It is impossible here to discuss in detail either the practical methods or the administrative principles of control. From a national and state point of view, however, it can be indicated in outline that the necessary controlling factors are somewhat as follows:

cuss in detail these corrective measures, but is practically impossible for a lead poisoned many of them are obvious, such as improved woman to give birth to a normal child. methods of ventilation, scientific dust removal, the wearing of respirators, the provision of eat ing and dressing rooms, general educational measures among employees by means of placards, leaflets, lectures, etc., a rigid and periodic medical examination, the discouraging of untimely female labor, the use of selected non-alcoholic labor, the development of intermittent labor with shorter hours and an attempt to retain regular employees, etc.

1. A thorough-going scientific labor law. 2. The coördination of authority.

3. Honest enforcement of the law including an adequate system of factory inspection. 4. Effective educational work.

5.

An adequate system for the reporting of industrial disease.

6. A sickness and accident compensation sys

tem.

We are all aware that industrial disease is an important factor in the public health of any industrial community. Unfortunately, very few of our states have labor statistics sufficiently accurate to be used as a basis for determining the exact significance of this industrial disease All Rhode Islanders are probably aware that factor. On the other hand, for the United one of the chief industries of their state is the States as a whole, based on extremely compre- dyeing of the textiles. As long ago as 1906 hensive German labor statistics, the American there were, according to the Rhode Island ComAssociation for Labor Legislation has estimated missioner of Industrial Statistics, 7,578 workers that by the 33,500,000 workers in the United States in 1910 there were lost because of sickness 284,000,000 days. It is estimated that the total financial loss in this year alone, including wages, loss to industry and medical cost, was $772,857,000. This is not only a tremendous loss in efficiency, a great economic waste and an extremely poor conservation of human resources, but it is placing an unnatural limitation upon the social and economic welfare of the most vital part of our national structurethe great mass of workers. It is estimated conservatively that at least one-third of this disability is easily preventable.

engaged in the dyeing trades. There is a particular poison associated with this industry as a result of the use of chrome dyes which, while not as serious as lead or phosporous poisoning, is ofttimes incapacitating and consequently the cause of economic loss. The skin ulcers or chrome holes, as they are called, and the nasal septum perforations, are, on the other hand, easily prevented with the use of gloves and respirators. Another example of specific industrial danger to be found in the state is the manufacture of felt for felt hats where, in the impregnation of the hides with mercury, a dangerous poison is introduced into the felt and hat trades. The dust and fumes arising, if inhaled, absorbed or ingested, excite a frequent picture of mouth ulcers, insomnia, tremors, and sometimes fatal exhaustion, all of which can be prevented by dust removal, the use of gloves, mouth washes and tooth brushes and frequent dental and medical inspection.

It must be remembered that the average man in the United States is an industrial worker having a family depending for its health, progress and happiness to a large extent upon the man's working conditions. It is easy, no doubt, for social workers to understand the inevitable social and economic reaction between the work and the home. It must be remembered also that Although there are many specific poisons ocin certain instances industrial disease itself curring in industry, lead poisoning occurring manages to reach indirectly through the worker itself in over 150 trades, nevertheless the great to the home and its members. Everyone is fa- mass of workers are not subject to any special miliar with the symptomatic picture of lead affection. From this point of view there poisoning-its anemia, discolored gums, paraly- would seem to be little foundation for the resis, blindness and insanity. This may be the cent statement that under present social and picture of the male lead worker poisoned with economic conditions all industry is a disease. On the metal. On the other hand there are many the other hand, far outweighing the sequelae of cases on record where the disease has been ac- specific toxemias are the more general evil required by the wife even when her only contact sults of unhygienic factory conditions and unwith lead industry was through the washing of wise labor stress such as the multiform neuroses her husband's lead-impregnated clothes, a and the cardiac and tubercular affections. We poisoning preventable by the provision of fac- have touched briefly on the relationship of tutory dressing rooms and insistence on a change berculosis to the textile industry. A similar of outer garments upon leaving the factory. relationship is found wherever workers are emThis is a particularly distressing picture be- ployed under unhygienic and insanitary concause of the fact that lead poisoning is an af- ditions for long periods. fection of even greater seriousness in women As you probably know, Rhode Island leads than in men for they may add to the usual run the country in the manufacture of jewelry. In of symptoms a sad succession of stillbirths and a statistical study conducted by Dr. Frederick abortions. Sir Thomas Oliver has said that it L. Hoffman in 1908, it was found that in the

jewelry industry in the age period from 25 to 54, 59.5% of all workers dying, succumbed to tuberculosis, whereas the rate for the same age period for all industrial workers at that time was only 31.3%. Another Rhode Island industry is pearl and bone button making and it was found by Dr. Hoffman that for the workers in this industry for the age period 15 to 24, the percentage dying of tuberculosis was 50 as compared with a general rate for all the United States industrial workers of 27.8%.

