79

THE PURSUIT OF INDUSTRIAL HEALTH*

By BRIAN PaINGLE.

I N these days, when the literature of every branch of medicine multiplies at an incredible, and to me terrifying, rate, when a man is too often judged by the number of words he has written or spoken, it

has become almost impossible to choose a topic which is not worn threadbare. I am lucky, therefore, in that a subject lay to my hand. I t is one which will increasingly occupy the attention of medical men in the future, but which has not yet, in my opinion, received the considera- tion it deserves in this country. I have been strengthened in my decision to choose this subject by the knowledge that it is certainly the only one on which I can claim to speak with a little personal authority.

" The Pursuit of Industrial Health " : that title gave me no trouble, but it perhaps deserves a few words of explanation, since it was not chosen haphazard. I had no hesitation in rejecting the terms " Industrial Disease " and " Industrial Medicine ", because both of these suggest ill-health--a negative conception while I prefer a title with a positive sound; and positive health is no mere catch-phrase, as I hope to show.

Again, why the word " Pursuit "? Well, I am anxious to emphasise that we are, or should be, actively engaged in chasing an ideal, and that we haven't caught it yet.

The conception of industrial health is hard to define, and I shall attempt no wordy definition; but before embarking on any historical survey, it would be well to t ry to lay down a few general principles embodied in that conception.

First of all, it is an attitude of mind, one far wider than any problem of purely medical organisation ; and because it is so wide I hope you will not be surprised if I include in this address no detailed plan for the efficient working of an industrial medical department. The principles are far too important to be clouded with a mass of detail, and it is the principles that I want to emphasise to-night ; once they are admitted, the rest will follow.

For the same reason I am not going to discuss the individual industrial diseases, such as silicosis, asbestosis, and all the other "-oses ".

This attitude of mind, then, is the realisation that the health of a man or woman is a 24-hour affair--round the clock--not just a question of " h e a l t h - a t - h o m e " and " h e a l t h - a t - w o r k " in two separate compart- ments. This first principle is admitted to some extent every time we ask a patient: " W h a t is your occupation?" But how often does the enquiry, if made at all, go no further, once the history-taker has satisfied himself, perhaps in rather perfunctory fashion, that the patient is not engaged in any of the trades which carry a high risk of special occupa- tional disease. Is not the frequent omission of that question by students in the wards a reproach to us as clinical teachers?

A second principle is the realisation that, quite apart from such legal obligations as the State may have imposed, the employer of labour has some moral responsibility for the health and well-being of his work-

* Presidertt 's Address to Dublin Univers i ty Biological Association, deliveicd 0c$. 25, 1947.

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people. The development of this conception through the ages is an interesting study, which forms some part of my address tonight.

The cynic will here chip in and say: " Ah, yes, but the so-called benevolent employer is simply one who has the money to spend on elaborate medical schemes, and who is far-sighted enough to realise that supervision of his employees' health will pay him good dividends in lower sickness rates, less absenteeism, fewer accident compensation cases, per- haps less labour trouble, and so on ". " In other words," says the cynic, " t h e employer is making a virtue, if not of necessity, at least of expediency."

This is admitted, but do not let us allow it to detract from the credit due to such progressive employers, simply because in this case virtue is its own reward in a material as well as an abstract sense.

A further principle, which to some extent arises out of the first two, is the acknowledgment of the individuality of the worker, and of his right place in the social scheme.

This conception, involving the true meaning of t he" dignity of labour " (a much abused term), has developed slowly through the ages. I t cannot be expected that any evidence would be found of an interest in the health of the worker in prehistoric times, when both man himself, his arts and crafts, and his ideas on health, were all in an early stage of development. But it is interesting, in passing, to observe that the earliest remains of an industry in England are those of a factory for the making of flint tools and weapons, and, curiously enough, this very industry is one which would now be regarded as carrying a high risk of industrial lung disease.

