Musculoskeletal complaints in an industry annual complaint rate and diagnosis absenteeism and economic loss.код для вставкиСкачать
Musculoskeletal Complaints in an Industry Annual Complaint Rate and Diagnosis, Absenteeism and Economic Loss By ROBERTBROWNAND CLAIRE LINGG An industry, with a diversity of occupations and many different types of working conditions, was surveyed for the incidence of rheumatic complaints among its employees. The incidence and site of complaint, as well as the varieties of musculoskeletal disorders, were correlated with age, sex and type of work. Estimates were made of the economic loss to the company owing to rheumatic complaints in terms of absenteeism and medical services required. A Un branca industrial, con diversissime occupationes e multe differentias in le conditiones de travalio, esseva studiate con respecto a1 incidentia de gravamines rheumatic inter le empleatos. Le incidentia e le sito del gravamines e etiam le varietates de disordine musculoskeletic esseva correlationate con le etate e le sex0 del subject- afficite e con le typo de lor travalio. Estimationes esseva facite concernente le perditas economic resultante pro le firmas empleante ab le gravamines rheumatic in consequentia de absentismo e requirimento de servicio medical. NUMBER OF SURVEYS of the incidence or prevalence of rheumatic diseases in general population groups have been made, with estimates ranging from 9 to 50 per There is a considerable doubt as to whether the data from different areas are comparable, but the more studies made, provided attention is given to sound sampling methods and uniformity of diagnostic criteria, the more complete will become our knowledge of this complex problem. Apart from sickness surveys of the general population, analyses of absenteeism in industrial populations have contributed substantially to the prevailing opinion on the importance of rheumatic diseases as a cause of impaired health in the community. Such studies have recently been ably reviewed and commented on by Mintz and Goldwater? As in population surveys, reported studies of absenteeism in industries usually give little precise information regarding the different types of rheumatic disorders and their severity. Outstanding among investigations in occupational groups are those made in England by Kellgren, Lawrence and Aitken-Swan,'-* in which it was possible to examine individuals with rheumatic complaints. From the Department of Medical Statlslics and the Rheumatic Diseases Study Group, N e w York University-Be1levu.e Medical Center, Xew York. This work was supported by Grant A-518 from the Public Health Seroict., National Instiof Health. The authors me indebted to iMks Hilrlegd hndsberger for her conscientious munagem i d of the collection of the data and secretarial n.sdstance; to Dr. Dormld M a i d a n d , Miss Lee Herrera, Miss Elisabeth Street and Mtss Marion I . Sutcliffe for advice and help in various phases of the work; and to Dr. Joseph J . Bunini for his interest and suggestionr, which initiated this study. 283 284 BROWN AND LINGG In a recent article, Bunimg listed the conditions that must prevail if the records of the medical department of an industrial concern are “correctly to reflect the prevalence or incidence of any or all diseases among the employees.” After approaching several industrial organizations, one in particular-the Consolidated Edison Company of New York-appeared to more or less fulfill the requirements. In 1952, therefore, a preliminary survey of the medical records of this company, for the five years 1947 to 1951 was made.l0’’ This led to a forward-going study which is the subject of this report. The aim of this study was to determine in a particular industry, by age, sex and type of occupation, the annual prevalence of the various rheumatic disorders and to learn how much disability and absenteeism resulted from such disorders. A further purpose of this research was to ascertain the feasibility of making such epidemiological studies in an industry. THESOURCE POPULATION The Consolidated Edison Company of New York is engaged in the distribution and sale of electrical energy and natural gas. It employs men and women trained in a wide variety of skills and exposed to many types of working conditions. This population is characterized by its exceptional stability. The average duration of employment in the year 1954 was 21 years. With the exception of the personnel in the higher executive positions, all those permanently employed are eligible for membership in the Mutual Aid Society, which provides, among other benefits, medical care for any and all physical complaints. This care incliides treatment in clinics maintained at the home office in Manhattan Borough and at the branch offices in other boroughs, including a diagnostic clinic at the home office to which patients with a diagnostic problem may be referred for a complete work-up; house visits and visits to the offices of selected physicians in private practice in the districts in which the employees live; hospitalization; outside consultation services and any laboratory work deemed necessary. The care, all and any part of it, is provided by the Medical Bureau of the Company, which utilizes the services of about 140 physicians. The cost is paid by the Mutual Aid Society, which deducts a fixed sum from the wages of every permanent employee. If an employee is absent from work two or more days, a visit to the Medical Bureau is mandatory. Repeated single day absences will elicit a polite but firm request to visit the Medical Bureau. This system virtually insures that no major illness escapes the attention of the Medical Bureau. Any minor illness involving absence from work is likewise entered in the medical record. Since, after an absence of more than two days because of illness, approval for return to duty must be obtained from the Medical Bureau, the majority of employees seek care for all their illnesses through the Medical Bureau and the few who are treated by outside physicians usually use the facilities of the Medical Department for laboratory or x-ray studies, so that a record of outside care is also obtained. In view of the rigid supervision of absences and the fact that with a few exceptions all employees pay for medical care through a payroll deduction plan, it is unlikely that any illness sufficiently severe to require medical care escapes recording. The medical record system of the company consists of individual forms for each examination made, whether in one of the clinics or by il district physician. These forms, made out in triplicate, are picked up by courier each day and brought to the home office, where they are bound in individual patient folders. Each form contains the physician’s notes as well as the diagnosis in code, Special forms are provided for x-ray and laboratory exami“This work was carried out under a research grant from the New York Arthritis and Rheumatism Foundation. 