tion. Thus can the state aid in the extension of
the compensation principle to occupational dis-
eases as well as to industrial accidents.
Of course, the citizens of Rhode Island are in-
terested in workingmen's compensation for em-
ployees of the Federal government. At the
present time the Kern-McGillicuddy Bill, H. R.
15222, has been favorably reported by the Com-
mittee on Judiciary of the House of Represen-
tatives at Washington. This bill needs strong
popular support and consequently letters and
resolutions should be addressed to the Rhode Is-
land representatives in Congress urging them to
give their hearty support to this meritorious
measure.

Tuberculosis in industry is, of course, associated particularly with the dusty trades, and considering the various types of dusts that occur in industry such as the metallic, the mineral, the municipal, the vegetable and the animal, it According to the December, 1913, Review of is estimated that there are probably 800,000 the American Association for Labor Legislaworkers engaged in dusty trades in the United tion, "at least six branches of government are States. In many factories and shops, moreover, authorized or required to enforce labor legiswe must add to the trade wastes the bad physio- lation in this, the smallest state in the Union.' logical and psychological effects of over-heating, This includes factory inspectors, the Bureau the contamination from overcrowded workers of Industrial Statistics, the Railroad Commisand often excessive moisture.

sion, the Inspector of Buildings, the school authorities and the police authorities and is sufficient evidence surely of the necessity for concentration and the coördination of control.

We have not touched upon the degenerative affections and accidents consequent to the stress and strain of such an industry as that of iron and steel production. We have said nothing of There is a great necessity here as elsewhere the great field of industrial accidents and we must for constructive educational work in connection now ignore these industrial factors to consider with the enforcement of sanitary and safety for a minute what might be said to be, in rough- standards. This educational work should be est outline, the most urgent necessities of this carried on by the state, by the vocational trainstate in the field of industrial welfare. There ing schools, by private philanthropic organizahas not been time to make a careful study of tions, by labor unions and by employers. local demands and consequently, to the knowl- There is needed here, as everywhere, the abiledge of many present the following may be ex-ity to make genuine value judgments in health ceedingly incomplete.

In fifteen or more states there is a law relative to the reporting of occupational diseases. This law usually requires that the physician attending the case report to the proper authorities, either the Labor Commissioner or the Department of Health. A penalty of from $10 to $200 is affixed for failing to comply with the law. Now, two years ago such a bill was introduced in Rhode Island but after a hearing, was never reported. Of course Rhode Island ought to have such a law.

Most of you have heard of the disease known as the "bends" or cais.on sickness, often associated with work under compressed air where proper precautions are not taken during the decompression process. The American Association for Labor Legislation has recently drafted a model bill on this subject and last year it was passed by the New Jersey legislature. This, or a similar enactment, is recommended by the Association for the state of Rhode Island. The Labor Legislation Association also intends to introduce in the Rhode Island legislature in January a sickness insurance bill which was drawn up by the Social Insurance Committee of this Association as a measure for use in the campaign for health conservation regarding sickness in industry, similar to the Safety First movement in accident preven

matters. We spend money wisely for health when we attempt to control communicable diseases; we spend it foolishly when we attempt to make our health budget cover such nonhealth activities as plumbing inspection and nuisance abatement. From the point of view of health values industrial hygiene is of prime importance and we must realize that the health of the worker is essential if industrial evolution is not to be abortive.

There are many things of a more general, national or indeed international importance which must be taken into consideration especially by the creative, socially-minded individuals who are able to discern other than simply material values in industry and who are desirous of having palliation succeeded by prevention and cure in social reform. As a nation, we must realize in the first place the tremendous economic waste resulting from our national inability. or disinclination to conserve the human resources in industry. Perhaps this will not be done until it is brought home to the industrial organizer that it actually pays to give at least as much attention to the human machine in industry as to the mechanical device. To quote a recent editorial in the Journal of the American Medical Association.