In Greek and Roman, and in even earlier civilisations, two factors made any development of industrial health measures unlikely. The first was the existence of slavery as part of the social system. The general laws regarding property applied to the loss of, or damage to, a slave belonging to someone else. These, or similar laws, were in fact in existence earlier still, for in the Code of Hammurabi, King o£ Babylon about 2,000 B.c. the following appears:

" If a physician operate on a slave of a freeman for a severe wound, with a bronze lancet, and cause his death, he shall restore a slave of equal value."

Incidentally, another edict in the same Code orders the cutting off of the fingers of the physician who operates on a freeman and causes his death. Note the remorseless assumption of cause and effect. I f such an order were in force today, medicine would be less in favour as a pro- fession, and mittens might be popular wear around Fitzwilliam and Merrion Squares.

Aristotle regarded the slave as a " living implement " (~ l~¢vxov gpya~,ov)

but the very use of the word ¢/~¢,Xo~ suggests that this living implement had a spirit or soul. The more enlightened Greeks were conscious of certain obligations to their slaves, just as a good engineer has a duty to his engine. In most cases human feelings did not enter into it.

Apart from slavery, the other bar to progress was the later Greek philosophers' view of craftsmanship. At the height of Greek, and in particular of Athenian, civilisation, all arts and crafts were equally honoured, but in 100 B.C. the philosopher Poseidonius expressed the view of his contempories in his assertion that the arts and crafts of

THE PURSUIT OF INDUSTRIAL HEAI/PH 81

material life---the original discoveries leading to the development of architecture, milling, weaving, agriculture and so on--were made by the superior intelligence of the philosophers, who considered the exercise of these humble crafts beneath them, and therefore handed them over to slaves.

I see too many distinguished and muscular-looking surgeons here tonight, to make it safe for me to do more than hint that that, after all, is what we physicians do today.

Although I am not greatly concerned with the legally-enforced care of the worker, yet it may be interesting to point out that in 643 A.D. an edict was passed in Rome making it compulsory for employers engaged in building houses to compensate masons who had been injured at work. I t would be very instructive to find out how such claims were investigated.

Aristotle, Plato, Pliny, Hippocrates and Galen all did work on occupational disease, especially lead poisoning. This simply showed an awareness of the influence of occupation on health, but nothing more. So far as prevention of disease is concerned, we have Pliny's mention of some form of respirator used to avoid inhalation of dust from red lead. No interest of any kind in the general health and welfare of the worker, as a human being, has so far been discerned.

A great gap yawns between these early efforts and the beginning of industrial medicine as we know it.

To Bernardino Ramazzini of Padua goes the credit of making, in 1700 A.D., the first real study of the crafts and trades of the time in relation to their influence on the worker's health. He was also the first to describe the pathology of silicosis. Ramazzini really did insist on the importance of that question : "What is your occupation?" and has justifi- ably been called the Father of Industrial Medicine. But before his child could see the light of day, or at least before it could thrive, a new view of social relationships was necessary.

During the nineteenth century, the value of the machine was really discovered, and the value of human health receded, for a time at least, into second place. There was no slavery in England at the time of the Industrial Revolution, but it must be remembered that so-eaUed " f r ee labour" can give rise to conditions worse than slavery---child labour, to give only one example.

In 1831, Charles Turner Thackrah, a surgeon of Leeds, wrote a treatise on The Effects of the Arts, Trades, and Professions and Habits of Living on Health and Longevity, with suggestions for the Removal of many of the Agents which produce disease and shorten the Duration of Life. This was the first publication in England concerning the rela- tionship of industry and disease.

Next came a layman, Edwin Chadwick, who really related industrial health to conditions of work, wages, cost of living, housing an¢~ many other factors which we now consider of the greatest importance. Since Chadwick's time many papers have been written, much midnight oil burnt and many words spoken on this subject, but one piece of work, carried out many years later, seems to me more important than all, epitomising the essential principle of the subject, and bringing men's thoughts back to Chadwick's work.