285 MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY nations. Reporb of outside consultations, hospitalization or private physicians not employed by the company are also filed in the patient’s chart. The medical records were cmfully examined and found to be comparable to those kept in a good hospital teaching clinic. The physicians are alert, interested and well trained, and the work-up and follow-up are of a distinctly high order. In the year 1954, 24,157 individuals were employed by the company on a permanent basis. In 1,332 of these, employment began sometime after the beginning or terminated before the end of the year, with a mean duration of employment of six months. It is estimated, therefore, that during the year there were 23,491 person-working-years. This figure constitutes the source population for this study. Table 1 shows the sex, age distribution and work classification of the population. It is readily seen that 90 per cent of the population is male. The mean age was 48 years: 47 years for males and 41 years for females. The modal age for males was 50 to 59 years and for females 40 to 49 years. About three-fourths of the employees were over age forty. The mean duration of employment in 1954 was 21 years, with 52 per cent of the population employed 25 or more years. The terms used in the table may be defined as follows: Light is assigned to clerical or other work requiring no or only slight physical effort. Heauy is assigned to work requiring individuals to work in cramped quarters, in a position in which the spine is held in flexion, or to lift weights of 30 or more pounds. Outdoor refers to work which requires spending the greater part of the time out of doors, exposed to the elements. The majority of the men (63 per cent) were engaged in heavy work involving bending and lifting. This was so in most of the age groups. Less than half of the male population (32 per cent) was engaged in outdoor work. This, too, seemed to be the case regardless of age. Of the women, 98 per cent were clerical workers. The remaining 2 per oent were engaged in heavy work, such as cleaning offices, etc. It is, of course, virtually impossible to determine with any accuracy what stresses people encountered at home or when engaged in leisure activities. The list of job classification groups consisting of some 340 payroll titles was examined with the aid of the payroll administrator of the company, who is thoroughly familiar with the demands and responsibilities-including physical strains and stresses-of each of the job titles. As a result, it was possible to break down the job categories into four classes: Indoor Light, including such occupations as clerical and other office work, delinquent accounts investigator, machine operator, etc.; Outdoor Light, including meter reader, delinquent accounts collector, crane operator, station guard patrolman, etc.; Indoor Heaoy. including mechanic, production or boiler operator, engineer, subway workman, coal hoister, janitor, stockmen, etc.; Outdoor Heuuy, including outside plant mechanic, production man, meter tester and inspector, yard or coal foreman, pipeman, lineman, drillman, etc. METHOD OF STUDY Because data pertaining to the entire population from which a stratified sample could be drawn were not readily available when the study was begun, but especially because Table 1.-Source Population by Age, Sex and Occupation Group Fenales Yale3 Occnpation Group. Occupation Groups Age Groups Under 30 30-39 40-49 50-59 60 and over All ages Indoor light Indoor heavy Outdoor light Outdoor Employees heavy Employees Indoor light Indoor heavy 2,110 2,988 8,842 7,083 2,141 287 355 2,788 2,323 65 1 762 1,323 2,222 2,765 963 128 142 508 729 135 818 808 41 727 120 805 593 36 2 15 11 15 106 935 1,168 1,328 1,488 421 21,182 6,404 8,035 1,387 5,338 2,329 2,281 48 Total ,507 Total 5 286 BROWN AND LINCC the rules and regulations of the company as well as the employee’s union would not permit apparently healthy employees without symptoms to be released from work for a medical examination, it was not possible to draw a random sample of the entire working population. It became feasible instead to sample individuals who registered complaints referable to the musculoskeletal system. This qtudy is, therefore, concerned with the frequency and nature of rheumatic complaints. Patients with rheumatic disease were not included if they were symptom-free or did not request medical advice during the year of the study. The level of discomfort at which individuals seek medical care vanes from patient to patient and is influenced by many factors--economic, emotional and physical. In this study, therefore, the threshold of inclusion is the visit to the doctor. In short, we are dealing here with an annual prevalence rate of rheumatic complaints, not necessarily with the annual prevalence of rheumatic diseases. In January 1954, a letter was sent to all physicians employed by the Edison Company explaining the planned study and requesting their cooperation. It was acconipanied by a copy of the most recent Primer on Rhenmatic Diseases, prepared by the American Rheumatism Association,ll which was to serve as a basis for a reasmiable degree of uniformity in diagnosis. During the period of February 1, 1954 through January 31, 1955, all the records of medical visits were examined each day and those were withdrawn which bore a code number representing one of the following titles, appearing in the company’s diagnostic code system, that might conceivably include a rheumatic (musculoskeletal) disorder: arthritis, acute, infectious; arthritis, chronic, infectious (including deformans ) ; gout; periarthritis; spinal osteoarthritis ( spondylitis ) ; traumatic arthritis; rheumatic fever; hypertrophic arthritis; sacroiliac disease; sciatica; lumbago, niyositis or myofascitis; tenosynovitis; bursitis; Charcot joint; ruptured intervertebral disc; and neuritis (not due to alcoholism). A card file was kept of all patients who reported rheumatic complaints from day to day, and the daily list of patients with conlplaints was checked against this file for the removal from the list of revisits,’ so that each individual with complaints had only one chance of entering the sample. Each day, after the removal from the list of “revisit” cases, the remaining were numbered chronologically and a random sample selected, using the Random Number Tables of Kendall and Smith. From preliminary calculations it was estimated that the total number of clinical examinations made each day would average about 400, and that about one-tenth would present rheumatic complaints. It was expected that with allowance made for repeat visits, an 8 per cent sample would yield about 1,OOO cases with rheumatic complaints within the year. At the end of the first month, however, it was found that the repeat visits were more frequent than had been anticipated. The size of the sample to be selected was accordingly increased to one of 25 per cent. It follows that in making the final estimates, the observed cases had to be multiplied by 4 during the eleven months of 25 per cent sampling, and by 12 for the month when the smaller sampling r a t i o - 8 per cent-was used. A more complicated procedure. using different sampling fractions in different subclasses (sex, age and occupation) was not practicable under the conditions of this survey. When a patient fell into the sample, his complete history (with the clinical findings dating from about 1945, when new record forms were adopted by the Medical Bureau, or, if employed since 1945, from the day of employment) was abstracted onto a specially prepared form and the record of the current illness reviewed in detail. Essential features of the plan included the following: ( 1) If laboratory or x-ray studies had not been ordered by the examining physician and the clinical record seemed to warrant them, or if further clinical examination seemed desirable, such procedures were to be instituted; and (2) patients whose disorders were of a doubtful nature after adequate x-ray and laboratory studies had been made were to be re-examined at the request of and in consultation with the rheumatologist (Dr. Robert Brown, representing the Rheumatic Diseases Study Group of the New York University-Bellevue Medical Center). The patient was then folODuring the year, 4,426 individuals registered rheumatic complaints. Together they made 15,169 revisits. 