the Steel Industry, Tech. Paper 156, U. S. Bur. Mines 
(1917). 
■ 66 Wilmer, W. H.: Effects of Carbon Monoxide upon the Eye. Amer. Jour, of Ophthal., 
IV, No. 2, Feb., 1921, pages 73-90. 
67 McGurn, W. J., Multiple Sclerosis Due to Repeated Inhalation of CO in (House) 
Furnace Gas. Med. Record, Jan. 27, 1917, pages 149-151 (Vol. XCI, No. 2412). SECTION 9 
LEAD POISONING: SOURCES, SYMPTOMS AND TREATMENT 
SIR THOMAS OLIVER, M. D., Newcastle-upon-Tyne, England 
Historical Evidences.-Although lead poisoning has existed from 
time immemorial, we yet learn little or nothing of it from Egyptian 
history. When Rome was at the height of her power and the supply of 
water for drinking purposes and for baths became a pressing requirement, 
also when the question had been partly solved by the large aqueducts 
built by her engineers, the use of lead pipes for domestic distribution 
became more or less a necessity. That the people suffered from drinking 
lead contaminated water is evident from the condemnation of the metal 
by Vitruvius, the Roman architect. In one of the large Roman Camps 
near Newcastle-upon-Tyne I found lead pipes which had been used for 
the conveyance of water through the Camp. The Romans in making 
lead pipes did not mould the pipe as is done to-day, they simply beat 
flattened lead into a tubular shape. 
Non-industrial Plumbism.-In medical literature lead poisoning occurs 
under various names, e.g., saturnism, plumbism, colica pictonum and colica 
pictorum. The sources of the poisoning are industrial and accidental. 
Occasionally lead poisoning has assuriied epidemic proportions: it has 
broken out in a town owing to the drinking water possessing strong 
plumbo-solvent properties. The "gathering ground" has much to do 
with the plumbo-solvency. A peaty soil is apt to render water slightly 
acid, owing to humic and ulmic acids, and to confer upon it plumbo- 
solvent properties. Rainy weather succeeding a long drought also 
favors the disposition of the water to attack lead. The presence of certain 
microorganisms in peaty water is not without considerable influence. 
Houston found two non-motile, non-liquefying bacteria in peat; these 
possessed separately the properties of acidity and plumbo-solvency. 
Distilled water attacks fresh lead pipes with considerable vehemence. 
The presence of oxygen in the water favors the action; so too does car- 
bon dioxide. On the other hand, the presence of calcium carbonate con- 
fers a protective influence so long as the water remains free from acid. 
Nitrates and chlorides in water tend to corrode lead. 
Silicates possess protective properties. The plumbo-solvency of drinking water 
can be considerably reduced and the water rendered safe for personal and domestic 
purposes by the addition of fragments of limestone, magnesium limestone and chalk, 
to the filtering beds, but care must be taken even with these, since the addition of 
too large a quantity of chalk, for example, may be followed by results, the direct oppo- 
site to those which were expected. There is a limit in regard to the power for good of 
412 SOURCES OF LEAD POISONING 
413 
these alkaline earths which can only become known by testing the plumbo-solvency 
of the water two or three times a year. There is a difference too in the effect due to the 
age of the lead pipe. New lead pipes are more susceptible to the influence of water 
than those which are old. J. F. Liversuge and A. W. Knapp,1 as the result of a series 
of experiments found that when a new pipe containing water was closed for 17 hours 
about half the lead removed was dissolved in the first 4 hours and that the average 
amount of lead dissolved from pipes increased with time up to 44 weeks. After a 
year the age of the pipes gains little or no further protection. Different parts of a 
lead pipe yield different amounts of lead to water under similar conditions. This 
circumstance and that of temperature are partly responsible for the fact that the 
water removed from a tap in a certain part of a town may possess different plumbo- 
solvent powers to that drawn in another part of the town. It was found that the lead 
pipes made in Paris responded less to the influence of water than those brought from 
Nantes. Water drawn from one of the large hospitals in Paris was found to contain 
55 mg. of lead per liter, whereas water drawn in a house in a different part of this city, 
but at the same time of day, contained only 1.6 mg. of the metal. The presence of 
metals other than lead in the pipe induces electrolytic action which causes dissolution 
of lead. Where pipes contain lead, and antimony and tin have been substituted for 
ordinary lead pipes, the results have not been satisfactory. 
It is impossible to say definitely what amount of lead in drinking 
water is dangerous. Much depends upon the amount of water drunk by 
the individual. Water containing 1 to 2 mg. of lead per liter might have 
little influence upon a person who consumed 1000 cc. in 24 hours but the 
results would be different if 2 liters or more were drunk daily. Toxicolo- 
gists are of the opinion that water which contains 5 mg. of lead per liter 
is dangerous. It is the daily absorption of minute quantities of lead 
which is harmful to the organism. Since water standing in the pipes 
over night may have dissolved a considerable quantity of lead, the tap 
ought to be turned on and the water allowed to run every morning for a 
few minutes before it is used for culinary purposes. The drinking water 
for the table should be passed through a carbon filter rich in animal 
phosphate. 
Another accidental source of lead poisoning is food-especially tinned 
food. An acid fruit such as pineapple is particularly prone to attack the 
lead present in the solder of the tin. 
One of my worst cases of lead poisoning was that of a lady librarian. She suffered 
severely from colic and double wrist drop in consequence of having eaten almost daily 
for months tinned salmon. In consequence of finding lead in the albuminous urine 
of British soldiers during the recent war, I secured a few cans of the tinned meat which 
was supplied to the men on the Western Front. Lead was found in the meat but in 
such infinitesimal quantities that I could hardly regard the metal obtained from this 
source as the cause of "war nephritis." 
Persons addicted to the habit of snuffing occasionally suffer. One of 
my patients was in the habit of keeping the snuff in lead foil. Discovery 
of the cause soon led to disappearance of the symptoms. 
Industrial lead poisoning is extremely prevalent. It is not always 
diagnosed. Lead is used in some form or other in upward of 110 indus- 
tries. , 414 
LEAD POISONING: SOURCES, SYMPTOMS AND TREATMENT 
Lead Mining.-Although lead mining is an old British industry it is 
not a cause of plumbism owing to the fact that the metal in the ore is 
in the form of sulphide and therefore extremely insoluble. In this form 
the ore is known as galena. Where the ore exists as cerussite, in 
other words as an almost pure carbonate, miners have suffered 
severely in health. This occurred two to three decades ago at the 
Broken Hill Mines in Australia. Since the cerussite at Broken Hill has 
all been worked out and nothing remains but galena the occupation of the 
miner has become healthier.0 
Smelting of Lead Ore.-The risk of plumbism commences with 
smelting of the ore. There are several ways of smelting lead ore, the best 
known being the open hearth, or Scotch system, and the blast furnace. 
During smelting, fumes are given off which are rich in lead. In windy 
weather or when the flues are not drawing well there may be a down- 
draught so that the men can hardly avoid inhaling some of the fumes. 
Moreover, in the Scotch hearth system when the molten lead keeps pour- 
ing into the receiver or when the slag is being broken up the workman 
runs the risk of inhaling fumes or dust. The greatest danger the smelter 
runs is in cleaning out the flues. 
These are the long passages which carry away from the hearth or the blast furnace 
the vapor of lead combined with the carbon and ash particles given off by the coal or 
coke with which the ore is smelted. The fumes may contain as much as 60 per cent, 
of lead or more in the form of oxide and sulphate. The flues converge toward a high 
chimney situated frequently a mile away from the smelting works. The object of 
the length of the flue is to allow the fume as it travels to become deposited, with the 
view of recovering the lead contained in it. The flues may be underground passages 
built of brick or wood and be 4 to 6 ft. high so that a man can stand upright in them, 
or they may be underground galleries built of stone or brick with doors here and there 
so that men can enter the flues to recover the lead deposited. Formerly, more than in 
recent years, the fumes which escaped from the chimney stalk being rich in lead not 
only spoiled vegetation in the immediate neighborhood of lead smelting works but, 
becoming deposited on pasture land upon which cattle were grazing, caused the death 
of these animals and led to frequent litigation between farmers and owners of smelt- 
ing works. It is well known that wild birds are occasionally found dead in the vicinity 
of such works. The district around Linares in Spain, an important center of the lead 
industry, has become extremely barren. The goats on the hillsides have suffered con- 
siderably; when pregnant they drop their young before term. In consequence of this 
immaternity there is a difficulty of rearing goats unless they are removed to another 
locality. 
Cleaning out the flues is a dangerous occupation. Men enter them and remove 
the deposit, but it is a dusty occupation and even though the men when thus employed 
wear respirators, the fine dust passes through the respirator and makes the men ill. 
It is dangerous work. 
The men should not be allowed to work in a flue for more than 2 
hours at a stretch; they should then be off for 4 hours. The work causes 
severe headache, creates a disinclination for food, induces retching and 
sometimes vomiting. If the headache commences when the men are at 
work it continues all day. It is followed by a sleepless night and HAZARDOUS LEAD PROCESSES 
415 
frequently also by a rise of temperature. Where the flues are on the 
slope and water can be added to flush them into large reservoirs where- 
in the deposit can be silted there is less risk of the men becoming ill. 
A good illustration of this occurred recently at a large lead works in Newcastle-upon- 
Tyne. Last year three of the men after cleaning out flues were ill and were obliged 
to be off work for several days. It was summer weather. After the men had opened 
the man-holes of the flues and had worked therein for a few hours a violent thunder- 
storm broke over the city, accompanied by a deluge of rain. For 2 days the rain fell 
off and on. In cleaning out the flues afterward not one man was ill, owing to the large 
quantity of water which had entered the open man-holes. It had soaked through 
the deposit and made the removal of it attended with comparatively little danger to 
the men. Employes feel that they must recover the dust from the flues for it may 
contain as much as 30 per cent, of metallic lead. Tons of deposit are removed from 
flues. 
De-silvering of Lead.-The lead removed from the furnace is not 
always pure metal. It contains silver and occasionally antimony and 
gold. These, from a white lead manufacturer's point of view, are impuri- 
ties and have to be got rid of. Lead crystallizes at a higher temperature 
than a mixture of lead and silver. When these two metals are present 
together in the melting pot a crust forms on the surface which contains 
much silver and little lead. This is skimmed off from time to time and is 
remelted. On each occasion the crust becomes richer and richer in silver. 
Sometimes zinc is added to the melting pot as well. The crust, which is an 
alloy of the three metals, is skimmed off and the zinc extracted in a 
de-zincing furnace. Men employed as de-silverers suffer from plumbism. 
The smelting of zinc is an occasional source of plumbism owing to the 
lead frequently contained in zinc ore. Spelter, although seldom contain- 
ing more than 2 per cent, of lead, is a frequent source of plumbism among 
furnace men. During 5^ years, ending December, 1922, 77 spelter 
workers in South Wales alone suffered from lead poisoning. Two 
different types of symptoms are met with in spelter workers: bronchitis 
and gastrointestinal disorders, which are attributed to the zinc fumes, 
also nervous affections believed to be due to lead. 
Red Lead Manufacture.-Where red lead is made in the open hearth 
by raking up the molten metal and allowing air to become intimately 
mixed with it the resulting product, known as massicot, is a greenish 
looking substance which becomes yellow or yellowish red on being washed 
with water. Washing is resorted to in order to remove any unoxidized 
lead which may be present. After having been thus treated the massicot 
is replaced in the furnace and kept at a lower temperature when in conse- 
quence of further oxidation its color changes to a bright red. It is then 
known as minimum or red lead. During the raking of the molten metal, 
fumes escape by the open mouth of the furnace and, although this is 
always hooded, some of the fumes may be inhaled by the men. In the 
breaking up and in the packing of red lead, dust rises very freely. There 416 
LEAD POISONING: SOURCES, SYMPTOMS AND TREATMENT 
is an opinion that red lead is not dangerous. Such is not my experience. 
As regards harmfulness there is little to choose between it and white 
lead. In this opinion I am supported by the experience of E. R. 
Stitt,2 now Surgeon General of the United States Navy, who treated three 
seamen who were suffering from saturnine encephalopathy due to inhaling 
red lead dust rising from dried surfaces during the act of chipping off 
of old paint on torpedo boats preparatory to their being repainted. One 
of the men became insane and had to be taken to an asylum; another 
after having suffered from colic developed convulsions. All the men 
recovered.6 Red lead, equally with the carbonate, is capable of producing 
the most severe type of plumbism. In one-fourth of the men who 
are ill in consequence of having been exposed to red lead the symptoms 
are usually severe. The making of red lead in closed furnaces and 
conduits will do much to diminish the number of cases of plumbism due 
to minium. 
White Lead or Carbonate of Lead Manufacture.-There is still a 
great demand for white lead despite all that has been said and written 
against it. The manufacture of white lead in the United States of 
America was begun in 1777. Over 100,000 tons are produced in the 
States annually. In Great Britain the amount produced is 72,000 
tons. The two principal methods of manufacture are the "Dutch" 
and "Chamber" processes. 
In the Dutch process thin perforated plates of metallic lead called "grids or 
'wickets'" are placed upon the open mouth of earthenware jars containing a quan- 
tity of weak acetic acid. These jars are resting on a layer of tan bark and are arranged 
in rows in a large quadrilateral space one side of which is open. Over the plates of 
metallic lead, planks of wood are placed and upon these planks fresh tan is strewn 
and on the tan another layer of earthenware jars is deposited. By a series of tiers 
alternating in the manner described the "stack" or "blue bed" is built from the 
bottom upward. When each tier is completed planks of wood are placed across the 
open space leading into the stack. The outer doors of the stack are finally closed and 
kept closed for a little over 3 months. Within a few days of closing the doors the 
temperature inside the stack rises. This may be partly owing to the activity and 
reproduction of bacteria within the tan or it may be due to chemical change. The 
acetic acid volatilizes and, attacking the lead grids, it transforms some of the lead into 
acetate of lead. While this is taking place, fermentation occurs in the tan and carbon 
dioxide gas is generated. This reacts upon the lead acetate whereby it is converted 
into hydroxycarbonate, a basic compound containing two molecules of normal carbon- 
ate of lead in combination with one molecule of lead hydrate or lead oxide, the formula 
being 2P6CO3P6(OH)2. After having been closed for fully 3 months, and when it is 
believed that conversion of the metallic lead into white lead has become complete, 
the doors are opened and men enter to remove the "corrosion" as it is called. The 
process is known as "stripping the white beds," and as there may be considerable 
quantities of dust raised this particular kind of work is denied to women. 
In the Chamber process strips of metallic lead resting on bars are exposed to hot 
acetic acid vapor, also to carbon dioxide coming from burning coke. The doors of the 
chamber are hermetically closed and kept shut for from 50 to 60 days. Before 
the workmen enter a lead chamber to empty it,, steam must be injected to render the INCIDENCE OF LEAD POISONING 
417 
converted white lead less dusty and therefore less dangerous. The doors ought to be 
opened also for some hours before the men enter in order to reduce the temperature. 
Opinions differ as to the relative values of white lead manufactured by 
the Dutch and Chamber processes. The latter method of manufacture is 
more cleanly and the time required for the corrosion of the lead is shorter. 
House painters who have been in the habit of using white lead made by 
the Dutch process prefer it. The fact that 66 per cent, of the total 
quantity of white lead is manufactured by the Dutch process is of itself its 
strongest recommendation. 
Incidence of Plumbism.-Industrial lead poisoning claims fewer 
victims now than formerly. During 13 years, 1900 to 1912 inclusive, 
there were reported to the Home Office as having occurred in white lead 
factories 1393 cases of plumbism with 33 deaths, equal to 2.2 per cent. 
If the total number of cases of plumbism notified to the Home Office as 
occurring in all trades be taken, there were during the 13 years already 
mentioned 8523 cases with 394 deaths, or a percentage of fatal cases of 4.5. 
During recent years there has been a greater reduction of fatal cases of 
plumbism among white lead workers than in any other lead process, 
largely in consequence of the regulations issued and enforced by the Home 
office. In 1900 the largest number of cases of plumbism occurred in 
the white lead trade, viz., 358 with six deaths; in earthenware and pottery 
manufacture 200 cases were reported with eight deaths. In 1912 the 
manufacture of white lead no longer occupied the first place on the list. 
This position was taken by the earthenware and pottery industry. In 
coach and house painting the number of cases of plumbism has risen 
largely owing to the prosperity of the motor car industry. House 
painters suffer from plumbism mostly through inhaling dust given off 
during the sand-papering of flattened surfaces or from the vapor given off 
during the burning-off of old paint preparatory to repainting/ In the 
case of persons who have become ill by sleeping in newly painted rooms 
opinions have somewhat changed as to the cause of their indisposition. 
Until recently it was thought that the symptoms were those of plumbism, 
and where a blue line was present in the gums of those who were ill the 
diagnosis was probably correct. On the other hand the symptoms, 
severe headache, nausea and retching, developed too soon after exposure to 
paint for lead to be their cause. The symptoms must therefore be due 
to the inhalation either of the vapor of turpentine alone or combined with 
emanations from the linseed-oil. Baly of Liverpool attributes the 
malaise to the inhalation of certain aldehydes given off by lead paints. 
He found that lead oxide gave off more "unsaturated aldehyde" than lead 
carbonate. Henry A. Gardner3 did not find any metal present in the 
vapors given off by lead-painted surfaces. These vapors contain varying 
percentages of carbon monoxide and carbon dioxide, to the former of which 
he thinks the headache, vertigo and retching may be ascribed. Under 418 
LEAD POISONING: SOURCES, SYMPTOMS AND TREATMENT 
certain conditions, where traces of sulphuric acid are present, carbon 
monoxide is given off. In the blood taken from the heart of a guinea-pig, 
which I had exposed to vapors from a freshly painted surface, the spectro- 
scope showed the presence of carbon monoxide. 
The driers which are added to paints are to some extent, therefore, 
responsible for the symptoms complained of by people who have been 
living in newly painted houses. Turpentine is a drier, lead is another, 
so too are benzol, benzine and petroleum spirit. Benzol and benzine 
vapor cause disintegration of red blood corpuscles, also hemorrhages on 
mucous membranes, and tender inflamed gums, conditions which recall 
those observed in scurvy/ 
The outcry against the use of lead has, particularly in house and ship 
painting, been followed by the introduction of various substitutes. For 
leadless paints the demand has increased during recent years. Zinc white 
is being more widely used and for internal decorative purposes it answers 
quite as well as white lead, but for external purposes the majority of master 
painters prefer lead carbonate. They regard its covering properties and 
enduring powers as superior to those of zinc.® Lithopone, which is a mix- 
ture of zinc sulphide and barium sulphate, is also coming into repute in 
house painting. Space will not permit of a comparison being drawn 
between the various forms of paints. For internal decoration it may be 
said that zinc paints give all the covering power required and are freer 
from danger than lead paints, although on one well-known occasion 
several persons became ill where zinc paint had been used owing to the 
presence of arsenic, which is frequently present in zinc and which in this 
particular instance had not been removed after smelting of the ore. The 
ordinary paints in use have distinctly bactericidal properties/ Newly 
painted rooms may therefore be said to be more or less aseptic. 
Between 1900 and 1909 there were reported to the Home Office 1973 
cases of lead poisoning with 380 deaths of house painters. Paralysis of 
the hands and fingers is extremely common in house painters. Tancque- 
rel des Planches found paralysis present in 8 per cent, of lead-poisoned 
French house painters, Teleky in 14.5 per cent, of Austrian painters, and 
Legge in 22.7 per cent, of British house painters. In the United States it 
was found that one in every six painters gave a history of having had 
plumbism in one form or another, in other words 16.6 per cent. 
In 1898 the number of cases of lead poisoning in the China and earthen- 
ware trades had been so large as to call for Government intervention. 
The industry is chiefly located in the district known as the Potteries in 
Staffordshire. To the Potteries Sir Edward Thorpe and I were sent by 
the Home Secretary to enquire into the prevalence of plumbism among 
the potters and to make such recommendations as seemed desirable. 
When we visited Staffordshire in 1898 Sir Edward Thorpe and I found 
several of the small master potters using for their ware glazes which 
contained 20 to 30 per cent, of raw lead. Our immediate desire was to EFFECTS OF LEAD UPON THE BODY 
419 
reduce the percentage of lead used in the glaze, to have the lead fritted 
and therefore rendered more insoluble, to keep women away from the 
dangerous processes and, where possible, to substitute leadless for lead 
glazes. In a modified form some of these recommendations have been 
given effect to and have been of distinct benefit to the workers. The 
percentage of fatal cases of lead poisoning in persons employed in the 
manufacture of pottery is small; it is only 0.1 per cent, in persons employed 
in lead processes, in other words 1 in 1000. In the manufacture of 
earthenware and pottery the work-people most exposed to lead poi- 
soning are the dippers, dippers' assistants, ware-cleaners and majolica 
paintresses. It is when glaze containing raw carbonate of lead becomes 
dried, pulverized and raised into the atmosphere that it becomes 
dangerous. 
Space will not permit my mentioning the 111 industries in which 
Layet, a French physician, tells us that lead is employed. File-cutting 
need only be mentioned as one of those unhealthy industries, the manu- 
facture of electrical accumulators is another, so too are printing, lino- 
typing, calico dyeing and enamelling of metal plates. In file-cutting and 
printing other dangers are added. Tuberculosis claims from followers of 
those occupations a large number of victims. Lead predisposes to 
tuberculosis by reducing the vital resistance of the individual. Printers 
and file-cutters run the risk of becoming tuberculous mainly through the 
presence of tubercular colleagues and the fact that the work is carried 
on in rooms too highly heated. 
Men employed in a lead factory should neither chew tobacco nor 
smoke when at work. There is an impression among the men that chew- 
ing tobacco is a preventive against plumbism. Considering the oppor- 
tunities there are of loose tobacco in the waistcoat pocket coming into 
contact with lead dust, also the fact that it has to be fingered, there is 
nothing to encourage their impression. Experience points the other way. 
EFFECTS OF LEAD UPON THE BODY 
Channels of Entrance.-Through the skin lead can be, but is infre- 
quently, absorbed. I have seen persons become the subjects of plumbism 
through using cosmetics and hair dyes which contained lead? The main 
channels of entrance are the alimentary canal and the lungs. From an 
industrial point of view lead in the form of dust is the enemy to be 
guarded against. When inhaled, lead dust can reach the lungs and be 
absorbed from the respiratory organs, but most of it is caught in the naso- 
pharynx and is swallowed. The experiments of Professor Lehmann of 
Wurzburg and his assistant, Saito, show that when lead dust is inhaled 
only 12 per cent, reaches the lungs and that 70 per cent, is found in the 
alimentary canal. When men at work are not wearing respirators much 
of the dust enters by the mouth and being caught there is dissolved in 420 
LEAD POISONING: SOURCES, SYMPTOMS AND TREATMENT 
the saliva and swallowed. On reaching the stomach it is acted upon 
by the hydrochloric acid of the gastric juice and converted into chloride 
which is soluble and capable of osmosis. When it has reached the blood 
it is believed to enter into combination with the proteids and to become 
lead albuminate, rather an insoluble compound. On the whole, lead 
carbonate is more soluble in the gastric juice than is lead sulphate. 
If food is being digested at the same time less lead will be dissolved; 
hence the desirability of men never commencing work in the morning 
without first having had food. Lead undissolved in the stomach passes 
out in the feces in the form of an insoluble sulphide. Some of the lead 
which has reached the blood stream is eliminated by the kidneys. If not 
thus removed some of it may pass out into the tissues where, in the 
form of albuminate, it may remain for months or years doing no harm 
to the individual, until some change occurs in his metabolism when 
the lead becomes redissolved and on being reabsorbed causes symptoms 
of plumbism. 
Symptomatology.-One of the earliest signs that a workman is becom- 
ing influenced by lead is a gradually increasing pallor? The anaemia, 
which is fairly quickly progressive at first, reaches a limit and ceases to 
proceed farther unless it be toward a deepening cachexia. It might there- 
fore be expected that the blood would show on microscopical examination 
alteration of its structural elements. In a percentage of cases varying 
from 30 to 70 the red corpuscles or erythrocytes are modified. With any 
of the Romanowsky's stains several of the erythrocytes show numerous 
dark dots scattered through their contents. These punctated cells 
are spoken of as basophiles and when present in the blood in large number 
the condition is known as basophilia. Methylene blue gives satisfactory 
staining. The best results have been obtained by using a formula 
recommended to me by Dr. Glibert of Brussels. The fluid is composed 
of methylene blue, 2 grams; sodium bicarbonate, 12 grams; distilled 
water 200 grams. 
The film of blood when dried is steeped in absolute alcohol or alcohol and ether for 
half an hour, then dried, afterward steeped for 1 minute in the above solution, removed 
and washed in distilled water until the color almost fades, when it is dried and is ready 
for examination. 
Ehrlich, Grawitz and others maintain that basophilia is diagnostic of plumbism. 
Anything over 100 basophiles per 1,000,000 red corpuscles is regarded as absolute 
proof of lead poisoning. As it is met with in forms of ansemia in no way associated 
with lead poisoning, basophilia is not entitled to this unique claim. When present, 
basophilia is an important aid in the diagnosis, but it is frequently absent in cases 
where it ought to be present and it is present where it is least expected. I do not 
attach to basophilia the importance some physicians ascribe to it nor, on the other 
hand, do I underrate its value in certain conditions. It has not been found that baso- 
philia bears a direct relation to the length of time workmen have been exposed to lead. 
In workmen with a well-marked blue line on the gums and with confirmed pallor and 
who are the subjects of digestive derangements basophilia may be present, but in 
many instances a most careful examination of the blood fails to reveal more than one THE BLOOD AND THE GUMS IN LEAD POISONING 
421 
or two basophile corpuscles in the whole film. What basophilia is, whether a degen- 
eration or regeneration, and what its meaning, we do not know. In 1031 blood exam- 
inations made in the Leipzig Institute of Hygiene, basophilia was present in 187 
instances, i.e., in 18.1 per cent. Dr. John Russell has found basophiles in pottery 
workers varying in number from 100 to 27,000 per million. It is because of other 
substances, e.g., nitrobenzene and anilin, being able to cause basophilia, also of the 
presence of basophilia in some forms of ansemia and malaria, that we are disposed to 
consider the value of basophilia in plumbism as overrated. As opposed to Teleky 
who reminds us that basophiles are present in the blood of healthy persons, P. Schmidt 
states that if there are found 100 punctated erythrocytes per million red corpuscles, 
upon this fact alone a diagnosis of plumbism may be made. At the 1906 Congress of 
Industrial Diseases in Milan, Biondi declared that he had not found basophile ery- 
throcytes in the blood of persons suffering from severe lead intoxication. On the 
other hand, Lutoslawsky in 1902 announced that of 107 persons suffering from chronic 
plumbism only in 17 were there no basophilic corpuscles. 
It may be stated that those physicians who believe in basophilia as a sign of lead 
poisoning maintain that it is in the early stages of the malady that it is most pro- 
nounced. Yet even in this respect there is no uniformity. It is possible that just as 
there is an individual idiosyncrasy to plumbism, so in those who are becoming lead 
poisoned the blood of some persons, more than others, may exhibit a greater tendency 
to basophilia. The change in the red blood corpuscle stained greenish blue by the 
reagent which has been used reveals itself by numerous dark dots scattered through- 
out the corpuscles and is not the general bluish coloration of the corpuscle, which is 
known as polychromatophilia. In the anaemia of lead poisoning there is a distinct 
reduction in the number of red blood corpuscles. Instead of the normal 5,000,000 
erythrocytes per cu. mm. of blood there may be only 3,000,000 to 3,500,000 and with 
this fall in the number of red corpuscles there is a corresponding diminution in the 
amount of hemoglobin. Basophilia when present stands in no definite relationship 
to the amount of hemoglobin. It is detected in the blood of men who are following 
their occupation in lead works without discomfort and without other signs of plumbism. 
There is no Certifying Factory Surgeon who would on the mere detection of basophilia 
alone, irrespective of special reference to the extent of it, make it the reason for sus- 
pending a workman from the factory. In 70 per cent, of my cases of lead poisoning 
basophilia was absent. While, therefore, basophilia is an aid to the diagnosis of 
plumbism its absence is no proof that the malady investigated is not lead poisoning. 
In plumbism the white corpuscles of the blood are occasionally 
increased in the direction of a polymorphonucleosis, but on the whole it 
may be said that numerical and structural alterations in the leucocytes 
are not well marked. 
The Blue Line on the Gums.-The blue line on the gums is another of 
those signs which can be of valuable assistance when other signs or 
symptoms are present, but of itself it is no proof of the person being 
under the influence of lead. The line I refer to is situated at the margin 
of the gum close to the teeth. In color it varies from a light slaty blue to 
one of an intenser shade. Although mostly observed on the gums of work- 
men who are careless in the use of the toothbrush and whose gums are 
ulcerated, I have found it where the teeth were excellent and where the 
gums were healthy. It is not necessary, therefore, to have a preceding 
gingivitis to cause the line, although such a condition of the gums may 
predispose to it. 422 
LEAD POISONING: SOURCES, SYMPTOMS AND TREATMENT 
If the mouth of several workmen in a lead factory be examined, in the majority 
of them a blue line will be detected on the teeth close to the margin of the gums. This 
type of blue line is observed in men who are employed in a dusty lead process in the 
factory. It is not the true Burtonian line but is simply a deposit of sulphide of lead 
on the teeth, for if the toothbrush is applied or the mouth rinsed with warm water the 
deposit at once disappears. In the typical blue line described by Burton an actual 
deposition of lead sulphide has taken place in the cells of the deeper layers of the gum- 
cells known as phagocytes. No brushing of the teeth can readily remove this line. 
It may persist for weeks or months. It is due either to lead which has been dissolved 
in the saliva or to lead which has been absorbed and brought to the gums by the blood 
stream, becoming acted upon by the sulphocyanide of potassium present in the 
mouth, or by sulphureted hydrogen evolved during the decomposition of particles 
of food retained between the teeth and being taken up by the phagocytic cells of the 
gums. 
A blue line on the gums is of great value in diagnosis when other signs 
are also present. Even where other signs or symptoms of plumbism are 
absent it is of importance to note its presence since succeeding events 
may reveal its origin and meaning. 
In persons, for example, who are taking large doses of bismuth or who are having 
fistulous wounds injected with bismuth paste a blue line may appear in the gums 
practically indistinguishable from that caused by lead. During the war I have seen 
several instances of a bright blue line on the gums, also on the inner side of the lower 
lip, with difficulty distinguishable from that of plumbism, in soldiers who had had 
their wounds packed with bismuth and iodoform paste. Eliminating such possi- 
bilities, persistence of a blue line on the gums after the use of the toothbrush is a sign 
not so much of lead poisoning as of lead in the system and that at any time, consequent 
upon altered metabolism, other signs or symptoms of plumbism may show themselves. 
The diagnostic value of the blue line on the gums must therefore neither 
be overrated nor underrated, since in many cases of undoubted plumbism 
it is absent altogether. No investigation however of a suspicious case of 
lead poisoning would be complete which did not include an examination 
of the gums. 
Occasionally in addition to a blue line on the gums there may be 
observed inside the lip or on the inside of the cheek, opposite a decayed 
tooth or one covered with tartar, a bluish-black patch the size of a three- 
penny piece or larger. The edges of the patch are irregular. It is due to 
friction of the mucous membrane against the unhealthy tooth. This patch 
is confirmatory evidence of plumbism, but only when the administration 
of bismuth, for example, can be excluded. In copper workers a greenish- 
blue line is frequently present on the teeth. This line is not, as in plum- 
bism, in the gums. In pyorrhea alveolaris the gums occasionally exhibit 
a delicate blue coloration, but it is more of a gentle shading than a definite 
line. 
Colic and constipation are early symptoms of lead poisoning. For 
several days before the onset of abdominal pains a patient may have 
experienced a disagreeable taste in the mouth. He may have complained 
of an unpleasant metallic taste and of an accompanying loss of appetite. CARDINAL SYMPTOMS OF LEAD POISONING 
423 
Without further warning he is seized with severe pain in the abdomen 
usually in the neighborhood of the umbilicus. The abdomen is tender to 
the touch, although in a few instances relief is obtained by pressing the 
abdomen. The pain is sometimes so severe that the patient is with 
difficulty restrained. Vomiting may or may not be present. In other 
other instances previous to colic there may be obstinate constipation. 
The bowels may be closed for a week and opened only with the greatest 
difficulty by the aid of medicine. Constipation usually attends upon colic, 
but severe abdominal pain may continue after the bowels have been 
relieved by medicine, and even where there is diarrhoea. During colic, 
Riegel found a high blood pressure which he attributed to constriction of 
the arteries in the splanchnic area, but in many of my patients during 
the height of the pain the blood pressure was low,, the pulse feeble and slow 
-only 30 to 40 beats per minute. The secretion of urine falls to 4 and 6 
oz. for the 24 hours. The cause of lead colic is obscure. In experimental 
plumbism I have found the intestinal canal in places so constricted 
by muscular spasm as to have the caliber completely obliterated. The 
pain might, therefore, be due to this muscular spasm or it might be the 
result of an effort on the part of the intestine above the constriction to press 
onward the contents into the contracted portion below. Colic can hardly 
be due to constipation and strong peristaltic contraction of the bowel to 
propel the contents onward, for as already stated the pain persists when 
there is diarrhoea. In the course of 2 or 3 days the severity of the abdom- 
inal pain is mitigated but there still remains uneasy painful sensations 
which become aggravated on pressure, usually worse on one side of the 
abdomen than on the other. Accompanying this type of pain there is 
inequality of the radial pulses, inequality of the pupils; also pain is 
complained of when pressure is made along the course of the vagi nerves 
in the neck. There may be also unilateral sweating of a limb. 
Lead colic has been occasionally mistaken for appendicitis and the 
abdomen opened by a surgeon only to find the diagnosis of appendicitis 
unconfirmed. 
Other maladies occurring in persons employed in lead processes have been certified 
as lead poisoning. While writing these pages I was requested to attend at an autopsy 
on a house painter, who after complaining of acute abdominal pains died a few hours 
afterwards. The doctor who saw him stated that death was due to lead poisoning, 
but as I pointed out that plumbism is hardly, if ever, fatal during an attack of colic, 
a post-mortem examination was ordered by the coroner. We found a perforated 
gastric ulcer, with acute peritonitis. There was a faint blue line on the gums. ' 
Headache.-When present in plumbism headache is usually severe. 
The pain is not confined to any particular part of the head. It may or 
may not be associated with albuminuria. When there is albumen in the 
urine the headache is probably uraemic, but in a great many persons 
the urine is quite free from albumen. The headache is toxaemic none the 
less, and may be due to lead itself or to poisonous substances formed in 424 
LEAD POISONING: SOURCES, SYMPTOMS AND TREATMENT 
the body as the result of the action of lead upon the internal organs. 
Frontal headache may be neuralgic and associated with arterial spasm. 
Severe headache is occasionally the forerunner of delirium or convulsions. 
When convulsions occur in a lead worker they are of grave significance. 
They may develop without albumen being present in the urine. Con- 
vulsive seizures attended by coma constitute what is known as saturnine 
encephalopathy, the most fatal form of plumbism. In females saturnine 
encephalopathy may be preceded by symptoms suggestive of ordinary 
hysteria, but the symptoms must not throw the medical attendant 
off his guard since toxic hysteria frequently gravitates into a more pro- 
found affection of the central nervous system. 
Albuminuria may be present as an early sign of plumbism during or 
after an attack of colic and it may disappear, but in a large percentage of 
patients who are the victims of chronic lead poisoning it persists and is 
accompanied by changes in the blood-vessels and the heart. The arterio- 
sclerosis may be accompanied by an elevated blood pressure. To old 
lead workers death frequently comes by cerebral hemorrhage and at the 
autopsy in addition to the cerebral lesions the kidneys are found con- 
tracted. Interstitial nephritis is the condition of the kidneys found in 
the late stages of the disease, but in the early stages and in the more 
acute forms of the malady the lesion affects more the cells which line the 
renal tubules/ The urine of lead workers frequently contains lead. 
War Nephritis and Lead Intoxication.-In 29 samples of urine of 
soldiers under my care in the Northumberland's War Hospital, lead was 
found by Mr. T. M. Clague in 9 instances, that is, in 31 per cent. 
The urine of a young corporal with a bullet in his right thigh contained lead, that of 
a soldier with shrapnel in his knee, and the urine of a young lieutenant, who was 
mortally wounded, the shrapnel lying in his pelvis, also contained lead. In the 
urine of a considerable number of the soldiers similarly held there was also albumin. 
There was at least in one case a distinct association between the retention of a piece 
of projectile and the kidney trouble. In the upper part of the left thigh of a soldier 
was imbedded a piece of shrapnel, the wound kept closing, opening and discharging, 
the patient meanwhile suffering from recurrent hsematuria and albuminuria. Under 
a local anaesthetic the piece of shrapnel was removed, the temperature gradually fell, 
the wound readily closed, the albuminuria disappeared entirely and permanently, 
and the patient made a good recovery. 
It was C. Powell White who first drew attention to lead in the urine in 
war nephritis. As I had seen several soldiers with pieces of projectiles 
in their body become anaemic and their wounds heal slowly, also albu- 
minuria develop, it seemed to me to be worth trying to ascertain the 
solvency of lead projectiles in animal fluids. 
Loeper and Verpy had found lead in the urine of 6 out of 16 soldiers to the 
extent of M to 1 mgm. per litre of urine. The men were passing by the kidneys 
1 mgm. of lead in 24 hours - a small quantity but sufficient in time to derange the 
function and probably alter the structure of the kidneys. PECULIAR ACTIONS OF LEAD IN THE BODY 
425 
Absorption of metallic lead from a bullet in the body is slow. It 
was not until 3 to 4 weeks after soldiers had been wounded that I found 
lead in the urine. That absorption was taking place was occasionally 
indicated by a gradual rise of the blood pressure, presence of albumin in 
the urine, decrease in the number of red blood cells with or without 
complaint of colic and constipation. 
In conjunction with Mr. T. M. Clague and Mr. A. T. Watson we found that if 
lead bullets were placed in the blood serum of sheep and macerated at a gentle tem- 
perature for 7 days, one million parts of the serum contained 10 of lead. In neat's- 
foot oil the amount of lead dissolved was 200 parts per million, in olive oil 100, in 
lard 5 and in suet 6. Pus has a solvent action upon lead. After exposing bullets to 
the influence of pus from a case of empyema for 48 hours at a temperature of 40°C. the 
pus contains 12 parts of lead per million. 
Lead bullets and shrapnel retained in the body can thus become a 
source of plumbism or of such a condition of bodily health, as may explain 
why wounds, apart from the circumstance of a foreign body do not 
heal readily. 
In female lead workers menstruation is increased; in those who are 
pregnant the tendency is for miscarriage to take place. The only possible 
way for a pregnant female to reach full term is to retire from the 
work "at the earliest possible date. I am disposed to believe that one 
of the reasons why females are more readily influenced for harm 
by lead than men is the peculiar action of lead upon the reproductive 
organs? 
Cerebral plumbism has occasionally been diagnosed as tumor of the 
brain and a portion of the calvarium has been removed to give relief to the 
headache and pressure. The symptoms are not unlike cerebral tumor: 
there are severe headache, vomiting and possibly, too, retinal changes. 
Should the patient who has been the subject of convulsions recover, it 
may be that the eyesight is lost. 
The loss of vision in lead poisoning is threefold: (1) There are no intraocular 
changes observed in the retina; (2) the discs are hyperaemic, swollen and mottled and 
their edges are irregular, the outline of the vessels is obscured and there are retinal 
hemorrhages; and (3) there are delicate white lines external to the retinal vessels, 
there are hemorrhages, and albumen is present in the urine. In the first form of loss 
of vision the cause is toxic or there is spasm of the arteries, for vision may be soon re- 
gained and no after-effects be left behind. In the second form we have the typical 
amaurosis of lead poisoning, viz., retinal hemorrhages and swollen discs. Here vision 
may never be quite regained. When formerly women were allowed to work in the 
white lead factories saturnine encephalopathy followed by loss of sight was not of infre- 
quent occurrence. Since women have been excluded from the dangerous processes 
of lead manufacture this severe type of plumbism has almost entirely disappeared. 
It is not exactly known how the intraocular changes- are brought about. Some 
physicians are of the opinion that lead induces effusion into the subarachnoid space of 
the brain and thereby causes distention of the sheath of the optic nerve with pressure. 
In one of my patients who died from saturnine encephalopathy there was found on 
microscopical examination of the optic nerve round-celled infiltration of the fibrous 426 
LEAD POISONING: SOURCES, SYMPTOMS AND TREATMENT 
trabeculae between the bundles of nerve fibers, the infiltration being most marked at 
the posterior portion and for some distance behind the lamina cribrosa. 
In persons dying from acutej plumbism with nervous phenomena small 
hemorrhages were found by Mosny of the Hospital St. Antoine, Paris, 
in the cortex of the brain. Miliary hemorrhages were found by F. W. 
Mott in the perivascular sheaths of the small vessels of the cortex and 
in the substance of the brain in a coach painter who had epileptic seizures. 
Goadby also found minute hemorrhages at the base of the brain and the 
vertex. 
Nervous System.-Lead exhibits a predilection for nerve tissue. 
Not only are the peripheral nerves liable to become affected but the cells 
of the central nervous system as well. Within recent years, owing to the 
great improvement in the conditions of labor in lead factories, opportuni- 
ties for studying the pathology of acute plumbism have become extremely 
rare. We are familiar with the paralyses of the fingers and hands 
which take place in lead workers, but persons thus afflicted seldom die 
in this stage of the illness. Paralysis of both wrists, the so-called wrist- 
drop, is characteristic of lead poisoning. Usually both hands are affected, 
a circumstance which suggests that a general cause such as a toxaemia 
has been in operation. Occasionally, however, one wrist alone is affected 
but the other will probably be found to be paretic. Generally speaking, 
the paralysis is more marked on that side of the body, the muscles of 
which are more actively employed. Teleky therefore thinks that fatigue 
is a contributory cause of the paralysis of plumbism. The influence of 
previous muscular strain cannot be altogether ignored. It has generally 
been taught that the loss of power in the muscles in lead paralysis is due 
to a lesion of the peripheral nerves, an interstitial neuritis; but Goadby, 
finding minute hemorrhages in groups of paralyzed muscles of which 
strain at work may have been a cause, as well as minute hemorrhages 
in the nerves supplying those muscles, regards the lesion as neuro-muscular. 
The common type of paralysis found in lead workers is "wrist-drop." The 
patient is unable to extend the wrists. The muscles involved are the extensors of the 
wrists, the interossei and extensors of the fingers. The supinators usually escape. 
This form of paralysis renders the individual extremely helpless. In the brachial 
type of paralysis the deltoid, triceps, brachialis anticus and supinator longus are 
affected along with the supra and infraspinati. In yet another form, the Aran-Duch- 
enne type, the muscles affected are those of the outer border of the hand, also those 
of the thumb including the interossei. Accompanying these there are such atrophy 
and fibrillary tremor as to suggest progressive muscular atrophy. Although lead 
paralysis usually affects the muscle of the upper extremity in correlated groups yet it 
may be irregular, more on one side than the other; also in children the peroneal muscles 
and the extensors of the toes may be the only muscles involved^ The greater liability 
of children, when subjects of plumbism, to paralysis of the lower extremities should be 
borne in mind. The circumstances may be explained by the theory that in children the 
muscles of the legs are more actively employed than those of the arms and therefore 
more likely to become fatigued. When there is loss of power in the lower extremities, 
the tibialis anticus as a rule escapes. The peroneal type of lead paralysis may LEAD POISONING SIMULATING SYPHILIS 
427 
occur alone or it may be associated with wrist-drop. I have seen this form of loss of 
power in the adult as part of a widely distributed paralysis in which the muscles of the 
limbs, the back and pelvis were involved. Such widely distributed paralysis is 
extremely dangerous owing to the possibility of the intercostal muscles becoming 
affected and of respiration being rendered almost impossible. Fortunately my own 
patients recovered, but death is known to have come from respiratory paralysis. 
The muscles of the larynx may become affected, also those of the bladder, but a much 
more frequent development is paralysis of the muscles of the eyeball causing 
diplopia. 
Persons who are working in lead or who are the victims of plumbism 
frequently complain of ill-defined pains in the limbs. The pains are 
spoken of as rheumatic. They may possibly be due to limited patches of 
neuritis. Occasionally before wrist-drop occurs, pain in the arms is com- 
plained of but once paralysis is developed pain is not a common complaint. 
The reflexes are not uniformly affected. They may be increased; more 
frequently they are diminished. Tremor of the labio-facial muscles is 
common and can be usually demonstrated by asking the individual to 
show his teeth. 
Simulation to Syphilis.-In a few male lead workers of 35 to 45 years 
of age, who have signs of plumbism, there develops an uneven gait, slow 
and interrupted speech, fibrillary tremor of the tongue and of the nasola- 
bial muscles, defective memory and unequal pupils. The knee-jerks are 
diminished or absent. The symptoms suggest general paralysis but there 
is nothing of the exaltation of ideas nor the uncertain temper met with 
in ordinary general paralysis. Saturnine pseudo-general paralysis can 
be recovered from. This circumstance marks it off from the better known 
malady. Practically all general paralytics, in consequence of the syphilitic 
origin of their illness, give a positive Wassermann reaction. Many lead- 
poisoned patients respond in a similar manner but while the Wassermann 
reaction complicates matters it does not prove that the pseudo-general 
paralysis of plumbism is of specific origin. Through the kindness of Dr. 
Irvine, Dr. Slade, Bacteriologist Royal Victoria Infirmary and I have been 
able to examine several men and women in a lead factory in regard to 
Wassermann reaction. In our first examination 11 men varying in age 
from 23 to 58 were taken-4 of them had a well-marked blue line. In 8 
of these men the results were positive; in 3 negative. In another series 
of different workmen, some with blue lines on gums, 4 gave positive results 
and 7 negative. Of 9 female lead workers 2 gave a positive reaction and 7 
negative. In another series of examinations of 8 male workers 3 gave a 
positive reaction and 5 negative. Of 39 lead workers thus examined in 
the factory 17 gave a positive Wassermann reaction and 22 a negative, 
the percentages being 43.6 and 56.4 respectively. It would almost seem 
as if a slowly developing plumbism and not latent syphilis was respon- 
sible for the positive reaction in some of these cases. The absence of a 
specific history on the part of a patient is of no importance in the diagnosis 
of syphilis but enquiry into the past with a careful appreciation of the 428 
LEAD POISONING: SOURCES) SYMPTOMS AND TREATMENT 
present conditions is a guide. In the largest percentage of the male and 
female workers who gave a positive reaction, syphilis, in my opinion, 
could be excluded. It is an interesting fact that a lead patient who gives 
a Wassermann positive reaction may later on return a negative. The 
precise meaning of a positive Wassermann reaction in a large percentage 
of lead workers is not yet forthcoming. It must always be borne in mind 
that lead workers are like other people, not free from syphilis, so that 
while in some instances a lead-poisoned person is also syphilitic, a circum- 
stance to which the symptoms suggesting general paralysis may justly 
be attributed, there are others presenting similar symptoms who neither 
are nor have been the subjects of syphilis. 
Time Relations in Plumbism.-When and how long after exposure 
to the metal either in the form of dust or fume, symptoms of lead 
poisoning will show themselves it is impossible to say. In patients by 
whom diachylon has been taken with the object of inducing abortion, it is 
usually 2 or 3 weeks before such a sign as paralysis appears, eventhough 
the patient may have had colic for several days. Much depends upon the 
susceptibility of the individual to lead and in the case of lead workers to 
the amount of dust or fume he is exposed to. Some persons are more 
readily influenced by lead than others. Females and young persons are 
more predisposed to plumbism than males and persons of mature years. 
One of my patients developed signs of lead poisoning 1 week after making 
electrical accumulators in a small room. Dr. Alice Hamilton found in a 
hospital a white lead worker suffering from colic and neuritis. He had 
worked in the factory only 3 days. Of 120 patients whom she examined 
8 had become ill in less than 2 weeks after commencing work, 36 in less 
than a month and 89 in less than a year. 
Colic may occur early in some persons, 1 to 6 weeks after exposure to 
lead. There is no stated time for signs or symptoms to appear. It is 
largely a question of individual predisposition and dosage. 
Toxicity of Lead.-Equally difficult is it to state the amount of lead 
which is capable of creating ill health. All physicians, however, agree that 
plumbism is much more likely to develop and the symptoms to be more 
severe when small doses of the poison pass into the body over a lengthened 
period of time than when only one or two large doses are taken. The 
system can absorb only minute quantities of lead at a time. When, 
therefore, one or two large doses are taken, the bulk of the poison is 
expelled in the faeces. As regards drinking water, Angus Smith and Pro- 
fessor Rubner tell us that 0.36 mg. of lead per liter of water is the limit of 
safety. In the famous Orleans case of 38 persons living at Castle Cler- 
mont, 13 became ill after having drunk during a period of a few months 
water which contained 0.2 to 1.5 mg. of lead. Teleky is of the opinion 
that if 1 mg. or a little more of lead is taken daily for several months, it will 
cause plumbism. A daily dose of 10 mg. would, in the course of a few 
weeks, be followed by serious symptoms.m LEAD TOXICITY-DIAGNOSIS OF LEAD POISONING 
429 
The bulk of industrial lead poisoning is caused by persons breathing 
fumes or inhaling dust. Kaup found in the air of the drying ovens in a 
white lead factory, taken at the level of the face of the workmen, 0.134 
mg. of lead. Muller found in the air of a lead smelting works 236.8 mg. of 
lead in 100 liters of atmospheric air. As during a working day of 10 hours 
4.5 cubic meters of air could be carried into the lungs there would be 
inhaled amounts of lead varying from 6 to 25.2 mg. Similarly, as in 
paint mixing and dry color grinding, there may be 0.178 to 0.25 mg. of 
lead per 100 liters of air, workmen thus exposed run the risk of becoming 
lead poisoned. When we add to the above, the dust adherent to the fingers 
and hands, the hair and moustaches, also the clothing and boots of work- 
people, the opportunities of plumbism are many. 
Whether it is absorbed through the lungs or through the stomach and 
upper part of the small intestines, lead enters into loose alliance with the 
proteid of the blood, forming an albuminate, rather an insoluble com- 
pound. This remains soluble in a neutral solution but the slightest 
degree of acidity or alteration of alkalinity as already stated tends to render 
it insoluble, a circumstance which explains the inertness of lead albuminate 
when deposited in the tissues-also the fact that lead which has lain long 
latent in the system and caused no symptoms suddenly and unexpectedly 
gives rise to these in consequence of altered metabolism. Since the bulk 
of lead which enters the body has passed in through the alimentary canal, 
the liver and spleen after death are the organs which are found to contain 
it in largest quantities, but lead is also found in the brain, muscles and 
kidneys. 
Diagnosis.-The diagnosis of plumbism may be comparatively simple 
or, owing to anomalous symptoms, it may be extremely difficult and espe- 
cially is this the case in industrial lead poisoning where the question of 
Workmen's compensation is concerned. Given a history of exposure to 
the metal, a blue line on the gums and a history of colic with or without 
wrist-drop there can be little or no doubt about the diagnosis. The cases 
which are obscure are those in which there is no history of exposure to 
lead and no blue line on the gums but a story of indifferent health, of 
headache and anaemia, with, it may be, paralysis of the muscles of the 
eyeball. Microscopical examination of the blood may reveal basophilia 
which, if not due to a recognizable form of anaemia, will be of assistance 
in coming to a determination. The detection of lead in the urine is of 
greater importance. It does not follow, however, because lead is found in 
the urine that therefore the case is one of plumbism for the man or woman 
may not be ill but it shows that lead is in the system, is being eliminated 
and that a check to elimination might at any moment be followed by 
active signs and symptoms of the malady. The harboring of lead within 
the body, or its elimination by the urine and feces in small quantities 
without the individual being ill places him in the same position as a typhoid 
carrier. A female lead worker will, for example, bring forth a still-born 430 
LEAD POISONING: SOURCES, SYMPTOMS AND TREATMENT 
infant, or a child who dies a few hours after birth, in whose organs lead is 
found on chemical examination, without herself having shown either 
signs or symptoms of plumbism. In patients who have become ill through 
drinking water contaminated by lead there may be none of the ordinary 
symptoms of plumbism. There may be gradual loss of health, headache, 
sleeplessness, inability to apply oneself to work, deranged appetite and 
extreme depression of spirits without any blue line on the gums or history 
of colic, without basophilia too, and yet traces of lead may be found in the 
urine. Then, too, it may be that after attacks of recurrent abdominal 
pain had been diagnosed and treated as dyspeptic, the individual devel- 
ops gout and albuminuria which are indirectly the result of the action 
of lead. 
Treatment.-The treatment of lead poisoning is preventive and 
curative. Drinking water gathered in a peaty soil should have its plumbo- 
solvency tested two or three times a year and dealt with accordingly. 
Various suggestions have been offered whereby substitutes may be found 
for lead pipes, but none of them are readily taken up by architects. In 
lead factories everything possible must be done to prevent the escape of 
fumes and dust into the atmosphere of the place when work is being 
carried on. Exhausts should be introduced • wherever possible. This 
recommendation is better than the wearing of respirators. The work- 
people themselves can be of great assistance by keeping themselves 
clean, taking warm baths frequently and never touching food without 
first washing the hands and rinsing the mouth. Females should not be 
allowed to work in the dangerous processes of any lead industry. Almost 
the first complaint for which a lead worker seeks advice is colic. Previous 
to this, friends may have observed that such and such a workman was 
becoming ansemic, but at this stage of the development of plumbism it is 
rare for medical advice to be sought. Formerly in lead works, in the 
hope of warding off colic, employers supplied the work-people with an 
acid lemonade in which magnesium sulphate was dissolved. It was of 
doubtful benefit. The good effected was mostly through the beverage 
acting as an aperient. It gave a false security to the workers. In some 
lead factories tabloids of calcium sulphide, 1 grain, are given almost 
daily to the men. Whether in consequence of, or despite, this simple 
prophylaxis, it must be stated that the men in these factories have kept 
remarkably well in health. 
When colic is severe the patient must be kept warm in bed, if possible, 
and hot applications applied to the abdomen. As there is usually consti- 
pation an enema may be given or a dose of castor oil administered by the 
mouth. In severe cases of constipation accompanying colic, should the 
castor oil or any other aperient not have acted, 1 drop of croton oil on a 
piece of sugar may be given by the mouth. Sometimes the pain is so 
excruciating that morphine has to be injected. The abdominal pain 
can be relieved by the administration of sodium mono-sulphite in or TREATMENT OF LEAD POISONING 
431 
1-grain doses thrice daily. Dr. Stevens of Cardiff has found the internal 
administration of ^-grain dose of calcium permanganate helpful. 
For colic and constipation a mixture of potassium iodide and sulphate 
of magnesium with a bitter is much resorted to. Care should be 
taken in the administration of potassium iodide that the dose to commence 
with is small, for potassium iodide has the power of dissolving lead lying 
inert in the tissues, of causing it to be reabsorbed, and as this circulates 
through the body it may induce a fresh attack of plumbism. To the 
iodide and magnesium sulphate mixture 5 drops of tinct. nux vomica with 
a carminative may be added." Massage and electricity should be pre- 
scribed in cases of paralysis which are recovering slowly. During epilepti- 
form seizures the bowel should be washed out with mustard and warm 
water, a tablespoonful of mustard to a pint of water, and afterward a 
small enema containing 30 or 40 grains of bromide should be admin- 
istered per rectum. 
For chronic plumbism and where there are anaemia, albuminuria, 
headache, loss of vision and oedema of feet the medical treatment resolves 
itself largely into one of symptoms. It is not absolutely necessary in 
every instance, when albumin has been found in the urine of old lead 
workers who have no symptoms, to suspend these men fronremployment. 
Removal from work will not effect a cure. These men live longer and are 
happier if they are allowed to go to the factory, do light work when there 
and receive wages for doing so. 
In addition to the above another method of treatment can be recom- 
mended, especially for lead workers. It is both preventive and curative, 
known as the Clague-Oliver method-it is an extension of the electrical 
treatment. 
The object to be obtained is primarily removal of lead from the body if any be 
present therein, and secondly the bracing up and stimulating effect of the electricity. 
The story of the double electrical bath treatment is briefly this: I had produced 
experimental plumbism in a rabbit. The animal was paralyzed in its limbs. It 
struck me as the animal had received a considerable quantity of lead by the mouth 
that if the metal could be removed from the body it might recover. Accordingly I 
consulted with Mr. T. M. Clague of Newcastle-upon-Tyne, and he suggested that by 
means of a double electrical bath we might succeed in accomplishing this object. 
Placing the forelimbs of the animal in one bath containing an electrode (positive) 
and the hind limbs in another containing another electrode (negative), the chest 
and abdomen of the animal resting on a pad of cotton between the two baths, a current 
of 15 volts and a milliamperage of 20 was allowed to pass through the animal for a 
little less than an hour. In the course of a few baths the paralysis had disappeared 
and the animal was quite well. On chemical examination of the electrodes and the 
bath-water lead was found. Subsequently lead was administered to the animal and 
again it became paralyzed. Double electrical treatment soon restored the animal 
to health again. Several months afterward lead was again given to the rabbit 
and for a third time it became paralyzed. No bath was given; the animal died. 
From its spleen and liver lead was extracted. Altogether, in the course of 3 years this 
animal had received by the mouth 1,096 grains of nitrate of lead, the equivalent of 
684 grains of metallic lead. Having succeeded in restoring to health an animal 432 
LEAD POISONING: SOURCES, SYMPTOMS AND TREATMENT 
which had been poisoned by lead it seemed that in industrial lead poisoning there was a 
possible field for the application of the double-bath electrical treatment. I have tried 
it in many cases with encouraging results. Under its influence the blue line on the 
gums disappears more quickly than with medicine, paralysis is recovered from more 
quickly and the duration of colic is shortened. Dr. Patterson of Philadelphia has 
had unusual success in the treatment of colic by it. As a preventive an electrical 
bath taken once a week, or at the most twice a week, keeps the work-people in better 
health than the use of the weekly warm full bath recommended by the Home Office. 
A lead worker who is absorbing the metal keeps free from symptoms owing to the fact 
that the daily elimination of lead from his body remains equal or is slightly larger than 
the intake. The double electrical bath favors elimination. The drawbacks to it are 
that where the skin is in contact with the salt water there may be slight irritation or 
itching of the skin; a mild dermatitis may follow. If the bather repeatedly keeps touch- 
ing the electrode with his hand or foot there may be painful redness followed by 
superficial ulceration. It might be thought that if by electrolysis lead can be removed 
from the body, other metals useful to the economy, e.g., iron, might also be removed. 
Experiment shows that lead is the more electrolizable of the two metals and that lead 
is not only the first metal to be removed but that it always comes away in larger 
quantity than iron. It is desirable to let the work-people have the bath at the close 
of the day's work since they can go home afterward and take matters quietly for a 
period. As a preventive the bath should be given for at least 15 to 20 minutes once 
a week; as a curative agent it should be taken every second or third day. 
Quite apart from the debatable point of whether lead is or is not 
removed from the body, the electrical baths have a distinctly bracing 
up and stimulating influence upon the workers. It is at any rate a line 
of treatment well worthy of a prolonged trial but, like all other forms of 
treatment, suitable cases, that is, those with not too advanced structural 
alteration of organs, should be chosen. 
REFERENCES 
1 The Action of Water on Lead Service Pipes. Public Works, Jan., 1914. 
2 U. S. Naval Medical Bulletin, Apr., 1912, page 161, Washington, D. C., Government 
Printing Office. 
3 Bulletin No. 41,1914, Paint Manufacturers' Association of the United States. 
REFERENCES TO APPENDIX 
N. B.-For references a to n in this Section, see Appendix IV, pages 1072-3. SECTION 10 
EARLY DIAGNOSIS OF LEAD POISONING 
BY H. LINENTHAL, M. D., Boston, Mass. 
Early diagnosis, important in every case of ill health, assumes especial 
importance in those diseases which are preventable, and in which the 
interest of public health demands that measures be taken to eradicate the 
conditions which give rise to them. The importance of early diagnosis in 
communicable diseases has been dwelt upon repeatedly in recent years. 
In tuberculosis, for instance, we have learned that our only chance of 
arresting the disease, of restoring the patient to health, and of removing 
a focus of infection is to recognize the disease in its incipiency. Like- 
wise, the early diagnosis of cases of typhoid fever, scarlet fever, diphtheria 
and other communicable diseases may call attention promptly to the 
source of infection and prevent the occurrence of many other cases. 
With equal force does this apply to occupational diseases. We must 
learn to diagnose them in their incipiency if we would protect the worker 
from the more serious manifestations of these diseases, and if we would 
institute preventive measures against the occurrence of other cases. 
Lead intoxication, on account of the great variety of industries in 
which the metal or its salts are used, is the most prevalent of occupational 
diseases. While the diagnosis in a well-marked case is usually not diffi- 
cult, it may not be so clearly defined in the early stages of the intoxication. 
The tendency among physicians generally is not to make the diagnosis 
unless the objective signs are found which are supposed to be pathogno- 
monic of the disease. This tendency to postpone the diagnosis in the 
absence of certain objective signs is dangerous and often does incalculable 
harm. The physician who fails to recognize tuberculosis, for instance, 
without the presence of tubercle bacilli in the sputum very often fails to 
avail himself of the opportunity of arresting the disease in its incipiency. 
The same is true of lead poisoning. The waiting for certain signs before 
establishing the diagnosis may permit the poison to undermine the con- 
stitution of the worker beyond any remedial measures, and may delay 
preventive measures against the source of the intoxication. The objec- 
tive signs supposed to be pathognomonic of lead poisoning, the presence 
of one or more of which is still regarded by many physicians as absolutely 
necessary before a diagnosis can be made, are the lead-line on the gums, 
basophilic degeneration of the red cells and the presence of lead in the 
urine and stools. 
433 434 
EARLY DIAGNOSIS OF LEAD POISONING 
The technical difficulty of testing for lead in the urine and stools is so 
great as to preclude such a test from a part of the routine examination in 
general practice. Moreover the presence of lead in the excretions is not 
constant even in well-marked cases of lead poisoning. On the other 
hand, lead has often been found in the urine and more frequently in the 
stools of persons exposed to lead who do not show any evidence of 
intoxication. 
The presence of the lead-line and the basophilic degeneration of the 
red cells are objective findings which are of practical use in the diagnosis 
of lead poisoning. As a matter of fact, neither one of these signs is pathog- 
nomonic of the disease, and while their presence is a valuable aid in the 
diagnosis of obscure cases, their absence should not be given undue weight 
against the diagnosis of lead poisoning when a history of definite exposure 
to lead can be obtained. 
Basophilic granules in the red cells may be found in severe secondary 
anaemias in which hemolysis has taken place, and are, on the other hand, 
often absent in cases in which a positive diagnosis of lead poisoning can be 
made. In looking over a large number of records in which a definite 
diagnosis of lead poisoning was made in the Out-Patient Department of 
the Massachusetts General Hospital, by the clinical symptoms and the 
presence of the lead-line, I found that in nearly 50 per cent, basophilic 
granules in the red cells were absent. 
Sir Thomas Oliver states that in only a few instances of the great 
number of examinations of the blood that he has made, in early as well 
as in late cases of plumbism, has he found the basophilic granules. Dr. 
Louis I. Harris of the Department of Health of the City of New York 
examined the blood of 103 active cases of lead poisoning and in only 13, or 
a little more than 12 per cent, did he find stippled cells. Basophilic 
degeneration of the red cells, in short, does not possess the diagnostic 
value which some attribute to it, but can at most be regarded as an 
important confirmatory sign. Still greater importance is attached to the 
presence of the lead-line. 
In my investigation of some of the lead industries of Massachusetts 
for the State Board of Health, I had occasion to confer with many physi- 
cians who, from time to time, treated patients engaged in these industries, 
and I frequently found that no matter how suggestive the symptoms 
complained of were of lead poisoning, the diagnosis was not made because 
of the absence of the lead-line. As a matter of fact, the lead-line presents 
a great many anomalies, and irreparable harm will often be done when 
a diagnosis of plumbism is not made because of its absence. In the 
investigation referred to above, I have frequently seen well-marked 
lead-lines among workers exposed to lead who did not present, at the 
time of investigation or at any previous time, any signs of ill health. 
On the other hand, if one looks into the very extensive literature on the 
subject, one will find many cases of severe lead poisoning reported in EARLY DIAGNOSIS OF LEAD POISONING 
435 
which lead has been definitely demonstrated in the urine and stools, and 
post-mortem in the tissues, and yet no vestige of a lead-line could be found. 
Dr. Harris in the investigation referred to found the lead-line in less than 
14 per cent, of the active cases of lead poisoning which he examined. 
Moreover, the lead-line is extremely rare when the gums are in a healthy 
condition and when the teeth are well cared for. Dr. Oliver fed experi- 
mental animals with lead for a long time without observing any lead-line. 
If, however, an infection of the gums of such animals was produced, the 
lead-line appeared within a short time. 
The distinction between lead absorption and lead poisoning is not, as 
a rule, clearly borne in mind. All persons working in lead, unless the 
most unusual precautions are taken, inhale or swallow some of the poison, 
but it is excreted through the kidneys and the intestinal tract, or is 
stored in the body tissues as an insoluble albuminate of lead. If, how- 
ever, for some reason metabolism is disturbed, poisoning is the result. 
The presence of the lead-line simply means that the person has been 
absorbing lead, and is in itself of no greater weight in the diagnosis of 
lead poisoning than is the fact that the patient's history shows that he is 
working in a lead process in which we know that he inevitably absorbs 
lead. A careful inquiry into the nature of the industrial process in which 
the patient is engaged is therefore of the utmost importance. A history 
of exposure to lead justifies the diagnosis of lead poisoning in patients 
presenting obscure symptoms which cannot otherwise be explained. The 
following cases seen at the clinic of the Massachusetts General Hospital 
illustrate this point: 
Case 1.-A man 45 years old has been a painter for 24 years; 15 years ago he is 
said to have had an attack of abdominal pain which lasted for 2 weeks. About 5 
months ago, after a short period of idleness, he obtained a job painting the inside of 
refrigerators. He worked for only 2 weeks, and one day while at work he was suddenly 
attacked with blindness and severe abdominal pain. The pain lasted 2 days; the total 
blindness persisted for 2 weeks and then he began to improve slowly. At the time 
of the examination he showed a low-grade optic neuritis and some retinitis of both 
eyes. The vision of the right eye was one-half and of the left eye two-fifths of the 
normal. He also had a somewhat contracted visual field for both form and color; 
examination otherwise was entirely negative. He showed no lead-line, and other 
than a moderate anaemia his blood was negative. No stippled cells were found. At 
the time of the onset of his trouble he is said to have had a very marked lead-line. 
The history of exposure to lead for 24 years, and the attack of colic 15 
years ago which lasted 2 weeks, makes it certain that he had absorbed a 
considerable amount of lead in his system. The work in refrigerators, 
without any ventilation, in all probability acted as a predisposing cause, 
disturbing his metabolism and thereby precipitating the present attack. 
Even if no lead-line had been observed at the time the blindness occurred, 
in the absence of lues or any other cause for the optic neuritis, the diagno- 
sis of lead poisoning is perfectly justifiable. 436 
EARLY DIAGNOSIS OF LEAD POISONING 
Case 2.-A man of 50, a painter for 30 years, is said to have had "painter's colic" 
12 years ago which lasted for 4 or 5 weeks. Two months previous to his present illness 
he had to sand-paper old paint a great deal, and was thus exposed more than usually 
to great quantities of dust. About 3 weeks previous to his coming to the clinic he felt 
a sudden stabbing pain in the left elbow which lasted only for a few minutes. His 
left arm then began to feel stiff and weak, and he had a continuous dull pain in the 
elbow-joint. Physical examination was entirely negative except for slight weakness 
of the flexor muscles of the forearm. There was no lead-line and no stippled cells. 
In this case, likewise, the history of long exposure and the absence of 
any other condition to explain the symptoms makes a diagnosis of lead 
poisoning justifiable; a subsequent examination revealed the presence of 
some stippled cells. 
The history of exposure is the all-important factor in the diagnosis of 
plumbism. 
In cases of non-industrial plumbism, however, in which no history of 
exposure can be obtained, the presence of the lead-line or of the basophilic 
granules is of inestimable value in the diagnosis, since it offers a clue for 
the explanation of certain symptoms which would otherwise be obscure. 
The following case reports taken from the records of the Massachu- 
setts General Hospital will illustrate the reluctance, even among good 
clinicians, to make a diagnosis of plumbism in the absence of the lead-line 
or stippling: 
Case 3.-A man of 36, a sheet-metal worker for 11 years, handles a great deal of lead 
in his work, complains of pains in the abdomen, loss of weight, weakness of extremities 
and attacks of diarrhea followed by constipation. No lead-line. 
Case 4.-A man of 34, a painter for 10 years, complains of attacks of colic, head- 
aches, obstinate constipation and general nervousness. No lead-line, no stippling. 
Case 5.-A man of 22, a painter for 4 years, complains of constipation, attacks of 
severe abdominal pains and headaches. He looks pale; no lead-line, no stippling. 
Case 6.-A painter of 22, who has worked at the trade for 10 years, complains of 
obstinate constipation, pain in his joints, headaches, numbness and weakness of 
extremities; he is easily fatigued. No lead-line or stippling found. 
Case 7.-A worker in a rubber factory for 6 years complains of abdominal pains, 
obstinate constipation, severe pains in lumbar region, loss of appetite, and general 
nervousness. No lead-line found. 
Case 8.-A man of 49, a painter for 25 years, gives a history of lead poisoning when 
he first started his work. He now complains of tremor and weakness of hands so that 
he frequently drops his brush while at work. He has attacks of abdominal pains, 
pains in his joints, and is pale. No lead-line or stippling found. 
Case 9.-A man of 38, who worked in a car factory for 14 years, and part of whose 
work consisted of mixing lead, complains of sharp pains in the abdomen, attacks of 
dizziness, fine tremor of hands, metallic taste in the mouth, and pains in the extrem- 
ities. He lost considerable weight. No lead-line or stippling found. 
In none of the foregoing cases was a definite diagnosis of lead poisoning 
made. There is no doubt, however, that if a lead-line was present in any 
of these cases or if stippled red cells were found, even if the symptoms had 
been less characteristic, a positive diagnosis of plumbism would have been 
made. Yet the occupation of these patients was sufficient evidence that DIAGNOSING LEAD POISONING FROM SYMPTOMS ALONE 
437 
lead absorption was taking place, and the symptoms were sufficiently 
characteristic to warrant a definite diagnosis without the corroborative 
evidence of the lead-line or stippling. 
In consequence of the undue weight which is given to the objective 
signs, persons who show themselves, by the symptoms of which they com- 
plain, susceptible to the influence of lead are permitted to continue at 
their work without any additional precautions and without any warning 
as to the danger to which they are exposed. This is shown by the follow- 
ing illustrative case reports, taken from the records of the Out-Patient 
Department of the Massachusetts General Hospital. These patients 
attended the clinic for a long time, and no diagnosis of plumbism was 
made because of the absence of the lead-line or stippling. At some later 
date, however, although the symptoms were the same, the diagnosis of 
plumbism was made because of the appearance of one or the other of 
these objective signs. 
Case 10.-A worker in a rubber factory came to the clinic complaining of precordial 
pains, headaches, pains in the arms and attacks of abdominal pains. He had evidence 
of mitral regurgitation. There was no lead-line, and no diagnosis of lead poisoning 
was made. He came again 8 months later with the same symptoms but of increased 
severity. A lead-line was found present at this time, and a diagnosis of plumbism 
was made. 
Case 11.-A painter of 23 came to the clinic, November, 1907, complaining of pain 
in the back, numbness and weakness of extremities, abdominal pains, headaches and 
nervousness. No lead-line was present, and no diagnosis was made. In 1912 he 
presented himself with the same symptoms. Lead-line and stippling were found, and 
a diagnosis of lead poisoning was made. 
Case 12.-A painter presented himself at the clinic in July, 1907, complaining of 
constant severe pain in the upper abdomen, attacks of vomiting, pains in the knees 
and dizziness. A diagnosis of arteriosclerosis was made. In July, 1913, he presented 
himself again with the same symptoms. A lead-line and stippling were found. 
Diagnosis, lead poisoning. 
Case 13.-A machinist of 28 came to the clinic in 1906 complaining of attacks of 
severe abdominal pains, bad taste in the mouth, obstinate constipation, attacks of 
nausea and vomiting. He came many times during 1910 and again in 1911, complain- 
ing of the same symptom-complex. In December, 1911, a lead-line was found and 
many stippled cells. Diagnosis of lead poisoning was made. 
Case 14.-A worker in a rubber factory, aged 57, came in 1904 complaining of pain 
in the cardiac area and in the right shoulder, pains in hips and legs, weakness of 
extremities, dizzy spells, easily tired and constipated, also wasting of extensor 
muscles. No lead-line was found (patient had false teeth). No diagnosis of lead 
poisoning was made until 1905, when lead was found in the urine. 
Case 15.-A carriage painter of 38 came, in 1903, complaining of pains in the back 
between the shoulder blades. There was no record of lead-line or stippling. No diag- 
nosis was made. Later, in the same year, he came complaining of attacks of dull pain 
in the region of the umbilicus, and sharp pains in the lumbar region which kept him 
awake for 2 nights. A history of alcoholic excess was obtained for the last 2 weeks. 
No lead-line was found. Diagnosis, alcoholism. In 1908 he came again, complaining 
of pains in his back and in his feet, general weakness and nervousness; no diagnosis 
was made. Several weeks later he came again complaining of the same symptoms. 
A lead-line was present at this time. Diagnosis of lead poisoning was made. 438 
EARLY DIAGNOSIS OF LEAD POISONING 
The unwarranted delay so frequent in diagnosing plumbism even in the 
presence of a definite history of exposure to lead is well illustrated by the 
last case. For nearly 5 years this man has been presenting himself at 
various times at the hospital, complaining of a train of symptoms which,, 
taken together with his work, should have made a diagnosis possible, and 
yet he was permitted, during all that time, to continue his work without 
any special precautions until the lead-line appeared, when the diagnosis 
of lead poisoning was made. 
Since 1913 efforts at systematic study of industrial diseases have been made at the' 
Massachusetts General Hospital. The work developed to such an extent that under 
the guidance of Dr. Edsall a special Industrial Clinic has been established. 
A trained assistant is placed every morning at the admitting desk of the Out- 
Patient Department, and all cases employed in industries where there are any hazards 
are sent up to the Industrial Clinic for study. Special attention is thus given to the- 
study and diagnosis of industrial diseases, which results in the discovery of cases which 
would have otherwise escaped attention in the general clinic. 
In contrast to the cases referred to above, where diagnosis was not 
made owing to the failure to consider the hazards to which the patients; 
were exposed, the following cases from the Industrial Clinic are cited 
to illustrate how the diagnosis was frequently made because of the 
consideration of the hazard. 
A man of forty-eight comes to the hospital complaining of attacks of epigastric 
pain, loss of appetite, and for the last ten days diarrhea. There was no lead-line on 
the gums. Investigation disclosed the fact that as a shipbuilder he had been working 
for ten weeks in a lead-lined cold-storage room, and in this work he was exposed to lead 
dust and lead fumes. A diagnosis of lead-poisoning was made, which was confirmed 
later by finding lead in the urine and stools. 
A plumber of forty-seven complains of attacks of abdominal pain radiating to the 
back. His appetite is poor; he has lost weight and he has pains in various joints. In 
spite of the absence of a lead-line, the symptoms and the lead hazard of his occupation 
pointed to a diagnosis of lead poisoning. The diagnosis was later confirmed by finding 
lead in his stool. 
A "spreader" in a rubber shop complains of attacks of abdominal pain which last 
a few minutes. He is very constipated. 
A shipyard worker of thirty-five complains of pain in the lumbar region for three 
months. 
A painter of thirty-one complains of loss of strength in his wrists and pains in his 
back and feet. 
A painter of forty-eight complains of attacks of abdominal pain associated with 
constipation and dizziness. 
An iron foundry worker of fifty-three has attacks of abdominal pain and consti- 
pation. 
In all the above cases there were no lead-lines found, but inquiry into 
the occupations indicated the real lead hazard. The diagnosis of lead 
poisoning was therefore made, and in every instance it was later con- 
firmed by the finding of lead in the urine or stools, or both. 
It would, of course, be folly to attribute to lead all the ill health of 
lead workers. The symptoms, therefore, have to be considered carefully VALUE OF ATTENTION TO EARLY SYMPTOMS 
439 
before the responsibility of the diseased condition is laid to the industry. 
The symptoms of early plumbism are not well defined, yet there is 
a group of symptoms which, when not open to explanation on any other 
basis, must, when a history of exposure to contact with lead has been 
obtained, be taken as evidence of early lead poisoning. Indeed, it is 
important to inquire carefully as to any possible industrial exposure to 
lead whenever certain ill-defined states of ill health present themselves 
among workers, when such diagnosis, for instance, as anaemia, debility, 
constipation, lumbago or chronic arthritis, is made. Inquiries as to the 
details of the patient's work should be made, for unless the physician has 
a familiarity with the various industrial processes, the general designa- 
tion of the patient's work may not indicate any exposure to lead. 
Pallor of the skin, muscular weakness, rheumatic pains, loss of appe- 
tite, constipation, or constipation alternating with diarrhea, abdominal 
pains, general nervousness, and persistent headaches should always be 
regarded seriously when occurring in persons exposed to lead, for they 
may be the precursors to the more serious nerve lesions, such as wrist- 
drop, encephalopathy, and to the more insidious and less dramatic 
changes in the vascular and excretory systems, that of arteriosclerosis and 
chronic nephritis.* 
* An idea of the lack of accord in regard to the various physical findings in making an 
early diagnosis of lead poisoning may be seen from the following: 
An article in the Monthly Labor Review (Aug., 1921, pp. 405-408) regards stippling 
as the earliest sign of lead poisoning. 'Stippling appears before any other sign is mani- 
fest. Its appearance is intermittent, and it is the duty of the industrial physician to 
make frequent examinations of the blood of lead workers.' Bottrich (Abst., Jr. Ind. 
Hyg., Dec., 1921, p. 185), finds lead pallor and the lead line to be characteristic of early 
lead poisoning, although he emphasizes stippling as a diagnostic sign of first importance. 
J. Schoenfeld (Centralbl. f. Gewerbehyg., Jan., 1921, No. 1, 3-7; abstr. by Jr. Ind. Hyg., 
Aug., 1921, 71), considers that stippling is the best guide to early diagnosis and to progress 
of recovery. He considers 100 per million as a positive diagnosis, but claims that stippled 
cells disappear when severe symptoms, such as nephritis or paralysis, occur; also they 
disappear gradually under treatment in the course of weeks to months, the anemia decreas- 
ing at the same time. 
The method of searching the blood for stippled cells is certainly of the utmost impor- 
tance. Overstaining with Wright's stain is said to be advisable in order to bring basophilic 
granules out. L. Schwartz uses a thick drop method (Abstr., Jr. Ind. Hyg., Jan., 1922, 
208), and claims that by it the examination of ten fields will disclose more stippled cells, 
if present, than the examination of 200 fields in ordinary smears. He was able to collect 
and examine the blood of 51 cases in 3J^ hours. The result of the Chicago Painters' 
Critical Examination for Evidences of Lead Poisoning in 1913 and of the Ohio Survey 
(1913-1915) was to the effect that stippling is a rare and undependable sign; that lead in 
the stool simply shows ingestion; that lead .in the urine, while frequently present and 
proving absorption, may not mean lead poisoning since the person may still be within his 
physiological limits of handling leads, as with any other poison absorbed and eliminated in 
small amounts; that the blue line on the gums is rare and only shows absorption; and 
that to make a diagnosis, as Dr. Linenthal says, a history of exposure accompanied by 
symptoms of systemic intoxication known to accompany lead poisoning is all-important, 
and must be,accepted as diagnostic. This is especially so when other obvious causes such 
as a febrile syndrome, food poisoning, and volatile poisoning of the trades, such as benzol, 
wood alcohol, carbon monoxide and bisulphide can be ruled out, and if preventive medicine 
is to mean anything in this field. As Dr. Linenthal indicates, the results of such assump- 
tions are, like diagnosing incipient tuberculosis, subject to occasional error, but the per- 
centage of correct assumptions is certainly very high. At least no harm is done by 
labeling such cases "lead suspects," and watching closely for additional confirmatory 
signs. (Hayhurst). SECTION 11 
LEAD POISONING IN THE UNITED STATES 
ALICE HAMILTON, M. D„ Chicago, Ill. 
During the last ten years many State and Federal investigations have 
been made to determine the prevalence of industrial lead poisoning in the 
United States. The earlier of these investigations revealed an unexpec- 
tedly and even startlingly large amount of occupational plumbism in 
certain of the lead trades as compared with the same trades in Great 
Britain and Germany. Some of these have undergone very great reforms 
during recent years and at present are conducted with a high standard 
of cleanliness and of protection for the workmen, but others are little if 
at all improved and it cannot yet be said that the lead trades in the 
United States are so well controlled as in Great Britain and Germany or 
that equal care is given to lead workers. The United States is also far 
behind these countries in the collection of information concerning 
occupational plumbism, for the compulsory reporting of such cases has 
not been provided for in all the states and in those in which the law does 
require it, the results are far from complete. 
Our methods are often dangerous and our factory sanitation, though in 
some places excellent, is in other places distinctly bad. Nor are the living 
conditions of American workmen better, their food more abundant, their 
housing superior to those of British or German workmen in certain lead 
trades. In skilled trades such as painting, plumbing, printing, white 
ware glazing, wages are high and the men live well, but in some of the most 
dangerous lead trades, the making of white lead or the oxides, the smelting 
and refining of lead, the making of storage batteries, the painting of 
manufactured goods, the employes work for wages which are below the 
sum required for a family to maintain what is called an American standard 
of living. 
Lead Poisoning in Illinois.1-This is a fairly typical state with such 
lead industries as smelting and refining, the manufacture of white lead and 
the oxides, paint grinding, sanitary ware enamelling, tile glazing, litho- 
transfer works, as well as all the ordinary industries in which metallic 
lead is used. The inquiry made by the Commission on Occupational 
Diseases covered 3 years, 1908 to 1910, and 578 cases of lead poisoning 
were found to have occurred during that time, 308 of them in the last year 
and chiefly in the city of Chicago. They were scattered through about 70 
occupations, some of which had never been supposed by Chicago physicians 
to involve risk of lead poisoning. Among the less familiar ones were: the 
440 LEAD POISONING IN ILLINOIS AND NEW YORK 
441 
making of car seals, of tin foil, the wrapping of cigars in tin-foil, laying lead 
coated electric cables, making artificial flowers, handling wall paper 
colored with lead pigments. 
Inquiry showed that several cases which were reported as brass poisoning were 
really lead poisoning and that the brass industry in Chicago was responsible for many 
cases of plumbism. Litho-transfer works sent several serious cases to the Cook 
County Hospital and owing to the general ignorance concerning industrial processes 
some of these were not recognized at first but were treated as appendicitis. The same 
thing was true of another industry which is very rarely mentioned in the literature of 
lead poisoning, the work of the commercial artist or retoucher. Several cases of 
supposed zinc poisoning were reported to the Illinois Commission, the victims being 
commercial artists who used what they thought was a zinc paint in making sketches 
for catalogues and advertisements, and in retouching the high light in photographs 
for the same purpose. Evidently several of them had been treated by physicians 
who did not suspect lead poisoning, but the supposedly zinc white paint proved to be 
white lead and the men's habit of bringing their brush to a point by sucking it explains 
the poisoning, as does also the use of the paint in the form of a very fine spray. Fifteen 
such cases were found among the members of the profession in Chicago. 
Another unexpected source of lead poisoning proved to be the zinc smelting 
industry in LaSalle County. The ore contains less than 1 per cent, of lead, it is said, 
but enough is volatilized to give rise to plumbism among the smelters. Tinsmiths, 
makers of coffin handles, copper and nickel buffers, sorters in junk shops, and men who 
finish cut glass by rubbing it with a lead putty powder, were others of the miscella- 
neous workers who made up the Illinois lists. 
Sixty Fatal Cases of Industrial Plumbism in New York State in 1909 and 1910.2- 
Histories of all the reported deaths from industrial plumbism in New York State 
during the years 1909 and 1910 were collected and published by John B. Andrews. 
Forty-five of the 60 cases recorded, or 75 per cent., had worked with wet paint, three 
had worked at lead smelting, four in the printing trades, three in white lead works, 
two in storage battery plants, and one each in tinning, in making rubber balls and in 
making lead pipe. As would be expected, nearly all of them were chronic cases, of 
several years' duration. Two cases, on the other hand, developed fairly rapidly. 
One of them, a painter, had worked at inside painting only 11 months during which 
time he had had cramps in his stomach during several months, but the final attack of 
" gastro-enteritis and chronic lead poisoning" lasted only 2 days. The other was a 
boy of 18 years who, some 17 months before, had gone to work in a comparatively safe 
lead trade, the making of tin pails, but it was carried on in a poorly ventilated shop. 
At the end of 6 months he felt ill and began to lose weight, at the end of the year he was 
forced to leave work and after an illness of 10 weeks died of "chronic lead poisoning." 
Among the more unfamiliar occupations in this series of 60 fatal cases were: 
The making of rubber toys and balls, the packing of machinery covered with wet paint, 
portrait painting, and drawing bristles through the pads of brushes which had been 
painted with white lead paint. 
Lead Poisoning in the City of New York.3-A survey of the lead trades in the city 
of New York and a report on cases of lead poisoning discovered by the investigators 
and occurring during 1909, 1910, and 1911 was made by Edward Ewing Pratt for the 
N. Y. State Factory Investigating Committee. The report includes a detailed 
description of some of the more important industries: The manufacture of white lead 
and red lead, the making of paints, the use of lead as a hardening and tempering agent. 
This last, an occupation, hardly mentioned in most of the works on lead poisoning, Dr. 
Pratt found to be very dangerous. He traced no less than nine cases of lead poisoning 
to one factory which had been in operation only 1 year and in which the regular force 442 
LEAD POISONING IN THE UNITED STATES 
employed was only nine men. The work involves hardening steel magnetos in a bath 
of molten lead the temperature of which in this case was from 1400° to 1800°F. 
Here they remain till red hot, when a workman takes them out and plunges them into 
a barrel of water to cool. Then they are stacked about an upright bar and rubbed 
with sandpaper to remove adhering bits of lead. In addition to the risk from fumes 
and from the lead dust caused by the rubbing there is dust from the oxide which forms 
on the surface of the molten lead and is skimmed off and thrown on the floor. A 
similar process was seen in a factory where piano wires and springs are made. 
Lead was found to be used in the making of linoleum and oilcloth, first as a drier 
added, in the form of litharge, to boiling oil, second in the paints which consist largely 
of lead colors. Six cases of lead poisoning were on record in the hospital nearest to the 
village in which the factory is situated. 
Dr. Pratt studied 109 of the 376 cases discovered by his investigators. Of these, 
six were fatal, 20 had wrist-drop, 18 paralysis of other limbs, 34 incipient paralysis, 
and two encephalopathy. The painting trade was most largely represented, with 
42 cases, then came white lead with 23, and then work with solder and other metallic 
lead. Among the less usual sources of lead poisoning in this list are such industries 
as stamping designs on embroidery with a mixture of rosin and white lead; chipping 
old red lead paint from the hold in a battleship; polishing diamonds, the diamond being 
embedded in a pear-shaped lump of lead and held against a revolving disc, which at 
the same time grinds off part of the lead. 
Very interesting and valuable tests to determine the presence of lead in the air 
surrounding lead pots, casting machines, soldering benches, etc., are described by 
C. T. Graham Rogers and John H. Vogt.4 The results are of great value in settling 
the question, which is still in dispute, as to whether or not lead fumes are given off 
under certain circumstances. For instance, when I was investigating storage battery 
plants, I was always assured that there could be no danger from the casting, because 
the lead in the kettle was below the fuming point. I found cases of lead poisoning 
nevertheless among moulders and the explanation is furnished by the tests of air in 
two casting rooms made by Rogers and Vogt. They found in 1 cubic meter of the air 
of a casting room 3.4 mg. of lead, and in another factory where the kettles are covered 
with hoods 1.0 mg. As an adult breathes about 4.5 cubic meters in the course of 10 
hours, this means that it would be possible for a man in the first factory to breathe 
15.3 mg. during one working day and for a man in the second, 4.5 mg. provided this 
contamination of the air were constant. Another striking report on the amount of 
lead in the air is found in the description of a factory making dairy implements. A 
number of cases of lead poisoning had been reported among the men engaged in 
making cream separators, and when a visit was made to the plant it was discovered 
that during the finishing process a putty consisting of 65 per cent, lead was put on the 
metal part, baked in an oven and when hard, sandpapered. An analysis of the air in 
the room, which was large and well ventilated, showed no lead but a sample taken at 
breathing level of a worker while sandpapering showed 68.8 mg. of lead per cubic liter 
of air, clearly proving that the danger came from inhaling the dust laden air during 
the process of sandpapering. 
A man in a factory where brass nozzles are caulked into hydrants by means of 
molten lead was heating his lunch at the lead pot. The air near this pot at the 
breathing level had 5 mg. of lead in 1 cubic meter. 
Some negative results also in this inquiry are interesting. We read in foreign 
works about lead poisoning in the making of glass, in dyeing, in the manufacture of 
shoes, in harness making and in polishing precious stones. Rogers and Vogt found 
only two out of six glass factories using lead, but in those two, dust is allowed to 
escape and the air of the mixing rooms is badly contaminated with lead. In other 
industries, dyeing, shoemaking, etc., there was found to be no danger from this source. 
On the other hand, the mixing of ingredients for rubber (lead oxide and lead chromate U. S. GOVERNMENT STUDIES OF LEAD POISONING 
443 
are used) was found to be attended with danger, as no precautions are taken to protect 
the weighers and mixers from dust. A sample of air taken in a mixing room during 
the process of filling the mixer yielded 8 mg. of lead per cubic meter. 
These writers advise that special rules be passed by the State for the following 
industries: Manufacture of white lead; of dry colors; of lead oxide; of paint and 
varnish; of storage batteries; potteries; smelting, making of alloys and plumbers' 
supplies; manufacture of articles from metallic lead; manufacture of rubber goods 
where lead is used; painting of manufactured articles. 
Studies Made by the Federal Government.--The inquiries carried on 
by the Bureau of Labor and more recently by the Bureau of Labor Statis- 
tics of the Department of Labor,4 have concerned individual industries 
and the method has been to make an intensive study of the establishments 
in which the work is done and to collect all the available information about 
lead poisoning in each one. This information is always far from complete. 
There are now many states which require that all cases of industrial lead 
poisoning be reported to some central office, but most of them have passed 
such a law only recently and have as yet no really trustworthy statistics. 
Moreover American physicians are not yet convinced of the necessity 
of this legislation and the majority do not take the trouble to send in 
reports of any but the severer cases, while some who are employed as 
company physicians feel that they are bound in loyalty to their employers 
to keep secret the number of cases of plumbism which occur in the plant. 
I have myself seen a bill presented by a doctor to the company asking pay 
for the treatment of 57 cases of acute lead poisoning, while his report to 
the State put the number at 27 only. 
This makes it impossible in all but a few instances to know exactly how 
much lead poisoning there is in any of the lead trades in the United States 
and the cases discovered in the course of these inquiries always fall below 
the truth. This was especially true of the first investigation, that of the 
white lead and lead oxide industries, for at that time the subject of lead 
poisoning among working people had attracted little attention and there 
were many employers who were genuinely ignorant of the extent of the evil 
in their own establishments. The only study I have been able to find in 
American medical literature of industrial lead poisoning among white 
lead workers is an article by Wm, R. Hobbs,6 written in 1898. He reports 
42 cases from one white lead works, all but eight of them severe in type. 
Two had epileptiform attacks, one was a case of acute meningitis, lasting 
2 weeks and ending in recovery, a fourth had complete paralysis of biceps 
and deltoids, dilated heart with mitral regurgitation, parenchymatous 
nephritis, later on, insomnia, loss of memory, listlessness, oedema, anasarca 
and death. Some of Hobbs' cases developed after only a few weeks' 
exposure, and no less than 35 of the 42 after less than a year's exposure. 
Manufacture of White Lead, Litharge, Orange Mineral, and Red 
Lead.-The processes used in making white lead in the United States are 
the Old Dutch, the Carter, the Matheson and the Mild, but the first is 
the most usual and the last two are used in only one factory each. 444 
LEAD POISONING IN THE UNITED STATES 
For the Old Dutch process, the lead is cast in thin discs and these are packed in pots 
with acetic acid and buried in old tan bark for about 100 days, when the metallic or 
"blue" lead is found to have "corroded," that is, changed to white lead, the basic 
carbonate. In removing this white lead ("stripping the white beds ") there is a great 
deal of dust and the men cannot sprinkle it with water as is done in England and 
Germany, because in our factories the products of the corrosion must go through a 
series of grinders and screens to separate the white lead from the unchanged metal in 
the center of the disc, and dampness would result in clogging the screens. In the 
factories I have visited in England and Germany this separation is done by washing 
the corroded lead off in great troughs of running water. A Belgian factory, near 
Brussels, had a process similar to the American. This use of dry instead of wet 
separation increases very much the difficulty of making American factories dust-free, 
and at the time this investigation was made the work of "stripping" was productive 
of a great deal of poisoning. Since then, however an excellent protective device has 
been introduced, a truck with a cover which has an opening just large enough to allow 
the pot of white lead to be emptied in. Another opening is for a large exhaust pipe 
which carries off the dust formed by the falling of the contents of the pot. This 
exhaust pipe is flexible and long so that the truck can be moved about without dis- 
turbing the mechanism. 
The second danger spot in a white lead establishment is the dry pan room, where 
the white lead after repeated washings is pumped into great hot pans and left to 
dry, when it is emptied into trucks and taken to the packers or to be ground in oil. 
In most establishments visited, a certain amount of white lead was ground as 
"pulp lead," the oil displacing the water without any drying process. Work as con- 
ducted in dry pan rooms was dangerous work when first investigated. I remember 
seeing two men in a low, hot pan room, standing on the dry white lead in the pan and 
shovelling it to the edge, then throwing it into a truck below as carelessly as if it were 
so much sand. Since then, however, this work has been much improved in the better 
factories, the pans entirely enclosed, connected with the exhaust system, and the dry 
lead emptied into a screw conveyor which is placed inside the enclosing jacket, so that 
the dust raised by shovelling does not escape but is drawn in by the suction of the 
exhaust. 
In the Carter process, the dust problem is a serious one, for this is a quick corrosion 
of lead which has been reduced to the finest powder, so that from start to finish the men 
are handling powdered material. The advantage of the method is that it requires 
a small force of workmen and the modifications made from year to year tend to lessen 
still further the amount of hand-work. 
The Matheson process is a precipitation process and safer than the Old Dutch, 
because work in the corroding stacks is replaced by precipitation of white lead in 
water. The Mild is also a wet process, atomized lead being exposed to air and carbon 
dioxide and water in large cylinders. However in both these factories the drying and 
grinding and packing of the finished product is as dangerous as in an Old Dutch 
establishment. 
The roasting of lead oxides is not carried on in connection with lead 
smelting in the United States as it is in most other countries, with the 
exception of one smelting plant. It is done either separately or in connec- 
tion with the making of white lead. The dangers in this work consist in 
the fumes from the furnaces, and in the dust from dumping, grinding, 
screening, and packing the oxides. I have seen some red lead factories in 
this country which were so free from dust that one would not guess from 
their appearance that colored materials were made there. Mechanical LEAD COMPOUNDS GLAZING DECORATING 
445 
furnaces, well hooded, have done away with fumes, exhausts over the 
dumps and closely covered grinders and screens have prevented the escape 
of dust. In such plants the danger of lead poisoning is slight, but in a 
poorly managed oxide works, with much hand-work, the danger may be 
even greater than in the white lead department. 
In one factory I found that during the preceding 16 months there had been 14 
cases of lead poisoning among 65 white lead men making a rate of 22.5 per hundred, 
and 7 among 12 red lead men, or 58.3 per hundred. The average period of employ- 
ment was 4 years for the white lead men and only 1 year for the red lead men. It is 
partly the great fluffiness and lightness of the oxides, especially litharge, which makes 
them so dangerous, for their solubility in human gastric juice is less than that of the 
basic carbonate. 
The number of cases of lead poisoning found in these two industries in 1911 was 
388, occurring during 16 months' time in factories with a pay roll of 1600 men. 
Neither of these figures is accurate. More men than 1600 were employed in these 
plants during that time, and more than 388 cases of lead poisoning undoubtedly 
occurred, for this number represents only those who could be traced by investigators 
working against great difficulties. The fatal cases numbered 16. The period of 
exposure before poisoning occurred was usually short, 98 out of 120 falling ill after 
less than a year's work. 
There is far less lead poisoning now i n this industry than at that time, for, 
in addition to the many improvements which have been made in the 
factories, physicians have been employed to examine and treat the men, 
but the falling off in the sickness rate cannot be statistically proven, since 
these physicians, if they report cases of lead poisoning at all, report only 
the severer ones. 
Glazing and Decorating White Ware and Sanitary Earthenware and 
Tiles.7-The pottery industry in the United States is carried on chiefly 
in two districts, the region around East Liverpool, Ohio, which includes 
towns in West Virginia, and in and about Trenton, N. J. White ware 
includes table and toilet ware; sanitary earthenware includes tubs, basins, 
closets, sinks, etc., which are made of glazed clay, in distinction from 
porcelain enamelled iron ware. 
In these potteries in 1911 about a thousand persons were employed in work which 
involves exposure to lead in some form, only 150 of them being women. No leadless 
glaze is used, except on the very large ware, the bath tubs, laundry tubs and sitz 
baths, which are covered with a leadless glaze and subjected to one prolonged firing 
that at once biscuits the clay and fuses the glaze. Smaller pieces, closets, wash- 
basins, and all table and toilet ware, are first fired to biscuit the clay and then covered 
with a lead glaze and fired again. The glazes used in the 30 table and toilet ware 
potteries investigated contained lead in proportions ranging from 5 per cent, to 20 
per cent., but in only seven was it as low as 5 per cent.; in the other 23, the lead was 
from 15 per cent, to 20 per cent. For sanitary ware less lead is used, seven out of 
nine potteries using a glaze with less than 15 per cent. lead. White lead is the com- 
pound almost always used. 
In England and on the Continent there has been for many years a 
strong movement in favor of insisting on the use of "fritted" glazes. In 446 
LEAD POISONING IN THE UNITED STATES 
fritting, the lead is added at the beginning to the other glaze-forming 
constituents and is fused with them, in the course of which a large part 
of it is changed from a soluble to an insoluble form, the disilicate. The 
statement has frequently been made to me in American potteries that 
the glaze in use has all been fritted, but unfortunately it is the American 
custom to add part, if not all, of the lead after fritting. 
The occupations which expose pottery workers to the danger of lead 
poisoning have to do with the glaze and with the lead colors used in 
decorating. Mixing the glaze is done by laborers under the direction of a 
skilled foreman. Dipping the ware in liquid glaze is skilled work and is 
always done by men, as is also the stacking of the dipped ware in the 
kilns for firing. The dippers' helpers, who clean the excess of glaze from 
the ware, are unskilled women or boys, or in sanitary ware potteries 
where the ware is very heavy, young men. Decorating is skilled work 
and employs' both men and women. Most ware in this country is now 
decorated by means of litho-transfer paper, which is entirely devoid of 
danger, but there is still some color blowing and hand decoration, though 
chiefly in art pottery, not white ware. 
At the time this study was made in none of the potteries visited were proper wash- 
ing facilities provided for the people exposed to lead, nor lunch rooms, nor working 
clothes, nor was there any evidence of an effort on the part of the management to 
protect the work-people from lead poisoning. Even in newly erected potteries the 
floor of the dipping room was always of wood and dry sweeping was very common. 
I saw the dippers' helpers in several places prepare for lunch by rinsing their hands in 
a pail of water which the dippers had already used, and then sit down and open their 
dinner pails in that very room. In the 9 years that have elapsed since this investi- 
gation was made much has been done to improve conditions in the industry, but very 
radical changes in construction and management would be needed to bring our potteries 
up to the British standard. 
White ware potters are an intelligent class of workmen with a strong 
trade union, good wages, and short hours. There are, however, in these 
same potteries laborers and boys and women and girls who earn low 
wages and do not have any of the advantages of organization. It was 
among these last that the highest rate of lead poisoning was found. 
Even among the dippers and kilnmen the rate was high. 
One dipper's local of 85 men had had in 1 year 13 cases of lead poisoning, as many 
as there were among 786 English male dippers, making a rate for our dippers of one in 
six or seven and for the Staffordshire dippers of one in 60 or 61. Though it is a skilled 
and well-paid trade 119 dippers averaged only from 17 to 18 years employment and 
200 glost-kilnmen only 141$ years. As for the dippers' helpers, the rate of lead 
poisoning among them was found to be 13 in 180 in Trenton, where men and boys are 
employed, and 29 among 150 in Ohio, where women are employed. This greater 
incidence among women is always noted by English authorities, especially by Oliver. 
Comparing the dippers in East Liverpool with their women helpers we find the men's 
rate to be 17 per 100 employed, the women's'33 per 100, almost double. 
Art and Utility Ware.-This term covers the yellow earthenware used 
in kitchens, the dark brown teapots known as Rockingham ware, and POTTERY-TILES 
447 
majolica or decorated ware of all kinds, vases, pedestals, umbrella stands, 
spittoons, etc. All these are made with a glaze rich in lead, containing 
from 20 per cent, up to 50 per cent. In these potteries there is much more 
mixing of glaze and much more decorating than in the white ware. 
Decorating is done partly by hand painting partly by spraying on the 
colors by means of an atomizer and a stream of compressed air. This is 
the process which in British reports is spoken of as "color blowing," and 
regarded as requiring special safeguards. The ware is held under a hood 
furnished with an air exhaust and if the draft is strong enough, the spray 
not driven with too much force, and the hood deep enough, and the 
decorator's sight good enough so that he can hold the ware at a distance 
from his face, the work is not dangerous, but in many American potteries 
these conditions are not found. Poor hoods and feeble exhausts were 
found to be quite common. 
The workers in this class of potteries are exposed to greater dangers 
than those in white ware, because the glaze is richer in lead and because 
more color blowing is done, and in addition it was found that the standard 
of cleanliness is even lower in these potteries than in the white ware 
branch, so that the exposure to lead dust is greater. Another great 
disadvantage in this branch of pottery work is the fact that it is entirely 
unorganized and consequently wages are low and the proportion of women 
employees is much higher. The influence of all these factors can be seen 
in the following table which gives the rate of lead poisoning among the 
white ware potters and that among the art and utility ware potters. 
The men only are included. 
White ware: 
Number employed, 796. Cases in 2 years, 60. Rate per 100, 7.5. 
Art and Utility Ware and Tiles: 
Number employed, 304. Cases in 2 years, 63. Rate per 100, 27. 
Tiles.-The glazing and decorating of tiles is carried on in the same 
district as the making of art pottery, the region around Zanesville, O., and 
as it is also a dangerous and insanitary and underpaid industry it was 
found impossible to separate the cases contracted in the potteries in this 
district from those contracted in tile works and the two industries had to 
be studied together, though in many ways the work in a tile factory is 
different from that in a pottery. Aside from the Zanesville region, tile 
factories were found in Trenton, N. J.; Newell, W. Va.; Covington and New- 
port, Ky.; Indianapolis, Ind.; Chicago Heights, Ill.; and Morristown, Pa. 
The glazes in these plants contain as little lead as 5 per cent., in the case 
of white glaze, and as much as 50 per cent, or even 60 per cent., in colored 
glazes. The lowest quantity, 5 per cent, was found in only two factories; 
in all the others the lead content ran from 20 per cent. up. White glaze 
is applied by machinery in some factories, but colored tiles are glazed by 
dipping or by pouring on the glaze, or in the case of mottled "onyx" 
tiles, by scattering it from a pail by hand. 448 
LEAD POISONING IN THE UNITED STATES 
Scraping off the excess of glaze, or "fettling" as it is called, is more 
dangerous than actual glazing because it is dustier. In all English tile 
works, and in many German, it is the rule to scrape the excess glaze while 
it is damp and let it fall into a pan of water. In all the tile works I have 
visited in this country, much of the fettling, if not all, is done dry and the 
glaze dust allowed to fall anywhere. I have even seen girls brush off 
glaze with a stiff brush, and then blow the tile clean. 
The rate of lead poisoning among men and women in these two branches in 1911 
is given in the following table. It will be noticed that here where there is no advan- 
tage on the part of the men, where all earn low wages, the men have a somewhat 
higher rate than the women, but then they remain longer in the industry than most 
of the women do. 
No. 
Employed 
Cases of 
Plumbism 
in 1 Year 
Rate Per 
100 
Males 
304 
48 
15.1 
Females 
243 
28 
11.5 
The full effect of the neglect of all hygienic precautions in this indus- 
try can be seen if we compare our record for 1 year with a year's record 
in British potteries, which are better managed than any I have visited in 
other countries. This table shows the contrast. 
Frequency of Lead Poisoning in Each Sex, in all Potteries, Great Britain 
1910, and in Potteries Visited, United States, 1911 
All potteries, Great Britain 
Potteries visited, United States, 
1911 
Sex 
Employes 
in 1907 
Cases of 
lead pois- 
oning, 1910 
Ratio of 
cases of 
lead pois- 
oning to 
number of 
employes 
Employes 
Cases of 
lead pois- 
oning 
Ratio of 
cases of 
lead pois- 
oning to 
number of 
employes 
Males 
Females 
4504 
2361 
40 
37 
1 to 113 
1 to 64 
1100 
393 
87 
57 
1 to 12 
or 13 
1 to 7 
Total 
6865 
77 
1 to 89 
1493 
144 
1 to 10 
or 11 
"Lead Poisoning in the Pottery Trades" (Bull. 116, U. S. Pub. Hlth. 
Service), by Newman, McConnell, Spencer and Phillips became available 
after the manuscript for this Section was prepared by Dr. Hamilton and 
should be consulted by all interested in the most recent survey of this 
question in America. The following is taken from a transcript prepared 
by one of the Editors (Hayhurst) for the Amer. Jour, of Pub. Hlth., XII, 
10, Oct. 1922, 882: POTTERY STATISTICS-PORCELAIN WARE 
449 
This Bulletin of 223 pages, containing tables, charts, and many illustrations, is by 
all means the most complete American statement of this subject yet published, and 
represents a great amount of intensive work done by the Public Health Service. It 
also makes continual comparisons with similar investigations made by Alice Hamilton 
in 1910-11 and Hayhurst in 1914 (the latter in Ohio only). The report points out 
that the reasons for making the investigation were alleged discriminations, particularly 
in the matter of insurance protection, against potters due to previous surveys, and that 
the Brotherhood of Operative Potters requested the investigation. There is dis- 
cussed the pottery industry and its importance, a statement that 92 representative 
potters of New Jersey, Ohio, Pennsylvania and West Virginia are included, a descrip- 
tion of the methods of technique of the survey, followed by an analysis of the types 
of pottery workers especially exposed to lead poison, a description of the plant proc- 
esses in which they work, a statement regarding plant hygiene, and plant manage- 
ment in relation to welfare of workers. One part is devoted to lead as a poisonous 
substance, summarizing the best information and followed by a statement of the cases 
of lead poisoning found in this survey. Causative factors in plumbism, as the disease 
exists in pottery workers, is carefully analyzed. The means and methods of reducing 
the lead hazard include the following sub-headings: individual means and methods 
(food, clothing, work-room practices); plant means and methods (bathing, drinking 
facilities, work-room practices); plant hygiene (illumination, ventilation, and dust 
prevention); buildings, processes, management, and modern improvements calculated 
to lessen the lead hazard (glazes with low-lead content, substitutes for lead, fritted 
lead glazes, continuous kilns, automatic machinery, etc.). 
"Whereas Dr. Hamilton in 68 plants in 1911-12 found a total of 501 cases of lead 
poisoning, with a rate of 7.2 to 13.2 in the number exposed, and Hayhurst in 47 plants 
in 1914 found 109 cases of lead poisoning or a rate of 4.2 of the number exposed, the 
Public Health Service in 1919-20 in 92 plants found 270 cases of lead poisoning, or a 
rate of 15.0 for those exposed. Of the same 109 cases which Hayhurst found suffering 
from lead poisoning, the report says it is interesting to note that our investigators 
found 40 out of 50 of the 109 cases still suffering from lead poisoning. Of the remain- 
ing 59 cases, our men procured information for about 24. Five of these had died of 
some unstated cause, 2 were employed in a pottery where lead is said not to be used, 
and the remainder were found to be insurance agents, farmers, teamsters, and 
foundrymen." 
Porcelain Enamelled Sanitary Ware.7-The very heavy, solid bath 
tubs which are found in large houses and in hotels are made of earthen- 
ware and covered with a leadless glaze, but the ordinary bath tubs which 
give a metallic sound when struck, are made of iron and covered with a 
lead glaze applied in the form of powder over the red hot surface. Wash- 
basins and kitchen sinks are enamelled in the same way. 
This is a large and important industry in the United States, the chief 
centers for which are the Pittsburgh region, Chicago, Louisville, Ky., 
Sheboygan, Wis., and Trenton, N. J. 
The cast-iron bath tubs, sinks and basins are first roughened by a 
sand blast and then placed by the enamellers in a furnace, heated red hot, 
brought out and sprinkled thickly with a powder which is essentially a 
ground glass containing soluble lead. Seven samples of enamel were 
subjected to the Thorpe test and were found to contain soluble lead in the 
following quantities: 0.51 per cent., 2.55 per cent., 6.31 per cent., 8.35 
per cent., 9.04 per cent., 10.22 per cent, and 20.4 per cent. The lead used 450 
LEAD POISONING IN THE UNITED STATES 
for making this enamel is red lead or litharge, and the mixture is always 
fritted, yet soluble lead is there. It is said that there is less lead in the 
enamel now than formerly. 
The men who mix and grind are exposed to dust, the men who enamel 
are also exposed to dust and to great heat and to fatigue from the exer- 
tion of handling the heavy pieces. It is a very dangerous trade and the 
amount of lead poisoning is great, yet even in the best factories little is 
done to protect the men and in the worst, conditions are very bad. 
The enamellers are well paid, for it is work requiring skill, but 250 men whom I 
interviewed had averaged only 6 years in the trade. Mixers who are paid day laborers' 
wages are still more shifting. 
Two hundred and seventeen cases of lead poisoning were found to have occurred 
among 1012 men during 1911, which would give a rate of 21.4 per 100 employed. 
This does not tell the whole story. It was excessively difficult to trace the cases in 
this trade, which employs so many non-English speaking Slavs but it so happened 
that I was able to make an intensive study of 148 men who were at the time out on 
strike and I found that one in three is probably the real proportion poisoned. Among 
these 148 men, 54 or 36 per cent., showed evidence of chronic plumbism and 38 others 
were not beyond suspicion. The form of lead poisoning among enamellers is often 
severe; 28 cases of palsy were found, and eight of the cerebral form of plumbism. 
Twelve were said to have been fatal, but only seven of these were reported by doctors. 
In Germany this is a leadless trade, the enamel used being leadfree 
and applied wet. In England it is leadless in some places, but in other 
factories a lead enamel is used and in these places the employers are 
obliged to follow strict rules for the protection of the men. In Austria 
where a similar method is used for enamelling stoves, there is, according 
to Teleky, a great deal of lead poisoning. 
A comparison between foreign factories and our own is hard to make, 
but in a German pottery where glaze is made in the same way as enamel in 
our country no cases of lead poisoning was reported among 15 mixers in 4 
years time, and in an English enamelling plant where a lead enamel is 
used, the average of lead poisoning among 26 employes was one in 2 
years. 
Lead Mining.-There has been no detailed study of lead poisoning 
among miners in this country, but in the course of an investigation of 
the smelting industry, one comes across cases in hospital records which 
show that the mining of lead ores is not devoid of risk of this sort. The 
Hospital of St. Vincent in Leadville has probably the oldest records of 
lead poisoning in miners and smelterers in the United States. 
In 1880, the year after the opening of the hospital, 67 miners and 54 smelters were 
treated for this disease. The next year the miners numbered 41 and in 1882, 54, while 
the smelters rose to 119 and then to 424. For some years the cases among miners 
keep on at about 40 to 50, as long as the surface ores, the sulphate, carbonate and 
oxides, continue to form a large proportion of the output of the mines, but as the 
lower levels are reached and the ore contains largely lead sulphide, galena, the cases 
of lead poisoning fall off. Even in 1910, however, there were eight cases, but the 
next year only three and in 1912 all the lead poisoning came from the smelting plants. LEAD MINING, SMELTING AND REFINING 
451 
It is commonly stated that lead sulphide ore is not dangerous, because 
the lead is in a form insoluble in human gastric juice. This has been held 
by eminent authorities to be true, on the basis of practical experience as 
well as animal experimentation. 
Rambousek stated at the International Congress of Industrial Hygiene in Milan, 
in 1906, that there had been no case of lead poisoning among 10,000 Bohemian miners 
while among 4000 smelters there were 150 cases. On the other hand, Biondi had seen 
such cases among the lead miners in Sardinia. The animal experiments performed by 
Blum confirm the theory of Rambousek as to the insolubility of lead sulphide, while 
those of Murgia and of Brezina and Eugling, seem to show that it is absorbed by the 
body.8 
In the search for cases of lead poisoning among the smelters of the St. Louis region, 
I found 25 cases which had been treated in one St. Louis hospital, all of the men having 
come from the lead belt of southeastern Missouri, chiefly from Desloge. The cases 
were serious enough to require hospital care and one man had palsy, another a lead 
psychosis. They were foreigners and as there is but one smelter in that region, 
employing only Americans, they must have come from the mines and the concentrating 
mills, where about a thousand foreign workmen are employed and where the ore is 
exclusively galena. 
To clear up the question as to possible poisoning from galena ore, 
Dr. A. J. Carlson, of the Physiological Department of Chicago University 
undertook to test the solubility of three of these Missouri ores in human 
gastric juice. He found the solubility to be: 1.38 per cent., 2.94 per cent., 
and 3.32 per cent., averaging about 2.5 per cent. There is, therefore, 
danger in mining lead ore even when the ore is pure sulphide.9 
Lead Smelting and Refining.8-The United States is one of the largest 
lead-producing countries and in addition to smelting and refining our own 
ores we refine much Mexican bullion. The 20 plants which formed the 
subject of a Federal investigation employ some 7500 men. They are situ- 
ated in Perth Amboy and Newark, N. J.; Graselli and East Chicago, Ind.; 
South Chicago, Federal, Granite City, and Collinsville, Ill.; Herculaneum 
and Joplin, Mo.; Omaha, Neb.; Denver, Leadville, Pueblo and Salida, 
Col.; Murray, Midvale and Tooele, Utah; and East Helena, Mont. 
The dangers in a smelting or refining plant are from fumes and dust 
and every man employed is more or less exposed to them, though in a 
clean, well managed plant there are parts which are almost free from 
danger. In a dusty neglected one there is not a single safe spot. In 
handling the ores, dust is the danger, though this varies according to the 
dampness of the ore and its composition, the sulphide ores being less 
poisonous than the carbonate and oxide ores. In pre-roasting, in roast- 
ing and in smelting there is danger from dust while the charges are being 
made up and put in the furnaces, and there is great danger from fumes 
while roasting and smelting proceed, and of both when the furnaces are 
emptied of their dusty and fuming product. In the later processes of 
refining the danger is chiefly from fumes. 
The fact that these processes result in the evolution of lead fumes has 
led to the construction of elaborate flues and bag houses to catch and con- 452 
LEAD POISONING IN THE UNITED STATES 
dense them. The fumes collect in these in the form of a very fine powder 
and the work of cleaning out and transporting this powder to the furnaces 
is very dangerous, except in one plant where it has been made possible to 
flush out the flues with water, and to empty the bag house mechanically. 
The most dangerous places in an American smelter are: the ore or 
Scotch hearths, where the ore is smelted in the open and the men exposed 
to fumes and to excessive heat and exertion; the emptying of the Hunting- 
ton-Heberlein roasting pots, which in this country is always done in a 
way to cause much dust and fume; the charging of the blast furnaces, 
which in several plants has been made fairly safe but which is usually 
bad; the tapping of blast furnaces, and the cleaning out of flues and bag 
houses. Other furnace work may be equally bad if poorly managed but 
it is an easier task to prevent fumes in refining processes than in smelting. 
It is simply because of neglect that American refineries are on the whole 
worse than the smelters. 
The provision of washing facilities for smelting employes is not nearly 
so important as the prevention of dust and fumes during work. Muller10 
has shown that the amount of lead that clings to a man's hands is insigni- 
ficant in comparison to what he may be obliged to breathe in if the work 
is dusty and fumes escape. I have seen a plant with an elaborately 
equipped lavatory, bath house and dining room, whose rate of plumbism 
was nevertheless far higher than that of many plants with no washing 
facilities, because of the excessive amount of poisonous fumes in the ore- 
hearth shed and of dust in the bag houses. If the lead on the hands were 
the great danger, there would be more plumbism among refiners and desil- 
verers than among furnace men, for the former handle almost pure lead, 
but the fact is that the refining department is the safest of all. 
We collected from physicians' records and from hospitals, 1667 cases of lead 
poisoning which occurred in 1 year, 1912, in 19 plants employing 7400 men. The 
twentieth had opened too recently to be included. This represents a rate of a little 
over 22 for every 100 employed. The British rate for that year was 1.8 per 100; 
the reports of four German smelters give a rate of 10 or 11 per 100, and in one large 
Austrian plant the rate was 9 per 100. 
Manufacture of Storage Batteries or Electric Accumulators.11-As the 
use of motor cars and of electric lighting increases, the demand for storage 
batteries increases. There are a great many small plants in this country 
engaged in the manufacture or repair of these batteries and there are six 
large ones which are situated in Cleveland, in Niagara Falls, in Depew near 
Buffalo, in Philadelphia and in Indianapolis. 
The lead work consists in casting lead grids, trimming off the irregular 
borders, mixing oxides of lead with other ingredients, making a paste of 
the mixture, rubbing and pressing this paste into the grids, drying them, 
connecting them in pairs and groups by means of pure lead melted with 
an air-hydrogen flame, carrying them to the forming room where an 
electric current is passed through, and making the final connections with STORAGE BATTERIES-THE PAINTER'S TRADE 
453 
lead and the air-hydrogen flame. Fumes from melted lead and dust from 
lead oxides and from dried paste are the dangers here, to which must be 
added the danger that the poisonous oxides smeared over the men's hands 
may contaminate their food and tobacco. 
The Federal investigation in 1913-14 brought to light 164 cases of lead poisoning, 
chiefly acute, in five plants employing about 915 men in work which exposed them to 
lead. This meant a rate of almost 18 per cent., while the British rate for 1912 was 
3 per cent, and the rate in the great German factory in Hagen was only 0.97 per 
cent. There has been a decided though uneven improvement in these factories in 
recent years and in the best plants lead poisoning has fallen to a gratifying low figure. 
The Painter's Trade.12-This is regarded in all countries as the most 
important of the lead industries, for it employs a large number of men and, 
as it is a skilled and well-paid trade, men do not drop out of it at the first 
attack of illness but usually keep on till actually incapacitated. It is 
harder to control conditions in the painting trade than in any other lead 
trade and therefore while industrial poisoning has been greatly diminished 
in other occupations, there has been no falling off in this trade in Germany 
or Great Britain. 
In the United States it is impossible to make any statement 
as to the amount of lead poisoning for which the painters' trade is respon- 
sible. All we can do is to gather scattered bits of information from various; 
sources. 
The Illinois Report has 157 painters among 578 cases from all trades, or 27 per 
cent. Pratt's report of 109 cases includes no less than 42 painters. Andrews quotes- 
the record of one New York hospital in which 59 cases of plumbism were treated, 28 of 
them painters, and the proportion among his 60 fatal cases was even greater, 40, or two- 
thirds. Several studies have been made of groups of working painters to determine 
the proportion suffering from chronic lead poisoning. Hayhurst12 examined 100 in 
Chicago in 1913. He did not find any with acute symptoms of lead, but indications 
of chronic plumbism were found in seventy. In 1915 Apfelbach and Gibson of the- 
State Factory Inspection Department of Illinois examined 150 painters and noted' 
that 23 had a history of lead colic, while diseases in which lead may have played a part, 
were found as follows: nephritis, 22; hypertrophied heart, 49; active tuberculosis, 26;. 
latent tuberculosis, 10. Harris of the Occupational Disease Clinic of the New York 
City Health Department published in 1918 the results of an examination of 304 
painters, 162 of whom, or 53 per cent., had symptoms of plumbism and 75 gave a 
definite reaction for lead in the urine. 
The most dangerous branches of this industry in our country are: 
interior house painting, ship painting and certain parts of carriage paint- 
ing, because these all involve the dry sandpapering of white lead paint, 
which dust-producing work is the most prolific source of lead poisoning 
among painters. The safest branches are the painting of farm imple- 
ments, of farm wagons and of automobiles, when this is done on a large 
scale, for hand-work has given way to dipping by machinery and only the 
final decorating needs brush work. In smaller carriage and automobile 
shops and in the painting of railway coaches, hand-work persists and there 454 
LEAD POISONING IN THE UNITED STATES 
may be much sandpapering, especially on the wheels, and in painting white 
milk carts, and the walls of toilet rooms in Pullman cars. 
Ship painting involves the use of much red lead which must be sand- 
papered and must be chipped off when a new coat is to be put on. As this 
may have to be done in the small unventilated spaces between the inner 
and outer shells of the ship the amount of dust inhaled may give rise to 
severe poisoning. 
E. R. Stitt13 of the U. S. Navy reported three cases of acute plumbism from 
this source. The men had been employed in chipping off old red lead paint from 
the inside of a ship and all suffered profound nervous symptoms, manic depressive 
insanity in the first, epileptiform seizures in the second, and what appeared like 
an early stage of dementia praecox in the third. All recovered completely. 
The prevention of lead poisoning among painters is fraught with much 
difficulty when the work is done outside a factory. House painting is 
often done in buildings where the water has not yet been turned on and 
there is no way for the men to wash properly before eating their lunch. 
In factories where this could be provided the arrangements are almost 
always quite inadequate. The dry sandpapering of lead paint is forbidden 
by law in several countries and it would be a sintple matter to do away 
with it if the men could learn to use a cheap mineral oil to moisten the 
paper and catch the dust. The national Trade Union has already taken it 
up but many coach and carriage painters are outside the union and they 
need legal protection. 
The Printing Trades.14-The most important of the industries using 
metallic lead is the printing trade, with its allied branches, electrotyping, 
stereotyping and typefounding. It has been from its inception a 
notoriously unhealthful trade in all civilized lands for it is productive of 
more illness than would be expected of an industry, in which wages are 
high, hours not long, and in which there is no great contamination of the 
air, nor exposure to excessive heat or cold, nor excessive muscular effort. 
The unhealthful features of the industry are these: It is an indoor 
occupation often carried on in hot, stagnant air; it does not require 
much physical exertion and therefore the printer's circulation is likely 
to be sluggish and he is oversensitive to cold; the nervous strain is great, 
especially in newspaper work and on the linotype machines; and the 
printer is exposed to various poisonous substances, of which lead is the 
most important. The amount of lead in the air of printing shops is small 
and the amount which the printer gets on his hands is small, yet though 
lead,poisoning is extremely rare as a cause of death among printers it is 
apparently an important cause of ill health. An examination of 100 
working printers in Chicago and of 100 in Boston showed that 18, or 
9 per cent., were suffering from chronic plumbism and 107 had 
impaired health. The significant symptoms were abdominal pain, consti- 
pation, articular pains and headache.15 THE PRINTING TRADES 
455 
.The sources of lead dust in a printing shop are the type cases, which are blown 
out from time to time, the scraps of lead which fall from linotype and monotype 
machines, from the routers, trimmers and saws for electrotype and stereotype plates, 
and the dross that is skimmed from melting pots and is brushed off the linotype 
plungers. Lead fumes arise from melting pots when the lead is stirred, ladled, skim- 
med or poured. The experiments of Phelps16 showed that the agitation of the lead 
in monotype and linotype machines is not sufficient to detach the fine layer of oxide 
on the surface and thus contaminate the air, but in stereotyping and electrotyping 
there is enough disturbance of the molten lead to bring this about. Linotypists 
usually believe that the discomfort they experience when the fumes from their lead 
pots are not carried off is due to lead, but it is really caused by carbon monoxide from 
the naked gas jets. Linotypists may, however, contract lead poisoning, from dust in 
the air or from fumes arising from the melting pots for old type which are often placed 
in the same room. 
Hand composition should be attended with little risk, provided the printer is 
cleanly in his habits, for he need come in contact only with the small amount of lead 
dust caused by handling type. If all composing rooms were properly arranged it 
would be possible to protect the workmen simply by providing ample washing facili- 
ties, but in most printing shops there are other sources of lead in the composing room, 
scraps from linotype machines, melting pots with their piles of dross and scrap and 
the fumes that arise from them during skimming and ladling. Monotype casting is 
usually carried on in a separate room, well ventilated, and the danger from lead is 
slighter. The same discomfort from the fumes of gas jets is experienced here as in 
linotyping, unless good exhaust ventilation is provided. In stereotyping there is 
decidedly more danger from the lead both in the form of fumes and of dust. All these 
evils are avoidable and in the best plants they have been done away with/but in the 
usual newspaper plant the stereotyping department is the worst housed of all and the 
most carelessly managed in this respect. Electrotyping also involves a good deal of 
exposure to lead, in melting down old plates, pouring, trimming, routing, bevelling, 
sawing. The temperature in the kettles is often allowed to run up higher than is 
necessary, increasing the danger of fumes. In the majority of electrotype foundries 
there is little if any effort to carry off these fumes. 
Whenever old type is melted down the oils in the printers' ink decompose and, long 
before the lead begins to be given off in fumes, very acrid, irritating fumes of acrolein 
arise. These are so disagreeable that it is usual to lower a hood over the kettle during 
the first stages, but then it is raised and when the lead begins to reach the point of 
danger the hood has been done away with and these fumes escape into the room. 
Tuberculosis, not plumbism, is the occupational disease of printers (Hahn16). 
For instance, Hayhurst 17 found that among 273 deaths of compositors and pressmen 
in Ohio, 58 or 21.25 per cent, were from pulmonary tuberculosis, while during those 
same years the rate for occupied males in Ohio was 13.3 per cent, and among men in 
agricultural life it was only 7.13 per cent. The death records of the International 
Typographical Union show, however, a marked improvement in this respect during 
recent years. Between the years 1900 and 1915 the membership in the Union 
increased from 32,105 to 59,571 and the per cent, of deaths from tuberculosis fell from 
31.2 to 19.1, the average age at death being raised by some 9.5 years. The reasons 
given for this improvement are the shorter working day, better sanitary conditions in 
the majority of shops, and the introduction of machinery with the consequent lessening 
of lead poisoning, for it has been abundantly shown that plumbism and tuberculosis 
go hand in hand (Hahn16). 
In Europe typefounding seems to be carried on as a branch of printing, 
and sickness among type founders is included with the sickness records 
for the printing trades. In the United States it is a separate industry, 456 
LEAD POISONING IN THE UNITED STATES 
being practically limited to two or three large plants. There is more 
lead poisoning among type founders than among printers, for these 
foundries contain large numbers of casting machine with open lead pots 
in which the heat is often allowed to run up to a dangerous point and 
which are never hooded, and in addition, until quite recently, all the type 
cast by these machines had to be "finished" i.e. trimmed, bevelled, 
smoothed, by hand with the production of much excessively fine lead dust. 
In Austria women foundry helpers have much the highest rate of plumbism in the 
printing trade, one case for nine employed, while compositors have only one for 35. 
In Germany five times as many founders as compositors have lead poisoning. In the 
United States the only cases of lead poisoning reported among women engaged in the 
printing and allied trades have been among foundry workers. 
The old type of machine is the Bruce and it casts type which must be "finished." 
The new type is the Barth, and as it casts type which is already finished the greatest 
source of lead dust, the hand dressing, filing, smoothing, etc. is no longer needed 
and foundries equipped with these machines are much safer than the older ones, 
although the Barth machines may give off lead fumes to contaminate the air. 
Manufacture of Rubber Goods.16-Lead, chiefly as litharge, but also 
as the basic sulphate, is used in compounding rubber. The lead com- 
pounds are sifted, weighed and carried in open boxes together with crude 
rubber, sulphur and other ingredients, to mixing mills, where the box is 
emptied and warmed cylinders grind the materials together into a paste. 
As grinding proceeds a good deal of the dry portion falls off and is caught 
in a mill pan and the mixer is obliged to stoop down and with a long 
handled brush sweep up the powder and throw it back into the mill. 
This he does repeatedly for each batch of rubber and he may mix as many 
as 50 batches in a day. 
The work of sifting, of weighing, and of mixing is dusty unless every 
precaution is taken in handling the lead and unless there is a good system 
of exhaust ventilation in connection with the sifting machines and the 
mills. Many mixing mills in American factories have been provided with 
hoods with suction to carry off the dust, but these hoods are usually poorly 
constructed and the exhaust seldom strong enough to be of any value. 
Cases of lead poisoning have been found to be not uncommon among 
rubber compounders and mixers in our factories, especially those in which 
the largest amount of lead is used, the footwear factories, plants for the 
manufacture of mechanical rubber, and tire works. White rubber and 
highly colored rubber cannot be compounded with lead, for the formation 
of lead sulphide blackens it and spoils the color. Hard rubber has little 
if any lead. The tendency now in the rubber industry is to substitute 
for lead, compounds which are usually less harmful to the workman, such 
as anilin-formaldehyde, thio-carbanilid, hexamethylene-tetramin or uro- 
tropin, and various pine oils. 
There has been no detailed study of lead poisining in the many trades 
in this country in which metallic lead is used, nor in the grinding and 
making of paints and colors nor in lithotransfer work. Enough work REFERENCES ON LEAD POISONING IN THE UNITED STATES 
457 
has been done, however, to show that all the lead industries of the United 
States need regulation and that we can hardly hope to lower our high 
morbidity rate till we adopt the measures which have been followed with 
signal success in other countries. 
REFERENCES 
1 Report of Illinois Commission on Occupational Diseases, Jan., 1911. 
2 Bulletin 95, U. S. Bureau of Labor. 
3 Reprint of Appendix VI to Preliminary Report of the N. Y. State Factory Investi- 
gating Committee, Mar., 1912. 
4 Bulletins of U. S. Bureau of Labor, Nos. 95, 104, 120, 141, 165, 166, 179, 204. 
5 Hobbs, W. I.-N. Y. Med. Journ., 1898, LXVII, page 322. 
6 Bulletin of U. S. Bureau of Labor, 95. 
7 Bulletin of U. S. Bureau of Labor, 104. 
8 Bulletin of U. S. Labor Statistics, 141, Appendix. 
9 Carlson, A. J. and Woelfel, A.-Journ. Pharmacol, and Exper. Therap., 1913-14, 5, 
549. 
10 Muller, Rich.-Bekampfung der Bleigefahr in Bleihutten, Jena, 1908. 
11 Bulletin of U. S. Bureau of Labor Statistics, 165. 
12 Bulletin of U. S. Bureau of Labor Statistics, 120. 
13 U. S. Nav. Med. Bull., 1912, Vol. VI, page 161. 
14 Bulletin of U. S. Bureau of Labor Statistics, 209. 
15 Hahn, M. Die Gesundheitsverhaltnisse im polygraphischen Gewerbe Deutschlands. 
Bericht an die internationale Vereinigung fur gesetzliche Arbeiterschiitz., 1908. 
16 Bulletin of U. S. Bureau of Labor Statistics, 179. 
17 Hayhurst, E. R.-Ohio Survey of Industrial Health Hazards and Occupational 
Diseases, State Board of Health, Feb., 1915, page 73. SECTION 12 
LEAD POISONING: NOTES, STATISTICS AND PREVENTIVE 
MEASURES 
GEORGE M. KOBER, M. D., Washington, D. C 
Introduction.-All occupations involving the handling of lead and its 
compounds and in which lead fumes or particles of lead dust may be 
inhaled, swallowed, or absorbed must be regarded as dangerous to health. 
Layet has enumerated 110 trades in which lead poisoning is liable to 
occur, but there are doubtless many other occupations in which lead 
intoxication may take place. Neisser,1 for example, reports a fatal case 
in a man who spent most of his time in fishing and contracted lead poison- 
ing by the habit of placing the lead sinker of the fish line in his mouth; 
another fatal case occurred in a saddler, who did not handle lead in any 
other way except that he used occasionally a small block of lead in pound- 
ing leather. 
Dr. Alice Hamilton2 cites a case reported by Pratt of a 22 year old 
man who was poisoned by unloading pig lead from barges; also a case 
of plumbism in a man who had for two months swept up the shavings from 
the casting and finishing machines in a factory where lead fixtures were 
made; she has known plumbism in a sorter of lead and brass junk, and in 
a man who swept up dross from around a kettle and carted it away; she 
also reports a case of a man, who suffered from acute lead poisoning 
after only three weeks' work making lead stoppersand perforated strainers 
for wash basins. Dr. Marvin D. Shie reports similar unusual cases, one 
of which apparently developed from the use of a cane with a lead head. 
(J. A. M. A., Mar. 28, 1921, page 835.) 
Great Britain has the most complete statistics on the subject of lead 
poisoning, notification of which was made compulsory in 1895. Dr. 
Legge3 has tabulated 6762 cases with 245 deaths, which occurred in 
different industries of that country between 1900 and 1909, both inclusive. 
I .have arranged his table according to frequency as follows: Of the 6762 
cases, 1295 were reported in the white lead industry, 1065 in the pottery 
industry, 697 in coach building, 422 in the manufacture of paints and 
colors, 452 in paints used in other industries, 412 in smelting of metals, 
285 in electric accumulator works, 269 in ship building, 217 in plumbing 
and soldering when carried on in factory premises, 211 in file cutting, 
200 in printing, 138 in tinning and enameling, 109 in the manufacture of 
sheet lead and piping, 108 in red lead works, 75 in brass works, 52 in 
enameling iron plates, 48 in glass cutting and polishing, 48 in litho- 
458 PREVALENCE OF LEAD POISONING 
459 
transfers and 659 in other industries. These figures do not include cases 
among house painters and house plumbers. 
In 1919, Dr. Legge reports that lead poisoning had increased in Great Britain 
owing to the return from the army to ordinary trades. It is now greatest in the manu- 
facture of electric accumulators, especially in "pasting." Similar reports have been 
made in France and Germany. In his report for 1921 Legge states: "Deaths from 
lead poisoning have by no means grown fewer; there were 23 in 1921 with 230 notified 
cases, as compared with the average for 1902-1905 of 23 deaths with 601 notified cases. 
The secret is that deaths concern old chronic poisoning established before modern 
preventive measures were adopted, while the reduction in notified cases represents 
immediate results of these measures. These results are also to be found in lessened 
severity in the cases, thus lead palsy was present in only 7.4 per cent, in comparison 
with 12.7 per cent, for the five years 1910-1914." 
Ettore Tedeschi reports four cases of saturnine neuritis, three in the printing 
trades and the fourth in a painter, all suffering from sciatica, confined chiefly to one 
side. 
He also reports 2 cases of saturnine bronchial asthma in men suffering from chronic 
lead poisoning. Lead is considered the cause in all of these cases. (Abstracted from 
Riforma Med., 1921-1922, in II Lavoro, Feb. 28th, 1922, and by Dr. Alice Hamilton 
in Jour. Ind. Hyg., Oct., 1922. Abst p. 85 and 87.) 
Dr. E. R. Hayhurst4 reported from the state of Ohio between July, 
1913, and November 30, 1914, 514 positive and 138 tentative cases of 
lead poisoning in 48 industries, chiefly in the manufacture of electric 
apparatus, storage batteries, babbitting metals, solder, painting automo- 
biles and carriages, and in the pottery and rubber industries. 
In Ohio, in the years 1921 and 1922, physicians' reports showed a shift in the chief 
source of lead poisoning from storage batteries to automobile painting (or enameling). 
Yet by the latter part of 1922, the substitution of pumice and water, or of a water- 
proof sand paper for dry sanding, had greatly reduced the incidence of plumbism in 
painting and enameling automobiles. 
Wachter,1 based upon a study of 1383 cases of lead poisoning in Prussia, 
rates the risks as follows: white lead workers, 33 per cent.; red lead workers, 
32 per cent.; shot and pipe workers, 20 per cent.; painters, 9-10 per cent.; 
lead and zinc smelters, 8-9 per cent.; printers, 0.5 per cent. 
Mining of lead ore involves the general hazards incident to metal- 
liferous mines. The danger from lead in this operation is generally 
regarded as slight, unless the ore contains lead in the form of carbonate or 
sulphate. It is not improbable, however, that the subtle forms of lead 
poisoning may occur in all lead-ore mining from the ingestion of lead 
dust. 
Lead Smelting.-The English statistics of 412 cases of lead poisoning 
in smelting of metals include 253 cases in persons engaged in the smelting 
of lead ores and in desilvering lead, 99 in the manufacture of zinc and 60 
cases in smelting other lead-containing metals, such as iron or copper 
ore. 460 
lead poisoning: notes, statistics and preventive measures 
Of 999 employes in Prussian lead smelters6 in 1905, 177 suffered from 
lead colic or lead palsy, involving 3056 days loss of work. In recent years 
conditions are more favorable. In 1909 among 550 lead smelters near 
Hildesheim, only four cases of lead poisoning were reported and at Pots- 
dam only five among 660 workers.7 
Muller8 found from 0.0029 to 0.00569 gram of lead per cubic meter in 
the air of smelting works, and the water in which the hands of litharge 
grinders and sifters were washed was found to contain 1.27 grams of lead 
per liter. 
White Lead.-In Massachusetts9 it was found that the men who 
empty the stacks did not remain long at work, partly because of their 
roving disposition and the disagreeable character of the work; others 
acquired lead poisoning and were obliged to quit, and even those of good 
intentions rarely worked more than a month. According to Prof. Roth,6 
quite a number of German proprietors of white lead works purposely 
employ men of roving disposition or make frequent changes, quite 
unmindful of the fact that this very class, because of ignorance and neglect, 
are much more liable to contract lead poisoning. The factory inspectors 
of Great Britain long ago pointed out the danger of employing casual 
labor. Dr. Legge reports that of 1463 persons employed in white lead 
works, the incidence of lead poisoning was 6 per cent, among the regular 
employes, against 39 per cent, in the casual workers. 
Preventive Measures.-Sanitarians have urged for years the substitu- 
tion of less harmful substances for lead, such as zinc oxide and lithopone 
for lead paints, leadless glaze in potteries for lead glaze, tin blocks for lead 
beds in file cutting, etc. Excellent preventive measures have been promul- 
gated and as a result of factory sanitation, official regulations, and educa- 
tional methods a gratifying reduction in the morbidity and mortality from 
plumbism has taken place. For example, in Great Britain, where com- 
pulsory notification exists, the number of cases of lead poisoning was 
reduced from 1278 in 1898 to 505 in 1910 and 230 in 1921. The percent- 
age of severe cases in men was 23.9 against 13.9 females, possibly due to 
the fact that females have cleaner habits and also stop work more 
promptly upon the appearance of the first symptoms. 
The general principles embodied in official regulations should provide 
for (1) the removal of the toxic fumes by forced ventilation; (2) reduction 
of dust production by the wet processes and automatic machinery, and its 
removal by exhaust ventilation. (3) Respirators should be worn and the 
hours of labor for those engaged in the oxidation chambers and other 
dusty processes should be shortened, with alteration of work. (4) 
Lockers should be provided so as to protect the street clothing worn by the 
employes. (5) Washing and bathing facilities should be provided. (6) 
Special lunch rooms are necessary. • (7) Semi-monthly medical inspection 
of employes, suspension of work in case of sickness, and re-examination MEDICAL SUPERVISION AND PREVENTION 
461 
before returning to work should be enforced. (8) Alcohol and tobacco 
should be forbidden during the working hours. 
According to L. Teleky (Jr. Ind. Hyg., Sept., 1922, p. 214) medical supervision of 
employes in Germany (in addition to physical examinations on entry), is at the pres- 
ent time prescribed in the following industries: 
Lead smelters, at least once a month (Law of June 16, 1905). 
Zinc smelters, at least once a month (Dec. 13, 1912). 
Storage battery plants, at least once a month (May 16, 1908). 
Manufacture of alkaline chromates, at least once a month (May 16, 1907). 
Nitro- and amido-compounds, at least once a month (1911). 
Thomas Slag, at least once a month (July 3, 1909 and Dec. 23, 1911). 
Vulcanizing of rubber goods, at least once a month (Mar. 1; 1902). 
Preparation of lead colors and other lead compounds, at least twice a month 
(Jan. 27, 1920). 
Painters and paint workers in connection with other industries, at least twice a 
year (June 27, 1905). 
E. Francke, cited by Teleky (above, p. 216) states that in the short fraction of the 
year 1912 for which the sickness insurance companies made their returns, in spite of 
the incompleteness of the reports, 1,119 cases of lead poisoning (lead line or suspicious 
cases not included) came to the notice of the industrial supervision officers, as com- 
pared with 174 in 1911, and 93 in 1910. Subsequently 564 cases were reported for 
1911 and 526 for 1910, making the total for these two years 738 and 619 respectively. 
While prevention of the inhalation of lead containing dust and fumes 
is recognized as the chief factor in limiting lead poisoning, in the way of 
individual hygiene, personal cleanliness, temperate habits, good food and 
fresh air are important. The work should be done in overalls, frequently 
changed and washed. The head should be covered with suitable caps; 
short hair and no beard offer distinct advantages. Before meals the 
exposed parts of the body should be "dry dusted," the hands, face and 
nostrils thoroughly washed with soap and warm water, and some advise 
that the mouth and throat be rinsed with a solution of tartrate of ammonia. 
All health rules should be conspicuously posted and the attending 
physicians should educate the employes so that they may guard against 
the dangers, remembering always Sir Thomas Oliver's view that lead 
poisoning may be easily caused and almost as easily prevented. The 
so-called sanitary drinks, made of epsom salt, lemon juice, etc., are of little 
avail; there is at present no real antidote to this subtle poison. The 
drinking of milk with, and between, meals and avoidance of lead exposure 
on an empty stomach (workers should always eat before beginning work, 
especially breakfast) have an experimental basis as proper procedure. 
Lead Pipe and Plumbers' Supplies.-The men engaged in the manu- 
facture of lead pipe and plumbers' supplies are exposed to lead poisoning 
not only from the fumes, but also from dust in handling sheet lead. 
The Massachusetts Report9 speaks approvingly of the efforts of the manu- 
facturers of plumbers' supplies to carry off the dust and fumes by hoods 
and exhaust ventilation, that all the employes took the necessary 
precaution and in no instance was it possible to trace a case of lead poison- 462 
lead poisoning: notes, statistics and preventive measures 
ing to faulty methods. Lead poisoning, however, is rare in this industry 
(Hayhurst). 
Solder and Babbitt Metal.-The manufacture of solder and babbitt 
involves exposure to lead. Common solder is a mixture of equal parts of 
lead and tin. Hard or fine solder is composed of two parts of tin and one 
of lead, and coarse or soft solder contains two parts of lead and one of tin. 
In an establishment9 for the manufacture of solder, although rats, cats 
and dogs appear to succumb to lead poisoning, only one case of plumbism 
occurred among the employes in 35 years. 
Soldering Tin Cans, Etc.-The use of solder and babbitt is evidently 
much more dangerous in this country than elsewhere. According to Dr. 
Alice Hamilton2 the records of most hospitals in our large cities contain 
more cases of plumbism among the users of solder and babbitt than among 
workers in such notoriously dangerous industries as white and red lead, 
paint grinding and making storage batteries. The Illinois Factory 
Inspectors Report for 1913-14 refers to 184 cases of lead poisoning from 
four places in which tin cans were manufactured. In one workshop with 
12 unhooded soldering machines and crowded with 100 persons, 18 cases of 
lead poisoning developed during one month of cold weather when the 
windows were closed. 
Harry W. Keatley (U. S. Pub. Hlth. Rept., Sept. 10, 1921) reports a large percent- 
age of burns in men engaged in soldering air-tight containers for shells from the acid 
soldering flux; it was found that by reducing the flux to one-half strength the work 
would be done just as well with 50 per cent, saving in cost of acid and elimination of 
the burns. 
Leaden Car Seals.-The casting and finishing of leaden car seals 
likewise furnishes a disproportionate amount of lead poisoning. In a 
force of 188 employes in Chicago there were 28 cases of lead poisoning in 
one year. 
Since the enforcement of the Occupational Disease Act of Illinois 
conditions have greatly improved. According to Austin D. Reiley10 the 
average number of employes examined for the year ending June 30th, 1917, 
in 150 plants in Chicago was 6497; the number of cases of lead poisoning 
discovered was 149 or 2.3 per cent, of those employed. Of these 104 
occurred in smelting and refining processes, 22 in painters, 5 in paint 
makers, 10 in tin ware workers and 8 in other industries, and none 
among car seal workers. In New York State during the six years ending 
August 31st, 1917, there were reported 617 cases with 91 deaths. Of these 
cases, 318 with 59 deaths occurred among the painting trades and (the 
lesser half) of 299 cases with 32 deaths occurred in over fifty industries. 
Storage Batteries.-In storage battery manufacture, Dr. W. H. Wood 
of the Willard Storage Battery Co., Cleveland, (Nat'l. Safety Council, 
7th Ann. Proc., 1918, 628-632) found that a solution of MgSO4 sprayed 
over floors and benches would change lead dust into a non-dusty state 
while at the same time it was not injurious to any part of the battery CERTAIN HAZARDOUS LEAD TRADES 
463 
and was easily cleaned up. This is an industry in which lead poisoning 
has very materially decreased in Ohio in recent years (Hayhurst). 
Plumbers, Gas and Steam Fitters.-These occupations are often 
carried on under unfavorable environments, especially in new construc- 
tion, which involves ditch work and exposure to dampness in cellars and 
basements. Exposure to lead is unavoidable in handling, cutting, and 
filing of lead pipes, bends, traps, etc., and also in the employment of white 
or red lead for making joint connections. The use of solder involves 
exposure to lead and acid fumes and the products of combustion of either 
an open charcoal fire or a gasoline torch. Cases of arseniureted hydrogen 
poisoning have been reported in plumbers, and the hydrogen flame con- 
stitutes a distinct menace. Soldering in confined places as in railway 
coach toilet rooms, ice boxes, etc., greatly enhances the risk to lead and 
other poisonings. Unwashed hands doubtless play a frequent role in the 
ingestion of lead. Sternberg11 has reported wholesale cases of plumbism 
in Vienna among this class of workers. The accident risk in new con- 
struction work is not inconsiderable; the morbidity hazard among the 
Leipsic plumbers and gas fitters amounts to 836 days per 100 workers per 
annum, with a mortality hazard of 0.60 per cent. Hoffman's12 statistics, 
based upon 1133 deaths among plumbers, show that 32.9 per cent, of the 
mortality from all causes was due to tuberculosis, followed by accidents 
with 11.7 per cent.; diseases of the urinary organs, 11.1 per cent.; pneu- 
monia, 7.7 per cent.; heart disease, 5.2 per cent. (See also pp. 729, 980.) 
Manufacture of Shot.-In the manufacture of shot, metallic lead is 
fused with arsenious acid or more frequently with metallic arsenic in suit- 
able proportions. Arsenic is added to harden the shot. When the mix- 
ture is ready it is poured through sieves of different sizes at the top of a 
tower filled with water at the base, which hardens the lead drops. The 
shot is subsequently polished by means of graphite in a revolving drum. 
The fusion process involves exposure to both lead and arsenic unless 
guarded against by suitable crucibles. 
The Paint and Varnish Industry.-During the 1910 census, 21,896 persons were 
engaged in the paint and varnish industry of whom 19,496 were males and 2400, or 
11 per cent., females. The statistics cover the returns of two classes of establishments, 
viz., those engaged primarily in the manufacture of pigments or paints and those 
engaged in the manufacture of varnishes, japans, lacquers or fillers. The principal 
products of the latter class are mainly solutions of gums, resins, asphaltum, or other 
ingredients, in such solvents or vehicles as turpentine, linseed-oil, alcohol, benzine, 
benzene, etc. 
The Massachusetts State Board of Health9 in discussing the manufacture of paints, 
colors and varnishes, points out that much of the work is done by men who have 
worked from 6 to 20 years; the man who makes.the lead colors has worked 17 years 
without sickness. The last case of poisoning occurred 16 years ago, when a number 
of inexperienced men were poisoned with Paris green. In a color and mordant factory, 
where anilin colors, logwood, starch, sodium dichromate, etc., are used, about one in 
five of the employes was noticeably pale and sallow, and inflamed eyes, caused by 
the sodium dichromate, were not uncommon. In the manufacture of "whiting" 464 
LEAD poisoning: notes, statistics and preventive measures 
about half of the 58 men employed in three establishments visited "looked to be in 
poor condition." In making shingle stains pigments, like chromate of lead, Prussian 
blue, zinc and iron oxide, are first mixed or ground with linseed-oil or with creosote or 
some of the "heavy or light oils." In two of the establishments the men appeared to 
be careless in the matter of handling the pigments. 
PAINTERS 
This occupation covers a large number of specialties, and some 
industrial statistics include glaziers,* whitewashers and paperhangers 
under the general head of painters, decorators and paperhangers. 
The general classification suggested by Dr. Hamilton13 includes house, 
sign, and ship painters; coach painters, inclusive of wagons and carriages, 
automobiles, railway and street railway coaches, bridge, tank, and struc- 
tural iron painters; painters of agricultural implements, furniture, picture 
frames and mouldings. It is obvious that the occupational risks vary con- 
siderably in the different departments, and depend to a great extent upon 
the materials employed, the character of the work, the conditions under 
which the work is performed and the precautions taken by the workers. 
The composition of paint may be very simple or quite complex. Among the 
poisonous pigments should be mentioned those containing arsenic, lead and mercurial 
compounds, and among the liquid vehicles, driers and varnishes, which may act as 
industrial poisons, are turpentine, benzine, benzol, creasote, wood alcohol, asphaltum, 
amyl acetate, banana oil (a mixture of amyl acetate, acetone and benzine) and carbon 
disulphide. 
All quick-drying flat-finish paints or varnishes are generally made of leadless 
pigments, but usually contain some of the petroleum products, which may be a source 
of benzine poisoning, as the work has to be done in closed rooms because open windows 
and drafts cause the paint to dry too rapidly and render the coat streaky. 
Alfred Arnstein (Wien. Klin. Wchnschr., 1922, 35, No. 21, p. 488) reports: Two 
painters were at work in a bank vault for 3 days. Tetralin (tetrahydronaphthalene) 
was used as a substitute for turpentine, and caused early irritation of the mucosa, 
also headache and stupor. The most striking symptom was a dark green coloration 
of the urine. The symptoms disappeared when the men stayed away from the work. 
Among other things tetralin is used in the preparation of floor wax, and it thus offers 
opportunity for the poisoning of many people. (Jour. Ind. Hyg., Nov., 1922, Abst., 
p. 105.) 
Lead poisoning among painters has long since characterized this 
occupation as a dangerous trade. Koelsch15 in a careful study of 5000 
painters in Munich found that only 8 per cent, were over 50 years of age; 
* Dr. Harry W. Keatley, U. S. P. H. S., under date of March 28th, 1921, reported 
to Dr. John W. Trask, Medical Director, U. S. Employes' Compensation Commission, 
a case of acute dermatitis caused by glazier's caulk. The patient while using squirt 
guns in the operation of fastening glass plates to frames, dipped his hands in the 
container. Glazier's Caulk being a patented preparation with no published formula, 
the report of the chemist of the Arsenal is of interest. Acidity (Oleic) 5 mg. to the 
gram of compound. The compound is distinctly acid, containing cresols and phenols 
with probable organic acids. painters' afflictions 
465 
the majority were between 16 and 40 years of age. Of this number 
13.83 per cent, had experienced symptoms of lead poisoning; about one- 
third had suffered from more than one acute attack. . Colic occurred in 
about 85 per cent, of the cases; lead palsy in 3.5 per cent.; joint affections 
in 2.7 per cent.; sciatica, visual disturbances, renal involvement and gout 
in about 2 per cent, of the cases. Cases of lead poisoning involving the 
brain were not encountered, since the physical examination was limited to 
actual workers; the hospital records of Munich show, however, a propor- 
tion of 5.5 per cent. About 29 per cent, of all the workers examined 
showed objective or subjective symptoms of lead poisoning; 11.8 per cent, 
revealed the characteristic gum lines; 6.5 per cent, were anaemic; digestive 
disorders, headache, tremor, dizziness, circulatory and kidney disorders 
and rheumatic affections were not infrequent. 
Koelsch's general percentage corresponds very closely with the 
results obtained by the Illinois Commission on Occupational Diseases for 
1911, which show that of 578 cases of lead poisoning, 27 per cent, were 
painters. The statistics of Pratt and Andrews, cited by Dr. Hamilton,13 
indicate a higher percentage. The average age of 1388 painters, decora- 
tors and paperhangers in Chicago in 1911 was 41 years and 3 months. 
It is of interest to note that the painters examined by Dr. Hayhurst were 
encouraged to state what they considered the most unhealthful feature of 
their work and 99 out of 100 mentioned the lead-paint dust from sand- 
papering, 70 complained of benzine, 64 of turpentine when used in close 
quarters, and nearly all stated that the fumes of benzine and turpentine 
in hard oiling made them sick temporarily. Three of the men had been 
victims of wood alcohol blindness, contracted while working in brewery 
vats. 
Hayhurst4 in his Ohio Survey reports 154 cases of lead poisoning, 
three from benzine and naphtha, two from turpentine and one each from 
varnish and wood alcohol. 
It is stated by Gardner11 that drying paints emit no metallic vapors, 
but they may evolve benzol, formic acid, aldehyde substances, carbon 
dioxide and carbon monoxide, and while all are more or less harmful, 
he very properly maintains that carbon monoxide may be a fruitful 
cause of anaemia among painters. Herman,17 more recently, experimented 
on the question of whether vapors or particles are emitted from lead 
painted surfaces. By hanging pieces of filter paper at various points 
within a room whose walls were coated with fresh lead paint he dis- 
covered lead on the papers under various conditions and concluded as 
follows: That very minute invisible paint droplets are emitted in consider- 
able numbers from freshly painted surfaces, that these tend to fall down- 
ward, that the emission consists of particles and not vapors, and that 
such emissions continue for a period of at least two hours, although they 
cease within forty-eight hours. These conclusions naturally suggest the 
need of copious ventilation. 466 
lead poisoning: notes, statistics and preventive measures 
Causes of Lead Poisoning among Painters.-(1) Mixing Dry Lead 
Pigments with Oil or Paints.-This source of danger is not pronounced, 
as most of the paints are manufactured in special establishments and very- 
few painters have occasion to use dry pigments, except those employed 
in structural iron painting who use red lead. Of 100 cases of lead poison- 
ing cited by Dr. Hamilton13 only two had used dry white or red lead. 
Unless the mixing is done carefully, or in inclosed machinery, there is 
danger from dust inhalation. 
2. Sandpapering of Lead Painted Surfaces.-This is universally acknowl- 
edged to be the most important cause of lead poisoning among painters, 
as the evolution of dust by dry sandpapering or rubbing with pumice- 
stone, naturally favors inhalation or ingestion of dust containing lead or 
other toxic agents. It is believed also that the sharp, angular character 
of sand or pumice-stone dust renders the mucous membrane vulnerable 
and hence more susceptible to the absorption of toxic dust. 
3. The Spray Method of Painting, Finishing and Decorating.--Albaugh18 
was the first one, we believe, to call attention to the dangers of use of the 
spraying machine in painting and decorating. He records a fatal case 
in the person of a young man whose death followed several months' 
exposure to ''quick dryers" used on small objects in a factory by a spray- 
ing machine, where the inhalation of benzine, benzol and turpentine 
were the undoubted causes of the fatality. Albaugh emphasizes that he 
had seen a number of cases of poisoning from naphtha, benzol and lead 
in this process. 
There were at that time, he estimated, approximately 2500 such sprayers in use in 
Ohio and in only about 25 per cent, of them had necessary precautions been taken to 
safe-guard the health of the operatives. The fine nebular clouds give opportunity 
for great diffusion and easy inhalation of the substances used, nearly all of which are 
poisonous. 
Sharpe19 made an experimental study of the hazard to the health of operatives 
using the spraying machine, from the point of view of lead poisoning, and says: 
" These experiments show that when lead is a constituent of the paint used in spraying 
walls inside a building there is danger of absorption of lead." 
He also found lead in the urine and stool of an operative after three days' work and 
says, "our figures show that a workman employed in spraying an inside wall might in 
a few days absorb 350 mgm. of lead (the minimum required to produce poisoning in a 
man of 150 pound's weight) over and above the amount which he can excrete. Conse- 
quently, he is exposed to a highly dangerous degree." 
Hence we have evidence here of the menace of rapid and even fatal 
poisoning from vehicles and pigments used in spraying machines. It is 
probable that the solution lies either in limiting their use to exhaust hoods 
or equipping the worker with a full helmet and air tube similar to a 
diver. 
The Mines Safety Appliance Company, Pittsburgh, Pa., has recently announced 
a mask and canister device of the Burrell type which is claimed to protect the 
wearer against all gases (including even carbon monoxide), dusts and vapors, which, 
from description, would appear serviceable in the paint spraying process. (Hayhurst.) CAUSES OF LEAD POISONING AMONG PAINTERS 
467 
4. The removal of old paint by means of benzine, wood alcohol, com- 
pressed air, chipping, or scraping is equally dangerous work, especially 
when this has to be done in confined spaces, notably between the outer 
and inner shell of steel ships. Burning oft the old paint by means of 
a small gasoline torch is a safer method, as there is little or no danger from 
lead fumes, unless the workman permits the flame to play long enough 
on the surface to volatilize the lead and produce a decided smoke, in 
which case particles of lead may, in the opinion of Prof. Stieglitz, be carried 
oft mechanically with the smoke.* The inhalation of lead dust from dirty 
drop cloths and overalls is doubtless a frequent cause of plumbism among 
house painters and decorators. And for obvious reasons the men should 
also be careful not to expose their street clothing to lead-containing dust. 
5. The ingestion of lead through unwashed hands, etc., while eating, 
drinking, smoking, or handling tobacco and pipes, is naturally a possible 
cause of plumbism. It is not nearly as important as the direct inhalation 
of lead dust, droplets, and fumes, however. While every painter 
knows that "hot water and soap and time enough to use them" are 
important protective measures, the fact is that these facilities, except in 
shop work, are not always available. In new construction work and 
vacant houses the water may not be turned on, and the workman is 
obliged therefore to clean his hands with benzine, turpentine, etc., 
provided for cleaning the paint brushes, and those who fear that these 
agents drive the lead into the pores of the skin, simply resort to a piece 
of rag, cotton waste, or paper for the removal of gross particles of lead. 
Among the contributory factors to lead poisoning should be mentioned 
chronic alcoholism. My personal observations lead me to conclude that 
the alcohol habit is quite prevalent among painters, and old topers do not 
hesitate to tipple alcohol from shellac and even denatured alcohol. 
Pieraccini has pointed out that lead in the system creates a desire for 
alcohol, and that the combined effects quickly damage the kidneys and 
arteries. The life insurance statistics, on the other hand, indicate that 
only 1.4 per cent, of the 2783 deaths among painters were caused by 
alcoholism, as against 1.9 per cent, for plumbers and masons and an 
average of 1.5 per cent, for 103,434 occupied males. The German and 
French statistics are not so favorable. 
* Dr. Legge20 makes special reference to the risk from using the oxyacetylene flame 
on painted steel plates in breaking up old battleships; at the high temperature gen- 
erated, 49 mg. of lead are given off as fumes in 10 c.m. of air, as compared with 3.4 mg. 
in the process of burning off lead paint with oxygen and gas flame. At the same 
process Dr. J. C. Bridge found men working on galvanized plates, suffering from typi- 
cal "brassfounders' ague" due to inhaling zinc fumes, of which there was risk of inhal- 
ing from 12-25 mg. daily. R. Engelmann,22 reports the case of a young man who 
operated an oxyacetylene or oxyhydrogen torch in dismantling a ship's boiler. In 
cutting through the boiler plate he also had to cut through a heavy sheet of zinc 
plate. The ventilation was poor so that the fumes from the vaporized zinc were 
inhaled and resulted in symptoms of "founders' fever." 468 
LEAD poisoning: notes, statistics and preventive measures 
Accidents and Other Afflictions of Painters.-The liability to 
accidents, such as falls from ladders and scaffolds, is not inconsiderable 
and house painters are likewise exposed to electric shocks from overhead 
wires. Hoffman's Industrial Insurance Statistics12 show that of 2783 
deaths among painters 23.8 per cent, were caused by tuberculosis, and 
9.9 per cent, from other respiratory diseases, making a combined rate of 
33.7 per cent, from diseases of the respiratory organs; the rate from lead 
poisoning was 1.5 per cent.; from nervous diseases 10.7 per cent.; from 
heart, kidney and liver diseases 25.9 per cent. The German figures, cited 
by Fleck,14 are 41.6 per cent., 1.3 per cent., 7.8 per cent, and 20.8 per 
cent, respectively. The Leipsic Sick Benefit records show 1017 days of 
sickness a year per 100 members and a mortality hazard of 0.72 per cent. 
Exposure to the elements doubtless plays an important role in the causa- 
tion of catarrhal and rheumatic affections and diseases of the respiratory 
organs. Pneumonia, according to Hirt, is more common among house 
painters than in decorators and varnishers. Diabetes is reported by 
Rosenfeld as not uncommon. Affections of the eyes, from exposure to 
dust, toxic fumes, etc., are likewise quite frequent, and dental and gastric 
diseases are equally common. See also diseases of the circulatory organs, 
arteriosclerosis and diseases of the kidneys. Flat-foot, knock-knee, and 
varicose veins as a result of prolonged standing are not uncommon, and 
housemaid's knee has been noted among men, who make a specialty of 
painting or polishing floors. Callosities of the palm of the hands, and 
inflammatory affections of the skin of the hands and arms caused by 
turpentine and petroleum products are not infrequent. (See also p. 980.) 
Preventive Measures.-Dr. Hamilton has pointed out elsewhere the 
salient features in the prevention of lead poisoning among painters. Pro- 
fessor Sommerfeld regards dry sandpapering as the most fruitful cause of 
lead poisoning and hence no effort should be spared to substitute moist 
processes and to resort to all the precautions referred to on page 460. 
The French Government adopted radical measures for the suppres- 
sion of white lead paint, to take effect January 1, 1915. According to 
the Monthly Review of the U. S. Bureau of Labor Statistics for November, 
1915, a committee appointed by the Home Department of Great Britain 
recommended the enactment of a law prohibiting the importation, sale, 
or use of any paint material containing more than 5 per cent, of its dry 
weight of a soluble lead compound.* Germany has forbidden the mixing 
of white lead by hand, and insists that the rubbing of fresh or old paint 
*Ludwig Teleky21 in his review of German views of the white lead question con- 
siders the prohibition of lead colors for indoor work (extended to window frames, 
garden furniture, carriage and automobile enamel) to be absolutely essential, and 
technically possible to carry out; he considers equally necessary the prohibition in 
all kinds of painting of the use of red lead, .which is unfortunately often forgotten 
in the discussion; and in addition he recommends compulsory declaration of con- 
tents. Even in exterior painting, prohibition of white lead is necessary in spite of 
the technical difficulties of finding suitable substitutes. PREVENTION AND TREATMENT REFERENCES 
469 
with sandpaper or pumice may be done only after previous dampening. 
Austria has a similar law and also forbids the use of white lead for inside 
work except in certain cases. The German law also requires that the 
contractor for house painting shall provide caps and suitable overalls, 
kept in order and washed, and temporary working sheds, where the men 
may keep their street clothing, keep and eat their lunches, supplied with 
warm water, soap, wash-basins, nailbrushes, and towels. The employer 
must suspend from work any painter known to him to be suffering from 
lead poisoning. The law regulating painting in factories also forbids the 
use of alcohol and tobacco, and provides for medical inspection of 
employes at least every 6 months. A fpw of the states have enacted 
laws for the protection of workers in lead, some of the laws cover also 
painters when employed in factories or workshops. 
The Brotherhood of Chicago Painters and Paperhangers during a 
strike in April, 1913, formulated the following reasonable demand: 11 No 
workman or apprentice shall be required to use any poisonous substance or 
material injurious to health, such as wood alcohol, varnish remover, 
oxalic acid, or the sanding of lead, etc., unless they are protected with 
respirators, gloves, etc., same to be furnished by the employer; nor shall 
they be required to use any dirty or insanitary waste, rags or drop cloths. 
There shall be an allowance of 5 minutes for wash time in each 4 hour's 
work, and where lead or other poisonous material is used, the employer 
shall furnish hot water, soap and towels to the workmen. The officers 
and members of the organization shall enforce this clause." 
Drs. J. C. Aub and Anne Minot23 of the Department of Applied 
Physiology of Harvard University report that lead when inhaled or 
ingested is stored nearly completely in the calcareous portion of the 
bones where it remains for long periods. Reduction of the alkali reserve 
in the body allows the liberation of lead from the bones. Starvation 
(in leaded cats) will act similarly. Also ingestion of acid causes a 
markedly increased excretion of lead by the urine and feces. Phosphoric 
acid is the most effective method so far found, being more efficient than 
potassium iodide and causes a four fold increase in the rate of lead 
excretion over that occurring without treatment. Thus, distortion 
of the acid-base equilibrium may liberate lead from the bones long after 
its absorption and explains why lead poisoning is a chronic disease with 
possible late acute manifestations. These experiments offer a new 
method for increasing or decreasing the excretion of lead. 
REFERENCES 
1 Neisser.-Internat. Ubersicht uber Gewerbehygiene, 1907. 
2 Hamilton, Alice.-The Journ. of Industrial Hygiene, Vol. I, No. 1, 1919, page 10. 
3 Legge, T. M.-Actes du II Congress Maladies Professionelles, Brussells, 1910. 
4 Industrial Health Hazards and Occupational Diseases in Ohio, February, 1915. 
5 Wachter, Karl.-Die Gewerbliche Bleivergiftung im Deutschen, Reiche, 1908. 470 
LEAD poisoning: notes, statistics and preventive measures 
6 Roth.-Gewerbehygiene, 1907. 
7 Rambousek.-Industrial Poisoning, London, 1913. 
8 Muller.-Die Bekampfung der Bleigefahr in der Industrie, Jena, 1908. 
9 Report of the State Board of Health of Mass, upon Sanitary Conditions of Factories 
and Workshops, 1907. 
10 Reily, Auston D.-The Journ. of Industrial Hygiene, Vol. I, No. 3, 1919, page 114. 
11 Sternberg.-Medical Reform, 1906, No. 50. 
12 The Prudential Insurance Company of America, 1912. 
13 Hamilton, Alice.-Bulletin 120, U. S. Dept, of Labor, May, 1913. 
14 Fleck, Albert.-Weyl's Handbuch d. Arbeiterkrankheiten, Jena, 1908. 
x46 Koelsch, cited by Brezina. Oestr. Sanitatswesen, 1913. 
16 Jour. Ind. and Eng. Chemistry, Vol. VI, page 91, Feb., 1914. 
17 Herman, M.-Bull. Acad. Med. Belg., 4th series, Vol. XXVIII, page 7, July, 1914, 
and Scalpel, Vol. LXXII, page 14, Aug. 10, 1919. Abs.: Journ. of Indus- 
trial Hygiene, Vol. I, 8, Dec., 1919, page 126. 
48 Albaugh, R. P.- Ohio Pub. Hlth. Jour., Vol. VI, No. 5, Nov., 1915, 512-514; also, 
Am. Jr. Pub. Hlth., Vol. VII, No. 3, March, 1917, 279-281. 
19 Sharpe, N. C- Jr. Ind. Hyg., Vol. Ill, No. 12, April, 1922, 378-386. 
20 Legge, T. M.-Report of the Chief Med. Inspector of Factories and Workshops 
for Great Britain, 1919 and 1921. * 
21 Teleky, Ludwig.-Jr. Ind. Hyg., July, 1022, p. 100. 
22 Engelmann, R.-Deutsch. Med. Wochnschr., April 14, 1922; Jr. Ind. Hyg., Jan., 
1923, Abst. p. 144. 
23Aub, J. C. and Minot, Annie.-Proc. Amer. Soc. for Clinical Investigations, 
J. A. M. A., Vol. LXXX, No. 22, June 2, 1923, 1643. SECTION 13 
MERCURY POISONING 
BY LUDWIG TELEKY, M. D„ Dusseldorf 
Translated from the German by LEWIS W. FETZER, Ph. D., M. D., Dallas, Texas 
Symptomatology and Pathology.-In every case of poisoning the time 
at which a certain amount of poison is taken into the organism is of the 
greatest significance as to the kind of symptoms which follow. 
This statement seems obvious when we compare acute and chronic 
alcohol poisoning because in these the differences are very readily apparent 
even to .the layman. Therefore, we understand the term acute poisoning 
to mean poisoning that occurs in a limited space of time, say several hours, 
and as a result of taking one or more doses of a toxic substance. 
When, however, we attempt to define the limits which bound the 
various states of poisoning, namely, the acute versus the chronic, we 
encounter difficulties. May we, for example, designate as chronic that 
kind of poisoning which follows the third, or even the sixth, application 
of blue ointment? Even though we recognize the existence of transitions 
from the acute to the chronic stages of poisoning, we are aware of the fact 
that under the designation of chronic poisoning we may have the greatest 
of variations. Only recently it was pointed out by T. M. Legge and Ell- 
man, that in lead poisoning, which is the most frequently occurring form 
of industrial poisoning, the symptoms vary with the time at which the 
poison is taken. In mercurial poisoning the relation of the time of poison 
on intake to the clinical picture evinced is even more striking than in lead 
poisoning. 
Acute Poisoning.-In acute mercurial poisoning the clinical picture is governed by 
the manifestations in the intestinal tract. As an initial symptom we have profuse 
diarrhea in addition to the corrosion which may be present, but this is rarely observed 
in industrial cases of poisoning and is usually an accompaniment of poisoning from 
bichloride of mercury taken either by accident or with suicidal intent. The stools of 
acute poisoning are feculent at the beginning but soon become watery and profuse. 
In many instances, according to Kunkel, the stools become bloody, sometimes contain 
pieces of mucous membrane and are of a very disagreeable odor. During the act 
of defecation a marked tenesmus and a severe pain in the lower part of the abdomen are 
present. In some cases vomiting occurs even when the poison has not been taken by 
way of mouth. 
Simultaneous with the occurrences in the intestinal tract, renal symptoms become 
evident. These consist of a marked reduction in the output of urine, which may go on 
to a complete anuria. The urine in such cases contains, in addition to renal epithe- 
lium, white and red blood corpuscles. Consciousness is not affected but often the 
patients have headache and a feeling of fear, and near the end somnolence. With the 
loss in strength death usually occurs after several days. 
471 472 
MERCURY POISONING 
When corrosive sublimate is taken instant pain and burning in the mouth occur 
as a result of the corrosive action of the substance, but where poisoning is effected by 
resorption of a solution of mercury through other channels, as the uterus or bladder, 
the major part of the symptoms in the buccal cavity which play an important role in 
subacute industrial poisoning, are absent. 
I have never had the opportunity of seeing among the numerous cases of industrial 
poisoning which have come under my observation a marked case resembling the one 
described. Although I have been informed of the occurrence of slight diarrheas and 
despite the fact that I have the idiosyncrasy of becoming thus affected after washing 
in a solution of bichloride of mercury, I have never observed or read of a case of 
industrial mercury poisoning with pronounced acute symptoms. I have described 
acute mercurial poisoning simply because the probability exists that such cases may 
happen as a result of inhaling large amounts of mercurial vapors in establishments 
where the conditions are extremely bad. 
Subacute and Chronic Poisoning.-In subacute mercurial poisoning 
the most prominent symptom is the inflammation of the buccal cavity. 
The patient complains of pain in the mouth and experiences difficulty in 
chewing at a time when other objective symptoms, save increased saliva- 
tion, are lacking. Loosening of the gums soon follows, however, and they 
eventually swell, become red and bleed very easily. From under the 
reddened parts of the gums a thin pus exudes. The entire mucous 
membrane of the buccal cavity becomes involved in the process and on 
the mucous membranes of the cheek and lips sharply defined yellow ulcers 
develop, giving rise to a disagreeable odor from the mouth. 
The stomatitis, with which is associated swollen lymph and salivary glands may 
reach a high degree of severity and result, in addition to the loosening of the gums and 
falling out of the teeth, in undermining the general health and, as the literature informs 
us, in a necrosis of the jaw bones. All degrees of stomatitis may result from industrial 
mercurial poisoning and there may be gradations from the slightest to the severest 
forms. 
Mercurial stomatitis is not easy to differentiate from other varieties of stomatitis 
especially when other symptoms of mercurialism are lacking. It may, however, be 
differentially diagnosed from chronic gingivitis, a condition which affects workmen 
who take no care of their teeth, and one which is almost always found in older men. 
Chronic gingivitis lacks all the evidences of acute stimulation. The inflammatory 
process confines itself to the edges of the gums and does not extend to the remaining 
mucous membranes. Furthermore the profuse salivation present in mercurial poison- 
ing is absent. In the lighter forms of stomatitis a purple red, slightly transparent 
line is evident which, however, is decidedly different from the lead line. 
In addition to the symptoms in the buccal cavity during mercurial poisoning, 
there may be minor manifestations noticeable in the digestive tract, even before the 
marked swelling, and pain in the mouth, and difficulty in eating are evident, such as a 
loss of appetite and slight diarrhea. With these manifestations, and often when all 
are lacking-the patient complains of indefinite pains in the extremities and joints. 
But above all things the patient shows evidences of psychic distur- 
bances which are peculiar to mercury poisoning-Erethismus mercuralis. 
They consist of a peculiar form of stimulation and timidity and are evident 
more especially when the patient is in the presence of strangers Nothing 
will describe this condition better than the statements made by the more MERCURIAL PSYCHOSES TREMOR 
473 
intelligent class of patients, after cure. A technologist narrated the 
following to me. 
"As a general thing I am a very energetic person and have taken part in many 
functions, but while affected with mercury poisoning I felt oppressed and uncom- 
fortable, and was as shy as in my later boyhood days, in the presence of grown people." 
A very intelligent workman, who had been engaged for many years in the experi- 
mental laboratory of one of the best known Austrian inventors, said: 
"An invention had been completed, strangers came, and it was decided to demon- 
strate to them the manufacture of the respective commodity. As long as I was con- 
scious of the fact that these people were standing behind I could not proceed to move a 
finger." 
A French author relates an instance where a stranger came into an inn 
(or saloon) in which a number of hat makers, affected with mercurial 
poisoning, were drinking wine. During the presence of the stranger 
none of the hat makers was able to lift a glass to his mouth. 
For a time these psychic manifestations were regarded as hysterical in 
nature, but this view has long since been dispelled. 
The descriptions of manifestations just given are observable only in 
marked cases. This class of patients at the outset complain only of 
lassitude, tiredness and nervousness. 
A further manifestation of the nervous system is the mercurial tremor. 
In marked cases of irritability or erethism one can often observe a slight 
twitching of the facial muscles, and a slight trembling of the fingers. 
The trembling, provided the patient continues to work with mercury, 
increases in intensity and finally extends to all parts of the body. In 
the early stages of the disease, and in lighter cases, only the hands and 
fingers tremble, but when the preliminary stage has passed, the tremors 
become of the characteristic type. 
In addition to the fine tremors, which, however, are not always present, there may 
be interruptions by coarse contractions (jerks) and fluctuations. It is these coarse 
shaking movements which characterize the mercurial tremor. The mercurial 
tremor also goes through peculiar variations inasmuch as it loses in intensity after 
to 1 minute, and then picks up and becomes strong again. When the disease is 
progressive there is gradual successive involvement of the arm, the head, the vocal 
musculature, the legs and the trunk, and in consequence the entire body trembles and 
shakes. The patient loses more and more the control of the muscles, and the tremor 
present is of a pronounced intentional type. When at complete rest the patient 
does not tremble: this point is taken into consideration when differentiating the 
condition from paralysis agitations or the tremor of senility. Although persons 
affected with mercurial poisoning can perform heavy work, it is utterly impossible 
for them to do the kind which calls into play the finer muscular movements. This has 
been approximately expressed by an affected workman "the lighter the body the more 
difficulty I have in lifting it." 
Cases are sometimes noted where persons affected with mercurial poisoning are 
still capable of carrying on a line of work to which they have become accustomed 
through years of practice, but are unable to lift a glass to the lips, and already have 
some difficulty in walking. Some patients drop to the ground on their way to work, 
and in consequence of the fact that each intentional movement will excite muscular 474 
MERCURY POISONING 
contractions, are unable to rise unless aided by others. Even this class of patients, 
however, are able to work at their regular occupation in the factory. 
Notwithstanding what has been said about these disturbances ataxia is never 
present, and it is only the shaking movements which make the desired movements 
impossible. 
While drinking is difficult for patients with light forms of the disease those affected 
with heavy forms are absolutely helpless, and are unable to eat or clothe themselves, 
without aid. In the most severe cases the slightest movement in bed will excite 
contractions. Kussmaul, to whom we are indebted for an excellent book on industrial 
mercury poisoning, describes cases of this severity. I personally never had a case of 
this kind under observation, as follows: 
"The entire body is thrown to and fro and at the same time every group of muscles 
and each single muscle appear to be engaged in boundless activity. The head moves 
incessantly to and fro; at times it is jerked backward or sideward, the eyelids go up 
and down, and the eyeballs are rolled from one side to the other. The al® of the 
nares and the mouth are jerked up and down, the face is contorted into all sorts of 
grimaces, the jaws move one upon the other, the arms and legs tremble and jerk 
together, and every individual muscle is engaged in the process. 
"The convulsions may become so severe that the combined strength of several 
strong men cannot control the jolts, which throw the patient to and fro, and it becomes 
necessary to restrain the patient in bed with strong straps to prevent him from being 
hurled out of bed." 
In very light cases when nothing characteristic is present except coarse 
or fine tremors, this tremor cannot be differentiated from others, par- 
ticularly from the alcoholic tremor. As the tremors become more intense 
and characteristic the jerking and shaking movements set in; the tremors 
may be sharply differentiated from the alcoholic tremor, the trembling 
of Basedows' disease and lead poisoning, and as previously stated from 
the shaking movements of paralysis agitans and the intentional tremor 
of senility. Difficulty in making a differential diagnosis can arise only 
when hysteria and multiple sclerosis come in question, but in these there 
are other nervous symptoms which will serve to determine their nature. 
We have now discussed the cardinal symptoms of industrial mercurial- 
ism, viz. stomatitis, erethism, and tremors; the method in which these 
combine will be discussed later, as well as those which are less characteris- 
tic or occur seldom. Often when the trembling is of a high degree the 
extremities become weak. This fact has led the older authorities to 
speak of paralysis as one of the symptoms of mercurialism, although it 
mustebe said that cases of actual paralysis have been noted. 
Ltulle observed paralysis of the arms twice, and paresis of the legs 
once whereas I have noted radial paralysis in two patients affected with 
mercurialism in one of whom I saw it develop. Glibert noted as a general 
thing weakness of the hand and digital extensors in lead and mercury 
workers. As Leyden has reported mercurial polyneuritis after mercury 
inunctions and others (Ketli, Fawoeski) as a result of acute poisoning with 
corrosive sublimate, and as Heller has produced paralysis in animals by 
the injection of mercuric chlorid, mercurial polyneuritis undoubtedly 
occurs, but probably very seldom. MERCURIAL NEPHRITIS AND SKIN AFFLICTIONS 
475 
I have already remarked about the occurrence of a nephritis in these 
cases. On autopsy they show calcium incrustations in the kidney. The 
therapeutic administration of mercury, even when the mercury cure con- 
sists of giving small doses, may lead to an albuminuria and cylindruria 
(Lang and Welander) but, excluding the improper use of mercury, these 
conditions are transient. In the literature no clear accounts of nephritis 
in industrial mercurialism are given, but I have found albuminuria in a 
large number of patients with industrial mercurialism and, consequently, 
I feel justified in drawing the conclusion that the kidney is also affected 
in the chronic form of the disease. 
Mercury when administered cutaneously, subcutaneously, and by 
way of mouth for therapeutic purposes, often produce exanthema, and 
according to Ehrmann the mercury exanthema is one of the best known 
varieties of drug exanthemata. Although the exanthema may be one of 
several varieties it is very often seen as a scarlatinous erythema which 
very frequently comes from the local application of mercury, as inunction 
with blue ointment. The erythema itches intensely and consists of 
puqctate, closely crowded, reddened areas which gradually conflux to 
a livid surface, that has a higher temperature than the adjacent tissue. 
Finally desquamation occurs and scales are cast off in large lamellae. 
Collis has observed cases with exanthema in industrial establishments and the 
case of a midwife poisoned as a result of washing in bichloride of mercury solution, 
reported by Wengler, might be included in this category. 
Oppenheim has seen a large number of cases of acute dermatitis in youthful per- 
cussion caps workers caused.by the effects of mercury and mercurial vapors upon the 
skin and mucous membranes of specially susceptible persons. The attacks are 
characterized by redness of the face and the back of the hands, followed by more or 
less swelling especially of the face. A pronounced dermatitis is rarely developed unless 
the patient continues his work or is exposed to other irritant substances. In quite a 
number of cases salivation, swelling of the gums and even ulcers of the gums were 
observed. There were no symptoms of digestive disorders, except loss of appetite, 
and a metallic taste in the mouth. Traces of mercury were found in some instances 
in the urine. The symptoms developed not long after beginning the work and 
gradually the female workers become habituated to the effects of mercury, and in 
only rare instances did resumption of the work cause a relapse. 
Finally it may be mentioned that mercury workers show a peculiar 
copper colored redness in the trachea and the mucous membrane of the 
mouth; this is regarded by Kussmaul as a symptom of habitual mercurial- 
ism, when weakness, stimulation and tremor are also present. I have 
often noted this copper colored redness among workmen in the mercury 
works at Idria when other pathologic signs were absent. 
Patients with the severe form of the disease have a striking paleness, 
lose their appetite and become emaciated. In the very worst cases the 
subjects are said to become cachectic. 
Summary.-The three principal symptoms of subacute and chronic 
mercurial poisoning, namely stomatitis, erethism and tremor, are not 476 
MERCURY POISONING 
present simultaneously in all cases, nor in the same degree. We have 
cases which present no other symptom than a stomatitis and this is 
especially true of patients who take up large amounts of mercury in a 
relatively short time. This occurs in persons who do fire gilding. Stoma- 
titis may therefore be regarded as a symptom of subacute poisoning. 
On the other hand, we see patients in whom all evidence of stomatitis is absent, 
or in whom it was previously present, but who have the mercurial tremor in an 
accentuated degree. This form is found in hat makers and others who have imbibed 
very small amounts of mercury over a period of many years. I have seen only one 
case where a mercurial tremor, and here only of a light degree, followed several 
days of work with mercury. In cases of this character we probably have to do with 
persons who are especially susceptible to the effects of mercury. As a rule, it is 
necessary to take in small amounts of mercury continually for months or even years, 
or large amounts repeatedly at wide intervals. Erethism is not found in cases which 
develop quickly nor is it observable, save an intimation, in entirely chronic cases. 
In the latter the presence of erethism might be presumed if the tremor increases when 
the patient is conscious of the fact that he or she is under observation. 
Erethism is most distinct in those cases which have the other two symptoms of 
mercurialism. There are undoubtedly cases in which the period of mercury intake 
was an average one, but just here we must not lose sight of the possibility that such 
cases might result by the imbibition of small amounts of mercury over a long period 
of time which would produce only tremors and then followed by the intake of large 
amounts of mercury in a short space of time which would yield an acute symptom as 
stomatitis. I will discuss the quantity of mercury necessary to produce poisoning in a 
subsequent paragraph. 
Receptiveness for Mercury.-From experience gained in the thera- 
peutic use of mercury we have come to know that great differences exist 
among individuals in regard to receptiveness for mercury. Some have a 
distinct idiosyncrasy to react with it. Sachur cites the case of a 20-year- 
old girl who after an inunction with about 5 grams of blue ointment, con- 
taining 1.5 grams of mercury, developed numerous rhagades on the skin 
of the forearm and fingers and died with all the manifestations of an acute 
mercurial poisoning, diarrhea, bloody stools, and nephritis. 
In the industries we also find distinct differences in regard to recep- 
tivity among the workmen. In these cases too the workers do not become 
affected at the same time. Where the conditions are not very bad only 
a part of the workmen become affected. 
I have observed an instance of extraordinary receptivity in a strong 17-year old 
girl who became affected with mercurialism a short time after beginning work in a 
hat factory. The first indication was diarrhea, and this was followed some 4 months 
later by stomatitis, erethism and a gentle tremor. The girl, according to her state- 
ment, was principally employed in the dyeing department of the factory where she 
did not come into contact with mercury or mercurial compounds. Once daily, how- 
ever, she was compelled to spend about 20 minutes in the felting division, where several 
cases of mercurialism had just occurred, handling mouth-wash water to workmen. 
The parents and grandparents of the girl although engaged in hat making and rabbit 
hair cutting (contractors) were never, as far as could be determined, affected with 
mercurialism. RECEPTIVENESS FOR MERCURY 
477 
I am unable to say on the basis of my own observations whether age or 
sex is a factor in mercurialism for the reason that men perform different 
kinds of work than women, and because the totally chronic form of the 
disease results from working years in the industry. However, if we use as 
a basis the knowledge gathered in therapeutics we must regard women and 
children, and tuberculous, anaemic, and cachectic individuals as most 
receptive. 
The amount of mercury necessary to cause poisoning is said by 
Gothlin to be 0.4-1.0 mg. taken daily over a period of several months; 
this was determined by laboratory tests. 
Tests made by Dr. R. Lang, at my suggestion, showed the dust from the blowing 
department of a hat factory to contain 2.338 per cent, of mercury. Granted that the 
air in an establishment of this kind will carry 40 mg. of dust per cubic meter, the 
amount of mercury inhaled by an individual would be 5.561 mg. per working day. 
Only 0.0576 mg. of this, however, is soluble in the digestive juices. 
Mercury on the hands of workmen and workwomen may also gain entrance into 
the body. In this connection we have the observation of Heim who collected 4 mg. 
of mercury from the hands of a scrap cutteress, but only 0.5286 mg. of it was soluble. 
As only a small part of the mercury on the hands gets into the mouth it is very 
evident that under the most unfavorable conditions a workwoman engaged in the 
blowing room of a hat factory will take in from this source, and by inhalation, a 
combined amount of mercury which is less than the figures reported by Gothlin. 
When we take cognizance of the fact that Gothlin observed cases of 
poisoning in which mercury was taken over a period of months, and 
furthermore that the author has noted only cases in the subjects employed 
in the one relatively well-equipped factory for over 10 years, we must 
conclude that the smallest amount of mercury taken continuously over 
a long period of time will eventually produce manifestations of the disease. 
This statement, however, must be amplified by mentioning the fact that in all 
probability only that portion of the mercury which is resorbed by the body, and not 
that present in the digestive organs or the mercury which has gained entrance to the 
body by other channels, is detrimental. Notwithstanding this, and leaving out of 
consideration the entirely different conditions of resorption in the lung, we must not 
lose sight of the fact that resorption of mercury does occur from the stomach, although 
the amount is small, and furthermore that some mercury is rendered soluble during 
the process of intestinal digestion. 
The investigation conducted by R. Lang in 1912, which I touched upon above, 
yielded the following data with rabbit's hair which has been treated with a mercurial 
mordant. 
Unblown mixed hair, digested with 0.346 per cent. HC1 yielded 0.018 per cent. sol. mercury; 
then digested with 0.346 per cent. HC1 + 0.1 per cent, pepsin, 0.044 per cent. sol. mercury; 
then digested with 0.2 sol. of Na2COa yielded 0.025 per cent. sol. mercury; 
then digested with 0.2 sol. of NaaCOa + pankreonyielded 0.018 per cent. sol. mercury 
Total 0.105 per cent. 
From these data it is evident that by progressive digestion the amount 
of mercury rendered soluble is greater than by gastric juice digestion 
alone. 478 
MERCURY POISONING 
We are apprised of a similar behavior for lead by Legge and Goadby 
(Lead Poisoning and Lead Absorption, London, 1912). 
Gothlin has determined that when the amount of mercury inhaled 
does not exceed 1 mg. per 4 cubic meters of air, practically all of it is 
resorbed. 
From what has been said in the foregoing it is obvious that the method 
whereby mercury enters the organism and the kind of mercury com- 
pound introduced, is of the greatest significance in mercury poisoning. 
In industrial mercurial poisoning, however, chiefly the element mer- 
cury (metallic and gaseous) and mercuric nitrate come into consideration; 
mercuric chloride and mercuric cyanide are only occasionally etiological 
factors. The point as to which of the portions inhaled, that gaining 
entrance to the stomach with swallowed saliva or the part taken up by 
the lungs, is the most dangerous must be left undecided for the present. 
Accordingly the greatest danger to those who have to do with mercury 
lies in the fact that mercury will volatilize even at ordinary temperature. 
In this connection Renk was able to show that at a temperature of 10°C. 1 cubic 
meter of air above an area of % square meter of mercury would contain the following 
amounts of mercury: 
Milligrams 
5 cm. above 1.86 
50 cm. above 1.26 
1 meter above 0.85 
The volatility of mercury increases with a rise in temperature, which is shown by 
the following table taken from Kunkels' toxicology, 1901, page 133: 
Grains of Mercury in a Cubic Meter of Air According to Various 
Investigators 
Temperature 
Regnault 
Hagen 
Hertz 
0°C. 
0.236 
0.177 
0.00224 
10°C. 
0.305 
0.205 
0.00569 
20°C. 
0.409 
0.231 
0.01430 
30°C. 
0.563 
0.276 
0.03083 
40°C. 
0.785 
0.338 
0 07787 
The elimination of mercury occurs briefly in the lowermost portions of 
the intestine from where it is discharged with the feces, and also in the 
urine, saliva and sweat. The elimination from all channels is slow and 
not continuous. 
Oberlander found mercilry in the urine 190 days after giving the sub- 
stance in a mercury cure. The elimination in this 190 days' period, 
however, was not continuous for there were often spaces of time, 10 days, 
in which no mercury would be noted in the urine. In the examination 
of organs of subjects succumbing to acute poisoning the largest amounts 
of mercury were found in the kidney, liver and large intestine. MERCURY POISONING.- TREATMENT, REFERENCES 
479 
Treatment.-In the treatment of industrial mercurial poisoning it is 
obvious that the first thing necessary is to keep the patient from all work 
which involves the slightest possibility of taking up mercury. The next 
thing necessary is to bring about the elimination of the mercury-how far 
this is possible we are not able to say-by stimulating intestinal activity, 
the secretion of urine and secretion of sweat (sweat baths). The admin- 
istration of sodium or potassium iodide seems to be indicated in these 
cases. 
Above all things these patients must be strengthened by giving good 
food, fresh air, and hydrotherapeutic treatment. The stomatitis is 
treated symptomatically with gargles and painting with astringent 
fluids. 
The stomatitis when appropriately treated is usually cured in the 
course of a few weeks and in light cases in a few days. The discharge of 
the erethism requires a somewhat longer period of time, but it also 
vanishes completely when the patient is kept from mercury work. 
The removal of the tremor in cases of average degree of severity usu- 
ally requires several months but in young patients it can be discharged 
completely. In individuals around and over 50 years of age the progno- 
sis is not always quite so favorable. I have seen persons who had 
ceased working with mercury still show a marked tremor 5, 6, 15 and 30 
years afterward. Although I.have repeatedly seen marked improvements 
and even cures in older patients, it is always advisable to refrain from 
forecasting a favorable prognosis in these cases. In the older literature 
many cases are described in which the mercurial tremor and the stomati- 
tis are said to have led to a fatal result. Mercurialism should most often 
be regarded as an indirect cause of death inasmuch as it lowers the 
vitality of the organism and thus prepares the soil for a tuberculous 
infection. With regard to the effect which mercurialism will have upon 
the progeny it is often stated that mercurial poisoning will produce 
abortion or will tend to bring forth weak offspring. There are in fact 
cases described in the older literature which support this contention. 
No proof exists, however, to show that mercurialism in the male has any 
detrimental influence upon the progeny. 
REFERENCES 
Collis.-Report of English Industrial Inspectors, 1909. 
Kunkel.-Handbuch der Toxikologie, Fischer, Jena, 1901. 
Lewin.-Die Nebenwirkungen der Arzneimittel, II, Auflage, 1893, Hirschwald, 
Berlin. 
Ehrmann.-"Toxische und infectibse Erytheme chemischen und mikrobiotischen Ur- 
sprunges." Mraceks Handbuch der Hautkrankheiten. Wien, 1902, I. B., 
page 644. 
Lang.-Vorlesungen uber Pathologic und Therapie der Syphilis. Wiesbaden, 1896, 
II, Auflage, I. B., pages 792-853. 
Oppenheim.-Wien. klin. Wochenschrift., 1915, 4 F. 480 
MERCURY POISONING 
Leyden.-Ueber Polyneuritis mercurial. Deutsche med. Wochenschrift, 1893, Nr. 31. 
Kussmaul.-Untersuchungen uber den konstitutionellen Merkurialismus und sein 
Verhaltnis zur konstitutionellen Syphillis. Wurzburg, 1861. 
Gothlin.-Gustav Fr. Kvicksilverhaltig Luft och fall af kronisk Kvicksilfverforgiftning 
vid en medicinsk laronstalt. Hygienisk Tidskrift, 1909, page 138, ref. Hygien- 
ische, Rundschau, 1911, page 390. 
Teleky.-Die gewerbliche Quecksilberverifgtung. Schriften des Instituts fur 
Gewerbehygiene, Seydel, Berlin, 1912. 
Giglioli.-Contribute alia studio dell idrargirismo professionale nel bacino cinabrifero 
del M. Amiata (Siena). Ramazzini, 1909. 
Letulle M.-Essai sur 1'hydrargyirisme professionel (les coupeur de poil); Revue 
d'hygiene et de police sanitaire, 1889, Bd. XI, page 40. 
Heim.-Rapport presente a la commission d'hygiene industrielle, touchant de projet 
de Decret reglementant les conditions hygieniques du travail dans les couperies 
de poils. Bulletin de 1'inspection de travail et de 1'hygiene industrielle, 
1909, Nr. 5 et 6 Paris, Ministere de travail et de prevoyance sociale. 
Moskauer Semstwo.-Ueber die quecksilberfreie Fabrikation der Filzhtite in Russland. 
Moskau, 1911. Internationale Hygieneausstellung, Dresden, 1911. 
Levitzky.-Au sujet de la suppression de 1'emploi du mercure dans 1'industrie de la 
couperie de poils. Revue d'hygiene, 1909, I, Heft. 
Martial.-Ren^e, Le nitrate acide de Mercure dans 1'operation du secretage, son rem- 
placement par des corps non toxique. Paris Masson, 1911. 
Wengler.-Zeitschrift fur Medizinalbeamte, 1906. 
Oberlander.-Ludwig, Weiner Med. Presse, 1889. SECTION 14 
MERCURIAL INDUSTRIES* 
BY LUDWIG TELEKY, M. D., Dusseldorf, Germany, and GEORGE M. KOBER, M. D„ 
Washington, D. C. 
WORKERS IN MERCURY AND ITS SALTS 
Mining of the Ore.f-Of the total output of 4300 metric tons in 1912,855 tons were 
produced in the U. S. Mercury is chiefly obtained from the sulphide of mercury ore, 
commonly known as cinnabar (HgS). Pure cinnabar contains 86.2 per cent, of mer- 
cury, the ordinary ore contains generally less than 1 per cent., exceptionally 2.5 per 
cent, as in Brewster County Texas, and as high as 9 per cent, in the mines of Almaden 
in Spain. Since cinnabar is insoluble there should be no danger from this source. 
Dr. Pope of London as early as 1665 referred to mercurial tremor of the 
hands among the miners of Italy. The Eleventh Census of the United 
States (page 28) reports that 10.44 per cent, of the men employed in the 
New Almaden mines suffered from mercurialism. Such instances are 
doubtless due to the fact that mercury in certain mines and galleries has 
been known to collect in small and large drops, which under the influence 
of a very warm and moist atmosphere is volatilized and inhaled. The 
mines at Monte Amiata are quite free from such a risk, while those of 
Idria and especially the Spanish mines present this danger. In all such 
cases it has been found practicable to reduce the danger by copious 
ventilation, and by a change of crews to other locations, so that the men 
may not work over 4 hours in dangerous places. 
Smelting. *-Mercury is usually obtained by subjecting cinnabar (mercuric sulphide) 
to a roasting process in furnaces. By this procedure the sulphur combines with oxygen 
forming sulphur dioxide, while the mercury which distils off is collected in special 
receptacles. The aim of the technologist on the one hand is to bring about a com- 
paratively complete disintegration of the ore and on the other he seeks to keep the 
escape of mercurial vapors from the furnaces down to a minimum. In this endeavor 
technology and hygiene join hands, because mercurial vapors are a source of grave 
danger to the workmen. Above all things in this industry it is necessary to build 
condensers of sufficient spaciousness so as to make the condensation of mercury as 
complete as possible. At Idria, in Jugoslavien, the outlet of the stack is 158 meters 
above the arch of the smelter and the total content of the condensing plant is 7631 
cubic meters. 
If a condensing plant is not sufficiently effective there occurs on the 
one hand a colossal loss of mercury, and on the other there is danger of 
jeopardizing not only the health of the workmen but also that of persons 
living in the vicinity of the smelter. 
* By Ludwig Teleky, Dusseldorf, Germany, 
t By George M. Kober, Washington, D. C. 
481 482 
MERCURIAL INDUSTRIES 
In Idria, in previous years it was apparently a common thing to have stock 
poisoned as a result of grazing on lands in the neighborhood of the smelter. 
Even when the amount of mercury escaping from a stack is small it must be 
regarded as dangerous to smelter workers when the outlet of the chimney is not 
sufficiently distant from the smelter or if it is badly placed. 
The greatest source of danger is from vapors escaping from the 
furnaces within the smelter. Escape of vapors can be prevented only 
when a negative pressure exists in the furnaces. 
A negative pressure is maintained by a mechanically driven ventilator (fan) which 
exerts its activity throughout the entire furnace system. It often occurs that the 
wings of a ventilator become corroded by the acid vapors which pass through the stack 
and consequently it is important at all times to hold an extra fan in reserve. 
In shaft furnaces, employed in the working up of coarse ore, difficulty is experienced 
in affecting a complete seal for preventing the escape of mercury vapors. Giglioli, 
for instance, found that the apparently efficient seal of Spirek also allows mercury 
vapor to escape. A condition similar to the one prevailing in the shaft ovens often 
obtains with the continuous automatic reverberatory furnaces (Fortschauflerbfen). 
In the most modern furnaces (Czermak-Spirek Schiittrostofen) the fine ore which is 
worked up therein serves as a seal. Even with this device one must be cautious. 
In working with this type of oven it is especially necessary to feed only ore which has 
the proper degree of fineness, and to have the uppermost layer of ore of a proper height. 
It is, furthermore, important to have a pipe with an especially strong suction in the 
upper layers of ore for the purpose of intensifying an existing negative pressure in the 
furnace. 
The greatest advantage, from a hygienic standpoint, obtained by employing the 
Czermak-Spirek (Schiittrostofen) furnace, is in the fact that the ore under treatment 
falls by gravity during the smelting process and consequently does not require further 
handling by the workmen. 
With all types of furnaces, however, great care must be exercised when 
removing the spent ore. In this case it is especially necessary to see that 
the workman who opens the grate bars is not overcome by mercury vapors 
and dust. This can be prevented by placing a wall of sheet-iron between 
the spent ore cart and the spot where the workman usually stands, and 
by installing suction pipes in appropriate localities. The carts, when 
filled with spent ore, which is cooled, should be conveyed to the spent 
ore heap automatically. (At Idria spent ore contains 0.00036 to 0.00148 
per cent, of Hg.) 
The gases which are produced in the furnace by the smelting process go over into 
condensers of large dimensions. In the condensers a soot technically called "stupp" 
collects which consists of a mixture of finely divided mercury, unburned particles of 
carbon, undecomposed hydrocarbons, ore dust and ash. As only a comparatively 
small portion of metallic mercury (5 to 10 per cent.) is obtained from the condensers, 
it becomes necessary to subject the soot (stupp) to special treatment in order to extract 
the mercury which it contains. The mercury content in stupp is variable, the amount 
depending upon the locality from which it is obtained. 
The removal of soot from the condensers must be regarded as an occupation which 
is quite detrimental to the health of those engaged in it. When practicable plenty 
of water should be played during the operation. Especially dangerous is the operation 
in cleansing the entire canal system. At this time it is necessary to stop all smelting MERCURY SMELTING 
483 
operations, and once each year at Idria the works are at a standstill for this purpose. 
To prevent disease as much as possible from this source requires the wearing of special 
clothing, the employment of respiratory apparatus and baths at the end of each work- 
ing period. The working period should not be over 4 hours for each shift. The 
extraction of mercury from stupp (soot) is done with specially designed presses. The 
presses should be provided with strong suction devices for the purpose of carrying off 
noxious dusts and gases. 
Every manipulation associated with the handling of stupp should be 
regarded as a source of danger to health because poisoning can occur from 
volatized mercury or by the absorption of finely divided mercury in a 
manner similar to the poisoning which sometimes occurs when blue oint- 
ment is rubbed on the skin. There is even danger of poisoning, through 
volatilization and absorption, during the operation of weighing and filling 
mercury into cast-iron flasks, etc. Accordingly it is advisable to keep the 
flask covered and to avoid spilling the metal, and to prevent mercury 
from coming into contact with the hands. In rooms where metallic 
mercury is handled the floors should be smooth and tight and should 
slope in the direction of a vat for the collection of mercury droppings. 
The same requirements hold good for work tables on which mercury is 
handled. 
Eating should not be permitted in the smelters and as additional general precau- 
tionary measures the help should be required to wash the hands and to take a bath 
daily before leaving the smelter. It is also important that the help wear clothing made 
of close-meshed fabrics for the purpose of preventing the penetration of the underwear 
with soot and mercurial vapors. Where this precaution is not taken the workmen are 
apt to carry mercury into the home. In doing this the workman jeopardizes not only 
his own health, by being continuously in an environment of mercury, but also that of 
the other occupants of the same house. At Idria cases of poisoning are often noted 
among members of a mercury worker's family. This is especially true where children 
sleep in the same bed with a father who is engaged in a mercury works. 
From what has been said it is evident that the untoward effects of 
mercury can be minimized if effective technical and hygienic appliances 
are installed in the smelter. It is also obvious that a complete prevention 
of disease from this cause is impossible. Under these conditions much 
can be gained by making frequent changes among the help and no person 
should be allowed to work over 4 weeks at a time in the smelter. Each 
period of smelter work should be followed by a comparatively longer 
period of labor at a less dangerous task, as mine work, etc. At Idria the 
help is required to work 1 month in the smelter and the following 2 to 3 
months in the mine. 
Although the technical equipment at Abbadia San Salvador is not less perfect 
than that of the works at Idria, the incidence of mercury poisoning is much greater. 
At Idria among 1200 miners I found nine severe cases of mercury poisoning. Five 
of these cases had received pensions for several years, and the remainder were still 
engaged in active work. I have frequently observed slight cases of mercurialism 
and among a group of 259 workers there were only 19 who gave a history which would 484 
MERCURIAL INDUSTRIES 
rule out mercury poisoning. The death rate at Idria is abnormally high and many die 
from tuberculosis. 
Manufacture of Physical Apparatus.*-The utilization of mercury for 
constructing various kinds of physical apparatus was and still is a source 
of mercury poisoning. 
In constructing the mercury barometer a great deal of mercury is employed and 
it often happens that globules of mercury fall to the floor of the factory and become 
a source of danger to the operatives. Poisoning from this source is not as frequent as 
formerly because the aneroid barometer has displaced the mercury instrument to 
quite a large extent. 
Mercury is also utilized to a considerable extent in the manufacture of thermom* 
eters. This occupation, which is still carried on in many cases in dwellings, is espe- 
cially dangerous because it is necessary to heat the mercury in order to expel air from 
the thermometer tubes. In order to prevent poisoning it is essential to keep the living 
quarters distinctly separate from the workshop. 
The tables in the workshop should be bordered with raised strips to prevent 
mercury from falling to the floor, and the table board should incline in the direction 
of a mercury-catching receptacle. 
Dr. William Jacobsohn (Jour. Indust. Hygiene, Sept., 1920, p. 193) 
investigated the manufacture of thermometers in New York and described 
two typical cases of mercurial poisoning. He informs us that clinical 
thermometers are made from rounded strips of glass with a central bore; 
the strips are cut to the required length. Each of these strips or stems 
is opened out to form the blister by means of a gas flame and air pump, 
and the bulb is then blown. The next process is that of filling the bulb 
with mercury heated by a Bunsen burner flame, then follows testing by 
standard comparisons. The tops of the stems are next sealed, the blister 
is contracted, the heads are rounded off, and the thermometer is engraved. 
During this process the workmen were exposed to the vapors of 
mercury, hot and bright flickering flames or torches, hydrofluoric acid 
fumes, paint, illuminating gas from leaky fixtures and pipes, and glass 
dust. There was an utter disregard of preventive measures. Hoods had 
been placed, but served no purpose, as they were neither enclosed or 
connected with the outer air. Mercury was found in cracks and crevices 
on work benches and floors. (G. M. K.) 
In the manufacture of incandescent lamps vacuum pumps are much used. The 
Sprengel and similar air pumps, whose powers depend upon the fall of a small stream 
of mercury through a narrow bore tube, are still frequently used. The glass parts of 
the pumps, when broken, often become a source of danger-due to spillage of mercury 
-to the working force, which is composed chiefly of women. It is therefore important 
to set up the pumps on tables similar to the ones described in the section on the ther- 
mometer, to prevent mercury coming on the floor and furthermore to replace as 
quickly as possible all cracked parts of pumps. The Sprengel pump in Germany and 
America is gradually being displaced by the rotary pump, but this too requires mer- 
cury for its makeup. Although the danger of poisoning from breakage of these pumps 
is not as great as with the Sprengel pump, poisoning can occur when the apparatus is 
cleaned. In the rotary pump there is a tendency for the mercury to collect in the MERCURIAL APPARATUS-AMALGAMS 
485 
joints and cavities and on the glass parts, but in the latter case it is due to impurities 
in the mercury. The mercury of pumps when impure must be cleansed by a process of 
distillation or by shaking it with sulphuric or nitric acid. In the first method when 
the distilling apparatus is imperfect and allows the escape of vapors the health of the 
operator is endangered. In the second method the acid is removed from the metal by 
washing with water. The water remaining incorporated with the metal is removed 
by heating, in consequence of which some of the mercury is rendered volatile. Here 
too is a source of poisoning. 
Mercury pumps are also used for exhausting Rontgen (X-ray) tubes. In this 
work the quantity of mercury employed is much greater than is used for exhausting 
incandescent lamps, and the danger arising from spillage of mercury and breaking of 
pumps is still greater. I have seen the old Toepier pump employed for this purpose. 
Inasmuch as workmen engaged in the repair and cleansing of mercury pumps are 
also exposed to the danger of poisoning, it is obvious that a periodic change of hands is 
indicated. It seems highly desirable from a hygienic standpoint to dispense with the 
use of the mercury pump and to employ instead Geryk pumps, such as have been 
introduced into Germany, America and elsewhere. 
There are also other physical apparatus in which mercury is used. Notably among 
these are instruments for taking electrical measurements. English industrial 
inspectors have reported cases of poisoning in those who use these instruments. 
I have also found numerous cases of poisoning among the help engaged in making 
a new kind of press gas lamp. By an ingeniously regulated volatilization and recon- 
densation of the mercury the pressure of the illuminating gas is increased in the lamps. 
Of 64 cases of mercurialism reported in Great Britain, 17 occurred among workers 
in electric meters and 16 were engaged in the manufacture of philosophical instru- 
ments. According to Legge, 3 cases of mercury poisoning occurred in Great Britain 
in 1919 in the manufacture of philosophical instruments, 2 in the manufacture of 
fulminate and 2 in a certain smelting process. (G. M. K.) 
In this connection it may be stated that Edsall1 relates the case of two dentists 
who contracted mercurial poisoning from the habit of working up the amalgam in the 
palms of their hands. Schulte in examining the urine of 15 dentists and technical 
assistants invariably found traces of mercury in some instances as high as 0.16 grains 
a day. In those working with copper-amalgam he found the highest quantity, probably 
because of the greater amount of mercurial vapor given off in heating the copper- 
amalgam. In no instance could any of the symptoms of disease be attributed with 
certainty to mercurial poisoning. (L. T.) Edsall1 refers to a patient engaged in work- 
ing with physical apparatus and who presented symptoms of excessive irritability and 
apprehensiveness, also persistent diarrhea. Edsall traced the source of poison to the 
fact that the patient kept an open jar of mercury on his office desk, and frequently 
spilled quicksilver on the floor of his office and bed room without paying any attention 
to it. After removal of the cause the symptoms disappeared. (G. M. K.) 
The Leipsic morbidity rate for makers of instruments of precision is 955 days per 
annum per 100 members, and the mortality hazard 0.78 per cent. (G. M. K.) 
Extraction of Gold and Silver.*-The property of mercury to forni an 
amalgam with metals, especially the precious metals, is made use of in the 
extraction of gold and silver. In Europe, however, mercury is no longer 
employed for extracting silver, but the process is apparently still utilized 
to a considerable extent in America. 
In Mexico the Patio or heap amalgamation process is still in use to a limited extent. 
In this procedure the finely reduced silver ore, placed in large flat piles, is strewn with 
sodium chloride, roasted chalcopyrite and mercury, and mixed with a shovel. The 
heaps are then treated by a burro or kneaded with electrically driven ploughs. After 486 
MERCURIAL INDUSTRIES 
several weeks of this kind of treatment the heavy amalgam is treated in agitators and 
settling tubs. 
Another method of extracting silver is the Washoe or pan amalgamation process. 
Here moist ore is stamped to powder and transferred to cylindrical or slightly conical 
steam-heated fans provided with a device termed a muller for stirring or rubbing the 
ore with mercury, copper sulphate and common salt. The amalgam is then separated 
from the residue in a settler provided with an agitator. 
In another process the ore before amalgamation is converted into chloride by 
roasting it with salt in a reverberatory furnace. The silver chloride so produced 
is then reduced with metallic iron or copper and the silver is then amalgamated by the 
Reese-River pan amalgamation process. 
In all of the processes discussed the silver must finally be obtained from an amal- 
gam. This is done by diluting the amalgam with mercury and filtering the diluted 
amalgam through canvas. This results in the retention of an amalgam in the canvas 
cloth, which consists of one part of silver to seven parts of mercury. The mercury 
in the retained amalgam is removed by distillation. During the preparation of amal- 
gam, irrespective of whether it is done in heaps or in flat open pans, a volatilization of 
mercury occurs. The vapor, as such, is detrimental, as already pointed out, from a 
hygienic standpoint. 
A less dangerous procedure seems to be the water amalgamation process carried on 
some years ago at Freiburg, Saxony. The loss in mercury, which can by no means be 
all due to volatilization, in the Patio process is 1.5 kg. per kilo of silver; Burrel amalga- 
mation 0.22 kg. per kilo of silver; and in the Reese-River process 0.25 per ton of ore. 
Even more dangerous to health is the operation *of removing mercury from the 
amalgam by distillation. This is particularly true when leaky or otherwise inappro- 
priate distilling apparatus are employed. 
Gold is to-day still extracted by the amalgamation method. In this 
procedure mercury is added to the finely reduced ore, or the amalgamation 
is done in cast-iron mills simultaneously with the stamping (reduction) 
process. The latter process-stamping mill amalgamation-is the most 
widely used. 
During reduction in which powerful stamping mills are used, water flows constantly 
over the ore, and mercury is introduced intermittently. The amalgamation which 
occurs in the stamping troughs is accentuated by amalgamated copper plates. Each 
day the amalgam is removed from the trough; that adhering to the copper plates is also 
scraped off and treated in a manner similar to silver amalgam, discussed above. 
Among other methods for extracting gold is the cyanide process of McArthur and 
Forrest. In most cases this process is preceded by a preliminary stamping mill 
amalgamation. 
Amalgamation is not resorted to in Europe for obtaining silver, but it is apparently 
employed to a wide extent in Mexico. 
■The fact that gold and silver mines are not usually located near larger 
cites is responsible for our lack of knowledge in regard to mercury poison- 
ing in this industry. We can, however, conclude from our knowledge 
obtained in other vocations, and from the fact that a large amount of 
mercury is used and the way it is handled in gold and silver extraction, 
that poisoning from this source must occur among the workmen. More 
information is required in this direction and a meritorious piece of work 
could be done in this connection by hygienists located near such plants 
and mines. AMALGAMS, FIRE GILDING, STORAGE BATTERIES, ETC. 
487 
Attention should also be directed at this juncture to the fact that there 
are establishments engaged in extracting gold from the refuse of gold- 
working plants by an amalgamation process. Here, too, the mercury is 
recovered by distillation. 
Fire Gilding.*-Extensive use of amalgamation is made in fire gilding 
(plating). 
In this process gold in small pieces is heated in crucibles with 8, 10 and often with 
15 parts of mercury, and stirred with an iron rod until complete amalgamation has 
taken place. The commodity to be gilded, previously smeared with a solution of 
mercury in nitric or cyanic acid, is painted with the amalgam and heated in an oven 
until all of the mercury is volatilized. In the preparation of the amalgam, but more 
especially in heating the commodity coated with amalgam, much mercury vapor is 
developed. Accordingly it is advisable in establishments of this kind to install 
powerful suction fans for carrying off the vapors. In addition to taking precautions 
against mercury vapors it is also necessary to use caution when removing the com- 
modities from the fire. 
Mercury when heated becomes more liquid (less viscid) and has a tendency to flow. 
Under these circumstances it is necessary to wipe the object gilded with a wad of 
cotton or brush in order to distribute the amalgam more uniformly and to prevent 
blistering. In the operation the eyes and mouth are often brought into close contact 
with mercury and its vapors. 
In England the smaller commodities subjected (uniform buttons) to amalgamation 
are heated in closed ovens. 
In the occupation of fire gilding (plating) more cases of acute mercury 
poisoning, salivation, stomatitis, possibly gastro-intestinal manifestations, 
occur than in any other calling. This is due to imbibing larger quantities 
of mercury in a short space of time. It is obvious from what has been 
said that complete prevention of disease from this source is not possible. 
According to my experience the number of cases is relatively large among 
those engaged in this work, even though many of the individuals work 
only a few hours each day or only a few days of every week. Fortunately 
the fire-gilding industry is on the decline and to-day only a few commodi- 
ties are plated by the amalgamation fire method. Among the commodi- 
ties still gilded by this method are church crosses, possibly cupolas, 
lightning-rod points, naval uniform buttons and articles in which a 
special resistance to the weather is desired. To-day plating is done 
principally by the galvanic method. 
Manufacture of Electrodes, Storage Batteries, Etc.*-A further use for amalgam 
is found in the manufacture of electrodes. In many cases the zinc pole (electrode) 
when kept in the sulphuric acid in the battery jar will corrode. As a preventive 
against corrosion the electrodes previously cleansed with sulphuric acid are coated 
(amalgamated) with mercury. In this operation mercury is poured on the plates, 
or the zinc electrodes are dipped into a solution of mercury in nitric acid or 
nitrohydrochloric acid. Several cases of mercury poisoning from this source have 
come under my observation. 
It should also be mentioned that the rapid solder employed in storage-battery 
work also contains mercury. I have also seen poisoning in those who manufactuerd 
and made use of such solder. 488 
MERCURIAL INDUSTRIES 
In manufacturing storage batteries (accumulators) corrosive sublimate is added 
to the plates in an amount of 30 grams per kilo of metal. 
Luigi Devoto (IlLavoro, Jan., 1922) describes three cases of subacute mercurialism 
which he saw recently in employes of a storage battery factory. The mercury had been 
absorbed in vapor form and produced the classical triad, stomatitis, tremor, and 
presence of mercury in the urine. These symptoms disappeared after a few weeks 
and with it the mercury in the urine. The recovery of these men was greatly assisted 
by absolute rest, a treatment which Devoto highly recommends. (Alice Hamilton, 
Jour. Ind. Hyg., October, 1922, Abst. p. 87.) f 
Corrosive sublimate and mercuric nitrate are used for Damascenizing gun barrels. 
Poisoning from sealing wax colored with cinnabar is also reported, but to me it 
seems improbable. During the preparation of fulminate of mercury, which is used 
for making cartridges, instances of mercury poisoning may occur. Poisoning from 
this source, however, is by no means confined to the ones engaged in its manufacture, 
in making cartridges, but it can also affect the attendants of shooting galleries when 
the ventilation is bad and where a large number of shots are fired in rapid succession. 
Instances of poisoning have also been observed among the shooters. 
Mercurial Chemical Compounds.! -The manufacture of calomel, corrosive 
sublimate, nitrate of mercury, red oxide and sulphide of mercury is attended with 
more or less danger from volatilization of the metal in the subliming processes and 
likewise by the inhalation and absorption of mercurial dust. Legge2 found that of 
27 chemical workers 4 had more or less salivation and 10 had symptoms of tremor, 
anaemia and gastric derangements. He believes that by the employment of wet 
methods throughout, most of the dangers can be eliminated, especially if the dusty 
processes, such as mixing and sieving, are done as far as practicable by enclosed 
machinery. 
Koelsch, cited by L. Teleky (Internal. Labor Rev., July, Aug., 1921, 51, 77) reports 
116 cases of mercury poisoning in a chemical works, preparing mercury and oxide of 
mercury (Jour. Ind. Hyg., Abst. p. 203, January, 1922). 
Mirror Plating, f-Of 7584 sick days among 160 mirror makers at Fiirth in 
1885, not less than 5463 days loss of work were caused by mercurial poisoning. This 
was at a time when mercury was poured as an amalgam on a sheet of tin foil and the 
glass plate placed over it and weighted down so as to squeeze out any excess of 
mercury. Dr. Hencke3 informs us that this process has been almost completely 
replaced by the use of a solution of nitrate of silver containing an alkaline reducing 
agent. The new process is not wholly free from danger, however, as cases of lead 
poisoning have occurred from the use of red lead with which the plate is backed. This 
danger can be obviated by the substitution of a coat of varnish. The use of 
acetaldehyde in connection with the modern process of silvering mirrors should 
likewise be avoided. 
According to Hay hurst,4 nitrate of silver and tartaric acid have entirely supplanted 
the use of mercury in this country. There is a distinct need of better ventilation in 
most of the establishments, especially for the removal of nitric acid fumes. The 
temperature of the silvering rooms is often excessively hot and the beveling, buffing 
and polishing with rouge paste is generally carried on in rather damp places. 
General Preventive Measures for Workers in Mercury.f-(1) The 
imperative necessity of providing local exhaust ventilation, wherever 
dust and fumes are evolved, as well as a reduction of working hours 
during the warm weather should be generally recognized. 
2. All processes involving the use of mercury should be carried on in 
separate rooms with a northern exposure of the windows, preferably at a 
temperature below 60°, so as to reduce the danger from volatilization of PROTECTION FOR WORKERS-HATTERS' FUR CUTTING 
489 
the metal to a minimum. Work should be suspended when the tempera- 
ture exceeds 78°. 
3. Wooden floors and work benches are objectionable as they favor 
the lodgment of spilled mercury in cracks and crevices. Enameled iron 
benches and smooth asphalt floors, provided with an incline and channels 
toward receptacles in which the mercury may collect should be chosen. 
The receptacles should be covered leaving only a narrow opening just 
sufficient for the metal to enter. 
4. Absolute care to prevent spilling of the mercury should be exercised. 
The work benches should be freed from the metal upon cessation of work, 
the floors should be sprinkled and swept two or three times a day. 
5. The workers should be supplied with respirators in all dust-pro- 
ducing processes; overalls and a suitable head covering of a perfectly 
smooth material should be used and washed weekly. The hair should be 
worn closely trimmed, preferably no beard; female and youthful employes 
should be excluded. The use of alcoholic beverages and tobacco should 
be prohibited. 
6. Cleanliness of person and clothing are of the utmost importance. 
No food should be taken in the workrooms and in no case until after 
thorough washing of the face and hands with soap and water, using a 
brush for the finger nails, also washing the mouth and teeth with brush 
and water, followed by the use of a mouth wash and gargle with a solution 
of either chlorate or permanganate of potash or phenate of sodium. 
Hencke recommends the use of akremin soap, containing soluble alka- 
line sulphides, and believes that the wash water should also contain 
potassium sulphnratum so as to convert the mercury into soluble 
sulphides. 
7. The firm should provide not only all the necessities referred to but 
also the facilities for warm shower and tub baths, suitable lockers for 
clothing, lunch rooms, and periodical medical examination of the 
employes, with suspension from work if any are found to present symp- 
toms of mercurial poisoning. 
Hatters' Fur Cutting.f-In the preliminary treatment of the fur for 
the manufacture of felt hats the workers are exposed not only to more or 
less dust, but also to mercurial poisoning. The latter danger is due to the 
fact that during the "carotting process" the fur side of the pelts is 
brushed with a solution of nitrate of mercury. 
The proportion of mercury used varies in different establishments. According to 
Heucke,3 100 kilos of the solution contains about 20 kilos of mercury and the average 
amount of the metal applied to each skin is about 1.64 grams. Analysis of the dust 
and sweepings of establishments revealed the presence of from 0.13 to 1.33 per cent, of 
mercury chloride. The solution generally employed in this country is made up of 4 
carboys of nitric acid, 75 lb. of mercury and 50 of water. 
Ly Europe the solution is usually composed of 1 part of mercury, 4 parts of nitric 
acid and 20-25 parts of water; in some instances 5-6 parts of the acid are used. 490 
MERCURIAL INDUSTRIES 
The men employed in making this solution and those who apply 
it are exposed not only to mercury, but also to nitrous fumes. One of the 
earliest manifestations of their combined action is a greenish discolora- 
tion with subsequent brittleness of the teeth. Rubber gloves usually 
suffice to protect the hands from the corrosive effects of the solution and 
the absorption of mercury. With reasonable precaution the chances of 
mercurial poisoning are quite slight as compared with the next process. 
After the application of mercurial solution the skins are taken to special drying 
rooms and their removal from there is fraught with some degree of danger, since Heim 
determined in a cubic meter of air of such rooms about 3 cc. of nitrous fumes and 12.5 
mg. of mercury. The subsequent storing of the dried pelts is a dusty process and 
increases the chances of mercurial poisoning with impregnated dust. The skins are 
next taken to the brushing machine which loosens the matted hair, and after cutting 
off the head, feet, etc., they are passed to the cutting machine, fitted with sharp knives, 
which shaves the fur from the skin. The fur is then assorted by female labor, accord- 
ing to quality, color, and part of the body, and is then packed in 5-lb. bundles. The 
brushing and cutting are both dusty processes and Heim and Herbert found in the air 
of the workrooms 65 mg. of dust with 5 mg. of mercury per cubic meter, which suffi- 
ciently emphasizes the need of efficient exhaust ventilation. The fur from the parts 
or trimmings which have been cut off cannot be removed by machines and this shearing 
is usually done by home hand labor, a most objectionable practice, since Heim and 
Herbert found in the air of such houses 75 mg. of dust with 42 mg. of mercury per 
cubic meter. 
In some countries, notably Belgium, most of the processes are carried 
on as a home industry. As a matter of fact, about four-fifths of the 
11,000 to 12,000 furriers in Belgium are still home workers. The sad 
effects of this system have been vividly described by Glibert, who finds 
that one-third of the women and over one-half of the men employed 
less than 5 years suffer from mercurial poisoning. 
This danger can be readily appreciated when it is remembered that a sample of the 
fur as received from the cutting machine was analyzed in the British Government 
Laboratory and was found to contain 1.34 per cent, of nitrate of mercury. The 
mercury, according to Legge,6 "forms a very insoluble combination with the keratine 
in the hair, which is not removed in the subsequent processes of felt hat making." 
In view of the fact that the men who handle the mercurial solution are exposed to the 
fumes and all others engaged in dusty processes to the inhalation of fine fur impreg- 
nated with particles of mercury, it is not surprising that Dr. Legge should have found 
20 of the 30 employes in one establishment and 27 out of 81 workers in another 
afflicted with defective teeth, and 17 with pronounced mercurial tremor. This same 
author, as well as Tylecote,6 Teleky and J. H. Lloyd, was among the first to recognize 
that the danger from mercurial poisoning was not confined to hatters' furriers, but 
that the majority of cases actually occurred in felt hat makers. 
Mrs. L. W. Bates8 in 1912 collected 102 cases of mercurial poisoning, occurring 
chiefly in the felt hat industry in New York City and vicinity; she reports only three 
cases in makers of incandescent electric lamps, two in chemists and two in makers 
of cosmetics. 
The Felt Hat Industry.!-During the 1910 census year, 27,091 persons 
were employed in this industry in the United States, of whom 25,064 were FELT HAT INDUSTRY 
491 
wage earners. Of the total number 72.2 per cent, were males and 27.8 
per cent, females; 531 persons, or 2.1 per cent., were under 16 years of age. 
The fur-felt hat industry employed a total of 18,510 wage earners 
in 1919, according to the U. S. Statistical Abstract (1921, p. 235). 
This industry begins with the utilization of the 5-lb. packages received from the 
fur cutters. The fur of different grades is mixed and thoroughly picked and separated 
in special machines, provided with tearing or teasing studded wire teeth, and although 
these machines are enclosed and provided with exhaust ventilation, more or less dust 
escapes. The "blowing machines" are employed to render the fur more fluffy and to 
deposit it, by specific gravity, into graded bins. This process in spite of enclosed 
machinery is very dusty and it is believed that most of the cases of mercurial poisoning 
originate in this department. The subsequent manipulation of forming, hardening, 
sizing, shellacing, blocking and dyeing are all wet processes. Much of the work is 
carried on in a hot and moist atmosphere, doubtless containing mercurial vapor. 
Over 30 per cent, of the mercury cases investigated by Mrs. Bates 
were contracted by formers, hardeners and sizers. Apart from mercurial 
skin affections, the plankers and blockers not infrequently suffer from 
eczema and disfiguration and loosening of the finger nails, caused by the 
use of hot acidulated water, or 11 planker's acid." The stovers, who 
handle the hard felt shapes at a temperature of 180°F. in the drying 
department, are exposed not only to mercurial vapors, but also in some 
establishments to the fumes of wood alcohol, or alcohol denatured with 
pyridin bases, employed in the shellacing process to stiffen the hats. 
A serious explosion, resulting in the killing of 14 persons and injuring of 50 others, 
occurred at Denton in England in 1901, from the ignition of spirit vapor in a drying 
stove. These dangers could be materially lessened by the use of drying chambers, 
such as are employed in connection with steam laundries, provided with exhaust 
ventilation and limiting the number of hats which could be placed at one time into 
the dryer. 
The "finishing or pouncing process" consists in smoothing off the coarse hair from 
the surface of the hat, during which a great deal of very fine dust impregnated with 
nitrate of mercury is given off. Apart from mercurial poisoning, Heinzerling and 
Lewin cited by Schutte9 have pointed out that there is also danger from arsenical 
poisoning, since the fleshy part of hare and rabbit skins is not infrequently treated 
with soap, containing arsenite of potassium or sodium. The liability to injuries, 
especially with the carotting machine, and to burns and scalds, should be mentioned. 
It is very evident that hatters are exposed to a very irritant dust 
and, as a result, catarrhal conditions of the eyes and upper air passages 
and chronic inflammation of the lungs, and pulmonary tuberculosis, are 
quite prevalent. 
Schuttes' German statistics8 show a morbidity rate per 1000 hatters as follows: 
diseases of the respiratory organs 44.1; pulmonary tuberculosis 21.6; diseases of the 
eye and ear 30; diseases of the skin 17.1; injuries and burns 18.1; industrial poisoning 
22.5; diseases of heat and blood-vessels 13.9; diseases of the digestive organs 28; 
diseases of the nervous system 21.6. Apart from the injurious factors already 492 
MERCURIAL INDUSTRIES 
mentioned the unsatisfactory working conditions and sedentary habits, especially of 
the female finishers, are doubtless responsible for an excessive amount of sickness. 
Hoffman's Industrial Mortality Statistics, based upon 832 deaths among hatters, 
show that 278, or 33.4 per cent., were caused by consumption, 71 by pneumonia, 12 by 
bronchitis and 14 by other respiratory diseases, making a combined mortality rate of 
45.1 per cent, from diseases of the respiratory organs. The Leipsic Sick Benefit 
statistics show a very high sickness rate among hatters; viz., 1124 days per annum per 
100 members, and a mortality hazard of 1.15 per 100 members. 
Dr. Wade Wright,11 in a clinical study of 108 fur workers and felt hatters, at Danbury, 
Conn., in 1921, presents the following results of 100 careful physical examinations: 
Sixty-nine of the group were rated as of good nutrition; 25 fair and 6 poor; partial 
deafness was noted in 18 cases, and a history of running ears in 10; 33 complained of 
tinnitus. The teeth of most members were in fair condition. In but rare instances 
was there evidence of extensive dental disease or loosening of the teeth. Many men 
had lost several molars; 5 wore plates in both jaws and 3 in one jaw; marked 
discoloration of the teeth was noted in a few cases. 
Pyorrhea was observed in 45 persons, occasionally with readily bleeding gums; 
there were but 2 cases of gingivitis so marked as to suggest some disease other than 
pyorrhea. In 3 men there was observed a definite blue line in the gums, somewhat 
similar to the Burtonian line of lead poisoning; 22 persons gave a reasonably trust- 
worthy history of salivation, usually very moderate in degree; only 3 showed salivation 
when examined; 11 had sore tongues; 18 had noted a metallic taste; coated tongues were 
observed in 26; dry throats in 6, dusky mucous membranes in 19; slight speech defects 
in 5; no noteworthy odor of the breath was reported. 
History of frequent colds were reported in 49; pneumonia in 16; pleurisy in 18; fre- 
quent coughs in 49 and hemoptysis in 9. Statements regarding fever were untrustworthy. 
Lymph nodes, slight or moderate, were observed in 36 persons; headaches in 13; dizziness 
in 43; neuralgia in 26; tremors of the muscles of the face or orbits, slight or moderate, 
in 17; tremor of the tongue, slight in 30; of the fingers, in 55 cases, slight in 28 and 
moderate or marked in 27; intention tremor of the fingers, 31: in 22 it was moderate or 
marked and in 9 slight. 
Dr. Wright's observations on mercury poisoning are of special interest. He points 
out that most authors, including Dr. Alice Hamilton, emphasizes the importance of sali- 
vation, dryness of the mouth, gingivitis, a blue line in the gums, tremors and psychic 
irritability. These six symptoms were recorded in his study with the following 
frequency: salivation 22, dryness of the mouth or throat 25, gingivitis (with pyorrhea) 
45, blue line 3, tremors 61; psychic irritability 59. 
Of twenty-one specimens of urine obtained from 39 persons: 5 showed albumin, 
58 men reported nocturia; a definite history of haematuria was obtained in but one 
case, associated with evidence of renal colic. No evidence of mercury in the urine 
reported. 
Of the 100 men examined, there were 53 who presented at least 2 of the above 
signs or symptoms. Of these, 10 have been eliminated as questionable for various 
reasons, the remaining 43 showing quite definite signs of mercurialism. These were 
classified as follows: severely affected 5; moderately, 14 and slightly, 24. 
No cases of active tuberculosis were recognized. Radiographs of 56 per cent, of 
the group disclosed no notable incidence of serious pulmonary disease. In 39 per 
cent, of the cases the systolic blood pressure was found to be unusually high. There 
were a number of heavy calluses of the hands and of Dupuytren's contraction. 
Dr. Alice Hamilton12 in discussing the hazards in the dyeing of felt hats refers 
especially to the toxic properties of ursol or anilin black, and cites the cases of 
distressing trade eruptions and cases of bronchial asthma reported by Von Criegern 
and Olson and contracted in dyeing and also by wearing fur dyed with ursol. (See 
also pages 516, 517 and 679). PREVENTIVE MEASURES IN FELT HAT INDUSTRY 
493 
Preventive Measures.!-The chief danger in this-industry lies in the 
employment of mercury and much attention has been paid to provide a 
suitable substitute for the acid nitrate of mercury. Lussigny suggested 
the use of a solution which has for its base caustic potash. This prepara- 
tion has been patented and is said to have been successfully employed 
in New York, and by some firms in Russia, but apparently failed to give 
satisfaction in France. Ronzat has urged the substitution of tin for 
mercury, and this process is now being tried in France, but reliable data 
concerning the employment of these substitutes are still wanting. 
Kefauver15 describes the "No-nitrate Method" discovered by William Braun, a 
brush maker by trade, by which the hair is shaved from the pelt, and then immersed 
in a solution of sodium carbonate, raised to a temperature of 210° to 220°F. and kept 
at this temperature for-from 18 to 25 minutes depending upon the variety of the hair. 
This is claimed to remove the animal fats and acids and softens the hair so it will felt 
readily, after which it is ready to be worked and sized immediately instead of after 
several days, as under the old process. In addition to freeing the workers from the 
hazard of mercury poisoning it permits a great saving in the cost of manufacture of 
felt hats. The author claims that the method has now had four years test and has 
proved satisfactory in every respect. 
Bortfelt16 describes a method discovered by Dr. Kurz of Bremen who employs 
a cold solution of nitric acid and a decoction of sumac to the hairy part of the skin, 
with subsequent drying at a temperature of 55R. Both of the above methods appear 
to accomplish the purpose, but apparently nothing short of compulsory legislation is 
likely to secure a prompt adoption of the non-toxic methods. 
Until a harmless substitute for mercury is generally adopted, adequate 
exhaust ventilation in all processes involving the evolution of dust and 
fumes should be insisted upon. This, together with the wearing of rubber 
gloves by those handling mercurial solutions, will at least diminish the 
dangers. Fortunately, the manufacture of wool-felt hats has displaced 
to a considerable extent the use of rabbit fur. 
In July, 1915, Lewis T. Bryant, Commissioner of the Department of Labor of the 
State of New Jersey, published "Sanitary Standards for the Felt Hatting Industry." 
The report very properly emphasizes the chief health hazards, such as mercurial 
poisoning, dust, humidity and other injurious environments, which have combined 
to produce a large number of cases of tuberculosis of the lungs. He states that the 
industry is regarded so dangerous to health that several of the largest insurance 
companies refuse to insure fur cutters, makers, starters and sizers at any premium, 
and workers in other departments are charged an extra heavy premium on ordinary 
policies. 
The general preventive measures and devices recommended in the Bulletin have 
been tried out in different factories and proved of value in reducing to a minimum 
the industrial hazards. Among the important measures recommended are that all 
mixing should be done mechanically in an inclosed device, and the fur mixture should 
be fed into the "devil" by means of an inclosed automatic device. 
Blowing machines should likewise be fed by means of an automatic device, and 
all dust and fur fiber liberated during the blowing and cleaning operations should be 
removed by means of the exhaust system, standardized in the Bulletin. Vacuum or 
wet cleaning only should be employed in the dusty departments. 494 
MERCURIAL INDUSTRIES 
The temperature in the blowing room and mill room (when due to artificial heat) 
should not be permitted to exceed 75° and when live steam is employed to increase the 
humidity, excess temperature should be prevented by means of a cold-water spray or 
other efficient methods. All steam generated in the operations of starting, first and 
second sizing, dyeing and blocking should be controlled and eliminated by means of 
exhaust ventilation. Wood alcohol fumes should not be permitted to pollute the air 
of the workrooms either during the shellacing or drying operations. Efficient means 
for their removal should be installed, and care exercised to safeguard against the 
hazard of explosion. All steam pots and singeing flames should be hooded and sup- 
plied with exhaust ventilation. All dust generated in the operation of pouncing and 
sandpapering machines should be removed by exhaust ventilation. All hand or 
mechanical ironing shells should be heated by electricity. Wherever gas is employed 
for ironing purposes the health of the worker must be safeguarded by means of exhaust 
ventilation. To control the excessive heat generated in the flanging and matricing 
operations, ample ventilation by means of windows, wall fans or other devices should 
be provided; all steam plates should be covered on bottom and sides with asbestos, 
and whenever possible an electrical device for heating the flange-bags should be 
installed. 
Standard safeguarding should be installed on all shafting under power-driven 
serving machines, and on all belts, gears and wheels; and all set screws should either 
be replaced or countersunk. 
REFERENCES 
1 Edsall, D. L.-Jour. A. M. A., Vol. LXXI, 1909, page 1876. 
la Schulte.-Archiv. f. Hygiene, Bd. 83, 1914. 
2 Legge.-Oliver's Dangerous Trades, London, 1902. 
3 Heucke, Karl.-15th Internal. Congress on Hygiene and Demography, Washington, 
D., C., 1913, Vol. Ill, Part II, page 788. 
4 Industrial Health Hazards and Occupational Diseases in Ohio, February, 1915. 
5 Legge.-Oliver's Dangerous Trades, London, 1902. 
6 Tylecote, Frank E.-15th Internat. Congress on Hygiene and Demography, 
Washington, D. C., 1913, Vol. Ill, Part II, page 778. 
7 Teleky.-Die gewerbliche Quecksilberergiftung, Berlin, 1912. 
8 Mercury Poisoning in the Industries of N. Y. City and Vicinity. Nat. Civic 
Federation, Woman's Welfare Department, 1913. 
9 Schutte.-Weyl's Handbuch der Arbeiterkrankheiten, Jena, 1908, page 386. 
10 Jacobsohn, William-Div. of Indust. Hyg., Dept, of Health, City of New York. 
Manufacture of Clinical Thermometers, Jour. Ind. Hyg., September, 1920, p. 193. 
11 Wright Wade.-A Clinical Study of Fur Cutters and Hatters, Jour, of Ind. Hygiene, 
November, 1922, p. 296. 
12 Industrial Hygiene and Diseases of Fur Cutters and Hatters, Alice Hamilton, 
Jour. Ind. Hyg. Aug., 1922, p. 137, Sept., 1922, p. 210. 
13 Minot, Annie S.-Estimation of Mercury in Hatters' Fur and Felt, Journal Ind. 
Hyg., October, 1922, p. 253. 
14 Johnson, John R.-The Preparation of Hatters' Furs, Etc. Journal Ind. Hyg., 
December, 1922, p. 325. 
18 Kefauver, Christine.-Felt Hat Making by the Acid-Nitrate-Mercury Method, and 
the No-Nitrate Method, Monthly Bulletin, Dept, of Health, City of New York, 
May, 1919, pages 127-128. 
16 Bortfelt.-Zentralb. f. Gewerbehygiene, April, 1919, p. 53. SECTION 15 
PETROLEUM AND ITS DERIVATIVES 
ALICE HAMILTON, M. D„ Chicago, Ill. 
Introduction.-A study of the literature of poisoning from the products 
of petroleum such as naphtha, benzine, gasoline, and from the products 
of coal-tar distillation, such as benzene, reveals a great deal of confusion 
and the student will often be left with a question in his mind as to just 
which one of the many complex bodies belonging to these two groups was 
involved in any specific instance of poisoning. This is partly because in 
the majority of cases a mixture was used, not a chemically pure substance, 
but it is also true that to distinguish between the physiological effects of 
poisoning by benzine and by benzene is difficult if not impossible. The 
similarity of names adds to the confusion. Benzol is a synonym for ben- 
zene, not for benzine, but it is not always possible to be sure, especially in 
French and Italian reports, exactly what body is meant when one of these 
words is used. Another confusing factor is the similarity of uses of the 
two groups of chemicals. Though it is clear that the fumes in a benzene 
still or in a petroleum refinery are of fairly well-known nature, it is not 
possible to say which will be present in a rubber factory, a dry-cleaning 
establishment, a varnish factory, or a room in which motor cars are tested, 
for both benzine and benzene are used for all these purposes. Therefore 
it is easy to see why some observers have not attempted to decide the 
real nature of the poison which was present, while others have reported 
their cases in such a way as to arouse doubts in the minds of critics. 
The increasing use of coal-tar solvents in recent years in the United 
States has led to numerous cases of industrial poisoning and a clear clinical 
picture has emerged from a study of the severer cases so that it is now easy 
to recognize such forms. The mild, chronic form, however, is not charac- 
terized by symptoms which differentiate it clearly from poisoning by 
certain other volatile compounds, notably those of the petroleum series. 
Another element of confusion is introduced by the commercial use of 
the term 11 solvent naphtha" for a mixture of benzene, toluene, etc. while 
ordinary naphtha is, of course, a petroleum product. 
Properties.-Petroleum is a dark brown, oily liquid derived from the subterranean 
distillation of vegetable matter. It has a structure of enormous complexity, differing 
in different regions. Pennsylvania petroleum contains a complete series of hydrocar- 
bons from CH4 to C16H34, also the solid hydrocarbons C35H52 C27H56 and C3oH62. 
When distilled, the lighter compounds pass over at 30°C. to 170°C. These are the 
benzines, naphthas and gasolines and contain 60 per cent, to 75 per cent, pentane 
(C5H12, b. pt. 36.3°C.) according to the boiling point. The compounds which distill at 
495 496 
PETROLEUM AND ITS DERIVATIVES 
30°C. to 70°C. are used chiefly for motor cars; those at 80° to 120°C. for extracting fats, 
as cleaning fluids, and, in combination with the distillates at temperatures up to 170°G. 
in varnish and as turpentine substitute in paint.1 Next in order of distillation comes 
kerosene, illuminating oil, and then the solid paraffins, vaseline, etc. Different 
proportions of these bodies are found in petroleum of different regions. West Virginia 
oil is said to have a good deal more of the heavier bodies than Ohio oil and Russian oil 
is heavier than American. 
Toxicity of Benzine.-Lehmann1 and his colleagues experimented with different 
benzines, letting animals inhale the fumes, and they found the effect to be irritation of 
the respiratory mucosa, muscular twitchings and a slowly increasing narcosis. Light 
benzine in large doses was decidedly less poisonous than the heavier. With Gunder- 
mann, he found that inhaling 20 mg. of light benzine had little or no effect, but when 
as much as 45 mg. was used they experienced a feeling of impaired mentality with weak- 
ening of the will power. Much larger doses were used by Felix3 in experiments carried 
out on prisoners in Bucharest. He administered benzine as one would chloroform for 
anaesthesia. While some individuals proved to be quite insusceptible, even to large 
doses, the majority after inhaling 5 to 15 grams for 7 to 12 minutes felt dizziness, 
nausea, smarting of the conjunctiva, and in some cases burning in the chest and 
drowsiness. Larger doses caused sleep and anaesthesia, succeeded by nausea, vomit- 
ing, headache, dizziness, depression and drowsiness. 
There are several records in the literature of poisoning after drinking 
benzine, but industrial benzine poisoning always takes place through the 
inhalation of fumes or through skin absorption, although so far as is 
known the latter gives rise to local symptoms only. 
The effects of acute poisoning from the inhaling of moderate amounts 
of fume resemble mild alcoholic intoxication, and in dry-cleaning establish- 
ments or rubber works, where the employes are very familiar with the 
condition, they speak of it as "naphtha jag." Dufour4 speaks of the 
excited gayety of girls employed in poorly ventilated dry-cleaning estab- 
lishments, a gayety soon yielding to depression, headache, clouded 
mentality. 
In the spring of 1913 I had the opportunity, through the courtesy of Dr. J. H. 
Landis, Health Officer of Cincinnati, to interview nine interior house painters who had 
recently experienced the effects of using a quick-drying paint, containing large quan- 
tities of benzine, in small and practically unventilated rooms. Dizziness, headache, 
spots before the eyes, dryness and choking in the throat, burning of the eyelids, were 
complained of by all, while some complained also of nausea, vomiting, pains in various 
parts of the abdomen, and painful urination. Several said that at the end of the day 
they could no longer do fine work and two had attacks of momentary blindness. One 
suffered from ulcers of the lips and gums. In several instances the worst discomfort 
came on leaving work, the dizziness and staggering coming on in the open air. Loss of 
appetite and a feeling in the morning of having been drunk the night before were usual 
features of his mild benzine poisoning. 
An inquiry into the condition of health of rubber workers in the United States5 
showed that symptoms of ill health, not very clearly defined, are common in the 
cementing departments, from the use of a solution of rubber in naphtha, and in the 
making of spread goods with a similar solution, and still more in the manufacture of 
dipped goods, where large quantities of solvent are used. Aside from the acute 
attacks of headache, dizziness, nausea, excitement, described above, the symptoms 
caused by these solvents are not characteristic and it is often impossible to link them CHRONIC BENZINE POISONING 
497 
up to the occupation with any degree of certainty. The Occupational Disease Clinic of 
the Massachusetts General Hospital has records of cases, however, which taken together 
seem significant. The complaint is usually of nervous symptoms such as pricking and 
crawling sensations, headache, poor sleep, drowsiness, twitching muscles, coldness and 
numbness in fingers and toes; digestive symptoms, loss of appetite, indigestion, colic, 
loss of weight. Chronic naphtha poisoning in rubber workers is said to be common in 
British rubber factories. After the use of caibon disulphide was discontinued in great 
part it was supposed that the health of the operatives would improve noticeably 
but the result was disappointing and the authorities concluded that the explanation 
lay in the presence of naphtha fumes. The women especially continued to complain of 
headache and dizziness and loss of appetite, the latter being increased if they were 
obliged to eat their lunch in the naphtha-laden air of the workroom. In an Ohio town 
I found a workman who had for three years dipped forms in a naphtha-rubber solution 
and who had frequent attacks of dizziness, was very nervous, was losing power in 
his right arm and was markedly anaemic. 
Dorendorff's6 cases are usually quoted as striking instances of 
chronic benzine poisoning. The men were rubber workers and the most 
prominent symptoms complained of were pains of a tearing character in 
muscles and joints, tenderness on pressure, weakness and coldness of the 
right hand, psychic depression, loss of memory, difficult speech. There 
was increased excitability of the skin to mechanical irritants and heightened 
tendon reflexes. 
More serious symptoms follow exposure to heavier fumes. Lewin7 
says that in the oil regions of Pennsylvania and in the refineries at Point 
Breeze he was told of men who when they went down into the tanks 
became so excited and irrational that they could with difficulty be per- 
suaded to come out. In still more serious cases, which are rare in propor- 
tion to the numbers employed, there is a rapidly increasing weakness, 
quick and weak pulse, labored respiration, delirium and coma. 
A physician in a town where there is a large rubber factory told me of such a case 
in his practice. The patient, a strong man, had been dipping wooden forms in a tank 
filled with a solution of rubber in benzine, to make seamless surgeons' gloves. He felt 
dizzy and ill and left work, but on his way home he staggered and would have fallen, 
had not two men helped him. Later, when in bed, he lapsed into unconsciousness and 
when the physician saw him he was comatose, very pale and almost pulseless. He 
recovered completely. 
Wichern8 describes an accident in a benzine tank where some remnants of benzine 
were floating on the surface of the water poured in to clean it. A man who climbed in 
was overcome by fumes and fell with his face in the benzine. He was quickly rescued 
but was unconscious, his muscles strongly contracted. He had severe chills and 
vomiting and though he recovered he had some irritation of the throat for two weeks. 
Cleaning out vats and tank cars is one of the most common causes of 
acute benzine poisoning.9 A former report of the German Factory 
Inspectors8 tells of a workman who entered the benzine cylinder of a wash- 
ing machine in a dry-cleaning establishment while there was still some 
benzine left in it, and was found lying unconscious overcome by the fumes, 
although the machine stood by an open door. Fumes from the benzine 498 
PETROLEUM AND ITS DERIVATIVES 
used in quick drying paints were responsible for two cases of poisoning 
noted in the 1912 report of the British Factory Inspector.10 
The cases of severe and even fatal poisoning from the exhaust gases of 
automobile engines, which have been so frequent of late years, were at 
first attributed to the fumes of gasoline and the name "petromortis" 
was suggested for death from this cause. It is now known that carbon 
monoxide is responsible for this form of intoxication, although true gaso- 
line poisoning may occur in connection with gasoline engines. 
For instance Johnson11 describes a wholesale poisoning of workmen in a tunnel in 
Montreal, involving no less than 42 men. The two first cases described were asphyxi- 
ated, unconscious for 20 minutes, face extremely flushed, pulse 100-108, good volume 
and tension, respirations 36 and deep. The patellar, plantar and cremasteric reflexes 
were absent, pupils moderately dilated. When they recovered consciousness they 
could not speak but could move their limbs. Later they complained of severe frontal 
headache but no nausea or vomiting. The effect was very transient, they went back 
to work in an hour and the next day experienced no discomfort while at work. Two 
others had clonic spasms. A spectroscopic examination of the blood showed no 
carbon monoxide hemoglobin and the air in the tunnel was free from this gas. 
In our own country Potts12 has described a case of "encephalitis" due to gasoline 
poisoning in a man who worked for 4 months filling automobile tanks. After about 
2 months of headache, nausea, and visual disturbances, he fell unconscious while at 
work and when aroused complained of intense headache. There was weakness of the 
right third nerve and of the left side with partial incoordination of the left arm and the 
gait was cerebellar in type. The weakness of eye and arm were permanent. 
Fatal cases are rare. Lehmann2 has collected several from the litera- 
ture and added one, a man who spilled 40 liters of benzine in a low cellar, 
tried to scoop it up, came out complaining of feeling faint and tired and a 
half hour later was found lying dead outside the door. Zimmermann's13 
fatal case died while trying to remove with benzine the crusts which had 
formed on the inside of a tank. Lewin7 heard of fatal cases of poisoning 
in the American oil fields and refineries among the workmen who have to 
enter the tanks. In England a case of poisoning from the use of benzine 
in paint ended fatally. These paints are especially dangerous when the 
surface to be painted is warm. 
In addition to poisoning from fumes there is a toxic action exerted on 
the skin by the petroleum products, especially the heavier. Paraffin 
workers develop multiple papillomata, or pemphigus-like or eczematous 
eruptions.14 Benzine also causes skin lesions. In 1913 many cases of 
skin diseases were reported from the printing trades of Berlin,15 and were 
traced to the introduction of a new benzine-containing fluid for cleaning 
ink from type. The disease was described as a localized eczema, with 
redness, tenseness, blisters and later scaling. 
More often the lesions caused by contact of the skin with petroleum 
are described as typical acne lesions. Lewin7 found this in the American 
oil country. The irritating effect of the oil causes inflammation of the 
sebaceous ducts, retention of secretion, suppuration, multiple skin CHRONIC GASOLINE POISONING REFERENCES 
499 
abscesses, etc. In the great factories for agricultural implements in this 
country the men and girls employed in the preparing and spinning rooms 
in the twine mills often suffer from very distressing acne. This twine is 
treated with a mixture of fuel oil 95 per cent, and wool oil 5 per cent, to 
soften it and keep it from being devoured by field insects when it is in use. 
The workers feel the effects of this oil most in summer when they work 
with their sleeves rolled up because of the heat. 
In studying the effects of gasoline fumes on 22 employes working on coupon 
stamping machines, Spencer16 diagnosed mild chronic gasoline poisoning in all, with 
symptoms for males which we can group in descending order as follows: headache, 
daily headache, drowsiness, dizziness, extreme tiredness in the morning; afternoon 
drowsiness, dull aching pain in eyes, irritated eyes (burning, smarting or gritty feeling), 
complaint of the work being nerve racking, loss of appetite, frequent urination (few 
days to four months); heaviness in head, excessive lachrymation, slight conjunctivitis, 
and loss of appetite. The symptoms were much more pronounced and frequent in the 
females and were, in descending order: irritated eyes (as in males), excessive lachryma- 
tion; headache, drowsiness, heaviness in head, overtiredness at quitting time; dull 
aching pain in eyes, loss of appetite; varying headache, dizziness, easily angered, often 
easily excited; daily headaches, sore and inflamed throat, constant dryness of throat, 
complaint of extreme muscular weakness, exhaustion or "all-in" condition by mid- 
afternoon, constipation, frequent urination; afternoon drowsiness, blurred vision, 
extreme nervousness, feeling of worry, nausea; slight conjunctivitis, work nerve 
racking, insomnia, occasional attack of colic; and various less frequent complaints. 
Spencer also summarizes the findings of other authorities for low boiling petroleum 
distillates (gasoline, naphtha and benzine) and points out that the chronic form 
sometimes goes to the extent of extensive impairments due to changes in the nerve or 
muscular systems and alterations of the blood. (Hayhurst.) 
Preventive measures are similar to those for benzol poisoning (see 
Section 16, following). 
REFERENCES 
1 Bartley.-Medical and Pharmaceutical Chemistry, Philadelphia, 1899. 
2 Lehmann, Weissenberg, v. Wojciewski, Luig and Gundermann.-Arch. f. Hyg., 
1912, LXXV, 1. 
3 Felix.-Quoted by Lehmann. 
4 Dufour.-Soc. med. d. Hop. d., Paris, Oct. 18, 1901. 
5 Bulletin 179 of the U. S. Bureau of Labor Statistics. 
6 Dorendorff.-Munch, med. Wchnschft., 1901, XLVIII, 236. 
7 Lewin.-Virch. Arch., 1888, CXII, 35. 
8 Wichern.-Munch, med. Wchnschft., 1909, LVI, 2. 
9 Rambousek.-Concordia, 1910, XVII, 448. 
10 Ann. Rep. Chief Inspector Fact, and Workshops for 1912, page 112. 
11 Johnson.-Canad. Med. Ass. Journ., Torhnto, 1913, III, 118. 
12 Potts.-Journ. Nerv. and Ment. Dis., 1914, XLI, 527. 
13 Ztschft. f. Gewerbehyg., 1907, 157. 
14 Volkmann.-Sammi, klin. Vortrage (Volkmann's), 1875, 1, 370. 
15 Zellner and Wolff.-Ztschft. f. Hyg. u. Infektionskrankh., 1913, LXXV, 69. 
16 Spencer, Octavius M.-U. S. Public Health Reports, XXXVII, 38, Sept. 22, 
1922, 2291-2307. SECTION 16 
COAL-TAR BENZENE (BENZOL) POISONING 
ALICE HAMILTON, M. D., Chicago, Ill. 
Introduction.-Pure benzene or benzol is CeHe and boils at 80.4°C., but the com- 
mercial variety contains substitution products as well, chiefly toluol and xylol, 
distilling at 80° to 85°C. It is a solvent for rubber, fats, gums, celluloid, and therefore 
much used in the rubber industry, in varnishing and varnish and paint removing, in 
gilding and bronzing, in coal-tar paints, and is coming increasingly into use as motor 
car fuel. Benzene, toluene and xylene are also the most important crudes for the 
manufacture of dyes, drugs and perfumes and certain explosives. Since the outbreak of 
the war the United States, which used to import these compounds, has produced them 
in large quantities and they are now substituted for the less powerful petroleum 
solvents in many trade processes. 
The action of crude benzene is the same in kind as that of pure 
benzene (Selling4), but the presence of toluene and xylene in the crude 
should diminish the toxicity, since these are methylated compounds and 
less poisonous than benzene. 
Symptoms.-The symptoms caused by the inhalation of these fumes 
point to a poison with a selective action on the central nervous system, 
and they are as follows in the order of their appearance: muscular tremors, 
salivation, violent twitchings, exhaustion, paralysis, narcosis, respirations 
first quick then slow, rapid pulse, low temperature. Usually the animal 
recovers but cats may show a striking idiosyncrasy and die after a short 
exposure, from respiratory failure. Lehmann1 found no characteristic 
changes in organs or blood but Chassevent and Garnier2 found congestion 
of the abdominal organs and peritoneum, and ecchymoses and ulcers along 
the upper border of the stomach in the mucous coat. Santesson,3 
experimenting with crude and with pure benzene was able to produce 
hemorrhages into the mucous membrane of the stomach and the intestines 
and into the lungs. He concludes that benzene dissolves the body fat and 
that emboli of fat lodge in the smaller vessels causing first stasis and then 
rupture of the vessel wall. Selling4 found blood changes in rabbits as a 
result of poisoning with pure and with commercial benzene, the most 
striking feature being a leucopenia which progressed till the white corpus- 
cles numbered 20 in a cubic millimeter of blood. He thinks benzene a 
specific poison for the leucocytes. In human beings, benzol is decidedly 
more toxic than benzine. Lehmann and Gundermann1 produced symp- 
toms in themselves with 10 grams of benzol which required 45 grams of 
benzine to produce. They consider it a poison of only moderate severity, 
while Rambousek finds the vapors of benzol mixed with air very poisonous 
500 SYMPTOMS OF BENZENE POISONING 
501 
and publishes a large number of serious and of fatal cases collected from 
the literature and from personal information.* 
The majority of serious cases of benzene poisoning have occurred in 
work which exposed the man to very heavy fumes, usually in the cleaning 
out of some receptable in which benzene had been kept and which in some 
cases still had remnants left when the cleaning began. Other men were at 
work with benzene stills where from some accident or neglect fumes were 
allowed to escape. In such cases death occurs with great suddenness and 
often after an exposure which is apparently slight. There have been 
several well authenticated cases in the United States of men dying from a 
fairly short sojourn in a benzene tank which had been not only emptied 
but washed out and steamed out repeatedly. The only safe method 
seems to be to provide the workman with fresh air through a helmet and 
it is essential that a second man remain on guard outside while the work is 
going on. 
Slower forms of benzene poisoning, also sometimes fatal, have been 
described in rubber works (Santesson,3 Harrington6), in connection with 
the use of coal tar paint7 and in a cannery where a sealing mixture of 
rubber dissolved in benzene was used (Selling,10 McClure8). This form is 
characterized by profound blood changes of the aplastic type and by 
lesions in the vessel walls which lead to multiple hemorrhages into serous 
and subcutaneous tissues and from the mucous membranes of nose and 
throat, less often of stomach and intestines, and from the uterus. 
Lenoir and Claude9 tell of a fatal case of purpura in a workman employed for 
several years in a dye house and exposed daily to fumes of benzene. There were 
subcutaneous hemorrhages, bleeding from nose and from gums, increasing cachexia 
and sudden death. At autopsy, bloody effusion into the pleural cavity, hemorrhages 
into the mucosa of stomach and intestines and under the endocardium and myocardial 
infarcts. 
Santesson3 has described the most famous cases in the literature of benzene poison- 
ing. Nine young women were employed for periods of a few weeks or months in a 
velocipede tire factory in Upsala. For a while before the appearance of the most 
serious symptoms they had been working overtime, 12 hours or more a day. The 
symptoms complained of were usually those already described as characteristic of 
acute benzene poisoning, but the more serious cases had in addition purpuric spots on 
the skin and a tendency to hemorrhage, sometimes excessive, from nose, mouth or 
gums. In one there was a menstrual hemorrhage. Four girls died, after illnesses 
lasting a month or two. Profound anaemia developed, in the third case reaching 
600,000 reds, and the fourth case had a striking leucopenia, hardly any whites being 
discoverable in a cubic millimeter of blood. Santesson found that the solution used in 
the factory was a crude coal-tar benzene distilling at 80° to 90°C. 
Lehmann1 thinks that the severity of these cases, so much greater than any 
reported in the literature and with the unusual feature of purpuric lesions, is to be 
* Frank P. Underhill and Benedict R. Harris (Jour. Ind. Hyg., March, 1923, pp. 
491-500) have studied the influence of benzol upon certain aspects of metabolism, and 
conclude that "benzol acts not only on the blood elements but exerts a catabolic influence, 
as manifested by a sharp rise in creatine and total nitrogen within a very short period 
after its subcutaneous injections into rabbits, far in excess of that found in rabbits under 
similar conditions under ordinary starvation." (Kober.) 502 
COAL-TAR BENZENE (BENZOL) POISONING 
explained on the ground of the youth and sex of the victims and the overexertion to 
which they had been exposed. Three almost precisely similar American cases 
reported by Selling10 seem to have escaped Lehmann's attention. These also were 
young girls, younger than the Swedish cases for they were only 14 years old, and it is 
this immaturity which probably explains the more rapid course of the disease in 
Selling's cases. The girls were employed in a cannery near Baltimore where recently 
a solution of rubber and rosin in commercial benzol had been substituted for solder in 
the sealing of cans. The work was done in a well-ventilated room and there is no note 
of excessive hours, but it was during the summer months when the heat in Maryland 
is intense. Three girls were brought to the Johns Hopkins Hospital suffering from 
anaemia, purpuric spots, dizziness, hemorrhages from throat, nose and gums. As in 
Santesson's cases, the symptoms increased after the exciting cause had ceased and two 
of the three girls died in a few days with symptoms of profound toxaemia. There was 
a count of only 1,090,000 reds, falling before death to 640,000, and the hemoglobin 
fell to 8 per cent., but leucopenia was the most striking feature of the blood picture. 
The whites numbered only 480 per cu. mm. and the loss affected chiefly the polymor- 
phonuclears, which formed 16 per cent., the small mononuclears forming 71 per cent, 
and the large, 10 per cent. Selling calls the condition one of aplastic anaemia, for in 
spite of the great loss no regenerating forms of blood corpuscles were found. He 
found the substance to be crude benzol chiefly, and with it as also with pure benzol he 
was able to bring about in rabbits a marked leucopenia, reaching 20 per cu. mm. at 
which point death occurred. 
It is worth noting that in Selling's cases and in two of Santesson's there was fever, 
while in experimental benzol poisoning a fall of temperature seems to be invariable. 
Some years later McClure8 reported another case from this same cannery, a woman 
who suffered from obstinate nosebleed, bleeding from the gums, shortness of breath, 
and loss of appetite. Black and blue spots like bruises appeared over the body. She 
was profoundly anaemic, one blood count made during her stay in the hospital showing 
only 840,000 red blood cells, and a hemoglobin percentage of only 29. This woman 
was apparently saved by repeated transfusions of blood. 
T. F. Harrington,6 late Medical Deputy Commissioner of Labor for Massachusetts, 
had an opportunity to study some very striking cases of purpura hemorrhagica in men 
who had been using benzene in such a way as to permit skin absorption as well as 
absorption through the breath. Of the five cases described by him three ended in 
death. The symptoms were weakness and breathlessness, bleeding from nose and 
gums, headache and dizziness. There were purpuric spots over the body and a 
pronounced loss of blood elements, the red corpuscles falling sometimes below two 
million and the whites below 900 with a disproportionate decrease of the polymor- 
phonuclears. 
Experimental studies made by Hektoen11 and by Rusk12 show that this action of 
benzene on the blood building tissues results in a reduction of antibody formation. 
Lysins and precipitins are diminished and consequently resistence to infection is 
lowered. Hektoen's experiments show that, in animals, poisoned with benzene the 
resistence to infection is reduced because of a lessened production of antibodies and of 
leucocytes, and by a lessened activity on the part of the leucocytes. 
The author gives a summary of numerous reports of poisonous 
properties of benzene in a special article13 which may be consulted by 
those interested further. * 
Preventive Measures.-The prevention of poisoning from fumes of 
benzene or benzine lies in good ventilation so that the fumes may be 
diluted down to the point of harmlessness. Even allowing for an indivi- 
dual susceptibility such as we have reason to think does exist in some REFERENCES ON BENZENE POISONING 
503 
people, the really serious cases of poisoning have all been caused by 
exposure to very heavy fumes, and the reports of chronic poisoning come 
from those countries chiefly where industrial hygiene is comparatively 
neglected. High ceilings, abundant ventilation, scrupulous cleanliness 
are enough in cases where fumes are not heavy; artificial ventilation with 
air exhaust must be installed when the danger is greater, preferably, 
according to the British inspectors, with a down-draft as these are heavy 
fumes. If a vat or tank must be cleaned out, the men must be furnished 
with divers' helmets. For the distressing skin diseases nothing but very 
strict bodily cleanliness will help and in susceptible cases there is no 
hope of cure as long as the work is kept up. 
REFERENCES 
Lehmann, K. B., Weissenberg, v. Wojciechowski, Luig and Gundermann.-Arch. f. 
Hyg., 1912, LXXV, 1. 
2 Chassevent and Garnier.-Arch. Internal, de Pharmacodyn. et de Therap., 1905, 
XIV, 93. 
3 Santesson.-Arch. f. Hyg., 1897, XXXI, 336. 
4 Selling, L.-Johns Hopkins Hosp. Reports, 1916, XVII, 83. 
5 Rambousek.-Concordia, 1910, XVII, 448. 
6 Harrington, T. F.-Boston Med. and Surg. Journ., 1917, 177, 203. 
7 Jahresbericht d. Gewerbeaufsichtsbeamten u. Bergbehorden f. d. Jahr., 1912, III, 
15 and 17. 
8 McClure, R. D.-Journ. Am. Med. Ass., 1916, LXVII, 693. 
9 Lenoir and Claude.-Soc. Med. d. Hop. d., Paris, Oct. 20, 1897. 
10 Selling, L.-Bull. Johns Hopkins Hosp., 1910, XXI, 33. 
11 Hektoen, L.-Journ. Infect. Dis., 1916, XIX, 69. 
12 Husk, G. Y-Univ. California Pub. in Path., 1914, II, 139. 
13 Hamilton, Alice.-The Growing Menace of Benzene (Benzol) Poisoning in Ameri- 
can Industry, Jr. Am. Med. Ass., 1922, LXXVIII, 627. SECTION 17 
THE PETROLEUM AND COAL-TAR INDUSTRIES 
GEORGE M. KOBER, M. D., Washington, D. C. 
PETROLEUM PRODUCTS 
The Petroleum Industry.-Employes in the petroleum industry are 
exposed to the gases evolved from the oil, namely, benzine, or petrol 
naphtha. The men near the wells and pumps and those who enter the 
tanks or clean out the retorts are especially exposed to concentrated 
petroleum vapors. 
Refining of Crude Petroleum.-Hayhurst1 states that in receiving the 
crude product, usually by pipe lines, there was an odor of hydrocarbons 
and of hydrogen sulphide present in some places, but not hazardous except 
when leaks occurred, and that cases of sore eyes were not infrequent. 
The distilling and refining of crude petroleum includes purification with 
sulphuric acid and its neutralization with caustic soda, de-colorization 
with Fuller's earth and de-odorization with hydrochloric acid and 
chloride of lime, and hence involves exposure to these industrial poisons. 
The residuum of American oil is especially rich in paraffin, vaseline 
and other lubricants which are extracted by different processes. In some 
places where the retorts are opened for the removal of the residue there is 
considerable exposure to sulphur dioxide, and in the recovery of tar there 
is generally exposure to sulphuric acid fumes. Lead oxide is also added 
to the oil and the men who shovel it into the open vats and those obliged 
to repair lead-lined tanks are exposed to the risk of lead poisoning. There 
is also considerable exposure to dust in the de-sulphurizing process, in 
which a mixture of copper, lead and iron oxides is used. 
Filtering and Pressing.-In this department the residue is separated into heavy 
•oils, greases and paraffin. The work is carried on at a temperature of 50°F. The 
paraffin is extracted by means of big presses and conveyed by machine work to a 
-chamber where it is heated and filtered. Exposure to ammonia fumes from the 
■cooling plant is noted in the Ohio Survey, and also a vile stench from the boiling 
•down of wool greases to be added to the lubricating oils. 
It is very likely, as pointed out by Dr. Wm. H. Sharp,2 that the toxic effects of 
petroleum vapors vary with the character of the oil, heavy oils producing mild attacks 
while the light oils may result in asphyxia. Some of the crude oils cause irritation of 
the respiratory passages, while others affect the central nervous system. 
Petroleum as a fluid has a direct action on the skin, and persons engaged in the 
filling of barrels, emptying retorts, and handling of paraffin and other residues are 
liable to develop obstinate inflammatory conditions of the skin-the so-called petro- 
leum and paraffin itch-also pimples, pustules, boils and warty growths. Mitchell3 
504 TRADES USING PETROLEUM AND BENZINE 
505 
was among the first to call attention to these skin affections. Similar effects are 
produced in furniture polishers, machine oilers and all others who handle either crude 
petroleum or paraffin, unless protected by impermeable gloves. The literature 
contains numerous references to cases of poisoning among persons employed in petro- 
leum and naphtha tanks, in cleaning out railway oil tanks, in the use of petroleum 
motors and in the refining of naphtha, as a result of inhalation of the light oils, benzine 
and gasoline. The employment of benzine as a motive power, as a cleaning agent, in 
dry-cleaning establishments, as a solvent of rubber and fats, and as a substitute for 
turpentine in the manufacture of paints, varnishes, lacquers, etc., is constantly 
widening the chances for acute or chronic forms of petroleum and benzine poisoning. 
Berthenson4 deplores the scarcity of reliable morbidity statistics in this industry, 
but reports that of 8465 employes treated at Baku (Russia) there were 1216 cases of 
diseases of the skin and subcutaneous cellular tissue, 696 burns, 1475 cases of catarrhal 
affections of the upper air passages, 34 cases of croupous pneumonia, 29 of catarrhal 
pneumonia, 36 of pleurisy, 5 of pulmonary tuberculosis, and 607 cases of muscular 
rheumatism. He also cites Petkewitch's observation that quite a number of 
employes purposely exposed themselves to the intoxicating vapors of petroleum. 
The German statistics presented by Weyl5 show that of 1380 employes in petroleum 
refineries 9 cases of poisoning and 34 cases of acne were reported in the course of a few 
years. 
Preventive Measures.-The utmost care should be taken to secure 
efficient removal of concentrated petroleum vapors from tanks and stills 
by means of compressed air, steam or oxygen. Careful supervision of the 
work, impermeable gloves, personal cleanliness by means of frequent 
ablutions of the hands, shower baths, and change of clothing upon cessa- 
tion of work are indicated. Suspension of work upon appearance of 
toxic symptoms should be insisted upon. (For further details and pre- 
ventive measures see pages 502, 506 and 658.) 
Dry Cleaning by Means of Benzine, Chemicals, Etc.-So-called 
"chemical cleaning establishments" are often carried on in connection 
with dye works which make a specialty of renovating wearing apparel, 
etc. The processes and chemical agents employed are quite varied. 
Apart from the dyes mentioned on page 267, various iron salts such as acetate 
nitrate and sulphate, and copper sulphate are used. Alum is employed as a mordant 
and permanganate of potassium as an oxidizing agent; acetic, hydrochloric, oxalic, 
and sulphuric acids are likewise employed. Borax, caustic potash, soap and sodium 
bisulphide are used for washing and bleaching purposes. 
The principal agents for the removal of stains are benzene, naphtha, wood alcohol 
and ammonia; potassium cyanide removes silver stains and oxalic acid removes ink 
and rust stains. 
In the cleaning process soiled gloves and garments are usually placed in a large, 
revolving, hermetically closed cylinder containing either naphtha or benzine, with or 
without the addition of soap. After the first cleaning the articles are placed in naph- 
tha alone. After the second rinsing the clothing is placed in a centrifugal machine 
for the removal of surplus benzine, etc., and then taken to the drying room which is 
kept at a temperature of between 100°-120°F. On account of the inflammable char- 
acter of the benzine vapors present extreme caution is necessary, in all processes, to 
avoid naked flames, matches or other igniting agents. The naphtha fumes in the 
drying department in spite of mechanical ventilation are very strong, and according 
to the Massachusetts State Board of Health,6 "the men employed are pale and some 506 
THE PETROLEUM AND COAL-TAR INDUSTRIES 
of them markedly sick looking;" some of the men are occasionally overcome by the 
fumes, or have shown the characteristic excitement and hysterical symptoms of 
benzene or naphtha intoxication. The presence of vaporized gasoline is frequently 
noted in the pressing department, where the irons are heated by means of gasoline 
gas. W. Patzsche and R. Plaut (Munch. Med. Wchnschrft., Sept. 2, 1921) report a 
case of anhidrosis. The patient first suffered from a toxic dermatitis after working on, 
and wearing, furs that had been treated with naphthalin. The generalized anhidrosis 
lasted a whole year. (Jr. Ind. Hyg., April, 1922, Abstr. p. 273.) 
Carpet Cleaning.-Some of the establishments also conduct a rug and 
carpet cleaning department, which is usually equipped with an enclosed 
dusting machine, exhaust fans and dust flues. The introduction of 
vacuum cleaners has rendered this operation less dusty and harmful, but 
the danger from the employment of benzine and benzol for the removal of 
stains has not diminished. 
Apart from the cases of poisoning already referred to on page 496, Dr. 
Neisser7 reports an instance in a carpet cleaning establishment of Berlin where 
large quantities of benzine had been used. Three of the workmen were found uncon- 
scious upon the floor and were with difficulty resuscitated by the inhalation of oxygen. 
O. M. Spencer (Pub. Health Rep., Sept. 22, 1922) made a survey of 22 persons 
operating coupon cancelling machines, who showed a very high dispensary attendance 
rate. This was found to be due to exposure to the fumes of gasoline used in cleaning 
stamps and belts in the cancelling machines. Substitution of kerosene, perfumed with 
anise oil, caused a lower sickness rate and an increased production. 
"Blanket Stoving."-This occupation is of interest chiefly because the 
blankets are bleached by means of sulphur fumes. It is generally held 
that the men who are engaged in this work are not especially liable to 
tuberculosis and other infectious diseases, but those exposed to the inhala- 
tion of sulphur fumes and to abrupt changes in temperature not infre- 
quently suffer from chronic bronchitis and emphysema of the lungs. 
Preventive Measures.-It is needless to insist that wherever benzine 
and benzol vapors are developed they should be immediately removed 
by adequate exhaust ventilation. This is demanded not only in the 
interest of wage earners, but also as a safeguard against fire. All machines 
containing benzine or benzol should be furnished with hermetically closed 
covers, to be removed only for such time as may be necessary to feed or 
remove the articles to be washed. Substitution for benzine of less toxic 
agents, such as carbon tetrachloride, has been urged (Rambousek8). 
The same general principles apply to the removal of dust or sulphur 
fumes in carpet cleaning and blanket bleaching establishments. 
COAL-TAR DISTILLATION PRODUCTS 
The manufacture of coal-tar products affords employment to a large 
number of wage earners, who are exposed to more or less dangerous 
agents. The coal-tar products industry, while still in its infancy in this 
country has made an enormous growth since the beginning of the Euro- COAL-TAR AND BENZENE 
507 
pean War. Mr. Archie Rice estimates that if the dye-making attains 
large proportions and toluol becomes relatively cheap, then trinitrotoluol 
could be used to the extent of 200,000,000 pounds annually as a com- 
mercial explosive to be combined with nitroglycerine or with nitrate of 
potash requiring about 4000 workmen in the manufacture of the product 
alone. 
Coal-tar.-Coal tar is obtained by dry distillation of coal and is an important by- 
product of illuminating gas and coke works. It is chiefly used for the production, by 
fractional distillation, of so-called coal-tar products, such as benzene, toluene, 
naphthalene, anthracene, carbolic acid, pyridin, etc., from which again are made 
saccharine, various drugs, dyes, perfumes, etc. About 50 per cent, of the coal-tar is pitch 
and remains in the stills as a residue. This substance, like tar, is used in the manufacture 
of varnishes, metal paints, artificial fuel (briquets), etc. Crude tar is also used for 
preserving wood, in the manufacture of roofing paper, in the construction of asphalt 
pavements, etc. 
The constitutional effects of inhalation of tar vapors are such as loss of appetite, 
nausea, diarrhea, headache, vertigo and catarrhal conditions of the upper air passages. 
In some instances, however, ischuria, strangury, albuminuria and cedema have 
developed, rarely of a serious nature. Affections of the skin, such as eczema, pimples 
and psoriasis are quite frequent among workers in tar, and may affect not only the 
hands and arms, but also other parts of the body. Cancroid ulcers, especially of 
the scrotum, are liable to develop not only among workers in the tar, lamp black and 
paraffine industry but also in chimney sweepers and briquet makers. * 
Dr. Otis B. Wight (J. A. M. A., Mar. 10, 1917, page 799) of Portland, Oregon, 
reports the occurrence of dermatitis especially during the summer months among the 
men employed in the local gas company, which manufacturers its gas from California 
fuel oil. One of the by-products is lamp black which by pressure and addition of a 
small amount of fuel oil is later made into briquets. The hot lamp black as it comes 
from the furnaces is shoveled and otherwise handled by some of the employes and 
in a number of instances dermatitis developed on the arms and hands of these workers. 