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An investigation was made into the mortality among miners. Well and goodmmany similar investigations had previously been undertaken; but the next step was th~ one which made this work important. I t occurred to the investigators to enquire into the mortality among miners' wives; and it was not the findings (which were important enough), but the fact that the investigation took this double form, which makes me regard this work as revolutionary. In fact, the mortality among miners' wives was found to be higher than that of the miners themselves. And so a new signpost was erected, and the way pointed for such enlightened investigators as Seebohm Rowntree to study the workers' home conditions.

I f the nineteenth century brought a realisation of the value of the machine, the twentieth may yet bring us to appreciate the importance of having a healthy man to work that machine. I say " may yet bring us to appreciate ", because I do not regard the academic recognition which industrial medicine has so far received as any guarantee that the neces- sary change has occurred.

In 1910 the Milan Clinic for Industrial Medicine was established, and a Diploma granted. In 1918, degrees in Industrial Medicine were first granted by Harvard University, followed by many other American Colleges. Yet, ironically enough, it has taken two world wars to bring industrial medical research into the limelight.

Early in the 1914-18 war, when munition work was at its height, it was found necessary to study the health of the workers, in order to keep up production. The Health of Munition Workers' Committee was set up, leading to the Industrial Fatigue Research Board, which in its turn became the Industrial Health Research Board.

A great deal of excellent work was done, as can be seen by a study of the many reports issued by these Boards. But with the end of the 1914-18 war interest seemed to wane, and it was not until almost identical problems of munitions' production again arose in 1939 and 1940 that attention was really focussed on the workers' health. Unfortunately, many lessons had to be learnt over again. Most notable of these was the lesson that you cannot get more production by pushing hours of work above a certain limit.

During the stress months of June, July and August, 1940, up to 75-hour weeks were worked in some factories in England. I t was soon found, however, that above 65 hours for men, and 60 hours for women, production fell, owing to an increase in time lost through sickness, accidents, and absence without leave. A study of reports made during the First World War would have shown that this was bound to happen.

Although other lessons have had to be re-learnt, it really does appear that the present concentration on industrial health schemes is not merely temporary, but that at last the subject has taken a permanent place in the social structure.

Such then, in bare outline, have been the stages by which society has slowly realised the necessity for some form of medical interest in the man or woman at work.

Very well; the necessity has been realised. But I submit that the employer who sets up a medical scheme, because he has to, is only going half way. This reluctant bowing ~, the inevitable, without voluntarily

THE PURSUIT OF INDUSTRIAL HEALTH 83

going just that bit further, displays a negative attitude which in my view constitutes the chief danger to the growth of the movement.

Here is a subject, old yet new : an old idea with what the Americans would call a new "s lan t ". And here I would like to come back to that term which I used earlier--" positive health ". I could never quite understand the popular American song "Accentuate the Positive," although I liked it for its catchy tune. But since starting to write this Address I think I have a good idea of what the author meant, if he meant anything. A few comments may make clear its meaning.

I t has often been said that the Chinese had the idea first, in that they paid the doctor while they were well. What actually happened in China was that the rich people in a village paid the physician a salary to give free attendance to the poor. The Greeks, as usual, had a word for i t ; they called positive health dr,'e~a, a virile word compared to its derivative, hygiene, which makes me think of advertisements for disin- fectants. So much for the Greeks, but the Chinese had already got in first with a couple of axioms : " T h e good physician pays constant atten- tion to keeping people well, so that there may be no sickness ", a n d " The sage does not treat those who are ill, but those who are well."

You may say this is simply preventive medicine, and ask what it has to do with industry? Well, it has been said by that eminent man, Professor Ryle, that : " medical students learn little of the foundations, meaning or measurement of health and rarely examine a healthy subject." I am afraid this is only too true, in spite of the following occurrence at the clinic of a distinguished Dublin physician. The patient was presented to the class, and each student was asked what evidence of ill-health could be observed by inspection of the man. After three minutes of such questioning the unfortunate patient was condemned as showing all the appearances of ten different diseases, mostly fatal. With the flicker of a smile the clinician rounded off the discussion as follows : " That is interesting, gentlemen; now, if you would like to know what I think, I will tell you; in my opinion this man is the very picture of health."