287 MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY lowed through his records until discharged, and the records were reviewed periodically for further evidence of symptoms and signs of rheumatic disease, throughout the year and for three years thereafter, when a final diagnosis was made in conformity with presentday concepts of rheumatic diseases. Although the medical department had endorsed the plan and lent its wholehearted interest and cooperation, difllculties were, nevertheless, encountered. Of 314 x-rays ordered, for example, the request was granted in only 41 per cent, and laboratory studies requested (341)were carried out in 42 per cent. In cases with unquestionable rheumatic disease, whether defined or undefined disorders, requests were granted in about 75 per cent, while in those with questionable rheumatic disease, studies were obtained in only 10 per cent ( 105 x-rays and 341 laboratory studies were requested). In other instances where further information was needed to clarify a case-such as a complete cardiac examination to rule out anginal pair., or a neurologic examination for possible disc disorder-of five such requests only one was granted. The reason generally given for not agreeing to further study of a case, or for the re-examination of a patient in consultation with the rheumatologist, was that since the patient’s symptoms had subsided siifficiently for him to be back on the job, further loss of time from work for medical reasons was not warranted unless the recurrence or persistence of symptoms brought the patient back for medical adivce. Throughout this study, when more than one diagnosis was made in a patient, the case was listed under each diagnosis, and if more than one area of complaint was given, each was assigned to the diagnosis presumably responsible for it. Similarly, days lost from work, as well as medical visits made or received by an employee already in the sample, on account of rheumatic complaints, were assigned, as they occurred during the year, to the particular type of disease or disorder which required the medical care or absence from work, CRmIA The cases were classified under the diagnostic terms recommended by the American Rheumatism Association as defined in the Primer on Rheumatic Diseases.11 In addition, three supplementary categories were included: ( 1 ) undefined rheumattc dlpenses--cornplaints and objective findings referable to the musculoskeletal system which failed to clearly fit one of the diagnostic headings; ( 2 ) questbnuble rheumatic disease (minor coniplaintshthe symptom of pain referable to the musculoskeletal system without objective findings and usually of less than seven days duration; (3) no diagnosis possible-symptoms and/or objective findings in patients who, for one reason or another, failed to have necessary laboratory or x-ray studies made or on whom follow-up was inadequate. RESULTS It is estimated that during the year, IS per cent of all employees sought medical advice because of rheumatic complaints (table 2). There was no Table 2.-Estimated Age Groups Incidence Total Employees of Rheumatic Complaints by Age and S e x Males Females Employees with Rheumatic Complaint8 Employees wlth Rheumatic Complainta Observed Number Toof Total Estimated Total Employees Observed Number Estimated yoof total 12 9 17 17 15 11 17 15 729 135 816 608 41 864 1,465 2,329 16 6 35 26 0 22 61 83 9 18 18 21 0 10 19 16 ~ Under 30 30-39 40-49 60 and over 2,110 2,986 8,842 7,083 2,141 Under 40 40 and over AU ages 16,066 21,162 5059 5,096 54 85 255 274 74 119 803 722 288 BROWN AND LlNCC I / 4 / I \ /' /' I I I i I I 1 f r' I /* i 289 MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY obvious difference in the over-all incidence between males and females. In both sexes there appeared to be a gradually increasing rate of complaint with advancing age. There was no apparent relationship between rheumatic complaints and work stress. Since all but 2 per cent of the females were engaged in light (indoor clerical) work, this applies only to the male population. Among males engaged in heavy labor or in non-physical work, whether indoor or outdoor, there seemed to be no great difference in the estimated incidence of rheumatic complaints. Among indoor light workers, the rate was the same for males and females (table 3). A tabulation of the mean daily patient-medical-visit per month for rheumatic complaints through the period of study showed a drop during the summer months, reaching a low of 60 in August and a high (80 or more) during the winter months (fig. 1). June to September are the months when a large majority of the company employees were on vacation, usually not in the city,, a fact that must be considered in any attempt to explain this falling off of medical visits during the warm weather. There has been considerable speculation whether rheumatic subjects suffer more than usually during the cold weather, and recommendations for sojourns in warm climates during the winter months are not infrequent. The curve suggests that a carefully controlled study along this line might be illuminating. Site of cornph.int. The most frequently reported site of complaint was the lumbosacral, buttock, thigh area-roughly, the pelvic girdle ( designated in the tables as lower region or L)-which, it is estimated, was reported, usually as low back pain, by 50 per cent of all complainants. The neck, shoulder, upper a r m - o r roughly the shoulder girdle (designated as upper region or U)was the area of complaint in 35 per cent, and other sites, usually one or more peripheral joints (designated as peripheral sites, or P), were reported as the area of complaint in 29 per cent of the patients. It is of interest to note that most studies of rheumatic complaints in industry have concentrated on the problem of pain referable to the pelvic girdle, and that very little has been said about pain referable to the shoulder girdle, which here involves a considerably large percentage of the population at risk. More than one of these three subdivisions of anatomic sites of complaint was reported by about one-tenth of the observed patients. Sex. There was an obvious difference in the estimated incidence of these areas of complaint between the sexes. Men appeared to have predominantly Table 3.