September 2007 | Back to Table of Contents

Perspective

Compromising Positions

By Jennifer Gunn, Ph.D.

A story of early 20th century occupational medicine on Minnesota's Iron Range.

When Drs. Charles and Mary Bassett Bray arrived in Biwabik, Minnesota, the morning after their wedding in March 1899, they had to trudge through deep snow to reach the hospital they had purchased from a medical school classmate for $4,000. Biwabik was hardly a honeymoon paradise. What was once towering old-growth forest surrounding a beautiful, pure spring where Native Americans camped had been clear-cut to make way for the rude settlement of about 1,200 people. Mine pits of mammoth proportions looked like open wounds in the landscape surrounding the village.¹

In the 1890s, the timber and mining industries brought together a mass of workers in northern Minnesota. Tents and shacks substituted for the towns still under construction. In this rugged setting, men, machines, and nature frequently collided, and doctors were needed to tend to the injured and sick. Physicians were attracted to the region by the possibility of securing franchises for caring for miners, railroad workers, and lumberjacks in the form of capitated contracts, an early prepayment plan.² The contract or ticket system had its roots in mutual benefit societies—fraternal orders that banded together to hire physicians on a contract basis—and the railroads’ hospitals and plans for their workers’ health care (see "A Contract Practice").³ But unlike in Appalachia, where the coal mining and manufacturing companies employed physicians in company-owned hospitals and clinics, it was generally doctors who built, owned, and operated the hospitals, clinics, and ambulances on Minnesota’s Iron Range.^2,3

The Brays, who met as students in the College of Medicine and Surgery at the University of Minnesota, from which they both graduated in 1895, did not start their medical careers with any particular interest in occupational medicine. Mary Bassett Bray graduated at the top of the class and followed one of the few paths open to women seeking hospital experience: She became a salaried staff physician in a state mental hospital.^4-7 Charles Bray did an internship at Ancker Hospital in St. Paul, then moved around the metropolitan area for the next two years to try to establish a practice. In 1897, his Minneapolis practice brought in only $256.⁸

Charles Bray’s situation wasn’t unusual. Many young physicians had a difficult time finding their financial footing, especially in the wake of the national depression of the 1890s.⁹ Even graduates of Harvard Medical School had to practice for at least three years before they were able to cover their expenses and earn a reasonable living.¹⁰ The Iron Range offered a certain economic security in the form of mining and logging company contracts. Although Mary Bassett Bray did not formally practice medicine after moving to the Range, during the family’s first year operating the Biwabik hospital, the Brays’ gross receipts from medical practice jumped to more than $4,100.⁸ The income came from Charles Bray’s logging and mining contracts and his work as a school physician and village health officer, in addition to his private practice. Charles Bray had become a country doctor with an industrial practice.

Growth of a Specialty
Occupational medicine was not part of the medical school curriculum at the turn of the century. Only 22 articles by U.S. authors had been published on industrial health between 1880 and 1900, and William Osler’s medical textbook listed only two occupational diseases, lead and arsenic poisoning.¹¹ Yet by the end of the 19th century, industrialization had produced high rates of accidents, injuries, and deaths on the job, and an increasing recognition that chronic diseases were related to certain occupations.¹²

At the time Charles Bray started to practice in Biwabik, the burden of occupational injury and disease rested solely on the workers, except in the rare cases where an injured worker successfully sued his or her employer for negligence. For most workers, getting hurt or sick on the job was a ticket to hopeless poverty for their families. This began to change at the beginning of the 20th century as Progressive Era social reformers, unions, and workers’ organizations sought legislation to pressure employers to take measures to prevent accidents and illness.¹³ Employers were increasingly interested in minimizing their exposure to lawsuits and ensuring a stable, productive workforce. The result was a compromise reform: In 1911, states began passing workmen’s compensation legislation that provided partial wages for workers who were injured on the job and limited payment for medical expenses. Minnesota passed a weak workmen’s compensation law in 1913. Initially, workmen’s compensation covered only on-the-job injuries. Only after concerted pressure did Minnesota in the 1930s become one of a handful of states to provide workmen’s compensation for a narrow list of occupational diseases.^14,15 Of the 23 diseases that were eligible for compensation, six were specifically associated with mining: one was Caisson’s disease, another was hookworm caused by poor sanitary conditions in the mines, and the others were related to inflammation of the skin or joints. No respiratory diseases were recognized as hazards of iron mining.¹⁵ (see "Defining Disease, Determining Cause")