"Abbe (Zeiss Optical Works in Germany) kept a careful record for the years when

the plant was operating on a nine-hour day. When the working day was reduced to eight hours the record showed the men earned over 3% more than during the previous years, the output of the works was increased 3% and the power plant was able to shut down an hour earlier, thus affecting a very material saving in the fundamental expense. The record was for 233 men of 31 years and many different occupations on a piece-work basis were represented in the shop.

"Both employers and employees need to be convinced of the evident fact that the healthy man is the most efficient and the cheapest employee and that any reasonable expense to maintain him in health is a profitable investment.

point the way to the time, not far distant, when there will be no army of men always content to do "the dirty work" of the world. There is also a time coming when the state shall recognize the right of all individuals to work and grow socially and spiritually as well as materially-a thing scarcely possible for a man who is to be concerned with continuous drudgery or with one minute industrial process all his life. Is there a remedy for this condition? That also is hard to tell, but there is a plan, outlined by William James, that calls for an industrial state in which no class shall toil unceasingly but, through a conscript labor army, everyone, man and woman, will have the preliminary years for education and development, will spend his allotted time doing the foundation work of the world under the direction of the state on a basis It should be realized that our industrial sys- of service to all, and not for the financial gain tem involves not only a waste of money and of the few. All the big necessities of life such men but also of energy and enthusiasm. The as transportation, mining, food distribution and men in Rhode Island who are making pearl but- production, etc., must come under government tons and who have nothing but pearl buttons supervision. For the individual to work his to look forward to for the rest of their life are allotted time in this great industrial army will employed at a deadly hope-killing occupation be to perform a great and recognized service to and are quite naturally not going to put into the state. Thus will drudgery be regulated and that occupation any more interest and energy rendered innocuous. Here will be at last a than is necessary. Is there a remedy for this? legitimate field for militarism. It is difficult to tell-certainly none has ever This may be exceedingly fantastic. It is at been tried on a large scale at least. One has least, far in the future. It is an attempt to anbeen suggested, however, by an English writer swer the many questions that are being asked and somewhat worked out by him in his dis- of organized society with ever increasing intencussion of the alternation of employments. This sity. Is industry to be reorganized by the ininvolves a periodic and progressive shifting telligent, coöperative, sympathetic effort of a from trade to trade at least in allied industries society with an awakened social consciousness, and requires of course intelligent governmental or is it to be seized and wrecked by the madsupervision, so necessary from every point of dened and exploited? Is the spirit of gain to view, rather than the haphazard anarchistic in- be replaced by the spirit of service or by the dustrial control or lack of control of today. This spirit of revenge? Is class distinction to grow thinker believes, and certainly our own experi- and class war to come, or are the classes themence would seem to confirm it, that most men selves to be socialized into extinction? Shall it will work at a high pitch at a new thing, especi- be the constructive evolutionary path or the deally if they have in view a better thing to fol- structive revolutionary one? Shall poverty be low. In this way society would obtain both enlightened and destitution made impossible! quantitively and qualitatively a superior service Pretty far from occupational disease? Yes and from the individual, and as a result of the con- no. Far from the palliative treatment of this centration would require less actual working social defect but very near perhaps to the heart time from the individual, thus allowing more of the cure of the great social maladjustments time for the preliminary educational period, of which preventable disease in industry is a and because of increased earning capacity, a manifestation.

greater saving against the nonproductive old

age.

Such a scheme would seem to be the only

LIP OPERATION.

logical alternative to a further development of MODIFICATION OF TECHNIC FOR HAREa more continuous specialization in industry, to a more fixed labor class and to the ultimate expression of the idea that man is first a worker and then a citizen as embodied in the pitiable program of "I. W. W. ism" in industry and syndicalism in politics.

BY W. E. LADD, M.D., BOSTON.