-Rheumatic Complaints and Work Stress Employeen with Rheumatic Complaint% Maim Females Occupation Groups ObeerVed Number Fgtimated d/o of total Observed Number Indoor light Outdoor light Indoor heavy Outdoor heavy 228 62 259 173 16 19 14 15 84 - Estimated 70 0ftot.l 16 - 290 BROWN AND LINGG low back pain, while in women discomfort seemed to be most common in the neck, shoulder, upper arm area (table 4 ) . This difference was not explained by the fact that nearly two-thirds of the males worked at heavy labor. When the incidence of the various complaint syndromes was compared in males and females engaged in indoor light work, and under age 60 (retirement age for women), the relative incidence was about the same. History of complaint. The records revealed that an estimated 80 per cent of the employees who applied for medical care owing to rheumatic complaints in the year of this study had been treated by the Medical Bureau for such complaints sometime within 10 previous years. It appears that in patients with complaints referable to the pelvic girdle, as well as those involving the shoulder girdle, over half (57 per cent) had had similarly localized complaints in previous years. DiQgn0d.s. Thirty-one per cent of the males and 40 per cent of the females with musculoskeletal complaints revealed diagnosable rheumatic disease. Undefined rheumatic disease was found in 20 per cent of the males and in 11per cent of the females; 42 per cent of the males and 47 per cent of the females presented minor complaints of short duration, without objective signs of disease; while in 10 per cent of the cases, insufficient laboratory or x-ray studies or none at all, or inadequate follow-up, made diagnosis impossible (table 5). Defined rheumatic disease. The estimated incidence of defined rheumatic disease was somewhat higher in females than in males. Bursitis and degenerative joint disease appeared to rank first and second in frequency, with fibrositis, disc disorder, and gout in third, fourth and fifth places. Rheumatoid arthritis appeared to be of infrequent occurrence. Under “other” diagnosable disorders are included additional musculoskeletal conditions of too infrequent occurrence to be listed separately, such as spondylolisthesis, psychogenic rheumatism, low back pain or lumbosacral strain, calcaneal or olecranon spur, scleroderma, epicondylitis, ruptured meniscus, tendonitis or synovitis, etc. (table 5). The estimated incidence of diagnosable rheumatic diseases, as a whole, was found to be much higher after (63 per 1000) than before (19 per 1OOO) age 40, and considerably higher after 40 in females (98 per 1000) than in males (60 per 1000). Of all cases of defined rheumatic disease, it is estimated that 53 per cent presented articular and 47 per cent presented some form of nonarticular rheumatism, about the same proportion in males as in females. The partial breakdown of the data up to this point-whether the differences in incidence of rheumatic complsints, as a broad group, differed significantly (in a statistical sense) from one category of subject to another-has, of course, Table 4.-Areas of Complaint ~~ Males Area of Comnhint Females - Observed Number Estimated % of total Observed Number 368 240 206 8 5 4 39. 28 23 Estimated % of total ~ Lower Region Upper Region Peripheral Sites 3 8 4 291 MUSCULOSKELETAL COMPLAINTS IN A N INDUSTRY Table S.--Rhsumtic Complaints b y Diagnosis Sample Cases Diagnosis Bursitis Degenerative joint disease Fibrositis Disc disorder Gout Rheumatoid arthritis Other defined disorders Total defined disorders Undefined rheumatic disease Questionable rheumatic disease (minor complaints ) No diagnosis possible Total with rheumatic complaints Total Employees - Number Males Females 61 13 54 5 6 4 Entimuted Cases Per Cent Males Females Per 1000 Employees Males Females 16 12 26 ' I 6 12 7 5 - 8 6 4 15 11 7 1 5 2 4 4 4 3 1 3 5 7 222, 33 31 40 50 67 144 9 20 11 29 19 306 39 73 7 42 10 47 8 62 15 67 15 722' 83t 100 100 21,162 2,329 27 28 20 9 23 1 8 2 - "More than one diagnosis in 22 cases. tMore than one diagnosis in 5 CdSeS. little meaning. The following breakdown by diagnostic categories is more informative, and here the question of statistical significance will be considered. Although a search for etiological or environniental relationships would be merely speculative, the data were broken down into the most obvious subclasses: sex, age, and general type of occupation." Tests of statistical significance were applied merely as a help in deciding whether separate incidence rates should be estimated for different subgroups. For example, in deciding whether to give separate bursitis rates for males doing light work and males doing heavy work, the males were first divided by age ( 5 decades) and job location (outdoor and indoor)-10 subgroups. Each subgroup was divided by work load (light versus heavy) to give a fourfold table containing the observed bursitis cases, the marginal totals being the total male employees in the appropriate category (occupation, decade and work load). Such series of tables often showed that there was no consistent relationship between the frequency of a particular type of complaint and the attribute under test (e.g., type of occupation or age). When the conclusion was in doubt, the weight of evidence presented by each fourfold table was measured by calculating chi-square. The evidence from all the tables ia the series was then combined by summating chi values (with appropriate plus or minus sign), and the significance of the sum was tested by its standard deviation (the square root of the number of component chi values). Unless the sum was more than twice its standard deviation, indicating a probability (PI of less than 0.05, it was arbitrarily decided that there was not sufficient evidence to justify keeping the attributes under test (e.g. heavy "The observed or sample cases on which the statistical analysis is based numbered 805. To provide material for further study, including comparison with other series, mimeographed reproductions of tables may be obtained from the authors on request. 292 BROWN AND LINGC and light work load) separate in estimating incidence rates. A more elaborate test of one series of fourfold tables indicated that the summation of chi values was sufficiently reliable for the purpose for which it was used in this survey. DEGENERATIVE JOINT DISEASE.It is estimated that of the total male employees, 12 per 1000 sought medical advice because of symptoms due to degenerative joint disease. There were no cases under age 40. Over 40 the estimated rate was 16 per 1O00, with an obvious increase in incidence with advancing age. There was no suggestion of a difference in complaint rate by location or load of work, outdoor or indoor, whether heavy or light. The ration of rates by regions of the body, L:U:P, was approximately 2:1:1, a difference not significant at the 5 per cent level ( P = 0.10 - 0.05). Among females there was no signi6cant difference from the rates in males, in a comparable group, engaged in indoor-light work, between the ages of 40 and 59 (table 6). DISCDISORDERS. Disc disorders, it is estimated, were present in 6 per 1000 employees (table 5). Most of the cases, 90 per cent, complained of symptoms in the lumbosacral, buttock, thigh area, as would be expected. In the remaining 10 per cent, the upper spine was the seat of complaint. There was no suggestion of a relationship between the incidence rates and age; location of work, outdoor or indoor; or load of work, heavy or light. Among females, the estimated over-all incidence was 7 per 1000, not significantly different from that in males, in a comparable group ( 5 per 1OOO). No other differences were detected between the sexes. GOUT. There were no cases of gout under age forty. The estimated incidence in males over forty was 5 per 1000 (table 5 ) . There was no relationship to occupation. In this experience, there were no cases of gout in females. Gout has long been known to be of rare occurrence in women, a subject which need not be discussed here. RHEUMATOID ARTHRITIS. The estimated incidence of rheumatoid arthritis among males as well as females was only 2 per 1000 (table 5 ) . No relationship to occupation was detectable (table 6). The small number of observed cases, both male and female, may well have prevented the detection of possible associations and differences. An incidence rate of only 2 per 1000 is in distinct contrast to the impression gained in arthritis clinics and in hospitals where rheumatoid arthritis constitutes a large percentage of the patient load. It was suggested that the low rate in this study might tre accounted for by the possible exclusion from employment of applicants with this disease, or the later separation from the company of rheumatoids because of physical incapacity, but examination of the records of medical rejections of applicants, as well as those of early disability retirement, failed to support this argument. The likelihood that individuals with rheumatoid arthritis would not seek employment with a large industrial concern in the first place was also considered, but ruled out in the light of the fact that, of the population at risk in the year of the study, 54 per cent were under 25 years of age, 78 per cent under 30, and 91 per cent under 35 when first employed by the company. Available statistics indicate that it is after the age of 35 that the rate for diagnosable rheumatoid arthritis is highest. MUSCULOSKELETAL COMPLAINTS IN AN 293 INDUSTRY Table 6.