Now that story ranks in most of your minds as a chestnut, which proves to me that that clinical lecture by becoming historic, has probably done a vast amount of good, constantly reminding us of the positive healthy side of each patient.

The physician engaged in industrial work has an opportunity for investigating the variations in so-called normal human beings, and the importance, or lack of importance, of those variations. He can, for example, follow the career of a man or woman with a mitral systoli~ murmur or scoliosis. For this reason industrial medicine has already contributed not a little to the sum of our knowledge. To quote only one example, I would mention Sir Henry Bashford's work among employees o f the Post Office in England, work which showed the harmlessness of orthostatic albuminuria, and so delivered the coup de grace to an 01d bugbear, and earned for the investigator the gratitude of examining medical officers all over the world.

I f the development of this work proceeds along the right lines it may Im a unifying influence, form a rallying point for the practice of medicine, which is in danger of over-specialisation and decentralisation.

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Hero every branch of medicine is needed and must be mobilised, with one object, the health of the industrial worker, and through him, of the com- munity as a whole.

We have been given two examples within recent years of po~b l0 methods of attacking the problem.

First, in 1943, was founded the Roffey Park Rehabilitation Centre at Horsham, whose Medical Director, Dr. Ling, we are privileged to have with us tonight.

Roffey Park has accommodation for 120 patients of either sex. Since its opening it has treated 1,360 men and 1,161 women, and 82 per cent. of these have been satisfactorily settled in industry. All aspects of tlm subject are dealt with there, and there is also a training department in which the methods of treatment are taught.

The ae~ond venture which I think significant is the more recent lishment of an Industrial Neurosis Unit at Sutton, Surrey, under the direction of Dr. Louis Minski. Here those who have been unable to settle down in work are being admitted, their psychological conditio~ determined and treatment given where necessary. Home conditions are co-related with the patient's state in each ease.

I have said that every braneh of medicine should be mobilised for the improvement of industrial health, but perhaps I should emphasise the part which the psychiatrist can play. Much has been said, and many unkind stories told about the psychiatrists (I will not give them the usual Army name), but I am myself utterly convinced of the good work which has been, and is being done by them. The experience gained in the selection of personnel during the recent war should now be turned to the benefit of industry. I do not go the whole way with those who would give over to the psychiatrist complete control of selective employment, and complete psychological supervision of the employee while at work. But I do say that difficult problems of selection (for special jobs or those o£ particular importance) should be referred to a psychiatrist in consul- tation with the industrial physician, as should all cases of definite psychological or mental illness, and the misfits--not those who are tact- fully given the name of Oscillatores plumbi--but the genuine misfits, so well-known to all industrial physicians.

Another sphere in which the psychiatrist can be most helpful is the investigation of those men or women who are "a l l thumbs "; in other words, the "accident-prone " employees. Accident proneness is just one example of the type of problem that faces an industrial physician and his team. I f all accidents, however trivial, are recorded and analysed, as they should be, it will be found that a small percentage of the employees is responsible for a large percentage of the accidents. These individuals are called "accident prone" and although the cause of accident proneness has not been determined, it is known that many factors are involved in its production, e.g., disorders of general health, psychological make-up, bad housing, financial worries, domestic un- happiness, alcoholism, and so on.

In the investigation of these possible causes the industrial medical officer should work in conjunction with the departmental manager, the psychiatrist, and the welfare worker.

There will in many cases be no cure of accident proneness, but the

THE PURSUIT OF INDUSTRIAL HEALTH 85

employee who suffers from it can at least be kept away from the type of job in which the consequences of his unfortunate tendency might be fatal to himself or his fellow workers.

What I would call the routine psychiatric management of the worker should be carried out by the industrial medical officer himself. Again the cynic asks : " Why should the worker need any psychiatric manage- ment? He got on alright without it before, didn't he?" The answer is that it is now realised that, regardless of mass effort or organisation, the worker will inevitably remain an individual and maintain the right to act, psychologically at any rate, as an individual.