Benzene.---This important coal-tar derivative is secured by fractional 
distillation (70°-130°C.) of tar in wrought-iron stills. The crude product 
consists chiefly of benzene and toluene. Pure benzene (called benzol) 
and pure toluene (called toluol) are secured by additional fractional 
distillation. Benzene is placed on the market as 90 per cent, benzol, 
and as solvent naphtha. Solvent naphtha (130°-170°C.) is the chief 
rubber solvent and "contains xylene and its homolognes and other un- 
known hydrocarbons." Pure benzene vapors are very poisonous. 
The limit for animals is between 0.015 and 0.016 per 1000. (For symptoms 
and branches of industry in which benzol is employed and poisoning 
may occur see pages 500 and 647.) 
Dr. Rambousek9 reports 34 cases of benzol poisoning of which 24 were acute cases 
and proved fatal. About one-half of the cases occurred in connection with benzene 
*Bayet and Slosse believe that the skin lesions in briquette workers are caused by the 
presence of arsenic in the coal and find support by chemical analyses of coal, and the 
hair, blood and urine of the workmen which were all positive for arsenic. Burchardt 
refutes this assertion. (Jour. Ind. Hyg., July, 1921, Abst., p. 47.) 508 
THE PETROLEUM AND COAL-TAR INDUSTRIES 
plants, either during the distillation process, or during the cleaning out of the extrac- 
tion apparatus, or storage and transportation tanks. Twelve cases occurred in the 
rubber industry, one in the manufacture of antipyrine; one in a painter while applying 
a coat of asphalt paint to the interior of a large iron tank, in which benzol, instead of 
turpentine, was used, and three cases occurred in a color factory, from the internal 
use of alcohol denatured by the addition of 1 to 2 per cent, of benzol. 
The N. Y. State Industrial commission in its Bulletin for November, 1920, 
reports two cases in men employed in the coating room of the Dupont "Fabrikoid" 
Comp. Plant who developed purpura hemorrhagica caused by the fumes of benzol. 
(Jour. Ind. Hyg., June, 1921, Abst., p. 23.) 
C. Flandin and J. Roberti (Bull: et Mem. Soc. Med. et Hdp. de Paris, Dec. 30, 
1921) report a case of fatal purpura in a young woman who was working with 
rubber dissolved in benzol. (Jour. Ind. Hyg., Aug., 1922, Abst., p. 60.) 
E. B. Starr, (Jour. Ind. Hyg., Sept., 1922, pp. 203-211) reports 10 cases of poison- 
ing by benzol, carbon tetrachloride cement in a millinery establishment. The author 
directs special attention to the importance of the early and relatively mild symptoms 
of benzol intoxication, such as irritation of the mucous membranes of the upper respira- 
tory tract, nausea, vomiting, burning sensation in the epigastrium, frequent urination, 
giddiness, slight air hunger and weakness, all showing a tendency to get worse after 
leaving the factory for the day. He regards all objective signs such as leucopenia 
or hemorrhage as too late for safe early diagnosis. (See Newton, C. R., J. A. M. A., 
1920, 74, 1149; Legge, T. M., Jr. Ind. Hyg., 1920, 1, 540.) 
Toluene.-Toluene is used in the manufacture of trinitrotoluene 
(see page 510) a very powerful explosive and also in the form of a 
mono-compound as a dynamite dope to lower the freezing point. 
The toxic effects of toluene are similar to those of benzene. It should 
be stated however that Rambousek in his animal experiments found that 
the narcosis from toluene comes more slowly and there were no symptoms 
of convulsions or spasms. Lehmann on the other hand found that the 
narcosis from toluene came more rapidly and passed away more slowly 
than from benzol. Dr. Hamilton13 refers to the effects of spilling 
benzene or toluene on the floor, hands or clothes and reports that the 
mild forms of poisoning attract little attention, but her 12 recorded cases 
were all of a severe type, 5 of which terminated fatally. 
Some of the accidents occurred while the men were cleaning out the stills or making 
repairs to pipes or in stills which were not thoroughly cleaned, the majority of the 
cases of poisoning however followed the use of the compound in making some explosive 
or phenol. Some of the fatal cases occurred in steam fitters while repairing benzene 
stills, and two other cases came from the sulphonating department "of a hastily 
constructed and poorly managed phenol factory, where defective equipment allowed 
benzene fumes in dangerous quantities to escape." 
Xylene.--A case10 of chronic industrial poisoning by xylene, a homo- 
logue of benzol (boiling about 140°), is referred to as having occurred in 
the rubber industry; also a case of carbon monoxide poisoning and several 
from sulphureted hydrogen gas in coal-tar distillation. 
Products of Higher Boiling Points.-In the coal-tar distillation, at a tempera- 
ture of 150-200°C., the middle oil passes over. This contains naphthalene, which 
upon cooling crystallizes out, and after washing with caustic soda and acid, is redis- COAL-TAR PRODUCTS 
509 
tilled and hot pressed. From the remaining liquor, phenol or carbolic acid is obtained. 
This serves as the basis for various chemical and pharmaceutical preparations, such as 
salicylic acid, picric acid, etc. The heavy oils which pass over at a temperature 
between 200 and 300°C. are rich in cresols, naphthols, naphthalene and fluid paraffine, 
from which lysol and other disinfectants may be obtained. But the bulk of the heavy 
oils are used for preservation of railway ties, shingles, etc. Raw anthracene oil, or 
green oil, passes over between 300° and 400°C. and is also used as a wood-preserving 
paint or stain. The alizarin dyes are made from the anthracene extracted from this 
oil. Workers in anthracene are subject to severe skin affections which occasionally 
develop into cancer (Rambousek).11 Pyridin, one of the constituents of tar, is used 
for denaturing alcohol and the eczematous condition of the skin in persons using 
denatured alcohol is probably caused by pyridine. 
Phenol or Carbolic Acid.-Phenol a product of coal-tar distillation is a 
corrosive poison and also produces degenerative changes in the blood and 
the Constitutional symptoms common to the nitro-derivatives of the 
benzene group. Apart from the caustic effects upon the skin, Weyl12 
states that chronic symptoms such as vomiting, difficulty in swallowing, 
increased flow of saliva and chronic nephritis, have been observed among 
surgeons and workers in the manufacture of carbolized dressings. Dr. 
Hamilton13 reports that in the manufacture and handling of phenol for 
picric acid there may be some opportunity for inhaling small quantities 
from open receptacles, but the chief danger is from splashing and spilling, 
hence phenol burns are not uncommon and if a large surface of the body 
is involved profound systemic effects are developed, as shown by a fatal 
case reported by Dr. T. F. Harrington of the Mass. Board of Labor: 
"A chemist aged 22, who at 5:50 P.M. upon leaving the phenol building accidently 
stepped into a "sump" of phenol waste in the yard and immersed his right leg up as 
high as the knee. He ran back and undressed and washed and soaked his foot and 
leg in distilled water, and shortly thereafter complained of ringing in his ears, dizziness 
and difficult breathing. The skin of the leg had turned white, but there was no burn. 
After dressing the leg he left the building at 6:20 to go to the laboratory to apply 
some alcohol. Upon leaving the room the men noticed that he seemed dazed, con- 
fused, excited, almost hysterical. Evidently he never reached the laboratory, for 
he was found the next morning on the road, dead. The autopsy showed the leg from 
foot to knee discolored, green and black." (See also page 658.) 
Trinitrophenol or picric acid is produced by the action of nitro- 
sulphuric acid upon phenol. In a pure state it forms pale yellow crystals 
and is extensivly used as a yellow dye stuff, and also as an ammonia 
compound in the manufacture of explosives (lyddite, melinite). It 
enters the body in the form of dust, by inhalation, and also exerts an 
irritant effect on the skin, mucous membrane, intestinal canal and upon 
the kidneys. Dinitrophenol may cause acute symptoms of industrial 
poisoning similar to those observed from nitrobenzol. 
Leymann, cited by Rambousek,24 describes cases where the workers were suddenly 
stricken with symptoms of collapse, vomiting, pains in the chest, difficult breathing, 
rapid pulse, convulsions and death within a few hours. The autopsy revealed a 
yellow substance with picric acid reaction, which appeared to be di- or trinitrophenol. 510 
THE PETROLEUM AND COAL-TAR INDUSTRIES 
In cases of nitrochlorobenzene poisoning, Leymann noted the typical gray-blue dis- 
coloration of the skin, and the chocolate-brown color of the blood produced by methe- 
moglobin. Dr. Alice Hamilton13 reports 7 cases of poisoning from picric acid which 
occurred in American munition plants from April to December, 1916. Apart from 
the symptoms described on page 660, she emphasizes the skin lesions popularly known 
as "picric itch" and that, in addition to gastro-intestinal symptoms, there may be 
respiratory disturbances. Two cases of acute poisoning from picric acid resulting 
from repair work in the nitrating room were reported by Dr. T. F. Harrington: 
"The men in both cases were incapacitated for over a fortnight, with pronounced 
nervous as well as gastric symptoms." 
"One fatal case was reported from a plant where picric acid was made, but the 
worker had also been exposed to nitrobenzol fumes. He died in convulsions after 
reaching home, and the autopsy revealed organs congested with dark blood and the 
circulating blood was chocolate colored." 
While both picric acid and nitrobenzol may produce the same blood 
changes, Dr. Hamilton is inclined to the belief that the severe and 
rapid course of the poisoning in this case is more suggestive of nitro- 
benzol than of picric acid. 
Trinitrotoluene also known as trinitrotoluol, triton, trotyl or TNT is 
obtained by nitrating toluene in closed retorts. Toluene primarily 
derived from coal-tar, is a benzene compound in which one atom of hydro- 
gen is replaced by CH3 and during the nitrating process three other hydro- 
gen atoms are replaced by the nitro radical NO2. 
The resulting product is solid at ordinary temperatures, reducible to a 
fine powder, melts at 80°C. and sublimes when melted. 
According to Dr. Hamilton13 while there is some danger from the 
accidental escape of nitrous fumes in the manufacture of trinitrotoluol, 
the real danger lies in the trinitrotoluol itself. In loading it into high 
explosives shells it is either packed in dry or poured in. The dry method 
involves exposure to fine dust and the pouring method to both dust and 
fumes. In either case the poison may enter the system through the pores 
of the skin, the mucous membranes of the nose, mouth and throat and 
possibly the lungs. 
According to English authorities* even a temporary exposure to imper- 
ceptible dust of this agent leaves a slight but distinctly noticable bitter 
taste in the mouth. Longer exposure is followed by some headache 
a more intense quinine-like bitter taste, accompained by nausea with 
white, frothy vomiting. Such are usually the effects upon the occasional 
visitor with a later tendency toward a degree of immunity. 
A bitter taste and a disgust for food are among the early symptoms of 
the gastrointestinal type of poisoning. In the more severe cases there 
may be griping abdominal pain, vomiting, constipation, flatulence and 
distension but more rarely diarrhea. As the disease progresses, nausea 
with inability to retain food becomes more marked and attacks of faint- 
ness are not infrequent. Cyanosis and the blood pressure also increases 
* Med. Press and Circular, 1916, N. S. 102, page 534. J. A. M. A., Feb. 10, 1917. 
page 459. TRINITROTOLUENE POISONING 
511 
and there may be jaundice and severe nose bleed, and also dropsy of the 
lower extremities and of the hands. Some of these cases may recover 
while others perish from the chronic effects of the poison. 
In some cases dermatitis, gastritis, cystitis and even fatty degeneration 
of the tubular epithelium of the kidneys are present. The urine is 
generally dark colored and contains blood and bile pigments and casts. 
Evidence of gradual absorption is shown by the pallor of the face and the 
ashen gray or bluish color of the lips and lobes of the ears. Occasionally 
the lips and tongue are deeply cyanosed. The blood changes are those of 
dinitrobenzene poisoning with the presence of methemoglobin, although 
the cyanosis and breathlessness are less marked. Cell degeneration is 
easily produced by trinitrotoluol and when the liver is involved toxic 
jaundice developes in some of the cases. Jaundice may be conjunctival 
or general, and frequently comes suddenly during the first four weeks 
of exposure. 
Liver dullness is variable, ascites is sometimes present, respiratory 
distress is not noticeable when the patient is in bed and pyrexia has occasion- 
ally been observed in severe cases, but neither bradycardia nor pruritus 
is common. Two deaths from anemia without jaundice have been 
reported in England with reduction of red cells to one million, of unequal 
size, but no poikilocytes or nucleated red cells. Microscopic examination 
excluded pernicious anemia and death evidently resulted from hemolytic 
aplastic anemia. 
Dr. Alice Hamilton emphasizes the fact that physicians, in the absence 
of jaundice and cyanotic symptoms, not infrequently overlook the intes- 
tinal type of poisoning, with the result that quite a number of men and 
women who had suffered for several weeks from gastric trouble and who 
might have been saved by timely change of work and proper treatment, 
suddenly become worse with symptoms of toxic jaundice and profound 
liver and kidney lesions. The disease can be distinguished from tetryl 
and picric acid poisoning, as the former stains the skin a yellow or apricot 
color, and the latter a canary or greenish yellow color. A yellowish tint 
of the skin may suggest symptoms of jaundice, -but unless the white of 
the eye is also involved, the discoloration is caused by the dye effects of 
some of these compounds, notably among workers in trinitrotoluene, 
picric acid and tetranitranilin, in which case the hands, face and hair of 
the workers will also reveal a dirty yellow color. 
Cases are described in the report in which post-mortem examinations revealed 
extreme fatty degeneration of the liver cells with atrophy, degeneration of kidney 
epithelium and not infrequently hemorrhages into serous surfaces and connective 
tissues. Such instances are evidently typical cases of chronic poisoning, and are 
not unlike those observed in fatal cases of benzene poisoning. 
Dr. Hamilton also reports fatal cases of acute poisoning in which profound symp- 
toms such as cyanosis, dizziness, mental disturbance, convulsions and coma developed 
within a few hours after exposure to unusually large amounts of trinitroluol fumes. 
One patient died within less than 24 hours, and the autopsy revealed a dark fluid blood, 512 
THE PETROLEUM AND COAL-TAR INDUSTRIES 
sometimes chocolate colored, edema of the lungs, though not enough to cause death, 
and congestion of the abdominal organs. 
Frequency of Trinitrotoluene Poisoning.-Dr. Alice Hamilton reports 
from 28 munition plants 701 cases of poisoning affecting 658 men and 43 
females. Of these 10 men and 2 females died from the effects. 
How many cases of triton poisoning may have developed and compelled men after 
recovery to seek other employment could not be determined. Fifty cases from the 
records of one physician had all worked less than eight months and he mentioned to 
Dr. Hamilton, as decidedly exceptional, a man who had handled triton for more than 
8 months and was still perfectly well. The report also brings out the fact that July 
and August of 1916 saw a decided increase of poisoning in most of the plants. Dr. 
Hamilton attributes this to the combined effects of heat and fatigue, especially the 
latter. One of the plants during those two hot months put on four shifts of men 
instead of three, each shift working only six hours, with the result that they had fewer 
cases of poisoning than during the cooler summer of 1915. 
Treatment.-In cases of trinitrotoluol poisoning, in the absence of 
jaundice, the treatment is comparatively simple, removal from contact, rest 
in bed for a few days, a milk diet, milk puddings, fruit and green vege- 
tables, demulcent drinks, such as barley water, weak tea, coffee; cascara 
or other vegetable laxatives, with a mixture containing sodium sulphate, 
potassium citrate and sodium bicarbonate are useful for the relief of 
constipation and elimination of the poison. In jaundice cases absolute 
rest in bed is essential. A milk diet beginning with small quantities 
gradually increased to two quarts a day, has proved most satisfactory, 
while the bowels are kept loose by repeated doses of a mixture of magne- 
sium carbonate, magnesium sulphate and peppermint water. 
In cases of toxic jaundice the citrates and bicarbonates have been 
recommended so as to preserve the alkalinity of the blood and prevent 
acid intoxication. Rectal and intravenous saline injections have also 
been used in some cases. The prognosis in such cases however is very 
grave. 
The coal-tar color industry is based upon the employment of the 
hydrocarbon compounds such as benzene, toluene, xylene, naphthalene, 
anthracene, phenol and cresoles. Other agents employed are wood 
alcohol, ethyl alcohol, phosgene and formaldehyde, nitric acid, sulphuric 
acid, caustic soda, chlorine and bromine. All of the nitro derivatives 
are obtained by the action of a mixture of nitric and concentrated sul- 
phuric acid on any one of the hydrocarbons of the benzene series. A 
most valuable monograph entitled Industrial Poisoning in Making Coal 
Tar Dyes and Dye Intermediates by Dr. Alice Hamilton was published 
by the Bureau of Labor Statistics in Bulletin 280, April, 1921. It covers 
87 pages and is the most authoritative statement concerning the hazards 
and hygiene of this important industry. 
Nitrobenzene, also known as mirbane oil, or imitation bitter almond 
oil, is an intermediate product in the manufacture of anilin, and is secured NITROBENZENES ANILIN 
513 
by the action of sulphuric and nitric acid upon benzene, thus forming nitro- 
benzene. Toluene and xylene are nitrated with the same acids. The 
dinitro products are obtained by further action of nitro-sulphuric acid on 
the mononitro-compound at a higher temperature. All nitro-compounds 
of benzene and its homologues, such as dinitrobenzene, dinitrochloro- 
benzene, nitrotoluol, nitrophenol, nitronaphthalene, etc., are more or less 
poisonous. Cases of poisoning from these agents have been reported in 
the coal-tar industry and establishments in which its intermediate prod- 
ucts are manufactured or handled, such as in the manufacture of anilin, 
explosives, perfumery, soap, pharmaceutical preparations, etc. Dr. 
Hamilton in her study of the American dye industry points out that 
nitrobenzene when splashed on the body may result in severe burns 
accompanied by the characteristic systemic symptoms described on page 
655, and states that several cases of this kind were found in the records of a 
Buffalo Hospital. In other cases poisoning seems to be caused by the 
fumes alone. 
Grandhomme12 has reported 60 cases of industrial poisoning by nitrobenzene, of 
which 24 or 42 per cent, proved fatal; 4 cases resulted from inhalation and in 55 cases 
the agent entered the system. Dr. S. S. Adams14 reports 15 cases with 3 deaths in 
which the agent was taken into the mouth; 6 cases with 2 deaths were caused by inhala- 
tion; 2 cases, 1 fatal, in which nitrobenzene was absorbed by the skin; 2 cases, 1 in 
which the agent was used with suicidal intent; and 3 cases with 2 deaths in which 
nitrobenzene was taken to induce abortion. Of the 28 cases, 9 were typical occupa- 
tional intoxications. 
F. Neuhoff (Mo. State Med. Assoc. Jour., Feb., 1921) reports the case of a man 
who suffered from nitrobenzene poisoning, five, and again, three hours after having 
dyed his shoes while wearing them. (Jour. Ind. Hyg., Aug., 1921, Abst., p. 70.) 
A similar case was reported by R. E. Cloud. (J. A. M. A., Jan., 1922, p. 280.) 
Dinitrobenzene is the combustible ingredient of roburite and other 
high explosives. Oliver18 reports a case in which a man engaged in clean- 
ing out the air flue, from which the fumes from three mixing pans were 
discharged, in spite of respirator and rubber clothing, was fatally injured 
by the fumes. The majority of workers in dinitro-compounds in Great 
Britain show evidence of chronic intoxication. Of 20 examined in explo- 
sive works, 14 presented a bluish-gray color of the lips and face, 10 were 
profoundly anemic and 6 suffered from slight tremblings and other 
nervous affections.16 Cases of inflammation of the optic nerve as a 
result of chronic nitrobenzene poisoning have been described. 
Professor Cords (Zentralbt. f. Gewerbehygiene, Jan., 1919, p. 6) reported a number 
of serious affections of the optic nerve among munition workers in Germany, and also 
cites cases from French and English literature which were caused by exposure to 
dinitrobenzene. (See also pp. 515 and 553.) 
Anilin, also known as anilin oil, is a colorless fluid which upon exposure 
to light and air gradually becomes dark in color. It is produced by the 
action of hydrochloric acid and iron filings upon pure nitrobenzol, and 
like all other compounds of benzol and its homologues, such as toluol, 514 
THE PETROLEUM AND COAL-TAR INDUSTRIES 
naphthalene, xylol, is a blood and nerve poison. Poisoning may occur in 
the manufacture of anilin and its derivatives, such as anilin dyes, 
pharmaceutical preparations, photographic materials, etc., and in dyeing 
establishments. The poison may be absorbed through the skin by 
direct contact or from saturated clothing, by inhalation of vapors and 
impalpable dust, and also by way of the digestive tract. The symptoms 
may be acute, subacute and chronic. (See page 644.) 
Cases of anilin poisoning are not infrequent in other industries, especially in dye 
works. Leymann18 reports four fatal cases of poisoning in the manufacture of black 
dyes from mono and dinitrophenols and nitrochlorobenzene and toluene compounds. 
White and Sellers19 report a fatal case of acute anilin poisoning in a worker who, 
while preparing anilin hydrochloride (used for dyeing yarn with anilin black), spilled 
a quantity over his hands, face and upper part of the body, and died within less than 
24 hours. Neisser20 reports a number of cases of anilin poisoning which occurred in 
different industries, such as wood staining in imitation of mahogany, and describes 
the case of a Swiss dyer who, in opening an iron drum, spilled a quantity of anilin 
oil which saturated part of his clothing. He continued work for several hours. The 
case resulted in insanity and impairment of vision. Cases of anilism have, been 
reported in black dyeing establishments and in cloth pressers working with black dyes. 
Senn21 has reported a typical bronzing of the skin with a dark brown discoloration 
and inflammation of the cornea occurring among men exposed to the hot vapors from 
an anilin black dye mixture, composed of anilin, hydrochloric acid and potassium 
chromate, known as "chinon." Hanke22 has observed cases of inflammation and 
opacity of the cornea caused by continued exposure to the vapors of nitronaphthalene 
or to spurting of the liquid into the eye. 
Dr. G. L. Apfelbach in 1913 reported the first two cases of industrial anilin poison- 
ing in this country, one in a press feeder, and one in a dry color factory. Birge in 
1914 reported two cases in painters, who were using anilin black paint. Hayhurst 
in 1915 reported three cases in men employed at rubber mixing mills and among print- 
ing pressmen, who used a roller-wash rich in anilin. Luce and Hamilton23 in their 
investigation for the Federal Bureau of Labor in 1915, collected a number of cases in 
connection with the rubber industry at Akron, Ohio. The World war compelled the 
manufacture of anilin oil in this country, and in one establishment at Akron with a 
daily output of 2500 pounds, cases of anilin poisoning were sufficiently common for 
workmen and physicians to speak of the victims as "blue men" or "blue boys." 
Poisoning in the Coal-tar Dye Industry in the United States.-Dr. 
Alice Hamilton in her exhaustive studies of this industry presents 
numerous instances gathered from various factories in this country show- 
ing the many ways in which absorption of anilin may occur. Dr. Hamil- 
ton emphasizes the important point that every physician should be familiar 
with the symptoms of anilin poisoning and refers to the record of a case in 
the New York State Department of Labor which came under the care of a 
physician unfamiliar with anilin poisoning: 
The man was lying unconscious on the floor of a dyehouse and was of such a deep 
purple color that the physician thought that he must have fallen into a dye-vat. 
A fatal termination is rare. Dr. Hamilton found records of only 3 
deaths from anilin poisoning in her American study: 
The first was a man employed in the reduction department of an anilin works, 
who had for some days suffered from headache and whose color was somewhat POISONING BY COAL-TAR DYES 
515 
cyanotic. He had not, however, complained of sickness. He left the plant at the end 
of the day, went to a saloon, and had a drink of whiskey. On his way home he became 
so disorderly that he was put off the street car. Some friends took him home and 
put himj to bed and he was found dead in the morning. This combined action of 
alcohol and an aromatic compound has been noted frequently among TNT workers 
in the explosives industry. 
Of the second case no more is known than that he was a carpenter who went into 
an anilin tank which had not been thoroughly washed out, and was poisoned. 
The third fatal case was a foreman in the anilin department of a small plant. He 
was experimenting at the time and had his hands in anilin a good deal. The ventila- 
tion in this department was ample, so that the fumes could not have played a part in 
this case. He came to work one morning complaining of headache, and was advised 
to go home, but stayed until noon. By the time he reached home, about 1 o'clock, 
he was so ill that a doctor was summoned. He was cyanosed, was vomiting yellow, 
frothy stuff, and his pulse was weak, but he did not seem to be in a serious condition. 
Twenty minutes later- he had a convulsion. The doctor returned at 3 o'clock and 
found that he was unconscious and that his heart was very weak. He had a second 
convulsion, and his heart action grew steadily weaker until the early morning, when 
he died. 
Dr. Hamilton in her study also includes the following anilin derivatives 
and other compounds which contain the NH2 group (for symptoms, etc., 
see pages 644-645). 
P ar anitr anilin.-A fatal case of poisoning occurred some years ago 
in the Hochst dye works in a man engaged for 5 hours in hydro-extracting 
paranitranilin and which was attributed by Lewin to inhalation of dust. 
Dr. Hamilton reports the following cases in her American study: 
"Two men were set to strengthen the hoops around barrels filled with parani- 
tranilin which had become loose so that the powder leaked out. In doing so they 
inhaled dust and also scattered it over their hands. As a result both men became 
cyanosed, breathless, dizzy and confused." * 
Metanitranilin is made by reduction of dinitrobenzene. Dr. Hamilton 
cites the following case of industrial poisoning from the records of a 
hospital near one of the dyeworks visited in her study, and refers to 
several other cases which for lack of space cannot be recorded here: 
"A man was ordered to clean out a tank which had held metanitranilin; soon after 
he complained of acute frontal headache and faintness and began to vomit. Then he 
lost consciousness and was taken in this condition to the hospital, where they found 
him deeply cyanosed, his lips and mucous membranes almost black and his pulse 
very weak and rapid." 
Dr. Hamilton reports that the same dye plant from which records of 
cases of metanitranilin poisoning were obtained also furnished information 
about dinitrobenzene poisoning. 
In this plant contrary to the generally accepted view dinitrobenzol is considered 
less dangerous than metanitranilin. The experience of this plant shows that fumes 
produced in washing dinitrobenzene cause a great deal of trouble, but that even more 
sickness occurs in screening, where the dust is quite heavy. It was noted that no 
immunity follows an attack, on the contrary, the succeeding attacks are severer and 516 
THE PETROLEUM AND COAL-TAR INDUSTRIES 
recuperation is slower. Nose bleed was mentioned as an additional symptom by the 
physicians in charge of the plant. In some of the factories the dinitrobenzene, after 
solidification, is taken up with picks and then shoveled out. This Dr. Hamilton 
regards as a fruitful source of sickness and it has been avoided in one plant by granulat- 
ing the DNB under water, in another, by melting it and pumping it out. 
Anilin Hydrochloride or Anilin Salt.-This salt is frequently employed 
in the manufacture of anilin dyestuffs. Dr. Hamilton states that its 
manufacture is almost always carried on in an open shed, since the fumes 
of anilin and hydrochloric acid would be dangerous if not greatly diluted. 
Reference is made to the history of a case of poisoning furnished by the 
New York State Department of Labor which it believes to have been 
caused by both chlorine gas and anilin. The man was employed in mak- 
ing chloride and was under hospital treatment for 17 days for nervous 
and gastrointestinal symptoms following an attack of cyanosis, with 
fainting spells. 
Diethylanilin is prepared in the same way as dimethylanilin, except 
that ethyl instead of wood alcohol is used. The nitroso compounds 
are produced by the action of nitrous acid (sodium nitrate and hydro- 
chloric acid) on the acid solution of diethylanilin. Dr. Hamilton was 
unable to secure individual case histories, but a physician in charge of 
a plant where diethylanilin is used in large quantities informed her that 
he had treated several cases of poisoning, with symptoms like those 
of anilin poisoning. 
Dimethylanilin is produced by heating anilin with anilin hydro- 
chloride and wood alcohol. Dr. Hamilton in her survey records 2 cases of 
poisoning from this agent. 
One of them who was baling it from one container to another was poisoned severely 
at the end of 7 hours' work; the other was even more severely poisoned by a few minutes' 
exposure to hot fumes. This man was working in the department where crude violet 
is made from phenol and dimethylanilin. He climbed to the top of the vat to inspect 
the dye. In lifting the lid he inhaled the hot fumes and almost at once fainted, 
he was unconscious for 8 hours. When taken to the hospital the next day he was 
complaining of loss of sight, noises in the ears, and intense abdominal pain. He was 
in the hospital 7 days. 
Para and Meta Phenylendiamines (C6H4(N.H.2) are important inter- 
mediates in the manufacture of dye and are very toxic. Para is known in 
the trade as ursol black and has been used since 1888 as a dye specially 
suitable for dying furs and leather goods. It was also used as a hair- 
dye until a number of serious effects were reported. Knowles (in the 
Medical Record, 1916, page 217) reports a case where in addition to 
dermatitis, it produced in the course of time also sleeplessness, dizziness, 
weakness of the legs, epileptiform convulsions, loss of consciousness 
and death. 
In fur-dye workers and even in persons handling or wearing the furs 
the most common effects are severe eczema with swelling of the eyelids; POISONING BY COAL-TAR DYES 
517 
in some instances, ulcers and cellulitis have been observed. Blashchko 
and Oleson attribute the skin eruption to the presence of a mid product 
known as quinon dichlordiamine. Lehmann reports that 187 cases of 
ursol poisoning occurred in a Leipsic furrier's establishment in one year. 
He states that the diamines are oxidized with H2O2 on the fiber; a mid- 
product (chinon diamin) is gradually formed on the hands which is very 
volatile and causes not only eczema and inflammation of the respiratory 
passages, but also typical cases of asthma, with Curschmann's spirals and 
Charcot's crystals in the expectoration. The attacks occur several hours 
after cessation of the work and cease after a few days. Prognosis is very 
good but instead of tolerance an increasing susceptibility is observed 
(V. Criegern, Munch. Med. Wochschf., 1902, page 852). Dr. Hamilton 
states that the files of the N. Y. Dept, of Labor contain the report of a 
case of eczema, bronchitis, and asthma in a man who mixed Ursol for 
dyeing furs. 
For other cases of furriers' asthmare ported from New York see page 
679. Gerdon (Zentralblt. f. Gewerbehyg., t Sept.-Oct.-Nov., 1920) 
attributes certain cases of bronchial asthma among furriers and workers 
in black leather goods to the anaphylactic action of phenylendiamines. 
He cites Kobert as stating that since the introduction of these dyes in 
1888, about 30 per cent, of the furriers using it suffer from asthmatic 
attacks. The use of rubber finger tips, respirators and copious ventila- 
tion have been urged by Lehmann, Carozzi and others. 
H. Curschmann (Munch. Med. Wochschf., Feb. 18, 1921) reports several cases of 
asthma in men who worked in the furs, dyed with ursol, to show the anaphylactic 
character of the disease. The work of Gerdon is summarized to show the experimental 
basis in guinea-pigs for the conclusion that this is true anaphylaxis. Cases were 
reported where the use of calcium intravenously or by subcutaneous route has been 
successful, as a prophylactic and in giving relief, when administered after the onset of 
an attack. Desensitization by increasing doses of the dye seems of no use. It is 
proposed to try the calcium treatment by inhalation of solutions of calcium salts in 
spray form. (Jour. Ind. Hyg., Sept., 1921, Abst., p. 95.) Dr. Paul J. Hanzlik 
(Jour. Ind. Hyg., Jan. and Feb., 1923) has made an exhaustive study of the phar- 
macology of some phenylendiamines, and one of his conclusions is that the asthma 
and respiratory symptoms of workers in the fur industry, in which para-phenylen- 
diamine is used, is due to direct irritation and bronchial stimulation rather than 
to anaphylaxis. 
Chlorobenzene- This compound is considered less toxic than benzene. 
Leymann, and Mohr, in 1902, reported instances of poisoning in men after 
exposure to chlorbenzene and DNB. Rambousek25 cites a case 
of chlorobenzene poisoning in a man who had only worked 3 weeks 
with the substance; 4 other chlorobenzene workers after a spree were 
found unconscious in the street and only recovered after 8 or 10 hours in 
hospital. The symptoms were gray-blue color of the skin, pallor of 
mucous membranes, lips, nose and conjunctivae, and chocolate colored 
blood. (For other symptoms see page 655.) 518 
THE PETROLEUM AND COAL-TAR INDUSTRIES 
Nitro and dinitro-chlorobenzene are much more toxic than dinitroben- 
zene and in addition to the constitutional symptoms the fumes ox dust 
may produce a violent inflammation of the skin, beginning between 
the fingers and behind the knees, from whence it may spread over the 
entire body. 
Dr. Hamilton refers to a man who had rubbed his eyes while at work and they 
became intensely swollen. The same author cites a case from the records of the New 
York State Labor Department, who 4 weeks before he saw the physician, had made 
repairs inside a tank which had contained dinitro-chlorbenzene, but had been emptied, 
boiled out with caustic soda and the sides washed with 10 gallons of grain alcohol. 
The next day his skin began to inflame and 24 hours later he had a severely itching 
eruption with edema extending from his feet to the lower border of the ribs. At the 
time he was seen he was still complaining of difficult breathing and slight weakness. 
Benzyl chloride is obtained by the action of chlorine on boiling toluene 
and the process involves exposure to fumes of chlorine, hydrochloric 
acid and possibly unchanged chlortoluene. (For symptoms see Benzol 
page 647, and Chlorine page 650). 
Dr. Hamilton reports a case of poisoning in a chemist, who worked in a dye-stuff 
laboratory for 9 months where he was exposed at times to the vapors referred to. He 
lost 25 or 30 pounds in weight, his color changed to a bluish grey and he found at the 
end of 9 months that he was wholly unable to perform the simplest form of physical 
work. Excessive insomnia was another symptom and he had trouble with his eye- 
sight, though this varied from day to day, increasing in severity if the room was 
heavily charged with benzyl chloride vapor. He was not examined by a physician; 
the symptoms are given as he described them. 
Phosgene {carbonyl chloride} is employed in the formation of Michler's 
ketone by the action of this gas on dimethylanilin. Michler's ketone is 
an important starting point for many colors, especially blues, greens and 
violets. The physiological effect of phosgene has become familiar because 
of its use in gas warfare. In addition to the effects described on page 659, 
Dr. Hamilton states that, "phosgene causes coagulation of the blood in 
the finest capillaries, thereby greatly increasing the work of the heart. 
Absolute repose may carry a man past the danger point, but if he is 
obliged to exert himself after inhaling phosgene, serious heart strain or 
death may result." 
Records were secured of two chemists who were overcome while experimenting 
with phosgene gas and who suffered from cardiac weakness for some time after. Two 
workmen were killed by it. Sheridan Delepine (Jour. Ind. Hyg., Feb., 1923, p. 433) 
reports 2 fatal cases of phosgene poisoning which occurred during the war in factories 
where they were exposed to the risk of inhaling this gas. 
Dimethyl Sulphate.-This agent is employed for the purpose of 
introducing the methyl group and is regarded next to phosgene as the 
most dangerous substance in the dye industry. In addition to the symp- 
toms enumerated on page 652, Dr. Hamilton states there is a rapid pulse, POISONOUS BY-PRODUCTS IN THE DYE INDUSTRY 
519 
the temperature rises, and death may come on in a few hours or there may 
be pneumonia or toxic jaundice. 
Arseniureted Hydrogen.-Dr. Alice Hamilton devotes considerable 
space to the consideration of this form of poisoning which may occur and 
should be suspected in any case of supposed poisoning by a nitro or 
amido compound when the symptoms do not clear up, but profound 
anemia or jaundice appear. In such cases the urine should be tested for 
arsenic. (For symptoms see pages 308 and 646). A record of 10 English 
and 5 American cases is given by Dr. Hamilton. 
Sulphureted Hydrogen.-This gas is evolved when sulphur and 
sodium sulphide are used as reduction agents in the manufacture of sul- 
phur dyes. (For symptoms see page 661.) Dr. Hamilton found in her study 
that it is more feared in the dye industry than any other. Danger to 
life begins when the quantity present in the atmosphere has reached 
0.075 per cent., and 0.1 to 0.15 per cent, is rapidly fatal. In making 
sulphur browns it is held to be unsafe to have one man working by him- 
self in the sulphide department, for if there is a leak and H2S escapes, the 
effect is almost instantaneous, as shown by instances cited: 
"A man who was employed in making sulphur browns had climbed a ladder to 
repair some belting. The fume pipe happened to be out of order, and he had only 
warning enough to enable him to reach the floor before falling unconscious from the 
fumes." Six men were overcome one night in another dye works. All were stupified 
and had to be carried out of doors. One fatal case is reported in a man who was 
treated with the pulmotor within 5 minutes of losing consciousness, and respiration 
was established, yet he died of heart failure. One case of blindness following H2S 
poisoning has been reported but without any details being given. 
Rambousek25 cites a number of cases of H2S poisoning which occurred in the 
chemical industry. Oliver cites an instance where 4 men succumbed in six weeks, in 
excavating soil for a dock; the water contained 12 vols per cent, of sulphureted 
hydrogen and cases of poisoning from this gas in sewer men have also been reported. 
(For other branches of industry in which poisoning from this gas may occur see page 
661). 
Dr. Hamilton states that there is an increasing susceptibility to H2S 
poisoning, and in one factory a man who has suffered from poisoning is 
always shifted to other work. This commendable rule applies even to 
foremen. 
Fumes from Mineral Acids.-Nitrous fumes are not nearly so danger- 
ous in the dye industry as in the manufacture of explosives, because the 
acid used is much less concentrated. The gas is dangerous when present 
in quantities as small as 0.05 per cent. (See nitrous gases page 657 for 
symptoms, etc.) The cases reported happened as follows: 
"A man fell and spilled the acid from a carboy. The foreman went 
to his assistance and both were overcome by the fumes, the workman 
dying from the effects, the foreman recovering after a week's illness." 
Sulphur Dioxide (SO2), which is given off when sulphuric acid is used 
in certain reactions in the dye industry, is looked upon by many as 520 
THE PETROLEUM AND COAL-TAR INDUSTRIES 
comparatively harmless, in spite of the fact that Ogata and Lehmann have 
proved by experiments that it has a serious effect when present in the 
proportion of 0.03 to 0.04 per 1000, in persons not accustomed to the 
fumes. (For symptoms and branches of industry in which poisoning may 
occur, see page 661). 
Dr. Thomas F. Harrington,* of the Massachusetts Board of Labor, reported a fatal 
case of SO2 poisoning in a man aged 42 employed as a night foreman in the nitrate of 
soda department of a chemical establishment with symptoms of cough, dypnoea and 
suffocation. Autopsy showed marked irritation of respiratory tract, edema of lungs, 
marked congestion of the liver, spleen and kidneys, bright red eruption on the elbows 
and marked cyanosis. Chemical analysis of specimens showed absence of carbon 
monoxide, no cyanogen, and only a slight amount of carbon dioxide. 
Chlorine gas is given off in the dye industry especially in the manu- 
facture of anilin chloride, benzyl chloride and nigrosin. It is dangerous 
to life in a strength of 0.1 per cent. (For symptoms and other branches of 
industry in which poisoning may occur see page 650). 
Caustic soda is used very freely in the dye industry and is the cause of 
many deep and painful burns, and splashing of the caustic solution into 
the eye. In well managed plants it is very carefully handled and the men 
who work with it are required to wear goggles. 
Ammonia fumes, according to Dr. Hamilton, have given rise to two 
cases of serious inflammation of the lungs with edema in connection with 
the manufacture of indigo and of aurantia. 
Resume of Dangers in the Dye Industry.-Much has been done in this 
last two or three decades to clear up many misconceptions as to the 
dangers attending the production of anilin and other coal-tar colors. 
According to Grandhomme12 and Curschmann,26 the raw product benzene 
probably caused the greatest number of cases of industrial poisoning. 
The statistics are not wholly clear since a great many authors fail to differ- 
entiate between petroleum and coal-tar benzene. The manufacture of the 
intermediate group, especially the nitro- and amido-compounds, involves 
considerable risk. Curschmann mentions particularly nitrobenzol, 
chloronitrobenzol and dinitrochlorobenzol. Grandhomme25 has observed 
no injurious effects from naphthalene and anthracene and considers the 
danger in the manufacture of fuchsin, of the blue dahlias, greens, resorcin, 
eosin and the alizarin colors and pharmaceutical compounds, comparatively 
slight. He mentions arsenic and arseniureted hydrogen as possible 
sources of danger in the manufacture of fuchsin and of methylene blue, 
and reports 42 cases of anilin poisoning in one of the chemical works 
within 3 years, with no fatalities. According to Lehmann, Grandhomme 
was the first to point out in 1877 that old workers in anilin at Hochst are 
liable to suffer from strangury and hematuria and Professor Rehm of 
Frankfurt in 1895 discovered 3 cases of tumors of the bladder in workers 
* Harrington, Monthly Review U. S. Bureau of Labor Statistics, February, 1917, 
page 282 andjPersonal Communication, March 22, 1917. SICKNESS STATISTICS IN THE DYE INDUSTRY 
521 
at the Hochst factory and attributed the cause to anilin. Roth17 refers 
to the fact that in 1905 not less than 38 cases of diseases of the bladder, 
mostly sarcoma and cancer, occurred among the workers in a German 
anilin factory. Between 1895 and 1920 no less than 177 cases of malig- 
nant tumors of the bladder have been reported by Rehn, Leuenberger, 
Curschmann, Oppenheimer, Schwerin and others as having occurred in 
the anilin dye stuff industry. Opinions as to the etiology of these tumors 
have widely differed. Curschmann27 in two articles on this subject, while 
still openminded, is by no means convinced that the amido compounds 
are the causative agents. 
Dr. Alice Hamilton28 in a most valuable contribution expresses the opinion that in 
view of the proof that chronic arsenical poisoning is capable of producing a continual 
irritation which gradually results in a cell proliferation, benign or malignant, and since 
the possibility of hydrogen arsenid poisoning is admittedly present in all the processes 
with which the bladder tumors of anilin workers have been associated, it seems fair 
to insist that hydrogen arsenid is a possible cause which must be considered, especially 
as there is not much proof of the power of amido-compounds to cause tissue 
proliferation. 
Records of Sickness in German Dye Manufacture.-Dr. Alice Hamil- 
ton with her usual thoroughness has made a careful search through 
German 'factory inspection reports for the seven years just preceding the 
war which show that nearly all the substances mentioned in the proceed- 
ing pages have been responsible for occupational poisoning in the color 
industry. The earlier statistics from 1874 to 1879 compiled by Grand- 
homme, show that in the manufacture of anilin colors there was an 
average of 60 per cent, of sickness; in making alizarin colors 46 per cent, 
and in the mfechanical department 40 per cent. The average duration of 
disability was greatest in the alizarin development on account of a greater 
number of obstinate skin affections. There is far less sickness shown in 
the more recent reports cited by Dr. Hamilton. Grandhomme's statistics 
in the 3 years from 1893-1895 cited by Rambousek25 show among the 
2500-2700 workers 122 cases of industrial illness involving 724 sick days. 
In addition to 42 cases of anilinism there were 76 cases of lead poisoning 
with 533 sick days. The frequency of sickness in the Hochst factory in 
each year was high: 120 per cent., 91 per cent., and 95 per cent. In the 
same factory between 1899-1906 in a working population of 2000 to 2200 the 
percentage of sickness was about 66, and Leymann, cited by Rambousek, 
records only 21 cases of industrial poisoning during the whole period. 
(See also Curschmann's statistics for 1909-1910, Chemical Industry, 
page 569.) In the report for the year 1913, a factory with 9376 men had 
only 12 cases of anilinism with 98 days of sickness. In another factory 
employing 251 men there were, during a year's time, 33 cases of industrial 
poisoning, with 500 days of sickness. For workers in the anilin depart- 
ment the average was 1.74 attacks of illness with a duration of 23.48 days 
each. In the non-anilin departments, the average was 0.97 attack of 522 
THE PETROLEUM AND COAL-TAR INDUSTRIES 
illness per man, each attack averaging 14.6 days. Ten per cent, of the 
cases in the latter department were skin diseases, as compared with 41.8 
per cent, in the anilin department. Digestive disorders contributed 17.4 
per cent, of the sickness in non-anilin workers against 45.4 per cent, in the 
anilin department. 
Records of Sickness in American Dye Works.-Dr. Hamilton's 
compilation shows that cases of poisoning have occurred in the United 
States from 50 different substances, as compared with 29 substances used 
in Germany in the making of dyes and dye intermediates. 
The record of a plant in which about 850 process men are employed and about 
400 laboratory men is as follows for one month of a hot summer: 
Cases 
Poisoning from nitro and amido compounds, new cases 29 
Poisoning from nitro and amido compounds, old cases still under 
treatment 26 
Acid burns of cornea 20 
Acid burns of cornea with conjunctivitis 29 
Dermatitis 122 
Alkaline in eye, inflammation 26 
Alkali burns 82 
Chlorine fumes • 1 
The improvement that has taken place in this plant within the last year is shown 
by the record of days lost on account of occupational disease in relation to the output 
of the plant. There was at first a great deal of trouble in the ortho and paratoluidin 
area, and for a time the cases of poisoning were very frequent. Then exhaust ventila- 
tion was installed to remove fumes not only from the liquids but from the solids 
also. The men were given rubber boots and gloves and they were strictly watched 
and sent to the hospital for treatment at once if the slightest sign of illness appeared. 
The days lost on account of poisoning, which in December had been 61 for an output 
of 125,000 pounds, had reached zero in June with an output of 340,000 pounds. 
For a second plant the records for six months in 1918, from January to July, 
are available. 
The number employed at this time was about 1600, something over 700 of whom 
were process men and about 100 engaged in laboratory work. The company con- 
sidered only cases of acute fume poisoning or of injury to skin or eyes by acids and 
caustics as "occupational" in character, so in order to get at the amount of illness in 
the different departments one must look through the list entitled "non-occupational." 
This gives the number of cases among 1640 men in six months as follows: 
Cases 
Gastro-intestinal diseases 63 
Colds, catarrh, coughs, grippe 69 
Lumbago, rheumatism, etc 12 
Headache 13 
Abscesses, boils, etc 27 
Skin eruptions 37 
Conjunctivitis and sundry eye diseases 72 
Unclassified 43 
Total 336 SICKNESS STATISTICS IN THE DYE INDUSTRY 
523 
The different classes of employes suffered in the following proportions during the 
six months: 
Class 
Number of 
employes 
Cases of 
sickness 
Per cent, 
sick 
Mechanical and yard 
627 
116 
18.5 
Office force, police, etc 
200 
11 
5.5 
Laboratory 
97 
18 
18.6 
Intermediates 
300 
85 
28.3 
Colors 
270 
73 
27.0 
Raw materials 
146 
33 
22.6 
During the same period a record of accidents was kept, both those involving 
loss of working time and those needing treatment but without loss of time-minor 
accidents. 
Character of injury 
Accidents 
causing loss 
of time 
Days lost 
Minor 
accidents 
Acid burns 
1 
3 
20 
Caustic soda burns 
16 
Steam and liquid burns 
4 
37 
34 
Burns from explosions 
3 
1605 
Sundry burns 
1 
13 
3 
Anilin poisoning 
4 
15 
2 
Nitrous fumes 
6 
21 
1 
Sundry fumes 
5 
74 
2 
Injuries to eye (not mechanical): 
From acids 
2 
6 
15 
From caustics and lime 
2 
5 
10 
- 
- 
- 
Total 
28 
1779 
103 
It is impossible to read these figures and not see the influence of the occupation 
on even the supposedly non-occupational diseases given in the second table. The 
workmen who come in contact with the raw material, intermediates, and colors 
have a decidedly higher sickness rate than have the workmen not so exposed. 
Preventive Measures.-The coal-tar industry requires careful techni- 
cal and medical supervision to safeguard the health of the wage earners. 
The distillation of tar and the purification and cooling of the distillation 
products must be carried on in properly constructed stills, apparatus and 
vessels provided with facilities for the removal of injurious gases, and all 
leaky or defective apparatus should be promptly remedied. In the coal- 
tar color industry we have to deal not only with the toxic properties of the 
raw material such as benzene and toluene, but also with the intermediate 524 
THE PETROLEUM AND COAL-TAR INDUSTRIES 
products such as nitrobenzol, aniline, toluidine. Many of the processes 
involve exposure to chlorine, acids, especially nitric acid, and sulphuretted 
hydrogen gas and othei' chemical agents, which must be guarded against 
by enclosed processes and mechanical suctional ventilation for the 
removal of toxic fumes and dust. In addition to these devices, the general 
ventilation of the establishment should be perfect. All sweeping and 
cleaning should be done by the vacuum system. General and personal 
cleanliness are of the utmost importance. The men should wear suitable 
eye protectors, work in special suits, frequently washed, rubber boots and 
gloves and eat in special lunch rooms. Frequent ablutions of the hands, 
especially before meals, and a bath with change of clothing upon cessation 
of work are essential. The workmen should receive systematic instruc- 
tion in the prevention of accidents, in first aid, the employment of respira- 
tors, artificial respiration, oxygen inhalation, etc. These measures, with 
careful periodical physical examination of the employes by a full-time 
salaried physician, have proved in large establishments of immense value 
to all concerned. Curschmann, with his large experience in the "de 
Creppin works," also emphasizes the importance of good wholesome food, 
abstinence from alcoholic beverages, sanitary homes for the wage earners 
and a careful selection of the employes engaged in this industry. 
Hydrocyanic Acid Gas Poisoning.-Thomas29 performed post-mortem 
examinations two days after death upon two men who were fatally 
gassed on the occasion of the fumigation of a large liner at Southampton. 
In view of the comparative paucity of definite information at present 
available on the subject of hydrocyanic acid gas poisoning, the summary 
of the findings is given verbatim (the original article contains a detailed 
analysis of the two cases in paralied columns): 
"it seems worth while to emphasize the outstanding features which are common 
to both cases-viz: Absence of smell of HCN before opening the body, the absence of 
this smell from the urine; gaseous distension of peritoneal cavity and of intestines; 
smell of HCN in all serous cavities; concentration of smell of HCN in lateral ven- 
tricles; intensity and precise colour of facial lividity; blue nails; pink colour of 
intestines and gastric mucosa; bright pink staining of intima of the aorta; uniform 
blue-green colour of the liver; green colour of grey matter of the brain; colour and 
chemosis of the conjunctivae; lividity and engorgement of buccal, pharyngeal, oeso- 
phageal, and respiratory mucous membranes; extravasation of blood into the tissues 
of the stomach wall posteriorly in the region of the fundus; flabbiness of the myo- 
cardium; absence of putrefactive odour, and of the ordinary post-mortem staining; 
and positive chemical and spectroscopic tests." 
One case also showed extensive separation of corium over upper half of thorax in 
front, and one or two blisters on the trunk and scrotum. 
REFERENCES 
1 Hayhurst, E. R.-Industrial Health Hazards and Occupational Diseases in Ohio, 
February, 1915. 
2 Sharp.-Editorial, Medical News, Vol. LII, 1888, page 554. 
3 Mitchell, J. K.-Medical News, Vol. LHI, 1888, pages 150-152. REFERENCES (CONCLUDED) 
525 
4 Berthenson, Leo.-Vierteljschft. offent. Gesundheitspfl., 1899, Bd. XXX, page 334. 
8 Weyl.-Handbuch d. Arbeiterkrankh., Jena, 1908, page 210. 
6 Report of the Massachusett's State Board of Health upon the Sanitary Condition of 
Factories, Workshops, etc., 1907. 
7 Neisser.-Internat. Ubersicht uber Gewerbehygiene, Berlin, 1907, page 238. 
8 Rambousek.-Industrial Poisoning, London, 1913, page 275. 
9 Rambousek.-Actes du II Congress Internat. des Maladies Professionelles, Brussels, 
1910. 
10 Ibid. Industrial Poisoning, London, 1913, page 106. 
11 Rambousek.-Industrial Poisoning, London, 1913, page 107. 
12 Weyl.-Handbuch d. Arbeiterkrankheiten, 1908, pages 204, 208. 
13 Hamilton, Alice.-Poisons used in the Making of Explosives. Monthly Review, 
Bureau of Labor Statistics, U. S. Dept, of Labor, February, 1917. 
14 Adams, S. S.-Trans. Assoc, of Am. Physicians, 1912, page 507. 
18 Oliver's Dangerous Trades, London, 1902, page 615. 
16 Neisser's Internat. Ubersicht uber Gewerbehygiene, 1906, page 19. 
17 Roth, E.-Gewerbehygiene, 1907. 
18Leymann.-Vierteljhschft. f. off. Gesundheitspflege, Suppl., 1902, page 371. 
19 White and Sellers.-Actes du II Congress Internat. des Maladies Professionelles, 
Brussels, 1910. 
20 Neisser.-Internat. Ubersicht fiber Gewerbehygiene, Berlin, 1907. 
21 Senn.-Corresdondenzbl. f. Schweizer Artze, 1897, page 161.. 
22 Rambousek.-Industrial Poisoning, London, 1913, page 116. 
23 Luce, Rey Vincent, and Hamilton, Alice, in J. A. M. A. for May 6, 1916. 
24 Rambousek.-Industrial Poisoning, London, 1913, pages 212, 213. 
28 Rambousek.-Industrial Poisoning, 1913, pages 25, 66, 67, 113. 
28 Curschmann, Fritz.-Actes du II Congress Internat. des Maladies Professionelles, 
Brussels, 1910. 
27 Zentralbt. f. Gewerbehygiene, Aug., Sept., 1920. 
28 Hamilton, Alice.-Jour. Industrial Hygiene, May, 1921, Vol. XVXI, page 16. i-* 
29 Thomas, G. R. Seager. The Lancet (London), Vol. CCIV, No. 5207, (June 16, 
1923), p. 1210. SECTION 18 
PHOSPHORUS POISONING: HISTORY, STATISTICS AND PRE- 
VENTION 
JOHN B. ANDREWS, Ph. D„ New York City, N. Y. 
Introduction.-Phosphorus poisoning arises in the extraction of phos- 
phorus, in the production of phosphorus compounds, such as igniting 
agents, in the extraction of coal-tar dyes, in the making of phosphor- 
bronze, and in the manufacture of matches. In America, as elsewhere, 
the last-named industry has been the main source of the disease. 
History.-White or yellow phosphorus was discovered in 1669 by Brand, of Ham- 
burg, while he was experimenting for a liquid to transform silver into gold. It is now 
obtained commercially by treating bone ash with sulphuric acid, filtering and evapor- 
ating the product, heating this with charcoal, and afterward distilling it. It is, when 
pure, a colorless, transparent, crystalline substance, which readily becomes yellow 
upon exposure to light. It is volatile at ordinary air temperature, and in addition to 
its poisonous qualities is highly inflammable. 
The ignition of phosphorus by friction was discovered in 1680, but although the 
first friction match was invented in England by John Walker in 1827, it was not until 
1833 or thereabouts that phosphorus was utilized in the composition of match heads, 
in Vienna. In 1836 the first American patent for a friction match was granted to 
Alonzo Phillips, of Springfield, Massachusetts, and in 1842 Reuben Partridge invented 
the first splint-cutting machine. From that time to the present the principal inven- 
tions of machines in this industry have been made by Americans. 
Matches.-Three kinds of phosphorus are now used in match manufacture, to 
which correspond three types of matches. 
One is the "safety match," which must be struck on a prepared surface. This 
match contains no phosphorus and is harmless. The igniting composition is painted 
on the box and contains the red or amorphous phosphorus discovered by Schriotter 
in 1845, which is made by baking the poisonous white or yellow variety in a closed 
vessel, and is consequently more expensive. The red phosphorus is insoluble in the 
human digestive tract, and when pure is therefore non-poisonous. Although used 
almost exclusively in one or two countries of Europe, the manufacture of "safety" 
matches is, in America, still very limited.* 
* The paste for safety matches consists of potassium chlorate, sulphur, or antimony 
sulphide, potassium bichromate and glass powder, mixed in a solution of gum or dextrine. 
The matches are saturated with paraffin or phosphate of ammonia. The friction surface 
for these matches is made up of a mixture of dextrine, antimony sulphide and red phos- 
phorus, the latter, on striking, acts as the igniting agent. 
The manufacture of Swedish safety matches, when chrome salts are used in the paste, 
has given rise to chrome ulcers and severe eczema. Wodtke1 reports 18 perforations of 
the nasal septum among 84 workers. (For preventive measures see chromium compounds). 
C. Rash (Ugeskrift for Laeger), Aug. 25, 1921, encountered 13 cases of dermatitis from 
carrying or handling safety matches. One of the cases was quite severe, involving the 
fingers, neck and face, lasting for two weeks, accompanied by conjunctivitis, and the eyelids 
swollen together. He ascribed the affection to the phosphorus sesquisulphide, P4S3, used 
in the matches, when amorphous phosphorus could not be obtained. (Jour. Ind Hyg., 
Jan., 1922, Abst. p. 212) (Kober). 
1 Wodtke, Vierteljhschft. f. Gerichtl. Med. u. offentl. Sanitatswesen, Vol. XVIII, page 
325. 
526 MATCH MANUFACTURE 
527 
The second kind of match-the familiar old-style "strike anywhere" parlor 
match-is now happily fast disappearing. The match can be struck on any ordinary 
rough surface, but possesses the disadvantage that the paste used for the heads con- 
tains from 5 to 7 per cent, of poisonous phosphorus, the other ingredients being glue, 
powdered glass, oxide of zinc, chlorate of potassium, and some coloring mixture. 
To the presence of the poisonous phosphorus can be traced the phosphorus necrosis 
among workers in match factories. The use of this poisonous element in match manu- 
facture is now prohibited in the leading countries of the world, including the United 
States where this result was accomplished through the imposition of a prohibitive 
tax. An older form of the phosphorus match is the sulphur or card match, so named 
on account of the sulphur in the head and the card form in which the matches were 
sold. Due to the disagreeableness of the sulphur fumes this match has fallen into 
almost complete disuse. 
The third variety of match also possesses the desirable quality of striking anywhere 
and is at the same time non-poisonous. This is the strike anywhere match now manu- 
factured and used in those countries where public sentiment has been sufficiently 
aroused to prohibit the use of white phosphorus. In France, where the substitute 
for white phosphorus was discovered and where it was first used, the match business 
has been a Government monopoly for more than 25 years, and as such threw upon the 
Government the burden of the human loss resulting from the peculiar hazards of the 
industry. Government officials noticed that the profit they had hoped to receive 
from the business was rapidly drawn away in the form of compensation for 
sickness and death from phosphorus poisoning. Experts were set to work and 
in 1898 Sevene and Cohen found a substitute for the poisonous element, in the 
sesquisulphide of phosphorus. This substitute has not only been successfully em- 
ployed in France but has been introduced almost everywhere where white phos- 
phorus is forbidden. 
Although complicated by modern methods and machines, the fundamental proc- 
esses in the manufacture of matches may be described in a few words: The wooden 
match splint is prepared; the phosphorus composition for the head of the match is 
mixed; one end of the splint is dipped into the paste; the "green" match is allowed to 
dry; and finally it is boxed and wrapped. 
The lumber from which match splints are made is usually poplar or basswood. 
White pine makes the best splints, but it is hard to get. Blocks which have been 
selected so as to be free from knots and of a certain dimension are fed into the machine 
by an operative called a "block feeder." The machinery holds the block against 
knives, which cut out the splints and force them into perforations in a series of hinged 
iron plates which move as an endless chain over the entire length of the machine. 
Projecting from the lower surfaces of the iron plates, the splints move from the front 
end of the machine into a bath of melted paraffin. They are then passed over a 
roller which is coated with phosphorus paste by running in a trough containing the 
composition, which trough is in turn supplied by a pipe leading from a covered tank 
on the machine holding a supply properly heated. This last operation puts the heads 
on the matches.- The finished matches are now ready to be dried, which is accom- 
plished by the movement of the endless chain of plates over a series of drums, bring- 
ing them during their transit in contact with a number of air currents. The time for 
drying varies with the weather, but usually takes an hour. Arriving again at the 
front of the machine, the matches are mechanically punched out of the plates, and 
are then handled by the filling mechanism, passing finally to a revolving table at which 
girls are seated who slide the covers on the boxes. 
If the poisonous variety of phosphorus is used, practically every process in this 
series following the preparation of the splints is dangerous. In the mixing, dipping, 
drying and packing rooms the danger from breathing phosphorus fumes, although it 
may be somewhat diminished by thorough ventilation and by the rigid enforcement 528 
PHOSPHORUS poisoning: history, statistics and prevention 
of preventive measures, is always present. Particles of phosphorus also become 
attached to the hands of the employes and are later transferred to their mouths. 
Statistics.-As early as 1838 Doctor Lorinser, of Vienna, diagnosed in a female 
match worker named Marie Jankovits the first authentically recorded case of 
industrial phosphorus poisoning. The rapid reporting of additional cases led 
the Austrian government to appoint a committee of inquiry, but the committee's 
recommendations apparently never become effective, for in the 10 years 1866 to 
1875 there were reported 126 cases of phosphorus necrosis in the hospitals of Vienna 
alone. 
The death of a match maker in London about 1896 and the consequent newspaper 
discussion of unhealthful conditions in the trade fixed British attention upon indus- 
trial phosphorus poisoning. A total of 105 cases, 19 of which resulted fatally, were 
reported in Great Britain up to the end of 1900, but the record is admittedly incom- 
plete. While in Great Britain less than 1 per cent, of match makers were found to 
have suffered from phosphorus necrosis, in Switzerland it was formerly 1.6 to 3 per 
cent., and in France 2 to 3 per cent. 
In America a surgeon published as early as 1855 a pamphlet giving the history of 
nine serious cases of phosphorus poisoning in New York City. One of these earliest 
cases required the removal of an entire jaw. 
In 1864, 12 more serious cases from these same match factories were recorded in 
a letter to the New York Evening Post. At that time there were 75 match factories 
scattered throughout the eastern states, but the toll taken by phosphorus from these 
many establishments is unknown. That phosphorus necrosis, however, was a com- 
mon malady 25 years ago among match factory employes in this country is not denied 
by anyone. 
In the course of their general investigation into the conditions of women and child 
wage-earners in 1908 and 1909, agents of the United States Bureau of Labor found 16 
definite cases of phosphorus poisoning among match factory operatives, and learned 
that many other cases had occurred, not only many years before, but also in recent 
years and in some of the factories where conditions were the best. This discovery, 
and the related activities in European countries, led to an intensive study under the 
joint auspices of the Bureau and of the American Association for Labor Legislation, 
of 15 of the 16 match factories then in operation, all of which were using poisonous 
phosphorus. * 
The 15 factories investigated employed, according to statements by the manu- 
facturers, 3591 persons, of whom 2024 were men, and 1253 were women 16 years of 
age and over. Children under 16 numbered 314, 121 boys and 193 girls. Detailed 
investigation showed that 65 per cent, of the employes were working under condi- 
tions which exposed them to the dangers of poisoning. The women and children were 
much more expdsed than the men, 95 per cent, of the women and 83 per cent, of the 
children under 16 years of age being so exposed. 
An investigation by the writer in the homes of the work-people of three of these 
factories yielded a total of 82 cases of phosphorus poisoning. In two factories at least 
eight perfectly authenticated cases were found to have occurred in 1 year, and refer- 
ences were obtained to three more. In one small factory records were secured of 
more than 20 serious cases during the past 30 years, many of them requiring the 
removal of the entire jaw. In one of the most modern establishments, records of 40 
cases were secured. Of this number 15 resulted in permanent deformity through the 
loss of one or both jaws, and several cases resulted in death. In another factory the 
records of 21 cases were secured, six of which were in the year of the investigation. 
In all, the records of over 150 cases, of which four were fatal, were collected in a very 
* Phosphorus Poisoning in the Match Industry, by John B. Andrews, Bulletin 86, United 
States Bureau of Labor. PROTECTIVE MEASURES IN MATCH MANUFACTURE 
529 
short time, although it had been the claim of the match manufacturers, and there tvas 
a popular impression to the effect, that the trouble had not existed in this country 
in a serious form for 20 years. 
Preventive Measures.-The early manufacture of matches was often 
carried on in dirty and ill-ventilated workrooms which exposed the 
employes to every danger of phosphorus poisoning. With the increasing 
demand for matches, conditions grew worse until within 11 years after the 
phosphorus match was discovered, government investigators in Europe 
were studying the conditions which brought on the disease. The infant 
industry was driven out of the cellars. The rules issued by the various 
governments in the attempt to "regulate" the effect of the poison upon 
the health of workers included such provisions as closed-in machinery, 
exhaust and ventilating systems, separate lunch rooms, dressing rooms 
and wash rooms, with mouth wash and soap and towels furnished by the 
employer, medical and dental inspection at the expense of the employer, 
and factories built according to architectural plans furnished by the 
government. The hours of labor were also strictly regulated, and 
women and children were rigidly excluded from the most dangerous 
departments. The percentage of phosphorus in the paste was limited 
until many manufacturers rebelled and made matches in defiance of the 
laws. Notices warning employes of the dangers involved in the han- 
dling of phosphorus were posted, and employers were required to read the 
warnings to their employes at stated intervals. Partly as a result of 
these extraordinary and expensive precautions the industry was rapidly 
concentrated in the hands of a comparatively few employers and condi- 
tions were improved, but wherever special study was made phosphorus 
poisoning was nevertheless found to exist in a serious form. During all 
of the past generation, in spite of attempts on the part of humane employ- 
ers and governments to regulate the evil, the malady continued to claim 
its victims one by one. So serious was the situation that the regulative 
method of dealing with the problem gradually became recognized as 
totally inadequate. 
In 1872 Finland gave up attempts at regulation and enacted the first law prohibit- 
ing the use of white phosphorus in match factories. Denmark, in 1874, with a similar 
experience, did the same. For 40 years they have had no cases of phosphorus necro- 
sis. France prohibited the poisonous ingredient in 1897, Switzerland in 1898, and 
the Netherlands in 1901. In 1906, on account of the difficulties of eliminating the 
use of phosphorus in countries with an important export trade, the International 
Association for Labor Legislation secured an international conference at Berne which 
resulted in an international convention providing for the absolute prohibition of the 
manufacture, importation or sale of white phosphorus matches. The convention 
was signed by Denmark, France, Germany, Italy, Luxemburg, the Netherlands, and 
Switzerland, to which were added Great Britain in 1908 and Spain in 1909, together 
with numerous colonies of the signatory states. Without signing the convention, 
Austria enacted a prohibitory law in 1909, New Zealand and New South Wales did 
so in 1910, Hungary in 1911, Mexico in 1912 and Canada in 1914. 530 
phosphorus poisoning: history, statistics and prevention 
In the United States, which, it was assumed, was prevented by con- 
stitutional limitations from signing the convention and where the national 
government may not regulate directly the conditions of industry within 
the states, resort was had to the federal taxing power. By a law drafted 
by the Association for Labor Legislation and enacted by Congress in 1912, 
to go into effect on July 1, 1913, a prohibitive tax of 2 cts. a hundred was 
levied on matches made of white phosphorus. Their importation and 
exportation were also absolutely forbidden after January 1, 1913, and 
January 1, 1914, respectively. Heavy penalties, ranging up to $5000, or 
imprisonment for 3 years, or both, were provided for violation of the act. 
Thus throughout the greater part of the whole civilized world, before 
the close of 1914, the use of poisonous phosphorus in the manufacture of 
matches had been definitely prohibited. And with such prohibition 
there was abolished from the match industry that most loathsome of 
occupational diseases, phosphorus necrosis. 
The original international treaty on phosphorus prohibition gave 
much encouragement to those who favored a definite provision in the 
Treaty of Versailles for international protective labor regulation. And 
at the first International Labor Conference under the League of Nations- 
held in Washington in the fall of 1919-a recommendation was adopted 
re-affirming this treaty and urging that it be adhered to by all of the 
remaining countries. Belgium adopted this program in 1919, Sweden 
in 1920, and in 1921 it was adhered to by Austria, Czecho-Slovakia, 
Finland, the Free City of Danzig, Greece, Japan, the Netherlands, 
Poland and Rumania. This international labor legislation is not only 
the first example of wide-spread international regulation of an industry 
for the protection of the workers; it is also one of the most satisfactory 
examples of labor legislation effectively enforced. SECTION 19 
PHOSPHORUS POISONING: SOURCES, SYMPTOMS AND 
TREATMENT 
ALICE HAMILTON, M. D„ Chicago, Ill. 
Introduction.-Industrial phosphorus poisoning may occur in chemical 
works where phosphorus is obtained from mineral phosphates, or in the 
manufacture of matches from white phosphorus, or in the use of phosphor 
bronze, or through exposure to the fumes from ferrosilicon, or possibly 
through the use of acetylene gas in which phsoporus is contained as an 
impurity. 
Sources of Poisoning.-In recovering phosphorus from mineral phosphates, 
the process is carried on under cover to hold in the fumes, and the phosphorus col- 
lected and kept under water. The work is, therefore, almost free from danger, yet 
there are a few records of cases of phosphorus necrosis in this industry. Pieraccini1 
says that the preparation of phosphorus from calcined bones in Italy is attended with 
danger of necrosis. The British report2 on phosphorus poisoning states that in the 
lone large English factory where phosphorus is prepared from apatite there have been 
17 cases scattered over a period of 50 years. The British Factory Inspection Re- 
ports for the year 1918 show that there have been two or three cases of phosphorus 
poisoning each year since 1915 in one factory which produces white phosphorus.3 
In France3 nine have been reported from the chemical works since 1880. Two 
typical cases of "phossy jaw" developed during the war in connection with the manu- 
facture of hand grenades. White phosphorus was used as a constituent of fuses and of 
incendiary projectiles in the United States but for a short time only and apparently 
without injury to the workers. 
Ferrosilicon is used in the manufacture of steel. It is an alloy of iron and silicon, 
the latter being present in proportions of 15 to 95 per cent, and containing arsenic 
and phosphorus as impurities. In the presence of moisture ferrosilicon which has 
more than 30 per cent, or less than 70 per cent, of silicon decomposes, giving off arseni- 
ureted and phosphureted hydrogen. Fatal poisoning has occurred from these 
fumes,4 chiefly on ships which were carrying a cargo of ferrosilicon and in which steer- 
age passengers were housed in ill-ventilated cabins near the hold. Such cases cannot 
be regarded as of industrial origin, but they serve as a warning that the use of ferro- 
silicon in industry is not free from danger. 
Phosphor bronze is an alloy of copper, tin, and a small amount of phosphorus, 
which should not exceed 2 or 3 per cent. Kaup 5 has found cases of phosphorus necro- 
sis in Austria where phosphor bronze is used in the making of cannon and of cartridges. 
His attention was first called to this danger by a case which occurred in 1897, and he 
found that the man had been working with an alloy consisting of copper 90 per cent., 
tin 8.9 per cent., and phosphorus 0.76 per cent. From so small a quantity as this, 
phosphureted hydrogen was given off in amount sufficient to cause poisoning. 
Another source of phosphorus poisoning in the United States was recently uncov- 
ered in New Jersey. Miss Lilian Erskine, of the New Jersey Department of Labor, 
is authority for the statement that in the making of fireworks in that state a paste of 
531 532 
PHOSPHORUS poisoning: sources, symptoms and treatment 
white phosphorus may be used and in such a way as to expose the men and girls em- 
ployed in certain departments to the fumes of phosphorus and to direct contact with 
the paste. The method is said to have been brought over to this country from Italy. 
A possible source of phosphorus poisoning, according to v. Jaksch,6 is acetylene 
gas which contains this element as an impurity, and, according to Holzer,7 the use of 
phosphorus in the making of miners' lamps. 
All these industries ar.e of little importance compared with the making 
of phosphorus matches, which is the phosphorus trade par excellence, 
employing as it does many more work-people than all the others put 
together. 
Symptoms.'-The first description we have of industrial phosphorus 
poisoning was written 12 years after the invention of lucifer matches. 
Lorinser,8 an Austrian physician, wrote in 1845 concerning 22 cases of 
necrosis which had occurred in the match factories near Vienna. The 
first recorded case in America is probably to be found in the books of the 
Massachusetts General Hospital in Boston for 1851. This was a man 48 
years of age, who for 14 years had been employed in paste making and in 
dipping matches. He had no symptoms pointing to phosphorus poison- 
ing till 18 months before his admission to the hospital, when he had had 
pain in one of the lower incisors and soon after lost the tooth. The record 
describes a stage of necrosis already far advanced, with swollen lower jaw, 
bloated face, eyes dull and staring, breath very offensive and half a dozen 
fistulous openings along the lower border of the jaw. The upper jaw was 
also affected. Later entries show extension of the disease and increasing 
toxsemia ending in death some 6 months after his first admission. Lorin- 
ser's work was followed during the next few years by publications on the 
subject of phosphorus necrosis in Germany, France and England, and 
from that time up to the present day no year has passed without a large 
number of reports as to the prevalence and the prevention of this 
disease. 
It is the most dreaded of all the industrial diseases, not because it is 
the most dangerous, for the mortality is only 15 to 20 per cent., nor 
because it is widespread, for in this respect it does not compare with lead 
poisoning, nor because it is sure in its action, for in reality only a small 
minority of those exposed are ever affected, but because of the great and 
prolonged suffering caused by the local disease and the shocking deformi- 
ties which almost always result. The mere fact that phosphorus attacks 
the bones of the face and makes its effects visible in pitiable disfigurement 
has probably had much to do with the vigorous efforts which have been 
made to do away with this industrial disease. 
In the making of matches three kinds of phosphorus may be used, but 
the only one which concerns us is the white or yellow, the amorphous and 
the sesquisulphide not being dangerous. Workers in white phosphorus 
match factories make the paste, dip the sticks in the paste, carry the 
matches to drying rooms, carry them from drying to packing rooms, SYMPTOMS AND TREATMENT OF PHOSPHORUS POISONING 
533 
and pack them in boxes. All these processes are attended with danger 
from the fumes of phosphorus, especially the first two. 
According to T. E. Thorpe,2 phosphorus exposed to air at ordinary temperature 
volatilizes, forming fumes which consist of phosphorous oxide, about 5.8 per cent.: 
phosphoric oxide, 73.1 per cent.; and phosphorus, 21 per cent. Thorpe found that 
these fumes have a solvent action on human teeth, for carious teeth exposed to phos- 
phorus for 12 hours lose 0.37 per cent, of their weight. Fumes dissolved in the saliva 
also have a solvent action on the teeth. Dilute phosphoric acid was allowed to flow 
over fragments of broken teeth for 3 hours and at the end of this time 8.9 per cent, 
of their weight was lost. 
Thorpe's analysis of samples of air in a match factory showed that at a dipping 
table covered with phosphorus paste there was 0.02 mg. of phosphorus per 100 liters 
of air, and in the middle of the boxing rooms, 0.12 mg. per 100 liters. An analysis 
of the water in which the workers had washed their hands after 4 hours' work showed 
an average of 4.2 mg. per head for a day of 10 hours. 
Individual susceptibility is an important factor in this form of poison- 
ing, for only a very small minority of those exposed ever develop necrosis, 
even of those with carious teeth. The same thing is found to be true of 
animals exposed to phosphorus fumes; only a few succumb. No abso- 
lutely complete statistics are to be found as to the occurrence of phosphorus 
poisoning among match workers, but the following are fairly so: Hirt14 
reported 70 cases during 20 years among 600 workmen in the Silesian 
factories; Magitot18 gives nearly the same figures for the French factories, 
70 in 21 years among 620 workers. The British report of 18962 states that 
among 1701 persons employed in occupations exposing them to the fumes 
of phosphorus were 300 men who, during the preceding 5 years, had had 
16 cases of necrosis, and 1401 women who had had 14 cases, making 30 
cases in 5 years among 1701 persons. 
Treatment.-It is still a matter of controversy whether the treatment 
of necrosis should be early and radical or expectant and conservative. 
Some dentists advise the extraction of all carious teeth if the person has 
been working in a match factory; others prefer to fill those that are in the 
first and second stages of caries. In either case there is no question that 
the patient must be forbidden to return to the factory till the mouth is 
in a sound condition. When the pulp is exposed, extraction is imperative 
and the resulting wound must receive careful treatment till it is healed. 
Abscesses must be freely incised, cleaned and drained. When necrosis of 
the bone has taken place there are many who advise immediate subperios- 
teal resection through healthy bone. Kocher2 follows this plan and 
claims 83.7 per cent, of cures. Kuipers17 has had 89.0 per cent, by the 
same method, while Garman15 waits for a sequestrum to form before he 
operates and claims that he has 83.0 per cent, cured. Teleky11 has lately 
come out for the expectant treatment. He believes that the early resec- 
tion of large parts of the jaw has seemed to give goods results largely 
because the relapses have not come under the observation of the surgeon. 
In order to bring about healing in such an early operation, it is necessary 534 
phosphorus poisoning: sources, symptoms and treatment 
to remove a much larger portion of bone than if one waits for the forma- 
tion of a sequestrum. This does prolong the disease, but results in less 
deformity and less disturbance of function. Therefore unless the disease 
is too protracted or the danger of sepsis too great he advises against 
early extensive operation. 
REFERENCES 
1 Pieraccini.-Patologia del Lavoro, Milan, 1906. 
2 Sessional Papers of the House of Lords, 1899, Vol. LXXII; T. E. Thorpe, Thomas 
Oliver, and George Cunningham. 
3 Poisons Industrielles. Office du Travail, Republique Francaise, Paris, 1901, 
Imprimerie Nationale. 
4 Glaister.-Industrial Poisoning by Gases of Arsenic and Phosphorus. Internat. 
Congr. Industrial Hygiene, Brussels, 1910. 
6 Kaup.-Bauer's Gesundheitsgefahrliche Industrien, Jena, 1903, page 119. 
6 Von Jaksch.-Die Vergiftungen, Vienna, 1910. 
7 Holzer.-Bauer's Gesundheitsgefahrliche Industrien, Jena, 1903, page 1. 
8 Lorinser.-Quoted by Holzer. 
9 Ropke.-Concordia, 1901, Vol. VIII, page 18. 
10 Andrews.-Bulletin 86, U. S. Bureau of Labor. 
11 Teleky.-Handworterbuch d. sozialen Hygiene. Edited by Grotjahn and Kaup, 
Leipzig, 1912. 
12 Oliver.-Dangerous Trades, London, 1902. 
13 Lewy.-Quoted by Holzer. 
14 Hirt.-Quoted by Holzer. 
15 Garman.-Quoted by Oliver in Sessional Papers. 
16 Villaret.-Quoted by Helbig. Weyl's Hb. d. Arbeiterkrankh., Jena, 1908, page 227 
17 Kuipers.-Inaug. Dissert., Jena, 1895. 
18 Magitot.-Quoted by Holzer. SECTION 20 
POISONINGS IN THE RUBBER INDUSTRY 
E. R. HAYHURST, M. D. and GEORGE M. KOBER, M. D. 
Introduction.-This industry includes all establishments in which 
rubber tires, waterproof cloth, garments, boots, shoes, rubber gloves, 
water bags, ice-caps, surgical appliances, children's toys, door mats and 
any other rubber goods are made. In 1919, according to the U. S. 
Statistical Abstract (Dept, of Commerce), there was an average of 
119,848 wage-earners in the rubber manufacturing industry (tires, tubes 
and rubber goods). It is probably safe to say that over half of the rubber 
workers of the United States are to be found in Akron, Ohio. Horan 
(See reference 12 below) claims that 2.1 of all employes in Massachusetts 
industries (1917) were rubber workers and that this industry reported 
all the fatal cases of benzol poisoning and 8^ per cent, of the lead poison- 
ing cases. 
India rubber is the inspissated juice of various rubber plants, and is 
known as caoutchouc. This is insoluble in water, but quite soluble in 
ether, acetone, petroleum, benzine, benzene, toluene, bisulphide of 
carbon and turpentine. 
Benzine is most frequently used as the solvent and serves to convert 
the rubber into a doughy mass. This is applied to large rolls which are 
usually warm and gradually other materials are added for the purpose 
of accelerating vulcanization, coloring the products and bestowing 
different physical properties to the finished goods. Chief among these 
materials are white lead, litharge, basic lead sulphate, zinc oxide, mercury 
sulphide, antimonial sulphides, sulphur, lime hydrate, aluminum flake, 
whiting, magnesia, asphalt, soapstone, carbon and certain organic com- 
pounds like anilin and urotropin. 
Cases of lead poisoning may occur from the use of litharge or other 
lead compounds. Of 162 cases of lead poisoning treated in the Massa- 
chusetts General Hospital Dispensary, 18, or 11 per cent., were among 
rubber workers.1 Of 544 cases of lead poisoning reported by Hayhurst2 
in the Ohio Survey, 43 occurred in the rubber industry. 
Cinnabar (mercury sulphide) and "crimson antimony" are among the 
red, and "golden antimony" among the yellow, coloring agents used. 
Both antimonies are poisonous, the red being about 8 per cent., and the 
yellow 3 per cent., soluble in human gastric juice,3 but industrial poison- 
ing due to them is rare. Five fatal cases of benzol poisoning are reported 
by Horan12 in one plant while Quinby12 says the occurrence of some 50 
535 536 
POISONINGS IN THE RUBBER INDUSTRY 
more cases caused that branch of the industry to be shut down in one 
plant. 
Roth3 refers to the fact that French authors some years ago called 
attention to a peculiar "caoutchouc disease" which they attributed to 
the cinnabar contained in the gutta-percha plates of artificial teeth. 
Oliver4 cites the observation of Lazarus, a German dentist, who reported 
20 cases of dental caries in gutta-percha workers, complicated in some 
instances with necrosis of the jaw bone, but offered no explanation as to 
the probable cause. 
The rubber industry is a very important one in the State of Ohio, and 
Hayhurst found the chief poisons employed, in the order of their danger to 
users, as follows: anilin oil, carbon bisulphide, benzol, lead and antimony 
compounds, mineral acids, alkalis, benzine (naphtha, petrol, gasoline) 
wood alcohol, sulphur chloride, carbon tetrachloride, mercuric sulphide 
and turpentine. Toluol is a little less toxic than benzol, while xylol, 
reported as used in English plants, is regarded as much less toxic. In 
some of the processes there was an additional risk from exposure to 
illuminating and fuel gas. To this list the organic accelerators which are 
the most frequent cause of the troublesome "rubber itch" must be added.* 
* Accelerators are used to increase speed, decrease temperature, and overcome retarders 
or negative catalyzers of vulcanization. They are used in small quantities-usually not 
over 2 per cent, of the batch for the organic accelerators. Up to a certain point, speed of 
vulcanization is directly proportional to amounts used after which retarding actions may 
follow. The first patents were taken out by the Eberfeld Company, in 1912. (R. Ditmar, 
Gummi Zeitung, 1915, XXIX, 424-26.) 
Practically all organic accelerators are basic in character and contain nitrogen. They 
act as catalyzers, due probably to the change in valency of N from three to five, thus 
functioning to carry the sulphur into the rubber. (Keats, Flower and Coolidge, Jr. Ind. 
and Eng. Chern., 1920, XII, 317-20.) 
Organic accelerators other than anilin which are used and reported upon are: (1) hexa- 
methylene-tetramine (urotropin, formin, cystogen; called "hex" in the trade, and is the 
one the most extensively used); (2) hexamethylene-diamine; (3) pentamethylene-diamine 
or cadaverin; (4) tetramethylene-diamine or putrescine; (5) para-phenylene-diamine--a 
substance also used as a hair-dye and causing scalp and facial dermatitis; (6) para-nitro- 
sodimethylanilin or "accelerine;" (7) thiocarbanilide-the result of the interaction of car- 
bon-bisulphide and anilin at vulcanizing temperatures; and piperidin bases. 
In the first edition we referred to the dermatitis present as due to antimony; however, 
it was undoubtedly due to these accelerators as at present. Kratz (India Rubber World, 
Dec. 1, 1917, LVII, 146-6) published the earliest American statement we have been able to 
find concerning it, but even he failed to suggest its likely cause. His description of the afflic- 
tion is excellent-the rash beginning on the wrists and proceeding to the forearms, face 
and neck, and subsequently, perhaps, pretty well over the surface of the body in marked 
cases. It begins as an intense erythema which soon becomes vesicular and later crusty 
and very much resembles the well-known rash due to poison-ivy. It is accompanied by 
intense itching, is worse at night, and frequently compels workers to lay off. It usually 
subsides in a few days after ceasing exposure. Predisposing factors are warm weather, 
humid atmosphere, sweating, exposure of bare skin to "green" stock handled, and rather 
worse with cotton fabricated stocks, but occurring also with the handling of plain (uncured) 
rubber goods like inner tubes. 
The prevalence and seriousness of dermatitis in the rubber industry induced the Rubber 
Section of the American Chemical Society to request its Committee on Organic Accelera- 
tors, Richard B. Earle, Chairman, to investigate the toxic properties of them. This Com- 
mittee submitted a brief report at the Cleveland Meeting, 1918, (see Jr. Ind. and Eng. 
Chem., 1918, X, 865), covering five of the most commonly used substances, stating the 
toxic peculiarities of each with recommendations as to personal cleanliness, clothing, 
gloves, suction hoods over mill, change of occupation, etc. That the recommendations 
were insufficient, probably because not practical enough, is evinced by the large number of CHIEF RUBBER HAZARDS RUBBER WASHING AND COMPOUNDING 
537 
In the order of exposure in relation to the number of employes, benzine 
undoubtedly comes first, followed by soap-stone dust and the organic 
accelerators. In the order of complaints as reported from the factories, 
the "itch" easily comes first. At the 11th Annual Safety Congress 
(Rubber Section) National Safety Council,12 C. F. Horan, as Chairman 
of the Committee on Health and Hygiene, presented a report on the 
common poisons used in the rubber industry and patterned after the 
well known "List of Industrial Poisons" (page 642), but adapted espe- 
cially to the rubber industry. Davis13 made a particular study of anilin 
poisoning among the rubber workers and considers that most symptoms 
develop from skin absorption, although the inhalation route is also very 
common. Poor ventilation, heat and concentration of gaseous substance 
is the dangerous combination. Some acquire a tolerant condition in 
which they show cyanosis, perhaps for years, but without development 
of apparently serious symptoms. The following is a summary of the 
Ohio Report of the different processes involving special hazards. 
1. Rubber Washing.-This process deals with the cleaning and prep- 
aration of the crude rubber, such as cracking it up in mills, washing it 
in cold and warm running water and subsequent steeping in large tanks of 
water. This process involves wet and sloppy work and exposure to a 
steamy atmosphere. Boils and carbuncles are frequent.12 In some of 
the plants lead and antimony are used in dust form in the same room, 
although quite foreign to this particular process, and with considerable 
liability to poisoning all the workers. 
2. Rubber Compounding.-In this department the various dry ingre- 
dients which go into the rubber, such as metallic oxides and salts (Al, 
cases which have continued to be reported to the Ohio State Department of Health. The 
figures are as follows: Fiscal year ending June 30, 1921, 321 cases; fiscal year ending June 
30, 1922, 519 cases; months ending Feb. 15, 1923, 445 cases. The special studies of 
Shepard and Krall, from the Research Division of the Firestone Tire & Rubber Co., at 
Akron, Ohio, on hexamethylene-tetramine (India Rubber World, Nov. 1, 1919, XLI, 75), 
showed that hot weather was one of the essential factors, the cases occurring in waves 
following hot spells and subsiding on cool days. Personal idiosyncrasy was the next 
chief factor. Acidity of the sweat, freeing formaldehyde from the compound, discovers 
the true nature of the offending substance. These writers point out, however, that the afflic- 
tion is not similar to that produced by formaldehyde (hardening of the skin with cracking 
and scaling), but resembles that due to formic acid. It is presumed that the soluble 
"hex" enters the skin where it is first decomposed and then oxidized in part to formic 
acid which is the real cause of the rash. On this basis the authors devised a prophylactic 
as well as a curative treatment consisting of (1) a thorough washing of the skin with soap 
and water, (2) drying and (3) applying a saturated solution of sodium bicarbonate which 
is allowed to dry on the skin. Two applications to the exposed parts per day suffice. 
Control tests with a squad of ten susceptible men in hot weather were said to prove the 
efficiency of the procedure. However, the specificity of alkaline washes in the prevention 
of " rubber dermatitis " is qu estioned (Horan12). That the trouble is not due to impurities is 
to be noted as the chemistry division of the Ohio State Department of Health pronounced a 
sample of "hex," collected from a tire factory where much trouble was experienced, as 
"pure hexamethylene tetramine." 
My associate, Dr. E. B. Starr, found from field inquiries that where "hex" was used 
in fa proportion over %-l per cent, dermatitis occurred quite regularly and that if no 
more than 6 oz. per 100 lb. of batch were used, it rarely occurred. One plant using it in 
the strength of 144 per cent, experienced much trouble, but found that a reduction to 
per cent, was followed by a cessation of the affliction (Hayhurst). 538 
POISONINGS IN THE RUBBER INDUSTRY 
Fe, Ca, Sn, Zn, Pb, Sb), soapstone, lampblack, tar, mica, organic accelera- 
tors, etc., are scooped from bins according to various formulas, weighed 
by hand, placed in open top tin boxes, and carried directly to the mixing 
mills or delivered close thereto through pipes, there to be incorporated 
with the rubber. Occasionally the ingredients are first bolted in shakers 
to break up lumps, which is an exceedingly dusty process unless the 
shaker is well inclosed. The work also involves exposure to harmful dusts 
and to the fumes of anilin oil, which is often poured directly upon the 
weighed powders from an ordinary cup. In the Ohio Survey 22 cases of 
positive and 5 cases of tentative lead poisoning were observed among the 
151 wage earners employed in this process. Two cases of acute anilin- 
poisoning were reported. Alice Hamilton, and later Luce and Hamilton, 
investigated the subject of anilin poisoning at Akron, Ohio, and reported 
the details of a series of cases from the rubber works. The use of anilin 
in rubber compounding increased during the war, some of the companies 
even manufacturing their own anilin, but its use has greatly decreased 
since, apparently due to the introduction of better accelerators. Most 
of the anilin intoxications are due to the spilling of the substance on the 
clothing whence it is absorbed by the skin. The intoxications also occur 
from breathing the fumes in closed places and especially on hot, humid 
days. Lintz describes a provocative test used on applicants for employ- 
ment where exposed to anilin to eliminate those particularly susceptible. 
A slight abrasion is made on the skin of the forearm and a little anilin 
rubbed in. Those with idiosyncrasies show moderate symptoms which 
follow rapidly. The workmen in this department should be subjected to 
careful supervision, monthly medical inspections, and one feels confident 
that the work could be rendered practically dustless, by competent 
ventilating engineers. 
3. Rubber Mixing Mills.-In this process the washed and dried rubber 
is macerated between steel rollers, and mixed with the compounds 
referred to in paragraph 2. In spite of hoods and exhaust flues, even 
when present, more or less dust escapes while the injurious ingredients 
are scooped out of the conveyance boxes and poured by hand upon the 
rolls. The amount of lead dust is estimated by the Ohio Survey as high 
as 25 per cent., and the odors from anilin oil and of antimony fumes were 
plainly detectable in several establishments. The investigators discovered 
22 positive cases and 4 tentative cases of lead poisoning, and 3 positive 
cases of anilin poisoning, among 252 male wage earners. The risks 
of poisoning were considered bad in 13 out of 21 establishments 
because of lack of adequate ventilation for the removal of dust and fumes, 
lack of medical supervision and instructions, and hence ignorance on the 
part of the workers, many of whom were wearing mustaches and eating 
and chewing while at work; there was also lack of personal care and 
of adequate washing facilities. "Rubber itch" is noticed in this, 
process. CALENDERING, WARMING MILLS, TIRE BUILDING 
539 
4. Rubber Calendering and Warming Mills.-In this process the com- 
pounded material brought from the mixing mills is placed into the rollers of 
the warming mills and of the calenders, which perfect and grade down the 
material into sheets of required thickness. The calenders are also used 
to spread and press the rubber mass over the fabric to be waterproofed, 
which process is called "frictioning." When this process is carried on 
in the same room with the mixing mills the danger from poisonous dust 
inhalation is quite great. There is also more or less soapstone dust, 
which is freely used in the handling and packing of the finished goods. 
The heat from the rollers is apt to be excessive, unless guarded against 
by adequate exhaust ventilation. Other occupational risks are exposure 
to benzine vapors especially from open cement cans. In the Ohio 
Survey no cases of occupational poisoning were observed in this process, 
although in only three places were all the workers healthy appearing. 
"Rubber itch" is often more or less pronounced among these workers. 
Mill and Calendar rooms are difficult to ventilate properly in winter 
because they become so excessively cold. It is also difficult to prevent 
glare from artificial illumination on rolls, etc.12 
5. Rubber-tire Building.-In the manufacture of casings for auto- 
mobile and bicycle tires different layers of rubber fabric are applied upon 
wheel-shaped moulds by workers who are seated before them, and when 
thus built up by hand or machine labor, the beads, cover layers, etc., are 
finally attached by means of rubber cement and pressure. In this proc- 
ess benzine and sometimes benzol is freely used with the sponge and also 
as a solvent for the cement. In 9 of the 13 establishments investigated 
in Ohio, the odor from benzine was strong enough to cause symptoms. 
Nine cases of benzine poisoning in female workers in a rubber-tire factory 
at Upsala are reported, of whom four died. The history does not make 
clear that they were cases of petroleum benzine or of benzene poisoning.5 
However, Horan's12 five fatal cases from benzol occurred at this work 
in one plant. He also states that English rubber concerns are using 
xylol. This is said to be superior to naphtha or benzine (and far safer). 
The chief complaints in the Ohio Survey were headache, dizziness and 
stupefaction. In recent years "hex" dermatitis or "rubber itch" is a 
frequent complaint, especially in warm weather. Boils and carbuncles 
are also frequent in some instances. Soapstone dust is present invariable 
amounts in all places. The effects of fatigue as a result of speeding up, 
faulty positions, jarring processes, pressure against the body and lifting 
and carrying of heavy moulds are evident in many places. In winter the 
effect of cold drafts on sedentary workers from windows kept open to 
drive out the fumes is an objectionable feature. 
The inner tubes for rubber-tires are made by lapping long strips 
of almost pure rubber around an iron rod of suitable size, or by butting 
the edges together on a table top. The rubber is made to adhere to 
itself by moistening with benzine or rubber cement. The long tube is 540 
POISONINGS IN THE RUBBER INDUSTRY 
next wrapped with a wet strip of cloth and then steam cured, after which 
the ends are spliced together, as a rule, by a cold-cure process. This 
work is performed to a great extent by youthful men and women and 
involves considerable standing and walking to and fro, but the chief 
hazards are exposure to benzine and soapstone dust. Benzine stupor and 
fainting spells were common, especially among females and recent 
employes. The characteristic "rubber itch" also occurs among these 
workers. Copious ventilation, a room temperature not exceeding 68°, 
and the substitution of closed containers with a pressure-valve benzine 
emitter, in place of the open cups so commonly used, would greatly 
diminish the dangers from benzine fumes. 
6. Rubber Buffing.-The process of buffing rubber-tire casings is done 
by revolving them on a wheel and holding a coarse file against them. 
Other semi-hard rubber objects are buffed by means of emery wheels. 
The object in either case is to secure a rough surface for the cement, in 
order to apply additional coats. There is also exposure to dust during 
the grinding and polishing of hard-rubber goods. 
This work, apart from being fatiguing and very dusty and dirty (work- 
ers look like coal heavers), involves the risk of lead poisoning, which varies 
in degree with the amount of lead contained in the rubber dust. Benzine 
fumes were also present in most of the establishments covered by the Ohio 
Survey. 
7. Rubber Dipping.-In this process moulds of gloves, finger cots, etc., 
are dipped mechanically into vats containing a solution of rubber dis- 
solved in benzine. Upon raising the objects' from the vats, a thin coating 
of rubber adheres to the mould, and the dipping is repeated until the 
required thickness is secured. The process involves exposure to benzine 
fumes and great precautions are necessary to avoid fire and explosions. 
Benzine fumes, from the vats and dipping frames above, constituted a bad 
hazard in seven places and to a less degree in four establishments covered 
by the Ohio Survey. The benzine tanks should be covered when not in 
use, the floor should be latticed, with a strong exhaust system beneath to 
draw off the benzine fumes, and the entire system of exhaust ventilation 
should be set in motion during the dipping process. 
8. Rubber Mechanical Goods, Drug Sundries, Accessories, Etc.- 
This group includes the manufacture (assembling and finishing) of a 
great variety of soft- and hard-rubber goods, such as rubber bands, 
washers, children's toys and balloons, water bags, ice-caps, surgical appli- 
ances, drug sundries, finishing of rubber gloves, assembling of boots, 
waterproof garments, door mats, fire hose, large belts for power trans- 
mission, and other rubber fabrics. The Ohio Survey covered 22 estab- 
lishments with 2912 male and 1668 female employes. The chief health 
risks were benzine fumes and soapstone dust; occasionally also benzol, 
sulphur chloride, carbon bisulphide, ammonia, anilin dyes and wood 
alcohol. Benzine vapors are constantly evolved, but are especially VULCANIZING 
541 
pronounced when rubber solutions are used for waterproofing, in the 
joining of the seams, in cementing edges, laps and splices, and during the 
evaporation of naphtha from the finished product, which is done over 
steam tables. In but one plant were all employes satisfactorily pro- 
tected from these forms of industrial poisoning. As a matter of fact, 
10 cases of chronic benzine (and perhaps benzol) poisoning were seen in 
four plants, and quite a number of the employes, especially females, 
suffered from nausea, dizziness, faintness, headaches, loss of appetite, 
loss of weight, tiredness, "benzine jags," eczema, coughs and colds. 
Close confinement and crowding of workers are often observed. Some- 
times windows are not permitted to be opened for fear of air effects, 
but there is no consistency about this and the recommendations for the 
removal of dust and fumes already referred to are equally indicated in this 
branch of the rubber industry. 
9. Rubber Vulcanizing.-All rubber goods, in order to withstand the 
influence of changes in temperature, and to retain their elasticity, are 
vulcanized. This process is also spoken of in the trade as "curing." 
Steam Vulcanizing of Tire Casings.-In the comparatively harmless or 
steam process, the tire casings are placed in iron moulds and these are 
placed within steam cylinders and exposed to a temperature of 260°F. In 
some plants the tires are steam-cured when partly built and again when 
finished. There are no special poison risks, except the escape of fuel gas 
fumes in some plants, but soapstone dust and the exposure to high tem- 
perature and humidity are common observations. Water and steam also 
abound. Much heavy lifting and hurrying piece-work are features. 
Press Rooms.-In these rooms steam vulcanizing is done by means of 
steel presses, having hollow chambers to accommodate the various shaped 
moulds through which the steam passes. The rubber goods, such as 
water bags, drug sundries, etc., are placed within the vulcanizers for from 
15 to 30 minutes. Limited amounts of sulphur compounds, such as 
chloride of sulphur, sulphide of barium, calcium or antimony, are added 
to the rubber goods. 
The special hazards observed in the Ohio Survey were benzine, benzol 
and occasionally antimony fumes from the rubber. Exposure to exces- 
sive heat (120°F.) humidity, abrupt changes in temperature, and consider- 
able quantities of soapstone dust are mentioned as injurious factors. 
The generous use of asbestos coverings to the presses and more copious 
room ventilation are recommended. 
Vapor Vulcanizing.-In this process the rubber goods, such as rubber 
gloves, finger cots, etc., are exposed to the vapors of sulphur chloride, 
placed upon a tin in a warming cupboard. In some establishments, car- 
bon tetrachloride and perhaps carbon bisulphide are used. In addition 
to exposure to these industrial poisons, there may also be exposure to 
benzine, benzol and soapstone dust. The fumes should be withdrawn 
before opening or entering the cupboards. 542 
POISONINGS IN THE RUBBER INDUSTRY 
Cold Vulcanizing.-This process, also known in the trade as "cold 
cure" and "acid cure," is chiefly used for joining the ends of inner tubes 
for tires and also for curing pure rubber goods and is quite dangerous, 
especially when carbon bisulphide is employed. In this process the 
rubber goods are passed through a solution containing usually 1:1000 
parts of carbon bisulphide and from 2 to 10: 1000 of sulphur chloride and 
subsequently dried in cupboards at a temperature of about 104°F. 
Sometimes the solution is applied with a brush or sponge. During this 
process the employes are exposed not only to the fumes of carbon bisul- 
phide but in the dipping of the goods also to absorption of the poison by 
the skin. This poison inflicts special damage to the blood cells and 
general nervous system, and like benzine also causes a dry and harsh condi- 
tion of the skin of the hands by removal of the natural fat. (See carbon 
bisulphide, pages 360 and 648.) 
Laudenheimer6 has collected three cases of mental disturbances and 19 cases of 
diseases of the nervous system, in 219 persons, who had come into contact with 
carbon bisulphide, and his comparative statistics show that these affections are much 
more prevalent in the rubber industry than in the textile industries. 
The Leipsic Psychiatric Clinic7 reported 50 cases of nervous disorders caused by 
carbon bisulphide poisoning, of which nearly one-third developed insanity. 
The present tendency is to replace carbon bisulphide by the employ- 
ment of chloride of sulphur in benzine, which is at least a less dangerous 
agent. As a substitute for benzine, dichlorethane and carbon tetra- 
chloride have been urged. Acetone, turpentine and ether are also 
employed as solvents instead of CS2, benzine and benzene.8 
The Ohio Survey which covered the "cold cure" process in 15 establishments with 
about 200 so employed revealed exposure to benzine, benzol, wood alcohol, carbon 
bisulphide, carbon tetrachloride, and sulphur chloride, soapstone and sulphur dust. 
A number of cases of poisoning were diagnosed and quite a number of pale and ansemic 
persons of both sexes were seen. Inflammatory affections of the skin, cases of dys- 
pepsia and neurasthenia were frequent observations. 
Von Harmsen9 reports that of 220 German vulcanizers, 18.6 per cent, suffered from 
gastro-enteric catarrh, 11.8 per cent, from tonsillitis and catarrh of the pharynx, 
6.8 per cent, from anaemia and 0.9 per cent, from diseases of the nervous system. The 
statistics of the Sick Benefit Society of Leipsic show a very high morbidity rate in the 
rubber industry, viz., 1028 days per 100 workers per annum, and a mortality hazard 
of 0.90 per cent. The same statistics give the percentage of carbon disulphide poison- 
ing as 1.83, including a considerable number of abortions and premature births, which 
were attributed to mild forms of acute poisoning. 
10. Rubber Cement Manufacture.-In this process, the powdered 
rubber is dissolved by means of benzine, benzol, carbon, tetrachloride or 
carbon bisulphide, either singly or combined and sometimes other ingre- 
dients are added depending upon the purpose for which the cement is 
to be used, as in cementing rubber, leather, cloth, etc. The mixing is 
frequently done by hand labor in open containers, but in modern establish- 
ments the process is carried on mechanically and the poisonous solutions 
and fumes are confined within rotary mixers, and the rooms are supplied RECLAIMING-SUBSTITUTES DISABILITIES 
543 
with efficient exhaust ventilation. The filling of cans or compressible 
tubes with cement may be done openly or within a confining apparatus. 
The process involves comparatively few employes but an undue expo- 
sure to the industrial poisons mentioned when performed by hand. The 
degree of danger varies with the mechanical protective measures provided 
and the care exercised by the individual worker. There is also consider- 
able danger from fire and explosions, on account of the inflammable 
character of the vapors present; hence isolated, unheated out-buildings 
are often used. 
11. Rubber Reclaiming.-This is a special industry for the purpose of 
reclaiming rubber from waste products and old rubber goods. The pro- 
cess consists in grinding, milling, chemical treatments and drying, and the 
product is generally known as "rubber shoddy." In addition to the 
rubber solvents already mentioned, mineral acids and alkalis are used. 
Rambousek10 cites cases of anilin poisoning, where anilin was used for 
the extraction of rubber. The grinding operation involves exposure to 
dust of a mixed character, often containing dangerous amounts of lead. 
Some of the processes involve exposure to a very steamy atmosphere and 
wet sloppy work. During the grinding process, which is done between steel 
rollers, the material becomes heated and emits bluish and very irritating 
vapors, probably antimony. 
Dr. Crzellitzer, cited by Neisser,11 reports a case of retro-bulbar neuritis in a man 
engaged in grinding refuse and fragments of hard rubber. On the second day of his 
work the patient developed symptoms of headache, nausea, dizziness and inflammation 
of the eyes. Dr. Crzellitzer leaves the question open whether during the grinding 
process sufficient heat was developed to disengage carbon bisulphide, or whether we 
have to deal with other low ebullition compounds, as the cause of these symptoms. 
12. Rubber Substitutes.-Substitutes for rubber have been made by 
boiling a mixture of vegetable oils, sulphur, and resin, with chloride of 
sulphur, during which process sulphureted hydrogen is evolved and may 
be inhaled. 
Disability in the Rubber Industry.-Quinby,14 in a study of industrial 
absenteeism, gives statistics and comments covering an average of 6,700 
employes for 28 months' time (Jan. 1, 1919, to April 30, 1921) from which 
the following summary is taken: 
Aggregate of 245,442 days lost from work during the 28 months. 
Sickness 6.61 days lost per employe per year. 
Industrial accidents 0.45 days lost per employe per year. 
Non-industrial accidents 0.25 days lost per employe per year. 
Personal reasons 10.95 days lost per employe per year. 
He suggests that absolute, or irreducible, sickness disability should not exceed 2 
per cent, of the working time except in very unusual periods. He found that single 
employes lost much less time than married persons, and single males 40 per cent, less 
than single females. Sickness at home accounted for part of the excess on the part 
of married persons. Widowed and divorced females lost 154 per cent, more, and 
married females 184 per cent, more, than single males. 544 
POISONINGS IN THE RUBBER INDUSTRY 
The types of sickness for the year 1920 were as follows (days per year): 
General diseases (tuberculosis, rheumatism, influenza, diphtheria, 
scarlet fever, typhoid fever, etc.) 1.463 
Respiratory diseases (colds, bronchitis, pneumonia, pleurisy, etc.)... 1.264 
Digestive diseases 1.107 
Sickness of short duration 0.687 
Afflictions produced by external causes 0.409 
Ill-defined and unclassified 0.379 
Diseases of bones and organs of locomotion 0.317 
All others 0.684 
Total 6.310 
"It is interesting to note that females lost practically twice as much 
time on account of influenza, colds and tonsillitis as males, that the dis- 
ability from pulmonary tuberculosis, rheumatism and all types of 
accidents was nearly the same for both sexes, while from broncho and 
lobar pneumonia, males lost more than twice as much time as females." 
Respiratory diseases alone caused over 35 per cent, of the total disability 
from sickness and accidents combined. 
The Department of Health of the B. F. Goodrich Co., Akron, 0. 
recorded and classified cases of sickness and non-industrial injuries 
causing absence from work for one full day or longer (up to one year), 
during the three year period ending Oct. 31, 1920. These records were 
then tabulated by the Equitable Life Assurance Society and published 
in the U. S. Public Health Reports.15 
The average number of employes was 16,285. A separate record was also kept 
of deaths, the life of an employe being insured by the Company after 3 months service. 
It is pointed out that statistics for this period probably do not represent the sickness 
expectancy of the present or of the immediate future, because of war influences, 
acute labor shortage and the major influenza epidemics. In brief, it was found that 
nearly half of the percentages of deaths of 491 employes were caused by two diseases: 
pneumonia (26.3) and influenza-pneumonia (18.1), which with the inclusion of non- 
industrial accidents (7.7), tuberculosis (6.9), and pancarditis, or total heart affections 
(6.1), accounted for 65 per cent, of all deaths. However, only 19 per cent, of all the 
disability was caused by influenza, grippe and pneumonia. The influenza epidemics 
and other factors combined accounted for more and more time being lost per 100 
employed as each year passed, and interrupted more or less gradual a decline in the 
disability rate. The important causes of disability remained practically the same 
throughout the three years for both sexes and were, in descending order: influenza and 
grippe, tonsilitis, colds, non-industrial injuries, bronchitis, rheumatism, pulmonary 
tuberculosis, disease of the stomach, appendicitis, headache, pneumonia, (etc.). 
Duration of disability showed improvement as each year passed, while the occurrence 
of disability showed a striking drop as greater length of service obtained, from which 
the efficacy of industrial medical work was considered to be demonstrated statistically. 
The per cent, absent on account of disability during any one month ranged from as 
low as 1.7 in summer months to as high as 9.1 in winter months. However, by the 
end of 1920 the rate had apparently been stabilized below 2 per cent, in its descent 
from an absenteeism of 5 or 6 per cent, of the force in 1916, or the possible minimum 
suggested by Quinby. PREVENTIVE MEASURES REFERENCES 
545 
Preventive Measures.-W. N. Fitch12 sums up the model arrange- 
ments at the B. F. Goodrich Company, Akron, Ohio, for the general 
questions of sanitation, while C. F. Horan (Hood Rubber Co.), Wm. 
Jameson (Fisk Rubber Co.) and several others cover the poison hazards 
in their papers12 beginning with the first symposium of the Rubber 
Section of the National Safety Council. 
" Practical Plans for Medical Supervision in Rubber Plants" is an 
especially valuable paper by Dr. R. S. Quinby, Service Mgr. Hood Rubber 
Co., Watertown, Mass. (10th Ann. Proc., 1921, N. S. C., pp. 70-79).12 
"Opportunities for Handicapped Men in the Rubber Industry," 
by Morris and Paull, is a study in rehabitation and occupational therapy 
relations. 
In view of the far reaching and evil consequences of bisulphide of 
carbon, especially in the rubber industry, its use should be exceptional. 
Until this is accomplished, the curing vats should be low placed since the 
vapors are heavy, and local confining apparatus and copious downward 
exhaust ventilation for the removal of all toxic vapors should be provided. 
The practice of dipping with unprotected hands should be stopped. 
Special curing and drying chambers with exhaust ventilation should be 
provided and all vessels containing poisonous agents should be kept 
covered. Medical inspection and suitable work suits and facilities for 
bathing should be provided, and all dangerous processes should be limited 
to 21^-hour shifts, with alternation of work. 
REFERENCES 
1 Report Mass. State Board of Health Inspectors, 1910, page 93. 
2 Hayhurst, E. R.-Industrial Health Hazards and Occupational Diseases in Ohio, 
February, 1915. 
3 Carlson.-Bull, whole No. 179, U. S. Bur. Labor Stat., Oct., 1915, 59-60. 
4 Oliver.-Dangerous Trades, London, 1902, page 474. 
8 Rambousek.-Industrial Poisoning, London, 1913, page 63. 
6 Laudenheimer.-Die Schwefelkohlenstoff Ver gif tung, 1899. 
7 Koelsch.-Krankheit und Soziale Lage, Munchen, 1912, page 186. 
8 Rambousek.-Industrial Poisoning, London, 1913, page 69. 
9 Von Harmsen.-Vierteljrschft. f. Gerichtl. Med., Bd. XXX, 149, 1905. 
10 Rambousek.-Industrial Poisoning, London, 1913, page 69. 
11 Neisser.-Internal. Ubersicht uber Gewerbehygiene, Berlin, 1907. 
12 An excellent series of papers and discussions is to be found in the Annual Proceed- 
ings, Rubber Section, National Safety Council, beginning with the year 1920. 
In particular, occupational diseases and hygiene are discussed by C. F. Horan 
and Dr. Robert S. Quinby of the Hood Rubber Co., Watertown, Mass.; W. N. 
Fitch and B. Mitchella of the B. F. Goodrich Co., Akron Ohio; Wm. Jameson 
of the Fisk Rubber Co., Chicopee Falls, Mass.; and many others. 
13 Davis, Paul A.: Jr. Ind. Hyg., Ill, No. 2, June, 1921, page 57. 
14 Quinby, Rovert S.-Mo. Labor Rev., XIII, No. 4, Oct., 1921, pages 1-9; also, The 
Nation's Health, HI, No. 10, Oct. 15, 1921, pages 572-576. 
15 Public Health Report, Vol. XXXVII, No. 50, Dec. 15, 1922, pages 3083-3092. 
16 Bur. of Voc. Guid., Div. of Educ., Harvard Univ., Series II, No. 9, June 14, 1919. SECTION 21 
THE MANUFACTURE AND USE OF EXPLOSIVES 
GEORGE M. KOBER, M. D., Washington, D. C. 
Introduction.-Explosive compounds are used not only for the purpose 
of propelling projectiles from firearms, but also for the explosion of shells, 
torpedoes, mines and blasting operations of all kinds. The principal 
propelling agent employed up to 1845 was gunpowder, but since that time 
new compounds have sprung into existence, many of which are known as 
high explosives and fulminates. 
According to "Cundill's Dictionary of Explosives," cited by Prof. 
Munroe1 there were upward of 1000 explosives in 1895, which have 
materially increased in number since. The manufacture of explosives is 
by no means confined to times of war; the total output of explosives in the 
United States in 1905 was 363,748,097 pounds and in 1920, 505,710,000 
pounds. 
INDUSTRIAL POISONS USED IN THE MANUFACTURE OF EXPLOSIVES 
Dr. Alice Hamilton28 visited 40 munition plants in the U. S. located 
chiefly in the Eastern States, with a working force of about 90,000 men, 
of whom about 30,000 were exposed to industrial poisons. 
She studied the hazards in the manufacture of the following explo- 
sives, viz.: Nitrocellulose (pyroxilin or military gun-cotton); smokeless 
powder, including mixed nitroglycerine powders; picric acid and ammo- 
nium picrate; nitroglycerine and dynamite; fulminate of mercury; trini- 
trotoluene or TNT or triton; nitronaphthalenes; tetranitranilin or TNA 
and tetranitromethylanilin, or tetryl. 
The following industrial poisons were encountered in the manufacture 
of these explosives, viz., nitric acid, sulphuric acid, benzene, toluene, nitro- 
benzene, anilin, chlorbenzene and nitrochlorbenzene, phenol or carbolic 
acid, sulphuric ether, mercury and mercuric nitrate, methyl alcohol, and 
amyl-acetate. Apart from these poisons, certain toxic fumes are evolved 
as a result of chemical reactions during the intermediate stages in produc- 
tion, as for example, oxides of nitrogen or nitrous fumes in all processes of 
nitration, sulphur dioxide and chlorine gas in the manufacture of phenol 
and nitric acid, respectively, and ethyl nitrite in the manufacture of 
fulminate of mercury. 
Frequency of Industrial Poisoning.-Dr. Hamilton's report deals with 
2504 cases all of which were serious enough to come under the observation 
of a physician and varied in degree from rapidly fatal congestion of the 
546 NITROUS FUMES NITRO AND AMIDO COMPOUNDS 
547 
lungs from nitrous fumes to cases of " fulminate itch/' the latter caused 
from filling caps with fulminate of mercury paste. There were 50 fatal 
cases, 48 in men and 2 in women. 
Nitrous Fumes.-All of the high explosives, such as gun-cotton, picric 
acid, nitroglycerin, the nitrotoluenes, nitrobenzenes and nitronaphthalenes 
are produced by a process of nitration, during which, as also in the manu- 
facture of nitric acid employed in combination with sulphuric acid for 
nitration, the workers, unless special precautions have been taken, are 
exposed to nitrous fumes. (For symptoms of poisoning and other details 
see page 657.) In addition to the effects enumerated there, cases of 
broncho-pneumonia are not infrequent and Dr. W. G. Hudson of the E. I. 
Du Pont de Nemours Co. has shown, and Dr. Hamilton confirm s his 
observation, that nitrous fumes, not concentrated sufficiently to cause 
rapid edema of the lungs may cause a lobar pneumonia. These pneu- 
monias usually clear up unless there has been some chronic lung lesion. 
It is well known that persons already suffering from diseases of the 
respiratory organs are especially susceptible. 
The report shows that 1389 cases, of which 28 terminated fatally, were caused by 
exposure to nitrous fumes. This excessive morbidity and mortality record is attrib- 
uted to the fact that the chemical industry, of which the manufacture of explosives is 
an important branch, is still in its infancy in this country and many of the sanitary 
engineering problems had to be solved by men with little or no practical experience. 
Dr. Hamilton presents the details of many interesting cases and points out that the 
two explosives that are attended with the greatest amount of poisoning from nitrous 
fumes, are nitrocellulose and picric acid; many of the plants were hastily constructed, 
recklessly managed and dangerous because of the escape of fumes. 
Nitro and Amido Compounds of the Benzene Group.-Dr. Hamilton 
reports that the following members of this group are used in the 
manufacture of explosives, viz., nitrobenzenes, nitrotoluenes, nitronaph- 
thalenes, nitrophenols, nitrochlorbenzenes, tetranitranilin and tetranitro- 
methylanilin. All of these compounds act more or less upon the central 
nervous system and are also blood poisons in this that they convert the 
normal oxyhemoglobin or blood coloring matter, into methemoglobin in 
which the oxygen is so firmly bound that the normal exchange of gases 
essential to life is rendered impossible and internal asphyxia may result in 
spite of an abundant supply of air. Convulsions have been observed but 
are rare. According to Curschmann cited by Dr. Hamilton the toxicity 
of these compounds increases with the degree of nitration "except when 
as in the case with the nitrotoluenes, the lower nitrated products are 
more volatile than the higher." 
Dr. Hamilton reports 12 cases of benzene and toluene poisoning; 7 cases of poison- 
ing from trinitrophenol; 701 cases of poisoning from trinitrotoluene and 205 cases of 
anilin poisoning; of the latter nine were of a serious nature. The report mentions two 
cases of nitronaphthalene poisoning, evidently of a very mild type and with the excep- 
tion of trade eczemas, Dr. Hamilton observed no serious effects from nitrochlorbenzene, 
diphenylanilin, tetranitromethylanilin (also known as tetryl) and tetranitranilin. 548 
THE MANUFACTURE AND USE OF EXPLOSIVES 
None of these however were manufactured on a large scale in this country. The 
British Committee on the Health of Munition Workers reports that tetryl produces 
a light dust which may produce troublesome eczema, headache, drowsiness and 
lack of appetite. Other industrial poisons will be noted in subsequent pages. 
Gunpowder.-The ingredients in gunpowder are 75 to 76 parts of saltpeter, 14 to 
15 of charcoal and 10 of sulphur. Slightly different proportions are used in various 
countries. Gunpowder explodes at a temperature of about 700°F. The force of 
the explosion resulting from the production of gases expanded by the intense heat 
developed by the chemical action of the combustible ingredients with the niter, varies 
with the conditions under which it is fired, the density of the gunpowder and the 
shape and size of the individual grains. 
The force of an explosion from gunpowder may become intelligible when we realize 
that according to some authorities there are a million foot-tons of energy per second 
for-each ton of powder. Black blasting powder in this country contains about 73 
parts of sodium nitrate, 16 parts of charcoal and 11 parts of sulphur. According to 
Munroe1 no marked changes have been made in the manufacture of or composition of 
gunpowder or blasting powder, but the latter has new competitors in the composition 
made by mixing finely divided metals, such as aluminum or alloys, such as ferrosilicon, 
with potassium or sodium nitrate or other oxidizing agents. 
The Ohio Survey2 investigated seven establishments for the 
manufacture of explosives in Ohio and the following is a brief summary of 
his findings. The actual number of persons employed was 303 wage 
earners of whom 51 were females. The general appearance of workers 
was fair to good in four places, but a considerable number of unhealthy 
men were found in some of the processes in two places. 
In the grinding rooms some of the men complained that the nitrate 
caused headaches and dizzy feelings at times, hence the machines should 
be properly enclosed. The pulverizing of charcoal was exceedingly 
dusty and complaints of bronchitis were made. The grinding of cakes of 
finished powder is usually done in isolated places, the workmen being 
provided with small sheds to avoid danger from explosion while the 
grinding is going on. 
In the incorporating mills the work is extremely dirty and care must be 
taken to see that the charge does not work out from under the grinding 
wheels, otherwise the wheel may cause contact with the base and form a 
spark. Since explosions are especially liable to occur in this process, 
water is thrown on constantly to keep the charge cool. The work in the 
press rooms where the pulverized charge is pressed into flat cakes by hand 
or machine presses is attended with the production of considerable 
amounts of dust. The same is true of the operations of the corning mills, 
which reduce the powder to the proper-sized grains. The glazing of the 
grains of powder with lead sulphide and graphite appears to be free from 
risk of lead poisoning, although some of the workmen had bad teeth. 
The separating, weighing and packing operations appeared to be free 
from hazards. 
Fulminating powder is used for charging percussion caps and parlor rifle shells, 
detonators and electric detonators. It is composed of about 35 parts of fulminate of 
mercury, 16 of chlorate of potassa, 45 of glass dust, 2 of gum arabic and 2 of gum traga- FULMINATE OF MERCURY GUN-COTTON 
549 
canth, the last three components being omitted in the charges of detonators. 
These are mixed by using the fulminate in a moist state. It explodes readily by per- 
cussion and by friction or by a heat of 367°F. The manufacture of fulminate of 
mercury which is made by dissolving mercury in nitric acid and adding alcohol, is 
attended with the evolution of injurious fumes containing, according to Rambousek,3 
ethyl acetate, acetic acid, ethyl nitrate, nitrous acid, and volatile hydrocyanic acid 
compounds. 
Apart from the inflammability of these vapors which have been the 
cause of fires and accidents, "their inhalation is liable to cause headache, 
vertigo, loss of consciousness, numbness of the extremities and a sense of 
constriction of the chest which may be accompanied by cyanosis" 
(Oliver).4 
In the manufacture of percussion caps, there is also danger of mercur- 
ial poisoning; about 40 per cent, of the females employed in a Nuremburg 
factory are reported to have suffered from mercurial poisoning, due 
according to Heinzerling to the inhalation of mercury fumes developed by 
tiny explosions in the pressing and filling. Neisser5 also reports cases 
'which occurred in a factory at Marseilles in 1907. 
Dr. Alice ^Hamilton reports 111 cases of fulminate of mercury poison- 
ing in 79 men and 32 women engaged in filling percussion caps in American 
munition plants. The majority were cases of dermatitis, known in the 
trade as "fulminate itch." 
Preventive Measures.-It is needless to insist that in the manufacture 
of fulminate of mercury , the dangerous gases like nitrous fumes, cyanogen, 
acetic acid compounds and mercurial fumes are promptly removed by 
efficient exhaust ventilation. The persons employed should be skilled 
and realize the danger both as to explosion and as to poisoning. 
Gun-cotton.-Ever since its discovery by Schonbein in 1846 attempts have been 
made to use it as a substitute for gunpowder, because its projectile force, when used in 
moderate charges is equal to about twice its weight of the best gunpowder. Its explo- 
sive force is also very much more intense than that of gunpowder and in this respect 
its nature is similar to the fulminates. Gun-cotton explodes at a temperature of 
about 277°F. and evolves little or no smoke as the principal residue of its combustion 
is water and nitrous acid. It is made by immersion of cotton or other form of cellu-' 
lose in strong nitric and sulphuric acids in so-called nitrating vessels. The danger 
from explosion was very great, when drying stoves were employed, but this has 
been overcome by using alcohol in dehydration. Gun-cotton is used in the manu- 
facture of smokeless powder and also as a charge for torpedoes and submarine 
mines. 
Collodion cotton or pyroxyline is prepared in a similar way as gun-cotton, except 
that the acids are weaker, and the product is a partially nitrated cellulose. When 
dissolved in alcohol-ether it is known as collodion, which is extensively used in surgery, 
photography and in the manufacture of celluloid, artificial silk, gas mantles, moving- 
picture films and other pyroxylin plastics. 
In the manufacture of gun-cotton and collodion cotton the chief dan- 
ger to the workmen are the fumes of nitric acid and nitrous fumes, but 550 
THE MANUFACTURE AND USE OF EXPLOSIVES 
with good air-tight machines these risks, and subsequent erosions of the 
incisor teeth have been greatly diminished. There is also danger from 
explosions in the drying process as evidenced by the accidents reported 
by Marshall.6 
In the manufacture of collodion, celluloid and artificial silk the work- 
men may also be exposed to ether, alcohol, acetone ether and camphor, 
but Rambousek found no cases of such poisoning in the literature of the 
subject. 
Preventive Measures.-In the preparation of gun-cotton and pyroxy- 
line, it is important that the acid fumes from the nitrating and centrifu- 
galizing machines are carried off by earthenware ducts and fans, and 
that the bulk of the acid is removed by centrifugal action. Cleanliness 
and efficient exhaust ventilation should be insisted upon in all the 
processes. 
Smokeless Powder.-This explosive is derived from gun-cotton or other forms of 
nitrocellulose and is gelatinized by the addition of alcohol-ether, or acetone, cam- 
phor, resin, etc. In the U. S. the solvent employed is alcohol ether except for rifle 
powder when amyl acetate is used, for the mixed "n.g." powders, when acetone is 
employed.* In order to make the powder more stable or to improve its physical 
properties it is mixed with such substances as diphenylamin, anilin and calcium 
carbonate. The resulting paste or dough is then rolled, washed, dried and pressed 
into rods. According to Marshall, "the press most commonly used is an adaptation 
of the machine employed for making macaroni. The resulting product is in the form 
of cords, strips or tubes, which can be cut into flakes of any desired thickness." It is 
of interest to note that the first successful smokeless powder was made in 1865 by 
Captain Schultze of the Prussian Artillery from nitrated wood, instead of nitro-cotton. 
Among the numerous kinds of smokeless powder should be mentioned the follow- 
ing: Nobel's nitroleum (artillery powder) which consists of one-half of nitroglycerine 
and one-half of collodion cotton. "Poudre B" named after General Boulanger and 
used in the French Army. The "Russian," "Spanish" and "American" powder. In 
this country according to Schiipphaus cited by Marshall7 a pyro-collodion powder has 
been adopted for all kinds of guns. The composition varies but averages 80 per cent, 
of gun-cotton, between 10 to 19.5 per cent, of soluble nitrocellulose, 0.5 to 1 per cent, of 
urea; some powders also contain 9 per cent, of nitroglycerine. Other varieties of 
smokeless powder are ballistite, a mixture of 40 to 50 per cent, of collodion cotton, and 
50 to 60 per cent, of nitroglycerine, invented by Nobel in 1887. 
Filite is the Italian name for ballistite because it is drawn out into cords instead of 
flakes. It consists of equal parts of nitroglycerine and collodion cotton with 0.5 to 
1 per cent, of anilin. Tonite is a mixture of gun-cotton and nitrate of barium in 
almost equal proportions. Solenite, also used as a military powder in Italy, is com- 
posed of 33 per cent, of nitroglycerine, 1 to 3 per cent, of light colored mineral jelly 
and the rest of nitrocellulose. The mixture is gelatinized with acetone and the dough 
is pressed into a tubular form and cut into short lengths. The grains are translucent 
and resemble light brown glass beads. 
* Dr. Alice Hamilton reports 52 cases of sulphuric ether poisoning with one death, in 
the manufacture of smokeless powder during a period of 9 months in the U. S. The alcohol 
used in connection with ether was in no case wood alcohol. The cases varied in degree 
from slight intoxications to profound unconsciousness lasting 24 hours; some of the workers 
acquire immunity, others do not. The report contains the histories of several cases of 
acute and chronic ether poisoning, one of whom died from chronic organic lesions. Evi- 
dence is cited to show that long continued absorption of ether fumes may inflict definite 
damage upon internal organs. SMOKELESS POWDER-NITROGLYCERINE 
551 
The Germans employ a variety of smokeless powder. The " Wiirfelpulver " 
is similar in composition to the Italian Filite, but is made up in the form of cubes 
instead of tubes. Cordite is essentially a British invention and is now considered one 
of the most successful smokeless powders. The composition of the modified form is 
gun cotton 65 per cent.; nitroglycerine 30 per cent, and vaseline 5 per cent. Marshall 
credits Col. Sir F. L. Nathan of the British Army with marked improvements in the 
manufacture of cordite as regards safety of the workmen, stability of the explosive and 
reduced cost of the product. 
Professor Munroe reports that a notable change in practice in the manufacture of 
smokeless powder in the United States has been the abandonment of the nitroglycerine 
-nitrocellulose powder by the Army, and the adoption of a straight nitrocellulose 
powder of definite nitrogen contents as used in the Navy. The tendency in military 
powder is to approach more closely the principle set forth by Munroe many years ago 
as governing the ideal smokeless powder, viz., that "it should be composed of a single 
chemical substance in a state of chemical purity." 
The smokeless shot gunpowders are manufactured in great variety, in different 
countries and are broadly divided into the "condensed" and "bulk types." In 
the former the gun cotton is completely gelatinized and the process of manufacture 
is similar to that of rifle powder, except that the paste is formed into small grains 
or thin flakes. 
In the production of bulk powder other ingredients such as paraffine wax, starch, 
lamp black, wood meal, various gums, potassium ferricyanide, nitrates of barium and 
potassium, bichromates of potassium and ammonia and the mono and dinitro deriva- 
tives of benzene and toluene are used in some of the powders. 
(For a very complete account of the production of smokeless shot gunpowder by 
Professor Munroe, see U. S. Census Bulletin No. 92, 1908, page 84, and Marshall's 
book on Explosives.) 
Nitroglycerine was discovered by Sobrero in 1847 and is made by the action of a 
mixture of nitric and sulphuric acids on anhydrous glycerine. 
Professor Munroe8 states that "by the use of artificial refrigeration the yield 
of nitroglycerine from a given mass of acid is increased, the speed of nitration is 
likewise increased, the danger attending nitration is decreased and the use of a second 
separator is rendered unnecessary." The first attempts to use nitroglycerine in a 
liquid form for blasting purposes proved so disastrous that a number of countries 
prohibited its use. Alfred Nobel in 1866 discovered that when mixed with "Kiesel- 
guhr" (an infusorial earth) previously heated to redness, it could be rendered less 
sensitive and more safely handled and transported. This product is now known as 
dynamite. Nobel further discovered in 1875 that by the substitution of gun-cotton 
for Kieselguhr in the proportion of 7 or 8 per cent, of the gun-cotton to 92 or 93 per 
cent, of nitroglycerine, the latter was converted into a gelatinous solid, which he called 
"blasting gelatine." This blasting gelatine forms the basis of numerous valuable 
high explosives. Other explosives referred to by A. Cooper Key9 are Gelatine dyna- 
mite, which is composed of nitroglycerine thickened by the addition of gun-cotton and 
combined with wood meal, charcoal or certain other non-explosive ingredients. 
" Gelignite a very widely used high explosive is practically gelatine dynamite with the 
addition of saltpeter. Carbonite is composed of about 27 per cent, of nitroglycerine 
absorbed in a dope of woodmeal and nitrate of potassium or barium." In America, 
according to Marshall, the formulae vary considerably, and ammonia dynamites are 
made in which a large proportion of the nitroglycerine is replaced by ammonium 
nitrate. 
Nitroglycerine can be readily detonated by friction or fulminate percussion caps. 
It is known to be a strong poison which may be inhaled and can also be absorbed by 
the skin and from the alimentary canal. (For effects, see List of Industrial Poisons, 
page 656.) 552 
THE MANUFACTURE AND USE OF EXPLOSIVES 
Key9 states that "no one can enter a cordite drying room without 
experiencing a peculiar sensation at the heart and at the back of the head, 
which in the absence of fresh air soon develops into a headache which 
reduces to insignificance all the other ills of life." -So far as he could 
gather no permanent harm resulted from this cause, and on most people 
the fumes appear to lose their effect after a few days, in others it takes 
weeks before they become inured and in still others a return to the work 
after a few days absence causes the original symptoms. Rambousek10 
cites Robert's case, where the rubbing of a single drop of nitroglycerine 
into the skin caused symptoms lasting 10 hours. 
While Oliver11 states that women who mix Kieselguhr and nitrogly- 
cerine do not suffer, Rambousek12 reports that workmen engaged in washing 
out nitroglycerine from Kieselguhr earth, having, in doing so, their bare 
arms immersed in the liquid, suffered. Other injurious effects especially 
noted in the mixing and sifting of dynamite are obstinate ulcers under the 
nails and finger tips and eruptions on interdigital spaces and the plantar 
aspect of the feet. There is also considerable danger from nitrous fumes 
unless the nitration is carried on in a closed apparatus. Accidents from 
this cause are still possible in the acid separating house, wash house and 
in the denitration room of waste acids. Rambousek reports a fatal 
case in a workman who tried to wash away with water the acid which had 
overflowed and inhaled so much nitrous fumes that he died 16 hours later. 
Among other fatal instances he mentions the case of an employe in a 
dynamite factory who perished in cleaning out a storage tank for waste 
acid, in spite of previous swilling and ventilation. Dr. Alice Hamilton 
in her study of American munition plants reports that apart from the 
risks of nitrous fumes from spilling or leaking nitric acid and the use 
of toxic compounds, such as nitrotoluene or nitro naphthalene in the "dope " 
the only occupational illness to be expected in the manufacture of nitro- 
glycerine is the severe throbbing headache. 
Dr. C. E. Laws12 gives a very vivid description of the "nitroglycerine 
head" from which the men employed in dynamite and gelatine factories, 
miners and excavators so frequently and severely suffer. He states that a 
man working in powder may cause another person a great deal of misery 
by simply shaking hands or permitting articles which he has been using 
to be handled by the other. A worker frequently carries some of the drug 
in his clothing to his home and may make his whole family sick. Sleeping 
in the same bed or wearing contaminated clothing will produce effects. 
(Apart from the symptoms described, see List of Industrial Poisons, page 
656.) Laws states that powder men become easily intoxicated with a 
tendency to develop acute maniacal attacks and that all who work in it 
are sooner or later troubled with dyspnoea and tachycardia on exertion; 
he also states that the drug has a marked aphrodisiac effect and that most 
glycerine men have large families. NITROGLYCERINE, ROBURITE, ETC. PICRIC ACID 
553 
Dr. Evans13 reports a case of nitroglycerine poisoning in a farmer. The symptoms 
developed after 1 week of work of blasting stumps with a giant powder of the nitro- 
glycerine variety. Dr. Evans found that the man wore cotton gloves which aided by 
perspiration had become saturated with the powder and evidently caused the symp- 
toms by absorption. 
Dr. Geo. E. Ebright14 in studying the effects of nitroglycerine in those 
engaged in its manufacture with the Dupont Powder Co. ,at Hercules, 
California, found only occasionally persons immune to the effects of nitro- 
glycerine, and that there is a special susceptibility in warm weather. In 
order to maintain their immunity workers are in the habit of placing some 
of the products under the hatband, during periods of absence from the 
factory. The general health appeared to be in no way impaired, but this 
he attributes largely to the picked character of the men. He also refers 
to the cordite habit which developed in the British Army during the Boer 
War. The narcotic effects were accidently discovered. The habitue 
is able to take the contents of a cartridge, his face flushes, his head throbs 
and seems to swell and then in about 15 minutes comes a long sleep. On 
awakening he suffers from intense headache and thirst. When mixed 
with beer or hot tea it causes a wild delirious intoxication and this is 
followed by sleep. 
Roburite, Ammonite, Securite, Etc. - Reference has been made on page 513 to 
dinitrobenzol, which is the combustible ingredient not only of the explosives named, 
but also of other high explosives, chiefly in combination with ammonium nitrate. 
There are a large number of explosives which contain more or less of dinitro- 
compounds mixed with a chlorinated hydrocarbon. While dinitrobenzol was formerly 
most commonly employed, trinitrotoluene is now most extensively used, alone or 
combined with nitrate of ammonium, potassium or barium as oxidizing agents. 
According to Rambousek ammonite is a mixture of nitro-naphthalene and ammon- 
ium nitrate; securite is the same as roburite with the addition also of ammonium 
oxalate. 
A number of cases of poisoning in the manufacture of roburite are cited 
by Rambousek1'5 and also the fact that in the Witten factory almost all the 
workers between 1890-7 suffered from pallor, blue lips and yellowish con- 
junctivae. The morbidity has, however, been materially decreased by 
efficient preventive measures. Cases of poisoning have also been reported 
in the nitrotoluene department of explosive plants due to nitrous fumes 
and mono-nitrotoluene. 
The process of grinding, melting, cooling, mixing and fitting in air- 
tight cartridges is generally well safeguarded; the chief danger is from 
dinitrobenzol and toluene. (For symptoms and effects, see List of Indus- 
trial Poisons, page 656.) 
Explosions are liable to occur in benzol plants as shown by the acci- 
dent reported in Birmingham, Alabama, October 1, 1915. 
Picric acid, formerly used in the manufacture of melinite and lydite, is 
being replaced to a considerable extent with trinitrotoluene. Cases of 
poisoning from picric acid are rare (see trinitrophenol, page 509). Cases of 554 
THE MANUFACTURE AND USE OF EXPLOSIVES 
poisoning from trinitrotoluene are quite common (see page 510). (For 
TNT as a blasting explosive: see Circular No. 94, U. S. Dept, of Agri- 
culture, by Charles E. Munroe, Chief Explosive Chemist, and P. 
Howell Spencer, Explosive Engineer, U. S. Bureau of Mines, May, 1920.) 
Safety Explosives.-There is no such a thing as a safety explosive. 
The term should be limited, first to those explosives which are compara- 
tively insensitive to blows and friction, such as ammonium nitrate explo- 
sives containing no nitroglycerine and hence are safe in handling, and 
second to those explosives that have been officially tested and found to be 
comparatively safe for explosion in the presence of fire damp and coal 
dust. In numerous countries so-called permissible explosives are listed 
and explosives which do not come up to the required standard cannot be 
used in coal mines.* 
The Choice of a High Explosive.-Marshall16 in discussing this subject states that 
for blasting very hard rock, such as gold quartz, blasting gelatine gives the best results, 
provided it be fired with a very powerful detonator or primer of non-gelatinized 
nitroglycerine explosive, such as American straight dynamite or lignin. 
For soft-rock blasting, gelignite is most commonly used in Great Britain; ammon- 
ium nitrate and chlorate explosives are also employed. For coal mining operations 
Robbinite is most popular. For agricultural purposes, such as breaking up hard sub- 
soil, removal of tree stumps, digging ditches, etc., if the charge can be tamped well, 
blasting powder will answer. If not, a detonating explosive should be used. For 
blasting rock under water a brisant explosive is required and the cartridge should be 
thoroughly water-proofed, unless the explosive contains a considerable percentage of 
gelatinized nitroglycerine. 
For military blasting operations, gun-cotton compressed in powerful hydraulic 
presses, also picric acid powder, trinitrotoluene, and other nitroderivative explosive 
compounds are most commonly employed. Smokeless powder and the ordinary 
commercial explosives are also used by military engineers. 
For submarine mines and torpedo war heads the requirements are much the same 
as for military blasting explosives. Nobel is said to have used mines of nitroglycerine 
to protect the mouth of the Neva during the Crimean War. Picric acid has been used, 
but this has been to a great extent replaced by trinitrotoluene. During the American 
Civil War torpedoes containing about 60 lb. of gunpowder were employed in the 
defense of rivers and harbors. On June 4, 1864, according to the Surgical History of the 
War, two large torpedoes were accidentally exploded near New Berne, killing 36 
soldiers and 8 negroes and seriously wounding 29 men. 
Fougasses are small subterraneous mines constructed in front of the weak parts of 
a fortification. During the American Civil War they were also placed along the roads 
leading to important points. They are as a rule simply large shells arranged with 
levers connected with a percussion cap and sunk below the surface of the ground in 
the supposed path of the assailing party. A pressure of the foot upon the concealed 
lever is sufficient to explode the shell. In modern times they are exploded by means 
of electrical current. 
For shells, which are hollow iron or steel projectiles adapted for enclosing a quan- 
tity of gunpowder or other explosive compounds and designed to be torn asunder 
upon the explosion of this material, the ordinary black powder was used almost exclu- 
* For classification and lists of permissible explosives see Production of Explosives in 
the United States during 1920 by William W. Adams. Bureau of Mines Technical Paper 
291, pages 28 to 42. Govt. Printing Office, Wash., 1921. SCHRAPNEL, ETC. PROJECTILES WAR GASES 
555 
sively for a long time. After the discovery of gun-cotton, picric acid and other high 
■explosives they were given a trial, and at the present time trinitrotoluene compounds 
are most commonly used. 
A shrapnel is a shell filled with musket balls consolidated into a mass by a composi- 
tion of sulphur, or the balls are imbedded in melted trinitrotoluene. The shells are 
exploded by a charge of powder fitted into their interior which may be ignited either 
by a time or percussion fuse. 
Armor piercing shells are expected to pass through the armor and explode when they 
are on the other side. Many of the mechanical difficulties for the attainment of this 
•object have been overcome. Black powder is still extensively used to fill these shells, 
-as the nitro-aromatic explosives generally detonate on the face of the armor plate. 
Ammonium nitrate explosives like ammonal also satisfy the requirements, except 
that they are very deliquescent, which renders their storage for long periods difficult. 
Hand grenades are small iron shells from 2 to 3 in. in diameter filled with powder 
and discharged by percussion. They were first introduced in the seventeenth century, 
lost for a time their importance but were used not only in our Civil War, but were 
also extensively employed in the recent European War in sieges and assaults at 
•close quarters. Their effects are similar to ordinary shells. At present the explosives 
most used are picric acid, trinitrotoluene, compressed gun-cotton, tonite and smoke- 
less powder. The bombs thrown from flying machines during the European War 
were doubtless of a similar nature. 
Liquid and Gaseous Projectiles.-In the first edition of this book on 
page 562 reference to this subject was made as follows: "During the 
world's war some projectiles of a liquid and gaseous nature appear to have 
been revived and possibly new ones invented. Among those may be the 
'carcass,' which is a spherical shell having three additional holes of the 
■same dimensions as the fuse hole, and filled with a composition which 
burns with intense power from 8 to 10 minutes and the flames issuing 
from the holes set fire to everything combustible within reach. It was 
chiefly used for incendiary purposes and to light up positions at night. The 
so-called 'Greek Fire,' composed of a mixture of coal tar, naphtha, turpen- 
tine or coal-oil mixed with phosphorus, according to the Surgical Historian 
of the Civil War was employed at the siege of Charleston in 1863, but its 
obvious barbarity led to its speedy discontinuance. The employment of 
the suffocating gases like chlorine and bromine has been reported in the 
present war. Among the liquid projectiles may be mentioned the water 
shell invented by Prof. Abel of Woolwich. The missile consists of ordi- 
nary shells filled with water and fixed with compressed gun-cotton and a 
detonator of fulminate of mercury." 
CHEMICAL WARFARE GASES 
Fries and West26 in a recent and most interesting book on Chemical 
Warfare present the history of poison gases and point out that the first 
recorded effort to overcome an enemy by the generation of poisonous and 
suffocating gases seems to have been in the wars of the Athenians and 
Spartans (404-431 B. C.) when besieging the cities of Platea and Belium, 
the Spartans saturated wood with pitch and sulphur and burned it under 556 
THE MANUFACTURE AND USE OF EXPLOSIVES 
the walls of these cities in the hope of choking the defenders and rendering 
the assault less difficult. Similar uses of poisonous gases are recorded 
during the Middle Ages. . . . The authors state that Admiral Lord Dun- 
donald of the English Navy, based upon his observations when viewing 
the sulphur kilns at Sicily in Italy, 1811, and impressed with the deadly 
character of the fumes, recommended the application of these facts to 
military and naval warfare. In 1855 he strongly urged the employment 
of sulphur fumes for the expulsion of the Russians from Sebastopol 
during the Crimean War, but his recommendation was not adopted by 
the Government. 
One of the early, if not the earliest suggestion as to the use of poison 
gas in shell is found in an article on "Greek Fire" by B. W. Richardson.27 
The authors state on page 8, "That the probable use of poisonous gas 
has often been in the minds of military men during recent times as evi- 
denced by the fact that at the Hague conference in 1899 several of the 
more prominent nations in Europe and Asia pledged themselves not to 
use projectiles whose only object was to give out suffocating or poisonous 
gases ... At the Hague Congress of 1907, article 23 of the rules adopted 
for war on land states: 1 It is expressly forbidden (a) to employ poisons 
or poisonous weapons.' Before the war suffocating cartridges were shot 
from the cartridge-throwing rifle of 26 mm. These cartridges were 
charged with ethyl bromoacetate, a slightly suffocating and non-toxic 
lachrymator (tear producer) . . . The employment of these devices 
not entailing death, did not contravene the Hague conventions. The 
only memorable operations in the course of which these devices were 
used before the War was the attack on the Bonnet gang at Choisy-le-roi 
"The use of toxic gas in the World War dates from April 22nd, 1915, 
when the Germans launched the first cylinder attack employing chlorine, 
a common and well known gas . . . (For symptoms of poisoning see page 
650.) The use of chlorine continued until the introduction on December 
19, 1915 of a mixture of phosgene with chlorine. In May, 1915, the Allies 
decided to adopt gas warfare and the British made their first gas attack on 
September 25th, 1915 . . . Almost simultaneously with the introduction 
of the gas wave attacks, in which liquified gas under pressure was 
liberated from cylinders came the use of lachrymatory or tear gases. 
These, while not very poisonous in the concentrations used, were very 
effective in incapacitating men through the effects produced upon their 
eyes. The low concentration required (one part in ten million of some 
lachrymators is sufficient to render vision impossible without a mask) 
makes this form of gas warfare very economical and effective. . . The 
first lachrymators used was a mixture of the chlorides and bromides of 
toluene . . . Xylyl bromide is also effective. Chloroacetone and 
bromoacetone are also well known lachrymators . . . The French used 
a mixture of 20 per cent, of the former and 80 per cent, of the latter; WAR GASES 
557 
they also developed bromobenzyl cyanide, which the authors consider 
the best lachrymator, while chloracetophenone would have played an 
important part had the war continued. Chloropicrin or 'Vomiting gas' 
is moderately toxic and somewhat lachrymatory; it was mainly used 
because of its peculiar property of causing vomiting and the difficulty of 
preparing a charcoal for the gas masks, which would absorb it." 
In the summer of 1917 the Germans introduced diphenylchloroarsine 
or "sneezing gas." The firing regulations prescribed its use with 
phosgene or other lethal shell. They also introduced dichloroethyl 
sulphide better known as "mustard gas" or "blistering gas" because of 
its peculiar effect on the skin. This gas is produced by the reaction 
between ethylene chlorhydrin and sodium sulphide, and subsequent treat- 
ment with hydrochloric acid. In addition to its local action upon the 
skin, mucous membranes and respiratory organs, there are also systemic 
effects due to the absorption of the substance into the blood stream, and its 
distribution to the various tissues of the body. Fries and West regard 
it as "probably the most important single poisonous substance used in 
gas warfare. "... Since then various arsenic derivatives were prepared 
in the laboratory and tested on a small scale. The Germans did actually 
introduce ethyldichloroarsine and the Americans were considering methyl- 
dichloroarsine. Attempts were made to improve upon mustard gas 
but they were not successful. It is rather a peculiar fact that so few new 
chemical compounds were used as war gases. Practically all the sub- 
stances were well known to the organic chemist long before the World War. 
One of the most interesting and valuable compounds which would have 
found extensive use had the war continued, is an arsenic compound called 
Lewisite from its discoverer, Capt. W. Lee Lewis of Northwestern 
University. 
With the exception of chlorine, phosgene and chloropicrin, which were 
discharged from heavy gas cylinders in so-called gas cloud attacks, the 
majority of gases were projected by means of artillery shell, trench mortar 
bombs, hand grenades and special projectors. 
Chapter XII-XV26 deal with the development of the gas mask, absor- 
bents and other defensive measures; Chapters XVI-XX deal with 
screening smokes, smoke filters, signal smokes and incendiary materials. 
Chapter XXI is of special importance to physicians as it deals with the 
pharmacology of war gases. Chapters XXII-XXIII are devoted to a 
consideration of war gases in relation to strategy and tactics, and consti- 
tute a strong plea for the retention of Chemical Warfare. On page 370 we 
read "The inhumanity of it is absolutely disproven by the results of its use 
in the World War." The death rate from gas alone was less than X2 that 
from bullets, high explosives and other methods of warfare. The dis- 
ability rate for gas patients discharged was only about that for the 
wounded discharged for other causes. The permanently injured is likewise 
apparently very much less than from other causes. No reliable statistics 558 
THE MANUFACTURE AND USE OF EXPLOSIVES 
that we can get show that gas in any way causes tuberculosis any more 
than a severe attack of bronchitis or pneumonia,26 etc. . . . 
On page 388 the authors26 state "The official list of casualties in battle 
as compiled by the Surgeon General's Office (U. S. Army) covering all 
cases reported up to September 1st, 1919, is 258,338. Of these 70,752 or 
27.4 per cent, were gas casualties. Also of the above casualties 46,519' 
resulted in death, of whom about 1400 only were due to gas. From these 
figures it is readily deducted that while 24.85 per cent, of all casualties 
from bullets and high explosives resulted in death, only 2 per cent, of 
those wounded by gas resulted in death, which means that a man 
wounded on the battle field with gas had twelve times as many chances 
of recovery as the man who was wounded with bullets and high explo- 
sives". . . Chapter XXIV deals with defense against gas, and Chapter 
XXV with peace time uses of gas. In this chapter the authors point 
out, that "chlorine is a valuable disinfectant and water purifier, the 
greatest bleaching material in the world, and has innumerable other uses 
in the laboratory. Chloropicrin, cyanogen chloride and cyanogen 
bromide are found to be very well adapted to the killing of weevil and 
other similar insect destroyers of grain. 
Hydrocyanic acid gas is the greatest destroyer today of insect pests 
that otherwise would ruin the beautiful orange and lemon groves of Cali- 
fornia and the South. Phosgene is finding an ever increasing use in the 
making of brilliant dyes, pinks, greens, blues and violets. On account of 
its cheapness and simplicity of manufacture, it has great possibilities in 
the destruction of rodents, such as rats around wharves, warehouses, etc. 
On account of the corrosive effects of phosgene on steel, iron, copper and 
brass it cannot be used in places where those metals are present. . . 
Cyanogen bromide has been developed for similar purposes, and is also 
used as a much safer method than hydrocyanic acid for the fumigation of 
rooms and buildings. The authors believe that the future will see the 
employment of hand grenades filled with chloroacetophenone (tear gas) 
by the police force, sheriffs, in penal institutions and in the suppression of 
riots. The same is believed to be true of diphenylaminechlorarsine. 
Both are considered harmless as far as any permanent injury is concerned, 
but are sufficiently irritating to the eyes, nose, throat and lungs to disable 
the offenders. The employment of some of these gases has also been 
suggested for the protection of bank vaults, safes and strong rooms. 
Hydrocyanic acid has been suggested for trapping wild animals, because 
it acts quickly and would prevent much suffering. 
Reference is also made to the preparation of artificial silk by the use 
of tetrachlorethane. (See page 276 of this volume.) Chapter XXVI dis- 
cusses the future of chemical warfare.26 
Manufacture of Small Arm Ammunition.-Key's table,17 indicates 
that of the 175 accidents which occurred in the decade from 1890-99 
in Great Britain in the explosive industry, 39 occurred in the manufacture AMMUNITION FUSES FIREWORKS 
559 
of ammunition, with 5 deaths and 43 injured. Apart from this danger, 
the workmen are also exposed to industrial poisons and the hazard inci- 
dent to brass founding, metal working, machine shopping, soldering, wood 
working, painting and varnishing. The following is a summary of condi- 
tions observed by Hayhurst18 in his Ohio Survey: 
The waterproofing of paper shells by means of hot paraffin was a hot and steamy 
process. The manufacture of felt and wads for these cartridges was also hot and 
steamy and attended with a peculiar foul odor due to the dirty cow hair. The work in 
the lead room and loading and packing of the shells was practically all mechanical and 
appeared to be free from occupational hazards. The manufacture of copper and brass 
shells, especially the annealing and washing process, was characterized as hot, wet and 
humid. The loading and packing of rifle cartridges was a mechanical process, girls 
operating the machines; they did not touch the lead. In the manufacture of fulminate 
priming caps the man who did the work was thoroughly skilled and realized the danger 
both as to explosion and as to poisoning from fulminate of mercury. In the nitro- 
glycerine department the work was also done by skilled men, but some of the helpers, 
it was said, occasionally complained of headache, flushing of the face and a feeling of 
distention in the stomach. 
Fuses.-A great many varieties of fuses for the ignition of the detona- 
tor or for the direct ignition of a blasting charge have been designed. 
Marshall and other authors describe in detail the manufacture of safety 
fuses, miner's squibbs, quills, quick match, instantaneous fuses, slow 
match, detonating fuses, electric fuses, mechanical fuses and shell fuses. 
The latter are made in two main varieties, viz., percussion and time fuses. 
The work is generally carried on with great precaution, as regards cleanli- 
ness, clothing and safety measures. The latest development in fuses for 
industrial blasting is "Cordeaux detonant" which consists of a lead tube 
having a cone of compressed TNT. 
Hayhurst in discussing the manufacture of electric fuses refers to noise as a factor 
in the spinning process of white cotton upon the copper wire to be used for insulation. 
He refers to the tarring of covered wire as hot and humid work, but considered the 
hazards in the bridging room, where the soldering of platinum wire points and running 
sulphur into moulds around the points was done by girls, as quite negligible. 
Fireworks.-Most of the mixtures used for rockets are practically iden- 
tical with those used as explosives, such as mealed powder, combined with 
slow burning substances. Among the different rockets described by 
Marshall are those used for pyrotechnique displays; the war rocket, 
employed for incendiary purposes and attacks of air ships; sound and 
light rockets, the latter employed as a flash light to light up positions. 
Life saving rockets are used by the Coast Life Saving Service and others 
for throwing life lines. Fireworks also include the various colored lights, 
such as green, yellow, blue, and red lights. Many of the ingredients 
such as phosphorus, sulphites of arsenic, antimony and copper are indus- 
trial poisons, but their chief danger lies in accidents from explosions. 
Marshall19 refers to 25 accidents from 1910-1913 causing 25 deaths 
and injuries to 64 persons. 560 
THE MANUFACTURE AND USE OF EXPLOSIVES 
Accidents in the Manufacture and Use of Explosives.-Considering 
the vast quantities of explosives manufactured, the number of accidents 
is surprisingly small. According to Key20 during the year 1899 the total 
quantity of gunpowder, other nitrate mixtures, nitro-compounds and 
chlorate mixtures manufactured in the United Kingdom exclusive of 
Government factories was 32,115 tons. There was also produced about 
500,000,000 cartridges for small arms, 50,000,000 detonators, electric 
detonators and fuses and about the same number of yards of safety fuses. 
In addition there were manufactured about 1788 tons of fire works while 
the output of fulminate of mercury could not be disclosed.. 
According to Munroe21 the output of gunpowder in the United States 
in 1900 amounted to 10,383,944 lb., blasting powder kegs of 25 lb. each, 
8,217,448 kegs, smokeless powder 7,009,720 lb., nitroglycerine 51,579,270 
lb., dynamite 130,920,829 lb. and gun-cotton 5,905,958 lb. The total 
output of explosives in the United States in 1905 was 363,748,079 lb.; 
in 1915, 481,752,000 lb. and in 1920, 505,710,000. 
In 1875 Great Britain passed a law for the prevention of accidents in the explosive 
industry, which provided for the appointment of inspectors with power to inspect 
all magazines and factories and see that the operations are carried on in a reasonably 
safe manner. As a result the fatalities from explosions have been reduced, according 
to Marshall, from an average of 43 killed per annum in 1870 to seven in 1913, in spite 
of a great increase in the number of employes. 
During the decade from 1890 to 1899, 175 accidents occurred in the manufacture 
of explosives in Great Britain, resulting in the death of 44 persons and injuries to 204 
out of a total of 4828 persons employed in the danger buildings, and 11,098 persons 
exposed in licensed area. This favorable showing is largely due to the intelligence and 
care taken by the employes and employers and general safety precautions. Among 
the specially dangerous processes Key22 enumerates the "milling" or "incorporation" 
of gunpowder, "the pressing of detonators and the mixing of cap composition." 
In addition to the above accidents in actual manufacture 69 accidents 
with 32 deaths and 81 injuries occurred during the storage and distribu- 
tion of the finished product. Among the principal preventive measures 
Key mentions the following: " (a) subdivision of risks, i.e., the number of 
persons allowed in any one 'danger' building is strictly limited and the 
communication of explosion between buildings is prevented by the erec- 
tion of mounds of earth or masonry and by making the quantity of explo- 
sive in any building directly dependent on its distance from others; (6) 
scrupulous attention to cleanliness; (c) prevention of the introduction of 
matches and other dangerous articles, by providing suitable clothing 
without pockets and by a thorough system of searching all those employed 
in danger buildings; and (d) the provision of an adequate number of 
escape doors opening outward, and provided with safety latches so as to 
yield easily to a push from the inside." 
It is the concensus of opinion, that the explosive industry with care 
and proper safeguard is not an extraordinary dangerous trade, and that 
the risk in the use of explosives is greater than in its manufacture. This ACCIDENTS 
561 
is illustrated in Key's table, showing the number of accidents- in the 
handling and use of various explosives during the decade of 1890-99. 
Nature of explosive 
No. of 
accidents 
No. of persons 
Killed 
Injured 
1. Gunpowder 
244 
94 
294 
2. Nitroglycerine compounds 
376 
135 
440 
3. Ammonium nitrates 
44 
12 
41 
4. Detonators 
143 
3 
193 
5. Fireworks 
41 
19 
96 
- 
- 
- 
Total 
848 
263 
1064 
Total in manufacture during same period. . 
175 
44 
204 
According to Key the majority of these accidents, 99 out of 100, could 
have been avoided by reasonable care. Among the immediate causes of 
explosions in mines in Great Britain in 1899 which killed 29 and injured 
195 were scraping out the detonators with pins, thawing dynamite over 
the fire, driving dynamite and gunpowder by means of iron rods into 
roughly drilled holes, and boring out of misfires. Key cites a fatal acci- 
dent which was reported as follows: A. B. was charging a bore hole in rock 
with pellet gunpowder. Finding a difficulty in inserting the charge he 
was holding the tamping rod on the powder while his mate drove it home 
with a sledge hammer when for no reason whatever the charge exploded. 
The italics are Key's. 
It is very evident from the examples of reckless folly cited by Key that 
much needs to be done in the way of instruction and discipline to diminish 
this needless sacrifice of life and limbs. 
ACCIDENTS DURING THE GREAT WAR 
Professor Charles E. Munroe in an able review of the forty-third Annual Report 
of His Majesty's Inspectors of Explosives, Ann. Rept. for the year 1918, makes 
the following comments: 
"Naturally much of the usual information given in these reports was suppressed 
during the Great War lest it give aid and comfort to the enemy and it is therefore well 
to know that there is included in this 1918 report tables of statistics of the accidents, 
fatalities and injuries in the various explosives factories from Aug. 4, 1914 to Nov. 11, 
1918, together with detailed statements of the kinds and quantities of the various 
explosives, ammunition, fireworks and smoke boxes produced. The accidents were 
most numerous in the manufacture of fuses for shells, detonators and electric detona- 
tors, and percussion and rim fire caps, but they were most devastating in the manufac- 
ture of picric acid and TNT. There was made 445,559 tons of explosives and over 
11,725,000,000 pieces of ammunition, the average number of employes being 61,808 
and the maximum number of 86,555. The analysis of this data shows but 1.25 persons 
killed per 1000 per annum while the last comparable data, obtained for 1910, showed 562 
THE MANUFACTURE AND USE OF EXPLOSIVES 
for the previous 5 year period 1 per 1000 per annum, which, considering the output 
produced under high pressure, largely by inexperienced workers, supervised in many 
instances by equally inexperienced officials, is remarkable. Incendiary and fireworks 
compositions containing powdered aluminum proved especially dangerous, not only 
on account of the intense heat produced by their combustion, but also from a 
peculiar sensitiveness which they appeared occasionally to unaccountably develop. 
This was especially true of "thermalloy" composed of Al, Fe20s and S. Because of 
the enormous quantities of hand grenades required the usual conditions in regard to 
"distances" were so relaxed as to permit their being filled in compartmented buildings 
with a quantity of explosive in each compartment considerably in excess of that 
allowed in normal times, yet in the filling of over 83 million, but 2 accidents occurred 
and but one person was injured. Details of the accidents of 1918 are given not only 
for explosives but, in significant instances, for petroleum, CaO2 and C2H2 also. Acci- 
dent 246 of the list rehearses that while examining a motor for driving a C2H6O pump 
in a solvent stove, a dark substance fell on the floor, and burst into flame on the wet 
floor. It proved to be metallic Na formed by electrolysis by a defect in the main 
electric supply. (Chemical Abstracts, Vol. XIII, No. 21, Nov. 10, 1919.) 
Dangers from the Products of Combustion.-Apart from the accidents 
referred to it should be remembered that the gaseous products of combus- 
tion in confined spaces, such as mines and tunnels, may prove a very serious 
danger to the operatives. 
The gaseous product in the explosion of various gunpowders averages 
.as follows: Carbon dioxide 49.3; carbon monoxide 12.5; hydrogen 2.2; 
methane 0.4; nitrogen 32.9; sulphureted hydrogen 2.6 volume per cent. 
Whenever an explosive is used in which the oxidizing agents are insuffi- 
cient to convert all the carbon into dioxide, and the hydrogen into water, 
the amount of monoxide, evolved may be greatly increased. The gas 
from black powder contains between 8 and 17 per cent, of carbon monoxide 
and many of the explosives used in mines give off more carbon monoxide 
than dioxide. Marshall6 refers to several fatalities from this cause in 
Germany in 1904 and 1908 and it is generally believed that the undue 
prevalence of respiratory diseases in the South African gold mines and 
elsewhere is influenced by the presence of monoxide of carbon in these 
mines. Munroe says "The Bureau of Mines is endeavoring to so regu- 
late the composition of Permissible Explosives that they shall yield but a 
safe minimum of poisonous gases." He also states that the high explosives 
used for military purposes such as gun-cotton, picric acid and trinitro- 
toluene* evolve large quantities of carbon monoxide when detonated 
and hence are unsuitable for underground operations. Sulphureted 
hydrogen is freely given off by American dynamite. Blown-out shots are 
liable to produce other poisonous gases and vapors such as acrolein and 
prussic acid. When nitroglycerine is decomposed by simple combustion 
instead of detonation apart from CO and CO2 the highly poisonous nitrous 
fumes are given off. Key22 refers to a number of instances of poisoning 
from one, or a combination of these gases. Nitroglycerine explosives 
* "Products of detonation of TNT." Charles E. Munroe and S. P. Howell, Proc. Am. 
Phil. Soc„ LIX, 194-223, 1920. TABLE OF EXPLOSIVE HAZARDS IN MANUFACTURING 
563 
according to Jakoby and His, cited by Marshall,23 distil off part of this 
constituent which condenses again to a fine mist in the air. If a sweet 
taste be observed in the air the miners should leave at once and not return 
until it has disappeared. Dr. Pirrie24 has recorded his observations on 
unsuspected dangers to the health of miners from the use of high explo- 
sives containing nitroglycerine. 
Oliver25 states that the inhalation of the fumes given off by high explo- 
sives may cause violent headache, vomiting, palpitation of the heart and 
partial or complete collapse. Removal to the fresh air, warm drinks and 
-external artificial heat are the most effective remedies. He also mentions 
the fact that "many of the miners after the 'gassing' suffer from extreme 
nervousness and of a sense of dread attended by a want of confidence in 
themselves." 
EXPLOS1VE HAZARDS IN MANUFACTURING PLANTS, ETC.* 
Chemicals, acids and acid 
vapors: 
Chromic acid, hydrochloric acid, nitric acid, hyponi- 
trous acid, perchloric acid, picric acid, styphnic acid, 
picramic acid, sulphuric acid. 
Gases: 
Acetylene blowgas, carbon monoxide, ethylene, 
hydrogen, gasoline and pintsch gas, water gas, methane, 
producer gas. 
Dust explosions: 
Starch, maize, cocoa, rice, celluloid, coal, cork, 
charcoal, malt, dextrin, flour, grains, horn meal, 
lampblack, mustard, plumbago, mineral and ivory 
black, shoddy, sugar, sulphur, tow, tobacco, wood dust. 
Explosive substances: 
Ammonium nitrite is explosive when heated or from 
percussion. 
Acetone peroxide is explosive from percussion. 
Acetyl peroxide is explosive when heated. 
Celluloid will explode from percussion and the dust 
from celluloid will explode from a very small spark of 
any kind. 
Chlorates are explosive from slight friction, shocks or 
when crushed. • 
Chlorine peroxide is explosive with organic matter. 
Collodion is explosive from heat or shock. 
Dynamite is explosive from heat or shock. 
Fulminates are explosive from heat, percussion, shock 
or strong acids. 
Gun-cotton is explosive when suddenly warmed or 
from pressure, shock or friction. 
Gunpowder is explosive from shock, pressure, friction 
or heat. 
Nitrogen chloride will explode under slightest provo- 
cation, sunlight or violent sound waves. 
Nitroglycerine is explosive from heat or shock. 
'Condensed from "Explosive Hazards in Manufacturing Plants," published by the 
Aetna Life Insurance Company, Hartford, Conn., 1914, with valuable additions made by 
the Aetna Company, March 6, 1922. 564 
THE MANUFACTURE AND USE OF EXPLOSIVES 
Explosive substances: 
Nitrous peroxide is explosive in contact with flam- 
mable vapors. 
Nitroform is explosive when warmed. 
Nitrogen bromide is explosive from percussion, 
vibration and friction. 
Nitrosaccharose is explosive from percussion. 
Nitrosophenol is explosive when warmed. 
Nitrogen iodide is explosive on slightest provocation. 
Picrates are explosive from heat, friction, shock. 
Uranium carbide is explosive from percussion or 
friction. 
Vinyl alcohol is explosive on the slightest warmth or 
other provocation. 
Liquids which may cause ex- 
plosions under right con- 
ditions : 
Acetone, amyl acetate 
Alcohol 
Benzol, 
Benzine 
Carbon disulphide 
Coal tar, 
Ether, 
Ethyl chloride, 
Ethyl nitrite 
Illuminating oils 
Lacquers 
Ligrain 
Ligroin, Petroleum 
Pentane 
Spirits, 
Varnishes 
Liquified gases: 
Air 
Acetylene liquid 
Ammonia 
Carbonic acid 
Gasoline 
Hydrogen 
Hydrogen sulphide 
Oxygen, Liquified petro- 
leum gas 
Sulphurous acid. 
INDUSTRIES IN WHICH EXPLOSIVE HAZARDS ARE PRESENT 
Airplane manufacturing: 
Explosive hazards are met with in the preparation 
and application of "dope" to the wing fabric. Cellu- 
lose nitrate dopes are considered highly flammable. 
The following is a partial list of other hazardous 
chemicals and chemical compounds used in this 
industry: varnish, benzine, acetone, benzol, pyroxylin, 
gasoline, methyl acetone, benzyl alcohol, xylol, 
camphor. 
Bleach, dye, print and finish- 
ing departments of textile 
mills: 
Bleaching chemicals: sodium peroxide gives off oxygen 
in contact with resin, ethereal oils, or mineral oils, or in 
a room containing inflammable gases or vapors, may 
easily cause a fire, or under right conditions, an 
explosion. Chlorates employed for oxidization pur- 
poses especially where anilin black dying is done are 
liable to liberate oxygen explosively if mixed with 
potassium cyanide or sulphur, or under the influence 
of friction, shock, concussion or heat. 
Breweries: 
Explosions from dust are liable to occur in the cleaning 
and separating room, also in malt grinding mills, from 
a foreign body such as a nail, etc., in the grain, striking 
a spark on the metallic part of the machine. 
Bronze and aluminum powder 
manufacturing: 
Extreme care must be exercised in the handling and 
storage of these powders because of their high explosi- 
bility when reduced to an impalpable state. TABLE OF EXPLOSIVE HAZARDS IN MANUFACTURING 
565 
Candy factories: 
Dust in starch bulk and sifting and drying rooms. 
Shellac and alcohol also create explosive hazards in 
these establishments. 
Clothing factories: 
From benzine cleaning or gasoline gas system for 
heating irons. 
Cotton mills: 
Dust and lint, open lights. 
Cotton seed oil mills: 
Dust and lint should not be allowed to accumulate in 
these rooms and material should be passed over 
magnets before going to linters. 
Cordage and twine works: 
Drug houses: 
Dust and oily flyings create explosive hazards. 
Dry grinding of chemicals and the handling of alcohols, 
anaesthetics, benzines and other volatile liquids may 
result in explosions. 
Fertilizer works: 
If cooking is done in closed steam kettles, a reducing 
valve, safety valve, gauge and proper drain should be 
provided for each kettle. 
Flour and cereal mills: 
Garages: 
Dust explosions not infrequent. 
From gasoline, calcium carbide and Presto-Lite tanks. 
Glass works: 
From fuel oil heating system. 
Glucose and starch works: 
Dust explosions in grinding rooms and drying rooms, 
also from sulphur burners and nitric acid used in 
converting processes. 
Grain elevators and grain 
threshing: 
Dust explosions from hot bearings, open lights, static 
electric sparks or any other form of fire. Sulphur 
and carbon bisulphide and other volatile and inflam- 
mable materials. 
Metal workers: 
From fuel oil, acids, japan lacquer, gas-heated japan 
ovens, dip tanks containing volatile oils. 
Motion picture: 
See Celluloid. 
Oil cloth and linoleum plants: 
Dust in the cork grinding room, linseed-oil boiling, 
compound mixing, explosive vapors. 
Oxy-acetylene welding 
plants: 
Explosions of generators used to make acetylene gas 
may occur. Acetylene gas has a wide range of 
explosibility when mixed with air. 
Packing houses: 
Patent leather and enamel 
leather works: 
Fires spread rapidly on account of grease and oil. 
Daubs, japan, varnish, oils, lampblack, naphtha. 
Direct heat and open flames of any kind should never 
be used or allowed where coating or mixing is done. 
Paint and varnish factories: 
Explosions in this industry are caused by flammable 
solvents, color drying, resin boiling, grinding of colors 
and paints, spontaneous combustion of colors. 
Printing, binding, and litho- 
graphing: 
From gasoline, gas or linotype machines, benzine used 
for type cleaning, collodion in photo-department. 
Pulp mills: 
Sulphur and sulphur burners, digesters. 
Refrigeration plants: 
Volatiles such as anhydrous ammonia, carbon dioxide, 
sulphur dioxide, ethyl chloride and methyl chloride 
are usually employed. Explosions are usually due to 
excessive working pressure or from ignition of explosive 
and combustible vapors when liberated to the atmos- 566 
THE MANUFACTURE AND USE OF EXPLOSIVES 
Refrigeration plans: 
phere. The mineral oil used to lubricate compressors 
becomes a hydrocarbon gas at temperatures which 
may easily obtain in operation. If subjected to 
ignition this mixture is highly flammable and 
explosive. 
Rice mills: 
Same as flour mills, sparks are especially dangerous at 
the attrition machines. 
Rubber mills 
From lampblack and oxides used for compounding. 
From naphtha especially in the churn room, and in the 
spreading machines, the latter should be properly 
grounded to prevent static sparks. 
Shirt, collar, cuff factories 
and steam laundries: 
From gasoline gas system and for heating irons, 
Shoe factories: 
Straw and felt hat factories 
From gasoline gas system, also sulphur and sodium 
peroxide. 
From rubber cement and waterproofing material. 
Sugar refineries: 
Danger from dust explosion. Vacuum boiling kettles 
should be provided with proper safety valves and 
gauges. 
Tanneries: 
Dust hazards in bark mill rooms. Naphtha in degreas- 
ing processes. 
Tobacco dryers: 
Dust explosion risk is due to the greasy and imflam- 
mable character of tobacco dust. 
Woodworkers: 
Dust explosion hazards in sandpapering room, also 
varnish dip tanks and from naphtha, oils and 
varnishes. 
Explosive Hazards in the Dyestuff and Dye Intermediate Industry* 
This industry begins with the fractional distillation of coal tar. Gen- 
eral hazards of coal-tar distillation are as follows: flammable gases such as 
methane and ethylene are given off, the pipes of the distilling apparatus 
may become choked up and cause explosive pressures, ammonia water 
corrodes the vessels which may, therefore, burst and liberate explosive 
gases and vapors, the tar often boils violently and froths over if water is 
present at the beginning of distillation. 
In the manufacture of intermediates and dyestuffs from the crudes 
three outstanding explosion hazards are present: 
1. Explosion of dyes and intermediates. 
2. Explosion of pressure equipment. 
3. Explosion of vapors mixed with air. 
Some of the heaviest losses have been due to explosions of the dyes 
themselves. For this reason all dyes which are handled in the form of dry 
powders should be carefully analyzed. 
All pressure apparatus should be provided with adequate relief 
systems. 
The risk of explosion due to the ignition of mixtures and combustible 
vapors with air presents a serious hazard. Flames should be kept away EXPLOSIVE HAZARDS IN DYE INDUSTRY REFERENCES 
567 
from flammable mixtures and as far as possible every precaution should be 
taken to do away with the chance formation of static electricity and 
overheated bearings. 
Preventive Measures.-It is very evident that every effort must be 
made to reduce the hazards to a minimum. It is of the utmost impor- 
tance that in all nitrating processes the retorts must be tight fitting, and 
that all escaping nitrous fumes are promptly carried off by earthenware 
ducts and exhaust fans. Dust and fumes wherever generated, must be 
promptly arrested by hoods at the point of origin and removed by efficient 
exhaust ventilation. All dry sweeping should be replaced by the vacuum 
system. The sanitary engineer should exercise the greatest ingenuity 
to accomplish these objects. The employment of respirators in the 
form of a pad of cheesecloth over the nose and mouth will prove useful 
as an auxiliary measure. It is important that workers be instructed to 
wash their hands, mouth and teeth before eating, and upon cessation of 
work. Indeed it is a good practice to rinse the mouth and throat before 
swallowing even water, as much of the injurious dust lodged in the mucous, 
surfaces will find its way into the stomach. No food should be taken 
or tobacco used in any form in the workrooms. Special lunch rooms 
should be provided and all lunch boxes protected from exposure to dust. 
Suitable work suits,* rubber gloves, wooden overshoes, sanitary drinking 
fountains, hot and cold showers, change of clothing after cessation of work 
are all essential. 
Every chemical and munition plant should have a competent physi- 
cian whose chief duty should be to familiarize himself with all the haz- 
ards, and exercise a watchful supervision of the workers, so that he may 
recognize the early cases and resort to prompt treatment by removal of 
the men from exposure to toxic agents. It is well known that direct 
personal instruction by the physician and a change of work together with 
a work day of six hours has been of great benefit to employes and 
employers alike. Alcoholic subjects and men suffering from diseases of 
the lungs and kidneys should not be employed in the explosive industry.! 
REFERENCES 
1 Munroe, Charles E.-U. S. Census Bulletin, No. 92, 1908. 
2 Hayhurst, E. R.-Industrial Health Hazards and Occupational Diseases in Ohio. 
Ohio State Board of Health, Feb., 1915, page 345. 
3 Rambousek, J.-Industrial Poisons, London, 1913. 
4 Oliver.-Diseases of Occupation, London, 1916. 
* The shop uniforms for women and girls, Munition Workers at Frankford Arsenal, con- 
sists of a khaki blouse and specially designed overalls, which are made full and button 
around the ankles. In order that there may be no place in the uniform for powder or flying 
dust to lodge, the blouse buttons over the overalls instead of under; the overalls button for- 
ward instead of backward, the collar of the blouse buttons tightly as does the flap of the over- 
all pocket. P uttees may be worn with the overalls. The cap which completes the costume 
is of lighter fabric than khaki and resembles an aviator's cap in shape. 
t See also Professor Lee's Chapter on Fatigue, page 737. 568 
THE MANUFACTURE AND USE OF EXPLOSIVES 
5 Neisser.-Internal. Ubersicht, etc. 
6 Marshall, Arthur.-Explosives: Their Manufacture, Properties, Test and History. 
P. Blakiston's Son Co., Philadelphia, 1915, page 224. 
7 Marshall, A.-Loc. cit. 
8 Munroe, Charles E.-Loc. cit. 
9 Key, Cooper A.-Oliver's Dangerous Trades, London, 1902. 
10 Rambousek, J.-Industrial Poisons, London,1913. 
11 Oliver.-Diseases of Occupation, London, 1916. 
12 Laws, C. E.- J. A. M. A., LIV, 1910, page 793. 
13 Evans, C. S.- J. A. M. A., LVIII, 1912, page 550. 
14 Ebright, Geo. E.-J. A. M. A., LXII, 1914, page 201. 
15 Rambousek, J.-Industrial Poisons, London, 1913, page 47. 
18 Marshall, A.-Loc. cit. 
17 Key.-Oliver's Dangerous Trades, London, 1902. 
18 Hayhurst, E. R.-Industrial Health Hazards and Occupational Diseases in Ohio, 
1915. 
19 Marshall, A.-Loc. cit., pages 437-449. 
20 Key.-Loc. cit. 
21 Munroe.-Loc. cit. 
22 Key.-Loc. cit. 
23 Marshall, A.-Loc. cit. 
24 Pirrie, R. Reid.-Practitioner, London, LXXXVIII, 1912, page 212. 
25 Oliver, T.-Diseases of Occupation, London, 1916. 
28 Fries, Amas A.--Brig. General, C. W. S., U. S. A. and West, Clarence G., Major, 
C. W. S., Reserve Corps, U. S. A. - Chemical Warfare, McGraw-Hill Book 
Co. Inc., New York, 1921, page 445. 
27 Popular Science Review, III, 1864, page 176. 
28 Hamilton, Alice.-Industrial Poisons Used in the Making of Explosives. Monthly 
Review, Bureau of Labor Statistics. U. S. Dept, of Labor, Vol. IV, February. 
1917, No. 2. SECTION 22 
MISCELLANEOUS CHEMICAL POISONS AND THE RELEVANT 
INDUSTRIES 
GEORGE M. KOBER, M. D„ Washington, D. C. 
The Chemical Industry.-Unfortunately we have no reliable Ameri- 
can morbidity and mortality statistics. The German statistics cited by 
Weyl1 show that among 185,820 employes in this industry in 1905, there 
were 163,522, or 88 per cent., cases of sickness, with an average dura- 
tion of 8 days. There were also 11,010 accidents, of which 122, or 1.11 
per cent., proved fatal. The majority of the fatal accidents were caused 
by gases, hot vapors, and the effects of explosions. The statistical data 
by Leymann2 show that the laborers and mechanics contributed about 
27 per cent, and the chemists 45 per cent, to the morbidity rate from 
internal diseases, and 37 per cent, and 43 per cent., respectively, to the 
morbidity from external affections. Diseases of the respiratory passages 
are especially prevalent among workers in the manufacture of hydro- 
chloric acid, the sulphates, chromates, caustic potash, chloride of lime 
and trinitrophenol. Diseases of the digestive organs are frequent in all 
chemical workers, especially among those engaged in the manufacture 
of hydrochloric acid, soda, sodium sulphates, chromates and anilin and 
in the regeneration of sulphur. Cases of poisoning are most frequent in 
the manufacture of anilin. Burns are most frequent in the manufac- 
ture of nitric acid, caustic soda, chromates and trinitrophenol. Diseases 
of the skin are most frequent in the anilin industry and affections of 
the eye in the regeneration of sulphur. 
Curschmann's3 more recent statistics indicate that the morbidity rate 
in the large German Chemical works is 54.9 per cent, per annum, with an 
average duration of 17.8 days. The rate for female workers is 65 per cent. 
The mortality rate was only 5 per 1000. The morbidity rate was dis- 
tributed as follows: 
Accidents : 16.15 
Diseases of the respiratory organs 16.40 
Tuberculosis 2.39 
Diseases of the digestive system 13.25 
Rheumatic affections 8.84 
Industrial poisoning 0.40 
Industrial skin diseases 0.24 
The number of cases of acute industrial poisoning is not so great as is 
generally assumed. Curschmann has tabulated the cases which occurred 
569 570 
MISCELLANEOUS CHEMICAL POISONS 
in the German chemical industry, 1909-1910, and reports 50 cases with 3 
deaths and 1 permanent disability in the manufacture of anilin, nitrani- 
lin and fuchsin; 29 cases with 1 permanent disability in the manufacture 
of nitro-compounds; 5 cases in the manufacture of chloranisidin, naphtha- 
lene and organic dye stuffs, 4 cases with 1 permanent disability in the 
manufacture of phosgene; 9 cases from salicylic, oxalic, phthalic acid and 
pitch; 30 cases in the manufacture of lead compounds; 5 cases in the 
manufacture of phosphor trichloride; 8 cases from chlorine and bromine; 
9 cases with 1 death, and 1 permanent disability from nitrous gases; 12 
cases with 1 permanent disability from sulphureted hydrogen; 1 case from 
ammonia; 5 from chromium compounds; total 167 cases with 14 deaths 
and 5 cases resulting in permanent disability. 
About two-thirds of all the cases of poisoning occurred during the 
summer, showing that a more rapid evaportion, and possibly the per- 
spiration and exposed skin favored absorption of the toxic agent, especially 
in the manufacture of dye stuffs and amido bodies. Of the 117 cases of 
occupational skin diseases in this tabulation, 74 were attributed to the 
misuse of chloride of lime for cleaning the hands; 23 were produced by 
benzol, toluol and naphthol compounds, and the remainder by quinine, 
tar, etc. 
Blamoutier and Joannon (Rev. d'hyg. 44, No. 6, June, 1922, 521-532) report a case 
of occupational quinine poisoning. After two weeks' employment in a chemical 
establishment preparing the drug, edema of the eyelids was noted. Subsequently 
an itching erythematous eruption involved the face, neck, antecubital spaces, genitalia, 
and thighs, associated with some edema and on the face, with vesiculation. The 
authors are of the opinion that cases of this nature are not essentially different from 
those originating on the ingestion of quinine therapeutically administered (Jour. Ind. 
Hyg., Jan., 1923, Abst. p. 146 by Wade Wright). 
Dr. Harry S. Bernton (Amer. Jour. Med. Science, Feb., 1923, page 196) reports 
the case of a chemist who acquired, in course of his occupation, a sensitiveness to the 
dust of the castor bean and submits the following summary and conclusions: (1) 
Attacks of sneezing and of asthma are the clinical manifestations of this sensitiveness. 
(2) The fat-free castor meal produces an urticarial wheal at the site of a superficial 
scratch on the forearm. (3) A cutaneous reaction is obtained with a drop of the 
protein solution of the meal in a dilution of 1:250,000. (4) Symptoms of protein 
intoxication result from the absorption of extracts of the castor meal from skin abra- 
sions. (5) The presumptive evidence indicates that the globulin fraction possesses 
antigenic properties. (6) Exposure to organic dust in industries may cause an acquired 
sensitiveness. Cutaneous testing with the suspected material is of value in diagnosis 
and treatment. 
F. Twedell (Med. Rec., Aug. 21, 1920) reports that in a total of 11,085 men, of 
whom 7,707 were habitually exposed to sulphur dioxide or sulphuric acid, only 22 
cases of tuberculosis were noted during the entire period of the existence of the 29 
firms interrogated. The author having used these agents in the treatment of pul- 
monary and laryngeal tuberculosis with good result for over four years, finds in the 
replies confirmation of his opinion, that men exposed to these chemicals are usually 
COMPARATIVE IMMUNITY FROM RESPIRATORY INFECTIONS SULPHURIC AND HYDROCHLORIC ACIDS 
571 
free from pulmonary and throat diseases including influenza and common colds. 
(Jour. Ind. Hyg., Feb., 1921, Abst. p. 198.) 
C. Baskerville et al, in a report of the Committee on Occupational Diseases in the 
Chemical Trades (Jour. Ind. Eng. Chern., XII, 1920, pp. 439-440, abstracted by 
L. W. Riggs in Chemical Abst., July 20, 1920) state as follows: "Specifications for 
goggles for various purposes may be had on application from the Bureau of Stand- 
ards. Immunity from influenza of workers in bromine plants was observed among 
large producers while data leading to the opposite conclusion was reported by small 
producers and users. Reports indicated that people working in the manufacture of 
illuminating gas, cordite, tin, poison gas, NO2 and SO2 were much less (^ - J^s) 
likely to contract influenza. Liberal and deep applications of lanolin to the interior 
of the nose protects the membrane from infection which causes colds. More research 
and publicity of an educational nature with reference to the industrial hygiene is 
recommended." 
Sulphuric Acid.-Sulphur dioxide for the manufacture of sulphuric 
acid is most generally obtained during the roasting of pyrites and various 
smelting processes and is converted into sulphuric acid either in the lead 
chamber or by the contact process. The fumes are very pungent and 
suffocating and doubtless exert not only irritating but also caustic effects 
upon the mucous membranes of the upper air passages, and have been 
known to produce spasm of the glottis. According to Lehmann, sulphur 
dioxide in the proportion of 0.03-0.04 per 1000 in the air may produce 
serious effects in persons not accustomed to it, while old hands appear to 
acquire a certain amount of tolerance. Leymann's statistics show that 
diseases of the respiratory organs are more frequent in sulphuric acid 
workers than among other chemical workers. Burns and injuries to 
the eyes from the acid are not uncommon. 
Koelsch4 reports 12 cases of poisoning by sulphur dioxide and sul- 
phuric acid fumes which occurred in the German chemical industry in 
1907. Most of these cases resulted from inhaling large quantities, while 
entering the lead chambers or acid tanks, or in cleaning out Gay-Lussac 
towers, or sulphuric acid tank-wagons. In some of these cases it is not 
always possible to exclude nitrous fumes and arseniureted hydrogen. It 
is important that sulphuric acid should be free from arsenic. (See sulphur 
dioxide, sulphuric acid, arseniureted hydrogen-List of Industrial Poisons.) 
Hydrochloric acid is a valuable by-product of alkali works in the 
manufacture of sodium sulphate, sodium sulphide, and of soda by the Le- 
blanc and Hargreave's processes. The fumes of the acid are very irritat- 
ing and, even in small volumes, may produce inflammation of the eyes 
and of the air passages, bronchial catarrh, coughs, etc. In a more 
concentrated form they have produced caustic effects on the tips and 
edges of the tongue, erosions of the teeth, and ulcerations of the nasal 
wall. When present to the extent of 2 to 5 volumes per 1000 the lungs 
become distended with blood, and hemorrhages from the lungs and diges- 
tive tract are liable to occur. Lehmann considers the safety limit between 
0.1 and 0.2 volume per 1000, and relates a case where even 0.5 per 1000 
produced a violent reaction. 572 
MISCELLANEOUS CHEMICAL POISONS 
In the production of sodium sulphate by the Leblanc process there is a 
possibility of exposure to the fumes of sulphuric and hydrochloric acid 
in the operations connected with the muffle furnaces. In the Hargreave's 
process there may be exposure to sulphur dioxide. There is also a 
possibility of danger from sulphureted hydrogen during the de-arsenicat- 
ing process of the acid and in the removal of the tank waste. Burns of 
the skin from contact with spilled acid are liable to occur and should be 
promptly neutralized and washed. (See Sodium, p. 598.) 
According to Leymann the health of employes in this industry is more 
liable to suffer than in the manufacture of sulphuric or nitric acid. While 
cases of acute poisoning are rare, diseases of the respiratory and digestive 
system and defective teeth are comparatively common. Burns from 
caustic soda occur in 13.87 per cent, of the workers in that department, 
and serious injuries to the eyes are liable to occur from the spurting of the 
strong lyes and should be prevented by suitable eye protectors. Diseases 
of the digestive system are also quite common in those engaged in the 
manufacture of sodium compounds. 
Nitric acid is most commonly produced by the action of sulphuric acid 
on saltpeter. The decomposition is carried on in cast-iron retorts and 
condensation takes place in fire-clay Woulff bottles, connected with a 
coke, or a Lunge-Rohrmann plate tower. The fumes of nitric acid and 
nitrous fumes, however generated (see List of Industrial Poisons), are very 
toxic and the cases often terminate fatally. The fumes do not, except 
in very concentrated volumes, produce acute and suffocative attacks like 
those produced by other irritant gases, and as a result the inhalation may 
go on for several hours and inflict great damage to the blood before the 
appearance of serious symptoms. The literature contains numerous 
instances of poisoning caused by leaky retorts, by inhaling the fumes in 
filling carboys or iron vessels, by spilling of the acid, breakage of carboys 
and attempts to mop up the spilled acid with saw dust. Not infrequently 
these accidents are the cause of fire and wholesale cases of poisoning have 
occurred among the firemen as a result of inhalation of nitrous fumes. 
Rambousek6 reports an instance where between 50 and 60 carboys stored in an 
open field caught fire. The 15 firemen experienced no special discomfort during the 
half hour of exposure, but 3 hours later all had suffocative attacks from which one 
died and the others recovered after suffering from 9 to 10 days from affections of the 
respiratory organs. 
Schultz6 reports an instance in which 60 firemen, who were fighting an extensive 
conflagration in a celluloid factory, suffered from nitrous fumes. The autopsy usu- 
ally reveals intense inflammation of the mucous meipbranes of the palate and upper 
air passages and congestion of the lungs. Czaplewski7 describes several cases caused 
by breakage of the carboys by carelessly dragging them along the floors. Lewin8 
discusses the subject of nitrous gas poisoning in the metal industry and proposes excel- 
lent methods for their prevention. The branches of industry in which cases of 
poisoning are liable to occur are enumerated in the List of Industrial Poisons (see page 
657). Apart from the serious effects referred to, the industry naturally involves CORROSIVE ACID PRECAUTIONS CHLORINE INDUSTRY 
573 
exposure to burns and predisposes to diseases of the respiratory organs, which consti- 
tute, according to Leymann, 12 and 11.8 per cent, respectively of the morbidity. 
Preventive Measures.-According to the Massachusetts State Board 
of Health9 the corrosive acids are made in such a way that practically no 
fumes whatever escape, the work being inclosed from beginning to end. 
In one of the largest chemical factories in that state, where 300 men are 
employed, it is said that the workmen are exposed very little to poisonous 
or irritating fumes and dust, or to contact with poisonous or irritating 
substances. At certain points in the building acid fumes in considerable 
strength are constantly present, but at these points there is good overhead 
ventilation, and the workmen are rarely obliged to approach very near. 
The utmost care is required to safeguard the health of the employes by 
processes, so that there may be no leakage of gases. All such processes 
should be carried on under official regulations. In the sulphuric acid 
industry the men who enter or clean out the chamber system, tanks and 
tank wagons should be provided with smoke helmets. Deposits from 
tanks should be either scooped out without the addition of water or dilute 
soda solution, or removed preferably by means of flushing hose without 
entering the tanks. 
In the hydrochloric acid industry it is important that the salt-cake pan 
and reverberatory furnace is properly constructed. The English Rules 
provide that: 1. The salt-cake pan must not be charged when over- 
heated. 2. Sulphuric acid shall be added only after all the salt has been 
charged and the door shut. 3. If hydrochloric acid fumes escape at the 
door when the Glover acid flows in, the flow must be interrupted. 4. All 
doors must be closed while work is in progress. 5. Definite times shall be 
fixed for withdrawal of the salt-cake in order to try to ensure that it be 
not still fuming, but should this be the case, cold sulphate of soda, shall 
be sprinkled over it. 
The Chlorine Industry.-This industry includes the production of 
chlorine, chiefly from manganese dioxide by the Weldon process, or the 
Deacon process together with its electrolytic generation with simultaneous 
production of caustic alkali. It also includes the manufacture of chloride 
of lime, the chlorates and hypochlorites. Chlorine is also used for the 
production of a number of other chemical compounds which will be alluded 
to later. In all of these processes there is more or less exposure to the 
inhalation of chlorine, which is most pronounced in the production of 
chlorine, by the Weldon process, and also in the manufacture of 
bleaching powder. Fortunately, even the smallest quantities of chlorine 
causes suffocative sensations which oblige the workmen to leave the rooms 
and acute cases of poisoning are naturally rare. (For symptoms and the 
industries in which chlorine poisoning may occur see page 650.) 
Exposure to the irritating fumes of chlorine, even in small volume, can- 
not fail to predispose to diseases-of the respiratory organs. According to 
Lehmann 0.01 per 1000 in the air is injurious, 0.1 per 1000 produces 574 
MISCELLANEOUS CHEMICAL POISONS 
ulceration of the mucous membrane and 1 or 2 hours' exposure endangers 
life. Leymann states that the morbidity rates from this class of diseases 
among men engaged in the manufacture of chlorine and bleaching powder 
is 17.8 per cent, as compared with 8.8 per cent, in other workers. The 
so-called chlorine rash or chloracne is believed by Roth and Lehmann not 
to be due to local external irritation, but to the excretion of chlorine by the 
skin. There is also danger from mercurial poisoning, if mercury is used 
in the electrolytical production of chlorine. 
Preventive Measures.-The same general principles which have been 
enunciated in the manufacture of corrosive acids apply to this industry 
and may be summed up in careful supervision of all the apparatus and 
processes, exhaust ventilation and general cleanliness. It is stated that 
since the use of "magnetite" instead of carbon for the anode, in the elec- 
trolytic production of chlorine, the number of cases of chloracne has 
diminished. If this be the case it is a strong argument in favor of the 
belief that the tar cement is a causative factor. 
Iodine and Bromine Compounds.-Chlorine is now very generally 
employed to liberate iodine from the mother liquors of Chili saltpeter and 
other salt industries. Iodine, apart from its medicinal properties, is used 
in the manufacture of iodoform and other pharmaceutical and chemical 
preparations. Ascher maintains that apart from exposure to chlorine 
gas there is also danger from iodine poisoning, affecting especially the 
nervous system and not infrequently also resulting in gastric ulcer, the 
effects being especially marked in photographers who use bromide of 
iodine in their work. Rambousek10 cites two cases of acute iodine poison- 
ing in a Swiss chemical factory where organic iodine compounds were 
made; one proved fatal and was characterized by severe cerebral symp- 
toms, giddiness, double vision and collapse. 
Grandhomme10 has described six cases of methyl iodide poisoning 
among workers engaged in the manufacture of antipyrine. 
Jos. Bodenstein (Mun. Klin. Wchnschft., May 12, 1921) reports that dimethyl 
sulphate is used in the chemical industry as an akylating agent in place of methyl 
iodide. This agent is very toxic. Inhalation of the vapor resulted in death from 
lung edema and lobular pneumonia. In lesser concentration it produces inflammation 
of the upper air passages and conjunctivitis lasting for months. (Jour. Ind. Hyg., 
Jan., 1922, Abst. p. 207.) 
The manufacture of bromine compounds involves exposure to chlorine 
and there is some evidence to indicate that there is danger from bromine 
poisoning. These compounds are used not only for medicinal purposes, 
but also in the coal-tar color industry and in photography. 
Methyl Bromide.-Schuler, in 1899, described three cases of methyl 
bromide poisoning in men engaged in preparing this compound by means 
of wood alcohol and sulphuric acid. These cases were regarded as 
doubtful, but additional cases have since been reported. METHYL, CHLORINE AND FLOURINE COMPOUNDS 
575 
Goldschmid and Kuhn (Zentralbt. f. Gewerbhyg, Feb., 1920), after citing eleven 
cases previously reported by Schuler, Jacquet, Bing, Floret and Steiger, report 9 
cases, three of which proved fatal. The cases occurred in the Hbchst Color Works in 
December, 1917, as a result of defective pipes and a boiler explosion containing brom- 
methyl. The Association of Physicians of the German Chemical Industry is on record 
as declaring brommethyl an acute poison, which produces rapidly paralysis of the 
central nervous system, with loss of consciousness, sensibility and motility. These 
symptoms do not disappear after the cessation of the immediate toxic effects, but 
increase in intensity with manifestations of psychical excitement. In serious cases 
there may remain after the elimination of the poison deep and irreparable lesions of the 
central nervous system. 
The authors divide the symptoms into three stages. The prodromal stage which 
begins a few hours after inhalation of the poison, and may last from 3 to 6 days, 
characterized by symptoms of paralysis of the central nervous system (transient 
stupor, vertigo and loss of equilibrium). Second stage of psychic disturbances, which 
in serious cases may last several weeks, attacks of mania, delirium, halucinations, 
epileptiform clonic-tonic spasms, general weakness, somnolency, unconsciousness, 
respiratory disturbances, coma. Third stage characterized by manifestations of 
nervous weakness, hypochondria, melancholy, hystero-neurasthenia, which may last 
for years resulting generally in complete recovery. 
The autopsy, in all three cases, revealed well marked acute changes of the cerebral 
ganglia, and in one case there was also evidence of purulent bronchitis and inflamma- 
tory edema of the lungs. 
Fritz Rohrer (Vrtljahrft f. gerichtl. Med., July, 1921) reports a case of acute 
poisoning from fumes of methyl bromide (Jour. Ind. Hyg., Feb., 1921, Abst. p. 193). 
Methyl chloride, methylene chloride and carbon tetrachloride are also 
poisonous. In the manufacture of the latter agent the workers are 
exposed to the possible combined effects of chlorine and carbon bisulphide. 
In the production of chloroform there is exposure to chlorine and the stupe- 
fying effects of chloroform. Chloride of nitrogen is said to be very irritat- 
ing and is a highly explosive compound. Rambousek10 mentions that 
there is some risk from the formation of chloride of nitrogen in the manu- 
facture of gunpowder, if the nitre contains chlorine. Cyanogen chloride 
is another very poisonous chlorine compound, and besides the danger in 
its manufacture, Albrecht, cited by Rambousek, has pointed out that it 
may also be generated in the production of red prussiate of potash, in 
case the solution is treated with an excess of chlorine. Rambousek12 
reports several instances of industrial poisoning from hydrofluoric acid, 
some of which occurred during its production, and presented evidence that 
the vapors exerted a corrosive effect on the mucous membrane of the 
respiratory passages and of the eyes. Blisters and burns, and even deep 
ulcers and gangrene of fingers, have resulted from the topical use of the 
acid in the etching of glass (see also List of Industrial Poisons).* 
Cases of poisoning have also been reported in the manufacture and use 
of phosphorus chloride, sulphur chloride, zinc chloride, and even rock salt 
has been known to produce in grinders and packers, ulcers and perfora- 
tions of the nasal septum. 
* Kockel and Zimmermann (Munch. Med. Woch., Vol. 67, 1920 pp. 777-779) report 
2 cases of fatal poisoning from fluorine compounds. 576 
MISCELLANEOUS CHEMICAL POISONS 
Phosgene.-Among the organic chlorine compounds should be men- 
tioned phosgene, which is employed in the manufacture of different color- 
ing material. Rambousek10 cites five cases of industrial poisoning and 
Grempke11 reports three fatal cases which were caused by the escape of 
this very toxic gas from leaky rubber tubing during its production. 
Irene Gerber (Rev. Med. de la Suisse Romande, June, 1920, p. 356) 
reports 3 cases of poisoning from this gas in chemists. Each felt some 
irritation after several hours' work and two of them threw off the con- 
junctivitis and cough. The other, after four hours of slight symptoms, 
showed signs of pulmonary asphyxia progressing to a fatal termination 
the twenty-fourth hour (Jour. Am. Med. Assoc., Aug. 28, 1920, p. 640.) 
(See List of Industrial Poisons). 
Tetrachlorethane or tetrachloride of ethane (C2H2CI4) known in the 
trade as Cellon has come into prominence as an industrial poison. Dr. 
W. H. Willcox12 of London, was the first to report a number of cases of 
poisoning from the use of a varnish employed in waterproofing the can- 
vas wings and bodies of airplanes. The varnish is composed of acetate of 
cellulose dissolved in various organic solvents, such as acetone, methyl 
alcohol, benzene, carbon-tetrachloride and tetrachlorethane. Dr. Will- 
cox recalled a case in which carbon-tetrachloride used as a hair wash 
proved fatal in London in 1909. From animal experiments it was con- 
cluded that tetrachlorethane although present to the extent of only 10 or 
12 per cent, was the chief toxic agent in the varnish. A study of the 
toxicology showed that it may inflict great damage on the liver and 
kidneys. 
Inhalation of the fumes of the varnish has caused drowsiness, head- 
ache, loss of appetite, a nasty taste and irritation of the throat, constipa- 
tion and in some cases vomiting, also pain in the stomach, jaundice, pale 
stools, high colored urine, enlargement of the liver, but no anemia. In 
very serious cases there was delirium, toxic jaundice, vomiting of blood, 
suppression of the urine, coma and death. The autopsy revealed toxic 
degeneration of the liver and kidneys. 
Indeed this new poison, which apparently caused no harm prior to 
1914 produced up to January, 1916, 43 cases of poisoning with 7 deaths, 
and the Board of Trade Labor Gazette for August, 1916 (page 204), states 
that 57 cases of toxic jaundice with 14 deaths had been reported since 
January 1st, 1916. 
Airplane Manufacture.-According to Dr. Alice Hamilton,13 analyses 
made for the Bureau of Labor Statistics show that American acetate 
dopes contain from .20 to 63 per cent, of tetrachlorethane; the German 
dopes contained from 40 to 80 per cent.; and that one author had collected 
18 cases of so-called toxic jaundice among the dopers in German factories. 
Dr. Hamilton observed no serious cases of poisoning in her visits to some 
18 airplane works, but Dr. Lester Roos and Dr. Rosalie Bell examined 52 
dopers and found some disturbance in health in 35. In some it was very AIRPLANE DOPES ARTIFICIAL SILK 
577 
slight, but in about 26 there were definite symptoms referable to the 
central nervous system, the gastro-intestinal or the urinary organs. 
Jaundice was observed in 2 men, one using tetrachlorethane dope, the 
other amylacetate-acetone dope. Several men had attacks of faintness 
and even loss of consciousness, and a greater number of these were using 
acetate dope than nitrate dope. No characteristic case of tetrachlor- 
ethane poisoning was found, probably, as pointed out by Dr. Hamilton, 
because up to that time they had not been exposed sufficiently long, and 
most of the doping was done in the open air. 
In a subsequent and more exhaustive paper Dr. Hamilton informs 
us that there are at present 3 kinds of dope in use for airplanes. The 
first is the one which was in general use before the war, cellulose-acetate 
dissolved in a mixture of solvents, the most important compound of 
which is tetrachlorethane. The second is acetate of cellulose dissolved 
in a mixture of acetone amyl-alcohol and benzol. The third is cellulose 
nitrate dissolved in amylacetate with, usually, acetone, or other ketones, 
alcohols and benzol. Of these solvents amyl-alcohol, amyl acetate and 
benzol are industrial poisons (for effects see pages 644, 647; also, 
Dr. Hamilton's paper). Tetrachlorethane has probably been discarded 
entirely in the airplane industry, but it was reported to Dr. Hamilton 
that it is used in rubber work, manufacture of non-inflammable films, 
lacquers, artificial silk and fire-proof fabrics. 
TETRACHLORETHANE POISONING IN MAKING ARTIFICIAL SILK 
Dr. D. C. Parmenter14 in an excellent contribution presents observa- 
tions on the general clinical aspects of tetrachlorethane poisoning in 
an American plant making artificial silk. It was found that the 
process of spinning out the thread on spools and drying it' involved the 
greatest exposure to this industrial poison. Among 95 persons employed 
at various times over a period of five months, 21 cases of poisoning 
occurred, 9 of which demanded temporary suspension of work. The other 
12 were sufficiently mild to permit continuance of work. No fatalities 
occurred, not one of the men were confined to his bed at any time, and 
not even in the two severe cases did permanent damage result, as the men 
made a good recovery after suspension from work for six to eight weeks, 
which indeed was the chief therapeutic and precautionary measure 
employed by the physician in charge. 
Symptoms.-The author emphasizes the importance of recognizing 
the symptoms of the early stages of tetrachlorethane poisoning, which 
are often not marked and consist of general gastric and nervous distur- 
bances. He calls attention to the proper interpretation of the blood pic- 
ture and quotes from the report of Drs. Minot and Smith who conducted 
the special investigation of the blood of the workers which is as 
follows: 578 
MISCELLANEOUS CHEMICAL POISONS 
1. Blood examination is unquestionably of value in the prevention of tetrachlor- 
ethane poisoning, and in the diagnosis and prognosis of poisoning by this substance. 
2. None of the cases presenting clinical symptoms of tetrachlorethane poisoning 
(twenty-one in number) occurred without characteristic blood abnormalities, which 
may be observed before clinical symptoms develop. 
3. The blood abnormalities include: (a) a progressive increase of large mononu- 
clear cells, often reaching 40 per cent.; (&) the appearance of many immature large 
mononuclears; (c) a slight elevation in the white count; (d) a progressive but slight 
anemia; (e) a slight increase in the number of platelets. 
4. A percentage of large mononuclear white cells above 12 is the first sign of a 
reaction to tetrachlorethane and is a signal for close observation of that person. All 
persons with such a picture do not necessarily develop clinical symptoms of poisoning. 
5. The presence of a considerable number of young mononuclears is to be looked 
upon as indicating a severer condition than a case with the same number of more 
mature large mononuclears. 
6. Practical utilization of blood examinations in connection with careful clinical 
observations has shown that these examinations are necessary for the regulation of the 
employment of workers and of the assignment of work to men likely to be exposed to 
tetrachlorethane. 
Preventive Measures.-In the way of prevention Dr. Parmenter 
advises that a person suffering from the loss of appetite and sleep and 
general nervousness for two or three days should have his blood examined 
and if that is abnormal he should be laid off for a time not exceeding a 
week. This should be done independent of the appearance of jaundice. 
On his return he will probably be able safely to continue work at the plant. 
A still milder case with vague general symptoms, and previous loss of 
weight should be watched carefully, but unless the blood picture suggests 
more severe poisoning than do the symptoms, work may safely be con- 
tinued under observation. In the case of more severe poisoning with 
abdominal pain in addition to the milder symptoms the man should be 
excused from work immediately, and should later have his blood exam- 
ined. He will probably show jaundice. The time of return to work 
depends upon the progress of symptoms and upon medical observation, 
in the ordinary case, probably after two to three weeks' absence. A 
case with sudden onset of vomiting accompanied by severe pain and 
much gas should be excused immediately. It is advisable for a person 
so affected to get other work if after his return there appears the slightest 
tendency to develop symptoms again. 
The influence of individual susceptibility and the effect of heat in this 
as in other forms of industrial poisoning is pointed out. It has been 
shown that men above 40 offer less resistance than the man of about 
twenty. In the plant in question powerful suction drafts have been 
installed for the purpose of removing the air in a downward direction out 
of the room. The spinning process has been almost entirely enclosed. 
The process of solution of the cellulose acetate is carried on in a separate 
room and the men wear masks. 
In addition to engineering skill, regulation of working hours, adequate 
vacations, special lunch rooms and work clothes, general sanitary super- PAINTS, VARNISHES, DRYERS, ETC. 
579 
vision of drinking water, lavatories, and intelligent management by men 
who understand and execute the necessary preventive measures are 
deemed important. The author feels quite convinced that with such 
precautions, cases of tetrachlorethane poisoning in the manufacture of 
artificial silk need not reach such a degree of severity as did the cases 
resulting from its war time use in the manufacture of airplanes. 
The Paint and Varnish Industry.-There are two classes of establish- 
ments, viz., those engaged primarily in the manufacture of pigments or 
paints and those engaged in the manufacture of varnishes, japans, 
lacquers or fillers. The principal products of the latter class are 
mainly solutions of gums, resins, asphaltum, or other ingredients, in 
such solvents or vehicles as turpentine, linseed-oil, alcohol, benzine, 
benzene, etc. 
The Massachusetts State Board of Health15 in discussing the manufac- 
ture of paints, colors and varnishes, points out that much of the work is 
done by men, who have worked from 6 to 20 years; the man who makes the 
lead colors has worked 17 years without sickness. The last case of poi- 
soning occurred 16 years ago, when a number of inexperienced men were 
poisoned with Paris green. In a color and mordant factory, where anilin 
colors, logwood, starch, sodium dichromate, etc., are used, about one in 
five of the employes was noticeably pale and sallow, and inflamed eyes, 
caused by the sodium dichromate, were not uncommon. In the manu- 
facture of "whiting" about half of the 58 men employed in three establish- 
ments visited "looked to be in poor condition." In making shingle stains, 
pigments, like chromate of lead, Prussian blue, zinc and iron oxide, 
are first mixed or ground with linseed-oil or with creosote or some of the 
"heavy or light oils." In two of the establishments the men appeared to 
be careless in the matter of handling the pigments. 
Manufacture of Linseed-oil, Dryers, Varnishes, Japans, Etc.-Lin- 
seed oil is extracted from linseed previously heated and crushed and sub- 
mitted to 3500 lb. pressure in hydraulic presses. The temperature in the 
press rooms often reaches above 125°F. Refined linseed-oil is obtained 
by treating the raw and filtered oil in lead-lined tanks with a 10 per cent, 
solution of strong sulphuric acid. Dryers and fillers are usually made by 
boiling linseed-oil with some oxidizing substance, such as oxide of lead, 
manganese, etc. During the boiling of linseed-oil, acrolein vapors and 
considerable heat are evolved, which should be carried off by means of 
hoods and exhaust ventilation. 
Varnishes are solutions of various gums and oleoresins dissolved in 
alcohol and turpentine. Unfortunately, quite commonly, benzene, ben- 
zine and wood alcohol are substituted as solvents. Among the many var- 
nishes may be mentioned asphalt, Burmese, copal, dammar, mastic, spar, 
and wax varnishes. Shellac dissolved in alcohol or wood alcohol is most 
frequently used for wood work. Thompson16 states that orpiment is 
occasionally employed to make poor grades of shellac yellow and opaque. 580 
MISCELLANEOUS CHEMICAL POISONS 
Copal and asphaltum varnishes are most commonly employed as a lacquer 
for metal work. Zapone lacquer, which is a solution of celluloid in amyl 
acetate and acetone, is employed in various industries, chiefly as a lac- 
quering agent in metallic ware and jewlery factories. Unfortunately, we 
have no morbidity and mortality statistics of these industries. 
The Ohio Survey of 1914 by Hayhurst covered 40 establishments 
with 757 men engaged in these processes. The investigation disclosed 
22 positive and 4 tentative cases of lead poisoning, and 5 positive cases of 
benzine poisoning. Among the common personal complaints were nausea, 
loss of appetite, dizziness, restless sleep, trembling, palpitation, frequent 
urination, headache, constipation, eczema and inflamed eyes. All of 
these symptoms can be reasonably attributed to the effects of injurious 
dusts, fumes and vapors. 
Preventive Measures.-Acrolein, amyl acetate, benzene, benzine, lead 
compounds, manganese, pitch, turpentine and wood alcohol are industrial 
poisons, and the workers should be protected by adequate ventilation 
during not only the manufacture but also the use of the agents contain- 
ing them. It should also be remembered that all quickly drying spirit or 
inflammable paints and varnishes are not only a source of benzine and 
wood alcohol poisoning, but may be the cause of serious burns from igni- 
tion of the vapors by a naked flame. (See also Painting.) 
Manufacture of Oil-cloth and Linoleum.-This industry is inimical 
to health on account of a number of injurious factors connected with the 
different processes of its manufacture. Linoleum is made by spreading a 
mixture of oxidized linseed-oil, resin and ground cork over a rough ground 
texture of cloth, which is varnished on its lower surface. It is made either 
in one color or in patterns. The patterns according to Doehring17 are pro- 
duced in three ways: (1) By the application upon the ground texture of a 
mixture of covering masses of different colors and grain; (2) by the juxta- 
position and fastening of differently colored and arranged patterns upon 
the ground texture; (3) by printing the plain linoleum with oil colors. 
The resulting products are known as grain, inlaid, and printed linoleum. 
The colors often contain arsenical, lead and mercurial pigments. It may 
be said that the covering mass of linoleum consists chiefly of an intimate 
mixture of oxidized linseed-oil (linoxyn) and finely ground cork meal. 
The latter is obtained from the waste material of the cork industry, cut up 
and ground into a very fine powder by suitable machines and rollers. 
This gives rise to large volumes of light floating dust, and although mor- 
bidity statistics are not available, there is every reason to believe that it 
is liable to produce diseases of the respiratory passages. Indeed the cork 
industry in general, such as making cork soles and corks for bottles has 
long since been regarded as a very dusty trade. Apart from the dan- 
ger of dust inhalation cork dust is highly inflammable and explosions have 
occurred not only during the grinding operations, but also during the 
subsequent mixing processes. LINOLEUM MANUFACTURE 
581 
For the purpose of making linoxyn the linseed-oil to which certain oxi- 
dizing substances such as litharge, sugar of lead, oxide of zinc, superoxide 
of manganese, etc., have been added is usually boiled at a temperature 
between 392° and 464°F. This may be done in open or hooded vessels; in 
either case frequent stirring is necessary to secure a thorough admixture 
of the oxidizing agents, and to prevent excessive heating of the oil on the 
walls of the utensil. This involves not only exposure to excessive heat 
and frequent burns but also to the inhalation of acrolein and other indus- 
trial poisons. As a matter of fact inflammatory conditions of the mucous 
membrane of the eyes, nose and upper air passages are not uncommon. 
When the oxidized linseed-oil is ready for use, it is mixed in a steam- 
heated vessel with 38 parts of resin, 13 parts of Cowrie or New Zealand 
gum, and some suitable coloring material. This mass is next thoroughly 
mixed with an equal weight of cork meal, in a suitable mixing machine. 
Benzine and turpentine are sometimes used to render the mass more plas- 
tic and less brittle. As substitutes for cork, wood flour, pulverized peat 
or other vegetable fiber have been used and in place of linseed-oil, the 
distillation residue of palm and cotton-seed oil are employed. The addi- 
tion of resin to hot linseed-oil develops volatile substances. The ether oil 
which forms is said to produce headache, nausea and sometimes com- 
plete stupor. Diseases of the upper air passages, chronic bronchial 
catarrh and even hemoptysis may be produced according to Eulenberg 
by the inhalation of these volatile vapors. Workers in resin are also liable 
to eczema and other affections of the skin. 
The next process in the manufacture of linoleum consists in the appli- 
cation of the covering mass (heated to a temperature between 280° and 
300°F.) to the ground texture, by means of plate and roller presses, which 
are hollow and heated by steam under pressure. The other processes are 
the cooling of the mass on cold rollers and the drying of the linoleum in 
special rooms at a temperature between 77° and 86°. The pattern print- 
ing is usually done by means of forms of wood or metal forms upon 
printing presses or machines in oil colors which not infrequently 
contain toxic pigments. The linoleum receiving the patterns is again 
placed in the drying rooms and when completely dried, it is cut, the 
upper surface is washed and occasionally receives a coat of zapone 
lacquer. 
Preventive Measures.-Adequate provisions should be made in the 
way of hoods and exhaust ventilation for the removal of dust and fumes; 
the latter on account of their offensive character should be conducted to 
the furnace fires and burnt up, or into the smoke stacks and discharged at 
great heights. Mechanical stirrers should replace the hand ladles. Since 
cork dust explosions are often caused by particles of iron-producing sparks 
in passing through the mills, Doehring17 recommends passing the cork 
through a magnetic separator before being placed on the comminuting 
machine. 582 
MISCELLANEOUS CHEMICAL POISONS 
Manufacture of Straw Hats.-The employes in this industry are 
exposed not only to the inhalation of dust and unfavorable working condi- 
tions, but also to a number of toxic agents in the bleaching, varnishing, 
sizing, staining and blocking processes. The stock is most commonly 
bleached by exposure to sulphur fumes in special chambers, and unless all 
fumes are driven off before the doors are opened the persons who remove 
the stock are subject to inhalation of these fumes. 
Bleaching is also accomplished by immersion of the stock for several 
hours in a solution of bisulphate of sodium, zinc dust and hydrochloric 
acid, or by the employment of a bath of oxalic acid, tartaric acid, acetic 
acid, sodium peroxide and hydrogen peroxide. After removal of the braid 
from the bath, the stock is placed in a drying room. The varnishing 
process with shellac dissolved in wood alcohol, and staining process with 
anilin in wood alcohol, involves exposure to the toxic fumes of this 
agent. The persons employed in sizing the hats with glue are exposed 
to excessive heat, since a temperature of about 100°F. appears necessary 
"in order that the glue may run off freely." The girls who trim the 
hats often occupy a stooped position. The general working conditions 
of all the employes should be improved by adequate air-space, exhaust 
ventilation and proper lighting. (See also felt hat industry.) 
REFERENCES 
1 Weyl's Handb. d. Arbeiterkrankh., Jena, 1908, page 184. 
2 Leymann.-Concordia, 1906, Nos. 7, 8, 9. 
3 Curschmann.--Krankenstatistik. d. deutschen chemisch. Industrie, Berlin, 1911. 
4 Koelsch.-Krankheit u. Soziale Lage, 1st Liefg., Munchen, 1912, page 184. 
5 Rambousek.-Industrial Poisoning, London, 1913, page 42. 
6 Schultze.-Arch. f. Soziale Hygiene, Vol. VII, page 66. 
7 Czaplewski.-Vierteljhschft. f. off. Gesundh., 1911, Vol. XLIII, page 356. 
8 Lewin, L.-Zeitschft. f. Hygiene u. Infect., 1911, Vol. LXVIII, page 401. 
9 Report upon Sanitary Condition of Factories, etc., 1907, page 103. 
10 Rambousek.-Industrial Poisoning, London, 1913, pages 35, 42, 57. 
11 Grempke, P. M.-Zeitschft. f. Gewerbehygiene, etc., 1912, Vol. XIX, page 65. 
12 Willcox, W. H.-J. A. M. A. February 27th, 1915, page 766. October 30th, 1915, 
page 1561, February 24th, 1917, page 636. See also Great Britain Annual 
Report of the Chief Inspector of Factories and Workshops, 1914, and Monthly 
Review of U. S. Bureau of Labor Statistics November, 1916, page 106, 107. 
13 Hamilton Alice.-Monthly Rev., Bur. of Labor Statistics, October, 1917. pages 
18-25 and February, 1918, pages 37-64. 
14 Parmenter, D. C.-Journal of Industrial Hygiene, 1921, page 456. 
15 Report of the Massachusetts State Board of Health upon the Sanitary Condition of 
Factories, Workshops, etc., 1907. 
16 Thompson.-The Occupational Diseases, 1914, page 165. 
17 Doehring, C. F. W.-Factory Sanitation and Labor Protection. Bull. No. 44, 
U. S. Dept, of Labor, January, 1903. SECTION 23 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
GEORGE M. KOBER, M. D., Washington, D. C. 
Aluminum.-This metallic element is silver-white, ductile, tenacious 
and very malleable, specific gravity 2.65. It is not oxidized by exposure 
to air or moisture nor tarnished by hydrogen sulphide. It resists the 
action of nitric and sulphuric and most of the organic acids. It is not 
found in nature in a metallic state, but is produced in an electric furnace 
from a mixture of cryolite with constant addition of pure clay. During 
this process according to Lehmann1 oxygen and fluorine develop at the 
anodes, which with carbon from the anodes form carbon monoxide 
and tetrafluor carbon. The latter in the presence of moisture generates 
hydrofluoric acid vapors which are very destructive to the surrounding 
vegetation of aluminum plants. 
Uses.-The metal is extensively used in the arts and in the manufacture of cook- 
ing, eating and drinking utensils, airplanes, etc. According to Lehmann, no injurious 
effects can be attributed to the metal itself during its production or use. The eating 
and cooking utensils give off only a few mg. a day and even the soluble salts of alumi- 
num like alum produce gastro-intestinal disturbances only when given in doses of 
several grams. A large number of the salts are used in pharmaceutical perparations, 
in the arts, dye and pottery industry and the natural aluminum oxide, in its impure 
state, is employed in the manufacture of abrasive material (see Emery and Corundum, 
page 171). 
Antimony.-This brittle silver-white metal is largely used as an alloy in type 
metal: 60 per cent, lead, 25 per cent, antimony, 15 per cent. tin. Hard lead: 3 per 
cent, antimony, 97 per cent. lead. Britannia metal: Antimony 8-10 per cent., 
copper 0-3 per cent., tin 90-92 per cent. In the manufacture of these alloys, and 
likewise in the remelting of old, and scrap metal, vapors of antimony or antimony 
oxide are evolved, the significance of which has remained somewhat obscure, although 
first pointed out by Lohmeyer2 cited by Lehmann1 who in a foot note suggests the 
possibility that some of the disturbances attributed to these vapors may be due to 
arsenic. 
On the other hand Erben3 considers that industrial antimony poisoning occurs 
among workmen in smelting antimony alloys and in making tartar emetic through 
inhalation of fumes of oxide of antimony. Rambousek4 refers to a workman in 
Hamburg engaged in pulverising pure antimony who was attacked with vomiting 
lasting several days and in another case the Inspector noted nose-bleeding and vomit- 
ing as following on the crushing of antimony ore. 
It was generally held that the chief danger from antimony alloys was lead, until 
Schrumpf and Zabel6 found among the younger operatives in a type-foundry very 
few cases of lead poisoning, but a goodly number presented the following clinical 
picture: "A remarkable facial expression, complaints of nervousness, irritability, 
sleeplessness, fatigue, dizziness, headache, both frontal and cerebellar, muscular pain, 
583 584 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
neuralgia in the extremities, nausea, loss of appetite, gastro-intestinal disturbances 
and constipation. Examination of the blood, apart from lower blood pressure, 
revealed a diminished leucocyte count and a notable eosinophilia. Antimony was 
found by the Marsh test in the fecal discharges. The symptoms disappeared after 
suspension of work for 2-3 weeks. The changes in the blood were also brought about 
by feeding rabbits with antimony sulphide and the oxide." 
P. Boveri6 fed rabbits metallic antimony suspended in oil in doses from 0.005- 
0.055 gm. every other day for a period of 30, 60 and 90 days, without apparent bad 
effects. Larger doses produced diarrhoea, with a progressive cachexia and death. 
As in lead and tobacco intoxications, so in antimony poisoning, abortions in pregnant 
animals are of frequent occurrence. Autopsies revealed hypertrophy of the heart and 
adrenals. The aorta and other arteries showed no alterations, such as are found in 
lead poisoning. (For antimony compounds see "List of Industrial Poisons," page 645.) 
According to Eulenberg cited by Lehmann,1 antimoniureted hydrogen which is 
given off in the burnishing of rifle barrels with antimony trichloride is not toxic but 
evolves very irritating vapors. In the manufacture of the antimonial salts, and in 
factories where they are used for enamel glaze, Rickmann claims to have seen no 
injurious effects. Lehmann, however, found, after boiling such utensels with a 4 
per cent, acetic acid solution, as much as 5 mg. of antimony per liter, and considers 
it injurious to health. Askanasy also objects on toxicological grounds to the employ- 
ment of this enamel known as "Leukonin" as a substitute for tin. 
The toxic effects of tartar emetics have been recognized for a long time, apart from 
producing pustular skin eruptions when applied locally. Bachem7 has shown that 
chronic ingestion of antimony produces serious degeneration of the internal organs 
without establishing a tolerance. 
Dr. Alice Hamilton8 could not find any evidence of antimonial poisoning in the 
examination of printers in 150 different shops, unless it was responsible for two bad 
cases of eczema of the hands and forearms of men working at the stereotype kettles. 
Her observations in the rubber industry where large quantities of golden and crimson 
sulphides of antimony are most carelessly used were also negative. She believes that 
since the men at the mixing mills are also handling litharge and lead sulphate that what 
symptoms they suffer from are much more likely to be caused by lead. In connection 
with this survey, Prof. A. J. Carlson of the University of Chicago found that 8 per 
cent, of the antimony in the crimson, and about 3 per cent, of the antimony in the 
golden sulphide was soluble in gastric juice, and considers it probable that this solu- 
bility is sufficient to be a source of danger to men who are obliged to use these com- 
pounds in such a way as to expose them to a good deal of dust, or who handle food or 
tobacco when their hands are smeared with these sulphides of antimony. 
Dr. Hamilton reports that antimony trisulphide is used in the manufacture of 
percussion caps and according to an expert of the Ordnance Department some cases 
of possible antimonial poisoning were reported during the war, but she considers it 
impossible to separate the effects of the antimony from those of the fulminate, as the 
symptoms referred to by the Ordnance expert, such as a local irritation of the skin and 
of the respiratory mucosa, might certainly be due to fulminate of mercury. 
REFERENCES 
1 Lehmann, K. B., Lehrb. d. Arbeits u. Gewerbehygiene, Leipzig, 1919. 
2 Lohmeyer, Casper, Wochschft., 1840, No. 17. 
3 Erben, Vergiftungen, Vol. II, page 285. 
4 Rambousek, Industrial Poisoning, 1913, page 146. 
6 A. Exper. Pathol., 1910, Bd. 63. 
6 Gewerbehyg., 1912, 23. Cited by Lehmann. 
7 Bachem, A., Experiment Pathologie, 64, 35. 
8 Hamilton, Alice, Jour. Industrial Hygiene, June, 1919, page 94. BARIUM, STRONTIUM, CADMIUM 
585 
Barium and Strontium.-According to Lehmann barium metal has 
no hygienic significance and even the salts of barium (Ba(OH)2, BaCl2, 
BaCO3) and BaS, although extremely toxic, have so far given no 
hygienic concern in the industries. He considers acute and chronic 
industrial barium poisoning theoretically possible in mills in which barium 
carbonate is ground up. In this connection it may be stated that a 
serious and often fatal form of poisoning among cattle and horses in the 
Southwestern states has been traced to the eating of certain plants, 
popularly called "loco" containing toxic, inorganic salts chiefly those of 
barium. 
Cadmium.-A metallic element resembling tin found in several of the 
ores of zinc. Dr. Stephens1 has recently published an article on cadmium 
poisoning based upon the post-mortem findings of a man who worked 
for many years at spelter works and who was supposed to be suffering 
from chronic plumbism. At the autopsy "the liver contained no lead and 
only a trace of copper. It also contained 0.91 grains of cadmium and 0.77 
grains of zinc per pound." During the last six years he has had 8 cases 
of a similar nature. The author refers to Erben, Kobert, Athanesia 
and Langlois, Kunkel and others in support of his contention that cad- 
mium possesses toxic properties and that men employed at zinc smelting 
are exposed to the absorption of cadmium in the form of fumes, and 
that these men experience symptoms not typical of lead poisoning, but 
similar to those attributed to cadmium. As cadmium is also used to 
make solders of low melting point it may be well to watch for symptoms 
of possible cadmium poisoning. On this point he says:- 
"Lead colic is a symptom once seen never forgotten, the agonizing 
paroxyms are characteristic, the patients roll about the bed or floor 
groaning or screaming. But I have only seen it in men from the lead 
works. The gastric symptoms of men who have worked at spelter works 
consist of marked pain or tenderness at the epigastrium, associated with 
nausea and some constipation. The patient is dull and heavy, with loss 
of appetite, thirst and unpleasant taste in the mouth and a thickly 
furred tongue. In some cases there is diarrhoea." 
Schwartze and Alsberg2 found that the chief effect of the oral adminis- 
tration of cadmium and zinc salts is emesis (cats), and that this depends 
upon the concentration of their salts rather than upon absolute amounts 
ingested. Cadmium is about nine times more effective as an emetic 
than zinc (400 parts, and 3500 parts, per million of raw hashed meat 
respectively). The lethal oral dose of cadmium salts (rabbits) is from five 
to seven times more toxic than zinc salts. Also, dilute solutions of cad- 
mium are more toxic than concentrated ones, although no differences 
were noted for zinc. Continued feeding of 250 parts of cadmium proved 
incompatible with life but there was no evidence of cumulative action or 
ill after-effects when slightly less was fed. Cadmium was not appreci- 
ably stored in any organs, though found in kidney, liver and occasionally 586 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
spleen. Cadmium precipitates proteid but not as actively as zinc so that 
zinc in meat diet is less toxic. This rapid proteid precipitation 
renders the study of subcutaneous injections useless; local irritation and 
indeed necrosis may follow. Intravenously, cadmium is rather less toxic 
than zinc, thus differing from the oral administration. (Hayhurst.) 
REFERENCES 
1 Stephens, G. Arbour, The Jour, of Industrial Hygiene, Vol. II, No. 4, Aug., 1920, 
page 129. 
2 Schwartze, Erich W., and Alsberg, Carl L., Studies on the pharmacology of cadmium 
and zinc with particular reference to emesis (to be published). Pharm. Labor., U. S. 
Dept, of Agr., Bur. of Chern. 
Calcium.-A yellow metallic element which does not occur naturally in 
a free state and the metallic element of lime, CaO, or quick lime, is 
obtained by roasting the carbonate of lime in a special kiln; addition of 
water produces Ca(OH)2 or milk of lime. The caustic action of quick lime, 
upon the skin and mucous membranes is well recognized, and its inhala- 
tion in the form of dust is also liable to produce inflammatory conditions 
of the respiratory passages, and occasionally ulceration and perforation of 
the nasal septum. The same is true of inhalation of basic slag dust. 
(See also lime burners, Thomas slag, and cement workers.) 
Calcium Carbide.-Is prepared by mixing equal parts of ground burnt 
lime and coke and melting it in an electric furnace at a temperature of 
about 3300 degrees, during which carbonic oxide is set free. The result- 
ing calcium carbide usually contains impurities such as silicon carbide, 
ferro-silicon, calcium sulphide and calcium phosphide. 
Acetylene.--C2H2 is generated by the decomposition of calcium 
carbide by means of water (C2Ca + 2H2O = Ca(0H)2 + C2H2). One 
kg. of carbide yields about 300 1. of acetylene gas, which in the raw state 
often contains ammonia, some sulphureted and phosphoreted hydrogen 
which are removed in the Wolff method by passing the gas through a 
washer, and* a purifying material consisting of chloride of lime and bichro- 
mate salts. In the Frank's method the gas passes through a system of 
vessels containing an acid solution of copper and also through a washer. 
Chloride of lime with sawdust is used as a purifying agent. The gas is 
highly explosive. It yields a very brilliant white flame. The possibili- 
ties of poisoning from impurities like carbon bisulphide, carbonic oxide 
present to the extent of 1-2 per cent, and phosphoreted hydrogen gas 
should be kept in mind. According to Jchle (Z. f. Gewerbehyg., 1901, 
pages 245-261) American calcium carbide yields acetylene containing 
0.04 per cent, of phosphoreted hydrogen. 
S. Pontopidan (Jour. Am. Med. Assoc., Nov. 25, 1921) reports a case of acetylene 
poisoning. The symptoms and circumstances indicated phosphoreted hydrogen 
poisoning in a young mechanic who had been using a blow flame of oxygen and 
acetylene. CALCIUM CYANAMIDE 
587 
Calcium nitrate, also known as calcium cyanamide, is produced by the 
action of nitrogen isolated from the atmosphere upon calcium carbide 
on a large scale, and sold as a valuable fertilizer. It contains, apart 
from nitrogen, about 31 per cent, of caustic lime, 16 per cent, of carbon 
and small quantities of other material of which calcium carbide, because 
of its explosive properties and phosphate of lime, which is liable to evolve 
phosphoreted hydrogen, are the most important. 
According to Koelsch1 workers in factories where calcium nitrate is 
produced are subject to a peculiar form of industrial poisoning, which is 
attributed to calcium cyanamide in the dust inhaled. The symptoms do 
not develop until some alcoholic beverage is taken; then the head becomes 
hot and flushed while the limbs feel cold. Pulsation is felt in the chest 
and neck, while respiration becomes difficult. Even minute quantities of 
alcohol may produce these symptoms. The face and neck then become 
cyanosed while the trunk and arms acquire a bright red-colored rash, 
unaccompanied by any great rise in temperature. The reflexes remain 
normal, and the senses are unimpaired. In severe cases giddiness and 
jactation occur. The duration of the attack is variable, according to the 
amount of alcohol taken. When vomiting or diarrhea occurs, instant 
improvement follows, and the rash immediately fades. No permanent ill 
effects have been observed hitherto. No case of acquired immunity 
has been recorded. A few hours' stay in the dusty factory is sufficient 
to render a workman liable to attack. Total abstainers are not 
affected. 
Similar observations were noted by Hayhurst in the Ohio Occupational 
Disease Survey (page 349) and have been reported to me by the chemist of 
a cyanamide plant in New York. Koelsch2 states that without the 
influence of alcohol 10 grams may be ingested without apparent effect, 
while with alcohol the inhalation of dust suffices. Experimentation on 
rabbits have shown that one gram doses per orem produce no effect until 
after the ingestion of alcohol. 
The employment of these fertilizers, owing to the caustic effects of 
quick lime, etc., gives rise to inflammatory conditions of the eyes, skin 
and mucous membranes of the mouth, nose and respiratory passages. In 
some instances, especially when working in wet or defective clothing, 
extensive denudations of the skin have resulted (Koelsch).3 
Pavia4 reports that calcium cyanamide has produced under similar conditions in 
Italian peasants severe lesions of the mucous membrane of the nose, throat and 
skin especially of the forearms. He also described a case with severe burning 
pains on the forearms and knees in which vesicles formed, and then slowly 
healing ulcers. Lesions from calcium cyanamide usually require from 20 to 40 
days to heal. 
E. Hesse5 points out that, apart from the effects already referred to, it is liable 
to injure the respiratory apparatus, and to induce an affection resembling the 
hyperemia of amyl nitrite, with malaise and acceleration of the pulse. 588 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
REFERENCES 
1 Koelsch, F., Munch. Med. Woch., 1914, page 1869. Pharm. J., 1915, 94, 241. 
2 Koelsch, F., Deut. Viert. off. Ges., 1915, Bd. 47, page 326. 
3 Zent. Gewerb. Hygiene, 1916, page 113. 
4Pavia, Giuseppe.-Il Lavoro, September 30, 1920, pp. 131-134. Abstr. Jour. Ind. 
Hygiene, Feb., 1921, p. 199. 
5Hesse, E., Med. Klin., April 9, 1922; Abst. in J. A. M. A., June 17, 1922. 
Chromium.-A metallic element extracted from native lead or iron 
chromate. Lehmann1 states that his feeding experiments on animals 
in doses of 2-5 mg. of Cr as mono- and bichromates per 1 kg. continued 
for 3 to 16 months produced no visible effects. Inhalation experiments 
in cats with chrome vapors produced severe bronchitis. In man of average 
weight of about 70 kg., from 10-30 mg. of potassium bichromate (2, 5-8 
mg. Cr) appear to be tolerated without injury, and even larger doses 
have been given for therapeutic purposes with good effects. 
Cases of poisoning are not uncommon however in the manufacture of the bichro- 
mates and may be caused by the steam escaping from the hot chrome liquors and by the 
dust evolved in the drying, crushing and packing of these salts. Lehmann has found 
from 0.1 to 0.5 mg. and Fischer from 0.1 to 37.2 mg. of chrome per cubic meter in the 
air of workrooms. The air at a breathing level of a crushing room cited by Rambou- 
sek contained from 3.30 to 6.30 mg., and in a packing room 1.57 mg. per cubic meter. 
Lehmann even under most unfavorable conditions was unable to find any evidence 
of injury to the kidneys. 
Eczema and characteristic chrome ulcers are the most common manifestations 
of industrial poisoning. Lehmann's statistics show that of 722 persons engaged in 
the manufacture of chromates. 252 suffered from chrome ulcers and perforations of 
the septum; of 257 workers observed by Hermanni2 107 had ulcers and 87 perforations. 
These ulcers are not confined to the nose, but may develop in the tonsils, palate, 
wind pipe, on the arms and in other parts of the body. Diseases of the respiratory 
organs were observed by Lehmann in 8.8 per cent, and diseases of the intestinal system 
in 12.3 per cent, of his cases. 
Cases of chrome poisoning have occurred in nearly every industry enumerated 
on page 651 and next to the manufacture of the salts, the tanning industry and the 
manufacture of safety matches produce the greatest number of cases. Occasional 
cases are also reported in the calico-printing and in the dyeing industry, in glass 
workers and in photographers who employ a bichromate developer, etc. The use of 
bichromate of lead involves an additional element of danger from lead poisoning. 
Preventive Measures.-The machinery used for grinding the raw 
material, such as chrome ironstone, lime and soda, and also of the finished 
product, should be impermeable and supplied with efficient exhaust ven- 
tilation. The latter is also necessary wherever dust or steam is evolved. 
Respirators, impermeable gloves, anointing face and hands with vaseline, 
proper working suits and caps, efficient general ventilation, frequent 
ablutions, special lunch rooms, baths, and change of clothing upon cessa- 
tion of work are recommended. Frequent medical inspections, prompt 
treatment of skin affections and chrome ulcers, change of work, and a 
constant educational campaign will do much toward the prevention of 
disabilities. MANGANESE 
589 
REFERENCES 
1 Lehmann, K. B., Arbeits u. Gewerbehygiene, Leipzig, 1919. 
2 Hermanni, Munch. Med. Wochnschft., 1901, No. 14, page 536. 
Manganese.-A metallic element, grey, hard, brittle and very difficult 
of fusion, and, like iron, forms both basic and acid salts. The metal itself 
is used as an alloy with steel or nickel. The raw material of the mangan- 
ese industry is manganese dioxide or "brown mineral" which occurs 
chiefly as a pyrolusite and in this country is mostly obtained from an ore 
of which zinc is the principal product. The ore is run through crushers and 
screens by means of magnetic belts; those containing iron and manganese 
are picked off by the belts and deposited in bins. The crushing, grinding 
and sifting is a dry process and the workers are exposed to the inhalation 
and swallowing of this dust. The pure, finely ground, washed and dried 
manganese dioxide is the starting point for all manganese preparations. 
It has been employed in the recovery of chlorine by the Weldon process, 
in the production of oxygen gas and of permanganate of potassium. 
Manganese is also used in the manufacture of dry batteries; in glass works 
as a coloring and discoloring agent; in the cement and ceramic industries, 
(stove tile, glazed brick, etc.) for coloring and glazing purposes and in the 
production of anilin colors; both the natural and artificial umber contain 
it. It is also used as a dryer in the varnish and oil -industry, and for 
coloring and graining of soaps. 
Toxicology.-According to Rambousek1 manganese and its compounds are 
dangerous when absorbed in. the system as dust. This statement is perhaps too sweep- 
ing as the presence or absence of protoxids may determine the relative toxicity of the 
dust. It has been shown that ores from the Caucasus containing only small quantities 
of protoxids are less toxic than those derived from Thuringia and Japan, which are 
rich in protoxids. Acute cases of manganese poisoning have never been reported, and 
feeding experiments in animals, both in this country and abroad have so far proved 
negative. Investigations by Reiman and Minot2 in the Laboratory of Applied 
Physiology at the Harvard Medical School demonstrate that pres containing mangan- 
ese as oxids and silicates are soluble in gastric juice. Prolonged feeding of large 
amounts of manganese ore failed to produce significant changes in manganese content 
of the blood and tissues or to cause any pathologic symptoms, and the conclusion is 
reached that in order to produce symptoms of poisoning, manganese ores must be 
ingested by persons who are peculiarly susceptible. All the cases of chronic poisoning 
appear to have been contracted in persons engaged in dusty processes. 
Historical.-Couper3 as early as 1837 reported five cases of nervous disorders which 
he attributed to the cumulative effects of manganese in workmen who ground man- 
ganese dioxide, but little or no attention was paid to the malady until Von Jacksch4 
described three cases in persons, who before the onset of the disease had been employed 
for six, nine and eighteen months respectively in the drying of Weldon mud, the dioxide 
of manganese having been used for the recovery of chlorine. In the same year 
Embden5 described three similar cases which were seen in Hamburg in men who were 
exposed for several months in grinding manganese dioxide. Later Von Jacksch4 
reported other cases and referred at the same time to a case of manganophobia among 
the workers who recovered in the course of three weeks, evidently a case of hysteria, in 
which the symptoms of manganese poisoning were simulated. 590 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
From 1903 to 1913 Friedel,6 Seiffer,7 Seebert8 and Chop9 reported additional cases 
of chronip manganese poisoning, making in all about 20 cases described in foreign, 
chiefly German, literature. In all of these cases the disease developed in persons 
engaged either in the drying of Weldon mud or in grinding the ore. The literature has 
been greatly enriched by Casamajor10 and Edsall11 and his coworkers. The former 
in 1913 reported 9 cases occurring in men who were working in the ore separating 
house of a large zinc mine, where the separation, as already stated, is effected by 
magnetic belts. The lower floor of the mill was devoted to the wet portion of the 
separation, and was free from dust. All of the patients came from the floor where 
dust was thickest. Casamajor in 1916 prepared an able article on this subject for 
Kober and Hanson's "Diseases of Occupation and Vocational Hygiene," p. 119. 
In 1919, Edsall, Wilbur and Drinker11 published a most exhaustive review of 
"the occurrence, course and prevention of chronic manganese poisoning" based upon 
the previous literature, and 38 new cases, all of which, with one exception, had occurred 
in the dusty parts of the same mill referred to by Casamajor. These authors inform 
us that the crude ore from this mill contains about 9 per cent, manganese combined 
as oxides and silicates. Lead is only present in most minute traces, and arsenic is 
entirely absent. The exceptional case referred to was in a man who developed the 
disease as a result of eight months spent in shovelling Japanese manganese ore into a 
hopper, an extremely dusty process. In 1920, the case of a totally incapacitated 
workman was reported to the Ohio State Department of Health, of some 4 years' stand- 
ing. Many specialists had seen him and several diagnosis were rendered, but it 
remained for Dr. Cranch at the plant where he had worked for 2 years at a mangan- 
ese mill to suggest what jvas undoubtedly the true diagnosis,-Mn poisoning. His 
symptoms resembled, most closely, multiple sclerosis. Ultimately, his successor 
at the mill began to show similar symptoms, but was removed before serious injury 
resulted. 
Portal of Entry.-The general conclusion arrived at by Edsall and his 
coworkers is that manganese may be absorbed both from the lungs and 
from the gastro-intestinal tract. 
"In only one case definite symptoms occurred after only 14^ months' 
work; the most rapid development of permanent crippling either in this 
country or abroad has required four months and five days exposure to a 
dusty atmosphere. The ore in question is readily soluble in the hydro- 
chloric acid of the gastric juice." Lehmann12 states that the solubility 
of MnO2 is gastric juice is very slight, as compared with MnO and Mn3O4. 
Pathology.-The symptoms of chronic manganese poisoning are quite 
definite, and there is little or no difference in the reports of clinical his- 
tories, presented by the various authors above cited. In addition to the 
symptoms enumerated on page 654 Neisser13 refers to headache, dizziness, 
loss of appetite, constipation, loosening of the teeth, lancinating muscular 
pains and general debility as symptoms observed in some of the workers 
in manganese. Edsall11 and his coworkers have never seen either the 
salivation or edema described in foreign cases. This may be explained 
by their own statement. When speaking of prevention they write: 
"Apparently some of the German cases working in a dust of practically 
pure manganese dioxide have been more severe than any, with one 
possible exception, seen in this country." But even in the foreign cases 
there have been great differences in the severity of the symptoms, influ- MANGANESE 
591 
enced doubtless by the susceptibility of the patient, dosage and whether 
or not the ore contained protoxide. 
No postmortem findings have appeared in foreign literature, as the 
disease itself so far has never proved fatal. One of Casamajor's advanced 
cases came to autopsy, the patient dying of pneumonia, and in this 
instance the pathological findings were so peculiar that he felt reluctant 
to speak of them as of nosological importance, until further similar obser- 
vations may confirm them. His description has been summarized as 
follows: 
Gross observations showed no changes in the brain, kidneys, liver, nor spleen. 
Microscopical observations showed the following changes: 
Kidneys.-A moderate chronic interstitial nephritis was present. 
Liver.-There was considerable biliary cirrhosis and the liver cells contained much 
pigment, the majority of the granules being iron-containing. 
Brain.--There was some degeneration of more or less regular character in the longi- 
tudinal fibres in the pons which run with those of the pyramidal tracts. While 
these degenerations are regular enough to be assembled into clearly defined tracts, 
nevertheless, it was not possible to determine exactly either the upper or lower level 
of the tracts in question. The degenerated portion does not appear to go above the 
upper level of the pons, nor does the lower portion extend to any appreciable extent 
into the medulla. . . . The pyramidal tract elements are clearly defined, and those 
of the fronto-pontine and temporo-pontine tracts are fairly so. 
Diagnosis.-Edsall and his coworkers have given the following find- 
ings which make up the syndrome of chronic manganese poisoning as seen 
by them, numbered in the most common order of appearance. 
"1. A history of work in manganese dust for at least three months. 
(2) Langour and sleepiness. (3) Stolid, mask like facies. (4) Low mono- 
tonous voice. Economical speech. (5) Muscular twitching, varying in 
degree from a fine tremor of the hands to gross rhythmical movements of 
the arms, legs, trunk and head. (6) Cramps in the calves and a complaint 
of stiffness in the muscles of the legs, the cramps usually coming on at 
night, and being worse after a day of exertion. (7) Slight increase in 
tendon reflexes. (8) Ankle and patellar clonus. Frequently, by stretch- 
ing any of the muscles of the body, it is possible to elicit rhythmical con- 
tractions. Romberg sign is inconstant; there is no incoordination. 
(9) Retropulsion and propulsion. (10) A peculiar slapping gait. The 
patient keeps as broad a base as possible, endeavoring involuntarily to 
avoid propulsion. The shoes are worn evenly and we have not been able 
to convince ourselves of the pronounced tendency to walk on the region 
of the metatarso-phalangeal joints, a feature strongly emphasized by von 
Jacksch. (11) Occasionally, uncontrollable laughter, less frequently 
crying. (12) Uniformly absent are any disturbances of deep or superficial 
sensation, eye changes, rectal, genito-urinary or gastro-intestinal dis- 
turbances, reaction of degeneration, blood, urine, and spinal fluid altera- 
tions. It is significant that, unlike lead, manganese produces no 
life-shortening degenerations. Seriously poisoned men are long-lived 592 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
cripples. The metal apparently makes a very definite attack upon some 
non-vital portion of the neuro-muscular system, destroys it thoroughly, if 
time for action is permitted, and leaves the victim quite well in every 
other respect." 
Embden15 reports another case of manganese dioxide poisoning in a grinder. 
The first symptom was stuttering; then came tremor of the hands, "character- 
istic action tremor;" then walking became more difficult. 
Treatment.-Early cases recover spontaneously if placed in a dust-free 
atmosphere, but as in all other forms of chronic metallic poisoning the 
treatment in advanced cases is of little or no avail. Some authors speak 
approvingly of eliminative measures through the kidneys, skin and 
the intestines, and also of baths, electricity, massage, exercise, etc. 
Preventive Measures.-The writer shares the opinion of Kaup14 
enunciated at the International Congress on Hygiene at Berlin in 1907 
that cases of chronic manganese poisoning are more common than is 
generally supposed and expresses with him and Edsall the hope that 
industrial physicians having opportunities to observe men handling man- 
ganese compounds will be prepared for a prompt recognition of all suspi- 
cious cases. It has been shown by von Jacksch that in the factory where 
he made his observations no new cases occurred when the dust was 
abolished. This is not always completely possible. But Edsall11 and 
his coworkers "have never seen a case of manganese poisoning develop 
as a result of work in a very thick dust averaging 5-6 per cent, of man- 
ganese, while in the same neighborhood the cases we have described have 
come from a mill, also thick in dust with a manganese concentration of 9- 
12 per cent. This latter concentration seems to be just able to poison 
if present in air thoroughly laden with dust." 
Casamajor writes that in the mill referred to the amount of dust in the 
air has been greatly reduced by the introduction of an elaborate suction 
and bag filter system and now, that the condition is known, any man who 
shows symptoms even resembling those of manganese poisoning is 
immediately removed from the dust and set to work outside in the open, 
and as a result no serious cases have occurred. 
In addition to effective ventilation, etc., suitable work clothes, facili- 
ties for ablutions, mouth washes and gargles before meals, supplemented 
by shower baths and change of clothing upon cessation of work should 
be insisted upon. 
REFERENCES 
1 Rambousek.-Industrial Poisoning, London, 1913, page 59. 
2 Rieman and Minot.-J. A. M. A., March 26, 1921, page 867. 
3 Couper.-Jour, de Chemie med., etc., 1837, second series, 223. 
4 von Jacksch.-Munch. Med. Wochschft., 1901, 612: 1907, 969. 
6 Embden.-D. Med. Wochschft., 1901, 27, No. 4, 795. NICKEL 
593 
6 Friedel.-Zeitschft. f. Med. Beamte, 1903, 16, 614. 
7 Seiffer.-Berl. Klin. Wochschft., 1904, 41, 370. 
8 Seebert.-Monatschft. f. Psychiat. u. Neurol., 1913, 34, 82. 
9 Chop.-Inaug. Dissert., Jena, 1913. 
10 Casamajor.-J. A. M. A., 1913, 60, 646. Diseases of Occup., Kober and Hanson, 
1916, pages 119-125. 
11 Edsall, Wilber and Drinker.- Jour. Indust. Hygiene, August, 1919, Vol. 1, No. 4, 
pages 183-193. 
12 Lehmann.-Lehrb. d. Arbeits. Gewerbehyg., 1919, page 226. 
13 Neisser.-Internat. Uebersicht uber Gewerbehygiene, Berlin, 1907. 
14 Kaup.-Internat. Congress of Hygiene, Berlin, 1907. Zeitschft. f. Gewerbehygiene, 
Wien, 1907, page 477. 
15 Embden.-Deutsche med. Wochnschr., Vol. 48, No. 14, April, 1922, 472; K. R. 
Drinker, Jr. Ind. Hyg., Abst., Jan., 1923, page 145. 
Nickel.-A white hard metal found in the metallic state in meteoric 
rocks, spec. gr. 8.9, melting point 1500°C. (Lehmann1) and because of its 
malleability, tenacity and non-corrosive properties, except in the presence 
of acids, has come into general use. 
German silver (Britannia metal) contains 50 per cent, of copper 
and 25 per cent, each of nickel and zinc. Similar compositions are also 
used for nickel coins. (Lehmann.) 
Nickelsteel contains about 3 per cent, of nickel and is especially 
adapted for steel armor plates. (Lehmann.) 
Mond metal contains 70 per cent, of nickel and 30 per cent, of copper 
and is quite generally used in the manufacture of propellers and marine 
screws. It is also rolled upon other metal sheets. (Lehmann.) 
In the extraction of nickel, when derived from arsenical ore, there is 
danger from arsenical fumes during the roasting operations. Nickel 
per se is free from toxic properties, for it has been shown by Lehmann1 
that in spite of the universal use of nickel cooking, eating and drinking 
utensils, during which at a single meal as high as 117 mg. of nickel may be 
ingested, no bad effects have been observed. Animals which were fed 
with their meals 4-5 mg. N per kilo of their weight, in the form of nickel 
salts, showed no injurious effects in spite of a very marked accumulation 
of nickel in the system. 
The salts of nickel may prove toxic under the certain circumstances. 
Mond in 1890 discovered that by passing a current of carbon monoxide 
over finely divided metallic nickel, a gaseous compound of nickel and CO 
was formed. When heated to 150°F. the gas is decomposed into its 
constituents and metallic nickel is deposited. 
Nickel carbonyl (NiCO^ is a clear, pale, straw-colored liquid which 
boils at a temperature of 43°C. This salt is quite volatile and a peculiar 
soot-like color is perceptible when present in the air to the extent'of 
12,000,000 vols., while a Bunsen flame becomes luminous when it is 
present to the extent of 1,400,000 vols. These two characteristics are 
relied upon to detect the escape of the gas during the manufacture of 594 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
nickel carbonyl, which, on account of its toxic properties, must be carried 
on in hermetically closed iron chambers. 
The process was introduced in the beginning of the present century and about 25 
workmen were poisoned, some fatally, before the danger was fully recognized. In the 
milder forms of poisoning the men suffer from headache, giddiness, unsteady gait, 
nausea and at times dyspnoea, which symptoms quickly disappear upon removal to 
fresh air. In the more severe forms, the dyspnoea, after a lapse of 12 to 36 hours, is 
increased, accompanied by cyanosis, a rise in temperature, and cough, with more or 
less blood-stained expectoration. The action of the heart is usually found to be 
increased, but otherwise normal. Delirium of varying types is generally present. 
According to H. W. Armit2 the fatal cases terminated between the fourth and eleventh 
days. Post-mortem examination revealed hemorrhages in the lungs, oedema of the 
lungs, and hemorrhages in the white matter of the brain. Some doubt exists as to 
whether any blood changes were present. Oliver states that some of the deaths were 
almost instantaneous. In the case of one man who died after 3 days' illness the lungs 
were found to be oedematous and intensely congested. In another case there was 
inflammation and consolidation of the lungs. In the third case, who died on the eighth 
day, numerous hemorrhages were found in the brain and cerebellum and the nerve cells 
of the respiratory nucleus in the medulla oblongata showed distinct chromolytic 
changes. For some years it was believed that these cases were instances of carbon 
monoxide poisoning. 
Armit2 experimented upon animals to determine: (1) whether the symptoms and 
lesions observed in nickel carbonyl poisoning were caused wholly or in part by the CO 
of the compound; (2) whether nickel carbonyl is absorbed as such; and (3) whether the 
nickel of the compound is the toxic factor. He concluded that the poisonous effects 
of this compound are due to nickel and not to carbon monoxide, and thinks the 
peculiar toxicity is caused by a deposit of nickel, as a slightly soluble compound in a 
very fine state of subdivision, over the immense area of the respiratory surface, where 
it is dissolved by the tissue fluids and is then taken up by the blood. The hemor- 
rhages found after death are in his opinion caused by fatty degeneration of the vessel 
walls, the specific pathological change having been set up by the nickel. 
Iron Carbonyl.-A light sherry-colored liquid which according to 
Oliver3 is, like nickel carbonyl, extremely volatile and equally poisonous. 
Preventive Measures.-As cases of nickel carbonyl poisoning occurred 
only when hand labor was used, during a breakdown of the automatic 
machinery, it is important that the utmost precautions for the detection 
and removal of the gas be taken. 
Nickel Plating.-The men engaged in nickel plating not infrequently 
develop a peculiar, eczematous, vesicular inflammation or ulcers of the 
skin affecting the hands and arms and occasionally also other portions of 
the body. The disease is attributed by some authors to the caustic 
action of nickel salts, especially nickel sulphate or nickel cyanide, em- 
ployed in the electrolytic bath. Others hold that such agents as alkaline 
cyanides, caustic potash or soda, benzene, petroleum, soap, and lime, 
which are quite generally used in all plating processes, are responsible 
for the mischief, while still others maintain that it is the result of a 
combined action of various irritants. Whatever the exact cause may be, 
careful attention to the skin, in the way of cleanliness and the application 
of vaseline or cold cream, are indicated as protective measures. OSMIUM, SELENIUM, TELLURIUM 
595 
REFERENCES 
1 Lehmann, K. B.-Arbeits. u. Gewerbehyg., Leipzig, 1919, page 226. 
2 Armit, H. W.-Journal of Hygiene, July, 1907. 
3 Oliver, T.-Diseases of Occupation, London, 1916, page 74. 
Osmium.-This rare metal is used in the manufacture of filaments 
for incandescent electric lamps because it does not melt in a vacuum. On 
the other hand it oxidizes very rapidly into colorless crystals of hyperos- 
mic acid, 0s04, which are very volatile, giving off a pungent poisonous 
vapor. This may occur at an ordinary room temperature while using a 
1-2 per cent, watery solution as a reagent in histological work for fatty and 
nerve tissues. The fumes are quite irritating to the mucous membranes 
of the eyes and nose, and in larger volume have produced diseases of the 
lungs and skin, blindness and even fatal cases of pneumonia and inflam- 
mation of the kidneys. (See Eulenburg, Berl. Klin. Wochschft., 1884, 
No. 7 and Frankel, ibid., 1884, No. 15, cited by Lehmann.1) 
Selenium and Tellurium.-The former is a non-metallic element 
having properties like sulphur. Tellurium is a rare metallic element 
found in the gold mines of Transylvania and also in Colorado. Both of 
these substances, according to Lehmann,1 are non-poisonous. The acid 
salts are moderately toxic and their transformation in the system into 
selen dimethyl or tellurdimethyl imparting to the breath and perspiration a 
garlic odor have been regarded for some time as interesting if not signifi- 
cant. But up to 1920 no cases of industrial poisoning had been reported. 
Tellurium as an Industrial Health Hazard.-On April 16th, 1920, Shie 
and Deeds2 of the U. S. P. H. S. published a preliminary report on this 
subject. From this interesting report we learn that tellurium may be 
prepared from its minerals or from the residue in several metallurgical 
processes. It may also be extracted from the slime resulting from the 
electro-refining of copper and lead and some other metals. The slimes 
from the electro-refining of lead contain larger amounts of tellurium than 
of selenium, which almost always accompanies tellurium, while the slimes 
from the copper electro-refining tanks contain a larger percentage of 
selenium than tellurium. 
Uses.-Tellurium has been used to some extent in a medicinal way, but 
the largest use in the past has been as a coloring agent in the manufacture 
of blue, red, and brown glass. 
The possibility that tellurium might act as an industrial health hazard 
first came to the attention of Shie and Deeds in the fall of 1918 while 
making a study of lead poisoning in an electrolytic lead refinery. During 
this study it was noted that practically all the men from one department 
smelled strongly of garlic. At first this odor was really attributed to 
garlic, until it was ascertained that no garlic had been eaten by these men. 
Further investigation revealed that a number of these men complained 
of dry skin and loss of the sweat function. As such findings could not be 596 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
attributed to lead poisoning further study suggested tellurium as the 
possible cause. The men in question were working in the silver refinery 
around blast furnaces and subjected to high temperatures. Here the slime 
from the electrolytic tanks was treated to remove the Dore metal, and 
tellurium was encountered as an impurity. The temperature attained 
in the blast furnaces was about 1200 to 1400 degrees F. and tellurium 
fumes probably in the form of hydrogen telluride were given off. Tellu- 
rium was also present in the dust about the furnaces, probably in the form 
of the oxide and telluride. 
Entrance into the Body.-The authors conclude that the main chan- 
nels of entry are the respiratory and digestive tract. They are inclined 
to believe that the salts of tellurium can also be absorbed through the 
skin. This seems to be particularly true of tellurous acid, as a short 
time after the substance has been handled the garlic odor of methyl 
telluride appears in the breath. 
Pathology and Symptomatology.-The authors state "Inasmuch as 
we have not yet been able to study the pathology of tellurium poisoning 
upon human subjects, we must rely upon the results of animal experi- 
mentation for this information. We know that in man tellurium causes 
a suppression of the secretion of saliva and of the sweat. In animals 
even small doses markedly reduce the secretion of acid in the gastric juice 
and stimulate the secretion of mucus in the stomach and intestines. 
These effects are apparently due to a paralysis of the terminations of the 
secretory nerves similar to that induced by atropin. The capillaries of 
the splanchnic area are dilated as with arsenic. In more severe poisoning 
in animals there is inflammation and disintegration of the mucous mem- 
brane of the gastro-intestinal tract, with intestinal hemorrhages. There 
is an intense hyperemia of the organs, with multiple hemorrhagic foci. 
Before death there is an intense degeneration of the red cells, with a 
diminution of hemoglobin. Myelocytes, normoblasts, and other cells 
denoting destruction and regeneration of red cells, may be found. There 
may also be considerable leucocytosis. As a result of the increased fragil- 
ity and destruction of the red cells, large quantities of urobilin, together 
with some hemoglobin, are usually found in the urine. In many instances 
a large quantity of some reducing substance is present . . . Large doses 
produce some albuminuria due to a parenchymatous nephritis." 
In the investigation 13 men were examined; 7 showed evidence of 
tellurium absorption as indicated by the garlic odor to the breath, sweat 
and urine, dryness of the mouth and metallic taste. Five of them had a 
considerable inhibition of the sweat function and the two who did not, had 
worked only two weeks. Three of the five had a dry itching skin, anorexia, 
nausea, some vomiting and some degree of depression or somnolence. 
The tellurium poisoning encountered thus far in industry has not been 
severe. The primary effects are suppression of the sweat, of the saliva, 
and of the acid in the gastric juice. This leads to a dry, itching skin, TELLURIUM, TITANIUM, CERIUM 
597 
dry mouth, metallic taste, anorexia, nausea, vomiting, indigestion, and 
constipation. Somnolence is often a prominent symptom. The earliest 
symptoms of tellurium absorption is the garlic odor of the secretions and 
excretions due to methyl telluride. Secondary effects to be expected are 
impaired nutrition with emaciation and, where the workers are exposed 
to high temperatures, increased susceptibility to heat exhaustion. 
Luzzati and Levi Angela3 presented the result of their research into the toxicology 
of tellurium. They show that sodium telluride is one of the most powerful of hemolytic 
poisons. The microscopic lesions in the organs following poisoning by tellurium 
compounds are secondary to the intense anemia and the hemoglobinuria; but the lesi- 
ons are not profound. They were not able to demonstrate urobilin or urobilinogen in 
the urine showing that the liver functions well. Histologic examination bears this out, 
for there are few lesions in this organ. They also call attention to the absence of 
icterus. 
Prognosis so far has been good, the condition gradually improving 
upon prompt removal of the cause. This is due to the fact that no serious 
cases have thus far been encountered. It is thought that the progno- 
sis will be less favorable when more severe poisoning occurs as a result of 
greater absorption of tellurium incident to its increased production. 
Preventive measures are similar to those used for other metallic 
poisons and may be summed up as good working conditions and proper 
personal hygiene. 
Treatment.-The most important measure is the removal of cause. 
After that, pilocarpin may be used to counteract the effect of the tellu- 
rium; the avenues of elimination should be opened and excretion favored 
by promoting secretions, diuresis, and free bowel movements. Hydro- 
chloric acid may be administered to remedy the deficiency of acid secre- 
tion. The remainder of the treatment is symptomatic. 
Titanium and Cerium.-The former is a hard metal discovered by 
Klaproth in 1795, spec, gravity 5.8. It is used in the preparation of tita- 
nium bronze and as a mordant. The acid salts of titanium are insoluble 
in water and have recently been used like bismuth in X-ray examinations 
of the gastro-enteric tract. Lehmann1 has not heard of any injurious 
effects. 
Cerium iron, an alloy of 70 per cent, of cerium and 30 percent, of 
iron, is used in the manufacture of patent lighters in which the sparks 
produced by friction ignite a benzine wick. Lehmann1 has had verbal 
reports about the toxicity of cerium compounds but found nothing in 
the literatus. 
Uranium, Wolfram (Tungsten), Molybdenum.-Kobert considers 
uranium the most toxic of all metals. Wolfram is less, and molydenum 
is still less poisonous. 'Uranium oxide is used to produce a yellow fluores- 
ence in glass, the sodium diuranate is also a coloring agent, nitrate of 
uranium is employed as a therapeutic agent, also in phosphoric acid titra- 
tion and in photography. 598 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
Tungsten is employed in the manufacture of filaments for incandescent 
electric lamps. Tungsten and molybdenum are also used in the steel 
industry. Molybdic acid, phospho-molybdic, and phospho-tungstic acid 
are employed as reagents. No reports of industrial poisoning from these 
substances have come to Lehmann's1 attention. 
REFERENCES 
1 Lehmann, K. B.-Arbeits. u. Gewerbehygiene, Leipzig, 1919. 
2 Shie, Marvin D. and Deeds, Forrest E.-The Importance of Tellurium as a Health 
Hazard in Industry; a preliminary report. Public Health Reports, April 16, 
1920. 
3Luzzati and Levi Angela, Il Lavoro, Nov. 30, 1920, XI, No. 7, 204-205. Abstr. 
Jour. Ind. Hyg., May, 1921, page 6. 
Sodium.-A brilliant, monatomic silver white metal discovered by 
Davy in 1808, resembling potassium in its general character. It is soft, 
malleable, fusible at 96°C. (204°F.) and burns when heated in contact 
with air. Spec, gravity 0.97, at. wt. 22.88; symbol Na. 
It is obtained by electrolysis from caustic soda and is employed 
in the production of cyanide of sodium which is used in the extraction of 
gold. Lehmann1 states that sodium is quite inflammable on wet clothing 
and has been known to cause fatal burns. The super-oxide of sodium 
is employed for numerous technical purposes and when carelessly mixed 
with moist organic matter is liable to ignite and cause slight explosions. 
Caustic soda (NaOH) is produced by introducing slaked lime into soda 
liquor in the iron caustic pots, heating with steam and agitating by 
blowing in air. The resulting clear solution is drawn off and evaporated 
in cast-iron pans. It is also obtained by electrolysis from chloride of 
sodium, in which chlorine is formed at the anode and caustic soda at the 
cathode; the latter is treated with carbonic acid to make soda. 
The production of hydrochloric acid (HC1), sodium sulphate (Na2SO4) 
and sodium sulphide (Na2S) forms part of the manufacture of soda 
(Na2CO3) by the Leblanc process, which is still largely employed, although 
it is apparent that it will be superseded by the Hargreave and the Solvay 
ammonia soda process. 
For want of space we can give only a brief outline of the various 
processes condensed from Rambousek's book on Industrial Poisoning.1 
1. Leblanc Soda Process.-The first part of the process consists in 
the production of the sulphate of soda from salt and sulphuric acid, 
during which hydrochloric acid is formed; this is carried out in two stages, 
represented in the following formulas: 
(1) NaCl + H2SO4 = NaHSO4 + HC1. 
(2) NaCl + NaHSO4 = Na2SO4 + HCL 
The first stage in which bisulphate is produced is carried out with 
moderate heat, the second requires a red heat. The reactions are made LEBLANC SODA PROCESS 
599 
in a furnace, combining a pan and muffle furnace. First, common salt is 
treated with sulphuric acid in the cast iron pan and when the generation 
of hydrochloric acid has ceased, the sliding door is raised and the partly 
decomposed mixture is pushed through the muffle, constructed of fire 
resisting brick and tiles and surrounded by the fire gases. While the 
muffle is raised to a red heat, the sulphate must be repeatedly stirred 
with a rake in order, finally, while still hot and giving off acid vapor to be 
drawn out at the working doors into iron boxes provided with doors where 
the material cools. The acid vapor given off while cooling is drawn 
through the top of the box into the furnace. Mechanical stirrers, because 
of their advantage from a health point of view, should not be abandoned 
because of their short life. 
The valuable by-product of the sulphate process, hydrochloric acid, 
is led away separately from the pan and the muffle into one absorption 
system of earthenware pipes or channels of stone pickled with tar, first 
into small towers of stone where they are cooled and freed from flue dust 
and impurities (sulphuric acid) by washing. They are next led through 
a series of fifty or more of Woulff bottles (bombonnes) 1 m. high, made of 
acid resisting stoneware, and finally into two water towers of stoneware. 
Occasionally absorption of hydrochloric acid is effected without the use 
of Woulff bottles in wash-towers, such as the Lunge-Rohrmann plate 
tower. 
The conversion of sodium sulphate into soda by the Leblanc method is 
effected by heating with coal and calcium carbonate, whereby, through 
the action of the coal, sodium sulphide forms first, which next, with the 
calcium carbonate, becomes converted into sodium carbonate and calcium 
sulphide. The reactions in small plants are carried out in open reverbera- 
tory furnaces having two platforms on the hearth and, with continuous 
'raking from one to the other, there is considerable escape of CO and CO 2. 
These hand-worked furnaces apart from being hygienically objec- 
tionable, have only a small capacity, and are being rapidly replaced by 
revolving, closed, movable cylindrical furnaces in which all hand work 
is replaced by mechanical devices and a purer product is secured. 
The raw soda thus obtained from the black ash furnace is subjected 
to lixiviation by water in iron tanks in which the impurities or tank waste 
are deposited. The crude soda liquor so obtained is then further treated 
and converted into calcined soda, crystal soda, or caustic soda. In the 
production of calcined soda the crude soda liquor is first purified (oxidized 
and carbonized) by blowing through air and carbonic acid gas, pressed 
through a filter press and crystallized by evaporation in pans and 
calcined. Crystal soda is obtained from well purified tank liquor by 
crystallizing in cast iron vessels. 
The tank waste in the Leblanc process forms mountains around alkali- 
works and constitute a great nuisance. It consists chiefly of calcium and 
calcium carbonate and weathers easily under the influence of air and rain, 600 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
forming soluble sulphur compounds with the evolution of sulphureted 
hydrogen gas, an intolerable source of annoyance to the district. At the 
same time all the sulphur introduced into the industry as sulphuric acid 
is lost in the tank waste. This loss and the nuisance created led to 
attempts to recover the sulphur. 
The best results are obtained by the Chance-Claus method in which 
the fire brick "Claus-Kiln" containing ferric oxide previously heated to 
dull redness is used. In this process calcium sulphide is acted on by car- 
bonic acid with evolution of gas so rich in sulphureted hydrogen that it 
can be burned to sulphur dioxide and used in the lead chambers for 
making sulphuric acid. Sulphur also as such is obtained by the method. 
2. Hargreave's process produces sodium sulphate without previous 
conversion of sulphur dioxide into sulphuric acid, directly by the passage 
of gases from the pyrites burners, air and steam, through salt blocks 
placed in vertical cast-iron retorts, a number of which are connected in 
series. A fan draws the gases through the system and leads the hydro- 
chloric acid fumes to the condenser. 
Sodium sulphate is used in the manufacture of glass, ultramarine, etc. 
It is converted into Glauber's salt by dissolving the anhydrous sulphate 
obtained in the muffle furnace, purifying with lime and allowing the clear 
salt solution to crystallize out in pans. 
Sodium Sulphide.-The sulphate of sodium is used in the preparation 
of the sulphide which is effected by melting together the sulphate and 
coal in a reverberatory furnace. If the bisulphate or sulphate con- 
taining bisulphate is used much sulphur dioxide is evolved. The mass 
is then lixiviated in vats and the lye either treated so as to obtain 
crystals or evaporated to strong sodium sulphide which is poured, 
like caustic soda, into metal drums where it solidifies. It is used in 
the preparation of sulphonal. (See also dye industry for ultra marine 
and diethyl sulphate.) 
3. Solvay's Ammonia Process.-In this process ammonia recovered 
from the waste of the industry is led into a solution of salt until satura- 
tion is completed. This is effected generally in a column apparatus such 
as used in the distillation of spirit. The solution is then drawn automati- 
cally by compressed air into a cylindrical tower where it is carbonized 
by CO2. In this process crystalline bicarbonate of soda is first formed 
which is separated from the ammoniacal mother liquor by filtration, 
centrifugalization and washing. The carbonate is then obtained by 
heating (calcining in pans) during which CO2 escapes and this, together 
with CO2 produced in the lime kilns is used for further carbonization. 
(See also Chemical Industry.) 
REFERENCE 
1 Rambousek, J.-Industrial Poisoning, Trans, by T. M. Legge, London, Edward 
Arnold, 1913. IRON, GOLD, SILVER, ETC.-TIN 
601 
Iron.-According to Lehmann,1 iron and its salts or compounds are 
not toxic. Apart from the numerous pharmaceutical preparations many 
of the salts are used for technical purposes. The red oxide of iron (Fe2 
O3) is employed as a coloring agent and for polishing of glass ware, and 
may be inhaled. Large doses of the chloride or sulphate of iron, like 
almost all of the metallic salts, exert a caustic effect. (See also the Iron 
and Steel Industry and Iron Carbonyl, 176 and 594.) 
Gold, Platinum and Palladium are generally regarded as possessing 
no interest from the standpoint of industrial poisons. 
Silver is not a toxic metal, but is of interest because the absorption of 
silver compounds, in the circulation and their deposition in the tissues, 
especially the kidneys and skin in the form of black silver metal produces a 
grey, green or brownish-black discoloration of the skin described as 
argyria. Kobert believes the reduction and discoloration to be brought 
about by the action of hydrogen sulphide and the influence of light. 
The discoloration usually begins with the appearance of a black edge on 
the gums, and darkening of the hair, nails, lips, temples and eyelids and 
gradually extends until the whole face, neck and throat, arms, fingers 
and the cavity of the mouth is involved. The discoloration is usually less 
pronounced on the breast and back and from the umbilical region down- 
ward. Most of the cases have been observed among workers in the glass 
pearl industry (Teleky2) who employ a solution of nitrate of silver for 
silvering purposes and apply suction by the mouth. This danger has 
been obviated by the use of air pumps. Lewin3 has reported several 
cases of local argyria in mirror platers and in photographers. Koelsch4 
reports a few cases of argyria in silver leaf workers and in persons handling 
and wrapping lunar caustic pencils, evidently resulting from the ingestion 
or penetration of silver dust. 
REFERENCES 
1 Lehmann, K. B., Arbeits und Gewerbehygiene, Leipzig, 1919. 
2 Teleky, Zent. Gewerbehyg., 1914, page 128. 
3 Lewin, Lokale Gewerbeargyrie (Berl. Klin. Wochensch., 1886, page 417). 
4 Koelsch, Munch Med. Wochenschft., 1912, page 304. 
Tin Industry, Tin Mining.-Dr. Ogle, when Registrar General of Great 
Britain, was perhaps the first to point out that the consumption rate 
among the Cornish tin miners was far in excess of any other class of 
miners; other diseases of the lungs are also more common. Consumption 
is the cause of 29.9 per cent, of all the deaths, bronchitis 13.5 per cent.; 
pneumonia and other diseases of the lungs contribute 12.5 per cent, of the 
mortality. The death rate in 1904 in miners between 25-45 years 
was eight to ten times higher than among coal and iron-ore miners of the 
same age. The increased mortality in recent years is attributed by 
Oliver to the increasing employment of rock drills, and to the fact that a 602 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
good many men have worked previously in the quartz mines of the 
Transvaal. Since tin is not regarded as a toxic metal like lead, the undue 
prevalence of diseases of the respiratory organs has generally been attri- 
buted to the inhalation of the hard, sharp and angular particles of dust. 
Uses of Tin.-Tin is used as an alloy with, lead in the manufacture of eating and 
drinking utensils, trophy cups, bronze and art goods, toys, tin foil, hard and soft 
solder, in tin plating, and as an amalgam by dentists, and in the manufacture of 
mirrors. According to Lehmann1 the amount of lead used for eating and drinking 
utensils is restricted in Germany to 10 per cent., the amount of lead in toys and tin foil 
varies from 60 to 95 per cent. German silver, aluminum and Brittania metal have to a 
considerable extent displaced the manufacture of the former tin-ware. The dangers in 
the tin industry are largely incident to the polishing processes and also from lead 
poisoning; the latter is proportionate to the amount of lead used. 
Tin Compounds.-A number of the salts of tin have been used in medicine as a 
disinfectant, drastic purge, antigonorrhoeic and anthelmintic. 
Tin hydroxide and the chloride are used in the dye industry, the stannous chloride 
is used as a reduction agent in the color industry, and the sulphide (Musivgold) is 
used in bronzing. 
Toxicology.-Cases of tin poisoning have been reported, but it has never been 
satisfactorily shown that tin was the real cause of the intoxication. Lehmann1 does 
not consider it an industrial poison. He admits that canned goods, when containing 
nitrates, or when the can is not air tight, may contain from 0.1-0.6 grm. tin per kilo. 
In isolated instances because of the presence of certain tin compounds or a peculiar 
susceptibility of the individual, symptoms of tin poisoning have developed.2 Leh- 
mann's experiments in cats fed daily for 13-20 months with 10-14 mg. per kilo in the 
form of tin acetate, tin tartrate and sodium stanous tartrate showed no harmful 
effects and only a slight accumulation of tin in the system. 
Salant3 in 1914 carried on experiments on the absorption and fate of tin in the body 
and subsequently carried out feeding experiments4 with the tartrate and chloride on 
cats administrating daily 10-50 mg. per kilo in the form of these salts for 23 days and 
followed by 20 mg. for 3 months failed to show any harmful effects. There was on the 
contrary a gain in weight of 100 to 400 gm. An increase to 30 mg. per kilo, fed for 
about 2^ months, reduced the weight in two of the cats 10^ per cent. At the end of 
4 weeks' feeding with 50 mg. of tin per kilo, the loss of weight in one cat amounted to 
10 per cent., and in the other to 16 per cent. Three other cats similarly treated were 
more resistant, as they lost only 5 per cent, of their weight during the 4 weeks. 
But a sixth cat which weighed 1400 gm. lost 450 gm. and died at the end of the period. 
He concludes that the public is entitled to the benefit of the doubt until the harmless- 
ness of such metals is firmly established. 
Tin plating on iron or steel sheets has become a large and still growing 
industry, in which more or less female and youthful laborers find employ- 
ment. The material is used for roofing purposes, the manufacture of tin 
cans, boxes, hollow ware, patent bottle caps, etc. Culinary and domestic 
utensils like saucepans and iron kettles are also tinned. The general 
process of tin plating is similar to the galvanizing with zinc, except that 
the metal requires more careful cleaning and smoothing of its surfaces. 