-The Relationship of Age, Location, Load of Work and Site to Males and Females in Different Diagnostic Groups Diagnostic Groups Degenerative M Joint Dieease F DiscDisOrders F Arthritic Bursitis Obvious increase with age Obvious increase with age NSR DNS - DNS NSR NSR DNS DNS F M F DNS Undefined M Rheumatic Disease F Significantlr higher over 40 Significantly higher over 40 DNS DNS - NSR DNS - - Highly nignificant exceas in “upper“ redon (U:L:P= 16:1:3) Highly significant excess in “upper” region (U:L:P = 13:O:O) Significantly higher Significant difference in in OL group (OL: IL: ratio for body regions OH:IH= 10:3:3:1) (U:L:P=6:3:1) NSR - Significantly higher in IH group, 6th decade (IH:IL=2.86:1) Obvious difference in ratio for body reeions (U:L:P = 1:4:2) Obvious difference in ratio forb& d M (U:L:P = 1:2:6) Significantly higher in “light” workers (L:H = 1.27:l) Significant difference In ratio for U L regiona, in indoor outdoor workers ( 0 = U:L:P = 1.2: 3.66:l) ( I = U:L:P = 2.a: a.s:i) - Significantly higher over 40 Questionable M Rheumatic Disease F - NSR Signifieanthr higher over 40 Significantly higher over 40 Obvious relationship to lower region NSR Significantly higher over 40 ~~~~~~ M F - NSR NSR DNS HighLrsignifi- Fibmsitis s i t e of Complaint Axe DNS M F Rheumatoid M CompIaint Location and Load af Work SaX M Gout of NSR - + + - DNS = Difference not significant. NSR = No auggestion of relationship. Two possible explanations are offered for the low rate found in this study: first, the uncertainty of diagnosis in atypical or early cases and secondly, and more probably, the influence of the remittant nature of the disease on an annual complaint rate. BURSITIS. The estimated over-all rate of complaints in patients with bursitis in males was 12 per lo00 (table 5).* There was no significant difference in complaint rate between men working outdoors or indoors, or between those engaged in heavy or light work. A highly significant excess of complaints appeared in the upper body region, with a ratio of rates U:L:P approximately 16:1:2.7. This did not appear to be related to any special occupation or age group (table 6 ) . *There was a significantly higher rate above forty ( P = 0.05 - 0.02) than below forty. 294 BROWN AND LINGG The estimated number of females with bursitis was 60 (only 1 observed or sample case under 40).The estimated rate for the over- 40 group was 37 per 1O00, compared with a rate of 18 per 1000 in a comparable group of males. The higher incidence rate in females was highly sigdicant (P = 0.05 - 0.02). Among females with bursitis, the shoulder, neck, upper arm area was the only body region of complaint. All were cases of subdeltoid bursitis, or hicipital tendinitis. Bursitis was the only one of the “defined rheumatic diseases in which the incidence rate was significantly higher in females than in a comparable group of males (indoor light workers, under age 60). In the study by Kellgren et al.,5 the incidence of bursitis and synovitis over a five-year period was 1.4per cent in males and 1.0 in females. Although their figure for males is approximately the same as the estimated figure in this study, they found no appreciable difference between the sexes. In our population, nonphysical indoor work engaged in by women comprises largely routine clerical jobs, such as typing, filing, operation of punch card and tabulating machines, etc., whereas among males it includes largely supervisory clerical work and other nonclerical types of indoor work. Since there is some opinion that apart from trauma, infection, and other factors, unusual repetitive use of a part may be associated with bursitis, it was thought that the fact that nearly three-fourths of the females (71 per cent) and less than one-half of the males (46per cent) were engaged in occupations requiring the constant use of the arms, might account for the higher incidence of subdeltoid bursitis or bicipital tendinitis in women than in men. Such occupations include the titles bookkeeper, accountant, draftsman, stenographer, typist, file clerk, telephone operator, machine operator, tabulating machine operator, accounting machine operator, addressograph operator and key punch operator. When the incidence of bursitis was investigated in males and females assigned to work in these occupations only, the difference in incidence between the sexes was not significant. Nor was there a significant difference in the incidence of bursitis between the sexes among employees assigned to work in all other occupations. There was, on the other hand, a significantly higher incidence of bursitis among employees, regardless of sex, engaged in the above listed occupations than among those assigned to other types of indoor light work (P = 0.01). In the opinion of the authors, the higher incidence of bursitis in the occupation groups enumerated above is directly attributable to the nature of the work involved. This is not to say that the relationship is necessarily etiological. It may be that in individuals w i t h - o r prone to--bursitis, the repetitive use of the arms and hands causes exacerbation of symptoms. FIBROSITIS. The estimated over-all incidence of complaints due to fibrositis was 8 per lo00 in males (table 5 ) . There was no significant relationship of complaint rate to age in any of the four occupation groups; nor did the combined evidence from all four groups indicate an age relationship. However, the occupation groups differed significantly in their rates (table 6). There was a significantly higher rate of complaints among patients with fibrosifis in the group engaged in outdoor light work, the ratio 0L:IL:OH:IH being approximately 10:3:3:1. To attempt to assign a reason, such as exposure to dampness and cold, for the higher incidence in this group, would MUSCULOSKELETAL COMPLAINTS I N A N INDUSTRY 295 be indulging in speculation. Too little is as yet known about the nature of this rheumatic disorder. Furthermore, the small number of cases available for statistical analysis in this as in some other of the defined rheumatic disease groups may well have prevented the detection of other associations and differences that might have been piesent. The ratio for body regions of complaint differed significantly from l : l : l , that of U:L:P being 5:3:1 ( P = 0.05 - 0.02). This inequality showed no obvious difference with age or occupation. In females with fibrositis, there was no significant difference from the rates in a comparable group of males. UNDEFINED RHEUMATIC DISEASE. The estimated incidence of undefined rheumatic disease in males was 29 per loo0 employees, and there was a significantly higher incidence from age 40 onward than below 40. This appeared to apply to all occupation groups except the outdoor light group. The only significant difference