In case it may be thought that I am over-emphasising the psychological element in this problem, let me mention that it has recently been shown in a very large-scale investigation carried out during the war, that 30 per cent. of industrial workers suffer to some degree from psychological disorders, and that one-third of these sufferers are seriously affected. Probably between one-quarter and one-fifth of time lost from all causes must be attributed to psychological illness.

The industrial medical offÉcer is the person to look after the routine psychiatry because he has the basic medical training necessary, and has probably for years been looking after the workers' physical ills, and often their home troubles as well. He is seeing the patient's life as a whole, in work and out of it, and if he has, as he must have, the complete con- fidence of that patient his position is unique.

I said earlier that I would not embark upon a description of the indus- trial medical department, so I will simply mention at this stage that the dentist, the physiotherapist, and the welfare superintendent, all take a full part in its efficient working. It can easily be seen how important each of these branches can be.

I must not fail to mention the part which can be played by nurses in this campaign. The importance of industrial work has been recognised by the Royal College of Nursing, which has organised most valuable courses of instruction. Certificates of Industrial Nursing are also being granted by several University Departments of Industrial Health.

The nurse's position in the factory is a most responsible one. She may be in sole charge for long periods, and must be able to use judgment and initiative: judgment in assessing the severity of illness or injury, and initiative in starting such treatment as is within her scope. • I would not like it to be thought that the industrial nurse's work con-

sists primarily of dealing with serious illness and accident. I t is largely preventive, particularly in such matters as wound sepsis. She can be most helpful, too, in giving advice on all sorts of minor problems, and so preventing the development of various psychological disorders. She will probably share with the industrial medical officer the doubtful compli- ment of being asked to adjudicate in matrimonial squabbles.

This is a time-consuming and disappointing task, for when we try to bring people together things don't always work out as we expect, and unheard-of difficulties sometimes arise.

Now we come to a most important point : the actual position occupied by the industrial medical officer in the scheme of things in a factory.

The workers may say the medical officer is the " employer's man" and therefore biased and not to be trusted. This attitude will soon change

86 IRISH JOURNAL OF MEDICAL SCIENCE

and the medical department will be regarded as neutral ground, where unbiased opinions can be given without fear or favour, if the employer's conception of industrial health is an enlightened one, and if the doctor has the personality to gain the confidence of both employer and employee. A difficult task, perhaps, but one which can be accomplished without any diminution of the doctor-patient relationship.

Here I would like to say that one of the most difficult problems arising in the formation of comprehensive schemes is the protection of the employee's practitioner. During the transition period, when new schemes are being organised, there is a danger of encroachment on the practice of doctors not connected with the firm. Until the general structure of medical practice is firmly established for the future, the formation of fully comprehensive medical schemes may be impossible, since such schemes would mean offering free, or partly free medical service to employees and their wives and families, thereby influencing them to transfer themselves from the care of their family doctors.

I feel sure that this, like other problems of development, will gradually settle itself; but in the meantime a close and friendly co-operation between the industrial and family doctor can be established, and in fact has been established in many cases.

Some of the theoretical considerations I have dealt with can only be made of practical value if the medical scheme in each factory is as com- prehensive as possible, subject to the limitations I have outlined. At present this depends on the attitude of the employer to the whole problem, and on the amount of money he can, or will, make available for the administration of the scheme.

Whether in the future this will be taken out of the employer's hands by some general scheme of State medicine I do not know; but I do know that whatever scheme may come, nothing can be more beneficial both to employer and employed than a really comprehensive medical scheme.

In these days we have become accustomed to the strife that is con- stantly going on between master and man. Common ground is hard to find, but here, ready to hand, is a mutual interest. It should be the hope of everyone that this interest, the combined seeking after an ideal, may increase in the coming years, and that each step towards industrial health may bring us nearer to that other goal, industrial peace.