The pickling with a weak solution of sulphuric acid is followed by dipping 
into a solution of weak hydrochloric acid and zinc chloride. The metal is 
then dipped into a bath of molten tin, but very often the percentage of TIN 
603 
lead exceeds that of the tin, and hence the operatives in addition to the 
exposure to acid and zinc fumes incur the risk of lead poisoning. 
Oliver5 points out that the cheaper ware is frequently dipped in a com- 
position of 70 per cent, of lead and 30 per cent, of tin, thus exposing not 
only the workers but also the purchaser of such utensils to the danger of lead 
poisoning. A number of cases of lead poisoning have likewise been 
reported in consumers of canned foods, especially of acid fruit, and even 
carpenters and shoemakers have contracted lead poisoning from holding 
so-called tinplated nails or tacks in their mouths. It is a satisfaction to 
learn from Dr. Alice Hamilton6 that while the manufacture of cheap 
kitchen ware is a bad lead trade in England, the ware in the United States 
is tinned without lead. 
The washing and dipping is extremely wet and disagreeable work, and 
the subsequent polishing involves inhalation of more or less dust of a 
mixed character. The acid dips, unless the hands are protected with 
rubber gloves or the articles are handled with wooden tongs, are liable to 
produce obstinate eczema, suppurative pustules and even symptoms of 
blood poisoning. Neisser7 reports a number of such instances requiring 
from 6-8 weeks' treatment. 
Tinners, Tinkers, Etc.-The work of roofers, tinners and tinkers 
involves the use of solder. Apart from the danger of lead poisoning, there 
is exposure either to carbon monoxide gas from open charcoal fire or the 
products of combustion from the gasoline torch, also to the irritating 
fumes of hydrochloric acid and possibly arseniureted hydrogen, if the acid 
happens to be derived from arsenical pyrites. The latter risk although 
slight may also be encountered in zinc, tin and lead-plating works. 
The handling of tin plates, with their sharp cutting edges, is very apt 
to cause injuries of the hands unless they are properly protected. Roofers, 
are often exposed to the elements and as a result many contract colds, 
catarrhal and rheumatic affections, and inflammation of the middle ear. 
Burns from the soldering iron, etc., are not infrequent. Acute and 
chronic conjunctivitis from dust, foreign bodies, and exposure to acid 
fumes is also common. The morbidity hazard of the Leipsic tin-ware 
factory workers is 827 days of sickness per 100 members per annum and 
the mortality hazard 0.79 per cent. 
Since many articles of tin ware are also painted and lacquered, the 
element of danger from toxic color pigments and varnishes must likewise 
be considered. In recent years the process of mixing copal varnish is done 
by means of compressed air, with efficient exhaust ventilation, so that the 
workers are no longer exposed to the inhalation of this dust.7 
Tin foil, which is so frequently used for bottle tops and wrappers for 
cheese, tobacco, snuff, cigarettes, etc., should be spoken of as lead foil as it 
contains generally from 85 to 95 per cent, of lead. The manufacture of 
lead foil should be discouraged as it exposes the workers to lead poisoning 
and is not wholly free from danger to the consumer. 604 
MISCELLANEOUS METALS AND THE RELEVANT INDUSTRIES 
REFERENCES 
1 Lehmann, K. B.-Arbeits and Gewerbehygiene, 1919, page 221. 
■2 Friedmann cited by Lehmann.-Zeitschft f. Hygiene, 75, page 55. 
3 Salant, Rieger and Treuthardt.-Jour. Biological Chemistry, 1914, Vol. 17, page 265. 
Editorial J. A. M. A., April 25, 1914, page 133. 
4 Salant.-The Pharmacology of Heavy Metals, Journal Industrial Hygiene, Vol. II, 
No. 2, June, 1920, page 72. 
5 Oliver's Dangerous Trades, 1902, page 319. 
6 Hamilton.-Lead Poisoning in the U. S., Trans. 15th Internal. Congress on Hygiene, 
etc., Vol. Ill, Part II, page 809, Washington, 1913. 
7 Neisser.-Internationale Ubersicht liber Gewerbehygiene, Berlin, 1907, pages 102, 
217. 
Vanadium.-This rare metal, a silvery crystalline substance, is obtained 
from vanadinite and other minerals. The pentoxide is used in photog- 
raphy as a developing agent; the chloride and trioxide are used as a mor- 
dant in the textile printing industry. The trioxide is also used in the 
manufacture of malleable, ductile steel, such as is used for making the 
chassis of automobiles. According to Dr. Dutton,1 persons employed in 
reduction plants or where the various kinds of vanadium, especially the 
trioxide, are produced are liable to suffer from chronic poisoning. Among 
the early symptoms he mentions a peculiar cachexia not unlike chlorosis. 
Irritation of the nose, eyes and throat and a dry paroxysmal cough 
sufficiently intense to cause pulmonary hemorrhage are frequent symp- 
toms. There is also progressive emaciation, loss of appetite, nausea, 
diarrhea, followed by obstinate constipation. Albumin, casts and blood 
corpuscles are often present in the urine. The metal is eliminated by the 
kidneys and has also been detected in the feces, saliva and sputum. Con- 
tinued exposure to the poison may produce tremors of the extremities, 
neuroretinitis, amaurosis, hysteria and melancholia. In fatal cases Dr. 
Dutton1 found the lungs highly congested with marked destruction of the 
alveolar epithelium; the kidneys were congested with evidence at times of 
an acute hemorrhagic nephritis; there was also more or less evidence of 
gastro-enteritis. While O. T. Cruikshank and Jackson have produced 
similar lesions in animal experimentation with vanadium, Lees2 failed to 
find that there is such a disease as vanadiumism. Dutton, however, is a 
man of large experience and his observations should carry great weight. 
He holds that a fatal termination frequently ensues as a result of continued 
exposure to the poison, but that the prognosis is good in the absence of 
grave renal, lung, blood and nervous involvement. 
Treatment.-In the way of treatment he suggests washing out of the 
stomach and intestinal evacuation by saline laxatives. For the relief of 
cough, terpin hydr. gr., heroin % gr., creosote Iff every 2 hours and 
counter-irritation over chest, also inhalation of steam vapors. Turkish, 
Russian or cabinet baths have proved useful to aid in the elimination of the 
poison, while in the less acute cases the administration of iron, calisaya, VANADIUM 
605 
strychnine, cod-liver oil, and outdoor exercise are of service for the relief 
the anaemic, nervous and debilitated condition. 
Preventive Measures.-Perfect ventilation and exhaust flues for the 
removal of dust and fumes, and the use of respirators, are essential. The 
nasal and oral cavities should be cleansed before meals and upon cessation 
of work by means of a spray with Dobell solution, followed by a mentho- 
lated oil spray. Change of work upon appearance of suspicious symp- 
toms is indicated. 
REFERENCES 
1 Dutton, W. F.-J. A. M. A., Vol. LVI, June 31, 1911, page 1648. 
2 Lees.-Eng. Mining Journal, 92-99. SECTION 24 
ALPHABETICAL LIST OF INDUSTRIES IN WHICH POISONING 
MAY OCCUR AND OTHER HAZARDS WHICH 
MAY BE PRESENT 
Arranged by GEORGE M. KOBER, M. D., Washington, D. C. 
The "Index to Occupations" of the U. S. Bureau of Census (1915), based on the 
13th Census, gives 9,000 or more occupational designations which fall under 428 group 
headings. Each designation is provided with a symbol number as well as having the 
industry to which it belongs stated in a parallel column. Practically every such 
occupational designation, we may say, has certain hazards to health and life and it 
would be well if we knew them all, but infinite study and investigation would first 
be necessary. Furthermore, old occupations are constantly passing out and new ones 
appearing. However, the industrial health hazards themselves of environmental 
character are comparatively few and are easily grouped, the list, according to 
Hayhurst, comprising the following: 
1. Poisons. 
2. Ventilation faults. 
3. Humidity extremes. 
4. Temperature extremes. 
5. Dust. 
6. Illumination extremes. 
7. Fatigue (prolonged strains, repeated 
motion, pressure, shock, speed; 
restricted movements). 
8. Infections and communicable diseases. 
9. Abnormal atmospheric pressures. 
10. Electricity. 
11. Sanitation inadequacies (sewage, 
refuse, water supply, general cleanli- 
ness). 
12. Demoralizing factors, distractions, dis- 
orders, dirt, etc. 
13. Accidents. 
A list of industries in which poisoning may occur was arranged by 
George M.. Kober in 1916 for Kober and Hanson's " Diseases of Occupa- 
tion," and has since received valuable additions by the publications of the 
Metropolitan Life Insurance Company and Bulletin No. 306 U. S. Bureau 
of Labor Statistics, April, 1922, prepared by Louis L. Dublin, Ph. D. and 
Philip Leiboff to whom, as also to Dr. Wm. S. Wadsworth, Physician to 
the Coroner of Philadelphia, special acknowledgments are due. 
Every physician should be familiar with the conditions under which 
our fellow men work and live, and in all doubtful cases no one should 
fail to inquire as to the patient's present and former occupation, and 
even the particular processes in which he is engaged. A glance at the 
alphabetical list will inform him of the hazards connected with the 
patient's work and prove a valuable guide to an early and correct diagnosis, 
especially of acute and chronic occupational intoxications. If not famil- 
iar with the toxicology of the different agents, reference to the alphabeti- 
cal List of Industrial Poisons and the more comprehensive chapters in 
the book will be necessary. 
606 ACETYLENE MAKERS ARTIFICIAL FLOWER MAKERS 
607 
With all of these, in actual practice, one must weigh the susceptibility of the given 
worker himself, which is largely ascertainable in advance by physical and mental 
tests or examinations in connection with matters of sex, age, habits, skill, home 
conditions, recreation tendencies, transportation evils, seasons, altitudes, localities, 
etc. In general about 50 per cent, of workers have physical impairments which 
predispose to given environmental hazards, and probably all have their "off seasons." 
About six-sevenths of disability time loss is the result of sickness and one-seventh, 
the result of accidents. Also it is approximately true that from one-half to three- 
fourths of sickness-disability among workers is preventable with the application of 
knowledge now at hand, the main problem being an educational or informative one 
combined with a will and an organized effort to "put it across." The following 
tabular list comprises about 700 industries and occupational designations, selected 
from combined experiences of record, which, it is believed, include most of the import- 
ant and usual callings with their corresponding health hazards, especially in the way 
of poisons.-Hayhurst. 
Acetylene makers: 
Inorganic dust, ammonia, carbon monoxide, phos- 
phureted hydrogen. 
Acid dippers: 
Dampness, arseniureted hydrogen, cyanogen com- 
pounds, hydrochloric acid, nitrous gases and nitric 
acid, sulphuric acid. 
Acid finishers (glass): 
Hydrochloric acid, lead and its compounds, sulphuric 
acid. 
Acid makers: 
Acid mixers: 
Acid recoverers: 
Acid transporters: 
See particular acids. 
Hydrochloric acid, nitrous gases and nitric acid, 
sulphuric acid. 
Air-plane wing varnishers: 
Tetrachlorethane (acetylene tetrachloride). See also 
varnishers. 
Alcohol distillery workers: 
Amyl acetate, amyl alcohol. 
Aldehyde pumpmen: 
Acetaldehyde, methyl alcohol. 
Alkali salt makers: 
Dampness, carbon dioxide, chlorine, hydrochloric 
acid, sulphur dioxide, sulphureted hydrogen. 
Amber workers: 
Ammonium salt makers: 
Lead and its compounds. 
Extreme dry heat, ammonia, carbon-disulphide, 
cyanogen compounds, sulphuric acid and hydrochloric 
acid. 
Ammonium sulphate makers: 
Anilin dye makers: 
Sulphuric acid. 
See dye makers. 
Anilin makers: 
Anilin, arseniureted hydrogen, benzol, hydrochloric 
acid, nitrobenzol, nitrous gases and nitric acid. 
Animal hair dressers: 
See hair workers. 
Animal handlers: 
Annealers: 
Anthrax, septic and other infections. 
Extreme dry heat; extreme light. 
Antimony extractors (re- 
finers) : 
Extreme dry heat, antimony and its compounds. 
Antimoiiy fluoride extractors: 
Antipyrin makers: 
Hydrofluoric acid. 
Methyl bromide, phenyl hydrazine. 
Arsenic roasters: 
Art glass workers: 
Extreme dry heat; arsenic and its compounds. 
Amyl acetate, benzine, hydrofluoric acid, lead and its 
compounds, methyl alcohol, turpentine. 
Artificial flower makers: 
Repeated motion, pressure, etc. Arsenic, benzol, car- 
bon tetrachloride, chromium, lead, mercury and their 
compounds; methyl alcohol. 608 
LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR 
Artificial ice makers: 
Artificial leather makers: 
Sudden variation of temperature; dampness; ammonia. 
Anilin, arsenic and its compounds; benzol, nitrous 
gases and nitric acid; sulphuric acid. 
Artificial manure makers: 
See fertilizer makers. 
Artificial silk makers: 
Dampness, ammonia, amyl-acetate, carbon disulphide, 
methyl alcohol, sulphureted hydrogen; tetrachlore- 
thane. 
Asbestos workers: 
Asphalt testers: 
Inorganic dust. 
Carbon disulphide. 
Auto painters: 
Dampness, dust, repeated motion, pressure; lead, 
quick dryers (benzol, wood alcohol); see also painters. 
Babbitters: 
Bakelite makers: 
Phenol. 
Lead and its compounds. 
Bakers: 
Sudden variation of temperature; organic dust; 
carbon monoxide. 
Balloon (toy) fillers: 
Arseniureted hydrogen. 
Barbers: 
Repeated motion, pressure, etc.; hair (dust); ring 
worm, etc. 
Bar-mill workers (iron and 
steel): 
Extreme dry heat 
Basic slag (artificial manure) 
workers: 
Inorganic dust; sulphureted hydrogen, calcium 
cyanamide. 
Batdh makers (glass works): 
See glass mixers. 
Batch makers (rubber 
works): 
See compounders (rubber). 
Baters (tannery): 
Battery (dry) makers: 
Dampness, anthrax. 
Inorganic dust, amyl acetate, arseniureted hydrogen, 
benzol; chromium compounds; hydrochloric acid; 
lead; mercury and its compounds; tar. 
Battery (storage) makers: 
Beamers (textile): 
Organic dust. 
See storage battery makers. 
Beamhouse workers (tan- 
nery) : 
Dampness; anthrax. 
Beatermen (paper and pulp): 
Dampness; chlorine. 
Bed rubbers (marble and 
stone): 
Inorganic dust. 
Bench molders (foundry): 
Benzol stillmen: 
Inorganic dust; brass, (zinc); lead and its compounds. 
Extreme dry heat; benzol. 
Bessemer-converter workers 
(iron and steel): 
Extreme dry heat. 
Beta still operators (beta 
naphthol): 
Extreme dry heat; sulphuric acid. 
Bevellers: 
Inorganic dust. 
Bicyclists: 
Billet mill workers (iron 
and steel): 
Repeated motion, pressure, shock, etc. 
Extreme dry heat. 
Bisque-kiln workers: 
Extreme dry heat; inorganic dust; carbon-monoxide. 
Blacksmiths: 
Extreme dry heat; extreme light; repeated motion; 
pressure, shock; etc.; carbon dioxide; carbon monoxide; 
cyanogen compounds; lead and its compounds. 
Blast furnace workers: 
Extreme dry heat; cyanogen compounds; sulphur 
dioxide; sulphureted hydrogen; CO, CO2, C2H2, PH3 
and O-want. 
Bleachers: 
Sudden variation of temperature; dampness; chloride 
of lime; chlorine; chromium compounds; hydrofluoric 
acid; nitrous gases and nitric acid; sulphur dioxide. ARTIFICIAL ICE MAKERS-CABLE SPLICERS 
609 
Bleachers (cloth): 
Bleachers (dryers): 
Sudden variation in temperature; dampness. 
Blockers (felt hats): 
Dampness; carbon monoxide. 
Blooders (tannery): 
Blooming mill workers (iron 
and steel): 
Extreme dry heat. 
Lead and its compounds. 
Blowers (felt hat): 
Organic dust; mercury and its compounds. 
Blowers (glass manufactures): 
See glass blowers. 
Blowers out (zinc smelting): 
Bluers (revolvers): 
Extreme dry heat. 
Extreme dry heat; brass (zinc). 
Boiler room workers: 
Bone-black makers: 
Extreme dry heat; carbon dioxide; carbon monoxide. 
Ammonia; phosphorus, infections; carbon. 
Bone renderers: 
Bone workers: 
Acrolein, infection. 
Organic dust, infection. 
Bookbinders: 
Bottle cap makers: 
Arsenic; lead and their compounds, methyl alcohol. 
Lead and its compounds. 
Brass founders: 
Extreme dry heat; antimony, arsenic, lead and their 
compounds; brass (zinc); carbon dioxide, carbon 
monoxide; phosphorus; sulphur dioxide. 
Brass polishers: 
Lead and its compounds, repeated motion, pressure; 
dust. 
Braziers: 
Extreme dry heat; brass (zinc); lead and its com- 
pounds. 
Brewers: 
Sudden variation of temperature; dampness; carbon 
dioxide. 
Brick burners: 
Extreme dry heat; carbon dioxide, carbon monoxide, 
lead and its compounds. 
Brick makers: 
Extreme dry heat; dampness; inorganic dust; hook 
worm; lead and its compounds; sulphur dioxide. 
Briquet makers: 
Tar. 
Bronzers: 
Inorganic dust; ammonia; amyl acetate; arsenic and 
its compounds; arseniureted hydrogen; benzine; 
benzol; brass (zinc); gasoline; lead, mercury and their 
compounds; methyl alcohol; sulphureted hydrogen. 
Broom makers: 
Browners (gun barrels): 
Organic dust; chlorine; sulphur dioxide. 
Cyanogen compounds; lead, mercury and their 
compounds; petroleum. 
Brushers (felt hat): 
Brush makers: 
Organic dust; mercury and its compounds. 
Organic dust; anthrax; lead and its compounds; 
methyl alcohol; tar. 
Buffers: 
Organic dust; inorganic dust; poor illumination. 
Buffers (rubber): 
Burners (enameling): 
Amyl acetate; benzine; lead and its compounds; dust. 
Extreme dry heat; lead and its compounds. 
Burnishers (iron and steel): 
Poor illumination; antimony and its compounds; 
sulphuric acid. 
Burnishers (rifle barrels): 
Antimony and its compounds. 
Burrers (needles): 
Burr filers: 
Inorganic dust. 
Inorganic dust. 
Butchers: 
Sudden variation of temperature; anthrax, septic and 
other infections. 
Button makers: 
Cable makers: 
Organic dust; inorganic dust. 
Lead and its compounds. 
Cable splicers: 
Dampness; carbon monoxide; lead and its compounds; 
sulphureted hydrogen; turpentine. 610 
LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR 
Caisson workers: 
Sudden variation of temperature; dampness; com- 
pressed air; poor illumination; carbon dioxide. 
Calenderers (rubber): 
Warm temperature; inorganic dust; irritants. 
Calico, printers: 
Sudden variation of temperature; dampness; anilin 
and other amino compounds of benzol and its homolo- 
gues; antimony, arsenic and their compounds; 
carbon monoxide; chlorine; lead and chromium com- 
pounds; cyanogen compounds; methyl alcohol; phenol; 
hydrochloric acid; sulphuric acid; turpentine. 
Camphor makers: 
Hydrochloric acid; turpentine. 
Candle (colored) makers: 
Candy makers: 
Arsenic; chromium compounds. 
Sudden variation of temperature; dampness. 
Canners: 
Variation of temperature; dampness; septic infections; 
lead and its compounds (if soldering performed). 
Cap loaders: 
Cappers (window glass): 
Mercury and its compounds. 
Extreme dry heat. 
Carbide makers: 
Carbolic acid makers: 
Extreme dry heat; inorganic dust; carbon monoxide. 
Benzol; hydrochloric acid; sulphur dioxide; sulphuric 
acid. 
Carbon brush makers: 
Inorganic dust. 
Carbon dioxide makers: 
Carbon dioxide. 
Carbon disulphide makers: 
Carbonizers (shoddy): 
Carbon disulphide. 
Organic dust; arseniureted hydrogen; hydrochloric 
acid; sulphuric acid. 
Carborundum workers: 
Extreme dry heat; inorganic dust. 
Carders (textile): 
Card grinders (textile): 
Organic dust. 
Organic dust; inorganic dust. 
Carpenters: 
Carpet makers: 
Repeated motion, pressure, shock, etc 
Organic dust; anthrax, arsenic and its compounds. 
Carroters (felt hats): 
Arsenic, and mercury compounds; nitrous gases and 
nitric acid. 
Cartridge cup washers: 
Dampness. 
Cartridge dippers: 
Hydrochloric acid; nitrous gases and nitric acid; 
sulphuric acid. 
Cartridge felt and wad 
makers: 
Dampness. 
Cartridge makers: 
Cartridge shot shell paraffin 
dippers: 
Lead and mercury compounds. 
Sudden variation of temperature; dampness. 
Case hardeners: 
Extreme dry heat, cyanogen compounds. 
Casters (brass foundry): 
See brass founders. 
Casters (iron and steel): 
Casting cleaners (foundry): 
Extreme dry heat. 
Inorganic dust. See also acid dippers. 
Cast scrubbers (electro- 
platers) : 
Benzine; benzol. 
Catchers (iron and steel): 
Cattle men: 
Extreme dry heat. 
Anthrax; actinomycosis; vaccinia; milk-sickness; 
septic infections. 
Celluloid makers: 
Acetaldehyde; amyl acetate; benzine, carbon disul- 
phide; carbon monoxide; cyanogen compounds; lead 
and its compounds; methyl alcohol; nitrous gases and 
nitric acid; sulphureted hydrogen; sulphuric acid; 
tetrachlorethane. 
Celluloid polishers: 
Organic dust. CAISSON WORKERS COMPOUNDERS (RUBBER) 
611 
Celluloid workers: 
Cementers (rubber shoes): 
Organic dust. 
Benzine, benzol; carbon disulphide; methyl alcohol; 
turpentine. 
Cement mixers (rubber): 
Benzine, benzol; carbon disulphide. 
Cement workers: 
Extreme dry heat; inorganic dust. 
Chambermen (sulphuric 
acid): 
Sulphur dioxide; sulphuric acid. 
Charcoal burners 
Charcoal workers (sugar 
refining): 
Carbon dioxide; carbon monoxide. 
Sudden variation of temperature; dampness; inorganic 
dust. 
Chargers (smelting): 
Extreme dry heat; inorganic dust. 
Chargers (zinc smelting): 
Extreme dry heat; inorganic dust; arsenic and its 
compounds; brass (zinc); carbon monoxide; lead and 
its compounds; sulphur dioxide. 
Chasers (steel): 
Chauffers: 
Inorganic dust. 
Repeated motion; pressure, shock, etc.; gasoline, 
carbon monoxide. 
Chimney sweepers: 
Inorganic dust; carbon monoxide, tar. 
Chippers: 
Chloride of lime makers: 
Inorganic dust. 
Chloride of lime; chlorine. 
Chlorine makers (electro- 
lytic) : 
Chlorine. Mercury and its compounds. 
Chloroform makers: 
Chloride of lime. 
Chromium workers: 
Cigar makers: 
Chromium compounds. 
Organic dust; repeated motion; pressure, etc. 
Clay and bisque makers 
(pottery). 
Sudden variation of temperature; dampness; inorganic 
dust. 
Clay plug makers (pottery): 
Clay products' workers: 
See pottery workers. 
Dampness; inorganic dust. 
Clerks: 
Cloth prepareres: 
Repeated motion, pressure, etc. 
Dampness. See also bleachers. 
Coal miners: 
Coal tar workers: 
See miners. 
Anilin, and other amino compounds of benzol and its 
homologues. Benzol; carbon monoxide; phenol. 
Cobblers: 
Organic dust; anthrax; repeated motion, pressure, 
shock, etc. 
Coke oven workers: 
Extreme dry heat, ammonia; benzol; carbon monox- 
ide; tar. 
Cold storage plant workers: 
Color makers: 
Sudden variation of temperatures; ammonia. 
Extreme dry heat; inorganic dust; antimony and 
arsenic, and their compounds; benzol; chromium; lead 
and mercury and their compounds. 
Colored paper workers: 
Arsenic and its compounds. 
Colorers (white) of shoes: 
Comb makers (celluloid): 
Lead and its compounds. 
Organic dust. 
Compositors: 
Inorganic dust; poor illumination; repeated motion, 
pressure, shock, etc.; anilin and other amino com- 
pounds of benzol and its homologues; antimony and 
its compounds; benzine, benzol; lead and its com- 
pounds. 
Compounders (rubber): 
Inorganic dust; anilin and other amino compounds of 
benzol and its homologues; lead, antimony, and arsenic 
and their compounds; benzine; benzol; chromium 
compounds. 612 
LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR 
Concentrating mill workers 
(lead and zinc): 
Dampness; inorganic dust; lead and its compounds. 
Coners (felt hats): 
Organic dust; mercury and its compounds. 
Confectioners: 
Construction camp workers: 
Hookworm. 
See candy makers. 
Cooks: 
Copper founders: 
Sudden variation of temperatures; carbon monoxide. 
Arsenic and its compounds. 
Copper miners: 
Copper smelters: 
See miners. 
Extreme dry heat, arsenic and its compounds; carbon 
monoxide; sulphur dioxide. 
Cord makers: 
Core makers: 
Organic dust; tar. 
Extreme dry heat; inorganic dust; brass (zinc); carbon 
monoxide. 
Cork workers: 
Organic dust. 
Cotton mill workers: 
Cotton twisters: 
Dampness; organic dust. 
Organic dust; repeated motion, pressure, shock, etc. 
Cranemen (iron, steel, and 
glass industry): 
Extreme dry heat; various gases and combustion 
products. 
Creosoting plant workers: 
Dampness; tar; creosote. 
Crucible mixer: 
Crucible steel workers. 
Inorganic dust. 
Extreme dry heat. 
Crushermen (clay and stone): 
Cupola men (foundries): 
Inorganic dust. 
Extreme dry heat, carbon dioxide; carbon monoxide. 
Curers, vapor, (rubber): 
Curriers (tannery): 
See vulcanizers. 
Organic dust; anthrax, arsenic and its compounds; 
benzine. 
Cut glass workers: 
Inorganic dust; arsenic and lead and their compounds. 
Cutlery makers: 
Inorganic dust; amyl acetate; lead and its compounds. 
Cyanamid makers: 
Dancers: 
Extreme dry heat; inorganic dust; calcium cyanamide. 
Repeated motion, pressure, shock, etc. 
Decorators (pottery): 
Arsenic and its compounds; benzine; benzol; lead and 
its compounds, turpentine. 
Degreasers (fertilizer, 
leather): 
Benzine; benzol; gasoline. 
Dentists: 
Detonator cleaners, fillers, 
packers: 
Mercury and its compounds. 
Devil operators (felt hats): 
Diamond cutters: 
Organic dust, mercury and its compounds 
Inorganic dust; repeated motion, pressure, shock, etc. 
Diamond polishers: 
Digester house workers (paper 
and pulp): 
Lead and its compounds. 
Sudden variation of temperatures; dampness. 
Dimethyl-sulphate makers: 
Arseniureted hydrogen; dimethyl sulphate; methyl 
alcohol; nitrous gases and nitric acid; sulphuric acid. 
Dippers (guncotton): 
Nitrous gases and nitric acid. 
Dippers (rubber): 
Dippers: 
Benzine. 
See acid dippers. 
Disinfectant makers, see 
also fumigators. 
Chloride of lime; chlorine; arsenic; mercury and 
phenol compounds. 
Divers: 
Compressed air. 
Doffers (textile): 
Dressers (glass): 
Dampness; organic dust. 
Extreme dry heat. 
Dressers tenders (textile): 
Drivers: 
Sudden variation of temperatures; dampness. 
Sudden variation of temperature; dampness. CONCENTRATING MILL WORKERS-FELT HAT MAKERS 
613 
Drop forgers: 
Extreme dry heat. 
Dry battery workers: 
Dry cleaners: 
See battery (dry) makers. 
Sudden variation of temperatures; benzine, benzol; 
carbon disulphide; methyl alcohol; turpentine. 
Dryers (felt hats): 
Sudden variation of temperature; methyl alcohol. 
Dryers (rubber): 
Drying room workers (mis- 
cellaneous) : 
Benzol; carbon disulphide. 
Sudden variation of temperatures; carbon dioxide; 
carbon monoxide. 
Dye-makers: 
Sudden variation of temperatures; dampness; acetal- 
dehyde; acridine; ammonia; amyl alcohol; anilin, 
antimony, and arsenic and their compounds; arseni- 
ureted hydrogen; benzol; chloride of lime; chlorine; 
chromium, and cyanogen compounds; dimethyl sul- 
phate; hydrochloric acid; lead and its compounds; 
methyl alcohol; methyl bromide; nitrobenzol; phenol; 
phenyl hydrazine; phosgene; picric acid; sulphur diox- 
ide; sulphureted hydrogen sulphuric acid; turpentine. 
Dyers: 
Sudden variation of temperature; dampness; ammonia; 
chromium compounds; gasoline; hydrochloric acid; 
hydrofluoric acid; lead and its compounds; phenol; 
picric acid. 
Electricians: 
Electric linemen: 
Extreme light and shock. 
Electroplaters: 
Dampness; arsenic and its compounds; benzine; 
benzol; cyanogen, lead and their compounds^ 
Electrotypers: 
Sudden variation of temperatures; inorganic dust; 
lead and its compounds. See also electroplaters. 
Elevator runners: 
Embroidery workers: 
Repeated motion, pressure, shock, etc. 
Poor illumination; lead and its compounds. 
Emery wheel makers: 
Inorganic dust; lead and its compounds. 
Enamelers: 
Enamel makers 
See Enamel makers. 
Amyl acetate, antimony, arsenic, arseniureted hydro- 
gen, benzine, carbon disulphide, carbon monoxide, 
chromium, hydrochloric acid, lead, nitrous gases, 
nitric acid, turpentine, extreme dry heat, dampness, 
repeated motion, etc. 
Engravers, see also steel 
engravers: 
Dust, inorganic dust, repeated motion, etc. 
Etchers: 
Hydrofluric acid, nitrous gases and nitric acid, phenol. 
Explosive workers, see also 
particular occupations: 
Acetaldehyde, amyl acetate, anilin and other amino 
compounds of benzol and its homologues, benzol, 
mercury, methyl alcohol, nitrobenzol, etc. Nitro- 
glycerin, nitrous gases and nitric acid, picric acid, 
sulphuric acid, trinitroluol, dampness. 
Extractor operators (soap): 
Sudden variation of temperature, dampness. 
Farmers: See also fertilizer. 
Fat renderers: 
Anthrax, hookworm and other parasitic infections. 
Sudden variations of temperature, acrolein, dampness. 
Feather curers: 
Feather workers: 
Organic dust, arsenic and its compounds. 
Organic dust, septic infections, anilin, and other 
compounds of benzol, etc., arsenic, benzine, benzol, 
methyl alcohol, petroleum and turpentine. 
Felt extractors: 
Dampness. 
Felt hat makers, see also 
particular occupation 
Arsenic, carbon monoxide, mercury, methyl alcohol, 
nitrous gases and nitric acid, sulphuric acid, sudden 
variation of temperature, dampness organic dust. 614 
LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR 
Ferro-silicon workers: 
Arsenic, arseniureted hydrogen, phosphureted hydro- 
gen. 
Fertilizer makers, see also 
phosphate mill workers: 
Arseniureted hydrogen, benzol, carbon dioxide, hydro- 
chloric acid, hydrofluoric acid, nitrous gases and nitric 
acid, phosphorus, sulphur dioxide, sulphureted hydro- 
gen, sulphuric acid; dampness, inorganic dust, anthrax, 
and septic infection. 
Fibre workers: 
Filament makers (incandes- 
cent lamps): 
Organic dust. 
Carbon monoxide, methyl alcohol. 
File cutters: 
Filers: 
Lead, inorganic dust. 
Antimony, lead, inorganic dust. 
Film makers, see celluloid 
makers: 
Filter press workers: 
Finishers (incandescent 
lamps): 
Dampness. 
Carbon monoxide. 
Finishers (leather): 
Organic dust. 
Finishers (shoes), see also 
shoe finishers: 
Organic dust. 
Fireworks makers, see also 
explosives: 
Antimony, mercury, phosphorus. 
Fishermen: 
Sudden variations of temperature, dampness, septic 
infections. 
Fitters (shoes): 
Methyl alcohol. 
Flangers (felt hats): 
Flatteners (glass): 
Sudden variations in temperature, carbon monoxide. 
Extreme dry heat. 
Flax rettery workers: 
Flax spinners: 
Sulphureted hydrogen. 
Dampness, organic dust. 
Flint workers: 
Inorganic dust. 
Floor molders (foundry): 
Flour workers: 
Organic dust. 
Brass (zinc), lead, inorganic dust, extreme dry heat. 
Flue cleaners: 
Flush tenders (aluminum): 
Dampness. 
Carbon monoxide, sulphur dioxide, tar, inorganic dust. 
Forgemen: 
Formers (felt hats): 
Organic dust. 
Extreme dry heat. 
Foundry workers, (see also 
particular metal): 
Carbon monoxide, extreme dry heat, inorganic dust. 
Fruit essence makers: 
Amyl alcohol. 
Fruit preservers: 
Fulminate mixers: 
Sulphur dioxide. 
Cyanogen compounds, mercury. 
Fumigators: 
Fur carders 
Fur clippers 
Fur cutters 
Cyanogen compounds, sulphur dioxide, formaldehyde. 
Organic dust, anthrax. 
Fur handlers: 
Furnace workers: 
Arsenic, mercury, anthrax, organic dust. 
Carbon dioxide, carbon monoxide, extreme dry heat, 
extreme light. 
Furniture polishers: 
Amyl acetate, anilin, benzine, gasoline, methyl 
alcohol, petroleum, turpentine. 
Fur preparers: 
Arsenic, mercury, nitrous gases and nitric acid, 
organic dust, anthrax. 
Fur pullers: 
Organic dust, anthrax. FERRO-SILICON WORKERS-HAIR WORKERS 
615 
Galvanizers: 
Acrolein, ammonia, arsenic, arseniureted hydrogen, 
zinc, hydrochloric acid, lead, nitrous gases and 
nitric acid, sulphux dioxide, sulphuric acid, dampness. 
Garage workers: 
Garbage workers: 
Septic infection. 
Carbon monoxide, gasoline. 
Gardeners: 
Gas (illuminating) workers: 
Arsenic, parasitic infections, charcoal. 
Ammonia, benzol, carbon monoxide, cyanogen com- 
pounds, phenol, sulphureted hydrogen, tar. 
Gas purifiers: 
Ammonia, cyanogen compounds, sulphureted hydro- 
gen. 
Gatherers (glass): 
Extreme dry heat. 
Gilders: 
Amyl acetate, benzine, benzol, gasoline, methyl 
alcohol. 
Glass blowers: 
Extreme dry heat, inorganic dust, extreme, light 
mouth and lip infection. 
Glass cutters: 
Dampness, inorganic dust. 
Glass finishers: 
Hydrochloric acid, hydrofluoric acid, lead, sulphuric 
acid, dampness, inorganic dust. 
Glass furnace workers: 
Glass mixers: 
Extreme dry heat, extreme light. 
Antimony, arsenic, chromium compounds, hydro- 
chloric acid, lead, inorganic dust. 
Glass polishers: 
Lead. 
Glaze dippers (pottery): 
Dampness, lead, antimony, arsenic, chromium, and 
their compounds. 
Glaze mixers (pottery): 
Inorganic dust, dampness, lead, antimony, arsenic, 
chromium, and their compounds. 
Glost kiln workers: 
Sudden variations of temperature, carbon monoxide, 
lead and its compounds. 
Glove makers (leather pre- 
parers), see also tannery 
workers: 
Dampness, organic dust, anthrax. 
Glue workers 
Sudden variation of temperature, organic dust, damp- 
ness, septic infection, ammonia, benzine, benzol, 
carbon disulphide, hydrochloric acid, nitrous gases and 
nitric acid, sulphur dioxide, sulphureted hydrogen. 
Gold beaters: 
Inorganic dust, repeated motion, shock, pressure, etc. 
Gold refiners: 
Inorganic dust, arsenic, and cyanogen compounds, 
hydrofluoric acid, lead, mercury and their compounds 
Grain elevator workers: 
Granite workers, see stone 
cutters: 
Organic dust. 
Graphite workers: 
Grinders (colors) see color 
makers: 
Extreme dry heat, inorganic dust. 
Grinders (metals) 
Dampness, inorganic dust, antimony, lead and their 
compounds. 
Grinders (rubber): 
Organic dust, antimony, lead and their compounds. 
Guncotton dippers: 
Guncotton pickers: 
Organic dust. 
Nitrous gases and nitric acid, sulphuric acid. 
Guncotton washers: 
Guncotton wringers: 
Dampness. 
Nitrous gases and nitric acid. 
Gypsum workers: 
Inorganic dust. 
Hair workers: 
Dampness, organic dust, anthrax, septic infection; 
dyes. 616 
LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR 
Hardeners (felt hats): 
Hammermen: 
Repeated motion, pressure, shock, etc. 
Mercury and its compounds, methyl-alcohol. 
Hardeners (metals); 
Harness makers: 
Organic dust. 
Extreme dry heat. 
Hat makers (felt): 
See felt hat makers. 
Heater boys (riveters): 
Lead and its compounds. 
Heel makers (shoes): 
Hemp workers: 
Organic dust. 
Organic dust. 
Horn workers: 
Hothouse workers: 
Mixed dust. 
Sudden variations of temperature; fertilizers; carbon. 
Hot rod rollers (iron and 
steel): 
Extreme dry heat. 
Hydrochloric acid makers: 
Hydrochloric acid, sulphuric acid. 
Ice (artificial) makers, see 
artificial ice makers: 
Ice cream makers: 
Sudden variation of temperature, dampness, repeated 
motion. 
Imitation pearl makers: 
Lead and silver compounds, nitrous gases and nitric 
acid. 
Incandescent lamp makers, 
see also particular occupa- 
pations: 
Amyl acetate, carbon monoxide, lead, mercury and 
their compounds, methyl alcohol, nitrous gases and 
nitric acid. 
Incandescent mantle hard- 
eners : 
Extreme light. 
Ink makers: 
Insecticide makers: 
Chromium compounds, methyl alcohol. 
Arsenic, lead and their compounds, carbon disulphide, 
phosphorus, pyrethrum, nicotine. 
Insulators: 
Tar. 
Iron and steel workers, see 
also particular occupa- 
tions : 
Extreme dry heat. 
Ironers: 
Sudden variation of temperature, carbon monoxide. 
Japan makers: 
Sudden variation of temperature, arsenic, and lead 
compounds, benzine, methyl alcohol, turpentine. 
Japanners, see japan makers: 
Jewellers: 
Inorganic dust, poor illumination, repeated motion, 
pressure, etc.; amyl acetate, arsenic and its com- 
pounds, hydrochloric acid, lead, mercury and their 
compounds,- nitrous gases and nitric acid, sulphuric 
acid. 
Junk metal refiners: 
Extreme dry heat, inorganic dust. Brass (zinc), lead 
and its compounds. 
Jute workers: 
Kiln tenders: 
Organic dust, infections. 
Extreme dry heat, carbon monoxide. 
Knitters: 
Knitting mill workers: 
Organic dust. 
Repeated motion, pressure, shock, etc. 
Labelers (paint cans): 
Lace makers: 
Organic dust, 
Lead and its compounds; repeated motion. 
Lacquerers, see lacquer 
makers: 
Lacquer makers: 
Amyl acetate, benzine, benzol, lead and its compounds, 
methyl alcohol, turpentine. 
Lampblack makers: 
Charcoal, petroleum, phenol. HAMMERMEN-MATTRESS MAKERS 
617 
Lapidaries: 
Lard makers: 
Inorganic dust, lead. 
Acrolein. 
Lasters (shoes): 
Sudden variation of temperature. Dampness, organic 
dust, methyl alcohol. 
Lathe turners: 
Repeated motion, pressure, shock, etc. 
Laundry workers: 
Sudden variation of temperature, dampness, carbon 
monoxide, chloride of lime, chlorine. 
Layer pullers (glass): 
Lead burners: 
Extreme dry heat. 
Arseniureted hydrogen, lead and its compounds. 
Lead foil makers: 
Lead miners, see also miners: 
Lead; siliceous dust. 
Extreme dry heat, lead and its compounds. 
Lead pipe makers: 
_ . ,, . 
Lead salts makers: 
Lead and its compounds. 
Lead smelters: 
Extreme dry heat, inorganic dust, antimony, arsenic, 
lead and their compounds, carbon monoxide, sulphur 
dioxide. 
Leather workers, see also 
tannery workers: 
Organic dust, anthrax. 
Leer tenders (glass): 
Letter sorters: 
Extreme dry heat. 
Repeated motion, pressure, shock, etc. 
Levermen (iron and steel): 
Lifters-over (glass): 
Extreme dry heat. 
Extreme dry heat. 
Lime burners: 
Inorganic dust, arseniureted hydrogen, carbon dioxide, 
carbon monoxide, sulphureted hydrogen, cyanogen. 
Lime kiln chargers: 
Inorganic dust, carbon dioxide, carbon monoxide. 
Lime pullers (tannery): 
Lime workers: 
Dampness, anthrax. 
Inorganic dust. 
Linen workers: 
Linoleum colorers: 
Organic dust. 
Arsenic and chromium compounds. 
Linoleum makers: 
Sudden variation of temperature, dampness inorganic 
dust, aerolein, amyl acetate, benzine, lead and its 
compounds, methyl alcohol, sulphuric acid, turpen- 
tine. 
Linotypers: 
Acrolein, antimony and lead, carbon monoxde. 
Linseed oil boilers: 
Lithographers: 
Acrolein, lead and its compounds. 
Inorganic dust, repeated motion, pressure, shock, etc. 
anilin, arsenic and its compounds, benzine, benzol, 
chromium, lead and their compounds, nitrous gases 
and nitric acid, turpentine. 
Litho-transfer workers: 
Lead and its compounds. 
Locksmiths: 
Repeated motion, pressure, shock, etc. 
Longshoremen: 
Lumbermen: 
Anthrax, extreme heat and cold. 
Sudden variation of temperature, hookworm. 
Luters (zinc smelting): 
Machinists: 
Extreme dry heat, brass (zinc). 
Repeated motion, pressure, shock, etc.; oils, cutting 
compounds, alkalies, infections. 
Marble cutters: 
Inorganic dust. 
Marblers (glass): 
Masons: 
Extreme dry heat. 
Dampness, antimony, inorganic dust. Repeated 
motion, pressure, shock, etc. 
Match factory workers: 
Dampness, inorganic dust, organic dust, carbon 
disulphide, antimony, chromium and lead compounds, 
phosphorus, sulphureted hydrogen. 
Mattress makers: 
Organic dust, anthrax. 618 
LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR 
Meat inspectors: 
Anthrax, and other infections. 
Melters (glass foundry): 
Mercerizers: 
Extreme dry heat. 
Ammonia, sulphuric acid. 
Mercurial vapor lamp 
makers: 
Mercury bronzers: 
Mercury miners, see also 
miners: 
Mercury and its compounds. 
Mercury salt workers: 
Mercury smelters: 
Extreme dry heat, carbon monoxide, mercury and its 
compounds, sulphur dioxide. 
Mercury solder makers: 
Mercury still cleaners: 
Mercury and its compounds. 
Metal polishers: 
Inorganic and organic dust; lead; repeated motions, 
pressure, shock, etc. 
Metal polish makers: 
Gasoline. 
Metal turners: 
Metal workers, see particular 
occupations: 
Inorganic dust. 
Mica strippers or splitters: 
Mica workers: 
Inorganic dust. 
Microscopists: 
Millinery workers: 
Repeated motion, pressure, shock, etc. 
Anilin compounds, benzine, benzol, methyl alcohol, 
petroleum, turpentine, carbon tetrachloride; repeated 
motion. 
Milkers: (see also cattlemen) 
Miners: 
Repeated motion, pressure, shock, etc.; infections. 
Sudden variation of temperature. Dampness, inor- 
ganic dust, poor illumination. Repeated motion, 
pressure, shock, etc., carbon dioxide, carbon monoxide, 
nitrous gases, sulphureted hydrogen, hookworm. 
Mirror silverers: 
Sudden variation in temperature, dampness, acetalde- 
hyde, lead, mercury and their compounds. 
Mixers (felt hats): 
Mixers (rubber): 
Organic dust. Mercury and its compounds. 
Sudden variation in temperature. Inorganic dust, 
anilin, benzine, benzol, antimony, arsenic, chromium 
and lead compounds; organic accelerators (urotropin, 
etc.). 
Mixing room workers (mis- 
cellaneous) : 
Inorganic dust, organic dust. 
Mold breakers (foundry): 
Inorganic dust, carbon monoxide. 
Molders, see bench molders, 
floor molders: 
Monotypers: 
Acrolein, antimony and lead. 
Mordanters: 
Amyl alcohol, antimony, arsenic and chromium 
compounds, benzine, benzol, nitrous gases. 
Motion picture film makers, 
see celluloid makers: 
Motormen: 
Sudden variation of temperature, repeated motion, 
etc. 
Mottlers (leather): 
Amyl acetate; methyl alcohol. 
Moving picture machine 
operators: 
Extreme light, 
Muffle tenders: 
Muriatic acid, see hydro- 
chloric acid. 
Extreme dry heat. MEAT INSPECTORS-PHOSGENE MAKERS 
619 
Musical instrument makers: 
Lead and its compounds. 
Musicians: 
Nickel platers, see also elec- 
troplaters : 
Dampness, nickel salts. 
Repeated motion, pressure, shock, etc. 
Nitrators: 
Nitrous gases and nitric acid, sulphuric acid. 
Nitric acid workers: 
Lead and its compounds, nitrous gases and nitric acid, 
sulphuric acid. 
Nitroglycerine makers: 
Arseniureted hydrogen, lead and its compounds, 
nitroglycerin, nitrous gases and nitric acid, sulphuric 
acid. 
Oilcloth makers, see linoleum 
makers: 
Oil extractors: 
Oil flotation plant workers: 
Carbon disulphide. 
Petroleum, sulphur dioxide, sulphureted hydrogen, 
sulphuric acid. 
Oil refiners, see petroleum 
refiners: 
Oil well workers: 
Petroleum. 
Open hearth department 
workers (iron and steel): 
Extreme dry heat. 
Oxy-acetylene blow-pipe 
workers. 
Extreme light: arseniureted and phosphureted hydro- 
gen. 
Packing house employees: 
Sudden variation of temperature, dampness, infec- 
tions. 
Painters: 
Repeated motion, pressure, shock, etc., anilin, benzine, 
benzol, chromates, carbon disulphide, gasoline, 
lead and its compounds, methyl alcohol, turpentine, 
turpentine substitutes (tetralin, benzol, methyl alco- 
hol, etc.). 
Paint makers: 
Dampness, anilin, benzine, benzol, carbon disulphide, 
lead, mercury and their compounds, methyl alcohol, 
tar, turpentine, tetralin. 
Paint removers: 
Inorganic dust, lead and its compounds; benzol; wood 
alcohol; alkalies. 
Paper box makers: 
Paper glazers: 
Repeated motion, pressure, shock, etc. 
Arsenic and its compounds. 
Paper hangers: 
Inorganic dust; arsenic, chromium, and lead com- 
pounds. 
Paper makers, see also rag 
workers: 
Sudden variation of temperature, dampness; sulphur 
dioxide. 
Paraffin workers: 
Carbon disulphide, petroleum, tar. 
Patent leather makers: 
Sudden variation of temperature, amyl acetate, 
carbon monoxide, lead and its compounds, methyl 
alcohol, sulphuric acid, turpentine, benzine. 
Pavers: 
Extreme dry heat, repeated motion, pressure, shock, 
etc., creosote, tar. 
Pencil (colored) makers: 
Anilin, arsenic and chromium compounds. 
Perfume makers: 
Petroleum refiners: 
Dimethyl sulphate, methyl alcohol, nitrobenzol. 
Extreme dry heat, dampness, gasoline, hydrochloric 
acid, lead and its compounds, petroleum, sulphur 
dioxide, sulphureted hydrogen, sulphuric acid, tar. 
Phenol makers, see carbolic 
acid makers: 
Phosgene makers: 
Carbon monoxide, chlorine, phosgene. 620 
LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR 
Phosphate mill workers, see 
also fertilizer makers: 
Sudden variation of temperature, dampness, inor- 
ganic dust, phosphorus. 
Phosphor-bronze workers: 
Phosphorus compound makers: 
Brass (zinc), phosphorus. 
Phosphorus evaporating 
machine operators: 
Sudden variation of temperature, dampness, sulphuric 
acid. 
Phosphorus extractors: 
Phosphorus (red) makers: 
Phosphorus, phosphureted hydrogen. 
Phosphureted hydrogen. 
Photoengravers: 
Benzol, chromium compounds, methyl alcohol, 
nitrous gases and nitric acid. 
Photographers: 
Extreme light, poor illumination, methyl alcohol, 
picric acid, metol. 
Photographic workers: 
Anilin, benzol, chlorine, chromium, cyanogen, mercury 
compounds. 
Photograph retouchers: 
Lead and its compounds. 
Picklers, see also metal 
polishers: 
Dampness, arseniureted hydrogen, cyanogen com- 
pounds, hydrochloric acid, nitrous gases, sulphuric 
acid. 
Picric acid makers: 
Pigment makers, see color 
makers: 
Nitrous gases, phenol, picric acid, sulphuric acid. 
Pipefitters: 
Lead and its compounds. 
Pitch workers: 
Pit molders (foundry): 
Arsenic and its compounds, tar. 
Extreme dry heat, inorganic dust. 
Planer men (stone, metal): 
Plasterers: 
Inorganic dust. 
Dampness, inorganic dust. 
Plaster of paris workers: 
Inorganic dust. 
Platers, see electroplaters: 
Plumbers, see also solderers: 
Lead and its compounds, carbon monoxide. 
Pneumatic tool workers: 
Polishers, see also metal pol- 
ishers: 
Inorganic dust, repeated motion, pressure, shock, etc. 
Inorganic dust, amyl acetate, gasoline, lead and its 
compounds, methyl alcohol. 
Polishers (furniture), see fur- 
niture polishers: 
Porcelain makers, see pot- 
tery: 
Porters: 
Pot fillers (glass): 
Pot lifters (iron and steel): 
Pot pullers (foundry): 
Pot room workers (aluminum) 
foundry; carbide plant): 
Repeated motion, pressure, shock, etc. 
Abnormalities of temperature. 
Pot setters: 
Pottery workers: 
Extreme dry heat; dampness, inorganic dust, arsenic 
and its compounds, carbon dioxide, carbon monoxide, 
hydrochloric acid, lead and its compounds, sulphur 
dioxide. See also particular occupations. 
Pouncers (felt hats): 
Pourers (brass foundry): 
Inorganic dust, organic dust. 
Extreme dry heat, brass (zinc), lead. 
Preparers (tannery): 
Pressers: 
Dampness, anthrax, septic infection. 
Repeated motion, pressure, shock, etc., carbon 
monoxide. 
Pressman (oil refining): 
Dampness. 
Pressmen (printers): 
Inorganic dust, anilin, benzine, benzol, dyes, PHOSPHATE MILL WORKERS SAGGER MAKERS 
621 
Pressmen workers (rubber): 
Sudden variation of temperature, anilin, antimony 
and arsenic compounds, benzine, benzol, chromium. 
Primers (explosives). 
Mercury compounds. 
Printers: 
Inorganic dust, anilin, and other amino-compounds 
of benzol and its homologues, antimony, arsenic, 
benzine, lead and its compounds, turpentine. 
Puddlers (iron and steel): 
Extreme dry heat, extreme light. 
Pullers out (felt hats): 
Pulp-mill employes: 
Dampness. 
Dampness. See also particular occupations. 
Putty makers: 
Inorganic dust, benzine, carbon disulphide, lead and 
its compounds. 
Putty polishers (glass): 
Inorganic dust, lead and its compounds. 
Pyrites burners: 
Extreme dry heat, inorganic dust, arsenic and its 
compounds, sulphur dioxide, sulphureted hydrogen. 
Pyroxylin makers: 
Quarrymen: 
See gun cotton. 
Inorganic dust, hookworm. 
Rag workers: 
Reclaimers (rubber): 
Organic dust, septic and other infections. 
Anilin and other animo-compounds of benzol and its 
homologues, benzol, carbon disulphide, hydrochloric 
acid, lead and its compounds, phenol, sulphuric acid; 
organic dusts. 
Red lead workers: 
Refiners (metals): 
Lead and its compounds. 
Extreme dry heat, arsenic and its compounds, arseni- 
ureted hydrogen, carbon monoxide, lead, mercury, 
nitrous gases, sulphur dioxide, tellurium. See also 
particular metal. 
Refiners (sugar): 
See sugar refiners. 
Refrigerating-plant workers: 
Riveters: 
Sudden variation of temperature, dampness, ammonia. 
Repeated motion, pressure, shock, etc., lead and its 
compounds. 
Roller coverers (cotton 
mills): 
Dampness, organic dust. 
Rollers (metals): 
Roll setter (iron and steel): 
Roll wrenchers (iron and 
steel): 
Extreme dry heat. 
Roofers: 
Sudden variation of temperature, lead and its com- 
pounds, tar. 
Roofing paper workers: 
Tar. 
Rope makers: 
Roughers (iron and steel): 
Organic dust. 
Extreme dry heat. 
Rubber glove makers: 
Benzine, benzol, carbon bisulphide and tetrachloride, 
sulphur chloride. 
Rubber-substitute makers: 
Rubber tire builders: 
Sulphur chloride. 
Antimony compounds, benzine, benzol, chromium 
compounds, organic accelerators (urotropin, etc.). 
Rubber workers, see also 
mixers, pressmen, reclaim- 
ers, spreaders, vulcanizers: 
Sudden variation of temperature, organic and in- 
organic dust, anilin, antimony, arsenic, benzine, 
benzol, chromium compounds, gasoline, hydrochloric 
acid, lead compounds, phenol, sulphur dioxide, 
turpentine, organic accelerators; septic infections, 
repeated motions, pressure, dampness. See also par- 
ticular occupations. 
Sagger makers: 
Dampness, inorganic dust, lead and its compounds. 622 
LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR 
Sailors r 
Sudden variations in temperature. Repeated motion, 
pressure, shock, etc. 
Salt extractors (coke oven by- 
products) : 
Ammonia, sulphuric acid. 
Salt preparers: 
Sudden variation of temperature, dampness, inorganic 
dust. 
Sand blasters: 
Sand cutters: 
Sanders: 
Sanding machine operators: 
Inorganic (especially siliceous) dust. 
Sandpaperers (enameling and 
painting auto bodies, etc.). 
Inorganic dust, lead and its compounds, see also 
painters. 
Saw filers: 
Inorganic dust. 
Saw mill workers: 
Sawyers: 
Scissor sharpeners: 
Organic dust, hookworm. 
Repeated motion, pressure, shock, etc. 
Scourers, wood lasts (shoes): 
Scrapers (foundry): 
Organic dust. 
Inorganic dust. 
Screen tenders (pulp mills): 
Screen workers (lead and 
zinc smelting): 
Dampness. 
Inorganic dust, lead and its compounds, zinc. 
Sealers (incandescent lamps): 
Carbon monoxide. 
Sealing wax makers: 
Seamstresses: 
Arsenic and its compounds, turpentine. 
Repeated motion, pressure, shock, etc. 
Sewer workers: 
Dampness, ammonia, carbon dioxide and monoxide, 
sulphureted hydrogen. 
Sewing machine operators: 
Repeated motion, pressure, shock, etc. 
Shale-oil workers: 
Shavers (felt hats, fur tan- 
nery) : 
See petroleum refiners. 
Dampness, organic dust, anthrax, septic infection. 
Shaving brush makers: 
Organic dust, anthrax. 
Sheep-dip makers: 
Sheet metal workers: 
Arsenic and its compounds. 
Lead and its compounds. 
Shellackers: 
See shellac makers. 
Shellac makers: 
Ammonia, amyl acetate, benzine, benzol, lead and its 
compounds, methyl alcohol, turpentine. 
Shell fillers: 
Shepherds: 
Anthrax. 
Nitroglycerin, picric acid, trinitrotuluol. 
Shoddy workers: 
Organic dust, septic and other infections, arseniureted 
hydrogen, hydrochloric acid, sulphuric acid. 
Shoe factory operatives: 
Organic dust, amyl acetate, benzol, methyl alcohol. 
See also particular occupations. 
Shoe finishers: 
Sudden variation in temperature, ammonia, amyl 
acetate, amyl alcohol, benzine, benzol, carbon bisul- 
phide, gasoline, methyl alcohol. 
Shoe makers: 
Shot makers: 
See cobblers. 
Antimony, arsenic, and lead and their compounds. 
Shove in boys (glass): 
Sifters: 
Extreme dry heat. 
Inorganic dust, organic dust. 
Silicate extractors: 
Silk workers: 
Hydrofluoric acid. 
Organic dust, septic infections, see also artificial silk. 
Silo workers: 
Silverers (mirrors): 
Carbon dioxide. 
See mirror silverers. 
Silver melters: 
Sudden variation in temperature, carbon monoxide. SAILORS-STONECUTTERS 
623 
Silver refiners: 
Singers (cloth): 
Cyanogen compounds. 
Carbon monoxide. 
Sintering plant workers: 
Inorganic dust. 
Sizers (felt hats): 
Skimmers (glass): 
Extreme dry heat. 
Dampness, mercury and its compounds. 
Slag machine tenders (iron 
and steel): 
Extreme dry heat, see also basic slag. 
Slate workers: 
Slip makers (pottery): 
Inorganic dust. 
Dampness, inorganic dust. 
Slushers (porcelain enamel- 
ing): 
Lead and its compounds. 
Smelterers: 
See particular metal. 
Smokeless powder makers: 
Amyl acetate, benzol, carbon disulphide, nitrobenzol, 
and other nitro compounds of benzol and its homo- 
logues, phenol, picric acid. See also particular occupa- 
tions. 
Smoothers (glass): 
Soap makers: 
Dampness, inorganic dust. 
Sudden variation of temperature, dampness, septic 
infection, acrolein, methyl alcohol, nitrobenzol. 
Soda makers: 
Dampness, ammonia, carbon dioxide, carbon monox- 
ide, nitrous gases and nitric acil, sulphureted hydro- 
gen. 
Sodium hydroxide makers: 
Dampness. 
Sodium sulphide makers: 
Softeners (tannery): 
Sulphureted hydrogen. 
Organic dust. 
Solderers: 
Carbon monoxide; hydrochloric acid, lead and its 
compounds, phosphureted hydrogen. 
Sole stitchers (Blake 
machine): 
Mercury and its compounds. 
Spinners (asbestos): 
Spinners (textiles): 
Inorganic dust. 
Organic dust, repeated motion, pressure, shock, etc. 
Spongers: 
Dampness. 
Sprayers: 
Sprayers (trees): 
Dampness. 
Arsenic and lead and their compounds; copper sul- 
phate; lime; sulphur; nicotine. 
Spreaders (rubber works): 
Sudden variation of temperature; benzine; benzol. 
Stablemen: 
Stainers (shoes): 
Anthrax and other infections, 
Lead and its compounds, nitrobenzol. 
Stamp mill workers: 
Starch makers: 
Dampness, inorganic dust. 
Organic dust, carbon dioxide, sulphureted hydrogen. 
Starters (felt hats): 
Dampness, mercury and its compounds. 
Statuary workers: 
Steam fitters: 
Inorganic dust. 
See pipe fitters. 
Stearic acid makers: 
Steel engravers: 
Sudden variation of temperature, acrolein. 
Poor illumination, lead and mercury compounds, 
nitrous gases, nitric acid. See also engravers. 
Stereotypers: 
Sudden variation in temperature, antimony and lead 
compounds; arsenic (as impurity); carbon monoxide. 
Stiffeners (felt hats): 
Mercury and its compounds, methyl alcohol. 
Still (coal tar) cleaners: 
Stillmen (carbolic acid): 
Extreme dry heat, benzol, tar. 
Stitchers (shoes): 
Methyl alcohol. 
Extreme dry heat, phenol. 
Stokers: 
Stonecutters (dry): 
Extreme dry heat, extreme light, carbon monoxide. 
Inorganic dust, repeated motion, pressure, shock, etc. 624 
LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR 
Stonecutters (wet process): 
Dampness, inorganic dust, pressure, repeated motion, 
shock, etc. 
Storage battery makers: 
Lead compounds, sulphur dioxide, sulphuric acid; 
arseniureted hydrogen. 
Straw hat makers: 
Sudden variation of temperature, organic dust, 
sulphur dioxide. 
Submarine (storage battery) 
workers: 
Arseniureted hydrogen, carbon dioxide, oxygen-want. 
Sugar refiners: 
Sudden variation of temperature, dampness, inorganic 
dust, ammonia, carbon dioxide, sulphur dioxide, 
sulphureted hydrogen. 
Sulphite cooks (pulp mills): 
Sudden variation of temperature, dampness, sulphur 
dioxide. 
Sulphur burners: 
Extreme dry heat, inorganic dust, arsenic and its 
compounds, sulphur dioxide. 
Sulphur chloride makers: 
Chlorine, hydrochloric acid. 
Sulphurers (hops and malt): 
Sulphur extractors: 
Sulphur dioxide. 
Carbon disulphide. 
Sulphuric acid workers: 
Arsenic, arseniureted hydrogen, lead and its com- 
pounds, nitrous gases and nitric acid, sulphur dioxide, 
sulphuric acid. 
Sumackers (tannery): 
Dampness, anthrax. 
Surgical dressing makers: 
Phenol, mercury bichloride. 
Table hands (tannery): 
Table operators (iron and 
steel): 
Dampness, anthrax. 
Extreme dry heat. 
Table turners (enameling): 
Sudden variation in temperature, inorganic dust, lead 
and its compounds. 
Tailors: 
Repeated motion, pressure, shock, etc. 
Takers down (glass): 
Tallow refiners: 
Extreme dry heat. 
Septic infection, acrolein, carbon disulphide, sulphuric 
acid. 
Tank men: 
Tannery workers: 
Dampness, and possibly toxic fumes. 
Dampness; anthrax; septic infection; anilin, arsenic, 
benzine, chloride of lime, chromium, cyanogen and 
lead compounds: sulphur dioxide; sulphureted hydro- 
gen, sulphuric acid. 
Tapers (airplanes): 
T etr achloreth ane. 
Tappers (smelting): 
Tar workers: 
Tar. 
Extreme dry heat. 
Taxidermists: 
Organic dust, authrax; arsenic and mercury com- 
pounds. 
Teazers (glass): 
Extreme dry heat; carbon monoxide. 
Telegraphers: 
Telephone linemen (trench 
work): 
Repeated motion, pressure, shock, etc. 
Dampness, carbon monoxide. 
Temperers 
Extreme dry heat; dampness; carbon monoxide, 
cyanogen and lead compounds, petroleum, sulphuric 
acid. 
Textile comb makers: 
Textile printers: 
Inorganic dust. 
See calico printers. 
Textile workers: 
Sudden variation of temperature, dampness, organic 
dust. See also particular occupation. 
Thermometer makers: 
Mercury and its compounds. STONECUTTERS-VULCANIZERS 
625 
Thread glazers: 
Sudden variation in temperature, dampness. 
Tile makers: 
Sudden variation in temperature, dampness, inorganic 
dust, lead and its compounds. 
Tin foil makers: 
Tinners: 
Extreme dry heat, lead and its compounds. 
Extreme dry heat, dampness, acrolein, ammonia, 
arseniureted hydrogen, hydrochloric acid, lead and its 
compounds, possibly phosphureted hydrogen if oxy- 
acetylene blow flame is used. 
Tin plate mill workers, see 
iron and steel workers: 
Tire builders, see rubber tire 
makers: 
Tobacco moisteners: 
Tobacco rollers: 
Organic dust. 
Dampness, carbon dioxide (in tobacco store houses). 
Tobacco workers: 
Tongsmen (iron and steel): 
Organic dust. 
Extreme dry heat. 
Tool makers: 
Inorganic dust. 
Top fillers (foundry): 
Extreme dry heat; inorganic dust; carbon monoxide 
and dioxide. 
Towermen (sulphuric acid): 
Arseniureted hydrogen, nitrous gases and nitric acid; 
sulphur dioxide, sulphuric acid. 
Toy makers: 
Transfer workers (pottery): 
Amyl acetate, arsenic and lead compounds. 
Arsenic; lead and its compounds, turpentine. 
Tree sprayers, see sprayers 
(trees): 
Treaders (rubber): 
Benzol, toluol. 
Trench diggers: 
Tubemakers (glass) 
Extreme dry heat. 
Hookworm and other infections. 
Tubulators (incandescent 
lamps): 
Carbon monoxide. 
Tumbling barrel workers: 
Tunnel workers: 
Inorganic dust. 
Compressed air, hookworm, poor illumination. 
Turners out (glass): 
Turpentine extractors: 
Dampness, turpentine. 
Extreme dry heat. 
Type cleaners: 
Type founders: 
Typesetters: 
Benzine, methyl alcohol. 
Antimony, arsenic; lead and its compounds. 
Typists: 
Upholsterers: 
Repeated motion, pressure, shock, etc. 
Organic dust, anthrax, septic infections, methyl 
alcohol. 
Vapor cures: 
See vulcanizers. 
Varnish boilers: 
Varnish makers: 
Acrolein. 
Sudden variation of temperature, acetaldehyde; 
acrolein, ammonia; benzine; benzol, methyl alcohol, 
turpentine. 
Vatmen: 
Dampness; carbon dioxide. 
Velvet makers: 
Veterinarians: 
Dampness; arsenic and its compounds. 
Anthrax, septic and other infections. 
Vignetters: 
Vinegar workers: 
Hydrochloric acid. 
Acetaldehyde, carbon dioxide. 
Vinters: 
Vulcanizers: 
Carbon dioxide. 
Sudden variation of temperature; dampness; anilin, 
antimony compounds; benzine, benzol; carbon disul- 
phide and tetrachloride, chromium compounds, 
methyl alcohol; sulphur chloride. 626 
LIST OF INDUSTRIES IN WHICH POISONING MAY OCCUR 
Vulcanizers (steam): 
Sudden variation of temperature; dampness. 
Wallpaper printers: 
Sudden variation of temperature; dampness, arsenic 
chromium and lead compounds. 
Warming house employes 
(guncotton): 
Sudden variation of temperature. 
Washerwomen: 
Extreme heat and humidity, repeated motion, pres- 
sure, shock, etc., see also laundry workers. 
Watchmakers: 
Poor illumination; repeated motion, pressure, shock, 
etc. 
Water gilders: 
Mercury and its compounds. 
Water-proof cloth makers: 
Weavers: 
Gasoline. 
Organic dust; repeated motion, pressure, shock, etc. 
Weighers: 
Welders: 
Inorganic dust, organic dust. 
Extreme dry heat, extreme light; brass (zinc), lead and 
its compounds; oxy-acetylene blow flame. 
White lead workers: 
Wire drawers: 
Carbon dioxide; lead and its compounds. 
Arsenic and its compounds; sulphuric acid. 
Wirers (incandescent lamps): 
Wood alcohol distillers: 
Amyl acetate. 
Methyl alcohol. 
Wood preservers: 
Arsenic and mercury compounds, creosote, phenol; tar, 
zinc chloride. 
Wood stainers: 
Woodworkers: 
Anilin; chromium and lead compounds. 
Organic dust (toxic wood dust), gasoline; methyl 
alcohol. 
Wool carders: 
Wool scourers: 
Organic dust; anthrax. 
Sudden variation in temperature; dampness. 
Wool spinners: 
Wool workers: 
Organic dust; anthrax. 
Organic dust; anthrax; see also particular occupations. 
X-ray workers: 
Yeast makers: 
Carbon dioxide. 
Extreme light; actinic rays. 
Zinc-chloride makers: 
Zinc-electrode makers: 
Arseniureted hydrogen; chlorine; hydrochloric acid. 
Mercury and its compounds. 
Zinc miners: 
Arsenic and lead compounds; inorganic dust. See 
also miners. 
Zinc smelterers: 
Extreme dry heat; arseniureted hydrogen; brass 
(zinc); carbon monoxide; lead and its compounds; 
sulphur dioxide. SECTION 25 
LIST OF MIXED INDUSTRIAL POISONS 
COMPOSITE INDUSTRIAL POISONS* 
BY JOHANN MUELLER, M. D., Taegervilen 
A Review BY WM. H. RAND, M. D., Washington 
In a case of occupational poisoning the investigator usually attempts 
to isolate a single toxic factor that happens to be present as raw material, 
or as a by-product, waste product, or end product in an industry, and to 
hold it responsible for the syndrome of diverse and perhaps incon- 
gruous symptoms of a subjective or objective character which may 
develop in the workman. 
There is an obvious fallacy in the conclusion to which this mode 
of procedure leads the observer. It is like a crude piece of detective 
work which attempts to fasten the guilt of a mysterious crime upon 
the one man in a community whose ill repute constitutes the sole ground 
of suspicion against him. 
In the particular instance at issue the suspect may be innocent, 
and able to prove an alibi £ or, if culpable, he may have been only an 
accessory or particeps criminis. 
Every occupational disease is an industrial problem. Its diagnosis 
is often obscured and rendered doubtful by apparently incompatible 
physical signs. Each of these should receive due consideration, for 
a differential diagnosis cannot be determined by giving attention to 
any salient feature in the case to the exclusion of all else. Ultimately 
the clinical picture must be visualized as a whole; but the separate symp- 
toms must first be considered one by one. 
The etiology of an occupational disease is always important, for a 
knowledge of the source of danger is prerequisite in order that appropriate 
measures may be adopted for its elimination. Against poisons used in the 
trades a man can often protect himself, provided he knows their origin 
and what their composition is. 
For example, take the risk of poisoning in hat manufacture. It is 
commonly assumed that the peculiar danger in this industry arises 
from poisoning with the acid nitrate of mercury with which the fur 
is brushed in the process of carroting. 
* This article is a review of a series of articles by Dr. Johann Mueller which appeared 
in the April to August, 1919, issues of the Zentralblatt fur Gewerbehygiene. Translated 
and reviewed by Dr. Wm. H. Rand for the U. S. Bureau of Labor Statistics and published 
in the Monthly Labor Review, Vol. X, No. 2, February, 1920. 
627 628 
LIST OF MIXED INDUSTRIAL POISONS 
But aberrant symptoms sometimes manifest themselves in carroters 
which are never present in uncomplicated mercurialism. Since every 
phenomenon must be accounted for, how are these anomalies to be 
explained? Not by attributing all unexpected developments and 
uncoordinated symptoms to the existence of some hypothetical idiosyn- 
crasy of the individual. That is an overworked method of begging the 
question. 
Inquiry at once elicits the fact that the carroting solution is not 
a simple mixture containing a single poison. Teleky gives the following 
formula for "die Sekretage:" 
Parts 
Mercury 4 
Sublimate 1 
Nitric acid 32 
Arsenic 2 
Water 120 
In handling such a compound one is exposed to a number of poisons. 
Consequently, the physical effects produced by the solution are not 
uniform but multiform. 
It is true that the manifestations of arsenic poisoning in this instance 
may be masked or obscured by the more obvious effects of the mercury. 
But the more insidious lesions occasioned by the arsenic, and the systemic 
disturbances due to nitric acid must not be ignored. The problem is not 
to be solved by finding the value of x. The statement of the equation 
involves also the values of y and z. 
Whenever possible, of course, it is advisable to isolate and identify 
the specific toxic agent in any case of industrial poisoning. But when 
several poisons enter into the composition of a mixture handled by the 
workman, the determination of the relative degrees of toxicity in the 
ingredients offers a complex question for analysis. Yet a candid investi- 
gator cannot disregard any of the conditions. 
In the instance already cited, where mercury is one of the elements 
in a carroting mixture, it is neither legitimate nor logical to impute all 
of the ill effects of the preparation to mercury poisoning alone. The other 
components of the solution are not inert, and the concurrent or consecu- 
tive pathological signs due to the presence of poisons other than mercury 
in the compound must be recognized and appraised. 
The net results of mixed poisoning are ascribable in part to definite 
chemical reactions, but partly, also, to antecedent physical conditions 
which determine the absorption and elimination of toxic substances. Our 
knowledge of the reactions between the body cells and poisons is still 
meager, and better acquaintance with the molecular changes produced 
in the organism by agents of this nature is most desirable. But while 
much is still uncertain, some points have been made clear. EFFECTS OF MIXED POISONS 
629 
Buergi (cited by Mueller) has shown that the variable effects of mixed 
poisons depend on several factors: 
1. Mixtures of two substances may yield a new chemical body. 
2. The solubility of one substance may be modified by the addition of another. 
3. The penetrability of the cell membranes by one substance may be affected by 
the addition of another. 
4. The cell becomes by saturation with one substance more or less absorptive 
of another. 
These statements seem like self-evident propositions, but it is well 
to have them explicitly formulated, since they have important corol- 
laries. Thus, from the combination of two virulent poisons, for example, 
copper sulphate and phosphorus, there may arise an innocuous compound. 
Conversely, a highly poisonous compound may result from mixing two 
nontoxic substances (iodide of potassium and calomel). It is in this way 
that industrial poisons often originate. 
Now, the toxicity of a substance depends on its potential pene- 
trability into the body, and on its combination in the body with the 
tissues of vitally important organs in sufficient concentration to cause 
functional disturbances. 
Poisons are absorbed by the system at a variable rate, which depends 
mainly on the solubility of the substances. Lead and its salts, for 
example, produce their effects on the nervous and muscular tissues only 
after the lapse of weeks or months. Lead is very slowly absorbed, but it 
is still more slowly eliminated; hence its cumulative action. 
Rapidity, facility, and degree of poisoning are conditioned also by 
the quantity absorbed, and by the frequency with which the poison 
is introduced into the system. A given amount of morphine, for example, 
administered in fractional doses at brief intervals, produces a more 
powerful effect than the entire quantity given as one dose. 
The principle holds good in reference to many industrial poisons. 
A short exposure to the hazard of poisoning in an atmosphere heavily 
charged with lead dust may occasion little trouble or none at all, 
while long-continued employment in a room where lead-dust diffusion 
is much less dense may give rise to chronic plumbism of the gravest 
type. 
LIST OF INDUSTRIES INVOLVING USE OF POISONS 
Dr. Johann Mueller of Taegervilen has published in the Zentralblatt 
fiir Gewerbehygiene (for April, 1919) a table in which are listed numerous 
industries and their peculiar processes in which workmen are subjected 
to the influence of multiple toxic agents (mixed poisons). The table is 
reproduced in full on account of its intrinsic value and its practical sugges- 
tiveness. 630 
LIST OF MIXED INDUSTRIAL POISONS 
List of Mixed Poisons to Whose Influence Workmen are Subjected in Various 
Industries 
Industry 
Process and 
product 
Poisons used in 
manufacture, and 
chief end products 
Poisonous by- 
products and 
impurities 
Remarks 
Sulphuric acid 
Roasting of py- 
Sulphurous acid; 
Arsenic impuri- 
Specially dangerous is 
manufacture. 
rites. 
lead; sulphuric 
acid. 
ties; arsenic; 
lead; evolution 
of arseniureted 
hydrogen; de- 
velopment of ni- 
trous gases in 
the lead cham- 
ber and tower. 
cleaning of the lead cham- 
ber in case of insufficient 
ventilation. Nitrous 
gases. Arsenic com- 
pounds. Sulphurous 
acid. Chronic lead poi- 
soning. 
Nitric 'acid 
manufacture. 
Distillation of ni- 
ter and sulphu- 
ric acid in cast- 
iron cylinders. 
Production of 
baryte nitrate 
by dissolving 
barium sulphate 
in nitric acid. 
Manufacture of 
lead nitrate by 
dissolving lead 
oxide in nitric 
acid. 
Manufacture of 
the acid nitrate 
of mercury. 
Manufacture of sil- 
ver nitrate. 
Manufacture of 
sodium nitrate 
by fusing niter 
with metallic 
lead. 
Fuming nitric 
acid with ni- 
trous acid. 
Nitrous acid; tet- 
roxide of nitro- 
gen. 
Nitrous acid; tet- 
roxide of nitro- 
gen; lead. 
Nitrous acid; tet- 
roxide of nitro- 
gen; mercury. 
Nitrous acid; tet- 
roxide of nitro- 
gen; silver. 
Nitrous acid; tet- 
roxide of nitro- 
gen; lead. 
Nitrous gases. 
Nitrous gases. 
Nitrous gases. 
Nitrous gases. 
Nitrous gases. 
Nitrous gases. 
Acid fumes, especially in 
case of leaks. 
In the ignitions and explo- 
sions much nitrous gas is 
set free. Used in pyro- 
technics and explosive 
trades. 
Used in color printing 
plants, match manu- 
facture, and chrome-yel- 
low pigment. 
Carroting fur, hat manu- 
facture, metal amalgam 
production, bronzing and 
silvering. 
Silver. 
Used in photography and 
in silvering glass pearls. 
Soda manufac- 
ture. 
Chlorine manu- 
facture. 
Leblanc process. 
Weldon process. 
Deacon process. 
Electrolytic proc- 
esses. 
Sulphuric acid; 
nitric acid. 
Hydrochloric 
acid; manga- 
nese; chlorine. 
Hydrochloric 
chlorine. 
Alkaline chlor- 
ides; chlorine; 
mercury. 
Arseniureted hy- 
drogen from im- 
purities of ar- 
senic. From 
smelting comes 
much carbon 
monoxide and 
carbon dioxide. 
By the efflores- 
cence of soda 
residua, s u 1- 
phureted h y- 
drogen. 
Since the sulphu- 
ric acid is taken 
from the sul- 
phate furnace 
direct, it holds 
as impurities ar- 
senic, sulphuric 
acid, and nitric 
acid. 
The evolution of carbon 
monoxide is especially 
dangerous. 
Acid fumes also injure the 
organs of respiration and 
the teeth. 
Chlorine danger great. 
Chlorine acne, probably a 
combined effect of chlo- 
rine and tar (chlorinated 
phenol). 
Chloride of lime 
manufacture. 
Chloride of 
phosphorus 
manufacture. 
Manufacture 
of the salt from 
lime and chlo- 
rine. 
Oxidation of phos- 
phorus and hy- 
drochloric acid. 
Use of carbon di- 
sulphide as sol- 
vent. 
Lead (chambers); 
chlorine. 
Hydrochloric 
acid; chlorine; 
carbon disul- 
phide. 
Carbon mono- 
xide; phosphorus 
trichloride; 
phosphorus pen- 
tachloride: ar- 
seniureted hy- 
drogen. 
Hvposulphurous 
Chlorine poisoning from 
shoveling the lime; too 
early entrance into cham- 
ber. 
Sulphur chlo- 
r i d e manu- 
facture. 
Heating chlorine 
Chlorine; hydro- 
Decomposition by addition 
and sulphur. 
chloric acid. 
acid. 
of water with formation of 
hydrochloric-acid fumes. 
Phosgene manu- 
facture. 
Chlorine and car- 
bon monoxide 
treated with an- 
imal charcoal. 
Chlorine; carbon 
monoxide; phos- 
gene. 
Used mainly in dyestuff 
manufacture. 
The effect is a combined 
one--of the entire mole- 
cules and decomposition 
products. ACIDS CHLORIDES DIMETHYL SULPHATE-EXPLOSIVES 
631 
List of Mixed Poisons to Whose Influence Workmen are Subjected in Various 
Industries--Continued 
Industry 
Process and 
product 
Poisons used in 
manufacture and 
chief end products 
Poisonous by- 
products and 
impurities 
Remarks 
Chloride of zinc 
manufacture. 
Methyl chlo- 
ride m a n u- 
facture. 
Heating of zinc 
oxide and 
hydrochloric 
acid. 
Made from methyl 
alcohol, com- 
mon salt, and 
sulphuric acid. 
Chlorine; hydro- 
chloric acid. 
Methyl alcohol; 
acid fumes; 
methyl chloride. 
Arseniureted hy- 
drogen. 
Arseniureted hy- 
drogen; nitrous 
gases; impuri- 
ties of methyl 
alcohol. 
Used as a mordant. 
Chloroform 
Distillation of al- 
Chlorine; ace- 
The most impor- 
Decomposition of phos- 
manufacture. 
Carbon tetra- 
chloride 
manufacture. 
cohol, acetone, 
and chloride of 
lime. 
Action of chlorine 
in carbon disul- 
phide with chlo- 
ride of antimony 
or aluminium. 
tone; alcohols. 
Chlorine; carbon 
disulphide; 
methyl chloride. 
tant are: Amyl 
alcohol; ethyl 
chloride; alde- 
hyde ; allylchlo- 
ride; tetrachlor- 
methane; phos- 
gene; chlorine 
derivatives of 
propyl, butyl, 
amyl acids. 
gene, ethyl chloride, and 
other chlorine com- 
pounds by free hydro- 
chloric acid in the air. 
In gas illumination evolve 
carbon dioxide, carbon 
monoxide, and hydro- 
chloric acid, with traces 
of free chlorine, but no 
phosgene. 
These products of com- 
bustion may cause severe 
irritation of the mucous 
membranes. 
.Nitrous c h 1 o- 
ride m a n u- 
facture. 
Cyanochlorite 
manufacture. 
Chlorine and sal 
ammoniac. 
Chlorine and cya- 
nide of mercury. 
Chlorine; ammo- 
nia. 
Chlorine; m e r- 
cury; cyanochlo- 
rite. 
Hydrocyanic 
acid. 
Highly explosive. 
Dimethyl s u 1- 
Sulphuric acid 
Alcohol; s u 1- 
Arseniureted hy- 
It acts: (a) As a whole 
phate. 
Explosives: 
and methyl al- 
cohol. 
phuric acid; 
dimethyl s u 1- 
phate. 
drogen; nitrous 
gases. 
molecule; (b) By split- 
ting up with water it 
develops sulphuric acid 
effect. 
Fulminate of 
Solution of mer- 
Mercury; nitrous 
Acetic acid; cya- 
Used in percussion-cap 
mercury. 
cury in nitric 
acid with alco- 
hol. 
gases; fulminate 
of mercury. 
n i d e co m- 
pounds. 
manufacture. 
In filling the caps there is 
special danger of chronic 
mercury poisoning from 
mercury fumes given off 
in pressing and filling as 
a result of small explo- 
sions giving rise to 
nitrous gases. 
Nitroglycerin. 
Action of mixed 
nitric and sul- 
phuric acids on 
glycerin in lead 
vats. 
Sulphuric acid 
fumes; nitrous 
gases (from the 
acid mixture es- 
pecially, but 
also by denitrat- 
ing of waste 
acids); nitro- 
glycerin; lead. 
Arseniureted hy- 
drogen. 
Dynamite is produced by 
mixing nitroglycerin 
with siliceous earth 
("dope"). 
Mixing and sifting of dyna- 
mite cause chronic ulcers 
at the finger tips and 
under the nails. 
Guncotton. 
Action of a mix- 
ture of nitric and 
sulphuric acid 
on cellulose. 
Acid fumes; ni- 
trous gases; cy- 
a n i d e co m- 
pounds. 
Arseniureted hy- 
drogen. 
According to Koelsch, the 
nitrated benzols are viru- 
lent poisons, and, pri- 
marily, blood poisons; 
(Methemoglobin forma- 
tion, damage to red blood 
cells.) Perhaps, also, 
primary injury to the 
central nervous system. 
Smokeless 
powder. 
.Gelatinizing of gun 
cotton with ace- 
tone. 
Solvents like ace- 
t o n e, alcohol, 
ether, carbon di- 
sulphide, etc. 
Toluol nitrites are rela- 
tively harmless and cause 
symptoms of poisoning 
only after long-continued 
exposure. 
Severe poisonings are trace- 
able to impurities.- 
Koelsch. 632 
LIST OF MIXED INDUSTRIAL POISONS 
List of Mixed Poisons to Whose Influence Workmen are Subjected in Various 
Industries-Continued 
Industry 
Process and 
product 
Poisons used in 
manufacture, and 
chief end products 
Poisonous by- 
products and 
impurities 
Remarks 
Explosives- 
Concluded. 
Smokeless 
p o w d e r-■ 
Concluded. 
(Other ingre- 
Nitrites. 
Nitrobenzol; ni- 
Benzol; benzol ni- 
dients.) 
Shot and bul- 
For hardening, ar- 
trotoluol; dini- 
trobenzol; phe- 
nols; picric acid, 
etc. 
Lead; arsenic; an- 
trites; unnitri- 
table hydrocar- 
bons; tetrani- 
tromethane. 
The proportion of 
let manufac- 
senic and anti- 
timony. 
arsenic used is 
ture. 
Iodine and 
mony are em- 
ployed. 
Production of io- 
Chlorine; iodine; 
0.2 to 0.8 per 
cent.; of a n t i- 
mony 8 to 14 
per cent. 
Irritating chlorine 
bromine 
dine and bro- 
bromine (wood 
compounds i n 
manufacture. 
mine salts from 
spirit as extrac- 
small quantities. 
Phosphorus in- 
mother liquors 
by the action of 
chlorine and 
oxidation agents. 
Production of phos- 
tion agent). 
Acid fumes; phos- 
(Slight action.) 
Arseniureted hy- 
dustry. 
phorus from 
phorus fumes. 
drogen. 
Swedish 
phosphorites by 
means of sul- 
phuric acid, or 
by electrolytic 
process. 
Phosphorus s u 1- 
phiae p r o d u c- 
In the distillation 
of the phos- 
phorus, p h o s- 
phine is given 
off, with phos- 
phorus fumes 
and carbon 
monoxide. 
Carbon disul- 
By disintegration 
of the bleached 
bones with sul- 
phuric acid arise 
sulphureted hy- 
drogen, carbon 
dioxide, hydro- 
cyanic acid, hy- 
drochloric acid, 
hydrofluoric 
acid. 
■Sulphureted hy- 
Besides the trouble from 
matches. 
ph ide in the 
drogen. 
gases, acrid fumes, etc., 
the dust is especially 
dangerous on account of 
its gross content of caus- 
tic lime (in Thomas slag 
as high as 50 per cent). 
Artificial fertil- 
tion by melting 
together red 
phosphorus 
and sulphur. 
Extraction of 
extraction of 
phosphorus. 
Acid fumes; sul- 
Hydrofluoric acid 
izers. 
phosphate of 
phurous acid; 
(since nearly all 
India rubber: 
lime by sulphur- 
ic acid. 
By the hot pro- 
carbon dioxide. 
Sulphur chloride; 
phosphates con- 
tain calcium 
fluoride); ni- 
trous gases; ar- 
seniureted h y- 
drogen. 
By disintegrating 
Nearly all rubber goods 
Vulcanizing. 
cess at about 
antimony. 
sulphur chloride 
are reinforced, often to 
140° sulphur 
compounds 
emerge (c h 1 o- 
rine, barium, 
and antimony 
sulphides). 
By the cold proc- 
ess, dipping the 
gum in a mix- 
ture of sulphur 
chloride and 
carbon d i s u 1- 
phide (or its 
substitute prod- 
ucts). 
Carbon disul- 
phide, as a sub- 
stitute, benzine; 
turpentine oil; 
carbon tetra- 
chloride; di ch- 
lormethane; 
benzol and its 
derivatives; ani- 
lin. 
in water: s u 1- 
phurous acid; 
sulphureted hy- 
drogen (from 
antimony sul- 
phide). 
the extent of 50 per cent, 
of substitutes mostly 
compounds with vege- 
table oils and sulphur 
chlorides, but sometimes 
containing lead or mer- 
cury. 
Hygienic control can under 
no circumstances be 
slackened over processes 
conducted often accord- 
ing to secret formula 
which prescribe strange 
ingredients for the mak- 
ing of dyestuffs. MISCELLANEOUS INDUSTRIES USING MIXED POISONS 
633 
List of Mixed Poisons to Whose Influence Workmen are Subjected in Various 
Industries-Continued 
Industry 
Process and 
product 
Poisons used in 
manufacture, and 
chief end products 
Poisonous by- 
products and 
impurities 
Remarks 
Dyeing. 
Artificial silk 
manufacture: 
1. Nitrocel- 
lulose. 
Substances princi- 
pally used are: 
antimony s u 1- 
phide; cinnabar; 
zinc white; 
frankfort black; 
white lead and 
other lead colors 
(in the making of 
rubber gloves); 
also arsenic 
colors. 
Nitriting cellulose. 
Action of a mix- 
ture of nitric 
and sulphuric 
acids on cellu- 
lose. 
Dissolving c a m- 
phor, toluol, etc., 
in acetic acid. 
Drying and spin- 
ning room proc- 
esses. 
Deni tri ting. 
Mercury; lead; 
arsenic. 
Acid fumes; nit- 
rous gases; cyan- 
ide compounds; 
acetic acid; 
camphor; toluol; 
alcohol fumes; 
ethers; u n d i s- 
solved hydrocar- 
bons; ammon- 
ium sulphate. 
Sulphureted hy- 
drogen e s p e- 
cially by the re- 
duction of the 
sulphide of anti- 
mony with 
acids. 
Arseniureted hy- 
drogen; sulphur- 
eted hydrogen; 
ammonia. 
The alkali and ammoniac 
manufacturers should do 
away with this method. 
Fire risk small. 
2. Oxide o f 
copper 
and am- 
moniac 
process. 
Precipitation o f 
copper oxide 
and solution in 
strong ammoni- 
ac menstruum. 
Strong alkalies 
and acids; acid 
fumes; ammo- 
nia. 
3. Viscose 
manuf ac- 
t u r e (n i- 
t r o c e 11 u- 
lose). 
By use of strong 
alkalies, but 
mostly with very 
large quantities 
of carbon disul- 
phide. 
Strong alkalies; 
ammonia; car- 
bon disulphide. 
Like rubber manufacture. 
4. A c e t y 1- 
cellulose. 
Production of ace- 
tylcellulose by 
addition of ethyl 
chloride to a so- 
lution of nitro- 
cellulose. 
Use of large quan- 
tities of anhy- 
drous acetic acid. 
Spinning process: 
Dissolving i n 
ether, alcohol, 
acetone, etc., 
and drying. 
N i t r ocellulose; 
acid fumes; ni- 
trous gases; cy- 
anide c o m- 
pounds; solvents 
-acetone; amyl 
acetate; carbu- 
reted hydrogen; 
benzol and its 
derivatives o r 
homologues. 
Ether and alcohol 
fumes; acetone, 
etc. 
■ 
Fire danger very great. 
Celluloid indus- 
The solvents are 
Acetone; aceto- 
Ignition and deto- 
Celluloid technique is ex- 
try. 
/ 
poisonous beyond 
all else. 
chlorhydrin; eth- 
er; benzine; ben- 
zol; amylacetate 
anhydrous acet- 
ic acid; nitroben- 
zol; dinitroben- 
zol; nitrochlor- 
benzol; epichlor- 
hydrin; m ethyl 
alcohol; carbon 
disulphide; car- 
bon tetrachlo- 
ride; hexachlor- 
e t h y 1 i n, and 
many other chlo- 
rine products. 
Mixtures :Benzine 
+amyl acetate; 
benzine + me- 
thylalcohol; ben- 
zine + alcohol; 
xylol + alcohol; 
ether + alcohol 
+ acetic acid. 
nation, e s p e- 
cially when there 
are drafts of 
air, evolve fumes 
of carbon mo- 
noxide, carbon 
dioxide, nitrous 
gases, hydrocy- 
anic acid, acro- 
lein, and cam- 
phor. 
tremely complicated. 
Dangers are mostly occa- 
sioned by the solvents: 
but celluloid itself has 
many peculiarities which 
make it very unsafe when 
stored in great heaps: 
(1) Ready decomposabil- 
ity. (2) Inflammability so 
that it ignites like a 
match. (3) Evolution of 
poisonous gases-(a) by 
decomposition and deto- 
nation; (b) by secondary 
explosions of denonating 
gases mixed with air. 
(Limit of explosibility, a 
content of 8 to 4 per 
cent.) 634 
LIST OF MIXED INDUSTRIAL POISONS 
List of Mixed Poisons to Whose Influence Workmen are Subejcted in Various 
Industries-Continued 
Industry 
Process and 
product 
Poisons used in 
manufacture, and 
chief end products 
Poisonous by- 
products and 
impurities 
Remarks 
Celluloid manu- 
facture. 
Gas industry: 
Coke ovens. 
Process of gas 
purification. 
Ammoniac pro- 
duction. 
Calcium carbide 
manufacture. 
Tar industry. 
Made of camphor, 
alcohol, and py- 
roxalin. 
Pyroxalin is ob- 
tained from vege- 
table fibers by 
treatment with 
sulphuric acid 
and nitric acid. 
Dry distillation, 
purification 
processes. 
Extraction of am- 
monium salts 
by washing with 
water. 
Extraction of sul- 
phur with car- 
bon disulphide. 
Production of the 
ferrocyanide o f 
potassium. 
Disintegration of 
the nonvolatile 
ammonium com- 
pounds with 
caustic alkali. 
Distillation. 
Reduction b y 
smelting or 
electrochemical 
process, produc- 
ing acetylene by 
addition of water. 
Dry distillation of. 
anthracite coal. 
Fractional d i s- 
tillation. 
Alcohol; c a m- 
phor; acid 
fumes; nitrous 
gases. 
Illuminating gas; 
carbon monox- 
ide, carbon di- 
oxide, ammonia 
methane, tar; 
ammoniac water 
gas: sulphureted 
hydrogen, c a r- 
bon disulphide, 
hydrocya nic 
acid; r h o d a n 
compounds 
(phosphorus, ar- 
senic, etc.). 
Cyanogen; am- 
monia; cyanide 
compounds; 
r h o d a n com- 
pounds. C a r- 
bon disulphide; 
ethyl trichlor- 
ide. 
Ammonia; sul- 
phuric acid; 
metaphosph oric 
acid. 
Penetration of 
ammonia fume 
into the acids 
gives rise to ill- 
smelling gases. 
Sulphureted hy- 
« drogen; cyano- 
gen. 
Lead poisoning 
from lead. 
Acetylene; carbon 
dioxide; carbon 
monoxide. 
Tar fumes con- 
sisting of: 
1. Hydrocarbons 
of the meth- 
ane series, par- 
affin, olefin. 
Hydrocarbons 
of the a r o- 
matic series, 
benzol and its 
homologues, 
naphthalin, 
anthracene, 
phenanthin, 
2. P h e n o 1 s, 
(c r e s o 1 i n, 
naphthalin). 
3. Sulphides 
(sulphureted 
hydrogen, car- 
b o n d i s u 1- 
phide, mercap- 
tan, thiophen). 
Pyridin, pyvrol, 
phenols, tar. 
Ammonia; s u 1- 
phureted hydro- 
gen; especially 
phosphine (to 
the amount of 
0.2 per cent.). 
Poisonous e n d- 
products: Pyri- 
d i n, benzol, 
toluol, xylol, 
naphthalin, 
phenols, s a 1 i- 
cylic acid, picric 
acid, cresols, 
naphthols, an- 
thracene. 
According to Jehle and 
Layet, the hygienic con- 
dition of the gas-plant 
workman is by no means 
satisfactory. 
Especially in the condens- 
i n g and purification 
rooms, the air is always 
charged with gas. 
Danger of poisoning is not- 
ably great in case of leaks 
and industrial accidents 
(bursting of pipes, etc.). 
Production of dense fumes 
of tar, especially in ex- 
traction plants, wood- 
preserving establish- 
ments, roofing-paper fac- 
tories, and, above all, 
from open kettles. Se- 
vere skin diseases occur 
(tar itch). MISCELLANEOUS INDUSTRIES USING MIXED POISONS 
635 
List of Mixed Poisons to Whose Influence Workmen are Subjected in Various 
Industries--Continued 
Industry 
Process and 
product 
Poisons used in 
manufacture, and 
chief end products 
Poisonous by- 
products and 
impurities 
Remarks 
Tar industry- 
Concluded. 
Dye manufac- 
ture. 
Metal industry: 
Lead. 
1. Nitrites with 
nitric acid _ and 
sulphuric acid. 
2. Reduction t o 
amines. 
3. Sulphurization 
with c o n c e n- 
trated sulphuric 
acid. 
4. Conversion o f 
sulphur acids 
into phenols by 
fusion with 
caustic soda. 
5. Chlorinating, 
brom i n a t i n g, 
combining with 
phosgene. 
6. Methylating. 
Roasting ore. 
Reduction of the 
oxides by coal, 
Patterson crys- 
tallization pro- 
cess. 
Lead refining. 
4. Nitrogen 
compounds 
(Ammonia, 
methylamin, 
anilin, p y r i- 
din, etc.). 
(a) Poisonous 
products: Methyl 
alcohol, ethyl 
alcohol, p h o s- 
gene, formalde- 
h y d e, hydro- 
carbons of the 
aromatic series 
(benzol, toluol, 
xylol, naphtha- 
lin, anthracene, 
phenols, cresols), 
oxalic acid, tar, 
acetaldeh yd e, 
anilin, toluidin, 
nitrobenzol picric 
acid, phenylgly- 
cocol, nitrosodi- 
methylanilin, 
monodi nitroben- 
zol. 
(&)Toxic reagents: 
chlorine, nitric 
acid, sulphuric 
acid, sulphur- 
eted hydrogen, 
ammonia, 
methyl bromide, 
methyl iodide, 
arsenic, anti- 
mony, lead, 
chromium d i- 
methyl s u 1- 
phate. 
(c)Poisonous end- 
products: Ni- 
trous products 
(nitrobenzol, to- 
luol, picric acid), 
aromatic bases 
(toluidin, anilin, 
xylidin, dimeth- 
ylanilin), s u 1- 
phur acids, phe- 
nols and cresols, 
paraphenyl e n- 
diamin, suspect- 
ed dyestuffs (as 
a rule, of course, 
dangerous only 
in large quan- 
tities), saffron 
yellow, anilin 
orange, picric 
acid, d i n i t r o- 
naphthol, ni- 
trous dyestuffs, 
aurantia-h e x a- 
n i t r odiphenyl- 
amin, kaiser yel- 
low, ethyl and 
methyl violet 
meldola dyes, 
corbulin, fast 
blue, etc. 
Lead danger. 
Incidental prod- 
ucts: Nitro and 
amino c o m- 
pounds of many 
varieties (nitro- 
benzol), acridin, 
cyanogen, 
diimin. 
By-products and 
impurities: Am- 
monia, sulphur- 
eted hydrogen 
(from sulphur 
dyes), . nitrous 
gases, acid fumes, 
cyanogen c o m- 
pounds, areseni- 
ureted hydro- 
gen stibine. 
Sulphur dioxide; 
arsenic; a n t i- 
mony; smoke of 
smelteries. 
The most frequent poison- 
ings are due to anilin- 
benzol and its homo- 
logues, nitr obeqzol, 
nitrous gases, arsenic. 
The shops are generally 
well equipped from a 
sanitary point of view. 
But poisonings contin- 
ually occur as results of 
improvidence or acci- 
dent. 
A special danger is that 
arsenic acts partly as an 
acid impurity in arseni- 
ureted hydrogen partly 
also because it is used in 
substance for bright 
colors. 
(Every factory boasts of 
special patents and special 
processes.) 636 
LIST OF MIXED INDUSTRIAL POISONS 
List of Mixed Poisons to Whose Influence Workmen are Subjected in Various 
Industries-Continued 
Industry 
Process and 
product 
Poisons used in 
manufacture, and 
chief end products 
Poisonous by- 
products and 
impurities 
Remarks 
Metal i n'd u s- 
try-Con. 
Mercury.. 
• 
Arsenic and 
antimony. 
Iron 
Ferrosilicon. 
Lime burning. 
Dyeing 
Tanning 
White lead manu- 
facture by the 
action of acetic- 
acid fumes and 
carbon dioxide 
(coke burning) 
on lead plates in 
closed chambers. 
Extraction from 
cinnabar in blast 
furnaces. 
Condensation and 
distillation. 
Roasting of a r- 
senic-b earing 
ores. 
In blast furnaces 
which are filled 
with a mixture 
of limestone and 
coke. 
Mordanting the fi- 
ber and dyeing 
it, often in lead- 
en vats. 
Depilation and 
curing of skins. 
Carbon dioxide; 
acetic acid; 
lead. 
Mercury. 
Arsenic; a n t i- 
mony 
From this come 
some mineral 
acid products, 
sulphureted hy- 
drogen, for ex- 
ample. 
Mordants: Chro- 
m i u m co m- 
pounds, especi- 
ally potassium 
dichromate, ace- 
tic a c id, s u 1- 
phuric acid, zinc 
chloride, potas- 
sium chlorate. 
Solvents: Methyl- 
ethyl-amyl alco- 
hol, turpentine, 
benzine, benzol- 
acetone. 
Dyes: Lead and 
arsenic colors, 
anilin colors, ni- 
trite of lead col- 
ors, lead chro- 
mates. 
Bleaches: chlo- 
rine, sulphurous 
acid, chloride of 
lime, phenol, 
fluorine. 
Sulphide of soda, 
lime gas, arse- 
inite of potas- 
Sulphur dioxide; 
smeltery smoke. 
Smeltery smoke, 
arseniureted hy- 
drogen, stibine. 
Furnace gases 
constitute the 
chief danger. 
These consist of 
arseniureted hy- 
drogen, stibine, 
carbon monox- 
ide, sulphur di- 
oxide, hydrocy- 
anic acid. 
Phosphine, arse- 
niureted hydro- 
gen, sulphureted 
hydrogen (with 
moisture), espe- 
cially under 70 
per c e n t. i n 
amount; carbon 
dioxide; carbon 
monoxide; sul- 
phureted h y- 
drogen; sulphur 
dioxide; and 
arseniureted hy- 
drogen. 
Acid fumes, espe- 
cially hydro- 
chloric acid, 
chlorine, ammo- 
nia, acetic acid, 
cyanogen, rho- 
dan compounds. 
Carbon dioxide; 
cyanogen com- 
pounds; s u 1- 
Especially hazardous is the 
work in the oxidizing 
chamber. 
Smeltery smoke: A prod- 
uct of imperfect combus- 
tion. It contains carbon 
monoxide, sulphur di- 
oxide, dust of toxic met- 
als (lead, zinc, mercury, 
arsenic, antimony). 
Smelting disease. 
Pallor of countenance. 
Lowering of physical re- 
sistance. 
Finally, specific poisonous 
effects. The smeltery 
smoke is always heavily 
charged with arsenic. 
There is absorption of 
small quantities of ar- 
senic or arsenious oxide. 
Like risks exist in the 
smelting of cobalt, nickel, 
lead, copper, iron, silver, 
and zinc. 
Ferrosilicon virtually al- 
ways contains phospho- 
rus, arsenic, and sulphur, 
so that the development 
of very poisonous com- 
pounds is to be ex- 
pected. (Poisonings oc- 
cur on ocean vessels when 
as a result of the entrance 
of water such gases 
evolve.) 
Schuler reports that severe 
epidermal inflammations 
result from using anilin 
black. 
Great danger from pollu- 
tion of the waste water. MISCELLANEOUS INDUSTRIES USING MIXED POISONS 
637 
List of Mixed Poisons to Whose Influence Workmen are Subjected in Various 
Industries-Continued 
Industry 
Process and 
product 
Poisons used in 
manufacture, and 
chief end products 
Poisonous by- 
products and 
impurities 
Remarks 
Tanning-Con. 
Arsenic for denud- 
ing of wool, cy- 
anogen for depi- 
lation. 
Ash process. 
sium, formalde- 
hyde, oxalic 
acid, cyanogen. 
Lime water, arse- 
nite of sulphur. 
phureted hydro- 
g e n; sulphur 
compounds. 
Putrid substances 
like sulphureted 
hydrogen, meth- 
ane, carbon di- 
oxide, sulphur 
compounds, cy- 
Mordant o f t a n 
and its substi- 
t u t e s (quebra- 
cho, clay mor- 
dants, decoction 
of wheat, bran, 
Chromium. 
anogen. 
Sulphur dioxide. 
and water, etc.) 
Chrome tanning. 
Dyeing with ani- 
lin colors, lead 
colors, etc. 
Anilin, anilin col- 
ors, potassium 
ferrocyanide, 
Furrier indus- 
try. 
Used especially for 
bright colors: 
Lead acetate 
and sulphuric 
acid solutions. 
Carroting. 
lead, arsenic, 
sulphuric acid, 
mercury colors, 
color solvents. 
Mercury, nitric 
acid; nitrous 
Accumulator 
Fur dyeing. 
gases; arsenic. 
White lead, lead 
sulphate, phe- 
nylendiamin. 
Litharge, mini- 
Acid fumes, arse- 
Especially hazardous as a 
house industry. 
There is a whole series of 
(electric) fac- 
tories. 
Celluloid solutions. 
um, sulphuric 
acid, mercury. 
Usually acetone 
and amyl ace- 
tate (but other 
solvents also). 
niureted hydro- 
gen. 
ill-defined ailments pro- 
duced by the action of 
irritating acetone fumes, 
and which, according to 
Lewin, cause asthma and 
bronchitis, and, accord- 
ing to Cossmann, result 
in a condition resembling 
diabetic coma, and com- 
plicated at the same time 
by lead poisoning. There 
are other combinations of 
lead and acid action. 
I ncandescent 
lamp facto- 
ries. 
Use of air pumps. 
Incineration of in- 
candescent bod- 
ies. 
Phosphorus penta- 
chloride drying. 
Mercury; fumes 
of nitric acid, 
collodion, and 
ether. 
Amyl acetate; 
smelter gases. 
Mixtures: Acety- 
lene, illuminat- 
Nitrous gases. 
Galvanotechnic. 
Tinning, etc., 
by hand. 
Galvanic reduc- 
tion of gold, sil- 
ver, copper, 
nickel, zinc, etc. 
Breweries. 
Cleaning and cor- 
roding of metals. 
ing gas, nitrous 
gas, etc. 
Hydrocyanic 
acid, dicyanogen, 
ferrocyanide of 
potassium, mer- 
cury (from the 
electrodes). 
Arsenious acids, 
h y d r ochloric 
acid, antimony. 
Sulphuric acid, 
h y d r ochloric 
acid. 
Metals, such as 
Lead, arsenic, and 
antimony from 
impure metals. 
Arseniureted hy- 
drogen, ammo- 
nia. 
Workmen may be as 
much endangered by ma- 
ceration fluids as by the 
escaping fumes, though 
acute poisoning by prus- 
sic acid is rare. Chronic 
effects are more frequent 
(owing especially to the 
inadequacy of precau- 
tionary regulations). 
Chronic eczema is com- 
mon as a result of con- 
tact with the solvents. 
lead, arsenic 
etc.; sal ammo- 
Tinning. 
niac. 
Acid fumes, metal 
fumes. 
Arseniureted hy- 
drogen, ammo- 
Brass refining. 
Nitrous gases, 
chlorine oxides. 
nia. 
Widely practiced in every 
small metal works. 638 
LIST OF MIXED INDUSTRIAL POISONS 
List of Mixed Poisons to Whose Influence Workmen are Subjected in Various 
Industries-Continued 
Industry 
Process and 
product 
■ Poisons used in 
manufacture, and 
chief end products 
Poisonous by- 
products and 
impurities 
Remarks 
Solder m a n u- 
Hard solder is 
Zinc fumes, zinc 
In this category 
Morbidity directly due to 
facture. 
made of brass 
oxides, lead, hy- 
belong gases and 
occupational poisonings 
and zinc. 
Soft solder is ap- 
plied to the joint 
as a saturated 
solution of tin 
and lead in hy- 
drochloric acid. 
(Gases: Acetylene, 
illuminating gas, 
oxygen admix- 
tures.) 
drochloric acid. 
fumes of the ar- 
seniureted h y- 
drogen combus- 
tion material, 
hence mostly 
carbon monox- 
ide. 
(aside from plumbism) is 
not, indeed, great. Roth 
shows, however, that 
phthisis plays a leading 
role among tinsmiths. 
For this result the gases 
and fumes rising from 
the solder are surely re- 
sponsible, provoking irri- 
tation of the respiratory 
organs (and by their con- 
tinual action greatly low- 
ering the resistance of the 
system). 
Glue, putty, 
Extraction of fats. 
Benzine, benzol, 
Acrolein, sulphur- 
It is worthy of notice that 
cement, etc., 
manufacture. 
Recovery of the 
residua from the 
glue kettles with 
sulphuric acid. 
Compositions. 
acetone, carbon 
disulphide, sul- 
p h u r chloride, 
sulphur dioxide, 
turpentine, car- 
bon tetrachlor- 
ide, etc. 
Acid fumes. 
Lead colors: cata- 
lytic agents. 
eted hydrogen. 
Ammonia, nitro- 
gen fermenta- 
tion products, 
mercaptan. 
Arseniureted hy- 
drogen. 
Combustion 
gases, like car- 
bon monoxide. 
there are many second- 
ary or collateral trades 
which are subject to spe- 
cial risks of the same sort. 
Plutty made oi 
litharge, red" 
lead, and lin- 
seed oil. 
Resinous cement 
made of wax, 
turpentine, etc. 
Solution of india- 
rubber and shel- 
lac in coal tar 
oil. 
Lead, mercury, 
carbon d i s u 1- 
phide, turpen- 
tine, benzine, 
benzol, tar prod- 
ucts. 
In putty factories there 
are mixed poisonings 
from lead, mercury, and 
carbon disulphide. 
Mixtures of carbon disul- 
phide holding materials 
are used as cleansing 
agents or grease deter- 
gents in combination 
with lead, less often with 
mercury compounds in 
cement, and in plastic 
masses for insulation. 
Porcelain manu- 
facture. 
Ultramarine pro- 
duction is a re- 
sult of fusing a 
mixture of kao- 
1 i n, sulphates 
and charcoal. 
Dyeing and paint- 
ing. 
Lead; arsenic; sil- 
ver nitrate; ni- 
tric acid; chrom- 
ium compounds 
(hydrochi o r i c 
acid, hydroflu- 
oric acid; sul- 
phuric acid). 
Sulphuric acid, 
sulphur dioxide, 
carbon monox- 
ide, carbon diox- 
ide. 
Glazes react powerfully in 
Enameled ware 
As raw materials 
Lead: tin oxide; 
Nitrous gases, 
Manufacture. 
are used feld- 
sulphur dioxide: 
acid fumes, 
combination. 
Photography. .. 
spar, fluorspar, 
clay, niter, soda, 
borax, lead ox- 
ide, tin oxide. 
Colors. 
antimony. 
Chromium, man- 
ganese, lead, ar- 
senic. . 
Bromine, . chlor- 
i n e, iodine, 
chromium, mer- 
cury, silver 
nitrate, cyano- 
gen, ferrocya- 
nide of potas- 
sium, anilin, ni- 
trobenzol, re- 
ducing agents 
(blood poisons). 
carbon-dioxide, 
monoxide. 
Dry-handled. 
Dust, etc. 
Furnace gases, etc. discussion of mueller's tabulation of mixed poisons 
639 
A cursory survey of Mueller's tabulation is likely to leave on the 
reader an unfavorable impression as to its value. The author avoids 
a discussion of such matters as the diagnosis, symptoms, and treat- 
ment of occupational poisonings and waives all reference to other 
related subjects of equal importance. His grouping of the industries 
seems arbitrary and anomalous, and the toxic substances said to be used or 
generated in the processes of manufacture are so diverse in their nature 
and effects that the entire presentation appears like a capricious collection 
of ill-assorted and incoordinate data. 
But on closer analysis and from a different angle, what seems a 
caricature becomes a clear picture. Let us take the author's point of 
view. He did not propose to make an elaborate and exhaustive classi- 
fication of industrial poisons. He merely undertook to study inten- 
sively a single phase of the subject and to report his observations. 
Now the lesions produced by exposure to conglomerate poisons are 
hybrid and heterogeneous; and it is the distinguishing merit of Mueller's 
work that it is the first to take cognizance of the complex and erratic 
forms of what may be termed amalgam poisonings in the trades. 
The dominant features in the author's classification are found in 
columns 3 and 4 of the table, and relate to the poisons used in manu- 
facture, and poisonous by-products and impurities. Everything else 
is subordinate. The industry and the process are relatively unimportant. 
It is the mixed character of the poisoning that Mueller aims to illustrate, 
and that alone. He is a pioneer in this field of exploration; though analog- 
ous examples of multiple infection are common in other departments of 
medicine. In influenza, for instance, it has been proved that Pfeiffer's 
bacillus is not the sole infective agency, but that pneumonococci, staphylo- 
cocci, and streptococci are often present in a given case, causing grave and 
discrepant complications. 
The appearance at this juncture of the foregoing elaborate table of 
mixed poisons used in the industries may be regarded as significant. It 
will be recalled that a time limit of 10 years was suggested by the Inter- 
national Association for Labor Legislation in 1911 as the maximum 
interval before the "List of industrial poisons" adopted and promulgated 
in that year should be subject to revision and brought up to date. This 
period has nearly expired, and it is evident that preparations are under way 
to insure incorporation in the revised list of additional matter of special 
importance. 
Though this work of Mueller in its present form contains no inti- 
mation that it is intended to serve as a basis for preliminary discus- 
sion or subsequent action at some future session of the association, 
many of its innovations deserve, and will undoubtedly obtain, recognition 
in the prospective revision. 
Mueller regards as an imminent danger the practice, now so common 
in many industries, of manufacturing substitute products to replace 640 
LIST OF MIXED INDUSTRIAL POISONS 
staple commodities. What was called an adulterated article before the 
war at present goes under the euphonoius name of a "substitute product;" 
and the middleman, the author says, has no interest in exposing the fraud. 
When methods and processes of production are fraught with danger it 
is customary to conceal the fact, and Mueller's experience indicates that 
fraudulent dealers seek to avoid an expert investigation. 
In one instance cited he saw the oily waste products of a chemical 
factory made into shoe polish, washing powder, etc., disguised sometimes 
with perfumes so as to fit the product for trade competition. The 
manufacturer troubled himself very little when the excessive proportion 
of nitrobenzol added to the mixture caused hemoglobinuria and severe 
poisoning, "such as we have repeatedly seen from the use of shoe polish 
and floor wax." 
Such reckless contempt for the consequences of their action on the 
part of unscrupulous manufacturers is likely to ruin the conscientious 
producer who has some regard for the law and the general welfare. The 
author holds that it is the plain duty of the Government to pluck up 
by the roots these fraudulent enterprises which vegetate in the dark, in 
order to protect the honest producer on the one hand and the unsophisti- 
cated user on the other. The latter cannot know his danger, since, so 
far as possible, it is kept out of sight. 
ACETYLENE AS AN ILLUSTRATION 
The coal used in the manufacture of acetylene often contains much sulphur and 
phosphorus. Although acetylene gas is poisonous only when highly concentrated, 
reports and observations attest the frequent occurrence of poisonings by this agent. 
The impure products which are evolved in the processes of manufacture form poisonous 
compounds that prove injurious, especially the hydrocarbons. 
Acetylene made from poor coal contains as much as 0.1 per cent, phosphine and 
sometimes arseniureted hydrogen, sulphureted hydrogen, and telluric compounds 
like ferrosilicon, the dangers of which have only recently become known. 
We saw one man whose duty was to clean a great many acetylene lamps. For a 
long time he felt ill when engaged in this work, especially when these lamps were 
not lighted but gave off acetylene gas. He suffered from headache, nausea and malaise, 
choking sensations, tenderness in the region of the liver, etc. 
Another form of acetylene poisoning results from imperfect combustion of the 
gas. This affords an example of the manner in which a host of industrial poisons 
may crop out in a single trade. The example is all the more interesting because in an 
industrial process now extensively employed in every large metal works the acetylene 
jet is utilized for welding. In this operation oxygen and acetylene must be kept 
mixed in definite proportions. The optimum for perfect combustion consists of an 
acetylene content of about 7.3 per cent. If acetylene enters into the combination 
in higher proportions, combustion is imperfect; and, as a result, there are evolved 
hydrogen, water, carbon dioxide, and above all carbon monoxide. From prolonged 
imperfect combustion of acetylene comes phosphine which with an attenuation of 
1: 100,000 kills rabbits in one hour; so it appears that even when slight concentrations 
occur, they are liable to injure the health. * 
* In the Journal of the American Medical Association for Sept. 6, 1919, p. 801, the 
death by acetylene gas poisoning is reported of "a man of 34 who had been welding for 
half an hour inside a large boiler." POISONS IN ACETYLENE WELDING 
641 
With the diffusion of unconsumed acetylene we may have sulphureted hydrogen 
and arseniureted hydrogen, so that in acetylene welding it is possible that six poisons 
may be produced: 
1. Acetylene (which forms an unstable combination with the hemoglobin of the 
blood). 
2. Carbon dioxide. 
3. Carbon monoxide (product of imperfect combustion). 
4. Sulphureted hydrogen (from the sulphur content of the coal which is converted 
into sulphureted hydrogen by the carbide process and finally oxidized into sulphur 
dioxide). 
5. Phosphine (from the phosphorus content of the coal). 
6. Arseniureted hydrogen (also resulting from the production of hydrogen). SECTION 26 
LIST OF INDUSTRIAL POISONS AND OTHER SUBSTANCES 
INJURIOUS TO HEALTH FOUND IN INDUSTRIAL 
PROCESSES* 
* This valuable list is by no means complete for as pointed out by Dr. Wm. T. Wads- 
worth, Coroners' Physician, in an address published in the N. Y. Med. Journal, June 26, 
1920, industrial toxicology is still in its infancy and much more remains to be done. " There 
is only one way, and that is to learn all substances that enter the factory, follow each sub- 
stance through from its point when it enters to its exit and note the processes and consider 
well the impurities that may be found in each; then watch the workers along these paths 
and especially watch the new men on the job, for they are not likely to have acquired that 
tolerance which makes serious chronic poisoning possible." 
642 ALDEHYDES ACRIDINE ACROLEIN AMMONIA 
643 
Prepared at the request of the Committee of the International Association for Labor 
Legislation, by Prof. Dr. Th. Sommerfeld and Industrial Councilor Dr. R. 
Fischer, and edited by the Permanent Advisory Council of Hygiene of the 
International Association. 
TRANSLATED BY DR. WM. H. RAND, WASHINGTON, D. C. 
Published in Bull. No. 100, Bureau of Labor, Washington, D. C., May, 1912 
Designation of the 
substance 
Branches of industry 
in which poisoning 
occurs 
Mode of entrance 
into the body 
Symptoms of poisoning 
ACETALDEHYDE, 
ETHYALDEHYDE, 
CHsCOH: A colorless, 
very volatile fluid, of 
pungent odor. 
Manufacture of vine- 
gar; silver mirror man- 
ufacture. 
In the form of va- 
por, through the 
respiratory 0 r- 
gans and mucous 
membranes. 
Irritation of the mucous membranes 
of the nose, larynx, and bronchi; 
irritation of the mucous membrane 
of the eyes; acceleration of the 
heart's action; profuse night 
sweats. 
ACRIDINE, C13H9N: 
Crystallizing in color- 
less needles; contained 
in anthracene. 
Organic dyes industry. 
Exerts effect in 
any state of ag- 
gregation on skin 
and mucous mem- 
branes. 
Irritation and inflammation of skin 
and mucous membranes; severe 
burning and itching of the skin; 
violent sneezing. 
ACROLEIN, C2H3- 
COH: A colorless, 
very pungent smelling 
fluid, of fiery taste. 
• 
In the frying out of 
fat and fat-containing 
material, e.g., in bone 
rendering plants; oil- 
cloth and linoleum 
factories; varnish- 
boiling shops; tallow- 
rendering establish- 
ments; soap factories 
(sulphuric acid proc- 
ess), and stearic-acid 
factories. 
In vaporous form, 
through the or- 
gans of respira- 
tion and the mu- 
cous membranes. 
Itching in the throat; irritation of 
the eyes, exciting lachrymation, 
conjunctivitis; irritation of the air 
passages, bronchial catarrh. 
AMMONIA, NHa: A 
colorless gas of sharply, 
penetrating odor. 
Coke ovens; mirror- 
silvering industry; 
coating iron plate with 
tin or zinc; manufac- 
ture of solidified am- 
monia, sulphate and 
chloride of ammonium 
(sal ammoniac) from 
ammonia water; man- 
ufacture of the car- 
bonate of soda and of 
orselle dye-stuffs; dye- 
ing industry; sewer 
cleaning; manufacture 
of bone black; gas 
plants; varnish and 
lacquer manufacture; 
tanning; beet-sugar 
manufacture; manu- 
facture of ice; refriger- 
ation plants. 
In gaseous form, 
through the or- 
gans of respira- 
tion. Seldom pure, 
mostly in com- 
bination with other 
gases. 
Immediate effect 
on the conjunc- 
tiva and the cor- 
nea. 
A proportion of more than.0.15 per 
cent, of ammonia in the air imme- 
diately causes an irritable condi- 
tion of the mucous membranes. 
Chronic bronchial catarrhs are 
especially liable to follow long- 
continued inhalation of small 
quantities of the gas diffused in the 
air. From these are to be discrim- 
inated the acute conditions of 
transient illness: Intense irrita- 
tion of the respiratory organs; vio- 
lent sneezing; lachrymation, red- 
ness of the eyes, inflammation of 
the cornea and of the conjunctiva; 
increased secretion of saliva; burn- 
ing in the pharynx, and a sense of 
constriction in the larynx; parox- 
ysmal cough, with secretion of 
tenacious, viscid, even bloody, 
mucus; embarrassment of respira- 
tion, attacks of suffocation; vom- 
iting of serous masses; ammoniacal 
odor of the perspiration; retention 
of urine, which may last many 
hours and even 2 or 3 days; 
acute inflammation of the respira- 
tory organs, and scattered areas of 
inflammation in the lungs, in se- 
vere cases, a fatal outcome. Pro- 
tracted breathing of small quan- 
tities is apt to cause chronic 
bronchial catarrh. 
Special measures of relief: Immediate removal from the poisonous atmosphere; artificial respiration; 
inhalation of steam; faradic stimulation of the phrenic nerve; free bloodletting; in case of obstinate 
spasm of the glottis, tracheotomy. 644 
LIST OF INDUSTRIAL POISONS 
List of Industrial Poisons-Continued 
Designation of the 
substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
AMYL ACETATE, 
C15H11CH3CO2: Zap- 
one, a solution of cell- 
uloid in amyl acetate 
and acetone. 
Zapone lacquer 
used as a lacquering 
agent in metallic 
ware and jewelry 
factories; manu- 
facture of metallic 
wire for incandes- 
cent electric lamps; 
oilcloth manufac- 
ture. 
In the form of 
vapor through 
the respiratory 
organs. 
Nervous symptoms; headache; fullness 
of the head; giddiness; nausea; numb- 
ness; disturbances of digestion; palpita- 
tions of the heart. 
AMYL ALCOHOL, 
CsHnOH: A colorless, 
oily fluid, of very 
sharp taste and pene- 
trating, disagreeable 
odor. 
Manufacture of fruit 
essences, nitrite of 
amyl, valeric acid, 
and anilin dyes; 
rectification of 
spirits. 
In the form of 
vapor through 
the organs of 
respiration. 
Congestion of the head; headache; op- 
pression of the chest; irritation of the 
air passages. 
ANILIN, C6H5(NH2): 
A colorless oil which 
acquires a tint on ex- 
posure to air and light. 
Like anilin, all other 
amide compounds of 
benzol and its homo- 
logues, as toluol, 
naphthaline, xylol, 
etc., are poisons. 
Especially should be 
mentioned alpha and 
beta naphthylamine, 
benzidine, tolidine, 
paranitraniline, the 
diamines (phenylene 
and tolylene diamine) 
as well as the alphyl 
and aryl compounds 
of anilin, like their 
homologues (dimethyl 
and diethyl anilin, 
diphenylamine, etc.). 
Manufacture of ani- 
lin and its deriva- 
tives, as well as of 
anilin dyes; manu- 
facture of photo- 
graphic materials 
and the like. 
Absorption 
through the 
skin, by direct 
contact or by 
saturation 0 f 
the clothing; 
through the di- 
gestive organs; 
absorption 
through the 
respiratory or- 
gans as volatile 
particles and 
impalpable 
dust. 
The toxicity of the separate products is 
very different in degree; the para com- 
pounds are usually more poisonous 
than the ortho and meta compounds. 
Acute Poisoning.--(a) Mild cases: 
Pallor of the skin and mucous mem- 
branes, with slight cyanosis; a feeling of 
weariness and weakness; head symp- 
toms-vertigo, reeling, unsteady gait; 
deficient elasticity of movement; slow, 
labored speech, irritability (anilin 
' * pip "); condition of slight inebriation, 
with loquacity, gaiety, and defective 
power of orientation; loss of appetite, 
constipation, and tense, rapid pulse. 
(b) Severe cases: Dark blue to swarthy 
cyanosis; formation of methemoglobin; 
bounding pulse; "air-hunger," with 
great frequency of respiration; lowering 
of sensibility; obliteration of the re- 
flexes; sometimes vomiting, strangury 
and bloody urine. 
(c) In the most serious cases: Sudden 
prostration; cold, pale skin, blue lips, 
nose and ears; diminution and even ex- 
tinction of sensibility; moist, cold skin; 
small pulse; death in a comatose condi- 
tion, sometimes after antecedent con- 
vulsions. 
Subacute and Chronic Poisoning.- 
Ansemia; slowing of the pulse; disorders 
of digestion, such as eructations, loath- 
ing of food, vomiting, diarrhea, and 
eczematous and pustular eruptions on 
various parts of the body, especially on 
the scrotum; nervous symptoms, as 
general debility, headache, ringing in 
the ears, vertigo, unrestful sleep, dis- 
turbances of sensibility, often also of 
motility; spasmodic muscular pain. 
Subacute and chronic poisonings are 
very rare. Ansemia and retarded pulse 
are early symptoms. 
The blood is of a brownish hue, but 
microscopically unchanged; occasion- 
ally the urine contains blood. 
Measures of relief: At the first symptoms of poisoning, immediate removal from the workroom to a cool 
shady spot; change of clothing; cool affusions; administration of oxygen in connection with artificial 
respiration; in severe cases, bloodletting with subsequent infusion of physiological salt solution; copious 
ingestion of milk; in case of weak action of the heart, stimulants (black coffee, camphor, ether, but no 
alcohol); caution against the use of alcohol during and immediately after labor; abstinence is advisable. AMYL, ANILIN AND ANTIMONY COMPOUNDS 
645 
List of Industrial Poisons-Continued 
Designation of the 
substance 
Branches of 
industry in which 
poisoning occurs 
Mode of entrance 
into the body 
Symptoms of poisoning 
ANILIN DYESTUFFS: The majority of 
the very numerous anilin dyes are non- 
poisonous. Generally the basic dyes are 
more dangerous than the acid dyes. 
Regarded as suspicious or injurious to 
health are-■ 
Action on the skin; 
in the form of dust, 
through the respir- 
atory organs; the 
digestive organs. 
Action on the skin; 
in the form of dust, 
through the respir- 
atory organs; the 
digestive organs. 
In the form of dust 
on the skin. 
In the form of dust 
on the skin. 
As dust or fine par- 
ticles in the eyes. 
As dust or atom- 
i z e d solution (in 
dyeing by the 
spraying process); 
action on the skin 
and respiratory or- 
gans. 
In the form of dust; 
effect on the skin. 
Itching, dermatitis, efflorescent erup- 
tion, yellow discoloration of the cu- 
ticle and conjunctiva; sneezing and 
nasal catarrh; inflammation of the 
buccal mucous membrane; bitter 
taste; disturbances of digestion; 
irritation of the central nervous sys- 
tem and of the kidneys. Picric acid 
is a feeble former of methemoglobin; 
industrial poisonings by it are ex- 
tremely rare.. 
Blood poisons, forming methemo- 
globin. The morbid symptoms re- 
semble those in poisoning by amido 
compounds; ailments of the central 
nervous system in great variety; 
paralyses. 
Intense irritation of the skin, caused, 
it is asserted, partly by using exces- 
sive quantities of chloride of lime in 
cleansing the skin. 
Intense irritation of the skin, caused, 
it is asserted, partly by using exces- 
sive quantities of chloride of lime in 
cleansing the skin. 
Inflammation of the conjunctiva or 
the cornea. 
Eruptions; severe irritation of the 
mucous membranes; uncontrollable 
sneezing. 
Eruptions (probably superinduced 
by the use of excessive quantities of 
the chloride of lime in washing the 
hands). 
(a) 1 h e various 
phenol nitrates, di- 
nitrophenol, dinitro- 
cresol (saffron yel- 
low, anilin orange), 
picric acid (trini- 
trophenol). 
(&) The many 
naphthol nitrates, 
dinitronaphthol, 
Manchester yellow, 
dinitro and naph- 
thol calcium; tet- 
ranitronaphthol. 
(c) The nitroso 
dyes. 
(d) The aurantia 
-hexantrodiphenyl- 
amine; imperial yel- 
low, its sodium salt. 
(e) Ethyl and 
methyl violet. 
(/) The Meldola 
dyes, corvulin, in- 
dulin, fast black. 
(0) Chrys 0 i d i n, 
fast black. 
(A) Bismarck blue. 
Amlin dye factories; 
dyehouses; also 
manufacture of ex- 
plosives. 
Anilin dye manu- 
factories; dye- 
houses. 
Anilin dye manu- 
factories; dye- 
houses. 
Anilin dye manu- 
factories; dye- 
houses. 
Anilin dye manu- 
factories; dye- 
houses manufac- 
ture of colored 
pencils. 
Anilin dye manu- 
factories; dye- 
houses. 
Anilin dye manu- 
factories; dye- 
houses. 
Anilin dye manu- 
factories; dye- 
houses. 
ANTIMONY COM- 
POUNDS: 
Trioxide of anti- 
mony, Sb20s. 
Antimony trichlo- 
ride, SbCls (anti- 
monious chloride, 
butter of antimony, 
antimonial ore but- 
ter). 
Tartar emetic (tar- 
trate of antimony 
and potassium), 
2(C4H4K[SbO]O6) 
H2O. 
Golden sulphide, 
SbjSs (antimony 
pentasulphide), an- 
Extraction of anti- 
mony and its com- 
pounds; burnishing 
of rifle barrels and 
steel ware; manu- 
facture of antimony 
alloys, type and ster- 
eotype metal, hard 
lead [ammunition 
factories],_ britannia, 
and white metal; 
remelting of old and 
scrap metal; manu- 
facture of anilin 
dyes, fireworks; vul- 
canizing and red-dye 
and fixing materials 
In the form'of vap- 
or (trioxide of anti- 
mony, antimonious 
acid, sulphide of 
antimony) through 
the organs of res- 
piration; irritation 
of the skin; in the 
form of dust, in the 
manipulation 0 f 
britannia and type 
metal. 
ing of India rubber 
n cotton dyeing and 
Intensely itching eruptions of the 
skin, caused by local irritation and 
aggravated in the case of a perspir- 
ing skin; inflammation of the mouth, 
throat, and stomach; constipation 
and intestinal colic; in acute cases, 
diarrhea, albumin in the urine, loss 
of strength, weakness of the heart, 
vertigo, and faintness. 
It appears to be somewhat doubt- 
ful, however, whether all of the 
enumerated compounds of antimony 
are detrimental to the health of the 
workers in them. 
(antimony pentasulphide); mordants 
textile printing. 
timony colors. 646 
LIST OF INDUSTRIAL POISONS 
List of Industrial Poisons-Continued 
Designation of the 
substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
ARSENICCOM- 
POUNDS: Arsenic tri- 
oxide, AS2O3 (arsenic, 
white arsenic, smelting 
dust); arsenous chlo- 
ride, AsCla; arsenic 
colors, e.g.- 
Scheele's green (Swed- 
ish green), arsenite of 
copper. 
Schweinfurt green (pat- 
ent, original, new, moss, 
mountain, parrot, May, 
Kaiser, Cassel, Paris, 
Vienna, Kirchberg, 
Leipsic, Wurzburg, 
Swiss green), compound 
of the arsenite and the 
sulphide of copper. 
Brunswick green, oxy- 
chloride of copper with 
copper oxide and sul- 
phate of lime. 
Neuwied green. (Simi- 
lar, only a larger pro- 
portion of arsenic tri- 
oxide.) 
Cochineal (Vienna red), 
arsenic acid with ex- 
tract of Pernambuco 
wood. 
central nervous system; 
impairment of the sensil 
and often loss of the ter 
they may last for years, 
Arsenic mining; 
roasting of arsenic- 
bearing ores; manu- 
facture of glass, col- 
ored chalk, chloride 
of arsenic for etch- 
ing on brass; shot 
manufacture; metal 
working; manufac- 
ture of arsenic col- 
ors: preparation of 
organic dyestuffs, 
colored lights, tex- 
tile printing, and 
dyeing; manufac- 
ture of wall-paper 
and colored paper; 
tanning; manufac- 
ture of oilcloth and 
artificial flowers; 
taxidermy; painting 
(outside and decora- 
tive) ; pyrotechnics 
(Indian white-fire). 
It is to be observed 
that zinc, silver, 
lead, bismuth, cop- 
per, and the com- 
mercial acids often 
contain more or less 
arsenic. 
intense, lightning lii 
>ility; chilliness; weak 
don reflexes; sometir 
leaving not infreque 
In the forms of 
gas and dust, 
through the 
respiratory or- 
gans and mu- 
c 0 u s mem- 
branes, the 
stomach, and 
intestinal canal. 
ce, lancinating pa 
ness of the muse! 
nes fever; albumi 
ntly permanent di 
Acute Poisoning.-The first symptoms 
usually appear after half an hour or an 
hour, viz., constriction of the esopha- 
gus, pains in the stomach and bowels, 
vomiting, diarrhea, debility, cold, blu- 
ish skin, sural cramp, lowering of 
heart's energy, vertigo, headache, faint- 
ness, illusions, loss of consciousness, 
convulsions; death, sometimes chol- 
eraic symptoms. In mild cases, burning 
in the pharynx, vomiting, salivation, 
difficult deglutition and indigestion. 
Chronic Poisoning.-Constant and 
persistent headache combined with 
melancholia, disinclination to labor, 
and sleeplessness, which are sometimes 
the only symptoms; further, gastric 
disturbances,, such as vomiting and 
diarrhea, which result in emaciation 
and decline of strength; persistent 
symptoms of catarrh of the mucous 
membranes, such as coryza, pharyn- 
gitis and bronchitis; frequently skin 
diseases in varying form: Erythema- 
tous, papular, and pustular cutaneous 
eruptions, which also produce ab- 
scesses with infiltrated and indurated 
borders; falling out of the hair and 
nails; melanosis-that is, the deposi- 
tion of a brownish pigment, not con 
taining arsenic, on the neck, trunk, 
and extremities. 
In severe cases, disturbances of the 
ins; formication; furriness of the skin; 
ss, also unilateral or bilateral paralysis, 
iuria. The paralyses are transient, or 
sturbances. 
Special measures of relief: If arsenic has been ingested, thorough gastric lavage is necessary; then ad- 
minister at once by'the mouth five tablespoonfuls of a solution of calcined magnesia (70 g. to 500 g. of dis- 
tilled water); afterward give a tablespoonful every 5 minutes until a movement of the bowels occurs; 
the internal use of lime water also is recommended for rinsing out the stomach and as an antidote; to 
counteract the exhaustion, cold affusions, rubbing, hypodermic injections of ether and camphor.1 
In case of chronic arsenical poisoning: Electric vapor baths and electrical treatment are in order; the 
disturbances of the stomach are to be treated with calcined magnesia and unirritating liquid nourish- 
ment (milk, milk porridge, rice porridge, salep); the cachexia, by fresh air and nutritious diet, in pa- 
ralyses, use iodine preparations and electricity. 
ARSENIURETED HY- 
This gas is formed 
In the form of a 
At first no disturbance, or only slight 
DROGEN, AsHs: A 
everywhere when, in 
gas, through 
the organs of 
indisposition; after some hours, chilli- 
c o'l o r 1 e s s, extreme- 
the use of arsenical 
ness, vomiting (food, bile, then blood), 
ly offensive gas with the 
acids and metals, 
respiration 
pain in the back, giddiness, ringing in 
odor of garlic. 
hydrogen is gener- 
ated for technical 
purposes (e.g.; the 
filling of children's 
toy balloons); in 
soldering and etch- 
ing, with arsenic- 
containing metals 
or acids, e.g., enam- 
el ware factories, ti 
plating works; imp 
by the absorption o 
arseniureted hydrog 
(generally mix- 
ed with hydro- 
gen). 
n, zinc, and lead 
ure iron silicate, 
: water, develops 
m. 
the ears, faintness, small pulse, bluish 
discoloration of the mucous mem- 
branes; labored respiration; urine at 
times dark or even black, containing 
blood or hemoglobin. 
After 24 hours, yellow hue of the skin 
and mucous membranes, from absorp- 
tion of biliary fluids, fetor of the 
mouth (resembling garlic), swelling 
and sensitiveness of the liver and 
spleen, headache, delirium, mortal 
anguish; death or slow convalescence. 
Special measures of relief: Fresh air and oxygen; later bloodletting; use of an alkaline solution of com- 
mon salt; mild alkaline drink; analeptics (coffee, camphor). 
1 Hydrated sesquioxide of iron is not mentioned. ARSENIC COMPOUNDS BENZINE-BENZOL 
647 
List of Industrial Poisons-Continued 
Designation of the 
substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
BENZINE: A mixture 
of low-ebullition por- 
tions of petroleum, 
known commercially 
under various names, 
e.g., petroleum, ben- 
zine, ligroine, gaso- 
line. 
Benzine distillation; 
chemical cleansing 
plants, glove clean- 
ing; removal of fat 
from bones, fat sol- 
vent; lacquer, var- 
nish and India rub- 
ber industries; man- 
ufacture of water- 
proof materials 
^(application of the 
rubber mass dis- 
solved in benzine); 
ornamental feather 
factories; used as a 
source of power. 
In the form of 
vapor, through 
the respiratory 
organs; to a 
less extent, 
probably, 
through the 
skin also. 
Headache, vertigo, nausea, vomiting 
cough, irregular respiration, weakness 
of the heart, drowsiness, and deep sleep 
with cyanosis of the countenance, cold- 
ness of the skin and complete insen- 
sibility; on awaking, headache, vertigo 
and depression, fibrillar twitching of 
the muscles, trembling, especially of 
the musculature, as if from chilliness. 
Benzoic acid is found in the urine. 
Chronic Poisoning.-Headache, flashes 
before the eyes, ringing in the 
ears, psychosis with excitement and a 
state resembling inebriation, sensory 
disturbances and hallucinations (but 
the prodromata of chronic benzine 
poisoning will also appear). The oc- 
currence of chronic poisoning by ben- 
zine has been contested. 
The symptoms vary greatly because 
the benzine used technically is a com- 
plex mixture and not always of the 
same composition. 
Special measures of relief: Removal of the patient into fresh air; in severe cases, stimulants, like coffee, 
camphor; then cold affusions. 
BENZOL, C6H6: A 
Manufacture of ben- 
In the form of 
Benzol, its homologues and the rest of 
very unstable, color- 
zol, its homologues 
vapor, through 
the hydrocarbons of coal tar, have a 
less fluid, burning with 
and numerous de- 
the respiratory 
specific affinity for the central nervous 
a bright very sooty 
rivates; technical 
organs; r e a b- 
system and a general action on the 
flame; extremely vola- 
use of these prod- 
sorption 
protoplasm of the organic cells (fatty 
tile; its homologues, 
ucts in the manu- 
through the 
degeneration). Female workers, par- 
e.o., toluol, xylol, and 
cumol. 
facture of colors, in 
carburizing illumi- 
nating and water gas 
in refining and dis- 
solving of caout- 
chouc, resins, fats, 
alkaloids, iodine, 
phosphorus, and 
sulphur; in the re- 
moval of grease 
from materials; 
dye works, laun- 
dries; lacquer and 
varnish factories; 
the rubber indus- 
try. 
nations, delirium, pre 
Subacute and Ch 
blood in the skin [pe 
with severe anaemia 
from the genitals; f 
kidneys). 
skin. 
>tracted unconsci 
ronic Poisonin 
techiae] similar 
hemorrhage fr 
atty degeneratio 
ticularly in their developmental years, 
especially at the time of menstruation, 
are more susceptible than men to the 
poisoning and in an extraordinary de- 
gree to the subacute and chronic forms 
of it. 
Acute Poisoning.-(a) In mild cases: 
Cerebral disturbances, humming in 
the ears, giddiness, somnolence, a con- 
dition resembling inebriation, vomit- 
ing and irritant cough, slight flushing 
of the face. There is often euphoria. 
(&) In severe cases: Symptoms on the 
part of the central nervous system, 
muscular tremor, like chilliness from 
exposure to cold; trembling of the whole 
extremities; finally, tonic and clonic 
spasms; euphoria; pale, livid skin; lips 
remarkably scarlet hued; blood bright 
red, thin. Discolorations of the skin, 
like those in anilin and nitrobenzol 
poisoning, are wanting in benzol 
poisoning. 
(c) In the most violent cases: Halluci- 
ousness, and death in tonic convulsions- 
g.-Numerous spots of extravasated 
o those of morbus maculosus, together 
om the mucous membranes-in women, 
n of the internal organs (heart, liver, 
Special measures of relief: Prompt removal of the patient into the fresh air; inhalation of oxygen: ex- 
clusion of female.workers from every employment in which benzol is used. 648 
LIST OF INDUSTRIAL POISONS 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
CARBON DIOX- 
I D E, CO2: A 
specifically dense, 
odorless, color- 
less gas, collect- 
i n g near the 
ground or floor. 
Generated in mines 
by the process of 
breathing, b y the 
burning 0 f miners' 
lamps, and by blast- 
ing; in lime and 
brick kilns and dolo- 
mite calcining kilns; 
in decomposition 
and putrefaction 
gases; in tanneries 
(tan pits); in sugar 
mills (saturation 
vessels); manufactui 
acid and of mineral v 
tilleries, compressed 
breweries, fermentin 
wine cellars; in sewer 
in firing and heating 
in the lighting of wc 
exhaled air in closed 
caissons. 
In the form of 
gas by inhala- 
tion. 
e of carbonic 
raters; spirit dis- 
yeast factories, 
g rooms and 
and well gases; 
establishments; 
rkrooms; by the 
workrooms and 
Large quantities occasion sudden death 
by suffocation. 
With the inhalation of smaller quan- 
tities the symptoms of illness begin with 
pressure in the head, vertigo, ringing in 
the ears and sparks before the eyes, dis- 
turbances of respiration, such as hurried 
breathing and pain in the chest, some 
times psychic excitement and con- 
vulsions. Usually in case of more pro- 
tracted effect there is loss of conscious- 
ness and of the power of motion (or even 
death by suffocation), with gradual de- 
cline of the pulse and respiration, and 
often with the occurrence of delirium. 
On prompt removal from the poisonous 
atmosphere there is a restoration of 
consciousness with subsidence of the 
symptoms of illness and recovery in a 
few days. 
The occurrence of chronic poisoning by 
carbon dioxide is doubtful. 
Special measures of relief : Examination of the air of the suspected places before entering them; imme- 
diate removal from the poisonous atmosphere; artificial respiration to be persevered in for a long time; 
finally inflation of the lungs with oxygen; cold affusions; stimulation of the skin; restoratives. 
CARBON DISUL- 
PHIDE (carbon 
sulphurate), CS2: 
In a pure state it 
is a limpid, highly 
refractive, extra- 
ordinarily volatile 
fluid, having an 
odor like that of 
chloroform; im- 
perfectly refined, 
its hue is pale yel- 
low and its odor 
offensive. 
and formication or 
thesia and analges 
constipation, the It 
the sense of vision 
central scotoma, d 
there is at first a c 
and explosive tern] 
several weeks or 
enunciation, obtus 
According to Ch 
under the semblan 
forms appear in c 
evidences of the p 
especially in the fi 
The prognosis, s 
of health, it is un 
Manufacture of CS2; 
an agent for extrac- 
tion of sulphur from 
the mass in the 
process of gas puri- 
fication; disinfec- 
tion; a solvent for 
caoutchouc, gums, 
fats, oils, etc.; in 
vulcanizing c a 0 u t- 
chouc and rubber 
(patent-rubber f a c- 
tories); for the ex- 
traction of lanolin, 
the refining of tal- 
low, stearin, para- 
ffine, and wax; pro- 
duction of carbon 
chloride; a s s e m b 1- 
ing and setting up 
carriage-wheel rims 
and rubber tires; 
imitation-silk facto- 
ries. 
the skin, reduction of 
1a; acceleration of the h 
itter condition prevailin 
, sometimes transient, 
sturbances of the senses 
ondition of excitement, 
jer, with hyperstimulat 
nonths, relaxation, me 
aness. 
larcot, psychic disturba 
ce of acute mania and 
ases where there is here 
iralyzing effect of the c< 
ngers, 
0 far as the preservation 
'avorable. 
In the form of 
vapor, through 
respiration; i n 
fluid form, 
through the 
skin, e.g., at the 
dipping of the 
hands i n the 
fluid. 
the reflexes, circur 
eart's action, nau 
g in the later stage 
>ut rare in the in 
of smell and taste 
followed by depre 
on of the sexual 
ancholy, a drean 
nces occur in 87. 
dementia occur w 
ditary predisposit 
irbon disulphide u 
of life is concerne 
It causes heavy damage to the red blood 
corpuscles and to the central nervous 
system. 
Acute Poisoning.-In mild cases, 
marked stupefaction and a sense of in- 
toxication; in more intense poisoning, 
pallor of the countenance, flaccidity of 
the arms and legs, even complete insensi- 
bility, obliteration of all reflexes, loss of 
consciousness, due to paralysis of the 
nervous system. With the inhalation of 
concentrated vapor there is a fatal result 
in a few minutes. 
Chronic Poisoning.-The earliest symp- 
toms (first becoming manifest, some- 
times after employment for a few weeks, 
but, for the most part, after months or 
even years) are headache, extending from 
the root of the nose to the temples, a sen- 
sation of giddiness and stupefaction, 
particularly at evening after the close of 
labor; later, pain in the extremities, mus- 
cular weakness with trembling, spasms 
or fibrillar twitching, also contractures, 
transient and permanent paralyses, with 
atrophy of the muscles; deafness; itching 
nscribed and more extensive areas of anses- 
sea, vomiting, colic, alternate diarrhea and 
s of the disease; emaciation, disturbance of 
tial stage; retrobulbar neuritis, choroiditis, 
. In respect to the central nervous system 
ssion; subsequently, very irritable, violent, 
nstinct; later, its abnormal decline. After 
iy manner, weakness of memory, puerile 
5 per cent, of the cases. Mental diseases 
ith good prospect of recovery; the severer 
ion. There have been observed also, local 
pon the parts brought into contact with it, 
d, is favorable; as to the full restoration of 
Special measures of relief: In acute poisoning, removal into the fresh air, warm baths, cold affusions; 
when there are symptoms of paralysis, electrical treatment; in disturbance of vision, potassium iodide 
and vapor baths; interdiction of the practice of dipping the unprotected hands into carbon disulphide. CARBON DIOXIDE, DISULPHIDE AND MONOXIDE 
649 
List of Industrial Poisons-Continued 
Designation of the 
substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
CARBON MONOXIDE, 
In industrial plants 
In the form of 
Acute Poisoning.-Increased blood 
CO: A colorless, taste- 
with defectively 
gas, through 
the respira- 
pressure at first, with slowing of the 
less gas, and, when in a 
planned or ill-tended 
pulse and pounding heart beat; later, 
state of diffusion, odor- 
less, burning with a blue 
flame in the air. 
Coal vapor has from 0.5 
to 5 per cent, of CO. 
Illuminating gas, 6 to 10 
per cent, of CO and 33 
to 40 per cent, of mine 
gas. 
Water gas, a mixture of 
41 per cent. CO, 50 per 
cent, hydrogen, 4 per 
cent. COa, and 5 per 
cent. N. 
Producer gas contains 
34 per cent. CO and 60 
per cent, hydrogen gas. 
firing and heating 
arrangements; 
plants for the pro- 
duction of i n d u s- 
trial gas; mining 
(mine gases); coal 
mines; blast fur- 
naces (furnace gas); 
Cowper apparatus; 
gas purification; 
coke ovens, smelt- 
ing furnaces; gas 
machines; lime and 
brick kilns, dolo- 
mite calcining kilns; 
iron and metal foun- 
dries (drying of the 
moulds); soldering 
in tin shops; char- 
coal burning; resin 
distillation; ironing; 
heating with open 
coal brasiers or coke 
stoves (drying the 
plaster and walls of 
new buildings); dry- 
ing chambers. 
tory organs. 
lowering of the pressure, with rapid 
but small pulse, and, not infrequently, 
with discrete spots of dilatation in the 
superficial blood vessels. Remarkably 
pale-red discoloration of the blood and 
of the dilated spots; formation of car- 
bon monoxide nemoglobin is demon- 
strable by the spectrum. 
(a) Disturbances of the general health: 
In mild cases, dull headache, flashes 
before the eyes, giddiness, ringing in 
the ears, nausea and fullness in the 
gastric region. 
(6) In severe cases: Bluish-discolora- 
tion of the skin; spasmodic, wheezing 
respiration; sometimes tonic and clonic 
convulsions, more often paralytic 
symptoms, either with weakness of all 
the extremities or of the lower only, or, 
indeed, of only single groups of mus- 
cles, including also the facial muscles. 
The convulsive stage, which may be 
altogether absent, is succeeded by the 
stage of asphyxia, with sensory and 
motor disturbances, involuntary void- 
ing of urine, semen, and feces; sub- 
normal temperature; weak, slow and 
intermittent pulse; loss of conscious- 
ness. 
As sequels there have been observed 
pneumonias, inflammations of the 
skin, paralyses and psychoses, the last 
two often pursuing an unfavorable 
course. 
Chronic Poisoning, (among ironers, 
firemen, cooks, etc.).-Frequent head- 
aches, dizziness, nausea, vomiting, 
coated tongue, weakness of memory; 
ansemia, without chlorosis; "hot 
flushes," formication, palpitation of 
the heart, insomnia, general debility 
and feebleness of the psychic functions. 
Special measures of relief: Removal from the poisonous atmosphere; admission of fresh air; artificial 
respiration, with inflation of the lungs by oxygen for hours, if necessary ; keep head of the injured person 
slightly elevated; subcutaneous injection of ether; camphor; cold affusions; rubbing; mustard poultice; 
electrical treatment; insufflation of ammonia vapor; administration of black coffee; alkaline salt infusion- 
entering where CO may be generated only when protected by safety masks and by a constant supply 
of air. 650 
LIST OF INDUSTRIAL POISONS 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
CHLORIDE OF 
LIME, CaOCh: A 
white granular, some- 
w h a t desiccative 
powder, having the 
odor of hypochlorous 
acid, and containing 
35 to 40 per cent, of 
chlorine. 
Manufacture of the chlo- 
ride of lime; use of the 
chloride of lime as an 
oxidizing and chlorinat- 
ing agent in the chem- 
ical industry (for exam- 
ple, dyestuffs); disin- 
fection; manufacture of 
chloroform, chlorine, 
oxygen; bleaching of 
linen, cotton, paper, 
cotton print works. 
In the form of 
vapor or 
dust,through 
the respira- 
tory organs 
(inhalation of 
chlorine gas); 
direct action 
on the skin. 
More or less severe, irritating cough, 
symptoms or inflammation in the upper 
air passages; difficulty of breathing, 
bronchitis, asthma, sometimes hemop- 
tysis, irritation of the conjunctiva, lach- 
rymation; skin hot from action of chlo- 
rine; hyperhidrosis; intensely itching 
and burning eruption on the skin, 
eczema, burns from the dust of lime and 
its chloride. 
Special measures of relief: Admission to the employment of such, and only such, workmen as are sound 
and strong and free from any predisposition to catarrhal affections; technical arrangements which per- 
mit the charging and emptying of the chambers from the outside. 
CHLORINE, Cl: A 
yellowish-green, suf- 
focating gas, of pene- 
trating odor, which 
forms a solution of a 
greenish-yellow color 
when dissolved in 
water. 
Manufacture of chlorine, 
chloride of lime, and of 
organic chlorine prod- 
ucts; bleacheries; pa- 
per mills; laundries; 
ironing; tinning works; 
manufacture and use of 
disinfecting agents con- 
taining chlorine. 
i 
In the form of 
gas, through 
the respira- 
tory organs. 
The smallest quantities excite severe suf- 
focative sensations and necessitate leav- 
ing the room, so that acute chlorine 
poisoning seldom occurs. 
Symptoms of Cutaneous Disease.- 
Burning, stinging,'formation of nodules, 
blebs, and even open wounds of the skin. 
Effect on the Mucous Membranes.- 
Lachrymation, coryza, cough, oppres- 
sion of the chest and intense dyspnoea; 
bronchial catarrh with hemorrhage; 
sometimes lobular pneumonia. The 
concentrated vapor causes uncontroll- 
able cough, spasm of the glottis, dys- 
pnoea, cold sweats, cyanosis and small 
pulse; death occurs within a few minutes 
(sudden collapse) 
In Its Chronic Effect.-Distress in the 
gastric region; chronic catarrh of the 
stomach; pyrosis; pallid countenance; 
catarrh of the respiratory tract; lobular 
pneumonia; headache, vertigo, insom- 
nia; gradual emaciation and premature 
senescence. 
Chlorine Acne.-(Occasioned in the 
electrolytic production of chlorine by 
chlorinated carburetted hydrogen.) In- 
flammatory processes in the dermal 
glands; the occurrence of unusually dif- 
fuse, confluent comedones with indu- 
rated, dark-green heads; solid infiltra- 
tion of the sebaceous follicles, their in- 
flammation and suppuration causing 
pustules and boils. 
Special measures of relief: Removal of the patient into the fresh air; inhalation of amyl nitrite; arti- 
ficial respiration; on account of the paralyzing effect of the chlorine on the heart, stimulants are required 
(black coffee, subcutaneous injection of camphorated oil); to control the irritating cough, hypodermics 
of morphine or cautious inhalation of steam. 
For the prevention of chlorine acne: Substitution of anodes made of molten metallic oxides for the car- 
bon anodes. 
CHLORODINITRO- 
BENZOL, CeHs- 
(NO2)2C1: Forming 
yellow crystals. (See 
Nitrobenzol.) 
CHLORONITRO- 
BENZOL, C6H4NO2- 
Cl: Forming yellow- 
ish crystals of aro- 
m a t i c odor. (See 
Nitrobenzol.) CHLORINE, CHROMIUM AND CYANOGEN COMPOUNDS 
651 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
CHROMIUM COM- 
Manufacture of 
Absorption by 
The chromates act very much like chromic 
POUNDS: Chromic 
chromium prepara- 
the skin and 
acid itself; pit-like, phagedenic ulcers, 
acid, anhydrous, CrO:; 
tions, chrome col- 
ors, and hectograph 
mucous mem- 
burrowing deep and spreading wide, very 
chromates and bichro- 
branes; in the 
difficult to heal and very painful, occur 
almost exclusively on the skin of the 
mates, e.g., sodium 
composition; photo- 
form of dust, 
chromate, Na2CrO«; 
graphy (color and 
through the 
hands, more rarely on the arms, thighs, 
sodium bichromate, 
carbon printing); 
respiratory or- 
scrotum, and penis, resembling syphilitic 
Na2Cr2O7; lead chro- 
mate, PbCrOi. 
Chromium colors: 
Chrome yellow (acid 
chromate of lead); 
chrome orange (basic 
oxidizing agent in 
the tar-color in- 
d u s t r y; manufac- 
ture of matches; 
wet batteries; 
bleaching fats, oils, 
gans. 
ulcers; they also appear, though seldom, 
on the mucous membrane of the tonsils 
and of the hard and the soft palate. With 
rare exceptions there is extension of the 
inflammation to, and perforation of, the 
nasal septum at the cartilaginous por- 
and neutral chromate 
of lead); chrome red 
(c h r o m e-cinnabar); 
acid chromate of lead 
oxide and lead hy- 
drate; chrome green, 
poisonous only as a 
mixture of chrome 
yellow and paris blue. 
(See also under Lead.) 
and wax; mordant 
in Turkish red dye- 
ing, textile printing 
(for neutralizing 
colors and for dye- 
ing); chrome tan- 
ning (two-vat proc- 
ess); staining of 
wood. 
tion; eczematous eruptions. 
Irritation of the conjunctiva. 
Irritation of the Bronchioles.-Chronic 
bronchial catarrh, and small areas of in- 
flammation in the lungs. In recent years 
the last-mentioned symptoms are hardly 
ever encountered in a remarkably wide 
field of observation. It is at least ex- 
tremely doubtful if disease of the kidneys 
is ever caused by chromium. 
In handling chromium dyes containing 
lead there is danger of chronic lead 
poisoning. 
Special measures of relief: Chromium ulcers are successfully overcome by careful treatment of the 
slightest injuries to the skin, and by the immediate, complete, and skillful closure of the lesions. 
CYANOGEN COM- 
Extraction of gold; 
In the form of 
Generally speaking, industrial poisonings 
POUNDS: Dicyano- 
silver and gold plat- 
gas, through 
the respiratory 
by cyanogen are rare. 
gen, C2N2; prussic 
ing, galvanoplasty, 
Acute Poisoning.-Moderate quantities 
acid, HCN: Hydro- 
electroplating; man- 
organs; prus- 
sic acid also 
of the gas cause vertigo, headache, rush 
cyanic acid, a color- 
ufacture of cyano- 
of blood to the head, oppression of the 
less, highly volatile 
gen compounds and 
through the 
chest, palpitation of the heart, a sensa- 
fluid, of penetrating, 
pungent, and irritat- 
ing odor. 
Natrium cyanide 
(NaCN), Cyanide of 
potassium, potassium 
cyanide, (KCN): A 
colorless salt, forming 
crystals which, after 
fusion, recrystallize, 
but readily decom- 
poses on exposure to 
the air, setting free 
hydrocyanic acid. 
Rhodanic (Sulphocy- 
a n i c, SCN) com- 
pounds : Poisonous 
dose of the dilute hy- 
drocyanic acid, 0.06 g. 
inorganic processes 
(when organic re- 
sidue are heated 
with alkalies); re- 
duction of residuum 
to gas; blast fur- 
naces ; gas works 
(purification proc- 
ess), dye works and 
printeries; photo- 
graphic establish- 
ments ; manufacture 
of celluloid. 
epidermis. 
tion of constriction at the throat with 
pharyngeal irritation and dryness, nausea 
and vomiting, difficult, gasping respira- 
tion, with retention of consciousness. 
To the stage of dyspnoea succeeds that of 
spasm with cold, perspiring skin, convul- 
sions and involuntary micturition, with 
loss of. consciousness. In the stage of 
asphyxiation there are temporary sus- 
pension of respiration, retardation of the 
heart's action, lividity of the skin and 
mucous membranes, lowering of the body 
temperature; with inhalation of large 
quantities, the stage of asphyxia super- 
venes immediately. Dilatation of the pu- 
pils; loss of consciousness; a few gasping 
inspirations; cyanosis of the skin, and 
mucous membranes; collapse; death. 
Chronic Poisoning (very doubtful).- 
Headache, vertigo, unsteadiness of gait; 
nausea, loss of appetite, disturbances of 
the gastric and intestinal functions; 
slowing of the pulse; albuminuria. 
Special measures of relief: Fresh air; artificial respiration; administration of oxygen; cold affusions 
and friction; hypodermatic injection of ether, camphor; if the poison has been taken into the stomach, 
give emetics, then immediately rinse out that viscus with water, with the addition of one-quarter to 
one-half of 1 per cent, of potassium permanganate. Kobert recommends a 3 per cent, solution of hydro- 
gen binoxide for subcutaneous injection, in doses of 1 cc. at different points in the body. But on the 
other hand, H2O2 is deemed unsuitable, and an alkaline solution of ferric sulphate or an antidote for 
arsenic with some ferric salt is indicated as the best remedy. To Control the convulsions give morphia 
hypodermically. 652 
LIST OF INDUSTRIAL POISONS 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
DIAZOMETHANE, 
CH2NH2: A very vola- 
tile yellow gas. 
In methylizing of 
every kind. 
As gas, through 
the lungs; ef- 
fect on the 
skin. 
Acute Poisoning.-Severe headache; 
great physical depression; grave le- 
sions of the lungs; other effects like 
those of dimethyl sulphate. 
DIMETHYL SUL- 
PHATE, (CH 3)2804 
A colorless oily fluid. 
Production of me- 
thyl ethers, methyl 
esters and methyl 
amines; manufac- 
ture of artificial per- 
fumes. 
In the form of 
gas, through 
the respiratory 
organs; direct 
action on the 
skin. 
Strongly corrosive effect on the skin 
and mucous membranes; burns; pains 
in the nape of the neck and in the thor- 
acic cavity; hoarseness; destruction of 
the mucous membrane and aspiration 
of the broken-down products into the 
lungs; lachrymation, conjunctivitis, 
formation of erosion-eschars, and 
oedema, photophobia and parenchyma- 
tous clouding of the cornea; even coma, 
convulsions, paralysis, and a fatal out- 
come. 
DINITROBENZOL or, 
BINITROBENZOL, 
CbH4(NO2)2: When pure, 
crystallizing as slender, 
colorless, rhombic 
needles; when impure, 
in yellow, crystalline 
cakes. (See Nitro- 
benzol.) 
FORMA LDEHYDE 
CH2O: A liquid, volatil- 
izing as a gaseous vapor 
of penetrating odor; 10 
per cent, formaldehyde, 
formalin. 
Disinfection; manu- 
facture of many or- 
ganic preparations, 
especially in the 
coal-tar color-indus- 
try; preserving and 
hardening of human 
and zoological 
preparations. 
In the form of 
vapor, through 
the respiratory 
organs and mu- 
c 0 u s mem- 
branes. 
Intense irritation of the skin and 
mucous membranes. 
Special measures of relief: Do not enter the disinfection chamber until after the introduction of am- 
monia and thorough ventilation. 
HYDROCHLORIC 
Treatment with chlo- 
Action on the 
As a rule the rarefaction of the hydro- 
ACID, HC1: Pure HC1 
rine of previously 
skin and nasal 
chloric acid gas is so considerable in the 
is a colorless gas that 
roasted ores; pot- 
teries (glazing), en- 
mucous mem- 
industries where it is used to any ex- 
fumes when open to the 
brane; seldom 
tent worth mentioning that only in ex- 
air, forming a dense, 
ameling works, glass 
in vaporous 
ceptional cases do injurious effects 
acid, white mist. The 
factories, soldering; 
form, affecting 
occur, such as irritation of the respira- 
crude commercial hy- 
in the chemical in- 
the respiratory 
tory organs. A proportion of 0.05 per 
drochloric acid is, for the 
most part, impure, con- 
taining arsenic among 
other admixtures. 
1 
dustry, manufac- 
ture of chloride and 
sulphate of soda, of 
muriatic acid, stan- 
nic acetate, etc.; 
manufacture of arti- 
f i c i a 1 fertilizers; 
bleaching, shoddy 
industry; cotton- 
print works; car- 
bonizing of mate- 
rials ; India-rubber 
industry. 
organs. 
mille of hydrochloric acid in the air is 
well borne, but only for a short time. 
A greater concentration (as well as the 
often-repeated inhalation even of mod- 
erate quantities in manufacturing in- 
dustries) causes chronic irritation of 
the mucous membranes to which the 
vapor has access. There result also 
catarrh of the conjunctiva, coryza, 
pharyngeal, laryngeal, and bronchial 
catarrh, together with dental caries. 
Concentrated HC1 vapor may cause 
unconsciousness and death. 
Special measures of relief: Removal of the patient from the dangerous atmosphere; inhalation of a 
finely nebulized solution of sodium bicarbonate.1 
1 In addition, for acute poisoning, give atropine (J^o grain) subcutaneously to stimulate the pneu- 
mogastric.-W. H. R. ORGANIC COMPOUNDS HALOGEN ACIDS-LEAD 
653 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of industry 
in which poisoning 
occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
HYDROFLUORIC 
ACID or FLUORIC 
ACID, HF: A color- 
less gas, of pungent 
odor and forming a 
dense mist in the 
air. 
Production in chemical 
works; glass factories, 
etching on glass; labora- 
tories of the pottery in- 
dustry; extraction of the 
fluorides of antimony 
(substitute for tartar 
emetic in dye works); 
fertilizer factories (ex- 
traction of phosphorites) 
bleaching of cane for 
chair seats and extractio 
In the form of 
gas, through 
the respiratory 
organs. In a 
fluid state it 
has an immedi- 
ate action on 
the skin and 
mucous mem- 
branes. 
n of its silicates. 
Intense irritation of the eyelids and 
conjunctiva, coryza,bronchial catarrh 
with spasmodic cough, ulceration of 
the nostrils, gums, and oral mucous 
membrane; also painful ulcers of the 
cuticle; erosions and formation of 
vesicles; suppuration under the finger 
nails. 
LEAD, Pb: A bluish 
white, highly lus- 
trous metal, which 
on exposure to the 
air acquires a gray 
tarnish. 
Lead alloys. 
Lead colors; other 
lead compounds. 
Lead Sulphuret 
(galena) is held to 
be non-poisonous, 
and'some lead poly- 
silicates are regard- 
ed as nearly so. 
Smelting of lead and lead 
bearing ores; manufac- 
ture and use of articles 
made of metallic lead 
(sheets, plates, boxes, 
pipes, wire, cans, flasks, 
pails, kettles, faucets, re- 
torts); manufacture and 
use of lead alloys, as 
type metal, shot (tin 
foil), for example, in 
type foundries, tin shops, 
b o t t 1 e-cap factories, 
composing rooms, file- 
cutting works; manufac- 
ture and use of lead col- 
ors and other lead com- 
pounds, as litharge, 
white lead, Krems white, 
red lead, lead chromates, 
acetate of lead, lead 
chloride in lead color 
works and storage-bat- 
tery factories, in -the 
trade of painter, house 
painter and varnisher; 
plants for installation o£ 
gas and water; in the 
ceramic industry, the 
textile industry, etc. 
It is to be observed that 
materials cont a i n i n g 
lead may occasionally 
be employed in every in- 
dustry, and that lead 
colors and other lead 
compounds are often 
met with in trade under 
fanciful names. 
Absorption o f 
lead and lead 
compounds oc- 
curs: (1) In 
isolated cases 
through the 
skin; whether 
through the 
uninjured skin 
is doubtful; 
(2) in the form 
of vapor (very 
finely divided 
oxide of lead), 
and as dust, 
through the 
respiratory or- 
gans; (3) by 
way of the di- 
gestive tract by 
means of con- 
taminated food 
and drinks (for 
example, cigars, 
cigarettes, 
chewing tobac- 
co). By inhal- 
ation the dust, 
laden with lead 
finds lodgment 
in the upper 
respiratory 
tract, and, mix- 
ed with saliva, 
may reach the 
stomach. 
optic nerve; ter 
smell and taste 
of the brain (se 
preceded only bj 
lability and hea 
more often, slow 
cede; epileptifor 
changes in the b 
neys (contracte 
and granular de 
Disturbances i 
tion, premature 
Industrial lead poisoning appears as a 
rule in the chronic form and arises from 
continuous absorption of the most in- 
finitesimal quantities of lead during a 
protracted period of time (weeks, 
months, and even years). 
The beginning is insidious, with dis- 
turbances of the general health, a sense 
of weakness, decline of bodily strength; 
sallow, pale-yellowish hue of the skin. 
Distress in the region of the stomach, 
eructations, lack of appetite, metallic 
taste in the mouth and fetid breath. 
The blue line (blue-gray discolora- 
tion of the gums) which, however,may 
be absent, even in the course of a se- 
vere attack; lead colic with most obsti- 
nate constipation, retention of urine; 
plumbic arthralgia (lacerating, boring) 
occurring for the most part paroxysm- 
ally, chiefly in the lower extremities, 
more rarely in the upper, often inter- 
preted as a symptom of rheumatism 
of the joints; frequently, fibrillar trem- 
bling of the fingers. Typical are the 
lead paralyses, of which disturbances 
of sensation (parsesthesia and anaes- 
thesia) take the precedence. Paraly- 
sis generally affects the extensor mus- 
cles of the arm and hand, with atrophic 
manifestations; more rarely, the flexor 
muscles. Sometimes also there are 
paralyses of the estensors and flexors 
of the lower extremities or muscles of 
the shoulder. From experience it is 
known that those groups of muscles 
are especially affected which are most 
used in the occupational activity. 
Transient blindness, but also gradu- 
ally progressive atrophy of the 
nporary loss of the special senses of 
violent, often fatally ending disease 
iturnine encephalopathy), sometimes 
slight premonitory symptoms, as irri- 
dache, ringing in the ears, insomnia; 
y increasing mental disturbances pre- 
n convulsions, hallucinations; morbid 
ood vessels and of the heart and kid- 
i kidney); increase of blood pressure 
generation of the red blood corpuscles, 
n the sexual sphere in women; abor- 
firth, low vitality of the children. 
Measures of relief: Discontinuance of work in lead at the slightest symptoms of lead poisoning. In 
lead colic, give first, by the mouth or subcutaneously, morphia, opium, or atropine; afterward, cath- 
artics (castor oil or podophyllin); in paralysis, electrical treatment, massage and baths; in every case, 
strengthening diet, iodide of potassium, and sudorifics. 654 
LIST OF INDUSTRIAL POISONS 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
MANGANESE DIOX- 
IDE, Mn02: Brown min- 
eral (occurring chiefly 
as pyrolusite). 
Breaking and grind- 
ing of manganese 
ore; sifting out of 
the refuse. 
tremities, in the sma 
in the legs and num 
and hands; later, loc 
ultimately, the impo 
Affections of the 
ning) combined witl 
ering of intelligence. 
Sometimes dropsica 
In the form of 
dust, through 
the respiratory 
organs. 
11 of the back a 
bness in the fee 
omotor disturbs 
ssibility of safe 
mice (low, whig 
flatness of ton 
effusion into th 
Mn02 produces cumulative effects. 
After protracted action of the agent the 
symptoms begin with disturbances of 
the general sensibility, general debility, 
languor, lancinating pains in the ex- 
nd nape of the neck, creeping sensations 
t; salivation; tremor of the head, tongue, 
inces with uncertain, stamping gait, and, 
and sure progression. 
pering) and of speech (indistinct, scan- 
e; forced laughter and weeping and low- 
e cellular tissue of the lower extremities. 
MERCURY, Hg: A sil- 
ver-white, shining metal, 
unchangeable in the air, 
but evaporating at 
house temperature. 
Mercury compounds, 
amalgams (alloys with 
metals). 
Cinnabar (HgS) is non- 
poisonous. 
Mining and smelting 
of quicksilver; oc- 
cupation of mirror 
plater, a m a 1 g am 
gilding and silver- 
ing; manufacture of 
thermometers, ba- 
rometers, and man- 
ometers, incandes- 
cent electric lamps. 
Rontgen and Hit- 
torf tubes, mercurial 
vapor lamps; manu- 
facture of the salts 
of mercury, amal- 
gams, and colors, 
pharmaceutic prod- 
u c t s, antiseptic 
dyes, inflammable 
materials, and ex- 
plosives ; employ- 
ment of the salts of 
mercury, especially 
in the hare's fur 
business and felt- 
h a t manufacture; 
photography and 
steel engraving. 
Absorption 
through the 
uninjured skin; 
absorbed i n 
the form of 
vapor and as 
dust (amalgam 
dust, dust of 
the compounds 
of mercury). 
legs and head, 
and erethism a 
able. Death 
quence pf the 
entire body; 
Cachexia. 
Industrial mercurial poisoning is a 
chronic poisoning occasioned, by work 
in this metal for a long period, com- 
monly weeks, months, years, or de- 
cades. The first symptom is generally 
increased. ptyalism, with swelling and 
inflammation of the gums and of the 
buccal mucous membrane, often with 
the formation of rodent ulcers, besides, 
there are, frequently, disturbances of 
digestion, lassitude, and pallor. As- 
sociated with the further absorption of 
mercury, "erethism" supervenes-a 
peculiar psychic excitability, (timor- 
ousness, bewilderment,, irritability) 
aside from the characteristic mercurial 
tremor. In a state of complete repose 
this tremor is not noticeable, and man- 
ifests itself only on voluntary, move- 
ment, causing a quite distinctive, 
irregular tremulousness of the fingers, 
hands, arms, and finally, also, of the 
In strictly chronic cases the stomatitis 
re absent, and only the tremor is observ- 
may result in the worst cases in. conse- 
violent tremor and spasms affecting the 
in other cases, increasing weakness 
Special measures of relief: Relinquishment of the employment; nutritious diet; vapor baths: potas- 
sium iodide. 
METHYL ALCOHOL 
(wood spirit), CHsOH: 
A colorless fluid of faint 
odor. 
Produced by the dry 
distillation of wood; 
used in the prepara- 
tion of varnish, lac- 
quer, polish, and 
perfumes; for the 
denaturing of spir- 
its; for the produc- 
tion of coal-tar col- 
ors and pharmaceu- 
tical preparations; 
a solvent for anilin 
dyes in cotton-prin 
used in combination 
coating the interior c 
net making, furnitui 
paint removing. 
Absorption 
through the 
digestive o r- 
g a n s, also 
through the 
skin; in t h e 
form of vapor, 
through the 
organs of res- 
piration. 
manufacture; 
with shellac for 
f casks; in cabi- 
e polishing and 
The effect is very persistent; nausea, 
headache, ringing in the ears, weak- 
ness of the muscles, insomnia, delirium, 
difficulty of breathing, and sometimes 
deafness; inflammation of the throat 
and the mucous membrane of the air 
passages extending to the finest rami- 
fications of the bronchial tubes; finally, 
death by paralysis of the respiratory 
apparatus. Conjunctivitis; also seri- 
ous affections of the retina and the 
optic nerve, resulting in blindness, 
even, from atrophy of this nerve.1 
In chronic cases, fatty degeneration 
of the liver and acidosis.2 
Special measures of relief: The substitution of innocuous media for methyl alcohol in the denaturing 
of spirits. 
1 Permanent blindness and even a fatal issue may be caused by the ingestion of small quantities of 
wood spirit; hence the risk incurred in using cheap essences of vanilla and other flavoring extracts 
which contain methyl alcohol.-W. H. R. 
2 J. A. M. A., Oct. 25, 1913, page 1544. METHYL COMPOUNDS, NITRANILIN, NITROBENZOL 
655 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
METHYL BROMIDE, 
CHsBr:A colorless, gas- 
eous body of aromatic 
odor. 
Methyl iodide, iodine 
methylate, CHsI: An 
ethereal, colorless fluid 
of somewhat penetrat 
ing odor, soonbecoming 
yellow on exposure to 
the air. 
Employed in anilin 
dye factories. 
In the form of 
gas through 
the respiratory 
organs and the 
mucous mem- 
branes. 
In mild cases, vertigo, headache, and 
transient stupor, with diplopia and a 
sensation of rigidity in the muscles of 
the eyes. 
In a severe case there was observed 
loss of consciousness continuing 8 
weeks, with staring look, pallor of the 
skin, retarded pulse, and obstinate 
constipation. During brief intervals 
of wakefulness there was unrest with 
increasing excitability. (Grand- 
homme.) 
NITRANILINE, CsH<- 
NH2NO2: Forming 
long, yellow crystals. 
(See Anilin.) 
NITROBENZOL (mir- 
bane oil, imitation bit- 
t e r-a 1 m 0 n d oil), 
CeHjNO2: A colorless, 
highly refractive fluid 
having an odor like that 
of bitter almonds; and 
all nitro-compounds of 
benzol and its homo- 
logues, e.g., dinitroben- 
zol, dinitrochloroben- 
zol, nitrotoluol, nitro- 
phenol, nitronaphtha- 
lene, etc. The most of 
the nitro- and chloro- 
compounds are the 
more poisonous. 
Coal-tar color indus- 
try and those estab- 
lishments in which 
its intermediate 
products are manu- 
factured, as in ex- 
plosives works, per- 
fumery and soap 
factories, pharma- 
ceutical laborator- 
ies, etc. 
hemoglobin. The c 
missions, exacerbati 
occur also in conne 
The symptoms whic 
ing, over the nervou 
Subacute and Cl 
comes cyanotic, me 
regeneration of the r 
ical picture is simih 
soned corpuscles ar 
hematophorphyrin 
(1) Absorption 
takes place, 
first of all, 
through the 
skin, both the 
uninjured and 
especially the 
pathologically 
altered skin, 
particularly in 
the case of pro- 
f u s e perspira- 
t i 0 n; (2) 
through the 
respiratory . or- 
g a n s; (3) 
through the 
digestive 0 r- 
gans. 
ourse of severe c 
ons may occur t 
ction with deep 
h point to blooc 
s symptoms. 
ironic Poisoning 
themoglobin fori 
ed-blood corpusc 
ir to that of per 
e sometimes der 
nd of albumen. 
Poisoning by all of the designated sub- 
stances is pretty nearly the same, quali- 
tatively; quantitatively, however, 
differences exist, so that the larger pro- 
portion they contain of the nitro (NO2) 
groups the more virulent they are like- 
ly to be. The nitrochloro-compounds 
are very much more dangerous than 
the simple nitro-compounds. The first 
toxic symptoms may appear within a 
few hours (8 to 24) after absorption of 
the poison. 
Acute Poisoning.-(a) In mild cases: 
Malaise, headache, giddiness, nausea, 
loss of appetite, costiveness, burning 
sensation of the skin and mucous 
membrane. 
(b) In severe cases: A feeling of anxiety, 
disturbances of sensation, like formi- 
cation on the legs and furriness of the 
soles of the feet, ringing in the ears; 
disturbances of coordination, (reeling 
gait, stammering speech), increased 
excitability of the reflexes, convulsions 
and a state of general spasm; later, 
with decline of sensibility, symptoms 
of paralysis; vomiting; odor of the 
vomitus and of the exhaled breath like 
that of bitter-almond oil; icterus of the 
skin; at first increased, afterward 
diminished activity of the heart, with 
lowered tension of the. pulse;, visual 
derangements (amblyopia, optic neu- 
ritis); blood viscid, brown to deep dun 
color; diminution of the red corpuscles 
and alterations in their.form; in the 
advanced cases, formation of . met- 
ases is exceptionally varied; after inter- 
vith a finally fatal result. Death may 
insensibility, without other symptoms, 
changes predominate, in severe poison- 
.-Icterial skin, which gradually be- 
nation; symptoms of degeneration and 
les; general debility, ansemia. The clin-' 
nicious ansemia. In the urine the poi- 
nonstrable, and finally the presence of 
Meaures of relief: Immediate removal faom the workroom; inhalation of oxygen; artificial respiration; 
eventually bloodletting; stimulants, non-alcoholic; prohibition of the use of alcoholic drinks during 
working hours; avoidance of the same, also, outside of employment. 656 
LIST OF INDUSTRIAL POISONS 
« 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
NITROGLYCERINE, 
C3HsO3(NO2)3, glycerine 
trinitrate: An oily, va- 
porable, colorless fluid, 
without odor. 
Manufacture of ex- 
plosives (dynamite, 
nitro-cellulose); in 
the use of dynamite. 
Inhalation of the 
vapor; absorp- 
tion through 
the uninjured 
skin, mucous 
membranes, 
and wounds of 
the skin. In 
the explosion of 
dynamite the 
action of car- 
b o n dioxide 
and nitrous 
monox ide, as 
well as that of 
undecomposed 
nitroglyce r i n e 
is present. 
Extraordinary toxicity, somewhat like 
effects of prussic acid; just a few drops 
are deadly, and even mere contact 
with products containing nitroglycer- 
ine may cause poisoning; severe head- 
ache, disturbance of the intellect, facile 
syncope, vertigo, burning in the throat 
and stomach; nausea; vomiting, colic; 
symptoms of paralysis in the muscles 
of the head and eyes, as well as in the 
lower extremities; bradycardia and 
retarded respiration, stertorous 
breathing and dyspnoea; cyanosis; 
coldness of the extremities; injection 
of the conjunctiva; reddening of the 
countenance. 
In the mixing and sifting of dynamite: 
Obstinate ulcers under the nails and 
on the finger tips, eruption on the 
plantar aspect of the feet and inter- 
digital spaces of both hands, with ex- 
treme dryness and formation of 
fissures. 
Explosion of nitroglycerine with little 
gas: Trembling, determination of 
blood to the head, vomiting, headache. 
Explosion of nitroglycerine with much 
gas: Vertigo, asphyxia, cyanosis, mo- 
tor paralysis and loss of consciousness; 
intermittent, stertorous respiration, 
coldness of the skin, small pulse; after 
recovery of consciousness, debility, 
nausea, vomiting, headache, inter- 
mittent pulse, and finally death. 
Chronic Poisoning.-Disturbances of 
digestion, trembling, neuralgia. 
Special measures of relief: Absolute avoidance of contact. 
NITRONAPHTHA- 
LENE, CioH7(N02): A 
yellow, friable, crystal- 
line mass of strongly ar- 
omatic odor. (See Nitro- 
benzol.) NITRO COMPOUNDS NITROUS GASES 
657 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
NITROUS GASES (low 
Nitrous gases are 
produced by the 
In gaseous form, 
Susceptibility to the effects of nitrous 
degrees of oxidation of 
through the 
gases fluctuates considerably. Persons 
nitrogen, which appear 
action of nitric acid 
respiratory 
who suffer from diseases of the respira- 
simultaneously): Nitro- 
gen protoxide, NO; ni- 
trogen deutoxide, NO2; 
nitrogen trioxide, N2O3; 
anhydrous nitrous acid 
(HNO2). Red fuming 
nitric acid is a saturated 
solution of N2O4 in crude 
NHO3. NO is a color- 
less gas which under the 
ififluence of atmospheric 
oxygen is readily trans- 
formed into brown nitro- 
g e n dioxide. Below 
-20°C. N2O3 is a blue 
fluid; at the ordinary 
temperature it separates 
into NO and NO2. 
on deoxidating sub- 
stances of various 
kinds, principally 
on metals (iron, 
lead, zinc, etc.), on 
organic substances 
(coal dust, wood, 
straw, paper, tex- 
tile fabrics, wool- 
en refuse, etc.) as 
well as many other 
substances (pyrites, 
sulphurous acid 
and its salts, soda 
sediment, h y d r 0- 
chloric acid, iron 
chlorides, sulphate 
of iron, etc.); in.the 
preparation of nitric 
acid, its combina- 
tions and salts, 
among which the ni- 
trous salts also are 
to be included; met- 
al etching and metal 
refining; stamp mills 
and mints; galvano- 
technics; nitrifica- 
tion in chemical 
works and manu- 
factories of explo- 
sives; celluloid man- 
ufacture; sulphuric 
acid manufacture; 
production of picric 
acid, anilin colors, 
nitrocellulose (gun 
cotton, collodion, 
cotton), xyloidine, 
nitro-starch, nitro- 
jute dynamite, abe- 
lite, nitromannite, 
nitrosaccharose, 
viscosine, etc.; ni- 
tric acid manufac- 
ture and storage; 
preparations of tho- 
rium and cerium; 
bleaching materials 
(oils, etc.); hat mak- 
ing (maceration of 
the hair); etching 
and engraving on 
copper (etching of 
the plate); dyeing 
and printing (fixer 
and mordant). 
organs. 
tory organs are especially susceptible; 
not infrequently the continual inhala- 
tion of small quantities, for many 
consecutive years even, occasions no 
serious disturbances of the health. A 
pale, sallow complexion and chronic 
bronchial catarrh may be deemed, 
nevertheless, the usual consequences 
of occupational inhalation of very 
moderate quantities of nitrous gases. 
Often, however, larger quantities of the 
poisonous gases are borne for hours 
together (6 to 8 hours) without dis- 
comfort; when suddenly, after a long 
interval without disturbance, ominous 
symptoms appear. 
Symptoms of irritation in the air 
passages are manifest, as a feeling of 
constriction of the larynx, spasmodic 
cough, oppression in the chest, labored 
respiration, anxiety, cold perspiration 
on the face, protrusion of the eyes, 
gasping speech, paroxysms of cough- 
ing, bluish discoloration of the coun- 
tenance, coldness of the extremities. 
Consciousness is at first unimpaired, 
but with increasing difficulty of 
breathing it becomes dimmed; injury 
to the teeth. The urine is scanty, 
brown in color, containing hemoglobin 
and albumen. Death results from 
oedema of the lungs. In very severe 
cases methemoglobin is observed, and 
then a general systemic poisoning may 
result. 
Special measures of relief: Immediate removal from the noxious atmosphere; inhalation of Oxygen; 
finally, bloodletting and infusion of normal salt solution. 658 
LIST OF INDUSTRIAL POISONS 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
OXALIC ACID, C2H2O4: 
It forms large, pellucid 
crystals. 
Manufacture of ox- 
alic acid; polishing 
of metals, especially 
of copper and brass 
utensils; used in dye 
works, chemical 
cleansing plants 
(rust and ink 
stains); straw hat 
manufacture and 
straw braiding. 
In the form of 
dust, through 
the respiratory 
organs. 
Opalescent or bluish discolorations 
(with brittleness) of the nails; blood 
stasis in the hands; corrosive action on 
the mucous membrane of the oesopha- 
gus, of the stomach and bowel; weak- 
ness of the heart; convulsions and 
spasms. 
However, industrial poisonings by 
oxalic acid are exceedingly rare. 
PETROLEUM: A mix- 
ture of various hydro- 
carbons of the methane, 
ethyl, and aromatic 
series. 
Production of oil; re- 
fining of the crude 
oil; furniture polish- 
ing by use of so- 
called polishing oil. 
In the form of 
vapor, through 
the respiratory 
organs. Asa 
fluid it has a di- 
rect action on 
the skin. 
The vapors of petroleum cause a pro- 
found acute poisoning with a condi- 
tion of inebriation; shouting, reefing, 
and prolonged sleep without any recol- 
lection of what has happened; in 
severe cases, loss of consciousness, 
lividity of the countenance, staring 
look and contracted pupils, almost im- 
perceptible pulse, asphyxia. The 
chronic effect of petroleum vapor 
causes numbness and irritation of the 
Schneiderian membrane. 
In general, the symptoms of the ac- 
tion of petroleum resemble those 
resulting from the action of benzine. 
By reason of the high boiling point of 
petroleum there are produced, in the 
extraction of paraffin butter, in the 
emptying of retorts, and in the filling 
of casks with petroleum, obstinate in- 
flammations of the hand in the form 
of acne (nodules, pustules, and boils). 
Special measures of relief: Removal into the fresh air; in collapse, a tepid bath with cold affusions; 
subcutaneous injections of camphorated oil. 
PHENOL, C2HsOH (car- 
bolic acid): A white 
crystalline mass, and its 
homologues, e.g., cresol, 
lysol, and their deriva- 
tives. 
Anthracite coal tar 
distillation; produc- 
tion of picric acid 
and of many organ- 
ic aromatic com- 
pounds; used, in 
dyeing, calico print- 
ing; manufacture of 
lampblack, in pho- 
togen factories; im- 
pregnating wood 
with tar and oil of 
tar; surgical dress- 
ing industry. 
Action on the 
epidermis and 
the digestive 
tract. 
Erosion of the skin, which by great 
extension may lead to severe internal 
injuries; symptoms of degeneration 
in the blood and in the internal organs 
(nephritis); gangrene, icterus, collapse. 
PHENYLHYDRAZINE, 
CsHsNH.NHj: A yel- 
lowish, oily fluid, shad- 
ing into brown, of pun- 
gent color. 
A by-product in the 
manufacture of an- 
tipyrine from ani- 
lin; manufacture of 
organic compounds. 
Absorption b y 
the skin; action 
on the skin. 
Obstinate vesicular eruption on the 
skin, with itching and burning; diar- 
rhea, loss of appetite; granular de- 
generation of the blood corpuscles; 
formation of methemoglobin; a sense 
of general malaise. OXALIC ACID PETROLEUM, ETC. PHOSGENE PHOSPHORUS 
659 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
PHOSGENE, COCh 
(carbon oxychloride): A 
colorless gas, of suffocat- 
ing odor. 
In the manufacture 
of phosgene and its 
use for the produc- 
tion of organic com- 
pounds. 
In the form of 
vapor, through 
the respiratory 
organs. 
Until the present time only the acute 
form of poisoning has been recognized. 
The first symptoms of illness some- 
times appear only after many hours. 
By means of the hydrochloric acid 
arising from the decomposition of the 
gases in the lungs, destruction of lung 
tissue results, with difficulty of breath- 
ing, paralysis of the lungs, and pul- 
monary oedema. A fatal outcome is 
often observed. 
Special measures of relief: Inhalation of oxygen and medical attendance immediately after breathing 
the phosgene gas. 
PHOSPHORUS, P: A 
colorless, transparent 
substance; on exposure 
to the light, translucent 
and of a yellowish, waxy 
luster. In the air it is 
luminous, and when 
heated in closed iron 
crucibles to a tempera- 
ture ranging from 250° 
to 300°C. it is converted 
into red or amorphous 
phosphorus, which is un- 
affected by the air. The 
yellow or white phos- 
phorus is very poison- 
ous; the red, non-poison- 
ous. 
Extraction of phos- 
phorus from phos- 
phorites and cop- 
rolites, bone-black 
(refuse of sugar 
mills), bone-ash 
(refuse of meat ex- 
tract manufacture); 
production of phos- 
phor-b r o n z e, of 
phosphorus com- 
pounds, igniting 
agents, matches, 
and tar colors. 
In the form of 
vapor, through 
the respiratory 
organs; into the 
digestive canal 
by means of 
food contami- 
nated by the 
fingers; action 
on the skin. 
As industrial poisoning it occurs only 
in the chronic form, occasioned by the 
absorption of very minute particles of 
the poison for a period of months, gen- 
erally, indeed, of years. Symptoms of 
the disease sometimes first appear 
long after relinquishment of the occu- 
pation. 
It is doubtful whether chronic phos- 
phorism occurs (that is, general sys- 
tematic poisoning by phosphorus). 
Chronic phosphorus poisoning uni- 
formly affects the bones of the face, 
beginning with inflammation and 
sclerosis of the bones and of the peri- 
osteum; then, by extension of the sup- 
purative process, necrosis results. 
This most frequently attacks that 
portion of the alveolar process of the 
jawbone which is least protected 
against infection. 
Swelling and ulcerations on the gums 
and the buccal mucous membrane, 
pain even in the sound teeth, loosen- 
ing and falling out of the teeth, infil- 
tration of board-like hardness occurs 
in the soft parts surrounding the jaw; 
suppuration and destruction of the 
jawbone (necrosis) with numerous fis- 
tulous channels which here and there 
burrow through the cheek. Hand in 
hand with the ulcerative processes go 
osteoplastic formations, so that, while 
suppurative destruction of tissue takes 
place at one point, at another the 
formation of new bone is going on. 
The under jaw is more often affected 
than the upper; here the process goes 
on insidiously without formation of 
new bone but with local destruction 
of the part. The palatal and orbital 
bones may be attacked with ulcera- 
tion and shrinking.of the eyeball. By 
extension of the inflammation along 
the sheaths of the vessels there result 
meningeal inflammation and cerebral 
abscess. 
There is remarkable brittleness of 
the bones, decline of appetite, pallid 
complexion, diarrhea, emaciation. 
Sometimes there is amyloid degenera- 
tion of the abdominal organs. Death 
by sepsis. 
Special measures of relief: To the utmost possible extent the prohibition of the use of white or yellow 
phosphorus; exclusion of laborers that have dental caries, after extraction of a tooth at least 2 weeks' 
exclusion from the employment; change of occupation; improvement of the general health; there is no 
specific medical treatment; in appropriate cases, operative intervention. 660 
LIST OF INDUSTRIAL POISONS 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
PHOSPHORUS SES- 
QUISULPHIDE, P2S3: 
A grayish yellow, odor- 
less and tasteless sub- 
stance. 
In chemical fac- 
tories. 
the kettles; dust i 
sifting of the past< 
sulphur vapors in t 
yellow phosphorus 
of CS2. 
Inhalation 0 f 
sulphur eted 
hydrogen in the 
fusion of phos- 
phorus and sul- 
phur as well as 
in the drawing 
off of the molt- 
en mass from 
n grinding and 
3; bicarburet of 
tie extraction of 
ind regeneration 
Irritation of the mucous membranes, 
especially obstinate conjunctivitis. 
Through the influence of dust in the 
grinding and sifting of the composi- 
tion there appear symptoms of CS2 
poisoning. To be noticed also is the 
danger of poisoning by sulphureted 
hydrogen. (See under Sulphureted 
hydrogen.) 
Special measures of relief: Prevention of the contamination of phosphorus sesquisulphide with yellow 
phosphorus; precautions against injury from the effects of sulphuretted hydrogen. 
PHOSPHURETED 
HYDROGEN, PH3: A 
colorless gas of nauseat- 
ing odor. 
In the extraction of 
phosphorus; in the 
preparation of red 
phosphorus and the 
sesquisulphide 0 f 
phosphorus; in the 
reduction of iron 
silicate containing 
phosphorus by the 
action of moisture; 
in the production 
of acetylene with 
calcium carbide 
that contains an ad- 
mixture of calcium 
phosphate. 
In the form of 
gas, through 
the respiratory 
organs. 
An anxious, oppressed feeling in the 
chest, changing to a burning, lan- 
cinating pain; affections of the head, 
vertigo, tinnitus aurium; general de- 
bility; loss of appetite; great thirst. 
Death occurs without convulsions, 
through the effect of the poison on the 
blood. 
PICRIC ACID, C6H2 
(OH)(NO2)3: Trinitro- 
phenol in a pure state 
forms pale-yellow, bitter 
tasting, foliate, metallic 
crystals. 
Chemical works, 
dye-houses; manu- 
facture of explosives 
and powder (lydd- 
ite, melinite); pro- 
jectile factories, fill- 
ing shops. 
In the form of 
dust, through 
the respiratory 
passages; di- 
rect action on 
the skin. 
Poisonings with picric acid are rare; 
when they occur there are itching; in- 
flammation of the skin, vesicular erup- 
tion, yellow pigmentation of the epi- 
dermis and of the conjunctiva, inflam- 
mation of the buccal mucous mem- 
brane, bitter taste, disturbances of 
digestion, epigastric pain, nausea, 
vertigo, diarrhea, and jaundice; picric 
acid decomposes the constituents of 
the blood. 
By the penetration of dust into the 
nostrils, sneezing and nasal catarrh 
are occasioned. 
PYRIDINE, CjHsN: A 
colorless fluid of pun- 
gent and characteristic 
odor. Its homologues, 
pyridine bases. 
In its manufacture 
out of coal tar and 
bone tar; in the use 
of denaturing spir- 
its (shops for wood- 
working, gilding 
and hat manufac- 
ture). 
In the form of 
vapor, through 
the respiratory 
organs. In a 
fluid state it 
acts on the skin 
of the hands 
and arms. 
Catarrh of the mucous membranes; 
hoarseness, irritation, and choking 
sensation in the throat; headache, ver- 
tigo, flaccidity and trembling of the 
extremities; difficulty of breathing 
and clonic convulsions; eczema of the 
hands. 
Industrial poisoning by pyridine is 
very rare. 
SULPHUR CHLORIDE, 
S2CI2: A thickish fluid, 
of brownish color and 
suffocating odor, fuming 
on exposure to the air. 
Solvent for sulphur 
and fats; caout- 
chouc and patent 
rubber industry. 
In the form of 
vapor, through 
the respiratory 
organs. 
In contact with water and atmospheric 
moisture, it is resolved into hydro- 
chloric acid vapor. The vapor of 
sulphur chloride is suffocating; if in- 
gested, it excites vomiting. 
Special measures of relief: Wearing of rubber gloves: instant removal of the patient from the poison- 
ous atmosphere. PICRIC ACID-PYRIDINE-SULPHUR COMPOUNDS 
661 
List of Industrial Poisons-Continued 
Designation of 
the substance 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
SULPHUR DIOX- 
IDE, SULPHUR- 
OUS ACID, (H2SO3): 
Its anhydride is SO2, 
in the form of gas; 
condensed, it b e- 
comes fluid. The gas 
is of pungent odor 
and suffocating 
effect. 
Roasting of sulphur- 
bearing ores; brick 
works, ceramic indus- 
try; manufacture of 
sulphuric acid, of ul- 
tramarine; extraction 
of bones, manufacture 
of glue and gelatine 
from bones; disinfec- 
tion; refining of petro- 
leum ; manufacture of 
candles; bleaching of 
wax, silk, and wool; 
chromium tanning 
(two-vat process) 
bleaching of straw 
hats and bristles; pre- 
serving wine and 
fruits; fumigating hops 
and casks with sul- 
phur; ice machines; 
heating plants (burn- 
ing of pyrite-bearing 
coal). 
In the form of 
gas, through 
the respiratory 
organs. 
In moderate concentration sulphurous 
acid is borne without inconvenience or 
injury; persons accustomed to the gas 
bear very well a proportion of 0.003 
to 0.004 per cent, of SOs in the air. 
Susceptible persons, at the beginning 
of their employment in an atmos- 
phere containing sulphurous acid, 
manifest a transient irritation of the 
mucous membrane of the respiratory 
organs and of the eyes. 
In its severe action there is spas- 
modic cough with secretion of tena- 
cious, often blood-tinged, mucus. 
The protracted effect of a high degree 
of concentration is livid discoloration 
of the mucous membranes, bronchial 
catarrh, croupous angina of the bron- 
chi and their branches, and inflamma- 
tory areas in the lungs; disturbances 
of digestion. 
Special measures of relief: Removal from the noxious atmosphere; admission of fresh air; artificial 
respiration; infusion of weak aklaline solutions (0.05 to 0.1 per cent, liquor natrii caustici [solution of 
caustic soda]). 
SULPHURETTED Blast furnace plants, 
HYDROGEN, or in granulating the slag; 
HYDRIC SUL- distillation of sulphur 
PHIDE, HzS: A waters; ultramarine 
colorless gas, having works; Leblanc soda 
the fetid odor of rot- and chemical factor- 
ten eggs. ies; in the manufac- 
ture of the compounds 
of sulphur and phos- 
phorus; sulphur metals 
(manufacture and use); 
sulphide of soda and 
sulphide of barium in- 
dustry (manufacture 
of sulphide colors and 
dyeing with these); 
the extraction of cellu- 
lose (straw and wood); 
in the waste waters of 
industries which make 
use of organic sub- 
stances; sedimenta- 
tion tanks of sugar 
works; precipitation 
of soda residua con- 
taining calcium sul- 
phide; work in sewers, 
latrines, and dung 
pits; illuminating-gas 
plants; flax retteries; 
tanneries. 
In the form of 
gas, through 
the respiratory 
organs, as pure 
hydric sulphide 
gas; often 
found in admix- 
ture with other 
gases (with 
CO2, N, NHt, 
andcarburetted 
hydrogen); di- 
rect action on 
the conjunc- 
tiva. 
Acute Poisoning.-In the less violent 
cases there are gastric distress, nau- 
sea, fetid eructations, irritation and 
inflammation of the conjunctiva; 
rarely, erosion of the cornea, forma- 
tion of vesicles on the lips, irritating 
cough, headache, and a sensation of 
giddiness. In long-continued inhala- 
tion convulsions and paralyses occur. 
In severe cases there are contraction 
of the pupils, slowing of the pulse, 
Cheyne-Stokes respiration, nystagmus, 
trismus, and tetanus. 
With a very high proportion of sul- 
phuretted hydrogen in the air a man 
suddenly falls, becomes unconscious 
and dies without convulsions (apo- 
plectic form). 
Chronic Poisoning.-Conjunctival 
catarrh; a sense of pressure in the head 
and on the chest; headache, debility, 
vertigo, nausea, disturbances of diges- 
tion; sallow complexion and emacia- 
tion; slowing of the pulse; tendency to 
the formation of boils. 
Special measures of relief: Before emptying of dung pits and the like, their contents should be thor- 
oughly mixed with iron sulphate (5 kg. pro 1 cbm.); the emptying should be effected by mechanical 
apparatus; safety ropes to be attached to the workmen; prompt hoisting out of the unconscious work- 
men; removal of the soiled clothing; artificial respiration; administration of oxygen; hypodermics of 
ether or camphor. 662 
LIST OF INDUSTRIAL POISONS 
List of Industrial Poisons-Concluded 
Designation of 
the substances 
Branches of 
industry in which 
poisoning occurs 
Mode of 
entrance into 
the body 
Symptoms of poisoning 
SULPHURIC ACID, 
H2SO4: A colorless, 
odorless, thick, oily, 
fluid. 
Manufacture of sul- 
phuric acid; accu- 
mulator factories 
(mould and charging 
rooms); burnishing 
of iron, steel, etc.; 
textile industry, hat 
factories; petroleum 
distillation; facto- 
ries for the manu- 
facture of powdered 
fertilizers. 
In the form of 
vapor, through 
the respiratory 
organs. 
Inflammatory disease of the respira- 
tory organs (acute and chronic ca- 
tarrh), inflammation of the lungs; 
anorexia; decalcification of the bones 
(according to Lewin); injury to the 
teeth through softening of the dentine. 
As a result of the bespattering of the 
skin with concentrated H2SO4, there is 
severe pain, a whitish discoloration 
of the skin, becoming brownish, with 
reddening and swelling of the sur- 
rounding tissues; in cases of extensive 
scalds there are, ultimately decompo- 
sition of the blood, formation of ulcers, 
of the duodenum, somnolence, and 
even death. 
TAR : A product obtain- 
ed by dry distillation, 
particularly of anthra- 
cite coal and lignite. 
Manufacture of illu- 
minating gas; coke 
ovens; tar works; 
tar-product facto- 
ries; plants for wood 
preserving; m a n u- 
facture of roofing 
paper; use for con- 
crete paving; paint- 
ing of metals; as a 
fuel; briquet facto- 
ries. 
It acts on the 
skin; in the 
form of vapor, 
on the respira- 
tory organs. 
Tar itch under the form of diffuse acne, 
eczema or psoriasis, primarily on the 
upper extremities, later, also, on the 
other parts of the body; not infre- 
quently on the irritated portions of 
the skin there appear cancroid ulcers, 
especially of the scrotum (among 
chimney sweepers, paraffin and soot 
workers and briquet makers). 
Together with the effect on the 
greater portion of the skin, there are 
also general symptoms: Loss of appe- 
tite, nausea, diarrhea, headache, 
numbness, vertigo, besides disturb- 
ances of the urinary bladder (ischuria, 
strangury), also albuminuria and 
oedema. 
TURPENTINE OIL: 
A mixture of various 
terebinthine hydrocar- 
bons, CioHib, differing 
in odor and in composi- 
tion according to the 
botanical species from 
which they are sever- 
ally derived. 
Manufacture of var- 
nish, cement, 1 a c- 
quer, sealing wax, 
colors; tapestry 
printing; trade of 
decorator, lacquer- 
er and house paint- 
er; as a cleansing a- 
agent in various 
industries. 
In the form of 
vapor, it acts 
upon the mu- 
cous mem- 
branes; in 
fluid state, it 
acts on the epi- 
dermis. 
Irritation of the mucous membrane of 
the eyes, of the nose (coryza), and of 
the upper air passages (hemming, 
cough, bronchial inflammation); sali- 
vation; besides there are insensitive- 
ness, giddiness, headache. 
Prolonged action of the oil causes 
irritation of the kidneys, and then 
these organs excrete urine having the 
odor of violets. 
Severe irritation of the skin is ex- 
cited, especially by the so-called pine 
oil (Russian oil of turpentine). CHAPTER II 
OCCUPATIONAL INFECTIOUS DISEASES 
SECTION 1 
ANTHRAX 
BY LANGDON FROTHINGHAM, M. D. V., Boston, Mass. 
Synonyms.-English: anthrax, splenic fever; in the human spe- 
cies, malignant pustule, wool sorters' disease, rag-pickers' disease. 
French: Charbon, Fiebre charbonneuse, Charbon bacteridien. Italian: 
Antrace, Febbre carbonchiosa. German: Milzbrand, Milzfieber, 
Karbunkelkrankheit. 
The Bacillus anthracis is intimately associated with the history of 
bacterial infection. Owing to its large size, ease of cultivation, rapidity 
of growth, the facility with which it may be stained, and the ready sus- 
ceptibility of experiment animals, it perhaps has been and is, more fre- 
quently employed than any other organism for morphological and 
biological study. It was first seen microscopically by Pollender in 1849 in 
the blood of a cow that had died of anthrax. It was later observed by 
others and in 1863 Davaine showed it to be the cause of the disease. It 
was therefore the first bacterium to be definitely associated etiologically 
with an infectious disease of animals. Its artificial cultivation by Koch 
(1876) and Pasteur (1877) established a new line of thought and study and 
Pasteur's classical experiments in attenuation and protective inoculation 
laid the basis of subsequent work in artificial immunization. There- 
fore it has been well claimed that the Bacillus anthracis is the very 
"cornerstone" of modern bacteriology. 
Morphology.-According to various observers the anthrax bacillus 
varies in length 1.5 to 10 m and in width from 1.0 to 2.5 It is non- 
motile, multiplies by direct division and under certain conditions by 
spore formation. 
The bacillus is readily stained by any of the simple stains and is Gram 
positive. The spores may be stained by the usual methods recommended 
to color these bodies. 
Cultural Characteristics.-The bacillus is a strict aerobe though 
Rosenthal by depriving it more and more of oxygen succeeded in con- 
verting it into a facultative anaerobe. Development occurs on artificial 
media at any temperature between 12°C. and 43°C. but the optimum 
is about 35°C. and at this temperature an extensive growth is evident in 
12 hours. Spores are said to form at temperatures between 18° and 42°C. 
663 664 
ANTHRAX 
Tenacity.-The vegetative rods are readily destroyed by heat and 
chemicals, the spores on the contrary are very difficult to kill. Thus the 
bacilli may be killed by a dry temperature of 55° to 58°C. in 10 to 15 
minutes, while dry heat at 140°C. for 3 hours is necessary to destroy the 
spores. Moist heat, on the other hand, as steam at 95°C., will kill spores 
in 10 minutes and steam at 100°C. in 1 to 3 minutes, and boiling water 
will kill spores in 5 minutes. Low temperature, even - 100°C. for an 
hour, does not injure either bacillus or spore, and at - 180°C. (liquid air) 
spores and bacilli are still alive after 3 to 15 hours (Ravanel, Belli). 
Bacilli will survive - 130°C. for a "few hours," -24°C. for 12 days, and 
- 10.6°C. for 24 days. In gastric juice the bacilli die in 15 to 20 minutes 
but the spores are not destroyed. 
An extraordinary example of the resisting power of anthrax spores is 
reported by W. V. Smith (Jour. Am. Vet. Med. Ass., 1916). A prepara- 
tion from a pure anthrax culture, fixed to the cover glass by heat, stained 
with plain fuchsin and mounted on the slide in Canada balsam nine years 
previously, was immersed in warm sterile water for several hours to 
loosen the cover slip which was broken in the attempt. Fragments 
placed in bouillon gave a luxuriant growth of anthrax bacilli. 
In soil fhe bacilli die out fairly rapidly but the spores are said to 
survive for 15 years (Sirena, by Besson) and in water for 17 months. 
On the inside of a manure pile a temperature from 76.5° to 72°C. is said 
to destroy spores in 4 days (Pheiler, by Hutyra and Marek). 
"Pickling destroys the bacilli in meat after 1^ months (Peuch), 
but it does not affect the spores (Abel). The drying and salting of hides 
does not destroy the attached spores which may remain virulent for 125 
days on hides that have been treated with fresh milk of lime (Griglio). 
In sunlight, hides containing the bacilli are sterilized in 6^ to 7 hours 
while those containing spores are not sterilized even after exposure for 
13 hours (Esmarch). Quick lime solution and lime kill the spores in 
the tanning process in 12 to 17 days. Infusion of quebracho bark does 
not affect them in 12 days (Keszler)." ANTHRAX TENACITY-ANTHRAX IN ANIMALS 
665 
ANTHRAX (CHARBON) WHEEL 
"DESTROY THE HUB" 
Explanation: 
The HUB represents the undestroyed diseased Carcass. 
The SPOKES represents various carries of infection from 
thejdiseased carcass. 
Recommendation n 
Destroy the HUB, the SPOKES will fall out, and the 
WHEEL collapse-Destroy the Carcass, the carriers will be 
rendered harmless, and the spread of infection prevented.* 
Anthrax in Animals.-The disease in animals is world wide in its 
distribution and has been known for centuries. The animals most sus- 
ceptible to the natural disease are cattle, sheep, horses, hogs, and 
carnivora, in the order named though infection in the last is excep- 
tional, resulting as a rule from the ingestion of flesh of anthrax 
animals. Algerian sheep, domestic fowls (probably most birds) and the 
cold-blooded animals are not susceptible to the natural disease and are 
exceedingly resistant to artificial infection. Of the laboratory animals, 
mice (white and gray), guinea-pigs, and rabbits are readily infected even 
with minute doses. Rats are less susceptible, especially black rats. 
Prevention.-Grazing should not be permitted on lands known or sus- 
pected to be sources of infection, though it is frequently possible to fence 
off certain stagnant pools or other suspicious zones. Usually the regions 
which harbor anthrax infection are swampy or peaty, subject to overflows, 
the soil loose and warm and resting perhaps on impervious substrata, also 
* The destruction of carcasses is required by State Live Stock Sanitary Board Regulation No. 9. 666 
ANTHRAX 
naturally wet regions (fens, deltas, bottom lands) which, however, make 
available pastures in dry seasons. The only rational treatment of such 
lands is thorough drainage and proper cultivation, and they should not be 
used again for grazing purposes for several years. In this connection it is 
important to remember that part of the life history of various tabanids 
and mosquitoes is semi-aquatic, and drainage therefore greatly reduces 
the number of these insects and hence tends to eliminate one source of the 
spread of anthrax. During outbreaks measures should be taken to 
carefully protect animals from the attacks of all insects. 
If an animal dies at pasture great care must be taken to avoid con- 
tamination of the ground with its blood or discharges, and other animals 
should be immediately removed. The carcass should not be skinned or 
opened; if possible it should be burned, otherwise covered with powdered 
unslaked lime and buried at least 6 ft. deep in an unfrequented, fenced-ofl 
place and ground known or suspected to have been contaminated with 
discharges should be burned over. If a carcass has been attacked by 
dogs, wild animals, buzzards, crows, etc., the danger of spreading 
infection is much increased; such creatures should be killed when 
possible and considerable ground in the vicinity of the carcass burned 
over. 
Suspicious food supply must be discontinued and destroyed. If an 
animal dies in the stable, everything suspected of being contaminated with 
its discharges should be thoroughly disinfected,-burned if possible. 
Animals from infected districts should be quarantined and the impor- 
tation of hides carefully controlled and prohibited from infected regions. 
Imported hides, calf skins, hide cuttings and parings, horns, hoofs, hair, 
wool, bristles, glue stock, etc., should be disinfected if possible and cer- 
tainly the waste from factories handling such products sterilized before it 
is permitted to reach fields. 
The United States Department of Agriculture, Bureau of Animal 
Industry, Order 256, December 14, 1917, referring to undisinfected, 
imported hides reads as follows: 
Hides and skins required by regulation 1, section 2, and regulation 
2 of said Joint Order No. 2 to be disinfected on arrival at a United 
States port of entry shall be moved to an approved warehouse at such 
port or in sealed cars or containers to an establishment having proper 
facilities for their sanitary control and disinfection. They shall be stored 
and handled prior to disinfection in compartments set aside for that 
purpose, and all hides and skins stored or handled in such compartments 
shall be treated in accordance with the following rules:* 
* A very complete summary of the U. S. rules and regulations pertaining to anthrax 
as well as the continental regulations, along with a historical discussion and the medical 
aspects of human infections is given by John B. Andrews in Bull. 267, U. S. Bur. of Labor 
Stat., July, 1920 (186 pages). The Bulletin is fully illustrated and should be consulted 
by all interested further in the public health or industrial points of view of the anthrax 
question. ANTHRAX REGULATIONS 
667 
1. All dust, litter, or waste arising from sorting, cutting, handling, or moving said 
hides or skins prior to soaking shall be burned or disinfected by exposure to a tempera- 
ture of not less than 100°C. (212°F.) moist heat for not less than 15 minutes. 
2. The hides and skins shall be subjected to disinfection by one of the following 
methods: 
(a) By immersion for not less than 20 hours in a solution containing 2 per cent, 
absolute hydrochloric acid (hydrogen chlorid) and 10 per cent, sodium chlorid. 
(6) By immersion for not less than 40 hours in a solution containing 1 per cent, 
absolute hydrochloric acid (hydrogen chlorid) and 10 per cent, sodium chlorid. 
(c) By immersion for not less than 24 hours in a solution containing 1 per cent, 
formic acid, and mercuric chlorid in the proportion of 1 part to 2500 parts of the 
solution. Hides or skins treated by'this process shall be held for two weeks following 
the treatment before neutralization. 
(d) By immersion for not less than 48 hours in a 1 to 1000 bichlorid of mercury 
solution. 
(e) By immersion for not less than 6 days in a 1 to 5000 bichlorid of mercury 
solution, plus not less than 5 days in lime of the usual strength for dehairing. 
Or, in lieu of disinfection by one of the foregoing mentioned processes, the effluent 
shall be subjected to treatment by one of the following methods: 
(/) Heat the effluent from soak vats, mill drums, breaking machines, or other similar 
equipment to a temperature of 100°C. (212°F.) and maintain at that temperature for 
at least one minute. 
(g) Treat the effluent from soak vats, mill drums, breaking machines, and other 
similar equipment with chlorin in such manner and in such amount (not less than 
(25 ) parts per million) as to secure efficient disinfection. 
(/i) Subject the effluent from soak vats, mill drums, breaking machines, and other 
similar equipment to filtration, the effluent from the filters to be treated with chlorin 
in sufficient amount and in such manner as to secure efficient disinfection: Provided, 
however, That in this method of treatment the sludge which collects on the filters shall 
be subjected to disinfection by heating at a temperature of not less than 100°C. 
(212°F.) for not less than 15 minutes. 
(i) Treat the effluent from soak vats, mill drums, breaking machines, and other 
similar equipment with 50 parts of chlorin per million parts of effluent and heat at not 
less than 80°C. (176°F.) for not less than 30 minutes. 
(J) In the case of sheepskins and goatskins, until further notice, by immersion for 
not less than 12 hours in a solution of milk of lime containing the equivalent of 5 per 
cent, of calcium oxid (CaO). 
The following is quoted from the English Report of the Departmental 
Committee appointed to inquire as to Precautions for Preventing Danger 
of Infection from Anthrax in the Manipulation of Wool, Goat Hair, and 
Camel Hair. (Vol. II-Report of the Committee, August 22, 1918.) 
" Based on a careful consideration of all the conditions of the experi- 
ments and of actual commercial practice, the following method is 
recommended: 
" Stage 1.-Preliminary treatment, consisting of agitation (by means of rakes which 
thrust the wool through liquid as in scouring machinery) for 20 minutes in a solution 
of soap in water (preferably also containing a little alkali like sodium or potassium 
carbonate) at a temperature of 102-110°F., assisted by squeezing through rollers. 
" Stage 2.-Disinfecting treatment, in which the material is agitated by similar 
means for 20 minutes in a 2-2 hj per cent, solution of formaldehyde in water at a tem- 
perature of 102-105°F., assisted by squeezing through rollers. 
" Stage 3.-Drying in a current of air heated to 160°F. 668 
ANTHRAX 
" Stage 4.-Standing for a short time to ensure by the progressive action of the 
formaldehyde, with which the blood and other substances have been saturated, 
the complete destruction of any weakened spores which may in rare cases survive 
stages 2 and 3." 
Anthrax in Man.-The intestinal form of anthrax is rare in man and is 
caused by the ingestion of infected foods, such as sausages which have 
been made from the meat of an anthrax animal, or the flesh of such an 
animal insufficiently cooked; it may also arise from eating with hands not 
properly cleansed after handling infectious material. Pulmonary anthrax 
is more common and arises from the inspiration of dust from infected wool 
rags, hair, etc., which contains anthrax spores-hence the names "wool 
sorters' and rag pickers' disease." The mortality from pulmonary 
anthrax is about 50 per cent., and less than this in the intestinal form. 
The more usual form in man is the carbuncular, the so-called malignant 
pustule, and is the result of skin infection, bacilli or spores gaining access 
through cuts or abrasions of any kind, and in some instances directly 
introduced by insect bites. The pure septicemic form is rare. It is, 
therefore, evident that certain occupations favor infection and the dis- 
ease is usually met with among workers on hides, hair, bristles, wool, etc., 
and in laboratory workers, veterinarians, meat inspectors, herders, 
farmers, cattle men, and butchers. 
Oliver reports that in certain woolen districts in England where much 
foreign wool was handled anthrax was quite common, while in other parts 
of England and Scotland where only colonial or home-grown wool was 
manipulated the disease was "conspicuously absent." Legge reports 
that there were 261 cases of anthrax in the factories and work shops of 
England in 6 years (1899-1904); of these, 88 occurred in worsted and wool 
factories, 70 in horsehair and bristle works, 86 among workers on hides 
and skins, and 17 in other industries; 67 cases were fatal. "The disease 
has appeared mostly in wool-sorting, wool-combing and spinning indus- 
tries, in the manipulation of horsehair for stuffing chairs and mattresses 
and in the preparation of bristles for brush-making" (Oliver). Only a 
very small percentage of the persons employed became infected. 
Hope and Hanna report 60 cases of anthrax in Liverpool which occur- 
red during the 8 years previous to 1912. Of these, 36 individuals unloaded 
or carted hides at wharves, 13 handled wool and 6 horsehair. 
In the United States the disease is reportable in only about half of the 
states and general statistics are lacking. Thus in Massachusetts for the 
period 1908-1915 there were six to eleven cases each year, an average of 
about eight cases and two deaths annually. During the war this number 
greatly increased: 1916, 31 cases with five deaths; 1917, 54 with ten 
deaths; 1918, 23 with seven deaths; 1919 (to October) 19 and four 
deaths. This increase was coincident with the shipping of hides and 
other raw material from new foreign areas made necessary by the extra 
demand for leather, etc., and to the general unstable condition of the ANTHRAX IN MAN 
669 
usual channels of trade. The majority of these cases were infected by 
hides coming from China (S. H. Osborn, Mass. Dept, of Health). 
A record of the reported fatal cases of anthrax is kept by the United 
States Bureau of the Census. In the 4 years 1910 to 1914, 79 such 
fatal cases were reported. As in other countries, Andrews points out 
that most of these cases occurred among persons whose occupations 
brought them in contact with infected material. The cases included 
farmers, tanners, leather workers, brush makers, workers on hair and 
haircloth, and assorters of hides. The most frequent source of infection, 
Andrews reports, was among assorters of hides. Other sources of infec- 
tion assigned were: fine wool or other animal hair, diseased cows, rags, old 
clothes, infected knives, and mosquito bite. 
In Germany, where records have been more carefully kept, there were 
in the period 1900-1908, 1042 cases of anthrax in man and 49,458 in 
animals. In 1910 there were 287 cases of which 40 were fatal; in 1911, 
281 cases with 40 deaths, and in 1912, 274 cases with 36 deaths. In 
England, in 1910, 51 cases and 9 deaths were reported; in 1911, 64 cases 
and 11 deaths, and in 1912, 47 cases and 6 deaths. In France, in 1910, 
1911 and 1912, there were 54, 42 and 38 cases respectively reported. 
John B. Andrews states that not all these cases were due to the workers' 
occupation. He reports that in Germany out of 287 cases that occurred 
in 1910, 24 were among persons whose occupations were not considered a 
factor in the disease, and points out that many cases occurred among 
persons of agricultural occupations. In Italy, 1890-1900, there was an 
annual average of about 2100 cases among people, and in Russia, 1904- 
1909, an average of 16,000 per year (Kolle and Wassermann). 
Cases of anthrax from shaving brushes have been occasionally recorded 
in the past, but during the war the number greatly increased, not only in 
the American and British forces at home and abroad, but among civilians 
(Pub. Health Reports, Vol. 33, 1918). In some cases it was definitely 
proved that infected brushes caused the disease; in others the assumption 
seemed warranted, as the sight of infection was in the shaving area soon 
after the use of new brushes, and investigation disclosed infected lots 
from which brushes had been distributed. The disease took the form of 
anthrax meningitis in a few instances with no local lesions other than the 
apparently uninfected razor cut. 
Chinese and Siberian horsehair used in the manufacture of shaving 
brushes seems to have been the chief cause of infection, and though a 
well-known source of danger the great demand for brushes and the diffi- 
culty of obtaining raw material due to the upsetting of usual trade 
routes seems to have caused carelessness among the old manufacturers 
and indifference on the part of the new. 'i 
The constant washing of a brush in use with hot water and soap 
seems to mechanically disinfect it, for most of the cases appeared soon 
after employing a new brush, "and in two brushes which caused anthrax 670 
ANTHRAX 
the free portion of the hair showed no infection, while anthrax bacilli 
were found on the ends of the hair imbedded in the handle; in the cor- 
responding unused brushes the anthrax bacilli were found on the free 
portion of the hair." 
Blue (Pub. Health Reports, 34, May, 1919) recommends that new 
shaving brushes should be sterilized as follows: soaked four hours in ten 
per cent, solution formalin kept at a temperature of 110°F., and brush 
so agitated as to bring solution into contact with all hair or bristles. 
Anthrax in man is observed in the following forms: (1) External 
Anthrax: (a) Malignant Pustule, (5) Malignant Anthrax (Edema. (2) 
Internal Anthrax: (a) Intestinal, (6) Pulmonary (Wool sorters' Disease). 
An unusual form! Anthrax Meningitis has been observed during the war. 
Symptoms. (1) External Anthrax, (a) Malignant Pustule.-The incu- 
bation period is from 1 to 3 days and the point of infection is usually the 
hand, arm, face, neck, etc., i.e., exposed parts likely to come into contact 
with hides and parts frequently scratched with the finger nails. Often 
within a few hours after infection there is itching and uneasiness and the 
gradual formation of a small hard pustule which soon becomes vesicular 
and discharges a bloody serum, and within 36 hours there is a dark brown- 
ish eschar. Inflammatory induration extends around the point of infec- 
tion and at a little distance there may be a series of small vesicles. (Edema 
causes marked swelling of the parts, the inflammation extends along the 
lymphatics and the neighboring glands are swollen and sensitive. The 
temperature rises rapidly at first, later falling and frequently becoming 
subnormal. There is much variation in the severity of the cases; death 
may take place in 3 to 5 days; where recovery occurs the constitutional 
symptoms are less marked, the eschar gradually sloughs and the wound 
heals. In the mildest form there may be but little swelling, the inocula- 
tion papule rapidly vesiculates and the resulting scab separates in a 
few days (Osler). 
(6) Malignant anthrax cedema is observed in the loose connective 
tissue of the eyelid, hand, neck, thigh, etc., and is characterized by 
absence of redness, papules and vesicles, but by the presence of extensive 
cedema-following rather than preceding constitutional symptoms- 
which is not well circumscribed, spreads rapidly and is apt to terminate in 
sloughing and gangrene. The mortality in infections about the head is 
26 per cent. (Narsarow) and infections of the legs 5 per cent. (Osler, 
Thompson). 
2. Internal Anthrax, (a) Intestinal.-This form results from the 
ingestion of anthrax-infected foods (see page 664), though it may follow 
the external type if the bacilli are carried to the mouth from the external 
lesions. The symptoms are those of intense poisoning: chill, followed by 
fever, vomiting, diarrhea or constipation, pain in various parts of the body 
dyspnoea, and cyanosis. There may be hemorrhages from the mucous 
membranes; the spleen is enlarged and the blood is dark and does not INTERNAL ANTHRAX 
671 
coagulate after death. Butler and Huber mention an instance where 
25 people became infected after eating meat from an anthrax animal and 
six died in from 48 hours to 7 days (Osler). 
(6) Pulmonary Anthrax, Wool Sorters' Disease.-This results from 
inhaling dust containing anthrax spores. The symptoms correspond more 
or less to those of the intestinal type with the addition of rapid respira- 
tion, cough and pain in the chest. Death may occur in 24 hours; when 
the disease is of longer duration there may be delirium and unconscious- 
ness (Osler). Oliver notes that although this form of anthrax is usually 
fatal in 2 to 4 days, there is an absence of the severe symptoms usually 
accompanying acute infections, and "the characteristic feature is the 
rapidity with which collapse sets in." 
Diagnosis.-The symptoms and history are sufficient to lead to a sus- 
picion of anthrax infection and laboratory methods must be resorted to 
for diagnosis. Anthrax bacilli may be demonstrated in the fluid from 
the pustules, the oedema, sputum (in the pulmonary form), and, during 
the last stages of the disease, in the blood. 
Treatment.-The use of actual cautery on the malignant pustule has 
been recommended, also the removal of the whole infected area and 
neighboring lymphatics with the knife. Local development of the bacilli 
is said to be retarded by subcutaneous injections of 3 per cent, carbolic 
acid or 1:1000 corrosive sublimate repeated two or three times a day, at 
various points in the neighborhood of the pustule. But these methods 
cannot be regarded as successful. 
On the other hand, there is much evidence that no surgical intervention 
whatever gives the best results, the treatment simply consisting of main- 
taining the general health and protecting the local lesion by aseptic or 
antiseptic dressings. For example, Leland has tabulated the cases occur- 
ring at the Massachusetts General Hospital, Boston, during the past 36 
years. These records show 23 cases; 7 of these were operated upon and 3 
died (42.8 per cent.); the other 16 were not operated and all recovered. 
Others reporting successful non-operative treatment are: Muskett 50 cases, 
Muller 13 cases, Remstedt 7, and Savini 5, all recovering, Creite 13 recov- 
eries and 1 death, and Graef 384 cases with 20 deaths. Normal beef and 
also horse serum has been considerably used in Argentina since 1917. 
The serum is heated twice for one-half hour at 56°C., and 20 to 50 cc. 
injected either intravenously or subcutaneously. A mortality below two 
per cent, is claimed. 
Treatment with Sclavo's serum is successfully reported both in local 
and general infections. Thus Italian statistics show a mortality of 
6.09 per cent, of the treated against 24.16 per cent, for the rest of Italy; 
and in England, including cases already moribund, 7.4 per cent, mortality 
among the serum-treated, while in previous years (1889-1903) without 
serum it was 26.5 per cent. In some cases this treatment has proved 
successful even after anthrax bacilli have invaded the blood. 672 
ANTHRAX 
Prevention.-It is evident from the foregoing discussion that anthrax 
would not occur in certain trades if all dangerous material were properly- 
disinfected before manipulation by the workers. To accomplish this 
without injuring the product for its intended manufacturing purpose is 
the difficulty not yet overcome in many lines of industry. Until adequate 
methods of disinfection are perfected and enforced other means of preven- 
tion must be recommended.* 
Dangerous dust should be drawn from the sorting tables, etc., by 
exhaust ventilation downward and so away from the face of the worker. 
The workers themselves should take every precaution against infection 
according to their special employment: proper clothing, dust masks, strict 
personal cleanliness, hands thoroughly washed before handling food, 
meals not eaten in dangerous surroundings, cuts and abrasions carefully 
protected, hides handled with gloves and not carried against bare neck, 
shoulders or arms. 
Preventive inoculation may also be seriously considered for workers in 
the dangerous trades, though as yet statistics are not available along these 
lines. 
Legislation.-"In order to minimize the danger to workmen, sanitary 
measures are prescribed by law in a number of European countries, for 
instance in England, Germany, France, Belgium and Holland. Quite 
effective legislation on anthrax is to be found in England where for 
a number of years the government factory inspectors have had the valuable 
cooperation of the Anthrax Investigation Board. In Germany the 
crusade against anthrax is of more recent origin; statistics are being kept 
there since 1910. Each case is thoroughly investigated and the source of 
the disease is traced as far as possible. In both countries notices are 
posted in factories calling attention to dangers and precautionary measures. 
'Tn England the law of 1901 referring to work on imported hides and 
skins makes provisions for keeping the workers' food and clothing in a 
clean place. Water, soap, towels and nail brushes must be furnished, also 
overalls and gloves if dangerous hides are handled. Every workman hav- 
ing an open cut is required to report immediately to the foreman and to 
leave the shop until the cut is healed. Still more careful regulations are 
prescribed for work on hair imported from Russia, also from China, 
Siberia and other Asiatic countries. Non-disinfected material must be 
kept in a separate room to which no food or drink may be taken. Careful 
rules are prescribed for opening, disinfecting and handling materials for 
the removal of dust and for personal cleanliness. The precautionary 
rules of Germany and France follow very closely those of England." 
(John B. Andrews.) 
* A suggested new method for the disinfection of hides and skins for anthrax is 
given in the American Journal of Hygiene (Vol. Ill, No. 3. May, 1923, pp. 224-237) 
by Henry F. Smyth and Edwin F. Pike, of the Univ, of Penn., in which the absolute 
efficacy of iodine as a disinfectant for anthrax is proved and the possibility of its use 
in the tanning industry without the slightest injury to the hides is claimed. Vapor 
or wet method disinfection with water or a volatile solvent (CCU or CCh-light hydro- 
carbon mixture) may be employed. SECTION 2 
THE HIDE, TANNING AND ALLIED INDUSTRIES 
(Involving exposure to anthrax and other occupational diseases) 
GEORGE M. KOBER, M. D., Washington, D. C. 
Historical.-Dr. John B. Andrews, Bulletin No. 205, U. S. Bureau of 
Labor Statistics, 1916, gives a history of anthrax in the U. S. from the 
first record of human cases in Philadelphia in 1834 to the present day. 
During the period from 1910 to 1915 there were 132 deaths from 
anthrax in the U. S. Registration Area. Of these 23 occurred in tannery 
employes; 21 were farmers, ranchmen etc; 31 were transportation workers 
including 9 longshoremen; 6 worked with wool, hair or bristles; 2 were 
rag handlers in paper mills; 2 were liverymen; 1 was a veterinarian; 
and 9 were laborers probably in some of the foregoing branches of 
industry. There were five deaths of infants from anthrax. Andrews 
estimates that about 1 in every 5 cases is fatal. 
Anthrax has been a notifiable disease in Germany since 1911. During 
that year there was 287 cases with 35 deaths. In 1914 there were 183 
cases with 39 deaths. Of the 287 cases, 121 occurred in farmers and 
stockraisers, and 103 among hide and tannery employes. 
Lehmann in his Arbeits u. Gewerbehyg. (1919, page 278) refers to 17 
cases of anthrax in a small German town, among them a 5 year old child, 
who was infected while picking violets fertilized with tanning refuse; 
a 12 year old boy who was infected while running barefoot in a tan- 
nery yard and stepped into a piece of glass; two other cases occurred, 
one in a boy 12 years old and one in a 14 year old girl whose parents were 
employed in a tannery. 
Hides.-The handling of hides and skins, apart from being disagreeable 
and when dry also very dusty work, is dangerous on account of liability 
to wounds and anthrax infections. 
The most common medium for the transmission of anthrax in handling 
infected skins or fleeces is the dried blood clots adhering to the hair or 
wool. Indeed so resistant are the spores of anthrax that infections have 
occurred not only among the men handling the hides and in tanners, but 
also among workers in the boot and shoe, and harness and glove industries, 
and in men using infected shaving brushes. 
In 1905 the Medical Inspector1 reported a case which occurred in the wife of a 
dock laborer in South London, who had been engaged in unloading foreign hides and 
evidently carried the germs in his clothing to his house. Another case occurred at 
Plymouth in a man engaged in unloading bones. Of the 261 cases of anthrax reported 
in Great Britain, between 1899 and 1904, 80 cases occurred in the hide and skin trade; 
673 674 
THE HIDES, TANNING AND ALLIED INDUSTRIES 
and of these, 21, or 24.4 per cent., proved fatal. In nearly 50 per cent, of the cases the 
seat of the pustule was in the neck, as against 29.5 per cent, in the wool industry. 
This difference has been justly attributed to the habit of carrying the hides on the 
shoulders, and is a strong argument in favor of removal by mechanical means. Dr. 
Hope2 cites two cases of anthrax infection in female bag menders; one of the bags had 
contained wool or hair, and the other, Egyptian cattle bones. Cases have also been 
reported in persons engaged in mending tarpaulins which had been used to cover wool. 
Dr. Legge reports a reduction in cases of anthrax from 72 in 1918 to 57 in 1919, and 
from 48 in 1920 to 25 in 1921, and gives some credit to the inauguration of a dis- 
infection station for imported wool and goat hair at Liverpool. This Disinfection 
Station is described in detail in a memorandum from the Home Office (1921). A new 
method has been devised which comprises three processes: (1) exposure to an alkaline 
solution at a temperature of 102°F. for about 30 minutes; (2) exposure for twenty 
minutes to a 2J^ per cent, solution of formaldehyde; (3) drying in a current of hot 
air. Everything is done by machinery from the time the untreated bales are opened 
until re-bailing has been completed. Employes' clothing as well as bail-covers are 
sterilized by machinery. 
Hubbard and Jacobson (Mo. Bull. Dept, of Health, N. Y. City, Nov. 1920, 10, No. 
11, 249-266) present case histories of 34 human anthrax infections occurring in New 
York City in 21 months (1919-1920) and find the disease to be rapidly increasing. 
Half of the cases resulted from using new shaving brushes, the balance occurring 
among artisans. Osborn (Am. Jour. Pub. Health, Aug. 1920, p. 657) gives a detailed 
study of many anthrax cases in Massachusetts acquired from imported hides, hair 
and wool from Buenos Aires, China and India. 
Dr. Hope2 states that the hides causing infection came from all parts 
of the world, but chiefly from China and the East Indies. The material 
causing infection in the case of hair was derived from Russian sources. 
He also refers to the fact that a large number of bales are transhipped to 
the United States, Since anthrax was extremely rare 30 years ago among 
the domestic animals of this country, the infections reported are perhaps 
chiefly due to the importation of hides and fleeces. Ravenel2a reports 
12 cases of anthrax among men and 60 in cattle, which occurred in 
three localities in Pennsylvania during the summer of 1897. All were 
traced to a tannery handling hides imported from China. The infection 
in the cattle was believed to be due to feeding on pastures watered by 
streams contaminated by tannery refuse. Similar instances have been 
reported in different parts of Europe, and indicate how imported infected 
hides may be a source of danger to the animal industry in sections hereto- 
fore free from anthrax, and also the danger to public health of permitting 
tannery refuse to be discharged into streams, without preliminary 
treatment. 
Preventive Measures.-In most civilized countries stringent rules have 
been adopted for the suppression of anthrax and other diseases communi- 
cable from animals to man. Among these rules may be mentioned: com- 
pulsory notification of the existence of anthrax; isolation and quarantine 
of the entire herd; prompt killing of the diseased animal and destruction of 
the carcass by cremation; and thorough disinfection of the stables and 
other infected premises. The owner is reimbursed for the loss sustained. ANTHRAX FROM HIDES-TANNING 
675 
These rules were primarily enacted in the interest of animal husbandry. 
The question of anthrax infection, in its relation to man, has been empha- 
sized only in recent years. In some countries, Germany for example, 
even now no compensation is paid for sheep and goats which perish from 
this disease, and as d result the farmer is sorely tempted to sell such 
infected skins to "fell-mongers." 
Tanning.-This occupation calls for strength and endurance as many 
of the processes are laborious, extremely wet, and disagreeable, and are 
often carried on under insanitary conditions. Indeed, the odors of " beam 
houses" are so offensive as to be considered a nuisance to the neighbor- 
hood. The injurious influence of these odors has, however, been over 
estimated. 
The handling of dried hides and skins involves the inhalation of more or less dust 
of organic and inorganic origin, fragments of hair, etc. The mortality rates in the 
U. S. for 1909 show that 15.2 per cent, of all the deaths among tanners were caused by 
tuberculosis, 14.3 per cent, by heart disease, 8.8 per cent, by pneumonia, and 8.7 per 
cent, by Bright's disease. 
According to Popper,3 one-sixth of all the deaths are caused by pneumonia and 
about 40 per cent, from tuberculosis. Diseases of the digestive organs and of the 
kidneys are not uncommon. Rheumatic and catarrhal affections, on account of 
exposure to wet and sudden changes, are also quite prevalent. Many of the hides also 
have sharp cutting edges, which are liable to produce wounds and abrasions and 
subsequent septic infections. In the handling of lime skins and during the removal 
of the hair, the workmen not infrequently get short pieces of hair under the finger nails, 
giving rise to septic conditions. As a result of immersion of the hands in caustic lime 
solutions Prof. Roth4 refers to a peculiar affection of the skin, characterized by loss of 
substance and bright red, shining finger tips, called by the French tanners "rossignol" 
or "pigeoneau" and by the Germans "Stieglitz." Other skin and nail affections are 
liable to develop, especially in persons engaged in scraping sheep and rabbit skins and 
also from the use of arsenic, the chromates and acid solutions. The danger from 
anthrax infections constitutes an important occupational risk; 63 such cases with 14 
deaths occurred in German tanneries in 1903-1904, and Neisser reported 29 cases in 
1905, the majority of which were traced to imported hides. Of 255 cases with 45 
deaths, tabulated by Holtzmann,5 which occurred in the German leather industry be- 
tween 1906-1910, the source of infection was traced in 154 instances to lamb, sheep and 
goat skins, and in 101 instances to hides from calves, heifers, cows, steers and wild 
animals. It has long been known that the handling of dried hides is more dangerous, 
and Dr. Hamer6 expressed the hope that the wet process of curing would diminish the 
spread of infection. But because of the increased weight of wet consignments the 
majority of imported hides are still cured and shipped in a dry state. 
A number of the tanneries in the Netherlands, as a result of long experience, have 
come to the conclusion that the dried hides are more dangerous as a rule because the 
countries from which they are shipped pay little or no attention to the prevention of 
anthrax. They caution especially against the purchase of hides with bayonet cuts, 
as such perforations are an indication that the skin came from a diseased animal which 
had been killed for the sake of the hide. They also fear the danger of arsenic-cured 
hides from China. Lastly, their observations lead them to conclude that hides 
imported from the United States are the least dangerous, as they come from abattoirs 
subject to Federal inspection, where none but healthy animals are'permitted to be 
slaughtered. 676 
THE HIDES, TANNING AND ALLIED INDUSTRIES 
Henry Field Smyth and Elizabeth Bricker (Jour. Ind. Hyg., June, 1922, p. 53) 
present an analysis of 123 cases of anthrax in the Pennsylvania tanning industry 
from 1910-1921. This number represents almost 12 per cent, of the directly exposed 
employes. The mortality was over 21 per cent. 
Tanning and Dressing Processes.-The old method of using tan bark 
and sumac has been largely supplanted by the use of chemicals. As a pre- 
liminary to either process the hides are first soaked in water and afterward 
in water to which lime, and sometimes disulphide of arsenic, has been 
added. This causes the hides to swell and facilitates the removal of the 
fleshy part of the hide, which with the hair is scraped off, either by hand 
or by suitable machinery. 
The de-hairing process is sometimes done in so-called "sweat chambers" under the 
influence of lime or its sulphide, or of sodium sulphate. The temperature in these 
chambers is often above 86° and not only attracts flies, but also favors the development 
of ammonium sulphide and of anthrax spores, if any be present. After this process, 
the hides are soaked in acidulated water, or a bath containing animal excrement, for 
the removal of lime. 
"When the hides or skins are ready for the actual tanning, they are placed either 
in a vat containing the old-fashioned tan bark liquor, or into a revolving drum known 
as a "pin wheel," or into a pit supplied with revolving paddles and containing a dilute 
solution of potassium or sodium dichromate, acidified with hydrochloric or sulphuric 
acid, and caused to revolve or to be overturned for 7 hours or longer, after which time, 
if the "pin wheel" is employed, the liquor is drawn off and replaced by an acidified 
solution of sodium thiosulphate or bisulphite and the revolution is continued several 
hours longer. If the pit is used, the skins are removed to another, containing the 
second solution, and kept at rest or overturned for a like period.7 
During these processes, the hands and arms of the workmen are exposed to the 
caustic and toxic effects of lime, chromates, etc. Dr. Neisser8 reports a number of 
cases of pustular eczema in chrome-tanning workers and 19 cases of chrome ulcers 
among 300 workers within 1 year. He also reports similar instances in connection 
with the tanning industry, resulting from the vapors developed in dissolving the 
chrome in hot water. Protection with long rubber gloves does not always prevent 
troublesome skin affections. 
In establishments in which arsenic-cured hides are handled, or realgar 
or orpiment is used as a chemical agent, there is a certain amount of 
danger from arsenical poisoning. There is more or less danger from lead 
poisoning during the finishing process of alum-tanned leather, which is 
rubbed with a mixture of talcum and white lead. Cases of lead poisoning 
have also been observed in men who, while tacking the hides on frames, 
are in the habit of holding the tinned tacks in their mouth. This habit 
is also objectionable from the fact that, sometimes, they have been spilled 
previously on the floor and are picked up and without washing placed 
in the mouth and may thus be the means of conveying disease germs. 
In the subsequent processes of leather dressing there is more or less 
danger from unprotected machinery. In the buffing process, which 
is characteristic of chrome-tanned leather, and which is done by means 
of wheels or revolving drums covered with sandpaper, the air of the room TANNING PATENT LEATHER-GLOVES 
677 
is frequently filled with very fine dust, presumably containing chromates. 
Since anilin dye stuffs and orpiment are used in the manufacture of 
"fancy leather," we may expect to find anilin and arsenical skin eruptions 
and even symptoms of systemic poisoning. Benzine is freely used as a 
solvent for the various dye stuffs. Dr. W. G. Thompson9 reports a case 
of multiple neuritis of both arms in a finisher of leather, caused by arsenic 
which had been used as a tanning agent and was evidently disengaged 
during the rubbing and polishing process. 
Patent Leather.-The manufacture of patent leather is largely a secret 
process, but sufficient is known to indicate that the workmen are exposed 
to such industrial poisons as lead, amyl acetate (zapone lacquer), naphtha, 
and wood alcohol, which are some of the ingredients of a mixture with 
which the leather is coated. This mixture, after being heated in iron 
kettles, is applied to the hide, stretched on frames, and evolves fumes 
which, even employers admit, cannot be withstood by the workmen for 
any length of time. The men generally work stripped to the waist. 
"In one of the two factories visited the odor of naphtha was noticeable 
in every department." Naphtha "drunks" were said to be not uncom- 
mon among the workers. The minors at work were all Italians, young 
and rugged, recently landed, so that the occupation had not as yet affected 
them.10 
Preventive Measures.-It is needless to insist that this occupation is 
intrinsically dangerous to health and that the utmost precaution should 
be exercised to safeguard, by adequate exhaust ventilation, the health of 
the employes. 
The Leather Glove and Mitten Industry.-The industry involves 
exposure to dust and toxic dyes and agents used in the preparation of the 
leather. The work is often carried on under unfavorable environments. 
Diseases of the respiratory organs, caused by exposure to bad air and dust, 
especially in the buffing process, are most frequent, and tuberculosis is 
responsible for 60 per cent, of all the deaths. Catarrhal affections, con- 
junctivitis, diseases of the digestive organs, varicose veins and leg 
ulcers are not uncommon. Occasional cases of lead poisoning, from the 
use of talcum and white lead, and isolated instances of anthrax infection 
have been reported. Persons engaged in the dyeing process not infre- 
quently develop chrome ulcers on the thumb of the left hand and on the 
second and third fingers of the right hand. Another form of ulceration 
has been observed between the toes of employes who are in the habit of 
using their bare feet for the purpose of soaking the leather in tubs. The 
alum used for tanning purposes and failure to wash and dry the feet prop- 
erly is believed by Bauer11 to be the cause of these ulcers. Callosities 
of the hands and contracted tendons are also observed. 
Preventive Measures.-All home work should be discouraged and the 
industry should be carried on in sanitary shops properly equipped with 
exhaust ventilation for the removal of dust and vapors. 678 
THE HIDES, TANNING AND ALLIED INDUSTRIES 
Brush and Broom Making.-In the manufacture of brushes, hog 
bristles and vegetable fiber are chiefly used; for the more delicate brushes, 
horse-hair, goat, camel and cattle hair, and hog wool are employed. The 
handling of these hairs in a raw state is a dirty, dusty and even a danger- 
ous process, on account of the possibility of anthrax infection. 
Of the 60 cases of anthrax infection reported by Dr. Hope12 in 1912, 7 contracted 
the disease in handling horsehair or bristles in hair factories; 14 cases with 7 deaths 
occurred in German hair and brush factories in 1904. It is usual and necessary, 
therefore, to boil the bristles for several hours, after which they are dried in steam 
dryers and bleached, and then dressed or combed by machinery and mixed. 
Shaving Brushes.-Sixty-five cases of anthrax with 10 deaths were reported 
from March, 1918, to April, 1919, in the American Expedition in France. With rare 
exceptions the initial lesion was on the shaving area of the face and a new shaving 
brush had recently been used. In a number of instances the brushes were examined 
and the bacillus anthracis was found. According to Haven Emerson (Mil. Surgeon, 
Dec., 1921, page 642) a number of other cases have been reported in England and 
in this country. 
In the manufacture of paint, varnish and kalsomine brushes, the bristles are set 
into the handles by means of a tar cement or a cement composed of wood alcohol and 
shellac; for shaving brushes, a cement of rosin and linseed-oil is used, which is kept 
fluid by means of electric or non-luminous gas flame heaters, provided with hoods. 
Hirt reports that nearly one-half of all the deaths among brush makers are caused by 
consumption. The danger is probably due to the irritation produced by the inhala- 
tion of sharp fragments of bristles, which are not easily dislodged. Instances of lead 
poisoning have also been reported in this industry. 
When vegetable fiber is used, dust production is also very great. This 
is especially true in the manufacture of "corn brooms." This danger is 
recognized, so that hooded stripping machines, provided with a chamber 
for the removal of dust, seeds, and other foreign material, have been 
installed. In some establishments the "wet process" has been adopted 
before removal of the seeds and dust. The bleaching process involves 
exposure to sulphur and chlorine fumes; anilin solutions are used for 
dyeing and staining purposes. Fatigue from piecework, long hours, 
jarring processes, faulty position and unfavorable working conditions are 
among the occupational hazards observed in this industry. 
P. Piccinini (Il Lavoro, Sept., 1920) reports that broom makers frequently develop 
dermatitis and callosities caused by mechanical irritation; conjunctival and bronchial 
catarrh are fairly frequent, but there is no evidence of industrial tuberculosis. There 
is, however, a mild transitory febrile affection which is industrial in origin (Abstr. 
Jour. Ind. Hyg., May 19th, 1921, p. 3). 
Curled Hair and Horse-hair Cloth Factories.-In all of these indus- 
tries, apart from the inhalations of mixed dust and of minute fragments of 
hair, there is danger of anthrax infection and other communicable diseases. 
Of the 261 cases of anthrax reported in Great Britain between 1899 and 1904, 70 
cases occurred in the hair industry. Nichols13 of this country reported 26 cases, which 
occurred in one curled hair factory in 3 years. The Massachusetts State Board of 
Health for 1908 reports four cases of malignant pustule, in a curled hair shop, during BRUSHES, BROOMS, CURLED HAIR, FURRIERS, ETC. 
679 
a period of 7 years. After the management adopted a method of disinfection, by 
prolonged fumigation with formaldehyde and subsequent boiling of the hair, no cases 
occurred. Smyth (Jr. Ind. Hyg., II, No. 11, Mar., 1921, p. 423) offers circumstantial 
evidence of the presence of anthrax-infected domestic hair, and claims to have 
demonstrated experimentally the "inefficiency of the Department of Agriculture's 
rule for disinfecting hair, even when opened out freely, by exposure to 200°F. for 15 
minutes," but finds that 24 hours is required, or, preferably, "steam under 15 pounds 
pressure for at least two hours for bailed hair, . . . with the bundles to be stacked 
loosely in the autoclave and all air to be exhausted before obtaining pressure." 
A peculiar painful affection of the finger tips extending at times to 
the margin of the finger nails, has been observed in some of the employes 
in hair cloth factories in France. 
Furriers and Taxidermists.-A similar affection, but more especially 
limited to the finger nails of men engaged in scraping rabbit and hare 
skins, was reported by Dr. Gilbert of Brussels in 1896. It was noticed in 
18 of the 22 workmen examined by him. The character and amount of 
dust evolved in the various processes of the fur industry are doubtless 
factors in the development of respiratory diseases. This is especially 
true in the manufacture of artificial furs and the preparation of rabbit 
fur for the felt hat industry. But in the manipulation of all kinds of fur 
there is more or less dust inhalation incident to repeated brushing, fur 
pulling and clipping, and such dust not infrequently harbors disease germs. 
Dr. W. G. Thompson14 states that pulmonary abscess is very common among the 
employes of a fur-manufacturing establishment in the State of New York. Arseni- 
ous acid in the proportion of 1 lb. to the gallon of water is often employed by furriers 
and taxidermists as a preservative. An American chemist demonstrated its presence 
in 11 of the 42 samples examined, amounting in some instances to 170 grains per square 
yard. Many of the furs are in whole or in part dyed with lead pigments, which consti- 
tutes an additional source of danger. 
A clinical and sanitary study of the fur and hatter's fur trade was conducted by 
the Department of Public Health in the City of New York (see Monthly Bulletin for 
October, 1915). Of 3839 persons engaged in dressing, dyeing or manufacturing fur, a 
complete physical examination was made of 542 persons. Of these, 67 individuals 
suffered from anjemia and 18 others showed marked malnutrition; 12 persons suffered 
from furriers' asthma;* 32 from subacute and chronic bronchitis; 11 from tuberculosis 
and 7 from emphysema; 163 suffered from skin diseases; 151 from nose and throat 
affections; 74 from diseases of the heart; 89 from ocular defects; 50 from dental defects; 
and 35 from orthopedic defects, inclusive of 14 cases of varicose veins and 10 of flat- 
foot. A number of the dyers and dressers showed the presence of dye pigments and 
sawdust in their nostrils. The nails of dyers frequently revealed deformities. Callus 
formations on the fingers, hands and on the flexor surface of the wrists were not uncom- 
mon in cutters, dressers and beaters. Only 77 individuals of those examined (about 
14 per cent.) were found free from physical defects. 
The report for 1921, prepared by Dr. D. Gilbert,18 head of the medical department 
of industry in Belgium, is a valuable monograph and deals with tanning, currying, 
unhairing, wool washing, pelt dyeing, felting and brush making. Each of the 9,317 
workers engaged in these industries was personally examined by the medical inspector. 
Of 1760 tanners, 165 had dermatoses. The sore known as " pigeoneau" characteristic 
of this occupation, is fully described. The author associates it with the length of 
* For probable cause of furriers' bronchial asthma, see pages 516-517. 680 
THE HIDES, TANNING AND ALLIED INDUSTRIES 
occupation and the arsenic and chrome used. Of 838 leather dressers inspected, 21 
showed affections of the skin. Unhairing, washing wool, dyeing and preparing 
bristles for brushes, do not appear to be particularly inimical to soundness of the body, 
whether these operations are done by hand, or by machinery. In the haircutting and 
plucking rooms conjunctivitis is very prevalent, 54 cases were observed in men and 
65 in women. Septic sores on the fingers are common in some of these workrooms. 
Reference is also made to the danger of mercurial poisoning in the carrotting room. 
Between the years of 1899 and 1920 only 55 cases of anthrax were reported: 35 among 
brushmakers, and 16 among tanners. (Jour. Ind. Hyg., April, 1922. Abstr. by 
R. Prosser White, p. 283.) 
Preventive Measures.-Reference has already been made to the 
danger of mercurial poisoning involved in the manufacture of felt hats. 
It is needless to insist that adequate exhaust ventilation should be pro- 
vided. It is gratifying to note that the morbidity in establishments 
which have provided such safeguards has been reduced fully one-half. 
Upholstery, Mattress Making and Feather Work.-These occupations 
have always been regarded as unhealthful, on account of the inhalation of 
dust incident to the manipulation of hair, wool, cotton, felt, excelsior, 
feathers, and other material. Even when new material is used, unless it 
has been thoroughly washed and disinfected, the process of picking and 
carding involves the inhalation of large amounts of dust which may con- 
tain disease germs, and which predisposes to respiratory diseases, anthrax 
infections, etc. All these dangers are enormously increased when second- 
hand material is handled, as in the renovation of mattresses, feather beds, 
bolsters, pillows, furniture cushions, etc., especially when such articles 
have been used by infectious patients. 
It is not surprising that a French Commission should have found that 
"old mattresses are often the means of spreading the germs or virus of 
smallpox, erysipelas, scarlet fever, diphtheria, measles and typhoid fever." 
As a matter of fact, among the few cases of smallpox reported in Germany 
in 190515 several were traced to a feather bed renovating establishment at 
Pilsen. The dangers of handling even new feathers imported from Russia, 
China and countries where smallpox prevails have been pointed out by 
Shablowsky.16 In the opinion of Sir Thomas Oliver17 feather dust is 
liable to produce ophthalmia and diseases of the respiratory organs. 
General Preventive Measures.-Fortunately in most of these occu- 
pations hooded machines with exhaust ventilation have taken the place 
of hand labor in the picking and carding processes of hair, wool and other 
material; but in spite of dust-removing devices, more or less dust escapes, 
and every effort should be made to render them more effective. A more 
general adoption of the wet processes will be a great aid. Even if the 
dust is free from disease germs, the inhalation of minute fragments of hair 
and organic and inorganic matter, some of which is derived from the 
perspiration of animals which has dried on the hair of horses, etc., doubt- 
less predisposes to diseases of the respiratory system. It is well known 
that cavalry troops are more susceptible to pneumonia than other arms UPHOLSTERY, MATTRESSES, ETC. REFERENCES 
681 
of the service. The writer in 1886 pointed out that the inhalation of 
organic dust, evolved in the grooming of horses, was a possible predis- 
posing factor. 
There is no question that old as well as new material of animal origin 
should first be subjected to disinfection, by means of steam under pressure 
by formaldehyde, or by boiling. Old and worthless bedding, used by 
infectious patients, should be burned. The precautions for the preven- 
tion of anthrax, especially in the handling of imported hides, hair and 
wool, have been described on page 666. 
A most praiseworthy example has been set by the Pachetti Bros., own- 
ers of a hair-cloth factory in Milan in which 700 persons are employed. 
Although the horsehair is disinfected by steam under pressure, a physi- 
cian makes daily visits, treats all wounds and abrasions, and examines 
all cases of indisposition, with special reference to anthrax infection. 
His office is equipped with apparatus for a bacteriological diagnosis and 
the prompt administration of Sclavo's serum. 
Reports show that the anti-anthrax serum is giving excellent results in the hands 
of American physicians, which Smyth19 says gives best prospects if combined with an 
injection of strong phenol solution (25 to 50 per cent.) locally around the area of the 
initial lesion, with or without excision of the lesion. 
REFERENCES 
1 Neisser.-Internal, tTbersicht uber Gewerbehygiene, Berlin, 1907, page 84. 
2 Hope, E. W.-The Incidence of Industrial Anthrax in Liverpool. Trans. 15th 
Internal. Congress on Hygiene, Sec. IV, Wash., D. C., Vol. Ill, Part II, 1913, 
page 735. 
2a Ravenel.-Phil. Med. Jr., Apr. 22, 1899, page 897. 
3 Popper.-Lehrbuch der Arbeiterkrankheiten, 1908. 
4 Roth, E.-Gewerbehygiene, 1906, page 121. 
5 Holtzmann.-Viertelj. fur offentl. Gesundheitspf., 1912, Vol. XLIV, page 444. 
6 Oliver's Dangerous Trades, 1902, page 633. 
7 Report of the Mass. State Board of Health upon the Sanitary Conditions of Fac- 
tories etc., 1907, page 116. 
8 Neisser.--Internal. Ubersicht fiber Gewerbehygiene, 1907, page 92. 
9 Thompson, W. G.-Trans. 15th Internat. Congress on Hygiene, Washington, Vol. 
Ill, Part II, 1913. 
10 Report of the Mass. State Board of Health, 1908, page 31. 
11 Bauer.-Weyl's Handbuch d. Arbeiterkrankh., Jena, 1908, page 509. 
12 Hope, E. W.-Trans. 15th Internat. Congress on Hygiene, etc., Wash., D. C., Vol. 
Ill, Part II, 1913. 
13 Second Annual Report of the State Board of Health of Mass., page 86. 
14 Trans. 15th Internat. Congress on Hygiene, Washington, D. C., Vol. Ill, Part II. 
1913, page 834. 
15 Neisser.-Internat. tibersicht fiber Gewerbehygiene, 1907, page 96. 
16 Shablowsky.-Zeitschft. f. Hygiene, etc., 1911, Vol. LXVIII, page 209. 
17 Oliver's Dangerous Trades, London, 1902. 
18 Glibert D.-Minist5re Belgique de'Industries, du Travail et du Ravitaillement, 
Service Medical du Travail, 1921. A. Lesigne, Brussels, 1921, pages 448. 
19 Smyth, Henry Field.-Jr. Ind. Hyg., II, No. 11, Mar., 1921, p. 423. Also Smyth 
and Bricker (Elizabeth), Jr., Ind. Hyg., Ill, No. 2, June, 1922, p. 53. SECTION 3 
PARASITES AND OCCUPATION 
BAILEY K. ASHFORD, M. D„ Porto .Rico 
Introduction.-Whatever may be our idea of what should constitute 
"occupational diseases," it is undoubtedly true that we have only recently 
begun to protect that most humble and yet most important of all laborers, 
the tiller of the soil. The diseases to which he is by reason of his occupa- 
tion especially exposed, malaria, uncinariasis, schistosomiasis, amebic 
dysentery, filariasis and ascariasis, are briefly summarized below. As our 
National tendency is toward the specializing of labor, toward the refine- 
ment of the raw product, toward the factory, so the southern countries are 
tending toward the refinement of agriculture, toward the production of 
the largest output and highest type of vegetable life where soil and climate 
best favor these products. But just as it was impossible to build a Pan- 
ama Canal until the parasitic foes of man were conquered, so will it be 
impossible to reap the fullest harvest from tropical and subtropical lands, 
to colonize in its broadest sense, until we learn to protect ourselves from 
the luxuriant parasitic life which is favored, as are valuable crops, by a 
propitious climate. With apologies to those who consider a tropical cli- 
mate per se an obstacle to the well-being of the white man, it is suggested 
that judgment be deferred until the effect of recent sanitary reforms has 
impressed itself upon those who, living in warm climates, seek to avoid 
the diseases heretofore considered unavoidable. Indeed many so-called 
"tropical diseases" might better be termed "rural diseases," so extensive 
also is their domain in certain country districts of the temperate zones. 
Already from tropical and subtropical lands has sprung the efficient 
prophylaxis of malaria, responsible for the agricultural depression of many 
sections of our south, of yellow fever, and other diseases which wave-like 
have beaten upon our shores, and have even, as in the case of "hookworm 
disease," successfully invaded nearly the half of our country in so subtle 
a form as to have been unrecognized for probably a hundred years. 
Thus we may consider the tropics as the original home of most diseases 
due to animal parasites. There still they best flourish and yield their 
greatest percentage of inefficiency for labor, due first to heat and humidity 
and second to ignorance of modern individual hygiene, upon which 
all true State and National hygiene is most firmly based. The essence 
of sanitation is education in preventing communicable disease. In emer- 
gencies, imposed by force of law, the natural evolution of sanitary living 
must ordinarily spring from the intelligent cooperation of the good citizen 
682 PARASITES MALARIA 
683 
whose will in the form of a comprehensive sanitary organization should 
control the ever-present ignorant, careless or criminal spreader of disease 
and death. In a perusal of these pages it will be seen that by a care- 
ful observance of the very simple prophylaxis of two notoriously danger- 
ous enemies of agricultural countries, malaria and uncinariasis, we go far 
toward exterminating on the one hand dengue, filariasis and yellow fever, 
and on the other, typhoid fever and the dysenteries, not to mention other 
communicable diseases less directly affected. 
PROTOZOA 
Malaria.-An infectious disease caused by the introduction into the 
human blood through the bite of certain anopheles mosquitoes, and by 
them alone, of the sporozoites of one of three species of hemosporidia- 
Plasmodium malariae, Plasmodium vivax and Plasmodium falciparum. 
The ameboid parasite enters the erythrocyte, transforming its hemoglobin 
into a black pigment " melanin," and finally, reaching its maximum growth, 
sporulates, liberating its daughter cells, or "merozoites," to attack fresh 
red cells. In rupturing its containing cell it discharges a hemolysin on the 
one hand and a pyretogenous toxin on the other, the latter provoking the 
typical sequence of chill, fever and sweat with their clinical accompani- 
ments. The predominant brood of P. malariae is liberated every 72 hours, 
that of P. vivax in 48 hours, and that of Laverania malariae in 24 to 48 
hours, these three varieties constituting the quartan, tertian and aestivo- 
autumnal forms of the disease, the latter being the tropical and most 
dangerous type. Typically there is an intermittent afebrile period 
between each brood, but in aestivoautumnal fevers this period, at best 
but short, may be merely indicated by a remittance if, indeed, a most 
irregular or continued fever be not seen. Craig believes in two varieties 
of aestivoautumnal parasites, one the subtertian the other the quotidian. 
As the immune bodies of the system develop, which may eventually 
bring about a cessation of symptoms, gametocytes or sexual forms 
appear which, ingested by a fresh mosquito of the proper species, undergo 
development therein and give rise to infective sporozoites in about 2 
weeks. Sporulation is not ordinarily seen in the peripheral blood in 
infections by Laverania malariae but in the internal organs, especially 
the spleen, liver and bone marrow. Here in these filter-like organs, 
as well as in the brain, intestines, pancreas, etc., the parasited erythrocy- 
tes damaged by the toxin tend to stick to the walls of capillaries likewise 
affected and cause emboli (Castellani and Chalmers) which are produc- 
tive of serious and often fatal accidents. All forms are capable of pro- 
ducing "pernicious malarial fever," but especially L. malariae, 1 per cent, 
of aestivo-autuminal infections forming this type. Relapses occur, 
alleged to be caused by the return to asexual activity of gametocytes 
dormant in the blood and internal organs, especially the spleen (latent 684 
PARASITES AND OCCUPATION 
malaria). Anything tending to weaken the acquired relative immunity 
may precipitate an exacerbation, such as excesses, exposure to hot sun, 
fatigue, etc. Children are the chief reservoirs of gametocytes, and from 
the examination of their blood and spleen Sir Ronald Ross constructs with 
other factors his "endemic index." This latter author has shown that 
when the number of anopheles capable of transmitting malaria is reduced 
below a certain ratio malaria will not develop. The necessary factors for 
endemic malaria are (1) certain anopheles in an active state, (2) infected 
persons, and (3) individual susceptibility. 
Malaria is not found usually above 62 degrees north in the Eastern and 
45 degrees north in the Western Hemisphere. Men engaged in ditching 
in railway construction, soldiers, sailors in port and agricultural laborers 
in infected districts are very liable to contract malaria. This disease in 
all time has been the greatest obstacle to colonization of the tropics by the 
white race; it has transformed fertile, rich and populous regions into 
lonely wastes; it has rendered the development of valuable natural 
resources impossible and by decimating armies has defeated the highest 
hopes of nations in critical struggles. In the Canal Zone the French lost 
22,000 with an average working force of 10,000 laborers. In the same 
length of time with an average force of 33,000 we have lost but 4000. 
The sanitation of the Zone cost but about $3.50 per capita of population 
per annum or about 1 per cent, of the total expense of building the canal. 
To-day the Zone is as healthy as many northern cities. In Havana 
the mortality from malaria fell from 350 a year to 10, and yellow fever 
disappeared. In Rio de Janeiro there has been a fall in mortality from 
malaria from 2235 in 1891 to 176 in 1911, and from 4456 deaths from 
yellow fever in 1891, that disease disappeared completely in 1908. 
All of this is the result of the organized application of modern prophylaxis. 
Prophylaxis.-There are four essentials: (1) prevention of schizogony 
in man and the cure of all infected, (2) prevention of mosquito breeding, 
(3) protection of man from their bites, (4) education of the public. The 
first is accomplished by the use of quinine. The second may be divided 
into (a) removal of water in which mosquitoes breed, (6) rendering water 
unfit for breeding. Removal of water is best carried out by drainage, and 
tile drains are especially effective and the most economical in the long run. 
Where drainage or filling is impracticable water is best rendered unsuita- 
ble for breeding by covering it with oil. Larvicides of various kinds, 
Phinotas oil, etc., may also be used efficiently. One ounce of crude 
petroleum to 15 sq. ft. of water is recommended applied not less than once 
in 2 weeks, better once a week. To drainage must be added the removal 
of mosquito shelter (jungle growth, long grass, shrubbery, etc.) for 
mile from habitations. Mosquito brigades, or a corps of men whose 
business it is to prevent mosquito breeding in or near human dwellings 
by the prevention of water collection in little pools, in old cans, depres- 
sions, etc., is a valuable adjunct. Wire screens to windows and doors are MALARIA AMOEBIC DYSENTERY 
685 
of great value in excluding the mosquito, as are head nets, mosquito bars, 
etc. The mesh should not be less than 16 wires to the inch. The 
gametocyte population should be segregated and all sick of malaria 
isolated and screened. In the Canal Zone, General Gorgas depended on 
the destruction of the habitat of anopheles within 200 yds. of all dwellings, 
as well as of harbors for adults (shrubbery, long grass, etc.), screening, the 
use of crude oil in temporary pools and of Phinotas oil, or copper sulphate 
for grass and water containing algae. The supply of prophylactic quinine 
to those who will voluntarily take it is an important method employed, 
but he depends on draining (especially on tile under-drains) for permanent 
results. He considers per cent, morbidity an indication of an 
improper working of his system. For prophylaxis Koch's method of 
1-gram doses every eighth or ninth day and Celli's method of 0.4 daily 
are the most popular. 
Treatment of Malaria.-Half a gram of quinine every 3 hours until 
parasites disappear is sufficient. It should be followed by 0.60 a day 
for at least six weeks thereafter, in order to sterilize the patient. It 
should never be given in pill or tablet form, and is best administered in 
solution with yerba santa or chocolate syrup. The severe forms may 
require hypodermic injections of quinine three times a day in l^-gram 
doses, better intravenous injections of even larger doses well diluted 
in salt solution. Avoid administering quinine in the height of an attack 
if possible. Substitutes for quinine are unreliable. Warburg's tincture 
is of little value and arsenic of less, save for subsequent anaemia. 
Amebic Dysentery.-While frequently found in temperate zones, it is 
really an endemic of the tropics. It is due to a protozoon, Endamoeba 
dysenteriae, usually from 25 to 40 microns in diameter, with a clear 
hyaline refractive ectoplasm and a finally granular endoplasm containing 
vacuoles, a variable nucleus (best studied by staining with Mallory's iron 
hematoxylin of wet fixed smears in Schaudinn's sublimate alcohol), and, 
almost constantly, red blood corpuscles. Under certain conditions it 
becomes resistant with the formation of a cyst containing four nuclei, a 
characteristic which is responsible for the term "E. tetragena." A 
precystic small form is often seen. The parasite enters the submucous 
tissue of colon, lower ileum and rectum, undermining the mucosa and 
producing large irregular ulcers usually placed at right angles to the 
bowel. It all too frequently passes by way of radicles of the portal vein 
to the liver where it sets up single or multiple abscesses. The majority 
of infections are liable to be undiagnosed, even in the presence of serious 
lesions, owing to latency and, frequently, colorless symptomatology. 
Accustomed to view "dysentery" as a disease whose syndrome is marked 
griping and tenesmus with frequent, small, muco-sanguinolent stools, the 
physician is often unprepared in the absence of the acute stage, for an 
alternate looseness and constipation of the bowels without marked con- 
stitutional involvement. The practitioner who lacks time or experience 686 
PARASITES AND OCCUPATION 
for the comparatively simple distinction between endamceba coli, a harm- 
less commensal and E. dysenterise, should refer the examination of the 
stool to a competent protozoologist. 
Treatment of Dysentery.-Lately the old "Brazilian method" of 
treating dysentery by ipecac has taken the form of administering emetine 
hydrochloride. Following the usual treatment, absolute rest, liquid 
diet, preliminary emptying of the bowel by salts or oil, and morphine, 
grain of emetine hydrochloride is administered hypodermically three 
times a day for 2 or 4 days. It has been objected that the Endamcebse 
do not always disappear under this treatment, but the writer can testify to 
almost uniformly favorable clinical results. James counsels the use of 9 
to 12 grains in as short a time as possible, compatible with individual toler- 
ance, to forestall relapses. A daily dose of from 2 to 4^ grains can be 
reached in 3 days. While this drug is capable of causing the disappear- 
ance of acute symptoms and James has reported degenerative changes in 
the Endamoebse following its use, it does not actually sterilize as it has 
little effect upon the cysts. Emetine-bismuth-iodide has been found to 
be more efficient in sterilizing the patient than emetine hydrochloride, but 
it seems to provoke vomiting in some cases. In addition to the lack 
of complete success in the use of emetine hydrochloride hypodermically, 
it seems to have produced toxicologic effects according to some observers 
if its use is continued over a considerable period. This treatment should 
be followed by a heaping teaspoonful of bismuth subnitrate every 3 hours, 
which usually causes prompt disappearance of the parasite, and is supposed 
to deprive it of certain substances necessary for its nutrition by combin- 
ing with sulphur in the intestinal canal. The prophylaxis consists in the 
avoidance of contaminated drinking water, raw vegetables and fruits. 
Sight should not be lost of the fact that certain authorities believe that 
it is in part if not wholly a contact infection. 
NEMATODES* 
Uncinariasis.f-This is an infectious disease caused by the presence in 
the small intestine of man of a sufficient number of adult nematodes of 
the sub-family Uncinariinae, species Anchylostoma duodenale and Neca- 
tor Americanus, to overcome his relative racial or individual resistance. 
The worm, from to % in. long and of the thickness of a pin sinks its 
buccal armature into the intestinal mucosa causing solution of continuity 
for the admission of bacteria and at times local hemorrhage, feeds upon 
the epithelium and produces a hypothetic toxic substance probably respon- 
sible for many clinical features of the disease. The ova do not hatch 
in the body of the host but, passed with the feces upon a damp soil, at a 
favorable temperature evolve into ensheathed larvae which infect a new 
host by penetration of the sound skin, usually of bare feet, causing 
"ground-itch." From this point they migrate to their site of election 
in the jejunum. The infective larvae are at first found upon the soil in 
* Worms with more or less pointed ends, 
t Hookworm infection. AMOEBIC DYSENTERY-HOOKWORM INFECTION 
687 
little nests, larger than, but corresponding to, the site polluted by ova- 
bearing feces. Cort has recently proven that these infective larvae die 
a natural death in even propitious soils in about two months. In 
endemic areas of the tropics and subtropics there is perennial infection 
Fig. 24.-A sagittal section of Necator Americanus attached to the intestinal mucosa. 
Microphotographs made by the late Dr. W. M. Gray, U. S. Medical School, of sections 
belonging to Colonel B. K. Ashford, member of the late Porto Rico Anaemia Commission. 
of agricultural laborers. In temperature zones, in mines and tunnels, 
and in the summer throughout farming districts, intensity of infection 
is only measured by the amount of surface pollution by ova-containing 
feces. Shaded, moist soil in warm weather and density of population 
in a barefooted people who directly pollute the surroundings of their 688 
PARASITES AND OCCUPATION 
Fig. 25.-Stages of development of ovum of Necator Americanus. Microphotographs 
by Dr. Wm. Gray, Army Medical School, of sections belonging to Colonel B. K. Ashford, 
member of the late Porto Rico Anaemia Commission. HOOKWORM INFECTION 
689 
homes and their place of work are the determining factors in producing 
severe endemics, given introduction of carriers. When larvae nests are 
few and far between, and ova deposited by carriers are scarce, a low 
endemic index may be reached capable only of producing carriers and 
even these quite accidentally. Regions thus lightly infected may become 
dangerous foci if their density of population is considerably increased 
by an unsanitary laboring class. Shoes are not always an efficient pro- 
Fig. 26.-Photograph of a patient of the Institute of Tropical Medicine and Hygiene 
of Porto Rico suffering from uncinariasis intense grade; hemoglobin 14 per cent., erythro- 
cytes 751,000, leucocytes 17,000, case of several years standing. Photograph furnished 
by Colonel Bailey K. Ashford. 
tection, as they are often flooded by muddy water. Light infections 
produce few or no symptoms, at best debility and disinclination for work, 
with a little dyspepsia and faint pallor, although such cases slowly but 
surely reduce the efficiency for labor. From such light cases we may 
proceed, as subsequent reinfections are superadded, to the very gravest 
forms of anemia, accompanied by an effacement of character and energy 
and retarded mental reaction quite peculiar to the disease. 690 
PARASITES AND OCCUPATION 
Treatment.-Until recently the best treatment has been, and by 
many still is, considered to be the weekly administration of thymol, 
based on an adult dosage of 4 grams, in capsules, 2 grams at 8 and 2 
at 10 A.M. on an empty stomach, preceded the night before by a light 
supper and a purge and followed at noon by a purgative dose of 
sodium sulphate. After three such doses the patient may feel reason- 
ably sure of a cure of his disease as he will have usually expelled over 
nine-tenths of his parasites, but persistent thymolizing may be required 
to rid him of all. The use of thymol has been supplanted of late 
among certain authorities by the oil of chenopodium which removes 
about 99 per cent, of the worms by two treatments, a week apart, of 1.5 
cc. in gelatin capsules, 0.5 cc. every hour, until three doses are taken. 
It is at times fatally toxic and a large dose of salts should follow in two 
hours. Necator Americanus will not be ordinarily expelled by filix 
mas, the preferred anthelmintic in Europe. Betanaphthol in 2-gram 
doses may be administered as recommended for thymol. 
Prophylaxis.-Uncinariasis is to-day one of the most serious obstacles 
to agricultural labor in the world's tropical and subtropical belt. Indeed, 
much of the "chronic malaria" of our South is uncinariasis. It has 
threatened the completion of tunnels and terminated mining operations; 
it has empoverished not only agricultural laborers but their employers; 
it has laid a benumbing hand on the growing country youth and, at 
times, it has been largely responsible for the poverty, ignorance and invalid- 
ism of a full four-fifths of the working classes of an entire country. The 
control of uncinariasis depends first on education in individual hygiene, 
second on the treatment of worm-sick, and third and least efficacious, on 
sanitary law. The first two are best served by the free rural dispensary. 
As the Porto Rico campaign was the first of its kind and has served as 
a basis, at least in part for subsequent ones in other countries, including 
our own, we will refer to its results. The hemoglobin percentage of 
579 country people averaged 43.09 before treatment in 1904. In 1913 
after the treatment of about one-half the island population of a million, 
the examination of 579 of the same type of people rendered an average of 
72.22 per cent, hemoglobin. As the hemoglobin percentage is roughly 
equivalent to percentage of efficiency for labor, it can be truthfully said 
that treatment and education alone have raised the laboring efficiency 
of the working class by nearly 68 per cent. By far the greatest effect 
has been from treatment, for although shoes are more generally worn, 
privies are still scarce enough. The sanitary privy is the finality toward 
which all work should tend and there will always be a hookworm problem 
until the privy problem is solved. 
Filariasis.-The term usually signifies a condition accompanying the 
presence in the lymphatic system of man of a hair-like nematode worm, 
Filaria Bancrofti, whose embryos or microfilarise appear in the blood. 
These cylindrical and ensheathed embryos, with blunt anterior and sharp HOOKWORM PROPHYLAXIS-THREADWORM INFECTION 
691 
posterior extremities, are 7 to 8 microns in diameter and 300 microns long, 
moving in graceful curves among the erythrocytes. Normally herding in 
the profoundest depths of the circulatory system by day, they invade the 
peripheral vessels by night, probably to better gain their intermediate 
host, certain species of Culex and Anopheles mosquitos. In the stomach 
of this insect their sheath is hemolyzed and, penetrating its wall, they 
develop in the muscles of its thorax, finally reaching labium and palps. 
When the mosquito thrusts its probosis into man, they escape by rupture 
of the distended tissue in which they are confined and enter the skin 
through the puncture as well as the unbroken surface in its vicinity. 