in the incidence in men engaged in heavy versus light work was among indoor workers in the fifth decade. In this group the H:L ratio was 2.85:l. Since this diagnostic group does not represent a distinct disease entity, any attempt to explain this difference in incidence would be meaningless. Of all males with “single” sites of complaint, the neck, shoulder, upper arm area was the body region of complaint in 14 per cent; the lumbosacral, buttock, thigh area in 56 per cent; and peripheral areas in 30 per cent. Among females there was no detectable relationship with age and no detectable difference from males engaged in indoor light occupations and under age 60.The estimated incidence over age 40 was 26 per 1O00, compared with 24 per 1000 in males (tables 5 and 6 ) . In 93 per cent of the cases classified as undefined rheumatic disease a tentative diagnosis was suggested by the symptoms, signs and general course of the episodes. These tentative diagnoses are as follows: fibrositis 27 per cent; disc disorder 20 per cent; degenerative joint disease 18 per cent; rheumatoid arthritis 10 per cent; gout 5 per cent; bursitis 5 per cent; other disorders (psychogenic rheumatism, traumatic synovitis, ruptured meniscus, etc.) 8 per cent. Should these tentative diagnoses turn out to be definitive, degenerative joint disease would head the list of the estimated frequency of occurrence with 18 instead of 13 cases per 1000 employees. The incidence of fibrositis would be doubled (from 8 to 16), as would that of disc disorder (from 6 to 12) and that of rheumatoid arthritis more than doubled (from 2 to 5 cases per lo00 employees ) . QUESTIONABLE RHEUMATIC DISEASE (MINOR COMPLAINTS). The estimated incidence of “minor complaints” among male employees was 62 per 1000. There was no s i g d c a n t age relationship. This applied to each of the four occupation groups. There was a significantly higher incidence in men engaged in light than in heavy work ( P = 0.05), the ratio of L:H being 1.27:l. This difference did not vary significantly with age, with location of occupation (outdoor versus indoor), nor with body region of complaint. There was little evidence of a difference in incidence in outdoor and indoor 296 BROWN AND LINGG workers except in the group with complaints in the lumbosacral, buttock, thigh area, and here it was confined to those engaged in light work, and under age 40. In this group the ratio of incidence in outdoor workers to that of indoor workers was 5:1. The outdoor and indour workers differed significantly in the proportion of complaints in the two body region classes U and L. Taking only “single” complaints, the figures were: outdoor-U’s, 21 per cent; L’s 62 per cent; P s 17 per cent; and, indoor-U’s, 35 per cent; L‘s 50 per cent; P s 15 per cent. These differences did not vary markedly as between heavy and light workers. Among females with “minor cclmplaints,” there was no suggestion of a difference in the estimated incidence with age, nor was there any suggestion of a difference in the over-all incidence in females versus that in males. The estimate was 69 per 1000 compared with 71 per 1000 in a comparable group of males (tables 5 and 6 ) . This large group is by far the most difficult with which to deal. Included in it are probably cases which are frequently classified as fibrositis or psychogenic rheumatism. The uncertainty which surrounds the nature of both these syndromes, and the fact that the symptoms are often mild and of short duration, has tended to make them a catchall for cases that do not fit the description of other more clearly defined rheumatic disorders. We have tried to avoid such allocations in all cases that did not fit as unqualified as possible a description of either syndrome, such as the fairly consistent clinical pattern, with negative laboratory findings, no pathological joint changes, and the exclusion of possible early rheumatoid arthritis as well as mild osteoarthritis. By classifying them in a separate group, there is a greater likelihood of arousing interest in and stimulating further study of these cases. About three-fourths of these patients had been seen sometime within the previous ten years by the medical bureau because of rheumatic complaints. The charts of this group of patients, classified as having minor complaints, were reviewed each year for three years after the year of study. At the end of the period, 45 per cent had returned to the medical department owing to further rheumatic complaints. Only 20 per cent had not reported any rheumatic complaints except during the sampling year. The rate of appearance of any diagnosable disease syndrome after three years was so small ( 1 per cent) as to he without significance. DISABILITY AND ECONOMIC Loss In its plea for funds for the support of organized research in rheumatic diseases, the Empire Rheumatism C ~ u n c i l ’reported ~ that 271/2-million days were lost to industry from June 1953 to June 1954 through the rheumatic dis10 per cent of the total days lost through every form of illness. ease.-nearly In Denmark, according to Kalbak‘s3 estimate, rheumatism accounts for a loss of approximately 7 million working days annually, and Bohman2 estimated that in Sweden the loss is about 14 million working days per year. The U. S . Public Health Service began as far back as 1990 to publish reports on sickness absenteeism by cause, based on data submitted by industrial sick benefit organizations. A review of absenteeism by cause in different industries and MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY 297 occupations, in this country and abroad, emphasizes beyond a doubt the importance of rheumatic disorders as an economic problem from the point of view of loss of working time. Ten or 15 per cent or more of total working time lost is attributed to some form of rheumatism. Lack of uniformity and precision in nomenclature, diagnostic criteria and in methods of collecting data, however, fails to permit direct evaluation of the economic effects of these diseases. Estimates are frequently made of the monetary cost of illness to a community or to an industry. Thus Kalbak3 estimates the annual cost of rheumatism in Denmark as $25 million, and Bohman2 arrives at a figure of at least $14 million in Sweden. Although such figures are impressive and probably do not overestimate the facts, means of arriving at them are so variable that they are seldom comparable. In its Sickness Report for the year 1954,13the Consolidated Edison Company of New York states that pay for time lost on account of sickness from all causes totaled $3,138,421 (Company Sick Pay Allowances and Mutual Aid Sick Benefits) of which the cost for the Consolidated Edison Company alone totaled $3,051,731. Obviously this figure does not represent the total economic loss to the company on account of sickness. The value of an individual employee to the company, which involves such imponderables as his particular aptitudes, years of training and experience, is seldom reflected in the amount of sick pay allowances or benefits paid. Insofar as the exact value of a working day varies from individual to individual and from job to job, it becomes meaningless to try to express economic loss in terms of dollars and cents. Therefore, in attempting to estimate the cost of the rheumatic diseases to the Consolidated Edison Company. two types of determinations were made: first, working days lust, and secondly, the medical cost expressed in patient visits to the various service modalities provided by the company. Working days tost. During the year, in the sample studied, rheumatic