preferable; in the absence of university training in industrial hygiene, he should have at least five years of general practice. The future industrial physician should maintain a connection with public health agencies such as the city health department with its various dispensaries, the general dispensary, and other public medical service, in order to develop the social viewpoint as well as to broaden professional skill; he should be capable of making elementary psychological and psychopathic observations, being certain, however, in their practical application of not confusing the psychopathies of the employer with those of the worker.

The industrial physician should have a knowledge, not necessarily profound, of the fundamentals of industrial relations, accident prevention, and the methods leading thereto. He should have knowledge of employment methods, some notion of job analysis, knowledge of race problems, knowledge of industrial training, apprenticeship, continuation schools for training in particular jobs. He should have knowledge of special problems relating to the employment of women and children, some knowledge of pensions and insurance, including liability, group and social, some knowledge of plant organization, which is likely to prove effective in dealing with the problem of labor.

He should have knowledge of the hours of work in relation to fatigue and output, knowledge of shift systems, rest periods, regularity, absenteeism, etc. He should have at least a superficial knowledge of the security and continuity of employment in slack seasons, while convalescing from accident or disease. He should have a general knowledge of physical working conditions, safeguards, disagreeable gases and dusts, heating, lighting, ventilation, locker rooms, wash rooms, rest rooms, restaurants, hospitals, laundries, toilets, showers, water supply, plant beautification, etc.

He should have very definite knowledge of housing, transportation, recreational and educational facilities, and at least some knowledge in relation to the cost of living according to local standards. He should be familiar with follow-up work, especially among new employees and with the injured, replacement of injured and crippled employees. He should be familiar with the athletic and social activities, company stores, commissaries, type of house suitable for economic administration and housing problems generally. He should be familiar with labor turnover and its cost, designs and data for the construction and operation of plant hospitals, neighborhood and community houses, general education and Americanization, together with a knowledge of broad methods of raising the standard of employees' living conditions.

Corporations have realized that they were shortsighted in providing medical service of the sort that disregarded the economic, social, education, political, and even moral phases of the worker's life.

Industrial medicine is not simply a field for the ordinary practice of general medicine and surgery, but bears the same relationship to medicine and surgery as does the specialty of gynecological surgery, or brain surgery, with their topical limitations, or traumatic or military surgery, with its special pathology.

Now with respect to the relationship of the doctor or medical department with other health agencies whether maintained by the government or private organizations. Probably the greatest opportunity for the promotion of the public health has arisen through the rapid development in industry of medical or health departments. Industry is the chief basis for the subsistence and existence of civilized peoples. Civilized peoples are always organized for governmental purposes. As such the organization is

commonly regarded as constituting the state. The state is vitally concerned in the promotion of the health and safety of its constituency.

Those who are employed in the various industries are part of the community for which, collectively and individually, the state is responsible. The state has therefore to consider how the conditions of life, necessitated by industries, affect them, and at the same time estimate the value of the safety and health of the community as a whole of the products of labor. Since industries expose the workers to risk of life and limb by reason of mechanical hazard, by reason of trade intoxications, and again by reason of the hazards of physical contact, the state has to balance the risk to the individual against the benefits accruing to the community from the results of the individual's work. The success of industries, the state's instrument for good, must depend in no small measure on the health of the workers, for the productive labor of unhealthy workers is inferior to that of healthy workers; the safety and health of all depends upon productive labor. The maintenance of healthy industries is therefore the state's first duty. To carry out this duty, health departments have been created. Modern health departments by reason of their varied responsibilities are divided into bureaus having the administration of various divisions on the subject-sanitation, communicable disease, housing, child hygiene, vital statistics, food, laboratories, nursing, or such other divisions as the given community has deemed necessary.

The past generation has witnessed radical changes in the theory of preventive medicine. Health officials are no longer permitted merely to meet emergencies as they arise. Health promotion has become more important than disease prevention and disease prevention has come to be regarded more important than disease suppression. The archaic policy of acting only in the development of an emergency, of merely being ready to make the best of a bad situation, in repairing damage after it has occurred, has been relegated to a less enlightened day. The larger industries will, as a matter of expediency, continue to maintain their own health departments, but the small industry employing few workers must have health supervision for which there now exists wellorganized health departments possessing all necessary machinery for supplying the need.

The success or failure of any movement for the benefit of public health depends to a considerable extent upon the attitude of the medical profession. Unfortunately, the canons of the medical profession provide that the first duty of the practicing physician is to the individual, whereas in the practice of preventive medicine, the first duty is to the public and it has been observed that the individual doctor is so occupied with a specific case that he all too frequently permits others to direct the social, economic, and professional adjustments that modern progress has made necessary. These, notwithstanding that the professional interests and those of the public are identical, should be solved and applied by socially minded medical leadership. The more intimately the individual doctor becomes acquainted with the aims and purposes and underlying motives of the modern health department, whether maintained by the public or a large industry, the more valuable his influence becomes to the community and the more useful the health department becomes to him in the pursuit of his practice. The more people think health and talk health, the more generally they seek medical guidance; consequently, the more generally the physician is employed.

There is one phase of the relationship of the physician, whether private or employed by the industrial organization, as in conflict with medical ethics as now understood,

namely, the right of the employer to so-called privileged information in possession of the medical department. Medical departments are or should be for the mutual benefit of the employer and employed, and if the information concerns the welfare of the individual, fellow-employee, the employer's property, or the public, mutuality demands that it should be commonly available.