BELIEVING that perhaps there may be some surgeons besides myself who have had difficulties It is inevitable that part of the labor of the in performing hare-lip operations with uniworld must always continue to be comparatively formly gratifying results, I am offering a modiuncreative and unimaginative. However, the fication in the technic for their consideration. ultimate cessation of immigration, more imme- The main principle of all hare-lip operations is diate impending events in the industrial world, the restoration of the normal line of the alveolar

clamps may now be removed and re-applied out "The delicate methods of Stevens, Landolt, and towards the angle of the mouth to control hemor- Gromsdale require much patience, and then the rhage. result depends upon a frail suture. Verhoeff's The edges of the two incisions, which of neces-partial plastic tenotomy is extraordinarily neat sity must be clean incisions of equal length and consequently fitting each other, can now be easily approximated, bringing the points B to D, A to C, and E to F (see Fig 5). This is done with one row of interrupted silk stitches, including all layers but the skin tied inside and another row of superficial approximation stitches of the same material, including the skin only, and tied outside.

This technic is applicable to all forms and varieties of single hare-lip, a fair example of which may be seen in the accompanying photographs before and after the operation.

Clinical Department.

on paper, but is difficult to perform on the living subject, and I am not convinced that any real slacking of the tendon is secured. I evolved a method of three cuts which gave me all I wanted. It was so simple that it seemed that some one must have done it already, and in Casey A. Wood's new text-books of eye operations, I find nearly the same method figured, but if the author of the operation-Dr. Todd-will forgive me the criticism, it seems that he has just stopped short of doing what he sets out to do. The steps of the operation, and the effect, can be seen very well if it be practiced upon a piece of narrow adhesive strapping stretched between two fingers of an assistant. The tendon to be lengthened is exposed a short distance from the insertion. Supposing it to be an internal rectus, a small vertical buttonhole is cut parallel to the plica semilunaris and close to its edge. Tenon's capsule is cut and pushed back similarly, a squint-hook is passed beneath the tendon and

PARTIAL TENOTOMIES BY THE TODD- slowly lifted, so as to draw the tendon into view,

EVER since the writer began the practice of ophthalmology he has been particularly interested in heterophoric cases. He has tried blurring in esophoria, and prisms and exercises in exophoria. Tenotomies, tuckings, and advance ments have produced fair and indifferent results. There has always been a feeling that it was rather a gamble as to just what result would be obtained in these cases. Some form of grad uated tenotomy has always seemed the least haphazard and the more scientific procedure, but none of the numerous methods advocated have created enthusiasm enough for the writer to try them.

In the Ophthalmoscope of January, 1913, Dr. N. Bishop Harmon of London, England, published an article entitled "Lengthening a Rectus Tendon in Squint Operations." The writer was so much pleased with the simplicity and ease of control in the operation described that he has since, with gratifying results, performed the operation four times on patients with phorias, who had marked general and locally distressing symptoms. The liberty is taken of quoting below a portion of Dr. Harmon's article, to refresh the reader's memory.

*Read at the nineteenth annual meeting of the American

then two cuts are made in the same edge of the tendon, one on either side of the hook, as far as possible, so as to divide the tension at each cut up to the middle line of the tendon. Then the hook is pushed slightly to one side so the cut may be made from the opposite edge of the tendon, between the two cuts already made, and this cut is made from the edge right across the middle line of the tendon so as to sever two-thirds of its width. Immediately the third cut passes beyond the middle line, the tendon will be felt to give and it will yield distinctly as the cut is continued."

Discussions of this operation, and operations performed for the same purpose, elicited the opinion that the immediate result would be no more than ten degrees lessening of the phoria. In spite of the discouraging consensus of opinion, the operation was undertaken with some degree of confidence. In the following case the operation was done on the internal rectus of each eye.

CASE 1. Nov. 15, 1912. Mrs. H. W. F., myope, age 34, severe headaches for the past fifteen years. Examined repeatedly with and without a mydriatic. Complains of pain through right eye, with no full relief from pain at any time. Appendix has been removed, turbinates operated upon, and an Alexander done. Has been in a sanitarium for nervousness several times. She is often awakened in the morning by severe pain in head. Fundi normal, pupillary reaction good, cornea clear, tension normal; small opacity in posterior surface of lenses. V.O.D. 20/30+, V.O.S. 20/70+. Esophoria seventeen degrees at twenty feet, tested with twelve degree prism base down, on the right eye. Esophoria between twelve and fifteen degrees at twelve inches. Homatropine ordered for examination.

Nov. 16, 1912. Ordered correcting glass with a Academy of Ophthalmology and Oto-Laryngology, October 20, 1914. three degree prism base out, in either eye.