The parasite is generally distributed throughout certain districts of inter- 
tropical regions with a decided preference for hot lowlands. The typical 
lesion is a varix of lymphatics set in fatty tissue, and the seat of recurrent 
lymphangitis. Frequently localized in the vicinity of the external 
genitals the extreme may be reached by the formation of a huge varix 
involving the glands and tributary vessels of the abdominal and pelvic 
lymphatics. To Manson's theory of mechanical obstruction of lymph 
channels by adults, embryos and immature ova should be added a 
lymphangitis by the repeatedly awakened virulence of some banal 
organism. 
Clinically we recognize: (1) Endemic lymphangitis with red, tender 
lines in the course of certain lymphatics, inflammation of the receiving 
glands, severe pain and a sharp constitutional febrile reaction. Bubonic 
plague may at times be simulated and death occur. Of serious prognosis 
is intra-abdominal or intrathoracic abscess, an unusual complication. (2) 
Lymphatic tumors. Adenolymphocele, generally at the base of Scarpa's 
triangle, has the feel of a mass of soft rubber tubes and may be confused 
with hernia, lymphadenoma and lipoma. Pedunculated inguino-scrotal 
lymphangioma has only a superior pedicle and exactly simulates hernia; 
when inflamed, a strangulated hernia. (3) Lymphatic varicocele and 
testicular lesions. Acute filarial, often misnamed "malarial" orchitis, 
often causes, as do inflamed lymphatic varicocele and adenolymphocele, 
pseudorenal colic, a pitfall for the unwary tropical practitioner. Lymph 
scrotum, a cutaneous and subcutaneous infiltration is generally accom- 
panied by hydrocele, often with thickened cartilaginous-like tunica 
vaginalis and a permanently damaged testicle and epididymis. (4) 
Lymphorrhagias. Chyluria is the emission of milky, greasy urine, and 
hematochyluria the passage of chylous urine mixed with blood. The 
pathologic basis for this phenomenon is the dilatation of the lumbo- 
sacral lymphatics with back flow into the lymph vessels of kidney, ureter 
and bladder. The attacks are usually irregular and embryos are apt to 
be found only in the first emissions of chylous urine. Lymphorrhagia 
externa is best seen on pricking a bulla of a lymph scrotum which allows 
the gradual filtration of quantities of lymph. (5) Elephantiasis. The skin 
is typically rough, tough, hard, covered with tubercles and often greasy. 692 
PARASITES AND OCCUPATION 
On section it is either like bacon rind, below which lies a yellowish gelatin- 
ous substance filling the connective-tissue spaces, or more fibrous, creak- 
ing under the knife. Such elephantoid tissue in marked cases hangs in 
huge folds and resembles elephant hide. This is the final result of a 
chronic filarial lymphangitis, often aggravated by acute attacks. The 
parts usually affected are the leg, foot and scrotum, but penis, labia 
majora, breasts, forearms and hands are not exempt. Some of these 
skin tumors are enormous, causing great deformity and even preventing 
locomotion. 
Treatment.-There is no specific. Salvarsan, atoxyl and other arsenic 
preparations are useless. Filarial lymphangitis with its dependent end- 
products is best treated by removal to a northern climate. When acute, 
ice locally with complete rest in bed and appropriate symptomatic medi- 
cation is all that can be recommended. Ichthyol locally seems to be of 
value. Extreme caution is necessary in dealing surgically with lymphatic 
tumors. They are most apt to become septic and are usually only a part 
of an extensive and hidden mass in the pelvis. Castration for filarial 
orchitis is usually unjustifiable. Elephantiasis is best treated by eleva- 
tion, compression, a daily course of 30 to 90 hypodermic injections of 
2 cc. of a 10 per cent, solution of fibrolysin and perhaps, if needed there- 
after, the excision of skin strips. In the scrotum, vulva, etc., extensive 
removal and adjusting of healthy skin flaps is the best procedure. The 
prophylaxis is as for malaria. 
Trichinosis.-Due to Trichinella spiralis, a nematode which passes its 
entire life cycle in man, rat and hog. The parasite is ubiquitous, but 
especially common among sausage makers. The larvae encysted in the 
muscles, when the flesh is ingested, become mature worms whose embryos 
penetrate the intestinal wall and again reach the muscles. The chief 
reservoir of Trichinella spiralis is the rat, which feeds on its kind and on 
scraps of infected hog flesh and on infected feces. Severe infections cause 
in man two stages of the disease; first a gastro-intestinal, and second 
a constitutional, with intense muscular pains, oedema, a sharp febrile 
reaction and eosinophilic leucocytosis. 
Treatment.-Smart purging in the first stage or santonin and calomel. 
The treatment of the second stage is symptomatic. 
Prophylaxis.-Meat inspection is impracticable as an efficient pro- 
phylactic measure. The larvae die after cooking at a temperature over 
160°F. or long-continued pickling. This is another argument besides 
plague for a rat warfare, especially in slaughter-houses, meat shops and 
the vicinity of hog pens. Hogs should not be fed on waste from slaughter- 
houses, and should be kept away from privies. 
Ascaris Lumbricoides.*-A white or rose-colored cylindrical worm, 15 
to 30 cm. long with a diameter of from 4 to 8 mm. The anterior extremity 
is blunt; the posterior pointed. The sexes are separate and the ova are 
ellipsoid, 50 to 75, by 40 to 50 microns, brown or amber-colored with two 
*The common round worm. TRICHINOSIS ROUND WORMS-OTHER WORMS 
693 
envelopes, the internal smooth and resistant, the external mammillated 
and easily detached. Habitat, small intestine of man. It is ubiquitous. 
Recent studies seem to point toward a peregrination of the embryo through 
the human body to its maturity in the intestine not unlike that of Ancylo- 
stoma duodenalis, the only great difference being that unlike Ancylostoma 
the cycle is complete within the same host. The experimental work 
done was on the hog but the application to human infections is self- 
evident. While not mentioned in connection with occupations in the 
temperate zones, in the tropics it is exceedingly common among agri- 
cultural laborers from the use of fruits and raw vegetables. The recent 
investigation of the Institute of Tropical Medicine of Porto Rico, 1913, 
shows it to be the prevailing intestinal parasite of the coffee laborers, 
about 90 per cent, of 10,140 persons of all ages and both sexes being 
infected. As clinical studies of these cases were made, it is interesting to 
note that no uniformly bad effects can be attributed to the very heavy 
infections seen. At times gastro-intestinal disturbances were noted, even 
entero-colitis. The elaborate train of nervous symptoms usually described 
were as a rule conspicuous by their absence. There are at least two 
serious aspects to ascariasis; (1) the tendency to upward wandering, 
causing vomiting of worms, penetration into the gall ducts and even into 
the liver, perforation of the bowel, generally through a preexisting ulcer, 
etc.; and (2) intestinal obstruction. In a small number of cases, however, 
the worm undoubtedly acts as a local irritant even to the extreme of simu- 
lating appendicitis or gastro-entero-colitis, and of indirectly producing 
profound nervous disturbances, or a cachetic condition. 
Treatment.-We are accustomed to give 1 centigram of santonin for 
each year to 25 years of age, combined with an appropriate dose of calomel. 
This is administered at bedtime in two doses, 2 hours apart, after a day of 
fasting, and followed next morning by a dose of castor oil. Great caution 
is recommended in using this drug as dangerous, if not fatal, accidents 
occur in young children. Usually it is a safe remedy, but somewhat 
undependable. A far surer but perhaps more dangerous drug is oil of 
chenopodium which acts as a motor paralyzant of the worm. 
Other Nematodes.-Neither Trichiuris trichuria nor Strongyloides 
stercoralis seems ordinarily to be definite factors in the causation of 
disease. The Institute of Porto Rico finds the first a very common 
parasite in man. Said to cause colitis, marked anemia, and nervous 
symptoms, we have never been able to incriminate this worm. It is 
difficult to expel, but thymol is sometimes successful. Strongyloides 
stercoralis is less common in Porto Rico but not rare. It does not seem 
to cause diarrhea as reported by other authors. It is especially found 
in brickyard workers, miners, tunnel workers and barefooted agricultural 
laborers as its mode of infection is similar to that of uncinariasis. It is 
not the cause of "Cochin China diarrhea" which is simply sprue. The 
embryo, not the ovum, is what is usually found in the feces. 694 
PARASITES AND OCCUPATION 
Cestodes.*-Taenia saginata frequently, and T. solium much less com- 
monly are found in these who eat insufficiently cooked, or even raw beef 
or pork, such as butchers, cooks, and sausage makers. These parasites 
are ubiquitous, but are rare where meat inspection and a proper disposal 
of excrement are exacted. Among Porto Rican agricultural laborers, 
where meat is rarely consumed and always well cooked, our Institute of 
Tropical Medicine, in over 10,000 nematode infections studied in 1913, 
failed to find one case of teniasis. Taenia saginata, 4 to 18 meters long, is 
a white flat worm with an unarmed head and about 1000 hermaphroditic 
segments (proglottides) each containing a uterus with from 25 to 35 lateral 
branches. Taenia solium, 2 to 3 meters long, has a double row of hooks 
upon its rostellum and each proglottis contains a uterus with from 7 to 
10 lateral branches. The ova, ingested by cattle (T. saginata) and by 
hogs (T. solium), develop into embryos which finally encyst in their flesh, 
forming Cysticercus bovis and Cysticercus cellulosae respectively. The 
habitat of the mature worms is man's intestine which they never perforate 
and from which they rarely wander. There is little doubt but that a tape- 
worm infection may be, and frequently is, compatible with apparent health 
but in the feeble symptoms are more apt to arise, usually those of a gastro- 
intestinal dyspepsia often with boulimia and obscure nervous manifes- 
tations generally limited to nasal and anal pruritus, dry cough, vertigo 
and cardiac palpitation. Occasionally the cysticercus stages of T. 
solium is passed in the tissues of man, and as these cysts, 0.006 to 0.020 
mm. long, at times invade the eye and brain, the prognosis is extremely 
grave. Whatever tenifuge be selected the patient should (1) take the 
drug on an empty stomach, and (2) follow up the last dose within a half 
hour by a vigorous purge to expel the stunned worm. Three drugs are 
worthy of special mention: (1) pelletierin tannate, preeminently effective 
but dangerous, (2) male fern, given with calomel in ^-gram capsules of 
the etheral extract, two every 10 minutes to 6 or 8 grams, and, (3) thymol 
as recommended for uncinariasis. Where toxicity is feared pumpkin 
seed, kousso or the expressed juice of cocoanut meat may be employed. 
The prophylaxis consists in treatment of all infected, strict national and 
international meat inspection, and proper disposal of human feces. 
TREMATODESf 
Schistomiasis.-Caused by Schistosoma hematobium, whose terminal 
spined ova produces a serious inflammation of the urinary tract with 
bleeding papillamatous granulation tissue, chiefly of the bladder wall, 
notably among the Fellaheen of the lower Nile who work in the fields up 
to their knees in water; by S. japonicum, encountered in the far East and 
causing grave hepatic and intestinal lesions often leading to cachexia and 
death; and by S. mansoni, the parasite responsible for American Schisto- 
* Tapeworms. ■ 
f Flukes (leaf-shaped worms). TAPEWORMS-FLUKES 
695 
miasis. In the latter disease, common in the West Indies and South 
America the histo-pathology is similar to that caused by S.hematobium 
but the lesions are found in the colon and rectum. The ova are all 
lateral spined and contain a miracidium which, liberated in water, enters 
several species of a snail, Planorbis, where they metamorphose and finally 
become C er car ice which penetrate the healthy skin of man, thus achiev- 
ing infection. (Leiper). In the series of 10,140 cases of the Institute of 
Tropical Medicine of Porto Rico, 1913, over 200 were found to be infected, 
very few of whom showed definite symptoms save a suspicious epigastric 
pain. These patients all gave a history of having bathed in a river sus- 
pected of being contaminated. Heavier infections cause 11 Schistosoma 
dysentery," a proctitis roughly simulating chronic dysentery, but with 
a tendency to prolapse of the rectum. The prognosis is generally favor- 
able in light infections, but treatment is futile. The prophylaxis is 
generally complete if one avoids bathing or wading in infected streams 
and the ingestion of unboiled water or contaminated fruits and vegetables SECTION 4 
OIL FOLLICULITIS, DERMATITIS AND FURUNCULOSIS 
One of the most frequent occupational afflictions recorded officially 
to bureaus of registration is the matter of dermatic infections among 
metal workers exposed to oleaginous, or saponaceous liquids, or "refrig- 
erants" used in the modern methods of cutting metals. The common 
terms for these substances are cutting compounds and cutting oils. 
These may consist of lard oil, mineral oil, fat oil, fatty acids, and soaps 
mixed with varying proportions of water to form emulsions, sometimes 
with the addition of small amounts of sal soda. Whatever mixture is 
used is usually piped to the various lathes, screw machines, etc. from a 
central reservoir. It pours over the metal at the point of operation, runs 
into a drain beneath the machine and is finally returned to the central 
reservoir. The compound acts as a cooling agent and also facilitates in 
the cutting of the metal.1 Also to prevent rusting. 
These infections are more prevalent in summer time. They are commonly known 
as "machinists' boils." However, infection is not always present, at least at first, 
as the writer found vesicles and ulcers only, in a large number of cases in a 
Columbus plant where tri-sodium phosphate dissolved in water was the sole com- 
pound used. 
Page and Bushnell,2 in a historical review of the subject, point out 
that the condition was first described as bouton d'huile by Purdon in 
Belfast, in 1867, and by Leloir in Belgium, in 1889, when it occurred with 
the use of oils on spinning machines. 
It has been emphasized from the first that the irritant action of the oil 
upon the skin is a prime factor. In the Annual Report of the Chief 
Inspector of Factories and Workshops of Great Britain, for 1910, Dr. 
Collis says: 
"Occupational dermatitis is known to be caused by a variety of materials, but one 
group, containing such different substances as olive oil, light mineral oil, turpentine, 
olein emulsions (soapy water), caustic alkalis and phenol derivatives, appear to have 
one property in common, viz., that of dissolving or paralyzing the secretion of the 
sebaceous glands, so leaving the cuticle dry and liable to crack when the microbic 
infection occurs and gives rise to the inflammatory condition known as dermatitis. 
This condition occurs on the exposed forearms and the back of the hands, but not on 
the palms of the hands, the cuticle of which has no sebaceous glands." 
The British Health of Munition Workers' Committee3 came to the conclusion 
that the occurrence of pustules and boils is probably due to sebaceous glands and 
hair follicles becoming blocked and infected with oily grime rubbed in by soiled 
overalls. 
In 1911 the National Acme Manufacturing Company,4 of Cleveland, Ohio, had an 
extensive outbreak of furunculosis among its employes. One thousand gallons of lard 
oil was used per month in the various cutting processes, and 50 per cent, of the 
EMERY R. HAYHURST, M. D„ Columbus, Ohio 
696 OIL FOLLICULITIS, DERMATITIS AND FURUNCULOSIS 
697 
employes had their hands and forearms constantly smeared with oil while working. 
This company was among the first in America to discover means of controlling the pus 
infections which followed. The oil was conveyed from the different departments to 
several large centrifuges on an upper floor. Here the solid materials such as cuttings, 
etc. were separated out by centrifuges; the oil then flowed by gravity to settling 
tanks where more sediment deposited; next it passed to sterilizing tanks connected in 
multiple and containing steam coils. From these it passed into storage tanks or 
directly to machines for use. In 1913 (two years later), the State's investigator, Dr. 
Ernest H. Cox, reported that a careful inspection of at least 400 men failed to show 
any evidence of furunculosis. 
In 1917 Shie5 made a special study of this condition in a Cleveland plant employing 
2000 men, where the trouble was found to be localized among lathe workers 
in the machine shops, about 35 per cent, of whom were afflicted. Pyogenic organisms 
were present in vast numbers in the cutting mixture and less numerous in the oil. 
Abundant portals of entry for these organisms were found on the arms of working 
men in innumerable small cuts and punctures made by flying chips of steel from 
the lathes. Shie passed an electric magnet over many arms apparently free from 
steel and the magnet came away covered with fine steel hairs and splinters pulled out 
of the skin, leaving almost microscopic puncture wounds. He recommended chemical 
disinfection (cresols), which caused a reduction from a general average of 5 per cent, 
to less than .05 per cent, in the incidence of affliction. 
In 1918 Albaugh6 and I made a special study of this subject in connection with a 
large metal products plant in Columbus and found that cutting compounds and oils 
are vehicles or carriers for pus-forming bacteria (staphylococcus pyogenes aureus') and 
are responsible for spreading the wound infections from worker to worker. The 
oils and compounds themselves are inert to bacterial life, being neither germicidal, 
antiseptic nor directly 'supportive. The oils and compounds as purchased from 
manufacturers are usually sterile but manifold opportunities for infecting them occur 
in their use (spitting into the reservoirs or into the flowing oil, the common use of the 
oil or compound, the frequency of workers with pus-infected lesions, use of wiping rags, 
etc.) and we came to the conclusion from our investigations that chemical disinfectants 
were not practical (lack of effectiveness in oil emulsions; the disinfectants must be so 
strong as to be irritating in themselves; and the objectionable odors associated with the 
cresols and pine oils and other coal tar disinfectants so far recommended) and recom- 
mended heat sterilization, which had been found to be quite successful at the National 
Acme plant in Cleveland. 
In more recent bacteriological studies, Page and Bushnell2 state that certain 
bacteria (colon type) seem to be able to retain their vitality in oil for long periods of 
time. A laboratory sample after 8 months "still contains as many bacteria as when 
it was received. One interesting point is that while there were typical fecal types 
of bacteria present in the oil, yet no spore-forming types or staphylococci could be 
isolated.'' Oil taken directly from a supply barrel, however, failed to show any 
pyogenic organisms. They cite Kurpjuweit who (1902) studied the length of time 
bacteria could retain their vitality in olive oil and found as follows: 
Staphylococcus aureus not obtained after 12 days. 
Bacillus coli not obtained after 14 days. 
Bacillus pyocyaneus not obtained after 14 days. 
Micrococcus ureae not obtained after 11 days. 
Bacillus diphtherice not obtained after 9 days. 
Bacillus typhosus not obtained after 14 days. 
Deeds,7of the U. S. Public Health Service made a special investigation 
of the subject at a Chicago plant for the Working Conditions Service and 
added to the points already recorded the following features: 698 
OIL FOLLICULITIS, DERMATITIS AND FURUNCULOSIS 
1. The chemical composition of the grease may have an irritant action on the skin 
of the workers exposed to it, particularly the unsaturated hydrocarbons in the 
higher distillates exert a dehydrating action upon the skin and tend to dissolve out the 
natural fats and oils, leading to a dryness of the skin, with possible subsequent crack- 
ing, and possibility of instigation of incipient dermatitis. 
2. It is evident that the grease may be contaminated with pus-producing organ- 
isms directly from normal hands. 
3. The washing or cleansing of the hands in a common supply of paraffin oil is 
dangerous and each worker should have his own individual supply, which may be 
kept in a small bottle for his own use. 
Bettmann8 describes four types of lesions due to the injurious effects 
on the skin of oils and vaselines used in the industries, which effects he 
believes are due to the presence of irritating tar products. His types 
and differential diagnoses are as follows: 
1. A sluggish, often itching folliculitis (differential diagnosis: tuberculosis). 
2. Follicular keratosis (differential diagnosis: pityriasis rubra pilaris, psoriasis, 
Darier's disease). 
3. Melanoderma of exposed skin surfaces (differential diagnosis: Addison's dis- 
ease, arsenic melanosis, pigmentation after lichen ruber planus). 
4. Circumscribed, warty areas (differential diagnosis: lupus erythematosus). 
Not infrequently two or more of these types are seen in the same patient and 
this aids materially in the differential diagnosis. Predisposing factors are previous 
skin disease, exposure to heat and light, etc. The conditions are chronic and very 
resistant to treatment. 
In 1920 the research staff of E. F. Houghton & Company,9 Philadel- 
phia, manufacturers of oils and leathers, made an extensive investigation 
and added several items of evidence: 
1. That the dermatological phenomenon never occurs on the skin of a Negro, 
while those whose skins are dark and swarthy are claimed to have a similar immunity. 
Hairy skins are most prone. 
2. That the irritant substances in the oils consist of organically combined hydro- 
carbon-sulphuric acid or alkaline sulphinates. 
3. There are at least four types of the infection which involves especially the 
extensor surface of the arms and perhaps the backs of the hands and the skin between 
the fingers: (a) A leathery condition of the skin, showing "black heads" thickly 
dotted over its surface; (b) red blotches on the skin, varying in size from bu in. to 
a quarter-of-a-dollar, which blotches become elevated; (c) progression of the red 
blotches to pustules; and (d) the true furunculosis or boil stage usually exhibiting 
several lesions. 
4. That the affliction is common among the employes of oil refineries and is espe- 
cially associated with paraffins which have been treated with sulphuric acid which is 
afterwards presumably neutralized. The specific irritant, it is claimed, is contained 
in the paraffin waxes while the clear, refined oil pressed from the paraffin is non- 
irritating, provided the separation is good. 
5. Dr. J. F. Schamberg could find no irritating properties in rancid and offensive 
lard oil (before its use in the machines). 
6. That the practice among workers of wiping the used oil from their skin with 
rags scratches the particles across the epidermis, inflicting abrasions, and that, instead 
of rags, ablutions only should be resorted to for cleaning the skin and preferably with 
a mild germicidal soap. OIL FOLLICULITIS, ETC., PREVENTIVE MEASURES 
699 
McConnell,10 in a careful study of large plants in Chicago, Minne- 
apolis, and St. Paul in 1921-1922, found that among 2060 workers 27 
per cent, had a dermatitis characteristic of this type of work. 
He stresses deficiency of the natural oiliness of the skin, perhaps brought about 
by drying agents, free fatty acids and free sulphuric acid in the lubricants them- 
selves, as the basic cause of the beginning dermatosis to which the mechanical obstruc- 
tion of the sebaceous glands adds the second factor. Scratching and minute abrasions 
produced by particles of metal open the way for an invasion of the ever-present 
pyogenic organisms whose dissemination the cutting liquids help to bring about. 
Hence the final infection is added upon a pre-existing dermatosis and is really invoked 
by wounding agents. 
Prevention.-The Bulletin of the Department of Scientific and Indus- 
trial Research11 (London, 1918) deals with the prevention of skin diseases 
produced by lubricants. The skin lesions recognized are of two kinds: 
(a) plugging of the glands of the hair follicles, and (6) mechanical injury 
to the skin by metallic particles. The prevention consists in: 
(a) Cleanliness of the worker-liberal washing facilities, hot water, soap, scrubbing 
brushes, avoidance of rags and of washing hands in the cutting compounds, use of 
ether-soap, and dusting of the arms with equal parts of starch and zinc oxide powder 
before commencing work; (6) cleanness of the lubricant (along the usual lines of remov- 
ing metallic particles, etc.); (c) cleanness of the machines; (d) additions of disinfectants 
and antiseptics to the lubricants (not altogether satisfactory); (e) sterilization of lubri- 
cants by heat and (/) removal from machines and treatment of workers who have septic 
infections of the hands. 
McConnell10 says that prevention depends upon supervised cleanliness 
of both skin and clothing and (as Collis and Greenwood12 state) the 
application of lanolin and castor oil ointment (equal parts) applied 
to the skin after washing and just before going to work, both in the 
morning and at noon. At quitting time the worker cleans up with warm 
water and soap, but applies no further emollients unless actual abrasions 
are present, in which event proper dressings are applied. The lesions 
on the thighs are prevented by wearing aprons impenetrable to oils. We 
quote herewith the rules laid down by the National Safety Council in a 
circular.13 
TO PREVENT INFECTION 
Provide cuspidors for employes and prohibit spitting in cutting oil or compound, 
enforcing the rule by close supervision. 
Prohibit the use of the common towel and the common drinking cup. Provide 
waste and wiping rags for each employe's individual use. 
Provide convenient washing facilities with suitable soap or hand cleaner. Do not 
allow employes to wash in alkali water. 
Encourage employes to wear tight fitting sleeves covering the arm to the wrist 
to prevent minute burns from flying hot chips. 
Encourage the employes to change their oil or compound-soaked clothing at. 
least twice a week, and to bathe frequently. 700 
OIL FOLLICULITIS, DERMATITIS AND FURUNCULOSIS 
Filter reclaimed oils and cutting compounds to remove minute metal particles, 
then sterilize. 
Sterilize reclaimed oil or compound by heating it to 140°F. and maintaining that 
temperature for from 20 to 30 minutes before using again. If practicable, sterilize 
the oil or compound in a common reservoir or in the reservoir of each machine by 
passing hot steam through it for a few minutes two or three times a day. The steam 
may be introduced by running a small steam pipe into the reservoir or by using a 
steam hose. 
If these measures do not suffice, employes subject to chapped skin, or susceptible 
to skin irritation, should not be allowed to operate machines using cutting oil or 
compound, and, if already employed, should be transferred to work on other machines. 
The same policy should be followed with employes who have minor injuries, such as 
cuts and scratches, or who have bandaged arms or hands. 
The use of chemical disinfectants has not been found to be satisfactory because if 
used in quantities sufficient to be effective they have an objectionable odor, interfere 
with lubricating properties of oil or compound, corrode metal, or irritate the skin. 
Purchase only sterile oils and compounds. 
Unquestionably, several factors are to be considered: (1) Irritants 
which occur in the oils so that the purchase of non-irritating oils is to be 
thought of; (2) keeping the oils and compounds while in use as free from 
foreign particles as possible by centrifuging, sedimentation, filtration 
and sterilization; (3) by cautioning workers against polluting them by 
spitting in them and working with discharging sores; (4) the testing of 
newly purchased material for bacterial contamination,, particularly the 
staphylococcus aureus. 
The National Safety Council (168 N. Michigan Avenue, Chicago) has 
prepared a "Safe Practices" Bulletin (No. 44), on the subject of "The 
Prevention of Skin Troubles from Cutting Oils and Emulsions," which, 
in addition to being fully illustrated, discusses in code form all the princi- 
ple features in connection with this subject. 
REFERENCES 
1 Yates, Anna B.-Memorandum No. 1, Special Investigation, Woman's Branch, 
Industrial Service Section, Chicago District Ordinance Office, Nov. 14, 1918. 
2 Page, Calvin G. and Bushnell, L. D.-Jr. Ind. Hyg., Ill, No. 2, June, 1921, 62-75. 
3 British Health of Munition Workers' Committee, Memorandum No. 8, 1916. 
4 Ohio Survey of Industrial Health Hazards and Occupational Diseases, State Board 
of Health, 1915, 98. 
3 Shie, Marvin D.-J. A. M. A., LXIX, No. 23, Dec. 8, 1917, 1927-1930. 
6 Albaugh, R. P.-Ohio Public Health Journal, IX, No. 4, April, 1918. 
7 Deeds, F. E.-Working Conditions Service, U. S. Dept. Labor, 1919. 
8 Bettmann.-M. m. W., 1918, 1344; abstracted by Therap. Monatschr., XXXIII, 
No. 3, March, 1919, 117; abstracted by Jr. Ind. Hyg., Dec., 1919, 129. 
9 Houghton, E. F. & Co.--Research Staff, Private Publication, Philadelphia, 1920. 
10 McConnell, Wm. J.-U. S. Public Health Reports, XXXVII, No. 39, July 21, 1922, 
1773-1794. 
11 Dept, of Sc. and Ind. Research.-Bull. No. 2, Part II, London, 1918. This is 
quoted in full in the Jr. Ind. Hyg., I, No. 11, March, 1920, abstr. 174-175. 
12 Collis and Greenwood.-"Health of the Industrial Worker," P. Blakiston's Son 
& Co., 1921, 396. 
13 National Safety Council (Chicago).-Executive Series No. 726, 1921. CHAPTER III 
OCCUPATIONAL DISEASES DUE TO DUST. TUBERCULOSIS 
SECTION 1 
DUST DISEASES OF THE LUNGS 
SIR THOMAS OLIVER, M. D., Newcastle-upon-Tyne, England 
Historical.-That pulmonary disease develops with greater frequency 
in persons following certain occupations compared with others has long 
been known. The circumstance did not escape the attention of Ramaz- 
zini 200 years ago. A century ago physicians in Great Britain were more 
familiar with the phthisis of coal miners than is the present generation. 
Colliers became the subjects of cough, they emaciated, they expectorated 
large quantities of an inky black material, and after death the lungs were 
found to be absolutely black and cavitated. Our knowledge of the dis- 
ease goes back to 1815 when Pearson presented a paper to the Royal 
Society of London upon the subject. In 1831 Gregory and Christesin 
of Edinburgh extracted from the lungs of coal miners dying from phthisis 
black material which they found to be carbon. The dark color of miners' 
lungs had been regarded by Laennec as the result of smoke from the 
lamps, but by Behier in 1837 and Rilliet in 1838 it was attributed to 
particles of carbon. Belgian colliery doctors, among whom Gobert of 
Hainaut (1827) and Kuborn of Liege (1861) may be mentioned, were 
familiar with the asthma of miners and its accompanying black spit. 
Another explanation of the discolored lungs of miners was offered by 
Virchow. The pigmentation arose according to him from a transforma- 
tion of the hematine of extravasated blood. It is needless to say that 
Virchow's theory has few exponents. 
COAL MINERS 
The malady is known as anthracosis or coal miners' phthisis. Miners 
working in certain coal fields are more affected than others, a circumstance 
which suggests that the physical character of the coal plays an important 
part in the development of the illness, some kinds of coal being harder 
than others. From a historical point of view the opening out of the South 
Wales coal fields is a modern development compared with those of 
Northumberland, but owing to the smokeless character of the coal and its 
suitability for steamship purposes the industry received an impetus half 
a century ago which has not yet begun to decline. When Sir John 
701 702 
DUST DISEASES OF THE LUNGS 
Simon wrote upon the subject nearly 50 years ago he was of the opinion 
that there was a larger amount of bronchial and respiratory disease among 
the Welsh miners than among the Northumberland, a circumstance which 
he attributed to the better ventilation of the mines in the North of Eng- 
land. To-day ventilation of coal mines in all the civilized world is good 
and as a consequence the health of coal miners is satisfactory. 
This is particularly so as regards tuberculosis. British coal miners do not exhibit 
a high mortality rate from this disease compared with men working in most other 
trades. Taking the tuberculosis mortality figures of all occupied males in England 
and Wales as 175, that of coal miners is only 85. In the United States the death rate 
from all causes among miners and quarrymen (the two occupations are linked together) 
is 120.9 per 100,000 living, for lawyers 139.9, for physicians and . surgeons 168.8, for 
carpenters and joiners 231.0, and for marble and stone cutters 540.5. According to 
the same census, pulmonary consumption caused 10.6 per cent, of deaths of all miners 
and quarrymen as against 16.2 for all occupied males. At Scranton,1 U. S. A., 
during 10 years, pulmonary tuberculosis caused 3.37 per cent, of all deaths and among 
"all other occupied males" 9.97 per cent. Of lung diseases alone tuberculosis caused 14 
per cent, of all deaths among anthracite miners in Scranton and 41 per cent, of deaths 
among "other occupied males." This comparative freedom of the coal miner from 
tuberculosis has raised the question as to whether some protective influence is not 
exercised by coal dust upon the lungs. From their experiments upon animals Wain- 
wright and Nichols were disposed to attribute a certain amount of protection to the 
lungs against tuberculosis. Nichols regards the calcium salts in coal dust as the 
protecting agent." 
While we admit that the comparatively good health and longevity of 
the coal miner are the result of the improved ventilation of recent years, 
there is just the possibility that excessive ventilation by overdrying the air 
of mines raises and carries onward very fine dust which may not only do 
damage to the lungs of those who inhale it but may also become a cause of 
explosion in the mine. If the work of a coal miner is hard, his hours are 
not long compared with other occupations and the atmosphere in which 
he works, if in the line of the intake air, is satisfactory. It is when men 
are working at the face, in confined places and away from the immediate 
delivery of air, that they are liable to be injured by dust. The more con- 
fined the space and the less readily the atmosphere can be cleared of fume 
and dust raised by the use of explosives to bring down the rock, the 
greater is the liability of the men to become the subjects of pulmonary 
disease. 
Definitions.-To the various forms of disease of the lungs caused by 
inhalation of dust the term pneumokoniosis was applied by Zenker-from 
the Greek word pneumon, lung, and konis, dust. Although the kind of 
dust inhaled directs the type of the pulmonary lesion, yet one pathological 
substratum underlies all forms of the disease, viz., fibrosis or a replace- 
ment of the elastic tissue of the lung by an unyielding fibro-connective 
tissue. The fibrosis imparts solidity to the lung and abridges its aerating 
function. To the black lung of the coal miner as already stated the COAL MINERS PATHOGENESIS OF LUNG DUST DISEASES 
703 
term anthracosis is applied, to the gray-black lung of the stone cutter 
chalicosis is given, to that of the gold miner silicosis, and to the lung of the 
worker in metal dust the term siderosis is applied. 
Pathogenesis.-The lungs of persons who live in large towns are 
always more deeply pigmented than those of persons living in the country, 
and on microscopical examination the cause of the pigmentation is 
invariably found to be particles of carbon or other kinds of dust. In 
a dusty atmosphere it is the finer particles which reach the lungs and 
damage them. The heavier particles are apt to be caught in the nares 
and upper portion of the respiratory tract and to be expelled in coughing. 
The ciliated epithelium of trachea and bronchi is a defensive barrier to the 
lungs, since dust caught in the mucus secreted by the tubes is by the wav- 
ing action of the ciliated epithelium wafted outward. Recurrent colds 
lead to a shedding of the ciliated epithelium and with this desquamation 
an important defense is lost to the lungs. This circumstance is not with- 
out importance since recurrent catarrh of the upper respiratory passages 
is a frequent prelude to pneumokoniosis. 
So far as coal miners' phthisis is concerned it may be stated that a 
collier who develops anthracosis may live for years and be little inconven- 
ienced by his malady. This applies only to the man who has worked in 
soft coal. It is otherwise if the coal has been of a hard, gritty and stone- 
like nature. Miners keep bringing up large quantities of black spit for 
years after they have ceased working in coal-a circumstance which shows 
not only that considerable deposits of carbon had taken place in the lungs, 
but that the lungs tend to rid themselves of the deposited carbon largely 
by means of the action of pulmonary phagocytes. It cannot be said of 
coal miners that they are an unhealthy class of men. Far from it; apart 
from the risks of mining their prospects of longevity are good. In a 
country like South Africa a comparison can be made between the harm- 
lessness of coal dust and the power for harm of the rock dust of the gold 
mines. Dr. F. I. Allen, who has been for several years Medical Officer 
to the leading Transvaal collieries, states that although anthracosis is com- 
mon among coal miners, it does not impair the health nor the working 
capacity of the men compared with the silicosis of the gold miner. This 
circumstance confirms what has already been stated, that the physical6 
character of the dust is an important factor in pneumokoniosis. The 
fibrosis present in the lungs of persons who have worked in a dusty 
atmosphere of itself suggests the question whether the fibrosis is the 
consequence of irritation induced by foreign particles inhaled, or whether 
the foreign particles seen in the lungs after death have not been caught 
and retained in the lungs owing to those organs having undergone a 
fibrotic change through the operation of some other cause than dust. 
For a comprehensive study of the relation of pulmonary fibrosis and 
dust Dr. Shufflebotham's Milroy Lectures will repay perusal.2 This 
subject is not less interesting than is that of penumokoniosis and such 704 
DUST DISEASES OF THE LUNGS 
microbic infection as tubercle to which we refer later. Dust of animal 
origin as wool, hair, and feathers induces catarrh of the respiratory- 
passages rather than structural changes in the lungs. 
Pathology.-In pneumokoniosis, so completely replaced is the sponge- 
like structure of the lungs by solid tissue, that it is difficult to understand 
how respiration is carried on even as well as it seems to be. In some 
occupations more than one kind of dust is present in the atmosphere. 
This is the case in the Sheffield steel grinders in whose lungs there may be 
particles of steel and also particles of stone from the grindstone. Masons 
who chisel fine sandstone are more prone to phthisis than men who chip 
and chisel granite where the particles of dust are heavier. It is owing 
to the larger and heavier size of the particles of dust that the compara- 
tive freedom of the Aberdeen granite worker from phthisis is attributed. 
A change apparently is creeping over this industry. Since the introduc- 
tion of pneumatic tools for cutting and smoothing the stone greater 
quantities of fine dust are raised, and as the work is carried on no longer 
in open sheds there has been recently more lung trouble among the granite 
workers.0 The lungs of men who work in oxide of iron are brownish red 
in color. The structural changes in the lungs in pneumokoniosis com- 
mence in the interstitial tissue; subsequently the pleura tends to become 
involved. Emphysema is also present and there are usually signs of a 
widespread bronchitis. 
The best types of pneumokoniosis are found in persons working in such 
dusty atmospheres as those of the Sheffield trades, ganister crushing, buhr- 
stone masonry, and the gold mines of South Africa and elsewhere. 
Since, practically speaking, the same morbid changes are present in all 
forms of pneumokoniosis, no matter the particular kind of dust which 
has caused the disease, it is unnecessary to describe in detail the various 
forms of pneumokoniosis. Although there is little difference in the patho- 
logical appearances presented by a lead miner's lung, a gold miner's lung 
and that of a Sheffield or other steel grinder, there is, setting aside individual 
idiosyncrasy, not perfect uniformity since in some forms of pneumokonio- 
sis there is during life a greater tendency to pulmonary hemorrhage than 
in others. 
OTHER DANGEROUS DUST INDUSTRIES 
Persons employed in dusty trades have a shorter life by a few years than those 
employed in occupations free from dust. It must not be forgotten that to this shorten- 
ing of life other circumstances than dust contribute. Buhrstone is one of the hardest 
stones known. It is used for making millstones for the grinding of cereals, coprolites, 
etc. It is not a large industry. I have visited the buhrstone yards on the Thames 
and at Fierte-sous-Jouarre in France. Few buhrstone workmen live beyond the age 
of 35-40. Most of them are intemperate in the use of alcohol. The men complain 
that, in the operation of chiselling, the dust gets into the back of the throat and creates 
an exasperating sense of dryness which stimulants remove. At Fierte-sous-Jouarre PATHOLOGY DANGEROUS DUST INDUSTRIES 
705 
I found men, comparatively young, who consumed a bottle of brandy daily in addition 
to a liter or more of red wine. The men who stood the work best and who exceeded 
50 years of age were abstainers. Alcohol made the men careless. 
Ganister disease is a form of silicosis due to inhalation of the dust of ganister, an 
exceedingly compact, close-grained and highly siliceous rock. It contains 95 per cent, 
of pure silica. Owing to the almost adamantine hardness of ganister the rock cannot 
be won by the ordinary methods of mining. It has to be blasted. The broken rock 
is placed in powerful grinding mills to be pulverized preparatory to being made into 
bricks which, since they are capable of resisting extremely high temperatures, are used 
for lining the interior of iron blast furnaces. The men who mine the ganister, those 
who grind it and those who make it into bricks all suffer, but in varying proportions, 
from pneumokoniosis. For every 1000 men employed Dr. Birmingham3 found that 
each year 
42.3 ganister miners die 
179.8 ganister grinders die 
22.2 ganister brickmakers die 
or 34.4 
per cent.;- 
179.8 deaths per 1000 ganister grinders is an appallingly high mortality rate. The 
invasion of the lungs by the dust is generally indicated by signs of bronchitis. As the 
disease advances the lung becomes the seat of well-marked fibrosis. Once symptoms 
reveal themselves the disease is found fully developed within 1 year. The miner 
becomes anaemic and enfeebled and his breathing quickened. There are dyspnoea on 
the slightest exertion and hacking cough. Few of the patients survive 2 or 3 years. 
Death is generally due to tuberculosis. 
According to Dr. Robertshaw, Medical Officer of Health, Stockbridge, the mortal- 
ity of ganister miners from pulmonary tuberculosis has fallen 15 per cent, in recent 
years, while the average age at death has risen from 37 to 45 years, owing to the com- 
pulsory use of steam jets in the grinding mills. 
According to Dr. Edgar L. Collis, English stone masons have a mortality rate 
three times greater than that of all occupied males; also while the average age at death 
used to be 37-38 it has in recent years risen to 43-44. Sandstone is more dangerous 
than limestone. The mortality rate of stone masons is not the same for every district. 
This Collis shows is largely due to the amount of silica present in different kinds of 
stone. The dangerous ingredient is silica. The pulmonary tuberculosis of stone 
masons comes on at a later period of life than in males generally, and is only slightly 
infective. A similar, absence of the infectiveness of tuberculosis in the Grinskill 
quarrymen is alluded to by Dr. Wheatley,4 Medical Officer of Health for Shropshire. 
He says that there is no excess of phthisis in the wives of men who are victims of the 
disease. The tuberculosis and pneumonia mortality rates of the granite and marble 
cutters of the United States of America have been the subject of careful inquiry by a 
Committee on the "Mortality from Tuberculosis in Dusty Trades" appointed by the 
National Tuberculosis Association,11 September, 1919. Taking the Granite industry of 
Vermont it is found that in the Barre District alone 89 plants are located. Here the 
mortality rate from tuberculosis is 121.8 per 100,000 of the population as against 81.4 
for the State as a whole but in some parts of Barre the mortality rates were even higher 
that those just given. The District of Barre City (Washington Co.) gave a death 
rate from pulmonary tuberculosis of 233.2 per 100,000 of the population contrasted 
with 90.6 the average for the State. It is difficult to set aside the probability that 
this high death rate from tuberculosis is directly connected with the stone industry 
which prevails there. It is interesting to contrast these mortality rates with those of 
marble producing districts. All the marble districts show a lower mortality rate 
from tuberculosis, and this remark applies equally to slate and talc producing 
areas. 706 
DUST DISEASES OF THE LUNGS 
Vermont 
Mortality from Tuberculosis of the Lungs by Districts. 1906-1915 
Deaths 
Death rate 
per 100,000 
Granite 
525 
143.0 
Slate •. 
90 
111.3 
Marble 
314 
97.1 
State, exclusive of above districts 
2301 
82.3 
Entire State 
3230 
90.6 
In the gold mines of the Rand the men who work rock drills driven by compressed 
air are short lived. Five to 6 years of work bowl most of the men over. Silicosis in 
rock drillers seldom develops until after 3 years' work, but once the disease originates, if 
the men continue to follow their employment, within another 2 years many of them die. 
The men who use the hand drill are less liable to be overcome by the dust than those who 
use drills driven by compressed air. The work is carried on at great depths. Several of 
the miners go down 3000 ft. and more. The work is fatiguing, the ventilation is bad, 
the temperature high and the noise is great. After a day's work in the mine the men 
when perspiring are rapidly transported by means of lifts to the surface where the 
temperature is several degrees colder than that in the mine. As bronchial catarrh 
thus induced is given little heed to by the miners, the way is prepared for any dust 
which is inhaled more readily to reach the lungs. In one sense the men themselves are 
partly responsible for the pulmonary disease. After firing explosives in the mine, 
when about 50 lb. of blasting powders are used each time, dislodging 12 to 15 tons of 
rock, the miners return too early to the place of work before the fumes have cleared 
away and the dust has had time to settle. The owners of the mines could do more 
than they have done to improve the ventilation of the South African gold mines. In 
some of the mines there is a total disregard of all hygienic measures. Unless greater 
attention is given to details of hygiene, personal and general, medical examinations of 
the men before undertaking the work avails, but little. 
Prevalence of Miners' Phthisis in South Africa.-Miners' Phthisis was not known in 
Witwatersrand until 1899 when men who had gone thither from Cornwall and North- 
umberland returned to England at the outbreak of the South African War. It was in 
1902, in the Lancet that I drew attention to "Gold Miners' Phthisis on the Rand" 
and shortly afterward Lord Milner appointed a Commission to enquire into the 
prevalence of the disease. In a lecture Dr. Watkins-Pitchford5 stated that in the 
opinion of the Transvaal Miners' Phthisis Commission of 1903 probably 21 per cent, of 
all underground miners were affected with silicosis. In 1912 the Second Commission 
after examining 3136 underground miners found 990 or 32 per cent, suffering from 
miners' phthisis in one or other of its stages, and of these about two-thirds of the cases 
were in the stage of early fibrosis. As the use of the rock drill is regarded as the 
main cause of the lung trouble it is to be noted that while in December, 1905, there 
were 1800 of these machines at work, in December, 1912, there was 5600. 
Since the gold mines of South Africa supply the best illustrations of pneumokoniosis 
and the largest number of victims of the malady, and since it is from the men who have 
worked in these mines and have returned in ill health to Great Britain that my own 
experience has been drawn, I may be pardoned if a further slight digression is made 
into the mining and other conditions which prevail in the Transvaal. 
White men, also Kaffirs, called "boys," are employed. On the Witwatersrand the 
average number of white miners working underground in 1912 was 11,607; in that MINERS' PHTHISIS PNEUMOKONIOSIS 
707 
year 161 white miners died from silicosis. Notwithstanding the fact that many 
invalided miners came home to the North of Eglannd, Cornwall and elsewhere the 
deaths from silicosis in the Transvaal were 13.8 per 1000 for the year. 
The number of natives working underground for 1912 was 149,782 out of an avail- 
able supply of 192,522; of these men 153 died from silicosis-a small number compared 
with the white men, but possibly explained by the fact that the natives do not remain 
long at work but return to their homes. 
When we consider that on an average there were, in 1912, 11,840 white miners 
working underground in the Rand and that at least 32 per cent, of these were affected 
with miners' phthisis it is safe to conclude that 3700 of these men became the victims 
of silicosis. 
Average Number of Persons at Work during 1918 Including Colored Convicts 
Gold Mines 
District 
Below ground 
Above ground 
Totals 
Whites 
Colored 
Whites 
Colored 
Whites 
Colored 
Witwatersrand 
10,996 
194 
134,329 
3,928 
10,066 
393 
36,644 
2,748 
21,061 
587 
170,973 
6,676 
Outside districts 
Transvaal 
11,190 
138,257 
10,459 
39,392 
21,649 
177,649 
The large number of persons employed in the gold mines of South Africa is of 
interest when reference is made to the estimated gold production of the world since 
1887, and the Transvaal percentage thereof. In 1887 the estimated gold production 
of the world was £21,735,000 and the Transvaal percentage 0.8; in 1897 the figures 
were £48,509,000 and 34 per cent.; during the South African war (1900-1901) the 
Transvaal percentage fell to 2.4 while in 1917 the figures were £87,040,000 and 44, and 
in 1918 the gold production of the world was £77,528,000 of which the Transvaal per- 
centage was 46.1. 
PNEUMOKONIOSIS IN GENERAL 
Etiology.-Inhalation of dust, hard and gritty, also sharply angular is 
the main cause of the disease. In the case of the coal miner it is not the 
carbon particles of the coal but the stony particles to which the carbon 
particles are affixed which injure the lung. The pneumokoniosis of the 
steel grinder is caused by inhalation of particles of steel and sandstone- 
mostly the latter; the lung disease of the Transvaal gold miner is the 
result of inhalation of quartzite, a siliceous sandstone which has become 
hardened and solidified by metamorphosis. Interbedded in the quartzite 
are shallow beds of conglomerate or "banket" composed of quartz 
pebbles and pellets of pyrites cemented into a solid mass by silica. 
The gold is found in a finely divided state in the material which binds the 
pebbles together. The main object of the gold-producing industry of the 
Rand is to mine the conglomerate, bring it to the surface, crush it to 708 
DUST DISEASES OF THE LUNGS 
powder and extract the gold by the amalgamative and cyanide of mercury 
process. "Silicosis is caused by the inhaling of the dust which arises 
when the conglomerate as well as the various rocks which have been 
mentioned are drilled, blasted, shovelled, and crushed." To secure the 
gold-bearing conglomerate the quartzite has to be broken. 
This is accomplished by drilling holes 4 to 8 ft. deep into the quartzite and placing 
in the bottom of the holes dynamite cartridges fitted with detonator and fuse. As 
hand drilling is a slow process the work is now almost entirely done by machine drills, 
of a percussive and not of a rotary type, driven by compressed air. In an 8-hour 
shift a rock-driller will bore through 22 to 50 ft. of solid rock, i.e., he will bore from 4 to 
8 holes. In order to lay the dust generated during the process of boring, the interior of 
the hole and the immediate surroundings are kept wet with water by spraying. By 
this means the dust which would otherwise be dangerous is converted into mud. 
Upwardly inclined holes are with difficulty kept wet. The rock drills used are 
principally the Ingersoll and the Leyner. It is advantageous to use a rock drill which 
automatically washes out the hole with water at the same time that it bores. The 
amount of mud thus formed is considerable. When dried this becomes a source of 
danger to the men. To obviate it the mines have to be kept as damp as possible. 
The moisture of the mine and the high temperature in which the men are working are 
not without influence in causing fatigue and in reducing the vital resistance of the 
workers. 
During blasting of the rock considerable quantities of fine dry dust are dissipated 
through the mine. Shovelling of the detached rock and its transference by wagon 
also contribute to the dustiness of the atmosphere. The fine particles of dust remain 
suspended in the air a long time; they are capable of passing through very fine sieves 
so that after the use of explosives it is absolutely essential that the miners should not 
return too early to that particular part of the mine in which they had been working. 
According to Mining Regulations half an hour's delay is considered to be long enough if 
the air is free from dust, smoke and fume as perceived by sight and smell, for miners 
to return to the working. Thirty minutes is hardly long enough for the fine dust to 
' settle. Somehow or other fine dust seems to take longer to settle in a mine than at the 
surface. Hitherto gold miners, as they are paid according to the number of feet 
driven by drilling, or sunk in development faces, have, in their haste to make large wages, 
disregarded many of the simple rules which make for health. The Transvaal Cham- 
ber of Mines recognizes that its first concern is to eliminate Miners' Phthisis as far as 
possible. Considerable progress has been made in this direction by the introduction 
of dust sampling of the air of mines. The two most important classes of underground 
work in which dust prevails are stoping and development and these are the classes where 
most men are employed. 
The introduction of means to reduce the dust in the mines so far has been satis- 
factory. When a comparison is made between the average of samples taken in stopes 
the following are the figures: 3.5 mgrms. in 1915, 2.7 in 1916, 2.9 in 1917, and 2.5 in 
1918. In development ends for the same periods, owing to the confined space and the 
difficulty of ventilation, the figures are 6.5, 5.8, 5.4 and 4.8/ 
Symptomatology.-Where miners are using the higher explosives in 
large quantity there is always the possibility of acute pulmonary trouble 
supervening owing to NO and NO2 products of incomplete combustion. 
In small quantity these may simply cause irritation of the respiratory 
tract, but in large quantity they may induce oedema of the lungs and 
cause death in twelve to twenty-four hours. We will not pursue further SYMPTOMATOLOGY OF PNEUMOKONIOSIS 
709 
the study of these acute maladies incidental to the use of the higher 
explosives. In nearly all the South African gold miners whom I have 
treated for pulmonary disease the malady has been in existence for 
several months. Once it is developed the disease may last 2 years or more.® 
There are cases on record of 11 acute pulmonary silicosis" where after a 
sharp attack of broncho-pneumonia the patient who had worked only a 
few months dies. After death the lungs are found to be congested, 
cedematous and irregularly pigmented without the naked-eye appearance 
of fibrosis. On microscopical examination of sections of the lungs by 
polarized light, in the connective tissue are seen myriads of siliceous 
particles. The pulmonary alveoli are filled with catarrhal cells and serous 
exudate. It is unusual for miners to die so early. The silicosis for which 
miners seek advice develops slowly, so insidiously in fact that it is difficult 
for the patient to assign a date to the onset of symptoms of which dry 
cough in the morning or on leaving the mine at the end of the day in one of 
the earliest symptoms. What appears to be a bronchial cold, with or 
without pleuritic pains, attended by a sense of increasing debility is an 
indication that the lung has become affected by mine dust. 
One feature stands out prominently throughout the whole course 
of gold miners' phthisis, viz., dyspnoea on the slightest exertion-a short- 
ness of breath far in excess of physical signs. The general appearance of 
the affected miner is frequently that of a man still in health. He may be 
slightly bronzed and looks weather-beaten, and yet the disease has 
probably already got a good grip of his lungs for on physical examination 
the chest is observed to expand feebly, there is a diminution of 1 in. or 
more in the ratio between inspiratory and expiratory measurements, also 
impairment of the percussion note at the base of the lung toward the 
axillary area with deficient respiratory murmur. S. V. Van Niekirk 
says that the right lung is more frequently affected than the left. The 
pulse is almost invariably quickened. In the later stages the respiratory 
murmur may become coarser, crepitation may be heard, also a cardio- 
respiratory murmur along the left border of the cardiac area. The expec- 
toration varies. In the early stages if there is little bronchial catarrh 
expectoration may be scanty, stringy and pearly white in character; 
in the later stages it may be mucopurulent, bluish black and rich in 
particles of silica. 
In the last stage of the disease tubercle bacilli are frequently present/ 
As the disease proceeds the tendency is for the expansive power of the 
chest still further to diminish in consequence of pleuritic adhesion and an 
increasing loss of elasticity of the lung due to extension of the fibrosis. 
Although gold miners' phthisis is of slow development, men have died 
suddenly from cardiac failure when at work in the mine. In only a few 
of the patients is hemoptysis a symptom. The thoracic organs are those 
which alone suffer. Those of the abdomen remain healthy; the urine is 
free from albumen. In chronic cases Van Niekirk found the red blood 710 
DUST DISEASES OF THE LUNGS 
corpuscles and haemoglobin increased as if nature had put forth a com- 
pensatory affect to overcome the disadvantages of the dyspnoea, also that 
when tuberculosis is grafted upon the pneumokoniosis the leucocytes are 
increased. In the hands of some medical men the application of the 
Rbntgen rays for illuminating the chest has been of service in showing the 
extent to which the lungs are infiltrated with dust. 
Prognosis.-The prognosis is good only in the early stages, provided 
the patient gives up work and takes to a life in the open.9 When tubercle 
bacilli have settled in the lung the patient goes rapidly downhill. Almost 
similar symptoms are observed in workers in other dusty trades. In 
some, bronchial symptoms predominate. Potters, for example, have 
been known to exhibit a high mortality rate from lung diseases. ' 'Potters' 
rot" or " asthma" was described by Arlidge and attributed by him to the 
inhalation of fine flint dust which is, practically speaking, pure silica. The 
symptoms are morning cough and shortness of breath with unimpaired 
general health; later the cough becomes paroxysmal and is attended by a 
degree of dyspnoea in excess of that observed in phthisis. Blood spitting 
is unusual. On physical examination of the chest there are patches of 
dulness detected at the bases and signs of emphysema in the front of the 
chest. Owing to the strain imposed upon the right side of the heart this 
organ dilates. The malady at first is non-tuberculous, but the fact I wish 
to impress is that later the lungs may become infected by Koch's bacillus. 
Metal grinders are especially exposed to the risk of pulmonary disease owing to 
the hard and angular form of the dust inhaled. Sanfield speaking of Sheffield steel 
grinders points out that they have a mortality rate from pulmonary phthisis three 
times greater than that of cutlers. The disease assumes the form of fibrosis and is 
attended by diminished expansion of the chest. In all of us as age advances the power 
of expansion of the chest diminishes. At the age period 45-49 years the normal indi- 
vidual expires 419 cc. of air less than he did at the age period 20-24, but A. E. Barnes 
of Sheffield states that the cutler expires 732 cc. less and the steel grinder 751 cc. less. 
Collis found a high blood pressure ran concurrently with diminished chest expansion. 
In Sept., 1919, during the Allied Armies' occupation of Rhineland, I visited the steel 
factories in Solingen-the Sheffield of Germany. Here the same problems exist as in 
England. Prof. Ropke, who has contributed largely to the subject of steel grinders' 
phthisis, told me that women had been pressed into the factories during the war to 
carry on the steel grinding. Sufficient time has not yet passed to show whether 
harmful effects, if any, have followed the employment. For a few years previously 
to the war the sickness and mortality rates of Solingen steel grinders had been declin- 
ing owing to improved conditions in the factories. 
The Transvaal Chamber of Mines6 has published in its Reports certain schedules 
of the Miners' Phthisis Board. In one of these the expectation of life based upon the 
permanently impaired physical capacity of the men for underground work is compared 
with the normal expectation of life of men of the same age calculated according to the 
Carlisle tables. The conclusion drawn is that whereas a person of the age of 42% 
years should have on an average 26 years to live, a person of the same age who has 
worked underground in the mines 9% years would have an expectation of only 1% 
years. The following figures, taken at random, for 200 cases of beneficiary miners 
supplied by the Miners' Phthisis Board for 6 months ending January 31, 1913, are not 
without interest even if they have not met with general acceptance. PROGNOSIS AND PATHOLOGY OF PNEUMOKONIOSIS 
711 
Actual service 
underground 
Average actual 
service under- 
ground, years 
Average age of 
of miners in 
each class, 
years 
Normal expec- 
tation of life, 
Carlisle tables, 
years 
Medical advis- 
ers' certificate 
of expectation 
of life average, 
years 
8 years or over.. . . 
9% 
42% 
26 
1% 
7 to 8 years 
7% 
36% 
31 
2% 
6 to 7 years 
6% 
38% 
28 
2% 
5 to 6 years 
5% 
36 
30 
3 
4 to 5 years 
4% 
40% 
27 
3% 
2 to 4 years 
3 
34 
31 
3% 
Of the miners who applied for compensation under the Miners' Phthisis Act, 1912, 
and have since died but were examined by the Medical Advisers to the Board before 
death, the number of deaths was 39. The Medical Advisers' average expectation of 
the applicants' life was 7% months, but instead of this their actual average life was 
only 1% months. 
Pathology.'-Irrespective of the particular kind of dust which has led 
to the development of pneumokoniosis, one and the same structural 
change is invariably present in all affected lungs, if only sufficient time is 
given. I refer to an increase of the fibro-connective tissue of the organs, 
an interstitial pneumonia in fact, accompanied by the presence of pigment 
without recognizable evidence of tubercle or syphilis. The fibrous tissue 
tends to assume in places concentric formation, the fibrosis being particu- 
larly well marked around blood-vessels and small bronchi. It is around 
these that the earliest changes are detected. The blood-vessels become 
thickened as a result of endarteritis or in consequence of prolonged venous 
congestion. There are usually signs of bronchial catarrh. On microscop- 
ical examination particles of dust can be seen imbedded in large endothe- 
lial cells lying inside the alveoli and also in the fibroblasts. Occasionally 
free red blood cells can be seen occupying the alveoli as a consequence of 
venous congestion or more probably as a consequence of hemorrhage 
from newly developed thin-walled vessels such as occur in granulation 
tissue. The development of new blood-vessels is an interesting feature in 
pneumokoniosis, for while at first they are capable of meeting all nutritive 
demands the blood supply ultimately becomes restricted, a condition 
which may lead to necrosis. 
This brief statement requires a further and more carefully detailed account of the 
microscopical appearance of sections of a lung in pneumokoniosis, and as the structural 
changes are particularly well marked in a non-tuberculous fibrotic lung, which was sent 
to me by Dr. Aitken of the Miners' Sanitarium, South Africa, I will make these the 
basis of my remarks. For assistance in the description of the pathological changes I 
am indebted to my colleague, Prof. Stuart McDonald. When animals have been 
exposed interruptedly to a dusty atmosphere over a considerable length of time one 
of the earliest signs in the lungs is the presence of large pigmented cells lying^free 712 
DUST DISEASES OF THE LUNGS 
within the alveoli. These cells are phagocytes. Some of the cells may be extruded 
leucocytes, others are modified alveolar endothelial cells. During the act of coughing 
some of these pigmented cells as well as others lying on the bronchial mucous mem- 
brane are expelled and can be found in the expectoration. In another way the fate 
of these dust alveoli is interesting. Many of them penetrate through the stomata, 
they break through between the alveolar epithelium into the lymphatics of the fibro- 
connective tissue framework of the lung and'are carried to the glands at the hilus or 
they disintegrate and induce an irritative fibrous hyperplasia. Irritation by this 
foreign material is capable alone of inducing the fibrous overgrowth observed in typical 
silicotic nodules, but probably other factors are in operation as well. 
Many of the smaller bronchioles have their lumen blocked by catarrhal products 
and by oedema attended by collapse of the immediate lung tissue. Where collapse 
has occurred, the alveolar walls become thickened and there develops an area of fibrous 
tissue which is, practically speaking, free from dust particles. Here and there may 
be seen small areas of lung, seats of acute pneumonic consolidation. The intra- 
alveolar exudate varies. It may be composed of mononuclear cells which have come 
from a proliferating alveolar endothelium, or it may be fibrinous in character and 
include numerous leucocytes within its meshes. Numerous free red blood cells are 
seen inside the alveoli and in irregular situations. The presence of newly formed 
capillaries in the exudate points to a fibrous organization taking place such as is 
occasionally seen in an unresolved pneumonia. 
As regards the source of the newly formed fibrous tissue it may be that some of the 
larger mononuclear cells and also some of the smaller cells of the lymphocyte type 
play a part. The bulk of it is the product of fibroblastic cells, which, spindle-shaped, 
flattened or branch-like, can be seen at the periphery of a densely fibrotic silicotic 
nodule while the smaller lymphocyte cells are situated more externally. The fibroblasts 
are also phagocytic for several of them can be seen ladened with foreign particles. 
Branches of the pulmonary artery show fibrous and elastic thickening of their inner 
coat. This is not so apparent in the finer divisions of the pulmonary vein. The 
alveolar capillaries are overfilled in places and antemortem thrombosis of the 
smaller blood-vessels is here and there apparent. Scattered through the lung are 
dense silicotic nodules. Most of these are avascular but where the morbid change is 
still progressing the tissue is distinctly vascular. In none of the sections neither 
to the naked eye nor on microscopical examination is there the slightest evidence of 
tubercle. Where the changes have become most marked all traces of alveolar struc- 
ture have disappeared; the outline of thickened and obliterated vessels may still be 
traced amid accumulations of dust particles, while as regards connective-tissue cor- 
puscles these are represented by little else than free nuclei. The absence of pus cells 
is a notable feature. The presence of pus corpuscles is usually a sign that tubercle 
has become grafted upon a lesion which was primarily non-tuberculous. In a large 
percentage of the cases, probably 70, death comes by secondary tuberculosis. On 
careful examination of the structureless material of fibrotic tissue and amid mineral 
particles tubercle bacilli may be found, but if present they are few in number and are 
without their usual histological accompaniment, giant cells. 
In the lung of a dog, the subject of experimental anthracosis, I was sur- 
prised at the large size of the particles of coal dust found in the pulmonary 
alveoli after death. The transport of dust into the lungs during inspira- 
tion is a fact beyond controversy-notwithstanding all that has been 
written up in the subject of tidal air in respiration and the renewal of the 
air in the small bronchi and pulmonary alveoli by diffusion. During 
inspiration when men are working hard a portion of the tidal air must be 
drawn into the pulmonary alveoli. PATHOLOGY OF PNEUMOKONIOSIS-SILICOSIS AND TUBERCULOSIS 
713 
The lungs of persons dying from silicosis are heavier than normal organs. Accord- 
ing to Dr. John McCrae, Government Analyst, Transvaal, the amount of silica in 
diseased lungs was 2.8 to 9.6 grammes, as compared with 0.55 grammes in normal 
organs: the proportion of silica in the ash of diseased lungs was 29-48 per cent., and in 
normal organs 14.7. There is, too, a marked excess of phosphoric oxide which is 
regarded by some writers as the main causes of the fibrosis. Iron oxides and alumina 
are also found in the ash. 
Silicosis and Tuberculosis.-Since in a considerable number of per- 
sons dying from silicosis no sign of tubercle is found in the lungs or in the 
body generally, silicosis must therefore in its early stages at least be 
regarded as a non-tuberculous disease. In some of my own patients 
the malady from first to last was non-tuberculous. Formerly the opinion 
prevailed that the tubercular bacillus and pneumococcus could not thrive 
underground owing to the acidity of the mine water in South Africa, but 
S. V. Niekirk states that in 15 per cent, of samples of expectorated mat- 
ters taken from ladder-ways and steps underground the tubercular 
bacillus was found. When tuberculosis develops not only is it secondary 
to pneumokoniosis but there occurs an alteration in the symptoms. 
Pneumokoniosis is of gradual development; it usually pursues its course 
without any pronounced rise of temperature. Once tubercle has been 
grafted upon the malady, emaciation becomes progressive, the temperature 
rises, there are night sweats, the expectoration becomes mucopurulent and 
frequently contains Koch's bacillus. Experience confirms the opinion 
based upon experimentally produced dust diseases of the lungs, viz., that 
a patient suffering from pneumokoniosis is more prone to develop tubercu- 
losis than a person otherwise healthy. It might appear as if the avascular 
state of the fibrotic areas of an affected lung did not lend itself to the 
reception and multiplication of the tubercle bacillus, but a suitable 
nidus is certainly provided in the catarrhal secretion within the pul- 
monary alveoli. That dust diseases of the lung specially predispose to 
other microbic diseases such as pneumonia is the experience of medical 
men on the Rand. The Kaffirs employed in the gold mines round 
Johannesburg have an extremely high death rate from pneumonia. 
Not only do the native miners take the disease readily, but their resis- 
tance to it is diminished. 
The South African Miners' Phthisis Commission of 1912 reported that 
silicotic lungs become increasingly liable to infection as the fibrosis pro- 
gresses. Of the patients in the early stage of the disease 6 per cent, were 
found to be tuberculous; of those in the middle stage 12 per cent, and in 
the later stages 44 per cent. 
Dr. G. A. Turner of Johannesburg and Dr. D. Macaulay have drawn attention to a 
form of tuberculosis affecting the spleen and mesenteric glands, found in gold miners. 
Not only is the spleen studded with nodules, but in the glands there is observed 
proliferation of the proper elements with fibrosis, and signs of tubercle bacilli are 
present in small numbers and are with difficulty detected. As indicating the types of 
tuberculosis found in the Kaffirs employed in the gold mines, Dr. Turner reports that 714 
DUST DISEASES OF THE LUNGS 
of 309 deaths which occurred in one of the Compound Hospitals during the 6 years 
1908-1913 and which were confirmed by post-mortem examination, 140 were pul- 
monary, 92 were cases of generalized tuberculosis, 33 peritoneal, 33 splenic, 7 hepatic, 
3 meningeal and 1 renal. Dr. G. D. Maynard7 also found tuberculous abdominal 
lesions prevalent in native miners and is therefore disposed to admit the possibility 
of infection having occurred through the alimentary canal. When we remember 
that in the mines the expectoration of the men who are the subjects of the malady is 
widely distributed and is found on the walls, floors, steps, hand rails of ladders, on the 
inside of cages, also that the native miners eat their food with unwashed hands, infec- 
tion by the alimentary canal is more than a possibility. These remarks raise the 
question as to what is the mode of entrance of dust into the lungs. 
MODE OF ENTRANCE OF DUST INTO THE LUNGS 
Is pulmonary anthracosis of aerial or intestinal origin? Where men 
have been working in a dusty atmosphere and their lungs after death are 
found to be deeply pigmented it is natural to suppose that the altered 
condition of the lungs is the result of particles of dust which were in- 
haled when at work. Physical and chemical confirmation of the identity 
of the dust found in the lungs with that present in the atmosphere of the 
workshop lends weight to this supposition. Calmette of Lille, Van 
Steenberghe and Grysez in their researches upon tubercle concluded that 
tuberculous lesions of the lungs are not so much the consequences of 
aerial infection by Koch's bacillus as that the microorganism enters 
the body by the alimentary canal and finally reaches the lungs by the 
lymphatics. If, as these pathologists maintain, this is the channel of 
infection by tubercle bacilli, so in all probability is it the portal of entry 
of the particles of carbon which cause the anthracosis of coal miners. In 
their experiments they found that the ultimate destination of pigment was 
greatly influenced by the age of the animal experimented upon. 
In the lungs of young guinea-pigs particles of carbon were not found, but they were 
present in the lungs of older animals, the opinion being that while carbon dust was 
arrested in the mesenteric and other abdominal glands of younger animals the more 
open meshes of the glandular structure in older animals permitted the passage of the 
particles through the glands, and thus allowed of their transport by the lymphatics to 
the lungs. I have carried out several experiments bearing upon the artificial produc- 
tion of anthracosis both by the intestinal canal and the respiratory passages. 
My own experience is that while pigmentation of the lung can be produced by 
materials carried into the intestinal canal, there is no comparison between this as the 
portal of entry and the respiratory passages. The presence of particles of carbon 
lying free within the pulmonary alveoli and their presence too in large phagocytic cells 
lying loose in the alveoli indicate that these particles must have reached the lung by 
the air channels. 
The absence of pigment in the lungs of animals whose esophagus had been 
ligatured and which had breathed air in which particles of soot were freely 
suspended is admittedly strong evidence in support of the intestinal mode of entrance 
as advanced by Calmette and his school; so too his other experiment where pigment 
was found in both lungs when the esophagus was open but one of the bronchi ligatured. 
In Great Britain Professor Whitla of Belfast is one of the strongest adherents of the 
intestinal origin of anthracosis. His conclusions rest upon data obtained by repeat- SILICOSIS AND TUBERCULOSIS 
715 
ing Calmette's experiments and especially those of the introduction of Indian ink by 
the intraperitoneal method. 
In my own intraperitoneal experiments I have been impressed by the rapidity with 
which even considerable particles of coal dust were transported to the abdominal 
glands, including such organs as the testes. The peritoneal cavity is a large lymphatic 
space from which infective material is rapidly absorbed and conveyed by the lym- 
phatics, but although such material may finally reach the lungs it never reaches them in 
■such quantity as when aspirated into the lungs by breathing. Supporters of the theory 
of the intestinal origin of pulmonary anthracosis lay stress upon the mechanical 
■obstacles such as the presence of ciliated epithelium in the upper portions of the 
respiratory canal, the branching and narrowing of the bronchial tubes which render it 
■difficult for dust to reach the lungs. The abdominal glands of coal miners are occa- 
sionally black but never in comparison with the bronchial glands or the lungs. In the 
alveoli of the lungs of rabbits and dogs exposed for 1 hour daily to an atmosphere 
Tendered dusty by means of finely powdered coal there can be seen numerous large cells 
•of the epithelioid type which have engulfed fine particles of dust. These cells are 
phagocytes. They are expelled in the expectoration or they may penetrate through 
the alveolar endothelium and reach the connective-tissue framework of the lungs or 
the lymphatics. They are carried by the lymphatics to the bronchial glands where 
they unburden themselves of the pigment they have brought or they undergo dis- 
integration dispersing the pigment as fine dust. Instead of using particles of soot 
■or of Indian ink, iron carbonate can be administered and its presence subsequently 
demonstrated by a blue color obtained with hydrochloric acid and ferrocyanide of 
potassium. 
Dr. Leonard Findlay8 repeated Calmette's experiments and he found that where 
animals were fed for days with emulsions of soot or Indian ink through a stomach tube 
the lungs showed no abnormal pigmentation, that when fed with iron carbonate by the 
stomach tube for 27 days, while large quantities of iron carbonate were present in the 
mesenteric glands, the lungs, with the exception of a small patch of broncho-pneu- 
monia, were free from iron carbonate although particles of soot were present in the 
epithelial cells of the alveoli. Where animals breathed an atmosphere ladened with 
soot, the esophagus and both of the bronchi at the time being free, the lungs were 
found invariably pigmented; in the case of other animals breathing a similar atmos- 
phere but whose esophagus had been ligatured the lungs were pigmented and 
the alveolar cells contained carbon, but the mesenteric glands were free from soot. 
Finlay caused a tracheotomized animal to breathe a soot-ladened atmosphere, its left 
bronchus being plugged with cotton wool. The animal inhaled dust for 2 hours. 
When killed the right lung was of dark color while the left still retained the rosy appear- 
ance of health. In the alveoli of the right lung were found considerable amounts of 
pigment. Where animals breathed for varying periods iron carbonate, their esophagus 
and bronchi free, the alveolar cells gave the Prussian blue reaction with potassium 
ferrocyanide. After intraperitoneal injections of soot, also of Indian ink, the lungs 
were usually entirely free from pigment while the mesenteric glands were pigmented. 
In a few instances the mediastinal glands were pigmented and the lymphatics of the 
lungs which run in the alveolar walls- contained the colored material. 
It is difficult to produce pulmonary anthracosis by feeding. The 
difference in the pigmentation of lung caused by the inhalation of foreign 
particles and the same when introduced by the alimentary canal is that 
when dust has been inhaled the dust particles are found lying inside the 
pulmonary alveoli, whereas when introduced by the intestinal canal if 
they reach the lung at all they are found lying in the interior of the lym- 
phatics. My own opinion in regard to the origin of pulmonary anthraco- 716 
DUST DISEASES OF THE LUNGS 
sis is that while the dust may reach the lungs by both the intestinal and 
respiratory passages the latter is the more frequent of the two. 
Prof. Beattie of Liverpool University has been extremely successful in 
producing the early stages of pneumokoniosis in guinea-pigs by causing 
them to breathe a dusty atmosphere. Sections of the affected lungs show 
the thickened alveolar walls due to proliferation of fibro-connective tissue, 
the presence of pigment in the pulmonary lymphatics; also in the large 
phagocytic cells lying within the pulmonary alveoli. His experiments 
prove that prolonged inhalation of dust is capable of producing structural 
alterations similar to those found in the lungs of miners dying from 
uncomplicated penumokoniosis. 
HOW COAL AND SILICA DUST IS REMOVED FROM THE LUNGS 
We have dealt with the channels by which dust enters the body of 
miners and finally reaches their lungs but the question of dust inhalation 
has assumed an importance which calls for consideration further apart 
from its pathological interest-it has an economic significance which 
cannot be ignored. To this subject Dr. J. S. Haldane12 of Oxford has made 
important contributions-vide the " Proceedings of the Institute of Mining 
Engineers," London (1918). 
The British coal miner is remarkably free from anthracosis. The dangers in 
several of the dry coal mines is that the fine carbonaceous dust may become fired 
and cause an explosion. It was therefore suggested that one means of obviating this 
possibility was to lay the fine dust in the mine by stone dust, but it was urged against 
this mode of treatment that the addition of stone dust might imperil the miners' 
health by causing disease of the lungs. According to Haldane it is only when the 
stone dust added is finely ground quartz or granite that such a possibility is likely to 
arise. Shale dust even if it contains a small quantity of crystalline silica and a large 
quantity of silicates, appears to be, comparatively speaking, harmless, as evidenced 
by the mortality rates of the miners in the Nottingham and Derby districts (England) 
who while hewing coal cannot but inhale stone dust containing crystalline silica. 
It is interesting to remember that in the Mysore mines (India) where the gold is 
imbedded in quartz, the miners are remarkably free from lung diseases, and the same 
remark applies to some extent to the miners in Western Australia. Haldane while 
admitting that all dust particles of an insoluble nature may, when inhaled, induce 
inflammatory changes in the lungs, if breathed in sufficient quantity, states that there 
is a great difference in their effects; some, such as crystalline silica may cause lasting 
and cumulative lung injury, while others, such as coal and shale, cause no cumulative 
injury unless breathed in large amounts. Fine coal dust was found in his experiments 
to reach the lungs of animals; so too did fine quartzite dust from a Transvaal Gold 
Mine, but on examining the animals some months after they had been allowed a period 
of freedom it was found that the coal and shale dust had entirely disappeared from the 
lungs, while, in those of animals which had inhaled the Transvaal dust, particles of 
quartzite and flint were still retained. These findings therefore raise fresh problems 
since it is special epithelial cells in the lungs which pick up the dust particles either to 
be discharged in the expectoration or to be carried by the cells as they wander into 
the pulmonary lymphatics and are carried to the glands at the root of the lungs. It 
would seem therefore as if, while the phagocytes, ladened with coal dust, migrate DUST REMOVAL FROM THE LUNGS TREATMENT 
717 
from the lungs into the lymphatics, those containing quartzite dust remain in the 
lungs, and there the dust particles tend to accumulate so long as the miner keeps 
working in a dusty atmosphere. The lesion in the lungs cannot always be explained 
either by the size, hardness or angularity of the dust particles for a certain amount of 
quartz is present in shale and yet the coal miner does not suffer. Nor does the 
explanation lie in the chemical composition of the dust. It may be as Haldane 
suggests, that the power for harm depends upon the capability of certain dusts to 
absorb other substances. Coal dust possesses such a power. So too does shale, but to 
a less degree, whereas crystalline substances like quartz have little absorptive power. 
Phagocytes carrying coal dust have probably the power of attracting other insoluble 
dust particles and become stimulated by these in proportion to the soluble substances 
present, whereas quartzite particles not possessing this absorbing power are unstimu- 
lating. There is probably something present in certain kinds of dust which stimulates 
the phagocytic epithelial cells to activity so that they wander off into the lymphatics 
and by this means they rid the lungs of dust. 
Mavrogardato13 extended Haldane's experiments and he found, when coal dust and 
fine flint dust were mixed and breathed by animals, that the whole of the flint dust 
was got rid of. 
The results of these experiments may be stated thus: while it may not 
always be possible to prevent miners from inhaling stone dust the conse- 
quence can be neutralized by mixing other kinds of dust such as coal or 
shale. Other materials in solution or suspension may answer equally 
well as in experiments carried out by Belger and myself in a dusty coal 
mine in the County of Durham, and which are alluded to herewith under 
the paragraph Treatment. 
Treatment.-If pneumokoniosis cannot be entirely abolished, it 
certainly can be largely prevented. It is a matter of getting rid of the 
dust to which men are exposed when at work, whether in the factory, 
grinding shed, quarry or mine. The improved conditions under which 
coal miners work, their better housing, shorter hours and higher wages, 
but above all the freer ventilation of coal mines by larger fans and by 
double shafts for "intake" and "outgo" air, have considerably reduced 
the mortality rate of miners' phthisis. Ventilation of coal mines, however, 
has its limits. There is just the risk of excessive ventilation sweeping 
away from the walls, floors, roofs and props and carrying forward through 
a mine the extremely fine dust which lies in the main ways. This fine dust 
is not only a menace to the health of the miners but a cause of explosion in 
coal mines. Spraying with water has, therefore, been resorted to, but 
coal dust and water do not mix together readily. Coal dust floats in 
water and is not quickly permeated by it; besides coal dust which has been 
wetted with water on becoming dry is found to have undergone further 
disintegration and to have become a finer form of dust. Soap-and-water 
spraying and spraying by other fluids have been recommended since 
they bind the dust and render it difficult for currents of air to lift it. 
Herman Belger of the Armstrong College, Newcastle-upon-Tyne, has 
for the last 2 years carried out in my laboratory at the College of Medicine 
a series of experiments as to how to bind the dust so that it will remain DUST DISEASES OF THE LUNGS 
718 
bound under all conditions of temperature and dryness of the atmos- 
phere. His solution possesses the property of abstracting moisture from 
the atmosphere so that a dusty surface treated by it remains more or less 
moist and therefore attractive to fresh dust. Belger's solution is a 
colloid and contains calcium and other salts. The colloid solution is 
harmless from a health point of view; it has no injurious influence upon 
the plant of a mine or upon the seam of coal rock or ore. Spraying of the 
interior of coal mines by Belger's solution has been tried over several miles 
of roadway in coal mines with great success. The colloid solution not 
only renders a mine free from dust but keeps it free. Wherever it has 
been sprayed there is created a coolness in the underground passages 
which makes the work of the miner easier, and at the same time it dimin- 
ishes the risk of explosion. 
There are dusty occupations in which men can work wearing a respira- 
tor. Inhalation of dust is thereby to a great extent diminished, but 
where the work is hard and of a laborious nature men complain that they 
cannot wear a respirator. Theoretically the wearing of a respirator is 
all right, but it creates heat and the men cannot breathe freely through 
the respirator. 
Of the curative treatment of pneumokoniosis little can be said. It is 
only in the early stages that satisfactory results can be obtained, and that 
is by the men on the first approach of symptoms retiring from the work 
and taking up occupations in the open air. I know of no specific medici- 
nal treatment for pneumokoniosis. Once fibrosis has begun there is 
always the probability of its progressing. From fibrolysin no special 
benefit has been obtained: iodalysin, a mixture of thiosineamine and 
iodine may be worthy of a trial, but in non-syphilitic patients neosal- 
varsan has done no good. If, however, the patient can be kept free from 
the possibility of tuberculous infection he may live for years, provided he 
is careful in his habits and avoids catching cold. By the administration 
of calcium salts such as chloride combined with a tonic like nux vomica, 
good food, abstinence from alcohol and by living in the open air health can 
be well maintained and a comparatively useful life spent. Once tubercle 
bacilli invade the lung the patient rapidly becomes worse and the case 
practically becomes hopeless. Silicosis and tuberculosis are mutally 
destructive to each other. A silicotic lung soon breaks up in the pres- 
ence of tubercle bacilli. 
On the question of the treatment of silicosis it would be well to read what Dr. 
Francis Aitken9 has to say, since he has had experience which falls to few physicians. 
In November, 1911, there was opened at Modderfontein, South Africa, a sanatorium 
for the treatment of miners' phthisis. Dr. Aitken, Medical Superintendent, states 
that since the opening of the sanatorium, to the end of December, 1913, there have been 
admitted 322 cases. Miners in all stages of the disease, with or without tuberculosis, 
have been received. Forty per cent, of the men admitted were tuberculous and had to 
be segregated from the other inmates. During 1913, 156 patients entered the sana- 
torium; 103 were discharged and 48 died. TREATMENT OF PNEUMOKONIOSIS REFERENCES 
719 
In regard to the curability of silicosis the Medical Superintendent 
expresses himself thus: "Recent researches in the pathology of the dis- 
ease reveal the important fact that the fibrous tissue which is formed as a 
result of the irritation by the dust in the lungs, and which is responsible 
for the hardening of the lungs and their impairment as respiratory organs, 
tends in time to become organized and permeated by newly formed blood- 
vessels. As a result, the fibrous tissue is in part absorbed and the 
particles of silica are liberated and carried away in the blood stream. 
This process makes for a good prognosis in cases which (1) are no longer 
exposed to a dusty atmosphere, (2) are free from tuberculosis, (3) have no 
breaking down of the lungs, (4) are able to survive the period of heart 
strain that always accompanies any marked degree of silicosis. Thus 
it would appear that early cases of silicosis that are able to fulfil these con- 
ditions should be regarded as curable and more advanced cases should 
improve to a marked extent." Without comment, I close this paper 
with the above expression of optimism on the part of Dr. Aitken? 
REFERENCES 
1 The Relation between Anthracosis and Pulmonary Tuberculosis, J. W. Wainwright 
and H. I. Nichols. The American Journal of the Medical Sciences, Sept., 1905, 
page 403. 
2 British Medical Journal, March 14, 1914. 
3 Journal of the Sanitary Institute, Apr., 1900, page 66. 
4 British Medical Journal, 1912, Vol. I, page 694. 
8 The Industrial Diseases of South Africa. Reprinted from the Medical Journal of 
South Africa, February, 1914. 
6 Annual Report, 1913, page 63. 
7 Transvaal Medical Journal, Oct., 1912, page 72. 
8 Uber der Ursprung der Anthrakose der Lungen. Verlag von Julius Springer, Berlin, 
1911. 
9 Transvaal Chamber of Mines, 24th Annual Report, 1913, page 578. 
10 Thesis. Miners' Phthisis on the Witwatersrand. S. V. Van NieKirk. 
11 Mortality from Tuberculosis in Dusty Trades. National Tuberculosis Association 
(U. S.), Sept., 1919. 
12 Dr. J. S. Haldane. Proceedings of the Institute of Mining Engineers. London, 
1918. 
13 A. Marvrogordato.-Experiments on the Effects of Dust Inhalations. Jour, of 
Hygiene, Oct., 1918, pages 439-459. 
REFERENCES TO APPENDIX 
N. B. For references a to A in this Section, see Appendix V, pages 1075-6. SECTION 2 
TUBERCULOSIS IN RELATION TO OCCUPATIONS 
GEORGE M. KOBER, M. D., Washington, D. C. 
From our knowledge of the etiology of tuberculosis, we know that 
while the tubercle bacilli are not ubiquitous, they are at least widely 
scattered and the modes of invasion are numerous, and yet there is 
a large proportion of those persons exposed to infection who do not 
develop the disease. This shows that in addition to the germ there 
must also be a suitable soil for the development of pathogenic effects. 
Such a soil is usually found in persons of feeble physique, victims of 
malnutrition, whose bodies have been weakened from any one or more 
of the numerous causes which are afloat,-a previous attack of sick- 
ness, hurry, worry, chronic fatigue, loss of sleep, vice, and dissipation, 
insufficient and improper food, insanitary homes, lack of pure air, etc. 
Clinical experience indicates that faulty nutrition,1 debility, loss of 
blood, anemia, mental anxiety, diabetes, whooping cough, measles, 
alcoholism, and many other diseases favor the development of tuber- 
culosis. 
We also know that a predisposition may be inherited, as evidenced 
by a delicate physique, narrow chest, and general vulnerability of the 
tissues. Certain race stocks, as the Negro, are more susceptible; others, 
as the Jew, less so. 
A vulnerability of the tissues may also be acquired by indoor life 
and dusty occupations, especially when the work involves exposure 
to dampness, extremes of heat and cold, sudden changes in tempera- 
ture, and last but not least, exposure to industrial poisons. 
There is abundant statistical evidence both here and abroad that 
persons engaged in the mechanical and manufacturing industries pay 
a terrible toll to the so called " white plague." The Census Statistics 
for 1910 show that the industrial classes, which constitute about one- 
third of the population, contribute almost one-half of all the deaths 
from pulmonary tuberculosis. This is not at all strange when we consider 
the many unfavorable factors to which they are subjected, such as 
crowded and insanitary workshops, long hours in bad air, overwork 
and fatigue and the other predisposing causes already mentioned. 
INDOOR LIFE AND OCCUPATIONS 
The latest occupational mortality statistics for the United States 
for 1909 show that the mortality from tuberculosis in agricultural 
720 TUBERCULOSIS IN RELATION TO OCCUPATIONS 
721 
pursuits was 8.7 per cent.; among bookkeepers and accountants, 22.5 
per cent.; and in servants and waiters, 27.4 per cent. If we stop 
right here the evidence would be overwhelming in favor of outdoor 
employment. But when we find that the tuberculosis mortality in 
Government officials and bankers is less than 8.7 per cent., and that for 
draymen, hackmen, and teamsters it is 23.4 per cent., it becomes 
apparent that in estimating the hazards of indoor occupations, other 
factors, such as physique, habits, exposure to dust, social and economic 
conditions, and standards of living, must be considered. 
DUSTY OCCUPATIONS 
Hoffman2 estimates that of the 44,130,000 American wage earners 
of both sexes, approximately 4,000,000 work under conditions more or 
less detrimental to health, on account of the presence of an excess of 
atmospheric impurities predisposing to or accelerating the relative 
frequency of tuberculous and nontuberculous respiratory diseases, 
and he submits the following table:3 
Trade group 
Males 
Females 
Number 
Per cent. 
Number 
Per cent. 
Metallic dust 
258,454 
7.6 
33,255 
4.9 
Mineral dust 
514,693 
15.8 
15,332 
2.3 
Mineral industries 
844,897 
25.9 
550 
.1 
Vegetable fiber dust 
336,323 
10.3 
296,135 
44.0 
Animal and mixed fiber dust.... 
183,937 
5.6 
149,262 
22.2 
Organic dust 
531,911 
16.3 
177,545 
26.4 
Mixed organic and inorganic 
(public) dust 
594,285 
18.2 
1,399 
.2 
Total 
3,264,500 
100.0 
673,478 
100.0 
The dust which we inhale is, fortunately, largely arrested in the upper 
air passages, especially in the nostrils, and in case of mouth breathers also 
in the buccal cavity. In an ordinary way the dust arrested in the nose, 
unless ejected by sneezing, mixes with the mucus, and after reaching the 
throat, also with the saliva, and is unconsciously swallowed. Only a 
small amount of the finer particles of dust actually reaches the lungs. 
Nature has provided numerous safeguards to prevent the lodgment 
of dust in the lungs which have already been described in the proceeding 
Section, by Sir Thomas Oliver. 
The degree of injury to the respiratory organs depends upon the 
character of the individual particles of dust and their chemical compo- 
sition. It is generally admitted that the sharp, angular, and nonab- 
sorbable particles of metallic and also of mineral dust, especially dust 722 
TUBERCULOSIS IN RELATION TO OCCUPATIONS 
containing silica, are much more apt to produce an intensive irrita- 
tion, and even actual abrasions, than organic dust; hence it is rea- 
sonable to assume that they may thus favor invasion of bacilli or the 
lighting up of inactive lesions. 
With a view of estimating the relative importance of the different 
kinds of dust, as a predisposing cause to tuberculosis I have analyzed 
the original tabulation by the Prudential Insurance Co. of American based 
upon its industrial experience from 1907 to 1912, and find the following: 
Municipal Dust.-There were 10,567 deaths in individuals exposed to 
municipal dust. This group includes street cleaners, drivers, draymen, 
teamsters, coachmen, street-car conductors and street-car motormen. 
The proportionate mortality from consumption is 23.8 per cent., and from 
other respiratory diseases, 11.8 per cent., at ages of 15 or over. But when 
we find that the mortality from consumption in the street cleaners is only 
12.9 per cent, compared with 25 per cent, in street-car conductors and 
motormen, and 33 per cent, in coachmen, we are forced to the conclusion 
that other factors besides the element of dust have to be considered. 
General Organic Dust.-In the same study we find that 5694 deaths 
occurred in workers exposed to general organic dust. This group includes 
bakers, candy makers, flour millers, glove makers, harness makers, belt 
and pocketbook makers, shoe-factory workers, tannery finishers, button 
makers, cigar makers, tobacco workers, comb makers, and grain handlers. 
The proportionate mortality from pulmonary tuberculosis is 24.9 per cent, 
and from other respiratory diseases 11.3 per cent. Here again we have 
reason to inquire how to account for the difference between 23.3 per cent, 
in bakers and 37.2 in tannery finishers, or 36.1 per cent, in cigar makers. 
Vegetable Fiber Dust.-Another study deals with 1120 deceased 
workers at ages of 15 and over, who were exposed to the inhalation of 
vegetable fiber dust. This group includes furniture finishers and sanders, 
woodwork finishers, cotton spinners, knitting-mill employes, lace, linen, 
flax, and other weavers, paper cutters and ropemakers. The proportion- 
ate mortality from pulmonary tuberculosis is 29.1 per cent, and from 
other respiratory diseases 11.1 per cent. Here again we observe great 
differences in the percentage of 22.1 from consumption in knitting-mill 
employes, against 49.2 per cent, in lace weavers. 
Animal and Mixed Fiber Dust.-Study No. 4 deals with 1276 deceased 
workers who were exposed to animal and mixed fiber dust. The occupa- 
tions included in this group are hatters, upholsterers, carpet weavers and 
workers, silk weavers, woolen mill employes, fur workers and mattress 
workers. The proportionate mortality from pulmonary tuberculosis 
is 29.1 per cent, and from other respiratory diseases 11.1 per cent., exactly 
the same as for vegetable fiber dust. 
Mineral Dust.--Study No. 5 refers to 3734 deceased workers who 
were exposed to mineral dust. The occupations included are potters, 
tile makers, glass blowers and cutters, marble and stone cleaners, cutters VARIOUS DUSTS IN RELATION TO TUBERCULOSIS 
723 
and polishers, core makers, molders, lapidaries, lithographers, paper 
hangers, and plasterers. 
The proportionate mortality from pulmonary tuberculosis is 25.9 
per cent, and from other respiratory diseases 14 per cent. It is impor- 
tant to note that the percentage of deaths from pulmonary tuberculosis, 
contrary to expectations, is 3.2 per cent, less than in the two preceding 
groups, which were exposed to vegetable dust, and animal and mixed fiber 
dust, although the percentage of deaths from other respiratory diseases is 
3 per cent, greater than in all other groups. 
Metallic Dust.-Study No. 6 refers to 3374 deceased workers, who 
were exposed to metallic dust. The occupations included are grinders, 
polishers, cutlery, file and tool workers, brass molders and finishers, gold 
beaters, jewelers, gold and silver polishers, type founders, engravers, 
printers, and pressmen.. The proportionate mortality from pulmonary 
tuberculosis in this group is 30.3 per cent, and from other respiratory 
diseases 11.1 per cent. 
Recapitulation 
Dust exposed to 
Number 
of 
workers 
Proportionate mortality from- 
Pulmonary 
tuberculosis 
per cent. 
Other respiratory 
diseases 
per cent. 
Metallic dust 
3,374 
30.3 
11.1 
Animal and mixed fiber dust. . . 
1,276 
29.1 
11.1 
Vegetable fiber dust 
1,120 
29.1 
11.1 
Mineral dust 
3,734 
25.9 
14.0 
General organic dust 
5,694 
24.9 
11.3 
Municipal dust 
10,567 
23.8 
11.8 
The foregoing data undoubtedly point to the fact that exposure to 
all kinds of dust plays a very important role in the causation of respir- 
atory diseases. Dust containing crystalline silica, such as quartz, 
quartzite (ganister, buhr-stone), flint, sandstone, carborundum, and 
emery is perhaps the most frequent cause of the more acute forms of 
fibrosis. It is possible that even in what is commonly called metallic 
dust the siliceous particles from grinding and polishing implements, 
are, with the possible exception of the red oxide of iron, chiefly 
responsible for the cases of siderosis. While other kinds of dust, may, 
and doubtless frequently do, produce a milder grade of pneumoconiosis 
and fibrosis, there is some evidence to indicate that the dust of coal, 
lime, gypsum and sulphur may have an inhibitory effect on the disease. 
(See pages 155 and 577.) 
Whether or not the lesions thus produced may eventuate in pulmon- 
ary tuberculosis depends probably upon a number of factors, the most 724 
TUBERCULOSIS IN RELATION TO OCCUPATIONS 
important of which is the presence of tubercle bacilli. Watkins-Pitchford 
cited by Landis4 found tubercle bacilli in 15.2 per cent, of samples of sputa 
collected underground in the Transvaal gold mines, as against 2.5 per 
cent, of sputa collected in the homes and places of resort of the workers. 
Similar investigations in other industries may bring us nearer the truth; 
but after all, the danger from droplet infection, the common drinking cup, 
including the whisky flask, which formerly in the spirit of good fellowship 
was not infrequently passed from mouth to mouth, and the question of 
massive infection can not be under-rated. 
In the light of our knowledge concerning infection in early childhood 
it is perfectly conceivable that the germs of tuberculosis may remain 
dormant because of the formation of fibroid tissue until the habitual 
inhalation of certain types of dust light up the latent lesions. But even 
in such instances the same factors which determine the development 
of an acute or chronic form of pulmonary tuberculosis and the reactiva- 
tion in apparently arrested cases have to be considered. Many of the 
general predisposing causes calculated to diminish the general power of 
resistance and thus create a suitable soil for the development of the disease 
have already been alluded to. Personally, I am convinced that exposure 
to dust alone does not account for the undue prevalence of tuberculosis 
in certain occupations, and that every factor which undermines the 
general health of the individual is at least of equal, if not greater, impor- 
tance in determining the course of the disease. 
OCCUPATIONAL MORTALITY STATISTICS 
I have arranged in the following tables the percentage distribution of 
pulmonary tuberculosis in certain occupations in an ascending scale and 
not according to exposure to the different varieties of dust. I will make 
such comments as I am able to offer as to the possible influence of physi- 
que, standards of living, and the effects of alcohol, lead, mercury, and 
other industrial poisons. 
Table I deals with 21 occupations. The percentage of deaths from 
tuberculosis ranges from 5.6 in lumbermen and raftsmen to 9.9 in mer- 
chants and dealers. The percentage of 5.8 in coal miners, based upon the 
experience of the Metropolitan Insurance Co. in 1557 deaths, is quite 
low as compared with 9.7 per cent, given by the Prudential Co. in 3658 
deaths, and 9.2 per cent, as given by Hayhurst5 based upon 5428 deaths 
among Illinois soft-coal miners from 1912 to 1918. 
Dr. Hayhurst in his excellent discussion of the subject invites atten- 
tion to the fact that the marked excess in deaths due to violence in 
mining operation nullifies to a large extent any comparison possible 
between the other causes of deaths. When, in the case of miners, he 
omitted violence as a cause of death and then compared the purely 
medical causes (with suicide included), he found the percentage of deaths 
from tuberculosis to be 14.6. OCCUPATIONAL MORTALITY STATISTICS AND TUBERCULOSIS 
725 
Table I.-Occupational Mortality Statistics, Per Cent. Distribution, with 
Special Reference to Tuberculosis. 
Occupations 
Number 
of 
deaths 
Tuber- 
culosis, 
per cent. 
Pneu- 
monia, 
per cent 
Other 
respira- 
tory 
diseases, 
per cent. 
Heart 
diseases, 
per cent. 
Diseases 
of 
digestive 
system, 
per cent. 
All occupations: 
Male 
210,507 
14.8 ' 
8.0 
2.2 
11.9 
2.8 
Female 
27,459 
21.0 
7.0 
2.2 
10.3 
3.6 
Lumbermen and raftsmen 
815 
5.6 
6.3 
0.6 
i 9.0 
2.2 
Coal miners* 
1,557 
5.8 
10.4 
1.1 
9.6 
Bankers 
712 
5.9 
10.8 
1.0 
12.1 
2.5 
Manufacturers and officials 
2,805 
6.3 
7.2 
2.0 
13.2 
3.5 
Farmers, planters, and overseersf 
34,662 
6.6 
6.6 
2.1 
16.3 
3.8 
Physicians and surgeons 
1,421 
6.6 
7.4 
1.8 
12.7 
3.5 
Clergymen 
1,216 
6.6 
7.1 
2.0 
15.5 
3.5 
Steam-rail employes 
5,555 
7.0 
4.3 
1.1 
5.3 
1.3 
Lawyers 
1,325 
7.5 
7.9 
1.9 
12.7 
3.1 
Farmers, planters, and overseerst 
799 
7.9 
6.9 
1.1 
14.8 
4.0 
Officials, Government 
997 
8.6 
7.3 
1.4 
15.3 
3.0 
Agricultural pursuits: 
Females 
879 
8.6 
6.8 
3.1 
15.1 
4.0 
Males 
50,844 
8.7 
7.1 
2.2 
15.1 
3.5 
Foremen and overseers ; . ; . 
745 
8.7 
6.8 
2.3 
11.3 
2.6 
Watchmen, police, and firemen 
2,355 
8.7 
7.9 
2.1 
14.6 
2.1 
Miners and quarrymen 
5,663 
8.8 
8.2 
4.3 
7.1 
2.0 
Hotel keepers 
765 
9.3 
6.8 
1.7 
11.2 
4.2 
Gardeners, florists, and nurserymen 
1,215 
9.3 
9.1 
3.6 
14.7 
3.6 
Farmers and farm laborers* 
3,890 
9.7 
6.2 
16.5 
Stock raisers, herders, and drovers 
766 
9.8 
6.8 
2.0 
12.0 
4.0 
Merchants and dealers (except wholesale). 
9,329 
9.9 
7.0 
1.9 
13.1 
3.3 
* Metropolitan Life Insurance Experience, 1911-1913. 
t Prudential Industrial Insurance Experience. 
Dr. William H. Davis, the chief statistician for vital statistics of 
the United States Bureau of Census, cautioned me at the outset of 
these studies that a proper interpretation of mortality percentage 
figures by age and occupation can only be made by constantly keeping 
in mind the normal death rates of the various occupations and ages. For 
example, a low percentage from tuberculosis may not mean an actually 
lower rate from this disease, but may mean that there is an unusually 
high rate from accidents or some other cause. The violence percentage 
in steam-railway employes was 53.6, and in lumbermen and raftsmen 
29.9; and this accounts for their remarkably low percentage of deaths 
from tuberculosis in this table, and also for the low percentage in miners 
and quarrymen. 
This table shows, however, quite clearly that tuberculosis is infrequent 
in occupations involving out-door life combined with muscular activity; 
but it also shows that it is infrequent in the liberal professions, among 
bankers, officials, hotel keepers, and shop keepers, presumably because 
of higher standards of living. 726 
TUBERCULOSIS IN RELATION TO OCCUPATIONS 
Table II.-Occupational Mortality Statistics, Per Cent. Distribution 
Occupations 
Number 
of 
deaths 
Tuber- 
culosis, 
per cent. 
Pneu- 
monia, 
per cent. 
Other 
respira- 
tory 
diseases, 
per cent. 
Heart 
diseases, 
per cent. 
Diseases 
of 
digestive 
system, 
per cent. 
Commercial travelers 
542 
10.0 
5 2 
1 2 
9 8 
3 9 
Carpenters and joiners 
7,883 
10.1 
7.1 
2.0 
14.4 
2.7 
Puddlers* 
251 
10.4 
6 2 
16 5 
Agents 
2,625 
10.4 
7.7 
1.0 
13.0 
2.8 
Boatmen and sailors 
1,757 
10.4 
7.4 
1.7 
10.0 
1.6 
Cabinetmakers 
632 
10.9 
5.5 
2.9 
12.3 
3.0 
Nurses and midwives 
915 
11.1 
7.8 
1.6 
11.4 
3.6 
Railway track and yard workers! 
1,932 
11.1 
6.4 
1.3 
12.0 
Blacksmiths 
2,456 
11.4 
8.0 
2.5 
13.8 
3.1 
Professional service, male 
9,214 
12.0 
7.3 
1.0 
12.3 
2.9 
Housewives and housekeepers! . . 
88,151 
12.0 
6.0 
1.4 
15.3 
Engineers and firemen, not locomotive... 
3,295 
12.6 
7.7 
1.9 
11.8 
2.5 
Boot and shoe makers and repairers 
2,702 
13.4 
8.5 
2.5 
13.7 
2.2 
Coopers 
570 
13.7 
8.9 
4.4 
12.6 
2.3 
Iron-ore miners 
563 
13.7 
7.6 
9.6 
Janitors and sextons 
1,065 
13.9 
12.6 
1.8 
13.0 
2.5 
Masons, brick and stone 
2,399 
13.9 
8.2 
2.5 
13.2 
2.3 
Railway engineers and trainmen* 
947 
14.0 
5:i 
5.4 
Agricultural laborers 
13,214 
14.5 
8.4 
2.2 
12.6 
2.8 
* Prudential Industrial Insurance Experience. 
f Metropolitan Life Insurance Experience, 1911-1913. 
Table II deals with 19 occupations. The percentage of deaths from 
tuberculosis ranges from 10 in commercial travelers to 14.5 in agricultural 
laborers. The percentage in the latter group appears high when com- 
pared with 8.7 per cent, in 50,844 persons engaged in other agricultural 
pursuits, unless accounted for by lower standards of living. It is rather 
remarkable that the percentage of tuberculosis in carpenters and cabinet- 
makers, exposed as they are to a mixture of vegetable and mineral dust 
in sandpapering, should be about the same as that in commercial travelers. 
We note, however, that the percentage of deaths from digestive diseases 
in the latter group is quite high, possibly indicating a lower state of nutri- 
tion. The percentages in all the other occupations enumerated in this 
table are below 14.8, which is the average for all occupations, in spite of 
the fact that a number of them are dusty trades. 
Table III includes 22 occupations. The percentage of deaths from 
tuberculosis varies from 15 in college professors and teachers to 19.9 
in day laborers. The percentage in female college professors and 
teachers is 21.5. Both are usually recruited from weak stock, and 
the high percentage of diseases of the digestive organs in both sexes 
is indicative of a low state of nutrition. The rates suggest the need 
of improvement in personal hygiene and the sanitation of classrooms. 
The percentage in saloon keepers is 15.5, as compared with 9.3 in hotel 
keepers, and 26 per cent, in innkeepers and bartenders. The con- OCCUPATIONAL MORTALITY STATISTICS AND TUBERCULOSIS 
727 
Table III.-Occupational Mortality Statistics, Per Cent. Distribution 
Occupations 
Number 
of 
deaths 
Tuber- 
culosis, 
per cent. 
Pneu- [ 
monia, 
per cent. 
Other 
respira- 
tory 
diseases, 
per cent. 
Heart 
diseases, 
per cent. 
Diseases 
of 
digestive 
system, 
per cent. 
Teachers and professors (college, male). . 
587 
15.0 
5.6 
1.7 
12.6 
4.3 
Saloon keepers 
973 
15 5 
8 5 
1.6 
7.3 
2.9 
Manufacturers, mechanical pursuits 
63,880 
15.5 
7.9 
2.4 
11.4 
2.6 
Salesmen 
2,550 
15.8 
7.6 
1.0 
11.5 
2.8 
Butchers 
1,503 
16.2 
8.3 
1.2 
12.0 
2.8 
Iron and steel workers 
2,838 
16 3 
10 8 
1.5 
10.0 
2.5 
Trade and transport workers 
44,941 
16.6 
7.3 
1.6 
10.2 
2.5 
Plasterers* 
977 
16 7 
Bakers 
952 
18 2 
8.6 
1.9 
10.8 
2.5 
Hucksters and peddlers 
799 
18 3 
9.5 
2.1 
10.8 
2.4 
Machinists 
3,317 
18 3 
7 9 
1.9 
11.1 
2.4 
Domestic servants and laundresses (fe- 
male) 
1,091 
18 5 
8 7 
2.6 
11.5 
3.9 
Domestics, personal service (female) 
17,735 
18.7 
7.5 
2.3 
10.6 
3.7 
Street-railway employes 
697 
18.9 
6.2 
1.3 
6.3 
1.4 
Painters, glaziers, and varnishers 
3,720 
18.9 
8.0 
1.7 
10.6 
2.4 
Tin-plate and tinware workers 
681 
18.9 
8.2 
2.5 
11.6 
2.9 
Tailors 
2,408 
19.0 
7.7 
3.5 
10.5 
3.0 
Dressmakers 
1,019 
19 2 
7.0 
1.3 
11.7 
2.9 
Servants and waitresses 
14,930 
19.5 
7.3 
2.3 
10.4 
3.7 
Professional service (female) 
1,725 
19.7 
6.9 
1.8 
8.8 
3.5 
Domestic and personal service (male).... 
41,624 
19.7 
10.2 
2.2 
10.4 
2.5 
Laborers, not specified 
29,345 
19.9 
11.0 
2.4 
10.1 
2.5 
* Prudential Industrial Insurance Experience, 1911-1913. 
elusion seems irresistible that chronic alcoholism plays an important 
role in the latter group. Butchers and steel workers have about the 
same percentage in tuberculosis, but the steel workers have a higher 
pneumonia rate. Butchers have a high venereal rate and are often 
alcoholic. In painters and tinware workers the element of chronic 
lead poisoning should be considered. The percentage of deaths from 
tuberculosis in tailors and dressmakers is almost the same. Exposure 
to a mixture of vegetable and animal dust and a postural influence may be 
discerned, since finishers (among males) show the greatest percentage of 
faulty postures. The rates for servants and laborers are above the 
average and are doubtless influenced by exposure to dust, bad ventilation 
and also by alcohol. 
Table IV includes 15 occupations with a percentage of deaths vary- 
ing from 20.5 in engravers to 25 per cent, in machinists. Steel engravers 
are exposed to mercury, electricians to lead and mercury, and painters 
and machinists (in certain processes) to lead. In the case of textile 
workers, bookkeepers, accountants, teachers, musicians, and tobacco 
workers it is fair to assume that the majority are recruited from feeble 
stock, as shown by very high rates before the completion of the twenty- 
fifth year. In some of these industries, notably in the textile mills and 728 
TUBERCULOSIS IN RELATION TO OCCUPATIONS 
Table IV.-Occupational Mortality Statistics, Per Cent. Distribution 
Occupations 
Number 
of 
deaths 
Tuber- 
culosis, 
per cent. 
Pneu- 
monia, 
per cent. 
Other 
respira- 
tory 
diseases, 
per cent. 
Heart 
diseases, 
per cent. 
Diseases 
of 
digestive 
system, 
per cent. 
Engravers* 
112 
20.5 
2.7 
0.9 
Hostlers 
540 
20.6 
13.9 
0.8 
12.2 
2 0 
Cotton-mill operatives 
686 
21.1 
6.9 
2.0 
11.5 
3.5 
Textile-mill workers! 
2,390 
22.0 
5.9 
10.7 
Teachers and professors (college, female) 
1,170 
21.5 
8.0 
1.6 
8.4 
3.5 
Painters and paper hangers! 
2,722 
21.9 
6.1 
10.7 
Iron molders! 
1,646 
21.9 
10.6 
13.1 
Bookkeepers and accountants 
1,740 
22.5 
6.1 
1.5 
12.5 
2.2 
Musicians and teachers of music 
509 
23.4 
6.8 
1.9 
11.0 
2.5 
Draymen, hackmen, and teamsters 
5,791 
23.4 
9.2 
1.7 
9.6 
2.2 
Barbers and hairdressers 
1,398 
23.9 
6.2 
1.4 
10.7 
2.5 
Electricians 
776 
24.1 
6.8 
1.0 
5.4 
1.3 
Seamstresses 
695 
24.2 
6.9 
2.4 
10.2 
4.5 
Tobacco and cigar operatives 
982 
24.3 
6.1 
1.7 
10.1 
2.3 
Machinists ! 
3,152 
25.0 
7.1 
11.1 
* Prudential Industrial Insurance Experience. 
t Metropolitan Life Insurance Experience, 1911-1913. 
tobacco factories, special investigations should be made as to the char- 
acter of dust and whether or not tubercle bacilli are found. Heucke6 
claims to have found 0.56 per cent, of nicotine in the dust of different 
tobacco establishments. 
Barbers and hairdressers are frequently exposed to droplet infection 
and also to inhalation of fine hair. The percentage of deaths from 
tuberculosis in hostlers is 20.6 and from pneumonia 13.9, as compared 
with 9.8 and 6.8 in stock raisers, herders, and drovers. Inasmuch as 
the pneumonia rate among cavalry troops is quite generally in excess 
of other arms of the service, it occurred to me during my Army expe- 
rience that the inhalation of the peculiar character of dust given off 
during the grooming of horses might be a factor in this increased sus- 
ceptibility. The high rates in draymen, hackmen, and teamsters 
are usually attributed to exposure to weather without opportunity 
for active exercise; they have, however, also a high rate for alcoholism. 
In Great Britain the percentage in private coachmen is much lower, 
probably because of better habits and living conditions. Iron molders 
have a high rate of alcoholism and are more or less exposed to dust and 
also to carbon monoxide. 
Table V includes 12 occupations, and the percentage of deaths 
from tuberculosis varies from 26 in saloon keepers and bartenders 
to 29.2 in longshoremen and stevedores. In both of these widely differ- 
ing occupations, as also in teamsters, drivers, and chauffeurs, the influ- 
ence of alcohol is apparent. My impression is that chauffeurs, if placed 
in a separate class, would probably show a lower percentage, as they are OCCUPATIONAL MORTALITY STATISTICS AND TUBERCULOSIS 
729 
Table V.-Occupational Mortality Statistics, Per Cent. Distribution 
Occupations 
Number 
of 
deaths 
Tuber- 
culosis, 
per cent. 
Pneu- 
monia, 
per cent. 
Other 
respira- 
tory- 
diseases, 
per cent. 
Heart 
diseases, 
per cent. 
Diseases 
of 
digestive 
system, 
per cent. 
Saloon keepers and bartenders* 
2,190 
26.0 
8.7 
8.3 
Manufacturing and mechanical pursuits 
(female) 
4,582 
27.4 
6.1 
1.3 
10.3 
2.9 
Servants and waiters 
3,017 
27.6 
8.0 
1.8 
10.3 
2.4 
Dressmakers and garment workers* 
2,172 
27.8 
5.7 
12.6 
Bartenders 
1,115 
27.9 
11.0 
1.6 
8.3 
2.3 
Teamsters, drivers, and chauffeurs* 
6,471 
28.2 
8.5 
9.7 
Clerks and copyists 
7,384 
28.3 
7.3 
1.6 
8.6 
2.1 
Porters and helpers in stores 
1,253 
28.3 
11.7 
2.3 
10.8 
2.3 
Marble and stone cuttersf 
822 
28.6 
7.9 
4.2 
10.0 
1.0 
Plumbers, gas and steam fitters 
1,178 
29.2 
8.7 
1.6 
9.3 
2.6 
Printers, lithographers, and pressmen.... 
1,490 
29.2 
7.5 
1.6 
9.0 
2.2 
Longshoremen and stevedores* 
651 
29.2 
8.3 
12.6 
*Metropolitan Life Insurance Experience 1911-1913. 
tPrudential Industrial Insurance Experience 1909-1913. (Reduces in 1914-1918 to 23.5 per cent., 7 
per cent, and 2.3 per cent.) 
usually men of good stock and habits. They are, however, frequently 
exposed to carbon-monoxide poisoning. 
The high percentage of 27.6 in male servants and waiters, against 
a percentage of 19.5 in female servants and waitresses, may be accounted 
for by the percentage of alcoholism, which was 0.2 in females and 1.8 
in male servants. Females on the other hand, have a much higher rate 
from tuberculosis than males in the manufacturing and mechanical 
pursuits, or those engaged as bookkeepers and accountants, clerks 
and copyists, and garment workers. The high percentage in porters and 
helpers in stores may, in part, be accounted for by exposure to a mixed 
variety of dust, and possibly infected dust. Their rate for alcoholism is, 
however, far above the average. The high percentage in marble and 
stone cutters is doubtless influenced by exposure to mineral dust. 
The percentage of tuberculosis in plumbers, gas and steam fitters, 
and in the printing industry are exactly the same. The influence of a 
subtle form of lead poisoning is apparent in both occupations, but 
appears to be more pronounced in plumbers. While it is true that 
many men of feeble stock enter the printing trades, the same can not 
be said of plumbers, gas and steam fitters. Alcoholism is charged 
with a percentage of 1.1 in printers, and 0.9 in plumbers. 
Table VI includes 7 occupations; and the percentage of deaths 
from tuberculosis varies from 30.9 in females engaged in trade and 
transportation (as compared with 16.6 in males) to 42.4 in female clerks, 
bookkeepers, and office assistants (as compared with 22.5 in men). 
Lead and mixed mineral and metallic dust doubtless play a role in the 
mortality in brass workers, metal polishers and buffers. The percentage 730 
TUBERCULOSIS IN RELATION TO OCCUPATIONS 
Table VI.-Occupational Mortality Statistics, Per Cent. Distribution 
Occupations 
Number 
of 
deaths 
Tuber- 
culosis, 
per cent. 
Pneu- 
monia, 
per cent. 
Other 
respira- 
tory- 
diseases, 
per cent. 
Heart 
diseases, 
per cent. 
Diseases 
of 
digestive 
system, 
per cent. 
Trade and transportation (female) 
2,538 
30.9 
5.4 
1.5 
7.7 
3.7 
Brass workers* 
201 
31.8 
9.0 
2.0 
Clerks and copyists (females) 
844 
31.9 
6.2 
1.2 
6.4 
3.6 
Metal polishers and buffers* 
242 
31.9 
12.9 
12.9 
Textile workers (female)t 
1,742 
35.5 
4.1 
8.8 
Store clerks and saleswomenf 
794 
38.7 
3.9 
7.7 
Clerks, bookkeepers, and office assistants 
(female )t 
1,235 
42.4 
3.6 
8.1 
* Prudential Industrial Insurance Experience. 
t Metropolitan Life Insurance Experience, 1911-1913. 
from tuberculosis in female textile workers is 35.5 against 21.1 in males. 
The percentage in clerks and saleswomen is 38.7 (as compared with 15.8 
per cent, in salesmen). The questions of physique, race, and nationality, 
and many other factors such as bad ventilation, fixed postures, strains, 
repeated motions, pressures, etc., doubtless influence these differences. 
Table VII covers 52 industries or occupations, which, because not 
specifically enumerated in the foregoing tables or because of differences 
in percentage, are here presented. With few exceptions the data are 
based upon the experience of the Prudential Insurance Co. or collected 
by Dr. F. L. Hoffman.7 
Many of these occupations have already been commented upon. 
The low figures for furnace tenders in steel plants may be due to a 
more rapid labor turnover. Puddlers are recruited from a very sturdy 
stock. Coremakers are exposed not only to dust, but also to carbon 
monoxide from open wood or coke fires or red-hot cast-iron stoves. 
Artificial flower makers were formerly exposed to lead and arsenite of 
copper; anilin colors have replaced to a great extent the latter coloring 
agent. Gold-leaf workers have also, in Europe, a very high mortality 
rate from respiratory diseases. It is possible that the copper and zinc 
contained in the alloy may exert a toxic effect. Carpet weavers, uphol- 
sterers, weavers, hatters, tanners, spinners, silk weavers and lace workers 
show a mortality percentage which is double and, in some instances, 
more than treble, the average for all .occupations. The rate for tanners 
is unusually high, as the occupation exposes to poisons and dampness, 
and calls for strength and endurance. The handling of the dry hides 
involves inhalation of more or less dust of an animal and inorganic origin, 
and fragments of hair. In certain of the tanning and dressing processes 
there is exposure to disulphide of arsenic, chromates, lead, benzine, and 
amyl acetate. The rate for hatters is also very high, and cannot be 
wholly attributed to the volume or the character of the dust; indeed some OCCUPATIONAL MORTALITY STATISTICS AND TUBERCULOSIS 
731 
Table VII.-Percentage of Deaths from Tuberculosis in Certain Occupa- 
tions, Based upon the Industrial Experience of the Prudential Insurance 
Co. of America, 1907-1912 
Occupations 
Total 
deaths 
Tubercu- 
losis, 
per cent. 
Occupations • 
Total 
deaths 
Tubercu- 
losis, 
per cent. 
Furnace tenders in steel works 
62 
6.5 
Weavers 
587 
34.7 
Coal miners 
3,658 
9.7 
Cigar makers 
36.1 
Street cleaners 
197 
12.9 
Glass blowers 
197 
36.3 
Brick and tile makers 
133 
12.0 
Printers 
1,733 
37.3 
Slaters 
93 
13.7 
Hatters 
529 
36.6 
Quarry workers 
149 
14.8 
Glass cutters 
220 
36.4 
Blacksmiths* 
1,273 
14.8 
Tanners 
192 
37.2 
Heaters in steel plants 
5 
15.7 
Polishers and grinders (iron 
Rollers 
112 
17.9 
and steel) 
136 
37.5 
Miscellaneous employment in 
Stonecutters 
616 
37.6 
steel plants 
68 
20.6 
Copper miners 
611 
37.9 
Cement-lime workers 
222 
20.7 
Lithographers 
325 
38.3 
Knitting-mill employes 
103 
22.1 
Granite-stone cutters 
204 
39.2 
Laborers in iron-steel plants... 
2,788 
22.5 
Jewelers 
361 
42.3 
Iron-steel workers 
1,341 
22.6 
Spinners 
144 
42.5 
Street car employes 
1,088 
25.7 
Polishers and grinders (iron 
Stove mounters and grinders. 
27.9 
and steel) 
138 
42.9 
Draymen and teamsters 
9,799 
29.4 
Sheffield metal grinders 
2,640 
43.0 
Core makers 
357 
29.4 
Brass workers 
95 
43.7 
Artificial-flower makers (male) 
13 
30.8 
Silk weavers 
137 
44.5 
Glass workers 
336 
30.9 
Polishers and finishers in 
Gold-leaf beaters 
53 
32.0 
brass 
143 
45.2 
Pressmen 
224 
32.6 
Tile makers 
62 
45.3 
Carpet weavers 
101 
32.7 
Lead and zinc ore miners.... 
96 
49.0 
Coachmen 
337 
33.1 
Lace workers 
31 
49.2 
Upholsterers 
400 
33.6 
Slate-pencils workersf....... 
260 
64.2 
Painters 
1,056 
34.1 
Flint knappers and buhr- 
Shoe-factory employes 
34.5 
stone dressersf 
77.8 
Potters 
267 
34.6 
* Metropolitan Life Ins. Co. 
! German and English (Hoffman). 
of the processes are carried on in a dust-free atmosphere. It has been 
held for some time that the chief danger in this industry is exposure to 
the inhalation of nitrate of mercury which is employed in the carrotting 
process, and which, in the opinion of Dr. Legge8 forms an insoluble 
compound with the keratine in the hair and is not removed in the subse- 
quent process of the felt-hat industry. The men who make the solution 
and those who apply it are exposed not only to mercurial, but also to 
nitrous fumes, and all others engaged in certain dusty processes are 
exposed to the inhalation of dust impregnated with particles of nitrate 
of mercury. The stovers, who handle the hard felt shapers at a tempera- 
ture of 180°F. in the drying department, are exposed not only to mer- 
curial vapors, but also in some establishments to the fumes of wood 
alcohol, employed in the shellacking process to stiffen the hats, which 
doubtless exerts a toxic effect on the system. There is also danger in 
some establishments from arsenical poisoning, since, according to 
Heinzerling and Lewin,9 the fleshy part of hare and rabbit skins is not 732 
TUBERCULOSIS IN RELATION TO OCCUPATIONS 
infrequently treated with a soap containing arsenite of potassium or 
sodium. 
The excessive rates in glass workers, potters, file makers, and brass 
workers are likewise influenced not only by the character of the dust, 
but by exposure to lead. The rates for copper miners, and lead and zinc 
ore miners are also very high. This may be due to the high percentage 
of crystalline silica content in the dust of some of the mining districts; 
but since the percentage of deaths is very much lower in gold quartz 
miners, we strongly suspect that lead and copper may exert a toxic effect 
on the system in this class of miners. 
Table VIII.-Average Age at Death, by Occupation* 
Male 
Average 
Age at 
Death 
Bookkeepers and office assistants 
36.5 
Engineman and trainmen (railway) 
37.4 
Plumbers, gas fitters, and steam fitters 
39.8 
Compositors and printers 
40.2 
Teamsters, drivers, and chauffeurs 
42.2 
Saloon keepers and bartenders 
42.6 
Machinists 
43.9 
Longshoremen and stevedores 
47.0- 
Textile-mill workers 
47.6 
Iron molders 
48.0 
Painters, paper hangers, and varnishers 
48.6 
Cigar makers and tobacco workers 
49.5 
Bakers 
50.6 
Railway, track and yard workers 
50.7 
Coal miners 
51.3 
Laborers 
52.8 
Masons and bricklayers 
55.0 
Blacksmiths 
55.4 
Farmers and farm laborers 
58.5 
All occupations 
47.9 
Female 
Average 
Age at 
Death 
Clerks, bookeepers, and office assistants 
26.1 
Store clerks and saleswomen 
28.0 
Textile-mill workers . 
33.9 
Dressmakers and garment workers 
42.0 
Domestic servants 
49.1 
Housewives and housekeepers 
53.3 
All specified occupations 
51.1 
* Based upon the Experience of the Metropolitan Insurance Co. Industrial Department, 
1911-1913, by Statistician Louis I. Dublin, Ph. D. 
The percentage for slate-pencil workers is exeedingly high. They 
are quoted by Hoffman from Sommerfeld and apply to a class of workers 
whose physical and social economic conditions are notoriously low; one- AVERAGE AGE AT DEATH A HOPEFUL OUTLOOK 
733 
third of the workers were children below the age of 14. The mortality 
from tuberculosis is also high for slate workers in Wales. A British 
commission found that pure slate dust was rarely met with, but as a rule 
the dust included a considerable proportion of minute particles of adher- 
ent quartz. 
The percentage of tuberculosis in lace workers is very high; in Great 
Britain it is somewhat below the average. It is quite possible that 
the dust inhaled during the making of linen lace is more injurious, 
because Greenhow, as early as 1865, has shown that flax dust contains 
silica. Excessive heat and humidity are injurious factors in some of 
the departments, and according to Arlidge, exposure to coal gas from 
gas-heated stoves in the process of "gauffering" is not infrequent. 
There is likewise danger from lead poisoning in workers in lace and silk 
weighted with lead acetate. 
A HOPEFUL OUTLOOK 
Fortunately, the effects of legislation and factory sanitation, together 
with the gospel of personal hygiene and higher standards of living condi- 
tions, which have been emphasized in the educational campaign against 
the great white plague, are strikingly shown by a most marked decrease 
in the mortality from tuberculosis in 8 of the so-called dangerous trades 
in the State of New Jersey. 
Dr. F. S. Crum, assistant statistician of the Prudential Insurance 
Co., has kindly furnished me with data relating to occupations in the 
State of New Jersey. The table shows that the percentage of mortality 
from tuberculosis in hatters has been reduced from 29.7 in the period of 
1909-1913 to 23.6 in the period of 1914-1918; the pneumonia rate 
during the same period has been reduced from 8.5 to 7, and other respira- 
tory diseases from 4.9 to 2.3. In stone cutters the percentage of deaths 
from tuberculosis during the same period has been reduced from 26.3 to 
19 7; in metal grinders, from 39.2 to 29.1; in molders, founders, and 
casters, from 19.7 to 17.4; in other iron and steel workers, from 24 to 
17.2, and in plumbers, from 32.5 to 22.6. There was no decrease in the 
textile industry, the rate in the period 1909-1913 being 21.3, and in 1914- 
1918 21.7 per cent. 
In potters there was an increase in the percentage of tuberculosis 
from 32.4 (1907-1913) to 36.6 during the period from 1914-1918. This 
increase, fortunately, does not indicate an increased hazard, for by 
reference to the tables it will be noted that there was a distinct decrease 
at ages between 10 and 39, showing that the protective measures are 
really effective in all newcomers, but that they could not avert the 
damage inflicted in the older workers before the adoption of the present 
safeguards. 
Prevention.-In the prevention of the predisposing causes of industrial 
tuberculosis, in addition to the consideration of all the factors already TUBERCULOSIS IN RELATION TO OCCUPATIONS 
734 
mentioned, due attention should be given to the influence of home 
environments, such as unclean, crowded or otherwise insanitary dwellings, 
insufficient food, ignorance or disregard of correct living and working 
conditions and last but not least to the bad effects of the abuse of alcohol. 
It has been shown that the abuse of alcohol not only lowers the general 
resistance of the body, but the habit of remaining in saloons for hours, 
sometimes until midnight, deprives the individual of a proper amount of 
rest and exposes him to devitalized air and the toxic fumes of tobacco. 
Education alone without adequate wages to provide the necessities 
of life in order to maintain a proper standard of health will be of little 
avail. The startling facts remain that the mortality rates from indus- 
trial tuberculosis are still excessive. It has been estimated that over 
70,000 wage earners perished in 1910 from this disease in this country, 
reduced in 1921 to about 54,000. While much has been accomplished 
more remains to be done. In our efforts, let us remember that every 
movement that makes for better health and a temperate, untainted and 
virile race, will offer the best safeguard in the prevention of this disease. 
Indeed it is perfectly safe to state that, by effective preventive methods, 
the mortality rates from tuberculosis and other respiratory diseases may 
be further reduced fully one-half. 
This is not at all speculative, since Prof. Ropke informs us that, as a 
result of general education and factory sanitation, including, of course, 
cuspidors and the prevention of promiscuous expectoration, the mortality 
at Solingen, in Germany, the population of which is largely made up of 
employes in the cutlery industry, was reduced from 20.63 per 1000 in 
1885 to 9.3 per 1000 in 1910, and the consumption death rate from 540 
in 1885 to 180 per 100,000 of population in 1910. Similar data are 
available to show that diseases of the respiratory organs in one of the 
German cement works have been reduced from 9.3 per cent, to 3.3 per 
cent., after the installation of a suitable apparatus for the removal of 
dust. 
What can be done in some of the most dangerous industries in New 
Jersey and in Germany can be done everywhere, and will be done as soon 
as the importance of the subject is fully appreciated. 
Rbpke's table, comparing Solingen with Sheffield, which is the seat 
of the cutlery industry in England, is reproduced for the lesson it conveys. 
The marked contrast between these two cutlery centers was com- 
mented upon by Mr. C. Johnston, in the Annual Report of the Chief 
Inspector of Factories, as early as 1906. We quote from this report as 
cited by Oliver as follows: "The atmosphere of Solingen is bright and 
clear. • It is seldom that black smoke is seen escaping from the factory 
chimney. This is largely the result of careful firing and the use of coal 
briquettes, instead of ordinary coal. The factories are said to be marvels 
of order and cleanliness; the floors are of concrete, and the air space for 
each worker is 565 cu. ft. All the grinding stones are protected by A HOPEFUL OUTLOOK REFERENCES 
735 
Solingen Industrial Insurance 
Statistics 1909-1910* 
Sheffield Med. Officer of Health, 
1901-19091 
Total 
mortality 
per 
1000 
Mortality 
from 
tuber- 
culosis 
Other dis- 
eases of the 
respiratory 
organs 
Total 
mortality 
per 
1000 
Mortality 
from 
tuber- 
culosis 
Other dis- 
eases of the 
respiratory 
organs 
Grinders, polishers, buffers, 
etc 
9.30 
4.37 
2.35 
30.40 
15.10 
5.40, 
Other employes in the steel 
and cutlery industry 
9.00 
2.66 
1.79 
29.30 
5.80 
6.90 
Mortality Statistics 
* Based upon the statistics of 7908 grinders and 10,872 other employes in the metal 
industry. 
t Based upon 3941 grinders and 3889 other metal workers. 
guards. The walls of the work rooms are lime washed every year; the 
floors are swept clean every evening and damp wiped once a week. The 
'racing' of grindstones is never undertaken during the working hours, 
except under a stream of water, or unless the stone is entirely inclosed in 
casing except at the working place of the raising tool. One of the 
features of Solingen is said to be the large number of 'home workers.' 
These workmen own their own houses, behind which is a garden and at 
the rear of this is their small factory. There are 1475 small factories of 
this type in the district. In these the greater part of the grinding and 
glazing of scissors and razors is done. The floors are kept clean and 
provisions are made for the removal of dust during the grinding. Cutlery 
manufacture is recognized as a dangerous trade in Solingen, and in recent 
years considerable improvement has taken place in the means to prevent 
dust. • With the clean and tidy appearance of these tenement factories 
those of Sheffield compare most unfavorably. In Solingen the grind- 
stones and polishing wheels are run toward the worker; in Sheffield they 
are run away from the worker so that the dust has an upward tendency 
and flies into the room." 
REFERENCES 
1 The influence of an inadequate food supply is shown by the fact that the mortality 
rate from tuberculosis in Germany is as high now as it was in the early eighties, 
all the gains having been wiped out because of lack of sufficient food, and the 
consequent diminished resisting power of the system. 
2 Hoffman, Frederick L., Mortality from Respiratory Diseases in Dusty Trades: 
U. S. Department of Labor, Bureau of Labor Statistics, No. 231, June, 1918. On 
pages 46-50, the list of occupations representing the various dusty-trade groups 
are given, and offer material for serious reflection. 
3 Compiled from the report of the Bureau of the Census on occupational statistics, 
1910. 736 
TUBERCULOSIS IN RELATION TO OCCUPATIONS 
4 Landis, H. R. M., Jour, of Ind. Hyg., July, 1919, page 125. 
5 Hayhurst, Emery R., The Heath Hazards and Mortality Statistics of Coal Mining 
in Illinois and Ohio, Jour, of Ind. Hyg., November, 1919. 
6 Cited by Stephani. Weyl's Handb. der Arbeiterkrankheiten. Jena, 1908, pages 
634-635. 
7 Hoffman, Frederick L., Mortality from Respiratory Diseases in Dusty Trades. 
Bull. U. S. Bureau of Labor Statistics, No. 231. June, 1918. 
8 Legge, Thomas M., Oliver's Dangerous Trades. 1902. 
9 Cited by Schutte. Weyl's Handb. der Arbeiterkrankheiten, Jena, 1908, page 386. CHAPTER IV 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
SECTION 1 
FATIGUE AND OCCUPATION 
Fatigue is a corporeal condition which ought to be taken account of in 
all human activities. This is especially true of the activities of industrial- 
ism, and in the discussion of industrial efficiency by the more enlightened 
thinkers fatigue is now coming more and more into the foreground.1 In 
its relation to disease the importance of fatigue has never been adequately 
recognized, and here again industrialism seems to offer many examples of 
the general principles. Before proceeding to discuss these matters, it 
will be well to get in mind a clear picture of the nature of fatigue.2 
Fatigue in the individual has its subjective and its objective aspects 
and hence may be considered from the two standpoints of the psychical 
and the physical. After he has been active mentally or physically the 
average man "feels" tired; that is, to him fatigue is a matter of sensation, 
and his sensations are the sole measure of his weariness; he has no com- 
prehension of any material changes in his body which accompany his 
feelings. Yet important material changes have occurred. Many of 
them, however, are still unknown even to the specialist in fatigue and, 
indeed, both the psychical and the physical aspects of the subject are 
much in need of intensive investigation. 
Fatigue in the usual sense of the word may be defined as a diminished 
capacity for work which is the result of previous work. This final clause 
imposes upon the use of the word a somewhat too narrow restriction, for 
diminished capacity for work, indistinguishable from that due to previous 
work, is often present when previous activity has not occurred. Thus, 
disease may put the body into such a condition that its working power 
is lessened; lack of food may do the same; the excessive use of one group 
of muscles may diminish the power of other muscles or of the brain to 
work. These cases have certain causative factors in common and it is 
often convenient to use the word "fatigue" so as to include a considerable 
variety of such instances. Thus a usage of the word sharply limited to a 
state following work is not desirable. 
Fatigue of Tissues.-Diminished capacity for work may be demon- 
strated very clearly by a single muscle.2 If the muscle of an animal, such 
as a frog or a cat, be removed from the body immediately after death, be 
FREDERIC S. LEE, Ph. D„ LL. D., New York City 
737 738 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
attached to a weighted recording lever which writes on a slowly revolving 
drum, and be stimulated by electric shocks at regular intervals, a graphic 
record may be made of the resulting contractions as a series of vertical 
Fig. 27.-Series of contractions of a frog's sartorius muscle, excised and stimulated at 
intervals of 2% seconds. The contractions at first increase in extent, this stage constituting 
the treppe, reach a maximum, and later decrease, this stage constituting fatigue. 
lines (Fig. 27). The contractions at first increase in extent, as is indicated 
by a progressively increased height of the successive lines. This is 
followed by a period of only slight change in their extent and later by a 
progressive decrease. These three phases are called respectively the 
period of the treppe, or staircase, the period of maximum contractions, 
and the period of fatigue. If the muscle be stimulated more rapidly 
(Fig. 28), or be made to lift a heavier weight (Fig. 29), fatigue comes on 
Fig. 28.-Series of contractions of the two excised gastrocnemius muscles of a frog, 
lifting equal weights, the upper stimulated at the rate of 20 times, the lower at the rate of 
45 times, per minute. Note the earlier fatigue of the more rapidly working muscle. 
more rapidly. If at any stage in the fatigue the stimulation be stopped 
and the muscle be allowed to rest, there is a restoration of working 
power which is more or less pronounced according to the conditions of 
the experiment. If a circulation of blood or other appropriate oxygenated 
liquid be established through the muscle, recovery may be complete 
(Fig. 30). All kinds of muscle are capable of fatigue, not only the 
skeletal muscles of the limbs and the trunk, but the muscle of the heart 
and the unstriated muscle of the other viscera. To what extent the 
phenomena mentioned have their counterpart within the intact living 
body is not wholly clear. Here the voluntary muscles act only after 
being stimulated by the nervous system. The motor end-plate junc- 
tional substance between the nerve fibre and the muscle fibre, seems 
to undergo fatigue earlier than the muscle substance itself, and thus FATIGUE OF TISSUES 
739 
may possibly protect the muscle fibre from pronounced diminution of 
its working power. 
The diminution in the capacity for work which is so evident in the 
fatigue of excised muscle has been demonstrated, although less clearly, 
Fig. 29.-Series of contractions of the two excised gastrocnemius muscles of a frog, 
stimulated at the same rate of 27 times per minute, the upper lifting 10 grams, the lower 
30 grams. Note the earlier fatigue of the muscle doing the more work. 
by laboratory experiments on certain other tissues and is in general 
characteristic of all living substance. Much effort has been expended in 
attempting to learn whether nervous tissue, either within or without the 
central nervous system, is capable of fatigue. This effort was for a long 
time blocked in the case of nerves themselves, which seem to exhibit no 
Fig. 30.-Series of contractions of a frog's gastrocnemius muscle in situ with the circu- 
lation of the blood undisturbed. The muscle was stimulated for 9 minutes, was allowed 
to rest for 15 minutes during the break in the series, and was then stimulated for 9 minutes. 
Note the recovery from fatigue during the brief rest. 
signs whatever of fatigue after being stimulated for even many hours. 
More recently it has become possible to detect a decrease in their electrical 
current of action and their irritability and thus a diminished capacity for 
work after nerves have conducted nervous impulses for a considerable 
period of time. It is not at all certain, however, that this occurs in the 
intact living body, where nerves seem to be extraordinarily resistant to 
the deleterious results of previous activity. So within the brain and 
spinal cord it has been difficult to demonstrate fatigue,2 and the idea is 
prevalent, also without wholly satisfactory experimental evidence, that 
while the central nervous system is capable of fatigue no part of the 
nerve cell, or neurone, is readily fatiguable, and that when nervous fatigue 740 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
does appear, it is localized primarily in the synapses or membranes at 
the junctions between successive neurones. 
Changes in the Tissues in Fatigue.-The diminished capacity for 
work that appears in living substance engaged in activity is a sequence of 
chemical changes that occur in the substance and are a part of its 
metabolism.2 These chemical changes involve physico-chemical and phys- 
ical changes. The chemical changes are, in general, of two kinds: First, 
material that is essential to activity is gradually used up and thus the 
stock of available material gradually becomes exhausted; if this process 
continues without new material being supplied, activity must in time 
necessarily cease. Secondly, there appear katabolites, or products of 
activity; these are detrimental to the living substance and, if allowed to 
accumulate, gradually diminish its working power; they are therefore 
often called 11 fatigue substances." These two processes constitute the 
chemical causes of fatigue. They occur simultaneously, and in a given 
instance it is hardly possible to determine their relative importance in the 
fatigue process. 
Chemical Changes in the Tissues in Fatigue.-As to the identity of 
the chemical substances involved in fatigue, the matter is still in much 
dispute, even after years of investigation. Chief attention has been given 
to the case of muscle. When muscle contracts, its available oxygen 
enters into chemical combination with other substances, and its glycogen, 
which is the chief source of muscular energy, undergoes disintegration. 
Unless oxygen and glycogen are replaced as fast as they are used up, the 
muscle in time ceases to contract. The same may be true of other 
substances. 
Much labor has been expended in efforts to identify the so-called 
"fatigue substances." More than fifty years ago the idea arose-and it 
has prevailed down to recent times-that carbon dioxide and lactic acid, 
produced in muscular activity, contribute to muscular fatigue. It has 
been shown2 that when administered to the excised muscle in certain 
quantity they act deleteriously upon the muscle cells, and diminish their 
irritability and their working power. When in smaller quantity, on the 
contrary, they act in the opposite manner and temporarily increase the 
working power of the muscle. To this latter action the author has 
ascribed the treppe, or preliminary period of progressively increased 
contractile power, which is present in the early stages of a prolonged period 
of muscular work. Other chemical substances involved in muscular 
metabolism have also been proposed as "fatigue substances," but with 
little justification. An endeavor has even been made to demonstrate 
the existence in fatigued muscles of a specific toxin of fatigue, resembling 
in various properties bacterial toxins. While this is inherently improb- 
able it seems also to be disproved experimentally.3 Until more is known 
of the chemical changes occurring in the muscle cells it seems idle to desig- 
nate certain specific substances as responsible for muscular fatigue. TISSUE CHANGES FATIGUE IN THE LIVING BODY 
741 
If this is true of muscle it is even more true of other tissues. It is con- 
ceivable that any katabolite accumulating in an active tissue may dimin- 
ish its working power, but the whole subject of metabolism in fatigue 
is much in need of investigation. 
Fatigue in the Living Body.-When we turn from the fatigue of specific 
tissues to the phenomena of fatigue in a complex organism like the human 
body, the problem becomes much more difficult. Here the tissues do not 
act separately; the excessive work of one increases the work of others. 
Contracting voluntary muscles must be directed by an active nervous 
system, and they demand more work by the heart and the respiratory 
organs and induce more secretion by the various glands. All of these 
actions in turn involve the nervous system in greater activity. Drain 
upon a store of metabolic material in one organ is followed by a call for a 
supply elsewhere in the body. Moreover, if a deleterious katabolic 
substance is produced in quantity by one organ it is conceivable that it 
may pass in circulating blood and lymph throughout the body, and may 
diminish the working capacity of other organs or tissues. The distribu- 
tion of the blood in the body is probably altered by a long-continued 
fatiguing task: by the end of a hard day's work much blood has probably 
been drained away into the viscera and the limbs, and the brain is left 
relatively anemic, this doubtless accounting in part for the feeling of 
sleepiness that is then present. In these ways fatigue of one part of the 
body may conceivably induce the phenomena of fatigue in other parts- 
local fatigue may result in general fatigue. The exercise of one set of 
muscles, for example, will fatigue most those muscles and the corre- 
sponding parts of the brain and spinal cord, but it may conceivably result 
also in some degree of fatigue in other parts of the body. A person who 
has worked sufficiently hard to tire his muscles may have a tired brain as 
well, and the exhausted brain worker is in no condition for performing 
hard physical labor. A change of work is often beneficial as a temporary 
expedient to relieve a part of the body that is in danger of becoming 
exhausted, but there are limits to the possibility of such benefits, and it 
ought always to be borne in mind that excessive work by one part may 
mean a certain degree of fatigue for all parts. 
It is now generally conceded that, contrary to popular belief, sensa- 
tions of fatigue are no measure of diminished capacity for work. It has 
been demonstrated by careful laboratory tests that a given task may be 
performed as effectively and as readily whether the individual feels fresh 
or tired. Thus, a student, although feeling used up and incapable of 
further work, may be able to solve arithmetical problems just as quickly 
and correctly at the end of a series of such tasks extending over many 
hours as at the beginning. A feeling of fatigue often may induce a dis- 
inclination to work and even a powerful aversion toward it, and this may 
diminish the amount of work accomplished, although at the same time 
not decreasing working capacity. A slight change in one's mental state 742 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
often makes a great difference in, achievement. Soldiers can march 
farther and with less feeling of fatigue when music accompanies them. 
Ayres4 found that in a 6-day bicycle race the average number of miles 
ridden per hour on one of the days of observation was 18.8 with no music, 
and 21 when the band played. 
Recovery from Fatigue.-Comparatively little is known of the details 
of the process of recovery from fatigue. Epinephrin, the active principle 
of the medulla of the adrenal bodies, when administered to fatigued muscles 
appears to have a powerful effect in increasing their irritability and their 
contractile power.5 It also counteracts the fatigue induced in excised 
muscles by perfusion with such a supposed "fatigue substance" as lactic 
acid. How it does this is not known. Nor is it known under what 
circumstances it acts in the living body. Some investigators have 
claimed the discovery of a specific antitoxin of fatigue, but the existence 
of such an improbable body is not proved. It is obvious that rest 
brings recuperation (Fig. 30). During rest there is an opportunity for 
whatever deleterious katabolites may be present to be eliminated from 
the fatigued tissues and from the body. At the same time rest gives 
an opportunity for the rebuilding within the cells of the substances 
that are necessary to further activity. 
Tests for Fatigue.-Much ingenuity and time have been expended by 
investigators in efforts to discover reliable objective signs of fatigue in 
human beings and to devise ready methods of demonstrating them. 
Fig. 31.-Series of voluntary contractions of the flexor muscles of the middle finger lifting 
a weight of 3 kilograms. Note the progressive fatigue. (From Mosso.) 
Many of these efforts have failed.6 One of the earliest contributions 
was that of the ergograph of Mosso7 which records the contractions of a 
certain set of muscles, such as those involved in the bending of a finger, 
when stimulated at regular intervals, either by the will through the nervous 
system or by electric shocks directly applied to the muscles, and when 
made to Eft a given weight (Fig. 31). The ergograph was believed to 
afford an exact method, easily applied, by which bodily fatigue can be 
readily demonstrated, and it was extensively used to obtain data for the FATIGUE RECOVERY FATIGUE TESTS 
743 
formulation of the laws of human fatigue. It has now been shown, 
however, that ergographic records are really significant only when made 
by a trained subject. Even then the fall in the curve as the work 
progresses is not necessarily a measure of ultimate fatigue of either the 
muscles or the nerve tissues. A slight diminution in the weight to be 
lifted often shows that the mechanism is in good condition and is capable 
of working for an indefinite period. 
A strength test devised by Martin8 has proved its usefulness in 
occupational investigation. Here the subject resists as powerfully 
as possible by muscular contraction traction applied to a certain group 
of muscles by means of a graduated spring balance. The number of 
pounds' pull required to overcome the resistance is the measure of 
the strength of the muscle group. In studying industrial workers five 
paired groups of muscles are employed: pectorals, forearm flexors, wrist 
flexors, thigh abductors and thigh adductors; and from the sum of 
the strengths of these ten groups is calculated by a simple method the 
total strength of the body. The method is easily and quickly applied. 
Besides various interesting facts regarding the strength of industrial 
workers and its relationship to their work, the method has demonstrated 
the fatigue of the day's work, its more pronounced character in hard than 
in easy operations and among weak than strong operators, its greater 
amount after a short than a long working day, its frequent persistance 
into the following day, its greater frequency following days of poor 
physical condition, etc. 
A quantitative method of demonstrating fatigue by a measurement 
and evaluation of vascular conditions, such as heart rate and blood 
pressure, has long been sought but is not yet perfected.6 Nor has a 
satisfactory chemical method yet been devised on the basis of metabolic 
changes in the body. 
Various so-called mental tests, such as speed and accuracy in the per- 
formance of arithmetical problems, the speed and accuracy of perception 
and of certain movements, attention tests, memory tests, the estimate of 
time, .the degree of sensitivity of the skin to stimuli variously applied, and 
others, have all contributed valuable data,9 yet they require intelligent 
trained subjects under exact experimental conditions and the expenditure 
of considerable time, and even when all the requirements for accurate 
observation are provided they cannot be relied on to reveal unerring signs 
of fatigue. 
Thus, until a larger number of adequate and readily applied methods 
of quantitative measurement and accurate localization in the intact indi- 
vidual can be devised, fatigue as a topic of exact science must remain in an 
unsatisfactory state. The lack of such methods is especially regrettable 
in the field of industrial occupations. Here our conclusions as to the 
presence and the degree of fatigue must for the present be largely a 
matter of indirect inference rather than of direct demonstration. 744 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
Fatigue and Disease.-The connection between fatigue and disease is 
probably much more frequent and close than is usually recognized. To 
disease fatigue stands in the relation of both cause and effect. That it may 
be a factor in causing infectious disease is, indeed, often believed, and 
this belief was apparently justified by laboratory experiments. Thus, it 
was found that of two groups of animals, the one resting and the other 
fatigued by muscular work and both inoculated by pathogenic bacteria, 
the fatigued animals exhibited a fall of the opsonic index and succumbed 
to the disease in larger numbers.10 This was interpreted as indicating 
that the resistance of the body to the action of bacteria was diminished by 
the metabolic changes involved in the fatigue processes. Later experi- 
mental work seems to throw doubt upon this conclusion, and further 
investigation is here needed. 
Outside the realm of infections, fatigue as a causative factor in 
disease seems obvious in neurasthenia. The most common single 
precedent of this form of neurosis is excessive activity of the nervous 
system. Continued muscular fatigue, if it is without accompanying exces- 
sive excitation of the nervous system, probably cannot induce neuras- 
thenia; the nervous system is the primary seat of the preceding fatigue 
process. There are, of course, many contributing causes, but overwork, 
overpressure, overstrain are the unavoidable precedent of the nervous 
breakdown. 
The immediate causative relation of fatigue to other diseases is not 
clearly established but it seems probable. Fatigue in a normal degree 
is a harmless, even a healthful, phenomenon-fundamentally metabolic 
-which involves a physiological depression of the bodily functions and 
induces its own termination and a return to the former capacity for work, 
but it can easily be carried too far; destruction of cellular material and 
the accumulation of toxic katabolic substances unwisely persisted in 
without adequate opportunities for recuperation can proceed to a 
pathological degree and interfere profoundly with the normal metabolic 
processes of the organism. Thus the foundation of profound diseased 
conditions may be laid. 
That fatigue, or at least proneness to fatigue, is an effect of disease is 
too obvious to require discussion: diminished capacity for work is the one 
almost universal accompaniment of diseases that involve alterations of 
general metabolism, such as infections, febrile diseases, and diabetes. 
Here the loss of substances that are essential to activity is well illustrated 
by the destructive metabolism of febrile diseases and the excretion of 
sugar in diabetes mellitus. Here too there appear certain toxic substances 
which from their depressing action may not inappropriately be called 
"pathological fatigue substances." This group includes probably 
bacterial11 toxins and a considerable number of intermediate metabolic 
products derived from the body's own cells. Examples of pathological 
fatigue substances are oxybutyric acid, which is common in diabetes FATIGUE AND DISEASE-FATIGUE AND OUTPUT 
745 
mellitus, and indol, which is common in intestinal putrefaction. These 
substances are known to be depressing to living tissues,12 and whenever they 
are present in quantity in the living body, fatigue is a prominent symptom. 
Further research will, without doubt, reveal the depressant action of other 
products of pathological metabolism. Here is a wide field for research. 
Research is much needed also in such conditions as neurasthenia, myas- 
thenia gravis, and various other diseases which are characterized by exces- 
sive susceptibility to fatigue. In these conditions it is justly conceivable, 
but not proved, that faulty metabolism, resulting in the occurrence of 
pathological fatigue substances, is responsible for the characteristic 
symptoms. 
Fatigue and Industrial Occupation.-For more than a century it has 
been increasingly recognized that fatigue plays a considerable role in 
industrial occupation, but it has been only within a decade that system- 
atic efforts have been made to investigate the matter with the accuracy 
of modern scientific methods. The world war with its unparalleled 
demands on industry gave a great impetus to such study, which is 
revealed especially in the publications, in England, of the Health of Mun- 
ition Workers Committee,13 the Industrial Fatigue Research Board and 
the National Institute of Industrial Psychology,14 and, in the United 
States, of the Public Health Service.15 It is now known that fatigue 
must be reckoned with in the output of workers, the time lost by 
workers, the accidents of industry, the health of workers, and other 
matters. These may now be successively considered. 
Fatigue and Industrial Output.-Fatigue diminishes industrial output. 
The U. S. Public Health Service15 made a carefully controlled study of the 
hourly and daily output of many workers in many operations in two large 
and representative metal-working factories, one maintaining eight-hour 
shifts, both day and night, the other ten-hour shifts for its day work and 
twelve-hour shifts for its night work. The course of output hour by 
hour in the total operations of the three shifts studied, namely the 
eight-hour day shift, the ten-hour day shift, and the twelve-hour night 
shift, is represented by curves in Figs. 32 and 33. The features common 
to the six spells of work here illustrated are the rise in the first part of the 
spell and the fall in the second part. The rise is usually interpreted as 
the effect of practice, the fall as the effect of fatigue. It is further to be 
observed that in all of the three shifts the fall from maximum is greater in 
the second spell, that is, where greater fatigue might be expected, than in 
the first spell. Furthermore, the relation between output and length of 
working period is revealed by the fact that there is an increasingly greater 
fall in the series: first spell of eight hours, second spell of eight hours, first 
spell of ten hours, second spell of ten hours, first spell of twelve hours, 
second spell of twelve hours. Most striking is the curve of the long night 
work, with its phenomenal fall to almost nothing in the early morning 
hours, when the greatest fatigue might be expected (Fig. 33). 746 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
The course of output varies with the kind of work performed. The 
investigators of the Public Health Service found that of two types of 
handwork which may be termed dexterous and muscular respectively, the 
output of the latter is characterized by an earlier appearance of the 
maximum in both spells-in the first hour instead of the second-a more 
rapid decline during each spell, a greater recovery as the result of the 
Eight Hour Plant 
Total of Representative Operations 
Ten Hour Plant 
Fig. 32.-Index numbers showing precentage variations of hourly output from limit of 
possible efficiency (U. S. Public Health Service Bulletin No. 106). 
luncheon period, and a much lessened achievement during the final hour 
of the day's work-all of which signifying that fatigue is more pronounced 
in the muscular than the dexterous operations. In machine operations, 
such as lathe work, there is a greater maintenance of hourly output as the 
day proceeds. 
Not all curves of output, however, are as clear-cut as these quoted, 
and it is probable that fatigue may be present with little or no fall 
in output, and that a fall in output does not always signify fatigue. FATIGUE AND OUTPUT FATIGUE AND LOST TIME 
747 
When the total outputs of the successive days of the week are com- 
pared it is possible to recognize both a weekly practice effect and fatigue. 
The low output of Monday, the "Monday effect," is well known. The 
output usually rises to a maximum in the middle of the week and then 
falls off as the worker's capacity is diminished. 
Fatigue and Lost Time.-Workers may lose time because of two quite 
different causes: first, those due to the breakdown of machines, waiting 
for material, and others, all outside the worker's control; and second, 
Ten Hour Plant Night Work Type 
Fig. 33.-Index numbers showing precentage variations of hourly output from limit 
efficiency (U. S. Public Health Service Bulletin No. 106). 
those dependent on his own capacity or volition. These latter may be 
expressed in absence from work, delayed arrival at and early leaving the 
working place, and deliberate cessation of work in the midst of the 
working period. Though the causes of lost time that are dependent on his 
own capacity or volition are often difficult of identification, it seems 
certain that fatigue is one of them. The U. S. Public Health Service15 
found, as regards the eight-hour and the ten-hour plants studied, that at 
the former, work with almost full power began and ended approximately 748 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
on the schedule times, and lost time throughout the day was reduced to a 
minimum; while at the plant with the longer day there was greater delay 
in starting work, much earlier stoppage, especially at the end of the after- 
noon spell, and much loss of time throughout the working period. Thus, 
using 90 per cent, of the total electric power consumption as the criterion, 
in the operations studied it required only 7 minutes to get under way in 
the morning at the eight-hour plant, and 12.2 minutes at the ten-hour 
plant; while at the end of the day the power consumption had fallen below 
90 per cent, at the eight-hour plant 8 minutes, and at the ten-hour plant 
21,5 minutes, before the schedule time for stopping work. 
From records of several thousand workers at three factories Vernon1 
found that there was a direct relation between the percentage of time 
lost through sickness and the number of weekly hours worked: the 
percentage of time lost through sickness was for men 7.0, 5.7 and 4.0 
with 63.25, 61 and 54 hours worked respectively, and for women 6.4, 
4.3 and 3.1 with 62, 54 and 44 hours worked. Rowntree16 reports that 
at the Cocoa Works of York, England, reduction of the week's hours from 
48 to 44 resulted in a reduction of the average percentage of the possible 
hours lost by the employes, excluding three absent for a whole week, 
for men from 2.7 to 1.8 and for women from 3.3 to 2.7. As a further fact 
of interest the figures of both these observers reveal, for the same 
number of hours worked, a higher percentage of time lost by women 
than by men. 
Fatigue and Industrial Accidents.-Accidents to workmen are caused 
by something going wrong with either the machine or the man. The 
larger number of industrial accidents are probably due to the latter. 
Of 2678 accidents in the state of Illinois in 1910 Bogardus17 found 17.2 
per cent, to result from events beyond the control of the injured-the 
breaking of machinery, the bursting of boilers, flying pieces of metal-and 
the remaining 82.8 per cent, to come from lack of proper movements by 
the workman himself. The distribution of accidents in the working day 
is probably significant. Bogardus found them to increase in number 
gradually throughout the forenoon reaching a maximum between 11 and 
12 o'clock, to diminish sharply during the hour when most workers are 
having their luncheon, and to rise progressively to a second and equally 
large maximum between 4 and 5 o'clock (Fig. 34). A progressive in- 
crease through both forenoon and afternoon is shown by the statistics 
of most countries where accurate records have been made, but the two 
maxima usually occur before the final hour. This falling-off in number 
toward the end of each half-day is usually ascribed partly to the decrease 
in the number of persons working, partly to a more leisurely attitude of 
most of the workers, and partly to a spurt on the part of a few who are 
stimulated to more acute attention and greater care by the prospective 
release from work. Besides the daily course of accidents there is in 
certain industries a weekly progression, more injuries occurring late in FATIGUE AND INDUSTRIAL ACCIDENTS 
749 
the week than early. Monday usually breaks into the regularity of the 
series by exhibiting a considerable number, which has been ascribed to 
dissipation on the day of rest; this inference is probably not wholly 
justified. The day after any holiday is similarly marked. 
Hours 
7 to 8 a. m. 
8 to 9 a. m. 
9 to 10 a.m. 
10 to 11 a. m. 
11 a. m. to 12 m. 
12 m. to 1p.m. 
1 to 2p.m. 
2 to 3 p.m. 
3 to 4p.m. 
4 to 5 p.m. 
5 to 6p.m. 
Other hours 
No. of accidents 50 100 150 200 250 300 
Fig. 34.-The distribution of industrial accidents during the working day. 
(From Bogardus.) 
The causative conditions under which accidents occur are several. 
Inexperience is a prolific cause: the U. S. Public Health Service15 found 
that the number of accidents varies directly with the number of new 
workers employed. Temperature is an important factor: Vernon1 found 
fewer accidents to occur between 65° and 69° F. than below and 
above these limits. Speed of production is a fertile cause: the faster the 
work the more injuries to the worker. It is generally recognized that 
fatigue is one of the chief causes of accidents. This is suggested by their 
increasing number as the working spell progresses and output diminishes. 
But the Public Health Service points out that more significant than the 
absolute accident curve is the curve of the ratio of accidents to output, 
in other words the accident risk. "A higher accident risk accompanies 
the deeper decline of working capacity-(1) in the second spell as com- 
pared with the first; (2) in muscular work as compared with dexterous 
and machine work; (3) at the ten-hour plant as compared with the 
eight-hour plant." Modern industrial work demands on the worker's 
part keenness of attention and precision of movement. A hair's breadth 
often marks the dividing line between safety and harm. Without a 
sharp focus of attention, without accurate coordination of the muscles 
involved in an act, the workman may come into contact with the molten 
metal, or touch the moving knife, or become caught in the revolving gear. 
Both keenness of attention and precision of movement are impaired in 
fatigue, and thus the work leads the worker on to his own injury. This 
is often ascribed to his carelessness, and yet in many cases carelessness 
has a physiological basis in fatigue, and thus we get back to the depres- 
sion of the physiological powers as one of the physical essentials of 
liability to accident. 750 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
Fatigue and Health of Industrial Workers.-One of the most striking 
evidences of the existence of fatigue and its seriousness in industrial work 
is found in a consideration of the health of workers. Here we must dis- 
tinguish between localized and general affections. Localized affections 
comprise those in which one part of the body, such as a group of muscles 
with their nervous connections, is overstrained by long-continued use. 
Here are to be grouped the fatigue neuroses, such as writers' cramp, 
telegraphers' cramp, and the various other spasmodic muscular condi- 
tions that occur in violin and piano players, seamstresses, shoemakers, 
hammermen, and others, as well as miners' nystagmus and the prof essional 
torticollis of tailors and cobblers. The seat of these pathological condi- 
tions is probably the central nervous system; they have, however, not yet 
been critically analyzed sufficiently from the physiological standpoint, 
and their real nature is therefore unknown. The ascription to fatigue as 
the causative agent of the more general diseases from which industrial 
workers suffer is not so clear as with the localized affections. It is doubt- 
ful, for example, whether the proneness of locomotive engineers to 
diabetes is rightly to be attributed, as has been done, to the nervous 
strain of their work. With nervous disorders and especially neurasthe- 
nia, however, the connection seems quite evident. There can be no 
question that this state of chronic generalized fatigue, which has usually 
been supposed to be peculiar to professional men, men of large affairs 
and the wealthy unemployed, is often directly the sequel of the cumula- 
tive fatigue of the long-continued, monotonous, wearing labor of indus- 
trial workers. There is a general consensus of opinion among those 
best fitted to know that in recent years there has been a marked increase 
of neurasthenia among working people, and that this is due largely to the 
overstrain of their occupations. Leubuscher and Bibrowicz18 showed 
that at the large industrial sanitoria at Giitergotz and Beelitz in Germany 
26 per cent, of the patients were neurasthenics, and the percentage of such 
cases for individual years rose from 18 in 1897 to about 40 in 1904 and 
1905. Some of these cases were classified according to occupation as 
follows: 
Per Cent. 
Type-setters 15.75 
Carpenters 9.45 
Locksmiths 5.00 
Mechanics 1.90 
In a study of 200 cases of neurasthenia and hysteria in the Industrial 
Sanatorium at Zehlendorf, Schonhals19 found the distribution between 
skilled and unskilled workers to be as follows: 
Artisans, highly skilled, 57 per cent. 
skilled, 17 per cent. 
unskilled, 26 per cent. 
74 per cent. 
General workers FATIGUE AND HEALTH-FATIGUE IN MODERN INDUSTRY 
751 
A marked percentage of these workers were engaged in factories, where 
the strain of work is apt to be great. Cardiac disorders of nervous origin 
are common among working people. Roth20 has pointed out the preva- 
lence of ansemia among young women workers, especially those in textile 
factories, shop-girls, sewing women, and maids in hotels and public 
houses, among all of whom overwork is common. 
Fatigue and Borderland of Illness.-Even where diminution of output 
is not present and where specific diseases cannot be traced directly to the 
fatigue of labor it is undoubted that industrial overwork often occurs and 
puts the worker into a physical condition, at present difficult to recognize 
by any specific test, wherein his physiological mechanism is in a state of 
depression and ready to fall a prey to specific maladies. Treves21 speaks 
of this as not presenting "a well-defined morbid picture; but it is a slow 
deviation, often obscured by its very slowness, and predisposing to illness 
of any nature; it is the borderland of illness." The future careful study of 
individuals will doubtless make this condition more precise. 
Characteristics of Modern Industry.-It is a common belief that 
fatigue and its resulting evils are relatively more common among indus- 
trial workers in recent than in earlier times. Notwithstanding the many 
evils of the earlier human slavery, now happily nearly extinct throughout 
the world, this belief is probably in the main correct. Greater fatigue is 
to be expected from certain specific characteristics of modern industry. 
While these differ in detail in different industries they frequently include 
the following: The great division of labor and the consequent specializa- 
tion of the work of each individual, the speed of the work, certain other 
factors of the work, the imposition of long working periods and of over- 
time work, the introduction of piecework, and the crowding together of 
large numbers of human beings within confined spaces often poorly ven- 
tilated. These will now be considered in detail. 
Specialization and Speed of Work.1 '22- A pronounced feature of modern 
industrialism is the great division of labor among the workers and the 
limitation of the task of each to a specific procedure. While certain kinds 
of work still require the expenditure of much muscular force by the 
worker, the introduction of machinery has tended in general to diminish 
muscular effort. It has, however, been replaced by a new element which 
is no less fatiguing, namely, speed. Thus, in the making of hinges a 
woman lifts a half-formed hinge, places it in the bending machine and 
quickly withdraws her hand, and repeats this series of movements at the 
rate of 50 times a minute, or 30,000 times a day. The tops of tin cans are 
cut by pressing the lever of a foot press 40 times a minute, 24,000 times a 
day. In the telephone service an operator can receive, answer and make 
the proper connections for from 200 to 300 calls in an hour; in weaving one 
woman must supervise 16 to 24 looms, ever watchful that they are running 
properly; in sewing a single girl watches intently the 12 jumping needles of 
her power machine; in the making of women's clothing by modern 752 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
machinery one operator in an hour will tuck 250 yards of lawn, another will 
hem 400 yards of voile, another will make 1000 buttonholes, and still 
another will sew on 800 buttons; in the manufacture of candy one 
employe will wrap 9000 caramels in a day; and in a cigar factory one man 
will bunch 2000 stogies. An expert can insert in one day the eyelets into 
4000 shoes; another can trim the superfluous leather from the uppers 
of 5200 shoes. A machine-made shoe in the process of manufacture is 
said to pass through the hands of no less than 100 workers. A worker 
doing one thing does nothing else, that is, his main activities are limited 
to a small part of his body, to a restricted neuromuscular mechanism, 
which undergoes a rapid rhythmic exercise. In some cases this exercise 
becomes hardly more than a series of exactly similar unconscious reflex 
actions; in others it demands the aid of an acutely attentive consciousness. 
The danger lies in the pace becoming so rapid that there is little opportu- 
nity, such as usually exists with the rhythmically beating heart, for 
recuperation between successive discharges of energy. At the end of 
the day's work, therefore, the physiological mechanism involved is too 
often near exhaustion and even the rest of the body may suffer likewise. 
We have here, indeed, a condition strikingly like that of the single 
excised muscle of the familiar laboratory experiment (Fig. 27): With the 
excised muscle the stimuli are electric shocks regularly and rapidly 
repeated; with the industrial worker there is a restricted group of muscles 
stimulated rhythmically from a particular part of the nervous system. 
In both cases necessary metabolic material is consumed and deleterious 
katabolites may be produced. With the excised bloodless muscle there is 
no replacement of the one or the removal of the other, and the stage of 
exhaustion is quickly reached; with the human muscles and the associated 
nervous tissues fuel and oxygen are brought and wastes are removed by 
the blood, but with the great speed of stimulation katabolism is pretty 
sure to exceed anabolism, and thus favorable conditions are provided 
for the production of pronounced fatigue in the parts involved and a lesser 
degree of fatigue in other parts of the body. The lesson of Fig. 28 is here 
directly applicable. 
Certain Other Factors of Work.-Besides speed there are certain other 
features of industrial work which contribute to fatigue. This is obvious, 
for example, in the lifting of heavyweights. Fig. 29 shows clearly that the 
heavier the load the earlier is the muscle exhausted. Processes that 
involve the jarring of the body are probably also similarly detrimental. 
This is a feature of the action of certain kinds of heavy machinery and 
especially of pneumatic tools. The excessive noise of some kinds of 
machinery, especially looms, acts to distract the attention and thus may 
make more wearing the specific task of the worker. This is doubtless a 
greater factor in the production of fatigue when the noise is variable in 
intensity and uncertain in its onset; it is conceivable that a worker may 
become accustomed to and learn to neglect a constant hum or roar in his FATIGUE IN MODERN INDUSTRY 
753 
environment. Faulty or strained postures of the body, necessitated by 
the holding of tools in certain positions or the tending of machines, are 
a fruitful and often unnecessary source of bodily fatigue. The same is 
doubtless true of unsuitable or inadequate food and an unhygienic home 
life of workers-matters which often are within the sphere of influence or 
control of employers. > 
Length of Working Period.23-The tendency of modern industrialism, 
actuated by commercial motives, has been to demand of laborers the 
longest possible working period. More than a century ago humanitarian- 
ism, urged by the evils of excessive labor, began to protest against this 
unbridled overtaxing of human beings and undertook to secure legal 
limits to the length of the working day. The passage by the British 
Parliament in 1802 of the Health and Morals of Apprentices Act marks 
the beginning of such legislation. The science of physiology can now 
provide even stronger arguments for reducing the hours of labor than can 
humanitarianism, and in recent years there is here a tendency to utilize 
physiological knowledge. That there has been great diversity of custom 
as to the duration of labor in different countries and within the United 
States is shown by the following tables. It is still too early to say 
whether these figures have been modified by the disturbing influence of 
the World War. 
Relative Percentage of Weekly Hours of Labor in Different Countries, 
Those of the United States being Taken as 10024 
United States 100 
England and Wales 104 
Germany . . 115 
France 121 
Belgium 126 
Weekly Hours of Labor in the United States25 
Prevailing hours of labor per 
week 
Wage earners in establishments with specified 
number of hours 
Average number 
Per cent, of total 
1909 
1914 
1909 
1914 
Total 
6,615,046 
7,036,337 
100.0 
100.0 
48 and under 
523,652 
833,330 
7.9 
11.8 
Between 48 and 54 
481,157 
945,735 
7.3 
13.4 
54 
1,019,438 
1,818,390 
15.4 
25.8 
Between 54 and 60 
1'999'307 
1,543,018 
30.2 
22.0 
60 
2,017,280 
1,487,891 
30.5 
21.1 
Between 60 and 72 
344,011 
247,798 
5.2 
3.5 
72 
116,083 
104,294 
1.8 
1.5 
Over 72 
114'118 
55'881 
1.7 
0.8 754 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
In considering the above table it should be borne in mind that 48 
hours of weekly labor mean customarily a working day of 8 hours for 6 
days in the week and a day of rest on Sunday; 54 hours mean a working 
day of 9 hours for 6 days in the week, 60 hours one of 10 hours for 6 days, 
and 72 hours one of 12 hours for 6 days. These are hours of actual labor 
and do not usually include the period of luncheon, except where the 72- 
hour week prevails. The table reveals a tendency toward a shortening 
of the working period. 
The most striking instance among well-organized modern industries of 
a long period of compulsory labor is afforded by the iron and steel industry 
of the United States. In 1910 the Department of Commerce and Labor26 
made a very full investigation of the conditions of labor in iron and steel 
factories and found that of the 172,671 employes of blast furnaces, steel 
works, and rolling mills, covered by the report, 62.98 per cent, customa- 
rily worked more than 60 hours per week; 42.58 per cent, worked 72 hours or 
more per week; while 20.59 per cent, worked 84 hours or more. A weekly 
labor of 72 hours means 12 hours every day except Sunday, while one of 
84 hours means 12 hours daily including Sunday. The luncheon period is 
here included, but it is usually brief and desultory. The customary 
working time of 29.28 per cent, of the employes was 7 days. Once in 
every week or every 2 weeks, when a night shift was changed to day work 
and vice versa, one shift remained at work continuously for either 
18 or 24 hours. Reliable statistics regarding working conditions 
in this industry since the above investigation was made are not 
available. 
In determining the proper length of the working period the factor that 
should be considered first is not the commercial but the physiological one. 
No one, except in rare emergencies, should be forced to labor continuously 
for such a period that subsequent time allowed for rest is insufficient 
to enable him to recuperate before the beginning of the next working 
period. Physiological facts, though exact data are here meager, leave no 
doubt that the desirability, as a custom for most individuals living under 
the social conditions of the present day, of one day's rest or change of 
occupation in every 7 days if one's body is to be kept in an efficient 
physiological state. The proper length of the working period of the 
other 6 days ought to depend, first, upon the degree of fatigue that is 
induced by the specific labor. Here again exact studies are much needed. 
Different varieties of labor undoubtedly differ greatly as to their fatiguing 
power and this can be modified by many things, but too little is known of 
this. Different individuals, too, differ greatly in susceptibility to fatigue. 
Moreover, the sociological question is a legitimate one, namely: What 
proportion of an individual's working hours ought equitably to be spent in 
his vocational work? A customary working day of 12 hours can hardly 
be justified on either physiological or sociological grounds. The limit in 
most occupations has, therefore, been gradually reduced, and the present FATIGUE AND LENGTH OF WORKING PERIOD 
755 
goal of most employes is that of an 8-hour day and a 44-hour week, which 
signifies a half-holiday on Saturday. In those industries, such as the 
manufacture of certain iron and steel products, where it is claimed that 
continuous operation of a plant is necessitated by the nature of the 
processes involved, either a 12-hour or an 8-hour shift would seem, 
if the claim is true, to be essential. In the iron and steel industry of 
Great Britain the shorter replaced the longer shift after the world war, 
and the former also exists now in many of the plants of the United 
States. In the United States movement in the direction of an 8-hour 
day was hastened by its adoption with a 44-hour week for all 
employes of the National Government. Its extension throughout the 
world will perhaps follow the action of the first International Labor 
Conference, held in Washington in 1919, as one of the international 
sequels to the inauguration of the League of Nations. This conference, 
in which forty nations participated, adopted the following resolution:27 
"The working hours of persons employed in any public or private 
industrial undertaking or in any branch thereof, other than an under- 
taking in which only members of the same family are employed, shall 
not exceed 8 in the day and 48 in the week, with the exceptions herein- 
after provided for." 
Where there has been an intelligent comparison of the 8-hour and a 
longer working period in actual experience, the result has proved satis- 
factory and advantageous to both employes and employers. Evidence 
of this is now abundant. Thus, the Salford Iron Works, engaged in the 
manufacture of machinery, at Manchester, England, in 1893 reduced 
the hours of weekly labor of its employes from 53 to 48, i.e., from a 
9-hour to an 8-hour day, and made a careful study of the result. It 
was found that production, instead of falling off, actually increased. 
A change in the steel works of South Wales from a 12-hour to an 8-hour 
shift resulted, so far as the figures have been cohated, in an average 
increase of output of 12^ per cent, in the smelting shops and 22J^ 
per cent, in the bar mills. A change from a 9-hour to an 8-hour day was 
made in 1900 by the Zeiss Optical Works in Jena,28 also with an increased 
output in the lessened time. As the workers there were pieceworkers, 
there were also increased earnings on their part. This result was due, not 
to a better feeling on the part of the workers, but to the increased speed 
and effort which they unconsciously exerted. This resulted, of course, in 
increased fatigue from the actual work of production, but, on the other 
hand, the shorter working period insured two advantages, namely: 
lessened "passive" fatigue, as Abbe called it, that is, the fatigue of con- 
stant attention, fixed attitude, and exposure to noise and confusion; 
and a longer period for recuperation. Abbe believed that for three-fourths 
of the industrial workers of Germany 8 hours was sufficiently long to 
reach their maximum of daily production. The ill-considered aspira- 
tions of extreme labor leaders toward a universal29 6-hour day can hardly 756 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
be considered, rational nor are Lord Leverhulme's29 arguments in favor of 
such a brief period for one's vocational occupation convincing. 
The fatigue of the regular working period is added to by the not infre- 
quent practice of requiring employes to work overtime in periods of emer- 
gency. In the canning industry, for example, the demands of perishable 
fruit or vegetables often induce employers to call back their staff for long 
evenings of work after the usual day of labor has ended. The Christmas 
"rush" season in shops is a time of overfatigue for many salesmen. Over- 
time work is always apt to be strenuous, and the fatigue that results from 
it is probably relatively less easily compensated for than is that of the 
usual day's labor. 
Whether the universal adoption of a rigid 8-hour work day for all 
industries would ultimately be best for society and the individual is 
doubtful. In the ideal scheme of labor it would seem that no person 
ought to be denied the pursuit of his vocation for a longer period than 8 
hours in 24, provided that the longer labor is not detrimental to him or 
to society. The leaders in the world's progress have not limited them- 
selves to brief working days; almost invariably they have been persistent 
hard laborers, with whom, impelled by whatever motive, the accomplish- 
ment of the task and not the avoidance of fatigue has been the aim. 
With the masses who follow instead of lead some limitation is necessary 
for protection, and an 8-hour day is for the present probably the most 
just, both physiologically and sociologically. It seems reasonable to 
believe, however, that when our knowledge of experimental methods has 
advanced sufficiently, by a careful study of the physiological powers of 
individuals, on the one hand, and the fatiguing capacities of occupations, 
on the other, we may arrive ultimately at an adaptation of worker 
to work which will approach the physiological ideal. This will probably 
require a work day of a length that differs for individuals and for occupa- 
tions. However this may be, it is obvious that society has not yet 
found a satisfactory solution of this complex problem. 
The Influence of Resting Periods.-The beneficial influence of 
a resting period in the midst of work has been mentioned, and is illus- 
trated for muscular tissue in Fig. 30. In industry a resting period for 
the purpose of taking luncheon has always been allowed. The bene- 
fit of additional breaks during the working spell, while long recognized 
for children during school hours, is still in dispute by both employers 
and workers in industrial occupation. Some employers believe that 
recess periods conduce to the welfare of their employes and have estab- 
lished them as a part of the regular routine. Whether they are thus 
established or not, most workers, if not all, take time off during the work- 
ing period. 
A few efforts have been made to measure exactly the effect of resting 
periods upon output. Hourly output is usually, and daily output may 
be, thus increased. Taylor30 found that largely by alternating work and FATIGUE IN MODERN INDUSTRY-VENTILATION 
757 
rest periods and imposing them upon a strong laborer whose task was 
to load pig iron upon a railway car, he was able without detriment to 
increase his daily output from 12.5 tons to 47.5 tons, or 280 per cent. 
The U. S. Public Health Service15 investigated the effect of introducing 
a recess of ten minutes in each of the two working spells at a 10-hour 
metal-working factory and an 8-hour automobile factory. At the 
former in eleven of the twelve operations studied the average daily 
output per worker was increased. Such increase was cumulative as the 
period of observation was prolonged; the amount of the increase varied 
with different workers and with different operations, reaching in one 
operation 25.9 per cent. At the 8-hour factory the results were 
indeterminate. While the general benefit of recess periods can hardly 
be denied there is much need of further exact data in regard to their 
bearing on output with relation to their number during the spell, their 
duration, what the worker does during the recess, the kind of work per- 
formed in the factory, the length of the working day, etc. 
Piecework.-It might seem that industrial fatigue imposed by long 
hours might be obviated by paying workers, not according to the time 
spent, but according to the amount of work accomplished, and, indeed, 
the piecework system has now become common in many trades. From 
the standpoint of its theory this system is to be commended, for instead of 
rewarding all workers alike, whatever their grades of efficiency, it allows 
those who are ambitious and capable to reap the benefits of their greater 
powers of accomplishment. But in practice it has often developed abuses 
for, when the rapid worker becomes in the opinion of the unprincipled 
employer too rapid, piece wages are lowered and further speeding-up 
is thus demanded. Moreover, the rapid worker is often called upon 
to set the pace for those who are physiologically slower, and thus they 
may be urged on at a dangerous rate. The piecework system, as thus 
practised, has become one of the frequent factors in the production 
of excessive industrial fatigue and for this reason has frequently been 
condemned.31 Its evils are most potent when it is combined with long 
hours. 
Ventilation.-The evil effects of the crowding of many human beings 
into confined spaces do not come from the chemical vitiation of the air, for 
the consequent diminution of oxygen and increase of carbon dioxide are 
not sufficient in amount to produce evil effects, and the hypothetical 
volatile organic poison of expired air does not exist. These effects, it has 
now been demonstrated,32 are due to the increase in the temperature and 
the humidity of the air, aided by its lack of motion. Increase in sur- 
rounding temperature makes it more difficult for the body to throw 
off by radiation and conduction the excess of heat which it is constantly 
producing; increase in humidity adds to this difficulty by diminishing the 
cooling evaporation of perspiration from the surface of the body; while if 
the air be not in motion the hot humid envelope next the skin does not 758 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
give place to a cooler dryer layer with its relieving quality. The result 
is an elevation of bodily temperature, a diminution of vasomotor tone, a 
gorging of the skin with blood and its consequent removal from the brain 
and elsewhere, increased perspiration, and the bodily discomfort, sleepi- 
ness, headache, and other characteristic sensations of a "close" room. 
In such an environment there are sensations of fatigue and less inclination 
to do either physical or mental work, and under extreme conditions actual 
inability to accomplish as much with the early oncoming of exhaustion. 
Vernon1 found a striking seasonal variation in the output of certain Brit- 
ish tin-plate factories, in which the work was strenuous: Output was 
greatest in January and least in August, and the output curve of the year 
rose and fell as the outside atmospheric temperature fell and rose. Good 
ventilation tended to lessen the difference between maximum and 
minimum output. Strenuous operations in the iron and steel industry 
also showed a somewhat similar seasonal variation of output. 
The following table gives the temperatures in degrees Fahrenheit 
that have been observed in various work places: 
Starching and ironing in laundries 95 
Tending electric furnaces 100-120 
Vulcanizing and japanning 90 
Evaporating rooms of sugar refineries 110-115 
Copper reduction 100 
Manufacture of oxygen 100-120 
Bakeries 90 
Scientific Management and Fatigue.-In recent years there has 
arisen a new system of organizing and conducting industrial work, known 
as "scientific management," or "efficiency engineering," and it has been 
enthusiastically advocated and widely adopted.33 It aims to find the 
worker best fitted for a particular task and then to bring him to his maxi- 
mum efficiency therein. This is done through a careful preliminary 
study by the efficiency engineer of the task itself, its requirements and 
the best ways of satisfying them, through the improvement and standard- 
ization of the machines required, the effective routing of material, the 
elimination of unnecessary motions by the worker, the introduction of 
frequent rest periods, the payment of bonuses, and, in general, the arrange- 
ment of all conditions so as to secure the doing of the task in question and 
no other, and its performance in the quickest possible time of which the 
worker without detriment to his physiological powers is capable. By 
eliminating useless motions and concentrating on those activities that 
upon analysis are found to be essential to the performance of the task 
much unnecessary fatigue can be avoided. It is obvious, however, that 
the greater exercise of the particular neuromuscular mechanisms that are 
involved leads to their greater fatigue-we seem to have here the proper 
conditions for speeding-up with all its possibilities of overstrain and 
exhaustion. Anything, however, that produces overstrain and exhaustion SCIENTIFIC MANAGEMENT INDUSTRIAL PHYSIOLOGY 
759 
diminishes the maximum efficiency of the worker and thus defeats one of 
the fundamental conditions of scientific management, and hence ade- 
quate resting periods, brief but frequent, must be provided. Taylor,30 
the leader in the new system, found that in the handling of pig iron, each 
pig weighing 92 lb. a first-class workman should be free from his load 
during 57 per cent, of his daily working time. With lighter loads this 
time may be decreased-with a half pig to 42 per cent, of the day. By 
scientifically systematizing the work of handling pig iron and selecting 
and educating the workmen, Taylor increased the daily output of each 
man from 12t^ to 47^ tons, apparently without overstraining him. 
Similarly Gantt34 by scientific management was able to increase the 
production in the various operations of a bleachery by 55 to 275 per cent., 
in small automatic screw-machine work by 25 to 250 per cent., and in 
large automatic machine work by 30 to 215 per cept. Gilbreth35 reports 
that in building a brick wall, while the customary rate was 120 bricks 
laid by each man in one hour, one who was skilled in the new method, 
by which the muscular motions required for each brick were reduced from 
eighteen to five, was able to lay 350 bricks in the same time. In inspect- 
ing and selecting bicycle balls 35 girls under the new system were able to 
do the work formerly done by 120. Similar instances of improved out- 
put under systematic organization of the work are frequently reported. 
In theory scientific management seems to offer a method by which 
excessive industrial fatigue may be avoided, and in practice at its best it 
doubtless frequently accomplishes this. Just as, however, the actualities 
of practice are often far removed from the ideals of theory, so here the 
great danger would seem to lie in the misuse of the new system, in an 
increase of work done without adequate regard to the powers and the wel- 
fare of the worker. Whether such a result actually occurs and, if so, 
how frequently, we have at present no adequate knowledge. There is 
little in the literature of the new system to indicate that its enthusiastic 
apostles understand the nature of fatigue and its manifestations. Its 
writers, indeed, say little of this phase of their subject. Nor do those who 
practice it know much of the physiological aspect of their system. It 
is obvious that there is much needed the collection of data from the new 
experience and the comparison of them with the facts of traditional 
industrialism. Only thus can we learn whether scientific management 
offers to the worker real release from the unwarranted strain of his 
occupation. 
Industrial Physiology.-The problems that have been presented in 
the present chapter are now being attacked from a standpoint and by 
methods which differ from those that have long prevailed. The stand- 
point is that in which the industrial worker, like all living beings, is 
recognized to be a complicated physiological and psychological mechan- 
ism, placed within a special environment, and with the task before him of 
doing certain things. It is to the advantage of both his employer and 760 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
himself that he perform his task in the most efficient manner possible and 
without imperilling the maintenance of his working power, in other words, 
that he be given the opportunity of leading a normal physiological and 
psychological life. The fundamental requisites of this opportunity are, 
first, the suitability of the worker for his task and, secondly, the existence 
of optimum working conditions. Some methods of determining suita- 
bility36 and optimum conditions are already devised and in use, and some 
of the results of their use have been presented in this chapter. But a 
great extension of research is here needed. Much could be gained if 
the industries themselves would maintain working laboratories, where 
their problems could be studied by the customary methods of all scientific 
research, namely, observation and experiment. Only through a science 
of industrial physiology-one broad enough to include the psychological 
aspects of work as well-only by an organization of work on such a 
scientific basis, can industry ever hope to be organized properly and 
efficiently. 
REFERENCES 
1 Goldmark, Josephine.-Fatigue and Efficiency, New York, 1912. The Report 
of the Committee to Study the Question of Fatigue from the Economic Stand- 
point. Proceedings of the British Association for the Advancement of Science, 
1915. Florence, Philip Sargent.-Use of Factory Statistics in the Investigation 
of Industrial Fatigue, New York, 1918. Lee, Frederic S.-The Human Machine 
and Industrial Efficiency, New York, 1919. Vernon, H. M.-Industrial Fatigue 
and Efficiency, London, 1921. Collis, E. L., and Greenwood, M.-The Health 
of the Industrial Worker, London and Philadelphia, 1921. Myers, C. S.-Mind 
and Work, New York and London, 1921. Drever, James.-The Psychology of 
Industry, New York, 1921. 
2 For accounts of the general physiology of fatigue the reader may consult: Lee, 
Frederic S.-Fatigue. Journal of the American Medical Association, 1906, 
XLVII, page 1491; also Harvey Lectures 1905-06, Philadelphia, 1906. Do.- 
The Nature of Fatigue. Popular Science Monthly, 1910, LXXVI, page 182. 
Do.-The Action of Normal Fatigue Substances on Muscle. American Journal 
of Physiology, 1907, XX, page 170. Do.-The Cause of the Treppe, Idem, 1907, 
XVIII, page 267.Do. and Everingham, S.-Pseudo-fatigue of the Spinal Cord. 
Idem, 1909, XXIV, page 384. Scott, E. L.-The Present Status of Our Knowl- 
edge of Fatigue Products. Public Health Reports, April 26, 1918, Scott, E. L. 
and Hastings, A. B.-Some Phases of Protein Catabolism and Fatigue,. Idem, 
October 15, 1920. Do.-Sugar and Oxygen Relationships in the Blood of Dogs. 
Proceedings of the Society for Experimental Biology and Medicine, 1920, XVII, 
pages 67 and 120. Hastings, A. B.-The Physiology of Fatigue: Physico- 
chemical Manifestations of Fatigue in the Blood. Public Health Bulletin, 
No. 117, Washington, 1921. 
3 Lee, Frederic S. and Aronovitch, B.-Does a Fatigue Toxin Exist? Proceedings of 
the Society for Experimental Biology and Medicine, 1917, XIV, page 153. 
4 Ayres, Leonard P.-Bicycling World and Motorcycle Review, April, 1911, page 78. 
5 Gruber, C. M.-American Journal of Physiology, 1913-1918. See also Cannon, 
W. B.-Bodily Changes in Pain, Hunger, Fear and Rage, New York, 1915. 
6 Lee, Freceric S., and Van Buskirk, J. D.-An Examination of Certain Proposed 
Tests for Fatigue. American Journal of Physiology, 1923, LXIII, page 185. REFERENCES ON FATIGUE 
761 
7 Mosso, A.-Fatigue, New York, 1904. 
8 Martin, E. G.- Strength Tests in Industry. Public Health Reports, August 13, 
1920. Do.-Tests of Muscular Efficiency. Physiological Reviews, 1921,1, page 
454. 
9 Offner, Max.-Mental Fatigue, Baltimore, 1911. Whipple, Guy M.-Manual of 
Mental and Physical Tests, Baltimore, 1910. 
10 Abbott, A. C.-University of Pennsylvania Medical Bulletin, 1910, XXIII, page 
169. 
11 Oppenheimer, E. H., and Spaeth, R. A.-The Relation Between Fatigue and the 
Susceptibility of Rats Towards a Toxin and an Infection. American Journal of 
Hygiene, 1922, II, page 51. 
12 Lee, Frederic S.-The Causes of Fatigue in Certain Pathological States. British 
Medical Journal, 1906, II, page 1806. 
13 Health of Munition Workers Committee, Ministry of Munitions.-Memoranda 
Numbers 1-21; Interim Report: Industrial Efficiency and Fatigue; Final Report: 
Industrial Health and Efficiency, London, 1915-18. Kent, A. F. Stanley.-■ 
Interim Report on an Investigation of Industrial Fatigue by Physiological 
Methods, London, 1915. Do.--Second Interim Report, Do. London, 1916. 
14 Industrial Fatigue Research Board.-Reports, London, 1919-. The Journal of 
the National Institute of Industrial Psychology, 1922-. 
16 Goldmark, Josephine; Hopkins, Mary D.; Florence, P. S. and Associates; Lee, 
Frederic S.-Comparison of an Eight-hour Plant and a Ten-hour Plant. United 
States Public Health Service, Public Health Bulletin, Number 106, Washington, 
1920. 
16 Rowntree, R. Seebohm.-The Human Factor in Business, London, 1921. 
17 Bogardus, Emory S.-The Relation of Fatigue to Industrial Accidents. American 
Journal of Sociology, 1912, XVII. 
18 Leubuscher P., and Bibrowicz, W.-Deutsche medizinische Wochenschrift, 1905, 
XXXI, page 821. 
19 Schonhals, Paul.-Uber die Ursachen der Neurasthenie und Hysterie bei Arbeitern, 
Berlin, 1906. 
29 Roth, E.-Bericht uber den XIV internationaien Kongress fur Hygiene und Demo- 
graphic, Berlin, 1907, II, page 593. 
21 Treves, Z.-Bericht uber den XIV internationalen Kongress fur Hygiene und 
Demographic, Berlin, 1907, II, page 626. 
22 Butler, Elizabeth B.-The Pittsburgh Survey: Women and the Trades, New York, 
1911. 
23 Lee, Frederic S.-Is the Eight-hour Working Day Rational? Science, 1916, 
XLIV, page 727. Frankfurter, Felix and Goldmark, Josephine.-The Case 
for the Shorter Work Day, National Consumers' League, New York, 1915. 
24 Bulletin of the United States Bureau of Labor, 93, Washington, 1911. (Summary of 
British Board of Trade Report.) 
26 Abstract of the Census of Manufactures, 1914, Washington, 1917. 
26 Report on Conditions of Employment in the Iron and Steel lndustry in the United 
States, Washington, 1911. See also Fitch, John A.-The Pittsburgh Survey: 
The Steel Workers, New York, 1910. 
27 League of Nations. International Labor Conference, First Annual Meeting, 1919, 
Washington, 1920. 
28 Abbe, Ernst.-Gesammelte Abhandlungen, Bd. Ill, Jena, 1906. 
29 Lord Leverhulme.-The Six-hour Day and Other Industrial Questions, London, 
1918. 
30 Taylor, F. W.-Principles of Scientific Management, New York, 1911. 
31 Bureau of Research, Railway Employes' Department, American Federation of 
Labor.-The Problem of Piece Work, Chicago. 762 
OCCUPATIONAL DISEASES DUE TO FATIGUE 
32 Lee, Frederic S.-Fresh Air. Popular Science Monthly, 1914, LXXXIV, page 313. 
Laboratory Experiments with Air. Journal of the American Medical Association, 
1914, LXIII, page 1625. The Effects of Temperature and Humidity on Fatigue. 
American Journal of Public Health, 1912, II, page 863. Lee, Edwards and 
Others.-The Action of Certain Atmospheric Conditions on Body Temperature 
and the Vascular System. Proceedings of the Society for Experimental Biology 
and Medicine, 1915, XII, page 72. Winslow, Kimball, Lee, Miller, Phelps, 
Thorndike, Palmer and Herzstein.-Report of the New York State Commission 
on Ventilation, New York, 1923. Lee, Frederic S., and Scott, Ernest L.-The 
Action of Temperature and Humidity on the Working Power of Muscles and 
on the Sugar of the Blood, American Journal of Physiology, 1916, XL. Hill, 
Leonard.-The Science of Ventilation and Open-air Treatment, Medical Re- 
search Committee, London, 1919-20. 
33 Thompson, C. B.-Scientific Management, Cambridge, 1914. Drury, H. B.- 
Scientific Management: A History and Criticism, Columbia University, New 
York, 1922. Hoxie, R. F.-Scientific Management and Labor, New York and 
London, 1916. 
34 Gantt, H. L.-Work, Wages and Profits, New York, 1913. 
35 Gilbreth, Frank B.-Bricklaying System, Chicago, 1909. Motion Study, New 
York, 1911. Gilbreth, Frank M. and Gilbreth, Lillian M.-Fatigue Study, New 
York, 1916. Do.-Applied Motion Study, New York, 1919. 
36 Link, Henry C.-Employment Psychology, New York, 1921. SECTION 2 
OCCUPATION NEUROSES 
E. E. SOUTHARD, M. D„ and H. C. SOLOMON, M. D„ Boston, Mass. 
Synonyms.-Copodyskinesia; dyskinesia; craft neurosis; occupational 
dyskinesia; dyskinesie fonctionelle (functional dyskinesia); professional 
ataxia; (cobrdinatorische) Beschaftigungsneurosen; affection nerveuse 
professionnelle; functional spasm; crampe fonctionelle; crampe profes- 
sionelle fonctionelle; fatigue disease; anapeiratic paralysis; local chorea; 
partial vertigo. 
The typical occupation neurosis is writer's cramp, for which the 
variety of names is significant ; e.g., scriveners' palsy, crampe des ecrivains, 
Schreibkrampf, steel pen palsy, mogigraphia, emotional dysgraphia, 
graphospasm, paralysis notariorum, stammering on paper, impotence 
fonctionelle des Ecrivains, loss of grip. 
FUNDAMENTAL AND SYSTEMATIC STUDIES 
The disease was apparently first described in modern times by Sir 
Charles Bell, in 1830, and by a German author, Bruck, in 1831. Con- 
siderable discussion followed in Germany and France, and was described 
in Canstatt's text-book of medicine. The first to describe the disease 
upon modern lines was Duchenne, who developed the theory of disturbed 
coordination (see below). Benedikt in 1874 added important aspects 
of a theoretical nature (cell group coordinations in the central nervous 
system). The first edition of Allbutt's System of Medicine contained a 
modern account by G. Vivian Poore. Poore's account has been revised 
and modified by Head in the current edition of Allbutt's text-book, to 
which the reader may be referred. 
General Definition.-Oppenheim's definition is the one most generally 
quoted, running as follows: 
By an occupation neurosis is understood a disturbance of innervation 
of the muscles, occurring only in certain complicated movements acquired 
by practice, of such a nature as to permit the same muscles to respond to 
the will in all other actions; thus, in the typical occupation neurosis, 
writers' cramp, the muscles paralyzed for the purpose of writing are 
found to be entirely mobile for the other purposes. 
Occupation neuroses are neuroses incident to special occupations, and 
might better be termed vocational neuroses. They have been termed 
craft-neuroses (Head); but this term, perfectly suitable for writers' cramp, 
763 764 
OCCUPATION NEUROSES 
would not so well fit a neurosis of preachers, namely, mogiphonia. Occu- 
pation-neuroses are neuroses of technique involving muscular action, and 
are well-nigh as numerous as are technical vocations themselves. It might 
be inquired whether certain apathies or neurasthenic phenomena could be 
regarded as a generalized occupation neuroses ("run down from over- 
work"); but this would be a doubtful usage of the term, since in such 
generalized disease the nervous system cannot be used effectively for the 
organism's general needs. The point of an occupation neurosis, on the 
other hand, lies in the fact that certain muscles, utilizable for all sorts of 
other purposes, can no longer be used for some special technical purpose 
in one particular manner learned by practice. Occupation neuroses are 
diseases of acquired function and as a rule of somewhat highly specialized 
function. Seldom do patients exhibit at one time two kinds of occupa- 
tion neurosis; but a victim of writers' cramp may fall victim to type- 
writers' cramp and retain both. 
It is a question what "neurosis" means in the term occupation neuro- 
sis. Occupation neuroses are, or should be, essentially functional neuro- 
pathies, in the most general sense of the term neuropathy, i.e., either 
peripheral or central in origin. Theory tends to consider occupation 
neuroses as neuropathies of central rather than peripheral origin (Bene- 
dikt). But practice tends to find peripheral origins for many (G. Vivian 
Poore). Of course, if research should prove a peripheral (or central) 
structural basis for the clinical phenomena, then the name occupation 
neurosis would be itself a misnomer. 
It is decidedly of more than academic interest to consider this question 
in individual cases. Consider in succession certain 
THEORIES OF ORIGIN 
1. Suppose, with a few authors, we consider occupation neuroses to 
be in part at least based on constitutional factors or diatheses; for example: 
Fere, 1887-1900; Bonnier, 1898; Lanel, 1909; Head, 1910; Frankl- 
Hochwart, 1913. 
Modern work has of course shown in all sorts of mental and nervous 
conditions, both functional, quasi functional, and frankly organic, that 
diathetic constitutional factors are fundamental and indispensable factors 
although they may not be the essential ones. The above-mentioned 
authors, in practically all cases, emphasize other non-constitutional factors 
in addition to the diatheses. The writers have histories available in a 
number of instances to show strong traces of hereditary factors, a finding 
which is not uncommon in the literature. This constitutional back- 
ground naturally has important bearing upon the prognosis as well as 
upon general therapeutic measures. 
Not only may the occupation neuroses be in a sense diseases of diathe- 
sis, but certain well-recognized diatheses may bring about phenomena THEORIES OF ORIGIN 
765 
which can with difficulty be distinguished from occupation neuroses; 
e.g., tremor of old age, arteriosclerosis, tabes dorsalis, and dementia precox, 
yielding graphic disorder attributed by the patient and his friends to a 
functional effect of occupation. Parkinson's disease may occasionally 
suggest occupation neurosis. There are scattering references td occupa- 
tion neurosis in gouty or rheumatic conditions. 
2. We may also consider occupation neuroses to be in some way 
dependent upon (as it were, permitted by), a general neurasthenic condi- 
tion which might be focalized in a particular muscular difficulty. The 
following authors touch upon this: Berger, 1885; Fere, 1887-1900; 
Bernhardt, 1896; Binswanger, 1896; Cassirer, 1900; Mettler, 1904; 
Lepinay, 1909; Starr, 1909; Vogt, 1909-1910; Head, 1910; Bing, 1912; 
Strumpell, 1912; Frankl-Hochwart, 1913; Jacobson, 1913; Oppenheim, 
1913; Jelliffe, 1914. 
The true neurasthenic should, as a rule, exhibit phenomena of more 
general distribution, involving numerous functions revolving about his 
complaints. The typical victim of writers' cramp will exhibit a complete, 
and indeed overeager, desire to write, although his paralysis forbids the 
process; whereas the graphic impotence of the neurasthenic is coupled with 
a diminution of will or absolute aboulia. 
3. The last few years have brought out a crop of theories according to 
which occupation neuroses are in some sense hysterical phenomena, 
perhaps based upon inhibitions in a Freudian sense. According to this 
account, a particular function, such as writing or managing a telegraph 
key, becomes impossible because a derived movement of an opposite 
nature with cramp, tremor, or ataxia has preempted the muscles so that 
they cannot perform the desired act. T. A. Williams, 1912, has expressed 
a hypothesis of this nature, but according to him the psychogenesis in 
these cases is not especially along sex lines. Other representatives of a 
psychogenetic basis, at least in part, are Berger, 1885; Cohn, 1897; 
Leri, 1900; Destarac, 1901; Brissaud, Hallion and Meige, 1903; Mettler, 
1904; Meige, 1908; Lepinay, 1909; Vogt, 1909-1910; Head, 1910; Lewan- 
dowski, 1912; Mohr, 1912; Frankl-Hochwart, 1913; Strumpell, 1912; 
Thomas, J. J., 1913. 
By no means would all of these authors class themselves among the 
Freudians, but they all to some extent lay stress upon functional bases for 
these conditions, conceiving that they may represent a form of psychoneu- 
rosis, if not always clearly neurasthenic. 
4. A number of French authors prefer to class the occupation neuroses 
among the tics; for example, Leri, 1900; Destarac, 1901; Rudler, 1903; 
Bonnus, 1905; Meige, 1908. 
J. J. Thomas also speaks of certain training exercises in writers' cramp 
as along the lines of treatment in tic. 
5. Emphasis upon overexertion in the particular professional act 
has been laid by Althaus, 1870; Vance, 1873; Berger, 1885; Benedikt, 1897 766 
OCCUPATION NEUROSES 
Church, 1898; Mettler, 1904; Meige, 1908; Vogt, 1909-1910; Head, 1910; 
Bing, 1912; Frankl-Hochwart, 1913, Jelliffe, 1912; Thomas, 1913; Cursh- 
man, 1915. 
Most of these authors combine the fact, or hypothesis, of overexertion 
with a variety of other explanatory schemes for the production of the 
neurosis; thus, overexertion may conceivably be muscular or neural and if 
neural, it might be peripheral or central in origin. But many of the 
above-named authors consider that the local use of the muscles in ques- 
tion has set up a myositis, bursitis, tenosynovitis, or other local change 
of a chronic inflammatory nature which could interfere with fine move- 
ments and still permit coarser movements to be produced. Such changes, 
which are doubtless not seldom found in cases that receive the diagnosis 
occupation neurosis, might well produce pain when muscles are used, 
particularly for finer coordinate movements. 
Under this heading should be mentioned also the toxins of fatigue 
which Weichardt has described; and the work of Lee upon the production 
of certain substances in prolonged activity of muscles, such as carbon 
dioxide, paralactic acid, and ammonopotassium-phosphate, is perhaps 
in point. It is not impossible that future research may work out hypo- 
theses along the lines of the hormones. Of course it is not necessary that 
the substances produced by muscular action or overexertion shall exert 
their effects upon the muscles in question, but they may act through the 
circulation or by way of tissue clefts upon the nervous system, notably 
upon the unstable surfaces of separation or synapses between the con- 
ducting nerve elements (Lee). 
6. There has been a recrudescence of arterial spasm theories which, 
although given up largely for the explanation (after the fashion of Theodor 
Meynert) of melancholia and mania, are thought possibly applicable to 
the occupation-neurosis group. As leaning in part to such a doctrine 
may be mentioned: Goldflam, 1901; Massaut, 1901; Goldstein, 1901; 
Determann, 1905; Erb, 1906; Raymond, 1906; Kronenberg, 1908;Lanel 
1909; Lepinay, 1909; Head, 1910. 
Nothnagel had already reported, in 1867, a case which he interpreted 
in this way. According to this account, the spasmodic form of writers' 
cramp would in some degree resemble the phenomenon of intermittent 
claudication. The spasm in question is conceived to be a local one. No 
extended application of the idea of arterial spasm as occurring in the 
central nervous system as a basis for peripheral effects has been found in 
the literature. 
7. Myotonia.-Curschmann, 1905, has laid emphasis upon the close 
resemblance of cases of writers' cramp to myotonia. He has reported 
the case of a young brush maker whose partial myotonia closely simulated 
a professional neurosis with muscular weakness, paraesthesia, and spasm. 
8. Under the influence of Duchenne and Benedikt, the majority of 
systematic writers, and a great many of the monograph and periodica] THEORIES OF ORIGIN 
767 
writers, have supported what may be called the central nervous theory of 
origin. It may almost be said that such a definition as that given above 
from Oppenheim really involves such a central nervous origin, although 
it is far from agreed as to the exact nature of the central dysfunction which 
gives rise to the dyskinesia. Among the supporters in part or as a whole 
of this account may be mentioned Giegel, 1864; Solly, 1864; Althaus, 
1870; Benedikt, 1874, 1897; Beard, 1879; Seeligmiiller, 1882; Berger, 
1885; Bernhardt, 1896; Cohn, 1897; Church, 1898; Cassirer, 1900; 
Savill, 1901; Haskovec, 1902, 1906; Brissaud, Hallian and Meige, 1903; 
Mettler, 1904; Edinger, 1906; Gowers, 1907; Lepinay, 1909; Vogt, 1909, 
1910, Head, 1910; Frankl-Hochwart, 1913; Binswanger, 1896; Duchenne, 
1860; Kouindjy, 1904-5; Strumpell, 1912; Thomas, 1913. 
Duchenne, in 1860, in his work "L'electrisation localisee," said that he 
defined as spasm with functional impotence of muscles certain affections 
characterized either by continuous contractions or by clonic contractions. 
The contractions might be painful, or they might not be accompanied by 
pain. The clonic contractions might appear in the form of tremors. The 
muscular impotence might manifest itself neither by contractions nor by 
pain, but solely in the exercise of certain voluntary or instinctive move- 
ments localized in the muscles appropriate to (synergic with) the 
movement. 
Duchenne strongly leaned to the central view. He quoted a patient 
who suffered from right-sided writer's cramp and learned to write with his 
left hand, only to become victim to left-sided cramp. Duchenne felt that 
such cases would argue an extension of the morbid state from one side of 
the spinal cord to the other. 
Other authors, notably Benedikt, take into account not the spinal 
cord alone, but the higher levels and notably the voluntary levels of the 
nervous system. Benedikt, 1874, was far more concrete than Duchenne 
in his hypotheses. He insisted that the cells disordered in writers' 
cramp must be associative cells rather than the cells governing single 
movements, for if the latter were affected, then paralysis must follow in 
such wise that none of the muscles in question could act. Benedikt 
assumed a condition of either (a) heightened irritability or (6) lessened 
irritability in a group of cells superintending the coordination of certain 
movements. In the case of heightened cell irritability, the normal stimu- 
lus from other areas (that is, by the "will") produces a cramp of the mus- 
cles. In case there is a lessened cell irritability, there will be a paralysis 
of coordination and the pen will drop loosely from the hand. 
9. The modern work has conspired to produce a group of peripheral 
theories of the origin of occupation neuroses, but it is a question whether, 
if proof could be adduced for such theories, the entity or group of entities 
called occupation neuroses would not largely fall to the ground. That 
this would be the case is shown by the great emphasis now being laid, 
even in systematic accounts (e.g., Head following the lead of G. Vivian 768 
OCCUPATION NEUROSES 
Poore), upon actual or conceived local changes in muscles, nerves, their 
investments, or adjacent structures. Time and again in the course of 
preparing this systematic account we have been impressed with the notion 
that no such group of diseases actually exists, but that every concrete 
case deserving the appellation will turn into something far more definite 
than such a definition as that of Oppenheim's above would entail, 
Vivian Poore gave a number of reasons against regarding central distur- 
bance of coordination as the basis of these so-called neuroses. Poore sta- 
ted that he had never seen a case without evidence of peripheral change. 
In most of his cases, he had no evidence of disease except at the periphery. 
The disease at the periphery consisted of muscular paresis, muscular 
spasm, localized tremor, fibrillary tremors of certain muscles, alteration 
of muscular irritability, localized pain, nerve tenderness. Poore writes: 
"One or more of these symptoms was always present. The writers' 
cramp of the text-books, in which failure of the writing power is the sole 
symptom, I have never seen." In most cases the symptoms grew more 
or less gradually, and accordingly did not seem to be related to a sudden 
debacle of coordination. Accordingly Poore thinks that writer's cramp 
belongs in a catalogue of diseases near neuralgia. 
An American neurologist, Beard, also thought, in 1879, that the 
disease was a peripheral and local disease of nerves and muscles. He 
thought it became only secondarily, and rarely, a central general disease. 
Another American neurologist, W. E. Paul, also follows the tendency of 
Poore and Beard. Paul states that the "principal result of an analysis 
of these 200 (Massachusetts General Hospital) cases is that muscles, 
joints, and regions near joints are preponderantly the loci of sensory 
symptoms rather than the course and distribution of definite peripheral 
nerves." He goes on to say that "This, then, is my conception, that the 
impacts, compressions, squeezings, tensions, and stresses of excessive 
physiological functioning, acting on muscle tissue, or on sensory and 
motor nerve structures which run in the soft tissues and terminate in 
muscle, tendon, joints, or fasciae, bring about neurolytic or myolytic 
changes responsible for the occupation neuroses and so-called occupation 
neuritis and occupation pain." 
We have gone over a number of cases in local Boston clinics, and Paul's 
results at the Massachusetts General Hospital have been confirmed. No 
case has been found which entirely satisfies the general definition of 
Oppenheim. In the first 2000 cases in the Harvard Medical School 
Out-patient Clinic, and its continuation in the Out-door Department of 
the Peter Bent Brigham Hospital, the diagnosis of occupation neurosis 
has not occurred. 
We feel that modern finer methods in local neurological diagnosis 
may serve to destroy the functional nature of other doubtful cases. In a 
case which might well be regarded as one of occupation neurosis, lately 
seen, a case which might be termed one of stonecutters' palsy, we were THEORIES OF ORIGIN-VARIETIES WRITERS' CRAMP 
769 
able to show long after the patient has ceased to complain of subjective 
sensory disorder a definite anaesthesia to faradism (Martin sensory tests). 
VARIETIES OF OCCUPATION NEUROSES 
A book of inordinate length would be required to deal with all varie- 
ties. Indeed, Vogt remarks that there is an endless number of occupation 
neuroses, as many as there are possibilities in handicraft activities and in 
varieties of technique. New types of occupation neuroses are developed 
as new handicrafts and techniques develop. The following is a partial 
list of occupation neuroses aside from the typical neurosis of all-namely, 
writers' cramp. These have been obtained from the literature, others 
could be added almost ad libitum. 
Auctioneer 
Bicyclist 
Cellist 
Cigar roller 
Cornetist 
Clarionetist 
Compositor 
Diamond cutter 
Dancer 
Engraver 
Enameller 
Flutist 
Flower maker 
Gold worker 
Harpist 
Hammerman 
Knitter 
Locksmith 
Lithographer 
Lathe turner 
Laborer 
Letter sorter 
Milker 
Miners' nystagmus 
Mason 
Money counter. 
Microscopist 
Nail maker 
Organist 
Pianist 
Painter 
Preacher 
Shoemaker 
Smith 
Sawyer 
Scissors sharpener 
Sewing machinist 
Singer 
Seamstresss 
Sailor 
Shaver 
Trap drummer 
Tennis player 
Tailor 
Tinker 
Telegrapher 
Trumpeter 
Turner 
Treadler 
Tawer 
Watchmaker 
Walker 
Zitherist 
I. WRITERS' CRAMP 
It is worth while to describe writers' cramp more in detail than the 
other occupation neuroses because it is more frequent than any other and 
because it has been more frequently described. Writers' cramp is still 
the most frequent form of occupation neurosis, although the number 
of cases has appreciably diminished since the advent of typewriters, which 
has of course entailed (but apparently in smaller numbers) a new form of 
occupation neurosis. Perhaps the best description of writers' cramp 
may be obtained from Gowers' text-book, although the disease is fully 
described in various places. 
Writers' cramp is commonly stated to occur in twice as many males as 
females. It occurs in all adult ages, and Gowers found two cases between 
10 and 20, 52 between 20 and 30, 50 between 30 and 40, 32 between 40 
and 50, 12 between 50'and 60, and 5 in patients over 60. This series of 
153 cases included 33 by Poore, 64 by Berger, and 54 of Gowers' own 
cases. There seems to be no special racial tendency to writers' cramp. 770 
OCCUPATION NEUROSES 
An hereditary tendency to nervous affections of various sorts has been 
found by certain authors. We have ourselves come upon an interesting 
example of familial writers' cramp. This case, a woman of 44, was a 
copyist, with a younger brother who has already at this time (aged 37) 
developed difficulty in his writing. The father of these two was likewise 
a copyist, and died at the age of 75 with mental symptoms and brain 
disease. The father's brother and sister also died in the seventies of shock, 
but neither they nor their children showed any trace of writers' palsy, 
although some of the children have been engaged in clerical work. 
Among the general underlying conditions which favor the develop- 
ment of writer's cramp have been mentioned neurasthenia, a variety of 
diatheses and general conditions (gout, rheumatism, Bright's disease, 
syphilis, arterio-sclerosis), overexertion, trauma, alcoholism, overuse of 
tobacco, etc. Emphasis has often been laid upon emotion, especially the 
emotion of anxiety, as a contributory cause. The Freudians are not 
loath to offer a sexual basis for certain cases. Some authors speak of 
influences lowering the tone of the nervous system, hypo-oxidation and 
the like; or the use of poor pens; or the continual improper holding of the 
pen; or even the use of poor paper. Somewhat more to the point prob- 
ably are suggestions to the effect that painful affections of the fingers, 
neuritis, and neuralgia lie at the basis of certain cases. Much has been 
written concerning the art of penmanship with relation to the use of the 
larger muscles, and an excursion from the elbow and shoulder rather 
than from the wrist alone. It is thought that the employment of these 
wider excursions diminishes fatigue, on the basis that the smaller the 
muscles the greater the fatigue. 
The typical case of writers' cramp, accordingly, is likely to appear in 
the male, but the figures signify rather that under European conditions 
more men than women follow clerical work for a living. Heredity will be 
found as a rule to be so vague as not to aid in the diagnosis. It is probable 
that the various "underlying conditions" above mentioned give rise to, or 
permit, the occurrence of neuritis rather than the true neurosis which 
classical authors signify by the term "writers' cramp." 
1. True writers' cramp in the narrow sense of the term (neurosis minus 
local, peripheral, structural, or functional changes): Poore found 32 
cases in a personal series of 75 which he was inclined to put in the group of 
true writers' cramp, but he states that, "In every case of impaired writing 
power that I have seen, there has been evidence, more or less marked, of 
derangement of one or more of the muscles used for writing." Poore's 
method of determining peripheral alteration in these cases was by artifici- 
ally stimulating the muscles used in writing by means of faradism. He 
maintains that he found an excess of irritability in one or more of the 
writing muscles in most cases. Benedikt, in 1874, remarked that there 
was an increased faradic irritability in the earlier phases of the disease 
whereas later phases were attended by a decrease. Benedikt, in 1897, writers' cramp 
771 
remarks that the actually paralyzed muscles exhibit a decreased electrical 
reaction, whereas the neighboring muscles exhibit an increased irritability. 
It may be remarked in passing that, if these remarks of Benedikt are 
correct, then the innervation streaming down from the central nervous 
system with a perfectly normal intensity, rate, and periodicity might on 
account of local neuropathic or myopathic conditions produce the effect of 
ataxic writing, or even agraphia, without our being forced to the hypothe- 
sis of central changes. Other authors are not so emphatic in their 
statements concerning altered local irritability, although most concede a 
slight degree of quantitative change to the ordinary electrical tests. 
The sub-groups of so-called true writers' cramp are, according to 
Gowers and most systematic authors, the following: 
(a") Spastic. 
(&) Paralytic. 
(c) Tremulous. 
(d) Neuralgic. 
(a) Spastic Writers' Cramp.-The onset in the spastic form is gradual, 
as a rule, beginning with slight errors in penmanship, such as irregular 
strokes and marks due to unintended movements; the writer finds his pen 
bring held overtightly; the total process of writing becomes slower; the 
tight holding of the pen augments to a genuine spasm, and the spastic 
condition, at first confined to a few muscles, spreads to more numerous 
muscles. In those few cases in which the spastic form of writers' cramp 
begins abruptly, Gowers states that the attack is ushered in by local pain. 
The fully established writers' cramp in spastic form shows almost 
always tonic spasm interrupted at rare intervals by a slight accentuation 
of the muscular contractions in the form of a starting or jerking move- 
ment. The tonic spastic cases are often accompanied by local tremors. 
There are more rarely clonic types of the spastic form. The clonus 
may be so severe also as to throw the pen across the room. 
The startling feature of such a tonic or clonic situation in the writing 
arm of the patient is that the patient can at the same time perform quite 
properly and readily practically all other coordinative movements as well 
as simple movements which are innervated through the same peripheral 
nerves. The altered potentiality of movement is so sharply defined that 
certain subjects becoming unable to use a pen can still write with a pencil. 
It is historically curious that with the modern increase of writing and the 
introduction of the steel pen, it was common to hear it said that there was 
no possibility of writers' cramp when using the old-fashioned goose-quill, 
and that the whole new-fangled difficulty was due to the invention of 
steel pens. Research disclosed, however, that scriveners' palsy was also 
a phenomenon of the goose-quill era. Such movements as those of the 
hand grasp are naturally retained, and the force of the grasp is as a rule 
unimpaired, although occasionally somewhat weakened. The instances 772 
OCCUPATION NEUROSES 
of local muscular wasting should probably not be considered to be in the 
class of true writers' cramp, even as long-standing end results. The data 
concerning electrical irritability are, as stated above, somewhat equivocal, 
but that doubt is probably due to the inclusion of neuritic cases among the 
supposedly neurotic ones in a series collected by various workers. 
Cases which are for convenience termed "spastic" cases are neverthe- 
less accompanied by more or less marked sensory symptoms. Indeed, 
sensory symptoms of some sort are seldom absent (and the sensory symp- 
toms may indeed occur alone in some instances; see below). The most 
frequent sensory symptoms include, besides a general sense of distressing 
fatigue, definite dull pains often referred to various structures in the hand, 
especially in the metacarpal region and the wrist. These pains subside 
quickly when the effort to write is relinquished. There may also be local 
tenderness as well as tingling and parsesthesia. It is probable that cases 
of various severe pains running apparently in the course of the nerves, 
with local tenderness, belong more truly in a neuritic group of definitely 
structural origin, but may be referred to here because of their association 
with local spasms. There are cases in which the patient when not writing 
is subject to local pains. Such cases may be interpreted along lines of 
argument as above stated as phenomena in cases of local neuritis. Cya- 
nosis has been stated to occur with such cases (Brissaud, Hallian, and 
Meige). (See Anomalous Group below.) The outcome of these cases 
is dealt with below. The milder neuralgic and tremulous forms tend to 
go over into the spastic form, as well as does the paralytic form, about to 
be described. In certain cases the spastic form passes eventually into 
the paralytic form. 
(6) Paralytic Form.-This form is perhaps the typical impotence fonc- 
tionelle des ecrivains. In this form the subject, after essaying the use of 
the pen, gets a feeling of weakness and is unable to bear hard enough upon 
the paper to make properly legible marks. It would be exceedingly val- 
uable if more extensive observations could be made with the Krsepelinian 
writing apparatus as studied by Gross; this apparatus permits registra- 
tion of the pressure and rapidity of writing. Kraepelin states that in the 
depressive cases of manic depressive psychosis, there is a slowing in speed 
of writing and a diminution of its size accompanied by a reduction in the 
pressure. It is probably true that numerous cases of writers' cramp bear 
a more general resemblance to depressive cases of manic depressive psy- 
chosis than they do to such conditions as the maniacal phase or the so- 
called catatonic phases of dementia prsecox. In the latter conditions, 
Kraepelin's associates found such writing as was performed to be per- 
formed as a rule without alteration or punctuated by characteristic 
sudden changes and interruptions. 
Berger has noted cases in .which the functional disorder appears to 
start in the shoulder girdle rather than in the forearm and hand. The 
surgeon would be tempted to see in such cases instances of local disease, writers' cramp 
773 
such as subdeltoid bursitis; the psychiatrist familiar with mild cases of 
dementia prsecox might be tempted to the hypothesis of a local muscular 
hypertension interpreted as a phenomenon of catatonia. Such a condi- 
tion would resemble either true flexibilitas cerea or the pseudo-flexibility 
of some authors. The shoulder placed in a certain posture would retain 
this posture in such wise as to defeat the proper exertion of the rest of the 
extremity. The paralytic form does not occur abundantly in the litera- 
ture of writers' cramp, but is mentioned as an end phase in certain cases. 
(c) Tremulous Form.-This form has been indicated above. The 
spastic and other forms of the disease often begin with tremors or show 
tremors near the onset. The writing in the pure examples of the tremu- 
lous forms is said to be not unlike the writing characteristic of paralysis 
agitans. The characteristic handwriting in paralysis agitans shows, at 
least in later phases, a certain periodicity, so that in writing a number of 
sentences the manuscript becomes tremulous several times only to return 
to normality. In the .case of multiple sclerosis, on the contrary, the 
tremors in writing become more and more marked as the "intention 
becomes more settled." The productions of the tremulous form have, 
however, in common with multiple sclerosis, the fact that with the pro- 
gressive execution of the task the ataxia becomes coarser. The victim 
of multiple sclerosis, however, does not give up through fatigue or through 
aboulia as does the victim of writers' cramp. One of the synonyms for 
writers' cramp, "local chorea," is in short due to the appearance of the 
tremulous form or the tremors found in several other forms. "There is no 
basis in the literature for any special relation between writers' cramp and 
true chorea. Work with the Kraepelinian writing registration apparatus 
would be of special service in cases thought to be of this form. 
(d) Neuralgic Form.-Perhaps the neuralgic form stands next to the 
spastic form of true writers' cramp in frequency. In this form evidences 
suggesting neuritis are not greatly in evidence. The local neuralgia of 
independent nature is often found spreading from a single point in the 
hand and to accompany movements, but the execution of all other move- 
ments is made without pain. Of course, if the pain were found 
following the course of a particular nerve, the chances are that the 
diagnosis of neuritis would be preferred. Associated with the pains 
may be paraesthesias. 
In general it may be observed, concerning the above-mentioned sub- 
forms of true writers' cramp, that the movements may be accentuated 
when the patient is under observation. The examining physician has to 
take this into account when evaluating the severity of a given case. It 
must become evident from references in the above paragraphs that the 
differential diagnosis is not always easy; further data in this direction 
will be given below. Systematic examination of these cases should show 
no alteration of mobility or of the touch, temperature, and pain senses. 
Some experience of the writers with the Martin sensory threshold tests 774 
OCCUPATION NEUROSES 
seems to indicate that at least in some forms of occupation neurosis this 
very finely quantitative test for faradic sensibility (perhaps more finely 
quantitative than any other sensory test so far described) indicates that 
in writers' cramp also we may find it desirable to resort to this method. 
It may well be that by means of it we shall be able still further to diminish 
the number of cases of "true" writers' cramp. If future researches are 
to yield eventually a small but distinctive group of true neuroses, it is 
possible or probable that they will be found in persons also otherwise 
"neurotic." The discovery of cases with increased reflexes, with vaso- 
motor symptoms, with tendency to morbid apprehensiveness, to moodi- 
ness and variability of temperament, would tend to bear out such an 
hypothesis. Cases on a so-called neurotic basis, "hereditary" cases, 
cases in which there is overwork and undernourishment, night work, 
alcoholism, and sexual excess, are mentioned, and perhaps belong in this 
vaguely definable group of neuroses. 
In addition to such general predisposing causes, Bernhardt mentions a 
number of other causes which doubtless contribute more to the growth of 
writers' cramp about to be described than they do to true writers' cramp. 
The groups to be described are of a more structural origin; accordingly 
cases of writers' cramp are said to follow injury, to be associated with 
Dupuytren's contracture, to be a partial phenomenon of neuritis, to be 
due to bad habits in writing, such as using the little finger for a pivot. 
2. Paralytic Writers' Cramp.-This form is intended to be distinct 
from the subform of paralytic true writers' cramp, since the present form 
is a form in which the paralysis of writing is due to the pressure of aneurysm 
on a section of the ulnar nerve, to local pressure, etc. It is conceivable 
that alterations in fine movements may be brought about by these pres- 
sures and yet leave enough of the major functions of the arm intact to 
convey the impression that we are dealing with true writers' cramp. The 
diagnosis must of course depend upon other investigations than those 
of the writing power. Vivian Poore found in his series of 75 cases six 
in this group. In full blown cases, there should be electrical changes that 
might well distinguish this group from true writers' cramp. 
3. Allied with the paralytic group just described is a group termed by 
Poore "degenerative," occurring in nine cases in his series. In this group, 
the first sign of the degenerative neural change is the impairment of writ- 
ing power; but in cases of this sort, the functional impairment gradually 
or rapidly passes off, and is supplemented by impairment in coarser 
functions. 
4. The spasmodic group, comprising five cases in Poore's analysis of 
75, may be of congenital origin; and in three cases was found to be due to 
hemiplegia and in large part related to post-hemiplegic phenomena. 
5. Neuritic or neuralgic group, forming 19 cases in Poore's series. 
Poore states that it is highly probable that we have to deal in this group 
with a mild form of neuritis, or at least some form of vasomotor irritability writers' cramp 
775 
involving one or more of the nerves of the affected arm. The symptoms 
in these cases involve a wider area than the writing muscles. Sometimes 
the symptoms appear without any endeavor at writing. Characteristic 
is the appearance of tenderness of the nerves. Many of the patients, 
according to Poore, complain of a queer feeling in the arm, especially at 
night, with a constant desire to shift its position and an inability to make 
the arm comfortable in bed. Poore found in five of his cases the assigned 
cause to be excessive work with the hand. In eight cases he found his- 
tory of previous strain or injury, in five cases worry and fatigue; in six 
cases he found vasomotor disturbance. 
6. Anomalous cases often diagnosticated as true writers' cramp. 
Writing disorder of the syphilitic group of disease of the nervous system 
may sometimes give rise to this diagnosis. Possibly the case of Brissaud, 
Hallian, and Meige of so-called acrocyanosis associated with writers' 
cramp may have been one of early dementia praecox. The patient in this 
case, 16 years of age, made fantastic figures, and had in addition to some 
psychical peculiarities a marked cyanosis of his hands. 
The disease usually lasts as long as attempts to write are persevered 
in; often when the patient learns to write with the other hand, the same 
disease sets in on the opposite side-at least in some cases. It appears 
that improper holding of the pen has been stated to be a cause of propor- 
tionately greater increase in the disease. Gowers has stated that the 
disease tends to involve more and more muscles in association with any 
general weakness of the nervous system which may exist. It seems to be 
the rule that sensory symptoms show a greater tendency to spread than 
motor. It is clear that the patient is subject to anxiety as to his writing 
capacity, involved as it is in his earning power, which leads to a piling up 
of the agony in the sense of the American slang phrase to the effect that 
the subject's actual disappointment is reduced to his being 11 rattled." 
It appears that in certain cases rest has been known to terminate the 
symptoms. 
The general prognosis is stated by the books to be often unfavorable, 
particularly if the disease has lasted for some time. Gowers states that 
those cases have a better prognosis in which pain rather than spasm or 
paralysis predominates. 
GENERAL EXAMINATION OF A SUBJECT WITH WRITERS' CRAMP 
It seems well at this point to make some statement concerning the 
general examination of a patient with writers' cramp because the general 
principles of such an examination are suitable for examining victims of 
other forms of occupation neurosis. Following the general tendency of 
Vivian Poore to regard the disease as perhaps more likely than not to be 
really of structural origin, Henry Head has offered valuable paragraphs 
upon the principles of such a general examination. Head states that 776 
OCCUPATION NEUROSES 
every patient complaining of an occupation neurosis should undergo a 
complete examination as if for life insurance. In other words, the patient's 
heredity, past and present history, to say nothing of his temperament and 
character, must be finically investigated. A routine neurological exam- 
ination must be performed with a special search for wasting processes as 
well as tremors and disabilities of coordination. The examination must 
be so thorough as to rule out arteriosclerosis, renal disease, and various 
diatheses. 
Head makes a great point of examining the functions of the two arms 
and of all the rest of the body, particularly its upper part, in the nude. 
Asymmetry in postures assumed at command may easily betray unilateral 
muscular weakness. Defective action of the trapezius, the levator anguli 
scapulae, rhomboids, and serratus magnus is thus made manifest if it 
exists. The general tests for motility are then applied. 
There follows a general examination of sensibility with particular 
attention to the possible tenderness of nerve-trunks. Head emphasizes 
the necessity of testing the tenderness of the coordinate nerve-trunks of 
the two sides because, as he says, every nerve-trunk normally shows some 
tenderness. The following statement from Head is interesting enough 
to quote: 
"This examination requires care, because normal nerve-trunks are somewhat 
tender, and it is only by comparison of one side with the other that we can arrive at any 
useful conclusion. The patient stands facing the examiner, with both hands resting, 
palms upward, on the examiner's shoulders. It is important that the patient's arms 
should be really at rest, and as free from all muscular efforts as possible. The physi- 
cian then examines the nerve-trunks of both limbs simultaneously by means of gentle 
pressure on the ulnars behind the olecranon, on the musculo-spirals at the inner borders 
of the supinator longus, and on the median at the elbows, on the inner side of the biceps 
tendon. The simultaneous examination of the medians can only be made if the exam- 
iner crosses his hands. If the examination of the nerve-trunks on the two sides be 
made simultaneously, there is greater likelihood of the pressure being equal; and if the 
examiner find a distinct difference in the tenderness of the nerves, he is justified in 
recording it as a symptom of importance. The patient is, of course, in ignorance of 
the object of the examination, and when the nerve-tenderness is well marked his 
response to a gentle pressure of the thumb is startling alike to examiner and examinee. 
This comparison of the two sides can only be trustworthy when the nutrition of the 
two is equal; if one arm be wasted, the comparison is no longer possible. The search 
for tender nerves is important in all these cases; and not seldom one of the palmar 
twigs of the medium or ulnar is found to be tender, or tenderness is detected along the 
course of the suprascapular, circumflex, or anterior thoracic nerves." 
Careful sensory tests should follow with special reference to their 
differences in coordinate parts of the two limbs. The orthopedic group 
of disorders must be looked for in the bones, joints, and ligaments. 
Many authors have mentioned differences in temperament in these 
cases.' We may again quote-from Head in this matter: 
"The patient, still stripped to the waist in a warm room, should now be made to 
carry out the particular act of which he complains. If it be to write, give him a sheet 
of paper and a good pen, see that he has a comfortable chair and table, and ask him to writers' cramp, examination and diagnosis 
777 
write his name and address, and the date. A great deal may often be learned by 
watching his attempts to perform the deranged action. Occasionally nothing amiss is 
to be detected, except perhaps that the writing may be produced rather slowly. The 
patient may tell you that the effort to write causes pain; but, so far as any change in 
the mode of production or in the product itself is concerned, there is nothing amiss. 
This, of course, is important both in diagnosis and prognosis. At the other end of the 
scale is the man who is scarcely able to make a mark upon paper; whose efforts are 
accompanied by most tumultuous movements of the shoulder, who is obliged to fix his 
arm securely before beginning to write; who grasps the pen with all his might, and 
perhaps drips with perspiration as he makes an abortive attempt to sign his name." 
Electrical examinations have been mentioned above. Reaction of 
degeneration is never found in uncomplicated cases of occupation 
neurosis. Diminution in galvanic excitability is said to be confined to 
the small muscles of the hand and to affect the first dorsal of the interos- 
seous group more frequently. 
Differential Diagnosis.-The diagnosis of a disease due to occupation 
seems to be an obvious matter in instances of writers' cramp. The 
difficulty lodges, not so much in placing the condition in the group of occu- 
pation diseases as in choosing the condition fundamental in the particular 
case. This latter choice usually lies between the supposition of a true 
neurosis in the sense of a disease not primarily due to local structural 
changes, and one or other forms of neuritis, neuralgia, myositis, myalgia, 
or other local disease. As our description has abundantly shown, the 
very nature of the disease is in question, and the description is split 
along the familiar lines of controversy between structuralists and 
functionalists in neuropathology. 
The fact seems to be that the majority of all cases of writers' cramp 
(which are said by some to form nine-tenths of all cases of occupation 
neurosis) are cases which fall outside the pale of the true neuroses. It is 
well to concede that there may be a small group of truly functional cases, 
and in any event to remember that in accordance with well-known 
principles, the range of functional symptoms in a given case may exceed 
the range of the immediately structural symptoms. Treatment may be 
governed accordingly. Taking for granted that the case presenting itself 
for treatment has in practically all cases made a diagnosis before resort 
to the physician, the physician must launch his differential diagnosis in 
the first place in the direction of excluding constitutional disease in which 
the writing defect may be merely the most striking phenomenon of weak- 
ness because perhaps it affects the earning power of the subject. Assum- 
ing that such constitutional diseases as have been mentioned above have 
been excluded by the most careful general medical and neurological 
examination, it would seem wise to include a careful psychopathological 
analysis from the diagnostic point of view. The books have probably 
not emphasized sufficiently the psychiatric possibilities in this direction 
and particularly mild depressive states which may or may not be dis- 
tinguishable in a given case from the phenomena of psychoneurosis. If 778 
OCCUPATION NEUROSES 
constitutional disease, the common neurological affections and psychiatric 
conditions of a pronounced character can be excluded, the process of 
diagnosis must begin to deal more particularly with orthopedic condi- 
tions, such as osteitis, periosteal changes, tenosynovitis, synovitis, arthri- 
tis and various forms of myositis and other myopathy. The discovery 
of various degrees of these orthopedic conditions does not, according 
to some authors, always mean that the entire condition is an orthopedic 
one. It may accordingly be well to hold in mind that osteopathy or 
myopathy is part and parcel of a more general process involving also the 
nerves, and that any or all of these changes may be associated with, 
preceded by, or followed by neurotic changes in the sense of purely func- 
tional conditions. 
The analysis must next consider the neuropathies, general and local. 
If we should adopt the triple classification of James Mackenzie of struc- 
tural, functional, and reflex symptoms, especially structural, functional, 
and reflex pain, we must, perhaps, exclude the so-called reflex pain from 
consideration inasmuch as it has not been shown that conditions in viscera 
can lead to such a condition as writers' cramp. However, if central nerv- 
ous conditions suitable for the production of reflex pain could be brought 
about by local disease in the central nervous axis, then it is conceivable 
that there might be cases of painful writers' cramp of central origin. We 
have not encountered such cases in the literature. The symptoms would 
then in general reduce in the sense of Mackenzie to functional and 
structural ones; probably in most cases there is a combination of these. 
Despite the tendency of the writers to look for psychiatric causes in this 
affection, we have become more and more enamoured of what might be 
called the peripheral hypothesis, and to agree with the general modern 
tendency to discover in these cases neuritis in greater or less degree. An 
enumeration of conditions which have been or may readily be mistaken 
for true writers' cramp bears out this general tendency. 
First among the conditions which should if possible be differentiated 
from the true occupation neurosis is what may be termed occupation 
neuritis in which there will be found sensory changes (tenderness of 
nerve-trunks, motor changes), paralysis, tremor, etc., and electrical 
changes (in the extreme case, reaction of degeneration). Neurasthenic 
and hysterical patients are among those who may eventually exhibit 
writers' cramp, and it may accordingly be difficult to pull apart the 
effects of the underlying general neurosis and the particular phenomenon 
of the cramp, particularly in hysterical cases in which there are so often 
unilateral symptoms. Among diseases which have given rise to errors 
in diagnosis may be mentioned multiple sclerosis, tabes-notably brachial 
tabes, hemiplegia of a gradual development (the thrombotic type), 
paralysis agitans, general paresis. A number of psychiatric conditions 
need mention since the writing disorder may emerge from them as one of 
the most striking symptoms: brain tumor, brain abscess, senile dementia, writers' cramp, diagnosis and treatment 
779 
alcoholic mental disease, post-infectious psychosis, chorea, the melan- 
cholic and catatonic phases of certain mental diseases, congenital agraph- 
ias, and so on. Dupuytren's contraction, acroparsesthesia, and even 
Raynaud's disease may need to be thought of. A fundamental study of a 
differential diagnosis of these disorders would, in fact, lead to including 
practically the entire range of nervous and mental disorders, together 
with a large group of orthopedic and general medical disorders. 
The Range of Treatment.-The range of treatment in occupation neu- 
roses is wide, corresponding to the hypotheses adopted by authors 
concerning cases. On the general hypothesis of fatigue, a number of 
bits of apparatus have been constructed which permit writing to be per- 
formed by the use of somewhat different muscles. It is probable that not 
one of these pieces of apparatus has been extremely effective. To meet 
local conditions, special gymnastic movements have been prescribed, 
active and passive movements, as well as passive movements executed 
by the non-affected hand. Work with Zander apparatus and massage 
has been tried, as well as galvanic and occasionally faradic electricity. 
Hydrotherapy has come in for a share of attention. Bier's hypersemic 
method has been employed. The relief of irritation as by counter-irrita- 
tion, and the use of the cautery, have been counselled, as well as muscle 
stretching. There is a large group of hygienic counsels; attention to the 
eyes, condition of the nerves and condition of the muscles, schemes for 
removal of the difficulty by suggestion or by subtler methods of psycho- 
therapy and by psychoanalysis. Re-educational processes are mentioned, 
as well as the so-called education of the will. There is a group of recom- 
mendations beginning with rest. The use of the other hand, the use of 
the typewriter instead of pen and paper, and mirror writing (with the 
object of the correction of early acquired habits) are noted in the litera- 
ture. There is a group of suggestions from the pharmacological side 
ranging from the local injection of carbolic acid (doubtless founded on 
the results in certain cases of trigeminal neuralgia with alcohol) to the 
exhibition of various tonics and other drugs. Both excitants and seda- 
tives are mentioned; we have noted the following drugs: strychnine, atro- 
pine, bromides, narcotics, quinine, valerianate of zinc, arsenic, iodoform, 
gelsemin; zinc phosphate, Gowers is inclined to recommend above all the 
rest. He is willing to counsel writing with the other hand, although it is 
said in 50 per cent, of all cases the cramp occurs in the other hand after 
a time. Gowers thinks that stimulants are superior to sedatives in the 
general treatment of these cases, but naturally employs sedatives in 
various instances in which, neuralgia is predominant. 
II. OTHER MANUAL NEUROSES 
First among these stands typewriters' cramp, a modern disease which 
comes on either independently, or after the therapeutic substitution of 780 
OCCUPATION NEUROSES 
typewriting for manuscript which is occasionally counselled. Type- 
writers' cramp does not supervene immediately, but it appears that it may 
occur within a period of weeks or months after the handwriting has been 
given up. This disease appears to be extremely rare; Head has person- 
ally observed but one case. Dr. W. E. Paul of Boston has had a case. 
Typewriters' cramp is as a rule bimanual. 
Telegraphers' Cramp.-This disease appears to be rare, whether in 
form of tremor, or paresis, or pain. One of Vivian Poore's cases may be 
abstracted as follows: 
A man, aged 39, had worked a. Morse key for 19 years. He had as 
much difficulty in writing as in telegraphing, and it was noticeable that 
all delicate acts-such as shaving, holding a teacup, or wielding a salt- 
spoon-were seriously impeded by tremor. The tremor affected all the 
muscles of the right upper limb, including the pectoralis major; but it 
was most marked when the hand was prone in the telegraphist's position. 
The median and musculospiral nerves on the right side were distinctly 
tender. 
This case might certainly be interpreted to signify a more general dis- 
order than that in the hypothetic association sense for the manipulation 
of the Morse key. The literature contains a discussion as to whether the 
Morse key or the Hughes key is the more likely to bring about 
telegraphers' cramp. 
Pianists' Cramp.-Cases of Poore, de Lepinay, and Riseau are men- 
tioned. The literature indicates that the disease occurs in beginners 
rather than in virtuosi. A case of de Lepinay quoted by Head was that 
of a musician who at first could not extend the little finger of the right 
hand in playing the oboe. Later, the ring finger could not be extended, 
and trouble in playing the piano followed. Examination demonstrated 
that there was also difficulty in several other delicate acts peformed by 
these muscles, to such an extent that it may be held that this case was 
one of musculospiral neuritis. 
Violinists' Cramp.-The characteristic digital corns of the violinist 
occasionally become tender and cause pain that radiates up the arm and 
prevents firm pressure of the fingers on the strings. Such cases would 
have to be regarded as pseudo-cramp cases. True cases of occupation 
neurosis in violin players and players of other stringed instruments 
appear to be extremely rare. 
Sewing Cramp and Scissors Cramp.-These are rare forms of manual 
occupation neuroses. The latter form appears under some circumstances 
to be due to actual neural and muscular atrophy produced by pressure 
from the scissors upon the thenar eminence. 
Hammermen's Cramp.-Head points out that many cases of sup- 
posed Hammermen's cramp are really otherwise to be explained. Thus 
the hephsestic palsy of Frank Smith, Head regards as a cerebral hemiplegia 
or monoplegia occurring in a hammerman. Head believes, however,. VARIOUS MANUAL CRAMPS 
781 
that there is a condition which .approaches a true occupation neurosis, or 
is in any event a distinct clinical entity. 
" I have seen many blacksmiths and men accustomed to the use of a hammer who 
complained that they could not hold it in one or other hand. But in every case the 
disability depended on the presence of pain in the neighborhood of the elbow, evoked 
by attempting to grasp anything firmly in the hand. This condition seems to be a 
distinct clinical entity of frequent occurrence, but, so far as I have been able to dis- 
cover, it has not been definitely described. Many cases of "hammermen's cramp" 
seem to have been instances of this disease, which I believe to be closely allied to 
meralgia paraesthetica in the leg (Bernhardt's disease). 
"The patient begins to complain of pain situated over the insertion of the long 
extensors of the fingers just below the external condyle. The pain is never entirely 
absent, but is greatly increased when he attempts to grasp with the hand of the affected 
extremity. Should the patient's occupation necessitate any movement in which the 
long extensors participate, he will complain of professional disability. Thus, I have 
seen a blacksmith, a ladler of metal for stereotyping, and a Government clerk, all of 
whom suffered from this complaint; the first could not use his hammer, the second his 
ladle, and the third his pen, without bringing on the pain so severely that work became 
impossible. The Government clerk gave the following history of the onset of pain. 
Coming home one winter night from a week-end in the country, he arrived at the 
station to find no cab. He was therefore obliged to carry a heavy bag some distance 
to his home. Next morning he noticed pain over the extensors of the forearm, which 
was easier when the arm was flexed. It was greatly increased by writing or by hand- 
ing a plate; grasping the spade while gardening produced severe pain. It gradually 
improved to such an extent that he was free from pain unless he wrote for long periods 
or performed any act which necessitated grasping. In these cases the pain seems also 
to produce a curious inhibiting effect upon the strength of the grasp, so that the patient 
complains that his hand 'feels weak;' and yet there is no weakness of any muscles of 
the hand. Extension is both painful and difficult, and so the wrist and fingers are no 
longer fixed, and the flexors cannot act for want of their normal support. This was 
well seen in the ladler of mental, who was no longer able to employ his right hand as a 
fulcrum when using his long handle. 
"I believe this condition is produced by injury to the nerve-twigs which pass 
through the extensors to come to the surface just below the external condyle. This 
spot is intensely tender to deep pressure, and there is generally a patch of tenderness 
to the point of a dragged pin, with or without a little diminution in cutaneous tactile 
sensibility, over a patch a few inches in length situated just below the external con- 
dyle. No other nerve trunks are tender, and the muscular reactions do not show any 
change. 
"Complete rest of the arm with blisters applied to the tender spot will generally 
cure the disease in 6 weeks. But it is liable to drag on if the arm is used, and may fall 
into a chronic intractable condition." 
Granite Cutters' Cramp.-We have had the opportunity of examining 
a case of cramp in which an apparent occupation neurosis was produced 
at the end of 15 years of work with a pneumatic tool used in quarrying. 
This tool caused considerable jarring of the arm. The patient when seen 
had had 6 months of symptoms. The first symptom was pain in the fore- 
arm, radiating back to a point above the elbow. The pain had grown 
.progressively worse, and the patient had thought of quitting work owing 
to a real or imagined difficulty in grasping the hammer. The patient 782 
OCCUPATION NEUROSES 
had ceased work with this tool, 4 months before our observation, but 
the pain had continued. The case was complicated by worry over the 
payment of bills and the possibility of insurance. Wassermann reaction 
was positive. We found that a pain in the elbow would appear when the 
hand was flexed. A similar ache would appear at night. Early in the 
disease, the patient had had a certain degree of numbness of the ring and 
little fingers. The patient found that he could flex his forearm if in the 
full position of supination or pronation; but that, if the hand was held 
in a semi-prone posture, he could not flex his forearm without pain. This 
semi-prone position of the arm was the position characteristically main- 
tained while working with the pneumatic tool. Examination of the sensi- 
bility of the skin gave a negative result to ordinary tests, nor was there 
any abnormal tenderness over nerve-trunks. The grasp of the left hand 
stood to that of the right as 42 to 38. We were, however, able to demon- 
strate by means of the Martin sensory threshold test for faradism, that 
there was still a slight degree of anaesthesia of the hand, most marked in 
the thumb and little fingers. It is, of course, possible that this electrical 
anaesthesia is in some sense functional, but it seemed more likely that it 
depends upon a structural neuritis disorder. Our experience with this 
case gives an intimation of what finer examinations may bring out in 
various cases of other forms of occupation neuroses, notably in writers' 
cramp. Cases in which no anaesthesia can be demonstrated with the 
methods ordinarily available to the clinician may yield results with this 
test. Upon inquiry, we learn that stonecutters not infrequently show a 
disease of this general character. 
Cigarmakers' Cramp.-In Boston, and doubtless elsewhere where 
cigarmaking is an habitual occupation, cases of cigarmakers' cramp 
appear from time to time. They have come to the attention of the 
Industrial Accident Board in Massachusetts, but it cannot be said that 
the condition has as yet been reduced to a well understood entity. We 
had the experience of a case characterized by a somewhat curious 
feature; just prior to each of several attacks of mania in the psychosis 
termed by Kraepelin manic depressive insanity, difficulty in rolling 
the tobacco leaves appeared, being the first sign or species of aura for 
these attacks. 
Artists' Cramp.-A form of disease doubtless not truly belonging to 
the occupation-neurosis group was observed by us in a painter, who was 
the victim of a psychoneurosis characterized by irritability, hypochondria, 
insomnia, and an inability combined with a persistent desire to work; 
with the onset of the aboulia, the pain and incapacity to use the brush 
would occur. The artist would then give up his work for a time. Upon 
recovery from the psychoneurosis under treatment by means of rest, hydro- 
therapy, and argumentation, the patient entirely recovered his capacity 
to use the brush. VARIOUS CRAMPS-PROGNOSIS AND TREATMENT 
783 
III. OTHER FORMS OF OCCUPATION NEUROSES 
There is a small group of what might be termed pedal neuroses, of 
which may be mentioned dancer's cramp, the most frequent or only form 
of which known is that in the toe dancer. In the list given above 
are several examples of still other forms, such as buccal, laryngeal, and 
the like. 
GENERAL PROGNOSIS AND TREATMENT 
It must be obvious from the above account that the diagnostic prob- 
lems of the occupation neurosis group are almost inextricably mixed 
with those of various neuropathies and myopathies associated with 
different forms of occupation. Accordingly the most essential problem 
to solve is that of diagnosis in a given case. The experience of almost 
every neurologist is likely to be rather meager in this field. The careful 
investigation and report of all cases of occupation neuropathy and neuritis 
may be recommended, so that as the years pass a more and more compre- 
hensive, systematic study of these allied conditions may be made. As 
in the case of stonecutters' disease mentioned above, it is possible that the 
Wassermann reaction may be of service in elucidating certain tendencies 
to neuritis. And it may be here that such a theory as the Ersatz Theorie 
of Edinger may have its application. According to this theory, functional 
overuse of a part may for intimate metabolic reasons produce or permit 
structural changes. 
As also noted above, a number of cases disappear from the occupation 
neurosis group and reappear in the group of the frank psychoses. 
Aside from various pseudo-forms of occupation neurosis (of which a suf- 
ficient list has been given under the heading/' Writers' Cramp"), the true 
occupation neuroses form a group whose prognosis is on the whole not good 
if we make it our aim to send the patient back with his original capacity 
to perform the function with which he now has difficulty. The prognosis 
as to a perfect recovery of the original function is decidedly not good. 
Also, in sundry instances, the prognosis is unfavorable with respect to the 
success of a substitution of some nearly allied function, such as type- 
writing for manuscript. On the whole, it would seem wiser to take steps 
at once to change the occupation somewhat radically if the diagnosis of 
true occupation neurosis can be made reasonably certain. 
As to treatment, the general counsel of rest from the occupation in 
question is well-nigh universal. Naturally, if the diagnosis be incorrect, 
the counsel "rest" may be also decidedly incorrect. 
Substitution of a new form allied to the old is the second general 
prescription. It would seem very unlikely that there should be an 
endless chain of disabilities ensuing upon substitutions of new forms of 
occupation unless there is some more fundamental form of disorder at the 
bottom of the condition, such as, for example, a psychoneurotic or frankly 784 
OCCUPATION NEUROSES 
psychopathic condition. In a country like the United States, wherein it 
seems to be almost the universal habit to change occupations more or less 
frequently, the securing of substitute occupations is perhaps not so 
difficult as in a country of more stable social conditions. We hardly 
possess in the United States such conditions as hold in the greatly 
extended civil services of Great Britain. 
If, however, rest, with or without a substitution of a new form of 
occupation, cannot be executed, or if the disability is such as to be, as it 
were, more irritative than destructive to the performance, then it might 
be inquired whether gymnastics and exercise would not be of benefit. 
It does not appear that in cases of true occupation neurosis gymnastic 
exercises have been of any benefit. 
A list of drugs used in writers' cramp has been given above and need not 
be repeated here. The best general injunction accordingly in a case of 
supposed occupation neurosis is that the diagnostician shall endeavor by 
all means to prove that the case is not one of occupation neurosis. The 
chances are very good, as the above account has intimated, that the expert 
diagnostician will prove that the majority of these cases are actually 
neuritides, or examples of neuropathies, myopathies, arthropathies, or 
other local forms of disorder affecting finer acquired habitual movements. 
Thus, the same general tendency which we observed in neuropathology 
at large obtains in this field also, namely, that the neuroses in the sense 
of functional conditions tend to disappear into conditions in some sense 
structural. To be sure, the structural conditions in question may not need 
to be overt examples of nerve or muscle wasting or of microscopically 
demonstrable fatty degeneration, but the technique of the future will 
doubtless prove able to demonstrate finer forms of physical and chemical 
disorder which will serve better to explain both neuroses in general and 
the small but perturbing group of occupation neuroses. 
A note should be made of a new and practical phase into which the 
occupation neurosis question passes through the enactment of various 
workmen's compensation acts. Problems of a most intricate nature come 
up in connection with arbitration boards dealing with these questions. 
The whole topic of simulation enters to obscure the issue. It is too early 
to speak of the practical effect of these acts in this country. It is probable 
that the theory of the condition will be greatly benefited by the careful 
expert examinations which will be performed in these cases. We have 
already noted a tendency to greater care in these examinations as a result 
of the work of a commission like the Industrial Accident Board of 
Massachusetts. 
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785 
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Schreibkrampf in Ziemssen's Handbuch der speciellen Pathologic und Therapie, 
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Eulenburg.-Real Encyk, XXIII. 
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Fiirnrohr.-Ref. Mtinch. Med. Woch., 1906, LIII, 681. 
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Gray.-Nervous and Mental Diseases, Phila., 1895. 
Hartenberg.-Crampe des ecrivains guerie par la ligature elastique. Arch. Neurol., 
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Haskovec.-Mouvements associes dans la crampe des ecrivains. Rev. neurol., 1902, 
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Head, Henry.-Allbutt and Rolleston's System of Medicine, 1910, Vol. VIII, 667. 
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Hughes.-Scriveners' Palsy not Solely Pen Fatigue. Canada Lancet, Toronto, 1896- 
97, XXIX, 139. REFERENCES ON OCCUPATION NEUROSES 
787 
Huttenbach.-Ein Beitrag zur Frage der Kombination organischer Nervenkrankungen 
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Jacobsohn.-Writers' Cramp and Other Occupation Cramps. Klin, der Nerven- 
krankheiten, 1913. 
Jelliffe, S. E.-Osler's Modern Medicine, 1910, VII, 786. 
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Kouindjy.-La crampe professionelle et son traitement par le massage methodique etla 
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Lanel.-Le spasme fonctionnel. Etiologie et traitement. Presse medicale, 1909, 
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Lepinay.-Etude sur crampes professionellis. Nouv. Icon, de la Salpetr., 1909, 
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Leri.-Crampes fonctionnelles et Professionelles. La pratique Neurol. Pub. Marie, 
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Lewandowsky.-Die Hysterie. Handbuch der Neurol. 
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Mace de Lepinay.-Claudication intermittente du membre superieur droit; crampe ses 
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OCCUPATION NEUROSES 
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Jour. Indiana Medical Association, 11, 297, August, 1918. CHAPTER V 
OCCUPATIONAL DISEASES DUE TO ABNORMAL ATMOSPHERIC 
PRESSURES 
SECTION 1 
COMPRESSED-AIR ILLNESS 
SEWARD ERDMAN, M. D„ New York City. 
Synonyms.-"Caisson disease," "divers' palsy," "bends," "screws," 
"courbatures," "aeropathy," "aeraemia," 
Definition.-An occupational disease occurring among divers, caisson 
workers, subaqueous tunnel workers, etc., following exposure to com- 
pressed air, the symptoms of which arise only after the too rapid removal 
of pressure (decompression), which liberates in the supersaturated body 
fluids and tissues bubbles of gas 
The symptoms are usually of sudden onset within from 15 minutes to a 
few hours after decompression, and include pains, paralyses, dyspnoea, and 
even circulatory failure and death. 
There is a strong tendency to early and spontaneous recovery in the 
majority of cases. 
Historical.-Descriptions of compressed-air illness date back only 75 
years and it is essentially, a disease of modern civilization. 
In 1839, Triger, a French engineer, who elaborated the first practical caisson and 
employed it in mining coal under the River Loire, describes the occurrence of pains in 
the extremities of certain of his caisson workers, and these observations constitute the 
earliest authentic recognition of compressed-air illness. 
However, from the times of Alexander the Great and Aristotle onward through the 
centuries, crude diving bells and helmets had been experimented with, and in 1665 
salvage from the sunken Spanish Armada was accomplished at the depth of 46 ft. 
In 1717 Halley devised a diving bell which could be used at a depth of 60 ft. 
A century later, Siebe, in 1819, devised the first diving helmet supplied with air 
from an air pump, and this diving dress which he perfected in 1837 is the prototype of 
those now in use. 
The principle of the caisson was patented by Cochrane in 1830 but first made a 
working device by Triger. 
Doubtless in the earlier experiments technical difficulties prevented exposure to 
sufficient pressures for a sufficient time to give rise to symptoms of compressed-air 
illness. 
Scientific investigation of caissoi^ disease was earliest undertaken by Pol and 
Wattelle1 in 1854, and although the mechanical pressure theory which they put for- 
790 COMPRESSED-AIR ILLNESS-FREQUENCY 
791 
ward has since been entirely rejected, nevertheless many of their observations and 
conclusions have remained uncontroverted. 
In 1857, F. Hoppe-Seyler, repeating the experiments which Boyle had begun in 
1670, upon animals subjected to rarefied atmosphere by use of the vacuum pump, 
confirmed the fact of the liberation of bubbles of gas in the body fluids. 
By ^analogy, Hoppe-Seyler propounded the correct theory of the causation of 
caisson disease. 
P. Bert2 in 1878, by the first animal experiments with compressed air, proved 
conclusively the truth of Hoppe-Seyler's theory, and his work is still regarded as a 
classic in the literature of compressed-air illness. 
Most valuable experimental work and contributions to the study of this disease 
are to be attributed to such men as Heller, Mager, von Schrotter,6 Silberstern,14 
Hill,12 Greenwood, Macleod,16 Haldane, Boycott, Damant and to numerous others. 
The building of the East River tunnels from New York to Long Island City for the 
Pennsylvania R. R. in 1906-1909 afforded material for monographs by F. L. Keays,8 
H. Japp,13 McWhorter10 and the writer,9'15 dealing chiefly with the practical and 
clinical aspects of the illness. 
Frequency.-Occurrence of this disease postulates the use of com- 
pressed air, and consequently its frequency has greatly increased with the 
development of submarine construction work and diving. 
Caisson work for the Kehl bridge over the Rhine in 1859 was one of the 
earlier large ventures. The St. Louis bridge, 1870, and the Brooklyn 
bridge, 1873, also the Danube bridge, 1890, afforded opportunities for 
the further study of caisson disease. 
However, river-tunnel construction employs so many more men in 
compressed air than does caisson work that we turn to those larger enter- 
prises to furnish the massive statistics for a clinical study. 
The East River tunnels employed over 10,000 men during their con- 
struction, at an average working pressure of +32 lb. with a maximum of 
+42 lb. 
The writer9 has reported on 1 year's work, and F. L. Keays,8 the medi- 
cal director, has ably analyzed the total statistics which embrace 3692 
cases of illness among the 10,000 men, or 36.9 per cent. But I feel certain 
that if every trivial case of "bends" had been recorded, the percentage 
would have to be doubled; indeed I doubt that even 10 per cent, escaped 
unscathed at all times. 
At the Eider bridge in 1885, with a maximum pressure of +35 lb., there occurred 
380 cases among 140 workers, or 270 per cent. 
There were reported 320 cases among 675 men who worked at the Danube bridge 
in 1890 at a maximum pressure of +32J^ lb., and this represents 47.4 per cent. 
But as the possibility of the development of symptoms is present every time the 
pressure is removed, comparison with the number of man shifts would be a more 
accurate method of estimating the frequency of the disease. 
Thus, at the East River tunnels there were 557,000 decompressions, and the 3692 
cases of illness would give an incidence of only 0.663 per cent. 
The British Admiralty Committee on Deep Sea Diving reported 60,000 decom- 
pressions with 577 cases, or 0.96 per cent. 792 
COMPRESSED-AIR ILLNESS 
GENERAL DISCUSSION OF THE NATURE OF COMPRESSED-AIR ILLNESS, 
BASED ON THE ACCEPTED GAS-BUBBLE THEORY 
When a man or an animal is exposed to compressed air, the blood, 
by diffusion from the alveoli, and later all the body fluids and tissues 
become supersaturated with the nitrogen of the atmosphere to a degree 
dependent upon three factors: (1) the amount of pressure (see Dalton's 
law); (2) the length of exposure to the pressure; (3) the vascularity 
and the absorptive ability of the individual tissues. 
Upon decompression the excess nitrogen (see below) tends always to 
flow off from the supersaturated tissues, by means of the circulating blood, 
into the alveoli and expired air where the pressure is lower. 
Such a gradual and orderly desaturation of the body tissues would 
occur under favorable conditions without the ebullition of any bubbles 
of free gas, and no symptoms would then result. 
As will be shown, however, the desaturation of the tissues always lags 
behind the lowering of pressure, and there is left a residuum of gas in the 
organism.11 
Therefore it follows that there is always the possibility that too rapid 
removal of pressure may result in the freeing of nitrogen in the form of 
bubbles in the tissues and body fluids. 
Probably if the bubbles be small in size and amount and occur in 
indifferent tissues, the circulation will get rid of them by way of the lungs 
and still no symptoms may arise. 
When free bubbles of gas by their expansion or coalescence form gas 
emboli in the circulation, or inflict direct mechanical injury upon delicate 
nervous tissue by expansion of the bubbles in accordance with Boyle's 
law, then symptoms may and do result. 
Fat, fluids, and nerve tissue are especially affected; consequently the 
irritation of peripheral nerves, or injury to the central nervous system by 
interference with its blood supply and by pressure of expanding bubbles, 
will give rise to many of the protein symptoms which characterize this 
malady, and in severe cases the resultant softening or hemorrhages may 
cause a true myelitis. 
Compressed-air illness then is the direct result not of the increased 
pressure, but of decompression which has been so rapid that bubbles of 
free nitrogen have been liberated in the organism. 
Hence the symptoms never occur under compression, however long 
continued, but only as the result of, and after, decompression. 
Such in brief is the gas-bubble theory which has been indisputably 
established as the correct and only explanation of compressed-air illness. 
A large proportion of all autopsies performed within 24 hours after 
death in the rapidly fatal cases, whether among men or in animal experi- 
ments, show visible bubbles of gas in the veins and right heart and often 
in other tissues. THEORIES PREDISPOSING FACTORS 
793 
Theories.-Other theories have been advanced and tenaciously held, but they must 
all fall to the ground if for no other reason than that they do not even attempt to 
account for the formation of a single bubble of gas. 
1. The mechanical pressure theory propounded by Pol and Wattelle1 in 1854, 
and held by A. H. Smith and others, is based upon false conceptions of the effect of 
compression upon the vascular system, and it fails to explain the pathological findings. 
2. The "effects of cold and fatigue," whose adherents include Jaminet,3 Tine and 
others, has truth in it only to the extent that fatigue and cold are minor contributing 
factors. 
3. The carbon dioxide poisoning theory of Snell4 does not explain the phenomena 
of gas-bubble formation; also its symptoms would occur during exposure to pressure, 
which is never true of compressed-air illness. 
Furthermore Hill12 and Greenwood, also Haldane and Priestley, have proven 
that the absolute partial pressure of CO2 in the alveoli is regulated by the rate of 
respiration and remains practically the same (5.6 per cent.) under compression even 
up to +6 atmospheres, and consequently no more is taken into the blood under pres- 
sure. Haldane7 states that even when the air in a caisson or diving helmet is so 
vitiated as to contain 3 per cent. CO2 pressure it will not affect the man in his work, 
although it would increase his respirations; if it contain more than 4 per cent. CO2 
pressure, the resulting dyspnoea would interfere with hard work, and only when the 
CO2 pressure is above 10 per cent, will unconsciousness from suffocation supervene. 
4. The oxygen poisoning theory of Lorrain Smith is based on, the fact that the 
breathing of very high pressures of oxygen, at from +7 to +15 atmospheres during 
long exposures, produces congestion and inflammation of the lungs. 
As an explanation of compressed-air illness, this theory is of course quite in- 
adequate. 
1. Degree of Pressure.-Other things being equal, the number of 
cases of illness increases directly with the degree of pressure. 
Only a very few minor cases of pain occurred at pressures up to +20 lb. One case 
of transient hemiplegia with aphasia after 8 hours at +15 lb. was reported by Keays,8 
although the hemiplegic case depends solely on the patient's own statement for he was 
not seen by a physician. 
Haldane thinks that bubbles will not form even after the most rapid decompres- 
sion from pressures up to +15 lb., and adds that symptoms begin with +20 lb., are 
rare up to +30 lb., but are serious in frequency above +30 lb. 
Bert,2 1878, was told of one fatal case after exposure to +21 lb., but there seems 
to be reason for doubting the correctness of this report. 
Haldane never heard of a fatal case below +29 lb. 
At the East River tunnels the lowest fatal case occurred at +28 lb. 
From a wide practical experience, Mr. Japp13 considers that pressures 
up to +27 lb. may be regarded as free from the risk of serious 
developments. 
However, it is clear that every additional pound above +30 lb. carries 
with it increasing risk. 
2. Length of Exposure.-The degree of saturation of the organism, is 
for any given pressure, a matter of time. Were it merely a question of the 
saturation of the blood, this might take place in 1 minute, if we premise, as 
is probably true, that the diffusion of gases from the alveoli to the blood 
occurs instantaneously and that the complete circulation of the blood takes 
CAUSATION-PREDISPOSING FACTORS 794 
COMPRESSED-AIR ILLNESS 
place in 1 minute (Plesch says 55 seconds during rest but only seconds 
during hard work). 
However, the saturation of the body fluids and tissues takes place only 
gradually from the blood, and those tissues which are deficient in blood 
supply will require more time for saturation. 
Again we find that certain tissues are better solvents for nitrogen than 
others. Thus, Vernon12 estimates that fat can dissolve five times more 
nitrogen than the blood and non-fatty tissues, by bulk. Hence fat, which 
makes up from 15 to 20 per cent, of the body weight and is little vascular, 
will saturate slowly and consequently desaturate slowly. 
Therefore as a unit in saturation of the organism containing so much fat, the blood 
has an effective bulk of only 5 , although in reality it is from to H 3 °f the body 
weight. 
Attempts have been made to calculate the rate of saturation of the body tissues 
on the basis that ^5 saturation occurs in 1 minute and ^5 of 3^5 in the second 
minute, etc. Thus Haldane7 and Boycott estimate that 22 per cent, saturation 
will occur in 5 minutes, 50 per cent, saturation in about 25 minutes and almost 
complete saturation in 90 minutes, but the slowest parts might require 5-9 hours for 
complete saturation. 
Turning from the theoretical consideration of this question to the results of prac- 
tical work in compressed air, Keays8 found that among 2719 men exposed to +31 lb. 
pressure for 1^ hours on a preliminary test and therefore not working, only three 
cases (0.18 per cent.) of illness developed, whereas among 2000 men working for 
hours at +32 lb. there were seven cases or 0.35 per cent. (In this instance the length 
of exposure was the same, but the effect of work in hastening saturation is illustrated.) 
After two 3-hour shifts at 31.7 lb. 1.46 per cent, developed symptoms, in 3360 man 
shifts, whereas in 23,760 man shifts (two shifts of 4 hours each) there were 216 cases 
or only 0.90 per cent. 
From these statistics Keays concludes that saturation is not complete after 1% 
hours, although it is more nearly so if the men are working than if they are resting; 
that after 3 hours' work saturation is practically complete and longer exposures, e.g., 
of 4 hours, did not increase the percentage of cases of illness. In fact the percentage 
after the 4-hour shifts was smaller than after the 3-hour shifts, which apparent dis- 
crepancy I would attribute to the fact that the longer interval between shifts (4 hours 
for the 4-hour shifts and 3 hours for the 3-hour shifts) enabled the 4-hour men to 
become more completely desaturated as well as rested before going down to their 
second shift. 
No less an authority in practical engineering than Mr. E. W. Moir12 states that he 
"is confident that a limitation of the exposure to even 3 hours distinctly diminishes 
the risk of bends as compared with 6 or 8 hours' exposure." 
However, we may conclude from the statistics cited above that for 
practical purposes saturation occurs after 3 hours' work under pressure, 
for the average man. 
3. The Personal Equation.-(A) Efficiency of the circulation would epito- 
mize the qualifications for good air workers, and any condition which 
tends to lower the tone and elasticity of the blood-vessels or to cause 
passive congestion will in so far retard desaturation and predispose to the 
collection and coalescence of gas bubbles in the circulation. Hence we 
note as predisposing factors debilitation from disease or malnutrition, PREDISPOSING FACTORS 
795 
from alcoholic and other excesses; constipation; fatigue; the effects of 
cold and the lack of exercise during decompression and afterward. 
(B) Organic diseases, especially arteriosclerosis, heart lesions, respira- 
tory diseases, interfere with rapid desaturation. Anaemia, oedema, 
status lymphaticus have all been reported in some of the fatal cases, and 
naturally such diseases should prohibit work in compressed air. 
(C) Age.-Ken from 18 to 30 years of age are the most desirable for 
pressure work, because of their efficient vascular and general conditions. 
Beyond 30 years the risk of serious illness increases, and with few excep- 
tions men over 40 years of age should be excluded. 
(D) Fat men are notoriously ill-fitted for work in high pressures, a 
practical observation which is fully explained by the slow desaturation of 
fat, and substantiated by the animal experiments of Boycott and Damant. 
(E) Fatigue may be conceived as playing a role in the causation, by 
impairing the efficiency of the circulation; indeed, Keays8 holds it respon- 
sible for the fact that for the same men at the same pressures there was an 
increase of cases of illness after the second 3-hour shift (0.72 per cent.) 
when compared with the first 3-hour shift (0.35 per cent.). However, I 
would note another possible factor here, namely, the incomplete desatura- 
tion during the 3-hour (often 2^-hour) interval between shifts. 
4. Atmospheric conditions above ground have been thought by some 
men to affect the incidence of illness, but we were not able to establish any 
such connection at the East River tunnels, where we kept a daily record 
of the temperature, barometer readings, humidity and direction of the 
wind. 
The humidity in the tunnels was always nearly at saturation, never 
under 90 per cent. (McWhorter).10 
5. Noxious Gases.-The possible presence of injurious quantities of 
carbon dioxide, of carbon monoxide, of methane, of sulphureted hydro- 
gen, or of nitric oxide in a tunnel or caisson might call for remedy in the 
way of better ventilation; but even supposing their presence in excess, 
either from the compressors, or from blasting, or from any cause whatso- 
ever, the resultant symptoms would be due to the exciting cause and 
would develop while the men were under pressure, and although con- 
ceivably they might be predisposing factors, they are never essential 
factors in the etiology of compressed-air illness. 
Carbon Dioxide.-At the East River tunnels, McWhorter's daily 
analyses of the tunnel air showed such excellent ventilation that the maxi- 
mum carbon dioxide reading was 0.1 per cent, (the equivalent of 0.3 
per cent, at 3 atmospheres); the minimum was 0.045 per cent., and the 
carbon dioxide variations had no effect upon the percentage of illness. 
Carbon Monoxide.-Haldane states "that anything over 0.15 per cent, 
of carbon monoxide must be regarded as distinctly dangerous, and prob- 
ably anything over 0.03 per cent, would in time produce symptoms 
distinctly felt on exertion." 796 
COMPRESSED-AIR ILLNESS 
Immediately after blasting in our tunnels, samples of air from the 
headings showed a maximum of 0.045 per cent. CO, but this was rapidly 
removed by ventilation; further, McWhorter says that although some of 
the men complained of headache after the blasting, he does not regard this 
as a symptom of carbon monoxide poisoning. 
Methane was never found and nitric oxide and sulphureted hydrogen 
only occasionally and in most minute quantities. 
Exciting Cause.-The immediate and exciting cause of compressed-air 
illness is too rapid decompression. (See Treatment, for details.) 
Immunity.-This is purely a relative matter and probably no absolute 
immunity exists, but the best-adapted men may escape symptoms, at 
least for a long time, and rarely one encounters old and experienced 
workers who have never had a twinge of the "bends." 
PATHOLOGY 
Bubbles of gas, set free in the tissues and fluids of the body, give 
rise to the pathological lesions found at autopsy, as well as to the tran- 
sient symptoms which characterize the non-fatal cases. 
The pathognomonic and most striking lesion is the presence of gas 
bubbles (gas emboli) in the veins of the systemic and portal system, in the 
right heart, and in the pulmonary and coronary vessels. These bubbles 
are found so constantly in animal experimentation and in the majority of 
autopsies upon men in the rapidly fatal cases (provided the autopsy be 
performed within 24 hours after death) that they constitute the basis of 
our understanding of this disease. 
Death in many cases is the result of distention of the right heart with 
gas, or of pulmonary air embolism. 
Nature of the Gas.-Analyses of the gas drawn from the right side of 
the heart of animals killed after rapid decompression from high pressures 
are represented by the following: 
Nitrogen, 
per cent. 
Oxygen, 
per cent. 
Carbon 
dioxide, 
per cent. 
Paul Bert,2 1878: 
1. Dog 
82.8 
2.0 
15.2 
2. Cat 
84.1 
None 
15.9 
Von Schrotter:6 
1. Dog 
79.98 
15.31 
4.71 
2. Dog 
80.37 
7.18 
12.45 
McWhorter10 and Erdman:15 
1. Tunnel worker* 
80.0 
None 
20.0 
* So far as I can find, this latter is the only recorded analysis of gas from the human 
heart after death from compressed-air illness. 
The autopsy was performed, about 14 hours after death, upon a tunnel worker who 
died Nov. 19, 1907, 1 hour after decompression, having been found in a state of collapse PATHOLOGY-PHENOMENA OF COMPRESSION 
797 
How then are we to explain these analyses if we maintain that nitrogen 
is the sole factor in supersaturation? Haldane states that the amount of 
oxygen taken by the blood under conditions of pressure adds but little to 
the total oxygen of arterial blood and in any event readily combines with 
the tissues, and for the reasons stated under "the carbon dioxide theory" 
we have seen that no more than the normal amount of CO2 is taken by the 
blood. 
Why do not the analyses reveal nitrogen alone? Hill12 explains this 
by saying that "when nitrogen is set free as bubbles, these act as a vacuum 
for CO2 and oxygen, and some of these gases are set free out of chemical 
combination with the blood; and as the oxygen is mostly used up by the 
tissues of the dying animal, we find the chief gas, besides nitrogen, is 
CO2." (Witness the analysis from the human heart, above recorded.) 
The nervous system may or may not show lesions at autopsy, although 
irritation of the peripheral nerves or spinal cord, by bubbles, gives rise to 
nearly 90 per cent, of the symptoms of the disease. 
Fat acts as a reservoir for nitrogen, and Vernon estimates that the 
spinal cord and the peripheral nerves contain 20 per cent. fat. 
Especially in cases of paralysis, autopsy may show capillary hemor- 
rhages, or areas of softening due to embolism, in the spinal cord, or even 
laceration of nerve cells by the expanding bubbles. In persistent para- 
plegias, a true "caisson myelitis" is found. 
The lower dorsal and the upper lumbar regions are most often affected 
because of their meager blood supply in comparison with the functionally 
more active segments. Gray matter has a richer blood supply than white 
matter and so more often escapes. 
Gas bubbles or resultant capillary hemorrhages and tissue changes 
may be found in the liver, spleen and other organs; indeed bubbles may 
occur in nearly all the body tissues and more detailed mention will be 
found in the symptomatology given below. 
Phenomena of Compression.15-Certain interesting physical and 
mechanical phenomena are noted during the process of compression: 
1. The rising pressure forces inward the ear-drum membrane, causing 
discomfort, acute pain, or even rupturing this structure, unless the pres- 
sure be equalized by admitting air through the Eustachian tube, by Val- 
salva's method or an equivalent, e.g., swallowing. This pressure on the 
ear-drum membrane is most marked with the first few pounds and so it 
is possible to rupture the membrane with +5 to +10 lb. pressure, but 
this cannot be considered a symptom of compressed-air illness. 
2. Slight rise in body temperature and sweating occur, due to the heat 
generated by the compression of the air. 
and unconsciousness near the works. The man had worked 8 hours in a pressure of +30 
lb. and had left the tunnel by a 17-minute uniform decompression. The right heart was 
found to be ballooned with gas and some of this (3.1 cc.) was aspirated into a specially 
devised collector after flooding the thorax with water and excluding all air from the collec- 
tor. The analysis was made by Dr. Metzger of Columbia University. 798 
COMPRESSED-AIR ILLNESS 
3. The denser air offers a slight resistance to expiration and phona- 
tion. Whispering becomes impossible, and the lessened amplitude of 
vibration renders whistling difficult or impossible, and in such an attempt 
the non-vibrating lips give a sensation of slight numbness. 
4. The voice loses its natural quality and sounds intensely nasal. 
5. A sense of exhilaration and an ease of movement are experienced, 
and it is claimed that compressed-air work increases the appetite. 
Other phenomena of compression have been reported, but are now generally 
discredited; thus: 
Pallor of the skin and mucous membranes does not occur unless it be from nervous- 
ness on the part of the man entering compressed air for the first time. 
There is no lessening of the volume of the pulse; no constant alteration in the blood 
pressure; no constant change in the rate either of the pulse or respirations. 
The superficial veins do not collapse; the capillary circulation in a frog's foot con- 
tinues unchanged (Hill and others). 
There is no gross change in the urinary or sweat secretions. Hearing is not 
affected. 
Phenomena of decompression include chilling of the body, due to the 
falling temperature in the air lock, and one may at times note a crackling 
sound in the ears as the air escapes through the Eustachian tubes. With 
rapid decompression the moisture in the atmosphere condenses' and the 
lock fills with a dense fog. 
SYMPTOMS 
The symptoms of compressed-air illness occur only as a result of, and 
after completion of, decompression; and no symptoms ever develop 
while a man remains in the compressed air, no matter what the degree 
of pressure nor the length of exposure. 
(A) Onset.-The time of onset is from within a few minutes up to a few 
hours after decompression. At the East River tunnels about 50 per cent, 
of the 3692 cases developed within 30 minutes, and 95 per cent, within 3 
hours; however, 1 per cent, were delayed over 6 hours and of these, four 
isolated and somewhat doubtful cases were said to have occurred between 
15 and 23 hours after decompression (Keays). 
Bert says that the bubbles do not form all at once but continue to 
form for some time after decompression. 
The onset of symptoms is often dramatic in its suddenness. A man in 
all the vigor of health and strength descends to his daily task in the river 
tunnel; enters the compressed air; works his regular shift of 3 or 4 hours; 
comes out through the air lock by the ordinary method of decompression; 
ascends to the street and starts for home, feeling perfectly well. 
Fifteen minutes later, without the slightest warning, he is attacked 
with intense boring pains in his legs and abdomen, or he staggers and 
falls helpless to the ground, paralyzed from his waist down. Fortunate 
he is if efficient treatment be near at hand, and by recompression in the SYMPTOMS OF COMPRESSED-AIR ILLNESS 
799 
medical air lock, his pains vanish, his paralysis dissapears, and on the 
morrow he returns to his work as usual. 
(B) Chief Symptoms in Order of Frequency: 
1. Pains in the extremities or abdomen occur in 88 per cent, of all cases 
2. Vertigo, in about 5 per cent. 
3. Cerebrospinal cases, in 2.16 per cent. 
4. Dyspnoea, or "chokes," in over 1.5 per cent. 
5. Prostration of moderate degree, with pains, in 1.25 per cent. 
6. Collapse with unconsciousness, in 0.46 per cent. 
(C) Classification of Acute Symptoms.-The symptoms of compressed- 
air illness will vary with the anatomical part affected, with the amount of 
gas set free, and with the consequent degree of disturbance of function; 
accordingly we will group the symptoms with reference to the structures 
affected. 