Industrial medicine and surgery is in fact a form of group practice, a modern creation which endeavors to bring together all of the arts and sciences which bear upon human welfare. It differs from other practices chiefly in organization, which insures co-ordination of effort, in records based upon both scientific findings and a provision for adequate written reports considered from professional, legal, and economic points of view.

Advanced thinkers now believe that industrial medicine on account of its influence on the profession and upon hospital equipment and other facilities should be given a place as a major department in hospital organization.

In conclusion: However broad the medical service in a given plant may be, or whatever support and sympathy the management may have for the medical department, the department must sell itself to the individual employee, and build up confidence, exactly as does the private practitioner in his relation to the public.

The more important items in the program of the American Association of Industrial Physicians and Surgeons are:

1. To determine and fix the relation of industrial medicine to general community health activities; also the relation of extra industrial illness or disability to the work of the private practitioner. The relationship of hospitals, community dispensaries, and diagnostic clinics.

2. The co-ordination and standardization of first-aid methods to be applied to industry.

3. The standardization of record-keeping of illness, accidents, and absenteeism, as well as the mortality statistics in industry.

4. To devise a simple method of cost accounting for medical service in industry that would attract the attention of plant executives.

5. Education and management-with the aim to raise the status of the head of the medical department in the plant organization to such a plane as will command the respect of the highest executive.

6. Evolve a practical scheme for supplying health service to small plants.

7. Make available for the medical profession at large special methods of treatment and technique which have been used to advantage by individuals or by a group in a more or less restricted territory.

8. The production of higher type of papers.

9. The production of scientific data.

10. Stimulation of active interest of the National and State Legislatures having to do with medico-economics.

II. Closer co-operation of the associated industries of the states.

12. Contact with chambers of commerce and other manufacturing associations, thus reaching a large group as to the value and progress of industrial medicine. 13. Codification of compensation laws.

14. Creation of departments for industrial hygiene, federal, state, and local health departments.

HEALTH AND MEDICAL WORK IN DEPARTMENT STORES Arthur B. Emmons, 2d, M.D., Director, Harvard Mercantile Health Work, Boston The Harvard Mercantile Health Work represents the idea of a progressive group of merchants who believed that improved health in stores would benefit the workers, the stores, and the community. They asked the Industrial Hygienic Division of the Harvard Medical School to supervise a health research. Twenty-five stores in six cities contributed to finance this five-year study. Half the time has elapsed. The stores have been surveyed from a sanitary point of view. Store health departments are being developed. Special subjects of store hygiene are being studied. This paper is planned to crystallize some of the observations and experiences, and to indicate their social significance.

Stores, from the health standpoint, are groups of people of industrial age intimately associated in the complex business of selling goods to the public at a profit. Early health work in stores undoubtedly had in it largely the motive of charity or philanthropy. "Welfare" is being replaced by the more self-respecting methods of "Personnel Activities" or Mutual Aid. Industrial and store medicine today is largely on a business basis. It pays. The progressive business man sees as an asset a team of healthy, contented workers, The tired, neglected, disgruntled, or worried salesperson cannot compete with the fresh, healthy, confident friend, who quickly grasps the customers' needs. Errors are costly. Accidents are expensive. Illness means waste. The key word today in store medicine is prevention—a minimum of drugging with a maximum of health measures.

The scope of medicine in industry and stores includes sanitation, the care and prevention of accidents, acute illness, and minor illness. It should also mean maintaining a healthy force on the job. Such health work consists in: first, determining the fitness of the applicant for the job; next, proper adjustment to the job; finally, maintaining the health and caring for the accident or illness of the worker.

Routine physical examination of applicants.—The history of physical examinations before employment in stores is still largely in the future. Four stores of the group of six outside of New England and two in Boston are using this valuable protective measure. One large store in New York successfully carries physical examinations, and in fact their whole health program is a vital part of their Mutual Aid Association. Participation by the employees in personnel management is steadily increasing in the store field. The difficulty in installing physical examinations in stores does not lie in any objection by the workers, but in the cost. These examinations are the basis of sound health work.

In developing health work in stores it is a wise policy to organize a health department to care for emergencies-first aid, and acute and chronic disease—before undertaking physical examinations of applicants for employment. To follow up physical defects to their logical conclusion is the chief justification for such examinations. Results justifying the expenditure must come from carrying out the advice and treatment intended to put the applicant in her best state of physical fitness. One observer found that but 6 per cent of the patients with physical defects had these corrected if left to themselves. By his follow-up system he obtained correction in 19 per cent more, leaving 75 per cent of defects uncorrected. The public, unless acutely ill, has been indifferent to health measures.

This health education as well as health supervision is often as much needed by the store executives as by the more humble workers. The "nervous breakdown" is probably never due to overwork, but usually to infection, worry, poor hygiene, physical, mental, or social causes.

"How do the employees take to this health work?" is frequently asked me. Chart I is the answer.

Chart II shows the common causes of applying for health service.

The major health problem in the twenty-five stores studied is not one of sanitation, though this may be somewhat improved, but is one of personal hygiene, including diet, mouth hygiene, posture, care of the eyes, rest and recreation, and mental hygiene. The major causes of disability thus have to do in a large measure with the individual vigor and health of the workers, with their health habits, their health opportunities and their health intelligence.

Who is responsible for health ignorance in a person of industrial age? First, the parents; second, the school. The age of health education is the pre-school and school age. By the time the individual reaches the industrial age health habits should be