complaints accounted for the loss of 2,863 working days, which gives an estimate of 15,040 total loss of working days for these complaints, or about 9 per cent of the total days (161,920)" lost on account of sickness by the company's employees in the occupational categories included in this study. The mean days lost because of illness in general is staggering-7" days per employee in the year 1954, of which, according to estimates from this study, one day was lost on account of rheumatic complaints. Among sick employees, the mean number of days lost during the year because of illness was 11," while among those with rheumatic complaints, reported in this study, it was four days. Of the total days lost on account of rheumatic complaints, leaving out those cases in which no diagnosis was possible, definable rheumatic disorders claimed more than half. with degenerative joint disease at the top of the list, and the distribution among the various categories as shown in table 7. Except in the case of gout, more than 40 per cent of the cases in each diagnostic category lost no time from work during the year. Seven of the ten cases whose records led to the diagnosis of rheumatoid arthritis lost no time from work on account of this disorder during the year of study, which may probably be explained by the remittent nature of the disease. Ten days or more were 'Figures supplied by the company.13 298 BROWN AND LINGG Table 7.-Time Lost from Work Owing to Rhatmutic Comphinints Workine D s r s Lost Due to Rheumatic Complaints No. of Diagnosis Barsitis Degenerative joint disease Fibrositis Disc disorder Gout Rheumatoid arthritis Other defined disorders Total defined disorders Undefined rheumatic disease Questionable rheumatic disease (minor comdaints 1 Percent Cases in of Total Days Lost 74 Mean per None 4 4 4 10 10 27 255 10 13 5 10 5 3 7 53 45 55 43 44 15 70 6 46 19 15 0 7 15 153 34 6 53 16 18 13 345 13 1 66 25 9 0 Sample 59 33 32 u) Patient 7 10 7 55 1-4 6-9 (Per Cent of Cases ) 20 15 9 20 15 33 3 35 10 19 19 10+ 15 15 15 34 35 20 19 20 lost by approximately one-third, each, of patients with gout and disc disorder, and from five to nine days by one-third, each, of patients with gout and fibrositis. Of all the time lost owing to musculoskeletal complaints, one-third was lost by patients with symptoms and objective signs of rheumatic disease which failed to satisfy completely the definition of any of the definable diagnostic groups. This time was lost by slightly less than half of these patients, an average of six days each. One-third of the patients with minor complaints of questionable rheumatic disease lost more than one-tenth of the total working days lost because of muscoloskeletal complaints. Medical smuices. Among the cases in the sample, 3,821 medical visits (by employee or physician) were made on account of rheumatic complaints during the year of study, which gives an estimated total of 20,800 visits-approximately one visit per employee, or six visits per employee with rheumatic complaints. The distribution of these visits was as follows: 49 per cent to clinics (40per cent to general medical clinics, 6 per cent to the diagnostic clinic, and 3 per cent to the office handling industrial compensation cases); 36 per cent to the private offices of district doctors; 12 per cent house visits by district doctors; and 3 per cent outside consultations. During the year, 1 per cent of the.patients reguired hospitalization. Two per cent were known to have been seen by a private physician some time during the year. Of each of the various types of medical visits, the largest number were made by patients with well-defined rheumatic disorders (table 8). Of visits to general medical clinics and to the offices of the district doctors, the largest proportion, considering only diagnosable rheumatic disease, was made by patients with degenerative joint disease and with bursitis. Of visits to the diagnostic clinic, the most frequent claimants were victims of rheumatoid arthritis and disc disorders. It is not surprising that most of the visits to the industrial compensation office were made: by patients suffering from disc dis- 299 MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY Table b.--Medical Sewices Provided for Patients with Rheumtic Complaints (Sample Cases) Both Sexes Per Cent of Total Visits Due to Rheumatic Complaints Diwnosis Bursitis Degenerative joint disease Fibrositis Disc disorder Gout Rheumatoid arthritis Other defined disorders Total defined disorders Undefined rheumatic disease Questionable rheumatic disease (minor complaints) Total Visits N0.M General Medical Clinic District Doetorn’ Ofices House Visits D.D. 74 59 33 32 20 10 27 10 13 4 5 3 2 4 14 18 8 5 9 6 6 9 11 2 3 255 41 59 153 30 29 Caeesin Sample 345 Number Percent 29 1526 100. 5 6 3 Indust. Compens. Office Outside Consult. 13 4 23 4 6 14 0 28 0 0 11 13 3 1 21 0 16 13 46 66 59 67 25 31 36 33 12 29 1393 100. 444 100. Dingnostic Clinic 6 9 7 3 216 100. 5 113 100. 0 129 100. orders, nor that most of the visits to outside consultants were made by patients with disc disorders and rheumatoid arthritis. One-fourth or more of all visits to each of the service modalities were made by patients with undefined rheumatic disease, about a third, each, to the diagnostic clinic and to outside consultants, which is evidence that expense was not spared in the effort to arrive at a definite diagnosis in these cases. Of visits to general medical clinics and of house visits made by district with minor doctors, more than one-fourth were made b y - o r to-patients complaints of questionable rheumatic disease. The usually mild and short duration of symptoms in this group made further investigation appear unwarranted. Yet it is estimated that these symptoms were responsible for the loss, during the year, of 1,608 working days, and for 1,988 visits to the medical clinics, 764 visits to offices of district doctors and 520 house visits by district doctors. DISCUSSION In the population under consideration, by far the greatest percentage of individuals with rheumatic complaints, omitting those classified as “no diagnosis possible,” suffered from disorders of a noncrippling nature. In only 17 per cent were the symptoms definitely-and in an additional 9 per cent possibly-attributable to rheumatoid arthritis, degenerative joint disease, disc disorders or gout. In the remaining 74 per cent, complaints were due to syndromes of a less severe and self-limiting nature. In the arthritis cIinics and on the wards of the medical school teaching centers, we see primarily the 17 or 28 per cent with severe disease. Most of the remaining 74 per cent never reach us.Yet it is these (three-fourths of the total) that pose an equally great problem 300 BROWN AND LINGG in time lost from work, which in this study amounted to an estimated 6,368 working days lost annually and involved treatment requiring 9,064 medical visits, as against 6,180 working days lost and 9,000 medical visits in the case of the 26 per cent (one fourth of the total) with severe, possibly crippling disease. Included in this large group are many syndromes, such as bursitis and fibrositis, the nature of which is still little understood, tenosynovitis and psychogenic rheumatism, and others that are as yet probably not even recognized. The largest proportion, as has already been noted, is the group with apparently minor complaints. In an industrial organization that usually offers medical care on the premises and during working hours, through a payroll deduction plan, one would natorally expect to find a larger proportion