In theory, occupational or industrial medicine was developing during this period as a specialty in which “curative and preventive medicine could be unified.”¹⁶ In reality, the practice emphasized treating accident victims, and reducing hazards and improving hygiene in the workplace. As state and federal governments became involved in the protection of workers’ health in the 1910s and 1920s, industrial medicine increasingly straddled the divide between private practice and public health, and between medical treatment of individual workers and responsibility for factory or mine hygiene. Bray wore many hats in his practice: private general practitioner, contract industrial physician, and town health officer. Unlike full-time salaried company doctors, he was responsible to taxpayers for the town’s health and hygiene and only for industrial hygiene as it impinged on the general public health.

Industrial medicine also became more professionalized during this period.¹⁷ The American College of Surgeons created a committee on industrial medicine and traumatic surgery to establish minimum standards for industrial medical service (especially for fracture care). At the same time, the American Association of Industrial Physicians and Surgeons and the Journal of Industrial Hygiene were founded, the National Safety Council was formed, Harvard Medical School established the first department of industrial medicine, and the U.S. Bureau of Mines was created to address the risks of coal mine explosions and other hazards.¹¹

Doctoring at the Mines
Mine doctors were called on frequently. Open-pit mining involved blasting large areas of rock and scraping the loosened ore with giant steam shovels. Workers walked on railroad tracks, moved up and down rickety wood ladders, and handled volatile explosives. Underground mines were also subject to flooding and cave-ins, and the loading and shipping of ore exposed all of the miners to the dangers inherent in railroading as well. Between 1909 and 1910 in Minnesota, 211 men were injured for every 1,000 employed in the mines, 57 per 1,000 on the railroads, and 47 per 1,000 in the wood [timber] industries. The total fatalities and injuries that year were 4,507 in the mines, 2,827 on the railroads, and 1,171 in lumbering. Although accidents were more frequent in the mines, an injury was more likely to prove fatal on the railroads. The railroad companies reported 94 deaths to mining’s 83 between 1909 and 1910.¹⁸

Certain jobs in the mines were more dangerous than others: A pitman who laid and cleaned the track for the huge steam shovel to move ahead was 24 times more likely to be hurt than a miscellaneous laborer who might be hit by rock or ore, run over by a train, or caught in machinery while making repairs. Trainmen suffered 34 percent of fatal accidents and 41 percent of nonfatal ones, even though they constituted less than 14 percent of the mining workforce. In the Adams open-pit mine near Biwabik, 30 men died between 1905 and 1920.¹⁸ Once, Bray rushed to a mine test pit with a pulmotor device to try to revive a young mining executive who had been asphyxiated by an unknown gas.¹⁹

In addition to the fatalities, there were significant numbers of serious injuries. Underground explosions led to crush wounds, and rock falls could shear off limbs and make cripples of young men.²⁰ Third-degree burns, especially on the face and arms, from lamp explosions or dynamite were common. The nature of the injuries and their treatment illustrates why the companies wanted to contract with physicians who owned hospitals. Leg fractures, for example, usually required a long period of immobilization, which was difficult to manage in a crowded boardinghouse where two men on different shifts often shared one bed. In 1905, three patients with leg fractures each spent between 31 and 52 days in the Biwabik hospital; 16 years later, a patient with a simple leg fracture was hospitalized for 48 days, still a fairly typical length of stay for a fracture.²¹

The workers most likely to die in the Biwabik hospital were miners or railroad workers who had been run over or crushed by trains, and unmarried workers with typhoid or lobar pneumonia (miners who had wives at home to care for them were not entitled to hospital treatment for illness in most cases, despite paying the hospital fee).^21,22