1. Nervous System.-(a) Peripheral Nerves.-Pain is by far the commonest 
symptom, occurring in over 88 per cent, of all cases, either as the only symptom or 
associated with others. Its most frequent (70 per cent.) site is in the lower extremities 
in the region of the knees, forcing the victim into an attitude which gives rise to the 
popular term "bends," or "courbatures." Next in frequency are pains in the 
upper extremities, about the elbows and shoulders in 30 per cent. Pains in the abdo- 
men occurred in about 5 per cent, of the cases, but were of greater significance than 
were pains in the extremities in that they more often preceded or accompanied cases of 
severe prostration or paralysis. 
Pain occurring in the extremities or abdomen in over 88 per cent, of all cases, 
without other evidence of spinal-cord irritation, except in a little over 2 per cent., 
must admittedly be due to peripheral irritation of nerves and nerve terminals by 
bubbles of gas in the nerve sheath, in fascial tissues, beneath the periosteum or in 
bone marrow, etc. 
Numbness, anaesthesia, and paraesthesia are doubtless capable of the same 
explanation. 
One form of paraesthesia, called by the workmen "itch," is quite common, and 
distressing while it lasts, but is never of serious import. This may be explained, as 
Hill does, as due to bubbles in the subcutaneous areolar tissue, but in my experience 
it is no more common in fat men than in thin men;15 it occurs especially when sweating 
has been less free, and it is usually at once' relieved by a hot bath or sweating, all of 
which make it more probable that it is caused by expanding bubbles in the sweat 
glands. 
The "itch" or "puces" has been attributed to irritation of the posterior nerve 
roots by bubbles in the spinal fluid. 
(b) Central Nervous System.-Brain: unconsciousness, stupor, and collapse may 
be due to cerebral gas embolism or the resulting oedema, or are secondary to circulatory 
failure due to coronary or pulmonary embolism. 
Cerebral gas embolism may also cause temporary aphasia, incoherence of speech, 
ataxia, vomiting, vertigo, headache; or such signs as hemiplegia, monoplegia, con- 
vulsions, nystagmus, and tongue deviations, depending upon what area is affected. 
Actual tearing of nerve tissue and hemorrhage may arise from the expansion of 
bubbles of gas, resulting in organic lesions. 
Vertigo, or, in the parlance of the workers, "staggers," was met with in over 5 per 
cent., and is explainable by the formation of bubbles in the labyrinth of the internal 800 
COMPRESSED-AIR ILLNESS 
ear, or when accompanied by nausea and vomiting it may be due to cerebellar gas 
embolism. 
Spinal Cord: Affections of the spinal cord include paraplegia, monoplegia, loss of 
bladder and rectal control, partial paralyses, spasticity, exaggerated, diminished, or 
absent reflexes, anaesthesia, anaesthesia dolorosa, etc.; and with hemorrhage into the 
cord the symptoms may become permanent and a true myelitis may develop. 
Frequently, however, there is only a temporary weakness and numbness of the 
legs, with or without retention of urine. 
2. Special Senses.-(a) Eye.-Transient blindness, diplopia and nystagmus may 
occur. 
(b) Ear.-Perforation of the membrani tympani due to compression is not properly 
a symptom of the illness. Deafness and vertigo or Meniere's disease may result from 
the formation of bubbles in the labyrinth. 
3. Vascular System.-The phenomena of gas emboli in the blood-vessels has been 
described, and undoubtedly the cases of extreme prostration and collapse and many 
of the fatalities are due to the collection of gas in the right side of the heart. 
A bluish "mottling" of the surface of the chest or abdomen, encountered in some 
of the more severe cases, is due to embolism of the superficial veins. 
Lymphatic obstruction by gas emboli explains the several cases of localized oedema 
which I have observed. 
4. Respiratory System.-A form of dyspnoea, called "chokes," of a type resembling 
an asthmatic attack, may well be due to multiple small emboli in the pulmonary 
vessels; for were it of central nervous origin, it would probably be attended by other 
serious nervous symptoms, which is not the case. 
In certain fatal cases there has been found oedema of the lungs, and at times an 
interstitial emphysema. 
5. Gastrointestinal symptoms further than the epigastric pains, the nausea and 
vomiting, above described, are not encountered. 
6. Internal organs, such as the liver, spleen, kidneys, do not give any acute signs, 
although at autopsy they may be found affected. 
7. The sexual apparatus is affected only as a result of spinal-cord injury, which 
may give rise to priapism, etc. 
8. The Bones, Joints and Periosteum.-In one case necrosis of the femur resulted 
apparently from thrombosis of the medullary artery. The deep-seated pains so 
frequently referred to the long bones of the extremities and to the joints may be due 
either to collections of expanding bubbles under the fascial planes or under the peri- 
osteum; or, as Hill suggests, in the yellow marrow, which structure is rich in fat and 
deficient in circulation. 
9. The Skin and Subcutaneous Tissues.-The symptoms of "itch" and the 
"mottling" of the skin have been described above. Subcutaneous emphysema, 
without trauma, is met with in a few cases during life, and frequently in autopsies, 
especially along the course of. the large vein of the extremities. Its presence as an 
accompaniment of contusions and punctured wounds I have several times demon- 
strated, and it is doubtless due to the setting free of gas from the extravasated blood; 
for it is hardly likely that such an amount of compressed air could enter through the 
puncture. 
10. Localized collections of gas, aside from the small emboli scattered through the 
body, include the large collections found in the right side of the heart at autopsy (case 
cited above). At one autopsy which I witnessed there was a collection of about 5 cc. 
of gas beneath9 the mucosa of the jejunum. In two other cases I succeeded in aspirat- 
ing about 1 cc. of gas from beneath the periosteum of the tibia; its presence was evi- 
denced by a soft cushion-like swelling in this area. 
11. Miscellany.-In general, the wounds bleed as freely and heal as readily in the 
compressed air as in the normal atmosphere. SYMPTOMS OF COMPRESSED-AIR ILLNESS 
801 
Complications.-Perforation of the membrani tympani may be called a complica- 
tion; also infections of the middle ear and of the sinuses which communicate with the 
nose are favored by the efforts of the men to force open the Eustachian tubes, and these 
factors account for the infrequent cases of epistaxis in caisson or tunnel work. 
In diving, however, bursting of the air tube has a cupping effect and may cause 
epistaxis, ecchymoses and rupture of the membrana tympani in an outward direction. 
Cystitis, pyelonephritis, myelitis and meningitis may be later results of spinal-cord 
injury. 
Symptoms: Chronic.-(a) Myelitis.-At the East River tunnels, exclusive of the 
fatal cases which died within 8 days, there were 10 cases of permanent paralysis, or 0.3 
per cent, of the total cases. Of the 10, four died within 5 months from complications, 
three were lost track of, and the remaining three, at last reports were still afflicted with 
spastic paraplegia. 
(fe) Permanent Ear Troubles.-I knew of but three cases (in the 3692), of ruptured 
membrana tympani and with persistent impairment of hearing; one of these developed 
an obstinate otitis media purulenta. 
As has been said above, these cases are perhaps complications of work in com- 
pressed air but are not symptoms of compressed-air illness; rather were they accidents 
of compression. 
However, cases of labyrinthine deafness are reported as setting in after decompres- 
sion, and due to bubbles in the labyrinth; such cases of which I saw no permanent ones, 
would be properly classed as symptoms of this disease. 
Meniere's symptom-complex is of similar origin and I knew of one persistent case. 
That many and vague symptoms in after life are attributed to the 
effects of compressed-air illness, which have,' however, no actual connec- 
tion therewith, is a fact to which the testimony submitted in certain 
damage suits bears eloquent testimony. 
Bassoe18 examined 161 men at a period of months or in some cases, 
years after they had worked in compressed air, and he reports 16 cases of 
demonstrable permanent injury, or 10 per cent., and ear troubles in over 
60 per cent. 
His grouping is as follows: 
Class 1. Caisson myelitis. 
(a) Trophic osteo-arthropathy due to cord lesion (cases, three). 
(6) Very limited persistent cord lesions (cases, two). 
(c) Caisson myelitis more or less extensive (cases, three). 
Class 2. Permanent joint disease (arthritis deformans) cases, seven. 
Class 3. Ear affections. 67 men complained of impaired hearing. 
33 complained of dizziness. 
Certainly from our experience at the East River tunnels in the 3692 
cases we consider Bassoe's statistics quite amazing. In a number of his 
cases, we feel that the very essential relation of cause to effect is not suf- 
ficiently well established. 
In a word we may state that as a result of Reays' analysis of the East 
River tunnel cases, the total of permanent injury cases does not exceed 1.0 
per cent, even when we include all fatal cases and all persistent paralyses 
and permanent ear affections. 802 
COMPRESSED-AIR ILLNESS 
MORTALITY 
Except for the doubtful case related by Bert of a man who died 
after exposure to +21.1 lb. (?), I can find no record of fatalities occurring 
under +28 lb. 
An idea of the great variation in mortality at different works may be 
obtained from the following statistics: 
(a) Mortality in relation to pressure and cases of illness. We believe 
that with modern methods of decompression and treatment the mortality 
should never amount to even 0.5 per cent, of the cases of illness. 
1 
Maximum 
pressure, 
pounds 
Cases 
Deaths 
Percentage 
1839, Douchy mines 
+37.5 
63 
2 
3.2 
1870, St. Louis bridge 
+50.0 
129 
14 
10.8 
1873, Brooklyn bridge 
+34.0 
110 
3 
2.72 
1885, Hudson tunnel 
+35.0 
50 workers 
9 
18.0 plus 
1890, Danube bridge 
+32.5 
154 
4 
2.6 
1895, Danube bridge 
+37.5 
320 
2 
0.625 
1906, Amsterdam 
+30.0 
228 
none 
1909, East River tunnel 
+32-42 
3692 
20 
0.54 
In comparing the above figures, note that only the maximum pressure employed 
at any period of construction is given, except in the case of the East River tunnels 
where the average for the whole work was +32 lb. and the maximum was +42 lb. 
At Amsterdam where there were no deaths it will be seen that the pressure at 
no time exceeded +20 lb.; and as has been stated it is every additional pound above 
+30 which especially enhances the danger of serious cases. 
(b) Mortality according to number of workers employed: 
Men 
Death 
Percentage 
Hudson tunnel 
50 
9 
18.0 
East River tunnel 
10,000 
20 
0.2 
(c) Mortality, according to decompressions: 
Decompressions 
Deaths 
Percentage 
Admiralty Com. Report 
60,000 
4 
0.0066 
East River tunnels 
557,000 
20 
0.0035 
Types of Fatal Cases.-The 20 fatal cases at the East River tunnels 
were either rapidly fatal (within a few hours or a few days), or delayed for 
weeks or months. 
(A) Rapidly fatal cases. 
1. Pains accompanied by marked prostration, 6 cases. 
2. Collapse and early unconsciousness, 9 cases. 
3. Paraplegia, with coma later, 1 case. MORTALITY-DIAGNOSIS-PROGNOSIS-TREATMENT 
803 
(B) Delayed Deaths.-These were due to complications in cases of 
myelitis; e.g., cystitis, pyelitis, bed-sores, etc.; in one case death occurred 
on the tenth day from an ascending paralysis. Only one of the twenty 
lived as long as 5 months. 
DIAGNOSIS 
The diagnosis is made from the history which will consist in the onset 
of symptoms within from a few minutes to a few hours after decom- 
pression from compressed air. Without such a history, the air worker 
who falls unconscious or hemiplegic upon the street, may well baffle 
the best diagnostician. 
PROGNOSIS 
Simple pains, or "bends," limited to the extremities are rarely of 
serious import, and occurred in 88 per cent, of all cases; they are often 
transient and shifting and usually yield at once to recompression. Pain 
in the abdomen often precedes severe symptoms. 
The Admiralty12 Committee considers "bends" to be the sign of satu- 
ration of very slow parts, which will be slow to desaturate, and therefore 
the "bends" are most difficult of entire elimination by any practical 
method of decompression; further they occur independent of the amount 
of fat in the subject. 
The more severe symptoms of dyspnoea, mottling, paralyses, collapse 
and unconsciousness, bespeak inadequate desaturation of the quick 
parts, and indicate much gas in the blood and are accordingly of serious 
portent. 
Of the 34 cases of paralysis, 23 recovered (19 of these after one 
recompression). 
Of 17 cases with early lapse into unconsciousness, 9 were fatal and 
represented 45 per cent, of the total mortality. 
To recapitulate we may state that many cases of the "bends" will 
subside in at most a few days even without recompression. About 90 
per cent, of all cases were entirely relieved by treatment, and 99 per cent, 
were in large part relieved by recompression. 
The fatal cases and the permanent injuries, taken together, amounted 
to only 1 per cent, of the 3692 cases. 
TREATMENT 
1. Prophylactic. 
(A) Choice of men. 
(B) Hygiene of the workers, 
(C) Amount of pressure. 
{D) Length of exposure. 
(C) Method and duration of decompression. 804 
COatPRESSED-AIR ILLNESS 
2. Active Treatment. 
(a) Recompression. 
(6) Palliative and adjuvant measures. 
1. Prophylactic Treatment. 
(A) Selection of men of suitable age and circulatory efficiency, with the exclusion 
of the fat, the anaemic, and the arteriosclerotic, are important factors which have 
been already discussed. Hill says "skinny men are the best for high pressure work." 
(B) The hygiene of the workers demands attention. Plenty of sleep, a nutritious 
diet (with but little of fatty food), avoidance of alcoholic and other excesses, exercise 
of the limbs (during and after decompression) and regularity of the bowels, are impor- 
tant rules for air workers. 
The locks during decompression become very cold and either they should be heated 
or the men should be protected by extra clothing. Hot coffee and warm dressing- 
rooms and baths should be furnished the men after leaving the compressed air. 
(C) The amount of pressure is of course the greatest etiological factor, but at the 
same time it is the one factor which is absolutely beyond control if work is to be 
accomplished at great depths. 
Greenwood12 safely underwent a pressure of +92 lb. in an experimental chamber, 
and Haldane reports that a diver descended to pressure of +92.4 lb. without accident, 
but probably +50 lb. must still be considered practically a maximumpressure for 
construction work although Hill believes that for short exposures of picked workers, 
+60 lb. is feasible. 
(D) Length of exposure means, practically, length of shifts. 
The question of the proper limits for working shifts at different pressures is still 
open to debate, and calls for unbiased consideration, for one must avoid, on the one 
hand, imposing unfair risk of injury, on the working man, by too long exposures; on 
the other hand, it is unfair to the contractors to stipulate unnecessarily short working 
periods. 
It is-well established that very brief exposures, e.g., up to % hour are attended 
with a minimum of risk; hence lock-tenders, engineers, inspectors, and time-keepers, 
by reason of their usually brief exposures are much less apt to develop symptoms than 
are the hard-working men on a regular shift, but of course similar conditions can 
never obtain in the two classes. 
It is interesting to compare different views on this question: 
1. Air-workers' union. Stipulations for caisson work. 
3% and 3% hours to +22 lb. 
3 and 3 hours to +33 lb. 
2 and 2 hours to +35 lb. 
1% and 1% hours to +40 lb. 
40 and 40 minutes to +45 lb. 
2. Rules proposed by 21 engineers, contractors and doctors and submitted to the 
N. Y. State Labor Commission. 
5 and 5 hours to +20 lb. 
8 hours with % hour for lunch to +32 lb. 
3 and 3 hours to +40 lb. 
3. Ordinary time limits for divers (Admirality Committee). 
Over 3 hours to +26% lb. 
3 hours to +29% lb. 
1% hours to +34% lb. 
1 hour to +40 lb. PROPHYLACTIC TREATMENT 
805 
4. Haldane who was on the Admiralty Committee, however, prepares his decom- 
pression table for caisson and tunnel work on the basis of two 3-hour shifts up to 
+45 lb. pressure. We personally believe that two 4-hour shifts up to +32 lb., and 
3-hour shifts up to +35 lb., and two 2-hour shifts up to +40 lb. are not unreasonably 
long, nor unduly short, and we believe that proper decompression will permit longer 
shifts. 
Keays believes that 6 hours continuous shift is preferable to two 3-hour shifts as it 
exposes the man to the risks of only one decompression instead of two, for he con- 
siders that the man is practically saturated in 3 hours and therefore the prolongation 
of his exposure does not add to the saturation. 
(S') Method and Duration of Decompression.-This is by far the most important 
element in prophylaxis, and as it is a matter fully under control we look to it for the 
best possible solution of the whole question. 
The two methods of regulated decompression are known as the Uniform and the 
Stage methods. 
1. Uniform decompression is the older and almost universally practised method 
and consists in reducing the pressure at a constant and uniform rate, e.g., 1 lb. per 
minute, 2 lb. per minute, etc. 
I will mention some practical illustrations; to wit, 
1839, Doughy mines 
Max. Pressure, 
Pounds 
+37M 
Uniform 
Decompression, 
Minutes 
30 
1885, Bridge over Eider 
+39 
1895, Nussdorf bridge 
+37^ 
35 
1906, Amsterdam viaduct 
+30 
32>f 
1908, East River tunnels 
+42 
21 (2 lb. per) 
* The Amsterdam work was conducted on this basis and up to the maximum of +30 lb. 
pressure; there were no fatalities but there were 229 cases of "bends." 
In Holland, 1906, legislation was passed as follows: 
For +15 lb. 15 minutes 
For +22% lb. 22% minutes 
For +30 lb. 32.5 minutes 
For +37% lb. 42.5 minutes 
A few years ago New York State adopted the following regulations for tunnel work 
New York State Law for Air Work 
Gauge 
pressure, 
pounds 
Time under pressure 
Interval between spells 
Uniform de- 
compression, 
minutes 
0-28 
8 hours less interval 
30 consecutive minutes spent 
in open air 
18% 
28-35.99 
2 spells of 3 hours each 
At least 1 hour 
24 
36-41.99 
2 spells of 2 hours each 
At least 2 hours 
42 
42-45.99 
2 spells of 1% hours each 
At least 3 hours 
46 
46-49.99 
2 spells of 1 hour each 
At least 4 hours 
50 
In June, 1920, the German Government put regulations into effect for the pro- 
tection of compressed-air workers. As quoted by Leymann20 the rules govern- 806 
COMPRESSED-AIR ILLNESS 
ing^the length of shifts at varying pressures follow quite closely the New York 
State Law. 
New York State Law for Caisson Work, in force Sept. 1, 1912: 
Time of Decompression for Caissons 
Time of Decompression 
Uniform Decompression (in Minutes) 
Up to 10 lb. pressure 1 
Up to 15 lb. pressure 2 
Up to 20 lb. pressure 5 
Up to 25 lb. pressure 10 
Up to 30 lb. pressure 12 
Up to 36 lb. pressure 15 
Up to 40 lb. pressure 20 
Up to 50 lb. pressure 25 
The incidence of illness and the mortality has been very considerable under the older 
method of decompression (see above). 
2. Stage Decompression.-Haldane, together with Boycott and Damant, as a 
result of exhaustive study and experimentation, have quite recently put forward a 
different method of decompression, the aim of which is still further to minimize the 
dangers of compressed-air work. 
This method, known as the "Stage" method, has been adopted by'the British 
Admiralty Committee on Deep Sea Diving. 
A brief theoretical discussion of decompression will best explain the different 
methods. 
Other things being equal, for the same difference in pressure, de-saturation of the 
tissues (during and after decompression) will occur at the same rate and in the same 
time that obtained for saturation. 
We have already mentioned that saturation does not occur at a uniform rate but is 
much more rapid at first, i.e., 22 per cent, in 5 minutes, 50 per cent, in 25 minutes, 
whereas 90 per cent, for the slower tissues requires 4 hours, and for complete saturation 
at least 5 hours according to Haldane, or 9 hours according to Bornstein. 
Therefore if de-saturation takes as long as saturation, it is at once evident that 
every man who has worked at +28 lb. pressure for 4 hours and then decompresses in 
18 minutes (see N. Y. State Law), must emerge from the lock very incompletely 
de-saturated; in fact Mr. Japp13 calculates that he will have a maximum air saturation 
of his body, on emerging, of 25.7 lb. 
Practically, universal experience in compressed-air work has demon- 
strated that no cases of illness, or a very few minor cases, will develop 
even after the most rapid decompression from pressures up to +20 lb. 
Allowing 5 lb. as a margin, Haldane concludes that it is impossible for any 
bubbles to form after decompression however rapid, following exposures 
up to +15 lb. In terms of absolute pressure this amounts to a sudden 
decompression from 30 lb. to 15 lb. or from 2 atmospheres to 1 atmosphere. 
Haldane7 continues, "now, the volume of gas capable of being liberated on decom- 
pression to any given pressure, is the same, if the relative diminution of pressure 
(absolute) is the same." 
To give an example: the reduction of pressure from 45 lb. gauge pressure to 15 lb. 
gauge pressure which is a reduction from 4 atmospheres to 2 atmospheres absolute, 
will liberate the same volume of gas as the reduction from 15 lb. gauge to atmosphere DECOMPRESSION 
807 
(or from 2 to 1 atmosphere absolute). If no bubbles can form in the latter instance, 
none will form in the former; hence Haldane concludes "that the absolute air pressure 
can always be reduced very rapidly without risk, to half the absolute pressure at which 
the tissues are saturated;" but from this point onward the decompression must be 
very slow, in order that the air pressure in the tissues may never be more than twice 
the gauge pressure. 
Further, as Boycott says, this method makes fullest use of the permissible differ- 
ence of pressure to get rid of the nitrogen from the tissues. 
As a result of his studies and his experiments with divers, Haldane offered, and the 
Admiralty Committee adopted the following "stage decompression" table, based on 
the assumption that the most rapid decompression from 19 lb. gauge pressure is 
without risk, i.e., from 2.3 atmospheres to 1 atmosphere absolute. 
Dr. Haldane's Rate of Decompression in Caisson and Tunnel Works 
(Extract from report of a committee appointed by the Lords of the Admiralty on deep 
water diving, August, 1907; Eyre and Spottiswoode.) 
Working pressure 
per square inch, 
pounds 
Number of minutes for each pound of decompression after the first rapid stage* 
After first 3-hour 
exposure, 
minutes 
After second or third 
3-hour exposure, show- 
ing an interval for a meal, 
minutes 
After 6 hours or more 
of continuous ex- 
posure, 
minutes 
18-20 
2 
3 
5 
21-24 
3 
5 ; 
7 
25-29 
5 
7 
8 
30-34 
6 
7 
9 
35-39 
7 
8 
9 
40-45 
7 
8 
9 
* In this table, the first rapid stage of decompression, down to one-half the absolute pressure 
is to be accomplished in 3 minutes. (See diagram of Haldane's Method I). 
Another method suggested by Haldane for tunnel work is illustrated by the 
following. Where possible, a part of the tunnel is maintained at a pressure equal to 
half the absolute pressure in the heading. The men now decompress rapidly to this 
half pressure, remain in this "purgatorial chamber" until the air pressure in the body 
falls to 19 lb., and then come out by a second 3-minute decompression. (See diagram 
of Haldane's Method II.) 
In view of his conception of decompression, Haldane condemns "uniform decom- 
pression" on three separate counts; viz.: (1) no use is made of the possibility of hasten- 
ing the exit of nitrogen from the tissues by putting on the greatest permissible stress; 
(2) "uniform decompression," to be safe, must be so prodigiously slow that it is an 
irrational proceeding; and however slow it be, the difference between the tissue 
pressure and the gauge pressure must become larger and larger; (3) following a short 
exposure, this method merely prolongs the exposure to effective pressure. 
The logic of Haldane's "stage decompression" seems irrefutable and 
Boycott and Damant, experimenting with goats, employed both methods. 
Their results showed fewer cases of illness (18 per cent.) and no deaths, 
with the stage method, whereas there were more cases of illness (53 per 
cent.) including two deaths, with the uniform method. The grea)i;; 
advantage of the stage method was noted after short exposures. 808 
COMPRESSED-AIR ILLNESS 
On the contrary, Hill and Greenwood, using pigs and rabbits, found 
no evidence of superiority of the stage method over the uniform 
decompression. 
Hill12 concludes that there is some evidence in favor of stage decom- 
pression after short exposures, but not a decisive superiority after long 
exposures, and he adds that "the theory is a captivating one, but 
experiment has not brought that conclusive support which was to be 
expected." 
At the Elbe tunnel the two methods were tried out in caisson work at +30 lb., 
but very little advantage could be demonstrated for the "stage" method as compared 
with the "uniform." 
DECOMPRESSING FROM 40 LB.GAUGE PRESSURE 
TO ATMOSPHERE AFTER 3 HOURS IMMERSION. 
DR.HALDANE'S TABLE FOR DECOMPRESSION 
Haldane's 
Method I 
DECOMPRESSING FROM 40 LB.GAUGE PRESSURE 
TO ATMOSPHERE AFTER 3 HOURS IMMERSION. 
DR. HALDANE'S PURGATORIAL CHAMBER METHOD 
Haldane's 
Method II 
Fig. 35.-Diagram of Haldane's decompression methods I and II 
Mr. H. Japp,13 managing engineer of the East River tunnels, recounts the entire 
freedom from serious and fatal cases in a series of 23,000 decompressions from +40 to 
42 lb. at a period in the construction of the tunnels, when a modification of the stage 
method was enforced by reason of the erection of two extra bulkheads (with air locks) 
atjntervals of 1000 ft. 
Three hundred and thirty men were employed for 36 days, working 3 hours on, 
3 hours off, and 3 hours on, and were decompressed in the following manner. DECOMPRESSION 
809 
Five minutes were spent in the first air lock in decompressing from +40 to +29 lb.; 
then followed a walk of 1000 ft., occupying 10 minutes before entering the second lock 
where 8 minutes were spent in reducing the pressure from +29 to +12% lb. (which 
latter is half the original absolute pressure). Another 10 minutes was spent in walking 
to and waiting for the third lock, in which 15 minutes were employed in reducing from 
+ 12% lb. to atmospheric pressure. 
Thus a total of 48 minutes was taken for decompression which would have required 
90% minutes by Haldane's method (1), or 123 minutes by Haldane's method (2); 
and Mr. Japp calculates that the maximum air saturation of the workers upon leaving 
the last lock was 27 lb. 
Hence Mr. Japp concludes that it is practically safe to decompress 
rapidly from pressures up to +27 lb., and has prepared the following 
tables for 11 stage decompression," by which the maximum air saturation 
of the tissues upon emerging shall never exceed 25 lb. 
Decompression Table Based on 25 Lb. Maximum Air Saturation oe Body on 
Emerging (Prepared by H. W. Japp) 
Gauge pres- 
sure, pounds 
Reduce 
pressure in 3 
minutes to- 
pounds 
Total time 
in air lock 
after 8 
hours' work, 
minutes 
Total time 
in air lock 
after 3 
hours' work, 
minutes 
Total time 
in air lock 
after 2 
hours' work, 
minutes 
Maximum 
air satura- 
tion of body 
on emerging,, 
pounds 
27 
6 
9 
25 
30 
7% 
24 
25 
32 
8% 
33 
25 
25 
35 
10 
35 
25 
40 
12% 
48 
25 
42 
13% 
51 
37 
25 
45 
15 
42 
25 
50 
17% 
48 
25 
Comparison op Uniform and Stage Decompression 
Tunnel 
pressure 
(gauge), 
pounds 
Time worked, 
hours 
Uniform decom- 
pression (New 
York State Law) 
minutes 
Maximum air 
saturation of 
body on 
emerging, 
pounds 
Stage compres- 
sion (based on 
Table above), 
minutes 
Maximum air 
saturation of 
body on 
emerging, 
pounds 
28.0 
3% and 3% 
18% 
25.70 
14 
25 
36.0 
3 and 3 
24 
30.25 
36 
25 
41.99 
2 and 2 
42 
31.25 
37 
25 
45.99 
1% and 1% 
46 
32.00 
35 
25 
50.0 
1 and 1 
50 
32.50 
33 
25 
Japp's table provides a great shortening of decompression as compared 
with Haldane's tables, which latter, Hill also agrees are unnecessarily 810 
COMPRESSED-AIR ILLNESS 
long. As compared with the New York State uniform decompression 
table, there is also a slight shortening in time, but a marked advantage in 
the maximum air saturation of the tissues, on emerging. 
Hill recommends one stage at +8 lb., lasting 15 minutes, after a shift at +30 lb., 
and 5 minutes given to completing decompression; also one stage of 30 minutes at 
+ 15 lb. after a shift at +40 to 45 lb., with 10 minutes spent in completing 
decompression. 
Von Schrbtter6 recommends from +30 lb. to reduce in 3 minutes to +12 lb. and 
then takes 32 minutes to complete; or from +45 lb. reduce to +22^ lb. in 3 minutes 
and takes 60 minutes to complete. 
Conclusions.-No one of the suggested methods of decompression is 
efficient in entirely eliminating cases of "bends," but the improved 
methods should certainly minimize the serious and fatal cases. 
Indeed in Mr. Japp's series of 23,000 decompressions by the modified 
stage method, there was an unusually large percentage of minor cases; for, 
reporting on 8510 of these decompressions, Keays found 1.6 + per cent, 
of minor cases, and only seasoned men were employed. 
However the writer believes that Mr. Japp's table is reasonably safe 
and is the most practical of those yet devised. 
Exercise during and after decompression, also the inhalation of oxygen 
in the last period of decompression and following it, are claimed by Hill 
and others to greatly hasten the elimination of nitrogen. (N. B.-The 
inhalation of pure oxygen under pressures above +30 lb. is irritant to the 
lungs and highly dangerous.) 
The following modifications of the New York State Law affecting all 
workers in compressed air, whether in caissons or tunnels became effective 
in March, 1920. 
Gauge pressure, pounds 
Time under pressure 
Interval between spells 
0-22 
2 spells of 4 hours each 
30 minutes 
22-30 
2 spells of 3 hours each 
1 hour 
30-35 
2 spells of 2 hours each 
2 hours 
35-40 
2 spells of 1^ hours each 
3 hours 
40-45 
2 spells of 1 hours each 
4 hours 
45-50 
2 spells of 45 minutes each 
5 hours 
Decompression shall be at the minimum rate of 3 lbs. every 2 minutes, 
unless the pressure shall be over 30 lbs., in which event the decompression 
shall be at the rate of a pound per minute. 
A Stage Decompression shall be employed in which a drop of one-half 
of the original gauge pressure shall be made in not over a period of time 
exceeding five minutes; the remaining decompression to be at a uniform 
rate. CONCLUSIONS RULES-ACTIVE TREATMENT 
811 
RULES TO BE STRICTLY OBSERVED BY COMPRESSED AIR WORKERS 
1. Never go on shift with an empty stomach. 
2. Be temperate-avoid alcoholic liquors. 
3. Eat moderately. 
4. Do not sleep less than seven hours daily. 
5. Keep the bowels regular. 
6. Extra outer clothing should be taken into the tunnel when going on shift. 
This should be worn during decompression in order to avoid chilling during that 
period. 
7. Keep arms and legs in motion while coming out; exercise in the lock. 
8. Remember that slow decompression means safety and a freedom from caisson 
sickness. 
9. Hot coffee, a warm shower and a brisk rub-down after each shift will be of 
great benefit to each worker's health. 
10. Report to the doctor in charge any compressed air illness at once; do not give 
men suffering from compressed air illness any intoxicating liquor. 
11. If taken sick away from the plant, report at once to the doctor in charge, 
Dr Telephone 
12. Wear an identification badge so that police officials will know what to do with 
you in an emergency. 
13. Stay about the works for at least one-half hour after locking out. One (1) 
hour is recommended. 
14. Re-examination of all air workers by the doctor every two months. 
15. Re-examination of all new men after working the first half shift. 
16. Absence from work for ten days or more, for any cause requires a re-examina- 
tion by the doctor, before a man will be permitted to work in compressed air. 
17. No man shall work more than two periods in any 24 hours. 
These regulations have a very great deal to commend them, and 
should provide great safety, both by reason of the very short periods 
of exposure to pressure and by the use of the stage decompression. 
2. Active Treatment. 
(a) Recompression.-Had infectious diseases as wonderfully a specific 
treatment as has compressed-air illness, the practice of medicine would 
be revolutionized. 
To behold a man paralyzed from the waist down, carried into the 
medical lock, or recompression chamber; the pressure raised, and with- 
in 5 minutes to see this man get down from his couch and walk about, 
is indeed little short of miraculous and yet this is of no uncommon 
occurrence. 
Recompression as a method of treatment arose, first, among the 
workers themselves, who found by experience that their pains were 
relieved upon reentering the caisson or tunnel. 
To-day every properly equipped compressed-air works should be 
supplied with one or more specially constructed recompression chambers 
called "medical air locks," which should be arranged with two compart- 
ments, thus permitting the medical attendant to enter or leave without 
disturbing the pressure in the medical chamber. Such locks are fitted 812 
COMPRESSED-AIR ILLNESS 
with electric lights, steam heat, clock, pressure gauge, telephone, and 
comfortable couches, also there is a glass port in the door which allows 
observation from the outside. 
1. Theory of recompression. 
If symptoms are due to the liberation of bubbles of nitrogen in the tissues and body 
fluids, then recompression will at once reduce the size of these bubbles and moreover, 
will urge them again into harmless solution in the tissues, and if decompression now 
be carried on at an appropriate rate, the nitrogen will be given off into the alveoli, by 
means of the circulating blood and without the formation of bubbles. 
2. Degree of pressure for recompression treatment. 
At the East River tunnels, it was the practice to raise the pressure to the equiva- 
lent of the tunnel pressure, and then at once to start decompression at a rate not 
exceeding 2 minutes per pound; but the best results were obtained by a rather rapid 
decompression from e.g., + 32 lb. to +15 lb. and thereafter very slow reduction to the 
atmospheric pressure, 60 to 90 minutes or even two hours being sometimes thus 
employed (This will be seen to be a modification of the stage decompression). 
Other men (L. M. Ryan17), claim that good results are obtained by raising the 
pressure to only two-thirds of the working pressure, and allowing 1 hour for reduction 
from +15 lb., and 3 to 4 hours for reduction from +20 lb., in severe cases. 
In criticism of Ryan's suggestion, although admitting that pains will often dis- 
appear long before the full pressure is reached, the writer believes with Haldane that 
the first rapid stage of decompression from the full pressure will aid "the exit of the 
nitrogen by making use of the greatest permissible stress;" and therefore full pressure 
should be employed. 
3. Time of administration of recompression treatment. 
By far the best results attend recompression when instituted as soon as possible 
after the onset of symptoms, although partial or complete relief often is obtained after 
a lapse of hours or even a whole day. 
4. Practical results of recompression. 
Keays8 showed that, in our 3692 cases, about 90 per cent, were completely relieved 
by recompression. Some required two or more treatments, but 68 per cent, were 
relieved by a single recompression. 
About 9 per cent, more were partially relieved and only 0.5 per cent, failed to get 
any relief. 
Even in the cases of partial paralysis of the legs (18 cases) 12 cleared up entirely 
with one recompression; and of the 16 cases of complete paraplegia, seven were cured 
by one recompression. 
Of cases with collapse and unconsciousness (17 cases), eight were relieved by one or 
two recompressions, but nine were fatal. 
(6) Adjuvant and Palliative Measures. 
Exercise and massage and the inhalation of Oxygen both in and out of the medica 
locks will aid elimination of nitrogen. 
Counter-irritation, heat, electricity, liniments and massage may suffice in, many 
minor cases of "bends" even without recompression, or may be used as adjuvants in 
refractory cases. 
Ergot was recommended by Dr. A. H. Smith,8 but I have never seen any benefit 
from its use, and moreover the indications for its administrations were based upon the 
discarded mechanical pressure theory. 
Symptomatic medical treatment will be indicated; e.g., anodynes in 
cases of unrelieved pain and hypodermatic stimulation in cases of collapse 
with impending circulatory or respiratory failure. REFERENCES ON COMPRESSED-AIR ILLNESS 
813 
REFERENCES 
1 Pol and Wattelle.-"Memoire sur les effets de la compression de Pair." Annales 
d'hyg. publ. et de med. legale, Paris, 1854. 
2 Paul Bert.-"La Pression Barom^trique," Paris, 1878. 
5 Jaminet.-"Physical Effects of Compressed Air," St. Louis, 1871. 
4 Snell.-"The Compressed-air Illness or Caisson Disease," London, 1896. 
* A. H. Smith.-"Caisson Disease." Presby. Hosp. Reports, New York, 1895. 
6 Heller, Mager, von Schrotter.-"Luftdruckerkrankungen," Vienna, 1900. 
7 Haldane.-"The Hygiene of Work in Compressed Air." Jour. Soc. of Arts., Vol. 
XVI, No. 1, Jan. 1908. 
8 Keays.-"Compressed-air Illness," New York, 1909. 
9 Erdman.-"Aeropathy or Compressed-air Illness," Journ. Am. Med. Assn., Nov. 
16, 1907, Vol. XLIX, page 1665. 
10 Me Whorter.-"The Etiological Factors of Compressed-air Illness." Am. Journ. of 
Med. Sc., March, 1910. 
11 Stettner.-"Uber Caissonkrankheit." Wiirzburger Abhan Band dl.,XI, Heft 12, 
1911. 
12 Hill.-"Caisson Sickness," London, 1912. 
13 Japp.-"Caisson Disease and Its Prevention." Trans. 15th Intern. Cong. Hyg. 
and Demog., Washington, 1912, Vol. III. 
14 Silberstern.-"DieGefahren der Caissonarbeit." Vol. Ill, Trans. 15th Intern. 
Cong. Hyg. and Demog., Washington, 1912. 
16 Erdman.-"Acute Effects of Caisson Disease." Vol. Ill, Trans. 15th Intern. Cong. 
Hyg. and Demog., Washington, 1912. 
16 Macleod.-"Hygiene of Work in Compressed Air." Vol. II, Trans. 15th Intern. 
Cong. Hyg. and Demog., Washington, 1912. 
17 Ryan.-'Compressed-air Illness in Caisson Work." Am. Labor Legislation 
Review, Vol. II, No. 2, New York, June, 1912. 
18 Bassoe.-"Late Manifestations of Caisson Disease." Vol. Ill, Trans. 15th Intern. 
Cong. Hyg. and Demog., Washington, 1912. 
19 Erdman.-"Standards for Prevention of Compressed-air Illness." American 
Jour. Public Health, Vol. VIII, pages 431-434, 1918. 
30 Leymann.-"Die Verordnung zum Schutze der Pressluftarbeiter," Zentralb. f. 
Gewerbehyg., IX, No. 2, Feb., 1921, 30-35. SECTION 2 
EFFECTS OF DIMINISHED ATMOSPHERE UPON HEALTH 
ALBERT E. TRUBY, M. D. * 
AND 
GEORGE M. KOBER, M. D. 
Washington, D. C. 
Physical Factors of Altitude.-As we progress from sea level to higher 
altitudes we have the following factors to deal with: 1. Diminished 
atmospheric pressure. 2. Diminished partial pressure of oxygen. 3. 
Lowered temperature and humidity. 4. Increased intensity of sunshine 
and electrical conditions. 
It is now well recognized that the important factor and the only 
one of primary importance is the diminished partial pressure of oxygen 
which results in imperfect oxygenation of the blood. 
At sea level the partial pressure of oxygen is 760 (Barometric pressure 
in millimeters) X 20.96 (per cent, of oxygen in air) = 159.29 plus. At 
10,000 ft. the partial pressure is 516 X 20.96 = 108.15 plus. At 
20,000 ft. it is 354 X 20.96 = 74.16 plus, etc. In other words the 
partial pressure of oxygen decreases as the altitude increases. 
The investigations of the Medical Research Board of the U. S. Avia- 
tion Service in 1918 have shown that in normal men characteristic altera- 
tions of functions begin even with a slight lowering of the oxygen 
tension and that for all persons there are limits beyond which the body 
cannot compensate. In this respect there are the widest individual varia- 
tions forming a scale from the man with a weak heart, who cannot with- 
stand scarcely any reduction of oxygen, up to the man whose respiration 
and circulation are of such adaptability and power that he can go to 
25,000 ft. and yet for a time be virtually normal. 
Schroeder of the United States in 1920 in an airplane ascent reached 
a height of slightly more than 38,000 ft., and Lieut. Macready of the 
U. S. Air Service attained a world altitude record of 40,800 ft. at 
Dayton, Ohio, September 28, 1921. It is generally held that the breathing 
of an atmosphere containing only 10 per cent, of oxygen, equivalent to an 
altitude of 19,400 ft. is a venture which only a few possessed of unusual 
resisting power can undertake with any hope of success. 
Effects of Altitude in General.-A reduction in barometric pressure 
and in partial pressure of oxygen causes imperfect saturation of the blood 
with oxygen. As a result, the tissues are insufficiently supplied with 
oxygen; the condition is called anoxemia. There are three types of 
* Chief Surgeon U. S. Air Service during the War. Commanding U. S. Army General 
Hospital, Presidio of San Francisco, Cal. 
814 EFFECTS OF DIMINISHED ATMOSPHERE UPON HEALTH 
815 
anoxemia, but the one that concerns aviation is the anoxic type, which 
depends on the pressure of oxygen in the blood. A chemical change 
in the blood, which is alkalosis, follows, that prevents a free passage of 
oxygen to the tissues. There are compensations to these changed con- 
ditions. The reaction of the individual depends on the suddenness, the 
extent, and the duration of the decrease in oxygen, and on his physical 
condition. 
We have temporary and permanent changes which are in the nature of 
compensations to the altered conditions. It is chiefly the temporary 
changes which concern the aviator. Major E. C. Schneider, one of the 
experts of the Medical Research Laboratory of the U. S. Air Service, sums 
up the responses of the individual by saying that they involve respiration, 
blood and circulation. Respiration is first affected, and then the circula- 
tion. Under respiration there is a fall in alveolar carbon dioxide pressure 
and a rise in alveolar oxygen pressure which are associated with increased 
ventilation of the lungs. In the blood there is an increase in the per cent, 
and total amount of hemoglobin; then there is a change in the acid-base 
relation in the blood and a rapidly increased pulse rate. The fall in 
atmospheric pressure and resultant decrease in partial pressure of oxygen 
would give a greatly lowered alveolar oxygen, but the changes in respira- 
tion result in the blood's being exposed to a greater alveolar oxygen pres- 
sure than would be expected at that atmospheric pressure. The increase 
in hemoglobin gives more oxygen to a unit volume of blood. The acid- 
base changes give a greater dissociation of oxyhemoglobin in the tissue 
capillaries. The circulatory changes probably give an increased blood 
flow which also increases the oxygen in the capillaries. 
Respiration.-Haldane showed that at low altitudes, the alveolar ten- 
tion of carbon dioxide is closely related to the per minute volume of breath- 
ing, the carbon dioxide remaining rather constant. At high altitudes the 
alveolar carbon dioxide tension is decreased and the breathing increased. 
Fitzgerald's law is, that alveolar carbon dioxide pressure diminishes 
4.2 mm. for every 100 mm. fall in barometric pressure. This in other 
words is an increase of 15 per cent, in ventilation of the lungs for every 5000 
ft. increase of altitude. Experiments at the Medical Research Labora- 
tory have shown that changes in the alveolar carbon dioxide pressure 
appear as low as 4000 ft. In ascents to 20,000 ft. the alveolar 
carbon dioxide tension falls from 39.7 to 30 mm. The alveolar oxygen 
tension falls from 103.2 to 34.8 mm. The after effects of a short stay at 
high altitude are fleeting; the tension rapidly returning to normal. The 
aviator sometimes develops a Cheyne-Stokes breathing, which is abolished 
by the administration of oxygen. There is a decrease in his vital capac- 
ity with lowered barometric pressure, but the cause is in dispute. 
Blood Changes.-Paul Bert1 as early as 1878 furnished experi- 
mental proof that the abnormal symptoms and dangers of altitude 
sickness depend on the imperfect aeration of the arterial blood with 816 
EFFECTS OF DIMINISHED ATMOSPHERE UPON HEALTH 
oxygen; he also predicted that the blood of man and animals living in 
high altitudes would be found to have a greater oxygen capacity than 
that of corresponding individuals living at lower levels. This prediction 
was verified by him in animals living at a high altitude in Bolivia in 1882. 
In 1890, Viault1 observed an increase in the number of red corpuscles 
per c.m.m of blood in himself and his companions during 3 weeks' visit 
in Peru at an altitude of 14,400 ft. Subsequent observations3-4 
have confirmed the earlier data. Among the American pioneer contri- 
butions we note the following: 
In 1903 a party composed of Professor George T. Kemp,5 E. R. Hay- 
hurst, 0. O. Stanley, and three students from the University of Illinois 
studied the effects of altitude on the blood. The results given are from a 
composite curve made by averaging the daily records on the blood of 
each of the six in the party. 
Red Corpuscles.-Upon going from Champaign, Ills., (700) feet to 
Cripple Creek, Col., (9400 ft.) there was no change in the number of red 
corpuscles on the afternoon of the day of arrival. In two days the 
count rose from 5,100,000 to 5,900,000 and maintained this level for 
three weeks, fluctuating between 6,100,000 and 5,600,000. At Pike's 
Peak (14,147 ft.) there was a rise of 400,000 the first day, then a slight 
fall and the level was maintained at about 6,000,000 for 8 days, the 
duration of their stay. Six days after leaving the Peak the count at 
Champaign had fallen to 5,400,000. The change in the ratio of the blood- 
plates (increase) to the red corpuscles was more striking than any other 
change in the blood; it was greater in degree, more regular in progres- 
sion, and of longer duration than the change in the number of the red 
corpuscles. 
Hemoglobin.-At Cripple Creek the rise in the amount of hemoglobin 
was fully 24 hours in advance of the increase in the number of red cor- 
puscles. The daily fluctuations in the hemoglobin were much less than 
the fluctuations in the red corpuscles, showing that when fewer red cor- 
puscles were circulating each carried an increased per cent, of hemoglobin. 
This point taken in connection with morning and afternoon fluctuations 
in the number of red corpuscles, suggests a new function for the spleen. 
The following figures illustrate the differences observed in mankind living at 
different altitudes: 1. The red corpuscles vary at sea level between 4.5 and 5.4 millions 
per c.m.m.; at Colorado Springs, altitude 6000 ft., between 5.5 and 6.3 millions; 
and on Pike's Peak, altitude 14,147 ft. between 6 and 8.2 millions. 2. The per- 
centage of hemoglobin at sea level varies between 94 and'106, average 100; in Colorado 
Springs, 105 to 118, average 110; and on Pike's Peak, 120 to 154, average 144. 3. The 
percentage of oxygen capacity in the blood at sea level varies between 17 and 18.7; in 
Colorado Springs, 20 and 21.7; and at Pike's Peak, approximately 27.4. 
The color index does not change. Fitzgerald's law is, that for every 
100 mm. fall in barometric pressure there is an increase of 10 per cent, in 
hemoglobin in acclimated individuals. In ascents up to 18,000 ft. at THE BLOOD AND CIRCULATORY MECHANISM AT HIGH ALTITUDE 
817 
1000 ft. a minute, Gregg, Lutz and Schneider found that 78 per cent, of 
all men showed an increase in hemoglobin and red cells. In the majority 
of cases this change comes on between 40 and 60 minutes. The theories 
advanced to explain this increase are: (1) Increased concentration of 
blood; (2) increased hematopoeticf unction of the bone marrow; (3) exis- 
tence of a reserve supply of corpuscles; (4) lengthening of the life of the 
red cells; (5) unequal distribution of red cells. 
There are various arguments for and against these theories, except 
in the case of 4, for which no experimental evidence exists. The weight 
of evidence, however, seems to be that the increase in hemoglobin in short 
exposures to high altitude is due to a loss of fluid from the blood, and the 
permanent variety of change is due to new formation of cells. There 
are no changes in the white cells in temporary adjustment. Schneider 
says "The whole problem of respiration at high altitude is very closely 
linked with the control of the chemical reaction of the blood, and there- 
fore, with the explanation of acidosis. Our interest centers about the 
balance of acids and alkali because the absorption and unloading of 
oxygen by the blood is altered by variations in these. Carbon dioxide 
by virtue of an acidic character affects not only the respiratory center but 
also the dissociation of oxyhemoglobin. An increase in the partial pres- 
sure of carbon dioxide augments the dissociation and a decrease causes 
the hemoglobin to hold more tightly to its oxygen." 
Leucocytes.-Altitude was found to have no effect on the leucocytes, 
either as to number or type.6 
Acid-Base Relationship.-In acclimatization to high altitude, the 
best explanation is given by Haldane. " The hydrogen-ion concentration 
of the blood is regulated with great delicacy by the respiration on the one 
hand and the kidneys and liver on the other, the respiration does the 
rough and immediate work by increasing or decreasing the elimination 
of carbon dioxide, and the kidneys the finer and slower work by adjusting 
fixed alkalis and acids. Oxygen-want serves as an additional stimulus 
to the respiratory center causing an increased amount of carbon dioxide 
to be washed out of the arterial blood. This loss of carbon dioxide makes 
the blood abnormally alkaline and causes the kidneys and liver slowly 
to redress the balance, the kidneys by excreting the excess of alkali and 
the liver by suppressing the accumulation of free ammonia." 
In the aviator this alkalosis described by Haldane is only beginning, 
and compensation is not complete. He suffers from oxygen-want, which 
is caused by a diminished partial pressure in the lungs and blood, and by 
an alkalosis of the blood. The effects on him depend on the degree of 
these factors, and it is the lack of oxygen in the brain that causes the chief 
danger of altitude to the aviator. 
Circulatory Mechanism at High Altitude.-The heart rate is shown by 
Hodgson, Lutz and Schneider, and Schneider and Truesdell, to be 
slowly and gradually increased to 14,000 ft. and from there on a greater 818 
EFFECTS OF DIMINISHED ATMOSPHERE UPON HEALTH 
increase occurs. If a level is maintained for an hour or more, according 
to Schneider and Lutz, the rate tends to return toward that at sea level. 
On return to sea level the rate returns at once to normal. 
Arterial Pressure.-Examinations at the Medical Research Labora- 
tory show, as pointed out by Schneider and Truesdell, that the systolic 
pressure maintains a level or shows a slight rise of 10 to 15 mm. at the 
end, in cases of good compensation. The diastolic pressure remains on a 
level to 15,000 ft. and then there is a gradual fall of 8 to 10 mm. In 
cases of poor compensation the systolic and diastolic may break and faint- 
ing occur. In rebreathing and in low pressure experiments, Schneider 
found the venous pressure to be reduced. 
Volume of Blood Flow.-The Medical Research Laboratory is working 
on this subject at the present time. The question is not yet satisfactorily 
determined, but there is probably a tendency to increased blood flow. 
Altitude Symptoms.-Major Schneider2 has an excellent chapter on 
the effects of high altitude upon aviators, of which the following is a 
summary: The majority of American aviators have had only one or 
perhaps several high altitude flights. Most of the training was secured 
at altitudes under 5000 ft. One hundred of the aviators who had 
been on active service at the front when questioned regarding discomforts 
of altitude replied as follows: 32 per cent, experienced no inconvenience; 
18 per cent, suffered from shortness of breath alone; 10 per cent, from 
cold and shortness of breath; 2 per cent, from headache and shortness of 
breath; 6 per cent, from headache; and 12 per cent, from feelings of 
physical exhaustion and mental depression. 
From an altitude of 12,000 ft. up, the following symptoms may 
occur, (a) Shortness of breath. This is extremely common but varies in 
degree. Very few aviators breathe through the nose above 12,000 ft. 
Breathlessness is usually noticed at 15,000 ft. and is exaggerated by 
muscular exertions and by cold. (&) Periodic breathing is occasionally 
reported. Birley personally experienced Cheyne-Stokes breathing at 
20,000 ft. which was relieved by breathing oxygen. One case is on 
record in which the periodic breathing came on at 18,000 ft. in so violent 
manner as to prevent the pilot from keeping his controls steady and 
continuing as he descended, made it very difficult for him to land. 
Effects on Nervous System.-The effects of altitude on the aviator 
come upon him unawares. The most striking effect is on the nervous 
system and results first in stimulation and a feeling of well being. This is 
quickly followed by a decrease in the field of attention, by an increased 
distractibility, and by a loss of control of voluntary muscles. At very 
high altitudes, memory, judgment, hearing and vision are impaired. 
Sleepiness is common and fainting may ensue. Between 23,000 and 25,000 
ft. is the upper limit of consciousness for a man without oxygen. 
Sleepiness.-The flyer gradually becomes dull and sleepy, he has no 
distress, and so insensibly becomes inefficient that he does not realize his SYMPTOMS AT HIGH ALTITUDES 
819 
condition. Individuals in the low pressure chamber who have gone to 
sleep revive when given oxygen, and declare it their opinion that they 
have been efficient or at least awake. It is probable that aviators who 
claim to feel perfectly fit at high altitudes may in reality have been quite 
inefficient and sleepy. 
Impairment of intellect and judgment is also a condition usually over- 
looked by the airman and with it there is often an unwarranted sense 
of security and well being. 
Birley2 refers to a pilot who met an enemy at 18,000 feet. He 
did not realize his danger, but waived his hand to him in spite of 
the protests of his observers. . . . Observers on high photographic 
reconnaissances frequently get muddled and fog their plates. Experi- 
ments in the American Research Laboratory also show that the power 
of attention and discrimination may be reduced; the handwriting at 
18,000 ft. in some subjects becomes difficult to read and errors in 
spacing, following the line, and omission of words are more or less 
frequent. The administration of oxygen for 2 minutes restored the 
individuals to normal. 
The psychic factors in aviation were studied in 1914 by Loewy and Placzek,® 
who report a series of tests of the attention and other psychic phenomena on them- 
selves and two others in a pneumatic cabinet with an atmospheric pressure corre- 
sponding to that of an altitude of 12,000 feet. The findings are summarized as 
follows: The objective findings were comparatively slight, although mistakes in doing 
sums were more frequent the more rarified the air. But the sensation of being 
incapable of giving close attention, of being unable to act promptly and with preci- 
sion-these subjective factors were pronounced, and even a subjective sensation of the 
kind has always more or less of a paralyzing effect and may serve to explain some 
of the fatalities to aviators for which the machines were not responsible. The effects 
in these tests were the more significant as the subjects were quiet, warm and free from 
responsibility in the pneumatic cabinet. "Compare this with the condition of the 
aviator," they remark, "the rapid changes in altitude causing physical disturbances 
and weakening the will power, while the wind makes it hard to breathe and chills the 
surface, and finally paralyzes the peripheral vessels so that the blood pours into them 
and the brain, etc., become anaemic." They think that the death of Chavez, for 
instance, was due to these causes, as he strove to break the altitude record. They 
warn aviators against high altitudes and urge them to train themselves to bear abrupt 
changes in atmospheric pressure. 
Muscular weakness has been noted by observers, who find it hard to 
manipulate a camera when above 15,000 ft. Muscular paralysis has 
been experienced at extremely high altitudes. 
Headache.-This is usually frontal and often sudden in its oneset in 
altitudes above 11,000 ft. It is also frequently an after effect of low 
oxygen and may persist for some hours. 
Fainting.-Some cases of sleeping may be confused with this, but 
there are flyers of long experience who believe that if an individual 
makes frequent flights at high altitudes he will sooner or later experience 
a fainting spell. Some feel faint and dizzy, but do not faint. 820 
EFFECTS OF DIMINISHED ATMOSPHERE UPON HEALTH 
Effects of Altitude on the Skin, Eye and Ear.-The effect of strong 
air currents and intensive insolation with increased activity of the violet 
and ultra-violet rays are harmful. Sunburns and severe forms of 
dermatitis caused by intensive insolation are common in high elevations. 
The excessive dryness of the upper strata of the air causes rapid evapora- 
tion of perspiration and pulmonary exhalation and may produce inflam- 
matory conditions of the skin and mucous membranes of the eyes and 
upper air passages. The effects of sudden changes in temperature and 
exposure to fogs, rain, hail, atmospheric electricity and extreme cold may 
prove harmful. Von Schrotter reports balloon flights in which the 
thermometer registered -40 degrees C. 
Mr. Douglas McCurdy, one of the most expert and intelligent of American 
aviators, in commenting upon the effects of exposure to extreme cold wrote Kober as 
follows: "I had an experience while flying at Baddeck, Nova Scotia, during the 
month of February, 1909. The temperature was about zero, and of course I was 
warmly clad. I had flown about 10 miles, landing at my starting point, when my 
hands seemed unusually cold I then felt a most curious feeling come over me, where 
people and sounds right around me. seemed distant. I was helped into a doctor's 
sleigh, which was near by, and covered up with warm robes. This sensation lasted 
for about 5 minutes when I gradually became normal again." 
Cases of conjunctivitis and pterygia are quite common, especially 
among aviators who wear leaky goggles or wear none at all. 
Wilmer and Berens found that altitude affected individuals with 
abnormal eyes more than it did those with normal eyes. In the case of 
the field of binocular fixation, the field was contracted at high altitudes in 
50 per cent, of the abnormal individuals and only in 8 per cent, of the 
normals. In accommodation, 63 per cent, of the subnormal cases showed 
a decrease of accommodative power and 47 per cent, of the normal cases. 
Fatigue of accommodation was more rapid at high altitudes; 50 per cent, 
of the normals showed decrease in converging power. In some of the 
subnormals recession of the near point was so great as to result in diplopia. 
Fatigue of the convergence was also much more rapid at high altitudes. 
Tests of the ocular muscles at 15,000 and 20,000 ft. showed decrease of 
the power of abduction, adduction and sursumvergence. 
Shroeder's experience2 in his record altitude flight shows that impair- 
ment of vision and hearing come on gradually and insensibly. At an 
altitude of 25,000 he could hardly hear his motor run; he then took oxygen 
and kept on until he experienced, at 29,000 ft., impairment of judgment, 
and the horizon seemed to him "very much out of place." According to 
Dr. Reymond,7 the effects on the ear are characterized by a painful ten- 
sion, ringing or buzzing noises and impaired hearing. These phenomena 
are due to differences in atmospheric pressure and hence are more pro- 
nounced during sudden changes in elevation and after a rapid descent. 
Ordinarily the act of yawning or swallowing, with mouth and nose closed, 
serves to restore the equilibrium between the inner and outer air of the SYMPTOMS AND AFTER EFFECTS OF HIGH ALTITUDES 
821 
internal ear. The temporary deafness varies in different individuals and 
would appear to go off with practice, but Reymond found that cases of 
catarrh of the Eustachian tube are greatly aggravated, especially in 
mouth-breathers, on account of the strong winds, and require more active 
treatment. The wind currents and pressure also favor the development 
of chronic rhinitis. Aviators with obstructions in the nose and throat 
are apt to have serious troubles because of the sudden changes of baro- 
metric pressure. Unless the Eustachian tubes are patent, retraction or 
even rupture of the drum membrane may occur on rapid drops to low 
levels. Mr. Earl L. Ovington, an expert American flier, describes the bad 
effects of rapid descents as follows: 
"If I cut off my engine at a 2-mile height and drop suddenly to a mile from the 
ground, it seems as if some one was standing behind me poking red hot pokers into my 
ears. . . . My usual practice, when I wished to avoid this inconvenience, was to 
drop 1000 ft. as slowly as possible with the power off, turn on the power and circle 
around at that level, swallowing vigorously. I would then drop another 1000 ft. 
In this way I could get to the ground from a height of 2 miles without any incon- 
venience. ... At Columbus I thought I would do a little grand-stand work and 
drop from the height of a mile straight to the ground as rapidly as possible. I stepped 
out of the machine with everything swimming before my eyes and just as my foot 
touched the ground I became unconscious and remained unconscious for 5 minutes 
or so. This was no doubt due to the rapidity of my descent, and this may have 
caused Chavez to lose control of his machine when only 100 ft. from the ground." 
Whatever difference of opinion there may be as to the ability of the 
mind and body to accommodate itself to the effects of diminished 
atmospheric pressure, and much of this doubtless depends upon inherent 
qualities of the aviator, prudence demands that rapid ascents and descents 
should be avoided. That there is special danger in sudden descents is 
apparent from the facts already stated, and is also evident from the fol- 
lowing personal note to Kober by Mr. McCurdy upon the death of 
Archie Hoxey at Los Angeles, California. He writes: 
"Mr. Hoxey was one of the most expert of flyers, and had given a good deal of 
attention to high flying (about 11,000 ft.). He had experienced at several times a 
dizzy sensation and a slight feeling of nausea upon landing, due we thought to a too 
rapid descent. We cautioned him and advised a slower rate of descent, but he paid 
no heed. At the time of which I speak he had attained an altitude of about 11,000 ft. 
and came down very rapidly to about 300 ft., when the machine was observed to con- 
tinue an abnormal descent and Mr. Hoxey seemed to have abandoned his controlling 
levers. The machine finally struck the ground and Hoxey was killed. He had made 
apparently no effort to land normally." 
After Effects.-Symptoms noticed after landing 
Fatigue.-All flying is fatiguing but the condition is much more 
pronounced after a flight above 15,000 feet. 
Respiration often becomes subnormal both in rate and depth and may 
show periodicity, the subnormal breathing in aviators continues until 822 
EFFECTS OF DIMINISHED ATMOSPHERE UPON HEALTH 
the carbon dioxide loss from the blood is made up and until alkali is 
recalled to the blood. 
Subnormal blood pressure and headache are attributed by some author- 
ities to circulatory fatigue. The longer the flight, the longer the after 
effects persist and permanent changes tend to replace the temporary. 
The war experience especially of our allies has shown that much high flying 
without oxygen gradually undermines an individual's ability to tolerate 
altitudes. He therefore progressively finds his "ceiling" getting lower. 
Men undergoing such an experience should be relieved from altitude work 
for a time, or a lasting effect may result which incapacitates for all 
flying. 
Diseases of Aviators.-Apart from the effects already referred to the 
most important disease or condition common to aviators is that of chronic 
fatigue or "staleness." The symptoms are those of neuro-circulatory 
asthenia with certain others added, and it is a result of too constant applica- 
tion to flying, either by long hours in the air, frequent flights at high 
altitudes, or flights at moderately high altitude without oxygen. Flying 
induces fatigue. Fatigue repeated constantly becomes chronic and this 
is "staleness." It may also be caused in aviators, as in other individuals, 
by lack of exercise, dissipation, etc. The flier becomes unfit for flying, 
is afraid to go into the air, in fact has to force himself to do so. He suffers 
from terrifying dreams about flying. While in the air he is a victim of 
poor judgment, and on return to the ground suffers from excessive fatigue. 
Cases of staleness are very frequent in war time when intensive flying is 
going on, but they are not infrequent in peace time. In staleness the 
adaptive mechanisms to low oxygen are interfered with and the individual 
is less able to withstand high altitudes. 
Experience at the Army Air Service Medical Research Laboratory has 
shown that one of the early symptoms of "staleness" in the flier is a 
decrease in his ability to judge distance, with a result that he makes poor 
landings. Phorias are apt to become worse or develop following fatigue. 
Diplopia may suddenly develop in the air as a result of fatigue if the 
individual has a phoria of any size. Retinal sensitivity and the speed of 
accommodation also become diminished, but these are probably due to 
fatigue. 
Fliers are in a new environment and they are subject to unusual and 
long continued and frequent stresses which are cumulative in effect. 
These stresses are capable of disturbing the stability of the normal 
nervous mechanism. If the flier be of an unstable type, the limits of his 
endurance are less, and the chance of exceeding these limits is greater. 
He is therefore prone to develop neuro-psychoses. 
Treatment.--The use of oxygen during flights at high altitudes is 
almost indispensible. Dr. E. Koschei,8 as early as 1914, reports that his 
pulse in a flight at an elevation of 5000 meters was 140, and 160 at an 
altitude of 6000 meters. In 1912 by resorting to timely oxygen inhala- DISEASES OF AVIATORS MOUNTAIN SICKNESS BALLOONING 
823 
tion, at an elevation of 3500 meters, he attained and remained in altitudes 
between 7500 and 9000 meters, with a pulse not exceeding 100 per minute 
and was perfectly capable of physical exertion, such as unloading sacks 
of sand ballast. 
The physiological experiments conducted in the Army Medical 
Research Laboratory, and the experience of flight surgeons, fully demon- 
strate the beneficient influence of oxygen in reducing systolic pressure 
and pulse rate, and quieting of respiration; also its timely use will increase 
muscular coordination and mental alertness, maintain or restore clearness 
and accuracy of vision, mitigate the fatigue of high altitude flights, and 
increase the length of service and amount of work. 
Mountain Sickness.-The effects of diminished atmospheric pressure 
and physical exertion in mountain climbing upon the heart and respiratory 
organs, characterized by rapid and difficult breathing, palpitation of the 
heart, blueness of the lips and face, headache, dizziness, faintness, nausea, 
vomiting, extreme muscular fatigue, and occasional hemorrhage from 
the nose and mucous membranes have been known and described 
for some time as mountain sickness or puna. These symptoms have 
been observed in persons not accustomed to rarified atmosphere in 
altitudes of 6000 to 10,000 ft. and higher elevations naturally intensify 
the effects. 
While most of these effects may be clearly traced to diminished 
atmospheric pressure and deficiency of oxygen, muscular exertion and 
fatigue substances doubtless also play an important role. Mountain 
climbing involves lifting the entire weight of the body through the 
distance climbed, which for a man weighing 175 lb. is equivalent to 
about 8 ft.-tons of work for every 90-ft. elevation. Hence work of this 
character, or any muscular exertion such as mining and construction work 
involves increased production of waste material in the blood, and doubt- 
less accounts for the insomnia, loss of appetite and chronic fatigue 
observed among the miners and other workers in high altitudes. The 
heart and lungs gradually adapt themselves to the diminished atmos- 
pheric pressure, the vital capacity of the lungs is increased in consequence 
of deeper inspirations, and the functions of the hemopoietic organs are, 
as already stated, increased. In spite of this beautiful adaptation it is 
evident that the efficiency of workers is greatly impaired; even the native 
copper miners at Cerro de Pasca, altitude 16,000 ft., according to 
Oliver,9 can only work in 8-hour shifts for a few months at a time when 
they are obliged to cease and return to their farms. 
Ballooning.-It has been generally assumed that in the absence of 
physical exertion, modifications in the action of the heart and lungs 
are less liable to ensue in balloon ascensions. Petard, in 1873, with four 
companions found this to be true, since in a balloon flight the phenomena 
of so-called mountain sickness were not observed until an elevation of 
between 12,000 and 13,000 ft. was reached, when the pulse rate was 114 824 
EFFECTS OF DIMINISHED ATMOSPHERE UPON HEALTH 
and respiration 44 per minute. Von Schrotter,10 since 1896, has made a 
number of balloon ascensions and determined that serious symptoms are 
rarely observed in aeronauts, except in specially predisposed subjects, 
until an elevation of 15,000 ft. is reached. 
This altitude he regards as the danger zone since, in addition to 
the cardiac and respiratory symptoms, there is also great mental depres- 
sion, and the slightest muscular effort, such as unloading a sack of ballast, 
is followed by faintness. In elevations above 15,000 ft. the pulse, at 
first rapid, becomes small and irregular. Dr. Flemming and Steyrer11 in 
June, 1911, attained an elevation of 26,000 ft. and experienced extremely 
grave symptoms, such as diminished cardiac and respiratory action, 
pulse almost imperceptible, cramps and tremblings of the muscles, 
diminished mental and spinal sensibility, cyanotic countenance, and 
unconsciousness-symptoms urgently calling for the use of oxygen inhala- 
tions. Zuntz believes that while these symptoms are caused by a defi- 
ciency of oxygen in the system, the diminished atmospheric pressure also 
produces a gaseous distension of the intestines which impinge upon the 
diaphragm and seriously interfere with the vital capacity of the lungs. 
Nausea with occasional vomiting, in fact all of the symptoms of seasick- 
ness, is liable to occur at any elevation if the movement of the airship, 
in consequence of irregularities of the winds and eddies, has become 
unsteady. 
In 1862, Glaisher, the well-known meteorologist, ascended in a balloon with his 
assistant; he first noticed at an altitude of about 26,000 feet that he could not read his 
instrument properly. Shortly after this his legs were paralyzed and then his arms, 
though he could still move his hand. Then his sight failed entirely and afterwards 
his hearing, and he became unconscious. His companion meanwhile found that his 
arms were paralyzed, but that he was still able to seize and pull the rope of a valve 
with his teeth; this permitted gas to escape, so that the balloon descended. As 
Glaisher recovered consciousness, he first heard his companion's voice and then was 
able to see him, after which he quickly recovered. The ballon reached an altitude of 
about 30,000 feet. 
A very graphic account, given by Tissandier, of a fatal balloon ascent in 1875 will 
also be found on page 10 of the Manual of Medical Research Laboratory. The bal- 
loon ascended 28,820 feet and then descended. In spite of the use of oxygen, his three 
companions lost their lives in the ascent, and he himself became powerless and uncon- 
scious at an elevation of about 26,000 feet, but made a miraculous recovery. 
Flemming12 reports two cases of unconsciousness which occurred at 
an elevation of between 3000 and 6000 feet which he attributed to the 
combined influence of cold, flatulent distension of the bowels and passive 
congestion, caused by tight fitting clothing. Other effects of altitude 
have already been discussed. 
Among the occupational risks of ballooning should be mentioned the 
possibility of "gas poisoning. " Von Schrotter11 refers to several instances 
of carbon monoxide poisoning which occurred during the inflation, 
deflation and collisions of balloons. Prof. Glaister13 of the University BALLOONING ACCIDENTS-CRASHES 
825 
of Glasgow reports 16 cases of poisoning from arseniureted hydrogen 
gas which occurred, in ballooning for military and other purposes, 
during the inflation or deflation of the balloons or from leakage during 
the balloon flights. Similar cases have been described by Dr. 
Maljean14 of the French Army, and Crone15 of the Prussian Army. It is 
hoped that this hazard may be removed by the use of helium gas. 
Dirigible Balloons.-Since the introduction of motors in dirigible 
balloons, new elements of danger have been added, such as gasoline 
explosions, breaks in the propeller, carbon monoxide poisoning, etc. 
Accident Liability.-According to Dr. Reymond,7 "the greater 
number of accidents of aviation are due to the apparatus, to the 
imprudence or the clumsiness of the aviator, to his physical condition, 
which may itself be caused by the conduct of the apparatus; but it would 
be premature to draw conclusions as yet." The accident liability in 
balloon flights is not as great as has been generally assumed. According 
to Flemming, cited by von Schrotter, during the year 1908 there were 
1713 balloon flights in Germany in which 5786 persons participated; of 
these, 50 persons were injured, four or 0.07 per cent, resulted in death, 
24 or 0.41 per cent, in serious injuries, and 22 in slight injuries. 
The percentage of fatal injuries is very much greater among aviators. 
The statistics compiled up to April 1, 1914, showed that 462 aviators had 
been killed since September 17, 1908, when the first man, Lieut. Selfridge, 
U. S. A.,16 lost his life. We have no precise data from April, 1914, 
until the entry of the American expedition in France,2 the records of 
which show that at the signing of the armistice on November 11th, 1918, 
169 American fliers had been listed as killed in combat, while 203 had 
succumbed to accidents at the front. 
The American aviation force consisted of 5646 men, of whom 3908 
were pilots and 1741 observers. The observer directs the activity of 
the plane, but so far as its actual control is concerned he is merely a 
passenger, the pilot being the chauffeur. 
Of the 3905 pilots, 1281, or 32.8 per cent, of those entering the schools 
of France reached the front either in the zone of advance or with the 
allied squadrons. For every 100 pilots who arrived at the front more 
than 15 were killed through accidents in the training schools of France. 
Of the 1741 observers more than 43 per cent, reached the zone of advance 
or allied squadrons, and for every 100 trained observers arriving at the 
front only one man was killed in training. 
CRASHES IN THE U. S. ARMY AIR SERVICE DURING 1920 
During 1920, there were 312 crashes in the U. S. Army Air Service. 
About 1000 officers, enlisted men and cadets were flying during that year. 
The number of hours flown by this personnel is estimated to be about 
74,105 hours. 826 
EFFECTS OF DIMINISHED ATMOSPHERE UPON HEALTH 
Result of Crash 
Uninjured 217 
Slightly injured 48 
Severely injured 13 
Killed 34 
For Pilot 
No passenger 84 
Uninjured 160 
Slightly injured 46 
Severely injured 10 
Killed 12 
For Passenger 
312 
312 
British Aviation (Civil) 
May 1, 1919 
to 
Mar. 31, 1920 
Work Done: Number of machine flights made 
37,821.0 
Approximate machine mileage 
691,859.0 
Number of passengers carried 
67,940.0 
Approximate number of hours flown by passengers 
18,096.0 
Accidents to Machines: Number of accidents resulting in death to 
one or more occupants of machine 
4.0 
Number of non-fatal accidents resulting in injury to occupants of 
- 
machine 
11.0 
Approximate number of machine miles flown per accident 
28.827.0 
Casualties to Personnel: Pilots killed per 1000 hours flown by pilots. 
0.415 
Pilots injured per 1000 hours flown 
0.934 
Passengers killed per 1000 passengers carried 
0.014 
Passengers injured per 1000 passengers carried 
0.176 
Passengers killed per 1000 hours flown by passengers 
0.055 
Passengers injured per 1000 hours flown 
0.663 
In the absence of complete statistics, the following excerpt from 
an article by Ladislas D'Orcy in the "Outlook," December 7, 1921, will 
be of interest, as it refers to a report, prepared by the Manufacturers' 
Aircraft Association, on the aviation accidents which occurred in the 
United States from January 1st to June 30th, 1921: 
"There are recorded for this period a total of 58 accidents for an aggregate flight 
mileage estimated at 3,250,000, and of this total, ten accidents caused fourteen 
fatalities; 20 accidents were responsible for injury to the occupants, while in 
18 instances there were no casualties. This works out as one fatal accident 
for every 325,000 miles flown, a ratio which compares favorably with official foreign 
figures, if the estimate of the American flight mileage is substantially correct. In 
Great Britain, for instance, the number of fatal aviation accidents per miles flown in 
1920 was one in 195,000 miles; but it is only fair to add that the English weather, with 
its frequent fogs, is particularly adverse to flying. Considering this circumstance, the 
showing made is remarkably good, for the total British flight mileage represents some 
62,000 aerial journeys, in which 106,712 passengers were carried, so that fatalities 
among the latter were one for every 7750 flights." AVIATION ACCIDENT RATES-PHYSICAL EXAMINATIONS 
827 
COMPARISON BETWEEN CASUALTIES IN MILITARY AND CIVIL AVIATION 
The Paris newspaper "Le Matin" of October 5th, 1921, in drawing a 
comparison between casualties in military and civil aviation states: 
"Whereas the toll of loss by military aviation averages persons killed 
and 3 persons wounded per week, civil aviation continues its ascending 
progress. The schedule for the month of September, 1921, shows 
the following favorable figures for the airport of Le Bourget alone: 433 
planes arrived and departed; 1418 passengers safely transported as 
against 1190 for the same month in 1920; 16^ tons of merchandise 
transported as against 12^ tons for the same month last year; 1150 
pounds of mail transported as against 1087 pounds for the same month 
last year. Only one accident reported, that at Le Bourget, where the 
plane from Strasbourg fell in consequence of faulty piloting. 
The inference drawn from the above is that civil aviation is far safer 
than military aviation, and as a matter of fact such appears to be the 
case, for this condition of affairs is not confined to France but to the 
United States and other countries as well. 
The Air Service News Letter of November 28th, 1921, presents some of 
the reasons why travel by commercial plane is safer, which may be 
summarized as follows: 
First, it is safe to assume that 9 out of 10 flyer-pilots in civil life have been trained 
in the military service and mastered the details of flying (50 per cent, of the accidents 
in the U. S. Army Air Service occurred among flying cadets or enlisted men undergoing 
various stages of flying training). Second, expertness in flying requires constant 
practice, and in this respect the commercial flyers possess a great advantage over the 
majority of the flyers in the military service. Then, again, the commercial pilot 
flying from one airport to another does only straight away flying, with no frills. His 
job is to get passengers and goods safely to their destination. The military flyer 
cannot confine himself to straight away flying when on duty with an aero-squadron, 
and when planes must be maneuvered in every conceivable manner to successfully 
combat the enemy. Third, commercial machines are generally much larger and of a 
slower moving type, while the military airplanes are smaller, faster and much more 
maneuverable. In war the pilot who flys the faster and more maneuverable plane 
has a great advantage over his adversary, and hence in the design of war machines 
greater stress is laid on speed and maneuverability than safety. Fourth, the matter in 
the difference of fixed routes and well established landing fields is also very greatly in 
favor of commercial aviators. The army pilot, even in peace time, had to patrol along 
the Mexican border, watching for hostile bandits, boot-leggers and ammunition run- 
ners with possible landing places few and far between. He had to run the same risk on 
forestry patrol duty in the great Northwest. 
Physical Examination of Aviators.-It is evident that the aviator's 
body is subject to an enormous physical and nervous strain. Even in 
pre-war times it was recognized that airmen should have sound eyes, ears, 
heart and lungs. Dr. Reymond7 refers, however, to an aviator with a 
heart lesion and another afflicted with pulmonary tuberculosis in the 
second stage; in both of these cases the symptoms were not aggravated by 828 
EFFECTS OF DIMINISHED ATMOSPHERE UPON HEALTH 
the continuous practice of aviation; "asthmatics and emphysematous 
subjects, on the other hand, suffer very much from the wind raised by 
the screw or from the speed of the relative air current." 
Mr. McCurdy informs Kober that Mr. Hubert Latham of France was practically 
given up by his physician as he was suffering from consumption. He therefore decided 
that he might as well have some excitement for the remaining few months of his life 
by flying. He became connected with the Antwanette Co., the makers of the beautiful 
monoplane which bears their name, and soon became the most expert flier in the world. 
He was in the open air so much that he almost completely recovered his normal health 
and lived for several years. He was, in the end, however, killed by a wild bull while 
hunting in Madagascar in 1912. 
It is apparent, however, that only physically sound persons should 
engage in this work, which is so full of possibilities in the future. 
STANDARDS OF PHYSICAL EXAMINATION FOR FLYING 
1. The United States Army has adopted a very thorough standard for the physical 
examination of fliers in order that no pilot will be able to subject himself or passengers 
to any flying hazards which might result because of physical or mental defects of a 
pilot. In other words, the object of the examination, and the regulations incident 
thereto, is to select for flying duty only such officers and enlisted men as are physically 
and mentally qualified for such duty, and to remove promptly from flying duty those 
who may become temporarily or permanently unfitted for flying because of mental or 
physical defects. 
2. The standards are published by the War Department in Army Regulations 40- 
110, June, 1921. The examination is comprised of the following: A thorough general 
examination, including an examination of all vital organs; a complete examination of 
the eye, ear, naso-pharynx, equilibrium, and nervous system. Any defect of these 
organs which would in any way interfere with the pilot in making a landing or in 
controlling his airplane during flying is considered a cause for disqualification. This 
examination is required of all applicants for flying training, and is also made twice a 
year for all fliers. 
3. In addition to the strict physical examination required, specially trained medical 
officers known as flight surgeons are assigned to duty at each flying field. It is their 
duty to carefully look after the physical condition of the pilots, observe them daily, 
and make necessary recommendations in individual cases whenever they consider a 
pilot physically or mentally unfit for duty, either temporarily or permanently. 
Lieutenant Colonel Leonard G. Rowntree, M. R. C., advises the 
aviator to consult the flight surgeon: When he is ill; when he is not feeling- 
fit; when he feels insecure in his work; when his flying records are poor; 
and when he has had an accident. 
The Hygiene of Aviators.-It is evident that physical fitness of airmen 
can only be maintained by strict observance of the rules of personal hygi- 
ene. This much they owe to themselves, their families and their country. 
Corbett and Bazett,2 from a wide experience with English aviators at the 
front, write: 
"We have seen numerous pilots who appear hardly to have heard of physical fitness 
and have never learned to take any sort of pride in their bodily health . . . They AVIATION PROTECTIVE MEASURES 
829 
indulge every whim. They are liable to smoke excessively, play cards all night if the 
game is interesting, use alcoholic liquors immoderately and in other ways overtax 
the mechanism. Guilbert has written-The first thing that would be necessary to 
the aviator is a great liberty of spirit. How can a pilot be a complete master of 
his apparatus if he is distracted in his mind and his thought is elsewhere." 
Major E. C. Schneider,2 emphasizes the following points: Flying is a 
question of an active, well-balanced, decisive mind, and of sound, quick 
reflex actions. Not a thing can be left to chance: Fear and worry may 
temporarily or permanently make an individual physically and mentally 
unfit for flying . . . Fatigue lowers efficiency in a measurable degree; 
among the evidences of fatigue may be nervous dyspepsia, palpitation 
of the heart, nervous eyestrain, and other similar functional ills. Regu- 
larity of living gives most certain assurance of health and efficiency, a 
proper balance of rest, work and a careful selection of food, gradually bring 
the individual to top form . . . Proper sleep is most important, eight 
hours is a good average. Only few men can do efficient work on seven 
hours or less. The diet should be generous and nourishing. The habit 
of eating between meals, of using soft drinks, and the constant or frequent 
eating of confectionery cause the digestive disturbances so commonly 
seen among aviators. 
The alcohol problem, despite the opinion of many aviators to the 
contrary, is a grave one. All the belligerent nations found that in order 
to save men from drunkenness, from the inefficiency that comes from 
partial intoxication and from venereal diseases that come from lack of self 
control when under the influence of alcohol, it was necessary to reduce and 
if possible eliminate the use of alcoholic drink. Alcohol may falsify 
sensations and predispose to foolish action. A number of serious crashes 
in France among American fliers occurred on the days following an eve- 
ning of excessive use of alcohol. Wilmer and Beserro2 write, "In our 
Army experience a number of airplane accidents occurred after the fliers 
had been using such drugs as aspirin, phenacetin, bromides, and an 
advertised remedy for seasickness." Guilbert refers to the importance of 
securing a movement of the bowels and also of emptying the bladder 
before going up in an airplane. The importance of exercise to secure 
physical fitness, and the old adage, "head fresh, abdomen free, feet warm," 
are duly emphasized. 
Protective Measures.-Flemming12 was the first to point out the 
dangers of tight fitting clothing. Woolen undergarments, with some 
impermeable outer garment, such as a fur-lined combination suit, and 
fur-lined boots offer the best protection against cold and winds. Pro- 
tection for the head and eyes by means of suitable helmets and goggles 
is necessary not only against excessive insolation but also in case of rain, 
hail and snow storms. 
The application of vaseline to the face and hands has been recom- 
mended for the prevention of frostbites, chapping of the skin, cracking 830 
EFFECTS OF DIMINISHED ATMOSPHERE UPON HEALTH 
of the lips, and a spray of petrolatum will be found useful in preventing 
the dryness of the nose and throat. 
All ascending and descending flights should be made gradually and 
elevations above 12,000 feet should be avoided. 
Arsenical poisoning of aviators in boll weevil eradication work, 
caused by distributing powdered arsenic mixtures over cotton fields, 
proved a troublesome and as yet unsolved feature.21 
REFERENCES 
The authors desire to express special obligations to Majors Bauer and Schneider, 
experts of the Medical Research Laboratory of the U. S. Army Air Service, Mitchell 
Field, Long Island, and the following publications: 
1 Manual of Medical Research Laboratory, War Department, Air Service Division 
of Military Aeronautics-Col. William H. Wilmer, M. C. N. A., Officer in Charge. 
Government Printing Office. 1918, 255 pages. 
2 Aviation Medicine in the A. E. F. The publication contains an account written 
by Col. William H. Wilmer, Medical Corps, who was in charge of the Air Service 
Medical Research Laboratories at Issoudon, France, from September, 1918, 
until the armistice. Government Printing Office. 1920, 322 pages. 
3 Cohnheim, O., and Weber.-Die Blutbildung in Hochgebirge. Deutsches Arch, 
f. Klin. Med., 1913, CX, page 225. 
4 Anglo-Am. Exped. to Pike's Peak. J. A. M. A., Aug. 10, 1912, page 449. 
6 Kemp, George T.-Report of an Expedition to Cripple Creek and Pike's Peak to 
Study the Effect of Altitude on the Blood. Am. Jour, of Physiology. No. 6, 
Vol. X, February 1, 1904. 
6 Berliner Klin. Wochnschft. June 1, 1914. Abstr., J. A. M. A., July 11, 1914, page 
203. 
7 Reymond.-Jour. State Medicine, London, 1913, Vol. XXI, page 500-503. 
8 Koschei, E.-Jahrbuch der wissenschafthchen Gesellschaft f. Flugtechnick, Vol. 
II, Part 2, 1914. 
9 Oliver.-Diseases of Occupation, London, 1916, page 118. 
10 Von Schrbtter, Hermann.-Hygiene d. Aeronautick und Aviatick, Wien, 1912. 
11 Von Schrbtter.-Loc. cit., pages 45, 46. 
12 Flemming.-Deutsche Med. Wochnschft., 1912, Vol. XXXVIII, 2, page 1338. 
13 Glaister, John.-Actes du II Congres. Internal, des Maladies Professionneles. 
Bruxelles, 1912. 
14 Maljean.-Archives de Med. et de Pharm. Milit., Vol. XXXV, page 82. 
15 Crone.-Deutsche Militaraztl. Zeitschft, Vol. XXIX, 1900, page 139. 
16 Boston Medical and Surgical Journal, 1913, CLXIX, page 365, and Press Reports. 
17 Schneider, E. C.-A Record of Experience with Certain Physical Efficiency and Low 
Oxygen Tests. A. J. Med. Sciences, March, 1921. 
18 Schneider, E. C. and Truesdell, Dorothy.-A Study of Low Oxygen Effects 
During Rebreathing, Am. Jour, of Physiology, March, 1921. 
19 Schneider, E. C.-A Study of the Influence of Various Circulatory Conditions on the 
Reaction of the Low Oxygen of Rebreathing. Am. Jour, of Physiology, June, 1921. 
20 Schneider, E. C.-Physiological Effects of Altitude, Physiological Reviews, 
October, 1921. 
21 Shook, Capt. Chas. F. (Montgomery, Ala.)-Army Medical Bulletin, No. 6 
Series 1922 (October), page 196. CHAPTER VI 
ELECTRICAL INJURIES AND ELECTRICAL SHOCK 
SIR THOMAS OLIVER, Newcastle-upon-Tyne, England 
Introduction.-Man's equipment has in recent years been considerably 
added to by his mastery over electricity. By utilizing the potent fluid, 
he has achieved results which have transcended the imagination of his 
forebears of a century ago. Distance has been abridged and the atmos- 
phere caused inaudibly to vibrate with the winged messages of human 
thought. While electricity has aided civilization and been of the greatest 
assistance to man, it has brought not only light and comfort into our 
homes but dangers as well. Electricity is a subtle fluid; we can store it 
and control its flow, although we know little or nothing about it. In this 
article we are concerned solely with the medical aspects of the subject. 
Statistics.-In Europe during 1910 there were 200 deaths caused by electrical 
shock. Of these 41 were in France and 26 in Great Britain. In America the number 
was probably larger. In Great Britain according to G. Scott Ram,1 H. M. Electrical 
Inspector of Factories, the electrical accidents for 1913 in electrical generating stations 
alone were 65 with two deaths. Of these the largest number 31, with one death, 
occurred during the cleaning and repairing of "live" switchboards and "live" con- 
ductors. Twelve accidents occurred at switchboards during routine work. Of the 
47.4 per cent, of the accidents in 1913 occurring during cleaning and repairing, many 
of them, with care, could have been prevented. Considering the number of electrical 
stations in Great Britain and the increasing demands upon their production the 
number of electrical accidents in the United Kingdom is not considered to be unduly 
high. To the accidents already recorded there occurred other 418 electrical accidents 
with 17 deaths in factories other than generating stations. Five deaths were due in 
1913 to conductors having no protection at all. Trimming of arc lights was the 
cause of three accidents with one death. Of 20 fatalities reported to the Home Office 
for 1913 as coming under the Factory and Workshops Act, 15 were due to shock, and 
12 of these 15 were due to alternating currents at pressures which are usually con- 
sidered low. Two of the deaths were the result of burns. In one of the patients 
blood poisoning followed external injuries. 
In his Report for 1918, G. S. Ram alludes to the striking development in the direct 
use of electrical energy in furnace works for the making of high grade special steels 
and alloys-the advantage being the ready control of the temperature and the fact 
that the charge is not in contact with the deleterious products of the combustion of 
carbonaceous fuel. During the four years 1915-1918 there were 99 fatal accidents 
as against 70 for the four years 1911-1914. Of the 99 fatalities 14 occurred in elec- 
trical stations of public offices; the remainder in ordinary factory premises; 95 of the 
99 fatalities occurred when the alternating current was in use; 19 of the deaths occurred 
in systems of less than 250 volts. 
The average age of 63 out of 66 persons injured in electrical generating stations 
was just over 20 years, a circumstance which shows that important operations such 
as testing should not be handed over to apprentices or to pupils who have little 
experience of the danger which is incurred. 
831 832 
ELECTRICAL INJURIES AND ELECTRICAL SHOCK 
Etiology.-Many of the accidents are no doubt unavoidable, but many 
can be prevented. Some of the common causes of accidents are mistakes 
in switching, failure to disconnect and to earth test leads before handling 
them, also cheap installation. Insulated spanners should be provided by 
employers, also India-rubber gloves. The absence of insulated spanners 
was, during 1913 in Great Britain, the cause of 13 non-fatal accidents. 
The nature of the floor, too, in which electricity is generated is of impor- 
tance. In one instance an installation plant was found in a building with 
an iron floor. 
Death in electric shock may be instantaneous without there being, 
on the body, any external evidences as to the cause of death. Three 
theories at least have been advanced to explain the fatal event: (1) 
inhibition of the respiratory center whereby breathing ceases (D'Arsonval) 
or of the cardiac center whereby the heart stops beating (Bourrot); (2) 
sudden and complete cardiac failure (Tatum, Prevost-Batelli); (3) 
hemorrhages or acute disruption of nerve cells (Donlin, Icllinck). 
Dealing with those cases where death does not supervene until several minutes 
or a few hours after the accident, Prof. J. P. Langlois2 expresses the opinion, not neces- 
sarily his own, that the death is probably to be explained by bulbar and bulbo-spinal 
paralysis due to structural alterations of the nerve cells, or by air embolism consequent 
upon chemical changes in the tissues induced directly by the electrical current or 
indirectly through changes in the trophic action of nerves. 
Before concluding under what circumstances an electrical current is likely to 
prove dangerous to an individual brought into contact with it, there are a few things 
which have to be thought of. There is the current itself, its pressure and intensity, 
its nature, e.g., alternating or continuous, the duration of the contact, resistance of 
the conductor, the position of the electrodes on the body and the insulated position 
of the individual at the time he received the shock. 
By the term voltage we mean pressure or tension and by amperage, intensity. 
It is difficult to say what voltage is fatal to man. Under some circumstances 240 
volts may prove fatal, under other circumstances 1000 volts may do no harm. Much 
depends upon the conditions under which the current is received. Of the two kinds 
of electric current, "continuous" and "alternating," the "alternating" is the more 
dangerous. In Great Britain during 1902-1908 for three deaths caused by continuous 
currents 30 were due to alternating. Circumstances such as these, however, do not 
absolutely prove that alternating currents are the more dangerous. On the other 
hand, the British Board of Trade considers alternating currents to be twice as danger- 
ous as continuous, while Weiss6 regards alternating currents as four times more 
dangerous than continuous. The duration of the contact is of importance. Prevost 
and Batelli state that the continuous current requires less time than the alternating: 
one-tenth of a second is sufficient for the continuous but the alternating requires three- 
tenths of a second. When a man comes into contact with live metal, one, or more than 
one, of three things happens: (1) he is burnt, (2) rendered unconscious and is con- 
vulsed or (3) he is killed instantaneously. Persons apparently killed by electric shock 
may be restored to life by artificial respiration. An electrocuted person is an asphyx- 
iated person. 
The consequences of the passage of an electrical current through the body are 
proportional to the quantity of current passed and the conditions under which contact 
is made. A moist skin intensifies the action of a current. A dry skin, on the other 
hand, may prevent serious consequences. Trotter found when wearing a pair of ELECTRICAL INJURIES. ETIOLOGY, LESIONS AND SYMPTOMS 
833 
dry boots a continuous current of 500 volts produced hardly any effects. He took 
a walk through the wet streets of the town and found that with the same current, 
500 volts, the milliamperage had risen and that the resistance of the boots had fallen 
15 per cent. Given fairly good contact, a low voltage may be sufficient to throw the 
muscles of the body into such a state of tetanic rigidity that it is impossible for the 
individual to breathe and to relax his grasp of any charged metal he may have taken 
hold of. To release such a person the circuit must be broken. Since it is when 
currents enter and leave the body that effects take place, the "making" and "break- 
ing" of contact are the dangerous occasions. Severe pain may be the result of the 
entrance of an electrical current owing to the strong muscular spasm induced, the 
electrolytic action upon nerves or of the action of the products of electrolytic decom- 
position. Should the individual not be immediately thrown into a state of uncon- 
sciousness, a condition of terror is produced which may not only cause the victim 
to swoon, but the mental effect may be such as to cause him to be nervous and appre- 
hensive for months afterward. 
Lesions and Symptoms.-Burning is one of the visible consequences of contact 
with electric currents of high potentiality. The skin is charred; if open wounds have 
been caused they are irregular and deep; the bone is frequently exposed; the sores are 
angry looking and are disposed to slough. They are painful and are slow to heal, 
probably owing to destruction of terminal nerve fibers. Burns occur when the action 
of the current has been local. A current sufficient to cause severe burns might, if it 
traversed the body, cause death. There are cases where, after contact with high 
electrical currents, little or no effect is seen on the skin but internal damage has been 
inflicted upon the deep tissues. In a youth in whom this had taken place there were 
no external signs of injury, but as a consequence of deeply seated effects followed by 
gangrene the limb had to be amputated below the knee. Later, owing to sloughing 
of the deeply seated tissues of the thigh, the remaining portion of the leg had to be 
amputated. A definite opinion therefore as to the extent of the injuries cannot always 
be given on a primary and superficial examination. One man whom I saw in consul- 
tation had, while crossing an electrified railway, inadvertently touched a live rail with 
his wet boot. He was immediately thrown down. Fortunately the accident oc- 
curred close to a signal box and was witnessed by the man on duty. Leaving the box 
and putting on India rubber gloves, the signal man succeeded in removing the injured 
person from the rails. Patient was unconscious. Help was secured and an ambu- 
lance obtained. On the road home the injured man while still insensible had a series 
of convulsions. Upon a cursory examination no external injuries were observed. 
It was not until his home was reached and his boots, which were uninjured, removed 
that the toes and front of each foot were found to be severely burned. In an hour 
or two consciousness returned. For several days the feet were extremely painful. 
The wounds were deep and angry looking; the bones of the big toes and of the metatar- 
sus were exposed. Healing was slow. I also saw a youth aged 19, the subject of 
severe burns, who received a shock of 6000 volts, alternating current, without fatal 
consequences. His right hand was almost burned through. The hand was charred, 
irritable looking and disposed to slough. The outer three fingers were destroyed, 
In addition there were acutely inflamed and blistered patches on the lower part of the 
right forearm, also blisters on the soles of the feet. Patient's boots were uninjured. 
This youth was working on the three-phase system; he had touched one wire and then 
another without any consequences, but on touching the third wire he fell and became 
unconscious. He was standing on a concrete floor at the time. 
One of the worst cases I have seen was that of a young laborer admitted into the 
Royal Victoria Infirmary, Newcastle, under the care of my surgical colleague, 
Professor H. B. Angus. The man had accidentally made contact with a current of 
20,000 volts. I saw patient 2 hours after the accident. He was unconscious but kept 
rolling about in bed in an extremely restless manner. His pupils were widely dilated. 834 
ELECTRICAL INJURIES AND ELECTRICAL SHOCK 
There were several large burns on the trunk, front and back, also on the limbs. There 
was a large circular burn on the back of the head with exposure of the occipital bone. 
He died 7 hours after receiving the shock. At the autopsy, 40 hours after death, 
there were hemorrhages in the occipital lobe of the brain, numerous minute hemor- 
rhages on the visceral layer of the pericardium; liver, kidneys and portions of the 
lungs were deeply congested. 
It is astonishing to see the amount of disfigurement which can be caused by elec- 
trical currents and yet life be maintained. I have mentioned the case of a youth who 
had practically his right hand destroyed, also burns on the forearm and on the soles 
of the feet. Weiss tells of a man who had lost both of his forearms, also his two legs, 
and whose general health remained good. 
In most of the above cases the voltage was high. As an illustration of a compara- 
tively low pressure-110 volts-causing death, the following note, taken from the 
pen of Dr. Fleury3 of Versailles, may be quoted. It is the case of a healthy married 
woman aged 35 who died in 25 seconds after receiving the shock. She was in the 
act of having her usual daily bath. The bath, which was made of enamelled iron, 
was closed by a metallic plug placed in the middle of the floor of the bath. The plug 
was attached to a chain and to this a float. An electric bell communicator, composed 
of a chain of metallic rings ending in a porcelain handle, was fixed to the wall close 
to the bath. Madame C after having been attended to by her maid was left to com- 
plete her bath. Hardly had the maid left when hearing a cry she rushed back to the 
bathroom where she found her mistress with her head out of the water but fallen 
forward, the face cyanosed and both hands spasmodically grasping the chain of the 
electric bell. In attempting to remove the chain the maid herself received a severe 
electric shock. Madame C was dead. All efforts to restore her proved unavailing. 
The whole tragedy was enacted within 25 seconds. It is presumed that Madame C 
must have, when in the bath, formed an electric circuit between the left hip which 
was resting on the metal plug in the bath and the chain of the electric bell which she 
was grasping in her hand at the time of her death. The current when tested was found 
to be capable of lighting a lamp of 110 volts. On examining the body after death 
two small hemorrhages were observed on the upper and posterior part of both arms 
near the axillae, and on the left hip there were a few blisters filled with blood. At the 
post-mortem examination nothing special was found in the heart, pericardium, abdo- 
men and brain, while beyond a few limited areas of congestion and a few old pleuritic 
adhesions the lungs presented nothing abnormal. The apperances generally speak- 
ing, but especially those presented by the heart, were those of asphyxia. The left 
ventricle was empty, the right ventricle was filled with dark non-coagulated blood. 
The-low voltage, 110, was at first thought to be an unlikely cause of death, and yet 
everything pointed to death from electric shock. 
Pathogenesis.-As already stated, pressure or tension, that is the 
number of volts, is one of the factors usually considered in electrical 
injuries, but the intensity or amperage is even of more importance. 
Prevost and Batelli of Geneva are of the opinion that voltage below 100 is 
only slightly dangerous, and yet death has followed contact with a current 
of 75 volts. The intensity of an electrical current as represented by and 
for the purpose of illustration is regulated much in the same way as the 
flow of water when a tap is turned on. From a medical point of view what 
is important is the intensity of the current as it traverses the body at the 
time of the accident. A current of 25 milliamperes is bearable; one 
between 25 and 60 is capable of doing considerable harm; beyond this the ELECTRICAL INJURIES: PATHOGENESIS, CAUSE OF DEATH 
835 
danger increases proportionally, death almost always supervening if the 
intensity reaches 100 milliamperes. 
A Commission appointed by the Minister of Public Works in France carried out a 
series of experiments upon chloralized dogs, graphic records being taken of the breath- 
ing and the blood pressure. A distinction was made between tension (voltage) and 
intensity (amperage) the former being estimated by a thermic volt meter while a 
thermic or electro-dynamic amperemeter allowed of the intensity being estimated. 
The French Commission emphasizes the importance of the intensity compared with 
the tension. 
The resistance offered by the body to the passage of the current has also to be 
considered. A relationship is thus established between the three factors: tension 
(E), intensity (J), and resistance (R). This, known as Ohm's law, is expressed thus: 
I=E 
R 
by which is meant that the intensity in amperes is proportional to the tension in volts 
and is inversely proportional to the resistance in ohms. In other words, the feebler 
the resistance offered by the subject the greater will be the intensity in amperage and 
the more likely will the subject be affected by the electrical current. Such other fac- 
tors as already mentioned, viz., the extent of the surface of the body exposed to the 
current and the dryness or humidity of the skin, cannot be ignored. A similar 
remark applies to the period of time during which the current passes. Resistance 
becomes diminished as the current traverses a body and as a consequence the inten- 
sity in amperage rises. In illustration of this, Fleury in his experiments found that 
while a dog could resist a current of 4000 volts during 2 seconds, it succumbed to 
contact with 110 volts applied for 19 seconds. 
The direction of the current, too, is of importance. Should the heart 
lie in the path of the current, danger to life is enormously increased; hence 
the risk of a current when it is passed through hands to feet and vice 
versa. 
The following cases recorded by Fleury are two of the fatalities which have been 
caused by what might be considered low voltages. A youth received a shock of 125 
volts; he fell to the ground and in rolling over caused the electric wire to encircle a 
metal bucket which was being carried by a woman standing close by. The woman was 
killed instantaneously. A female cook in Geneva attempted, while one of her wet 
hands held an electric lamp, to draw water from a lead pipe with the other. She had 
hardly touched the tap when she received a shock from a current of 110 volts and 
succumbed almost immediately. Since death has been caused by voltages of 110 to 
170 in the case of persons completing circuit through touching electric lamps in dwell- 
ing houses, people ought to be forewarned of the dangers. • 
Cause of Death in Electric Shock.-In order to ascertain the cause of 
death in electric shock I carried out, a few years ago, a series of experiments 
with my colleague, Prof. R. A. Bolam, upon anaesthetized dogs and rabbits, 
the continuous current being employed. Two of the main theories 
of the cause of death are: (1) arrest of respiration; (2) stoppage of the 
heart. In order to ascertain which of these two is the cause of death, 
we had arranged before bringing the animals into contact with the 
electrical current that a record of the blood pressure and respiratory 
movements should be taken simultaneously. In this way we sought to 836 
ELECTRICAL INJURIES AND ELECTRICAL SHOCK 
demonstrate how the heart and respiration became affected when high 
electrical currents are passed through the body. 
On making electrical contact the animal would at once be thrown into an attitude 
of opisthotonos, the muscles generally throughout the body becoming rigid. The 
lever of the apparatus recording the respiratory movements would be suddenly and 
violently raised, while the other, indicating the blood pressure and beat of the heart, 
would also be suddenly lifted owing to general arterial constriction. Momentarily 
maintained in these positions the levers would gradually fall so that their oscillations 
covered a shorter range. On breaking contact, the respiration would become deeper 
and quicker than it was before the shock. Thereafter, within a few seconds, breath- 
ing and the heart's beat would become normal. In dogs which succumbed rapidly to 
electrical shock there was the same initial respiratory spasm with a sudden rise of 
arterial pressure followed by an immediate fall. A few further oscillations of the 
lever marking the arterial pressure would be observed, and then a sudden fall of the 
the lever would occur indicating that the heart had ceased beating. In some of 
the electrocuted animals respiration continued for several seconds after the heart had 
stopped. In other experiments with 240 volts, continuous current, death in electrical 
shock was of cardiac Origin and not respiratory. Where an electrical current was not 
sufficient to kill a dog immediately, the heart's beat would be momentarily delayed, 
then quickened, during which the cardiac sounds could be heard quite well, but when 
currents of higher potential were employed the sounds of the heart on contact being 
made would cease almost immediately while the respiration continued. If artificial 
respiration was not adopted the breathing gradually ceased and the beat of the heart 
did not return, the pupils dilated, mucus flowed from the mouth and increasing pallor 
stole over the body. 
On exposing the heart of anaesthetized dogs and inserting a canula into the trachea 
in order to carry on artificial respiration, we had ocular demonstration that it was the 
heart which was primarily arrested as a consequence of the passage through the body 
of continuous electrical currents of 240 volts. 
Professor A. M. Bleile of Ohio State University, as the result of experiments, 
concluded that death in electrical shock is due to the current producing, through the 
nervous system, constriction of the arteries whereby there is created a mechanical 
impediment to the flow of blood which the heart is unable to overcome. Bleile 
found that when drugs were given beforehand to counteract the contraction of the 
arteries higher voltages could be borne. Bolam and I came to a similar conclusion. 
When we caused anaesthetized animals to inhale amyl nitrite before making the elec- 
trical contact we noticed that stronger currents could be borne. In our experi- 
ments we found that the heart was the organ primarily affected even when atropine 
had been previously administered to abolish the influence of the vagus. Whether 
the heart muscle is paralyzed by the electrical current, destroyed by the molecular 
changes produced by the current, or brought to a standstill by the enormous resistance 
of the constricted arteries above referred to I am not in a position to say. Not only 
is there no definite relation between the size and weight of an animal and the strength 
of the current, but a current which is passed for a few seconds one day without bad 
effect may, on another, kill the animal in 2 or 3 seconds. 
Fleury found in dogs, when the milliamperage rose to 70-80, that within 5 seconds 
the heart showed fibrillary tremor. When the current was cut off there was marked 
fibrillation of the ventricles of the heart and respiration which had ceased, recom- 
menced and shortly afterward gradually died away. To explain death in electric 
shock Dr. G. Weiss advances the following theory: Under the influence of alternating 
currents the muscles of the body are thrown into a state of tetanus, organic combustion 
is enormously increased and there is an imperative necessity on the part of the animal 
to absorb oxygen and to exhale carbon dioxide. These the animal cannot accomplish ELECTRIC SHOCK: CAUSE OF DEATH, PATHOLOGY 
837 
for respiration is embarrassed owing to tetanic rigidity of the body of the thorax and 
as a consequence asphyxia develops slowly. Fleury, basing his opinion upon the fatal 
case alluded to in the text, regards the mechanism of death in electric shock as com- 
plex; there are asphyxia and paralysis of the heart. When these occur death is rapid. 
When death is not instantaneous he is of the opinion that death is brought about by 
fibrillary tremor of the heart. 
J. L. Prevost and F. Battelli of Geneva found, with alternating currents of low 
tension, that the heart was thrown into a condition of fibrillary tremor. With a 
tension of 20-40 volts the heart became paralyzed but respiration continued. When 
high alternating currents of 240-600 volts were employed the heart and respiration 
ceased simultaneously. Prevost and Battelli found in using continuous currents that 
the results were practically the same as with alternating, there being, however, this 
important difference, that when continuous currents were employed voltages less than 
50 did not produce fibrillary arrest of the heart's action, but alternating currents of 
only 10 volts induced fibrillary tremor followed by stoppage of the beat of the heart. 
There is a general consensus of opinion that electrical currents below 
150 volts, if they prove fatal, cause death by stopping the beat of the heart 
which had been previously thrown into a condition of fibrillary tremor. 
High tension currents, e.g., 1200 volts, leave the heart intact, but they 
arrest breathing and induce asphyxia which if not treated may end in 
death. With voltages between these two, sometimes the heart ceases 
beating, sometimes respiration is arrested or the two events occur simul- 
taneously. Experience shows that such low voltages as 75-100 are not 
free from danger. (See Addendum, p. 843.) 
Hitherto it has been believed that danger is incurred only when both 
electrodes are touched. M. Guery7 holds that this opinion is incorrect 
(in cases where, although the wires may be carefully protected, the 
body is not perfectly isolated from the soil), for while in the case of^a 
wire perfectly isolated and carrying a continuous current, no danger may 
be incurred by touching one conduct since the body will not actually be 
subjected to any difference of potential, it is not quite the same with 
wires carrying alternating currents. There is danger in touching a wire 
if it is carrying an alternating current of high tension. 
Pathology.-If the body is examined shortly after death there is usually 
rigidity of the muscles. There may or may not be external signs of burn- 
ing. The body may be pale or livid. On the other hand there may be no 
external signs to indicate that the person died from electric shock. Simi- 
larly at the autopsy there may be no absolute signs to explain the cause 
of death. On opening the body cavities it is usual to find the abdominal 
veins filled with dark liquid blood and the viscera congested. The right 
ventricle of the heart is flaccid and the left ventricle hard and tense. 
In the right side of the heart the blood is dark and liquid; the left ventricle 
is practically empty but the left auricle usually contains dark liquid blood. 
The absence of coagulation of the blood is noteworthy. This is of great 
significance, but it is not absolutely diagnostic as in some of my experi- 
ments I found coagula in the right side of the heart. Beyond a few 
ecchymoses and signs of congestion the lungs may show no special feature. 838 
ELECTRICAL INJURIES AND ELECTRICAL SHOCK 
Generally speaking, the signs are those of asphyxia. The brain and spinal 
cord may be congested or they may show no abnormality. The blood on 
spectroscopic examination was found to contain in some of my cases both 
oxyhemoglobin and reduced hemoglobin. Usually the pupils are dilated. 
On examining the brain of one of the patients killed by currents of high 
potentiality there were observed minute hemorrhages due to rupture of 
small vessels in the cortex and white matter. The blood showed evidences 
of hemolysis. Sir. F. W. Mott and Dr. Schuster, who were kind enough 
to examine sections of the brain microscopically for me, found chromolytic 
changes in the brain cells. Similar changes were noticed in the cells of 
the medulla oblongata. 
As bearing upon the lesions found in the brain, mention must be made of the 
important contribution to this subject by Drs. E. A. Spitzka4 and H. E. Raschi of 
Jefferson Medical College, Philadelphia. Their findings are of importance since the 
lesions described obtained in the brain and spinal cord of five criminals who had been 
electrocuted-the voltages varying from 1750 to 1850, amperage 8 to 11 and the con- 
tacts two to four. The brain in each instance was removed 15 minutes after death so 
that there was no time for post-mortem decomposition to have set in. The parts of 
the brain examined were the mid-brain, the pons and medulla oblongata. At the 
levels mentioned Spitzka and Raschi found peculiar areas, circular in outline and vary- 
ing in size from 25 to 300 /z. They consisted of two portions-a central rarified zone 
and a peripheral condensed zone. The areas contained a blood-vessel surrounded 
by a delicate reticulum, the fibrils of which were radially directed. Nuclei were 
observed along their course. The peripheral zone immediately in contact with the 
central stained more readily and deeply than the external. In the peripheral zone 
there was an absence of nuclei. In the upper part of the spinal cord close to the 
pyramidal decussation the myelin did not stain well with hematoxylin and eosin, 
Van Gieson's or Weigert's staining fluid. Along the course of the blood-vessels were 
bead-like expansions like clear beads adherent to the wall of the vessel. The writers 
are of the opinion that the bead-like expansions, the condensation zone limiting these, 
the radially disposed fibers and the torn tissues indicate a sudden liberation of gas 
bubbles due to the electrolytic properties of the current seeking paths of least resis- 
tance along the course of the blood-vessels. 
Treatment.--Where the electrical shock has been slight and the individ- 
ual has not been rendered unconscious no treatment is called for. The 
effects pass away almost immediately. Some persons thus injured remain 
nervous for several days or weeks afterward. Burns or wounds caused 
by electricity must be treated on ordinary surgical lines. 
Where the heart has ceased beating and respiration has been arrested 
the treatment which is most likely to give satisfactory results is artificial 
respiration. It matters little so far as this line of treatment is concerned 
whether death is primarily of cardiac or respiratory origin. Artificial 
respiration must be carried on for a considerable time. Too great stress 
cannot be laid upon the necessity of the workmen immediately putting it 
into practice immediately they have rescued their comrade from electrical 
contact. Medical men, too, ought to know more about the matter so as 
to give the procedure an adequate trial, since lives have been lost for want ELECTRIC SHOCK: TREATMENT 
839 
of adopting and continuing for an hour or more artificial respiration. 
Death in electrical shock is only apparent at first. 
In the case of a man who had accidentally been electrocuted and who 
was seen shortly afterward by a medical man, artificial respiration was 
under his supervision carried on for at least half an hour without any 
response. Believing that apparent death had been actual the medical man 
pronounced life to be extinct, and left the place. The workingmen in the 
factory, of their own accord, carried on artificial respiration for a con- 
siderable time after the doctor left and were rewarded about an hour after 
the accident by seeing their comrade restored to life. 
Twice Bolam and I succeeded in resuscitating a dog whose heart had ceased beating 
once for 13 minutes and on the second occasion for 8. The heart was exposed to view 
so that we could follow the events which took place. The heart had become rapidly 
distended with blood so as to bulge out the pericardium and had become perfectly 
motionless after having passed through a stage of fibrillary tremor. By persisting in 
artificial respiration, aided subsequently by occasional spontaneous inspirations, also 
through rhythmic traction of the tongue, the contents of the right side of the heart 
were gradually aspirated into and through the lungs and the auricular beats were 
reestablished, at first irregularly and feebly. By degrees the auricular pulsations 
became stronger and passed over into the ventricles so that after 13 minutes, during 
which the left ventricle had remained irresponsive, Bolam and I had the satisfaction 
of seeing the normal beat of the heart restored, the pulmonary and general circulation 
reestablished and life return. Leduc points out that when an animal has been appar- 
ently killed by electricity and the heart has ceased beating, the animal can usually be 
restored to life by applying the same amount of current to the body, for since this 
produces immediate contraction of the muscles of the body, including those of inspira- 
tion, artificial respiration is to some extent aided and can be proceeded with. There 
is a belief on the part of some physiologists, where death is of cardiac origin and has 
been preceded by fibrillary contraction, that neither artificial respiration nor massage 
of the heart is of the slightest value in restoring the victim. Artificial respiration upon 
one of our animals in whom fibrillary tremor had occurred was, as already indicated, 
successful, but setting that aside for the moment and still insisting that artificial 
respiration is a mode of treatment well worthy of adoption, the following may be not 
less successful. It has been demonstrated that where a dog has been killed by 
electric currents of high potentiality and the heart still shows signs of fibrillary tremor, 
the application directly to the heart of an electrode carrying a still larger current 
than the one which apparently proved fatal will cause cessation of the fibrillary move- 
ments and on withdrawal of the current the heart will resume its rhythmic beats 
again. In some cases the sufferer is killed outright so that all attempts at resuscita- 
tion fail. * 
* There is a belief common among some electrical workers that the effect of a 
fall of the victim, as from a pole, may revive him. Through the kindness of the 
Chicago Edison Company, who set up an elaborate electrical equipment for testing 
this point as well as other features of resuscitation, Dr. Frank Chauvet, who is also 
an electrical engineer, with E. R. Hayhurst assisting, tried many experiments with 
dogs at the University Hospital, Chicago, in 1912. The results were entirely 
negative when known fatal currents were used except when failure to breathe was 
due to respiratory suspension only. In many of these, recovery of respiration was 
established and, thereby, life. In cases of cardiac suspension no reviving effects 
were brought about by gross manipulations of any kind, nor by injections directly 
into the heart of various stimulants. 840 
ELECTRICAL INJURIES AND ELECTRICAL SHOCK 
Under all circumstances, however, where persons are the subjects of 
apparent death from electrical shock artificial respiration should be 
resorted to and continued for at least 2 or 3 hours. Workmen in their 
efforts to rescue a comrade should be provided with India-rubber gloves 
and insulated spanners, or where these are unattainable should wrap thick, 
coarse, dry clothing round their hands, for otherwise in their attempts to 
rescue a stricken fellow-workman they themselves may receive a fatal 
shock. To cut a live wire, long shears with wooden handles should.be 
used. 
In all generating stations and in factories wherein electricity is used on 
a large scale, danger signals should be employed to avert the disasters 
alluded to in the text, while all workmen likely to be brought into contact 
either with live metal itself or with fellow-workmen injured by electrical 
contact should be instructed in rescue work and in the precautions nec- 
essary for self-protection. 
ELECTRICA OPHTHALMIA 
Electricity is used in the welding of metals. In this operation the 
brightness of the glare causes injury to the eyesight. Dr. George 
L. Apfelbach5 draws attention to a morbid eye condition, electrica 
ophthalmia, caused by electric light rays. In these rays the ultra-violet 
predominate. The signs and symptoms of the malady are conjunctivitis, 
photophobia and profuse secretion of tears with occasionally loss of 
vision. Such electrical flashes as cause eye troubles are usually due to 
short circuiting, loose electrical connections and strong arcs. 
Dr. Apfelbach cites 50 cases of electrica ophthalmia occurring in a large iron 
works. It is the actinic rays present in electrical flashes which do harm. Electricians 
exposed to accidental short circuiting often suffer from temporary blindness of 1 or 2 
hours' duration. In some people the eyes become bloodshot and the eyelids swollen. 
Photophobia is a common symptom. Patients feel as if the eyes contained sand. 
Keratitis and iritis are not unknown. A similar remark applies to pigment changes 
in the retinae. As a rule the prognosis is good. A more detailed statement of the 
harmful effects of exposure to electric light and to electric welding is given in my 
book "Dangerous Trades" by the late Mr. Simeon Shell of Sheffield. The applica- 
tion of a few drops of a 4 per cent, solution of cocaine to the eyes gives relief to pain. 
Irrigation of the eyes with weak boracic lotion may be necessary, followed later by the 
instillation into the eyes of a few drops of argyrol-25 per cent, solution. If photo- 
phobia continues, smoked glasses ought to be worn. Dr. Apfelbach states that in 
some of the large steel works electrica ophthalmia is prevented by the men wearing 
glasses made up of two blue glasses with a red one between. By this means the strong 
actinic or ultra-violet rays are prevented from filtering through. 
CATARACT DUE TO ELECTRICAL DISCHARGES 
Cataract is known to have followed upon electrical discharges. A workman 
through whose body there has passed an electrical current of high intensity falls and 
becomes unconscious. The unconsciousness may continue from half an hour to three 
hours. For a period after the injury nothing abnormal is noticed in the crystalline ELECTRICAL INJURIES REFERENCES-RESUSCITATION 
841 
lens, but after an interval averaging two months there develops cataract, partial or 
complete. In 5 cases the cataract was confined to one eye. Herein lies the differ- 
ence between it and the cataract caused by the glare of a furnace. This is usually 
double (11 out of 19 cases). It would seem as if in the former the electrical current 
exercised both a mechanical and electrolytic action upon the lens. The possibility 
of cataract coming on during occupation and not showing itself until a few months 
after the accident should be borne in mind.9 
REFERENCES 
1 Annual Report of the Chief Inspector of Factories. Great Britain, 1913. 
2 Revue Generale die Sciences, Apr. 30, 1913, page 294. 
Annales d'Hygiene Publique, Apr., 1914. 
4 The American Journal of Medical Sciences, Sept., 1912, page 341. 
6 Factory Inspector's Bulletin, State of Illinois, Apr. 14, 1914. 
£ Sur les Effets Physiologiques des Courants Electriques. Soci€t£ Internationale des 
Electriciens. Paris, page 13. 
7 See Ref. 6, page 83. 
8 Annual Report of Chief Inspector of Factories and Workshops, Great Britain, 1918. 
9 Archives d'ophthalmologie, 15 Aodt, 1909. 
RESUSCITATION FROM ELECTRIC SHOCK 
RULES RECOMMENDED BY 
Commission on Resuscitation from Electric Shock 
Representing 
The American Medical Association 
The National Electric Light Association 
The American Institute of Electrical Engineers 
DR. W. B. CANNON, Chairman, 
Professor of Physiology, Harvard Uni- 
versity. 
DR. YANDELL HENDERSON 
Professor of Physiology, Yale University. 
DR. S. J. MELTZER 
Head of Department of Physiology and 
Pharmacology, Rockefeller Institute for 
Medical Research. 
DR. EDW. ANTHONY SPITZKA 
Formerly Director and Professor of Gen- 
eral Anatomy, Daniel Baugh Institute of 
Anatomy, Jefferson Medical College. 
DR. GEORGE W. CRILE 
Prof, of Surgery, Western Reserve 
University. 
MR. W. C. C. EGLIN 
Past-President, National Electric Light 
Ass'n. 
DR. A. E. KENNELLY 
Professor of Electrical Engineering, 
Harvard University. 
DR. ELIHU THOMSON 
Electrician, General Electric Company. 
MR. W. D. WEAVER, Secretary Editor, 
Electrical World. 
Copyright, 1912, by 
National Electric Light Association 
FOLLOW THESE INSTRUCTIONS EVEN IF VICTIM APPEARS DEAD 
With a single quick motion free the victim from the current. Use any dry non- 
conductor (clothing, rope, board) to move either the victim or the wire. Beware of 
I. Immediately Break the Circuit 842 
ELECTRICAL INJURIES AND ELECTRICAL SHOCK 
using metal or any moist material. While freeing the victim from the live conductor 
have every effort also made to shut off the current quickly. 
1. As soon as the victim is clear of the conductor, rapidly feel with your finger in his 
mouth and throat and remove any foreign body (tobacco, false teeth, etc.). Then 
II. Instantly Attend to the Victim's Breathing (Schaefer Method) 
Fig. 36.-Expiration; pressure on. 
Fig. 37.-Inspiration; pressure off. 
begin artificial respiration at once. Do not stop to loosen the victim's clothing now; 
every moment of delay is serious. Proceed as follows: 
(a) Lay the subject on his belly, with arms extended as straight forward as possible, 
and with face to one side, so that nose and mouth are free for breathing (see Fig. 36). 
Let an assistant draw forward the subject's tongue. 
2L. (b) Kneel straddling the subject's thighs and facing his head; rest the palms of 
your hands on the loins (on the muscles of the small of the back), with fingers spread 
over the lowest ribs, as in Fig. 37. RESUSCITATION 
843 
(c) With arms held straight, swing forward slowly so that the weight of your body 
is gradually, but not violently, brought to bear upon the subject (see Fig. 36). This act 
should take from 2 to 3 seconds. 
(d) Then immediately swing backward so as to remove the pressure, thus return- 
ing to the position shown in Fig. 37. 
(e) Repeat deliberately 12 to 15 times a minute the swinging forward and back-a 
complete respiration in 4 or 5 seconds. 
(/) As soon as this artificial respiration has been started, and while it is being con- 
tinued, an assistant should loosen any tight clothing about the subject's neck, chest, 
or waist. 
2. Continue the artificial respiration (if necessary, 2 hours or longer), without 
interruption, until natural breathing is restored, or until a physician arrives. If 
natural breathing stops after being restored, use artificial respiration again. 
3. Do not give any liquid by mouth until the subject is fully conscious. 
4. Give the subject fresh air, but keep him warm. 
III. Send for Nearest Doctor as Soon as Accident is Discovered 
The following Doctors are recommended: 
Name Address Telephone Call 
The prone-pressure method of artifical respiration described in the rules (Section II) is equally 
applicable, after clearing the mouth and throat of froth, to the resuscitation of the apparently drowned 
and also to cases of suspended respiration due to inhalation of gas or to other causes. 
ADDENDUM 
Gildemeister and Diegler, in their experiments upon dogs, rabbits and guinea 
pigs electrocuted by an alternating current of 50 phases per second found that 
heart failure was cause of death. (Gildemeister, M., and Diegler, R., Primary 
Heart Failure as an Effect of Strong Electric Currents. Klin. Wchnschr. 1: 1310, 
June 24, '22.) PART IV 
SYSTEMIC OCCUPATIONAL DISEASES 
CHAPTER I 
OCCUPATIONAL AFFECTIONS OF THE NOSE, MOUTH 
AND THROAT 
T. M. LEGGE, M. D., Home Office, London, England 
I. THE EFFECT OF DUST AND FUMES ON THE UPPER AIR PASSAGES 
Corrosives.-The bichromates are one example of corrosive chemical 
action causing acute inflammation of the upper air passages and progressing 
to a definite pathological lesion in perforation of the septum of the nose. 
Almost precisely similar corrosive action is exhibited after inhalation of 
the intensely irritating dust of white arsenic, or of compounds into which 
arsenic largely enters, such as arsenite of copper (Scheele's green), aceto- 
arsenite of copper (emerald or Paris green), and a mixture of white arsenic, 
caustic potash and flowers of sulphur largely used as a sheep dip. As to 
the action of these the reader is referred to the chapter on 11 Arsenic 
Poisoning." 
Hygroscopic Dusts.-Dusts of a hygroscopic nature also are known 
to cause inflammation of the nasal mucous membrane accompanied not 
infrequently by perforation of the septum. Examples of this are sodium 
chloride (common salt) and the chlorides of calcium and magnesium. 
Among 165 persons employed in salt grinding and packing, Muller found 
45 suffering from catarrh of the mucous membrane and 42 with perfora- 
tion of the septum. Cement dust similarly seems to exert nearly all its 
effect on the upper air passages (causing occasionally perforation of the 
septum), leaving the lung tissue practically unaffected. 
Ordinary Dusts.-Any general consideration of the action of dust on 
the upper air passages, however, must take account not only of the chem- 
ical composition but also of quantity, quality (whether organic or inorgan- 
ic and, if the latter, whether metallic or non-metallic), and size and shape 
of the particles. The effect of gases and fumes which we are considering 
in this relation depends similarly on their chemical nature and on the 
concentration in which they are present in the atmosphere breathed. 
Dealing first with dust it is safe to say that no dust, if inhaled in inordi- 
nate amount, can be without effect on the mucous membrane of the upper 
air passages. And by inhalation in inordinate amount is meant dust 
844 DUSTS AND FUMES ON THE UPPER AIR PASSAGES 
845 
which can be seen constantly rising to the face of the operative in any 
manufacturing process. The effect of such inhalation is to produce a 
hyperaemia of the blood-vessels and frequently an eczematous condition 
round the alse nasi, and to keep up a constant irritation of the mucous 
membrane lining the nasal passages, which leads first to hypertrophy with 
discharge of mucus (the signs of chronic nasal catarrh) and passes on 
eventually, in the course of years, to atrophy showing itself in pallor of 
the mucous membrane and loss of vibrissae. The subject becomes a 
mouth breather. These evidences I have invariably noticed in workers 
wherever the air has been charged with fluff or dust, as in such occupa- 
tions as fur pulling, cotton-waste sorting, flannelette raising, and all 
kinds of polishing operations on a wheel. The harder and more gritty 
the particles of dust produced are, as in metal grinding, sandstone 
cutting and the like, the more rapidly and surely will the condition 
described be produced. My colleague, Dr. Collis, after examining 
thousands of grinders and granite cutters and others exposed to inhala- 
tion of dust in Sheffield, Aberdeen and elsewhere, found, as a rule, that the 
lining membrane of the interior of the nose for a distance of % in. was 
smooth, dry and pale colored; the mucous membrane behind this was red 
and inflamed and generally covered with dust, while the back of the phar- 
ynx and the pillars of the fauces were tolerant of the touch of the spatula 
used to depress the tongue, having lost their sensitiveness. 
The action of ordinary dust, therefore, on the upper air passages is a 
mechanical one. Repeated irritation and pressure caused by deposit of 
dust on the septum may lead to ulceration passing on to a small perfora- 
tion. Such perforation-very different from that set up by arsenic and 
bichromates-I have observed in metal grinding and cotton-waste 
sorting. Associated with this mechanical irritation arises not infrequently 
by extension along the Eustachian tubes, inflammation of the middle 
ear resulting in partial deafness. The inflammatory process in the nose is 
continued down into the pharynx, eventually leading to atrophy of the 
mucous membrane as a result of the chronic pharyngitis set up. 
The distinction between the effect of dust upon the upper air passages 
and upon the lungs is a narrow one. It would be out of place, however, to 
deal here with asthmatic, bronchitic and fibroid affections of the lungs, 
except to say that the researches of Dr. Collis bring out the fact that 
dusts of vegetable tissue, especially such fine dust as is given off in clean- 
ing cotton-carding machines ("card stripping") and in the early processes 
of heckling and carding flax, hemp and jute, give rise to chest affections 
which may be described as asthmatic, while inhalation of mineral dusts 
containing free silica gives rise to fibroid phthisis in proportion as the 
free silica in the dust increases in amount. Animal dusts appear to have 
less injurious action than either vegetable or mineral dusts. 
Metallic Dusts.-As to the mucous membrane of the mouth, mention 
only need be made of the blue line on the gums caused by absorption 846 
AFFECTIONS OF THE NOSE, MOUTH AND THROAT 
of lead sulphide, and of the intense inflammations set up by inhalation of 
mercury vapor or dust and of fumes of white phosphorus, as they are all 
dealt with at length in special chapters. Inhalation of lime dust in the 
unloading of such cargoes as calcined spathic ores, in addition to severe 
inflammation of the nose, gives rise to development of small ulcers in the 
mucous membrane lining the buccal cavity. 
Gases.-Mention also need only be made of the extremely irritating 
effect on the mucous membrane of the respiratory tract of gases such as 
chlorine, sulphur dioxide and ammonia, and of vapors such as are given off 
from hydrochloric, sulphuric and nitric acid. Chlorine gas in the air 
breathed to an extent of only 0.001 per cent, is highly injurious to man, 
causing cough, dyspnoea, bronchial catarrh and, if excessive quantities are 
breathed, great respiratory distress and rapid death. Hydrochloric acid 
fumes, on the other hand, in the proportion mentioned are much less 
irritant. When the proportion reaches 0.005, toleration becomes 
difficult. Nitrous fumes are a grave source of poisoning-if such a 
term can be correctly applied to a gas setting up, when inhaled in con- 
centrated form, inflammation of the lungs with all its accompanying 
symptoms of respiratory distress. Onset of the acute symptoms is 
often delayed for from 12 to 24 hours after inhalation of the fumes, the 
workman meanwhile being able to continue at his work. The explana- 
tion of this is that time is needed for the inflammation to bring about the 
exudation into the smaller bronchial tubes and air vesicles which may 
eventually completely fill them. 
Hydrofluoric acid causes, even in weak solutions (0.02 per cent.), 
irritant symptoms of catarrh of the mucous membrane of the respiratory 
tract, lachrymation, etc. Strong solutions set up obstinate ulcers, 
difficult to heal, in the mucous membrane and skin. 
Preventive Measures.-In considering preventive measures against 
inhalation of dust, precedence must be given to its removal by locally 
applied exhaust ventilation as, unfortunately, the wearing of a respirator 
is neither in itself a sufficient protection nor, if it were, could the constant 
wearing of one be enforced. The conditions which a respirator should 
fulfil to be effective are, first, that the air breathed is freed from dust and, 
secondly, that it should not give discomfort to the worker. Further, it 
should be simple in construction, easily applied, and allow of frequent 
cleansing or renewal of the filtering material. As a matter of fact the 
more closely to the face a respirator is made to fit, and the more 
effectually it filters the air breathed, the greater is the inconvenience 
experienced when it is worn. This is shown in increase of the respiratory 
movements and pulse rate brought about by the exertion involved in 
aspirating the air through the filtering medium, and unavoidable rebreath- 
ing of some of the expired breath. Respirators, therefore, except for 
work lasting a short time-half an hour to an hour-cannot be con- 
sidered a sufficient means of protecting the worker against dust. UPPER AIR PASSAGES: GASES, CHROME COMPOUNDS 
847 
II. CHROME COMPOUNDS AND THEIR EFFECTS 
Chromic acid and the bichromates of potassium and sodium are used 
in a number of important industries and may cause peculiar lesions, 
namely; erosion of the septum of the nose from inhalation of the dust, and 
eczematous eruptions or ulceration of the skin when abrasions allow either 
the crystals or solutions containing them to penetrate below the epidermal 
layers of the skin. 
Manufacture.-Potassium bichromate is made on the large scale by roasting a 
mixture of chrome ironstone, potash and lime, lixiviating the fused mass with water, 
and adding enough sulphuric acid to convert the neutral chromate into bichromate. 
The crystals form beautiful adherent masses on the sides and floor of the crystallizing 
vats. They are broken up by a pick, removed on barrows to be washed, dried in open 
stoves by hot air or steam pipes, and finally packed in barrels. Sodium bichromate is 
made in practically the same way, sodium carbonate taking naturally the place of 
potassium carbonate. In the packing of the sodium compound there is little or no 
dust owing to the hygroscopic nature of the salt, whereas with the potassium com- 
pound elaborate exhaust ventilation is necessary to prevent its dissemination into the 
air. 
Uses.-The bichromates are much more used in the arts than the chromates since 
they are the richer in chromic acid. Their principal uses are: 
1. In the manufacture of the well-known chrome yellows, oranges and reds, by 
interaction of a solution of lead acetate and a bichromate; the chrome yellows by 
mixture with Prussian blue yield the greens called "Brunswick" greens. In their 
manufacture in addition to the risk from chrome there is the still greater one of lead 
poisoning. 
2. In dyeing and calico printing. In dyeing cotton yarn an orange color the 
hanks are first soaked in limewater and transferred, after wringing, to a vessel con- 
taining lead acetate. They then pass through a dilute solution of a bichromate which 
develops the yellow color on the fiber. Treatment differs according to the particular 
shade of yellow color desired. Danger of lead poisoning has to be carefully guarded 
against from the dust given off in the "heading" or shaking of the dried hanks over a 
post, which can be secured only by exhaust ventilation carefully applied to the 
heading post. 
In calico printing potassium bichromate is used in the discharge style for indigo 
blue and Turkey red, when it may be printed from a paste containing 40 per cent, of 
bichromate which will discharge the color from the blue or red material after suitable 
treatment. Or it may be used for the production of chrome lead colors by first print- 
ing the desired pattern on the calico with a paste containing acetate of lead, and 
subsequently passing this through a 2 to 5 per cent, solution of bichromate. 
In anilin black dyeing, similarly, after treatment with anilin hydrochloride, the 
calico cloth is passed through a bath containing dilute solution of bichromate. 
3. In photography and litho-etching. The carbon process depends on the fact 
that gelatine and potassium bichromate combine under the influence of light to form 
an insoluble compound. Thus the gelatine under the transparent portions of a 
negative when exposed to light becomes insoluble, retaining the pigment, while the 
darker parts are unacted upon and may be dissolved in warm water. 
4. As an oxidizing agent for the manufacture of coal-tar colors, especially of anthra- 
cene to alizarin, and, in solution with sulphuric acid, as a bleaching agent for oil, 
tallow, etc. 
5. In tanning leather by the "two-bath" process. This process which in the last 
15 years has come into wide use requires special mention as it is a frequent cause of 848 
AFFECTIONS OF THE NOSE, MOUTH AND THROAT 
chrome ulceration. In the "one-bath" process basic chrome salts are used-chrome 
alum, etc.-which do not affect the skin. The "two-bath" process involves treatment 
of hides or skins in two distinct solutions generally known as "chromic acid bath" and 
"hypo " bath. The skins are first treated with a solution of chromic acid made by the 
action of hydrochloric acid on potassium bichromate (sometimes 4 per cent, bichro- 
mate and 4 per cent, acid on the weight of the pelt is used) and afterward with a 
solution of slightly acidified sodium thiosulphate to reduce the chromic acid to a 
basic chromic salt which produces the tannage. Risk of chrome ulceration is greatest 
in the operation of removing the skins from the first bath, spreading them out on a 
wooden horse to drain, and subsequently striking out the excess liquor-usually by 
machines carrying the skin upward between rolls, but sometimes by hand on sloping 
tables. H. G. Bennett in his book on "The Manufacture of Leather" says: "Equally 
good leather is produced by the "two-bath" and "one-bath" processes, but the latter 
is the cheaper process and is usually more convenient to manipulate. It has also 
the advantage that it does not give rise to the painful chrome sores which are very 
liable to occur with those who work in chromic acid liquors. The "two-bath" 
process is usually considered to give a more mellow tannage and a better color than 
the "one bath." . . . Broadly speaking, it is more suitable for the lighter leathers." 
The advantages of chrome tanning seem to lie in the quickness of the process so that 
the tanner has a larger turnover than with vegetable tanning. Hyposulphite of soda 
is recognized as useful in the treatment of chrome sores and use can be made of this 
fact by transference to work on the "hypo " bath of those suffering from chrome holes. 
6. In French polishing, especially for darkening mahogany and walnut wood, the 
grain of which is brought out more clearly by bichromate than by any other substance. 
The liquid is applied generally with a cloth-more rarely with a brush. 
7. As an ingredient of safety matches and in the preparation of colored glass and 
porcelain. 
Effect on the Skin.-There is consensus of medical opinion that bichro- 
mate solutions do not attack the unbroken skin. The slightest break in 
continuity, however, especially where this is thin, as over the knuckles or 
between the fingers, suffices to start the destructive process which, once it 
has begun, will penetrate gradually through the soft tissues unless means 
are taken to prevent further contact with the solution. The seat of 
election for these sluggish ulcers or "chrome holes," as they are called by 
the workmen, is either on the knuckles or at the root of the nail, but they 
may occur on any part of the hands, forearm or foot. Where contact 
has been with dust I have seen them on the neck and in the groin. 
The tissues around the circular ulcer are heaped up, thickened, indurated and 
always undermined; the center is filled by a slough. When the slough has been 
removed the floor of the ulcer is seen to consist of grayish-yellow granulation tissue. 
In the majority of cases the diameter of the ulcer is not more than 34 in., in diameter, 
in a few it is 34 in. and the largest I have seen measured % by 34 in. The number of 
active chrome holes to be found on the hands of some workers when supervision is lax 
is surprising. In one man employed as a breaker in the crystal department of a 
bichromate works I found four on the right forearm, ten on the left, two in the groin and 
one on the back of the neck. In another man, similarly employed, chrome holes were 
found at the matrix of the nail of the index-finger of the right hand, and ring and little 
fingers of the left hand; the index-finger was much swollen and inflamed; on other 
parts of the hands also chrome holes were numerous. It is unusual not to be able to 
find small ulcers or the scars of ulcers that have healed on the hands of those employed CHROME COMPOUNDS 
849 
in chrome tanning and in dyeing. Fortunately, to-day, penetration into joints and 
loss of fingers, described by early writers on the subject, are very rarely seen. Some- 
times instead of taking the form described of localized ulcers, chromic acid in solution, 
as in the "two-bath" tanning process, sets up, in susceptible subjects, an extensive 
papular eruption on the hands and forearms, and occasionally on the feet and ankles 
also, accompanied by intense itching. In slub dyeing the chrome affection is found 
usually around the knuckles, on the palm, in the fold between the thumb and first 
finger, and about the wrist and forearms. The eczematous condition may extend to 
other parts of the body such as the face and back. Susceptibility plays an important 
part in disease of an eczematous nature the skin of some persons reacting much more 
readily to definite known irritants such as chromic acid than that of others. Experi- 
ence can alone decide whether a particular person will be able to continue at the work 
or not. 
Where the ulcerative process is serious it is impossible not to be struck either by 
peculiar susceptibility of the skin or by the evident want of care or ignorance on the 
part of the sufferers. New workers suffer much more than the seasoned who have 
experienced the painful condition. Lads of 14 and 15 years of age who start work in 
chrome tanning are sure to suffer if supervision is lax. The amount of pain and 
inconvenience caused by chrome holes is considerable.. They are never a menace to 
life, but I have known six men absent in 1 year from one establishment for periods 
varying from 3 to 9 weeks on account of them. Even when the severity is not such as 
to necessitate absence from work, months may elapse before they heal. 
My experience dates back to the year 1899 when in consequence of the prevalence 
of chrome ulceration in the large bichromate works in Scotland employing 743 men, 
of whom 306 were engaged in processes involving exposure to chrome, I visited the 
factories and examined the workmen, taking note in each case of the age, duration of 
employment, precise occupation, condition of the septum after examination with the 
nasal speculum, sense of smell after testing with the essential oils of cloves and cam- 
phor, condition of the throat and eyes, and existence or absence of present or past 
chrome ulceration. In 39 out of the 176 men (22.1 per cent.) examined, one or more 
unhealed ulcers were found and in several others numerous scars marking the site 
of bygone ulcers. 
In 126 men (71.5 per cent.) the septum of the nose was the site of perforation, and 
in 20 others of ulceration, in all probability a stage preceding perforation. Nearly 
all the men employed in the crystal department and at the furnaces showed perfora- 
tion. It was noted as having taken place in one instance after a duration of employ- 
ment of only 7 weeks, and in two others of less than 3 months. Usually it appears 
between the sixth and twelfth month after commencing work. 
The seat of election for the perforation to commence is a point about 
34 in. from the lower and anterior margin of the septum; the ulceration 
extends in a direction upward and backward. This point is precisely 
that where inhaled dust alights and I have no doubt dust is the cause. 
Effects on the Upper Respiratory Tract.-The cartilaginous framework of the 
nose consists of five pieces-the two upper and the two lower lateral cartilages, and 
the cartilage of the septum. The two upper and the two lower lateral cartilages give 
the nose much of its shape and form the alse nasi. The ulceration process due to 
bichromate dust never attacks them. The cartilage of the septum is somewhat 
triangular in form and thicker at its margins than at the center. The anterior 
margin, thickest above, is connected from above downward with the nasal bones, 
the front part of the two upper lateral cartilages, and the inner portion of the two lower 
cartilages. Its posterior margin is connected with the perpendicular lamella of the 
ethmoid; its inferior margin with the vomer and the palate processes of the superior 
maxillary bones. 850 
AFFECTIONS OF THE NOSE, MOUTH AND THROAT 
The limitation of the perforation to the cartilage of the septum is accounted for by 
the fact that the mucous membrane covering it is adherent, forming the perichondrium, 
and is far less vascular than the mucous membrane lining the rest of the nasal fossse. 
Once the mucous membrane is destroyed, the blood supply to the cartilage is cut off, 
and necrosis ensues. The ulceration having progressed upward as far as the junction 
of the septum with the ethmoid and backward to the vomer, becomes arrested. Heal- 
ing then takes place, the bone never being attacked, and the cicatrix usually becomes 
covered with an echthymatous crust of mucus. In no instance was the anterior of 
lower border of the septum destroyed. Consequently the rigidity of the parts is 
maintained, and deformity, so prominent in other ulcerative processes attacking the 
nose, is absent. 
The onset of the morbid process is ushered in by sneezing and the ordi- 
nary symptoms of nasal catarrh. The pain accompanying the ulceration 
appears to be insignificant. At any rate it had never been severe enough 
to necessitate absence from work or to call for medical treatment. The 
only apparent inconvenience which results is the formation of plugs of 
mucus in the nasal passages. 
Mucous deposits and white patches were occasionally noted on the 
pharynx, but definite ulceration was in no case detected. Asthma, noted 
by the French writers on the subject, Delpech and Hillairet, was found in 
one instance-that of the partner in one of the works. In his case there 
was a family predisposition to it, but the first definite attack dated from 
contact with bichromate dust. 
Preventive and Remedial Measures.-In factories for the manu- 
facture of bichromates Regulations are necessary, prescribing as their 
main provision periodical medical examination of the workers and treat- 
ment by the appointed surgeon^of lesions contracted in the work. In 
addition, it is essential that some responsible person with knowledge of 
first aid should be appointed to treat daily such cuts and abrasions as 
occur. One of the surgeons carrying out this work writes to me as follows: 
As chrome holes are usually produced from trifling or unseen abrasions about the 
hands I insist upon the foreman examining the hands of the men daily in order to see 
if there is any irritation of the skin and, if found, to have the parts thoroughly washed 
and afterward protected by dressings. This recommendation, I consider, is impor- 
tant in that it impresses on the men the benefit of checking at once tendency to the 
development of chrome holes. They can be developed in a day although the escha- 
rotic effect of the chrome may not be apparent for a day or two afterwards. 
In order to seal up a chrome hole and prevent further contact with the liquor I 
use an ointment of zinc or borax on a small piece of lint to cover the hole. I cover 
the lint with gutta-percha tissue the edges of which I soften with heat from a taper 
or chloroform and then squeeze close to the skin. Adhesive plaster may also be used 
as a further protection over the gutta-percha tissue. Attention must be paid to see 
that the men are following out the treatment and that the sores are improving- 
otherwise there is no alternative but to remove the man from the chrome department 
until the wounds are healed. 
Instead of poulticing some surgeons use boracic fomentations and 
apply yellow ointment of mercury, or clean with hydrogen peroxide CHROME COMPOUNDS 
851 
solution and treat with an ointment containing ichthyol applied under an 
absolutely waterproof plaster. Washing with a 5 per cent, solution of 
sodium bisulphite has been recommended on the ground that by its 
means the chromic acid radicle is split up and rendered inert. 
Where the hands come into contact with bichromate solutions, as in 
chrome tanning by the "two-bath" process and in dyeing, the first essen- 
tial again is daily inspection of the hands and arms of all the workers 
and immediate covering over the smallest abrasion so as to protect it 
against further contact with the solution. For this purpose collodion 
("new skin") is invaluable, but if, as may be the case over the knuckles it 
is inapplicable a dressing under an impermeable waterproof plaster or 
closely fitting India-rubber fingerstall must be used instead. In chrome 
tanning India-rubber gloves reaching well up toward the elbow are a 
great protection, but the wearing of them does not make the treatment 
of abrasions unnecessary. I have found them generally provided and 
worn, but the retention of perspiration caused by their use may tend 
to soften the skin in some cases. Only where discipline and supervision 
are thorough would it be safe to throw aside the protection of India- 
rubber gloves. Substitutes for them such as leather gloves are in my 
experience wholly unsatisfactory. Periodic medical examination of 
persons employed in chrome tanning is useful as it ensures choice of 
proper dressings, is a check on the way in which the foreman exercises 
supervision, and will prevent chrome holes from causing prolonged 
absentation from work. 
Lastly, smearing of the arms and hands with fat or with special oint 
ments undoubtedly serves as a protection to the skin. 
The following is the preparation recommended by Levi, Chemist of the Pfister 
and Vogel Leather Company, Milwaukee: 
Petrolatum (Paraffinum molle of the B. P.) 3 parts 
Lanoline , 1 part 
Melt on the water bath or stove; when melted and thoroughly mixed, add 10 to 15 
drops of 90 per cent, pure carbolic acid to every 400 grams, or 5 drops to every 4 oz. 
of the mixture. Pour into a glass or earthenware jar and allow the mass to solidify, 
when it is ready for use. 
The application is as follows: Let the workman clean his hands and arms thor- 
oughly with soap and water. Rinse with warm water and while still moist apply 
the ointment. Rub in well, so as to cover all exposed skin, for about 2 to 3 minutes. 
Then take a clean cloth and wipe dry. The skin will be left entirely dry and with no 
greasy feeling. Lanoline is absorbed by the skin and the petrolatum forms a light 
coating on the surface. The application of the two inert substances prevents the 
action of the chrome upon the surface and at the same time the absorbed grease 
prevents the action of the chrome, should the outer coating of petrolatum wear off. 
My colleague, Dr. Collis, struck by the remark of a chrome tanner that a dilute 
solution of mercuric chloride or solution of cyllin when used as a hand bath prevented 
the development of ulcers, possibly because the ulcer formation was due to microbic 
action, supervening on the action of the bichromate, has had trial given with fair 
success to an ointment composed of mineral lard 3 lb., paraffine wax 6 oz., and cyllin 852 
AFFECTIONS OF THE NOSE, MOUTH AND THROAT 
3 oz. Mineral lard is used instead of lanoline to prevent oxidation by the chromic 
acid. 
In a case of severe papular eczema arising from contact with ammonium bichro- 
mate used in photo-engraving application of equal parts of calamine and boracic acid 
lotions quickly proved efficacious. These are the cases, however, which are liable 
to relapse on fresh exposure and raise the question as to further continuance in the 
process. 
The effect of chrome dust on the nasal septum, despite elaborate exhaust ventila- 
tion applied in packing the crystals, cannot wholly be avoided. The inconvenience 
caused by its occurrence is not sufficiently great apparently to induce the workmen 
to adopt precautions which might, if regularly used, be effective, such as, cotton wool 
plugs or smearing the septum with paraffine. The surest preventive measure is effort 
directed to reduce to a minimum generation of dust. Fischer states that daily use 
of an ointment composed of 50 grams zinc oxide, 22 grams olive oil, 18 grams lique- 
fied ichthyol, and 10 grams balsam of Peru has caused the disappearance in from 
3 to 4 weeks of signs of ulceration on the septum in those commencing work. 
I agree with the conclusion of Fischer and Lehmann, who have recently 
carefully examined the conditions in the bichromate works in Germany 
(the latter having also carried out animal experiments as to the effects of 
chrome compounds), that no constitutional disease, and especially no 
disease of the kidneys, is induced by work in bichromate factories or in 
chrome tanning. 
Manufacture of chromates of lead is attended with considerable risk of lead 
poisoning. Lighter shades are made by a cold precipitation process and the deeper 
shades of orange and red by boiling the ingredients-lead acetate, pulp white lead, 
bichromate of potash and soda and sulphate of soda-while barytes is added as the 
color is being made. Danger in the first method hardly arises until drying and grind- 
ing under edge runners, sieving and packing, are effected. The dust, when inhaled, 
is quickly absorbed, and carefully arranged exhaust ventilation is necessary in all 
operations in which dust is generated. Vessels in which boiling is effected require 
to be hooded over and the hood connected up with an efficient exhaust draught. 
Grinding of chrome greens is a very dusty process and, although only 10 per cent, of 
lead may be present, poisoning will occur in the absence of encasing and exhaust 
ventilation. In an analysis of 225 cases of lead poisoning distributed according to 
precise occupation I found at least 10 per cent, were traceable to chrome colors. 
Cotton yarn is dyed on a considerable scale with chromate of lead. Much of the 
yarn so dyed goes to Oriental markets and it is the orange chrome-that most heavily 
weighted with lead-which is most in demand there. Not a few outbreaks of severe 
lead poisoning have occurred among the workers-generally women-engaged in 
shaking out the yarn over heading posts-due, in every case, to a breakdown in the 
exhaust ventilation locally applied. 
In both the manufacture of paints and colors and heading of yarn 
dyed with lead compounds, Regulations are in force in Great Britain 
prescribing periodic medical examination. 
Chrome ulceration became notifiable under Section 73 of the Factory 
and Workshop Act, 1901, by medical practitioners to the Chief Inspector 
of Factories on January 1st, 1920. In the three years, 1920-1922, 
197 cases have been included in the Returns, of which, 100 were reported CHROME COMPOUNDS (CONCLUDED)-REFERENCES 
853 
from factories for the manufacture of bichromates, 83 in dyeworks, 7 in 
tanneries and 7 in other industries. 
In 1918, Welfare Orders were made by the Secretary of State for Dye- 
works and for Tanneries using the "Two Bath" process. Omitting 
the provisions as to washing accommodation, cloakrooms and mealrooms, 
those having special relation to chrome in the latter are as follows: 
1. The occupier shall provide and maintain in good condition, for the use of all 
persons coming into contact with chrome solutions, rubber or leather aprons and bib, 
and rubber boots or leather leggings which will protect open tops and laceholes of 
clogs or boots, and for those who are continually immersing their hands in the solu- 
tions, loose-fitting rubber gloves of suitable length. 
2. The occupier shall provide in readily accessible positions a sufficient number of 
"First Aid" boxes or cupboards. 
Each box or cupboard shall be distinctively marked, and if newly provided after 
the date of this Order shall be marked plainly with a white cross on a red ground, and 
shall contain, besides any other medical appliances or requisites, a supply of:- 
(i) Collodion and Brushes. 
(ii) Impermeable Waterproof Plaster. 
(iii) Ointment, Lint, Bandages and Scissors. 
(iv) A 2 per cent. Alcoholic Solution of Iodine. 
Nothing except appliances or requisites for First Aid shall be kept in a "First 
Aid" box or cupboard. 
Each "First Aid" box or cupboard shall be kept stocked and in good order and 
shall be placed under the charge of a responsible person, who shall always be readily 
available. 
A notice or notices shall be affixed in every workroom stating the name of the 
person in charge of the box or cupboard provided in respect of that room. 
3. The occupier shall see that the Official Cautionary Notice as to the effects 
of chrome on the skin is kept posted up in the Works, and shall arrange for an inspec- 
tion of the fingers of all persons coming into contact with chrome solutions to be 
made twice a week by the person in charge of the "First Aid" box or cupboard. 
REFERENCES 
1 "Memoire sur les accidents auxquels sont soumis les ouvriers employes a la fabrica- 
tion des chromates." Annales d Hygiene publique, 1869, page 5; and 1876, 
pages 5 and 193. 
2 "Die in Chromatfabriken beobachteten Gesundheitsschadigungen und die zur 
Verhiitung derselben erforderlichne Massnahmen," by Drs. Wutzdorf and Heise. 
Arbeiten aus dem Kaiserlichem Gesundheitsamte, Vol. XIII. 
3 Article on "The Lesions Resulting from the Manufacture and Uses of Potassium 
and Sodium Bichromate," by T. M. Legge, in Oliver's "Dangerous Trades," 
page 447. 
4 "Die Berufskrankheiten des Ohres und der oberen Luftwege," by Dr. F. Rbpke, 
J. F. Bergmann, Wiesbaden, 1902. 
6 "Die industrielle Herstellung und Verwendung der Chromverbindungen, die dabei 
entstehenden Gesundheitsgefahren fiir die Arbeiter und die Massnahmen zu 
ihrer Bekampfung," by Dr. R. Fischer. One of the publications of the Institut 
fiir Gewerbehygiene of Frankfurt a. Main. A. Seydel, Berlin, 1911. 
6 "Die Bedeutung der Chromate fiir die Gesundheit der Arbeiter," by Professor K. B. 
Lehmann. One of the publications of the Institut fiir Gewerbehygiene of Frank- 854 
AFFECTIONS OF THE NOSE, MOUTH AND THROAT 
furt, Julius Springer, Berlin, 1914, Die Zeitschrift fur Gewergehygiene, 1908, 
page 307. 
7 Annual Reports of the Chief Inspector of Factories for 1899, page 334, and 1914, 
pages 146 and 147. 
8 "The Effects of Dust in Producing Diseases of the Lungs," by E. L. Collis, M. B. 
17th International Congress of Medicine, London, 1913. 
9 "Industrial Pneumonoconioses with Special Reference to Dust-Phthisis, by E. L. 
Collis (Milroy Lectures, 1915), "Public Health." 1915. CHAPTER II 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
SECTION 1 
HARRY VANDERBILT WURDEMANN, M. D„ Seattle, Wash 
Introduction.-Certain industrial occupations involve particular 
risk to the eyes from acquired disease and intoxication or by reason of 
accidents. It may be said that each trade has its own eye diseases and 
particular forms of trauma, and in some the relation of the ocular damages 
to the risk encountered is very great indeed. 
The employer has now to take into consideration not only the medical 
care and hospital service for injured employes and compensation of 
damages therefor, but in many states and countries is compelled by law 
as well as sentiment to put in safety appliances which have come to be 
known as money-saving propositions, as well as reducing the number 
of workmen laid up by reason of accident and disease. 
The intelligent workman does not desire plenary damages, for health 
as well as sight is priceless, but he does now insist upon his work being 
made as safe and free from accident and disease as possible. 
A very large proportion of the injuries occurring in trades happen to 
the eyes, probably as many in number as all other injuries, and as a 
workman needs good eyesight he is usually totally incapacitated by 
such a lesion. 
The subjects to be considered may be arranged as follows, in which 
discussion I will deal mostly with the etiology and prevention of such 
incapacitations: 
I. Injuries from accidents. 
II. Diseases due to occupations, involving excessive eye strain. 
III. Diseases due to excessive exposure to light and heat. 
IV. Toxicology or systemic poisoning causing loss of sight. 
V. The estimation of economic damage. 
I. ACCIDENTAL INJURIES* 
By far the larger proportion of these happen in the iron and steel 
trades where the workman is exposed to cuts, burns, bruises and flying 
foreign bodies. Indeed in shops, such as wire, chain, tool and machinery, 
* The United States Bureau of Labor Statistics, in the Monthly Labor Review, March, 
1923, p. 110, published an important article on the Causes and Cost of Industrial Eye 
Injuries in the United States. This information was received from the National Bureau 
of Casualty and Surety Underwriters and represents the accident and compensation experi- 
855 856 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
as many accidents to the eye may occur in a year as there are workmen 
employed. Most of them are trivial injuries such as motes in the eye, 
laying the man up but for an hour or a day or two; others, however, 
expose him to partial or complete loss of eyesight with total loss of earning 
power immediately following the accident or occurring months or even 
years afterward, as from sympathetic disease. 
The cosmetic relations of these eye injuries are important, for a one- 
eyed man finds it difficult to obtain a job. A white scar on the cornea, 
or a squint, even though little or not at all affecting the vision may be 
the deciding power in rejecting a man who otherwise is well qualified. 
ETIOLOGY OF INDUSTRIAL INJURIES 
The Trades.-In the so-called dangerous trades, particularly those 
dealing with the iron and steel industries, workers in machinery, butcher- 
ing work, and building trades, occur the larger number of ocular injuries. 
Among these are the miners of iron, copper and coal, the smelters and 
machine builders. Those that are most subject to flying foreign bodies 
causing wounds of the eye are foundrymen, machinists, turners, borers, 
boiler makers, fettlers, smiths and polishers; workers by the fire and 
heat, puddlers, casters, glass workers, etc., are burned by fire, ashes or 
iron and slag. Contusions of the eye from falls, blows and thrusts 
come to all classes. 
In agricultural pursuits there are many kinds of injuries, especially 
from foreign bodies. In lands where the ground is tilled largely by 
hoes, as in the stony country of Switzerland, the breaking of these instru- 
ments against the rocks causes many such injuries. In agricultural 
pursuits the causes are injuries by straws, by branches in the woods, in 
working about cattle and by farming implements. There are injuries 
from foreign bodies in the cornea and conjunctiva, perforating wounds, 
contusions from sharp or pointed objects, injuries from lime or dung, 
burns and insect stings. Cauterizations from the arsenate of lead have 
recently been reported in spraying orchards. 
In the building trades there are injuries from iron, stone particles, and 
splinters of wood, and from instruments used in work; in quarries and 
mines, explosions of powder and dynamite. Injuries from lime are 
ence of several insurance carriers for the policy year 1919. . . . Unfortunately the data 
cover only about 10 per cent, of the total industrial eye injuries in this country. The data 
deal, however, with 32,825 injuries requiring medical aid, 7,826 tabulated injuries and 1,400 
compensable injuries. The total cost of all the injuries amounted to $671,569, of which the 
medical cost contributed $186,602 and the compensation cost $484,967. 
An analysis of the data brings out some significant facts for the safety engineer. Flying 
particles and objects account for 70 per cent, of the total eye injuries and 50 per cent, of 
the total cost. Of these, abrasive wheels produced 10,210, or 31 per cent, of the total 
medical-aid injuries, but only about 9 per cent, of the total cost; objects flying from tools 
handled by the workers account for 9 per cent, of the accidents, which represent 15 per 
cent, of the cost; and flying particles not otherwise classified account for 30 per cent, of the 
cost. From the foregoing it will be seen how important a factor goggles and other eye- 
protecting devices may be in reducing the hazard resulting in eye injuries. (Kober.) CAUSES OF INDUSTRIAL EYE INJURIES 
857 
common among painters; in laboratory workers, foreign bodies, burns 
and scalds, and splinters of glass; in glass blowing, burns and formation of 
cataract; in cabinet workers, injuries from the materials they work with, 
steel, wood and bone; in turners, injuries from wood, bone, ivory, and 
stone, blows from sharp knives, etc. 
Generally the injury is inflicted by fragments flying off while the 
mechanic is striking a chisel or piece of metal, as a hatchet or hammer. 
The Trade Processes.-Solids or gaseous substances may cause conjunctivitis in 
people exposed to the inclemencies of weather, stone impregnation of the cornea in 
stonecutters, ribbon-shaped keratitis in hat makers, masons, steel grinders; opacities 
of cornea due to nitronaphthalin and anilin; keratitis of oyster openers and caisson 
laborers; cataract of glass blowers. We may probably give the most prominent place 
to Grinders or to workmen in factories who are either constantly employed in grinding 
edged tools, or, as is common in this district, care for their own tools, and find occasion 
to go to the grindstone or emery wheel a number of times daily. In such trades 
foreign bodies are very prone to become lodged in the cornea. In the course of a day 
a grinder may get several foreign bodies in his cornea or many days may elapse without 
so doing. If the cornea of an old grinder be examined carefully with a magnifying 
glass, it will be frequently found studded over with nebulae caused by damage from 
getting motes in the eye which, by frequent repetition, will dull the cornea and after 
a while will diminish the acuteness of vision. I have, however, seen many workmen 
with such scars who possess normal visual acuity. These nebulae have been caused 
by small fragments of emery, or, more rarely, stone or pieces of iron. In localities 
where emery is used for glazing cutlery, such accidents are very common. To those, 
who have watched a grinder at work it is remarkable how any one can remain at the 
wheel without getting foreign bodies into the eye every few minutes. The shower of 
sparks which proceeds from the dry grinding wheel shows the large number of foreign 
bodies that come away. Dry grinding is certainly more dangerous as regards the 
eyes than wet grinding, as in the former the sparks fly freely and it is a chance whether 
they hit the man's eye or scatter about the room. The pneumatic fans which are 
required in many of the United States and in England, in consequence of the dele- 
terious effect of the dust upon the health of the operators, protect the workman's eyes 
by drawing into themselves the sparks and particles flying from the wheel. In wet 
grinding the particles do not fly about so much; still the workman's face becomes 
bespattered. 
In the great majority of cases the damage occasioned by mishaps of this character 
is not serious unless ulceration follows. Other accidents, of course, may follow upon 
the injury to the eye on account of the disability and lessened protection that is 
thereby produced. In the case of workmen who frequently get injuries to their 
eyes, and always where a workman or patient has lost an eye, I advise the securing of 
an accident policy on account of the greater danger of injury from the lessened func- 
tional ability. 
M By far the most serious eye accidents happen to men engaged in working in iron or 
steel. Particularly in iron manufacturing districts the majority of serious eye 
accidents occur from chipping or fettling iron and steel, in the lighter iron and steel 
industries as well as in the heavy trades, where armor plates are made and heavy 
castings of scores of tons. A very large proportion of the accidents are occasioned by 
what is called "chipping" and "fettling." "Dressing" is the name given in some 
parts of this process. This work consists in chipping the rough edges from steel and 
iron castings, ingots, and all kinds of iron and steel work, and, among other things, 
even large armor plates. 858 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
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 
to chip castings in corners or where the chipping strikes the metal and rebounds. 
Chippings from the castings are about X to % in. long and very sharp. When thin 
plates are chipped on the edges, the chirpings are sometimes 1, 2, and 3 in. long before 
they break off. All castings are fettled at the foundry, that is, the runners are cut off, 
and the plates 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 roughness is removed. Frequently, also, while one man places the chisel, 
Fig. 38.-Men at boring mill should provide themselves with goggles as at any time 
a chip is liable to injure the eyes. U. S. Steel Corp'n. {Wurdemann.) 
another, or even two others, will use the hammer and are called strikers. I under- 
stand 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, and many blinded in this way have come 
under my notice. The chipper himself is often hit by the rebound of the splinter after 
it has struck perhaps the narrow angle of steel or iron upon which he may have been 
working, or 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, 
but there are three other places from which splinters may be, and actually are, given 
off and cause injury, namely: the hammer-head, the chisel-head, and the chisel-point EYE injuries: causes, lesions 
859 
The sizes 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 frag- 
ments may be thrown off with such velocity that they penetrate the eyeball and 
become imbedded in its interior, in some instances passing through the eyelid before 
reaching the globe. The destruction to sight in this way is very large. 
In the case of breweries and bottling works, particularly of bottling of aerated 
water, there is a comparative frequency of accidents from the breaking of the con- 
tainers. A firm in Sheffield having several different factories employing from 2500 to 
4200 hands states that in spite of the most careful enforcement of the use of masks, 
gauntlets, etc., in 1 year there were nearly 400 accidents. The number of bottles 
that burst in 1 year is very considerable; new bottles or syphons are twice as liable to 
break as the old ones. About 1 per cent, of the new and old bottles break when filled. 
Syphons burst less frequently but the explosion and danger is greater; about one in 
5000 breaks in winter, while the percentage is greater in hot weather. The greater 
number of bottles break in the filling machine but there is practically no work in any 
part of the factory which may be regarded as free from danger. 
Particular Lesions.-Certain forms of injury are more apt to happen 
to some parts of the eye than others. Cuts and gashes occur mostly upon 
the anterior portion of the eye and its protecting organs; the lids, globe, 
cornea, ciliary region. Perforating wounds may go from the cornea and 
sclera through the bulb into the orbit and the optic nerve. Lacerations, 
tears, and the wounds from the bites of animals, are upon the more 
exposed parts, while shot wounds affect all portions of the eye. Flying 
foreign bodies or motes are usually found under the lids, though they may 
be impacted in the outer part of the bulb, especially the cornea. These 
consist of cinders, iron and copper splinters, the latter of which are often 
imbedded in the anterior, or even go to the posterior portion of the eye, 
remaining in the iris, vitreous, or the coats. The cornea most often 
contains foreign bodies, less often the conjunctiva and sclera. The 
effects of blows is most apparent upon the outer portions, the lids, brow, 
and then the bulb. In the eye itself the blow may cause tearing of the 
retina and choroid, indenting the eye, and may push the lens away, causing 
detachment. Burns and cauterizations, as a rule, affect only the outer 
structures, the lids, cornea, and conjunctiva. The same may be said of 
burns from flame, the effect of lightning, electricity and sunlight, which 
may affect the lens and also the retina. 
Types of Lesions, with Respect to Objects Causing Ocular Injuries.-On account of 
the great sensitiveness of the cornea, the formation of scar tissue and the danger of infec- 
tion, a very small solution of continuity of this membrane is of great importance. All 
substances which come into contact with the surface of the cornea are apt to cause eros- 
ions. These may occur from the finger nail, pieces of straw and twigs. Cuts of the eye 
obtain from sharp instruments, such as knives, shears, glass; thin points of metal such 
as tin, and all cutting substances. Piercing wounds also occur from sharp points of 
metal, wood, and glass, which are round and thin, such as needles, pins, awls, nails, 
pieces of wire, forks and other table instruments, thorns, styles, or animal's claws; or 
those pointed, but not specially sharp instruments, as daggers, poinards, swords, 
sabers, bayonets, knives, steel pens; or those long triangular or irregular, as the 860 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
points of compasses, sharp-pointed pieces of wood, pencils, sticks, parasols, walking 
canes, and umbrellas. Gashes are formed by knives, chisels, sabers, axes, daggers, etc. 
Contused wounds are caused by either sharp or blunt objects of iron, wood or 
other stuff; by flying pieces of such substances as iron, nails, pieces of horseshoes, and 
all substances used in iron works; by files, pieces of wood, sticks, stone, shell, etc. 
Such may also occur by the horns and hoofs of cattle, the beaks of birds, which cause 
combined tearing and contusion. A large number of cases of whip-lash injuries have 
been reported. Lacerating wounds obtain through the above objects but are not 
particularly due to injuries by machinery, hooks, nails, or to the teeth and claws of 
dogs and cats. Bite-wounds, however, are generally due to dogs, except in rare cases 
of hunting accidents where they occur from boars, bears, and wildcats. 
FIg. 39.-Men pouring babbitt should wear goggles or a wire mesh screen covering the face, 
as at any moment an explosion is liable to occur. U. S. Steel Corp'n. (Wilrdemann.) 
Foreign bodies remain either superficially or go deeply into the eye or orbit. They 
are carried either by the air or the wind, falling upon the eye, as cinders, particles of 
stone, coal or wood ashes, pieces of grain or sawdust-the so-called domestic accidents. 
Industrial injuries are due to machinery or hand-work, and as a rule are from 
pieces broken loose from objects and go more deeply into the structure of the eye or 
into its interior. These are particles of iron, coal, copper, slate, stone, wood, bone, 
and those foreign bodies which are driven by explosions, such as glass splinters from 
exploding retorts, pieces of copper from caps or cartridges, etc. 
Contusions occur from blunt or round objects, as a rule of large size; from falls on 
furniture, blows of fists, instrument handles, etc., or from objects which have been EYE injuries: causes, mechanism 
861 
thrown with force, as stones, baseballs, tennis balls, snowballs, potatoes, apples, 
etc.; also from corks, glasses, concentric tops of bottles from explosion of the 
same. 
Burns are caused by the flame itself, by the sun or electric light, from glowing 
rods and glass, by hot but not melted metal, by hot ashes, grains of powder, burns of 
the hair, from burning gas and hot steam, from hot water, oil, petroleum, pitch, etc. 
Cauterization may be due to acids, such as sulphuric, nitric, hydrochloric, phenol, 
vitriol, to alkalies and caustics, as soda and potash, to lime burns, arsenate of lead, 
and to methyl violet pencils and other substances. 
Bacteriology.-The aspergillus fumigatus is the only mould that has 
been found to cause infection of ocular wounds. The micrococci occur in 
the following order: the diplo-pneumococcus, streptococcus pyogenes, 
staphylococcus pyogenes, aureus and albus. The ozena bacillus, gono- 
coccus, bacillus pyocyaneus, bacillus pyogenes, staphylococcus pyogenes, 
citreus and fetidus, micrococcus cereus, tetragenus prodigiosus, and 
bacillus of tetanus are less often found. To these perhaps may be later 
added the presently unknown microorganism producing sympathetic 
ophthalmitis. 
Staphylococci are constantly found in the skin at the edge of the lid 
and sometimes in the normal conjunctival sac; streptoccoci and pneumo- 
cocci are never found in the normal eye. 
Disposition of Diseased and Abnormal Eyes to Injury.-Weak sight 
disposes to bodily injury, because the individual does not see well enough 
to escape accidents, as well as specific injuries to the eyes. 
Diseased and abnormal eyes, as in those suffering from senile degenera- 
tion and weakened walls of the blood-vessels, are predisposed to bleeding 
into the tissues from contusions and concussions, and to this condition 
persons suffering from arteriosclerosis, glaucoma, diabetes, leukemia, and 
renal diseases are likewise subject. 
Traumatism as an Exciting Cause of Constitutional Eye Disease.- 
Traumatism may be the exciting cause of syphilitic iritis and it is possible 
that a corneal wound may be the point of entrance for an exogenous infec- 
tion, or a syphilitic iritis may be superimposed on an iritis from other 
cause. 
MECHANISM OF SPECIAL TYPES OF INJURIES 
Incised, piercing, and flap wounds are produced by sharp instruments 
or objects applied with more or less force; while contused, lacerated, and 
bite wounds are more often of the nature of tears produced by blunt 
instruments. 
Small objects, as motes, may be borne by the wind and carried to the 
eyes, where they stick to the conjunctiva, and become impacted therein, 
or are carried under the lids and by rubbing may be impacted into 
the cornea. Others come with force from the breaking of an object 862 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
and are impacted directly, or, if hot, burn themselves a place in the 
tissues. 
Explosions of firearms, powder and dynamite result in the impaction 
of foreign bodies, not only from the exploding compound, but also from 
surrounding objects. 
Contusions cause both direct and indirect damage; the direct by 
impaction of the object; the indirect from rebound of the tissues from the 
elastic contents of the orbit and its bony walls. Ruptures occur through 
compression and inward pressure, which, when the coefficient of resistance 
of the structure is reached, causes disassociation of contiguity and 
bursting. If the structure gives under the force, it breaks away from 
its surroundings and direct rupture with dislocation results. 
Rupture of the cornea or sclera is produced by the pressure of the 
foreign body being so distributed that there is no place for the globe to 
go and it thus bursts. 
In direct rupture the break occurs at the point of pressure in another 
part of the globe. The mechanisms of corneal, scleral, iridic and choroi- 
dal ruptures are under the anatomic heading. 
The mechanism is often that of burning; in solar that of burning 
combined with the electro-chemic effects of ultraviolet light; in electric 
injuries burning, light, and electrolysis, and in some instances the effect 
of concussion. 
The effect of explosions of gunpowder and dynamite, and of firearms, 
causes, through a combination of wounds, with and without penetration 
of foreign bodies, contussion, ruptures, and infection. 
Infected wounds have the characteristics of other wounds, combined 
with loss of tissue from ulceration due to necrosis, following the develop- 
ment of microorganisms within. The infection may be carried by the 
object producing the injury, by accompanying foreign bodies, exposure 
to the air, or by contact with fingers, unclean instruments, medicaments, 
or bandages. 
PROPHYLAXIS OF INJURIES OF THE EYE 
While many eye accidents are unavoidable, yet the large majority are 
preventable by due care of the patient, parents, fellow-workmen or 
employers. 
In agricultural life many accidents occur from carelessness, as injuries 
from baling wire, straw, hooks, branches, splitting wood, horning from 
cows, kicks from cows, horses, etc., most of which are to be avoided by 
due care. 
Safeguards against accidents to workingmen have been forced upon 
the attention of manufacturers, transportation companies and others, 
not only by legal measures, but by the necessity for conservation of their 
own goods and machinery, and the loss of service and the cost of care and PROPHYLAXIS OF EYE INJURIES 
863 
expense in treatment of such workingmen, as well as protection from 
damage suits, which give lawyers lots of work. The policy of making 
factory work safer and more healthful is profitable as well as humane, and 
it makes the workman more contented. Safety appliances are in use in 
most dangerous trades and have markedly decreased the proportion of 
accidents, particularly of the eye. Note the lessened number of blind 
from accidents within the last 10 years. But it is with reluctance that the 
workman uses them and he will shirk their application unless carefully 
watched and continuously warned. Even if protectors hang alongside 
of the grindstone they are rarely used. There are a variety of protectors 
Fig. 40.-A man at an emery wheel should at all times wear goggles even if wheel has a 
permanent glass guard. U. S. Steel Corp'n. (Wurdemann.) 
in the market. Gauze wire, fitting close to the eye like a cup and attached 
to the head by a string, is employed by stone breakers, and in some iron 
works. 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 interfere with sight as little as possible. 
Large, heavy glasses made of plain glass with heavy frames are used by 
stone masons; plain glass with leather fittings, for workers in chemicals 
and in lime works where the acrid fumes may affect the eyes. Automobile 
protectors are now in common use for out-of-door people using these 
vehicles. 864 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
Amber, novial, Crookes' and even plain white glass not only offer 
protection from small flying objects, but in a great measure cut off the 
violet or chemical rays. 
Where grinders or workmen in the iron trades sharpen their tools a number of 
times a day at the wheel, thousands of foreign bodies fly about, many of which strike 
the person despite safety appliances that may be used. I have in my possession a pair 
of ordinary spectacles used by a workman, which is completely studded with hundreds 
of abrasions caused by flying particles of emery-a not uncommon observation. 
If one examine carefully the cornea in the eye of a grinder he may be surprised 
to find a large number of specks, which are the results of previous injuries. If they 
be situated without the visual area they give rise to no inconvenience, but if in the 
visual axis, a very small scar may cause decided lowering of the visual acuity. All 
such trivial accidents could be prevented by the workingman wearing protection while 
at such forms of work. 
The use of the pneumatic chipper has, in many cases, almost superseded the hand 
chipping by sate and hammer, and thus the dangers of chipping are largely avoided. 
It accomplishes in 1 hour what would take 6 hours by hand, and prevents the flying 
about of fragments, as it is more like running a scoop over fairly soft cheese than using 
a tool on hard steel. 
The proper arrangement of men at their work and the use of screens to 
avoid injury to their fellow-workmen and to passers-by have, together 
with the wearing of proper eye protectors, assured the safety of sight 
in factories where such have been installed and made obligatory. 
My experience has shown that there is less difficulty in enlisting the 
support of the employers than the assent of the men to adopt precaution- 
ary measures. 
PROTECTIVE LEGISLATION 
Our own workmen are protected by various laws for the regulation of 
machinery, of different natures in the several states, and in the case of 
public carriers, as the railway and steamship companies, by the Interstate 
Commerce Commission and by their own stringent rules, which, however, 
have more to do with conservation of the public safety and their own 
goods and machinery than with the individual workman. 
Devices have been put into use, moreover, to prevent accidents, and 
provision has been made to attend to the men injured when accidents 
occur. Ten years ago an accident would drive a factory engineer away 
from his throttle at the critical moment. Nowadays a factory girl can 
shut down the most ponderous engine by pressing a button. Accidents 
do happen, however, many of them. In the best regulated factories 
the victim goes to the factory hospital. 
In case of negligence being shown on the part of the employer by 
reason of defective tools, surroundings, or placing the men at extra 
dangerous work for which they have not specially contracted and from 
which circumstances accidents arise, the workmen are entitled by law 
to recover some compensation. In all such suits, however, the compensa- PROTECTIVE LEGISLATION DIAGNOSIS 
865 
tion asked for is more, and ofttimes many times the amount, that 
should be allowed. We claim that all compensation, not alone that to be 
given as the result of claims at law but also claims for insurance, should 
be regulated by the amount of the economic damage. 
11 Workmen's compensation laws" enacted in the American Union, 
Alaska, Hawaii and the Panama Zone are far from uniform, showing the 
widest diversities in the methods and amounts of compensation and 
scope of the laws. Equalization of these laws is in process of consum- 
mation by various committees of scientific societies. The Treasury 
Department of the United States of America is now working in 
conjunction with the authorities of Great Britain and France to evolve 
an equitable compensation table for disabled soldiers which will no 
doubt be a model for the several countries and states for industrial 
purposes. 
Usually the injuries must cause disablement for a specified number of days or 
weeks before compensation becomes due. The employer may usually be relieved from 
the payment of compensation if he can prove that the injury was caused intentionally 
or by willful misconduct, or, in some countries, by the gross negligence of the injured 
person or during the performance of an illegal act. 
The industries usually covered by the acts occur in manufacturing, mining and 
quarrying, transportation, building and engineering work, and other employments 
involving more or less hazard. In Belgium, France and Great Britain the laws apply 
to practically all employments. In Austria, Norway, Russia, Spain and Sweden 
only workmen engaged in actual manual work, and in some cases those exposed to 
the same risks, such as overseers and technical experts, come within the operations 
of the law. On the other hand, in France, Great Britain, the British colonies, and 
Hungary the laws apply to salaried employes and workmen equally. Overseers 
and technical experts earning more than a prescribed amount are excluded in Belgium, 
Denmark, Germany, Great Britain, Italy, Luxemberg and Russia. Employes of 
the state, provincial and local administrations usually come within the provisions 
of the act. 
The entire burden rests upon the employer in all but four countries-Austria, 
Germany, Hungary and Luxemberg, where the employes bear part of the expense. 
The laws in every case fix the compensation to be paid. Except in Sweden the com- 
pensation is based upon the wages of the injured person. It consists of medical and 
surgical treatment and periodical allowances for temporary disability, and annual 
pensions or lump sum payments for permanent disability or death. 
In America and in other countries the estimation of the damage done by accidents 
in legal cases is left to the empirical dictum of the judge, who is guided by precedent, 
and to the sympathies or prejudices of the jury, which may be aroused by the attorney 
presenting the case, pain of body and anguish of mind being apparently very impor- 
tant factors. 
DIAGNOSIS OF INJURIES TO THE EYE 
The diagnosis of injuries to the eye is made by subjective and objective 
examinations, of which the history, symptomatology, and the visual 
acuity, field, condition of the ocular musculature and the refraction are 
given their proper consideration. 866 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
Objective examination by direct and focal illumination, the oph- 
thalmoscope, diaphanoscope, sideroscope, magnetic attraction and the 
X-ray offer exact means of diagnosis. 
A careful history should be obtained, giving the date and hour of the 
accident, the character of the work and surroundings, the instrument con- 
cerned, object or foreign body causing the lesion, and, in special cases, the 
names of the witnesses to the accident; also the character of attempts to 
remove a foreign body, and whether or not the case has been attended by 
a physician, are facts that should be elicited. Remember that, while the 
interests of the patient are of prime importance, we should be guarded in 
our prognosis, as it depends very largely upon previous injuries and the 
character of the first dressing. We should never give an opinion reflecting 
upon the first consultant, or as to the liability of the employer, for these 
are theories that the lawyers may be allowed to fight about and 
the courts decide. The less we have to do with the legalized human 
parasites who are in the habit of soliciting personal damage suits, the 
better it is for the physician, and we should not furnish information in 
advance upon which a personal damage or malpractice suit might 
be based. 
Usually an examination may be conducted without a local anaesthetic, 
as cocaine or holocaine, but such are frequently needed to subdue irrita- 
bility, adrenalin to lessen congestion, and cocaine, homatropine, 
euphthalmine, or atropine for mydriasis. The visual acuity, and in some 
cases the visual field, muscle balance, duction and versions, the refrac- 
tion, etc., should be ascertained. In fact, in medico-legal cases a full 
examination should always be made, and sketch drawings or water 
colors may be made, as well as full notes taken. The literature of the 
subject should be looked up, as then the examiner, as a medical witness, 
will be fully prepared for his answers in court. The demeanor, willing- 
ness of the patient and actions of his companions should be noted as 
thereby hints as to malingering may be ascertained. 
The examination of an injured person from a medico-legal standpoint should be 
conducted in a sympathetic manner in order to obtain the patient's confidence, and 
while the examiner should ever be on the watch for malingering, yet he should not 
take an antagonistic stand. Such an examination is often grudgingly submitted to, 
the patient looking upon the examiner in the light of an opponent who has been hired 
by the defense to find some excuses for prevention of the collection of damages. 
The opposite frame of mind is shown by those injured persons who themselves 
secure an examination as a basis for malpractice, or'personal injury suit. Yet they, 
too, invariably distort and magnify the importance of the economic damage. 
It behooves us, therefore, in examination of injury cases, to leave no impression 
upon the patient as to the advisability of his seeking recourse at law, but to conduct 
the examination in an impartial and sympathetic manner, at the same time leaving 
a favorable opinion upon his mind. 
A comparatively small proportion of accidental injuries have, in American law, 
a basis for collection of damages; the larger number have been worked up for pecuniary 
rather than elemosynary purposes. Be this as it may, one should not lose sight of the DIAGNOSIS-OBJECTIVE EXAMINATION 
867 
fact that cases occur in which there are really grounds for damages and which should 
obtain pecuniary relief thereby. 
Owing to the transparency, translucency, and delicacy of the ocular 
structures a number of special methods of examination are of help, of 
which general inspection by direct and reflected light should first be used. 
Objective Examination.-Inspection by direct illumination by day- 
Fig. 41.-A fellow workman attempts to remove a foreign body from the eye. A 
dangerous practice which should be absolutely forbidden, and which causes much infec- 
tion. When injured report at once to the emergency hospital. U. S. Steel Corp'n. 
{Wurdemann.} 
light, electric light or reflecting mirror is first made. The skin, lids, 
cornea, conjunctiva, puncta, lacrimalia, etc., are observed. Then the 
retrobulbar folds and undersurface of the lids are brought into view by 
eversion with the fingers, but preferably by pushing down the retrotarsal 
folds by a smooth instrument, as a small glass rod, handle of an instru- 
ment, or cotton-tipped stick, as it is here that most diseases of the con- 
junctiva are prominent and foreign bodies may be impacted therein. 868 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
Many small and otherwise almost indistinguishable abrasions of the 
corneal epithelium, wounds and small foreign bodies in the cornea, may be 
brought into view by the staining of the tissues with a 2 per cent, fluores- 
cein; add 2 per cent, bicarbonate of soda solution. This anilin dye will 
not stain the intact corneal epithelium, but readily passes into the subja- 
cent parenchyma and abraded epithelial cells, forming a bright green 
background upon which foreign bodies are readily perceived. 
Magnification of the eye by a lens, preferably by the Berger or Jackson 
binocular loupe, is of great value. 
Focal illumination in the dark room is ordinarily carried out by focus- 
ing the light upon the eye by a large loupe. The use of the diaphanoscope 
for this purpose gives, however, a much better illumination, as the light is 
confined to a narrow beam. The author's transilluminator is the size of 
an ordinary fountain pen and is as readily handled. 
The ophthalmoscope should first be used at a distance of a couple of feet from the 
eye and magnification obtained by use of a + 3.00 to + 16.00 lens in the instrument, 
the patient being directed to look in various directions, whereby a foreign body may 
be brought into view against the red background of the fundus; approaching closer 
to the eyes, after the cornea and anterior chamber have been examined in this manner, 
the lens, vitreous, and fundus are then successfully investigated. The electric oph- 
thalmoscope with light regulated by a rheostat gives the most elastic means of such 
examination. 
Diaphanoscopy is a means of rendering the eyeball luminous, whereby the shadow 
of the ciliary body, iris, tumor, or large foreign body within the eye may be observed. 
I have a number of times determined the presence of foreign bodies which were at first 
indiscernable by other methods behind the iris, in the lens or in the fundus by this 
method. 
The sideroscope, if properly made and mounted, will determine the presence of 
a foreign body, but it must be magnetic, and the accuracy with which you are able 
to locate foreign bodies within the eye often varies from 1 to 3 cm. "The instrument 
is a marvel of delicacy, but to handle it requires the patience of a saint." 
The giant magnet will reveal the presence of magnetizable pieces of steel and iron 
by causing traction within the eye, varying from a drawing sensation to decided pain 
on approach of the eye to the magnet. The foreign body may likewise be drawn into 
view, or the eye may adhere or curve forward toward the magnet if the body be suffi- 
ciently large. Such a method of examination is, however, somewhat dangerous, on 
account of the foreign body, while approaching the magnet, acting as a missile and 
tearing structures that might not have been previously injured. In such examina- 
tion the eye, needless to say, should not be anaesthetized. 
The increasing use of magnesium and nickel steel renders the number 
of non-magnetizable foreign bodies somewhat larger in proportion than 
previously. 
The exact determination of the existence, position and size of foreign 
bodies within the globe has only become possible since the advent of the 
Rbntgen rays. 
As the frequency of injuries to the eye from flying copper increases in 
number each year, due to more extended use of that metal, largely from DIAGNOSIS RELATIONS RESPONSIBILITY 
869 
the increased use of electricity, the value of accurate radiographs becomes 
more apparent. 
In a series of experiments to determine the degree of penetration of the X-rays 
to various substances, such as glass, marble, granite, cement, etc., Sweet placed parti- 
cles of these substances in the inner canthus of a cocanized eye. The size of each was 
approximately 2 X 2% mm. The result shows that all of these substances can be 
made visible if proper technique be followed. The figures show the density of shadows 
of each material, the exposure being the same for all materials, coal being the only 
one used that failed to demonstrate a shadow of any usefulness. 
Accidental injuries to the eyes maybe imitated by the patient's putting 
in medicinal or irritative substances or wounding or otherwise causing 
actual injuries to his own eyes (self inflicted damage), or, what is more 
commonly the case, alleging loss of sight or other function or liability to 
use the eyes, or painful affections (simulation), or overstating the degree 
of damage to the function of sight (aggravation)-all of which classes 
under the generic term of malingering. 
More difficult to determine are those cases where the existence of acci- 
dental lesion is apparent in which the injured party claims greater func- 
tional damages than actually exists in the individual. A number of 
observations should here be made in order to determine the proper 
relations. 
THE RELATION BETWEEN ACCIDENTAL INJURIES AND PREVIOUSLY 
INTERCURRENT AND POST-TRAUMATIC CHANGES IN THE EYE 
Conditions due to an accidental injury must be differentiated from 
those existing before, those concurrent with, or those occurring after the 
injury from other causes. 
In uncomplicated fresh cases, blemishes due to previously existing 
disease, or the results of former accidents, are readily determined, but 
especially those which come to the examiner a long time after the alleged 
injury; such may not be so evident, and afford weighty problems. 
It is especially necessary in these cases to make a general examination 
of the body and to note carefully the condition in the non-injured eye. 
In the injured organ note whether typical scars or inflammatory changes 
or their effects are to be seen. 
Many persons suddenly discover that they cannot see well with one or 
both eyes after an accident, whereas from myopia, high astigmia, hyperopia 
or even presbyopia they have previously been poor sighted and have not 
known of the condition. Some are honest in their claims; others seize the 
opportunity afforded by an accident to blame the deficiency upon the 
alleged trauma. 
THE RESPONSIBILITY OF THE PHYSICIAN 
Legally, the physician may be said to have no responsibility, as regards 
prognosis, and this is a matter of personal opinion rather than of fact, but 870 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
ethically his position is one which is twofold. From his own standpoint 
and that of the patient's good it is necessary that the patient retain a 
favorable opinion of the physician and, in many cases, continue to take 
treatment. Thus, by an unfavorable prognosis which may not prove to 
be true-for wonderful are the ways of Nature in curing disease and heal- 
ing injury-the physician may be discredited by a partial or complete 
restoration to health of the patient. Pecuniarily he may suffer as a result 
of the patient leaving him to go to some other physician who gives a more 
favorable prognosis. Secondarily the effect upon the patient's mind is 
one that should be considered, and hope should always be afforded to 
what is esteemed the hopeless cases. While the whole truth should be 
told the family physician and to the family of the patient, yet the whole, 
and what may be most unpalatable, truth need not be told the patient 
himself. This has to be learned by experience in the most unpleasant 
manner by the average physician as the result of an unfavorable prognosis. 
Prognosis of Injuries to the Eye.-The prognosis of ocular injuries 
depends largely upon the part of the eye that is damaged, more especially 
that having to do with the function of sight. Of first importance is the 
central visual acuity; secondly, the visual field; thirdly, the ocular move- 
ments; and lastly, the light and color sense. To these may be added the 
cosmetic damage and the ability to use the eyes for work, or, as Magnus 
puts it, the ability to compete; and the sum of them all results in the 
economic vision. 
Trauma acting on the parts of the eye necessary for clear vision, as the 
visual zone of the cornea, the lens, vitreous, macula lutea, does more 
damage in proportion than that to one side, and offers a more unfavorable 
prognosis on account of resultant obstruction to vision. Injuries to the 
optic nerve and visual sphere are usually followed by atrophy and blind- 
ness. Injuries of the ciliary region are provocative of sympathetic oph- 
thalmitis and loss of the other eye as well. As a rule, clean-cut wounds 
heal well if not infected. Infection may, as a rule, be successfully com- 
bated if seen in the early stages. Retained foreign bodies are always 
dangerous. Contusions are generally dangerous, as they lead to second- 
ary degenerative changes and detachment of the retina. Burns of the 
anterior portion of the globe are always to be feared, lime injuries espe- 
cially. Electrical injuries result in primary or secondary damage to the 
lens and retina. Double perforating wounds of the globe, even with 
retained foreign bodies behind in the orbit, are compatible with com- 
paratively small amount of damage to the function. 
Local fractures of the orbital walls are of less moment, quoad vitam, 
than those which extend along the base of the brain. 
The future prospects for eyes that have been injured opens a wide and 
doubtful field for prognosis, but as the physician is frequently asked in 
court concerning prognosis, and as this is a matter of constant inquiry 
from patients, he must have certain knowledge of the subject and be PROGNOSIS-CONSERVATION OF THE WOUNDED EYE 
871 
prepared with proper answers. There are certain lesions of the eye 
which almost invariably result in loss of function and even in loss of the 
eyeball itself; for instance, ulcerations of the cornea are as a rule followed 
by opacities, varying from nebulae to leucomata, which materially dimin- 
ish the visual acuity, especially if these be in the visual axis. Likewise, 
lesions complicated with iritis may, if not properly treated, result in occlu- 
sion of the pupil. Injuries of the lens almost invariably result in total 
opacity, although there have been a number of cases observed and 
reported in which foreign bodies have remained in situ for a number of 
years without causing further opacity; and development of partial cata- 
ract is observed in many cases. To this we refer to cataract from elec- 
tricity and distinguish true contusion of the lens. 
Contusions and wounds of the ciliary region frequently result in 
chronic irido-cyclitis and atrophy of the bulb. Retained foreign bodies in 
the eye result in blindness from such causes, as well as from sympathetic 
ophthalmitis. 
Many cases of amaurosis follow, as is well known, a blow on the head, 
of which the pathogeny is an indirect fracture through the optic canal, or 
an effusion of blood in the nerve sheath. But more frequently is it the 
case that, following a trauma of the cranium, the injured person, in good 
faith or not, claims the visual loss to be due to the injury, while the 
lessened vision may have existed prior to the accident. Of course, when 
the case is seen just after the trauma and amaurosis exists it is impossible, 
before some days have elapsed, to discover any optic nerve change. Optic 
nerve atrophy will follow in a short time. The optic papilla will guide in 
these cases. When the case is seen long after the accident, while the 
etiology is determined with less certainty, nevertheless to the trauma of 
the cranium may be attributed the cause if the contour of the atrophied 
papilla is clear. 
Precaution and attention to apparently trivial details of treatment 
would curtail in a marked degree the number and success of personal 
injury suits. 
The handling of an injured eye should be conservative from the first, 
to keep vision, preserve the appearance, relieve the agony, and even in 
some cases to save life. 
The public should be taught that the best first aid to injured eyes is, as 
a rule, to let them alone, apply clean cloth bandage and to immediately 
seek a physician, more especially an oculist, except where large quantities 
of foreign material as sand, dirt or corrosive substances, as lime or chemi- 
cals enter the eye; then the first application is free douching with clean, 
clear water. 
The radical treatment of injuries to the eye is practically summed up in 
the word enucleation, nearly all other procedures being conservative. 
CONSERVATION OF THE WOUNDED EYE 872 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
The therapy of the wounded eye is based upon general surgical 
principles, and from beginning to end the watchword is asepsis, or cleanli- 
ness. 
Concerning the septicity of the wound, all chips of metal entering an 
eye may be considered as free from organisms, the septic inflammations 
being produced by the subsequent entry of organisms either through the 
tract of the wound or during the operation for removal. 
It is universally recognized that when the foreign body is in the 
anterior segment of the eye, the injury is much less serious than when it 
has passed on through the lens into the posterior segment or has entered 
the vitreous chamber through the ciliary region or the sclera. 
A different story of the dangers, damages and results must be told 
about foreign bodies in the posterior segment of the eye, for as a rule these 
have flown with much force, have already wounded the anterior struc- 
ture in their course, and if allowed to remain in the eye not only destroy 
the sight and cause atrophy of the globe, but may result in sympathetic 
ophthalmitis. 
For the technical treatment of injuries to the eye the reader is referred 
to the text-books on ocular therapeutics. 
II. DISEASES DUE TO OCCUPATION INCURRING EXCESSIVE EYE STRAIN 
The second group consists of neuropathies, as nystagmus of miners, 
spasms of the orbicularis of watchmakers, of the ocular muscles from mili- 
tary drilling, and to the production of eye strain from the close study of 
students and in occupations requiring prolonged use of the eyes. 
But few oculists see the typical nystagmus of miners, but to those who 
live in coal-mining districts as well as to the workmen and employers this 
subject is of great importance. Some claim this is due to the con- 
strained position of the workers, either in excavating the coal or in 
inspectors from tapping the roof to see if it is safe.* 
* In this connection the Brit. Jour, of Ophthalm. (April, 1920) reports the discussion by 
the Illuminating Engineering Society (Eng.) upon the illumination of mines. Dr. Lle- 
wellyn opened the discussion with special reference to defective illumination as the cause 
of nystagmus. "A notable feature of the discussion," says the London Lancet, "was that 
no one was found to defend the view that the cramped position of the miner at his work 
is mainly responsible for nystagmus; this is in contradiction to the teaching of Mr. F. L. 
Hoffman's pamphlet, issued by the American Bureau of Mines, but the American report 
has no basis of personal experience. Whatever factors other than deficiency of illumination 
may enter into the causation of nystagmus, it is amply proved that the most important is 
the amount of light reflected from the surface of the coal at which the miner is working." 
Dr. Stassen in his book on ''The Fatigue of the Visual Apparatus of Mine Workers" 
(La Fatigue de 1'Appareil Visuel chez les Ouvriers Mineurs) agrees that the evidence is 
overwhelming that defective lighting of coal mines is, in the main, responsible. The 
visual apparatus of the miner is overworked, producing a nervous syndrome of inco- 
ordination and exaggerated visual reflexes (Jr. Ind. Hyg., II, No. 7, Nov., 1920, abstr. p. 
142). 
Dr. Frank Shufflebotham (Jr. Ind. Hyg., II, No. 7, Nov., 1920, 254) writing from 
England says that nystagmus is the commonest occupational disease known to medical 
science. He cites that the Home Office Statistics of Compensation for Great Britain 
during 1914 show that the total number of miners receiving compensation for nystagmus 
was approximately 6,000 of whom 2,775 were totally incapacitated for work. The disease EYE STRAIN LIGHT AND HEAT 
873 
The movements of the eyes are mostly rotatory, occasionally to and 
fro, but seldom vertical. The oscillations may be stopped by turning 
the eyes downward. Five to 20 per cent, of miners suffer and have to 
quit the occupation for intervals or altogether.f 
Nystagmus is also met in engravers, draughtsmen and compositors, 
jewelers and typists, but is only incidental. It is similar in type to 
writers' cramp and is speedily relieved by rest. 
Now we come to the great subject of eye strain from muscular and 
refractive defects, to which perhaps 90 per cent, of civilized eyes are sub- 
ject, and which is brought on by defective illumination and close use of 
the eyes. The latter is relieved by lenses and ocular muscle operations, 
and not to be elaborated here as thousands of pages of print on this 
subject may be found in text-books and medical magazines. It must 
be remembered that perfectly normal as well as diseased eyes may suffer 
from glare and eye strain from overwork. 
The production of myopia in schools and by close work is a live issue. 
Certain races as the Teutons and the Jews seem more apt to develop this 
anomaly, which in some leads to grave changes in the eyes and loss of 
visual acuity or even blindness; for this see other text-books. 
III. DISEASES DUE TO EXCESSIVE EXPOSURE TO LIGHT AND HEAT 
The constant gazing at bright objects, as by dentists in gold filling and 
by electroplaters, may cause evanescent scotomata which, though 
alarming at the time, disappear on resting and may be prevented by the 
use of appropriately tinted glasses. 
A more severe affection may be seen in steel melters, electro-welders, 
glass workers and furnace men and in exposure to strong light, when the 
brighter light may not only temporarily use up the visual purple but cause 
a degeneration of the retina at the macula similar in type to that caused 
by looking at the sun in a solar eclipse. Cobalt and dark glasses may 
prevent the occurrence. 
The heat of melted iron, glass, electric and other furnaces, etc., is 
responsible for burning of the lids, cornea and perhaps even for the cata- 
ract of glass blowers and degeneration of the retina. Protection by dark 
glasses and helmets prevents this occurrence. 
takes from 10 to 20 years to mature before complete incapacity, for which there is no 
treatment except quitting the work. He regrets that, although the cause is known, nothing 
has been done effectively to prevent the disease in British mines. 
In America, Lane and Ellis examined the eyes of 500 Illinois coal miners, or % o of the 
entire number, in 1910, without finding a single case of nystagmus and concluded the cause 
to be due to the fact that the "Gross Weight Law," which removed the necessity for miners' 
picking down coal from overhead with selective care, as well as the introduction of machine 
mining in place of much of the pick mining, had abated the unnatural positions assumed 
at work (Report of Ill. Commission on Occ. Diseases, Jan., 1911, p. 155). However, 
Hayhurst and his co-workers, who investigated the subject in Illinois and Ohio in 1918, 
concluded that the adequacy of illumination probably explains the absence of nystagmus 
(see the present Volume page 151). (Hayhurst). 
tThis refers to statistics from England and elsewhere than America. 874 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
Short circuiting of electric wires give rise to terrible general burns, and 
the electrolysis, to formation of cataract and changes in the retina, 
amblyopia and blindness. Most of these accidents are due to care- 
lessness of employes and are to be prevented only by education and 
intelligence. 
IV. TOXICOLOGY-SYSTEMIC POISONING CAUSING LOSS OF SIGHT 
The ingestion, inhalation, epidermic, hypodermic, endermic, intra- 
muscular or any other method by which certain toxic substances may get 
into, or be developed within, the system induces changes in the tissues of 
the eye by which diverse effects are produced, denominated by the term 
toxic amblyopia. 
Among the commonest poisons thus affecting the eye are alcohol, 
tobacco, iodoform, naphthalin, caffeine, acetanilide, salicylic acid, atoxyl, 
arsenic, felix mas, santonin, and pomegranate (to which latter some persons 
have an idiosyncrasy, particularly as regards damage to vision and the 
eyes, even in medicinal doses). 
Arsenic is extensively used in wall paper, clothing, artificial flowers, making Paris 
green and in paints, and these workers, as well as those who take it medicinally or use 
cosmetics, are liable to suffer from eczema of lids and conjunctival hypersemia as well 
as (in a few cases) from amblyopia and optic neuritis. 
Of those occurring in trades, there have been reported cases of miners' arsenical 
poisoning with resultant optic nerve atrophy, following the dust from the brittle 
mineral known as sulfarsenide of cobalt; but as arsenic is usually found in the form of 
arsenical pyrites it does not seem to cause any injurious effects. 
Likewise in ordinary lead mines lead poisoning is almost unknown, as it is usually 
mined in the form of galena, the sulphide of lead, a heavy and quite insoluble sub- 
stance. In carbonate mines, the earthy lead carbonates give rise to lead poisoning, 
and in a few cases paralysis of the extrinsic muscles of the eye has been noted. In the 
production of the white oxides of lead for paint, plumbism has been often seen, and 
with the general symptoms paralysis of the ocular muscles has been noted. Lead is 
used in many occupations, especially painting, plumbing, file cutting. No acute 
eye cases are reported, but chronic cases from inhalation of dust in sand paper- 
ing once-painted surface; from wetting of fingers, and holding of paint brushes and 
tools in the mouth. Central and peripheral contractions of the visual field are seen 
from retrobulbar neuritis; palsy of the eye muscles is also encountered. 
Amyl alcohol or fusel oil, found in impure wines, whiskies, etc., seldom causes 
complete blindness and is rarely known in trades, generally following chronic alco- 
holism usually associated with tobacco. 
It may be that cases have occurred of tobacco blindness in producers and handlers 
of tobacco from inhalation of the dust or from licking the leaves as is sometimes the 
filthy habit of cigar makers, but I have never seen such. Those tobacco workers that 
I have encountered with toxic amblyopia were all heavy drinkers. 
Methyl alcohol or wood spirit is frequently used in the preparation of varnish, 
lacquer, polish, perfumes and other industries enumerated in the List of Industrial 
Poisons (see page 654). Cases of conjunctivitis, also serious affections of the retina 
and the optic nerve resulting even in blindness from atrophy of this nerve, have been 
reported. * TOXIC BLINDNESS-ECONOMIC DAMAGE 
875 
Tea tasters consume an enormous amount of the tea and I have seen several cases 
of amblyopia in these people, who have all recovered when they have taken a vacation 
from their vocation together with appropriate treatment. 
Bisulphide of carbon in rubber making has been shown to produce amblyopia.' It 
is less used than formerly in curing rubber. 
In the manufacture of explosives, dinitrobenzol is responsible for general changes 
in the blood and nervous system and in the making as well as the using of same for 
explosive charges, especially in mines, has given rise to toxic amblyopia. 
In dye factories and in the manufacture of coal-tar products there are complaints 
of irritation of the eyes and loss of vision from its inhalation and absorption, possibly 
due to anilin poison. Arsenic as a contamination must also be considered. 
Iodoform is used in surgery and has caused kidney and eye lesions, but no evil 
effect has been reported from its manufacture. 
V. THE ESTIMATION OF ECONOMIC DAMAGE 
Upon the use of the organ of vision depends the earning powers for the 
large majority of trades and professions; thus earning ability is economic- 
ally synonymous with visual earning ability. 
It is self-evident that a totally blind person is absolutely incompetent in any 
trade or profession requiring eyesight. An economically blind person-i.e., one 
whose visual acuity is less than 5 per cent, of the normal-is in the same position, for, 
although he may be able to get about, the vision is not sufficient to allow of even the 
lowest grade of remunerative work. The vast majority of blind people are not only 
incapable of earning anything, but are a charge upon their families and upon the 
community. It is true that there are certain exceptions to the above proposition. 
There are, and have been, blind persons who have become poets, machinists, chair 
makers, broom makers, etc., but cases that have become economic factors are so 
unusual as to be commented upon in the public press and held up as especially tal- 
ented and well-placed persons who, by great labor of their teachers, and by their own 
exceptional diligence, have been so highly educated as to be able to meet, in a measure, 
with the competition of normal individuals. In the case of an adult suddenly becom- 
ing blind, his previous economic education goes for naught, and he at once steps out of 
the ranks of workers. 
Nearly all trades and professions require good eyesight, even the coarsest sort of 
labor being affected if the vision falls below 50 per cent., and being impossible if it is 
below 0.05 per cent, of the normal visual acuity. For finer kinds of work, the visual 
range is between 75 per cent, and 15 per cent. A workingman who either suddenly 
or gradually becomes blind loses his job, and with it his earning ability. Aside from 
the loss of time and wages ensuant upon the injury and convalescence therefrom, poor 
sight certainly affects the amount and character of Work, the quality and output 
diminishing in a direct ratio to the loss of sight, until a degree is reached where the 
person cannot work any more. The remuneration for work necessarily depends upon 
its amount and its quality. Thus injury to vision generally necessitates loss of earn- 
ing powers. 
The pecuniary value of a man's life may, for our purposes, be expressed 
by the amount of money that he may earn in the course of his life. We 
stated above that the visual earning ability was economically synony- 
mous with the full earning ability, and we may thus value vision with the 
pecuniary valuation of life. 876 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
We may say that 11 sight is priceless" and "vision is not a commodity 
that may be purchased or disposed of in the market," for there are few 
persons who would voluntarily allow of the infliction of any unnecessary 
bodily injury for any compensation whatever; but such matters of ethics 
do not fall within the pale of our present discussion. We are dealing with 
the established economic fact that injury to vision of more than a certain 
extent necessitates limitation of the amount and character of work. 
Following upon this, it is easily deduced that the amount of wages receiv- 
ed would be less. 
The question now arises, how are we to reckon the loss of wages? 
This we may do from experience in examining large numbers of indivi- 
duals. It has been found that the loss of vision of a certain amount 
results in a certain effect upon the earning ability of the individual. 
We may also deal with futurities, and figure the probable loss in any 
given case by finding the percentage of damage to the normal function, 
and apply our reasoning to the calculation of the probable pecuniary loss. 
In order to do this we have accepted the visual earning power as equiva- 
lent to the total earning power. 
The Formula of Magnus.-Magnus therefore evolved a formula which 
we have accepted as the simplest and most appropriate, which considers 
the visual earning ability as composed of the several factors entering onto 
vision together with the ability to compete, expressed as an arithmetic 
equation. 
Thus: 
E =Fy/K. 
E = Earning ability = ocular earning ability. 
F ■ = Visual act. 
y/K = Ability to compete. 
F = C (maximum) y/Py/M = physiologic act of vision in which 
C (maximum) = maximum acuity of the better eye. 
y/P = Binocular visual field. 
X^ M = y/M = normal value of ocular muscles. 
This is modified by the ability to compete: 
yx = 
Ci + C2 - 
in which 5 = the added acuities of both eyes, y/P the visual field, 
and y/M the muscular action, the complete formula for the ocular earning 
ability being 
E = C (maximum) y/Py/M^^~^ 
which is the mathematical expression of the earning ability and which 
may be readily calculated by anyone who can do a simple algebraic ESTIMATING EYE DISABILITIES 
877 
equation, as it is reduced to a simple multiplication example by using 
tables which have been compiled for the purpose, as the algebraic signs 
are replaced by figures which are readily found therein. The roots are 
readily calculated or may be found in our tables. Wurdemann has added 
monetary computation to this formula and the method is now known and 
accepted as a scientific fact and is received as such in present forensic 
practice. (Visual Economics, Magnus and Wurdemann, 1902, and 
subsequent essays.) * 
Schedule of Ratings for Eye Disabilities.-The generally accepted 
rules for the estimation of pensions, insurance and damages at law from 
injury to vision are based wholly upon precedent and are purely empirical. 
The most satisfactory and simple are those of the U. S. Treasury Depart- 
ment, Bureau of War Risk Insurance, which are quite similar to those 
of the Service Insurance Department of France and to those of the De- 
partment of Labor and Social Accident Prevention of Italy. Those of 
the U. S. Treasury Department are followed in part by a number of the 
States of the American Union. The author had the occasion to collate 
those which are herewith appended :f 
"In arriving at the following schedule of ratings for eye disabilities, the various 
opinions of leading eye specialists in the United States and the schedule of rat- 
ings of Belgium, France, Canada and England, now in effect, have been taken into 
consideration. 
Abbreviations used: T. P.-Temporary partial. 
P. P.-Permanent partial. 
P. T.-Permanent total. 
1. The ratings for refractive errors as herein stated are in all cases where visual 
acuity has been corrected with proper lenses. If due entirely to refractive errors, no 
rating should be awarded for any defect in visual acuity. Progressive high myopia 
with degenerative changes in the eye should be considered a disease and rated under 
Par. II. 
2. For the purpose of rating visual disabilities due to corrected refractive errors, 
20/40 vision (Snellen's) in each eye shall be considered the minimum of NORMAL 
VISION, and vision of less than 10/200 in an eye will be considered as equivalent to 
total loss of vision in that eye. If due to an injury or disease originating during 
service, no rating should be awarded for any defect in visual acuity which is 10/20 or 
better in each eye, or can be corrected by glasses up to 10/20 or better in 
each eye. 
3. In determining whether the defect in the visual acuity is due in any way to an 
injury or disease originating during the service, the history of the case and the result 
of a complete ophthalmologic examination should be carefully considered and the 
specialist's report confirmed by a consultant eye specialist. 
4. If recorded on enlistment, or having history of injury pre-existing to enlistment, 
thedollowing conditions may be considered as "obviously apparent" on enlistment- 
* The results obtained by this formula and other methods have been subjected 
to> much discussion, but few changes in the results computed have been made. 
tWiirdemann, H. V.; "Industrial Insurance and Indemnity Rules,'' Trans., Pacific 
Coast Oto-Ophthal. Soc., 1921. 878 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
External injuries or scars; organic disease in the interior of the eye, such as chorioiditis, 
optic atrophy, or possible lens changes. 
5. Functional loss of vision should be rated as less than ten per cent, whether in 
one or both eyes. 
In functional visual defects it is necessary to take into account- 
(a) Visual acuity 
(b) Field of vision 
(c) Binocular vision. 
Errors of color and light sense notwithstanding their rarity are symptoms of lesions 
of the nervous system and should be taken into account in conference with the Neuro- 
psychiatric Section in the estimation of the disability due to these lesions. 
Color blindness of congenital origin is not to be considered of service origin. 
Schedule of Permanent Ratings for Properly Corrected Refractive Errors In Vision 
(One Eye) 
Other 
eye of 
or less 
than 
Or less 
than 
1%oo> 
per cent. 
1%oo, 
per cent. 
2%00, 
per cent. 
2%oo, 
per cent. 
2%0, 
per cent. 
2%0, 
per cent. 
2%0, 
per cent. 
1%oo 
100 
90 
80 
70 
60 
40 
30 
1%oo 
90 
80 
70 
50 
45 
30 
25 
2%00 
80 
70 
50 
40 
35 
25 
15 
2%00 
70 
50 
40 
30 
25 
20 
10 
2%0 
60 
45 
35 
25 
20 
15 
7 
2%0 
40 
30 
25 
20 
15 
10 
5 
2%o 
30 
25 
15 
10 
7 
5 
0 
To the above table of ratings, a certain percentage shall be added for special 
conditions enumerated as follows: 
(a) Obliteration of direct vision such as from corneal opacity, deformed pupils, 
central chorioiditis, lenticular opacity and retinal detachment. 
For one eye Add 10 per cent, permanent partial 
For both eyes Add 20 per cent, permanent partial 
(b) Extraction of lens: 
For one eye Add 15 per cent, permanent partial 
For both eyes Add 30 per cent, permanent partial 
In rating for extraction of lens either unilateral or bilateral the combined visual 
acuity for correction should be taken into account. 
PROVIDED, that part of the above percentages will not be added which will 
increase the total percentages to exceed 100 per cent.; that no percentages for more 
than one of the above conditions, will be added to the same case, and that no total 
percentages will be given for any of the above conditions which is in excess of that 
given for complete loss of sight in the affected eye. 
It is necessary to establish a general rule: 
1. In each case where ocular functional troubles, without anatomical lesions of 
the eye or its adnexa, as evidenced by objective examination, can only be considered 
absolutely incurable when the central or peripheral vision is involved. RATINGS FOR EYE DISABILITIES 
879 
2. It is also considered the same in all lesions as cataracts, retinal detachments 
and ocular hemorrhages, in the stage of evolution. 
Blindness or Irremediable Loss of Sight 
In this category should be considered the absence or atrophy of the two globes, 
leukoma, cicatrical staphylomas occupying the greater part of the corneas, complete 
atrophy of the optic nerve, extensive cicatrical lesions of the chorioretina in the region 
of the posterior pole, and retinal detachment in the stage of evolution. 
From a practical standpoint blindness can be considered to exist where the central 
vision of one eye equals Ho with a deficient visual field, the other being inferior 
to Ho 100 per cent. 
In other words in one eye, and less than 1%oo with deficient 
visual fields 100 per cent. 
It is necessary to distinguish cases of loss of vision without apparent lesions, from 
loss of vision accompanied by mutilation such as enucleation, atrophy of globe, and 
extensive staphylomas. 
Lack of accommodation and convergence (according to Duane's 
table) P.P. 20 per cent. 
Diplopia (uncorrectable) P.P. 30 per cent. 
Loss of conjugate movement in both eyes or three movements in the 
seeing eye P.P. 50 per cent. 
Permanent concentric contraction in field of vision in one eye to 
10 per cent, not subject to restoration by treatment P.P. 10 per cent. 
Permanent concentric contraction in both fields to 60 per cent, or 
loss of temporal halves P.P. 75 per cent. 
Loss of nasal halves in both fields. P.P. 50 per cent. 
Homonymous hemianopsia, lateral, superior or inferior P.P. 40 per cent. 
Concentric contraction of both fields to 30 per cent P.P. 25 per cent. 
Concentric contraction of both fields to 10 per cent, of normal with 
retention of normal central vision P.P. 50 per cent. 
Scotomas rated on interference with visual acuity 
Color blindness P.P. 10 per cent. 
Heterophoria to a degree sufficient to produce asthenopia P.P. 10 per cent. 
Nyctalopia (in proportion to degree of light sense) P.P. 20 per cent. 
Retinitis Pigmentosa. Rate on contraction of visual field and 
visual acuity. 
1. EYE LIDS: 
Infectious processes and tumors 
Lagophthalmus 
Ectropion-Uncomplicated 
Remediable 
Entropion-Irremediable 
Symblepharon-Complicated 
Epiphora remediable 
Irremediable. 
Ptosis 
One eye 
Two eyes 
See- Face. 
P.P. 20 per cent. 
Less than 10 per cent. 
Less than 10 per cent, to 30 per cent. 
Permanent partial. 
Rate on complications. 
T.P. 10 per cent. 
Temporary total if hospitalized. 
P.P. 10 per cent, for one eye 
P.P. 15 per cent, for both eyes 
P.P. 15 per cent. 
P.P. 25 per cent. 880 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
2. EYE BALL: 
(a) Injuries, infections and inflam- 
mations (including glau- 
coma, keratitis, iritis, irido- 
cyclitis. Uveitis, scleritis, 
pan-ophthalmitis. 
Sequelae-(Rate on visual and 
cosmetics defects.) 
Temporary partial 10 per cent, to tempor- 
ary total depending on clinical findings. 
(b) Tumors: 
Benign 
Malignant 
Nystagmus 
Rate on visual and cosmetic defects. 
P.P. 10 per cent, to permanent total 
Rate on visual defects. 
(c) Enucleation of eye ball: P.P. 40 per cent. 
(d) Traumatic Cataracts: 
Non-operable (the rating to depend upon degree of visual acuity). 
Operable, or where the cataract is absorbed: 
(If the vision is below that of the non-affected eye by reason of the impossibility 
■of fusion of images, add 10 per cent, if the total disability will not be more than the 
loss of vision of one eye.) 
If the vision of the non-cataractous eye is worse or absent refer to the table of 
visual acuity, rating the aphakic eye according to the best optical correction. 
(e) Dislocation of the crystalline lens, intra-ocular hemorrhages, and detachment 
of the retina, causing different degrees of disability will be rated according to the 
■degree of vision. 
(/) In all conditions involving the optic nerve the fields of vision must be recorded. 
(7) In conditions with diplopia muscles involved must be specified. 
Paralysis of muscles of only one eye P.P. 25 per cent. 
Paralysis of muscles of one eye and one muscle in working eye... . P.P. 35 per cent. 
Paralysis of muscles of both eyes, working eye, 3 or more muscles... P.P. 40 per cent. 
Paralysis of all muscles of both or of working eye 100 per cent. 
to 50 per cent. 
(h) In all cases of total blindness where the claimant is in constant need of a 
nurse or attendant an additional rating of 20 per cent, shall be had from the date of 
permanent and total blindness. 
Complete loss of taste and smell . P.P. 35 per cent. 
Loss of taste P.P. 25 per cent. 
Loss of smell - P.P. 15 per cent. 
In all border line cases a conference should be held with the Section within whose 
jurisdiction the disability is handled, and a combined rating derived at to cover the 
disability." 
VISUAL POWER IN AN ECONOMIC SENSE* 
ARRANGED BY EMERY R. HAYHURST, M. D„ Columbus, Ohio 
The fractions by which the oculist records visual acuity as obtained by 
reading the letters of the ordinary test chart do not express the fractional 
value of visual power in an economic sense. It is well known that many 
individuals with normal eyes and little if any ametropia may not read 
* Brown, John Edwin, Eye Injuries and the Workingman's Compensation Law, Ohio 
State Medical Journal, Dec., 1920, XVI, No. 12, 909-914. EYE RATINGS ECONOMICS OF VISUAL POWER 
881 
better than 2%o by chart, yet such individuals suffer no inconvenience 
in any way from such vision. The appended table, adopted by the 
Chicago Ophthalmological Society in November, 1919, is taken to express 
the present valuation of visual loss in one eye.* 
Chart for Evaluating Visual Loss in One Eye 
2%o indicates 100 per cent, of visual efficiency and no loss of vision 
2%o indicates 94.5 per cent, of visual efficiency and 5.5 per cent, loss of vision 
2^o indicates 89.0 per cent, of visual efficiency and 11.0 per cent, loss of vision 
2%o indicates 83.5 per cent, of visual efficiency and 16.5 per cent, loss of vision 
2%o indicates 78.0 per cent, of visual efficiency and 22.0 per cent, loss of vision 
2%o indicates 72.5 per cent, of visual efficiency and 27.5 per cent, loss of vision 
2%o indicates 67.0 per cent, of visual efficiency and 33.0 per cent, loss of vision 
2%oo indicates 56.0 per cent, of visual efficiency and 44.0 per cent, loss of vision 
2%2 0 indicates 41.0 per cent, of visual efficiency and 59.0 per cent, loss of vision 
2%50 indicates 28.5 per cent, of visual efficiency and 71.5 per cent, loss of vision 
2%70 indicates 18.5 per cent, of visual efficiency and 81.5 per cent, loss of vision 
2%oo indicates 10.0 per cent, of visual efficiency and 90.0 per cent, loss of vision 
The Ohio regulations give no compensation on a permanent disability 
of less than 25 per cent, loss of vision in one eye, allowance being made 
only for temporary disability; the section reading "For permanent par- 
tial loss of sight of an eye 66% per cent, of the average weekly wages 
for such portion of one hundred weeks as the Commission may, in each 
case, determine, based upon percentage of vision actually lost as a result 
of the casualty, but in no case shall an award be made for less than a 
25 per cent, loss of vision." It is to be noted from the above table and 
likewise by the action of the Commission that any person whose vision 
is below 2%oo, «-e., whose visual power is below 10 per cent., is industri- 
ally blind. 
The loss of one eye lessens the reserve against possibilities of the future 
by one-half. Now the loss of one eye only is ordinarily valued at from 
% to % the economic value of both. Suppose such an award is made, 
and later in life the remaining eye is lost through disease or non-industrial 
causes. In what position is this man who by the loss of the first eye by 
injury is now placed in the class of permanently totally disabled, it being 
considered that total loss of vision in both eyes is comparable to loss of 
life in an industrial sense? Again, is there any difference in the visual 
worth of an eye that has its vision reduced to say 2%oo by (a) corneal 
opacity, and (6) trouble of the fundus, whether of optic nerve, retinal, or 
choroidal origin? It has impressed the writer that an eye whose vision 
was reduced to 2%oo by fundus trouble was not nearly so useful an organ 
of vision as one whose vision of 2%oo may have been brought about by 
corneal opacities. In the latter case it has seemed that vision at short 
range was relatively better. 
* Sharp, Walter N., Loss of Industrial Vision. Am. Jour. Ophth., June, 1920, 3, No. 6, 
434-435. 882 
OCCUPATIONAL INJURIES AND DISEASES OF THE EYE 
The expense to the state in 135 cases of eye inj ury has been: 
(a) compensation allowed, 
$58,101.37 + 3PT = $76,101.37 
(6) for medical service $9,514.53 
Average compensation, 135 cases = $563.71 
Average medical service = $70.40 
This does not include any part of the overhead in the administration 
of the law. Since August, 1919, when the practice was established of 
serially numbering the cases referred for special ophthalmologic examina- 
tion and report, there have been up to the end of May, 1920, 834 such 
cases referred to the various referees. SECTION 2 
GLASS-WORKERS' CATARACT 
T. M. LEGGE, M. D., Home Office, London, England 
Significance.-Following on the Workmen's Compensation Act, 
1906 which, in section 8, applied the principle of compensation as in the 
case of accidents to poisoning by lead, arsenic, phosphorus, and mercury, 
and to the two infections by anthrax and ankylostomiasis, a Committee 
was appointed to consider what other diseases were due to industrial 
occupation, were distinguishable as such, and could properly be brought 
under the provisions of the section. One of the most interesting diseases 
thus brought under review, and the one upon which there was the greatest 
difficulty in coming to a decision, was occurrence of cataract in glass 
workers. In regard to the disease four questions had to be decided: 
(1) Did it exist? (2) Was it much more frequent in glass workers than 
in the general male population? (3) Was it characteristic? (4) 
Would it be in the interests of the workers themselves to schedule it 
since not the fact of having cataract entitled to compensation but only 
incapacity resulting from it? 
The attention of the Committee was first directed to the subject by the evidence 
of the secretary of the glass-bottle makers of Yorkshire United Trade Protection 
Society-a signal instance of the value of the material contained in such Society 
records if only they are properly used. He suffered from defective eyesight himself 
and in noting the sickness claims was struck by the frequency with which cataract 
appeared as a cause leading to superannuation. Thus he was able to show that 
among some 2000 members of whom 114 were superannuated, no less than 34 (30.0 per 
cent.) had suffered or were suffering from cataract. In another similar trade society 
with 1000 members it was ascertained that 6 out of 30 members on the superannuation 
fund were disabled on account of cataract. 
The employers, on the other hand, attached small importance to the ailment no 
doubt because the number of cases in proportion to the number of men employed was 
small and, in individual works, so extremely small as to make some of them deny its 
existence as a trade disease. The matter, from the administrative point of view, was 
further seriously complicated by the fact that employers threatened in self-defence, if 
glass workers' cataract were scheduled, to have periodical examination of the eyes of 
the persons employed made and to discharge, many years it might be before there was 
any incapacity, those showing changes in the lens. Nor did the Committee at the 
time they had to report know of any statistics showing what the incidence of cataract 
was among the general population. If cataract, they said, was found to be 10 times as 
frequent in glass workers as among other people of similar age the disease ought to be 
scheduled, even although in one case out of ten the employer would be required to pay 
compensation to a man in whom it would have developed had he never been employed 
in that trade. The matter, therefore, was left over for further inquiry which I was 
asked to make. 
883 884 
GLASS WORKERS' CATARACT 
Already, in 1903, Dr. W. Robinson,1 Surgeon to the Sunderland and Durham 
County Eye Infirmary-a district comprising several bottle and pressed glass works- 
had published a paper in which he concluded that hard cataract in bottle finishers was 
very common. "How much commoner it is than among the rest of the community is 
shown by the fact that 18 out of 75 (1 in 4) hard cataracts operated on last year in our 
Eye Infirmary were in bottle finishers, there being only 200 or 300 bottle finishers in a 
population of nearly a million and a quarter in this county." 
Glass-making Processes.-Briefly described the work in a glass-bottle factory is as 
follows: The mixed materials spoken of as "metal" and consisting of sand, clay, lime, 
marl, etc., are thrown by the "founder" into a furnace or "tank" kept at a white heat 
of about 1500°C. At the opposite end of the furnace are several openings at which the 
bottle makers work in squads of five each. The "gatherer" dips the iron blowpipe 
into the metal, having in doing so naturally to look into the white mass, and takes up 
sufficient to make a bottle. This he hands to the bottle blower who places it in a 
mould and blows down the pipe to form the bottle. From the glass blower the bottle, 
still on the end of the pipe, is handed to the finisher who cuts it off from the pipe. The 
finisher, standing right up against the "gloriole," looks through this into the molten 
metal and takes up sufficient to form the rim on the neck of the bottle. He then seats 
himself, sheltered by a brick projection, and puts the rim on round the neck. 
Robinson calculated that during each shift of 11 hours from 110 to 120 bottles are 
finished, and reckoning the time of looking into the furnace at about 3 seconds a time, 
the eyes of the finisher are exposed to the glare for 5^ hours a week. 
In the making of pressed and flint glass the heat is not so intense and the finisher 
of flint glass bottles sits some yards away from the furnace into which he need never 
look. The processes in the manufacture of sheet and plate glass are essentially the 
same. Sheet glass, however, in the present day is blown not by the mouth but by 
means of compressed air into huge cylinders which are first annealed and then cut into 
two halves and flattened out in a furnace kept at a dull red heat only. 
Pathology and Incidence.-As to the character of the cataract, 
Robinson pointed out in proof of its industrial origin from exposure to the 
intense heat and light of the furnace that it commenced always at the 
posterior pole of the lens involving the cortex. Ordinary senile cataract 
on the other hand develops usually in the form of sectors or radii from 
the periphery of the lens. His explanation of its origin was that the 
posterior pole was practically the optical center where the principal rays, 
falling on the lens, cross and pass on without refraction, and further, the 
point where undue crowding together of all the rays from the furnace, 
except the direct and principal, rays which undergo refraction at the 
anterior surface of the lens. 
In a subsequent paper in 1907 Robinson2 adduced as further evidence 
of his contention the results of his examination of the men in three glass 
works in the Sunderland district where among 400 men he found 37 
finishers and 3 gatherers who were suffering from cataract. 
Comparative data, however, were wanting. To obtain them I 
examined the crystalline lens in the eyes of 513 glass workers engaged in 
the gathering, blowing, finishing and flattening of glass. Subsequently, 
under precisely the same conditions, I examined the eyes of 278 persons 
who were not glass workers. 
The results are shown in Table 1. PATHOLOGY AND INCIDENCE 
885 
Table 1.-Changes in the Lens among 513 Men Engaged in the Gathering, 
Blowing, Finishing, and Flattening of Glass, and 278 Other 
Persons, All 30 Years of Age and Over 
Occupation 
30-40 
Per- 
cent- 
age 
41-50 
Per- 
cent- 
age 
51-60 
Per- 
cent- 
age 
Over 
60 
Total 
Per- 
cent- 
age 
Sheet glass- 
Blowers 
48 
10 
2 
- 
1 
61 
Positive 
5 
10.4 
2 
20.0 
33.3 
1 
8 
13.1 
Gatherers 
90 
19 
2 
111 
Positive 
7 
7.8 
2 
10.5 
2 
100.0 
11 
9.9 
Flatteners 
78 
23 
2 
103 
Positive 
12 
15.4 
4 
17.4 
2 
100.0 
18 
17.5 
Total 
216 
52 
6 
1 
275 
Positive 
24 
11.1 
8 
15.4 
4 
71.4 
1 
37 
13.5 
Glass bottles- 
Finishers 
88 
68 
32 
.- 
4 
192 
Positive 
7 
7.9 
14 
20.6 
16 
52.8 
3 
40 
20.8 
Blowers ...'. 
9 
1 
5 
3 
18 
Positive 
2 
50.0 
2 
4 
22.2 
Gatherers 
5 
3 
1 
9 
Positive 
2 
40.0 
1 
33.3 
3 
33.3 
Total 
102 
72 
38- 
7 
219 
Positive 
9 
8.8 
15 
20.8 
18 
51.1 
5 
47 
21.5 
Pressed glass- 
Finishers 
7 
3 
4 
.- 
1 
15 
Positive 
1 
14.3 
3 
80.0 
1 
5 
33.3 
Gatherers 
4 
4 
Positive 
1 
25.0 
1 
25.0 
Total 
11 
3 
4 
1 
19 
Positive 
2 
18.2 
3 
80.0 
1 
6 
31.6 
Grand total 
329 
127 
48 
_ 
9 
513 
Positive 
35 
10.6 
23 
18.1 
25 
56.1 
7 
90 
17.5 
Other persons 
141 
90 
45 
.- 
2 
278 
Positive 
3 
2.1 
8 
8.9 
8 
17.0 
19 
6.8 
Viewed in this way changes in the lens are shown to be about five times 
as frequent in glass workers between 30 and 40 years of age as in other 
persons, about twice as frequet in those between 41 and 50, and over 
three times as frequent in those over 50. All classes of workers exposed 
to incandescent molten glass appeared to suffer, and the differences 886 
GLASS WORKERS' CATARACT 
which are to be noted in the incidence on those making sheet glass, glass 
bottles, and pressed glass, are not striking. A point of interest was that 
the class of gatherers in sheet glass works showed considerably the 
smallest number affected. The heat from the furnace here is so intense 
that the gatherer is compelled to shield his face with a screen, held in 
the mouth, with blue glass in front of the eyes. 
Mere statement of the number needs to be amplified by character of 
the changes observed. The very striking differences thus brought out 
can be tabulated as follows: 
Comparison of the Nature of the Changes in the Crystalline Lens of the 
513 Glass Workers and 278 Other Persons 
513 glass 
workers 
278 other 
persons 
Right 
Left 
Right 
Left 
Cataract extracted 
3 
5 
Cataract so mature that its nature could not be determined 
4 
2 
Posterior cortical cataract 
17 
19 
1 
Commencing posterior cortical cataract 
5 
8 
1 
Dot-like posterior cortical opacity (in central area) 
Posterior cortical opacities (not in central area), radii, 
5 
2 
striae 
4 
11 
1 
1 
Peripheral stria;, radii and sectors 
14 
15 
11 
9 
Other opacities 
5 
3 
1 
2 
General dulness of lens 
7 
7 
Total 
64 
72 
14 
13 
When viewed with the ophthalmoscope by the indirect method the characteristic 
change in the lens of the glass worker is opacity of the posterior cortical layers (like 
a blot of ink) of varying size, within the pupillary area. Changes in the posterior 
layers were present indeed in over half the positive cases. In the control population 
examined the characteristic change was, as one would have expected, the appear- 
ance of peripheral striae around the margin of the lens, the central pupillary area remain- 
ing perfectly clear. There was exception to this in two cases only and in them the changes 
could not be distinguished from the condition observed in glass workers. The occu- 
pation of one of these had been constant attendance for 25 years at an annealing 
furnace in Woolwich Arsenal--work similar to that of a glass flattener. Among the 
control population none had sought treatment for cataract, and certainly in not more 
than three were the opacities so pronounced as to cause any impairment of sight. 
Among the glass workers, however, in addition to six in whom a single extraction for 
cataract had been performed and in one a double extraction, there were at least 25 
others in whom the sight of one or other of the eyes was seriously impaired by the 
opacity. Yet it was surprising how almost unimpaired for work the sight appeared 
to be of several of those in whom small but quite definite posterior cortical cataract 
was present. Even when vision is affected the bright light given out from the molten 
glass and the mechanical nature of the work both help to overcome or mask the defect. PATHOLOGY-COMPENSATION CAUSAL FACTORS 
887 
Were the occupation one necessitating fine work the condition would become appar- 
ent much sooner. Many, no doubt, pass through the normal working life ignorant 
of its existence. 
I next sought figures as to cataract as a cause of disablement and 
superannuation in other trade societies. The Hearts of Oak Benefit 
Society with a membership of some 300,000 had a large class receiving 
reduced sick allowance the conditions of receipt of which were that the 
member should have been on the Society's sick funds for at least 12 
months. I believed that if the number of those in receipt of this reduced 
sick allowance could be ascertained for a number of years fair comparison 
was possible with the figures supplied to the Committee of superannuated 
members by various glass-bottle Trade Societies. This I was able to do, 
finding the incidence of cataract among the 10,549 members in receipt 
of reduced sick allowance 0.78 per cent, as compared with 22.6 per cent, 
among the 186 superannuated members of glass-bottle Societies. The 
average age of incapacity from cataract was in both about the same-56 
years. Cataract, indeed, as a cause of disablement among superannuated 
members of the Yorkshire Bottle Makers' Society considerably exceeded 
the disablement from every form of heart and lung disease among the 
members on the reduced sick allowance of the Hearts of Oak Benefit 
Society. 
When to Compensate.-While the case was thus proved for the indus- 
trial origin of the disease the fact remained that it was of very slow 
growth, and that, during the many years when the efficiency of the work- 
man remained unimpaired, it would be impossible for him to claim 
compensation. And yet an ophthalmoscopic examination of the eyes 
would reveal the disease in an incipient stage. The scheduling of the 
disease without qualification thus opened out grave questions as to the 
probable effect of such a course upon the prospects of the men affected. 
These were anxiously considered by the Committee with the result that 
a half-way course was recommended, namely, the scheduling of the 
disease but with compensation restricted to cases where an operation was 
undergone and for a period not exceeding 6 months. Thus not only 
would there be inducement for the sufferer to submit to the comparatively 
safe operation for the removal of cataract after which usually glass 
workers are able to obtain employment again-sometimes even at the 
highly skilled work of finishing, and employers also would not deem it 
worth while to incur the expense of arranging for periodical examination 
or hesitate to employ a glass worker with incipient cataract because of 
possible compensation to him for a period so short as 6 months. 
Causal Factors.-I was unable to say whether heat rays or light rays 
caused the condition nor could I suggest an efficient remedy. The com- 
bined knowledge of the physicist and physiologist, I said, was required to 
arrive at a conclusion on these points. This side of the question, however, 
was taken up by a Committee of the Royal Society among whom were 888 
GLASS WORKERS' CATARACT 
the late Sir William Crookes, O. M., F. R. S.3 on the physical side and 
Dr. J. Franklin Parsons on the physiological. 
The former directed his attention to the effect of adding various metallic oxides 
to the constituents of glass in order to cut off the invisible rays at the ultra-violet and 
the infra-red ends of the spectrum, i.e., to cut off those rays from highly heated molten 
glass which are believed to damage the eyes of workmen without, at the same time, 
obscuring too much light. X-rays were not, he found, emitted by the highly incan- 
descent molten glass. In the radiation from molten glass Crookes found the heat 
rays in far greater abundance than the ultra-violet, and from this he inferred that it 
is to the heat rays rather than the ultra-violet that glass workers' cataract is to be 
ascribed. It is, however, certain, he adds, that exposure to excess of ultra-violet 
light also injuriously affects the eye. 
Preventive Measures.-By means of extraordinarily exact scientific 
experiments with apparatus devised by himself and with different glasses 
made by himself to which known quantities of pure metallic oxides and 
earthy salts were added, Crookes determined for each glass so prepared: 
1. The percentage amount of infra-red rays absorbed. 
2. The percentage amount of ultra-violet rays absorbed. 
3. The percentage amount of luminous rays transmitted. 
To be generally useful a glass should absorb rays of longer wave length than about 
X 7200 and so cut off dark heat radiation and it should also be opaque to wave lengths 
shorter than about X 3550 thus cutting off the most chemically active rays. 
Finally he was able to prepare glasses cutting off over 90 per cent, of heat radia- 
tion, opaque to the invisible ultra-violet rays, and sufficiently free from color to be 
scarcely noticeable when used as spectacles. All three desiderata, however, could 
not be combined in one and the same specimen. The glasses he describes "include 
specimens suitable for spectacles adapted to all requirements-from eyes of youth 
to eyes of age." He gives the composition of the glasses cutting off as much as possi- 
ble of the heat radiation. Thus in one of a neutral tint cutting off 94 per cent., opaque 
to ultra-violet rays of shorter wave length than X 3610 and allowing 30 per cent, of 
incident light to pass through, the composition was raw soda flux 88.5 per cent., 
black mica 11.5 per cent.; of another enabling the worker to see better at the expense 
of a little athermancy the proportions were: fused soda flux 88.47 per cent., ferric 
oxide 1.50 per cent., cobalt sulphate crystallized 0.03 per cent., and cerium nitrate 
10.00 per cent. This is of a pale blue and transmits 63 per cent, of luminous rays 
while cutting off 51 per cent, of the heat rays. Spectacles of this glass, he says, 
scarcely appear to obstruct light at all and the colors of the objects are practically 
unchanged. 
Glasses such as these may prevent the incapacity arising from glass- 
workers' cataract. The disease, however, is so slow in its onset that pre- 
judice against wearing anything interfering in the least with work is great 
and will have to be overcome. Few glass workers to-day are found 
attempting to preserve their eyesight by spectacles, partly from the reason 
stated, and partly because moisture, when perspiration is excessive, con- 
denses on the glass. The latter objection can be overcome by rubbing the 
glasses with a "Lasin" pencil made of a kind of soap. 
Another and very powerful cause is at work which will tend not only to 
minimize the chance of occurrence of cataract, but also of another occupa- PREVENTIVE MEASURES REFERENCES 
889 
tional disease, which has occasionally been the result of infection from com- 
mon use of the same blowpipe, namely, syphilis among glass-blowers. To 
guard against syphilis contracted in this way the French Government has 
enacted regulations requiring medical examination of glass-blowers at 
fort-nightly intervals. The cause to which I refer is the substitution of 
machinery for hand-work in the manufacture of glass bottles. A machine 
is already installed in some works-and the example will be quickly 
followed elsewhere-which, as it is made to revolve over the margin of the 
molten glass, sucks up just the necessary amount, then transfers the glass 
so sucked up to a mould where the bottle is formed by compressed air 
automatically supplied to it, and finally discharges the bottle in a finished 
condition ready to be annealed. The machine does its work at the rate of 
40 bottles a minute at a cost for labor for the three men needed to super- 
vise its operations about one-ninth that now paid for the same number of 
bottles manufactured in the old method involving manipulation by 
40 men and boys. At present the machine cannot make every kind of 
bottle. It cannot, for example, introduce the glass marble which forms 
the stopper in the popular form of lemonade bottle so that for some years 
to come bottle making by hand must continue. The hard conditions in 
glass works are just those which should gradually be replaced by machin- 
ery and how effectively the new machine achieves this must be seen to be 
believed. 
REFERENCES 
12Bottle-finishers' Cataract, by W. Robinson, M. D., M. S.-Brit. Med. Journ., 1903. 
On Bottle-makers' Cataract, by W. Robinson, M. D.-Brit. Med. Journ., 1907. 
See also: 
An Inquiry into the Alleged Frequency of Cataract in Bottle Makers, by Simeon 
Snell-F. R. C. S.-Edin. Brit. Med. Journ., 1907. 
Second Report of the Departmental Committee on Compensation for Industrial 
Diseases. Minutes of Evidence and Appendix, 1908. (This contains the papers 
by Robinson and Snell.) 
Katarakt bei Glasblasern, J. Rbhlinger.-Munich, 1888. 
Zur Aetiologie des Grauen Stars. Jugendliche Katarakten bei Glasmachern, By 
D. Meyhbfer in Gbrlitz. 
Klinische Monatsblatter ftir Augenheilkunde, 1886, Vol. XXIV, page 49. 
On the Origin and Chemical Peculiarities of Glass-blowers' Cataract, by Sanitatsrat, 
Dr. E. Cramer in Kottbus. Klinische Montasblatter fur Augenheilkunde, 1907. 
3 The Preparation of Eye-preserving Glass for Spectacles, by Sir William Crookes, 
O. M. F. R. S.-Phil. Trans., Series A., Vol. CXIV, pages 1-25. CHAPTER III 
OCCUPATIONAL INJURIES AND DISEASES OF THE EAR 
BY CLARENCE JOHN BLAKE, M. D„ Boston, Mass. 
Revised by WALTER A.WELLS, M. D., Washington, D. C. 
Injuries and diseases of the ear, of occupational origin, may be grossly 
divided into three classes; those which are limited to the external ear, 
those which affect the sound-transmitting apparatus of the middle ear, 
and those which are ultimately expended in their deleterious effect upon 
the more delicate sound-transmitting apparatus of the cochlea and the 
terminal .nerve distributions which constitute the static organ of the 
labyrinth. 
Of these three classes the latter two are more likely to have an inter- 
mediate ground of relationship, insofar as major disturbances are con- 
cerned, disruptive injuries to the middle ear being sometimes associated, 
in their consequences, with disturbances of the labyrinthine mechanism 
and function but labyrinthine disturbances incident to the trades stand 
apart by themselves, the middle-ear implication being purely secondary 
to the deeper seated excitation or, possibly, part of a natural protective 
process. The injuries to the ear, of occupational origin, may range from 
a solution of continuity of the auricle incident to a blow to the structural 
changes induced in the membranous cochlea by continued exposure to 
loud sounds. 
THE AURICLE 
Standing outward from the side of the head, to which it is attached by 
three groups of muscles, in addition to its ligamentous and other soft 
tissue attachments, composed of a thin plate of cartilage covered with a 
very vascular skin, the auricle is especially subject to injury in such trades 
as imply exposure to extremes of temperature, and to possibilities for 
forcible contact with hard substances. 
The effect upon the auricle of exposure to extreme cold in the indoor 
trades is less frequently observed than that produced by climatic exposure, 
but the results are the same, a circumscribed dermatitis, sometimes a peri- 
chondritis with resultant thickening and, occasionally, a sero-sanguinolent 
effusion beneath the skin, on the anterior surface of the auricle, with 
consequent distortion of its contour; the more extreme results of the 
induced inflammation, necrosis with sloughing and loss of a portion of the 
auricle being less frequent in the indoor trades-cold-storage plants for 
890 THE AURICLE 
891 
instance-than in cases of climatic exposure, both because the exposure 
is less and because the subjection to it is more under individua 
control. 
Similar inflammatory changes in the auricle are the result of exposure 
to extreme heat; stokerers, smelters, braziers, puddlers and railway firemen 
are liable to circumscribe inflammations of the dermis on the anterior, the 
more exposed surface of the auricle and especially in the region of the 
helix and the tragus; while the dust and grime accompanying these and 
similar occupations, including metal, glass, stone and wood workers, 
using denatured alcohol, and grinders and polishers, mother-of-pearl 
cutters, brush makers, are frequently productive of some form of eczema 
of the auricle and of the external canal. 
In all the trades dealing with molten metals wounds and burns of the 
auricle are frequently possible. These injuries are usually circumscribed 
and, unless they penetrate to and involve a serious solution of continuity 
of the cartilage, are usually superficial in their effects; where, however, 
this solution of continuity has taken place, the intrinsic muscles of the 
auricle exert, by their contraction against lessened resistance, a distorting 
effect and the resultant deformity of the auricle is enhanced. 
In the major injuries of the auricle the three bundles of extrinsic 
muscles attaching and supporting the auricle, the attollens, attrahens 
and retrahens aurem, have to be taken into consideration for under condi- 
tions in which the auricle has been nearly severed from its ligamentous 
and minor muscular attachments together with division of its mainly 
supporting muscular bundles, the attollens and retrahens aurem, it is 
necessary in effecting surgically reapposition of the wounded parts to 
stitch the severed muscles as well as the surrounding soft tissues in order 
to insure the lumen of the reconstructed external auditory canal,-failure 
to resupply this muscular Support of the auricle resulting in faulty apposi- 
tion of the disrupted cartilaginous portion of the external auditory 
canal. 
Blows upon the auricle incident to the trades and to some sports, 
boxing and football for example, are frequently productive of othaema- 
toma, a subdermal or subperichondrial sero-sanguinolent effusion occur- 
ring upon the anterior surface of the auricle to the obliteration of the 
superior fossae. Similar effusions of lesser extent and occurring usually 
in the concha and lower portion of the auricle are the result, sometimes, 
not of directly applied violence but of strain in the lifting of heavy weights 
or of violent exertion as in running, the occurrence of the effusion in such 
instances usually implying some structural weakness in the cartilage or in 
the blood vessels of the auricle. 
In all forms of othaematoma the thorough evacuation of the sac 
cavity and the permanent apposition of its walls are necessary to avoid- 
ance of the disfiguring distortion of the auricle evidenced not infrequently 
to-day, as well as portrayed in the busts of ancient gladiators. 892 
OCCUPATIONAL INJURIES AND DISEASES OF THE EAR 
THE EXTERNAL CANAL 
Injuries not only to the auricle but also to the external canal and even 
the drum head are not infrequent in the trades which have to deal with the 
fabrication of metals (blacksmiths, and other hammerers and forge workers) 
and subject to injury from flying particles, as are also stone masons and, 
less frequently, wood workers while the dust resultant in these and similar 
occupations settling upon the auricle and about the entrance of the 
external auditory canal and requiring vigorous washing for its removal 
may be, in the course of that process, washed into the external-canal and 
there retained with the effect not only of obtunding the hearing but of 
setting up irritation in the skin lining the canal. In this latter respect 
the character and constitution of the dust has a determinative effect, 
the dust of iron, steel and of coal having usually a merely obstructive 
effect, while that of zinc ore, containing also lead, cadmium and arsenic, 
is more or less irritating and consequently productive of eczema of the 
auricle and canal and of furunculosis and diffuse dermatitis. In wood 
polishers and jig sawyers where denatured alcohol has been used in the 
dressing and finishing of the wood or where acids have been used for 
checking and staining, the resultant dust is more irritating than that of 
the raw wood alone. 
Wounds of the external canal from the entrance of foreign bodies occur, 
in the majority of instances, upon the posterior-superior wall of the canal 
at the junction of the cartilaginous and osseous canal, this region being 
particularly exposed to the impact of stiff foreign bodies thrust into the 
canal in the line of its long axis and from in front, such injuries having 
been recorded in game beaters and huifters from the entrance of twigs 
and in reapers, from grain straws. 
The stoppage of the external canal by accumulation of dust is mate- 
rially guarded against by the growth of fine hairs projecting across the 
lumen of the canal; smeared as they are by the sticky and tenacious pro- 
duct of the c'erumenous glands they afford an efficient protection unless, 
by forcible washing and pressure inward into the canal, the accumulated 
dust, mingled with the natural secretion, is thrust beyond them or they 
are artificially removed in ignorance of their protective value. The 
custom of barbers to cut hairs growing from the inner surface of the 
tragus and about the entrance of the external canal not only removes a 
valuable protection but allows the canal to become filled with the cut ends 
of the hairs. The frequency of inflammation of the external canal in the 
Chinese and some other oriental peoples is due to the mischievous mani- 
pulation of the public barbers, who use a slender razor to shave the hairs 
in the external canal, wooden and metal scoops or curets to remove parti- 
cles of dry skin, and pellets of duck's down to wipe out the canal. All 
of these instruments, being unsterilized and indiscriminately used, not 
only mechanically irritate and inflame the delicate dermis but infect it, 
sometimes with serious results. EXTERNAL CANAL MIDDLE EAR 
893 
Mycosis of the external canal, usually aspergillus nigricans or flaves- 
cens, is found in weavers, spinners, wool sorters and other dust workers 
handling oily substances as well as in persons working in a moist atmos- 
phere, paper mill tenders and laundry women for example-the condition 
favorable to the development of the spores of these and similar fungi being 
an oily or fatty soil and a warm moist atmosphere. The instances of this 
disease as described by Wreden in 1868 occurred in Russian cavalrymen 
who anointed their hair with grease and slept in the moist foul air of the 
barrack stables with their horses. The aspergillus is exceedingly tena- 
cious in the hold of its mycelium upon the skin, causes much irritation 
and is disposed of only by sedulous cleansing and drying of the 
implicated skin area. Repeated attacks of myringomycosis aspergillina 
sometimes cause a thickening of the dermoid coat of the membrana 
tympani and consequent impairment of hearing. 
THE MIDDLE EAR 
The disorders of the membrana tympani incident to the trades are 
usually of traumatic origin; while the disturbances of function of the 
remaining portions of the sound transmitting apparatus may also be the 
result of sources of irritation in contiguous and communicating parts, 
most commonly the mucosa of the nose and nasopharynx. 
All inflammations which reach the nasopharynx have a constant 
tendency to involve sooner or later the organs of hearing, either by bring- 
ing about an obstructive condition of the Eustachian tube and thus 
impairing auditory functions or by direct extension of the inflammation 
to the middle ear whose walls are lined with a mucous membrane directly 
continuous through these tubes with that of the nasopharynx. We 
must not forget therefore, to include among the industrial causes of ear 
diseases those which are well known for their baneful effects upon the 
upper air passages-all trades attended with irritating dusts and fumes, 
as well as those which require exposure to extremes or sudden changes 
of temperature, and to unusual states <of atmospheric humidity. 
But apart from these numerous causes the organ of the special sense 
of hearing may be injuriously affected by certain special causes incident 
to trades, which require independent consideration. These are (1) 
chemical poisons which show predilection for the auditory end organ 
and nerve; (2) sudden excessive change in atmospheric pressure, as in 
the concussion from explosion and (3) undue exposure to noises or long 
continued disagreeable sounds which overstrain the delicate filaments 
of the auditory sense organ. There are some trades in which one or 
more of this latter group of causes may unfortunately co-operate with 
the former. Many machinists for example are exposed to irritating 
dusts, in addition to continuous disagreeable noises; aviators to the 
continuous noise of the motor in addition to sudden changes of tem- 
perature and barometric pressure; railway employes to much soot and 894 
OCCUPATIONAL INJURIES AND DISEASES OF THE EAR 
dust, and to bad weather as well as to the shrill whistle of the engine 
and the noise of the moving train. 
Aside from direct application of force to a limited area of its surface, as 
in punctured or incised wounds of the membrana tympani, the more 
serious injuries of this membrane incident to the trades are those which 
come from sudden and considerable variations in air pressure and from 
disruptive force applied to the periphery of the membrane through the 
medium of the bones of the head. Sudden atmospheric condensation 
incident to unexpected explosions in mining, blasting and tunnelling, 
and the nearby discharge of artillery, especially in enclosed spaces, 
may cause so sudden an excursion of the membrana vibrans as to result 
in its rupture. This rupture thus produced usually occurs along the 
line of the handle of the malleus-the line of greatest excursion 
and most immediate check; ruptures of this sort are usually irregular in 
outline, the torn edges bleed freely and secure, by coagulation of the 
blood, an agglutination of the edges with resultant speedy healing which is 
less likely to be the case when the wound is the product of direct contact 
and possible infection. The greater frequency of concussive ruptures 
of the drum-head in the navy, as compared with land artillery service, is 
due to the condensation of the concussive effect in the circumscribed 
spaces on shipboard, in the turrets and shields; the same is true of the 
concussions occurring in mining operations as compared with explosive 
occurrences in open trenches or on a level in the open air. 
The observation has been frequently made by independent observers 
that concussion of the internal ear was less, and more rapidly recovered 
from, if one of the effects of the explosion was to produce a rupture of 
the drum membrane. Dundas Grant has shown the rationale of this 
protective effect of the drum membrane rupture by a simple experiment. 
A light wooden hoop covered with a fairly resistant paper is suspended 
over one end of a drain pipe; when a revolver with a blank cartridge is 
fired into the other end a marked upward excursion of the hoop results. 
When the firm resistant paper in the hoop is replaced by a thin fragile 
layer, the latter gives away on firing the revolver and the movement of 
the hoop is very slight. 
A similar rupture of the membrana tympani may be induced by a blow 
upon the head, especially if this occurs on the parieto-occipital angle of 
the opposite side--the effect, by contrecoup, being to disrupt the inelastic 
structure at the side of the circle opposite to that at which the force is 
applied. Except insofar as the middle ear is implicated, or an inflam- 
matory process follows, the simple rupture of the drum-head is liable to 
spontaneous recovery. But if the apposition of the edges is incomplete, 
healing may be enhanced by the application of a thin paper dressing, 
applied on a moist cotton-tipped probe and allowed to remain in 
place, its removal being ensured by the normal progressive growth of the 
dermoid coat of the drum-head and of the external canal. MIDDLE EAR-TYMPANIC CAVITY 
895 
Another example of the effect of variation in atmospheric pressure is to 
be found in caisson workers, divers and aviators; in the former the con- 
tinued exposure to increased atmospheric pressure with the subsequent 
return to normal pressure, if incautiously and too rapidly made, results 
in circulatory changes in the middle ear, impairing the hearing often 
quite as much as a solution of continuity of the drum-head incident to 
the still more rapid change in air pressure constituting a concussion. 
The ruptures of the drum-head incident to diving, in the open air, are 
commonly the result of accident produced by sudden condensation of air 
in the external canal at the moment of striking upon, or entering, the 
water; while congestion of the tympanic mucosa and limited areas of 
effusion into the tissues of the drum-head with the creation of serous or 
hemorrhagic bullae upon its outer surface are the manifestations more 
frequent in bell divers and submarine workers in armor. 
In aviators the rapid alterations of altitude, productive of circulatory 
changes in the middle ear and labyrinth, as evidenced by the variable sub- 
jective noises, the resultant nervous strain with the accompanying secon- 
dary contraction of the tensor tympani muscle and the subjection to the 
continuous noise of the motor are all conditions which prove prejudicial, 
if only temporarily, to the hearing power, and when frequently repeated 
entail permanent results. 
Recent extensive studies made by E. R. Lewis upon the effect in 
aviators of altitude upon the hearing and motion-sensing apparatus of 
the ear, were to effect (1) that the acoustic portions of the internal ear 
showed no deterioration unless the altitude was such as to bring about 
impairment of the higher cerebral centers (as evidences by semi-conscious- 
ness or unconsciousness); (2) that there was nearly always at least a 
transitory affection of the conduction apparatus; (3) that in some cases 
there occurred rupture of the drum membrane, in a few instances followed 
by otitis media and (4) that the motion-sensing part of the ear was 
always unimpaired. The conclusions are in agreement with those of a 
French observer La Croix, who furthermore refers to the fact that in 
normal individuals the ear is largely protected from the variations in 
atmospheric pressure by the act of deglutition, which however, may not 
be so effective with diseased conditions of the nose and throat-an addi- 
tional reason for a high standard of health in aviators in respect to these 
organs. 
The Tympanic Cavity.-Variations of atmospheric pressure, moreover, 
in any of these occupations, if the change is rapid, are liable to excite 
reflex symptoms of nausea and vomiting through the medium of the effect 
more immediately produced in the irritation of the end apparatus in 
the semicircular canals. Protracted exposure to loud sounds of either 
very low or very high pitch is liable to excite the same reflex symptoms- 
tones of low pitch being more readily conveyed through the medium of 
the earth and of the body than the tones of high pitch, which reach 896 
OCCUPATIONAL INJURIES AND DISEASES OF THE EAR 
the sensorium more readily through the medium of the air and the sound- 
transmitting mechanism of the middle ear. 
In all of the trades which entail more or less continuous exposure to 
heated air laden with dust and foul with poisonous gases, the effect upon 
the ear is secondary to that induced in the mucous membrane of the 
nose and nasopharynx and varies, according to the degree and character 
of the irritation or infection, from a non-suppurative progressive thicken- 
ing process in the soft tissues of the middle ear to a suppurative process 
more or less destructive in its course. 
The number of the trades in which these two forms of implication of 
the middle ear are observable is large and their enumeration includes 
almost all of the occupations which are conducted in a dusty atmosphere 
and those especially in which dust and irritating vapors are among the 
by-products of manufacture. When to these unfavorable conditions 
there is added the loud noise of continuously operative machinery, the 
cycle of injurious effects, so far as the auditory transmitting and percep- 
tive apparatus is concerned, is complete, and the welfare work of the 
trades will not have become adequate to its purpose until it has eliminated 
both dust and noise as essential factors. 
In addition to the obtunding effect, in the external auditory canal, of 
dust accumulations, either spontaneously deposited or impacted by 
washing, with varying irritative results, according to the character of the 
dust, distinction in degree may be made in considering the consequences, 
to the middle ear, of continued occupational exposure of the mucosa of 
the nose and nasopharynx, to dust of varying qualities and to atmospheric 
conditions varying in regard to temperature and moisture of the air. 
In mining operations, for example, especially in the lower levels, the 
temperature is that of the tropics and the miner pursues his strenuous 
work under conditions which subject the mucous membrane of the upper 
air passages to a moist air laden with dust particles more or less irritating 
according to the character of the mining operation. The moisture in the 
air of the level and chambers in coal mines tends to throw the dust down 
or to minimize its irritative effect upon the mucous membrane, the dis- 
turbances of the upper air passages in miners being less in proportion than 
in the cases of miners or above-ground workmen in dry, dust laden air. 
Roepke, who made personal observations, describes the coal miner as 
coming to the surface at the end of a day's work, with the nose and the 
nasopharynx coated with moist coal dust but, in a few hours, entirely free 
from obstruction and the mucous membrane relieved of its layer of coal 
dust, normally secreting and free from excoriation. 
The percentage of implications of the mucous membrane of the upper 
air passages and the middle ear in other forms of mining in comparatively 
dry air varies with the character of the ore ; the drier air and the more pene- 
trating dust particles being productive of a more irritating effect than that 
which accompanies the mining of both the soft and hard coals. Rock TYMPANIC CAVITY 
897 
dust, more particularly that containing metallic particles, is especially 
irritating; the most pronounced cases of disturbance being found in the 
miners excavating the silicates of copper, of zinc, siliceous quartz, slate 
rock and the arsenical ores. In cases of exposure to arsenical ore dust 
the implication of the mucous membrane, especially that of the nose and 
nasopharynx, seems to bear a relationship both in frequency and in 
severity, to the proportion of arsenic in the product mined-suppurative 
nasopharyngeal catarrh and, secondarily, suppurative middle-ear inflam- 
mation being not unusual, the nasal mucous membrane covering the 
cartilaginous septum showing a predilection as a locality for the resultant 
circumscribed swellings and ulcerations. In the more chronic cases of 
arsenical poisoning Lewin has reported inflammation of the internal 
ear, as a sequence of the evidence of arsenical poisoning in the nasophar- 
ynx and middle ear. In mercury mining the initial lesions occur most 
commonly in the mouth, the nasopharynx being comparatively unaffected 
but in the more severe cases of mercurial poisoning Wolf has observed 
acute labyrinthitis accompanied by Meniere's complex of symptoms. 
In all mining operations there must always be taken into considera- 
tion, in addition to the air contaminations of natural origin, those which 
are artificially produced as a part of the process of mining, adding the 
fumes resultant from the explosion of gunpowder and dynamite, and 
also endangering the ear through the concussive effect of the explosion 
confined within a limited space. 
In all of the chemical industries the similar contamination of the air by 
the liberation of acid fumes becomes a factor in the production of naso- 
pharyngeal irritation and consequent implication of the middle ear; while 
the various dust-producing trades, exercised above ground but in the 
circumscribed spaces of factories, mill rooms, and workshops, vary in the 
degree of irritation produced according to the constitution of the dust and 
its ponderability. In the reports of sickness among anilin-dye workers, 
and those engaged in the manufacture of high explosives, the frequent 
mention of giddiness as an early conspicuous symptom gives ground to 
believe that the fumes from the poison incident to these trades has an 
unfavorable selective influence over the vestibular nerve or its termination 
in the static portion of the labyrinth. The coarser dusts resulting from jig 
sawing and other forms of wood working would be less deleterious but 
for the acids and oils and varnishes with which the wood has been 
permeated or covered in previous steps of the process toward the finished 
product: while the weight of the finer dust resulting from metal, stone, and 
glass cutting, grinding, and polishing, incisive and irritating in itself, 
makes it less prejudicial to the artisan because of its less prolonged sus- 
pension in the air. 
The exceptions to this rule are the trades in which the worker is in close 
relationship to a machine producing a dust of a mechanically irritating 
quality and of little ponderability, such as metal burnishing, glass grind- 898 
OCCUPATIONAL INJURIES AND DISEASES OE THE EAR 
ing and mother-of-pearl cutting, lime burning, fertilizer mixing and pack- 
ing, and also the trades dealing with wool, hair, and grass sorting, packing 
and upholstering, flax heckeling, jute and hemp spinning, in which the 
infectious nature of the dust favors the inception of suppurative disease. 
THE INNER EAR 
Under modern processes of manufacture the majority of the trades are 
conducted through the intervention of machinery interposed between the 
workman and the material employed; with the resultant introduction of 
another prejudicial factor, especially and continuously invading the organ 
of hearing and even, in some instances, affecting that other portion of the 
internal ear which is a peripheral organ of equilibration; it being clinically 
observable that high grades of impairment of hearing are more common 
among those metal workers whose day labor confines them to subjection 
to intense sounds made up largely of overtones of high pitch than among 
the workers in noises of lower pitch,-beamers in cotton mills for 
example. 
Gottstein and Kayser found marked impairment of hearing in 50 per 
cent, of smiths and machinists examined by them. Holt found marked 
impairment of hearing in 35 per cent, of coppersmiths and Barr found 
normal hearing in a little over 9 per cent, only of boiler makers; while 
Habermann reports that out of 31 boiler makers there was not one with 
normal hearing. 
The consensus of opinion is to the effect that the degree of impairment 
of hearing in all these cases had a definite relationship to the duration and 
the intensive character of the operative sound. Both ears were usually 
tested, but more particularly that which was habitually directed toward 
the sound source. Subjective noises were an almost unvarying accom- 
paniment of the impairment of hearing; but dizziness or vertigo was 
present only in the more advanced cases, where the upper tone limit in 
hearing was notably decreased. Dizziness is also more likely to be an 
accompanying symptom, in mill and factory operatives, when to the noise 
of the machinery there is added a sensible vibration. 
The majority of authorities dealing with this subject regard the affec- 
tion of the hearing incident to exposure to loud sounds of high pitch as one 
of the internal ear solely; but Holt expresses the opinion that changes in 
the middle ear and sound transmitting apparatus are mainly the cause of 
the impairment of hearing. Gradenigo makes three differentiations: 
labyrinthitis without middle-ear implication, chronic catarrhal middle-ear 
disease with labyrinthitis, and chronic advanced middle-ear inflammation 
with implication of the labyrinth and vertigo as an accompanying symp- 
tom; while Ropke is of the opinion that the majority of the cases of 
impaired hearing consequent upon exposure to loud noise are a combina- 
tion of a disturbance of the labyrinth and of a catarrhal process in the 
middle ear. Urbantschitsch reports a case in which the concussion of INNER EAR 
899 
the labyrinth was accompanied by contraction of the intrinsic muscles 
of the middle ear. 
These occupational sounds are divisible into two classes: sounds of 
sudden access and considerable amplitude, detonations, for example; and 
sounds of prolonged duration, intensive, of high pitch and replete with 
metallic overtones. 
In all the clinical observations in regard to the effect of sound waves of 
considerable amplitude aerially conveyed, as a part of the occupational 
inroad upon the organ of hearing, the evidence is mainly in favor of the 
supposition that the principal channel through which the internal ear is 
subjected to injury from this source is that through the medium of the 
sound-transmitting apparatus of the middle ear and not through other 
bodily channels; this view being further supported by the fact that it is 
not the tones of medium low pitch, those most readily transmitted by bone 
conduction, which are the operative factors in the causation of the pro- 
gressive impairment of hearing in the majority of the cases of occupational 
origin, but those of comparatively high pitch which find their access to the 
internal ear through the sound-transmitting apparatus only because of 
the obstacle presented to the passage of their short sound waves through the 
soft tissues of the body in which their impulse is almost immediately lost. 
The mass of reported clinical observations upon this subject has found 
its more intimate support in physiological experimentation only within a 
few years and that by a series of investigations made by individual observ- 
ers, but often in collaborative relationship, their purpose being the exact 
determination of the effects produced in the acoustic labyrinth as the 
result of subjection of animals to the continued influx of loud noises of 
different kinds. 
The majority of these experiments included the use of very high 
pitched tones produced by whistles, organ pipes, high-pitched metallic 
bodies of various kinds, and metallic sounds of lower pitch under reso- 
nance conditions simulating those of the trades as exhibited in factory 
operatives, machinists, and boiler makers, the general results of these 
observations being that the exposure of one or both ears continuously, 
for a period of several days or weeks, to a pure tone of high pitch or to a 
mixed tone of medium low pitch, with correlated high-pitched overtones, 
was followed by a degenerative process in the organ of Corti, beginning in 
the nucleated ciliated cells, progressing to the neuron, and then, second- 
arily, attacking the vibrating mechanism and extending to the contiguous 
membranous labyrinth. 
The degenerative process was found to bear a measure of relationship 
to the intensity and duration of application of the invasive tone and to be 
situated in corresponding relationship in the upper part of the first and 
the beginning of the second whorl of the cochlea. 
Dr. Richie Rodger, from a series of experiments made in Dr. Logan 
Turner's clinic at Edinburg to determine the effects of loud noises upon the 900 
OCCUPATIONAL INJURIES AND DISEASES OF THE EAR 
labyrinth of boiler makers came to the conclusion that the loss of hearing 
for high notes (in the lowest whorl of the cochlea) is not an outstanding fea- 
ture of noise deafness as hitherto taught; but that the predominant noises 
to which the individual had been exposed determined the site of the initial 
lesion of the ear, and that for a considerable time the depreciation of 
hearing is mainly for sounds of a pitch corresponding to these noises; 
later on there is marked loss of hearing for high tones owing to the greater 
vulnerability of the lower part of the cochlear canal. 
Where one ear was closed to the extent of preventing the entrance of 
sound waves through the normal external passage, the cochlea exposed to 
the sound waves was alone found to have undergone a degenerative 
process. Von Eichen, for example, stopped the left ear air-tight in one 
experiment and, subjecting the animal to a whistle tone of C5, found only 
the right labyrinth affected by the characteristic degenerative process, 
the left labyrinth remaining normal. Care was taken, in the majority 
of the experiments, to transmit these experiment tones aerially only and 
not through the medium of the cage or box in which the animal was con- 
fined and consequently through the body. 
Gruenberg exposed the right ear of a pigeon from 7 to 14 days to the 
continuous tones of a Bezold-Edelmann whistle A3, A4 with resultant 
evidences of degenerative processes in the papilla acoustica up to one- 
quarter the length of the ductus cochlearis, the left ear remaining normal. 
Hoessli used, as the container for his animals, a suspended section of 
an iron water pipe, struck by automatic hammers to reproduce the con- 
ditions to which boiler makers are subjected, one ear being closed by cotton 
and collodion and, in some instances, both ears, in order to determine the 
effect of the sound corporeally conveyed. Where one ear was closed the 
degenerative process was exhibited in the ear remaining open; where both 
ears were closed the degenerative process was not exhibited, the observer 
concluding that air conduction was the only medium through which the 
acoustic effect was produced and that the ossicular chain is a conductive 
and not a protective mechanism. 
In concurrence with the determinations of other observers Hoessli 
found that the labyrinth lesion occurred in relatively the same area in 
the cochlea in all the animals subjected to the influence of a continuous 
tone of high pitch, and that the higher the tone the lower was the area of 
lesion in the cochlear tube; while Habermann, in the observations made 
upon boiler makers and blacksmiths, found that the degenerative altera- 
tions in the organ of Corti, in the nerve, and in the related ganglion cells 
was more extensive in the basal whorl, the upper portion of the cochlea 
remaining normal. 
Wittmarck found that with intense sounds of high pitch and even of 
short duration the corresponding area in the cochlea was affected, in 
contradistinction to other observers; but placed especial stress upon the 
influence exerted by influx of sound corporeally conveyed. INNER EAR-CLINICAL EXPERIENCE 
901 
Marx is of the opinion, from a corresponding series of investigations, 
that the local degenerative process is the organ of Corti is, in proportion 
to the intensity of the high pitch employed, not only more pronounced 
but also more extensive in area; the high tones of a continuously blown 
whistle, A3 and A4, produced the recognized degenerative effects in the 
organ of Corti; corresponding tones of lower pitch A2 and E2, being less 
intense, did not result in degeneration. 
In the detonation experiments of Hoessli only the upper portion of the 
first whorl and the lower portion of the second whorl were affected, a result 
consonant with the results of Siebenmann and others and with the clinical 
observations of Friedrich and Jaehne; while Yoshlii reports, as the result 
of detonation with middle-ear injury, rupture of the membrane of the 
round window in but one case, the membranes of the oval and round 
windows remaining intact notwithstanding the presence of petechise 
and hemorrhage in the vicinity of the windows; there being corres- 
ponding changes in all parts of the organ of Corti, the outer and inner 
ciliated cells being swollen, distorted and sometimes separated from their 
base, the rods distorted and the intermediate space filled with cellular 
detritus. 
Clinical experience has shown that with continued exposure of the 
human subject to intense sounds of high pitch there is evoked, in addition 
to a sense of fullness, subjective noise and malaise, a greater or less 
degree of dizziness; and the laboratory evidences of the location of degen- 
erative changes in the lower portion of the cochlea suggest the possibility, 
in view of the vestibular contiguity, of a possible secondary excitation of 
the equilibrating end-organ. 
While the demonstration of labyrinthine changes has been sufficiently 
precise and sufficiently extensive to emphasize the importance of prophy- 
lactic measures in reference to the noises of the trades, there is another 
question still a matter of debate and open to clinical observation for its 
determination, and that is the possible secondary implication of the sound 
transmitting apparatus of the middle ear, a change progressively decreas- 
ing the conductivity in the channel through which the causative factor 
in the cochlear degeneration finds access to the internal ear. 
Hensen, Bockendahl, and Pollak have reported observations of appa- 
rent reflex contraction of the tensor tympani muscle in response to high 
tones, and it is not uncommon clinical experience to find in boiler makers, 
machinists, locomotive engineers and firemen, in addition to a decrease 
in hearing for tones of medium and high pitch, both by bone conduction 
and aerially conveyed, objective changes in the sound-transmitting appa- 
atus of the middle ear evidencing a thickening of the tympanic mucosa 
and a contraction of the tensor tympani muscle, conditions referable in 
many instances to such other occupational influences as sudden changes 
in temperature and exposure to dust, and other causes inducing irritation 
of the nasal and nasophryngeal mucous membrane. 902 
OCCUPATIONAL INJURIES AND DISEASES OF THE EAR 
In the earlier stages of impairment of hearing as the result of exposure 
to loud, continuous noise, clinical observation shows a depression of the 
membrana tympani consequent upon retraction of the tensor tympani 
muscle, this objective evidence appearing in advance of the thickening 
process in the middle-ear. 
Further observations in the cases of workers in loud noises serve to 
substantiate the idea that the muscular contracture and consequent 
fixation of the sound-transmitting apparatus, supplemented by the 
thickening of the tympanic mucosa, serve as an obstacle to the inroad of 
those loud and high-pitched sounds which have been shown, by animal 
experimentation, to find their access to the labyrinth with deleterious 
effect, especially through the natural channel of audition. 
Similar changes, more especially the muscular contracture, have been 
found in telephone operators, and are more probably the result of the 
sudden and unexpected movements of the telephone armature in response 
to current interruptions than of the normal, ordinary use of the instru- 
ment in listening to the human voice-measurements of the intensity of the 
voice at the receiving instrument, as compared with that at the trans- 
mitting end of the line, having shown so considerable a loss as to make the 
volume of voice received a very inconsiderable percentage of that imme- 
diately transmitted, while the concentration of the voice directly upon the 
ear of the operator, as is the case in the majority of the forms of apparatus 
including close adjustment of the telephone receiver, makes the deter- 
mination of even a very moderate tone a matter of custom without effort 
except insofar as accommodation to the qualitative overtones of the 
consonant sounds of nearest resemblance is concerned. 
Repeated observations, made at intervals, in the cases of telephone 
operators with normal or approximately normal hearing have shown that 
very little change in the hearing, even in years of service, results from the 
occupation: but that with changes in the sound-transmitting apparatus 
with appreciable diminution of hearing upon entering the service, a 
further diminution is noticeable after prolonged occupation in telephone 
work. 
The demand upon the normal hearing power in telephone operation 
would seem, therefore, to be so little in excess of the usual conversational 
demand as to cause no resultant defect. 
The sum of the recorded statistics of observations in this rapidly 
increasing branch of public utility service is too small to make other 
than very broad and very general conclusions possible; and the subject is 
one which might advisedly receive more attention on the part of the 
medical profession. 
Among the most complete are the conclusions arrived at by Blegvad 
as the result of a series of precisely conducted observations, embodied in 
an extended record beyond the capacity of a brief review but well repaying 
careful reading, to the following effect: In 26.4 per cent, of the 371 TELEPHONE OPERATORS-PREVENTIVE MEASURES 
903 
telephone operators with normal hearing, who were made the subject of 
examination, there was a retraction of the drum-head in the ear to which 
the receiving instrument was usually applied, the other ear evidencing 
either none or only a slight retraction. The continued use of the tele- 
phone caused no depreciation of the hearing in operators with normal 
ears, nor was there, on the other hand, any appreciable increase in the 
capacity for the hearing of tones of high pitch and slight intensity, as is 
sometimes claimed by the operators-this claim being supported rather by 
the increase in the accommodative power for tones of this class and by 
the gradually acquired habit of eliminating mentally the coincident 
and the extraneous noises. The aural lesions and traumatic neurosis 
incident to the accidental introduction upon the line of strong currents 
are the results of the operation of a loud and sudden sound and are to be 
guarded against by proper protective construction in the telephone lines. 
It is evident, therefore, that in addition to the occupational conditions 
which should come under the consideration of welfare work as they have 
been previously regarded, there should be especial attention given syste- 
matically, both by study of cause and effect and by effort at protection 
from the results of continued exposure to loud and especially penetrating 
noises. 
More recent experiments have completely demonstrated the fallacy 
of Wetmaacks that loud noises produced their effects upon the labyrinth 
by way of bone conduction rather than air conduction and that ear 
protectors placed in the canal to exclude excessive sound were therefore 
of no avail. 
It has been found that of two ears exposed to the same noise the pro- 
tected ear was less affected or not at all; and besides it appears that an 
affection of the middle ear impeding conduction had somewhat the same 
result. 
Experience in the army proved also conclusively the value of protective 
devices in lessening casualties due to concussion. Here the main problem 
is to get an ear protector that allows enough hearing to hear orders and 
at the same time save the labyrinth. 
In the trades the problem is to get a simple convenient protector that 
the workman will use. Hard metallac devices which in case of accident 
might be driven inward, are generally to be avoided. Cotton wool is a 
very satisfactory protector when moistened with glycerine or vaseline, or 
worked up with some material like plasticene. When any protector 
which completely fills the canals has remained in place a long time the 
warm air confined within expands and produces an unpleasant sensation. 
Removal at intervals for ventilation is therefore advisable. 
The sound-transmitting apparatus of the middle ear serves the double 
purpose of sound transmission and of protection to the transmitting and 
PREVENTIVE MEASURES 904 
OCCUPATIONAL INJURIES AND DISEASES OF THE EAR 
perceptive mechanism beyond it; but is capable of exerting this office only 
for periods of limited duration and, under conditions of continuous sub- 
jection to loud sounds, covering a limited portion of the audible scale, in 
itself becomes fatigued and incapable of exercising its protective office. 
The obstacle presented to the passage of sounds of short wave lengths 
through the soft tissues of the body affords a certain measure of protection 
in one direction, and the obtunding of the external auditory canal pre- 
vents the influx of the objectionable sound through that natural passage; 
but this serves as only a partial protection and an important step in the 
welfare work of the trades will be in the elimination of that offensive and 
injurious by-product of mechanical action,-sustained and unnecessary 
noise. CHAPTER IV 
OCCUPATIONAL AFFECTIONS OF THE SKIN* 
JOHN T. BOWEN, M. D„ Boston, Mass. 
Dermatitis Venenata.-The term dermatitis venenata has been given 
to that class of inflammations of the skin that is produced by external 
contact with irritating agencies, whether of a solid, liquid or gaseous 
nature. These agencies may be of very different character, and may 
belong to the animal, vegetable or mineral world. No pathognomonic 
symptoms or appearances are associated with this class of inflammations, 
although certain more or less general characteristics may, if present, 
serve to distinguish them. James C. White, in his classical monograph 
on Dermatitis Venenata, enumerates among these characteristics "mainly 
a sudden onset, a rapid evolution of primary lesions, some peculiarities 
in their situation within the cutaneous tissues, an unusual color in their 
fluid contents, a greater intensity of inflammatory action, and continuity 
of development within given areas, the localities attacked and the 
sharply defined limitations of the regions affected, a marked asymmetry 
and an artificial-appearing configuration in the eruption, their occurrence 
in those employed in certain arts and. professions, and other unusual ex- 
traordinary appearances at times, which cannot be defined." 
On the whole the greatest number of cases of dermatitis venenata is 
produced by the action of plants possessing irritating properties, and 
foremost among these poisonous species may be mentioned the different 
varieties of rhus: poison ivy, poison sumach, etc. Other frequent causes 
of dermatitis venenata are the use of irritating cosmetics, and clothing 
which has been colored by poisonous dyes. The French writers often 
group these cases of dermatitis venenata under the broad conception of 
"eruptions artificielles," which includes feigned eruptions, eruptions of 
digestive origin, eruptions from external and internal medicaments, 
therapeutic eruptions, and professional eruptions. 