of cases with minor complaints than among patients who apply to hospital clinics or to the offices of private physicians for relief of symptoms. Rheumatologists are well aware of the fact that the early stage of rheumatoid arthritis, for instance, has not only not been studied, but has not even come under medical surveillance, since the symptoms complained of are usually considered unimportant. It has been suggested that persons who may be in the process of developing rheumatoid years or arthritis should be kept under observation for long periods-ten more.14 The tendency is to dismiss cases without detectable objective signs as unimportant, and consider the symptoms as probably due to hypersensitivity to pain or other forms of discomfort, or to a general malingering attitude on the part of some individuals. Although such inferences deserve consideration, especially in group health insurance, prepayment medical care and payroll deduction plans, too much reliance should not be placed on them without further investigation to rule out the possibility that the symptoms may be prodromal of true rheumatic disease. The reasons for selecting this particular industrial population for a study of the incidence or prevalence of the different rheumatic diseases were pointed out earlier in this report. They include the exceptional stability of the population at risk, the fact that this population is under the close surveillance of an active and competent medical department, and that there are available on most patients detailed records of medical history and observation over a period of 10 previous years (since 1945), thus obviating the disadvantage of having to rely on the patient’s memory, a notoriously inaccurate instrument. Although the medical department’of the company gave wholehearted interest and cooperation to this project, difficulties are, nevertheless, met in conducting such a study as this in an industry. As has been pointed out, it was not always possible to have patients whose symptoms were episodic, or in whom the diagnosis was doubtful, re-examined in consultation with the rheumatologist or referred for further x-ray or laboratory studies, as had originally been agreed to by the medical department. The reason for this was usually that since the patient’s symptoms had subsided sufficiently for him to be back on the job, further loss of time from work for medical reasons was not granted. From the point of view of the industry, which is in business not to promote research but to sell its services, and which maintains an efficient medical department primarily for the purpose of reducing absenteeism due to illness, time off for 301 MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY any reason, provided the employee is able to work, is an unnecessary loss to the company. Yet the need is great for more careful observation and follow-up of the less well defined syndromes, and the development, if possible, of more and better diagnostic tests and a more rational approach to therapy. Close observation over a period of years of a group of individuals with apparently minor rheumatic complaints, including available diagnostic tests and psychiatric examinations, may delineate syndromes now unrecognized. Clearly, it is in an industrial population that these cases can best be studied. Neither the specialist in private practice, nor the man in full time medicine, nor one who conducts community studies, is in a position to make such observations. Industry alone has the opportunity to undertake and help provide resources for such investigations, and it will be among the first to benefit from whatever knowledge may grow out of them. SUMMARY A study of the incidence of the various types of rheumatic disorders in a sample population with rheumatic complaints among the employees of the Consolidated Edison Company of New York, within a period of one year (January 1, 1954 to January 31, 1955), has been reported. The reasons for selecting this particular industry, and some of the difficulties encountered in making industrial surveys, are discussed. A strictly random sample of 25 per cent was selected from daily medical records in categories that would, or might, according to the company physicians’ coding, contain rheumatic disorders. The records of 805 cases which constituted the sample were studied. It is estimated that 15 per cent of the employees requested medical care because of rheumatic complaints. Thirty-two per cent of the sample cases revealed diagnosable rheumatic disease. Undefined rheumatic disease was found in 19 per cent, and 43 per cent presented symptoms, episodic in nature, without objective signs of disease, The relationship of age, sex, body region of complaint, and location or load of work-whether indoor or outdoor, heavy or light-was investigated in each of the diagnostic groups. Differences found were tested for statistical significance, and possible explanations for such differences were offered. Rheumatic complaints accounted for an estimated loss of 15,040 days during the year, which was 9 per cent of the total working days lost on account of sickness by employees of the company, and an estimated 20,800 melical visits were made by employee or physician because of rheumatic complaints. Twelve per cent of the days lost and 18 per cent of the medical visits were attributed to patients with minor though frequently recurring complaints, but without objective signs of disease. The need for more careful and prolonged observation of patients with the less well defined syndromes is emphasized. A unique opportunity for industry! REFERENCES 1. Woolsey, T. D.:Prevalence of arthritis and rheumatism in the United States. Pub. Health Rep. 87:505, 1952. 2. Bohman, F.: Social importance of rheumatic diseases in Sweden. Acta med. scandinav. 132:150, 1948. 302 BROWN AND LINGG 3. Kalbak, K.: Rheumatic diseases in Denmark. Ann. Rheumat. Dis. 12:306, 1953. 4. de Bltcourt, J. J.: Investigation as to the prevalence of rheumatic diseases and to their dependence upon the degree of dampness in dwellings. Res. Inst. Health Engineering, T.N. O., Rep. No. 20, December 1953. 5. Kellgren, J. H.,Lawrence, J. S. and Aitken-Swan, J.: Rheumatic complaints in an urban population. Ann. 1953. Rheumat. Dis. 12~5, 6. Mink, B. aud Goldwater, L. J.: Occupational aspects of rheumatic diseases-a review. Indust. hled. 83: 335, 1954. 7. Lawrence, J. S. and Aitken-Swan, J.: Rheumatism in miners. Brit. J. Indust. Med. 9:1, 1952. 8. Kellgren, J. H. and Lawrence, J. S.: Rheumatism in miners, part 11, x-ray study. Brit. J. Indust. Med. 9:197, 1952. 9. Bunim, J. J.: The incidence of the rheumatic diseases in industry. Indust. Med. 22:302, 1953. 10. Brown, R.: The incidence of various rheumatic diseases in an industry. Presented at the scientific session of the Council on Industrial Health, American Medical Association. Bethesda, Md., Jan. 24, 1955. 11. American Rheumatism Association. Primer on the rheumatic diseases. J.A.M.A. 152:323, 405, 522, 1953. 12. Empire Rheumatism Council. Industry and rheumatism. 13. Sickness Analysis, 1954; Consolidated Edison Company of New York, April 1, 1955. 14. Personal Communication, Sidney Cobb, M.H., MP: H; Advisory Committee, Pittsburg Arthritis Study, March 1953. Robert Brown, M.D., Assistant Professor of C1,iriical Aledkinc: and Member, Rheumatic Diseases Study Group, New York University College of Medicine, New York, N . Y. Claire Lingg, M.A., formerly with the Department of Medical Statistics, at present with the Rheumatic Dkeases Study Group, N . Y. University College of Medicine, New York, N . Y.