Between the end of November 1911 and May 1919, the St. Louis County Mine Inspector reported more than 24 fatalities and 18 disabling injuries in the mines at Biwabik, Mesaba, and Aurora (a community served by the Biwabik hospital) alone.²³ Through at least 1915, about one-third to one-half of the patients in Biwabik Hospital were there as a result of on-the-job injuries, many staying for one to three months.²¹

Injuries were not the only reason doctors were needed: infectious diseases, particularly typhoid, were rampant on the Iron Range during the early years, and the logging camps were especially vulnerable to smallpox outbreaks. The physician at Tower reported 17 fractures, several cases of typhoid and diphtheria, and 110 cases of measles, with two deaths at the Soudan Mine in 1902.²⁴ Eveleth physician C.W. More recalled his own three-month recovery from typhoid and the “hundreds of cases of typhoid fever” he treated, acquired from the filthy alleys and sewage-contaminated water supplies of the early Range towns.²⁵ After the town of Biwabik got a municipal water and sewage system in 1908, with water supplied from the Biwabik Mine shaft, the Biwabik hospital patient register showed that hospitalized typhoid cases actually increased. Eleven out of 78 patients in 1909, and 16 out of 82 patients in 1910, almost all miners, were treated for typhoid; two of the patients in 1910 died of the disease.²¹

Although treating sick miners was a significant part of Bray’s work, he treated only one disease that could be clearly classified as occupational, and that largely because it was the result of industrial mishap. In 1907, four patients were admitted to Biwabik Hospital with Caisson’s disease (the bends). One man died. The disease was caused by working too long in or decompressing too quickly from compressed air caissons or tunnels, such as those used for sinking foundations or mining under bodies of water.²⁶ Because disabling occupational illnesses were not recognized or compensable under most state workmen’s compensation laws at the time, there was little incentive to study or prevent work-related illnesses or diseases.

Walking a Fine Line
We do not know what Charles Bray knew or thought about the patterns of illness he saw among the workers he treated, or even what he thought about his patients or the companies that contracted with him. But a local doctor such as Bray, whose practice was anchored by industrial contracts and whose paying patient population included workers’ families and other community members, must have experienced divided loyalties at times. As one industrial hygienist wrote in 1919, “physicians and employers both must realize that industrial medicine is, in a measure, a compromise between the ideals of medicine and the necessities of business.”²⁷ For example, the company looked to its contract physicians to provide supporting testimony against workers’ claims in cases of accidents and injuries. Bray and his assistants were paid (usually $25) for testimony in lawsuits on behalf of an employer, and they earned additional fees for doing pre-employment physicals and teaching first aid classes to the mine rescue teams.⁸ As the town’s public health officer, Bray also had to enforce sanitation regulations on mine and timber company housing. Once transportation on the Range improved, residents could travel to another community to see a physician, so Bray had to earn workers’ confidence in his skills and fairness in order to gain their families as patients.

The extractive industries’ vulnerability to national economic changes meant that contract physicians had to cultivate a robust community practice to survive the periodic downturns in their industrial practice. When logging bottomed out, the Benedictine Sisters closed their hospital in Grand Rapids and the community was forced to rely on small outlying mining hospitals for five years, until Itasca County’s citizens banded together to build a county hospital. From the 1910s on, Bray steadily shifted Biwabik Hospital from being an industrial hospital caring mainly for male workers under the contract system to a general community hospital for medical and surgical patients, including obstetrical patients. As mining and lumbering employment on the Iron Range declined and the companies sold off their housing, Bray sold or closed small hospitals he had built at Adriatic and Mesaba.

Bray died in 1937 while examining a patient. His oldest son, Robert, took over Biwabik Hospital. An obstetrician by preference, Robert increased the number of babies delivered and operations performed in the hospital before selling it in the late 1940s. By 1950, Biwabik Hospital, like many of the other small, proprietary hospitals on the Range, had been converted for use as a nursing home or group home. MM

Jennifer Gunn is an assistant professor of the history of medicine at the University of Minnesota.

References
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