Much emphasis should be laid on dermatitis venenata in a chapter 
dealing with the professional dermatoses, because by far the larger 
number of cases of these affections belongs to the former group. The so- 
called trade eczemas, affecting chiefly the hands and the parts exposed to 
contact with the irritating substances handled in various trades, are 
forms of dermatitis venenata, at least at the onset and etiologically, 
before, in other words, the element of chronicity and stubbornness that is 
associated with the term eczema has asserted itself. These so-called 
* For bibliography see alphabetically arranged author-reference-list at end of Chapter. 
905 906 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
trade eczemas are the most common examples of occupational dermatoses 
and will be considered in this chapter under the eruptions peculiar to 
the various occupations. 
Trade Stigmata.-Before describing the various occupational derma- 
toses that may properly be included under this title, a word may be said 
with regard to the so-called trade stigmata. This name has been given 
to those changes in the skin, caused by various occupations, which are 
not of sufficient pathological importance to be classed as dermatoses, 
and which may yet be quite typical and characteristic of the work in 
which the subject is engaged. They often consist in a simple coloring or 
circumscribed thickening of the skin due either to exposure to the sun or 
to the mechanical effects of constant pressure. Such appearances of 
the skin, while of no great consequence as regards their symptoms to the 
one by whom they are acquired, may be important from a medico-legal 
point of view. 
In the case of dyers and of those who work in anilin manufacturies, an obstinate 
staining may resist all efforts to clean the hands at the end of the working day. The 
strong alkalies and other substances that are often employed to aid in cleansing may 
be very injurious to the skin as will be later emphasized, and give rise to an active 
inflammation. Exposure to the sun's rays in the case of cabmen, sailors, soldiers, 
etc., causes the reddening and later bronzing that are associated with an out-of-door 
life, and that may often reveal the occupation of the subject by their intensity and 
localization. In this case the reddening and pigmentation are to be regarded as 
protective phenomena against greatly increased action of the sun's rays. 
Thickening of the skin may occur either diffusely or in circumscribed patches, 
when constant pressure or friction is brought to bear on certain places in the perform- 
ance of different kinds of work. The inner surface of the hands of those who engage 
in almost any kind of rough manual labor tends to become thickened, this being due 
chiefly to the piling up of the horny cells of the outer epidermic layer. From circum- 
scribed thickenings, callous places, a hint may be given as to the occupation of the 
subject, and in this way the skin changes may be of value in medico-legal matters. 
Thus shoemakers exhibit callous patches on the flexor surface of the right hand from 
the pressure from the hammer, also circumscribed thickening in the sacral and coccy- 
geal regions on account of their constant sitting. Tailors, blacksmiths and carpenters 
are affected with similar cutaneous thickenings at the site of pressure from the tools 
that they use, on various parts of their fingers. Analogous appearances are observed 
sometimes in musicians, those who play on stringed instruments showing callous 
thickenings at the end of the thumb and forefinger. A circumscribed thickening of 
the skin of the neck is occasionally observed in violin players from the constant irrita- 
tion caused by the violin pressing upon this spot. 
With regard to the discolorations of the skin, apart from the bronzing and pigmen- 
tations that occur in those whose occupation exposes them to the weather and to the 
sun's rays, there are several conditions produced by the penetration of foreign bodies 
into the skin. Blaschko has described an affection common in workers in silver, in 
which small spots from the size of a pin's head to that of a pea, of a bluish-black color, 
appear on the hands and fingers, especially on the dorsal surface of the left hand. 
These spots do not tend to disappear with time but are permanent, remaining of just 
the same appearance after they have attained a certain size. The bluish-black color 
is produced by the penetration of very small particles of silver through the epidermis 
into the corium, in the process of filing, sawing and planing. The silver is then dis- TRADE STIGMATA-DERMATITIS 
907 
solved in the alkaline tissue fluids and again precipitated in the form of very fine 
particles, which are deposited in the connective tissue and elastic fibers. Lewin 
regards the lymph channels as the place of deposition of the silver. 
Similarly Elliot, in 1891, described a "pseudo-pigmentation on the hands of 
millers." His case concerned a man whose occupation was to smooth off with a steel 
chisel the roughnesses that occurred every day in the grinding stone, and on the backs 
of whose hands and fingers there were numerous dark discolored spots varying in tint 
from brown to black, some of them as large as a pea. These were caused by the small 
particles of metal that were chipped off constantly in the course of this work. The 
discolored spots were evidently caused by the oxidation of the small bits of metal, and 
it was shown that when the cause was removed, there was gradual elimination of 
the rust particles. These discolorations in millers have been confirmed by others, 
and the dorsal aspect of the left hand has been shown to be their most common seat. 
They have been used by Tardieu as a means of identification. 
Occupational Dermatoses Proper.-In almost all the cases in which 
poisonous material is introduced into the economy through the skin, 
there is a fracture or opening of the integument, however small, at the 
point of contact. Tuberculosis, syphilis, glanders and other serious 
systemic infections are thus introduced, and there is no good reason for 
assuming that these noxious bacterial agents can pass through a wholly 
intact epidermis. 
An exception to this rule is found notably in the case of mercury, which, as is well 
known, may produce severe constitutional and poisonous effects after its absorption 
through the unbroken skin, and also in such cases may produce a universal and even 
dangerous form of dermatitis. Somewhat analogous to this dermatitis from mercurial 
intoxication is a form described as occurring in workers in anilin factories and in dye 
houses, which runs an exceedingly acute and virulent course. It starts as an acute 
dermatitis, beginning on the exposed portions-hands and face-and showing its most 
active characteristics in those places. From here it spreads to the arms, trunk and 
lower extremities. The affection may be confined to the erythematous stage, causing 
much oedema of the hands, ears, penis and scrotum, or it may progress to a quite 
intense bullous dermatitis, with large and small, often confluent, bullae, followed by a 
long-lasting and profuse desquamation. When the feet are more acutely affected than 
the hands, it can usually be shown that the subjects have been working without 
stockings or other protective covering. This affection has a definite course and is 
followed by a marked idiosyncrasy to this form of poisoning. It is assumed that 
in this case certain toxic substances find their way through the intact epidermis to 
the deeper parts of the skin, expending their action especially on the vessels of the 
skin. Blaschko gives a list of 19 colors with which such a type of dermatitis has been 
observed, but points out that they must not be looked upon as generally poisonous 
substances, inasmuch as a certain idiosyncrasy seems to be necessary in the persons 
affected. Such forms of dermatitis have also been observed in the case of workers 
in quinine factories, in those who have to handle various foreign woods, satinwood, 
teak, etc. 
Dermatitis, Usually of an Eczematous Type.-By far the larger num- 
ber of cases of occupational dermatoses are exhibited in the form of a 
dermatitis of an eczematous type, and most of them come under the com- 
monly used heading "trade eczema." It does not come within the scope 
of this article to discuss at any length the much mooted question of eczema, 908 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
including the application and limitation of this term. Many of the cuta- 
neous disturbances caused by the occupations produce an acute derma- 
titis very similar to, if not indistinguishable from, an ordinary dermatitis 
venenata, caused in the same way by the direct contact with poisonous or 
irritating substances. Most of these inflammations affect the hands, 
head, or whatever parts of the body may be exposed to direct contact with 
the irritating substance. Those who hold to the older view class these as 
cases of acute eczema, their recurrence and persistence, whether by 
continued exposure to the primary exciting cause, or without this objec- 
tive incentive, placing them in the group of chronic eczemas. A very 
large number of the cases of occupational dermatitis begin, as will be 
seen in the course of this article, in quite a different way, going through no 
preliminary acute stage, but presenting the various clinical features 
common to ordinary cases of eczema to which no definite external causa- 
tion can be assigned. These cases of occupational dermatitis, or 11 trade 
eczemas," form an astonishingly large proportion of the total number of 
cases seen in the dermatological departments of hospitals. 
Fordyce has stated that at his clinic at the University and Bellevue Hospital 
Medical College about 2 per cent, of the total number of new cases for 1911 constituted 
occupational dermatoses. The great majority of these were of the type known as 
trade eczemas, and while a good many of them yielded readily to treatment, a con- 
siderable number proved refractory, and necessitated abandonment of the particular 
work for a time, or changing of occupation. Knowles reviewed 24,459 cases of dis- 
eases of the skin that had been seen by him during 9 years at the dermatological 
departments of the Pennsylvania University and Howard Hospitals. Of this number 
4142 were diagnosticated as eczema, and of these 768 were from distinctly occupational 
causes. He points out that this estimate included only those cases where there was 
direct exposure from the occupation, and cases of eczema rubrum, for example, that 
were evidently produced by long standing at various occupations, were not considered. 
Predisposing Factors.-It is a matter of common knowledge that not 
all persons who are exposed to cutaneous irritants are affected adversely 
by them. This is well seen in the exemption of many people from poi- 
soning by ivy and other plants which may produce a severe dermatitis 
in others. In the same way not all the workmen exposed to the same con- 
ditions in their particular trade are similarly affected by them. Others, 
after once exhibiting a susceptibility, become increasingly sensitive to 
such irritating influences, as time goes on. As a rule, the occupational 
dermatoses do not occur suddenly, or at the outset of exposure, but after 
a considerable time, sometimes several years. This acquired sensitive- 
ness may be explained either by the cumulative action of the constant 
irritant, or on the theory of a gradually diminished power of resistance. 
It is an undoubted fact that the sensitiveness of the skin toward irri- 
tants varies with the individual. Also it is apparent that this individual 
sensitiveness is more pronounced in the case of exposure to some kinds of 
irritants than to others. There is comparatively little difference in the 
sensitiveness of various people to the action of thermic irritants. How to ECZEMA PREDISPOSING FACTORS-TRADES AND CALLINGS 
909 
account for this varying susceptibility of the skin to reaction from poisons 
and irritants is by no means agreed upon. Thibierge and Jacquet have 
considered that general or bodily conditions have the same effect in pro- 
ducing skin inflammations as local conditions, and especially in respect to 
digestive disturbances. 
Of 27 cases of trade eczema studied by Jacquet and Jourdanet, in 22 there were 
errors in digestion; the subjects being either alcoholics, addicted in excess to tea and 
coffee, or accustomed to insufficient mastication and to hurried eating. In 25 of these 
cases, when these causes were removed there was improvement. Darier, also, con- 
siders that alimentary hygiene has a marked influence on the vulnerability of the 
skin. Four patients were cured or improved in 7 days by the treatment of the 
digestion without local treatment, and nine were cured or improved without sup- 
pression of professional contact. On the other hand, Herxheimer states that in a great 
many trade eczemas, and other chronic eczemas, observed in the course of years, no 
progress toward amelioration was made by attention to the diet alone. He does not 
consider it necessary to invoke trouble with the internal organs in trade eczemas, as 
there are many local factors, such as the varying fat content of the skin, the composi- 
tion of the sweat, etc., that may account for varying susceptibility. 
On the whole, there is insufficient data from which to determine the 
underlying reason for this varying susceptibility of the individual. There 
is no foundation for the assumption that it implies a difference in the con- 
dition of the internal organs, or of the vital processes in general. 
The number of different occupations that have been found to be the 
cause of cutaneous disturbances is very large. Herxheimer has compiled 
74 different 11 trade eczemas" and asserts that probably some were over- 
looked, while new ones may be expected to arise constantly, with new 
methods of technique. 
Age and sex appear to be factors of very little importance in occupa- 
tional dermatoses generally, although Merzbach's figures show that 
the ages from 20 to 40 are the ones in which subjects are most likely to be 
affected. In certain occupations, it is true, only women have been found 
to be affected, in others only men. Nationality is not a factor of impor- 
tance. Knowles, from the investigations alluded to, found that a very 
large majority of the outbreaks occurred during the winter months, in 
practically all of the occupations concerned; also that most of the cases 
collated by him lasted over a period of weeks or months independently 
of the abandonment of the irritating occupation; that the eruption had a 
tendency to relapse, and that a less amount of irritation was needed to 
excite the later attacks. 
OCCUPATIONAL DERMATOSES, CONSIDERED ACCORDING TO THE VARI- 
OUS TRADES AND CALLINGS 
Housemaids and Houseworkers.-People engaged in these occupations contribute 
a very large number of cases to the class we are discussing. The type of eruption usu- 
ally presented is that of an eczema, most commonly of the squamous or vesicular 
variety, but not infrequently papular, erthematous or oozing in character. In almost 910 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
all cases the dermatitis is present on the hands and arms, spreading oftentimes to the 
legs, feet, face and neck. Extensive eruptions may have their origin in this way. 
The direct cause of most of these cases is the constant use of water and soap. Water 
and soap are both cutaneous irritants, withdrawing the protecting fat and softening 
and removing the outer horny layer so that the skin is deprived of some of its power of 
resistance and becomes more vulnerable. Washerwomen, who are included in this 
class, are especially liable to a dermatitis of the hands and arms from the continual 
immersion of these parts in soap and water. The strong alkaline soaps that are used 
on account of their superior detergent powers are responsible in great measure for these 
irritating effects. Various washing powders and cleansing alkalies are added often- 
times, especially for the greater facility in washing clothes, and these are to the 
highest degree irritating. The poor character of many of the soaps is also responsible, 
a free alkali when present adding much to the irritating properties. These results 
from the use of soap and water, so common in houseworkers, are often seen in people 
who are not obliged to work, but have acquired the habit of constantly scrubbing their 
hands with soap and water. Fordyce states that nearly one-third of the occupational 
diseases seen in his clinic during a year were in people whose work caused them to 
employ soap and water freely, or else the various alkaline cleansing agents. Knowles 
found that in his experience housewives who had to do all of their own work on account 
of financial reasons, such as cleaning, washing and cooking, were the ones most likely 
to be affected in this way. Another affection to which people of this class are more or 
less subject, together with all those whose occupations require them to stand con- 
stantly, is chronic dermatitis of the lower legs, combined oftentimes with varicose 
veins and resulting not infrequently in the well-known stubborn varicose ulcer. In 
washerwomen, besides the inflammation that has been described, a peculiar condition 
of the face is often met with. This is characterized by the presence of a number of 
rounded, translucent yellowish-white vesicles, of about the size of a small pea on the 
average, which are called hydrocystomata, and which represent a cystic condition of 
the sweat ducts of the middle third of the face. These lesions also occur sometimes in 
those who perspire freely, and in the case of washerwomen are attributed to the warm 
moist atmosphere in which the subjects work. 
Bakers.-A dermatitis of the hands and forearms of bakers, caused by constant 
contact of the skin with the moist dough, aided by the heat of their surroundings, 
has been frequently observed. Knowles remarks that "bakers' eczema" or "bakers' 
itch," as it has been called, was first referred to by Willan in 1817 under the name of 
psoriasis diffusa. Knowles reports that he has met with 11 cases of this affection. 
Although no accurate figures are available, it is no doubt true that a large number of 
cases have been observed in the skin department of the Massachusetts General 
Hospital during the last 20 years. The lesions present the appearance of rather cir- 
cumscribed crusted patches, often circinate in shape and resembling psoriasis some- 
what. They are most common upon the hands, and are often similar in character to 
the appearances seen in workers in sugar. Acne, furuncles, and localized abscesses 
are said to be of frequent occurrence among bakers, the last two named being doubtless 
from the abundant opportunity for secondary infection afforded by the situation and 
character of the dermatitis. It is quite unlikely that the presence of mites in the 
flour is to any degree responsible for the eruption. 
Barbers.-Barbers and hairdressers are exposed to much the same external in- 
fluences as are washerwomen and houseworkers, from the necessity of constant contact 
of their hands with soap and water, in the process of rubbing in the soap for shaving 
and in shampooing the head with various soap preparations. They often use alcoholic 
solutions of the potash soaps, employed on account of their greater detergent qualities. 
The various stimulating lotions that are rubbed into the scalp are also often the cause 
of irritation, such as strong cantharidal preparations, the various anilin hair dyes, 
quinine hair tonics, etc. The resulting dermatosis usually takes the form of a papu SKIN AFFECTIONS IN VARIOUS TRADES 
911 
lar eczema confined to the hands, and especially affecting the fingers, although the 
arms also may be involved. Knowles has collected 15 cases of this affection. 
Fordyce has seen unusually severe forms of eczematous dermatitis in barbers who had 
been in the habit of using anilin hair dyes on their customers. 
Workers in Sugar, Chocolate and Candies-Confectioners.-A dermatitis of the 
hands and arms of those who were in the habit of handling sugar was one of the first 
forms of trade dermatoses recognized. White says, "The old-fashioned term 'gro- 
cer's itch' is rarely applicable in these days of refined and double-refined sugars. 
Formerly, when brown sugars were almost universally used in the household, it was 
employed to signify an eczema of frequent occurrence upon the hands of the grocer 
who handled not only these but many other substances belonging to his trade, which 
were more or less irritating to the skin. What share the sugar had in thus exciting the 
skin, it is impossible to say, but to it was attributed the greatest. These sugars often 
contained an abundance of mites, but it is improbable that they excited any irritation 
by contact." 
Eruptions of an eczematous type of the hands of those who work in sugar and 
candy manufacturies are frequently observed, and are well known to all dermatol- 
ogists who have had experience in public clinics. The eruption may at times extend 
to the arms. Knowles has noted an outbreak in four female candymakers and in two 
of the male sex, three working in a sugar refinery, and one a chocolate roaster. He con- 
siders it difficult to determine the exact causation in these cases, but the trade was 
undoubtedly responsible for them, as the condition relapsed whenever the subjects 
resumed their occupation. At one time numerous cases were seen by the writer in 
girls whose occupation was to dip candies in chocolate in order to produce a coating of 
the latter. These eruptions usually took the form of a papular dermatitis. As White 
says, another cause than that of the sugar is present here, viz., direct heat and general 
high temperature of the workshops. Remy and Broca have reported four cases of 
ecthyma of the arms and legs in people who worked in sugar refineries, either naked or 
partially so. These eruptions they considered due to contact with the sugar, as they 
affected the uncovered portions of the body, beginning with a pustule, and often being 
associated with an eczema. These cases were found to be especially common in the 
workmen who had recently arrived, and to be very uncommon in those who prac- 
tised frequent washing and paid strict attention to hygiene. In all cases it occurred 
in those whose skins had been in contact with melted sugar or molasses, or whose 
trousers had become impregnated with these fluids. In these cases of molasses 
workers, it is common to work in the saccharine fluid up to the waist. Fordyce 
refers to a personal communication from Winfield in which he speaks of a dermatitis 
in sugar refineries, occupying the hands, forearms and legs and suggesting scabies 
somewhat. 
Poncet, Albertin, Chaussende, and other French writers have described a form of 
inflammation of the nails occurring in confectioners. This has been observed chiefly 
in the workmen employed in the great factories of southern France in making sugared 
fruits. The eruption has been attributed by many to the chemical acids contained in 
the juice of the fruits, into which the hands are dipped; others consider that it is due to 
the saccharine solutions and that it is analogous in its causation to the usual "sugar 
bakers' eczema." There can be no doubt that the cold and hot water into which the 
fingers are constantly dipped acts as a contributing factor, at least, in the etiology. 
The affection begins in the form of erosions and fissures about the nail fold, followed 
by inflammation, ulceration and granulations, together with a sero-purulent secretion. 
The nail is often loosened from its nail bed and is destroyed. The course is very 
chronic, lasting for years, with subacute intervals. The characteristics are: its affect- 
ing a number of the nails simultaneously, the discoloration of the nails, the granula- 
tions about the nail fold, and the flattening of the nail phalanx. Poncet considers 
that the onychia is sufficiently characteristic to warrant its serving in legal medicine, 912 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
as a means of identification. The middle and ring fingers are those first affected. 
After the fall of the nail the extremities of the fingers take on a characteristic form, a 
spatulate shape, which is lasting. Strauss has reported three cases of this affection, 
together with a good description. 
A lymphangitis has been described by Oliver as occurring in workers in sugar 
refineries, among the refiners and molasses stirrers. A slight degree of constitutional 
disturbance has been noted, and furuncles are sometimes an accompaniment. Gaillot 
has attributed the cause of this lymphangitis to the staphylococcus pyogenes aureus 
which is found in the residue of the molasses, acting in conjunction with the tempera- 
ture of the factory and the condition of the skin. 
Builders, Masons, Brickmakers, Laborers.-This class of people are subject to 
dermatoses from the character of their occupation, as well as from the exposure to 
the weather incident to their calling. Excessive cold, beside the various degrees 
of more or less generalized dermatitis that it may produce, is the cause in many 
instances of chilblains, which often produce much suffering and may interfere seriously 
with the occupation. In this connection the rosacea so common in drivers, coachmen, 
and those whose faces are much exposed to the action of the wind and weather, may 
be alluded to. It is also true that much of this may be attributed to the effect of 
alcohol, to which this class of people is notoriously addicted. Varicose veins with 
their sequel, chronic ulcer of the lower legs, is also a prominent affection in these 
callings, as well as in all others in which long hours of standing at work are necessary. 
Builders and masons are very often affected by a dermatitis of the exposed parts of 
the body caused by the irritation from the lime and cement with which they have to 
do. Plasterers, whitewashers, and paperhangers are similarly affected. Brickmakers 
are often affected with a dermatitis of the palms. 
Tobacco Workers.-Long-continued, stubborn eruptions upon the hands are ob- 
served in those who work constantly with tobacco, in the process of cigar making as 
a rule. These eruptions are very liable to relapse. The dermatitis has by some been 
attributed to the irritating effects of the nicotine, by others to the caustic solutions 
that are used for separating the tobacco leaves. Tobacco workers generally work 
under very unfavorable hygienic conditions, and the heat and moisture to which 
they are subjected must be looked on as prominent factors in the etiology of this 
dermatitis. 
Furniture Polishers.-This trade lends itself with a surprising frequency to a well- 
marked and rather characteristic dermatitis of the hands and especially of the fingers, 
the so-called "polishers' itch." It is attributed to methyl or impure alcohol which is 
used in making various varnishes and polishes, and impure benzine for cleaning 
purposes. A somewhat characteristic appearance is produced in these cases from the 
staining of the nails and skin by the preparations used, and by the odor that in recent 
cases clings to the epidermis, sodden and impregnated with the preparations. Not 
infrequently the writer has noticed a dermatitis of the face also in these cases, of an 
erythematous type, situated especially about the mouth, nose, and ears, and of a 
peculiarly shining, glistening aspect. Also in many cases there has seemed 'to be a 
condition of general anaemia, and lowered physical vigor. Machinists and oilers 
may also be similarly affected. Blaschko states that before the introduction of 
denatured spirit (i.e., before 1879) there were very few skin affections in furniture 
polishers. He refers especially to troubles with the eyes, catarrh, and pulmonary 
affections in this class of subjects. After a careful search of the other substances 
used by furniture polishers, Blaschko concludes that the pyridin used in denaturing 
the alcohol is possibly concerned in the causation of the dermatitis. 
Bartenders and Liquor Dealers.-Knowles reports eight cases of dermatitis of 
the fingers, hands, and forearms in bartenders, one in an alcohol dealer, and another 
in a brewer. The mechanism is much the same as in the case of housemaids and cooks, 
constant immersion of the hands in water while cleaning glasses and the strong soaps SKIN AFFECTIONS IN VARIOUS TRADES 
913 
used, causing a dermatitis of the hands and forearms that is often very intractable, 
especially if the occupation is persisted in. 
Printers.-Numerous instances of dermatitis in workers at these trades have been 
reported, and are commonly met with in dermatological clinics. Knowles records 
eight cases in printers, two in typesetters, one in a press-room worker, one in a handler 
of the dye presses, one in an architect, one in a draftsman, and one in a newspaper 
seller. He says further: "The helper around a type foundry is apt to have an out- 
break because of the irritating oils he is forced to handle. The electrotypers handle 
lye to wash off the forms because of the graphite and the dust. They take a mould, 
consisting of plumbago and wax, and place it in a wash of bluestone and muriatic 
acid, an electric current is then turned on, and a copper coating is formed on this 
wax 'shell.' This shell remains in the solution for from 40 to 45 minutes. This mould 
is then placed in a machine and lead is run in on it, the wax is then removed and the 
electrotype is finished. Stereotypers use a lead mould without the copper surface. 
The compositors handle only gasoline or benzine to clean the type. The eruption is 
therefore more apt to occur in the electrotypers, the stereotypers, the helpers in the 
foundry and in the makers of the moulds than in the compositors." 
Zellner and Wolff report that there have been a great many cases of skin affections 
of very similar character occurring during the year 1912 among printers employed by 
Berlin newspapers. The first appearances were those of a subacute dermatitis of 
the hands and forearms, somewhat artificial in type. It was found upon enquiry 
that the workmen themselves attributed these affections to certain substitutes for 
the oil of turpentine, which had heretofore been used for the purpose of cleaning type. 
It is stated that of late benzine, lye, petroleum and certain kinds of pine oil have been 
used as cheap substitutes for turpentine oil in removing the ink from printer's forms. 
These substances are either directly poisonous to the skin themselves or contain irri- 
tating impurities. An inferior benzine, which it has been found is often used as a 
substitute for turpentine oil is decidedly irritating to the skin. This substance is 
also being used in certain cheap kinds of paint. Thirty-seven samples of these sub- 
stances used for cleaning were analyzed, with the result that 32 or 87 per cent, of them 
were found to be harmful, and a return to the use of a high-grade oil of turpentine 
is therefore considered imperative from the point of view of the workmen's health. 
As illustrating the poisonous character that may be present in some grades of benzine, 
the testimony of Dr. Oestreicher of Berlin is adduced, who has seen eczema caused by 
wearing gloves that had been cleansed by benzine, and he further states that harmful 
skin effects have been caused by cleaning the skin with benzine before operations, and 
also by using this substance to remove surgical dermatological plasters. 
Workers with metals and minerals, especially those engaged in the silver and 
electrotyping trades are very subject to a dermatitis of the hands and forearms. 
Hall, quoted by Knowles, has described the mechanism by which workers in these 
trades acquire an eruption of the type of a papular or papulovesicular eczema. The 
goods are cleaned by means of a revolving brush, on which sour beer drops from a 
trough above, and the liquid from this revolving brush is splashed upon the hands, 
forearms and sometimes faces of those engaged in the work, acting thus as a more or 
less acute cutaneous irritant. The same writer describes an outbreak of dermatitis 
on the hands and arms of polishers and burnishers of silver, where the irritation is 
due to the "rouge" used for burnishing, this so-called "rouge" being a mixture of 
"quicksilver," iron and wax. There are various grades of this "rouge," the coarser 
variety showing greater powers of irritation. Bichromate of potash is said by Crocker 
to be used by French polishers and to be productive of a dermatitis frequently. 
The cyanide of potash is also used for cleaning silver and gold, and may produce 
cutaneous trouble. Knowles cites several cases in point. 
Dyers and Anilin Workers, Dressmakers and Photographers.-For years severe 
cases of dermatitis have been noted in dyers and those employed in establishments for 914 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
the manufacture of anilin colors. Compounds of arsenic, mercury and chromium 
have been used in making these brilliant dyes from coal tar-substances that are of 
themselves powerful cutaneous irritants, and are to be regarded as in some measure 
responsible for the dermatitis common in those engaged in this trade. Bichromate 
of potash when applied to the skin produces an eruption of papules and pustules, 
and later deep sloughs and ulcers. Hence those workmen who use this substance 
in their trade-flyers, electricians, photographers, etc.-often exhibit deep and painful 
ulcers of the hands and arms. Harrington has published the case of a capmaker who 
was poisoned on the face, neck and hands after cutting up a piece of dark blue cloth 
for boys' caps. Analysis showed the presence of a large amount of chromium. Two 
years afterward a similar eruption appeared after dusting and packing away the same 
unmade caps. Poisoning from the anilin dyes and bichromate of potash is by no 
means confined to those working in these substances. Numerous instances occur of 
varying grades of dermatitis in the wearers of stockings, gloves, caps, underwear 
and shoes which have been dyed in this manner. White reports several cases of deep- 
seated dermatitis produced by gloves and stockings of quiet colors that may have 
been due to the presence of chrome mordants. Other instances of analogous methods 
of poisoning are in those who cut paper flowers and patterns from paper impregnated 
with anilin dyes, upholsterers, milliners and dry-goods clerks, shirt-makers, etc. 
Aurantia or hexanitro-phenylamine is a dye that has often been used for coloring 
cheap yellow leather shoes. Crocker states that those who work with it are liable to 
a severe dermatitis of the hands, as the liquid is sponged on to the leather to be dyed. 
Among photographers numerous instances of dermatitis have been observed which 
were attributed to bichromate of potash, and Richardson of London has described 
these cases under the title of "the bichromate disease." Beers reports cases of der- 
matitis among photographers due to the irritating effects of metol. Knowles pro- 
duced a series of four photographers and one photo-engraver afflicted in this way, and 
has also referred to the case of a moving-picture operator poisoned from handling the 
films, carbon, and cement. 
Rident has noted cases among the linen-dyers in the cloth manufactories of 
Elbeuf who dip the linen in a bichromate solution. As a rule, after working from 5 to 
6 weeks with the hands immersed in this solution, redness, vesiculation and oozing 
of the backs of the hands follow. 
The dermatitis that occurs upon the hands and forearms of tanners may be alluded 
to in this place; this is due to the chemical process through which the hide and leather 
are passed. Knowles thinks that the bath of bichromate of potash and muriatic 
acid in which the hides are placed, and in which the workmen's hands remain for a 
considerable time, is the cause of the dermatitis. The eruption from this cause may be 
quite long in duration, compelling the workmen to suspend work either temporarily or 
permanently. Da Costa has seen 44 cases of chrome ulcer, mostly in tanners, who 
worked with the chrome process and not with the old tan bark. The most common 
situation is in the folds of the dorsal surface of the fingers, over or near the knuckles. 
There is often severe pain. 
Blaschko has described the appearances of the dermatitis in anilin workers 
as of manifold character and of very quick onset often. He says the eruption is so 
typical that a diagnosis of the trade may be made from the appearances, the backs 
of the hands being much swollen, tinged here and there with dye, with intervening 
eczematous plaques. Hyperhidrosis of the palms (Grandhomme) has also been 
emphasized. The affection is often made worse by the means used for getting off the 
dye, chloride of sodium and chloride of lime, the use of the latter substances being 
partly responsible for the eczema. 
Workers in Chemicals and Drugs, Arsenic, Chlorine.-Those who handle chem- 
icals constantly are naturally subject to dermatitis of the hands from the irritation 
due to the contact. Chemists are very frequently annoyed by obstinate eczemas and SKIN AFFECTIONS FROM DYES, ARSENIC AND CHLORINE 
915 
are often obliged to suspend or abandon their occupation temporarily. Oftentimes 
an intense susceptibility is acquired-a state of anaphylaxis-to such a degree that 
a very small amount of exposure will call forth an outbreak. Sometimes chemists are 
very susceptible also to the fumes of various chemicals. The face is naturally affected 
very frequently from contact with the fumes. Fordyce has several times seen a simi- 
lar anaphylactic condition from formalin in laboratory workers. In all of these 
cases the action of the chemical is undoubtedly increased by the constant immersion 
of the hands in liquids, and by the use of strong soaps and alkalies in the process of 
cleansing. 
Arsenic, on account of its wide use in the arts, is a frequent cause of dermatitis. 
Preparations of arsenic have been used as pigments in the preparation of wall-papers, 
and of colored paper for other purposes, in printed and dyed cloths for garments and 
artificial flowers, in combination with anilin and other dyes, as preservatives of 
sizings and pastes, and for curing hides and bird skins. James C. White in his 
monograph on Dermatitis Venenata enumerates these various occupations in which 
arsenic is used, and states that the workmen engaged in manufacturing and those 
manipulating these products are subject to a great variety of inflammatory processes 
of the skin. An erythema is the first and mildest grade of inflammation produced 
by the action of arsenic on the skin, which is quickly followed by papules, vesicles and 
pustules. A further development is the formation of characteristic ulcers, round, of a 
grayish or reddish moist base, and sometimes surrounded by a dense induration. 
These may be quite deep and painful, and are commonly seated upon the hands, espe- 
cially about the nails, and the forearms, parts which come directly into contact with 
the arsenic. The face, especially the regions of the lips and nose, behind the ears, 
about the neck, the scrotum and surfaces of the thighs adjoining, and the toes are 
other parts frequently affected. "Arsenic pock" is a name that has been given to 
arsenical ulcers of the hands in color workers. The dermatosis that frequently occurs 
on the hands of furriers, especially of those who are engaged in handling dyed furs of 
an inferior grade, has been attributed to the sulphide of arsenic that is used with 
lime in the curing of the fur. White has reported cases of arsenical dermatitis on the 
hands of taxidermists in whom the typical ulcerations about the nail were developed 
in a marked way. He records the case of a man who suffered from a severe dermatitis, 
so that the eyes were closed, and there was present considerable constitutional dis- 
turbance. It was found that he had been engaged for 3 days previous to the cutaneous 
appearances in fastening pieces of white webbing into sample books, the paper linings 
of which were covered with green arsenical pigment as determined by chemical 
analysis. 
White says (Dermatitis Venenata, 1887): "Chlorine gas acts as an irritant upon the 
skin, producing prickling and redness when held in contact with it, and sometimes an 
eruption of papules and vesicles. Chlorinated soda and chlorinated lime solutions 
occasionally cause a mild degree of inflammation, erythematous and papular in 
character, in workmen employed in bleacheries, paper mills, etc." 
Herxheimer described (1899) for the first time an affection which he called chlorine 
acne, which gave rise to numerous publications confirming his observations but dis- 
agreeing as to the etiology and nomenclature. It is observed in electrochemical 
establishments among workers in rooms in which free chlorine is obtained from chloride 
of potash by electrolytic decomposition. Hence it was concluded that this acne was 
caused by the chlorine, analogously to that produced by bromine and iodine, being 
breathed in and then excreted by the sebaceous glands. Doubt was thrown on this 
view later by the fact that a similar affection was not observed in establishments in 
which chlorine was generated by other than electrolytic means. Kaposi suggested 
that it was a tar acne, and this view, although at first rejected, has since attained 
much prominence, the direct agent being paranitrochlorbenzol which is generated in 
the electrolytic process. The constant feature of this affection is the comedo, of the 916 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
type common in acne vulgaris. At the start it is seen on the central portion of the face 
alone, but later it appears on the ears, neck, trunk and extremities, often in great 
numbers. With this comedo formation there is associated an eruption of acne lesions 
often attaining a large size, and presenting the appearance of sebaceous cysts. These 
lesions develop very rapidly, the affection reaching its full extent in a few weeks 
usually, and then remaining stationary for a long time, even if the patient has aban- 
doned his work. Complete healing is the final result. Anatomically the lesions do 
not differ from those of ordinary acne and comedones. They differ clinically from 
these affections by their extension over the body generally. The affection is painless 
and without influence on the general health. It has seemed to be more common in 
summer than in winter. 
Workers in High Explosives.-During the war the great increase in the manu- 
facture of high explosives brought to notice the occurrence of a considerable number 
of cases of dermatitis among the workers. The dermatitis produced by high explo- 
sives is of practically identical types, as those already described, although the staining 
of the skin that accompanies may be characteristic. 
Tetryl is a very strong chemical irritant especially in the form of powder. It 
causes in those who work with it a yellow or apricot staining of the skin and of the 
hair. The dermatitis usually appears within a fortnight of beginning work with the 
substance, varying from an erythema to edema and deep-seated vesiculation asso- 
ciated with a very severe type of itching. A marked susceptibility is produced in 
those who have once been poisoned with it and is met with not only in the workers 
themselves, but in people who handle soiled clothes which have been worn in the 
factory. Eyelids are very apt to be affected and there is often conjunctivitis and 
irritation of the mucous membranes of the upper respiratory tract and of the stomach. 
Ruxton has seen constitutional symptoms only once. 
Trinitrotoluene.-This is given off in the form of a fine dust in filling canisters and 
shells, which, coming in contact with the skin of the worker, gives rise to a severe type 
of dermatitis, and may, by absorption, result in toxic and even fatal symptoms. 
It may, like tetryl, be inhaled or swallowed with severe resulting effects. The erup- 
tion is often of a papulo-vesicular or bullous type, and is apt to become infected 
secondarily. There is also a yellowish staining, not so intense, however, as in the 
case of tetryl. The parts not covered with clothing are the most affected, and it is 
often especially severe about the wrists and neck. Putnam's and Herman's cases 
were of the small papular type, and the favorite location was the extensor surface of the 
forearm. In all of their cases there were symptoms of mild gastrointestinal irrita- 
tion, but with one or two exceptions they did not seem to be very sick. Others have 
described serious general effects in the form of toxic gastritis, toxic jaundice, and toxic 
anemia. Idiosyncrasy seems to be especially marked in this form, as some skins are 
completely immune from it, while with others it appears at once and recurs on the 
slightest exposure. It is most common in hot weather and in oily skins. 
Lyddite.-With this the irritant effect is due to the picric acid that it contains, 
which stains the skin a yellowish or greenish color. There may be a severe dermatitis, 
preventing sleep, and occurring on the face, hands and fingers especially. 
Other substances that have been reported as causing a dermatitis in munition 
workers are nitrate of ammonium, stomonal, "conditioning fluid" (a preparation con- 
taining formaldehyde), and "composition," an explosive combination containing 
fulminate of mercury. 
Thibierge has described under the title "Le Bouton d'Huile des Tourneurs d'Obus" 
a dermatitis that occurs on the dorsal surfaces of the fingers, hands and forearms in 
workmen engaged in turning out shells. It is characterized by rounded pustules, 
containing thick pus, and surrounded by an inflammatory zone. There is also 
often a plugging of the pilo-sebaceous orifices with a black substance as in tar 
workers. (See Oil Folliculitis, Dermatitis and Furunculosis, page 696.) EXPLOSIVES, WOOD, FLAX AND LINEN WORKERS 
917 
Wood Workers.-A number of species of wood handled in the different trades 
have been shown to be poisonous to the skin of those working with them. These for 
the most part are the foreign species, satinwood, teakwood, ebonywood, cocobolawood, 
etc. Epidemics of dermatitis from satinwood have been reported by Cash as occurring 
in the shipyards on the Clyde, and the East Indian satinwood is regarded as more 
irritating than the West Indian variety. The alkaloid chloroxylonine which the 
satinwood contains is regarded as the active agent, but Knowles found that the local 
application of East Indian satinwood dust caused the eruption in a person who had 
previously been poisoned by contact with chloroxylo nine. The unprotected por- 
tions of the skin-the hands, wrists, face and ears-are the parts most frequently 
affected. Crocker has recorded cases of dermatitis in flute makers who use 
cocuswood, due, he thinks, to a resin in the wood, which belongs to the family 
euphorbiacese. Horand describes under the title "mains de crocodile" a dermatosis 
observed in workers in chestnut wood, which begins as an erythema and ends in a 
hyperkeratosis. 
Flax and Linen Workers.-Purdon (quoted by White) described in 1875 a peculiar 
form of acne on the forearms of workers in the linen mills of Belfast, Ireland. The 
young girls who removed the bobbins from the machinery and the spinners were those 
chiefly attacked. The arms were the parts most affected; next, the face, owing, 
it was thought, to wiping the face with the oily hands. The eruption was of a 
papulopustular type, with a shotty feel in its early stages, and resembled smallpox 
somewhat. 
Leloir in 1885 reported a skin affection in flax spinners in Lille. The eruption was 
situated mostly on the hands, and especially on the palms, more commonly the left 
one, and was peculiar to those who worked with damp linen. The hands of these 
workmen were kept constantly moist with the hot water from a trough through which 
the threads were made to pass for the purpose of cleansing the flax, and in this way 
the hands became covered with a mucilaginous coating, which was found to contain 
butyric and lactic acids combined with carbonate of lime in solution. The dermatitis 
was of an erythematous, vesicular and squamous type. 
White observes that in the cases of Purdon and Leloir the poisonous action cannot 
be ascribed with certainty to the flax alone, as there are other irritating factors present. 
Thorough enquiries made by White of the proprietors and managers of flax mills 
failed to discover any irritating properties in the flax itself. 
In 1889 Leloir described an epidemic of folliculitis and perifolliculitis in spinners 
The place of prominence was the extensor surface of the lower limbs, especially where 
the wet trousers came into contact with the skin. It is rare that it affects the upper 
limbs as the workmen usually work without covering the arms, and it is characterized 
clinically by papules and papulo-pustules which may attain a considerable size. 
The pruritus may be quite severe. Leloir considers that the affection is due to the 
irritating oil with which the looms are impregnated. The location is explained by 
soaking of the trousers in the oil and by wiping the hands on the trousers. The 
subjects affected were usually males, although some cases were observed in females 
when a thin closely fitting petticoat was worn. Leloir pointed out the aid that this 
dermatosis may be in legal medicine. He estimated that from 5 to 8 per cent, of the 
workmen were subject to this affection. 
Knowles has seen outbreaks of dermatitis in five workmen in a cotton mill, four 
workmen in woolen mills, and four cases in weavers. He points out the fact that the 
dye houses connected with the mills are much more apt to be the seat of an outbreak 
than the mills proper. 
White refers to an instance of a rash reported to him as occurring among workers 
in jute. There is also a German account of an eczema of the hands and arms prevalent 
in jute mills, attributed to the oil with which the fibers are saturated in order to work 
them. 918 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
Oliver has published photographs obtained from Dr. Glibert of Belgium, showing 
varying degrees of erosions on the palms of workers in flax, especially the female 
workers, due to the frequent contact of the hands with the irritating material con- 
tained in the liquid for spinning. 
Tar, Paraffin and Petroleum Workers.-The various preparations of tar have 
been used from very early times quite extensively in the treatment of skin diseases. 
The indications for this group of preparations are in general the relief of pruritus and a 
diminution of inflammatory infiltration and hyperkeratosis-what has been termed 
a reducing action. Two forms of dermatosis may be produced by the pathological 
action of tar. One is a diffuse dermatitis, often accompanied by much burning and 
itching and which may merge into a long-continued eczema. The other form is an 
acniform inflammation of the follicles, the mouths of the follicles being often sharply 
defined by a black stain of dried tar, so that the appearance of comedones is simulated. 
Oftentimes these black comedo-like lesions are surrounded by an inflammatory 
border, and in this way the "tar acne" is produced. In some cases the comedo-like 
appearances are present without any inflammation of the follicles. This tar acne 
has sometimes been seen in workmen who are employed with machinery which has 
been lubricated with tarry compounds, and when the air of the workshop is filled with 
the vapor of tar. In some cases this tar acne changes into a more diffuse form of 
dermatitis, of an eczematous nature, which has been called "tar itch." In still other 
cases workers in coal-oil, and tar products generally, have developed indurated 
plaques and hyperkeratoses and multiple papillomata which have in turn degenerated 
into malignant growths. 
White, writing in 1887, states that while it has been reported that workmen in 
petroleum suffer from a scarlatinoid eruption or from furuncles on exposed parts of the 
skin, the crude petroleum itself cannot have very irritating properties, as it has been 
used for years in considerable quantity for the destruction of scalp and pubic lice, 
without causing a dermatitis. He has seen teamsters, who were engaged in carrying 
the crude oil from the railroad tank to the refining factories, wash their faces and 
hands in a bucket of the oil. He thinks it probable that the poisoning arises from 
contact with some of the numerous products obtained by the various processes there 
employed, and not from the crude oil. 
Lewin in 1888 published an elaborate article on general and cutaneous poisoning- 
by petroleum. He made a trip to America and saw cases of skin affections in the 
Atlantic Refining Company, which had their seat especially on the upper leg, knee, 
and arms. There were often acniform lesions on the arms, as well as large furuncles 
with inflammatory appearances in the vicinity. He found that it was the heavier 
oils that caused the trouble, for no affections of the skin were found among those who 
worked with the lighter oils. 
Derville and Guermonprez, writing in 1890, report that they examined between 
400 and 500 workers in petroleum refineries, with the result that they found only four 
affected with papillomata, and these were the men who were engaged in cleaning the 
apparatus used in the last distillation of the petroleum. The clothing becomes satur- 
ated with the oily substance, and exhales a penetrating odor of petroleum. The fore- 
arms and hands are most frequently attacked, although other parts may be affected, 
such as the eyelid and scrotum. The warty growths are of a very variable size, and 
seated upon a deeply pigmented skin which is dry and often spotted with white 
cicatrices. 
Mackenzie has described similar appearances in a man 30 years of age who worked 
in creosote. In this case the forearms and backs of the hands showed numerous 
comedones between which were warty elevations as large as a pea in some instances. 
There were similar lesions on the scrotum. The microscope showed epithelial! 
degeneration. TAR, PETROLEUM WORKERS, ETC. FLORISTS, ETC. 
919 
Piffard quotes Ogston as describing a dermatitis of the hands, wrists, feet and legs 
in the workmen engaged in working crude paraffin. The eruption is composed of 
bright red nodules about the follicles, and these nodules gradually subside leaving the 
mouths of the follicles dilated and filled with black dots. The backs of the hands 
are most severely affected, and in exaggerated cases present a peculiar honeycombed 
appearance, due to thick clusters of distended hair follicles. 
Florists, Gardeners, and Those Who Handle Plants and Flowers.-At the time of 
the publication of his valuable monograph on Dermatitis Venenata in 1887, White 
estimated roughly that about 60 native plants or those introduced into the United 
States were capable in some way of injuring the skin. Since then he himself and others 
have added considerably to this list. Among the most common of the plants that 
call forth a reaction in the human skin are poison ivy, poison sumach, poison oak, the 
two species of nettle, Japanese primrose; etc. Gardeners and florists suffer frequently 
from a dermatitis of the hands and arms, extending often to the face and other parts 
of the body, from handling and working among these plants. A pretty serious acute 
dermatitis may be present, such as all are familiar with in intense cases of poisoning 
from ivy, extending in some cases over a large part of the body and causing great 
oedema and discomfort. 
White was the first to call attention to the frequency with which those who handled 
the primula obconica, or Japanese primrose, acquired an artificial dermatitis upon the 
face and hands. Since then others have observed this occurrence, especially the 
English. This plant was introduced to European florists in 1882 from China. The 
first case observed was in a florist, who was attacked at the same time during 2 
successive years, a day or two after this plant came into bloom, and on each occasion 
two of his assistants were also affected. A botanist finds that the hairs with 
which the leaf and flower stems are abundantly provided are easily detached, pointed, 
jointed, and contain a large amount of silex, and that none of the other species of 
primula are provided with these hairs; hence it is probable that they produce the 
inflammation. 
Walsh has described a dermatitis among flower pickers in the Scilly Islands, the 
so-called "lily rash." The narcissus is cultivated in great quantities in these islands 
and exported in the spring. The workmen who cut the flowers are subject to an arti- 
ficial dermatitis of the hands, arms, and face; not all varieties are said to be equally 
harmful, the most dangerous being the "campanelle." 
An epidemic of dermatitis among the workers in rice fields has been alluded to by 
Mantegazza, affecting the feet, legs, hands and arms. He found that it was only in 
certain fields and during certain years that this occurred, and attributed it to a small 
plant covered with numerous spines up to the top, which he found in the fields in 
question. These spines possess no secretory apparatus that produces a toxin, but 
have a mechanical action, boring into the skin of the laborer who goes into the water 
and therefore rubs against the leaves of the plant. 
Lacquer is obtained from the juice of a species of rhus in Japan, closely allied to 
our native plant. White says that the history of the preparation of this celebrated 
varnish of Japan and its effect on the workmen engaged in its manufacture and use 
are very little known. Incisions are made in the bark extending about one-quarter 
of the trunk's circumference and just deep enough to reach the wood. The clear sap 
which flows out becomes rapidly darker on exposure to the air, and gradually takes 
on a dark brown almost black color. The sap is preserved in bamboo tubes, to keep 
it from turning black. It is shown by older writings that those who worked with 
this sap were frequently poisoned. White found that the embossed Japanese wall- 
papers that are used in our houses have produced severe inflammation on the hands 
of the hangers, in consequence, he assumes, of the abundant lacquer with which they 
are covered. Allen of Korea has reported that many foreigners as well as natives in 
the East are affected with "varnish poisoning," which is in some cases so pronounced 920 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
that the person cannot pass a furniture shop where articles are being varnished 
without being poisoned. This susceptibility is more pronounced during the rainy 
season. 
Citrus vulgaris, the bitter orange, is largely used for the manufacture of marmalade 
in Florida and in some parts of Europe. Bazin described the occurrence of a derma- 
titis of the face and upper extremities in workmen employed in peeling this fruit in 
France. The left hand, in which the fruit is held while being cut, is especially affected. 
In the United States it is stated that persons employed in manufacturing oil of orange 
peel suffer greatly from erythematous, papular, and vesicular eruptions of the skin, 
especially of the hands. White states that inquiry among the large orange growers 
of southern California fails to discover the occurrence of poisoning in those who 
handle the fruit. Marmalade is not commonly made there. 
Vanilla comes from the bean of a plant Cultivated in Mexico, Central America, 
the West Indies, and also in the East. It grows best in Mexico. White reports a 
case of acute dermatitis of the head and hands in a man who had been twice affected 
in the same way since he had been engaged in managing a vanilla commission house. 
In the manufacture of vanilla the beans are collected, put through a "sweating" 
process, turned frequently under blankets, and sometimes submitted to artificial 
heat, until they assume a dark chocolate or blackish color. In handling these pods 
many of the workmen acquire a dermatitis of the hands and face, which has been 
attributed to two causes: first, an acarus, which is improbable; second, in the lower 
qualities of pods it is known that an artificial method is used for coloring them 
black, and that this material is the oil of the cashew nut found in the rind, called 
cardol. White says that there is little doubt that these cases of so-called vanilla 
poisoning are from the cardol of this nut. 
Quinine and its compounds are capable of setting up a severe dermatitis in those 
handling them. White was not able to find any history of the occurrence of inflamma- 
tion of the skin from contact with the crude cinchona bark or other parts of the tree. 
Bazin stated that the workmen employed in the principal quinine factories of France, 
Germany and England were liable to a cutaneous disturbance, which was sometimes 
so severe as to cause them to give up their occupation. These accidents are most 
common in Germany and France. The workmen affected are chiefly those who boil 
the bark, those who convert the quinine into the sulphate, and those who bottle the 
sulphate. A simple residence in the factories, without being employed, is sometimes 
sufficient to cause this affection. The affection had the form of a typical, acute arti- 
ficial dermatitis and was due, it was thought, to quinine emanations. All of the work- 
men did not seem to be equally predisposed to the effection, as some had been engaged 
in this occupation for years with no ill effect. In some cases the subjects seemed to 
become habituated to these influences, and the attacks gradually ceased; others were 
forced to give up their work permanently. White found that occasional cases occurred 
among the workmen in American manufactories. Idiosyncrasy seems to play a more 
prominent part in quinine rashes than in most others. 
Musicians.-Stern has divided the dermatoses of musicians into three categories: 
(1) A sycosis of violinists. He collected six cases, three of whom were musicians, one 
a teacher, and two tradesmen, in which a sycosiform eruption developed on the left 
half of the face, at the lower boundary of the beard, in essentially the submaxillary 
region, the part of the skin against which the violin is accustomed to press in playing 
on that instrument. (2) An eczema of flute players, a moist dermatitis of the lips 
and neighboring parts of the cheeks and neck. In one case the eczema recurred every 
time the flute playing was resumed. An instrument maker to whom the flute was 
submitted said that it was made of "Grenadillholz," red ebony-wood from the East 
Indies, and declared that he had received back a similar flute from a musician because 
it had caused a similar lip affection. (3) Lip affections of trumpeters. In a number of 
cases on the lower lip near the middle a sort of abortive furuncle occurs, without ten- FLORISTS, ETC.-PROFESSIONS ANIMAL SOURCES 
921 
derness. In other cases he observed scaling, horny excrescences in the same class of 
people, appearances much like those of cornucutaneum. 
Physicians, Surgeons, Nurses, Etc.-Since the adoption of the principle of asepsis, 
the use of various solutions for the treatment of the skin both of patients and of sur- 
geons, dressers, nurses and attendants has developed many cases of obstinate derma- 
titis, especially upon the hands. The constant use of soap, water, corrosive sublimate, 
carbolic acid, strong alkaline solutions, creolin, formalin, etc., is responsible in great 
measure for these conditions. The same conditions are responsible for a similar 
occurrence in dentists. Several instances have come under the writer's notice in 
which surgeons, after repeated rests from all irritating work, have been compelled 
finally to abandon their calling on account of the lamentable and dangerous condition 
that their hands were continually in. Numerous instances have also come under the 
writer's knowledge in nurses who have been obliged to give up their training and seek 
some other occupation. Formalin is a very irritating substance, and the cause of 
many cases of dermatitis. In some instances even a slight exposure to the fumes will 
be sufficient to cause an irritation of the skin. This susceptibility often increases 
after several attacks. 
In this connection it will suffice merely to mention the possibilities that are offered 
to those attending the sick of becoming infected with various diseases. The numerous 
cases of physicians who have become infected with syphilis through a wound in the 
finger, often in the practice of obstetrics and gynecology, are well known. The form 
of tuberculosis of the skin that has been called tuberculosis verrucosa cutis, and that 
is due to direct inoculation of tuberculous virus on the cutaneous tissues, is seen occa- 
sionally in physicians and nurses, as well as in medical students and dissectors, ward 
tenders, etc. 
Butchers, Cooks, and Those Who Have to Do with Animals and Animal Products.- 
Most of the cutaneous affections caused or influenced by special occupations, which 
have been considered in the preceding pages, are a serious menace to life only in excep- 
tional instances and, as a rule, when they become generalized. Among people who 
deal with animals and with animal products we find a class of cases due to direct infec- 
tions that are, as a rule, much more serious in their results and often a menace to the 
life of the individual. 
Pyogenic and Tricophytinic Infections.-Very numerous instances of the pyogenic 
affections of the skin, such as impetigo contagiosa, furuncles, carbuncles, etc., are 
found in butchers, cattlemen and those who have to do with dead animal matter. 
The opportunity for acquiring these affections in the course of such occupations is 
obvious. Tinea tricophytina and allied forms of vegetable parasites often are found 
in animals, especially domestic animals. Frequent instances of contagion from cats 
and dogs are found in children, and occasionally, as is natural, these affections are 
transmitted to dog fanciers and those who have the care of such animals. Tinea 
tricophytina has been described as occurring in nursemaids and in those who take 
care of similarly affected children in institutions and day nurseries. Several years 
ago a herder from Vermont was received into the skin ward of the Massachusetts 
General Hospital suffering from a very aggravated case of tinea of the beard, so-called 
parasitic sycosis. The skin of the maxillary regions was much tumified and indurated 
and covered with large nodular sycosiform tumors. It was ascertained that others 
among his fellow-workers were affected in a milder degree with the same trouble, 
and that there had been an epidemic among the cattle of a cutaneous disturbance 
causing a falling of the hair. 
A much more serious cutaneous infection may occur in butchers, an example of 
which was observed by the writer in 1902. The subject was a wholesale meat cutter, 
28 years of age, who was affected with a universal pemphigoid eruption accompanied 
by fever and severe constitutional symptoms, following a cut received on his hand in 
the course of his occupation that had become septic. This patient recovered, but 922 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
Pernet, who has made a special study of this subject, finds the prognosis very grave, 
most cases ending fatally. He collected 16 cases, one-half of which were in butchers; 
but in all of the remaining cases the occupation was one that brought the subject into 
contact with animals or animal products, one case being that of a tanner, another that 
of a person who had milked some cows that had a bullous affection of the udders and 
teats. Pernet's conclusions were as follows: 1. That there is a group of rare cases 
of acute bullous eruption, accompanied by severe constitutional symptoms and gen- 
erally ending fatally, which affects butchers. 2. The disease follows a wound on the 
hands or fingers. 3. It is probably due to a microorganism. 4. The same infectious 
disease probably occurs in other persons who are brought into contact with animals 
or animal products. Allen has reported a case in a blacksmith. 
The writer's case occurred simultaneously with the prevalence of an epizootic 
of "foot and mouth" disease in New England, and the possibility of a relationship 
between the two affections was considered. With regard to the occurrence of foot- 
and-mouth disease in man, while strictly medical text-books and publications contain 
little on this subject, there are many allusions to it in veterinary literature. According 
to Nocard and Leclanche, Segar in 1765 was the first to report cases of the infection 
of man by animals from this source. Nicolaier, in Ebstein and Schwalbe's Handbuch 
der praktischen Medizin, describes foot-and-mouth disease when occurring in man as 
characterized by fever, constitutional symptoms, and by a generalized eruption of 
vesicles and pustules, especially marked on the fingers and feet, and affecting the 
mucous membranes of the lips, cheeks and tongue, when the poison has gained en- 
trance in this way. He says that when the infection has taken place through an 
abrasion of the skin, as is often the case in milking or in slaughtering diseased animals, 
the eruption appears first at the place where the poison entered. 
Anthrax, glanders, and actinomycosis are among the affections that may occur in 
animals and be transmitted to man. Anthrax is very common, especially in cattle 
and sheep, in various parts of Europe and Asia. The disease in man is most common 
in those who have to do with animals or animal products, such as slaughterers, 
farmers, tanners, wool-sorters, stevedores, meat inspectors, employees in brush fac- 
tories, etc. 
Glanders is usually contracted from horses and is seen therefore most frequently 
in stablemen and in those who have to do with these animals. It may be acquired 
through a break or lesion of the skin or through the mucous membrane of the mouth 
or nose. In some instances the mucous membranes are the parts most affected; in 
others large nodules, the so-called "farcy-buds," may arise from infection of the 
lymph glands, and there may be also a thickening of the lymphatic vessels. The skin 
eruption is in general of a pustular nature, but is not especially characteristic and is 
often not especially prominent and even wanting. The nasal discharge may be very 
profuse or quite moderate and is due to ulceration of the mucous membrane, which 
may penetrate to the bone. A chronic form has been described and its description 
and history elaborated by Besnier. The constitutional symptoms are usually pro- 
nounced and the mortality is high. The disease is usually contracted either by direct 
inoculation of the secretions on a wound or through the mucous membrane, from 
the snorting of the animal affected. Crocker quotes the case of a laundress 
who was infected from washing the clothes of a coachman who had died of, the 
disease. 
Actinomycosis does not in most instances affect the skin, the internal organs being 
the parts most frequently involved. It has been estimated that the disease is located 
in the skin in only about 3 per cent, of the cases and, although sometimes primary in 
this situation, it is usually secondary to internal involvement. The seat is usually 
about the face, jaw and neck, and it has often been proved to have obtained access to 
the jaw through a decayed tooth. The clinical appearances are those of hard nodular 
swellings, which develop fistulse discharging pus mingled with which are the charac- ANIMAL SOURCES MISCELLANEOUS 
923 
teristic yellow granules of the ray fungus. This ray fungus is the cause of the affec- 
tion and is supposed, although it has not been proved, to flourish on hay, corn and 
straw. At all events, the affection is undoubtedly caused by inoculation of the ray 
fungus, and is most commonly seen in those who have to do with cattle and horses, 
including farmers, dairymen and millers. It has been thought to have been acquired 
by chewing straw, grain and malt, a common practice among stablemen, farmers, 
dairymen, etc., the infection probably occurring by inoculation through a carious 
tooth. 
Tuberculosis in the form of tuberculosis verrucosa, that has been referred to as 
occurring among physicians, dissectors, nurses, etc., is also very commonly seen in 
butchers, cooks, cattlemen and those who have to do with animals and animal products. 
It is due to direct inoculation of the skin with the tubercle bacillus and is the most 
frequent type of cutaneous lesion due to this cause. The lesion has also been called 
the anatomical wart, verruca necrogenica, etc., from the fact that it was first observed 
on the hands of anatomists and those who made autopsies, at a time when its tubercular 
nature was unsuspected. It is seated on the hands and arms almost exclusively and 
presents the appearance of a papillomatous nodule with a rather soft, infiltrated 
base. It may easily assume a more pustular appearance from secondary infection. 
This form of tuberculosis is very slow in its course, and the patches may remain for 
years without undergoing much change. In some cases, however, it may result in 
infection of the neighboring lymphatics and in foci of lupus in the vicinity. A dissem- 
inated tuberculosis and an infection of the internal organs, with fatal termination, 
may also follow occasionally. This form of tuberculosis has been seen not infrequently 
in those engaged in caring for tuberculous patients, especially relatives, where the 
rules of hygiene, so rigorous in all well-conducted hospitals, are not adhered to. 
Erysipeloid is the name given to an infection, usually comparatively mild in char- 
acter, that is acquired by butchers, fish dealers, poultry dealers, and cooks in the pur- 
suit of their occupations. Of the cases seen by the writer, in Boston and vicinity, 
the majority were in people who handled fish in some way, either as fish dealers, 
fishermen, or cooks. It is usually situated on the fingers and hands and appears as 
a sharply bounded, spreading erythema, not unlike a mild form of erysipelas, and tends; 
to spontaneous disappearance after a few weeks, although its course may be much 
abridged by treatment. Rosenbach has discovered a micrococcus of the order Clado- 
thrix found in decomposing animal matter, which has produced the affection experi- 
mentally when inoculated in pure culture. He obtained a pure culture on gelatine 
from a case of erysipeloid acquired from foul cheese, which he inoculated upon his 
own arm in three places. Three days later a raised erysipelatous patch appeared 
at the site of inoculation, which spread peripherally. Gilchrist has recorded 329 
cases, of which 323 were caused by crab bites or lesions produced by crabs. The cases 
were naturally chiefly in those who dealt in crabs or were engaged in cleaning them. 
Gilchrist and others in Baltimore have totally failed in their attempts to find a causa- 
tive organism, nor were they able to produce the affection by experimental inoculation. 
Miscellaneous Occupations.-Under this heading it will be convenient to group 
a few observations of less prominence and importance than those that have been 
discussed. The theatrical profession has been the subject of an article by Brown 
entitled "The Theatrical Profession as a Factor in the Dissemination of Disease.,f 
Scabies, pediculosis, syphilis, and other contagious cutaneous affections are common 
among theatrical troupes, as the opportunities for communicating such diseases are 
considerable. The mode of life, sojourn in cheap hotels, frequent changes of domicile, 
the use of cosmetics, and above all the danger of infection from costumes and wigs 
render such affections more frequent than usual. The writer has had under his care 
a celebrated actress who suffered from a very serious parasitic affection of the scalp, 
attended by almost complete loss of hair, which she had acquired from wigs used in 
the" theatre. 924 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
Since the introduction of the X-ray for diagnostic and therapeutic purposes, very 
severe and sometimes serious conditions of the skin have occurred in operators who 
had been engaged in this work for long periods of time; a persistent, unusually rebel- 
lious dermatitis, and a condition of atrophy, telangiectasis and keratosis, resembling 
the lesions seen in the rare affection called xeroderma pigmentosum and often followed 
by cancer, are not infrequently the result of this occupation. This subject is fully 
treated in the chapter on Cancer. 
Audry has published an observation on a papular and suppurative lesion in 
milkmen which affects the back of the hand, causing it to become greatly inflamed, 
and he thinks this is analogous to the cases published by Winternitz of nodular lesions 
on the hands, forearms and noses of milkmaids. 
A disease of the nail has been described by Glibert of Belgium in furriers, especially 
those who scrape rabbit and hare skins in the manufacture of artificial furs. The work 
of separating the aponeurosis that occurs on the undersurface of the hide causes the 
groove under the nail to become deeper, and the nail is subsequently detached from 
the finger and falls off. The thumb and the middle and ring fingers of the right hand 
are especially affected. This has been said to be quite common in the fur pullers of 
Belgium. A keratosis formation of the palms and flexor side of the fingers has been 
observed in those employed in removing the hair from hogs. Stein has seen a similar 
appearance in glass workers. Spietschka reports a peculiar affection of the backs 
of the hands and fingers in young women workers in enamel manufactories, consisting 
of nodular elevations with infiltrated edges, hollowed at the top. 
Under the title "grain itch" Schamberg has described an affection that became 
quite persistent in Philadelphia in the spring and summer of 1909. It was charac- 
terized by an urticarial eruption, the wheals in many instances exhibiting at their 
summits a central pinpoint-sized vesicle. This eruption was usually accompanied 
by most intolerable itching, which was worse at night, and mild fever. This affection 
was found to be especially prevalent among farmers and laborers who handle sacks 
of wheat, barley, and other grains, and to be due to a mite, the Pediculoides ventrico- 
sus, found in grain or straw. 
TREATMENT 
It is impossible to do full justice to the treatment of the various pro- 
fessional dermatoses without discussing at some length the methods of 
treatment applicable to a large number of morbid cutaneous conditions 
very varying in character. To do this would be to exceed the limits or 
purpose of this article. 
Prophylaxis.-With regard to prophylactic treatment (the most 
important part of the therapeutics of occupational diseases), the avoid- 
ance of the exciting cause is naturally the first matter that presents itself. 
Total abandonment of the occupation that has proved injurious is not 
infrequently necessary. In many instances less drastic measures may be 
sufficient, and these measures naturally vary according to the specific 
occupation and often according to the individual case. In the case of 
people who are obliged to have their hands in contact with water and 
soap quite frequently, such as housemaids, bartenders, etc., the use of 
rubber gloves has become a valuable prophylactic aid, now that these 
articles are manufactured so well as to withstand moderately rough 
usage. In these cases of susceptibility to irritation from soap and water, 
as well as in all other cases of poisonous irritants, the application of a TREATMENT OF SKIN AFFECTIONS 
925 
bland, softening and protective cream after exposure, or before going to 
bed, is of much value. Either simple cold cream ointment or a combina- 
tion of cold cream with a small proportion of lanolin will be found most 
serviceable. Loose white cotton gloves worn during the night are a good 
substitute for a protective bandage. In the case of nurses, physicians and 
those whose hands are exposed to contact with strong antiseptics, 
thorough anointing with a bland cream in this manner is most useful as a 
preventive. These precautions should be strictly followed as soon as 
the subject shows a well-defined idiosyncrasy to any form of irritation. 
Various measures of protection have been devised to suit the particular 
kind of irritation or the especial work of the individual. Masks have 
been used in various occupations in which the fumes that are developed 
have proved poisonous. Measures of this nature have been employed 
by those working with lacquer. 
Various measures of protection for the skin of those working in the 
war gas industry have been devised during the late war. It was found 
that the gas-mask gave good protection to the eyes and lungs, but that 
the skin was not protected by ordinary garments. Rubber garments 
were found to be ineffective. Varnished oil-cloths, made by impregnat- 
ing very closely woven fabrics proved most successful, and complete 
suits were made from this material. For the hands, leather gloves impreg- 
nated with carnauba wax and oil proved most effective and the same 
formula was used for leather shoes. These methods had, however, 
many disadvantages, and no very satisfactory procedure had been devised 
when the war ceased. 
Local Treatment.-The immediate treatment of the greater part of 
the cases of occupational dermatoses resolves itself into an understanding 
of the principles of treatment of dermatitis generally, since a dermatitis 
either of the type of dermatitis venenata or of the eczematoid variety 
is most frequently met with. An acute dermatitis venenata demands first 
of all the removal from the skin of any of the irritant that may still be 
adherent. For this purpose soap and water is often essential, although, 
as has already been seen, these agents are irritating in themselves, and 
their vigorous use is often responsible for the aggravation of the trouble. 
Bran or starch may be added to the water for the purpose of "softening" 
it, as in the case of infants and those with delicate skins, and the various 
superfatted soaps, less irritating on account of the excess of fat that they 
contain, may be employed. The use of alcohol and strong alkalies for 
the purpose of removing stains and obstinately adherent substances 
should be resorted to as sparingly as possible. 
Locally, in the acute forms, lotions mildly alkaline and slightly carbo- 
lized, with or without a bland soothing powder suspended in them, and 
perhaps with the addition of a small amount of glycerine, are of great 
value at the outset on account of their antipruritic properties, as well as 
their relief of the acute inflammation. Where there is not a large amount 926 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
of crusting, a bland dusting powder of talcum, zinc, or starch, is a useful 
application. Crusts, if thick, should be softened off by applications of oil, 
or by moist compresses continually worn. At a somewhat later period, or 
if the early stage is absent, bland ointments and pastes are indicated, in 
which the parts affected are wrapped, with an outer covering of soft cotton 
or linen. In a large majority of cases of dermatitis from external irritants 
these measures are sufficient to control the individual attack at least, 
provided the source of irritation is removed. The more chronic forms 
of eczema are, however, well represented among the occupational derma- 
toses. In these cases the more stimulating applications are to be resorted 
to on the same principles and with the same regard for the individual case 
as in eczemas with a different etiology. 
Internal Treatment.-It is needless to point out the fact that there is 
no form of internal treatment that can be regarded as in any way specific 
in the management of dermatitis. Each case must be treated for itself. 
The condition of anaemia that is often seen in factory operatives, and that 
has been especially referred to in the case of furniture polishers, requires 
careful attention, and the same may be said as to dietary errors, and 
especially the excessive use of alcohol. The wise adviser will pay careful 
attention to the correction of hygienic conditions as far as possible, and to 
the patient's general well-being. 
Special Instructions.-As regards the more serious affections, such as 
those acquired in handling animals and animal products, in the course 
of medical and surgical attendance, etc., the greatest care must naturally 
be taken to prevent the entrance into the skin of any foreign matter. 
On this account people engaged in these occupations should be instructed 
as to the dangers attendant upon their work, the probable modes of 
inoculation, and the importance of protecting all wounds or abrasions 
of the skin by some form of protective dressing. 
REFERENCES 
Audry.-Une lesion papuleuse et suppurative chez les laitiers. Annales de derm, et 
de syph., 1899, page 972. 
Barnard.-A Case of Tar-worker's Disease, Exhibiting Eczema, Warts, Mollusca, 
etc. Policlin., London, 1904, VIII, 51, 53. 
Bazin.-Lecons theoriques et cliniques sur les affections cutan5es, Paris, 1862. 
Blaise.-Les barbiers et coiffeurs au point de vue de 1'hygiene. Ann. d'hyg., Paris, 
1894, XXXII, 229. 
Blaschko.-Die Hautkrankheiten der Anilinarbeiter. Deutsch. Med. Woch., 1891, 
1241. 
Blaschko.-Uber das vorkommen von metallischen silber in der Haut von Silberar- 
beitern. Monatsh. f. prak. dermat., 1886, V. 197-202. 
Blaschko.-De 1'hygiene des offices de barbiers. Annal. de derm, et de syph., 1893, 
IV, 765. 
Blaschko.-Die Berufsdermatosen der Arbeiter. Deutsch. Med. Wochens., 1890. 
Blaschko.-Gewerbliche Hautkrankheiten. Handbuch der Arbeiterkrankheiten, 
Th. Weyl. Gustav Fischer, 1908. REFERENCES ON SKIN AFFECTIONS 
927 
Bowen.-Acute Infectious Pemphigus in a Butcher, etc. Journal of Cut. Dis., 
June, 1904 
Bradley.-Protective garments in the war-gas industry. Journal of Industrial 
Hygiene, Sept. 1919. 
Brocq et Laubry.-Le Pigeonneau. Annales de derm., 1901, page 305. 
Brown.--The Theatrical Profession as a Factor in the Dissemination of Disease. 
Med News, N. Y., 1904, LXXXIV, 551-555. 
Cash.-Br. Med. Journal, 1911, II, 784. 
Castellani and Chambers.-Lacquer Poisoning. Manual of Tropical Medicine, 1910, 
118. 
Crocker.-Diseases of the Skin, 1903. 
Da Costa, Jones, and Rosenberger.-Tanner's ulcer. Annals of Surgery, Feb., 1916. 
Derville et Guermonprez.-Le papillome des raffineurs de p5trole. Jour. d. sc. med. 
de Lille, 1892, 1-313. Annales de derm, et de syph., 1890, 369. 
Ebstein und Schwalbe.-Handbuch des praktischen Medicin. 
Editorial.-The Printing Industry and Skin Diseases. J. Amer. Med. Assoc., Nov. 
15, 1913. 
Elliot.-Pseudo-pigmentation on the Hands of Millers. Jour. Cut. and G. U. Dis., 
1891, 206. 
Fordyce.-Occupational Diseases of the Skin. N. Y. Med. Record, Feb. 3, 1912. 
Gilchrist.-Erysipeloid, etc. Jour. Cut. Dis., 1904, XXII, 507. 
Harrington.-Chrome Poisoning. Boston Med. and Surg. Jour., Aug. 12, 1886. 
Herxheimer.-Uber die gewerblichen Erkrankungen der Haut. Deutsch. Med. 
Wochensch., 1912, No. 1. 
Herxheimer.-Uber chlorakne. Munch, med. Wochensch., 1899, 278. 
Hoppe.-Barbierflechte. Archiv f. derm. u. syph., 1869, 289. 
Horand.-Dermatose produite par de bois de Chataignier. Gazette des hop., 24 
F6vr., 1907, page 255. 
Jacquet et Jourdanet.-Des dermites professionelles des mains. Annales de derm, 
et de syph., 1911, page 11. 
Knowles.-The External Origin of Eczema, Particularly the Occupational Eczemas, 
etc. Jour, of Cut. Dis., Jan., 1913. 
Labelle.-Dermatose et onyxis professionels. Mal des plongeurs, Paris, 1898. 
Lehmann.-Chlorakne. Archiv f. derm. u. syph., 1905, 265. 
Leloir.-Eczema des fileurs et varouleurs de lin.' Annales de derm, et de syph., 1885. 
Leloir.-De la folliculite et perifolliculite des fileurs et rattacheurs. Annales de 
derm, et de syph., 1889, X, 672. 
Lewin.-Uber allgemeine u. Hautvergiftung durch Petroleum. Virchow's Archiv, 
CXII, H. 1. 
Lewin.-De l'argyrie locale des ouvriers en argenterie. Annales de derm, et de syph., ' 
1887, 2, VIII, 520. 
Lutz.-Accidents provoques par la manipulation de la laque de Tonkin. Bull. d. sc. 
pharmac, Paris, 1905, XII, 322. 
MacLeod.-Dermatology in connection with the war-practitioner, Feb.; 1919. Also 
Proceedings of the Royal So. of Medicine, Feb. 16, 1916. 
Mantegazza.-Dermatitis der Reisarbeiter. Ref. Archiv f. derm. u. syph., 1911, 108, 
314. 
Margain.-Hyperkeratose palmaire chez les laveurs de mineral de cobalt. Prog. 
m&L, Paris, 1904, XIX, 97. 
Merzbach.-Uber Gewerbeeczema. Derm. Zeitschr., 1896, 161. 
Mitchell.-The General and Local Effects of Paraffine Oil upon Those Working in 
It. Med. News., Phil., 1888. 
Nocard et Leclanche.-Paris, 1903. 
Oliver.-Dangerous Trades, London, 1902. 928 
OCCUPATIONAL AFFECTIONS OF THE SKIN 
Oliver.-Diseases of Occupation. E. P. Dutton & Co., 1908. 
Pernet.-Acute Pemphigus. Br. Jour. Derm., May and June, 1896. 
Piffard.-A Treatise on the Mat. Med. and Ther. of the Skin, New York, 1881. 
Planchon.-Coloration artificielle des fleurs. Ann. d'hyg., Paris, 1892, XXVII, 
404. 
Poncet.-Note relative & une vari£t€ d'onyxis propre aux confiseurs. Bull. Acad, 
de Med., 1889, XXI, 330-332. 
Purdon.-Br. Jour. Dermat., 1891, page 82. 
Putnam and Herman.-A study of 50 workers in Trinitrotoluene. Jour, of Indus- 
trial Hygiene, Sept., 1919. 
Remy et Broca.-Sur 1'ecthyma des raffineurs. Revue de Chir., Paris, 1886, VI, 
717-723. 
Rident.-Des Eruptions eczemateuses chez les teinturiers. Cong, intern, d'hyg. et de 
demog., Paris, 1890, 768. 
Riehl und Paltauf.-Tuberculosis Verrucosa Cutis. Archiv f. derm. u. syph., 1886, 
19. 
Rollet.-Tatouages chez les ouvriers de briquette de houille, etc. Gazette hebd de 
med., Paris, 1890, XXVII, 552. 
Rosenbach.-Verhandl. der Deutschen Gesellschaft f. Chirurgie, 1887, Vol. XVI, 
76. 
Ruxton.-Industrial diseases due to Tetryl. Br. Jour. Derm. Jan., March, 1917. 
Sainturet.-Lesions professionelles de la main chez les tonneliers, Paris, 1897. 
Schamberg.-Grain Itch, etc. Jour. Cut. Dis., 1910, XXVIII, 67. 
Siegheim.-Uber Satinholzdermatitis. Berl. klin. Wochens., 1909, No. 55, s., 2020. 
Spietschka.-Erkrankung der Arbeiter in Emailfabriken. Archiv f. derm. u. syph., 
1910, 83. 
Stein.-Gewerbedermatose bei Glasmachern. Wien. Klin. Wochen., 1904, XXII, 
298. 
Stelwagon.-Diseases of the Skin, 1914. 
Stern.-Uber einige Hautkrankheiten der Musiker. Munch. Med. Wochens., 1891. 
Strauss.-Die Nagelentziindung der Konditoren, etc. Deutsch. Med. Woch., 1912, 
XXVIII, 854, 856. 
Thibierge.-LeBouton d'Huile des Tourneurs d'obus. Bulletin de C'Academic de 
Medicine, 1918. 
Thibierge et Pagniez.-L'acne chlorique. Annales de derm, et de syph., 1900, 
815. 
Vallin.-La protection des blanchisseuses contre les dangers du linge sale. Revue de 
Hyg., Paris, 1897, XIX, 953. 
Variot et Raoult.-Tatouages des piqueurs et des Rhabilleurs de meules. Soc. med. 
des hop. de Paris, 1891, 597. 
Walsh.-Dermatitis among Flower Pickers in the Scilly Islands. Br. Med. Jour., 
Sept. 24, 1910, 854. 
Wechselmann.-Deutsch. Med. Wochensch., 1909, 1389. 
White.-Dermatitis Venenata, Boston, 1887. 
White.-Primula Obconica. Boston Med. and Surg. Journal, May, 1890. 
White.-Poisoning by Vanilla. Boston Med. and Surg. Journal, Nov. 2, 1893. 
White.-Notes on Dermatitis Venenata. Boston Med. and Surg. Journal, Jan. 28, 
1897. 
White.-Some New Forms of Occupational Dermatoses. Lancet, Feb. 19, 1916. 
Willan.-Description and Treatment of Cutaneous Diseases, London, 1798-1815. 
Winternitz.-Knotenbildungen bei Melkerinnen. Archiv f. derm. u. syph., 1899, 
XLIX, 195. 
Zellner u. Wolff.-Uber die Ursachen der Hauterkrankungen in Buchdruckereien. 
Zeitsch. f. Hyg. u. Infectionskr., 193, LXXV, 69. REFERENCES ON SKIN AFFECTIONS (CONCLUDED) 
929 
Additional References 
(Hayhurst) 
Oliver, E. Lawrence.-Skin Diseases Commonly Seen by the Industrial Physician. 
Jr. Ind. Hyg., IV, No. 1, May, 1922, 21-29. (1. Furunculosis, 2. Acne vulgaris, 
3. Impetigo contagiosa, 4. Scabies, 5. Psoriasis, 6. Eczema and Dermatitis, and 7. 
Ulcers of the Leg. The author dwells especially on treatment.) 
Pusey, Wm. A.-Industrial Dermatoses, Their Sources, Types and Control. Jr. 
Ind. Hyg., I, No. 8, Dec., 1919, 385-390. 
White, R. Prosser.-The Detection and Treatment of Some Trade Eruptions. Medi- 
cal Times (London), 48, No. 2113. (Abstr. by Jr. Ind. Hyg., July, 1920, 47-48.) 
Also: Do We Neglect the Industrial Skin Sufferer? Jr. of State Med., XXX, No. 
2, Feb., 1922, 47-59. 
Legge, T. M.-Industrial Dermatitis. Ann. Rep., Chief Inspector Factories and 
Workshops, Gr. Brit., for 1918, 82-83. (Abstr. by Jr. Ind. Hyg., Nov., 1920, 
138-140.) CHAPTER V 
DISEASES OF THE BLOOD, CIRCULATORY SYSTEM AND 
KIDNEYS 
THOMAS S. LEE, M. D., Washington, D. C 
As this chapter must of necessity be limited in its scope, only the main 
features of the diseases can be considered. For convenience these diseases 
will be treated under their usual headings and special attention given to 
the facts that bear more or less directly on the occupational aspects of 
the subject. 
Brief mention is made of the trades or occupations, in which statistics 
show that these diseases are unusually frequent, a fuller consideration of 
the different occupations being found under their separate headings in 
other sections of the book. 
The etiological factors considered being only those unavoidably con- 
nected with the various industries, no mention is made of the effects of 
tobacco, alcohol and syphilis which, though unusually prevalent among 
certain classes of workers, are in no way necessarily connected with the 
occupations themselves. 
Broadly speaking, the etiological factors of the diseases of the blood, 
the circulatory system and the kidneys, considered as occupational dis- 
eases, are either those that act mechanically, such as strain, overwork, and 
exposure to physical forces, or the industrial chemical poisons. The 
defective hygienic surroundings under which, almost of necessity, many 
trades are carried on also have their part in causing certain of these 
diseases. 
DISEASES OF THE BLOOD 
Under the heading of Diseases of the Blood will be considered the sec- 
ondary or symptomatic anaemias, as well as certain pathological condi- 
tions of the blood that are brought about by industrial poisons. These 
latter are not in themselves disease entities, but are commonly important 
features of the poisoning and not infrequently dominate the picture of 
the syndrome. A full account of the more important poisons is given in the 
preceding chapters. 
Hemoglobinemia.-The abnormal presence of hemoglobin in the 
plasma of the blood is brought about by hemolysis. In this manner the 
hemoglobin is discharged from the erythrocytes, and to a large extent they 
are destroyed. Among the industrial poisons causing hemolysis may be 
930 OCCUPATIONAL BLOOD DISEASES 
931 
mentioned arseniureted hydrogen, carbureted hydrogen, and phos- 
phureted hydrogen, which latter together with arseniureted hydrogen 
is liberated when ferrosilicon comes into contact with water. Many 
cases have been reported in recent years in ships carrying ferrosilicon. 
If, as often happens, the hemolysis is rapid and overwhelming, a fatal 
result ensues with tissue suffocation. If less severe, the patient presents 
the typical symptoms of acute secondary anaemia, whereas a moderate 
hemolysis acting over a longer period of time is one of the recognized 
causes of chronic secondary anaemia. 
Methemoglobinemia.-Methemoglobin is found partly in the erythro- 
cytes and partly in the plasma as the result of an associated hemolysis. 
It is considered isomeric with oxyhemoglobin, but is a more stable com- 
pound and is not capable of carrying on its oxygenating functions. It 
imparts a brownish or chocolate color to the blood and is easily recogniz- 
able by its characteristic spectrum. Among the industrial poisons causing 
methemoglobinemia may be mentioned benzene, nitrobenzol, nitrous 
gases, phenylhydrazine, anilin, and various anilin dye stuffs. Many 
other substances, such as acetanilid or phenacetin in excessive dosage, 
may bring about this condition, but they appear to be of greater medical 
or chemical than industrial interest. 
Sulphemoglobinemia.-Sulphemoglobin is formed by the action of 
sulphureted hydrogen on the blood, and it has been found that in the 
presence of a reducing or oxidizing agent very small quantities may bring 
about this change. It gives the blood a purple color and has its charac- 
teristic spectrum, slightly different from that of methemoglobin. The 
first cases were reported by Van der Bergh in 1905. These were idio- 
pathic or enterogenous. A number of cases have been reported since, 
both of this type and following industrial poisoning. 
Symptomatology of Methemoglobinemia and Sulphemoglobinemia.-Large 
doses of some of the poisons causing these disturbances, as for example the 
breathing of air charged with a high proportion of sulphureted hydrogen, 
are rapidly fatal. Death may be preceded by a short stage of unconscious- 
ness, with slow pulse, Cheyne-Stokes respiration and increasing asphyxia-- 
symptoms doubtless due to bulbar paralysis. In the more prolonged and 
non-fatal cases marked cyanosis develops-a gray-blue discoloration of 
the skin and mucous membranes. Headache with gastric disturbances 
and general muscular weakness are associated symptoms. In the entero- 
genous cases, more particularly, it has been noted that chronic diarrhea is 
present in methemoglobinemia and constipation in sulphemoglobinemia. 
The blood may not show great abnormality on ordinary examination, a 
moderate degree of anaemia with leucocytosis being present in the acute 
cases. Spectroscopic examination is pathognomonic. 
Carboxyhemoglobinemia.-This is typical of carbon monoxide poison- 
ing. The blood is bright cherry-red in color, flows very freely, and 
presents a definite spectrum. Carbon monoxide has an affinity for hemo- 932 
DISEASES OF THE BLOOD, CIRCULATORY SYSTEM AND KIDNEYS 
globin more than 200 times greater than that of oxygen, so that even small 
amounts in the inhaled air are readily absorbed by the blood and retained 
in stable combination. Carboxyhemoglobin does not react with reducing 
agents and is useless for purposes of oxygenation. It has been found by 
experiment that the effects of the poisoning are not noticed until about one- 
third of the hemoglobin has been converted into carboxyhemoglobin, that 
they become urgent when the corpuscles are about half saturated and that 
death usually occurs when the respiratory capacity of the blood has been 
reduced to about 30 per cent, of the normal. A leucocytosis is sometimes 
present and in the chronic cases an increase in the number of the 
erythrocytes. 
Symptomatology.-The symptoms are mainly due to the changes in the 
blood, and defective internal respiration. In a highly contaminated 
atmosphere the attack may be very sudden. The person falls unconscious 
with loss of muscular power, and the heart's action, becoming progres- 
sively weaker, soon stops. Usually the symptoms of acute poisoning are 
gradual in their onset-first severe frontal headache, throbbing of the 
arteries, buzzing in the ears, vertigo, nausea and vomiting, muscular 
weakness, dyspnoea and oppression, with rapid pulse and respirations. 
Pale or bright red patches are seen upon the skin due to local dilatation 
of the peripheral vessels and the change in the color of the blood. Some- 
times, however, a bluish discoloration of the skin is more noticeable. 
Later there are motor disturbances, tremors, convulsions and paralyses 
with loss of consciousness. Death is usually due to respiratory paralysis 
and asphyxia; or recovery may occur even after severe poisoning, with a 
slow convalescence. 
Chronic poisoning is characterized by headache, dizziness, nausea, 
impairment of memory, muscular weakness and secondary anaemia. 
Cyanmethemoglobinemia is present in poisoning by the cyanogen com- 
pounds, especially by the fumes of hydrocyanic acid and the cyanides. 
The cyanogen ion acts both upon the hemoglobin, forming a new com- 
pound with characteristic spectrum, and upon the tissues, directly inhibit- 
ing their power of oxygen absorption. The result is tissue asphyxia. 
The blood is a bright red color and the venous return flow resembles the 
arterial. The alkalinity of the blood is diminished and lactic acid appears 
therein. 
Symptomatology.-Death follows quickly on the inhalation of large 
quantities. It may be preceded by a stage of deep unconsciousness, with 
dyspnoea and heart failure. In the acute but non-fatal cases there is 
headache, vertigo, palpitation, dyspnoea and great prostration. Con- 
vulsions and loss of consciousness may follow. There is usually cyanosis 
of the skin and mucous membranes. In those who are exposed to con- 
stant inhalations of minute quantities of the vapor, a form of chronic 
poisoning may develop, in which all of the above symptoms are present in a 
minor degree. Anorexia, nausea and disturbance of the gastro-intestinal OCCUPATIONAL BLOOD DISEASES 
933 
functions are also present, and the picture of a chronic secondary anaemia 
is presented. 
Acute Secondary Anaemia.-As an occupational disease, this is caused 
by acute intoxication by various industrial poisons. These comprise for 
the most part those mentioned in previous sections, and in many cases 
other signs of acute anaemia are added to the changes in the hemoglobin. 
Acute anaemia may also be caused by other poisons, such as carbon disul- 
phide or mercury, which cause rapid destruction of the elements of the 
blood. 
Symptomatology.-The condition is often ushered in with nausea and 
vomiting. Dyspnoea is an early and constant symptom and there is 
usually a feeling of anxiety and extreme difficulty in breathing. With 
this is associated faintness, vertigo and a small rapid pulse and subnormal 
temperature. Headache and severe nervous symptoms are frequently 
present. There is marked pallor of the skin except in those cases where 
the hemoglobin is destroyed, when we have the various characteristic 
changes previously noted. The blood picture may be that of chronic 
secondary anaemia, described in the next section, but often resembles 
the pernicious type--great reduction in erythrocytes with a relatively high 
hemoglobin content and high color index, extreme variations in shape 
and size of the erythrocytes with an excess of oversized cells, polychroma- 
tophilia, many normoblasts and megaloblasts. A leucocytosis is, how- 
ever, usually present, except in the case of benzol poisoning, where there 
is a marked leucopenia. 
Treatment.-Oxygen is our most valuable agent in combating the 
sudden and extreme diminution of the hemoglobin content of the blood. 
Oxygen treatment, as stated by Rambousek, ''rests on the fact that by rais- 
ing the pressure of the oxygen from 113 mm., as it is generally in ordinary 
air, to 675 mm., which is reached in the presence of pure oxygen, the 
quantity of oxygen absorbed by the blood rises from 0.3 to 1.8 per 100 cc. 
Further, the saturation of the hemoglobin undergoes an increase of 2.4 
per cent." This increase of oxygen in the blood, he says, can save life in 
cases where, through poisoning, a deficiency of oxygen has resulted. 
Special apparatus for the administration of oxygen should be provided 
wherever there is a likelihood of industrial blood poisoning. In acute 
hemoglobin transformation, venesection with infusion of normal saline 
or, better, transfusion of blood is indicated. This relieves the blood of at 
least a part of its useless hemoglobin compound and remaining toxin, 
and may just suffice to enable the organism to turn the scale in its efforts 
for regeneration. 
During convalescence the case should be treated as one of chronic 
secondary anaemia. 
Chronic Secondary Anaemia.-This disease may be due to the effects 
of the insanitary conditions that necessarily surround certain occupations. 
Bad air, prolonged exposure to heat, frequent and sudden changes of tern- 934 
DISEASES OF THE BLOOD, CIRCULATORY SYSTEM AND KIDNEYS 
perature, and irregularity in eating all tend to bring about a condition of 
inanition in which a typical secondary anaemia plays the conspicuous part. 
Statistics show that this is unusually prevalent among bakers, painters, 
iron and foundry workers, miners and smiths. Less typical forms of 
chronic secondary anaemia, characterized in some cases by special features, 
are caused by the continued or frequent action of poisons to which indus- 
trial workers are accidentally or necessarily exposed. Among these 
poisons may be mentioned lead, mercury, antimony (which causes also 
leucopenia and eosinophilia), phosphorus, chlorine and bromine, as also 
the dust inhaled in the cotton and jute industries. Many of the poisons 
causing acute anaemia may also cause the chronic form, if they act in 
smaller quantities over a longer period of time. 
Symptomatology.-Pallor of the skin and mucous membranes is marked. 
There is loss of weight, with muscular weakness and loss of mental 
vigor. The appetite is poor, the digestion impaired, the nourishment fails. 
There is usually palpitation, an irritable heart, rapid pulse, with feelings 
of faintness and vertigo, and, later, signs of inefficient circulation, such as 
constant fatigue, rapid respiration, dyspnoea on exertion, and swelling of 
the feet. There may be extravasations of blood into the mucous mem- 
branes, petechise in the skin, or retinal hemorrhages. There is frequently 
a slight remittent fever. 
The blood shows a moderate reduction in the number of erythrocytes 
to between 2,000,000 and 4,000,000 per cubic millimeter, greater 
proportionate reduction of hemoglobin, giving a color index of about 0.8 
to 0.5; many erythrocytes are pale, irregular, nucleated, polychroma- 
tophilic; the leucocytes are slightly increased in number, usually the 
multinuclear neutrophiles. 
In chronic hemolysis the blood approaches the type of pernicious anae- 
mia : a great reduction in the number of erythrocytes, which frequently fall 
below 2,000,000 per cubic millimeters, great variations in size with a 
general average increase, and a relatively high hemoglobin content, giving 
a high color index, and the presence of many normoblasts and 
megaloblasts. 
In chronic lead poisoning many of the erythrocytes are small and with 
basic stains exhibit a sprinkling of blue-black dots upon the corpuscle, 
known as stippling or basophilic granulation. This may be associated 
with the blood picture of pernicious anaemia, but often it is accompanied 
by but few other abnormal signs. 
Treatment.-But little can be done in the way of treatment without 
removal of the cause. The patient must be placed in good hygienic sur- 
roundings and the poison eliminated where possible. This frequently 
necessitates a change of occupation. Fresh air and a nutritious diet are 
the main points to be insisted upon. Iron in any form and in full doses is 
indicated, with arsenic as an adjuvant. Care must be taken to avoid con- 
stipation. In the severe cases rest in bed is necessary for a certain period. OCCUPATIONAL DISEASES OF THE CIRCULATORY SYSTEM 
935 
DISEASES OF THE CIRCULATORY SYSTEM 
Primary Cardiac Overstrain.--Although many, perhaps most, of the 
persons who are subject to attacks of cardiac failure with dilatation are 
possessors of a damaged myocardium, or defective valves, most authors 
now agree that disturbance, inefficiency or failure of the circulation may 
be brought about in a healthy heart by overstrain. As an occupational 
disease, primary cardiac overstrain is frequent among soldiers, porters, 
miners, blacksmiths and metal workers. 
Pathology.-The cavities of the heart are usually dilated and the mus- 
cular walls may show a certain amount of antecedent hypertrophy, with- 
out degeneration. The muscular tonicity is diminished, but otherwise 
the heart is normal. 
Symptomatology.-1The cardinal symptom is a limitation of the field of 
cardiac response, the patient being unable to support any considerable 
exertion without distress, though he may be comfortable when at rest. 
There is frequently palpitation, cardiac pain, a sense of pressure or con- 
striction over the chest resembling angina pectoris, often restlessness, 
headache, buzzing in the ears and vertigo. The pulse is small, feeble 
and rapid, and sometimes irregular; the cardiac impulse is wavy and 
diffused; the area of dullness may be enlarged; the sounds are distant and 
feeble, or short and sharp; and a soft blowing systolic murmur of func- 
tional mitral or tricuspid insufficiency is often present. In the more 
severe cases, or with those who make an effort to continue their work, 
dyspnoea, oedema, and other symptoms of cardiac decompensation 
ensue. 
Treatment.--For the sake of emphasis the treatment might almost be 
summed up in one word-prolonged rest. Some weeks or months are 
none too long in a moderately severe case. This must of course be 
supplemented by adjuvant measures as to hygiene, diet, etc. Tonic 
doses of digitalis, 1 to 2 grains a day, are a great aid in restoring the tonic- 
ity of the heart muscle. The return from complete rest to full activity 
must be made very gradually. What can be accomplished by care and 
prolonged treatment is shown by the remarkable results obtained by da 
Costa in many very severe cases among Union soldiers of the Civil War. 
The fact that many of these were again able to perform strenuous work 
and lead perfectly healthy lives is further proof, if any were needed, that 
cardiac overstrain and dilatation may be a primary disease. 
Functional Affections of the Heart.-Recent advances in cardiac path- 
ology have tended to limit considerably the field of purely functional affec- 
tions of the heart. It has been shown that many diseases previously 
considered functional are in reality due to lesions of some part of the 
cardiac musculature. It is still customary and convenient, however, to 
group under this heading various disturbances of the rate, rhythm or 
force of the heart's action. Of these, palpitation, tachycardia, and brady- 936 
DISEASES OF THE BLOOD, CIRCULATORY SYSTEM AND KIDNEYS 
cardia are frequently caused by the chemical industrial poisons and may 
be the chief manifestation of such poisoning, but more often are only a 
part of the general symptom-complex. 
Palpitation is the forcible overaction of the heart, whereby its beating 
becomes disagreeably perceptible to the individual. It may or may not be 
associated with some form of irregularity, although it must be emphasized 
that the great majority of the arrhythmias are now thought to be due to 
myocardial diseases or degeneration. The industrial poisons most likely 
to cause palpitation are amyl acetate, carbon monoxide, naphtha and 
gasoline, hydrocyanic acid and the cyanides, and tobacco inhaled as dust 
in the process of manufacture. 
The term tachycardia is usually applied to a condition of marked 
rapidity of the heart's action, independent of fever or evident physical 
cause such as exercise or excitement. It may be continuous or intermit- 
tent and the rhythm may be regular or irregular. Its etiology is varied, 
the more common forms being due to heterogenetic impulse formation, 
and being designated according to their nature as auricular 
flutter, auricular fibrillation, and paroxysmal tachycardia. Very rarely 
the cause is a destructive lesion of the pneumogastric nerve. As an indus- 
trial disturbance tachycardia is usually associated with poisoning by 
acetaldehyde, anilin and the nitrophenols. 
Bradycardia indicates a condition in which the heart's action is abnor- 
mally slow, although here it is difficult to set the limits between health and 
disease. Although some people are said to have had healthy lives with 
extremely slow hearts, a pulse below 50 must practically always indicate 
some disturbance either organic or functional. Except in the terminal 
stages of disease, a pulse below 35 is usually due to heart-block, while 
one between 35 and 50 may result from many causes. Bradycardia 
is more frequent than palpitation or tachycardia in the severe cases 
of chemical poisoning, and is a usual accompaniment of poisoning by 
carbon monoxide, hydrocyanic acid and the cyanides and sulphureted 
hydrogen. 
Pathology.-These functional cardiac disturbances in chemical poison- 
ing are due to the direct action of the poisons on the heart or its nervous 
mechanism, or to the blood changes which they produce. In one or the 
other manner the cardiac musculature may be deprived of its proper 
nutrition and rendered inefficient; or the inner stimulus of the blood on 
which the heart depends for its automatic rhythmicity may be dis- 
organized; or the centers or terminals of the vagus or accelerator nerves 
may be either irritated or depressed, according to the nature or selective 
action of the poison. 
Treatment.-The first object to be attained in the treatment of these 
toxic conditions is the elimination of the poison, hence free catharsis and 
diuresis are always indicated, and in the aqute cases chemical antidotes 
where possible. Rest to a considerable degree is called for, although the CIRCULATORY SYSTEM ACUTE ENDOCARDITIS 
937 
more nearly the disturbance approaches the purely nervous type, the less 
is this necessary or advisable. Here well-regulated exercise may often be 
substituted. 
For palpitation and tachycardia the bromides of potassium, ammo- 
nium and strontium are of some value, and large doses of aconite sometimes 
act favorably. The application of an ice-bag or a cold-water coil over the 
heart is often the best remedy in the acute cases. In auricular flutter 
full dosage of digitalis is indicated. This frequently converts the flutter 
into fibrillation, with subsequent prompt reversion to a normal rhythm. 
In the tachycardia of auricular fibrillation, full digitalis dosage reduces 
the ventricular rate and eliminates a pulse deficit in the vast majority of 
cases, whereas smaller doses are ineffective for this purpose. Full dosage 
is approximately estimated at % of a grain per pound of the body weight. 
This amount may be given in a day or a week according to the urgency 
of the condition. In the latter method, allowance must be made for 
elimination at the rate of about 2 grains a day, and this amount be added 
to the total dose. Vomiting and other toxic signs should be looked for, 
but hardly ever manifest themselves before these doses are administered. 
If the fibrillation persists for a week or so, after the heart rate has been 
slowed by digitalis, such cases should be favorable for treatment by 
quinidine. Reversion to normal rhythm, which might not otherwise 
occur, may be brought about in more than half the cases, and as the condi- 
tion is usually recent and there has been no long standing stasis of blood in 
the auricles, the principal danger, that of embolus is reduced to a minimum. 
If this treatment is instituted the patient should be under constant 
observation, preferably in a hospital. If the bradycardia is due, as is 
sometimes the case, mainly to increased inhibition, atropine is indicated 
for its selective action on the vagal terminals. Here, however, we are 
more likely to have some signs of circulatory inefficiency and must often 
have resort to caffeine or digitalis, the latter being contraindicated however 
if the bradycardia is due to partial heart-block. 
Acute Endocarditis.-Acute endocarditis frequently follows or is one 
of the manifestations of acute rheumatic fever, and is frequently met with 
as an occupational disease in accordance with the prevalence of the latter 
among certain workers. Although this form of rheumatism is now 
generally conceded to be due to a specific organism, the infecting agent is 
doubtless widespread, and certainly attacks with greater frequency those 
exposed to severe cold or dampness, and especially to sudden changes of 
temperature. The continued inhalation of certain forms of dust seems 
also to be a predisposing cause. These conditions are the necessary 
accompaniment of certain occupations, and statistics show that acute 
rheumatism in its arthritic, tonsillar, or endocarditic manifestations is 
unusually frequent among cotton spinners, wool sorters and drapers, 
brewers, bakers, carpenters and stokers. Rheumatic endocarditis, there- 
fore, is an increased risk attending these occupations. 938 
DISEASES OF THE BLOOD, CIRCULATORY SYSTEM AND KIDNEYS 
Pathology.-Its pathology here in no way differs from that seen in 
other cases; the arrest of the organisms upon, or more often within, the 
tissue of the valve, or on the lining membrane of the heart chambers, the 
deposition of blood platelets, leucocytes and fibrin in varying propor- 
tions, forming minute vegetations of a warty or verrucose appearance; 
later, the organization of these vegetations by the disintegration and 
absorption of the blood cells and fibrin, and the outgrowth of connective 
tissue, leading ultimately to sclerosis, thickening and deformity of the 
valves. 
Symptomatology.-The symptomatology of acute rheumatic or simple 
endocarditis is not very characteristic. There is usually a slight fever, or 
an exacerbation of a previously existing fever, often palpitation and a 
pulse rate out of proportion to the fever, usually some respiratory distress, 
with dyspnoea on exertion, occasionally slight oedema, ascites or enlarge- 
ment of the liver. Anaemia and anorexia are often associated symptoms. 
The physical signs are uncertain. There is usually accentuation and some- 
times reduplication of the pulmonic second sound, and a systolic bruit at 
the apex. The latter, however, is more often a sign of myocarditis than 
of endocarditis, and entirely disappears with the subsidence of the acute 
attack. In some cases the typical signs of damage to one or more of the 
valves develop under observation, but many cases are latent, and the 
condition is unsuspected, only to become apparent later as a chronic 
endocarditis. 
Treatment.-The treatment of acute rheumatic endocarditis should be 
mainly prophylactic, and our present knowledge of the subject seems to 
indicate that tonsillectomy should be considered in all patients who have 
had rheumatic infections in any of its forms, or who seem to be specially 
exposed to, or susceptible to it. The further prophylactic treatment con- 
sists in prolonged rest during an acute rheumatic infection. This is more 
potent than salicylates or other specific treatment in decreasing the 
chances of endocarditis. These are considered effective only in so far 
as they may shorten the course of the disease. If endocarditis develops, 
the rest should be still more prolonged and the active treatment 
symptomatic. 
Chronic Endocarditis.-This may be a sequel of acute endocarditis; 
but more frequent, as an occupational disease, is the sclerotic type, of 
insidious onset and gradual development, which is usually but one mani- 
festation of a more or less generalized sclerosis affecting the heart, arteries 
and kidneys, and often the liver and spleen. Long-continued overexer- 
tion or frequently repeated severe muscular strain are fundamental causes 
of these lesions, and to these may be added the effects of chronic lead 
poisoning and chronic anaemia. Among the other causes that are com- 
mon among industrial workers are gout and intestinal toxaemia due to the 
prolonged use of an improper diet. An abnormally high percentage of 
chronic heart cases are found among iron and metal workers who wield ENDOCARDITIS 
939 
heavy hammers and carry heavy burdens in foundries, blacksmiths, 
miners, bakers, soldiers, and lead workers. 
Pathology.-The pathology of chronic endocarditis may be briefly sum- 
marized as follows: sometimes as a sequence of an acute endocarditis, 
more often as a slow and insidious growth as a result of the causes above 
referred to, the edges of the valves become thickened and present small 
nodular prominences. The substance of the valve loses its translucency 
and its delicate tenuity. Later there is a further overgrowth of fibrous 
tissue, causing marked thickening of the valves or mural endocardium or 
both. The chordae tendinse also are frequently affected. The fibrous 
tissue then contracts and produces shortening of the chordae and gross 
deformity of the valvular segments, causing either a narrowing of the 
orifice, or a retraction and incompetency of the valves, or both. Finally 
lime salts are frequently deposited in the sclerotic tissue, so that the 
remnants of the valve and the orificial ring may become a calcareous 
mass, quite ineffectual for serving its natural function. 
Symptomatology.-The symptoms of chronic endocarditis depend on 
the nature and extent of the lesion, and on the reaction of the heart 
muscle to the increasing demands that are made upon it. When the 
heart's hypertrophy and its muscular integrity keep pace with the dis- 
ability due to the valvular defect, they are but slight, and are evidenced 
chiefly by a limitation of the field of cardiac response. If this is over- 
stepped, as it almost necessarily will be at an early stage in the patients 
under consideration, there will be some dyspnoea and general weakness, 
often with palpitation and precordial distress. As decompensation sets 
in gradually, or often in more or less sudden and recurring attacks, a train 
of symptoms is presented due to (1) the slowing of the circulation with 
diminished supply of oxygen and accumulation of carbon dioxide, (2) 
the overfilling of the veins with blood, and (3) reflex nervous disturbances. 
The symptoms will vary according to the part of the organism chiefly 
affected by this venous stasis: dyspnoea, cough, cardiac asthma, pul- 
monary congestion, hemorrhage and oedema of the lungs; cyanosis, 
oedema of the extremities, ascites, hydrothorax; congestion of the liver, 
indigestion, occasionally jaundice; congestion of the kidney, with scanty 
and albuminous urine; headache, restlessness, sleeplessness, irritability, 
and sometimes more serious nervous and mental disturbances. The 
physical signs vary with the lesion and with the valve affected and need 
not be rehearsed here. 
Treatment.-The treatment of chronic endocarditis in the class of 
patients under consideration would seem to consist primarily in devising 
some means of lessening their cardiac strain. If the patient is seen early 
and this end can be obtained, he may reasonably look forward to many 
years of useful work. The two most important factors in obtaining it are: 
first, personal instruction in cardiac hygiene, second, the obtaining of 
some less arduous work than that which has brought about or favored 940 
DISEASES OF THE BLOOD, CIRCULATORY SYSTEM AND KIDNEYS 
the development of the disease and the consequent cardiac decompensa- 
tion. In our clinic we are constantly urging and helping patients to seek 
positions such as watchmen, janitors, or messengers, or other such places, 
where they may earn a livelihood with the least effort. It is often sur- 
prising how little intelligent workingmen may know of personal hygiene, 
and especially of its bearing on their cardiac condition. It is important 
therefore to give definite instructions as to overwork and rest, strain 
and worry, clothing, ventilation, bathing, diet, and the care of the bowels. 
The injurious effect of alcohol and tobacco should also be clearly explained. 
As chronic anaemia is frequently a factor in these cases, it should receive 
appropriate treatment. When the case goes on to some grade of cardiac 
decompensation, the patient should be confined to bed and is usually 
better cared for in a hospital. As these patients so often have made an 
effort to work to the last moment possible, and have thus weakened the 
myocardium out of all proportion, it would seem, to their endocardial 
lesion, far better results are obtained and more time is gained by them in 
the end, by prolonging the rest in bed to the limit; that is, far beyond 
what the patient himself feels is necessary. The chief difficulty usually 
comes in persuading the patient that this is desirable. In our clinic we 
do not hesitate to keep patients with only moderately severe decom- 
pensation in bed for 2 months, and have found that the results more than 
repaid us. After the period of complete rest, systematic exercises are 
instituted that the patient may return very gradually to the amount 
of exertion necessary to the avocation decided upon. The medicinal 
treatment of chronic endocarditis is of greatest importance in the stage of 
decompensation. Digitalis is the drug par excellence in this condition. 
To give a full account here of the use and effect of digitalis, its indications 
and contraindications would lead us too far afield. Suffice it to give a 
few general principles which to-day guide us in its usage. In the failing 
heart of chronic endocarditis digitalis is seldom contraindicated. It 
must, however, often be used tentatively and with great caution. On the 
other hand bold and prompt exhibition of full doses, when indicated, often 
saves lives that would have been lost by the more deliberate methods 
of our ancestors. The best method, and the necessary one in severe cases, 
is that popularized largely by the writings of Eggleston. The dosage 
necessary to produce full digitalis effects is calculated in reference to the 
patient's weight; approximately of a grain per pound. This may be 
given in a few large doses within twelve hours; or in smaller doses over a 
period of some days. If a patient is likely to die in a day or two, it is 
manifestly useless to give such doses as would produce full effect only 
after a week's accumulation in the body. On the other hand, the more 
gradual method of obtaining these effects has advantages in cases of 
moderate decompensation. We give digitalis in full doses and with the 
expectation of the most brilliant results in cases of auricular fibrillation, 
especially if they be associated with mitral disease; and in secondary low ENDOCARDITIS ARTERIOSCLEROSIS 
941 
blood pressure cases, which have retained a fairly good heart muscle. 
We look for a slower and less certain result in aortic cases with a regular 
pulse or with premature contractions. And finally we use the drug with 
great caution, beginning with small doses, in all cases complicated by severe 
myocardial disease or degeneration, especially of the fatty type; and in 
advanced arterial degeneration, avoiding its use if we have reason to 
suspect impending arterial rupture. The principal absolute contraindica- 
tion is high grade partial heart-block. 
Arteriosclerosis.-Arteriosclerosis, local or general, is undoubtedly 
the commonest form of circulatory disease due directly to the influence of 
occupation. Two of its etiological factors are prevalent among many 
industrial workers, namely, arterial strain and lead poisoning. The 
former is brought about by prolonged and heavy muscular exercise, espe- 
cially that associated with much lifting, or by constantly repeated sudden 
efforts, which produce a great increase in blood pressure, and ultimately 
a permanent high tension. This condition may be also brought about by 
occupations that are accompanied by severe and prolonged mental strain 
or worry. The manner in which lead acts on the arterial system is still 
somewhat uncertain. It may act directly as an irritant to the arterial 
walls, and it certainly raises the bood pressure, probably by its action on 
the kidneys. Increased blood pressure in itself, if sufficiently long con- 
tinued, inevitably leads to arteriosclerosis. A third factor which is 
doubtless very prevalent among these patients, though perhaps no more 
so than among other classes of the population, is intestinal auto-intoxica- 
tion, more particularly that caused by the decomposition or faulty meta- 
bolism of certain purin proteids. We find arteriosclerosis very common 
among stevedores, iron and steel workers, smiths, butchers, and soap 
boilers, painters and others exposed to chronic poisoning by the heavy 
metals; as also among those who are subjected to severe mental strain and 
worry. 
Pathology.-In considering the pathology of this disease it must be 
remembered that in the aorta and larger branches of the arterial tree there 
is much elastic tissue and relatively little muscle, while the smaller arteries 
and those distributed to the various organs contain much smooth muscle 
and relatively little elastic tissue. This of course favors a greater varia- 
tion in the flow of blood to the different organs by means of vasocon- 
striction and vasodilatation. Two main types of arteriosclerosis are 
described: the nodular, affecting chiefly the aorta, and the diffuse, which 
mainly attacks the smaller vessels. The latter is the type usually 
caused by chronic arterial hypertenion, in the absence of syphilis, gout 
or other infectious or toxic agents. These are prone to affect the aorta, 
and the incidence of aortitis in this country appears to be increasing. In 
diffuse arteriosclerosis, fibrous overgrowth is found in all three coats of the 
arteries, followed later by degeneration and often by calcareous deposi- 
tion, especially in the intima and media. The distribution of. arterio- 942 
DISEASES OF THE BLOOD, CIRCULATORY SYSTEM AND KIDNEYS 
sclerosis is variable. Sometimes all of the arteries are more or less affected; 
more often only certain groups or systems. And on this fact depends the 
diverse clinical manifestations of the disease. 
Symptomatology.-The symptoms, then, express themselves in groups 
dependent upon the arteries most affected. Hypertension, though by no 
means a necessary accompaniment of all cases of arteriosclerosis, is 
constantly present in those cases brought about by muscular strain and 
lead poisoning. This means that the main visceral trunks and their 
branches, usually referred to as the splanchnic area, or the renal arteries 
are sclerosed, frequently both. The following are the more notable 
symptoms grouped under the heading of the system affected; 
(a) Cardiac, embracing the aorta and coronary arteries: Pain in the 
cardiac area extending to the shoulders and down the arms, frequently 
hyperaesthesia in the same area, palpitation and a sense of weight in the 
precordium; sometimes attacks of angina pectoris. If death does not 
supervene, myocardial fibrosis is the natural sequence in these cases, with 
all the signs of cardiac insufficiency; dyspnoea, congestion of the kidneys, 
oedema, ascites, hydrothorax. 
(6) Cerebral: Headache, often severe and obstinate, attacks of faint- 
ness and vertigo, nervousness and insomnia, transient attacks of irra- 
tionality, asphasia or partial paralysis. The retinal arteries are often 
affected early, and give a characteristic picture, often accompanied by 
scotomata and some dimness of vision. The degree of sclerosis in the 
retinal arteries is frequently a fair index of the condition of those in the 
brain. Cerebral hemorrhage or thrombosis may be the final outcome. 
(c) Renal: Chronic interstitial nephritis of a mild grade is very fre- 
quently present, and the more severe forms sometimes appear later in 
the disease. 
(d) Abdominal: Disturbances of digestion are often the earliest symp- 
toms manifested, but unfortunately for purposes of diagnosis are in no 
way characteristic. Attacks of severe abdominal pain, often seen in 
lead poisoning, are most likely due to spasm of the partially sclerosed 
abdominal vessels. 
(e) Peripheral: A similar spasm of the vessels of the extremities is 
the cause of the less frequent attacks of intermittent claudication, with 
severe pain and intermitting loss of function. 
Treatment.-All that we can hope to accomplish by the treatment of 
an existing arteriosclerosis is to arrest its progress, and to relieve some of 
its symptoms. Should the patient be seen early, when hypertension is 
alone present, in what has been called the presclerotic stage of arterio- 
sclerosis, much more may be hoped for. In either case, the measures that 
are most useful are unfortunately often those that it is difficult for the 
workingman to carry out. Of the first importance is the avoidance of the 
causes of hypertension, and in most cases this means change of occupa- 
tion, so as to obtain more rest and greater freedom from strain, or, to ARTERIOSCLEROSIS-DISEASES OF THE KIDNEYS 
943 
avoid the further saturation of the body with lead. Systematic exercise, 
however, which must often be insisted upon among the leisure classes, 
is usually unnecessary in the cases under consideration. The diet is 
important, as even those engaged in laborious occupations often eat too 
much, or injudiciously. The proteid intake should be reduced as much 
as is consistent with the maintenance of strength, and those forms of 
proteids used that experience has shown are least injurious. My own 
preference in the more severe cases is for cheese and eggs, and with a 
moderate amount of these together with the proteid obtained from bread- 
stuffs and some of the vegetables and fruits, the 70 to 80 grams a day 
necessary for a hard-working man may be obtained, at least for a certain 
period. If meat is allowed at all, it should be eaten sparingly, not 
oftener than once a day. Medical opinion varies somewhat as to the 
deleterious effect of alcohol in arteriosclerosis, but certainly in the forms 
of the disease under consideration, it is better avoided altogether. Nico- 
tine has more recently been shown to affect the arterial coats delete- 
riously, so tobacco in any form should be avoided or reduced to a minimum. 
The bowels should be kept unusually free, and this can, as a rule, be accom- 
plished in those of an active life by careful dieting. If not, laxatives may 
be necessary from time to time. It is better to resort to them as often 
as need be, than to allow constipation to persist, with the resultant 
resorption of a greater amount of poisonous substances. Frequent bath- 
ing is desirable, a tepid sponge in the morning or a warm bath at night, 
and the sweating incidental to labor is a distinct advantage. Too much 
cannot be expected from medicinal treatment. Potassium iodide is the 
classical remedy, and if given in a suitable vehicle in small doses, it is 
usually well borne and seems to be of undoubted service. The nitrites 
are often valuable in combating the symptoms dependent on hyper- 
tension, or aortic or coronary disease, though they should not be given 
constantly with the idea of permanently lowering the pressure. What is 
not accomplished in this way by hygiene, will hardly be by drugs; and 
indeed it is now a commonplace that the optimum pressure in arterio- 
sclerosis, though often less than what is found in an untreated case is 
usually well above the normal. Finally in many cases of arteriosclerosis, 
we have to deal with the cases of secondary low blood pressure due to a 
failing heart. Here digitalis in full doses is indicated, and is often 
followed by brilliant results. 
DISEASES OF THE KIDNEYS 
Acute Nephritis.-Acute congestion of the kidneys, followed usually 
by acute nephritis, as an occupational disease, is caused by the inhala- 
tion of the concentrated fumes of turpentine, vanadium, arsenic or 
carbolic acid, and not infrequently occurs among the workers in these 
substances. 944 
DISEASES OF THE BLOOD, CIRCULATORY SYSTEM AND KIDNEYS 
Pathology.-In these cases the kidneys are usually large, soft, and 
either red from the large amount of blood present or grayish yellow with 
fatty degeneration; the capsule strips easily; the tubular epithelium is 
swollen, hazy, granular and contains fat droplets; the glomeruli are con- 
gested and their capsules filled with blood cells and debris. There is at 
least some inflammatory oedema in the interstitial tissue. 
Symptomatology.-The onset is usually sudden, with headache, pain 
in the back, nausea, vomiting, pallor and the early development of slight 
oedema. Fever is slight or absent. The urine is scanty and may at first 
be completely suppressed; the specific gravity is high; it contains much 
albumen, blood and casts. Acute uraemic symptoms occur in a certain 
number of cases-vomiting, mania, convulsions or coma. Although 
always a serious disease, there is a natural tendency to recovery with 
complete restoration of function after a course of from several weeks to 
several months. 
Treatment.-A minimal amount of work should be put upon the kidneys 
by reducing metabolism and body waste, and utilizing other methods of 
elimination. The patient is put to bed on a salt-free diet yielding 
about 50 grams of proteid and 2000 or 2500 calories. This is best obtained 
by milk and cream. A small amount of cereal, breadstuffs and milk, 
sugar may be added when the more acute symptoms begin to subside. 
If oedema is present the amount of fluid should be greatly restricted. 
Free catharsis should be maintained. Diuretics may be used, but are of 
doubtful value. If uraemia threatens, sweating and free venesection are 
indicated. Iron should be given during convalescence. 
Chronic Interstitial Nephritis.-This is the more common form of 
renal disease caused by the deleterious effects of various occupations, 
and is met with among workers in lead and other heavy metals, or occurs 
as an accompaniment of arteriosclerosis from overstrain. 
Pathology.-The kidneys are usually small, the capsule thickened and 
adherent, the epithelium degenerated, the vessels sclerotic and there is a 
marked overgrowth of the interstitial connective tissue. The heart is 
always hypertrophied and the arteries usually sclerosed. Anaemia nearly 
always develops in the course of the disease. 
Symptomatology -The disease is usually insidious in its onset, and is 
first recognized as a result of a urinary examination, or by the occurrence 
of a serious complication. Early symptoms are failure of strength, head- 
ache, dizziness, sleeplessness, loss of appetite and dyspepsia, and moderate 
dyspnoea on exertion. The urine is increased in quantity, is of low 
specific gravity, contains a trace of albumen and a few casts. Distur- 
bances of vision may occur, with retinal hemorrhages or albuminuric 
retinitis. The pulse is tense and full and the systolic and the dias- 
tolic blood pressures increased. The later developments of the case 
are usually those of chronic uraemic poisoning, nocturnal dyspnoea, 
with Cheyne-Stokes respiration, uncontrollable vomiting, local palsies, DISEASES OF THE KIDNEYS 
945 
mania, convulsions, coma; or of cardiac decompensation, described 
above. 
Treatment.-Pathologically the disease is incurable, but much may be 
done to prevent its progress and keep the patient in a fair degree of health. 
The causes of kidney irritation or of arterial strain should be obviated. 
This usually means a change of occupation, with the adoption of one that 
is less strenuous, or in which chronic poisoning from any source may be 
avoided. The diet should be light and nourishing, similar to that recom- 
mended for arteriosclerosis. If active work is to be continued 70 to 80 
grams of proteid a day may be allowed; if a sedentary life is adopted, 50 
grams is sufficient. The fluid intake should be restricted to about 2 quarts, 
to relieve the kidneys of extra work. The bowels and skin require careful 
attention. Sweating and active catharsis may be called for later, with 
the nitrites, if the early symptoms of chronic uraemia supervene. Venesec- 
tion is one of our most valuable adjuvants in well marked uraemia, 
and should never be neglected in those cases which are associated with 
pulmonary oedema. Iron is nearly always required for the anaemia, 
and digitalis in full doses for the later cardiac insufficiency tides over 
many a crisis. CHAPTER VI 
CANCER AND OCCUPATION. X-RAY. RADIUM 
E. E. TYZZER, M. D„ Boston, Mass., and THOMAS ORDWAY. M. D„ Albany, N. Y. 
SECTION I 
CANCER 
Definition.-The term cancer may be used in two senses: in its general 
application it signifies any form of malignant tumor; in its restricted and 
more accurate sense it is synonymous with carcinoma, a malignant epi- 
thelial tumor. A tumor is a mass of tissue which arises from the atypical 
proliferation of certain tissues of the body and which is without function. 
Tumors which possess powers of unlimited growth, which invade and 
interfere with the activity of normal tissues or organs, which penetrate 
the circulatory system and thus become disseminated throughout the 
body so that death ultimately results, are termed malignant. Tumors 
which grow very slowly by expansion or become stationary, and neither 
tend to invade normal tissues nor become disseminated so that they are 
not ordinarily fatal, are termed benign. 
Incidence.-The frequency of cancer is shown by the fact that it 
ranks fifth in the list of causes of death.1 According to the mortality 
statistics of England for the year 1909, about one in 10 males and one in 
7 females who died at the age of 35 years or over succumbed to cancer.2 
This condition differs from many other diseases in that it is almost 
invariably fatal if not artificially eradicated. The cases recorded of 
spontaneous recovery from cancer3 are extremely rare, so that the progno- 
sis of untreated cases is bad. 
Distribution.-Cancer has a wide zoological distribution, occurring in 
many different species, in fact in representatives of practically all orders 
of the vertebrates. The greater number have been found in man and 
domestic animals or in animals living in captivity. Tumors have been 
reported, however, in animals living in the wild state under natural 
conditions so that, notwithstanding the meagerness of such observations, 
it is certain that the development of tumors is not restricted to the arti- 
ficial conditions of domestication.4'5 The swellings which accompany 
various parasitic infections in lower animals are often reported as tumors, 
but the term tumor is in such instances used loosely to designate any 
swelling irrespective of its character. The frequency of tumors varies 
in different species, and some appear to be practically free from any form 
of malignant growth. The longevity of the individuals in each species 
should be taken into account, however, in determining relative frequency. 
Thus, for example, tumors appear to occur frequently in short-lived 
946 cancer: introduction-THEORIES 
947 
animals, such as the mouse and the rat, which live no more than 2 or 3 
years at the most. Although statements based on statistical studies or 
upon personal impressions would tend to show that certain less civilized 
races are relatively exempt from cancer,6'7 such conclusions cannot be 
accepted until more systematic clinical and pathological investigations 
are carried out among wild tribes. It frequently requires only systematic 
search for a condition to be revealed where it had not previously been 
suspected. 
Age.-The incidence of cancer increases with age, especially with 
respect to involution changes in certain organs. If the incidence is 
represented by a curve, we have in early life the deaths from congenital 
tumors, following which there is a drop and the curve remains low during 
puberty, rises rapidly toward the end of the reproductive period and 
with advanced life tends again to fall. Age then is of considerable 
importance in the development of tumors. In this respect there is marked 
variance from the definitely infectious diseases which either occur early 
in life or are more or less distributed with respect to age incidence. The 
changes which take place in the skin and their bearing on the development 
of skin cancer is especially important. 
Theories.-Many theories have been advanced in explanation of the etiology of 
cancer. It will be impossible to discuss all these theories within the allotted space, 
and thus only a number of the more important will be reviewed. Thiersch and 
Waldeyer8 have presented the hypothesis that there exists between the epithelium and 
connective tissue an equilibrium through which the growth of the former is held in 
check. On the degeneration of the connective tissue in old age the epithelium pro- 
liferates and tumors develop according to this hypothesis. Cohnheim9 attached great 
importance to the displacement of cells or groups of cells from their normal relations 
during the course of development, the so-called "embryonic rest" theory. This idea 
of the dislocation of cells has also been utilized by Ribbert10 in explaining the origin 
of tumors. He, however, considered other forms of tissue dislocation than that which 
occurs naturally in development. He found that epithelium implanted in the con- 
nective tissue remained alive for a time and was capable of a certain amount of growth. 
Although epithelial cysts could be formed in this manner, the transplanted tissue 
possessed only limited powers of growth and never resulted in a tumor. Ribbert 
utilized the disturbance of the normal relationship of tissues in chronic inflammatory 
conditions to account for the origin of tumors. 
The theory of the gametoid nature of cancer tissue reached its greatest develop- 
ment in articles by Farmer, Moore, and Walker11 although it is not original with them. 
By this theory the unusual activity and growth of tumor tissue is considered to be due 
to a process of fertilization taking place between cells of the somatic tissues. The 
fusion of such cells gives rise to a sort of hybrid tissue capable of active growth. A 
support for this theory was claimed in the presence of a reduced number of chromo- 
somes in dividing cancer cells, also in the morphological similarity of the chromo- 
somes to those which are found in the reproductive cells. Von Hansemann12 explains 
this reduction in the number of chromosomes as the result of asymmetrical mitotic 
division and suggests that with the loss of chromatin there may be also a loss of differ- 
entiation in tissues, which he terms "anaplasia." 
The view that cancer develops as the result of some specific infection has found 
many adherents and through the employment of a great variety of methods many 948 
CANCER AND OCCUPATION. X-RAY. RADIUM 
different organisms have been reported as the cause of cancer. None of these has 
found acceptance although the association of certain parasites with inflammatory 
conditions which may be followed by cancer is worthy of further consideration. In a 
single species, the common fowl, it has been demonstrated that tumors may be pro- 
duced by the introduction into normal fowls of an agent which is readily passed 
through a Berkfeld filter and which also resists drying sufficient to kill all tumor cells.13 
Whether this is of the nature of a microorganism or of a chemical substance is not yet 
conclusively shown. Repeated attempts to isolate such an agent from mammalian 
tumors have invariably failed. 
In the etiology of cancer the importance of certain agents, which produce long- 
continued injury and chronic inflammation, is now universally recognized. Such 
Fig. 42.-Hyperplasia in vegetable tissues due to infection with a myxmycete, Plas- 
modiophora brassicas. Several of the slender normal roots of the cabbage are apparent 
but nearly all are greatly thickened as the result of proliferation. 
agents demand consideration from the standpoint of occupational disease and will 
thus be discussed somewhat in detail later on. 
The Question of Contagion.-The question is frequently raised as to the possible 
contagiousness or infectiousness of cancer. It is definitely known that cancer may be 
transplanted from one portion of the body to another. This frequently happens 
naturally during the course of the disease either by the apposition of a tumor to the 
surface of healthy tissue or by the transplantation of tumor cells loosened in the 
fluids of the body, and it may occur artificially during surgical operation. Further- 
more it would probably be possible, at least in some instances, to transplant tumor 
cells to normal individuals, since this is actually done in the experimental propagation cancer: theories-contagion-HOUSE infection 
949 
of tumors in lower animals. The danger of the transplantation of tumor cells from 
tumor patients to normal individuals is undoubtedly very slight, and is theoretically 
possible only in instances where living tumor is brought into contact with abrasions 
or introduced by accident through incision or puncture. There is, however, no 
instance recorded of the accidental transplantation of human tumor to normal 
individuals either during surgical operation or pathological examination. If there 
were an infectious agent concerned, we would expect the nurse who is in attendance 
and the surgeon who is frequently operating on cancer cases and especially the pathol- 
ogist who is brought into frequent contact with tumor tissue to show a high incidence 
of cancer. This, however, has never been demonstrated. 
The Question of House Infection.-The occurrence of a number of cases in a 
single dwelling or in a certain locality has raised the question of house infection.14 
It has been pointed out, however, that the so-called "cancer houses" are usually 
occupied by individuals of more than the average age of the community at large and 
are also explained in some instances by cheap rentals with a consequent tendency of 
Fig. 43.-Metaplasia of the epithelium of the biliary ducts in Fiber zibethicus as the 
result of the presence of a species of trematode, one of which is shown in longitudinal 
section. 
people with chronic disease to gravitate toward such localities. There is furthermore 
no evidence to indicate that the attendants in certain hospitals, almshouses, and other 
institutions where such cases are cared for, show a higher incidence than others. 
When the frequency of cancer in a community at large is taken into account, it would 
be expected that by mere chance distribution a large number of cases would occa- 
sionally be grouped in a restricted locality or in a single dwelling. 
Heredity.-In the consideration of the part played by heredity in the occurrence 
of tumors, it has become more or less of a dogma in medical instruction that heredity 
is here of no significance. This teaching is based upon the investigations of Pearson15 
and others and was made on the basis of the theory of inheritance which has never 
been successfully applied as a working hypothesis and which is not recognized at the 
present time. Sufficient data have been collected in the lower animals to reopen this 950 
CANCER AND OCCUPATION. X-RAY. RADIUM 
question, so that the subjects of heredity with reference to cancer in human beings is 
now also under investigation.16' 171 18 Tumors of a similar nature occur in closely 
related individuals sufficiently often as to create the belief not only among the laity 
but also in the minds of many physicians that heredity is of importance. While the 
data collected up to the present time from animal experimentation is insufficient to 
serve as a basis for any sweeping conclusions concerning human inheritance, we are of 
the opinion that the results already obtained are sufficient to call for a consideration 
of the subject of heredity with reference to cancer. 
Hyperplasia.-While certain tumors appear to rise de novo without the knowledge 
of any preceding abnormal condition, many are preceded by conditions which are of 
long standing and which are frequently spoken of as "precancerous." There are 
various agents which produce unusual growth or proliferation of tissues. Such tissues 
during proliferation may correspond more or less closely in structure with the normal 
tissues. An increase in the amount of the tissue as the result of proliferation is termed 
hyperplasia. The increases in the size of the tonsils under conditions frequently 
met with in early life are examples of such hyperplasia. Certain hyperplasias are 
Fig. 44.-Irregular proliferation simulating adeno-carcinoma in cnronic 
pancreatitis of the cat. 
attributable to known causes such as microorganisms or higher parasites, others are 
of unknown etiology, and we also have examples of the compensatory hyperplasia 
to supply an increase in function by reason of loss of parts or other failure elsewhere. 
During hyperplasia there is frequently a loss of differentiation of tissues which 
von Hansemann has termed "anaplasia." In fact, it appears that structural differ- 
entiation may bear an inverse relation to the rapidity of tissue growth. 
Metaplasia.-Under certain stimuli certain tissues may not only depart markedly 
from the normal but become transformed to quite another type and this is known as 
metaplasia. The transformation of the glandular endometrium into stratified 
squamous epithelium as the result of eversion of the uterus has been considered an 
example of such metaplasia, but here there is the possibility that the transformation 
is due to replacement with squamous epithelium growing in from contiguous surfaces 
rather than true metaplasia. A better example is to be found in the transformation 
of the epithelium of the bile ducts as the result of the presence of parasitic worms. 
This organ is completely isolated from all surfaces covered with squamous epithelium cancer: tissue changes-INJURIES, etc. as causal 
951 
and may therefore be taken as a true example of metaplasia. In certain forms of 
chronic pancreatitis, the glandular portion of the organ may become greatly modified 
and resemble cancer. The bronchial epithelium may also become changed from a 
columnar to a squamous type in certain instances.19 Such conditions occur naturally 
but some may also be produced experimentally by infecting animals with the proper 
parasites. These changes, however, are not to be regarded as constituting true tumor 
although they may closely simulate the latter. They differ in this respect that^they 
are self-limited and have a tendency to return to the normal especially when the 
exciting cause is removed. 
Fig. 45.-Uoccidium nodule of the rabbit's liver simulating papillary adenocystoma. 
This lesion differs from a tumor in that it is self limited, and following the elimination of 
the causal agent, becomes replaced by scar tissue. 
INJURIES AND CHRONIC INFLAMMATION AS A BASIS FOR CANCER 
There is now available a large amount of data which shows that long- 
continued inflammation due to various causes is frequently followed by, in 
fact paves the way for, the development of cancer. Probably the most 
convincing example is the production of cancer following long or repeated 
exposure to the X-ray, an unusual and artificial agent which will be 
referred to later on in more detail. A considerable number of tumor cases 
give a history of trauma preceding the appearance of tumor. In this con- 952 
CANCER AND OCCUPATION. X-RAY. RADIUM 
nection it is necessary to take into account the tendency of human nature 
to find a plausible cause to which to attribute any infirmity. We should 
also consider the undue prominence given certain injuries on account of 
the previous involvement of certain structures by tumor. Thus an 
individual attributes the development of sarcoma of a given bone to a 
blow or other injury although it may very well be that no great impor- 
tance would have been attached to such an injury in case the bone had 
been normal at the time. From a medico-legal aspect such cases present 
most perplexing problems. It is possible, even probable, that in a limited 
number of cases, trauma is to be considered as a contributory cause. The 
principle cause would appear to lie in the peculiarity of the individual, for 
trauma is of so great frequency that it cannot in any sense be regarded as 
the specific cause of any type of tumor. The involvement of any portion 
of the body by the metastatic growth of tumor previous to a given injury 
is usually more easily determinable either by the clinical evidence of 
tumor elsewhere, by the histological character of the tumor, or by post- 
mortem demonstration of the primary tumor located elsewhere. The 
frequency of the fracture of bones secondarily invaded by tumor which 
has originated elsewhere is familiar. A radiograph taken as soon as 
possible after the fracture should usually show and serve as a record of the 
presence of either primary or metastatic growth. 
The number of agents that are known to produce chronic inflammation 
of such character that new growth frequently follows, is continually grow- 
ing and it is with certain of these that we are concerned in the considera- 
tion of occupational disease. There are agents to which all individuals 
are exposed to a greater or less degree that are mildly injurious. The 
undue or prolonged exposure to the skin to such agents evidently has a 
tendency to bring on a premature senility of its tissues especially in 
certain individuals. The effects of light, heat, and drying on the exposed 
portion of the skin are familiar to medical men and it is upon these sur- 
faces, especially on the face and hands, that such changes appear in later 
life. The more immediate effects of undue heat and cold on the skin are 
well known, especially to dermatologists, and the future condition of the 
tissues will depend on the powers of repair in each individual case. 
For example, by the habitual application of cold, a dry scaly condition 
of the skin may be produced at will in many individuals. Thus abnor- 
malities in the form of undue greasiness and accumulations of the cornified 
epithelium, the so-called keratosis senilis, are found on the exposed 
portions of the skin of the aged in addition to a more generalized tendency 
to atrophy and loss of hair and glands. Certain individuals possess a pro- 
nounced idiosyncrasy to light, for example, and light has been shown to be 
unusually injurious to individuals subject to a skin affection known as 
Xeroderma pigmentosum.20 
There are certain specific diseases that produce chronic inflammation 
which is not infrequently followed by cancer. Thus the long-continued cancer: injuries, inflammations, parasites, habits 
953 
injury to the skin in Lupus vulgaris serves as a basis for the subsequent 
development of cancer. Cancer may also develop in chronic syphilitic 
lesions, and that there is no incompatibility for the coexistence of these 
various diseases is shown by the occurrence of all three in a single patient.21 
Considerable evidence has been collected indicating that syphilitic lesions 
about the mouth, if untreated, tend to become cancerous. 
Animal Parasites.-The invasion of the pelvic veins with the parasitic 
worm, Schistosomum hematobium (Bilharzia) and the inflammation 
resulting from the passage of the ova of these worms through the bladder 
wall is said to be frequently followed by carcinoma of the bladder. 
Cancer is occasionally reported in association with unusual parasites 
as, for example, carcinoma of the liver, as the result of the infestation of 
the bile ducts of the human being with a species of fluke which is usually 
restricted to the cat.22 De Jong, who has recently made an extensive 
study of the changes occurring in the bile passages as the result of the 
action of various species of liver flukes, concludes that the changes are 
hyperplastic in character but do not constitute true cancer, for they tend 
to regress with the disappearance of the parasite. On the other hand it 
has been conclusively demonstrated in lower animals that certain para- 
sitic worms set up processes which eventually result in malignant tumors. 
Fiebiger23 has succeeded in the experimental production of both gastric 
and lingual cancer in rats and mice through the agency of a round worm. 
That this is a true cancer is shown by its tendency to metastasize and 
by its continued growth independent of the exciting agent. More 
recently sarcoma of the liver has been produced in a large proportion of 
rats experimentally infected with the larval stages of a certain species of 
tapeworm. 
Habits.-Of special interest is the influence of habit on the frequency 
of tumors. The use of alcohol in large amounts, since it is commonly 
attended with more or less exposure or disease, is probably of some impor- 
tance in bringing on a premature senility of the tissues. Cancer of the 
tongue is restricted for the most part to males and is in most cases attribu- 
table to local irritation resulting from habitual smoking. The use of a 
short-stemmed clay pipe is especially to be avoided and prompt medical 
attention to any chronic local inflammation may serve to prevent serious 
consequences. Countries in which preparations of betel nut and lime 
are habitually used for chewing purposes show a high incidence of 
cheek carcinoma.24 Statistics for such countries are especially interesting 
in that they show a high frequency of carcinoma of the cheek in women, 
whereas new growth in this location is infrequent in women of European 
nations. Cancer of the abdominal wall is relatively infrequent in most 
countries, but is frequent in this location in certain parts of India where 
the body is warmed artificially by a small stove, the kangri.25 
Occupational Relationships.-The effects of the various agents 
enumerated should be regarded in varioys occupations. Those which 954 
CANCER AND OCCUPATION. X-RAY. RADIUM 
involve excessive exposure to light, heat, and cold may be expected to be 
of influence in bringing on a premature aging of the exposed portions of 
the skin and thus to factor in the development of skin cancer. Since, 
however, most of the tumors of this type are of comparatively slight 
malignancy, such influences are not of first importance. Occupations 
such as that of the soldier which expose individuals to certain parasitic 
infections, such as Schistosomiasis, etc., must be taken into account. 
The occupation of the physician and that of the nurse, however, are not 
shown to be dangerous with respect to direct infection from cancer 
cases. No very marked preponderance of cancer in any of the more 
usual occupations is shown by Newsholme's statistics.26 The incidence 
of cancer in chimney sweeps, however, is more than double than in any of 
the other occupations. Since these statistics are based upon data relating 
to cancer in general, it is not remarkable that they show no more. 
If the statistics were collected for each type of tumor much more 
significant results would be expected with reference to the occupation. 
Notwithstanding this there is a strikingly high incidence in chimney 
sweeps. 
Special Occupations.-The distribution and character of the tumors 
and the preceding conditions which are associated with certain occupations 
are of special interest. The occupations which have to do with the manu- 
facture or use of certain coal-tar products are to be especially considered. 
In such occupations the exposure of skin surfaces to the irritating 
substances is said to be followed by a more or less characteristic type of 
inflammation or by warty growths. The liability to tumors under such 
circumstances is recognized in England so that certain trades are 
scheduled as coming under the workmen's compensation act. It is said, 
however, that addiction to alcohol tends to diminish such personal hygiene 
as would readily prevent the prolonged action of the materials used. 
Workers with anilin oil frequently develop carcinoma of the bladder and 
it is believed that this substance in the process of excretion remains for 
a time in the bladder and so excites the proliferation which follows.27 
Certain individuals also show a peculiarly marked reaction to arsenic so 
that those trades in which arsenical compounds are used would prove 
dangerous in such instances. Osler states that cobalt miners are said 
to be prone to primary carcinoma of the lung, an organ which is ordinarily 
rarely the primary site of cancer. 
Medico-legal Aspect.-The medico-legal aspect of the subject is of 
some importance. Usually no more than a contributory influence is to 
be claimed with respect to injury in the causation of new growth. In a 
limited number of trades and occupations, however, the careless use of 
materials such as certain coal-tar products or physical forces such as the 
X-ray and radium should always be emphasized and measures taken to 
avoid all unnecessary exposure. The dangers in the use of X-ray are 
at the present time so well understood that it would appear that the CANCER AND OCCUPATIONS 
955 
majority of injuries produced should be considered as due to ignorance or 
carelessness, whether the injury effects operator or patient. There are as 
yet no recorded cases of carcinoma arising from radium burns but the 
similarity of the more penetrating rays of radium and of its biological 
effects leads to the expectation of similar results and to a warning against 
the indiscriminate or careless use of this agent. 
Mortality from Cancer in Different Occupations.-Dr. Hoffman28 devotes 28 
pages to the mortality from cancer in different occupations and presents an excellent 
review of the literature of the subject with special reference to cancer among chimney 
sweeps, gardners, petroleum industry and paraffin workers, coal, soot, tar and pitch 
workers, including the patent fuel industry, brewers, furriers, skinners, seamen, 
tinplate workers, lead workers, rubber workers, chemical workers and X-ray workers. 
The relation of cancer to injuries is emphasized by quotations from Greer's treatise 
oh the Industrial Diseases and Accidents. 
A very valuable reference on the effect of the synthetic dye industry on the 
occurrence of tumors by Dr. S. G. Leuenberger of Zurich will be found on page 68 
of Hoffman's work. 
Arnstein calls attention to the remarkable prevalence of malignant disease of the 
lungs in the miners in the Schneeberg district in Saxony,28 the minerals mined being 
mostly nickel, cobalt containing arsenic, and bismuth. Harting and Hesse in 1878 re- 
ported that a lymphosarcoma of the bronchial lymph nodes, or an endothelial sarcoma 
was responsible for 75 per cent, of all the deaths among the miners. Arnstein in a recent 
investigation found that between 1907-1911 all the miners admitted to the hospital, 
entered with a diagnosis of cancer of the lung and it was given as the cause of death 
in 44 per cent, of the death certificates. In the opinion of Arnstein it is probable that 
in many cases tuberculosis and possibly also pneumoconiosis may have been 
erroneously diagnosed as cancer of the lung as necropsies are rare. In the two cases 
which he was able to examine post-mortem, the trouble proved to be chronic 
pulmonary tuberculosis in one case but in the other true carcinoma of the lung with 
metastasis. He urges further study. 
The English Mortality Statistics referred to28 bring out the fact that "the highest 
standardized cancer death rate occurred among chimney sweeps for which occupation 
the rate was 224.9 per 100,000 exposed to risk. The rate for seamen was 170.5 and for 
brewers 166.6. Relatively high, but not abnormally excessive, cancer death rates are 
met with in the following occupations: Fishermen 111.9; tailors 112.9; textile workers 
112.6; lawyers 111.8; innkeepers 108.8; corn-millers 105.3; gas works service 107.1; 
shoemakers 103.2; and butchers 102.8. Lower cancer death rates but still sug- 
gestive of special predisposing conditions are met with in the following occupations: 
Farmers and graziers 94.8; farm laborers 79.7; gardners and nurserymen 85.2." 
Hoffman states that cancer as a cause of invalidity is, according to German 
experience, not of serious importance. Out of every 1000 recipients of invalidity 
annuities, the proportion retired on account of cancer was 16 for males and 21 for 
females. The corresponding proportions for tuberculosis of the lungs were 122 for 
males and 76 for females. It was the seventeenth most important cause of invalidity 
among males and the fifteenth among females. 
Cancer and Tarry Products.*-According to Ross,29 from Government 
inquiries into pitch cancer at the briquette works in South Wales, England, 
it would appear that some chemical rather than mechanical action is 
concerned in the causation of industrial cancer. While the crude 
* Prepared by Emery R. Hayhurst, M. D. 956 
CANCER AND OCCUPATION. X-RAY. RADIUM 
derivatives from soft coals, such as are used in gas works, produce patho- 
logical conditions which frequently develop into cancer, similar products 
from the hard coals used in blast furnaces appear to be without such effect. 
Ross investigated coal, tar, pitch, soot, napthalene, and other tarry 
commodities, anilin dyes, petroleum, and grease, and compared their 
results with those obtained from kangri burns, tobacco, betal nut, 
X-ray, radium, arsenic, and manure. This investigation showed that 
the various commodities differ physically very greatly (ranging from 
liquids to solids), yet when one such becomes impacted in the tissues it 
tends to give rise to cell proliferation followed by a warty condition. 
The warts usually ulcerate at their bases and drop off, leaving an intract- 
able sore whose edges tend to become epitheliomatous. 
All of the commodities mentioned, with the exception of arsenic, are 
products of the death, and decomposition of living matter, although such 
deaths may have occurred centuries previously. The only exception, 
arsenic, is a powerful cell poison and may produce the products of cell 
death and decomposition in the tissues. Ross also calls attention to the 
fact that carcinoma seems more frequent, in general, at sites which are 
continually subjected to organic matter undergoing bacterial decomposi- 
tion (rectum, stomach, mouth, etc.). That part which is the dirtiest or 
which is affected with open ulceration is the one most liable to malignant 
change. Decaying organic matter of all descriptions fertilizes living 
matter, and promotes cell proliferation, being used extensively for the 
growing of plants in agriculture. Up to a certain point the more putrid 
the matter, the more pronounced is this fertilizing property. Certain 
substances, among others some of the purine bases such as creatin, 
xanthin, and tyrosin, that were found to stimulate cell division, are 
termed by this author auxetics. Other substances, kinetics, which stimu- 
late cells to great activity, amoeboid movement, et cetera, are supposed to 
be concerned also in the development of cancer. Ross' hypothesis, 
however, fails to furnish a satisfactory account of the development of 
cancer, for even if the existence of auxetics and kinetics be accepted, no 
explanation is given of the permanent biological modification of the 
cancer cell as conclusively shown by experimental transplantation to 
other individuals of the same species (E. E. Tyzzer). 
The Trend of Cancer *-Upon the question whether cancer incidence 
in general is increasing or decreasing, Dublin,30 chief statistician for the 
Metropolitan Life Insurance Company, quotes Hoffman to the effect 
that: "the mortality from cancer is increasing at a more or less alarming 
rate throughout the entire civilized world and that this increase implies 
most serious consequences, present and future, to the population con- 
cerned," and then Willcox as follows: "the reported mortality from can- 
cer is increasing in almost every part of the world, but the real mortality, 
if increasing at all, is certainly not increasing with equal rapidity . . . 
* Prepared by Emery R. Hayhurst, M. D. CANCER AND TARRY PRODUCTS TREND OF CANCER 
957 
The cumulative evidence that improvements in diagnosis and changes 
in age composition explain away more than half, and perhaps all of the 
apparent increase in cancer mortality, rebuts the presumption raised 
by the figures and makes it probable, though far from certain, that cancer 
mortality is not increasing." Dublin's own study of industrial insurance 
statistics brings him to the following conclusion: "Our data, therefore, 
appear to confirm the idea that the cancer death rate is not increasing, 
though if such a conclusion were drawn it could be but preliminary. 
There is a need of reserve and caution in predicating any decisive opinion 
with regard to the real trend of cancer mortality during recent years, for a 
longer period of time will be required to collect authentic figures upon 
which a definite judgment can be based." Dublin bases his conclusions 
upon cancer death rates covering six years (1911-1916) and relating, in 
all, to fifty million years of like exposed to risk which show no decisive 
upward or downward tendency for all age classes combines. In the 
experience of the Metropolitan Company's Industrial Department, he 
finds, further, that "the cancer mortality rate at the ages where the 
cancer rate is significant decreases as we go up in the economic scale," 
and that "This is true for both sexes and by age period where sufficient 
data are available." "Cancer of the skin is, almost altogether, confined 
to white persons. In the Metropolitan experience 887 of the 938 deaths 
due to skin cancer were those of white persons, the total death rate being 
1.9 per 100,000 exposed as compared with 0.8 for the colored insured. 
In the matter of sex incidence a considerable excess in the white experience 
is shown for males over females; the rate for the former being 2.2 as 
compared for 1.6 for the latter." 
Strong31 also concludes that we cannot at present determine whether 
cancer mortality is slightly increasing, practically stationary, or slightly 
decreasing, but is convinced that it is not greatly increasing. Finally 
H. Gideon Wells32 in comparing the clinical diagnosis of cancer to the 
actual necropsy diagnosis, as obtained from 2712 necropsies at Cook Co. 
Hospital, Chicago, for the years 1917-1922, and also 1000 other records 
of his own necropsies, finds that clinical diagnostic errors, under the best 
conditions of modern methods of diagnosis, range from 25 to 40 per cent., 
so that his "study shows emphatically the lack of value of all recorded 
vital statistics on cancer." The extent to which errors may have 
balanced each other is not made clear, but it is clear that we shall have 
no dependable statistics until a very much larger proportion of such 
statistics hinge on postmortem examinations than is now the case.* 
* In a personal communication from Dr. Dublin (April 23, 1923) he states, "I think * ♦ * * the 
accuracy of cancer statistics may be considered about stationary during the last ten years." He also 
calls attention to the figures given in the Statistical Bulletin of the Metropolitan Life Insurance Co. 
for Jan., 1923, p. 9, which shows the death rate per 100,000 for cancer (all forms) for the successive 
years 1912 to 1922: 
1922 
1921 
1920 
1919 
1918 
1917 
1916 
1915 
1914 
1913 
1912 
71.5 
71.7 
69.8 
67.0 
67.2 
70.9 
70.3 
70.9 
69.8 
70.5 
70.3 958 
CANCER AND OCCUPATION. X-RAY. RADIUM 
The American Society for the Control of Cancer (25 West 45th St., 
New York City) has especially appealed to industrial physicians for 
assistance in the educational efforts which physicians are promoting in 
large industrial plants throughout the country. 
The National Safety Council has prepared an educational poster, 
through the courtesy of the American Society for the Control of Cancer, 
to be displayed on bulletin boards of industrial establishments (Poster 
No. H. S. 43 and Health Service Series, No. 33, Nat'l Safety Council, 168 
N. Michigan Avenue, Chicago, Ill.). 
REFERENCES 
1 Mortality Statistics. U. S. Bureau of the Census, 1913, 24. 
2 Bashford.-Middleton Goldsmith Lecture. Proceedings of New York Path. Soc., 
1912. 
3 Gould.-Bradshaw Lecture on Cancer, 1910. 
4 Bashford.-Third Scientific Report of the Imperial Cancer Research Fund, 1908, 1. 
6 Murray.-Third Scientific Report of the Imperial Cancer Research Fund, 1908, 
41. 
6 Levin.-Zeitschr. for Krebsforschung, 1910. 
7 Seligmann.-Third Scientific Report of the Imperial Cancer Research Fund, 
1908, 26. 
8 Waldeyer.-Virchow's Archiv, 1867, 470. 
9 Cohnheim.-Vorlesungen uber allegemeine Pathologic, Berlin, 1882, I and II. 
10 Ribbert.-Beitrage zur Entstehung der Geschwiilste, Baun, 1906-8. 
11 Farmer, Moore and Walker.-Proc. Roy. Soc., 1903, 72. 
12 Von Hansemann.-Studien fiber die Spezificitat, den Altruismus and die Anaplasie 
der Zellen, Berlin, 1893. 
13 Rous and Murphy.-Journal of Experimental Medicine, 1914, XIX, 52. 
14 Oliver.-House Infection, April, 1914. 
16 Pearson.-Archives of the Middlesex Hospital, 1904, II, 104 and 127, and V, 
103. 
16 Tyzzer.-Journal of Medical Research, 1909, XXI, 479. 
17 Slye, Holmes and Wells.-Journal of Medical Research, 1914, XXX, 417. 
18 Warthin.-Journal of the Michigan State Medical Society, 1914. 
19 Haythorne.-Journal of Medical Research, 1912, XXVI, 523. 
20 Councilman and Magrath.-Journal of Medical Research, XXI, 331. 
21 Kellert.-Journal American Medical Association, Vol. LXIII, No. 21, Nov. 21, 1914. 
22 Braun.-Animal Parasites of Man. William Wood & Co., 1908, 165. 
23 Fiebiger, J.-Det Kongelige Danske Videnskabernes Selskab. Biologiske Meddellel- 
ser, I, 14, 1919. 
24 Davis.-Jour. Amer. Med. Assoc., Vol. LXIV, No. 9, Feb. 27, 1915, 711. 
26 Bashford.-Third Scientific Report of the Imperial Cancer Research Fund, 1908. 
26 Newsholme.-The Practitioner, 1899, LXII, 371. 
27 Davis.-Jour. Amer. Med. Assoc., May 30, 1914, page 1716. 
28 Hoffman, F. L.--The Mortality from Cancer Throughout the World, Prudential 
Press, 1915, pp. 61, 68, also Appendix C, Tables 4, 5 and 6, pp. 311-314.^ 
29 Ross, H. C.-Jour. Cancer Research, Baltimore, Oct., 1918, Vol. Ill, No. 4, 
321. 
30 Dublin, Louis I.-Jour. Cancer Research, 1919, Vol. IV, No. 3, 235-260' 
81 Strong, W. E.-Jour. Cancer Research, 1921, VI, 251. 
82 Wells, H. Gideon.-Jour. Am. Med. Assoc., LXXX, No. 11, March 17, 1923, 737. REFERENCES ON CANCER X-RAY 
959 
Additional References 
(Hay hurst) 
Glibert, D.-Occupational Cancer: Jr. Ind. Hyg., I, No. 10, Feb., 1920, Abstr. p. 
163 from Bull. Acad. Med. Belgique, May, 1919, 29, No. 4, 627-634. 
American Society for the Control of Cancer.-Pamphlets and leaflets for popular 
education, such as, "Fighting Cancer with Facts," "What You Should Know 
About Cancer," "What to do About Cancer," "What we Know About Cancer," 
etc. Address: 25 W. 45th St., New York City. 
Davis, B. F.-Paraffinomina and Wax Cancer: J. A. M. A., LXXV, No. 25, 1709- 
1711, Dec. 18, 1920. 
Block, B. and Dreifuss, W.-Experimental Tar Cancer. Abstr. by J. A. M. A. 
Jan. 14, 1922, 152. (From Dermatologic Clinic at Zurich. Author found 
cancer inducive fraction in tar is a substance with a boiling point over 300°C.) 
From Schewiz. med. Wchnschr., Vol. LI, No. 45, Nov. 10, 1921, p. 152. 
Fiebiger, J. and Bang, F.-Experimental Tar Cancer. Abstr. by J. A. M. A., 
March 4, 1922, 696. (Historical resume of evidence of irritation cancer. 
Authors obtained positive results in 90 per cent, of white mice by waiting long 
enough.) From Hospitalstidende, Vol. LXIV, |No. 48, Nov. 30, 1921, 51. 
Legge, T. M.-Pitch Ulceration. (Analysis of 64 cases in briquette works of South 
Wales-Also reference to refining of paraffin in oil shale works of Scotland). 
Ann. Report Chief Inspect, of Fact, and Workshops, Gt. Brit., 1918, 81-82 
(Abstr. by Jr. Ind. Hyg., Nov., 1920, 141-142). 
O'Donovan, W. J.-Epitheliomatosis Ulceration Among Tar Workers. (Analysis 
of 18 patients at the London Hospital. Valuable etiological review). Brit. Jr. 
Derm, and Syph., July-Aug. Sept., 1920,-beginning p. 245. (Abstr. by Jr. Ind. 
Hyg., Nov., 1920, 140-141). Also:-Carcinoma Cutis in an Anthracene Factory. 
(Three cases). Brit. Jr. Derm, and Syph., Vol. XXXIII, 1921, 291 (Abstr. by 
Jr. Ind. Hyg., Dec., 1921, 187). 
SECTION II 
X-RAY 
Exposure to the Rontgen rays, more particularly the repeated exposure 
of X-ray operators without adequate protection, over a long period of 
time, has produced skin lesions which have in numerous instances eventu- 
ally been followed by true cancer. Thus the causal relation of the X-ray 
and cancer is now a well-known and an established fact. 
It has long been known that characteristic burns might be produced 
by exposure to the X-ray. These burns differ in many respects from 
those caused by heat; there may be a considerable latent period between 
the exposure and the subsequent appearance of the inflammatory reac- 
tion. This interval may vary from a few hours to several days or even 
weeks; the burn is of longer duration, the healing may be very slow, requir- 
ing weeks and even many months; in some instances healing does not 
occur, and there may be a persistent chronic ulcer which may become 
cancerous, particularly during scar formation. 
The degree of the acute reaction following exposure to the X-rays is 
very variable, depending on several factors, namely: the intensity and 
quality of the radiation, the duration of the exposure, the part of the 960 
CANCER AND OCCUPATION. X-RAY. RADIUM 
body exposed, and the individual sensitiveness or tolerance. The 
intensity and quality of the rays depend upon the amperage, voltage, the 
distance from the tube and the filtration and protection. Gocht1 claims 
that there is no special idiosyncrasy to the X-ray as was at one time 
believed. The effects depend on the quantity of rays absorbed by the 
tissue. 
Acute X-ray Dermatitis.--Depending on the factors above referred to, acute 
X-ray dermatitis may appear as a slight or intense erythema varying in shade from a 
light pink color, which is more or less transitory, and may have a slightly punctate 
character, to a deep red erythema, which may not disappear even on pressure. This 
is often accompanied by itching. The erythema, if intense, may fade slowly and be 
followed by brownish pigmentation. On the other hand vesiculation may result, 
with subsequent exfoliation of the surface layers. Ulceration in varying degree and 
even sloughing may occur. The acute reactions most frequently occur in patients 
exposed to the X-ray for diagnosis or treatment; such injuries have caused much 
Fig. 46.-Photograph of the left hand and wrist of a Rontgenologist who had been 
engaged in X-ray work for ten years (Huntington Hospital, No. C. O. 14, 240). 
The lesions chiefly on the palmar surface, which is unusual, consist of scaling, fissures, 
keratoses, atrophy, telangiectases and pigmentation. 
suffering and disability, and many legal suits, often most disastrous to physicians, 
have resulted.2 
The mucous and serous surfaces seem to be more resistant to injury by the X-ray 
than the skin, while the appendages of the skin are even more easily affected. Marked 
changes in the hair follicles often lead to falling out of the hair; dryness of the skin due 
to injury of the sweat glands is common. 
Normal' living tissues are said to be affected in the following order: lymphoid 
tissue, epithelial cells of the glands, the hair follicles, skin, lining of the blood-vessels, 
and to a much less extent the cells and fibers of muscles and connective tissue. 
From the standpoint of occupational disease, however, the chronic changes 
caused by repeated exposure to relatively small doses of X-ray over a long period of 
time are of far more importance than the acute reactions above referred to. They 
may be discussed as to the local and general effects. 
Chronic X-ray Dermatitis and Cancer.-Chronic X-ray dermatitis is 
the term given to the changes produced in the skin by repeated exposure X-RAY DERMATITIS AND CANCER 
961 
to relatively small doses of X-ray. In certain instances they may be 
preceded by acute reactions; the characteristic changes are closely 
analogous to those found in the skin of the aged, or of those exposed to 
the elements. Similar changes may be produced in the skin of the 
paraffin worker and the chimney sweep. The atrophy, keratosis and 
localized scaling is so like that of age, that the chronic effects of the X-ray 
upon the skin have been claimed by some3 to be permaturely induced 
senescence. 
Fig. 47.-Photograph of an X-ray demonstrator showing on the chest keratoses, telan- 
giectases and pigmentation; on the hands keratoses, fissures and loss of left fore-finger 
due to previous amputation for X-ray carcinoma. In the left axillary region a black line 
indicates the anterior border of a metastatic cancer mass. These chest lesions were 
caused by repeatedly demonstrating the heart outline and action by fluoroscope and the 
lesions on the left hand were due to the use of the latter for a penetrometer and as an 
object of demonstration for bone structure. Man first began X-ray work in 1897. The 
case was previously reported by Porter, No. VII. of his 1909 series, also Huntington Hos- 
pital, No. C. O. 15. 1. Jan., 1915. 
In addition to the atrophy, scaling and keratosis, there is also pigmentation, 
development of fissures and telangiectasis, which may be marked (Fig. 46); loss of 
hair and dryness of the skin are frequent; the nails may become brittle, ribbed and 
chipped (Fig. 48). Beneath the keratoses changes occur in the underlying blood- 
vessels and connective tissue, the epidermis may invade the corium and true car- 
cinoma may result, with metastasis, not only in the regional glands, but even widely 
disseminated. This represents the first real experimental cancer.4 962 
CANCER AND OCCUPATION. X-RAY. RADIUM 
Cancer may develop not only in preexisting papillomata and keratoses, but also 
in the intractable chronic ulcers caused by the X-ray, either by intense single or 
repeated exposures. Many cases are reported of the development of cancer in patients 
who have undergone X-ray treatment for lupus; indeed, this disease may in certain 
instances be followed by cancer, even without treatment by the X-ray. Mendes da 
Costa8 cites 71 cases of lupus in which the X-ray was used; of these seven became 
cancerous. Schurmann6 thinks the danger of cancer from X-ray treatment of lupus is 
slight when compared with its extensive use and the fact that cancer may occur in 
lupus without the use of the X-ray. 
The pioneer workers with the X-ray little suspected the dangers of 
occupational disease and the late occurrence of serious injury among 
Fig. 48.-Photograph showing details of Fig. 47, i.e., telangiectases, keratoses and 
pigmentation of chest, the bulbous stump of the left fore-finger, the multiple keratoses, 
crusts, and fissures, and the chipping and ribbing of the nails on the left hand, which is 
laid across the chest. 
them is appalling (Figs. 22, 23, 24). Many cases have now been reported 
which emphasize the importance of adequate protection and care in 
working with the X-ray. 
Special emphasis should be placed upon the necessity for great care 
in protection of both the operator and patient, particularly at this time 
when portable X-ray outfits have been so perfected-notably by Coolidge 
and his co-workers-that they are likely to come into very common use 
among men who little realize the dangers in the unskilled application of 
the X-rays. Porter,7 in a most admirable article, has reported a consider- X-RAY DERMATITIS AND CANCER 
963 
able number of cases, and discussed methods of treatment. Of the 
symptoms caused by X-ray injuries pain is most distressing; in certain 
instances it is agonizing; disability may be great. 
Goeneu8 found a mortality of 24 per cent, in 33 cases of X-ray carcinomata gath- 
ered from the literature, while of ten cases reported by Porter and White9 six died in 
spite of surgical operation. Various other writers have reported single or a series of 
cases of X-ray carcinoma.10 
It is important to note that these X-ray carcinomata are frequently multiple,11 
there are usually several centers of growth.16 
Sarcoma11 as well as carcinoma may result from exposure to the X-rays. 
Fig. 49.-Photograph showing ulcerations on chest of a demonstrator of X-ray appara- 
tus due to the removal of numerous X-ray keratoses by actual cautery; between these 
pigmentation and telangiectases are seen. The stump of the fore-finger the site of a pre- 
vious X-ray cancer, and the middle finger have been amputated because of recurrence; 
the scar in the left axilla indicates where a large, metastatic cancer mass was removed; 
the primary growth was on the left fore-finger. Feb. 8, 1915. 
Of the 36 cases of X-ray carcinomata collected by Porter,7 34 were in professional 
X-ray workers (Figs. 47, 48, 49), and two in patients, the latter with abdominal 
tumors which had been treated for a long time. 
Histology of Chronic X-ray Dermatitis and Carcinoma.-Wyss,4 Unna,3 and 
Wolbach,12 agree that the epithelium is not primarily affected but that the essential 
changes are in the underlying connective tissue and blood-vessels. There is sufficient 
injury so that complete repair does not take place-degenerative and reparative 
process go on in the corium but the vascular lesions are progressive. Young fibro- 
blasts were described by Wolbach in the media of the small blood-vessels which, from 
the proliferation of the connective tissue and the swelling of the collagenous material 
may be in certain instances obliterated. 964 
CANCER AND OCCUPATION. X-RAY. RADIUM 
The necrotic foci found in both the superficial and deep corium are probably 
of vascular origin. The cells in the basal layers of the epithelium may show many 
mitoses. Only by the downgrowth of the epithelium is it able to reach viable con- 
nective tissue. The glands are atrophied and the fat .tissue is absorbed and replaced 
by connective tissue. 
Hyperkeratosis, rarification of the corium, irregularity of the papillae are common; 
cell infiltration, especially lymphoid and plasma, is variable. Epithelium may be 
found growing into necrotic foci and into thrombosed telangiectases; in more 
advanced cases epithelial pearls situated in the deeper structures are frequent, 
giving an appearance differing in no way, histologically, from a true epidermoid 
carcinoma. 
General Effects of the X-ray.-Much less is known of the deeper and 
more general chronic effects due to exposure to the X-ray. It has, how- 
ever, been definitely established that the sexual glands are particularly 
affected. Atrophy of the ovaries and testicles may occur with resulting 
sterility; changes take place also in the blood, lymphatic tissue and bone 
marrow. Anaemia, even of the pernicious type, may be produced and 
blood findings, similar to those described from exposure to radium, are 
frequent, particularly in the form of a relative lymphocytosis.13 On the 
other hand, it has been claimed that certain cases of leukemia have 
resulted from exposure to X-ray. 
In a series of mice and rats exposed repeatedly to the X-rays, marked 
changes were found in the lymphatic tissue; the spleen was markedly 
affected being very much reduced in size due to destruction of the Malpig- 
hian corpuscles and other cellular elements.14 In such animals resistance 
to infection is markedly decreased.15 Certain cases of myelogenous 
leukemia, after exposure of the spleen to the X-ray, if special precaution is 
taken regarding screening, protection and dosage show a marked reduc- 
tion in the size of the greatly enlarged spleen, great decrease in the white- 
cell count, and more or less temporary improvement in the general 
condition of the patient. Leucocytolytic substances are said to have been 
found in the blood of such cases. 
Toxaemia of varying degree may be produced by exposure to the 
Rbntgen ray, particularly in patients in whom there is poor elimination by 
the kidneys. Slight toxaemias have been noted by Edsall16 even after 
diagnostic exposures in such patients. Profound, even fatal, toxaemias 
have been recorded; such a severe case with resulting stupor has been per- 
sonally observed by us. 
This toxaemia may be the result of poisoning from failure to eliminate 
products of protein metabolism. There may be increase of total nitrogen, 
ammonia, urea in the urine, and nitrogen retention in the blood. On 
purin free diet there is to be found an increase in endogenous protein 
metabolism. 
Other general effects of the X-ray are said to occur; lassitude is of 
common occurrence, frequently patients doze or even fall asleep while 
undergoing X-ray treatment and there is often a feeling of undue fatigue x-ray: general effects-treatment 
965 
after long exposure. Alopecia is common in X-ray operators and patients 
exposed. 
The details of the pathological findings have been described by Cavaz- 
zeni and Minelli17 in a post-mortem examination of one who had been 
exposed to the X-ray for many years. 
Treatment.-The best treatment for acute Rbntgen dermatitis is said 
by Dodd18 to be the liberal application of whitewash which is sopped on 
the inflamed area but not to be used with a dressing. He decries the 
use of ointments. The formula given by Dodd is as follows: 
1$. Zinc oxide 30 3 i 
Phenol 2 5ss 
Glycerine 4 $i 
Limewater 240 gviii 
Sig.-Shake well and bathe area for 5 to 10 minutes, twice or three times 
a day. 
For slight burns Unna's zinc gelatine, and for the more chronic condi- 
tions on the hands compound tincture of benzoin, may be used. 
The chronic changes produced in the skin by the X-ray require varied 
treatment depending on their nature. The so-called precancerous kera- 
toses, papillomata and ulcers, call for excision, curettage, or skin-grafting, 
and the more border-line and cancerous lesions may demand amputation. 
Porter7 in the excellent article above referred to describes the treatment 
of these lesions in detail. Further, Caldwell19 has called attention to the 
value of surface applications of radium in the less severe and strictly 
cutaneous chronic lesions, such as fissures, persistent scaling and keratoses. 
Freezing methods and the electric spark, are more painful. 
Of even greater importance than treatment in individual cases is the 
matter of preventing these injurious effects of the X-ray. 
Prophylaxis.-As our knowledge of these injurious effects has 
increased, many methods have been devised to prevent exposing the body 
of the operator to the rays, and of adequately protecting the patient. 
For the X-ray worker mirrors, cords and pulleys have been planned for 
indirect observation of the patients and control of apparatus. Protection 
for the operator in the form of leaded cabinets, screens, gloves, aprons, etc. 
have been provided. These are well illustrated in special works in Ront- 
genology and in catalogues of dealers in X-ray apparatus. 
The patient is now more carefully guarded by screens, leaded cloth 
and more particularly by our knowledge of dosage, filtration and protec- 
tion, each varying with the object of the treatment. Exposures should 
be as short as possible and other forms of irritation of the skin avoided. 
The details of the appropriate technique will be found in the general or 
special works on Rontgenology and in its application to the diagnosis 
and treatment of pathological conditions of the various special organs for 
which such procedure is of value. 966 
CANCER AND OCCUPATION. X-RAY. RADIUM 
That such prophylactic measures are adequate is probable from the 
fact that those who have carefully used such measures though engaged 
in X-ray work for over 12 years have not suffered any harmful effect. 
SECTION III 
RADIUM 
The increasing use of large quantities of radium for therapeutic pur- 
poses makes it important to describe in detail the symptoms and signs 
produced by it and to emphasize the importance of these as occupational 
injuries so that more serious late effects may not result. 
Rutherford20 states that "Walkhoff first observed that radium rays produce 
burns of much the same character as those caused by Rontgen rays. Experiments 
in this direction have been made by Giesel, Curie and Becquerel and others with 
very similar results. There is at first a painful irritation, then inflammation sets in, 
which lasts from 10 to 20 days. This effect is produced by all preparations of radium, 
Pig. 50.-Photograph of the thumb, index-, middle- and ring-fingers of the left hand 
showing the scaling of the thickened superficial layer of the skin on the radial side of the 
terminal phalanges; this is due to the handling of radium in making therapeutic applications. 
and appears to be due mainly to the a and 0 rays. Care has to be taken in handling 
radium on account of the painful inflammation set up by the rays. If a finger is held 
for some minutes at the base of a capsule containing a radium preparation, the skin 
becomes inflamed for about 15 days and then peels off. The painful feeling does not 
disappear for 2 months." 
Although these rather acute reactions due to radium are apparently well known 
to physicists, working with radioactive substances, and considerable experimental 
work has been done on animals by biologists, very little attention has been paid to the 
more chronic changes. 
The increasing use of large quantities of radium should call attention to these 
changes not only because of the annoyance and discomfort caused but as a warning 
from analogy to the X-ray of more serious late effects, such as atrophy, intractable 
ulceration and even cancer. Already in certain instances there has been caused not 
only great annoyance from discomfort but actual impairment in manual dexterity in 
performing delicate manipulations because of persistent local anaesthetic-effects. 
The symptoms caused by handling radium may occur very insidiously 
and consist of blunting of sensibility of the finger tips, paraesthesia such as RADIUM 
967 
increased sensitiveness to heat and pressure, amounting at times to actual 
pain, and anaesthesia of varying degree. 
The subjective disturbances are out of all proportion to the objective 
findings which include flattening of the natural ridges on the effected 
fingers with consequent changes in the characteristic markings of the 
finger prints, thickening of the horny layer of the epidermis with scaling 
in varying degree (Fig. 50), failure of the tips of the fingers to resume 
their normal shape after pressure-a sort of pitting, upgrowth of the 
cuticle at the base of and underneath the nails which tend to stand off 
from the fleshy part of the fingers and which become easily cracked and 
extremely brittle (Fig. 51). We have observed that in one instance a 
constantly reforming keratosis of the tip of the thumb has persisted over 
four years since the person affected handled radium in routine work. 
Various general symptoms such as headache, malaise, weakness, undue 
fatigue, unusual need of sleep, increased excitability, fretfulness, irritabil- 
Fig. 51.-Photographs of fingers showing how the free edge of the nails stands away 
from the fleshy part of the affected finger tips; the upgrowth of the horny skin beneath 
the nails is marked. The changes are the result of handling radium in making therapeutic 
applications. 
ity, disorders of menstruation, attacks of dizziness, etc., have been said by 
Gudzent and Halberstsedter21 to be caused by repeated and long-contin- 
ued exposure to radioactive substances. Such symptoms are, however, 
common in many people at times and as they cannot be accurately and 
objectively recorded there is doubt if they can be definitely proved to be 
due to exposure to radium. They may be due to close confinement, tiring 
routine and lack of out-door exercise and other causes. The exposures of 
some of the cases reported were doubtless large; some were assistants in 
"Fabriks" for manufacture of radium apparatus and some had been 
engaged for years during the entire day in work with radioactive sub- 
stances. It is therefore probable that certain general symptoms do occur 
as a result of exposure. 
Changes in the blood of radium workers were observed by Gudzent 
and Halberstaedter. Most striking was the relative and absolute increase 
in lymphocytes from 36 per cent, to 63 per cent., average of 10 cases 
46.4 per cent.; a relative and absolute decrease in neutrophiles, average 
50.3 per cent. There was little change in red blood corpuscles, slight 968 
CANCER AND OCCUPATION. X-RAY. RADIUM 
diminution in white cells and the hemoglobin was lowered in only two 
cases, 70 per cent, and 71 per cent, respectively. 
Prophylaxis.-Various methods have been devised for avoiding these 
injurious effects by the least possible contact of the fingers with the 
radium. Forceps or special vices are used for holding tubes and screwing 
in or out the tips and eyes; special applicators in the form of metal boxes 
have been constructed so that the active tubes may be added after the 
filtration and protection have been arranged, and the surface applicator 
is then slipped by forceps into a special rubber envelope and fastened with 
adhesive. This is particularly to avoid wrapping the radium up by hand 
in sheet rubber. Leaded gloves, fingers, etc., are clumsy and are not 
readily worn. 
In placing active tubes in special applicators it will probably not be 
possible to avoid all contact with radium and as the effects are not appar- 
ent at once, as when handling very hot objects such as heated glass, but 
only after a period of days or even weeks, it will be difficult to train a 
worker to avoid all contact with the active apparatus. 
In the work of making routine applications of radium there should be a 
rotation in the staff and persons affected should be freed at least tempo- 
rarily from such work. 
In order to avoid general disturbances the body should be protected as 
far as possible by metal screens in form of boxes or plates about the 
radium; there should be frequent ventilation of workrooms, particularly 
if there is radium emanation present, and a change of duty and shorter 
hours; periodic physical examination of those working with radioactive 
substances with special reference to the blood examination is indicated. 
Summary and Conclusions.-From the above it is evident that marked 
changes may occur on the fingers of those engaged in routine work with 
radioactive substances. These local objective changes consist chiefly of 
flattening of the characteristic ridges, thickening and scaling of the super- 
ficial layers of the skin and even atrophy and intractible ulceration. 
These lesions are usually slight compared with the marked subjective 
symptoms, such as parsesthesia, anaesthesia of varying degree, tenderness, 
throbbing and even pain. The persistence of such effects is noteworthy. 
Various general systemic symptoms and also blood changes may be 
produced by exposure to radioactive substances. To avoid such local and 
general disturbances special protective and preventive measures have 
been devised and those engaged in routine handling of radioactive sub- 
stances are particularly cautioned. 
REFERENCES 
1 Gocht.-Berl. Klin. Woch., 1909-10. 
2 Gottheil, W. S.-X-ray Uses, Dangers and Abuses. Jour. A. M. A., Nov. 21, 1908. 
3 Unna.-Fortschr. a. d. G. d. R., Bd. VIII, S. 66. 
4 Wyss, M. O.-Entsteshung des Rontgencarcinomus der Haul und des Carcinomus 
im Allgemeine. Beitrage zur Klinische Chirurgie, XLVI, 1906, S. 185. REFERENCES ON X-RAY AND RADIUM 
969 
8 Mendes da Costa.-Revue pratique des maladies cutan., 1905, page 224. 
6 Schurmann, E.-Entstechung bosartiger Neubildungen auf der rontgenbestralbilten 
Haut. Archiv fiir Klin. Chirurgie, Berlin, LXXXIV, No. 3, 1907. Rep. VII 
collected cases and one of own esp. Histology. 
7 Porter, C. A.-The Surgical Treatment of X-ray Carcinoma and Other Severe 
X-ray Lesions Based upon an Analysis of Forty-seven Cases. Jour, of Med. 
Research, Vol. XXI, 1909, page 357. 
8 Goeneu.-Berl. Klin. Wochensch., 1909, No. 7. 
9 Porter, C. A. and White, C. J.-Multiple Carcinomata Following Chronic X-ray 
Dermatitis. Annals of Surgery, Nov., 1907. 
10 Lindenborn, Karl.-Ueber Rontgentumoren. Beitrage zur Klin. Chirurgie, Vol. 
LIX, 1908, page 384. 
11 Rosenbach, Fritz.-Das Rontgencarcinom und seine entstehung. Archiv f. Klin, 
Chirurgie, Bd. XCII, S. 1, 1910. 
12 Wolbach, S. B.-Pathologic History of Chronic X-ray Dermatitis and Early X-ray 
Carcinoma. Journal Med. Research, Oct., 1909. 
13 Von Jagic, N., Schwarz, G., v. Siebenrock, L.-The Blood Findings in Rontgenolo- 
gists. Berl. Klin. Wochenschr., July 3, 1911, XLVIII. 
14 Heinecke.-Archiv of Rdntgen Rays, 1907. 
15 Murphy, J. B., and Ellis, A. W. L.-Jour. Exper. Med., Vol. XX, No. 1, Oct. 1, 
1914, page 397. 
16 Edsall, D. L., and Pemberton, B.-Nature of General Toxic Reaction Following 
Exposure to Rontgen Rays. Amer. Jour, of Med. Sc., Mar., 1907. 
17 Cavazzeni and Minelli.--La Radiologie Medica, Feb., 1914. Rev. in Arch, of 
Rdntgen Ray, April, 1914. 
18 Dodd, W. J.-Treatment of Acute Rontgen Ray Dermatitis. Amer. Jour, of 
Rontgenology, Sept. 1, 1914, No. 11. 
19 Caldwell, E. W.-Treatment of Chronic Rdntgen Dermatitis. 15th Ann. Meeting. 
Amer. Rdntgen Ray Soc., Sept. 9-12, 1914. 
20 Rutherford.-Radioactive Substances and Their Radiations. Cambridge Uni- 
versity Press., 1913, page 327. 
21 Gudzent and Halberstsedter.-Deutsche Med. Wochenschr., Mar. 26, 1914, No. 13, 
page 633. 
General References 
Behla, Robert.-Die Carcinoma litteratur Eine Zusammenstellung der in-und aus- 
landischen Krebsschrieben bis, 1900, Berlin, Verlag von Richard Schoetz, 1901. 
Williams, W. Roger.-The Natural History of Cancer with Special Reference to its 
Causation and Prevention. London, William Heinemann, 1908. 
Bainbridge, W. S.-The Cancer Problem. The Macmillan Co., N. Y., 1914. 
Additional References 
(Hayhurst) 
Safety Engineer.-Radium in the Safety Movement. (Luminous radium material 
on objects in mines, etc., to prevent accidents.) Vol. XL, No. 5, Nov., 1920, p. 210. 
British Medical Journal.-X-Ray and Radium Protection, Report of Special 
Committee Upon. No. 3156, June 25, 1921, 936-937. 
Mottram, J. C.-Effect of Increased Protection from Radiation upon the Blood 
Condition of Radium Workers. (From the Radium Institute, London.) Arch. 
Radial, and Electrother., Vol. XXV, 1921, p. 368. 
Bergonid, J.-Radium Treatment of Roentgen Dermatitis. Abstr. by J. A. M. A., 
July 30, 1921, p. 409 from Medecine, June, 1921, II, No. 9, p. 625. 
Broca, A.-Dangers of Penetrating Radiations and Methods of Avoiding Them. 
(See quoted Abstr. in Jr. Ind. Hyg., IV, No. 2, June, 1922, p. 28.) PART V 
THE PRINCIPLES OF INDUSTRIAL HEALTH ADMINISTRATION 
CHAPTER I 
COMPARATIVE OCCUPATION STATISTICS 
It is a matter of interest to study the movement of the population 
engaged in gainful occupations in the United States; Dr. Alba M. 
Edwards, Expert Special Agent has prepared under the supervision of 
William C. Hunt, Chief Statistician for Population of the 14th Census 
1920, the following data: 
Table 1 is a summary table showing, by sex, the number and propor- 
tion of persons engaged in gainful occupations at each census from 1880 
to 1920. This table shows that the number of persons thus employed 
has increased more than double, viz. from 17,392,099 in 1880 to 41,614,248. 
Table 2, also a summary table, shows, for both sexes and for each sex 
separately, a number and a percentage distribution of the gainful workers 
in 1920 and in 1910. Table 3 is a detailed table showing the total persons, 
COMPILED BY GEORGE M. KOBER, M.D., Washington, D. C. 
Table 1.-Number and Proportion of Persons Gainfully Occupied, by 
Sex: 1880-1920 
Sex and census year 
Total 
population 
Population 
10 years of 
age and over 
Persons 10 years of age and over 
engaged in gainful occupations 
Number 
Per cent 
of total 
popula- 
tion 
Per cent 
of popu- 
lation 10 
years of 
age and 
over 
1920.. 
Both sexes 
105,710,620 
82,739,315 
41,614,248 
39.4 
50.3 
1910.. 
91,972,266 
71,580,270 
38,167,336 
41.5 
53.3 
1900.. 
75,994,575 
57,949,824 
29,073,233 
38.3 
50.2 
1890*. 
62,622,250 
47,413,559 
2 23,318,183 
37.2 
49.2 
1880.. 
50,155,783 
36,761,607 
17,392,099 
34.7 
47.3 
1920.. 
Male 
53,900,431 
42,289,969 
33,064,737 
61.3 
78.2 
1910.. 
47,332,277 
37,027,558 
30,091,564 
63.6 
81.3 
1900.. 
38,816,448 
29,703,440 
23,753,836 
61.2 
80.0 
18901. 
32,067,880 
23,352,659 
2 19,312,651 
60.2 
79.3 
1880.. 
25,518,820 
18,735,980 
14,744,942 
57.8 
78.7 
1920.. 
Female 
51,810,189 
40,449,346 
8,549,511 
16.5 
21.1 
1910.. 
44,639,989 
34,552,712 
8,075,772 
18.1 
23.4 
1900.. 
37,178,127 
28,246,384 
5,319,397 
14.3 
18.8 
1890*. 
30,554,370 
23,060,900 
24,005,532 
13.1 
17.4 
1880.. 
24,636,963 
18,025,627 
2,647,157 
10.7 
14.7 
1 Figures for 1890 are exclusive of persons in Indian Territory and on Indian reservations, area spec - 
tally enumerated at that census, but for which occupation statistics are not available. 
2 Corrected figures; for explanation, see Occupation Report for 1900, pp. LXVI-LXXIII. | 
970 PERSONS GAINFULLY OCCUPIED-MORTALITY STATISTICS 
971 
the males and the females engaged in each specified occupation in 1920, 
and in 1910. From this table for lack of space only certain figures are 
reproduced. (See addendum note, p. 987.) 
Table 2.-Total Persons 10 Years of Age and Over Engaged in Gainful 
Occupations, Distributed by Sex and General Divisions of 
f Occupations: 1920 and 1910 
Sex and general division of occupations 
1920 
1910 
Number 
Per cent 
distribu- 
tion 
Number 
Per cent 
distribu- 
tion 
Both sexes 
All occupations 
41,614,248 
100.0 
38,167,336 
100.0 
Agriculture, forestry, and animal husbandry 
10,953,158 
26.3 
i 12,659,082 
33.1 
Extraction of minerals 
1,090,223 
2.6 
i 965,169 
2.5 
Manufacturing and mechanical industries 
12,818,524 
30.8 
i 10,628,731 
27.8 
Transportation 
3,063,582 
7.4 
2,637,420 
6.9 
Trade 
4,242,979 
10.2 
3,614,670 
9.5 
Public service (not elsewhere classified) 
770,460 
1.9 
459,291 
1.2 
Professional service 
2,143,889 
5.2 
i 1,693,361 
4.4 
Domestic and personal service 
3,404,892 
8.2 
i 3,772,595 
9.9 
Clerical occupations 
3,126,541 
7.5 
1,737,053 
4.6 
Male 
All occupations 
33,064,737 
100.0 
30,091,564 
100.0 
Agriculture, forestry, and animal husbandry 
9,869,030 
29.8 
i 10,851,581 
36.1 
Extraction of minerals 
1,087,359 
3.3 
i 964,075 
3.2 
Manufacturing and mechanical industries 
10,888,183 
32.9 
1 8,808,161 
29.3 
Transportation 
2,850,528 
8.6 
1 2,530,795 
8.4 
Trade .. 
3,575,187 
10.8 
3,146,582 
10.5 
Public service (not elsewhere classified) 
748,666 
2.3 
445,733 
1.5 
Professional service 
1,127,391 
3.4 
i 959,470 
3.2 
Domestic and personal service 
1,217,968 
3.7 
1 1,241,338 
4.1 
Clerical occupations 
1,700,425 
5.1 
1,143,829 
3.8 
Female 
All occupations 
8,549,511 
100.0 
8,075,772 
100.0 
Agriculture, forestry, and animal husbandry 
1,084,128 
12.7 
1,807,501 
22.4 
Extraction of minerals 
2,864 
(2) 
1,094 
(2) 
Manufacturing and mechanical industries 
1,930,341 
22.6 
1,820,570 
22.5 
Transportation 
213,054 
2.5 
106,625 
1.3 
Trade 
667,792 
7.8 
468,088 
5.8 
Public service (not elsewkere classified) 
21,794 
0.3 
13,558 
0.2 
Professional service 
1,016,498 
11.9 
»733,891 
9.1 
Domestic and personal service 
2,186,924 
25.6 
1 2,531,221 
31.3 
Clerical occupations ; 
1,426,116 
16.7 
593,224 
7.3 
1 Corrected figures; see text, p. 1. 
2 Less than one-tenth of 1 per cent. 
It is deeply regretted that no occupational mortality statistics have 
been published by the Census Bureau since 1909. It became necessary 
therefore to reproduce in Table 3, the best obtainable data on mortality 
and morbidity statistics. The bold figures under occupation in the first 
column represent the number of persons engaged in the various occu- 
MORTALITY STATISTICS 972 
COMPARATIVE OCCUPATION STATISTICS 
pations in 1920 and are taken from Table 3 of the Census Bulletin, while 
all the other figures relate to the period of 1909. 
Table 3.-Mortality and Morbidity Statistics* 
Occupation and age at 
death 
Number of persons em- 
ployed in 1920 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No of 
days of 
sickness 
per 
annum 
per 100 
mem- 
bers1 
No. of 
deaths 
per 100 
mem- 
bers1 
All 
causes 
Per cent, of all causes at specified age 
Typhoid fever 
Tuberculosis 
of lungs 
Cancer 
Apoplexy and 
paralysis 
Heart disease 
Pneumonia 
(all forms) 
Bight's dis- 
ease 
Suicide 
Accident 
Males 
Females 
Males 
Females 
All occupations reported.. 
41,614,248 
10 to 14 years 
210,507 
176 
2.2 
4.0 
9.0 
14.8 
4.0 
5.5 
7.3 
1.1 
11.9 
2.3 
8.0 
8.5 
8.5 
1.1 
2.6 
1.7 
10.5 
42.0 
15 to 19 years 
5,356 
12,197 
28,635 
32,461 
35,711 
35,953 
33,462 
20,802 
5,464 
290 
23.0 
0.5 
0.5 
3.8 
7.0 
1.5 
2.2 
26.6 
20 to 24 years 
7.6 
31.7 
0.9 
0.6 
3.5 
6.3 
2.1 
3.4 
12.6 
25 to 34 years 
5.0 
31.0 
1.3 
1.2 
4.8 
7.4 
4.0 
3.7 
18.4 
35 to 44 years 
2.7 
23.6 
3.3 
2.7 
7.7 
9.5 
6.6 
3.7 
14.4 
45 to 54 years 
1.5 
14.4 
6.8 
5.9 
11.3 
9.0 
9.7 
3.5 
10.2 
55 to 64 years 
0.7 
7.5 
9.4 
10.1 
15.4 
8.3 
11.7 
2.3 
6.3 
65 to 74 years 
0.3 
3.6 
8.4 
13.4 
18.9 
7.6 
12.0 
1.2 
3.9 
75 to 84 years 
0.1 
1.3 
5.6 
15.1 
18.5 
7.0 
10.5 
0.5 
3.1 
85 years and over 
0.6 
3.1 
12.5 
14.1 
6.3 
7.7 
0.3 
3.4 
Unknown 
0.7 
8.3 
2.8 
5.2 
7.2 
4.5 
2.8 
6.6 
41.0 
All occupations reported, 
females, 8,549,511 
27,459 
2.8 
21.0 
8.1 
5.9 
10.3 
7.0 
7.3 
1.6 
3.2 
10 to 14 years 
71 
12.7 
26.8 
1.4 
5.6 
7.0 
2.8 
1.4 
5.6 
15 to 19 years 
2,198 
3,653 
5,141 
4,500 
4,398 
4,174 
1,887 
1,078 
338 
9.2 
33.3 
0.7 
0.4 
4.7 
6.0 
2.6 
3.0 
5.3 
20 to 24 years 
5.7 
39.8 
0.7 
0.6 
4.8 
5.3 
3.0 
2.9 
3.9 
25 to 34 years 
3.3 
35.7 
3.1 
1.3 
6.4 
5.7 
4.6 
2.4 
3.0 
35 to 44 years 
2.0 
21.3 
10.1 
4.0 
10.5 
6.4 
7.7 
1.1 
2.6 
45 to 54 years 
1.0 
10.2 
15.6 
8.4 
12.7 
8.0 
10.0 
0.9 
2.9 
55 to 64 years 
0.6 
5.6 
14.7 
12.3 
15.4 
9.0 
11.5 
0.8 
2.5 
65 to 74 years 
0.3 
3.2 
9.5 
13.7 
17.5 
9.1 
11.1 
0.3 
2.9 
75 to 84 years 
0.1 
1.8 
7.0 
15.1 
16.3 
9.0 
9.2 
0.4 
4.4 
years and over 
4.1 
11.5 
12.4 
5.0 
7.1 
4.1 
Unknown 
21 
4.8 
4.8 
4.8 
19.0 
9.5 
4.8 
4.8 
Agr cultural pursuits, 
forestry, etc. 
10,953,158 
25 to 34 years 
3,711 
4,138 
5,816 
8,424 
7.9 
26.2 
1.6 
1.4 
4.6 
6.3 
2.7 
4.2 
18.3 
35 to 44 years 
4.5 
19.3 
4.5 
2.6 
7.4 
8.4 
4.7 
5.4 
15.4 
45 to 54 years 
2.4 
12.3 
8.4 
5.9 
11.9 
8.4 
6.9 
3.9 
9.1 
55 to 64 years 
1.1 
6.7 
10.1 
11.5 
16.8 
7.6 
9.0 
2.3 
6.1 
1020 
1159 
1.34 
0.72 
8,249,121 
25 to 34 years 
1,800 
7.1 
28.6 
1.0 
1.6 
4.8 
6.5 
2.1 
5.2 
20.2 
35 to 44 years 
1,701 
1,958 
2,269 
2.8 
20.0 
2.9 
2.5 
8.5 
10.0 
4.4 
5.6 
18.0 
45 to 54 years 
1.8 
14.9 
5.1 
5.3 
12.8 
10.6 
5.7 
3.2 
9.6 
55 to 64 years 
0.7 
8.4 
7.6 
11.5 
16.9 
8.8 
9.6 
2.4 
7.4 
* The mortality statistics showing the number and per cent, distribution, by important causes 
of deaths of persons at least 10 years of age engaged in certain specified occupations, classified by 
age, for the registration area in the United States, are based upon data published in Bulletin 108. 
Bureau of the Census, in 1909. 
1 The morbidity statistics are based upon a study of sickness and mortality hazards in certain 
occupations, compiled from the experience of the Local Sick Benefit Society of Leipsic, 1887 and 1904, 
by Dr. Lee K. Frankel, Vice-Presid-. nt Metropolitan Life Insurance Company, New York, and presented 
before the Detroit Conference, Niagara Falls, September 4, 1913. ALL OCCUPATIONS BARBERS AND HAIRDRESSERS 
973 
Mortality and Morbidity Statistics.--Continued 
Occupation and age at 
death 
Number of persons em- 
ployed in 1920 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No. of 
days of 
sickness 
per 
annum 
per 100 
mem- 
bers1 
No. of 
deaths 
per 100 
mem- 
bers1 
All 
causes 
Per cent, of all causes at specified age 
Typhoid fever 
Tuberculosis 
of lungs 
Cancer 
Apoplexy and 
paralysis 
Heart disease 
Pneumonia 
(all forms) 
Bright's dis- 
ease 
Suicide 
Accident 
Males 
Females 
Males 
Females 
Farmers, planters, and 
overseers 12,402,522 
25 to 34 years 
1628 
9.2 
24.9 
2.3 
1.4 
4.6 
6.4 
3.3 
3.1 
13.4 
35 to 44 years 
2091 
6.0 
18.8 
5.5 
2.8 
6.6 
7.4 
5.0 
5.2 
11.7 
45 to 54 years 
3366 
2.9 
11.0 
10.4 
6.2 
11.5 
7.0 
7.4 
4.2 
8.2 
55 to 64 years 
5589 
1.2 
6.1 
11.0 
11.5 
17.1 
7.1 
8.8 
2.3 
5.4 
Gardeners, florists, nurs- 
erymen, etc. 
602,800 
25 to 34 years 
69 
5.8 
23.2 
1.4 
1.4 
4.3 
8.7 
4.3 
4.3 
13.0 
35 to 44 years 
96 
4.2 
33.3 
7.3 
3.1 
2.1 
9.4 
5.2 
5.2 
7.3 
45 to 54 years 
184 
1.1 
15.2 
6.5 
5.5 
14.7 
11.4 
9.2 
3.8 
5.4 
55 to 64 years 
223 
0.4 
7.2 
13.0 
7.6 
16.1 
9.9 
10.3 
2.7 
5.8 
Agents-Transportation 
31,878 
25 to 34 years 
262 
5.7 
32.8 
2.3 
0.4 
5.3 
7.6 
3.8 
6.1 
10.7 
35 to 44 years 
366 
4.4 
18.9 
5.2 
1.4 
7.7 
7.4 
7.1 
7.4 
7.6 
45 to 54 years 
552 
1.6 
8.0 
9.6 
6.9 
11.4 
7.4 
12.0 
5.3 
6.9 
55 to 64 years 
650 
0.8 
4.9 
10.2 
12.0 
15.7 
6.6 
10.9 
4.5 
3.7 
Aluminum and brass 
• 
workers 35,967 
761 
0.50 
Artificial ice makers 
701 
0.56 
Asphalters 
.1317 
0.88 
Asphalt and concrete 
workers 
1320 
0.71 
Bakers 118,853 
952 
497 
0.15 
25 to 34 vears 
141 
3.5 
29.1 
1.4 
0.7 
1.4 
12.1 
2.8 
5.7 
12.8 
35 to 44 vears 
176 
1.1 
29.0 
4.0 
1.7 
10.2 
7.4 
8.5 
4.5 
5.7 
45 to 54 years 
198 
3.0 
18.7 
9.6 
4.5 
9.6 
8.6 
10.6 
4.5 
5.6 
55 to 64 years 
181 
0.6 
9.4 
6.6 
8.8 
17.7 
8.3 
10.5 
5.0 
3.3 
Bankers and brokers 
323,226 
712 
25 to 34 years 
74 
2.8 
36.1 
2.8 
11.1 
8.3 
5.6 
5.6 
35 to 44 years 
119 
6.8 
12.2 
4.1 
2.7 
2.7 
14.9 
5.4 
8.1 
5.4 
45 to 54 years 
174 
2.5 
3.4 
10.9 
10.1 
10.1 
8.4 
17.6 
4.2 
2.5 
55 to 64 years 
165 
4.6 
7.5 
9.8 
14.9 
9.8 
14.4 
3.4 
3.4 
Barbers and hairdressers. 
216,211 
395 
0.32 
25 to 34 years 
283 
3.9 
40.6 
1.1 
0.4 
7.1 
4.2 
2.5 
4.6 
7.1 
35 to 44 years 
345 
2.6 
25.8 
2.6 
2.6 
8.4 
6.1 
9.6 
4.6 
6.9 
45 to 54 years 
314 
1.3 
16.2 
4.8 
7.3 
12.4 
6.4 
9.6 
3.2 
7.0 
55 to 64 years 
180 
0.6 
11.7 
6.7 
8.9 
19.4 
3.3 
12.8 
1.7 
3.3 974 
COMPARATIVE OCCUPATION STATISTICS 
Mortality and Morbidity Statistics.-Continued 
Occupation and age at 
death 
Number of persons em- 
ployed in 1920 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No. of 
days of 
sickness 
per 
annum 
per 100 
mem- 
bers1 
No. of 
deaths 
per 100 
mem- 
bers1 
All 
causes 
Per cent, of all causes at specified age 
Typhoid fever 
Tuberculosis 
of lungs 
Cancer 
Apopiexy and 
paralysis 
Heart disease 
Pneumonia 
(all forms) 
Bright's dis- 
ease 
Suicide 
Accident 
Males 
Females 
Males 
Females 
Bartenders 26,085 
633 
771 
0 67 
0 27 
25 to 34 years 
359 
442 
3.3 
37 0 
0 6 
1 9 
6 1 
9.7 
6 1 
3 3 
4 4 
35 to 44 years 
0 9 
29 4 
2 0 
1 4 
8 8 
9.7 
9 5 
2 7 
4 j 
45 to 53 years 
203 
17 7 
4 9 
3 9 
8.4 
21.2 
14 8 
12 3 
3 0 
6 4 
55 to 64 years 
52 
1.9 
5.8 
9.6 
9.6 
13.5 
1 9 
Basket makers 
947 
1002 
1 10 
Blacksmiths 195,255 
0 54 
25 to 34 years 
216 
4.2 
29 6 
1 9 
1.4 
6.5 
7.4 
5 6 
3 7 
10 2 
35 to 44 years 
280 
3.9 
27.1 
3 2 
2.5 
6.4 
10.0 
5 0 
2 5 
13 2 
45 to 54 years 
409 
1.7 
15 9 
9 0 
7.1 
10.8 
8.1 
8 8 
3 2 
8 3 
55 to 64 years 
485 
0.4 
6 0 
10.5 
10.5 
15.3 
8.7 
10.7 
2 3 
4 1 
Bleachers, dyers, laundry 
workers 15,109 
979 
877 
966 
0.79 
0.58 
Boat builders and car- 
penters 62,351 
0 69 
Boatmen and sailors 
1278 
1.46 
25 to 34 years 
242 
6.6 
16.5 
1.7 
0.8 
4.1 
6.2 
4.5 
3 3 
31 8 
35 to 44 years 
242 
3.7 
15.7 
2.5 
4.5 
9.1 
8.3 
4.5 
4.1 
25 2 
45 to 54 years 
309 
0.6 
12.0 
6.5 
4.9 
10.7 
9.4 
9 4 
1.0 
22.7 
55 to 64 years 
288 
0.3 
5.9 
9.4 
9.7 
12.2 
9.4 
11.8 
1.7 
12.1 
Bookkeepers and accoun- 
tants 1,469,376 
511 
560 
0.75 
0.24 
25 to 34 years 
347 
5.5 
42 9 
1.2 
1.4 
2.9 
5.5 
5 5 
5 2 
4 3 
35 to 44 years 
294 
3.4 
31 6 
3 4 
1 4 
11.9 
7.5 
6 5 
5 1 
3 4 
45 to 54 years 
280 
1 4 
12 9 
8 2 
6.4 
13.2 
9 3 
10 7 
4 6 
3 6 
55 to 64 years 
305 
0.3 
5.2 
9.5 
11.1 
17.4 
6.2 
13.4 
2.3 
2.6 
Bookbinders 
904 
1238 
0.69 
0.63 
Boot and shoe makers and 
repairers 225,435. . .. 
642 
932 
0.68 
0.41 
25 to 34 years 
35 to 44 years 
45 to 54 years 
55 to 64 years 
256 
260 
339 
456 
4.7 
1.5 
0.6 
0.7 
35.5 
31.9 
16.8 
6.6 
1.2 
3.1 
4.4 
7.0 
1.2 
3.1 
7.1 
12.5 
7.0 
9.2 
10.0 
14.7 
7.4 
9.6 
13.0 
5.7 
4.3 
5.4 
14.7 
15.1 
3.9 
5.4 
5.3 
2.6 
8.2 
6.5 
3.2 
5.0 
Brass and aluminum 
workers 35,967 
761 
0.50 
Brewers and malsters 
1106 
1.16 
Brick and terra cotta 
workers 48,636.. . 
1118 
0.89 
Bronze factory workers.. 
890 
910 
0.23 
Brush and Broom workers 
.... 
0.95 
12,606 BARTENDERS COOKS 
975 
Mortality and Morbidity Statistics.-Continued 
Occupation and age at 
death 
Number of persons em- 
ploped in 1920 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No of 
days of 
sickness 
per 
annum 
per 100 
mem- 
bers1 
No. of 
deaths 
per 10O 
mem- 
bers1 
All 
causes 
Per cent, of all causes at specified age 
Typhoid fever 
Tuberculosis 
of lungs 
Cancer 
Apoplexy and 
paralysis 
Heart disease 
Pneumonia 
fall forms) 
Bright's dis- 
ease 
Suicide 
Accident 
Males 
Females 
Males 
Females 
Butchers 122,105 
577 
0.36 
25 to 34 years 
208 
3.4 39.4 
1.4 
1.9 
5.3 
10.1 
5.8 
2.9 
8.7 
35 to 44 years 
293 
4.1 
22.9 
4.8 
2.7 
9.6 
8.5 
8 2 
4.4 
8 2 
45 to 54 years 
341 
1.8 
13.8 
6.7 
4.1 
13.2 
5.6 
10.3 
5 3 
6 5 
55 to 64 years 
295 
0.3 
6.8 
12.5 
11.5 
12.2 
7.5 
13.2 
5 4 
3 4 
Cabinet makers, wood 
polishers 45,511 
810 
0 72 
Cabmen 9.057 
899 
1 09 
Card-board and paper-box 
workers 
1574 
1358 
1165 
1 06 
0 49 
Carpenters' helpers 
0.80 
Carpenters 887,370 
877 
0 68 
25 to 34 years 
565 
7.1 
26.0 
2.3 
0.9 
4.8 
5.8 
5.1 
4 1 
24 4 
35 to 44 years 
874 
3.3 
22.5 
4.8 
3.3 
7.7 
8.7 
5.9 
3.8 
15.8 
45 to 54 years 
1256 
2.1 
13.6 
7.1 
6.5 
10 4 
8 9 
8 9 
3 8 
12 0 
55 to 64 years 
1621 
0.7 
8.5 
10.0 
10.0 
16 3 
7.7 
9 3 
3 2 
7 3 
Cement mixers and hod 
carriers 
1439 
0 90 
Chemical ind. 117,602... 
947 
1342 
1158 
0 85 
0.85 
Cigar and tobacco 145,222 
Clerks and salesmen and 
909 
1.44 
0.95 
women 1,125,782. . . . 
404 
733 
0 48 
0.34 
Clerks and copyists 
1,487,905 
25 to 34 years 
1762 
4.8 
44.2 
1.6 
1.5 
5.3 
6.4 
5.2 
4.1 
5.3 
* 
35 to 44 years.... 
1297 
2.1 
31.5 
3.4 
2.7 
7.5 
10.7 
8.2 
3.2 
4.5 
45 to 54 years 
1056 
0.9 
17.0 
6.2 
7.6 
10.4 
8.0 
11.3 
3.6 
4.9 
55 to 64 years 
848 
0.8 
7.2 
8.0 
10.0 
15.4 
7.5 
15.6 
1.7 
3 4 
Clergymen 127,270 
25 to 34 years 
61 
3.3 
41.0 
1.6 
3.3 
6.6 
6 6 
1 6 
3 3 
35 to 44 years 
104 
5.8 
19.2 
5.8 
7.7 
9.6 
7.7 
7.7 
1 0 
3 8 
45 to 54 years 
176 
4.5 
9.1 
7.4 
8.5 
12.5 
7.4 
13 6 
5.1 
55 to 64 years 
255 
1.2 
2.7 
9.4 
10.6 
14.5 
7.1 
17.3 
0 4 
4 3 
Compositors and type- 
setters 140,165 
1155 
0.83 
Concrete and asphalt 
workers 
1320 
0 71 
Confectioners 46,675 
524 
0 08 
Cooks 398,475 
893 
0.34 976 
COMPARATIVE OCCUPATION STATISTICS 
Mortality and Morbidity Statistics-Continued 
Occupation and age at 
death 
Number of persona em- 
ployed in 1920 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No. of 
days of 
sickness 
per 
annum 
per 100 
mem- 
bers1 
No. of 
deaths 
per 100 
mem- 
bers1 
All 
causes 
Per cent, of all causes at specified age 
Typhoid fever 
Tuberculosis 
of lungs 
Cancer 
Apoplexy and 
paralysis 
Heart disease 
Pneumonia 
(all forms) 
Bright's dis- 
ease 
Suicide 
Accident 
Males 
Females 
Males 
Females 
Coopers 19,066 
570 
1122 
1.30 
25 to 34 years 
30 
33.3 
3.3 
16.7 
13.3 
3.3 
6.6 
35 to 44 years 
59 
45.8 
1.7 
6.8 
10.2 
5.1 
5.1 
10.2 
45 to 54 years 
84 
23.8 
7.1 
3.6 
15.8 
10.7 
7.1 
3.6 
8.3 
55 to 64 years 
89 
1.1 
10.1 
14.6 
6.7 
16.9 
9.0 
7.9 
2.2 
3.4 
Decorators and painters 
641,064 
1017 
0,72 
Domestic and personal 
serv., males 258,813 . . . 
25 to 34 years 
7303 
4.5 
32.3 
0.9 
1.2 
5.1 
9.5 
4.6 
3.5 
12.6 
35 to 44 years 
8370 
2.3 
25.5 
2.5 
2.6 
8.3 
11.1 
7.2 
2.6 
0.8 
45 to 54 years 
8398 
1.1 
17.1 
5.6 
5.3 
12.2 
10.7 
10.1 
3.0 
8.5 
55 to 64 years 
6914 
0.6 
10.2 
8.2 
7.9 
14.7 
10.9 
13.4 
2.1 
5.6 
Domestic and personal 
serv., females 1,012,133 
25 to 34 years 
774 
0.48 
3155 
3.2 
33.2 
3.0 
1.5 
6.0 
6.5 
4.7 
2.1 
3.0 
35 to 44 years 
3066 
2.2 
21.3 
9.2 
3.9 
10.4 
6.6 
7.8 
1.1 
2.1 
45 to 54 years 
3232 
1.1 
10.1 
14.1 
8.9 
13.1 
8.2 
10.7 
0.8 
2.7 
55 to 64 years 
Janitors and sextons 
3280 
0.6 
5.0 
13.9 
12.8 
15.2 
8.5 
12.2 
0.8 
2.5 
178,628 
78 
47.4 
2.6 
10.3 
10.3 
1.3 
3.8 
35 to 44 years 
157 
1.9 
21.7 
2.5 
3.2 
8.3 
13.4 
8.3 
5.7 
9.6 
45 to 54 years 
219 
0.9 
14.6 
9.1 
6.8 
13.7 
11.9 
10.0 
5.0 
5.5 
55 to 64 years 
276 
9.4 
9.1 
8.0 
16.7 
12.3 
13.0 
2.9 
5.4 
Draymen, expressmen, 
teamsters, etc. 696,177 
25 to 34 years 
899 
1.09 
1333 
3.9 
35.8 
1.0 
1.2 
5.9 
10.0 
4.2 
2.9 
14.2 
35 to 44 years 
1369 
1.3 
29.3 
2.6 
2.5 
8.4 
10.8 
6.3 
2.2 
15.1 
45 to 54 years 
1086 
1.4 
18.2 
5.6 
4.2 
11.0 
9.7 
9.9 
2.7 
13.4 
55 to 64 years 
736 
0.5 
10.2 
9.9 
10 5 
14,1 
8.7 
12.2 
1.5 
12.0 
933 
0.50 
25 to 34years 
186 
3.2 
40.3 
1.6 
1.1 
5.9 
5.4 
5.4 
2.7 
3.8 
35 to 44 years 
191 
1.6 
19.9 
14.1 
2.6 
9.9 
5.2 
9.4 
3.1 
2.1 
45 to 54 years 
195 
11.8 
24.6 
6.7 
11.8 
8.2 
5.6 
1.0 
3.1 
55 to 64 years 
143 
8.4 
22.4 
11.9 
18.2 
9.8 
10.5 
0.7 
2.1 
Dyers, and bleachers 
15,109 
979 
966 
0.79 
0.58 COOPERS LABORERS (NOT SPECIFIED) 
977 
Mortality and Morbidity Statistics.-Continued 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No. of 
days of 
sickness 
No. of 
Occupation and age at 
Per cent, of all 
causes at specified age 
per 
annum 
inn 
deaths 
per 100 
mem- 
death 
Number of persons em- 
ployed in 1920 
All 
causes 
Typhoid fever 
Tuberculosis 
of liiners 
Cancer 
Apoplexy and 
naralvsis 
Heart disease 
Pneumonia 
(all forms) 
Bright's dis- 
ease 
Suicide 
| 
Accident 
Males 1 h * 
2 CD 
a 3 
Females 1 
Males j 
. CD 
Females " 
Electric apparatus factory 
workers 26,789 
722 
0.60 
0 98 
Engineers (not locomo- 
tive) 522,080 
767 
25 to 34 years 
35 to 44 years 
45 to 54 years 
55 to 64 years 
Errand boys and girls, 
porters 402,380 
471 
605 
694 
683 
8.2 
3.6 
0.9 
1.0 
25.7 
18.7 
10.5 
7.0 
1.5 
5.6 
7.9 
10.8 
0.2 
2.3 
6.1 
11.9 
6.6 
8.3 
12.2 
14.8 
6.2 
9.6 
9.4 
7.0 
3.2 
7.4 
10.4 
11.7 
3.6 
3.1 
4.5 
1.6 
18.9 
17.5 
9.9 
6.9 
621 
1043 
0 77 
0 57 
Excavation laborers and 
house wreckers 
1519 
1.03 
1 13 
File makers 
1117 
Flourmills 26,233 
651 
0 67 
Forgemen and blacksmiths 
1002 
0 54 
Furriers and fur dyers... . 
736 
1193 
0 94 
0 61 
Gas workers 
1084 
0 66 
Glaziers 
804 
910 
0 57 
Hair and brush workers. . 
0.95 
1 15 
Hatters, felt 21,178 
1124 
Hide industry workers.... 
1123 
1978 
1 92 
0 75 
Hod carriers 
1439 
0 90 
Hotel kitchen helpers 
689 
1810 
0 59 
0 40 
House wreckers 
1519 
1.03 
0.77 
0.78 
0.71 
0.83 
0 69 
Illuminators p h o t o e n- 
gravers and photog- 
raphers 
573 
955 
1189 
461 
814 
1147 
1166 
0 41 
Instruments of precision 
makers 
0.51 
2.30 
Iron founders and machin- 
ists 237,712 
Jewelry industry, gold and' 
silver 82,876 
Iron and steel 729,613... 
1256 
25 to 34 years 
35 to 44 years 
45 to 54 years 
55 to 64 years | 
Laborers (not specified).. . 
623,203 
25 to 34 years i 
35 to 44 years 
45 to 54 years 
55 to 64 years 
524 
617 
556 
394 
5,180 
5,606 
5,635 
4,797 
5.0 
3.6 
1.3 
1.0 
5.1 
2.5 
1.1 
0.7 
25.2 
22.0 
15.3 
7.9 
30.8 
25.9 
18.2 
10.7 
2.3 
2.3 
4.0 
10.2 
1.0 
2.4 
5.5 
8.2 
1.1 
2.8 
6.8 
8.6 
1.2 
2.7 
4.8 
7.4 
3.6 
7.9 
10.3 
14.7 
5.0| 
8.0 
12.5 
14.11 
10.9 
12.2 
11.3 
11.2 
10.2 
12.1 
11.9 
12.2 
3.4 
5.5 
7.9 
8.4 
4.5 
6.4 
9.1 
13.5 
3.6 
2.8 
2.9 
1.5 
2.9 
1.7 
2.5 
1.8 
28.1 
20.9 
14.0 
7.1 
13.9 
12.6 
9.3 
5.7 978 
COMPARATIVE OCCUPATION STATISTICS 
Mortality and Morbidity Statistics.-Continued 
Occupation and age at 
death 
Number of persons em- 
ployed in 1920 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No. of 
days of 
sickness 
per 
annum 
per 100 
mem- 
bers1 
No. of 
deaths 
per 100 
mem- 
bers1 
All 
causes 
Per cent, of all causes at specified age 
Typhoid fever 
Tuberculosis 
of lungs 
Cancer 
Apoplexy and 
paralysis 
Heart disease 
Pneumonia 
(all forms) 
Bright's dis- 
ease 
Suicide 
Accident 
Males 
Females 
Males 
Females 
Lace workers 19,083 
620 
691 
910 
847 
966 
0 35 
0 54 
Ladies' tailors and mill- 
liners 137,770 
0.82 
0 55 
Laundry oper. 120,715 
Laundresses 396,756 
0.58 
25 to 34 years 
212 
3.3 
33.0 
3.8 
1.4 
7.5 
4.2 
3.8 
1 9 
4 j 
35 to 44 years 
216 
3.2 
18.5 
7.9 
3.2 
12.0 
8.8 
9.3 
1 9 
2.8 
45 to 54 years 
243 
1.6 
11.5 
8.6 
8.2 
15.2 
11.5 
9.1 
0 4 
1 6 
55 to 64 years 
165 
2.4 
10.3 
12.7 
13.9 
10.3 
13.9 
3 0 
Lawyers 122,519 
25 to 34 years 
105 
8.6 
25.7 
1.9 
1.9 
7.6 
1.9 
7 6 
9.5 
35 to 44 years 
141 
2.1 
19.9 
2.1 
4.3 
7.1 
L7.7 
14.9 
4 3 
3 5 
45 to 54 years 
236 
0.4 
8.9 
6.8 
13.1 
9.7 
8.9 
9.3 
4 2 
5 5 
55 to 64 years 
303 
0.3 
5.0 
8.6 
12.5 
16.5 
6.6 
12.5 
1 7 
2 6 
Leather, artificial and oil- 
cloth workers 
878 
892 
1.38 
0.59 
0 59 
Locksmiths 
Lithographers 8,222 
650 
1189 
Machinists 801,901 
1666 
0 71 
2.30 
25 to 34 years 
574 
5.4 
35.0 
1.2 
1.7 
4.5 
5.9 
4.0 
5 1 
15.5 
35 to 44 years 
567 
3.5 
23.8 
3.7 
1.9 
7.8 
9.2 
4 4 
4 4 
11 6 
45 to 54 years 
567 
0.7 
13.1 
8.1 
4.2 
13.9 
0.6 
11.3 
4 4 
8 6 
55 to 64 years 
556 
1.1 
7.2 
7.7 
12.8 
16.2 
8.8 
12.9 
2 3 
5 6 
Manufacturers and offi- 
cials 231,615 
25 to 34 years 
164 
5.5 
28.0 
1.8 
3.0 
3.0 
6.7 
3.0 
3 0 
18 3 
35 to 44 years 
327 
4.3 
14.1 
6.4 
4.3 
8.3 
8.3 
8.3 
1 8 
14 4 
45 to 54 years 
526 
2.7 
7.2 
7.4 
7.4 
9.5 
6.3 
12.2 
5.7 
9 9 
55 to 64 years 
708 
1.1 
3.2 
5.6 
11.2 
15.7 
6.6 
11.7 
1 1 
5 9 
Manufacturing and me- 
chanical pursuits, 
males 10,888,183 
25 to 34 years 
35 to 44 years 
8,481 
10,405 
11,597 
11,408 
4.7 
2.5 
30.8 
25.0 
1.5 
3.6 
1.1 
2.6 
4.8 
7.2 
7.0 
9.1 
3.8 
6.5 
4.0 
3 6 
21.9 
16 7 
45 to 54 years 
1.4 
15.6 
6.6 
5.7 
10.7 
9.0 
9.6 
3 8 
11 0 
55 to 64 years 
0.6 
8.2 
9.3 
10.1 
15.0 
8.0 
11.5 
2.6 
3 3 
6 3 
Manufacturing and me- 
chanical pursuits, 
females 1,930,341 
25 to 34 years......... 
885 
2.4 
40.8 
2.9 
1.2 
7.6 
5 1 
5 0 
2 8 LACE WORKERS-OIL-CLOTH, ETC., MAKERS 
979 
Mortality and Morbidity Statistics.-Continued 
Occupation and age at 
death 
Number of persons em- 
ployed in 1920 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No. of 
days of 
sickness 
per 
annum 
per 100 
mem- 
bers1 
No. of 
deaths 
per 100 
mem- 
bers1 
All 
causes 
Per cent, of all causes at specified age 
Typhoid fever 
Tuberculosis 
of lungs 
Cancer 
Apoplexy and 
paralysis 
Heart disease 
Pneumonia 
(all forms) 
Bright's dis- 
ease 
opiomg 
Accident 
Males 
Females 
Males 
Females 
35 to 44 years 
730 
600 
462 
822 
75 
156 
177 
218 
1.1 
0.3 
0.4 
26.3 
12.3 
9.3 
11.4 
20.3 
18.8 
3.2 
7.0 
11.3 
12.3 
12.3 
16.5 
5.5 
7.7 
10.4 
7.8 
8.0 
8.7 
1.6 
0.7 
0.4 
2.6 
3.2 
3.0 
1294 
777 
1215 
1456 
847 
1.27 
0.70 
1.02 
0.88 
0.69 
1.38 
0.81 
0.55 
45 to 54 years 
55 to 64 years 
Marble and stone cutters 
5,084 
25 to 34 years 
2.7 
2.6 
0.6 
0.5 
46.7 
41.0 
42.9 
19.3 
3.8 
5.1 
7.8 
1.3 
1.9 
4.0 
6.9 
6.7 
3.2 
8.5 
13.8 
12.2 
6.8 
6.9 
6.7 
5.3 
5.1 
8.5 
9.6 
0.6 
0.9 
10.7 
10.3 
5.6 
3.2 
35 to 44 years 
45 to 54 years 
55 to 64 years 
Masons (brick and stone) 
131,264 
25 to 34 years 
188 
346 
419 
512 
837 
1,369 
1,901 
2,091 
4.8 
0.6 
1.4 
0.2 
6.1 
3.0 
1.4 
0.9 
33.0 
29.8 
19.6 
7.4 
30.3 
18.7 
10.2 
5.2 
1.1 
3.2 
6.7 
11.3 
2.2 
4.4 
8.1 
10.2 
1.6 
1.7 
4.5 
9.4 
2.2 
4.3 
6.9 
11.8 
3.7 
9.0 
11.9 
14.5 
6.5 
9.4 
12.3 
14.8 
10.1 
10.7 
8.6 
7.8 
8.1 
7.8 
6.3 
6.6 
3.2 
5.8 
7.9 
12.3 
5.1 
9.8 
12.1 
13.3 
2.7 
4.3 
4.5 
3.3 
3.2 
4.1 
3.8 
1.8 
17.0 
15.6 
11.7 
8.0 
6.4 
5.8 
4.5 
2.2 
35 to 44 years 
45 to 54 years 
55 to 64 years 
Merchants and dealers 
(except wholesale) 
1,328,275 
25 to 34 years 
35 to 44 years 
45 to 54 years 
55 to 64 years 
Metal polishers and 
grinders 119,570 
Milliners 73,255 
Miners and quarrymen 
194,009 
25 to 34 years 
1496 
778 
878 
1,132 
1,135 
993 
725 
151 
182 
319 
407 
3.7 
2.4 
1.4 
0.3 
8.4 
10.5 
11.3 
10.8 
11.9 
12.1 
6.6 
3.4 
1.1 
2.0 
4.6 
7.6 
1.5 
2.7 
3.4 
6.9 
1.9 
4.3 
6.9 
0.7 
1.6 
4.1 
7.6 
2.1 
3.1 
8.0 
15.6 
4.4 
6.6 
8.8 
10.8 
5.5 
9.4 
10.7 
11.4 
7.4 
10.4 
14.7 
11.3 
1.5 
3.1 
4.1 
6.2 
1.5 
6.6 
7.8 
11.5 
2.0 
1.9 
1.6 
1.2 
2.2 
2.2 
2.2 
0.7 
61.3 
47.0 
27.3 
13.9 
43.7 
30.2 
15.7 
9.3 
35 to 44 years 
45 to 54 years 
55 to 64 years 
Miners, coal* 733,936 
25 to 34 years 
35 to 44 years 
45 to 54 years 
55 to 64 years 
Oils, essential and volatile 
workers 
Oil-cloth and artificial 
leather makers 
'Compiled from mortality statistics of the Metropolitan Life Insurance Company, New York, 
published September,1915. 980 
COMPARATIVE OCCUPATION STATISTICS 
Mortality and Morbidity Statistics.-Continued 
Occupation and age at 
death 
Number of persons em- 
ployee!, in 1920 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No of 
days of 
sickness 
per 
annum 
per 100 
mem- 
bers1 
No. of 
deaths 
per 100 
mem- 
bers1 
All 
causes 
Per cent, of all causes at specified age 
Typhoid fever 
Tuberculosis 
of lungs 
Cancer 
Apoplexy and 
paralysis 
Heart disease 
Pneumonia 
(all forms) 
Bright's dis- 
ease 
Suicide 
Accident 
Males 
Females 
Males 
Females 
Opticians, clock and watch 
makers 
674 
1017 
1017 
0.66 
0 72 
Painters and decorators... 
Painters, glaziers, and 
varnishers 323,032. . . 
0.72 
25 to 34 years 
471 
3.2 
37.2 
1.7 
0.4 
4.5 
6.8 
5 £ 
4.C 
2.4 
3 3 
16.8 
13.0 
11.0 
5.9 
35 to 44 years 
756 
0.8 
28.4 
3.4 
4.1 
7.3 
8.7 
11 2 
45 to 54 years 
842 
0.7 
17.3 
5.1 
6.9 
9.7 
7.8 
13 4 
55 to 64 years 
733 
0.4 
9.8 
7.5 
11.1 
13.5 
7 6 
16.2 
9 5 
Paper-box factory workers 
20,452 
1574 
827 
1317 
1 06 
Paper-g oods factory 
workers 
1202 
0 96 
0 57 
Pavers and asphalters.... 
0.88 
Physicians and surgeons 
144,977 
25 to 34 years 
99 
4.0 
21.2 
2.0 
4.0 
6.1 
12 1 
4 0 
7.1 
9 7 
11.1 
6.5 
5.6 
3.7 
35 to 44 years 
184 
3.8 
15.8 
2.2 
3.3 
5.4 
12.0 
6 0 
45 to 54 years 
251 
2.0 
9.2 
5.2 
7.2 
7.6 
8 0 
16 7 
3 6 
55 to 64 years 
301 
0.7 
4.0 
11.3 
10.0 
15.0 
4 3 
10 6 
9 7 
Piano and organ makers 
15,173 
845 
815 
738 
718 
836 
1055 
1214 
0.88 
0.81 
0.46 
0 52 
0.55 
0 15 
Picture-f r a m e factory 
workers 
Plasterers 38,255 
Plate printers 
Plumbers, and gas and 
steam fitters 206,718 
0 61 
25 to 34 years 
2711 
4.8 
43.2 
1.5 
2.6 
5.5 
7.4 
4 8 
5 
11 4 
35 to 44 years 
3231 
2.5 
35.9 
2.8 
1.5 
6.8 
11.1 
6 8 
1 
10 5 
45 to 54 years 
213 
1.9 
14.6 
5.2 
8.0 
12.2 
12.7 
6 6 
2 a 
11 3 
55 to 64 years 
18.3 
6.9 
10.7 
17.6 
9 2 
6.9 
3 8 
3.8 
6 4 
Porters and helpers (in 
stores, etc.) 125,007 
25 to 34 years 
131| 
264 
1.5 
38.3 
0.4 
0.8 
6.1 
10.2 
1 K 
35 to 44 years 
323 
1.2 
31.6 
1.9 
3.4 
11.5 
11.5 
6 8 
2 
5 6 
45 to 54 years 
264! 
1.5 
21.6 
4.5 
1.9 
16.3 
15 2 
6.7 
4 8 
q 
4 5 
55 to 64 years 
155 
0.6 
10.3 
6.5 
7.7 
14.8 
9.71 
3 
1 0 
Potters and pottery 
workers 27,934 
957 
),77 OPTICIANS, ETC.-SHOEMAKERS AND COBBLERS 
981 
Mortality and Morbidity Statistics.-Continued 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No. of 
days of 
sickness 
No. of 
Per cent, of all causes at specified age 
per 
annum 
deaths 
per 100 
Occupation and age at 
mem- 
death 
ft -0 C 
mem- 
bers1 
Number of persons em- 
Si ® fl " ' 
All > is 03 ® 
bers1 
ployed in 1920 
o 
c > 
co fl 
o 
CD 
d fe 
ulos 
gs _ 
xy 
rsis 
Use 
onis 
it ms 
s d 
at 
CO 
tn 
o £ C ft .24? o 
ft s g a <« ■£ 5 -a ® IS ns 
0 
0Q 
02 
Typ 
Tub 
of ' 
Can 
Apo 
par 
Hea 
Pne 
(al 
Brig 
eas 
Suic 
Acci 
Mal 
Fem 
Mal 
Fem 
Printers, lithographers, 
I 
and pressmen 259,903 
851 1130 
0.58 0.54 
25 to 34 years 
291 2.7 51.5 0.7 2.7 4.1 5.5 3.4 4.1 4.1 
35 to 44 years 
328 2.432.6 5.5 3.7 8.2 7.6 7.3 5.2 7.3 
45 to 54 years 
265 1.9 22.3 7.2 5.7 9.4 8.310.2 1.5 4.5 
55 to 64 years 
168 0.6 6.5 9.5 11.3 14.9 9.514.3 5.4 4.2 
Professional service, 
males 1,127,391 
25 to 34 years 
1192 5.7 33.6 1.4 1.3 4.9 5.7 3.3 4.614.4 
35 to 44 years 
1329 2.9 20.4 3.2 4.5| 7.2 9.9 7.8 4.7 7.7 
45 to 54 years 
1567 1.9 9.9 6.3 8.1 10.8 7.812.3 3.6 6.2 
55 to 64 years 
1712 0.7 4.4 9.5 10.8 15.7 6.913.0 1.8 3.9 
Professional service, 
females 1,016,498 
25 to 34 years 
385 5.5 37.1 4.7 1.3 6.8 4.7 2.9 1.3 3.6 
35 to 44 years 
293 2.0 16.0 15.7 6.1 8.5 9.2 6.8.... 3.4 
45 to 54 years 
268 0.7 7.5 20.9 7.5 9.7 5.2 9.0 1.9 3.7 
55 to 64 years 
196 0.5 7.7 15.8 10.2 11.7 8.710.7 0.5 2.0 
Quarrymen and stone- 
breakers 45,102 
1496 .... 
0 88 
Rubber goods workers.... 
1028 1494 
0.90 0 83 
Refiners in sugar factories 
1443 
0 54 
Railway enginemen and 
trainmen * 
947 
283,491 
25 to 34 years 
3.3 14.7 0.7 0.3 1.3 4.7 2.0 2.356.0 
35 to 44 years 
3.5 24.9 1.7 1.2l 5.2 6.9 7.5 2.928.3 
45 to 54 years 
13.8 0.9 6.4 10.1 9.2 9.2 2.818.3 
55 to 64 years 
7.4 5.3 13.8 13.8 6.410.6 2.116.0 
Railroad employes, street 
870 
3 76 
95,514 
Saddlers, leather workers 
684 . . . 
1.49 
20,020 
Sailors 
1278 .... 
46 
Saw mill workers 245,683 
1179 
73 
Shoemakers and cobb- 
lers 78,859 
1 
642 .... ( 
1.68 
•Compiled from mortality statistics of the Metropolitan Life Insurance Company, New York 
September, 1915. 982 
COMPARATIVE OCCUPATION STATISTICS 
Mortality and Morbidity Statistics.-Contimted 
Occupation and age at 
death 
Numbers of persons em- 
ployed in 1920 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No. of 
days of 
sickness 
per 
annum 
per 100 
mem- 
bers1 
No. of 
deaths 
per 100 
mem- 
bers1 
All 
causes 
Per cent, of all causes at specified age 
Typhoid fever 
Tuberculosis 
of lungs 
Cancer 
Apoplexy and 
paralysis 
Heart disease 
Pneumonia 
(all forms) 
Bright's dis- 
ease 
Suicide 
Accident 
Males 
Females 
Males 
Females 
Steam-railroad employes 
678,895 
25 to 34 years 
1382 
2.7 
10.5 
0.7 
0.9 
1.7 
2.6 
1.5 
1.2 
67 9 
35 to 44 years 
1133 
1.9 
9.2 
1.9 
1.2 
3.9 
4.4 
2.7 
2.5 
56 3 
45 to 54 years 
941 
1.2 
6.6 
5.3 
3.5 
5.8 
5.1 
6 3 
1.3 
47 7 
55 to 64 years 
724 
3.2 
8.1 
7.9 
12.2 
5.7 
9.1 
1.0 
30.2 
Servants and waiters, male 
370,877 
25 to 34 years 
633 
771 
0.67 
0.27 
693 
2.9 
40.4 
0 6 
1 3 
6 3 
7 4 
4 2 
5 5 
7 8 
35 to 44 years 
701 
1.7 
29.7 
2.3 
1.4 
11.0 
7.8 
8.4 
3 9 
6 7 
45 to 54 years 
644 
0.8 
20.2 
4.5 
6.7 
14 6 
7.5 
12.7 
2 6 
6 8 
55 to 64 years 
407 
0.2 
17.0 
9.6 
8.1 
11 8 
9 6 
12.3 
2.5 
2 9 
Servants and waiters, 
females 1,129,054 
25 to 34 years 
2704 
2.9 
33.9 
3.0 
1.5 
5.9 
6.6 
4.7 
2.0 
2 8 
35 to 44 years 
2578 
1.8 
22.0 
9.3 
3.9 
10.1 
6.2 
7.7 
0.8 
1 9 
45 to 54 years 
2671 
1.0 
10.2 
14.4 
9.1 
12 9 
7.9 
11.3 
0.7 
2 6 
55 to 64 years 
2760 
0.5 
5.5 
13.6 
13.0 
15.7 
8.4 
12.2 
0.6 
2 3 
Storage battery workers.. 
722 
1276 
0.60 
0.55 
Tailors 192,232 
715 
884 
0.88 
0.56 
25 to 34 years 
326 
2.1 
37.7 
2.1 
1.5 
6.1 
7.4 
6.4 
6.1 
7 4 
35 to 44 years 
415 
2.7 
33.7 
4.3 
1.7 
8.0 
5.8 
10.1 
6.3 
3.4 
45 to 54 years 
456 
0.9 
16.7 
8.1 
6.1 
9.9 
8.1 
10.1 
4.6 
4.8 
55 to 64 years 
361 
6.9 
13.6 
8.3 
13.6 
9.4 
12.2 
4.7 
3.6 
Tallow and soap factory 
workers 10,998 
1035 
1.14 
Tanners 32,226 
1049 
0.46 
Teachers and professors 
females 645,282 
25 to 34 years 
269 
6.3 
38.7 
4.8 
1.5 
5.2 
5.2 
2.6 
0.7 
3.3 
35 to 44 years 
194 
3.1 
19.1 
13.9 
4.1 
9.3 
11.9 
7.2 
1.5 
f 
45 to 54 years 
167 
1.2 
7.8 
22.2 
7.8 
8.4 
7.2 
9.0 
1.2 
3.6 
55 to 64 years 
130 
0.8 
7.7 
16.2 
6.9 
10.0 
11.5 
10.0 
2.3 
Terra cotta and. brick 
workers 48,636 
1118 
0.89 
Textile mills* 872,389.. .. 
25 to 34 years 
2390 
876 
1229 
0.83 
0.58 
5.3 
47.5 
0.4 
0.4 
5.7 
4.3 
2.5 
1.4 
5.7 
35 to 44 years 
1.3 
37.7 
1.3 
1.0 
5.5 
9.0 
7.1 
1.0 
6.8 
45 to 54 years 
1.5 
18.0 
4.8 
5.8 
10.3 
6.3 
12.5 
3.5 
4.5 
55 to 64 years 
0.8 
8.9 
7.1 
9.9 
17.0 
5.7 
12.1 
1.4 
3.4 
'Compiled from mortality statistics of the Metropolitan Life Insurance Company, New York, 
published September, 1915. STEAM RAILWAY EMPLOYES WICKERWARE AND BASKET WORKERS 
983 
Mortality and Morbidity Statistics.-Continued 
Occupation and age at 
death 
Number of persons em- 
ployed in 1920 
Deaths of persons at least 10 years of age engagedin 
certain specified occupations 
No of 
days of 
sickness 
per 
annum 
per 100 
mem- 
bers1 
No. of 
deaths 
per 100 
mem- 
bers1 
All 
causes 
Per cent, of all causes at specified age 
Typhoid fever 
Tuberculosis 
of lungs 
Cancer 
Apoplexy and 
paralysis 
Heart disease 
Pneumonia 
(all forms) 
Bright's dis- 
ease 
Suicide 
Accident 
Males 
Females 
Males 
Females 
Tin plate and tinware 
makers 89,091 
681 
824 
0.79 
25 to 34 years 
92 
7.6 
37.0 
1.1 
'1.7 
8.7 
5.4 
4.3 
5.4 
15.2 
35 to 44 years 
120 
32.5 
3.3 
6.7 
8.3 
5.8 
1.7 
13.3 
45 to 54 years 
134 
0.7 
17.9 
7.5 
6.7 
13.4 
9.0 
9.0 
3.7 
9.7 
55 to 64 years 
136 
7.4 
9.6 
5.9 
15.4 
7.4 
13.2 
2.9 
6.6 
Tobacco and cigar factory 
workers 180,479 
982 
909 
1158 
1.44 
0.95 
25 to 34 years 
136 
5.1 
49.3 
0.7 
2.9 
6.6 
4.4 
5.1 
5.1 
35 to 44 years 
181 
.... 
33.7 
1.1 
4.4 
12.2 
6.1 
3.3 
4.4 
7.7 
45 to 54 years 
233 
23.2 
9.4 
3.0 
11.2 
6.9 
9.0 
5.2 
5.6 
55 to 64 years 
187 
0.5 
8.0 
12.3 
7.0 
11.8 
4.8 
19.3 
4.3 
2.7 
Typefounders, 
stereotypers 
1064 
1108 
(?) 
0.89 
Typesetters and composi- 
1155 
0.83 
(t? 
tors < 
.... 
Trade and transportation, 
males 6,425,715 
25 to 34 years 
7948 
4.4 
31.9 
1.4 
1.2 
4.7 
6.5 
4.2 
3.3 
20.5 
35 to 44 years 
8219 
2.4 
22.8 
3.3 
2.8 
8.0 
8.7 
6.8 
3.9 
15.8 
45 to 54 years 
8333 
1.3 
12.3 
7.1 
6.2 
10.8 
7.8 
10.9 
3.4 
12.3 
55 to 64 years 
7495 
0.6 
5.8 
9.6 
10.5 
15.0 
7.3 
13.2 
2.0 
7.5 
Trade and transportation, 
females 880,846 
25 to 34 years 
667 
4.3 
39.9 
3.0 
0.9 
6.4 
3.6 
5.2 
3.1 
3.0 
35 to 44 years........ 
348 
1.4 
16.1 
11.5 
4.0 
10.1 
4.9 
8.0 
1.7 
5.2 
45 to 54 years. . 
207 
1.4 
7.7 
18.8 
6.8 
8.7 
9.2 
9.2 
0.5 
2.4 
55 to 64 years 
121 
0.8 
2.5 
14.9 
9.1 
19.0 
17.4 
8.3 
1.7 
1.6 
Upholsterers 29,605 
720 
0.69 
Veneer factory workers... 
.... 
1154 
0.88 
Watchmen, policemen, 
firemen 248,444 
25 to 34 years 
190 
2.1 
24.2 
1.6 
2.1 
4.2 
6.8 
5.8 
4.7 
21.1 
35 to 44 years 
315 
2.5 
17.8 
1.9 
2.5 
9.2 
8.3 
6.8 
6.7 
6.0 
14.6 
45 to 54 years 
527 
2.1 
9.5 
8.2 
6.8 
15.6 
11.4 
4.7 
11.2 
55 to 64 years. 
657 
0.3 
4.9 
7.5 
9.9 
18.2 
7.8 
12.3 
3.5 
8.4 
Waiters 228,985 
633 
771 
0.67 
0.27 
Weaving mill operatives. . 
557 
0.75 
Wicker ware and basket 
947 
workers 
1.10 
- 984 
COMPARATIVE OCCUPATION STATISTICS 
Mortality and Morbidity Statistics.-Continued 
Occupation and age at 
death 
Numbers of persons em- 
ployed in 1920 
Deaths of persons at least 10 years of age engaged in 
certain specified occupations 
No. of 
days of 
sickness 
per 
annum 
per 100 
mem- 
bers1 
No. of 
deaths 
per 100 
mem- 
bers1 
All 
causes 
Per cent, of all causes at specified age 
Typhoid fever 
Tuberculosis 
of lungs 
Cancer 
Apoplexy and 
paralysis 
Heart disease 
Pneumonia 
(all forms) 
Bright's dis- 
ease 
Suicide 
Accident 
Males 
Females 
Males 
Females 
Woodworkers 951,956 
25 to 34 years 
197 
201 
264 
248 
2.0 
2.5 
1.1 
0.4 
40.6 
25.4 
18.6 
11.3 
1.0 
3.5 
7.2 
9.7 
1.0 
3.0 
4.2 
10.9 
3.6 
10.0 
10.2 
16.5 
7.6 
7.0 
8.7 
4.4 
2.5 
8.5 
10.6 
10.9 
6.6 
7.0 
3.4 
3.6 
18.3 
17.4 
12.9 
6.0 
863 
0.48 
35 to 44 years 
45 to 54 years 
55 to 64 years 
Yeast factory workers.... 
Other miscellaneous in- 
dustries 622,662 
25 to 34 years 
35 to 44 years : 
45 to 54 years 
55 to 64 years 
571 
566 
604 
523 
5.4 
2.5 
1.7 
0.2 
30.6 
23.3 
13.6 
7.8 
1.2 
3.0 
6.3 
9.6 
1.6 
3.0 
6.8 
10.5 
5.8 
6.2 
8.9 
16.8 
7.7 
10.6 
10.4 
6.9 
2.3 
7.2 
9.9 
8.8 
4.2 
3.2 
4.0 
2.5 
21.9 
16.1 
12.7 
6.1 
THE SIGNIFICANCE OF THE PREVENTABLE CAUSES OF DEATH.* 
BY EMERY R. HAYHURST. M. D„ Columbus, Ohio 
A glance at the following table suffices to show that the vast majority 
of preventable deaths occur before middle life: 
Per Cent, of Preventable Causes of Death Which Occur under 45 Years 
of Age 
Males, 
Females, 
Causes 
Per Cent. 
Per Cent. 
Typhoid fever 
80.0 
90.1 
Tuberculosis 
69.7 
87.0 
Accidents 
63.8 
57.8 
Accidental poisonings 
56.7 
74.8 
Suicides 
51.6 
81.4 
Occupational poisonings 
43.2 
50.0 
Pneumonia 
37.3 
47.7 
Cancer 
13.9 
29.4 
Remarks.-Omitting cancer, which occurs seven-eighths of the time after 45 
years of age, we find that the other causes listed produce approximately 60 per cent, 
of the preventable deaths before 45 years of age in the case of males, and 75 per cent, 
in the case of females. 
HOW THOSE ENGAGED IN UNDERLING OCCUPATIONS SUFFER FROM 
THE PREVENTABLE CAUSES OF DEATH 
(a) Males: Occupied persons may be divided into two classes, 
the "Proprietor and Professional Class," and the " Underling Class." 
* Compiled from Occupational Mortality Statistics, U. S. Census, 1909, and reprinted 
with some curtailment from Monthly Bulletins, Ohio Statej Board of Health, July and 
August, 1913. WOODWORKERS-PREVENTABLE CAUSES OF DEATH 
985 
The "Proprietor and Professional Class" (males) comprises thirty-one 
of the occupations and callings mentioned in the census report. They 
are 59,926 in number and are composed of: 
Farmers, planters and overseers 34,662 
Retail dealers 9,329 
Fifteen professional callings 9,214 
The balance of 6721 persons were employed in the following call- 
ings: Bankers and brokers, boarding and lodging house keepers, dairy- 
men, foremen and overseers (manufacturing), gardeners, florists and 
nurserymen, hotel keepers, livery stable keepers, wholesale dealers, 
officials of banks and companies, restaurant keepers, saloon keepers, 
stock raisers, and undertakers. 
Those engaged in 109 "Underling" occupations, a total of 147,674 
persons (male) make up the balance of the occupations listed in the 
original table. The preventable causes of death, as they occur 
among these two classes, are shown in the following table: 
Cause of Death 
Per cent. P. & P. 
Class 
Per cent. Underling 
Class 
Tuberculosis 
8.22 
17.53 
Accidents and injuries 
5.20 
11.85 
Pneumonia 
6.89 
8.48 
Suicide 
2.13 
2.76 
Typhoid fever 
1.88 
2.35 
Accidental poisoning 
0.43 
0.78 
All preventable causes 
24.75 
43.75 
Cancer, which is to be considered more or less a preventable cause 
of death, claims 6.99 per cent, of the deaths in the Proprietor and Profes- 
sional Class, as against 4.83 per cent, of all causes of death in the Under- 
ling Class. This is because more of the former live in the cancer ages. 
(b) Females: In the case of females, we have made no division 
between the overling and underling classes, but the pre-eminence of 
the preventable causes of death in the whole group speaks for itself. 
The deaths among occupied females are grouped by pursuits as 
follows: 
Agricultural pursuits 879 
Professional 1,725 
Domestic 17,735 
Trade and transportation 2,538 
Manufacturing 4,582 
Total 27,459 
The recognized preventable causes of death among these were as 
follows: 986 
COMPARATIVE OCCUPATION STATISTICS 
Per Cent. 
Pulmonary tuberculosis 21.0 
(Cancer) 8.1 
Pneumonia 7.0 
Accidents, etc 3.2 
Typhoid 2.8 
Suicide 1.6 
Total 43.7 
These are conservative estimates, since many other causes of death 
than those particularly specified were preventable in many individual 
cases. Probably a fair estimate would be that 50 per cent, of all deaths 
among occupied persons are due to preventable causes. This would 
mean that over 120,000 workers in 140 occupations were needlessly 
sacrificed in the year 1909, in the Registration Area alone, which in- 
cludes 56.1 per cent, of the total population of the country. Hence 
something over 225,000 persons, or approximately a quarter of a 
million, would be more nearly the correct figure. 
THOSE WHO SUCCUMBED TO THE MORE NATURAL CAUSES OF DEATH 
Accepting the calling of "farmers, planters, and farm overseers" 
as the one which is freest of all untoward occupational influences it 
is of value to note that the four chief causes of death among 34,662 
such persons are found to be: Heart disease (16.1 per cent.), apoplexy 
(11.3 per cent.), Bright's disease (8.2 per cent.) and cancer (7.2 per cent.). 
These same causes of death occur in in the following callings, in almost 
the same order, although in some instances, circulatory causes juggle with 
cancer for fourth place: Clergymen, lawyers, physicians and surgeons, 
bankers and brokers, wholesale dealers, manufacturers and officials in 
general. 
Even allowing for some difference in age periods, it is due to the 
great preponderance of the preventable causes of death-tuberculosis, 
pneumonia, accidents, etc., that these four chief senile causes of death 
mentioned in the preceding paragraph do not obtain in the list of 
Underling Occupations. 
SUMMARY 
1. Few occupational diseases kill in themselves. They are simply 
under-miners. Consumption is the principal terminal occupational 
disease. Consumption is the leading cause of death in 110 of the 140 
groups of occupations given in the U. S. Mortality Statistics in which 
24 principal causes of death (other than by injuries) are listed. 
2. In callings where accidents proved the chief cause of death, 
tuberculosis invariably ran second, or was the chief cause of death due 
to disease. PREVENTABLE CAUSES OF DEATH 
987 
3. While the general death rate among occupied females from cancer 
was 8.1 per cent., among 915 nurses and midwives it was 12.2 per cent. 
4. Considering the preventable causes of death to be only tuber- 
culosis, accidents, accidental poisonings, typhoid fever, pneumonia, 
occupational poisoning and suicides, we find that in the case of males, 
over 60 per cent, died before 45 years of age, and in the case of females, 
over 75 per cent, died before 45 years of age. 
5. The preventable causes of death operate almost twice as fre- 
quently among those in the Underling occupations, as among those in the 
Proprietory and Professional classes. (The ratio being about 43 to 24 in 
the case of males.) 
6. Conservatively put, over 50 per cent, of all deaths among occupied 
persons are preventable. This amounts to about a quarter of a million 
lives a year in the United States.* 
7. Among those classes of occupied persons who usually reach 
old age the chief causes of death prove to be heart disease, Bright's 
disease, apoplexy, circulatory diseases and cancer. 
8. The knowledge of the close association between unfavorable 
environment and disease is not possessed by the people in general to a. 
sufficient degree. Legislation will accomplish much in the removal 
of health-hazards, but education will accomplish infinitely more. 
ADDENDUM NOTE 
A reclassification of the U. S. Census, 1920, by industry, and for facilitating the 
estimating of hazard rates is given by Carl Hookstadt, in the July, 1923, issue (Vol. 
XVII, No. 1) of the Monthly Labor Review. A distinction is made between the 
number of (1) employes, (2) officials and managers, and (3) employers, independent 
workers, etc. There were 28,968,350 in the first group; 908,194 in the second group; 
and 11,737,704 in the third group, making a total of 41,614,248. Sub-classifications 
are then made for the 9 large industrial groups of the Census, and a comparison 
made with the "census of manufactures of 1919." 
* This figure is but a little short of the total quota of immigrants permitted to enter the United 
States under the Immigration Act for the present year (1923) and emphasizes the "man-power'' 
economical aspects of industrial hygiene and accident prevention during periods of labor shortage. CHAPTER II 
THE USE AND THE FALLACIES OF STATISTICS 
GEORGE C. WHIPPLE, S. B„ Cambridge, Mass. 
The Use and the Fallacies of Statistics.-Statistics are facts expressed 
in numbers, collected and arranged for study. When there are few facts 
to be considered statistics are not necessary; the mind does not need this 
aid. Suppose one asks the wages of the five men who work for Smith. 
The reply is easily given and understood if the facts are known: Tom 
gets $15 a week, George and Henry receive $12 each, and Bill and Mike 
get $10 each. But suppose one asks the wages of the laborers in a large 
factory where several thousand men are employed. We might go through 
the list in the same way-in fact the paymaster is obliged to do so-but 
for purposes of study we must generalize and say that so many men get 
$15 a week each, so many more get $12 each, and so on, expressing the 
results in figures. This is the statistical method-to enumerate, to 
classify and to compare. 
As the number of different facts to be considered in any problem 
increases, the need of studying them by the numerical method becomes 
constantly greater and we are obliged to resort to arithmetical processes 
of various kinds. Sometimes we are compelled to use quite complicated 
mathematical methods, but the mathematics required in most statistical 
work are very simple. 
The great danger in all this work is that in our consideration of the 
numbers we may lose sight of the facts for which they stand, in the same 
way that the countryman could not see the city because there were so 
many houses. Failure to visualize is the besetting sin of those who deal 
with facts in this abstract way. But if it is hard for the statistician it is 
even harder for persons who are not familiar with statistical methods to 
visualize when the facts enumerated are scattered in time or place. If a 
factory burns and a dozen girls are killed it is regarded as a tragedy, 
people shudder and demand safeguards that will make a repetition of the 
accident impossible; but if the same number of girls had been killed one 
at a time in different factories from the same lack of adequate fire protec- 
tion the world would make no comment, because it is the usual order of 
nature for people to die one at a time. It is one of the tasks of the statis- 
tician to bring together such scattered facts so that they may be visualized 
and their true significance made known. Thus it happens that occasional 
typhoid fever epidemics tend to reduce the total number of deaths from 
this disease; that occasional railroad accidents tend to make travel safer; 
988 STATISTICS: USES AND FALLACIES-METHOD-ENUMERATION 
989 
and that occasional conflagrations tend to reduce the total loss of life 
and property from fire. In other words, because of our failure to visu- 
alize the scattered facts our actions are controlled more by the occasional 
occurrence of a striking incident than by the prosaic little happenings 
which in the aggregate are of much greater importance. Constant 
dropping wears away the stone. It is part of the vital statistician's work 
to enumerate the drops, that the magnitude of the force at work may be 
appreciated. It is his function to induce people to substitute action 
based on judgment for action based on emotion. 
The statistical method is always found to be popular and useful when 
people are interested in the facts considered. The boys of the country 
are statistical encyclopedias when baseball and batting averages are 
considered; merchants follow the statistic of prices and sales with an eye 
keen to the main issue; while the politician knows almost by heart the 
votes for all the candidates in the election districts under his charge. 
Yet, taken as a whole, it cannot be said that the art of using statistics 
has become so well developed that the general public appreciates it. 
In fact, the contrary appears to be the case. President Kirkland of 
Harvard College used to say: "the chief use of statistics is to refute other 
statistics," and everyone has heard the apothegm that "figures will not 
lie, but liars will figure." There are several reasons for this state of mind 
in regard to the use of statistics, but three of them stand out prominently: 
first, the data are not presented clearly and in an interesting way; 
second, the data are not used in a logical manner; and third, the reader 
fails to make the necessary mental effort to understand and visualize 
the facts for which the numbers stand. The writer believes that vital 
statistics, in order to be of practical benefit, must be used with truth; 
with imagination and with power. 
Again, we may apply to statistical proof the two fundamental requi- 
sites which we learned in our study of geometry and which are expressed 
in the words "necessary and sufficient." 
The Statistical Method.-The statistical method involves three 
fundamental processes-enumeration, classification and comparison. 
Or, as the logician might say, we collect the data and then abstract them. 
In making these studies we resort to various devices; we arrange our data 
in tables; we generalize from these tabulations by computing averages 
and medians and modes; we illustrate our facts by diagrams and cartoons; 
we compare the results of one class or group with those of another class or 
group; we express these relations by mathematical formulae and thus 
determine certain laws or show the absence of a law. In all of these 
processes we must be ever on our guard against fallacies that lurk therein. 
Let us consider some of these. 
Enumerations.-Enumeration is counting-an easy process, one says.. 
So it is if we know what is to be counted. Here, at the outset, we meet' 
our first difficulty. What are we going to count? It depends upon the 990 
THE USE AND FALLACIES OF STATISTICS 
definition of the unit under consideration. Suppose we are enumerating 
the dwelling-houses in a city. What shall we regard as a dwelling house? 
Is a church a dwelling-house if the sexton lives in it, or a stable if the 
hostler dwells there? Is a single building with two front doors one 
dwelling-house or two? Is a "three decker" one house or three? It 
will be seen that the term "dwelling-house," familiar as it is to us, needs 
exact definition if it is to be used as a basis for statistical study. 
Again let us suppose that we are studying the effect of the environ- 
ment in a cotton mill on the health of the operatives. Whom shall we 
consider to be an operative? Shall we include only those who work in 
the rooms where cotton is made or shall we include also the machinists 
and packers and the watchmen and the clerks in the office? And if we 
take only the cotton workers shall we take into account the period of time 
that they have been employed? If a man has worked in the mill only a 
week ought he to be included? Obviously these matters must be decided 
before the enumeration is begun. Many statistical studies are worthless 
because of failure to properly define the units in the beginning. If the 
reader wished to obtain an illustration of the difficulty of enumerating 
people in well-defined groups let him ask three or four of his friends 
to count the number of well-dressed men or the number of beautiful 
women in an assembly. The results will tend to make him conserva- 
tive, and perhaps pessimistic, as to the usefulness of the statistical 
method. 
A second source of error in enumeration is failure to find the units to 
be counted. In taking a census some persons are never found by the 
enumerators. At the last census in England, where the census is taken 
on a given night, it is said that some of the suffragettes walked the streets 
all night so as not to be counted, arguing that if they could not vote they 
would not be counted. It is well known that birth records are incom- 
plete in all countries, and that cases of reportable contagious diseases 
are not reported in full or anywhere near it. On the other hand, there 
is the contrary danger that the same unit may be counted twice. This 
may result from accident or carelessness; but padded census records, 
counts of tissue ballots and all sorts of tricky methods are at times 
resorted to by the unscrupulous. An old darkey selling eggs used to 
count them thus: "one, two, three, four, six, seven, eleven, fourteen," 
and so on. The process of enumeration which is our fundamental 
statistical process should be regarded as the accurate counting of well- 
defined units. 
There is a rather peculiar form of error, which often creeps into 
statistical enumerations, known as the error of round numbers. Thus in 
recording dates of past events some will be given on the exact day of 
occurrence, but where memory fails, some will be given approximately as 
"on the first of the month," or "on the fifth, tenth, fifteenth" and so on. 
This causes a preponderance of numbers recorded on these days. The ENUMERATIONS-CLASSIFICATION 
991 
same is true in regard to age. A person who is 39 or 41 years of age may 
state his age as 40, a round number which to his mind is near enough. 
The tendency to this error may be discovered by finding that an undue 
proportion of the collected figures are divisible by 5 or 10 or 100. Another 
means of discovery is by plotting the data. 
Classifications.-There are three general methods of studying 
statistical enumerations. First, there is the complete statistical study, 
which includes a full account of all the units within the desired area or 
within the specified time. This method, of course, brings the surest 
results and can often be employed when the study is not too extensive. 
Often it is impracticable. Second is the mono gr ami c method, a procedure 
in which a detailed and exact study is made of a particular group. When 
the group selected for study is a well chosen type the application of this 
method yields valuable results, but there is always a danger in generaliz- 
ing from monographic researches. The third method is the representative 
method, as the method of sampling, when a selected part is taken as 
representative of the whole. The value of this method is dependent 
upon the accuracy of the sampling process, often a difficult matter to 
negotiate. Sampling may be by ramdom selection, or by mixture and 
subdivision. In any sampling process there is always a tendency to take 
the obvious and the accessible, and this may cause the sample to be 
unrepresentative; or one may be governed in his sampling, consciously 
or unconsciously, by some preconceived notion as to the probable results 
or the desired results. 
The technique of statistical induction, says Royce, consists in learn- 
ing, first, how to take fair samples of the facts in question and, second, 
how to observe these facts accurately and adequately. 
In classifying the data we arrange them in sections, classes, groups, 
and series for purposes of comparison. Collections of units differing 
from other collections by characteristics not expressed in figures are 
termed sections or classes. Thus, populations are divided into classes 
according to sex, nationality, conjugal condition, civil divisions. Collec- 
tions of units differing from other collections by characteristics expressed 
in figures are called groups. As an example, population is divided into 
age groups or into groups of persons having different weights or heights. 
In generalizing, the average is found for each group and these are com- 
pared with each other and with the whole. Data are also arranged in 
series according to some natural sequence or some order of magnitude or 
chronological order. 
The difference between a class and a group is well illustrated by a 
little joke that recently appeared in one of the papers. The question 
was asked, "What class of people live to be the oldest?" The answer 
was, "Centenarians." The reader will recognize that this witty reply 
was not responsive to the question, in that centenarians represent a 
"group" of people, not a "class." 992 
THE USE AND FALLACIES OF STATISTICS 
Tabulation.-For purposes of study and display the collected data 
are commonly arranged in tabular form. The preparation of tables is an 
important part of statistical work and cannot be done too well. Essential 
qualities of good tabular work are clearness, compactness, and neatness. 
In the first place every table should have a title that describes clearly 
what the data are. Preferably it should be as short as possible and it is 
good training in the use of words to produce an artistic title. Each 
column should also have a clear and appropriate title, in which well 
understood or well explained abbreviations may be used if it is necessary 
to save space. Where the heading is complex, that is, where certain 
parts of the heading cover more than one column, care should be 
taken to have this clearly indicated by proper ruling. Where different 
columns are referred to in the text accompanying the table it may be 
found convenient to give each column a serial number, from left to 
right, placed in parenthesis just below or above the heading. Long 
unbroken columns of figures are confusing to the eye and horizontal 
spaces between every five lines are often left. This practice is to be 
commended. 
Ratios-Rates.-Ratios may be expressed by common fractions or by 
decimals. It is seldom wise to use common fractions of which the 
denominator is greater tha 10, unless it is some commonly used multiple 
of 5 or 10, such as ^5 or ^oo- In statistical tabulations decimals 
should be used. Rates are merely ratios in which the basis of comparison 
is some well-recognized division of area or time or some common unit of 
the decimal system. Examples: gallons of water per day, persons per 
square mile, number of births per 1000 marriages. Compound rates 
are commonly used when comparison is made with two bases: thus, 
gallons per capita per day, number of births per 1000 marriages per 
annum. Most of the rates used for the comparison of vital statistics 
are compound rates as they involve both area and time. Sometimes 
these are termed compound averages. 
Misuse of Averages and Rates.-Fictitious accuracy should be 
avoided. If 35 out of 57 balls were white the percentage of white balls 
would be 61.40 per cent. The smallest possible error, i.e., 1, would 
change the percentage to 59.65 per cent, or 63.16 per cent. Clearly for 
figures less than 100, fractions of per cents, are illogical. In the same 
way death rates for populations of less than 1000 are useless beyond the 
third significant figure. Comparisons of averages of fictitious value are 
also to be avoided. 
Changes of basis in the computation of rates should be kept in mind in 
order to avoid error of statement. Thus, in the year 1880 the receipts of a 
water company were $400,000; between 1880 and 1890 they decreased 10 
per cent., so that between 1890 and 1900 they became $396,000 (not 
$400,000). The basis used should be stated in words if it is not perfectly 
clear from the context. TABULATION RATIOS-MISUSES-THE INDEX 
993 
When interpreting ratio's it should be carefully noted whether the 
numerator bears a direct relation to the denominator. In proportion 
as it fails to do so, any inference from it is less valuable. For example, 
the ratio between the number of births and the total population is less 
close than between the number of births and the number of married 
females of child-bearing age. In the same way crude death rates based 
on total population regardless of sex or.age are less useful in studying 
relative hygienic conditions than when age and sex are taken into account. 
It is failure to take this element into account that has led people to 
say, "You can prove anything by statistics," and that has given unscru- 
pulous persons opportunity to deceive the unthinking or the unin- 
formed. A moral responsibility of no mean order thus rests upon the 
statistician. 
Ratios are sometimes necessarily used in an indirect way. Thus, the 
average annual exports and imports are taken to represent the business 
condition of a country. Here a part is taken for the whole. The method 
is proper if in the interpretation it is recognized that it is a par.t. Or the 
typhoid fever death rate of a city is taken as an index of the sanitary 
quality of the public water supply. It may be indeed such an index, 
but it is only one. 
Another danger is that common to all forms of reasoning, namely, that 
of using post hoc for propter hoc. This fallacy is very likely to creep in 
unawares in statistical work under cover of apparent accuracy and 
thoroughness of investigation implied by the use of columns of figures. 
Baily has well said that "the phrase 'other things being equal' has covered 
up a multitude of sins. As a rule other things are not equal." It is 
even worse, perhaps, to take it for granted that other things are equal. 
Baily also warns against the hidden errors that may lie under the use of 
the terms "it is undoubtedly true that, etc.," and "it is probably the 
case that, etc." Of vital importance is it, therefore, to make sure that 
the data collected are sufficient in kind and number for the purpose for 
which the statistics are intended. It saves time and labor in the end to 
consider carefully at the outset just what data are needed. Where, as is 
often the case, the statistician had no control over the collection of the 
data, he should make every possible attempt to ascertain the reliability 
of the sources of information and not attempt to draw conclusions not 
warranted by the conditions under which the figures were collected. 
The statistician cannot safely write newspaper headlines. 
The Index.-Averages of different groups and even of different classes 
are sometimes combined to give a single ratio, more convenient for use and 
perhaps more accurate as a measure of certain phenomena. Thus, the 
prices of various standard commodities sold in any year are combined 
to give a single figure that is taken to indicate the state of trade during 
that year. This may be done by taking a weighted average of the differ- 
ent articles sold in any one year and comparing it with the weighted 994 
THE USE AND FALLACIES OF STATISTICS 
average for some particular year or series of years taken as a standard. 
Obviously there are various ways in which an index can be prepared. 
The index has not come into use to any extent in the study of vital 
statistics, but it would seem logical to use it in comparing the relative 
hygienic conditions of different cities. This is to a certain extent accom- 
plished when crude death rates are adjusted to take into account the 
composition of population, as to age, sex and nationality. 
Variations.-In the treatment of objects or organisms that belong to 
some definite group or in the observation of natural phenomena it is com- 
monly found that the results are much alike, although not precisely alike. 
Thus, the heights of most men are quite near the average of all, but a few 
men are above the average height and a few below it. The same is true of 
the weights of persons in any age group. It is true of the ages at which 
people die from different causes. And so in many of the phenomena that 
come under the head of vital statistics many observations will be found 
near the average of all, but a few will be quite different. These varia- 
tions commonly follow certain mathematical laws of probability which are 
found to be quite useful in statistical work. The study of variations is 
fascinating in itself. It has already played a large part in biological inves- 
tigations and little by little the idea is being extended into the engineering 
sciences. For example, it has been found that the frequency of rainfalls 
of different magnitudes can be expressed in accordance with the law of 
probability, and the same is true of the occurrence of floods, and similar 
natural phenomena. 
In this brief chapter it is impossible to discuss this interesting subject 
of variation and frequency, but the reader is urged to pursue it in the 
standard text-books on Statistics and Least Squares. 
Death Rates.-A figure commonly used in sanitary and hygienic 
studies is the death rate. By this is meant the ratio between the number 
of persons dying in a given period of time and place, and the number of 
persons in the place alive at the middle of the period, referred to some 
round number, as 1000 or 10,000 or 100,000 as the basis of comparison. 
Unless otherwise specified the period of time is taken as 1 year. When con- 
sidering deaths from all causes the basis of population is taken as 1000, 
but when considering deaths from particular causes 100,000 makes a 
better basis for comparison. 
In a certain city in the year 1910 there were 5710 deaths from all 
causes. The population was 390,000, consequently for every thousand 
population the number of deaths was 5710 divided by 390 thousands, or 
14.6. This represents the general death rate, or the crude death rate, 
as it is often called. Such a rate enables us to compare on the same basis 
the mortality for places of different size. It is a convenient yard stick, 
but it must be used with great caution. It is often misused. The expres- 
sion "crude death rate" is to be taken literally for such a rate is indeed a 
very crude one. VARIATIONS-DEATH RATES 
995 
Let us consider, for a moment, how it is made up. In the first instance 
it is a common fraction, and has a numerator and a denominator. The 
numerator is the number of deaths at all ages, from all causes, from all 
sorts of occupations, in all kinds of houses, the only boundary of the group 
being that the deaths occurred within the given place and within the 
period of a calendar year. Presumably, it includes all the deaths there 
were, but even this is not always the case. Suppose a child is born dead, 
or, as we say, is still-born; is this still-birth included among the deaths? 
In some places it has been so included. Modern statistical practice does 
not include it. Again, suppose a person whose home is in the given place 
dies away from home and is brought home for burial, or that another 
dies in a hospital within the given place and is buried outside of the place. 
Here are other chances for uncertainty. Hence, the numerator of our 
death-rate fraction is more or less unreliable and ambiguous. 
The denominator is equally so. Except in years when a census is 
taken in mid-year population must be estimated, and this estimate may 
be wide of the mark. The natural tendency is for population to increase 
at a geometrical rate, that is, to increase like compound interest, but actu- 
ally the population of a given place changes from various other causes 
which mask this normal rate of increase, from emigration and immigration 
and from changes in the birth rate. These changes are often sudden and 
large. The United States Census Bureau makes a practice of estimating 
that between the census years the population in any given place increases or 
decreases by a constant annual increment. On the whole, this may be 
true and it is probably the best general rule to follow in this country at 
the present time, but in any given place it may be wide of the mark, and 
the denominator of our fraction may therefore be wrong in any particu- 
lar year. Bur even if correct, the denominator stands for a composite 
population and includes the young and the old, male and female, the rich 
and the poor, the well and the sick, the native and the foreign. The only 
boundary of the group is that the persons included must be alive and 
living in the given place at mid-year. 
The general death rate, therefore, is an imperfect measure of hygienic 
and sanitary conditions except between groups of population similar in 
character. The crude death rate of a manufacturing city like Lawrence, 
Mass., cannot be fairly compared with that of a residential city like 
Newton. The general death rate of a big city, with its large middle-aged 
population cannot be compared with that of a rural country deserted by 
the middle-aged people who have gone to the city. Chicago cannot be 
fairly compared with Boston on this basis, nor New York, with New 
Orleans. It is true that this is done repeatedly, but the figures mean but 
little, and the conclusions reached from such comparisons are often false 
and mischievous. 
The fallacy in the general death rate lies partly in its liability to error, 
but still more in the composite character of the two quantities which 
together give us the ratio. 996 
THE USE AND FALLACIES OF STATISTICS 
General Death Rate Influenced by Infant Mortality.-It is not gen- 
erally realized that about one-fifth, to use an approximate figure, of all 
of the deaths in a given year are of children less than a year old. One- 
quarter of the total deaths are almost always children less than 2 
years old. Hence, whatever influences the deaths of children influences 
very greatly the general death rate. An abnormally hot summer may 
do this or an epidemic of children's diseases. 
It follows also that a high birth rate results in a higher general death 
rate and a comparison of the curves of birth rates and general death rates 
shows a surprising synchronism. Birth rates and marriage rates both 
fluctuate with the general death rate. 
During the last quarter century the general death rates have been 
falling. This has been due in great measure to improving sanitary condi- 
tions but it has been due also to lowering birth rates. 
In this connection, however, it should be remembered that the birth 
rate influences the denominator of the death-rate fraction as well as the 
numerator, for most of the children born do not die at an early age. Were 
the population of a place not influenced by immigration a lowering birth 
rate would not continually reduce the general death rate, for with fewer 
children born there would be a smaller population upon which to figure the 
death rate. The problem is endlessly complicated and requires a deep 
mathematical mind for its full comprehension. It is sufficient to remem- 
ber that as long as the birth rate continues to fall and a high immi- 
gration keeps up so long will the crude death rates continue to fall. And 
when some years hence the birth rates cease to fall, as they must, and 
when they increase, as it is to be hoped they will, this will be accompanied 
by an increase in the general death rate. This increase in the death rate 
will be normal and must not be regarded as a sign of failure on the part 
of sanitation. It is hardly to be expected that the improvement in sani- 
tation will prevent this ultimate increase in the general death rates. 
If sanitarians will recognize this fact today it may save them some heart 
burnings in years to come. 
Infant Mortality Not an Index of Sanitary Environment.-Studies of 
the death rates of the world show that until within a very few years there 
has been no substantial decrease in infant mortality, and this, too, in 
spite of the fact that the specific death rates for children and persons up to 
middle life have materially decreased. The lowering of the death rates 
from those diseases which are caused by specific infections have been very 
conspicuous for a generation, and this is clearly due to improvements in 
sanitation resulting from our better knowledge of bacteriology. Infant 
mortality does not reflect so clearly our recent efforts to obtain a clean 
environment. Hence, the infant mortality of itself does not offer a 
satisfactory index of sanitary conditions. 
The decrease in infant mortality which has occurred during the last 
5 or 10 years has been due rather to the various activities that come under INFANT MORTALITY INFLUENCES-RESTRICTED DEATH RATES 
997 
the heads of infant welfare and motherhood training. It is important to 
keep the distinction between this work and the work of sanitation clearly 
in mind. A study was made in Boston a few years ago which showed 
marked variations in the specific death rates of infants at different ages. 
The data collected were tabulated by months and by nationalities. It 
was found that the Italian infants had a low death rate during the first few 
months, that is, during those months when the children were being nursed 
by the mother, but that after the age of about 9 months the death rates 
began to increase, a fact that was apparently due to the child entering a 
new and unclean environment. The children of Jewish parentage main- 
tained a relatively low death rate for a long period. It is only by study- 
ing vital statistics in a detailed way that such facts as these are brought to 
light. While the processes of generalization are of value the opposite 
processes of subdivision and classification are equally important. 
Restricted Death Rates.-Instead of computing the general death rate 
of a place in the manner indicated we may restrict either the numerator or 
the denominator of the fraction. We may limit the time to something 
less than a year and thus obtain monthly rates, or weekly rates, or even 
daily rates. We may limit the deaths to those from a particular cause, 
and obtain the annual death rate from tuberculosis or from typhoid fever, 
or from lead poisoning. Or we may limit the group or class represented 
by the denominator to certain ages or occupations or nationality or sex, 
and in various ways we may obtain rates that are useful for study and 
comparison. These rates may have in common scarcely anything more 
than that they are referred to some round number as 100, or 1000, or 
100,000 as the basis of comparison, or in other words that they are express- 
ed by the decimal system. Such rates we term " specific rates '' for the 
reason that they include only the data for definitely specified groups or 
classes. 
In making up these restricted or specific death rates and in comparing 
them it is of the greatest importance to make sure that in restricting a 
group by one set of boundaries we do not at the same time and without 
knowing it, perhaps, restrict it by other boundaries. Thus, by dividing 
the instructing staff of a university into classes such as assistants, instruc- 
tors, assistant professors, associate professors, and full professors, we may 
at the same time be establishing a grouping according to age. In dividing 
the workmen employed by a city into policemen and laborers, we might 
at the same time be dividing them by nationality into Irish men and 
Italians. This is a fallacy against which those who use statistics must be 
continually on their guard. In very many cases age comes in as a dis- 
turbing factor. Scores of instances might be given. Why is the death 
rate so high among bank presidents? Not because the occupation is 
hazardous, but because this position is commonly meted out only to men 
of mature years. By the same token the average age at death of bank 
presidents is said to be high. The average age at death of lady stenog- 998 
THE USE AND FALLACIES OF STATISTICS 
raphers is low. Why? Not because the use of shorthand and the 
hammering of the keys tends to premature death, but because so large a 
percentage of lady stenographers marry and take themselves out of the 
group of stenographers before they attain an advanced age. To a very 
considerable extent classification by occupation results automaticallv 
in an age grouping. For example, the average death rate of newsboys is 
low. Why? Because all newsboys are young. The average death rate 
SPECIFIC DEATH RATES 
AT 
DIFFERENT AGES 
U-S^REGISTRATIONAREA. /890and 1900 
Crude death-rate per /,000 
Age 
Fig. 52. 
of civil war veterans is high. Why? Because the entire class is now 
composed of old men. Likewise, certain diseases are most commonly 
associated with certain age periods, and some diseases are confined 
exclusively to one sex. 
Hence, in tabulating data and in computing rates for the purpose of 
measuring the importance of some factor one should endeavor to so 
arrange the classification as to leave this as the only factor that varies. 
They may involve a more detailed study than we are in the habit of mak- 
ing, and it is not always possible to make such a separation of the data. 
The general principle should, however, always be borne in mind. Often 
an age grouping in addition to some other classification will be sufficient. DEATH RATES DISPLAY OF DATA 
999 
Specific Death Rates.-The variations in the specific death rates at 
different age groups are illustrated by Fig. 52, in which it will be seen that 
the death rates are high in early infancy. They decrease rapidly and 
attain a minimum at the age of about 12 years, then they slowly increase 
until the age of 60, and after that, of course, there is a rapid increase. 
Curves like this are much more satisfactory for comparing the sanitary 
conditions of different cities than a single figure representing the death 
rate can possibly be, because one may obtain at a single glance a picture of 
the conditions which exist at any age. The two lines in the diagram show 
the change that occurred in the specific death rates between 1890 and 
DIAGRAM SHOWING DISTRIBUTION 
OF DEATHS FROM ALL CAUSES 
AMONG DIFFERENT AGES IN 
MASSA CHUSETTS 
1910 
Percentages of Total Deaths 
Ages 
Fig. 53. 
1900 for the United States Registration Area. It will be seen that there 
was a decrease in the rates for infants and children, but an increase in the 
specific death rate above the age of 60. 
Figure 53 is equally interesting. It shows the distribution of deaths 
from all causes among different ages in Massachusetts in 1910. The 
importance of the infant mortality as compared with the deaths at other 
ages is strikingly evident.* 
Display of Statistical Data.-Having made an accurate and sufficiently 
complete enumeration and classification of the data and compared them 
in a logical manner, guarding against the many fallacies that lie in wait to 
catch the unwary, one thing yet remains-that of displaying the data so 
that he who runs may read, or as the farmer said when he put up a sign to 
* Diagrams were drawn by Mr. Sylvester Schnattschneider, Assistant in Sanitary 
Engineering, Harvard University. 1000 
THE USE AND FALLACIES OF STATISTICS 
beware of the dog, "so that he who reads may run." One reason why 
statistics produce so little effect on the ordinary reader is because they 
are so poorly displayed. Even in tabulating data or drawing diagrams to 
illustrate the data graphically it is possible to falsify the facts. The art 
of statistical graphics has been learned by few and practised by a still 
smaller number of vital statisticians. And the public has become so in 
the habit of seeing diagrams that conceal and mislead rather than those 
that clearly display that it has no taste for diagrams that are really well 
drawn. 
Tabular printing is expensive; hence, tables should be made as simple 
as possible, with short clear headings for the columns, good alignment, 
with columns numbered for convenient reference, and above all with a 
title that tells what the table contains. The figures should not be allowed 
to sprawl over a page. Where there are but two or three columns these 
may be repeated in parallel series, unless a single set of columns is needed 
for the sake of presenting a clearer mental picture. Hundreds of dollars 
are wasted every year by using poorly arranged tables, with no one the 
gainer but the printer and the paper maker. 
The Future of Demography.-Demography is at once a very old and a 
very new study. It might well be called one of the lost arts. Some of the 
reports that were published a half century or more ago might almost be 
taken as models of good statistical work. An excellent example is the 
report of the Massachusetts Sanitary Commission of 1850, which was pre- 
pared by Lemuel Shattuck. The vast accumulation of data in recent 
years has not been accompanied by an improvement in the art of classify- 
ing and studying the data. In fact there has been of late something of a 
retrogression. A very large number of poorly prepared reports contain- 
ing undigested data have been issued. The statistical work has been 
crude and slipshod and has tended to bring the science into disrepute. 
But there are signs of a change for the better. In this movement the 
Bureau of the Census of the United States has been a conspicuous leader. 
Aside from the academic value of the science of demography there are 
immense practical values which are just beginning to be realized. For 
example, we have come to learn that various sanitary reforms are tending 
to increase the cost of living. Pure food, pure air, and pure water are not 
obtained without expense. Oftentimes the expense is fully justified and 
the investment yields a substantial reward, but there are fields of activity 
where the rewards are less and where the increased cost of sanitation 
fails to yield a sufficient return. The law of diminishing returns has its 
application in sanitation as well as in economics. It is only by careful 
study of the results of sanitation that we shall be able to properly evaluate 
the different sanitary measures that are available to us, and it is in this 
direction that the practical value of vital statistics lies. More and more 
is the science of demography playing an important part in the adminis- 
tration of public health and it seems certain that at no distant future the DISPLAY OF DATA DEMOGRAPHY 
1001 
science of demography will rank as one of the most necessary subjects for 
students to pursue in their training for the public health service. 
It is recognized also that the realm of demography cannot be confined 
to the statistics of marriages, births, and deaths, but must be extended to 
include physiological data as well as social and economic statistics. CHAPTER III 
METHODS AND SCOPE OF PROTECTIVE LEGISLATION 
JOHN B. ANDREWS, Ph. D., New York City, N. Y. 
In the development of our civilization from the individualism of primi- 
tive savagery to the complexity of modern industrial society, we have 
created many perplexing social problems. When individuals worked 
singly and in averyreal sense "minded their own business,"it was possible 
for the individual worker to adjust himself or his surroundings to suit at 
least his own best judgment concerning personally agreeable and health- 
ful conditions of temperature, humidity, fresh air and physical strain. 
But when factories were built and large numbers of people came to work 
under artificial conditions over which they themselves had little or no 
direct control, there was created a very different problem. Conditions of 
temperature and humidity and purity of air and labor strain are now 
often prescribed by the most convenient, the most rapid, and the cheapest 
process of manufacture from the standpoint of selfish or thoughtless 
employers. 
Every person in the community is concerned in the conservation of the 
health, vitality, energy, and industrial efficiency of wage earners. All 
agencies in society should cooperate in preventing unnecessary suffering 
and death among the producing classes. The protection of the health of 
the industrial worker is not an individual question. It is a social ques- 
tion demanding social regulation. 
The prevention of occupational diseases is, moreover, too great an 
undertaking to be left entirely to individual action. It cannot be left to 
the worker who, even when not ignorant of the danger, is driven by neces- 
sity to his task. It cannot be entrusted to the employer whose principal 
business, after all, under competitive conditions, is to secure profits. It 
cannot be left to medical treatment alone, for prevention and not after- 
care is the remedy. Not only on account of the magnitude of the prob- 
lem, but also because of its nature, the prevention of occupational diseases 
is properly a function of government. Governmental action, however, in 
promoting industrial hygiene does not mean that private or voluntary 
efforts of the workmen, or of their employers, or of their physicians shall 
be in any way minimized. On the contrary, such voluntary efforts will 
be vastly encouraged. 
It must be obvious to any thoughtful person that in preventing 
unnecessary occupational diseases we must have investigation, education 
and administration. These three requisites can, in a democracy, best 
be secured through legislation. 
1002 INTRODUCTION PRINCIPAL METHODS 
1003 
Investigation is expensive. But through legislation we can set aside 
ample funds for scientific study. In New York state during the 2 years 
1912-1913 the legislature appropriated $110,000 to the factory investi- 
gating commission, in addition to the usual sustaining funds for the 
permanent departments of health and labor, and other states have made 
similar outlays. 
Education is expensive. But through legislation we can provide the 
means for the necessary dissemination of facts gained by investigation. 
The reports of the Occupational Disease Commission in Illinois and of the 
Factory Investigating Commission in New York, as well as the splendid 
researches of several governmental commissions in England and elsewhere, 
have given a remarkable impetus to the task of providing sanitary work 
places. Reports on occupational diseases issued by our bureaus of labor 
have stimulated wide interest among manufacturers and wage earners. 
The laws in a score of states and in several European countries requiring 
the reporting of occupational diseases have pointed out the sore spots in 
industry and have resulted in valuable cooperation between physicians 
and factory inspectors. 
Administration is essential. Protective devices often involve the 
expenditure of large sums of money and, under conditions of sharp compe- 
tition and cheap labor in an industry, the humane and careful employer 
may be placed at an unfair disadvantage in dealing with his less conscien- 
tious business competitor unless there is uniform enforcement of sanitary 
regulations. It is only through uniformity of regulation, which legal 
enactments alone can secure, that the more progressive and humane 
employers can themselves be protected from less scrupulous competitors 
who would otherwise often fail to provide expensive safeguards, and it is 
only through compulsory regulations that the health of the employes of 
these unscrupulous competitors can be protected. A notable example of 
this was the condition which culminated successfully in the poisonous 
phosphorus prohibition act described in an earlier section. Match 
manufacturers representing 95 per cent, of the total product testified 
before Congress that they could not substitute a harmless compound for 
the slightly cheaper poison without a uniform law compelling all employ- 
ers in that industry to abandon the poison. All of the other match manu- 
facturers, however, representing the remaining 5 per cent, of the product, 
stood out stoutly to the last, even declaring that they would close their 
factories before they would submit to this sanitary measure, already in 
compulsory operation in practically all the civilized countries of the 
world. It required labor legislation to end the use of this unnecessary 
deadly poison before "phossy jaw," the most loathsome of all industrial 
diseases, could be abolished. 
Three Principal Methods.-The principal legislative remedies for 
the prevention of occupational diseases are of three classes. These 
are: 1004 
METHODS AND SCOPE OF PROTECTIVE LEGISLATION 
1, The method of prohibition. 
2. The method of regulation. 
3. The method of compensation or insurance. 
The mass of legislation which falls into these three categories is con- 
stantly expanding and undergoing amendment. Any study of it is 
further complicated by the rapid spread, in America as well as in Europe, 
of the method of enforcement by administrative order, in which the legis- 
lature lays down a general rule, such as "the work places shall be safe," 
and leaves to a commission or to an administrative official the duty of 
making the necessary specific regulations. In the pages which follow 
the attempt has been made to present only the broad outstanding princi- 
ples of the law. Much that would be essential to the legislative drafts- 
man has been omitted in the hope that, unencumbered by excessive detail, 
the lay reader may arrive at a comprehensive understanding of what 
the various governments are doing for the abatement of occupational 
diseases among their wage-earning population. Full texts of the Euro- 
pean laws cited may be found in the files of the bulletins of the Interna- 
tional Labor Office. 
1. THE METHOD OF PROHIBITION 
No more striking example of the method of prohibition could be found 
than the suppression of white phosphorus in the match industry. As has 
been shown elsewhere in this volume, every leading country of the world 
has now outlawed this occupational poison, even resorting to the unique 
expedient of forming an international treaty to prohibit an occupational 
disease. 
The only other substance against which such drastic action has been 
taken in industry is lead, and in this case the prohibitory legislation is con- 
fined to Europe. Austria was first to act, forbidding in 1908 the use of 
lead in all paints, colors or cement used for interior work, and the same 
year the various Swiss administrative departments were ordered to pro- 
hibit the use of white lead in painting carried on in their behalf. In 
1909, however, France took the most advanced stand by declaring that 
after July 20, 1914, the use of "white lead, of linseed-oil mixed with lead, 
and of all products containing white lead will be forbidden in all painting, 
no matter of what nature, carried on by working painters either on the 
outside or in the inside of buildings." Sweden and Greece havejalso 
partially prohibited the use of white lead in this industry. More signifi- 
cant still is a draft convention adopted by the third official International 
Labor Conference at Geneva in 1921 which would prohibit the use of 
white lead in most interior painting and regulate its use where not 
prohibited. 
Another type of prohibitive labor legislation is directed against the use 
of dangerous instruments. Thus in textile mills the extent to which methods: prohibition, regulation 
1005 
tuberculosis and other contagious diseases were transmitted by the workers 
sucking thread into the shuttles led to this process being called the "kiss of 
death." Massachusetts, Connecticut, and Rhode Island accordingly, 
forbid the use of any form of shuttle which requires the employe to use 
his lips or mouth in threading it. 
2. THE METHOD OF REGULATION 
The method of regulation, in the prevention of occupational diseases as 
in other social problems, is based on the principle of toleration within 
limits. The majority of the people may believe that certain harmful 
conditions are so necessary a part of our industrial life that their prohibi- 
tion is at present undesirable or at least impracticable. As a result, the 
method of regulation is far more widely used than the method of prohibi- 
tion, as well as being historically much older. 
The adoption of this method leads to limitations in three different 
directions: (1) upon the methods of handling the hazardous material; (2) 
upon the period of exposure; and (3) upon the persons exposed. These 
three types of limitation are seldom used singly, but are usually combined 
in the same law. In the following discussion no attempt will be made to 
describe the laws now existing in most industrial states and countries with 
reference to air-space, ventilation, general dust and fume removal, tem- 
perature regulation, toilet facilities, weekly rest days, and similar general 
matters, because while all these measures have a bearing on the health of 
the operatives they are not designed as protection against any specific 
occupational illness. No mention will be made, either, of provisions 
applying only to the labor of women and children, as such provisions are 
treated separately elsewhere in this volume. 
Lead.-The most widespread of industrial poisons, lead is also most 
frequently the subject of regulative laws. Public attention was first 
called to its dangers in America by the report of the Illinois Commission 
on Occupational Diseases in 1911, since which date about half a dozen 
states have enacted specific protective measures. 
The most advanced of these measures, prepared by the American Asso- 
ciation for Labor Legislation, is that adopted in practically identical form 
by the Ohio and Pennsylvania legislatures in 1913, and in New Jersey in 
1914. Every employer is required to provide, without cost to his work- 
men, reasonably effective devices to prevent illness incident to the processes 
at which they are engaged. In addition, specific regulations are made to 
protect those employed in the manufacture of white lead, red lead, 
litharge, sugar of lead, arsenate of led, lead chromate, lead sulphate, lead 
nitrate or fluo-silicate and, in the New Jersey law, in the manufacture of 
pottery, tiles, or porcelain enameled sanitary ware. Workrooms must be 
thoroughly lighted and ventilated. Separate rooms must be provided for 
the dusty and therefore more dangerous processes, with floors which can 1006 
METHODS AND SCOPE OF PROTECTIVE LEGISLATION 
be cleaned daily either by wet methods or by vacuum cleaners. Vessels 
for crushing, drying or conveying the lead or lead salts must be protected 
by hoods or dust removers. Great emphasis is laid on washing facilities, 
the requirements including hot and cold water, soap, towels, nail brushes, 
and shower baths; there must also be separate dressing rooms, eating 
rooms, drinking fountains and double lockers, and respirators must be 
furnished. At least 10 minutes on the employer's time must be allowed 
each employe before lunch and at closing for the use of the wash room, 
and an additional 10 minutes twice a week for the use of the shower baths. 
The employes are made subject to fine in case of failure to use the facilities 
for cleanliness which are provided, and are not to take any food or drink 
into the workrooms. Every employe exposed to danger from lead dust 
or fume must be examined medically at least once a month by a physician 
paid by the employer. If lead poisoning symptoms are found, a record 
must be filed with the factory inspection department within 48 hours and 
a copy sent to the employer, who may not thereafter employ that worker 
in any place exposing him to lead without a written permit from a 
physician. Notices in English and in such other languages as the cir- 
cumstances require must be prominently posted, stating the dangers and 
giving instructions for avoiding them. 
The Missouri law, also of 1913, and the Illinois act of 1911 contain 
very nearly the same provisions with respect to washing and lunch-room 
facilities, dust removal, and medical examination of employes. They 
lack, however, the clause imposing hygienic duties on the workers as well 
as on the employers. Both these laws, also differ from that just described 
by being less specific but more inclusive. The Illinois act of 1911 applies, 
in addition to occupations involving contact with the familiar poisonous 
lead salts, to brass manufacture and to lead and zinc smelting, while the 
Missouri statute aims to cover any process "in which antimony, arsenic, 
brass, copper, lead, mercury, phosphorus, zinc, their alloys or salts, or any 
poisonous chemicals, minerals, acids, fumes, vapors, gases or other sub- 
stances are generated or used in harmful quantities or under harmful 
conditions." The Delaware law of 1917 is similar to those of Missouri 
and Illinois but makes no provision for medical examinations and applies 
only to factories where women are employed. In plants employing 
both men and women, the men, of course, are also benefited by this 
law. 
The New York law, enacted in 1912, merely forbids the taking of food 
into any workroom where lead, arsenic or other poisonous substances are 
present, and requires the maintenance of a separate lunch room. 
In Europe the tendency is away from such omnibus legislation and 
toward minute regulation for each of the important lead industries sepa- 
rately. This tendency is perhaps best exhibited in Germany, which 
country not only was one of the first to establish scientific standards for 
the lead-using trades, but has to-day the greatest mass of legislation bear- METHODS OF REGULATION: LEAD TRADES 
1007 
ing on the subject. Separate statutes exist for lead mining, casting, zinc 
smelting, type founding and stereotyping, typesetting, white lead manu- 
facturing, lead oxides and paints, electric accumulators, painting and file 
cutting. England has passed separate laws or issued separate adminis- 
trative orders governing lead smelting and casting, lead founding, white 
lead, lead oxides and paints, electric accumulators and file cutting, heading 
yarn dyed with a lead compound, earthenware and china, color transfers 
on earthenware and china, and tinning and enameling. In Austria, 
France, Belgium, Switzerland, Greece, and Sweden, similar but shorter 
lists of industries have been individually regulated. 
In the more dangerous trades in many of the countries named, the 
workers are forbidden to eat or to leave the premises where they are 
employed until they have first thoroughly washed their hands and their 
faces and in some cases their mouths and noses also. No food or beverage 
of any kind, and no tobacco either for smoking, chewing, or snuffing, may 
be used in or even carried into the workroom. In the more dusty trades, 
such as white lead making, lead oxidizing and electric accumulator manu- 
facture, the men must take warm baths regularly, in some cases weekly 
and in some cases daily. In the white lead industry in England a register 
must be kept of these baths. 
Much emphasis is thrown on adequate ventilation and lighting. The 
walls and floors of the chambers where dusty processes are carried on must 
be hard and impervious, and must be cleaned by moist methods or with a 
hose at regular intervals. Mechanical, hooded contrivances for crushing, 
mixing and transporting dangerous lead products are generally specified 
in the law. The employer must furnish working clothing, gloves, respira- 
tors, and sometimes head coverings, and lockers in which to keep them. 
There must be dressing rooms, and wash rooms supplied with hot and cold 
water, soap, towels, nail brushes, and bathing facilities; a dust-free room, 
warmed in cold weather and in some cases provided with means for warm- 
ing the workmen's food, must be set aside as a lunch room. In some of 
the more arduous trades the hours are made short and are broken by 
frequent rest pauses. Notices of the law must be posted, and sometimes 
must also be distributed to the employes. 
Germany in the lead smelting, white lead, lead oxide, storage battery 
and painting trades, England in all but the last of these, with the addition 
of yarn heading and earthenware, and Austria in lead and zinc smelting 
require a "control book" or health register. The German book is a very 
elaborate affair, requiring records of the name of the person keeping it, 
first and last name, address and age of each workman, date of his entering 
and leaving the employment, date and nature of his illness, date of his 
recovery, name of the factory physician, and dates and results of the medi- 
cal examinations. The employer is responsible for the correctness of this 
record and must show it to the factory or medical inspector on demand. 
The Austrian health register goes into even more detail. 1008 
METHODS AND SCOPE OF PROTECTIVE LEGISLATION 
Before a workman in Germany, England, France, Austria, or Russia 
can legally obtain work in the dangerous lead trades, he must provide him- 
self with a medical certificate showing that he is of sound physique and 
constitution and fairly capable of withstanding the poisons with which he 
will have to work. Lung, kidney or stomach trouble, alcoholism and a 
generally weak constitution are debarring ailments in Germany. The 
French law excludes workers who exhibit symptoms of lead poisoning or 
of any complaint likely to be dangerously aggravated by plumbism. 
In Belgium no workman addicted to alcohol may be employed in white 
lead, lead oxide or lead paint making. Women, as particularly liable to 
serious injury from lead dusts, have been excluded entirely from the more 
dangerous lead trades in most European countries. The International 
Labor Conference at Washington in 1919 recommended still further 
protection of women and minors in this respect. The recommendation 
had been adopted by the beginning of 1922 in a number of countries 
including Great Britain, Denmark, the Netherlands, Portugal, and 
Roumania. 
Having secured employment in a lead trade, the workman's continua- 
tion therein is usually dependent on his successfully resisting its inherent 
hazards. The frequency of compulsory medical examination ranges from 
1 every 6 months for painters in Germany to 1 a week in the English white 
lead industry. In most cases, however, 1 examination a month is the 
requirement; in white lead and lead oxides in Germany it is 2 a month. 
When a worker is discovered to have symptoms of plumbism, the laws 
almost universally require that he be "suspended," that is, given employ- 
ment which keeps him out of contact with lead until he has fully recovered. 
Belgium, in the white lead industry, requires that a leaded man be kept 
out of that sort of work permanently. 
A decisive clause found repeatedly in the German laws, and also in the 
Austrian statute on lead and zinc smelting, is that a workman continually 
violating, after warning, the hygienic duties laid upon him is to be perma- 
nently discharged without notice. A similar but much weaker clause is 
the provision occasionally found in England that a reckless worker lays 
himself open upon conviction to a fine. 
Several countries have turned their attention to house painting, a pro- 
lific source of painful and annoying but less often fatal attacks of plumb- 
ism. In addition to the laws described above, which to a greater or lesser 
degree prohibit the use of white lead in painting, there are others which 
seek to protect the workers in this industry by the less drastic method of 
regulation. France, Germany and Belgium forbid all rubbing or scraping 
of lead paint in a dry state. In France the manipulation with the bare 
hands of any material containing white lead is forbidden. Belgium in 
1909 decided that white lead for painting could be transported, sold or 
used only in the form of a paste or liquid mixed with oil. The ministry 
was given power to extend the same restriction to white lead for any METHOD OF REGULATION: LEAD, BRASS, DUSTS, COMPRESSED AIR 
1009 
other purpose, but later the law was weakened to allow special permits to 
persons who could prove the necessity of their using white lead in powder 
or cakes. A mild ministerial order is found in Austria, where it is allow- 
able to import or sell lead colors or cement only if the fact that they 
contain lead is 11 expressly marked upon them in a clear and comprehen- 
sible manner." Switzerland also has some regulations on this subject. 
Brass.-Legislative provision is made for the control of brass fume and 
dust under the Illinois and Missouri lead laws already mentioned, but 
nowhere else specifically in this country. In England exhaust drafts for 
the prompt removal of fumes, and arrangements for preventing the fumes 
from spreading to other rooms, must be provided. For the personal care 
of the employes, also, there must be washing accommodations, with 
soap, nail brushes and towels. 
Miscellaneous Dusts.-Three states-Illinois, Michigan and New 
Jersey-have detailed legislation looking toward the removal of the 
miscellaneous dusts generated in the grinding and polishing rooms of 
many industrial establishments. These laws designate the kind of 
machines covered by the act, how the protective devices shall be adjusted 
to the machines, the dimensions of the connecting pipes, and the degree 
of the angles as well as the rate of speed at which the fans or blowers 
shall run. In addition, about half the states in the union have enacted 
more general laws on the same topic. Fairly representative of this type 
of legislation is the Oregon statute of 1907, providing that "if in any 
factory, mill or workshop any process is carried on in any enclosed room 
thereof, by which dust is generated and inhaled to an injurious degree by 
the persons employed therein, conveyors, receptacles or exhaust fans, or 
other mechanical means, shall be provided and maintained for the purpose 
of carrying off and receiving such dust." As scientific standards of dust 
control and removal are developed, and inspectors become technical 
experts and advisers instead of mere detectives, such laws can be made 
more and more useful agencies in factory hygiene. 
Similar general legislation, directed mainly toward the protection of 
metal polishers, exists in a number of European countries, among them 
being Holland, Italy and Norway. 
Compressed Air.-Another important source of industrial illness and 
death which has been brought under legislative regulation in America is 
work in compressed air. The earliest American statute designed to com- 
bat this hazard is the New York act of 1909, which has twice been 
strengthened by amendment and is now much excelled by the standard 
law adopted by New Jersey in 1914 and Pennsylvania in 1917. In other 
states similar steps have been taken through the method of administrative 
orders. 
The standard law requires a medical examination of all persons apply- 
ing for employment in caissons or tunnels where work in abnormal air 
pressure is carried on. Only those found physically qualified may be 1010 
METHODS AND SCOPE OF PROTECTIVE LEGISLATION 
employed, and persons addicted to the excessive use of intoxicants are 
expressly debarred. Examinations must be repeated on returning to work 
after 10 days' absence and after 3 months' continuous employment, and 
records must be kept of all examinations. 
France and Holland have also legislated concerning compressed-air 
work. (For further details see Compressed Air Illness, page 790.) 
The use of the diving dress in sponge fishing has been prohibited in 
Austria-Hungary, Crete, Egypt, and Samos, while both Greece and Italy 
have placed restrictions on the depth to which divers may go, the Grecian 
limit being 127 ft. 
Textile Dust.-Specific regulations against dust and lint in textile 
establishments have for some years been established in England. In the 
dusty rooms exhausts and respirators are required, as well as thermom- 
eters and hygrometers for the regulation of temperature and humidity. 
The law provides also for the purity of the water used for humidifying. 
These regulations apply to the spinning and weaving of flax, tow, hemp 
and jute. In Massachusetts a 1910 law safeguards the purity of the 
water used in humidifying weaving and spinning rooms, and standardizes 
the thermometers for regulating temperature. 
Rag Dust.-An Austrian law aims to protect workers in paper mills 
from the irritating and infectious dust often carried by old rags. Tearing 
and dusting of the rags must be done mechanically. Washing, bathing 
and dressing accommodations, working clothes, respirators and first-aid 
materials are required, and eating and smoking are prohibited in the work- 
rooms. Persons with delicate respiratory organs, consumptives, and 
workers with open wounds may not be employed. 
Stone Dust.-To guard the workers in stone quarries and stone-dress- 
ing establishments from the dangerous dust created, Germany requires 
that the floors shall be kept damp, and workmen may not sit closer together 
than 2 meters (about 6)^ ft.). Roof shelters must be erected to protect 
the workers from the weather; men may work at dressing sandstone only 
9 hours a day, and at other occupations 10 hours. In Austria quarrymen 
must be provided with goggles or eye shades. The regulations in Holland 
are more thorough. Hours are limited to 10 a day for the first 2 years 
and 9 thereafter, precautions must be taken against the formation and 
spread of dust, and workmen are entitled to medical examination once 
a year. 
Chromates.-Provisions for the prevention of chrome ulceration 
and other diseases caused by contact with chromates are found in Austria, 
Germany and England. The German rules are that dust-producing 
processes must be carried on away from the general workrooms, and the 
chromates must as far as possible be crushed in hermetically sealed 
apparatus. Working clothes, caps and respirators are required for the 
employes, together with warm baths, soap, towels and nail brushes, cloak 
rooms and lunch rooms. For employment a certificate is necessary, stating METHOD OF REGULATION: DUSTS, POISONS, ANTHRAX 
1011 
that the applicant has no open wounds or skin disease. Monthly medical 
examinations are required, and workmen showing symptoms of chrome 
poisoning in the form of irritation of the mucous membrane of the nose 
must be suspended. 
The English regulations covering the manufacture of chromates of 
sodium are almost identical with the German. A notable addition is that 
foremen must report to their managers the names of workmen who fail 
to observe the rules for personal hygiene. 
Bisulphide of Carbon.-In rooms where bisulphide of carbon is used in 
vulcanizing rubber, England forbids work for longer than 5 hours a day, 
and no food may be eaten there. Employes must be examined monthly 
and records kept of the examinations. 
More detailed precautions against the same poison are established in 
Germany. Provision is made for special ventilators, devices to prevent the 
escape of the fumes, cloak rooms and washing accommodations with soap 
and towels. Monthly medical examinations are required. 
Mercury.-In animal hair-cutting establishments where mercury is 
used, France requires the posting of the following notice: 
Notice.-Mercury and its compounds are dangerous. They may enter the body 
with the air breathed in (dust, vapors), with food (unclean hands, unclean tables), 
through the skin (cracks, scratches, or cuts). 
Should you have any cracks, scratches or cuts please inform the management 
immediately of the fact. 
Before eating or drinking carefully clean your hands with soap and your mouth 
with drinking water. 
Should you have any pains in the mouth or teeth and excessive quantity of saliva, 
should you shiver, should you have swellings of the legs, the hands, or under the eyes, 
consult the doctor at once. 
Tobacco.-Injurious quantities of tobacco dust are carefully guarded 
against in Germany. The floors, ceiling, height of walls, windows and 
air-space of rooms where tobacco is worked up are regulated. The 
tobacco must be kept moist, and only enough for 1 day's work may be 
stored in the workroom, which must be aired three times a day and 
thoroughly cleaned twice a year. The dust must be removed from floors 
and tables daily by washing or by damp duster, and spittoons and lavatory 
accommodations with soap and towels must be provided. Spitting on 
the floor is prohibited, the mouth must not be used in making cigars, nor 
may the cigar knife be moistened with saliva. A worker who violates 
the rules after repeated warning is to be discharged without notice. 
Anthrax.-Of the infectious diseases which have gained occupa- 
tional prominence, anthrax-described in detail in an earlier chapter- 
has most widely beemmade the subject of preventive legislation. Austria, 
Belgium, France, Germany, some of the German states, Great Britain, 
Italy, Norway and the United States, have all turned their attention to 
stamping out the disease. 1012 
METHODS AND SCOPE OF PROTECTIVE LEGISLATION 
In 1901 Great Britain ordered that provision be made for keeping the 
workers' food and clothing in a clean place. Water, soap, towels and nail 
brushes are to be furnished, and all requisites for treating scratches and 
slight wounds must be at hand. If dangerous hides are handled, overalls 
protecting the neck and arms, and gloves, are required. It is the duty of 
every workman having an open cut to report the fact immediately to the 
foreman and to withdraw from the shop until the cut is healed. Still 
more careful regulations were later prescribed for work on horsehair from 
China, Siberia or Russia, and on wool, goat and camel hair. In addition 
to the foregoing requirements, material which has not been disinfected 
must be kept in a separate room to which no food, drink or tobacco may 
be taken, and no work except opening and sorting may be done upon it 
before disinfection. In addition to overalls and head coverings, the work 
people must be provided with respirators. An Act of 1919 makes addi- 
tional provisions. 
The German rules for disinfection and for sanitation of the work place 
are more strict, but otherwise the regulations follow very closely those of 
England. An administrative order in France, dated October 1, 1913, 
compiles and amplifies several earlier rules. Three notable requirements 
are the appointment of a factory physician for the examination, treatment 
and recording of cases, a first-aid box, and lime-washing of the work- 
rooms "whenever necessary, and especially when a case of anthrax has 
occurred." 
Belgium first turned its attention to the prevention of anthrax among 
longshoremen, forbidding in 1903 their direct touching of skins, horns, 
bristles or other material capable of conveying the infection, and dock 
workers with wounds on exposed parts of the body were required to band- 
age the wounds before handling such material. Five years later managers 
of brush factories were ordered to subject all bristles, immediately upon 
unpacking, to a system of disinfection capable of destroying anthrax 
spores. Austria in 1913 enacted the sweeping provision that on the 
appearance of any one of a number of contagious diseases, anthrax among 
them, a plant might be ordered closed if its operation entailed urgent 
danger to the population. Italy has as yet gone no further than offering 
a prize for the best essay on anthrax prevention. In the United States the 
Department of the Treasury which supervises imports, the Department 
of Agriculture which deals with the safety of cattle, and certain state 
boards of health have issued regulations on the subject. Action was 
stimulated by the alarming increase of cases during the war, due to the 
importation of animal hides and hair from countries with low sanitary 
standards. 
The recommendation of the International Labor Conference at Wash- 
ington in 1919 urging the disinfection, either in the exporting country or 
at the port of entry, of all wool contaminated with anthrax spores, had 
been approved by at least four countries before the end of 1921. ANTHRAX, ETC. METHOD OF COMPENSATION 
1013 
Ankylostomiasis.-As the infection of miners with ankylostomiasis, or 
"miners' hookworm," takes place mainly through soil pollution by others 
already suffering from the parasite, a few countries have taken precau- 
tions to prevent persons with the disease from securing employment in 
mines. In 1904 the Austrian Minister of Agriculture issued a circular to 
the mine inspectors in the districts of Vienna, Klagenfurt and Kracow 
prescribing the examination of applicants with this end in view. Similar 
laws exist in the Dortmund district of Prussia and in the kingdom of 
Saxony, while a royal order prescribing this and other hygienic precau- 
tions was issued in Spain in 1912. 
Contagious Diseases among Glass-blowers.-While many industrial 
conditions predispose to tuberculosis, in no case is the occupational causa- 
tion of this disease clearer than when it occurs among glass-blowers. A 
French law requires the appointment of a physician for the medical super- 
vision of employes in glass works, and the keeping of a health register. 
The same law contains the rather weak provision that "workers shall not 
be allowed to undertake any work necessitating the common use of one 
blowpipe, except only by the written certificate of the medical man to the 
effect that they are not suffering from any contagious disease at a stage 
in which such illness is capable of being transmitted by the blowpipe." 
An earlier law in Portugal makes the prohibition complete. It says: "As 
good ground exists for supposing that the prevalence of tuberculosis in 
glass-blowing works is largely caused by permitting free use of the same 
blowpipe by different workmen, his majesty the king hereby commands 
that every workman shall be provided with a blowpipe for his personal 
use, marked with his name or number, and that the use of such blowpipe 
by other workmen shall be absolutely forbidden." 
3. THE METHOD OF COMPENSATION OR INSURANCE 
The third and last of the principal legislative remedies for the preven- 
tion of occupational diseases is the method of compensation or insurance. 
While newer than the other two methods, its results are already by no 
means inconsiderable. 
The method of compensation or insurance is based on the principle 
that those individual misfortunes which cannot be prevented, either by 
prohibition or regulation, can best be borne by the community. When 
applied to industrial injuries sustained by workmen in the course of their 
employment, the justification for this principle is particularly obvious. 
It is worthy of note also that with almost startling rapidity the American 
people are coming to demand that workingmen's insurance be recognized 
as a proper function of government. 
The expense of broken machines is borne by the industry, which passes 
the burden on to society. In recent years we have come to insist that so, 
also, should be borne the financial expense of broken legs and arms. The 1014 
METHODS AND SCOPE OF PROTECTIVE LEGISLATION 
next step must be the extension of the same principle to include incapacity 
due to arms paralyzed by lead poisoning or incapacity due to other diseases 
of occupation. Instead of leaving the money loss, as well as the physical 
suffering, to be borne by the unfortunate victim or his family the financial 
burden of relief should be placed upon industry where it belongs. 
During the past few years the industrial accident problem, under the 
urge of impending legislation, has attracted the abilities of hundreds of 
experts. In addition to stringent regulations for the direct prevention of 
such industrial injuries, 46 states and territories, and the federal govern- 
ment for its own half-million civilian employes, had by the end of 1921 
boldly overthrown the discredited and out-worn system of employers' 
liability and had adopted the workmen's compensation or insurance 
principle. No agitation has been more effective in preventing accidents 
than the campaign to provide for the victims a just system of indemnity. 
And in attempting to deal effectively with the occupational disease 
problem, practical people will very soon recognize the wisdom of placing 
upon those responsible for unhealthful work conditions the financial 
burden of caring for the victims. No intelligent person can go far in the 
study of compensation for industrial accidents without realizing that a 
logical consideration of the facts must lead likewise to compensation for 
industrial diseases. In fact the arguments used so effectively by advocates 
of compensation for accidnets, and now so generally accepted by all men, 
apply with even greater force in the consideration of relief for the victims 
of occupational diseases. A considerable part of the money now paid 
to employers' liability companies and to ambulance chasers could, under 
a just system of compensation, go where it belongs-to the injured work- 
man or his family. Expensive, annoying, and unsatisfactory litigation 
could be reduced to a minimum. Information concerning special danger 
points in industry would be automatically pointed out to the factory 
inspectors in a manner both prompt and sure. Unnecessary occupa- 
tional diseases would then be prevented and that is the real problem. 
While a few large awards have been made under liability laws, Ameri- 
can victims of occupational diseases are still, except in twelve compensa- 
tion jurisdictions, practically without relief. In Massachusetts and North 
Dakota the term "injury" has been interpreted by the commissions and 
courts to include many cases of occupational disease. The California 
legislature in 1915 brought occupational diseases within the scope of her 
compensation law of 1911 by striking out the word "accidental " as applied 
to compensable personal injuries. In similar manner the compensation 
laws of Connecticut, Hawaii, Wisconsin and of the federal government 
for its own civilian employes, have been made to embrace occupational 
disease. Moreover, in 1920 New York, and in 1921 Illinois, Minnesota, 
Ohio and Porto Rico provided schedules of a limited number of com- 
pensable disabilities due to occupational diseases. But the total amount 
of compensation awards in America on account of occupational disease METHOD OF COMPENSATION GREAT BRITAIN 
1015 
is still very small. The meager results may be suggested in the brief 
statement that the New York law, hailed by Frederick L. Hoffman in 
1920 as "adequate," resulted in the entire year ending July 1, 1921, in 
but sixty-six compensation claims with only about one dozen actual 
compensation awards. 
Great Britain.-The country which led and still leads in the matter of 
compensation for occupational diseases is Great Britain. Its workmen's 
compensation act of 1906 contained a pioneer schedule of six diseases for 
which compensation was to be paid on the same basis as for accidents. 
This list has twice been extended until to-day no fewer than 28 maladies 
of occupation entitle the victims to relief. So important is this list that 
it is given in full: 
Occupational Diseases Subject to Compensation under the British Work- 
men's Compensation Act 
Diseases Listed in Original Act, December 21, 1906 
Description of disease 
Description of process 
Anthrax. 
Lead poisoning or its sequelae. 
Mercury poisoning or its sequelae. 
Phosphorus poisoning or its sequelae. 
Arsenic poisoning or its sequelae. 
Ankylostomiasis. 
Handling of wool, hair, bristles, hides 
and skins. 
Any process involving the use of lead or 
its preparations or compounds. 
Any process involving the use of mercury 
or its preparations or compounds. 
Any process involving the use of phos- 
phorus or its preparations or compounds. 
Any process involving the use of arsenic 
or its preparations or compounds. 
Mining. 
Subsequent Additions, in Effect as of Feb. 28, 1918, by Order of Secretary 
of State 
Description of disease 
Description of process 
1. Arsenic poisoning or its sequelae. 
2. Lead poisoning or its sequelae. 
3. (a) Poisoning by benzine and its homo- 
logues, or the sequelae. 
(b) Poisoning by nitro and amido 
derivatives of benzine and its 
homologues (trinitrotoluene, ani- 
lin, and others), or the sequelae. 
Handling of arsenic or its preparations or 
compounds. 
Handling of lead or its preparations or 
compounds. 
Handling benzine or any of its homo- 
logues, or any process in the manufacture 
or involving the use thereof. 
Handling any nitro or amido derivatives 
of benzine or any of its homologues, 
or any process in the manufacture of 
involving the use thereof. 1016 
METHODS AND SCOPE OF PROTECTIVE LEGISLATION 
Subsequent Addition, in Effect as of Feb. 28, 1918, by Order of Secretary 
of State.-Continued 
Description of disease 
Description of process 
4. Poisoning by dinitrophenol or its 
Handling dinitrophenol, or any process 
sequelae. 
in the manufacture or involving the 
use thereof. 
5. Poisoning by nitrous fumes or its 
Any process in which nitrous fumes are 
sequelae. 
evolved. 
6. Dope poisoning; that is, poisoning by 
Any process in the manufacture of 
any substance used as, or in conjunc- 
tion with, a solvent for acetate of 
cellulose, or its sequelae. 
aircraft. 
7. Poisoning by tetrachlorethane or its 
Any process in the manufacture or involv- 
sequelae. 
ing the use of tetrachlorethane. 
8. Poisoning by carbon bisulphide or its 
Any process involving the use of carbon 
sequelae. 
bisulphide or its preparations or com- 
pounds. 
9. Poisoning by nickel carbonyl or its 
Any process in which nickel carbonyl gas 
sequelae. 
is evolved. 
10. Poisoning by African boxwood (Goni- 
Any process in the manufacture of articles 
oma Kamassi) or its sequelae. 
from African boxwood (Gonioma Kam- 
assi). 
11. (a) Dermatitis produced by dust or 
liquids. 
(b) Ulceration of the skin produced by 
dust or liquids. 
(c) Ulceration of the mucous mem- 
brane of the nose or mouth pro- 
duced by dust. 
12. (a) Epitheliomatous cancer or ulcer- 
Handling or use of tar, pitch, bitumen, 
ation of the skin due to tar, pitch, 
mineral oil, or paraffin, or any com- 
bitumen, mineral oil, or paraffin, or 
pound, product, or residue of any of 
any compound, product of residue 
of any of these substances. 
these substances. 
(b) Ulceration of the corneal surface 
Do. 
of the eye, due to tar, pitch, bitu- 
men, mineral oil, or paraffin, or any 
compound, product or residue of 
these substances. 
13. Chrome ulceration or its sequelae. 
Any process involving the use of chromic 
acid or bichromate of ammonium, 
potassium, or sodium, or their prepara- 
tions. 
14. Scrotal epithelioma (Chimney sweeps' 
Chimney sweeping. 
cancer). 
15. Compressed-air illness or its sequelae. 
Any process carried on in compressed air. 
16. Cataract in glassworkers. 
Processes in the manufacture of glass 
involving exposure to the glare of 
molten glass. compensation: great Britain, south Australia 
1017 
Subsequent Addition, in Effect as of Feb. 28, 1918, by Order of Secretary 
of State-Continued 
Description of disease 
Description of process 
17. The disease known as miners' nystag- 
mus, whether occurring in miners 
or others and whether the symptom 
of oscillation of the eye-balls be 
present or not. 
Mining. 
18. Subcutaneous cellulitis of the hand 
(beat hand). 
Do. 
19. Subcutaneous cellulitis over the pa- 
Do. 
tella (miners' beat knee). 
20. Acute bursitis over the elbow (miners' 
beat elbow). 
Do. 
21. Inflammation of the synovial lining of 
the wrist joint and tendon sheaths. 
Do. 
22. Glanders. 
Care of any equine animal suffering from 
glanders; handling the carcass of such 
23. Telegraphists' cramp. 
animal. 
24, Writers' cramp. 
Use of telegraphic instruments. 
This apparently makes a list of 30 diseases subject to compensation. 
It will be noted, however, that two of these (lead poisoning and arsenic 
poisoning among the diseases added by the secretary of state) are duplica- 
tions, inserted merely to widen the scope of occupations to which the Act 
applies, the 11 Description of Process" in both cases being changed to 
include the "handling" as well as the "use" of the dangerous material. 
Under the British law expenses of medical attendance and burial up to 
£10 are paid in cases of death if there are no dependents. If there are, 
they receive a maximum sum equal to 3 years' earnings, with minimum 
and maximum limits of £150 and £300. In case of total incapacity, 50 per 
cent, of wages is paid, not exceeding £1 weekly, while for partial incapa- 
city the injured workman may receive the entire difference between his 
earnings before and after illness. 
South Australia.-The precedent set by Great Britain in 1906 has 
been followed by two of her colonies. Five years after the passage of the 
British law South Australia repealed its earlier compensation code and 
adopted a new one, scheduling for compensation the same six diseases 
with which occupational disease indemnity had begun in the mother 
country. The rates of compensation are, however, considerably higher 
than in Great Britain. Burial expenses are increased to £20, and the 
minimum compensation to dependents is £200 instead of £150. For 
partial as well as for total disability 50 per cent, of wages, not to exceed 
£1 a week, is given. On the other hand, remuneration for disability, 
instead of running for the entire period, is limited to £300. 1018 
METHODS AND SCOPE OF PROTECTIVE LEGISLATION 
Ontario.-In 1914 the Canadian province of Ontario adopted its first 
workmen's compensation law, modeled after that of England, and sched- 
uling the same original six diseases. Burial expenses are limited to $75, 
and compensation to dependents to $40 a month. Benefit for total 
disability is 55 per cent, of wages, and for partial disability is 55 per cent, 
of loss of earning power, both payable for life. 
France.-In France the principle of compensation for occupational 
diseases is recognized, but is as yet limited in application to four diseases. 
A section of the financial law of 1911 requires employers of miners 
suffering from ankylostomiasis to bear the expense of all medical treat- 
ment, and also to pay benefits during the treatment equal to those 
established under the accident compensation law-66% per cent, of wages 
for total disability and 50 per cent, of loss of earning power for partial 
disability. Anthrax is also rated, for compensation purposes, as an acci- 
dent. And an amendment, adopted in 1919, to the accident insurance 
law includes industrial lead poisoning and mercury poisoning for purposes 
of compensation. 
Germany.-In Germany, also, anthrax is classed as an accident for 
purposes of compensation. Moreover, in Germany, as well as in many 
other countries, occupational diseases are to some extent taken care of 
under national systems of health insurance. The rates of benefit under 
this form of insurance are, however, much lower than under accident 
insurance or compensation, and consequently sentiment is steadily 
growing in favor of placing diseases directly attributable to the industry 
in the latter system, where they properly belong. The strength of this 
sentiment in Germany is revealed in the workmen's insurance code of 
1911. Here it is provided that: "By decision of the federal council the 
accident insurance can be extended to specified occupational diseases in 
industries." 
Switzerland.-In Switzerland the same movement is also in pro- 
gress. The Swiss federal law of 1911 relating to sickness and accident 
insurance provides that "the federal council shall prepare a list of sub- 
stances, the production or employment of which occasions dangerous dis- 
eases. Every disease exclusively or essentially due to the action of one of 
these substances in an enterprise subject to insurance is deemed an acci- 
dent within the meaning of the present law." This provision, it will be 
seen, is stronger than that in the German code, which is merely permissive. 
Bulgaria.-Industrial disability compensation in Bulgaria is as yet 
limited to employes of the state, but for them the law of 1906 estab- 
lishes compensation for accident and for illness if it "arises out of" the 
employment. 
Health Insurance.-While, as has been pointed out, the benefits to the 
employe under a system of health insurance are lower than under acci- 
dent compensation, rquch may be expected, in the direction of occupa- 
tional disease prevention, from, the rapid spread of compulsory health compensation: various countries-CONCLUSION 
1019 
insurance throughout the world. Austria, Czechoslovakia, Germany, 
Great Britain, Holland, Hungary, Luxemburg, Norway, Portugal, Rou- 
mania, Russia and Serbia-already have such compulsory systems, while a 
number of others, Switzerland, for instance, offer subsidies to voluntary 
health funds. An active campaign for a compulsory health insurance 
system is now under way, also, in the United States. 
Conclusion.-At a time when the health of the people receives thought- 
ful attention, and sociologists, lawyers and physicians vie with one 
another in pressing upon national legislatures the need of action, the 
effects of industries upon health call for thoughtful study. At a time 
when compensation for accidents received in employments is the most 
actively discussed phase of labor legislation, the question of occupational 
diseases demands consideration. 
Gradually, and surely, but almost without realizing it, we have passed 
within the last 20 years into a new period of economic history. The 
courts are beginning to get a new perspective on life. Century-old pre- 
cedents based on individualism are trembling in the balance. Here and 
there a judge shows clearly that he has been studying economics as well as 
law. Recent court decisions clearly indicate that protective labor legis- 
lation will be sustained as a legitimate exercise of the police power when 
it is made apparent that conditions justify such interference on the grounds 
of health. 
Future labor legislation, and court decisions which mark the path of 
social progress, will be based upon scientific study of industrial hygiene. 
Only through careful study can we secure accurate information which will 
finally enable us to establish scientific standards. The establishment of 
such standards is prerequisite to intelligent legislation, to enlightened 
court opinions, and to efficient enforcement of the law. 
While such researches are under way, we should emphasize at every 
opportunity the following considerations: (1) all preventable occupational 
diseases must be prevented; (2) those occupational diseases which we do 
not yet know how to prevent must be reduced to a minimum; and (3) the 
victims of occupational disease must be compensated for their injuries by 
some just system of insurance. CHAPTER IV 
CHILD LABOR 
OWEN R. LOVEJOY, New York City 
It is practically axiomatic in this generation that children need special 
safeguards in industry-if they are to be in industry at all. All child 
labor laws regulating hours, night work, and so on, are based upon this 
assumption, and in most of the United States the lawmakers have gone 
further, in the belief that if a given trade is known to be injurious or dan- 
gerous to adults, it is doubly so to children and therefore they must 
be excluded from it. Our dangerous trades laws, as affecting minors, are 
various in scope, some covering only mines and quarries, some including 
trades in which there is a moral as well as physical hazard, and some 
naming a long, carefully classified list of occupations from which children 
are excluded. But in their basic idea, the protection of youth from 
industrial hazards, they are the same, and most of them, enacted on the 
premise that children may enter industry at the age of 14, prohibit the 
employment of children under 16 in certain dangerous trades (such as 
work on specified dangerous machines, in connection with processes in 
which poisonous acids are used, in mines, on scaffoldings, in tobacco 
factories, etc.) and of children under 18, or even 21, in other more hazard- 
ous occupations (as in connection with blast furnaces, in the operation of 
emery or abrasive wheels, in the manufacture of white or yellow phos- 
phorus, or phosphorus matches, etc.).* 
The intent is good: we want to protect our children from all the 
hazards of modern industry. But are we doing it? 
If the laws were serving their purpose, accidents to children in industry 
would be far between, and would occur only when a child was employed in 
direct violation of law. But, unfortunately, the records show that this is 
not the case. Each year, leaving occupational diseases out of account for 
the present, thousands of American children suffer industrial accidents, 
some of which are fatal and many of which result in permanent partial 
disability. 
In Massachusetts, for instance, which has one of the most comprehen- 
sive dangerous trades laws in the country, there were 1691 tabulatable 
accidents to children between 14 and 16 in the year 1919. These repre- 
sented only about 45 per cent, of all recorded industrial accidents to 
minors in that state, but were the most serious, and of them 10 were 
fatal, while 62 resulted in permanent partial disability of the child. In 
*}A typical dangerous trades law for minors is appended to this chapter. It should 
not,-however, be taken as a model; it is simply typical. 
1020 CHILD LABOR LAWS 
1021 
Pennsylvania, which also has a comprehensive dangerous trades law, 
there were recorded 4663 industrial accidents to children under 16 in the 
last four years. The state law here specifically prohibits the employ- 
ment of children under 18 in extra-hazardous occupations, yet there 
were in this same four-year period 59 fatal accidents to children of 17 
and 18 alone. In Kentucky, which has a similar law, the State Com- 
pensation Board reported in 1918 that 213 children aged 16, 30 aged 15, 
10 aged 14, and 2 aged 13, received compensation for injuries during the 
year ending June 30, 1918. 
It must not be supposed that the above records imply either that the 
law is ignored in these states or that conditions there are exceptionally 
bad. These reports are cited chiefly because they are among the few 
complete records available. For there are states in which no record of 
industrial accidents to minors is kept, arid it is a grave indictment of our 
system, or lack of system, that no complete figures as to accidents to 
minors in the whole United States are to be found. The state records 
given above are, so far as we know, typical. There were some violations 
of the law, especially as to children operating dangerous machines without 
permits, but apparently most of the children were at work in complete 
accordance with the law. And yet the accidents occurred. Is not the 
natural conclusion, therefore, that there is something wrong with the laws 
themselves, that their weakness is not in their administration, but in their 
scope, that they are, very evidently, failing to protect our children? 
When we come to study the laws carefully we find that their under- 
lying weakness is, probably, that they have been enacted on the basis of 
adult and not child experience. That is, children are excluded from trades 
or processes which have proved injurious or dangerous to adults-not to 
children. So far as this goes, it is well enough; that is, it is a beginning. 
But the child, owing to his peculiar characteristics and susceptibilities 
is bound to be affected by conditions which do not necessarily affect the 
normal adult. A recent study of industrial accidents to children in 
Massachusetts* states that "inability to control perfectly the machinery 
or tools with which they worked was the chief cause of the accidents. 
. . . The awkwardness of children of the adolescent age, particularly 
of the boys, proves that they have not learned to direct perfectly the 
activities of their own bodies, so their inability to control fully any 
additional force is not surprising." Here is clear evidence of the need 
of special legislation based on our knowledge of children's limitations. 
A machine which is wholly safe for the normal adult may be unsafe for 
a child, and so there must be room in our laws for such discrimination. 
Some states have already made provision for something of the kind by 
creating through their laws a board with discretionary powers which shall 
from time to time make rulings as to trades and operations from which 
* One Thousand Industrial Accidents to Massachusetts Children. The American 
Child, Nov., 1920, page 222#. 1022 
CHILD LABOR 
minors must be excluded. Such a board is essential to the protection of 
minors in industry, and should be a part of the administrative machinery 
in every state. It may be a section of the Industrial Commission, 
or of the Department of Labor, or it may be under the State Board of 
Health, but in any case it must be made up of responsible persons, 
preferably physicians, who can and will study the conditions surrounding 
minors in the various trades in which they engage. 
Such a board, however, has scant material for its work unless there is 
information available as to the actual physical effects of occupations upon 
children. And here we come upon the weakness of all our child labor 
laws: we do not really know what the physical effects of industry, or indus- 
tries, are so far as children are concerned. The health of the working-child 
has long been neglected. We have studied infant mortality and baby 
welfare; we have stepped into the field of school-hygiene and are trying to 
improve the health of our school-children; but when a child goes out of 
school to a factory, he is regarded, apparently, as in no further need of 
health-protection, and is left, generally, to look after himself. 
Only seventeen states in the Union make a physical examination a 
prerequisite to entrance into industry, while nine other states require such 
examination only when there is doubt as to the child's physical fitness. 
Naturally, a thorough physical examination by a selected doctor should 
be required of every child who leaves school for work. Even the most 
cursory study of the physical defects found among school children will 
show the necessity for this preventive measure. But even this is not 
enough to assure us that the child will not develop physical ills after going 
to work, that he will not be adversely affected by the conditions under 
which he works. Only periodic examinations, while the child is at work, 
will assure us of this, and no state in the Union has provided for such 
examinations, although three states, and some communities, do require a 
re-examination each time that a child changes his employment. 
The International Conference on Child Welfare Standards, held under 
the auspices of the United States Children's Bureau in 1919, emphasized 
especially the need of these periodic examinations. Indeed, this confer- 
ence did a great service to the cause of child-protection by bringing out 
clearly the grave need of studying the health conditions of working- 
children. Not only did the conference pass on certain minimum stand- 
ards of protection immediately necessary, but, it appointed a permanent 
committee to formulate standards of normal development and physical 
fitness for the use of doctors examining children who apply for employ- 
ment certificates. This committee is now at work, and in a preliminary 
report has urged the need of scientific study of the effects of different 
occupations upon the health of the adolescent, and has suggested seven 
different lines of possible research. 
The standards passed by the whole conference in 1919, which we may 
well study in connection with our dangerous trades laws, were as follows: PHYSICAL EXAMINATIONS-PROHIBITED TRADES AND PROCESSES 
1023 
" A child shall not be allowed to go to work until he has had a physical examination 
by a public health physician, and has been found to be of normal development for 
a child of his age and physically fit to do the work at which he is to be employed. 
"There shall be periodical medical examination of all working children who are 
under 18 years of age."* 
The advisory committee of the National Child Health Council has 
recently made similar recommendations in its "Health Provisions for 
State Laws Relating to Children." These were drawn up by a special 
committee representing the American Child Hygiene Association, 
National Physical Education Service, U. S. Public Health Service, 
National Child Labor Committee, Children's Bureau, Bureau of Educa- 
tion, and American Red Cross, and included the following statement: 
"As long as a child is of school age he should receive health education and super- 
vision. (Note: Experience shows that the continuation school offers an effective 
medium of health education and supervision.) Physical examinations should be 
given when he leaves school to go to work, at each change of employment, and period- 
ically thereafter while he is of school age." 
While these recommendations are made for the protection of children 
in industry in general, and not simply in dangerous trades, they have a 
definite value in the study of dangerous trades. For only through 
examinations of children on change of employment and at definite periods 
while the child is at work, can we learn the actual effect of different proc- 
esses upon children's health. And only by such examinations will the 
boards empowered to make rulings as to occupations dangerous to minors 
secure real data as to the occupations from which children should be 
excluded. 
Where any such examinations are given there is immediate evidence of 
their value. In Maryland, for instance, examinations were given for a 
time to every child who changed employment, and one case alone will give 
an idea of the results: 
"This girl was examined by a board physician on February 2, 1915, after she had 
been working as a preparer in a cannery and her health was found to be normal. She 
then went to work in a tobacco factory and when she was again examined on Jan. 
25, 1916, was found to be anemic, and to have a heart murmur. Next she worked in 
a paper-box factory, and when examined on March 7, 1916, was found to have recov- 
ered from her anemia and heart murmur and to have gained 10 pounds in weight. 
The employment of children under 16 is now prohibited in tobacco factories." f 
This is an isolated case of course, but typical, and its implications are 
clear. 
The question of the trades and processes from which children must be 
excluded is, however, only half of our problem. For there is always, 
going hand in hand with it, the other question of the age at which a minor 
may safely undertake a given job. That is, if we are to exclude children 
* See Standards of Child Welfare, U. S. Children's Bureau publication, No. 60, 1919. 
t Administration of Child Labor Laws, Employment Certificate System, Maryland. 
U. S. Children's Bureau publication, No. 41, page 41. 1024 
CHILD LABOR 
from dangerous work, how long shall we exclude them? Until they are 
16? Or 18? Or 21? 
As has been stated, the ordinary dangerous trades law of this country 
is based upon the idea that children go to work at 14 (and most of our 
state child labor laws are still framed on this premise). It has therefore 
been concluded that if a child goes to work at 14, he is probably strong 
enough and mature enough by the time he is 16, to go into trades where 
there is at least some physical hazard. And so the laws prohibit the 
employment of minors under 16 in mines, quarries, and other dangerous 
occupations. Only children over 18, however, are allowed to enter extra- 
hazardous occupations, in the more advanced laws, and it should be noted 
in this connection, that in many cases the processes included in the extra- 
hazardous classification are those in which the presence of an immature 
person might be dangerous to the welfare of his fellow-workmen as well as 
to himself. These classifications of dangerous and hazardous occupations 
have come to be very generally accepted, but they are based rather on 
usage than on facts as to the peculiar susceptibilities and characteristics of 
minors, or their reaction to any occupation. 
And in spite of usage, in spite of our habit of thinking that 14 is the 
proper age for a child to go to work, there has been growing in the last 
decade a strong belief that our whole system is wrong, a belief based upon 
what facts we have as to childhood and industry. More and more people 
are telling us every day that industry is no fit place for a child until he is 
16, that the years between 14 and 16, indeed, are especially critical 
because of the physical changes that take place in the child at that time. 
Doctors tell us this, psychologists, even factory inspectors and labor 
commissioners. And the same people who say that the child must be 
kept out of industry until he is 16, demand that all minors be excluded 
from the hazardous or dangerous occupations. The Children's Bureau 
Conference on Standards, mentioned above, made up of child-specialists 
and health experts from Europe as well as America, and representing the 
most advanced and scientific opinion on the subject, decided upon the 
following age minimums: 
"An age minimum of 16 for employment in any occupation, except that children 
between 14 and 16 may be employed in agriculture and domestic service during vaca- 
tion periods. 
"An age minimum of 18 for employment in and about mines and quarries. 
"An age minimum of 21 for night messenger service. 
"An age minimum of 21 for girls employed as messengers for telegraph and mes- 
senger companies. 
"Prohibition of the employment of minors in dangerous or hazardous occupations 
or at any work which will retard their proper physical development."* 
This is something very different fom our present system, and yet we 
suspect that it is something that will come-when we know more about the 
* Standards of Child Welfare. U. S. Children's Bureau Publication, No. 60, page 433 
1919. THE AGE QUESTION-DANGEROUS TRADES LAW FOR MINORS 
1025 
physical effects of child work than we do at present. The regulation of 
child-employment has from the beginning been open to change; as our 
knowledge has grown, so have our standards. There was a time when 
the world talked with horror of 5-year-old children in factories, but saw 
nothing evil in 12-year-old children's presence there. And yet now we 
consider the 12-year-old far too immature to take up industrial burdens. 
There may come a time, therefore, when we shall all agree, without argu- 
ment, that there is no place at all for the minor in any occupation which 
is dangerous or productive of health hazards. At present we are still 
learning-slowly, but with, at least, a growing sense of the breadth of our 
problem. The permanent committee on health standards appointed by 
the Children's Bureau Conference, the interest of the International Labour 
Office in the regulation of child-employment, the work of the National 
Child Health Council in coordinating and stimulating our child-health 
activities, the various health studies by individuals and such organizations 
as the National Child Labor Committee, and the attempts of state labor 
departments, such as that of Massachusetts, to provide safety education 
for minors in factories, are all hopeful signs for the future, signs of a 
desire to approach the problem scientifically. But until we know far 
more in fact than we do at this moment, until regulation of the employ- 
ment of minors is based not on opinion, feeling or expediency, but on 
actual knowledge of the effects of a given kind of work upon a normal 
adolescent, we cannot say that we are actually protecting minors from the 
hazards of industry. 
Text of a Typical Dangerous Trades Law for Minors in the United States 
Section 3.-No child under the age of 16 years shall be employed, per- 
mitted or suffered to work at any of the following occupations or in any of 
the following positions: Adjusting any belt to any machinery; sewing or 
lacing machine belts in any workshop or factory; oiling, wiping or cleaning 
machinery or assisting therein; operating or assisting in operating any of 
the following machines: Circular or band saws, wood shapers, wood 
jointers, planers; sandpaper or wood-polishing machinery; wood-turning 
or boring machinery; picker machines or machines used in picking wool, 
cotton, hair or any other material; carding machines; paper-lace machines 
leather-burnishing machines; job or cylinder printing presses operated by 
power other than foot power; boring or drill presses; stamping machines 
used in sheet metal and tinware or in paper and leather manufacturing, or 
in washer and nut factories; metal or paper cutting machines; corner stay- 
ing machines in paper-box factories; corrugating roll, such as are used in 
corrugated paper, roofing or washboard factories; steam boilers;dough 
brakes or cracker machinery of any description; wire or iron straightening 
or drawing machinery; rolling mill machinery; power punches or shears; 
washing, grinding or mixing machinery; calendar rolls in paper and rubber 
manufacturing; laundering machinery; or in proximity to any hazardous 
or unguarded belts, machinery or gearing; or upon any railroad, whether 1026 
CHILD LABOR 
steam, electric or hydraulic; or upon any vessel or boat engaged in naviga- 
tion or commerce. 
Section 4.-No child under the age of 16 years shall be employed, per- 
mitted or suffered to work in any capacity in, about or in connection with 
any processes in which dangerous or poisonous acids are used; nor in the 
manufacture or packing of paints, colors, white or red lead; nor in solder- 
ing; not in occupations causing dust in injurious quantities; nor in the 
manufacture or use of dangerous or poisonous dyes; nor in the manufacture 
or preparation of compositions with dangerous or poisonous gases; nor in 
the manufacture or use of compositions of lye in which the quantity thereof 
is injurious to health; nor on scaffolding; nor on a ladder; nor in heavy 
work in the building trades; nor in any tunnel or excavation; nor in, about 
or in connection with any mine, coal breaker, coke oven, or quarry; nor 
in assorting, manufacturing or packing tobacco; nor in operating any 
automobile, motor car or truck; nor in a bowling alley; nor in a pool or 
billiard room; nor in any other occupation dangerous to the life and limb, 
or injurious to the health or morals of such child; nor shall any child 
under the age of 16 years be employed upon the stage of any theatre or 
concert hall or in connection with any theatrical performance or other 
exhibition or show. 
Section 5.-The state board of health may, from time to time, deter- 
mine whether or not any particular trade, process of manufacture or 
occupation, in which the employment of children under the age of 16 years 
is not already forbidden by law or any particular method of carrying on 
such trade, process of manufacture or occupation, is sufficiently dangerous 
to the lives or limbs or injurious to the health or morals of children under 
16 years of age to justify their exclusion therefrom. No child under 16 
years of age shall be employed, permitted or suffered to work in any 
occupation thus determined to be dangerous or injurious to such 
children. 
Section 18.-No child under the age of 18 years shall be employed, per- 
mitted or suffered to work in, about or in connection with blast furnaces, 
docks or wharves; or in the outside erection and repair of electric wires; in 
the running or management of elevators, lifts or hoisting machines; in 
oiling or cleaning machinery in motion; in the operation of emery wheels 
or any abrasive, polishing or buffing wheel where articles of the baser 
metals or iridium are manufactured; at switch tending, gate tending, 
track repairing, or as brakemen, firemen, engineers, motormen or conduc- 
tors upon railroads, or as railroad telegraph operators; as pilots, firemen 
or engineers upon boats and vessels; or in or about establishments wherein 
nitroglycerine, dymanite, dualin, guncotton, gunpowder or other high 
or dangerous explosives are manufactured, compounded or stored; (13) 
or in the manufacture of white or yellow phosphorus or phosphorus 
matches; (14) or in any distillery, brewery, or any other establishment 
where malt or alcoholic liquors are manufactured, packed, wrapped or DANGEROUS TRADES LAW FOR MINORS 
1027 
bottled; (15) or in any hotel, theatre, concert hall, place of amusement, 
or any other establishment where intoxicating liquors are sold. 
Section 19.-The state board of health may, from time to time, deter- 
mine whether or not any particular trade, process of manufacture or occu- 
pation, in which the employment of children under 18 years of age is not 
already forbidden by law, or any particular method of carrying on such 
trade, process of manufacture or occupation, is sufficiently dangerous to 
the lives or limbs or injurious to the health or morals of children under 18 
years of age to justify their exclusion therefrom. 
No child under 18 years of age shall be employed, permitted or suffered 
to work in any occupation thus determined to be dangerous or injurious to 
such children. 
Section 20.-No minor under 21 years of age shall be employed, per- 
mitted or suffered to work in, about or in connection with any saloon or 
barroom where intoxicating liquors are sold. 
Section 21.-No female under 21 years of age shall be employed, per- 
mitted or suffered to work in or about any (1) mine, (2) quarry, (3) or 
coal breaker, except in the office thereof, (4) or in oiling or cleaning 
machinery while in motion. 
Section 22.-No female under 21 years of age shall be employed, per- 
mitted or suffered to work in any capacity where such employment com- 
pels her to remain standing constantly. 
Every person who shall employ any female under 21 years of age in 
any place or establishment mentioned in Section 1 shall provide suitable 
seats, chairs or benches for the use of the females so employed, which 
shall be so placed as to be accessible to said employees; and shall permit 
the use of such seats, chairs or benches by them in so far as the nature 
of their work allows, and there shall be provided at least one seat to every 
three females. CHAPTER V 
WOMEN WAGE EARNERS 
IRENE OSGOOD ANDREWS, New York City 
Because of the physical differences between men and women, working 
women are exposed to health dangers which do not so seriously affect 
men. With a physique slighter and less strong, woman has not the same 
power to resist conditions which insidiously break down health and which 
predispose to more serious disturbances. She has, therefore, been given 
by most civilized countries special legislative protection. 
In sharp contrast with the leisurely, easy-going methods found in the 
early stages of factory production, practically all countries have seen a 
new and threatening strain created in industry by the introduction of 
machinery followed by constant speeding up, by an ever increasing number 
of machines to be handled or attended by one person, and by the require- 
ment of a constantly enlarged output. The complexity of modern indus- 
try and machinery, in marked distinction from the simplicity of the earlier 
forms, has resulted in a division of labor which has greatly increased the 
speed and monotony of work and tends to bring on a fatigued condition. 
Authorities have shown that the wastes of the body, which under normal 
conditions of work and exercise would be thrown off, under conditions of 
overwork and exhaustion are allowed to accumulate in the blood and the 
worker is literally poisoned by these waste products and predisposed to 
specific ailments as well. This condition also increases the danger of 
contracting those definite occupational diseases which threaten many 
industrial workers. 
The movement toward protective legislation has been greatly stimu- 
lated by the significant increase during the last 30 years in the number of 
females industrially employed in this country. In 1880 this number 
reached over 2,500,000; in 1900 the number rose to over 5,250,000 and in 
1910 the number had grown to 8,075,772, or 21 per cent, of the entire 
gainfully employed population.* Upon the basis of the census we find 
that the number of female breadwinners is increasing faster than the num- 
ber of male breadwinners, and also much faster than the female popula- 
tion. 
* "According to an advance statement by the Bureau of the Census, the total number of 
females ten years and over industrially employed in 1920 was 8,549,399. The number of 
those engaged in manufacturing and mechanical pursuits show a substantial increase; 
trade and transportation, professional work, and mining show practically a 50 per cent, 
increase. On the other hand, there was a decline in the number of females employed in 
domestic and personal service and in agriculture." 
1028 STATISTICS CONTROL LEGISLATION 
1029 
Females 16 years of age and over represent about 25 per cent, of the 
total number employed over that age and are distributed as follows: 
Agriculture 1,807,050 
Domestic and personal service 2,620,857 
Manufacturing and mechanical 1,772,095 
Mining 1,094 
Trade and transportation 1,502,352 
Professional 673,418 
While the proportion of women to men in the manufacturing and 
mechanical industries, which most concern us here, has remained since 
1899 the same-that is, 19.5 per cent.-the total number of women has 
increased, and in certain of the larger industries it has increased faster 
than the number of men. Among these industries are boots and shoes, 
canning and preserving, confectionery, printing and publishing, silk and 
silk goods, tobacco, and woolen and worsted goods. Among those indus- 
tries where the number of women is apparently increasing, but not at so 
rapid a rate as the men, are cotton goods, men's and women's clothing, 
hoisery and knit goods, and millinery and lace goods. A smaller industry 
in which the number of women is increasing not only very rapidly but also 
much more rapidly than the number of men is the manufacture of electri- 
cal machinery, apparatus and supplies. Here the number of women over 
16 increased from 6956 in 1899 to 19,831 in 1909-an increase of 185 per 
cent.; the number of men in the meantime increased only 93 per cent. 
Although men still form the larger number of employes, the proportion 
of women to the total number employed increased from 16 per cent, 
to 22 per cent. 
The necessity for control over women's work is now generally accepted 
in this country, both by legislators and by the courts. This acceptance 
has been secured because of the emphasis which has been placed upon the 
need of protecting the health of women.1 As Justice Brewer said (Miller 
vs. Oregon, 208 U. S. 412): "That woman's physical structure and 
the performance of maternal functions place her at a disadvantage in the 
struggle for subsistence is obvious. This is especially true when the 
burdens of motherhood are upon her. Even when they are not, by 
abundant testimony of the medical fraternity, continuance for a long time 
on her feet at work, repeating this from day to day, tends to injurious 
effects upon the body, and as healthy mothers are essential to vigorous 
offspring, the physical well-being of woman becomes an object of public 
interest and care in order to preserve the strength and vigor of the race." 
In regard to legislation, however, concerning those occupations in 
which the employment may directly produce disease, we find ourselves far 
behind European countries. Practically no thoroughgoing, extensive 
investigations of the specific occupational diseases among women workers 
have been made in this country. Indeed it has been only within the last 
few years that the subject here has been widely discussed at all. It is 1030 
WOMEN WAGE EARNERS 
mainly because of this lack of public information and interest that we find 
special legislation on this subject in America so meager. 
Control over woman's work is secured by two main methods. The 
first is prohibition, by which women are entirely excluded from certain 
occupations which present unusual danger, such as those involving the use 
of poisons, the presence of excessive dust or very high temperatures. The 
second method is regulation, by which conditions in work places must 
conform to certain specified minimum standards before women may be 
employed therein. Regulations relate usually to air conditions, sanitary 
conditions, temperature, or hours of labor. In addition to direct legis- 
lation, control is also indirectly secured through compulsory insur- 
ance, by which more adequate protection is afforded workers through the 
action of the employer who for economic reasons desires to reduce costs 
due to compulsory compensation for industrial accidents or sickness. 
Before entering upon the details of specific legislative enactments 
attention should be given to the difference which exists between the 
European method of establishing protective regulations and that employed 
in America. Here, for legislative purposes, we as a rule group many 
industries together, as manufacturing, mercantile or transportation. But 
in Europe, for the more important legislation, each particular industry is 
studied by itself and rules are provided to fit the peculiar dangers of that 
industry. In addition, if any occupation or process within the industry 
holds special dangers, special rules are made to apply for that occupation 
or process alone. Thus in France women and children are excluded from 
a list of over 100 occupations unless certain regulations are complied with, 
and they are entirely excluded from an additional list of over 50 
dangerous trades. 
The method of administration in Europe also differs considerably from 
that in America. In foreign countries a general law is usually accompan- 
ied by the authority to make, through administrative orders, rules and 
regulations for each separate industry or occupation as the needs of the 
industry or occupation may demand, including also the power to make 
limited exceptions. This applies to the limitation of hours of work as well 
as to the regulation of physical conditions. Until recent years in America 
all protection was secured through legislative enactment alone, with con- 
siderable discretionary power in the hands of the inspection officials. 
Within very recent years several American states, notably California, 
New York, Oregon, Pennsylvania and Wisconsin, have enacted labor 
legislation based upon the method used in Europe, and used in America 
for many years by public service commissions and by boards of health. 
Having in mind, therefore, the European method of enacting protec- 
tive legislation, one is not surprised at finding the factory acts of those 
countries a mass of detail frequently applying only to one industry, one 
occupation or one process, containing many exceptions and in most cases 
providing for special orders by the administrative authorities. PROTECTIVE LEGISLATION PROHIBITED EMPLOYMENTS 
1031 
PROHIBITED EMPLOYMENTS 
In taking up the first method of control over woman's work we find 
that practically all civilized countries have recognized that certain 
employments, because of unusual physical or moral dangers, should be 
closed to women, and they have given legal sanction to such exclusion. 
In America most of these prohibitive laws relate to mines and saloons. 
Women are forbidden to work in mines in most of the mining states and in 
saloons, unless they are members of the family, in about 16 states. 
The employment of women is forbidden also in a few states in cleaning 
moving machines and in the use of emery, polishing or buffing wheels 
where articles of iridium or of the baser metals are manufactured. 
Effective legislation of this character, however, presupposes careful 
intensive investigation and very few such investigations have been made 
in this country; they are particularly lacking for the more dangerous occu- 
pations such as those involving the use of poisons or the presence of harm- 
ful dusts or gases. We find ourselves, therefore, far behind European 
countries in this particular. Take, for example, the one instance of the 
use of lead. The harmful effects of contact with this poisonous substance, 
and particularly the peculiar susceptibility of women, have long been 
known. In America2 women employed in lead processes in potteries, for 
■example, are engaged usually in dipping the ware in the lead glaze, remov- 
ing the excess glaze, decorating with lead colors and cleaning or sweeping 
floors, boards or tables where lead dust is present. Investigations have 
shown that among women employed in potteries in America the ratio of 
cases of lead poisoning is 1 to 7, while in Great Britain the ratio is 1 to 64. 
Yet in only six states are there any protective regulations and in no state 
are women excluded from work involving the use of lead. Abroad, how- 
ever, this prohibition is placed with more or less thoroughness upon 
women and children in many countries, Argentina, England, Germany, 
France, Italy and Holland having had legislation on the subject prior to 
the year 1919. The recommendation of the International Labor Con- 
ference of 1919 in regard to the exclusion of women, as well as of children 
under eighteen, from work in a number of dangerous lead trades, has been 
adhered to by Great Britain, Denmark, the Netherlands, Portugal and 
Rumania. 
Among the other occupations involving the use of poisonous sub- 
stances and forbidden to women in various countries are the making of 
electric accumulators, the manufacture of paints, varnishes and colors, 
brass casting, zinc or lead smelting, certain parts of glass manufacture, 
the manufacture of explosives, the curing of skins or fur of rabbits, and 
many other occupations involving the use of injurious chemicals. Most 
foreign countries also prohibit the underground work of women in mines. 
In France a list of over 100 occupations is entirely forbidden to women 
and to children under 18, including such occupations as lace bleaching 
with white lead, curing the skins or fur of rabbits, sharpening or polishing 1032 
WOMEN WAGE EARNERS 
metals, coating mirrors with quicksilver, and the cutting or tearing of 
rags. Twelve more employments are forbidden entirely to children 
under 18, and an additional list of occupations in which these persons may 
not engage, unless certain harmful conditions are removed, includes 
establishments for bleaching cloth, straw or paper, rubber works where 
fumes of sulphide of carbon are given off, and print cloth factories, dye 
works, and metal-lacquering establishments where poisonous substances 
are used. Spain has a well-classified list of over 100 occupations forbidden 
to children under 16 and female minors. Similar lists, while not identical, 
are found in the more important countries. In most of these countries 
the administrative authorities are given power to extend the lists of pro- 
hibited employments at any time that investigation reveals the necessity 
for exclusion. 
REGULATED EMPLOYMENTS 
The majority of the occupations which are forbidden to women in 
Europe involve the presence of dusts, fumes, vapors, gases, or substances 
of a poisonous or well-defined harmful character. There exists, in 
addition, a large group of occupations where injurious substances or 
conditions are present but where the ill effects upon health are less 
definite. This second and much larger group comprises those occupations 
which expose workers to such harmful conditions as extremes of heat or 
cold, undue humidity, impure air, insufficient or poorly distributed 
lighting, or excessive speed or strain. While these conditions produce a 
marked effect upon the health of women, predisposing them to such dis- 
eases as pneumonia, tuberculosis, functional and nervous disorders, eye 
injuries or 'orthopedic derangements, yet it is difficult to designate sick- 
nesses of this character as specifically occupational in origin, since condi- 
tions outside the work place may be a factor in producing the illness. 
The control of conditions in occupations of this class is usually effected 
by means of regulations either directly specified in the laws or issued by 
the administrative authorities as rules or orders. In America legislation 
of this class is extremely general in character, is loosely drawn and seldom 
amounts to more than a mere declaration of principles. Such laws apply 
usually to all industries and relate to adequate ventilation, proper toilet 
facilities, cleanliness, lighting, overcrowding and seats for females. 
These measures in most cases apply to both sexes alike and depend for 
their enforcement almost entirely upon the spirit and intelligence of the 
administrative authorities. They are to be found in all of the industrial 
states of America. 
In a very few cases more specific provisions are found, as in New York 
where females may not be employed in connection with core making in 
any brass, iron or steel foundry unless the room where cores are baked is 
separated from the making process by partitions extending from the floor 
to the ceiling and so constructed as to prevent the passage of gases and REGULATED EMPLOYMENTS 
1033 
fumes into the room where the women are working. The State Board of 
Labor and Industries in Massachusetts, also, may make regulations for 
the control of work in core rooms, and a few states provide for additional 
cleanliness and toilet facilities where women are employed. 
The lifting of heavy weights is regulated in five states. California 
and Massachusetts require pulleys or castors for receptacles of 75 lb. or 
more handled by women; New York and Pennsylvania prohibit the hand- 
ling of heavy cores; Ohio prohibits freight handling and the frequent 
lifting of weights over 25 lb; and Pennsylvania rules also that women in 
explosive plants shall not lift heavy weights. 
In a few additional states specific regulations have been adopted which 
apply to men and women alike, as in Massachusetts where the relation of 
humidity to temperature in textile mills is regulated, in New Jersey, 
Michigan and Illinois where specific rules exist for dust removal, and in 
New York and Wisconsin where very extensive regulations have been 
promulgated; yet the instances cited above practically exhaust the 
special protective regulations for women in this country. 
In contrast to these prevailing vague general provisions applying to 
both sexes alike, we find in Europe detailed regulations as to temperature, 
humidity, lighting, and the lifting of weights, applying to women and 
minors alone. In regard to the important factor of temperature in work- 
rooms, we find specific regulations in many countries. In Holland, for 
instance, women and young persons under 16 years of age may not be 
exposed to a temperature of 89%°F. if the outside temperature is below 
84^°F. in the shade; if the temperature is 84^°F. in the shade or higher, 
the inside temperature may not exceed this by more than 5%°F. They 
may not be employed where the temperature is continuously from 77° 
to 89%°F. unless the measures prescribed by the district inspector 
labor for lowering the temperature have been adopted; neither may they 
be employed in any place which is not heated to 50°F. or any higher 
temperature which the district inspector may require, particularly if 
the employes are to do work which requires little physical exertion. 
In addition, special requirements as to temperature and humidity are 
placed upon special processes; in spinning or weaving establishments, 
for instance, if the atmosphere is artificially dampened, a wet-bulb 
thermometer must be provided and the temperature may not exceed 77°F. 
unless the outside temperature exceeds 89%°F. in the shade, in which case 
the inside temperature may vary in the same proportion as the outside 
temperature. Experts in this country might disagree upon the exact 
degree of temperature to be allowed, but as yet we have not even taken 
steps for regulations of any kind. 
In Holland, also, we find special provisions in regard to proper lighting. 
Women and young persons under 17 may not be employed in places which 
are insufficiently lighted or where artificial light is required between 9 A.M 
and 3 P.M. unless the nature of the work done makes it impossible to 1034 
WOMEN WAGE EARNERS 
admit light, in which case the hours of work may be regulated by the 
administrative authorities and every such person must be given a certain 
number of hours each day in the sunlight. In addition, the illumination 
must equal at least 30 Hefner units at a distance of 1 meter in the following 
■occupations: embroidering, weaving damask, silk or cotton colored mate- 
rials, the treatment of diamonds or other precious stones, glass-cutting, 
■engraving or wood-cutting, instrument making, lace working, bead 
threading, typesetting, machine knitting, gold and silversmith's work, 
making of hair goods, sewing, quilting (except leather quilting), drawing 
(designing), and the manufacture or repair of clockwork. In all other 
kinds of work the illumination must equal at least 20 Hefner units at a 
distance of 1 meter. Workers must also be protected from glaring light. 
While we find only a very few American states providing pro- 
tection for women and young persons in the matter of lifting heavy 
weights, such regulations are frequent in foreign countries. In France 
weights to be handled are regulated according to age and to the method of 
moving; women over 18 may not carry any weight over 25 kg. nor move, 
-on two-wheeled handcarts, more than 130 kg. (including weight of hand- 
cart). In Argentina this regulation is confined to persons of both sexes 
under 20 and weights to be lifted or moved are carefully adjusted to the 
•age of the worker. 
During the war many of the European countries, and a few employers 
in the United States, provided for the creation of nurseries in connection 
with factories where employed mothers might leave their babies while at 
work. Usually the mothers were allowed time off during the day in 
which to nurse their children. The children in these creches were often 
given medical as well as nursing care. In France, teachers, and females on 
the staff of the Department of Posts Telegraphs and Telephones, are 
granted, at the time of childbirth, a leave of absence for 2 months together 
with full treatment. 
American Conditions Need Protective Legislation.-While it is true, 
ns already stated, that specific health investigations have been so rare in 
this country that competent data do not exist for the formulation of special 
regulations, yet sufficient data are at hand to indicate many industries 
which threaten the health of women and children. Among such dangerous 
callings may be mentioned the manufacture of cordage, twine and jute 
goods in which several thousand women and children are employed. In 
this industry many women are frequently employed without adequate 
protection from the steam, heat and wet of the spinning rooms, where the 
spray and drippings frequently wet their clothing up to the waist and 
where pools of water, gathered on the floors, often compel them to go 
barefoot. Among such workers, colds, rheumatism, bronchitis, and 
menstrual troubles are prevalent. One of the countries which has 
regulated conditions of work in these industries is England where the 
rules require adequate dressing rooms for holding dry clothes and chang- REGULATED EMPLOYMENTS-AMERICAN CONDITIONS 
1035 
ing after working hours; wet room floors made of material impervious 
to moisture, which will maintain the level, and will not crack; splash 
boards for the protection of the workers; and trays or groovings in the 
floor under the frames to catch the drippings and to drain off the water. 
Adequate ventilating devices to draw off the steam are also often required. 
In France, also, women and children under 18 may not be employed at 
the wet spinning of flax unless the overflow of water is properly removed. 
In certain other processes of this same industry a large quantity of 
harmful dust is present, causing physical injury to the workers. Physi- 
cians practicing among operatives in the dusty processes testify that 
chronic bronchitis, asthma and catarrh are unduly prevalent. Other 
physicians have found a certain skin disease which they attribute to the 
presence of irritating dusts or harsh oils. In France children under 18 
may not be employed in the stripping of flax, hemp, or jute where dust is 
freely given off. 
The difference between the method of legal regulation as adopted in 
Europe and that adopted in most American states is well illustrated by a 
comparison of the English law governing dusty work of this kind with that 
of most American states where dusty work is carried on. In most cases 
these laws merely authorize the inspector to require the use of a fan or 
some mechanical means of ventilation if he thinks injurious dusts are 
present and are inhaled in a harmful degree.* 
The English law requires that in every room in which roughing, sorting, 
hackling, preparing or carding of flax or tow is carried on, efficient exhaust 
and inlet ventilation shall be provided to draw away the dust from the 
workers, at or as near as possible to the point at which it is generated. 
The sectional area of the exhaust openings near to each set of hackles must 
be so arranged as to secure a proper velocity of the air passing through 
each exhaust opening. The air inlet must be so managed that no direct 
draft falls upon the persons employed, and the arrangement of inlet 
ventilation must, as far as practicable, be such that the temperature of 
the incoming air shall not be less than 60°F. 
Investigations of the Federal Bureau of Labor Statistics3 have also 
given data on unhealthful occupations. An illustration of such condi- 
tions is found in the glass industry which employs about 10,000 women 
over 16 years of age in certain departments. 
In making of incandescent lamps, we find examples of extreme speed 
and minuteness of work. In the tungsten department, for instance, in 
one operation "the gossamer-like tungsten filament, which can hardly 
be seen by the untrained eye, must be inserted in a tiny hole punched in 
the end of a copper wire no thicker than the finest needle, where it is kept 
in place by pinching the sides of the wire together. This operation is 
repeated a thousand times a day at the rate of about three every 2 minutes. 
* Within the last ten years, the rapid spread of industrial commissions empowered to 
issue binding orders has resulted in the growth of detailed and specific codes to supple- 
ment these general laws in a number of states. 1036 
WOMEN WAGE EARNERS 
Almost everyone has done at some time equally delicate work, so that the 
effects which operations of this nature must have on the eyes and nerves 
can best be appreciated by conceiving of the repetition of such work 
through a 10-hour day at a rate approximating that cited above." It is 
pointed out that without any extensive reduction in the cost of materials 
used, a great reduction in the price of electric lamps has been effected 
largely because of the subdivision of processes, increased speed and the 
ultilization of female labor. 
In the glass industry proper, the chief processes employing large 
numbers of women and involving danger to health are those in finishing 
and decorating which consist mainly of polishing, sand blasting, acid 
etching, cutting the glass, and painting and enameling. In sand blasting, 
if the apparatus is not properly covered, the finely powdered sand escapes 
through the top of the machine in a forcible blast, passes freely into the 
room and fills the air while the operator receives in the face the full force 
of the dust stream. This dust is extremely fine and hangs suspended in 
the air for a considerable time. The federal investigation revealed the 
fact that nearly all the women employed at this work complained that the 
dust caused a painful irritation of their eyes and throat. The inhala- 
tion of dust together with the necessity for constant standing make the 
work of sand blasting particularly harmful to women. The process of 
acid etching, while employing few women, exposes these few workers to 
the fumes of hydrofluoric acid which causes violent irritation of the eye- 
lids and conjunctiva, cold in the head, bronchial catarrh with spasmodic 
coughing, sores on the gums and mucous membrane of the mouth, and 
ulcers, corrosion and blisters. The investigators found that in one 
factory where women were employed at this work they frequently had 
trouble with their eyes, and several former employes had been so badly 
injured by the fumes that they were compelled to stop work entirely. 
In painting and enameling glassware, also, danger exists from the fine 
enameling compounds which are dusted or sprayed on the glass and which 
usually contain lead and arsenic. This fine dust is inhaled by the opera- 
tives. Women engaged in the occupation of silvering mirrors often work 
in rooms where the temperature reaches 104°F., this temperature being 
considered necessary for the best results. Most of this work is done while 
standing, and by women over 20 years of age. 
Beyond the most general laws, no American state attempts to regulate 
such work, while in European countries it is frequently controlled by 
special rules. In Italy women and children may not be employed at all 
in gilding and silver plating, and those under 21 may not be employed in 
grinding and polishing glass, nor in making it opaque or corroding it with 
hydrofluoric acid or sand jets. In Holland women and children may not 
be employed where excessive dust is present. In France, women and 
children under 18 may not be employed at the dry-polishing of glass, nor 
in any process where dust is given off freely, nor where poisonous materials AMERICAN CONDITIONS-RESTRICTIONS--LIMITATIONS 
1037 
are used. In England women and children may not take their meals in 
any part of a flint glass factory where grinding, polishing or cutting is 
carried on. 
The federal investigation of 1910-1912 indicated many other indus- 
tries which exposed women to unnecessary harmful conditions and which 
were not controlled by legislation such as we find in European countries. 
Among these may be mentioned the making of brassware, particularly 
in work in the core rooms and around the ovens which expose the women 
to high temperature and injurious fumes; in nickel plating where injurious 
and often poisonous fumes are present; in the manufacture of firearms 
and ammunition where mercury in the form of a fulminate is used; in 
making hardware where the lacquer involves the use of lead and irritating 
volatile solvents; in the making of saws and files and polishing wooden 
handles where lime, metallic and other irritating dusts are present; in the 
rubber industry where poisonous fumes exist; in artificial flower and calico 
cloth making where anilin dyes are used; and in pearl button making 
where ammonia, pumice stone and hydrochloric acid are present. 
Restrictions upon Workpeople.-Control of woman's work by regula- 
tion is also secured by a second method-that of restrictions upon the 
workpeople themselves. The chief restrictions at present fall into four 
main groups: limitations upon the duration of the work period, restric- 
tions in regard to eating places, prohibition of work preceding and follow- 
ing childbirth, and the medical examination of employes. 
Limitations upon the Duration of the Work Period.-After all possible 
protection has been provided through prohibiting work in dangerous 
places and by regulating the physical conditions under which women may 
be employed, experience has shown that it is still necessary to limit the 
number of hours which a woman may be employed in a day or a week. 
Unless this is done, the fatigue resulting from excessive hours of work will 
in time undermine a woman's health, even under the most sanitary condi- 
tions. In American states this limitation has practically always taken 
the form of the same hour rate for all industries to which the law applies. 
In Europe such inclusive limitations are often supplemented by excep- 
tions both above and below the limits of the general law. 
Day and Week Limitations.-On the question of hour limitations for 
daytime work many American states have gone farther than the European 
countries. A few western states, Massachusetts, and the District of 
Columbia permit only 8 hours a day, while over a dozen more limit hours 
to 9 a day. A larger group permits 10 or 11 hours a day, but in many 
cases the total number of hours per week must not exceed 54 or 56. In 
actual operation this frequently means that Saturday afternoon becomes a 
half-holiday, particularly in the summer time. Still another group allows 
10 hours a day and 60 a week, while about six states place a 9- or 10-hour 
limit on day work but place no limit on the hours per week; this may per- 
mit full time work for 7 days a week. While only a few states restrict 1038 
WOMEN WAGE EARNERS 
work to 6 days a week the limitation by both daily and weekly periods 
has a tendency to eliminate 7-day work. At present about half a dozen 
American states still have no legislation restricting the hours of labor 
for women workers. American laws apply as a rule to most industries 
where women are employed, but exceptions exist which permit overtime 
for certain periods, in certain industries or under specified conditions. 
European legislation respecting the hours of labor for women presents 
a mass of detail similar to that found in legislation for the control of work 
conditions. While general laws exist in most countries, hours in many 
industries or occupations are governed by special regulations, which may 
grant a work period either longer or shorter than that stated in the general 
law. In many European countries, as in several American states, the 
canning and preserving industries, for example, are permitted a longer 
work day than that allowed in the general law. On the other hand, many 
special rules are found which reduce the work period below that stated in 
the general law. Thus in the canton of Berne no girl under the age of 17 
years may be employed at a treadle machine for more than 3 consecutive 
hours a day. Women may be employed in the work of making paving 
stones only by special permission, and then the hours are limited to 6 per 
day. Frequently also European countries fix in the law the time of the 
day within which working hours must fall. Thus in England in textile 
factories employment must fall between 6 A.M. and 6 P.M. or between 
7 A.M. and 7 P.M.; employment on Saturdays must end not later than 
1 P.M. 
Two American states, Oregon and Wisconsin through their Indus- 
trial Commissions, have established for certain occupations a shorter 
work day for women than that stated in the general law. A few 
employers have voluntarily or because of trade-union pressure reduced 
hours below the legal maximum set by the state. 
Night Work.-The leading nations of the world have recognized the 
physical and moral dangers of night work for women and have enacted 
laws prohibiting such work for given periods. Scientific investigations 
everywhere have shown that the work of women at night is exceptionally 
injurious. Insufficient, broken and irregular sleep, lack of sunlight, 
irregular meal times, disarrangement of the normal customs of life, injury 
to eyesight, increased chance of accidents-all of these factors combine 
to lower vitality, to weaken the power of disease resistance, to produce 
impoverished blood and ansemia, to weaken the female reproductive 
functions and generally to increase morbidity and mortality. In addition 
a legal limit placed upon night work is a great aid in enforcing the laws 
limiting the hours of work per day. 
But American states have been slow to remedy this serious evil. The 
movement here received a decided setback when in 1907 the New York 
Court of Appeals declared unconstitutional a law forbidding the work of 
women over 21 years of age in factories between 9 P.M. and 6 A.M. But HOURS OF LABOR NIGHT WORK 
1039 
in 1913 New York reenacted her earlier law, placing the closing hour at 
10 P.M. and the Court of Appeals in 1915 reversed its earlier decision. 
Since 1890 in Massachusetts women have not been permitted to work in 
manufacturing establishments between 10 P.M. and 6 A.M., nor in 
textile factories between 6 P. M. and 6 A.M. since 1907. Similar laws 
prohibiting night work for women, or discouraging it by limiting it to a 
shorter period than day work, existed in 1921 in more than a dozen states. 
In a few other jurisdictions the same result was achieved by rulings of 
Industrial Welfare Commissions. 
On the question of protection from night work European countries 
have greatly surpassed the American states. There 14 of the leading 
nations have entirely prohibited by international treaty the work of 
women between certain periods at night. This treaty is the result of a 
conference called by the International Association for Labor Legislation in 
Berne, Switzerland, in 1906. To this conference delegates were sent by 
the governments of Austria, Belgium, Denmark, France, Germany, Great 
Britain, Holland, Hungary, Italy, Luxemburg, Portugal, Spain, Sweden 
and Switzerland, and an international convention forbidding night work 
for women was signed by all of the 14 countries. By 1912 all of the 
countries except Denmark had enacted legislation embodying the pro- 
visions of the convention and had ratified the treaty. By the terms of 
this treaty, which applies to women over 18 years of age, the 14 countries 
bind themselves to allow to women at least 11 consecutive hours of rest at 
night and to permit no night work between 10 P.M. and 5 A.M. Further 
application of this agreement has been made as the result of a convention 
adopted by the first International Labor Conference in 1919. The states 
adhering to the convention, other than those which had already ratified 
the treaty of 1906, are British Columbia, Czechoslavakia, Greece, 
Poland and Rumania. 
In addition many of the smaller states and dependencies have indi- 
cated their adherence to the provisions of the treaty, while several of the 
signatory states have gone even further than the treaty requirements. 
France, Belgium, and Spain, for instance, have forbidden night work 
between 9 P.M. and 5 A.M., Austria has forbidden work at night between 
8 P.M. and 5 A.M., Germany between 8 P.M. and 6 A.M., and Holland 
between 7 P.M. and 6 A.M. Even in India the night work of women is 
forbidden in factories between 7 P.M. and 5:30 A.M.; in Argentina,, 
between 9 P.M. and 6 A.M. Most of these countries permit exceptions 
under certain conditions, particularly where the nature of the materials 
used is such that a delay in handling would cause great financial loss. 
In such cases, however, very strict limitations are imposed, as, for exam- 
ple, in Holland where large numbers of women are employed in skewering 
herrings, a seasonal trade. Here employment after 10 P.M. is permitted 
for a limited number of hours and for a limited time. In addition, breaks 
in the work must be allowed every 4 hours, and if any break be less than 1040 
WOMEN WAGE EARNERS 
hour it must be counted as part of the period of employment; moreover, 
hot coffee or some other hot non-alcoholic beverage must be supplied to 
the night workers free of charge, extra wages must be paid for overtime 
work, and no woman may be employed after 10 P.M. without first secur- 
ing a medical certificate stating that her health will not be injured by 
such work. Elaborate provisions for enforcement also exist. 
Rest Periods.-With the exception of requiring from to 1 hour for 
the noon meal each day (or after 6 or 6^ hours' work), practically no 
legal attention has as yet been given in this country to the question of 
day time rest periods. With the increasing speed and complexity of 
modern industry, entailing great nervous strain, short intervals of rest 
during the morning and afternoon periods would mean much both to the 
physical welfare and to the efficiency of the worker. In the telephone 
service, for example, the nervous strain is particularly severe. A Cana- 
dian Royal Commission, reporting in 1907 on a dispute involving the 
Bell Telephone Company, recommended that the total work period be 
not longer than 6 hours spread over a period of from 8 to 8% hours; this 
would allow for at least three rest periods of from to 1 hour's duration. 
A few American firms have voluntarily adopted the plan of giving 
their employes a 15-minute rest in the morning and in the afternoon 
and during this time thoroughly airing the workrooms. This principle is 
enforced by law in several European countries. Thus in Italy, women 
and children under 15 years of age who work from 8 to 11 hours per day 
must be allowed at least 1^ hours' rest each day; if work lasts longer than 
11 hours, 2 hours' rest must be given. In Belgium, women in fruit pre- 
serving must be allowed at least 15 minutes' rest in every 5-hour period of 
work in addition to the noon rest. In the chocolate and confectionery 
industry, when work lasts between 9 and 10 hours a second rest period of 
at least 15 minutes must be allowed, and if the working hours exceed 10, 
a third rest period of 15 minutes must be granted. 
In this country, annual rest periods, or vacations with pay, have been 
voluntarily granted by a few firms, but such a provision for private em- 
ployments has never been incorporated into law. In the canton of Berne, 
Switzerland, however, we find the provision that every woman who has 
been employed on time rates in the same business for more than 1 year is 
entitled to 6 consecutive holidays on pay; after the second year's work, 
to 8 days; after the third, to 10 days; and after the fourth year, to 12 days. 
Regulation of Eating Places.-Still another provision for the protec- 
tion of women is that prohibiting the eating of meals in workrooms where 
processes are carried on which involve the use or presence of injurious or 
poisonous materials, dusts or fumes. Women and children in England 
are especially forbidden to take a meal or remain during meal hours in 
glass works where materials are mixed or where flint glass is made, 
polished, ground or cut; in earthenware works where dipping, drying or 
china scouring is done; where transfers are made; or where the tinning and REST PERIODS EATING EXAMINATIONS CHILDBIRTH 
1041 
enameling of metal hollow ware and cooking utensils are carried on. 
In addition, employes in such work must thoroughly wash their faces and 
hands before eating, and the employer is required to furnish adequate 
soap, towels, nail brushes and hot and cold water. Such restrictions are 
found in most countries and more often apply alike to both sexes. This 
is true in America, where the eating of meals in workrooms where certain 
poisonous substances, as lead, zinc or arsenic are used, is forbidden for all 
employes in New York, Illinois, Missouri, Pennsylvania, Ohio and New 
Jersey. In most countries or states where such prohibitions exist the 
employer is required to provide sanitary eating rooms for the convenience 
of employes. 
Medical Examination.-Perhaps one of the most difficult things for an 
American to realize is the extent to which medical inspection of employes 
is practiced in European countries. It is very commonly enforced for 
both men and women in the dangerous trades. We have seen that women 
and young persons are excluded from many of the more dangerous 
employments, particularly those embodying the use or presence of poison- 
ous substances. In other occupations, where the workers are threatened 
with injury to health, women may not be employed unless after a thorough 
medical examination they are deemed to be physically fit. In many 
industries such examinations must be repeated at stated intervals. 
In the decoration of china and earthenware, for instance, women in 
England must be medically examined at the beginning of employment and 
once each month thereafter. A health register is kept wherein is recorded 
the facts concerning the examination. If a woman is suspended from 
work she must be reexamined before she can return. In the enameling of 
iron plates, if any woman complains of illness which may be due to the 
nature of her work the employer must, at his own expense, give an order 
upon a doctor for immediate professional attendance. In this work it is 
recommended that light food, such as milk and biscuits, be supplied each 
woman before beginning work in the morning. Certificates of physical 
fitness are at times required before a woman may engage in night work or 
be permitted to work overtime. 
In America while employers have at times voluntarily established 
medical examination of employes, yet special legal requirements for the 
medical examination of women do not exist. Women are, however, 
included with men in the laws requiring monthly physical examination of 
all employes engaged in dangerous processes in Illinois, Missouri, New 
Jersey, Ohio and Pennsylvania. These laws affect but few women, but 
should serve as a beginning for a much wider extension of this important 
preventive measure in the protection of women's health. 
Childbirth Protection.-The desirability of additional protection for 
working women at the time of childbirth has been recognized by most 
European countries and several outside of Europe. This protection con- 
sists of forbidding the work of women for a stated period, usually from 1042 
WOMEN WAGE EARNERS 
2 to 4 weeks before and from 4 to 6 or 8 weeks after childbirth. Many 
■countries furnish in addition medical and nursing care or cash benefits, 
or both. In this country only six states-New York, Massachusetts, 
Connecticut, Missouri, Vermont and Washington-have forbidden the 
employment of women for periods of two to four weeks before and after 
childbirth, but no state has provided cash or medical benefits. 
The International Labor Conference in 1919 recommended that the 
rest period should include the six weeks following childbirth with the 
additional right to leave work six weeks before childbirth upon presen- 
tation of a medical certificate stating that confinement will probably 
take place within that time. During this absence from work the mother 
must be paid "benefits sufficient for the full and healthy maintenance of 
herself and child," and free attendance by a doctor or certified midwife is 
to be provided. These benefits are to be paid either out of public funds 
or through a system of insurance, and are to apply to mothers whether 
married or unmarried. 
Insurance.-It has often been found that progressive employers pro- 
vide more adequate protection for their employes than can be secured 
by direct legislation. An illustration of such a situation is found in the 
extensive preventive work which has followed upon the enactment of 
insurance or compensation laws. Such laws offer an economic inducement 
to prevent sickness or accident, and form,- therefore, a third method of 
protection. These insurance measures apply with but few exceptions 
to men and women alike and are treated in detail elsewhere in this volume. 
In passing it may be said, however, that women are included in all of the 
health insurance laws of Europe-Germany, Austria, Hungary, Holland 
Luxemburg, Norway, Great Britain, Russia, Roumania, and Serbia-and 
in the accident compensation laws of all civilized countries and of the 
46 American states and territories which by the end of 1921 had adopted 
accident compensation. 
In addition to the ordinary sickness among industrial workers, women 
present a special problem-that is, illness at the time of childbirth. While 
in many cases, childbirth is a normal function causing disability for a 
short period only, yet most foreign countries have recognized the desira- 
bility, from the point of view of the mother, the child and the state, of 
granting special financial aid at this time.4 In Germany and Norway the 
female wage worker is granted maternity benefits for 6 weeks, the period 
during which she is forbidden to return to work. Hungary follows the 
same time limit, while in Russia the period is only 4 weeks. Great 
Britain allows a lump sum of $7.20 to all insured women, regardless of 
marital condition, and $7.20 to wives of insured men, making a total 
of $14.40 for the insured wife of an insured man. A woman who is 
incapacitated for work can also claim, in addition to the lump sum of 
$14.40, a sickness benefit of 7 s. 6 d. a week for twenty-six weeks following 
the four weeks after confinement. In Australia a mother is allowed $25 CHILDBIRTH INSURANCE-REFERENCES 
1043 
upon the birth of each child. Special mention must be made of the Italian 
system of maternity benefits established in 1910. This national com- 
pulsory system applies to all women wage earners in factories between 
the ages of 15 and 50, and applies alike to married and unmarried workers. 
It is supported by contributions from the state and from the employer and 
employe who contribute in equal amounts. The total amount of the 
benefit given is $7.72 which in Italy aids greatly in assuring proper care of 
both mother and child at this critical time. Although several American 
states have already prohibited the industrial employment of women 
for a period before and after childbirth, yet no form of health or maternity 
insurance exists by law in America, although many voluntary societies 
provide such insurance for their members. 
It is apparent that in the United States considerable progress has been 
made toward adequate protection of the health of working women, yet 
in many respects American legislation lags far behind the legal protection 
already afforded by leading European countries to the women who, with 
slighter physique, are competing with men amid the special health hazards 
of modern industry. 
REFERENCES 
1 For an excellent statement of the world's experience in the effect of industry upon the 
health of working women see Fatigue and Efficiency, by Josephine Goldmark, 
Russell Sage Foundation, New York City. 
2 Lead Poisoning in Potteries, Tile Works, and Porcelain Enameled Ware Factories, 
Alice Hamilton, M. D., U. S. Bureau of Labor Statistics, Bulletin No. 104. 
3 The Condition of Women and Child Wage-earners in the United States. U. S. 
Bureau of Labor, 1910-1912. 19 volumes. 
4 Maternity Benefit Systems in Certain Foreign Countries, by Henry J. Harris, 
Federal Children's Bureau, Washington, D. C. CHAPTER VI 
THE UNITED STATES EMPLOYES' COMPENSATION ACT AND 
ITS ADMINISTRATION 
JOHN W. TRASK, M. D„ Washington, D. C. 
The United States Employes' Compensation Act is an act of Congress 
approved September 7, 1916. It is a measure intended for the relief of 
civil employes of the United States Government injured in the perform- 
ance of their work. It is an outgrowth of the various state laws which 
had been previously enacted for the medical care and compensation 
of workmen injured in private industries. The law provides for its 
administration a Commission of three members. 
The United States Employes' Compensation Commission was created 
by the act as the administrative authority charged with the duty of giv- 
ing effect to its provisions. The organization of the Commission dates 
from March 17, 1917, when two of the commissioners took the oath of 
office and formally organized. 
By express authority of the law (sec. 42) the President, by Executive 
order of September 15, 1916, transferred the administration of the Act 
so far as employes of the Panama Canal and Panama Railroad Co. are 
concerned to the governor of the Panama Canal, and by a similar order, 
dated September 26, 1916, transferred the administration as far as 
employes of the Alaskan Engineering Commission are concerned to the 
chairman of the Alaskan Engineering Commission. 
To the present date no amendments have been made to the law except 
that in the Act providing appropriations for the expenses of the govern- 
ment of the District of Columbia, effective July 1, 1919, the benefits 
of the Compensation Act were granted to all civil employes of the 
District of Columbia government except policemen and firemen. The 
reason for the omission of policemen and firemen from the benefits of the 
Act was that there was already a law providing disability and death bene- 
fits which was considered in certain respects more liberal than the Federal 
compensation Act. 
The administration of the Act met with unusual difficulties owing to 
the War activities with the consequent great and rapid increase in gov- 
ernment work and the number of employes. Many of the officials in 
charge of workmen were inexperienced in government organization and 
were unaware of the provisions for the care of the injured. With the bur- 
den of work incident to the war occupying the minds of all combined with 
the haste with which organizations were brought together it was exceed- 
1044 INTRODUCTION PRINCIPAL PROVISIONS 
1045 
ingly difficult to make in all cases proper provisions for carrying out the 
purpose of the Act. Following this was the ending of the war and the 
rapid disbandment of organizations interferring materially with records 
and evidence upon which many claims might properly have been based. 
PRINCIPAL PROVISIONS OF THE ACT 
Date of Enactment.-September 7, 1916; in effect same date. 
Burden of Administration and Benefits.-All borne by the United 
States Government through special appropriations. 
Industries Covered.-All civilian employments of the United States 
Government and of the Panama Railroad Co. 
Persons Covered.-All civil employes of the United States and of the 
Panama Railroad Co. 
Injuries Covered.-Personal injuries sustained while in the perform- 
ance of duty, if not due to intoxication, willful misconduct, or intention 
to bring about injury. 
Benefits.-(A) Reasonable medical, surgical, and hospital services 
and supplies for all injuries sustained; such services and supplies to be 
furnished by United States medical officers and hospitals wherever 
practicable. 
(B) Compensation for partial disability for work; 66% per cent, of the 
difference in wage-earning capacity due to such disability. 
(C) Compensation for total disability for work; 66% per cent, of the 
monthly pay during continuance of such disability. 
(D) Compensation for death: (1) Burial expenses not exceeding 
$100 and transportation of body of residents of the United States dying 
away from home station, if relatives desire it. 
2. To widow or dependent widower alone, 35 per cent, of the 
monthly wages of the deceased, with 10 per cent, additional for each 
child, the total not to exceed 66% per cent. 
3. If no parent survives, 25 per cent, to one child and 10 per cent, 
additional for each additional child, the total not to exceed 66% per cent. 
4. To wholly dependent parents of deceased, 25 per cent, if one, 
40 per cent, if both, are dependent; if partially dependent, a lower per- 
centage according to the degree of dependency; if there is a widow, 
widower, or child, the parents' rights are subordinate, and the total 
awards may not exceed 66% per cent. 
5. Other dependent relatives receive benefits in smaller amounts 
subject to the claims of the foregoing relatives. 
Payments to a widow or dependent widower terminate on their death 
or remarriage; to a child on marriage, reaching the age of 18, or if over 18 
and incapable of self-support, on becoming capable of self support; pay- 
ments to other beneficiaries are subject to the above limitations, but may 
in no case continue beyond eight years. 1046 
THE UNITED STATES EMPLOYES' COMPENSATION ACT 
Payments in any case for disability or death are subject to a maximum 
of 866.67 per month, and to a minimum of 833.33, unless the actual 
earnings are less than that account, when the compensation shall equal 
the earnings. 
Payments on account of death or permanent disability may be com- 
muted to a lump sum, in the discretion of the commission. 
Revision of Benefits.-Awards may be reviewed by the commission at 
any time, either on request or by the commission on its own motion. 
Security of Payments.-Compensation is paid from special compensa- 
tion fund established by congressional appropriation. 
Settlement of Disputes.-The United States Employes' Compensa- 
tion Commission administers the Act except that the administration of 
the Act in the Panama Canal Zone is by the Governor of the Panama 
Canal, and in the work of the Alaskan Engineering Commission by the 
chairman of that commission. The administration of the Act as applied 
to District of Columbia employes is by the Compensation Commission, but 
payments of benefits after award by the commission is by the disbursing 
officer of the District government out of a special appropriation. 
SCOPE OF THE ACT AS REGARDS NATURE OF INJURIES COVERED 
THEREBY 
The Commission early took the view that the term " personal injuries " 
used in the Act covers not only accidents, as ordinarily defined, but in 
addition to ordinary traumata, covers any bodily injury or disease due to 
the performance of work. As thus construed the law would apply to 
diseases and maladies caused by the nature or conditions of employment. 
Among such diseases would be included occupational poisonings, as lead 
poisoning, zinc poisoning, and carbon monoxide poisoning. It would 
apply to such diseases as tuberculosis, typhoid fever, pneumonia and 
malarial fever, when these were traceable directly to the nature of the 
employment or to the conditions under which the employment was 
carried on. These all constitute injuries to the person (personal injuries) 
and may be sustained while in the performance of work, and be due 
to the conditions under which the work is carried on. However under 
date of July 5, 1922, the Comptroller General rendered a decision that 
to furnish the benefits of the Compensation Act for death or disability 
resulting from disease and not from personal injury was without 
authority of law. And, on September 23, 1922, the Comptroller Gen- 
eral in another decision stated in part, "It is clear that the later 
statute (the Compensation Act of September 7, 1916) contemplates 
that compensation shall be paid for such injuries only as are of an 
accidental nature, or at least that payment shall be confined to injuries 
which are referable to some particular event capable of being fixed in 
point of time." SCOPE-PRE-EXISTING DEFECTS "iN DUTY" 
1047 
The claims made for benefits under the Act are for the most part on 
account of traumata in the ordinary sense-wounds, contusions, lacera- 
tions, fractures, strains and sprains. Relatively few are made on account 
of such diseases as tuberculosis, pneumonia, malarial fever and typhoid. 
Still fewer are made on account of occupational poisonings, chief of 
which is lead poisoning. 
AGGRAVATION OF PRE-EXISTING DEFECTS 
Frequently injuries are sustained by employes which, although not. 
serious in themselves, aggravate existing disease and cause an unexpected 
disability for work. An example of this is a chest injury in a person 
having a quiescent pulmonary tuberculosis. To cover such cases the 
Commission formulated the following rule: 
"A disability for work resulting from the material aggravation of a 
previously existing defective physical condition is compensable when the 
aggravation is clearly due to a personal injury sustained while in the 
performance of the claimant's duty. However, compensation shall be- 
paid only for the period ©^disability due to the injury. 
"If the results of the injury do not cause disability for work, but 
require medical, surgical or hospital services or supplies not previously 
required, the injured employe shall be entitled to reasonable medical, 
surgical or hospital services or supplies made necessary as a result of 
the injury. He shall also be entitled to compensation during the period 
of disability resulting from such medical or surgical treatment. 
"But, in any case, the evidence must show with reasonable clearness, 
that the alleged aggravation was the direct result of a definite injury 
sustained while in the performance of duty, and that it was not merely the 
acceleration or culmination of a pre-existing progressive defect which was 
accelerated or aggravated to only a slight degree by the injury." 
"WHILE IN THE PERFORMANCE OF DUTY" 
The Commission soon after its organization found the need of con- 
struing the provisions of the Act limiting its scope as regards the benefits 
to be awarded an individual to the results of injuries "sustained while in 
the performance of his duty." The question arose as to injuries sustained 
during the lunch hour, or while the employe had left his work and gone 
for a drink of water, or when he had come in in the morning and before he 
had actually picked up his tools. The Commission therefore adopted, 
the following rule on the subject: 
"The Commission decides that a personal injury sustained by a civil 
employe of the United States while on the industrial premises of a navy 
yard, arsenal or other place of employment, provided such employe is on 
such premises for the purpose of going to or returning from his work or 
performing duties connected with or incidental to his work, and is not on 1048 
THE UNITED STATES EMPLOYES' COMPENSATION ACT 
such premises merely for purposes of his own, shall be an injury sustained 
'while in the performance of his duty' within the meaning of that phrase 
as used in section 1 of the Compensation Act of September 7, 1916. 
This ruling is based upon the responsibility of the United States, as the 
employer, for the safe and sanitary condition of its premises." 
DISTRIBUTION OF BENEFICIARIES 
Government employes are at work in practically all parts of the 
country. In the city of Washington there are the headquarters of the 
great executive departments and the legislative branch of the Govern- 
ment. At various points throughout the country are the arsenals and 
quartermasters' depots of the War Department and the navy yards and 
naval depots of the Navy Department. Most of these have been during 
the war and many still are large industrial establishments employing 
thousands of workers. Then scattered throughout the country are the 
small groups of employes of the Interior Department and the Depart- 
ment of Agriculture. The Reclamation Service has its reclamation pro- 
jects. The Forestry Service has its faithful and more or less isolated 
employes on duty in the most sparsely settled regions. The Bureau of 
Mines has its various working parties. The Treasury Department has 
many establishments and groups of workers. The Interstate Commerce 
Commission has its field employes-men traveling from place to place. 
The Engineer Department of the Army, at all times engaged in river and 
harbor work, has its working groups on the rivers and coasts. The 
Federal Courts throughout the country have their civil employes, and 
every city, town and hamlet has its post office. 
PROVISIONS FOR MEDICAL, SURGICAL, AND HOSPITAL TREATMENT 
The underlying purpose of compensation legislation is to relieve the 
injured employe of the loss and burden resulting from injuries incident 
to his work. The primary loss in these injuries is essentially one of 
physical damage. Physical restoration is the one means of actually 
repairing the damage and restoring the principal loss. 
Section 9 of the Compensation Act provides that employes injured in 
the performance of duty shall be furnished reasonable medical, surgical 
and hospital services and supplies by United States medical officers and 
United States hospitals and that this treatment shall be furnished for a 
reasonable time. Where United States medical officers or hospitals are 
not available for the purpose, or where it is otherwise impracticable for 
medical care to be thus furnished, the Commission is to make other pro- 
visions for treatment. The Government hospitals and medical officers 
available to the commission for the treatment of injured employes are 
chiefly those of the United States Public Health Service. 
All the hospital and dispensary facilities of the Public Health 
Service have been available to the Commission in the treatment of 
beneficiaries of the Act. The Bureau of Medicine and Surgery of the BENEFICIARIES-TREATMENT PROVISIONS 
1049 
Navy Department has 26 Naval hospitals which are available for the 
treatment of employes of the Navy Department and in emergency for 
the treatment of employes of other departments. 
To supplement the government medical facilities and to secure ade- 
quate medical service in other places the Commission has, in compliance 
with section 9 of the Compensation Act, selected and designated compe- 
tent, well-trained physicians. These have been men of good reputation 
and for the most part experienced in general surgery, inasmuch as most 
of the injuries coming under the Compensation Act are of a kind 
requiring treatment by a surgeon. A number of physicians selected 
have been ophthalmologists, appointed for the treatment of eye injuries. 
Where well-trained orthopedic surgeons were to be found they have 
usually been designated, particularly for the care of sprains, fractures 
and back injuries. Medical facilities have been provided in this way in 
1391 cities and localities. 
The Commission gives particular attention to the medical supervision 
of injured employes entitled to treatment under the act. This is neces- 
sary to protect the interests of the employes, many of whom would be in 
a large measure helpless to secure adequate and efficient treatment on 
their own initiative. The Commission has a medical division to which all 
reported injuries are referred immediately upon receipt in order that 
active medical treatment of the cases may be inaugurated if they are not 
shown to be already receiving adequate care. 
The experience of the Commission and particularly its experience with 
the unfortunate results which have not been infrequent in cases of fracture 
and of so-called sprains where the employes have secured treatment on 
their own initiative, has emphasized the necessity of medical supervision 
on the part of the commission. As a result a considerable proportion of 
the administrative work in carrying out the provisions of the compensa- 
tion act has been found to be of a medical nature. It has proven to be as 
necessary to see that the injured employe gets efficient medical and 
surgical treatment for his injury as it is that he be paid compensation. 
Medical and surgical treatment is often afar greater benefit to the injured 
employe than is compensation for pay lost because of the injury. The 
bestowing of the benefit of efficient treatment is frequently accompanied 
by greater difficulties and may require a greater amount of administrative 
supervision than does the bestowing of the benefit of compensation for 
loss of pay. 
Few general practitioners of medicine have occasion to treat many 
injury cases. The result is that often they do not have the necessary 
experience and training in handling the more serious injuries to bring 
about satisfactory results; particularly is this true in fractures and dis- 
locations of bones. These are as a rule treated satisfactorily only by 
those having much experience in treating injuries, by industrial surgeons, 
orthopedic surgeons, and general surgeons. In many of the fracture cases 1050 
THE UNITED STATES EMPLOYES' COMPENSATION ACT 
treatment by those without adequate experience often means making 
permanent cripples, while procuring treatment by those of experience 
means getting the employes back to work with sound, useful limbs. 
Efficient treatment constitutes a distinct and immediate benefit under 
the compensation act. Inefficient treatment may not be a benefit and 
may even add unnecessary disability to the original injury. As compen- 
sation for loss of wages is paid as long as disability for work continues 
only efficient treatment which brings about recovery from the injury 
and returns the employe to work is economical. Inefficient treatment 
is wasteful of public funds as it prolongs the period during which com- 
pensation is paid. 
The number of injured employes who receive the benefit of medical 
care is much greater than the number receiving the other benefits of the 
act. All injured employes are entitled to treatment whereas only those 
are entitled to the other benefits of the act who sustain injuries causing a 
loss of wages as a result thereof for more than three days. Generally 
speaking therefore the medical benefits apply to all cases of injury while 
the other benefits apply only to the more serious and disabling injuries. 
The Commission has felt keenly its responsibility in furnishing 
medical treatment. It has appreciated the duty that rests upon it, not 
only to furnish medical treatment but to furnish the best available 
treatment, that which will be most certain to cause recovery from the 
injury and to restore useful function to injured parts. It has felt the 
responsibility of furnishing that treatment which will most quickly and 
surely restore to usefulness the broken arms and the crushed legs, the 
perforated eyeballs and the fractured skulls, the fractured spines and the 
mashed hands. Such treatment and no less has been considered reason- 
able in cases of injury. The time during which treatment is given is as 
long as treatment is needed or will be useful in overcoming the results of 
the injury. Treatment for a greater or less time has been considered 
unreasonable and contrary to the provisions of the act. 
HOSPITALIZATION 
When the Commission first began its work it was thought that where 
there were no government hospitals medical facilities for injured employes 
could be best obtained by the designation of local hospitals. It was 
thought that by selecting the better equipped hospitals in a community 
and having employes sent to them when injured the best medical service 
would be obtained. The plan was to leave it to the hospital to have the 
case taken care of by someone on its staff. The thought was that in this 
way group medicine would be secured; that if the case was an eye injury 
it would be put in charge of the opthalmologist; if a bone or joint injury, 
in charge of the orthopedic surgeon; if it combined injuries relating to 
more than one specialty, it would receive the attention of the proper HOSPITALIZATION 
1051 
experts. Working on this theory the plan was begun of designating 
hospitals and not physicians. The arrangement with the hospitals was 
for a charge of so much per day for ward service with extra charges for 
private rooms. There was no provision in this arrangement for the pay- 
ment of the individual members of the hospital staff who took care of the 
cases. If paid at all they would be paid by the hospital as the hospital 
charge was supposed to cover medical and surgical service. 
The plan was a failure except as regards the small privately owned 
hospital where the Chief of the Staff was also the owner of the hospital. 
It was the experience that injury cases taken to hospitals were all too 
often left under the medical care of an intern or of a junior house physician 
or surgeon. In many instances even when the cases were taken care of by 
a surgeon on the hospital attending staff, too much was left to others. 
The result was quite unsatisfactory. Efficient medical and surgical 
treatment of injured employes was not, in a large proportion of cases, 
obtained. Diagnoses were incomplete, and records fragmentary, and at 
times utterly worthless, even in cases of serious injury. 
The facts seemed to be that, with unimportant exceptions, to get 
satisfactory medical supervision and treatment it was necessary that the 
injured person bear to the medical attendant the relationship of personal 
patient. The medical supervision was invariably better where the attend- 
ing physician was to be paid for his services in the case. It appeared that 
a hospital was little more than an institution for the furnishing of bed, 
board and a certain amount of orderly and nursing service; that the 
quality of medical supervision depended entirely upon the training, 
intelligence and temperament of the physician in charge of the case; 
that a physician or surgeon temperamentally qualified and with adequate 
experience would render good medical service under all conditions, in 
hospital or out, in a well equipped hospital, or in a poorly equipped 
hospital. Compared with the individuality of the medical attendant 
nothing else mattered much. 
The Commission, therefore, adopted the plan of selecting and desig- 
nating surgeons and requiring that injured employes be placed under 
the care of these surgeons when it was not possible or practicable to 
have treatment furnished by government medical officers. It was left, 
usually, to the surgeon as to whether the case should be taken care of in 
a hospital, and if so, what hospital. The injured employe is a patient 
of the surgeon. There is no division of responsibility. 
In New York City, Philadelphia and one or two of the other larger 
cities, it has been necessary to designate hospitals conveniently located 
to which emergency injuries might be taken. The only practicable course 
if a letter carrier, let us say, meets with an injury in traffic, would be 
to take him to a nearby hospital. The need in these instances has been 
met by designating the larger and better hospitals and at the same time 
designating certain of the members of the attending surgical staffs of 1052 
THE UNITED STATES EMPLOYES' COMPENSATION ACT 
these hospitals and requesting that all Compensation cases be placed 
under the personal supervision of one of these surgeons. 
NATURE AND SCOPE OF TREATMENT 
The Commission has taken the point of view that in caring for 
beneficiaries of the Compensation Act the chief consideration is to be 
given to the repairing of the damage resulting from the injury and to the 
restoration of function, insofar as possible, to the injured part in the 
best interests of the injured employe. Where the injury is of such a 
nature that it can be treated best by a specialist, the services of a special- 
ist are to be secured, either to take charge of the case or to act as a 
consultant. Whenever practicable, eye injuries are to be treated by oph- 
thalmologists, bone and joint injuries by trained orthopedic surgeons or by 
general surgeons having ample experience. Operations requiring an 
anesthetic, unless of an emergency nature, are to be performed only by 
competent experienced surgeons. 
For the most part, cases are to be considered as either hospital cases 
or as office or dispensary cases. Cases, where the injured persons are too 
ill to go to the dispensary or office for treatment, are assumed to be 
proper cases for hospital. Where the particular circumstances are such 
that treatment in the home seems to be the best solution, such treatment 
is given. 
When cases are sent to hospitals they are given general ward service, 
provided the hospital furnishes satisfactory ward service and provided the 
case is one suitable for such service. If the nature of the case is such that 
a private room is necessary in the interests of the patient, care in private 
rooms is furnished. 
ORTHOPEDIC AND PROSTHETIC APPLIANCES 
Beneficiaries who have sustained an amputation of a leg, as a result 
of an injury, are furnished with the necessary artificial legs. They are 
given a temporary leg as soon as the amputation stump is in suitable con- 
dition. When the stump is shrunken satisfactorily, a permanent leg is 
furnished, if the temporary leg no longer fits. There is no essential 
difference between the temporary and permanent legs. All the legs 
furnished have to be passed upon by competent surgeons as being satis- 
factory in workmanship, construction and fit. Standard legs of good 
construction from reputable limb manufacturers are obtained. With 
the artificial leg there is furnished a supply of stump socks. Six fine wool 
socks made by machine, and not by hand, long enough for ample protec- 
tion of the stump are furnished. After this initial supply, two stump 
socks a year will be furnished, if requested. 
Where a part of the upper extremity has been amputated artificial 
arms are furnished, either a mechanical arm or an arm for use with a TREATMENTS APPLIANCES REPORTS 
1053 
Dorrance hook, or, if desired by the employe, both a mechanical arm 
and one with the Dorrance hook are furnished. Where both are furnished 
the mechanical arm is likely to be used for dress purposes and the 
Dorrance hook for working. 
When an employe has lost an eye, two properly fitting and matched 
artificial eyes are furnished. One to be kept by the employe for use in 
case of accidental loss or breakage of the other. It is frequently difficult 
to secure locally an artificial eye which will match the sound eye and 
injured employes, at times, need to be sent a considerable distance to get 
properly fitting and matched eyes. When furnished, the eyes are 
required to be passed upon as satisfactory by a competent ophthalmo- 
logist. If both the eyes originally furnished are lost or broken through 
the ordinary vicissitudes of use and not because of any essential fault of 
the employe, the Commission replaces them with others. 
If the injury to the eyes has been of such a nature as to require the 
use of glasses, glasses are furnished. 
When teeth are broken or knocked out as a result of injury, for which 
the employe is entitled to the benefits of the Compensation Act, nec- 
essary dental repair work is allowed to replace the damage done to 
natural teeth or to fixed false teeth. Removable false teeth are not 
repaired by the Commission, injury to them not being considered a 
personal injury. 
Orthopedic braces and appliances are furnished by the Commission 
whenever needed. Orthopedic shoes are purchased provided special 
shoes need to be made. If it is simply a matter of minor alteration of an 
ordinary shoe, the cost of the alterations will be met by the Commission. 
MEDICAL REPORTS 
The question of medical reports was one to be given consideration. 
From Government Medical Officers the Commission could in most 
instances get any kind of a report it desired on cases treated by them. 
The more difficult question was the manner of reports which the Com- 
mission would request from the practicing physicians and surgeons whom 
it had designated to take care of injury cases sent to them. 
It has been the practice in most undertakings to prepare detailed 
report blanks with numerous itemized questions to be answered. The 
Commission found that to make an itemized blank report that would 
cover all cases, the number of items, or questions, to be answered would be 
considerable and the blank would necessarily be a large one. Also, that 
in filling out the report for any one case a great many questions would 
have to be answered which would have no bearing upon the case. The 
studying of medical reports made on carefully itemized forms revealed 
the fact that there was a strong tendency when an itemized form was 
supplied for making a report, to run hastily through the form answering 
the various questions-Yes or No, where possible-always briefly, and 1054 
THE UNITED STATES EMPLOYES' COMPENSATION ACT 
that when the bottom of a form had been reached, the surgeon making 
the report would assume, and properly so, that the report was finished. 
Reports thus made out frequently would not give a description of the 
injury case which would be intelligible or give a true picture of the 
case when received at the central office, whereas, a true and accurate 
picture of the case would probably have been given by an intelligent 
surgeon in a short letter, perhaps in a single paragraph. 
Then too the Commission early realized that the competent busy sur- 
geon who had become well established in his community very often found 
the filling out of such blank reports distasteful. So much so at times, 
that rather than make such reports, he would refuse to handle Compensa- 
tion cases. So the question not only was one of which report was the 
more serviceable but was, also, one as to what the Commission desired 
most-good surgery by well trained men or detailed itemized reports 
from less busy, less well trained men. It was concluded that surgical 
service was of the greater importance, if a choice had to be made. Rou- 
tine reports on compensation cases were, therefore, limited to two simple 
card reports for which 3 X 5-in. card forms were furnished. One was an 
admission report to be forwarded to the Commission when a case came 
under treatment, the other a discharge report to be forwarded when the 
case was discharged. These were the only reports to be forwarded in 
minor injuries. In more serious injuries a report was to be made by 
letter giving information on the following subjects: 
1. The patient's account of the injury. 
2. The names and specialties, if any, of the physicians or medical 
officers examining the case. 
3. The condition found on examination. 
4. Diagnosis of the injury sustained. 
5. Nature and extent of the disability for work. 
6. Tentative prognosis. 
7. Recommendations. 
An intelligent surgeon in making a letter report on a case will invari- 
ably describe it satisfactorily and in such a way that the person reading 
the report gets a good and dependable picture of the case. Such reports 
very frequently will contain information that never would have been 
contained in any itemized blank form. If the writer of the report is 
intelligent, it gives the essential facts and is free from unrelated matter 
which serves usually only to hide the facts and obscure the picture. 
The necessary personal items regarding the injured employe are all 
furnished by the establishment or office where he worked, on their report 
of the case. 
The experience of the Commission would lead one to conclude that an 
applicant for benefits can get most any kind of a medical certificate he 
MEDICAL CERTIFICATES MEDICAL REPORTS CERTIFICATES CHARGES 
1055 
desires. This probably was to have been expected. Those familiar with 
such things would recognize that because a certain statement is made by 
an individual who has been licensed to practice medicine is no essential 
reason to take the statement seriously nor to conclude that it is a sincere 
or a particularly intelligent or expert comment. Such statements are not 
necessarily medical evidence. One statement by a disinterested, well- 
trained and experienced surgeon is worth more than a volume of 
statements by men who either do not recognize the condition before 
them or perhaps are not attempting to state accurately the nature of 
the disability. The practicing physician is likely to be kind-hearted, a 
general well-wisher, one who aims to help and assist. As a result, with 
the patient sitting on the other side of the desk, the probabilities are 
that his certificate will often correspond fairly closely with what the 
patient desires, or believes he needs to establish a claim. 
This benevolent tendency on the part of the practicing physician is 
most confusing to the non-medical members of Compensation Boards and 
Commissions, who are likely until experience teaches otherwise to take it 
for granted that every physician's statement represents the opinion of 
a qualified expert. 
CHARGES FOR MEDICAL SERVICES 
While the Commission furnishes medical treatment to injured 
employes through government hospitals and government medical officers 
where practicable a considerable proportion of the injuries coming under 
the Act are necessarily treated by private physicians and surgeons, mainly 
by those designated by the Commission for that purpose, as provided 
by Section 9 of the Act. 
The Commission was confronted early with the question whether it 
should draft a fee table of maximum charges which it would pay. It 
seemed to be the natural thing to do and generally expected. Here again 
the question arose as to the effect such a table would have upon the 
securing of efficient service of well trained men. In the early days of the 
work there was an evident reluctance on the part of busy surgeons to 
"be bothered with Compensation work," and there seemed to be a prob- 
ability that the busy successful surgeon would be further disinclined 
to engage in the work under the restriction of such a fee schedule. And it 
was competent service by trained men that was wanted. Then too, it 
seemed difficult to formulate any fee schedule. Who can say what the 
treatment of a fracture is worth? One may be a simple affair in a young 
adult with sound physique and without disease which may unite readily 
and quickly, with a minimum of care and supervision, other than reduc- 
tion and suitable fixation. Another fracture, apparently identical but in 
a different subject, may make great demands upon the surgeon's skill 
and time for a long period. Who can say what the treatment of a dis- 
located shoulder is worth? In some instances it is worth much, in others 1056 
THE UNITED STATES EMPLOYES' COMPENSATION ACT 
it is worth less than nothing. The Commission believed that the only 
hope for actually rendering adequate medical service was to select 
competent surgeons, qualified by training and temperament, and to leave 
much to them. The result of this policy has been most satisfactory. The 
charges paid for medical services have been, for the most part, well within 
what would have been allowed by a fee schedule, had one been made, 
and it is the belief that the spirit of co-operation which has resulted and 
the interest which the average surgeon has taken, when he realized the 
Commission placed the responsibility for the care of the case on him and 
had confidence in him, has been gratifying. 
As a check upon the making of excessive charges by surgeons, the 
Commission keeps a record of the charges made by each surgeon and 
wherever they seem to be excessive the sending of cases to them is dis- 
continued. In this way those who have a tendency to overcharge are 
rapidly eliminated. 
There are numerous diseases and conditions for which claims are made 
under the Act which are not injuries as commonly considered. The 
relationship of these conditions to the employment, although often 
indirect, may be truly one of cause and effect. Unless the result of a 
personal jnjury, however, they do not come under the provisions of 
the Act. The brief consideration of the more common of these may 
be of interest. 
DISEASES AND CONDITIONS FOR WHICH CLAIMS ARE MADE 
APOPLEXY-CEREBRAL HEMORRHAGE 
Numerous claims are made for benefits of the Act in cases of Cerebral 
hemorrhage. These cases may be grouped in three classes. 
1. Those in which the claimant falls and when found is discovered to 
be unconscious or paralyzed as a result of cerebral (or meningeal) hemor- 
rhage. Usually in falling the claimant is said to have struck his head 
against some object and the blow to the head is supposed to have caused 
the hemorrhage. 
2. Those in which a cerebral hemorrhage occurs while the claimant is 
at work (usually manual work) necessitating a degree of physical exertion. 
In these cases the supposition upon which the claim is based is that the 
exertion produced the hemorrhage by increasing the blood pressure and 
the attending physician usually so expresses his opinion. 
3. Those in which an injury to some part of the body other than the 
head has been sustained and while disabled by such injury cerebral hemor- 
rhage develops. Claims in these cases are usually made on the supposition 
that the shock or general consitutional effect of the injury or the succeed- 
ing hospitalization has in some way brought on the hemorrhage. 
In the first group of cases the principal question for the Commission 
to decide is usually whether the claimant fell and in the falling struck his MEDICAL CHARGES APOPLEXY TUBERCULOSIS 
1057 
head in such a way that the head injury caused a cerebral or meningeal 
hemorrhage or whether the claimant merely had an attack of apoplexy 
which caused him to fall and in falling struck his head. In other 
words whether the head injury caused the apoplexy or was merely an 
incidental result of it. Frequently there have been no witnesses to the 
fall and at times when there have been the conditions are such that their 
evidence is not helpful. From a medical point of view the factors to be 
considered are (1) whether the conditions were such as to have made a fall 
probable previous to the hemorrhage, (2) whether the resulting paralysis 
is of such distribution that it would be expected to result from the head 
injury and (3) whether the symptoms of the apoplexy are fully developed 
at the time of the fall or develop subsequent to it. The evidence is often 
unsatisfactory and the claims have to be adjudicated frequently on the 
basis of the probabilities. 
The second group of cases also offers difficulties owing to the fact that 
apoplexy develops under the most varied conditions. It frequently 
develops while the individual is exerting himself as during the perform- 
ance of heavy manual labor. It also develops while the individual 
affected is engaged in very ordinary activities and not infrequently 
develops during sleep. One would expect in an individual with arterio- 
sclerosis, if a rupture of an artery occurred, it would take place at a time 
when the blood pressure was greater than the ordinary pressure habitual 
to the individual and that unusual exertion might cause such increase 
of arterial pressure. The Commission has considered unusual physical 
exertion as a probable proximate cause in certain cases of cerebral 
hemorrhage. 
A number of cases belonging to the third group, that is apoplexy 
developing subsequent to an injury of some part of the body other than the 
head and during the disability resulting from such injury, have been pre- 
sented. In these cases the question -for decision has been whether the 
occurrence of the apoplexy at this time was merely accidental and without 
etiologic relationship to the injury and the ensuing disability or whether 
the effects of the injury constituted a factor of material etiologic impor- 
tance. In these cases the possibility of the apoplexy being a result of the 
effects of the injury has been usually too problematical to warrant an 
award of the claims by the Commission. 
TUBERCULOSIS 
Claims on account of tuberculosis coming under the Compensation Act 
may be divided into bone tuberculosis and pulmonary tuberculosis. The 
bone tuberculosis frequently follows bone injury. It may come on 
rapidly after the injury or it may not definitely manifest itself for some 
months. It may result from an injury to the shaft of a long bone or to a 
joint. It may also follow spinal injuries. 1058 
THE UNITED STATES EMPLOYES' COMPENSATION ACT 
Active pulmonary tuberculosis may develop as a result of: 
1. Chest injury, particularly crushing injuries accompanied by 
fracture of a rib with injury to the pleura and lung. 
2. Injury of other parts. The Commission has had instances where, 
following severe injuries, not of the chest, active tuberculosis has devel- 
oped, the chronological relationship being such as to suggest that the 
shock and depression following the injury had caused a quiescent tubercu- 
lous focus to become active. 
3. The disease may develop in persons engaged in the so-called dusty 
trades, particularly in trades where there is stone or metal dust. 
4. There have been instances of tuberculosis developing in employes 
who had been intimately associated at their work, over a considerable 
period with a fellow employe having active pulmonary tuberculosis and 
frequently careless as to personal habits and the disposition of sputum. 
In view of the Comptroller General's decisions such cases would not 
appear to come under the Act.* 
MINOR INJURIES MADE SERIOUS BECAUSE OF PRE-EXISTING DISEASE 
Occasionally an injury which in the average individual would cause 
but a short disability, causes a serious disability in an individual having 
some pre-existing pathologic condition. A minor injury to the toe or 
foot of one affected with diabetes mellitus may produce an ulceration 
which will take weeks to heal, or it may even cause gangrene and necessi- 
tate the amputation of the foot or leg. The result may be fatal. In one 
having syphilis, a simple uncomplicated fracture may refuse to unite or 
when union is attained it may be with a considerable degree of deformity. 
An injury to a joint which might ordinarily be expected not to be very 
disabling may in a syphilitic develop into a serious and long continued 
disability, possibly permanently crippling. 
In an individual advanced in years and with arteriosclerosis, an injury 
may have much the same result as in one with diabetes. A minor injury 
to a limb may precipitate a gangrene which will require amputation. 
Such cases as these have at times been perplexing, however, they have 
usually been allowed and the Commission has extended under the Com- 
pensation Act, benefits for all the disability ensuing from the injury. 
It has been kept in mind that the effect of most injuries and the nature 
and duration of the disabilities following them, are influenced, in large 
measure, by the diseases, the anatomical and physiological defects, the 
immunities and susceptibilities of the person injured, that the theoretical 
normal individual is a concept and not a fact. 
While many of the cases of lesser injuries producing profound and 
prolonged disability in persons affected with other diseases can be classed 
readily as to their position under the Compensation Act, there are many 
cases that are on the border line and difficult to determine. For example, 
paresis may follow a head injury in one previously affected with syphilis. 
*See Appendix VI, page 1076. INJURIES AND PRE-EXISTING DISEASE TYPHOID, ETC. 
1059 
In view of the fact that head injuries are by no means a necessary factor 
in bringing on paresis, such cases offer particular difficulties. Such a 
case has been allowed under the Compensation Act. 
TYPHOID FEVER 
Typhoid fever has been considered a personal injury sustained in the 
performance of duty only when it appears that contaminated and impure 
water has been furnished for drinking purposes at the place of employ- 
ment or has been so placed that it was likely to be drunk by employes 
and that some actually was drunk by the claimant, and where there is not 
evidence of some other more probable source of infection. A number of 
cases of typhoid fever were also allowed where the employes had lived 
and spent most of their time at a camp, under such conditions that they 
neither ate nor consumed beverages, except occasionally, away from the 
camp. The Commission reasoned that the employes living and spend- 
ing practically all of their time at the camp, in all probability contracted 
the typhoid fever there and awarded the cases. In view of the Comp- 
troller's decisions, previously referred to, such cases may in the future 
not be considered as coming within the Act.* 
PNEUMONIA 
Benefits have been awarded in cases of pneumonia where the attack 
of pneumonia began within 72 hours of a severe chilling of the body 
sustained while employed and because of the nature and conditions 
of work. The factor of fatigue accompanying the chilling has been 
considered to strengthen the case. Such cases may occur subsequent to 
falling into water during cold weather. They may occur in out door 
workers, where prolonged labor is carried on under extreme cold weather 
conditions. A clear history of fatigue accompanied by a definite pro- 
longed chilling of the body, when followed within 72 hours by symptoms 
of pneumonia were formerly considered sufficient to call for award. 
Occasionally pneumonia follows an injury, or comes on during hos- 
pitalization for an injury. At these times attacks of pneumonia may be 
considered to be a result of the injury. 
MALARIA 
The Government, at times, has groups of employes working in locali- 
ties where malarial infection is known to exist and in which anopheline 
mosquitoes are abundant. The Commission formerly followed the policy 
of considering attacks of malarial fever developing under these conditions 
to be personal injuries sustained in the performance of duty, for which the 
employes are entitled to the benefits of the Compensation Act. To 
establish such a case the evidence must be satisfactory, that malarial 
infection and anopheline mosquitoes are present, that the employes 
actually had malarial fever and that the probabilities are that the malarial 
*See Appendix VI, page 1076. 1060 
THE UNITED STATES EMPLOYES' COMPENSATION ACT 
fever was contracted during the hours of work, or at the place of work. 
The Commission has not considered it pertinent whether the employe, 
had he not been working for the Government, would have been working 
in a place equally exposed to malarial infection. The fact that the man 
was working for the United States and that the place where he was work- 
ing was such that he contracted malarial fever, because of the conditions 
in the locality, have been considered sufficient. Awards in such cases 
may be affected by the later decisions of the Comptroller.* 
HEART CONDITIONS, AGGRAVATED BY WORK 
Heart conditions are frequently perplexing. While conditions of 
work probably seldom bring on organic heart disease, they may seriously 
aggravate a heart condition which is not well compensated. Strenuous 
work or heavy lifting may overcome existing compensation and give rise 
to a serious and prolonged disability. In considering these cases, many of 
which have been difficult to analyze, the Commission has usually had to 
depend upon definite evidence of prolonged exertion or of a severe 
physical effort of shorter duration. 
While it is probable that some of these cases are instances where 
an unsound heart is on the point of losing its compensation and where 
it is merely a question of days or perhaps weeks before the disability 
would occur, still the probable causal relationship of strenuous physical 
exertion at work in such a case cannot be overlooked. Such cases when 
allowed are allowed as instances of material aggravation of a pre-existing 
condition. 
Carcinomata.-The Commission has had numerous claims made on 
account of carcinomata which have not been allowed because so little 
is known of the etiology of carcinomata and the evidence in these cases 
was not such as to indicate any very great probability that the carcino- 
mata were due to the injuries alleged. The Commission however has 
allowed two such cases, both instances of carcinoma of the breast, both 
giving a definite history of an injury, a contusion from which symptoms 
were continuous up to the time the symptoms of tumor became apparent. 
Award in these cases was made upon the evidence of chronological rela- 
tionship, the symptoms of the tumor extending back to and being a part 
of the symptoms of contusion resulting from the injury. 
Sarcomata.-The Commission has had a number of cases of sarcomata 
developing particularly as the result of injuries to the bones of the legs. 
These have developed mainly in young adults. As in the case of the 
carcinomata above referred to the chronological relationship of the 
sarcomata to the injuries was definite and the etiological relationship 
assumed as probable. 
Herniae.-In the early days of the Commission when it was beginning 
its work and evolving the policies which it would follow, the question of 
the attitude to take towards the development of herniae in workmen was 
*See Appendix VI, page 1076. HEART CONDITIONS CANCER-HERNIJS 
1061 
one of some difficulty. The attitude of a large part of the medical pro- 
fession has been that ordinary herniae, particularly the inguinal type, are 
congenital and not the result of injuries in later life; that the basis 
for such a hernia is anatomical. This has led to considerable confu- 
sion. It assumes that the workman is supposed to be anatomically 
perfect. Such an assumption is erroneous and entirely impracticable. 
No workman is anatomically perfect. Perfection is an ideal, not a 
fact. 
The Commission has accepted as true that certain individuals were 
anatomically so constructed that they would not, under practically any 
circumstances of stress or strain, develop a hernia, while others were so 
constructed that an inguinal hernia would be produced by almost any 
unusual effort or even by a usual effort performed in a disadvantageous 
posture. 
The anatomical factors in herniae probably differ little, if any, from 
those of back strain and of certain knee injuries. Some are anatomically 
so constructed that there is almost no possibility that they will sustain a 
low back strain, involving, say the sacro-iliac joint; others are so con- 
structed that they sustain such a strain readily and without unusual provo- 
cation. The same thing applies to certain strains of the knee joint. As 
much or more depends upon the anatomical structure of the individual 
and the tone and strength of the supporting muscles and ligaments as 
upon the external factors producing injury. 
Whether the development of an inguinal hernia is considered'an injury 
or merely an aggravation of a pre-existing condition, it would, according 
to the policy of the Commission, entitle to the benefits of the Compensa- 
tion Act, provided the evidence was such as to show that the development 
of the hernia was etiologically associated with the employment. As a 
statement of its policy and point of view the Commission adopted the 
following rule on herniae: 
"1. Predisposition to hernia shall be regarded as immaterial. 
"2. Any new hernia, whether complete or incomplete, resulting from 
an injury, if causing incapacity for work, is compensable, or if not causing 
incapacity for work, shall entitle the injured employe to operation and 
compensation during the resulting incapacity, but the evidence must show 
with reasonable clearness that: 
"(a) The alleged hernia was immediately preceded by some sudden 
effort, severe strain, or the application of external force. 
"(b) The injury was accompanied or immediately followed by pain and 
discomfort. 
"(c) The claimant had no knowledge of the existence of the hernia 
prior to the alleged injury. 
"3. Any existing hernia which has not incapacitated for work, if 
materially aggravated as result of an injury, is compensable if causing 
incapacity for work, or if not causing incapacity for work, shall entitle.- 1062 
THE UNITED STATES EMPLOYES' COMPENSATION ACT 
the injured employe to operation and compensation during the resulting 
incapacity, but the evidence must show with reasonable clearness that: 
"(a) The alleged aggravation was immediately preceded by some 
sudden effort, severe strain, or the application of externa force. 
"(b) The injury was accompanied or immediately followed by pain 
and discomfort. 
"(c) There was a material aggravation of the condition of the hernia 
existing prior to the alleged injury. 
"4. In all cases of hernia which the Commission shall find remediable 
by operation, the claimant shall be awarded such operation as a proper 
and necessary part of medical, surgical and hospital treatment. If he 
refuses either to accept or to secure operative treatment, he shall be denied 
further compensation and treatment, unless there are particular circum- 
stances warranting the waiving of this rule." 
Back Injuries.-Among the most troublesome injuries are those of the 
back. These injuries are not only among those most troublesome to the 
injured person, and cause long disability but are among the most difficult 
to have taken care of medically. The common injuries are, what is 
known as back strain, particularly low back strain, involving the sacro- 
iliac joints. Less common are fractures of the vertebrae, either of the 
processes or of the bodies themselves. One without experience would 
imagine that fractures of the vertebrae would be seldom overlooked by 
medical men. This is not so however. Not only are such injuries over- 
looked by physicians with limited practice in small communities, but they 
are frequently not diagnosed by men having special training and pre- 
sumably well qualified to care for such conditions. It might be of interest 
to cite one case which illustrates a not uncommon medical experience. 
December 5, 1917, a man fell into the hold of a vessel and was picked 
up unconscious and taken to a large metropolitan hospital where he 
remained 62 days. The diagnosis was fracture of the base of the skull. 
Spinal puncture had shown blood in spinal fluid. There was still some 
motor paralysis of the legs when he left the hospital and he continued to 
complain of pain in the back. He was examined in July, 1918, by a physi- 
cian who diagnosed the then existing disability as "Sprain or truamatic 
lumbago probably resulting from flexion of spinal column at time of 
accident, but now involving muscles only." The patient complained of 
constant dull aching pain in the lumbar region and walked slowly with 
body bent slightly forward (kyphosis). 
The case was again examined in November, 1918, by another physician, 
who stated-"Patient complains of pain when the spine, from the eighth 
to the twelfth thoracic vertebrse, is tapped lightly. In rising from a 
chair his movements are slow and he assists himself by catching hold of 
the arms of the chair. Massage was recommended." 
Another physician highly recommended and connected with a large 
metropolitan hospital examined the case in December, 1918, and reported BACK INJURIES 
1063 
•-"I find no signs of any organic disease, muscular and skeletal systems 
being apparently normal. He has, however, a well marked traumatic 
neurosis, similar in every respect to the so-called railroad spine. In other 
words the condition is purely functional, but as such it is none the less 
serious as far as ultimate recovery is concerned. The effect of treatment 
in this man's case would be problematic. The only thing that might be 
tried would be of a suggestive nature and associated with moderately 
severe electrical applications. In the above findings I have had the 
assistance and corroboration of Dr. , , Neurologist, at the . 
Hospital." 
In May, 1919, the case was sent for examination to an orthopedic 
surgeon of well known experience in the handling of injury cases. He 
found upon X-ray examination of the spine that there was a compression 
fracture of the eleventh and twelfth dorsal vertebrae. A proper back 
brace was supplied which gave relief and added much to the comfort of 
the patient. 
Fractures of the cervical vertebrae are similarly likely to be over- 
looked by the physician. The writer has in mind one case where an 
employe who had fallen ten or twelve feet was discharged, after having 
been kept under observation for two or three weeks, with what was diag- 
nosed, "a not very disabling injury to the shoulder." The disability 
persisted, headache and stiff neck developing. The case was sent to an 
experienced surgeon who found a fracture of one of the upper cervical 
vertebrae. 
More common and as difficult to diagnose, or at least as frequently 
undiagnosed are the low back strains, due at times to lifting, at others to 
falling or slipping. These strains frequently involve the sacro-iliac joint. 
Few physicians in general practice diagnose the condition correctly 
and still fewer extend proper treatment or give relief to the patient. 
These conditions are very disabling. If the injured man goes to his fam- 
ily physician complaining of his back, the physician will diagnose it 
either lumbago or strain of the back, apply heat or liniment, or perhaps 
give internal medication. If the patient is sent to some other physician, 
all too often the physician will report that there are no objective signs of 
injury, that the patient is apparently exaggerating the symptoms, that he 
is able to return to work. Many of these back strains cause a consider- 
able disability for common labor, or labor in which there is lifting or 
stooping. This disability may last for months. A support to the back 
or lower spine, or to the pelvic girdle in the shape of adhesive plaster 
strapping properly applied, or a properly fitting support or corset, gives 
relief in many of the cases and makes it possible for the injured person to 
return to work. Usually after a few weeks, sometimes months, the 
support can be dispensed with. 
The Commission has frequently had cases of this kind which it has 
sent from one surgeon to another, the patient maintaining his inability to 1064 
THE UNITED STATES EMPLOYES' COMPENSATION ACT 
work and complaining of discomfort in his back, the physicians stating 
that there were no objective symptoms and that the claimants were not 
disabled, frequently implying, if not stating, that the claimants were 
malingering. This has frequently gone on until finally the case would be 
brought a considerable distance perhaps to an orthopedic surgeon who 
had had experience in such injuries, a jacket would be applied, the patient 
would be made comfortable and return to light work within a short time 
happy that relief had at last been obtained. 
Fractures.-Fractures of the limbs are among the most common of the 
more serious injuries with which the Commission has to deal. Most 
physicians feel competent to handle fracture cases. Most people feel 
content as long as a "doctor" has charge of the case. It is the experience 
of the Commission that a large number of physicians have not had 
adequate training or experience in the treatment of fractures and as a 
result do not handle them satisfactorily. This conclusion is based upon 
the number of cases of what appear to be unnecessary deformity and 
permanent crippling which have followed the handling of fractures by 
physicians who had not had special experience in their care. In fact it 
has been the experience of the Commission that fractures are handled 
satisfactorily by exceedingly few and these few are found mostly among 
general surgeons, orthopedic surgeons and industrial surgeons. A 
tendency has been noted on the part of many surgeons to consider their 
work ended when a satisfactory union of the fragments has been attained. 
In many fracture cases the most trying period of disability is still ahead. 
If the work of the surgeon is the restoration of function, then he may have 
just begun his care of the case. 
A common fault in the handling of fractures is too little use of the 
X-ray both to ascertain the nature and condition of the fracture before 
reduction and as a means of ascertaining during the period of fixation 
whether the fragments maintain the position attained by reduction. 
The Commission requires X-ray examination to be made of every frac- 
ture at the time the fracture comes under treatment and again when the 
case is discharged from treatment. The following is copied from the 
Regulations of the Commission as promulgated to govern the medical care 
of fracture cases: 
"Fractures.-In all cases of fractured bones adequate X-ray 
examination should be made and X-ray plates preserved for record. 
During the course of treatment of the fracture if other X-ray examina- 
tions are indicated, they should be made. When union shall have 
taken place and convalescence been established, and before the case is 
discharged from treatment, further X-ray plates showing both the anterio- 
posterior and lateral views of the fragment should be made. Photo- 
graphic prints from all plates showing the injury should be forwarded to 
the Commission for filing with the other records in the case. Film 
negatives may be forwarded instead of prints. FRACTURES AMPUTATIONS-INFECTIONS 
1065 
"Suspected Fractures.-X-ray examinations should be made in 
injuries where fracture is suspected or thought possible, and the negatives 
kept as a part of the record of the case. 
' 'Sprains.-In sprains or injuries believed to be sprains, unless examina- 
tion shows that there is absolutely no reason to suspect a fracture, 
X-ray examination should be made and negatives kept as a part of the 
record." 
Physicians inexperienced in the care of fractures frequently leave the 
joints above or below the fracture fixed by the splints or other fixation 
dressing for too long a period, limitation of motion and sometimes even 
ankylosis developing. 
The requirement that X-ray examination shall be made in all cases 
of so-called sprains was made because a large proportion of so-called 
sprains are actually fractures, sometimes serious fractures. In fact a 
sprain that disables for work is almost always a fracture. 
Amputation.-The experience of the Commission would seem to indi- 
cate that a great many surgeons in making an amputation of a limb do 
not take into consideration the need of furnishing a proper stump for the 
fitting of an artificial limb. This is particularly so in the case of leg 
amputations. With an arm the policy of save-as-much-as-possible may 
be the proper one. With a leg the proper course is to secure the best 
possible stump for an artificial limb. At the present time when such 
excellent artificial legs are available and when so much time and thought 
have been given to their construction, it may very properly be said that 
no surgeon is competent to perform an amputation who is not familiar 
with the construction of artificial legs and the location and nature of the 
amputation which will give the most satisfactory stump for use with an 
artificial leg. 
Hand Infections Due to Minor Wounds.-The Commission has many 
instances of infections of the upper extremities leading to palmar absces- 
ses, and frequently with infection extending past the wrist into the arm. 
These infections commonly begin from trivial wounds of the fingers, 
particularly the little finger and the thumb. They are most distressing 
in their results. The infection has usually progressed into the palm of the 
hand before a physician is consulted. The end result is all too frequently 
adhesion of the tendon sheaths and contracture of the fascia with a 
deformed hand having limited usefulness remaining. The original injury 
may have been a scratch or pin prick or other wound so trivial as to be 
overlooked in many cases and at times its very existence is in doubt. 
Dermatitis Due to Cutting Mixtures.-The Commission has had a con- 
siderable number of cases where claims for benefits of the Compensation 
Act have been made on account of skin lesions, frequently described as 
dermatitis, characterized usually by multiple small abscesses. The cause 
for this condition is alleged, and it is believed properly so, to be the use of 
cutting mixtures, such as are used in many shops on lathes and cutting 1066 
THE UNITED STATES EMPLOYES' COMPENSATION ACT 
machines. This mixture consists essentially of an emulsion of lubricating 
oil in caustic soda solution. Most of the cases which have come before 
the Commission have been in men working at machines in the use of which 
the cutting mixture was employed. The lesions have usually been on the 
parts exposed, mainly the arms, as the cutting mixture gets more fre- 
quently on the arms than on any other part of the body. There have 
been instances, however, where the dermatitis seems to have spread from 
the primarily affected areas. 
Several suggestions have been made as to the manner in which these 
cutting mixtures produce the infectious dermatitis. The mixture is used 
over and over again and may become contaminated with expectoration of 
the workers. The presence of pus producing organisms in the mixture 
has been demonstrated in a number of instances. Some observers have 
thought the dermatitis due to the oil, others to the soda, others have 
suggested that it is due to minute abrasions made by small fragments of 
metal on the exposed skin. 
The Commission has had numerous cases of dermatitis in workmen 
who have handled and come in contact with metal which was smeared with 
grease to preserve its surface. This grease had none of the caustic soda 
common to cutting mixtures and few of the opportunities for contamina- 
tion with pus producing organisms common to these mixtu res. 
Lead Poisoning.-The cases of lead poisoning reported to the Commis- 
sion in Government employes have been principally in painters. The 
symptoms of lead poisoning often have been indefinite. Many of the 
cases appear to be of the type in which an employe is broken down in 
health and the physician, who discovers that his occupation is that^of a 
painter, that there are evidences perhaps of arteriosclerosis and that the 
history indicates acute lead attacks in times past, comes to the conclu- 
sion, possibly properly, that the condition is one fundamentally due to 
lead absorption. Comparatively few of the cases coming before the 
Commission are definite cases of acute lead attacks. Seldom is the lead 
line on the gums mentioned and still less often is an attempt made to 
determine the presence or absence of lead in either the urine or the blood. 
Liberality in Administration of the Act.*-The purpose of the Act 
being to relieve the injured employe of the principal burdens resulting 
from his injury in so far as can be done, a certain degree of liberality in its 
administration is necessary. Frequently the facts of injury are not 
possible of proof, at times there are no witnesses. Where there is a 
reasonable probability that an injury was sustained, even though some 
doubt exists, immediate relief must be furnished else the need for it may 
be gone before a collection can be made of all the relevant data and 
a careful analysis made of the facts. Fortunately such doubtful 
cases constitute but a comparatively small proportion of the total 
claims. Benefits are refused where the facts of injury are unproved 
and improbable. 
*See Appendix VI, page 1076. APPENDIX 1068 
APPENDIX 
Note: Use X for slight hazard {within limits of natural TOLERATION); XX, more marked hazard {but within limits of natural ADAPTATION at least for a 
lime); XXX, bad hazard {is producing DISEASE, or will rapidly do so). 
Age Sex M. S. W. D. Place of birth Nativity of parents Religion Date of immigration Time in this vicinity 
Renter Owner Boarder Home industry No. adults No. children Sleeping room: Vent., Light, Dampness, Heating, No. pres. 
Names of Employers 
Addresses of Employers 
Industry 
Occupation 
Census 
Symbol 
Date 
Began 
Date 
Stopped 
1 ... . 
2 . 
3 
Amount; breathed, skin, eyes; prevention, confinement, removal, respirators, carelessness; dry sweeping, dusting or clean- 
ing during work hours; promotes accidents, sickness.. 
DISORDER: (DIRT), Building structure, floors, surroundings, materials, insufficient cleaning, ordering; negligence; promotes low standards, inefficiency and 
injuries. 
Congested: neighborhood, house, apartment, tenement. No. floors Vent. Light Dampness Heating 
Dissipative Recreative Other work Sleep 
Day Night Overtime Noontime Other recesses Per week Steadiness Seasons 
...Date:... 
L CHART FOR ANALYZING AN INDUSTRIAL HEALTH COMPLAINT 
(FROM THE DIVISION OF INDUSTRIAL HYGIENE, OHIO STATE DEPARTMENT OF HEALTH*) 
Prepared by Emery R. Hayhurst, M. D. 
No. Street City 
WHY HAZARDOUS (suggestions) 
...ADDRESS:.. 
..Spare time.. 
(OVER)' 
Given name 
Bathing facilities Toilets Organization memberships 
..Clothing.. 
* Printed on stiff white card, 5X8 inches. 
Surname 
PREVIOUS INDUSTRIAL DATA: 
UNEMPLOYMENT CAUSES:.. 
PRESENT WORK PLACE: 
HABITS: Food.. 
HOURS:. 
DUST: Type. 
NAME:. 
HOME: CHART FOR INDUSTRIAL HEALTH COMPLAINT 
1069 
ILLUMINATION: Obstructed surroundings, limited window space, lighting (AEGO and by process); shadows, contrasts, flickering, glare, brilliancy, colors; 
poor shades, eye shades, goggles, helmets, screens; dark-room work; facing light source; promotes sickness, injuries, inefficiency 
4IR: Stagnation, room temperature (high?), humidity (low?); fine dust, smoke; leaks of gas, vapors, fumes; open fires, gas flames; very close confinement; 
promotes sickness and inefficiency. 
SEAT: Insufficient protection, rest intervals, drinking facilities, showers, baths, lockers, change rooms, clothes-drying quarters; long hours; permitting undue 
exposure; promotes sickness, injuries and inefficiency. 
COLD: Insufficient heating, clothing; drafts, inactive work, alternations with heat, outdoor closets; weather exposure; basement work; promotes sickness and 
inefficiency 
FATIGUE: Laborous work, long hours, piece work, speeding up, monotony, constant standing, prolonged strains, chairs without backs, faulty postures, hard 
floors, jarring processes, pressures against body, eye strain, noise; insufficient rest periods, female quarters, variations, rotations, recreations 
.insects, animals, persons; mouthed articles, short intervalled handling of objects, wiping rags, oil; frequent, 
trivial injuries, burns, flying particles; proximity to others, spitting on floors, common towels, cups; absent or insufficient wash places, closets, gloves, 
goggles, cuspidors, rules, medical care, physical exams, first aid, hospital arrangements. 
amt. of risk, worker ignorant, careless; instructions insufficient, dis- 
regarded, wrongful, harmful; mislabelling; eating at work, in work room; mustache, beard, indifference, medical supervision, gloves, respirators, clothes 
lockers, washing facilities, lunch room. 
FACTORS PROMOTING DESIRE FOR STIMULANTS: Thirst, dust, depressing air conditions, cold, poisons, fatigue, tradition, habit, stimulants; per- 
mitted during work; drink parlors near, ignorance of effects: lack of recreation facilities, home gardens 
N. B. In addition to the marks X, XX, and XXX, use L when hazards are due to the Locality (or neighborhood), and S for hazards which belong especially 
to the Space (or work room) rather than the occupation (or process) itself. All other hazards are presumed to be due to the nature of the Process itself. 
..work variation, rotation. 
HUMIDITY: Water, steam, vapors, dampness; confined dampness or dryness; promotes injuries, sickness and inefficiency 
PRESSURES: Caisson work, diving, high altitude, concussion. ODORS: Sickening. ELECTRICITY: 
Venereal diseases: suggestive pictures, writings, language-especially where sexes work together. 
THIRST: Drinking water not good, or convenient, or properly cooled, improper beverages preferred. 
INACTIVITY: Sedentary work, limited movements, mental concentration, confined work space 
Signed.. 
HAZARDS-(Continued.) 
INFECTIONS: Materials 
POISONS: Name and form 
Mechanical protection.. 1070 
CHART FOR PERSONAL HEALTH DATA 
Age Sex M. S. W. D. Place of birth Nativity of parents Religion Date of immigration Time in this vicinity 
Apparent age Height Weight Posture Gait Gross deformity Apparent general condition of health 
Medical or surgical attention, especially since 12 yrs. of age, such as: Diseases Mutilations Fractures Cures 
Pallor Suffusion Cyanosis Skin dis. Deform. 
Hearing Wax Cotton Discharge Odor Eczema Tender mastoid Scars 
Tartar Caries irregularity Malocclusion Absence Odor Dental work Use of brush 
No. Street City 
Squint Proptosis Diploplia Nystagmus Increased tension Lid reflex Deformity Disease Puffiness 
Obstructed breathing Nasal voice Ozeana Deformity Color Movements Defects 
Retraction Redness Pyorrhoea Discolor Atrophy Coated Defects Movements 
Alcohol Tobacco Coffee Tea Drugs Gum 
Color blindness 
Icterus Pallor Injection Pterygium Pupils: unequal, contracted, dilated, irregular, opacity, reflexes 
.TEMPERATURE:. 
II. CHART FOR PERSONAL HEALTH DATA 
(FROM THE DIVISION OF INDUSTRIAL HYGIENE, OHIO STATE DEPARTMENT OF HEALTH*) 
Prepared by Emery R. Hayhurst, M. D. 
Tuberculosis Diabetes Arterial disease Cancer Insanity 
VOICE:.. 
DATE.. 
Miscellaneous 
With glasses 
Note'. Use X for slight defect; XX, more marked; XXX, very marked; R, right, L, left, as required. 
Address. 
FACE:.. 
TONGUE:. 
Degree of intelligence Ability to understand English Miscellaneous 
..LIPS:. 
..PHARYNX:. 
Gray hair Parasites Scalp disease Deformity 
..UVULA:. 
(OVER) 
Surname Given name 
Health migrations Venereal diseases 
Without glasses 
* Printed on stiff yellow card, 5. X 8 inches. 
PRESENT HEALTH (Complaints). 
IDENTIFICATION: Name.. 
PHYSICAL EXAM.-HEAD: 
In own health 
PREVIOUS HEALTH:. 
EYES (Snellen Chart):. 
Present 
Past 
INTEREST:. 
FAMILY: 
HABITS: 
NOSE:. 
EARS: 
TEETH:. 
GUMS:. 
TONSILS: 
PALATE:. CHART FOR PERSONAL HEALTH DATA 
1071 
Skin affections Flatness Sunken apices Emaciation Limited expansion Suspicious breathing 
Hernia Patency of rings Adenitis Varicocele Hydrocele 
Deformities Scars Ulcers Varicose veins Skin affections Edema Arches 
Toes Toe nails Soles Pulse at ankles Patellar reflexes Ataxia 
Day Month Date Year Place Ship Months in year Names Days in week Names Backward 
Bronchitis Pleurisy Tuberculosis Pneumonia Emphysema Stoop Spinal disease Breasts Deformity 
Skin affections Adiposity Distension Dullness (flanks) Ventral hernia Liver? Gall bladder? 
Arteriosclerosis (radial, brachial) Glands Mise. 
Appearance Sp. gr. Reaction Sediment Albumin Reducing substance Indican Microscope 
Cube tests: line Trials Reverse Alternates Mathematics Binet age 
Goiter Glands Pulsations Scars Movements 
Deformities Skin affections Venereal diseases Hemorrhoids Fistula Mise. 
Fingers Hands Wrists Arms 
Counts 1-20 Counts 20-1 Mistakes Repeats figures Grasps funny story Construction blocks 
Valvular disease Myocarditis Pericarditis Mise. 
Spleen? Kidneys? ' Visceroptosis Tender points Abnormal swellings 
Pulse pressure 
Lumbar or sacroiliac affections 
* See also, Army Mental Tests, Yoakum, C. S. and Yerkes, R. M., Henry Holt & Co., N. Y., i920, price $1.50. 
(PERSONAL HEALTH DATA-Continued.) 
Defects or diseases of female organs 
Signed.. 
Diastolic 
Pulse (both wrists) 
( Before exercise 
I After exercise 
Systolic 
PELVIS, GENITALS & RECTUM:. 
Scars 
MENTALITY TESTS:* 
EXTREMITIES: 
BLOOD PRESSURE: 
ABDOMEN: 
MISC. 
SUMMARY 
DISPOSITION 
NECK: 
CHEST: 
URINE:. 1072 
APPENDIX 
III. GUIDE FOR CHIEF DIAGNOSTIC SIGNS OF LEAD POISONING 
Prepared By Emery R. Hayhurst, M. D. 
I. History 
(Allow for alcohol, smoking, chewing tobacco, excessive coffee or tea, drug 
habits.) 
Physician's diagnosis of lead poisoning, etc. 
Abdominal operations, especially appendicitis. 
Falls. 
Number of children (limited). 
Number of miscarriages. 
History of breathing dust containing lead (sanding). Inspect work process. 
History of breathing fumes or vapors containing lead. Inspect work process. 
The lead triad (spells lasting a day or so of abdominal colic, obstinate con- 
stipation, severe headache without fever). 
The Milan Clinic triad: paleness, dyspepsia and weakness. 
Rheumatism, muscular or joints (without fever). 
Backache, lumbago, sciatica. 
Loss of weight. 
Weakness, particularly of arms or hands. 
Paralysis, particularly of arms or hands. 
Palpitation of heart. 
Headache. 
Constipation. 
Use of laxatives. 
Diseased teeth and gums. 
Metallic taste. 
Sweet taste in mouth. 
Loss of appetite. 
Dizziness, "nervousness." 
Fainting, fits, "jags." 
Staggering spells. 
Blind spells. 
Confusion. 
Insomnia. 
Memory defective. 
Diplopia. 
Tinnitis, deafness. 
Epistaxis. 
Nocturnal urination. 
Chronic bronchitis. 
Insanity, or detention for peculiar actions. 
II. Present Symptoms 
Abdominal pain (especially colicky). 
Dyspepsia. 
Constipation. 
Poor appetite. 
Headache. 
Backache. 
Rheumatism (etc.). 
Weakness (general or local). 
Mental depression. 
"Neurasthenia." 
Dizziness. 
Nervousness. 
Poor sleep. LEAD POISONING 
1073 
III. Physical Signs 
Premature ageing. 
State of nutrition (hands, arms; general; emaciation?) 
Pallor (especially about mouth and lower face). 
Excessive sweating. 
Anxious facial expression. 
Deafness. 
Ocular palsies. 
Tremors (tongue, lips, chin, hands). 
Incoordination (fingers, arms). 
Grip strength weak (dynamometer). 
Strength of wrist extension (weak). 
Wrist drop. 
Reflexes usually decreased (knee jerks, wrists, elbows, cremastric) 
Ataxia. 
Arterio-sclerosis (radial, brachial, temporal). 
Abnormal blood pressure (systolic), but subject to wide variations. 
Teeth and gum diseases (look for "lead line"). 
Acne, dermatitis. 
Gouty signs (ears, great toe joints, palms, other joints). 
Edema of ankles. 
Dropsy. 
IV. Laboratory Tests 
Blood- 
Anemia (secondary). 
Basophilia (especially to be looked for during colic). 
Urine- 
Albumin. 
Lead. 
Casts. 
Red corpuscles. 
Findings for chronic (interstitial) nephritis. 
Skin- 
Lead in epidermis (sodium sulphide test, 10 per cent., to prove recent 
exposure to lead). 
IV. ADDENDA ON LEAD POISONING: SOURCES, SYMPTOMS 
AND TREATMENT 
Sir Thomas Oliver, M. D.,Newcastle-upon-Tyne, England 
(See Part III, Chapter I, Section 9, pp. 412-423) 
a (p. 414). Recently however lead poisoning has again appeared among the miners, 
and it has been suggested that chemical changes are taking place in the exposed 
galena whereby soluble lead products are formed and are given off in the dust. 
b (p. 416). I have recently seen a similar outbreak of plumbism among men engaged 
in breaking up war ships, and apparently due to inhalation of fumes from red lead 
paint with which the surface of the plates have been coated. Some of the iron plates 
are 8 to 10 inches thick and have to be burned through by means of the oxy-acetylene 
flame. Another source of the lead poisoning is inhalation of the dust evolved during 
the separation of the teak wood from the iron plates. 
c (p. 417). C. Klein, however, has shown that equally satisfactory results, from a 
decorative point of view, can be obtained by the wet method of sandpapering and 
that therefore the risk to housepainters can thus be considerably lessened. 
d (p. 418). All these spirits exercise a particularly harmful influence upon the 
kidneys. 1074 
APPENDIX 
e (p. 418). Bearing upon this point the United States' producers of paints carried 
out a series of tests with the result that the Government in its contracts specifies that 
in white and tinted paints there shall be not less than 45 per cent, of white lead and 
not more than 70 per cent., while one of the largest zinc paint firms, recognizing the 
value of white lead for outside work, advises the use of white paints containing not 
less than from 35 to 50 per cent, of lead compounds mixed with zinc white. 
f (p. 418). This is largely due to the spirit they contain. With the assistance of 
Prof. H. J. Hutchens I carried out a series of experiments to test the bactericidal 
influence of paints upon the bacillus coli and we found that lead paints containing 
turpentine or benzol prevented all growth and that a paste made of white lead and 
vaseline only inhibited growth but did not prevent it. Paints made with zinc white 
and containing turpentine or benzol entirely inhibited growth like the lead paints. 
g (p. 419). In Sheffield, file cutting by hand has practically ceased: files are now 
made by machinery. 
h (p. 419). Hair dyes have caused paralysis and death. I have drawn attention 
(The Lancet, 1922, II, 907) to recurrent attacks of asthma in a man who was in the 
habit of using a hair wash containing lead, in whose urine lead was found, and in his 
blood punctate basophilia. The attacks of asthma disappeared when the hair wash 
was discontinued, and reappeared on its application. Teschedi also refers to saturnine 
asthma occurring in two workmen whose asthma permanently disappeared on change- 
ing their employment in which they had been exposed to lead. Although the associa- 
tion of lead and asthma is not, I admit, quite clear, yet the attacks in Teschedi's 
patients and my own seem to have been more than mere coincidences. 
i (p. 420). The anaemia of plumbism has generally been attributed and rightly 
so to the effect of lead upon the blood-making organs of the body, but a somewhat 
novel theory has been advanced by Dr. Sanchez Girona (Los Progresses de la Clinica, 
4'Serie, Tome xxxviii, 1922, No. 6) of Madrid to explain the anaemia of lead smelters, 
as he had failed to find lead in the viscera of workmen, also in the urine and blood. 
'During the process of lead smelting, sulphur compounds are given off. This particu- 
larly occurs, during the roasting of pyrites by the Scotch method. The sulphurous 
anhydride is inhaled and along with the oxygen and moisture present in the atmos- 
pheric air comes into contact with the blood. Becoming transformed into sulphuric 
acid it removes the iron from the hemoglobin of the red blood corpuscles and forms 
ferrous sulphate. Girona is disposed to attribute the anemia of all metallurgical 
workers to the presence of sulphate of iron in the blood. 
j (p. 423). Cases of pyloric spasm and of dilation of the stomach have frequently 
been mistaken for lead colic, while in more than one instance, where death was 
certified as due to lead poisoning, I have found malignant disease of the intestine. 
k (p. 424). The urine of lead workers frequently contains lead, and yet there may 
be no basophilic red corpuscles in the blood. 
I (p. 425). In the still-born infants of female lead workers I found lead especially 
in the liver. 
m (p. 428). It would be helpful if we had some definite information in regard to 
just the amount of lead present in drinking water which is dangerous. The water led 
into a house would have to be examined at different hours of the day, since, while the 
first drawn off might contain 1 grain of lead per gallon, in the water drawn off a few 
hours later there might be only 1/10 of a grain. Dr. John C. Thresh is of the opinion 
that if the water does not contain more than 1 part of lead per 100,000 it is passable. 
n (p. 431). For lead colic Vinaj (Il Lavoro, XIII, No. 4, April 30, 1922), has used 
with considerable success the injection of warm water into the bowel through a sound 
which is connected with a posterior pole of an electric battery, the negative pole, 
covered with absorbent cotton, being placed upon the abdomen. That no scarring 
of the intestinal mucous membrane may occur, a liter and a half of watfer is introduced 
before the galvanic current is turned on. This should not exceed 50 milliamperes: 
the current can be interrupted and reversed. ADDENDA ON DUST DISEASES OF THE LUNGS 
1075 
V. ADDENDA ON DUST DISEASES OF THE LUNGS 
Sir Thomas Oliver, Newcastle-on-Tyne, England 
(See Part III, Chapter III, Section 1, pp. 701-719) 
a (page 702). As to whether there is or is not a protecting agent in coal dust 
medical opinion remains divided. While coal miners as a class have, next to agri- 
cultural laborers, a low mortality rate from phthisis, yet coal dust cannot altogether 
be protective since, as Edgar L. Collis* points out, miners who are working at the 
face suffer from phthisis more than other underground workers. Allusion has been 
made to the experiments of Wainwright and Nichols. By them guinea pigs were 
placed for two months during the greater part of each day in an atmosphere containing 
coal dust. Subsequently cultures of tubercle bacilli were injected into the animals. 
It was found that although the anthracosed animals developed extensive tuberculosis 
of the abdominal viscera and of the glands around the trachea, the lungs remained 
free. In the control animals, on the other hand, there was extensive tuberculosis of 
the lungs and abdominal viscera. 
5 (page 703). The chemical as well as the physical character of the dust is also an 
important factor in pneumokoniosis. 
c (page 704). Fred. L. Hoffman in his statistical inquiry with phthisis among 
granite workers found while the housing conditions of the workers were good and the 
men above the average in physique that those who were employed in granite cutting, 
especially where this was done by using pneumatic tools, showed a high death rate 
from pulmonary tuberculosis and, at the present time, instead of the death rate lessen- 
ing, it is increasing. It is the fine granite dust almost in the form of ultra-microscop- 
ical particles which do harm. The average silicotic content of granite is 72.96, of 
sandstone 85.45 and of limestone 1.22. 
d (page 708). E. L. Middleton f reminds us that into the causation of silicosis 
there enter the following factors-the amount of pure silica in the dust inhaled, the 
size of the particles, the gaseous atmosphere of the mine and the physical state of 
the worker. By means of a Kotze konometer the number of particles in a cubic 
centimeter of air can be counted. Dust particles over 12 microns in diameter may be 
regarded as non-injurious. Air containing over 300 particles of dust per cubic cen- 
timeter is harmful. Since the particles of silica removed from the lungs of a miner 
who has died from silicosis are usually less than 2 microns, anything below this is 
dangerous for it is just these extremely minute particles which pass through respirators. 
Haldane and Mavrogordato as a result of their experiments upon animals showed 
that the addition of such relatively inert dust as shale and coal to silica stimulated the 
bronchial mucous membrane and its ciliated epithelium to expel the dust before it 
became fixed in the pulmonary tissue. 
e (page 709). One of my patients, a man aged 49, died 13 years after working 
in a gold mine. 
f (page 709). ' W. E. Gye and E. H. Kettle J have tried to answer the question as to 
how silica induces pulmonary fibrosis and how the silicotic fibrosis induced favors 
the establishment of tuberculosis. Hitherto perhaps too much attention has been 
paid to the physical character of the dust inhaled to the exclusion of the chemical. 
Together silica dust and tubercle bacilli act as irritants and lead to reactions on the 
part of the lung which neither of these separately might induce. Colloidal silica is 
by itself a cell poison. The bacteria which are ordinarily present in the soil possess 
the power of converting mineral silicates into soluble silica of which the colloidal type 
is the more readily formed. When soluble silica or silica dust is injected into the 
* Journal of Industrial Hygiene, Oct., 1922, p. 256. 
t Journal of Industrial Hygiene, March, 1921, p. 432. 
tLancet, Oct. 21, 1922, p. 855. 1076 
ADDENDA ON DUST DISEASES OF THE LUNGS 
tissues of animals there occurs fibrosis. Soluble silica produces this the more quickly 
but the effects are transient. On the introduction of silica along with tubercle bacilli 
into mice the silica caused a necrotic area in the tissues, in which tubercle bacilli 
multiplied abundantly. The tissues appeared to lose their immunity to the organisms. 
Gye and Kettle are of the opinion that silica dust when inhaled destroys the pulmonary 
cells and that there occurs limited areas of necrosis in which tubercle bacilli multiply. 
g (p. 710). Once fibrotic change has taken place it is hardly possible to arrest its 
further development in the lung. 
h (p. 719). Before closing this article mention might be made of dust phthisis 
occurring in printers. To the prevalence of pulmonary diseases in printers in the 
United States Dr. Fred. L. Hoffman has drawn attention. It has for long been known 
that printers as a class exhibit a high death rate from phthisis. In Great Britain this 
was the case 40 years ago more than it is today. I have generally attributed the 
circumstance to the men working in over-heated and ill ventilated rooms, to the 
inhalation of dust and the possibility of infection by diseased workmen, but Dr. E. 
Halford Ross while admitting the influences of the above attributes the malady mostly 
to inhalation of the dust which collects in the boxes which hold the type. This dust 
is rich in silica and iron. It has been examined and found sterile as far as tubercle 
bacilli are concerned. The opinion advanced by Ross therefore is that printers' 
phthisis is in its incidence a silicosis. The statement has been subjected to hostile 
criticism by several observers. Since at the present time no decision has been 
arrived at it is sufficient perhaps just to raise the question of the causation of printers' 
phthisis, and to await the results of further observation and experiment. 
VI. ADDENDUM ON UNITED STATES EMPLOYES' COMPEN- 
SATION ACT 
Regarding the scope of the term personal injury, the U. S. Attorney General, 
on May 16, 1923, ruled as follows: "I am therefore of the opinion that the Federal 
Employes' Compensation Commission is endowed with the power under the Act 
of September 7, 1916, finally to determine questions arising under said Act and 
that the interpretation of the term 'personal injury' to include injuries arising 
from occupational diseases is justified under the law and intent of Congress."- 
(Kober.) INDEX OF AUTHORS 
Note: (1) The alphabetically arranged lists of authors given for the Section on 
"Occupation Neuroses," pages 785-789, and for the Chapter on "Occupational 
Affections of the Skin," pages 926-929, are not repeated in this Index. 
(2) Occasionally, simple chemical symbols are used for simplicity and in 
order to save space, such as, CO for carbon monoxide, CO2 for carbon dioxide, 
and CS2 for carbon bisulphide. 
Abb6, "passive" fatigue, 755 
Abb6, Ernst, shorter work day, (755), 
761 
Abbott, A. C., opsonic index in fatigue, 
(744), 761 
Abel, anthrax spores, 664 
water shell projectile, 555 
Abrahamson, psychoses in CO poisoning, 
397 
Ackermann, reviser of Ramazzini's work, 
xxii 
Adams, S. S., nitrobenzene poisoning, 513 
Adams, W. W., explosives, 554 
mine accident statistics, 146 
Adelmann, George, sick workers, early 
institute for, xx 
Adler-Herzmark, Jennie, brassfounders' 
ague in autogenous welding, 342 
Aetna Life Insurance Co., explosive 
hazards in industry, 563 
Ahrens, dust, in foundries, 184 
in other industries, 18 
Aitken, pneumokoniosis, 711 
Aitken, Francis, treatment of silicosis, 
718 
Aitoff, Vladimir, carbon bisulphide, 
(360), 367 
Alaskan Engineering Commission, U. S. 
Compensation Act, 1044, 1046 
Albany Medical College, public health 
course, xlviii 
Albaugh, R. P., CO poisoning, 388 
exhaust cabinets for shellacing (349), 
352 
office, industrial hygiene, xlviii 
pottery industry, 168 
spray painting, dangers of, 466 
Albaugh (and Hayhurst), oil folliculitis, 
697 
Alberti, CO poisoning, 398 
Albrecht, consumption in printers, 247 
cyanogen chloride, 575 
"Handbuch," xxiv 
Aldrich, "trap drum" neurosis, 290 
Aldrich and Schmuckler, copper statis- 
tics, (321), 327 
Alexander the Great, diving bells in 
time of, 790 
Allbutt's "System of Medicine," occupa- 
tional neuroses, 763 
Allen, F. I., anthracosis, 703 
Allen, J. C., hook-worm disease, 157 
Allevi, women in printing trades, 110 
Allison, Katz and, stenches in gas 
leaks, 400 
Alsberg, Schwartze and, cadmium solder, 
329 
poisoning, 585 
Amar, Jules, "Physiology of Industrial 
Organization," xxiv, 144 
American, see also U. S. 
American Association for Labor Legisla- 
tion, first conference on occupa- 
tional diseases, lii 
occupational disease bill, xxxi 
phosphorous match poisoning, 4, 528 
publications of, xliv 
standard lead law, 1005 
American Association of Industrial Phy- 
sicians and Surgeons, inception 
of, Ivii 
American Bar Association, child labor, 
xxxv 
American Chemical Society, chemical 
poisonings, liv, 571 
organic accelerators, 536 
"American Child," accidents to children, 
1021 
1077 1078 
INDEX 
American Child Hygiene Association, 
recommendations, 1022 
(American) Commission on Resuscita- 
tion from Electric Shock, rules 
of, 841 
(American) Committee on Public Acci- 
dent Statistics, 81 
American Federation of Labor, attitude 
on piece work system, (757), 
761 
conference on health, Iv 
President of, important agenda, Ivi 
American Hospital, Chicago, industrial 
clinic, 113 
American Institute of Electrical Engi- 
neers, resuscitation, 841 
American Institute of Medicine, public 
health course, xlix 
American Labor Legislation Review, 
industrial nurse, 144 
American Locomotive Company, use of 
goggles, 83 
American Medical Association, rules for 
resuscitation, 841 
symposium, liv 
American philantropists, research fund, 
108 
American Public Health Association, 
conference, Ivi 
creation of Section on Industrial 
Hygiene, xlv, liv 
editorial, historical, 1 
history of public health, vii 
pulmonary diseases, zinc miners, 154 
American Red Cross, child labor, 1023 
lumber camps, 202 
safety exhibits, xliii 
American Research Laboratory (see also 
U. S. Air Service) altitude 
symptoms, 819 
American Social Insurance Conference, 
(112), 113 
American Society for the Control of 
Cancer, educational work, 958 
pamphlets and leaflets, 959 
Anacker, glass polishers. 174 
Anderson, historical industry, x 
Andrews, Irene Osgood, office, labor 
legislation, xliv 
women wage earners, 1028 
Andrews, John B., anthrax, 666, 669, 672, 
673 
in historical medicine, Ivi 
labor protection principles, xix 
Andrews, John B., lead poisoning, liii, 3, 
441, 453, 465 
legislation, 526, 672, 1002 
phosphorous poisoning, 3, 526 
reconstruction work, 85 
report, epoch-making, lii 
secretary, xliv 
symposium on industrial hygiene, 
xlv 
Andrews, Commons and, occupational 
diseases, xl 
Angela, Luzzati and, tellurium poisoning, 
597 
Angermeyer, experimental studies, xlviii 
Anglo-American Expedition to Pike's 
Peak, altitude and blood 
changes, (816), 830 
Angus, H. B., electrical accidents, 833 
Antonelli, artificial fertilizer workers, 213 
Antonines, slave labor protection, xi 
Antwanette Co., health of aviators, 828 
Apfelbach, (Geo. L.), anilin poisoning, 
514 
arsenical poisoning, 317 
carbon monoxide poisoning, 407 
electrical eye hazards, 177, 840 
Apfelbach and Gibson, painters, 453 
Apfelbach (revised by Hayhurst), carbon 
monoxide poisoning, 369 
Apfelbach, Karasek and, CO poisoning, 
380, 405 
Appert, glass blowing, 174 
Aristotle, diving bells in time of, 790 
Arkwright, spinning machine, ix, xxv 
Arlidge, (Thomas), copperworkers, 326 
"Diseases of Occupation," xxiii 
lace workers, 733 
"potters' rot" or "asthma," 710 
Arlidge and Blaudet, copper intoxication, 
322 
Armit, (H. W.), nickel fume poisoning, 
3 30, (331), 339, 594 
Armit, iron, and cobalt fume poisoning, 
(331), 339 
Arnstein, cause of cancer, 955 
zinc poisoning, 332, (329), 339 
Arnstein, Alfred, turpentine substitutes, 
464 
Aronovitch, Lee and, fatigue toxin 
question, (740), 760 
Ascher, brick and stone masons, 170 
iodine poisoning, 574 
smoke and soot, and health, 21 
Ascher and others, dust in mines, 149 INDEX 
1079 
Ashford, (Bailey K.), hookworm in 
Porto Rico, 7, 211 
hookworm and efficiency, 80 
parasites and occupation, 682 
Ashley, Lord, legislation, xiv 
Askanasy, "Leukonin," 584 
Association of Iron and Steel Electrical 
Engineers, liii 
Athanesia, toxicity of cadmium, 585 
Atwater, food calories, 62 
Aub, J. C., lead in the body, 469 
Austrian Minister of Agriculture, hook- 
worm in mines, 1013 
Avery, C. O., physical examinations, li 
Ayers, music in bicycle racing, 742 
Babcock, alcoholism, 65 
Bach, E. E., preventibility of accidents, 
(83), 86 
Bachem, antimony poisoning, 584 
Bachfeld, investigations in industrial 
hygiene, xxiv 
Baily, statistical truism, 993 
Bain, Jules, sulphur-carbon compounds, 
362 
Bainbridge, W. S., cancer problem, 
(ref.), 969 
Baly, malaise in painted rooms, 417 
Bang, Fiebiger and, experimental tar 
cancer, (ref.), 959 
Bard, carbon bisulphide poisoning, 366 
Barnes, A. E., chest expansion in workers, 
710 
Barr, boiler makers, hearing of, 898 
Bartley, turpentine substitute, (496), 499 
Bashford, cancer, (946), (953), 958 
Baskerville et al, Report of Committee on 
Occupational Diseases, 571 
Bassett, brass fumes, analysis of, (341), 
351 
zinc chills, 338 
volatilization of, (328), 339 
Bassoe, compressed air illness, 112, 801 
Batelli, (F.), electrical accidents, 834, 837 
Bates, L. W., mercury poisoning, 490, 491 
Bauer, glove industry, alum ulcers in, 677 
Bauer, Lehmann and, industrial hygiene, 
xxii 
Baum, foot presses and pregnancy, 198 
Baum and Seeliger, copper poisoning, 
322, (323), 327 
Bayet and Slosse, briquette makers, 507 
Bazett, Corbett and, hygiene of aviators, 
828 
Beattie, pneumokoniosis, 716 
Beatty, J., boot and shoe workers, 280 
Becquerel, radium experiments, 966 
Behier, dust diseases of the lungs, 701 
Behla, Robert, carcinoma, (ref.), 969 
Belger, Herman, dust binding methods, 
717 
Belger and Oliver, effects of mixed dusts, 
717 
Bell, Rosalie, airplane dopers, 576 
Bell Telephone Company, hours of 
telephone operators, 1040 
Bennett, H. G., tanning, chrome com- 
pounds in, 848 
Berbes, carbon bisulphide poisoning, 264 
Berens, altitude symptoms, 820 
Bergeron, anilin and nitrobenzol poison- 
ing, xxiii 
Bergonie, J., radium dermatitis, (ref.), 
969 
Berlin Sick Insurance Companies, brick 
and stone masons, 170 
printers, consumption among, 247 
Bernhart, farmers, coxa vara in, 210 
telephone operators, 299 
Bernton, Harry S., castor bean poison- 
ing, 570 
Bernutz, pottery workers, 166 
Berry, Fred, animals in detection of CO, 
378 
Bert, (Paul), compressed air illness, 791, 
793, 796, 802 
altitude and blood changes, 815 
Berthenson, Leo, petroleum industry, 505 
Bertillon, liberal professions, 288 
Bertrand et Javillier, zinc test, (328), 339 
Beserro, Wilmer and, aviators, 829 
Besson, anthrax spores, 664 
Beth, air filter devised by, 23 
Bettmann, oils and vaselines, 698 
Beyer, needle polishers, age of, 189 
Bezold-Edelmann, noise and impaired 
hearing, 900 
Bible, brass mentioned in, 341 
Bibra and Geist, phosphorous match 
workers, xxiii 
Bibrowicz, Leubuscher and, industrial 
neurasthenia, 750 
Billings, Frank, focal infections, 81 
Bing, brommethyl poisoning, 575 
Biondi, lead poisoning basophilia, 421 
lead miners, poisoning in, 451 
Birckner, zinc testing, (328), 339 
Birge, painters, anilin poisoning in, 514 1080 
INDEX 
Birge and Havens, pearl button industry, 
xlix 
Birley, altitude symptoms, 818, 819 
Birmingham, ganister disease, 705 
Blake, C. J. (revised by Wells), affections 
of the ear, 890 
Blakiston's Son & Co., "Diseases of 
Occupation," Etc., liv 
Blamoutier and Joannon, occupational 
quinine poisoning, 570 
Blashchko, ursol black dermatitis, 517 
Blaudet, Arlidge and, copper intoxica- 
tion, 322 
Blegvad, telephone operators, hearing 
of, 902 
Bleile, A. M., electric shock, 836 
Block and Dreifuss, experimental tar 
cancer, (ref.), 959 
Bloedorn, W. A., accidents in Navy 
Yard, 294 
Bloodgood, industrial surgery, Ivii 
Blue, anthrax in shaving brushes, 670 
Blum, lead sulphide solubility, 451 
Board of Trade Labor Gazette, tetra- 
chlorethane poisoning, 576 
Bock, CO poisoning, 392 
Bockendahl, the ear, high tones on, 901 
Bodansky, zinc in marine animals, 329 
Bodenstein, Jos., dimethyl sulphate 
poisoning, 574 
Bogardus, fatigue and accidents, 748 
Bogner, pottery workers, 166 
Bolam, (R. A.), electric shock, 835, 836, 
839 
Bolis, Reisman and, brassfounders' ague, 
342 
Bollinger, glanders and farcy, 8 
Borattaue, automobilists, 244 
Bortfelt, mercury poisoning, 493 
Bottrich, lead poisoning, 439 
Bouchut, zinc chills, (338), 340 
Boulanger, smokeless powder, 550 
Bourrot, electric shock, 832 
Boveri, P., antimony poisoning, 584 
Bowen, John T., affections of the skin, 
905 
Box, chauffeurs, gasoline poisoning, 244 
Boycott, compressed-air illness, 791, 
806, 807 
Boycott and Damant, compressed-air 
illness, 795 
Boycott, Haldane and, compressed-air 
illness, 794 
Boyle, caisson disease, 791 
Brady, Anthony N., memorial medal, xlv 
Brand, discover of phosphorus, 526 
Bratt, investigations in industrial hy- 
giene, xxiv 
Brauer, tobacco dust on mucous mem- 
branes, 228 
Braum, etiology of cancer, (953), 958 
Braun, William, "no-nitratemethod," 493 
Breton, Raoult and, copper poisoning, 
(323), 327 
Brezina, lead sulphide, absorption of, 451 
Briau, carbon bisulphide poisoning, 361 
Brian (de Creusot), carbon bisulphide 
poisoning, (364), 367 
Bricker, Smyth and, anthrax infection, 
676 
Bridge, J. C., oxy-acetylene flame on 
galvanized plates, 467 
Bridge, T. C., twisters' cramp, 258 
Bridge and Structural Iron Workers' 
Union, accident rates, 187 
Briggs, gangrene in CO poisoning, 399 
British, see also Great Britain, English 
British Admiralty Committee, com- 
pressed-air illness, 791, 803, 
806, 807 
British Army, phthisis in, 292 
British Association for the Advancement 
of Science, fatigue, economics 
of, (737), 760 
British Board of Trade, electrical acci- 
dents, 832 
hours of labor in different countries, 
(753), 761 
British commission, slate dust, 733 
British Committee, glassworkers' cata- 
ract, 883 
(British) Department of Scientific and 
Industrial Research, lubricants, 
699 
British Factory Acts, CS2 poisoning, 366 
CO poisoning, 400 
British Factory Inspector, brass poison- 
ing, (ref.), 359 
quick drying paints, 498 
British Government Laboratory, mer- 
cury in fur sample, 490 
British Health of Munition Workers' 
Committee, fatigue and occupa- 
tion, 745 
oil folliculitis, 696 
welfare legislation, xviii 
British Home Office, CO poisoning, 382 
anthrax disinfection station, 674 INDEX 
1081 
(British) Industrial Fatigue Research 
Board, reports of, 745 
British Inspectors of Explosives, acci- 
dents, 561 
(British) Institute of Mining Engineers, 
dust elimination from the lungs, 
716 
British (Medical) Inspector, anthrax 
infection, 673 
benzene poisoning, 503 
dyes and mordants, 268 
British Medical Officer of the Privy 
Council, reports of, (historical), 
xv 
British Medical Research Council, CO 
and CO2 poisoning, 375 
British Merchant Service, mortality of, 
296 
British National Institute of Industrial 
Psychology, reports of, 745 
British Parliament, Health and Morals 
of Apprentices' Act, 753 
British regulations, lead dyes, 852 
British reports, phosphorous poisoning, 
531, 533 
British Royal Commission, arsenical 
poisoning from beer, 312, (313) 
mining, xvi 
silicosis, xviii 
British Royal Navy, mortality of, 296 
British Royal Society, glassworkers' 
cataract, 887 • 
British Special Committee, X-ray and 
radium protection, 969 
Broadhurst, Jean, "Home and Com- 
munity Hygiene," 144 
Broca, A., danger of radiations, 969 
Brouardel-Chantenmesse and Mosny, 
industrial hygiene, xxiii 
Brown, Hal., eye-sight and productivity, 
(81), 86 
Brown, H. H., inflammability of grain 
dusts, 216 
Brown, John E. (prepared by Hayhurst), 
visual power in an economic 
sense, 880 
Brown, Phillip King, efforts of, Ivii 
Brown, Sanger, CO poisoning, 398 
Bryant, Lewis T., felt hat industry, 
493 
Bryn Mawr College, industrial psychol- 
ogy statistics, xlix 
Bubbe, Johanes, masons' and miners' 
phthisis, xxii 
Buecher, methods of industrial produc- 
tion, vii 
Buergi, mixed poisons, 629 
Buffalo Hospital, nitrobenzene poisoning, 
513 
Buffalo, Miller's Committee of, explo- 
sions, 216 
Burchardt, briquette workers, 507 
Burkhardt, dusty trades, 20 
linen workers, 265 
Burnham, A. C.,. "Community Health 
Problems," 144 
Burrell, CO detector, 67 
CO poisoning, protective mask, 399 
mine gases, properties of, 378 
natural gas, analysis of, 372 
Burrell, Gauger and, CO in garages, 390 
Burrell et ah, oxygen-want and lamps, 
377 
Burry, James, CO poisoning, 398 
Bushnell, Page and, oil folliculitis, 696, 
697 
Butler, miners' nystagmus, 155 
Butler, Elizabeth B., speed effects, 
(751), 761 
Butler and Huber, internal anthrax, 671 
Buttersach, zinc chloride, (330), 339 
Cabot Fund, "The 12-Hour Shift," 1 
Cabot, Hugh, industrial surgery, Ivii 
Cabot, Richard, industrial surgery, Ivii 
Cadman and Whalley, black damp, 376 
Caldwell, X-ray dermatitis, 965 
California, occupational disease law, 
xxxi, 4 
California State Board of Health, hook- 
worm infection in gold mines, 
156 
California, University of, research work, 
xlix 
public health course, xlviii 
Calmette, pulmonary tuberculosis, 714 
Canadian Royal Commission, telephone 
operators, 1040 
Cannon, W. B., resuscitation, 841 
Canstatt's Textbook of Medicine, occu- 
pation neuroses, 763 
Capart, M., telephone operators, 300 
Carlisle, life expectation, (ref.), 710 
Carlson, A. J., solubility of galena, 451; 
of antimony sulphides, (535), 
545, 584 
Carnegie Foundation, immigrant em- 
ployes, 1 1082 
INDEX 
Carnegie Institution, nutrition studies, 
xlix 
Carnegie Steel Company, guard, hot saw, 
(ill.), 179 
Carozzi, researches of, Milan Clinic, 110 
ursol poisoning, 517 
Carpenter, D. N., smoke and powder 
gases, 294 
Carter, S., urinalysis in CO poisoning, 396 
Cartwright, power loom invention, ix 
Caryophilis, Greek sulphur miners, 154 
Casamajor, manganese poisoning, (328), 
(335), 339, 590 
muscular atrophy in bronze worker, 
350 
Castaneda, telephone operators, 300 
Castellani, A., tea tasters, 230 
Castellani and Chalmers, malarial 
emboli, 683 
Cavazzeni and Minelli, X-ray pathology, 
965 
Cazaneuve, lead in yarns, 267 
Celli, quinine in malaria, 685 
Celsus, varied exercise, 53 
Cenci, carbon bisulphide poisoning, 362 
Cesa-Bianchi, researches of, Milan Clinic, 
106, 111 
Chajes, commercial and mercantile pur- 
suits, 298 
Chalmers, Castellani and, malarial 
emboli, 683 
Charcot, carbon bisulphide poisoning, 
648 
Chassevent, benzol poisoning, 500 
Chauvet, Frank, electric shock, 839 
Chavez, death of, at high altitude, 819, 
821 
(Chicago) Brotherhood of Painters and 
Paperhangers, demands of, 469 
Chicago Edison Company, electric shock, 
839 
(Chicago) Industrial Health Service 
. Bureau, xlviii 
Chicago Ophthalmological Society, 
evaluation of visual loss, 881 
(Chicago), Peoples Gas Co., physical 
examinations, li 
Chicago Police Force, mortality of, 287 
Chicago Telephone Co., telephone oper- 
ators, 300 
Chicago, University of, industrial 
hygiene, xlvii 
occupational disease clinic, 112 
Childs, Lanza and, zinc miners, (334), 339 
Chittenden, food and calories, 62 
Chittenden, Taylor, Long and, copper 
poisoning, 322 
Chop, manganese poisoning, 590 
Christesin, Gregory and, dust diseases of 
lungs, 701 
Chyzer, pottery, homeworkers, 166 
Cincinnati General Hospital, occupa- 
tional disease clinic, 113 
Cincinnati manufacturer, industrial 
hygienist, 121 
Cincinnati Milling Machine Co., physical 
examinations, li 
Cincinnati, University of, industrial 
hygiene, xlviii 
Ciovini, researches of, Milan Clinic, 106, 
111 
Clague, T. M., lead in blood serum, 425 
lead in soldiers' urine, 424 
Clague-Oliver, electrical treatment of 
lead poisoning , 431 
Clark, industrial surgery, Ivi 
Clark, H. W., textile mills, humidifica- 
tion, 261 
Clark, L. D., investigations, xxxvii 
Clark, W. I., Jr., "Health Service in 
Industry," Ivi, 144 
physical examinations, li 
Claude, benzene poisoning, 501 
Clayton, arseniureted hydrogen poison- 
ing, 310 
lead poisoning in dye industry, 267 
Clemens, W. A., dermatitis in fishermen, 
220 
Cleveland Hospital Council, industrial 
health survey, xlix 
Cloak and Suit industry, Joint Board of 
Sanitary Control, improved con- 
ditions, 281 
workers' clinic, 113 
Cloud, R. E., nitrobenzene poisoning, 513 
"Coal Miners' Pocketbook," mine gases, 
(148), 161 
Cochrane, caisson principle patentee, 790 
Cohen, visual defects of photographers, 
254 
Cohen, Sevene and, discoverers of non- 
poisonous match, 527 
Cohn, watch and clock makers, 199 
Cohnheim, etiology of cancer, 947 
Cohnheim, O., altitude and blood 
changes, (816), 830 
Cole, W. Graham, lumber industry, 202 
Collis, chrome ulcers, 851 INDEX 
1083 
Collis, dust inhalation, 845 
historical industry, vii, viii, x, xi, xiii 
mercury poisoning, 475 
metal grinders and chest expansion, 
710 
oil folliculitis, 696 
Collis, Edgar L., coal miners' phthisis, 
1075 
"The Industrial Clinic," 144 
investigations of, xxiv 
stonemasons, mortality of, 705 
Collis and Greenwood, alcoholism in 
England, 67 
dust dangers, (ref.), 268 
"Health of the Industrial Worker," 
144 
industrial fatigue, (737), 760 
oil folliculitis, 699 
Colorado, University of, public health 
course, xlviii 
Columbia University, public health 
course, studies in industrial 
fatigue, xlix 
Commons and Andrews, occupational 
disease reporting, xl 
Conference Board of Physicians in Indus- 
trial Practice, creation of, Ivii 
Connecticut, occupational disease report- 
ing, 4 
Cook County Hospital, cancer statistics, 
957 
carbon monoxide poisoning, 371 
lead poisoning, 441 
Cooke-Taylor, historical citations, viii, 
xii 
Coolidge, Keats, Flower and, organic 
accelerators, 536 
Cooperative Safety Congress, joint 
action of, liii 
Copeman, ferrosilicon, 319 
Corbett and Bazett, hygiene of aviators, 
828 
Corbin, industrial small-pox, 9 
Cords, dinitrobenzene poisoning, 513 
Cornell University, occupational disease 
• clinic, 112 
Cornet, sisters of Charity, tuberculosis, 
289 
Coronulas, CS2 in tuberculosis, (361), 
367 
Corper, copper in tuberculosis, 324 
Cort, hookworm infection, 687 
Corwin, industrial surgery, Ivi 
mining and lumber advances, Ivii 
Cossmann, diabetic coma and acetone 
poisoning, 637 
Cotton, industrial surgery, Ivii 
Cottrell, electric precipitation of dust, 
23 
Councilman and Magrath, xeroderma 
pigmentosum, (952), 958 
Couper, manganese poisoning, 589 
Cox, Ernest H., oil folliculitis, 697 
Craig, malarial parasites, 683 
Cramer, E., glassworkers' cataract, 889 
Cranch, manganese poisoning, 590 
Crane Co., yellow brass, (color plate), 346 
Creite, anthrax treatment, 671 
de Creppin (works), dye industry, 524 
Cridland, glassblowers' cataract, 172 
Crile, George W., resuscitation, 841 
Crone, balloonists, arsenical poisoning, 
825 
Crookes, Sir William, glass workers' 
cataract, 888 
Cruice, Jump and, CS2 poisoning, 362, 
(364), 367 
Cruikshank and Jackson, vanadium 
poisoning, 604 
Crum, loss from accidents, 83 
Crum, F. S., mortality, New Jersey 
trades, 733 
Crzellitzer, eye lesions, electric light, 177; 
rubber worker, 543 
Cumming, Surg. Gen., merchant marine 
service, 296 
Cundill, "Dictionary of Explosives," 
546 
Cunning, James C., hookworm in mines, 
156 
Cunningham, G., phosphorous poisoning, 
530, 534 
Curie, radium experiments, 966 
Curschmann, anilin workers, 521 
benzene poisoning, (520), 525 
chemical industry, 569 
CO poisoning simulation, 393 
dye industry, 521, 524 
nitro and amino compounds, 547 
Curschmann, F., investigations, xxiv 
Curschmann, H., asthma due to ursol, 
517 
Czaplewski, nitric acid poisoning, 572 
Czermak-Spirek, mercury smelting, 482 
D'Arsonval, electric shock, 832 
Da Costa, irritable heart, 52, 292 
tobacco heart, 68 1084 
INDEX 
Daifis, wood polishers. 206 
Damant, compressed-air illness, 791, 806, 
807 
Damant, Boycott and, compressed-air 
illness, 795 
Daniels, Anna S., tenement industries, 
26 
Davaine, discover of anthrax infection, 
663 
Davis, etiology of cancer, (953), (954), 
958 
Davis, B. F., paraffinoma and wax can- 
cer, (ref.), 959 
Davis, Paul A., rubber workers, 537 
Davis, Wm. H., mortality figures, inter- 
pretation of, 725 
Davy, discover of sodium, 598 
Day, W. C., stone polishing process, 158 
Dean, H. M., soldiers' irritable heart, 
292 
Deardon, anilin dye poisoning, 267 
Deeds, F. E., oil folliculitis, 697 
tellurium poisoning, 595 
Dejong, etiology of cancer, 953 
Delavan, automobilists, 243 
Delepine, arsenical poisoning, 307 
arsenic trichloride poisoning, 317 
arseniureted hydrogen poisoning, 
309 
phosgene poisoning, 518 
Delpech, asthma from bichromate dust, 
850 
CSz poisoning, xxiii, 360, 363 
Delpech and Hilairet, chrome poisoning, 
xxiii 
Delray Industrial Hospital, Detroit, 
industrial dispensary, 113 
Demetjeff, age and muscular strength, 
75 
Demosthenes, father of, and slave 
workers, viii 
Detroit College of Medicine and Surgery, 
public health course, xlviii 
De Voos, lead dust in printing, 250 
Devoto, L., "Food of Working Classes," 
111 
industrial poisons' council, 2 
infant mortality and parents' occu- 
pation, 110 
mercury poisoning, 488 
Milan Clinic for occupational dis- 
eases, xx, 101 
"Poisoning Among Professionals in 
the War," 111 
Diegler, electric shock, 843 
Dirksen, dust in a coal bunker, 18 
District of Columbia, U. S. Compensa- 
tion Act, 1044, 1046 
Ditman, N. E., official, industrial 
hygiene, xliv 
Ditman, R., organic accelerators, 536 
Dittoe and Groeniger, water, sewage and 
refuse standards, 31 
Dodd, X-ray dermatitis, 965 
Doehring, C. F. W., dust explosions, 216 
fertilizer plants, 237 
first federal investigator, li 
oil cloth manufacture, 580 
tallow manufacture, 234 
Donlin, electric shock, 832 
Dorendorff, benzine poisoning, 497 
Doty, Alvah H., recipient of Seaman 
medal, xlv 
Dowling, economic loss from hookworm, 
80 
tobacco amblyopia, 229 
Dreifuss, Block and, tar cancer, (ref.), 
959 
Dreissbach, intoxication from mouldy 
oats, 214 
Drever, J., industrial fatigue (psy- 
chology), (737), 760 
Drinker, C. K., managing editor, Journal 
of Industrial Hygiene, Ivi 
Drinker, Katherine R., see Drinker, C. K. 
(et al) 
Drinker, Philip, zinc ague, 331 
Drinker, (C. K. and K. R.), economic 
aspects of industrial medicine, 
(83), 86 
Drinker, Drinker, Shaw and Redfield, 
CO asphyxia, (ref.), 411 
Drinker and Wilbur, Edsall and, man- 
ganese poisoning, (335), 340, 590. 
Drury, dust in ax factory, 19 
Drury, H. B., scientific management, 
(758), 762 
Dubitzki, arseniureted hydrogen poison- 
ing, 308 
Dublin, Louis I, accident statistics, 
(82), 86 
average age at death in occupations, 
732 
cancer statistics, 956, 957 
industrial hazards, list of, 606 
mortality statistics, 79 
Dublin and Whitney, cost of tuberculosis, 
(80), 86 INDEX 
1085 
Duchenne, carbon bisulphide poisoning, 
360 
Dudley, arseniureted hydrogen poison- 
ing, 308, 309 
Dufour, dry cleaning, 496 
Dumas, waterproof clothing, 46 
Dumas, (Alex.), suicide by CO poisoning, 
371 
Dundonald, Lord, warfare gases, 556 
Dunlap, Lawrence G., arsenious oxide, 
315 
Du Pont de Nemours Co., explosives, 
547, 553 
Du Pont "Fabrikoid" Company, benzol 
poisoning, 508 
Dutch government, diamond polishing, 
201 
Dutton, W. F., vanadium poisoning, 604 
Dysart, N. C., official, industrial hygiene, 
xlviii 
detection of CO gas, 378 
Earle, Richard B., organic accelerators, 
536 
Eberfeld Company, organic accelerators, 
536 
Ebright, (G. E.), irritability of blasters, 
149 
nitroglycerine, 553 
Eddy, W. H., "Vitamine Manual," 57 
vitamines, table showing, 60 
Edsall, (David L.), editor, Journal of 
Industrial Hygiene, Ivi 
eyes, effects of puddling on, 178 
industrial clinic, 438 
lead poisoning in textile industry, 264 
mercurial poisoning in dentists, 288, 
485 
sciatica in locomotive engineers, 239 
scavengers, etc., good health of, 246 
stone cutters, use of air hammer, 158 
X-ray injuries, 964 
Edsall and Pemberton, X-ray cancers, 
(963), 969 
Edsall, Drinker and Wilbur, manganese 
poisoning, (335), 340, 590 
Edward IV, truck Act, xii 
Edwards, Alba M., occupation data, 970 
Edwards, Lander and, zinc compounds, 
(330), 339 
Edwards and others, (Lee, F. S.), tem- 
perature and humidity on 
fatigue, (757), 762 
Eggleston, chronic endocarditis, 940 
Eglin, W. C. C., resuscitation, 841 
Egyptian history, lead poisoning, 412 
Ehrlich, basophilia in lead poisoning, 420 
Ehrmann, mercury exanthema,, 475 
Eisenstadt, German postal officials, 299 
Elizabeth's reign, legislation, hours of 
labor, xi 
Elliott, Ralph W., medical and dental 
services, xlix 
Ellis, J. D., health of printers, 249 
Ellis, Lane and, miners' nystagmus, 873 
Ellis, Murphy and, X-ray effects, (964), 
969 
Ellman, lead poisoning, 471 
Elsberg, Salant and, zinc poisoning, 
(329), 339 
Embden, manganese poisoning, 589 
Emerson, Haven, anthrax in shaving 
brushes, 678 
Encyclopedia Britannica, 11th ed., 
"spelter," (328), 339 
Endicott, hook-worm infection, 156 
Englemann, R., oxy-acetylene flame on 
zinc, 467 
Englisch, osteomyelitis in "pearl 
turners," 274 
English, see also British, Great Britain 
English authorities, TNT poisoning, 510 
English Departmental Committee, an- 
thrax, 667 
English Factory Inspector, arsenical 
poisoning, 305, 307 
carbon monoxide poisoning, 398 
cutlery industry, mortality, 734 
(English) "Ladies Sanitary Associa- 
tion," homes for wage earners, 
93 
English Medical Inspector, anilin dyeing, 
267 
English Navy, warfare gases, 556 
English philanthropists, research fund, 
108 
English regulations, temperature and 
humidity, 17 
English rules, hydrochloric acid industry, 
573 
Epstein, consumption in tailors, 282 
Epstein, Layet and, garment workers, 282 
Equitable Life Assurance Society, rubber 
workers, 544 
Erben, antimony poisoning, 583 
cadmium poisoning, 585 
Erdman, Seward, compressed-air ill- 
ness, 790,796 1086 
INDEX 
Erskine, Lilian, phosphorus in fire 
works, 531 
Esch, Heil and, rubber goods, (ref.), 
367 
Esmarch, anthrax spores, 664 
Eulenberg, antimonureted hydrogen, 584 
ether oil in linoxyn, 581 
osmium poisoning, 595 
Eulenberg, Hermann, lead in silk thread, 
282 
toxic gases, xxiii 
Eulenburg's Encyclopedia, list of 31 
industrial poisons, 2 
Eugling, absorption of lead sulphide, 
451 
Evans, C. S., nitroglycerine poisoning, 
553 
Evans, H., afflictions of fishermen, 22 
Evans, Wm. A., petitioner, industrial 
hygiene, xlv 
Everingham, S., nature of fatigue, (737), 
760 
Eysel, syphilis in glassblowers, 172 
Fagan, J. O., "Railroad Signalman," 144 
Falk, Strassmann and, foot machines and 
sexual diseases of women, 77 
Farmer, Moore and Walker, cancer, 947 
Farnum, C. G., physical examinations, li 
industrial surgery, Ivi 
Farnum, Henry W., industrial diseases, 
lii 
Farrand, workers' objections to safety 
devices, 94 
Fawoeski, mercury poisoning, 474 
Federated American Engineering Socie- 
ties, "Twelve Hour Shift," 1 
Felix, toxicity of benzine, 496 
Ferrell, hookworm infection and effi- 
ciency, 80 
Ferris, G. H., phthisis rate in Belfast, 268 
Fetzer, Lewis W., (Teleky), mercury 
poisoning, 471 
Fiebiger, etiology of cancer, 953 
Fiebiger and Bang, tar cancer (ref.), 959 
Findlay, Leonard, pneumokoniosis, 715 
Firestone Tire and Rubber Co., derma- 
titis, 537 
Fisac, lime and gypsum workers, 155 
Fischer, (R.), bichromate poisoning, 852 
chromium poisoning, 588 
industrial poisoning, 2, 6 
military musicians, 290 
pearl workers, 274 
Fischer, Sommerfeld and, CS2 poisoning 
(363), 367 
CO poisoning, 405 
industrial poisons, list of, 643 
Fisher, Irving, exercise, 73 
"National Vitality," 79 
Fisher and Fisk, "How to Live," 144 
mortality among drinkers, (65), 78 
Fisk, E. L., eye strain, (81), 86 
fatigue and output, 73 
petitioner, industrial hygiene, xlv 
waste in industry, 79 
Fisk Rubber Co., poison hazards, 545 
Fiske, morbidity in U. S. Navy, 293 
Fitch, John A., hours of labor, (754), 761 
Fitch, W. N., rubber industry, 545 
Fitzgerald, altitude and pressure, 815 
Flandin, C., purpura from benzol, 508 
Fleck, statistics of painters, 468 
Fleisher, Frankel and, "Human Factor 
in Industry," 144 
Flemming, aeronauts, 824, 825 
Flemming and Steyrer, aeronauts, 824 
Fleury, electrical accidents, 834, 835, 836 
Flick, L. F., smoking and consumption, 
67 
Florence, P. S., industrial fatigue, (737), 
760 
Floret, brommethyl poisoning, 575 
investigations, xxiv 
Flower, Keats, Coolidge and, organic 
accelerators, 536 
Forbes, CO poisoning, 397, 408 
Ford, C. E., writings of, Ivi 
Foster, C. LeN., symptoms of gassing, 
394 
France, Service Insurance Department, 
eye disabilities, 877 
Francke, arsenic poisoning, 317 
Francke, E., lead poisoning, 461 
Frank, acetylene method, 586 
Frankford Arsenal, uniforms for women, 
567 
Frankfort, institute for industrial 
hygiene, xxi 
Frankel, Lee K., government employes, 
88 
morbidity statistics, 972 
postal employes, 299 
Frankel and Fleisher, "Human Factor 
in Industry," 144 
Frankfurter and Goldmark,. "The 
Shorter Work Day," Iv, (753), 
761 INDEX 
1087 
Frankl-Hochwart, occupational neuroses, 
765, 767 
tetany in shoemakers, 278 
Frazer, Lamb, Hoover et al., CO gas 
mask, 373 
Frederick, Robert C., tobacco storage, 
227 
Freedmen's Hospital (Washington), her- 
nia, 43 
French authors, "caoutchouc disease," 
536 
French Commission, electrical accidents, 
835 
infections from mattresses, 680 
French government, butter substitutes, 
221 
syphilis in glassworkers, 889 
white lead paint, 468 
French, Office du Travail, phosphorous 
poisoning, 531, (534) 
Frey, brass industries, (346), 352 
Friedel, manganese poisoning, 590 
Friedmann, tin poisoning, (602), 604 
Friedrich and Jaehne, detonation and 
hearing, 901 
Fries and West, chemical warfare gases, 
555 
Fromm, printing, lead poisoning, 248 
Frothingham, Langdon, anthrax, 663 
Fujitani, pyrethron, 209 
Fulton, Frank, physical examinations, li 
Funk, Casimir, "The Vitamines," 57 
Funk, effects of tobacco dust, 229 
Gade, Kurt, wood dust, 204 
Gaglio, carbon monoxide poisoning, 381 
Gaillot, M., lymphangitis in sugar refiners, 
219 
Gairdner, bagpipe players, 290 
Galen, unhealthful occupations, xxi 
Galet, CS2 poisoning, 361, 362 
Galezowski, tobacco workers, 229 
Ganassini, test for zinc, 328 
Gantt, increased production, bleachery, 
759 
Gardner, (Henry A.), painted surfaces, 
417, 465 
Gardner, Mary S., "Public Health Nurs- 
ing," 137, 144 
Garforth, dust in coal mines, 149 
Garman, phosphorus necrosis, 533 
Garnier, benzol poisoning, 500 
Garrison, Fielding H., "History of Medi- 
cine," vii, Ivi 
Garrison, Fielding H., industrial hygiene, 
xxii 
miners' diseases, xxi 
Gasser and Loevenhart, CO poisoning, 
383 
Gast, morbidity of saloon-keepers, etc., 
231 
Gatewood, J. D., illumination on war- 
ships, 293 
Gauger and Burrell, CO in air of garages, 
390 
Gay, Augustus, health of scavengers, etc., 
246 
Gaylord and Marsh, goiter and marine 
life, 60 
Geier, Otto P., on fundamental princi- 
ples, Ivi 
"Industrial Medicine and Surgery 
as a War Measure," Iv 
physical examinations, li 
pioneer, and preparer of symposium, 
liv 
Geist, Bibra and, phosphorus match 
workers, xxiii 
le Gendre, Paul, heart lesions in chauf- 
feurs, 244 
General Electric Company, "day-light 
light" bulb, 41 
experimental investigations, xlix 
foot-candle meter, 39 
George I, truck Act, xii 
Gerber, Irene, phosgene poisoning, 576 
Gerdon, furriers' asthma, 517 
German authorities, plaster of Paris, 169 
German authors, "margarine" erysip- 
elas, 222 
morbidity of cement workers, 169 
German Benefit Society, tuberculosis 
statistics, 155 
German Chemical Industry, brommethyl 
poisoning, 575 
German clinician, glycosuria in CO 
poisoning, 396 
German Factory Inspectors, benzine 
poisoning, 497 
German factory reports, dye industry, 521 
German Government, compressed-air ill- 
ness, 805 
German Imperial Health Office, xxiv 
(German) Imperial Insurance Office, eye 
injuries, iron and steel industry, 
180 
German Industrial Insurance Institute, 
statistics on poisonings, 3 , 1088 
INDEX 
Gertz, carbon monoxide poisoning, 377 
Gherardi, G., corneal infection from rice 
leaves, 211 
Gibbon, slave labor protection, xi 
Gibbs, W. E., CO2-oxygen apparatus, 
430 
Gibson, Apfelbach and, lead poisoning in 
painters, 453 
Giese, CO poisoning, 397, 398 
Giesel, radium experiments, 966 
Giglioli, mercury poisoning, (480), 482 
Gilbreth, Frank M., bricklaying effi- 
ciency, 759, (762) 
Gilbreth, Lillian M., Frank M. and, 
fatigue study, 759, (762) 
Gildemeister, electric shock, 843 
Gillet, zinc carbonyl, 330 
Girona, Sanchez, anemia in lead smelter- 
ers, 1074 
Gladstone, H. J., regulations, brass 
casting, 359 
Glaisher, symptoms in aeronauts, 824 
Glaister, John, arseniureted hydrogen, 
307, 824 
ferrosilicon poisoning, 318, 531, (534) 
Glaister and Logan, CO poisoning, 369 
Gilbert, D., cancer, (ref.), 959 
flax workers' ulcers, 264 
fur industry, 679 
lead poisoning, 420 
mercury poisoning, 474, 490 
Goadby, lead poisoning, 426, 478 
type founding, vapors in, 249 
Goadby, Legge and, "Lead Poisoning 
and Lead Absorption," xxiii 
Gobert, dust diseases of the lungs, 701 
Gocht, X-ray idiosyncrasy, 960 
Goeneu, X-ray carcinomata, 963 
Goldberger, Schamberg and, wheat straw 
affection, 10 
Goldflam, occupational neurosis, 766 
Goldmark, Josephine, "Fatigue and 
Efficiency," liv, (737), 760 
in history of medicine, Ivi 
legislation, women workers, (1029), 
1043 
Goldmark, • Frankfurter and, "Shorter 
Word Day," Iv, (753), 761 
Goldschmid and Kubin, brommethyl 
poisoning, 575 
Goldwater, S. S., occupational disease 
clinic, 112 
Gompers, Samuel, conference on health, 
Iv 
Goodrich Co., B. F., physical examina- 
tions, li 
rubber workers, 544 
sanitation methods, 545 
Gorgas, William C., malaria control, 685 
medal bestowed upon, xlv 
miners' phthisis, 22 
overcrowding in respiratory diseases, 
12 
Gorn, carbon monoxide poisoning, 380 
Gothlin, mercury poisoning, 477, 478 
Gottheil, X-ray legal suits, (960), 968 
Gottschalk, clay products industry, 163 
Gottstein, deafness in blacksmiths, 187 
Gottstein and Keyser, hearing, in smiths, 
etc., 898 
Gould, prognosis of cancer, (946), 958 
Grab, tuberculosis in limestone workers, 
155 
Gradenigo, hearing impairments, 898 
Graeve, spleen after zinc ague, 332 
Graham and Nasmith, CO poisoning, 406 
Graham-Ro gers, C. T., see also Rogers, 
arsenic poisoning, 316 
symposium on industrial hygiene, xlv 
Graham-Rogers and Vogt, lead and 
arsenic poisoning, (313) 
Grandhomme, benzene poisoning, (520), 
524 
dye industry, German, 521 
investigator, xxiv 
methyl compounds poisoning, 574, 
655 
nitrobenzene poisoning, 513 
Grant, Dundas, the middle ear, 894 
Grawitz, basophilia in lead poisoning, 420 
Gray, W. M., hookworm, (ill.), 687, 688 
Great Britain, see also British, English: 
legislation, colored slaves, xiii 
occupational diseases, 4 
ventilation standards, 13 
Great Britain, Chief Inspector, oil folli- 
culitis, 696 
Great Britain, Factory Department, 
brass workers, 353 
casual labor in lead works, 460 
licking labels, 272 
plaster of Paris dust, 169 
Great Britain, Home Office, lead poison- 
ing, 417, 418, 468 
Great Britain, Medical Inspector, lead 
poisoning, 348 
Great Britain, Registrar General, diseases 
of coal miners, 154 INDEX 
1089 
Great Britain, Secretary of State, brass 
regulations, 357 
Greece, legislation, lead poisoning, 1004 
Greenhow, D. H., brassfounders' ague, 
342, (359) 
silica in flax dust, 733 
Greenburg, dust in various industries, 18 
Greenburgs, The, experimental studies, 
xlviii 
Greenwood, Collis and, alcoholism in 
England, 67 
dust dangers, (ref.), 268 
"Health of the Industrial Worker," 
144 
industrial fatigue, (737), 760 
oil folliculitis, 699 
Greenwood, Hill and, decompression, 808 
Greenwood, (M.), compressed-air ill- 
ness, 791, 793, 804 
researches of, xxiv 
Greer, cancer in industries, 955 
Gregg, effects of altitude, 817 
Gregory and Christesin, lung dust dis- 
eases, 701 
Grempke, P. M., phosgene poisoning, 576 
Groeniger, Dittoe and, water, sewage 
and refuse standards, 31 
Gross, study of writing apparatus, 772 
Gruber, toxicity of CO, 377 
Gruber, C. M., fatigued muscles, (742),760 
Gruber, Max, CO and SO2, xxiv 
Gruenberg, noises and hearing, 900 
Grun, fatty acids and gastric catarrh, 222 
kidney affections from soap dyes, 235 
Grysez, pulmonary tuberculosis, 714 
Gudzent and Halberstaedter, radioactive 
substances, 967 
Guery, M., electric shock, 837 
Guilbert, hygiene of aviators, 829 
Gundermann, toxicity of benzine, 496 
Gundermann, Lehmann and, benzol 
poisoning, 500 
Gunn, Herbert, hookworm in miners, 156, 
(324), 327 
Gunn, (S. M.), industrial hygiene, xlvi 
Industrial Hygiene Section, xlv 
Gunther, carbon monoxide poisoning, 391 
Gussenbauer, pearl workers, 274 
Gye and Keith, silicosis and tuberculosis, 
1075 
Habermann, boiler makers' deafness, 898, 
900 
Hadrian, slave labor protection, xi 
Haggard, Henderson and (et al.), CO 
poisoning, 379, 380 
Haggard and Scott, Henderson and, CO2- 
oxygen apparatus, (403), 411 
test for CO, 375 
Hague Congress, gases in warfare, 556 
Hahn, (M.), printing trades, (247), 248, 
256, (454), 455, 457 
Hahns, hemp-combing, 18 
Haines, Peterson and, toxicity of CO, 
(377), 410 
Haldane, CO poisoning, 377, 378, 379 
compressed-air workers, 376, 791, 
793, 795, 797, 804 
decompression method, 805, 806, 807 
dust and self-respect, 21 
removal from lungs, 716 
high altitudes, 815, 817 
investigations, xxiv 
low oxygen percentages, 376 
nitroglycerine poisoning, 148 
Haldane and Boycott, compressed-air 
illness, 794 
Haldane and Mavrogordato, lung dust 
experiments, 1075 
Halberstaedter, Gudzent and, radio- 
active substances, 967 
Halfort, institute for sick workers, xx 
Halfort, A. Cl., industrial diseases, xxiii 
Hall, M. C., hookworm disease, 157 
Haller, miners' diseases, xxii 
v. Haller, Albrecht, lead diseases, xxi 
Halley, diving bell, 790 
Hallion, Brissaud, Meige and, occupa- 
tional neuroses, 765 
Hamer, anthrax infection, 675 
Hamill, W. H. T., copper fumes, 323 
Hamilton, Alice, see also Illinois Occupa- 
tional Disease Commission, U. 
S. Bur. of Labor, U. S. Bur. of 
Labor Statistics, airplane dopes, 
576 
anilin poisoning, 516, 521, 538 
antimonial poisoning, 584 
arsenical poisoning, 315-317, 519 
benzene poisoning, 500, 508, 524 
benzyl chloride poisoning, 518 
carbolic acid poisoning, 509 
carbon monoxide poisoning, 244, 
369, 409 
diethylanilin poisoning, 516 
dimethyl sulphate poisoning, 518 
dimethylanilin poisoning, 516 
dye industry, 512-523 1090 
INDEX 
Hamilton, Alice, explosives, 546-552, 568 
fur and felt hat workers, 492 
gold and silver workers, 196 
in history of medicine, liv 
lead poisoning, liii, 3, 264, 335, 428, 
440, 458, 462 
mercury poisoning, 492 
metanitranilin poisoning, 515 
nitro and amino compounds, 547 
nitrobenzene poisoning, 513 
nitrochlorobenzene poisoning, 518 
painters, 464-466 
paranitranilin poisoning, 515 
petitioner, industrial hygiene, xlv 
petroleum and derivatives, 495 
phosgene poisoning, 518 
photo-engravers, tuberculosis in, 255 
picric acid poisoning, 510 
pottery trades, liii, 167, 449 
printers, 248-250 
stonecutters, 158 
sulphureted hydrogen poisoning, 519 
tin plating, 603 
trinitrotoluol poisoning, 510 
ursol poisoning, 517 
women in lead processes, 1031, 1043 
woodworkers, asthma in, 205 
Hamilton, Luce and, anilin poisoning, 
(514), 525, 538 
Hammonds, The, child labor, x 
labor legislation, xiii 
Hanke, nitronaphthalene poisoning, 514 
Hanna and Hope, anthrax in Liverpool, 
668 
Hanna and Stallybrass, Hope and, 
"Industrial Hygiene and Medi- 
cine," 144 
von Hansemann, cancer, 947, 950 
Hanson, copper fume poisoning, (324), 
327 
Hanson, Wm. C., boot and shoe industry, 
280 
brass buffing, 347-348 
casting, 344-345 
dusty trades, xxxiii, liii, 182 
editor, liv 
goggles in grinding, 188 
in history of medicine, Ivi 
in industrial hygiene, xxxiv 
laundry ventilation, 284-285 
Hanson, Kober and, "Diseases of Occu- 
pation," xxiii 
in history of medicine, Ivi 
textile and allied industries, 257 
Hanzlik, Paul J., ursol poisoning, 517 
Harbitz, CO poisoning, 378, 394 
Hargreaves, spinning jenny, ix 
Harriman, E. H., memorial medals, 
safety and health protection, 
xlv 
Harrington, objections to respirators, 94 
mental breakdown in farmers, 211 
Harrington, (Chas.), "Hygiene," xlvi 
Harrington, D., temperature and humid- 
ity, 156 
Harrington, T. F., benzene poisoning, 
501-502 
carbolic acid burns, 509 
sulphur dioxide poisoning, 520 
Harrington and Richardson, cotton strip- 
ping, (261), 268 
Harrington, Sayers and, ventilation in 
mines, (157), 162 
Harris, CO poisoning, (390), 410 
Harris, B. R., action of benzol, 501 
Harris, Henry J., maternity benefits, 
1042 
Harris, J. R., flat feet, 70 
Harris, Louis I., CO poisoning, 370 
lead poisoning in painters, 434-435, 
453 
Harrison, Hutchins and, historical indus- 
try, xi 
Harting and Hesse, sarcoma in miners, 955 
Hartridge, carboxyhemoglobin in 
smokers, 371 
Hartzell, Josiah, occupational diseases, 1 
Harvard Medical School, industrial 
hygiene, xlvi 
manganese poisoning, 589 
occupational neuroses, 768 
Harvey, industrial surgery, Ivii 
de Hass, H. K., arsenic poisoning, 317 
Hastings, A. B., nature of fatigue, 
(737), 760 
Hauft, H. G., CS2 poisoning, (364), 367 
Havens, Birge and, pearl buttons, xlix 
Hayhurst, E. R., see also Ohio State 
Board of Health, survey by, 
ammunition factories, 559 
anilin poisoning, 514 
brass workers, 112, (330), 339, 341 
calcium cyanamide poisoning, 587 
cancer and tarry products, 955 
canning industry, 224 
carbon bisulphide poisoning, 360 
monoxide poisoning, (revision of 
Apfelbach), 369 INDEX 
1091 
Hayhurst, E. R., coal miners, 150, 724 
copper workers, 321, (323), 327 
electric fuses, 559 
shock, 839 
exhaust system laws, 348 
foundry workers, 184 
galvanizers, (338), 340 
garment workers, 282 
glassworkers, 172, 173 
Illinois, occupational diseases inves- 
tigation, (328), 339, (341), (342), 
352 
illumination standards, 38 
industrial health data (chart), 1068 
hazards, 606 
hygiene, courses in, xlvii 
"stimulantism," 66, 1069 
iodine deficiency of common salt, 60 
iron and steel industry, 181-182 
junk workers, 351 
lead poisoning, 112, 272, 439, 449, 
459, 462, 463, 465, 535 
guide, 1072 
miners' nystagmus, 873 
mirror plating, 488 
occupational disease clinic, 112 
office, industrial hygiene, xlviii 
oil folliculitis, etc., 696 
painters, 465, 466 
personal health data (chart), 1070 
petroleum industry, 504 
photo-engravers, 255 
pottery industry, 167, 449 
preventable causes of death, 984 
printing industry, 249, 455 
rubber industry, 536, 537 
salt in relation to health, 60 
sea water in diet, 60 
shellacing vapors, (349), 352 
stonecutters, 160 
"Survey of Industrial Health Haz- 
ards, Etc.," Ohio, liv, Iv 
susceptibility of workers, 607 
symposium on industrial hygiene, xlv 
ventilation standards, 28 
visual power, (Brown, abstract), 880 
vitamines, 57 
Workers' Health Bureau, 113 
Zinc workers, 328, (338), 340 
Hayhurst, Albaugh and, oil folliculitis, 
697 
Hayhurst and Kober, brass and brass 
industries, 341 
rubber industry, 535 
Hayhurst and Scott, silo workers, gas- 
sing, 212 
Hayhurst and Stanley, Kemp and, 
altitude and blood changes, 816 
Haythorne, cancer, (951), 958 
Haywood and Warmer, arsenic in paper 
and fabrice, (ref.), 313 
Hazen, farm laborers' parasites, 10 
flax workers, 264 
Hearts of Oak Benefit Society, cataract, 
887 
Heath, F. C., CS2 poisoning, (364), 367 
Hebert, plaster of Paris, 169 
Hebert, Heim and, industrial hygiene, 
(ref.), xxiii 
Hebrews, The, slave-labor, xi 
Hedinger, hearing in engineers, 240 
Heil and Esch, rubber goods, (ref.), 367 
Heim, mercury, on hands, 477 
Heim and Hebert, industrial hygiene, 
(ref.), xxiii 
Heim and Herbert, mercury vapor, 490 
Heinecke, X-ray effects, (964), 969 
Heinzerling, arsenic poisoning, 491 
mercurial poisoning, 549 
Heinzerling and Lewin, hatters, 731 
Hektoen, L., action of benzene, 502 
Hektoen and Reismann, kidneys in CO 
poisoning, (391), 410 
Heller, compressed-air illness, 791 
mercury poisoning, 474 
Henderson, C. R., "police power" of 
government, xxvii 
Henderson et al., CO poisoning, 378, 394 
Henderson, Haggard et al., CO poison- 
ing, 379-380 
Henderson, Haggard and Scott, test for 
CO, 375 
CO2-oxygen apparatus, (403), 411 
Henderson and Paull, CO poisoning, 
379-381, 399, 402 
Henderson, (Yandell), CO poisoning, 380, 
402 
resuscitation commission, 841 
Henry Phipps Institute, studies of, xlix 
Hensen, sound waves and the ear, 901 
Herbert, Heim and, mercury vapor, 490 
Herman, lead painted surfaces, 465 
Hermanni, chrome ulcers, 588 
Herzstein, atmospheric fatigue effects, 
(757), 762 
Hess and Unger, rickets, 58 
Hesse, dust in core and mould making, 
184 1092 
INDEX 
Hesse, E., calcium cyanamide poisoning, 
587 
Hesse, Harting and, sarcoma in miners, 
955 
Heucke, mercury poisoning, 489 
mirror plating, 488 
nicotinp in tobacco dust, 228, 728 
Higgins, dust in Joplin mines, 19 
Higgins, Lanza and, zinc miners (334), 339 
Higgins, Lanza, Laney and Rice, siliceous 
dust in zinc miners, (334), 339 
Hilairet, Delpech and, chrome workers, 
xxiii 
Hill, Leonard, CO and CO2, 375 
carbon dioxide effects, (147), 161 
compressed- air illness, 791, 793, 797, 
800, (803), 804, 808-810, 815 
investigations of, xxiv 
ventilation effects, (757), 762 
Hill and others, compressed-air illness, 
798 
Hill and Semerak, CO poisoning, 391 
Hillairet, asthma from bichromate dust, 
850 
Hippocrates, unhealthful occupations, 
xxi 
Hirschberg, cataract in glassblowers, 172 
"electrica ophthalmia," 177 
Hirt, animal and vegetable dusts, 275 
brush makers, 678 
flour millers, 215 
house painters, 468 
leaf metal workers, 200 
metal workers, 188 
phosphorus poisoning, 533 
rope makers, 266 
Hirt, Ludwig, occupational diseases, 
xxiii 
His, Jacoby and, explosives, 563 
Hitchcock, CO poisoning, 398 
Hobbs, Wm. R., white lead workers, 443 
Hodgson, altitude and heart rate, 817 
Hoessli, sound waves and hearing, 900- 
901 
Hoffman, F. L. see also Prudential Life 
Insurance Co., compensation 
effects on sanitary conditions, 
(335), 340 
compensation law, New York, 1015 
diamond setters' afflictions, 201 
in history of medicine, Ivi 
malaria, economical aspects of, (80), 
86 
miners' nystagmus, 872 
Hoffman, F. L., monographs, historical, lii 
occupational mortality statistics: 
atmospheric impurities, workers 
in, 721 
bakers, 217 
boot and shoemakers, 280 
brass workers, 351 
brick and stone masons, 170 
button makers, 274 
cancer, 955-956 
carpet and rug makers, 263 
cement workers, 169 
clay products industry, 163 
copper miners, 324 
cordage makers, 266 
draymen, etc., 245 
electric linemen, 300 
firemen (New York City), 297 
flour millers, 216 
glassworkers, 173-174 
grain handlers, 215 
granite workers, 159, 1075 
hatters, 492 
life saving service (296), 302 
limestone workers, 159 
painters, 468 
paperhangers, 171 
plasterers, 170 
plumbers, 463 
pottery workers, 166 
printers, 1076 
railway brakeman, 240 
sandstone workers, 159 
slate pencil workers, 732 
stonecutters, 160 
street cleaners, 245 
tobacco workers, 228 
tuberculosis, 730, 731 
zinc miners, 336 
silicotic content of stones, 159 
Hogben, D., brass workers, (ref.), 359 
Holcomb, R. C., ship ventilation, 294 
Holitscher, ceramic industry, 166 
Holmes, mining accidents, 145, 149 
Holmes, Slye, Wells and, etiology of can- 
cer, (950), 958 
Holt, hearing impairment, 898 
Holtzmann, anthrax in tanners, 675 
jewelry workers, 198 
Holzer, phosphorus poisoning, 532 
Homann, iron fume poisoning, (331), 339 
Homann, Kisskalt and, cadmium poison- 
ing, (331), 339 
Hood Rubber Co., poison hazards, 545 INDEX 
1093 
Hookstadt, Carl, reclassification of indus- 
tries, 987 
Hoover, CO gas mask, (373), 409 
Hoover Commission, economic waste in 
industry, 79 
Hoover, Frazer, Lamb et al, CO gas 
mask, 373 
Hope, E. W., anthrax infection, 674, 
678 
Hope and Hanna, anthrax in Liverpool, 
668 
Hope, Hanna and Stallybrass, "Indus- 
trial Hygiene and Medicine," 
xxiv, 144 
Hopkins, American Museum of Safety, 
xliv 
Hoppe-Seyler, F., caisson disease, 791 
Horan, C. F., rubber industry, 535, 537, 
539, 545 
Hough and Sedgwick, "Hygiene and 
Sanitation," 144 
Houghton Co., oil folliculitis, xlix, 698 
Houston, lead-solvent water, 412 
Howard University, public health school, 
xlviii 
Howe, E. C., public health courses, xlix 
Howell, S. P., TNT for blasting, 553 
Hoxie, R. F., scientific management, 
(758), 762 
Hubbard and Jacobson, anthrax statis- 
tics, 670 
Huber, Butler and, internal anthrax, 670 
Hudson, W. G., nitrous fumes, explosives, 
547 
Hugo, Victor, suicide by CO, 371 
Hunt, child labor, x 
tenosynovitis in tailors, 290 
Hunt, J. R., "drummers' paralysis," 290 
Hunt, W. C., occupation data, 970 
Huntington, irritability of blasters, 149 
Huntington Hospital, X-ray case report, 
960, 961 
Hutchens, H. J., bacteria and paint, 1074 
Hutchins and Harrison, historical indus- 
try, xi 
Hutchinson, Sir Jonathan, arsenic and 
cancer, 305 
Hutyra, anthrax spores, 664 
Hyatt, celluloid invented by, 275 
Icllinck, electric shock, 832 
Illinois, occupational disease law, 4, 462 
Illinois Commission on Health Insurance, 
153 
Illinois Commission on Occupational 
Diseases, brass workers, (341), 
349, 351 
carbon monoxide poisoning, 369, 406 
lead poisoning, 225, 249, 254, 440, 
453, 465, 1005 
report of, liii, 4, 1003 
zinc ores, (328), 339 
Illinois Factory Inspection Department, 
brass foundry, (color plate), 346 
carbon monoxide poisoning, 388 
lead poisoning in tin-can makers, 462 
Paris green poisoning, 316 
Illinois Steel Company, CO poisoning, 
398, 400 
Illinois, University of, altitude and blood 
changes, 816 
Illuminating Engineering Societies, 
illumination, 38 
Illuminating Engineering Society (Eng.), 
miners' nystagmus, 872 
Imbert, accidents and fatigue, 82 
Immermann, exercise and elimination of 
CO2, 54 
Ingalls, W. R., zinc smelting plant, 337 
International Association for Labor 
Legislation, establishment of, 
xix, 5 
industrial poisons, 2, 629, 643 
night work for women, 1039 
white phosphorus in matches, 529 
International Conference on Child Wel- 
fare Standards, periodic exam- 
inations, 1022 
International Congress on Hygiene, 
accidents and fatigue, 82 
Berlin meeting, 1907, li 
manganese poisoning, 592 
transactions, Iv 
International Congress on Hygiene and 
Demography, XVth, Washing- 
ton meeting, 1912, liii 
International Congress on Occupational 
Hygiene in Milan, lead poison- 
ing, miners, 451 
International Congress (on Labor) at 
Paris, labor protection, xix 
International Congress on Occupational 
Diseases, first, XX, 101 
International Congress on Tuberculosis, 
Vlth, liv 
International Labor Conference, anthrax 
recommendations, 1012 
childbirth recommendations, 1042 1094 
INDEX 
International Labor Conference, first, xix 
forty-four-hour week, 755 
minors, 1008 
white lead, 1004 
women wage-earners, 1008, 1031, 
1039 
International Labor Conference under 
the League of Nations, protec- 
tive regulations, 530 
International Labor Congress, Washing- 
ton (1919), Ivi 
International Labor Office, European 
laws, 1004 
safety education 1025 
International Medical Congress (Paris), 
transmission of syphilis in glass- 
blowers, 172 
International Typographical Union, 
health of printers, 248, 455 
Interstate Commerce Commission, eye 
protection, 864 
Iowa, University of, public health course, 
and research, xlix 
Ireland, J. H., Lomb Prize Essay 
recipient, 1 
Irvine, Wasserman reaction in lead pois- 
oning, 427 
Italian observers, rattan workers, 207 
Italian Government, fund for scientific 
research, 108 
Italian Parliament, social laws, 101 
Italian philanthropists, fund for scientific 
research, 108 
Italy, Department of Labor and Social 
Accident Prevention, eye dis- 
abilities, 877 
Italy, King of, research fund, 108 
Italy, night work in bakeries, 218 
Iwakawa, "tagayasa" wood, 203 
"Jack of Newberry," historical clothier, 
viii 
Jackson, Cruikshank and, vanadium 
poisoning, 604 
Jacobsohn, William, thermometer work- 
ers, 484 
Jacobson, Hubbard and, anthrax statis- 
tics, 674 
Jacquet, brommethyl poisoning, 575 
Jaehne, Friedrich and, detonation and 
hearing, 901 
Jakoby and His, nitroglycerin explosives, 
563 
James, treatment of dysentery, 686 
James, William, rubber industry, 545 
Jaminet, compressed-air illness, 793 
Jankovits, Marie, phosphorus poisoning, 
528 
Japp, H., compressed-air illness, 791, 793 
decompression, 806, 808, 809 
Javillier, zinc in plants, (329), 339 
Javillier, Bertrand and, test for zinc, 
(328), 329 
Jchle, leaf metal workers, 200 
phosphoreted hydrogen in acetylene, 
586 
Jean Baptiste Alphonse Chevallier, in- 
dustrial hygiene, xxii 
Jehle, gas plant conditions, 634 
Jevons, hours of labor, xi 
Jewett, life expectation of drinkers, 66 
Joannon, Blamontier and, occupational 
quinine poisoning, 570 
Johns Hopkins Hospital, benzol poison- 
ing, 502 
Johns Hopkins University, industrial 
hygiene, xlvii 
Johnson, gasoline poisoning, 498 
Johnson, G. W., motor fumes in mines, 
153 
Johnston, C., cutlery industry, 734 
Jones, John D., occupational diseases, 1 
Jones, W., extraction of gold and silver, 
196 
Journal American Medical Association, 
explosions in milling industry, 
(216), 232 
Jouvenal, Martial, occupational stig- 
mata, xxi 
Jump and Cruice, CS2 poisoning, 362, 
(364), 367 
Karasek, Matthew, CO poisoning, 405, 
406, 409 
photographers, 255 
Karasek and Apfelbach, CO poisoning, 
380, 405 
Katz and Allison, studies in gas leaks, 400 
Katz, M., literary research, li 
Kaup, lead, air borne, 429 
manganese poisoning, 592 
phosphor-bronze poisoning, 531 
roof-tiling establishments, 165 
statistics, Berlin painters, 4 
Kay, High, spinning jenny invention, ix 
Kayser, deafness in blacksmiths, 187 
Kayser, Gottstein and, hearing in smiths, 
etc., 898 INDEX 
1095 
Kazda, Franz, ulcer in rope maker, 267 
Keatley, Harry W., glazier's caulk, 464 
soldering, acid burns from, 462 
Keats, Flower and Coolidge, organic 
accelerators, 536 
Keays, F. L., compressed-air illness, 
793-795, 798, 801 
decompression, 805, 810 
results of recompression, 812 
Kefauver, mercury poisoning in hatters, 
493 
Kellert, etiology of cancer, (953), 958 
Kemp, Hayhurst and Stanley, altitude 
and blood changes, 816, (817), 
830 
Kennedy, Lyon and, copper smelting, 325 
Kennelly, A. E., rules for resuscitation, 
841 
Kent, A. F. S., industrial fatigue, (745), 
761 
Keszler, anthrax spores, 664 
Ketli, mercury poisoning, 474 
Kettle, Gye and, silicosis and tuber- 
culosis, 1075 
Key, explosives, 551, 552, 558, 560, 561, 
562 
Kilker, McCord and, zinc chloride burns, 
329 
Kilker and Minster, McCord and, insect 
powder dermatitis, 209 
wood preservatives, 205 
Kimball, atmospheric fatigue effects, 
(757), 762 
Kimball (Marine and), iodine factor and 
goiter, 60 
Kirkland, President, use of statistics, 989 
Kisskalt, zinc in animal tissues, (329), 339 
Kisskalt and Homann, cadmium poison- 
ing, (331), 339 
Klaproth, discoverer of titanium, 597 
Klein, C., wet sand papering, 1073 
Klink, Jane S., female laundry workers, 
287 
Knapp, A. W., lead-solvent water, 413 
Knauer, zinc ions in metabolism, (329), 
339 
"Knights of Labor," legislation, xli 
Knights of St. Crispin, labor legislation, 
xl 
Knowles, paraphenylendiamine poison- 
ing, 516 
Knyvett, Simon and, copperworkers, 326 
copper and brassworkers, (ref.), 359 
lead in bronze powders, 350 
Kober, George M., altitude symptoms, 
820 
arsenic poisoning, peculiarities in, 
315 
aviators, health of, 828 
boot and shoe industry, 278 
brass polishing and buffing, 347 
specialties, 349 
button, horn, celluloid and allied 
industries, 273 
Chairman, Industrial Hygiene Sec- 
tion, xlv 
chemical poisons, 569 
clay products, pottery, glass and 
allied industries, 163 
copper workers, 325 
economic loss from sickness and 
accidents, 79 
eye injuries, (foot note), 856 
explosives, 546 
farmers, gardners, planters and 
farm laborers, 210 
food stuffs, 214 
granite and marble industry, (160), 
162 
hide, tanning, and allied industries, 
673 
historical review (Prefatory), vii 
in history of medicine, Ivi 
industries m which poisoning may 
occur, 606 
iron, steel and allied industries, 176 
lead poisoning, 458 
liberal professions, public services, 
etc., 288 
lumber industry, 202 
metals and relevant industries, 583 
mining and quarrying industries, 145 
occupation statistics, comparative, 
970 
occupational disease clinics, 112 
diseases, 1 
personal hygiene, 42 
personnel, selection of, li 
petroleum and coal tar industry, 504 
pneumonia in cavalry troops, 681 
precious metals, jewelry and plating 
industries, 196 
printing and publishing industry, 247 
rag, shoddy and paper industries, 269 
railway and transportation services, 
239 
rendering, soap, glue and fertilizer 
industries, etc., 233 1096 
INDEX 
Kober, George M., tailors, garment and 
laundry workers, 281 
tuberculosis in relation to occupa- 
tions, 720 
in veterinarians, etc., 10 welfare 
measures, 87 
Kober and Hanson, "Diseases of Occu- 
pation," Etc., xxiii 
industries in which poisoning may 
occur, 606 
in history of medicine, Ivi 
textile and allied industries, 257 
Kober, Hayhurst and, brass and the 
brass industries, 341 
rubber industry, 535 
Kober, Teleky and, mercurial industries, 
481 
Kober, Truby and, diminished atmos- 
phere on health, 814 
Kobert, argyria, 601 
cadmium poisoning, 585 
copper poisoning, (321), 327 
cyanogen poisoning, 651 
nitroglycerine poisoning, 552 
uranium poisoning, 597 
ursol dye, 517 
Koch, anthrax culture, 663 
quinine in malaria, 685 
Kocher, phosphorus necrosis, 533 
Kockel and Zimmerman, fluorine com- 
pounds, 575 
Koelsch, (Fred), argyria in silver leaf 
workers, 197, 601 
arseniureted hydrogen poisoning, 
308 
calcium cyanamide poisoning, 587 
cement works, dust in, 18, 169 
diamond polishers, plumbism in, 201 
investigations, xxiv 
musicians, social conditions of, 290 
nitrated benzols, 631 
physicians,-tobacco and drug 
habits, 288 
porcelain industry, dust in, 166 
pregnancy, care during, 76 
sex and muscular strength, 76 
statistics: 
anthrax, 8 
brewers, 225 
glanders and farcy, 8 
lead poisoning in painters, 4 
lime, cement and plaster of Paris 
workers, 155 
mercury poisoning, 488 
Koelsch, (Fred), statistics: painters, 464, 
465 
peddlers and shopkeepers, 298 
shoe industry, 278 
Sisters of Charity, 289 
street cleaners, etc., 245 
sulphuric acid, etc., 571 
working women, 77 
telephone operators, high .tension 
currents, 300 
textile workers, "mill fever" in, 264 
wood polishers' "itch," 208 
work day, length of, and morbidity, 
74 
Kolisko, brain in CO poisoning, 391 
Kolle and Wassermann, anthrax preva- 
lence, 669 
Korosi, indoor and outdoor occupations, 
11 
Koschei, E., high altitude, 822 
Kostial, tobacco workers, 68, 228, 229 
Kraepelin, manic depressive psychosis, 
772 
Krall, Sheperd and, "rubber" dermatitis, 
537 
Kratz, dermatitis in rubber workers, 536 
Krautz, lead poisoning in zinc smelterers, 
337 
Kristen, tubercle bacilli in street dust, 
246 
Kryz, character of dust from ashes, 246 
Kuborn, dust diseases of the lungs, 701 
Kuhn, Goldschmidt and, brommethyl 
poisoning, 575 
Kuipers, phosphorus necrosis, 533 
Kunkel, cadmium, toxicity of, 585 
mercury poisoning, 471, 478 
Kurpjuweit, bacteria in oil, 697 
Kurz, mercury poisoning, 493 
Kussmaul, Adolf, mercurialism, xxiii, 474 
Laboulbbne, CS2 poisoning, 362 
La Croix, air pressure, and the ear, 895 
Laennec, dust diseases of the lungs, 701 
Lake, G. C., hookworm disease, 157 
Lamb et al., "hopcalite," absorbent for 
CO, 399 
Lamb, Hoover, Frazer and others, CO 
gas mask, 373 
Lampadius, discoverer of CSj, 360 
Lancereaux, CO poisoning, 398 
Lancet (London), miners' nystagmus, 872 
tobacco smoke, 68 
zinc sulphate poisoning, 330 INDEX 
1097 
Lander and Edwards, zinc compounds, 
(330), 339 
Landis, (H. R. M.), garment workers, 
tuberculosis in, 282 
gold miners, tuberculosis in, 724 
textile workers, 264 
tobacco dust, effects of, 229 
Landis, J. H., quick-drying paints, 496 
Landouzy, laundry workers, tuberculosis 
in, 286 
Lane, dentists, dermatitis in, 288 
Lane and Ellis, miners' nystagmus, 873 
Laney and Rice, Higgins, Lanza and, 
siliceous dust in Joplin mines, 
(334), 339 
Lang, mercury poisoning, 475, 477 
Langlois, J. P., cadmium, toxicity of, 585 
electric shock, 832 
industrial poisons council, 2 
Langworthy, C. F., food, 56, 63 
Lanossier, CO poisoning, 380 
Lanza, A. J., health of miners, 19, 154, 
157 
office, industrial hygiene, xlii 
Lanza and Childs, zinc miners, (334), 339 
Lanza and Higgins, zinc miners, (334), 339 
Lanza and White, copper miners, 324 
Lanza, Laney and Rice, Higgins and, 
siliceous dust in Joplin mines, 
(334), 339 
Lassar, butchers and abattoir employes, 
10 
Latham, Hubert, health of aviators, 828 
Latimer, "copperman's chest," (321), 327 
Latta, sciatica in locomotive engineers, 
239 
Laudenheimer, CS2 poisoning, 542 
Lauffer, industrial surgery, Ivii 
Lauffer, O. A., hernia statistics, 43 
Laureck, alcoholism and zinc chills, (333), 
339 
Lavin, Moyer and, brassfounders' ague, 
342 
Laws, C. E., "nitroglycerine head," 552 
Layet, Alex., blacksmiths, 186 
gas plants, 634 
hygiene of industries, xxiii 
lead poisoning, 419, 458 
Layet and Epstein, arsenic poisoning, 282 
Layet, iron fume poisoning, (331), 339 
Lazarus, gutta-percha workers, 536 
League of Nations, 44-hour week, 755 
International Labor Conference of, 
530 
Leake, J. P., stonecutters, use of air 
hammer, 158 
Lecky, alcoholism in England, 67 
Leduc, treatment of electric shock, 839 
Lee and Aronovitch, fatigue toxin ques- 
tion, (740), 760 
Lee, Edwards and others, temperature 
and humidity on fatigue , (757), 
762 
Lee, Frederic S., fatigue, 73 
fatigue and air conditions, (757), 762 
and occupation, 737 
studies, xlix 
substances, pathological 766 
heat-fatigue toxins, (322), 327 
"Human Machine and Industrial 
Efficiency," 144 
smoking, and blood pressure, 67 
Lee, Thomas S., the blood, circulatory 
system and kidneys, 930 
Lees, vanadium poisoning, 604 
Legge, Thomas M., anthrax, 263, 668, 
arsenic poisoning, 303 
benzol poisoning, 508 
brassworkers, health of, 353 
glass-workers' cataract, 883 
hatters, hazards of, 731 
industrial dermatitis, (ref.), 929 
diseases, xxii 
lead poisoning, 458-460, 471, 478 
mercury poisoning, 485, 488, 490 
the nose, mouth and throat, 844 
oxyacetylene flame on painted sur- 
faces, 467 
painters, paralysis in, 418 
pitch ulceration, (ref.), 959 
type founding, 249 
Legge and Goadby, "Lead Poisoning and 
Lead Absorption," xxiii 
Legge, R. T., "packers' itch," xlix 
the work of, Ivii 
Legry and Lermoyez, CO poisoning, 381 
Lehmann and Bauer, industrial hygiene, 
xxii 
Lehmann and Gundermann, benzol poi- 
soning, 500 
Lehmann, K. B., air, when inhaled, 21 
aluminum manufacture, 583 
anilin poisoning, 520 
anthrax infections, unusual, 673 
antimony poisoning, 583, 584 
arsenic poisoning, 315, 317 
artificial silk manufacture, 276 
artists, 289 1098 
INDEX 
Lehmann, K. B., barium, significance of, 
585 
basket makers, 208 
benzine poisoning, 496, 498 
benzol poisoning, 500, 501 
bichromate poisoning, 852 
blacksmiths, kidney diseases in, 186 
brassfounders' ague, 330 
carbon bisulphide poisoning, (360), 
361, 367 
carbon dioxide poisoning, 212 
chlorine poisoning, 573, 574 
chromium, on animals, 588 
cotton, mould fungi in, 264 
diamond cutters, plumbism in, 201 
dust investigations, 18, 419 
dye industry, 520 
farmers, infections in, 211 
gases and fumes, xxiv 
German silver, 593 
hydrochloric acid toxicity, 571 
hydrogen sulphide poisoning, 148 
industrial hygiene, historical review, 
vii, viii 
insect stings, 10 
institute for sick workers, xx 
iron and its salts, 601 
jewelry workers, 198 
lead poisoning, xxi, 602 
liberal professions, 288 
manganese dioxide, 590 
Mond metal, 593 
nickel, properties of, 593 
oats (moldy), intoxication from, 214 
osmium poisoning, 595 
perfumery making, 233' 
pigeon raisers, mould fungi in, 11 
plaster of Paris, 168 
postal officials, (German), 299 
radio operators, 299 
rag industry, 269 
satinwodd, toxicity of, 204 
selenium and tellurium, 595 
silk worm industry, 265 
sodium burns, 598 
sublimate eczema, 205 
sulphur dioxide poisoning, 571 
titanium, effects of, 597 
tobacco smoke, nicotine content, 68 
toluene poisoning, 508 
tungsten, in electric lamps, 598 
ursol poisoning, 517 
Lehmann and Saito, respiration studies, 
21, 419 
Leiboff, Philip, list of industrial hazards, 
606 
Leiper, schistomiasis, 695 
Leipsic Institute of Hygiene, lead poison- 
ing, 421 
Leipsic Insurance Statistics, see also 
Koelsch, barbers and hair 
dressers, 232 
basket makers, 208 
garment workers, 283 
lead poisoning, 4 
Leipsic Psychiatric Clinic, CS2 poisoning, 
542 
Leipsic Sick Benefit Society, see also 
Koelsch, brick and stone 
masons, 170 
cement workers, 169 
hatters, 492 
morbidity statistics, 972 
painters, 468 
plasterers, 170 
quarrymen and stone breakers, 155 
rubber workers, 542 
Leipsic statistics, see also Koelsch, 
brewers and malsters, 225 
laundry workers, 287 
marble cutters, 160 
pregnancy, care and rest during, 76] 
soap workers, female, 235 
sugar refineries, 218 
tin-ware factory, 603 
Leiser, morbidity in butchers, 221 
in chromo-lithographers, 253 
Leland, anthrax treatment, 671 
Leloir, oil folliculitis, 696 
"Le Matin," casualties in civil and mili- 
tary aviation, 827 
Lenberger, Wachholz and, CO poisoning, 
392 
Lenoir, benzene poisoning, 501 
Lermoyez, Legry and, CO poisoning, 381 
Leslie, zinc smelting plants, 336 
Letulle, mercury poisoning, 474 
Leubuscher and Bibrowicz, neurasthenia, 
750 
Leuenberger, anilin workers, 521 
etiology of cancer, 955 
Leurin, copper intoxication, 322 
Leverhulme, Lord, the six-hour day, 756 
Levi, ointment for bichromate poison- 
ing, 851 
osteomyelitis in pearl workers, 274 
Levin, distribution of cancer, (947), 958 
Levitsky, mercury poisoning, (ref.), 480 INDEX 
1099 
Lewin, Heinzerling and, hatters, 731 
Lewin, L., acetone fumes, asthma from, 
637 
arsenical poisoning, 479, 491, 897 
benzine poisoning, 497, 498 
CO poisoning, 369, 379, 380, 401 
copper poisoning, (323), 327, 359 
industrial poisoning, xxiv 
mirror platers, etc., argyria in, 601 
nitrous gas poisoning, 572 
paranitranilin poisoning, 515 
sulphuric acid poisoning, 662 
vapors in type founding, 249 
Lewis, E. R., altitude (on the ear), 895 
Lewis, W. Lee, Lewisite (explosive), 557 
Leyden, mercury poisoning, 474 
Leymann, air decompression, 805 
anilin poisoning, 514 
asphaltum fumes, 170 
chemical industry, 569 
chlorine morbidity rates, 574 
chlorobenzene poisoning, 517 
German dye industry, 521 
hydrochloric acid workers, 572 
nitrochlorobenzene poisoning, 510 
picric acid poisoning, 509 
sulphuric acid workers, 571 
Libin, CO poisoning, (391), 397, 410 
Liebkind, glassblowers' emphysema, 173 
Life Extension Institute, economic waste 
in industry, 79 
Lindemann, miners' afflictions, 145, 150, 
155 
Lindenborn, X-ray carcinomata, (963), 
969 
Linenthal, H., cloak and suit industry, 
281 
industrial health control, xxxiv 
lead poisoning, early diagnosis of, 
433 
Link, H. C., employment psychology, 
760, (762) 
Lintz, provocative anilin test, 538 
Liversuge, lead-solvent water, 413 
Llewellyn, miners' nystagmus, 872 
Lloyd, J. H., "Diseases of Occupation," 1 
mercury poisoning, 490 
Loeper, lead in soldiers' urine, 424 
Loevenhart, A. S., CO poisoning, 393 
Loevenhart, Gasser and, CO poisoning, 
393 
Loeway, altitude symptoms, 819 
Logan, Glaister and, CO poisoning, 369 
Lohmeyer, Casper, antimony vapors, 583 
Lomb Prize Essay, historical, 1 
Lombard, smoking and muscular 
strength, 67 
London Factory Department, CO poison- 
ing, 382 
London Medical Society, arsenic in wall 
papers, 304 
Long and Taylor, Chittenden and, copper 
poisoning, 322 
Lorinser, phosphorus poisoning, 528, 532 
Loth, morbidity of farmers, 210 
Louisville, University of, public health 
course, xlix 
Lounsbury, industrial surgery, Ivii 
Lovejoy, Owen R., child labor, 1020 
Lowe, (D. B.), physical examinations, li 
Luce and Hamilton, anilin poisoning in 
rubber workers, 514, 538 
Luden, Georgine, CO poisoning, 372, 408 
Luig, Bruno, CS2 poisoning, (362), 368 
Lusk, Graham, "Science of Nutrition," 
57 
Lussigny, mercury poisoning, 493 
Luther, zinc oxide workers, (338), 340 
Lutoslawsky, lead poisoning, 421 
Lutz, altitude and the circulation, 817 
Luzzati and Angela, tellurium poisoning, 
597 
Lynch, amount of exercise, 53 
Lynes, Rainsford and, ventilation device 
for brass crucible, 355 
Lyon and Kennedy, copper smelting, 325 
Lyon and Ralston, milling of zinc ores, 
(334), 340 
Lysias, slave workers of, viii 
M., W., (in Science), fate of CO in the 
atmosphere, (373), 409 
Macaulay, D., tuberculosis in gold 
miners, 713 
Mackenzie, James, nervous symptoms, 
778 
Macleod, compressed-air illness, 791 
Macready, airplane ascent, 814 
Mager, compressed-air illness, 791 
Magitot, phosphorus poisoning in match 
workers, 533 
Magnus, first secretary, Conference 
Board, Ivii 
eye afflictions, 82, 870, 876 
Magrath, Councilman and, xeroderma 
pigmentosum, (952), 958 
Maljean, balloonists, 825 
Mangold, zinc mining, (335), 340 1100 
INDEX 
Mann, Dixon, arsenical poisoning, 311 
Manning, stereotyping, 251 
Manson, theory regarding filariasis, 691 
Manufacturer's Aircraft Association, 
aviation accidents, 826 
Marek, anthrax spores, 664 
Margoniner, synovitis in laundry 
workers, 286 
Marie, Pierre, CS2 poisoning, (363), 
367 
Marine and Kimball, iodine and goiter, 
60 
Marks, L. B., standards of lighting, 39 
Marsh, Gaylord and, goiter and marine 
life, 60 
Marshall, Arthur, explosions, 550, 554, 
559, 562, 563 
Martial, mercury poisoning, (ref.), 480 
Martin, (E. G.), studies of strength 
tests, xlix, 743 
sensory threshold tests, 769, 773, 782 
Martin, Edward, industrial surgery, Ivii 
Martin, Franklin, organizer, industrial 
medicine, Iv 
Martin, tubercle bacilli in street dust, 246 
Maryland, child employment certificate 
system, 1023 
Marz, sound waves and hearing, 901 
Massachusetts, factory legislation, xxxii 
Massachusetts Board of Labor, carbolic 
acid burns, 509 
sulphur dioxide poisoning, 520 
Massachusetts Board of Labor and 
Industries, creation and work 
of, xxxiv 
cutlery industry, (189), 195 
women workers in core rooms, 1033 
Massachusetts General Hospital, anthrax 
cases, 671 
industrial diseases, studies of, 112, 
438 
lead poisoning, 434, 435, 436, 437 
occupational disease clinic, xlvi, 
438, 497 
neuroses, 768 
phosphorus necrosis, 532 
Massachusetts Industrial Accident 
Board, cigar-makers' cramp, 
782, 784 
compensation of neuroses, 784 
Massachusetts Institute of Technology, 
xlvi 
Massachusetts Medical Commissioner of 
Labor, benzene poisoning, 502 
Massachusetts Sanitary Commission, sta- 
tistical data, 1OOO 
Massachusetts State Board of Health, 
anthrax, in curled hair, 678 
boots and shoes, 278 
brass polishers, 348 
candle makers, 235 
chromo-lithography, 254 
cloak and suit industry, 281 
corrosive acids, 573 
de-hairing processes, (676), 681 
dry cleaning process, 505 
early investigations, li 
emery and corundum workers, 171 
factory sanitation, xxxiii 
granite, marble and soapstone dusts, 
159 
grinding of castings, 188 
jewelry workers, (197), 201 
laundry ventilation, 284, 285 
lead poisoning, 434, 461 
paints, colors, etc., 463, 579 
paper industry, 270 
patent leather industry, (677), 681 
pearl dust protection, (275), 277 
rope making, 266 
vegetable ivory workers, 273 
wire industry, (192), 195 
Massaut, occupational neuroses, 766 
Matzkewitch et ah, zinc poisoning, (329), 
339 
Maute, plaster of Paris, 169 
Mavrogordato, dust experiments, 717 
Mavrogordato, Haldane and, dust experi- 
ments, 1075 
Maynard, tuberculosis in miners, 714 
Mayo Clinic, incidence of venereal infec- 
tion, 81 
CO poisoning, 408 
McBrayer, L. B., tuberculosis in silk 
mills, 265 
McCarrison, Robt., intestinal flora, 60 
"Studies in Deficiency Diseases," 57 
McClintic, Thos. B., CS2, (ref.), 367 
McClure, benzene poisoning in cannery, 
501, 502 
McCollum, E. V., "Newer Knowledge of 
Nutrition," 57 
McConnell, Spencer and Phillips, New- 
man and, "Lead Poisoning in 
the Pottery Trades," 448 
McConnell, Wm. J., oil folliculitis, 
699 
printers, dermatoses in, 252 INDEX 
1101 
McCord and Kilker, wood preservatives, 
205 
zinc chloride burns, 329 
McCord, Kilker and Minster, insect 
powder dermatitis, 209 
McCrae, John, silica in diseased lungs, 
713 
McCready, B. W., prize dissertation, 1 
McCurdy, Douglas, health of aviators, 
'820,828 
McCurdy, 8. M., physical examinations, 
li 
McDonald, Duncan, statistics of coal 
miners, 153 
McDonald, Stuart, pneumokoniosis, 711 
McGill University, public health course, 
xlix 
McGowan, shocks in telephone operators, 
300 
McGurn, CO poisoning, 391, 398, 409 
McLean, CO poisoning, 398 
McNally, CO poisoning, 370, 371, 373, 
381 
McWhorter, compressed-air illness, 791, 
795, 796 
Meaker, Samuel T., dysmenorrhcea, 77 
Medical Press and Circular, TNT poison- 
ing, 510 
Medico-Actuarial Investigation, mortal- 
ity of drinkers, (65), 78 
Meeker, Royal, U. S. Commissioner of 
Labor, xli 
Meinel, Friedrich, hygiene of industries, 
xxiii 
Melier, Francis, tobacco workers, xxiii 
Mellon Institute, industrial medicine 
researches, xlix 
Mendes da Costa, cancer, 962 
Merkel, G., dust diseases, xxiii 
Metropolitan Life Insurance Co., see 
also Dublin, L. I., and Frankel, 
Lee K., average age at death, 
732 
cancer, incidence of, 956 
coal miners, 724, 979 
health insurance, xl 
industrial hazards, 606 
loss from sickness, 77, 79 
morbidity statistics, 972 
railway enginemen, (etc.), 981 
textile mills, 982 
(welfare work), 299 
Metzger, S. J., compressed-air illness, 797 
resuscitation, 841 
Meyer, dust determinations, xlvii 
Meyhofer, glass-workers' cataract, 172, 
889 
Meynert, Th., melancholia and mania, 766 
Michaelis, zinc in human tissues, 329 
Michigan, occupational disease law, 4 
Michigan, University of, public health 
course, xlviii 
Middleton, E. L., silicosis, 1075 
Milan Clinic, garment workers, 282 
Milan working people, fund for scientific 
research, 108 
Miller, atmospheric fatigue effects, (757), 
762 
effects of tobacco dust, 229 
Miller, D. J., lead-dyed textiles, 264 
Miller and Smyth, dust in cement mill, 18 
Mills, hotels for working men, 93 
Mills, C. M., zinc mining district, 336 
Milner, Lord, miners' phthisis, 706 
Mine Safety Appliances Co., carbon diox- 
ide-oxygen apparatus, 403 
CO protective device, 399 
protective device, spray painting, 
466 
Minelli, Cavazzeni and, X-ray pathology, 
965 
Minnesota, University of, public health 
course, xlix 
Minot, Anne, lead in the body, 469 
Minot and Smith, tetrachlorethane 
poisoning, 577 
Minot, Reiman and, manganese poison- 
ing, 589 
Minster, McCord, Kilker and, insect 
powder dermatitis, 209 
Missouri, occupational disease law, 4 
Missouri, University of, nursing work 
among zinc miners, 336 
public health course, xlix 
Mitchell, J. K., petroleum itch, 504 
Mock, Harry A., "Industrial Medicine 
and Surgery," Ivi 
industrial surgery, Ivi, Ivii 
organizer, industrial physicians, Ivii 
physical examinations, li 
reconstruction work, 84 
workers' health plans, Iv 
Mohr, chlorobenzene poisoning, 517 
Moir, E. W., compressed-air illness, 794 
Molinari, carbon bisulphide, uses, 360 
CO properties, (372), 409 
copper, occurrence of, (321), 327 
zinc smelting, (328), 339 1102 
INDEX 
Mommsen, historical industry, xi 
Montana, early insurance law (miners), 
xxxvii 
Moore, Farmer, Walker and, cancer, 947 
Moore-Oldershaw-Williams, zinc, (329), 
339 
Moorhead, industrial surgery. Ivi 
Morgan, Gerald, "Public Relief of Sick- 
ness," 144 
Morris, Scheele's green in wall paper, 317 
Morris and Paull, handicapped men and 
the rubber industry, 545 
Mosny, Brouardel-Chantenmasse and, 
industrial hygiene, xxiii 
Mosny, lead poisoning, 426 
Mosso, progressive fatigue, 742 
Mott, F. W., CO poisoning, 391, 397 
lead poisoning, 426 
Mott, Sir F. W., electric shock, 838 
Mottram, J. C., radium workers, 969 
Mouries, Mege, originator oleomargarine, 
221 
Moyer and Lavin, brassfounders' ague, 
342 
Mueller, Johann, mixed industrial poi- 
sons, 627 
Muller, anthrax treatment, 671 
lead poisoning, 429, 452, 460 
salt workers, 226 
Muller, Robert, investigations, xxiv 
Munich, institute for industrial hygiene, 
xxi 
Munich Pathological Institute, tailors, 
282 
Munroe, Charles E., explosives, 546, 551, 
554, 560, 561 
Munson, foot arch supports, 71 
lighting and area, (25), 27 
Murgia, absorption of lead sulphide, 451 
zinc mining, (335), 340 
Murphy and Ellis, X-ray effects, (964), 
969 
Murphy, Rous and, cancer, (948), 958 
Murray, distribution of cancer, (946), 958 
Murray, Wm., brass poisoning, (ref.), 359 
chandelier makers, 348 
Muskett, anthrax treatment, 671 
Myers, C. S., mind (fatigue), (737), 760 
Narsarow, anthrax mortality, 670 
Nasmith and Graham, CO poisoning, 406 
Nathan, Sir F. L., explosives, 551 
National Acme Mfg. Co., oil folliculitis, 
696 
National Bureau of Casualty and Surety 
Underwriters, eye injuries, 855 
National Canners Association, lead poi- 
soning, 224 
National Child Health Council, recom- 
mendations of, 1023 
safety education, 1025 
National Child Labor Committee, (his- 
torical), xxvii 
recommendations of, 1023 
uniform law, xxxv 
National Conference on Industrial Dis- 
eases, first, lii 
National Conference on Social Insurance, 
first, xliv 
National Conservation Committee, 
national vitality, 79 
National Council for Industrial Safety, 
liii 
National Electric Light Association, 
resuscitation, 841 
National Industrial Conference Board, 
medical work in industry, 84 
research reports, 1 
National Lamp Works, experimental 
investigations, xlix 
foot-candle meter, 39 
National Museum in Washington, safety 
exhibit, liv 
National Organization for Public Health 
Nursing, 143 
National Physical Education Service, 
child labor recommendations, 
1022 
National Safety Council, accident statis- 
tics, 82 
cancer education, 958 
creation of, liii 
industrial hygiene, xlviii 
lecture courses, xliv 
oil folliculitis, 699 
"Principles and Practice of Safety," 
83 
rubber industry, 537, 545 
National Safety News, automobile acci- 
dents, 244 
National Tuberculosis Association, mar- 
ble and granite cutters, 705 
symposium of, (1914), li 
Nation's Health, The, (citation), 144 
Neill, Charles P., U. S. Commissioner of 
Labor, xli 
Neisser, anilin poisoning, 514 
anthrax infection, (673), 675, 681 INDEX 
1103 
Neisser, benzine poisoning, 506 
brass polishing, (348), 352 
carbon bisulphide poisoning, 543 
chromo-lithography, (cataract), 254 
cocobola wood workers, 203 
dinitrobenzene poisoning, 513 
dyeing works, 267 
explosives, 549 
farmers' wives, miscarriages in, 211 
feather beds, smallpox from, 680 
fisherman, lead poisoning in, 458 
foot presses, and women, 76 
manganese poisoning, 590 
metal etchers, 255 
pearl factory, sickness in, 274 
sugar plants, 219 
tanners, eczema in, 676 
tin plate workers, 603 
walking stick makers, 207 
Neisser, E. J., "International Review," li 
Nela Research Laboratory, investiga- 
tions, xlix 
Nesbitt, Walter, Illinois coal miners, 153 
Nestler, A., toxic woods, 203, 204 
Neuhoff, F., shoe dye poisoning, 513 
Neumann, bee stings, 10 
housing, 92 
Neumann, Felix, literary researches, li 
New International Encyclopedia, brass 
products, (341), 351 
New Jersey Department of Labor, felt 
hat industry, 493 
phosphorus in fire works, 531 
Newman, B. J., office, industrial hygiene, 
xlii 
Newman, McConnell, Spencer and 
Phillips, "The Pottery Trades," 
Etc., 448 
Newsholme, occupational cancer inci- 
dence, 954 
Newton, C. R., benzol poisoning, 508 
(N. Y. City) Civil Service Surgeons, 
street cleaners, 245 
N. Y. City Fire Department, fatal acci- 
dents in, 297 
N. Y. City Health Department, fur and 
hatters' trade, 679 
painters, 453 
(N. Y. City) Metropolitan Police Depart- 
ment, safety exhibit, xliii 
(N. Y. City) Metropolitan Safety Coun- 
cil, lecture courses, xliv 
N. Y. Evening Post, phosphorus match 
poisoning, 528 
N. Y. State, decompression regulations, 
805, 810 
occupational diseases, xl, 4 
investigations, 1003 
tenement manufactures, 12 
N. Y. (State) Court of Appeals, night 
work for women, 1038 
N. Y. (State) Factory Investigating 
Commission, report, educational 
value of, 1003 
foundry sanitation, (186), 195 
lead poisoning, 441 
N. Y. State Industrial Commission, 
benzol poisoning, 508 
N. Y. State Labor Commission, rules for 
air decompression, 804 
N. Y. State Labor Department, anilin 
poisoning, 514, 516 
dinitro-chlorbenzene poisoning, 518 
flour millers, pneumonia in, 216 
ursol poisoning, 517 
N. Y. State Medical Society, prize dis- 
sertation, 1 
N. Y. Working Girl, "True Story of," 
284 
Nichols, anthrax infections, 678 
Nichols, Wainwright and, coal dust and 
phthisis, (702), 719, 1075 
Nicloux, CO poisoning, 390, 401 
Niekirk, silicosis and tuberculosis, 
713 
Nieszytha, miners, digestive disorders, 
154 
Nobel, Alfred, explosives, 550, 551, 554 
North-German Union, industrial code, 
xviii 
Norton Grinding Co., physical examina- 
tions, li 
Oberlander, mercury in the urine, 478 
O'Donovan, tar workers, (ref.), 959 
Offner, fatigue mental tests, (743), 761 
Offret, CS2 poisoning, (364), 367 
Ogato, CO and SO2 poisoning, xxiv 
sulphur dioxide in dyeing, 520 
Ogle, respiratory diseases in miners, 154, 
601 
Ohio Industrial Commission, CO poison- 
ing, 394 
eye injuries, 881 
Ohio, occupational disease law, xl 
Ohio State Board of Health, early 
committee of, 1 1104 
INDEX 
Ohio State Board of Health, Survey by: 
ammunition makers, 558 
automobile industry, 193 
brass foundries, 344 
calcium cyanamide poisoning, 587 
explosives, 548, 567 
file cutters, 191 
foundry workers, 184 
gilds, analysis of, 351 
glassworkers, 172, 173 
incandescent lamps, 350 
lead poisoning, 351, 439, 465, 538, 
580 
motorcycle, bicycle, sewing-machine 
and cash-register industries, 194 
oil refining, 504 
painters, 465, 580 
pottery workers, 164, 165, 168 
rubber workers, 535, 538, 539, 542 
stonecutters, 160 
"Survey of Industrial Health Haz- 
ards," etc., liv 
Ohio State Department of Health, CO 
poisoning, 369 
industrial health data (chart), 1068 
hygiene, division of, xlviii 
manganese poisoning, 590 
personal health data (chart), 1070 
"rubber" dermatitis, 537 
Ohio State University, CO poisoning, 393 
industrial hygiene, xlvii 
occupational disease clinic, 113 
Oldendorff, steel grinders, 189 
Oldershaw-Williams-Moore, excretion of 
zinc, (329), 339 
Oleson, ursol black, 517 
Oliver, Sir Thomas, altitude symptoms, 
823 
anilin and nitrobenzol, xxiii 
anthrax (see also Woolsorters), 668 
army, phthisis rate in, 292 
arsenic poisoning, (ref.), 313 
brass fumes, (341), 351 
bronzing, 350 
buhr-stone workers, 160 
cancer, infectiousness of, (949), 958 
carbon bisulphide poisoning, 362 
monoxide poisoning ,379, 393 
chauffers, 244 
coal mines, 149 
compensation requirements, 5 
cordage makers, deafness in, 267 
cotton carders, asthma in, 264 
cutlery workers, 171, 734 
Oliver, Sir Thomas, "Dangerous 
Trades," xxiii, xxiv 
diamond polishers, 201 
dinitrobenzene poisoning, 513 
dust, (cit.), 18 
diseases of the lungs, 701, 1075 
women, 246 
electrical injuries and electrical 
shock, 831 
explosives, 563 
feather dust in eye diseases, 680 
fulminate vapors, 549 
gutta-percha workers, 536 
industrial poisons committee, 2 
laundry workers, 286 
lead poisoning, 5, 338, 412, 434, 435, 
461, 1073 
marine service, 296 
nickel carbonyl poisoning, 594 
nitroglycerine poisoning, 552 
pearl workers, osteomyelitis in, 274 
phosphorus poisoning, (531), 534 
pottery workers, (165), 166, 175 
printers, 248, 250 
putty powder, 173 
skin diseases, 929 
slate workers, 155 
soldiers' irritable heart, 292 
sulphureted hydrogen poisoning, 519 
textile workers, "mill fever" in, 294 
tin workers, 601, 603 
tobacco dust, 228 
toxic woods, (203), 204, 209 
woolsorters' disease, 671 
zinc paints, 5, 338 
Olson, Von Criegen and, felt hatters, 492 
O'Malley, CO poisoning, 397, 398 
Opitz, Karl, Thomas slag workers, 237 
Oppenheim, brassfounders' ague, 342 
mercury poisoning, 475 
Oppenheimer, anilin workers, 521 
Oppenheimer and Spaeth, bacterial 
toxins and fatigue, (744), 761 
Ordway, Tyzzer and, cancer, 946 
Ordway, Tyzzer and, cancer, 946 
radium, 966 
X-ray, 959 
Osborn, anthrax infection, 669, 674 
Osler, anthrax infection, 670, 671 
cancer, etiology of, 954 
Ovington, EarlL., altitude symptoms, 821 
Pachetti Bros., hair cloth factory, 681 
Pacific Mills, accident records, 82 INDEX 
1105 
Page and Bushnell, oil folliculitis, 696, 
697 
Palmer, atmospheric fatigue effects, 
(757), 762 
dust counting method, 29 
Palmer, W. W., health of printers, 249 
Palmer, Vaughan and, pneumonia 
statistics, 376 
Panama Canal, health of employes, 87 
U. S. Compensation Act, 1044, 1046 
Pansa, Martin, miners' diseases, xxii 
Panwitz, lead dust in compositors' rooms, 
248 
Paracelsus, miners' diseases, xxi, xxii 
Park, "Hygiene and Public Health," 
xlvi 
Parkes, amount of daily exercise, 52 
Parmenter, tetrachlorethane poisoning, 
577 
Parsons, J., glassworkers' cataract, 888 
Parsons, wasting of zinc, (328), 339 
Partridge, Reuben, match-making 
machine, 526 
Pasteur, anthrax culture, 663 
Patissier, reviser of Ramazzini's book, 
xxii 
Patterson, lead poisoning treatment, 432 
organizer, industrial physicians, Ivii 
Patterson, Mary M., fish industry, 219 
Patzsche and Plaut, dry cleaning, 506 
Paull, Henderson and, CO poisoning, 379, 
380, 381, 399, 402 
Paull, Morris and, handicapped men and 
the rubber industry, 545 
Pavia, G., calcium cyanamide poisoning, 
587 
Pavia, University of, course on occupa- 
tional diseases, 102 
Pazen, CS2 poisoning, 360 
Pearson, dust diseases of the lungs, 701 
Pearson, etiology of cancer, 949 
Pearson, G., coal dust hazards, xxiii 
Pearson, H. C., carbon bisulphide, (360), 
. 367 
Peel, odor of methane, (148), 161 
Peele, Sir Robert, child-labor acts, 
xi, xii 
Peigney, copperworkers' afflictions, 322, 
(331), 339 
Pemberton, Edsall and, X-ray cancer, 
(963), 969 
Pennsylvania Department of Labor and 
Industry, eye compensation, 
(83), 86 
Pennsylvania Industrial Commission, 
compensation for accidents, 83 
Pennsylvania Legislature, minors' Act, 
xxvi 
Pennsylvania Railroad Co., accident 
prevention, 241 
sciatica in locomotive engineers, 239 
Pennsylvania, University of, industrial 
hygiene, xlvii, xlix 
occupational disease clinic, xlvii, 112 
Peri, A., morbidity of artists, 289 
Perlen, repairers of clothing, etc., 10 
Perrin, CS2 poisoning, 362 
Petard, effects of ballooning, 823 
Peter Bent Brigham Hospital, occupa- 
tional neuroses, 768 
Peterson, CS2 poisoning, 366 
Peterson and Haines, toxicity of CO, 
(377), 410 
Petkewitch, petroleum vapors, 505 
Petren, neurasthenia in laborers, 74 
Pettenkofer, experimental hygiene, xxiv 
Pettenkofer-Ziemssen, "Handbuch der 
Hygiene," xxiii 
Peuch, anthrax and pickling, 664 
Pfister and Vogel Leather Co., bichro- 
mate poisoning, 851 
Pheiler, anthrax spores, 664 
Phelps, atmospheric fatigue effects, (757), 
762 
lead fumes, air borne, 455 
Phelps, E. B., printing, 248, 249 
Phillips, Alonzo, the friction match, 526 
Phillips, Newman, McConnell, Spencer 
and, "Lead Poisoning in the 
Pottery Trades," 448 
Phoenicians, knowledge of brass making, 
341 
Photo-engraver's Union, tuberculosis, 
255 
Piccinini, P., bronze makers afflictions, 
678 
Pieraccini, lead and alcoholism, 467 
phosphorus, preparation, 531 
tobacco workers, miscarriage in, 229 
Pietrowiecz, brassfounders' ague, 342 
Pigeon, L., CS2 poisoning, (361), 367 
Pike, Smyth and, anthrax disinfection of 
hides and skins, 672 
Pincherle, P., wood dust, 204 
Pirrie, nitroglycerine poisoning, 563, 
Placzek, altitude symptoms, 819 
Plaut, Patzsche and, dry cleaning, 506 
Plautus, occupational stigmata, xxi 1106 
INDEX 
Plesch, compressed-air illness, 794 
Pliny, brass fumes, 341 
sulphur and zinc dangers, xxi 
Poelchen, CO poisoning, 380 
Poincare, CS2 poisoning, 362 
industrial hygiene, xxiii 
Pol and Wattelle, caisson disease, 790 
Pollak, sound waves and the ear, 901 
Pollender, discoverer of B. anthrasis, 663 
Pompilius, Numa, guilds in time of, xi • 
Pontopidan, S., acetylene poisoning, 586 
Pope, mercurial tremor, (1665), 481 
Popoff, muscular atrophy in bronze 
worker, 350 
Popper, tanning statistics, 675 
Porter, X-ray injuries, 961, 962, 965 
Porter and White, X-ray carcinomata, 963 
Porto Rico Anaemia Commission, hook- 
worm disease, 687, 688 
Porto Rico, Institute of Tropical Medi- 
cine and Hygiene, hookworm 
disease, 689, 693, 694, 695 
Post, Wilbur, physical examinations, li 
Potters, Brotherhood of Operative, lead 
poisoning investigation, 449 
Potts, gasoline poisoning, 498 
Power, anthrax infection, 275 
Pratt, E. E., lead poisoning, 441, 442, 
458, 465 
Preti, researches, 106, 110, 111 
Prettin, emphysema in glassblowers, 173 
Prevost, J. L., electric shock, 834, 837 
Prevost-Batelli, electric shock, 832 
Price, Geo. M., cloak and suit industry, 
281 
in history of medicine, Ivi 
industrial hygiene, historical, vii, xi, 
xix, xxv, xxxii 
" Medical Factory Inspection," liv 
pioneer in industrial hygiene, lii 
"The Modern Factory," Ivi 
Priestley, compressed-air illness, 793 
Prblss, arseniureted hydrogen poisoning, 
317 
Prudential Life Insurance Co., see also, 
Hoffman, F. L., coal miners, 724 
dusty occupations, 722 
farmers, etc., cancer among, 210 
metal miners and smelters, (325), 327 
textile workers, 265 
trainmen, accidents to, 240 
tuberculosis in occupations (table), 
730, 731 
zinc miners, 336 
Prussian Government, ferrosilicon trans- 
port, 319 
health insurance, 89 
Public Health Nurse, The, (journal), 144 
Purdon, (oil folliculitis), 264, 696 
Pusey, Wm. A., industrial dermatoses, 
(ref.), 929 
Putzey, Sommerfeld, Oliver and, indus- 
trial poisons committee, 2 
Putzeys, illumination, 25 
Pye-Smith, cancer in sheep-dip makers, 
305 
Pyl, Uden and, early publishers, xxii 
Pyle etal., "Personal Hygiene, "144 
Queen Anne, truck Act, xii 
Queen's University, public health course, 
xlix 
Quinby, R. S., rubber industry, 535, 543, 
544, 545 
Rainsford and Lynes, ventilation, brass 
fumes, 355 
Ralston, Lyon and, zinc ores, (334), 340 
Ram, electrical accident statistics, 831 
Ramazzini, Bernardino, "De Morbis 
Artificium Diatriba," xxii 
hemp and flax workers, 266 
marble and stone workers, 157 
motto, 111 
pulmonary disease in occupations, 
701 
Rambousek, J., anthracene workers, 509 
arsenical poisoning, 269, 317 
benzine poisoning, (497), 499 
benzol poisoning, 500, 507 
brass foundries, (346), 352 
carbon monoxide poisoning, 163 
chlorobenzene poisoning, 517 
chrome in air of workrooms, 588 
collodion, etc., 550 
copper poisoning, 323 
cyanogen chloride, 575 
diamond polishing, 201 
dry cleaning, 506 
dye industry, 521 
hydrofluoric acid poisoning, 575 
"Industrial Poisoning," xxiii 
iodine poisoning, 574 
lead poisoning, 451 
manganese poisoning, 589 
mercury fulminate, 549 
nitrogen compounds, 552, 572, 575 
phosgene poisoning, 576 INDEX 
1107 
Rambousek, J., picric acid poisoning, 509 
pottery home workers, 166 
roburite poisoning, 553 
rubber workers, (539), 543, 545 
soda manufacture, 598 
sulphureted hydrogen poisoning, 519 
toluene poisoning, 508 
xylene poisoning, (508), 524 
zinc poisoning, (329), 337, 339 
Rand medical men, silicosis and 
pneumonia, 713 
Rand, Wm. H., industrial poisons, 643 
mixed poisons, etc., 627 
Raoult et Breton, copper poisoning, 
(323), 327 
Raschi, H. E., electric shock, 838 
Rathenau medal, electrical industry, xlv 
Ravenel, anthrax infections, 674 
Reckzeh, tuberculosis in lime districts, 
155 
Redfield, the Drinkers, Shaw and, CO 
asphyxia, (ref.), 411 
Reeb, "pyrethrotoxic acid," 209 
Reed, tuberculosis among garment 
workers, 282 
Reeves, dust in various industries, 18 
Rehm, anilin poisoning, 520 
Rehn, anilin workers, 521 
Reiley, lead poisoning statistics, 462 
Reiman and Minot, manganese poison- 
ing, 589 
Reisman and Bolis, brassfounders' ague, 
342 
Reisman, Hektoen and, CO poisoning, 
(391), 410 
Remstedt, anthrax treatment, 671 
Renk, investigations, xxiv 
mercury, air-borne, 478 
Reymond, altitude symptoms, 820, 825, 
827 
Ribbert, etiology of cancer, 947 
Rice, Archie, TNT poisoning, 507 
Rice, Higgins, Lanza, Laney and, silice- 
ous dust in miners (zinc), (334), 
339 
Richards, illumination on warships, 293 
Richardson, B. W., Greek fire, 556 
Richardson (Harrington-), cotton strip- 
ping, 268 
Rickmann, antimonial salts, 584 
Riegel, lead colic, 423 
Rigler, statistics on actinomycosis, 8 
Rilliet, dust diseases of the lungs, 701 
Riseau, pianists' cramp, 780 
Ritter, pearl button industry, 275 
Roberti, J., purpura from benzol, 508 
Robertshaw, mortality of ganister 
miners, 705 
Robertson, ferrosilicon poisoning, 319 
tubercle bacilli in street dust, 246 
Robinson, W., etiology of glassworker's 
cataract, 884 
Robinson and Wilson, tuberculosis in 
coopers, etc., 208 
furniture makers, 206 
piano makers, 207 
soap makers, 236 
Rockefeller Sanitary Commission, hook- 
worm infection, 212 
Rockwood, lime dust in tuberculosis, 155 
Rodger, hearing in boiler makers, 899 
Roepke, coal dust in nose, etc., 896 
Rogers, Graham, (see also Graham- 
Rogers), dust in certain indus- 
tries, 18 
lead, air-borne, 442 
Rohe, George H., investigations, 1 
Rohlinger, J., glassworkers' cataract, 889 
Rohrer, copper workers, (322), 327 
Rohrer, Fritz, methyl bromide poisoning, 
575 
Romans, lead poisoning, 412 
manufactories, viii 
Ronzat, mercury poisoning, 493 
Roos, Lester, airplane dopers, 576 
Paris green poisoning, 316 
Roosevelt, National Conservation 
Committee, 79 
Roosevelt, President's Homes Commis- 
sion, children, physically defec- 
tive, 42 
cost of food, 63 
health insurance, 88 
industrial betterment, etc., lii 
hygiene, state laws, 85 
Ropke, file cutters, plumbism in, 191 
impairments of hearing, 898 
iron and steel industry, 180,181,189, 
710 
reduction in mortality-rate, 734 
Roscher, English death rate, lx 
Rose, hookworm infection, 212 
Rosenau, /'Preventive Medicine and 
Hygiene," xlvi 
Rosenbach, Fritz, X-ray injuries, (693), 
969 
Rosenfeld, diabetes in painters, 468 
miscarriage in tobacco workers, 229 1108 
INDEX 
Rosenthal, B. anthrax, 663 
Ross, cancer and tarry products, 955 
Ross, E. Halford, printers' phthisis, 1076 
Ross, Sir Ronald, "endemic index" of 
malaria, 684 
Rossie, tuberculosis in lime-, cement-, 
porcelain- and glassworkers, 168 
Rost, investigations, xxiv 
Rost, E., copper in vegetables, (323), 327 
Rost and Weitzel, copper poisoning, 
(323), 327 
Roszaheggi, type metal, (246), 256 
Roth, (Emil), accidents and fatigue, 82 
anemia and overwork, 751 
anilin poisoning, 521 
bone dust, 273 
. "caoutchouc disease," 536 
chlorine rash, 574 
dusty trades, 20 
"Handbuch," xxiv 
mother-of-pearl dust, 274 
steel grinding and polishing, 187 
stone workers, 159 
sugar mill employes, 219 
tanners' skin afflictions, 675 
tinsmiths, phthisis, in, 638 
tobacco workers, 226 
white lead workers, 460 
women, overwork in, 76 
wood turners, 203 
zinc smelterers, (337), 340 
Rouget, charcoal burners, 208 
Rous and Murphy, cancer, (948), 958 
Rowntree, fatigue and work hours, 748 
Rowntree, L. G., medical service for 
aviators, 828 
Royce, statistical induction, 991 
Rubner, (Max), age influences, 75, 82 
food and calories, 62 
laboratory on nutrition, etc., xxi 
lead in drinking water, 428 
still-births in working women, 76 
Rucker, CS2, on rodents, (360), 367 
Rudlin, railway employes, 239 
Rush Medical College, industrial dis- 
eases, xlvii 
occupational disease clinic, 112 
Rusk, G. Y., benzene poisoning, 502 
Russell, housing, 92 
Russell, John, lead-poisoning, 421 
Russell, Richard, sea-water in diet, 60 
Rutherford, CO poisoning, 372 
radium effects, 965 
Ryan, L. M., compressed-air illness, 812 
Sacher, mercury receptiveness, 476 
zinc albuminate, (329), 339 
Sadler, M. T., child labor, xiii 
Saelhof, bacteria in telephones, 300, 302 
Safety Engineer, radium in the safety 
movement, 969 
Safety Institute of America, publications 
of, xliv 
Saito, Lehmann and, respiration studies, 
21, 419 
Salant, tin in the body, 602 
Salant and Elsberg, zinc in rabbits, (329), 
339 
Sanfield, steel grinders' lung diseases, 710 
Santesson, benzol poisoning, 500, 501 
Savini, anthrax treatment, 671 
Sayers, R. R., air of mines, 146 
temperature and humidity in mines, 
156 
Sayers and Harrington, ventilation in 
mines, 157, 162 
Sayers and Yant, test for CO, 374 
Schafer, method of resuscitation, 842 
Schamberg, J. F., oil folliculitis, 698 
Schamberg and Goldberger, pediculoides 
ventricosis in wheat straw, 10 
Schereschewsky, J. W., garment workers, 
(282), 287 
governmental health agencies in 
promoting industrial hygiene, 95 
in history of medicine, Ivi 
office, industrial hygiene, xlii, liv 
trachoma in steel workers, xliii 
Scheuer, occupational syphilis, 9 
Schlauf, sublimate eczema, 205 
Schlokow, tuberculosis in limestone 
workers, 155 
Schmidt, emphysema and lung strain, 173 
school teachers, 289 
Schmidt, P., lead poisoning, 421 
Schmuckler, Aldrich and, copper statis- 
tics, (321), 327 
Schnattschneider, statistical diagrams, 
999 
Schneider, aviation, 815, 817, 818, 829 
Schoenfeld, J., lead poisoning, 439 
Schbnbein, discoverer of gun-cotton, 549 
Schonhals, neurasthenia and skill, 750 
Schridrowitz, Philip, rubber, (ref.), 367 
Schroeder, aviation, 814, 820 
Schrotter, discoverer of red phosphorus, 
526 
von Schrotter, aviation, 820, 824,. 825 
compressed-air illness, 791, 796, 810 INDEX 
1109 
Schrumpf and Zabel, antimony poison- 
ing, 583 
Schuchard, anilin and nitrobenzol, xxiii 
Schuler, (F.), dyeing, anilin black in, 636 
dusty trades, morbidity, 20 
investigations, xxiv 
linen workers, 265 
methyl bromide poisoning, 574 
printers, morbidity of, 247, 249 
Schulte, mercury, urine of dentists, 485 
Schultes, foot deformities in recruits, 231 
Schultze, nitric acid poisoning, 572 
smokeless powder, 550 
Schumacher, J. N., CO in motor ex- 
hausts, 389 
Schiipphaus, smokeless powder, 550 
Schurmann, X-ray cancer, 962 
Schuster, electric shock, 838 
Schutte, hatters, statistics, 491 
Schwab, grament workers, 282 
Schwartz, L., lead poisoning, 439 
Schwartze, arsenic toleration, 315 
Schwartze and Alsberg, cadmium poison- 
ing, 329, 585 
Schwarze, street railway employes, 242 
Schwechten, railway employes, 239 
de Schweinitz, eye afflictions, 178, 229 
Schweitzer, natural foods and health, 60 
Schwerin, anilin workers, 521 
investigations, xxiv 
Science, (W. M., in), fate of CO, 373 
Scientific American Medal, safety de- 
vices, xlv 
Sclavo, anti-anthrax serum, 671, 681 
Scott, Alex, CO poisoning, 398 
Scott, E. L., fatigue, (737), (757), 760, 762 
Scott, W. J., "Hygiene of Laboring 
Classes," 1 
Scott, Hay hurst and, CO2 asphyxia in 
silos, 212 
Scott, Henderson, Haggard, and, CO 
poisoning, 375, (403), 411 
Scurfield, steel grinders, 189 
Seamen, L. L., medal, hygiene and occu- 
pational diseases, xlv 
Sears, Roebuck & Co., physical examina- 
tions, li 
Seaver, Jay W., flat feet, 71 
Seavers, effects of smoking, 67 
Sedgwick, Hough and, "Hygiene and 
Sanitation," 144 
Seebert, manganese poisoning, 590 
Seelinger, Baum and, copper poisoning, 
322, (323), 327 
Seiffer, manganese poisoning. 590 
Seiffert, zinc smelterers, 329 
Seibert, Norma, health of zinc miners, 
336 
Selby, C. D., industrial medical service, 
Iv, 114 
writings of, Ivi 
Selby Smelter Commission, copper smelt- 
ing, 325 
Selfridge, death of, (aviation), 825 
Seligmann, cancer, (947), 958 
Selkirk, lime and cement workers, 155 
Sellers, White and, anilin poisoning, 514, 
524 
Selling, L., benzene poisoning, 500, 501, 
502 
Semerak, Hill and, CO poisoning, 391 
Semstwo, Moskauer, mercury poisoning, 
(ref.), 480 
Senn, anilin poisoning, 514 
Sevene and Cohen, discoverers of non- 
poisonous match, 527 
Shablowsky, industrial smallpox, 9, 680 
Sharp, brass foundries, (345), 352 
Sharp, Walter N., loss of vision, 881 
Sharp, Wm. H., petroleum vapors, 504 
Sharpe, paint spraying machines, 466 
Shattuck, Lemuel, statistics, 1000 
Shaw, the Drinkers, Redfield and, CO 
asphyxia, 411 
Shell, Simeon, electric welding, 840 
Shepard and Krall, "rubber" dermatitis, 
537 
Sherman, H. C., "Chemistry of Food1 and 
Nutrition," 57 
Shie, Marvin D., lead poisoning, 458 
oil folliculitis, 697 
tellurium poisoning, 595 
Shoudy, industrial surgery, Ivii 
Shufflebotham, F., miners' nystagmus, 
872 
pulmonary fibrosis and dust, 703 
Shuford, experimental dust hazards, xlviii 
Shultes, varicose veins, in standing, 70 
Sibelius, CO poisoning, 397 
Sicard, brassfounders' ague, 342 
Siccardi, P. D., " I cterhemorrhagic spiro- 
chetosis," 111 
pathogenesis of lead colic, 107 
Siebe, diving helmet, 790 
Siebenmann, detonation and impaired 
hearing, 901 
Sigel, blood in zinc ague, 332 
Silberstein, printers, 247, 249 1110 
INDEX 
Silberstein, compressed-air illness, 791 
miscarriages in women, (printing), 
251 
Simon, copper intoxication, 322 
Simon, Sir John, anthracosis, 702 
Simon and Knyvett, copper and brass 
workers, 326, 350, 359 
Singer, William H., Memorial Research 
Laboratory, studies, xlix 
Sirena, anthrax spores, 664 
Slade, lead poisoning, 427 
Slater, cotton factory in Rhode Island, 
xxv 
Slosse, arsenobenzenes, 317 
Slye, Holmes and Wells, cancer, (950), 
958 
Smith, A. H., compressed-air illness, 793, 
812 
Smith, Angus, lead in drinking water, 428 
Smith, Lorrain, compressed-air illness, 
793 
Smith, Minot and, tetrachlorethane 
poisoning, 577 
Smith, Theobald, copper poisoning, 322 
Smith, W. V., anthrax spores, 664 
Smyth, (H. F.), anthrax infection, 
679, 681 
tobacco dust, 229 
Smyth and Bricker, anthrax infection, 
676 
Smyth, Miller and, dust in cement mill, 
18 
Smyth and Pike, anthrax disinfection, 
672 
Snell, compressed-air illness, 793 
Snell, Simeon, glassworkers' cataract, 889 
Sobrero, nitroglycerine poisoning, 551 
Solomon, Southard and, occupation neu- 
roses, 763 
Sommerfeld, Th., blacksmiths and forge- 
men, 186 
brewers, 225 
engravers, 254 
"Handbuch," xxiv 
• industrial poisons council, 2 
lead poisoning in painters, 5, 468 
printers, 247, 249 
slate pencil workers, 732 
stonecutters, 159 
wood workers, 203 
Sommerfeld and Fischer, CS2 poisoning, 
(363), 367 
carbon monoxide poisoning, 405 
industrial poisoning, 643 
Sonnenschein, CO poisoning, 378 
Soper, G. A., subway dust, 243 
South Africa Miners' Phthisis Prevention 
Committee, silicosis, (336), 340, 
713 
South African Investigators, dust in 
mines, 19, 20 
Southard and Solomon, (revised by 
Solomon), occupation neuroses, 
763 
Spaeth, studies of fatigue, xlvii 
Spaeth, Oppenheimer and, bacterial 
toxins and fatigue, (744), 761 
Speck, CO2 elimination, 54 
Spencer, O. M., benzine (gasoline) 
poisoning, 499, 506 
Spencer and Philips, Neuman, McCon- 
nell and "Lead Poisoning in the 
Pottery trades'"448 
Spirek, mercury seal, 482 
Spitzka, E. A., electric shock, 838, 841 
Sprague, F. F., hookworm in mines, 156 
Sprague Memorial Institute, clinic for 
occupational diseases, 112 
Sprenger,' plumbism in file cutters, 191 
Squire, dangers of label licking, 272 
St. Louis Hospital, lead poisoning, 335 
St. Vincent Hospital (Leadville), lead 
poisoning, 450 
Stanford University, public health 
course, and research, xlix 
Stallybrass, Hope, Hanna and, "Indus- 
trial Hygiene and Medicine," 
144 
Stanley, Kemp, Hayhurst and, altitude 
and the blood, 816 
Starr, E. B., benzol poisoning, 508 
carbon-tetrachloride poisoning, 365 
influenza-pneumonia in mining 
camps, 151 
office, industrial hygiene, xlviii 
rubber dermatitis, 537 
Stassen, miners' nystagmus, 872 
Steiger, brommethyl poisoning, 575 
Steiner, E. A., "Trail of the Immigrant," 
144 
Stengle, Alfred, copper poisoning, 322 
Stephani, felon in tobacco workers, 229 
nicotine poisoning in tobacco work- 
ers, 228 
Stephens, G. A., cadmium poisoning, 585 
Sternberg, cabinet makers' morbidity, 
206 
"Indian rosewood" dermatitis, 204 INDEX 
1111 
Sternberg, plumbers, lead poisoning in, 
463 
saw and planing mill accidents, 202 
shellac concretions, in stomach, 206 
shoe industry, heart diseases in, 278 
vapors in type founding, 249 
Stettner, compressed-air illness, (792), 
813 
Stevens, George A., health of printers, 248 
Stevens, lead poisoning, 431 
Stewart, Ethelbert, U. S. Commissioner 
of Labor, xli 
Stewart, W. M., occupational diseases, 
xxxiv, Iviii 
Steyrer, Flemming and, aviation, 824 
Stieda, historical industries, viii 
Stieglitz, lead poisoning in painting, 467 
Stierlin, carbon monoxide poisoning, 397 
Stiles, hookworm infection, 7, 212 
Stitt, E. R., lead poisoning, 416, 454 
Stockhausen, Samuel, lead diseases, xxi 
Stokes, hazards in U. S. Navy, 293, 371 
Strasser, printers' type case, 250 
Strassman, signs, CO death, 390 
Strassman and Falk, foot machines and 
diseases of women, 77 
Strong, trend of cancer, 957 
Sue, Eugene, suicide by CO gas, 371 
Survey, The, (citation), 144 
Sutherland, CO2 in subways, 243 
Sweden, white lead legislation, 1004 
Sweet, X-ray penetration (eye), 869 
Sydenstriker, Warren and, garment 
workers, (283), 287 
Switzerland, white lead legislation, 1004 
Tancquerel des Planches, paralysis in 
painters, 418 
lead workers, xxiii 
Tatham, copperworkers, 326 
file cutters, 190 
gunsmiths, 191 
zinc workers, 337 
Tatum, electric shock, 832 
Tavera, carbori bisulphide poisoning, 360 
Taylor, copper drilling, (324), 327 
Taylor, F. W., fatigue experiments, 756, 
759 
Taylor, Long and Chittenden, copper 
poisoning, 322 
Tedeschi, Ettore, saturine neuritis, 459 
Teleky, (Ludwig), argyria, glass pearl 
industry, 601 
button workers, 274 
Teleky, (Ludwig), carroting solution, 
628 
file cutters, 191 
industrial poisons council, 2 
investigations of, xxiv 
lead poisoning, 282, 418, 421, 426, 
428, 450, 461, 468 
medical supervision, 461 
mercury poisoning, 471, 488 
phosphorus necrosis, 533 
Teleky and Kober, mercurial industries, 
481 
Terrien, carbon bisulphide poisoning, 364 
Teschedi, asthma in lead poisoning, 1074 
Thackrah, C. T., brassfounders' ague, 342 
industrial diseases, xxiii 
Thiele, ferrosilicon poisoning, 319 
Thiersch, etiology of cancer, 947 
Thoinot, industrial hygiene, xxiii 
Thomas, G. R. S., cyanogen poisoning, 
(524), 525 
Thompson, anthrax mortality, 670 
Thompson, C. B., scientific management, 
(758), 762 
Thompson, Elihu, resuscitation, 841 
Thompson, J. David, research work in 
medical schools, xlix 
Thompson, John D., explosives, 112 
Thompson, L. R., office, industrial 
hygiene, xlii 
Thompson, W. Gilman, carpet and rug 
weavers, 264 
carbon monoxide poisoning, 395, 396 
fur workers, 679 
in history of medicine, Ivi 
"The Occupational Diseases," liv 
occupational disease clinic, 112 
committee, liii 
orpiment in shellac, 579 
reconstruction work, 84 
tanner, arsenic neuritis in, 677 
Thorndike, atmospheric fatigue effects, 
(757), 762 
Thornton, coal dust in mines, 149 
Thorpe, leadless glazes in pottery, 166 
Thorpe, Sir Edward) lead poisoning in 
potters, 418 
Thorpe, T. E., phosphorus poisoning, 
(531), 533, 534 
Thresh, lead in drinking water, 1074 
Tine, compressed-air illness, 793 
Tissandier, fatal balloon ascent, 824 
Tolman, Wm. H., director, safety 
museum, xliv 1112 
INDEX 
Toronto University, public health course, 
xlix 
Tracy, morbidity in diamond setters, 201 
Tracy, R. 8., female tobacco workers, 229 
Transvaal Miners' Phthisis Board 
(Chamber, Commission), min- 
ers' phthisis, 706, 708, 710 
Trask, John W., glaziers' caulk, 464 
U. S. Employes Compensation Act, 
1044 
Traveler's Insurance Co., safety medal, 
xlv 
Treves, overwork, and disease, 751 
Triger, compressed-air illness, 790 
Trotter, electrical accidents, 832 
Truby and Kober, diminished atmos- 
pheric pressure, 814 
Truesdell, altitude and heart rate, 817 
Tucker, industrial health, Ivii 
Tulane University, public health course, 
xlviii 
Turner, C. E., industrial hygiene instruc- 
tion, xlvi 
Turner, G. A., gold miners' phthisis, 713 
Turner, John A., "oxide pox" in zinc 
workers, 338 
Turner, Logan, hearing in boiler makers, 
899 
Twedell, F., respiratory infections, 570 
Tylecote, mercury poisoning, 490 
Tyzzer, E. E., etiology of cancer, (950), 
958 
Tyzzer and Ordway, cancer, 946 
radium, 966 
X-ray, 959 
Uden and Pyl, early publishers, xxii 
Uffelmann, paper operatives, 270 
washerwomen, 286 
U. M. W. A., Illinois coal miners, 153 
Underhill, F. P., action of benzol, 501 
Underwood Typewriter Co., faulty vi- 
sion, 81 
Unger, Hess and, rickets, 58 
U. S. Air Service, altitudes and aviation, 
814, 815, 818, 822, 823, 825, 827 
U. S. Army, health of, 290, 292 
ballooning, etc., 824, 828 
U. S. Army and Navy, in executive 
orders, Iv 
U. S. Attorney General, opinion, com- 
pensation act, 1076 
U. S. Bureau of Animal Industry, anthrax 
regulations, 666 
U. S. Bureau of Census, anthrax, 669 
blacksmiths, 186 
cancer, (946), 958 
canning and preserving industry, 
(223), 232 
female employes, number of, 1028 
hours of labor, 753 
"Index to Occupations," 606 
influenza and pneumonia, (80), 86 
occupational mortality statistics, 984 
population estimation method, 995 
reliable statistical data, 1000 
tobacco workers, 228 
U. S. Bureau of Chemistry, health 
activities, 96 
U. S. Bureau of Education) child labor 
recommendations, 1023 
U. S. Bureau (see also Department) of 
Labor, bronze workers, (350) 352 
bulletins of, 144 
canning and preserving, (224), 232 
creation of, xl 
early monographs of, lii 
iron and steel industry, 177, 179, 180 
lead poisoning, 4, (441), 443, (445), 
457 
"List of Industrial Poisons," 2, 643 
phosphorus match poisoning, 528 
shoe industry, 280 
women, in glass industry, 1035 
U. S. Bureau of Labor Statistics, acci- 
dents, 83 
airplane dopes, 576 
coal-tar industry, 512 
health activities of, 96 
industrial hazards, list of, 606 
iron workers (bridge, etc.), 187 
lead poisoning, 439, 443 
painters' trade, (453), 457 
printing trades, (454), 457 
publications of, liii, xli, 144 
rubber industry, (456), 457, 514 
storage batteries, (452), 457 
U. S. Bureau of Mines, accident statistics, 
146 
carbon monoxide detection, 147 
CO2-oxygen apparatus, 403 
miners' nystagmus, 872 
permissible explosives, 562 
publications of, xli 
resuscitation, (401), 411 
safety exhibits, xliii 
temperature' and humidity in mines, 
156 INDEX 
1113 
U. S. Bureau of Standards, goggles, 571 
U. S. Bureau of War Risk Insurance, eye 
disabilities, 877 
U. S. Chemical Warfare Service, CO gas 
mask, 373, 399 
U. S. Children's Bureau, age minimums, 
1024 
health activities, 96 
physical examinations, 1022 
publications of, xlii 
recommendations, 1023 
safety education, 1025 
U. S. Commission on Industrial Rela- 
tions, loss from sickness, 79 
U. S. Commissioner of Labor, compila- 
tion of labor laws, xxx 
workmen's insurance, xxxvi 
U. S. Committee on Social Betterment, 
industrial hygiene, lii 
health insurance, 88 
U. S. Comptroller General, decision in 
compensation Act, 1046, 1058 
U. S. Congress, iron and steel industry, 
(ref.), (177), 194 
public health activities, 96, 98 
reconstruction work, 85 
wire industry, (192), 195 
U. S. Council of National Defense, 
conference on industrial health, 
Iv 
standards of lighting, 39 
U. S. Department of Agriculture, blasting 
explosives, 554 
health activities, 96 
privy construction, 213 
welfare work, 88 
U. S. Department of Commerce, cotton 
industry, xxv 
U. S. Department see also Bureau of 
Labor, compilation qf labor 
laws, xxvi 
data, early, li 
health activities, 96 
industrial betterment, 87 
in history of medicine, Ivi 
iron and steel industry, 754 
oil folliculitis, 697 
survey under, Iv 
working conditions service, Iv, xlii, 
697 
U. S. Department of State, hookworm 
infection, 212 
U. S. Draft Boards, physical defectives, 
42 
U. S. Employes' Compensation Com- 
mission, glaziers' caulk, 464 
U. S. Government, arsenals, 94 
forty-four hour week, 755 
health standards, 98 
industrial betterment, 87 
industrial establishments of, 99 
lead poisoning, 443 
paint specifications, 1074 
printing office, 250, 251 
relief of civil employes, 1044 
safety exhibit, xliii, liv 
steel plants, 180 
storage battery manufacture, 453 
U. S. (Merchant) Marine Service, afflic- 
tions in, 295, 296 
U. S. National Committee for the Pre- 
vention of Blindness, goggles, 
(83), 86 
U. S. National Museum, industrial 
betterment, 87 
U. S. Navy, Army and, in executive 
orders, Iv 
U. S. Navy, CO poisoning, 388 
lead poisoning, 416, 454 
statistics of, 292, 293 
U. S. Ordnance Department, antimonial 
poisoning, 584 
U. S. Paint Mfgrs.' Assoc., 432 
U. S. paint producers' tests, 1074 
U. S. Pharmacological Laboratory, ar- 
senic toleration, 315 
U. S. Philippine Commission, compensa- 
tion provisions, xxxvii 
U. S. Post Office Department, welfare 
work, 299 
U. S. Public Health Service, accident 
rates, 749 
child labor recommendations, 1023 
cloak and suit industry, 281 
fatigue studies, 745, 757 
garment workers, 282 
health powers of, 96 
industrial betterment, 87 
hygiene, liv, 291 
investigations, xliii, xlviii 
marine hospitals of, 296 
oil folliculitis, 697 
pottery industry, 167, 168, 448 
publications of, Iv 
stonecutters, use of air hammer, 158 
temperature and humidity in mines, 
156 
tellurium poisoning, 595 1114 
INDEX 
U. S. Referee Board, copper poisoning, 
322 
U. S. Senate, physical education, 43 
U. S. Steel Corp'n, eye protection (illus.), 
181, 185, 858, 860, 863, 867 
U. S. Supreme Court, shorter work day, 
Iv 
U. S. Surgeon General(s), gas casualties 
in World War, 558 
library of, 1, li 
mortality of enlisted men, 291 
U. S. Treasury Department, eye disabili- 
ties, 877 
U. S. Women's Bureau, publications of, 
xliii 
University and Bellevue Hospital Medi- 
cal College, public health 
course, xlviii 
Unna, X-ray cancer, (961), 963, 965, 968 
Urbantschitsch, impairment of hearing, 
898 
Vallardi, researches of, 106, 107, 111 
Van Buskirk, Lee and, fatigue tests 
examined, (742), 760 
Van der Bergh, sulphemoglobinemia, 931 
Van Eyk, printers and lead dust, 250 
Van Niekirk, miners' phthisis, 709 
Van Steenberghe, pulmonary tuber- 
culosis, 714 
Vaughan and Palmer, pneumonia dis- 
tribution, 376 
Vernon, compressed-air illness, 794, 797 
fatigue and efficiency, (737), 748, 
749, 758, 760 
Verpy, lead in soldiers' urine, 424 
Verrill, health of printers, 248, 249 
Versailles, (Treaty of), labor legislation, 
530 
Viault, altitude and blood changes, 816 
Victor Emanuel III, hygiene problems, 
101 
Villaret, yeast affection, 225 
Vinaj, lead colic, electricity in, 1074 
Virchow, dust diseases of the lungs, 701 
Vitruvius, lead pipes in ancient Rome, 
412 
Vogt, J. H., arsenic poisoning, 316 
lead, air-borne, 442 
Vogt, Graham-Rogers and, lead and 
arsenic poisoning, (ref.), (313) 
Von Criegern, ursol poisoning, 517 
Von Criegern and Olson, asthma in felt 
hat workers, 492 
Von Eichen, sound waves and hearing, 
900 
Von Harmsen, rubber vulcanizers, 542 
Von Jagic, X-ray workers, 174, (964), 969 
Von Jacksch, manganese poisoning, 589 
phosphorus in acetylene gas, 532 
Von Wurthenau, drummers' paralysis, 
290 
Wachholz and Lenberger, CO posioning, 
392 
Wachter, lead poisoning, 459 
Wade, R. R., factory inspector's report, 
xxxii 
Wadsworth, Wm. S., industrial hazards, 
606 
Wadsworth, Wm., T., industrial toxic- 
ology, 642 
Wainwright, tuberculosis in miners, etc., 
702 
Wainwright and Nichols, coal dust and 
phthisis, (702), 719, 1075 
Waldeyer, etiology of cancer, 947 
Walker, F. A., monograph, (historical), 1 
Walker, Farmer, Moore and, cancer, 947 
Walker, John, inventor, friction match, 
526 
Walkhoff, radium effects, 966 
Walther, gold threaded textiles, 201 
Warmer, Haywood and, arsenic in paper 
and fabrics, (ref.), 313 
Warnshius, industrial surgery, Ivii 
Warren, B. S., petitioner, industrial 
hygiene, xlv 
Warren and Sydenstricker, garment 
workers, (283), 287 
Warthin, etiology of cancer, (950), 958 
miners' boils, (324), 327 
Washington (D. C.), Children's Hospital, 
43 
committee on social betterment, 42 
housing companies, 91 
Washington (State), grain dust explo- 
sions, (214), 232 
Washington State Industrial Insurance 
Commission, lumber industry, 
202 
Washington University, industrial clinic 
at, 113 
Wassermann, Kolle and, anthrax pre- 
valence, 669 
Watkins, carbon monoxide poisoning, 408 
Watkins-Pitchford, "ptilosis" from 
ostrich feathers, 18 INDEX 
1115 
Watkins-Pitchford, phthisis in Rand 
miners, 21, 724 
Watson, lead in blood serum, 425 
Wattelle, Pol and, caisson disease, 790, 
793 
Watts, steam engine invention, ix 
Weaver, W. D., resuscitation, 841 
Weber, altitude effects, 816 
Weichardt, fatigue toxins, 766 
Weidner, carbon monoxide poisoning,£97 
Weihrauch, brewers' statistics, 225 
Weiss, osteomyelitis in pearl workers, 274 
Weiss, G., electrical accidents, 832, 834, 
836 
Weitzel, Rost and, copper poisoning, 
(323), 327 
Welander, mercury poisoning, 475 
Welch, Wm. H., industrial hygiene, xlvii 
Wellesley College, public health course, 
xlix 
Wells, H. Gideon, diagnosis of cancer, 957 
Wells, Slye, Holmes and, cancer, (950), 
958 
Wells, Walter A., (revisions of Blake), 
diseases and injuries of the ear, 
890 
Wengler, mercury poisoning, 475 
Wentzki, arsenic in hydrogen gas, 317 
West, Fries and, chemical warefare gases, 
555 
Wetmaacks, impairment of hearing, 903 
Weyl, Theodor, chemical industry, 569 
"diseases of occupations," xxiv 
petroleum refineries, 505 
street railway employes, 242 
surgeons, carbolic acid poisoning, 
509 
Whalley, Cadman and, mine gas, 376 
Wheatley, tuberculosis in quarrymen, 
705 
Whipple, George C., use and fallacies of 
statistics, 988 
White, C. Powell, lead in soldiers' urine, 
424 
White, J. H., hookworm in mines, 156 
White, R. Prosser, trade eruptions, (ref.), 
929 
White, W. C., smoke and soot, 21 
White, Lanza and, copper miners, 324 
White and Sellers, anilin poisoning, 514 
White, Porter and, X-ray cancers, 963 
Whiting-Davis Co., vision and produc- 
tivity, 81 
Whitla, anthracosis, 714 
Whitney, Dublin and, cost of tuberculosis, 
(80), 86 
Whittelsey, labor legislation, xxvi 
Wichern, benzine poisoning, 497 
Wight, lamp black dermatitis, 507 
Wignall, arseniureted hydrogen poison- 
ing, 308 
Wilbur, Edsall, Drinker and, manganese 
poisoning, (335), 340, 590 
Wilcox, incidence of cancer, 956 
Willard Storage Battery Co., lead poison- 
ing, 462 
Willcox, F. H., blast furnace "gassing," 
176, (382), 410 
Willcox, W. H., tetrachlorethane poison- 
ing, 576 
Williams, J. F., "Personal Hygiene 
Applies," 144 
Williams, J. R., CO poisoning, (395), 
410 
Williams-Moore-Oldershaw, zinc, (329), 
339 
Williams, W. R., cancer, (ref.), 969 
Wills, W., brass casting, (ref.), 359 
Wilmer, CO poisoning, 408 
Wilmer, Wm. H., altitude symptoms, 
820, 830, (918) 
Wilmer and Beserro, aviators, 829 
Wilson, J. T., address (historical), 1 
Wilson, (Woodruff), public health activi- 
ties, Iv 
Wilson, Robinson and, tuberculosis in 
workers, 206, 207, 208 
Winslow, C.-E. A., atmospheric fatigue 
effects, (757), 762 
dust in various industries, 18 
experimental work, xliii, xlviii 
instruction in industrial hygiene, 
xlvi 
Wisconsin, occupational disease law, 4 
Wisconsin, University of, public health 
course, xlviii 
Wiseman, C., gas heated appliances, 
(ref.), 287 
Wittgen, cement workers, 169 
rag industry, 269 
Wittmarck, sound waves and hearing,. 
900 
Wodke, safety matches, 526 
Wolbach, X-ray cancer, 963 
Wolf, mercury mining, 897 
Wolffhiigel, investigations, xxiv 
Wolff, Zellner and, printers' affections, 
252 1116 
INDEX 
Wollner, bronze workers, (350), 352 
Wood, W. H., lead poisoning, 462 
Wood & Co., "Reference Handbook of 
Medical Sciences," lii 
Woodhull, A. A., effects of smoking, 68 
Workers' Health Bureau, organized- 
labor clinic, 113 
Wreden, fungi in ear canal, 893 
Wright, C. A., zinc miners, (334), 336, 
339 
Wright, Carroll D., U. S. commissioner 
of labor, xl, xli, li 
industrial evolution, xxv 
labor legislation, historical, xl 
Wright, Florence S., the industrial nurse, 
136, 144 
Wright, Wade, fur and felt hat workers, 
492 
industrial diseases studies, 112 
Wurdemann, H. V., injuries and diseases 
of the eye, 177, 179,181,185, 855 
Wutzdorf, investigations, xxiv 
Wyer, S. S., radiant gas stoves as CO 
generators, 371 
Wyss, M. O., cancer, (961), 963, 968 
Yale University, industrial hygiene, 
xlvii 
Yant, Sayers and, test for CO, 374 
Yates, oil folliculitis, (696), 700 
Yokum, work of, Ivii 
Yorkshire Bottle Makers' Society, cata- 
ract, 887 
Yorkshire United Trade Protection 
Society, glassworkers' cataract, 
883 
Yoshlii, detonation and hearing, 901 
Young, toxicity of boxwood, 204 
Youngstown, Ohio, Medical Society, 
publication (historical), 1 
Youngstown Sheet and Tube Co., phys- 
ical examinations, li 
Zabel, Schrumpf and, antimony poison- 
ing, 583 
Zadek, brass workers, (342), 352 
copper alloy poisoning, 322 
engravers, 255 
watchmakers, (199), 201 
zinc ague, (331), 339 
Zander, apparatus in neuroses, 779 
Zangger, carbon monoxide poisoning, 397 
Zanker, red oxide of iron, xxiii 
Zeiss Optical Works, shorter work day, 
755 
Zellner and Wolff, printers, 252 
Zenker, pneumokoniosis, 702 
Zimmermann, benzine poisoning, 498 
Zimmermann, Kockel and, fluorine com- 
pound poisoning, 575 
Zondek, carbon monoxide poisoning, 397 
Zuntz, aeronauts, symptoms in, 824 INDEX OF SUBJECTS 
Note.-(1) The alphabetically arranged "List of Industries in which Poisonings 
and OtherHazards May Occur," given on pages 607-626, is not repeated in this 
Index and should be consulted separately. (2) The numerous industries, trades 
and callings mentioned in the tables on pages 724-732, "Tuberculosis and Other 
Diseases in Relation to Occupation," and in the tables on pages 971-984, "Com- 
parative Occupation Statistics," are not repeated in this Index and should be 
consulted separately. 
Abattoir employes, 10 
Ablutions and baths, 45 
Abnormal atmospheric pressures (see 
also Compressed-air, Diminished 
atmosphere), 790 
Abortions, antimony, 584 
carbon bisulphide, 542 
lead, 653 
overwork, 76 
Abrasive industry, xlviii 
dust estimations, 18 
eyes, 856 
Abscesses (see also Furunculosis), bakers, 
910 
benzine, 499 
furriers, 679 
Absenteeism, 139, 143, 543 
childbirth, 1034 
fatigue, 747 
Accelerators, rubber industry, 536 
"Accelerine," rubber ingredient, 536 
Accidents, age, 984, 987 
alcoholism, 66 
automobile, 244 
aviation, 825 
blindness, 82 
compensation for, 1014, 1020, 1042 
discussion of, ix, 79, 81, 83 
dye works, 523 
explosives, 560 
fatigue, xxiv, 75, 748 
female workers, 986 
hour of day, 82 
iron and steel, 179 
legislation upon (see also reporting 
of, infra), xix 
mining, xli, 145 
navy yard, 294 
Accidents, output and, 749 
radium in prevention of, 969 
railway, 240 
reporting of, xiv, xxx, xxxviii, 115 
statistics, 607, 985 
Acclimation to carbon monoxide, 379, 
405, 408 
to low oxygen percentages, 376, 
817 
Accountants, 298 
illumination, 38 
tuberculosis, 721 
Accumulator factories (see also Storage, 
Electric), 637 
arsenic, 317 
Acetaldehyde, 643 
tachycardia, 936 
Acetanilide, eye, 874 
methemoglobin, 931 
Acetate of cellulose, airplanes, 576 
compensation, 1016 
Acetic acid, artificial silk, 633 
celluloid dip, 276 
metals, dyeing, 636 
Acetone, bronzing, 351 
mixed poisons, 631-638^ 
painting, 464 
rubber solvent, 542 
zapone lacquer, 644 
Acetylcellulose, 633 
Acetylene (see also Oxy-acetylene) 586, 
640 
carbon bisulphide manufacture, 634 
incandescent lamps, 637 
lamps, oxygen deficiency, 377 
lighting, 26 
phosphoreted hydrogen, 531, 532, 
660 
1117 1118 
INDEX 
Acid fumes, 349, 563, 630-638 
solutions, dry batteries, 350 
glass, 1036 
plating, 348 
plumbism, 337 
rubber, 536 
tanning, 675 
Acidosis, carbon monoxide poisoning, 396 
high altitudes, 817 
Acids, (see each, respectively) arsenic 
in, 646 
Acne (see also Folliculitis, Furunculosis, 
Dermatitis, Skin affections), 
chlorine, 630, 650, 915 
petroleum products, 498, 505, 658 
salt workers, 226 
tar, 662 
vulgaris (ref.), 929 
Acridine, 643 
Acrolein, 222, 643 
blow-out shots, 562 
celluloid, 633 
fat extraction, 638 
glue, gelatin, 236 
printing industry, 249, 250 
ink, 455 
rendering, 234 
Actinomycosis (lumpy jaw), 8, 922 
dairying, 223 
farmers, etc., 211 
slaughtering, etc., 220 
Actresses, wig infections, 923 
Adaptation of worker (see also Worker, 
Ideal), 756 
Addison's disease, from blows upon the 
abdomen, 6 
simulated by oil folliculitis, 698 
Administration, (see Industrial health). 
Administrative orders, system of, 1004, 
1030 
Adulterations, (see Impurities). 
"Uraemia," ''aeropathy," 790 
TErographing, 165 
Aeronauts (see also Altitude, Aviation), 
824 
After-damp in mines, 148, 372 
Age, average at death, ix, 732 
child labor question, xiv, 1024 
compressed-air illness, 795 
glassworkers' cataract, 887 
Agraphia, 771 
Agricultural implements, 191, 499 
Agriculture, afflictions associated with, 210 
explosives, high, 554 
Agriculture, afflictions, eye injuries, 856 
hookworm, 687 
malaria, 684 
round worms, 693 
tuberculosis, 720, 726 
child labor, xvii, 1024 
statistics, 210, 1028, 1029 
Air conditions (see also Ventilation, etc.), 
17, 28, 1032, 1069 
expired, poison in, 757 
fresh, and fatigue, (757), 762 
pressure (see also Compressed-air, 
Diminished atmosphere) 894 
recompression, 811 
Air-hammer (see also Stonecutters), 158 
Airplane manufacturing, 564, 576 
Aisles, lighting for, 38 
Alcohol, denatured and skin affections, 
508, 912 
(ethyl), in manufacturing, 631-634 
Alcoholism, as cause of cancer, 953 
caisson work, 795, 1010 
combined with certain poisons, 68 
aromatic compounds, 515 
cyanamides, 587 
explosives, 567 
nitrobenzol, 655 
dusty occupations, 160 
educational work upon, xx, 110 
effects of, as a habit, 64, 85, 86 (912) 
arteriosclerosis, 943 
lack of good food, 93 
neuroses, 770-,4-,9 
tuberculosis, 727-735 
fatigue, xlix, 73 
industrial (charted), 1069 
legislation (Belgian), 1008 
occupations (special), 85 
aviation, 829 
brass, 343 
lead, 107 
mining, 152 
painters, 467 
servants, 729 
soldiers, 291 
zinc, 337 
simulated by certain poisons, 
benzine, 496, 647 
benzol, 647 
carbon bisulphide, 365, 648 
' monoxide, 394 
petroleum products, 658 
tuberculosis, 727-735 INDEX 
1119 
Aldehyde (s), 643 
mixed poisons, 631-638 
painted surfaces, 417 
Alizarin (colors), 520, 521 
chrome, 847 
Alkalies, cleansing hands, 915 
cutting compounds, (696) 
. dye works, 522 
effects on skin, 906 
mixed poisons, 630-638 
rubber works, 536 
soap makers, 235 
Alkaloids of spices, 226 
Alkalosis, 396 
high altitudes, 815, 817 
Allylchloride, in chloroform manufacture, 
631 
Alopecia, from X-ray exposures, 965 
Alphyl and aryl compounds of anilin, 644 
Altitude phenomena (see also Aviation), 
814-825, 1069 
Alum ulcers, glove industry, 677 
Aluminosis, 18, 163 
Aluminum, 564, 583 
finger guards, 131 
Amalgams, 487, 639, 654 
Amberwood, toxicity of, 204 
Amblyopia (see also Blindness), tobacco, 
68, 229 
"Ambulance chasers," 1014 
Amebic dysentery, 157, 685 
American Steel & Wire Co., zinc smelting 
plant, 337 
Amido compounds, 547 
bladder tumors, 521 
dye works, 522 
medical supervision, 461 
Ammonia, effects of, 643, 846 
exposure to, in various industries, 
(631-638) 
dye manufacture, 520 
dynamite, 551 
petroleum, 504 
soda process, 598, 600 
Ammoniac manufacture, 633, 634 
Ammonite, explosive, 553 
Ammonium chloride vapor, as test for air 
movement, 28 
phosphate, in safety matches 526 
sulphate, in artificial manure, 238 
Ammunition manufacture, 558 
Amnesia (see also Memory, loss of), 398 
Amperage, in electrical accidents, 835 
Amputations, compensation for, 1065 
Amyl acetate, effects of, 644, 936 
industries (special), artificial silk, 
633 
bronzing, 351 
incandescent lamps, 637 
painting, 464 
patent leather, 677 
shellacing, 349 
stench, for gas leaks, 400 
Amylacetate-acetone dope, for airplanes, 
577 
Amyl alcohol, chloroform manufacture, 
631 / 
effects of, 644, 874 
Amylthioether, stench, for gas leaks, 
400 
Anaemia, acute secondary, 933 
arsenical poisoning, 309, 519 
autointoxication, 50 
benzene poisoning, 501, 502, 647 
chronic secondary, 933, 938 
carbon monoxide poisoning, 409, 
649, 932 
fatigue, 751, 1038 
female workers, 298, 1038 
hookworm infection, 689 
hotel keepers, etc., 231 
miners, 157 
nitrobenzol poisoning, 655 
parasitic, 682-695 
pernicious in type, 934 
arsenic, 309 
nitrobenzol, 655 
X-ray, 964 
plumbism (see also Lead poison- 
ing), 1074 
tellurium poisoning, 596 
tobacco workers, 229 
trinitrotoluene poisoning, 511 
Anaesthesia, chronic carbon bisulphide 
poisoning, 648 
granite cutters' cramp, 782 
lead poisoning, 653 
Anaphylactic phenomena, 233 
ursol, 517 
zinc, 330 
Aneurysm, and writers' cramp, 774 
Angina, arterial disease, 942 
automobilists, 244 
overstrain, 935 
sulphur dioxide, 661 
Anilin, and anilin dyes, xxiii, xlvii, 
513-521, 644 
arsenic in, 304, 371 1120 
INDEX 
Anilin, British compensation Act, 1015 
hair dyes, skin affections, 910 
hydrochloride, or anilin salt, 516 
industries (special), dyeing, 514, 
636, 645 
felt hat, 492 
laundries, 285 
leather, fancy, 677 
photography, 255 
rubber, 456, 535, 536 
tanning, 637 
tar, 635 
- sensitivity toward, test for, 538 
special symptoms of, 364 
bladder, 954 
blood, 421, 931 
cancer, 956 
ears, 897 
eyes, 875 
heart, 936 
skin, 906, 907, 913, 914 
women workers and, 1037 
Animals, hazards from, 845, 921 
marine, zinc in, 329 
Ankylosis, chauffeur's knee, 244 
spine, 108 
Ankylostomiasis (see also Hookworm 
disease), 1013 
compensation, 1015 
French miners, 1018 
Anoxaemia, effects of, 376, 814 
Anthracene, 507, 509 
acridine, 643 
chrome, 847 
dyes, 520 
reference, 959 
tar, 634 
Anthracosis, xlix, 18, 701, 703, 714, 716 
Anthrax, 663 
animals, 665 
forms of, 669-671, 922 
industries exposed to, 211 
flaying, etc., 234 
food handlers, 220 
hides, 675-679 
horn workers, 275 
miners, 151 
rags, 269 
wool sorters, 263 
legislation upon, xvi, xl, 672, 1011, 
1015, 1018 
man, 668 
prevention of, 665, 672, 674 
statistics of, 8, 673 
Anthrax, studies of, xlvii, 663 
treatment, in man, 671, 681 
Antimony, xxii, 583, 636, 645, 934 
brass alloys, 341 
dyeing, 267, 633 
firearm manufacture, 191, 584 
lead industries, 196, 413, 635 
matches, 526 
mixed poisons, 632-637 
rubber industry, 535, 536, 541, 543, 
632 
type metal, 249, 342 
zinc smelting, 337 
Antipyrine, 574, 658 
Anxiety (see also Neuroses), 54, 73 
Aphthous fever, 8 
Apoplexy, 986 
compensation, 1056 
railway employes, 239 
Appendicitis, laundry workers, 286 
lead poisoning, 423, 441 
round worms, 693 
Apprentices, factory system demand, ix 
health and morals Act, 753 
legislation on, xi, xxvi, xxviii, xxx 
training of, 90 
"Approach," medical service methods, 
130 
Area, per worker, standards for, 29 
Argyria, 601 
glass-pearl silverers, 174, 197 
Arm, synovitis of, laundry workers, 286 
Armor piercing shells, explosives for, 555 
Arms, fore-, in filariasis, 692 
and oil folliculitis, 696 
Arsenals, Army and Navy, 88 
Arsenate of lead (see also Lead), 316 
Arsenic (see also Arseniureted hydrogen), 
303, 315, 636, 646 
afflictions of special nature, air 
passages, 844, 897 
bladder tumors, 521 
blood, 931 
cancer, 954-956 
collateral effects, 479 
eye affections, 874, 875 
fatal dose, considered, 310 
lung diseases, malignant, 955 
melanosis, 698 
nephritis, acute, 943 
polyneuritis, 322 
skin affections, 914, 915 
toleration to, 315 
historical, xxii INDEX 
1121 
Arsenic, industrial exposures, brass alloys, 
341 
brewing processes, 225 
briquette workers, 507 
bronze powders, 350 
carroting solutions, 628 
dyes and dyeing, 267, 304, 519 
633, 635 
furs and skins, 491, 679 
galvanizing, 338, 637 
glass industry, 172 
glucose manufacture, 218 
mining, 315, 324, 335 
paper hangers, 170 
industry, 271 
shot manufacture, 463, 632 
smelting, etc., 165 
copper, 324 
gold and silver, 196 
nickel, 593 
zinc, 328, 337 
spray mixtures, 211, 830, 1036 
tanning, 675 
legislation, xvi, xl, 318, 1006, 1015 
unsuspected sources, acids (HC1), 
as impurity, 652 
balloonists, 825 
beverages, 312 
coal, coke and gas, 312 
eating and washing-up, 35 
ferrosilicon storage, 318, 531 
garment workers, 282 
laundry workers, 286 
malt drying, 312 
metal vapors, 583 
zinc, 329 
shoddy carbonizing, 269 
soap, furriers', 732 
yarn, 263 
"Arsenic eaters," 315 
Arsenic trichloride, 306, 317 
Arseniureted hydrogen (see also Arsenic), 
303, 307-313, 646 
industrial exposures, acetylene gas 
welding, 640 
artificial silk, 633 
cyanide extraction process, 196 
silver jewelry, 198 
soda manufacture, 630 
soldering, 326, 463, 603 
zinc chloride manufacture, 631 
Arsenobenzenes, 317 
Arterio-sclerosis, 941 
compensation, 1058 
Arterio-sclerosis, eye diseases, 861 
occupational neuroses, 770 
pellagra, 108 
Arthralgia, lead poisoning, 653 
Arthritis, deformans, 801 
neuroses, 778 
"strikers," 182, 187 
wrist, fixed motions, 108 
Art glass processes, 173 
goods, leaf metal in gilding of,r200 
"Art metal," arsenical poisoning, 312 j 
ware, lead poisoning, 446 
Artificial fertilizers, 632 
flowers, 607 
anilin, 914 
arsenic, 317, 646 
lead, 441 
skin affections, 915 
tuberculosis, 730 
women workers, 1037 
respiration (see Resuscitation). 
silk, 549, 577, 633 
Artillery service, the ear in, 894 
Artists, 288 
lead poisoning, 441 
neuroses, 782 
Aryl compounds, 644 
Ascaris lumbricoides (see also Round 
worm), 692 
Ash men, 245 
Ashes, dust from, 246 
Asparagus, skin eruption, 211 
Aspergillus, cotton weavers, 264 
ear, 893 
tea testing, 230 
Asphalt, 169 
pavements, 507 
rubber industry, 535 
Asphyxia (-tion), blood poisons, 931 
carbon dioxide, (q.v.) 
monoxide, 649 
cyanogen, 651 
electric shock, 832, 838 
fermentation, 225 
gasoline, etc., 498, 504, 658 
nitrogen, 380 
phosgene, 576 
silos Iq.v.} 
vinegar plants, 226 
Asthma, 845 
acetone, 637 
brass workers, 342 
cardiac, 939 
felt hatters, 492 1122 
INDEX 
Asthma, furriers, 517 
"grinders," 188 
lead, 459, 1074 
"millers," 215 
"miners" (see also Lungs, Miners), 
151,152 
rope makers, 266 
weavers, 264 
woodworkers, 204 
"zinc" (smelting), 337 
"Aston," steamer, ferrosilicon poisoning 
upon, 319 
Ataxia, professional, 763 
Atmosphere (see Air, Compressed-air, 
Diminished air, Ventilation). 
Atrophy, carbon bisulphide poisoning, 
364, 365, 648 
Auctioneers, throat affections, 289 
Aurantia, ammonia fumes, 520 
anilin dye, 645 
skin, 914 
Auricle (see also Ear), 890 
Austrian legislation, 528, 1004 
statistics, 227, 228 
Autogenous welding, cause of ague, 342 
Auto-intoxication, constipation, 50 
zinc poisoning, confusion, 334 
Automobiles (-ists), 193, 243 
accident statistics, 82 
benzol, 500 
exhaust gases, 371, 389, 498 
gasoline, 498 
painting, 453, 459, 608 
lead prohibition, 468 
tires, 535, 539 
wastes from, in garages, 36 
Autopsies, arsenical poisoning, 309 
benzine poisoning, 501 
cancer diagnostic errors, 957 
compressed-air illness, 792, 796 
copper poisoning, 323 
"Auxetics," etiology of cancer, 956 
Averages and rates, misuse of, 992 
Aviation, crashes, 825 
diseases, 814, 822 
ear, 893, 895 
hygiene of, 828 
physical examinations, 827, 828 
Ax factory, dust in, xlviii, 19 
Babbitting, lead poisoning, 332, 462 
Bachelors, health statistics, 288 
Back injuries, compensation, 1061, 1062 
Bacteria (see also Various infections), 
colon type, vitality in oil, 697 
lead-solvent waters, 412 
standards for, in air, 29 
telephones, 300 
Bactericidal properties of paints, 418 
Bagpipe players, emphysema absent, 290 
Bakers, 216, 217 
anemia, 934 
heart disease, 939 
high temperature, 758 
rheumatic fever, 937 
skin affections, 910, 911 
tuberculosis, 722 
Balata rubber, in belt making, 361 
Ballistite (smokeless powder), 550 
Balloonists, 820-825 
arseniureted hydrogen, 317 
"Banana oil," 207, 464 
Bandages, application of, 131 
Bank vaults, war gases, in protecting, 
558 
Bankers, mortality, 986, 997 
tuberculosis, 721 
Barbers, 231 
skin affections, 910 
Barefooted workers, parasitic affections, 
687, 693 
Barium, significance of, 585 
Barley bug, 211 
Barometers, hazards in making, 349 
484 
Barometric pressure, aviation, 814, 816 
carbon monoxide poisoning, 372, 
388 
Bartenders, 231 
skin affections, 912 
Bartlesville Zinc Co. plant, 337 
Baseball, as exercise, 53 
Basic slag (see also Thomas slag), 236 
Basket makers, 208 
Basophilia, lead poisoning, 420, 434, 1074 
nitro benzol poisoning, 421 
Bath (-s,-ing), xvii, 24, 31, 45 
after exercise, 53 
infected water, 695 
lead trades, 1007 
Batteries (see also Accumulator, Electric, 
Storage), 308, 651 
Battleships, carbon monoxide poisoning, 
371 
welding flame on plates of, 467 
Bavarian statistics, tuberculosis, street 
cleaners, etc., 245 INDEX 
1123 
Bayonets, manufacture of, 191 
Beard, hazards of, 49 
"Beat elbow," 72, 153 
compensation, 1017 
"Beat knee," 70, 153 
Bed and bedding, 55 
Bedbugs, 10 
Bedrooms, ventilation of, 44 
Beef, raw, and tapeworm, 694 
Beer, arsenical poisoning, 312 
dealers, mortality, 65 
Bees, field workers, 10 
Belger's solution, for binding dust, 718 
Belgian process, zinc smelting, 336 
Belgium, coal miners' rates, 145 
Belt makers, carbon bisulphide, 361 
textile dust, 266 
Bench work, lighting for, 38 
"Bends," in compressed-air illness, 790, 
799, 803 
Benefit societies, medical service for, 133 
Benefits, Maryland Act, xxxvii 
U. S. employes' compensation act, 
1045 
Benzene (see also Benzol), 495, 500, 507 
bronze workers, 351 
methemoglobin, 931 
turpentine substitute, 579 
Benzidine, 644 
Benzine (see also Gasoline, Naphtha, 
Petrol, Petroleum products), 
36, 495, 504, 647 
carbon bisulphide, differentiation, 
365 
chronic poisoning, 497, 499 
rubber, 541 
compensation Act, 1015 
industries (special), celluloid, 633 
garments, 282 
glue, 638 
India rubber, 632 
linseed oil, etc., 579 
painting, 464, 465 
pottery, 166 
printing, 913 
rubber, 535-541 
shellacing, 349 
tanning, 677 
Benzol (see also Benzene), 495, 500, 647 
amide compounds of, 644 
carbon bisulphide, differentiation, 
365 
industrial uses, air plane dopes, 577 
dry batteries, 350 
Benzol, industrial uses, ink driers, 252 
millinery workers, 508 
mixed poisons, 632-634, 638 
paints, bactericidal action, 1074 
rubber, 535-541 
leucopenia due to, 933 
Benzols, nitrated, 631 
Benzyl chloride, 518, 520 
B eri-b eri, food deficiency and, 58 
Berlin, museum of safety, etc., xx 
Bernhardt's disease, 781 
Bessemer steel works, 176 
Betel nut, etiology of cancer, 953, 956 
Betterment, industrial, 90 
Bichromates (see also Chromates), 588, 
844 
photo-engravers, 255 
skin affections, 913, 914 
Bicycles, 194 
exercise with, 53 
tires for, 539 
Billiard balls, 275 
Binding (books, etc.), 253, 565 
Binitrobenzol, (see Dinitrobenzol) 
Biological standards, atmospheric, 29 
Birds, lead poisoned about smelters, 414 
skin of, arsenic as preservative, 304 
Birth rates, 996 
Bismarck blue, 645 
Bismuth, cobalt minerals, 955 
line, confusion with lead poisoning, 422 
Bisulphide of carbon (see Carbon 
bisulphide). 
Bitter almond oil, imitation (nitroben- 
zene), 512, 655 
Bitumen, (see Asphalt). 
Black, fast (dye), 645 
"Black heads," in oil folliculitis, 698 
Black powder, 555 
Black-damp, air of mines, 148, 376 
Blacksmiths, 186 
ear affections, 892 
endocarditis, chronic, 939 
hammermen's cramp, 781 
pemphigoid eruptions, 922 
Bladder, anilin workers, 520, 954 
schistomiasis, 694 
Blast furnaces, 176, 382, 608 
carbon monoxide poisoning, 397 
cyanogen compounds, 651 
lead smelting, 414 
long hours, 754 
shower baths, 35 
Blasters, 149 1124 
INDEX 
Blasting, 546 
caisson work, nitrous gases, 795 
carbon monoxide after, 389 
dust from, in mines, 708 
ear affections, 894 
fuses for, 559 
gelatine, 551, 554 
Bleaching, 608 
chlorine gas, 915 
dyeing, 636 
explosives, 564 
glue, chloride of lime in, 236 
laundries, skin irritation, 285 
powder, arsenic in making, 310 
scientific management, 759 
sulphur dioxide, 661 
tallow, 234 
Blebs (see also Blisters, Vesicles), carbon 
monoxide poisoning, 391, 398 
Blende (zinc ore), 328 
Blindness (see also Eyes), head injury, 871 
momentary, benzine poisoning, 496 
occupations for, 875 
smokers, 68 
sulphureted hydrogen poisoning, 519 
transient, lead poisoning, 653 
types of, 879 
wood alcohol, 654, 874 
painters, 465 
"Blistering gas," in warfare, 557 
Blisters (see also Blebs, Vesicles), 
hydrocyanic acid poisoning, 524 
Blood, 930 
altitude changes in, 815 
artificial manure manufacture, 238 
carbon monoxide, retention in, 381 
tests for, 374, 390 
lead poisoning, 420, 439, 1073 
letting ("bleeding"), in carbon 
monoxide poisoning, 402 
mixed poisons, 631-638 
nitro compounds, 510 
parasites, 682-695 
poisoning (see also Septic infection), 9 
poisons, miscellaneous, 643-662 
pressure, 941 
carbon monoxide poisoning, 395, 
397 
charted, 1071 
diminished atmosphere, 822 
radium effects, 967, 969 (Mottram 
ref.) 
X-ray effects, 964 
Blowers, legislation on, xxxiv 
Blowpipe, contagious disease spread by, 
1013 
glass-workers, syphilis, 889 
Blowpipes, oxy-acetylene, etc., metal 
chills, 342, 640 
phosphoreted hydrogen, 586 
Blue, Bismark (dye), 645 
"Blue boys," "-men," anilin poisoning, 
514 
Blue dahlia (dye), 520 
"Blue gum," dermatitis from, 204 
Blue line in the gums, fur and felt hat 
workers, 492 
lead poisoning, 422, 653 
"Blue water" gas, 387 
Boatmen, death rates, 295 
Body, the, composition of, 56 
Bohemian miners, lead poisoning, 451 
Boilermakers, 187 
deafness, 898-901 
Boilers, explosions, number of, 84 
inspection of, xxviii, xxxii, xxxviii 
operations of, and gassing, 388 
shower baths for workers, 35 
steel works, gassing from, 385 
Boils (see also Furunculosis) 
cutting compounds, 696 
fishermen, 220 
petroleum, 504, 658 
rubber, 537 
study of, xlix 
sulphureted hydrogen, 661 
zinc ore dusts, 337 
Boll weevil, eradication work of aviators, 
arsenical poisoning, 830 
Bombs, explosives used in, 555 
Bone ash, source of phosphorus, 526, 
659 
black dust, in sugar refining, 219 
"Bone coal," 150 
Bone dust, artificial manure, 237 
yards, 233 
Bones, industrial affections of, copper 
workers, 323 
lead poisoning, 469 
pearl workers, 21 
phosphorus poisoning, 659 
Book binding (see also Binding), 247 
Bookkeepers, morbidity, 298 
tuberculosis, 721 
Books on industrial hygiene, recent, 
144 
Boots (see also Shoes), xxxiii, 278 
wooden, for wet work, 48 INDEX 
1125 
Bottling, carbon dioxide hazard, 225 
eye injuries, 859 
milk, 223 
Bouton d'huile (oil folliculitis), 696. 
Bowling, as exercise, 53 
Boxing, effects of, on the auricle, 891 
Boxwood, toxicity of, 204, 1016 
"Boys" (or Kaffirs), miners' phthisis, 
706 
Bradycardia, 935 
carbon monoxide poisoning, 397 
hydrogen sulphide poisoning, 661 
nitroglycerine poisoning, 656 
Brain (see also Mental, Psychoses, and 
the various poisons and hazards) 
carbon monoxide poisoning, 391, 524 
tumor, and writers' cramp, 778 
work, body processes and, 53 
fatigue from, 741 
value of physical exercise in, 51 
Brakemen, railway, mortality, 240 
Bran packers, respiratory diseases, 215 
Brass workers, afflictions (various), xxiii, 
342,354 
lead poisoning, 441 
nitrous gas exposures, 637 
tuberculosis, 723 
"founders' ague," 330, 341, 353 
galvanized plates and, 467 
hecklers' hemp fever, resembling, 
266 
threshers' ague, resembling, 214 
hazards of, 341, 353, 609, 637 
copper, use of, 321 
lead in air of rooms, 442 
women, core rooms, 1037 
prohibited, 1031 
legislation regarding, xl, 1006, 1009 
Braziers, arseniureted hydrogen poison- 
ing, 308 
disease peculiar to, 331 
ear affections, 891 
metal chills in, 342 
"Brazilian method," in dysentery, 686 
Bread manufacture, historical, viii 
Breasts, in filariasis, 692 
Brewers and brewing, cancer, 955 
carbon dioxide, 212, 376 
explosive hazards, 564 
eye injuries, 859 
mortality of, 65, 224 
poisons, 637 
rheumatic fever, 937 
zinc oxide, 338 
Brick-wall building, Gilbreth's system, 
759 
Brickmakers, 163 
skin affections, 912 
trichuria infection, 693 
Bright's disease (see also Kidney), mor- 
tality due to, 986 
occupational neuroses, 770 
old age, 987 
Briquette makers, carbon monoxide 
poisoning, 371 
pitch cancer, 955 
ulcers, 507, 959 (ref.) 
tar cancroid ulcers, 662 
Brisant explosive, rock blasting under 
water, 554 
Bristle workers, consumption in, 678 
Britannia metal, antimony used in, 583 
composition of, 593 
British (see also "Author Index") 
house painters, 418 
mines, nystagmus in, 151 
workmen's compensation Act, 1015 
Broken Hill Mines in Australia, 414 
Bromine anaemia, 934 
color industry, 512 
hazards of, 574 
lachrymating gas, 556 
manufacture of, 632 
photography, 255, 638 
Brommethyl, 575 
Bromobenzyl cyanide, lachrymator, 557 
Bronchial asthma, in furriers, etc., 517 
catarrh, ammonia exposures, 643 
hydrofluoric acid, 1036 
nitrous gases, 657 
zinc workers, 338 
Bronchitis (see also Respiratory diseases, 
Tuberculosis), acetone fumes, 
637 
brass foundries, 342 
cordage, etc. (women workers), 
1034 
tea tasters, 230 
ursol dyeing, 517 
Broncho-pneumonia (see also Respiratory 
diseases, Pneumonia), carbon 
monoxide poisoning, 391, 397 
silicosis, 709 
Bronze, composition of, 341 
foundries, health in, 323 
phosphor-, as poison, 531 
powder, chromo-lithography, 253 
copper in, 326 1126 
INDEX 
Bronze, powder, explosives in, 564 
manufacture of, 350 
wall paper, 271 
zinc dust in, 338 
zinc ague from, 332 
Bronzing, arseniureted hydrogen, 307 
benzol, 500 
editorial, historical, 1 
hazards of, 609 
lead, picture-frames, 207 
of skin, anilin poisoning, 514 
tin sulphide, 602 
Brooklyn bridge, compressed-air disease, 
791 
Broom making, blind persons, 875 
hazards of, 678 
Brown mineral (manganese dioxide), 
589, 654 
Brunswick green (arsenical compound), 
646 
Brush making, anthrax, laws regarding, 
1012 
hazards of, 678 
skin affections, 922 
Budapest, institute for industrial hygiene, 
xxi 
Buffing, brass, 347 
copper and nickel, 441 
Buhach (Persian insect powder), 209 
Buhr-stone workers, dust, steel and 
mineral, 160 
fibrosis, 723 
flour milling, 215 
lung diseases, 704 
Building trades, eye injuries, 856 
skin affections, 912 
Bullion refining, arseniureted hydrogen 
poisoning, 307 
Bunions, prevention of, 50 
Burial expenses, in compensation acts, 
1017, 1018 
Burlap, in paper making, 270 
Burnishing, antimony compounds, 645 
ear disorders, 897 
skin affections, 913 
sulphuric acid, 662 
Burns, electric, 833 
explosives, 523 
eye, 861 
statistics, 82 
treatment, 131 
Burrel amalgamation process, 486 
Burrell carbon monoxide detector, 373 
tobacco smoke, 67 
Bursitis, compensation, 1017 
neuroses, 766, 773 
pottery workers, 166 
Burtonian line (see also Blue, Gums, Lead), 
422 
Bury ventilator, 13 
Bushing hammer, dust from, 158 
Butane, air of mines, 148 
Butchers, anthrax, 668 
arteriosclerosis, 941 
cancer death rate, 955 
skin affections, 921-923 
tapeworms, 220, 694 
trichiura, 220 
Butter factories, statistics, 222 
Buttons, bones, use of, 234 
horn, use of, 275 
makers of, 273 
tuberculosis, organic dust, 722 
Butyric acid, acne in spinners, 264, 917 
By-products and poisonous impurities, 
630-638 
Bysinosis, 18 
Cabinet makers, 206 
eye injuries, 857 
Cachexia, 654 
round worms, 693 
schistomiasis, 694 
Cadaverin, rubber ingredient, 536 
Cadmium, brass alloys, 341 
solder, in food containers, 329 
zinc ores, 328, 337 
Caffeine, effect of, on the eye, 874 
Caisson myelitis, 797, 801 
workers (see also Compressed-air 
illness), ear disorders, 895 
industrial hazard chart, 1069 
investigation of, xxiv 
law, standard, 1009 
Calamine (zinc ore), 328 
Calcium, 586 
carbide, 586, 634 
carbonate, lead-solvent properties, 
412 
chloride, on nasal mucous mem- 
brane, 844 
cyanamide, 587 
cyanide (see also Cyanogen com- 
pounds), artificial manure, 238 
nitrate, artificial manure, 238 
hazards of, 587 
Calico cloth industry, (women), 1037 
printing, 267, 610 INDEX 
1127 
Calico, printing, chrome compounds, 
588, 847 
Callosities, 72, 906 
blacksmiths, etc., 187 
cabinet makers, 206 
clay products workers, 164 
elevator employes, 302 
flax hecklers, 265 
milkers, 223 
miners, 152 
shoe workers, 278, 279 
Calomel, iodide of potassium and, 629 
Calories, discussion of, 62 
Camel's hair, anthrax regulations, 667 
Camps, 27, 388 
Camphor, celluloid manufacture, 634 
odor of, 233 
pyrethrum, 209 
Can manufacturing (see also Tin), 
carbon monoxide poisoning, 388 
Canal boats (ferrosilicon poisoning), 319 
Canalmen, death rate, 295 
Canaries, as detectors of carbon monoxide, 
147, 373, 378 
Cancer (see also Tumor), xxiv, 946 
compensation question, 1016, 1060 
industrial relations, anilin, 521 
anthracene, 509 
arsenic, 305 
chimney sweeps, 1016 
coal miners, 152 
cobalt miners, 315 
dry batteries, 350 
farmers, 210 
injury, 6, 948 
lace workers, 266 
X-ray, 174, 959 
medico-legal aspects, 954 
statistics of, 946, 955-957, 984-987 
theories regarding, 947 
race, 957 
tar, etc., 955, 959 
Candlepower, measure of, 39 
Candles, effluvia from factories, 233 
manufacture, 221 
odors from, 235 
test for combustion products, 377 
Candy making, 565 
skin affections, 911 
speed in, 722 
tuberculosis, 752 
Cane bleaching, hydrofluoric acid, 653 
Canning industry, 223 
benzol poisoning, 501, 502 
Canning industry, overtime work, 756 
Cannon, phosphorus bronze, 531 
Cans, old, in malaria breeding, 684 
Caoutchouc, 535, 536 
Caps, as head-gear, 24, 47, 567 
percussion, 548 
protection against sun, 49 
Car seals, lead poisoning, 441, 462 
wheels, zinc ague in casting of 
journals for, 332 
Carbide lamps (see also Calcium, Acety- 
lene), 
coal mines, 151 
Carbolic acid (see also Phenol), 507, 509, 
658 
nephritis, 943 
Carbon bisulphide, xxiii, 360, 648 
afflictions (special), blood, 933 
eye, 875 
industrial relations (various), 
acetylene, 586 
artificial silk, 276 
carbon tetrachloride, 631 
fat extraction, 638 
gas purification, 634 
phosphorus chloride, 630 
sesquisulphide, 660 
rubber, 536, 541, 542 
vulcanizing, 542 
legislation, xviii, 545, 1011, 1016, 
1032 
statistics, 361 
dioxide, 12, 29, 375 
altitude relations, 815, 817 
compressed-air illness, 793, 795 
fatigue substance, 740 
industries (special), 648 
explosives, 562 
felt hat, xlvii 
fermentation, 225 
fertilizer, 632 
mining, 147, 376 
silo (filling), 212 
soda, 599 
subways, 243 
welding, 640 
wine, 192 
lead-solvent properties of, 412 
privy pits and sewers, 233 
treatment of carbon monoxide 
poisoning, 402 
disulphide, (see Carbon bisulphide). 
dust, dry battery manufacture, 350 
monoxide poisoning, xxiv, 369, 649 1128 
INDEX 
Carbon monoxide poisoning, acute, 370 
animals, 378, 393 
blood, 381, 396, 931 
coma due to, 395 
diagnosis, 365, 396, 594 
heart, 397, 936 
nervous system, 398 
pathology, 390 
prodromata, 394 
prognosis, 397, 399 
psychoses, 397 
sequelae, 397 
symptoms, 393,396 (late), 649 
toxicity, 373, 377 
treatment, 399,411 (ref. under 
Henderson et al) 
chronic, 405 
acclimation, 405, 407 
diagnosis, 408. 409 
pathology, 406 
symptoms, 407 
industries (special) and other 
sources, 382-390, 649 
acetylene gas, 640 
automobiles, 244, 498 
balloonists, 824, 825 
battleships, 293 
brass foundries, 345 
brewing, 225 
celluloid, 633 
coal-tar, 508 
compressed-air work, 795 
explosives, 562 
felt hat, xlvii 
firemen, 296, 388 
garment, 283 
iron and steel, 176, 636 
kilns, 163 
mines, 147, 148, 150 
painted surfaces, 417, 465 
phosgene, 630 
phosphorus, 632 
printing, 250, 455 
soda, 630 
soldering, 603, 638 
sulphur dioxide, 520 
tenement work, 282 
textiles, 259 
tobacco smoke, 67 
welding, 640 
tests for, 147, 373 
oxychloride (see also Phosgene), 
659 
tetrachloride, 365, 575 
Carbon tetrachloride, cement, 508 
fire extinguishers, 388 
hair wash, 576 
hookworm treatment, 157 
manufacture of, 631 
rubber industry, 536, 632 
substitute, for benzene, 506 
for benzine, 542 
for carbon bisulphide, 361, 366 
Carbonated waters, 226 
Carbonic acid (see Carbon dioxide). 
Carbonite (explosive), 551 
Carbonizing (of shoddy), arsenic poison- 
ing, 269 
Carbonyl chloride (see also Phosgene), 
518 
nickel (see also Nickel carbonyl), 593 
Carborundum dust and fibrosis, 723 
Carboxyhemoglobin, 371, 379, 931 
Carbuncles (see also Furunculosis), 
butchers, etc., 921 
rubber workers, 537, 539 
Carbureted hydrogen, air of mines, 148 
artificial silk manufacture, 633 
blood poison, 931 
"Carcass" (projectile), 555 
Carcinoma (see Cancer). 
Cardboard workers, 271 
Cardiac disorders (see also Heart), 751, 
935 
Cardol, skin affections, 920 
Carelessness, fatigue factor in, and 
accidents, 749 
Carlisle, life expectation tables (cited), 
710 
Carpenters (and joiners), 702 
neurasthenia, 750 
rheumatic fever, 937 
tuberculosis rates, 726 
" Carpenters' stoop," 203 
Carpet cleaning, 506 
Carpets, dust and respiratory diseases, 
722 
manufacture, 263 
tuberculosis, 265 
Carpoglyphus passularum, dermatitis, 224 
Carotting process, furrier industry, 489, 
627, 637 
Carriage makers, 206 
Carter process, white lead, 444 
Cartridges, mercury poisoning, 488 
phosphor-bronze, 531 
suffocative types, 556 
wads and felt for, 559 INDEX 
1129 
Case hardening, {see also Tempering), 
186, 190 
records, 115, 131 
Cash benefits, childbirth, 1042 
Cashiers, morbidity, 298 
Cash-registers, 194 
Casters (of brass, etc.), 184, 353 
regulations for (British), 357, 358 
tuberculosis decreased, 733 
Castor bean, toxic properties, 570 
Casual labor, employment of, where 
poisons a hazard, 89, 460 
Cataract, chromo-lithographers, 254 
electric discharges, 840, 874 
glassworkers', 172, 883-889 
compensation for, 1016 
Catarrh, alcohol (denatured), 912 
arsenic, 646, 897 
chlorine, 846 
chrome, 850 
cordage, etc., 1035 
dusts, 845, 704 
pyridine, 660 
sulphur dioxide, 661 
Catatonia and neuroses, 772, 779 
Catch-basins, on plans and charts, 36 
Caterpillar hairs (eye injuries), 211 
Cattle, lead poisoning, about smelters, 
414 
Cattlemen, anthrax risks, 668 
tubercular warts, 923 
Caustic soda, etc., coal tar industry, 512 
dye industry, 520 
manufacture, 598 
oil folliculitis, 696 
Cavalry troops {see also Soldiers), fungi, 
in ears, 893 
pneumonia, 680, 728 
Cellon, (tetrachlorethane), 576 
Cellulitis, compensation, 1017 
miners, 153 
ursol, 517 
Celluloid, 273, 275, 610, 633 
accumulator factories, 637 
amyl acetate, 644 
benzol, 500 
collodion, 549 
Cellulose acetate, artificial silk, 276 
compensation list, 1016 
guncotton, 631 
nitrate, airplane dope, 577 
sulphite, wood pulp, 271 
Cement for building purposes, basic slag, 
237 
Cement, health statistics, 168, 169 
manganese, 589 
respiratory diseases decreased, 734 
skin irritation, 912 
upper air passages, 844 
Cements (resinous, rubber, wax), 539, 
542, 638 
benzol, 508 
carbon bisulphide, 361 
turpentine, 662 
Ceramic industry, dust, 166 
manganese, 589 
Cereal mills, explosive hazards, 565 
Cerebral hemorrhages, carbon monoxide 
poisoning, 391, 398 
compensation, 1056 
lead poisoning, 424 
plumbism, 425 
Cerebrospinal fluid, carbon monoxide 
poisoning, 381 
Cerium, 597 
iron, 599 
Certificates, medical, xiv, 1041 
Certifying surgeons, xiv 
Cerussite, (lead carbonate ore), 414 
Cestodes {see also Tapeworms), 694 
Chair factories, 207 
blind persons, 875 
hydrofluoric acid, 653 
Chalicosis, 18, 703 
Champagne factories, carbon dioxide, 224 
Champaign, Ills., altitude (comparison), 
816 
Chance-Claus method of sulphur recov- 
ery, 600 
Chandelier makers, lead poisoning, 347, 
348 
Charbon, (anthrax), 663 
Charcoal braziers, carbon monoxide 
poisoning, 370 
burners, 208 
Charity, nursing service not such, 139 
Charges for medical services, 1055, 1056 
Chart, drainage systems, 36 
industrial health complaints, 1068 
personal health data, 1070 
Chauffeurs {see also Automobilists, 
Garages), carbon monoxide poi- 
soning, 390 
gasoline poisoning, 244 
tuberculosis and alcoholism, 728 
Cheek, distension, glass-blowers, etc., 72, 
290 
Cheese factories, 222 1130 
INDEX 
Chemical workers, xvii, xxi, xxii, 569 
afflictions (various), cancer, 955 
ears, 897 
heart, 936 
skin, 914 
arseniureted hydrogen, 307 
explosives, 563 
impurities in atmosphere, suggest- 
ed standards, 29 
warfare gases, 555 
Chert, (flint beds), 334 
Chest deformities, boot and shoe indus- 
try, 278 
Chestnut wood, skin affections, 917 
Cheynes-Stokes respiration, aviators, 
815 
blood poisons, 931 
carbon monoxide poisoning, 396 
high altitudes, 818 
nephritis, 944 
sulphureted hydrogen poisoning, 
365 
Chicago painters, lead poisoning, 439 
Chicken lice, farmers, 211 
Chiggers, field workers, 10, (211), (224) 
Child birth, absence-leave during, (75), 
1034 
health insurance, 1042 
legislation, xvi, xxxvi 
protection, 1041 
labor and children (see also Minors, 
Women), ix, x, xxv, 75, 1020 
health supervision necessary, 104 
industries (special), canning, 224 
coal mines, xxviii 
lead processes, 109, 426 
phosphorus matches, 528 
tenements, 91, 282 
legislation regarding, xi, xii, xviii, 
xxx-xxxviii, xli-xlii, 1020, 1025 
number employed, 76 
physical defects, 42 
Children's Bureau, (U. S.), creation of, 
xxix 
Chills and chilliness, benzine poisoning, 
497 
carbon monoxide poisoning, 395 
combustion products, 376 
malaria, 683 
zinc ague, 333 
Chimney sweeps, cancer, 954, 955 
child labor, xi 
compensation Act, 1016 
legislation, xii 
Chimney sweeps, skin affections, 507, 662, 
961 
China (seeaZso Earthenware), lead poison- 
ing, 418 
legislation (English), 1007 
women medically examined, 1041 
Chinese, diarrhoea, 693 
ear affections, 892 
hookworm infection, 212 
legislation regarding, xxvii, xxix 
"Chinon" (anilin dye mixture), 514 
Chinon diamin, 517 
"Chipping," eye injuries, 857, 864 
Chloride, lime, 630, 650 
nitrogen, 575 
Chlorides of toluene, 556 
in water, and lead corrosion, 412 
Chlorine, afflictions (special), "acne," 
574, 630, 650 
anemia, 934 
respiratory, 846 
skin, 914, 915 
coal-tar color industry, 512 
dye industry, 520 
mixed poisons, 631-638 
Weldon stills (arsenic hazard), 310 
Chloro-acetone, as lachrymator, 556 
Chloro-acetophenone, in suppression of 
riots, 557, 558 
Chloro-benzene, 517 
Chloro-dinitrobenzol, 650 
Chloroform, 575, 631 
Chloro-nitrobenzol, 650 
Chlorophyll, carbon monoxide fixed by, 
373 
Chloro-picrin, as war gas, 557 
Chlorosis, commercial pursuits (females), 
298 
hotel keepers, etc., 231 
overwork, 76 
tobacco workers, 229 
Chloro-sulphuric water, for lead intoxi- 
cation, 106 
Chocolate-colored blood (see also Met- 
hemoglobinemia), chlorobenzene 
poisoning, 510, 517 
Chocolate workers, skin affections, 217, 
911 
Choke-damp (see also Mine gases), xxi 
"Chokes," in compressed-air illness, 799, 
800 
Cholera infection, rag industry, 269 
tobacco workers, 228 
washerwomen, 286 INDEX 
1131 
Choleraic symptoms, acute arsenic poison- 
ing, 646 
ferrosilicon poisoning, 319 
Chorea, and writers' cramp, 773, 779 
Christian civilization, 92, 93 
Christmas "rush" season, 756 
Chrome and Chromium (see also Bichro- 
mates), xxii, xxiii, 588, 651, 847 
industrial exposures (various), card- 
board manufacture, 271 
dyeing, 636 
glass, 172 
gloves and mittens, 677 
matches, 526 
metal etching, 255 
photography, 255 
porcelain, 638 
tanning, 637, 675, 676 
laws regarding, 461, 1010, 1016 
skin affections, 914 
Chronic diseases, increase in, 80 
Chrysanthemum, insect powder from, 
209 
Chrysarobin-like substance in "taga- 
yasa" wood, 203 
Chrysoidin, (dye), 645 
Church, breach between wage-earners 
and, 93 
Chyluria, in filariasis, 691 
Cigar makers, xlvii, 227 
cramps, 782 
fatigue, 752 
tuberculosis, 722 
Cigar-box makers, 208 
Cigarettes, manufacture, 227 
smoking, effects of, 68 
Cinders, carbon monoxide poisoning, 
389 
Cinnabar, source of mercury, 481, 535, 
636, 651, 654 
Circulatory system, 51, 930, 935 
old age and, 987 
Clague electrical treatment, lead poison- 
ing, 431 
Classifications, 117, 991 
"Clay lungs," 163 
Clay products industry, 163-175 
Cleanliness, standards of, xxxiii, 23 
Clergymen, mortality rates, 288, 986 
throat affections, 289 
"Clergymen's sore-throat," 72, 289 
Clerks (mercantile), anilin dye irritants, 
914 
diseases of, 298 
Clinics, industrial or occupational 
disease, xx, xlvi-xlviii, 98, 438 
Milan, 101-112 
Clocks, manufacture of, 199 
Closets, number of, suggested, 34 
Cloth manufacture, historical, viii 
Clothing industry, 46, 47 
dusty processes, xxi, 24, 567 
dyes (arsenic), 915 
explosive hazards, 565 
legislation, xii, xvii, xviii, xxvi, xxix, 
1007 
non-inflammable materials, 46 
speed in manufacturing, 751 
Clover dust, farmers, 210 
Cloves, oil of, toxic odor from, 233 
Club organizations for industrial better- 
ment, 90 
Coachmen, skin affections, 912 
Coal dust, influence of, on lungs, 151, 
702, 716, 723, 1075 
gas, carbon monoxide in, 382, 649 
composition, 386 
heavers, 245, 297 
cancer, 955 
mining (see also Mining), 35, 145,150 
anthracosis, 701, 716 
carbon monoxide, 397 
explosives, 146, 554 
legislation, historical, xxviii 
statistics, 145 
tuberculosis, 152, 724 
Coal-oil, skin affections, 918 
Coal-tar, colors, 501, 512, 847 
dyes, 267, 501, 514 
chrome, 847 
phosphorus, 526 
products (495), 500,' 504, 506, 507 
cancer, 954 
Cobalt, arsenic poisoning in decorating 
pottery, 165, 315 
cancer of lungs, 954, 955 
Cobblers' torticollis, 750 
Cocabola-wood, toxic skin effects, 203, 
917 
"Coca-cola topers," nervous diseases, 67 
Cochin China diarrhea, 693 
Cochineal, 646 
Coconut oil, 235 
Cocus and Cokuswood, skin affections, 
204, 917 
Code, industrial, North German Union, 
xviii 
Codes of lighting, state, 38 1132 
INDEX 
Cod liver oil, vitamin in, 57 
Coffee, concentrated food, 60 
laborers, round worm infection, 
693 
mental stimulant, 54 
"Coffee topers," 67 
Coffin-handles, lead poisoning, 441 
Coke ovens and stoves, 634 
ammonia, 643 
arsenic, 312 
carbon monoxide, 394 
shower baths, 35 
tar, 662 
Cold (see also Ice), effects of, 14, 16 
accidents, 180 
baths, 45 
cancer, 952, 954 
charted as a hazard, 1069 
clothing, protective, 46 
"dead fingers," 158 
ears, 890 
kidneys, 104 
rheumatism, 937 
skin, 912 
winds, 46 
in various callings, air hammer, 158 
compressed-air illness, 793, 795 
cordage workers, women, 1034 
garages, 390 
high altitude, 820 
storage warehouses, 226, 565 
"Cold dinner pail," evils of, 66, 93 
"Colds," cause of disease, 66 
combustion products and, 376 
heat-exposed workers, 16 
wet work, 1034 
Colic, due to poisoning, antimony, 645 
carbon bisulphide, 648 
lead, 422, 653 
nitroglycerine, 656 
zinc smelting, 337 
Colica pictonum, and pictorum, 412 
"Colics, summer," zinc smelting, 337 
Colles' fracture, chauffeurs, 244 
Colliers (see also Coalminers), 701 
Collodion cotton (pyroxyline), 549 
Coilodium, in artificial silk, 276 
Cologne glue, 236 
Colorado Springs, effects of altitude, 816 
"Color blowing," source of lead poison- 
ing, 447 
Colored slaves, historical legislation, xiii 
Coma, due to poisoning, anilin, 644 
benzine, 497, 
Coma, due to poisoning, carbon mon- 
oxide, 395 
nephritis, 944, 945 
tetrachlorethane, 576 
Comb-makers, 275 
Combustion products, detection of, 377 
gas and fuel, 376 
gasoline, 243 
lamps and lights, 26 
soldering, 463 
spontaneous, historical legislation, xv 
Comedo(-nes), (see also Acne), 915, 918 
Commercial pursuits, morbidity, 298 
Commission on carbon monoxide as- 
phyxia, final report (ref.), 411 
Commissions, first American, xxxvii 
Common law defenses, xxxi 
Communicable diseases (see also the 
various infectious diseases), pre- 
vention, 123 
recurrences, historical, x 
reporting by nurse, 139 
study of, xliii 
Community, aid, industrial physicians 
and, 124 
conditions, 124 
nurse, responsible to, 141 
Comparative occupation statistics, 970 
Compensation, accidents, xxxv, 97, 1030, 
1042 
eye injuries, 865, 881, 887 
glassworkers' cataract, 887 
hazards (various), 1015-1017 
industrial poisoning, 5 
laws, xviii, xxix, xxx, xxxi, xxxv, 
xxxvi, xl, 97, 881, 1013, 1042 
method of, 1013 
miners' phthisis, xxviii, 335 
neuroses, 784 
tumors, 954 
U. S. employes, xxix, xxx, 1044-1066 
Compositors, death rates, 247 
dust inhalations, 249 
hazards, 611 
nystagmus, 873 
tuberculosis, 455 
Compressed-air illness (see also Caissons), 
xxiv, 790-813 
carbon dioxide, 376 
compensation, 1016 
legislation, xl, 1009 
miners, etc., 153 
Concentrates, in diet, 59 
Concussion, effects on the ear, 893, 898 INDEX 
1133 
Conduction, in ventilation, 14 
Conductors, street railway, 242 
Confectioners (see also Candy), 216 
skin affections, 911 
Conjunctivitis, 861, 868 
aviators, 820 
basic slag workers, 237 
phosphorus sesquisulphide, 660 
printers, 255 
sulphureted hydrogen, 661 
Conservation of disabled workers, 84, 85, 
97, 124 
Constipation, abnormal postures, 69 
compressed-air illness, 795 
lead poisoning, 422 
sedentary occupations, 50 
Construction camps, 27 
carbon monoxide poisoning, 388 
Consumption (see also Tuberculosis), 986 
brush makers, 678 
employment question, 1010 
hospitals, 89 
housing conditions, 92 
postures, 69 
smoking, 67 
Continuation schools, 1023 
Convalescents' homes (German), 88 
Convulsions, due to poisoning, anilin, 644 
arsenic, 646 
benzol, 647 
carbon dioxide, 648 
monoxide, 396, 649, 932 
. cyanogen, 651, 932 
dimethyl sulphate, 652 
lead, 424, 653 
mercury, 474 
nephritis, 944, 945 
nitrobenzol, 655 
oxalic acid, 658 
pyridine, 660 
sulphureted hydrogen, 661 
Cook County Hospital, Chicago, carbon 
monoxide poisoning, autopsies, 
391 
Cooking, improper, 93 
schools, 91 
Cooks, 216 
heat exhaustion, 231 
skin affections, 921, 923 
tapeworms, 694 
Coolie (Cooly) labor, legislation, xxix 
Cooling systems, 38 
Coolness, preferred to draft, 30 
Coopers, 208 
Cooperation nursing work, 133, 137, 
141 
Coordination, health activities, 100 
Copaiba, toxic odor of, 233 
Copper, 321-327 
aceto-arsenite, 303 
industries (special), 324 
recovery, arsenic poisoning, 311, 
312, 317 
reduction, high temperature, 758 
smelting, arsenic nasal perfora- 
tions, 315 
miners, 323, 324 
altitude, 823 
pulmonary disease, 154 
poisoning from (disputed), xxii, 
321, 322 
tuberculosis predisposition, 732 
salts, as insecticides, 303 
smelting, 312, 323, 325 
sulphate, phosphorus and, 629 
wire industry, 192 
wood preservative, 205 
Copper-amalgam (dentists), 485 
"Copper chills," 323 
"Copper colic," 321 
Copper-colored redness, mercury poison- 
ing, 475 
"Coppermans' chest," 321 
Copper-oxychloride, arsenic poisoning, 
646 
Copper-silicate, upper air passages, 
897 
Coppersmiths, 323, 326 
hearing, 898 
polyneuritis, 322 
Cordage and twine, viii, 266 
explosive hazards, 565 
legislation, women and child- 
workers, 1034 
"Cordeaux detonant," fuse for blasting, 
559 
Cordite, 551 
habit, 553 
"Core binders," composition of, 184 
Core makers, 184 
brass foundry work, 343 
regulations, 1032 
tuberculosis, 723 
women workers, 1037 
Cork dust explosions, 216 
Corn, dust from, 215 
Cornishmen, hookworm disease, 324 
Corns, prevention, 50 1134 
INDEX 
Correspondence-study course, industrial 
hygiene, Ohio Health Depart- 
ment, xlviii 
Corrosive sublimate (see also Mercury 
bichloride), 472 
skin, 921 
storage batteries, 488 
wood preservative, 205 
Corrosives, on upper air passages, 844 
Corset stays, to be condemned, 47 
Corundum, xxxiii, 171 
Corvulin (dye), 645 
Coryza (see also "Colds," Upper respira- 
tory, etc.). 
turpentine poisoning, 662 
Cosmetic relations, eye injuries, 856 
Cosmetics, irritants, 905 
lead poisoning, 419 
mercury poisoning, 490 
skin affections, 923 
Cost (see also Charges, Remuneration), 
medical services, 134 
nursing service, 143 
of living, sanitary reforms and, 1000 
Costumes, source of skin infections, 923 
Cotton fields, 830 
mill industry, 257 
anemia, 934 
child-labor legislation, xi, xiii 
diseases, 262, 898 
ear affections, 898 
explosive hazards, 565 
first, in United States, xxv 
skin affections, 917 
spinners, endocarditis, etc., 937 
tuberculosis, 722 
Cotton seed oil mills, explosive haz- 
ards, 565 
Cotton-waste sorting, 845 
Cottonwool, in artificial silk, 276 
Cotton yarn, dyeing, 852 
Coumarine, toxic odor, 233 
"Courbatures" or "bends, " compressed- 
air illness, 790, 799 
Court decisions, on labor legislation, 
1019 
Cow-pox, contracted industrially, 9 
farmers, 211 
milkers, 223 
Coxa vara, in farmers, 210 
Craft neurosis, 763 
Craftsmen, historical, xi 
Crashes, U. S. Army Air Service, 825 
Creches, and women workers, 1034 
Creosote, dry batteries, 350 
ore reduction, 335 
skin affections, 205, 918 
Cresols, tar industry, 634 
Cripple Creek, Col., altitude effects, 816 
Cripples, rehabilitation, 84, 97 (124) 
Crookes' glass for eye protection, 864, 888 
"Crowd poisoning," 11 
Crowding, in modem industry, 751 
Crying, chronic manganese poisoning, 591 
Cryolite, aluminum mfg., 583 
Cubic air-space, for each worker, 12 
standard suggested, 29 
Cumol (benzol homologue), 647 
Curvature of the spine, abnormal pos- 
tures, 70 
young persons, 76 
Cutaneous functions, exercise and, 51 
Cut-glass, rouge and putty powder, 173 
Cutlery industry, 187 
lung diseases, 710 
metallic dust and tuberculosis, 723 
mortality reduced (Solingen), 734 
Cutting oils and compounds (see also 
Folliculitis), 696 
compensation, 1065 
Cyanmethemoglobinemia, 932 
Cyanochlorite, 631 
Cyanogen (compounds), 651 
artificial silk, 633 
blood effects, 932 
brass plasters, 349 
bromide, in fumigation work, 558 
case hardening, 186, 190 
chloride, 575 
dye manufacture, 635, 636 
electroplating, 198 
fertilizer works, 587 
gas purification, 634 
gold extraction, 196, 317, 486, 598 
mercury fulminate manufacture, 631 
photo-engraving, 255 
polishing, 913 
Cyanosis, chronic endocarditis, 939 
due to poisons, anilin, 537, 644 
blood poisons, 931 
carbon monoxide, 395 
cyanogen, 587, 651, 932 
nickel carbonyl, 594 
nitrobenzol, 655 
nitroglycerine, 656 
sulphur dioxide, 520 
trinitrotoluene, 510 
local neuroses, 772, 775 INDEX 
1135 
Cysticerd, afflictions from, 10 
Cystogen, rubber ingredient, 536 
Dairy industry, 222 
Dalmatian insect powder, 209 
Dancers' cramp, 783 
Dancing, as exercise, 52 
Dangerous machinery, legislation, xxxv, 
xxxviii 
trades, xv, xx, 1025 
Danube bridge, compressed-air illness, 791 
Darier's disease, confusion with oil 
folliculitis, 698 
Day-light, intensity of, 41 
"Day-light light" (special lamp-bulb), 41 
Dayton, Ohio, world altitude record, 814 
Deacon process, chlorine manufacture, 
573, 630 
"Dead fingers," due to air-hammer, 158 
Deafness, boiler-makers', 182 
carbon bisulphide poisoning, 364 
compressed-air illness, 801 
copperworkers, 326 
cordage makers, 267 
dusts, 845 
fur and felt hat workers, 492 
miners, 152 
Death, average age at, 997 
Archie Hoxey, aviator, 821 
chief causes, 986 
compensation, 1045 
electric shock, 835, 843 
hair dyes, 1074 
high altitudes, 819 
housing facilities and, 92 
per cent, preventable, 987 
rate, historical, ix 
rates, forms of, 993-999 
result of preventable afflictions, 984 
Decalcomania, 166 
Decompression, in compressed-air illness, 
798-810 
Decorating, clay products, 165 
glass, 173 
white-ware, 445 
Deep sea diving, 791, 806 
Deformities, 52, 76 
De-hairing processes, 676 
Delirium from industrial poisoning, 497 
carbon bisulphide, 363 
dioxide, 648 
monoxide, 398 
Dementia (praecox), carbon monoxide 
poisoning, 398 
Dementia (praecox), lead poisoning, 454 
neuroses, 772 
writers' cramp, 775 
Demography, the future of, 1000 
"De Morbis Artificum Diatriba," Ramaz- 
zini, xxii 
Denatured alcohol (see also Alcohol), 
pyridin, 509 
Dengue, extermination of, 683 
Dental attention, 123 
caries, 337, 536 
Dentists, 288 
mercury poisoning, 485 
scotomata, 873 
skin affections, 921 
Deoxygenated air, 233, 376 
Depilatory, red orpiment as, 304 
Dermatitis (see also Eczema, Folliculitis, 
Skin). 
compensation for, 1016, 1065 
cutting mixtures, 1065 
dust and liquids, 1016 
dyes, 516, 522 
high altitude, 820 
mercury, 475 
naphthalene, 506 
oil and cutting compounds, 696, 
1065 
printers, 252 
rubber workers, 536 
shells, workmen on, 916 
trinitrotoluene, 511 
venenata, 905 
X-ray, 960 
zinc workers, 337. 338 
Dermatoses, 252, 907, 909 
Designs, stamping, 442 
Detective, nurse not such, 137, 139 
Detonation (see also Ears, Hearing), 
celluloid industry, 633 
Detonators, 548, 559 
Diabetes insipidus, from injury, 6 
mellitus, acetone poisoning (resembl- 
ing), 637 
compensation, 1058 
engineers, 750 
eye affection, 861 
fatigue, 744 
painters, 468 
strain, 6, 750 
Diagnosis (special emphasis), 119, 627 
Diamines, 644 
Diamond cutters, 200 
Diarrhea, Cochin China, 693 1136 
INDEX 
Diarrhea, summer, in mining camps, 151 
Diatheses, in occupational neuroses, 
764, 770 
Diazomethane, 652 
Dichlorethane, substitute for benzine, 
542 
Dichlormethane, rubber industry, 632 
Dichloro-ethyl sulphide ("mustard gas"), 
557 
Diet, (see Food). 
Diethylanilin, 516 
Digestive diseases, arranged by occupa- 
tions, 725-730 
functions, exercise effects, 51, 104 
hard work, 104 
miners, 154 
skin effects, 909 
Dimethylanilin, 516 
Dimethyl sulphate, 518, 574, 631, 652 
Dining cars, heat exhaustion, cooks, etc., 
231 
Dinitrobenzene (-benzol), (DNB), 513, 
515, 632, 652 
Dinitro-chlorobenzene, 518 
Dinitrophenol, 509 
anilin dyestuffs, 645 
compensation act, 1016 
Dinitro products, 513 
Diphenylamine, 644 
Diphenylamine-chlorarsine, in riots, 558 
Diphenylchloro-arsine, "sneezing gas," 
557 
Diphtheria, old mattresses, 680 
rag industry, 269 
Diplopia, aviators, 822 
carbon monoxide poisoning, 398 
methyl compounds, 655 
Disability, compensation acts, 1018 
glassworkers' cataract, 887 
time loss 607 
U. S. employes, 1045 
Disinfection station, for anthrax, 674 
Disorder of workplace (charted), 1068 
Dispensary (see also Clinics), 125, 126 
hookworm disease, 690 
Dissipation, and "Monday" accidents, 
749 
Distilled water, lead-solvent properties, 
412 
Distillers, carbon dioxide asphyxia, 212, 
224 
Divers, carbon dioxide hazard, 376 
middle-ear disorders, 895 
"Divers' palsy," 790 
Diving, bells, 790 
deep water, 807 
dress, 1010 
helmet, 790 
DNB, (see Dinitrobenzol). 
Dock workers, 1012 
Dog fanciers, skin affections, 921 
Dogs, vagrant, carbon monoxide for 
killing, 378 
Domestic mishaps, carbon monoxide, 369 
service, 231 
child labor, 1024 
females, 1028, 1029 
mortality rates, 985 
Dopes, airplane, 576, 1016 
Draft, in ventilation standards, 30 
Boards, physical defectives found by, 
42 
Drafting and draughtmen, nystagmus, 
873 
proper lighting, 38 
Drainage systems, malarial regions, 684 
suggested standards for, 36 
Dramatic clubs, industrial betterment, 90 
Draymen, 244 
Dressing rooms (see also Clothing), 24, 
1007, 1010, 1034 
unit for dispensary, 126 
Dressmakers, 283, 913 
Driers (Dryers), 418, 579 
Drills, machine, and rock dust, 708 
Drinking fountains, standards for, 35 
water, dusty occupations, 25 
lead poisoning, 412, 430, 1074 
legislation, xviii 
postal railway cars, xxix 
standards for, 31 
Drivers, morbidity, 298, 912 
Dross refiners, 331. 
Drowning, resuscitation, 843 
statistics, 82 
Drowsiness, benzine poisoning, 496 
carbon monoxide poisoning, 408 
Drugs, coal-tar, 507 
explosives in manufacturing, 565 
mental stimulants, 54 
skin affections, 914 
toluene, 500 
"Drummers' paralysis," 290 
"Drunk," carbon bisulphide poisoning, 
363 
naphtha (see also Benzine, Gasoline), 
496, 677 
Dry batteries, 350 INDEX 
1137 
Dry batteries, manganese, 589 
cleaning, 1, 496, 497, 505 
Dundee Infirmary, pneumonia among 
jute workers, 267 
Dupuytren's contraction, hat workers, 492 
writers' cramp, 774, 779 
Duration of life extended, 79 
Dust counter (Kotze), 1075 
(Palmer), 18, 29 
determination, xlvii, 18, 29, 1068, 
1075 
diseases, alcoholism, 66 
ear, 892, 901 
inhibitory effects, 723 
lungs, 154, 334,701-719, 721-736, 
1075 
occupational, 17 
rheumatic fever, 937 
tuberculosis, see Lungs (above) 
upper air passages, 844 
hazards of (charted), 1068 
historical, xv, xxiii, xxxii, xxxiii, liii 
industrial exposures, animal and 
mixed fiber, 722 
coal, (see Mining below). 
cordage, 1035 
drilling, xvii 
explosive hazards, 563 
lead, 429 
metallic, 723 
mineral, 334, 722 
mining, xxiii, 151, 154, 334 
municipal, 722 
organic, 722 
siliceous, xxiii 
textile, 1010 
tobacco, 728 
vegetable, 722 
infected, 729 
legislation, xv, xvii, xxxii, xxxiv, Iv, 
1009, 1010, 1033 
men, 246 
preventive measures, 21, 35 
standards, 29, 844, 445 
statistics, 20 
tuberculosis, 721-736 
studies, xxiv 
institutions, xxiv, xlvi-xlix 
Milan Clinic, 106 
women, 246 
workers, 1030, 1033, 1035 
Dutch process, white lead manufacture, 
416 
Dwellings, workmen's (German), 88 
Dye manufacturing, viii, 267, 507, 1032 
acridine, 643 
anilin, 645 
arsenic, 646 
arseniureted hydrogen, 307 
phosgene, 558, 630 
tin, 602 
Dyeing (see also Colors, respective indus- 
tries and poisons). 
disabilities, 522, 570 
blood, 931 
skin, 906, 913 
tumors, 955 
industries (special), viii, 267, 613, 
633, 636, 645 
calico, 419 
felt hats, 492, 637 
rubber, 535, 632 
shoes, 513 
soap, 235 
textiles, 564 
poisons (special), 633, 636 
anilin, 514 
arsenic, 566, 646 
benzene, 500, 501 
chrome, 588, 847 
coal-tar products, 507 
explosives, 564, 566 
lead, 419, 442 
nitrobenzene, 513 
tin compounds, 602 
Dynamite, 148, 551, 562, 656 
Dynamometer, use of, in carbon mon- 
oxide poisoning, 409 
lead poisoning, 1073 
Dysentery, 683 
amebic, 685 
lumber camps, 202 
miners, 151 
schistomiasis, 695 
Dyskinesia, 763 
Dysmenorrhcea, industrial problem, 77, 
287 
Dyspepsia, lead poisoning, 430 
nephritis, 944 
postural, 69 
smoking, 68 
Dyspnoea, anemias, 933, 934 
arteriosclerosis, 942 
cardiac overstrain, 935 
cyanogen poisoning, 932 
endocarditis, 939 
miners' phthisis, 709 
nephritis, 944 1138 
INDEX 
Ears, 890 
air compression, 797 
altitude effects, 820 
care of, 48 
dust effects, 845 
Earthenware, 164, 418, 1007, 1040 
East River tunnels, compressed-air illness, 
791, 795 
Eating places, 93, 1040 
Ebonywood, 204, 917, 920 
Economic loss, preventable sickness and 
accidents, 79, 984 
scale, and cancer, 957 
Economy, and industrial betterment, 94 
Eczema (see also Dermatitis, skin afflic- 
tions and the various industries 
and poisons), 905 
ears, 891, 892 
poisons (special), benzine, 498 
chrome, 254, 588, 847 
matches, 526 
tanning, 676 
paraffin, 498 
pyridine, 660 
ursol, 516 
workers (special), dust-exposed, 21 
flax, 264 
garment, 282 
lithographers, 254 
matches, 526, 848 
printers, 252 
standing occupations, 70 
tanners, 676, 847 
tinning, 603, 637 
Education, xx, xxxii, xli, 987, 1003 
Educational courses in industrial hygiene, 
xlvi, xlviii, 112 
Efficiency engineering, and fatigue, 758 
and hookworm infection, 690 
industrial hygiene basis of (ref.), xlv 
Effluvia, sewers, stables, etc., 233 
Egyptian workers, xi, 694 
Elbow-joint afflictions, 187, 1017 
Electric apparatus, accumulators (see 
also Accumulator, Storage), 
308, 452, 651 
lead poisoning, 419, 459 
legislation (Europe), 1007 
women workers excluded, 1031 
cables, 441 
furnaces, 346 
lamps, 26, 38 
machinery, 349 
meters, 485 
Electric shock, 831 
linemen (see also Electricians), 
300 
mines, 146, 151 
resuscitation, 841 
treatment, 838 
welding, 342, 840 
Electrica ophthalmia (see also Electricity), 
151, 177, 840 
Electricians, 300 
eyes, 840 
lead exposure, 441 
mercury exposure, 485 
Electricity, accident statistics, 146, 216, 
831 
explosions, 214, 216 
eye injuries, 26, 38, 146, 151, 300, 
840 
hazard, (charted), 1069 
injuries from, 831 
static, 214, 216 
therapeutics, lead poisoning, 431, 
1074 
occupational neuroses, 771, 777, 
779 
Electrodes, mercury poisoning, 487 
Electrolytic processes, arseniureted hy- 
drogen poisoning, 317 
chlorine, 630 
copper recovery, 317, 324 
lead water-pipes, 413 
Electroplating (see also Cyanogen, Nickel, 
Skin), 198 
carbon monoxide, 388 
cyanogen, 651 
eyes, 873 
Electrotyping, 248, 249, 251 
carbon monoxide, 388 
lead, 454 
skin affections, 913 
Elephantiasis, in filariasis, 691 
Elevator employes, 301 
Emaciation, poisoning by: arsenic, 646 
carbon bisulphide, 648 
mercury, 475 
vanadium, 604 
Emboli, gas, in compressed-air illness, 
796 
malarial, 683 
Emerald green, 303 
Emergency, nurse may act in, 138 
Emery, (dust), xxxiii, 171, 723 
Emotion, in occupational neuroses, 770 
Emphysema, brass founders, 342 INDEX 
1139 
Emphysema, caisson workers, 800 
garment workers, 283 
glassblowers, 172, 173 
lung overstrain, 72 
musicians, 290 
Employers' liability laws, xxxi, xxxvii, 
89, 1014 
Employers, number, United States, 987 
unprincipled, 757 
Employes, industrial betterment, 94 
mutual benefit associations, xl 
new, and accident rates, 749 
number, United States, 987 
representation, 134 
selection, 114 
Employment (see also various indus- 
tries), irregular, garment work- 
ers, 283 
Enameling, 613, 638 
explosions, 565 
hydrochloric acid, 652 
leather, 565 
metal plating, 419 
pottery ware, 450 
regulations, 1005, 1007, 1041 
sanitary ware, liii, 449 
skin effects, 924 
Encephalitis, carbon monoxide poisoning, 
391, 394 
gasoline poisoning, 498 
Encephalitis lethargica, carbon monoxide 
poisoning, simulating, 394 
Encephalopathy, lead poisoning, 416 
424, 653 
" Endemic index," malaria, 684 
Endocarditis, 937, 938 
Endo crinal system, 60 
Engineers, locomotive, diabetes, 750 
hearing, 240, 901 
sciatica, 239 
stationary, 297 
English (see also British), anthrax regula- 
tions, 667 
machine shops, 75 
statistics, cancer, 955 
drinkers, 66 
Engraving, 247, 254 
lighting for, 38 
nystagmus, 873 
tuberculosis, 723 
Eosin (dye), 520 
Eosinophilia, antimony, 584, 934 
carbon monoxide, 406, 407 
Epidemics, in industry, x, xlii 
Epileptiform seizures, lead poisoning, 
454, 653 
Epinephrin, on fatigued muscles, 742 
Epistaxis (see Nose-bleed). 
Epithelioma (see also Cancer), 959, 1016 
Epizootic "foot and mouth" disease, 922 
Erethismus mercuralis, 472 
Ergograph (muscle fatigue recorder), 
742 
"Erholung," convalescence places (Ger- 
many), 105 
Ersatz fatigue theory, of Edinger, 783 
Erysipelas, carbon monoxide poisoning, 
simulating, 395 
lard making, 222 
old mattresses, 680 
Erysipeloid, in various workers, 923 
Erythema multiforme, simulated by 
pediculoides eruption, 10 
Essential oils, toxic odors, 233 
pyrethrum, 209 
soap, 235 
Esther(s), inhalation of, 233 
Etching, arsenic poisoning, 646 
glass, hydrophoric acid, 575, 653 
metal, 255 
Ethane, 148, 372 
Ether(s), artificial silk, 633 
investigation of, xlvii 
methyl, 652 
oil, linoxyn manufacturer, 581 
rubber industry, 542 
smokeless powder, 550 
Ethics, nursing, 136 
Ethyl bromo-acetate, suffocating cartrid- 
ges, 556 
chloride, artificial silk, 633 
chloroform manufacture, 631 
mercaptan, stench, in gas leaks, 400 
violet, (dye), 645 
Ethylaldehyde, 643 
Ethyldichloro-arsine, 557 
Europe (see also component countries), 
legislation, lead poisoning, 1004 
Examinations, physical, child labor, 
1022, 1023 
workers, 119 
Exanthema, mercury poisoning, 475 
Excelsior, 680 
Exercise, benefits of, 50 
Exhaust fumes, gasoline engines, 335, 
389 
ventilation, brass crucibles, 346, 355 
legislation, xxxiv, 1009, 1010 1140 
INDEX 
Exhausted feeling, fatigue toxins, 51 
Exhaustion,and "scientific management," 
758 
Exhibits, safety devices, etc., xliii, li, liv 
Exodus, slave labor, xi 
Experimental hygiene, historical, xxiv 
Explosions, 564-567 
carbon monoxide, 372, 389 
celluloid, 276 
coal mines, 146 
ear effects, 897 
combustion products, 377 
ear disorders, 897 
eye injuries, 856 
felt hats, 491 
flour mills, 216 
legislation (early), xvii 
manufacturing plants, 563 
mines, xvii, 389, 897 
starch, 218 
sugar mills, 219 
threshing operations, 214 
Explosives, legislation on, historical, xxxi, 
xxxv, 1031 
relation to poisons, 546, 562, 613, 
631 
eye affections, 875 
nitro-compounds, 513, 655, 708 
picric acid, 509 
skin affections, 916 
statistics, 546 
toluene, 500, 508 
trinitrotoluene, 510 
types, 546 
accidents, 560 
high, 554 
permissible, 157, 554 
safety, 554 
Eye, affections of, accidental injuries, 855 
examination, 866, 867 
foreign bodies in, 872 
injuries, 869 
conservation, 871- 
diagnosis, 865 
investigations, xxiv 
prognosis, 870 
particular lesions, 859 
strain, 81, 872, 873, 1035 
care and treatment of, 49, 862, 867, 
871 
artificial eyes, 1053 
glasses, xlix, 275, 863, 877 
compensation for injuries, 855, 877, 
880, 1016 
Eye, hazards to, 643 
aldehydes, 643 
altitude, 820 
bacteria, 861, 872 
benzol, 647 
benzyl chloride, 518 
chrome salts, 526 
combustion products, 377 
constitutional and local, 861 
electric short circuits (see also 
Electricity), 152 
food deficiency, 58 
head injuries, 871 
lead, 425 
lighting, 25, 39 
match manufacture, 526 
methyl compounds, 655, 874 
nitrous gases, 657 
petroleum, 504 
poisons, special, 874, 875 
sulphur dioxide, 661 
textiles, 258 
tungsten lamp manufacture, 1035 
ursol, 516 
welding, 840 
legislation regarding, 864 
Fabrics, arsenic poisoning, 304 
Factory, approval of plans for, xxxi 
definition of, xvi 
inspection, xiv, xix, xxx, xxxiv, xxxix 
legislation, xxxii 
progress of, 1890-1920, xxxv 
system, growth of, xxv 
modern, viii 
Factory acts, brass industry (British), 340 
historical, xv, xvi 
Fainting (see also Syncope), high altitude, 
819 
nitroglycerine, 656 
Faradism, occupational neuroses, 769, 
774 
Farcy (and glanders), in man, 8 
"Farcy-buds," horse- and stablemen, 922 
Fanners, 210 
actinomycosis, 923 
anthrax, 668, 673 
mortality, 985, 986 
nitroglycerine-, 553 
skin affections, 922, 924 
wives, miscarriages, 211 
Fatigue, 73, 737-762, 763-789 
absence from work, 747 
accidents, xxiv, 82, 748 INDEX 
1141 
Fatigue, altitude effects, 821 
anemia, 934 
antitoxin, claims for, 742 
aviators, 822 
borderland of illness, 751 
changes in the tissues, 740 
charted, as a hazard, 1069 
compressed-air illness, 793-795 
defined, 737 
diseases and, 744 
historical, xxiii, xlvii, liv 
industrial (special), xxiv, xlix, Ivi, 
745, 750 
lost time and, 747 
miners, 151 
zinc, 335 
"Monday effect," 747 
muscular vs. dexterous operations, 
746 
neuroses, 763, 766 
occupation and, 737 
output and, 745 
"passive," defined, 755 
practice effect upon, 747 
professional men, 750 
recovery from, 742 
scientific management and, 758 
sensation of, 741 
studies, xxi, xlvii, liv 
metabolism, 741 
"substances," 740, 742, 744 
tests, 742 
toxins, 54, 740 
exhausted feeling and, 51 
undue, X-ray exposures, 964 
ventilation relations, 757 
Fat men, compressed-air illness, 795, 797 
oil, in cutting compounds, 696 
Fats, extraction of, 496, 638 
Fatty acids, in cutting compounds, 696 
rendering plants, 234 
volatile, 236 
degeneration, carbon monoxide 
poisoning, 391 
Favus, 11 
farmers, 211 
Feather dust, respiratory catarrh, 704 
workers, 680 
"Featherbeds," when desirable, 55 
Febrile affections (see also Fever), broom 
makers, 678 
diseases, fatigue and, 744 
Federal (see also United States and 
"Author Index"), health 
agencies, 95 
Department of Health, plea for, 88 
Department of Public Welfare, plea 
for, 88 
Fee table, U. S. employes' compensation 
Act, 1055 
Feet, care of, 50 
Felt goods, wool, 262 
hat industry, 613 
carbon dioxide and carbon mon- 
• oxide studies (ref.), xlvii 
dust, 679 
explosive hazards, 566 
mercury poisoning, 490, 654 
workers' hazards, 680 
Female workers (see also Women), 
absenteeism, 544 
benzine poisoning, 539 
benzol poisoning, 647 
cancer rate, 984, 987 
core making, 184 
fish industry, 219 
garment industry, 282 
hours of labor, 75 
lead industries, 425, 1074 
legislation, xii, xxx, xxxiv, xxv, 1027 
mines, xiv 
minors, 1027 
mortality rates, 77, 985 
number employed, 1028 
pottery industry, 166 
Femur, distortion of, farm laborers, 210 
Ferrosilicon, 318, 636 
acetylene manufacture, 640 
blood effects, 931 
in calcium carbide, 586 
iron and steel industry, 182 
phosphorus poisoning, 531 
Fertilizer industry, 213, 233, 614 
acids in, hydrochloric, 652 
hydrofluoric, 653 
sulphuric, 662 
bones, 234 
calcium nitrate, 587 
dust and ear disorders, 898 
explosive hazards, 565 
investigation, Federal, li 
shower baths, 35 
Fettling, eye injuries, 857 
lead poisoning, 448 
pottery industry, 165 
Fever, chill and sweat, malaria, 683 1142 
INDEX 
Fever, remittent, in anaemia, 934 
zinc ague, 333 
Fiberloid, 275 
Fictitious values, in statistics, 992 
Fig-packers, finger infection, xlix 
Figs, dried, dermatitis, 224 
Filariasis, 683, 690 
File cutting, 190 
lead poisoning, 419 
machinery for (Sheffield), 1074 
tuberculosis, 188, 723, 732 
Filite (smokeless powder), 550 
Fillers, paint, manufacture of, 579 
Films, pyroxylin, 549 
non-inflammable, 577 
Finger nails, furriers, 924 
hair cloth workers, 679 
hydrofluoric acid, 653 
Fingers, aluminum guards for, 131 
pottery workers, 166 
radium effects upon, 966 
Finland, prohibition of white phosphorus 
in matches, 529 
Fire damp, mine gases, 148 
departments, 290, 296 
extinguishers, carbon monoxide 
from, 388 
Firearms, 191 
carbon monoxide, 371 
women workers, 1037 
Fire-escapes, legislation, xvi, xxxv, 
xxxviii 
Fire-gilding, mercury poisoning, 476, 
487 
Firemen, carbon monoxide "gassing," 
388 
fatal accident rates, 297 
locomotive, ear affections, 240, 891, 
901 
stationery, 297 
Fire-proof fabrics, tetrachlorethane, 577 
Fires, celluloid industry, 276 
legislation, xxxii, xxxiv 
packing houses, 565 
protective, clothing for, 46 
water supply standards, 32 
threshing operations, 214 
Fireworks, 559 
antimony, 645 
white phosphorus, 531 
First-aid (see also Industrial medical 
service). 
legal requirements, xvii, 
xviii, 1010 
First-aid, nurse in, 138, 143 
Fish dealers, skin affections, 923 
industry, 219 
oil, 234 
Fishermen, 295, 296 
cancer rate, 955 
Fishing, as exercise, 53 
Fitzgerald's law, barometric pressure, 
etc., 815, 816 
"Flat-foot," bakers, 217 
barbers and hair dressers, 232 
compositors, 251 
elevator employes, 302 
flax workers, 264 
laundry workers, 286 
saloon-keepers, etc., 231 
shoe workers, 278 
soldiers, 291 
standing occupations, 70 
street railway employes, 242 
Flavoring extracts, methyl alcohol, 654 
Flax workers, 264, 1035 
minors' legislation, xxvi 
skin affections, 917 
Flaying yards, 233 
Fleas, as occupational affliction, 10 
Flies, disposal of dead animals, 234 
fertilizer plants, 237 
field workers exposed to, 10 
Flint dust and fibrosis, 716, 723 
Flock workers, protein poisoning, 264 
Flogging, legislation, xxix 
Floor plan, water supplies, 33 
walkers, morbidity, 298 
wax, poisons in, 464, 640 
Florists, skin affections, 919 
Flour handlers, pediculoides ventricosis, 
10 
mills (see also Mills), 215 
explosive hazards, 565 
mites, skin affections, 910 
Flowers (see also Artificial), Scheele's 
green as dye, 303 
toxic effects of inhaling, 233 
Flue dust poisoning (lead), 415 
Fluke, liver, in etiology of cancer, 953 
Fluoric acid (see Hydrofluoric acid). 
Fluorine, aluminum manufacture, 583 
Flutists, laryngeal spasm, 290 
"Fly" cotton, 261 
woolen, 283 
Flying particles, eye injuries, 856 
Foamite, fire extinguisher, 388 
Focal infection, 80, 81 INDEX 
1143 
Fodor's test, carbon monoxide, 381 
"Folie du cuir," carbon bisulphide, 361 
Folliculitis'(see also Acne), oil, xlvii, 696- 
700, 918 
spinners, 696, 917 
Food, xx, xxiv, 56-64 
arsenic limitation in, 312 
dangerous trades, 1007 
fatigue and, 753 
laws regarding, 1006, 1007 
lead poisoning, accidental, 413 
poisoning, carbon monoxide poison- 
ing simulating, 408 
products, in relation to toilets, 34 
tuberculosis, 735 
stuffs, industry of, 214-227 
Foot and mouth disease, 8, 223, 922 
baths, value, 50 
presses, in the diseases of women, 
76, 77 
operations per day, 751 
premature births charged to, 198 
wear, value of, 47 
Football, as exercise, 53 
effects on the ear, 891 
Foot-candle, 38-41 
meter, 39-41 
Foremen, management and instruction 
of, 121 
Forestry aviation patrol, 827 
Forges, 186 
fumes and gases, 189 
shower baths for workers, 35 
Formaldehyde, 652 
coal tar industry, 512 
combustion products, 373, 377 
"rubber dermatitis," 537 
Formalin (see also Formaldehyde) ana- 
phylaxis, 915 
skin affections, 921 
Formic acid, "rubber" dermatitis, 537 
Formin, rubber ingredient, 536 
Forrest and McArthur, amalgamation 
process, 485 
Fougasses, high explosives, 554 
Foundry workers, anaemia, 934 
brass industry, 342, 345 
chronic endocarditis, 939 
iron industry, 183 
shower baths, 35 
tuberculosis, 723, 733 
Fracture Commission, U. 8. employes, 
1064 
Fractures, compensation, 1062, 1064 
etiology of tumor, 952 
France, coal miners' accidents rates, 
145 
prohibition of white lead, 1004 
Fraudulent enterprises, poison hazards, 
640 
French house-painters, paralysis, 418 
Fresh air, per hour, per worker, 12 
"Fritted" lead, 165 
lead poisoning from, 419 
Frost-bite, street railway employes, 
242 
Fruit essences, amyl alcohol, 644 
Fruits, dysentery, 686 
round worms, 693 
schistomiasis, 695 
when to be eaten, 49 
Fuchsin (dye), 520 
Fuel gas, vulcanizing, 541 
rubber industry, 536 
oil in twine preservation, 499 
on vessels, legislation, xxix 
Fulminate of mercury, 548, 559, 631 
"Fulminate itch," 547, 549 
Fumes, in occupational diseases, 17, 35 
upper air passages, 844 
Functional reeducation in the incapaci- 
tated, 124 
Funerals, a cause of poverty, 89 
Fungi, arsenic compounds and, 304 
Ceylon tea dust, 230 
cotton fibers, 264 
field workers, 10 
Furfural, tobacco smoke, 68 
Furnace men, eye affections, 873 
tenders, 297 
"Furnace-workers cataract," 172, 886 
Furniture makers, 206, 207 
tuberculosis, 722 
polishers, skin affections, 
505, 912 
Furrier industry, 489-494, 614, 637, 
654, 679 
cancer, 955 
dust, 722, 845 
respiratory diseases, 679, 722 
skin affections, 924 
"Furriers' asthma," 517 
Furs (see also Hides), 304, 915 
preservatives, 304 
dyes, paraphenylendiamine, 516 
Furuncles (-ulosis) (see also Boils, Follic- 
ulitis), 910 1144 
INDEX 
Furuncles (-ulosis) butchers, etc., 921 
cutting compounds, 696-700 
dust exposed workers, 21 
of the ear, 892 
oil workers, xlvii, 696-700 
petroleum workers, 918 
(reference), 929 
Fusees, copper poisoning, 322 
Fusel oil, (see Amyl alcohol). 
Fuses, blasting, 559 
Galena, lead poisoning, 414, 653, 1073 
solubility in gastric juice, 451 
zinc mining, 335 
Galvanic excitability, writers' cramp, 777 
Galvanized plates, oxyacetylene flame on, 
467 
stewing vessels, zinc sulphate poison- 
ing from, 330 
Galvanizing, 192, 337, 615, 637 
arseniureted hydrogen, 307, 311 
zinc ague, 331 
Gangrene, carbon monoxide, 379, 391, 398 
hydrofluoric acid, 575 
phenol, 658 
Ganister, 160 
dust and fibrosis, 704, 705, 723 
legislation, xvii 
Garages, carbon monoxide, 244, 390, 406 
explosive hazards, 565 
gasoline, 244 
wastes disposal, 36 
Gardners, 210 
cancer, 955 
skin affections, 919 
Garlic odor, arseniureted hydrogen, 646 
tellurium, 595 
Garment workers, xlix, 281 
"Garrett," in sandpaper making, 171 
Garters, tight, as harmful, 48 
Gas, artificial, types of, 382 
engines, carbon monoxide poisoning, 
385 
fitters, 463 
illuminating, 386 
industry (see also Gas works), 
poisons, 615, 634 
lights, 26 
mercury poisoning, 485 
mantles, pyroxylin, 549 
masks (see also Masks, Respirators), 
557 
men, carbon monoxide poisoning, 
405 
Gas, natural, composition of, 371, 372 
poisoning (see also Carbon monoxide), 
369 
balloonists, 824 
brassfounders, 344 
explosives, 563 
heating stoves (287), 369, 370, 376 
laundry workers, 286 
linotyping and monotyping, 250 
455 
miners, 152 
motor exhausts, mines, 153 
resuscitation by Schafer method, 
843 
statistics, 82, 385 
steel industry, 385 
zinc smelterers, 337 
producer, 387 
works, 382-387 
ammonia, 643 
arseniureted hydrogen, 307 
cancer death rate, 955, 95 
carbon tetrachloride, 365 
cyanogen compounds, 651 
shower baths for workers, 35 
Gases, chemical warfare, 555-558 
phosgene in, 518 
ear effects, 896 
explosive, 563 
investigations, xxiv 
legislation, xxxiv 
organic, 233-236 
respiratory effects, 846 
washing facilities, 35 
Gasoline (see also Benzine), 495, 498, 647 
chauffeurs,244 
chronic poisoning, 499, 506 
heart palpitation, 936 
motor fumes in mines, 335 
skin affections (printers), 913 
rubber industry, 536 
wastes disposal, 36 
"Gassing," (see Carbon monoxide poison- 
ing). 
Gastric catarrh, garment workers, 282 
ulcer, iodine poisoning, 574 
vulcanizers, 542 
lead colic, confusion with, 423 
pottery workers, 166 
Gelatine, dietetic, 236 
dynamite, 551 
Gelignite, in blasting, 551, 554 
Genesis, slave labor, xi 
Genitals, filariasis, 691 INDEX 
1145 
Geographical locations, as health hazards 
97 
German,( see "Author Index"). 
industrial insurance system, 6, 88, 89 
silver, 324, 341, 593 
statistics, accidents and fatigue, 82 
anthrax 8, 
clay products, 163, 166, 170 
commercial and mercantile pur- 
suits, 298 
dye industry, 521 
glass-blowers, 173 
military bands, 173 
miners, tunnel workers and quarry- 
men, 150 
mining accidents, 145, 150 
railway employes, 239 
Germany, "Erholung" or convalencence 
places, 105 
industrial legislation, xviii 
regulations, tobacco factories, 229 
Gilchrist-Thomas, method of steel manu- 
facture, 236 
Gilding, benzol, 500 
copper, 326 
leaf metal, 200 
mercury amalgam, xxii 
picture frames, 207 
pyridine, 660 
women workers prohibited, 1036 
Gilds, analyses of, 351 
Gin drinking, increase of, in England, 67 
Gingivitis (see also Gums), mercury 
poisoning, 492 
Girls, working, homes for, 93 
Glanders, 8, 922 
absent in coal miners, 151 
compensation, 1017 
disposal of dead animals, 234 
slaughtering industry, 8, 220 
stockmen, 211 v 
Glands, abdominal, and anthrocosis, 715 
Glare, and eye-strain, 873 
electric welding, 840 
Glass industry, 163,172, 615, 884 
arsenic, 646 
cataract, 883, 1016 
chrome compounds, 588, 848 
ear affections, 891, 897 
explosive hazards, 565 
eye injuries, 857, 873 
hydrochloric acid, 652 
Glass industry, hydroflouric acid, 653 
laws, compensation for cataract, 
1016 
against contagious diseases, 
1013 
lead poisoning, cut-glass, 441, 442 
manganese, 589 
shower bath facilities, 35 
skin affections, 924 
tellurium, 595 
tuberculosis, 722, 731, 732, 1013 
uranium, 597 
women workers, 1031, 1035, 1036, 
1040 
Glasses, for eye protection, xlix, 863, 888 
Glass-pearl makers, argyria, 197, 601 
Glazier's caulk, dermatitis, 464 
Glazing, 464 
enamelling, 638 
hydochloric acid, 652 
lead poisoning, 445 
pottery industry, 164, 165 
Glaucoma, 861 
Glovemakers, tuberculosis, 722 
Glucose industry, 218, 565 
Glue industry, 233, 236, 615, 638 
Glycosuria, carbon monoxide poisoning, 
396 
Goat hair, anthrax regulation, 667 
Goats, lead poisoning about smelters, 414 
Gob, in coal mines, 150 
fires, carbon monoxide, 389 
Goggles, eye accidents reduced by, 83 
law regarding, quarrymen, 1010 
Goiter, theories regarding, 60 
Gold industry, viii, 601 
mercury poisoning, xxii, 485 
mining, 196 
hook-worm infection, 156 
respiratory diseases, 154 
silicosis, 703, 706 
tuberculosis, 713, 723, 724 
Golden sulphide, (antimony color), 645 
Gold-leaf workers, 199, 730 
Goldsmiths, xxii, 197 
Golf, as exercise, 53 
Goose-berries, mites from, 211 
Gout, alcoholism, 65 
lead trades, 4, 430 
occupational neuroses, 770 
Government, American system, police 
power under, 95 
Grain industry, 214 
explosive hazards, 565 1146 
INDEX 
Grain industry, skin affections, 924 
tuberculosis, 722 
"Grain itch,' 924 
Granite cutters, dust inhalation, 845 
cramp, 781 
mortality rates, 705 
pulmonary tuberculosis, 159, 1075 
Mill horror, xxxii 
Graphics, 1000 
Graphite-paste, electrotyping, 251 
Grass, mosquito dissemination, 685 
Grease, cancer etiology, 956 
dermatitis, compensation for, 1066 
disposal of, in drainage, 36 
extraction, carbon bisulphide, 361 
folliculitis, 698 
Great Britain (see also British, English 
and "Author Index"), 230 
coal miners' accident rates, 145 
compensation system, 1015 
Greece, historical labor, xi 
"Greek fire," 555, 556 
carbon bisulphide, 360 
Green color, chrome compounds, 651 
Grenades, 555 
phosphorus poisoning, 531 
"Grinders, wet," lung diseases, 189 
Grinding industry, xlviii, 187 
dust inhalation, 845 
ear disorders, 891, 897 
eye injuries, 857, 864 
insurance premiums, 351 
laws regarding, 1009 
lung diseases, 189, 704, 710 
tuberculosis, 723 
"Grocers' itch," 911 
"Ground-itch," stage in hookworm infec- 
tion, 686 
Group insurance, xl 
Guano, artificial manure, 237 
Guilds, mediaeval trades, xi, xxii 
Guinea pigs, carbon monoxide toleration, 
378, 406 
Gum chewing, relation to industrial 
poisoning, 69 
Gums, the, care of, 49 
copperworkers, 323 
mercury poisoning, 492, 654 
phosphorus poisoning, 659 
Gun barrels, Damascenizing, 488 
metal, 348, 353 
Gun-cotton, 549, 554, 631 
Gunners, poor vision in, 293 
Gunny cloth, 266 
Gunpowder, 548 
Gunsmiths, 191 
Gutta-percha, 361, 536 
Gypsum dust, inhibitory effects of, 723 
workers, tuberculosis, 155, 168 
Habits, cancer etiology, 953 
charted, 1068, 1070 
Hackmen, 244 
Haem-, (see Hem-). 
Hair, arsenic excreted in, 313 
care of, 49 
falling out, arsenic poisoning, 646 
green-stained, copperworkers, 323 
Hairdressers, skin affections, 232, 910 
Hair dyes, lead, 419, 1074 
paraphenylendiamine, 516 
Hair industry, 678, 681 
anthrax, 667 
ear disorders, 898 
French laws regarding, 1011 
mercury poisoning, 476 
respiratory catarrh, 704 
Hairpins, manufacture, 275 
Hallucinations, benzine, 647 
benzol, 647 
carbon bisulphide, 363 
carbon monoxide, 394, 408 
lead, 653 
"Hammerman's cramp," 750, 780 
"Hammerman's paralysis," 182 
Hand(s), care of, 50 
cellulitis, compensation, 1017 
contracted tendons, cabinet mak- 
ers, 206 
filariasis, 692 
folliculitis, 696 
infections, compensation, 1065 
walking stick makers, 207 
Hand grenades, explosives in, 555 
Handicapped men, opportunities for, 
rubber industry, 545 
Handicraft production, vii 
Hang nails, treatment of, 50 
Hardening (see also Tempering), magne- 
tos, lead poisoning, 442 
Hard lead, antimony, 583 
Hard-rubber goods, 540 
Hard-solder workers, metal chills, 342 
Hargreave process, soda manufacture, 
571, 598, 600 
Harness makers, 722 
Harvest bug, dermatitis, 10, 211 
mite, 211 INDEX 
1147 
Harvest work, 106 
Hats, (see also Caps), special sun protec- 
tion, 47 
Hatters, 489, 627, 730 
mercurial tremors, 476 
pyridine poisoning, 660 
respiratory diseases, 722 
statistics, 492, 733 
Hay fever, in farmers, 210 
Headache, anemias, 933 
arsenic, 646 
arteriosclerosis, 942 
atmospheric fatigue conditions, 758 
carbon monoxide, 394, 408, 649, 932 
eyestrain, (textile industry), 258 
high altitude, 819, 822 
lead, 423, 653 
nephritis, 944 
nitroglycerine, 552, 656 
pyridine, 660 
sulphureted hydrogen, 661 
Head dress, 47, 567 
Health authorities, cooperation with, 125 
complaints, as ventilation standards, 
30 
data, chart for, 1070 
employes, states legislating upon, 
xxxviii 
fatigue and, 750 
hazards, industrial chart for analyz- 
ing, 1068 
grouped, 606 
inspectors, industrial, xxxiv 
instruction, 122 
insurance, xl, xlv, 1018, 1042 
maintenance, 122 
registers, in places of employment, 
116, 1007, 1013, 1041 
rural, appropriation for, by Con- 
gress, 99 
service in industry, 1, 98, 114 
facilities for, 122 
status of workers, as ventilation 
standard, 30 
"Health and morals," legislation, xii, 
xxxv 
Hearing (see also Ears), locomotive 
engineers, 240 
telephone operators, 299 
Heart (see also Cardiac), 935-941 
carbon monoxide poisoning, 397 
diseases, boot and shoe workers, 278 
compensation, U. S. Employes, 
1060 
Heart diseases, mortality in certain 
groups, 986 
statistical tables, by occupations, 
725 
functional affections, 935 
irritable, soldiers, 292 
Heat (see also Temperature), 16, 66 
accident rates, 180 
anemia, 933 
cancer, 952, 954 
cataract, 886, 888 
charted, for hazards, 1069 
clothing as protection, 46 
ear effects, 891, 896 
eye diseases, 873 
prostrations, brassfounders, 344 
carbon monoxide poisoning mis- 
taken for, 293, 371 
zinc smelters, 337 
skin effects, sugar workers, 911 
vs. X-ray burns, 959 
stroke, 15 
head protection, 47 
ventilation questions, 14 
women workers, regulations, 1032 
Heat-fatigue toxins, copper miners, 324 
polyneuritis, 322 
Heating appliances, combustion products, 
376 
legislation, xxxi, xxxiv 
standards, 28 
toilet rooms, 34 
"Hecklers," callosities, 265 
dust exposure, 264 
Hecklers' hemp fever, 266 
Helmets (see also Masks), tropical heat, 47 
Hematoporphyrinuria, nitrobenzol, 655- 
Hematuria, anilin, 520 
arseniureted hydrogen, 308 
Hemeralopia, charcoal burners, 208 
Hemiplegia, carbon monoxide, 398 
hephaestic palsy, 780 
writers' cramp, 778 
Hemoglobin, acetylene combination, 641 
altitude effects, 816 
carbon monoxide, 373, 401, 406 
hookworm infection, 690 
Hemoglobinemia, 362, 930 
Hemoglobinuria, arseniureted hydrogen,. 
308 
floor wax, 640 
shoe polish, 640 
Hemoptysis, ether-oil, linoxyn making,. 
581 1148 
INDEX 
Hemoptysis, fur and felt hatters, 492 
Hemorrhages, benzol, 500, 501, 508, 647 
uterine, overwork, 76 
Hemorrhoids, abnormal postures, 69 
constipation, 50 
garment workers, 282 
shoe workers, 278 
Hemp fever, 210, 266 
workers, protein poisoning, 264 
Herders, anthrax risks, 668 
Heredity, cancer, 949 
occupational neuroses, 764, 770 
writers' cramp, 774 
Hernia, glassblowers, 173 
compensation, U. S. employes, 1060 
incidence, 43 
laundry workers, 286 
muscular strain, 72 
street railway employes, 242-243, 
Herpes, carbon monoxide, 391 
"Hex," rubber ingredient, 536 
Hexamethylene-diamine, rubber ingre- 
dient, 536 
Hexamethylene-tetramin, rubber ingre- 
dient, 456, 536 
H.-H. inhalator, resuscitation, carbon 
monoxide poisoning, 404 
Hide depots, effluvia, 233 
Hides (see also Furs, Skins), 673, 675, 924 
anthrax, 666, 669 
arsenic, 304, 915 
disinfection, 672 
legislation, xvii, 1012, 1031 
Historical Review of Industrial Hygiene, 
vii-xlviii 
Hoarseness, arsenic, 305 
pyridine, 660 
Hochst dye-works, afflictions, 515, 521 
Hog, host in trichinosis, 692 
Holidays, U. S. employes, xxviii 
Holyoke horror, xxxii 
Home (see also House), hazards, 124 
charted, 1068 
tuberculosis, 734 
unhygienic, fatigue factor, 753 
visiting, industrial nurse, 140 
workers (see also Houseworkers, 
Tenements), hatting trades, 490 
Homes for wage-earners, 43, 91, 93 
Homicide, carbon bisulphide mania, 366 
rare, by natural gas, 371 
Honorarium, the industrial physicians' 
reward, 135 
Hook-worm, 7, 80, 682, 686 
Hook-worm, clay industries, 163 
farmers, 211 
Governmental measures, 1013 
lumber camps, 202 
mining, 149, 150, 156, 432, 336 
"Hoolamite," detector for carbon monox- 
ide, 373 
"Hopcalite," absorbent for carbon 
monoxide, 399 
Hop-pickers' ophthalmia, 211 
Hops, fumigation, 224 
Hormones, occupational neuroses, 766 
Hom industry, 273, 275 
source of artificial manure, 238 
Horsehair, laws regarding, 1012 
Horse-hair cloth factories, 678 
Horses, glanders, 8, 922 
grooming, and pneumonia, 681 
Hospitals, industrial, German insurance 
system, 88 
legislation, xxix 
miners, legislation, xxxvi 
railway, legislation, xxxvi 
U. S. employes, 1050 
Hotel employes, 230, 751 
Hotels, Mills, for workmen, 93 
Hours of labor, 1, 75 
accident rates, 180 
dangerous trades, 1007 
fatigue factor, 755 
legislation, xi, xxviii, xxix, xxxii, 
1007, 1010, 1030 
quarrymen, 1010 
railroads, xxix - 
tables of, in different countries, 753 
U. S. employes, xxx 
women workers, 1030, 1037 
House (see also Home), "haunted," 
chronic carbon monoxide 
poisoning, 408 
"Housemaid's knee," 70, 206 
Houseworkers, skin diseases, 909 
Housing facilities, mortality, 92 
tuberculosis, xxiv 
Hoxey, Archie, aviator, death of, 821 
Humanitarianism vs. physiology, 753 
Humic acid, lead solvent waters, 412 
Humidity, compressed-air illness, 795 
ear canals, fungi, 893 
fatigue factor, 757 
hazards, charted, 1069 
kidney disease, 104 
mines, 151, 156 
regulations, 1010, 1032, 1033 INDEX 
1149 
Humidity, standards, 28 
textile mills, 259, 261, 1010 
ventilation questions, 14, 15 
women workers, 1032, 1033 
Hunters, ear injuries, 892 
Hyacinth bulbs, infested by mites, 211 
Hydra, dermatitis, fishermen, 220 
Hydrocarbons, 495, 504, 512 
Hydrocele, in filariasis, 691 
Hydrochloric acid (see also Chlorine), 
571, 573, 630, 652 
arseniureted hydrogen poisoning, 
308, 310 
respiratory injuries, 845 
soda manufacture, a by-product, 
599, 630 
vapor from sulphur chloride, 660 
Hydrocyanic acid (see also Cyanogen), 651 
autopsy findings, 524 
blood effects, 932 
blow-out shots, 562 
bradycardia, 936 
insecticide, 558 
heart palpitation, 936 
mixed poisons, 631, 632, 636, 637 
Hydrofluoric acid, 575, 653 
aluminium manufacture, 583 
artificial fertilizers, 237, 632 
glass industry, 173, 1036 
phosphorus industry, 632 
rattan factories, 207 
respiratory injuries, 846 
thermometer industry, 484 
Hydrogen gas, arsenical poisoning, 308, 
309, 317, 646 
sulphide (see Sulphureted hydrogen). 
Hydrogen-ion concentration, 817 
Hygrometers, (see also Psychrometer), 
textile mills, 262, 1010 
Hygroscopic dusts, upper air passages, 
330, 844 
Hypochrondriasis, lack of exercise, 53 
Hyposulphurous acid, 630 
Hysteria, carbon bisulphide, 363, 365 
carbon monoxide, 408 
Freudian sense, 765 
lack of exercise, 53 
lead, 424 
railway employes, 239 
vanadium, 604 
zinc ague, 334 
Hystero-neurasthenia, benzine, 499 
brommethyl, 575 
carbon monoxide, 405 
Ice, artificial, 225 
machines, sulphur dioxide, 661 
men, 245 
I cterhemmorrhagic Spirochetosis, Milan 
Clinic, 111 
Icterus (see also Jaundice), phenol poison- 
ing, 658 
Idleness, a hazard among soldiers, 291 
Ignorance, hookworm infection, 690 
Illinois coal miners, nystagmus, 873 
death rates, 152 
Illness, (see Sickness). 
Illuminating gas, 395 
carbon bisulphide poisoning, differ- 
entiated, 365 
monoxide poisoning, 380, 649 
influenza immunity, alleged, 571 
rubber industry, 536 
oil, from petroleum, 496 
Illumination (see also Lighting), xlix, 
26, 38 
charted as a hazard, 1069 
coal mines, 151, 872 
dust estimations, 29 
eye strain, 81, 873 
warships, 293 
Immigrants, 1, 144, 996 
Immunity production, copper poisoning, 
323 
nitroglycerine, 553 
respiratory infections, certain gases, 
570 
Imperial yellow (dye), 645 
Impetigo contagiosa, 921 (929) 
Impurities, as sources of poisoning, 
630-641 
Inactivity, charted as a hazard, 1069 
Incandescent lamp factories, 350, 637, 
1035 
mercury (vacuum pumps), 484, 
490 
osmium, 595 
tungsten filaments, 598 
Incendiary materials, 555, 557 
Index, in statistical procedures, 993 
"Index to Occupations," 1915, U. S. 
Census, 606 
India, coal miners' accident rate, 145 
Indian stride, correction of flat feet, 71 
Indigo, ammonia fumes, 520 
Indol, pathological fatigue substance, 745 
Indoor occupations, 11 
Industrial betterment, 91 
commissions, xxx, xxxi 1150 
INDEX 
Industrial diseases, (see Occupational 
diseases). 
health, administration, 1-27, 970 
child labor, 1020 
compensation, 1043 
complaints, chart for analyzing, 
1068 
Government promotion, 95 
hazards, grouped, 606 
legislation, 1002 
medical aspects, 114 
national program, 96 
nursing, 136 
standards, 28 
welfare, 87 
women wage earners, 1028 
hygiene, educational courses, xlvi, 
xlviii 
Government promotion, 95, 1002 
historical review, vii, xxv 
medals for promoting, xlv 
principles of, Part I, Part V 
recent books, 144 
insurance (see also Health, Insur- 
ance), xl 
medicine, xxiv, Ivi, 114-135 
cost of, 134 
war measure, Iv 
nursing, bibliography, 144 
physiology, 759 
poisons, alcoholism, 65 
alphabetical list of, 642-662 
composite, or mixed, 627-640 
medico-legal standpoint, 5 
protective measures, 6 
reclassification, U. S. Census, 987 
surgery, Ivi, 114-135 
wastes, sewerage for, 37 
"Industrial stimulantism" (see also Alcho- 
lism), 66 
Industries classified, explosive hazards, 
564-567 
mixed poisons, 627-641 
poisons, and other hazards (alpha- 
betically arranged), 606-626 
Infant welfare, and death rates, 996, 997 
Infantilism, industrial occurrence, 104, 
108 
Infectious diseases (see also the various 
infections), xiii, 7, 663-700 
cancer etiology, 947 
charted as a hazard, 1069 
costumes, etc., 923 
fatigue production, 744 
Infectious diseases, mines, 151 
resistance decreased by X-ray 964, 
Influenza (pneumonia), copper poisoning, 
simulating, 324 
historical repetition, x 
loss from, 80 
mining camps, 151 
mixed infectious nature, 639 
rubber workers, 544 
soldiers, 292 
studies of (industrial), xlix 
sulphur compounds, alleged infre- 
quency, 571 
zinc ague, simulating, 332, 333 
Infra-red rays, glassworkers' cataract, 888 
Ingersoll rock drills, 708 
Inhumanity of war gases, questioned, 557 
Injuries, 81, 985 
cancer etiology, 948, 951 
medico-legal aspect, 954 
nurse in relation to, 138 
occupational neuroses, 770 
record forms, 117, 118, 131 
treatment, 123, 130-131 
U. S. Navy, 293 
writers' cramp, 774 
"Injury," interpretation of, 1014, 1046 
"In-knee," standing occupations, 70, 217 
231 
Inks, printers', and dermatoses, 252, 255, 
256 
Innkeepers, cancer death rate, 955 
mortality, 65 
Insanity (see also Dementia, Mania, 
Psychoses), a'coholism, 65 
anilin poisoning, 514 
cigarmakers' cramp, 785 
farmers, 211 
railway employes, 239 
Insect powder makers, 209 
Insecticides, arsenic, 316 
copper salts, 303 
hydrocyanic acid gas, 558 
Insects, in air, standards for, 29 
Insolation, high altitudes, 820 
Insomnia (see also the various poisons, 
etc.), constant jarring, 72 
heavy smokers, 68 
Inspection, employes, 119 
factories, creation of, xxxii 
legislation, xiv, xxxviii 
mines, states requiring, xxxviii 
Institute for sick journeymen, xx 
Institutes for industrial hygiene, xx INDEX 
1151 
Instruction (see also Education), foremen 
and management, 121 
nurse's function, 140 
Instruments, scientific, brass hazards, 349 
mercury poisoning, 485 
Insurance, industrial, xxxvi, 88, 89, 
1013, 1042 
law, cooperative, xxxvii 
premiums restricted, brass 
workers, 351 
Intermittent claudication, occupational 
neuroses, 766 
International protection of labor, xix 
Interstate traffic, Federal powers, 95 
Intestinal canal, anthracosis, 714 
indol, (pathologic fatigue substance), 
745 
round worms, 693 
Inulin, in pyrethrum, 209 
Investigation, factor in preventing occu- 
pational diseases, 1003 
Iodine, 574, 632 
anthrax disinfectant, 672 
goiter theory, 60 
photography, 255, 638 
Iodoform, eye effects, 874, 875 
Iritis, syphilitic, 861 
Iron and steel industry (see also Steel), 
176, 601, 636 
anemia, 934 
arteriosclerosis, 941 
endocarditis, chronic, 938 
eye afflictions, 856, 857 
forging, Roman military, viii 
hours, 1, 754 
lead poisoning, 438 
seasonal temperature effects, 758 
shower baths, 35 
statistics, 183 
structural workers, 187 
carbonyl, 594 
sanitary ware, 192 
sulphate theory, anemia in smelters, 
1074 
Ironing, arsenical poisoning, 312 
carbon monoxide poisoning, 283 
Irritable heart, overexertion, 52 
Ischuria, tar vapor, 507 
Isinglass, 169 
"itch" (see also Scabies), compressed- 
air illness, 799 
ground, hookworm infection, 686 
mites (see also Chiggers, farmers, 
211 
Itching, intense, mercury poisoning, 475 
Ivory, vegetable, 273 
Ivy poison, farmers, 211 
"Jack" (zinc sulphide ore), 328 
Janitors, 129, 231 
Japan, coal miners' accident rates, 145 
"Japan," for lacquering, 349, 579 
Japanese hard wood, dermatitis, 203 
primrose, skin affections, 919 
Japanning, temperature and fatigue, 758 
Jarring processes, 72, 752 
Jaundice, airplane varnish, 576 
arsenical poisoning, 308, 519 
explosives (TNT, etc.), 916 
picric acid, 660 
trinitrotoluene, 511 
Jaw affections, actinomycosis, 922 
gutta-percha workers, 536 
mother-of-pearl workers, 274 
phosphorus workers, 528, 532, 659, 
1003 
Jewellers, 196, 616 
nystagmus, 873 
tuberculosis, 723 
Jews, lessened susceptibility to tuberculo- 
sis, 720 
myopia among, 873 
Job requirements, standards of, 120 
Jollity, carbon bisulphide poisoning, 
363 
Joplin zinc mines, 19, 336 
Journal of Industrial Hygiene, Ivi, 144 
Journals for car wheels, zinc ague, 332 
Junk workers, 331, 351, 441 
"Jurisprudence," heading, Surgeon Gen- 
eral's Library, li 
Jute workers, 264, 266, 917, 934 
Kaffirs, respiratory diseases, 706, 713 
Kangri burns, cancer etiology, 953, 956 
Katabolites, in fatigue, 742, 752 
Katathermometer, studies of, xlviii 
Keepers, life saving service, 296 
Kehl bridge, compressed-air illness, 791 
Keratosis senilis, 952 
Kerosene, 26, 496 
Ketone (see also Acteone), 233 
Kidneys, 930, 943 
hydrogen-ion concentration, 817 
paint spirits, 1073 
standing occupations, 108 
turpentine poisoning, 662 
Kieselguhr, in explosives, 551, 552 1152 
INDEX 
Kilning, 165 
Kinetics, in cancer etiology, 956 
"Kiss of death," weaver shuttles, 
265, 1005 
Kitchen wastes, disposal of, 36 
Knee, chauffeur's, 244 
injuries, compensation, 1061 
Knitting-mill employes, tuberculosis, 
265, 722 
Knives, historical manufacture, viii 
Knock-knee, bakers, 217 
blacksmiths, etc., 187 
saloon-keepers, etc., 231 ' 
standing occupations, 70 
Konometer, Kotze's, 1075 
Korsakow's syndrome, simulated by 
carbon monoxide poisoning, 398 
Kraepelinian writing apparatus, 772, 773 
Labels, hazards from, 271 
Labia, in filariasis, 692 
Labor, bureaus of, states having such, 
xxx viii 
laws, uniform, 5 
legislation, xxvii, xxx, xliv 
organizations, incorporation of, xxviii 
protection, xliii, xl 
international, xix 
shortage, and industrial hygiene, 987 
turnover, 79, 114 
influence on tuberculosis, 730 
Laboratories, safety devices, xliv 
Laboratory workers, anthrax risks, 668 
carbon monoxide poisoning, 405 
dye works, 522 
eye injuries, 857 
formalin anaphylaxis, 915 
Laborers, 93, 231, 245, 298 
skin affections, 912 
Labyrinthitis, mercury mining, 897, 898 
Lace workers, tuberculosis, 265, 733 
Lachrymator, in cartridges, 556 
Lacing, to be condemned, 47 
Lacquering, 349, 1032 
Lacquers, 579, 644 
benzine, 505 
methyl alcohol, 654 
skin affections, 919 
tetrachlorethane, 577 
turpentine oil, 662 
Lactic acid, cyanogen poisoning, 932 
fatigue substance, 740, 742 
spinners' acne, 264, 917 
La grippe (see Influenza). 
Lampblack, rubber ingredient, 538 
scrotal ulcers, 507 
Lamps (see Acetylene, Electric, Incan- 
descent, etc.)., burning low, danger 
of combustion products, 377 
Lancaster, Ohio, tragedy, carbon monox- 
ide poisoning, 378, 408 
Lanolin, oil folliculitis, 699 
skin protective, bichromate poison- 
ing, 851 
Lard manufacture, 221, 222 
oil, cutting compounds, 696 
Larvicides, in malaria, 684 
Larynx, constriction, nitrous gas poi- 
soning, 657 
"Lasin" pencil, for moisture on spec- 
tacles, 888 
Lathe workers, hourly output, 746 
lighting for, 38 
oil folliculitis, 696 
compensation, 1065 
Laughter, forced, manganese poisoning, 
591, 654 
Launches, gasoline, carbon monoxide 
poisoning, 371, 389 
Laundries, arsenical poisoning, 312 
explosive hazards, 566 
fungi in ears, 893 
legislation, historical, xvi, 281, 
284-287 
temperature, and fatigue, 758 
Laundry tubs, sewerage system, 37 
Lavatories, standards, 31, 33 
Law of diminishing returns, in sanitation, 
1000 
violation by workmen, 1008 
Lawyers, cancer death rate, 955 
mortality rates, 986 
Lead absorption, defined, 435 
acetate, in silk "weighting," 265 
carbonate, 414, 416, 420 
chromate (see also Chromium), 852 
"fritted," composition, 165 
poisoning, 412, 419, 433, 440, 458, 
629-638, 653, 1072, 1073 
causes, dust, 250, 419, 429, 466 
hours of work, 414 
time relations, 428, 471 
unwashed hands, 466, 467 
compensation, 1015, 1018, 1047, 
1066 
diagnosis, 429, 433, 439 
differential, brass and copper 
poisoning, 322 INDEX 
1153 
Lead poisoning, diagnosis, differential, 
cancer, etc., 1074 
carbon bisulphide poisoning, 
365 
syphilis, 427 
guide for, 1072 
historical, xxi, xxii, 412, 443 
industrial, usual sources, 413, 440, 
458, 635, 653, 1074 
air-borne, 442 
automobiles, 193, 243, 417, 
453, 458, 459 
brass, 341, 344, 347-349, 
350, 353, 354 
painting, 417, 441, 453, 464 
case reports, 435-438 
potteries, 165, 167, 447 
printing, 249-251, 455 
rubber, 441, 535, 536 
storage batteries, 350, 441, 
442, 452, 458, 459, 637, 
653 
tin can mfg., 462, (603), 
(638) 
zinc industry, 328, 332, 335, 
337, 338 
various sources, industries, alpha- 
betically arranged, 
606-626 
using mixed poisons, 
630-638 
List of poisons, 642-662 
legislation, xxxvi, 460, 468, 1005 
Europe, 1004, 1007 
France, 468 
Germany, 461, 468 
Great Britain, 460, 468 
historical, xvi, xvii, li 
U. S. A. (various States), xxxvi, 
xi 
non-industrial, 412, 419, 436, 458 
drinking water, 412, 413, 1074 
painted surfaces, 465 
tinned meat, 413 
prevention, 35, 449, 460, 468 
filters in water pipes, 413 
magnesium sulphate to lay dust, 
462 
statistics, 4,167, 413, 417,441, 448, 
452, 465 
Great Britain, 458 
United States, 440 
studies of, xlvii, liii, 108-112, 
symptomatology, 420-427, 433- 
439, 1072 
Lead poisoning, various symtomatology, 
abortions, 76, 425, 429, 430, 
1074 
anemia, 934, 1074 
arterioscelrosis, 941, 943 
basophilic red corpuscles, 420, 
434, 439, 934, 1074 
bones, storage in, 469 
cancer, 955 
case reports, 109, 435-438, 441 
colic, 109, 422, 585, 653, 1074 
constipation, 423, 439 
eye effects, 874 
gums, blue line, 421, 434 
headache, 423, 439 
heart effects, 938 
kidney effects, 424, 653, 944 
laboratory tests, list of, 1073 
nervous system, 425, 426, 459, 
653 
physical signs, list of, 1073 
temperature rise in, 415 
tuberculosis, influence on, 727, 
729, 732 
toxicology, 107, 108, 413, 419, 
424, 425, 428, 469 
treatment, 430, 1074 
chloro-sulphuric acid, 106 
phosphoric acid, 469 
women workers (see also Abor- 
tions), 1031, 1036 
polysilicates, 653 
red, manufacture, 443 
substitutes, 418 
sulphate, solubility, 420 
sulphide poisoning, zinc mining, 
335, 414, 451 
Leadless glazes, 165, 167 
Leaf metal workers, 199 
Leather, fancy, anilin dye stuffs, 516, 677 
patent, 677 
refuse, artificial manure, 238 
workers (see also Tanning), 361, 
677, 680 
Leblanc soda process, 571, 598, 630, 661 
Leg(s), chronic ulcer, 912 
dermatitis, 910 
filariasis, 692 
Legal suits (see also Medico-legal). 
X-ray work, 960 
Legislation (see also the various hazards 
and industries), xi, 1002-1019 
anthrax, 672 
child labor, xxvi, xxvii, 1020-1027, 
1034 1154 
INDEX 
Legislation compensation or insurance, 
1013 
England, xi-xviii 
eye injuries, 864 
France, xviii 
heading, Surgeon General's Library, 
li 
Holland, compressed-air illness, 805 
omnibus, tendency against in Europe, 
1006 
women, 1028-1033, 1034 
Leucocytes, altitude effects, 817 
lead poisoning, 421 
Leucocytosis, anaemia, 933 
carbon monoxide, 390, 395, 406, 932 
Leucopenia, antimony, 584, 934 
benzol, 500, 502, 508, 933 
Leukemia, eye effects, 861 
X-ray workers, 175, 964 
zinc ague, differentiation, 333 
"Leukonin," tin substitute, antimony, 584 
Lewisite, as war gas, 557 
Leyner rock drills, 708 
Liability laws, awards under, 1014 
of employers, injuries, legislation 
on, xxxv 
states requiring, xxxviii 
Liberal professions, 288 
tuberculosis infrequent, 725 
Library, safety, creation of, xliv 
Lice, (see Pediculosis) 
Lichen ruber planus, oil folliculitis, 
simulating, 698 
Life Saving Service, occupational risks, 
296 
Lifting, at different ages, 75 
heavy weights, 752 
Lighters, patent, cerium iron, 597 
Lighting (see also Illumination), 25, 34, 38 
cancer, etiology, 952, 954 
eye diseases, 872, 873 
floor space relations, 25 
investigations, xxiv, Iv 
legislation, xxxi, xxxiv, 1007, 1032, 
1033 
codes, state, 38 
Lights, colored, arsenic, 646 
tests for low oxygen conditions, 377 
Ligroine (benzine), 647 
"Lily rash," 919 
Lime, quick, 586 
skin irritation, 645, 912, 914 
Swedish matches, 632 
burning, 168, 636, 898 
Lime dust, inhalation effects, 846 
inhibitory effect on disease, 723 
gas, tanning, 636 
Limestone, comparative dangerousness, 
705 
workers, tuberculosis, 155, 159 
Limewashing, factory walls, legislation, 
xxxi 
Linares, Spain, lead smelting industry, 
414 
Linemen, telephone, 300 
Linen workers, ix, 264, 914, 917 
Linoleum manufacture, li, 580, 617 
acrolein, 643 
explosive hazards, 565 
lead poisoning, 442 
Linotyping, 249, 250, 454 
carbon monoxide risk, 388 
lead poisoning, 249, 419 
Linoxyn, in linoleum industry, 580 
Linseed oil, 579 
federal investigation, historical, li 
Lips, gray, anilin dyers, 268 
musicians, 920 
vesicles (sulphureted hydrogen poi- 
soning), 661 
List of industrial poisons, alphabetical, 
642-662 
composite or mixed, 627-640 
explosive hazards, 563-566 
industries having poisons and 
other hazards, 606-626 
Literature on industrial hygiene, Ameri- 
can, 1 
European, xxi 
Litharge, (fused lead monoxide), 443, 
535 
Litho-etching, chrome poisoning, 847 
Lithographing, 247, 617 
chrome poisoning, 253, 847 
explosive hazards, 565 
mineral dust and tuberculosis, 723 
Lithopone, substitute for lead paint, 338, 
418, 460 
Litho-transfer work, 166, 441, 446, 456 
Liver sensitiveness, arsenical poisoning, 
309, 646 
Liverymen, anthrax statistics, 673 
Lock jaw (see Tetanus). 
Lockers, for workers' clothing, 24, 
1007 
Locks, air, (see Compressed-air illness). 
Locksmiths, neurasthenia, 750 
"Loco': plants, barium poisoning, 585 INDEX 
1155 
Locomotor ataxia, simulating carbon 
bisulphide poisoning, 365 
disturbances, manganese poisoning, 
654 
Lodging houses, for wage-earners, 93 
"Long Day, The," description of workers' 
lives, 93, 284 
"Long wall" mining of zinc, 334 
Longshoremen, anthrax laws, 1012 
Loom, invention, ix, xxv 
Lost time (see also Absenteeism), fatigue, 
747 
Lubricants (see Oil, Petroleum products). 
Lumbago, brassfounders, 344 
clay products industry, 163 
compensation, 1062, 1063 
farm laborers, 210 
miners, 152 
spine ankylosis, simulating, 108 
zinc smelterers, 337 
Lumber industry, Ivii, 202, 725 
"Lumpy jaw" (see Actinomycosis). 
Lunch period, injuries sustained during, 
1047 
iron and steel industry, 754 
rooms, dusty occupations, 25 
laws regarding, 1006, 1007, 1010 
Lungs (see also the various infections, 
poisons, etc.), cancer of, cobalt 
miners, 954, 955 
dust diseases, xlvii, 701, 1075 
Lupus, X-ray cancer in, 962 
erythematosus, oil folliculitis simu- 
lating, 698 
vulgaris, cancer etiology, 953 
Lyddite (explosive), 509, 553, 916 
Lye, as turpentine substitute, 913 
Lymphatic tissues, filarial infection, 691 
fur and felt-hat workers, 492 
sugar workers, 218, 912 
•tuberculosis dissemination, 714 
X-ray workers, 964, 967 
Machinery, accident statistics, 82 
Machinists, 35, 617, 875 
ear disorders, 893, 899, 901 
skin affections, 696-700, 912 
Magnesium chloride, nasal mucous mem- 
branes, 844 
Magnet, use of, eye injuries, 868 
Magnetite, chloracne from, 574 
Magnus, formula, vision defects, 876 
Mahogany, stain, anilin poisoning, 514 
wood, 205 
Mahogany wood, polishing, chrome 
poisoning, 848 
Mail carriers, 299 
Majolica ware, lead poisoning, 447 
Malaria (see also Chills), 682, 683 
compensation, 1046, 1059 
economic loss from, 80 
hookworm infection, simulating, 690 
Males, absenteeism, 544 
Malignant pustule (see also Anthrax), 
663, 668 
Malingering, compensation question, 784 
1064 
eye injuries, 869 
Malt, arsenic in, 312 
Manganese, xlvii, 589, 654 
brass alloys, 341 
chloride, in Weldon steel, 310 
chlorine manufacture, 573, 630 
enamel, 638 
glass industry, 172 
linoxyn, 581 
paint dryers and fillers, 579 
zinc industry, 328, 335, 337 
Manganese-bronze, 342 
Mania, carbon bisulphide, poisoning, 
363, 366 
carbon monoxide poisoning, 398 
nephritis, acute, 944, 945 
Manic depressive insanity, cigarmakers' 
cramp, 782 
lead poisoning, 454 
Manson's theory, filariasis, 691 
Manual training, value of, 90 
Manufacturing, mortality statistics, 985, 
986 
females in, 1028, 1029 
Manure, artificial, 233, 234, 237 
etiology of cancer, 956 
Marble workers, 157 
mortality rates, 702, 705, 722 
"Margarine" erysipelas, 222 
Marine Corps, hazards of, 292 
paint, lithopone in, 338 
service (merchant), xlii, 295 
Maritime traffic, Federal powers over, 95 
Marriage rates, statistical factor, 996 
Married persons, absenteeism among, 
543 
Marsh-Berzelius test, arsenic, 313 
Martin sensory tests, 769, 773, 782 
Mask and canister devices, carbon 
monoxide poisoning, 399 
spray painting, 466 1156 
INDEX 
Masks (see also. Respirators), carbon 
monoxide poisoning, 399 
(British), 382 
Masons, phthisis, 704 
skin affections, 912 
statistics, 170 
Massachusetts (see also "Author Index"), 
labor legislation, historical, xxvi, xl 
Massage, in neuroses, 779 
Massicot (red lead),. 415 
Matches, 526, 531, 659 
chromium poisoning, 651, 848 
historical, xxiii, lii, 526 
legislation, xvii, xxix, 4, 1003, 1004 
Lucifer, 532 
parlor, 527 
safety, 848 
"strike anywhere," 527 
sulphur or card, 527 
Swedish, 632 
test for oxygen deficiency, 377 
Maternal functions, protection, 1029 
Maternity benefits, 1043 
Matheson process, white lead manufac- 
ture, 444 
Mattress workers, 680, 722 
"Mazda" lamps (see also Incandescent), 
41 
McArthur and Forrest amalgamation 
process, 196, 486 
McKinnell's ventilator, 13 
Meals, legislation upon, xv, xviii, xxxii, 
1037, 1041 
Measles, old mattresses, 680 
Meat industry, 220, 668, 692 
tinned, lead poisoning, 413 
Mechanics, neurasthenia, 750 
Medals, safety and health protection, xlv 
Medical practice acts, violation, 129 
services, industrial, 114, 1034, 1065 
benefits, 1050 
certificates, 1008, 1054 
child birth, 1042 
compensation, 1017, 1034-1065, 
1076 
examinations, 114, 1006-1011, 
1041, 1070, 1071 
factory inspections, xvi, liv, 
121, 1068, 1069 
legislation, xiii, xxvi, xxxvi, 461, 
1006-1011, 1015-1019, 1049, 
1076 
records and reports, 115, 123, 
1053 
Medicine chest, xxix, 126-129 
Medico-legal questions, cancer, 952 
carbon monoxide poisoning, 391, 
392, 394 
eye injuries, 866 
industrial poisons, 5 
skin disorders, 906 
Meerschaum, respiratory diseases, 169 
Melancholia (see also many of the chronic 
poisonings), arsenic, 646 
carbon bisulphide, 364 
monoxide, (398), 408 
vanadium, 604 
writers' cramp, 779 
Melanosis, arsenic poisoning, 646, 698 
Meldola dyes, 645 
Melinite (explosive), 509, 553 
Melituria, carbon monoxide, 396 
Memorial on occupational diseases, lii 
Memory, loss of (see also the various 
chronic poisonings), (amnesia), 
benzine poisoning, 497 
carbon monoxide poisoning, 398, 
649 
Meniere's disease, compressed-air illness, 
800, 801 
Meningitis, anthrax, 669 
Menopause, mortality rates after, 77 
Menstrual disorders (see also the various 
chronic poisonings), benzene, 
501 
carbon bisulphide, 364 
cordage workers, etc., 1034 
foot-power machines, 77 
lead, 425 
Mental disorders (see also Brain, Psy- 
choses), arterioscleriosis, 941 
benzine poisoning, 496 
electrical accidents, 833 
farmers, 211 
fatigue, 54, 758 
focal infections, 81 
hookworm infection, 689 
Mental stimulant, interest, the true one, 
54 
tests, 743, 1071 
Mercantile establishments, study of, 
xlvii, 38, 298, 299 
Mercaptan, glue kettles, 638 
tar industry, 634 
Merchant marine, care of seamen, xlii, 
295 
Mercury colors, tanning, 637 
fulminate, 488, 916, 1037 INDEX 
1157 
Mercury nitrate, 490, 491, 627 
sulphide (cinnabar), 481, 535, 536 
poisoning, 471, 481, 654, 897 
anemia, 934 
anilin colors, 633, 914 
barometers, etc., 349 
batteries (dry), 350 
blood effects, 933 
carbon bisulphide poisoning, differ- 
entiated, 365 
chemicals, 488, 574, 631, 636 
compensation, 1015, 1018 
dentists, 288 
ear disorders, 897 
etching of metals, 255 
furriers (hatters), 489, 491, 627, 
680, 730, 731 
gold and silver extraction, 196, 485 
historical, xxii, xxiii 
incandescent lamps, 350 
jewelry, 197 
leather stitching, 279 
legislation, xvi, xl, 1011 
mercury, 481, 897 
mirror platers, etc., 4, 488, 643, 
1036 
percussion caps, 549 
physical apparatus, 349, 484 
putty manufacture, 638 
skin affections, 475, 488, 907, 916 
sword making, 191 
toxicology, 476-478 
Murcury-vapor lights, 26 
Meriere's complex, mercury poisoning, 
897 
Messenger service, 298, 1024 
Metabolism, fatigue, 741 
Metals (see also the various metals), 
583-605 
arsenical poisoning, 316, 646 
ear affections, 897 
explosive hazards, 565 
heart affections, 938 
polishing, oxalic acid, 658 
precious, 196 
respiratory diseases, 723, 733, 845 
skin diseases, xlix, 696, 913 
"Metal shakes," 331 
"Metallic poisoning," zinc mining, 335 
Metalliferous mines, regulation Act, xvi 
Metallochrome powder, lead, 254 
Metanitranilin, (dye), 515 
Meta-phenylendiamine, 516 
Methane, 148, 795, 796 
Methemoglobin, anilin, 644 
dye stuffs, 645 
nitrated benzols, 510, 547, 631, 655 
phenyl hydrazine, 658 
Methemoglobinemia, industrial, 931 
Methyl alcohol (see also Dyes, Paints, 
etc.), 654 
artificial silk, 276 
bronze processes, 351 
carbon monoxide, simulating, 393 
dye industry, 512, 635, 636 
eye effects, 874 
felt hat industry, 491 
incandescent lamps, 350 
leather, patent, industry, 677 
legislation, xl 
mixed poisonings, 631, 633, 635, 
636 
rubber industry, 536, 542 
shellacing, 349 
shoe lasting, 279 
skin effects, 912 
staining (wood), 205, 678 
straw hat making, 582 
varnish solvent, 579 
bromide, 574, 655 
chloride, 575, 631 
iodide, 574, 655 
telluride, "garlic" breath, 596 
violet, (dye), 645 
Methylamidophenol, dermatitis, 255, 
Methylated compounds, 500 
Methyldichloro-arsine, war gas, 557 
Methylene blue, 520 
chloride, 575 
Metol, dermatitis, 255, 914 
Mexican labor, amebic dysentery, 157 
Mica, 169, 271 
Mice, in mines, 151 
Michigan copper strike, 324 
Michler's ketone, phosgene risk, 518 
Microscopes, manufacture, 349 
Midshipmen, non-effective rates, 293 
Midwives, cancer, 987 
Milan Clinic, 101-111, (421), (451) 
Military aviation, 827 
ballooning, arsenical poisoning, 307 
blasting, gun-cotton, 554 
training, 43, 872 
Milk factories, numbers engaged, 222 
Milkmen, skin affections, 924 
"Mill fever," textile workers, 264, 270 
Millers, 214 
actinomycosis, 923 1158 
INDEX 
Millers, cancer death rate, 955 
skin pigmentation, 907 
tuberculosis, 722 
Milliners, 618 
anilin dye irritants, 914 
benzol poisoning, 508 
Milling, iron, etc., 35, 185 
Millstone cutting, 160 
Milzbrand, or anthrax, 663 
Mineral acids, fumes, dye industry, 519 
oil, cutting compounds, 696 
wool, 174 
workers (see also the various metals 
and ores), 722, 845, 913 
"Mineral cotton" (mineral wool), 174 
Minimum wages, remedial legislation, 
xxxii 
Mining (see also Coal, and the various 
metals and ores), xxi, 145, 618 
accidents, 82, 725, 856, (969) 
anemia, 934 
asthma, (see Phthisis, infra'). 
"beat elbow," 153, 1017 
"beat hand," 153 
"beat knee," 153, 1017 
carbon monoxide poisoning, 389 
child labor, xviii, 1024 
compensation, xxxvii, 335,1017, 1018 
dust, 149, 151, 154, 701, 708, 896 
ear disorders, 894 
explosions, 149, 390, 894 
eye injuries (see also Nystagmus, 
infra), 856 
gases, 146 
heart affections, 935, 939 
historical, xviii, xxi, xxii, xxiv, xxx, 
Ivii 
collieries Act, xiv 
hookworm infection, 152, 156, 690 
legislation, xiv, xxx, xxxvi-xxxviii, 
xli, 708, 1031 
nystagmus, 152, 155, 750, 872, 1017 
phthisis, xxi, xxii, 152, 154, 334, 335, 
701 
trichiuria infection, 693 
women workers, 1028, 1029, 1031 
Ministers, protestant, longevity, 288 
Minium (red lead), 415, 637 
Minors (see also Child), legislation, xxvi, 
1008, 1024, 1025 
Mirbane oil (see also Nitrobenzol, 512, 
655 
"Mire fever," 213 
Mirror plating, 488, 1036 
Mirror plating, ammonia poisoning, 643 
argyria, 197, 601 
mercurialism, 4 
Miscarriages (see also Abortions), carbon 
bisulphide poisoning, 364 
farmers' wives, 211 
lead poisoning (q.v.) 
overwork, 76 
printing industry, 251 
tobacco workers, 239 
Mites, dermatitis, 10, 211, 224 
Mitten industry, 677 
Mixed industrial poisons, 627-641 
Moa-wood poisoning, 204 
Modern Medicine (periodical), Ivi 
Mogiphonia, (voice neurosis), 764 
Moisture (see also Humidity), precipita- 
tion, as sign of combustion 
products, 377 
Molasses workers, skin affections, 218, 
911, 912 
Mold makers, foundries, 184 
Molders (see Foundry workers). 
Molybdenum, 597 
Mond metal, 593 
Monde gas, carbon monoxide, 382, 387 
Monogramic method, statistics, 991 
Monoplegia, in hephaestic palsy, 780 
Monotony, cause of fatigue, 73, 750 
mental depressant, 54 
Monotyping, 248-250, 455 
Morals, legislation on, xi, xii, xxxv 
Morbidity, reporting, 97 
statistics, tables, 972-984 
iron and steel plant, 183 
pottery workers, lead poisoning, 
167 
Morbus maculosus, benzol poisoning, 
resembling, 647 
Mordants, in dyeing, 636 
Mortality statistics, tables, 724-732. 
971-986 
Mosquitoes, filariasis, 691 
malaria, 683, 684 
occupational afflictions and, 10 
Moss green, arsenical poisoning, 646 
Motherhood training, death rates, 997 
Mother-of-pearl, dust, 274, 898 
Mothers, dependent children, xxxii 
pensions, legislation, xxxv 
Moths, dermatitis, 10 
Motions, useless, elimination of, 758 
Motor riding, exercise, 53 
Motorboats, carbon monoxide, 378, 399 INDEX 
1159 
Motorcycles, 194 
Motormen, street railway, 242 
Motors, petroleum poisoning, 505 
testing of, exhaust fumes, 194 
Moulding makers (lumber), 207 
Moulds, arsenic compounds, 304 
workers exposed to, 10, 11 
Mountain sickness, analogous to carbon 
monoxide poisoning, 405 
diminished atmosphere, 823 
Mouth breathing, caused by dusts, 845 
care, 48 
copper-colored, mercury poisoning, 
475 
forbidding use of, on shuttles, 1005 
occupational affections, 844 
ulceration, British compensation Act, 
1016 
Moving pictures, explosive hazards, 565 
metol skin irritation, 914 
Mower mite, farmers' dermatitis, 10, 211 
Mucor corymbifer, cotton sizing, 11 
Multiple sclerosis, carbon monoxide 
poisoning, 391, 409 
manganese poisoning, 590 
writers' cramp, 773, 778 
Munich brewers, causes of death, 225 
Museums, safety, etc., xx, xliv, 110 
Music, influence on fatigue, 742 
Musical clubs, industrial betterment, 90 
instruments, lead poisoning, 349 
Musicians, 288, 290, 920 
Musivgold, bronzing, 602 
Mussels, dust from shells, 21 
"Mustard gas," warfare, 557 
Myasthenia gravis, fatigue and, 745 
Mycosis, ear, in weavers, etc., 893 
Myelitis, chronic compressed-air illness, 
797, 801, 803 
Myositis, occupational neuroses, 766 
Myotonia, occupational neuroses, 766 
Nail cutters, consumption, 188 
Nails (see also Finger-nails), care of, 50 
falling out, arsenic poisoning, 646 
fur-workers, 924 
Naphtha (see also Benzine, Gasoline), 
495, 497 
"drunks," 677 
heart palpitation, 936 
"jag," 496 
waste, disposal, 36 
Naphthalene (-lin, -line), 507, 508, 644 
dye industry, 520 
Napthalene, eye effects, 874 
tar industry, 634 
Narcissus, skin affections, 919 
Nasal affections, (see Nose). 
Nasopharynx, relation to middle ear, 893, 
896 
Nassau Zinc Works, model plant, 337 
National Committee on Child Labor, 
incorporation of, xxvii, xxix 
National Vitality, report on, 79 
Nation's Health, The (periodical), Ivi 
Nature's food products, 59 
Nausea, atmospheric pressure changes, 
895 
"offensive trades," 233 
Naval shops, 294 
Navy, 292, 894 
Necator americanus, in Europe, 107 
Neck, covering for, 47 
Necropsies (see Autopsies). 
Needle polishers, consumption, 187 
Negro, cancer of skin rare, 957 
oil folliculitis rare, 698 
tuberculosis susceptibility (in- 
creased), 720 
Nematodes, (parasitic worms), 360, 686, 
693 
Nephritis, acute, 943 
chronic interstitial, 942, 944 
Nervous system, alcoholism, 65 
altitude, 818 
anemia, 933 
compressed-air illness, 797 
exercise and, 51 
fatigue, 739, 744 
focal infection, 81 
food deficiency, 58 
poisoning, amyl acetate, 644 
anilin, 644 
arsenic, 646 
benzol, 647 
brommethyl, 575 
carbon bisulphide, 648 
monoxide, 396 
dyestuffs, 645 
manganese, 589 
nitrobenzol, 655 
Nets, manufacture, 266 
Nettles, skin affections, 919 
Neuralgia, clay products industry, 163 
miners and quarrymen, 155 
occupational neuroses, 768,770 
posture abnormalities, 70 
Neurasthenia, 750, 765, 770 1160 
INDEX 
Neurasthenia, fatigue factor, 744 
garment workers, 283 
jarring processes, etc., 72 
laborers, etc., 74 
mental effort, prolonged, 54 
overwork, 76, 750 
proofreaders, 251 
railway employes, 239, 242 
simulated by poisonings, 
e.g., carbon bisulphide, 365 
monoxide, 397, 405 
rubber "cold cures," 542 
zinc, 334 
Neuritis, alcoholic, 65 
arsenical, 305 
as basis of neuroses, 770, 772 
carbon bisulphide, 364 
monoxide 397, 398 
granite cutters' cramp, 782 
rubber workers (ocular), 543 
tobacco workers, 229 
writers' cramp, 778 
Neuroses (occupational), 52, 763-789 
cardiac overstrain, 935 
fatigue, localized, 750 
foot and leg, 242, 290, 783 
gastro-intestinal, from jarring, 72 
manual, 779 
telegraphers, 300 
tobacco workers, 68 
traumatic, compensation, 1063 
varieties, 769 
writers' cramp, 774 
Neuwied green (arsenical color), 646 
New Jersey, decrease in tuberculosis, 
certain trades, 733 
Newcastle-upon-Tyne, flue dust poison- 
ing (lead), 415 
lead water-pipes, Roman camps, 412 
Newspaper plants, hazards, 455 
Nickel, 324, 593 
brass alloys, 341 
carbonyl, 593, 1016 
cyanide, in plating, 594 
miners, malignant lung disease, 955 
plating (see also Electroplating), 
594, 1037 
Nickelsteel, armor plates, 593 
Nicotine poisoning, chronic, 68 
in tobacco dust, 228, 728 
"Niellosilver," 198 
Night blindness, zinc smelterers, 337 
work, accidents, 180 
bakeries, 218 
Night work, child labor, 75, xiii 
fatigue relations, 73, 745, 754 
legislation, xiii, xxviii 
not unwholesome, 44 
objections to, 55 
women workers, 1038 
writers' cramp, 774 
Nightmen, health, 246 
Nigrosin, chlorine gas in, 520 
Nile workers, schistomiasis, 694 
Nitraniline, 655 
Nitrated benzols, 631 
Nitrates, in water, lead corrosion, 412 
Nitric acid, 572, 630 
fur hats, 489 
mirror plating, 488 
respiratory tract, 846 
Nitric oxide, compressed-air illness (etiol- 
ogy), 795 
Nitrites, smokeless powder, 632 
Nitrobenzene (-benzol), xxiii, 233, 510, 
512, 655 
anilin color manufacture, 304 
blood effects, 421, 931 
shoe polish and washing powder, 640 
smokeless powder, 632 
soap manufacture, 235 
stench, in gas leaks (233), 400 
Nitrocellulose, 633, 656 
Nitrochlorobenzene, 510, 514, 518 
Nitro-compounds, 461, 513, 522, 547, 
1015 
Nitrogen, factor in compressed-air illness, 
749 
oxides, air of mines, 148 
tetroxide, 630 
Nitroglycerine, 148, 149, 551, 559,''631, 
656 
Nitronaphthalene, 514, 656 
Nitrophenols, tachycardia, 936 
Nitroso dyes, 645 
Nitrotoluol, smokeless powder, 632 
Nitrous chloride, manufacture, 631 
gases, 630, 657 
artificial silk, 633 
blood effects, 931 
compensation, 1016 
dye industry, 519 
dynamite manufacture, 552 
explosives, 547, 708 
Noises (excessive), cordage industry, 267 
ear effects, 893 
fatigue effects, 752, 898 
nausea production, 895 INDEX 
1161 
Noises, (subjective), in hearing impair- 
ment, 898 
welfare work should abolish, 896 
Non-ferrous metals, 341 
Non-inflammable clothing, 46 
"No-nitrate method," fur felting, 493 
Normal individual, the theoretical, 1058, 
1061 
Nose affections, 48, 844-854 
ammoniac smoke, 338 
antimony ores, 583 
arsenic, 305, 646, 844, 897 
benzol, 502 
carbon bisulphide, 364 
chrome salts, 526, 588, 651, 844, 849 
compensation, 1016 
copper smelterers, 315 
dinitrobenzine, 516 
dust (ear disorders), 896 
metal grinders, etc., 845 
pearl workers, 274 
quick lime, 586 
salt workers, 226, 575, 844 
trinitrotoluene, 511 
Nurse, industrial, 129, 130, 136-144 
Nurseries, women workers, 1034 
Nurses, 288 
cancer among, 949, 954, 987 
skin affections, 921 
tubercular warts, 923 
Nursing, furnished at childbirth, 1042 
miners, legislation (California), xxxvi 
zinc miners (Joplin district), 336 
Nutmegs, oil of (odor), 233 
Nutrition studies, xxi, xlix 
Nystagmus, carbon monoxide poisoning, 
396 
miners', 150, 151, 155, 872 
compensation, 1017 
sulphureted hydrogen poisoning, 661 
tunnel workers, 150 
Oakum makers, tar itch, 266 
Oats, dust, 210 
mouldy, protein intoxication, 214 
Occupation statistics, comparative, 970- 
987 
Occupational designations, "Index to 
Occupations, ' ' 606 
diseases, 1-27 
clinics, xlvi-xlviii, 101-113 
commissions on (citation), liii. 
commonest (nystagmus), 872 
exhibits, xx, xxxiii, xliv, li, 110 
historical, ix, xxxi, xlv 
Occupational diseases, legislation, xix, 
xxvii, xxxi, xxxvii, 
4, 1002-1019,1043-1066 
schedule, 1014, 1015-1017 
specific, 303 
therapy, for the incapacitated, 124 
Occupations, "underling," 984 
Ocean baths, value, 45 
Odors, "burnt gas," (in detection of 
combustion products), 377 
charted as a hazard, 1069 
drinking water, 31 
fragrant, inhalation, 233 
offensive trades, 233 
standard for, 29 
ventilation testing, 29 
Office employes, morbidity, 298 
work, lighting, 38 
Officials, comparative mortality, 986, 987 
Oidium, fungi, Ceylon tea-dust, 230 
Oil cakes, source of artificial manure, 
238 
furnace fumes, 344 
refinery employes, folliculitis, 361,. 
698 
Oilcloth manufacture, li, 580 
acrolein, 643 
amyl acetate, 644 
arsenic, 646 
explosive hazards, 565 
lead, 442 
Oilers, skin affections, 505, 912 
Oils, afflictions due to, compensation, 
1016, 1066 
skin, xlvii, 505, 696, 912, 917,918, 
959, 1035 
essential, 226, 233 
waste, disposal, 36 
Old Dutch process, white lead manu- 
facture, 444 
Olein, 234, 235, 696 
Oleomargarine, 221 
Olive oil, 235, 696 
Onychia, bakers, 911 
Open-hearth furnaces, 177, 183, 385, 
414 
Ophthalmitis, sympathetic, 861 
Ophthalmologist, and lighting question, 
38 
Oppression in chest, acetylene gas, 660- 
cyanogen, 651 
nitrous gases, 657 
sulphureted hydrogen, 661 
Opsonic index, fatigue, 744 1162 
INDEX 
Optic lenses, manufacture, 349 
neuritis, carbon monoxide, 408 
nitrobenzene, 513 
Orange, bitter, skin affections, 920 
mineral, 443 
Oranges, toxic effects, 233 
Organ making, 206 
Organic matter, decaying, cancer, 956 
Orleans case, lead poisoning, 428 
Orpiment dyes, 267, 304, 676 
Orthopedic appliances, compensation Act, 
1052 
conditions, 72, 778, 1061, 1062 
Osmium, 595 
Osteitis, simulating writers' cramp, 778 
Osteomyelitis, pearl-button workers, 21, 
274 
Ostrich feathers, "ptilosis, " 18 
Othaematoma, boxers and football play- 
ers, 891 
Output, fatigue, 745 
resting periods, 756 757 
Ovens, carbon monoxide poisoning, 388 
Overalls, soiled, oil folliculitis, 696 
Overcrowding, historical industry, x 
legislation, xxxiv, 1032 
Overexertion, 51, 72 
endocarditis, 938 
nephritis, 944 
occupational neuroses, 765, 770, 
774 
research in, Milan Clinic, 106 
"scientific management," 758 
Overseers, mortality, 985 
Overtime work, fatigue effects, 756 
modern industry, 751 
women workers, 1038, 1041 
"O-want" (see Oxygen deprivation). 
Oxalic acid, 658 
copper polishing, 326 
dye works, 267 
photography, 255 
"Oxide pox," zinc workers, 338 
Oxy-acetylene (see also Acetylene, Blow- 
pipes, Welding), 640 
explosive hazards, 565 
lead poisoning, 467, 1073 
Oxybutyric acid, pathological fatigue 
substance, 744 
Oxygen, compressed-air illness, 793 
decompression, 810 
deprivation, 373, 377 
altitude, 815 
carbon monoxide poisoning, 380 
Oxygen, deprivation, sewers, 233 
lead solvent waters, 412 
partial pressure, 814 
percentages producing symptoms, 
375 
standards, 29 
use of, anemia, 933 
carbon monoxide poisoning, 397 
Oystermen, 295, 296 
Ozone, radio operators, 299 
Pacemakers, fatigue, 757 
"Packers' itch," xlix 
Packing industry, 298, 565 
Pail industry, dusts, 208 
Paint, bactericidal properties, 418, 1074 
composition, 464, 505 
emanations, aldehyde substances, 
465 
carbon monoxide gas, 465 
formic acid, 465 
lead particles, 417, 429 • 
manufacturing, 463, 579 
explosive hazards, 565 
federal investigation, li 
prohibitory legislation against 
lead, 1004 
women workers excluded, 1031 
removers, 464 
benzol, 500 
methyl alcohol, 654 
spraying machines, 466 
Painters, lii, 464-469, 619 
anemia, 934 
anilin poisoning, 514 
arsenic poisoning, 646 
arteriosclerosis, 941 
benzene poisoning, 501 
benzine poisoning, 505 
compensation, 1015-1017, 1066 
eye injuries, 856 
inflammable paint hazards, 1 
lead poisoning, 453 
historical, xxii 
statistics, 4, 417 
legislation, 1004, 1007, 1008 
medical supervision (German), 461 
quick dryers, 464, 466, 496, 498 
skin affections, 913 
turpentine oil, 662 
wet sandpapering, 1073 
"Painters' colic," case report, 436 
union, occupational disease clinic, 
113 INDEX 
1163 
Painting of factory walls, legislation, xxxi 
Palladium, 601 
chloride test, for carbon monoxide, 
374, 381 
Palm oil, manufacture, 235 
Palmitin, 234, 235 
Palpitation (cardiac), arteriosclerosis, 942 
carbon monoxide, 395 
exercise and overstrain, 51, 935, 939 
industrial poisons, 936 
Palsies, chronic interstitial nephritis, 944 
Palsy, hephaestic, 780 
"Pancarditis" (rubber workers), 544 
Panics, legislation, xxxii 
Paper flowers (see also Artificial flowers), 
xxxiii, 269, 270-272 
arsenical poisoning, 307 
chlorine gas, 915 
ear affections, 893 
explosive hazards, 565 
legislation, xxvi, 1010 
vegetable fiber dust, 722 
Paper-box workers, 271 
Paperhangers, 170, 464 
arseniureted hydrogen, 317 
tuberculosis (mineral dust), 723 
Papillomata, paraffin workers, 498 
petroleum workers, 918 
tubercular, 923 
Paraffin workers, 496, 498, 504 
cancroid ulcers, 662, 955, (959), 961 
1016 
match manufacture, 526, 527 
skin affections, 658, 698, 918, 919 
Paraffinomina and wax cancer (ref.), 959 
Paralysis agitans, mercury poisoning, 
confusion, 473 
writers' cramp, 773, 778 
compressed-air illness, 797, 801, 803 
file cutters' thumb, 191 
"hammermans'," 182, 186 
high altitudes, 824 
poisons, arsenic, 646 
carbon bisulphide, 648 
monoxide, 394, 398, 649, 932 
dimethyl sulphate, 652 
hair dyes, 1074 
lead, 425-427, 653 
mercury, 474 
nitroglycerine, 656 
sulphureted hydrogen, 661 
writers' cramp, 772, 774 
Para-nitranilin, 515, 644 
Para-nitrochlorbenzol, "tar acne," 915 
Para-nitroso-dimethylanilin, rubber 
ingredient, 536 
Para-phenylendiamine, 516, 536 
Para-toluidin, dye manufacture, 522 
Parasites and occupation, xxiii, 10, 
682-695 
cancer, 948, 953, 954 
Paresis, carbon bisulphide poisoning, 
differentiated, 365 
monoxide poisoning, simulating, 
398 
compensation question, 1058 
pellagra, 108 
writers' cramp, 778 
Paris, carbon monoxide cases, 370, 378 
green, 303, 316, 646 
upper air passages, 844 
Parquetry, "housemaids' knee," 206 
Passageways, lighting, 38 
Passengers, steam railway, accidents, 
241 
Pasteurizing of milk, 223 
Patent leather, 565, 677 
Paternalism, to be avoided (nursing 
service), 138 
Pathologists, cancer infection, 949 
Patio amalgamation process, 485 
Pattern making, lighting, 38 
Pearl industry, xlix, 21, 273, 274, 1037 
glass, argyria, 601 
Peat pits, carbon dioxide, 212 
Peaty soil, lead-solvent waters, 412 
Peddlers, tuberculosis, 298 
Pedicidoides ventricosis, wheat straw, etc., 
10, 924 
Pediculosis (lice), 10, 923 
Pellagra (deficiency disease), 58, 107 
Pelletorin, in pyrethrum, 209 
Pelts (see Furs, Hides, Skins) 
Pemphigoid eruptions, carbon monoxide, 
391 
meat cutters, 921 
paraffin workers, 498 
Pennicillium, Ceylon tea dust, 230 
brevicaule, arsenic compounds and, 
304 
Penis, in filariasis, 692 
Pension funds, xxxi 
Pensioners, German insurance system, 88 
Pentamethylene-diamine, rubber ingre- 
dient, 536 
Pentane, 495 
Peonage, legislation, xxix 
Percussion-caps, mercury poisoning, 631 1164 
INDEX 
Perfumes, 233 
coal-tar, 507 
dimethyl sulphate, 652 
methyl alcohol, 654 
nitro-compounds, 513, 655 
soap manufacture, 235 
toluene, 500 
Permissible explosives, 562 
Pernicious anemia (see Anemia). 
Persian insect powder, 209 
Personal hygiene, 42, 144 
service, 231, 1028, 1029 
Personnel, for industrial medicine, 128 
Persons employed, various occupations, 
971 
Perspiration, green, copperworkers, 323 
Petrol, rubber industry, 536 
Petroleum, 495, 504, 619, 647, 658 
cancer, 955 
skin affections, 918 
turpentine substitute, 913 
"Petroleum itch," 504 
Petrol-naphtha, petroleum industry, 504 
"Petromortis" (motor gas fatality), 
498 
Pharmaceutical compounds, 520 
anilin, 514 
methyl alcohol, 654 
nitro-compounds, 513, 655 
Pharyngitis, chronic, due to dusts, 845 
Phenacetin, and the blood, 931 
Phenol, 509, 658 
ammoniac production, 634 
benzene poisoning, 508] 
oil folliculitis, 696 
smokeless powder, 632 
Phenylendiamines, 516, 517 
furriers, 637 
Phenylene, 644 
Phenylhydrazine, 658, 931 
Phenyl-isocyanide, stench, gas leaks, 
400 
Philanthropy, wage-earners, 91, 108 
"Philosopher's wool ''(zinc oxide fumes), 
330 
Philosophical instruments, mercury 
poisoning, 485 
Phonation, compressed-air illness, 798 
Phorias, in aviators, 822 
Phosgene, 518, 576, 630, 659 
chloroform manufacture, 631 
dye manufacture, 512, 558, 630 
in World War, 556 
Phosphate, animal, prevention of lead 
poisoning, 413 
tri-sodium, cutting compounds, 696 
Phosphine (see also Phosphureted hydro- 
gen), acetylene gas, 640 
calcium chloride manufacture, 634 
ferrosilicon manufacture, 636 
phosphorus industry, 632 
Phosphor-bronze, phosphorous poisoning, 
342, 526, 531 
Phosphoric acid, treatment of lead 
poisoning, 469 
oxide excess, silicosis, 713 
Phosphorism, study, Milan Clinic, 107 
Phosphorus chloride, 575, 630 
pentachloride, 630 
incandescent lamp manufacture, 
637 
poisoning, lii, 526, 531, 617, 659 
acetylene gas, 640, 641 
anemia, 934 
arseniureted hydrogen simulation, 
309 
brass alloys, 341 
compensation, 1015 
copper sulphate, 629 
ferrosilicon manufacture, 636 
historical, xxii, xxiii, lii, 526, 531 
incandescent lamp manufacture, 
350 
legislation, xvi, xvii, xxiii, xxix,?xl, 
4, 1003, 1004 
match manufacture, xxiii, 526, 
531, 659, 660 
statistics, 528, 533 
sugar mills, 219 
treatment, 529, 531, 533 
sesquisulphide, 526, 527, 
532, 660 
varieties of, 350, 526, 527, 532, 659, 
660 
Phosphureted hydrogen, 660 
acetylene gas, 586 
blood effects, 931 
ferrosilicon, 318, 531 
fertilizers (calcium nitrate), 587 
"Phossy jaw,'' 531, 1003 
Photo-engravers, 255, 914 
Photographers, 255, 638 
anemia (Milan Clinic), 110 
argyria, 197, 601 
brom-iodine, gastric ulcer, 574 
chrome poisoning, 588, 651, 847 
skin affections, 913, 914 INDEX 
1165 
Photographers, uranium oxide, 598 
Photographic materials, anilin in manu- 
facture, 514 
Photo-lithography, 253 
Photometer, 39 
Phthisis (see also Dust diseases, Lungs, 
Pneumokoniosis, Tuberculosis), 
brass workers. 354 
compensation, xviii, 335 
Rand miners, 21, 335, 706 
tinsmiths, 638 
Phylloxera, destruction of, carbon bisul- 
phide, 360 
Physical education, value, 43 
examinations, 80, 114 
aviators, 827, 828 
chart for, 1070 
child labor, 1022 
fitness, child labor, 1022 
women, certificates, 1041 
impairments, 42, 607 
Physicians, cancer, 954 
selecting of, 129 
skin affections, 921 
statistics, 288, 702, 986 
tubercular warts, 923 
Physicists, arsenical poisoning, 308 
Physiological standards, ventilation con- 
ditions, 29 
Physiologists, arsenical poisoning, 308 
Piano manufacture, 206 
wires, tempering, lead poisoning, 442 
Pianists' cramp, 290, 780 
"Pickling" (acid dipping), 337 
Picric acid, 509, 553, 645, 660 
dye works, 267, 645 
explosives, 554, 555, 632 
trinitrotoluene, differentiation, 511 
"Picric itch," 510 
Picture frames, leaf metal, 200, 207 
"Piece-meal" habit, miners, 154 
Piecework, and fatigue, 757 
and the shorter work-day, 755 
in modern industry, 751 
Pig-iron loading, Taylor's experiments, 
757, 759 
Pigeon ticks, farmers, 211 
"Pigeoneau," tanners' skin affliction, 
675, 679 
Pigmentation, arsenic, 305, 646 
carbon bisulphide, 362, 364 
of lungs, from intestinal canal, 714 
oil folliculitis, 698 
photographic developing, 256 
Pigmentation, picric acid, 660 
sun exposure, 906 
"tagayasa" wood, 203 
Pike's Peak, altitude effects, 816 
Pilots, 295, 296 
Pine oil, printing industry, 252 
rubber industry, 456 
turpentine substitute, 913 
Pins, celluloid, manufacture, 275 
Pioneer work, Massachusetts State Board 
of Health, xxxiii 
United States, Ivi 
"Pip," anilin poisoning, 644 
Piperidin, rubber ingredient, 536 
Pipestems (horn), 275 
Pitch (see also Asphalt, Tar), dry 
battery manufacture, 350 
mineral, 169 
workers, cancerous ulcerations, 955, 
(959), 1016 
Pityriasis rubra pilaris, folliculitis con- 
fusion with, 698 
Plague, danger of, in mines, 151 
Planing mills, 202 
"Plankers' acid," felt hat industry, 491 
Planters (see also Farmers), 210, 985, 986 
Plants, copper in, 323 
zinc in, 329 
Plaster of Paris, dust, 155, 164, 168 
Plasterers, 170, 723 
Plating industry, 196 
amalgams, 487 
brass castings, 348 
silver (women workers), 1036 
Platinum, 601 
paper, photographers, 255 
Pleurisy, subway employes, 243 
Plumbago, electrotyping, 248, 251, 253, 
913 
Plumbers, 463 
arsenical poisoning, 308 
lead poisoning, 438, 620 
tuberculosis (decreased), 733 
Plumbers' supplies, manufacture, 461 
Plumbing fixtures, toilet rooms, 34 
Plumbism (see Lead poisoning). 
Plumbs, dried, dermatitis, 224 
Pneumatic tools, eye injuries, 864 
fatigue, 752 
lung diseases, 704 
occupational neuroses, 781 
Pneumokoniosis, xxii, xxiv, 204, 701-719, 
1075 
etiology, 707 1166 
INDEX 
Pneumokoniosis, pathology, 711 
prognosis, 710 
symptomatology, 708 
treatment, 717 
Pneumonia (see also Influenza), alcohol- 
ism predisposition, 65 
anthracosis (studies), xlix 
basic slag workers, 236 
carbon monoxide, 391, 395, 397, 402, 
649 
cities vs. rural districts, 377 
compensation, 1046, 1059 
dimethyl sulphate, 574 
epidemics, historical repetition, x 
flour millers, 216 
jute operatives, 267 
miners, 149, 151, 152 
osmium fumes, 595 
overcrowding, 12 
painters, 468 
pneumokoniosis, 713 
rubber workers, 544 
smoke nuisance, 21 
statistics, 80, 725-736, 984 987 
Poisoning (industrial), 2-7 
degree of, 629 
statistics, 984, 985, 987 
symptoms, for various poisons, 643- 
662 
systemic (eyesight), 874 
Poison ivy, 905, 919 
rubber dermatitis, simulating, 536 
sumach, skin affections, 919 
Poisonous by-products and impurities, 
630-641 
Poisons (industrial), xxiv 
absorbtion, 629 
charted as hazards, 1069 
laws regarding, 1006 
list of (alphabetical), 643-662 
industries (alphabetical), 606-626 
mixed, 630-638 
women, exclusion, 1030 
Police departments (health of), 290, 296 
force, tear gas, riots, 558 
power, factory inspection, xxxii 
Federal, 95 
intra-state health, 97 
labor legislation, xxvii, 1018 
"Polishers' itch," wood, 206, 208, 912 
Polishing trades, xlviii, 620 
afflictions (various), anemia, 912 
ear disorders, 891, 897 
lungs (see Pneumokoniosis). 
Polishing afflictions, skin, 206, 208, 912, 
913 
upper air passages, 845 
brass, 347, 353 
chrome compounds (French), 848 
copper, 326 
insurance premiums (brass), 351 
legislation, 1009 
metals, 187, 658, 723, 1031 
methyl alcohol, 654 
oxalic acid, 326, 658 
precious stones, 200, 442 
silver, 913 
stone, 158 
women workers, 1031, 1037 
wood, 205 
Pollen, air-borne, standards, 29 
Polycythemia, carbon monoxide, 380, 406 
Polymyositis, carbon monoxide, 392 
Polyneuritis (see also Neuritis), 391 
mercury, 474 
Pools, a factor in malaria, 684 
"Poor man's diet," 59 
Porcelain ware, liii, 164, 449, 638 
chrome compounds, 848 
historical manufacture, viii 
regulations, 1005 
Pork, tapeworm infestation, 694 
Porters, morbidity, 298 
Portland cement, manufacture, 169 
Porto Rico (see also "Author Index"), 
hookworm prevention work, 80 
Post hoc for propter hoc, in statistics, 993 
Post-mortems (see Autopsies). 
Post-office employes, diseases (German 
statistics), 299 
model labor law needed, 88 
mortality statistics lacking, 299 
railway, legislation, historical, xxix 
U. S. Compensation Act, 1047 
Postures (faulty), fatigue, 753 
historical, xxiii, 69 
tuberculosis, 727 
Potash solutions, brass plating, 349 
Potassium arsenite, tanning, 636 
bichromate, safety matches, 526 
chlorate, safety matches, 526 
cyanide (see also Cyanogen). 
brass plating, 349 
cyanide process, gold and silver 
extraction, 196 
iodide and calomel, mixed poisons, 629 
Pot metal, lead content, 348 
"Potters' asthma," 710 INDEX 
1167 
"Potters' rot," xxii, 710 
Pottery industry, 35, 163, 620 
historical, viii, xxii 
hydrochloric acid, 652 
lead poisoning, xxii, liii, 163, 445, 
620, 653, 1005 
mineral dust and tuberculosis, 722, 
732, 733 
regulations, lead poisoning, 1005 
women workers, 1031 
Poultry dealers, skin affections, 923 
Powder gases, naval warfare, 294 
(gun-powder), 548 
Power consumption, and fatigue, 748 
gas, carbon monoxide in, 382, 387 
"Precancerous" conditions, 950, 965 
Precious metals, industry, 196 
Pre-existing disease, compensation ques- 
tion, 1058 
Pregnancy (see also Abortions, Child- 
birth), goats, about lead smel- 
ters, 414 
lead poisoning, 425, 653 
rest and care during, 76 
varnishers' wives, 107 
Prehistoric industry, vii 
Premature births, carbon bisulphide 
poisoning, 542 
lead poisoning, 653 
overwork, 76 
"Premises," U. S. employes compensa- 
tion Act, 1047 
Premiums, German industrial insurance, 
88 
Preservatives, wood, 205 
Preserving, formaldehyde, 652 
industry, 223 
Pressers (garment), anemia, 283 
carbon monoxide poisoning, 388 
Pressmen (see also Printing), 247, 455, 
514, 723 
Preventable deaths, significance, 984 
sickness, economic loss, 79 
Priests, longevity, 288 
Primary sense impression, ventilation 
test, 29 
Primrose, skin eruptions, 211, 919 
Printers' ink, acrolein, 455 
anilin colors, 255 
Printing trades, xxix, 247, 454, 621 
anilin, 514 
antimony, 584 
benzine skin lesions, 498 
explosive hazards, 565 
Printing trades, lead, 419, 441 
skin affections, 913 
tuberculosis, 723, 1076 
Privy problem, parasitic diseases, 690, 692 
Procain, dermatitis, in dentists, 288 
Producer gas, carbon monoxide in, 382, 
387, 649 
Production, and shorter working hours, 
755 
Professional persons, xxi, 288, 984, 985 
women, 1028, 1029 
Prohibition, child-labor, 1024 
legislative method, 1004 
white lead, 1008 
women workers, 1031 
Projectiles, 531, 555 
Proofreaders, neurasthenia, 251 
Propane, mine air, 148 
Proprietor and professional class, deaths 
984 
Propulsion, manganese poisoning, 591 
Protein intoxication, grain threshers, 214 
oats and clover dust, 210 
rope makers, 266 
textile workers, 264 
zinc fumes, 330 
Protozoa, 683 
air-borne, standards for, 29 
Pruritus, anal, tapeworm infestation, 694 
Prussian blue (dye), 847 
Prussic acid (see Hydrocyanic acid). 
Pseudo-brass poisoning, 341 
Pseudo-tabes, carbon bisulphide poison- 
ing, 364 
Psoriasis, industrial, (929) 
oil folliculitis, simulating, 698 
tar workers, 507, 662 
Psychic shock, telephone operators, 300 
states, aviation, 819, 822 
benzine poisoning, 497 
carbon bisulphide poisoning, 648 
carbon monoxide poisoning, 649 
mercury poisoning, 472, 492, 654 
Psychological aspects of work, 760 
studies, industrial, xlix 
Psychoses, carbon monoxide sequelae, 
391, 649 
occupational neuroses, 772, 779, 783 
Psychrometer, use of, 31, 262, 1010 
Pterygia, aviators, 820 
"Ptilosis" (feather dust affection), 18 
Ptomaine poisoning (see also Food), 
ferrosilicon poisoning, simula- 
ting, 319 1168 
INDEX 
Ptyalism, mercury poisoning, 654 
Public opinion, Federal power and, 95 
service employes, 288 
speakers, throat affections, 289 
Publishing industry, 247 
Puddling (metals), 178, 891 
Pullman ventilator, 13 
Pulmotor, treatment of carbon monoxide 
poisoning, 405 
Pulp mills (see Paper industry). 
Pumps, vacuum, mercury poisoning, 484 
Puna (see Mountain sickness). 
"Purgatorial chamber," in decompres- 
sion, 807 
Purpura, benzene poisoning, 501, 508 
Pus cavities, dental, 49 
Pustules, "foot and mouth" disease, 922 
malignant (anthrax), 663, 668 
oil folliculitis, 696 
paraffin workers, 658 
sugar workers, etc., 911 
Putrescine, rubber ingredient, 536 
"Putrid fever," cotton mills (historical), x 
Putty, 442, 638 
Pyogenic infections, skin, 697, 921 
Pyorrhoea, copperworkers, 323 
lead poisoning, 422 
mercury poisoning, 492 
Pyrethron, 209 
Pyrethrum, 209 
Pyridin, 507, 660 
alcohol, denatured, 912 
ammoniac manufacture, 634 
felt hat industry, 491 
skin affections, 509 
stench, gas leaks, 400 
tar industry, 635 
Pyrites dust, coal mines, 151, 152 
Pyro-collodion powder, 550 
Pyrogallic acid, photography, 255 
Pyrolusite, manganese ore, 654 
Pyrotechnics, arsenic poisoning, 646 
Pyroxylin, 549 
bronze processes, 351 
celluloid manufacture, 275, 634 
Pyvrol, ammoniac manufacture, 634 
Quarries, child age minimums, 1024 
general discussion, 145 
legislation, xvi, xxxvii 
Quarrymen, discussion, 145 
death rate, 702 
eye injuries, 856 
violence rates, 725 
Quartz dust, fibrosis, 716, 723 
Quick-drying paints, 496, 580 
Quicksilver (see also mercury),485, 654 
Quinine, malarial treatment, 684 
poisoning, case of, 570 
skin affections, 907, 910, 920 
Quinon dichlordiamine, skin eruption, 
517 
Rabbit, unusual acclimation to carbon 
monoxide, 379 
Race stocks, and tuberculosis, 720 
"Radiant" gas stoves, carbon .monoxide 
poisoning, 371 
heat, effects of, 16 
Radiation, in ventilation question, 14 
Radio operators, 299 
Radium, 175, 966-969 
cancer etiology, 954-956 
safety movement, 969 
X-ray injuries, 965 
Raftsmen, violence rates, 725 
Rag industry, xxxiii, 269 
anthrax statistics, 673 
laws regarding, 1010 
oil folliculitis, 697, 698 
women workers' limitations, 1032 
Rag-pickers' disease, 663, 668 
Rag rugs, lead poisoning, 264 
"Railroad spine," compensation question, 
239, 1063 
Railroad ties, skin eruptions, 205, 509 
Railway employes, 239 
accident statistics, 82, 725 
ear disorders, 893 
influenza (study), xlix 
legislation, xxix, xxxv, xxxvi, xxxvii 
mail clerks (see also Post-office), 299 
malaria, 684 
Rain, protective clothing, 46 
Rainy weather, lead-solvent waters, 412 
Rand gold mines, 706 
Rat, host in trichinosis, 692 
Rates, statistical procedures, 992 
Ratios, statistical procedures, 992 
Rats, carbon monoxide poisoning, 378 
in mines, 151 
phosgene as destroyer, 558 
Rattan factories, 207 
"Rattlers," cleaning of casting, 347 
"Ray cataract," glassblowers, 172 
Ray fungus (see Actinomycosis). 
Raynaud's disease, and writers' cramp. 
779 INDEX 
1169 
Realgar tanning process, 676 
Reapers, ear affections, 892 
Recess periods (see Resting). 
Reclamation, disabled workers, 84, 97, 
124 
Reclassification of industry, U. S. Census, 
987 
Recompression, in compressed-air ill- 
ness, 811, 812 
Reconstruction Hospital, New York 
City, 85 
Record forms, 115-118, 129, 131 
industrial health hazards, 1068, 1069 
' kept by nurse, 137, 139 
personal health data, 1070, 1071 
Red lead, manufacture, 415, 443, 1073 
ship painting, 454 
Reese-River pan amalgamation process, 
486 
Refrigeration plants (see Cold, Ice). 
Regulation, method of, in legislation, 
1005 
Rehabilitating injured workmen, 85, 97, 
124 
Rejection of the unfit, 114, 119 
Religious views of patients, the nurse 
and, 137 
work, and industrial betterment, 
90 
Remedies, standard, for dispensary, 
127 
Rendering plants, 233, 234 
Reporting, industrial morbidity, 97, 
1053 
Rescue work, mines, legislation, xvii 
Research, industrial physician's duty, 
125 
Resins, in pyrethrum, 209 
Resorcin, 520 
Respiration, artificial (see Resuscitation). 
Respirations, altitude effects, 815, 821 
violent exercise, 50 
Respirators (see also Masks). 
in dust protection, 23, 94, 718 
effectiveness, 846 
English textile regulations, 1010 
laws regarding (anthrax), 1012 
workers' objections to, 94 
Respiratory diseases (see also Lungs, 
Upper air passages). 
statistical tables by occupation 
725-737 
infections, alleged immunity, from 
certain gases, 570 
Rest (see also Resting), "one day's, 
in seven," 754 
when indicated, 53, 54 
Restaurant, employes, 230 
wastes, disposal, 36 
Resting periods, fatigue relations, 756 
scientific management, 759 
women workers, 1040 
Resuscitation, electric shock, also drown- 
ing, etc., 838, 839, 841 
poisonous gases, especially carbon 
monoxide, also drowning, etc., 
382, 401-405 
carbon monoxide poisoning, final 
report on (ref.), 411 
Schafer (prone pressure) method, 
842, 843 
Retail dealers, mortality, 985 
Retirement funds, xxxi 
Retropulsion, manganese poisoning, 591 
Rheumatic fever, and acute endocardi- 
tis, 937 
Rheumatism, alcoholism and suscepti- 
bility to, 65 
clay products industries, 163 
founders (brass), 344 
lead poisoning, 427, 653 
miners and quarrymen, 152, 155 
occupational neuroses, 770 
women workers, 1034 
zinc workers, 336, 337 
Rhinitis (see Upper air passages). 
Rhodanic compounds, 651 
dyeing industry, 636 
gas industry, 634 
Rhythmic exercise and fatigue, 752 
Rice field workers, 211, 919 
mills, explosive hazards, 566 
Rickets, vitamin question, 58 
Rifle barrels, antimoniureted hydrogen, 
584 
Right of entry, historical, xxxii 
Ring worm, 11, 211, 223 
Riots, suppression by tear gas, 558 
Riveters, 187 
Roaches, carbon monoxide and, 147 
Roadways, lighting, 38 
Roasting of ores, 315 
Roburite (explosive), 513, 553 
Rock salt workers, nasal affections, 575 
Rock-drillers, dust hazards, 706, 708 
Rockets, varieties of, 559 
Rockingham ware, lead poisoning, 165, 
446 1170 
INDEX 
Rodents, phosgene as destroyer, 558 
Roentgen rays (see X-ray). 
Rolling mills, 178, 754 
Roof conductors, construction, 36 
water, drainage, 38 
Roofers, 603, 662 
Roofing-paper, tar poisons, 507, 634 
Roman camps, lead water-pipes in, 412 
Rome (ancient), "free workers," xi 
lead water-pipes, 412 
Rbntgen rays (see X-ray). 
"Room comfort," as ventilation test, 30 
Roosevelt, physical health of, 51 
Ropemakers, 266, 722 
Rosewood, Indian, dermatitis, 204 
"Rossignol," tanners' skin affliction, 675 
"Rot" (see Grinders, Potters, etc.). 
"Rouge," skin affections, 913 
Round shoulders, abnormal postures and, 
70 
worms, 692, 693 
Roundhouses, safety devices, 241 
Rowing, as exercise, 52 
Rubber industry, 1, 456, 535-545, 621 
afflictions, 543-545 
anilin poisoning, 514 
antimonial poisoning, 584 
benzine, 497, 508, 535-541, 621, 
632, 647 
benzol used in, 500, 501, 508, 
535-541, 632, 647 
cancer mortality, 955 
carbon bisulphide poisoning, 
xxiii, 361, 364, 536, 541-542, 
632, 648 
explosive hazards, 566 
lead poisoning, 441, 442, 456, 
535-540, 621, 632, 653 
case reports, 436-438 
"rubber itch," 536 
skin, 536-537 
tetrachlorethane, poisoning, 577 
chief processes, 537-543 
automobile tires, 535, 539 
cement manufacture, 542 
vulcanizing, 541-542, 625, 632, 
645 
legislation, xvii, 461, 1011 
women workers, 544, 1037 
plantations (Malay), hookworm 
infection, 212 
"Rubber shoddy," 543 
Rubber substitutes, 543 
Rugs, manufacture, 263 
Rural diseases, in the tropics, 682 
dispensary, hookworm control, 690 
workmen's areas, committee on, Iv 
"Rush" seasons, overtime work, 756 
Russian baths, value, 45 
oil, 496 
of turpentine, 662 
Rye dust, 215 
Sabers, mercurial poisoning, 191 
Sabicu wood, 203 
Saccharin (coal-tar product), 507 
Sacro-iliac joint, compensation question, 
1061-1063 
Safety, 83 
devices, xliii, xxxi, xxxv, xxxviii 
exhibit of (see also Exhibits), 
xliii, xliv 
legislation, xvi-xviii, xxviii-xxxii, 
xxxix 
radium, 969 
workers' objections to, 94 
education, 1025 
explosives, 554 
Institute of America, xliv 
lamps (mines), xv-xvi, 149 
matches, 526, 588 
medals, donors, xlv 
"Safety first" movement, 241 
Safrol, toxic odor, 233 
Saffron yellow, 645 
Sailors (see also Seamen), xxi, 290, 292,295 
malaria, 684 
Salamander gases, 170, 345, 388 
Salary, industrial nurses, 143 
industrial physicians, 135 
Salesmen, traveling, morbidity, 298 
Salicyl-spirit, 264 
Salivation, carbolic acid, 509 
manganese, 590, 654 
mercury, 472, 492 
Saloon employes, 230 
Salt, a concentrated food, 60 
workers, 226, 844 
Saltpeter, 572 
Salts, inorganic, as food, 57 
"Salufer," as a preservative, 224 
"Sampling," statistical procedure, 991 
Sanatoria, in German insurance system, 
88 
Sand-casting, definition, 358 
Sandalwood, 205 
Sandblasting, xlviii, 18, 347 
in glass etching, 173, 1036 INDEX 
1171 
Sandpaper, manufacture, 171 
Sandpapering, dust and tuberculosis, 722 
painting trade, 454, 465, 466 
wet method, 1073 
Sandstone industry, airhammer, 158 
comparative hazards, 705 
dust and fibrosis, 723 
legislation, xvii, 1010 
tuberculosis, 155, 159 
Sanitary provisions, 23-27 
drainage systems, 36 
infant mortality, 996 
legislation, xxx-xl 
standards, 31-38 
reforms, cost of living effects, 1000 
ware, 192, 445, 449 
lead poisoning regulations, 1005 
Sarcoma, bladder, in anilin workers, 521 
compensation question, 1060 
etiology, 952 
liver, tapeworm infection, 953 
X-ray injuries, 963 
Sassafras oil, inhalation of, 233 
Satin walnut, 204 
Satinwood, 203, 907, 917 
Saturnism (see Lead poisoning). 
Sausage makers (see also Butchers, 
Packing), parasitic diseases, 692, 
694 
Saw mills, 202 
Scabiei, in farmers, 211 
Scabies (see also Itch, Mites), 10, 211, 
217, 278, 923, (929) 
"Scald head," 11, 211 
Scarlet fever, old mattresses, 680 
rag industry, 269 
Scavengers, 233, 246 
Schafer method, of resuscitation, 401, 
842, 843 
Schedules, compensation for occupa- 
tional diseases, 1014 
Scheele's green, arsenical dye, 303, 
646, 844 
artificial flowers, 303, 317 
upper air passages, 844 
Schistomiasis, (parasitic disease), 694 
"Schluck-pneumonia," carbon monoxide 
poisoning, 397 
Schneeberg, cancer of lungs, cobalt 
miners, 315 
Schools, enforcement of child labor laws, 
xxxii 
industrial, 90 
promotion of personal hygiene, 43 
Schools, teachers' mortality rates, 289 
Scurvy, prevention and cure, 58 
Scurvy-like afflictions, paint dryers, 418 
Schweinfurt green, arsenical color, 303, 
646 
Sciatica, abnormal postures, 70 
clay products industry, 163 
lead poisoning, 459 
locomotive engineers, 239 
miners, 152 
Scientific management, and fatigue, 758 
Scissors cramp, (neurosis), 780 
Sclavo's serum, anthrax treatment, 671, 
681 
Sclerosis (see Multiple sclerosis). 
Scotch hearths, lead smelting, 414, 452 
"Scotch hone," stone polishing, 158 
Scrap metal, brass alloys, 341 
Screening smokes, warfare, 557 
Screw machine workers, oil folliculitis, 696 
"Screws," compressed-air illness, 790 
Scriveners' palsy, 771 
Scrotum, cancroid ulcers, tar workers, 
507, 662 
compensation, 1016 
Sealing wax, 488, 662 
Seamen (see also Sailors), xlii 
apprentices (historical), xxviii 
cancer, 955 
lead poisoning, 416 
legislation, xxix, xlii 
non-effective rates, 293 
Seamstresses, 283, 750, 751 
Search-lights, eye injuries, 293 
Seats, 70 
legislation, xviii 
for females, xvii, xxx, xxxiv, 
xxxviii, 1027, 1032 
street railway employes, xxxvi 
Sea water, in diet, 60 
skin affections, 220 
Seaweed, artificial manure source, 238 
Securite (explosive), 553 
Sedentary life, effects, 69 
Seins, manufacture, 266 
Selection, employes, 114, 119 
Selenium, 595 
Senile dementia, and writers' cramp, 778 
Senility tremor, mercury poisoning, simu- 
lation, 473 
Sensory tests (see also Martin), writers' 
cramp, 776 
Sepiolite (meerschaum), 169 
Septic infections, industrial types, 9 1172 
INDEX 
Sequoia wood, 203 
Servants, sickness rates, 231, 721 
Service, medical elements of, 125 
Sewage disposal, standards, 36-38 
"Sewer gas," carbon monoxide, 389 
Sewer pipe industry, 163 
Sewers, effluvia, 233 
Sewing (see Seamstresses, Tailors, etc.). 
cramp, 780 
Sewing-machines, 194 
Sextons, 231 
Sex, abuses of, 68, 774 
diseases, 89, 221 
glands, X-ray effects, 964 
occupational neuroses, 770, 774 
powers, carbon bisulphide poisoning, 
364, 648 
Shale dust, comparatively harmless, 716 
oil works, arsenical poisoning, 307 
ulcerations (ref.), 959 
Shaving brushes, anthrax risk, 669, 678 
Sheep dip, arsenical poisoning, 211, 304, 
844 
Sheet-metal worker, lead poisoning, 436 
Shellac, concretions in the stomach, 206 
methyl alcohol, 34, 253, 279, 579, 654 
Shells, explosives for, 554, 555 
mussels, dust, 21 
Shift, eight-hour, etc., fatigue, 745-754 
Shingle stains, 464, 579 
Shingles, preservation, 205, 509 
Ship painting, lead poisoning, 438, 453 
Ships, ferrosilicon poisoning, 319 
Shirt, collar and cuff factories, explosive 
hazards, 566 
"Shoddy fever," 270 
industry, 264, 269, 543 
Shoe industry, 278, 622 
cancer death rate, 955 
carbon bisulphide, 361 
dyes, 513, 640, 914 
explosive hazards, 566 
lead, 278, 442 
speed, and fatigue, 752 
tuberculosis, 722 
Shoe-lasts, dust hazard, 208 
Shoemakers' cramp, 750 
Shoes, best type, 48 
hookworm prophylaxis, 689 
Shop-girls, anemia and overwork, 751 
Shopkeepers, tuberculosis, 298 
Shooting, as exercise, 53 
mercury poisoning, 488 
"Shooting" (in mines), carbon monoxide 
poisoning, 389 
Shot manufacture, 463, 632 
arsenical poisoning, 306, 316, 646 
Shoulder, osteomyelitis, pearl workers, 
274 
synovitis, laundry workers, 286 
Shower baths, standards, 33, 35, 45 
Shrapnel, manufacture, 555 
in tissues, lead poisoning, 425 
Shrubbery, mosquito spread, 685 
Shuttle weavers, communicable diseases, 
265 
"kiss of death," 265, 1005 
poisoning hazard, 204 
Sickness, classified, in record forms, 117, 
118 
insurance organization (German), 88- 
89 
nurse's relation to, 138 
rates, 80, 607 
dye industry, 521-3 
time lost, fatigue, 748 
trivial, treatment, 123 
Siderosis, 18, 703 
Sieman's burner, in lights, 26 
Signal smokes, 557 
Silage, carbon dioxide evolution, 212 
Silica, brick industry, 161, (162) 
colloidal, 1075 
crystalline, fibrosis and tuberculosis, 
723, 732 
ganister stone, 160, 161, 705 
granite, limestone and sandstone, 159 
lead-solvent waters, 412 
mica, 169 
mining, copper, 325, 732 
zinc, 334, 732 
subway dust, 243 
"Silicate cotton" (mineral wool), 174 
Silico-fluoric acid, artificial manure, 237 
preservative, 225 
Silicosis (see also Phthisis, Pneumokonio- 
sis), 18, 703-719, 1075, 1076 
compensation, xviii, 335 
legislation, xvii, 708 
tuberculosis, 713, 845 
Silk workers, 265 
artificial silk, 276 
disease statistics, 722 
factory, minors' legislation, histori- 
cal, xxvi 
historical, viii 
lead poisoning, 282, 733 INDEX 
1173 
Silos, carbon dioxide hazard, 212 
Silver nitrate, mould fungus destroyer, 
264 
photography, 255 
workers, 196, 198, 200, 601 
arsenical poisoning, 317 
historical, viii 
mercury poisoning, 485 
mirrors, 488 
skin affections, 906, 913 
tellurium fumes, 596 
tuberculosis, 723 
Simulation (see Malingering). 
Singers, throat affections, 289 
Single employes, absenteeism, 543 
Sink drains, flues for carbon monoxide 
gas, 389 
Sisters of Charity, tuberculosis, 289 
Skating, as exercise, 52 
Skeins, labelling hazards, 272 
Skilled workers, neurasthenia, 750 
Skin, the (see also Dermatitis, Eczema, 
etc.), 44-48, 51, 905-929 
affections (occupational ), xlix, liii, 
905-926 
causes, predisposing, 908 
compensation, 1016, 1065 
dermatitis, 696-700 
eczematous, 907 
venenata, 905 
dermatoses, 907, 909-924 
trade stigmata,- 906 
treatment, 924, 929 (ref.) 
important industrial exposures (see 
especially the following: Acids, 
Alkalies, Anilin, Anthrocene, Anti- 
mony, Arsenic, Benzine, Bensol, 
Carbon monoxide, Chrome com- 
pounds, Creosote, Cyanides, Dye- 
stuffs, Furriers, Mercury, Nitro 
compounds, Oils and cutting 
compounds, Paraffin, Petroleum, 
Printers, Rubber, Tanning, and 
Tar 
Skins (see Hides). 
Slag (see also Thomas slag), lead smelting, 
414 
and cinder dumps, carbon monoxide, 
389 
"Slag wool" (see also Mineral wool), 174 
Slate workers, 155, 705, 732 
Slaughtering industry, 220, 692 
Slave labor, historical, viii, ix, xi, xiii 
Sleep, nature and benefits of, 54j 
Sleepiness, anemia, 741 
atmospheric fatigue conditions, 758 
carbon monoxide poisoning, 394 
high altitude, 818 
Sleeping apartments (see also Seamen), 
legislation, historical, xii 
Sleeplessness, arsenic poisoning, 646 
"Slime fever," 213 
Sling hygrometer (see also Psychrometer), 
262 
Smallpox, 9, 47 
mining camps, 151 
oil acne, resemblance, 917 
old mattresses, 680 
paper industry, 271 
rag industry, 269 
Smelting industry (see also the various 
minerals and ores), xxi, (liii) 
ear affections, 891 
legislation, xxxvi 
"shakes," 331 
skin affections, 315 
Smith, "blear eyed," historical, xxi 
Smiths, arteriosclerosis, 941 
Smoke, carbon monoxide, 67, 373 
fire department employes, 296 
gasoline combustion, 243 
health effects, 21 
naval warfare, 294 
test of air-movement, 28 
Smoking, etiology of cancer, 953 
habit, 67-69 
legally prohibited, 1010 
Smokeless powder, 550, 551, 631 
Smut, fire hazard in threshing, 214 
Snaefell Mine disaster, carbon monoxide 
poisoning, 378 
"Sneezing gas," in warfare, 557 
Snuff, lead poisoning, 413 
manufacture, 227 
Soap, akremin, mercurial, 489 
arsenic compounds, 732 
cutting compounds, 696 
industry, viii, 233, 235 
manganese, 589 
nitrobenzol, etc., 513, 655 
laws regarding provision, 1007 
skin affections due to, 696, 910, 915, 
921 
treatment of skin affections, 924 
Soapstone (dust), 159, 535 
Social aid by physicians, 124 
conditions and long working hours, 
754 1174 
INDEX 
Society, and the eight hour day, 756 
Soda solutions, skin affections, 696, 1066 
Sodium (soda), 598-600, 630 
chloride (see also Salt), 226, 844 
cyanide (see Cyanogen compound), 
nitrate, artificial manures, 238 
sulphate, 572, 599 
sulphide, 599 
telluride, 597 
Soil, moist, hookworm, infection, 687 
pipes, standards, 36 
Solar heat, effects, 16 
Solder manufacture, 638 
Soldering, 602-603 
acids (hydrochloric), 326, 652 
arsenic, 317, 326, 646 
cadmium, 585 
carbon monoxide, 388, 409, 463 
lead, 224, 326, 462, 463 
mercury, 487 
Soldiers, xxi, 84, 290 
cancer, 954 
irritable heart, etc., 52, 935, 939 
lead in urine, 424 
malaria, 684 
scurvy, 111 
Solenite (smokeless powder), 550 
Solingen, cutlery industry, 734 
Solomon's time, brass making, 341 
Solvay process, soda manufacture, 598, 
600 
Solvent naphtha, 495, 507 
Soot, 21 
artificial manures, 238 
ear disorders, 893 
workers, cancer mortality, 955 
tar cancroid ulcers, 662 
Sore throat epidemics, historical repeti- 
tion, x 
Sounds (see Noises). 
South African gold mines, 707 
Spanish Armada, diving bell, salvaging, 
790 
Spasms (see also Convulsions), functional, 
763 
gasoline, 498 
occupational neuroses, 768 
oxalic acid, 658 
Speaker's sore-throat, 72, 289 
Specialization and speed of work, 751 
Spectacles (see Glasses). 
Spectroscopic test for carbon monoxide, 
374, 379 
Speech affections, benzine poisoning, 497 
Speech affections, manganese poisoning, 
591, 654 
nitrobenzol poisoning, 655 
Speed, accident rates, 749 
women workers, 1032, 1035 
"Speeding up," 73, 350, 1035 
"scientific management," 758 
Spelter, 328, 415 
Sphalerite (Zinc sulphide ore), 328 
Spices, grinding and packing, 226 
Spinning, ear disorders, 893, 898 
oil acne, 917, 918 
regulations (English), 1010 
textile industry, viii, xxv, 258 
tuberculosis, 265 
Spinning-jenny, invention, ix, xxv 
Spirek seal, for mercury, 482 
Spirochaeta, selective action, 108 
Spitting, anti-, ordinances, 246 
into cutting compounds, 697 
Spittoons, laws regarding (tobacco work- 
ers), 1011 
Spleen, in malaria, 683 
tuberculosis of, in gold miners, 713 
Splenic fever (anthrax), 663 
Sponge fishing, diving dress prohibited, 
1010 
Sports, as exercise, 53 
Spotted fever, in historical industry, x 
Sprains, X-ray examinations, 1065 
Spraying, (art decorating,-women), 
1036 
machines, painting trade, 466 
mixtures, arsenical poisoning, 211 
orchards, etc., eye injuries, 856 
Springs, hardening, lead poisoning, 442 
Sprue (Cochin China diarrhoea), 693 
"Spurt" work, mines, and fatigue, 151 
"Squibbing," dust from, zinc mines, 334 
St. Louis bridge, compressed-air illness, 
791 
Stables, effluvia, 233 
"Staggers," in compressed-air illness, 799 
Stains, removal agents, 505 
wood, 205 
Stairways, lighting, 38 
Standards (see also Legislation on various 
matters), child labor, xlii, 1024- 
1027 
cleanliness, report on, xxxiii 
compensation, 1013-1019, 1043-1066 
health supervision (governmental), 
98 
illumination, 38-41 INDEX 
1175 
Standards, industrial health service, Ivii, 
114-135 
nursing service, 137 
job requirements, 120 
sanitation, 31-38 
ventilation, 28-30 
Standing constantly (see also Varicose 
veins), females, 1027, 1036 
kidney diseases, 108 
skin affections (builders, etc.), 912 
Staphylococcus aureus, oil folliculitis, 697 
Starch works, 218, 565 
State (industrial health functions), boards 
of health, 95-100, 1026, 1027 
departments of labor, 100 
hospitals, coal fields, xxxvi 
industrial commissions, 100 
Statistics, use and fallacies, 988-1001 
Steam engine, effect on industry, ix 
fitters, 463, 508 
locomotives, editorial, historical, 1 
Steam-railway (see Railway). 
Stearin, in tallow and soap, 234, 235 
Steel industry (see also Iron), basic 
slag manufacture, 236 
carbon monoxide, 382, 408 
ferrosilicon, 381 
influenza studies, xlix 
lung diseases, 710 
trachoma, xliii 
Stenches, for finding gas leaks, 400 
Stenographers, 298, 997 
Stereotyping, 249, 250, 454, 623 
carbon monoxide poisoning, 388 
separate statutes for (Europe), 1007 
skin affections, 584, 913 
Stevedoors, 922, 941 
Stibine, iron production, 636 
"Stieglitz," (tanners' skin affliction), 
675 
Still-births, harmful occupations, 76 
lead poisoning, 429, 1074 
Stimulants (see also Alcohol), desire for, 
(charted), 1069 
"Stink-damp," air of mines, 147 
Stock yards, effluvia, 233 
Stockings, hygienic aspects, 47, 50 
Stokers, acute rheumatic fever, 937 
carbon monoxide poisoning, 388 
ear affections, 891 
Stomatitis, copperworkers, 323 
mercury poisoning, 472, 654 
Stone dust, prevention of mine explo- 
sions, 716 
Stone industry, 157-161, 703 
ear disorders, 891, 897 
eye injuries, 863 
legislation, 1010 
neuroses, 768, 782, 783 
statistics, 150, 155, 702, 705 
tuberculosis, 702, 722, 733 
Stonecutters' disease (neurosis), 783 
palsy, 768 
Stoneware industry, 164 
Stoping, in mines, dust production, 708 
Storage battery manufacture, 349, 452, 
624 
lead poisoning, 441, 442, 459, 
462 
medical supervision (Germany). 
461 
mercury poisoning, 487 
soldering (<pa.), 317 
spaces, lighting, 38 
Storm drainage systems, 36 
Stove foundries, lung diseases (ref.), 
xlvii 
Strain, arteriosclerosis, 941 
heart disorders, 935 
regulations (women workers), 1032 
Strained postures, 104 
Strangury, anilin poisoning, 520, 644 
arsenical poisoning, 308 
tar vapor, 507, 662 
Straw industries, 582 
explosive hazards, 566 
oxalic acid, 658 
"packers' itch," xlix 
Stream pollution (sugar mills), 219 
Street cleaners, municipal dust, 245, 722 
railway employes, xxxvi, 242, 722 
Strength, tests, studies, xlix, 743 
women, 76 
Strongyloides stercoralis, infection, 693 
Strotium, 585 
Students, eye strain, 872 
Stupor, carbon bisulphide, 648 
carbon monoxide, 398 
ether oil (linoxyn manufacture), 581 
X-ray exposure, 964 
"Stupp," (mercury soot), 482 
Submarine crews, arsenical poisoning, 
308 
ear affections, 895 
low oxygen percentages, 376 
mines, explosives, 554 
Subsoil drainage, excluded from sanitary 
system, 37 1176 
INDEX 
Subsoil water, carbon monoxide, 372 
"Substitute products," adulterated arti- 
cles, 640 
Subway employes, 243 
Suction gas, carbon monoxide, 382, 387 
Suffocating cartridges, 556 
Suffocation, carbon dioxide, 648 
coal mines, (statistics), 146 
sulphur dioxide, 661 
Sugar, a concentrated food, 59 
craving, chronic carbon monoxide 
poisoning, 408 
industry, viii, 217, 218, 624 
arsenic, 312 
explosives, 566 
hookworm infection, 212 
skin affections, 911 
sulphureted hydrogen, 661 
temperature, and fatigue, 758 
Suggestions from employes, system of, 90 
Suicides, 984, 985 
carbon bisulphides, 336 
monoxide, 371 
female workers, 986 
rare, by natural gas, 371 
Suits and uniforms (see also Clothes), 
for women, 567 
Sulphemoglobinemia, 931 
Sulphur, brass alloys, 341 
chloride, 365, 575, 630, 660 
rubber industry, 361, 536, 542, 632 
compounds, alleged immunity from 
(respiratory infections), 570, 
723 
dioxide, 661, 846 
dye industry, 519 
lead production, 635 
oil distillation, 504 
dust, coal mines, 151, 152 
fumes, hat manufacture, 506, 582 
historical dangers of, xxi 
matches, 527 
mining, tuberculosis (Greece), 154 
Sulphureted hydrogen, 365, 661, 936 
acetylene gas, 586, 640 
basic slag, 237 
coal-tar distillation, 508 
compressed-air illness, 795, 796 
dye industry, 519, 633 
explosives, 562 
fat extraction, 638 
match industry (phosphorus), 632, 
660 
mining, 147 
Sulphureted petroleum refining, 504 
rubber substitutes, 543 
soda manufacture, 600, 630 
sugar refining, 219 
Sulphuric acid, 571, 624, 630, 662 
arseniureted hydrogen in, 308 
methyl alcohol manufacture, 631 
ether poisoning, powder manufacture, 
550 
Sulphurous acid, historical, xxiv, 630, 661 
clay products industries, 163 
rubber industry, 632 
Sumach poisoning, farmers, 211 
Sumps, in drainage systems, 36 
Sun hat, tropics, 47 
Sunburn, 820, 906 
"Sunburn," exposure to heated sub- 
stances, 181 
Sunday-work, xv, 754 
Sunlight, and malnutrition, 58 
intensity, 41 
Sunstroke, cause, 16 
Surfmen, average age, 296 
Surgeons (see also Physicians), cancer 
infectiousness, 949 
carbolic acid poisoning, 509 
skin affections, 921 
Surgical treatments, injuries, 123 
Surveys, industrial health, xlviii, xlix, 
xlix, liv, 97 
Susceptibility of the given worker, 607, 
908, 921 
Suspenders, how to wear, 47 
Swampy regions, anthrax, 665 
malaria, dysentery, etc., 682-695 
Sweat, constituents, 44 
shops, xxxi, xxxiv, 281, 284 
Sweet clover, toxic odor, 233 
"Sweet gas," mine air, 147 
Swimming as exercise, 45, 52 
Swiss accident statistics, 82 
Swords, manufacture, mercurial poison- 
ing, 191 
Sycosis, 920, 921 
Synovitis, 153, 286, 778 
compensation, 1017 
Syphilis, 9, 81, 103 
cancer etiology, 953 
compensation question, 1058 
glassworkers, 172, 889 
lead poisoning simulating, 427 
occupational neuroses, 770, 775 
physicians, 921 
theatrical profession, 923 INDEX 
1177 
Tabacosis, defined, 18 
Tabes, and writers' cramp, 778 
Tabulation, statistical procedure, 992 
Tachycardia, industrial poisons, 397, 
935, 936 
Taenia saginata, (tapeworm), 694 
solium, (tapeworm), 694 
"Tagayasa" wood, 203 
Tailors, xxi, 281 
cancer death rate, 955 
tenosynovitis of thumb, 290 
torticollis, 750 
Talc industry, tuberculosis rates, 705 
Tallow manufacture, li, 234 
Tannic acid test, for carbon monoxide, 
374 
Tannin, in pyrethrum, 209 
Tanning industry, xxi, 624, 636, 673-677, 
679 
arsenic, 646 
chrome compounds, 588, 651, 847 
explosive hazards, 566 
skin affections, 914, 922 
sulphureted hydrogen, 661 
tuberculosis, 722 
Tapeworm infestation, 10, 221, 694, 
953 
Tar (see also Asphalt), 170, 507, 634, 
662 
cancer, 955, 959 
compensation, 1016 
carbon tetrachloride, 365 
chlorine, 574 
rubber industry, 538 
skin affections, 205, 266, 634, 915, 
918, 698, 1016 
sulphuric acid fumes, 504 
"Tar acne," 915, 918 
"Tar itch," 266, 634, 662, 918 
Tartar emetic, 584, 645 
Tartaric acid, mirror silvering, 488 
Taxidermy, 646, 679, 915 
Tea, concentrated food, 60 
estates, hookworm infection, 212 
mental stimulant, 54 
testing, 230, 875 
"Tea topers," nervous diseases, 67 
Teachers, 288, 726 
Teakwood, skin affections, 204, 907, 917 
Teamsters, tuberculosis rate, 244, 721, 722 
Tear gas, (suppression of riots), 556, 558 
Teeth, 48, 49, 123 
acids, e.g., sulphuric, 662 
compensation, 1053 
Teeth, greenish discoloration, 323, 490 
mercury poisoning, 490, 492 
phosphorus poisoning, 533, 659 
shoemakers, 278 
sugar, dust, 217 
Telegraph service, 299, 300 
child age minimum, 1024 
Telegraphers' cramp, compensation, 
1017 
localized fatigue, 750, 780 
Telephone service, ear pathology, 902 
mortality statistics lacking, 299, 
751 
rest periods for women, 1040 
Tellurium, 172, 595, 640 
Temperance saloons, 67 
Temperature, xxi, xxiii, 758 
accident rates, 749 
ear effects, 901 
fatigue, 757, 758 
lead-solvent waters, 413 
mines, 151, 156, 157 
regulations, 157, 1010, 1030, 1033 
rheumatic fever, 937 
standards, 28 
ventilation questions, 14 
Tempering, 190, 624 
Tendon affections, cabinet makers, 206 
compensation, 1017 
elevator employes, 302 
miners, 153 
Tenement industries, 26, 91, 92, 282, 283 
Teniasis, (tapeworm infestation), 694 
Tennis, as exercise, 53 
Tenosynovitis (see also Synovitis,Tendon 
affections), drummers, 290 
occupational neuroses, 766, 778 
Ternary metals, 321 
Terra-cotta workers, 163, 164 
Testes, anthracosis, 715 
filariasis, 691 
Tetanus, (lockjaw), 9 
coal miners, 151, 152 
cordage makers, 267 
disposal of dead animals, 234 
farmers, 211 
junk workers, 351 
laundry workers, 286 
slaughtering industry, 220 
Tetany, shoemakers, 278 
sulphureted hydrogen, 661 
Tetrachlorethane, xlvii, 576 
artificial silk, 276 
compensation, 1016 1178 
INDEX 
Tetrachlormethane, chlorine manufac- 
ture, 631 
Tetrahydronaphthalene, turpentine sub- 
stitute, 464 
Tetralin, turpentine substitute, 464 
Tetramethylene-diamine, rubber ingre- 
dient, 536 
Tetranitranilin, 511 
Tetranitromethane, 632 
Tetryl, 511, 547, 916 
Teutons, myopia, 873 
Textile industry, ix, 38, 257 
anemia, overwork, 751 
cancer death rate, 955 
regulations, 17, 1010, 1033 
tuberculosis decreased, 733 
printing industry, vanadium salts, 
604 
Theatrical profession, skin diseases, 923 
Thein intoxication, tea testers, 230 
Theisen washer, for furnace gases, 384 
Therm-alloy, 562 
Thermometers (see also Temperature), 
28, 349, 484, 1010 
Thio-carbanilid, rubber industry, 456, 
536 
Thirst, charted as industrial hazard, 1069 
Thomas slag, 236, 461, 632 
Thorpe test, soluble lead in enamels, 449 
Thrashing process, paper making, 270 
rag cleaning, 269 
Thread manufacture, 266 
Threshing, cereals, 214, 565 
Throat, occupational affections, 844 
Thumb, paralysis in file cutters, 191 
tenosynovitis, in drummers, 290 
weakness, or "twisters' cramp," 258 
"Thumb-lip-movement," in labelling, 272 
Ticks, field workers, 10 
Tics, occupational neuroses, 765 
Tile industry, 163 
lead poisoning, liii, 445, 447, 1005 
mineral dust, tuberculosis, 722 
Tin cans, soldering, lead poisoning, 462, 
751 
compounds, dye mordants, 267 
foil, 603 
arseniureted hydrogen, 311 
lead poisoning, 441 
industry, 601 
arsenical poisoning, 307, 311 
mining, 154, 601 
plating, 307, 602, 637, 758, 955 
lead poisoning, 441 
Tin industry, plating, legislation 
(English), 1007 
women and children employes, 
1040 
oxide, 602, 638 
substituted for lead, in water pipes, 
413 
Tinea, in nursemaids, etc., 921 
Tinkers, 603 
Tinned food, lead poisoning, 413 
tacks, lead poisoning, (shoemakers), 
278 
Tinners, 603, 625 
Tinsmiths, 441, 638 
Tire casings (see also Rubber tires), 541 
Titanium, 597 
TNT, (see Trinitrotolunene). 
Tobacco habit, xlix, 67, 68 
arteriosclerosis, 943 
cancer etiology, 956 
carbon monoxide inhaled, 371 
chewing, source of lead poisoning, 
419 
eye effect, 874 
occupational neuroses, 770 
tuberculosis, 734 
industry, xxiii, 227-230 . 
child labor, 1023 
dust, heart palpitation, 936 
tuberculosis, 722 
explosive hazards, 566 
laws regarding, 1007, 1011 
nicotin poisoning, 68, 936 
skin affections, 912 
Toilet facilities, legislation, xxix, xxxiv, 
xxxv, xxxviii 
standards, 34 
Tolerance, (see Acclimation, Suscepti- 
bility). 
Tolidine, 644 
Toluene (toluol), 495, 508, 644 
artificial silk manufacture, 633 
benzol, as impurity, 500 
dye manufacture, 500 
rubber industry, 536 
Toluol nitrates, 631 
"Tongue, stamp lickers," 271 
Tonite, (smokeless powder), 550, 555 
Tonka bean, toxic odor, 233 
Tool making, 38, 187, 723 
Torticollis, professional, 750 
Towels, common, prohibited, 34 
Toxic gas, first use of, in World W 
Toxicity, nature of, 629 INDEX 
1179 
Toxin of fatigue, discussion, 740 
Toxins, bacterial, and fatigue, 744 
systemic, loss of sight, 874 
Toys, dyeing, Scheele's green, 304 
Trachoma, metal trades, xliiii, 336 
Trade and transportation, females, 985, 
1028, 1029 
eczemas, 905, 907 
stigmata, 906 
unions, incorporation, xviii 
occupational disease clinic, 113 
Trainmen, (see Railway employes). 
Transfers, lithographic, lead poisoning, 
254 
Transfusions, blood poisonings, 933 
carbon monoxide poisoning, (dis- 
couraged), 402 
Transportation, involuntary, historical, 
xxvii 
service, 239, 673 
Trauma, (see Injuries). 
Trematodes, (tropical parasites), 694 
Tremor (trembling), noteworthy, carbon 
bisulphide, 648 
monoxide, 397, 932 
lead, 653 
manganese, 654 
mercury, 473, 481, 654 
nitroglycerine, 656 
occupational neuroses, 768, 771 
Trenches, carbon monoxide poisoning, 
372 
Trench fever, resemblance to "mine 
fever," 213 
Trichinosis, 10, 221, 692 
Trichiuriasis, 693 
Tricophytinic infections, 11, 921 
Trinitrophenol, 509 
Trinitrotoluene (TNT), xlvii, xlix, 507, 
510-12, 554 
compensation, 1015 
skin affections, 916 
Triton, 510 
Tropical diseases, 293, 682-695 
Tropics, head dress, 47 
Trotyl, 510 
Truant officers, child labor laws, xxxii 
nurses not such, 140 
Truck Act, historical legislation, xii 
farmers, cancer, 210 
Tuberculosis (see also Phthisis), 9, 
105, 106, 720-736 
alcoholism, 65 
compensation question, 1046, 1057 
Tuberculosis, food deficiency, 58, 735 
ganister workers, 705 
granite workers, 1075 
housing conditions, xxiv 
lead workers, 419 
liberal professions, 288-302 
metal trades (copper, zinc), 333, 
336, 351 
miners, 152, 702 
outlook, 733 
silicosis, 713 
of skin, folliculitis confusion, 698, 
921, 923 
statistics, 80, 733, 984-987 
sulphur compound exposures, 570 
weather exposures, 11, 725, 728 
Tumor (see also Cancer). 
brain, lead poisoning confused with, 
425 
compensation question, 1060 
filariasis, 692 
lower animals, 946 
Tungsten, 597, 598 
lamps, 26, 1035 
Tunnel workers, 150 
compressed-air illness, 790, 796, 
1009 
explosions, (ear disorders), 894 
hookworn infection, 690 
trichuria infection, 693 
Turkey red (dye), arsenical poisoning, 
267 
Turkish baths, value, 45 
Turpentine, 233, 662 
bactericidal action, 1074 
folliculitis, 696 
kidney effects, 943 
painting, 465 
rubber industry, 536, 542, 632 
substitutes, 464, 496, 505, 913 
Twine manufacture, 266, 499, 1034 
"Twisters' cramp," cotton industry, 258 
Type metal workers, 248, 249, 454, 455, 
625, 1007 
antimony poisoning, 342, 645 
metallic dust and tuberculosis, 
723 
skin affections, 913 
Typesetters, 249, 750 
"Typewriters' cramp," 779 
Typewriting, 38, 298, 873 
Typhoid fever, alcoholism, 65 
camp laborers, 202 
compensation question, 1046, 1059 1180 
INDEX 
Typhoid fever, copper workers not 
immune, 324 
extermination, 683 
mattress infection, 680 
miners, 151, 152 
soldiers and sailors, 291, 293 
statistics, 80, 984-987 
washerwomen, 286 
Typhus fever epidemics, historical, x 
Ulceration, eye, compensation question, 
(855-879), 1016 
gastric, benzol poisoning, 500 
rope makers, 267 
gums, mercury poisoning, 654 
legs (varicose), standing occupa- 
tions, 70, 910 
mouth and tongue, stamp lickers, 271 
mucous membranes, basic slag, 236 
compensation, 1016 
nose, arsenical, 915 
chrome compounds, 526, 588, 848, 
1010 
quick lime, 586 
rock salt, 575 
scrotal, arsenic, 316 
, tar, 507 
skin, chrome, 651, 676, 848, 914 
compensation, 1016 
cyanides, 594 
dynamite, 656 
hydrofluoric acid, 575, 653, 1036 
metol, 256 
oil and cutting compounds, 696 
sulphuric acid burns, 662 
tar, etc., 507, 955, 959 
ursol black, 517 
X-ray burns, 959 
Ulmic acid, lead-solvent waters, 412 
Ultra-violet rays, electric welding, 840 
glassworkers' cataract, 888 
high altitude, 820 
sunstroke, 16 
Uncinariasis (see Hookworm). 
Unconsciousness, long continued, 
methyl compounds, 655 
Undergarments, best types, 47 
Uniforms, (see Clothes). 
Unions, incorporation, xviii 
occupational disease clinic organized 
by, 113 
United States (see also "Author index"). 
United States Bureau of Mines, creation 
of , xxix, xli 
United States Children's Bureau, creation 
of, xli 
United States Department of Labor, 
creation of, xl 
United States employes' compensation 
Act, 1044-1066 
addendum on, covering occu- 
pational diseases, 1076 
appliances, orthopedic and 
prosthetic, 1052 
beneficiaries, distribution, 
1048 
charges for medical services, 
1055 
diseases and conditions for 
which claims are made, 
1056 
hospitalization, 1050 
liberality in adminstration, 
1066, 1076 
medical certificates, 1054 
reports, 1053 
minor injuries made serious 
because of pre-existing dis- 
ease, 1058 
pre-existing defects, 1047 
principal provisions, 1045 
scope, 1046 
treatments, nature and scope, 
1052 
surgical and hospital, 1047 
"while in the performance of 
duty," 1047 
United States Public Health Service, 
brief history, xlii, xliii 
United States Registration Area, death 
rates, 79, (673) 
United States Women's Bureau, creation 
of, xliii 
Upholstery workers, 680 
anilin dye irritants, 914 
dust, ear disorders, 898 
respiratory diseases tatistics, 
722 
Upper air passages, effects of dust and 
fumes, 844-854, 896, 897 
Uraemic poisoning, 944 
Uranium, 255, 597 
Uric acid, elimination, hard muscular 
work, 106 
Urinals, standards, 33, 35 
Urinary system, alcoholism, 65 
schistosomiasis, 694 
Urination, painful (see Strangury). INDEX 
1181 
Urine (see also Kidney, Nephritis), 
65, 1071 
ammonia poisoning, 643 
arsenical poisoning, 311, 313, 646 
benzine poisoning, 647 
benzol poisoning, 508 
carbon monoxide poisoning, 396 
exercise effects, 51 
lead poisoning, 424, 453, 1073, 1074 
mercury poisoning, 471 
quick drying paints, 496 
tetrachlorethane poisoning, 576 
tetralin poisoning (turpentine sub- 
stitute), 464 
trinitrotoluene poisoning, 511 
zinc ague, 332 
Urotropin, rubber industry, 456, 535, 536 
Ursol black (dye), 492, 516 
Uterine disorders, 50, 76 
Utility ware, lead poisoning, 446 
Vacations, for postal clerks, xxix 
Vaccination of employes, legislation, 
xxxvi 
Vaccines, for communicable diseases, etc., 
123 
Vacuum cleaners, in lead poisoning 
regulations, 1006 
" Vaderland," 8. 8., ferrosilicon poisoning, 
319 
Vanadium poisoning, 255, 604, 943 
Vanilla beans, skin affections, 920 
cheap essences of, methyl alcohol, 
654 
Variations, in statistics, 994 
Varicocele, lymphatic, in filariasis, 691 
Varicose veins, clay products industry, 
163 
compositors, 251 
elevator employes, 302 
flax workers, 264 
garment workers, 282 
garters as cause, 48 
laundry workers, 286 
legs, 910, 912 
saloon-keepers, etc., 231 
shoe workers, 278 
standing occupations, 70 
Varnish(es), airplane, 576 
benzine, 505 
benzol, 500 
dried, and ear disorders, 897 
explosive hazards, 565 
industry, 463, 579 
Varnish(es), investigation, federal, li 
lead, 207 
pitch, 507 
quick-drying flat-finish, 464 
removers, benzol used in, 500 
skin affections, 919 
turpentine oil, 662 
Varnishers' wives, pregnancy, 107 
Vaselines, injurious effects, 496, 504, 698 
Vegetables, afflictions from, 686,693, 695, 
845, 921 
Vegetation, lead smelting vicinities, 414 
Venereal diseases, in various callings, 
81, 152, 291, 293, 295, 727, 829 
Venery, alcoholism and, 65 
Venesection, in blood poisonings, 933 
Venous pressure, altitude effects, 818 
Ventilation, 13 
bed rooms, 44 
fatigue, 757 
investigations, xxiv, xlviii 
legislation, xiv, xxx, xxxii, xxxviii, 
1007 
regulations regarding (women), 1032, 
1035 
standards, 28 
toilet rooms, 34 
Ventilators, various types, 13 
Vents, construction, 36 
Vermin, in lumber camps, 202 
Vertebrae, fractures of, compensation, 
1062 
Vesicles, from skin irritants, 362, 587, 
696,905 
Vessels, steam, inspection, xxviii 
Veterinarians, anthrax risks, 668, 673 
mortality, 288 
Vibrations (see also Jarring processes), 
cause of "dead fingers," 158 
Vienna, museum of, xx 
red, arsenical poison, 646 
Vinegar makers, 212, 226, 643 
Vintners, asphyxia among, 212 
Violence statistics, 152, 725 
Violet rays (see also X-ray, etc.), 820, 
864 / 
"Violinists' cramp," 290, 780 
Viscera, staining of, hydrocyanic acid 
poisoning, 524 
Visual loss, chart for evaluating, 881 
power, in an economic sense, 880 
Vision (see also Eye), impairments in 
various industries, 425, 514, 
648, 655, 855, 883 1182 
INDEX 
Viscose (see also Nitrocellulose). 
artificial silk, 276, 633 
Visiting nurse associations, 139 
Vitamins, discussion, 57, 61 
Vitriol, de-arsenicating, British rules, 318 
Vocational neuroses, 763 
Voice disturbances, 72, 654, 798 
Voltage, electrical accidents, 834 
Vomiting, atmospheric pressure changes, 
895 
nephritis, 944 
of round worms, 693 
poisonings (various), 394, 646, 655 
"Vomiting gas," in warfare, 557 
Vulcanizing, hazards, 535, 536, 541, 542, 
625, 632, 645 
legislation, xvii, 1011 
Parke's process, 361 
temperature, and fatigue, 758 
Wading, in infected streams, 695 
Wages, industrial health and, 91,283, 734 
females underpaid, 299 
legislation regarding, xi, xxviii, xxxii 
Wagon makers, 206 
Waiters, 231 
Walking, as exercise, 52 
to work, and fatigue, 73 
Wall-paper, arsenic, 303, 317, 646, 915 
Japanese, skin affections, 919 
lead poisoning, 441 
manufacture, 271 
Walnut wood, chrome compounds in 
polishing, 848 
War measures, Iv 
"War nephritis," lead poisoning, 413, 424 
Warships, carbon monoxide poisoning, 
stokers, 388 
Warty growths, 504, 918, 954, 956 
Washerwomen, 286, 910 
Washing (laving) facilities, 24, 33, 35, 
1009 
regulations, xviii, xxvi, xxxv, 1006- 
1011 
powders, 640, 910 
Wassermann reaction, lead poisoning, 
427 
neuroses, 783 
Wastes, industrial, disposal, 36, 79 
Watchmaking, 38, 199, 872 
Water (see also Drinking water), aerated, 
editorial upon, 1 
as food, 57 
lead-solvent properties, 412 
skin affections, 910 
Water, aerated, spraying in mines (hook- 
worm), 149 
standards, 31 
closets, standards, 33 
gas, carbon monoxide, 382, 386, 
649 
heaters, carbon monoxide, 369, 370 
motors, surface drainage, 38 
Waterproof cloth, etc., 46, 361, 535, 540, 
559, 576 
Waxes, 488, 698, 959 
Weakness, sudden, on arising, detection 
of combustion products, 377 
Weapon makers, 191 
Weather, skin affections, 912 
Weavers (-ing), viii, x, 258, 722, 751, 893, 
917, 1010 
Weeping, forced, manganese poisoning, 
654 
Weevil, gases in destruction of, 558 
"Weighting," silk, acetate of lead, 265 
Weights, heavy, lifting, 752, 1033, 1034 
Welding, 176, 640,840, 873 
Weldon chlorine process, 310, 573, 589, 
630 
Welfare measures, 87-94 
investigations, xxiv 
legislation, xviii, 
international, xix 
warfare committee, Iv 
women, xliii 
Welsback gas burner, and glare, 26 
Westphalian miners, hook-worm infec- 
tion, 156 
Wet grinding, hazards, 19, 188 
Whale oil, tallow source, 234 
Wheat, afflictions from, 211, 215 
Whispering, impossible, in air compres- 
sion, 798 
White cells (see Leucocytes). 
lead (see also Lead), 443 
persons, cancer of skin, 957 
"White damp," in mines, 147 389 
White-washing (see Lime-washing). 
Whiting, 579 
Wholesale dealers, mortality, 986 
Wigs, source of skin infections, 923 
Will power, weakened, benzine poisoning, 
496 
Wind, skin affections, 912 
Windmills, historical industry, viii 
Window shades, lead poisoning, 264 
Wine cellars, carbon dioxide risk, 225 
dealers, mortality, 65 INDEX 
1183 
Winter season, carbon monoxide poison- 
ing, 389 
Wiping rags, folliculitis, 697 
Wire industry, 192 
Witwatersrand, miners' phthisis in, 706 
Wolfram (see also Tungsten), 597 
Women wage earners, 75, 1028-1043 
benzene poisoning, 501 
canning industry, 224 
carbon monoxide, resistance to, 
• 378 
factory inspectors, xxxii 
fifty-four hour law, xxxi 
legislation regarding, xviii, xvvi, 
xxxi, xxxviii, 1008, 1030, 1037 
phosphorus match industry, 528 
seats for, xxxviii 
strength, 76 
tenement industries, 91 
time lost by, 748 
welfare of, xliii 
Wood alcohol (see Methyl alcohol). 
gas (producer gas), 387 
Pernambuco, 646 
pulp industry, 270 
spirit (see also Methyl alcohol), 
654, 874 
stains, 514, 651 
ticks, 211 
Wooden shoes, wet operations, 48 
Wood-preserving, 509, 634, 662 
Wood-workers, 203, 566, 626 
ear affections, 891, 897 
skin affections, 917 
tuberculosis, 722 
Wool, anthrax in, recommendations, 1012 
dust, respiratory catarrh, 704 
wall-paper making, 271 
greases, refining of oil, 504 
oil, as twine preservative, 499 
refuse, artificial manure, 238 
washing, 679 
workers, hazards, 626 
Woolen clothing, Roman manufacture, 
viii 
mill workers, xi, xxvi, 262, 722, 917 
Woolsorters' disease (see also Anthrax), 
263, 663, 668, 671 
ear affections, 893, 898 
rheumatic fever, 937 
skin affections, 922 
Woolwich Arsenal, gun-metal casting, 
354 
Work, hard muscular, results, 106 
Work, continuous, 754 
psychological aspects, 760 
writers' cramp, 775 
Workers, adaptation of, as ideal, 756 
disabled, physical reconstruction, 84 
unskilled, neurasthenia, 750 
Working clothes, legally required, 1010 
hours (see also Hours), canning 
industry, 224 
long, in modern industry, 751 
proper length, 754 
statistics on length, 753 
Workmen's compensation acts, 1015- 
1018, 1044-1066 
Worm infestations, 686 
Worms, cancer etiology, 953 
Worry, a mental depressant, 54 
its relation to fatigue, 73, 750 
Worsted (see Woolen). 
Wounds, guide for treatment, 130 
Wrist affections, 72, 153, 187, 191, 206, 
253, 1017 
Wrist-drop (see also Lead poisoning), 
426 
Writers' cramp, 750, 763, 769-780 
compensation, 1017 
Wry-neck, professional, 750 
"Wiirfelpulver," smokeless powder, 551 
Xeroderma pigmentosum, 952 
X-ray, 174, 175, 959 
as cause of cancer, 951, 954, 955, 
956, 963 
dermatitis, 924, 960, 963 
examinations, United States 
employes, 1064 
eye penetration, 869 
general effects, 964 
glass penetration, 888 
injuries, treatment, 965 
mercury poisoning, 485 
Xylene, 500, 507, 508 
Xylol, 644, 647 
in commercial benzol, 500 
rubber industry, 536, 539 
Xylyl bromide, as lachrymator, 556 
Yale students, smoking experiments, 68 
Yard-thoroughfares, lighting, 38 
Yeast, finger-nail affection, 225 
makers, carbon dioxide asphyxia, 
212 
Yellow dyes, 509, 645 1184 
INDEX 
Yellow fever, simulated by arsenical 
poisoning, 309, 311, 646 
tropical prophylaxis, 682 
pigmentation, picric acid poisoning, 
660 
Youths, zinc mining, 335 
Zander apparatus, neuroses, 779 
Zapone, lacquer, 349, 580, 644, 677 
Zinc, 328-340, 626 
ague (see also Brassfounders' ague), 
330, 331, 337, 338, 343 
asthma, 331, 342 
carbonyl, 330 
chloride, 205, 310, 329, 342, 350, 
575, 631 
compounds, arsenic poisoning, 307, 
310, 330 
Zinc, de-silvering lead, 415 
dust, dermatitis, 338 
mining, 154, 334, 590 
oxy-acetylene flame upon, 467 
oxide, 338, 450 
paint (lithopone), 338, 418, 450, 
1074 
silicate, 897 
smelting, 336 
cadmium fumes, 585 
lead poisoning, 415, 441 
regulations, 461, 1006, 1007, 1031 
soldering, 638 
tests for, 328 
tin plating, 603 
toxic properties, xxi, 329, 333, 441 
sulphate, 310^ 330 
white, 307, 338, 418, 1074